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NÔÛËÏ¢ÙÈ΋ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ Î·È Ó¢ÌfiÓˆÓ ÛÙËÓ ME£ Î·È ÛÙÔ ı¿Ï·ÌÔ ......................................................................................................................................................................................................................... 47 A. ¶Ï·Ù·ÓÈ¿
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E›Ó·È ÔÈ Ù·ÍÈÓÔÌ‹ÛÂȘ Banff 2003-2005 ÈηӤ˜ Ó· ÚÔÛ‰ÈÔÚ›ÛÔ˘Ó ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜; .............................................................................................................................................................................. 65 M. §ÂÔÓÙÛ›ÓË
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NÂÊÚÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. EÚÁ·ÛÙËÚȷ΋ ÂÎÙ›ÌËÛË ÙˆÓ ·ÛıÂÓÒÓ: NÂfiÙÂÚ˜ ÂÍÂÏ›ÍÂȘ Î·È Û˘ÁÎÚÈÙÈο ‰Â‰Ô̤ӷ ........................................................................................ 94 B. K‡ÚÎÔ˘
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8 17. IoÁÂÓ›˜ Ë·Ù›Ùȉ˜: YÔÙ·ÚÔ‹ ÛÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· ............................................................................................... 260 I. °Ô˘Ï‹˜ 18. YÔÙÚÔ‹ Ë·Ù›Ùȉ·˜ C ÛÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· Î·È ·fiÚÚÈ„Ë. ¢È·ÊÔÚԉȷÁÓˆÛÙÈο ÚÔ‚‹Ì·Ù· ....................................................................................................................................................................................................................... 267 K. ¶·ÙÛÈ·Ô‡Ú· 19. AÓÔÛÔÔ›ËÛË ˆ˜ ̤ÙÚÔ ÚÔÛÙ·Û›·˜ ÚÈÓ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·È‰È¿ ................................... 272 K. ™‡ÚÔÁÏÔ˘
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™Y°°PAºEI™ •¤ÓÔÈ ™˘ÁÁÚ·Ê›˜: 1. Priv. –Doz. Dr. med. Fuat Hakan Saner, DEAA, Intensive Care Unit, Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Germany 2. Professeur Raymond Reding, Hôpital Saint-Luc, Unité de chirurgie pédiatrique abdominale et générale, Bruxelles, Belgique 3. Prof. Dr. Johan W. de Fijter, MD, PhD, Leiden University Medical Center, Leiden, The Netherlands 4. Prof. Erich Pohanka, Division of Nephrology and Dialysis, Internal Medicine III, Medizinische Universität Wien, Vienna A-1090, Austria
ŒÏÏËÓ˜ ™˘ÁÁÚ·Ê›˜: 1. ∞Ó·ÁÓÒÛÙÔ˘ ¢¤ÛÔÈÓ·, ¶ÚÔ˚Ûٷ̤ÓË ∞ÈÌ·ÙÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ °¡£ «°. ¶··ÓÈÎÔÏ¿Ô˘» 2. ∞ÓÙˆÓÈ¿‰Ë˜ ¡ÈÎfiÏ·Ô˜, §¤ÎÙÔÚ·˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ Î·È ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ °¡£ «πÔÎÚ¿ÙÂÈÔ» 3. ∞ÓÙˆÓ›Ô˘ ∂˘ÛÙ¿ıÈÔ˜, §¤ÎÙÔÚ·˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ªª¡ °¡∞ «§·˚Îfi» 4. ∞ÔÛÙÔÏ›‰Ë˜ πˆ¿ÓÓ˘, ∞ÈÌ·ÙÔÏfiÁÔ˜, ∂ÈÌÂÏËÙ‹˜, ∞ÈÌ·ÙÔÏÔÁÈ΋ ∫ÏÈÓÈ΋-ªªO °¡∞ «O ∂˘·ÁÁÂÏÈÛÌfi˜» 5. ∞ÔÛÙfiÏÔ˘ £ÂÔÊ¿Ó˘, ¡ÂÊÚÔÏfiÁÔ˜, ∞Ó. ¢È¢ı˘ÓÙ‹˜ ¡ÂÊÚÔÏÔÁÈÎfi ΔÌ‹Ì· Î·È ªªO °¡∞ «O ∂˘·ÁÁÂÏÈÛÌfi˜» 6. μ·ÛÈÏÂÈ¿‰Ë˜ £ÂÌÈÛÙÔÎÏ‹˜, (∞Ó·Ï. ¢È¢ı˘ÓÙ‹˜ μ’ ¶¶, °¡£ «πÔÎÚ¿ÙÂÈÔ, thvas2@otenet.gr ) 7. μ¤ÚÁÔ˘Ï·˜ °ÂÒÚÁÈÔ˜, ∞Ó·Ï. ¢È¢ı˘ÓÙ‹˜, ¡ÂÊÚÔÏfiÁÔ˜, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ °¡£ «πÔÎÚ¿ÙÂÈÔ» 8. μÔ˘Á¿˜ μ·Û›ÏÂÈÔ˜, ÃÂÈÚÔ˘ÚÁfi˜, ∂ÈÌÂÏËÙ‹˜ ∞’, ∞’ ÃÂÈÚÔ˘ÚÁÈÎfi ΔÌ‹Ì· Î·È ªªO, °¡∞ «O ∂˘·ÁÁÂÏÈÛÌfi˜» 9. μÚÔ¯›‰Ë˜ ¢ÈÔÓ‡ÛÈÔ˜, ÃÂÈÚÔ˘ÚÁfi˜, ∂ÈÛÙËÌÔÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ ÃÂÈÚÔ˘ÚÁÈ΋˜ ∫ÏÈÓÈ΋˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô 10. °ÂˆÚÁ¿ÎË ¶·Ú·Û΢‹, ¡ÔÛËχÙÚÈ· ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛˆÓ, °¡£ «πÔÎÚ¿ÙÂÈÔ» 11. °ÂˆÚÁÔÔ‡ÏÔ˘ μ›‚È·Ó, ∂ÈÌÂÏ‹ÙÚÈ· μ’ ∞ÎÙÈÓÔÏÔÁÈÎÔ‡ ΔÌ‹Ì·ÙÔ˜, °¡£ πÔÎÚ¿ÙÂÈÔ 12. °È·ÎÔ˘ÛÙ›‰Ë˜ ¢ËÌ‹ÙÚÈÔ˜, §¤ÎÙÔÚ·˜ ∞¶£ ÃÂÈÚÔ˘ÚÁÈ΋˜, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ °¡£ «πÔÎÚ¿ÙÂÈÔ» 13. °ÈÔ˘ÏÂ̤ ŸÏÁ·, §¤ÎÙÔÚ·˜ ∞¶£, °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜, °¡£ ∞Ã∂¶∞ 14. °Ô˘Ï‹˜ πˆ¿ÓÓ˘, °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ∞¶£, ¢’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ» 15. °Ô‡ÌÂÓÔ˜ ¢ËÌ‹ÙÚÈÔ˜, ∞Ó·Ï. ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜-¡ÂÊÚÔÏÔÁ›·˜, ¶·ÓÂÈÛÙ‹ÌÈÔ ¶·ÙÚÒÓ 16. ¢ÂÛfiÙË ÃÚ˘ÛÙ¿ÏÏ·, ™˘ÓÙÔÓ›ÛÙÚÈ· ªÂÙ·ÌÔۯ‡ÛˆÓ, ¡ÔÛÔÎÔÌÂ›Ô §Â˘ÎˆÛ›·˜ 17. ∑ȿη˜ ¡ÈÎfiÏ·Ô˜, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ OÊı·ÏÌÔÏÔÁ›·˜ ∞¶£, ∞’ OÊı·ÏÌÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ °¡£ «∞Ã∂¶∞» 18. £·ÓfiÔ˘ÏÔ˜ ∞fiÛÙÔÏÔ˜, ∂ÈÌÂÏËÙ‹˜ ∞’, ∞Ó·ÈÛıËÛÈÔÏÔÁÈÎfi˜ ΔÔ̤·˜ øÓ¿ÛÂÈÔ ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎfi ∫¤ÓÙÚÔ 19. ÿÌ‚ÚÈÔ˜ °ÂÒÚÁÈÔ˜, ÃÂÈÚÔ˘ÚÁfi˜, ∞Ó·Ï. ¢È¢ı˘ÓÙ‹˜, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ °¡£ «πÔÎÚ¿ÙÂÈÔ» 20. πÓȈٿÎË ∞Ï›ÎË, ∞ÓÔÛÔÏfiÁÔ˜ ∞Ó·Ï. ¢È¢ı‡ÓÙÚÈ·, ∂ıÓÈÎfi ∫¤ÓÙÚÔ πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, ¶°¡∞ «°. °ÂÓÓËÌ·Ù¿˜» 21. ∫·Ú··Ó·ÁÈÒÙÔ˘ ∞ÚÂÙ‹, ∞Ó·ÛÈÛıËÛÈÔÏfiÁÔ˜, ∂ÓÙ·ÙÈÎÔÏfiÁÔ˜,∂ÈÌÂÏ‹ÙÚÈ· ∞’ª∂£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 22. ∫·Ùۛη ∂ϤÓË, ∞Ó·ÈÛıËÛÈÔÏfiÁÔ˜, ∂ÈÌÂÏ‹ÙÚÈ· ∞’, °¡£ «πÔÎÚ¿ÙÂÈÔ» 23. ∫ÔÛΛӷ˜ πˆ¿ÓÓ˘, ∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜-∏·ÙÔÏÔÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, μ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ °¡∞ πÔÎÚ¿ÙÂÈÔ 24. ∫Ô˘ÎÔ˘Ï¿ÎË ª·Ú›·, ∂ȉÈ΢Ô̤ÓË ¡ÂÊÚÔÏfiÁÔ˜, °¡∞ «O ∂˘·ÁÁÂÏÈÛÌfi˜»
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14 25. ∫‡ÚÎÔ˘ μ·Ú‚¿Ú·, ¡ÔÛËχÙÚÈ· ¶∂, À¢ı. ° ΔÌ‹Ì·ÙÔ˜ ∂Oª 26. §ÂÔÓÙÛ›ÓË ª·Ú›·, ∫·ıËÁ‹ÙÚÈ· ∞¶£, ¢È¢ı‡ÓÙÚÈ· ¶·ıÔÏÔÁ·Ó·ÙÔÌÈÎÔ‡ ∂ÚÁ·ÛÙËÚ›Ô˘ 27. ª·Ú·ıÈ¿ ∞ÈηÙÂÚ›ÓË, ¶Ó¢ÌÔÓÔÏfiÁÔ˜, ∂ÓÙ·ÙÈÎÔÏfiÁÔ˜, ÀԉȢı‡ÓÙÚÈ· ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜, øÓ¿ÛÂÈÔ ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎfi ∫¤ÓÙÚÔ 28. ªÂÙ·ÏÏ›‰Ë˜ ™›ÌÔ˜, ¶·ıÔÏfiÁÔ˜, §ÔÈ̈ÍÈÔÏfiÁÔ˜, ∂ÈÌÂÏËÙ‹˜ μ’, ∞’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ °¡£ «∞Ã∂¶∞» 29. ªÂϯڋ ∞ÓÓ·-ª·Ú›· , ¡ÂÊÚÔÏfiÁÔ˜, ∞Ó. ¢È¢ı‡ÓÙÚÈ· ¡ÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ °¡£ «πÔÎÚ¿ÙÂÈÔ» 30. ªÈÙ˙¿ÓË ªËÏ›ÙÛ·, ¶Ó¢ÌÔÓÔÏfiÁÔ˜, ∂ÓÙ·ÙÈÎÔÏfiÁÔ˜, ∞Ó·Ï. ¢È¢ı‡ÓÙÚÈ· ∞’ ª∂£ °¡£ «°. ¶··ÓÈÎÔÏ¿Ô˘» 31. ª˘ÛÂÚÏ‹˜ °ÚËÁfiÚÈÔ˜, ¡ÂÊÚÔÏfiÁÔ˜, ∞Ó·Ï. ¢/ÓÙ‹˜, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ 32. ¡ÈÎÔÏ¿Ô˘ ∂˘‰ÔÍ›·, ¡ÔÛËχÙÚÈ· Δ∂, ∫ÂÓÙÚÈ΋ ™˘ÓÙÔÓ›ÛÙÚÈ· ∂Oª 33. ¡Ù·ÓÙ·Ó¿ ª›Ó·, ¶ÚÔ˚Ûٷ̤ÓË ªÔÓ¿‰·˜ ∂ÓÙ·ÙÈ΋˜ ¶·Ú·ÎÔÏÔ‡ıËÛ˘ °¡£ «¶··ÁˆÚÁ›Ô˘» 34. ¡Ùfi‚·˜ ™˘Ú›‰ˆÓ, ¡ÂÊÚÔÏfiÁÔ˜, ¶°¡ §¿ÚÈÛ·˜ 35. ¡ÙÔ˘Ú¿Î˘ ™‡ÚÔ˜, ∞Ó·Ï. ∫·ıËÁËÙ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 36. OÈÎÔÓÔÌ›‰Ô˘ ¢ÔÌÈÓ›ÎË, ¡ÂÊÚÔÏfiÁÔ˜, ∂ÈÌÂÏ‹ÙÚÈ· ∞’ ¡ÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ» 37. ¶·Ó·ÁÔÔ‡ÏÔ˘ ∂‡¯·ÚȘ, æ˘¯ÔÏfiÁÔ˜ ÀÁ›·˜, §¤ÎÙÔÚ·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ∞¶£ 38. ¶··ÁÈ¿ÓÓË ∞ÈηÙÂÚ›ÓË, ∂ÈÎ. ∫·ıËÁ‹ÙÚÈ· ¡ÂÊÚÔÏÔÁ›·˜ ∞¶£, ¡ÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈÎË °¡£ «πÔÎÚ¿ÙÂÈÔ» 39. ¶··ı·Ó·Û›Ô˘ ªÈÏÙÈ¿‰Ë˜, ∂ÈÌÂÏËÙ‹˜ , OÊı·ÏÌ›·ÙÚÔ˜ 40. ¶··ıÂÔ‰ˆÚ›‰Ë˜ °ÂÒÚÁÈÔ˜, ∂ÈÎ. ∫·ıËÁËÙ‹˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, μ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ °¡∞ πÔÎÚ¿ÙÂÈÔ 41. ¶··ÛËÌ·ÎÔÔ‡ÏÔ˘ ∞ÓÙÈfiË, ¡ÔÛËχÙÚÈ· ªª¡ °¡∞ «§·˚Îfi» 42. ¶··ÓÈÎÔÏ¿Ô˘ μ·Û›ÏÂÈÔ˜, ∂ÈÎ. ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ Î·È ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ °¡£ «πÔÎÚ¿ÙÂÈÔ» 43. ¶··¯Ú‹ÛÙÔ˘ ºÒÙ˘, ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∞¶£ 44. ¶·Û·‰¿Î˘ ¶ÏÔ˘Ì‹˜, ∞Ó·Ï. ∫·ıËÁËÙ‹˜ ¡ÂÊÚÔÏÔÁ›·˜, π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¢ËÌÔÎÚ›ÙÂÈÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ £Ú¿Î˘ 45. ¶·ÙÛÈ·Ô‡Ú· ∫·ÏÏÈfiË ¶·ıÔÏÔÁÔ·Ó·ÙfiÌÔ˜, ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ, °¡£ πÔÎÚ¿ÙÂÈÔ 46. ¶ÂÚÈÛÙ¤ÚË πÔ˘Ï›·, ∞Ó. ¢È¢ı‡ÓÙÚÈ·, ·ÈÌ·ÙÔÏfiÁÔ˜, ªªªO ¡ÔÛ ¶·›‰ˆÓ ∞Á. ™ÔÊ›·, ∞ı‹Ó· 47. ¶Ï·Ù·ÓÈ¿ ∞ÏÂÍ¿Ó‰Ú·, ™˘ÓÙÔÓ›ÛÙÚÈ· ªÂÙ·ÌÔۯ‡ÛÂˆÓ øÓ¿ÛÂÈÔ ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎfi ∫¤ÓÙÚÔ ∞ıËÓÒÓ 48. ™·ÎÂÏÏ¿ÚË πˆ¿ÓÓ·, ∂ÈÌÂÏ‹ÙÚÈ·, ∞ÈÌ·ÙÔÏfiÁÔ˜, ∞ÈÌ·ÙÔÏÔÁÈ΋ ∫ÏÈÓÈ΋-ªªªO °¡£ «°. ¶··ÓÈÎÔÏ¿Ô˘» 49. ™·Ú·Ù˙‹ •·Óı‹, ¡ÔÛËχÙÚÈ· Δ∂, ªª¡ °¡∞ «§·˚Îfi» 50. ™Ì›·˜ ÃÚ‹ÛÙÔ˜, ∂ÈÌÂÏËÙ‹˜, ∞ÈÌ·ÙÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ªªªO, °¡£ «°. ¶··ÓÈÎÔÏ¿Ô˘» 51. ™ÔÊÈ·ÓÔ‡ ¢·Ó¿Ë, ¢È¢ı‡ÓÙÚÈ· ªÈÎÚÔ‚ÈÔÏÔÁÈÎÔ‡ ∂ÚÁ·ÛÙËÚ›Ô˘, °¡£ πÔÎÚ¿ÙÂÈÔ 52. ™‡ÚÔÁÏÔ˘ ∫ÏÂÔ̤Ó˘, ∞Ó·Ï. ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∞¶£ 53. ΔÂÚ˙›‰Ô˘ ÃÚ‡Û·, OÊı·ÏÌ›·ÙÚÔ˜, ∂ÈÌÂÏ‹ÙÚÈ· ∞’, °.¡. ¶·ÙËÛ›ˆÓ 54. ΔÛÔ˘Ú¤Ï˘ §Ô˘Î¿˜, ∂ÈÌÂÏËÙ‹˜ ∞,’ ∞’ ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ΔÌ‹Ì·ÙÔ˜ Î·È ªÔÓ¿‰Ô˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ øÓ·Û›Ԣ ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ∫¤ÓÙÚÔ˘ 55. ΔÛfi¯·Ù˙˘ ª·ÓÒÏ˘, π·ÙÚfi˜, μ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ °¡∞ πÔÎÚ¿ÙÂÈÔ 56. ºÔ‡˙·˜ πˆ¿ÓÓ˘, §¤ÎÙÔÚ·˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ Î·È ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛˆÓ, °¡£ «πÔÎÚ¿ÙÂÈÔ» 57. ºÔ˘ÚÙÔ‡Ó·˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, ∂ÈÎ. ∫·ıËÁËÙ‹˜ ¡ÂÊÚÔÏÔÁ›·˜, ¶°¡¶ 58. ÷Ù˙ËÍËÚfi˜ ∂˘ÛÙÚ¿ÙÈÔ˜, ¡ÔÛËÏÂ˘Ù‹˜ Δ∂, ∫ÂÓÙÚÈÎfi˜ ™˘ÓÙÔÓÈÛÙ‹˜ ∂Oª 59. ÃÔÏfiÁÎÈÙ·˜ ∂˘¿ÁÁÂÏÔ˜, ¶·ıÔÏfiÁÔ˜, μ’ ¶·ÓÂÈÛÙËÌȷ΋ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡∞ πÔÎÚ¿ÙÂÈÔ 60. Ã˘Ù›ÚÔÁÏÔ˘ ¶Úfi‰ÚÔÌÔ˜, ∞Ó·Ï. ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁÈ΋˜ ∞Ó·ÙÔÌÈ΋˜ ∞¶£
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ÓÔ˘Ó ÂΛ, ̤¯ÚÈ Ó· ÂÍ¢ÚÂı› ÌfiÛ¯Â˘Ì·, fiˆ˜ ÛÙËÓ ∂ÏÏ¿‰·.
OÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÒÓ Â›Ó·È ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Ô˘ ¤¯Ô˘Ó ÚÔÛʤÚÂÈ ‚ÂÏÙ›ˆÛË ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ 750 ÂÚ›Ô˘ ·ÛıÂÓÒÓ Ì ÃÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, ·fi ÙÔ 1986 – 2007 ÛÙËÓ ∫‡ÚÔ. ∞fi ·˘Ù¤˜ ÌfiÓÔ 248 ¤¯Ô˘Ó Á›ÓÂÈ ·fi ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ – ÓÂÊÚÒÓ – ÂÁÎÂÊ·ÏÈο ÓÂÎÚÒÓ. ∞fi ÙÔ 2001 ˆ˜ Û‹ÌÂÚ· ÌfiÓÔ 63 ÌÂÙ·ÌÔۯ‡ÛÂȘ, ‰ËÏ·‰‹ ≈ 9/¤ÙÔ˜, Ì ÙÔ 2003 Ó· ¤¯Ô˘Ì ÙÔ ÌÈÎÚfiÙÂÚÔ Ì ‰‡Ô ÌÂÙ·ÌÔۯ‡ÛÂȘ. ŸÛÔÓ ·ÊÔÚ¿ ¿ÏÏ· fiÚÁ·Ó· ‰˘ÛÙ˘¯Ò˜ Ë ÂÌÂÈÚ›· Â›Ó·È ÂÏÏÈ‹˜ ̤¯ÚÈ ·Ó‡·ÚÎÙË.
O ÚfiÏÔ˜ ÙÔ˘ ™˘ÓÙÔÓÈÛÙ‹ ªÂÙ·ÌÔۯ‡ÛÂˆÓ Ÿˆ˜ ÔÚ›˙ÂÙ·È ‰ÈÂıÓÒ˜ Î·È Á›ÓÂÙ·È ÂÈÛ‹ÁËÛË Ó· ‰È·ÛÊ·ÏÈÛı› ̤ۈ ÙÔ˘ ¡ÔÌÔıÂÙÈÎÔ‡ ™ÒÌ·ÙÔ˜ ÛÙËÓ ∫‡ÚÔ: • ∂›Ó·È Ô Â·ÁÁÂÏÌ·Ù›·˜ Ô ÔÔ›Ô˜ ·Ó·˙ËÙ› Î·È ÂÓÙÔ›˙ÂÈ ÙÔ˘˜ Èı·ÓÔ‡˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ • ∞Ó·Ï·Ì‚¿ÓÂÈ ÙËÓ ÂÓË̤ڈÛË, ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙÔ ıÂÚ¿ÔÓÙ· È·ÙÚfi, ÙÔ˘ Û˘˙‡ÁÔ˘ Î·È ÙˆÓ Ù¤ÎÓˆÓ ÙÔ˘ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡, ‹ ÂÏÏ›„ÂÈ ÙÔ‡ÙˆÓ, ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÂÓ‹ÏÈÎˆÓ ·‰ÂÏÊÒÓ ÙÔ˘, ÁÈ· ÙÔ ı¿Ó·ÙÔ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· ‰ˆÚ¿˜ ÙˆÓ ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ì ÛÙfi¯Ô ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ù˘ Û˘Ó·›ÓÂÛ˘ ÙÔ˘˜ ÁÈ· ‰ˆÚ¿. • ¢È¢ÎÔχÓÂÈ ÙËÓ ‰È·‰Èηۛ· ‰È¿ÁÓˆÛ˘ ÙÔ˘ ∂ÁÎÂÊ·ÏÈÎÔ‡ £·Ó¿ÙÔ˘ • ™˘ÓÙÔÓ›˙ÂÈ fiϘ ÙȘ ‰È·‰Èηۛ˜ ·Ê·›ÚÂÛ˘ Î·È ‰È·ÎÔÌȉ‹˜ ÙˆÓ ÔÚÁ¿ÓˆÓ ÛÙ· ηٿÏÏËÏ· ΤÓÙÚ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË • ™˘ÓÂÚÁ¿˙ÂÙ·È Ì ¿ÏÏ· ∫¤ÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ Î·È Û˘ÓÙÔÓ›˙ÂÈ ÙȘ ‰È·‰Èηۛ˜ ÁÈ· ÔÏÏ·Ï‹ ·Ê·›ÚÂÛË ÔÚÁ¿ÓˆÓ • ∂Ȃ‚·ÈÒÓÂÈ fiÙÈ ÙÔ ÛÒÌ· ÙÔ˘ ÓÂÎÚÔ‡ ¯ÂÈÚ›˙ÂÙ·È Ì Û‚·ÛÌfi Î·È ÂÎÙÂÏÔ‡ÓÙ·È ÔÈ ÂÈı˘Ì›Â˜ ÙˆÓ ÔÈΛˆÓ
∞ÚÈıÌfi˜ ªÔÛ¯Â˘Ì¿ÙˆÓ ÛÙËÓ ÂÚ›Ô‰Ô 2001 - 2007 ™‡ÓÔÏÔ ¡ÂÊÚ ªÔÛ¯
¡ÂÊÚ ªÔÛ¯ (∂¡)
2001
30
5
2002
46
13
∫·Ú‰ ªÔÛ¯
∏·Ù ªÔÛ¯
∂ÁÎÂÊ ¡ÂÎÚÔ›
2
7
1
8
3
2003
41
2
2004
44
15
1
2005
53
10
2006
46
8
2007
40
10
1
2
5
™˘ÓÔÏÈο
300
63
2
5
33
1
5 4
∞fi ∂˘Úˆ·˚ο ÛÙÔȯ›· ÁÈ· ÙËÓ ÂÚ›Ô‰Ô 2001 ÔÈ ·ÚÈıÌÔ› Â›Ó·È Ôχ ÌÂÁ·Ï‡ÙÂÚÔÈ, Ì ÙËÓ πÛ·Ó›· Ó· η٤¯ÂÈ ÙËÓ ÚÒÙË ı¤ÛË Ì 32.5 ‰fiÙ˜/ ÂηÙÔÌ̇ÚÈÔ ÏËı˘ÛÌÔ‡. ΔÔÓ›˙ÂÙ·È fiÙÈ ÔÈ ·Ó¿ÁΘ ÛÙËÓ ¯ÒÚ· Ì·˜ Â›Ó·È ÙÔ ›‰ÈÔ ÌÂÁ¿Ï˜ fiÛÔ Î·È ÛÙȘ ˘fiÏÔȘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜. ™ÙËÓ ∫‡ÚÔ Á›ÓÔÓÙ·È ÌfiÓÔ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÒÓ Î·È ÎÂÚ·ÙÔÂȉÒÓ. ¢ÂÓ ˘¿Ú¯ÂÈ ˘Ô‰ÔÌ‹ ÁÈ· ÌÂÙ·ÌÔۯ‡ÛÂȘ ¿ÏÏˆÓ ÔÚÁ¿ÓˆÓ. ∞ÛıÂÓ›˜ Ô˘ ·Ó·Ì¤ÓÔ˘Ó ÁÈ· ¿ÏÏ· fiÚÁ·Ó· fiˆ˜ ηډȿ, ‹·Ú, Ó‡ÌÔÓ˜, Â›Ó·È ·Ó·ÁηṲ̂ÓÔÈ Ó· ÂÁÁÚ·ÊÔ‡Ó Û ¿ÏÏË ¯ÒÚ·, Î·È Ó· ·Ú·Ì¤-
¢ˆÚ¿ ÔÚÁ¿ÓˆÓ Î·È ÈÛÙÒÓ ¢ˆÚ¿ OÚÁ¿ÓˆÓ Î·È ÈÛÙÒÓ Â›Ó·È Ë ¯·ÚÈÛÙÈ΋ ·Ê·›ÚÂÛË Ì ÛÎÔfi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ¿ÏÏÔÓ ¿ÓıÚˆÔ Ô˘ ¤¯ÂÈ ¿ÌÂÛË ·Ó¿ÁÎË ÙÔ˘ ÔÚÁ¿ÓÔ˘ ÁÈ· Ó· ˙‹ÛÂÈ, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ÔÔÈÔÓ‰‹ÔÙ ÔÈÎÔÓÔÌÈÎfi fiÊÂÏÔ˜ Û ηӤӷ ·fi Ù· ÚfiÛˆ· Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÈÔ ¿Óˆ ‰È·‰Èηۛ·. ∏ ‰È·Ù‹ÚËÛË Ù˘ ‚ȈÛÈÌfiÙËÙ·˜ ÙˆÓ ÈÛÙÒÓ ÙÔ˘ ˘Ô„‹ÊÈÔ˘ ‰fiÙË, ·ÔÙÂÏ› ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ.
17
18
X. ¢∂™¶√Δ∏
μ‹Ì·Ù· ÛÙËÓ ¢ˆÚ¿ ÔÚÁ¿ÓˆÓ 1. 2. 3. 4. 5.
∫ÏÈÓÈ΋ ‰È¿ÁÓˆÛË ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ∂ÓË̤ڈÛË ÙÔ˘ ™˘ÓÙÔÓÈÛÙ‹ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∂ÓË̤ڈÛË Û˘ÁÁÂÓÒÓ ∞′ ‚·ıÌÔ‡ ŒÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÁÈ· ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ §‹„Ë ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ ¯. ÈÔÏÔÁÈÎÒÓ, Ù˘ÔÔ›ËÛË ·ÓÙÈÁfiÓˆÓ ‰fiÙË 6. ∂ÓÙ·ÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ¢fiÙË 7. ∞Ê·›ÚÂÛË ÔÚÁ¿ÓˆÓ 8. ª∂Δ∞ªO™Ã∂À™∏
¡ÔÌÔıÂÙÈ΋ Ú‡ıÌÈÛË - ∫‡ÚÔ˜ ªÂ ÙÔÓ ¡fiÌÔ 97/1987 Î·È ÙÔÓ ÙÚÔÔÔÈËÙÈÎfi 5 (1) 1999. ƒ˘ıÌ›˙ÂÙ·È Ë ·Ê·›ÚÂÛË Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË μÈÔÏÔÁÈÎÒÓ O˘ÛÈÒÓ ∞ÓıÚÒÈÓ˘ ¶ÚÔ¤Ï¢Û˘. ∫·ıÔÚ›˙ÂÙ·È Â›Û˘ Ë ¤ÓÓÔÈ· ∂ÁÎÂÊ·ÏÈÎfi˜ £¿Ó·ÙÔ˜. ™‹ÌÂÚ·, ‚Ú›ÛÎÂÙ·È Â›Û˘ Û ÂͤÏÈÍË ÙÚÔÔÔ›ËÛË ÙÔ˘ ÓfiÌÔ˘ Ì ÙËÓ ÔÔ›·: ηıȉڇÂÙ·È ™˘Ì‚Ô‡ÏÈÔ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ ÔÔ›Ô ı· ‰È·ÛÊ·Ï›˙ÂÈ ÙËÓ ›ÛË Î·È Ì ‚¿ÛË Ù· ηıÔÚÈṲ̂ӷ ÎÚÈÙ‹ÚÈ·, ÚfiÛ‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ Û fiÚÁ·Ó· Î·È ÙËÓ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ıÂÛÌÔ‡ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÔÚÁ¿ÓˆÓ. ∂›Û˘, ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÚfiÏÔ˜ ÙÔ˘ ™˘ÓÙÔÓÈÛÙ‹ ªÂÙ·ÌÔۯ‡ÛˆÓ.
OÚÈÛÌfi˜ ÙÔ˘ ı·Ó¿ÙÔ˘: «·Ó·ÓfiÚıˆÙË ·ÒÏÂÈ· Ù˘ ÈηÓfiÙËÙ·˜ ÁÈ· Û˘Ó›‰ËÛË, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·Ó·ÓfiÚıˆÙË ·ÒÏÂÈ· Ù˘ ÈηÓfiÙËÙ·˜ ÁÈ· ·˘ÙfiÌ·ÙË ·Ó·ÓÔ‹» Ô˘ ·ÔÙÂÏ› ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ‰È·Ù‹ÚËÛË ·˘ÙfiÌ·Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ °È· ÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ ·Ó·ÓÔ‹˜ Î·È Ù˘ ΢ÎÏÔÊÔÚ›·˜, ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ·ÔÙÂÏ› Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜. μÏ¿‚Ë ‹ Ó¤ÎÚˆÛË ÙÔ˘ ÛÙÂϤ¯Ô˘˜, Ô‰ËÁ› ÛÙËÓ Î·Ù¿ÚÁËÛË Ù˘ ·˘ÙfiÌ·Ù˘ ·Ó·ÓÔ‹˜ Î·È Î˘ÎÏÔÊÔÚ›·˜, ‚Ï¿‚Ë ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ËÌÈÛÊ·ÈÚ›ˆÓ, ·‰‡Ó·ÙË ÁÓˆÛÙÈ΋ Î·È Û˘Ó·ÈÛıËÌ·ÙÈ΋ ˙ˆ‹. ∏ ‰È¿ÁÓˆÛË ÙÔ˘ ı·Ó¿ÙÔ˘ ÙÔ˘ ·ÓıÚˆ›ÓÔ˘ ÛÒÌ·ÙÔ˜ Ù·˘Ù›˙ÂÙ·È Ì ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ı·Ó¿ÙÔ˘ ÙÔ˘ ∂°∫∂º∞§π∫OÀ ™Δ∂§∂ÃOÀ™. °È· Á›ÓÂÈ ‰È¿ÁÓˆÛË ı·Ó¿ÙÔ˘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ Ú¤ÂÈ Ó· ˘¿Ú¯Ô˘Ó ÔÚÈṲ̂Ó˜ ÚÔ¸Ôı¤ÛÂȘ Î·È Û˘Óı‹Î˜ Î·È Ó· ·ÔÎÏ›ÂÙ·È Ë Èı·Ó¿ ·Ó·ÛÙÚ¤„ÈÌË Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜. Δ¤ÏÔ˜ Á›ÓÔÓÙ·È ÔÈ ‰ÔÎÈ̷ۛ˜ ÂϤÁ¯Ô˘ Ù˘ ·ÒÏÂÈ·˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜.
μ·ÛÈΤ˜ Û˘Óı‹Î˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ • ¢È·›ÛÙˆÛË fiÙÈ Ô ¿ÚÚˆÛÙÔ˜ Â›Ó·È Û ·ÓÔ˚Îfi ÎÒÌ·. • ∫·ıÔÚÈÛÌfi˜ Ù˘ ·ÈÙ›·˜ ÙÔ˘ ÎÒÌ·ÙÔ˜ ÁÈ· ÙË ‰È·›ÛÙˆÛË ‰˘ÓËÙÈο ÌË ·Ó·ÛÙÚ¤„ÈÌˆÓ ‚Ï·‚ÒÓ. • ∞ÔÎÏÂÈÛÌfi˜ Èı·Ó¿ ·Ó·ÛÙÚ¤„ÈÌ˘ ηٷÛÙÔÏ‹˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ (ηٷÛÙ·ÏÙÈο Ê¿Ú̷η, ÌÂÙ·‚ÔÏÈο - ÂÓ‰ÔÎÚÈÓÈο ÓÔÛ‹Ì·Ù·). • §ÂÙÔÌÂÚ¤˜ ÈÛÙÔÚÈÎfi Î·È ÔÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔÓ ¿ÚÚˆÛÙÔ Ó· Â›Ó·È Û·Ê›˜ Î·È ÂÈÛÙÈΤ˜. • ∫ÏÈÓÈ΋ ÂͤٷÛË • ¶·Ú·ÎÏÈÓÈÎfi˜ ¤ÏÂÁ¯Ô˜ O ¤ÏÂÁ¯Ô˜ Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÎÏÈÓÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÔÈ Ôԛ˜ Á›ÓÔÓÙ·È Ì ÙËÓ ÙÔÌ‹ ÚÔ˜ ÙÔÌ‹ ‰ÈÂÚ‡ÓËÛ‹ ÙÔ˘. OÈ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̷ۛ˜ ¤¯Ô˘Ó ÛÎÔfi Ó· ·Ó·‰Â›ÍÔ˘Ó ÙËÓ ÔÚÈÛÙÈ΋ ηٿÚÁËÛË ÙˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ Î·È ÙËÓ ‡·ÚÍË ¿ÓÔÈ·˜. T· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÎÏÈÓÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ Â›Ó·È Û·Ê‹ Î·È Î·ÙËÁÔÚËÌ·ÙÈο ÁÈ· ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ÁÈ·Ù› ·Ó·Ê¤ÚÔÓÙ·È ÛÙËÓ ·ÚÔ˘Û›· ‹ ·Ô˘Û›· ·ÓÙȉڿÛÂˆÓ Î·È fi¯È Û ‰È·‚·ıÌ›ÛÂȘ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ·ÌÊ›‚ÔϘ ηٷÛÙ¿ÛÂȘ.
ŒÏÂÁ¯Ô˜ ı·Ó¿ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ – ∫ÏÈÓÈΤ˜ ‰ÔÎÈ̷ۛ˜ Δ· ·ÓÙ·Ó·ÎÏ·ÛÙÈο ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ ı· Ú¤ÂÈ Ó· Â›Ó·È Î·Ù·ÚÁË̤ӷ. 1. ΔÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi Ù˘ ÎfiÚ˘ ÛÙÔ Êˆ˜ (¤ÏÂÁ¯Ô˜ ππ Î·È πππ ÂÁÎÂÊ·ÏÈ΋˜ Û˘˙˘Á›·˜) 2. ΔÔ ÔÊı·ÏÌÔ - ÎÂÊ·ÏÈÎfi ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi (¤ÏÂÁ¯Ô˜ Ù˘ III, IV Î·È VI ÂÁÎÂÊ·ÏÈ΋˜ Û˘˙˘Á›·˜) 3. ΔÔ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ (¤ÏÂÁ¯Ô˜ πππ ÂÁÎÂÊ·ÏÈ΋˜ Û˘˙˘Á›·˜) 4. ΔÔ ·ÈıÔ˘ÛÔ-ÔÊı·ÏÌÈÎfi ·ÓÙ·Ó·ÎÏ·ÛÙÈÎfi (¤ÏÂÁ¯Ô˜ Ù˘ πππ, VI Î·È VIII ÂÁÎÂÊ·ÏÈ΋˜ Û˘˙˘Á›·˜) 5. ∞ÓÙ·Ó·ÎÏ·ÛÙÈΤ˜ ÎÈÓ‹ÛÂȘ ÙˆÓ Ì˘ÒÓ ÙÔ˘ ÚÔÛÒÔ˘ ÛÙÔÓ ÈÛ¯˘Úfi ÂÚÂıÈÛÌfi ÔÔÈÔ˘‰‹ÔÙ ÛËÌ›Ԣ ÙÔ˘ ÛÒÌ·ÙÔ˜ (¤ÏÂÁ¯Ô˜ Ù˘ V Î·È VII ÂÁÎÂÊ·ÏÈ΋˜ Û˘˙˘Á›·˜) 6. º·Ú˘ÁÁÔ-Ï·Ú˘ÁÁÈο ·ÓÙ·Ó·ÎÏ·ÛÙÈο (¤ÏÂÁ¯Ô˜ Ù˘ IX Î·È X ÂÁÎÂÊ·ÏÈ΋˜ Û˘˙˘Á›·˜)
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
7. ¢ÔÎÈÌ·Û›· Ù˘ ¿ÓÔÈ·˜ • ∂›Ó·È ÙÔ ÙÂÏÈÎfi ‚‹Ì· ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘. ∫·Ù¿ ÙË ‰ÔÎÈÌ·Û›· Ù˘ ¿ÓÔÈ·˜ Ú¤ÂÈ: • ¡· ‰ÈÔÚıˆı› Èı·Ó‹ ˘Ôηӛ·. • ¡· ·ÔÊ¢¯ı› Ë ˘ÔÍ·ÈÌ›· ηٿ ÙÔ ‰È¿ÛÙËÌ· Ù˘ ·ÔÛ‡Ó‰ÂÛ˘ ·fi ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú·. • ¡· ¤¯ÂÈ ÂÚ¿ÛÂÈ ·ÚÎÂÙfi˜ ¯ÚfiÓÔ˜ ·fi ÙË ‰È·›ÛÙˆÛË Î·È ‰ÈfiÚıˆÛË ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ p∏.
∂ÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ∂›Ó·È Û˘ÌÏËڈ̷ÙÈΤ˜ ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ‰È¿ÁÓˆÛ˘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘. ∏ ¯ÚËÛÈÌfiÙËÙ· ÙˆÓ ·ÔÙÂÏ› ·ÎfiÌË ÙÔ Î˘ÚÈfiÙÂÚÔ ı¤Ì· ‰È·ÊˆÓ›·˜ ÌÂٷ͇ ÙˆÓ ÂÈÛÙËÌfiÓˆÓ. OÈ Ì¤ıÔ‰ÔÈ Ô˘ ¤¯Ô˘Ó ÚÔÙ·ı› ·ÊÔÚÔ‡Ó: • ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ • ÙÔÓ ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ∞fi ÙȘ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ›ӷÈ: • ∏ ·ÁÁÂÈÔÁÚ·Ê›·, Ì ÙËÓ ÔÔ›· ··ÈÙÂ›Ù·È Ô Î·ıÂÙËÚÈ·ÛÌfi˜ ÙˆÓ Î·ÚˆÙ›‰ˆÓ Î·È ÙˆÓ ÛÔÓ‰˘ÏÈÎÒÓ ·ÚÙËÚÈÒÓ. • ƒ·‰ÈÔ˚ÛÔÙÔÈΤ˜ Ù¯ÓÈΤ˜ (‰ÂÓ ·ÂÈÎÔÓ›˙Ô˘Ó ÚÔ‹ ÛÙÔÓ Ô›ÛıÈÔ ÂÁΤʷÏÔ) ªÔÚ› Ó· Á›ÓÔ˘Ó Û˘ÌÏËڈ̷ÙÈο ÁÈ· Ó· ÂÎÙÈÌËı› Ë ·ÈÌ·ÙÈ΋ ÚÔ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ¯ ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ Ô ·ÛıÂÓ‹˜ Ï¿Ì‚·Ó ‚·Ú‚ÈÙÔ˘ÚÈο • ∏ÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ̤ıÔ‰ÔÈ: ∏ÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ·: ·ÂÈÎÔÓ›˙ÂÙ·È Ë ËÏÂÎÙÚÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ÊÏÔÈÔ‡ Î·È fi¯È ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ …‰ÂÓ ÌÔÚ› Ó· Á›ÓÂÈ ‰È¿ÎÚÈÛË ÌÂٷ͇ ÏÂÈÙÔ˘ÚÁÈ΋˜ ηٷÛÙÔÏ‹˜ Î·È ÔÚÁ·ÓÈ΋˜ ‚Ï¿‚˘. ¶ÚÔÎÏËÙ¿ ‰˘Ó·ÌÈο ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜
™˘ÌÂÚ¿ÛÌ·Ù· ∏ ‰È¿ÁÓˆÛË ÙÔ˘ ∂ÁÎÂÊ·ÏÈÎÔ‡ £·Ó¿ÙÔ˘ ÛÙËÚ›˙ÂÙ·È ÛÙȘ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̷ۛ˜ Ô˘ ·ÔÙÂÏÔ‡Ó ·ÍÈfiÈÛÙÔ Î·È Â·ÚΤ˜ ÎÚÈÙ‹ÚÈÔ Û ·ÁÎfiÛÌÈÔ Â›Â‰Ô. ∏ ·ÍÈÔÈÛÙ›· ÙˆÓ ÎÏÈÓÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ Î·ÙÔ¯˘ÚÒÓÂÙ·È ÌÂ: ·˘ÛÙËÚ‹ Ù‹ÚËÛË ÙˆÓ ·Ó·Áη›ˆÓ ÚÔ¸Ôı¤ÛÂˆÓ ÙËÓ ÂÎÙ¤ÏÂÛË ‰ÔÎÈÌ·ÛÈÒÓ
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ÙË Û˘ÌÌÂÙÔ¯‹ ‰‡Ô ÂȉÈÎÒÓ È·ÙÚÒÓ ÛÙË ‰È·‰Èηۛ· ÙËÓ Â·Ó¿ÏË„Ë ÙˆÓ ‰ÔÎÈÌ·ÛÈÒÓ OÈ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ÌÔÚÔ‡Ó Ó· Á›ÓÔ˘Ó ˘ÔÛÙËÚÈÎÙÈο.
¢È·‰Èηۛ· ‰È¿ÁÓˆÛ˘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ • °È·ÙÚÔ› Ô˘ ÌÔÚÔ‡Ó Ó· οÓÔ˘Ó ‰È¿ÁÓˆÛË: Ô ˘Â‡ı˘ÓÔ˜ ÁÈ· ÙÔÓ ¿ÚÚˆÛÙÔ ÁÈ·ÙÚfi˜ Ó¢ÚÔ¯ÂÈÚÔ˘ÚÁfi˜ Ó¢ÚÔÏfiÁÔ˜ ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ ÂÓÙ·ÙÈÎÔÏfiÁÔ˜, ¯ÂÈÚÔ˘ÚÁfi˜ ÎÏ • ¶ÔÈÔ˜ Ô ¯ÚfiÓÔ˜ ·ӿÏ˄˘ ‰ÔÎÈÌ·ÛÈÒÓ; ΔÔ˘Ï¿¯ÈÛÙÔÓ 24 ÒÚ˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ÎÒÌ·ÙÔ˜ Î·È 8 ÒÚ˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÂٷ͇ ÙˆÓ ‰ÔÎÈÌ·ÛÈÒÓ
Δ˘È΋ ‰È·‰Èηۛ· ‰È¿ÁÓˆÛ˘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ¶ÚÒÙÈÛÙÔ Ì¤ÏËÌ· Â›Ó·È Ó· Á›ÓÔ˘Ó ÔÈ ··Ú·›ÙËÙÔÈ ¯ÂÈÚÈÛÌÔ› ÁÈ· ÙËÓ ‰È¿ÛˆÛË ÙÔ˘ ·ÙfiÌÔ˘. ∂ÊfiÛÔÓ ÙÂı› Ë ‰È¿ÁÓˆÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ÙÔ ¿ÙÔÌÔ ıˆÚÂ›Ù·È ÓÂÎÚfi Î·È Ë ·Ú·¤Ú· ıÂڷ¢ÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ıˆÚÂ›Ù·È ¿ÛÎÔË ∂∫ΔO™ Â¿Ó ÚfiÎÂÈÙ·È Ó· Á›ÓÂÈ ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŸÚÁ·Ó· Ô˘ ÌÔÚÔ‡Ó Ó· ÌÂÙ·ÌÔÛ¯Â˘ıÔ‡Ó Â›Ó·È Ë Î·Ú‰È¿, ÔÈ Ó‡ÌÔÓ˜, ÙÔ ‹·Ú, ÙÔ ¿ÁÎÚ·˜, ÔÈ ÓÂÊÚÔ›, Î·È ÙÔ ¤ÓÙÂÚÔ. ∂›Û˘ ÔÈ ÎÂÚ·ÙÔÂȉ›˜, Ù¤ÓÔÓÙ˜, ÔÛÙ¿, ‰¤ÚÌ·, ‚·Ï‚›‰Â˜ Î·È ·ÁÁ›·.
™˘ÌÂÚ·ÛÌ·ÙÈο … • O ·ÚÈıÌfi˜ ÙˆÓ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÒÓ Â›Ó·È ·ÚÎÂÙ¿ ÌÂÁ¿ÏÔ˜, fiˆ˜ Î·È ÛÙȘ ˘fiÏÔȘ Â˘Úˆ·˚Τ˜ ¯ÒÚ˜. • ªÂ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ıÂÛÌÔ‡ ÙÔ˘ ™˘ÓÙÔÓÈÛÙ‹ ªÂÙ·ÌÔۯ‡ÛˆÓ, Ë Â˘·ÈÛıËÙÔÔ›ËÛË ÁÈ· ÙËÓ ¢ˆÚ¿ ÔÚÁ¿ÓˆÓ ı· ·˘ÍËı› Ì ·ÎfiÏÔ˘ıÔ ÂÚÈÛÛfiÙÂÚ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ·ÛıÂÓ›˜. • O ·ÚÈıÌfi˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ı· ‹Ù·Ó Ôχ ÌÂÁ·Ï‡ÙÂÚÔ˜ • ªÔÚԇ̠ӷ ‚ÔËı‹ÛÔ˘Ì Ôχ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰È·ÊÔÚÂÙÈο ‰ÂÓ ı· ›¯·Ó ÂÏ›‰· ÁÈ· ˙ˆ‹ • ∏ ÂÓË̤ڈÛË Î·È Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÎfiÛÌÔ˘ ÁÈ· ÙËÓ ¢ˆÚ¿ OÚÁ¿ÓˆÓ Â›Ó·È ·fi Ù· ÂfiÌÂÓ· ‚‹Ì·Ù· Ô˘ ı· Ú¤ÂÈ fiÏÔÈ fiÛÔÈ ¤¯Ô˘Ó Û¯¤ÛË,
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X. ¢∂™¶√Δ∏
Ó· ÚÔÛ·Ó·ÙÔÏÈÛÙÔ‡Ó. • £· Ú¤ÂÈ Ó· ‰›ÓÂÙ·È Ë Â˘Î·ÈÚ›·, ÛÙÔ˘˜ Û˘ÁÁÂÓ›˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Â›Ó·È ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ›, Ó· ·ÔÊ·Û›ÛÔ˘Ó Ó· ÚÔÛʤÚÔ˘Ó ˙ˆ‹ ̤۷ ·fi ÙÔÓ ı¿Ó·ÙÔ ÙÔ˘ ÔÏ˘·Á·Ë̤ÓÔ˘ ÙÔ˘˜ ·Ó Ô ›‰ÈÔ˜ ‰ÂÓ Â›¯Â ¿ÚÂÈ Ù¤ÙÔÈ· ·fiÊ·ÛË. ∞fi ÙË 1Ë πÔ˘Ó›Ô˘ Ô˘ ¤¯ÂÈ ÂÊ·ÚÌÔÛÙ› Ô ÚfiÏÔ˜ ÙÔ˘ ™˘ÓÙÔÓÈÛÙ‹ ªÂÙ·ÌÔۯ‡ÛÂˆÓ Â›¯·Ì 2 ÂÚÈÙÒÛÂȘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Ô˘ η٤ÏËÍ·Ó Û ¢ˆÚ¿ OÚÁ¿ÓˆÓ ÌÂÙ¿ ÙËÓ Û˘ÁηٿıÂÛË ÙˆÓ ÔÈΛˆÓ ÙÔ˘˜. ∞fi ÙÔ˘˜ ‰‡Ô ÓÂÎÚÔ‡˜ ›¯·Ì ·Ê·›ÚÂÛË ‰¤Î· ÔÚÁ¿ÓˆÓ Û˘ÓÔÏÈο Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ Ù¤ÛÛÂÚÂȘ ÓÂÊÚÔ‡˜, ‰‡Ô ‹·Ú ÌÈ· ηډȿ Î·È ÙÚÂȘ ÎÂÚ·ÙÔÂȉ›˜. ŒÓ· ÌÂÁ¿ÏÔ Â˘¯·ÚÈÛÙÒ Î·È ·ÈÒÓÈ· ¢ÁÓˆÌÔÛ‡ÓË ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¢ÂÚÁÂÙ‹ıËηÓ, ÛÙÔ˘˜ Û˘ÁÁÂÓ›˜ Ô˘ ›¯·Ó ÙËÓ ‰‡Ó·ÌË Ó· ¯·Ú›ÛÔ˘Ó Ù· fiÚÁ·Ó· ÙˆÓ ÓÂÎÚÒÓ ÙÔ˘˜, ÛÙÔ˘˜ Û˘Ó·ÓıÚÒÔ˘˜ ÙÔ˘˜. ……..ŸÙ·Ó ·fi ÙËÓ ˙ˆ‹ Ô˘ ¯¿ÓÂÙ·È ….·Ó·‰‡ÂÙ·È ˙ˆ‹ Î·È ÂÏ›‰·
μÈ‚ÏÈÔÁÚ·Ê›· 1. TPM (2001) Transplant Coordination Manual. Les Heures, Fundacio Bosch I Gimbera Universat de Barcelona. 2. ∫ˆÛÙ¿Î˘ ∞. (2005) ªÂÙ·ÌÔۯ‡ÛÂȘ πÛÙÒÓ Î·È OÚÁ¿ÓˆÓ. ∂ÁÎÂÊ·ÏÈÎfi˜ £¿Ó·ÙÔ˜ http://www. transplantation.gr 3. Ozdag N. (2004). Public awareness and acceptance of tissue and organ donation. EDTNA ERCA J. Oct-Dec; 30(4):188-95. 4. Verble M, Worth J. (1998). Adequate consent: its content in the donation discussion. J Transpl Coord. Jun; 8(2):99-104.
O ÚfiÏÔ˜ ÙÔ˘ EıÓÈÎÔ‡ OÚÁ·ÓÈÛÌÔ‡ MÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ
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B·Ú‚¿Ú· K‡ÚÎÔ˘
μ) ∏ ‰È·‰Èηۛ· ·Ó·˙‹ÙËÛ˘ ÌË Û˘ÁÁÂÓ‹ (ÂıÂÏÔÓÙ‹) ‰fiÙË ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÁÈ· ŒÏÏËÓ˜ ·ÛıÂÓ›˜ Ì ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù· ̤ۈ Ù˘ ‰ÈÂıÓÔ‡˜ ‰ÂÍ·ÌÂÓ‹˜ (μªDW) °) ∏ ÂÓË̤ڈÛË Î·È Ë ÚÔÒıËÛË Ù˘ ȉ¤·˜ Ù˘ ‰ˆÚ¿˜ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ.
O ∂ıÓÈÎfi˜ OÚÁ·ÓÈÛÌfi˜ ªÂÙ·ÌÔۯ‡ÛˆÓ, ‚¿ÛÂÈ ÙÔ˘ ÓfiÌÔ˘ 2737/99 ·ÔÙÂÏÂ›Ù·È ·fi: ÙÔ ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Î·È ÙÚ›· ÙÌ‹Ì·Ù·, ÙÔ ÙÌ‹Ì· Û˘ÓÙÔÓÈÛÌÔ‡ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ, ¤Ó· ÔÈÎÔÓÔÌÈÎfi‰ÈÔÈÎËÙÈÎfi ÙÌ‹Ì· Î·È ÙÔ ÙÌ‹Ì· °′ ÈÛÙÒÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Î·È ÙÚ·Â˙ÒÓ ÈÛÙÒÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÙÔ ÔÔ›Ô Ô˘ÛÈ·ÛÙÈο Â›Ó·È ·˘Ùfi Ô˘ ·Û¯ÔÏÂ›Ù·È Ì ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ‹ fiˆ˜ ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·Ó·Ê¤ÚÔÓÙ·È Û ·˘Ù¤˜ – ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. OÈ ∞ÏÏÔÁÂÓ›˜ ªÂÙ·ÌÔۯ‡ÛÂȘ ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Â›Ó·È Û˘¯Ó¿ Ë ÌfiÓË ıÂڷ¢ÙÈ΋ ¤Ó‰ÂÈÍË ÁÈ· ·ÛıÂÓ›˜ Ì ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù·, Û‡Ó‰ÚÔÌ· ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ Î·È ÌÂÙ·‚ÔÏÈÎÒÓ ÓfiÛˆÓ. ¢˘ÛÙ˘¯Ò˜, ÌfiÓÔ ¤Ó· ÔÛÔÛÙfi 25 Ì 30 ÙÔȘ ÂηÙfi ÙˆÓ ·ÛıÂÓÒÓ ‚Ú›ÛÎÔ˘Ó Û˘Ì‚·Ùfi ‰fiÙË Ì¤Û· ÛÙÔ Û˘ÁÁÂÓÈÎfi ÙÔ˘˜ ÂÚÈ‚¿ÏÏÔÓ. OÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·˘Ù¤˜ ‰È·Ê¤ÚÔ˘Ó ÛÙÔÓ ÙÚfiÔ Û˘ÓÙÔÓÈÛÌÔ‡ Û ۯ¤ÛË Ì ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ, ÌÈ· Ô˘ ÛÙȘ ÙÂÏÂ˘Ù·›Â˜ fiÙ·Ó ˘¿Ú¯ÂÈ ‰fiÙ˘ „¿¯ÓÔ˘Ì ӷ ‚Úԇ̠ÙÔ˘˜ Û˘Ì‚·ÙÔ‡˜ Ï‹Ù˜ ÔÈ ÔÔ›ÔÈ ˘¿Ú¯Ô˘Ó Û ÌÈ· Ï›ÛÙ· ·Ó·ÌÔÓ‹˜, ÂÓÒ Â‰Ò ¤¯Ô˘Ì ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ Ï‹Ù˜ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ·Ó·˙ËÙ¿Ì ·Ú¿ÏÏËÏ· ÙÔÓ Î·Ï‡ÙÂÚÔ Û˘Ì‚·Ùfi ‰fiÙË Ì¤Û· ·fi ÌÈ· ‰ÂÍ·ÌÂÓ‹ ηٷÁÂÁÚ·ÌÌ¤ÓˆÓ Ì ‚¿ÛË Ù· ·ÓÙÈÁfiÓ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ‰ÔÙÒÓ, Î·È ÔÈ ‰fiÙ˜ Â›Ó·È ÂÓ ˙ˆ‹ (‰ÂÓ ˘Ê›ÛÙ·Ù·È ‰ËÏ·‰‹ Ë ¤ÓÓÔÈ· Ù˘ Ï›ÛÙ·˜ ·Ó·ÌÔÓ‹˜). ∞fi ÙȘ ·Ú¯¤˜ ÙÔ˘ 2003 Ô Û˘ÓÙÔÓÈÛÌfi˜ Ù˘ ‰È·‰Èηۛ·˜ ·Ó·˙‹ÙËÛ˘ Û˘Ì‚·ÙÒÓ ‰ÔÙÒÓ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÁÈ· ŒÏÏËÓ˜ ·ÛıÂÓ›˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ Ù˘ ¯ÒÚ·˜ Á›ÓÂÙ·È ·fi ÙÔ ÙÌ‹Ì· °′ ÙÔ˘ ∂ıÓÈÎÔ‡ OÚÁ·ÓÈÛÌÔ‡ ªÂÙ·ÌÔۯ‡ÛˆÓ. OÈ ‚·ÛÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ·˘ÙÔ‡ ÔÈ Ôԛ˜ ·Ó·Ê¤ÚÔÓÙ·È ÂÈÁÚ·ÌÌ·ÙÈο ·Ú·Î¿Ùˆ ›ӷÈ: ∞) ∏ Ù‹ÚËÛË Î·È ‰È·¯Â›ÚÈÛË ÙÔ˘ ∂ıÓÈÎÔ‡ ªËÙÚÒÔ˘ ¢ÔÙÒÓ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ
ΔÔ ÙÌ‹Ì· ¤¯ÂÈ ˆ˜ ÛÙfi¯Ô Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÙÔ Î·Ù¿ÏÏËÏÔ Ï·›ÛÈÔ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÙfiÛÔ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ªÔÓ¿‰ˆÓ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ fiÛÔ Î·È ÙˆÓ ˘ËÚÂÛÈÒÓ ·Ó·˙‹ÙËÛ˘ ÂıÂÏÔÓÙÒÓ ‰ÔÙÒÓ ÁÈ· ŒÏÏËÓ˜ Î·È Í¤ÓÔ˘˜ ·ÛıÂÓ›˜. ¶·Ú¿ÏÏËÏ· ÛÙԯ‡ÂÈ ÛÙËÓ ÂÓË̤ڈÛË ÙÔ˘ ÎÔÈÓÔ‡ Î·È ÛÙËÓ Î·Ù·ÁÚ·Ê‹ Ó¤ˆÓ ÂıÂÏÔÓÙÒÓ ‰ÔÙÒÓ. O ∂Oª, Ì ‚¿ÛË ÙÔÓ ÓfiÌÔ 2737/99 ηٷÚÙ›˙ÂÈ ÙÔ ∂ıÓÈÎfi ªËÙÚÒÔ ∂ıÂÏÔÓÙÒÓ ¢ÔÙÒÓ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ, ÙÔ ÔÔ›Ô Â›Ó·È ÂÓÈ·›Ô ÁÈ· fiÏË ÙË ¯ÒÚ· Î·È ÛÙÔ ÔÔ›Ô ÙËÚÔ‡ÓÙ·È Ù· ÛÙÔȯ›· ÙˆÓ ÂıÂÏÔÓÙÒÓ ‰ÔÙÒÓ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ. O ∂.O.ª, ÌÂÙ¿ ·fi ÂÈÎÔÈÓˆÓ›· Ì ٷ ÂÚÁ·ÛÙ‹ÚÈ· πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Î·È ∞ÓÔÛÔÏÔÁ›·˜ Û˘ÁΤÓÙÚˆÛ ٷ ·Ú¯Â›· ÙˆÓ ‰ˆÚËÙÒÓ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Î·È ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·Ú¯Â›ˆÓ ·˘ÙÒÓ ·ÔÙ¤ÏÂÛ ÙËÓ ‚¿ÛË Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ ÙÔ˘ ªËÙÚÒÔ˘. ™‹ÌÂÚ· ÙÔ «∂ıÓÈÎfi ªËÙÚÒÔ ∂ıÂÏÔÓÙÒÓ ¢ÔÙÒÓ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ» Ù˘ ¯ÒÚ·˜ Ì·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ¤Ó· Û‡ÓÔÏÔ 24.000 ÂıÂÏÔÓÙÒÓ ‰ÔÙÒÓ. Δ· ÂÚÁ·ÛÙ‹ÚÈ· ÛÙ· ÔÔ›· ηٷÁÚ¿ÊÔÓÙ·È ÔÈ ‰fiÙ˜ Ô˘ ··ÚÙ›˙Ô˘Ó ÙÔ ÂıÓÈÎfi ÌËÙÚÒÔ ‰ÔÙÒÓ ‚Ú›ÛÎÔÓÙ·È ÛÙ· ·Ú·Î¿Ùˆ ¡ÔÛÔÎÔÌ›· Ù˘ ¯ÒÚ·˜:
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B. KYPKOY
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™Ù· ÂÚÁ·ÛÙ‹ÚÈ· ·˘Ù¿ ÌÔÚ› Ó· ÂÁÁÚ·Ê› οÔÈÔ˜ ËÏÈΛ·˜ 18-50 ÂÙÒÓ ˆ˜ ÂıÂÏÔÓÙ‹˜ ‰fiÙ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ·ÚΛ Ó· ‰ÒÛÂÈ ÌÈ· ÌÈÎÚ‹ ÔÛfiÙËÙ· ·›Ì·ÙÔ˜ Î·È Ó· ˘ÔÁÚ¿„ÂÈ ÙË ‰‹ÏˆÛË ‰ˆÚ¿˜ Î·È ÂÊfiÛÔÓ ‰ÂÓ ¿Û¯ÂÈ ·fi ¯ÚfiÓȘ ·ı‹ÛÂȘ, ÌÂÙ·‰ÔÙÈΤ˜ ·Ûı¤ÓÂȘ Î·È ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·. ¶ÚÔ˜ fiÊÂÏÔ˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¯Ú‹˙Ô˘Ó ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÏÏ¿ ‰ÂÓ ˘¿Ú¯ÂÈ HLA Û˘Ì‚·Ùfi˜ Û˘ÁÁÂÓ‹˜ ‰fiÙ˘, Â›Ó·È ‰˘Ó·Ùfi Ó· ·Ó·˙ËÙËı› ÌË Û˘ÁÁÂÓ‹˜ ‰fiÙ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Ì¤Ûˆ Ù˘ ¢ÈÂıÓÔ‡˜ ¢ÂÍ·ÌÂÓ‹˜ ‰ÔÙÒÓ μªWD, Ë ÔÔ›· Û˘ÁÎÂÓÙÚÒÓÂÈ ÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰ÔÙÒÓ ÙˆÓ ÂÈ̤ÚÔ˘˜ ‰ÂÍ·ÌÂÓÒÓ ‰È·ÊfiÚˆÓ ¯ˆÚÒÓ. H ‰ÈÂıÓ‹˜ ‰ÂÍ·ÌÂÓ‹ BMDW Ô˘ÛÈ·ÛÙÈο ˘‹ÚÍÂ Ë ÎÔÈÓ‹ ÚÔÛ¿ıÂÈ· ‰È¿ÊÔÚˆÓ ¯ˆÚÒÓ Ó· ·˘ÍËıÔ‡Ó ÔÈ Èı·ÓfiÙËÙ˜ ·Ó‡ÚÂÛ˘ Û˘Ì‚·ÙÔ‡ ‰fiÙË ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜, Ì ÙÔ Ó· ¤¯Ô˘Ó ÚfiÛ‚·ÛË fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ fiÏˆÓ ÙˆÓ ¯ˆÚÒÓ ÛÙÔ˘˜ ÂıÂÏÔÓÙ¤˜ ‰fiÙ˜ fiÏˆÓ ÙˆÓ ¯ˆÚÒÓ. ªÈ· ·fi ÙȘ ÚÒÙ˜ ‰ÂÍ·ÌÂÓ¤˜ ‰ÔÙÒÓ Ô˘ ‰ËÌÈÔ˘ÚÁ‹ıËÎ·Ó ˘‹ÚÍÂ Ë ‰ÂÍ·ÌÂÓ‹ Ant. Nolan ÛÙËÓ ∞ÁÁÏ›·, Ë ÔÔ›· ‰ËÌÈÔ˘ÚÁ‹ıËΠ·fi ÙË ÌËÙ¤Ú· ÙÔ˘ ÌÈÎÚÔ‡ Antony, Shirley Nolan, Ë ÔÔ›· ÛΤÊÙËΠ„¿¯ÓÔÓÙ·˜ ‰fiÙË ÁÈ· ÙÔÓ ÌÈÎÚfi fiÙÈ Ë Ï‡ÛË ÛÙËÓ ·Ûı¤ÓÂÈ· ÙÔ˘ ÌÈÎÚÔ‡ ı· ÌÔÚÔ‡Û ӷ ‚Ú›ÛÎÂÙ·È ÛÙËÓ ‰ÈÏ·Ó‹ fiÚÙ· ·ÏÏ¿ ̤¯ÚÈ ÙfiÙ ‰ÂÓ ˘‹Ú¯Â ÙÚfiÔ˜ Ó· Á›ÓÂÈ ·˘Ùfi. ∏ ‰È·‰Èηۛ· ·Ó·˙‹ÙËÛ˘ Â›Ó·È ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÂÓÂÚÁÂÈÒÓ Ô˘ ·ÊÔÚÔ‡Ó Èı·ÓÔ‡˜ ‰fiÙ˜, ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙȷΤ˜ ÌÔÓ¿‰Â˜ Î·È ·ÛıÂÓ›˜ ÛÙËÓ ÚÔÛ¿ıÂÈ· Ó· ‚ÚÂı› Ë Î·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ËÁ‹ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∫·Ù¿ ÙËÓ ‰ÈÂÍ·ÁˆÁ‹ Ù˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û˘ÁÎÂÎÚÈ̤ӷ ‚‹Ì·Ù· Î·È Î·ÓfiÓ˜ Ì ‚¿ÛË ÙÔ˘˜ ‰ÈÂıÓ›˜ ηÓÔÓÈÛÌÔ‡˜. Δ· 4 ΤÓÙÚ· Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡Ó ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi ÌË Û˘ÁÁÂÓ›˜ ÂıÂÏÔÓÙ¤˜ ÛÙËÓ ∂ÏÏ¿‰· Â›Ó·È ÔÈ ªO¡∞¢∂™ ª∂Δ∞ªO™Ã∂À™∏™ ∞∞∫ ÙˆÓ ·Ú·Î¿Ùˆ ¡ÔÛÔÎÔÌ›ˆÓ:
«∂À∞°°∂§π™ªO™» «°. ¶∞¶∞¡π∫O§∞OÀ» £∂™™∞§O¡π∫∏™ «∞°π∞ ™Oºπ∞» «¶. ¡O™O∫Oª∂πO ƒπO-¶∞Δƒ∞™»
Δ· ΤÓÙÚ· ·˘Ù¿ Ô˘ÛÈ·ÛÙÈο Â›Ó·È ·˘Ù¿ Ô˘ ÂÓÂÚÁÔÔÈÔ‡Ó ÙËÓ ‰È·‰Èηۛ· ·Ó·˙‹ÙËÛ˘ ‰ÔÙÒÓ,
ÂÓÒ fiÏÔÈ ÔÈ ·ÈÌ·ÙÔÏfiÁÔÈ ¤¯Ô˘Ó ÙËÓ ‰˘Ó·ÙfiÙËÙ· Ó· ÌÔÚÔ‡Ó Ó· ÂϤÁÍÔ˘Ó ÙËÓ ‰ÈÂıÓ‹ ‰ÂÍ·ÌÂÓ‹ Î·È Ó· ‰Ô˘Ó ·Ó¿ ¿Û· ÛÙÈÁÌ‹ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Û˘Ì‚·ÙÒÓ ‰ÔÙÒÓ Î·È ÙË ¯ÒÚ· ÛÙËÓ ÔÔ›· ·˘ÙÔ› ‚Ú›ÛÎÔÓÙ·È ÁÈ· οı ·ÛıÂÓ‹, Ó· οÓÔ˘Ó Ô˘ÛÈ·ÛÙÈο ÙËÓ «·Ú¯È΋ ·Ó·˙‹ÙËÛË». ªÂÙ¿ ÙËÓ ·Ú¯È΋ ·Ó·˙‹ÙËÛË, Ë «ÂÓÂÚÁÔÔ›ËÛË Ù˘ ·Ó·˙‹ÙËÛ˘» Ë ÔÔ›· ÂÌÂÚȤ¯ÂÈ Î·È ÙËÓ ¤ÓÓÔÈ· ÙÔ˘ ÔÈÎÔÓÔÌÈÎÔ‡ ÎfiÛÙÔ˘˜, Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÌfiÓÔ Ì ÂÓÙÔÏ‹ È·ÙÚÔ‡ ÌÔÓ¿‰·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘. To Û‡ÓÔÏÔ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Û ŒÏÏËÓ˜ ·ÛıÂÓ›˜ ·fi ‰fiÙ˜ Ô˘ ‚Ú¤ıËÎ·Ó Û˘Ì‚·ÙÔ› Î·È ·Ó‹Î·Ó Û ͤÓ˜ ‰ÂÍ·ÌÂÓ¤˜ Â›Ó·È 12 ÙÔ 2003, 21 ÙÔ 2004, 30 ÙÔ 2005 Î·È 38 ÙÔ 2006, ÂÓÒ Ë ¯ÒÚ· Ì·˜ Û˘ÓÙfiÓÈÛÂ Î·È ÙË ‰È·‰Èηۛ· ‰ˆÚ¿˜ 5 ∂ÏÏ‹ÓˆÓ ÌË Û˘ÁÁÂÓÒÓ ‰ÔÙÒÓ ÁÈ· ·ÛıÂÓ›˜ ¯ˆÚÒÓ ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. º¤ÙÔ˜ ̤¯ÚÈ ÙÔÓ OÎÙÒ‚ÚÈÔ ÙÔ˘ 2007 Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó 42 ÌÂÙ·ÌÔۯ‡ÛÂȘ Î·È ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ Ì¤¯ÚÈ ÙÔ Ù¤ÏÔ˜ ÙÔ˘ 2007 ı· ÊÙ¿ÛÔ˘Ó ÙȘ 50. ΔËÓ ÙÂÏÂ˘Ù·›· 4ÂÙ›· Î·È ·fi ÂÓ¿Ú͈˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ªÔÓ¿‰·˜ ∞Ó·˙‹ÙËÛ˘ ·Ú·ÙËÚÂ›Ù·È ÌÈ· ÁˆÌÂÙÚÈ΋ ·‡ÍËÛË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ∞∞∫ ÛÙË ¯ÒÚ· Ì·˜. ∞fi ÙÔ 2003 ̤¯ÚÈ ÙÔ 2006 ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ô˘ ‰ÈÂÓÂÚÁ‹ıËÎ·Ó ÛÙ· 4 ÂÏÏËÓÈο ΤÓÙÚ· ·˘Í‹ıËÎ·Ó Î·Ù¿ 216,7%. ∏ ‰ÂÍ·ÌÂÓ‹ ÙˆÓ ‰ÔÙÒÓ ·ÚÈıÌ› 24.000 ÂıÂÏÔÓÙ¤˜ Î·È ¤¯ÂÈ ·˘ÍËı› ηٿ 108,3% ·fi ÙËÓ ¤Ó·ÚÍË ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙÔÓ ∂Oª ̤۷ ·fi Û˘ÓÙÔÓÈṲ̂Ó˜ ÚÔÛ¿ıÂȘ ÂÓË̤ڈÛ˘ ÙÔ˘ ÎÔÈÓÔ‡ ÛÂ Û˘ÓÂÚÁ·Û›· Ì ¿ÏÏÔ˘˜ ÊÔÚ›˜ Î·È Û˘ÏÏfiÁÔ˘˜. ¶ÚÔ˜ ÙÔ ·ÚfiÓ Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ¯ÔÚËÁ‹ıËÎ·Ó ÚÔ‹Ïı ·fi ‰fiÙ˜ ¿ÏÏˆÓ ¯ˆÚÒÓ Ì¤Ûˆ Ù˘ ‰ÈÂıÓÔ‡˜ ‰ÂÍ·ÌÂÓ‹˜ BMDW ∏ ÂÈÙ˘¯›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ˆ˜ ıÂڷ›·˜ Ô‰ËÁ› Î·È Û ηٷÎfiÚ˘ÊË ˙‹ÙËÛË. OÈ ·ÈÙ‹ÛÂȘ ÁÈ· ·Ú¯È΋ ·Ó·˙‹ÙËÛË ·˘Í‹ıËÎ·Ó ÙËÓ ÙÂÏÂ˘Ù·›· 4ÂÙ›· ηٿ 143,4% Î·È ·˘Ù‹ Ë ÔÏÔ¤Ó· ·˘ÍËÙÈ΋ Ù¿ÛË Ì·˜ ˘Ô¯ÚÂÒÓÂÈ Ó· ÂÓÙ›ÓÔ˘Ì ÙȘ ÚÔÛ¿ıÂȘ ·Ó‡ÚÂÛ˘ Î·È Î·Ù·¯ÒÚËÛ˘ Ó¤ˆÓ ‰ÔÙÒÓ ¤ÙÛÈ ÒÛÙÂ Ë ¯ÒÚ· Ì·˜ Ó· Â›Ó·È ·˘Ù¿Ú΢ Î·È ÔÈ ·ÛıÂÓ›˜ Ì·˜ Ó· ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚ˜ Èı·ÓfiÙËÙ˜ ›·Û˘. ™Ùfi¯Ô˜ ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ° ÙÔ˘ ∂Oª Â›Ó·È Ë ÚÔÒıËÛË Ù˘ ȉ¤·˜ Ù˘ ‰ˆÚ¿˜ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Ì ÛÎÔfi ÙËÓ ·‡ÍËÛË ÙÔ˘ ÂıÓÈÎÔ‡ ÌËÙÚÒÔ˘ ‰ÔÙÒÓ ÚÔ˜ fiÊÂÏÔ˜ fiÏˆÓ ÙˆÓ ∂ÏÏ‹ÓˆÓ ·ÛıÂÓÒÓ Ô˘ ¯Ú‹˙Ô˘Ó ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·Ú¯¤ÁÔÓˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÙÔ˘˜ ÂÚÈ‚¿ÏÏÔÓ Û˘Ì‚·Ùfi˜ ‰fiÙ˘.
EÓÙfiÈÛË Î·È AÓ·ÊÔÚ¿ ¢ÔÙÒÓ OÚÁ¿ÓˆÓ – ¢È·‰Èηۛ· ™˘ÓÙÔÓÈÛÌÔ‡
3
E˘ÛÙÚ¿ÙÈÔ˜ X·Ù˙ËÍËÚfi˜
∂π™∞°ø°∏
Ú˘ıÌ›˙ÂÙ·È Ì ·Ó¿ÏÔÁË ÓÔÌÔıÂÛ›· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÂÌÔÚ›·˜. ™ÙËÓ ∂ÏÏ¿‰· Ë ÂÓ ˙ˆ‹ ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÛÂ Û˘ÁÁÂÓ‹ ∞′ ‚·ıÌÔ‡.
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› ÙËÓ Î·Ï‡ÙÂÚË Î·È Û οÔȘ ÂÚÈÙÒÛÂȘ ÙË ÌÔÓ·‰È΋ ÂÓ·ÏÏ·ÎÙÈ΋ ıÂڷ›· ÁÈ· ·ÛıÂÓ›˜ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ·Ó¿ÚÎÂÈ· οÔÈÔ˘ ÔÚÁ¿ÓÔ˘. ¢˘ÛÙ˘¯Ò˜ Û˘Ó¯Ҙ ·˘Í¿ÓÂÙ·È ÙÔ ¯¿ÛÌ· ·Ó¿ÌÂÛ· ÛÙË ˙‹ÙËÛË ÁÈ· ÌÂÙ·ÌÔۯ‡ÛÂȘ Î·È ÛÙËÓ ·ÚÔ¯‹ ÔÚÁ¿ÓˆÓ Î·È ÈÛÙÒÓ. ΔÈ ÌÔÚ› Ó· Á›ÓÂÈ ÁÈ· Ó· ÁÂÊ˘Úˆı› ÙÔ ¯¿ÛÌ·; ∂ÌÊ·ÓÒ˜ ı· Ú¤ÂÈ ÚÒÙ· Ó· ·˘ÍËı› Ë ‰È·ıÂÛÈÌfiÙËÙ· ÔÚÁ¿ÓˆÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ù·˘Ùfi¯ÚÔÓ· Ó· ÌÂȈı› Ë ˙‹ÙËÛË fiÓÙ·˜ ÂÚÈÛÛfiÙÂÚÔ ÂÈÏÂÎÙÈÎÔ› ÛÙËÓ ·Ô‰Ô¯‹ ·ÛıÂÓÒÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ ‚·ÛÈÎÔ› ÏfiÁÔÈ Ù˘ ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÔÚÔ‡Ó Ó· Û˘ÓÔ„ÈÛÙÔ‡Ó Û ÙÚÂȘ ηÙËÁÔڛ˜.
¶Δøª∞Δπ∫Oπ ¢OΔ∂™ ŸÏÔÈ ÔÈ ı·ÓfiÓÙ˜ ı· Ú¤ÂÈ Ó· ÂÎÙÈÌÒÓÙ·È ÂÍ ·Ú¯‹˜ ˆ˜ Èı·ÓÔ› ‰fiÙ˜ ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ. ∞Ó¿ÏÔÁ· Ì ÙÔ ·›ÙÈÔ Î·È ÙȘ Û˘Óı‹Î˜ ÙÔ˘ ı·Ó¿ÙÔ˘, ·Ó·ÁÓˆÚ›˙Ô˘Ì 3 ‰È·ÊÔÚÂÙÈο ›‰Ë ‰ÔÙÒÓ.
∂ÁÎÂÊ·ÏÈο ÓÂÎÚÔ› ‰fiÙ˜ (‰fiÙ˜ Ì ¿ÏÏÔ˘Û· ηډȿ) ∞˘ÙÔ› Â›Ó·È ·ÛıÂÓ›˜ Âı·›ÓÔ˘Ó ÛÙ· ÓÔÛÔÎÔÌ›· Ì ÂÁÎÂÊ·ÏÈ΋ Ó¤ÎÚˆÛË Î·ÙfiÈÓ ÛÔ‚·Ú‹˜ ÂÁÎÂÊ·ÏÈ΋˜ ‚Ï¿‚˘ (ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË, ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, ·ÓÔÍ·ÈÌÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ÎÏ). ∂ϤÁ¯ÂÙ·È Ë ÌË ·Ó·ÛÙÚ¤„ÈÌË ·ÒÏÂÈ· Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ Î·È ÙˆÓ ËÌÈÛÊ·ÈÚ›ˆÓ Î·È ‚Ú›ÛÎÔÓÙ·È ‰È·ÛˆÏËӈ̤ÓÔÈ Î·È ˘fi Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË. ™˘ÓÂÒ˜ ÏfiÁˆ Ù˘ ʇÛ˘ ÙÔ˘˜ Â›Ó·È ‰˘ÓËÙÈÎÔ› ‰fiÙ˜ fiÏˆÓ ÙˆÓ ÔÚÁ¿ÓˆÓ Î·È ÙˆÓ ÈÛÙÒÓ.
1. OÈ ‰˘ÓËÙÈÎÔ› ‰fiÙ˜ ÔÚÁ¿ÓˆÓ ‰ÂÓ ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ·fi ÙÔ ÚÔÛˆÈÎfi ÙˆÓ ÌÔÓ¿‰ˆÓ fiÔ˘ ÓÔÛËχÔÓÙ·È. 2. ΔÔ ÚÔÛˆÈÎfi ÙˆÓ ª∂£ ÔÏϤ˜ ÊÔÚ¤˜ ‰ÂÓ ÂÓËÌÂÚÒÓÂÈ ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ. 3. OÈ ™˘ÁÁÂÓ›˜ ‰ÂÓ ‰›ÓÔ˘Ó ÙËÓ Û˘ÁηٿıÂÛË ÙÔ˘˜.
¢fiÙ˜ Ì ηډÈÔÓ¢ÌÔÓÈ΋ ·‡ÛË (arrest)
∏ ·‰˘Ó·Ì›· ÂÓÙfiÈÛ˘ Î·È ·Ó·ÁÓÒÚÈÛ˘ ÙˆÓ ‰ÔÙÒÓ ·ÔÙÂÏ› ÙËÓ Î‡ÚÈ· ·ÈÙ›· ÌÂȈ̤Ó˘ ÚÔÛÊÔÚ¿˜ ÔÚÁ¿ÓˆÓ.
∞˘Ù‹ Â›Ó·È Ë ÈÔ ÔÏ˘ÏËı‹˜ ÔÌ¿‰· Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ¿ÙÔÌ· Ô˘ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÓÂÎÚ¿ ÏfiÁˆ ÌË ·Ó·Ù¿ÍÈÌ˘ ΢ÎÏÔÊÔÚȷ΋˜ ·‡Û˘ ÔÔÈ·Û‰‹ÔÙ ·ÈÙÈÔÏÔÁ›·˜ ›Ù ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Â›Ù ÂÎÙfi˜ (ÎÔÈÓfiÙËÙ·). ªÔÚÔ‡Ó Ó· ÂÎÙÈÌËıÔ‡Ó ÌfiÓÔ ÁÈ· ‰ˆÚ¿ ÈÛÙÒÓ.
∂π¢∏ ¢OΔø¡ ∏ ‰ˆÚ¿ πÛÙÒÓ Î·È OÚÁ¿ÓˆÓ ÌÔÚ› Ó· ÚÔ¤ÏıÂÈ ·fi ‰‡Ô ‚·ÛÈΤ˜ ηÙËÁÔڛ˜ ‰ÔÙÒÓ: ˙ÒÓÙ˜ ‰fiÙ˜ Î·È ÙˆÌ·ÙÈÎÔ› ‰fiÙ˜.
¢fiÙ˜ Ì ÌË ¿ÏÏÔ˘Û· ηډȿ (non-heart-beating)
∑ø¡Δ∂™ ¢OΔ∂™
∞˘ÙÔ› ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó ˆ˜ ˘ÔηÙËÁÔÚ›· Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ÔÌ¿‰·˜ Î·È Â›Ó·È ¿ÙÔÌ· Ô˘ ¤¯Ô˘Ó Âı¿ÓÂÈ ˘fi «·Ú·ÎÔÏÔ˘ıÔ‡ÌÂÓË» ÌË ·Ó·Ù¿ÍÈÌË Î˘ÎÏÔÊÔÚȷ΋ ·‡ÛË fiÔ˘ ÂȉÈΤ˜ Ù¯ÓÈΤ˜ „‡Í˘ Î·È Û˘ÓÙ‹ÚËÛ˘ ÌÔÚÔ‡Ó Ó· ÂÊ·Ú-
∞˘ÙÔ› Â›Ó·È ¿ÙÔÌ· Ô˘ ‰ˆÚ›˙Ô˘Ó ¤Ó· fiÚÁ·ÓÔ (‹ ÙÌ‹Ì· ÔÚÁ¿ÓÔ˘) ‹ ÈÛÙfi ΢ڛˆ˜ ÁÈ· ÏfiÁÔ˘˜ Û˘Ó·ÈÛıËÌ·ÙÈÎÔ‡˜ ‹ Û˘ÁÁÂÓÈÎÔ‡˜ ‰ÂÛÌÔ‡˜ Û οÔÈÔ ¿ÙÔÌÔ Ô˘ ¤¯ÂÈ ·Ó¿ÁÎË. ∏ ÂÓ ˙ˆ‹ ‰ˆÚ¿
23
24
E. XATZH•HPO™
ÌÔÛÙÔ‡Ó Û Ôχ Û‡ÓÙÔÌÔ ¯ÚfiÓÔ (ÁÂÓÈο ÏÈÁfiÙÂÚÔ ·fi 30 ÏÂÙ¿) ÒÛÙ ӷ ÂÍ·ÛÊ·ÏÈÛÙ› Ë ·Ê·›ÚÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ. ¶·Ú¿ ÙȘ ‰È·ÊÔÚ¤˜ ·fi ¯ÒÚ· Û ¯ÒÚ·, Ë Î‡ÚÈ· ËÁ‹ ÔÚÁ¿ÓˆÓ ·ÁÎÔÛÌ›ˆ˜ Â›Ó·È ÔÈ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ› ‰fiÙ˜.
∂ÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜ Î·È ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ ªÂÙ¿ ÙÔÓ ÂÓÙÔÈÛÌfi ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ı· Ú¤ÂÈ Ó· Á›ÓÂÈ ·ÍÈÔÏfiÁËÛË. ÃÚÂÈ¿˙ÂÙ·È Ôχ ÚÔÛÂÎÙÈ΋ ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È ‰ÈÂÚ‡ÓËÛË ÁÈ· ÔÔÈ·‰‹ÔÙ ·ıÔÏÔÁ›· Ô˘ ÌÔÚ› Ó· Â›Ó·È Èı·Ófi˜ ΛӉ˘ÓÔ˜ ÁÈ· ÙÔÓ Ï‹ÙË. ∞ÎÔÏÔ˘ı› ÛÙË Û˘Ó¤¯ÂÈ· Ë ··Ú·›ÙËÙË ÎÏÈÓÈ΋ Î·È ÓÔÌÈ΋ ηÙÔ¯‡ÚˆÛË ÙÔ˘ ∂£. ™‡Ìʈӷ Ì ÙËÓ ·fiÊ·ÛË 9 Ù˘ 21˘ ÔÏÔ̤ÏÂÈ·˜ ÙÔ˘ ∫∂™À (20/3/1985) Ë ‰È¿ÁÓˆÛË ÙÔ˘ ∂£ Á›ÓÂÙ·È ·fi 3 È·ÙÚÔ‡˜ Û 2 ¯ÚfiÓÔ˘˜. ∫·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È·‰Èηۛ·˜, Ú¤ÂÈ Ó· ‰È·ÙËÚÂ›Ù·È Ë ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚfiÙËÙ· ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ÁÈ· Ó· ÂÍ·ÛÊ·ÏÈÛÙ› Ë ‚ȈÛÈÌfiÙËÙ· ÙˆÓ ÔÚÁ¿ÓˆÓ. Δ¤ÏÔ˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÚÔÛÂÁÁÈÛÙ› Ë ÔÈÎÔÁ¤ÓÂÈ· Î·È Ó· ÂÈÏ˘ıÔ‡Ó fiϘ ÔÈ ÓÔÌÈΤ˜ ÏÂÙÔ̤ÚÂȘ (Û˘Ó·›ÓÂÛË).
ª¤ıÔ‰ÔÈ ÂÓÙÔÈÛÌÔ‡ ‰ÔÙÒÓ O ÂÓÙÔÈÛÌfi˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÒÓ Ô˘ÛÈ·ÛÙÈο ‚·Û›˙ÂÙ·È Û ÙÚÂȘ ıÂÌÂÏÈÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜: 1. ΔËÓ ‡·ÚÍË ·ÙfiÌÔ˘ (™˘ÓÙÔÓÈÛÙ‹˜) ¿ÌÂÛ· ˘Â‡ı˘ÓÔ ÁÈ· ÙË ‰È·‰Èηۛ·. ¶Ú¤ÂÈ Ó· Â›Ó·È ÁÓˆÛÙfi ÚfiÛˆÔ Û fiÏÔ ÙÔ ¡ÔÛÔÎÔÌ›Ô, ÂȉÔÔÈÂ›Ù·È Î·È ·Ó·Ï·Ì‚¿ÓÂÈ ‰Ú¿ÛË, ›Ù ‚Ú›ÛÎÂÙ·È ÛÙËÓ full-time ÂÚÁ·Û›· ÙÔ˘, ›Ù ÛÙËÓ parttime, ÛÙÔ °Ú·ÊÂ›Ô ™˘ÓÙÔÓÈÛÌÔ‡, ›Ù ÂÎÙfi˜ ¡ÔÛÔÎÔÌ›Ԣ. 2. ⁄·ÚÍË ÂȉÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ Ô˘ ‰È¢ÎÔχÓÔ˘Ó Î¿ı ÛÙ¿‰ÈÔ Ù˘ ‰È·‰Èηۛ·˜, ÚÔÛ·ÚÌÔṲ̂ӷ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ οı ¡ÔÛÔÎÔÌ›Ԣ. 3. ™˘ÓÂÚÁ·Û›· fiÏÔ˘ ÙÔ˘ È·ÙÚÈÎÔ‡ Î·È ·Ú·˚·ÙÚÈÎÔ‡ ÚÔÛˆÈÎÔ‡, Ë ÔÔ›· ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ ‰È·Ù‹ÚËÛË Î·ÏÒÓ ‰ËÌÔÛ›ˆÓ Û¯¤ÛÂˆÓ ·fi ÙËÓ ÏÂ˘Ú¿ ÙÔ˘ ™˘ÓÙÔÓÈÛÙ‹ Î·È Ì ÙËÓ Û˘¯Ó‹ ÂÓË̤ڈÛË, Âη›‰Â˘ÛË Î·È ÎÈÓËÙÔÔ›ËÛË fiÏÔ˘ ÙÔ˘ ÚÔÛˆÈÎÔ‡. ™·Ê‹˜ ·Ó·ÊÔÚ¿ ÛÙÔ˘˜ ÚfiÏÔ˘˜ Î·È ·ÚÌÔ‰ÈfiÙËÙ˜ ÙˆÓ ÂÌÏÂÎÔ̤ӈÓ.
O ‚·ÛÈÎfi˜ Û˘ÏÏÔÁÈÛÌfi˜ Û¯ÂÙÈο Ì ÙÔÓ ÂÓÙÔÈÛÌfi ‰ÔÙÒÓ Â›Ó·È fiÙÈ ·˘Ù‹ Ë ‰Ú·ÛÙËÚÈfiÙËÙ· Ú¤ÂÈ Ó· Â›Ó·È Î·ı‹ÎÔÓ ÙÔ˘ ™˘ÓÙÔÓÈÛÙ‹ ªÂÙ·ÌÔۯ‡ÛÂˆÓ (™ª) Ô ÔÔ›Ô˜ ı· ηıÔÚ›ÛÂÈ ÙȘ ÈÔ Î·Ù¿ÏÏËϘ ÌÂıfi‰Ô˘˜ ·Ó¿ÏÔÁ· Ì ÙÔ Î¤ÓÙÚÔ ÛÙÔ ÔÔ›Ô ÂÚÁ¿˙ÂÙ·È Î·È ÙÔ˘˜ Ù·¯‡ÙÂÚÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÚfiÛ‚·Û˘ Û ÏËÚÔÊÔڛ˜. ∞ӷʤÚÔÓÙ·È 3 ̤ıÔ‰ÔÈ:
1. ª¤ıÔ‰Ô˜ ∞Ó·ÛÎfiËÛ˘ O ™ª ·Ó·ÙÚ¤¯ÂÈ ÛÙË Ï›ÛÙ· ÂÈÛ·ÁˆÁÒÓ ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, ÂÓÙÔ›˙ÂÈ ·˘ÙÔ‡˜ Ì ÛÔ‚·Ú‹ ÂÁÎÂÊ·ÏÈ΋ ‚Ï¿‚Ë Î·È ·Ú·ÎÔÏÔ˘ı› ÙËÓ ÔÚ›· ÙÔ˘˜. £ÂˆÚÂ›Ù·È Ë ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ̤ıÔ‰Ô˜.
2. ª¤ıÔ‰Ô˜ ¢È·Û‡Ó‰ÂÛ˘ ∞fi ÙË ÛÙÈÁÌ‹ Ô˘ ‰È·ÈÛÙÒÓÂÙ·È, ‹ Èı·ÓÔÏÔÁÂ›Ù·È Ô ÂÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜ Û οÔÈÔ Î¤ÓÙÚÔ (ΤÓÙÚÔ ·Ó·ÊÔÚ¿˜), ÙfiÙÂ Ô ‰fiÙ˘ ÌÂٷʤÚÂÙ·È Û ÓÔÛÔÎÔÌÂ›Ô (ΤÓÙÚÔ ‰fiÙË) fiÔ˘ ˘¿Ú¯ÂÈ ™˘ÓÙÔÓÈÛÙ‹˜ ÁÈ· Ó· ·Ó·Ï¿‚ÂÈ ÙËÓ ÂÎÙ›ÌËÛË Î·È ÙË Û˘ÓÙ‹ÚËÛ‹ ÙÔ˘, ÙËÓ ÈÛÙÔÔ›ËÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ÙË ÚÔÛ¤ÁÁÈÛË Î.Ô.Î..
3. ª¤ıÔ‰Ô˜ ∂ÈÙ‹ÚËÛ˘ ∏ ÈÔ ÛËÌ·ÓÙÈ΋ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ̤ıÔ‰Ô˜, ·ÊÔ‡ ÂÚÈÏ·Ì‚¿ÓÂÈ : - ΔÔÓ ™˘ÓÙÔÓÈÛÙ‹ ªÂÙ·ÌÔۯ‡ÛˆÓ, Ô˘ ÂÈÛΤÙÂÙ·È Û ηıËÌÂÚÈÓ‹ ‚¿ÛË fiϘ Ù˘ ÌÔÓ¿‰Â˜ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ fiÔ˘ ÌÔÚ› Ó· ÂÓÙÔÈÛÙ› ¤Ó·˜ Èı·Ófi˜ ‰fiÙ˘. - ∂˘·ÈÛıËÙÔÔÈË̤ÓÔ ÚÔÛˆÈÎfi fiÏÔ˘ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Î·È ÂȉÈο ÙˆÓ ª.∂.£., ÙÔ ÔÔ›Ô ÂȉÔÔÈ› ÙÔÓ ™˘ÓÙÔÓÈÛÙ‹ Û οı ÂÚ›ÙˆÛË. - ŒÏÂÁ¯Ô˜-ÂÎÙ›ÌËÛË ÂÂÈÁfiÓÙˆÓ ÎÚ·ÓÈ·ÎÒÓ ÙÔÌÔÁÚ·ÊÈÒÓ Ô˘ ‰ÈÂÓÂÚÁÔ‡ÓÙ·È ÛÙÔ ÓÔÛÔÎÔÌ›Ô. - ∂ÚÁ·Û›· ηٿ ÙËÓ ÒÚ· Ù˘ ηÓÔÓÈ΋˜ ‚¿Ú‰È·˜ ÙÔ˘ Û˘ÓÙÔÓÈÛÙ‹. ∏ ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ Â›Ó·È ÁÂÓÈο ÌÈ· Ì·ÎÚ¿ Î·È ÔχÏÔÎË ‰È·‰Èηۛ· Ô˘ ÌÔÚ› Ó· ‰È·ÚΤÛÂÈ ·fi 12 ¤ˆ˜ 48 ÒÚ˜ Î·È ÂÔ̤ӈ˜ ‰ÂÓ ÌÔÚ› Ó· ·ÊÂı› Ó· ÂÍÂÏȯı› Ù˘¯·›· ·ÏÏ¿ ··ÈÙ› ÙËÓ Î·ıȤڈÛË ÚˆÙÔÎfiÏÏˆÓ Î·È ·˘ÛÙËÚ‹ ›‚ÏÂ„Ë ·fi ÙÔÓ ™ª ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÔÔÈÔ˘‰‹ÔÙ ·˘ÙÔۯ‰ȷÛÌÔ‡.
EÈÏÔÁ‹ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ Î·È Î·Ù·ÓÔÌ‹ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ
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ŒÊË NÈÎÔÏ¿Ô˘
™‡Ìʈӷ Ì ÙÔÓ ÓfiÌÔ Â›Ì·ÛÙ ˘Ô¯Úˆ̤ÓÔÈ Ó· ·ÍÈÔÔÈËıÔ‡Ó fiÏ· Ù· ηٿÏÏËÏ· fiÚÁ·Ó·. ¶ÚÒÙ· ÚÔÛ·ıԇ̠ӷ ‚Úԇ̠ÙÔ˘˜ ηٿÏÏËÏÔ˘˜ Ï‹Ù˜ ÛÙÔÓ ∂ÏÏ·‰ÈÎfi ¯ÒÚÔ ÎÈ ·Ó ·˘Ùfi ‰ÂÓ Â›Ó·È ÂÊÈÎÙfi, Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ Û˘Ì‚Ô˘Ï›Ô˘ Ù˘ ∂˘ÚÒ˘ ÁÈ· ı¤Ì·Ù· ˘Á›·˜, ÚÔÛʤÚÔ˘Ì ٷ fiÚÁ·Ó· Û ·ÓÙ›ÛÙÔÈ¯Ô˘˜ Ì ÙÔÓ ∂Oª Â˘Úˆ·˚ÎÔ‡˜ ÔÚÁ·ÓÈÛÌÔ‡˜. Δ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Ù· ÔÔ›· ·˘Ù‹ ÙË ÛÙÈÁÌ‹ ¤¯Ô˘Ó ¿‰ÂÈ· Î·È ‰ÈÂÓÂÚÁÔ‡Ó ÌÂÙ·ÌÔۯ‡ÛÂȘ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ ›ӷÈ:
O ∂.O.ª Â›Ó·È ¤Ó·˜ ÌË ÎÂÚ‰ÔÛÎÔÈÎfi˜ ÔÚÁ·ÓÈÛÌfi˜, ȉڇıËΠ̠ÙÔ ÓfiÌÔ 2737/99, ¿Ú¯ÈÛ fï˜ Ô˘ÛÈ·ÛÙÈο Ó· ÏÂÈÙÔ˘ÚÁ› ÛÙȘ 12/3/2001. ∞ÔÙÂÏ› ¡ÔÌÈÎfi ¶ÚfiÛˆÔ π‰ÈˆÙÈÎÔ‡ ¢Èη›Ô˘ Î·È Â›Ó·È ˘fi ÙËÓ ÂÔÙ›· ÙÔ˘ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜. ™ÎÔfi˜ ÙÔ˘ ∂.O.ª. ÁÈ· ÙÔÓ ÔÔ›Ô Ë ÔÏÈÙ›· ÙÔÓ fiÚÈÛ ›ӷÈ: ∏ ˘Ô‚Ô‹ıËÛË ÙÔ˘ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜ ÁÈ· ÙËÓ ¯¿Ú·ÍË ÂıÓÈ΋˜ ÔÏÈÙÈ΋˜ ÛÙÔÓ ÙÔ̤· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ. °È· ÙËÓ Â›Ù¢ÍË ÙÔ˘ ÛÎÔÔ‡ ÙÔ˘ ¤¯ÂÈ ÌÂٷ͇ ¿ÏÏˆÓ Î·È ÙȘ ·ÎfiÏÔ˘ı˜ ·ÚÌÔ‰ÈfiÙËÙ˜: • ÂÈÛËÁÂ›Ù·È ÙÔ˘˜ fiÚÔ˘˜, ÙȘ ÚÔ¸Ôı¤ÛÂȘ Î·È ÙËÓ ‰È·‰Èηۛ· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Î·ıÒ˜ Î·È ÙË Û‡ÓÙ·ÍË ÎÒ‰Èη ‰ÂÔÓÙÔÏÔÁ›·˜ ÁÈ· ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÌÔÓ¿‰ˆÓ ªÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ÙˆÓ ΔÚ·Â˙ÒÓ πÛÙÒÓ ÚÔ˜ ªÂÙ·ÌfiÛ¯Â˘ÛË • ÔÚÁ·ÓÒÓÂÈ Î·È Û˘ÓÙÔÓ›˙ÂÈ Û ÙÔÈÎfi, ÎÚ·ÙÈÎfi Î·È ‰È·ÎÚ·ÙÈÎfi Â›Â‰Ô ÙËÓ ‰È·Î›ÓËÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ Î·È ÙÔ˘ ª˘ÂÏÔ‡ ÙˆÓ OÛÙÒÓ • ηٷÁÚ¿ÊÂÈ ÙÔ˘˜ ‰ˆÚËÙ¤˜ ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ, ÙÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ ‰fiÙ˜ Î·È ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ Ï‹Ù˜ ÔÚÁ¿ÓˆÓ • ÂÈÛËÁÂ›Ù·È ÛÙÔÓ ÀÔ˘ÚÁfi ÀÁ›·˜ Î·È ∫ÔÈÓˆÓÈ΋˜ ∞ÏÏËÏÂÁÁ‡Ë˜ ÙË ¯ÔÚ‹ÁËÛË ¿‰ÂÈ·˜ ÁÈ· ÙËÓ ›‰Ú˘ÛË ªÔÓ¿‰·˜ ªÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ÚÔ‚·›ÓÂÈ Û ÂÙ‹ÛÈ· ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÙÚfiÔ˘ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ªÔÓ¿‰ˆÓ ªÂÙ·ÌfiÛ¯Â˘Û˘ • Û˘ÓÂÚÁ¿˙ÂÙ·È Ì ·ÓÙ›ÛÙÔÈ¯Ô˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜ Î·È ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡ ÁÈ· ÚÔÌ‹ıÂÈ· Î·È ·ÓÙ·ÏÏ·Á‹ ÌÔÛ¯Â˘Ì¿ÙˆÓ • ÂȉÈÒÎÂÈ Ì οı ÚfiÛÊÔÚÔ Ì¤ÛÔ ÙËÓ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È È‰›ˆ˜ Ì ÙËÓ ÔÚÁ¿ÓˆÛË Î·Ù¿ÏÏËÏ˘ ÂÓË̤ڈÛ˘ ÙÔ˘ ÎÔÈÓÔ‡.(ÔÌÈϛ˜, ÙËÏÂÔÙÈο ÛÔÙ, ·Ê›Û˜, ÂÓËÌÂÚˆÙÈο ¤ÓÙ˘·)
øÓ¿ÛÂÈÔ ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎfi ∫¤ÓÙÚÔ (ηډȿ – Ó‡ÌÔÓ˜) °¡∞ §·˚Îfi (ÓÂÊÚÔ‡˜ – ‹·Ú) °¡£ πÔÎÚ¿ÙÂÈÔ (ÓÂÊÚÔ‡˜ – ‹·Ú) °¡∞ ∂˘·ÁÁÂÏÈÛÌfi˜ (ÓÂÊÚÔ‡˜) ¶°¡¶ ƒ›Ô (ÓÂÊÚÔ‡˜) °È· ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ Ï‹Ù˜ ηډȿ˜, Ó¢ÌfiÓˆÓ Î·È ‹·ÙÔ˜ Ë ‰È·‰Èηۛ· ÂÁÁÚ·Ê‹˜ ÛÙËÓ Ï›ÛÙ· Â›Ó·È Ë ÂÍ‹˜: Ô ıÂÚ¿ˆÓ È·ÙÚfi˜ ÙÔ˘˜ ÂÈÎÔÈÓˆÓ› Ì ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ Î·È ÛÙ¤ÏÓÂÈ ¤Ó· Ï‹Ú˜ ÈÛÙÔÚÈÎfi ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÙȘ ÙÂÏÂ˘Ù·›Â˜ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ. ∞fi ÎÂÈ Î·È ¤Ú· ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ ÙÔÓ Î·ıÔ‰ËÁ› Î·È ·ÊÔ‡ ÎÚ›ÓÂÈ ÙËÓ Î·Ù·ÏÏËÏfiÙËÙ· Î·È ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Ó· ÂÓÙ·¯ı› ÛÙË Ï›ÛÙ·, ÙÔÓ ÂÓÙ¿ÛÛÂÈ Î·È ÂÓËÌÂÚÒÓÂÈ ÙÔÓ ∂Oª. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ Ï‹ÙË Î·Ú‰È¿˜, Ó¢ÌfiÓˆÓ Î·È ‹·ÙÔ˜ fiÙ·Ó ˘¿Ú¯ÂÈ Î¿ÔÈÔ˜ ‰fiÙ˘, Ù· ·ÓÙ›ÛÙÔȯ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ¤¯Ô˘Ó ÙËÓ ÙÂÏÈ΋ ÂÈÏÔÁ‹ ÙÔ˘ ηٷÏÏËÏfiÙÂÚÔ˘ Ï‹ÙË, Ì ‚¿ÛË ¿ÓÙ· ÙȘ ۈ̷ÙÔÌÂÙÚÈΤ˜ ‰È·ÛÙ¿ÛÂȘ, ÙËÓ ÔÌ¿‰· ·›Ì·ÙÔ˜, ÙÔ Â›ÁÔÓ Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ οı ˘Ô„‹ÊÈÔ˘ Ï‹ÙË, ηıÒ˜ Î·È ÙȘ È·ÙÚÈΤ˜ ÚÔÙÂÚ·ÈfiÙËÙ˜. O ∂Oª Û οı ÂÚ›ÙˆÛË ÂÓËÌÂÚÒÓÂÙ·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ Ï‹ÙË ·fi ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÔ‡ ΤÓÙÚÔ˘ fiˆ˜ Î·È ÁÈ· ÙËÓ ¤Î‚·ÛË
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E. NIKO§AOY
Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. °È· ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘ Ï‹Ù˜ ÓÂÊÚÔ‡ Ë ‰È·‰Èηۛ· ÂÁÁÚ·Ê‹˜ ÛÙËÓ ÂıÓÈ΋ Ï›ÛÙ· ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ Â›Ó·È ‰È·ÊÔÚÂÙÈ΋. OÈ ·ÛıÂÓ›˜ Û ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË Ú¤ÂÈ Ó· ÔÏÔÎÏËÚÒÛÔ˘Ó ÙÔÓ «ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô», (ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÛÂÈÚ¿ ·fi ÂÚÁ·ÛÙËÚȷΤ˜ Î·È ÎÏÈÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ), Î·È Ó· ÙÔÓ Î·Ù·ı¤ÛÔ˘Ó ÛÙÔÓ ÓÂÊÚÔÏfiÁÔ ÙÔ˘˜, Ô ÔÔ›Ô˜ Ú¤ÂÈ Ó· ÙÔÓ ˘ÔÁÚ¿„ÂÈ ·ÊÔ‡ ¤¯ÂÈ ÎÚ›ÓÂÈ ÙËÓ Î·Ù·ÏÏËÏfiÙËÙ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Ó· ÂÓÙ·¯ı› ÛÙË Ï›ÛÙ·. ΔÔ ‰Â‡ÙÂÚÔ ‚‹Ì· Â›Ó·È ÔÈ ·ÛıÂÓ›˜ Ó· ÂÈϤÍÔ˘Ó Û ÔÈÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ ÓÂÊÚÔ‡ ÂÈı˘ÌÔ‡Ó Ó· ÂÓÙ·¯ıÔ‡Ó (¿Û¯ÂÙ· Ì ÙÔÓ ÙfiÔ ‰È·ÌÔÓ‹˜ ÙÔ˘˜) Î·È Ó· ¤ÚıÔ˘Ó Û ÂÈÎÔÈÓˆÓ›· Ì ÙÔ Î¤ÓÙÚÔ ÂÈÏÔÁ‹˜ ÙÔ˘˜, ¤¯ÔÓÙ·˜ Ì·˙› ÙÔ˘˜ Î·È ÙÔÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô, Ô ÔÔ›Ô˜ Ú¤ÂÈ Ó· ˘ÔÁÚ·Ê› ·fi ÙÔÓ ‰È¢ı˘ÓÙ‹ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÔ‡ ΤÓÙÚÔ˘. ΔÔ ÙÚ›ÙÔ Î·È ÙÂÏÂ˘Ù·›Ô ‚‹Ì· Â›Ó·È Ô ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ó· ÊÙ¿ÛÂÈ ÛÙÔÓ ∂Oª ÁÈ· Ó· ÂÓÙ·¯ı› Ô ˘Ô„‹ÊÈÔ˜ Ï‹Ù˘ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ∞˘Ùfi Á›ÓÂÙ·È Â›Ù ·Ú·Ï·Ì‚¿ÓÔÓÙ¿˜ ÙÔÓ Ì fax ·fi ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ, ›Ù ·Ú·Ï·Ì‚¿ÓÔÓÙ¿˜ ÙÔÓ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ÓÂÊÚÔ·ı‹. Δ· و̷ÙÈο ÓÂÊÚÈο ÌÔۯ‡̷ٷ ‰È·Ù›ıÂÓÙ·È Ì ÌÔÚÈÔÔÈË̤ÓÔ Û‡ÛÙËÌ· ‚·ıÌÔÏfiÁËÛ˘ ÙˆÓ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ, ÔÈ ÔÔ›ÔÈ Î·Ù·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ∂ıÓÈ΋ §›ÛÙ· ÌÂÙ¿ ÙËÓ ˘Ô‚ÔÏ‹ ÙÔ˘˜ Û ¶ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô Î·È ÙËÓ ¤Ó‰ÂÈÍË ÙˆÓ ˘Â˘ı‡ÓˆÓ È·ÙÚÈÎÒÓ ÔÌ¿‰ˆÓ «∫·Ù¿ÏÏËÏÔ˜ ÚÔ˜ ªÂÙ·ÌfiÛ¯Â˘ÛË» ∏ ∂ıÓÈ΋ §›ÛÙ· Â›Ó·È ªπ∞ Î·È ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ Â›Ó·È ÂÁÁÂÁÚ·Ì̤ÓÔÈ ·˘ÛÙËÚ¿ Î·È ÌfiÓÔÓ Û ·˘Ù‹Ó. ∏ ‰È·ÛÊ¿ÏÈÛË Ù˘ ‰ËÌfiÛÈ·˜ ÂÌÈÛÙÔÛ‡Ó˘, ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ Ï‹ÙË ÓÂÊÚÔ‡, ˘ÏÔÔÈÂ›Ù·È Ì ÙË ¯Ú‹ÛË ÂÓfi˜ ¢ڤˆ˜ ·Ô‰ÂÎÙÔ‡, ÏÂÈÙÔ˘ÚÁÈÎÔ‡ Î·È ‰›Î·ÈÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÔÚÈÔÔ›ËÛ˘ Û‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· Ù˘ ∂.∂. ∂ȉÈÎfiÙÂÚ· Ë ÌÔÚÈÔÔ›ËÛË Á›ÓÂÙ·È ˆ˜ ÂÍ‹˜: • ™‡Ìʈӷ Ì ÙËÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ· ‰fiÙË – Ï‹ÙË. ŒÍÈ Â›Ó·È Ù· ·ÓÙÈÁfiÓ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Ù· ÔÔ›· ÂϤÁ¯Ô˘ÌÂ: HLA A, HLA B, HLA DR (‰‡Ô ÛÙÔ Î·ı¤Ó·). °È· οı ÎÔÈÓfi ·ÓÙÈÁfiÓÔ ‰fiÙË – Ï‹ÙË Ù· ÌfiÚÈ· Â›Ó·È 66,67. °È· Ï‹ÚË ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ· (¤ÍÈ ÛÙ· ¤ÍÈ ÎÔÈÓ¿ ·ÓÙÈÁfi-
Ó·) Ô Ï‹Ù˘ ·›ÚÓÂÈ 400 ÌfiÚÈ· Î·È ÚÔËÁÂ›Ù·È fiψÓ. • °È· ·È‰È¿ οو ÙˆÓ 16 ÂÙÒÓ Á›ÓÂÙ·È ‰ÈÏ·ÛÈ·ÛÌfi˜ ÙˆÓ ÌÔÚ›ˆÓ Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙÔÓ ˘ÔÏÔÁÈÛÌfi Ù˘ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜. • ∏ ËÌÂÚÔÌËÓ›· ¤Ó·Ú͢ ·ÈÌÔοı·ÚÛ˘ ·ÔÙÂÏ› ÎÚÈÙ‹ÚÈÔ ÂÈÏÔÁ‹˜ ÙÔ˘ ηٿÏÏËÏÔ˘ Ï‹ÙË Ô ÔÔ›Ô˜ Ï·Ì‚¿ÓÂÈ 20 ÌfiÚÈ· ÁÈ· οı ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ ÙÔ˘ ÛÙËÓ ·ÈÌÔοı·ÚÛË. • ™‡Ìʈӷ Ì ȷÙÚÈΤ˜ ÚÔÙÂÚ·ÈfiÙËÙ˜. OÈ ·ÛıÂÓ›˜ Ô˘ ı· ÂÁÁÚ·ÊÔ‡Ó ÛÙË Ï›ÛÙ· ›ÁÔ˘Û·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·›ÚÓÔ˘Ó ÙÔ 1Ô ‰È·ı¤ÛÈÌÔ ÌfiÛ¯Â˘Ì· ·fi ‰fiÙË ÌÂ Û˘Ì‚·Ù‹ ÔÌ¿‰· ·›Ì·ÙÔ˜ Î·È ·ÚÓËÙÈÎfi cross match, ·Û¯¤Ùˆ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜. ¶ÚÔ¸fiıÂÛË ÁÈ· Ó· ÂÁÁÚ·Ê› οÔÈÔ˜ ·ÛıÂÓ‹˜ ÛÙËÓ Â›ÁÔ˘Û· Ï›ÛÙ· Â›Ó·È Ó· ¤¯ÂÈ ÂÍ·ÓÙÏËı› Ë ‰˘Ó·ÙfiÙËÙ· ÔÔÈ·Û‰‹ÔÙ ıÂڷ›·˜ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ Î·È ÔÈÔ Û˘ÁÎÂÎÚÈ̤ӷ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ·ÈÌÔοı·ÚÛË Ó· ˘¿Ú¯ÂÈ ·‰˘Ó·Ì›· ÔÔÈ·Û‰‹ÔÙ ÙÔÔı¤ÙËÛ˘ ηıÂÙ‹Ú· (·‰‡Ó·ÙË ·ÁÁÂȷ΋ ÚÔۤϷÛË), ηıÒ˜ Î·È Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÂÚÈÙfiÓ·ÈÔ˘ οÙÈ ÙÔ ÔÔ›Ô ·ÔÎÏ›ÂÈ ÙËÓ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË. ∂Ô̤ӈ˜ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ·fiÏ˘ÙË ·‰˘Ó·Ì›· ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÌÈ· ·fi ÙȘ ÁÓˆÛÙ¤˜ ÌÂıfi‰Ô˘˜. ΔÔ‡ÙÔ ‰È·ÈÛÙÒÓÂÙ·È Ì ·ÈÙÈÔÏÔÁË̤ÓË ·fiÊ·ÛË ÙÔ˘ ıÂÚ¿ÔÓÙÔ˜ È·ÙÚÔ‡ Î·È ÙÔ˘ ˘Â‡ı˘ÓÔ˘ ¯ÂÈÚÔ˘ÚÁÔ‡ Ù˘ ªÔÓ¿‰·˜ ªÂÙ·ÌfiÛ¯Â˘Û˘. • ™‡Ìʈӷ Ì ÙËÓ ÔÌ¿‰· ·›Ì·ÙÔ˜. ·. OÌ¿‰· O Û OÌ¿‰· O ¡ÂÊÚÔ› ·fi ‰fiÙ˜ Ì ÔÌ¿‰· O Ú¤ÂÈ Ó· ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Û ϋÙ˜ Ì ÔÌ¿‰· ·›Ì·ÙÔ˜ O, ÂÎÙfi˜ ·Ó ˘¿Ú¯ÂÈ Ï‹Ù˘ ¿ÏÏ˘ ÔÌ¿‰·˜ ·›Ì·ÙÔ˜ Ì ϋÚË ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ· HLA ·ÓÙÈÁfiÓˆÓ ( 6 ·ÓÙÈÁfiÓ· Ù·˘ÙfiÛËÌ· ) ‚. OÌ¿‰· ∞ Û OÌ¿‰· ∞ ∂¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ù¿ÏÏËÏÔ˜ ˘Ô„‹ÊÈÔ˜ Ì ϋÚË Û˘Ì‚·ÙfiÙËÙ· ÙfiÙ ·Ó·˙ËÙÂ›Ù·È ˘Ô„‹ÊÈÔ˜ Ì ϋÚË Û˘Ì‚·ÙfiÙËÙ· ·fi ÙËÓ ÔÌ¿‰· ∞μ Á. OÌ¿‰· μ Û OÌ¿‰· μ ∂¿Ó ‰ÂÓ ˘¿Ú¯ÂÈ Î·Ù¿ÏÏËÏÔ˜ ˘Ô„‹ÊÈÔ˜ Ì ϋÚË Û˘Ì‚·ÙfiÙËÙ· ÙfiÙ ·Ó·˙ËÙÂ›Ù·È ˘Ô„‹ÊÈÔ˜ Ì ϋÚË Û˘Ì‚·ÙfiÙËÙ· ·fi ÙËÓ ÔÌ¿‰· ∞μ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
‰. OÌ¿‰· ∞μ Û OÌ¿‰· ∞μ
27
ΚΑΤΑΝΟΜΗ ΕΘΝΙΚΟΥ ΚΑΙ ΤΟΠΙΚΟΥ ΝΕΦΡΟΥ
• ÀÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ ·ÛıÂÓ›˜.
Εθνικός Νεφρός
OÈ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ Ï‹Ù˜ ¤¯Ô˘Ó ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙËÓ ∂ıÓÈ΋ §›ÛÙ· ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ ÙÔ˘ ∂.O.ª. £ÂˆÚÔ‡ÓÙ·È fiÏÔÈ fiÛÔÈ ¤¯Ô˘Ó Ù›ÙÏÔ Î˘ÙÙ·ÚÔÙÔÍÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ > 70 %. ÀÔ¯ÚÂÒÓÔÓÙ·È Û ¤ÏÂÁ¯Ô ·ÓÙÈÛˆÌ¿ÙˆÓ ·Ó¿ ÙÚ›ÌËÓÔ. ∫ÚÈÙ‹ÚÈ· ÁÈ· Ó· ÚÔ¯ˆÚ‹ÛÔ˘Ó Û crossmatch ›ӷÈ: ABO Û˘Ì‚·ÙfiÙËÙ· Î·È Û˘Ì‚·ÙfiÙËÙ· Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ 1 HLA-∞ ‹ μ Î·È 1 HLA-DR. Ÿ¯È ÌË – ·Ô‰ÂÎÙ¿ ·ÓÙÈÁfiÓ· ÛÙÔ ‰fiÙË.
Στον πρώτο ασθενή της εθνικής λίστας που προκύπτει από το παραπάνω σύστημα μοριοδότησης
Τοπικός Νεφρός Στον πρώτο ασθενή της τοπικής λίστας του μεταμοσχευτικού κέντρου που έκανε την αφαίρεση
ΠΑΡΑΔΕΙΓΜΑ ΔΟΤΗ ΣΤΟ ΑΧΕΠΑ ΘΕΣΣΑΛΟΝΙΚΗΣ ΔΟΤΗΣ ΣΤΟ ΑΧΕΠΑ
Τοπικός νεφρός Παραμένει στον 1ο της τοπικής λίστας του Ιπποκρατείου
Εθνικός νεφρός Αφαιρεί το Ιπποκράτειο Θεσσαλονίκης
¶¤Ú· ·fi ÙȘ ÛËÌ·ÓÙÈΤ˜ ÂÈÛÙËÌÔÓÈΤ˜ ÂÍÂÏ›ÍÂȘ ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Ó ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Î·È ÙËÓ ÚfiÔ‰Ô Ô˘ ÛËÌÂÈÒÓÂÙ·È ÛÙÔÓ ÔÚÁ·ÓˆÙÈÎfi ÙÔ̤·, Ë È·ÙÚÈ΋ Î·È ÂÈÛÙËÌÔÓÈ΋ ÏÂ˘Ú¿ ·ÔÙÂÏ› ÙË ªπ∞ fi„Ë ÙÔ˘ ˙ËÙ‹Ì·ÙÔ˜, Ë ÔÔ›· Â›Ó·È Î·È Ô ÙÂÏÂ˘Ù·›Ô˜ ÎÚ›ÎÔ˜ Ù˘ ‰È·‰Èηۛ·˜ ·ÊÔ‡ ÚÔËÁËı› Ë ‚·ıÈ¿, ·ÓıÚÒÈÓË, ÎÔÈÓˆÓÈ΋ Î·È ËıÈ΋ fi„Ë ÙÔ˘.
Διανέμεται στον 1ο της εθνικής λίστας
∂ΛÓÔ Ô˘ ÚÔËÁÂ›Ù·È fiÏˆÓ Â›Ó·È ÙÔ ·ÓıÚÒÈÓÔ ÌÂÁ·Ï›Ô, ηıÒ˜ ÙËÓ ÒÚ· Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ Ô‰‡Ó˘ ÁÈ· ÙËÓ ·ÒÏÂÈ· ·Á·Ë̤ÓÔ˘ ÚÔÛÒÔ˘, Ô ÕÓıÚˆÔ˜ Ì ÌfiÓÔ ÙÔ˘ ΛÓËÙÚÔ ÙËÓ ·Á¿Ë, ÙÔÓ ·ÏÙÚÔ˘˚ÛÌfi Î·È ÙË ÁÂÓÓ·ÈÔ‰ˆÚ›· ÙÔ˘, ·ÔÊ·Û›˙ÂÈ, ˘ÂÚ‚·›ÓÔÓÙ·˜ ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ fiÓÔ Ó· ÁÂÊ˘ÚÒÛÂÈ ÙË ˙ˆ‹ Ì ÙÔ ı¿Ó·ÙÔ.
OÈ Û˘Ó¤ÂȘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Î·È Ù˘ Û˘ÓÙ‹ÚËÛ˘ ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ‰fiÙË ÛÙË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË Î·È ‚ȈÛÈÌfiÙËÙ· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ
5
NÈÎfiÏ·Ô˜ AÓÙˆÓÈ¿‰Ë˜
∂ÈÛ·ÁˆÁ‹
Ì›· ηٿÛÙ·ÛË Ô˘ ‰È·Ù·Ú¿ÛÛÂÈ ÙË Ê˘ÛÈÔÏÔÁ›· Î·È ÙË ÌÔÚÊÔÏÔÁ›· fiÏˆÓ ÙˆÓ Û˘ÛÙËÌ¿ÙˆÓ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ÂÓÂÚÁÔÔÈÒÓÙ·˜ ÌË ÂȉÈΤ˜ ÊÏÂÁÌÔÓÒ‰ÂȘ ‰ÈÂÚÁ·Û›Â˜ ÛÙ· fiÚÁ·Ó· ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ÌÔÛ¯Â˘Ì¿ÙˆÓ. ªÂÙ¿ ÙËÓ ÂÁηٿÛÙ·ÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Û˘Ì‚·›ÓÂÈ Ì›· ÛÂÈÚ¿ ·fi Ó¢ÚÈΤ˜, ÔÚÌÔÓÈΤ˜ Î·È Î˘ÙÙ·ÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î˘ÙÙ·ÚÈ΋ ‚Ï¿‚Ë Î·È ÙË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË. ™Â ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜, ÂÈÙ·¯‡ÓÂÙ·È Ë ÂÌÊ¿ÓÈÛË ÔÍ›·˜ ·fiÚÚȄ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È·ÎÒÓ, ÓÂÊÚÈÎÒÓ Î·È Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜ Ô˘ ·Ô‰›‰ÂÙ·È ÛÙËÓ ·‡ÍËÛË Ù˘ ·ÓÙÈÁÔÓÈÎfiÙËÙ·˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÙËÓ ‹‰Ë ÂÓÂÚÁÔÔÈË̤ÓË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË Û ·˘Ù¿.5,6,7 ÀÔÛÙËÚ›˙ÂÙ·È Ï¤ÔÓ fiÙÈ Ù· ÌÔۯ‡̷ٷ, ȉȷ›ÙÂÚ· ·fi ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜, ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜ (ÌË È‰·ÓÈÎÔ› ‰fiÙ˜) ÌÔÚ› Ó· Â›Ó·È “ÚÔÁÚ·ÌÌ·ÙÈṲ̂ӷ” ÁÈ· Ó· ÍÂÎÈÓ‹ÛÔ˘Ó ‹ Ó· ÂÓÈÛ¯‡ÛÔ˘Ó ÙȘ ·ÎfiÏÔ˘ı˜ ·ÓÔÛÔÏÔÁÈΤ˜ ·ÓÙȉڿÛÂȘ ÛÙÔÓ Ï‹ÙË. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹, Ë Û‡ÌÊ˘ÙË ·ÓÔÛ›· (innate immunity) ·ÏÏËÏÔÂȉڿ Ì ÙË ıÂÙ‹ ·ÓÔÛ›· (adoptive immunity) Î·È ¤ÙÛÈ Ë ·Ú¯È΋ ÊÏÂÁÌÔÓ҉˘ ‚Ï¿‚Ë ‰ÈÂÁ›ÚÂÈ ÙËÓ ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ̤ۈ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ Î·È ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡, Ù˘ ÂÓÂÚÁÔÔ›ËÛË ÚfiÛıÂÙˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ¿ÚˆÓ, Ù˘ ÂÓ›Û¯˘Û˘ Ù˘ ‰È·Î›ÓËÛ˘ ‰ÂÓ‰ÚÈÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ì¤Û· ÛÙÔ ÌfiÛ¯Â˘Ì·, Ù˘ ·‡ÍËÛ˘ Ù˘ ¤ÎÊÚ·Û˘ ÙˆÓ ÌÔÚ›ˆÓ ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (MHC) Î·È ÙˆÓ ÌÔÚ›ˆÓ Û˘Ó‰È¤ÁÂÚÛ˘ Î·È Â›Û˘ ̤ۈ Ù˘ ÂÓ›Û¯˘Û˘ Ù˘ ‰È·ÊÔÚÔÔ›ËÛ˘ ÙˆÓ Δ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ.8 ¢ÂÓ ¤¯ÂÈ ·Ô‰ÂȯÙ› ÎÏÈÓÈο Â¿Ó ÔÈ ÊÏÂÁÌÔÓÒ‰ÂȘ ‰ÈÂÚÁ·Û›Â˜ ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ‰fiÙË Î·Ù¿ ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÙˆÓ Ó¢ÚÔÔÚÌÔÓÈÎÒÓ ‹ ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ‹ ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ. ∂›Ó·È fï˜ ·ÓÙÈÏËÙ‹ Ë ÌÂÁ¿-
ΔȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÛÙÔ Â‰›Ô ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛËÌÂÈÒıËÎ·Ó ÛËÌ·ÓÙÈΤ˜ ÚfiÔ‰ÔÈ Ô˘ ÂÚÈÏ¿Ì‚·Ó·Ó ÙËÓ ÙÂÏÂÈÔÔ›ËÛË ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ, ÙËÓ Î·Ï‡ÙÂÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ Î·È ÙËÓ ÂͤÏÈÍË Ó¤·˜ ÁÂÓÈ¿˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ. ¶·Ú·Ù·‡Ù· Ô ·fiÏ˘ÙÔ˜ ÛÙfi¯Ô˜ Ù˘ ÈÛfi‚È·˜ Î·È ·Ó›ÏÂÎÙ˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÂÓ ¤¯ÂÈ ÂÈÙ¢¯ı›, Ì ٷ ·ÚÈ· ÚÔ‚Ï‹Ì·Ù· Ó· ·Ú·Ì¤ÓÔ˘Ó Ë ¯ÚfiÓÈ· ·fiÚÚÈ„Ë Î·È Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∂ÈÚfiÛıÂÙ· Â›Ó·È Ï¤ÔÓ ·ÓÙÈÏËÙfi fiÙÈ ÌË ·ÓÔÛÔÏÔÁÈΤ˜, ÌË ·ÓÙÈÁÔÓÈο ÚÔÎÏ˘fiÌÂÓ˜ ‰ÈÂÚÁ·Û›Â˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ‚Ï¿‚˘ ÛÙÔ ÌfiÛ¯Â˘Ì· ÂËÚ¿˙ÔÓÙ·˜ ÙËÓ ÚÒÈÌË ·ÏÏ¿ Î·È ÙËÓ ÌÂÙ·ÁÂÓ¤ÛÙÂÚË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿ ÙÔ˘.1 Δ· ÂÚÈÛÛfiÙÂÚ· fiÚÁ·Ó· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÌÔۯ‡̷ٷ ÚÔ¤Ú¯ÔÓÙ·È ·fi و̷ÙÈÎÔ‡˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜. ∞fi ÙËÓ ·Ú¯‹ Ù˘ ÎÏÈÓÈ΋˜ ÂÊ·ÚÌÔÁ‹˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·Ú·ÙËÚ‹ıËΠfiÙÈ ÔÈ ÓÂÊÚÔ› ·fi ÙÔ˘˜ ˙ÒÓÙ˜ ‰fiÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ï‡ÙÂÚË ÏÂÈÙÔ˘ÚÁ›· ·fi Ù· ÓÂÊÚÈο ÌÔۯ‡̷ٷ و̷ÙÈÎÒÓ ‰ÔÙÒÓ.2 ∏ ‡·ÚÍË ÌË ·ÓÔÛÔÏÔÁÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ‰ÈÂÚÁ·ÛÈÒÓ Î·Ù·‰ÂÈÎÓ‡ÂÙ·È ·fi ÙÔ fiÙÈ Û˘ÁÎÚÈÙÈο Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ˙ˆÓÙ·ÓÔ‡˜ ÌË Û˘ÁÁÂÓ›˜ ‰fiÙ˜ Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù¿ ·fi ÚÒÙÔ˘ ‚·ıÌÔ‡ Û˘ÁÁÂÓ›˜ (ÎÔÈÓfi˜ ·ÏfiÙ˘Ô˜ ÌÂٷ͇ ‰fiÙË - Ï‹ÙË) ‰fiÙ˜ Î·È Â›Ó·È ÛÙ·ıÂÚ¿ ηχÙÂÚ· ·fi Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜.3 ∞˘Ù‹ Ë ‰È·ÊÔÚ¿ Ê·›ÓÂÙ·È Ó· ÌËÓ Â›Ó·È ·ÔÎÏÂÈÛÙÈο Û˘Ó¤ÂÈ· ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ·ÏÏ¿ Û˘Ì‚¿ÏÏÔ˘Ó Î·È ÔÈ ·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Ô˘ ¢ı‡ÓÔÓÙ·È ÁÈ· ÙȘ ÌË ÂȉÈΤ˜, ÏÂÈÙÔ˘ÚÁÈΤ˜ Î·È ÌÔÚÊÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ÛÙ· ÌÔۯ‡̷ٷ.4 O ÂÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜ ›ӷÈ
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÏË ÛËÌ·Û›· Ù˘ ÛˆÛÙ‹˜ ÂÓÙ·ÙÈ΋˜ ıÂڷ¢ÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË, ȉȷ›ÙÂÚ· ÙÔ˘ ÌË È‰·ÓÈÎÔ‡ ·ÛÙ·ı‹ ‰fiÙË, Î·È ÙË ıÂÙÈ΋ ›‰Ú·ÛË Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ ÛÙËÓ ÚÒÈÌË Î·È ÌÂÙ·ÁÂÓ¤ÛÙÂÚË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ.
OÈ ·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ∂ÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜ ηıÔÚ›˙ÂÙ·È Ë Î·Ù¿ÛÙ·ÛË Ï‹ÚÔ˘˜ Î·È ÌË ·Ó·ÛÙÚ¤„ÈÌ˘ ηٿÚÁËÛ˘ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜.9 ™ÙÔÓ ÂÁÎÂÊ·ÏÈο ÓÂÎÚfi ·ÛıÂÓ‹ ÔÈ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙˆÓ ˘ÔÏÔ›ˆÓ Û˘ÛÙËÌ¿ÙˆÓ ÌÔÚÔ‡Ó Ó· ‰È·ÙËÚËıÔ‡Ó ÌfiÓÔ Ì ÂÓÙ·ÙÈ΋ ıÂڷ¢ÙÈ΋ ˘ÔÛÙ‹ÚÈÍË Î·È Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. ∏ ÂÁÎÂÊ·ÏÈ΋ ‚Ï¿‚Ë Ô˘ Ô‰ËÁ› ÛÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ Û˘Ó‹ıˆ˜ ÚÔηÏÂ›Ù·È ·fi ÂÓ‰ÔÎÚ¿ÓÈ· ·ÈÌÔÚÚ·Á›· ‹ ÂÁÎÂÊ·ÏÈ΋ οΈÛË. ¶ÈÔ Û¿ÓȘ ·Èٛ˜ ·ÔÙÂÏÔ‡Ó ÙÔ ÂÁÎÂÊ·ÏÈÎfi ·fiÛÙËÌ·, Ô fiÁÎÔ˜ ÂÁÎÂÊ¿ÏÔ˘, Ë ÌËÓÈÁÁ›Ùȉ· ‹ Ë ÂÁÎÂÊ·Ï›Ùȉ·. ∞˘Ù¤˜ ÔÈ ÂÚÈÙÒÛÂȘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ¯ˆÚÔηٷÎÙËÙÈ΋ ȉÈfiÙËÙ· ÛÙËÓ ÔÔ›· ÔÊ›ÏÂÙ·È Ë Û˘Ì›ÂÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÈÛÙÔ‡ Î·È Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ·Ô¯¤Ù¢Û˘ ÙˆÓ ˘ÁÚÒÓ Î·È Ù˘ ÊÏ‚È΋˜ ·ӷÊÔÚ¿˜, ÚÔηÏÒÓÙ·˜ ¤ÙÛÈ ÂÁÎÂÊ·ÏÈ΋ ˘ÔÍ›· Î·È Ô›‰ËÌ· Ô˘ Ô‰ËÁÔ‡Ó Û ÂÚ·ÈÙ¤Úˆ ·‡ÍËÛË Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘.10 ∞ÎÔÏÔ˘ı› Û˘Ì›ÂÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜, Ì ÂÁÎÔÏ·ÛÌfi ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜ ̤۷ ÛÙÔ ÈÓÈ·Îfi ÙÚ‹Ì· Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ·‡ÛË. ∏ ·fiÊÚ·ÍË ÂΠȤÛˆ˜ ÙˆÓ ·ÚÂÁ¯˘Ì·ÙÈÎÒÓ Î·È ‚·ÛÈÎÒÓ ·ÚÙËÚÈÒÓ ÂÈʤÚÂÈ ÙËÓ Ï‹ÚË ÂÁÎÂÊ·ÏÈ΋ ÈÛ¯·ÈÌ›· Î·È ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤‰ÂÈÍ·Ó fiÙÈ Ô ÂÁÎÔÏ·ÛÌfi˜ ·ÔÙÂÏ› ÌÈ· ÈÛ¯·ÈÌÈ΋ ‰È·‰Èηۛ· Ô˘ ÍÂÎÈÓ¿ÂÈ ·fi ÙÔÓ ÌÂÛÂÁΤʷÏÔ ÚÔ˜ ÙË Á¤Ê˘Ú· Î·È ÙÔÓ ÚÔÌ‹ÎË Ì˘ÂÏfi, ÁÈ· Ó· ÂÚÈÏ¿‚ÂÈ ÛÙÔ Ù¤ÏÔ˜ Î·È ÙÔ ÓˆÙÈ·›Ô Ì˘ÂÏfi.11 ¶ÚÔ˜ ÙÔ Ù¤ÏÔ˜ Ù˘ ‰È·‰Èηۛ·˜, fiÙ·Ó Ô ÚÔÌ‹Î˘ Ì˘ÂÏfi˜ Á›ÓÂÙ·È ÈÛ¯·ÈÌÈÎfi˜, fiÏË Ë ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ Ó¢ÌÔÁ·ÛÙÚÈÎÔ‡ ηٷÚÁÂ›Ù·È Î·È ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÌfiÓÔ ÛÙËÓ ·ÓÂÌfi‰ÈÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÂÎÙÂٷ̤ÓË ‰È¿¯˘ÛË Î·Ù¯ÔÏ·ÌÈÓÒÓ, ˆ˜ Ì›· ÙÂÏÈ΋ ÚÔÛ¿ıÂÈ· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ó· ‰È·ÙËÚ‹ÛÂÈ ÙËÓ ·ÈÌ¿ÙˆÛË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Î·È ÂΉËÏÒÓÂÙ·È Ì ٷ¯˘Î·Ú‰›·, ˘¤ÚÙ·ÛË, ˘ÂÚıÂÚÌ›· Î·È ‰ÈÏ¿ÛÈ· Ì ÙÚÈÏ¿ÛÈ· ·‡ÍËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜.11 °È’ ·˘Ùfi ÙÔ ÎÏÈÓÈÎfi Ê·ÈÓfiÌÂÓÔ Î·ıÈÂÚÒıËÎÂ Ô fiÚÔ˜ ı‡ÂÏÏ· η-
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Ù¯ÔÏ·ÌÈÓÒÓ ‹ “autonomic storm”. ∞˘ÍË̤ӷ ›‰· ηÙ¯ÔÏ·ÌÈÓÒÓ ÚÔηÏÔ‡Ó ·ÚÚ˘ı̛˜ Î·È ÌÔÚ› Ó· ÂÈʤÚÔ˘Ó Î·Ú‰È·Î‹ ÈÛ¯·ÈÌ›·. O ¤ÓÙÔÓÔ˜ ÂÚÈÊÂÚÈÎfi˜ ·ÁÁÂÈfiÛ·ÛÌÔ˜ ·˘Í¿ÓÂÈ ÙËÓ ÊÏ‚È΋ ·ӷÊÔÚ¿ ÚÔ˜ ÙË ‰ÂÍÈ¿ ηډȿ Î·È ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙËÓ Î·Ú‰È·Î‹ ·ÚÔ¯‹, Û˘ÌÌÂÙ¤¯ÔÓÙ·˜ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ηٿ ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ. ∏ Û˘Ì·ıËÙÈ΋ ‰È¤ÁÂÚÛË Î·È ÔÈ ·˘ÍË̤Ó˜ ÂÓ‰ÔÁÂÓ›˜ ηÙ¯ÔϷ̛Ә ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÈÛ¯·ÈÌ›· ÙˆÓ ÔÚÁ¿ÓˆÓ ÏfiÁˆ ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ ÙȘ Ôԛ˜ ‰ÂÓ ÌÔÚ› Ó· ˘Âڂ› Ë ·˘ÍË̤ÓË ›ÂÛË ·ÈÌ¿ÙˆÛ˘. ™˘Óԉ‡ÂÙ·È ·fi ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ·fi ·ÂÚfi‚ÈÔ Û ·Ó·ÂÚfi‚ÈÔ, ·‡ÍËÛË ÙÔ˘ ΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÔ‡ ·Û‚ÂÛÙ›Ô˘, ÂÏ¿ÙÙˆÛË Ù˘ ÙÚÈʈÛÊÔÚÈ΋˜ ·‰ÂÓÔÛ›Ó˘ (ATP), Û˘ÛÛÒÚ¢ÛË Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ, ÂÍ¿ÓÙÏËÛË ÙˆÓ Ë·ÙÈÎÒÓ ÂʉÚÂÈÒÓ Û ÁÏ˘ÎÔÁfiÓÔ, ·Ú·ÁˆÁ‹ ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ, ·ÒÏÂÈ· Ù˘ Ú‡ıÌÈÛ˘ Ù˘ ıÂÚÌÔÎÚ·Û›·˜ Î·È ·fi ÌÂÙ·‚ÔϤ˜ ÛÙȘ ÌÈÙÔ¯ÔÓ‰ÚȷΤ˜ ÌÂÌ‚Ú¿Ó˜. ΔËÓ ı‡ÂÏÏ· ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ ·ÎÔÏÔ˘ı› Ì›· ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ Û˘Ì·ıËÙÈÎÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ Ô˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ Ê¿Û˘ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ‹ ¯·ÌËÏ¿ ·ÚÙËÚȷ΋ ›ÂÛË. ª›· ·fi ÙȘ ·Èٛ˜ Ù˘ ˘fiÙ·Û˘ Â›Ó·È Ë ·ÒÏÂÈ· Ù˘ Ú˘ıÌÈÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ·˘ÙfiÓÔÌÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ì ·ÎfiÏÔ˘ıÔ ÙËÓ ·ÓÂÌfi‰ÈÛÙË ·ÁÁÂÈԉȷÛÙÔÏ‹ Î·È ÙËÓ ÂÏ·Ùو̤ÓË ÈÓfiÙÚÔÔ Â›‰ÔÛË ÙÔ˘ Ì˘Ôηډ›Ô˘. ∏ ÂÈÎfiÓ· ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Ì ÙȘ ¯·ÔÙÈΤ˜ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÂÚÈÁÚ¿ÊÂÙ·È ÛÙÔ 50 % ÙˆÓ ÂÚÈÙÒÛˆÓ. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÛÙ· ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Ô ‚·ıÌfi˜ Ù˘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ‰È·Ù·Ú·¯‹˜ Î·È Û˘Óԉ¢fiÌÂÓˆÓ ÂÈÙÒÛÂˆÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Ù·¯‡ÙËÙ· ÂÈÛfi‰Ô˘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Î·È ÙÔÓ Ú˘ıÌfi ·‡ÍËÛ˘ Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘.12,13 ∞˘Ù¤˜ ÔÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ÛËÌ·ÓÙÈ΋ ÈÛ¯·ÈÌÈ΋ Î·È ÊÏÂÁÌÔÓÒ‰Ë ‚Ï¿‚Ë ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ‰fiÙË Ì ·ÎfiÏÔ˘ıÔ ÙËÓ ÂËÚ·Ṳ̂ÓË ÏÂÈÙÔ˘ÚÁ›· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘Û‹ ÙÔ˘˜. OÈ ÂÓ‰ÔÎÚÈÓÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÔÊ›ÏÔÓÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ·Ó¿ÚÎÂÈ· ÙÔ˘ ¿ÍÔÓ· ˘Ôı·Ï¿ÌÔ˘ – ˘fiÊ˘Û˘, Ô˘ ¯·Ú·ÎÙËÚÈÛÙÈο ÂΉËÏÒÓÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÂÈÔ˘ ‰È·‚‹ÙË, ·ÏÏ¿ ›Ûˆ˜ Î·È ÛÙËÓ ·Ó¿ÚÎÂÈ· ÙÔ˘ ¿ÍÔÓ· ˘fiÊ˘Û˘ – ı˘ÚÂÔÂȉ‹.11 ŸÌˆ˜, Û οÔÈÔ˘˜ ·ÛıÂÓ›˜ ‰È·ÙËÚÔ‡ÓÙ·È Î¿ÔÈ· ÛËÌ›· ÙÔ˘ Ô›ÛıÈÔ˘ ÏÔ‚Ô‡ Ù˘ ˘fiÊ˘Û˘. ∂›Û˘, ¤ˆ˜ Î·È 1 ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ ÂÁηٿÛÙ·-
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N. ANTøNIA¢H™
ÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ¤¯Ô˘Ó ·Ó¢ÚÂı› ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›· ÔÚÌfiÓ˜ Ù˘ ÚfiÛıÈ·˜ ˘fiÊ˘Û˘ (ACTH, TSH). ¢ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÔÓÙ·È È‰È·›ÙÂÚ· Ù· ›‰· ÎÔÚÙÈ˙fiÏ˘, ÈÓÛÔ˘Ï›Ó˘ Î·È Ó·ÙÚÈÔ˘ÚËÙÈÎÔ‡ ÂÙȉ›Ô˘ ÙÔ˘ ÎfiÏÔ˘, ηıÒ˜ Î·È Ô ¿ÍÔÓ·˜ ÚÂÓ›Ó˘ – ·ÁÁÂÈÔÙÂÓÛ›Ó˘ – ·Ï‰ÔÛÙÂÚfiÓ˘.11
OÈ ·ÏÏÔÈÒÛÂȘ ÛÙ· fiÚÁ·Ó· Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ˘¿Ú¯ÂÈ ·ÚÎÂÙfi ÂӉȷʤÚÔÓ ÛÙÔ Ó· ‰È¢ÎÚÈÓÈÛÙ›, ÂÈÚ·Ì·ÙÈο ΢ڛˆ˜ ·ÏÏ¿ Î·È ÎÏÈÓÈο, Â¿Ó Î·È ˆ˜ Ô ÂÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜ ¤¯ÂÈ ÂÈÙÒÛÂȘ ÛÙËÓ ÚÒÈÌË ·ÏÏ¿ Î·È ÙËÓ ÌÂÙ¤ÂÈÙ· ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÔÚÁ¿ÓˆÓ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È. OÈ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ (Ë ˘¤ÚÙ·ÛË ÛÙËÓ ·Ú¯È΋ Ê¿ÛË Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ë ˘fiÙ·ÛË Î·È Ë ¯·ÌËÏ‹ ÚÔ‹ ·ÈÌ¿ÙˆÛ˘) ›Ûˆ˜ Â›Ó·È Ë ·ÈÙ›· Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ‚Ï·ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ ÌÈ¿˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓ‰ÔıËÏȷ΋˜ ·ÓÙ›‰Ú·Û˘. ∞˘Ù¤˜ ÔÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Èı·ÓÒ˜ ÚÔηÏÔ‡Ó οÔÈÔ˘ ‚·ıÌÔ‡ ÂÓ‰ÔıËÏȷ΋˜ ‰È·ÙÌËÙÈ΋˜ Ù¿Û˘ (shear stress) ÛÙ· ·ÁÁ›· ÙˆÓ ÔÚÁ¿ÓˆÓ, Ë ÔÔ›· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi Ì›· ÂÚ›Ô‰Ô ·ÁÁÂÈfiÛ·ÛÌÔ˘ Ô˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÚÔ‰È΋ ÈÛ¯·ÈÌ›· ÙˆÓ ÔÚÁ¿ÓˆÓ.14 ΔÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ‰È·ÙÌËÙÈ΋˜ Ù¿Û˘ ÛÙ· ·ÁÁ›· Î·È Ë ÈÛ¯·ÈÌ›· Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÌÔÚÔ‡Ó Ó· ÂÓÂÚÁÔÔÈ‹ÛÔ˘Ó ÙÔ ÂÓ‰Ôı‹ÏÈÔ Î·È Ó· ˘ÚÔ‰ÔÙ‹ÛÔ˘Ó ÙË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË.15 ¶·ÚfiÌÔȘ Ì ÙȘ ÔÍ›˜ ÌÔÚÊÔÏÔÁÈΤ˜ Î·È ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ÔÚÁ¿ÓˆÓ ηٿ ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ Â›Ó·È Î·È ·˘Ù¤˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ‚Ï¿‚˘ ·fi ÈÛ¯·ÈÌ›· – ·ӷÈÌ¿ÙˆÛË.16 ∞˘Ùfi ˘Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ Û˘Û¯¤ÙÈÛË Ô˘ ˘¿Ú¯ÂÈ ÌÂٷ͇ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Î·È ÈÛ¯·ÈÌ›·˜. Δ· ·˘ÍË̤ӷ ›‰· ηÙ¯ÔÏ·ÌÈÓÒÓ, ÂÎÙfi˜ ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÂÈÙÒÛÂÒÓ ÙÔ˘˜, ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ÌÔÚÊÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ÛÙËÓ Î·Ú‰È¿.17 ∞ÊÔÚÔ‡Ó È‰È·›ÙÂÚ· ÙÔ ˘ÂÓ‰ÔοډÈÔ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Î·È Û˘Ó›ÛÙ·ÓÙ·È ·fi ÂÙ¯ÂÈÒ‰Ë ·ÈÌÔÚÚ·Á›· Î·È ËÎÙÈ΋ Ì˘Ô΢ÙÙ·ÚfiÏ˘ÛË (coagulative myocytolysis) Ì ‰È‹ıËÛË ·fi ÌÔÓÔ·ÙÙ·Ú·.18 ¡¤ÎÚˆÛË Ì˘Ôηډ›Ô˘ Ì ·ÚÔ˘Û›· ˙ˆÓÒÓ Û˘ÛÙÔÏ‹˜ ‚Ú¤ıËΠ۠¿ÙÔÌ· Ô˘ ÂÈ‚›ˆÛ·Ó ÁÈ· ·Ú·ÙÂٷ̤ÓÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÙ¿ ·fi ÂÓ‰ÔÎÚ¿ÓÈ· ·ÈÌÔÚÚ·Á›·. ¶ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ÔÍ›· ÂÁηٿÛÙ·ÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Ô˘ ÚÔÎÏ‹ıËΠ·fi ·˘ÍË̤ÓË ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÚÔ‰È-
΋ ·‡ÍËÛË ÛÙÔ Ì˘ÔοډÈÔ Ù˘ ·‰ÂÓÔÛ›Ó˘ Î·È ÙÔ˘ Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ, Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ Î·Ù¿ ÙË Ê¿ÛË Ù˘ ı‡ÂÏÏ·˜ ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ ÔÈ ··ÈÙ‹ÛÂȘ ÁÈ· Ô͢ÁfiÓÔ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚ˜ Î·È ‰ÂÓ Î·Ï‡ÙÔÓÙ·È.19 ™Â ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Û ÂÈÚ·Ì·Ùfi˙ˆ· Ë ÚÔÛÔÌÔ›ˆÛË Ù˘ ı‡ÂÏÏ·˜ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÔοÏÂÛ ·ÚÔ‰È΋ Û˘ÛÙ·ÏÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙËÓ ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Î·Ù¿ ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ.20 ¶·ÚfiÌÔȘ ‚Ï¿‚˜ ·Ú·ÙËÚ‹ıËÎ·Ó Û ·ÛıÂÓ›˜ Ô˘ ¤ı·Ó·Ó ·fi Ô͇ ÈÛ¯·ÈÌÈο ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È Û ˙Ò· Ô˘ ÙÔ˘˜ ¯ÔÚËÁ‹ıËÎ·Ó Â͈ÁÂÓÒ˜ ηÙ¯ÔϷ̛Ә.17 ∂ÈÚfiÛıÂÙ· ÙˆÓ ·˘ÍËÌ¤ÓˆÓ ÂȤ‰ˆÓ ηÙ¯ÔÏ·ÌÈÓÒÓ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·, ÛÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ ·˘Í¿ÓÂÈ Ë ÂÍˆÎ˘ÙÙ¿ÚÈ· ·ÂÏ¢ı¤ÚˆÛË Ù˘ ÓÔÚ·‰ÚÂÓ·Ï›Ó˘ ·fi ÙȘ ·ÔÏ‹ÍÂȘ ÙˆÓ Û˘Ì·ıËÙÈÎÒÓ Ó¢ÚÈÎÒÓ ÈÓÒÓ ÛÙË Î·Ú‰È¿.21 ŒÙÛÈ, ·ÎfiÌË Î·È Û ηϿ ·ÈÌ·ÙÔ‡ÌÂÓË Î·Ú‰È¿ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Ì˘Ôηډȷ΋ Ó¤ÎÚˆÛË Ë ÔÔ›· ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ fi¯È ÌfiÓÔ ÙȘ ·ÏÏÔÁÂÓ›˜ ·ÓÔÛÔÏÔÁÈΤ˜ ·ÓÙȉڿÛÂȘ ·ÏÏ¿ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· Ì·ÎÚÔÚfiıÂÛÌ˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ Ï‹ÙË. ∫ÏÈÓÈΤ˜ ÌÂϤÙ˜ ÂȂ‚·ÈÒÓÔ˘Ó ÙË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Î·È ÂÂÈÛÔ‰›ˆÓ ·fiÚÚȄ˘ ÙˆÓ Î·Ú‰È·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ª›· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ¤‰ÂÈÍ fiÙÈ ÔÈ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ô˘ ˘¤ÛÙËÛ·Ó ÙÚ·˘Ì·ÙÈΤ˜ ηÎÒÛÂȘ ·ÚÔ˘Û›·Û·Ó ÌÂÙÂÁ¯ÂÈÚËÙÈο ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ·fiÚÚȄ˘ Û ۇÁÎÚÈÛË Ì ϋÙ˜ Ô˘ ¤Ï·‚·Ó ηډȷο ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì ˘·Ú·¯ÓÔÂȉ‹ ·ÈÌÔÚÚ·Á›·.22 O ÙÚfiÔ˜ Ô˘ ÚÔÎÏ‹ıËÎÂ Ô ÂÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜ ‰ÂÓ ÂËÚ¤·Û ÛËÌ·ÓÙÈο ÙËÓ ÚÒÈÌË Î·È Ì·ÎÚÔÚfiıÂÛÌË ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÂËÚ¤·Û fï˜ ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ·ÔÚÚ›„ˆÓ. ∂›Û˘, Ê¿ÓËΠfiÙÈ Ë ·Ú·ÙÂٷ̤ÓË, ¿Óˆ ·fi 72, ÒÚ˜ ÓÔÛËÏ›· ÛÙË ª.∂.£. Û¯ÂÙ›˙ÂÙ·È Ì ÂÌÊ¿ÓÈÛË ‰˘ÛÌÂÓÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÂÈ‚›ˆÛ˘ ÛÙÔ˘˜ Ï‹Ù˜ ηډȷÎÔ‡ ÌÔۯ‡̷ÙÔ˜.22 ™Â ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ÔÈ ÌÔÚÊÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÙÔ˘ Ì˘Ôηډ›Ô˘, Ô˘ ·Ô‰›‰ÔÓÙ·È ÛÙËÓ ˘¤ÚÌÂÙÚË ·ÂÏ¢ı¤ÚˆÛË Î·Ù¯ÔÏ·ÌÈÓÒÓ, ÌÂÈÒÓÔÓÙ·È ÛËÌ·ÓÙÈο fiÙ·Ó Ô ÂÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜ ÚÔηÏÂ›Ù·È ·fi ‚·ıÌÈ·›· ·‡ÍËÛË Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘.23 ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛËÌ·ÓÙÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÛÙȘ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜. OÈ ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ ÂÓÈÛ¯‡Ô˘Ó ÙÔÓ Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ ÛÙËÓ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÔÈfiÙËÙ· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ÈÛÙÈ΋ ‚Ï¿‚Ë ÏfiÁˆ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ÂÓÂÚÁÔÔÈ› (ÂÈÚ·Ì·ÙÈο) Ï¢ÎÔ·ÙÙ·Ú· Î·È ÚÔÊÏÂÁÌÔÓÒ‰ÂȘ ÌÂÛÔÏ·‚ËÙ¤˜ (΢ÙÙ·ÚÔΛÓ˜, ¯ËÌÂÈÔΛÓ˜, ÌfiÚÈ· Û˘ÁÎfiÏÏËÛ˘) ÛÙ· ηډȷο ÌÔۯ‡̷ٷ Ì ·ÎfiÏÔ˘ıÔ ÙËÓ ÂÌÊ¿ÓÈÛË ÂÓÙÔÓfiÙÂÚˆÓ ÙˆÓ ·ÓÙȉڿÛÂˆÓ Ù˘ ÈÛ¯·ÈÌ›·˜ – ·ӷÈÌ¿ÙˆÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.24 ∏ ÈÛ¯·ÈÌ›· ÏfiÁˆ ·Ú·ÙÂٷ̤Ó˘ Û˘ÛÙËÌ·ÙÈ΋˜ ˘fiÙ·Û˘, ·ÓÂÍ¿ÚÙËÙ· ·ÈÙÈÔÏÔÁ›·˜, ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ Î‡ÚÈ· ·ÈÙ›· ÓÂÊÚÈ΋˜ ‚Ï¿‚˘. ∂ȉÈÎfiÙÂÚ· Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÌÔÚ› Ó· ÂËÚ·ÛÙ› ¿ÌÂÛ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏfiÁˆ ÙˆÓ Î·Ú‰ÈÔ·ÁÁÂÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ, ÂÓ Ì¤ÚÂÈ ÏfiÁˆ ÙÔ˘ ¤ÓÙÔÓÔ˘ ·ÁÁÂÈfiÛ·ÛÌÔ˘ Ô˘ Û˘Ì‚·›ÓÂÈ Î·Ù¿ ÙË ı‡ÂÏÏ· ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ. À„ËÏfi ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ÔÍ›·˜ ÛˆÏËÓ·Úȷ΋˜ Ó¤ÎÚˆÛ˘ ¤¯ÂÈ ·Ú·ÙËÚËı› Û ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·fi ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜.25 OÈ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔ ÓÂÊÚfi ˘fi Û˘Óı‹Î˜ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ¿ÌÂÛË ¤Ó·ÚÍË ÂÎÙÂٷ̤Ó˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ˘ÂÚ·ÈÌ›·˜, ÙËÓ ·Ó¿Ù˘ÍË ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜, ˘ÂÚÏ·Û›·˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Î·È ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜. ª¤Û· Û 3 Ë̤Ú˜ ·fi ÙËÓ ÂÁηٿÛÙ·ÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ·Ú·ÙËÚ‹ıËΠ۷ʋ˜ ÂÎʇÏÈÛË, ·ÙÚÔÊ›· Î·È Ó¤ÎÚˆÛË ÙˆÓ ÛˆÏËÓ·ÚÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ™Â ÙÌ‹Ì·Ù· ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ·fi ÂÈÚ·Ì·Ùfi˙ˆ· Ô˘ ˘¤ÛÙËÛ·Ó ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ ÌÂÙÚ‹ıËÎÂ Ë ÂÓ‰Ô΢ÙÙ¿ÚÈ· ·Ó·ÏÔÁ›· Na+/K, ˆ˜ ‰Â›ÎÙ˘ ‚ȈÛÈÌfiÙËÙ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. μÚ¤ıËΠfiÙÈ Ë ‚ȈÛÈÌfiÙËÙ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Â›Ó·È ÛËÌ·ÓÙÈο ÂÏ·Ùو̤ÓË ÌÂÙ¿ ·fi ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘, ˘Ô‰ÂÈÎÓ‡ÔÓÙ·˜ ÙȘ ‚Ï·ÙÈΤ˜ Û˘Ó¤ÂȘ Ù˘ ı‡ÂÏÏ·˜ ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ, Ù˘ ·Ú·ÙÂٷ̤Ó˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Î·È Ù˘ ÔÚÌÔÓÈ΋˜ ÂÍ¿ÓÙÏËÛ˘ ÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·.26 O ¯ÚfiÓÔ˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ¤ˆ˜ ÙË Ï‹„Ë ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‚·Ú‡ÙËÙ· ÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙ· fiÚÁ·Ó· ηıÒ˜ Ì ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿ ÙÔ˘˜. ¶ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ fiÙ·Ó ·Ú·Ù›ÓÂÙ·È Ë ‰È¿ÚÎÂÈ· ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÚÔηÏÂ›Ù·È ‚·Ú‡ÙÂÚË ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ÊÏÂÁÌÔÓÒ‰Ë ÈÛÙÈ΋ ‚Ï¿‚Ë. 27 ∞˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË Ô˘‰ÂÙÂÚfiÊÈψÓ, ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Î·È ÌÔÚ›ˆÓ Û˘ÁÎfiÏÏËÛ˘ (VCAM-1, ICAM-1) ¤¯Ô˘Ó ‚ÚÂı› ÛÙÔ˘˜
31
ÓÂÊÚÔ‡˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÒÓ ‰ÔÙÒÓ Û ÂÈÚ·Ì·ÙÈΤ˜ ·ÏÏ¿ Î·È ÎÏÈÓÈΤ˜ ÌÂϤÙ˜.27 ªÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜ ·Ú·ÙËÚ‹ıËΠ̷˙È΋ ÂÈÛ‚ÔÏ‹ Ì·ÎÚÔÊ¿ÁˆÓ Î·È Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ Ï‹ÙË Î·È ˘ÂÚ¤ÎÊÚ·ÛË ÌÔÚ›ˆÓ Û˘ÁÎfiÏÏËÛ˘ Î·È HLADR ·ÓÙÈÁfiÓˆÓ, Ê·ÈÓfiÌÂÓ· Ô˘ ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÌÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÓÂÊÚÒÓ ·fi ÌË ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜.28 OÈ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔ ‹·Ú ÛÂ Û˘Óı‹Î˜ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Â›Ó·È ÏÈÁfiÙÂÚÔ Î·ıÔÚÈṲ̂Ó˜. ™Â οÔȘ ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ Ê¿ÓËΠfiÙÈ ÙÔ ‹·Ú ·Ó¤¯ÂÙ·È ÙȘ ηٷÛÙ¿ÛÂȘ ·Ú·ÙÂٷ̤Ó˘ ˘fiÙ·Û˘ Î·È ¤¯ÂÈ ·ÚÎÂÙ¤˜ Ê˘ÛÈÔÏÔÁÈΤ˜ Âʉڛ˜.29 ™Â ¿ÏϘ ÌÂϤÙ˜ Ê¿ÓËΠfiÙÈ ÂÓÒ ÔÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‰ÂÓ ¤¯Ô˘Ó ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙËÓ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ¤¯Ô˘Ó fï˜ ÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· ÙÔ˘ ‹·ÙÔ˜. ∂ÎÙÂٷ̤ÓË ÎÂÓÙÚÈ΋ ÊÏ‚È΋ Û˘ÌÊfiÚËÛË ·Ú·ÙËÚ‹ıËΠ4 Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ÂÁηٿÛÙ·ÛË ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Û ·ÓıÚÒÔ˘˜. ∂›Û˘, ÌÂÙ¿ ÙË 15Ë Ë̤ڷ ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË Ù˘ ÂÚÈÔ¯È΋˜ Î·È Ù˘ ÂÚÈ˘Ï·›·˜ Ó¤ÎÚˆÛ˘.30 ¶·Ú·Ì¤ÓÂÈ ·ÓÂÍ·ÎÚ›‚ˆÙÔ Â¿Ó ·˘Ù¤˜ ÔÈ ·ÏÏÔÈÒÛÂȘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙËÓ ›‰È· ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ‹ ·fi ÙËÓ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Ì ·ÁÁÂÈÔÛ˘Û·ÛÙÈο Û΢¿ÛÌ·Ù·. ∂˘Ú‹Ì·Ù· ·fi ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ù· Ë·ÙÔ·ÙÙ·Ú· ·fi ‹·Ù· ÂÁÎÂÊ·ÏÈÎÒÓ ÓÂÎÚÒÓ ‰ÔÙÒÓ ÂÌÊ·Ó›˙Ô˘Ó ·ÏÏÔÈÒÛÂȘ ÛÙË ‰È·ÂÚ·ÙfiÙËÙ· Î·È ·ÎÂÚ·ÈfiÙËÙ· Ù˘ ΢ÙÙ·ÚÈ΋˜ ÙÔ˘˜ ÌÂÌ‚Ú¿Ó˘.31 ∫ÏÈÓÈΤ˜ ÌÂϤÙ˜ ‚Ú‹Î·Ó fiÙÈ Ù· ‹·Ù· ·fi ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜ ›¯·Ó ÛËÌ·ÓÙÈο ÂÓÙÔÓfiÙÂÚË ÊÏÂÁÌÔÓÒ‰Ë ‰È‹ıËÛË Û ۇÁÎÚÈÛË Ì ٷ Ë·ÙÈο ÌÔۯ‡̷ٷ ·fi ˙ÒÓÙ˜ ‰fiÙ˜.32 ∞Ó Î·È ·˘Ù¤˜ ÔÈ ÊÏÂÁÌÔÓÒ‰ÂȘ ‰ÈÂÚÁ·Û›Â˜ ‰ÂÓ Ê¿ÓËÎ·Ó Ó· ÂËÚ¿˙Ô˘Ó ÙËÓ ÚÒÈÌË ¯ÚÔÓÈο ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, Ê·›ÓÂÙ·È fï˜ fiÙÈ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ÌÂÙÂÁÂÓ¤ÛÙÂÚË ÂÌÊ¿ÓÈÛË ·ÏÏÔ¿ÓÔÛˆÓ ·ÓÙȉڿÛÂˆÓ Î·È ÛÙË ‰È·Ù·Ú·¯‹ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì·ÎÚÔÚfiıÂÛÌ·. OÈ Ó‡ÌÔÓ˜ Â›Ó·È È‰È·›ÙÂÚ· ÂÈÚÚ›˜ ÛÙÔ Ó· ˘Ê›ÛÙ·ÓÙ·È ‚Ï¿‚Ë ·fi ÙȘ Ù·¯Â›Â˜ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙË ı‡ÂÏÏ· ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘. ∫·ıÒ˜ Ë Î·Ú‰È¿ ‰¤¯ÂÙ·È ·˘ÍË̤ÓË ÊÏ‚È΋ ·ӷÊÔÚ¿ ·›Ì·ÙÔ˜ ηٿ ÙËÓ ÂÚ›Ô‰Ô ÙÔ˘ ¤ÓÙÔÓÔ˘ ·ÁÁÂÈfiÛ·ÛÌÔ˘, Ë ›ÂÛË ÛÙÔÓ ·ÚÈÛÙÂÚfi ÎfiÏÔ ˘ÂÚ‚·›ÓÂÈ ·ÚÔ‰Èο ÙËÓ ›ÂÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ÚÔηÏÒÓÙ·˜ ·ÚÔ‰È΋ ÛÙ¿ÛË ÛÙËÓ Ó¢ÌÔÓÈ΋ ΢ÎÏÔÊÔÚ›· ηÈ
32
N. ANTøNIA¢H™
Ó¢ÌÔÓÈ΋ ÙÚȯÔÂȉÈ΋ ˘¤ÚÙ·ÛË. O Ó¢ÌÔÓÈÎfi˜ ÈÛÙfi˜ Ô˘ ÂÎÙ›ıÂÙ·È Û ·˘ÙÔ‡ ÙÔ˘ ›‰Ô˘˜ ÙËÓ ˘¤ÚÙ·ÛË ˘fiÎÂÈÙ·È Û ‚·ÚÂÈ¿ ‚Ï¿‚Ë Ì ‰È¿Û·ÛË Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙˆÓ ÂÓ‰ÔÓ¢ÌÔÓÈÎÒÓ ÙÚȯÔÂȉÒÓ Î·È ÙËÓ ÂÌÊ¿ÓÈÛË Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Î·È ‰È¿ÌÂÛ˘ ·ÈÌÔÚÚ·Á›·˜.33 ¶ÚÔÊ·ÓÒ˜ Ô ·Ó·Áη›Ô˜ Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜ ÚÔηÏ› ÚfiÛıÂÙË ÂÈ‚¿Ú˘ÓÛË ÛÙÔ˘˜ Ó‡ÌÔÓ˜. OÈ ÂÈ‚Ï·‚›˜ Û˘Ó¤ÂȘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ·Ú·ÙËÚ‹ıËÎ·Ó Î·È Û ΢ÙÙ·ÚÈÎfi ›‰Ô. μÚ¤ıËÎ·Ó ·˘ÍË̤ӷ ›‰· IL-8 ÛÙÔ Ó¢ÌÔÓÈÎfi ¤ÎÏ˘Ì· Ì·˙› Ì ·˘ÍË̤ÓË ‰È‹ıËÛË ·fi Ô˘‰ÂÙÂÚfiÊÈÏ· ÛÙÔÓ Ó¢ÌÔÓÈÎfi ÈÛÙfi.34
∏ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ÔÍ›· ·‡ÍËÛË Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Û ÂÈÚ·Ì·Ùfi˙ˆ· ·˘Í¿ÓÂÈ ÛÙ· ۈ̷ÙÈο fiÚÁ·Ó· ÙËÓ ¤ÎÊÚ·ÛË ‰È¿ÊÔÚˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È Ì·ÎÚÔÊ¿ÁˆÓ.12 Δ·¯Â›· ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ Ï¢ÎÔ΢ÙÙ·ÚÈÎÒÓ ÏËı˘ÛÌÒÓ Î·È ÚÔ˚fiÓÙˆÓ ÙÔ˘˜ ¤¯ÂÈ ·Ú·ÙËÚËı› Û ηډȷο Î·È ÓÂÊÚÈο ·ÏÏÔÌÔۯ‡̷ٷ ·fi ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜, ÚÈÓ Î·È Î·Ù¿ ÙȘ ÚÒÙ˜ Ë̤Ú˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.35,36 Œ¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ ÛÙÔ˘˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰˘ÓËÙÈÎÔ‡˜ ‰fiÙ˜ ˘¿Ú¯Ô˘Ó ·˘ÍË̤Ó˜ ÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÙ·ÚÈΤ˜ ‰ÈËı‹ÛÂȘ Û fiÏ· Ù· fiÚÁ·Ó· Ô˘ ÌÔÚÔ‡Ó Ó· ÌÂÙ·ÌÔÛ¯Â˘ÙÔ‡Ó.14 ∂ÎÙfi˜ ·fi ÙËÓ ‡·ÚÍË Î˘ÙÙ·ÚÔÎÈÓÒÓ, ¯ËÌÂÈÔÎÈÓÒÓ Î·È ÌÔÚ›ˆÓ Û˘ÁÎfiÏÏËÛ˘, ·ÚÔ˘ÛÈ¿˙ÂÙ·È ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÙˆÓ ·ÓÙÈÁfiÓˆÓ Ù¿Í˘ ππ ÙÔ˘ Ì›˙ˆÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (MHC), ÂÓÂÚÁÔÔÈÒÓÙ·˜ Ì›· Ù·¯‡ÙÂÚË Î·È ÂÓÙÔÓfiÙÂÚË ·ÏÏÔ¿ÓÔÛË ·ÓÙ›‰Ú·ÛË ÛÙÔÓ Ï‹ÙË, Û ۇÁÎÚÈÛË Ì ÙËÓ ·ÓÙ›‰Ú·ÛË Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ·fi Ù· “·‰Ú·Ó‹” ÌÔۯ‡̷ٷ ˙ÒÓÙˆÓ ‰ÔÙÒÓ. Δ· ÌfiÚÈ· Û˘ÁÎfiÏÏËÛ˘ ηÙ¢ı‡ÓÔ˘Ó ÙËÓ ·ÏÏËÏÔ›‰Ú·ÛË ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Ì ÙÔ ÂÓ‰Ôı‹ÏÈÔ, ¤¯Ô˘Ó ÚÔÛ‰ÈÔÚÈÛÙ› Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ˆ˜ ˘Â‡ı˘Ó· ÁÈ· ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ·ÓÔÛÔÏÔÁÈÎÒÓ ·ÓÙȉڿÛˆÓ.31 OÈ ÛÂÏÂÎÙ›Ó˜, Ô˘ Â›Ó·È Ù· ÚÒÙ· ÌfiÚÈ· Û˘ÁÎfiÏÏËÛ˘ Ô˘ ÂÎÊÚ¿˙ÔÓÙ·È, ‰ÂÓ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Û ηÓÔÓÈΤ˜ Û˘Óı‹Î˜ ·ÏÏ¿ ˘ÂÚÂÎÊÚ¿˙ÔÓÙ·È Ù·¯‡Ù·Ù· ÌÂÙ¿ ·fi ‰ËÌÈÔ˘ÚÁ›· ‚Ï¿‚˘, ÂÓÂÚÁÔÔÈÒÓÙ·˜ ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚÁ·Û›Â˜. ªÂÙ¿ ÙË Û‡Ó‰ÂÛË ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ, ÂÓÈÛ¯‡ÂÙ·È Ë ÂÓÂÚÁÔÔ›ËÛË Úfi-
ÛıÂÙˆÓ ÌÔÚ›ˆÓ Û˘ÁÎfiÏÏËÛ˘ Î·È Î˘ÙÙ·ÚÔÎÈÓÒÓ. Δ· Û˘Ó‰Â‰Â̤ӷ Ï¢ÎÔ·ÙÙ·Ú· ÂÎÊÚ¿˙Ô˘Ó ÎÈ ¿ÏÏ· ›‰Ë ÌÔÚ›ˆÓ Û˘ÁÎfiÏÏËÛ˘ (ICAM-1, VCAM-1, LFA-1) Î·È ÂÎÎÚ›ÓÔ˘Ó ÚÔÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÙ·ÚÔΛÓ˜ (TNF·, IFN-Á). ∂›Û˘ ·˘Í¿ÓÂÙ·È Ë ¤ÎÊÚ·ÛË Ù˘ Ù¿Í˘ π Î·È ππ MHC ÌÔÚ›ˆÓ. ∏ ˘ÂÚ¤ÎÊÚ·ÛË ÙˆÓ MHC ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¿ÁÂÙ·È Î˘Ú›ˆ˜ ·fi ÙËÓ IFN-Á, Ë ÔÔ›· ·˘Í¿ÓÂÙ·È ·fi ÙȘ Û˘Óı‹Î˜ ÈÛ¯·ÈÌÈ΋˜ ‚Ï¿‚˘ (ÏfiÁˆ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘) Î·È ·fi ÙË ‚Ï¿‚Ë Â·Ó·ÈÌ¿ÙˆÛ˘. ¶·ÚfiÏÔ Ô˘ ·fi ÌfiÓË Ù˘ Ë ¤ÎÊÚ·ÛË ÙˆÓ MHC ·ÓÙÈÁfiÓˆÓ ‰ÂÓ Ô‰ËÁ› ÛÙËÓ ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ·˘Í¿ÓÂÈ ÙËÓ ·ÓÙÈÁÔÓÈÎfiÙËÙ¿ ÙÔ˘ ̤ۈ Ù˘ ‰È·‰Èηۛ·˜ ·Ó·ÁÓÒÚÈÛ‹˜ ÙÔ˘ ·fi Ù· ΔÏÂÌÊÔ·ÙÙ·Ú·. ∏ ·ÓÙÈÁÔÓÈ΋ ˘ÂÚ¤ÎÊÚ·ÛË, ‰Â˘ÙÂÚÔÁÂÓÒ˜ Ù˘ ÌË ÂȉÈ΋˜ ÂÓ‰ÔıËÏȷ΋˜ ‚Ï¿‚˘, ÌÔÚ› Ó· ·˘Í‹ÛÂÈ ÙË Û˘¯ÓfiÙËÙ· Ù˘ ÚÒÈÌ˘ ÂÌÊ¿ÓÈÛ˘ ÔÍ›·˜ ·fiÚÚȄ˘. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ÂȂ‚·ÈÒÓÔ˘Ó ÙË ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ÛÙËÓ ·Ú¯È΋ ÂÚ›Ô‰Ô Ù˘ ÂÁηٿÛÙ·Û˘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘. ∏ ·‡ÍËÛË ·˘Ù‹ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÌÂÙ·ÁÚ·ÊÈÎÒÓ Ú·ÁfiÓÙˆÓ NF-ÎB, c-Jun Î·È ATF2.37 ∂ÎÙfi˜ Ù˘ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Î·È Ù˘ ‰È‹ıËÛ˘ ·fi Ô˘‰ÂÙÂÚfiÊÈÏ· Î·È ·ÈÌÔÂÙ¿ÏÈ·, ÚfiÛÊ·Ù˜ ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ·‡ÍËÛË Ù˘ ·fiÙˆÛ˘ ÛÙ· fiÚÁ·Ó· ÂÁÎÂÊ·ÏÈο ÓÂÎÚÒÓ.38
£Âڷ›· ηډÈÔ·ÁÁÂȷ΋˜ Î·È ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ Î·È Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ ·ÔÙÂÏ› ıÂÌÂÏÈ҉˘ ÚÔÙÂÚ·ÈfiÙËÙ· Ù˘ ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ. ∏ ηٿÏÏËÏË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Î·Ú‰ÈÔ·ÁÁÂÈ·ÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÛÙԯ‡ÂÈ ÛÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ê˘ÛÈÔÏÔÁÈ΋˜ Û˘ÛÙËÌ·ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ Î·È ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÔÚÁ¿ÓˆÓ ÒÛÙ ӷ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ Î·Ï‡ÙÂÚË Î·Ù¿ÛÙ·ÛË Î·Ù¿ ÙËÓ ‰È·‰Èηۛ· Ù˘ Ï‹„˘ ÙÔ˘˜. ∏ ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ··ÈÙ› ¤Ó· Û˘Ó¯¤˜ Â›Â‰Ô ÂÁÚ‹ÁÔÚÛ˘, fiÌÔÈÔ Ì ·˘Ùfi Ô˘ ··ÈÙÂ›Ù·È ÁÈ· οı ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ·, ηٷÓÔÒÓÙ·˜ fiÙÈ Ë ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ ·ÔÙÂÏ› ̤ÚÔ˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ 7 Èı·ÓÒÓ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ. ∏ ÂÓÙ·ÙÈ΋ ıÂڷ›· ÙÔ˘ ‰fiÙË Ì ÂÈΤÓÙÚˆÛË ÛÙËÓ ·ÓÙÈÌÂ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ, ÁÈ· ÙȘ Ôԛ˜ ¢ı‡ÓÂÙ·È ÂÓ Ì¤ÚÂÈ Ë Î·Ù¿ÛÙ·ÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ·¤‰ÂÈÍ fiÙÈ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙÔÓ ·ÚÈıÌfi ÙˆÓ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ Ô˘ ¯¿ÓÔÓÙ·È ÏfiÁˆ ηډȷÁÁÂȷ΋˜ ηٿÚÚ¢Û˘ (·fi 42 % ÛÙÔ 5%), Ó· ‚ÂÏÙÈÒÛÂÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ‰ÔÙÒÓ Ô˘ ·fi ·Î·Ù¿ÏÏËÏÔÈ ÏfiÁˆ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÎÚ›ÓÔÓÙ·È ÙÂÏÈο ηٿÏÏËÏÔÈ (·fi 26,6 % ÛÙÔ 41,2%) Î·È Ó· ·˘Í‹ÛÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÔÚÁ¿ÓˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÌÔۯ‡̷ٷ.39 ™ÙËÓ ·Ú·¿Óˆ ÌÂϤÙË ÔÈ ÂÈÏÔΤ˜ Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ‹Ù·Ó: ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ·ÁÁÂÈÔÛ˘Û·ÙÈÎÒÓ (97,1 %), ‰È·Ù·Ú·¯¤˜ Ù˘ ‹Í˘ (55,1 %), ıÚÔÌ‚Ô΢ÙÙ·ÚÔÂÓ›· (53,3 %), ¿ÂÈÔ˜ ‰È·‚‹Ù˘ (46,4%), ηډȷ΋ ÈÛ¯·ÈÌ›· (30,4 %), Á·Ï·ÎÙÈ΋ ÔͤˆÛË (24,6 %), ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (20,3 %) Î·È ÙÔ Û‡Ó‰ÚÔÌÔ ÔÍ›·˜ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (13 %).40 ∏ ÂÈıÂÙÈ΋ ÂÓÙ·ÙÈ΋ ıÂڷ›· Û˘Ó›ÛÙ·ÓÙÔ ÛÙËÓ Ù·¯Â›· ·Ó·ÁÓÒÚÈÛË Î·È ÂÈÏÔÁ‹ ÙˆÓ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ, ÙËÓ ‰ÈfiÚıˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ˘ÁÚÒÓ Î·È ËÏÂÎÙÚÔÏ˘ÙÒÓ Î·È ÙËÓ ÔÚÌÔÓÈ΋ ˘ÔηٿÛÙ·ÛË Ì ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË (solumedrol) Î·È ı˘ÚÔÍ›ÓË. OÈ ÚˆÙ‡ÔÓÙ˜ ıÂڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ÔÌ·ÏÔÔ›ËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ÙË ‰È·Ù‹ÚËÛË Ê˘ÛÈÔÏÔÁÈ΋˜ ıÂÚÌÔÎÚ·Û›·˜ ÛÒÌ·ÙÔ˜, ‚ÂÏÙÈÛÙÔÔ›ËÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ Ó¢ÌfiÓˆÓ, ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ Î·È ‰ÈfiÚıˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ Î·È ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ.41 ™ÙËÓ ÂÈÎfiÓ· 1 ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÌÈ· ·ÏÁÔÚÈıÌÈ΋ ÚÔÛ¤ÁÁÈÛË ÛÙËÓ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ÔÚÁ¿ÓˆÓ. ΔÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÎÙÈÌÔ‡Ó ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ηٿÛÙ·ÛË ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘ ‰fiÙË ·ÔÙÂÏÔ‡Ó Ë ·ÚÙËÚȷ΋ ›ÂÛË, Ë ··ÈÙ‹ÛÂȘ Û ·ÁÁÂÈÔÛ˘Û·ÛÙÈο, Ë ‰ÈÔ‡ÚËÛË, Î·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ ˯ÔηډÈÔÁÚ·ÊÈÎÔ‡ ÂϤÁ¯Ô˘ Ô˘ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û fiÏÔ˘˜ ÙÔ˘ ‰fiÙ˜. ∂·Ú΋˜ ÔÛfiÙËÙ· ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‹ ÎÔÏÏÔÂȉÒÓ Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ÒÛÙÂ Ë Ì¤ÛË ·ÚÙËÚȷ΋ ›ÂÛË Ó· ·Ú·Ì¤ÓÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ›ÛË ‹ ÌÂÁ·Ï‡ÙÂÚË ·fi 60 mm Hg Î·È Ë ÎÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË Ó· Â›Ó·È 4 – 10 cm H2O. ∏ ‡·ÚÍË Î·ıÂÙ‹Ú· Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ‰›ÓÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙȘ ȤÛÂȘ ÎÔÈÏȷ΋˜ ÏËÚÒÛˆ˜, ÙËÓ Î·Ú‰È·Î‹ ÏÂÈÙÔ˘ÚÁ›· Î·È ÙÔÓ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ, ‚ÔËı¿ÂÈ ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË Ú‡ıÌÈÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ˘ÁÚÒÓ, ȉȷ›ÙÂÚ· ÛÙÔ˘˜ ‰fiÙ˜ Ó¢ÌfiÓˆÓ Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ì ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ·: ̤ÛË ∞¶
33
≥ 60 mmHg, CVP ≤ 12 mmHg, PCWP ≤ 12 mmHg, Û˘ÛÙËÌ·ÙÈΤ˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ 8001200 dyne/sec/cm -5 , ηډȷÎfi˜ ‰Â›ÎÙ˘ ≥ 2,5 L/min/m2, ‰Â›ÎÙ˘ ¤ÚÁÔ˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ > 15, ‰fiÛÂȘ ÓÙÔ·Ì›Ó˘ < 10 Ìg/kg/min (∂ÈÎfiÓ· 1). ™‡Á¯ÚÔÓ˜ ÌË ·ÈÌ·ÙËÚ¤˜ ̤ıÔ‰ÔÈ ÂÎÙ›ÌËÛ˘ Ù˘ ›ÂÛ˘ Î·È Ù˘ ÚÔ‹˜ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ÌÂ Û˘Ó¯‹ ˯ÔηډÈÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô Î·È Û˘Û΢¤˜ ̤ÙÚËÛ˘ Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ ·ÔÙÂÏÔ‡Ó ÈÛ¿ÍȘ ÂÓ·ÏÏ·ÎÙÈΤ˜ ÙÔ˘ ηıÂÙ‹Ú· Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ÁÈ· ÙËÓ ‰È¿ÁÓˆÛË Î·È Î·Ù¿ÏÏËÏË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ∏ ÌÂÙ¿ÁÁÈÛË Û˘Û΢·ÛÌ¤ÓˆÓ ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÂӉ›ÎÓ˘Ù·È fiÙ·Ó Ô ·ÈÌ·ÙÔÎÚ›Ù˘ Â›Ó·È Î¿Ùˆ ·fi 25 %. ∞ÁÁÂÈÔÛ˘Û·ÛÙÈο Û΢¿ÛÌ·Ù· ¯ÔÚËÁÔ‡ÓÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ ·Ó¿ÁÎË ‰È·Ù‹ÚËÛ˘ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Û ÈηÓÔÔÈËÙÈο ›‰· ÒÛÙ ӷ ÌËÓ ˘ÔÏ›ÂÙ·È Ë ·ÈÌ¿ÙˆÛË ÙˆÓ ÔÚÁ¿ÓˆÓ. ¢fiÛÂȘ ÓÙÔ·Ì›Ó˘ ÌÂÁ·Ï‡ÙÂÚ˜ ·fi 10 Ìg/kg/min Â›Ó·È ÂÓ‰ÂÈÎÙÈΤ˜ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜. ∏ ÔÛfiÙËÙ· ÙˆÓ ·Ô‚·ÏÏÔÌ¤ÓˆÓ Ô‡ÚˆÓ Â›Ó·È Ô ¯Ú‹ÛÈÌÔ˜ ‰Â›ÎÙ˘ ·ÚÎÔ‡˜ ·ÈÌ¿ÙˆÛ˘ ÙˆÓ ÔÚÁ¿ÓˆÓ Î·È Ú¤ÂÈ Ó· ‰È·ÙËÚÂ›Ù·È ÌÂÁ·Ï‡ÙÂÚË ·fi 1 ml/kg/min. ªÔÏÔÓfiÙÈ Ô Ë¯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È Û fiÏÔ˘˜ ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ ‰fiÙ˜, Â›Ó·È Û‡ÓËı˜ Ó· Â›Ó·È ·ıÔÏÔÁÈÎfi˜ fiÙ·Ó ‰ÈÂÓÂÚÁÂ›Ù·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ȉȷ›ÙÂÚ· fiÙ·Ó ˘¿Ú¯Ô˘Ó ‰È·Ù·Ú·¯¤˜ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜, ηıÒ˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ Î·È ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜.42 ∏ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙˆÓ ·ıÔÏÔÁÈÎÒÓ Ë¯ÔηډÈÔÁÚ·ÊÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÔÊ›ÏÂÙ·È ÛÙËÓ Â›ÙˆÛË ÙˆÓ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ÛÙÔ Ì˘ÔοډÈÔ. μÚ¤ıËΠfiÙÈ ÙÔ 42 % ÙˆÓ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ì˘Ôηډȷ΋ Û˘ÛÙÔÏÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ô˘ fï˜ ηٿ ¤Ó· ÌÂÁ¿ÏÔ ‚·ıÌfi Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË Î·È ÁÈ’ ·˘Ùfi ‰ÂÓ Ú¤ÂÈ Ó· ·ÔÚÚ›ÙÂÙ·È Ë Î·Ú‰È¿ ÁÈ· ÌfiÛ¯Â˘Ì· Ì ‚¿ÛË ¤Ó· ·Ú¯ÈÎfi ˯ÔηډÈÔÁÚ¿ÊËÌ·. ™Â Ì›· ·Ó·ÛÎÔÈ΋ ÌÂϤÙË Ê¿ÓËΠfiÙÈ Ë ÂÓÙ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ‰fiÙË, Ì ‰ÈfiÚıˆÛË ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ, ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘, Ù˘ ÔͤˆÛ˘, Ù˘ ˘ÔÍ›·˜, Ù˘ Ù·¯˘Î·Ú‰›·˜, ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Î·È Ù˘ ·Ó·ÈÌ›·˜ ·ÏÏ¿ Î·È ÙË ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ ̤Û˘ ÙÈÌ‹˜ ÙÔ˘ ÎÏ¿ÛÌ·ÙÔ˜ Â͈ı‹Ûˆ˜ ·fi 41 % Û 56 % ÌÂÙ·ÙÚ¤ÔÓÙ·˜ ·Î·Ù¿ÏÏËÏÔ˘˜ ‰fiÙ˜ ηډȿ˜ Û ηٿÏÏËÏÔ˘˜.43 ∏ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· ÙÔ˘ ÂÁÎÂÊ·ÏÈο ÓÂ-
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N. ANTøNIA¢H™
∂ÈÎfiÓ· 1. £Âڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ÔÚÁ¿ÓˆÓ. ∞fi Massachusetts Medical Society 2004.41
ÎÚÔ‡ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÙÚÈ¿‰· ˘ÔÔÁηÈÌ›·, ηډȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ·ÁÁÂÈԉȷÛÙÔÏ‹. ∏ ˘ÔÔÁηÈÌ›· Û˘Ó‹ıˆ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ˘ÁÚÒÓ Î·È ÙË ¯Ú‹ÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Î·È Ì·ÓÓÈÙfiÏ˘ ÛÙ· Ï·›ÛÈ· Ù˘ ıÂڷ›·˜ Ù˘ ·˘ÍË̤Ó˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘. ∏ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ Ô›ÛıÈ·˜ ˘fiÊ˘Û˘ Ô˘ ÂΉËÏÒÓÂÙ·È Ì ¿ÂÈÔ ‰È·‚‹ÙË Î·È Ë ÔÛ̈ÙÈ΋ ‰ÈÔ‡ÚËÛË ÏfiÁˆ ˘ÂÚÁÏ˘Î·ÈÌ›·˜ Û˘Ì‚¿ÏÏÔ˘Ó Â›Û˘ ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∏ ηٿÚÁËÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÁÁÂÈԉȷÛÙÔÏ‹ Î·È Û˘ÛÛÒÚ¢ÛË ÙÔ˘ ÂÓ‰Ô·Á-
ÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ÛÙËÓ ÂÚÈÊÂÚÈ΋ ÊÏ‚È΋ ‰ÂÍ·ÌÂÓ‹. ∏ ·ӷı¤ÚÌ·ÓÛË ˘ÔıÂÚÌÈÎÔ‡ ·ÛıÂÓ‹ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÁÁÂÈԉȷÛÙÔÏ‹ Î·È Ó· ÂÈ‚·Ú‡ÓÂÈ ÌÈ· ηٿÛÙ·ÛË Ì ÂÏ·Ùو̤ÓÔ ÂÓÂÚÁfi ÂÓ‰Ô·ÁÁÂÈ·Îfi fiÁÎÔ.44 ∂ÓÒ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÂÓÈÛ¯‡ÂÙ·È ‰È·ÙËÚÒÓÙ·˜ ÈηÓÔÔÈËÙÈ΋ ‰ÈÔ‡ÚËÛË Ì ÙËÓ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ÙËÓ ·‡ÍËÛË ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘, ·fi ÙËÓ ¿ÏÏË Ë ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ó¢ÌfiÓˆÓ ‚ÂÏÙÈÒÓÂÙ·È Ì ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∞˘Ùfi ÙÔ ·ÓÙ·ÁˆÓÈÛÙÈÎfi ÂÚÈ‚¿ÏÏÔÓ ··ÈÙ› ÂÂÌ‚·ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË (ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜) ÒÛÙ ӷ ÂÈÙ¢¯ı› ÙÔ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÈÛÔ˙‡ÁÈÔ ˘ÁÚÒÓ Î·È Ó· ‰È·ÛÊ·ÏÈÛÙ›, ·fi ÙË Ì›· ÏÂ˘Ú¿, Ë ··Ú·›ÙËÙË ›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÙˆÓ ÓÂÊÚÒÓ Î·È ·fi ÙËÓ ¿ÏÏË Ó· ÚÔÏËÊı› Ë Û˘ÛÛÒÚ¢ÛË ˘ÁÚÒÓ ÛÙÔ˘˜ Ó‡ÌÔÓ˜ Ô˘ ı· ÌÔÚÔ‡Û ӷ ı¤ÛÂÈ Û ΛӉ˘ÓÔ ÙËÓ Î·Ù·ÏÏËÏfiÙËÙ· ÙˆÓ Ó¢ÌfiÓˆÓ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÌÔۯ‡̷ٷ. 45 ª›· ÚÔÛ¤ÁÁÈÛË Û ·˘Ùfi ÙÔ ı¤Ì· Â›Ó·È Ó· ÂÎÙÈÌËı› ·fi ÙËÓ ·Ú¯‹ Ë Î·Ù·ÏÏËÏfiÙËÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙˆÓ Ó¢ÌfiÓˆÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Â›Ó·È ÍÂοı·ÚË Ë ·Î·Ù·ÏÏËÏfiÙËÙ¿ ÙÔ˘˜ (ÂÈÛÚfiÊËÛË, ÙÚ·‡Ì·) ÌÔÚ› Ó· Â›Ó·È ÈÔ ÂχıÂÚË Ë ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ, Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ‰È·ÙËÚÂ›Ù·È ÈηÓÔÔÈËÙÈ΋ Ë Û˘ÛÙËÌ·ÙÈ΋ Ô͢ÁfiÓˆÛË. ŸÛÔ ·Ó·ÊÔÚ¿ Ù· ¯ÔÚËÁÔ‡ÌÂÓ· ˘ÁÚ¿, Â›Ó·È ÚÔÙÈÌfiÙÂÚË Ë ¯ÔÚ‹ÁËÛË ÈÛfiÙÔÓÔ˘ Ringer’s ‰È·Ï‡Ì·ÙÔ˜ ÁÈ· Ó· ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜. ∏ ˘ÂÚÓ·ÙÚÈ·ÈÌ›· ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÙÔ˘˜ ÚÒÙÔ˘˜ 3 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ˘ÂÚÓ·ÙÚÈ·ÈÌ›· Ú¤ÂÈ Ó· ‰ÈÔÚıÒÓÂÙ·È ÛÙ·‰È·Î¿ Ì ÙË ¯ÔÚ‹ÁËÛË ˘fiÙÔÓˆÓ ‰È·Ï˘Ì¿ÙˆÓ. ∏ ηډȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È Ë ·ÁÁÂÈԉȷÛÙÔÏ‹ Â›Ó·È Û˘Ó‹ıÂȘ ηٷÛÙ¿ÛÂȘ Ô˘ Û˘Ó˘¿Ú¯Ô˘Ó ÛÙÔÓ ‰˘ÓËÙÈÎfi ‰fiÙË ÔÚÁ¿ÓˆÓ. ∏ ηډȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÌÔÚ› Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÚÔ¸¿Ú¯Ô˘Û·˜ ÓfiÛÔ˘, Ó· Û¯ÂÙ›˙ÂÙ·È Ì οΈÛË Ì˘Ôηډ›Ô˘ ‹ ÂÚÈηډȷÎfi ÂȈ̷ÙÈÛÌfi Û ¤Ó·Ó ÔÏ˘ÙÚ·˘Ì·Ù›·, Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÈÛ¯·ÈÌ›·˜ ‹ fiˆ˜ ¤¯ÂÈ ÚÔ·Ó·ÊÂÚı› Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ Ó¢ÚÔÁÂÓÔ‡˜ Ì˘Ôηډȷ΋˜ ‚Ï¿‚˘ ÛÙ· Ï·›ÛÈ· ÙˆÓ ÂÈÙÒÛÂˆÓ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘. ∂›Û˘ ÌÔÚ› Ó· Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÂΉ‹ÏˆÛ‹ Ù˘ Ë ÔͤˆÛË, Ë ˘ÔıÂÚÌ›·, Ë ˘·Û‚ÂÛÙÈ·ÈÌ›·, Ë ˘ÔÍ›·, Ë ˘ÔÊÔÛʈڷÈÌ›· Î·È Ë ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ· Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ. ∏ ·ÁÁÂÈԉȷÛÙÔÏ‹ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÒÏÂÈ·˜ ÙÔ˘ ·ÁÁÂÈÔÎÈÓËÙÈÎÔ‡ ÂϤÁ¯Ô˘ Ô˘ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ. ÕÏϘ ηٷÛÙ¿ÛÂȘ Ô˘ ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÔ˘Ó Â›Ó·È ÙÔ ÓˆÙÈ·›Ô ÛÔÎ, Ë ¤Ó‰ÂÈ· ηÙ¯ÔÏ·ÌÈÓÒÓ, Ë Û¯ÂÙÈ΋ ÂÈÓÂÊÚȉÈ΋ ·Ó¿ÚÎÂÈ· ÙÔ˘ ÔÏ˘ÙÚ·˘Ì·Ù›· Î·È ÙÔ˘ ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ·, Ë ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ· ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Î·È Ë Û‹„Ë. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ› ‰˘ÓËÙÈÎÔ› ‰fiÙ˜ ¤¯Ô˘Ó ·Ó¿ÁÎË ˘ÔÛÙ‹ÚÈ͢ Ì ·ÁÁÂÈÔÛ˘Û·ÛÙÈο, ›Ù Ì ¤Ó· Û··ÛÌ· ›Ù ÌÂ Û˘Ó‰˘·ÛÌfi ‰È·ÊÔÚÂÙÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ.44 ∏ ÏÔÁÈ΋ Ù˘ ¯ÚËÛÈÌfiÙËÙ·˜ ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÚÈÁÚ·ÊfiÌÂÓË ÂÏ¿ÙÙˆÛË ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›· ÙˆÓ ÂÓ‰ÔÁÂÓÒÓ Î·Ù¯ÔÏ·-
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ÌÈÓÒÓ (ÌÂÙ¿ ·fi ÙË ı‡ÂÏÏ· ηÙ¯ÔÏ·ÌÈÓÒÓ Ù˘ ¤Ó·Ú͢ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘) Ô˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÒÏÂÈ· ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÙfiÓÔ˘ Î·È ÂÏ¿ÙÙˆÛË Ù˘ ÈÓfiÙÚÔ˘ ‰Ú¿Û˘. ∏ ·ÔÊ˘Á‹ ¯ÔÚ‹ÁËÛ˘ ηÙ¯ÔÏ·ÌÈÓÒÓ Û˘Ó¿ÁÂÙ·È ÙË ¯ÔÚ‹ÁËÛË ÌfiÓÔ ˘ÁÚÒÓ ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, Ë ÔÔ›· ÌÔÚ› Ó· ·Ú¤¯ÂÈ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚfiÙËÙ· ÌfiÓÔ ÁÈ· ÂÚÈÔÚÈṲ̂ÓÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, Ó· ÂȉÂÈÓÒÛÂÈ ÂÚ·ÈÙ¤Úˆ ÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ Î·È Ó· ·˘Í‹ÛÂÈ ÙËÓ ÂÍ·ÁÁ›ˆÛË ˘ÁÚÔ‡ ÛÙÔÓ Ó‡ÌÔÓ· ı¤ÙÔÓÙ·˜ Û ΛӉ˘ÓÔ ÙËÓ Î·Ù·ÏÏËÏfiÙËÙ· ÙˆÓ Ó¢ÌfiÓˆÓ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÌÔۯ‡̷ٷ.45 ∞fi ÂÈÚ·Ì·ÙÈΤ˜ ·ÏÏ¿ Î·È ÎÏÈÓÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ Ê·›ÓÂÙ·È fiÙÈ Ë ¯ÔÚ‹ÁËÛË Î·Ù¯ÔÏ·ÌÈÓÒÓ ·Ó·ÏËÚÒÓÔ˘Ó Ù· ÂÏ·Ùو̤ӷ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ›‰· ηÙ¯ÔÏ·ÌÈÓÒÓ Î·È ÚÔÛı¤ÙÔ˘Ó ÈÓfiÙÚÔË ÂÓ›Û¯˘ÛË ÛÙÔ Ì˘ÔοډÈÔ. ™Â ·ÓÙÈ·Ú¿ıÂÛË, ˘¿Ú¯Ô˘Ó ·ÎfiÌË ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÁڷʤ˜ ÁÈ· ÙȘ ·ÓÂÈı‡ÌËÙ˜ ‰Ú¿ÛÂȘ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ. ∞˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ÂÍ¿ÓÙÏËÛË ÙˆÓ ˘„ËÏ‹˜ ÂÓÂÚÁÂȷ΋˜ ·fi‰ÔÛ˘ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ ÙÔ˘ Ì˘Ô΢ÙÙ¿ÚÔ˘, ÙËÓ Î·Ù·ÛÙÔÏ‹ ÙˆÓ Ì˘ÔηډȷÎÒÓ ·‰ÚÂÓÂÚÁÈÎÒÓ ‚ – ˘Ô‰Ô¯¤ˆÓ Î·È ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ¿Ú‰Â˘Û˘ ÙˆÓ ÓÂÊÚÒÓ, ÙÔ˘ ‹·ÙÔ˜ Î·È ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜.46 §fiÁˆ Ù˘ ıÂÙÈ΋˜ ‰Ú¿Û˘ Ù˘ ÓÙÔ·Ì›Ó˘ ÛÙËÓ ·ÈÌ¿ÙˆÛË ÙÔ˘ ÓÂÊÚÔ‡ ·ÔÙÂÏ› ÙËÓ ÚÒÙË ÂÈÏÔÁ‹ ·‰ÚÂÓÂÚÁÈÎÔ‡ Û΢¿ÛÌ·ÙÔ˜ Ì ÈÓfiÙÚÔË ‰Ú¿ÛË, Û ‰fiÛÂȘ Ô˘ Ú˘ıÌ›˙ÔÓÙ·È ÒÛÙ ӷ ˘¿Ú¯ÂÈ ÈηÓÔÔÈËÙÈ΋ ηډȷ΋ ·ÚÔ¯‹ Î·È ·ÁÁÂÈÔÛ‡Û·ÛË Ô˘ Ó· ÂÍ·ÛÊ·Ï›˙ÂÈ ÙËÓ Î·Ù¿ÏÏËÏË ›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÙÔ˘ ÓÂÊÚÔ‡. ™˘¯Ó¿ fï˜ Ë ÓÙÔ·Ì›ÓË ‰ÂÓ Â·ÚΛ, ȉȷ›ÙÂÚ· ÛÙÔ˘˜ ·ÁÁÂÈԉȷÛÙ·Ï̤ÓÔ˘˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜. °È’ ·˘Ùfi Û˘ÓËı›˙ÂÙ·È Ï¤ÔÓ fiÙ·Ó Ë ÓÙÔ·Ì›ÓË ‰ÂÓ Â·ÚΛ Û ‰fiÛÂȘ 10 Ìg/kg/min Ó· ·ÓÙÈηı›ÛÙ·Ù·È Ì ·‰ÚÂÓ·Ï›ÓË ‹ ÓÔÚ·‰ÚÂÓ·Ï›ÓË.41 OÈ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ Ú¤ÂÈ Ó· ·Ú·Ì¤ÓÔ˘Ó 800 – 1200 dynes sec/cm. °ÓˆÚ›˙ÔÓÙ·˜ ÙË ‚Ï¿‚Ë Ù˘ Ô›ÛıÈ·˜ ˘fiÊ˘Û˘ Î·È Ù˘ ÚÔηÏÔ‡ÌÂÓ˘ ·Ó¿ÚÎÂÈ·˜ Ù˘ ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ÔÚÌfiÓ˘, ÚÔÙ›ÓÂÙ·È Ë ¯ÔÚ‹ÁËÛË arginine vasopreessin ÁÈ· ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ˘ÔÛÙ‹ÚÈÍË Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¿ÂÈÔ˘ ‰È·‚‹ÙË. ∏ ¯Ú‹ÛË Ù˘ vasopressin ÂÈÙÚ¤ÂÈ Î·Ï‡ÙÂÚË ·ÈÌÔ‰˘Ó·ÌÈ΋ ˘ÔÛÙ‹ÚÈÍË Ì Ì›ˆÛË ÙˆÓ ··ÈÙÔ‡ÌÂÓˆÓ ‰fiÛÂˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ.47 ŒÙÛÈ Û‡Ìʈӷ Ì ÙÔÓ ıÂڷ¢ÙÈÎfi ·ÏÁfiÚÈıÌÔ Ô˘ ÚÔÙ›ÓÂÙ·È ÁÈ· ÙÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ ‰fiÙ˜, ÂÍ·ÛÊ·Ï›˙ÂÙ·È ÚÒÙ· Ô Î·Ù¿ÏÏËÏÔ˜ ÂÓ‰Ô·ÁÁÂÈ·Îfi˜ fiÁÎÔ˜, ¯ÔÚËÁ›ٷÈ
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N. ANTøNIA¢H™
Û˘Ì·ıËÙÈÎÔÌÈÌËÙÈÎfi Û··ÛÌ· ÁÈ· ÙËÓ ÈÓfiÙÚÔË ˘ÔÛÙ‹ÚÈÍË Û ÂÚÈÙÒÛÂȘ ¯·ÌËÏ‹˜ ηډȷ΋˜ ·ÚÔ¯‹˜ ‰È·ÙËÚÒÓÙ·˜ ÙÔÓ Î·Ú‰È·Îfi ‰Â›ÎÙË ¿Óˆ ·fi 2,4 L/min Î·È ÚfiÛıÂÙ· ¯ÔÚËÁÂ›Ù·È ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎfi Û ηٷÛÙ¿ÛÂȘ ¤ÓÙÔÓ˘ ·ÁÁÂÈԉȷÛÙÔÏ‹˜.47,48 ™Â ÂÚ›ÙˆÛË ·˘ÍË̤Ó˘ ‰ÈÔ‡ÚËÛ˘ ÛÙË ıÂڷ›· ÚÔÛÙ›ıÂÙ·È arginine vasopressin. ŸÙ·Ó ÔÈ ·ÈÌÔ‰˘Ó·ÌÈÎÔ› ·Ú¿ÌÂÙÚÔÈ ÙÔ˘ ‰fiÙË ˘Ô‰ËÏÒÓÔ˘Ó ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· ÚÔÙ›ÓÂÙ·È Ë ¤Ó·ÚÍË ıÂڷ›·˜ ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘. OÈ ÂӉ›ÍÂȘ ÁÈ· ÙËÓ ¤Ó·ÚÍË ıÂڷ›·˜ ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘ ÌÔÚ› Ó· ‰È·Ê¤ÚÔ˘Ó ÌÂٷ͇ ÙˆÓ ÌÔÓ¿‰ˆÓ ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜. ∞fi ÙË Ì›· ÏÂ˘Ú¿ Û˘ÛÙ‹ÓÔ˘Ó ÙËÓ ¤Ó·ÚÍË Ù˘ ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘ ¿ÌÂÛ· Ì ÙËÓ ÂÁηٿÛÙ·ÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Î·È ·fi ÙËÓ ¿ÏÏË ÂÈÏÂÎÙÈο ÙË ¯ÔÚËÁÔ‡Ó ÛÙÔ˘˜ ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜ ‰fiÙ˜ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙË Û˘ÓËıÈṲ̂ÓË ÂÓÙ·ÙÈ΋ ˘ÔÛÙËÚÈÎÙÈ΋ ıÂڷ›·.
£Âڷ›· ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘ Œ¯ÂÈ ÂÚÈÁÚ·Ê› fiÙÈ Ó¢ÚÔÂÓ‰ÔÎÚÈÓÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ¿ÍÔÓ· ˘Ôı·Ï¿ÌÔ˘ – ˘fiÊ˘Û˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ¤ˆ˜ Î·È ÛÙÔ 40 % ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ˘¤ÛÙËÛ·Ó ‚·ÚÈ¿ ÂÁÎÂÊ·ÏÈ΋ ‚Ï¿‚Ë. ∂›Û˘ ηٿ ÙË ÓÂÎÚÔ„›· ‚Ú¤ıËÎ·Ó ÛÙÔȯ›· ·ÈÌÔÚÚ·Á›·˜ ‹ Ó¤ÎÚˆÛ˘ Ù˘ ˘fiÊ˘Û˘ ÛÙÔ 80 % ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ˘¤ÛÙËÛ·Ó ÙÚ·˘Ì·ÙÈ΋ ÂÁÎÂÊ·ÏÈ΋ ‚Ï¿‚Ë.49 ∂ÓÒ ÛÙ· ÌÔÓ٤Ϸ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Û ÂÈÚ·Ì·Ùfi˙ˆ· ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ó¢ÚÔÂÓ‰ÔÎÚÈÓÈÎÔ‡ ¿ÍÔÓ·, ÛÙÔÓ ¿ÓıÚˆÔ ÔÈ ÌÂϤÙ˜ Û ‰fiÙ˜ ÔÚÁ¿ÓˆÓ ¤¯Ô˘Ó ·ÌÊÈÏÂÁfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· fiÛÔ ·Ó·ÊÔÚ¿ ÙËÓ ‡·ÚÍË Ù¤ÙÔÈ·˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ·ÏÏ¿ Î·È ÙÔ ıÂÙÈÎfi ÚfiÏÔ Ù˘ ıÂڷ›·˜ ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘.50 ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ‰ÂÓ ·Ô‰ÂÈÎÓ‡Ô˘Ó Î¿ÔÈ· Û¯¤ÛË ÌÂٷ͇ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜ Î·È ÂȤ‰ˆÓ ÂÓ‰ÔÁÂÓÒÓ ÔÚÌÔÓÒÓ. ∏ ÂÚÈÛÛfiÙÂÚË Û˘˙‹ÙËÛË fiÛÔ ·Ó·ÊÔÚ¿ ÙË ıÂڷ›· ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘ ÂÛÙÈ¿˙ÂÙ·È ÛÙȘ ‰È·Ù·Ú·¯¤˜ ‰È¤ÁÂÚÛ˘ Î·È ·Ú·ÁˆÁ‹˜ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ.44 ™Â ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ‚Ú¤ıËÎ·Ó ÌÂÙ¿ ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ ÌÂȈ̤ӷ ›‰· T4, T3 Î·È TSH. ™Â ÌÂÚÈΤ˜ ·fi ·˘Ù¤˜ ‚Ú¤ıËΠ›Û˘ ·ÓÙ›ÛÙÔÈ¯Ë ·‡ÍËÛË Ù˘ ·Ó¿ÛÙÚÔÊ˘ ÙÚÈȈ‰ÈÔı˘ÚÔÓ›Ó˘, ÂÓ‰ÂÈÎÙÈÎfi ÙÔ˘ euthyroid sick syndrome ·Ú¿ Ù˘ ·Ó¿ÚÎÂÈ·˜ ÎÂÓÙÚÈ΋˜ Ú‡ıÌÈÛ˘.44 °È· ÙȘ ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË
ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ‚ÂÏÙÈÒÓÂÈ ÙËÓ Î·Ú‰È·Î‹ ÏÂÈÙÔ˘ÚÁ›· Î·È ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ηٿÛÙ·ÛË ˘¿Ú¯ÂÈ Ô ·ÓÙ›ÏÔÁÔ˜ fiÙÈ ·˘Ùfi ›Ûˆ˜ ÔÊ›ÏÂÙ·È ÛÙËÓ ÈÓfiÙÚÔË ‰Ú¿ÛË ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ÛÙ· Ï·›ÛÈ· Û˘Ó‡·Ú͢ euthyroid sick syndrome. ¶¿ÓÙˆ˜ ÔÈ Novitzky Î·È Û˘Ó., ¯ÔÚËÁÒÓÙ·˜ ‰fiÛÂȘ Δ3 20-30 Ìg, ¤Ù˘¯·Ó ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ ‰fiÙË Î·È Ó· ÌÂȈıÔ‡Ó ÔÈ ·Ó·Áη›Â˜ ‰fiÛÂȘ ÓÙÔ·Ì›Ó˘, ·Ô 20-40 Ìg/kg/min Ô˘ Î˘Ì·›ÓÔÓÙ·Ó, Û ¤Ó· ̤ÛÔ fiÚÔ ‰fiÛ˘ 7,8 Ìg/kg/min.51 ŸÛÔ ·Ó·ÊÔÚ¿ ÙË ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ÚÔÛı‹ÎË ÙÔ˘˜ ÛÙËÓ ˘ÔÛÙËÚÈÎÙÈ΋ ıÂڷ›· ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË Ì ‚¿ÛË ·Ú·ÙËÚ‹ÛÂȘ ÂÏ·Ùو̤Ó˘ ¤ÎÎÚÈÛ˘ ÛÙÔ˘˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ˘Ô„‹ÊÈÔ˘˜ ‰fiÙ˜.52 ŸÌˆ˜ ¿ÏÈ ¿ÏϘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ‰ÂÓ ·Ô‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ÙÒÛË ÙˆÓ ÂȤ‰ˆÓ ÎÔÚÙÈ˙fiÏ˘ ÛÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ. ∫ÏÈÓÈο Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ Ô›ÛıÈ·˜ ˘fiÊ˘Û˘ ÂÌÊ·Ó›˙ÂÙ·È Û˘¯Ó¿ ÛÙÔ˘˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰˘ÓËÙÈÎÔ‡˜ ‰fiÙ˜ Ì ÙËÓ ÂΉ‹ÏˆÛË ¿ÂÈÔ˘ ‰È·‚‹ÙË. Ÿˆ˜ ·Ó·Ê¤ÚıËΠÚÔËÁÔ˘Ì¤Óˆ˜ Ë ¯ÔÚ‹ÁËÛË arginine vasopressin ·ÔηıÈÛÙ¿ ÁÚ‹ÁÔÚ· ÙËÓ ÔÛ̈ÙÈÎfiÙËÙ· ÙˆÓ Ô‡ÚˆÓ Î·È ÂÏ·ÙÙÒÓÂÈ ÙȘ ˘ÂÚ‚ÔÏÈΤ˜ ·ÒÏÂȘ Ô‡ÚˆÓ. ¶·Ú¿ Ù· ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙË ¯ÚËÛÈÌfiÙËÙ· ÙË ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘, ÌÈ· ÌÂϤÙË (Papworth, ∞ÁÁÏ›·) Ì ÌÂÁ¿ÏË ÛÂÈÚ¿ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ ·¤‰ÂÈÍ ٷ ÏÂÔÓÂÎÙ‹Ì·Ù· Ù˘ ÚÔÛı‹Î˘ ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘ ÛÙËÓ ÂÓÙ·ÙÈ΋ ıÂڷ›· ÙÔ˘ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡ ‰fiÙË.53 ™Â ·˘Ù‹ ÙË ÌÂϤÙË ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜ (·Î·Ù¿ÏÏËÏÔÈ) ‰fiÙ˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ÂÓÙ·ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË (˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·, ηıÂÙ‹Ú·˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ Î.Ï..) Î·È ÙËÓ Î·Ù¿ÏÏËÏË ıÂڷ›· Ë ÔÔ›· Û˘ÌÏËڈ̷ÙÈο ÂÚÈÂÏ¿Ì‚·Ó ÂÓ‰ÔÊϤ‚È· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ÈÓÛÔ˘Ï›ÓË Î·È ‰È·Ï‡Ì·Ù· ÁÏ˘Îfi˙˘, vasopressin Î·È ÙÚÈȈ‰Ôı˘ÚÔÓ›Ó˘ (Papworth cocktail). ∞˘Ù‹ Ë ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Â›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÔÈ 44 ·fi ÙÔ˘˜ 52 ·Ú¯Èο ·Î·Ù¿ÏÏËÏÔ˘˜ ‰fiÙ˜ Ó· ÌÂÙ·ÙÚ·Ô‡Ó Û ηٿÏÏËÏÔ˘˜ ‰fiÙ˜. ¢ËÏ·‰‹ ÙÔ 93 % ·˘ÙÒÓ Ô˘ ıˆڋıËÎ·Ó ·Ú¯Èο ·Î·Ù¿ÏÏËÏÔÈ ÌfiÚÂÛ·Ó Ó· ¤¯Ô˘Ó ÈηÓÔÔÈËÙÈ΋ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·Ó¿ÓË„Ë. Δ¤ÏÔ˜, ÚÔÙ›ÓÂÙ·È ÔÌfiʈӷ fiÙÈ ÛÙÔ˘˜ ‰fiÙ˜ Ô˘ ¤¯Ô˘Ó ‹‰Ë Ï¿‚ÂÈ ÙËÓ ÎÏ·ÛÈ΋ ÂÓÙ·ÙÈ΋ ıÂڷ›· ·ÏÏ¿ ·Ú·Ì¤ÓÔ˘Ó Ì ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ÌÈÎÚfiÙÂÚÔ ÙÔ˘ 45 %, Ó· ÚÔÛÙ›ıÂ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ù·È ÛÙËÓ ·ÁˆÁ‹ ÙÔ˘˜ Ô Û˘Ó‰˘·ÛÌfi˜ ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË, Δ3 Î·È vasopressin. ∞˘Ù¤˜ Ë Ô‰ËÁ›Â˜ ÛÙËÚ›¯ÙËÎ·Ó ÛÙËÓ ·Ó¿Ï˘ÛË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÒÓ ‰ÔÙÒÓ ·fi ÙË ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ UNOS Ô˘ ¤‰ÂÈÍ fiÙÈ Ë ·˘Ù‹ Ë ÙÚÈÏ‹ ÔÚÌÔÓÈ΋ ıÂڷ›· ‚ÂÏÙ›ˆÛ ÛËÌ·ÓÙÈο ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ‚¿ÛÂÈ ÙˆÓ ÔÔ›ˆÓ ÎÚ›ÓÔÓÙ·È Î·Ù¿ÏÏËÏÔÈ ÂÈÏÔÁ‹˜ ÔÈ ‰fiÙ˜.
£Âڷ¢ÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË Ó¢ÌfiÓˆÓ ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ fiÙÈ ÔÈ Ó‡ÌÔÓ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÌÔۯ‡̷ٷ ÌfiÓÔ ÛÙÔ 16 % ÙˆÓ ‰ÔÙÒÓ ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ. À¿Ú¯Ô˘Ó ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÈ‚·Ú‡ÓÔ˘Ó ÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ó¢ÌfiÓˆÓ Î·È Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔ ·Ú·¿Óˆ ¯·ÌËÏfi ÔÛÔÛÙfi. ™Â ·˘ÙÔ‡˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ·fi ÙË Ì›· Ë Ó¢ÌÔÓÈ΋ ‚Ï¿‚Ë Ô˘ ÌÔÚ› Ó· Û˘Óԉ‡ÂÈ ÙËÓ ÚˆÙÔ·ı‹ ·ÈÙ›· ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ÏfiÁˆ ÂÈÛÚfiÊËÛ˘, Ó¢ÌÔÓÈ΋˜ ıÏ¿Û˘, ηٿÛÙ·Û˘ ÛÔÎ Ì ÙÔ Û¯ÂÙÈÎfi Ê·ÈÓfiÌÂÓÔ ÈÛ¯·ÈÌ›·˜ – ·ӷÈÌ¿ÙˆÛ˘ Î·È ·fi ÙËÓ ¿ÏÏË Ë Ó¢ÌÔÓÈ΋ ‚Ï¿‚Ë Ù˘ ÂÚÈfi‰Ô˘ ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡, ÏfiÁˆ ·ÙÂÏÂÎÙ·Û›·˜, Ó¢ÌÔÓÈ΋˜ Ïԛ̈͢, ‚·ÚÔÙÚ·‡Ì·ÙÔ˜ ‹ ÔÁÎÔÙÚ·‡Ì·ÙÔ˜ Î·È ·fi ÙȘ ÂÈÙÒÛÂȘ Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙÔ˘ Ô͢ÁfiÓÔ˘. ¶ÚfiÛÊ·Ù· ·Ó·ÁÓˆÚ›ÛÙËΠfiÙÈ Ë ı‡ÂÏÏ· ηÙ¯ÔÏ·ÌÈÓÒÓ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Î·È Ë ·ÎfiÏÔ˘ıË ÂÓÂÚÁÔÔ›ËÛË Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰ÈÂÚÁ·Û›·˜ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ·ÚÓËÙÈο ÙËÓ Ó¢ÌÔÓÈ΋ Ê˘ÛÈÔÏÔÁ›· Î·È ÏÂÈÙÔ˘ÚÁ›·. ∏ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘ ·fi ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ ÙÔ˘ San Antonio ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÓÙ˘ˆÛȷ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ¯ÚËÛÈÌÔÔ›ËÛ˘ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÙÔ˘˜ ‰È·ı¤ÛÈÌÔ˘˜ ‰fiÙ˜.55 ΔÔ ÔÛÔÛÙfi ¯ÚËÛÈÌÔÔ›ËÛ˘ Ó¢ÌÔÓÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ¤ÊÙ·Û ÛÙÔ 25 %, ·fi 11,5 % Ô˘ ‹Ù·Ó ÚÔËÁÔ˘Ì¤Óˆ˜. ∂›Û˘ ηٿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘, ÙÔ 54 % ÙˆÓ ‰ÔÙÒÓ ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÙÂÏÈο Ï‹ÊıËÎ·Ó Ó¢ÌÔÓÈο ÌÔۯ‡̷ٷ ·Ú¯Èο Î·È Ì ÙË Û˘ÓËıÈṲ̂ÓË ÂÓÙ·ÙÈ΋ ıÂڷ¢ÙÈ΋ ˘ÔÛÙ‹ÚÈÍË Â›¯·Ó ÎÚÈı› ˆ˜ ·Î·Ù¿ÏÏËÏÔÈ ‰fiÙ˜ Ó¢ÌÔÓÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. Δ· ȉȷ›ÙÂÚ· ÛÙÔȯ›· ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘ ·ÔÙÂÏÔ‡Û·Ó ÔÈ ¯ÂÈÚÈÛÌÔ› ÛÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ Î˘„ÂÏ›‰ˆÓ, Ô ÂÚÈÔÚÈ-
37
ÛÌfi˜ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ˘ÁÚÒÓ, Ë ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Î·È Ù¯ÓÈΤ˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÂÈÛÚfiÊËÛ˘. OÈ ¯ÂÈÚÈÛÌÔ› ÛÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ‰ÈÂÓÂÚÁÔ‡Ù·Ó fiÙ·Ó Ë ·Ú¯È΋ ·Ó¿Ï˘ÛË ÙˆÓ ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜ ¤‰ÂȯÓ ÙËÓ ·Ó·ÏÔÁ›· PaO2/FIO2 Ó· Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 300 mmHg Î·È fiÙ·Ó ˘‹Ú¯·Ó Ó¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ ‹ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· ‹ ·ÙÂÏÂÎÙ·Û›·. OÈ ¯ÂÈÚÈÛÌÔ› ·˘ÙÔ›, ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË ÙˆÓ Î˘„ÂÏ›‰ˆÓ, Û˘Ó›ÛÙ·ÓÙÔ Û ÂÏÂÁ¯fiÌÂÓ˘ ›ÂÛ˘ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Ì ÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË 25 mmH2O Î·È ıÂÙÈ΋ ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË 15 mmH2O ÁÈ· 2 ÒÚ˜. ™ÙË Û˘Ó¤¯ÂÈ· Ô ÙÚfiÔ˜ ·ÂÚÈÛÌÔ‡ Á˘ÚÓÔ‡Û ÛÙÔÓ ÎÏ·ÛÈÎfi ÂÏÂÁ¯fiÌÂÓÔ˘ fiÁÎÔ˘ ·¤Ú· ·ÂÚÈÛÌfi Ì fiÁÎÔ ÂÈÛÓÂfiÌÂÓÔ˘ ·¤Ú· 10 ml/kg Î·È ıÂÙÈ΋ ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË 5 mmHg. ∏ ·Ú¤Ì‚·ÛË ıˆÚÔ‡ÓÙ·Ó ÂÈÙ˘¯Ë̤ÓË fiÙ·Ó ‚ÂÏÙÈÒÓÔÓÙ·Ó Ë ·Ó·ÏÔÁ›· PaO2/FIO2 Ì ÙÈ̤˜ ›Û˜ ‹ ÌÈÎÚfiÙÂÚ˜ ·fi 300 mmHg Î·È ·Ú¿ÏÏËÏ· ‚ÂÏÙÈÒÓÔÓÙ·Ó Ë ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜. ÀÔÏÔÁ›˙ÔÓÙ·Ó ÙÔ ÈÛÔ˙‡ÁÈÔ ˘ÁÚÒÓ Ì ÛÙfi¯Ô ÙÔ ·ÚÓËÙÈÎfi ÈÛÔ˙‡ÁÈÔ, ÂÚÈÔÚ›˙ÔÓÙ·˜ Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ Î·È ¯ÔÚËÁÒÓÙ·˜ ‰ÈÔ˘ÚËÙÈο. O ΛӉ˘ÓÔ˜ ÂÈÛÚfiÊËÛ˘ ÂÚÈÔÚ›˙ÔÓÙ·Ó Ì ÙËÓ ·Ó‡„ˆÛË ÙÔ˘ ÎÂÊ·ÏÈÔ‡ ηٿ 300 Î·È ÊÔ˘ÛÎÒÓÔÓÙ·˜ ÙÔÓ ·ÂÚÔı¿Ï·ÌÔ ÙÔ˘ ÂÓ‰ÔÙÚ·¯ÂÈ·ÎÔ‡ ۈϋӷ Ì ›ÂÛË 25 mmH2O. μÚÔÁ¯ÔÛÎfiËÛË ‰ÈÂÓÂÚÁÔ‡ÓÙ·Ó Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ‚ÚÔÁ¯Ô΢„ÂÏȉÈ΋ χÛË ÒÛÙ ӷ ÂÎÙÈÌËıÔ‡Ó ÂÚÈÔ¯¤˜ Ì Ó¢ÌÔÓÈΤ˜ ‰ÈËı‹ÛÂȘ, ıÏ¿ÛË, ‹ ÂÈÛÚfiÊËÛË Ô˘ ÌÔÚ› Ó· ·ÂÈÎÔÓ›˙ÔÓÙ·È ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜. ∞˘Ù‹ Ë ıÂڷ¢ÙÈ΋ ÛÙÚ·ÙËÁÈ΋ Û˘Ó¯›˙ÂÙÔ Ì¤¯ÚÈ ÙË ÛÙÈÁÌ‹ Ù˘ Ï‹„˘ ÙˆÓ Ó¢ÌfiÓˆÓ.
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6
B·Û›Ï˘ BÔ‡Á·˜
ÛÙ¤˜, ÓÔÛËÏÂ˘Ù¤˜, È·ÙÚÔ‡˜ ÎÈÓËÙÔÔÈ›ٷÈ, Ì ÚÒÙË ÚÔÙÂÚ·ÈfiÙËÙ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÏËÚÔÊÔÚÈÒÓ ·fi ÙÔ ‰fiÙË (ËÏÈΛ·, ‡„Ô˜, ‚¿ÚÔ˜, ·ÈÙ›· ı·Ó¿ÙÔ˘, ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ ÛÙË ª∂£, ·ÈÌÔ‰˘Ó·ÌÈÎfi profile, ÔÌ¿‰· ·›Ì·ÙÔ˜ ÎÏ.) ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· Ï‹„˘ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚˆÓ ÙÔ˘ ÂÓfi˜ ÔÚÁ¿ÓˆÓ(1,2). ŸÙ·Ó Ô Î‡ÎÏÔ˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Î·È ÎÏÈÓÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÙÔ˘ ‰fiÙÔ˘ ÔÏÔÎÏËÚˆı› Î·È ÈÛÙÔÔÈËı› Ë ‰˘Ó·ÙfiÙËÙ· ÚÔÛÊÔÚ¿˜ ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ Î·È ÂÓ ÚÔÎÂÈ̤ӈ ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ, ÍÂÎÈÓ¿ Ë ‰È·‰Èηۛ· ÙÔ˘ Û˘ÓÙÔÓÈÛÌÔ‡ ÙˆÓ ÔÌ¿‰ˆÓ ÙˆÓ ¯ÂÈÚÔ˘ÚÁÒÓ (‹·Ú, ÓÂÊÚÔ‡˜, ÏÂÙfi ¤ÓÙÂÚÔ, ¿ÁÎÚ·˜ Î.Ô.Î.) ‹ Ù˘ ÌÈ·˜ ÔÌ¿‰·˜ Ô˘ ı· ·Ó·Ï¿‚ÂÈ Ó· ·Ê·ÈÚ¤ÛÂÈ fiÏ· Ù· fiÚÁ·Ó·. ∏ ¤̂·ÛË ÙÂÏÂ›Ù·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÙÔ˘ ‰fiÙÔ˘ Î·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· ¤¯ÂÈ ÙÔÓ ··Ú·›ÙËÙÔ Ù¯ÓÈÎfi ÂÍÔÏÈÛÌfi, ηıÒ˜ Î·È ÙË Ê·Ú̷΢ÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÁÈ· Ó· ÂÈÙÂϤÛÂÈ ÙÔ ÌÂÁ¿Ï˘ ÛËÌ·Û›·˜ ¤ÚÁÔ Ù˘. ªÔÚ› Ó· ˘¿Ú¯ÂÈ Î·È ÂȉÈÎfi˜ ÂÚÁ·ÏÂÈÔ‰fiÙ˘ ÓÔÛËÏÂ˘Ù‹˜ ÛÙËÓ ÂοÛÙÔÙ ÔÌ¿‰· ηıÒ˜ Î·È ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ Ô˘ ‚ÔËı¿ ÙÔ ¤ÚÁÔ ÙÔ˘ ÙÔÈÎÔ‡ ·Ó·ÈÛıËÛÈÔÏfiÁÔ˘(3). ∏ ¤̂·ÛË ÛÙÔ ‰fiÙË ÍÂÎÈÓ¿ Ì ÌÈ· ̤ÛË ˘ÂÚ˘ÔÌÊ¿ÏÈÔ ÙÔÌ‹ Ô˘ ÌÔÚ› Ó· ÂÂÎÙ·ı› Î·È Û ̤ÛË ÛÙÂÚÓÔÙÔÌ‹. ∏ ÙÂÏÂ˘Ù·›· (Â¿Ó ‰ÂÓ ÂÌϷΛ ÔÌ¿‰· ηډÈÔ¯ÂÈÚÔ˘ÚÁÒÓ ÁÈ· ·Ê·›ÚÂÛË Î·Ú‰È¿˜Ó¢ÌfiÓˆÓ) Á›ÓÂÙ·È Î˘Ú›ˆ˜ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ‰È‡ڢÓÛ˘ Ù˘ ̤Û˘ Ï··ÚÔÙÔÌ›·˜ ·ÏÏ¿ Î·È ÙË ‰È·ÎÔ‹ Ù˘ ΢ÎÏÔÊÔÚ›·˜ [·ÔÚÙ‹˜ (cross clamping), οو ÎÔ›Ï˘ (∫∫º)-‰ÂÍ. ÎfiÏÔ˜ (venting)] ̤۷ ÛÙÔ ıÒڷη Î·È ÙË ‰È¢ÎfiÏ˘ÓÛË ÙˆÓ ¯ÂÈÚÈÛÌÒÓ ÛÙËÓ ÎÔÈÏȷ΋ ¯ÒÚ·. °È· ÙËÓ ·Ú·Û΢‹ Î·È ·Ê·›ÚÂÛË ÙˆÓ ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÔÚÁ¿ÓˆÓ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È 2 Ù¯ÓÈΤ˜: ·) ∏ Ù¯ÓÈ΋ Ù˘ Ù·¯Â›·˜ ¤̂·Û˘ (rapid technique). ‚) ∏ ¤̂·ÛË ÌÂ Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ ¯ÚfiÓÔ˘˜ ·Ú·Û΢‹˜ ÙˆÓ ÛÙÔȯ›ˆÓ. ∏ ‰È·ÊÔÚÔÔ›ËÛË Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ‡·ÚÍË,
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› ÙË ıÂڷ›· ÂÎÏÔÁ‹˜ ÁÈ· ·ÛıÂÓ›˜ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓfiÛÔ ÙˆÓ ‰È·ÊfiÚˆÓ ÔÚÁ¿ÓˆÓ (ηډȿ, ‹·Ú, ÓÂÊÚÔ› ÎÏ.). ªÂ ÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Û·Ó Î‡ÚÈ· ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹, Ô ·ÚÈıÌfi˜ Î·È Ô Ù‡Ô˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‚ÂÏÙÈÒıËΠÂÓÙ˘ˆÛȷο Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó¿Ù˘ÍË Î·È ÙÂÏÂÈÔÔ›ËÛË ÙˆÓ Ù¯ÓÈÎÒÓ ÁÈ· Ï‹„Ë ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ ·fi ¤Ó· ‰fiÙË Î·È ÙËÓ ÂÍÂȉ›Î¢ÛË ÙˆÓ ¯ÂÈÚÔ˘ÚÁÒÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ·˘Ù¤˜ ÙȘ ÂÂÌ‚¿ÛÂȘ. ∏ ˙‹ÙËÛË ÙˆÓ ÔÚÁ¿ÓˆÓ ·˘Í‹ıËΠηٷÎfiÚ˘Ê· Ì ·ÔÙ¤ÏÂÛÌ· Ë Û·ÓÈfiÙ˘ ÙˆÓ ‰ÔÙÒÓ Ó· ηٷÛÙ‹ÛÂÈ ·Ó·Áη›· ÙË ‰˘Ó·ÙfiÙËÙ· ÙˆÓ È·ÙÚÈÎÒÓ ÂȉÈÎÔÙ‹ÙˆÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ó· ·Ó·ÁÓˆÚ›˙Ô˘Ó ‰˘ÓËÙÈÎÔ‡˜ ‰fiÙ˜ ÛÙȘ ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ Î·È Ó· ÙȘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Î·Ù¿ÏÏËÏ·. ∞fi Ù¯ÓÈ΋˜ ·fi„ˆ˜ Ë Ï‹„Ë ÔÚÁ¿ÓˆÓ ‰È·ÎÚ›ÓÂÙ·È Û ÙÚÂȘ ηÙËÁÔڛ˜: 1. ΔË Ï‹„Ë ÔÚÁ¿ÓˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ì ¿ÏÏÔ˘Û· ηډȿ. 2. ΔË Ï‹„Ë ÔÚÁ¿ÓˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ì ÌË ¿ÏÏÔ˘Û· ηډȿ. 3. ΔË Ï‹„Ë ÔÚÁ¿ÓˆÓ ·fi ˙ÒÓÙ˜ Û˘ÁÁÂÓ›˜ ‹ ÌË Û˘ÁÁÂÓ›˜ ‰fiÙ˜. OÈ ‰‡Ô ÚÒÙ˜ ηÙËÁÔڛ˜ ·ÊÔÚÔ‡Ó ·ÔÎÏÂÈÛÙÈο ÙÔ ·ÓÙÈΛÌÂÓÔ Ù˘ ·ÚÔ‡Û˘ ÂÈÛËÁ‹Ûˆ˜ Î·È ÂȉÈÎfiÙÂÚ· ÙË Ï‹„Ë ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÔÚÁ¿ÓˆÓ.
1. §‹„Ë ÔÚÁ¿ÓˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ì ¿ÏÏÔ˘Û· ηډȿ (cadaveric heart beating donors) OÈ ÙˆÌ·ÙÈÎÔ› ‰fiÙ˜ ·ÔÙÂÏÔ‡Ó ÙË ÛËÌ·ÓÙÈÎfiÙÂÚË ·fi ÏÂ˘Ú¿˜ ·ÚÈıÌÔ‡ ËÁ‹ ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÔÚÁ¿ÓˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞fi ÙË ÛÙÈÁÌ‹ Ù˘ ‰È·ÁÓÒÛˆ˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ – ‚·ÛÈ΋ ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ÚÔÛÊÔÚ¿ ÔÚÁ¿ÓˆÓ Î·È ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ù˘ Û˘ÁηٿıÂÛ˘ ·fi ÙÔ˘˜ Û˘ÁÁÂÓ›˜ ÁÈ· ÙË ‰ˆÚ¿ – ¤Ó·˜ Ì˯·ÓÈÛÌfi˜ ·fi Û˘ÓÙÔÓÈ-
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÛÙËÓ ÚÒÙË ÂÚ›ÙˆÛË, ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜ ÙÔ˘ ‰fiÙÔ˘ Ô˘ ÂÈ‚¿ÏÏÂÈ ÁÚ‹ÁÔÚ˜ ÎÈÓ‹ÛÂȘ ¯ˆÚ›˜ ȉȷ›ÙÂÚË ·Ú·Û΢‹ ÙˆÓ ÛÙÔȯ›ˆÓ, ·ÏÏ¿ ÌfiÓÔ ÙÔÔı¤ÙËÛË ÙˆÓ Î·ıÂÙ‹ÚˆÓ (cannulation) Î·È ¤Ó·ÚÍË ÂÎχÛˆ˜ ·fi ÙËÓ ·ÔÚÙ‹, Ì ‹ ¯ˆÚ›˜ ¤ÎÏ˘ÛË ·fi ÙËÓ ¿Óˆ ÌÂÛÂÓÙ¤ÚÈÔ ÊϤ‚·. ™ÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË Ë Â¤Ì‚·ÛË ÍÂÎÈÓ¿ ηٿ ηÓfiÓ· Ì ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· ÙÔ˘ ‹·ÙÔ˜ fiÔ˘ Î·È ·ÊÔ‡ Á›ÓÂÈ ÏÂÙÔÌÂÚ‹˜ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ ÛÙÔȯ›ˆÓ ‹ ¤Ú¢ӷ ÁÈ· ‡·ÚÍË ¿ÏÏˆÓ ·ıÔÏÔÁÈÒÓ (·ÈÌ·ÙÒÌ·Ù·, ÓÂÔϷۛ˜, Û˘ÌʇÛÂȘ, ÊÏÂÁÌÔÓ¤˜ ÎÏ.), Ë ·Ú·Û΢‹ ÍÂÎÈÓ¿ Ì ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ ‹·ÙÔ˜ ·fi ÙÔ˘˜ ÙÚÂȘ Û˘Ó‰¤ÛÌÔ˘˜ Î·È ÙËÓ ·Ú·Û΢‹ ÙÔ˘ Ë·ÙÔ‰ˆ‰Âη‰·ÎÙ˘ÏÈÎÔ‡ Û˘Ó‰¤ÛÌÔ˘ Ì ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘, ·ÔϛӈÛË ·˘ÙÔ‡ Î·È ·Ó·ÁÓÒÚÈÛË Î·È ·Ú·Û΢‹ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ ÁÈ· Èı·Ó¤˜ ·Ú·ÏÏ·Á¤˜ Ù˘, ηıÒ˜ Î·È Ù˘ ÔÚ›·˜ Ù˘ ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì‹ÎÔ˜ ̤¯ÚÈ ÙÔÓ ·ÏÏ‹ÚÂÈÔ ÙÚ›Ô‰·. ∞ÎÔÏÔ˘ı› Ë ·Ú·Û΢‹ Ù˘ ˘Ï·È¿˜ ÊϤ‚·˜, ÂÓ Û˘Ó¯›· ·Ú·Û΢¿˙ÂÙ·È Î·È ÂÚÈÁ˘Ú›˙ÂÙ·È Ë ˘ÊË·ÙÈ΋ ∫∫º, ηıÒ˜ Î·È Ë ˘ÂÚË·ÙÈ΋ οو ÎÔ›ÏË Î¿ÙˆıÂÓ ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜. ∞ÊÔ‡ ·Ó·ÁÓˆÚÈÛıÔ‡Ó Ù· ÛΤÏË ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ ÂÚÈÁ˘Ú›˙ÂÙ·È Ë ˘Ô‰È·ÊÚ·ÁÌ·ÙÈ΋ ·ÔÚÙ‹ ¿ÓˆıÂÓ ÙÔ˘ ·ÏÏËÚ›Ԣ ÙÚ›Ô‰Ô˜. ∂Ó Û˘Ó¯›· ·Ú·Û΢¿˙ÂÙ·È Ë ¿Óˆ ÌÂÛÂÓÙ¤ÚÈÔ˜ ÊϤ‚· Â¿Ó ÚfiÎÂÈÙ·È Ó· ÂÎÏ˘ı› ÙÔ ‹·Ú ‰È· Ù˘ ˘Ï·›·˜ ÊϤ‚·˜. ™Â ÂÚ›ÙˆÛË Ï‹„ˆ˜ Î·È ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ·˘Ùfi˜ Ô ¯ÂÈÚÈÛÌfi˜ ·ÔʇÁÂÙ·È. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· Ù˘ Ï‹„ˆ˜ ÙˆÓ ÓÂÊÚÒÓ ÂÈÛ¤Ú¯ÂÙ·È ÌÂÙ¿ Î·È ·Ú·Û΢¿˙ÂÈ ÙÔ˘˜ Ô˘ÚËÙ‹Ú˜ ÛÙÔ Î·ÙÒÙÂÚÔ ÚÔ˜ ÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË Â›Â‰Ô Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙȘ ÎÔÏÔ·ÚÂȷΤ˜ ·‡Ï·Î˜ Ì ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ÓÂÊÚÒÓ ·fi ÙÔÓ Î˘ÙÙ·ÚÔÏÈÒ‰Ë ÈÛÙfi. ∂Ó Û˘Ó¯›· Î·È ÛÂ Û˘ÓÙÔÓÈÛÌfi Ì ÙËÓ Î·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· ÁÈ· ÙË Ï‹„Ë Ù˘ ηډȿ˜-Ó¢ÌfiÓˆÓ, Á›ÓÂÙ·È iv ¤Á¯˘ÛË 15.000-20.000 ÌÔÓ¿‰ˆÓ Ë·Ú›Ó˘. ΔÔÔıÂÙÔ‡ÓÙ·È Î·ıÂÙ‹Ú˜ ˘ÁÚÔ‡ ÂÎχÛˆ˜-Û˘ÓÙËÚ‹Ûˆ˜ ÛÙËÓ ·ÔÚÙ‹ ¿ÓˆıÂÓ ÙÔ˘ ‰È¯·ÛÌÔ‡ ÙˆÓ Ï·ÁÔÓ›ˆÓ, ηıÒ˜ Î·È ÛÙËÓ ¿Óˆ ÌÂÛÂÓÙ¤ÚÈÔ ÊϤ‚·-˘Ï·›· ÊϤ‚· (™¯‹Ì· 1). ΔÔ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ ˘ÁÚfi Û˘ÓÙ‹ÚËÛ˘ Â›Ó·È ÙÔ UW (University of Wisconsin)(Belzer) ‹ ÙÔ ÚÔÛÊ¿Ùˆ˜ ÛÙËÓ ∂ÏÏ¿‰· ∏Δ∫ (Histidine Tryptophane Ketogloutarate) (Custodiol) Ù· ÔÔ›· ‰›‰ÔÓÙ·È ÛÂ Û˘ÓÔÏÈ΋ ÔÛfiÙËÙ· 2-3 lt Î·È 4-5 lt ·ÓÙÈÛÙÔ›¯ˆ˜, ÂÌÏÔ˘ÙÈṲ̂ӷ Ì ·ÓÙÈ‚ÈÔÙÈο, ÎÔÚÙÈÎÔÂȉ‹ Î·È ÈÓÛÔ˘Ï›ÓË. °È· ÙËÓ ¤ÎÏ˘ÛË ÙˆÓ ÓÂÊÚÒÓ ÌfiÓÔ, ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈË-
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ı› Î·È ÙÔ ˘ÁÚfi Marshall’s, ·Ú·Ï‹ÛÈÔ ÙÔ˘ UW Û ËÏÂÎÙÚÔχÙ˜ ·ÏÏ¿ Î·È ¯·ÌËÏfiÙÂÚÔ˘ ÎfiÛÙÔ˘˜. ∂Ó Û˘Ó¯›· ·ÎÔÏÔ˘ı› ·ÔÎÏÂÈÛÌfi˜ Ù˘ ·ÔÚÙ‹˜ (cross-clamping) ˘Ô‰È·ÊÚ·ÁÌ·ÙÈο, ¤Ó·ÚÍË Ù˘ Âί‡Ûˆ˜ ÙˆÓ ˘ÁÚÒÓ ¤ÎÏ˘Û˘ Î·È Û˘ÓÙ‹ÚËÛ˘ Û 4∞C Ì ÎÏÂÈÛÙfi ·Îψ̷ ¤Î¯˘Û˘ Î·È „‡Í˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ ·ÏÏ‹ÚÂÈÔ ÙÚ›Ô‰·, ÙËÓ ¿Óˆ ÌÂÛÂÓÙ¤ÚÈÔ ·ÚÙËÚ›· Î·È ÙȘ ÓÂÊÚÈΤ˜ ·ÚÙËڛ˜ (‹·Ú + ¿ÁÎÚ·˜ + ÏÂÙfi ¤ÓÙÂÚÔ + ÓÂÊÚÔ›) Ì ٷ˘Ùfi¯ÚÔÓË ‰È·ÙÔÌ‹ Ù˘ ˘ÂÚË·ÙÈ΋˜ οو ÎÔ›Ï˘ ÊϤ‚·˜ Î·È ·Ê·›Ì·ÍË ÙÔ˘ ‰fiÙÔ˘ (venting). ΔÔÔıÂÙÔ‡ÓÙ·È ÙÂÌ¿¯È· ¿ÁÔ˘ ÛÙËÓ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ· Î·È 1-2 lt ·ÁˆÌ¤ÓÔ˘ (4∞C) Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡ (N/S) ηıÒ˜ ‰ÈÂÓÂÚÁÂ›Ù·È ‰È¿ÓÔÈÍË Ù˘ ¯ÔÏˉfi¯Ô˘ ·ÛÙˆ˜ Î·È ¤ÎÏ˘ÛË ·˘Ù‹˜ ·fi ÙË ¯ÔÏ‹ Ì 20-40 ml N/S Î·È Ù·˘Ùfi¯ÚÔÓË ‰È¿ÓÔÈÍË Î·È ¤ÎÏ˘ÛË ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘ Ì N/S solution. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÎχÛˆ˜ ·Ê·ÈÚÔ‡ÓÙ·È ·Ú¯Èο Ë Î·Ú‰È¿ Î·È ÔÈ Ó‡ÌÔÓ˜ Â¿Ó ˘¿Ú¯ÂÈ Î·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· Î·È ÂÓ Û˘Ó¯›· ·Ú¯›˙ÂÈ Ë ‰È·‰Èηۛ· ·Ê·›ÚÂÛ˘ ÙÔ˘ ‹·ÙÔ˜ Ì ·Ú·Û΢‹ Î·È ‰È·ÙÔÌ‹ Ù˘ ∫∫º ‡ÂÚıÂÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ÊÏ‚ÒÓ, ‰È·ÙÔÌ‹ Ù˘ ÛÏËÓÈ΋˜ Î·È ·Ú. Á·ÛÙÚÈ΋˜ ·ÚÙËÚ›·˜ Ì ·Ú·Ì¤ÓÔÓ ·ÚÎÂÙ¿ ÌÂÁ¿ÏÔ Ì‹ÎÔ˜ ·˘ÙÒÓ Î·È ÂÓ Û˘Ó¯›· ‰È·ÙÔÌ‹ Ù˘ ÎÔÈÏȷ΋˜ ·ÚÙËÚ›·˜ Ì ·ÚÎÂÙ¿ ÌÂÁ¿ÏÔ ÙÌ‹Ì· ·ÔÚÙ‹˜ (carell patch). ™Â ÂÚ›ÙˆÛË Ù·˘ÙÔ¯ÚfiÓÔ˘ Ï‹„ˆ˜ en bloc Î·È Supra hepatic vena cava
Diaphragm Stomach
Infra hepatic vena cava Superior mesenteric vein Right kidney
Portal vein Left kidney Aorta
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B. BOY°A™
·ÁÎÚ¤·ÙÔ˜ ‹ Î·È ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (cluster operation), Ë ‰È·ÙÔÌ‹ ÛÙËÓ ·ÔÚÙ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙËÓ ¿Óˆ ÌÂÛÂÓÙ¤ÚÈÔ ·ÚÙËÚ›· Ì ÎÔÈÓ‹ ¤ÎÊ˘ÛË (patch). ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ¤¯ÂÈ ÚÔËÁËı› ηϋ ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ‰ÂÍ. ÎfiÏÔ˘ ÚÔ˜ ÙË Ì¤ÛË ÁÚ·ÌÌ‹, ·ÔÎ¿Ï˘„Ë Ù˘ ∫∫º Î·È ÙȘ ·ÔÚÙ‹˜ ̤¯ÚÈ ÙÔ ÛËÌÂ›Ô ÂÎʇÛˆ˜ Ù˘ ¿Óˆ ÌÂÛÂÓÙÂÚ›Ô˘ ·ÚÙËÚ›·˜, ·ÊÔ‡ Á›ÓÂÈ Î·Ï‹ ÎÈÓËÙÔÔ›ËÛË Kocher ÁÈ· ÙËÓ ·ÔÎ¿Ï˘„Ë Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜. ™ÙË ÌÂÌÔӈ̤ÓË Ï‹„Ë ÙÔ˘ ‹·ÙÔ˜, ·ÊÔ‡ ÔÏÔÎÏËÚˆı› Ë ·ÁÁÂȷ΋ ÚÔۤϷÛË Î·È ‰È·ÙÔÌ‹ ÙÔ˘ ·ÔÚÙÈÎÔ‡ patch, ‰È·Ù¤ÌÓÂÙ·È Ë ˘ÂÚË·ÙÈ΋ ∫∫º Ì ÙÌ‹Ì· ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Î·È ·Ê·ÈÚÂ›Ù·È ÙÔ ‹·Ú ·fi ÙËÓ ÎÔÈÏ›· Î·È ·Ú¯›˙ÂÈ Ë ‰È·‰Èηۛ· ÂÚ·ÈÙ¤Úˆ ÂÎχÛÂÒ˜ ÙÔ˘ ÛÙÔ ÙÚ·¤˙È-¿ÁÎÔ (bench table) Î·È ÙÔÔı¤ÙËÛ‹ ÙÔ˘ Û ۿÎÔ˘˜ Ì UW 4∞C Î·È ÌÂÙ¿ ÛÙÔ ÎÈ‚ÒÙÈÔ Ì ÙÔÓ ¿ÁÔ. ™Â ÂÚ›ÙˆÛË ÌÂÌÔÓˆÌ¤ÓˆÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ, ÙÌ‹Ì· ÙÔ˘ 12/ÏÔ˘ ÁÈ· ÙË 2Ë Î·È 3Ë ÌÔ›Ú· ·Ú·Ì¤ÓÂÈ ÛÙËÓ ÎÂÊ·Ï‹ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Î·È Ù·˘ÙÔ¯ÚfiÓˆ˜ ÛÙÔ ÙÚ·¤˙È-¿ÁÎÔ Á›ÓÂÙ·È Î·È Ë ‰È·›ÚÂÛË ÙÔ˘ Ï. ÂÓÙ¤ÚÔ˘ ·fi ÙËÓ 4Ë ÌÔ›Ú· ÙÔ˘ 12/ ÏÔ˘. ∏ ·Ê·›ÚÂÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·ÎÔÏÔ˘ı› ÛÙÔ Ù¤ÏÔ˜ Ì ϋ„Ë ·˘ÙÒÓ Â›Ù en bloc Î·È ‰È·ÙÔÌ‹ Ù˘ ∫∫º Î·È ·ÔÚÙ‹˜ ¿ÓˆıÂÓ Î·È Î¿ÙˆıÂÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ Î·È ·ÊÔ‡ ¤¯Ô˘Ó ‰È·ÈÚÂı› ÔÈ Ô˘ÚËÙ‹Ú˜ ¯·ÌËÏ¿, ›Ù Î¯ˆÚÈṲ̂ӷ, Ì ÚÔÛÂÎÙÈ΋ ·Ú·Û΢‹ Ù˘ ·ÔÚÙ‹˜ Î·È ∫∫º Î·È ·Ú·Û΢‹ Î·È ‰È·ÙÔÌ‹ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ Î·È ÊÏ‚ÒÓ Ì ϋ„Ë Î·ÏÔ‡ patch. ∏ ·Ú·Û΢‹ Î·È ‰È·ÙÔÌ‹ ÙˆÓ ·ÁÁ›ˆÓ Á›ÓÂÙ·È Ì ÚÔÛÔ¯‹ ÁÈ· ·Ó·ÁÓÒÚÈÛË Èı·Ó‹˜ ·ÁÁÂȷ΋˜ ·Ó·ÙÔÌÈ΋˜ ·Ú·ÏÏ·Á‹˜ ‹ ‡·ÚÍË ÔÏÈÎÒÓ ·ÚÙËÚÈÒÓ. ∏ ·Ê·›ÚÂÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÔÏÔÎÏËÚÒÓÂÙ·È Ì ÙÔÓ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Î·Ï‡ÙÂÚÔ Î·ı·ÚÈÛÌfi ·fi ÙÔ ÂÚÈÓÂÊÚÈÎfi ϛԘ ›Ù in situ, ›Ù ÛÙÔ ÙÚ·¤˙È-¿ÁÎÔ (bench table) Î·È ˘fi ¿ÛËÙ˜ Û˘Óı‹Î˜. Δ· fiÚÁ·Ó· ÙÔÔıÂÙÔ‡ÓÙ·È Û Í¯ˆÚÈÛÙÔ‡˜ Û¿ÎÔ˘˜ Ì „˘¯Úfi ‰È¿Ï˘Ì· UW ÛÙÔ˘˜ 4∞C Î·È ÂÓ Û˘Ó¯›· Û ÎÈ‚ÒÙÈ· Ì ¿ÁÔ. ∏ ÂÁ¯Â›ÚËÛË ÔÏÔÎÏËÚÒÓÂÙ·È Ì ÙË Ï‹„Ë ÙˆÓ ÎÔÈÓÒÓ, ¤Íˆ Î·È ¤Ûˆ Ï·ÁÔÓ›ˆÓ ·ÁÁ›ˆÓ Ô˘ ÌÔÈÚ¿˙ÔÓÙ·È ÛÙȘ ÔÌ¿‰Â˜ ‹·ÙÔ˜, ·ÁÎÚ¤·ÙÔ˜ Î·È ÂÓÙ¤ÚÔ˘ ÚÔÎÂÈ̤ÓÔ˘ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Û·Ó ·ÁÁÂȷο ÌÔۯ‡̷ٷ ÂÈÌË·ÓÛˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÛÙÔ˘˜ Ï‹Ù˜. §·Ì‚¿ÓÔÓÙ·È Ù¤ÏÔ˜ Î·È ÙÂÌ¿¯È· ÛÏËÓfi˜ ηıÒ˜ Î·È ÏÂÌÊ·‰¤Ó˜ ÁÈ· ·ÓÔÛÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. O ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ‰ËÏ. Ô ¯ÚfiÓÔ˜ ·fi ÙËÓ ·Ú¯‹ Ù˘ ÂÎχÛˆ˜ ̤¯ÚÈ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛ‹
ÙÔ˘˜ ÛÙÔ˘˜ Ï‹Ù˜ ÁÈ· Ù· ‰È¿ÊÔÚ· fiÚÁ·Ó· Â›Ó·È ÂÚ›Ô˘ 10-11 ÒÚ˜ ÁÈ· ÙÔ ‹·Ú, 4-5 ÒÚ˜ ÁÈ· ÙÔ ¿ÁÎÚ·˜ Î·È Ì¤¯ÚÈ 6 ÒÚ˜ ÁÈ· ÙÔ ÏÂÙfi ¤ÓÙÂÚÔ. °È· ÙÔ˘˜ ÓÂÊÚÔ‡˜ Ô ¯ÚfiÓÔ˜ ·˘Ùfi˜ ÌÔÚ› Ó· ÂÈÌË΢Óı› ÛÙȘ 24-26 ÒÚ˜. ¶ÚÔÊ·Ó¤˜ Â›Ó·È fiÙÈ Ù· ηχÙÂÚ· ÏÂÈÙÔ˘ÚÁÈο ·ÔÙÂϤÛÌ·Ù· ¤Ú¯ÔÓÙ·È Ì ÙÔÓ ÌÈÎÚfiÙÂÚÔ ‰˘Ó·Ùfi ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜(3).
2. §‹„Ë ÔÚÁ¿ÓˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ì ÌË ¿ÏÏÔ˘Û· ηډȿ (cadaveric nonheart beating donors) Δ· ÚÒÙ· ¯ÚfiÓÈ· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ (19501960) ÚÈÓ Î·Ó ˘ÈÔıÂÙËıÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ˆ˜ ÙÔ Ú·ÁÌ·ÙÈÎfi ¯ÚÔÓÈÎfi ÛËÌÂ›Ô ÙÔ˘ ı·Ó¿ÙÔ˘, Ë Ï‹„Ë ÙˆÓ ÔÚÁ¿ÓˆÓ Ú·ÁÌ·ÙÔÔÈ›ÙÔ ÌÂÙ¿ ÙËÓ ·‡ÛË Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∞˘Ùfi ›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ·, ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ¯ÚfiÓÔ˘ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜, Ó· ˘¿Ú¯Ô˘Ó ˘„ËÏ¿ ÔÛÔÛÙ¿ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ ‹ Î·È ‚·Ú›·˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÁηٿÏÂÈ„Ë Ù˘ ÌÂıfi‰Ô˘. ™Ù· Ù¤ÏË Ù˘ ‰ÂηÂÙ›·˜ 1980 Ë Ì¤ıÔ‰Ô˜ ¿Ú¯ÈÛ ӷ ·ÔÎÙ¿ ÂӉȷʤÚÔÓ ÏfiÁˆ Ù˘ Û·ÓÈfiÙËÙÔ˜ ÙˆÓ ‰ÔÙÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÙËÓ ·˘Í·ÓfiÌÂÓË ˙‹ÙËÛË, Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙˆÓ Ôχ ηÏÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ·fi ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ (‚ÂÏÙ›ˆÛË Ù¯ÓÈÎÒÓ, ‚ÂÏÙ›ˆÛË ÂÈ‚›ˆÛ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ·ÓÔÛÔηٷÛÙÔÏ‹ ÎÏ.). ΔÔ ¤ÙÔ˜ 1995 ÚÔÙ¿ıËÎ·Ó Î·È Î·ıÈÂÚÒıËÎ·Ó ÔÈ Î·ÙËÁÔڛ˜ ÁÈ· Ï‹„Ë ÓÂÊÚÒÓ ·fi ‰fiÙ˜ Ì ÌË ¿ÏÏÔ˘Û· ηډȿ, ÁÓˆÛÙ¤˜ Û·Ó Î·ÙËÁÔڛ˜ Maastricht(4,5). ™’·˘Ù¤˜, ÔÈ ·ÛıÂÓ›˜ ¯ˆÚ›˙ÔÓÙ·È ÛÂ: ·) ÓÂÎÚÔ‡˜ ηٿ ÙËÓ ¿ÊÈÍË ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ‚) ÓÂÎÚÔ› ÌÂÙ¿ ·fi ·ÓÂÈÙ˘¯‹ ·Ó·˙ˆÔÁfiÓËÛË, Á) ·fiÊ·ÛË ÁÈ· ‰È·ÎÔ‹ ΢ÎÏÔÊÔÚ›·˜ ÛÙË ª∂£, ‰) ·Ó·ÎÔ‹ Î·È ·‡ÛË Î˘ÎÏÔÊÔÚ›·˜ ηٿ ‹ ÌÂÙ¿ ÙË ‰È·‰Èηۛ· ‚‚·›ˆÛ˘ ÙÔ˘ ı·Ó¿ÙÔ˘, Â) ÌË ·Ó·ÌÂÓfiÌÂÓË ·Ó·ÎÔ‹ Î·È ·‡ÛË Î˘ÎÏÔÊÔÚ›·˜ ÓÔÛËÏ¢Ô̤ÓÔ˘ ÛÙË ª∂£. OÈ Î·ÙËÁÔڛ˜(Á) Î·È (‰) Â›Ó·È ÔÈ ˘Ô„‹ÊÈÔÈ ‰fiÙ˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ˘fi ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ÙÔ˘˜ ·Ú·Ì¤ÙÚˆÓ Î·È ·ÔÙÂÏÔ‡Ó ÙËÓ Î·Ï‡ÙÂÚË ËÁ‹ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ™’·˘ÙÔ‡˜, ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ Î·Ú‰È·Î‹ ·‡ÛË, ÌÔÚÔ‡Ó Ó· ÙÂıÔ‡Ó Â› ÎÏ›Ó˘ ηıÂÙ‹Ú˜ ÛÙË ÌËÚÈ·›· ·ÚÙËÚ›· Î·È ÊϤ‚· Î·È Ó· ·Ú¯›ÛÂÈ Ë ¤Ï˘ÛË-„‡ÍË Î·È ·Ê·›Ì·ÍË ÙˆÓ ÔÚÁ¿ÓˆÓ Î·È ÂÓ Û˘Ó¯›· ·ÊÔ‡ ÂÍ·ÛÊ·ÏÈÛı› Ë ··ÈÙÔ‡ÌÂÓË Û˘ÁηٿıÂÛË ·fi ÙÔ˘˜ Û˘ÁÁÂÓ›˜ Ó· Ô‰ËÁËıÔ‡Ó ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ÁÈ· ÙËÓ ·Ê·›ÚÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ (™¯‹Ì· 2).
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Balloon
Left kidney Right kidney
Renal arteries
Vena cava
Renal veins
Foley vein Foley cartheter
Aorta Balloon Femoral artery Double balloon triple lumen cartheter
∏ Ù¯ÓÈ΋ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô Â›Ó·È Ë ›‰È· Ì ·˘Ù‹Ó ÛÙÔ˘˜ و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ì ¿ÏÏÔ˘Û· ηډȿ. ¶Úfi‚ÏËÌ· ·Ú·Ì¤ÓÂÈ Ô ¯ÚfiÓÔ˜ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜ Ô˘ fiˆ˜ ¤¯ÂÈ Ê·Ó› ·fi ÙË Ì¤¯ÚÈ Û‹ÌÂÚ· ÂÌÂÈÚ›· ·fi Ù· ‰È¿ÊÔÚ· ∫¤ÓÙÚ· Û ∂˘ÚÒË Î·È ∏¶∞, fiÙÈ ÂÓÒ ¤¯ÂÈ Á›ÓÂÈ ·Ô‰ÂÎÙfi ¤Ó· fiÚÈÔ 120′ ÁÈ· ÙÔ˘˜ ÓÂÊÚÔ‡˜, ·˘Ùfi ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÔÚ› Ó· ÌÂȈı› Û ηϿ ÂÏÂÁ¯fiÌÂÓÔ˘˜ ‰fiÙ˜. °ÂÓÈο Ù· ·ÔÙÂϤÛÌ·Ù· ÂÈ‚›ˆÛ˘ ÌÔÛ¯Â˘Ì¿-
43
ÙˆÓ ·fi Ù¤ÙÔÈÔ˘˜ ‰fiÙ˜ Â›Ó·È Ùˆ¯fiÙÂÚ· ÏfiÁˆ ·˘ÍËÌ¤ÓˆÓ ÔÛÔÛÙÒÓ ÚˆÙÔ·ıÔ‡˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ (‹·Ú) Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ (‹·Ú, ÓÂÊÚÔ›) ·ÏÏ¿ ·ÚfiÏ· ·˘Ù¿ ·Ô‰ÂÎÙ¿, ‰ÈfiÙÈ ÌÔÚÔ‡Ó Ó· ·˘Í‹ÛÔ˘Ó ÙË ‰ÂÍ·ÌÂÓ‹ ÙˆÓ ÔÚÁ¿ÓˆÓ ηٿ 20-25% ÂÓÒ Ë ·Ó·ÊÂÚfiÌÂÓË ÌÂÛÔÌ·ÎÚÔÚfiıÂÛÌË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÔÚÁ¿ÓˆÓ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ·fi ·˘Ù‹ ·fi ‰fiÙ˜ Ì ¿ÏÏÔ˘Û· ηډȿ. ∞fi ÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹ ÙˆÓ ‰ÔÙÒÓ ¤¯Ô˘Ó ÏËÊı› Î·È ·ÁÎÚ·ÙÈο ÌÔۯ‡̷ٷ ηıÒ˜ Î·È Ó‡ÌÔÓ˜. ΔÔ ÁÂÁÔÓfi˜ Â›Ó·È fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ ∫¤ÓÙÚˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÌÔۯ‡̷ٷ ·fi ·˘ÙÔ‡˜ ÙÔ˘˜ ‰fiÙ˜ Û˘Ó¯Ҙ ·˘Í¿ÓÂÙ·È(6).
μÈ‚ÏÈÔÁÚ·Ê›· 1. Criteria for the diagnosis of brain stem death. Working Party Review. J R Coll Phys (1995); 29:381-2. 2. Gore SM, Ross Taylor RM, Wallwork J. Availability of transplantable organs from brain stem death donors in intensive care units. Br Med J (1991); 302:149-53. 3. Heaton ND. Organ donation: logistics and technical aspects (1997). In: John L.R. Forsythe (editor). Transplantation Surgery. W.B. Saunders Company Ltd. 4. Kootstra G, Daemen JHC, Oowen APA. Categories of non-heart beating donors. Transplant Proc (1995); 27:2893-95. 5. Casavilla A, Ramirez C, Shapiro R et al. Experience with kidney and liver allografts from non-heart beating donors. Transplantation (1995); 59:197-203. 6. Muiesan P, Girlanda R, Baker A et al. Successful segmental auxiliary liver transplantation from a non-heart beating donor: implications for split liver transplantation. Transplantation (2003); 75(9):1443-5.
§‹„Ë Î·È Û˘ÓÙ‹ÚËÛË ÂÓ‰ÔıˆÚ·ÎÈÎÒÓ ÔÚÁ¿ÓˆÓ
7
§Ô˘Î¿˜ TÛÔ˘Ú¤Ï˘
·. §‹„Ë – ™˘ÓÙ‹ÚËÛË ∫·Ú‰È¿˜ ªÂÙ¿ ÙËÓ ‰ÈÂÓ¤ÚÁÂÈ· ̤Û˘ ÛÙÂÚÓÔÙÔÌ‹˜, ·ÎÔÏÔ˘ı› Ë ‰È¿ÓÔÈÍË ÙÔ˘ ÂÚÈηډ›Ô˘ Î·È Ë ÙÔÔı¤ÙÈÛË ÙˆÓ ÛÙËÚÈÎÙÈÎÒÓ ÂÚÈηډȷÎÒÓ Ú·Ì¿ÙˆÓ, Ì ÛÎÔfi ÙËÓ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Î·Ï‡ÙÂÚË ÔÙÈ΋ ·ʋ Ì ÙËÓ Î·Ú‰È¿ ÙÔ˘ ‰fiÙË. ∞ÎÔÏÔ˘ı› Ë Ê¿ÛË Ù˘ ÂÈÛÎoÈÛ˘ Î·È Ù˘ „ËÏ¿ÊÈÛ˘ ÙÔ˘ ηډȷÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ™ÎÔfi˜ ·˘Ù‹˜ Ù˘ ‰È·‰Èηۛ·˜ Â›Ó·È Ë ·Ó·˙‹ÙËÛË/·ÔÎÏÂÈÛÌfi˜ ‰È·ÊfiÚˆÓ Î·ÎÒÛˆÓ/‚Ï·‚ÒÓ ‹ Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ Ô˘ Èı·ÓfiÓ Ó· ηٷÛÙ‹ÛÔ˘Ó ÙÔ ÌfiÛ¯Â˘Ì· ·Î·Ù¿ÏÏËÏÔ. ŒÙÛÈ ı· Ú¤ÂÈ Ó· Âϯı› Ë ‡·ÚÍË ·ÈÌ·ÙÒÌ·ÙÔ˜ ‹ Âί˘ÌÒÛÂˆÓ ÛÙfi ÂÈοډÈÔ, Ë ·ÚÔ˘Û›· Û˘ÌʇÛÂˆÓ Ì ÙÔ ÂÚÈοډÈÔ, ÛÙÔȯ›· Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ÚÔËÁËı›۷ οΈÛË ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È Ô˘ ·ÔÙÂÏÏÔ‡Ó ·Èٛ˜ η΋˜ ÚÔÛÙ·Û›·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ηٿ ÙËÓ ¯Ôr‹ÁËÛË ÙÔ˘ ηډÈÔÏËÁÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ Î·È ı· ¤¯ÂÈ Û·Ó Û˘Ó¤ÂÈ· ÙËÓ ÌÂȈ̤ÓË ¤ˆ˜ ·Ó·Ú΋ ÚÔÛÙ·Û›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ Î·Î‹ ÏÂÈÙÔ˘ÚÁÈ΋, ·fi‰ÔÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ÙËÓ ÂÌʇÙÂ˘Û‹ ÙÔ˘ ÛÙÔ ıÒڷη ÙÔ˘ Ï‹ÙË. æËÏ·ÊËÙÈο Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ ÁÈ· ÙËÓ ‡·ÚÍË, ÂÓÙÔÈṲ̂Ó˘ ‹ ‰È¿¯˘Ù˘ ·ıËڈ̿وÛ˘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, οÙÈ Ô˘ ÛËÌ·›ÓÂÈ ·˘ÙÔÌ¿Ùˆ˜ ˆ˜ ÙÔ ÌfiÛ¯Â˘Ì· Â›Ó·È ·Î·Ù¿ÏÏËÏÔ. Δ¤ÏÔ˜, „ËÏ·ÊËÙÈο ·ÏÏ¿ Î·È ÔÙÈο ÂϤÁ¯ÂÙ·È Ë ‡·ÚÍË ‰˘ÛÎÈÓËÙÈÎÒÓ ‹ ·ÎÈÓËÙÈÎÒÓ ÂÚÈÔ¯ÒÓ. ∂ÊfiÛÔÓ Ô ·ÓˆÙ¤Úˆ ¤ÏÂÁ¯Ô˜ ‰ÂÓ ·Ó·‰Â›ÍÂÈ Î¿ÔÈÔ Úfi‚ÏËÌ·, ·ÎÔÏÔ˘ı› Ë ÂfiÌÂÓË Ê¿ÛË Ù˘ Ï‹„˘ ÙÔ˘ ηډȷÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ¶·Ú·Û΢¿˙ÂÙ·È Ë ·ÓÈÔ‡Û· ·ÔÚÙ‹ ¤ˆ˜ ÙËÓ ¤ÎÊ˘ÛË Ù˘ ·ÓˆÓ‡ÌÔ˘ ·ÚÙËÚ›·˜, ηıÒ˜ Î·È Ë ¿Óˆ ÎÔ›ÏË ÊϤ‚·. ΔÔÔıÂÙÂ›Ù·È ÛÙË ÌÂÛfiÙËÙ· Ù˘ ·ÓÈÔ‡Û˘ ·ÔÚÙ‹˜ Ô Î·ıÂÙ‹Ú·˜ ¯ÔÚ‹ÁÈÛ˘ ÙÔ˘ ηډÈÔÏËÁÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ (Û¯. 1). ¢È·¯ˆÚ›˙Ô˘Ì ÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹ ·fi ÙÔ Û٤ϯԘ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜. ∞ÊÔ‡ Ë·ÚÈÓ›ÛÔ˘Ì ϋڈ˜ ÙÔÓ ·ÛıÂÓ‹ (3mg/kgr), ·ÎÔÏÔ˘ı› ·ÔϛӈÛË Ù˘ ¿Óˆ ÎÔ›-
Ï˘ ÊϤ‚·˜ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Ì·ÎÚ‡ÙÂÚ· ·fi ÙÔÓ ÊÏ‚fiÎÔÌ‚Ô, Ù¤ÌÓÔ˘Ì ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚·, ηıÒ˜ Î·È ÙËÓ ·ÚÈÛÙÂÚ‹ ¿Óˆ Ó¢ÌÔÓÈ΋ ÊϤ‚·, ÌÂÛÎÔfi Ó· ÌÂȈı› ÙÔ ÚÔÊfiÚÙÈÔ ÙˆÓ ÎÔÈÏÈÒÓ. ∞̤ۈ˜ ÌÂÙ¿ ÚÔ‚·›ÓÔ˘Ì Û ۇÁÎÏÈÛË Ù˘ ·ÓÈÔ‡Û·˜ ·ÔÚÙ‹˜ Î·È ÙËÓ ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ηډÈÔÏËÁÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜, ÂÓÒ Â͈ÙÂÚÈο ηχÙÔ˘Ì Ì „˘¯Úfi ‰È¿Ï˘Ì· Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡. ∞ÎÔÏÔ‡ıˆ˜ Ù¤ÌÓÔ˘Ì ÙËÓ ¿Óˆ ÎÔ›ÏË ÊϤ‚·, ÙËÓ Î¿Ùˆ Î.Ê. Î·È ÙȘ ‰ÂÍȤ˜ Î·È ·ÚÈÛÙÂÚ¤˜ Ó¢ÌÔÓÈΤ˜ ÊϤ‚˜. ∞ÎÔÏÔ‡ıˆ˜ Îfi‚Ô˘Ì ÙÔ Û٤ϯԘ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ÛÙÔ ‡„Ô˜ ÙÔ˘ ‰È¯·ÛÌÔ‡ Ù˘ Î·È Ë ÂÎÙÔÌ‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÔÏÔÎËÚÒÓÂÙ·È Ì ÙËÓ ‰È·ÙÔÌ‹ Ù˘ ·ÔÚÙ‹˜ ÛÙÔ ‡„Ô˜ Ù˘ ¤ÎÊ˘Û˘ Ù˘ ·ÓˆÓ‡ÌÔ˘ ·ÚÙËÚ›·˜ (Û¯. 2). ∞ÎÔÏÔ˘ı› ÂÈÛÎfiÈÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ¤-
44
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÏÂÁ¯Ô˜ Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ÌÂÛÔÎÔÏÈÎÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ ηıÒ˜Î·È Ë Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ÛÙÔÌ›Ô˘ ÙÔ˘ ÛÙÂÊ·ÓÈ·›Ô˘ ÎfiÏÔ˘. Δ¤ÏÔ˜, ÙÔÔıÂÙÂ›Ù·È Ì¤Û· Û ۿÎÎÔ Ì ηډÈÔÏËÁÈÎfi ‰È¿Ï˘Ì· Î·È ·ÎÔÏÔ‡ıˆ˜ Û ¿ÏÏÔ˘˜ ‰‡Ô Û¿ÎÎÔ˘˜, ÁÈ· Û›ÁÔ˘ÚË ·ÓÙÈÛË„›·, Î·È Ù¤ÏÔ˜ ̤۷ Û ‰Ô¯Â›Ô Ì ¿ÁÔ ÁÈ· ÙËÓ ÌÂÙ·ÊÔÚ¿ ÙÔ˘. ª¤ÁÈÛÙÔ˜ ÂÈı˘ÌÈÙfi˜ ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜ 4 ÒÚ˜.
‚. §‹„Ë Î·È Û˘ÓÙ‹ÚËÛË ¶Ó¢ÌÔÓÈÎÔ‡ ªÔۯ‡̷ÙÔ˜ ªÂÙ¿ ÙË ‰ÈÂÓ¤ÚÁÂÈ· ̤Û˘ ÛÙÂÚÓÔÙÔÌ‹˜, ÚÔ‚·›ÓÔ˘Ì Û ‰È¿ÓÔÈÍË ÙÔ˘ ‰ÂÍÈÔ‡ Î·È ·ÚÈÛÙÂÚÔ‡ ËÌÈıˆÚ·Î›Ô˘ ÁÈ· ¿ÌÂÛË ÂÈÛÎfiÈÛË Î·È „ËÏ¿ÊÈÛË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. ∞ÎÔÏÔ˘ı› ‰È¿ÓÔÈÍË ÙÔ˘ ÂÚÈηډ›Ô˘, ·Ú·Û΢‹ ¿Óˆ – οو ÎÔ›Ï˘ ÊϤ‚·˜ Î·È ‰È·¯ˆÚÈÛÌfi˜ ·ÓÈÔ‡Û˘ ·ÔÚÙ‹˜ÛÙÂϤ¯Ô˘˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜. ∞ÎÔÏÔ˘ı› Ë ÙÔÔı¤ÙËÛË Ù˘ οÓÔ˘Ï·˜ ¯ÔÚ‹ÁËÛ˘ ηډÈÔÏËÁ›·˜ ÛÙËÓ ·ÓÈÔ‡Û· ·ÔÚÙ‹, ÂÓÒ ÛÙÔ Û٤ϯԘ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ ÙÔÔıÂÙÂ›Ù·È Ë Î¿ÓÔ˘Ï· Ù˘ Ó¢ÌÔÓÔÏËÁ›·˜ (ÌÂÙ·ÏÏÈ΋ 6.5mm, Sarns). ∞ÎÔÏÔ˘ı› Û‡ÁÎÏÂÈÛË Ù˘ ·ÓÈÔ‡Û·˜ ·ÔÚÙ‹˜ Î·È Ù˘ ¿Óˆ ÎÔ›Ï˘ ÊϤ‚·˜, ‰È·Ù¤ÌÓÂÙ·È Ë Î¿Ùˆ ÎÔ›ÏË ÊϤ‚· Î·È ÙÔ ˆÙ›Ô ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÎfiÏÔ˘, ÂÓÒ Á›ÓÂÙ·È ¤Ó·ÚÍË Ù˘ ¯ÔÚ‹ÁËÛ˘ Ù˘ ηډÈÔÏËÁ›·˜ Î·È Ó¢ÌÔÓÔÏËÁ›·˜. ¶Ú›Ó ÙËÓ ¤Ó·ÚÍË Ù˘ Ó¢ÌÔÓÔÏËÁ›·˜ ¯ÔÚËÁԇ̠ÂÊ¿·Í, ÛÙÔ Û٤ϯԘ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ 500Ìg ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ ∂1. ∏ ÔÛfiÙËÙ· Ù˘ Ó¢ÌÔÓÔÏËÁ›·˜ Â›Ó·È 50-75
45
cc/Kgr/μ.™. Perfadex, ıÂÚÌÔÎÚ·Û›·˜ 4 ‚·ıÌÒÓ ∫ÂÏÛ›Ô˘. Δ·˘Ùfi¯ÚÔÓ· ÁÂÌ›˙Ô˘Ì ٷ ËÌÈıˆÚ¿ÎÈ· Ì ·ÁˆÌ¤ÓÔ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi, ÂÓÒ ÔÈ Ó‡ÌÔÓ˜ Û˘Ó¯›˙Ô˘Ó Ó· ÂÎÙ‡ÛÔÓÙ·È Ì ¯·ÌËÏÔ‡˜ fiÁÎÔ˘˜ ÒÛÙ ·ÊÂÓfi˜ Ó· ·ÔÊ¢¯ıÔ‡Ó ÔÈ ·ÙÂÏÂÎٷۛ˜ Î·È ·ÊÂÙ¤ÚÔ˘ Ó· ‰È¢ÎÔÏ˘Óı› Ë ‰È¿¯˘ÛË Ù˘ Ó¢ÌÔÓÔÏËÁ›·˜ ÛÙÔ ·Ú¤Á¯˘Ì·. ªÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ‰È·Ï˘Ì¿ÙˆÓ, ·Ê·ÈÚÂ›Ù·È ÚÒÙ· ÙÔ Î·Ú‰È·Îfi ÌfiÛ¯Â˘Ì· ηٿ Ù· ÁÓˆÛÙ¿, Ì ÙË ‰È·ÊÔÚÚ¿ fiÙÈ ‰È·Ù¤ÌÓÂÙ·È Ô ·ÚÈÛÙÂÚfi˜ ÎfiÏÔ˜ ÛÙÔ ÛËÌÂ›Ô ÌÂٷ͇ ÛÙÂÊ·ÓÈ·›Ô˘ ÎfiÏÔ˘ Î·È ·ÚÈÛÙÂÚ‹˜ Ó¢ÌÔÓÈ΋˜ ÊϤ‚·˜, ÒÛÙ ӷ ·Ú·Ì›ÓÂÈ ÎÔÏÈÎfi˜ ÈÛÙfi˜ ˆ˜ «ÎÔÏÏ¿ÚÔ» ¤ÚÈÍ ÙˆÓ ÛÙÔÌ›ˆÓ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÊÏ‚ÒÓ (Û¯. 3). ∞ÎÔÏÔ˘ı› ‰È¿ÓÔÈÍË ÙÔ˘ Ï¿ÁÈÔ˘ ÂÚÈηډ›Ô˘ Î·È ‰È·ÙÔÌ‹ ÙˆÓ Î¿Ùˆ Ó¢ÌÔÓÈÎÒÓ Û˘Ó‰¤Û̈Ó, ÂÓÒ ·Ú·Û΢¿˙ÂÙ·È Î·È ÂÚÈ‚ÚÔÁ¯›˙ÂÙ·È Ë ÙÚ·¯Â›· ÛÙÔ ‡„Ô˜ ÙÔ˘ ·ÔÚÙÈÎÔ‡ ÙfiÍÔ˘. ∞ÊÔ‡ ·ÔÎÔÏËıÔ‡Ó ÔÈ ‡Ï˜ ÙˆÓ Ó¢ÌfiÓˆÓ ·Ô ÙÔ Ô›ÛıÈÔ ÌÂÛÔıˆÚ¿ÎÈÔ ·ÔÊÚ¿ÛÂÙ·È ÛÙÂÁ·Ó¿ Ë ÙÚ·¯Â›· Ì ϋڈ˜ ÂÎÙ˘Á̤ÓÔ˘˜ ÙÔ˘˜ Ó‡ÌÔÓ˜. ∞Ê·ÈÚÔ‡ÓÙ·È «¤Ó ÌÏfiλ ÔÈ Ó‡ÌÔÓ˜, ÔÈ ÔÔ›ÔÈ ÙÔÔıÂÙÔ‡ÓÙ·È ÂÓÙfi˜ ÛÙÂÁ·ÓÔ‡ Û¿ÎÎÔ˘ Ï‹Úˆ˜ Î·Ï˘Ì¤ÓÔÈ ·Ô Ó¢ÌÔÓÔÏËÁÈÎfi ‰È¿Ï˘Ì·. ™ÙË Û˘Ó¤¯ÂÈ· ÙÔÔıÂÙÔ‡ÓÙ·È Û ¿ÏÏÔ˘˜ ‰˘Ô Û¿ÎÎÔ˘˜ Î·È ·ÎÔÏÔ‡ıˆ˜ Û ‰Ô¯Â›Ô Ì ¿ÁÔ ÁÈ· Ó· ÌÂÙ·ÊÂÚıÔ‡Ó ÛÙÔ Î¤ÓÙÚÔ ÂÌʇÙÂ˘Û‹˜ ÙÔ˘˜. ª¤ÁÈÛÙÔ˜ ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜ 8 ÒÚ˜.
O ÚfiÏÔ˜ ÙÔ˘ Û˘ÓÙÔÓÈÛÙ‹ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙËÓ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ Û˘ÁÁÂÓÈÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÙÔ˘ و̷ÙÈÎÔ‡ ‰fiÙË
8
M›Ó· NÙ·ÓÙ¿Ó·
Áӈ̛˜ Î·È ÙȘ ‰È·ÊÔÚÂÙÈΤ˜ ·fi„ÂȘ ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜, Ù· ‰ÈÏ‹ÌÌ·Ù·, ÙȘ ÚÔηٷϋ„ÂȘ, ÙȘ ·ÌÊÈ‚Ôϛ˜, Ù˘ ¤ÏÏÂÈ„Ë ÂÌÈÛÙÔÛ‡Ó˘ ÙÔ˘˜ ·ÏÏ¿ Î·È ÙÔÓ fiÓÔ Ô˘ ÙÔ˘˜ ÚÔηÏ› ‹ ·ÒÏÂÈ· ÙÔ˘ ·Á·Ë̤ÓÔ˘ ÙÔ˘˜ ÚÔÛÒÔ˘. ∏ ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ Û ¤Ó· Û˘Ó¿ÓıÚˆfi ··Ï‡ÓÂÈ ÙÔÓ fiÓÔ Î·È Ì‹Ó˘Ì· ÂÏ›‰·˜, ·Óıڈȿ˜ Î·È ·ÏÏËÏÂÁÁ‡Ë˜. OÈ ÔÈÎÔÁ¤ÓÂȘ ÙˆÓ ‰ÔÙÒÓ ‰ÈηÈÔ‡ÓÙ·È Ó· ÙÔ˘˜ ‰Ôı› Ô ¯ÚfiÓÔ˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È, ÒÛÙ ÚÒÙÔÓ Ó· ‰È·¯ÂÈÚÈÛÙÔ‡Ó Û˘Ó·ÈÛıËÌ·ÙÈο ÙËÓ ·ÒÏÂÈ· ÙÔ˘ ·Á·Ë̤ÓÔ˘ ÙÔ˘˜ ÚÔÛÒÔ˘, ‰Â‡ÙÂÚÔÓ Ì¤Û· Ûã ·˘Ù‹Ó ÙË Û˘Ó·ÈÛıËÌ·ÙÈ΋ ÙÚÈÎ˘Ì›· Ó· ‚ÚÔ˘Ó ÙË ‰‡Ó·ÌË Î·È ÙË ÓËÊ·ÏÈfiÙËÙ· Ó· ¿ÚÔ˘Ó ÌÈ· ·fiÊ·ÛË Ë ÔÔ›· Ó· Â›Ó·È ·ÓÙÈÚÔÛˆÂ˘ÙÈ΋ ÙˆÓ ÂÈı˘ÌÈÒÓ, ÂÔÈı‹ÛÂˆÓ Î·È ·ÓÙÈÏ‹„ÂˆÓ ÙÔ˘ ı·ÓfiÓÙÔ˜ ÔÈΛԢ ÙÔ˘˜ Î·È ‰˘ÓËÙÈÎÔ‡ ‰fiÙË, Î·È ÙÚ›ÙÔÓ Ó· ηٷÓÔ‹ÛÔ˘Ó ÙËÓ «Â˘Î·ÈÚ›·» Ô˘ ÙÔ˘˜ ÚÔÛʤÚÂÙ·È ·fi ÙÔ Û˘ÓÙÔÓÈÛÙ‹ ÁÈ· ÌÈ· ÚÔÛÊÔÚ¿ ˙ˆ‹˜. ∞Ó Ô ¯ÚfiÓÔ˜ Ô˘ ı· ÙÔ˘˜ ‰Ôı› ‰ÂÓ Â·ÚΛ, ÒÛÙ ӷ ÔÏÔÎÏËÚˆı› Ë ‰È·‰Èηۛ· ·Ô‰Ô¯‹˜ Ù˘ ·ÒÏÂÈ·˜, ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ Ó· Â›Ó·È ·ÚÓËÙÈÎÔ› ÛÙË ‰ˆÚ¿. °È· ÙËÓ ÂˆÊÂÏ‹, ÁÈ· ÙÔ ÎÔÈÓˆÓÈÎfi Û‡ÓÔÏÔ, ÔÏÔÎÏ‹ÚˆÛË Ù˘ ‰È·‰Èηۛ·˜ ÚÔÛ¤ÁÁÈÛ˘ ÙÔ˘ Û˘ÁÁÂÓÈÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Ô Û˘ÓÙÔÓÈÛÙ‹˜ Ú¤ÂÈ Ó· ‰È·ı¤ÙÂÈ ›ÛÙË ÛÙÔ ı·‡Ì· Ù˘ ªÂÙ·ÌfiÛ¯Â˘Û˘, ÁÓÒÛË, ÂÌÂÈÚ›·, ˘ÔÌÔÓ‹ ¯ÚfiÓÔ Î·È ÈηÓfiÙËÙ· ÂÈÎÔÈÓˆÓ›·˜.
∏ ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ Î·È ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÚÔηÏÔ‡Ó ÙfiÛ˜ ÂÚˆÙ‹ÛÂȘ, ·ÌÊÈÛ‚ËÙ‹ÛÂȘ Î·È ËıÈο ‰ÈÏ‹ÌÌ·Ù·, fiÛ· Ï›Á· ‰›· Ù˘ π·ÙÚÈ΋˜ ÂÈÛÙ‹Ì˘. ∞˘Ùfi Ê·›ÓÂÙ·È ·Ó·fiÊ¢ÎÙÔ, ·Ó Ï¿‚ÂÈ Î·Ó›˜ ˘fi„Ë ÙÔ˘ fiÙÈ ÛÙË ‰È·ÌfiÚʈÛË ÙˆÓ ·fi„ÂˆÓ ÙÔ˘ ÎÔÈÓˆÓÈÎÔ‡ Û˘ÓfiÏÔ˘ Û fi,ÙÈ ·ÊÔÚ¿ ÙȘ ªÂÙ·ÌÔۯ‡ÛÂȘ, ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ·Ú¿ÁÔÓÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙȘ ıÚËÛ΢ÙÈΤ˜ ÂÔÈı‹ÛÂȘ ÙÔ˘ ηıÂÓfi˜, ÙȘ ÔÏÈÙÈÛÙÈΤ˜ Î·È ÚÔÛˆÈΤ˜ ÙÔ˘ ·Í›Â˜ Î·È ÚÔÛ‰Ô˘, ηıÒ˜ ›Û˘ Î·È ı¤Ì·Ù· Âη›‰Â˘Û˘ Î·È ÏËÚÔÊfiÚËÛ˘. °È· Ó· Ú·ÁÌ·ÙÔÔÈËı› ÌÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ú¤ÂÈ Ó· ÔÏÔÎÏËÚˆı› ÌÈ· ·Ï˘Û›‰· ÁÂÁÔÓfiÙˆÓ Ë ÔÔ›· ÂÓÂÚÁÔÔÈÂ›Ù·È Ì ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË Î·È ÔÏÔÎÏËÚÒÓÂÙ·È Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙˆÓ ÔÚÁ¿ÓˆÓ ÛÙÔ˘˜ ÈÔ Û˘Ì‚·ÙÔ‡˜ Ï‹Ù˜. O ÈÔ ·‰‡Ó·ÙÔ˜ ÎÚ›ÎÔ˜ ·˘Ù‹˜ Ù˘ ·Ï˘Û›‰·˜ ηıÔÚ›˙ÂÈ ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· Î·È ·Ó ·˘Ùfi˜ Û¿ÛÂÈ ¯¿ÓÔÓÙ·È Ù· ÌÔۯ‡̷ٷ. ΔȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ Ë ‰È·‰Èηۛ· Ù˘ ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ ‰È·ÎfiÙÂÙ·È ÌÂÙ¿ ÙËÓ ¿ÚÓËÛË ÙÔ˘ Û˘ÁÁÂÓÈÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Ó· ‰ÒÛÂÈ ÙË Û˘ÁηٿıÂÛ‹ ÙÔ˘. ∏ ¢ı‡ÓË ÙÔ˘ Û˘ÓÙÔÓÈÛÙ‹ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Â›Ó·È Ó· ‰ÈÂÚ¢ÓËıÔ‡Ó ÔÈ ·fi„ÂȘ Î·È ÔÈ ÂÈı˘Ì›Â˜ ÙÔ˘ ‰fiÙË, fiÙ·Ó ·˘Ùfi˜ ‹Ù·Ó ·ÎfiÌË ÂÓ ˙ˆ‹. ∏ ÛÙ¿ÛË ÙÔ˘ ∂ÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡ ‰fiÙË Û fi,ÙÈ ·ÊÔÚ¿ ÙË ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ ÌÔÚ› Ó· ‹Ù·Ó ıÂÙÈ΋, ·ÚÓËÙÈ΋ ‹ ¿ÁÓˆÛÙË ·ÎfiÌË Î·È ÛÙÔ˘˜ ÔÈΛԢ˜ ÙÔ˘. OÈ Û˘ÁÁÂÓ›˜ ÙÔ˘ fï˜ Â›Ó·È ÔÈ ÌfiÓÔÈ ÓfiÌÈÌÔÈ ÂÎÚfiÛˆÔ› ÙÔ˘ Î·È ÔÈ ¿ÓıÚˆÔÈ Ô˘ ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó Ó· Ú·ÁÌ·ÙÔÔÈËıÔ‡Ó ÔÈ ÂÈı˘Ì›Â˜ ÙÔ˘. ∂ÎÚÔÛˆÔ‡Ó fï˜ ¿ÓÙ· Ì ÙÔÓ Î·Ï‡ÙÂÚÔ ‰˘Ó·Ùfi ÙÚfiÔ ÙÔÓ ¿ÓıÚˆfi ÙÔ˘˜ ÔÈ ÔÈΛÔÈ ÙÔ˘; O ÚfiÏÔ˜ ÙÔ˘ Û˘ÓÙÔÓÈÛÙ‹ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Â›Ó·È Ó· ‚ÔËı‹ÛÂÈ ÙÔ˘˜ Û˘ÁÁÂÓ›˜ ÙÔ˘ ‰fiÙË Ó· ·ÔÊ·Û›ÛÔ˘Ó. ™ÙË ‰È¿ÚÎÂÈ· fiÏ˘ ·˘Ù‹˜ Ù˘ ‰È·‰Èηۛ·˜ ÏÔÈfiÓ ¤Ú¯ÂÙ·È ·ÓÙÈ̤وԘ Ì ÙȘ Èı·Ó¤˜ ‰È¯Ô-
μÈ‚ÏÈÔÁÚ·Ê›· 1. Sells, R.A. Proceedings of the Ethics Committee of the Transplantation Society 1990 – 1992. The Transplantation Society Bulletin, August 1993. 2. Principles of Health Care Ethics. Gillon R (ed). John Wiley and Sons 1994. 3. Joralemon D. Shifting ethics: debating the incentive question in organ transplantation. Journal of Medical Ethics 2001.
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ı· Ú¤ÂÈ Ó· ʤÚÂÈ Ù· ··Ú·›ÙËÙ· ̤ÙÚ· ÚÔÛÙ·Û›·˜. O ·ÛıÂÓ‹˜ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙËÓ ª∂£ ʤÚÂÈ ÂÓ‰ÔÙÚ·¯ÂÈ·Îfi ۈϋӷ, Levin ÛÂ Û˘Ó¯‹ ·ÚÔ¯¤Ù¢ÛË, ÊȿϘ ·ÚÔ¯¤Ù¢Û˘, ÎÂÓÙÚÈΤ˜ ÁÚ·Ì̤˜ (3lumen – Swan Ganz), Â͈ÙÂÚÈÎfi ‚ËÌ·ÙÔ‰fiÙË, Ô˘ÚÔηıÂÙ‹Ú· ÁÈ· ˆÚÈ·›· ηٷ̤ÙÚËÛË Ô‡ÚˆÓ Î·È Èı·Ófi ÂÓ‰Ô·ÔÚÙÈ΋ ·ÓÙÏ›·. O ·ÛıÂÓ‹˜ ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÌÂ Û˘Ó¯‹ ηٷÁÚ·Ê‹ ËÏÂÎÙÚÔηډÈÔÁÚ·Ê‹Ì·ÙÔ˜, ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Î·Ú‰È·Î‹˜ ·ÚÔ¯‹˜. °È· οı ·ÏÏ·Á‹ ÂÓËÌÂÚÒÓÔÓÙ·È ¿ÌÂÛ· ÔÈ ıÂÚ¿ÔÓÙ˜. OÈ ÂÈÏÔΤ˜ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ÛÙË ª∂£ ÙȘ ‰È·ÎÚ›ÓÔ˘Ì ÛÙȘ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ Î·È Ù˘ ÌÂÙ·ÌÔۯ‡Û˘. ŒÙÛÈ ÛÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ·Ó·Ì¤ÓÔ˘Ì ӷ ·ÓÙÈÌÂÙˆ›ÛÔ˘ÌÂ: 1) ∞ÚÚ˘ı̛˜ (‚Ú·‰˘Î·Ú‰›· – ¤ÎÙ·ÎÙ˜ ÎÔÈÏȷΤ˜ Û˘ÛÙÔϤ˜) 2) ∞ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· (˘fiÙ·ÛË, ˘¤ÚÙ·ÛË, Û‡Ó‰ÚÔÌÔ ¯·ÌËÏ‹˜ ηډȷ΋˜ ·ÚÔ¯‹˜) 3) ∞ÈÌÔÚÚ·Á›· – ÂȈ̷ÙÈÛÌfi˜ 4) ¢È·Ù·Ú·¯¤˜ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ – ËÏÂÎÙÚÔÏ˘ÙÒÓ ∂ÈÏÔΤ˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È: 1) ∞fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜ 2) §Ô›ÌˆÍË 3) ∞ıËÚˆÛÎÏ‹ÚˆÛË ÌÔۯ‡̷ÙÔ˜ 4) ¡ÂÔϷۛ˜ ™ÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÊÚÔÓÙ›‰· ‰›‰ÂÙ·È È‰È·›ÙÂÚË ¤ÌÊ·ÛË ÛÙËÓ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Ë ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÂÈ: – πÓfiÙÚÔ· – ∞ÁÁÂÈԉȷÛÙ·ÏÙÈο – ∞ÓÙÈ·ÚÚ˘ıÌÈο – ∞ÓÙÈ‚ÈÒÛÂȘ – ¶·˘Û›ÔÓ· – ∞ÓÔÛÔηٷÛÙ·ÏÙÈο (΢ÎÏÔÛÔÚ›ÓË, ATG, Mycophenolate Mofetil Î·È ÛÙÂÚÔÂȉ‹)
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ Î·È Ó¢ÌfiÓˆÓ ¤ÌÔÈ·˙ Ì ԢÙÔÈÎfi ÂÁ¯Â›ÚËÌ·, Ô˘ ¤ÁÈÓ ÂÊÈÎÙfi ·ÊÔ‡ ÂÍÂÏ›¯ıËÎ·Ó ÔÈ Ù¯ÓÈΤ˜ Û˘ÚÚ·Ê‹˜ ·ÁÁ›ˆÓ Ù˘ Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜, ηıÒ˜ Î·È Ë ·Ó¿Ù˘ÍË ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ. ø˜ ÙÂÏÂ˘Ù·›· ÂÏ›‰· ÁÈ· ÌÈ· ÔÈÔÙÈ΋ ˙ˆ‹ ‚Ï¤Ô˘Ó ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÔÈ ·ÛıÂÓ›˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘ ÙÔ˘˜. ¶·ı‹ÛÂȘ Ô˘ Ô‰ËÁÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ Â›Ó·È Ë πÛ¯·ÈÌÈ΋, ¢È·Ù·ÙÈ΋ ª˘ÔηډÈÔ¿ıÂÈ·, ÔÈ μ·Ï‚ȉÈΤ˜ ¶·ı‹ÛÂȘ ηıÒ˜ Î·È ÔÈ ™˘ÁÁÂÓ›˜ ∫·Ú‰ÈÔ¿ıÂȘ. ¶·ıÔÏÔÁÈÎfi ˘fiÛÙڈ̷ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó¢ÌfiÓˆÓ ıˆÚÔ‡ÓÙ·È Ë π‰ÈÔ·ı‹˜ ¶Ó¢ÌÔÓÈ΋ ÿÓˆÛË, ÙÔ ∂ÌʇÛËÌ·, Ë ÃÚfiÓÈ· ∞ÔÊÚ·ÎÙÈ΋ ¶Ó¢ÌÔÓÔ¿ıÂÈ· Î·È Ë ∫˘ÛÙÈ΋ ÿÓˆÛË. Δ¤ÏÔ˜ Û˘Ó‰˘·ÛÌfi ÌÂÙ·ÌfiÛ¯Â˘Û˘ ηډȿ˜ / Ó¢ÌfiÓˆÓ ¯Ú‹˙Ô˘Ó ·ı‹ÛÂȘ fiˆ˜ ÙÔ ™‡Ó‰ÚÔÌÔ ∂isenmenger, Ë ¶Ó¢ÌÔÓÈ΋ ¿ıËÛË Ì ÌË ·Ó·ÛÙÚ¤„ÈÌË Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË Î·È Ë ∞ÚÈÛÙÂÚ‹ ηډȷ΋ ·Ó¿ÚÎÂÈ· Ì Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË. ∏ ‰È·‰Èηۛ· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ ÂÍÔÓ˘¯ÈÛÙÈÎfi ÂÚÁ·ÛÙËÚÈ·Îfi Î·È ‰ÈÂÚ¢ÓËÙÈÎfi ¤ÏÂÁ¯Ô, ÙËÓ ¤ÓÙ·ÍË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙËÓ Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ Î·È Ù¤ÏÔ˜ ÙËÓ ·Ó·ÌÔÓ‹ ÙÔ˘ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË Î·Ù¿ÏÏËÏÔ˘ ‰fiÙË. O ÚfiÏÔ˜ ÙÔ˘ ÓÔÛËÏÂ˘Ù‹ ÍÂÎÈÓ¿ÂÈ ·fi ÙËÓ ÛÙÈÁÌ‹ Ù˘ ·Ó‡ÚÂÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∂ÓÂÚÁÔÔÈÂ›Ù·È Ô Ì˯·ÓÈÛÌfi˜ Î·È Ë ª∂£ ÍÂÎÈÓ¿ÂÈ ÙȘ ‰È·‰Èηۛ˜ ÚÔÂÙÔÈÌ·Û›·˜ ÙÔ˘ ¯ÒÚÔ˘, ¿ÓÙ· ‚¿ÛÂÈ ÚˆÙÔÎfiÏÏÔ˘. ∞Ú¯Èο ÂÍ·ÛÊ·Ï›˙ÂÙ·È ÌÔÓfiÎÏÈÓÔ ‰ˆÌ¿ÙÈÔ ÙÔ ÔÔ›Ô ÂÎÎÂÓÒÓÂÙ·È Î·È ·ÔÏ˘Ì·›ÓÂÙ·È. ∫·ÙfiÈÓ ÙÔ ÂÍÔÏ›˙ÂÙ·È Ì ·Ó·ÏÒÛÈÌÔ ˘ÏÈÎfi Ô˘ ı· ¯ÚËÛÈÌÔÔÈËı› ·ÔÎÏÂÈÛÙÈο ÛÙË ÓÔÛËÏ›· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘. O ¡ÔÛËÏÂ˘Ù‹˜ Ô˘ ı· ÙÔÓ ÊÚÔÓÙ›ÛÂÈ ‰ÂÓ Ú¤ÂÈ Û ηÌÈ¿ ÂÚ›ÙˆÛË Ó· ÓÔÛËχÂÈ ¿ÏÏÔÓ ·ÛıÂÓ‹. ΔÔ È·ÙÚÔÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi Ô˘ ı· ¤¯ÂÈ ¿ÌÂÛË Â·Ê‹ Ì ÙÔÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ
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A. ¶§ATANIA
∞fi ÙËÓ ÛÙÈÁÌ‹ Ô˘ Ô ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˜ ÛÙ·ıÂÚÔÔÈËı› ·ÈÌÔ‰˘Ó·ÌÈο ÂÚÓ¿Ì ÛÙÔ ÂfiÌÂÓÔ ÛÙ¿‰ÈÔ Ô˘ ·ÊÔÚ¿ ÙËÓ ·Ê‡ÓÈÛË, ·ÔۈϋӈÛË, ÙËÓ ÌÂÙ¤ÂÈÙ· ÊÚÔÓÙ›‰· ¤ˆ˜ Î·È ÙËÓ ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÛÙÔ ÙÌ‹Ì·. ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë ¿ÌÂÛË ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ηıÒ˜ Î·È Ë Ê˘ÛÈÎÔıÂڷ›· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÁÂÓÈο Ë ÎÈÓËÛÈÔıÂڷ›· Ì ÙÂÏÈÎfi ÛÙfi¯Ô ÙËÓ Ï‹ÚË ·Ó¿ÎÙÈÛË ÙˆÓ ‰˘Ó¿ÌÂÒÓ ÙÔ˘. Δ·˘Ùfi¯ÚÔÓ· Ô ·ÛıÂÓ‹˜ ÍÂÎÈÓ¿ÂÈ Ó· ÛÈÙ›˙ÂÙ·È ‚¿ÛÂÈ ÙÔ˘ ÂȉÈο ‰È·ÌÔÚʈ̤ÓÔ˘ ‰È·ÈÙÔÏÔÁ›Ô˘ Î·È Û‡Ìʈӷ Ì ÙȘ ÂÓÂÚÁÂȷΤ˜ ÙÔ˘ ·Ó¿ÁΘ. ¶Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ‰Â ηıËÌÂÚÈÓ‹ ηٷ̤ÙÚËÛË ÙÔ˘ ۈ̷ÙÈÎÔ‡ ÙÔ˘ ‚¿ÚÔ˘˜. ∏ Ï‹„Ë ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Î·ıÒ˜ Î·È Ô ÚÔÁÚ·ÌÌ·ÙÈÛÌfi˜ ÁÈ· ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÂÍÂÙ¿ÛÂȘ fiˆ˜ ‚ÈÔ„›· Ì˘Ôηډ›Ô˘ – Ó¢ÌfiÓˆÓ, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜, ÛÈÚÔ̤ÙÚËÛË Ó¢ÌfiÓˆÓ Î·È ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ó¢ÌfiÓˆÓ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ‚¿ÛÂÈ ÚˆÙÔÎfiÏÏÔ˘ Î·È Û‡Ìʈӷ Ì ÙȘ ÂÈÙ·Á¤˜ Ù˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋˜ ÔÌ¿‰·˜. O ·ÛıÂÓ‹˜ ÌÂٷʤÚÂÙ·È ÛÙÔÓ ı¿Ï·ÌÔ fiÙ·Ó ¤¯ÂÈ ·Ó·Î¿Ì„ÂÈ Ï‹Úˆ˜. ∏ ÓÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰· ‰ÂÓ ‰È·Ê¤ÚÂÈ Ô˘ÛÈ·ÛÙÈο. ∂Í·ÎÔÏÔ˘ı› Î·È ·Ú·Ì¤ÓÂÈ Û ÌÔÓfiÎÏÈÓÔ ‰ˆÌ¿ÙÈÔ ÂÓÒ ÙÔ ÂÈÛÎÂÙ‹ÚÈÔ
ÙÔ ÚÒÙÔ Î·ÈÚfi ··ÁÔÚ‡ÂÙ·È. Δ· ̤ÙÚ· ÚÔʇϷ͢ ÙˆÓ ÓÔÛËÏ¢ÙÒÓ ÚÔ˜ ÙÔÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ·Ú·Ì¤ÓÔ˘Ó ·˘ÛÙËÚ¿. ∂Ê·ÚÌfi˙ÔÓÙ·È ÚˆÙfiÎÔÏÏ· fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÊÚÔÓÙ›‰· ÙÔ˘, ÙËÓ Ï‹„Ë ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÙÔ˘ ηıÒ˜ Î·È ÙËÓ ‰ÈÂÓ¤ÚÁÂÈ· ÙˆÓ ÏÔÈÒÓ ÂÍÂÙ¿ÛˆÓ. ™ËÌ·ÓÙÈÎfi ÎÔÌÌ¿ÙÈ Â›Ó·È Ë ¿ÌÂÛË ÂÈÎÔÈÓˆÓ›· Ì ÙÔÓ ·ÛıÂÓ‹ ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË ÚÔ‚ÏËÌ¿ÙˆÓ Î·È Ë Û˘Ó¯‹˜ ÂÓË̤ڈÛË Ù˘ OÌ¿‰·˜ ̤ۈ ÙˆÓ ™˘ÓÙÔÓÈÛÙÒÓ. ¶ÚÈÓ ÙÔ ÂÍÈÙ‹ÚÈÔ Ô ÓÔÛËÏÂ˘Ù‹˜ ÔÊ›ÏÂÈ Ó· Âηȉ‡ÛÂÈ ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ÛÙËÓ ÛˆÛÙ‹ Ï‹„Ë ÙˆÓ Ê·ÚÌ¿ÎˆÓ ÙÔ˘, ÛÙËÓ ˘ÁÈÂÈÓ‹ ÙÔ˘ ηıÒ˜ Î·È ÛÙËÓ ·Ó·ÁÓÒÚÈÛË ¿ÌÂÛ· ÚÔ‚ÏËÌ¿ÙˆÓ Î·È ÙÔÓ ÙÚfiÔ ·Ó·ÊÔÚ¿˜ ÙÔ˘˜ ÛÙËÓ ªÂÙ·ÌÔÛ¯Â˘ÙÈ΋ OÌ¿‰·. ™˘ÌÂÚ·ÛÌ·ÙÈο Ë ˘„ËÏ‹ ÔÈfiÙËÙ· ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÍÂȉÈÎÂ˘Ì¤ÓË ÁÓÒÛË ÙÔ˘ ·ÓÙÈÎÂÈ̤ÓÔ˘, ¤¯ÂÈ Î˘Ú›·Ú¯Ô ÚfiÏÔ ÛÙËÓ ÔÌ·Ï‹ ÂͤÏÈÍË ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘. ∏ Û˘Ó¯‹˜ Âη›‰Â˘ÛË Î·È ·Ó·Ó¤ˆÛË ÙˆÓ ÁÓÒÛÂˆÓ ·ÔÙÂÏ› ̤ÏËÌ· fiÏˆÓ ÙˆÓ ÓÔÛËÏ¢ÙÒÓ, ÙfiÛÔ ÁÈ· ÙËÓ ÂͤÏÈÍË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, fiÛÔ Î·È ÙË Î·Ï‡ÙÂÚË ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ.
H ‰È·Ù‹ÚËÛË ÙÔ˘ ‰fiÙË
10
M›ÏÏ˘ MÈÙ˙¿ÓË
∂ÈÛ·ÁˆÁ‹
∏ ÛÔ˘‰·ÈfiÙËÙ· Ù˘ ¤ÁηÈÚ˘ Î·È ÛˆÛÙ‹˜ ÊÚÔÓÙ›‰·˜ ÙˆÓ ‰ÔÙÒÓ Â›Ó·È ‰Â‰Ô̤ÓË. °È· ÙÔ ÛÎÔfi ·˘Ùfi, Û˘ÓÈÛÙ¿Ù·È Ë ÂÊ·ÚÌÔÁ‹ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ıÂڷ¢ÙÈÎÒÓ ·ÏÁÔÚ›ıÌˆÓ Ô˘ Ê¿ÓËΠfiÙÈ ˆÊ¤ÏËÛ·Ó fiÏ· Ù· fiÚÁ·Ó·, ÂÓÒ ·Ô‰Â‰ÂÈÁ̤ӷ ¤ÙÚ„·Ó ÙËÓ ‰È¿ÛˆÛË ÔÚÁ¿ÓˆÓ, Ù· ÔÔ›· ›¯·Ó ·Ú¯Èο ıˆÚËı› ·Î·Ù¿ÏÏËÏ·, ·˘Í¿ÓÔÓÙ·˜ ¤ÙÛÈ ÙˆÓ ·ÚÈıÌfi ÙˆÓ ÔÚÁ¿ÓˆÓ Ô˘ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó.
H ÚfiÔ‰Ô˜ Ô˘ ÂÈÙ‡¯ıËΠÛÙÔÓ ÙÔ̤· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, ·Ó¤‰ÂÈÍ ·ÁÎÔÛÌ›ˆ˜ ÙÔ Úfi‚ÏËÌ· Ù˘ ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∂›Ó·È ÁÂÁÔÓfi˜ fiÙÈ ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË ‰È¿ÛÙ·ÛË ·Ó¿ÌÂÛ· ÛÙÔÓ ·ÚÈıÌfi ÙˆÓ Èı·ÓÒÓ ‰ˆÚËÙÒÓ ÔÚÁ¿ÓˆÓ Î·È ·˘ÙÒÓ Ô˘ ÙÂÏÈο Á›ÓÔÓÙ·È ‰fiÙ˜. ŒÓ·˜ ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚ› Ó· ÂÍÔ̷χÓÂÈ ÙȘ Û˘Ó¤ÂȘ Ù˘ ‰È·ÊÔÚ¿˜ ·˘Ù‹˜, Â›Ó·È Ë ÂÍ·ÛÊ¿ÏÈÛË ÔÚÁ¿ÓˆÓ Ô˘ Ó· Û˘ÁÎÂÓÙÚÒÓÔ˘Ó ÌÂÁ¿ÏË Èı·ÓfiÙËÙ· ÂÈÙ˘¯Ô‡˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∞˘Ùfi ‚¤‚·È· ÚÔ¸Ôı¤ÙÂÈ ‚ÂÏÙÈÛÙÔÔ›ËÛË Ù˘ ÊÚÔÓÙ›‰·˜ Ô˘ ÚÔÛʤÚÂÙ·È ÛÙÔ˘˜ Èı·ÓÔ‡˜ ‰fiÙ˜, ·Ó Ï¿‚Ô˘Ì ̿ÏÈÛÙ· ˘ fi„ÈÓ Ì·˜ fiÙÈ Ô Ì¤ÛÔ˜ fiÚÔ˜ ËÏÈΛ·˜ ÙˆÓ ‰ÔÙÒÓ ¤¯ÂÈ ·˘ÍËı›. ∏ ÊÚÔÓÙ›‰· ÙÔ˘ Èı·ÓÔ‡ ‰fiÙË ·Ú¯›˙ÂÈ ¤ÁηÈÚ·, ·ÎfiÌ· Î·È ÚÈÓ ÙËÓ Â›ÛËÌË ÈÛÙÔÔ›ËÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ¤ÙÛÈ ÒÛÙ ӷ ˘¿Ú¯ÂÈ ¯ÚfiÓÔ˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ηٷÏÏËÏfiÙËÙ·˜. O ¤ÏÂÁ¯Ô˜ ·˘Ùfi˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÌÈ· ÛÂÈÚ¿ ÔÚÔÏÔÁÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Î·È Ï‹„Ë ·Ó·ÌÓËÛÙÈÎÔ‡ ÈÛÙÔÚÈÎÔ‡. ∏ Ïԛ̈ÍË Ì ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ B Î·È C ‰ÂÓ ·ÔÙÚ¤ÂÈ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ Û ¿ÏÏÔ˘˜ ÔÚÔıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ ·ÎfiÌË Î·È Û ÌË ¿Û¯ÔÓÙ˜, ˆ˜ ıÂڷ›· ‰È¿ÛˆÛ˘. ∞fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ·ÔÙÂÏ› Ë Ïԛ̈ÍË Ì ÙÔÓ Èfi ÙÔ˘ HIV, ÔÈ Û˘ÛÙËÌ·ÙÈΤ˜ ÈÒÛÂȘ, ÔÈ Î·ÎÔ‹ıÂȘ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÔÈ ÂÓÂÚÁ›˜ ÓÂÔÏ·ÛÌ·ÙÈÎÔ› ÓfiÛÔÈ. ∞ÓÙ›ıÂÙ·, ÈÛÙÔÚÈÎfi ÓÂÔÏ·ÛÌ¿ÙˆÓ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÏËÓ ÙÔ˘ ÌÂÏ·ÓÒÌ·ÙÔ˜, ÌÂÌÔÓˆÌ¤ÓˆÓ ÚˆÙÔ·ıÒÓ fiÁÎˆÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÂÓÙÔÈṲ̂Ó˜ ÏÔÈÌÒÍÂȘ ‰ÂÓ ·ÔÎÏÂ›Ô˘Ó ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ΔÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ ·ÚÂÌ‚¿ÏÏÂÙ·È ÌÂٷ͇ Ù˘ ÂÁηٿÛÙ·Û˘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Î·È Ù˘ Ï‹„˘ ÙˆÓ ÔÚÁ¿ÓˆÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÂÁ¿ÏË ·ÛÙ¿ıÂÈ·, Ë ÔÔ›· ÂȉÂÈÓÒÓÂÙ·È ÛÙ·‰È·Î¿ Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘. ™ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ¤گÂÙ·È ÛˆÌ·ÙÈÎfi˜ ı¿Ó·ÙÔ˜ Î·È ¯¿ÓÔÓÙ·È ÙÔ 1020% ÙˆÓ Èı·ÓÒÓ ‰ÔÙÒÓ.
1. ∫·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· OÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙÔ˘˜ Èı·ÓÔ‡˜ ‰fiÙ˜ ÔÊ›ÏÔÓÙ·È ÙfiÛÔ ÛÙËÓ ›‰È· ÙËÓ ÈÛ¯·ÈÌ›· ÙÔ˘ ÛÙÂϤ¯Ô˘˜, fiÛÔ Î·È Û ÌÈ· ÔÌ¿‰· ·ÈÙ›ˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÚfiÙÂÚË Î·Ù¿ÛÙ·Û‹ ÙÔ˘. OÈ Î˘ÚÈfiÙÂÚ˜ ·fi ÙȘ ‰È·Ù·Ú·¯¤˜ ·˘Ù¤˜ Â›Ó·È Ë ˘fiÙ·ÛË, Ë ˘¤ÚÙ·ÛË Î·È ÔÈ Î·Ú‰È·Î¤˜ ·ÚÚ˘ı̛˜. ÀfiÙ·ÛË ·Ú·ÙËÚÂ›Ù·È ÛÙÔ 80% ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·È Â›Ó·È ·ÓıÂÎÙÈ΋ ÛÙË ¯ÔÚ‹ÁËÛË ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÂÚ›Ô˘ ÛÙÔ 20% ÂÍ ·˘ÙÒÓ. ™˘Ó‰˘¿˙ÂÙ·È Ì η΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ΢ڛˆ˜ fiÛÔÓ ·ÊÔÚ¿ Ù· ÓÂÊÚ¿ Î·È ÙÔ ‹·Ú, ÂÓÒ Û Èı·ÓÔ‡˜ ‰fiÙ˜ Ì ˘fiÙ·ÛË Ù· ÂÂÈÛfi‰È· ηډȷ΋˜ ·Ó·ÎÔ‹˜ Â›Ó·È Û˘¯ÓfiÙÂÚ· ™˘ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË 100-120mmHg ÂÍ·ÛÊ·Ï›˙ÂÈ Î·Ï‹ ›ÂÛË ‰È‹ıËÛ˘ ÛÙ· fiÚÁ·Ó· ÙÔ˘ ‰fiÙË Î·È Û˘Ó‰˘¿˙ÂÙ·È Ì ηϋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘fiÙ·Û˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ·Ú¯Èο ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÁηÈÌ›·˜ Ì ÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ. ™˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ÈÛfiÙÔÓˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ (N/S, L/R) ‰È·Ï˘Ì¿ÙˆÓ, ÂÎÙfi˜ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜, ÔfiÙÂ Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ˘fiÙÔÓˆÓ ‰È·Ï˘Ì¿ÙˆÓ (¡/S 4.5%) ‹ ÈÛfiÙÔÓˆÓ ‰È·Ï˘Ì¿ÙˆÓ ÁÏ˘Îfi˙˘. ¶·Ú·ÙÂٷ̤ÓË ¯ÔÚ‹ÁËÛË ÎÔÏÏÔÂȉÒÓ ‰È·Ï˘Ì¿ÙˆÓ Û˘ÓÈÛÙ¿Ù·È Ó· ·ÔʇÁÂÙ·È, ÏËÓ ÙˆÓ ÂÚÈ-
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50
M. M¶ITZANH
ÙÒÛÂˆÓ Èı·Ó‹˜ ‰ˆÚ¿˜ Ó¢ÌfiÓˆÓ. ∞ÚÎÂÙÔ› Û˘ÁÁÚ·Ê›˜ ÚÔÙ›ÓÔ˘Ó ÙË ¯ÔÚ‹ÁËÛË Ì›ÁÌ·ÙÔ˜ 65% ÎÚ˘ÛÙ·ÏÏÔÂȉԇ˜ ‰È·Ï‡Ì·ÙÔ˜ Î·È 35% ÎÔÏÏÔÂȉԇ˜ Ì ÚÔ‹ 5ml/kg/5-10min. OÏÈÎfi ·›Ì· ‹ Û˘Ì˘Îӈ̤ӷ ÂÚ˘ıÚ¿ ¯ÔÚËÁÔ‡ÓÙ·È Û ÂÚÈÙÒÛÂȘ ·Ó·ÈÌ›·˜ ¤ÙÛÈ ÒÛÙ ӷ ‰È·ÙËÚËı› ÙÈÌ‹ Hct 30% Î·È ∏b >10mg%. ∂¿Ó Ë ∞¶ ·Ú·Ì¤ÓÂÈ ¯·ÌËÏ‹ ·Ú¿ ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ CVP ·Ú¯›˙ÂÈ Ë ¯ÔÚ‹ÁËÛË ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ê·Ú̿ΈÓ. ∏ Dopamine (3-12Á/kg/min) ·ÔÙÂÏ› ÙÔ Ê¿ÚÌ·ÎÔ ÚÒÙ˘ ÂÈÏÔÁ‹˜. ªÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ ¯ÔÚ‹ÁËÛË Ì ·˘Ù‹ ÙË ‰ÔÛÔÏÔÁ›· ‰ÂÓ Ê¿ÓËΠӷ ÂËÚ¿˙ÂÈ ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· Ù˘ ηډȿ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ Dobutamine ¯ÔÚËÁÂ›Ù·È Û ‰fiÛË 5-15Á/kg/min Î·È ÂӉ›ÎÓ˘Ù·È Û Èı·ÓÔ‡˜ ‰fiÙ˜ Ì ÔÍ›· ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·, ıÏ¿ÛË Ì˘Ôηډ›Ô˘ ‹ ηډȷ΋ ·Ó¿ÚÎÂÈ·. ™˘Ó‰˘¿˙ÂÙ·È Ì Dopamine Î·È Ô Û˘Ó‰˘·ÛÌfi˜ Û˘Óԉ‡ÂÙ·È ·Ô ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ· ·fiÚÚȄ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ¶ÂÚ›Ô˘ ÙÔ 70-90% ÙˆÓ ‰ÔÙÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚÔÔ›ËÛË Ì ÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ÌÈÎÚ‹˜ ‰fiÛ˘ ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ê·Ú̿ΈÓ. ™Â ÂÚÈÙÒÛÂȘ Ô˘ Ë ∞¶ ·Ú·Ì¤ÓÂÈ ¯·ÌËÏ‹, Û˘ÛÙ‹ÓÂÙ·È Ë ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· ÛÙËÓ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·, ÁÈ· ÂÚ·ÈÙ¤Úˆ monitoring Î·È ÛÙË Û˘Ó¤¯ÂÈ· ¯ÔÚ‹ÁËÛË ¿ÏÏˆÓ ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ê·Ú̿ΈÓ, fiˆ˜ Ë ¡oradrenaline ( 210Á/kg/min), Ô˘ fï˜ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙ· ÓÂÊÚ¿ Î·È ÙÔ ‹·Ú Î·È Ë Epinephrine (< 0.1Á/kg/min) fiÙ·Ó ·ÔÙ‡¯ÂÈ Ë ¡oradrenaline, ‹ ··ÈÙÂ›Ù·È ·Ú·ÙÂٷ̤ÓË ¯ÔÚ‹ÁËÛË. ∏ Epinephrine ¤¯ÂÈ ÙÔ ÏÂÔÓ¤ÎÙËÌ· fiÙÈ ·˘Í¿ÓÂÈ ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙÔ ‹·Ú. OÈ ·˘ÍË̤Ó˜ ·Ó¿ÁΘ ÙÔ˘ ‰fiÙË Û ·ÁÁÂÈÔ‰Ú·ÛÙÈο Ê¿Ú̷η ‰ÂÓ ·ÔÎÏÂ›Ô˘Ó ÙËÓ ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·Ó Î·È ‚¤‚·È· Ë ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ‰È·ÊfiÚˆÓ ÔÚÁ¿ÓˆÓ Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Û˘Ó¯Ҙ Î·È Ó· ÂÓËÌÂÚÒÓÂÙ·È Ë ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÔÌ¿‰·, ÒÛÙ ӷ ÂÎÙÈÌ¿ ÙËÓ Î·Ù·ÏÏËÏfiÙËÙ¿ ÙÔ˘˜ . À¤ÚÙ·ÛË ÂÌÊ·Ó›˙ÂÙ·È ÚÈÓ ‹ ηٿ ÙËÓ ·Ú¯È΋ Ê¿ÛË Ù˘ ÂÁηٿÛÙ·Û˘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ÌÔÚ› fï˜ Ó· ÂÌÊ·ÓÈÛı› Î·È ÌÂÙ¿, Û ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘, ‹ ¤ÓÙÔÓ· ıÂÙÈÎfi ÈÛÔ˙‡ÁÈÔ. ÃÚÂÈ¿˙ÂÙ·È ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË Ì ÙË ¯ÔÚ‹ÁËÛË b-blockers ‚Ú·¯Â›·˜ ‰Ú¿Û˘, ‰ÈfiÙÈ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ‚Ï¿ÙÂÈ ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·Î‹˜ ·ÓÂ-
¿ÚÎÂÈ·˜, ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. AÚÚ˘ı̛˜ ÂÁηı›ÛÙ·ÓÙ·È Û˘¯Ó¿. ∏ ‚Ú·‰˘Î·Ú‰›· Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈο ·ÓıÂÎÙÈ΋ ÛÙË ¯ÔÚ‹ÁËÛË atropine (¢È·ÁÓˆÛÙÈÎfi test ∂£), ÂÓÒ Û ÂÚÈÙÒÛÂȘ Ô˘ ÂËÚ¿˙ÂÙ·È Ë ·ÈÌÔ‰˘Ó·ÌÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì Dopamine (<10Á/kg/min), Isoprenaline (1-3Á/min) ‹ Epinephrine ÛÂ Û˘Ó‰˘·ÛÌfi Ì Dopamine. OÈ ˘ÂÚÎÔÈÏȷΤ˜ ‹ ÎÔÈÏȷΤ˜ ·ÚÚ˘ı̛˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ·Ú¯Èο ·ÈÙÈÔÏÔÁÈο Î·È Â¿Ó ‰ÂÓ ˘Ô¯ˆÚ‹ÛÔ˘Ó Ì ÙË ¯ÔÚ‹ÁËÛË ·ÌÈÔ‰·ÚfiÓ˘ Î·È ÏȉÔη˝Ó˘ ·ÓÙ›ÛÙÔȯ· ÂÓÒ Ë ‰Â ÎÔÈÏȷ΋ Ù·¯˘Î·Ú‰›· torsade de pointes Ì ÙË ¯ÔÚ‹ÁËÛË Bretylium tonsylate (5-10mg/kg). ™Â ÂÚÈÙÒÛÂȘ ηډȷ΋˜ ·Ó·ÎÔ‹˜ Á›ÓÂÙ·È ¿ÌÂÛË ÚÔÛ¿ıÂÈ· ·Ó¿Ù·Í˘ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔ˘˜ ÁÓˆÛÙÔ‡˜ ·ÏÁÔÚ›ıÌÔ˘˜. ™Â ηٷÛÙ¿ÛÂȘ ÌË ·Ó·ÛÙÚ¤„ÈÌ˘ ηډȷ΋˜ ·Ó·ÎÔ‹˜ Á›ÓÂÙ·È Û ÌÂÚÈο ΤÓÙÚ· ÚÔÛ¿ıÂÈ· ‰È¿ÛˆÛ˘ οÔÈˆÓ ÔÚÁ¿ÓˆÓ.
2. ÀÔÛÙ‹ÚÈÍË ÙÔ˘ ·ÂÚÈÛÌÔ‡ ∏ ηϋ ÈÛÙÈ΋ Ô͢ÁfiÓˆÛË Â›Ó·È ··Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ‰È·Ù‹ÚËÛË ÙˆÓ ÔÚÁ¿ÓˆÓ Û ηϋ ηٿÛÙ·ÛË, ¤ÙÛÈ ÒÛÙ ӷ ·˘ÍËıÔ‡Ó ÔÈ Èı·ÓfiÙËÙ˜ ηϋ˜ ¤Î‚·Û˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. OÈ Èı·ÓÔ› ‰fiÙ˜ ‚Ú›ÛÎÔÓÙ·È Û Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi Î·È Â›Ó·È ÂÈı˘ÌËÙ‹ Ë Â›Ù¢ÍË ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜ Ì pH ~ 7.4, PCO2 35-45mmHg Î·È PO2 >100mmHg Ì ÙËÓ ¯·ÌËÏfiÙÂÚË ‰˘Ó·Ù‹ ÙÈÌ‹ ÙÔ˘ FiO2 Î·È ÙÔ˘ PEEP. °ÂÓÈο, ¯ÚÂÈ¿˙ÂÙ·È ÚÔÛÔ¯‹ ÁÈ·Ù› ˘¿Ú¯ÂÈ ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ˘ÂÚ·ÂÚÈÛÌÔ‡, ·Ó Î·È ÛÙÔ˘˜ ˘ÔıÂÚÌÈÎÔ‡˜ ‰fiÙ˜ (Δ<35ÆC) Â›Ó·È ÂÈı˘ÌËÙ‹ ÌÈ· ̤ÙÚÈ· ·ÏοψÛË. ŸÙ·Ó ˘¿Ú¯ÂÈ Èı·ÓfiÙËÙ· ‰ˆÚ¿˜ Ó¢ÌfiÓˆÓ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ ÂÍ‹˜ Ô‰ËÁ›Â˜: • ∞ÂÚÈÛÌfi˜ Ì FiO2 <50% • ∂Ê·ÚÌÔÁ‹ PEEP 5 cmH2O • ÃÔÚ‹ÁËÛË ˘ÁÚÒÓ Ì ԉËÁfi ÛËÌÂ›Ô ÙË ‰È·Ù‹ÚËÛË Ù˘ CVP 5-10cm H2O • ΔÂÏÔÂÈÛÓ¢ÛÙÈ΋ ›ÂÛË plateau <30 cm H2O • ∂Ê·ÚÌÔÁ‹ ·˘ÛÙËÚÒÓ Î·ÓfiÓˆÓ ·ÓÙÈÛË„›·˜ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ïԛ̈͢ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ™˘¯ÓfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Â›Ó·È ÔÈ ·ÙÂÏÂÎٷۛ˜ Î·È ÙÔ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·. ¶ÚÒÈÌË ‚ÚÔÁ¯ÔÛÎfiËÛË, Û˘¯Ó¤˜ ·Ó·ÚÚÔÊ‹ÛÂȘ, ÚÔÛÂÎÙÈ΋ Ú‡ıÌÈÛË ÙˆÓ ·Ú·Ì¤ÙÚˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú·, ‰ÈÔ˘ÚËÙÈο Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·‡ÍËÛ·Ó ÛËÌ·ÓÙÈο ÙÔÓ ·-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÚÈıÌfi ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. π‰·ÓÈÎfi ÌfiÛ¯Â˘Ì· ıˆÚÂ›Ù·È Ô Ó‡ÌÔÓ·˜ Ô˘ ¤¯ÂÈ ‰Â›ÎÙË Ô͢ÁfiÓˆÛ˘ >350 Î·È ¤¯ÂÈ ˘ÔÛÙËÚȯı› Ì Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi <24h.
3. ÀÔÛÙ‹ÚÈÍË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ∏ ‰ÈÔ‡ÚËÛË ÙÔ˘ ‰fiÙË ıˆÚÂ›Ù·È ÈηÓÔÔÈËÙÈ΋ fiÙ·Ó Â›Ó·È ÂÚ›Ô˘ 1ml/kg/h ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È 2ml/kg/h ÛÙ· ·È‰È¿. ¶ÔÏ˘Ô˘Ú›· (>3-4ml/kg/h) ÂÌÊ·Ó›˙ÂÙ·È Î˘Ú›ˆ˜ ÏfiÁˆ ÙÔ˘ ¿ÔÈÔ˘ ‰È·‚‹ÙË Î·È ¯Ú‹˙ÂÈ ¿ÌÂÛ˘ ·ÓÙÈÌÂÙÒÈÛ˘. ∏ ÔÏÈÁÔ˘Ú›· (<0.5ml/kg/h) Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ÙËÓ ·‡ÍËÛË Ù˘ ∞¶ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Ì ʿÚÌ·ÎÔ ÚÒÙ˘ ÂÈÏÔÁ‹˜ ÙË ÊÔ˘ÚÔÛÂÌ›‰Ë.
4. ∫ÂÚ·ÙÔÂȉ›˜ °È· ÙËÓ Î·Ï‡ÙÂÚË ÚÔÛÙ·Û›· ÙˆÓ ÎÂÚ·ÙÔÂȉÒÓ Ù· ‚Ϥʷڷ Ú¤ÂÈ Ó· ‰È·ÙËÚÔ‡ÓÙ·È ÎÏÂÈÛÙ¿, ÂÓÒ Û˘ÓÈÛÙ¿Ù·È Ó· ÙÔÔıÂÙÔ‡ÓÙ·È Î·È ÂÈı¤Ì·Ù· ¿ÁÔ˘. ¶ÂÚÈÛÙ·Ûȷο ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÂÓ˘‰·ÙÈο ‹ ·ÓÙÈ‚ÈÔÙÈο ÎÔÏχÚÈ·.
5. ÀÔıÂÚÌ›· ™˘Ó·ÓÙ¿Ù·È ÛÙÔ 86% ÂÚ›Ô˘ ÙˆÓ Èı·ÓÒÓ ‰ÔÙÒÓ Î·È Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆÈÛı› Ù·¯‡Ù·Ù· ‰ÈfiÙÈ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÈΛӉ˘Ó˜ ‰È·Ù·Ú·¯¤˜ ∏ ·ÓÙÈÌÂÙÒÈÛË ÍÂÎÈÓ¿ÂÈ Ì ÙËÓ ÚfiÏË„Ë. ™ÙÔ˘˜ Èı·ÓÔ‡˜ ‰fiÙ˜ Ë ıÂÚÌÔÎÚ·Û›· ÙÔ˘ ÛÒÌ·ÙÔ˜ Ú¤ÂÈ Ó· ‰È·ÙËÚÂ›Ù·È >35_C. ∞˘Ùfi Û˘Ó‹ıˆ˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ ·‡ÍËÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÛÙÔ˘˜ 23-24_C Î·È ÙË ¯ÔÚ‹ÁËÛË ¯ÏÈ·ÚÒÓ ÔÚÒÓ ÌÔÚ› fï˜ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Â›Û˘ ÂȉÈΤ˜ ËÏÂÎÙÚÈΤ˜ ÎÔ˘‚¤ÚÙ˜ Î·È Ï¿Ì˜.
6. ∏ÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ∂›Ó·È Û˘¯Ófi ‡ÚËÌ· Î·È ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÙÔ ∫, ÙÔ Na, ÙÔ P Î·È ÙÔ Mg. ™˘¯ÓfiÙÂÚ˜ Â›Ó·È Ë ˘ÂÚÓ·ÙÚÈ·ÈÌ›· Î·È Ë ˘ÔηÏÈ·ÈÌ›·, ΢ڛˆ˜ ÂÍ ·ÈÙ›·˜ ÙÔ˘ ¿ÔÈÔ˘ ‰È·‚‹ÙË. ∏ ‰ÈfiÚıˆÛ‹ ÙÔ˘˜ Á›ÓÂÙ·È Ì ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÁηÈÌ›·˜ Î·È ÙËÓ ¯ÔÚ‹ÁËÛË ˘fiÙÔÓˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‹ ÁÏ˘ÎÔ˙Ô‡¯ˆÓ ‰È·Ï˘Ì¿ÙˆÓ ÂÌÏÔ˘ÙÈÛÌ¤ÓˆÓ Ì KCL.
7. ÀÂÚÁÏ˘Î·ÈÌ›· ¶Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Î·È Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÁÚ‹ÁÔÚ·. ™Ùfi¯Ô˜ Â›Ó·È Ë ‰È·Ù‹ÚËÛË ÙÔ˘ ۷ί¿ÚÔ˘ Û ›‰· 120-140mg%, Ì ÙË ¯ÔÚ‹ÁËÛË ÎÚ˘ÛÙ·ÏÏÈ΋˜ ÈÓÛÔ˘Ï›Ó˘ ÛÂ Û˘Ó¯‹ ÛÙ¿Á‰ËÓ
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¤Á¯˘ÛË.
8. ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ËÎÙÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘¯Ó¿ Î·È ÛÙÔ 88% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÚfiÎÂÈÙ·È ÁÈ· DIC. §fiÁˆ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÚfiÎÏËÛ˘ ‰Â˘ÙÂÚÔ·ıÒÓ ·ÈÌÔÚÚ·ÁÈÒÓ, Ô˘ Èı·ÓfiÓ Ó· ÂȉÂÈÓÒÛÔ˘Ó ÙËÓ ÁÂÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ‰fiÙË, Û˘ÓÈÛÙ¿Ù·È Ë ¿ÌÂÛË ‰ÈfiÚıˆÛ‹ ÙÔ˘˜ Ì ÙË ¯ÔÚ‹ÁËÛË FFP.
9. ÕÔÈÔ˜ ‰È·‚‹Ù˘ OÊ›ÏÂÙ·È ÛÙËÓ ¤ÏÏÂÈ„Ë Ù˘ ADH. ∂¿Ó Ë ·ÒÏÂÈ· Ô‡ÚˆÓ Â›Ó·È Ì¤ÙÚÈ·, ÂȯÂÈÚÂ›Ù·È ·Ó·Ï‹ÚˆÛË ÙˆÓ ·ˆÏÂÈÒÓ. ΔÔ Â›‰Ô˜ ÙˆÓ ˘ÁÚÒÓ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÂÍ·ÚÙ¿Ù·È Î˘Ú›ˆ˜ ·fi Ù· ›‰· ÙÔ˘ Na. ∞ÓÙ›ıÂÙ· Â¿Ó Ë ‰ÈÔ‡ÚËÛË Â›Ó·È >5-7ml/kg/h ÙfiÙ ¯ÚÂÈ¿˙ÂÙ·È ÂÈÚfiÛıÂÙ· ¯ÔÚ‹ÁËÛË ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ÔÚÌfiÓ˘ (Vasopressin). ™˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ˘‰·ÙÈÎÔ‡ ‰È·Ï‡Ì·ÙÔ˜ Ù˘ Vasopressin (iv 0.5-50 IU/h ‰È·ÙËÚ› ÙË ‰ÈÔ‡ÚËÛË Û ›‰· 23ml/kg/h) ‹ ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ Ù˘ ·Ó·ÏfiÁÔ˘ Ù˘ ‰ÂÛÌÔÚÂÛÛ›Ó˘ Ë ÔÔ›· ¤¯ÂÈ ÂÎÏÂÎÙÈ΋ ·ÓÙȉÈÔ˘ÚËÙÈ΋ ‰Ú¿ÛË. ∏ ‰ÂÛÌÔÚÂÛÛ›ÓË ¯ÔÚËÁÂ›Ù·È ÂÓ‰ÔÚÈÓÈο, ˘ÔÁÏÒÛÛÈ·, per os, im Î·È iv. ∂Ó‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË0.5-2Á/8-12 h Û˘Ó‹ıˆ˜ ·ÚΛ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ ¿ÔÈÔ˘ ‰È·‚‹ÙË. À¿Ú¯ÂÈ ·ÎfiÌË ÛËÌ·ÓÙÈ΋ ·ÓÙÈÁӈ̛· Û¯ÂÙÈο Ì ÙËÓ ÔÚÌÔÓÈ΋ ˘ÔηٿÛÙ·ÛË Î·È È‰È·›ÙÂÚ· fiÛÔÓ ·ÊÔÚ¿ ÙȘ ı˘ÚÔÂȉÈΤ˜ ÔÚÌfiÓ˜. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ Novitzky Î·È Û˘Ó ¯ÔÚËÁÒÓÙ·˜ Δ3 ·¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈÎfi fiÊÂÏÔ˜ ÁÈ· ÙÔ ‰fiÙË Î·È Î·Ï‡ÙÂÚË ¤Î‚·ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜ ‰ÂÓ Â›¯·Ó Ù· ›‰È· ·ÔÙÂϤÛÌ·Ù· Î·È ÚÔ˜ ÙÔ ·ÚfiÓ ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰ÂÓ ˘¿Ú¯ÂÈ Û‡ÛÙ·ÛË ÁÈ· Û˘ÛÙËÌ·ÙÈ΋ ¯Ú‹ÛË Ù˘ ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘. ∂ÍÂÙ¿˙ÂÙ·È Ë Èı·Ó‹ ¢ÂÚÁÂÙÈ΋ ‰Ú¿ÛË Ù˘ ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ Û ‰fiÙ˜ ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜ ·Ú¿ ÙË ¯ÔÚ‹ÁËÛË Dopamine Û ‰fiÛË 10g/Kg ‹ Ì EF<45% ∏ ÛˆÛÙ‹ ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ ‰fiÙË ÚÔ¸Ôı¤ÙÂÈ ÛˆÛÙfi monitoring, ÙÔ ÔÔ›Ô ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ∏∫°, Ù˘ ∞¶ ÙÔ˘ SPO2, Ù˘ CVP Î·È Ù˘ ‰ÈÔ‡ÚËÛ˘, ÂÓÒ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Î·È Ù˘ Pcwp. ∂CHO ηډ›·˜ Â›Ó·È ··Ú·›ÙËÙÔ Û fiÏÔ˘˜ ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ ‰fiÙ˜ ηډȿ˜. ∏ ÊÚÔÓÙ›‰· ÁÈ· ÙÔ ‰fiÙË ·ÔÙÂÏ› ·Ú¿ÏÏËÏ· Î·È ÊÚÔÓÙ›‰· ÁÈ· ÙÔ˘˜ Ï‹Ù˜. ∏ ÛˆÛÙ‹ ‰È·Ù‹ÚËÛË ÙÔ˘ ‰fiÙË ÂÍ·ÛÊ·Ï›˙ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ÌÔ-
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M. M¶ITZANH
Û¯Â˘Ì¿ÙˆÓ Û ηϋ ηٿÛÙ·ÛË, ¤ÙÛÈ ÒÛÙ ÔÈ Èı·ÓfiÙËÙ˜ ÂÈÙ˘¯›·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ó· ·˘Í¿ÓÔ˘Ó ÛËÌ·ÓÙÈο. ∏ ÂÊ·ÚÌÔÁ‹ ÙˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ·ÏÁÔÚ›ıÌˆÓ Û˘Ì‚¿ÏÂÈ ÛËÌ·ÓÙÈο ÛÙË ‰È¿ÛˆÛË ÔÚÁ¿ÓˆÓ Ô˘ ·Ú¯Èο ıˆÚÔ‡ÓÙ·È ·Î·Ù¿ÏÏËÏ·.
™˘ÓÈÛÙÒÌÂÓË ‚È‚ÏÈÔÁÚ·Ê›· 1. Sanchez-Miret JI., Hernandez JO., Procaccio F.: «Donor maintenance » in Transplant coordination manual, pp 113-133, ed TPM-Les Heures – Universitat de Barcelona, Barcelona 2001. 2. Kutsogiannis D. Pagliarello G., Doig C., Ross H., Shemic S: Medical management to optimize donor organ potential: review of the literature. Can J Anesth 2006; 53(8):820-830 3. Wood K., Becker B., McCartney J., D’Alessandro A., Coursin D: Care of the potential organ donor. NEJM 2004;351:2730-9 4. Rosendale J., Chabalewski F., McBride M., et al: Increased transplanted organs from the use of standardized donor management protocol. Am J Transplant 2002; 2:761-8 5. Edgar P., Bullock R., Bonner S.: Management of the heart-beating organ donor. BJA: CEACCP 2004; 4(3):86-90
6. Tuttle- Newhall J., Collins B.,Kuo P., Schoeder R.: Organ donation and treatment of the multi-organ donor. Curr Probl Surg 2003;40:266-310 7. Vaireti M., Ferrigno A., Rizzo V., et al: Liver damage during ischemia /reperfusion and glutathione: implications for potentialorgan donors. Transplant proc. 2007;39(6):1768-70 8. Khush KK.,Menza R., Babcock W., Zaroff: Donor cardiac troponin I levels do not predict recipient survival after cardiac transplantation. J Heart Lung Transplant 2007;26(10): 1048-53 9. Roels I., Pirenne J., Delooz H., Lauwers P., Vandermeersch E: Effect of triiodothyronine replacement therapy on maintenance characteristics and organ availability in hemodynamically unstable donors. Transplant proc 2000; 32 :1564-6 10. Mullis –Jansson S., Argenziano M., Corwin S., et al: A randomized double blind study of the effect of triiodothyronine on cardiac function and morbidity after coronary bypass surgery. J Thorac Cardiovsc Surg 1999; 117:1128-35 11. Rosendale J., Kauffman H., McBride m., et al: Hormonal resuscitation yields more transplanted hearts , with improved early function. Transplantation 2003; 75:1336-41
METAMO™XEY™H NEºPOY IO°ENEI™ §OIMø•EI™
53
MÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡ ÛÙ· ·È‰È¿
1
ºÒÙ˘ ¶··¯Ú‹ÛÙÔ˘
ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi ˙ÒÓÙ· ‰fiÙË Â›Ó·È Ë ÌÂÁ·Ï‡ÙÂÚË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ‰˘Ó·ÙfiÙËÙ· ÚÔÁÚ·ÌÌ·ÙÈÛÌÔ‡ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È Ù· „˘¯ÔÏÔÁÈο ÔʤÏË. ¶ÚfiÛÊ·Ù· ÙÔ 25% ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Û ·È‰È¿ Ô˘ ¤ÁÈÓ·Ó ÛÙË ª. μÚÂÙ·Ó›· Î·È ÙÔ 55% ÛÙËÓ μ. ∞ÌÂÚÈ΋ ‹Ù·Ó ·fi ˙ÒÓÙ· ‰fiÙË. O ÂÚÈÂÁ¯ÂÈÚËÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ· ÙÔÓ ‰fiÙË Â›Ó·È ÌÈÎÚfi˜ Ì ıÓËÙfiÙËÙ· Ô˘ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 0,03% Î·È 0,06%. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· ÙˆÓ ·ÙfiÌˆÓ ·˘ÙÒÓ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÙ·È ·fi ÙË ÓÂÊÚÂÎÙÔÌ‹. ∏ ·Ó¿Ù˘ÍË Ù˘ Ï··ÚÔÛÎÔÈ΋˜ ÓÂÊÚÂÎÙÔÌ‹˜ Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ· ¤¯ÂÈ ÌÂÈÒÛÂÈ ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ÙÔ ÔÛÔÛÙfi ÙˆÓ ÂÈÏÔÎÒÓ. ™ËÌ·ÓÙÈ΋ ÂͤÏÈÍË Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·ÔÙ¤ÏÂÛÂ Ë ÂÈÏÔÁ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û ÚÔÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜, Ì ÂÍ›ÛÔ˘ ηϿ ·ÔÙÂϤÛÌ·Ù· ·ÔʇÁÔÓÙ·˜ ‹ ÂÚÈÔÚ›˙ÔÓÙ·˜ ÙȘ ÛÔ‚·Ú¤˜ „˘¯ÔÏÔÁÈΤ˜, ·Ó·Ù˘ÍȷΤ˜ ·ÏÏ¿ Î·È ÎÔÈÓˆÓÈΤ˜ ÂÈÙÒÛÂȘ ·fi ÙËÓ ¤ÓÙ·ÍË ÙÔ˘ ÓÂÊÚÔ·ıÔ‡˜ ·È‰ÈÔ‡ Û ÚfiÁÚ·ÌÌ· ˘ÔηٿÛÙ·Û˘. ™‹ÌÂÚ· ÙÔ 25% ÛÙË μ. ∞ÌÂÚÈ΋ Î·È ÙÔ 20% ÂÚ›Ô˘ ÙˆÓ ·È‰ÈÒÓ Ì Ã.¡.∞ ÛÙË ª. μÚÂÙ·Ó›· ˘Ô‚¿ÏÏÔÓÙ·È Û ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÚÔÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ã.¡.∞. ™Ù· Ôχ ÌÈÎÚ¿ ·È‰È¿ ÛÙËÓ ·fiÊ·Û‹ ÙÔ˘˜ Ô ÁÈ·ÙÚfi˜ Î·È Ë ÔÈÎÔÁ¤ÓÂÈ· Ú¤ÂÈ Ó· ÛÙ·ıÌ›ÛÔ˘Ó Ù· ÔʤÏË Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÛÙÔ ÚÔÙÂÏÈÎfi Ã.¡.∞., ÙȘ ‰˘ÛÎÔϛ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ÌÂıfi‰Ô˘˜ ˘ÔηٿÛÙ·Û˘ (·ÁÁÂȷ΋ ÚÔۤϷÛË, η΋ ·Ó¿Ù˘ÍË Î.¿), ÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚÒÈÌ˘ ·fiÚÚȄ˘ Û ·˘Ù‹Ó ÙËÓ ËÏÈΛ· ηıÒ˜ Î·È ÙȘ ÂÈÏÔΤ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô Î·È ÙËÓ ·ÓÔÛÔηٷÛÙÔÏ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. Δ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ¤¯Ô˘Ó ÂÓÙ˘ˆÛȷο ‚ÂÏÙȈı› ÙÂÏÂ˘Ù·›·. ¶ÚÔÎÏ‹ÛÂȘ ÁÈ· ÙÔ Ì¤ÏÏÔÓ ·Ú·Ì¤ÓÔ˘Ó Ë ·‡ÍËÛË Ù˘ ÚÔÛÊÔÚ¿˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ë ·‡ÍËÛË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi ˙ÒÓÙ· ‰fiÙË, Ë
∏ ¤ÓÙ·ÍË ÙˆÓ ·È‰ÈÒÓ, Ô˘ ¿Û¯Ô˘Ó ·fi ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (Ã.¡.∞.Δ.™.), Û ÚfiÁÚ·ÌÌ· ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘, ·Ú¿ Ù· ÛËÌ·ÓÙÈο ‚‹Ì·Ù· ‚ÂÏÙ›ˆÛ˘ Ô˘ ¤¯Ô˘Ó ÂÈÙ¢¯ı› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Û˘Óԉ‡ÂÙ·È ·fi ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù·. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·ÔÙÂÏ› ÙË ıÂڷ›· ÂÎÏÔÁ‹˜ ÁÈ· οı ·È‰› Ì Ã.¡.∞.Δ.™. ¶ÚÔ‚Ï‹Ì·Ù· fiˆ˜ Ë ·Ó·ÈÌ›·, Ë ˘ÔıÚ„›·, Ë Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË Î.¿. Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶¿Óˆ ·fi ÙÔ 1/3 ÙˆÓ ·È‰ÈÒÓ Ì Ã.¡.∞. ¤¯Ô˘Ó ˆ˜ ÚˆÙÔ·ı‹ ·ÈÙ›· ·ÔÊÚ·ÎÙÈΤ˜ Ô˘ÚÔ¿ıÂȘ, ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›· Î·È ÓÂÊÚÔ¿ıÂÈ· ·fi ·ÏÈÓ‰ÚfiÌËÛË. ™ËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ ÛÙËÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ‰È·‰Èηۛ· ·ÔÙÂÏ› Ë Ï‹Ú˘ Ô˘ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Î·ıÒ˜ Î·È ÔÈ ··Ú·›ÙËÙ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ‰ÈÔÚıˆÙÈΤ˜ Ô˘ÚÔÏÔÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ. ŒÓ·˜ ·fi ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙ÂÈ ÙËÓ ¤Î‚·ÛË Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Â›Ó·È Ë ÂÈÏÔÁ‹ ÙÔ˘ ‰fiÙË ÓÂÊÚÈÎÔ‡ ÌÂÙ·ÌÔۯ‡̷ÙÔ˜. ∏ ÌÈÎÚ‹ ËÏÈΛ· ÙÔ˘ ‰fiÙË Ê·›ÓÂÙ·È fiÙÈ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Î·Î‹ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÚˆÙÔ·ıÒ˜, ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ·ÁÁÂÈ·ÎÒÓ ıÚÔÌ‚ÒÛˆÓ, ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÔÍ›· ·fiÚÚȄ˘ Û˘¯Ó¿ ÌË ·Ó·ÛÙÚ¤„ÈÌ˘, Î·È ¯·ÌËÏfiÙÂÚË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. °È· ÙÔ ÏfiÁÔ ·˘Ùfi ·ÔʇÁÂÙ·È ÁÂÓÈο Ë ¯ÚËÛÈÌÔÔ›ËÛË Û ·È‰È¿ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ‰fiÙ˜ οو ÙˆÓ 5 ÂÙÒÓ. OÈ ·ÁÁÂȷΤ˜ ıÚÔÌ‚ÒÛÂȘ ·ÔÙÂÏÔ‡Ó ÙËÓ ÙÚ›ÙË ·ÈÙ›· ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙ· ·È‰È¿. ªÔۯ‡̷ٷ ·fi ÌÈÎÚÔ‡˜ ‰fiÙ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘Ó‹ıˆ˜, ÂÊfiÛÔÓ ÏËÚÔ‡Ó ÙȘ ÚÔ¸Ôı¤ÛÂȘ, ÁÈ· en-bloc ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÂÓ‹ÏÈΘ. EÊË‚ÔÈ Î·È Ó·ÚÔ› ÂÓ‹ÏÈΘ ıˆÚÔ‡ÓÙ·È Î·Ù·ÏÏËÏfiÙÂÚÔÈ ‰fiÙ˜ ÁÈ· ÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. Δ· ΢ÚÈfiÙÂÚ· ÏÂÔÓÂÎÙ‹Ì·Ù· ÙˆÓ ÓÂÊÚÈÎÒÓ
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º. ¶A¶AXPH™TOY
‚ÂÏÙ›ˆÛË Ù˘ Û˘Ì‚·ÙfiÙËÙ·˜ ÛÙ· و̷ÙÈο ÌÔۯ‡̷ٷ, Ë Ì›ˆÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ÁÈ· ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ‚ÂÏÙ›ˆÛË Ù˘ Û˘ÓÙ‹ÚËÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÓÂÒÙÂÚ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· Î·È Ù¤ÏÔ˜ ·Ó¿ÁÎË ÁÈ· ÌÂϤÙ˜ Ô˘ ı· ÂÍÂÙ¿ÛÔ˘Ó ÙËÓ ·ÛÊ¿ÏÂÈ·, ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ÙËÓ ·ÓÔ¯‹ ÓÂÒÙÂÚˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙ· ·È‰È¿.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Webb NJA, Johnson R, Postlethwaite R. Renal Transplantation. Arch Dis Chld 2003;88 844-847 2. Tejani A, Harmon W. Clinical Transplantation. In Bar-
ratt M, Anver E, Harmon W eds. Pediatric Nephrology. 4th ed. Baltimore; Lippincot Williams and Wilkins 1999;1309-1337. 3. Seikaly M, Ho P, Emmett L, Fine R, Tejani A. Chronic renal insufficiency in children: The 2001 Annual Repor of the NAPRTCS. Pediatr Nephrol 2003; 18:796-804. 4. Seikaly M, Ho P, Emmett L, et al. The 12th Annual Report of the North American Pediatric Renal Transplant Cooperative Study: renal transplantation from 1987 through 1998. Pediatr Transplant 2001;5:215-231 5. Smith J, et al. Contributions of the Transplant Registry: The 2006 Annual Report of the North American Pediatric Renal Trials and Collaborative Studies. Pediatric Transplant 2007; 11:366-373.
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2
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ΔȘ ÙÂÏÂ˘Ù·›Â˜ ‰‡Ô ‰ÂηÂٛ˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ (™¢) ·ÔÙÂÏ› ÙËÓ Ù·¯‡ÙÂÚ· ·˘Í·ÓfiÌÂÓË ·ÈÙ›· ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, ÒÛÙÂ Ô ·ÚÈıÌfi˜ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ô˘ ··ÈÙÔ‡Ó ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ó· ‚Ú›ÛÎÂÙ·È ·ÁÎÔÛÌ›ˆ˜ ÛÙËÓ ÚÒÙË ı¤ÛË (45%) ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜. ∏ ·‡ÍËÛË ·˘Ù‹ ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ ÛÙË Û˘Ó¯‹ ·‡ÍËÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì· ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2, ÁÂÁÔÓfi˜ Ô˘ ÂËÚ¿˙ÂÈ ÙËÓ ‰ËÌÔÁÚ·Ê›· Ù˘ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, ÂÓÒ Ô ™¢ ·ÔÙÂÏ› ›Û˘ ÙËÓ ÚÒÙË ·ÈÙ›· ÓÂÊÚÔ¿ıÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ô˘ ·Ó·Ê¤ÚÂÙ·È ÁÈ· ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· ÙÔ˘ USRDS [1], oÈ ÂÚÈÛÛfiÙÂÚÔÈ (¿Óˆ ·fi 80%) ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ì ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÂÈÛ¤Ú¯ÔÓÙ·È Û ¯ÚfiÓÈÔ ÚfiÁÚ·ÌÌ· Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ Ì Δ¯ÓËÙfi ¡ÂÊÚfi, ÂÓÒ ·fi ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ÛÙÔ 12% ÂÊ·ÚÌfi˙ÂÙ·È ¶ÂÚÈÙÔÓ·˚΋ ∫¿ı·ÚÛË (¶.∫.) Î·È ÙÔ 8% Ï·Ì‚¿ÓÂÈ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ΔËÓ ‰ÂηÂÙ›· 1970 ÔÈ ·ÛıÂÓ›˜ Ì ̷ÎÚ¿ ‰È¿ÚÎÂÈ· ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ÏfiÁˆ ÙˆÓ ÔÈÎ›ÏˆÓ ¿ÏÏˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Î·È ÂÈÏÔÎÒÓ, fiˆ˜ Ë ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·, Ë Ó¢ÚÔ¿ıÂÈ·, Ë ·ÚÙËÚÈÔ¿ıÂÈ· Î·È Ë Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ˜, ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·Ó Ì ÌÂÁ¿ÏË ÂÚ›ÛÎÂ„Ë fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÈÎÈÓ‰˘ÓfiÙËÙ· Ù˘ ıÂڷ¢ÙÈ΋˜ ÙÔ˘˜ ·ÓÙÈÌÂÙÒÈÛ˘ ·ÏÏ¿ Î·È ÙËÓ ‰˘Ó·ÙfiÙËÙ· ¢ÂÚÁÂÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ∞˘Ùfi ‹Ù·Ó ȉȷ›ÙÂÚ· ÂÌÊ·Ó¤˜ ÛÙËÓ ÚÔÒıËÛ‹ ÙÔ˘˜ ÁÈ· ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û ‚·ıÌfi Ô˘ ÂıˆÚ›ÙÔ fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ‰ÂÓ ‹Û·Ó ηٿÏÏËÏÔÈ ˘Ô„‹ÊÈÔÈ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ÏfiÁˆ Èı·ÓÒÓ ÂÈÏÔÎÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞ÓÙ›ıÂÙ· Ë ÛΤ„Ë fiÙÈ Ì ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹Ù·Ó Èı·Ófi Ó· ‚ÂÏÙȈıÔ‡Ó ÔÈ ‰Â˘ÙÂÚÔ·ı›˜ ÂÈÏÔΤ˜ ÙÔ˘ ‰È·‚‹ÙË, ÔÈ Ôԛ˜ ÂȉÂÈÓÒÓÔÓÙ·È ·fi ÙËÓ Ô˘Ú·ÈÌ›·, Ô‰‹ÁËÛ ÌÂÚÈο ΤÓÙÚ· ÛÙËÓ ‰ÈÂÓ¤ÚÁÂÈ· ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘, Ì ·ÔÙ¤ÏÂ-
ÛÌ· Ó· ‰È·ÈÛÙˆı› fiÙÈ Ë ÂÈ‚›ˆÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË ·fi ·˘ÙÒÓ Ô˘ ·Ú¤ÌÂÓ·Ó ÛÙËÓ ·ÈÌÔοı·ÚÛË. ∂ÙÛÈ ÁÈ· ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·ÔÙÂÏ› ÙËÓ Ï¤ÔÓ ÂÈı˘ÌËÙ‹ ıÂڷ›·, ÂÊfiÛÔÓ Ô ·ÛıÂÓ‹˜ Ì ¤Ó· ηÏÒ˜ ÏÂÈÙÔ˘ÚÁfiÓ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·, ¤¯ÂÈ Û˘Ó‹ıˆ˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ÂÈ‚›ˆÛ˘, ηχÙÂÚË ÔÈfiÙËÙ· ˙ˆ‹˜ ηıÒ˜ ›Û˘ Î·È ¤Ó·Ó ˘„ËÏfiÙÂÚÔ ‚·ıÌfi ·ÔηٿÛÙ·Û˘ ·fi ÙÔÓ ·ÛıÂÓ‹ Ô˘ ˘Ô‚¿ÏÏÂÙ·È Û ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ·ÈÌÔοı·ÚÛË [2,3,4]. ΔÔ 1977 Ô Najarian ‰ËÌÔÛ›Â˘Û [5] ÙËÓ ·ÔÎÙËı›۷ ÂÌÂÈÚ›· ÁÈ· ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· Ù· ÙÂÏÈο ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó Û˘ÁÎÚ›ÛÈÌ· Ì ·˘Ù¿ ÙˆÓ ÌË ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ. ∂ÈÚfiÛıÂÙ· ·Ú¿ ÙÔÓ ıˆÚÔ‡ÌÂÓÔ ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ· ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ‹Ù·Ó ·ÓÒÙÂÚ· ·fi ·˘Ù¿ Ô˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È Ì ÙËÓ ¯ÚfiÓÈ· Â͈ÓÂÊÚÈ΋ οı·ÚÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ. ∂›Û˘ Ë ÂÚ›ÛÎÂ„Ë Û¯ÂÙÈο Ì ÙËÓ Èı·Ó‹ ·ÓÂÌÊ¿ÓÈÛË Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÛÙÔ ÌfiÛ¯Â˘Ì·, ‰È·Ï‡ıËΠ‚·ıÌÈ·›· ÂÊfiÛÔÓ ¤ÁÈÓ ۷ʤ˜ fiÙÈ ÁÈ· ·ÚÎÂÙ¿ ¤ÙË ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ ÂÌÊ·Ó›˙ÂÙ·È ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋ ÓÂÊÚÔ¿ıÂÈ·, ÂÓÒ ÔÈ ‚Ú·¯˘ÚfiıÂÛ̘ Â΂¿ÛÂȘ ·ÛıÂÓÔ‡˜ Î·È ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ·ÚfiÌÔȘ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ï‹Ù˜ ÓÂÊÚÒÓ Î·È ÙÔ˘˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, Ô˘ ·Ó¤Ù˘Í·Ó ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ‰Â˘ÙÂÚÔ·ı‹ Û ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ· [6,7]. ™ÙËÓ ÂÓfiÙËÙ· ·˘Ù‹ ı· ·Ó·ÊÂÚıÔ‡Ó Ù· ·ÚÈ· ÛÙÔȯ›· Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓÒÓ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ·.
1) ™˘¯ÓfiÙËÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û ·ÛıÂÓ›˜ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ™‹ÌÂÚ· Ë ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ·ÔÙÂÏ› ÛÙȘ ∏¶∞ ÂÚ›Ô˘ ÙÔ 20% ÙˆÓ ÂÙ‹ÛÈˆÓ ÓÂÊÚÈÎÒÓ
57
58
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ÌÂÙ·ÌÔۯ‡ÛˆÓ, ›Ù ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ (Ù·˘Ùfi¯ÚÔÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ¿ÁÎÚ·˜-ÓÂÊÚÔ‡, SPKT) ›Ù ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ (ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌfiÓÔ ÓÂÊÚÔ‡, KTA) [1]. ∂›Û˘ ·fi ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ·fi ÙÔ 1993 (¿Óˆ ·fi 10000), ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ÌÈÛ¤˜ ‹Ù·Ó Ù·˘Ùfi¯ÚÔÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ – ·ÁÎÚ¤·ÙÔ˜ (SPKT), Ì ÙÔ ˘fiÏÔÈÔ 1/3 Ó· ·ÊÔÚ¿ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ·ÁÎÚ¤·ÙÔ˜ ÌÂÙ¿ ÙÔ ÓÂÊÚfi ‹ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÌfiÓÔ ·ÁÎÚ¤·ÙÔ˜ [8]. 줂·È· ÔÈ ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË Ù‡Ô˘ 2 Î·È ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÂÈϤÁÔÓÙ·È ÁÈ· ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ [9]. ¶Ú¿ÁÌ·ÙÈ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÁÈ· ÌÂÚÈΤ˜ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ Û˘ÌÂÚÈÏ·Ì‚·ÓfiÌÂÓˆÓ ÙˆÓ Á˘Ó·ÈÎÒÓ, ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ Î·ıÒ˜ ›Û˘ Î·È ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ, Â›Ó·È ÌÈÎÚfiÙÂÚË Ë Èı·ÓfiÙËÙ· Ù˘ ÙÔÔı¤ÙËÛ˘ ÛÙÔÓ Î·Ù¿ÏÔÁÔ ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŒÙÛÈ ÙÔ 2001 Ë ÙÔÔı¤ÙËÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ì ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÛÙÔÓ Î·Ù¿ÏÔÁÔ ·Ó·ÌÔÓ‹˜, ›¯Â Èı·ÓfiÙËÙ· 12%, ¤Ó·ÓÙÈ ÂÎÂ›ÓˆÓ Ì ڈÙÔ·ı‹ ‰È¿ÁÓˆÛË ˘¤ÚÙ·ÛË, ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·, ‹ ÙËÓ Î˘ÛÙÈ΋ ·Ûı¤ÓÂÈ· ÙˆÓ ÓÂÊÚÒÓ ÛÙȘ Ôԛ˜ Ù· ÔÛÔÛÙ¿ ‹Ù·Ó 16%, 26%, Î·È 29% ·ÓÙ›ÛÙÔȯ· [1]. ™Â ÌÈ· ÚfiÛÊ·ÙË ÌÂϤÙË, ·Ó·Ï‡ıËÎ·Ó Ù· ÛÙÔȯ›· ÙˆÓ ·ÛıÂÓÒÓ Û ÙÚ›· ÓÂÊÚÔÏÔÁÈο ΔÌ‹Ì·Ù· Ù˘ °·ÏÏ›·˜, ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ Û¯¤Û˘ ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ ·ÛıÂÓÒÓ, fiˆ˜ Â›Ó·È Ë ÌÂÁ¿ÏË ËÏÈΛ· (60 ¤ÙË) Î·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 2 Î·È Ù˘ Èı·ÓfiÙËÙ·˜ ÂÁÁÚ·Ê‹˜ - ·Ó·ÌÔÓ‹˜ ÛÙÔÓ Î·Ù¿ÏÔÁÔ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘, [10]. ∞fi ÙËÓ ÌÂϤÙË ·˘Ù‹ Ê¿ÓËΠfiÙÈ ÔÈ ·ÛıÂÓ›˜ ÚÔ¯ˆÚË̤Ó˘ ËÏÈΛ·˜ Î·È ÔÈ ‰È·‚ËÙÈÎÔ› Ù‡Ô˘ 2, ›¯·Ó ¯·ÌËÏ¿ ÔÛÔÛÙ¿ ÚÔ-ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋˜ ÂÎÙ›ÌËÛ˘ Î·È ·Ó·ÁÚ·Ê‹˜ ÛÙȘ Ï›ÛÙ˜ ·Ó·ÌÔÓ‹˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ·ÎfiÌ· Î·È ÌÂÙ¿ ·fi ÙË Ú‡ıÌÈÛË Ô˘ ¤ÁÈÓ ÁÈ· Ù· ¿ÏÏ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ.
2) ∂È‚›ˆÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Î·È ·ÛıÂÓÒÓ ∏ ÂÈ‚›ˆÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÙˆÓÛ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ·fi ·˘Ù¿ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·ÛıÂÓÒÓ Ì ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ¿ÏÏ˘ ÚˆÙÔ·ıÔ‡˜ ÓfiÛÔ˘. ¶Ú¿ÁÌ·ÙÈ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÁÈ· ·ÓÔÛÔÏÔÁÈ΋ ÔÍ›· ‹ ¯ÚfiÓÈ· ·fiÚÚÈ-
„Ë ÌÔۯ‡̷ÙÔ˜, Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ [1]. ÕÛ¯ÂÙ· ·fi Ë ·ÈÙ›· Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜, Ë ÂÈ‚›ˆÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÙfiÛÔ ÙˆÓ ÙˆÌ·ÙÈÎÒÓ fiÛÔ Î·È ÙˆÓ ˙ˆÓÙ·ÓÒÓ ‰ÔÙÒÓ Û˘Ó¯›˙ÂÈ Ó· ‚ÂÏÙÈÒÓÂÙ·È, ÏfiÁˆ ÔÏ˘¿ÚÈıÌˆÓ ·Ú·ÁfiÓÙˆÓ fiˆ˜ Â›Ó·È Ù· ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÔÍ›·˜ ·fiÚÚȄ˘, Ë Î·Ï‡ÙÂÚË ·ÓÙÈÌÈÎÚԂȷ΋ ÚÔʇϷÍË, ηıÒ˜ ›Û˘ Î·È Ë ÁÂÓÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ È·ÙÚÈ΋˜ Î·È ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÊÚÔÓÙ›‰·˜. ¶·ÚfiÌÔȘ ‚ÂÏÙÈÒÛÂȘ ¤¯Ô˘Ó ·Ú·ÙËÚËı› Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÒÓ Û ·ÛıÂÓ›˜ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ·. ∂ÓÙÔ‡ÙÔȘ fiÙ·Ó Û˘ÁÎÚ›ÓÔÓÙ·È ÔÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ Ì ·ÛıÂÓ›˜ ¿ÏÏˆÓ ÓÂÊÚÈÎÒÓ ·ÛıÂÓÂÈÒÓ, Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÏÏÔÌÔÛ¯Â˘Ì¿ÙˆÓ, Î˘Ì·›ÓÔÓÙ·È Â˘Ú¤ˆ˜, ÌÂٷ͇ ÙˆÓ Î¤ÓÙÚˆÓ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ·fi Ù· ¯ÂÈÚfiÙÂÚ· Ì·ÎÚÔÚfiıÂÛÌ· ·ÔÙÂϤÛÌ·Ù· ̤¯ÚÈ Ù· Ôχ ÂÈÙ˘¯‹ ·ÔÙÂϤÛÌ·Ù·, Ù· ÔÔ›· Â›Ó·È Û˘ÁÎÚ›ÛÈÌ· Ì ·˘Ù¿ Ô˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È Û ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ [3]. ∏ 5-ÂÙ‹˜ ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ King’s College Hospital, ÁÈ· Ù· ¤ÙË 1980-1989 ‹Ù·Ó 61% Î·È 76% ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙÔ ÙˆÌ·ÙÈÎfi Î·È ˙ÔÓ ÌfiÛ¯Â˘Ì·, ÔÛÔÛÙ¿ Ô˘ Ì ٷ ϤÔÓ ÚfiÛÊ·Ù· ÛÙÔȯ›· Î˘Ì¿ÓıËÎ·Ó ·fi 79% ¤ˆ˜ 87% ÁÈ· ÂΛÓÔ˘˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÓÂÊÚ¿ و̷ÙÈÎÒÓ Î·È ˙ÒÓÙˆÓ ‰ÔÙÒÓ ·ÓÙ›ÛÙÔȯ·, Ì ·ÔÙÂϤÛÌ·Ù· Ú˘ıÌÈṲ̂ӷ ˆ˜ ÚÔ˜ ÙËÓ ËÏÈΛ·, ÙÔ Ê‡ÏÔ, ÙË Ê˘Ï‹ Î·È ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË [11]. Δ· ÔÛÔÛÙ¿ ·˘Ù¿ Â›Ó·È ·ÚfiÌÔÈ· Ì ÚfiÛÊ·Ù· ÛÙÔȯ›· 5-ÂÙÔ‡˜ ÂÈ‚›ˆÛ˘ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ USRDS, ÁÈ· ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ÌÂÙ¿ ·fi ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô˘ Î˘Ì¿ÓıËÎ·Ó ·fi 75% ˆ˜ 83% [12,13], ·ÔÙ¤ÏÂÛÌ· ÈÛÔ‰‡Ó·ÌÔ Ì ÓÂÊÚÈÎfi ·ÏÏÔÌfiÛ¯Â˘Ì· Î·È Ù· ÁÂÓÈο ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÁÈ· و̷ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÙȘ Ù·˘Ùfi¯ÚÔÓ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ¿ÁÎÚ¤·ÙÔ˜-ÓÂÊÚÒÓ (SPKT), ÌÂÙ¿ ·fi ÙË Ú‡ıÌÈÛË Û¯ÂÙÈο Ì ÙÔ˘˜ ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ [14]. ∏ ‡·ÚÍË Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ·ÁÁÂȷ΋˜ ÓfiÛÔ˘ Â›Ó·È Î·Ù¿ ¤Ó· ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ ˘Â‡ı˘ÓË ÁÈ· Ù· ˘„ËÏ¿ ÔÛÔÛÙ¿ ıÓËÛÈÌfiÙËÙ·˜ ÙÔ˘ ·ÏÏÔÌÔۯ‡̷ÙÔ˜ Î·È ÙˆÓ ·ÛıÂÓÒÓ ÂÓÒ Ë Î·Ï‡ÙÂÚË Î·Ù·ÓfiËÛË Ù˘ ·ıÔÁ¤ÓÂÈ·˜ Ù˘ Â͈ÓÂÊÚÈ΋˜ ·ÁÁÂÈÔ·ıËÙÈ΋˜ ÂÈÏÔ΋˜ Ì·˙› Ì ÙËÓ Ï¤ÔÓ ·ÛÊ·Ï‹ ·ÓÔÛÔηٷÛÙÔÏ‹, ÌÔÚÔ‡Ó Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÂÚ·ÈÙ¤Úˆ ÙËÓ ¤Î‚·ÛË Û ¤Ó· Â›Â‰Ô ÈÛÔ‰‡Ó·ÌÔ Ì ·˘Ùfi Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ [15,16]. ¶¿ÓÙˆ˜ ·fi Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Ê·›ÓÂÙ·È fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÒÓ, ˆ˜ ÚÒÙË ıÂ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ڷ›·, Ú¤ÂÈ Ó· ÂÓı·ÚÚ˘Óı› Û fiÏÔ˘˜ ÙÔ˘˜ ÚfiÛÊ·Ù· ÂÎÙÈÌfiÌÂÓÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ì ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ™¯ÂÙÈο Ì ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ù· ÛÙÔȯ›· ·fi ÙËÓ ∂˘ÚÒË Î·È ÙȘ ∏¶∞ ¤‰ÂÈÍ·Ó fiÙÈ Ë Î‡ÚÈ· ·ÈÙ›· ÙÔ˘ ı·Ó¿ÙÔ˘ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Ë Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ˜, ˘Â‡ı˘ÓË ÁÈ· ÙÔ 30%-40% ÙˆÓ ı·Ó¿ÙˆÓ [17,18]. Δ· ÔÛÔÛÙ¿ ı·Ó¿ÙÔ˘ ·fi ηډȷÁÁÂȷ΋ ÓfiÛÔ Â›Ó·È ·ÛÊ·ÏÒ˜ ÌÂÁ·Ï‡ÙÂÚ· ÂÎÂ›ÓˆÓ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ ·Ó Î·È Â›Ó·È ¯·ÌËÏfiÙÂÚ· ·fi Ù· ·ÓÙ›ÛÙÔȯ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ·ÈÌÔοı·ÚÛ˘. ∏ ıÓËÛÈÌfiÙËÙ· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ê·›ÓÂÙ·È Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ù‡Ô˘ 2 ·fi ·˘Ù‹Ó ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ù‡Ô˘ 1, ÏfiÁˆ Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Î·È Ù˘ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ Û˘ÓÔ‰Ô‡ ÓÔÛËÚfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ™¢ Ù‡Ô˘ 2. ∂Ô̤ӈ˜ ÙfiÛÔ Ë Î·Ú‰È·ÁÁÂȷ΋ fiÛÔ Î·È Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜, Ú¤ÂÈ Ó· ÂÎÙÈÌËıÔ‡Ó ÚÔÛÂÎÙÈο, ÂÊfiÛÔÓ Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ÌÔÚ› Ó· Â›Ó·È ·ÚÔ‡Û· ›Ù ·Û˘Ìو̷ÙÈο ‹ fi¯È, Û ÔÛÔÛÙfi ÂÚ›Ô˘ 20 Û 30% ÙˆÓ ‰È·‚ËÙÈÎÒÓ ˘Ô„ËÊ›ˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË [19]. ™ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÚÈÓ ·fi ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÚÔ˘Û›· ‹ fi¯È ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ‹ ˘Ô‰ËψÙÈÎÒÓ Û˘ÌÙˆÌ¿ÙˆÓ fiˆ˜ Â›Ó·È Ë ÛÙËı¿Á¯Ë, Ë ÌË ·ÈÌ·ÙËÚ‹ ‰ÔÎÈÌ·Û›· Î·È Â¿Ó ÂӉ›ÎÓ˘Ù·È, Ô Î·Ú‰È·Îfi˜ ηıÂÙËÚÈ·ÛÌfi˜ Î·È Ë ·ÁÁÂÈÔÁÚ·Ê›· ÌÔÚ› Ó· ·Ôηχ„Ô˘Ó ÙËÓ ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ [20] Î·È Û ÛÙ¤ÓˆÛË ÌÂÁ·Ï‡ÙÂÚË ·fi 75% ÔÈ ıÂڷ¢ÙÈΤ˜ ÂÂÌ‚¿ÛÂȘ ÌÔÚÔ‡Ó Ó· ÂÚÈÏ¿‚Ô˘Ó Î·È ÙË Û˘Ì‚·ÙÈ΋ È·ÙÚÈ΋ ıÂڷ›· Î·È ÙËÓ Â·Ó·ÁÁ›ˆÛË.
3) ªÂÙ·ÌfiÛ¯Â˘ÛË Û ۯ¤ÛË Ì ÙËÓ Â͈ÓÂÊÚÈ΋ οı·ÚÛË °È· ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÒÓ Â›Ù و̷ÙÈ΋ ›Ù ·fi ˙ÒÓÙ· ‰fiÙË, Ë ÂÈ‚›ˆÛË Â›Ó·È Û˘Ó‹ıˆ˜ ÌÂÁ·Ï‡ÙÂÚË Î·È Ë ·ÔηٿÛÙ·ÛË Â›Ó·È ·Ú¿ Ôχ ηχÙÂÚË ·fi ÂΛÓË Ô˘ ·Ú·ÙËÚÂ›Ù·È Ì ÙË ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ [2,3,4], Ì ÙËÓ ·ÈÌÔοı·ÚÛË ‹ Ì ÙËÓ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË, ÛÙȘ Ôԛ˜ Ë 3-ÂÙ‹˜ Î·È Ë 5-ÂÙ‹˜ ÂÈ‚›ˆÛË Â›Ó·È ÂÚ›Ô˘ 50% Î·È 34%, ¯ˆÚ›˜ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÌÂıfi‰ˆÓ [21,22]. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ıˆÚÂ›Ù·È fiÙÈ ÚÔηٷϷ̂¿ÓÔÓÙ·È ·fi ‰È·ÊÔÚ¤˜ ÛÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ Î·È ÛÙ· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ÙÔ˘˜ ·ÓÙÈÌÂÙψÈ-
59
Û˘. ŒÙÛÈ ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÈϤ¯ıËÎ·Ó Ó· Ï¿‚Ô˘Ó ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â›Ó·È Û˘Ó‹ıˆ˜ ÓÂÒÙÂÚÔÈ, Â›Ó·È ÏÈÁfiÙÂÚÔ Èı·Ófi Ó· ÂÚÈÏËÊıÔ‡Ó ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË Ù‡Ô˘ 2, ÔÈ ÔÔ›ÔÈ Â›Ó·È Ù˘Èο ÌÂÁ·Ï‡ÙÂÚÔÈ Î·È ¤¯Ô˘Ó Û˘¯ÓfiÙÂÚ· ÎÏÈÓÈο ÂÌÊ·Ó‹ ·ıËÚÔÛÎÏ‹ÚˆÛË ‹ Â͈ÓÂÊÚÈ΋ ·ÁÁÂȷ΋ ¿ıËÛË [23,24]. O ÂÙ‹ÛÈÔ˜ Ú˘ıÌfi˜ ı·Ó¿ÙÔ˘ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ Â›Ó·È ÂÚ›Ô˘ ÙÔ 1/3 ÙÔ˘ Ú˘ıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú·Ì¤ÓˆÓ ÛÙËÓ ·ÈÌÔοı·ÚÛË, ÁÂÁÔÓfi˜ Ô˘ ›Ûˆ˜ Ó· ·ÓÙ·Ó·ÎÏ¿ ÙËÓ ÂÈÏÔÁ‹ Ó·ÚÒÙÂÚˆÓ Î·È ˘ÁȤÛÙÂÚˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË [25]. ™˘ÁÎÚ›ÓÔÓÙ·˜ fï˜ ÙȘ Èı·ÓfiÙËÙ˜ ÂÈ‚›ˆÛ˘ ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜, ·ÎfiÌ· Î·È ÛÙÔÓ Î·Ù¿ÏÔÁÔ ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ó¯›˙Ô˘Ó Ó· ¤¯Ô˘Ó ¤Ó· ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ıÓËÛÈÌfiÙËÙ·˜ (ÂÚ›Ô˘ 38% ÌÂÁ·Ï‡ÙÂÚÔ) ·fi ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÁÂÁÔÓfi˜ Ô˘ ·ÔÙÂÏ› ÈÛ¯˘Úfi ‰Â›ÎÙË fiÙÈ ÂÎÙfi˜ ·fi ÙË ÓÂÒÙÂÚË ËÏÈΛ·, ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÌÔÚ› Ó· Â›Ó·È Ï¤ÔÓ ÛËÌ·ÓÙÈÎÔ› ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ Ë ÓÔÛËÚfiÙËÙ¿ ÙÔ˘˜ ÌÔÚ› Ó· ÂËÚ·ÛÙ› ·fi ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ıÂڷ›· [25,26]. ∂Ó·˜ ¿ÏÏÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ Û˘ÓÂÈÛʤÚÂÈ ÛÙËÓ Î·Ï‡ÙÂÚË ¤Î‚·ÛË Â›Ó·È Èı·ÓfiÓ Ë Î·Ï‡ÙÂÚË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ô˘ ·ÎÔÏÔ˘ı› ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ÔÔ›· ÌÔÚ› Ó· Â›Ó·È Ô Î‡ÚÈÔ˜ ÏfiÁÔ˜ ÁÈ· ÙËÓ Èı·Ó‹ ·Ó·ÛÙÔÏ‹ ‹ ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ÚÔfi‰Ô˘ Ù˘ ‰È·‚ËÙÈ΋˜ ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·˜. ŒÙÛÈ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ù· ›‰· ÙˆÓ ÁÏ˘ÎÔ˙˘ÏÈˆÌ¤ÓˆÓ ÚÔ˚fiÓÙˆÓ (AGEs), ÌÂÈÒÓÔÓÙ·È Ì¤Û· Û 8 ÒÚ˜ ÌÂÙ¿ ·fi ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·Ú·Ì¤ÓÔ˘Ó Ì¤Û· ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· ÁÈ· Ì·ÎÚÈ¿ ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô [27]. ∂›Û˘ Ë ‰˘Ó·ÙfiÙËÙ· ·ÓÂÌÊ¿ÓÈÛ˘ Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÌÂÈÒÓÂÙ·È Û ÏÈÁfiÙÂÚÔ ·fi 5% ÛÙ· ÓÂÊÚÈο ·ÏÏÔÌÔۯ‡̷ٷ [28].
4) ∂ÈÏÔΤ˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË OÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ‰È·Ê¤ÚÔ˘Ó fiÛÔÓ ·ÊÔÚ¿ ÛÙȘ ÂÈÏÔΤ˜ Ô˘ Â›Ó·È ‰˘Ó·Ùfi Ó· Û˘Ì‚Ô‡Ó ÌÂÙ¿ ÙËÓ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™˘ÁÎÂÎÚÈ̤ӷ ÔÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ Î·È Ô˘ÚÔÏÔÁÈΤ˜ ÂÈÏÔΤ˜ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ·ÚfiÌÔȘ ·˘ÙÒÓ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. πÛÔ‰‡Ó·ÌÔ˜ Â›Ó·È Î·È Ô Î›Ó‰˘ÓÔ˜ ÁÈ· Ô˘ÚÔÏÔÈÌÒÍÂȘ, ÔÈ Ôԛ˜ ÂÌÊ·Ó›˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÙÔ˘˜ ÚÒ-
60
¶.™. ¶A™A¢AKH™
ÙÔ˘˜ Ì‹Ó˜, ÂÓÒ ÔÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ Ì ÁÓˆÛÙ‹ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·ÛÙˆ˜ ›Ûˆ˜ Ó· ¯ÚÂÈ·ÛÙÔ‡Ó ÙËÓ ‚Ô‹ıÂÈ· ·˘ÙÔηıÂÙËÚÈ·ÛÌÒÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÏ·ÙÙˆı› Ô Î›Ó‰˘ÓÔ˜ ÙˆÓ ˘ÔÙÚÔÒÓ. ∂›Û˘ Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ¢ηÈÚȷΤ˜ ÏÔÈÌÒÍÂȘ ÂÎ Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜, Ì ÔÚÁ·ÓÈÛÌÔ‡˜ fiˆ˜ Ë Pneumocystis carinii, Ô Aspergillus, Ô Î˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜, Ô ·ÏÔ‡˜ ¤Ú˘, ‰ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜.
·) ÀÔÙÚÔ‹ Ù˘ ‰È·‚ËÙÈ΋˜ ÓfiÛÔ˘ ÛÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ÓÂÊÚfi ∏ ˘ÔÙÚÔ‹ Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÛÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ÓÂÊÚfi ¯·Ú·ÎÙËÚ›˙ÂÙ·È Î·ÓÔÓÈο ·fi ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·ÚfiÌÔÈ· Ì ÙȘ ‚Ï¿‚˜ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÛÙËÓ ÚˆÙÔ·ı‹ ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ·, ÂÓÒ ÔÈ Ô˙Ò‰ÂȘ ·ÏÏÔÈÒÛÂȘ Ô˘ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ Ù˘ ‰È·‚ËÙÈ΋˜ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘, Û¿ÓÈ· ·ӷϷ̂¿ÓÔÓÙ·È ÛÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ÓÂÊÚfi [29]. ™Ù· ÚÒÈÌ· Â˘Ú‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ·‡ÍËÛË ÙÔ˘ ÌÂÛ·ÁÁ›Ԣ Î·È Ë ¿¯˘ÓÛË Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘, Ô˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Û 2 ¤ÙË, ÂÓÒ Ë ˘·ÏÈÓÔÔ›ËÛË ÙÔ˘ ··ÁˆÁÔ‡ Î·È ÚÔÛ·ÁˆÁÔ‡ ·ÚÙËÚÈÔÏ›Ô˘, ÌÔÚÔ‡Ó Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ·ÚÁfiÙÂÚ·, ÛÙ· 4 ¤ÙË [29,30]. ∞Ó Î·È ÙÔ ÎÔÈÓfi ÎÏÈÓÈÎfi ÈÛÔ‰‡Ó·ÌÔ Ù˘ ˘ÔÙÚÔÈ¿˙Ô˘Û·˜ ¢¡ Â›Ó·È Ë ÚˆÙÂ˚ÓÔ˘Ú›·, Ë ·Ó¿Ù˘ÍË ÛÙ· ÓÂÊÚÈο ÌÔۯ‡̷ٷ ÚˆÙÂ˚ÓÔ˘Ú›·˜ ÓÂÊÚˆÛÈÎÔ‡ Ù‡Ô˘ Û˘Óԉ‡ÂÙ·È ·fi η΋ ÚfiÁÓˆÛË [31]. ∏ ÂÌÊ¿ÓÈÛË ¢¡ ÛÙ· ÌÔۯ‡̷ٷ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û¯Â‰fiÓ Û fiÏÔ˘˜ ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¯ˆÚ›˜ Û˘ÓÔ‰fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ‹ ÓËÛȉ›ˆÓ, ÒÛÙ ӷ ·Ô‰›‰ÂÙ·È Èı·ÓfiÓ ÛÙÔ Â›Â‰Ô ÙÔ˘ ÁÏ˘Î·ÈÌÈÎÔ‡ ÂϤÁ¯Ô˘ ‹/Î·È ÙËÓ ·Ó¿ÚÎÂÈ· Ù˘ ÈÓÛÔ˘Ï›Ó˘, ·Ú¿ÁÔÓÙ˜ Ô˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È Î·ıÔÚÈÛÙÈÎÔ› ÛÙËÓ Â·ÓÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘. ∞ÓÙ›ıÂÙ· Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ‹ ÙËÓ ÂÓÙ·ÙÈ΋ ÈÓÛÔ˘ÏÈÓÔıÂڷ›·, Ë ·Ú·ÙÂٷ̤ÓË ‰È·Ù‹ÚËÛË Ù˘ ¢ÁÏ˘Î·ÈÌ›·˜ Ê·›ÓÂÙ·È fiÙÈ ·¤ÙÚ„ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ÛÂÈÚ·Ì·ÙÈÎÒÓ Î·È ·ÚÙËÚȉȷÎÒÓ ‰È·‚ËÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ [32,33]. ∂ÈÚfiÛıÂÙ· Ë ÂÌÊ¿ÓÈÛË ÁÈ· ÚÒÙË ÊÔÚ¿ (de novo) ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ·ÔÙÚ¤ÂÙ·È Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜.
‚) ∂ÌÊ¿ÓÈÛË ‰È·‚‹ÙË ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ™‡Ìʈӷ Ì ٷ ÚfiÛÊ·Ù· ÛÙÔȯ›· USRDS Ë
Û˘¯ÓfiÙËÙ· Ù˘ Ó¤·˜ ÂÌÊ¿ÓÈÛ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ÌÂÙ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (ªª™¢) Â›Ó·È Ôχ ˘„ËÏ‹, ȉȷ›ÙÂÚ· ÛÙÔ˘˜ ÚÒÙÔ˘˜ ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË [1]. ∏ ËÏÈΛ· Â›Ó·È Ô ÈÛ¯˘ÚfiÙÂÚÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ªª™¢, ÒÛÙ Û ËÏÈΛ· ·ÛıÂÓÒÓ > 65 ÂÙÒÓ Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ªª™¢ Ó· Â›Ó·È ‰˘fiÌÈÛÈ ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi ·˘ÙfiÓ ÛÙ· ¿ÙÔÌ· 18–34 ÂÙÒÓ. ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË Ì·‡ÚË Ê˘Ï‹, ÙË ‰fiÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ÛÙÂÚÔÂȉÒÓ Î·È ÙȘ ˘„ËϤ˜ ‰fiÛÂȘ ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ calcineurin. ∫·Ù¿ Û˘Ó¤ÂÈ· fiÔ˘ Â›Ó·È ‰˘Ó·ÙfiÓ, ÛÙ·ıÌ›˙ÔÓÙ·˜ ¿ÓÙÔÙ ÙËÓ Èı·ÓfiÙËÙ· Î·È ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ·fiÚÚȄ˘, ÔÈ ‰fiÛÂȘ ÙˆÓ ÛÙÂÚÔÂȉÒÓ (Î·È ÛÙÔÓ ‰È·‚‹ÙË Ù‡Ô˘ 2, ÔÈ ‰fiÛÂȘ ÙÔ˘ tacrolimus) Ú¤ÂÈ Ó· ÂÏ·¯ÈÛÙÔÔÈËıÔ‡Ó. ªÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ªª™¢ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ‰È¢ıÂÙËıÔ‡Ó Ì ÙËÓ ÂÍÂȉÈÎÂ˘Ì¤ÓË ÂÓ‰ÔÎÚÈÓÔÏÔÁÈ΋ ÊÚÔÓÙ›‰·, ÙËÓ ÙÚÔÔÔ›ËÛË ÙÔ˘ ÙÚfiÔ˘ ˙ˆ‹˜ Î·È ÙËÓ ÙÚÔÔÔ›ËÛË ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ.
Á) ∫·Ú‰È·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ™ÙÔ˘˜ ˘Ô‚·ÏÏfiÌÂÓÔ˘˜ Û ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ 40% ÙˆÓ ı·Ó¿ÙˆÓ ·Ô‰›‰ÔÓÙ·È ÛÙ· ηډȷÁÁÂȷο Û˘Ì‚¿Ì·Ù·, fiˆ˜ ÙÔ ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È Ù· ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È· [34]. O ۷ί·Ú҉˘ ‰È·‚‹Ù˘ ·ÔÙÂÏ› ¤Ó· ·fi ÙÔ˘˜ ÛËÌ·ÓÙÈÎfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ù· Û˘Ì‚¿Ì·Ù· ·˘Ù¿ [35], ·fi Ù· ÔÔ›· Ù· ÂÌÊÚ¿ÁÌ·Ù· ÙÔ˘ Ì˘Ôηډ›Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ 14-22% Î·È Ù· ·ÁÁÂÈÔÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È· ÛÙÔ 19% ÙˆÓ ·ÛıÂÓÒÓ [36]. OÛÔÓ ·ÊÔÚ¿ ÛÙȘ ÂÈÏÔΤ˜ Ù˘ ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈÔ¿ıÂÈ·˜ Ô˘ Ô‰ËÁÔ‡Ó ÛÙÔÓ ·ÎÚˆÙËÚÈ·ÛÌfi, ¤¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ 13-25% Î·È ·ÔÙÂÏÔ‡Ó ÙÔ Ï¤ÔÓ Û˘¯Ófi ‰˘ÛÌÂÓ¤˜ ÁÂÁÔÓfi˜ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ ‰È·‚ËÙÈÎÔ› Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤¯Ô˘Ó 3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ· Û˘Ì‚¿Ì·Ù· Û¯ÂÙÈο Ì ÙȘ ÈÛ¯·ÈÌÈΤ˜ ηډȷΤ˜ ·ı‹ÛÂȘ ·fi fiÙÈ Ô ÁÂÓÈÎfi˜ ÏËı˘ÛÌfi˜ [37], ÂÓÒ ÔÈ Á˘Ó·›Î˜ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ Ê·›ÓÂÙ·È Ó· ‰È·ÙÚ¤¯Ô˘Ó ȉȷ›ÙÂÚ· ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ. ∞ÏÏÔÈ ·Ú·‰ÔÛÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙȘ ÈÛ¯·ÈÌÈΤ˜ ηډȷΤ˜ ·ı‹ÛÂȘ, fiˆ˜ Â›Ó·È Ë ËÏÈΛ·, Ë ˘¤ÚÙ·ÛË, ÙÔ Î¿ÓÈÛÌ·, Ë ˘ÂÚ¯ÔÏÂÛÙÂÚÔÏ·ÈÌ›· Î·È Ë ·¯˘Û·ÚΛ·, ÌÔÚÔ‡Ó Â›Û˘ Ó· Â›Ó·È ·ÚfiÓÙ· Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜, Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔ ÁÂÓÈÎfi ΛӉ˘Ófi ÙÔ˘˜. ∞‡ÍËÛË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚÔ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ηÏÔ‡Ó Â›Û˘ ·Ú¿ÁÔÓÙ˜ ÔÈ ÔÔ›ÔÈ Û˘Ó‰¤ÔÓÙ·È Ì ÙËÓ ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Î·È ÙËÓ ıÂڷ›· ·ÈÌÔοı·ÚÛ˘ Î·È ÚÔ˘¿Ú¯Ô˘Ó Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, fiˆ˜ Â›Ó·È Ë ˘ÂÚÙÚÔÊ›· Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜ (LVH) ÏfiÁˆ Ù˘ ¯ÚfiÓÈ·˜ ˘ÂÚÊfiÚÙˆÛ˘ fiÁÎÔ˘, Ë ÔÍ›‰ˆÛË ÙˆÓ ÏÈȉ›ˆÓ, ÔÈ ·ÁÁÂȷΤ˜ ·ÔÙÈÙ·ÓÒÛÂȘ ÏfiÁˆ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ Î·È ÙÔ˘ ʈÛÊfiÚÔ˘, Ë ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· Î·È Ë ·‡ÍËÛË ÙÔ˘ ıÚÔÌ‚ÔÁÂÓÂÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, [38,39]. ™ËÌÂÈÒÓÂÙ·È Â‰Ò fiÙÈ ÌÂÚÈÎÔ› ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ‡˜, fiˆ˜ Ë ˘ÂÚÊfiÚÙˆÛË fiÁÎÔ˘ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÛÙÔ ·Û‚¤ÛÙÈÔ Î·È ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ʈÛÊfiÚÔ˘, ÌÔÚÔ‡Ó Ó· ‚ÂÏÙȈıÔ‡Ó ÌÂÙ¿ ·fi ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞ÓÙ›ıÂÙ·, Ë ¯Ú‹ÛË ÛÙÂÚÔÂȉÒÓ Î·È ÙˆÓ ·Ó·ÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ù˘ calcineurin (cyclosporine Î·È tacrolimus) ÁÈ· ÙËÓ Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÌÔÚÔ‡Ó Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ‰È·Ù‹ÚËÛË-ÂÌÌÔÓ‹ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÛÙ· ÏÈ›‰È·. ∂›Û˘ Û ÂÚ›ÙˆÛË ÌÂȈ̤Ó˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ù· Ù˘¯fiÓ ˘„ËÏ¿ ›‰· homocysteine ÌÔÚÔ‡Ó Ó· Û˘Ó¯›ÛÔ˘Ó Ó· Â›Ó·È ·ÚfiÓÙ· [40]. Ÿˆ˜ Â›Ó·È ·Ó·ÌÂÓfiÌÂÓÔ, ÔÈ ·ÛıÂÓ›˜ Ì ÚÔ¸¿Ú¯Ô˘Û· ·ÁÁÂÈÔ¿ıÂÈ· ‰È·ÙÚ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. O Manske [41] ¤‰ÂÈÍ fiÙÈ ÔÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ ˘Ô„‹ÊÈÔÈ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ô˘ ·ÚÔ˘Û›·Û·Ó ÛÙÔ ·ÁÁÂÈÔÁÚ¿ÊËÌ· ÌÈ· ‹ ÂÚÈÛÛfiÙÂÚ˜ ÛÙÂÓÒÛÂȘ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ Ì ÛÙ¤ÓˆÛË ≥75% ›¯·Ó ÂÙ·Ï¿ÛÈÔ Î›Ó‰˘ÓÔ ·ÎÚˆÙËÚÈ·ÛÌÔ‡ Î·È ÙÂÙÚ·Ï¿ÛÈÔ Î›Ó‰˘ÓÔ Ì˘ÔηډȷÎÔ‡ ÂÌÊÚ¿ÁÌ·ÙÔ˜, ̤۷ Û 3 ¤ÙË ÌÂÙ¿ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.
‰) OÛÙÈ΋ ÓfiÛÔ˜ OÈ ‰È·‚ËÙÈÎÔ› Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ê·›ÓÔÓÙ·È Ó· ‰È·ÙÚ¤¯Ô˘Ó ȉȷ›ÙÂÚ· ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ Î·Ù·ÁÌ¿ÙˆÓ, ÁÂÁÔÓfi˜ Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙË ¯·ÌËÏ‹ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· ÎfiÎηψÓ, Ë ÔÔ›· ¤¯ÂÈ Â›ÙˆÛË Ì¤¯ÚÈ 40-49% [42, 43, 44]. O ™¢ ¤¯ÂÈ Û˘Ó‰Âı› Ì low bone turnover Î·È ÊÏÔÈÒ‰Ë ÔÛÙÂÔÂÓ›·, ÂÓÒ Ë ÔÛÙÈ΋ ·ÒÏÂÈ· ·Ô Ù· ÛÙÂÚÔÂȉ‹ ¤¯ÂÈ Â›ÙˆÛË ÛÙÔ ‰ÈÎÙ˘ˆÙfi ÔÛÙ›ÙË ÈÛÙfi. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Û ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯Ô˘Ó ‰Â›ÍÂÈ ÛÙ·ıÂÚÔÔ›ËÛË ‹ ·ÎfiÌ· Î·È ·‡ÍËÛË ÛÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· Ì ıÂڷ¢ÙÈΤ˜ ·ÁˆÁ¤˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÙË ‚ÈÙ·Ì›ÓË D Î·È ÙÔ ·Û‚¤ÛÙÈÔ Ì ‹ ¯ˆÚ›˜ ÙËÓ ¯Ú‹ÛË ‰ÈʈÛÊÔÓÈÎÒÓ [45], ¯ˆÚ›˜ Ó· Â›Ó·È ÁÓˆÛÙfi ·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ı· Â›Ó·È ·ÚfiÌÔÈ· ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜.
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5) Δ·˘Ùfi¯ÚÔÓË ªÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ÓÂÊÚÔ‡ (SPKT) ∏ Û‡Ó‰ÂÛË ÌÂٷ͇ Ù˘ ‚ÂÏÙ›ˆÛ˘ ÙÔ˘ ÁÏ˘Î·ÈÌÈÎÔ‡ ÂϤÁ¯Ô˘ Î·È Ù˘ Ì›ˆÛ˘ ÙˆÓ ‰Â˘ÙÂÚÔ·ıÒÓ ÂÈÏÔÎÒÓ ÙˆÓ ‰È·‚ËÙÈÎÒÓ, ÙÂÎÌËÚÈÒıËΠÙÔ 1993 ·fi ÙË ÌÂϤÙË Diabetes Control and Complications Trials (DCCT) [46]. ∂ÓÙÔ‡ÙÔȘ ·ÓÙ›ıÂÙ· ·fi ÙËÓ ÂÓÙ·ÙÈ΋ ıÂڷ›· Ì ÈÓÛÔ˘Ï›ÓË, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ·Ú·Ì¤ÓÂÈ Ë ÌfiÓË ıÂڷ›· ÁÈ· Ó· ÂÈÙ¢¯ı› Ì›· ÛÙ·ıÂÚ‹ ¢ÁÏ˘Î·ÈÌÈ΋ ηٿÛÙ·ÛË, ¯ˆÚ›˜ ÙȘ ··ÈÙ‹ÛÂȘ ÁÈ· ‰È·ÈÙËÙÈÎÔ‡˜ ÂÚÈÔÚÈÛÌÔ‡˜ Î·È ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ˘ÔÁÏ˘Î·ÈÌÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, ηٿÛÙ·ÛË ‰˘ÛÌÂÓ‹˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙËÓ ¯ÔÚ‹ÁËÛË ÔÏÏ·ÏÒÓ Î·ıËÌÂÚÈÓÒÓ ÂÁ¯‡ÛÂˆÓ ÈÓÛÔ˘Ï›Ó˘. ∂›Û˘ Ë Ù·˘Ùfi¯ÚÔÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÒÓ ÚÔÛʤÚÂÈ ÙÔ ÚfiÛıÂÙÔ fiÊÂÏÔ˜ Ù˘ Û¯ÂÙÈο Ê˘ÛÈÔÏÔÁÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ô˘ ÂÚÈÔÚ›˙ÂÈ ÙËÓ ·Ó¿ÁÎË ÁÈ· ˘ÔηٿÛÙ·ÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∫·Ù¿ Û˘Ó¤ÂÈ· Ë ÏÔÁÈ΋ ÁÈ· ÙËÓ Ù·˘Ùfi¯ÚÔÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜-ÓÂÊÚÔ‡ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, Â›Ó·È ‚·ÛÈṲ̂ÓË ÛÙÔ ÏÂÔÓ¤ÎÙËÌ· Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙË ¿ÌÂÛË ‰ÈfiÚıˆÛË ÙfiÛÔ Ù˘ ˘ÂÚÁÏ˘Î·ÈÌ›·˜ fiÛÔ Î·È Ù˘ Ô˘Ú·ÈÌ›·˜, ÂÓÒ Ê·›ÓÂÙ·È Èı·Ófi fiÙÈ Ë SPKT ÌÔÚ› Ó· ·ÓÙÈÛÙÚ¤„ÂÈ ÌÂÚÈΤ˜ ·fi ÙȘ ÔÏ˘Û˘ÛÙËÌ·ÙÈΤ˜ ÂÈÏÔΤ˜ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙË Ì·ÎÚfi¯ÚÔÓË Â›‰Ú·ÛË ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË [47,48,49]. ∞fi ÙÔ 1966, ÙÔ ¤ÙÔ˜ Ù˘ ÚÒÙ˘ ÂÈÙ˘¯Ô‡˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÁÎÚ¤·ÙÔ˜ Ô˘ ¤ÁÈÓ Ì ٷ˘Ùfi¯ÚÔÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ¿Óˆ ·fi ÙÔ 85% ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·ÁÎÚ¤·ÙÔ˜ Ô˘ ‰ÈÂÓÂÚÁ‹ıËÎ·Ó ·ÁÎÔÛÌ›ˆ˜, ‹Ù·Ó ÌÂÙ·ÌÔۯ‡ÛÂȘ ·ÁÎÚ¤·ÙÔ˜ÓÂÊÚÒÓ (SPKT). ΔÔ ¿ÁÎÚ·˜ ÚÔ¤Ú¯ÂÙ·È ·fi ¤Ó·Ó و̷ÙÈÎfi ‰fiÙË ÔÚÁ¿ÓˆÓ, ÂÓÒ ¤¯Ô˘Ó ÂÎÙÂÏÂÛı› ›Û˘ ›ÏÂÎÙ˜ ÂÚÈÙÒÛÂȘ ÌÂÙ·ÌÔۯ‡Ûˆ˜ ·ÁÎÚ¤·ÙÔ˜ ·fi ˙ÒÓÙ˜ ‰fiÙ˜. ¶ÂÚ›Ô˘ ÙÔ 10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÎÙÂÏÔ‡ÓÙ·È ÌÂÙ¿ ·fi ÌÈ· ÚÔËÁÔ˘Ì¤Óˆ˜ ÂÈÙ˘¯‹ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ηٿÛÙ·ÛË Ë ÔÔ›· ·Ó·Ê¤ÚÂÙ·È ˆ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ÌÂÙ¿ ·fi ÙÔ ÓÂÊÚfi (¶ª¡) (pancreas-after-kidney transplant, PAK), ÂÓÒ 5% ÂÎÙÂÏÔ‡ÓÙ·È ˆ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ÌfiÓÔ (PTA), Û ·ÛıÂÓ›˜ ÌË Ô˘Ú·ÈÌÈÎÔ‡˜ Ì ÚÔ‚ÏËÌ·ÙÈÎfi ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. ¶Ú¿ÁÌ·ÙÈ Ë Û˘Ó‰˘·Ṳ̂ÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡-·ÁÎÚ¤·ÙÔ˜ ÁÈ· ÙÔ˘˜ ÂÈÏÂÁ̤ÓÔ˘˜ ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË Ù‡Ô˘ 1 Î·È ¢¡ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ¤¯ÂÈ ÂÎÙÂÏÂÛı› ˆ˜ ηıÈÂڈ̤ÓË ÔÚÈÛÙÈ΋ ıÂڷ›· ·fi
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ÔÏÏ¿ ȉڇ̷ٷ, Ì fiÏÔ˘˜ ÙÔ˘˜ ·ÛÊ·ÏÈÛÙÈÎÔ‡˜ ÊÔÚ›˜ Ó· ηχÙÔ˘Ó Ô˘ÛÈ·ÛÙÈο ÙË ‰È·‰Èηۛ·. °È· ÙËÓ ·Ô‰Ô¯‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¶ª¡, Ù· È·ÙÚÈο ÎÚÈÙ‹ÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘Ó‹ıˆ˜ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ·) ·Ú΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ÓÂÊÚÔ‡, ‚) ‰È·‚‹Ù˘ Ù‡Ô˘ 1 Ì ·ÚÔ˘Û›· Û˘ÛÙËÌ·ÙÈÎÒÓ ÂÈÏÔÎÒÓ ÙÔ˘ ‰È·‚‹ÙË fiˆ˜, ·˘ÙfiÓÔÌË Ó¢ÚÔ¿ıÂÈ·, ÚÔԉ¢ÙÈ΋ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·, ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜, ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔ¿ıÂÈ·, ·ÔÙ˘¯›· ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ÂϤÁ¯Ô˘ ·Ú¿ ÙË Ì¤ÁÈÛÙË È·ÙÚÈ΋ ÊÚÔÓÙ›‰·, ‹ Ù¤ÏÔ˜ Ù· ·ӷϷ̂·ÓfiÌÂÓ· ÂÂÈÛfi‰È· Ù˘ ˘ÔÁÏ˘Î·ÈÌ›·˜, Û·ÛÌÒÓ ‹ ·ÒÏÂÈ·˜ Û˘Ó›‰ËÛ˘. ™ÙȘ 31 ¢ÂÎÂÌ‚Ú›Ô˘ ÙÔ˘ 2003, ÂÚÈÛÛfiÙÂÚ˜ ·fi 21.000 ÌÂÙ·ÌÔۯ‡ÛÂȘ ·ÁÎÚ¤·ÙÔ˜ ›¯·Ó ·Ó·ÊÂÚı› ÛÙÔ ‰ÈÂıÓ¤˜ registry ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÁÎÚ¤·ÙÔ˜ (IPTR, ÂÚÈÛÛfiÙÂÚ˜ ·fi 15.000 ÛÙȘ ∏¶∞ Î·È ¿Óˆ ·fi 5.000 ÂÎÙfi˜ ∏¶∞). Δ· ÛÙÔȯ›· ÙˆÓ ·ÌÂÚÈηÓÈÎÒÓ ÂÚÈÙÒÛÂˆÓ ·fi ÙÔ 1987 ˆ˜ ÙÔ 2003 ·ÚÔ˘Û›·Û·Ó ÚÔԉ¢ÙÈ΋ ‚ÂÏÙ›ˆÛË ÛÙËÓ ¤Î‚·ÛË (p<0.04), Ì ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÁÈ· 1 ¤ÙÔ˜ Ó· ·˘Í¿ÓÔ˘Ó ÛÙȘ ÂÚÈÙÒÛÂȘ SPK, PAK Î·È PTA ·ÓÙ›ÛÙÔȯ· ·fi 76% Û 85%, ·fi 57% Û 79%, Î·È ·fi 55% Û 76% [50,51]. ∂›Û˘ Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÁÈ· 1 ¤ÙÔ˜, ÙÔ˘ ·ÛıÂÓÔ‡˜, ÙÔ˘ ÓÂÊÚÔ‡ Î·È ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÁÈ· ÙÔ˘˜ ÂıÓÈÎÔ‡˜ Ï‹Ù˜ ÌÈ·˜ SPK ÌÂÙ·ÌfiÛ¯Â˘Û˘ Â›Ó·È 95%, 89%, Î·È 85%, ·ÓÙ›ÛÙÔȯ· [50]. ™‡Ìʈӷ Ì ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·ÁÎÚ¤·ÙÔ˜ ÂÎÙfi˜ ∏¶∞, Ë ÌÂÁ¿ÏË ÏÂÈÔ„ËÊ›· ‹Ù·Ó ÛÙËÓ Î·ÙËÁÔÚ›· SPK (n = 2.163 ÁÈ· ÙÔ 1996-2002), Ì ٷ ÔÛÔÛÙ¿ ÂÓfi˜ ¤ÙÔ˘˜ ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ, ÓÂÊÚÒÓ Î·È ·ÁÎÚ¤·ÙÔ˜ 96%, 91% Î·È 85% ÙÔ ›‰ÈÔ Î·Ï¿ ‹ Î·È Î·Ï‡ÙÂÚ· ·fi ÙȘ Â΂¿ÛÂȘ ÙˆÓ ·ÌÂÚÈηÓÈÎÒÓ ÂÚÈÙÒÛˆÓ. ∫·Ù¿ Û˘Ó¤ÂÈ·, ÙÔ ‰È¿ÛÙËÌ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ 1996-2002 Ì ÙË Û‡Á¯ÚÔÓË ·ÓÔÛÔηٷÛÙÔÏ‹ (TAC + MMF ÁÈ· ÙË Û˘ÓÙ‹ÚËÛË), Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÌÔۯ‡̷ÙÔ˜ ·ÁÎÚ¤·ÙÔ˜ ‹Ù·Ó ≥ 80% Û ¤Ó· ¤ÙÔ˜ Û fiϘ ÙȘ ηÙËÁÔڛ˜ ÏËÙÒÓ (SPK, PAK, PΔ∞). ∞˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÚÔÛı‹ÎË ÙÔ˘ ¿ÁÎÚ·ÙÔ˜ ‚ÂÏÙÈÒÓÂÈ ÙË Ì·ÎÚÔÚfiıÂÛÌË ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ¤Ó·ÓÙÈ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ÏËÙÒÓ ÂÓfi˜ ÓÂÊÚÔ‡ ÌfiÓÔ (TKA). ªÂ ÙËÓ ·˘Í·ÓfiÌÂÓË ‰È·ıÂÛÈÌfiÙËÙ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ˆ˜ ıÂڷ›·˜ ÂÈÏÔÁ‹˜ ÁÈ· ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, Â›Ó·È ÎÚ›ÛÈÌÔ Ó· ‰›ÓÂÙ·È ÚÔÛÔ¯‹ ÛÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜. OÈ Î·Ï‡ÙÂÚÔÈ ˘Ô„‹ÊÈÔÈ ÁÈ· ÙË ‰È·-
‰Èηۛ· SKPT Â›Ó·È ÓÂÒÙÂÚÔÈ ·ÛıÂÓ›˜ (ÌÂٷ͇ 20-50 ÂÙÒÓ) Ì ÂÈΛÌÂÓË ‹ ÂÁηÙÂÛÙË̤ÓË ÓÂÊÚÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, ȉȷ›ÙÂÚ· ÂΛÓÔÈ Ì ÙȘ ÂӉ¯Ô̤ӈ˜ ·Ó·ÛÙÚ¤„È̘ ‰È·‚ËÙÈΤ˜ ÂÚÈÏÔΤ˜ [52]. ∞˘ÙÔ› ÔÈ Ï‹Ù˜ Ú¤ÂÈ Ó· Â›Ó·È Â›Û˘ ÂχıÂÚÔÈ ·fi ÛËÌ·ÓÙÈ΋ ηډȷÁÁÂȷ΋ Û˘ÓÔ‰fi ÓÔÛËÚfiÙËÙ· ÁÈ· Ó· ·Ó¯ÙÔ‡Ó ÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi Î·È ÙÔ ÌÂÙ· ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË stress.
6) ªÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ·ÙÈÎÒÓ ÓËÛȉ›ˆÓ (PIT) ∞ÔÙÂÏ› ÌÈ· ÂÓ·ÏÏ·ÎÙÈ΋ Ó¤· ıÂڷ›· Ô˘ ÌÔÚ› ›Û˘ Ó· ‚ÂÏÙÈÒÛÂÈ ÙÔ ‰È·‚‹ÙË, Ë ÔÔ›· ÁÂÓÈο ÂÚÈÔÚ›˙ÂÙ·È ÛÙ· ¿ÙÔÌ· ¯ˆÚ›˜ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Ì Ôχ ·ÛÙ·ı‹ ‰È·‚‹ÙË. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î˘ÙÙ¿ÚˆÓ ÓËÛȉ›ˆÓ [53] ÚÔÛʤÚÂÈ ÙÔ ÏÂÔÓ¤ÎÙËÌ· Ù˘ ÂÎÙ¤ÏÂÛ˘ ÌÈ·˜ ÂÏ¿¯ÈÛÙ· ·ÈÌ·ÙËÚ‹˜ ‰È·‰Èηۛ·˜, ÛÙËÓ ÔÔ›· Ù· ÓËÛ›‰È· ÌÔÚÔ‡Ó Ó· ‰ÔıÔ‡Ó ‰È·‰ÂÚÌÈο ÛÙÔ ‹·Ú ̤ۈ Ù˘ ˘Ï·›·˜ ÊϤ‚·˜. ∞fi ÙÔÓ πÔ‡ÓÈÔ ÙÔ˘ 2003, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ·ÁÎÔÛÌ›ˆ˜ 705 ·ÁÎÚ·ÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓËÛȉ›ˆÓ (ITR) [54]. ∏ ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÔȯ›ˆÓ ¤‰ÂÈÍ ÂÓfi˜ ¤ÙÔ˘˜ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Û ÔÛÔÛÙfi 97%, Ì ¤Ó· ÏÂÈÙÔ˘ÚÁfiÓ ÌfiÛ¯Â˘Ì· ÓËÛȉ›ˆÓ ÛÙÔ 54% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÂÓÒ Ë ·ÓÂÍ·ÚÙËÛ›· ÈÓÛÔ˘Ï›Ó˘ ÂÈÙ‡¯ıËΠ۠20% ÙˆÓ ·ÛıÂÓÒÓ. ΔÔ ÙÂÏÂ˘Ù·›Ô ÔÛÔÛÙfi ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο Êı¿ÓÔÓÙ·˜ Û ¤Ó· Â›Â‰Ô 50-80%, Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÂÓfi˜ Ó¤Ô˘ ÚˆÙÔÎfiÏÏÔ˘, ÁÈ· ÙËÓ ÂÈÙ˘¯‹ ‰È·Ù‹ÚËÛË ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ÓËÛȉ›ˆÓ, Ì ÙËÓ ¯ÚËÛÈÌÔÔ›ËÛË ÓËÛȉ›ˆÓ ·fi ‰‡Ô ‰fiÙ˜ ÔÚÁ¿ÓˆÓ ·Ú¿ÏÏËÏ· Ì ¤Ó· Ó¤Ô ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Û¯‹Ì· ¯ˆÚ›˜ ÛÙÂÚÔÂȉ‹ (Û˘Ó‰˘·ÛÌfi˜ ÂÓfi˜ ·ÓÙ·ÁˆÓÈÛÙÔ‡ ˘Ô‰Ô¯¤ˆÓ IL-2, ·ÔÙÂÏÂÛÌ·ÙÈÎÔ‡ ÛÙËÓ ÂÚ›Ô‰Ô Â·ÁˆÁ‹˜ Î·È Û˘ÓÙ‹ÚËÛË Ì Sirolimus (Rapamycin) Î·È Tacrolimus (FK506), ÙÔ˘˜ Δ-΢ÙÙ·ÚÈÎÔ‡˜ ·Ó·ÛÙ·ÏÙ¤˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘Ó‹ıˆ˜ Û ¿ÏϘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÛÙÂÚÂÒÓ ÔÚÁ¿ÓˆÓ, ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η ¯ˆÚ›˜ Ù· ‰È·‚ËÙÔÁfiÓ· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÁÏ˘ÎÔÎÔÚÙÈÎÔÂȉÒÓ Î·È Ù˘ cyclosporine) [55]. ∞ÎfiÌË Î·È ÂÏÏ›„ÂÈ Ù˘ Ï‹ÚÔ˘˜ ·ÓÂÍ·ÚÙËÛ›·˜ Û ÈÓÛÔ˘Ï›ÓË, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ ¤¯ÂÈ Ê·Ó› ›Û˘ Ó· Ô‰ËÁ› ÛÙȘ ‰Ú·Ì·ÙÈΤ˜ ‚ÂÏÙÈÒÛÂȘ ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ ¤Ï¤Á¯Ô˘, ÌÂÈÒÓÔÓÙ·˜ ÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ÂÈÏÔÎÒÓ. Δ¤ÏÔ˜, Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÏ΢ÛÙÈ΋ Ë ¤ÓÓÔÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ΢ÙÙ¿ÚˆÓ ÓËÛȉ›ˆÓ ‹ ÌÂÙ·ÌfiÛ¯Â˘Û˘ stem cell, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÚÔÛʤÚÂÈ ÔÏ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ϥ˜ ÚÔÔÙÈΤ˜, fiˆ˜ Â›Ó·È Ë ‰˘Ó·ÙfiÙËÙ· ÁÈ· ·ÂÚÈfiÚÈÛÙË ¯Ú‹ÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÓËÛȉ›ˆÓ Î·È Ë ‰˘Ó·ÙfiÙËÙ· ÁÈ· ·ÙÙ·Ú· ÓËÛȉ›ˆÓ ‹ stem cell Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ¯ˆÚ›˜ ÈÛfi‚È· ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂڷ›· ÙÔ˘ Ï‹ÙË [54].
μÈ‚ÏÈÔÁÚ·Ê›· [1] U.S. Renal Data System, USRDS 2003 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2003. [2]. Khauli RB, Steinmuller DR, Novick AC, Buszta C, Goormastic M, Nakamoto S, Vidt DG, Magnusson M, Paganini E, Schreiber MJ.A critical look at survival of diabetics with end-stage renal disease. Transplantation versus dialysis therapy. Transplantation. 1986;41(5): 598-602. [3]. Grenfell, A, Bewick, M, Snowden, S, et al. Renal replacement for diabetic patients: Experience at King’s College Hospital 1980-1989. Q J Med 1992; 85:861. [4]. Markell MS, Friedman EA. Care of the diabetic patient with end-stage renal disease. Semin Nephrol. 1990;10(3):274-86. [5]. Najarian JS, Sutherland DE, Simmons RL, Howard RJ, Kjellstrand CM, Mauer SM, Kennedy W, Ramsay R, Barbosa J, Goetz FC. Kidney transplantation for the uremic diabetic patient. Surg Gynecol Obstet. 1977 May;144(5):682-90. [6]. Bohman SO, Tyden G, Wilczek H, Lundgren G, Jaremko G, Gunnarsson R, Ostman J, Groth CG. Prevention of kidney graft diabetic nephropathy by pancreas transplantation in man. Diabetes. 1985; 34(3): 306-8 [7]. Mauer SM, Steffes MW, Connett J, Najarian JS, Sutherland DE, Barbosa J. The development of lesions in the glomerular basement membrane and mesangium after transplantation of normal kidneys to diabetic patients. Diabetes. 1983;32(10):948-52. [8]. Gruessner AC, Sutherland DE.Analyses of pancreas transplant outcomes for United States cases reported to the United Network for Organ Sharing (UNOS) and non-US cases reported to the International Pancreas Transplant Registry (IPTR).Clin Transpl. 1999; 51-69. [9]. Schiel R, Heinrich S, Steiner T, Ott U, Stein G.Longterm prognosis of patients after kidney transplantation: a comparison of those with or without diabetes mellitus. Nephrol Dial Transplant. 2005;20(3):611-7. [10]. Villar E., Rabilloud M, Berthoux F, Vialtel P, Labeeuw M and Pouteil-Noble C A multicentre study of registration on renal transplantation waiting list of the elderly and patients with type 2 diabetes Nephrol Dial Transplant; 2004: 19: 207-14. [11]. Ojo, A. The scientific registry of transplant recipients http:// www. ustransplant. org, accessed May, 2004. [12]. United States Renal Data System. Excerpts from the
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prevalence in kidney-pancreas allograft recipients, J Am Soc Nephrol 1998;9: 677-83. [44]. Smets Y, van der PijI J, de Fijter J et al. Low bone mass and high incidence of fractures after successful simultaneous pancreas-kidney transplantation. Nephrol Dial Transplant 1998; 13: 1250-5. [45]. Moe S. The treatment of steroid induced bone loss. Curr Opin Nephrol Hypertens 1997; 6: 544-9. [46]. The Diabetes Control and Complications Trial Research Group.The effect of intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus.N Engl J Med. 1993 Sep 30;329(14):977-86 [47]. Gaber AO, el-Gebely S, Sugathan P, Elmer DS, Hathaway DK, McCully RB, Shokouh-Amiri MH, Burlew BS. Early improvement in cardiac function occurs for pancreas-kidney but not diabetic kidney-alone transplant recipients. Transplantation. 1995 Apr 27;59(8):1105-12. [48]. Hathaway DK, Abell T, Cardoso S, Hartwig MS, el Gebely S, Gaber AO. Improvement in autonomic and gastric function following pancreas-kidney versus kidneyalone transplantation and the correlation with quality of life. Transplantation. 1994 Mar 27;57(6): 816-22. [49]. Sutherland DE, Dunn DL, Goetz FC, Kennedy W, Ramsay RC, Steffes MW, Mauer SM, Gruessner R, Moudry-Munns KC, Morel P, et al.A 10-year experience with 290 pancreas transplants at a single institution. Ann Surg. 1989 Sep;210(3):274-85; discussion 285-8. [50]. Gruessner AC, Sutherland DE. Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of October 2002. Clin Transpl. 2002;41-77. [51]. Gruessner AC, Sutherland DE.Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of May 2003. [52]. Sollinger HW. Current status of simultaneous pancreas-kidney transplantation. Transplant Proc. 1994 Apr; 26(2):375-8 [53]. Rother, KI, Harlan, DM. Challenges facing islet transplantation for the treatment of type 1 diabetes mellitus. J Clin Invest 2004; 114:877. [54]. Bretzel RG, Eckhard M, Brendel MD. Pancreatic islet and stem cell transplantation: new strategies in cell therapy of diabetes mellitus. Panminerva Med. 2004 Mar;46(1):25-42. [55]. Shapiro AM, Lakey JR, Ryan EA, Korbutt GS, Toth E, Warnock GL, Kneteman NM, Rajotte RV. Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med. 2000 Jul 27;343(4):289-90.
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3
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ÊÚÈ΋ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›· Ì ·‡ÍËÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜.
∏ ȉ·ÓÈ΋ ‰È·ÁÓˆÛÙÈ΋ Ù·ÍÈÓfiÌËÛË ÙˆÓ ·ÏÏÔÈÒÛÂˆÓ Ù˘ ‚ÈÔ„›·˜ ÌÔۯ‡̷ÙÔ˜ ı· Ú¤ÂÈ Ó· ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ·, Ó· ¤¯ÂÈ ıÂڷ¢ÙÈ΋ ÂÊ·ÚÌÔÁ‹ Î·È Ó· Â›Ó·È ·Ó··Ú·ÁÒÁÈÌË. ΔÔ ·Ú¯ÈÎfi Û‡ÛÙËÌ· Ù·ÍÈÓfiÌËÛ˘ Banff 1993 ÁÈ· ÙȘ ·ÏÏÔÈÒÛÂȘ Ù˘ ‚ÈÔ„›·˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤¯ÂÈ ˘ÔÛÙ› ̤¯ÚÈ Û‹ÌÂÚ· ÛÂÈÚ¿ ·Ó·ıˆڋÛÂˆÓ Î·È ÙÚÔÔÔÈ‹ÛˆÓ. OÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ‹Ù·Ó ·˘Ù¤˜ ÙÔ˘ 1999, ÛÙËÓ ÔÔ›· ‰È·¯ˆÚ›ÛÙËÎÂ Ë Î·ÙËÁÔÚ›· Ù˘ ÂÓ‰·ÚÙËÚ›Ùȉ·˜, ÙÔ˘ 2003, ÛÙËÓ ÔÔ›· ÚÔÛÙ¤ıËÎÂ Ë ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë Î·È Ë ÙÂÏÂ˘Ù·›·, ÙÔ˘ 2005, ÛÙËÓ ÔÔ›· ·Ó·ÁÓˆÚ›ÛÙËÎÂ Ë ÔÓÙfiÙËÙ· Ù˘ ¯ÚfiÓÈ·˜ ÂÓÂÚÁÔ‡ ·ÓÙÈۈ̷ÙÈ΋˜ ·fiÚÚȄ˘ Î·È ÂÍ·Ï›ÊıËÎÂ Ô ·Û·Ê‹˜ fiÚÔ˜ «¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜».
¶›Ó·Î·˜ 1. Δ‡ÔÈ ÔÍ›·˜ Δ Î˘ÙÙ·ÚÈ΋˜ ·fiÚÚȄ˘ Banff 2003-2005. Δ‡Ô˜ π
∞: μ:
i2 ‹ i3 ÌÂ t2 i2 ‹ i3 ÌÂ t3
Δ‡Ô˜ ππ
∞: μ:
v1 v2
Δ‡Ô˜ πππ
:
v3
⁄ÔÙË / ÔÚȷ΋: v0, ÔÔÈÔ‰‹ÔÙ t, i0 ‹ i1
¶›Ó·Î·˜ 2. μ·ıÌÔÏÔÁÈΤ˜ ηÙËÁÔڛ˜ ·ÏÏÔÈÒÛÂˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ Banff 2003-2005 ¢È¿ÌÂÛË ‰È‹ıËÛË % ÙÔ˘ ÊÏÔÈÔ‡
OÍ›· Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë ™ÙÔ Û‡ÛÙËÌ· Banff 2005 ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ÙÚÂȘ ·ÚȘ ηÙËÁÔڛ˜ ÔÍ›·˜ Δ Î˘ÙÙ·ÚÈ΋˜ ·fiÚÚȄ˘ (¶›Ó·Î·˜ 1). μ·ıÌÔÏÔÁÔ‡ÓÙ·È ÔÈ ÌÂÌÔӈ̤Ó˜ ÈÛÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ù˘ ‚ÈÔ„›·˜ Ì ÙÔ ÎÔÈÓfi ÌÈÎÚÔÛÎfiÈÔ Î·È ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ Ù·ÍÈÓfiÌËÛË Ù˘ ·fiÚÚȄ˘ (¶›Ó·Î·˜ 2). °È· ÙËÓ ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ Δ Î˘ÙÙ·ÚÈ΋˜ ·fiÚÚȄ˘ (OΔ∫∞) ÔÈ ‰ÈËı‹ÛÂȘ ÛÙÔÓ ‰È¿ÌÂÛÔ ÈÛÙfi ı· Ú¤ÂÈ Ó· ÍÂÂÚÓÔ‡Ó ÙÔ 25% Ù˘ ‚ÈÔ„È΋˜ ¤ÎÙ·Û˘ Î·È Ó· Û˘Ó˘¿Ú¯ÂÈ ÛˆÏËÓ·Ú›Ùȉ·. ¶ÂÚÈÙÒÛÂȘ Ì ‰È¿ÌÂÛË ‰È‹ıËÛË ÌÈÎÚfiÙÂÚË ÙÔ˘ 25% Ù·ÍÈÓÔÌÔ‡ÓÙ·È ÛÙȘ ÔÚȷΤ˜/ ‡ÔÙ˜ ÁÈ· OΔ∫∞, ÂÓÒ ·˘Ù¤˜ ¯ˆÚ›˜ ÛˆÏËÓ·Ú›Ùȉ·, ¿Û¯ÂÙ· Ì ÙËÓ ˘ÎÓfiÙËÙ· Ù˘ ‰È¿ÌÂÛ˘ ‰È‹ıËÛ˘, ‰ÂÓ ÌÔÚÔ‡Ó Ó· ıˆÚËıÔ‡Ó OΔ∫∞. ∏ ÎÏÈÓÈ΋ ÛËÌ·Û›· Ù˘ ÔÚȷ΋˜ ·fiÚÚȄ˘ ·ÌÊÈÛ‚ËÙ›ٷÈ. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ·ÏÏ¿ fi¯È fiϘ, Â›Ó·È Ú¿ÁÌ·ÙÈ ·ÔÚÚ›„ÂȘ. ªÂÁ¿Ï˜ ÛÂÈÚ¤˜ ‰Â›¯ÓÔ˘Ó fiÙÈ 75-88% ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹, Ì ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ‚ÂÏÙÈÒÓÔ˘Ó ÙË ÓÂ-
i0 <10%
i1 10-25%
i2 26-50%
i3 >50%
™ˆÏËÓ·Ú›Ùȉ· ∫‡ÙÙ·Ú·/ÂÁοÚÛÈ· ‰È·ÙÔÌ‹ ÛˆÏËÓ·Ú›Ô˘
t0
t1
t2
t3
0
1-4
5-10
>10
∞ÚÙËÚ›Ùȉ· ŒÛˆ ¯ÈÙÒÓ· ‹ ‰È·ÙÔȯˆÌ·ÙÈ΋
v0 0
v1 ¤Ûˆ ¯ÈÙ. <25%
v2 ≥25% ·˘ÏÔ‡
v3 ‰È·ÙÔȯˆÌ·ÙÈ΋
™ÂÈÚ·Ì·Ù›Ùȉ· % ÛÂÈÚ·Ì¿ÙˆÓ
g0 0
g1 <25%
g2 25-75%
g3 >75%
¢È¿ÌÂÛÔ-ÛˆÏËÓ·Úȷ΋ ·fiÚÚÈ„Ë (Δ‡Ô˜ π): Δ Î‡ÙÙ·Ú· (CD3+ Î·È CD8+) ΢ڛˆ˜ Î·È ÏÈÁfiÙÂÚ· Ì·ÎÚÔÊ¿Á· ‰ÈËıÔ‡Ó ÙÔÓ ‰È¿ÌÂÛÔ ÈÛÙfi, ȉ›ˆ˜ ÙÔ˘ ÊÏÔÈÔ‡ Î·È ÂÈÛ‚¿ÏÏÔ˘Ó ÛÙÔ ÛˆÏËÓ¿ÚÈÔ, ‰ÈÂÈÛ‰‡ÔÓÙ·˜ ÌÂٷ͇ ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ (ÛˆÏËÓ·Ú›Ùȉ·). O Ù‡Ô˜ ·˘Ùfi˜ Ù˘ ·fiÚÚȄ˘ ·ÓÙ·ÔÎÚ›ÓÂÙ·È Û˘Ó‹ıˆ˜ Û ÒÛÂȘ ÛÙÂÚÔÂȉÒÓ Î·È Û·Ó›ˆ˜ ÚÔηÏ› ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ¢È¿ÌÂÛË ÌÔÓÔ˘ÚËÓÈ΋ ÊÏÂÁÌÔÓ‹ Î·È ÛˆÏËÓ·Ú›Ùȉ· ·Ú·ÙËÚÔ‡ÓÙ·È Û ÔÈÎÈÏ›· ¿ÏÏˆÓ ÓÔÛËÌ¿ÙˆÓ, fiˆ˜ Û ʷÚ̷΢ÙÈ΋ ‹ ÊÏÂÁÌÔÓÒ‰Ë ‰È¿ÌÂÛÔ-ÛˆÏËÓ·Úȷ΋ ÓÂÊÚ›Ùȉ·, Û ÏÂÌÊÔ΋ÏË Î·È Û ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù·. ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Â›Ó·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ÚÔ‚ÏËÌ·ÙÈ΋.
65
66
M. §EONT™INH
∂Ó‰·ÚÙËÚ›Ùȉ· (Δ‡Ô˜ ππ): ¶·ıÔÁÓˆÌÔÓÈ΋ ‚Ï¿‚Ë Â›Ó·È Ë ‰È‹ıËÛË Ì ÌÔÓÔ‡ÚËÓ· ·ÙÙ·Ú· ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ Î·È ·ÚÙËÚÈÔÏÈÎÔ‡ ¤Ûˆ ¯ÈÙÒÓ·. ∏ ÛËÌ·Û›· Ù˘ ·Ï‹˜ ·ʋ˜ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ì ÙÔ ÂÓ‰Ôı‹ÏÈÔ Â›Ó·È ·Û·Ê‹˜. O Ù‡Ô˜ ·˘Ùfi˜ ¤¯ÂÈ ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË ·fi ÙÔÓ Ù‡Ô π, ÌÈÎÚfiÙÂÚË ·¿ÓÙËÛË ÛÙ· ÛÙÂÚÔÂȉ‹ Î·È ÌÂȈ̤ÓË ÂÙ‹ÛÈ· ÂÈ‚›ˆÛË. ∞Ó·Ù‡ÛÛÂÈ ·ÚÁfiÙÂÚ· ›ÓˆÛË ÛÙÔÓ ¤Ûˆ ¯ÈÙÒÓ· Î·È ÛÙ¤ÓˆÛË ÙÔ˘ ·˘ÏÔ‡. ∏ Δ Î˘ÙÙ·ÚÈ΋ ·ÚÙËÚ›Ùȉ· (Δ‡Ô˜ πππ): Ì ˘ÎÓ‹ ÌÔÓÔ˘ÚËÓÈ΋ ‰È‹ıËÛË fiÏˆÓ ÙˆÓ ¯ÈÙÒÓˆÓ Ù˘ ·ÚÙËÚ›·˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· Û˘Á¯¤Ù·È Ì ÙËÓ ÓÂÎÚˆÙÈ΋ ·ÚÙËÚ›Ùȉ·, Ë ÔÔ›· Â›Ó·È Â‡ÚËÌ· Ù˘ ·ÓÙÈۈ̷ÙÈ΋˜ ·fiÚÚȄ˘. ∏ Δ Î˘ÙÙ·ÚÈ΋ ·ÚÙËÚ›Ùȉ· ¤¯ÂÈ Î·Ï‡ÙÂÚË ·ÓÙ·fiÎÚÈÛË Û ·ÓÙÈ-Δ Î˘ÙÙ·ÚÈ΋ ·ÁˆÁ‹ Î·È ˘„ËÏfiÙÂÚË ÂÙ‹ÛÈ· ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (61%) Û ۯ¤ÛË Ì ÙËÓ ÓÂÎÚˆÙÈ΋ ·ÚÙËÚ›Ùȉ· (29%). ™ÙÔ 20-30% ÙˆÓ ‚ÈÔ„ÈÒÓ Ì ·ÏÏÔÈÒÛÂȘ OΔ∫∞ Û˘Ó˘¿Ú¯ÂÈ ÂÓ·fiıÂÛË C4d ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ ÂÚÈÛˆÏËÓ·ÚÈ·ÎÒÓ ÙÚȯÔÂȉÒÓ.
∫ÏÈÓÈÎÔÈÛÙÔ·ıÔÏÔÁÈÎÔ› Û˘Û¯ÂÙÈÛÌÔ› O ÛËÌ·ÓÙÈÎfiÙÂÚÔ˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ Ù˘ ¤Î‚·Û˘ ÂÓfi˜ ·ÔÚÚÈÙÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ Â›Ó·È ÔÈ ·ÚÙËÚȷΤ˜ ‚Ï¿‚˜. ∏ ·ÚÔ˘Û›· ÂÓ‰·ÚÙËÚ›Ùȉ·˜ ‰ÈÏ·ÛÈ¿˙ÂÈ ÙÔ ÔÛÔÛÙfi ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (31% OΔ∫∞ Ì ÂÓ‰·ÚÙËÚ›Ùȉ· – 15% OΔ∫∞ ¯ˆÚ›˜). ∏ ÂÙ‹ÛÈ· ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ë ·ÓÙ·fiÎÚÈÛË ÛÙ· ÛÙÂÚÔÂȉ‹ Â›Ó·È ˘„ËÏfiÙÂÚË ÁÈ· ÙÔÓ Ù‡Ô π, ·Ú¿ ÁÈ· ÙÔÓ Ù‡Ô ππ OΔ∫∞. OÈ ÂÚÈÙÒÛÂȘ Ì ÚÔÛ‚ÔÏ‹ ÌÂÁ·Ï‡ÙÂÚË ÙÔ˘ 25% Ù˘ ·˘ÏÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ·ÁÁ›Ԣ (Banff ππμ) ¤¯Ô˘Ó ¯ÂÈÚfiÙÂÚË ·¿ÓÙËÛË ÛÙËÓ ·ÓÙÈ·ÔÚÚÈÙÈ΋ ıÂڷ›· Î·È ‰‡Ô ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Û ۯ¤ÛË Ì ÙȘ ÂÓ‰·ÚÙËÚ›Ùȉ˜ ÛÙȘ Ôԛ˜ ÚÔÛ‚¿ÏÏÂÙ·È ÏÈÁfiÙÂÚÔ ÙÔ˘ 25% Ù˘ ·˘ÏÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ (Banff ππ∞). ∏ ÂÓ‰·ÚÙËÚ›Ùȉ· ÂÍÂÏ›ÛÛÂÙ·È Û ›ÓˆÛË ÙÔ˘ ¤Ûˆ ¯ÈÙÒÓ· ÙÔ˘ ·ÁÁ›Ԣ Û ‰È¿ÛÙËÌ· 3 ÌËÓÒÓ. ∏ Ù‡Ô˘ πππ ·fiÚÚÈ„Ë ¤¯ÂÈ ·ÎfiÌË ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË ·fi ÙËÓ ÂÓ‰·ÚÙËÚ›Ùȉ·. ∏ ·ÚÔ˘Û›· ÂÌÊÚ¿ÎÙÔ˘ ·ÔÙÂÏ› ‰˘ÛÔ›ˆÓÔ ‚ÈÔ„ÈÎfi ‡ÚËÌ·, ÂÊfiÛÔÓ ·ÔÎÏÂÈÛı› Ô ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ÙÚ·˘Ì·ÙÈÛÌfi˜. ŒÌÊÚ·ÎÙÔ ÌÔÚ› Ó· Û˘Óԉ‡ÂÈ Ïԛ̈ÍË Î·È È‰È·›ÙÂÚ· ‰È¿¯˘ÙË CMV Ïԛ̈ÍË. ¶·Ï·È¿ ÈÓÒ‰Ë ¤ÌÊÚ·ÎÙ· ·Ó¢ÚÈÛÎfiÌÂÓ· Û ηϿ ÏÂÈÙÔ˘ÚÁÔ‡ÓÙ· ÌÔۯ‡̷ٷ, ÔÊ›ÏÔÓÙ·È Û ¯ÂÈÚÈÛÌÔ‡˜ ÛÙÔ ¯ÚfiÓÔ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È Â›-
Ó·È ¯ˆÚ›˜ ÛËÌ·Û›·. ∏ ˘ÎÓfiÙËÙ· Ù˘ ‰È‹ıËÛ˘ ÛÙÔ ‰È¿ÌÂÛÔ ÈÛÙfi, fiˆ˜ Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ CD3+ Î·È CD8+ ΢ÙÙ¿ÚˆÓ, ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂͤÏÈÍË ÙÔ˘ ·ÔÚÚÈÙÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘. ŒÙÛÈ Ë ÛÙ·‰ÈÔÔ›ËÛË Ì ‚¿ÛË ÙËÓ ˘ÎÓfiÙËÙ· Ù˘ ‰È‹ıËÛ˘ Â›Ó·È ·ÌÊ›‚ÔÏ˘ ·Í›·˜. ™Â ÌÂÚÈΤ˜ ÛÂÈÚ¤˜ Ë ·Ó·ÏÔÁ›· CD8+ ΢ÙÙ¿ÚˆÓ Û¯ÂÙ›˙ÂÙ·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ·¿ÓÙËÛË ÛÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂڷ›·, ÂÓÒ Û˘Ó‰¤ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ÈÛÙÈ΋ ‚Ï¿‚Ë. ΔÔ ˘ÂÚ‰ÈÏ¿ÛÈÔ ÔÛÔÛÙfi ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ˘ÎÓfiÙËÙ· ˆÛÈÓÔÊ›ÏˆÓ ¿Óˆ ÙÔ˘ 2%, Èı·ÓÒ˜ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ Û˘Ó‡·ÚÍË ·ÁÁÂȷ΋˜ ÚÔÛ‚ÔÏ‹˜ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜. O ·˘ÍË̤ÓÔ˜ ·ÚÈıÌfi˜ Ì·ÎÚÔÊ¿ÁˆÓ Û˘Ó‰¤ÂÙ·È Â›Û˘ Ì ‰˘ÛÌÂÓ‹ ¤Î‚·ÛË. ∏ ˘„ËÏ‹ ÂÚÈÂÎÙÈÎfiÙËÙ· ÙÔ˘ ‰È¿ÌÂÛÔ˘ ‰ÈËı‹Ì·ÙÔ˜ Û ϷÛÌ·ÙÔ·ÙÙ·Ú· Û˘Ó‰¤ÂÙ·È Ì ÊÙˆ¯fiÙÂÚË ÚfiÁÓˆÛË ÛÙ· ·ÔÚÚÈÙÈο ÂÂÈÛfi‰È· ÌfiÓÔ ÙˆÓ ÚÒÙˆÓ 6 ÌËÓÒÓ. ∏ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÛˆÏËÓ·Ú›Ùȉ·˜ ·ÔÙÂÏ› ÛËÌÂ›Ô ·ÌÊÈÛ‚ËÙ‹ÛÂˆÓ Î·È ‰È·Ì¿¯Ë˜. ™Â ÌÂÚÈΤ˜ ÌÂϤÙ˜ Ë ‚·ÚÂÈ¿ ÛˆÏËÓ·Ú›Ùȉ· (Banff t3) Î·È Ë ÂÎÙÂٷ̤ÓË Ú‹ÍË Ù˘ ÛˆÏËÓ·Úȷ΋˜ ‚.Ì. (>10/mm2) Û¯ÂÙ›˙ÔÓÙ·È Ì ۈÏËÓ·Úȷ΋ ·ÙÚÔÊ›· Î·È ¯ÚfiÓÈ· ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÂÓÒ Û ¿ÏϘ Ô‡ÙÂ Ë Banff ‚·ıÌÔÏfiÁËÛË Ù˘ ÛˆÏËÓ·Ú›Ùȉ·˜, Ô‡ÙÂ Ë ¤ÎÙ·ÛË Ú‹Í˘ Ù˘ ÛˆÏËÓ·Úȷ΋˜ ‚.Ì. ‰ÂÓ Â›Ó·È ÚÔÛ‰ÈÔÚÈÛÙÈΤ˜ Ù˘ ÂͤÏÈ͢. ∏ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ Û·Ó›ˆ˜ ·Ó¢ÚÈÛÎfiÌÂÓ˘ (7%) Û OΔ∫∞ ÛÂÈÚ·Ì·Ù›Ùȉ·˜ ·ÌÊÈÛ‚ËÙÂ›Ù·È Î·È ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ÎÚÈÙ‹ÚÈÔ ‚·Ú‡ÙËÙ·˜ ÛÙ· Û¯‹Ì·Ù· Banff.
OÍ›· ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë (O∞∞) ∏ O∞∞ Û¯ÂÙÈο ÚfiÛÊ·Ù· ¤¯ÂÈ Û·ÊÒ˜ ηıÔÚÈÛÙ› ˆ˜ ͯˆÚÈÛÙ‹ ‰È·ÁÓˆÛÙÈ΋ ηÙËÁÔÚ›·. ¶·Ï·ÈfiÙÂÚ· ÔÓÔÌ·˙fiÙ·Ó «ÂÈÙ·¯˘ÓfiÌÂÓË ÔÍ›·», «ÂÈ‚Ú·‰˘ÓfiÌÂÓË ¯˘ÌÈ΋» ‹ «ÂÈ‚·‰˘ÓfiÌÂÓË ˘ÂÚÔÍ›·» ·fiÚÚÈ„Ë, fiÚÔÈ Ô˘ ı· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È. ∏ O∞∞ ·Ú·ÙËÚÂ›Ù·È Û ·ÛıÂÓ›˜ Ô˘ ·Ó·Ù‡ÛÛÔ˘Ó ˘„ËÏfi Â›Â‰Ô ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ·ÓÙÈÁfiÓˆÓ ‰fiÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û ·ÓÙ›ıÂÛË Ì ÙËÓ ˘ÂÚÔÍ›· ·fiÚÚÈ„Ë ÛÙËÓ ÔÔ›· ÚÔ¸¿Ú¯ÔÓÙ· ·ÓÙÈÛÒÌ·Ù· ηٷÛÙÚ¤ÊÔ˘Ó ÙÔ ÌfiÛ¯Â˘Ì· ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË. Δ· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ù˘ O∞∞ Â›Ó·È ÔÈΛϷ Î·È ·Ó·Ú΋ ÁÈ· ηıÔÚÈÛÙÈ΋ ·ÛÊ·Ï‹ ‰È¿-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÁÓˆÛË. OÈ Feucht Î·È Û˘ÓÂÚÁ¿Ù˜, ÙÔ 1991, ‹Ù·Ó Ë ÚÒÙË ÔÌ¿‰· Ô˘ ‰ËÌÔÛ›Â˘Û fiÙÈ ÂÓ·fiıÂÛË C4d Û ÂÚÈÛˆÏËÓ·Úȷο ÙÚȯÔÂȉ‹ (¶™Δ), ÔÚ·Ù‹ Û ÙÔ̤˜ „˘ÎÙÈÎÔ‡, Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ˘Ô‰ËÏÒÓÂÈ ¤Ó· ·ÓÙÈۈ̷ÙÈÎfi ÛÙÔÈ¯Â›Ô ÛÙËÓ ·fiÚÚÈ„Ë ·ÏÏÔÌÔۯ‡̷ÙÔ˜. ΔÔ Â‡ÚËÌ· ·˘Ùfi ‰È¢ÎÔχÓÂÈ ÙË ‰È¿ÁÓˆÛË ·˘ÙÔ‡ ÙÔ˘ ›‰Ô˘˜ ·fiÚÚȄ˘, Ë ÔÔ›· Û˘¯Ó¿ Û˘Óԉ‡ÂÙ·È Î·È ·fi ΢ÙÙ·ÚÈÎfi ÛÙÔÈ¯Â›Ô (ÌÂÈÎÙ‹ Δ Î˘ÙÙ·ÚÈ΋ Î·È ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë). ¶ÂÚ›Ô˘ 5-7% ÙˆÓ ·ÛıÂÓÒÓ ·Ó·Ù‡ÛÛÔ˘Ó ÂÂÈÛfi‰ÈÔ O∞∞ ÂÓÒ, ÛÙÔȯ›· O∞∞ ·Ó¢ڛÛÎÔÓÙ·È ÛÙÔ 25% ÙˆÓ ‚ÈÔ„ÈÒÓ ÁÈ· ÔÍ›· ·fiÚÚÈ„Ë. ∏ ·ÚÔ˘Û›· ÌÔÓÔ˘ÚËÓÈ΋˜ ÛÂÈÚ/›Ùȉ·˜ ÔÈΛÏÂÈ Â˘Ú¤ˆ˜ ·fi 19-90% ÛÙȘ ‰È¿ÊÔÚ˜ ÛÂÈÚ¤˜. ™ÙËÓ O∞∞ ÚÔÂÍ¿Ú¯Ô˘Ó Ù· ÌÔÓÔ·ÙÙ·Ú·/ Ì·ÎÚÔÊ¿Á·, ÂÓÒ ÛÙËÓ OΔ∫∞ Ù· Δ ÏÂÌÊÔ·ÙÙ·Ú·. OÍ›· ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë ÌÔÚ› Ó· Â›Ó·È Ë ÌfiÓË ÂΉ‹ÏˆÛË O∞∞ ÛÙË ‚ÈÔ„›·. O˘‰ÂÙÂÚÔÊÈÏÈ΋ ‹ Ì·ÎÚÔÊ·ÁÈ΋ ÛˆÏËÓ·Ú›Ùȉ· ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ. ™ÙÔ ‰È¿ÌÂÛÔ ÈÛÙfi Ù· ÌÔÓÔ‡ÚËÓ· Â›Ó·È Ï›Á·, fiÛ· Û ̛· ÔÚȷ΋ ·fiÚÚÈ„Ë. ¢È¿ÌÂÛË ·ÈÌÔÚÚ·Á›· Â›Ó·È Û˘¯Ó‹, ·ÏÏ¿ fi¯È ÂÓ‰ÂÈÎÙÈ΋ O∞∞. ¶Ï·ÛÌ·ÙÔ·ÙÙ·Ú· Î·È ÏÂÌÊÔ·ÙÙ·Ú· ·Ó¢ڛÛÎÔÓÙ·È Û ·ıÚÔ›ÛÂȘ, ¯ˆÚ›˜ Ó· ¤¯ÂÈ ·Ô‰Âȯı› Ë ¿ÌÂÛË Û¯¤ÛË ÙÔ˘˜ Ì ÙËÓ O∞∞. ∏ ·ÚÔ˘Û›· ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Û ÂÚÈÛˆÏËÓ·Úȷο ÙÚȯÔÂȉ‹ ‰ÂÓ ·ÔÙÂÏ› ÛÙ·ıÂÚfi ‡ÚËÌ·, ÂÓÒ Ë «ÈÓȉÔÂȉ‹˜» ÂÓ·fiıÂÛË Û ÙÔ›¯ˆÌ· ·ÁÁ›Ԣ, ÂÈÎfiÓ· ·ÚfiÌÔÈ· Ì ÙË ÓÂÎÚˆÙÈ΋ ·ÁÁ½Ùȉ·, ÂÌÊ·Ó›˙ÂÙ·È Û ϛÁ˜ ÂÚÈÙÒÛÂȘ (10-25%). ∂›Û˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ·ÏÏÔÈÒÛÂȘ Ù‡Ô˘ ıÚÔÌ‚ˆÙÈ΋˜ ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·˜. ¢È¿¯˘ÙË (>50% ÙˆÓ ÙÚȯÔÂȉÒÓ) ıÂÙÈÎfiÙËÙ· ÛÙÔ C4d ·Ó¢ڛÛÎÂÙ·È Ì ÔÌÔÈfiÌÔÚÊË Î·È Û˘Ó¯fiÌÂÓË ÁÚ·ÌÌÔÂȉ‹ ηٷÓÔÌ‹, Û·ÓÈfiÙÂÚ· ÎÔÎÎÒ‰Ë, ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ ÂÚÈÛˆÏËÓ·ÚÈ·ÎÒÓ ÙÚȯÔÂȉÒÓ Û ÙÔ̤˜ „˘ÎÙÈÎÔ‡ ‹ ·Ú·Ê›Ó˘. ∂Ó·ÔÙ›ıÂÙ·È ÛÙ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ΢ڛˆ˜ Î·È ÛÙÔ ÎÔÏÏ·ÁfiÓÔ IV Ù˘ ‚.Ì.. O ‰ÂÛÌfi˜ ·˘Ùfi˜ ÙÔ˘ C4d Ì ‰ÔÌÈΤ˜ ÚˆÙ½Ó˜ ÂÚÌËÓ‡ÂÈ ÙËÓ ÈÛÙÈ΋ ·Ó‡ÚÂÛ‹ ÙÔ˘ ·ÚÎÂÙ¤˜ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ÂÍ·Ê¿ÓÈÛË ÙˆÓ ·ÏÏÔ·ÓÙÈÛˆÌ¿ÙˆÓ ·fi ÙÔÓ ÔÚfi. ∏ ÂÛÙȷ΋ (<50% ÙˆÓ ÙÚȯÔÂȉÒÓ) ÂÓ·fiıÂÛË C4d Â›Ó·È ·ÌÊ›‚ÔÏ˘ ÛËÌ·Û›·˜, ÂÈ‚¿ÏÏÂÈ fï˜ ¤ÏÂÁ¯Ô ÁÈ· ·ÓÙÈÛÒÌ·Ù· ηٿ ·ÓÙÈÁfiÓˆÓ ‰fiÙË (∞∞¢) ÛÙÔÓ ÔÚfi. ™ÂÈÚ·Ì·ÙÈ΋ ıÂÙÈÎfiÙËÙ· ÁÈ· C4d Û˘Ó˘¿Ú¯ÂÈ
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ÛÙÔ 1/3 ÙˆÓ ÂÚÈÙÒÛÂˆÓ O∞∞ Î·È ÂÎÙÈÌ¿Ù·È Î·Ï‡ÙÂÚ· Û ÙÔ̤˜ ·Ú·Ê›Ó˘. ™Â ‚·ÚȤ˜ ÂÚÈÙÒÛÂȘ O∞∞, ÌÂÙ¿ 2-3 Ì‹Ó˜, ÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ÂÚÈÛˆÏËÓ·ÚÈ·ÎÒÓ ÙÚȯÔÂȉÒÓ ¤¯ÂÈ ·Ô¤ÛÂÈ Î·È Ë ‚.Ì. Â›Ó·È ·¯˘Ì¤ÓË Î·È ÔÏ˘ÛÙÔÈ‚·‰ˆÙ‹. Δ· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙËÓ ‰È¿ÁÓˆÛË Ù˘ O∞∞ (¶›Ó·Î·˜ 3) ÂÓۈ̷ÙÒıËÎ·Ó ÛÙÔ Û¯‹Ì· Banff 2003 Î·È 2005 Î·È ·ÊÔÚÔ‡Ó Â˘Ú‹Ì·Ù· ÌÔÚÊÔÏÔÁÈο ÔÍ›·˜ ÈÛÙÈ΋˜ ‚Ï¿‚˘, ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈο Î·È ÔÚÔÏÔÁÈο. ¶›Ó·Î·˜ 3. ∫ÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ O∞∞ 1. ªÔÚÊÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÈÛÙÈ΋˜ ‚Ï¿‚˘ - ‚·ıÌfi˜ π. OÍ›· ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë - ‚·ıÌfi˜ ππ. ¶ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· Û ¶™ Î·È ™¶ ÙÚȯÔÂȉ‹ ηÈ/‹ ÙÚȯÔÂȉÈ΋ ıÚfiÌ‚ˆÛË - ‚·ıÌfi˜ πππ. πÓȉÔÂȉ‹˜ Ó¤ÎÚˆÛË ·ÚÙËÚÈÒÓ 2. ∞ÓÔÛÔ˚ÛÙÔ¯ËÌÈο Â˘Ú‹Ì·Ù· - C4d Û ¶™Δ - IgM, IgG, C3, ÈÓÈ΋ Û ·ÚÙËÚ. ÙÔ›¯ˆÌ· 3. OÚÔÏÔÁÈο Â˘Ú‹Ì·Ù· - ΢ÎÏÔÊÔÚÔ‡ÓÙ· ·ÓÙÈÛÒÌ·Ù· ηٿ ·ÓÙÈÁfiÓˆÓ ‰fiÙË (HLA ‹ ÂÓ‰ÔıËÏȷο)
¶ÂÚÈÛÙ·ÙÈο Ô˘ Û˘ÁÎÂÓÙÚÒÓÔ˘Ó ÌfiÓÔ ‰‡Ô ·fi Ù· ÙÚ›· ›‰Ë ÎÚÈÙËÚ›ˆÓ ıˆÚÔ‡ÓÙ·È ‡ÔÙ· ÁÈ· O∞∞. ∞ÚÓËÙÈ΋ ¯ÚÒÛË ÁÈ· C4d ‹ ·ÚÓËÙÈο ÔÚÔÏÔÁÈο Â˘Ú‹Ì·Ù· ‰ÂÓ ·ÔÎÏÂ›Ô˘Ó ÙËÓ O∞∞, fiˆ˜ Î·È ÈÛÙÔ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Â›Ó·È ·fi ÌfiÓ· ÙÔ˘˜ ·Ó·Ú΋ ÁÈ· ÙËÓ ‰È¿ÁÓˆÛË O∞∞. μÈÔ„›Â˜ ÌÂ Û˘ÓÔ‰¿ ÎÚÈÙ‹ÚÈ· ÁÈ· O∞∞ Î·È OΔ∫∞ ıˆÚÔ‡ÓÙ·È fiÙÈ ¤¯Ô˘Ó ·ÌÊfiÙÂÚ· Ù· ›‰Ë ·fiÚÚȄ˘. ∂Ó·fiıÂÛË C4d ¯ˆÚ›˜ ÈÛÙÔ·ıÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ıˆÚÂ›Ù·È ÂΉ‹ÏˆÛË ÚÔÛ·ÚÌÔÁ‹˜ ÙÔ˘ Ï‹ÙË ÛÙÔ ·ÏÏÔÌfiÛ¯Â˘Ì·.
∂˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÙÔ˘ C4d ŒÓ· ·fi Ù· Û˘Ó‹ıË ‰È·ÁÓˆÛÙÈο ÚÔ‚Ï‹Ì·Ù· Û ‚ÈÔ„›Â˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È Ë ‰È¿ÎÚÈÛË ÌÂٷ͇ ıÚÔÌ‚ˆÙÈ΋˜ ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·˜ ÔÊÂÈÏfiÌÂÓ˘ Û ÙÔÍÈÎfiÙËÙ· ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘, Û ˘ÔÙÚÔ‹ Ù˘ ·Ú¯È΋˜ ÓfiÛÔ˘ ÛÙÔ ÌfiÛ¯Â˘Ì· ‹ Û O∞∞. ¶ÔÏϤ˜ ÌÂϤÙ˜ ‰ÂÓ Î·Ù¿ÊÂÚ·Ó Ó· ·Ô‰Â›ÍÔ˘Ó ÙËÓ ·ÚÔ˘Û›· C4d ÛÙ· ¶™Δ Û ηӤӷ ÓfiÛËÌ· Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ. ∫ÔÎÎÒ‰ÂȘ ÛÂÈÚ·Ì·ÙÈΤ˜ ÂÓ·Ôı¤ÛÂȘC4d Â›Ó·È Ù˘ÈΤ˜ Û ·ÓÔÛÔÛ˘ÌÏÂÁÌ·ÙÈο ÓÔÛ‹Ì·Ù· (.¯. ÌÂÌ‚Ú·ÓÒ‰Ë ÛÂÈÚ/›Ùȉ·), ÂÓÒ ÌfiÓÔ Û ÙÔ̤˜ „˘ÎÙÈÎÔ‡ ·Ú·ÙËÚÔ‡ÓÙ·È C4d ÂÓ·Ôı¤ÛÂȘ ÛÙÔ ÛÂÈÚ·Ì·ÙÈÎfi ÌÂÛ¿ÁÁÂÈÔ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÓÂÊÚÒÓ.
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M. §EONT™INH
¶›Ó·Î·˜ 4. ΔÔ ·Ó·ÌÔÚʈ̤ÓÔ Û¯‹Ì· Banff 2005 ÁÈ· ÙȘ ‰È·ÁÓˆÛÙÈΤ˜ ηÙËÁÔڛ˜ Ù˘ ‚ÈÔ„›·˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. 1. º˘ÛÈÔÏÔÁÈ΋ 2. ∞ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë - OÍ›· ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë Δ‡Ô˜ π : OÌÔÈ¿˙Ô˘Ó Ì O™¡, C4d+ Δ‡Ô˜ ππ : ΔÚȯÔÂȉ‹ Ì ÔÏ˘ÌÔÚÊÔ‡ÚËÓ· ‹ / Î·È ıÚfiÌ‚ˆÛË, C4d+ Δ‡Ô˜ πππ : ∞ÁÁÂÈ·Îfi˜ v3, C4d+ - ÃÚfiÓÈ· ÂÓÂÚÁfi˜ ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë - ™ÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ ‹ / Î·È ÔÏ˘ÛÙÔÈ‚¿‰ˆÛË ‚.Ì. ÂÚÈÛˆÏËÓ·ÚÈ·ÎÒÓ ÙÚȯÔÂȉÒÓ, ‹ ‰È¿ÌÂÛË ›ÓˆÛË/ ÛˆÏËÓ·Úȷ΋ ·ÙÔÚÊ›· ‹ / Î·È ÈÓ҉˘ ¿¯˘ÓÛË ¤Ûˆ ¯ÈÙÒÓ· ·ÚÙËÚÈÒÓ, C4d+ 3. ⁄ÔÙË / ÔÚȷ΋ ÁÈ· ÔÍ›· Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë v0, t1-t2-t3, i0-i1 4. Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë - OÍ›· Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë Δ‡Ô˜ π∞ : i2 – i3, t2 Δ‡Ô˜ πμ : i2 – i3, t3 Δ‡Ô˜ ππ∞ : v1 Δ‡Ô˜ ππμ : v2 Δ‡Ô˜ πππ : v3 - ÃÚfiÓÈ· Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë ÃÚfiÓÈ· ·ÚÙËÚÈÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ (›ÓˆÛË ¤Ûˆ ¯ÈÙÒÓ· Ì ÌÔÓÔ˘ÚËÓÈ΋ ‰È‹ıËÛË) 5. ¢È¿ÌÂÛË ›ÓˆÛË (¢π) Î·È ÛˆÏËÓ·Úȷ΋ ·ÙÚÔÊ›· (™∞), ¯ˆÚ›˜ ÂȉÈ΋ ·ÈÙÈÔÏÔÁ›· μ·ıÌfi˜ π :‹È· ¢π Î·È ™∞ (<25% Ù˘ ÊÏÔÈ˚΋˜ ¤ÎÙ·Û˘) μ·ıÌfi˜ ππ :̤ÙÚÈ· ¢π Î·È ™∞ (26-50% Ù˘ ÊÏÔÈ˚΋˜ ¤ÎÙ·Û˘) μ·ıÌfi˜ πππ :‚·ÚÈ¿ ¢π Î·È ™∞ / ·ÒÏÂÈ· (>50% Ù˘ ÊÏÔÈ˚΋˜ ¤ÎÙ·Û˘) 6. ÕÏϘ: ·ÏÏÔÈÒÛÂȘ ÌË ÔÊÂÈÏfiÌÂÓ˜ Û ·fiÚÚÈ„Ë (ÂÚȤ¯ÔÓÙ·È ÛÙÔÓ ›Ó·Î· 7)
80% ÙˆÓ C4d + ÏËÙÒÓ ¤¯Ô˘Ó ΢ÎÏÔÊÔÚÔ‡ÓÙ· ∞-∞¢. ∞ÓÙÈı¤Ùˆ˜ ÙÔ ÔÛÔÛÙfi ÙˆÓ ‚ÈÔ„ÈÒÓ ¯ˆÚ›˜ ÂÓ·Ôı¤ÛÂȘ C4d ÛÙ· ¶™Δ Ì ∞-∞¢ Î˘Ì·›ÓÂÙ·È ·fi 2-53%. ΔÔ ÌÂÁ¿ÏÔ ·˘Ùfi ‡ÚÔ˜ ÔÊ›ÏÂÙ·È Èı·ÓÒ˜ ÛÙËÓ Â˘·ÈÛıËÛ›· Ù˘ ÂοÛÙÔÙ ÌÂıfi‰Ô˘ ·Ó›¯Ó¢Û˘ ÙˆÓ ∞-∞¢.
¶›Ó·Î·˜ 5. ¢È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ¯ÚfiÓÈ·˜ ÂÓÂÚÁÔ‡ ·ÓÙÈۈ̷ÙÈ΋˜ ·fiÚÚȄ˘. 1. • • • •
ÃÚfiÓÈ· ·fiÚÚÈ„Ë
™ÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ (‹ / ηÈ) ¶ÔÏ˘ÛÙÔÈ‚¿‰ˆÛË ‚.Ì. ¶™Δ (‹ / ηÈ) ¢È¿ÌÂÛË ›ÓˆÛË ‹ ÛˆÏËÓ·Úȷ΋ ·ÙÚÔÊ›· (‹ / ηÈ) πÓ҉˘ ¿¯˘ÓÛË ¤Ûˆ ¯ÈÙÒÓ· ·ÚÙËÚÈÒÓ ¯ˆÚ›˜ ‰ÈÏ·ÛÈ·ÛÌfi ¤Ûˆ ÂÏ·ÛÙÈÎÔ‡ ÂÙ¿ÏÔ˘ 2. • ¢È¿¯˘ÙË ÂÓ·fiıÂÛË C4d ÛÙ· ÂÚÈÛˆÏËÓ·Úȷο ÙÚȯÔÂȉ‹ 3. • ¶·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ‰fiÙË
ΔÔ ‚·ÛÈÎfiÙÂÚÔ ı¤Ì· Ô˘ Û˘˙ËÙ‹ıËΠÛÙËÓ 8Ë Û˘Ó¿ÓÙËÛË Banff 2005 (ÛÙÔ Edmonton ÙÔ˘ ∫·Ó·‰¿) ‹Ù·Ó Ë Î·Ù¿ÚÁËÛË ÙÔ˘ fiÚÔ˘ «¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜» (áª) Ô˘ ˘‹Ú¯Â ÛÙ· ÚÔËÁÔ‡ÌÂÓ· Û¯‹Ì·Ù· (¶›Ó·Î·˜ 4). ∏ ·Ó·ÌfiÚʈÛË ·˘Ù‹ ¤ÁÈÓ ÏfiÁˆ Ù˘ ¯Ú‹Û˘ ÙÔ˘ fiÚÔ˘ ᪠ˆ˜ ÁÂÓÈÎÔ‡ fiÚÔ˘ ÁÈ· fiϘ ÙȘ ·Èٛ˜ ¯ÚfiÓÈ·˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ›ÓˆÛË, ÁÂÁÔÓfi˜ Ô˘ ÂÌfi‰È˙ ÙËÓ Û·Ê‹ ·ÈÙÈÔ·ıÔÁÂÓÂÙÈ΋ ‰È¿ÁÓˆÛË Î·È ÙËÓ Î·Ù¿ÏÏËÏË ıÂڷ›·. ∞fi ÙËÓ ¿ÏÏË, Ì ÙËÓ ÂÎÙÂٷ̤ÓË ÚfiÛÊ·ÙË ‚È‚ÏÈÔÁÚ·Ê›·, ·Ó·ÁÓˆÚ›ÛıËÎÂ Ô ÚfiÏÔ˜ ÙˆÓ ·ÏÏÔ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙËÓ ¯ÚfiÓÈ· ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ù·˘ÙÔÔÈ‹ıËÎÂ, Ì ÈÛÙÔ·ıÔÏÔÁÈο ÎÚÈÙ‹ÚÈ·, ÙÔ ·ÓÙÈۈ̷ÙÈÎfi ÛÙÔÈ¯Â›Ô ÛÙË ¯ÚfiÓÈ· ·fiÚÚÈ„Ë. ™ÙÔÓ ¶›Ó·Î· 5 ·Ó·ÁÚ¿ÊÔÓÙ·È Ù· ‰È·ÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ù˘ ¯ÚfiÓÈ·˜ ÂÓÂÚÁÔ‡ ·ÓÙÈۈ̷ÙÈ΋˜ ·fiÚÚȄ˘ (Ã∂∞∞), fiˆ˜ ηıÔÚ›ÛıËÎ·Ó ·fi ÙË Û˘Ó¿ÓÙËÛË Banff 2005.
∂Ó·fiıÂÛË C4d Û ¶™Δ ·Ó¢ڛÛÎÂÙ·È ÛÙÔ 61% ÙˆÓ ‚ÈÔ„ÈÒÓ Ì ¯ÚfiÓÈ· ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ ηÈ/ ‹ ¯ÚfiÓÈ· ·ÚÙËÚÈÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ (›ÓˆÛË ¤¯ˆ ¯ÈÙÒÓ· Î·È ‰È‹ıËÛ‹ ÙÔ˘ Ì ÌÔÓÔ‡ÚËÓ· ‹/ Î·È ·ÊÚÒ‰Ë Î‡ÙÙ·Ú·), Î·È ÛÙÔ 88% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·˘ÙÒÓ ·Ó¢ڛÛÎÔÓÙ·È ∞-∞¢. ∏ ·ÚÔ˘Û›· C4d ÂÓ·Ôı¤ÛÂˆÓ Â›Ó·È ÙÔ ·ÛʷϤÛÙÂÚÔ in situ ÛÙÔÈ¯Â›Ô ÌÈ·˜ ÂÓÂÚÁÔ‡ ·ÓÔÛÔÏÔÁÈ΋˜ ‰È·‰Èηۛ·˜. ÕÏÏ· ÌÔÚÊÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ˘Ô‰ËψÙÈο ·ÏÏ¿ fi¯È ·ıÔÁÓˆÌÔÓÈο Ã∂∞∞, Â›Ó·È ÔÈ Û˘ÏÏÔÁ¤˜ ÌÔÓÔ˘Ú‹ÓˆÓ ÛÙ· ¶™Δ, ‹ ÛÂÈÚ·Ì·Ù›Ùȉ· Î·È Ë Ï·ÛÌ·ÙÔ΢ÙÙ·ÚÈ΋ ‰È‹ıËÛË ÛÙÔÓ ‰È¿ÌÂÛÔ ÈÛÙfi. Ÿˆ˜ Î·È ÛÙËÓ O∞∞ Â¿Ó ÏËÚÔ‡ÓÙ·È ÌfiÓÔ ‰‡Ô ·fi Ù· ÙÚ›· ›‰Ë ÎÚÈÙËÚ›ˆÓ ÁÈ· ÙËÓ Ã∂∞∞, Ë ÂÚ›ÙˆÛË ıˆÚÂ›Ù·È ˆ˜ ˘Ô‰ËψÙÈ΋ ‹ ‡ÔÙË Ã∂∞∞.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Œ¯ÂÈ ÚfiÛÊ·Ù· ÚÔÙ·ı› Ë ¿Ô„Ë fiÙÈ Ë Ã∂∞∞ ·ÔÙÂÏ› ÌÂÚÈ΋ ÚÔÛ·ÚÌÔÁ‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙËÓ ·ÓÙÈۈ̷ÙÈ΋ ‚Ï¿‚Ë, ηٿÛÙ·ÛË Ô˘ ÌÔÚ› Ó· ÂÌÔ‰›ÛÂÈ ÙËÓ Ï‹ÚË Î˘ÙÙ·ÚÈ΋ χÛË ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ·ÏÏ¿ fi¯È ÙËÓ ·ÏÏÔ›ˆÛË Î·È ÙËÓ ÂÓÂÚÁÔÔ›ËÛ‹ ÙÔ˘. ∏ ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ Î·È Ë ÔÏ˘ÛÙÔÈ‚¿‰ˆÛË Ù˘ ‚.Ì. ÙˆÓ ¶™Δ Û˘Ó‹ıˆ˜ Û˘Ó˘¿Ú¯Ô˘Ó, Â›Ó·È fiÌÔȘ ·ÏÏÔÈÒÛÂȘ Î·È ıˆÚÔ‡ÓÙ·È ‰Â›ÎÙ˜ ·ÓÂÈÏËÌÌ¤ÓˆÓ ‚Ï·‚ÒÓ ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Â·ÓfiÚıˆÛ‹˜ ÙÔ˘˜. O ‰ÈÏ·ÛÈ·ÛÌfi˜ Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‚.Ì. ·fi ÌfiÓÔ˜ ÙÔ˘ ‰ÂÓ Â›Ó·È ÂȉÈÎfi ‡ÚËÌ· Ã∂∞∞, ‰ÈfiÙÈ ·ÚfiÌÔÈ· ·ÏÏÔ›ˆÛË ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ıÚÔÌ‚ˆÙÈ΋ ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·, ÛÙËÓ ÙÔÍÈÎfiÙËÙ· ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘, ÛÙÔ ÛÎÏËÚfi‰ÂÚÌ· Î·È ÂÎÏ·Ì„›·. ∞ÏÏ¿ Ë ÔÏ˘ÛÙÔÈ‚¿‰ˆÛË Ù˘ ÛÂÈÚ.‚.Ì., Ë ÔÔ›· ÂÎÙ›ÓÂÙ·È Û ÔÏfiÎÏËÚË ÙËÓ ÂÚÈʤÚÂÈ· ÙÔ˘ ÙÚȯÔÂȉԇ˜, ·ÎfiÌË Î·È ÌÂٷ͇ ÂÓ‰ÔıËÏ›Ô˘ Î·È ÌÂÛ·ÁÁ›Ԣ, fiÔ˘ ηÓÔÓÈο ·Ô˘ÛÈ¿˙ÂÈ Ë ‚.Ì., ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È Û ¿ÏÏË ÛÂÈÚ·Ì·ÙÈ΋ ÓfiÛÔ. ∏ ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ ¤¯ÂÈ ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË. ∞ÎfiÌË Î·È ‚·ıÌÔÏÔÁÈ΋ ηÙËÁÔÚ›· cg 1 (¶›Ó·Î·˜ 6) Û˘Ó‰¤ÂÙ·È Ì ÙÒÛË Ù˘ GFR ÂÚÈÛÛfiÙÂÚÔ ·fi fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ÛÎÏËÚ˘Ì¤ÓˆÓ ÛÂÈÚ·Ì¿ÙˆÓ. OÈ ·ÛıÂÓ›˜ Û˘Ó‹ıˆ˜ ÂΉËÏÒÓÔ˘Ó ÚˆÙÂ˚ÓÔ˘Ú›·, ·ÏÏ¿ ÛÙÔ 25% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·˘Ù‹ ·Ô˘ÛÈ¿˙ÂÈ. ∏ ·ıÔÁ¤ÓÂÈ· Ù˘ C4d ·ÚÓËÙÈ΋˜ ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ Î·È Ù˘ ÔÏ˘ÛÙÔÈ‚¿‰ˆÛ˘ Ù˘ ‚.Ì. ÙˆÓ ¶™Δ Â›Ó·È ·Û·Ê‹˜. °È· ÙÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi Èı·ÓÔÏÔÁÔ‡ÓÙ·È: (·) ÂÍ·Ê¿ÓÈÛË ¶™Δ ÏfiÁˆ ‰È¿ÌÂÛ˘ ›ÓˆÛ˘, (‚) ÛÂÈÚ. ÌÔۯ‡̷ÙÔ˜, ÔÊÂÈÏfiÌÂÓË ÛÂ Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë ‹ (Á) ¿ÏϘ ·Èٛ˜ ÛÂÈÚ. ÌÔۯ‡̷ÙÔ˜, fiˆ˜ ıÚÔÌ‚ˆÙÈ΋ ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·. ∏ ÔÏ˘ÛÙÔÈ‚¿‰ˆÛË Ù˘ ‚.Ì. ÙˆÓ ¶™Δ ÂÍ¿ÏÏÔ˘, Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ Â›Ó·È ·ıÔÁÓˆÌÔÓÈÎfi ÛÙÔÈ¯Â›Ô ·ÓÙÈۈ̷ÙÈ΋˜ ·fiÚÚȄ˘, ‰ÈfiÙÈ ÌÔÚ› Ó· ·Ú·ÙËÚËı› Û ‰È¿ÊÔÚ· ¿ÏÏ· ÓÔÛ‹Ì·Ù·, ÙfiÛÔ ÛÙÔ ÌfiÛ¯Â˘Ì·, fiÛÔ Î·È ÛÙÔÓ Èı·ÁÂÓ‹ ÓÂÊÚfi, fiˆ˜ ÛÙËÓ ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·, ÛÙËÓ ÓÂÊÚÔ¿ıÂÈ· ·fi ·Ó·ÏÁËÙÈο Ê¿Ú̷η, ÛÙËÓ ıÚÔÌ‚ˆÙÈ΋ ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·, Û ‰È¿ÊÔÚÔ˘˜ Ù‡Ô˘ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜ Î·È ÛÙËÓ ·ÎÙÈÓÈ΋ ÓÂÊÚ›Ùȉ·. ŒÙÛÈ Ë ·ÛÊ·Ï‹˜ ‰È¿ÁÓˆÛË Ã∂∞∞ ··ÈÙ› C4d ıÂÙÈÎfiÙËÙ· Î·È ·ÚÔ˘Û›· ÛÙÔÓ ÔÚfi ·ÓÙÈÛˆÌ¿ÙˆÓ ∞-∞¢.
69
¶›Ó·Î·˜ 6. Banff ‚·ıÌÔÏÔÁÈΤ˜ ηÙËÁÔڛ˜ ·ÏÏÔÈÒÛÂˆÓ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘ ¢È¿ÌÂÛË ›ÓˆÛË % ÙÔ˘ ÊÏÔÈÔ‡
ci0 ci1 ci2 ci3 ≤5% 6-25% 26-50% >50%
™ˆÏËÓ·Ú›·Î‹ ·ÙÚÔÊ›· % ÙÔ˘ ÊÏÔÈÔ‡
ct0 0
ct1 ct2 ct3 ≤25% 26-50% >50%
™ÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ cg0 cg1 cg2 cg3 % ÂÚÈʤÚÂÈ·˜ ÙÚȯÔÂȉÒÓ Ì <10% 10-25% 26-50% >50% ‰ÈÏ‹ ·Ú˘Ê‹ ÛÙ· ϤÔÓ ÚÔۂ‚ÏË̤ӷ ÛÂÈÚ¿Ì·Ù· ∞ÚÙËÚȷ΋ ÈÓ҉˘ ¿¯˘ÓÛË ¤Ûˆ ¯ÈÙÒÓ· % ÛÙ¤ÓˆÛË Ù˘ ·˘ÏÈ΋˜ ÂÚÈÔ¯‹˜ Û ‚·Ú‡ÙÂÚ· ÚÔۂ‚ÏË̤Ó˜ ·ÚÙËڛ˜
cv0 0
cv1
cv2
cv3
≤25% 26-50% >50%
™ÙÔÓ ¶›Ó·Î· 7 ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ Û˘Ó‹ıÂȘ ·Èٛ˜ ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ Î·È ÛˆÏËÓ·Úȷ΋˜ ·ÙÚÔÊ›·˜ (¢π / ™∞) ÂÎÙfi˜ Ù˘ ·fiÚÚȄ˘. ∂ÎÙfi˜ ÙˆÓ ·ÓˆÙ¤Úˆ, ÛÂÈÚ·Ì·ÙÈο ‹ ·ÁÁÂȷο ÓÔÛ‹Ì·Ù· Û ˘ÔÙÚÔ‹ ‹ de novo, Ô‰ËÁÔ‡Ó Û ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË Î·È ¢π/™∞. OÈ de novo ‰È·‚ËÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÂÍ¿ÏÏÔ˘, ÔÈ Ôԛ˜ ÚÔηÏÔ‡Ó ¢π/™∞, Â›Ó·È ÎÔÈÓ¤˜ ÛÙÔ ÌfiÛ¯Â˘Ì·. ™ÙËÓ Î·ÙËÁÔÚ›· 5 ÙÔ˘ Û¯‹Ì·ÙÔ˜ Banff 2005 (¶›Ó·Î·˜ 6) ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÌË ÂȉÈΤ˜ ÛÎÏËÚ˘ÓÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÂÈÚ·Ì¿ÙˆÓ Î·È ·ÁÁ›ˆÓ, ·ÏÏ¿ Ë ‚·ıÌÔÏÔÁ›· ÛÙËÚ›˙ÂÙ·È ÌfiÓÔ ÛÙȘ ‰È·ÌÂÛÔÛˆÏËÓ·ÚȷΤ˜ ·ÏÏÔÈÒÛÂȘ. ¶›Ó·Î·˜ 7. ∞Èٛ˜ ¢π / ™∞ ÂÎÙfi˜ ·fiÚÚȄ˘ ∞ÈÙÈÔÏÔÁ›· • ÃÚfiÓÈ· ˘¤ÚÙ·ÛË
ªÔÚÊÔÏÔÁ›· πÓ҉˘ ¿¯˘ÓÛË ¤Ûˆ ¯ÈÙÒÓ· ·ÚÙËÚ›ˆÓ Ì ÔÏ˘ÛÙÔÈ‚¿‰ˆÛË ¤Ûˆ ÂÏ·ÛÙÈÎÔ‡ ÂÙ¿ÏÔ˘.
• ΔÔÍÈÎfiÙËÙ· ·Ó·ÛÙÔϤˆÓ À·Ï›ÓˆÛË ·ÚÙËÚÈÔÏ›ˆÓ Ì ˘·ÏÔÂÈηÏÛÈÓ¢ڛÓ˘ ‰Â›˜ fi˙Ô˘˜ ÛÙÔÓ Ì¤Ûˆ ¯ÈÙÒÓ·, Î·È ·Ô˘Û›· ˘¤ÚÙ·Û˘ ‹ ‰È·‚‹ÙË. πÛÔÌÂÙÚÈ΋ ÎÂÓÔÙÔ›ˆÛË ÛˆÏËÓ·ÚÈ·ÎÔ‡ ÂÈıËÏ›Ô˘. • ÃÚfiÓÈ· ·fiÊÚ·ÍË
¢È¿Ù·ÛË ÛˆÏËÓ·Ú›ˆÓ, ÔÁÎÒ‰ÂȘ ·ÏÈÓ‰ÚÔÈ ÚˆÙ½Ó˘ Tamm –Horsfal l Î·È ·ÚÔ˘Û›· Ù˘ ÚˆÙ½Ó˘ ÛÙÔÓ ‰È¿ÌÂÛÔ ÈÛÙfi Î·È Ù· ÏÂÌÊ·ÁÁ›·.
• μ·ÎÙËÚȷ΋ ˘ÂÏÔÓÂÊÚ›Ùȉ·
∂Ó‰Ô- Î·È ÂÚÈÛˆÏËÓ·Úȷο ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·, Û¯ËÌ·ÙÈÛÌfi˜ ÏÂÌÊÔ˙ȉ›ˆÓ.
• ÃÚfiÓÈ· ÈÔÁÂÓ‹˜ Ïԛ̈ÍË π˚ο ¤ÁÎÏÂÈÛÙ· ÔÚ·Ù¿ Ì ÎÔÈÓfi ÌÈÎÚÔÛÎfiÈÔ, ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·, in situ È‚ÚȉÈÛÌfi ‹ ∏.ª.
ÕÏÏË ·ÏÏ·Á‹ ÛÙÔ ·Ó·ıˆÚË̤ÓÔ Banff 2005 Â›Ó·È Ë ·ÓÙÈηٿÛÙ·ÛË ÙÔ˘ fiÚÔ˘ «Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë» Ì «Δ ΢ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë», ÂÊfiÛÔÓ Ì·ÎÚÔÊ¿Á· ÌÔÓÔ·ÙÙ·Ú·, μ ·ÙÙ·Ú· Î·È Ï·ÛÌ·-
70
M. §EONT™INH
ÙÔ·ÙÙ·Ú· ·Ó¢ڛÛÎÔÓÙ·È Î·È ÛÙËÓ ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë. ™˘ÓÔÏÈο ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ÙÔ˘ Û¯‹Ì·ÙÔ˜ Banff 2005 Û ۯ¤ÛË Ì ٷ ÚÔÁÂÓ¤ÛÙÂÚ· Û¯‹Ì·Ù· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔ ¶›Ó·Î· 8. ¶›Ó·Î·˜ 8. OÈ ÙÚÔÔÔÈ‹ÛÂȘ ÙÔ˘ Û¯‹Ì·ÙÔ˜ Banff 2005. ∫·ÙËÁÔÚ›· 2
∏ ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë ÙÒÚ· ÂÚȤ¯ÂÈ 2 ˘ÔηÙËÁÔڛ˜: - OÍ›· ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë - ÃÚfiÓÈ· ÂÓÂÚÁfi ·ÓÙÈۈ̷ÙÈ΋ ·fiÚÚÈ„Ë
∫·ÙËÁÔÚ›· 3
OÚȷΤ˜ ·ÏÏÔÈÒÛÂȘ: «‡ÔÙ˜» ÁÈ· ÔÍ›· Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë. ∫·ıÔÚ›ÛÙËΠ۷ʤÛÙÂÚ· fiÙÈ t2 Î·È t3 Ì i0 ‹ i1 ·Ó‹ÎÔ˘Ó Û ·˘Ù‹ ÙËÓ Î·ÙËÁÔÚ›·.
∫·ÙËÁÔÚ›· 4
O fiÚÔ˜ «Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë» ·ÓÙÈηٷÛÙ¿ıËΠ̠ÙÔÓ fiÚÔ «Δ ΢ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë» Î·È ÂÚȤ¯ÂÈ 2 ˘ÔηÙËÁÔڛ˜: - OÍ›· Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë - ÃÚfiÓÈ· ÂÓÂÚÁfi Δ Î˘ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë
∫·ÙËÁÔÚ›· 5
O ÁÂÓÈÎfi˜ fiÚÔ˜ «¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜» ·ÓÙÈηٷÛÙ¿ıËΠ̠ÙÔÓ fiÚÔ «‰È¿ÌÂÛË ›ÓˆÛË Î·È ÛˆÏËÓ·Úȷ΋ ·ÙÚÔÊ›· ¯ˆÚ›˜ ÂȉÈ΋ ·ÈÙÈÔÏÔÁ›·».
OÈ ·Ó·Ï‡ÛÂȘ Ù˘ ÁÔÓȉȷ΋˜ ¤ÎÊÚ·Û˘ ÛÙËÓ ‚ÈÔ„›· ÌÔۯ‡̷ÙÔ˜ ÛÙÔ ·›Ì· Î·È ÛÙ· Ô‡Ú· ¤¯Ô˘Ó ‰ÒÛÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÛË Î·È ÙË ‰È¿ÁÓˆÛË Ù˘ ·Ó¿ÚÎÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. OÈ ‰ÔÎÈ̷ۛ˜ ·˘Ù¤˜ ¤¯Ô˘Ó ÚÔÙÂÚ‹Ì·Ù· ¤Ó·ÓÙÈ Ù˘ ‚ÈÔ„›·˜ ‰ÈfiÙÈ ÌÔÚÔ‡Ó ÓˆÚ›ÙÂÚ· Ó· ÚÔÂȉÔÔÈ‹ÛÔ˘Ó ÁÈ· ÌÈ· ·fiÚÚÈ„Ë Î·È Ó· ‰ÒÛÔ˘Ó ÏËÚÔÊÔڛ˜ ÁÈ· ËÓ ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›· Î·È ÛÙËÓ ÂÍ·ÙƠ̂΢ÛË Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜. Δ· DNA microarrays ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Û ‚ÈÔ„›Â˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÁÈ· ÙËÓ ¤ÎÊÚ·ÛË ÁÔÓȉ›ˆÓ Û¯ÂÙÈ˙fiÌÂÓˆÓ Ì ÙÔÓ Î˘ÙÙ·ÚÈÎfi ı¿Ó·ÙÔ, ÙËÓ ·¿ÓÙËÛË ÛÙÔ stress, ÙËÓ ÚÔÛÎfiÏËÛË, ÙÔÓ Î˘ÙÙ·ÚÈÎfi ·ÎÏÔ Î·È ÙËÓ ÊÏÂÁÌÔÓ‹, ¯ÚËÛÈ̇ÔÓÙ·˜ ÛÙËÓ ·Ó‡ÚÂÛË ·Ú¯fiÌÂÓ˘ ·fiÚÚȄ˘. ∂›Ó·È ÛËÌ·ÓÙÈÎfi fï˜ Ë ÌÔÚȷ΋ ÂͤٷÛË Ó· ÌÔÚ› Ó· ‰È·ÊÔÚԉȷÁÓÒÛÂÈ ÙȘ ÌË ·ÔÚÚÈÙÈΤ˜ ·Èٛ˜ ÊÏÂÁÌÔÓ‹˜ ÛÙÔ ÌfiÛ¯Â˘Ì·, fiˆ˜ ‚·ÎÙËÚȷΤ˜ ‹ ˚ÈΤ˜ ÏÔÈÌÒÍÂȘ ÙËÓ Ê·Ú̷΢ÙÈ΋ ÙÔÍÈÎfiÙËÙ·, ηıÒ˜ Î·È ÙÔ˘˜ Ù‡Ô˘˜ ÔÍ›·˜ ·fiÚÚȄ˘. ∂Ó ÙÔ‡ÙÔȘ, Û ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ‰È·ÈÛÙÒıËΠfiÙÈ ÂÚÈÙÒÛÂȘ ÔÍ›·˜ ·fiÚÚȄ˘ C4d+ ÂÌ›ÙÔ˘Ó Û ÔÔÈÔÓ‰‹ÔÙ ·fi ÙÔ˘˜ Ù‡Ô˘˜ ÔÍ›·˜ ·fiÚÚȄ˘ Ì ‚¿ÛË ÙË ÁÔÓȉȷ΋ ηٷÓÔÌ‹. ∂ÈÚÔÛı¤Ùˆ˜ ‰ÂÓ ‰È·ÈÛÙÒÓÂÙ·È ÂÌÊ·Ó‹˜ ‰È·ÊÔÚ¿ ÁÔÓȉȷ΋˜ ¤ÎÊÚ·Û˘ Û ÂÚÈÙÒÛÂȘ ›ÓˆÛ˘ ÔÊÂÈÏfiÌÂÓ˘ Û ‰È·ÊÔÚÂÙÈΤ˜ ·Èٛ˜. ™Â ÌÔÚÈ·Îfi Â›Â‰Ô Ù· ΢ÚÈ·Ú¯Ô‡ÓÙ· Û‹Ì·Ù· ÁÔÓȉȷ΋˜ ¤ÎÊÚ·Û˘ ·ÓÙ·Ó·ÎÏÔ‡Ó Èı·ÓÒ˜ ÙÔ˘˜ ‚·ÛÈÎÔ‡˜ ·-
ıÔÏÔÁÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÛÙÔÓ ÈÛÙfi .¯. ›ÓˆÛË ‹ ÊÏÂÁÌÔÓ‹, ¯ˆÚ›˜ Ó· Û˘Ó‰¤ÔÓÙ·È Ì ÙËÓ ÂȉÈ΋ ·ÈÙ›· Ô˘ ÙÔ˘˜ ÚÔηÏ›. Δ· ·ÓÂÈÏËÌ̤ӷ Û¯‹Ì·Ù· Banff ·ÔÙ˘ÒÓÔ˘Ó ÙËÓ ÛÙ·‰È·Î‹ ·Ó¿Ù˘ÍË Ù˘ ÁÓÒÛ˘ ÛÙËÓ ‰È·ÁÓˆÛÙÈ΋ Î·È ÚÔÁÓˆÛÙÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È Î˘Ú›ˆ˜ Ù˘ ·ÔÚÚÈÙÈ΋˜ ‰È·‰Èηۛ·˜. ∂ÚˆÙ‹Ì·Ù· fiˆ˜: – Ë ‚·ıÌÔÏfiÁËÛË ÂÓfi˜ ÂοÛÙÔ˘ ÙˆÓ ÈÛÙÔ·ıÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ·›˙ÂÈ ÚfiÏÔ ÛÙËÓ ÚfiÁÓˆÛË; – Ú¤ÂÈ Ó· ‰›ÓÂÙ·È ¤ÌÊ·ÛË ÛÙËÓ ÔÛÔÙÈ΋ ·ÍÈÔÏfiÁËÛË Â˘ÚËÌ¿ÙˆÓ fiˆ˜ Ë ÛˆÏËÓ·Ú›Ùȉ·, Ë ÂÚÈÛˆÏËÓ·Úȷ΋ ÙÚȯÔÂȉ›Ùȉ·, Ë ÛÂÈÚ·Ì·Ù›Ùȉ·; – ÔÈÔ˜ Â›Ó·È Ô ÚfiÏÔ˜ ÙˆÓ μ ΢ÙÙ·ÚÈÎÒÓ ‰ÈËı‹ÛÂˆÓ ÛÙÔ ÌfiÛ¯Â˘Ì·; ∂ËÚ¿˙Ô˘Ó ÙËÓ ıÂڷ›· Î·È ÙËÓ ÚfiÁÓˆÛË Ù˘ ·fiÚÚȄ˘; – ÌÔÚÔ‡Ó ÔÈ ÌÔÚÈ·ÎÔ› ‰Â›ÎÙ˜ ÁÈ· ÔÍ›· ‹ ¯ÚfiÓÈ· ·fiÚÚÈ„Ë Ó· ͯˆÚ›ÛÔ˘Ó ÙÔ˘˜ Ù‡Ô˘˜ Ù˘; – Ò˜ ÌÔÚÔ‡Ó Ó· ‰È·¯ˆÚÈÛÙÔ‡Ó ÔÈ ÂÚÈÙÒÛÂȘ ÔÚÈ·ÎÒÓ / ‡ÔÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ·ÓÙÈ·ÔÚÚÈÙÈ΋ ·ÁˆÁ‹ ·fi ·˘Ù¤˜ Ô˘ ‰ÂÓ ¯ÚÂÈ¿˙ÔÓÙ·È; – Ë Ù‡Ô˘ 3 ηÙËÁÔÚ›· (‰È·ÙÔȯˆÌ·ÙÈ΋ ·ÚÙËÚ›Ùȉ· / ÈÓȉÔÂȉ‹˜ Ó¤ÎÚˆÛË) ˘Ê›ÛÙÙ·È ˆ˜ ÌÔÚ‹ ·ÌÈÁÔ‡˜ OΔ∫∞, O∞∞ ‹ Â›Ó·È ÌÂÈÎÙ‹ ÌÔÚÊ‹; – ÙÈ Û˘Ì‚·›ÓÂÈ ÛÙÔ Ê·ÈÓfiÌÂÓÔ ÚÔÛ·ÚÌÔÁ‹˜; ›Ûˆ˜ ··ÓÙËıÔ‡Ó ÛÙÔ ÂÁÁ‡˜ ̤ÏÏÔÓ Ì ‚¿ÛË ÙËÓ ÌÂϤÙË ‚ÈÔ„ÈÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ÌÂÁ¿Ï˜ ÛÂÈÚ¤˜ ·ÛıÂÓÒÓ.
μÈ‚ÏÈÔÁÚ·Ê›· • Racusen L.C., Colvin R.B. et al. Antibody – Mediated Rejection Criteria – an Addition to the Banff ’97 Classification of Renal Allograft Rejection. Am J Transplant 2003; 3: 708-714. • Solez K., Colvin R.B. et al. Banff ’05 Meeting Report: Differential Diagnosis of Chronic Allograft Injury and Elimination of Chronic Allograft Nephropathy (CAN). Am J Transplant 2007; 7:518-526. • Colvin RB, Nickeleit V. Renal Transplant Pathology. In Heptinstall’s Pathology of the Kidney 2007, pp 13471490. • Colvin R.B. Renal Transplant Pathology. American Congress of Renal Pathology 2005, pp 259-282. • Mengel M., Bogers J. et al. Incidence of C4d Stain in Protocol Biopsies from Renal Allografts: Results from a Multicener Trial. Am J Transplant 2005; 5:1050-1056. • Haas M., Rahman M.H. et al. C4d and C3d Staining in Biopsies of ABO – and HLA – Incompatible Renal
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
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Allografts: Correlation with Histologic Findings. Am J Transplant 2007; 7: 724-724 (1) Nankivell B.J. and Chapman J.R. The Significance of Subclinical Rejection and the Value of Protocol Biopsies. Am J Transplant 2006; 6:2006-2012. Cornell L.D., Colvin R.B. Chronic allograft nephropathy. Curr Opin Nephrol Hypertens 2005; 14:229-234. Hara S. Matsushita H., et al. Allograft Glomerulitis: Histologic Characteristics to Detect Chronic Humoral Rejection. Transplant Proc 2005;37:714-716. Mauiyyedi S., Crespo M. et al. Acute Humoral Rejection in Kidney Transplantation: Morphology, Immunopathology and Pathologic Classification. J Am Soc Nephrol 2002; 13:779-787. Regele H., Bohmig G.A. et al. Capillary Deposition of Complement Split Product C4d in Renal Allografts in
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Associated with Basement Membrane Injury in Peritubular and Glomerular Capillaries: A contribution of Hummoral Immunity to Chronic Allograft Rejection. J Am Soc Nephrol 2002; 13:2371-2380. Feucht H.E., Mihatsch M.J. Diagnostic value of C4d in renal biopsies. Curr Opin Nephrol Hypertens 2005; 14: 592-598. Racusen L.C. Molecular Techniques in Transplantation. Transplant Proc 2004; 36:731-732. Sarwal M., Chua M.S. et al. Molecular heterogeneity in acute renal allograft rejection identified by DNA microarray profiling. N Engl J Med 2003; 349:125-138. Chicano S.L., Cornell L.D. et al. distinctive ultrastructural features of chronic allograft glomerulopathy: new formation of circumferential glomerular basement membrane. Lab Invest 2006; 86 (Suppl. 1).
ŒÎÙˆÛË ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ŒÎÙ·ÛË Î·È ÂÈÙÒÛÂȘ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜
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°ÚËÁfiÚÈÔ˜ M˘ÛÂÚÏ‹˜
°∂¡π∫∞
Áˆ Ù˘ ÚÔfi‰Ô˘ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ıÂڷ›·˜, ÂÓÙÔ‡ÙÔȘ ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÌÂÁ¿ÏˆÓ ÂıÓÈÎÒÓ ·Ú¯Â›ˆÓ Ô˘ ‚·Û›˙ÔÓÙ·È Û ‰Âο‰Â˜ ¯ÈÏÈ¿‰Â˜ ÌÔۯ‡̷ٷ ¤¯ÂÈ ‰Âȯı› ÛÙ·‰È·Î‹ Ì›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ ¯ÚfiÓÈÔ˘ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ ηıÒ˜ ·˘Í¿ÓÂÙ·È Ô ·ÚÈıÌfi˜ ÙˆÓ HLA ·Û˘Ì‚·ÙÔÙ‹ÙˆÓ 1,2. ∏ ÛËÌ·Û›· Ù˘ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Á›ÓÂÙ·È ·ÚÎÂÙ¿ ÂÌÊ·Ó‹˜ fiÙ·Ó ˘¿Ú¯ÂÈ ÌˉÂÓÈ΋ ‰È·ÊÔÚ¿ ·ÓÙÈÁfiÓˆÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ÌÂٷ͇ ‰fiÙË Î·È Ï‹ÙË.
™ËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ¤ÎÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÙfiÛÔ ·ÓÔÛÔÏÔÁÈÎÔ› fiÛÔ Î·È ÌË ·ÓÔÛÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ (¶ÈÓ. 1). OÈ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› ·Ó Î·È ‰È·ÎÚ›ÓÔÓÙ·È ÌÂٷ͇ ÙÔ˘˜, Û˘¯Ó¿ Û˘Ó˘¿Ú¯Ô˘Ó Î·È ‰ÚÔ˘Ó Ù·˘Ùfi¯ÚÔÓ· ÛÙËÓ ÚfiÔ‰Ô Ù˘ ‚Ï¿‚˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ¶›Ó·Î·˜ 1. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ ∞¡O™O§O°π∫Oπ
ª∏ ∞¡O™O§O°π∫Oπ
HLA ·Û˘Ì‚·ÙfiÙËÙ· ∞ÓÙÈ-HLA ·ÓÙÈÛÒÌ·Ù·
∏ÏÈΛ· ÙÔ˘ ‰fiÙË ™˘ÓÔ‰fi˜ ÓÔÛËÚfiÙËÙ· ‰fiÙË/Ï‹ÙË ¶ÚԤϢÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ∏ÏÈΛ· ÙÔ˘ Ï‹ÙË μÏ¿‚Ë ÈÛ¯·ÈÌ›·˜Â·Ó·ÈÌ¿ÙˆÛ˘ ¡ÂÊÚÈ΋ Ì¿˙· Î·È μªπ CMV Ïԛ̈ÍË ÀÂÚÏÈȉ·›ÌÈ· À¤ÚÙ·ÛË ∫·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÌÔۯ‡̷ÙÔ˜ ΔÔÍÈÎfiÙËÙ· CNIs
ÀÔÎÏÈÓÈ΋ ·fiÚÚÈ„Ë OÍ›· ·fiÚÚÈ„Ë ªË-Û˘ÌÌfiÚʈÛË ·ÛıÂÓÔ‡˜ ∞Ó·Ú΋˜ ·ÓÔÛÔηٷÛÙÔÏ‹ «∂˘·ÈÛıËÙÔÔ›ËÛË» ÙÔ˘ Ï‹ÙË
O•∂π∞ ∞¶Oƒƒπæ∏ (O∞) ∏ ÔÍ›· ·fiÚÚÈ„Ë ·ÔÙÂÏ› ÙÔÓ Ï¤ÔÓ ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘ 3. ∏ ‚·Ú‡ÙËÙ· Î·È Ô ¯ÚfiÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ O∞ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂͤÏÈÍË Ù˘ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘ ηıÒ˜ Ê·›ÓÂÙ·È fiÙÈ Ù· ·ÒÙÂÚ· (>3 Ì‹Ó˜) Î·È ·˘Ù¿ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi ·ÁÁÂȷΤ˜ ·ÏÏÔÈÒÛÂȘ Û˘Ó‰¤ÔÓÙ·È Ì و¯fiÙÂÚË ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜4. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ›Û˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ·ÎfiÌË Î·È Ë ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÛˆÏËÓ·ÚÈ›Ùȉ· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ¤¯ÂÈ ‰˘ÛÌÂÓ‹ ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ÂͤÏÈÍË Ù˘ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘, ·ÚfiÌÔÈ· Ì ·˘Ù¿ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È fiÙ·Ó ˘¿Ú¯ÂÈ ‹ÈÔ˘ ‚·ıÌÔ‡ ·ÚÙËÚÈ›Ùȉ·5,6. ™Â οı ÂÚ›ÙˆÛË Ë ¯˘ÌÈÎÔ‡ Ù‡Ô˘ ÔÍ›· ·fiÚÚÈ„Ë Ë ÔÔ›· ÔÊ›ÏÂÙ·È Û ·ÓÙÈÛÒÌ·Ù· (HLA ·ÓÙÈÛÒÌ·Ù·, ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙˆÓ ·ÁÁ›ˆÓ) ¤¯ÂÈ ÙËÓ ‰˘ÛÌÂÓ¤ÛÙÂÚË ÚfiÁÓˆÛË7. OÈ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ‚Ï¿‚˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÏfiÁˆ ÔÍ›·˜ ·fiÚÚȄ˘ ÔÈΛÏÔ˘Ó. ªË ·Ó·ÛÙÚ¤„ÈÌË ·ÒÏÂÈ· ÓÂÊÚÒÓˆÓ Ë ÔÔ›· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÛÂÈÚ·Ì·ÙÈ΋ ˘ÂډȋıËÛË Î·È ˘¤ÚÙ·ÛË Ô‰ËÁ› Û ʷ‡ÏÔ Î‡ÎÏÔ ·Ó¿ÚÎÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∂›Û˘, ÛˆÏËÓ·Úȷο ÂÈıËÏȷο ·ÙÙ·Ú· Ù· ÔÔ›· ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi Δ-ÏÂÌÊÔ·ÙÙ·Ú· ·Ú¿ÁÔ˘Ó IL-
∞¡O™O§O°π∫Oπ ¶∞ƒ∞°O¡Δ∂™ ∫π¡¢À¡OÀ Δ∏™ ÃO¡π∞™ ¡∂ºƒO¶∞£∂π∞™ ªO™Ã∂Àª∞ΔO™ (áª) Œ¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ ÔÈ ·ÓÔÛÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È ˘Â‡ı˘ÓÔÈ ÁÈ· ÙËÓ ‰È·Ù‹ÚËÛË ÂÓfi˜ Û˘Ó¯ԇ˜ ÂȤ‰Ô˘ ·ÓÔÛÔ··ÓÙËÙÈÎfiÙËÙ·˜ ¤Ó·ÓÙÈ ÙˆÓ ·ÓÙÈÁfiÓˆÓ Ô˘ ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ∏ ÛËÌ·Û›· ÙÔ˘˜ ¤¯ÂÈ Î·Ù·‰Âȯı› Û ÔÏϤ˜ ÌÂϤÙ˜.
HLA ™Àªμ∞ΔOΔ∏Δ∞ ∞Ó Î·È Ë Â›ÙˆÛË Ù˘ HLA Û˘Ì‚·ÙfiÙËÙ·˜ ÛÙËÓ Ã¡ª ¤¯ÂÈ ÌÂȈı› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ïfi-
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
15, Ë ÔÔ›· ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÂȉÈÎÒÓ CD8+ (΢ÙÙ·ÚÔÙÔÍÈÎÒÓ) Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ì¤Ûˆ ÙˆÓ ÔÔ›ˆÓ ¤گÔÓÙ·È ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ‰È·ÌÂÛÔÛˆÏËÓ·ÚÈ·ÎÔ‡ ¯ÒÚÔ˘, ‰È¿ÌÂÛË ›ÓˆÛË Î·È Û ̷ÎÚÔ¯ÚfiÓÈ· ‚¿ÛË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜6. ∏ ‚Ï¿‚Ë ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙˆÓ ·ÁÁ›ˆÓ Û˘Á¯ÚfiÓˆ˜ Ì ÙËÓ ·ÚÔ˘Û›· Î·È ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ fiˆ˜ ˘¤ÚÙ·ÛË, ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Î·È CMV Ïԛ̈ÍË ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ϋÚË ·fiÊÚ·ÍË ÙÔ˘ ·˘ÏÔ‡ ÙˆÓ ·ÚÙËÚÈÒÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ȉȷ›ÙÂÚË ÛËÌ·Û›· ·ÔÎÙ¿ Ë ˘ÔÎÏÈÓÈ΋ ·fiÚÚÈ„Ë ˆ˜ ˘Â‡ı˘ÓË ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ·ÔÙÂÏ› ¤Ó·Ó ·ÓÂÍ¿ÚÙËÙÔ ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÌÂȈ̤Ó˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜8,9.
∞¡Δπ-HLA ∞¡Δπ™øª∞Δ∞ Δ· ·ÓÙÈ-HLA ·ÓÙÈÛÒÌ·Ù· Ô˘ ·Ó·Ù‡ÛÛÔÓÙ·È ÌÂÙ¿ ÙËÓ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏÔ‡Ó ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ Ô ÔÔ›Ô˜ Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘.10,11,12 ∏ ·ÚÔ˘Û›· C4d ÛÙ· ÂÚÈÛˆÏËÓ·Úȷο ÙÚȯÔÂȉ‹ ·ÛıÂÓÒÓ Ì áª, ıˆÚÂ›Ù·È fiÙÈ ·ÔÙÂÏ› ¤ÎÊÚ·ÛË ÚfiÛÊ·Ù˘ ¤ÎıÂÛ‹˜ ÙÔ˘˜ Û ΢ÎÏÔÊÔÚÔ‡ÓÙ· ·ÓÙÈÛÒÌ·Ù· Ô˘ Ô‰ËÁÔ‡Ó Û ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜13.
∞¡O™O∫∞Δ∞™ΔO§∏ O ÚfiÏÔ˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ıÂڷ›·˜ ¤¯ÂÈ Â›Û˘ ‰ÈÂÚ¢ÓËı›. ¢‡Ô Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ‰ÂηÂÙ‹ ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ Û ·ÛıÂÓ›˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó CsA Û ۇÁÎÚÈÛË Ì ·˘ÙÔ‡˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó ·˙·ıÂÈÔÚ›ÓË.14,15 ∏ ÌÈÎÚÔÁ·Ï·Îو̷Ù҉˘ ÌÔÚÊ‹ CsA Î·È ÙÔ FK506 (Ù·ÎÚfiÏÈÌÔ˘˜) Û˘Ó‰¤ıËÎ·Ó Ì ÌÂÁ·Ï‡ÙÂÚË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ Û ۇÁÎÚÈÛË Ì ÙËÓ ·Ï·ÈfiÙÂÚË ÌÔÚÊ‹ ÂÏ·ÈÒ‰Ô˘˜ ‰È·Ï‡Ì·ÙÔ˜ CsA.16 ∏ ÚÔÛı‹ÎË MMF (Ì˘ÎÔÊÂÓÔϤ˚Ù ÌfiÊÂÙÈÏ) ÛÙÔ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Û¯‹Ì· Ì›ˆÛ ÙËÓ Û˘¯ÓfiÙËÙ· ÙfiÛÔ Ù˘ ÚÒÈÌ˘ fiÛÔ Î·È Ù˘ fi„ÈÌ˘ ÔÍ›·˜ ·fiÚÚȄ˘.17,18 ∂›Û˘, Ë ‰È·ÎÔ‹ ÙÔ˘ MMF ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·Ó¿Ù˘ÍË C4d ıÂÙÈ΋˜ ¯˘ÌÈ΋˜ ·fiÚÚȄ˘.19 ∏ ÔÈΛÏË ‚ÈԉȷıÂÛÈÌfiÙËÙ· Ù˘ per os CsA Û˘Û¯ÂÙ›˙ÂÙ·È Â›Û˘ Ì ÂÌÊ¿ÓÈÛË ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘.20,21.
ª∏ ™ÀªªOƒºø™∏ ∞™£∂¡OÀ™ ∏ ÌË Û˘ÌÌfiÚʈÛË ÛÙËÓ ·ÁˆÁ‹ ·ÔÙÂÏ› ÛËÌ·-
73
ÓÙÈ΋ ·ÈÙ›· ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞fi Ì›· ÌÂÙ·-·Ó¿Ï˘ÛË ÙˆÓ ÌÂÏÂÙÒÓ ÔÈ Butler Î·È Û˘Ó. ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ 22% ÂÚ›Ô˘ ÙˆÓ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (¡ª) ‰ÂÓ Û˘ÌÌÔÚÊÒÓÔÓÙ·Ó ÛÙË Ï‹„Ë ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Î·È Î·Ù¿ ̤ÛÔ fiÚÔ ÙÔ 35% ÙˆÓ ·ˆÏÂÈÒÓ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·Ú·ÙËÚÔ‡ÓÙ·Ó Û ·ÛıÂÓ›˜ Ì و¯‹ Û˘ÌÌfiÚʈÛË.22 O ΛӉ˘ÓÔ˜ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ÌË Û˘ÌÌÔÚÊÒÛÈÌÔ˘˜ ·ÛıÂÓ›˜ Â›Ó·È ÂÙ·Ï¿ÛÈÔ˜ Û ۇÁÎÚÈÛË Ì ϋÙ˜ ¡ª Ô˘ Ï·Ì‚¿ÓÔ˘Ó Î·ÓÔÓÈο ÙËÓ ·ÓÔÛÔηٷÛÙÔÏ‹. ¶·Ú¿ÁÔÓÙ˜ ÔÈ ÔÔ›ÔÈ Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ Ùˆ¯‹ Û˘ÌÌfiÚʈÛË ÙÔ˘ Ï‹ÙË Â›Ó·È Ë ÂÊË‚È΋ ËÏÈΛ·, Ë Û‡ÓıÂÙË Î·È ÔχÏÔÎË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, Ë ÌË Û˘ÌÌfiÚʈۋ ÙÔ˘ ÛÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ·ÈÌÔοı·ÚÛ˘, Ë ÎÔÈÓˆÓÈ΋ ·ÔÌfiÓˆÛË Î·È Ù· ÎÔÛÌËÙÈο ÚÔ‚Ï‹Ì·Ù· (˘ÂÚÙÚ›¯ˆÛË, ˘ÂÚÙÚÔÊ›· Ô‡ÏˆÓ Î·È ÚÔÛˆÂ›Ô Cushing).
¢∂π∫Δ∂™ ∞¡O™O§O°π∫∏™ ∞¶∞¡Δ∏™∏™ ª¤¯ÚÈ Û‹ÌÂÚ· ‰ÂÓ ‰È·ı¤ÙÔ˘Ì ÈÛÙÔÔÈË̤ÓÔ˘˜ ‰Â›ÎÙ˜ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÌ¤ÓˆÓ ·ÛıÂÓÒÓ. À¿Ú¯Ô˘Ó, fï˜, ‰Â‰Ô̤ӷ Ù· ÔÔ›· ‰Â›¯ÓÔ˘Ó ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛË ÔÚÈÛÌ¤ÓˆÓ ‰ÂÈÎÙÒÓ Î·È ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·fiÚÚȄ˘ ÌÂÙ¿ ÙËÓ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. §‹Ù˜ ¡ª Ì ˘„ËÏ‹ Û˘ÁΤÓÙÚˆÛË CD30 ÛÙÔÓ ÔÚfi ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ Î·È ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÒÏÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ Û ۇÁÎÚÈÛË Ì ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ¤¯Ô˘Ó ¯·ÌËÏ¿ ›‰· CD30 ÔÚÔ‡.23 ∂›Û˘, ˘„ËÏ¿ ›‰· Ù˘ CXCL 10 ΢ÙÔΛÓ˘ (> 150pg/ml) Û˘Û¯ÂÙ›ÛıËÎ·Ó Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚÒÈÌ˘ ÛÔ‚·Ú‹˜ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È ÂÌÊ¿ÓÈÛ˘ áª.24 Δ· ·ÓˆÙ¤Úˆ Â˘Ú‹Ì·Ù· ηٷ‰ÂÈÎÓ‡Ô˘Ó ÙÔÓ Ì›˙ÔÓ· ÚfiÏÔ ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÂͤÏÈÍË Ù˘ áª.
ª∏ ∞¡O™O§O°π∫Oπ ¶∞ƒ∞°O¡Δ∂™ ∫π¡¢À¡OÀ Δ∏™ ÃO¡π∞™ ¡∂ºƒO¶∞£∂π∞™ ªO™Ã∂Àª∞ΔO™ OÈ ÌË ·ÓÔÛÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ¤Ó·Ó ·ÚÈıÌfi ‚Ï·‚ÒÓ ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È Ó· ·˘Í‹ÛÔ˘Ó ¤ÙÛÈ ÙÔÓ Î›Ó‰˘ÓÔ ·ÒÙÂÚ˘ ·ÒÏÂÈ·˜ ÙÔ˘. OÈ ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È Ë ÌÂÁ¿ÏË ËÏÈΛ· ÙÔ˘ ‰fiÙË, Ë Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ë ÚԤϢÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ Ï‹ÙË ¡ª.
°P. MY™EP§H™
74 ∏§π∫π∞ ¢OΔ∏
∏ ÌÂÁ¿ÏË ËÏÈΛ· ÙÔ˘ ‰fiÙË ·ÔÙÂÏ› ÈÛ¯˘Úfi ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË Ùˆ¯‹˜ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ™Â ·Ó·ÛÎfiËÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ UNOS ÔÈ Cecka Î·È Û˘Ó ¤‰ÂÈÍ·Ó fiÙÈ ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ¿Óˆ ·fi 55 ÂÙÒÓ ·ÚÔ˘Û›·˙·Ó ÌÂȈ̤ÓË Î·Ù¿ 13% ÙÚÈÂÙ‹ ÂÈ‚›ˆÛË (78 ¤Ó·ÓÙÈ 65%) Û ۇÁÎÚÈÛË Ì ÓÂÊÚÈο ÌÔۯ‡̷ٷ ‰ÔÙÒÓ ÌÈÎÚfiÙÂÚ˘ ËÏÈΛ·˜. 2 ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ô Ú˘ıÌfi˜ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR) Î·È ÔÈ Âʉڛ˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù›ÓÔ˘Ó Ó· ÌÂÈÒÓÔÓÙ·È Ì ÙËÓ ¿ÚÔ‰Ô Ù˘ ËÏÈΛ·˜, ·Ó Î·È ÙÔ 1/3 ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ‰ÔÙÒÓ ‰È·ÙËÚÔ‡Ó Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÚfiÓÔ˘.25 ∂›Û˘, ¤Ó· ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ÚÔÂÚ¯fiÌÂÓÔ ·fi ËÏÈÎȈ̤ÓÔ ‰fiÙË Âȉ¤¯ÂÙ·È Î·È ¿ÏϘ ‚Ï¿‚˜. ŒÙÛÈ Â›Ó·È ·ÚÎÂÙ¿ ¢·›ÛıËÙÔ Û ‚Ï¿‚Ë Ë ÔÔ›· ÚÔηÏÂ›Ù·È Â›Ù ·fi ÙÔ˘˜ ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ‹ ·fi ÙËÓ ÔÍ›· ·fiÚÚÈ„Ë.26
‡ı˘ÓË ÁÈ· ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ë ÔÔ›· ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ·ÒÙÂÚË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘, ȉȷ›ÙÂÚ· Ì¿ÏÈÛÙ· fiÙ·Ó Û˘Ó‰˘¿˙ÂÙ·È Î·È Ì ÔÍ›· ·fiÚÚÈ„Ë30,31. ªÂ ÙËÓ ‚Ï¿‚Ë ÈÛ¯·ÈÌ›·˜-·ӷÈÌ¿ÙˆÛ˘ ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È ÔÈ toll-like ˘Ô‰Ô¯Â›˜32 ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ¤ÙÛÈ ÊÏÂÁÌÔÓÒ‰Ë Î·Ù¿ÛÙ·ÛË ÛÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ∂ÈϤÔÓ ‰ÈÂÁ›ÚÂÙ·È Ë ˆÚ›Ì·ÓÛË ÙˆÓ ‰ÂÓ‰ÚÈÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ·ÎÔÏÔ˘ı› ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜33. ™Â ¤‰·ÊÔ˜ ÈÛ¯·ÈÌÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ ÙˆÓ ÙˆÌ·ÙÈÎÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÂÎÊÚ¿˙ÔÓÙ·È HLA-DR ·ÓÙÈÁfiÓ· Î·È ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ ¿ӈ ÛÙ· ÂÈıËÏȷο ÛˆÏËÓ·Úȷο ·ÙÙ·Ú· Î·È ÂΉËÏÒÓÂÙ·È ÔÍ›· ·fiÚÚÈ„Ë34.
¶ƒO∂§∂À™∏ ¡∂ºƒπ∫OÀ ªO™Ã∂Àª∞ΔO™
∏ Û˘Ó˘¿Ú¯Ô˘Û· ÛÙÔÓ ‰fiÙË ÓÔÛËÚfiÙËÙ· ÌÔÚ› ›Û˘ Ó· ÂËÚ¿ÛÂÈ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ¶ÔÏÏÔ› و̷ÙÈÎÔ› ‰fiÙ˜ ·fi ηډȷÁÁÂȷο ÂÂÈÛfi‰È· ÏfiÁˆ ˘ÔΛÌÂÓ˘ ˘¤ÚÙ·Û˘, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ë/Î·È ·ÚÙËÚÈÔÛÎÏ‹Ú˘ÓÛ˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û‡Á¯ÚÔÓË ÚÔÛ‚ÔÏ‹ ÙˆÓ ÓÂÊÚÒÓ ·fi Ù· ·ÓˆÙ¤Úˆ ·›ÙÈ·27. ∏ ›وÛË Ù˘ ˘¤ÚÙ·Û˘ ‹ ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ÙÔ˘ ‰fiÙË ÛÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ Â›Ó·È ÛËÌ·ÓÙÈ΋ ‚Ú·¯˘ÚfiıÂÛÌ·. ª·ÎÚÔ¯ÚfiÓÈ· fï˜ Ë ÙÚÈÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È ÌÂȈ̤ÓË fiÙ·Ó ÚÔ¤Ú¯ÔÓÙ·È ·fi ‰fiÙ˜ Ì ·˘Ù¿ Ù· ÓÔÛ‹Ì·Ù·.28 ∏ ÛÔ˘‰·ÈfiÙËÙ· Ù˘ Û˘ÓÔ‰Ô‡ ÓÔÛËÚfiÙËÙ·˜ ÙÔ˘ ‰fiÙË Ê·›ÓÂÙ·È Â›Û˘ Î·È ·fi Ù· Â˘Ú‹Ì·Ù· Ù˘ CT (Collaborative Transplant) ªÂϤÙ˘ ÁÈ· ÙÔ˘˜ ˙ÒÓÙ˜ ‰fiÙ˜. ∞ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ¤Ï·‚·Ó ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ˙ÒÓÙ˜ ‰fiÙ˜ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 65 ÂÙÒÓ ·ÚÔ˘Û›·˙·Ó ÙËÓ ›‰È· ÂÓÙ·ÂÙ‹ ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ (78%) Ì ϋÙ˜ ¡ª ·fi ˙ÒÓÙ˜ ‰fiÙ˜ ÌÂٷ͇ 16 Î·È 40 ÂÙÒÓ29. ∏ ·Ô˘Û›· ÂÔ̤ӈ˜ Û˘ÓÔ‰Ô‡ ÓÔÛËÚfiÙËÙ·˜ ÙˆÓ ˙ÒÓÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ‰ÔÙÒÓ ˘ÂÚηχÙÂÈ Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ÙˆÌ·ÙÈÎÒÓ ‰ÔÙÒÓ.
∏ ÚԤϢÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (·fi ˙ÒÓÙ· ‹ و̷ÙÈÎfi ‰fiÙË) ·ÔÙÂÏ› ¤Ó·Ó ·ÎfiÌË Ì›˙ÔÓ· ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. Δ· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È Ì ÙÔ˘˜ ˙ÒÓÙ˜ Û˘ÁÁÂÓ›˜ ‹ ÌË-Û˘ÁÁÂÓ›˜ ‰fiÙ˜ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ و̷ÙÈÎÔ‡˜ HLA Û˘Ì‚·ÙÔ‡˜ ‰fiÙ˜ ÂÚÌËÓ‡ÔÓÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÓÂÊÚÈο ÌÔۯ‡̷ٷ ÙˆÓ ÚÒÙˆÓ ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ÌÂȈ̤ÓË ÓÂÊÚÈ΋ Ì¿˙· ‹/Î·È Û˘Ó˘¿Ú¯Ô˘Û˜ ·ÏÏÔÈÒÛÂȘ ÏfiÁˆ ËÏÈΛ·˜, ˘¤ÚÙ·Û˘ ‹ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË35. ∞ÎfiÌË, ÌÂÙ¿ ·fi ÂÁÎÂÊ·ÏÈο ·›ÙÈ· ı·Ó¿ÙÔ˘ (ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈΤ˜ ηÎÒÛÂȘ, Ú‹ÍË ·Ó¢ڢÛÌ¿ÙˆÓ ÂÁÎÂÊ¿ÏÔ˘, ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È·) ·Ú·ÙËÚÔ‡ÓÙ·È ‚·ÚÈ¿ ˘fiÙ·ÛË, ˘ÂÚËÎÙÈÎfiÙËÙ·, ˘ÔıÂÚÌ›· Î·È ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù· ÔÔ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘ÂډȤÁÂÚÛË ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÓÂÊÚÈ΋ ÈÛ¯·ÈÌ›·. ΔÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ˙ÒÓÙ· ‰fiÙË ‰ÂÓ ÂËÚ¿˙ÂÙ·È ÛËÌ·ÓÙÈο ·fi ÙËÓ ‚Ï¿‚Ë ÈÛ¯·ÈÌ›·˜-·ӷÈÌ¿ÙˆÛ˘ fiˆ˜ ÂÈÛËÌ¿ÓıËΠÚÔËÁÔ˘Ì¤Óˆ˜. O ÂÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜ ›Û˘, Û˘¯Ó¿ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ˘fiÙ·ÛË, ·‡ÍËÛË ÙˆÓ Î·Ù¯ÔÏ·ÌÈÓÒÓ, ·‡ÍËÛË Ù˘ ȤÛˆ˜ ÙÔ˘ ∂¡À Ù· ÔÔ›· Ô‰ËÁÔ‡Ó Û ˘ÂÚ·Ú·ÁˆÁ‹ ΢ÙÔÎÈÓÒÓ Î·È ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ˘ÂÚ¤ÎÊÚ·ÛË ·ÏÏÔ·ÓÙÈÁfiÓˆÓ Â¿Óˆ ÛÙ· ÂÈıËÏȷο ÛˆÏËÓ·Úȷο ·ÙÙ·Ú·36.
μ§∞μ∏ π™Ã∞πªπ∞™-∂¶∞¡∞πª∞Δø™∏™
ª∂πøª∂¡∏ ¡∂ºƒπ∫∏ ª∞∑∞
™À¡O¢O™ ¡O™∏ƒOΔ∏Δ∞
∏ ‚Ï¿‚Ë ÈÛ¯·ÈÌ›·˜- ·ӷÈÌ¿ÙˆÛ˘ Â›Ó·È ˘-
O ·˘ÍË̤ÓÔ˜ ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (Body
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Mass Index-BMI) ÙÔ˘ Ï‹ÙË Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÌÈÎÚfiÙÂÚË ÂÈ‚›ˆÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜37. ªÂÁ·ÏfiÛˆÌÔÈ ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ Ï·Ì‚¿ÓÔ˘Ó ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ÌÈÎÚfiÛˆÌÔ˘˜ ‰fiÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ù¿ 43% ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ۇÁÎÚÈÛË Ì ̤ÛÔ˘ ÌÂÁ¤ıÔ˘˜ Ï‹Ù˜ ÔÈ ÔÔ›ÔÈ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi ·ÚfiÌÔÈÔ˘˜ ‰fiÙ˜38. ¶ÚÔ˜ ÙÔ ·ÚfiÓ fï˜, Â›Ó·È ˘fi ‰ÈÂÚ‡ÓËÛË ·Ó Ë ÂÏ·Ùو̤ÓË ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·¯‡Û·ÚÎˆÓ ÏËÙÒÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ó·ÏÔÁÈο ÌÈÎÚfiÙÂÚË ÓÂÊÚÈ΋ Ì¿˙· ÙËÓ ÔÔ›· ‰¤¯ÔÓÙ·È Ë Û ·˘Ù‹ ÙËÓ ›‰È· Û˘ÓÔ‰fi ÓÔÛËÚfiÙËÙ¿ ÙÔ˘˜.
∫∞Δ∞™Δ∞™∂π™ ¶OÀ ™Ã∂Δπ∑O¡Δ∞π ª∂ ΔO¡ §∏¶Δ∏ ΔOÀ ¡∂ºƒπ∫OÀ ªO™Ã∂Àª∞ΔO™ ∏ ËÏÈΛ· ÙÔ˘ Ï‹ÙË ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ¤ÎÙˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. OÈ ËÏÈÎȈ̤ÓÔÈ Â›Û˘ ·ÛıÂÓ›˜, ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ı·Ó¿ÙÔ˘ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· ΢ڛˆ˜ ÂÍ·ÈÙ›·˜ ηډȷÁÁÂÈ·ÎÒÓ ·ÈÙ›ˆÓ2. OÈ ËÏÈÎȈ̤ÓÔÈ ·ÛıÂÓ›˜ Û ÔÏÏ¿ ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Ï·Ì‚¿ÓÔ˘Ó ÌÔۯ‡̷ٷ ·fi ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜. ∏ Ù·ÎÙÈ΋ ·˘Ù‹ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÚfiÏÔ Ô˘ ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· Ì ÙËÓ ÚÔÛ¤ÁÁÈÛË: ÌfiÛ¯Â˘Ì· ·fi ËÏÈÎȈ̤ÓÔ ‰fiÙË Û ËÏÈÎȈ̤ÓÔ Ï‹ÙË39. T· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÂÍËÁÔ‡ÓÙ·È ÂÓ Ì¤ÚÂÈ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÚˆÙÔÎfiÏÏˆÓ ÚÒÈÌ˘ ·ÔÊ˘Á‹˜ ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Î·È ÙËÓ ÌÂȈ̤ÓË ¯ÔÚ‹ÁËÛË ‹ ‰È·ÎÔ‹ ÙˆÓ ÛÙÂÚÔÂȉÒÓ Û ¯ÚfiÓÈ· ‚¿ÛË40. ∏ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·, Ë ˘ÂÚÏÈȉ·ÈÌ›·, Ë ˘¤ÚÙ·ÛË Î·È Ô ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Û˘ÓÈÛÙÔ‡Ó ·ÓÂÍ¿ÚÙËÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ ÓÂÊÚ·Û‚¤ÛÙˆÛË Î·È Ô ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ‰Â˘ÙÂÚÔ·ı‹˜ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi˜ Û˘ÓÈÛÙÔ‡Ó Â›Û˘ ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ Û‡Ìʈӷ Ì ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜41.
CMV §Oπªø•∏ ∏ CMV Ïԛ̈ÍË ÂËÚ¿˙ÂÈ ÙfiÛÔ ¤ÌÌÂÛ· (̤ۈ Ù˘ ÂÊ·ÚÌÔ˙fiÌÂÓ˘ ˘Ô·ÓÔÛÔηٷÛÙÔÏ‹˜) fiÛÔ Î·È ¿ÌÂÛ· ÙËÓ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ CMV Ïԛ̈ÍË Û˘Ó‰¤ÂÙ·È Ì ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ˘ÂÚÏ·Û›· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙˆÓ ·ÁÁ›ˆÓ Û ÂÚÈÙÒÛÂȘ Ùˆ¯‹˜ HLA Û˘Ì‚·ÙfiÙË-
75
Ù·˜ ‰fiÙË-Ï‹ÙË Î·È Ì ·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ·˘ÍË̤Ó˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘42,43,44.
¡∂ºƒOΔO•π∫OΔ∏Δ∞ Δø¡ ∞¡∞™ΔO§∂ø¡ Δ∏™ ∫∞§™π¡∂Àƒπ¡∏™ ∏ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ (CNIs) ıˆÚÂ›Ù·È ·fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ Ë Î‡ÚÈ· ·ÈÙ›· ÚÔԉ¢ÙÈ΋˜ ¤ÎÙˆÛ˘ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ΔfiÛÔ Ë Î˘ÎÏÔÛÔÚ›ÓË ∞ (CsA) fiÛÔ Î·È ÙÔ Ù·ÎÚfiÏÈÌÔ˘˜ (FK506) Ô‰ËÁÔ‡Ó ¯ÚÔÓ›ˆ˜ Û ‰È¿ÌÂÛË ›ÓˆÛË Î·È ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜. ∏ Û˘ÛÙËÌ·ÙÈ΋ ·Ó·ÛÎfiËÛË ÙˆÓ USRDS (United States Renal Data Sytem) ‰Â‰ÔÌ¤ÓˆÓ ¤‰ÂÈÍ ·ÚfiÌÔÈ· ·ÔÙÂϤÛÌ·Ù· ¤Î‚·Û˘ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ›Ù ÂÏ¿Ì‚·Ó·Ó ÌÈÎÚÔÁ·Ï·Îو̷ÙÒ‰Ë ÌÔÚÊ‹ CsA (Neoral®) ‹ Ù·ÎÚfiÏÈÌÔ˘˜16. ∂›Û˘ ·fi Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË ‚ÈÔ„ÈÒÓ ÚˆÙÔÎfiÏÏÔ˘ ‰ÂÓ Ê¿ÓËΠ‰È·ÊÔÚ¿ ÛÙÔÓ ‚·ıÌfi ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ ÌÂٷ͇ ÙˆÓ ‰‡Ô ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘45. ÕÏÏË ÌÂϤÙË Ë ÔÔ›· ·ÊÔÚÔ‡Û ϋÙ˜ ÓÂÊÚÈÎÔ‡ Î·È ·ÁÎÚ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó CNIs Î·È ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó Ì ·Ó¿ ¤ÙÔ˜ ‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘, ¤‰ÂÈÍ fiÙÈ ÛÙ· 10 ¯ÚfiÓÈ· fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ ›¯·Ó ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ·fi CNIs Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ ÛÙÔ 58,4% ÙˆÓ ·ÛıÂÓÒÓ Î·È ÛÎÏ‹Ú˘ÓÛË ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ÛÙÔ 37,3%46. ŸÙ·Ó ϤÔÓ ÂÁηٷÛÙ·ıÔ‡Ó ‰È¿ÌÂÛË ›ÓˆÛË Î·È ÛÎÏ‹Ú˘ÓÛË ÛÂÈÚ·Ì¿ÙˆÓ ÙfiÙÂ Ë ‚Ï¿‚Ë ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ÌË ·Ó·ÛÙÚ¤„ÈÌË. ∞fi ‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘ ›Û˘ ¤¯ÂÈ Ê·Ó› fiÙÈ Ë ·‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ 4 Ì‹Ó˜ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û¯ÂÙ›˙ÂÙ·È Ì ηχÙÂÚË GFR ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÏËÙÒÓ Û ۇÁÎÚÈÛË Ì ÙËÓ GFR ·ÛıÂÓÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ‰ÈfiÁΈÛË ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜47. OÈ Liphowitz Î·È Û˘Ó ·Ú·ÎÔÏÔ‡ıËÛ·Ó 91 ·ÛıÂÓ›˜ ÁÈ· 7-9 ¯ÚfiÓÈ· Ì ‚ÈÔ„›· ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÙfiÛÔ Û ÂÚÈÙÒÛÂȘ Âȉ›ӈÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ fiÛÔ Î·È Û ·ÒÏÂÈ· Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿˜ ÙÔ˘. ªÂÙÚÒÓÙ·˜ οı·ÚÛË ÈÔ‰ˆı·Ï·ÌÈÎÔ‡ ·Ú·Ù‹ÚËÛ·Ó fiÙÈ ÙÔ 65% ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘Û›·˙ ÛÙ·ıÂÚ‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ·Ú¿ ÙËÓ ‰È·Ù‹ÚËÛË ÂȤ‰ˆÓ CsA (trough levels) ÛÙ· 200ng/ml. OÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ·fi ΢ÎÏÔÛÔÚ›ÓË ∞ ÚÔηÏ› ÌÂÓ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÂӉ¯Ô̤ӈ˜ fï˜ ÌÔÚ› Ó· ¯ÔÚËÁÂ›Ù·È Û ÂÏ¿¯ÈÛÙË ‰fiÛË ¯ÚÔÓ›ˆ˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÙËÚ›-
76
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Ù·È ¤Ó· ȉ·ÓÈÎfi Â›Â‰Ô ·ÓÔÛÔηٷÛÙÔÏ‹˜48. ∏ ÂÏ·¯ÈÛÙÔÔ›ËÛË Ù˘ ‰fiÛ˘ Ù˘ CsA Ì ÛÙfi¯Ô ÛÙ·ıÂÚÔÔ›ËÛË ‹ ‚ÂÏÙ›ˆÛË Ù˘ GFR ·ÛıÂÓÒÓ Ì áª ÌÔÚ› Ó· ÂÈÙ¢¯ı› Û‹ÌÂÚ· Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË everolimus (mTOR ·Ó·ÛÙÔÏ›˜). OÈ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ› ·˘ÙÔ› ·Ú¿ÁÔÓÙ˜ ÂÊ·ÚÌfi˙ÔÓÙ·È Û ·ÛıÂÓ›˜ Ì ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ì GFR >30ml/min/1,73m2 Î·È ÂÊfiÛÔÓ Ë ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ Ù· 800mg/24h. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿ ˘¿Ú¯Ô˘Ó Î·È ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó ÛÙ·ıÂÚÔÔ›ËÛË ‹ ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ fiÙ·Ó ‰È·ÎfiÙÔÓÙ·È ‹ ÌÂÈÒÓÔÓÙ·È ÔÈ CNIs Ì ·Ú¿ÏÏËÏË ¯ÔÚ‹ÁËÛË MMF49. E›Û˘ ·fi ·ӷϷ̂·ÓfiÌÂÓ˜ ‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘ Ê¿ÓËΠÈÛÙÔÏÔÁÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ·ÚÙËÚÈÔÏÈÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ÙËÓ Ì›ˆÛË Ù˘ ‰fiÛ˘ Ù˘ CsA50. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÔÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Û ¯ÚfiÓÈ· ‚¿ÛË Ô‰ËÁÔ‡Ó Û ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∞fi ÙËÓ ¿ÏÏË fï˜ ÌÂÚÈ¿, ÌÔÚ› Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¯ˆÚ›˜ Ó· Ô‰ËÁÔ‡Ó Û ·ÒÏÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ fiÙ·Ó Ë ‰fiÛË ÙÔ˘˜ ÚÔÛ·ÚÌfi˙ÂÙ·È ·Ó¿ÏÔÁ· Ì ٷ ›‰· ÙÔ˘ ·›Ì·ÙÔ˜, ÙËÓ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÙËÓ ÁÂÓÈÎfiÙÂÚË ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙÔ ˘fiÏÔÈÔ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Û¯‹Ì·.
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ù·Ó Û˘Ì‚·›ÓÂÈ fi„ÈÌ· ÛÙËÓ ÔÚ›· Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ô‰ËÁ› Û˘Ó‹ıˆ˜ Û ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· Ì ‰È·Ú΋ Î·È Û˘ÛÙËÌ·ÙÈÎfi ÙÚfiÔ Î·È ·Ó¿ÏÔÁ· ÙÔ˘ ¯ÚfiÓÔ˘ Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘, Ë Âη›‰Â˘ÛË ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ÙËÓ ·Ó¿ÁÎË ·˘Ù‹˜ Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ı· ÚÔÛʤÚÂÈ ÌÈ· ¤ÁηÈÚË ‰È·›ÛÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Î·È Èı·Ó¿ ÂÈÙ˘¯‹ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘.
ªË ·ÓÔÛÔÏÔÁÈο ·›ÙÈ· Δ· ÂÚÈÛÛfiÙÂÚ· ·fi ·˘Ù¿ Ù· ·›ÙÈ· Â›Ó·È ‰˘ÓËÙÈο ·Ó·ÛÙÚ¤„ÈÌ· Î·È Èı·Ó¿ Ë ÂÊ·ÚÌÔÁ‹ ÚÔÏËÙÈÎÒÓ Ì¤ÙÚˆÓ Ó· ÚÔÛʤÚÂÈ Î·ı˘ÛÙ¤ÚËÛË ‹ ·Ó·ÛÙÔÏ‹ Ù˘ áª. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë ÛÙËÓ ·Ú¯È΋ Ê¿ÛË Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ı· Ú¤ÂÈ Ó· Á›ÓÂÈ ÚÔÛ¿ıÂÈ· ÂÚ·ÈÙ¤Úˆ Ì›ˆÛ˘ Ù˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ·ÁÁÂÏÌ·ÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ê·›ÚÂÛ˘ ÔÚÁ¿ÓˆÓ Î·È ·ÔÊ˘Á‹˜ ÙÚ·˘Ì·ÙÈÎÒÓ ‚Ï·‚ÒÓ Î·È ›Ûˆ˜ ¯ÚËÛÈÌÔÔ›ËÛË ÂÚÈÛÛfiÙÂÚÔ ‚ÈÔÛ˘Ì‚·ÙÒÓ ‰È·Ï˘Ì¿ÙˆÓ Û˘ÓÙ‹ÚËÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ÂÊ·ÚÌÔÁ‹ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ÁÈ· ·Ô‰Ô¯‹ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (‰fiÙ˜ ÓÂÊÚÔ‡ ÌÂÁ¿Ï˘ ËÏÈΛ·˜, Ì ·ÚÔ˘Û›· ‰È·‚‹ÙÔ˘ Î·È ˘¤ÚÙ·Û˘ ÎÏ) ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÂÍ·Ú¯‹˜ ÌÂȈ̤ÓË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û de novo ÌÂÙ·ÌÔۯ‡ÛÂȘ Î·È ÂÚÈÔÚÈṲ̂ÓË ‰È¿ÚÎÂÈ· ÓÂÊÚÈ΋˜ ˙ˆ‹˜ Û ·ÚÎÂÙÔ‡˜ ·ÛıÂÓ›˜. ∏ ÙÔÔı¤ÙËÛË Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ϋÙ˜ ÌÂÙ¿ ·fi ۯ‰ȷṲ̂ÓË ÔÏÈÙÈ΋ (.¯. ηٿÏÏËÏÔÈ Ï‹Ù˜ ÌÂÁ¿Ï˘ ËÏÈΛ·˜ Ì ÌÈÎÚfi ÚÔÛ‰fiÎÈÌÔ ˙ˆ‹˜) ¯ÔÚ‹ÁËÛË ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ì ‰˘ÓËÙÈο ÌÂȈ̤ÓË Èı·ÓfiÙËÙ· ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜, Èı·Ó¿ Ë en block ÙÔÔı¤ÙËÛË Î·È ÙˆÓ ‰‡Ô ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ¤Ó·Ó Ï‹ÙË, Ë ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ ÎÏ, ı· ÌÔÚÔ‡Û ӷ Ô‰ËÁ‹ÛÂÈ Û ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È ÛˆÛÙfiÙÂÚË ¯Ú‹ÛË Ù¤ÙÔÈˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. O ·˘ÛÙËÚfi˜ ¤ÏÂÁ¯Ô˜ ‰È·‚‹ÙÔ˘ Î·È Ë Ú‡ıÌÈÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Û‡Ìʈӷ Ì ÙȘ ÎÏÈÓÈΤ˜ Ô‰ËÁ›Â˜ ·ÓÙÈÌÂÙÒÈÛ˘ ˘¤ÚÙ·Û˘ Û ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ÓfiÛÔ (∞¶ < 125/85, ¯ÔÚ‹ÁËÛË ·-ª∂∞ ‹ ·Ó·ÛÙÔϤˆÓ ˘Ô‰Ô¯¤ˆÓ ∞ππ Ù˘ ·ÁÁÂÈÔÙ·Û›Ó˘), Ë ‰È·Ù‹ÚËÛË Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÏÈȉ·ÈÌÈÎÔ‡ ÚÔÊ›Ï Î·È ·Ó¿ÏÔÁ· Ì ÙÔÓ ÚÔÛ‰ÈÔÚÈ˙fiÌÂÓÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ (ÛÙ·Ù›Ó˜, ¿ÏÏ· Ê¿Ú̷η) Â›Ó·È ··Ú·›ÙËÙ˜ ÚÔ¸Ôı¤ÛÂȘ ÁÈ·
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ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ áª. ŸÛÔÓ ·ÊÔÚ¿ ÙȘ ÏÔÈÌÒÍÂȘ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· Û›ÁÔ˘ÚÔ fiÙÈ ·˘Ù¤˜ Ô‰ËÁÔ‡Ó Û áª, fï˜ Ë ÚfiÏË„Ë ÂÌÊ¿ÓÈÛ˘ ÏÔÈÌÒÍÂˆÓ Î·È Ë ıÂÚ·¤È· ÙÔ˘˜ fiˆ˜ Ë CMV Î.¿. ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ‚¿ÛÂÈ Î·ıÈÂڈ̤ÓÔ˘ ÚˆÙÔÎfiÏÏÔ˘ Î·È ·Ó¿ÏÔÁ· ÙÔÓ ·ÛıÂÓ‹. ΔÔ Î¿ÓÈÛÌ· Ê·›ÓÂÙ·È fiÙÈ ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÚÔԉ¢ÙÈ΋ ¤ÎÙˆÛË ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ŒÙÛÈ ı· Ú¤ÂÈ Ó· Û˘ÓÈÛÙ¿Ù·È Ë ‰È·ÎÔ‹ ÙÔ˘ Î·È Ó· Á›ÓÂÙ·È Û˘Ó¯‹˜ ÚÔ·Á¿Ó‰· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÙÔ˘. ∏ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· Â›Ó·È Î·È ·˘Ùfi˜ ¤Ó·˜ ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÛËÌ¿‰È Û›ÁÔ˘Ú˘ áª Î·È ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ ·Ó·˙‹ÙËÛË ÙÔ˘ ·ÈÙ›Ô˘ (Èı·Ó¿ ˘ÔÙÚÔ‹ Ù˘ ‚·ÛÈ΋˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘, ᪠‹ de novo ÂÌÊ¿ÓÈÛË ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›ÙȉԘ) Î·È Ë ÂÊ·ÚÌÔÁ‹ οÔÈˆÓ ıÂڷ¢ÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ Èı·Ó¿ ı· ‚ÔËıÔ‡Û ÛÙËÓ ·Ó·ÛÙÔÏ‹ ‹ ηı˘ÛÙ¤ÚËÛË ·ÒÏÂÈ·˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ™˘ÌÂÚ·ÛÌ·ÙÈο ÁÈ· ÙËÓ ÚÒÈÌË ·Ó›¯Ó¢ÛË ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ Î·È ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘, Ô ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÂÈ ÙË Û˘ÌÌfiÚʈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙËÓ ·ÁˆÁ‹ ÙÔ˘, Ó· ÂϤÁ¯ÂÈ ÛÙÂÓ¿ Î·È Î·Ù¿ Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·, ·Ó¿ÏÔÁ· Î·È Ù˘ ¯ÚÔÓÈ΋˜ ‰È¿ÚÎÂÈ·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÙËÓ ÓÂÊÚÈ΋ ÙÔ˘ ÏÂÈÙÔ˘ÚÁ›·, Ó· οÓÂÈ ÁÚ‹ÁÔÚË ‰È¿ÁÓˆÛË Ù˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÎfiÌË Î·È Ì ‚ÈÔ„›· ÙÔ˘ ÓÂÊÚÔ‡, Ó· ·Ú¤¯ÂÈ ÂÈıÂÙÈ΋ ıÂڷ›· Ù˘ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘, Ù˘ ˘ÂÚÏÈȉ·ÈÌ›·˜ Î·È Ó· ‚ÔËı¿ ÛÙËÓ ‰È·ÎÔ‹ ÙÔ˘ ηӛÛÌ·ÙÔ˜, fiˆ˜ Î·È Ó· ÚÔÛ·ı› Ó· ›ÛÂÈ ÁÈ· ÙËÓ ·Ó¿ÁÎË ·ÏÏ·Á‹˜ ÙÚfiÔ˘ ˙ˆ‹˜ (¿ÛÎËÛË, ‰›·ÈÙ·, Ì›ˆÛË ÛˆÌ·ÙÈÎÔ‡ ‚¿ÚÔ˘˜) ÌÂÈÒÓÔÓÙ·˜ ¤ÙÛÈ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÂÌÊ¿ÓÈÛË ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜.
∂ÈÏÂÁ̤ÓË ‚È‚ÏÈÔÁÚ·Ê›· 1. Nankivell BJ, Borrows R, Fung C, et al. The natural history of chronic allograft nephropathy. N Engl J Med 2003; 349:2326-2332. 2. Pascual M, Theruvath T, Kawai T, et al. Strategies to improve long term outcomes after renal transplantation. N Engl J Med 2002; 346:580-590. 3. Matas A, Humar A, Gillingham K et al. Five preventable causes of kidney graft loss in 1990s: a single center analysis. Kidney Inte 2002;62:704-708. 4. Colvin RB. Chronic allograft nephropathy. N Engl J Med 2003; 349:2287-2291.
XÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ – ™‡Á¯ÚÔÓ˜ ıÂڷ¢ÙÈΤ˜ ηÙ¢ı‡ÓÛÂȘ
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¢ËÌ‹ÙÚÈÔ˜ ™. °Ô‡ÌÂÓÔ˜
∂ÈÛ·ÁˆÁ‹
ÙËÓ ÂÌÊ¿ÓÈÛË ¤ÎÙˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË Î·È Ô ı¿Ó·ÙÔ˜ ·fi ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, Ô ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Î·È Ë Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ë ·ÚÔ˘Û›· ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘, ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È Ë ·ÚÔ˘Û›· ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘.
∏ ÚfiÏË„Ë ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È Ë Ì·ÎÚÔ¯ÚfiÓÈ· ‰È·Ù‹ÚËÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÓÂÒÙÂÚ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η, ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ (΢ÎÏÔÛÔÚ›ÓË ‹ tacrolimus) Î·È mycophenolate mofetil (MMF), ¤¯Ô˘Ó ÌÂÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÔÍ›·˜ ·fiÚÚȄ˘, Ë ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ·ÒÏÂÈ·˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ. O ı¿Ó·ÙÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì·, ÏfiÁˆ ηډȷÁÁÂÈ·ÎÒÓ ·ÈÙ›ˆÓ, ηÎÔ‹ıÂÈ·˜ ‹ Ïԛ̈͢ Î·È Ë ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ·ÔÙÂÏÔ‡Ó Ù· Û˘¯ÓfiÙÂÚ· ·›ÙÈ· ·ÒÏÂÈ·˜ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û‹ÌÂÚ·. Δ· ÎÔÚÙÈÎÔÂȉ‹ Î·È ÔÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·ıËڈ̿وÛ˘, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ Û˘Óԉ‡ÂÙ·È ·fi ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·. ªÂ ÛÎÔfi ÙËÓ Î·Ï‡ÙÂÚË ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ¤¯ÂÈ ÂȯÂÈÚËı› Ë Ì›ˆÛË Ù˘ ‰fiÛ˘ ‹ Ë ‰È·ÎÔ‹ ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Û ̷ÎÚÔ¯ÚfiÓÈ· Û¯‹Ì·Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜.
πÛÙÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο OÈ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÊÔÚÔ‡Ó ÛÙ· ·ÁÁ›·, ÛÂÈÚ¿Ì·Ù·, ‰È¿ÌÂÛÔ ¯ÒÚÔ Î·È ÂÈıËÏȷο ÛˆÏËÓ·Úȷο ·ÙÙ·Ú·. ΔÔ ÙÔ›¯ˆÌ· ÙˆÓ ·ÁÁ›ˆÓ Â›Ó·È Â·¯˘Ṳ̂ÓÔ ·fi ÙËÓ Û˘ÛÛÒÚ¢ÛË ¯·Ï·ÚÔ‡ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÔÚÁ·ÓˆÌ¤ÓÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ ˘fi ÙÔÓ ¤Ûˆ ¯ÈÙÒÓ· Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ÔÈΛÏÔ˘ ‚·ıÌÔ‡ ‰È‹ıËÛË ·fi ÌÔÓÔ‡ÚËÓ·, ˘ÂÚÏ·Û›· ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ Î·È Ú‹ÍË Ù˘ ÂÏ·ÛÙÈ΋˜ ÛÙÈ‚¿‰·˜. ∏ ÊÏÂÁÌÔÓ‹ Î·È Ë ‚Ï¿‚Ë ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ¤¯Ô˘Ó ›Û˘ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ¿¯˘ÓÛË Î·È ÚÔԉ¢ÙÈ΋ ÛÙ¤ÓˆÛË ÙÔ˘ ·˘ÏÔ‡ ÙÔ˘ ·ÁÁ›Ԣ. ΔÔ ÙÔ›¯ˆÌ· ÙÔ˘ ÛÂÈÚ·Ì·ÙÈÎÔ‡ ÙÚȯÔÂȉԇ˜ ÌÔÚ› Ó· Â›Ó·È Â·¯˘Ṳ̂ÓÔ Ì ÂÈÎfiÓ· ‰ÈÏ‹˜ ·Ú˘Ê‹˜, fiˆ˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ÌÂÌ‚Ú·ÓÔ¸ÂÚÏ·ÛÙÈ΋˜ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜ (™¡). ∏ ·ÚÔ˘Û›· ‰ÈÏ‹˜ ·Ú˘Ê‹˜ ıˆÚÂ›Ù·È ÙÔ ÈÔ ÂȉÈÎfi ‡ÚËÌ· ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÂÓÒ ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ ÙÌËÌ·ÙÈ΋ ‹ ‰È¿¯˘ÙË ÛÎÏ‹Ú˘ÓÛË. ™ÙËÓ ÂͤٷÛË ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ ‰ÂÓ ‰È·ÈÛÙÒÓÂÙ·È ·ÚÔ˘Û›· ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ‹ ÛÙÔȯ›ˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ ÛÙ· ÛÂÈÚ¿Ì·Ù·, ·ÏÏ¿ ÛÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ ·Ú·ÙËÚÂ›Ù·È ‰È›ۉ˘ÛË ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Û˘ÛÛÒÚ¢ÛË ËÏÂÎÙÚÔ-‰È·Ê·ÓÔ‡˜ ˘ÏÈÎÔ‡ ÛÙÔÓ ˘ÂÓ‰ÔıËÏÈ·Îfi ¯ÒÚÔ. H ‚Ï¿‚Ë ÙÔ˘ ‰È¿ÌÂÛÔ˘ ¯ÒÚÔ˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÔÈΛÏÔ˘ ‚·ıÌÔ‡ ›ÓˆÛË Î·È ‰È‹ıËÛË ·fi ÏÂÌÊÔ·ÙÙ·Ú· Î·È Ï·ÛÌ·ÙÔ·ÙÙ·Ú·, ÂÓÒ Û˘Ó˘¿Ú¯ÂÈ ·ÙÚÔÊ›· ÙˆÓ ÂÈıËÏÈ·ÎÒÓ ÛˆÏËÓ·ÚÈ·ÎÒÓ Î˘Ù-
∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ∏ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÂΉËÏÒÓÂÙ·È Ì ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™˘Ó‹ıˆ˜ ·Ú·ÙËÚÂ›Ù·È ÚÔԉ¢ÙÈ΋ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË Î·È ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·. ∏ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚ› Ó· ÂÎÙÈÌËı› Ì ·ӷϷ̂·ÓfiÌÂÓ˜ ÌÂÙÚ‹ÛÂȘ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡, ·ÏÏ¿ ÈÔ ·ÍÈfiÈÛÙË Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ Ì ÙËÓ Â͛ۈÛË Cockroft-Gault Ô˘ Ï·Ì‚¿ÓÂÈ ˘fi„Ë ÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜, ÙËÓ ËÏÈΛ· Î·È ÙËÓ ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡. OÈ Î˘ÚÈfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ÌÂ
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ù¿ÚˆÓ. Δ· Â˘Ú‹Ì·Ù· ·˘Ù¿ Â›Ó·È ÌË ÂȉÈο Î·È ·Ó¢ڛÛÎÔÓÙ·È Î·È Û ¿ÏϘ ηٷÛÙ¿ÛÂȘ, fiˆ˜ ÛÙË ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ·fi ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· Â˘Ú‹Ì·Ù· Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ Î·È ·ÁÁÂȷ΋˜ ‚Ï¿‚˘ Â›Ó·È ÈÔ ÂȉÈο ÁÈ· ÙË ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ë ÂÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ (Ù·ÍÈÓfiÌËÛË Î·Ù¿ Banff) Á›ÓÂÙ·È Ì ‚¿ÛË ÙËÓ ›ÓˆÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ¯ÒÚÔ˘ Î·È ÙÔÓ ‚·ıÌfi ·ÙÚÔÊ›·˜ Î·È ·ÒÏÂÈ·˜ ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ, ‰ÈfiÙÈ ÔÈ ‚Ï¿‚˜ ·˘Ù¤˜ Â›Ó·È ÈÔ ‰È¿¯˘Ù˜ Î·È ÌÔÚÔ‡Ó Ó· ÂÎÙÈÌËıÔ‡Ó Î·È Û ÌÈÎÚ¿ ‰Â›ÁÌ·Ù· ‚ÈÔ„›·˜. ∏ ·ÚÔ˘Û›· ›ÓˆÛ˘ Î·È ·ÙÚÔÊ›·˜ ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ ÛÙÔ 6-25% Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ÊÏÔÈÔ‡ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ‹È· (‚·ıÌfi˜ π), ÛÙÔ 2650% Ù˘ ÂÈÊ¿ÓÂÈ·˜ ˆ˜ ̤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ (‚·ıÌfi˜ ππ) Î·È Û ÔÛÔÛÙfi ¿Óˆ ÙÔ˘ 50% ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ ˆ˜ ÛÔ‚·Ú‹ (‚·ıÌfi˜ ‚·Ú‡ÙËÙ·˜ πππ). ∏ ÓÂÊÚÔ¿ıÂÈ· Ù·ÍÈÓÔÌÂ›Ù·È Â›Û˘ Û ‰‡Ô ˘fiÙ˘Ô˘˜ (· Î·È ‚) ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÚÔ˘Û›· ÌfiÓÔ ÛˆÏËÓ·Úȷ΋˜ ·ÙÚÔÊ›·˜ Î·È ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ (·) ‹ Î·È ÙËÓ Ù·˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ÛÂÈÚ·Ì·ÙÈ΋˜ Î·È ·ÁÁÂȷ΋˜ ‚Ï¿‚˘ (‚).
¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ∏ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÈÛÙÔÏÔÁÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Ô˘ ¤¯Ô˘Ó ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∏ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Î·È Û ¿ÏϘ ηٷÛÙ¿ÛÂȘ, fiˆ˜ ˘ÔÙÚÔ‹ ‹ de novo ÂÌÊ¿ÓÈÛË ™¡, ÓÂÊÚÔ¿ıÂÈ· ·fi Èfi μ∫, fi„ÈÌË ‹ ˘ÔÙÚÔÈ¿˙Ô˘Û· ÔÍ›· ·fiÚÚÈ„Ë, ÛÙ¤ÓˆÛË ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ Î·È ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ· Ô˘ Ú¤ÂÈ Ó· ‰È·ÎÚ›ÓÔÓÙ·È ·fi ÙË ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‚Ï¿‚˘ ¯Ú‹˙ÂÈ ‰È·ÊÔÚÈ΋˜ ‰È¿ÁÓˆÛ˘ ·fi ÙË ÌÂÌ‚Ú·ÓÔ¸ÂÚÏ·ÛÙÈ΋ ™¡ Ô˘ ÔÊ›ÏÂÙ·È Û ˷ٛÙȉ· C Î·È ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› de novo ‹ ÏfiÁˆ ˘ÔÙÚÔ‹˜ Ù˘ ÚˆÙÔ·ıÔ‡˜ ÓfiÛÔ˘. ÷ڷÎÙËÚÈÛÙÈÎfi ‡ÚËÌ· Ù˘ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Ë ¤ÏÏÂÈ„Ë ˘ÂÓ‰ÔıËÏÈ·ÎÒÓ ÂÓ·Ôı¤ÛˆÓ. ∏ ·ÚÔ˘Û›· ˘·Ï›Ó˘ ÛÙ· ·ÚÙËÚÈfiÏÈ· Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ·fi ΢ÎÏÔÛÔÚ›ÓË. ŸÙ·Ó Û˘Ó˘¿Ú¯ÂÈ Ì ›ÓˆÛË Î·È ·ÙÚÔÊ›· ÙÔ˘ ‰È·ÌÂÛÔ˘ÛˆÏËÓ·ÚÈ·ÎÔ‡ ¯ÒÚÔ˘ ˘Ô‰ËÏÒÓÂÈ ÙËÓ ·ÚÔ˘Û›· ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ·fi ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘, ·ÏÏ¿ Ë ‰È¿ÎÚÈÛË ‰ÂÓ Â›Ó·È ¿ÓÙÔÙ ‡ÎÔÏË, ÂÓÒ ÌÔÚ› ÛÙËÓ ›‰È· ‚ÈÔ„›· Ó· ˘¿Ú¯Ô˘Ó ·ÏÏÔÈÒÛÂȘ
81
Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙË ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÛÙËÓ ÙÔÍÈÎfiÙËÙ· ÙˆÓ Ê·Ú̿ΈÓ. ∏ ·ÚÔ˘Û›· ıÂÙÈ΋˜ ¯ÚÒÛ˘ ÁÈ· ÙÔ C4d Â›Ó·È Û˘Ó‹ıˆ˜ ÂÓ‰ÂÈÎÙÈ΋ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.
¶·ıÔÁ¤ÓÂÈ· ∏ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· Â›Ó·È ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ›‰Ú·Û˘ ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ, ·ÓÔÛÔÏÔÁÈÎÒÓ Î·È ÌË. ∏ ·ÚÔ˘Û›· ·ÓÔÛÔÏÔÁÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ·Ô‰ÂÈÎÓ‡ÂÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÌÔۯ‡̷ٷ Ì ηχÙÂÚË Û˘Ì‚·ÙfiÙËÙ· ÌÂٷ͇ ‰fiÙË Î·È Ï‹ÙË ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ï‡ÙÂÚË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË, ÂÓÒ Ë ‰È·ÎÔ‹ Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ (ÏfiÁˆ ÌË Û˘ÌÌfiÚʈÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜) ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ΢ÙÙ·ÚÈ΋ ·ÓÔÛ›· Ì ÂÈ‚Ú·‰˘ÓfiÌÂÓÔ˘ Ù‡Ô˘ ¢·ÈÛıËÛ›· Î·È Û˘ÌÌÂÙÔ¯‹ Ì·ÎÚÔÊ¿ÁˆÓ Î·È CD4(+) Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ë ¯˘ÌÈ΋ ·ÓÔÛ›· Ì ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ΢ÙÙ¿ÚˆÓ ÙÔ˘ ‰fiÙË, ΢ÙÙ·ÚÔΛÓ˜ (Á-ÈÓÙÂÚÊÂÚfiÓË, ÈÓÙÂÚÏ¢ΛÓ˜), ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (PDGF, HGF, TGF-beta) Î·È ·ÁÁÂÈÔÛ˘Û·ÛÙÈο ÂÙ›‰È·, fiˆ˜ Ë ÂÓ‰ÔıËÏ›ÓË, Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÂÌÊ¿ÓÈÛË Î·È ÂͤÏÈÍË Ù˘ ‚Ï¿‚˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ ·ÚÔ˘Û›· ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ Û¯ÂÙ›˙ÂÙ·È Ì ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi Â›Ó·È ·Ó·Áη›· Ë Â·Ú΋˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹. OÚÈṲ̂ӷ fï˜ Ê¿Ú̷η, fiˆ˜ ÔÈ ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘, ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ¯ÚfiÓÈ·˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜, Ë ÔÔ›· Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË (‰fiÛË Î˘ÎÏÔÛÔÚ›Ó˘ >5mg/kg™μ/Ë̤ڷ ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË). °È· ÙÔ ÏfiÁÔ ·˘Ùfi Û‹ÌÂÚ· Ù· Ê¿Ú̷η ·˘Ù¿ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û ÌÈÎÚfiÙÂÚ˜ ‰fiÛÂȘ ‹ ·ÔÛ‡ÚÔÓÙ·È ·fi ÙÔ ·ÓÛÔηٷÛÙ·ÏÙÈÎfi Û¯‹Ì· ÌÂÙ¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ Î˘ÚÈfiÙÂÚÔÈ ÌË ·ÓÔÛÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÂÌÊ¿ÓÈÛË ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Ë Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ô˘ Û˘Ó‹ıˆ˜ ÔÊ›ÏÂÙ·È Û ÔÍ›· ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë, Ë ˘ÂډȋıËÛË, Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, Ë ˘ÂÚÏÈȉ·ÈÌ›· Î·È Ë ÂÌÊ¿ÓÈÛË ˘ÔÙÚÔ‹˜ ‹ de novo ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·˜. O Û˘Ó‰˘·ÛÌfi˜ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ, ÈÛ¯·ÈÌ›·˜ Ì ÂÍ¿ÏÂÈ„Ë ÙˆÓ ÂÚÈÛˆÏËÓ·ÚÈ·ÎÒÓ ÙÚȯÔÂȉÒÓ, ÊÏÂÁÌÔÓˆ‰ÒÓ ÂÚÂıÈÛÌ¿ÙˆÓ Ì ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ Î·È ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ
82
¢. °OYMENO™
(TGF-beta) ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙË ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë Î·È ÙË ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Û ÌÂÛÂÁ¯˘Ì·ÙÈο Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ú·ÁˆÁ‹ Û˘ÛÙ·ÙÈÎÒÓ Ù˘ ıÂ̤ÏÈ·˜ Ô˘Û›·˜ Ô˘ Û˘ÛÛˆÚ‡ÔÓÙ·È ÛÙÔ ‰È·ÌÂÛÔÛˆÏËÓ·ÚÈ·Îfi ¯ÒÚÔ Î·È Ô‰ËÁÔ‡Ó Û ›ÓˆÛË. ™Â ‚ÈÔ„›Â˜ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ Á›ÓÔÓÙ·È ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘) ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ‰‡Ô Ê¿ÛÂȘ ‚Ï¿‚˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÚÒÈÌË ‚Ï¿‚Ë, Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ¯ÚfiÓÔ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÚÔηÏÂ›Ù·È Î˘Ú›ˆ˜ ·fi ·ÓÔÛÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ ÔÍ›· Î·È ÂÈ̤ÓÔ˘Û· ˘ÔÎÏÈÓÈ΋ ·fiÚÚÈ„Ë, ·ÏÏ¿ Î·È ·fi ÈÛ¯·ÈÌ›·. ∏ ‚Ï¿‚Ë ·Ú¯›˙ÂÈ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Ê¿ÛË ÈÛ¯·ÈÌ›·˜ - ·ӷÈÌ¿ÙˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÁÚ‹ÁÔÚË ÂÌÊ¿ÓÈÛË ›ÓˆÛ˘ ÙÔ˘ ‰È¿ÌÂÛÔ˘ ¯ÒÚÔ˘, Ë ÔÔ›· ηٿ ÙË Ê¿ÛË ·˘Ù‹ ˘ÂÚ‚·›ÓÂÈ ÙË ‚·Ú‡ÙËÙ· Ù˘ ÛˆÏËÓ·Úȷ΋˜ ·ÙÚÔÊ›·˜. ∏ ËÏÈΛ· ÙÔ˘ ‰fiÙË, ÙÔ ·›ÙÈÔ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, Ë ‡·ÚÍË ¤ÎÙˆÛ˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ë ¯Ú‹ÛË ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÒÓ Ê¿Ú̷ΈÓ, Ô ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, Ë ·ÚÔ˘Û›· ÂÂÈÛÔ‰›ˆÓ ·fiÚÚȄ˘ ‹ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ·fi Ê¿Ú̷η ÂÓ¤¯ÔÓÙ·È ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÚÒÈÌ˘ ·˘Ù‹˜ ‚Ï¿‚˘. ∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi μ∫ Ô‰ËÁ› ›Û˘ Û ¯ÚfiÓÈ· ‰È·ÌÂÛÔÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë Ì ÌË ÂȉÈΤ˜ ·ÏÏÔÈÒÛÂȘ ›ÓˆÛ˘ Î·È ·ÙÚÔÊ›·˜ 3-12 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ¯Ú‹˙ÂÈ ‰È·ÊÔÚÈ΋˜ ‰È¿ÁÓˆÛ˘ ·fi ÙË ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜. ∏ ¤ÓÙÔÓË ·ÓÔÛÔηٷÛÙÔÏ‹ Ô‰ËÁ› Û ·Û˘Ìو̷ÙÈ΋ ·ӷ‰Ú·ÛÙËÚÈÔÔ›ËÛË ÙÔ˘ ÈÔ‡ Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. O Èfi˜ ÔÏÏ·Ï·ÛÈ¿˙ÂÙ·È ÛÙ· ÛˆÏËÓ¿ÚÈ· Î·È Û¯ËÌ·Ù›˙ÂÈ ¤ÁÎÏÂÈÛÙ·, ÂÓÒ ·Ú·ÙËÚÂ›Ù·È ÂÓÂÚÁÔÔ›ËÛË ÌÔÓÔ΢ÙÙ¿ÚˆÓ, ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ, Ï·ÛÌ·ÙÔ΢ÙÙ¿ÚˆÓ Ì ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Ô˘ ÌÔÈ¿˙ÂÈ Ì ÔÍ›· ·fiÚÚÈ„Ë, ·ÏÏ¿ ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ·ÚÙËÚ›Ùȉ·˜ Î·È ÂÓ·fiıÂÛ˘ C4d. ∏ ÚÒÈÌË ‚Ï¿‚Ë ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ˘·Ï›ÓˆÛ˘ ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ Î·È ÛÙ¤ÓˆÛ˘ ÙÔ˘ ·˘ÏÔ‡ ÙˆÓ ÌÈÎÚÒÓ ·ÁÁ›ˆÓ, ÛÂÈÚ·Ì·ÙÈ΋˜ ÛÎÏ‹Ú˘ÓÛ˘ Î·È ÚÔԉ¢ÙÈ΋˜ Âȉ›ӈÛ˘ Ù˘ ›ÓˆÛ˘ Î·È ·ÙÚÔÊ›·˜ ÙÔ˘ ‰È·ÌÂÛÔÛˆÏËÓ·ÚÈ·ÎÔ‡ ¯ÒÚÔ˘. ∏ ÂÈÎfiÓ· ·˘Ù‹ ıˆÚÂ›Ù·È fiÙÈ ·ÓÙÈÚÔۈ‡ÂÈ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ·fi ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘. ∏ ·ÚÔ˘Û›· Ù·ÈÓÈÔÂȉԇ˜ ›ÓˆÛ˘ Î·È ˘·Ï›ÓˆÛ˘ ÙˆÓ ·ÚÙËÚÈÔ-
Ï›ˆÓ Ì ‹ ¯ˆÚ›˜ ·ÔÙÈÙ¿ÓˆÛË ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ ‰È·ÈÛÙÒÓÂÙ·È ÛÙȘ ‚ÈÔ„›Â˜ ۯ‰fiÓ fiÏˆÓ ÙˆÓ ·ÛıÂÓÒÓ 10 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÂȉÈÎfiÙÂÚ· Û ·˘ÙÔ‡˜ Ô˘ ‹Ù·Ó Û ·ÁˆÁ‹ Ì ΢ÎÏÔÛÔÚ›ÓË >5mg/™μ/Ë̤ڷ ÁÈ· Ù· ÚÒÙ· 5 ¯ÚfiÓÈ·. ∏ ˘·Ï›ÓˆÛË ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ ÔÊ›ÏÂÙ·È Û ӤÎÚˆÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ Î·È ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Â›ÛÔ‰Ô ÚˆÙ½Ó˘ ÛÙÔ ÙÔ›¯ˆÌ· ÙÔ˘ ·ÁÁ›Ԣ Î·È ·ÔÙÂÏ› ÙÔÓ ÈÔ ·ÍÈfiÈÛÙÔ ‰Â›ÎÙË ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ·fi ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘. ∏ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ˘·Ï›ÓˆÛË ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ ÚÔηÏ› ÛÙ¤ÓˆÛË Î·È ÈÛ¯·ÈÌÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË. ∏ Ù·ÈÓÈÔÂȉ‹˜ ›ÓˆÛË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ›ÓˆÛ˘ Î·È ·ÙÚÔÊ›·˜ ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ ÌÂٷ͇ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÚÈÔ¯ÒÓ ÙÔ˘ ÊÏÔÈÔ‡. ÕÏϘ ·ÏÏÔÈÒÛÂȘ, fiˆ˜ Ë ˘ÂÚÏ·Û›· Ù˘ ·Ú·ÛÂÈÚ·Ì·ÙÈ΋˜ Û˘Û΢‹˜ ‹ Ë ÈÛÔÌÂÙÚÈ΋ ÎÂÓÔÙÔ›ˆÛË ÙˆÓ ÛˆÏËÓ·ÚÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ, Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ Î·È ·ÌÊ›‚ÔÏ˘ ‰È·ÁÓˆÛÙÈ΋˜ ·Í›·˜. ∏ ÛÂÈÚ·Ì·ÙÈ΋ ÛÎÏ‹Ú˘ÓÛË ·Ó·Ù‡ÛÛÂÙ·È Û ‰‡Ô Ê¿ÛÂȘ. ∞Ú¯Èο ·ÎÔÏÔ˘ı› ÙËÓ ÂÚÈÛÂÈÚ·Ì·ÙÈ΋ ›ÓˆÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ¯ÒÚÔ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙËÓ ˘·Ï›ÓˆÛË ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ Ô˘ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ÈÛ¯·ÈÌ›· ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ. ŒÓ· ·ÚΤ˜ ‰Â›ÁÌ· ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ 10 ÛÂÈÚ¿Ì·Ù· Î·È 2 ·ÚÙËÚÈfiÏÈ· ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‚Ï¿‚˘ Î·È Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ÙˆÓ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘. ∏ ‚·Ú‡ÙËÙ· Ù˘ ‰È·ÌÂÛÔÛˆÏËÓ·Úȷ΋˜ ‚Ï¿‚˘ ÌÔÚ› Ó· ÂÎÙÈÌËı› ·ÎfiÌ· Î·È Û ÌÈÎÚ¿ ‰Â›ÁÌ·Ù· ‚ÈÔ„›·˜. OÈ ·ÏÏÔÈÒÛÂȘ ÌÔÚ› Ó· Â›Ó·È ÂÛÙȷΤ˜ Î·È ÁÈ· ÙÔÓ ÏfiÁÔ ·˘Ùfi Â›Ó·È Î·Ïfi Ó· Ï·Ì‚¿ÓÂÙ·È ÌÂÁ¿ÏÔ ‰Â›ÁÌ· ‹ ‰‡Ô ¯ˆÚÈÛÙ¿ ÎÔÌÌ¿ÙÈ· ÈÛÙÔ‡, ÂÓÒ Ë Ï‹„Ë ‚ÈÔ„›·˜ ηٿ ÙËÓ ÂÌʇÙ¢ÛË Â›Ó·È ¯Ú‹ÛÈÌË ÁÈ· ÙË ‰È¿ÁÓˆÛË ÚÔ¸¿Ú¯Ô˘Û·˜ ÓfiÛÔ˘ ÛÙÔÓ ‰fiÙË. ∏ ÂͤٷÛË ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ Â›Ó·È ¯Ú‹ÛÈÌË ÁÈ· ÙË ‰È¿ÁÓˆÛË de novo ·Ó¿Ù˘Í˘ ™¡, ˘ÔÙÚÔ‹˜ ÚˆÙÔ·ıÔ‡˜ ÓfiÛÔ˘, ÈÔÁÂÓÔ‡˜ Ïԛ̈͢ (μ∫, ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi) ‹ ¯ÚfiÓÈ·˜ ¯˘ÌÈ΋˜ ·fiÚÚȄ˘ Ì ·ÚÔ˘Û›· C4d.
¶ÚfiÏË„Ë Î·È ıÂڷ›· ∏ ÚfiÏË„Ë Î·È Ë ıÂڷ›· Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ‰˘ÛÎÔϛ˜ ‰ÈfiÙÈ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛ‹ Ù˘ ¢ı‡ÓÔÓÙ·È ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜. ∏ ÚÔÛ·ÚÌÔÁ‹ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ·Ó¿ÏÔÁ· Ì ÙÔ ¯ÚÔ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ. ΔÔ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Û¯‹Ì· Ú¤ÂÈ Ó· Â›Ó·È ÈÛ¯˘Úfi ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ı· Ú¤ÂÈ ÔÈ ‰fiÛÂȘ ÙˆÓ Ê·ÚÌ¿ÎˆÓ Ó· ÌÂÈÒÓÔÓÙ·È Ì ÛÎÔfi ÙËÓ ·ÔÊ˘Á‹ Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ·fi ÙÔ˘˜ ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘. ∞ÓÙ›ıÂÙ· Û ÂÚÈÙÒÛÂȘ Ì ˘ÔÎÏÈÓÈ΋ ‹ fi„ÈÌË ·fiÚÚÈ„Ë Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ı· Ú¤ÂÈ Ó· ÂÓÈÛ¯‡ÂÙ·È. ¢Â‰Ô̤Ó˘ Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÙˆÓ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘, Ë ·fi ·Ú¯‹˜ ·ÔÊ˘Á‹ Ù˘ ¯Ú‹Û˘ ÙÔ˘˜ ‹ Ë ·fiÛ˘ÚÛ‹ ÙÔ˘˜ ·fi ÙÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· Ì ‹ ¯ˆÚ›˜ ·ÓÙÈηٿÛÙ·Û‹ ÙÔ˘˜ Ì ¿ÏÏÔ Ê·ÚÌ·ÎÔ ¤¯Ô˘Ó Á›ÓÂÈ ·ÓÙÈΛÌÂÓ· ÌÂϤÙ˘. ∏ ·ÏÏ·Á‹ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Ì tacrolimus Î·È Ë ¯Ú‹ÛË ÙÔ˘ mycophenolate mofetil (MMF) ‹ ÙˆÓ mTOR inhibitors (sirolimus, everolimus) ¤¯Ô˘Ó ‰ÔÎÈÌ·ÛÙ› Û ‰È¿ÊÔÚ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Û¯‹Ì·Ù·. OÈ Î˘ÚÈfiÙÂÚ˜ ·Ú¿ÌÂÙÚÔÈ Ô˘ Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó ˘fi„Ë ÛÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ Û˘Ó‰˘·ÛÌÔ‡ Ê·ÚÌ¿ÎˆÓ Â›Ó·È Ë ‰È·Ù‹ÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ë Ì›ˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ ÂÌÊ¿ÓÈÛ˘ ÔÍ›·˜ ‹ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘ Î·È ÔÈ ·ÚÂÓ¤ÚÁÂȘ ÙˆÓ Ê·Ú̿ΈÓ. ∏ ÈÔ Û˘Ó‹ı˘ ÚÔÛ¤ÁÁÈÛË ÁÈ· ÚfiÏË„Ë ‹ ÂÚÈÔÚÈÛÌfi Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Ë Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙÔ˘ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ ‹ Ë ÚÔÛı‹ÎË ¿ÏÏÔ˘ Ê·ÚÌ¿ÎÔ˘ Ì ·Ú¿ÏÏËÏË Ì›ˆÛË ‹ ‰È·ÎÔ‹ ÙÔ˘ ·Ó·ÛÙÔϤ·. ∏ Ì›ˆÛË Ù˘ ‰fiÛ˘ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ÛÙÔ 50% Ù˘ ·Ú¯È΋˜, 12 Ì‹Ó˜ ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û ·ÛıÂÓ›˜ Ì ÛÙ·ıÂÚ‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÔÍ›·˜ ·fiÚÚȄ˘, ÂÓÒ Ë Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙÔ˘ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ Û ·ÛıÂÓ›˜ Ì ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· Û˘Óԉ‡ÂÙ·È ·fi ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ tacrolimus Ê·›ÓÂÙ·È Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· Û ۯ¤ÛË Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË, ‰ÈfiÙÈ Û ‚ÈÔ„›Â˜ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ 12 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ë ¤ÎÊÚ·ÛË Û˘ÛÙ·ÙÈÎÒÓ Ù˘ ıÂ̤ÏÈ·˜ Ô˘Û›·˜ Î·È Ë ›ÓˆÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ¯ÒÚÔ˘ Â›Ó·È ÈÔ ¤Î‰ËÏË ÛÙÔ˘˜ ·ÛıÂÓ›˜ ˘fi ΢ÎÏÔÛÔÚ›ÓË, Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿. ™ÙË ÌÂϤÙË USRDS ÛÙËÓ ÔÔ›· Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 9449 ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ˙ÒÓÙ· ‹ و̷ÙÈÎfi ‰fiÙË Î·È Ï¿Ì‚·-
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Ó·Ó ·ÁˆÁ‹ Ì ÎÔÚÙÈÎÔÂȉ‹, mycophenolate mofetil Î·È tacrolimus ‹ ΢ÎÏÔÛÔÚ›ÓË, ‰È·ÈÛÙÒıËΠfiÙÈ Ë 3ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‹Ù·Ó Û˘ÁÎÚ›ÛÈÌË ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ. ∂ÈϤÔÓ, Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ 2 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiˆ˜ ‰È·ÈÛÙÒıËΠ۠‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘, ‰ÂÓ ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó Î˘ÎÏÔÛÔÚ›ÓË ‹ tacrolimus. °È· ÙÔ ÏfiÁÔ ·˘Ùfi Ë ¤Ú¢ӷ ÂÈÎÂÓÙÚÒÓÂÙ·È Û‹ÌÂÚ· ÛÙË ¯ÚËÛÈÌÔÔ›ËÛË ÙˆÓ MMF Î·È sirolimus ‹ everolimus. ∏ ‰È·ÎÔ‹ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ·fi ÙÚÈÏfi Û¯‹Ì· ÎÔÚÙÈÎÔÂȉÒÓ, ΢ÎÏÔÛÔÚ›Ó˘ Î·È MMF Û ·ÛıÂÓ›˜ Ì ÛÙ·ıÂÚ‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È Ë Û˘Ó¤¯ÈÛË ‰ÈÏÔ‡ Û¯‹Ì·ÙÔ˜, Û˘Óԉ‡ÂÙ·È ·fi ηχÙÂÚË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ·ÏÏ¿ ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÔÍ›·˜ ·fiÚÚȄ˘ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ (10.6 ¤Ó·ÓÙÈ 2.4%). ∏ Ì·ÎÚÔ¯ÚfiÓÈ· (5ÂÙ‹˜) ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È ÂÚ›Ô˘ ›‰È· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰È¤ÎÔ„·Ó ‹ Û˘Ó¤¯ÈÛ·Ó ÙË ıÂڷ›· Ì ΢ÎÏÔÛÔÚ›ÓË Î·È ˘ÂÚ‚·›ÓÂÈ ÙÔ 88%. ∏ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó MMF Û ‰fiÛË <2g/Ë̤ڷ Î·È Ú‰ÓÈ˙ÔÏfiÓË <10mg/Ë̤ڷ. ∏ ¯ÚËÛÈÌÔÔ›ËÛË Û¯‹Ì·ÙÔ˜ Ì ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘-2 (IL2R·), (daclizumab ‹ basiliximab), ÎÔÚÙÈÎÔÂȉ‹ Î·È MMF Û˘Óԉ‡ÂÙ·È ·fi ˘„ËÏfi ÔÛÔÛÙfi ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó·ÁηÛÙÈ΋ ÚÔÛı‹ÎË ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ ÛÙÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì·. ∏ ¯ÔÚ‹ÁËÛË Û˘Ó‰˘·ÛÌÔ‡ daclizumab, tacrolimus, mycophenolate mofetil Î·È ÎÔÚÙÈÎÔÂȉÒÓ Û˘Óԉ‡ÂÙ·È ·fi ηχÙÂÚË ‰È·Ù‹ÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ì›ˆÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È ÌÂȈ̤ÓË Â›ÙˆÛË Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË Î·È ‰˘ÛÏÈȉ·ÈÌ›·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘ÁÎÚÈÙÈο Ì ·Ó¿ÏÔÁÔ Û¯‹Ì· ÙÔ ÔÔ›Ô ·ÓÙ› ÙÔ˘ mycophenolate mofetil ÂÚÈÏ·Ì‚¿ÓÂÈ sirolimus. ∏ ¯ÔÚ‹ÁËÛË sirolimus ÛÂ Û˘Ó‰˘·ÛÌfi Ì MMF Î·È ÎÔÚÙÈÎÔÂȉ‹ Û˘Óԉ‡ÂÙ·È ·fi ηχÙÂÚË ‰È·Ù‹ÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û˘ÁÎÚÈÙÈο Ì ÙË ¯ÔÚ‹ÁËÛË Î˘ÎÏÔÛÔÚ›Ó˘, ÎÔÚÙÈÎÔÂȉÒÓ Î·È MMF, ÂÓÒ Ë ·Ô˘Û›· ¯ÚfiÓÈˆÓ ·ÏÏÔÈÒÛÂˆÓ ÙÔ˘ ‰È·ÌÂÛÔÛˆÏËÓ·ÚÈ·ÎÔ‡ ¯ÒÚÔ˘ ‰È·ÈÛÙÒÓÂÙ·È Û˘¯ÓfiÙÂÚ· Û ‚ÈÔ„›Â˜ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·ÛıÂ-
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¢. °OYMENO™
ÓÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó sirolimus. OÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ (‰˘ÛÏÈȉ·ÈÌ›·, ıÚÔÌ‚ÔÂÓ›· Î·È Á·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜) ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ sirolimus, MMF Î·È ÎÔÚÙÈÎÔÂȉÒÓ Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó¤˜. ∏ ‰È·ÎÔ‹ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ·fi ÙÚÈÏfi Û¯‹Ì· ÎÔÚÙÈÎÔÂȉÒÓ, ΢ÎÏÔÛÔÚ›Ó˘ Î·È sirolimus, Û ·ÛıÂÓ›˜ Ì ÛÙ·ıÂÚ‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· 3 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ Û˘ÁÎÚÈÙÈο Ì ÙË Û˘Ó¤¯ÈÛË ÙÔ˘ ÙÚÈÏÔ‡ Û¯‹Ì·ÙÔ˜, ·ÏÏ¿ ηχÙÂÚË ‰È·Ù‹ÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÂÙ¿ ·fi 3 Î·È 4 ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ (96% vs. 91%). ™Â ·ӷÏËÙÈΤ˜ ‚ÈÔ„›Â˜ 1 ¯ÚfiÓÔ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Ô ‚·ıÌfi˜ ›ÓˆÛ˘ ÙÔ˘ ‰È·ÌÂÛÔÛˆÏËÓ·ÚÈ·ÎÔ‡ ¯ÒÚÔ˘ ‹Ù·Ó ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰È¤ÎÔ„·Ó ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË (41% vs. 70%). ∏ ¯ÔÚ‹ÁËÛË sirolimus Û ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÙÔ tacrolimus ‹ Ë Î˘ÎÏÔÛÔÚ›ÓË ‰ÈÂÎfiËÛ·Ó ÏfiÁˆ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û˘Óԉ‡ÙËΠ·fi ÛÙ·ıÂÚÔÔ›ËÛË ‹ Î·È ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ¯ˆÚ›˜ ·‡ÍËÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘. ΔÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ Úfi‚ÏËÌ· ÛÙË ıÂڷ›· Ì sirolimus Â›Ó·È ÔÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ. ΔÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¤¯ÂÈ ‰È·Îfi„ÂÈ ÙÔ Ê¿ÚÌ·ÎÔ ÏfiÁˆ ˘ÂÚÏÈȉ·ÈÌ›·˜, Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ÔȉËÌ¿ÙˆÓ Î·È ·‡ÍËÛ˘ Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ ˘ÂÚ‚·›ÓÂÈ ÙÔ 20% Û ‰È¿ÊÔÚ˜ ÌÂϤÙ˜. ∞fi ÙËÓ ÂÚÈÔÚÈṲ̂ÓË ÂÌÂÈÚ›· Ô˘ ˘¿Ú¯ÂÈ ·fi ÙË ¯Ú‹ÛË ÙÔ˘ sirolimus ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ê·›ÓÂÙ·È fiÙÈ Ë ·ÏÏ·Á‹ ÙÔ˘ ·Ó·ÛÙÔϤ· Ù˘ ηÏÛÈÓ¢ڛÓ˘ Û sirolimus, ÂÓÒ ÔÈ ·ÛıÂÓ›˜ Û˘Ó¯›˙Ô˘Ó Ó· ·›ÚÓÔ˘Ó ÎÔÚÙÈÎÔÂȉ‹ Î·È mycophenolate mofetil, Û˘Óԉ‡ÂÙ·È ·fi ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ·ÏÏ¿ Âȉ›ӈÛË Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜. ∏ ¯ÔÚ‹ÁËÛË everolimus Ì basiliximab, ÎÔÚÙÈÎÔÂȉ‹ Î·È ¯·ÌËÏ‹ ‰fiÛË Î˘ÎÏÔÛÔÚ›Ó˘ ÏÂÔÓÂÎÙ› Û ۯ¤ÛË Ì ÙË ¯ÔÚ‹ÁËÛË Ù˘ Û˘Ó‹ıÔ˘˜ ‰fiÛ˘ ΢ÎÏÔÛÔÚ›Ó˘ ÛÙÔ ›‰ÈÔ Û¯‹Ì· ‰ÈfiÙÈ Û˘Óԉ‡ÂÙ·È ·fi ηχÙÂÚË ‰È·Ù‹ÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Û¯ÂÙÈο ÌÈÎÚfiÙÂÚË Â›ÙˆÛË ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ 3 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (12.1% ¤Ó·ÓÙÈ 20.8%). ∏ ÂÌÊ¿ÓÈÛË ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ (΢ڛˆ˜ ˘ÂÚÏÈȉ·ÈÌ›·˜) Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó‹ Ì ÙË ¯ÔÚ‹ÁËÛË ÌÈÎÚfiÙÂÚ˘ ‰fiÛ˘ ΢ÎÏÔÛÔÚ›Ó˘, ÂÓÒ Ë Û˘Á¯ÔÚ‹ÁËÛË ÙÔ˘ basiliximab
ÂÈÙÚ¤ÂÈ ÙËÓ ¯Ú‹ÛË ÌÈÎÚfiÙÂÚ˘ ‰fiÛ˘ ÙÔ˘ everolimus (1.5 mg/day) Ì ¯·ÌËϤ˜ ‰fiÛÂȘ ΢ÎÏÔÛÔÚ›Ó˘, ¯ˆÚ›˜ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÔÍ›·˜ ·fiÚÚȄ˘ (ÔÛÔÛÙfi 14%). ∏ ‚Ú·¯˘¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÙ·È ·fi ÙË ÌË ¯ÚËÛÈÌÔÔ›ËÛË ‹ ÙË ÁÚ‹ÁÔÚË Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙÔ˘ ·Ó·ÛÙÔϤ· Ù˘ ηÏÛÈÓ¢ڛÓ˘. ∏ Û˘¯Ó‹ fï˜ ÂÌÊ¿ÓÈÛË ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ Â›Ó·È Èı·Ófi Ó· ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·˘ÍË̤ÓË Â›ÙˆÛË Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÂȉÈÎfiÙÂÚ· Û ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÔÈ ÔÔ›ÔÈ ÂÈϤÁÔÓÙ·È ÁÈ· Û¯‹Ì·Ù· ¯ˆÚ›˜ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ªªF Î·È Ë Ì›ˆÛË Ù˘ ‰fiÛ˘ ‹ Ë ‰È·ÎÔ‹ ÙÔ˘ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ ¤¯Ô˘Ó ¢ÂÚÁÂÙÈ΋ ›‰Ú·ÛË ÛÙË ‰È·Ù‹ÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÙÔÓ ÂÚÈÔÚÈÛÌfi ˘¿Ú¯Ô˘Û·˜ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ΔÔ sirolimus ¤¯ÂÈ Â›Û˘ ¢ÓÔ˚΋ ›‰Ú·ÛË ÛÙË ‚Ú·¯˘¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ. OÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Î·È ÂȉÈÎfiÙÂÚ· Ë ˘ÂÚÏÈȉ·ÈÌ›· ·ÔÙÂÏÔ‡Ó ¤Ó· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ÛÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ sirolimus, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ù· ηډȷÁÁÂȷο ·›ÙÈ· ·ÔÙÂÏÔ‡Ó Ù· Û˘¯ÓfiÙÂÚ· ·›ÙÈ· ı·Ó¿ÙÔ˘ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ.
™˘ÌÂÚ¿ÛÌ·Ù· ∏ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ·Ú·Ì¤ÓÂÈ Û˘¯Ófi ·›ÙÈÔ ·ÒÏÂÈ·˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ¯Ú‹ÛË ÙÚÈÏÔ‡ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÎÔÚÙÈÎÔÂȉ‹, ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ (΢ÎÏÔÛÔÚ›ÓË, tacrolimus) Î·È mycophenolate mofetil ‹ sirolimus/everolimus Â›Ó·È ·Ó·Áη›· ‰ÈfiÙÈ ÂÚÈÔÚ›˙ÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÔÍ›·˜ ·fiÚÚȄ˘, ηٿ ÙËÓ ·Ú¯È΋ Ê¿ÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ‰È·ÎÔ‹ ‹ Ë Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙÔ˘ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ ı· Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÂÙ·È ÛÙË Û˘Ó¤¯ÂÈ· Û ÛÙ·ıÂÚÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Ì ÛÎÔfi ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜. ∏ ·¿ÓÙËÛË ÛÙÔ ÂÚÒÙËÌ· Â¿Ó Ë ·ÏÏ·Á‹ ‹ Ë Ì›ˆÛË ÙÔ˘ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ Î·È Ô Û˘Ó‰˘·ÛÌfi˜ Ì MMF, sirolimus ‹ everolimus ¤¯ÂÈ Â˘ÂÚÁÂÙÈ΋ ›‰Ú·ÛË ÛÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ı· ‰Ôı› ·fi ÌÂϤÙ˜ Ì ̷ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È Ù·˘Ùfi¯ÚÔÓË ÈÛÙÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË Ì ‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘. ∏ ηϋ Û˘Ì‚·ÙfiÙËÙ·, Ë Ì›ˆÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘, Ô Â-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÚÈÔÚÈÛÌfi˜ Ù˘ ÈÛ¯·ÈÌÈ΋˜ ‚Ï¿‚˘ Î·È Ë ·ÔÊ˘Á‹ Ù˘ ¢·ÈÛıËÙÔÔ›ËÛ˘ ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ Ú‡ıÌÈÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (< 130/80mmHg) Ì ¯Ú‹ÛË ·Ó·ÛÙÔϤˆÓ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ ‹ ·ÓÙ·ÁˆÓÈÛÙÒÓ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ Î·È Ë ‰ÈfiÚıˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ÏÈȉ›ˆÓ ·ÔÙÂÏÔ‡Ó ¿ÏϘ ÛËÌ·ÓÙÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ ÚfiÏ˄˘ Î·È ıÂڷ›·˜.
μ‚ÈÏÈÔÁÚ·Ê›· 1. Danovitch GM. Immunosuppressive medications for renal transplantation: A multiple-choice question. Kidney Int 2001; 59: 388-402. 2. Pascual M, Theruvath T, Kawai T, Tolkoff-Rubin N, Cosimi B. Medical progress: Strategies to improve long-term outcomes after renal transplantation. N Engl J Med 2002; 346(8): 580-590. 3. Vincenti F. Immunosuppression minimization: Current and future trends in transplant immunosuppression. J Am Soc Nephrol 2003; 14: 1940-1948. 4. Afzali B, Taylor AL, Goldsmith JA. What we CAN do about chronic allograft nephropathy: Role of immunosuppressive modulations. Kidney Int 2005; 68: 24292443. 5. Chapman JR, O’Connell PJ, Nankivell BJ. Chronic renal allograft dysfunction. J Am Soc Nephrol 2005; 16: 3015-3026. 6. Nankivell BJ and Chapman JR. Chronic allograft nephropathy: Current concepts and future directions. Transplantation 2006; 81: 643-654. 7. Augustine JJ and Hricik DE. Minimization of immunosuppression in kidney transplantation. Curr Op Nep-
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hrol Hypert 2007; 16: 535-541. 8. Solez K, Vincenti F, Filo RS. Histopathologic findings from 2-year protocol biopsies from a U.S. multicenter kidney transplant trial comparing tacrolimus versus cyclosporine. Transplantation 1998; 66: 1736-1740. 9. Srinivas TR, Kaplan B, Schold JD, Meier-Kriesche HU. The impact of mycophenolate mofetil on longterm outcomes in kidney transplantation. Transplantation 2005; 80: S211-S220. 10. Groth CC, Backman L, Morales JM, Calne R et al. Sirolimus (rapamycin)-based therapy in human renal transplantation. Transplantation 1999; 67: 1036-1042. 11. Abramowicz D, Manas D, Lao M, Vanrenterghem Y, Del Castillo D, Wijngaard P, Fung S for the Cyclosporine Withdrawal Study Group. Cyclosporine withdrawal from a mycophenolate mofetil-containing immunosuppressive regimen in stable kidney transplant recipients: A randomised, controlled study. Transplantation 2002; 74: 1725-1734. 12. Johnson RWG, Kreis H, Oberbauer R et al. Sirolimus allows early cyclosporine withdrawal in renal transplantation resulting in improved renal function and lower blood pressure. Transplantation 2002; 72: 777786. 13. Vincenti F, Ramos E, Brattstrom C et al. Multicenter trial exploring calcineurin inhibitors avoidance in renal transplantation. Transplantation 2001; 71: 1282-1287. 14. Nashan B, Curtis J, Ponticelli C, Mourad G, Jaffe J, Haas T. Everolimus and reduced – exposure cyclosporin in de novo renal – transplant recipients: A three – year phase II, randomised, multicenter, open – label study. Transplantation 2004; 78: 1332-1340. 15. Pascual J, Boletis IN, Campistol JM. Everolimus in renal transplantation: A review of clinical trial, data, current usage and future directions. Transplantation Reviews 2006; 20: 1-18.
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ÓÂÊÚÔ·ı›˜ ·ÛıÂÓ›˜. ª›· Èı·Ó‹ ·ËÛË ¤¯ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Â˘·ÈÛıËÙÔÔ›ËÛ˘ Ù˘ ÌËÙ¤Ú·˜ ηٿ 20-25%8. ∏ ΢ÚÈfiÙÂÚË Î·È Ë Û˘¯ÓfiÙÂÚË ¿ÓÙˆ˜ ·ÈÙ›· ¢·ÈÛıËÙÔÔ›ËÛ˘ Û‹ÌÂÚ· Â›Ó·È Î¿ÔÈ· ÚÔËÁËı›۷ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÊÔ‡ Ù· ÌÔۯ‡̷ٷ Ôχ Û¿ÓÈ· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó HLA ‰È·ÊÔÚ¤˜ (mismatches)9. ∏ Èı·ÓfiÙËÙ· ¢·ÈÛıËÙÔÔ›ËÛ˘ ·fi ¤Ó· ÌË ÏÂÈÙÔ˘ÚÁÒÓ ÌfiÛ¯Â˘Ì· ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÌË Û˘Ì‚·ÙÒÓ HLA: 20% (0-1 mismatches) ¤ˆ˜ 46-52% (5-6 mismatches)8. O ÔÚÈÛÌfi˜ Ù˘ ˘ÂÚ¢·ÈÛıËÙÔÔ›ËÛ˘ ‰È·Ê¤ÚÂÈ ÌÂٷ͇ ‰È·ÊfiÚˆÓ Î¤ÓÙÚˆÓ ·ÏÏ¿ ¿ÓÙˆ˜ ˘Ô‰ËÏÒÓÂÈ ÙËÓ ‡·ÚÍË ıÂÙÈÎÔ‡ crossmatch ¤Ó·ÓÙÈ ÂÓfi˜ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ (Panel Reactive Antibody (PRA) status). ∏ ÔÛÔÙÈÎÔÔ›ËÛË ÙÔ˘ Á›ÓÂÙ·È Ì ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ Èı·ÓÒÓ ‰ÔÙÒÓ ¤Ó·ÓÙÈ ÙˆÓ ÔÔ›ˆÓ Ô ÔÚfi˜ ÂÓfi˜ ·ÛıÂÓÔ‡˜ ·ÓÙȉڿ (ıÂÙÈÎfi Δ-cell crossmatch), ÏfiÁˆ ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ IgG ·ÓÙÈۈ̿وÓ. £· Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› ¿ÓÙˆ˜ fiÙÈ Î¿ÔÈÔ˜ ˘„ËÏfi˜ Ù›ÙÏÔ˜ PRA ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙ÂÈ ··Ú·›ÙËÙ· Î·È Î¿ÔÈÔ ÌÂÁ¿ÏÔ Â‡ÚÔ˜ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi ÙÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË, ·ÏÏ¿ ·ÔÙÂÏ› Î·È ·ÓÙ·Ó¿ÎÏ·ÛË Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ HLA Ê·ÈÓÔÙ‡ˆÓ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. °È· ·Ú¿‰ÂÈÁÌ· ·ÊÔ‡ ÙÔ HLA A2 ·Ó¢ڛÛÎÂÙ·È ÛÙÔ 28% ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡, Ë ‡·ÚÍË Î·È ÌfiÓÔÓ ÂÓfi˜ ·ÓÙÈÛÒÌ·ÙÔ˜ ¤Ó·ÓÙÈ ·˘ÙÔ‡ ÙÔ˘ HLA, ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ·ÔÎÏÂÈÛÌfi ÙÔ˘ 28% ÙˆÓ Èı·ÓÒÓ ‰ÔÙÒÓ4. ΔÔ ·Ú·¿Óˆ ·Ú¿‰ÂÈÁÌ· ·Ó·‰ÂÈÎÓ‡ÂÈ Î·È ÙÔ Úfi‚ÏËÌ· Ù˘ ÂȉÈÎfiÙËÙ·˜ Ù˘ ¢·ÈÛıËÙÔÔ›ËÛ˘. ™‹ÌÂÚ· Ì ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Ù¯ÓÈÎÒÓ Ù·˘ÙÔÔ›ËÛ˘ ·ÓÙÈÛˆÌ¿ÙˆÓ ıˆÚÂ›Ù·È Ôχ ÈÔ ÛËÌ·ÓÙÈ΋ Ë ·Ó›¯Ó¢ÛË Î·È ÛˆÛÙ‹ Ù·˘ÙÔÔ›ËÛË ÙˆÓ ÂȉÈÎÒÓ ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÙÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË, ·Ú¿ Ô ·ÚÈıÌfi˜ Ô˘ ÂÎÊÚ¿˙ÂÈ ÙÔÓ Ù›ÙÏÔ ÙÔ˘ PRA. ∫¿ÔÈ· ΤÓÙÚ· ÔÚ›˙Ô˘Ó ˆ˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈ-
OÈ Kissmeyer Î·È Û˘Ó ‹Ù·Ó ÔÈ ÚÒÙÔÈ Ô˘ ·Ó·ÁÓÒÚÈÛ·Ó fiÙÈ ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ˘ÂÚÔÍ›·˜ ·fiÚÚȄ˘ ÂÓfi˜ ÓÂÊÚÈÎÔ‡ ·ÏÏÔÌÔۯ‡̷ÙÔ˜ ÔÊ›ÏÂÙ·È ÛÙËÓ ‡·ÚÍË ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ù· ÔÔ›· ·ÓÙȉÚÔ‡Ó Ì ·ÏÏÔ·ÓÙÈÁfiÓ· Ù· ÔÔ›· ˘¿Ú¯Ô˘Ó ÛÙÔ ÌfiÛ¯Â˘Ì·1. ∏ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ÎÏÈÓÈ΋ Ú¿ÍË ÙˆÓ ÌÂıfi‰ˆÓ ‰È·ÛÙ·‡ÚˆÛ˘ (cross-match) ·fi ÙÔ˘˜ Patel Î·È Terasaki2 Î·È Ô ·ÔÎÏÂÈÛÌfi˜ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ ÔÈ ÔÔ›ÔÈ ·ÚÔ˘Û›·˙·Ó ıÂÙÈ΋ ‰ÔÎÈÌ·Û›· cross-match Ì›ˆÛ·Ó ‰Ú·Ì·ÙÈο Ù· ÂÂÈÛfi‰È· ˘ÂÚÔÍ›·˜ ·fiÚÚȄ˘. ¶·ÚfiÏ· ·˘Ù¿ Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› Ô Ù‡Ô˜ ÙÔ˘ crossmatch Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È Î·È Ù· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙËÓ ·fi‰ÂÈÍË ÂÓfi˜ ıÂÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ ‰È·Ê¤ÚÔ˘Ó ÌÂٷ͇ ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ ÂÚÁ·ÛÙËÚ›ˆÓ Î·È ÎÚ›ÓÂÙ·È ÛÎfiÈÌË Ë Û˘Ó¯‹˜ ·ʋ Î·È Û˘ÓÂÚÁ·Û›· ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ Î·È ÙˆÓ ÂÚÁ·ÛÙËÚ›ˆÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ 3-5. ∏ ‡·ÚÍË ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ „¢‰Ò˜ ıÂÙÈÎÔ‡ crossmatch Î·È ı· Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È ¤ÁηÈÚ·. ™ÙËÓ Û˘ÓÙÚÈÙÈ΋ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¿ÓÙˆ˜, Ë ·Ó›¯Ó¢ÛË ÂÓfi˜ ıÂÙÈÎÔ‡ crossmatch ˘Ô‰ËÏÒÓÂÈ ÙËÓ ·ÚÔ˘Û›· IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ HLA ·ÓÙÈÁfiÓˆÓ Ù¿Í˘ π ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË Î·È ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ÔÚÁ¿ÓÔ˘. ∏ ¢·ÈÛıËÙÔÔ›ËÛË ‰ËÏ·‰‹ Ë ‰ËÌÈÔ˘ÚÁ›· ·ÓÙÈ-HLA IgG ·ÓÙÈۈ̿وÓ, ÌÔÚ› Ó· Á›ÓÂÈ Ì ÙÚÂȘ ÙÚfiÔ˘˜4,6,7: ·) ÌÂÙ¿ÁÁÈÛË ÚÔ˚fiÓÙˆÓ ·›Ì·ÙÔ˜ ‚) ·ËÛË (Á˘Ó·›Î˜ ·ÛıÂÓ›˜) Á) ÚÔËÁËı›۷ ÌÂÙ·ÌfiÛ¯Â˘ÛË ∏ ¢Ú›· ÂÊ·ÚÌÔÁ‹ Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ·Ó·ÈÌ›·˜ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ Ì ·Ó·Û˘Ó‰È·Ṳ̂ÓË ·ÓıÚÒÈÓË ÂÚ˘ıÚÔÔÈËÙ›ÓË Î·Ù¿ ÙËÓ ÙÂÏÂ˘Ù·›· ÂÈÎÔÛ·ÂÙ›· ¤¯ÂÈ ÌÂÈÒÛÂÈ (·ÏÏ¿ fi¯È ÂÍ·Ï›„ÂÈ) ÙËÓ ·Ó¿ÁÎË ÌÂÙ·ÁÁ›ÛÂˆÓ ·›Ì·ÙÔ˜ ÛÙÔ˘˜
86
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ë̤ÓÔ ¤Ó·Ó ·ÛıÂÓ‹ fiÙ·Ó ÂÌÊ·Ó›˙ÂÈ Ù›ÙÏÔ PRA> 50%, ÂÓÒ ¿ÏÏ· ¯ÚËÛÈÌÔÔÈÔ‡Ó ˘„ËÏfiÙÂÚÔ˘˜ ·ÚÈıÌÔ‡˜ (∂urotranspant Registry> 85%)8. ™ÙË ¯ÒÚ· Ì·˜ ˆ˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È Î¿ı ·ÛıÂÓ‹˜ Ô ÔÔ›Ô˜ ÂÌÊ·Ó›˙ÂÈ Ù›ÙÏÔ ·ÓÙÈÛˆÌ¿ÙˆÓ > 70% ¤Ó·ÓÙÈ ÙÔ˘ panel.
∂¶π¢∏ªπO§O°π∫∞ ¢∂¢Oª∂¡∞ ∫·Ù¿ ÙË ‰ÂηÂÙ›· 1994-2003 Ô ·ÚÈıÌfi˜ ÙˆÓ Â˘·ÈÛıËÙÔÔÈËÌ¤ÓˆÓ ·ÛıÂÓÒÓ Ô˘ ¢ڛÛÎÔÓÙ·Ó Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· و̷ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙȘ ∏¶∞ ·Ó‹Ïı ·fi ÙÔ˘˜ 12800 ÛÙÔ˘˜ 17814 ·ÛıÂÓ›˜. ΔÔ ¤ÙÔ˜ 2003 ÙÔ 32% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘Û›·˙·Ó οÔÈÔ˘ ‚·ıÌÔ‡ HLA ¢·ÈÛıËÙÔÔ›ËÛË Î·È 13,7% ·fi ·˘ÙÔ‡˜ ›¯·Ó Ù›ÙÏÔ PRA>80%3,9. ΔÔ ›‰ÈÔ ¤ÙÔ˜ ÌfiÓÔÓ 6,3% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙȘ ∏¶∞ ·ÊÔÚÔ‡Û ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜, ·ÚfiÏÔ Ô˘ ·ÔÙÂÏÔ‡Û·Ó ÂÚ›Ô˘ ÙÔ 14% ÙˆÓ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ. Δ· ÛÙÔȯ›· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÔÌ¿‰· ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È Î·Ù·‰ÈηṲ̂ÓË Û ̷ÎÚfi¯ÚÔÓË ·Ó·ÌÔÓ‹, ·Ú·Ì¤ÓÔÓÙ·˜ Û ıÂڷ›˜ ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ·ÈÌÔοı·ÚÛË ‹ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË. O ¯ÚfiÓÔ˜ ·Ú·ÌÔÓ‹˜ ÛÙȘ ıÂڷ›˜ ·˘Ù¤˜ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ·ÔÙÂÏ› ·ÓÂÍ¿ÚÙËÙÔ ·Ú¿ÁÔÓÙ· ÁÈ· ÌÂȈ̤ÓË ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÂÙ¿ ·fi ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂›Û˘ Ë ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Â›Ó·È Û›ÁÔ˘Ú· ηÙÒÙÂÚË Î·È Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ „˘¯ÔÏÔÁÈ΋ ‰ÔÎÈÌ·Û›· Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ·Ó·ÌÔÓ‹˜10. ™‡Ìʈӷ Ì ÚfiÛÊ·Ù· ÛÙÔȯ›· ÙÔ˘ ∂ıÓÈÎÔ‡ OÚÁ·ÓÈÛÌÔ‡ ªÂÙ·ÌÔۯ‡ÛÂˆÓ (OÎÙÒ‚ÚÈÔ˜ 2007) ·fi ÙÔ˘˜ 819 ·ÛıÂÓ›˜ Ô˘ Â›Ó·È ÂÓÂÚÁÔÔÈË̤ÓÔÈ ÛÙË Ï›ÛÙ· ÁÈ· و̷ÙÈ΋ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, 79 ·ÛıÂÓ›˜ (9%) ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù›ÙÏÔ PRA>70% Î·È ıˆÚÔ‡ÓÙ·È ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ. ΔÔ ÔÛÔÛÙfi ·˘Ùfi Â›Ó·È ÌÈÎÚfiÙÂÚÔ ·fi ¿ÏϘ ¯ÒÚ˜, ·ÏÏ¿ ÌÔÚ› Ó· ÂÍËÁËı› ‡ÎÔÏ· ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙË ¯ÒÚ· Ì·˜ ηٿ Ù· ÚÔËÁÔ‡ÌÂÓ· ¤ÙË. ∏ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÙˆÓ ˘ÂÚ¢·ÈÛıËÙÔÔÈËÌ¤ÓˆÓ ·ÛıÂÓÒÓ Á›ÓÂÙ·È ‰˘ÛÎÔÏfiÙÂÚË ·fi ÙÔ ÁÂÁÔÓfi˜, fiÙÈ ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ ·ÓÔÛÔÏÔÁÈÎfi ΛӉ˘ÓÔ ÁÈ· ÂÌÊ¿ÓÈÛË ÔÍ›·˜ ·fiÚÚȄ˘ ̤ۈ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È Û·ÊÒ˜ ÂÏ·Ùو̤ÓË Ì·ÎÚfi¯ÚÔÓË ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ.
87
™‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ‰‡Ô ÙÚfiÔÈ ÚÔÛ¤ÁÁÈÛ˘ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜: – ·) Ë «‚ÈÔÏÔÁÈ΋» fiÔ˘ Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· ·Ó‡ÚÂÛ˘ ηٿÏÏËÏˆÓ ‰ÔÙÒÓ Ì ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ıÂÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ crossmatch, ̤۷ ·fi ÌÂÁ¿Ï˜ ‰ÂÍ·ÌÂÓ¤˜ ‰ÔÙÒÓ Î·È ·˘ÍË̤ÓË ÚÔÙÂÚ·ÈfiÙËÙ· ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Ì ÔÈΛϷ ÚÔÁÚ¿ÌÌ·Ù· ÚÈÌÔ‰fiÙËÛ˘. – ‚) Ë «Ê·ÚÌ·ÎÔÏÔÁÈ΋», fiÔ˘ Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· ·ÔÌ¿ÎÚ˘ÓÛ˘ / ·‰Ú·ÓÔÔ›ËÛ˘ ÙˆÓ ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ anti-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ‰È¿ÊÔÚ˜ Ù¯ÓÈΤ˜.
«μπO§O°π∫∏» ¶ƒO™∂°°π™∏ Eurotransplant Acceptable Mismatching Program ΔÔ Acceptable Mismatching Program (AMP) Ù˘ Eurotransplant Â›Ó·È ¤Ó· ÔÏ˘ÎÂÓÙÚÈÎfi Î·È ÔÏ˘ÂıÓÈÎfi ÚfiÁÚ·ÌÌ· Ì ÛÎÔfi ÙˆÓ Î·ıÔÚÈÛÌfi ·ÓÙÈÁfiÓˆÓ HLA ÛÙ· ÔÔ›· Ô ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˜ ·ÛıÂÓ‹˜ ‰ÂÓ ¤¯ÂÈ ÚÔÛ¯ËÌ·ÙÈṲ̂ӷ ·ÓÙÈÛÒÌ·Ù· Î·È Û˘ÓÂÒ˜ Ó· ÚԂϤ„ÂÈ Èı·Ó¿ ÌÂÏÏÔÓÙÈο ·ÚÓËÙÈο crossmatch Ì ÂȉÈο HLA mismatches8. ΔÔ ÚfiÁÚ·ÌÌ· ¤¯ÂÈ ÂÚ·ÈÙ¤Úˆ ‚ÂÏÙȈı› ̤ۈ ÂÓfi˜ ·ÏÁÔÚ›ıÌÔ˘ ‚·ÛÈṲ̂ÓÔ˘ Û ËÏÂÎÙÚÔÓÈÎÔ‡˜ ˘ÔÏÔÁÈÛÙ¤˜ (HLA Match-maker) Ô˘ ÌÔÚ› Ó· ˘ÔÏÔÁ›˙ÂÈ Èı·Ó‹ Û˘Ì‚·ÙfiÙËÙ· Ì ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜. ™Â Ù¤ÙÔÈ· ÂÚ›ÙˆÛË ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ÌÂٷʤÚÂÙ·È ÛÙÔ Î¤ÓÙÚÔ ÙÔ˘ ·ÛıÂÓÔ‡˜, fiÔ˘ Á›ÓÂÙ·È ÙÔ ÙÂÏÈÎfi crossmatch Î·È Â› ·ÚÓËÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜, Ô ·ÛıÂÓ‹˜ ˘Ô‚¿ÏÏÂÙ·È ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞fi ÙË ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜, ÂÚ›Ô˘ 450 ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ ·ÛıÂÓ›˜ ˆÊÂÏ‹ıËÎ·Ó Î·È ˘Ô‚Ï‹ıËÎ·Ó Û ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂ÙËÛ›ˆ˜ ÂÚ›Ô˘ 45 ·ÛıÂÓ›˜ Ï·Ì‚¿ÓÔ˘Ó Û˘Ì‚·Ù¿ ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·fi Ì›· ‰ÂÍ·ÌÂÓ‹ 3100 ÔÚÁ¿ÓˆÓ Ù˘ Eurotransplant. O ·ÛıÂÓ‹˜ Ô˘ Ï·Ì‚¿ÓÂÈ Ì¤ÚÔ˜ ÛÙÔ ÚfiÁÚ·ÌÌ· ¤¯ÂÈ Èı·ÓfiÙËÙ· 43% Ó· Ï¿‚ÂÈ Û˘Ì‚·Ùfi ÌfiÛ¯Â˘Ì· ηٿ ÙÔ ·′ ¤ÙÔ˜ ·Ó·ÌÔÓ‹˜ Î·È 58% ̤۷ Û 21 Ì‹Ó˜. ∂›Û˘ Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ‰ÈÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì¤Ûˆ ÙÔ˘ AMP Â›Ó·È 87%, ·ÎÚÈ‚Ò˜ ·Ú·Ï‹ÛÈ· Ì ÙÔ˘˜ ÌË Â˘·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜8.
¶ÚˆÙfiÎÔÏÏÔ ªÂÁ¿Ï˘ μÚÂÙ·Ó›·˜ (UK) ∏ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ Ï‹ÙË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ÙËÓ ÂıÓÈ΋ Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ·
88
K. ºOYPTOYNA™
و̷ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‚·Û›˙ÂÙ·È ÛÙËÓ ·Ú¯‹ Ù˘ Ôχ˜ ηϋ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (ÌˉÂÓÈÎfi mismatching)10. OÈ ·È‰È·ÙÚÈÎÔ› ·ÛıÂÓ›˜ Î·È ÔÈ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÚÔÙÂÚ·ÈfiÙËÙ· ¤Ó·ÓÙÈ ÙˆÓ ˘ÔÏÔ›ˆÓ. ∞Ó·ÊÔÚÈο Ì ÙÔ˘˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÙÔ Û‡ÛÙËÌ· ‚·Û›˙ÂÙ·È ÛÙËÓ ·Ó›¯Ó¢ÛË Ù˘ ÂȉÈÎfiÙËÙ·˜ ÙˆÓ anti-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ Ù· ÔÔ›· ·ÚÔ˘ÛÈ¿˙ÂÈ Ô ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˜ ·ÛıÂÓ‹˜ ηıÒ˜ Î·È ÂȉÈÎfiÙËÙ˜ Ô˘ ıˆÚÔ‡ÓÙ·È ÌË ·Ô‰ÂÎÙ¤˜ (HLA mismatches ·fi ÚÔËÁÔ‡ÌÂÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÔÏϷϤ˜ ΢‹ÛÂȘ). ªÂ ÙÔ ÚˆÙfiÎÔÏÏÔ ·˘Ùfi ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯ÂÈ ÙÚÈÏ·ÛÈ·ÛÙ› Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Û ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÛÙË ªÂÁ¿Ï˘ μÚÂÙ·Ó›· 9. ¶·ÚfiÌÔÈÔ ÚˆÙfiÎÔÏÏÔ ·ÎÔÏÔ˘ıÂ›Ù·È Ì ÂÈÙ˘¯›· Î·È ÛÙË ¯ÒÚ· Ì·˜ .
¶ÚˆÙfiÎÔÏÏÔ ¶·ÓÂÈÛÙËÌ›Ô˘ Emory (∏¶∞)«∂ÈÎÔÓÈÎfi» crossmatch ΔÔ ∞ÌÂÚÈηÓÈÎfi ¶·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ Emory ·ÚÔ˘Û›·Û ÚfiÛÊ·Ù· ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ Û¯ÂÙÈο Ì ÙËÓ ÚÔÛÊÔÚ¿ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ Ï‹Ù˜ (PRA>30%)11. ΔÔ ÚˆÙfiÎÔÏÏÔ ·˘Ùfi Â›Ó·È ·ÚfiÌÔÈÔ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ Ù˘ Eurotransplant ·ÏÏ¿ ‚·Û›˙ÂÙ·È Û ¿ÏϘ Ù¯ÓÈΤ˜ Ù·˘ÙÔÔ›ËÛ˘ ÌË ·Ô‰ÂÎÙÒÓ ‰ÔÙÒÓ. ∏ ‚·ÛÈ΋ ÙÔ˘ ·Ú¯‹ Â›Ó·È Ë Ù·˘ÙÔÔ›ËÛË ÂȉÈÎÒÓ antiHLA ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi ÙÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË Ì ¢·›ÛıËÙ˜ ÌÂıfi‰Ô˘˜ (flow cytometrybased solid phase assay). ŸÙ·Ó Ô ÙˆÌ·ÙÈÎfi˜ ‰fiÙ˘ ʤÚÂÈ Ù· HLA ·ÓÙÈÁfiÓ· Ù· ÔÔ›· ·ÓȯÓ‡ıËÎ·Ó ÛÙÔÓ ÔÚfi ÙÔ˘ Èı·ÓÔ‡ Ï‹ÙË ·˘Ùfi˜ ÎÚ›ÓÂÙ·È ·Î·Ù¿ÏÏËÏÔ˜ (ÂÈÎÔÓÈÎfi crossmatch), ¯ˆÚ›˜ ÙË ‰ÈÂÓ¤ÚÁÂÈ· ·ÏËıÔ‡˜ crossmatch. OÈ ·ÌÂÚÈηÓÔ› ÂÚ¢ÓËÙ¤˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ ·˘Ùfi ¤¯Ô˘Ó ·˘Í‹ÛÂÈ ÛËÌ·ÓÙÈο ÙˆÓ ·ÚÈıÌfi ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ۯÂÙÈο ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ (30% Û ·ÛıÂÓ›˜ Ì PRA>30% Î·È 15% Û ·ÛıÂÓ›˜ Ì PRA>80%.
«º∞ƒª∞∫O§O°π∫∏» ¶ƒO™∂°°π™∏ ¶ÚˆÙfiÎÔÏÏ· ¯ÔÚ‹ÁËÛ˘ ÌÂÁ¿ÏˆÓ ‰fiÛÂˆÓ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ (IVIG). ¶ÚfiÎÂÈÙ·È ÁÈ· ÙËÓ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÌÂÁ¿ÏˆÓ ‰fiÛÂˆÓ (Û˘Ó‹ıˆ˜ 2gr/ ∫μ™) IgG ·ÓÔÛÔÛÊ·ÈÚ›Ó˘, Ë ÔÔ›· ·Ú¿ÁÂÙ·È ·fi ÌÈ· ÌÂÁ¿ÏË ‰ÂÍ·ÌÂÓ‹ ‰ÔÙÒÓ. À¿Ú¯ÂÈ Ì›· ÌÂÁ¿ÏË ÔÈÎÈÏ›· Û΢·ÛÌ¿ÙˆÓ Î·È ÙÔ ÈÔ ÛËÌ·ÓÙÈÎfi ÂÚÒÙËÌ· ·-
ڷ̤ÓÂÈ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ οı Û΢¿ÛÌ·ÙÔ˜ (fi¯È ÌfiÓÔ ÌÂٷ͇ ‰È·ÊÔÚÂÙÈÎÒÓ ÂÙ·ÈÚÈÒÓ ·ÏÏ¿ Î·È Û΢·ÛÌ¿ÙˆÓ Ù˘ ·˘Ù‹˜ ÂÙ·ÈÚ›·˜) ·Ó·ÊÔÚÈο Ì ÙËÓ ·Â˘·ÈÛıËÙÔÔ›ËÛË, ·ÊÔ‡ ‰ÂÓ ˘¿Ú¯Ô˘Ó Û˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜. OÈ Clark Î·È Û˘Ó Û˘ÁÎÚ›ÓÔÓÙ·˜ 22 ‰È·ÊÔÚÂÙÈο Û΢¿ÛÌ·Ù· ·fi 7 ‰È·ÊÔÚÂÙÈΤ˜ ÂÙ·ÈÚ›˜ ·Ú·Ù‹ÚËÛ·Ó ÌÈ· ÙÂÚ¿ÛÙÈ· ‰È·Î‡Ì·ÓÛË ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘˜ Ó· ÌÂÈÒÛÔ˘Ó ÙÔÓ Ù›ÙÏÔ ÙÔ˘ PRA Ì ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ fiÙ·Ó ÚÔÛÙ¤ıËÎ·Ó ÛÙÔ crossmatch12. ∞Ó·ÊÔÚÈο Ì ÙÔ Ì˯·ÓÈÛÌfi ‰Ú¿Û˘ ¤¯Ô˘Ó ÚÔÙ·ı› ÔÈΛÏÔÈ Ì˯·ÓÈÛÌÔ› ̤ۈ ÙˆÓ ÔÔ›ˆÓ Ë ·ÓÔÛÔÛÊ·ÈÚ›ÓË ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÓÔÛÔÙÚÔÔÔÈËÙÈΤ˜ ȉÈfiÙËÙ˜3,13,14: ·) ÌÂÙ·‚ÔÏ‹ ÙˆÓ ÂȉˆÓ ·˘Ùfi- Î·È ¿ÏÏÔ-·ÓÙÈÛˆÌ¿ÙˆÓ Ì¤Ûˆ ·ÓÙÈ-ȉÈÔÙ˘ÈÎÒÓ ·ÓÙÈۈ̿وÓ, ‚) ·Ó·ÛÙÔÏ‹ ÂÓÂÚÁÔÔ›ËÛ˘ ÁÔÓȉ›ˆÓ ΢ÙÙ·ÚÔÎÈÓÒÓ, Á) ‰Ú·ÛÙËÚÈfiÙËÙ· ¤Ó·ÓÙÈ ÙÔ˘ ˘Ô‰Ô¯¤· ÙÔ˘ Δ-ÏÂÌÊÔ΢ÙÙ¿ÚÔ˘, ‰) ·ÏÏËÏ›‰Ú·ÛË ·ÓÙÈÁÔÓÔ-·ÚÔ˘ÛÈ·ÛÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Fc ˘Ô‰Ô¯¤·, Â) anti-CD4 ‰Ú·ÛÙÈÎfiÙËÙ·, ÛÙ) ÂÓÂÚÁÔÔ›ËÛË ·ÓÙ·ÁˆÓÈÛÙÒÓ ˘Ô‰Ô¯¤ˆÓ ΢ÙÙ·ÚÔÎÈÓÒÓ, ˙) ·Ó·ÛÙÔÏ‹ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜. ∏ ÙÂÏÂ˘Ù·›· ‰Ú¿ÛË ·Ó·Ê¤ÚıËΠÚfiÛÊ·Ù· Î·È ·ÊÔÚ¿ ÙË Û‡Ó‰ÂÛË ÙÔ˘ Fc ÙÌ‹Ì·ÙÔ˜ Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ Ì ÂÓÂÚÁÔÔÈË̤ӷ ÛÙÔȯ›· ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ (C3b, C4b), ·ÏÏ¿ Î·È ·Ó·ÛÙÔÏ‹ Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ C5b-C9 MAC15. OÈ Glotz Î·È Û˘Ó ·ÚÔ˘Û›·Û·Ó ÙËÓ ÂÌÂÈÚ›· ÙÔ˘˜ ·fi 15 ·ÛıÂÓ›˜ Ì PRA>50% ‹ ıÂÙÈÎfi crossmatch Ì ˘Ô„‹ÊÈÔ˘˜ ˙ÒÓÙ˜ ‰fiÙ˜, ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË 2 mg/∫μ™ IVIG οı 4 ‚‰ÔÌ¿‰Â˜ ÁÈ· ÙÚ›˜ ÊÔÚ¤˜ ÂϤÁ¯ÔÓÙ·˜ ÙÔÓ Ù›ÙÏÔ ÙÔ˘ PRA Î·È ÌÂÏÂÙÒÓÙ·˜ ÙÔ crossmatch 3 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ·fi ÙËÓ Î¿ı ‰fiÛË IVIG16. ¢ÂηÙÚ›˜ (13) ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ·ÍÈÔÛËÌ›ˆÙË ÙÒÛË ÙÔ˘ Ù›ÙÏÔ˘ ÙÔ˘ PRA Î·È ÌÂÙ·ÌÔۯ‡ıËÎ·Ó (2 ·fi ˙ÒÓÙ˜ ‰fiÙ˜). OÈ ·ÛıÂÓ›˜ ¤Ï·‚·Ó ·ÁˆÁ‹ Ì thymoglobulin Î·È ÙÚÈÏfi Û¯‹Ì· Ì tacrolimus, MMF Î·È ÛÙÂÚÔÂȉ‹. ∂›Û˘ IVIG ¯ÔÚËÁ‹ıËΠÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙËÓ ›‰È· ‰ÔÛÔÏÔÁ›· (2 mg/kg) ÌÂÙ¿ ·fi 3 Î·È 6 ‚‰ÔÌ¿‰Â˜. ŒÓ· ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ¯¿ıËΠÙËÓ ÚÒÙË Ë̤ڷ ·fi ıÚfiÌ‚ˆÛË (Ë IVIG ·ÚÔ˘ÛÈ¿˙ÂÈ ÚÔıÚÔÌ‚ˆÙÈ΋ ‰Ú¿ÛË), ¤Ó· ·fi ÔÍ›· ·fiÚÚÈ„Ë, ¤Ó· ·fi Ïԛ̈ÍË Ì Èfi BK Î·È ‰‡Ô ÌÔۯ‡̷ٷ ÏfiÁˆ ı·Ó¿ÙÔ˘ ÙÔ˘ Ï‹ÙË. OÈ Jordan Î·È Û˘Ó ·Ó¤ÊÂÚ·Ó 48 ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ¤Ï·‚·Ó 1-4 ‰fiÛÂȘ IVIG17. §fiÁˆ ÔÈÎÔÓÔÌÈÎÒÓ ÂÚÈÔÚÈÛÌÒÓ ÔÈ ·ÛıÂÓ›˜ ˘Â‚Ï‹ıËÛ·Ó ÚÈÓ ÙËÓ ¯ÔÚ‹ÁËÛË πVIG
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Û ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÁÈ· ÂÈÏÔÁ‹ ·˘ÙÒÓ Ô˘ Èı·ÓÒ˜ Ó· ˆÊÂÏÔ‡ÓÙ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi ÙË ıÂڷ›·. ∏ ·ÚÓËÙÈÎÔÔ›ËÛË ÂÓfi˜ ıÂÙÈÎÔ‡ CDC crossmatch ÌÂÙ¿ ·fi ÚÔÛı‹ÎË IgG ıˆڋıËΠÂÓ‰ÂÈÎÙÈ΋ ηϋ˜ ·¿ÓÙËÛ˘ ÛÙË ¯ÔÚ‹ÁËÛË IVIG. ™Â ·ÓÙ›ıÂÙË ÂÚ›ÙˆÛË Ô ·ÛıÂÓ‹˜ ·ÔÎÏ›ÔÓÙ·Ó ·fi ÙË ıÂڷ›·. ™·Ú¿ÓÙ·-‰‡Ô (42) ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ·ÚÓËÙÈÎfi crossmatch Ì IgG Î·È ÚÔ¯ÒÚËÛ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó ÔÛÔÛÙfi ÔÍ›·˜ ·fiÚÚȄ˘ 31% (3 ·ÒÏÂȘ ÌÔÛ¯Â˘Ì¿ÙˆÓ) Î·È 89% ‰ÈÂÙ‹ Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ÌÂϤÙË πG02 Â›Ó·È Ë ÌfiÓË ‰ÈÏ‹ Ù˘ÊÏ‹ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË Ì ÔÌ¿‰· ¤ÏÂÁ¯Ô˘ (placebo) ·Ó·ÊÔÚÈο Ì ÙË ‰Ú·ÛË Ù˘ IVIG Û ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ (PRA >50%) Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û ·ÈÌÔοı·ÚÛË Î·È ¯ÚËÌ·ÙÔ‰ÔÙ‹ıËΠ·fi ÙÔ ∂ıÓÈÎfi πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙˆÓ ∏¶∞18. ¶ÚfiÎÂÈÙ·È ÁÈ· ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË 98 ·ÛıÂÓÒÓ Ì ¯ÔÚ‹ÁËÛË 2 mg/kg IVIG/ Ì‹Ó· ÁÈ· Û˘ÓÔÏÈο 4 Ì‹Ó˜ Î·È ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ ¿Óˆ ·fi 4 ¤ÙË. ¶·Ú·ÙËÚ‹ıËΠ̤ÙÚÈ· ·ÏÏ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÒÛË ÙÔ˘ Ù›ÙÏÔ˘ ÙÔ˘ PRA Û¯ÂÙÈο Ì ÙÔ ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ Î·È Ë ¤Á¯˘ÛË Ù˘ ‹Ù·Ó ηϿ ·ÓÂÎÙ‹. 35% ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÔÌ¿‰·˜ Ù˘ IVIG ¤Ó·ÓÙÈ 17% Ù˘ ÔÌ¿‰·˜ ÙÔ˘ ÂÈÎÔÓÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘ ηٿÊÂÚ ӷ ˘Ô‚ÏËı› Û ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂ÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ ·ÚÔ˘Û›·Û·Ó 9/17 ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ Ù˘ IVIG Î·È 1/10 Ù˘ ÔÌ¿‰·˜ ÙÔ˘ ÂÈÎÔÓÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘. ∏ ‰ÈÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‹Ù·Ó 80% Î·È 75% ·ÓÙ›ÛÙÔȯ·. ∏ ÙÒÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ PRA Û ۯ¤ÛË Ì ÙË ÌÂϤÙË ÙˆÓ Glotz Î·È Û˘Ó15 ‹Ù·Ó Û·ÊÒ˜ ÌÈÎÚfiÙÂÚË Î·È ·Ô‰fiıËΠÛÙ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ (20% ·ÊÚÔ·ÌÂÚÈηÓÔ›) Î·È ÙÔ Û··ÛÌ· Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ. ∏ ıÂڷ›· ·Â˘·ÈÛıËÙÔÔ›ËÛ˘ Ì IVIG ıˆÚÂ›Ù·È ÂÍ·ÈÚÂÙÈο ‰··ÓËÚ‹. ™‡Ìʈӷ Ì ÌÈ· ÔÈÎÔÓÔÌÔÙ¯ÓÈ΋ ÌÂϤÙË ÛÙȘ ∏¶∞ ÙÔ ÎfiÛÙÔ˜ Ù˘ ıÂڷ›·˜ ÁÈ· ¤Ó· ·ÛıÂÓ‹ 70 kg Ì 4 ÂÁ¯‡ÛÂȘ Û ‰fiÛË 2 gr/kg Êı¿ÓÂÈ Ù· 30000 USD18. ∞Ó ÏËÊı› ˘fi„Ë ÙÔ ÎfiÛÙÔ˜ ·Ú·ÌÔÓ‹˜ ÛÙËÓ ·ÈÌÔοı·ÚÛË ÛÙȘ ∏¶∞, ÙfiÙ ۇÌʈӷ Ì ÙËÓ ›‰È· ÌÂϤÙË ı· ÂÍÔÈÎÔÓÔÌËıÔ‡Ó ÂÚ›Ô˘ 300.000 USD ÁÈ· οı ·ÛıÂÓ‹ Ô˘ ı· ·Ú¤ÌÂÓ ÛÙËÓ ·ÈÌÔοı·ÚÛË Â› Ì›· ÂÓÙ·ÂÙ›·3. ∏ ¯ÔÚ‹ÁËÛË ÌÂÁ¿ÏˆÓ ‰fiÛÂˆÓ IVIG ‰ÂÓ Â›Ó·È ¿ÌÔÈÚË ·ÚÂÓÂÚÁÂÈÒÓ. O Jordan ·Ó·Ê¤ÚÂÈ fiÙÈ Î·Ù¿ ÙËÓ ÌÂϤÙË IG02 ¤ÁÈÓ·Ó 300 ÂÁ¯‡ÛÂȘ IVIG ηÈ
89
300 ÂÁ¯‡ÛÂȘ placebo3. ∫·ÙÂÁÚ¿ÊËÛ·Ó 24 ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ÛÙËÓ ÔÌ¿‰· Ù˘ IVIG Î·È 23 ÛÙËÓ ÔÌ¿‰· ÙÔ˘ ÂÈÎÔÓÈÎÔ‡ Ê·ÚÌ¿ÎÔ˘. ∏ ÈÔ Û˘¯Ó‹ ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· ÛÙËÓ ÔÌ¿‰· Ù˘ IVIG ‹Ù·Ó Ë ÎÂÊ·Ï·ÏÁ›·, Ë ÔÔ›· ˘Ô¯ˆÚÔ‡Û Ì ÂÏ¿ÙÙˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ¤Á¯˘Û˘ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È ¯ÔÚ‹ÁËÛË ·Ú·ÎÂÙ·ÌfiÏ˘. ÕÏϘ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ô˘ ¤¯Ô˘Ó ·Ó·ÊÂÚı›13,19 Â›Ó·È ˘ÚÂÙfi˜ Î·È Ú›ÁË Ô˘ ˘Ô¯ˆÚÔ‡Ó Ì ÙËÓ ·ÓˆÙ¤Úˆ Ú·ÎÙÈ΋, ·Ó·Ê˘Ï·Í›· Û ¿ÙÔÌ· ÌÂ Û˘ÁÁÂÓ‹ ·Ó¿ÚÎÂÈ· IgA, ıÚÔÌ‚ˆÙÈο ÂÂÈÛfi‰È· (Ù· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· Û‹ÌÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡Ó ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈıÚÔÌ‚ˆÙÈ΋ ·ÁˆÁ‹) Î·È ÔÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (ÔÊÂÈÏfiÌÂÓË Î‡ÚÈ· ÛÙË ÛÔ˘ÎÚfi˙Ë Ô˘ ÂÚȤ¯Ô˘Ó ÔÚÈṲ̂ӷ Û΢¿ÛÌ·Ù·) ·ÊÔ‡ ÔÈ ÂÁ¯‡ÛÂȘ Û˘Ó¯›˙ÔÓÙ·È Î·È ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË19.
¶ÚˆÙfiÎÔÏÏ· ¶Ï·ÛÌ·Ê·›ÚÂÛ˘ ¢È¿ÊÔÚ· ΤÓÙÚ· ¤¯Ô˘Ó ·Ó·Ê¤ÚÂÈ Ôχ ηϿ ·ÔÙÂϤÛÌ·Ù· Ì ڈÙfiÎÔÏÏ· ·Â˘·ÈÛıËÙÔÔÏ›ËÛ˘ ‚·ÛÈṲ̂ӷ ÛÙËÓ ‰ÈÂÓ¤ÚÁÂÈ· Ï·ÛÌ·Ê·›ÚÂÛ˘. Δ· ÚˆÙfiÎÔÏÏ· ·˘Ù¿ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ Ì ˘Ô„‹ÊÈÔ˘˜ ˙ÒÓÙ˜ ‰fiÙ˜ Ì ÙÔ˘˜ ÔÔ›Ô˘˜ fï˜ ÂÌÊ·Ó›˙Ô˘Ó ıÂÙÈÎfi crossmatch. ∏ ‚·ÛÈ΋ ÙÔ˘˜ ·Ú¯‹ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ anti-HLA IgG Ì ϷÛÌ·Ê·›ÚÂÛË Î·È ÙË ¯ÔÚ‹ÁËÛË ÌÈÎÚÒÓ ‰fiÛÂˆÓ IVIG Ë ÔÔ›· ¤¯ÂÈ ·ÓÔÛÔÙÚÔÔÔÈËÙÈΤ˜ ȉÈfiÙËÙ˜ ÙÚÂȘ ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. °È· ÙËÓ ·ÔÊ˘Á‹ ·ӷ‰ËÌÈÔ˘ÚÁ›·˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Á›ÓÂÙ·È Ù·˘Ùfi¯ÚÔÓË ¤Ó·ÚÍË ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ıÂڷ›·˜ Ì tacrolimus, MMF Î·È ÛÙÂÚÔÂȉ‹ (ÌÂÚÈο ÎÂÓÙÚ·) Î·È ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÁˆÁ‹˜ ¤Ó·ÓÙÈ Â˘Î·ÈÚÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ (SXT) Î·È ÈÒÓ (acyclovir, gancyclovir). ™Â ÂÚ›ÙˆÛË ·ÚÓËÙÈÎÔ‡ crossmatch Á›ÓÂÙ·È ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ë Ï·ÛÌ·Ê·›ÚÂÛË Â·Ó·Ï·Ì‚¿ÓÂÙ·È ÁÈ· ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ ηٿ ÙȘ 2 ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ Schweitzer Î·È Û˘Ó ·Ó·Ê¤ÚÔ˘Ó 11/15 ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ Î·Ù¿ÊÂÚ·Ó Ó· Ï¿‚Ô˘Ó ÌÔۯ‡̷ٷ ·ÊÔ‡ ·ÚÓËÙÈÎÔÔ›ËÛ·Ó ÙÔ crossmatch, ·ÏÏ¿ ÛÙË ÛÂÈÚ¿ ·˘Ù‹ Ô Ù›ÙÏÔ˜ ÙÔ˘ PRA ‰ÂÓ ‹Ù·Ó Ôχ ˘„ËÏfi˜20. OÈ Gloor Î·È Û˘Ó ·ÎÔÏÔ‡ıËÛ·Ó ¤Ó· ÈÔ ÂÈıÂÙÈÎfi ÚˆÙfiÎÔÏÏÔ, Ô˘ Û˘ÌÂÚÈÂÏ¿Ì‚·Ó ÛÏËÓÂÎÙÔÌ‹ Î·È ¯ÔÚ‹ÁËÛË rituximab21. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ (14/14) ·ÚÓËÙÈÎÔÔ›ËÛ·Ó ÙÔ crossmatch Î·È ˘Â‚Ï‹ıËÛ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŒÓÙÂη (11) ÌÔ-
90
K. ºOYPTOYNA™
ۯ‡̷ٷ ·ÚÔ˘Û›·˙·Ó ÈηÓÔÔÈËÙÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÌÂÙ¿ ·fi ¤Ó· ̤ÛÔ fiÚÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 18 ÌËÓÒÓ. ŒÓ· ÌfiÛ¯Â˘Ì· ¯¿ıËΠÏfiÁˆ ÔÍ›·˜ ·fiÚÚȄ˘, ¤Ó· ÏfiÁˆ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ¤Ó· ÏfiÁˆ ı·Ó¿ÙÔ˘ ÙÔ˘ Ï‹ÙË. OÈ Montgomery Î·È Û˘Ó ·fi ÙÔ ¡ÔÛÔÎÔÌÂ›Ô John Hopkins ÙˆÓ ∏¶∞ ·ÚÔ˘Û›·Û·Ó ı·̷ÙÈο ·ÔÙÂϤÛÌ·Ù· Û 80 ·ÛıÂÓ›˜ Ì Ôχ ˘„ËÏfi Ù›ÙÏÔ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ÙË ¯Ú‹ÛË 100 mg CMV ˘ÂÚ¿ÓÔÛ˘ ÛÊ·ÈÚ›Ó˘ ÌÂÙ¿ ·fi οıÂ Û˘Ó‰ڛ· Ï·ÛÌ·Ê·›ÚÂÛ˘, ·Ó Î·È ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ÛÙÔȯ›· Ô˘ Ó· ‰Â›¯ÓÔ˘Ó ˘ÂÚÔ¯‹ Ù˘ ¤Ó·ÓÙÈ Ù˘ ÎÏ·ÛÛÈ΋˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘22. ΔÔ ÚˆÙfiÎÔÏÏÔ Â›Û˘ ÂÚÈÂÏ¿Ì‚·Ó ÙË ¯ÔÚ‹ÁËÛË rituximab Û ·ÛıÂÓ›˜ ˘„ËÏfiÙÂÚÔ˘ ÎÈÓ‰‡ÓÔ˘ (2Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÈÛÙÔÚÈÎfi ÚÒÈÌ˘ ·ÒÏÂÈ·˜ ÌÔۯ‡̷ÙÔ˜, ÔÏÏ·Ï¿ anti-HLA ·ÓÙÈÛÒÌ·Ù·). ∏ Mayo Clinic ÚfiÛÊ·Ù· ·Ó·ÎÔ›ÓˆÛ ÙËÓ ÂÌÂÈÚ›· Ù˘ ·fi ÙË Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ‰È·ÊfiÚˆÓ ÚˆÙÔÎfiÏÏˆÓ ‚·ÛÈÛÌ¤ÓˆÓ ÛÙË ¯ÔÚ‹ÁËÛË ÌÂÁ¿ÏˆÓ ‰fiÛÂˆÓ πVIG, Î·È Û˘Ó‰˘·ÛÌÒÓ Ï·ÛÌ·Ê·›ÚÂÛ˘ Ì ¯ÔÚ‹ÁËÛË ÌÈÎÚÒÓ ‰fiÛÂˆÓ πVIG Û ·ÛıÂÓ›˜ Ì ıÂÙÈÎfi crossmatch ¤Ó·ÓÙÈ ˙ÒÓÙ· ‰fiÙË23. ∏ ÚÒÙË ÔÌ¿‰· (32 ·ÛıÂÓ›˜) ˘Ô‚Ï‹ıËΠÛÂ Û˘Ó‰ڛ˜ Ï·ÛÌ·Ê·›ÚÂÛ˘, ¯ÔÚ‹ÁËÛË 100 mg Kμ™ IVIG Î·È rituximab, ÂÓÒ 19/32 ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó Î·È Û ÛÏËÓÂÎÙÔÌ‹ ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ‰Â‡ÙÂÚË ÔÌ¿‰· (13 ·ÛıÂÓ›˜) ¤Ï·‚ ˘„ËϤ˜ ‰fiÛÂȘ (2gr/∫μ™) IVIG. ∏ ÙÚ›ÙË ÔÌ¿‰· (16 ·ÛıÂÓ›˜) ¤Ï·‚ fiÙÈ Î·È Ë ÚÒÙË ÔÌ¿‰·, ÌÂ Û˘¯Ó‹ ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ‰fiÙË (donor specific antibodies). MfiÓÔ 5 ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ Ù˘ IVIG ηٿÊÂÚ·Ó Ó· ·ÚÓËÙÈÎÔÔÈ‹ÛÔ˘Ó ÙÔ crossmatch Î·È Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞fi ·˘ÙÔ‡˜, 80% ÂÌÊ¿ÓÈÛ ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ ·fiÚÚȄ˘. ™ÙȘ ÔÌ¿‰Â˜ Ù˘ Ï·ÛÌ·Ê·›ÚÂÛ˘ 80% ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ·ÌÔۯ‡ıËηÓ, ÂÌÊ·Ó›˙ÔÓÙ·˜ ÔÍ›· ·fiÚÚÈ„Ë Û ÔÛÔÛÙfi 30%. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó Û·Ê‹ ˘ÂÚÔ¯‹ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ Ì ϷÛÌ·Ê·›ÚÂÛË, ·ÏÏ¿ Î·È Â‰Ò Ù· ÔÛÔÛÙ¿ ÔÍ›·˜ ·fiÚÚȄ˘ ·Ú·Ì¤ÓÔ˘Ó ˘„ËÏ¿.
∞ÓÔÛÔÚÔÛÚfiÊËÛË ∏ ̤ıÔ‰Ô˜ Ù˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ¤¯ÂÈ ÙÔ ÏÂÔÓ¤ÎÙËÌ· ¤Ó·ÓÙÈ Ù˘ ÎÏ·ÛÛÈ΋˜ Ï·ÛÌ·Ê·›ÚÂÛ˘, Ù˘ ÂÎÏÂÎÙÈ΋˜ ·ÔÌ¿ÎÚ˘ÓÛ˘ Ù˘ IgG, ¯ˆÚ›˜ ÙËÓ ·ÒÏÂÈ· ˆÊ¤ÏÈÌˆÓ ·Ú·ÁfiÓÙˆÓ fiˆ˜ ÔÈ ·-
Ú¿ÁÔÓÙ˜ ‹Í˘ ‹ ÙËÓ ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ˘ÁÚÒÓ ·Ó·Ï‹ÚˆÛ˘. OÈ Lorenz Î·È Û˘Ó ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÙËÓ ·ÓÔÛÔÚÔÛÚfiÊËÛË ˆ˜ ıÂڷ›· ·Â˘·ÈÛıËÙÔÔ›ËÛ˘ Û ·ÛıÂÓ›˜ Ì ıÂÙÈÎfi crossmatch ¤Ó·ÓÙÈ ÙˆÌ·ÙÈÎÔ‡ ‰fiÙË24. ∂¿Ó ÌÂÙ¿ ·fi Ì›· Û˘Ó‰ڛ· ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ÙÔ crossmatch ÁÈÓfiÙ·Ó ·ÚÓËÙÈÎfi, Ô ·ÛıÂÓ‹˜ ÂÏ¿Ì‚·Ó ÙÔ ÌfiÛ¯Â˘Ì·. ∏ ‰ÈÂÓ¤ÚÁÂÈ· ÌfiÓÔÓ Ì›·˜ Î·È fi¯È ÂÚÈÛÛÔÙ¤ÚˆÓ Û˘Ó‰ÚÈÒÓ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ÎÚ›ıËΠ·Ó·Áη›· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÌÂÁ¿Ï˘ ·Ú¿Ù·Û˘ ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜. OÈ Û˘Ó‰ڛ˜ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ Û˘Ó¯›˙ÔÓÙ·Ó ÁÈ· ¤Ó· Ì‹Ó· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂ÓÓ¤· (9/14) ·ÛıÂÓ›˜ ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Ì ·˘Ùfi ÙÔ ÚˆÙfiÎÔÏÏÔ Ì 78% ÙÚÈÂÙ‹ ÂÈ‚›ˆÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ. ΔÔ ÌÂÈÔÓ¤ÎÙËÌ· ·˘ÙÔ‡ ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ Â›Ó·È fiÙÈ ·Ó ‰ÂÓ ·ÚÓËÙÈÎÔÔÈËı› ÙÔ crossmatch, Ô ÂfiÌÂÓÔ˜ Ï‹Ù˘ ı· Ï¿‚ÂÈ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· Ì ·˘ÍË̤ÓÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜. ¶ÚfiÛÊ·Ù· ÔÈ Silverman Î·È Û˘Ó ‰È·Ù‡ˆÛ·Ó ÙË ıˆڛ· fiÙÈ Ë ÚˆÙ½ÓË ∞ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙËÓ ·ÓÔÛÔÚÔÛÚfiÊËÛË ·ÂÏ¢ıÂÚÒÓÂÙ·È Î·Ù¿ ÙË Û˘Ó‰ڛ· Ù˘ ıÂڷ›·˜ ÛÙÔ ·›Ì· ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ‰Ú· ¢ÂÚÁÂÙÈο ÚÔηÏÒÓÙ·˜ ÂÏ¿ÙÙˆÛË ÙˆÓ μ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ25. OÈ ›‰ÈÔÈ ÂÚ¢ÓËÙ¤˜ ÚoÙ›ÓÔ˘Ó ÙËÓ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Ù˘ ˆ˜ ̤ıÔ‰Ô ·Â˘·ÈÛıËÙÔÔ›ËÛ˘!
Rituximab To rituximab Â›Ó·È ¯ÈÌÂÚÈÎfi ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÈÊ·Ó›·˜ CD20, ÙÔ ÔÔ›Ô Â˘Ú›ÛÎÂÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· Ê˘ÛÈÔÏÔÁÈÎÒÓ Î·È ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ μ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ΔÔ Ê¿ÚÌ·ÎÔ ¤¯ÂÈ Ï¿‚ÂÈ Â›ÛËÌ· ¿‰ÂÈ· ¯Ú‹Û˘ ÁÈ· ÙË ıÂڷ›· non-Hodgkin ÏÂÌÊˆÌ¿ÙˆÓ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È ÙˆÓ ÏÂÌÊÔ-˘ÂÚÏ·ÛÙÈÎˆÓ ÓÔÛËÌ¿ÙˆÓ ÌÂÙ¿ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, PTLD) , Î·È Û ÂÚ¢ÓËÙÈο ÚˆÙfiÎÔÏÏ· ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ Ì ÂÌÏÔ΋ Ù˘ ¯˘ÌÈ΋˜ ·ÓÔÛ›·˜3. ∫¿ÔÈ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ rituximab ÛÙ· ÚˆÙfiÎÔÏÏ· ·Â˘·ÈÛıËÙÔÔ›ËÛ˘ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ·ӷ‰ËÌÈÔ˘ÚÁ›·˜ ÙˆÓ anti-HLA ·ÓÙÈۈ̿وÓ. £ÂˆÚËÙÈο ÙÔ ·ÓÙÈÁfiÓÔ CD20 ‰ÂÓ ÂÎÊÚ¿˙ÂÙ·È ÛÙ· Ï·ÛÌ·ÙÔ·ÙÙ·Ú· Ù· ÔÔ›· Â›Ó·È Ù· ·ÙÙ·Ú· ·Ú·ÁˆÁ‹˜ ÙˆÓ ·ÓˆÙ¤Úˆ ·ÓÙÈۈ̿وÓ, ·ÏÏ¿ ¤¯Ô˘Ó ÚÔÙ·ı› ‰‡Ô Ì˯·ÓÈÛÌÔ› Èı·Ó‹˜ ÂÌÏÔ΋˜ ÙÔ˘: ·) ̤ۈ ÂÍ·Ê¿ÓÈÛ˘ Úfi‰ÚÔÌˆÓ (precursor) μ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ‚) ̤ۈ ·Ó·ÛÙÔÏ‹˜ Ù˘ ·ÓÙÈÁÔÓÔ·ÚÔ˘-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Û›·Û˘ ̤ۈ μ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È Û˘Ó‰È¤ÁÂÚÛ˘ ÙˆÓ Δ- ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ΔÔ rituximab ‰ÔÎÈÌ¿ÛÙËΠ۠ÌÂϤÙË Ê¿Û˘ I Û 9 ˘ÂÚ-¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ ˘fi ·ÈÌÔοı·ÚÛË, ÚÔηÏÒÓÙ·˜ ·Ú·ÙÂٷ̤ÓË ÂÍ¿ÏÂÈ„Ë ÙˆÓ μ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ26. ¶·ÚfiÏ· ·˘Ù¿ ·Ú·ÙËÚ‹ıËΠÌfiÓÔÓ ÌÈ· ÌÈÎÚ‹ ÙÒÛË ÙÔ˘ Ù›ÙÏÔ˘ ÙÔ˘ PRA Û ÌfiÓÔ Û ÌÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ÃÚËÛÈÌÔÔÈÂ›Ù·È Ì ۯÂÙÈ΋ ÂÈÙ˘¯›· (off-label) ÛÙÔ ÚˆÙfiÎÔÏÏÔ ·Â˘·ÈÛıËÙÔÔ›ËÛ˘ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ John Hopkins, Û ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì ∞μO ·Û˘Ì‚·ÙfiÙËÙ· (ÙÂÏÂ˘Ù·›Â˜ ÌÂϤÙ˜ ·ÌÊÈÛ‚ËÙÔ‡Ó ÙË ¯ÚËÛÈÌfiÙËÙ· ÙÔ˘) Î·È Û ÂÚÈÙÒÛÂȘ ·ÓıÂÎÙÈ΋˜ ÛÙË ıÂڷ›· ÔÍ›·˜ ·fiÚÚȄ˘ ÔÊÂÈÏfiÌÂÓ˘ Û ·Óٛۈ̷. ∏ ıÂڷ›· Ì rituximab Â›Ó·È ÂÍ·ÈÚÂÙÈο ‰··ÓËÚ‹ Î·È ¯ÚÂÈ¿˙ÔÓÙ·È Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Ì ÔÌ¿‰Â˜ ÂϤÁ¯Ô˘ ÁÈ· Ó· ·ÔÛ·ÊËÓÈÛÙÔ‡Ó Ï‹Úˆ˜ ÔÈ ÂӉ›ÍÂȘ Ù˘ ¯Ú‹Û˘ ÙÔ˘ ÛÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË3,4.
ÕÏϘ Δ¯ÓÈΤ˜ ∏ ÎÏÈÓÈ΋ ·Ú·Ù‹ÚËÛË fiÙÈ Ë ÂÌÊ¿ÓÈÛË ÔÍ›·˜ ·fiÚÚȄ˘ ·fi ·ÓÙÈÛÒÌ·Ù· Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· Û ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ·ÎfiÌË Î·È Â› ·ÚÔ˘Û›·˜ ıÂÙÈÎÔ‡ crossmatch, Ô‰‹ÁËÛ ÛÙË ıˆڛ· Ù˘ ·ÔÚÚfiÊËÛ˘ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ·fi ÙÔ ‹·Ú. OÈ Olausson Î·È Û˘Ó ·fi ÙË ™Ô˘Ë‰›· ˘¤‚·ÏÏ·Ó 7 ·ÛıÂÓ›˜ Ì ˘„ËÏfi Ù›ÙÏÔ PRA (50-99%) Û ٷ˘Ùfi¯ÚÔÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Î·È ÙÌ‹Ì·ÙÔ˜ ‹·ÙÔ˜ ·fi ‰fiÙ˜ Ì ıÂÙÈ΋ ‰ÔÎÈÌ·Û›· crossmatch27. ¶¤ÓÙ ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ¿ÚÈÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (¯ˆÚ›˜ ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘) ÁÈ· 20-60 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÂÓÒ ÙÔ crossmatch η٤ÛÙË ·ÚÓËÙÈÎfi ¿ÌÂÛ· ÌÂÙÂÁ¯ÂÈÚËÙÈο, ·ÏÏ¿ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘. ™Â ¤Ó· ·ÛıÂÓ‹ ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ‰ÂÓ ÏÂÈÙÔ‡ÚÁËÛ (primary non function) Î·È Û ¤Ó· ·ÛıÂÓ‹ ·Ú·ÙËÚ‹ıËΠ‚·ÚÈ¿ ÔÍ›· ·fiÚÚÈ„Ë ·fi ·Óٛۈ̷ (C4d+) Ô˘ Ô‰‹ÁËÛ Û ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞Ó Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Â›Ó·È ÂÓı·ÚÚ˘ÓÙÈο ÂÁ›ÚÔ˘Ó ÔÈΛϷ ˙ËÙ‹Ì·Ù· ËıÈ΋˜ (·˘ÍË̤ÓÔ˜ ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ΛӉ˘ÓÔ˜, ¯Ú‹ÛË Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÁÈ· ¿ÏÏÔ˘˜ ÏfiÁÔ˘˜ ÎÏ).
¶ƒøΔO∫O§§∞ ∞¡O™O∫∞Δ∞™ΔO§∏™ ª∂Δ∞ Δ∏ ª∂Δ∞ªO™Ã∂À™∏ §fiÁˆ ÙÔ˘ ·˘ÍË̤ÓÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘, Ù· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÂÈϤ-
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ÁÔ˘Ó ÈÛ¯˘Ú¿ ·ÓÔÛÔηٷÛÙ·ÏÙÈο Û¯‹Ì·Ù· Ì ıÂڷ›· ·ÁˆÁ‹˜ Ì ÔÏ˘ÎψÓÈ΋ ·ÓÙÈı˘ÌÔ΢ÙÙ·ÚÈ΋ ÛÊ·ÈÚ›ÓË (thymoglobulin) Î·È ÙÚÈÏ‹ ıÂڷ›· Ì tacrolimus, MMF Î·È ÛÙÂÚÔÂȉ‹. ªÂÚÈο ΤÓÙÚ· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÛÙÔ ·ÓˆÙ¤Úˆ ÚˆÙfiÎÔÏÏ· Î·È rituximab. £ÂˆÚËÙÈο Ë ¯Ú‹ÛË thymoglobulin ˘ÂÚ¤¯ÂÈ ¤Ó·ÓÙÈ ÙˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘-2 (basiliximab, daclizumab) ÛÙËÓ ÚfiÏË„Ë Ù˘ ÔÍ›·˜ ΢ÙÙ·ÚÈ΋˜ ·fiÚÚȄ˘. ¶·ÚfiÏ· ·˘Ù¿ Û ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜ ‚Ú¤ıËΠfiÙÈ Ë ¯Ú‹ÛË thymoglobulin Û¯ÂÙ›˙ÂÙ·È Ì ÌÈ· ·Ú¿‰ÔÍË ·‡ÍËÛË ÙˆÓ anti-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ù· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· Û‹ÌÂÚ· ÚÔÙÈÌÔ‡Ó ıÂڷ›˜ ·ÁˆÁ‹˜ Ì basiliximab ‹ daclizumab. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÙÔ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ CD52 alemtuzumab (Campath 1H) ÙÔ ÔÔ›Ô ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û‹ÌÂÚ· ¢ڤˆ˜ Û ڈÙfiÎÔÏÏ· ·ÔÊ˘Á‹˜ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ ‹ ÛÙÂÚÔÂȉÒÓ Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·fiÚÚȄ˘ ÔÊÂÈÏfiÌÂÓ˘ Û ·ÓÙÈÛÒÌ·Ù· Î·È ‰ÂÓ ¤¯ÂÈ ı¤ÛË ÛÙ· ÚˆÙfiÎÔÏÏ· ·˘Ù¿3.
¶∂ƒπOƒπ™ªOπ Δø¡ ª∂§∂Δø¡¶ƒOμ§∏ª∞Δπ™ªOπ- ¶ƒOO¶Δπ∫∂™ OÈ ÌÂϤÙ˜ Ì ‰È¿ÊÔÚÔ˘˜ Ê·ÚÌ·ÎÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÚԷӷʤÚıËÎ·Ó ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÍÈÔÛËÌ›ˆÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ ÔÈ ÔÔ›ÔÈ Î·È ı· Ú¤ÂÈ Ó· ÂÈÛËÌ·ÓıÔ‡Ó: – ∫·Ù·Ú¯‹Ó Ì ÌÔÓ·‰È΋ ÂÍ·›ÚÂÛË ÙË ÌÂϤÙË IG02, Ù· ÚˆÙfiÎÔÏÏ· ·˘Ù¿ ‰ÂÓ ¤¯Ô˘Ó ÌÂÏÂÙËı› ÛÂ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Ì ÔÌ¿‰· ÂϤÁ¯Ô˘. OÈ ˘ÔÛÙËÚÈÎÙ¤˜ ÙÔ˘˜ ÂÎÊÚ¿˙Ô˘Ó ÙËÓ ÂÔ›ıËÛË fiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ·ÓÒÙÂÚ· ·fi ÙËÓ ÂÌÂÈÚ›· ·Ï·ÈfiÙÂÚˆÓ ÂÙÒÓ (historical controls), ·ÏÏ¿ ‰ÂÓ Ï·Ì‚¿ÓÔ˘Ó ˘fi„Ë ÙË ¯Ú‹ÛË Û‹ÌÂÚ· ÈÛ¯˘ÚfiÙÂÚˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (tacrolimus, MMF, sirolimus, everolimus). – ΔÔ ÎfiÛÙÔ˜ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ ·˘ÙÒÓ Â›Ó·È ¿Ú· Ôχ ˘„ËÏfi. ∏ ÌÔÓ·‰È΋ ÔÈÎÔÓÔÌÔÙ¯ÓÈ΋ ÌÂϤÙË Ô˘ ¤ÁÈÓ ·fi ÙËÓ ÌÂϤÙË IG02 ‰Â›¯ÓÂÈ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÌÂÁ¿ÏˆÓ ‰fiÛÂˆÓ IVIG ·ÚÔ˘ÛÈ¿˙ÂÈ ıÂÙÈÎfi ÚfiÛËÌÔ ÎfiÛÙÔ˘˜/ˆÊ¤ÏÂÈ·˜ Û ۯ¤ÛË Ì ÙËÓ ·Ú·ÌÔÓ‹ ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ ·ÈÌÔοı·ÚÛË, ·ÏÏ¿ Ù· ÔÈÎÔÓÔÌÈο ÌÂÁ¤ıË ·ÊÔÚÔ‡Ó ÌfiÓÔÓ ÙȘ ∏¶∞. – ∏ Ô˘Ì·ÓÈÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ı¤Ì·ÙÔ˜ ¤Ú¯ÂÙ·È Û ۷ʋ ·ÓÙ›ıÂÛË Ì ÙËÓ ÔÈÎÔÓÔÌÈ΋ ÚÔ-
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K. ºOYPTOYNA™
Û¤ÁÁÈÛË ÙÔ˘, ·ÊÔ‡ Â›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ˘ÂÚ¤¯ÂÈ ¤Ó·ÓÙÈ ÙˆÓ ıÂÚ·ÂÈÒÓ ˘ÔηٿÛÙ·Û˘ (·ÈÌÔοı·ÚÛË, ÂÚÈÙÔÓ·˚΋ οı·ÚÛË), ÙfiÛÔ ·Ó·ÊÔÚÈο Ì ÙËÓ ÂÈ‚›ˆÛË fiÛÔ Î·È Ì ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ∂Ô̤ӈ˜ ıˆÚÂ›Ù·È Ì¿ÏÏÔÓ ·Ó‹ıÈÎÔ ÙÔ Ó· ÌËÓ ÚÔÛʤÚÂÙ·È Î¿ÔÈ· ÂÓ·ÏÏ·ÎÙÈ΋ χÛË, ¤ÛÙˆ Î·È Ì ÂÚÈÔÚÈṲ̂ÓË ÂÈÙ˘¯›·, ·ÊÔ‡ Á›ÓÔ˘Ó ÁÓˆÛÙ¿ ÛÙÔÓ ˘Ô„‹ÊÈÔ ·ÛıÂÓ‹ Ù· ‰ÈÂıÓ‹ ‰Â‰Ô̤ӷ, ·ÏÏ¿ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ οı ΤÓÙÚÔ˘. ΔÔ ·ıÚÔÈÛÙÈÎfi ̤ÁÂıÔ˜ Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜, ÙfiÛÔ Î·Ù¿ ÙËÓ ÚÔÂÙÔÈÌ·Û›· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiÛÔ Î·È ÌÂÙ¿ ·fi ·˘Ù‹Ó Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ Û˘ÛÙËÌ·ÙÈÎÒÓ ÏÔÈÌÒ͈Ó, ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ·fi CMV ‹ Èfi μ∫ Î·È ÓÂÔÏ·ÛÈÒÓ. ∂Ô̤ӈ˜ ÔÈ ˘Ô„‹ÊÈÔÈ ·ÛıÂÓ›˜ ÁÈ· ·ÚfiÌÔÈ· ÚˆÙfiÎÔÏÏ· ı· Ú¤ÂÈ Ó· Â›Ó·È Î·Ï¿ ÏËÚÔÊÔÚË̤ÓÔÈ ÁÈ· ÙȘ Èı·Ó¤˜ ÌÂÏÏÔÓÙÈΤ˜ ÂÈÏÔΤ˜. ¢ÂÓ ˘¿Ú¯Ô˘Ó ·ÎfiÌË ·ÔÙÂϤÛÌ·Ù· Ì·ÎÚfi¯ÚÔÓ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘. OÈ ÔϤÌÈÔÈ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ ·˘ÙÒÓ ÂÎÊÚ¿˙Ô˘Ó ¤ÓÙÔÓ˜ ÂÈÊ˘Ï¿ÍÂȘ ÁÈ· ÙËÓ Ì·ÎÚfi¯ÚÔÓË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·Ó·ÊÔÚÈο Ì ÙË ÛÙ·‰È·Î‹ ·ӷ‰ËÌÈÔ˘ÚÁ›· anti-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÙȘ Èı·Ó¤˜ ˘Ô-ÎÏÈÓÈΤ˜ ÌÔÚʤ˜ ÔÍ›·˜ ·fiÚÚȄ˘ ·fi ·Óٛۈ̷. Δ· ÚˆÙfiÎÔÏÏ· ·Â˘·ÈÛıËÙÔÔ›ËÛ˘ Ô˘ ‚·Û›˙ÔÓÙ·È ÛÙËÓ Ï·ÛÌ·Ê·›ÚÂÛË ‰ÂÓ ÎÚ›ÓÔÓÙ·È Î·Ù¿ÏÏËÏ· ÁÈ· ˘Ô„‹ÊÈÔ˘˜ ÁÈ· و̷ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÊÔ‡ Ô ¯ÚfiÓÔ˜ ·Ó‡ÚÂÛ˘ ηٿÏÏËÏÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ ‰‡Ó·Ù·È Ó· ÚÔ‚ÏÂÊı›, Ë ıÂڷ›· Ì ϷÛÌ·Ê·›ÚÂÛË ‰ÂÓ Â›Ó·È ¿ÌÔÈÚË ÂÈÏÔÎÒÓ Î·È Â›Ó·È ‰··ÓËÚ‹, ÂÓÒ Ô Ù›ÙÏÔ˜ ÙˆÓ anti-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ ı· ·˘ÍËı› ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘. ∏ ÚfiÏË„Ë Ù˘ Èı·Ó‹˜ ¢·ÈÛıËÙÔÔ›ËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ıˆÚÂ›Ù·È ıÂÌÂÏÈ҉˘. ∏ ¿ÛÎÔË ¯ÔÚ‹ÁËÛË ÚÔ˚fiÓÙˆÓ ·›Ì·ÙÔ˜ ı· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Î·È Ë Â˘Ú›· ¯Ú‹ÛË Ù˘ ·Ó·Û˘Ó‰È·Ṳ̂Ó˘ ÂÚ˘ıÚÔÔÈËÙ›Ó˘ ¤¯ÂÈ ÂÏ·ÙÙÒÛÂÈ ÙËÓ ·Ó¿ÁÎË ÌÂÙ·ÁÁ›ÛˆÓ. ∂›Û˘ ÂȉÈο ÛÙÔ˘˜ Ó¤Ô˘˜ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Î·È Ì·ÎÚ‡ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘, Ë Î·Ù¿ÏÏËÏË ÂÈÏÔÁ‹ ÂÓfi˜ ÚÒÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙËÓ Î·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·, ıˆÚÂ›Ù·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ¢·ÈÛıËÙÔÔ›ËÛ˘ ÛÙÔ Ì¤ÏÏÔÓ. O ÚfiÏÔ˜ Ù˘ ·Ê·›ÚÂÛ˘
ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ÙËÓ Â·Ó¤ÓÙ·ÍË Û ıÂڷ›· ˘ÔηٿÛÙ·Û˘ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ˜, ·ÊÔ‡ ˘¿Ú¯Ô˘Ó ‰Â‰Ô̤ӷ ·‡ÍËÛ˘ ÙÔ˘ Ù›ÙÏÔ˘ ÙÔ˘ PRA ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. – ΔËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯Ô˘Ó Á›ÓÂÈ ÌÂÁ¿Ï˜ ÚfiÔ‰ÔÈ ÛÙȘ Ù¯ÓÈΤ˜ Ù·˘ÙÔÔ›ËÛ˘ ÙˆÓ HLA ·ÓÙÈÁfiÓˆÓ Î·È ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÂȉÈÎÒÓ antiHLA ·ÓÙÈۈ̿وÓ. ∏ ÂȉÈÎfiÙËÙ· Î·È Ë Â˘·ÈÛıËÛ›· ÙˆÓ ÌÂıfi‰ˆÓ ·˘ÙÒÓ, ·ÏÏ¿ Î·È Ë ÂÚ·ÈÙ¤Úˆ ‚ÂÏÙ›ˆÛË ÙÔ˘˜, ı· ÌÔÚÔ‡Ó ÛÙÔ Ì¤ÏÏÔÓ Ó· ÚԂϤ„Ô˘Ó Î·Ï‡ÙÂÚ· ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË ÙÔ˘ Ï‹ÙË ÛÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· Î·È Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ Ì·ÎÚfi¯ÚÔÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘. – ªÈ· ÚÔÛÂÎÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ πG02 Ù˘ ÌÔÓ·‰È΋˜ Ù˘¯·ÈÔÔÈË̤Ó˘ ÌÂϤÙ˘ fiˆ˜ ÚԷӷʤÚıËÎÂ, ‰Â›¯ÓÂÈ Û·Ê‹ ˘ÂÚÔ¯‹ Ù˘ «‚ÈÔÏÔÁÈ΋˜» ÚÔÛ¤ÁÁÈÛ˘ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ (·Ó‡ÚÂÛË Î·Ù¿ÏÏËÏÔ˘ ‰fiÙË) Û ۯ¤ÛË Ì ÙË Ê·ÚÌ·ÎÔÏÔÁÈ΋ (¯ÔÚ‹ÁËÛË IVIG) ·ÊÔ‡ Ù· ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ ‹Ù·Ó Û˘ÓÙÚÈÙÈο ˘„ËÏfiÙÂÚ· ÛÙË ‰Â‡ÙÂÚË ÔÌ¿‰·. ∞ÎfiÌË Ù· ‰ÈÂÙ‹ ·ÔÙÂϤÛÌ·Ù· Ù˘ Eurotransplant, Ù· ÔÔ›· Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù¿ Û ÌË Â˘·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÂÈ΢ÚÒÓÔ˘Ó ·˘Ù‹Ó ÙËÓ ˘ÂÚÔ¯‹. – ∂Ô̤ӈ˜ ÙÔ ÂӉȷʤÚÔÓ ı· Ú¤ÂÈ Ó· ÂÈÎÂÓÙÚˆı› ÛÙËÓ ·‡ÍËÛË Ù˘ ‰ÂÍ·ÌÂÓ‹˜ ÙˆÓ ‰ÔÙÒÓ Î·È ÌfiÓÔÓ Û ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ (Û¿ÓÈ· ∏LA ·ÓÙÈÁfiÓ·, Ôχ¯ÚÔÓË ·Ó·ÌÔÓ‹ ÎÏ) ı· Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÂÙ·È Ë ÂÚ›ÙˆÛË Ê·ÚÌ·ÎÔÏÔÁÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜. ∞˘Ù‹ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û ÂÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ· Ì ÂÌÂÈÚ›· ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘ ·fi ·ÓÙÈÛÒÌ·Ù· (¿ÌÂÛË ÚfiÛ‚·ÛË Û ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ÂÚÁ·ÛÙ‹ÚÈ· Ì ‰˘Ó·ÙfiÙËÙ· ·Ó‡ÚÂÛ˘ C4d ÛÙÔ ˘ÏÈÎfi Ù˘ ‚ÈÔ„›·˜) Î·È Î·Ù¿ÏÏËÏ· ÂÍÔÏÈṲ̂ӷ ·ÓÔÛÔÏÔÁÈο ÂÚÁ·ÛÙ‹ÚÈ·, ·ÊÔ‡ ÔÈ ‰ÔÎÈ̷ۛ˜ crossmatch ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂËÚ¿˙ÔÓÙ·È ·fi ÙË ¯ÔÚ‹ÁËÛË IVIG, rituximab Î·È ¯ÚÂÈ¿˙ÔÓÙ·È ÈÔ ÂÍÂÏÈÁ̤Ó˜ ‰ÔÎÈ̷ۛ˜.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Kissmeyer-Nielsen F, Olsen S, Peterson VP, Fjeldborg O. Hyperacute rejection of kidney allografts associated with pre-existing antibodies against donor cells. Lancet 1966; 2: 662-665. 2. Patel R, Terasaki PI. Significance of the positive crossmatch test in kidney transplantation. N Engl J Med 1969; 280;735-739.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
3. Jordan SC, Pescovitz MD. Presensitization: the problem and its management. Clin J Am Soc Nephrol 2006; 1: 421-432. 4. Magee CC. Transplantation across previously incompatible immunological barriers. Transplant Int 2006;19: 87-97. 5. Zachary AA, Montgomery RA, Leffell MS. Desensitization protocols improving access and outcome in transplantation. Clin Appl Immunol Reviews 2005;5: 373-395. 6. Beimler JHM, Susal C, Zeier M. Desensitization strategies enabling successful renal transplantation in highly sensitized patients. Clin Transplant 2006; 20(Suppl 17): 7-12. 7. Crew RJ, Ratner LE. Overcoming immunologic incompatibility: Transplanting the difficult to transplant patient. Sem Dial 2005;18: 474-481. 8. Doxiadis IIN, Duquesnoy RJ, Claas FHJ. Extending options for highly sensitized patients to receive a suitable kidney graft. Curr Opin Immunol 2005;17: 536-540. 9. Fuggle SV, Martin S.Towards performing transplantation in highly sensitized patients. Transplantation 2004;78;186-189. 10. Akalin E, Pascual M. Sensitization after kidney transplantation. Clin J Am Soc Nephrol 2006; 1: 433-440. 11. Bray RA, Nolen JDL, Larsen C et al. Transplanting the highly sensitized patient: The Emory algorithm. Am J Transplant 2006;6: 2307-2315. 12. Clark B, Cole JY, Wortley A et al. Intravenous immunoglobulin-induced panel reactive antibody reduction: not all preparations are created equal. Transplantation 2003;75:242-245. 13. Negi VS, Elluru S, Siberil S et al. Intravenous immunoglobulin: an update on the clinical use and mechanisms of action. J Clin Immunol 2007;27: 233-245. 14. Anglicheau D, Loupy A, Superbielle C et al. Posttransplant prophylactic intravenous immunoglobulin in kidney transplant patients at high immunologic risk: A pilot study. Am J Transplant 2007;7: 1185-1192. 15. Watanabe J, Scornik JC. IVIG and HLA antibodies: Evidence for inhibition of complement activation but not for anti-idiotypic activity. Am J Transplant 2005;5: 2786-2790. 16. Glotz D, Antoine C, Julia P et al. Desensitization and subsequent kidney transplantation of patients using intravenous immunoglobulins. Am J Transplant 2002;2;
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758-760. 17. Jordan SC, Cunnigham-Rundles C, McEwan R. Utility of intravenous immune globulin in kidney transplantation: efficacy, safety and cost implications. Am J Transplant 2003;3: 653-664. 18. Jordan SC, Tyan D, Stablein D et al. Evaluation of intravenous immunoglobulin as an agent to lower allosensitization and improve transplantation in highly sensitized adult patients with end-stage renal disease: Report of the NIH IG02 trial. J Am Soc Nephrol 2004; 15: 3256-3262. 19. Vo AA, Cam V, Toyoda M et al. Safety and adverse events profiles of intravenous immunoglobulin products used for immunomodulation: A single center experience. Clin J Am Soc Nephrol 2006;1: 844-852. 20. Schweitzer EJ, Wilson JS, Fernandez-Vina M et al. A high panel reactive antibody rescue protocol for crossmatch positive live donor kidney transplants Transplantation 2000;70:1531. 21. Gloor JM, DeGoey SR, Pineda AA et al. Overcoming a positive crossmatch in living donor kidney transplantation. Am J Transplant 2003;3;1017. 22. Montgomery RA, Zachary AA. Transplanting patients with a positive donor specific crossmatch: a single center’s perspective Pediatr Transplant 2004;8:535 23. Stegall MD, Gloor J, Winters JL, Moore SB, DeGoey S. A comparison of plasmapheresis versus high dose IVIG desensitization in renal allograft recipients with high levels of donor specific alloantibody. Am J Transplant 2006;6: 346-351. 24. Lorenz M, Regele H, Schillinger M et al. Peritransplant immunoabsorption: a strategy enabling transplantation in highly sensitized crossmatch positive cadaveric kidney allograft recipients. Transplantation 2005; 79: 696-701. 25. Silverman GJ, Goodyear CS, Siegel DL. On the mechanism of staphylococcal protein A immunomodulation. Transfusion 2005; 45:274-280. 26. Viera CA, Agarwal A, Book BK et al. Rituximab for reduction of anti-HLA antibodies in patients awaiting renal transplantation: safety, pharmacodynamics and pharmacokinetics. Transplantation 2004;77: 542 27. Olausson M, Mjornstedt L, Norden G et al. Successful combined partial auxilliary liver and kidney transplantation in highly sensitized cross-match positive recipients. Am J Transplant 2007;7; 130-136.
NÂÊÚÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ EÚÁ·ÛÙËÚȷ΋ ÂÎÙ›ÌËÛË ÙˆÓ ·ÛıÂÓÒÓ: NÂfiÙÂÚ˜ ÂÍÂÏ›ÍÂȘ Î·È Û˘ÁÎÚÈÙÈο ‰Â‰Ô̤ӷ
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AÏ›ÎË IÓȈٿÎË
Œ¯Ô˘Ó ÂÚ¿ÛÂÈ Û¯Â‰fiÓ 40 ¯ÚfiÓÈ· ·fi ÙfiÙ Ԣ ·Ó·ÁÓˆÚ›ÛıËÎÂ Ô ÚfiÏÔ˜ ÙˆÓ ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ ÂȉÈÎÒÓ ÛÙÔ ‰fiÙË HLA ΢ÙÙ·ÚÔÙÔÍÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙËÓ ÔÚ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ Î·È Ë Î˘ÙÙ·ÚÔÙÔÍÈ΋ ‰ÔÎÈÌ·Û›· ÈÛÙÈ΋˜ ‰È·ÛÙ·‡ÚˆÛ˘ (CDC -crossmatch) ÂÊ·ÚÌfi˙ÂÙ·È Û˘ÛÙËÌ·ÙÈο Ú›Ó ·Ô οı ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶·Ú fiÏ· ·˘Ù¿ Ë Â˘·ÈÛıËÙÔÔ›ËÛË Ú›Ó ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú¤ÌÂÓ ÁÈ· ÔÏÏ¿ ¯ÚfiÓÈ· ¤Ó· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ·. ¢‡Ô ΢ڛˆ˜ ‹Ù·Ó ÔÈ ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÔÈ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ ·ÛıÂÓ›˜ Î·È ÔÈ ·ÛıÂÓ›˜ Ì ÂȉÈο ¤Ó·ÓÙÈ ÙÔ˘ ‰fiÙË ÚÔÛ¯ËÌ·ÙÈṲ̂ӷ HLA ·ÓÙÈÛÒÌ·Ù·. ™‹ÌÂÚ· Ù· ÂÚÁ·ÛÙ‹ÚÈ· ¤¯Ô˘Ó ÌÂıfi‰Ô˘˜ Ó· ηıÔÚ›˙Ô˘Ó Ù· ·ÛÊ·Ï‹ HLA ·ÓÙÈÁfiÓ· ÛÙ· ÔÔ›· ÔÈ Â˘·ÈÛıËÙÔÔÈË̤ÓÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ¤¯Ô˘Ó ·ÓÙÈÛÒÌ·Ù· Î·È Ó· ηıÔÚ›˙Ô˘Ó ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ Ú·ÁÌ·ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ crossmatch. ΔÔ ·ÔÙ¤ÏÂÛÌ· Â›Ó·È fiÙÈ ÔÈ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ ·ÛıÂÓ›˜ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Ì ÂÍ·ÈÚÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÂÓÒ Ë ÂÊ·ÚÌÔÁ‹ ÚˆÙÔÎfiÏÏˆÓ ·Â˘·ÈÛıËÙÔÔ›ËÛ˘ ÂÈÙÚ¤ÂÈ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ô ˙ÒÓÙ· ‰fiÙË ÛÙÔÓ ÔÔ›Ô Ô ˘Ô„‹ÊÈÔ˜ Ï‹Ù˘ ¤¯ÂÈ ÚÔÛ¯ËÌ·ÙÈṲ̂ӷ ÂȉÈο ·ÓÙÈÛÒÌ·Ù·. ŸÏ· ·˘Ù¿ ÚÔ¯ÒÚËÛ·Ó ÁÈ·Ù› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ Á›ÓÂÈ ÙÂÚ¿ÛÙÈ· ÚfiÔ‰Ô˜ ÛÙËÓ Î·Ù·ÓfiËÛË ÙÔ˘ ÚfiÏÔ˘ Î·È ÛÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ ·ÏÏÔ·ÓÙÈۈ̿وÓ. ¢‡Ô ÛËÌ·ÓÙÈο ÂÈÙ‡ÁÌ·Ù· ¤ÂÍ·Ó ÚfiÏÔ ÛÙËÓ Î·Ù·ÓfiËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ ·fiÚÚȄ˘ ·fi ·ÓÙÈÛÒÌ·Ù·. ΔÔ ÚÒÙÔ Â›Ó·È Ë ‰˘Ó·ÙfiÙËÙ· ·Ó›¯Ó¢Û˘ ÙÔ˘ ·Ú¿ÁÔÓÙ· C4d Ô˘ ·ÔÙÂÏ› Ì›· ·fi‰ÂÈÍË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ ·ÓÙÈÛÒÌ·ÙÔ˜ ÛÙÔ ÌfiÛ¯Â˘Ì·. ΔÔ ‰Â‡ÙÂÚÔ Â›Ó·È Ë ·Ó¿Ù˘ÍË ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÌÂıÔ‰ÔÏÔÁÈÒÓ ÛÙÂÚ¿˜ Ê¿Û˘ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÎÂηı·Ṳ́ӷ ‹ ·Ó·Û˘Ó‰È·Ṳ̂ӷ HLA ÌfiÚÈ·. OÈ ÌÂıÔ‰ÔÏÔÁ›Â˜ ·˘Ù¤˜ ¤¯Ô˘Ó ¤Ó·
ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· Û˘ÁÎÚÈÙÈο Ì ÙȘ ÚÔËÁÔ‡ÌÂÓ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Û·Ó Î‡ÙÙ·Ú· Û·Ó ÛÙfi¯Ô˘˜ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ·ÓÙÈۈ̿وÓ, ÁÈ·Ù› ÂÈÙÚ¤Ô˘Ó ÙË ‰È¿ÎÚÈÛË ÌÂٷ͇ HLA Î·È ÌË HLA ÂȉÈÎÒÓ ·ÓÙÈۈ̿وÓ. ∂Ô̤ӈ˜ ÔÏÏ¿ ·ÓÙÈÛÒÌ·Ù· Ô˘ ÚÔηÏÔ‡Ó ıÂÙÈÎfi crossmatch ·ÏÏ¿ ‰ÂÓ ·Ó·ÁÓˆÚ›˙Ô˘Ó HLA ·ÓÙÈÁfiÓ· ·ÁÓÔÔ‡ÓÙ·È. ∂ÈϤÔÓ, Ë ¯Ú‹ÛË ÌÂıÔ‰ÔÏÔÁ›·˜ ΢ÙÙ·ÚÔÌÂÙÚ›·˜ ÚÔ‹˜ Î·È ÛÊ·ÈÚ›‰È· Î·Ï˘Ì̤ӷ Ì ¤Ó· HLA ·ÏÏËÏfiÌÔÚÊÔ ÙÔ Î¿ı ¤Ó· (single antigen bead ̤ıÔ‰Ô˜) ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ·ÓÙÈÁfiÓˆÓ Ù· ÔÔ›· Û˘ÓÂÎÊÚ¿˙ÔÓÙ·È,·Ó·ÁÓˆÚ›˙ÔÓÙ·˜ «ÎÚ˘Ì̤Ó˜» ÂȉÈÎfiÙËÙ˜. ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ηıÔÚ›˙ÂÙ·È Ë ·ÎÚÈ‚‹˜ ÂȉÈÎfiÙËÙ· ÙˆÓ ·ÏÏÔ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Û˘ÁÎÂÎÚÈÌÌ¤ÓˆÓ HLA ·ÏÏËÏÔÌfiÚÊˆÓ Ù· ÔÔ›· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È. ™‹ÌÂÚ· ÁÓˆÚ›˙Ô˘Ì fiÙÈ Ë ·Ú·ÁˆÁ‹ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È Ì›· ‰˘Ó·ÌÈ΋ ‰È·‰Èηۛ· Î·È fiÙÈ Ô Ù›ÙÏÔ˜ ÙˆÓ HLA ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È ÛËÌ·ÓÙÈÎfi ÛÙÔÈ¯Â›Ô Ô˘ ηıÔÚ›˙ÂÈ ÙËÓ Â›‰Ú·ÛË Ô˘ ı· ¤¯Ô˘Ó Ù· ·ÓÙÈÛÒÌ·Ù· ÛÙfiÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ· ÈÛÙfi. Δ· ›‰· ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ·˘Í¿ÓÔÓÙ·È ‹ ÂÏ·ÙÙÒÓÔÓÙ·È Ì ÙÔ ¯ÚfiÓÔ, Ì›· ‰È·‰Èηۛ· Ô˘ ÂÍ·ÚÙ¿Ù·È ·Ô ·Ú¿ÁÔÓÙ˜ ȉȷ›ÙÂÚÔ˘˜ ÁÈ· οı ·ÛıÂÓ‹. A˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ¤Ó·˜ ·ÛıÂÓ‹˜ fiÙ·Ó ÂÏÂÁ¯ı› ÓˆÚ›˜ ÌÂÙ¿ ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ı· ·ÚÔ˘ÛÈ¿˙ÂÈ Î˘ÙÙ·ÚÔÙÔÍÈο ·ÓÙÈÛÒÌ·Ù·, 5 ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· Ù· ·ÓÙÈÛÒÌ·Ù· ÌÔÚ› Ó· ·ÓȯÓ‡ÔÓÙ·È ÌfiÓÔ Ì Ôχ ¢·›ÛıËÙ˜ Ù¯ÓÈΤ˜ fiˆ˜ Ì ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜ Î·È ‰‡Ô ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ· Ô ·ÛıÂÓ‹˜ Ó· ıˆÚÂ›Ù·È ÌË Â˘·ÈÛıËÙÔÔÈË̤ÓÔ˜. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ Ô Ú·ÁÌ·ÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÁÈ¿ ¤Ó· ÌfiÛ¯Â˘Ì· ÂÎÙÈÌ¿Ù·È ·Ô ÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ·ÙfiÌÔ˘ fiÛÔÓ ·ÊÔÚ¿ ÚÔËÁÔ‡ÌÂÓ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ÌÂÙ·ÁÁ›ÛÂȘ, ΢‹ÛÂȘ ‹ ¿ÏÏ· ·ÓÔÛÔÏÔÁÈο ÁÂÁÔÓfiÙ· Ô˘ Ô‰ËÁÔ‡Ó Û ·ÏÏÔ¢·ÈÛıËÙÔÔ›ËÛË. ΔË ‰˘Ó·ÙfiÙËÙ· ÂϤÁ¯Ô˘ Ù˘ ¢·ÈÛıËÙÔÔ›ËÛ˘
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÙfiÛÔ Ù˘ ·ÚÔ‡Û·˜ fiÛÔ Î·È Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ÌÓ‹Ì˘, ¯ÚËÛÈÌÔÔÈԇ̠ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÁÈ· Ó· ηıÔÚ›ÛÔ˘Ì ÙÔ˘˜ ‰fiÙ˜ Ì ÙÔ˘˜ ÔÔ›Ô˘˜ ı· ‰ÒÛÔ˘Ó ¤Ó· ·ÚÓËÙÈÎfi crossmatch ÔÈ ˘ÂÚ¢·ÈÛıËÙÔÈË̤ÓÔÈ ·ÛıÂÓ›˜. ΔÔ ÚˆÙfiÎÔÏÔ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ‰fiÙË Â›Ó·È ÙÔ ÚˆÙfiÎÔÏÏÔ ÙˆÓ ·Ô‰ÂÎÙÒÓ ·Û‡Ì‚·ÙˆÓ ·ÓÙÈÁfiÓˆÓ. ∞Ô‰ÂÎÙ¿ ·Û‡Ì‚·Ù· ·ÓÙÈÁfiÓ· Â›Ó·È Ù· ͤӷ HLA ·ÓÙÈÁfiÓ· Ù· ÔÔ›· ÂÎÊÚ¿˙ÂÈ Ô ‰fiÙ˘ Î·È ÛÙ· ÔÔ›· Ô ·ÛıÂÓ‹˜ ‰ÂÓ Â›¯Â ÔÙ¤ ¢·ÈÛıËÙÔÔÈËı›. °È· ÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ·Ô‰ÂÎÙÒÓ ·Û‡Ì‚·ÙˆÓ HLA ·ÓÙÈÁfiÓˆÓ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ηٿ ηÈÚÔ‡˜ ·Ô Ù· ÂÚÁ·ÛÙ‹ÚÈ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ‰È¿ÊÔÚ˜ ̤ıÔ‰ÔÈ. ∏ ¯Ú‹ÛË ÙÔ˘ ·ÏÁfiÚÈıÌÔ˘ HLA Matchmaker Î·È Ô Î·ıÔÚÈÛÌfi˜ Ù˘ ÂȉÈÎfiÙËÙ·˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì single antigen bead ·Ó¿Ï˘ÛË Â›Ó·È ÔÈ Ì¤ıÔ‰ÔÈ Ì ٷ ·ÛÊÂϤÛÙÂÚ· ·ÔÙÂϤÛÌ·Ù·. OÈ ÌÂıÔ‰ÔÏÔÁ›Â˜ ·˘Ù¤˜ ÂÈÙÚ¤Ô˘Ó ÙËÓ ·Ó‡ÚÂÛË Î·Ù¿ÏÏËÏˆÓ ‰ÔÙÒÓ Î·È ÙËÓ ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ¶ÂÚÈÛÛfiÙÂÚÔ ÂÈıÂÙÈ΋ ÔÏÈÙÈ΋ ÁÈ· ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ϷÛÌ·Ê·›ÚÂÛË ‹ ÁÈ· ·Â˘·ÈÛıËÙÔÔ›ËÛË Ì ÂÓ‰ÔÊϤ‚È· ·ÓÔÛÔÛÊ·ÈÚ›ÓË Î·È ·ÓÔÛÔηٷÛÙÔÏ‹, Ì ÛÎÔfi Ó· ·ÚÂÌÔ‰ÈÛÙ› Ë Û‡ÓıÂÛË Ó¤ˆÓ ·ÓÙÈۈ̿وÓ, ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·fi ÔÚÈṲ̂ӷ ΤÓÙÚ· ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ¤Ó· HLA ·Û‡Ì‚·ÙÔ ˙ÒÓÙ· ‰fiÙË. ∏ ÚÔÛ¿ıÂÈ· ÛÙËÚ›˙ÂÙ·È ÛÙË ÁÓÒÛË fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ·Ô ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÚÔÛ¯ËÌ·ÙÈṲ̂ӷ ÛÙÔ ‰fiÙË ·ÓÙÈÛÒÌ·Ù· Â›Ó·È ‰È·ÊÔÚÂÙÈÎfi˜ Û οı ·ÛıÂÓ‹ Î·È ÂÍ·ÚÙ¿Ù·È ·Ô ÙÔ ·ÓÔÛÔÏÔÁÈÎfi ÈÛÙÔÚÈÎfi,ÙËÓ Ù¿ÍË Î·È ÙÔÓ Ù›ÙÏÔ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÙË ‰È·ÊÔÚÂÙÈ΋ ¢·ÈÛıËÛ›· ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ÔÚÁ¿ÓˆÓ ÛÙËÓ Î·Ù·ÛÙÚÔÊ‹ ·Ô ·ÓÙÈÛÒÌ·Ù·. ∂ȤÔÓ, ÌÂϤÙ˜ Ì ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ¤‰ÂÈÍ·Ó fiÙÈ Ë Û‡Ó‰ÂÛË HLA Ù¿Í˘ π ÌÔÚ›ˆÓ Ì ¯·ÌËÏ‹ Û˘ÁΤÓÙÚˆÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ÚÔηÏ› ÙËÓ ¤ÎÊÚ·ÛË ÚˆÙÂÈÓÒÓ Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ,ÂÓÈÛ¯‡ÔÓÙ·˜ ÙËÓ Èı·ÓfiÙËÙ· fiÙÈ Î¿Ùˆ ·Ô ÔÚÈṲ̂Ó˜ Û˘Óı‹Î˜ ÙÔ ÌfiÛ¯Â˘Ì· ÚÔÛٷهÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ù· ÔÔ›· ÂÓÈÛ¯‡Ô˘Ó ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ Ì˯·ÓÈÛÌÔ‡˜ ·ÓÙÔ¯‹˜ Û ·ÓÔÛÔÏÔÁÈ΋ Î·È ÊÏÂÁÌÔÓÒ‰Ë Î·Ù·ÛÙÚÔÊ‹. ∂ÈÙ˘¯‹˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÂÙ¿ ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ ÛÙÔ ‰fiÙË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤¯ÂÈ Û›ÁÔ˘Ú· ÂÈÙ¢¯ı› Û ÂÚÈÙÒÛÂȘ ∞μO ·Û˘Ì‚·ÙfiÙËÙ·˜ ·ÏÏ¿ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û HLA ·Û‡Ì‚·Ù· ˙¢Á¿ÚÈ· ÌÂÙ¿ ·Â˘·ÈÛıË-
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ÙÔÔ›ËÛË ‰ÂÓ Â›Ó·È ÙfiÛÔ ÂÓı·Ú˘ÓÙÈο fiÛÔ ·Ó·ÌÂÓfiÙ·Ó.∞Ó Î·È ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ Ì ÙÚÔÔÔÈË̤Ó˜ ÌÂıfi‰Ô˘˜ ÌÔÚ› Ó· ‰ÒÛÂÈ ·ÎÚȂ›˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ·ÚÔ‡Û· ·ÓÔÛÔÏÔÁÈ΋ ÂÈÎfiÓ· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ·ÎÔÏÔ˘ıfiÓÙ·˜ ÚˆÙÔÎÔÏÏ· ·Â˘·ÈÛıËÙÔÔ›ËÛ˘ Î·È Ó· ‚ÔËı‹ÛË ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ù· ÂÂÈÛfi‰È· ÔÍ›·˜ ¯˘ÌÈ΋˜ ·fiÚÚȄ˘ Â›Ó·È Û˘¯Ó¿ ÂÓÒ Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÔÚ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Â›Ó·È Ì¿ÏÏÔÓ ¿ÁÓˆÛÙË. ŸÛÔ ·˘Ù¤˜ ÔÈ ÛÙÚ·ÙËÁÈΤ˜ ˘ÈÔıÂÙÔ‡ÓÙ·È ·Ô Ó¤· ΤÓÙÚ· ı· ‹Ù·Ó ÛËÌ·ÓÙÈÎfi Ó· ÂÎÙÈÌËıÔ‡Ó Ù· ·ÔÙÂϤÛÌ·Ù· ÒÛÙ ӷ ·ÔÊ·ÛÈ·Ûı› ÙÔ Â›Â‰Ô Ù˘ ¢·ÈÛıËÙÔÔ›ËÛ˘ Ô˘ ··ÈÙ› ÙËÓ ÂÊ·ÚÌÔÁ‹ ÚˆÙÔÎfiÏÏˆÓ ÂÓÂÚÁÔÔ›ËÛ˘ ÁÈ· ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹ ·Â˘·ÈÛıËÙÔÔ›ËÛË. ªÂ ÙȘ ÔÏϤ˜ Î·È È‰È·›ÙÂÚ· ¢·›ÛıËÙ˜ ÌÂıfi‰Ô˘˜ Ô˘ ¯ÚËÛÈÌÔÔÈ› Û‹ÌÂÚ· ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ͯˆÚ›˙ÂÈ ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÌÔÚÔ‡Ó ·ÛÊ·ÏÒ˜ Ó· ÚÔ¯ˆÚ‹ÛÔ˘Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ¯ˆÚ›˜ ıÂڷ›· ·ÏÏ¿ Ì ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ‰fiÙË ·Ô ÂΛÓÔ˘˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹ ·Â˘·ÈÛıËÙÔÔ›ËÛË.
μÈ‚ÏÈÔÁÚ·Ê›· Patel R, Terasaki P: Significance of the positive crossmatch test in Kidney transplantation. N Engl J Med 280:735, 1969 Claas FH, Witvliet M, Dequesnoy R et al: The acceptable mismatch program as a fast tool to transplant highly sensitized patients awaiting a post –mortal kidney: short waiting time and excellent graft outcome. Transplantation 78:190, 2004 Iniotaki-Theodoraki A, Kalogeropoulou H, Apostolaki A, Doxiadis I.N., Stavropoulos-Giokas C: Humoral sensitization against rejected grafts: specific antibodies to graft immunogenic amino acid triplets Transpl Proc 36: 1728, 2004 Cecka M, Zhang Q, Reed E: Preformed antibodies in potential allograft recipients: recent data Human Immunol 66:343, 2005 Zachary A, Montgmery R and Leffel M: Factors associated with and predictive of donor specific antibody after treatment with plasmapheresis and intravenous immunoglobulin Human Immunol 66:364, 2005 Kerman R, Stepkowski S Clinica significance of HLA antigens and non-HLA antigens in solid organ transplantation Cur Opin Org Transpl 11:418, 2006 El-Awar N, Lee J-H, Tarsitani Ch and Terasaki: P HLA class I epitopes: recognition of binding sites by mAbs or eluted alloantibody confirmed with single recombinant antigens. Hum Immunol 68:170, 2007
MÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ì ABO ·Û˘Ì‚·ÙfiÙËÙ˜: AÓÙ›ÏÔÁÔ˜
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°ÂÒÚÁÈÔ˜ B¤ÚÁÔ˘Ï·˜
ÙˆÓ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ì ·Û‡Ì‚·ÙË ÔÌ¿‰· ·›Ì·ÙÔ˜ ÛÙËÓ π·ˆÓ›· ¤‰ÂÈÍ fiÙÈ Â›Ó·È Ôχ ˘„ËÏfi ÙfiÛÔ ÙÔ ÔÛÔÛÙfi ÙˆÓ ı·Ó¿ÙˆÓ ÙˆÓ ÏËÙÒÓ fiÛÔ Î·È ÙÔ ÔÛÔÛÙfi ·ÒÏÂÈ·˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÏfiÁˆ ÔÍ›·˜ ‹ ÂÈÙ·¯˘ÓfiÌÂÓ˘ ·fiÚÚȄ˘. ΔÔ ˘„ËÏfi ÔÛÔÛÙfi ·fiÚÚȄ˘ ÂȂ‚·ÈÒıËÎÂ Î·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (·fi 19 ¤ˆ˜ 58%). ™Â ÚfiÛÊ·ÙË ‰Â ÂÚÁ·Û›· ÙÔ˘ Haas Î·È Û˘ÓÂÚÁ·ÙÒÓ ÙÔ 80% ÙˆÓ ‚ÈÔ„ÈÒÓ ÚˆÙÔÎfiÏÏÔ˘ Î·È ÙÔ 59% ÙˆÓ ‚ÈÔ„ÈÒÓ ÏfiÁˆ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì ·Û‡Ì‚·ÙË ÔÌ¿‰· ·›Ì·ÙÔ˜ ¤‰ˆÛ·Ó ıÂÙÈ΋ ¯ÚÒÛË ÁÈ· C4d. Δ· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· ÂÓÈÛ¯‡ÔÓÙ·È Î·È ·fi ÙË ÌÂϤÙË ‚ÈÔ„ÈÒÓ ÚˆÙÔÎfiÏÏÔ˘ ¤Ó· ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ Gloor Î·È ÙˆÓ Û˘ÓÂÚÁ·ÙÒÓ ÙÔ˘ Ô˘ ¤‰ÂÈÍ ·Ó¿Ù˘ÍË ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ∞μO ·Û‡Ì‚·Ù˜ Ì ÚÔËÁËı›۷ ·ÓÙÈۈ̷ÙÈÎÔ‡ Ù‡Ô˘ ·fiÚÚÈ„Ë. ¶·Ú¿ ÙȘ ÚÔÛ¿ıÂȘ Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÛÙËÓ ∂˘ÚÒË, π·ˆÓ›· Î·È ∞ÌÂÚÈ΋ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ˘¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈο ÂÚˆÙËÌ·ÙÈο Ô˘ ‰ÂÓ ¤¯Ô˘Ó ··ÓÙËı›. ŒÙÛÈ: ·) ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi ÙÔ ·ÓÒÙÂÚÔ fiÚÈÔ ∞μO ·ÓÙÈÛˆÌ¿ÙˆÓ Ô˘ Â›Ó·È ·Ô‰ÂÎÙfi ÙË ÛÙÈÁÌ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÁÈ· Ó· ·ÔÊ¢¯ı› Ë ¯˘ÌÈÎÔ‡ Ù‡Ô˘ ·fiÚÚÈ„Ë, Î·È ‚) ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi Â¿Ó Ú¤ÂÈ Ó· Á›ÓÔ˘Ó Û˘Ó‰ڛ˜ Ï·ÛÌ·Ê·›ÚÂÛ˘ / ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ıÂڷ›· Ì ·ÓÙÈ CD20 Î·È ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÓÙÈ – ∞μO ΢ÎÏÔÊÔÚÔ‡ÓÙ· ·ÓÙÈÛÒÌ·Ù·. ŒÓ· ¿ÏÏÔ ÛËÌ·ÓÙÈÎfi ÂÌfi‰ÈÔ Â›Ó·È ÙÔ ˘„ËÏfi ÎfiÛÙÔ˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·˘ÙÒÓ. ™ÙȘ ∏.¶.∞. ÙÔ ÎfiÛÙÔ˜ ÌÈ·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ ·fi ·Û‡Ì‚·ÙÔ ∞μO ‰fiÙË ·Ó¤Ú¯ÂÙ·È ÛÙȘ 38.000 ‰ÔÏ¿ÚÈ·. ™ÙËÓ ∂˘ÚÒË ÌfiÓÔ ÙÔ ÎfiÛÙÔ˜ ÌfiÓÔ Ù˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ Î˘Ì·›ÓÂÙ·È ·fi 18.000 ¤ˆ˜ 36.000 ‰ÔÏ¿ÚÈ·. ¶ÚfiÛÊ·Ù· ‰Â ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·˘Ù¤˜ ·Ó·Ê¤ÚıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÈÏÔÎÒÓ Ô˘ ·Ó‚¿˙ÂÈ ÙÔ ÎfiÛÙÔ˜ ·˘ÙÒÓ ÙˆÓ ÌÂ-
∏ ¤ÏÏÂÈ„Ë ‰ÔÙÒÓ ÔÚÁ¿ÓˆÓ ÂȉÈο ÛÙȘ ÓÂÊÚÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Û˘Ó¯‹ ·‡ÍËÛË Ù˘ ‰È·ÊÔÚ¿˜ ÌÂٷ͇ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ηٿÏÔÁÔ ·Ó·ÌÔÓ‹˜ ÁÈ· ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÓÂÊÚÒÓ Ô˘ ‰È·Ù›ıÂÓÙ·È ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶·Ú¿ ÙËÓ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi ˙ˆÓÙ·Ófi ‰fiÙË, ¤Ó·˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ ‰ÂÓ ÌÔÚ› Ó· οÓÂÈ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÈfiÙÈ Ë ÔÌ¿‰· ·›Ì·Ùfi˜ ÙÔ˘ Â›Ó·È ·Û‡Ì‚·ÙË Ì ·˘Ù‹ ÙÔ˘ ‰fiÙË. £ÂˆÚËÙÈο ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ·ÔÙÂÏÔ‡Ó ÙÔ 30% ÂÚ›Ô˘ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÚfiÁÚ·ÌÌ· Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘. ™ÙËÓ Ú¿ÍË fï˜ Â›Ó·È Ôχ ÏÈÁfiÙÂÚÔÈ. ªÂ ·ÔÙ¤ÏÂÛÌ· ÛÙÔ °ÂÚÌ·ÓÈÎfi (ÏËı˘ÛÌfi˜ 82.468.000) Î·È ™Ô˘Ë‰ÈÎfi (ÏËı˘ÛÌfi˜ 9.000.000) registry Ó· ¤¯Ô˘Ó ηٷÁÚ·Ê› ÂÚ› ÙȘ 60 ÌÂÙ·ÌÔۯ‡ÛÂȘ Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ Ù· ÙÂÏÂ˘Ù·›· 5 ¯ÚfiÓÈ· ·ÚÈıÌfi˜ Ô˘ ·ÓÙÈÛÙÔȯ› Û 7 ÂÚ›Ô˘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Û 10 ÂÎ ÏËı˘ÛÌÔ‡ οı 5 ¯ÚfiÓÈ·. OÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ Û ¿ÙÔÌ· Ì ·Û‡Ì‚·ÙË ÔÌ¿‰· ·›Ì·ÙÔ˜ ¿Ú¯ÈÛ·Ó Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ·fi ÙËÓ ‰ÂηÂÙ›· ÙÔ˘ 1970 Î·È Î·ıÈÂÚÒıËÎ·Ó ÛÙËÓ π·ˆÓ›· ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980. ∂Ó ÙÔ‡ÙÔȘ, ÂÂȉ‹ Ë ÛÏËÓÂÎÙÔÌ‹, Ë ÂÓÈÛ¯˘Ì¤ÓË ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È ÔÈ ÔÏϷϤ˜ Û˘Ó‰ڛ˜ Ï·ÛÌ·Ê·›ÚÂÛ˘ ›¯·Ó Û˘Ó‰˘·Ûı› Ì ˘„ËÏ‹ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·, ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÙÔ˘ Ù‡Ô˘ ·˘ÙÔ‡ ‰ÂÓ Â›¯·Ó ÎÂÚ‰›ÛÂÈ ÌÂÁ¿ÏÔ ÂӉȷʤÚÔÓ Î·È Á›ÓÔÓÙ·Ó ÛÙËÓ π·ˆÓ›· ÂÂȉ‹ ‰ÂÓ ˘‹Ú¯Â ¿ÏÏË Ï‡ÛË. ΔËÓ ÙÂÏÂ˘Ù·›· ÂÓÙ·ÂÙ›· ÙÔ ÂӉȷʤÚÔÓ ÁÈ· ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Û ·ÛıÂÓ›˜ Ì ∞μO ·Û‡Ì‚·ÙÔ ˙ˆÓÙ·Ófi ‰fiÙË ¤¯ÂÈ ·Ó·Óˆı› ÁÂÁÔÓfi˜ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ó·ÎÔ›ÓˆÛË ÈηÓÔÔÈËÙÈÎÒÓ Ì·ÎÚÔ¯ÚfiÓÈˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÂÈ‚›ˆÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙËÓ π·ˆÓ›· ·ÏÏ¿ Î·È ÛÙËÓ ·˘Í·ÓfiÌÂÓË ¤ÏÏÂÈ„Ë ‰ÔÙÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ŸÌˆ˜, Ô ÏÂÙÔÌÂÚ‹˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÔÙÂÏÂÛÌ¿-
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ù·ÌÔۯ‡ÛÂˆÓ ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ. ΔÔ ÎfiÛÙÔ˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·˘ÙÒÓ Â›Ó·È ÌÂÓ ÌÈÎÚfiÙÂÚÔ ·fi ÙÔ ÎfiÛÙÔ˜ Ù˘ ·ÈÌÔοı·ÚÛ˘ ·ÏÏ¿ Â›Ó·È ··ÁÔÚ¢ÙÈο ˘„ËÏfi Û˘ÁÎÚÈÓfiÌÂÓÔ Ì ÙÔ ÎfiÛÙÔ˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·fi ˙ˆÓÙ·Ófi ‰fiÙË. ¶ÚfiÛÊ·Ù˜ ÂÓ·ÏÏ·ÎÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜, fiˆ˜ Ë ·ÓÙ·ÏÏ·Á‹ ‰ÔÙÒÓ, Ê·›ÓÂÙ·È fiÙÈ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηٷÛÙ‹ÛÔ˘Ó ÙȘ ∞μO ·Û‡Ì‚·Ù˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡. ¢Â‰Ô̤ÓÔ˘ ‰Â fiÙÈ ··ÈÙÔ‡ÓÙ·È ÌÂÁ¿Ï˜ ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜ ¤Ó· μ·ÏηÓÈÎfi registry ·ÛıÂÓÒÓ Ì ·Û‡Ì‚·ÙÔ˘˜ ∞μO ‰fiÙ˜ ı· ÌÔÚÔ‡Û ӷ ‰ÒÛÂÈ Ï‡ÛË Û ·˘Ùfi ÙÔ ÂÌfi‰ÈÔ.
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μÈ‚ÏÈÔÁÚ·Ê›· Tyden G, Kumlien G, Fehrman I. Transplantation 2003; 76: 730, Sonnenday CJ, Warren DS, Cooper M, et al. Am J Transplant 2004; 4: 1315 Takahashi K, Saito K, Takahara S, et al. Am J Transplant 2004; 4: 1089 Tanabe K, et al. Excellent outcome …Transplant Proc 2004; 36:2175 – 217 Gloor JM, Cosio FG, Rea DJ, et al. Am J Transplant 2006; 6:1841-1847 Haas M, Rahman MH, Racusen LC, et al. Am J Transplant 2006; 6:1829 -1840
OÛÙÈ΋ ÓfiÛÔ˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ I
10
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ÂÌÊ¿ÓÈÛË Ù˘ ÔÛÙÈ΋˜ ÓfiÛÔ˘ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ‰Ú¿ÛË ÙÔ˘˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ‰ÔÛÔÏÔÁ›· Î·È ÙËÓ ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜.
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ (ª¡) Â›Ó·È ÂÈÙ˘¯‹˜ ıÂڷ›· ÙÔ˘ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (á∞). ∂ÈÙ˘Á¯¿ÓÂÈ ‚ÂÏÙ›ˆÛË ÙˆÓ ÂÓ‰ÔÎÚÈÓÈÎÒÓ Î·È ÙˆÓ Â͈ÎÚÈÓÒÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ á∞ ηıÒ˜ Î·È ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ Ca Î·È ÙÔ˘ P Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Â˘ÂÚÁÂÙÈ΋ ›‰Ú·ÛË ÛÙ· ÔÛÙ¿. øÛÙfiÛÔ Ë ÔÛÙÈ΋ ÓfiÛÔ˜, Ô˘ ·ÔÙÂÏ› ÛÔ‚·Ú‹ Î·È Û˘¯Ó‹ ÂÈÏÔ΋ ÙÔ˘ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, Ù˘ á∞ Û˘¯Ó¿ ·Ú·Ì¤ÓÂÈ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞˘Ùfi ηٿ ·ÚÈÔ ÏfiÁÔ ÔÊ›ÏÂÙ·È ÛÂ Û˘Ó‡·ÚÍË Î·È ÂÈÚfiÛıÂÙˆÓ ·Ú·ÁfiÓÙˆÓ, ‚ÈÔ¯ËÌÈÎÒÓ Î·È ÔÚÌÔÓÈÎÒÓ. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ÔÛÙÈ΋ ÓfiÛÔ ÌÂÙ¿ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Â›Ó·È ÔÈ ÂÍ‹˜: 1. ∏ ηٿÛÙ·ÛË ÙˆÓ ÔÛÙÒÓ ÚÈÓ ÙË ª¡ ∏ ÓÂÊÚÈ΋ ÔÛÙÂÔ‰˘ÛÙÚÔÊ›· (¡O¢), Ô˘ ÚÔ¸¿Ú¯ÂÈ. H ‚·Ú‡ÙËÙ· ÙÔ˘ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌÔ‡ (¢À¶£) Â›Ó·È Ô ¤Ó·˜ ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘ÓÙËÚÔ‡Ó ÙËÓ ÔÛÙÈ΋ ÓfiÛÔ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. 2. ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡. ∏ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·, Ë ˘ÔʈÛÊ·Ù·ÈÌ›· Î·È Ù· ¯·ÌËÏ¿ ›‰· Ì·ÁÓËÛ›Ô˘ ÛÙÔÓ ÔÚfi ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ Î·ıÒ˜ Î·È Ù· ˘„ËÏ¿ ÁÈÓfiÌÂÓ· Ca x ƒ ηٿ ÙË ÛÙÈÁÌ‹ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ¤̂·Û˘, ¢ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÔÛÙÈ΋˜ ÓfiÛÔ˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜. 3. ∏ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÔÊ›ÏÂÙ·È Û ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë Î·È ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. 4. ¢È¿ÊÔÚ˜ ¿ÏϘ ‰È·Ù·Ú·¯¤˜ fiˆ˜ Ë ÂÌÌËÓfi·˘ÛË Î·È Ë ·ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. 5. Δ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η. Δ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ë Î˘ÎÏÔÛÔÚ›ÓË, ÙÔ Tacrolimus Î·È Ë Ú··Ì˘Î›ÓË Ê·›ÓÂÙ·È fiÙÈ ·›˙Ô˘Ó ÚfiÏÔ ÛÙËÓ
ªOƒº∂™ O™Δπ∫∏™ ¡O™OÀ ª∂Δ∞ ∞¶O ¡∂ºƒπ∫∏ ª∂Δ∞ªO™Ã∂À™∏ OÈ Î˘ÚÈfiÙÂÚ˜ ÌÔÚʤ˜ Ù˘ ÔÛÙÈ΋˜ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È: 1. ¡ÂÊÚÈ΋ ÔÛÙÂÔ‰˘ÛÙÚÔÊ›·, (¡O¢) ÌÂ Û˘¯ÓfiÙÂÚË ÙËÓ ÂÌÊ¿ÓÈÛË ¢À¶£. 2. OÛÙÂÔÂÓ›·-OÛÙÂÔfiÚˆÛË. 3. OÛÙÈ΋ Ó¤ÎÚˆÛË (¿ÛËÙË Ó¤ÎÚˆÛË). 4. ™‡Ó‰ÚÔÌ· ÔÛÙÈÎÔ‡ fiÓÔ˘. 5. ∞Ì˘ÏÔ›‰ˆÛË ·fi ‚Ç ÌÈÎÚÔÛÊ·ÈÚ›ÓË. 6. ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡: ÀÂÚ·Û‚ÂÛÙÈ·ÈÌ›·, ˘ÔʈÛÊ·Ù·ÈÌ›· ˘ÔÌ·ÁÓËÛÈ·ÈÌ›·. ∏ ΢ÚÈfiÙÂÚË ÌÔÚÊ‹ Ù˘ ÔÛÙÈ΋˜ ÓfiÛÔ˘ Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ÌÂÙ¿ ÙËÓ ª¡ Â›Ó·È Ë ¡O¢ Ì ·Ú·ÌÔÓ‹ ÙÔ˘ ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌÔ‡. O ÂÌÌ¤ÓˆÓ ¢À¶£ ÂÌÊ·Ó›˙ÂÙ·È Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ 50% ÙˆÓ ·ÛıÂÓÒÓ. OÛÙÂÔfiÚˆÛË ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ 44% (ÔÈ ·Ó·ÊÔÚ¤˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Î˘Ì·›ÓÔÓÙ·È ·fi 28 ¤ˆ˜ 88%). OÛÙÂÔÂÓ›· Î·È Î·Ù¿ÁÌ·Ù· ·ÚÔ˘Û›·Û ÙÔ 7-21% Î·È ÔÛÙÈ΋ ¿ÛËÙË Ó¤ÎÚˆÛË ÙÔ˘ ÈÛ¯›Ô˘ ‹ ÂÓÙÔÈṲ̂ÓË Û ¿ÏÏ· ÔÛÙ¿ ¤Ó· ÔÛÔÛÙfi 4,8% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ. ŒÓ·˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ (11%) ·ÚÔ˘ÛÈ¿˙ÂÈ ‰È¿ÊÔÚ· Û‡Ó‰ÚÔÌ· ÔÛÙÈÎÔ‡ fiÓÔ˘, ÂÓÒ 3% ÂÍ·ÎÔÏÔ˘ı› Ó· ÂÌÊ·Ó›˙ÂÈ Û˘Ìو̷ÙÔÏÔÁ›· ·Ì˘ÏÔ›‰ˆÛ˘ ·fi ‚Ç ÌÈÎÚÔÛÊ·ÈÚ›ÓË. ∞fi ÙȘ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÂÚ›Ô˘ ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ª¡ Î·È 15 % 2 ¯ÚfiÓÈ· ÌÂÙ¿, ÂÓÒ ˘ÔʈÛÊ·Ù·ÈÌ›· ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ 90% ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ˘˜ 4 Ì‹Ó˜ Î·È ÛÙÔ 45% ÛÙÔÓ 1 ¯ÚfiÓÔ. ÀÔÌ·ÁÓËÛÈ·ÈÌ›· ·ÚÔ˘ÛÈ¿˙ÂÈ ÂÚ›Ô˘ ÙÔ 40% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ Û ÔÔÈ·‰‹ÔÙ ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ ÌÂÙ¿ ÙË ª¡. (1)
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
1. ¡∂ºƒπ∫∏ O™Δ∂O¢À™ΔƒOºπ∞ ∂À¡O´∫∂™ ∂¶π¢ƒ∞™∂π™ Δ∏™ ª¡ ™Δ∏ ¡∂ºƒπ∫∏ O™Δ∂O¢À™ΔƒOºπ∞
∏ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ¢ÓÔ˚Τ˜ ÂȉڿÛÂȘ ÛÙËÓ ÓÂÊÚÈ΋ ÔÛÙÂÔ‰˘ÛÙÚÔÊ›·. ∏ ·‡ÍËÛË Ù˘ ÓÂÊÚÈ΋˜ ·¤ÎÎÚÈÛ˘ ÙÔ˘ ʈÛÊfiÚÔ˘ Â›Ó·È ·fi ÙȘ ÚÒÙ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ Ô˘ Û˘Ì‚¿ÏÔ˘Ó ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ¡O¢. ∏ ·Ú·ÁˆÁ‹ Ù˘ ηÏÛÈÙÚÈfiÏ˘ ·fi ÙÔÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ÓÂÊÚfi ·˘Í¿ÓÂÈ. ∏·‡ÍËÛË ·˘Ù‹ Â›Ó·È ¿ÌÂÛË Î·È ·Ú¯›˙ÂÈ Ï›Á˜ ÒÚ˜ ÌÂÙ¿ ÙË ª¡. ∂ÈϤÔÓ, Ë ‰ÈfiÚıˆÛË Ù˘ Ô˘Ú·ÈÌ›·˜, Ë Ì›ˆÛË ÙˆÓ Ô˘Ú·ÈÌÈÎÒÓ ÙÔÍÈÓÒÓ ÏfiÁˆ Ù˘ ·Ô‚ÔÏ‹˜ ÙÔ˘˜ Ì ٷ Ô‡Ú·, ηıÒ˜ Î·È Ë ·Ô‚ÔÏ‹ ÙÔ˘ ·ÚÁÈÏ›Ô˘ Ô‰ËÁÔ‡Ó Û ‚ÂÏÙ›ˆÛË Ù˘ ¡O¢. Δ· ›‰· Ù˘ ·Ú·ıÔÚÌfiÓ˘ (iƒΔ∏) ÌÂÈÒÓÔÓÙ·È ÌÂÙ¿ ÙËÓ ª¡ Î·È ÂÈÛÙÚ¤ÊÔ˘Ó ÎÔÓÙ¿ ÛÙ· Ê˘ÛÈÔÏÔÁÈο. ∂ÈÙ˘Á¯¿ÓÂÙ·È ‰ÈfiÚıˆÛË Ù˘ ·ÓÙ›ÛÙ·Û˘ ÙˆÓ ·Ú·ı˘ÚÂÔÂȉÒÓ ·‰¤ÓˆÓ (¶∞) ÛÙËÓ Î·ÏÛÈÙÚÈfiÏË ∞˘Ùfi ÔÊ›ÏÂÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ÛÙÔ˘˜ ·Ú·ı˘ÚÂÔÂȉ›˜ ·‰¤Ó˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ì›ˆÛË Ù˘ ˘ÂÚÏ·Û›·˜ ÙˆÓ ¶∞. ¢∂ÀΔ∂ƒO¶∞£∏™ À¶∂ƒ¶∞ƒ∞£Àƒ∂O∂π¢π™ªO™ (¢À¶£) ª∂Δ∞ Δ∏ ª¡
∏ ‰È¿ÁÓˆÛË ÙÔ˘ ¢À¶£ ÌÂÙ¿ ÙË ª¡ ‚·Û›˙ÂÙ·È ÛÙ· ·˘ÍË̤ӷ ›‰· Ù˘ iPTH fi¯È ··Ú·›ÙËÙ· Û ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ¶·Ú·ÙËÚÂ›Ù·È ÛÙ·‰È·Î‹ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ iPTH Ô˘ ‰È·ÚΛ 3-6 Ì‹Ó˜ ÌÂÙ¿ ÙË ª¡, ÂÓÒ ‰ÂÓ ·Ó·Ì¤ÓÂÙ·È ÂÚ·ÈÙ¤Úˆ ÙÒÛË. ΔÂÏÈο ÔÈ ÙÈ̤˜ Ù˘ Û˘Ó‹ıˆ˜ ηٷϋÁÔ˘Ó ÛÙ· ·ÓÒÙÂÚ· Ê˘ÛÈÔÏÔÁÈο ›‰·. Œ¯ÂÈ ·Ó·ÊÂÚı› fiÙÈ ·ÛıÂÓ›˜ Ì ¢À¶£ Ô˘ ·Ú·Ì¤ÓÂÈ ÌÂÙ¿ ÙË ª¡ ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ ÌÂÁ¿ÏË ‰È¿ÚÎÂÈ· Û ·ÈÌÔοı·ÚÛË (∞∫) Î·È ÂÔ̤ӈ˜ ÌÂÁ·Ï‡ÙÂÚ˜ Èı·ÓfiÙËÙ˜ Ó· ·Ó·Ù‡ÍÔ˘Ó ‚·Ú‡ ¢À¶£. ∞ÛıÂÓ›˜ Ì ›‰· iPTH > 200 pg/ml ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ OÛÙÈ΋˜ ª¿˙·˜ (Oª). ∂ÈϤÔÓ ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÔÈ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÙÔ˘ ¢À¶£ ‰ÂÓ ·Ôηı›ÛÙ·ÓÙ·È Ô‡Ù ÌÂÙ¿ ·fi 2 ¯ÚfiÓÈ· ·fi ÂÈÙ˘¯‹ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. (2,3,4) ™ÙË ‰È·Ù‹ÚËÛË ÙÔ˘ ¢À¶£ ÌÂÙ¿ ÙË ª¡ Û˘Ì‚¿ÏÏÔ˘Ó ÔÈ ·Ú·Î¿Ùˆ ·Ú¿ÁÔÓÙ˜: ·) ∏ ·ÚÁ‹ ·fiÙˆÛË ÙˆÓ ·Ú·ı˘ÚÂÔÂȉÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·ıÒ˜ Î·È ÙÔ Â›‰Ô˜ Î·È Ô ‚·ıÌfi˜ Ù˘ ˘ÂÚÏ·Û›·˜ ÙˆÓ ¶∞ ™Â ÔÏÏÔ‡˜ ·ÛıÂÓ›˜ Ë
99
Ì›ˆÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Î·È Ù˘ ˘ÂÚÏ·Û›·˜ ÙˆÓ ¶∞ Â›Ó·È ·ÚÁ‹ Î·È ‰ÂÓ Â›Ó·È Ï‹Ú˘ ‰ÈfiÙÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ Ì¤ÁÂıÔ˜ Ì ÂÚÈÔ¯¤˜ Ô˙Ò‰Ô˘˜ ˘ÂÚÏ·Û›·˜ ‹ ÚfiÎÂÈÙ·È ÁÈ· ÌÔÓÔÎψÓÈ΋ ·Ó¿Ù˘ÍË ·˘ÙfiÓÔÌÔ˘ ·‰ÂÓÒÌ·ÙÔ˜. (5) ‚) ∏ Ì›ˆÛË ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ‚ÈÙ·Ì›Ó˘ D Ô˘ ˘¿Ú¯ÂÈ ÛÙÔ˘˜ ¶∞ Ô˘ Ô‰ËÁ› Û «¢˘Û·Ó¿ÏÔÁ·» ›‰· ηÏÛÈÙÚÈfiÏ˘ ηÙÒÙÂÚ· ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ. Á) ªÈ· Èı·Ó‹ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (ÎÚ·Ù. >1,5 mg/dl). (6) ‰) Δ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Î·È Î˘Ú›ˆ˜ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Ô‰ËÁÔ‡Ó Û Ì›ˆÛË ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÂÓÒ Ë Î˘ÎÏÔÛÔÚ›ÓË Î·È ÙÔ tarcolimus ·˘Í¿ÓÔ˘Ó ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi. ∂›Ó·È ÁÓˆÛÙfi ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ >2mg/dl, 1 Ì‹Ó· ÌÂÙ¿ ÙË ª¡ ÙÔ 50% ¤¯ÂÈ iƒΔ∏ ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·. OÈ ›‰ÈÔÈ ·ÛıÂÓ›˜ ‰È·ÙËÚÔ‡Ó Â›Â‰· ‰ÈÏ¿ÛÈ· ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ 6 Ì‹Ó˜ Î·È 1 ¯ÚfiÓÔ ÌÂÙ¿ ÙË ª¡. ªÂÙ¿ ·fi 2 ¯ÚfiÓÈ· ÙÔ 27% ÙˆÓ ·ÛıÂÓÒÓ ¤¯ÂÈ ‰ÈÏ¿ÛÈ· ›‰· iƒΔ∏. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ >1mg/dl ÙÔ 43% ¤¯ÂÈ Â›Â‰· iƒΔ∏ ‰ÈÏ¿ÛÈ· ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ. (7,8) Ÿˆ˜ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· 4 ¯ÚfiÓÈ· ÌÂÙ¿ ·fi ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË, 25% ÙˆÓ ·ÛıÂÓÒÓ ¤¯ÂÈ ¢À¶£ ¯ˆÚ›˜ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·, 30% Ì ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· Î·È 15% ¤¯ÂÈ ˘Ô‚ÏËı› Û ·Ú·ı˘ÚÂÔÂȉÂÎÙÔÌ‹ (4). ∏ ÛËÌ·Û›· ÙˆÓ ÂȤ‰ˆÓ Ù˘ iƒΔ∏ ÚÈÓ ÙË ª¡ Â›Ó·È ÌÂÁ¿ÏË. ∞ӷʤÚÂÙ·È Û˘Û¯¤ÙÈÛË Ù˘ iPTH ÚÈÓ Î·È ÌÂÙ¿ ·fi 71,4±28 Ì‹Ó˜, ·fi ÙË ª¡, Û 46 ·ÛıÂÓ›˜, Ì ÎÚ·ÙÈÓ›ÓË < 1,5 mg/dl (9,10). ∏ Ì›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈ΋˜ ·Ú·ı˘ÚÂÔÂȉÈ΋˜ Ì¿˙·˜ ÌÂÙ¿ ·fi ÂÈÙ˘¯‹ ª¡ Â›Ó·È Ê·ÓÂÚ‹ ·fi ÙȘ ·ÏÏ·Á¤˜ ÛÙȘ ÌÂÙ·‚ÔÏÈΤ˜ ÔÛÙÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ ÙÔ˘ ÔÚÔ‡ 6 Ì‹Ó˜ ÌÂÙ¿ ·fi ª¡. ŒÙÛÈ ·Ó·Ê¤ÚÔÓÙ·È Ê˘ÛÈÔÏÔÁÈο ›‰· ƒ (1o Ì‹Ó·), Ê˘ÛÈÔÏÔÁÈ΋ 1,25(O∏)2 D3 ·fi ÙÔÓ ÚÒÙÔ Ì‹Ó·, ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· ÛÙÔ 64% ÙˆÓ ·ÛıÂÓÒÓ ÙÔÓ 3Ô Ì‹Ó·, Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ iƒΔ∏ ·fi ÙÔÓ 1Ô ¤ˆ˜ ÙÔÓ 6Ô Ì‹Ó· Î·È Â›Â‰· ÔÛÙÂÔηÏÛ›Ó˘, 3 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚ· ·fi Ù· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·. øÛÙfiÛÔ Ë Î·Ì‡ÏË iCa/iƒΔ∏ ÌÂÙ¿ ·fi ‰ÔÎÈÌ·Û›· ÚfiÎÏËÛ˘ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·˜ Û 11 ·ÛıÂÓ›˜ 1 Î·È 6 Ì‹Ó˜ ÌÂÙ¿ ÙË ª¡. Œ‰ÂÈÍ fiÙÈ Ë ‰È·ÊÔÚ¿ ‰ÂÓ Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋(% Ù˘ ‚·ÛÈ΋˜ iƒΔ∏).(11)
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A.-M. M¶E§EXPH
∂ÈϤÔÓ Ë ÛÈÁÌÔÂȉ‹˜ η̇ÏË iCa - iPTH 1 Î·È 6 Ì‹Ó˜ ÌÂÙ¿ ÙË ª¡ Û 7 ·ÛıÂÓ›˜ Ì ÚfiÎÏËÛË ˘fi Î·È ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·˜ ¤‰ÂÈÍÂ: 1. ªÂÙ·ÙfiÈÛË Ù˘ η̇Ï˘ ·ÚÈÛÙÂÚ¿ ÛÙÔ˘˜ 6 Ì‹Ó˜ Î·È Ì›ˆÛË ÛÙ· ›‰· Ù˘ iPTH (p<0,05). 2. ∫·Ì›· ‰È·ÊÔÚ¿ ÛÙÔ ÛËÌÂ›Ô Ú‡ıÌÈÛ˘ (set point) ÙÔ˘ Ca Î·È ÙËÓ ÎÏ›ÛË Ù˘ η̇Ï˘ ÛÙȘ ÙÈ̤˜ Ù˘ iPTH (% Ù˘ ̤ÁÈÛÙ˘ ÙÈÌ‹˜ Ù˘) 1 Î·È 6 Ì‹Ó˜ ÌÂÙ¿ ÙË ª¡. ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ˘¿Ú¯ÂÈ Ì›ˆÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ·Ú·ı˘ÚÂÔÂȉÒÓ ÌÂÙ¿ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ Â›Ó·È fï˜ ÛËÌ·ÓÙÈ΋. (11) ∞¡Δπª∂Δø¶π™∏ ΔOÀ ¢À¶£ ª∂Δ∞ ∞¶O ª¡
∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¢À¶£ ÌÂÙ¿ ·fi ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÚÈÏ·Ì‚¿ÓÂÈ: 1·. ÃÔÚ‹ÁËÛË ·Ï¿ÙˆÓ Ca Î·È Î·ÏÙÛÈÙÚ›ÔÏ˘ 2·. ∞Û‚ÂÛÙÈÔÌÈÌËÙÈο 3·. ¶·Ú·ı˘ÚÂÔÂȉÂÎÙÔÌ‹ (¶£∂) 4·. ÃÔÚ‹ÁËÛË Î·ÏÛÈÙÔÓ›Ó˘ 5·. ∞¤ÎÎÚÈÛË ÙÔ˘ ∞ÚÁÈÏ›Ô˘ (∞l) 1·. ÃOƒ∏°∏™∏ ∞§∞Δø¡ C· ∫∞π ∫∞§Δ™πΔƒπO§∏™
∏ ¯ÔÚ‹ÁËÛË ·Ï¿ÙˆÓ Ca Î·È Î·ÏÙÛÈÙÚÈfiÏ˘ ÂÈÙ˘Á¯¿ÓÂÈ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ iƒΔ∏, ·ÎfiÌ· Î·È Û ·ÛıÂÓ›˜ ÌÂ Ê˘ÛÈÔÏÔÁÈο ›‰· Ca, Ì›ˆÛË Ù˘ ʈÛÊ·ÙÔ˘Ú›·˜ Ù˘ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·˜, Î·È Ù˘ ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›·˜. ŒÙÛÈ ÂÈÙ˘Á¯¿ÓÂÙ·È ·ÔÊ˘Á‹ Âȉ›ӈÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ·Ú·¿Óˆ ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ ÂÈÙ˘Á¯¿ÓÂÈ ÂÈϤÔÓ ÚÔʇϷÍË ·fi ÙËÓ ·ÒÏÂÈ· ÔÛÙÈ΋˜ Ì¿˙·˜ (6-7% ÛÙÔÓ 1 ¯ÚfiÓÔ). ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë Ì·ÎÚ¿ ¯ÔÚ‹ÁËÛË Î·ÏÙÛÈÙÚÈfiÏ˘ ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ·‡ÍËÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡. (12) 2·. ∞™μ∂™ΔπOªπª∏Δπ∫∞ (Cinacalcet)
∂›Ó·È ÓÂfiÙÂÚ· Û΢¿ÛÌ·Ù· Ô˘ ÚÔηÏÔ‡Ó ·‡ÍËÛË Ù˘ ¢·ÈÛıËÛ›·˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ Ca ÛÙȘ ÌÂÙ·‚ÔϤ˜ ÙÔ˘ ÂÍˆÎ˘ÙÙ¿ÚÈÔ˘ Ca Î·È ÂÈÙ˘Á¯¿ÓÔ˘Ó ¤ÙÛÈ Ì›ˆÛË Ù˘ iPTH, ÂÓÒ ÙÔ Ca ÙÔ˘ ÔÚÔ‡ ‰È·ÙËÚÂ›Ù·È ÛÂ Ê˘ÛÈÔÏÔÁÈο ‹ ÂÏ·ÊÚÒ˜ ¯·ÌËÏfiÙÂÚ· ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ›‰·. ÃÔÚ‹ÁËÛË 30 mg ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ÙËÓ Ë̤ڷ ›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ca, Î·È Ù˘ iPTH (18% Û 10 ‚‰ÔÌ¿‰Â˜) ¯ˆÚ›˜ ·‡ÍËÛË ÙÔ˘ ƒ Î·È ÙˆÓ ÁÈÓÔÌ¤ÓˆÓ Ca x P. À¿Ú¯ÂÈ ÂÚ›ÙˆÛË Ó· ÂÌÊ·ÓÈÛı› ·ÓÙ›ÛÙ·ÛË
ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙˆÓ ¶∞ ÛÙÔ ·Û‚ÂÛÙÈÔÌÈÌËÙÈÎfi Î·È Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ Ó· ÌËÓ ¤¯ÂÈ Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù·. ∂›Ó·È ›Û˘ ‰˘Ó·ÙfiÓ Î·È Ó· ÚÔηϤÛÔ˘Ó ·‡ÍËÛË ÙÔ˘ Ca ÔÚÔ‡ Î·È ÙˆÓ Ô‡ÚˆÓ Î·È ˘ÂÚ·Û‚ÂÛÙÈÔ˘Ú›· Ì ‰Ú¿ÛË ÛÙËÓ ·Á·ÏË ÙÔ˘ Henle. (13,14,15). 3·. ¶∞ƒ∞£Àƒ∂O∂π¢∂∫ΔOª∏ (¶£∂)
ΔÔ 3,9 - 5 % ÙˆÓ ÏËÙÒÓ Ì ¢À¶£ Ô˘ ‰ÂÓ ˘Ô¯ˆÚ› Ì ÙËÓ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ ˘Ô‚¿ÏÏÂÙ·È Û ¶£∂. ¶ÚÒÈÌË ¤Ó‰ÂÈÍË ÁÈ· ÙËÓ ¶£∂ ıˆÚÂ›Ù·È Ë ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ›‰· Ca>12,5 mg/dl › 3 Ì‹Ó˜ ¤ˆ˜ 1 ¯ÚfiÓÔ ÌÂÙ¿ ÙË ª¡ ¤Ó· ÔÛÔÛÙfi 1,6-17 % ˘Ô‚¿ÏÏÔÓÙ·È Û ¶£∂. ∂ÈϤÔÓ ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ù· ÂÂÈÛÔ‰›· Ù˘ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·˜ ›¯·Ó Û˘Û¯¤ÙÈÛË Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ¶£∂ (p<0,001). (16) OÈ ÂӉ›ÍÂȘ ÁÈ· ¶£∂ ÌÂÙ¿ ÙË ª¡ ›ӷÈ: 1. ÀÂÚ·Û‚ÂÛÙÈ·ÈÌ›· Ì Ca>12,5 mg/dl › 1 ¯ÚfiÓÔ (44% ÙˆÓ ·ÛıÂÓÒÓ). 2. ¢À¶£ Ô˘ ·Ú·Ì¤ÓÂÈ 1 ¯ÚfiÓÔ ÌÂÙ¿ ÙË ª¡. 3. ∂›Â‰· iƒΔ∏ > 150 pg/dl ÛÂ Û˘Ó‰˘·ÛÌfi Ì Ca>11,5 mg/dl. 4. ∂ÈÏÔΤ˜: ¡ÂÊÚÔÏÈı›·ÛË, ·ÁÎÚ·ٛÙȉ·, ·ıÔÏÔÁÈο ηٿÁÌ·Ù·, ·Û‚ÂÛÙÒÛÂȘ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, calciphylaxis, ·ÁÁÂȷΤ˜ ·ۂÂÛÙÒÛÂȘ. 5. ª¤ÁÂıÔ˜ ¶∞>1 cm ÚÔÛ‰ÈÔÚÈṲ̂ÓÔ Ì ˘¤ÚË¯Ô ‹ sesta ªπμπ. (17) ∏ ¶£∂ ÌÂÙ¿ ÙË ª¡ ÌÔÚ› Ó· ¤¯ÂÈ ‰È¿ÊÔÚ˜ ÂȉڿÛÂȘ ÙfiÛÔ ÛÙÔÓ ·ÛıÂÓ‹ fiÛÔ Î·È ÛÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ∞˘Ù¤˜ ›ӷÈ:
1. ¢Ú¿ÛË ÛÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË (∞¶) ∂ÌÊ·Ó›˙ÂÙ·È Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ∞¶, Èı·ÓfiÓ ÏfiÁˆ ÙÔ˘ fiÙÈ ÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· ÌÂÙ¿ ÙËÓ ¶£∂. Œ¯ÂÈ ‚ÚÂı› Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÂȤ‰ˆÓ Ca Î·È Ì›ˆÛ˘ Ù˘ ∞¶ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ¶£∂. ∂ÈϤÔÓ ÂÏ¿ÙÙˆÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ Î·È Ì›ˆÛË ¤ÎÎÚÈÛ˘ ηÙ¯ÔÏ·ÌÈÓÒÓ.
2. ¢Ú¿ÛË ÛÙÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï ªÂÙ¿ ÙËÓ ¶£∂ ÂÌÊ·Ó›˙ÂÙ·È Ì›ˆÛË Ù˘ ¯ÔÏËÛÙÂÚ›Ó˘. OÊ›ÏÂÙ·È Û ·‡ÍËÛË Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ ÏÈÔÚˆÙÂ˚ÓÈ΋˜ Î·È Ù˘ Ë·ÙÈ΋˜ ÏÈ¿Û˘ Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ Ì›ˆÛË Ù˘ iPTH.
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3. ¢Ú¿ÛË ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜
4·. ÃOƒ∏°∏™∏ ∫∞§™πΔO¡π¡∏™
ªÂÙ¿ ÙËÓ ¶£∂ Â›Ó·È Û˘¯Ófi Ê·ÈÓfiÌÂÓÔ Ë Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∞‡ÍËÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ >15% ÂÌÊ·Ó›˙ÂÙ·È Û 65,6% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‰È·ÚΛ ·fi 1 ‚‰ÔÌ¿‰· ¤ˆ˜ 3 Ì‹Ó˜. OÊ›ÏÂÙ·È Èı·ÓfiÓ ÛÙËÓ ÙÒÛË Ù˘ ∞¶, ÏfiÁˆ Ù˘ Ì›ˆÛ˘ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ca, ÛÙËÓ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ iPTH Ô˘ ÚÔηÏ› ·ÁÁÂÈԉȷÛÙÔÏ‹ ÛÙ· ÚÔÛ·ÁˆÁ¿ ·ÚÙËÚ›‰È· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ηıÒ˜ Î·È ÛÙË ÂÏ¿ÙÙˆÛË Ù˘ ÚÂÓ›Ó˘, ‰ÈfiÙÈ fiˆ˜ Â›Ó·È ÁÓˆÛÙfi Ë iPTH ·˘Í¿ÓÂÈ ÙËÓ ¤ÎÎÚÈÛË Ù˘. ∂ÈϤÔÓ Ë ¯ÔÚ‹ÁËÛË Û΢·ÛÌ¿ÙˆÓ Ù˘ ‚ÈÙ·Ì›Ó˘ D Ô˘ Â›Ó·È ··Ú·›ÙËÙË ÌÂÙ¿ ·fi ÙËÓ ¶£∂ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË Ù˘ ÛˆÏËÓ·Úȷ΋˜ ·¤ÎÎÚÈÛ˘ Ù˘ ÎÚ·ÙÈÓ›Ó˘. ∏ ‰Ú¿ÛË ·˘Ù‹ Ù˘ ‚ÈÙ·Ì›Ó˘ D Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË.(4,18, 19,20)
∂ÈÙ˘Á¯¿ÓÂÈ Ì›ˆÛË ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ì ¢ÓÔ˚΋ ‰Ú¿ÛË ÛÙÔÓ ¢À¶£. ∂›Û˘ ÚÔηÏ› Ì›ˆÛË Ù˘ ·ÒÏÂÈ·˜ OÛÙÈ΋˜ ª¿˙·˜ (Oª) Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚfiÏË„Ë Ù˘ ÔÛÙÂÔfiÚˆÛ˘.
4. ÃÚfiÓÈ· ˘ÔʈÛÊ·Ù·ÈÌ›· Ô˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ‰È¿ÊÔÚ˜ ÂÈÏÔΤ˜ (21) ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ̤ıÔ‰Ô˜ Ô˘ ÚÔÙÈÌ¿Ù·È Â›Ó·È Ë ÔÏÈ΋ ¶£∂ Î·È Î˘Ú›ˆ˜ ·Ó ÚfiÎÂÈÙ·È ÁÈ· ÌÂÁ¿ÏÔ Ì¤ÁÂıÔ˜ ¶∞ Ì Ô˙Ò‰Ë ˘ÂÚÏ·Û›·. ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ¤¯ÂÈ ÔÚÈṲ̂ӷ ÏÂÔÓÂÎÙ‹Ì·Ù·: 1. ¶ÚÔÊ˘Ï¿ÛÛÂÈ ·fi ˘ÔÙÚÔ‹ ÙÔ˘ ¢À¶£ Î·È ÙËÓ Â·Ó¤̂·ÛË ÛÙÔÓ ÙÚ¿¯ËÏÔ. 2. Δ· ÂÌ‚Ú˘˚ο ˘ÔÏ›ÌÌ·Ù· ·Ú·ı˘ÚÂÔÂȉÈÎÔ‡ ÈÛÙÔ‡ Ô˘ ·Ú·Ì¤ÓÔ˘Ó ‹ Ë ‰È·ÛÔÚ¿ ÙˆÓ ·Ú·ı˘ÚÂÔÂȉÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·Ù¿ ÙËÓ ¶£∂ (·Ú·ı˘ÚÂÔÂȉˆÌ¿ÙˆÛË) ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· Ó· ·ÓȯÓ‡ÂÙ·È iPTH Û ›‰· ··Ú·›ÙËÙ· ÁÈ· Ê˘ÛÈÔÏÔÁÈÎfi ÔÛÙÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi. À¿Ú¯Ô˘Ó fï˜ Î·È ÌÂÈÔÓÂÎÙ‹Ì·Ù· fiˆ˜: 1. ∏ Èı·Ó‹ Ï‹Ú˘ ¤ÏÏÂÈ„Ë Ù˘ iPTH Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·‰˘Ó·ÌÈ΋ ÓfiÛÔ. 2. ∏ Ì·ÎÚ¿ ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ù˘ ηÏÙÛÈÙÚÈfiÏ˘ Ì ÙȘ ‰˘ÛÌÂÓ›˜ ÂȉڿÛÂȘ Ù˘ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÙÔÔı¤ÙËÛË ·Ú·ı˘ÚÂÔÂȉÈÎÔ‡ ÂÌÊ˘Ù‡̷ÙÔ˜; ·ÚÔ˘ÛÈ¿˙ÂÈ ˘„ËÏ¿ ÔÛÔÛÙ¿ ΛӉ˘ÓÔ˘ ˘ÔÙÚÔ‹˜ ÁÈ’ ·˘Ùfi Î·È ·ÔʇÁÂÙ·È. °È· ÙÔ˘˜ ·Ú·¿Óˆ ÏfiÁÔ˘˜ ÔÈ ·ÛıÂÓ›˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‹ و̷ÙÈÎfi ‰fiÙË Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¢À¶£ Ô˘ ‰ÂÓ ˘Ô¯ˆÚ› Ì ÙËÓ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ¶£∂ ÚÈÓ ÙË ª¡. (22,23)
5·. ∞À•∏™∏ Δ∏™ ∞¶∂∫∫ƒπ™∏™ ∞l
∂ÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ¢ÂÛÊÂÚÚÈÔÍ·Ì›Ó˘ (Desferal). Œ¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Î·È Ë ¯ÔÚ‹ÁËÛË ÎÈÙÚÈÎÔ‡ ∫. ¶·Ú·ÙËÚ‹ıËΠfiÙÈ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ·Ô‚ÔÏ‹˜ ÙˆÓ ÎÈÙÚÈÎÒÓ ÛÙ· Ô‡Ú· (p<0,001) Î·È Ù·˘Ùfi¯ÚÔÓ· ·‡ÍËÛË Ù˘ ·Ô‚ÔÏ‹˜ ÙÔ˘ ∞l (p<0,01). (24)
2. O™Δ∂O¶∂¡π∞ - O™Δ∂O¶Oƒø™∏ ∞¶ø§∂π∞ O™Δπ∫∏™ ª∞∑∞™
∏ ·ÒÏÂÈ· OÛÙÈ΋˜ ª¿˙·˜ (Oª) ÌÂÙ¿ ÙË ª¡ ÔÈΛÏÂÈ. OÈ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó ÔÛÔÛÙ¿ ·ÒÏÂÈ·˜ Oª Ô˘ ·Ó¤Ú¯ÔÓÙ·È ·fi 28 ¤ˆ˜ 88% ÙˆÓ ·ÛıÂÓÒÓ Ì ª¡. ∞fi ·˘Ù‹Ó 6,8% Á›ÓÂÙ·È ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ (1,6%/ÌËÓ·), ÂÓÒ Ë ·ÒÏÂÈ· Û˘Ó¯›˙ÂÙ·È Ì ڢıÌfi 1,7% οı ¯ÚfiÓÔ Ì¤¯ÚÈ Î·È 10 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ª¡. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi 40% ÙˆÓ ÏËÙÒÓ ÂÌÊ·Ó›˙Ô˘Ó ÔÛÙÂÔÔÚˆÙÈο ¿ÏÁË Î·È 22% ηٿÁÌ·Ù· Ù· 2 ÚÒÙ· ¯ÚfiÓÈ· O ΛӉ˘ÓÔ˜ Ù˘ ÂÌÊ¿ÓÈÛ˘ ηٷÁÌ¿ÙˆÓ Â›Ó·È ÙÚÈÏ¿ÛÈÔ˜ ·fi ¿ÙÔÌ· ·ÓÙ›ÛÙÔȯ˘ ËÏÈΛ·˜ ¯ˆÚ›˜ ª¡. (25,26) ∞πΔπ∞ ∞¶ø§∂π∞™ Oª
Δ· ΢ÚÈfiÙÂÚ· ·›ÙÈ· Ù˘ ·ÒÏÂÈ·˜ Ù˘ Oª Â›Ó·È Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Î·È Î˘Ú›ˆ˜ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ȉȷ›ÙÂÚ· ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û ‰fiÛÂȘ ÌÂÁ·Ï‡ÙÂÚ˜ ÙˆÓ 6 mg/ËÌÂÚËÛ›ˆ˜ ηıÒ˜ Î·È ÔÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ (∫˘ÎÏÔÛÔÚ›ÓË A, Tacrolimus). ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÒÏÂÈ· Oª ·›˙ÂÈ ÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ÛÙÚ¤˜, Ë ‰È·ÙÚÔÊ‹ ÙˆÓ ·ÛıÂÓÒÓ, Ë ˘ÔʈÛÊ·Ù·ÈÌ›· Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÔÛÙÂÔ̷ϷΛ·˜ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ‚ÈÙ·Ì›Ó˘ D ÏfiÁˆ Ù˘ Èı·Ó‹˜ ¡O¢ Ô˘ Û˘Ó˘¿Ú¯ÂÈ. (27,28,29) ∂¶π¢ƒ∞™∂π™ Δø¡ ∫OƒΔπ∫O™Δ∂ƒO∂π¢ø¡ ™ΔO¡ O™Δπ∫O ª∂Δ∞μO§π™ªO
∏ ‰Ú¿ÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÂÍ·ÛÎÂ›Ù·È Î·Ù¢ı›·Ó ÛÙËÓ ˘fiÊ˘ÛË Î·È ÙȘ ÁÔÓ¿‰Â˜ Î·È Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË Î·È ·ıÚÔÈÛÙÈ΋. ¶ÚÔηÏÔ‡Ó
102
A.-M. M¶E§EXPH
‰È·Ù·Ú·¯‹ Ù˘ ¤ÎÎÚÈÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ÔÚÌÔÓÒÓ Î˘Ú›ˆ˜ Ù˘ ηÏÛÈÙÚÈfiÏ˘, Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È Ù˘ ÎÔÚÙÈÎÔÙÚÔÊ›Ó˘ ηıÒ˜ Î·È Ì›ˆÛË Ù˘ ‰Ú¿Û˘ ÙÔ˘˜. ™ÙËÓ ·ÒÏÂÈ· Ù˘ Oª Û˘Ì‚¿ÏÏÂÈ Ë Ì›ˆÛ˘ Ù˘ ÂÓÙÂÚÈ΋˜ ·ÔÚÚfiÊËÛ˘ Ca, Ô˘ ÚÔηÏÔ‡Ó Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË, ηıÒ˜ Î·È Ë ·‡ÍËÛË Ù˘ ÓÂÊÚÈ΋˜ ·¤ÎÎÚÈÛ˘ ÙÔ˘ Ca Î·È ÙÔ˘ ƒ. ∏ ˘·Û‚ÂÛÙÈ·ÈÌ›· Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ iƒΔ∏ Ô˘ Ô‰ËÁ› ÛÙËÓ ·‡ÍËÛË Ù˘ ÔÛÙÈ΋˜ ·ÔÚÚfiÊËÛ˘. ∂ÈϤÔÓ Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ¤¯Ô˘Ó Î·È ¿ÌÂÛË Â›‰Ú·ÛË ÛÙ· ÔÛÙ¿: ¶ÚÔηÏÔ‡Ó Ì›ˆÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ ÔÛÙÂÔ‚Ï·ÛÙÒÓ, Ì›ˆÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÚÔÎÔÏ·ÁfiÓÔ˘ Î·È ÔÛÙÂÔηÏÛ›Ó˘, Ì ٷ˘Ùfi¯ÚÔÓË ·‡ÍËÛË Ù˘ ‰È¤ÁÂÚÛ˘ ÙˆÓ ÔÛÙÂÔÎÏ·ÛÙÒÓ Î·È ·‡ÍËÛË Ù˘ ÔÛÙÈ΋˜ ·ÔÚÚfiÊËÛ˘. ªÂÈÒÓÔ˘Ó ÙË ÁÂÓÂÙÈ΋ ¤ÎÊÚ·ÛË ÙˆÓ Î˘ÙÙÔÎÈÓÒÓ (IL-1, IL-6,TNF) Ì ÙË ÌÂÛÔÏ¿‚ËÛË ÙˆÓ Δ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∞ÎfiÌË ÚÔηÏÔ‡Ó ·‡ÍËÛË Ù˘ ¢·ÈÛıËÛ›·˜ ÙˆÓ ÔÛÙÒÓ ÛÙËÓ iƒΔ∏ ŸÏ· ·˘Ù¿ ‰ËÌÈÔ˘ÚÁÔ‡Ó ·ÚÓËÙÈÎfi ÈÛÔ˙‡ÁÈÔ Ca Î·È ÔÛÙÂÔÂÓ›·. ¶ƒO§∏æ∏ Δ∏™ O™Δ∂O¶Oƒø™∏™
Œ¯ÂÈ ÚÔÙ·ı› Ó· ¯ÔÚËÁÔ‡ÓÙ·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Û ˘Ô„‹ÊÈÔ˘˜ Ï‹Ù˜ ÚÈÓ ÙË ª¡ fiÙ·Ó ‚Ú›ÛÎÔÓÙ·È Û ·ÈÌÔοı·ÚÛË. ªÂÙ¿ ÙË ª¡ ÚÔÙ›ÓÂÙ·È Î·ıËÌÂÚÈÓ‹ ¿ÛÎËÛË 30 ÏÂÙ¿, Ê˘ÛÈÔıÂڷ›· Î·È ·ÔÊ˘Á‹ ÙÔ˘ ·ÏÎÔfiÏ Î·È ÙÔ˘ ηӛÛÌ·ÙÔ˜. ∏ ¯ÔÚ‹ÁËÛË Û˘ÓıÂÙÈ΋˜ iPTH ¤¯ÂÈ ·Ú¯›ÛÂÈ Ó· Á›ÓÂÙ·È Û ‰È¿ÊÔÚ· ΤÓÙÚ·. Δ· ÔÈÛÙÚÔÁfiÓ· Û ϋÙÚȘ Ì ÂÌÌËÓfi·˘ÛË ıˆÚÔ‡ÓÙ·È ·fi ÌÂÚÈÎÔ‡˜ Û˘ÁÁÚ·Ê›˜ fiÙÈ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ÚfiÏË„Ë Ù˘ ÔÛÙÂÔfiÚˆÛ˘. £∂ƒ∞¶∂π∞ Δ∏™ O™Δ∂O¶Oƒø™∏™
¶Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ¿ÌÂÛ· Û ϋÙ˜ ÌÂÙ¿ ·fi ̤ÙÚËÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ fiÙ·Ó ÙÔ Tscore Â›Ó·È 2,5 ‹ Î·È ÌÈÎÚfiÙÂÚÔ. ∂›Û˘, Û ‰È·‚ËÙÈÎÔ‡˜, Û ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ηٷÁÌ¿ÙˆÓ Î·ıÒ˜ Î·È fiÙ·Ó ˘¿Ú¯ÂÈ Û‡Á¯ÚÔÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Î·È ·ÁÎÚ¤·ÙÔ˜. ¶ÂÚÈÏ·Ì‚¿ÓÂÈ ¯ÔÚ‹ÁËÛË ·Ï¿ÙˆÓ Ca ·fi ÙÔ ÛÙfiÌ· ηÏÙÛÈÙÚÈfiÏ˘. ηÏÙÛÈÙÔÓ›Ó˘ Î·È ‰ÈʈÛÊÔÓÈÎÒÓ ·Ï¿ÙˆÓ.(30,31) ∏ ¯ÔÚ‹ÁËÛË Ca, ηÏÙÛÈÙÚÈfiÏ˘ ‹ ηÏÙÛÈÙÔÓ›Ó˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·fi ÙËÓ ¯ÔÚ‹ÁËÛË ‰ÈʈÛÊÔÓÈÎÒÓ ·Ï¿ÙˆÓ.(32)
¢πºø™ºO¡π∫∞ ∞§∞Δ∞
∏ ¯ÔÚ‹ÁËÛË ÙÔ˘˜ Â›Ó·È Û‹ÌÂÚ· Ë Ï¤ÔÓ ‰È·‰Â‰Ô̤ÓË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙËÓ ıÂڷ›· Ù˘ ÔÛÙÂÔfiÚˆÛ˘ Î·È ıˆÚÂ›Ù·È fiÙÈ ÂÈÙ˘Á¯¿ÓÔ˘Ó Î·Ï‡ÙÂÚË ÚfiÏË„Ë ÛÙË Ì›ˆÛË Ù˘ ·ÒÏÂÈ·˜ Ù˘ Oª ·fi ÙËÓ Î·ÏÙÛÈÙÚÈfiÏË. ∞Ó·ÛÙ¤ÏÏÔ˘Ó ÙËÓ ÔÛÙÈ΋ ·ÔÚÚfiÊËÛË Î·È ÌÂÈÒÓÔ˘Ó ÙÔÓ ÔÛÙÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi. ¢ÚÔ˘Ó ÛÙÔ˘˜ ÔÛÙÂÔÎÏ¿ÛÙ˜ Î·È ÌÂÈÒÓÔ˘Ó ÙÔÓ ·ÚÈıÌfi, ÙË ‰Ú·ÛÙÈÎfiÙËÙ· Î·È ÙÔÓ ¯ÚfiÓÔ ˙ˆ‹˜ ÙÔ˘˜. ∂›Û˘ ‰ÚÔ˘Ó ÛÙÔ˘˜ ÔÛÙÂÔ‚Ï¿ÛÙ˜ Î·È ÚÔηÏÔ‡Ó ·‡ÍËÛË ‰Ú·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘˜. ªÂ ÙȘ ·Ú·¿Óˆ ‰Ú¿ÛÂȘ ÂÈÙ˘Á¯¿ÓÔ˘Ó ÙË Ì›ˆÛË Ù˘ ·ÒÏÂÈ·˜ Ù˘ Oª. Δ· ΢ÚÈfiÙÂÚ· ·fi Ù· ‰ÈʈÛÊÔÓÈο ¿Ï·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â›Ó·È: 1. ¢ÈÓ·ÙÚÈÔ‡¯Ô˜ ¶·ÌȉÚÔÓ¿ÙË (Aredia) ÃÔÚËÁÂ›Ù·È Û ‰fiÛË 0,5 mg/kg ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ª¡. ∏ ¯ÔÚ‹ÁËÛË Â·Ó·Ï·Ì‚¿ÓÂÙ·È ÌÂÙ¿ 4 ‚‰ÔÌ¿‰Â˜. ¢È·ÈÛÙÒıËΠ̛ˆÛË Ù˘ ·ÒÏÂÈ·˜ Ù˘ Oª Û 1 ¯ÚfiÓÔ (0,9%). 2. ¡·ÙÚÈÔ‡¯Ô˜ ∞ωÚÔÓ¿ÙË (Fosamax) ÃÔÚËÁÂ›Ù·È Û ‰fiÛË 1mg/kg Ì›· ÊÔÚ¿ ÙËÓ Â‚‰ÔÌ¿‰·. ™˘Ó‹ı˘ ¯ÔÚËÁÔ‡ÌÂÓË ‰fiÛË Â›Ó·È 70 mg ÙËÓ Â‚‰ÔÌ¿‰·. ªÂ ÙË ‰fiÛË ·˘Ù‹ ÔÈ ·ÛıÂÓ›˜ ÂÌÊ¿ÓÈÛ·Ó Ì›ˆÛË Ù˘ ·ÒÏÂÈ·˜ Ù˘ Oª Û 1 ¯ÚfiÓÔ (0,7%). 3. ¢ÈÓ·ÙÚÈÔ‡¯Ô˜ E‰ÈÙÚÔÓ¿ÙË (Ditronel,Ostopor) ∏ ‰ÔÛÔÏÔÁ›· ÙÔ˘ Â›Ó·È 400 mg/Ë̤ڷ › 2,5 Ì‹Ó˜ Ì ٷ˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË Ca Û ‰fiÛË 500 mg/Ë̤ڷ. °›ÓÔÓÙ·È 4 ·ÎÏÔÈ ıÂڷ›·˜ Î·È ‰È·ÈÛÙÒıËΠfiÙÈ Â›¯·Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· Ì›ˆÛË ÙˆÓ Î·Ù·ÁÌ¿ÙˆÓ (40%) Û 1 ¯ÚfiÓÔ (33,34,35)
3. O™Δπ∫∏ ∏ ∞™∏¶Δ∏ ¡∂∫ƒø™∏ Δ· ΢ÚÈfiÙÂÚ· ·ıÔÁÂÓÂÙÈο ·›ÙÈ· ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÛËÙ˘ Ó¤ÎÚˆÛ˘ ÙˆÓ ÔÛÙÒÓ Â›Ó·È: 1. ∞‡ÍËÛË Ù˘ ›ÂÛ˘ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Ô˘ Ô‰ËÁ› Û ӤÎÚˆÛË ÔÛÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Ó¤ÎÚˆÛË ÙˆÓ ÔÛÙÈÎÒÓ ÛˆÏ‹ÓˆÓ 2. ∂Ì‚ÔÏ‹ Ï›Ô˘˜ ÛÙ· ÔÛÙ¿, Ô˘ ÚÔηÏ› ·ÁÁÂÈ›Ùȉ· Î·È ÂÌÊÚ¿ÁÌ·Ù· ÙˆÓ ÌÈÎÚÒÓ ·ÁÁ›ˆÓ ÙˆÓ ÔÛÙÒÓ 3. ÀÂÚÏ·Û›· ÙÔ˘ ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡ ∫˘ÚÈfiÙÂÚË ·ÈÙ›· ÁÈ· ÙË ÂÌÊ¿ÓÈÛË ÙˆÓ ·Ú·¿Óˆ ıˆÚÔ‡ÓÙ·È Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ∏ ‰Ú¿ÛË ÙÔ˘˜ Â›Ó·È ·ıÚÔÈÛÙÈ΋ Î·È ÂÈÙ›ÓÂÙ·È ·fi ÙËÓ ÂÈϤÔÓ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ÛÙ· ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ ∞ӷʤÚÂÙ·È fiÙÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ó˘ (΢ÎÏÔÛÔÚ›ÓË ∞) ÌÂÈÒÓÔ˘Ó ÙËÓ Û˘¯ÓfiÙËÙ· Ù˘ ÔÛÙÈ΋˜ Ó¤ÎÚˆÛ˘
∂ÓÙfiÈÛË -∫ÏÈÓÈ΋ ÂÈÎfiÓ· ∏ ¿ÛËÙË Ó¤ÎÚˆÛË ÂÌÊ·Ó›˙ÂÙ·È Û˘¯ÓfiÙÂÚ· ÛÙËÓ ÎÂÊ·Ï‹ ÙˆÓ ÌËÚÈ·›ˆÓ Î·È Ù· ÁfiÓ·Ù·. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Û˘Ó‹ıˆ˜ ÛÙÔ 15% ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ ·Ú·ÙËÚÂ›Ù·È Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ (4,8%). ÷ڷÎÙËÚ›˙ÂÙ·È ·fi fiÓÔ, ÂÚÈÔÚÈÛÌfi Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ Ù˘ ¿ÚıÚˆÛ˘ Î·È ÙÔÈ΋ ¢·ÈÛıËÛ›·.
¢È¿ÁÓˆÛË – ∞ÓÙÈÌÂÙÒÈÛË O ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÈÛ¯›ˆÓ Ì ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›·, ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÔÛÙÒÓ, Ë ·ÍÔÓÈ΋ Î·È Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ı· Ô‰ËÁ‹ÛÔ˘Ó ÛÙËÓ ‰È¿ÁÓˆÛË. ∏ ıÂڷ›· ÂÚÈÏ·Ì‚¿ÓÂÈ ÛÙ· ÚÒÈÌ· ÛÙ¿‰È· (π Î·È ππ∞) ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔÛ˘Ì›ÂÛË Ì ÙÚ˘·ÓÈÛÌÔ‡˜ Î·È ÛÙ· ÚÔ¯ˆÚË̤ӷ ·ÓÙÈηٿÛÙ·ÛË Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ÌËÚÈ·›Ô˘.
¶ÚfiÏË„Ë ∏ ÚfiÏË„Ë Ù˘ ¿ÛËÙ˘ Ó¤ÎÚˆÛ˘ ÙˆÓ ÔÛÙÒÓ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È ÙË ¯ÔÚ‹ÁËÛË Î·ÏÙÛÈÙÚÈfiÏ˘ ‹ ‰ÈʈÛÊÔÓÈÎÒÓ ·Ï¿ÙˆÓ Ô˘ ÚÔηÏÔ‡Ó Ì›ˆÛË Ù˘ ·ÒÏÂÈ·˜ Ù˘ Oª.(1, 36)
4. ™À¡¢ƒOª∞ O™Δπ∫OÀ ¶O¡OÀ OÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘¯Ó¿ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡˜ fiÓÔ˘˜ Ô˘ ÂÓÙÔ›˙ÔÓÙ·È ÛÙ· οو ¿ÎÚ·, ÛÙÔ˘˜ ·ÁÎÒÓ˜ Î·È ÛÙ· ÁfiÓ·Ù· (19-35% ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ ÚÒÙÔ 6ÌËÓÔ). OÈ ÔÛÙÈÎÔ› fiÓÔÈ ÌÔÚ› Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ‰ÂÚÌ·ÙÈÎfi ÂÍ¿ÓıËÌ·. OÊ›ÏÔÓÙ·È ÛÙȘ ·˘ÍË̤Ó˜ ‰fiÛÂȘ ∫˘ÎÏÔÛÔÚ›Ó˘ A, Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ 10% ÙˆÓ ÏËÙÒÓ È‰È·›ÙÂÚ· ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ ÌÂÙ¿ ÙË ª¡.
¶·ıÔÁ¤ÓÂÈ· OÊ›ÏÔÓÙ·È Û ÌÈÎÚ¿ ηٿÁÌ·Ù·, ‹ Û ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË ÛÙȘ ÂÈʇÛÂȘ ÙˆÓ ÔÛÙÒÓ, ηıÒ˜ Î·È Û ԛ‰ËÌ· ÙÔ˘ Ì˘ÂÏÔ‡, Ô˘ ‰ËÌÈÔ˘ÚÁ› ·˘ÍË̤ÓË ›ÂÛË Û ·˘ÙfiÓ. ∂›Û˘ Û ÂÓÙÔÈṲ̂ÓË ÌÈÎÚÔ·ÁÁÂÈÔ¿ıÂÈ· ÙˆÓ ÔÛÙÒÓ Î·È ·‡ÍËÛË Ù˘ ÔÛÙÂÔ‚Ï·ÛÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜.
103
¢È·ÁÓˆÛË- ¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË: °›ÓÂÙ·È Ì ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÔÛÙÒÓ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· Ô˘ ı· ·ÔÎÏ›ÛÂÈ ÔÛÙÈÎÔ‡˜ fiÓÔ˘˜ Ô˘ ÔÊ›ÏÔÓÙ·È Û ¿ÏÏ· ·›ÙÈ·, ÂÓÒ Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ı· Á›ÓÂÈ ·fi ¢À¶£, ÔÏ˘Ó¢ÚÔ¿ıÂÈ·, ÔÛÙÂÔfiÚˆÛË Î·È ÔÛÙÈ΋ Ó¤ÎÚˆÛË.
∞ÓÙÈÌÂÙÒÈÛË ¶ÂÚÈÏ·Ì‚¿ÓÂÈ Ì›ˆÛË ÙˆÓ ‰fiÛÂˆÓ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘, ¯ÔÚ‹ÁËÛË ·ÓÙ·ÁˆÓÈÛÙÒÓ ÙˆÓ ‰È·‡ÏˆÓ Ca, ¯ÔÚ‹ÁËÛË Î·ÏÙÛÈÙÚÈfiÏ˘, Î·È ÌË ÛÙÂÚÔÂȉÒÓ ·ÓÙÈÊÏÂÁÌÔÓˆ‰ÒÓ ÁÈ· ÌÈÎÚ‹ ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ·. (37, 38)
5. ∞ªÀ§O∂π¢ø™∏ ∞¶O ‚2 ªπ∫ƒO™º∞πƒπ¡∏ ªÂÙ¿ ÙË ª¡ ηٿ ηÓfiÓ· Á›ÓÂÙ·È ˘ÔÛÙÚÔÊ‹ ÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ·fi ‚2 ÌÈÎÚÔÛÊ·ÈÚ›ÓË. °È ·˘Ùfi ˘Ô¯ˆÚÔ‡Ó ÔÈ ·ÏÏÔÈÒÛÂȘ ·fi ÙȘ ·ÚıÚÒÛÂȘ Î·È ÙÔ Û‡Ó‰ÚÔÌÔ ÙÔ˘ ηÚÈ·›Ô˘ ۈϋӷ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈ ¯ÚfiÓÈÔÈ ÓÂÊÚÔ·ı›˜ fiÙ·Ó ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÈÌÔοı·ÚÛË. øÛÙfiÛÔ ÂÓ·Ôı¤ÛÂȘ ·Ì˘ÏÔÂȉԇ˜ ÌÔÚ› Ó· ·ÓȯÓ‡ÔÓÙ·È ÛÙÔ˘˜ ÈÛÙÔ‡˜ ÙˆÓ ·ÛıÂÓÒÓ ·ÎfiÌË Î·È ÌÂÙ¿ ·fi10 ¯ÚfiÓÈ· ·fi ª¡. ¶ÚÔηÏÔ‡Ó ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ ÛÙȘ ·ÚıÚÒÛÂȘ Î·È ÂÎÊ˘ÏÈÛÙÈ΋ ·ÚıÚÔ¿ıÂÈ·. °È· ÙÔ ÏfiÁÔ ·˘Ùfi fiÙ·Ó ÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÛÙÈο ¿ÏÁË ¯ˆÚ›˜ ¿ÏÏÔ ·›ÙÈÔ ÙfiÙ ڤÂÈ Ó· Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ ÁÈ· ·Ì˘ÏÔ›‰ˆÛË Ì ·ÎÙÈÓÔÁڷʛ˜ ÔÛÙÒÓ, Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·, ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÔÛÙÒÓ Î·È ÔÛÙÈ΋ ‚ÈÔ„›·. (39)
6. ¢π∞Δ∞ƒ∞Ã∂™ O™Δπ∫OÀ ª∂Δ∞μO§π™ªOÀ 1. ÀÂÚ·Û‚ÂÛÙÈ·ÈÌ›· ÌÂÙ¿ ÙË MN ∞›ÙÈÔ ÂÌÊ¿ÓÈÛ˘ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·˜ Û ·ÛıÂÓ›˜ Ì ª¡ ÌÔÚ› Ó· Â›Ó·È Ô ¢À¶£. Ÿˆ˜ ¤¯ÂÈ ‹‰Ë ·Ó·ÊÂÚı› Ë ÌfiÓË ¤Ó‰ÂÈÍË ÙÔ˘ ¢À¶£ ÌÔÚ› Ó· Â›Ó·È Ë ·‡ÍËÛË ÙÔ˘ Ca, ÂÓÒ ÌfiÓÔ ÙÔ 1/3 ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ·Ó›˙ÂÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ. ªÔÚ› ·ÎfiÌË Ó· ÔÊ›ÏÂÙ·È Û ·fiÙÔÌË Ì›ˆÛË ‰fiÛ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ‹ ÛÙË ¯ÔÚ‹ÁËÛË ÌÂÙ·‚ÔÏÈÙÒÓ Ù˘ ‚ÈÙ·Ì›Ó˘ D ÏfiÁˆ ¢À¶£ ‹ ˘ÔʈÛÊ·Ù·ÈÌ›·˜. ªÈ· Èı·Ó‹ ·ÈÙ›· ıˆÚÂ›Ù·È Ë «§‡ÛË» ÙˆÓ ¤ÎÙÔˆÓ ÂÓ·Ôı¤ÛÂˆÓ Ca / P Ô˘ ›¯·Ó ‰ËÌÈÔ˘ÚÁËı› ÛÙÔ˘˜ ·ÛıÂÓ›˜ ηٿ ÙËÓ ·ÈÌÔοı·ÚÛË, ‹ Û ÔÛÙÈ΋ ÓfiÛÔ ÙÔ˘ ·ÚÁÈÏ›Ô˘ (ÔÛÙÂÔ̷ϷΛ· ·fi Al). ∞ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ‰ÈfiÚıˆÛË ÙÔ˘ ·ÈÙ›Ô˘ Ô˘ ÙËÓ ÚÔηÏ›.
104
A.-M. M¶E§EXPH
2. ÀÔʈÛÊ·Ù·ÈÌ›· ÌÂÙ¿ ÙË ª¡ ∂ÌÊ·Ó›˙ÂÙ·È ÛÙÔ 25-30% ÙˆÓ ·ÛıÂÓÒÓ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ÀÔʈÛÊ·Ù·ÈÌ›· ÌÂÙ¿ ÙË ª¡ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ 93% ·ÛıÂÓÒÓ ÛÙÔ˘˜ 4 Ì‹Ó˜ Î·È 20-40% ÛÙÔÓ 1 ¯ÚfiÓÔ. OÊ›ÏÂÙ·È Û Ì˯·ÓÈÛÌÔ‡˜ ÂÍ·ÚÙË̤ÓÔ˘˜ ·fi ÙËÓ iƒΔ∏, Ô˘ Â›Ó·È Ù· ·˘ÍË̤ӷ ›‰· Ù˘ iƒΔ∏, ÏfiÁˆ ÙÔ˘ ¢À¶£ Ô˘ ·Ú·Ì¤ÓÂÈ, ηıÒ˜ Î·È Ë ·‡ÍËÛË Ù˘ ·¿ÓÙËÛ˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÛˆÏËÓ·Ú›Ô˘ ÛÙËÓ ƒΔ∏. ∂›Û˘ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û Ì˯·ÓÈÛÌÔ‡˜ ·ÓÂÍ¿ÚÙËÙÔ˘˜ ·fi ÙËÓ ƒΔ∏ fiˆ˜ Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ë Û¯ÂÙÈ΋ ¤ÏÏÂÈ„Ë Î·ÏÙÛÈÙÚÈfiÏ˘, Ë Ì›ˆÛË Ù˘ ÂÓÙÂÚÈ΋˜ ·ÔÚÚfiÊËÛ˘ Î·È Ë ·‡ÍËÛË Ù˘ ÛˆÏËÓ·Úȷ΋˜ ·¤ÎÎÚÈÛ˘ ÙÔ˘ ƒ. ∞ÎfiÌ· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙ· ›‰È· Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈο, ‹ Ù· ‰ÈÔ˘ÚËÙÈο Ô˘ ›Ûˆ˜ ·›ÚÓÔ˘Ó ÔÈ ·ÛıÂÓ›˜. ∂›Â‰· ƒ ÛÙÔÓ ÔÚfi 0,9 - 1,4 mg/dl ÚÔηÏÔ‡Ó Ì˘˚΋ ·‰˘Ó·Ì›· Î·È ÔÛÙÂÔ̷ϷΛ·, ÂÓÒ ·Ó Ô ƒ Â›Ó·È < 0,9 mg/dl ÚÔηÏÂ›Ù·È ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, Ú·‚‰ÔÌ˘fiÏ˘ÛË, Ì›ˆÛË Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·. (40,41) ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔʈÛÊ·Ù·ÈÌ›·˜ ÌÂÙ¿ ÙË ª¡ ÂÚÈÏ·Ì‚¿ÓÂÈ ¯ÔÚ‹ÁËÛË Û΢·ÛÌ¿ÙˆÓ ƒ ·fi ÙÔ ÛÙfiÌ·. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ¯ÔÚ‹ÁËÛË ÙÔ˘˜ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ª¡ ‰ÂÓ Âȉڿ ÛÙ· ›‰· ÙÔ˘ Ca Î·È Ù˘ iPTH, ÂÓÒ ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË Ù˘ iPTH 41 Ì‹Ó˜ ÌÂÙ¿ ÙË ª¡, Û ·ÛıÂÓ›˜ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ô˘ ÂÏ¿Ì‚·Ó·Ó Û΢¿ÛÌ·Ù· ƒ ·fi ÙÔ ÛÙfiÌ·. ÃÚÂÈ¿˙ÂÙ·È ÚÔÛÔ¯‹ ÛÙË ¯ÔÚ‹ÁËÛË ÙÔ˘˜ ‰ÈfiÙÈ ÔÈ ÌÂÁ¿Ï˜ ‰fiÛÂȘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÂÌÊ¿ÓÈÛË ¢À¶£. (42)
™Àª¶∂ƒ∞™ª∞Δ∞ O ¤ÏÂÁ¯Ô˜ ÁÈ· ÔÛÙÈ΋ ÓfiÛÔ Û ·ÛıÂÓ›˜ Ì ª¡ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: 1. μÈÔ¯ËÌÈÎÔ‡˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡˜. ∫Ú·ÙÈÓ›ÓË, Ca, iCa++, ƒ, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, iPTH, ÔÛÙÂÔηÏÛ›ÓË, ÔÛÙÈÎfi ÎÏ¿ÛÌ· ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ ÔÚÔ‡. 2. ∞ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ∫Ú·Ó›Ô˘, ¿ÎÚˆÓ ¯ÂÈÚÒÓ Ì ̷ÛÙÔÁÚ¿ÊÔ, ÏÂοÓ˘, ÈÛ¯›ˆÓ ¿Ìʈ. 3. ª¤ÙÚËÛË ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Ì ‰ÈÏ‹ ʈÙÔÓȷ΋ ·ÔÚÚoÊËÛË Ì ·ÎÙ›Ó˜ Ã Î·È ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ T-score, Î·È ÙÔ˘ Z-score ÛÙËÓ Î·Ùã ÈÛ¯›ÔÓ ¿ÚıÚˆÛË, ÛÙÔÓ ·˘¯¤Ó· ÙÔ˘ ÌËÚÈ·›Ô˘ ÔÛÙÔ‡ Î·È ÛÙËÓ ÔÛÊ˘˚΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘.
4. μÈÔ„›· ÔÛÙÔ‡ Î·È ÈÛÙÔÌÔÚÊÔÌÂÙÈ΋ ·Ó¿Ï˘ÛË Û ÂÚÈÙÒÛÂȘ Ô˘ ·˘Ù‹ ıˆÚÂ›Ù·È ·Ó·Áη›·. ∏ ÚÔʇϷÍË Î·È Ë ıÂڷ›· Ù˘ ÔÛÙÈ΋˜ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ª¡ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ı› οÔÈÔ˘˜ ηÓfiÓ˜. ∞˘ÙÔ› Û‡Ìʈӷ Ì ÙȘ ‰ÈÂıÓ›˜ Ô‰ËÁ›Â˜ Â›Ó·È ∫/DOQI GUIDELINES
ÃÔÚ‹ÁËÛË BÈÙ·Ì›Ó˘ D: ∫·ÏÙÛÈÙÚÈfiÏË 0,25-0,5 Ìg/Ë̤ڷ ‹ 600 ÌÔÓ¿‰Â˜ ¯ÔÏÔηÏÛËÊÂÚfiÏË /Ë̤ڷ. ¶ÚfiÛÏË„Ë Ca: 1000 Ìg/Ë̤ڷ Î·È Û Á˘Ó·›Î˜ Û ÂÌÌËÓfi·˘ÛË 1500 Ìg/Ë̤ڷ. ∞ÔÊ˘Á‹ ‰ÈÔ˘ÚËÙÈÎÒÓ ·Á·Ï˘ (ıÂÈ·˙›‰Â˜) ∞ÔηٿÛÙ·ÛË Ù˘ ÔÚÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ÃÔÚ‹ÁËÛË ÔÚÌÔÓÒÓ ÙÔ˘ ʇÏÔ˘ Î·È ı˘ÚÂÔÂȉÈÎÒÓ ÂÊfiÛÔÓ ·˘Ùfi Â›Ó·È ·Ó·Áη›Ô. £Âڷ›· Ù˘ ˘ÔʈÛÊ·Ù·ÈÌ›·˜ ·Ó Ô ƒ Â›Ó·È Û ›‰· ÌÈÎÚfiÙÂÚ· ·fi 2,5 mg/dl Î·È Ù˘ ˘ÔÌ·ÁÓËÛÈ·ÈÌ›·˜. ¢À¶£ Ô˘ ÂÈ̤ÓÂÈ: O ·ÛıÂÓ‹˜ ¯ÚÂÈ¿˙ÂÙ·È ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· 1 ¯ÚfiÓÔ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·ÓÙÈÌÂÙÒÈÛË. ∫ÔÚÙÈÎÔÛÙÂÚÔÂȉ‹: ÃÔÚ‹ÁËÛË ÛÙË ÌÈÎÚfiÙÂÚË ‰˘Ó·Ù‹ ‰fiÛË (<6 mg/Ë̤ڷ) ‹ ̤ڷ ·Ú¿ ̤ڷ. ÃÔÚ‹ÁËÛË ¢ÈÊÔÛʈÓÈÎÒÓ: ™Â ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ ÔÛÙÂÔÂÓ›· (ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· Δscore <2,5), ηٿÁÌ·Ù· Î·È GFR>50-60 ml/min. ∞‡ÍËÛË ·¤ÎÎÚÈÛ˘ Al: ¢ÂÛÊÂÚÚÈÔÍ·Ì›ÓË-ÎÈÙÚÈο. ∫·ÏÙÛÈÙÔÓ›ÓË ÁÈ· Ì›ˆÛË ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Î·È Ì›ˆÛË Ù˘ ·ÒÏÂÈ·˜ Ù˘ Oª ¢È·ÎÔ‹ ηӛÛÌ·ÙÔ˜ ÕÛÎËÛË (43) ∂ΛÓÔ Ô˘ Ú¤ÂÈ Ó· ÛËÌÂȈı› Û·Ó Û˘Ì¤Ú·ÛÌ· Â›Ó·È fiÙÈ ·ÚfiÏÔ Ô˘ Ì ÙË ÁÓˆÛÙ‹ ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙËÓ ÔÛÙÈ΋ ÓfiÛÔ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ηٷÁÌ¿ÙˆÓ, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÛÙË Ì›ˆÛË Ù˘ ·ÒÏÂÈ·˜ Ù˘ Oª ˘fiÛ¯ÔÓÙ·È ÔÏÏ¿. ∏ ıÂڷ›· Ì ‰ÈÊÔÛʈÓÈο, ‚ÈÙ·Ì›ÓË D Î·È ·Ó¿ÏÔÁ· Ù˘, ·Û‚ÂÛÙÈÔÌÈÌ‹ÙÈο ‹ ¯ÔÚ‹ÁËÛË Î·ÏÛÈÙÔÓ›Ó˘ Û ÔÔÈÔ‰‹ÔÙ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÙ¿ ÙË ª¡ ¤¯ÂÈ Â˘ÂÚÁÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÛÙÔÓ ÔÛÙÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi, ÂÓÒ ÔÈ ·ÚÂÓ¤ÚÁÂȘ Â›Ó·È ÂÏ¿¯ÈÛÙ˜.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
μÈ‚ÏÈÔÁÚ·Ê›· 1. Spterschneider H, Stein G. Bone disease after renal transplantation Neprhol Dial Transplant 2003;18 (5): 874-877 2. Δraindl O, Lange F, Regarding S et al. Secondary hyperparathyroidismand acute tubular necrosis follÔwing kidney transplantation Nephrol Dial Transplant 1993; 8: 173-176 3. Reinbardt W, Bartelworth H, Jockenhovel F et al. Sequential changes of biochemical bone parameters after kidney transplantation Nephrol Dial Transplant 1998; 13: 436-442 4. Evenepoel P, Claes K, Kuypres D et al. Natural history of function and calcium metabolism after kidney transplantation a single centre study Nephrol Dial Transplant 2005; 19(5): 1281-1287 5. Druke TB. Cell biology of parathyroidgland hyperplasia in chronic renal failure J Am Soc Nephrol 2000; 11 (6): 1141-1152 6. Caravaca F, Fernantez MA, Cubero J et al. Are plasma 1.25-dihydroxycitamin D3 concetrations appropriate after successful kidney transplantation. Nephrol Dial Transplantation 1998; 13(3): 91-93 7. Dumoulin G, Horry B, Nguyen NU et al. No trends towards a spontaneus improovment of hyperparathyroidism.and high] bone turnover in normocalcemic long-term renal transrlant recipients Am. J. Kidney Dis. 1997; 29: 746-753 8. Enevepoel P, Kuypers D, Maes B et al. President hyperparathyroidism requiring parathyroidectomy after successful kidney transplantation. In 10 ESOT Congress 5-11 Octrober 2001 9. Torres A, Lorenzo V, Salido E. Calcium metabolism and skeletal problems after transplantation J Am Soc Nephrol 2002; 13 (2): 551-558 10. Torres A, Rondriquez AR, Concepcion MT et al. Parathyroid function in long term renal transplant patients importance of pre transplant PTH concentrations Nephrol Dial Transplant 1998; 13(3): 94-97 11. μonarek H, Merville P, μonarek M et al. Reduced parathyroid functional mass after succesful kidney transplantation Kidney Int 1999; 56: 642-649 12. Lobo P, Cortez MS, Stevenson W et al. Normocalcemic hyperparathyroidism associated with relatively low 1,25 vitamin D levels post-renal transplant can be successfully treated with oral calcitriol. Clin Transpl 1995; 9: 277 13. Druke TB. The place of calcium and calcimemetics in the treatment of secondary hyperparathyroidism Neprhol Dial Transplant 2001; 16(6): 15-17 14. Kruse AE, Eisenberger U, Frey FG, Mohaupt MG. The calcimemetic cinacalcet normalizes serum calcium in renal transplant patients with persistent hyperparathyroidism. Neprhol Dial Transplant 2005; 20(7): 13111314
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15. Serra AL, Schwarz AA, Wick FH et al. Successful treatment of hypercalcemia with cinacalcet in renal transplant patients with persistent hyperparathyroidism Nephrol Dial Transplant 2005; 20 (7): 1315-1319 16. Mourad M, Malaise J, Chautems R.C et al Early post transplant calcemia as a predictive indicator for parathyroidectoy in kidney transplant allograft recipients with trietary hyperparathyroidism. Transpl Proc 2000; 32: 437-440 17. Garcia A, Mazuecos A, Garcia T et al. Effect of parathyroidectomy on renal graft function Transpl Proc 2005; 37(3):1459-1461 18. Evenepoel P, Claes K, Kuypers DR, et al. Parathyroidectomy after succesful kidney transplantation Nephrol Dial Transplant 2007; 22(6): 1730-1737 19. Hangstrom E, Lundgren E, Litherll H et al. Normalized dyslipidaemia after parathyroidectomy in mild primary hyperparathyroidism: population-based study over five years. Clin Endocrinol 2002; 56: 253-260 20. Envepoel P, Claes K, Kuypers D et al. Impact of parathyroidectomy on renal graft function, blood pressure and serum lipids in kidney transplant recipientsa single centre study. Nephrol Dial Transplant 2005; 20: 17141720 21. Druke TB. Renal osteodystrophy management of hyperphosphataemia. Nephrol Dial Transplant 2000; 15 (5): 32-33 22. Wheatley TJ, DoughmanT, Veitch PS et al Clinical and physiological responses to total parathyroidectomy after renal transplantation Transpl Proc 1997; 29: 30543055 23. Slatopolsky E, Lopez –Hilker S, Delmez J et al. The parathyroid-calcitriol axis in health and chronic renal failure Kidney Int 1990; 29: 41-47 24. Massari P. Disordersof bone and mineral metabolism after renal transplantation ∫idney Int 1997; 52: 14121421 25. Patel S, Kwan JTC, McCloskey E et al. Prevalence and causes of low bone sensity and fractures in kidney transplant patients. J Bone Miner Res 2001; 16: 18631870 26. Pichette V, Bonnardeaux A, Prudhomme L et al. Long term bone loss in kidney transplant recipients : A crosssectional and logistical study. Am J Kidney Dis 1996; 28: 105-114 27. Goodman GR, Dissanayade IR, Sodam BR et al. Immunosuppressant use without bone loss-implications for bone loss after transplantation. J Bone Miner Res 2001; 16: 72-78 28. Monier-Faugere MC Mawad H,QiQ et al.High prevalence of low bone turnover and occurence of osteomalacia after kidney transplantation J Am Soc Nephrol 2000; 11(6):1093-1099 29. Giannini S, D’ Angelo A, Carraro G et al. Persistently increased bone turnover and low bone sensity in long-
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term survivors to kidney transplantation. Clin Nephrol 2001; 56: 353-363 30. Giannini S, D’ Angelo A, Carraro G et al. Aledronate prevents further bone loss in renal transplant recipients. J Bone Miner Res 2001; 16: 2111 31. Neer RM,Amaud CD,ZanchettaJR et al. Effect of parathyroid hormone (1-34)on fractures and bone mineral density in postmenopausal women with osteoporosis N Engl J Med 2001; 334(19): 1434-1441 32. Lane NE,Sanchez S, Modin GW et al. Parathyroid hormone treatment can reverse corticosteroid –induced osteoporosis. Results of a randomized controlled clinical trial. J Clin Invest 1998; 102(8): 1627-1633 33. Fan SLS, Almond MK, Balll E et al. Pamidronate therapy as prevention of bone loss following renal transplantation. Kidney International 2000; 57: 684-690 34. Shane E, Addresso V, Namerow PB et al. Aledronate versus calcitriol for the prevention of bone loss after cardiac transplantation. New Eng J Med 2004; 350(8): 767-776
37. Grotz WH, Breitenfeldt MK, Braune SW et al. Calcineurin inhibitor induced pain syndrome (CIPS): a severe disabling complication after organ transplantation. Transplant Int 2001; 14: 16-23 38. Barbosa LM, Gauthier VJ, Davis CL. Bone pain that responds to calcium channel blockers a retrospective and prospective study of transplant recipients. Transplantation 1995; 59(4): 541-544 39. Bardin T, Lebail-Darne JL, Zingraft J et al: Dialysis arthropathy :outcome after renal transplantation Am J Med 1995; 99 (3): 243-248 40. Ambhul PM, Meier D, Wold B et al. Metabolic aspects of phosphate replacement therapy for hypophosphatemia after renal transplantation: Impact on muscular phosphate content. Mineral metabolism, and acid/base homeostasis. Am J Kidney Dis 1999; 34: 875-883 41. Levi M. Post transplant hypophoaphatemia: Kidney Int 2001; 59(6): 2377-2387
35. Grotz W, Nagel C, Poeschel D et al. Effect of ibrandronate on bone loss and renal function after kidney transplantation. J Am Soc Nephrol 2001; 12: 1530-1537
42. Caravaca F, Fernantez MA, Ruiz-Calero R et al. Effects of oral phosphorus supplementation on mineral metabolism o frenal transplant recipients. Nephrol Dial Transplant. 1998 Oct;13(10):2605-11.
36. Grotz WH, Mundinger FA, Rasenack J et al. Bone loss after kidney transplantation: A longitudinal study in 115 graft recipients. NDT 1995; 10: 2096-2100
43. Saab G, Mathew S, Chaudhary L et al .Post-transplant osteodystrophy in the ERA of the K/DOQI Guidelines: Dialysis and Transplantation 2003; 32: 651- 663.
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™‡ÚÔ˜ NÙfi‚·˜
∂ÌÌ¤ÓˆÓ ¢À¶£ Î·È ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·
OÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘, ÙÔ˘ ʈÛÊfiÚÔ˘ Î·È ÔÛÙÒÓ (ÔÛÙÂÔ‰˘ÛÙÚÔÊ›·) Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (á∞) ÙÚÔÔÔÈÔ‡ÓÙ·È ÛËÌ·ÓÙÈο ÌÂÙ¿ ·fi ÂÈÙ˘¯‹ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË (¡ª). OÈ Î‡ÚÈÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ ÂÌÊ¿ÓÈÛË ·˘ÙÒÓ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Â›Ó·È ÙÔ Â›‰Ô˜ Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ÓÂÊÚÈ΋˜ ÔÛÙÂÔ‰˘ÛÙÚÔÊ›·˜ (¡O¢) Ô˘ ˘‹Ú¯Â ÚÈÓ ·fi ÙË ¡ª, Ë ¯ÔÚ‹ÁËÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È Î˘ÎÏÔÛÔÚ›Ó˘) Ô˘ ·ÚÂÌ‚·›ÓÔ˘Ó ÛÙÔÓ ÔÛÙÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi Î·È Ë Û˘¯Ó‹ Û˘Ó‡·ÚÍË ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÏfiÁˆ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ™˘¯Ó¤˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÌÂÙ¿ ·fi ¡ª Â›Ó·È Ë ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· Î·È Ë ÊˆÛÊ·ÙÔ˘Ú›· Ì ‹ ¯ˆÚ›˜ ˘ÔʈÛÊ·Ù·ÈÌ›·. ™˘Ó‹ıˆ˜ ·Ú·ÙËÚÔ‡ÓÙ·È ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ·fi ÙË ¡ª Î·È ÔÊ›ÏÔÓÙ·È Î˘Ú›ˆ˜ Û ÂÌ̤ÓÔÓÙ· ‰Â˘ÙÂÚÔ·ı‹ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌfi (¢À¶£). º·›ÓÂÙ·È fiÙÈ Ë ˘ÔÛÙÚÔÊ‹ ÙˆÓ ·Ú·ı˘ÚÂÔÂȉÒÓ ·‰¤ÓˆÓ (¶∞) Â›Ó·È Ôχ ·ÚÁ‹ ‹ ÏÂÈÙÔ˘ÚÁÔ‡Ó ˆ˜ ·˘ÙfiÓÔÌ· ·‰ÂÓÒÌ·Ù·, ¤ÙÛÈ ÒÛÙ ÔÏÏÔ› ·ÛıÂÓ›˜ Ó· ˘Ê›ÛÙ·ÓÙ·È ÙȘ Û˘Ó¤ÂȘ ÙˆÓ ˘„ËÏÒÓ ÂȤ‰ˆÓ Ù˘ ·Ú·ıÔÚÌfiÓ˘ (PTH) › ÔÏÏ¿ ¯ÚfiÓÈ·. ÕÏϘ ‰È·Ù·Ú·¯¤˜ Â›Ó·È Ë Ì›ˆÛË ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Î·È Ù˘ ÔÛÙÈ΋˜ Ì¿˙·˜, Ô˘ ·Ô‰›‰ÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ Â›‰Ú·ÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È Ë ¿ÛËÙË ÔÛÙÈ΋ Ó¤ÎÚˆÛË, Û˘Ó‹ıˆ˜ Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ÌËÚÈ·›Ô˘ ÔÛÙÔ‡. ¶ÚÔ¸¿Ú¯Ô˘Û· ·‰˘Ó·ÌÈ΋ ÓfiÛÔ˜ ‹ ÔÛÙÂÔfiÚˆÛË (O¶) Û˘Ó‹ıˆ˜ ÂȉÂÈÓÒÓÔÓÙ·È ÌÂÙ¿ ÙË ¡ª Î·È Ô‰ËÁÔ‡Ó Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Î·Ù·ÁÌ¿ÙˆÓ Î·È ·Ó·ËÚ›·, ·ÎfiÌË Î·È Û Ó·ڿ ¿ÙÔÌ·. ÕÏÏÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÛÙ· ÔÛÙ¿ Â›Ó·È Ë ÚÔËÁÔ‡ÌÂÓË ¯Ú‹ÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, Ë ‡·ÚÍË Û·Î¯·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË (™¢), Ù· ¯·ÌËÏ¿ ›‰· ÔÈÛÙÚÔÁfiÓˆÓ Î·È ÙÂÛÙÔÛÙÂÚfiÓ˘ ÏfiÁˆ á∞ Î·È Ë Ì·ÎÚ¿ ‰È¿ÚÎÂÈ· ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜.
∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ¡ª ‰Ú· ¢ÂÚÁÂÙÈο ÛÙÔÓ ¢À¶£ ‰ÈÔÚıÒÓÔÓÙ·˜ ÙËÓ ˘ÂÚʈÛÊ·Ù·ÈÌ›· Î·È ‚ÂÏÙÈÒÓÔÓÙ·˜ ÙËÓ ·Ú·ÁˆÁ‹ ηÏÛÈÙÚÈfiÏ˘. Δ· ›‰· Ù˘ ƒΔ∏ ÌÂÈÒÓÔÓÙ·È ÚÔԉ¢ÙÈο ηٿ ÙÔ˘˜ ÚÒÙÔ˘˜ 3-6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¡ª. øÛÙfiÛÔ, Û ÔÏÏÔ‡˜ ·ÛıÂÓ›˜ Ô ¢À¶£ ‰ÂÓ ˘Ô¯ˆÚ› Ï‹Úˆ˜. OÈ ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ¢ı‡ÓÔÓÙ·È ÁÈ· ·˘Ùfi Â›Ó·È Ë ‰È¿ÚÎÂÈ· ·ÈÌÔοı·ÚÛ˘, ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ¶∞ Î·È Ë ·Ó¿Ù˘ÍË Ô˙Ò‰Ô˘˜ ‹/Î·È ÌÔÓÔÎψÓÈ΋˜ ˘ÂÚÏ·Û›·˜ ÙˆÓ ¶∞. ∂ÈϤÔÓ, Ë ÌÂȈ̤ÓË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, Ù· ÌÂȈ̤ӷ ›‰· ηÏÛÈÙÚÈfiÏ˘ Î·È Ë ÌÂȈ̤ÓË ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘ Ô˘ ÚÔηÏÔ‡Ó Ù· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Ô‰ËÁÔ‡Ó Û ‰È·Ù‹ÚËÛË ˘„ËÏÒÓ ÂȤ‰ˆÓ ƒΔ∏. ∏ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· ÌÂÙ¿ ·fi ¡ª Â›Ó·È Û˘¯Ó‹ Î·È ÔÊ›ÏÂÙ·È Û˘Ó‹ıˆ˜ Û ÂÌ̤ÓÔÓÙ· ¢À¶£. Δ· ˘„ËÏ¿ ›‰· ƒΔ∏ ‰ÈÂÁ›ÚÔ˘Ó ÙË ÓÂÊÚÈ΋ ·Ú·ÁˆÁ‹ ηÏÛÈÙÚÈfiÏ˘, Ë ÔÔ›· Ì ÙË ÛÂÈÚ¿ Ù˘ ·˘Í¿ÓÂÈ ÙËÓ ÂÓÙÂÚÈ΋ ·ÔÚÚfiÊËÛË ·Û‚ÂÛÙ›Ô˘. ∏ ‰ÈfiÚıˆÛË Ù˘ Ô˘Ú·ÈÌ›·˜ Î·È Ë ·ÔηٿÛÙ·ÛË ÙˆÓ ÂȤ‰ˆÓ ʈÛÊfiÚÔ˘ Ô‰ËÁÔ‡Ó Û ˘Ô¯ÒÚËÛË Ù˘ ·ÓÙ›ÛÙ·Û˘ ÛÙË ‰Ú¿ÛË Ù˘ ƒΔ∏ ÛÙÔ ÛÎÂÏÂÙfi. ∏ ·ÔÚÚfiÊËÛË Â·Û‚ÂÛÙÒÛÂˆÓ ÙˆÓ Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ ÌÔÚ› ›Û˘ Ó· Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· ÌÂÙ¿ ·fi ¡ª. ∏ ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· Ô˘ ÂÌÊ·Ó›˙ÂÙ·È ÌÂÙ¿ ·fi ¡ª Â›Ó·È Û˘Ó‹ıˆ˜ ·ÚÔ‰È΋ Î·È ÁÂÓÈο ˘Ô¯ˆÚ› ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ¡ª. øÛÙfiÛÔ, Û Ôχ ÌÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ë ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· ÂÈ̤ÓÂÈ ¤Ú·Ó ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜, ·ÏÏ¿ ˘Ô¯ˆÚ› ÛÙ·‰È·Î¿ ÌÂÙ¿ ·fi 2-5 ¤ÙË. ∏ ‹È· ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›· Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ ηϿ ·ÓÂÎÙ‹ Î·È ‰ÂÓ ÚÔηÏ› ÂÈÏÔΤ˜. ™Â ÌÈ· ÚÔÔÙÈ΋ ÌÂϤÙË Û 21 ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ ÛÙÔ πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ (π°¡£), ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÔÈ ÙÈ̤˜ Ù˘ ƒΔ∏ ÌÂÈÒÓÔÓÙ·È ÛËÌ·ÓÙÈο ÌÂÙ¿ ÙË ¡ª.
107
108
™. NTOBA™
∏ ̤ÛË ÙÈÌ‹ ƒΔ∏ ÚÈÓ ÙË ¡ª ‹Ù·Ó 181±170 pg/ml, ÙÔÓ ‰Â‡ÙÂÚÔ Ì‹Ó· ÌÂÙ¿ ÙË ¡ª 67±57 pg/ml (p<0.05) Î·È ÛÙÔ˘˜ 12 Ì‹Ó˜ 64±45 pg/ml (p<0.05). ¶·Ú¿ ÙËÓ Û·Ê‹ ‚ÂÏÙ›ˆÛË ÙÔ˘ ¢À¶£, 35% Î·È 29% ÙˆÓ ·ÛıÂÓÒÓ Â›¯Â ›‰· ƒΔ∏ ˘„ËÏfiÙÂÚ· ÙÔ˘ ·ÓÒÙÂÚÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÛÙÔ˘˜ 6 Î·È 12 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ ›‰È· ÌÂϤÙË ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÔÈ ÙÈ̤˜ ÙÔ˘ ·Û‚ÂÛÙ›Ô˘ ·˘Í¿ÓÔÓÙ·È ÛËÌ·ÓÙÈο ÌÂÙ¿ ÙË ¡ª. ∏ ̤ÛË ÙÈÌ‹ ·Û‚ÂÛÙ›Ô˘ ÚÈÓ ÙË ¡ª ‹Ù·Ó 9.2±0.9 mg/dl ÂÓÒ ÙÔÓ ÚÒÙÔ Ì‹Ó· ÌÂÙ¿ ÙË ¡ª 9.7±0.9 mg/dl Î·È ÛÙÔ˘˜ 12 Ì‹Ó˜ 9.9±0.6 mg/dl (p=0.02 Î·È p=0.01 ·ÓÙ›ÛÙÔȯ·). ÀÂÚ·Û‚ÂÛÙÈ·ÈÌ›· (>10.4 mg/dl) ÂÌÊ¿ÓÈÛ ÙÔ 33% ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ ÌÂÙ¿ ÙË ¡ª, ÂÓÒ ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÌÂÈÒıËΠ۠5% ÛÙÔ˘˜ 12 Ì‹Ó˜. ∂ÈϤÔÓ, ·fi ÙË ÌÂϤÙË 72 ·ÛıÂÓÒÓ Ì ̷ÎÚÔ¯ÚfiÓÈ· ¡ª (>12 Ì‹Ó˜) Î·È Î·Ï‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ≤2 mg/dl) ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÌfiÓÔ ÙÔ 40% ·˘ÙÒÓ Â›¯Â ›‰· ƒΔ∏ ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ ÂÓÒ ÔÛÔÛÙfi 20% ›¯Â ›‰· ƒΔ∏ ˘„ËÏfiÙÂÚ· ÙÔ˘ ‰ÈÏ¿ÛÈÔ˘ ÙÔ˘ ·ÓÒÙÂÚÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚ›Ô˘. Δ· ›‰· Ù˘ ƒΔ∏ ÚÈÓ ÙË ¡ª Û¯ÂÙÈ˙fiÙ·Ó Ì ÂΛӷ ÌÂÙ¿ ÙË ¡ª (r=0.389, p=0.006). ∏ ‚·Ú‡ÙËÙ·, ‰ËÏ·‰‹, ÙÔ˘ ÚÔ¸¿Ú¯ÔÓÙÔ˜ ¢À¶£ Ê·›ÓÂÙ·È Ó· ηıÔÚ›˙ÂÈ ÙËÓ ÂÈÌÔÓ‹ ÙÔ˘ ÌÂÙ¿ ÙË ¡ª. ∞ÔÙ¤ÏÂÛÌ· ÙÔ˘ ÂÌ̤ÓÔÓÙÔ˜ ¢À¶£ Â›Ó·È Ë ˘ÂÚ·Û‚ÂÛÙÈ·ÈÌ›·. Δ· ›‰· ƒΔ∏ ÌÂÙ¿ ÙË ¡ª Û¯ÂÙÈ˙fiÙ·Ó Ì ٷ ›‰· ·Û‚ÂÛÙ›Ô˘ (r=0.450, p<0.001).
ÀÔʈÛÊ·Ù·ÈÌ›· ∏ ˘ÔʈÛÊ·Ù·ÈÌ›· Â›Ó·È Ôχ Û˘¯Ó‹ ÌÂÙ¿ ·fi ¡ª. ∫·Ù¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ·fi ¡ª ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ ÂÌÊ·Ó›˙Ô˘Ó Ì¤ÙÚÈÔ˘ ‚·ıÌÔ‡ ˘ÔʈÛÊ·Ù·ÈÌ›· (0.9-2.25 mg/dl), Ë ÔÔ›· ÔÊ›ÏÂÙ·È Û ˘ÂÚʈÛÊ·ÙÔ˘Ú›·, ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂÏ·Ùو̤Ó˘ ·ӷÚÚfiÊËÛ˘ ʈÛÊfiÚÔ˘ ·fi ÙÔ ÓÂÊÚÒÓ·. ∏ ·˘ÍË̤ÓË ·¤ÎÎÚÈÛË ÊˆÛÊfiÚÔ˘ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ Î·È ÔÊ›ÏÂÙ·È Û ÂÌ̤ÓÔÓÙ· ¢À¶£, Û ڈÙÔ·ı‹ ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë, ·ÏÏ¿ Î·È ÛÙ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Î·È Ù· ‰ÈÔ˘ÚËÙÈο. ŸÙ·Ó Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Î·Ï‹, Ë ÂÏ¿ÙÙˆÛË Ù˘ ƒΔ∏ Î·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ÛˆÏËÓ·Úȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ô‰ËÁÔ‡Ó Û ·ÔηٿÛÙ·ÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ʈÛÊfiÚÔ˘, Ï›ÁÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ÙË ¡ª ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜. ∏ ‹È· ˘ÔʈÛÊ·Ù·ÈÌ›· Ô˘ ÂÈ̤ÓÂÈ ÌÂÙ¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ¡ª ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÂÌ̤ÓÔÓÙÔ˜ ¢À¶£. ªÂÁ¿ÏÔ
ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ë ·Ó·Î¿Ï˘„Ë ÙˆÓ ÊˆÛÊ·ÙÔÓÈÓÒÓ, ÔÚÌÔÓÒÓ Ô˘ ÚÔηÏÔ‡Ó ÊˆÛÊ·ÙÔ˘Ú›· ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ƒΔ∏. ™Â ÚÔÔÙÈ΋ ÌÂϤÙË ÛÙÔ π°¡£ ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÔÈ ÙÈ̤˜ ÙÔ˘ ʈÛÊfiÚÔ˘ ÌÂÈÒÓÔÓÙ·È ÛËÌ·ÓÙÈο ÌÂÙ¿ ÙË ¡ª. ∏ ̤ÛË ÙÈÌ‹ ʈÛÊfiÚÔ˘ ÚÈÓ ÙË ¡ª ‹Ù·Ó 5.6±1.7 mg/dl, ÙÔÓ ÚÒÙÔ Ì‹Ó· ÌÂÙ¿ ÙË ¡ª 2.9±0.7 mg/dl (p<0.001), ÂÓÒ ÛÙ·‰È·Î¿ ·˘Í‹ıËÎÂ Î·È ÛÙÔ˘˜ 12 Ì‹Ó˜ ‹Ù·Ó 3.8±0.7 mg/dl (p<0.001). ¶·ÚÔ‰È΋ ˘ÔʈÛÊ·Ù·ÈÌ›· (<2.5 mg/dl) ÂÌÊ¿ÓÈÛ ÙÔ 43% ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ¡ª. Δ· ›‰· ÙÔ˘ ʈÛÊfiÚÔ˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙË ÛˆÏËÓ·Úȷ΋ ·ӷÚÚfiÊËÛ‹ ÙÔ˘ (TmPO4/GFR) (r=0.850, p<0.001). ∏ ̤ÛË ÙÈÌ‹ ƒΔ∏ ÌÂÙ¿ ÙË ¡ª Û¯ÂÙÈ˙fiÙ·Ó Ì ÙȘ ÙÈ̤˜ ÙÔ˘ ʈÛÊfiÚÔ˘ ÚÒÈÌ· ÌÂÙ¿ ÙË ¡ª (r=-0.579, p=0.007), ·ÏÏ¿ Î·È Ì ÙËÓ ÎÏ·ÛÌ·ÙÈ΋ ·¤ÎÎÚÈÛË ÙÔ˘ ʈÛÊfiÚÔ˘ (r=0.591, p=0.02).
ºˆÛÊ·ÙÔÓ›Ó˜ Œ¯ÂÈ ‰È·ÈÛÙˆı› ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ ‹ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ á∞ Ë ‡·ÚÍË ÔÚÌÔÓÒÓ, ÔÈ Ôԛ˜ ‰È·Ê¤ÚÔ˘Ó ·fi ÙËÓ ƒΔ∏, ÂÓÒ ÌÔÚ› Ó· ·Ú·Ì¤ÓÔ˘Ó Û ˘„ËÏ¿ ›‰· ·ÎfiÌË Î·È ÌÂÙ¿ ·fi ÂÈÙ˘¯‹ ¡ª. OÈ ÔÚÌfiÓ˜ ·˘Ù¤˜ ıˆÚÔ‡ÓÙ·È ˘Â‡ı˘Ó˜ ÁÈ· ÙË ‰È·Ù·Ú·¯‹ Ù˘ ÛˆÏËÓ·Úȷ΋˜ ·ӷÚÚfiÊËÛ˘ ÙÔ˘ ʈÛÊfiÚÔ˘ ÌÂÙ¿ ·fi ¡ª. ∂›Û˘, ÂÌϤÎÔÓÙ·È ·ıÔÁÂÓÂÙÈο Û ‰È·Ù·Ú·¯¤˜ Ì «ÓÂÊÚÈ΋ ·ÒÏÂÈ· ʈÛÊfiÚÔ˘», fiˆ˜ Ë ÔÛÙÂÔ̷ϷΛ· Ô˘ ÔÊ›ÏÂÙ·È Û fiÁÎÔ (tumor induced osteomalacia, TIO), Ë ÃÊ˘ÏÔÛ‡Ó‰ÂÙË ˘ÔʈÛÊ·Ù·ÈÌÈ΋ Ú·¯›Ùȉ· (Xlinked hypophosphatemic rickets, XLHR) Î·È Ë ÂÈÎÚ·ÙÔ‡Û· ·˘ÙÔۈ̷ÙÈ΋ ˘ÔʈÛÊ·Ù·ÈÌÈ΋ Ú·¯›Ùȉ· (autosomal-dominant hypophosphatemic rickets, ADHR). ∞˘Ù‹ Ë Ó¤· ÔÌ¿‰· Ú˘ıÌÈÛÙÈÎÒÓ ÙÔ˘ ʈÛÊfiÚÔ˘ ÔÚÌÔÓÒÓ, Ô˘ fï˜ ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ƒΔ∏, ¤¯ÂÈ ÔÓÔÌ·ÛÙ› «ÊˆÛÊ·ÙÔÓ›Ó˜». O FGF-23 Â›Ó·È ÌÈ· ·fi ÙȘ ÈÔ Î·Ï¿ ÌÂÏÂÙË̤Ó˜ ʈÛÊ·ÙÔÓ›Ó˜ Î·È ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ TIO, Ù˘ XLHR Î·È Ù˘ ADHR. ¶ÚÔηÏ› ʈÛÊ·ÙÔ˘Ú›· Î·È ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ 1-· ˘‰ÚÔÍ˘Ï¿ÛË Ô‰ËÁÒÓÙ·˜ Û ÌÂȈ̤ÓË Û‡ÓıÂÛË Î·ÏÛÈÙÚÈfiÏ˘. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÛÂ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· ¤¯Ô˘Ó ·Ô‰Â›ÍÂÈ ÙÔÓ ÚfiÏÔ ÙÔ˘ FGF-23 ÛÙËÓ ÔÌÔÈfiÛÙ·ÛË ÙÔ˘ ʈÛÊfiÚÔ˘. ™Â ÌÈ· ÌÂϤÙË, ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘ FGF-23 ÌÂÈÒıËÎ·Ó ÛËÌ·ÓÙÈο ÛÂ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ· Ô˘ ÂÏ¿Ì‚·Ó·Ó
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
‰›·ÈÙ· ¯·ÌËÏ‹ Û ÊÒÛÊÔÚÔ, ÂÓÒ ·˘Í‹ıËÎ·Ó ÌÂÙ¿ ·fi ÙËÓ ÚÔÛı‹ÎË ÊˆÛÊfiÚÔ˘ ÛÙË ‰›·ÈÙ·. ∞˘Ù¤˜ ÔÈ ·ÏÏ·Á¤˜ ‹Ù·Ó ·ÓÂÍ¿ÚÙËÙ˜ ÙˆÓ ÂȤ‰ˆÓ ƒΔ∏. ∏ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ FGF-23 ·˘Í¿ÓÂÈ ÚÔԉ¢ÙÈο Ì ÙËÓ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Â›Ó·È Ë Ì¤ÁÈÛÙË Û ·ÛıÂÓ›˜ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ á∞. ÀÔÛÙËÚ›˙ÂÙ·È fiÙÈ ·˘Ù‹ Ë ·‡ÍËÛË ÙÔ˘ FGF-23 ·ÔÙÂÏ› ÚÔÛ·ÚÌÔÛÙÈÎfi Ì˯·ÓÈÛÌfi ÁÈ· ÙË Ú‡ıÌÈÛË ÙÔ˘ ʈÛÊfiÚÔ˘. ∂ÈϤÔÓ, ˘¿Ú¯ÂÈ ÌÈ· ·ÓÙ›ÛÙÚÔÊË Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ ʈÛÊfiÚÔ˘, ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ FGF-23 Î·È Ù˘ 1,25(O∏)2D3 ÛÂ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ·. ¶Ú¿ÁÌ·ÙÈ, ˘¿Ú¯Ô˘Ó ‚ÈÔ¯ËÌÈΤ˜ Î·È Ê·ÈÓÔÙ˘ÈΤ˜ ÔÌÔÈfiÙËÙ˜ ÌÂٷ͇ ›ÎÙËÙˆÓ Î·È Û˘ÁÁÂÓÒÓ ‰È·Ù·Ú·¯ÒÓ ÓÂÊÚÈ΋˜ ·ÒÏÂÈ·˜ ʈÛÊfiÚÔ˘ Î·È Ù˘ ˘ÔʈÛÊ·Ù·ÈÌ›·˜ ÌÂÙ¿ ·fi ¡ª. ∞˘Ù¤˜ Â›Ó·È Ë ¯·ÌËÏ‹ Û˘ÁΤÓÙÚˆÛË ÊˆÛÊfiÚÔ˘ ÛÙÔÓ ÔÚfi, Ë ÂÏ·Ùو̤ÓË TmP/GFR (·˘ÍË̤ÓË ·¤ÎÎÚÈÛË ÊˆÛÊfiÚÔ˘), Ë Û¯ÂÙÈ΋ ¤Ó‰ÂÈ· 1,25(O∏)2D3 Î·È Ë ÔÛÙÂÔ̷ϷΛ·. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Â›Ó·È ÏÔÁÈÎfi Ó· ˘Ôı¤ÛÂÈ Î·Ó›˜ fiÙÈ Ô FGF-23 (‹ ¿ÏϘ ʈÛÊ·ÙÔÓ›Ó˜) ·Ú·Ì¤ÓÂÈ ÌÂÙ¿ ÙË ¡ª Î·È ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ˘ÔʈÛÊ·Ù·ÈÌ›·˜. ™Â ÌÈ· ÚfiÛÊ·ÙË ÌÂϤÙË, Ô FGF-23 Û¯ÂÙÈ˙fiÙ·Ó Ì ٷ ›‰· ÙÔ˘ ʈÛÊfiÚÔ˘, ÙËÓ ·¤ÎÎÚÈÛË ÙÔ˘ ʈÛÊfiÚÔ˘ Î·È Ù· ›‰· ηÏÛÈÙÚÈfiÏ˘. Δ· ›ÌÔÓ· ·˘ÍË̤ӷ ›‰· FGF-23 ÛÙËÓ ÚÒÈÌË ÂÚ›Ô‰Ô ÌÂÙ¿ ÙË ¡ª Î·È fi¯È Ë ƒΔ∏ Ê¿ÓËÎ·Ó Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ˘ÔʈÛÊ·Ù·ÈÌ›· ÌÂÙ¿ ÙË ¡ª. ∞fi ÙËÓ ÚÔÔÙÈ΋ ÌÂϤÙË Û ¡ª ‰È·ÈÛÙÒÛ·Ì fiÙÈ Ù· ›‰· ÙÔ˘ ·Î¤Ú·ÈÔ˘ ÌÔÚ›Ô˘ ÙÔ˘ FGF-23 ÌÂÈÒÓÔÓÙ·È ı·̷ÙÈο (ηٿ 89%) ÌÂÙ¿ ·fi ÂÈÙ˘¯‹ ¡ª Î·È ·Ú·Ì¤ÓÔ˘Ó ¯·ÌËÏ¿ ÙÔ˘˜ ÚÒÙÔ˘˜ 12 Ì‹Ó˜ (ÚÈÓ ÙË ¡ª: 346±146 pg/ml, 3 Ì‹Ó˜: 37±19 pg/ml (p=0.001), 3-12 Ì‹Ó˜: ÛÙ·ıÂÚ¿ ›‰·). Δ· ›‰· ÙÔ˘ FGF-23 ÚÈÓ ÙË ¡ª Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ ›‰· ÙÔ˘ ʈÛÊfiÚÔ˘ ÚÒÈÌ· ÌÂÙ¿ ÙË ¡ª (r=-0.745, p<0.005). ¢ÂÓ ‰È·ÈÛÙÒÛ·ÌÂ Û˘Û¯¤ÙÈÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ FGF-23 Ì ٷ ›‰· ηÏÛÈÙÚÈfiÏ˘ ÌÂÙ¿ ÙË ¡ª.
BÈÙ·Ì›ÓË D Δ· ›‰· Ù˘ 1,25(O∏)2D3 ·˘Í¿ÓÔÓÙ·È ÁÚ‹ÁÔÚ· ÌÂÙ¿ ÙË ¡ª. ∞fi ÙË ÌÂϤÙË Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ ÛÙÔ π°¡£ ‰È·ÈÛÙÒÛ·Ì ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ 1,25(O∏) 2 D 3 ·fi 18.5±6.7 pg/ml ÚÈÓ ÙË ¡ª Û 34.6±14.3 pg/ml ÛÙÔ˘˜ 3 Ì‹Ó˜ (p<0.05). ªfiÓÔ 10% ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ¿ÓÈÛ ¤ÏÏÂÈ„Ë 1,25(O∏)2D3 (›‰· <20 pg/ml). Δ· Â-
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›Â‰· Ù˘ 25(O∏)D3 ·ÓÙ›ıÂÙ· ‰ÂÓ ÂÌÊ¿ÓÈÛ·Ó ÛËÌ·ÓÙÈ΋ ÌÂÙ·‚ÔÏ‹ ÌÂÙ¿ ÙË ¡ª (37.5±23.4 ng/ml ÚÈÓ ÙË ¡ª Î·È 29.9±10.9 ng/ml 3 Ì‹Ó˜ ÌÂÙ¿, p=NS). ¶ÔÛÔÛÙfi 30% ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ¿ÓÈÛ ·Ó¿ÚÎÂÈ· 25(O∏)D 3 (›‰· 10-30 ng/ml). ™Â Ì·ÎÚÔ¯ÚfiÓÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ (>12 Ì‹Ó˜) Ì ηϋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ≤2 mg/dl) ÌfiÓÔ 8% ÙˆÓ ·ÛıÂÓÒÓ Â›¯Â ¤ÏÏÂÈ„Ë 1,25(O∏)2D3 (›‰· <20 pg/ml). Δ· ›‰· 1,25(O∏)2D3 Û¯ÂÙÈ˙fiÙ·Ó Ì ÙËÓ ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ (r=-0.308, p=0.025). ŸÛÔÓ ·ÊÔÚ¿ Ù· ›‰· Ù˘ 25(O∏)D3, ÙÔ 40% ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ¿ÓÈ˙ ¿ÚÎÂÈ·, ÙÔ 57% ÂÌÊ¿ÓÈ˙ ·Ó¿ÚÎÂÈ·, ÂÓÒ 3% ÂÌÊ¿ÓÈ˙ ¤ÏÏÂÈ„Ë.
∞ÒÏÂÈ· ÔÛÙÈ΋˜ Ì¿˙·˜ ÌÂÙ¿ ·fi ¡ª ∏ ·ÒÏÂÈ· ÔÛÙÈ΋˜ Ì¿˙·˜ ·Ú¯›˙ÂÈ ÓˆÚ›˜ ÌÂÙ¿ ÙË ¡ª, ·ÊÔÚ¿ ΢ڛˆ˜ ÙÔ ÛÔÁÁ҉˜ ÔÛÙfi Î·È Â›Ó·È Ù·¯‡ÙÂÚË ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜. ∏ ÔÛÙÈ΋ Ì¿˙· ÛÙ·ıÂÚÔÔÈÂ›Ù·È ‹ ·ÎfiÌ· Ù›ÓÂÈ Ó· ·˘ÍËı› ÛÙÔ˘˜ 12 Ì‹Ó˜. ™Â Ì·ÎÚÔ¯ÚfiÓÈ·, ›Û˘, ¡ª Ì ÛÙ·ıÂÚ‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ¤¯ÂÈ Ê·Ó› ¤Ó·˜ ‚Ú·‰‡ÙÂÚÔ˜, ·ÏÏ¿ ÛËÌ·ÓÙÈÎfi˜ Ú˘ıÌfi˜ ·ÒÏÂÈ·˜ ÔÛÙÈ΋˜ Ì¿˙·˜. ∏ ΢ÚÈfiÙÂÚË ·ÈÙ›· ·ÒÏÂÈ·˜ ÔÛÙÈ΋˜ Ì¿˙·˜ ÌÂÙ¿ ·fi ¡ª Â›Ó·È Ë ıÂڷ›· Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹. ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ·ÒÏÂÈ· ÔÛÙÈ΋˜ Ì¿˙·˜ ÌÂÙ¿ ·fi ¡ª Â›Ó·È Ë Î˘ÎÏÔÛÔÚ›ÓË, Ô ¢À¶£ Î·È Èı·Ó¿ ÔÈ ÔÏ˘ÌÔÚÊÈÛÌÔ› ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ‚ÈÙ·Ì›Ó˘ D. Δ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙÔ Û¯ËÌ·ÙÈÛÌfi ÔÛÙÔ‡ Î·È ÙËÓ ˆÚ›Ì·ÓÛË ÙˆÓ ÔÛÙÂÔ‚Ï·ÛÙÒÓ Î·È ÚÔηÏÔ‡Ó ·fiÙˆÛË ÙˆÓ ÔÛÙÂÔ‚Ï·ÛÙÒÓ Î·È ÙˆÓ ÔÛÙÂÔ΢ÙÙ¿ÚˆÓ. ∂Ï·ÙÙÒÓÔ˘Ó ÙËÓ ·ÔÚÚfiÊËÛË ÙÔ˘ ·Û‚ÂÛÙ›Ô˘, Ô‰ËÁÒÓÙ·˜ Û ·ÚÓËÙÈÎfi ÈÛÔ˙‡ÁÈÔ Î·È ¢À¶£. ∂ÈϤÔÓ, ηٷÛÙ¤ÏÏÔ˘Ó ¿ÌÂÛ· ÙȘ ÁÔÓ·‰ÔÙÚÔ›Ó˜ Î·È ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ˘ÔÁÔÓ·‰ÈÛÌfi. O ÚfiÏÔ˜ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ÛÙË ¡O¢ ÌÂÙ¿ ·fi ¡ª ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛÙ› Ï‹Úˆ˜. πÛÙÔÌÔÚÊÔÌÂÙÚÈο ‰Â‰Ô̤ӷ Û ̷ÎÚÔ¯ÚfiÓÈ· ¡ª Ì ΢ÎÏÔÛÔÚ›ÓË ‰Â›¯ÓÔ˘Ó ·˘ÍË̤ÓË ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÔÛÙÂÔÎÏ·ÛÙÒÓ, ηٷÛÙÔÏ‹ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÔÛÙÂÔ‚Ï·ÛÙÒÓ Î·È Î·ı˘ÛÙ¤ÚËÛË ÛÙÔ Û¯ËÌ·ÙÈÛÌfi ÔÛÙÔ‡, ·ÓÂÍ¿ÚÙËÙ· ·fi Ù· ›‰· ƒΔ∏. O ÚÔ¸¿Ú¯ˆÓ ¢À¶£ ÂÌÊ·Ó›˙ÂÈ ¿ÌÂÛË Û˘Û¯¤ÙÈÛË Ì ÙÔ ‚·ıÌfi Ù˘ ÚÒÈÌ˘ ·ÒÏÂÈ·˜ ÔÛÙÈ΋˜ Ì¿˙·˜ ÌÂÙ¿ ÙË ¡ª. ¶¿Ú·˘Ù·, Û ̷ÎÚÔ¯ÚfiÓÈ· ¡ª ‰ÂÓ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ ƒΔ∏ Î·È Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ‹ ‰È¿ÊÔÚ˜ ÈÛÙÔÌÔÚÊÔÌÂÙÚÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜. Δ¤ÏÔ˜, ¤-
110
™. NTOBA™
¯ÂÈ ‚ÚÂı› fiÙÈ ÔÈ ÔÏ˘ÌÔÚÊÈÛÌÔ› ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ‚ÈÙ·Ì›Ó˘ D ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ Ú˘ıÌfi ·ÒÏÂÈ·˜ ÔÛÙÈ΋˜ Ì¿˙·˜ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ Ù˘ ¡ª. ∞ÔÙ¤ÏÂÛÌ· Ù˘ ·˘ÍË̤Ó˘ ·ÒÏÂÈ·˜ ÔÛÙÈ΋˜ Ì¿˙·˜ Â›Ó·È Ô ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÁÌ¿ÙˆÓ. ªÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÂÌÊ·Ó›˙Ô˘Ó ÔÈ ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ π Î·È ÔÈ ÌÂÙÂÌÌËÓÔ·˘ÛȷΤ˜ Á˘Ó·›Î˜. ¶¿Ú·˘Ù·, Ë Ì¤ÙÚËÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Èı·Ó¿ Ó· ÌËÓ ¤¯ÂÈ ÙËÓ ›‰È· ÚÔÁÓˆÛÙÈ΋ ·Í›· Ì ÙËÓ ÂÚ›ÙˆÛË Ù˘ ÌÂÙÂÌÌËÓÔ·˘Ûȷ΋˜ O¶, fiÔ˘ ˘¿Ú¯ÂÈ Û·Ê‹˜ Û˘Û¯¤ÙÈÛË ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Î·È Û˘¯ÓfiÙËÙ·˜ ηٷÁÌ¿ÙˆÓ. OÈ Î˘ÚÈfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ıÂڷ›· Ù˘ ·ÒÏÂÈ·˜ ÔÛÙÈ΋˜ Ì¿˙·˜ ÌÂÙ¿ ÙË ¡ª Â›Ó·È Ù· ‰ÈʈÛÊÔÓÈο Î·È ÔÈ ÂÓÂÚÁÔ› ÌÂÙ·‚Ôϛ٘ Ù˘ ‚ÈÙ·Ì›Ó˘ D. ∏ ıÂڷ›· Ì ‰ÈʈÛÊÔÓÈο ‰È·ÙËÚ› ÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· ÙfiÛÔ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ÙË ¡ª fiÛÔ Î·È Û ̷ÎÚÔ¯ÚfiÓÈ· ¡ª, ÂÓÒ ÔÈ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ Ï·Ì‚¿ÓÔ˘Ó ıÂڷ›· ÂÌÊ·Ó›˙Ô˘Ó ·ÒÏÂÈ· ÔÛÙÈ΋˜ Ì¿˙·˜. º·›ÓÂÙ·È Ì¿ÏÈÛÙ· fiÙÈ Ë ıÂڷ›· Ì ‰ÈʈÛÊÔÓÈο ¤¯ÂÈ ÌÈ· ÂÏ·ÊÚÒ˜ ηχÙÂÚË Â›‰Ú·ÛË ·fi fiÙÈ Ë ıÂڷ›· Ì ηÏÛÈÙÚÈfiÏË ‹ ·ÏʷηÏÛȉfiÏË. ∏ ıÂڷ›· Ì ηÏÛÈÙÚÈfiÏË ‹ ·ÏʷηÏÛȉfiÏË Â›Ó·È Â›Û˘ ·ÓÒÙÂÚË Ù˘ ¯ÔÚ‹ÁËÛ˘ ÌfiÓÔÓ ·Û‚ÂÛÙ›Ô˘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·ÒÏÂÈ·˜ ÔÛÙÈ΋˜ Ì¿˙·˜ ÌÂÙ¿ ·fi ¡ª. ∏ ¯ÔÚ‹ÁËÛË ÂÓÂÚÁÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ Ù˘ ‚ÈÙ·Ì›Ó˘ D ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ ı¤ÛË ÛÙË ¡ª Î·È ÏfiÁˆ ÙÔ˘ ÂÌ̤ÓÔÓÙÔ˜ ¢À¶£ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÔÏÏÔ› ·ÛıÂÓ›˜, ·ÏÏ¿ Î·È Û ÂΛÓÔ˘˜ Ì ÂÏ·Ùو̤ÓË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ·Ó·Ú΋ ÂÓ‰ÔÁÂÓ‹ ·Ú·ÁˆÁ‹ ηÏÛÈÙÚÈfiÏ˘. ∏ fi„ÈÌË Â›Û˘ ·ÒÏÂÈ· ÔÛÙÈ΋˜ Ì¿˙·˜ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì ¯ÔÚ‹ÁËÛË ·ÏʷηÏÛȉfiÏ˘ ‹ ηÏÛÈÙÚÈfiÏ˘, ÔÈ Ôԛ˜ ˘ÂÚ¤¯Ô˘Ó Ù˘ ¯ÔÚ‹ÁËÛ˘ ·Û‚ÂÛÙ›Ô˘ ‹ Ù˘ ÌË ¯ÔÚ‹ÁËÛ˘ ıÂڷ›·˜ (ÂȉÈο ÛÙËÓ ÔÛÊ˘˚΋ ÌÔ›Ú· Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘ (Oª™™)). ÕÁÓˆÛÙÔ Û οı ÂÚ›ÙˆÛË ·Ú·Ì¤ÓÂÈ ·Ó Ù· ÔÛÔÛÙ¿ ηٷÁÌ¿ÙˆÓ ÂËÚ¿˙ÔÓÙ·È ·fi ÙËÓ ıÂڷ›·. ™Â ÌÈ· ÌÂϤÙË 72 ·ÛıÂÓÒÓ Ì ̷ÎÚÔ¯ÚfiÓÈ· ¡ª (>12 Ì‹Ó˜) Î·È Î·Ï‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ≤2 mg/dl), ‰È·ÈÛÙÒÛ·Ì fiÙÈ 79% ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ¿ÓÈ˙ ÔÛÙÂÔÂÓ›· (T score <-1) ÛÙËÓ Oª™™ Î·È 91% ÛÙÔÓ ·˘¯¤Ó· ÙÔ˘ ÌËÚÈ·›Ô˘ ÔÛÙÔ‡. ∏ ÔÛÙÂÔÂÓ›· Û ÔÔÈÔ‰‹ÔÙ ÛËÌÂ›Ô (Oª™™ ‹ ·˘¯¤Ó·˜ ÌËÚÈ·›Ô˘) ·Ó¤Ú¯ÔÓÙ·Ó Û 97%. OÛÙÂÔfiÚˆÛË (T score <-2.5) Û ÔÔÈÔ‰‹ÔÙ ÛËÌÂ›Ô ÂÌÊ¿ÓÈ˙ ÙÔ 45% ÙˆÓ ·ÛıÂÓÒÓ. ¢ÂÓ ˘‹Ú¯Â ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· (T
score) Û ۯ¤ÛË Ì ÙÔ Ê‡ÏÔ ÛÙËÓ Oª™™ (¿Ó‰Ú˜ 1.7±0.8 vs Á˘Ó·›Î˜ -1.9±1.0, p=NS), ·ÏÏ¿ ÛÙÔÓ ·˘¯¤Ó· ÙÔ˘ ÌËÚÈ·›Ô˘ ÔÈ Á˘Ó·›Î˜ ›¯·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· (-2.0±0.7 vs 2.5±1.0, p=0.021). OÈ ÌÂÙÂÌÌËÓÔ·˘ÛȷΤ˜ Á˘Ó·›Î˜ ›¯·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· ÛÙÔÓ ·˘¯¤Ó· ÙÔ˘ ÌËÚÈ·›Ô˘ (-3.0±0.8 vs 2.0±1.1, p=0.025), ·ÏÏ¿ ÌfiÓÔ Ù¿ÛË ÁÈ· ¯·ÌËÏfiÙÂÚË ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· ÛÙËÓ Oª™™ (-2.1±1.2 vs 1.5±0.8, p=NS). ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÁÚ·ÌÌÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÙÔ Á˘Ó·ÈÎÂ›Ô Ê‡ÏÔ, Ë ÌÂÁ¿ÏË ËÏÈΛ·, Ë Ì·ÎÚ¿ ‰È¿ÚÎÂÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘, o ¯·ÌËÏfi˜ Ú˘ıÌfi˜ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (Cockroft-Gault) Î·È ÙÔ ¯·ÌËÏfi ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ (μ™) ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· O¶ Û ÔÔÈÔ‰‹ÔÙ ÛËÌ›Ô, Û ̷ÎÚÔ¯ÚfiÓÈ· ¡ª (ÌÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË). ™ÙËÓ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ‰È·ÈÛÙÒÛ·Ì fiÙÈ Ë ÌÂÁ¿ÏË ËÏÈΛ·, ÙÔ ¯·ÌËÏfi μ™ Î·È Ë Ï‹„Ë ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÚÈÓ ÙË ¡ª ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· O¶ Û ̷ÎÚÔ¯ÚfiÓÈ· ¡ª. ™ÙËÓ ·Ó¿Ï˘ÛË ÏÔÁÈÛÙÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, Ë ÌÂÁ¿ÏË ËÏÈΛ· Î·È ÙÔ ¯·ÌËÏfi μ™ ‚Ú¤ıËÎ·Ó Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ¯·ÌËÏ‹ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· ÛÙËÓ Oª™™, ÂÓÒ ÙÔ Á˘Ó·ÈÎÂ›Ô Ê‡ÏÔ Î·È Ë ÌÂÁ¿ÏË ËÏÈΛ· Û¯ÂÙÈ˙fiÙ·Ó Ì ¯·ÌËÏ‹ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· ÛÙÔÓ ·˘¯¤Ó· ÙÔ˘ ÌËÚÈ·›Ô˘. ™ÙËÓ ›‰È· ÌÂϤÙË, 45 ·fi ÙÔ˘˜ 72 ·ÛıÂÓ›˜ ›¯·Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÈ· ÚÔËÁÔ‡ÌÂÓË Ì¤ÙÚËÛË ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Ì DEXA. ™Â 25 ·ÛıÂÓ›˜ ¯ÔÚËÁÔ‡ÓÙ·Ó ·ÓÙÈÔÛÙÂÔÔÚˆÙÈ΋ ıÂڷ›· (14 ·ÛıÂÓ›˜ ÂÏ¿Ì‚·Ó·Ó ·ÏʷηÏÛȉfiÏË Ì ‹ ¯ˆÚ›˜ ·Û‚¤ÛÙÈÔ Î·È 11 ·ÛıÂÓ›˜ ÂÏ¿Ì‚·Ó·Ó ·ÏÂÓ‰ÚÔÓ¿ÙË, 3 ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·ÏʷηÏÛȉfiÏË). ∏ ¯ÔÚ‹ÁËÛË ıÂڷ›·˜ Ê¿ÓËΠfiÙÈ ·˘Í¿ÓÂÈ ÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· (T score) ÛÙËÓ Oª™™, ·Ó Î·È fi¯È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο (-2.0±1.2 vs 1.8±1.0, p=NS), ÂÓÒ ÔÈ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ÂÏ¿Ì‚·Ó·Ó ıÂڷ›· ÂÌÊ¿ÓÈÛ·Ó ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÛÙËÓ Oª™™ (-1.4±1.1 vs 1.8±0.8, p=0.026). ™ÙÔÓ ·˘¯¤Ó· ÙÔ˘ ÌËÚÈ·›Ô˘ ‰ÂÓ ˘‹Ú¯Â ÛËÌ·ÓÙÈ΋ ÌÂÙ·‚ÔÏ‹ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ (-2.1±1.1 vs 2.4±1.1, p=NS Î·È -1.6±1.1 vs -2.0±0.8, p=NS).
μÈ‚ÏÈÔÁÚ·Ê›· 1. Torres A, Lorenzo V, Salido E. Calcium metabolism and skeletal problems after transplantation. J Am Soc Nephrol 2002; 13:551-558.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
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∏ ·ıËÚÔÛÎÏËÚˆÙÈ΋ ηډȷÁÁÂȷ΋ ÓfiÛÔ˜ η ÔÈ ÂÈÏÔΤ˜ Ù˘ ·ÔÙÂÏÔ‡Ó ÙËÓ Î‡ÚÈ· ·ÈÙ›· Ù˘ ·˘ÍË̤Ó˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Î·È È‰È·›ÙÂÚ· ÂÎÂ›ÓˆÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∂›Ó·È fï˜ ηϿ ıÂÌÂÏȈ̤ÓÔ fiÙÈ, ÔÈ ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯Ô˘Ó ηχÙÂÚË ÂÈ‚›ˆÛË Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÈÌÔηı·ÈÚfiÌÂÓÔ˘˜ ·ÛıÂÓ›˜ Û ·Ó·ÌÔÓ‹ ÁÈ· ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜. ∏ ÛËÌ·ÓÙÈ΋ ·˘Ù‹ ‰È·ÊÔÚ¿ Â›Ó·È ¤Î‰ËÏË ·ÎfiÌË Î·È ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ηıÒ˜ ›Û˘ Î·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi ÌË È‰·ÓÈÎÔ‡˜ ‰fiÙ˜. ∂ÓÙÔ‡ÙÔȘ, ÔÈ Î·Ú‰È·ÁÁÂȷΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È Û˘¯Ó¤˜ Î·È ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È Ù· ηډȷÁÁÂȷο ÂÂÈÛfi‰È· ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ·ÔÙÂÏÔ‡Ó Ì¤¯ÚÈ Û‹ÌÂÚ· ÙËÓ Î˘ÚÈfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ŒÙÛÈ, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ı·Ó¿ÙˆÓ ·fi ηډȷÁÁÂȷο ·›ÙÈ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 17 ¤ˆ˜ 50% ÙˆÓ ÂÚÈÙÒÛˆÓ, ÂÓÒ Ë Â›ÙˆÛË Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È 3 ¤ˆ˜ 4 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Û ۇÁÎÚÈÛË Ì ÂΛÓË Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÏËı˘ÛÌÔ‡˜ ÂϤÁ¯Ô˘ ·ÚfiÌÔÈ·˜ ËÏÈΛ·˜. ∞ÔÙ¤ÏÂÛÌ· ÙˆÓ ·Ú·¿Óˆ Â›Ó·È Ô ÂÚÈÔÚÈÛÌfi˜ ÙˆÓ Ì·ÎÚÔ¯ÚfiÓÈˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi ¤Ó· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ·, ÂÎÙfi˜ ·fi ÙË ¯ÚfiÓÈ· ·fiÚÚÈ„Ë, ÙÔ ı¿Ó·ÙÔ ·ÛıÂÓÒÓ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì·. ΔÔ ÁÂÁÔÓfi˜ ·˘Ùfi ¤Ú¯ÂÙ·È Û ·ÓÙ›ıÂÛË Ì ÙËÓ ·Ú·ÙËÚÔ‡ÌÂÓË ÚfiÛÊ·Ù· ·‡ÍËÛË Ù˘ ‚Ú·¯‡¯ÚÔÓ˘ ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ÏfiÁˆ ÙˆÓ ‚ÂÏÙÈÒÛÂˆÓ ÛÙË ÁÂÓÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ÂÍÂÏ›ÍÂˆÓ ÛÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ÙÔ̤· Î·È È‰È·›ÙÂÚ· ÛÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ô˘ Ì›ˆÛ·Ó ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘. ™ËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ÙfiÛÔ Ë Î·Ú‰ÈÔÌ˘Ô¿ıÂÈ· (Û˘ÌÊÔÚËÙÈ΋ ηډȷ΋ ·Ó¿ÚÎÂÈ· Î·È ˘ÂÚÙÚÔÊ›· ·ÚÈÛÙÂÚ¿˜ ÎÔÈ-
Ï›·˜), fiÛÔ Î·È Ë ÈÛ¯·ÈÌÈ΋ ηډȷÁÁÂȷ΋ ÓfiÛÔ˜. ÀÂÚ˯ÔηډÈÔÁÚ·ÊÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Û˘ÌÊÔÚËÙÈ΋˜ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ ·Ó¢ڛÛÎÔÓÙ·È Û˘¯ÓfiÙÂÚ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ۇÁÎÚÈÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ Ë ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› ÂӉ¯fiÌÂÓ· ÌÈ· ηٿÛÙ·ÛË “ÂÈÙ·¯˘ÓfiÌÂÓ˘” ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜. ∞ÎfiÌË, ÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó 10ÂÙ‹ ·ıÚÔÈÛÙÈÎfi ΛӉ˘ÓÔ ÁÈ· ·Ó¿Ù˘ÍË ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ Ù˘ Ù¿Í˘ ÙÔ˘ 20%, ·ÚfiÌÔÈÔ ‰ËÏ·‰‹ Ì ÂΛÓÔÓ ÙˆÓ ·ÛıÂÓÒÓ Ì ÚÔ¸¿Ú¯Ô˘Û· ηډȷÁÁÂȷ΋ ÓfiÛÔ. ŒÙÛÈ, ÌÔÏÔÓfiÙÈ Ë ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ ‰Âȯı› fiÙÈ ÌÂÈÒÓÂÈ ÙËÓ ÂͤÏÈÍË ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ, ÛËÌ·ÓÙÈÎfi˜ ‚·ıÌfi˜ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ·Ú·Ì¤ÓÂÈ Î·È ÌÂÙ¿ ·fi ÙËÓ Â¤Ì‚·ÛË Î·È Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÂÈıÂÙÈο Û fiÏË ÙË ˙ˆ‹ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ·ÛıÂÓÔ‡˜. ™ÙËÓ ˘„ËÏ‹ ›وÛË ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Û˘Ì‚¿ÏÏÂÈ Ë ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· ÔÈÎ›ÏˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ηıÒ˜ Î·È Ë Â·‡ÍËÛË ÔÚÈÛÌ¤ÓˆÓ ·’ ·˘ÙÔ‡˜ ÌÂÙ¿ ·fi ÙËÓ Â¤Ì‚·ÛË. ∞Ó·Ì‚ÈÛ‚‹ÙËÙ·, ÛÙÔÓ Î·Ú‰È·ÁÁÂÈ·Îfi ΛӉ˘ÓÔ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ, fiˆ˜ Î·È ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi, ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ·›˙Ô˘Ó fiÏÔÈ ÔÈ Ì›˙ÔÓÙ˜ “·Ú·‰ÔÛÈ·ÎÔ›” ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘, Ë ÚÔ¯ˆÚË̤ÓË ËÏÈΛ·, ÙÔ Î¿ÓÈÛÌ·, Ù· ·˘ÍË̤ӷ ›‰· ÙˆÓ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ›ÓÒÓ (LDL) Î·È Ù· ÌÂȈ̤ӷ ›‰· ÙˆÓ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙ›ÓÒÓ (∏DL). ∂ÓÙÔ‡ÙÔȘ, Ë ·ÔÎÏÂÈÛÙÈ΋ ÂÈΤÓÙÚˆÛË ÛÙÔ˘˜ ·Ú·¿Óˆ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, Ô‰ËÁ› ÂӉ¯fiÌÂÓ· Û ˘ÔÂÎÙ›ÌËÛË ÙÔ˘ Ú·ÁÌ·ÙÈÎÔ‡ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÛÙÔÓ ÏËı˘ÛÌfi ·˘Ùfi ÙˆÓ ·ÛıÂÓÒÓ. ∞˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ ·Ó¢ڛÛÎÂÙ·È Î·È ¤Ó·˜ ·ÚÈıÌfi˜ “ÌË ·Ú·‰ÔÛÈ·ÎÒÓ” ‹ “Û¯ÂÙÈ˙fiÌÂÓˆÓ Ì ÙËÓ Ô˘Ú·È-
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ì›·” ·Ú·ÁfiÓÙˆÓ, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÚÈṲ̂ÓÔÈ ˘¿Ú¯Ô˘Ó Î·È ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Î·È ÔÈ ÔÔ›ÔÈ ÂÈÚÔÛı¤ÙÔ˘Ó ÛÙÔ Û˘ÓÔÏÈÎfi ηډȷÁÁÂÈ·Îfi ΛӉ˘ÓÔ. ªÂٷ͇ ·˘ÙÒÓ ÂÚÈÏ·‚¿ÓÔÓÙ·È ÔÈ ·ÁÁÂȷΤ˜ ·ۂÂÛÙÒÛÂȘ, Ë ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ë ·Ó·ÈÌ›·, Ë ˘ÂÚÊfiÚÙˆÛË Ì ˘ÁÚ¿, Ë ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹, ÙÔ ÔÍÂȉˆÙÈÎfi ÛÙÚ˜, Ë ˘ÂÚÔÌÔ΢ÛÙÂ˚Ó·ÈÌ›· Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡. Δ¤ÏÔ˜, ¤Ó· ÔÛÔÛÙfi ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤¯ÂÈ ·Ó·Ù˘Á̤ÓË Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ Ë ÔÔ›· Î·È ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο ÙÔÓ Î·Ú‰È·ÁÁÂÈ·Îfi ΛӉ˘ÓÔ ÌÂÙ¿ ·fi ÙËÓ Â¤Ì‚·ÛË. Δ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η ÂȉÚÔ‡Ó Û ‰È¿ÊÔÚÔ˘˜ ηıÈÂڈ̤ÓÔ˘˜ ηډȷÁÁÂÈ·ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ Â›Ó·È Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, Ë ˘ÂÚÏÈȉ·ÈÌ›·, Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Î·È Ë ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È Â·ÎfiÏÔ˘ı· Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙÔ Û˘ÓÔÏÈÎfi ηډȷÁÁÂÈ·Îfi ΛӉ˘ÓÔ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ. Δ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ÚÔηÏÔ‡Ó ÂÓ‰ÔıËÏȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ˘¤ÚÙ·ÛË, ˘ÂÚÏÈȉ·ÈÌ›· Î·È Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË. O ·Ó·ÛÙÔϤ·˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ΢ÎÏÔÛÔÚ›ÓË ÚÔηÏ› ›Û˘ ˘¤ÚÙ·ÛË, ˘ÂÚÏÈȉ·ÈÌ›· Î·È Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË, ÂÓÒ ÂÈϤÔÓ Â›Ó·È ÓÂÊÚÔÙÔÍÈÎfi˜. O Ù·ÎÚfiÏÈÌÔ˘˜, ¤Ó·˜ ¿ÏÏÔ˜ ·Ó·ÛÙÔϤ·˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘, ¤¯ÂÈ ÌÈÎÚfiÙÂÚË ‹ Î·È Î·ıfiÏÔ˘ ›‰Ú·ÛË ÛÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË Î·È ÛÙ· ÏÈȉȷ ÙÔ˘ ÔÚÔ‡ Î·È Â›Ó·È ÏÈÁfiÙÂÚÔ ÓÂÊÚÔÙÔÍÈÎfi˜, Û ۇÁÎÚÈÛË Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË, ·ÏÏ¿ ¤¯ÂÈ ‰È·‚ËÙÔÁfiÓÔ ‰Ú¿ÛË, ȉȷ›ÙÂÚ· ÛÙȘ ˘„ËÏfiÙÂÚ˜ ‰fiÛÂȘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙËÓ ¿ÌÂÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÚ›Ô‰Ô. ÂÓÒ ·ÎfiÌË ÔÈ ÂӉ¯fiÌÂÓ˜ ‰Ú¿ÛÂȘ ÙÔ˘ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙˆÓ ·ÁÁ›ˆÓ ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈṲ̂Ó˜. ΔÔ Ì˘ÎÔÊ·ÈÓÔÏÈÎfi Ô͇ ¯ÂÈ ÌÈÎÚ‹ ÌfiÓÔÓ Â›‰Ú·ÛË ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· ·ÏÏ¿ ÚÔηÏ› ·Ó·ÈÌ›· Ë ÔÔ›· ÂӉ¯fiÌÂÓ· Ô‰ËÁ› ¤ÌÌÂÛ· ÛÙËÓ ·Ó¿Ù˘ÍË ˘ÂÚÙÚÔÊ›·˜ Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜. O ·Ó·ÛÙÔϤ·˜ ÙÔ˘ ÛÙfi¯Ô˘ Ù˘ Ú··Ì˘Î›Ó˘, ÛÈÚfiÏÈÌÔ˘˜, ÚÔηÏ› ›Û˘ ·Ó·ÈÌ›·, ·ÏÏ¿ Â›Ó·È ˘ÔÛ¯fiÌÂÓÔ˜ ·Ú¿ÁÔÓÙ·˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ÔÚÈṲ̂Ó˜ ·ÓÙÈ·ıËÚÔÛÎÏËÚˆÙÈΤ˜ ‰Ú¿ÛÂȘ. ¶ÚÔηÏ› fï˜ ˘ÂÚÏÈȉ·ÈÌ›· Î·È Î·Ù¿ fiÛÔÓ ·˘Ù‹ ÂÍÔ˘‰ÂÙÂÚÒÓÂÈ ÙȘ ·Ú·¿Óˆ ¢ÂÚÁÂÙÈΤ˜ ‰Ú¿ÛÂȘ ÙÔ˘ ·Ú·Ì¤ÓÂÈ Â› ÙÔ˘ ·ÚfiÓÙÔ˜ ·‰È¢ÎÚ›ÓÈÛÙÔ. A˜ ÛËÌÂȈı› fiÙÈ, ÌÂϤÙ˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ‹ ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÁÂÓÈο ‚ÂÏÙ›ˆÛË ÔÚÈÛÌ¤ÓˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ Â›Ó·È Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, Ë ‰˘ÛÏÈȉ·ÈÌ›· Î·È Ë
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ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. ∂ÓÙÔ‡ÙÔȘ, Ù· ·Ú·¿Óˆ ˆÊ¤ÏË ¤¯Ô˘Ó Û˘¯Ó¿ Û˘Û¯ÂÙÈÛı› Ì ·˘ÍË̤ÓË Â›ÙˆÛË ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘, ÌÔÏÔÓfiÙÈ Ô Ú˘ıÌfi˜ Û˘ÓÔÏÈ΋˜ ·ÒÏÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ Î·È Ë ıÓËÙfiÙËÙ· ‰Â ÌÂÙ·‚Ï‹ıËÎ·Ó ÛËÌ·ÓÙÈο. ∞ÎfiÌË, ‰˘ÛÙ˘¯Ò˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ Ó· ·Ú¤¯Ô˘Ó ·fiÏ˘Ù˜ ÂӉ›ÍÂȘ Û¯ÂÙÈο Ì ÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. °ÂÓÈο fï˜, ·fi Ù· ˘¿Ú¯ÔÓÙ· ‰Â‰Ô̤ӷ Ê·›ÓÂÙ·È fiÙÈ: ÚÒÙÔÓ ÔÈ Î˘ÚÈfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ Â›Ó·È ·ÚfiÌÔÈÔÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Î·È ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi; ‰Â‡ÙÂÚÔÓ, ıÂڷ›˜ Ô˘ ·ÔÛÎÔÔ‡Ó ÛÙËÓ ÙÚÔÔÔ›ËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Ë ¯ÔÚ‹ÁËÛË ·Ó·ÛÙÔϤˆÓ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ‹ ·ÓÙ·ÁˆÓÈÛÙÒÓ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘, ÛÙ·ÙÈÓÒÓ Î·È ·ÛÈÚ›Ó˘ Î·È ÔÈ Ôԛ˜ ¤¯Ô˘Ó ·Ô‰Âȯı› ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi, ÂӉ¯fiÌÂÓ· Â›Ó·È ÂÍ›ÛÔ˘ ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ Î·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË; Î·È ÙÚ›ÙÔÓ, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ·fi ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ ·Ú·¿Óˆ Ê·ÚÌ¿ÎˆÓ Â›Ó·È Û¯ÂÙÈο ÌÈÎÚ‹ Î·È Â·ÎfiÏÔ˘ı· Ô ıÂڷ¢ÙÈÎfi˜ ‰Â›ÎÙ˘ ¢ÓÔ˚Îfi˜. °ÂÓÈο fï˜, ˘¿Ú¯ÂÈ ÂÈÙ·ÎÙÈ΋ ·Ó¿ÁÎË ÁÈ· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ ÔÈ Ôԛ˜ ı· ÚÔÛ‰ÈÔÚ›ÛÔ˘Ó ÙÔ˘˜ ÂÈı˘ÌËÙÔ‡˜ ÛÙfi¯Ô˘˜ ıÂڷ›·˜ ÙˆÓ ·Ú·¿Óˆ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘. ∂ÈϤÔÓ, Â›Ó·È ·Ó·Áη›Â˜ ÌÂϤÙ˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ÚÔÛ‰ÈÔÚÈÛıÔ‡Ó Ù· “ȉ·ÓÈο” ÚˆÙfiÎÔÏÏ· ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ıÂڷ›·˜ Ù· ÔÔ›· ı· ·Ú¤¯Ô˘Ó ·Ú΋ ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È Â·ÎfiÏÔ˘ı· ‚¤ÏÙÈÛÙË Ì·ÎÚfi¯ÚÔÓË ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ ÂÓÒ, Ù·˘Ùfi¯ÚÔÓ·, ı· ÂÏ·¯ÈÛÙÔÔÈÔ‡Ó ÙÔÓ Î·Ú‰È·ÁÁÂÈ·Îfi ΛӉ˘ÓÔ.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Rigatto C. Clinical epidemiology of cardiac disease in renal transplant recipients. Semin Dial 2003; 16: 106-110 2. Rigatto C. Management of cardiovascular disease in the renal transplant recipient. Cardiol Clin 2005; 23: 331-342 3. Adams PL. Long-term patient survival: strategies to improve overall health. Am J Kidney Dis 2006; 47 (Suppl 2): S65-S85 4. Marcen R. Cardiovascular risk factors in renal transplantation-current controversies. Nephrol Dial Transplant 2006; 21 (Suppl 3): iii3-iii8 5. Morales JM, Dominguez-Gil B. Cardiovascular risk profile with the new immunosuppressive combinations after renal transplantation. J Hypertens 2005; 23: 1609-1616
NÂfiÙÂÚ˜ ÂÍÂÏ›ÍÂȘ ÛÙË ÊÚÔÓÙ›‰· ·ÛıÂÓÒÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ A. ¶··ÛËÌ·ÎÔÔ‡ÏÔ˘, H. ™·Ú·ÓÙ˙‹, A. °ÂˆÚÁ¿ÎË, M. X·Ù˙ÔÔ‡ÏÔ˘, E. °Î·Ï¿Ë, E. ºÂÚÂÓÙ›ÓÔ˘, ™. KÔ˘ÙÛÔ˘Úԇ̷˜, A. NÙfiÎÔ˜
∏ ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÛÙËÓ ∂ÏÏ¿‰· ¯ÚÔÓÔÏÔÁÂ›Ù·È ·fi ÙÔ 1968. ¶·ÚfiÏÔ Ô˘ Ù· ·Ú¯Èο ·ÔÙÂϤÛÌ·Ù· ‰ÂÓ ‹Ù·Ó ÂÓı·ÚÚ˘ÓÙÈο Î·È ÔÈ ÂÍÂÏ›ÍÂȘ, Ô˘ ·ÊÔÚÔ‡Û·Ó ÛÙËÓ ÔÚÁ¿ÓˆÛË Î·È ÛÙÔÓ Î·Ù·ÌÂÚÈÛÌfi ·ÚÌÔ‰ÈÔÙ‹ÙˆÓ Î·ıÒ˜ Î·È ÙÔ ÓÔÌÔıÂÙÈÎfi Ï·›ÛÈÔ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Â›Ó·È Ï¤ÔÓ Ì›· Û˘¯Ó‹ ¯ÂÈÚÔ˘ÚÁÈ΋ Ú·ÎÙÈ΋. ∞·ÈÙ› Ì›· ȉȷ›ÙÂÚ· ÚÔÛÂÎÙÈ΋ ‰È·‰Èηۛ· ÂÈÏÔÁ‹˜ Î·È ÚÔÂÙÔÈÌ·Û›·˜ ÙÔ˘ ηٿÏÏËÏÔ˘ ÌÔۯ‡̷ÙÔ˜ ›Ù ·˘Ùfi ÚÔ¤Ú¯ÂÙ·È ·fi ˙ÒÓÙ· ›Ù ·fi و̷ÙÈÎfi ‰fiÙË. ∏ ÚfiÔ‰Ô˜ ÛÙË ¯ÂÈÚÔ˘ÚÁÈ΋, Ë ·Ó¿Ù˘ÍË ÌÂıfi‰ˆÓ ÂϤÁ¯Ô˘ Ù˘ Û˘Ì‚·ÙfiÙËÙ·˜ ÙˆÓ ÈÛÙÒÓ Î·È Ë ÚfiÔ‰Ô˜ ÛÙȘ ·ÓÙÈ·ÔÚÚÈÙÈΤ˜ ıÂڷ›˜ ‚Ô‹ıËÛ·Ó ÛÙËÓ ÂͤÏÈÍË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ÛÙËÓ ·ÚÔ¯‹ ηχÙÂÚ˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ∏ ÂÍÂȉ›Î¢ÛË Â›Ó·È ÛËÌ·ÓÙÈ΋ Î·È ·ÊÔÚ¿ fiÏÔ˘˜ ÙÔ˘˜ ·ÁÁÂÏ̷ٛ˜ ˘Á›·˜ Ô˘ Û˘ÓÂÚÁ¿˙ÔÓÙ·È ÙfiÛÔ ÂÚÈÂÁ¯ÂÈÚËÙÈο fiÛÔ Î·È Î·Ù¿ ÙË Û˘Ó¯‹ ÂͤÏÈÍË Ù˘ ÔÚ›·˜ Ù˘ ˘Á›·˜ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ (™˘Ú¿ÎÔ˜, 1992). ∏ ÏÂÈÔ„ËÊ›· ÙÔ˘ ÓÔÛËÏ¢ÙÈÎÔ‡ ÚÔÛˆÈÎÔ‡ Ô˘ ÛÙÂϯÒÓÂÈ ÙȘ 4 ÌÔÓ¿‰Â˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ Ù˘ ¯ÒÚ·˜ Ì·˜ ·Ó·ÁÓˆÚ›˙ÂÈ ÙȘ ȉȷÈÙÂÚfiÙËÙ˜ Î·È ÙȘ ·Ó¿ÁΘ Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ηÙËÁÔÚ›·˜ ·ÛıÂÓÒÓ Î·È ·ÔÙÂÏ› ̤ÏÔ˜ Ù˘ ‰ÈÂÈÛÙËÌÔÓÈ΋˜ ÔÌ¿‰·˜ ˘Á›·˜, Û˘ÌÌÂÙ¤¯ÔÓÙ·˜ Ô˘ÛÈ·ÛÙÈο Î·È Ì ›ÁÓˆÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î¿ı ÚÔ‚Ï‹Ì·ÙÔ˜ ‹ ÂÈÏÔ΋˜ Ô˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ›. ∏ ¯Ú‹ÛË ÚˆÙÔÎfiÏÏˆÓ Â›Ó·È ÂȂ‚ÏË̤ÓË ·ÊÔ‡ ÔÈ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ¯Ú›˙Ô˘Ó ÂÍÂȉÈÎÂ˘Ì¤Ó˘ È·ÙÚÔÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜. ∏ Û˘ÁÎÂÎÚÈ̤ÓË Î·ÙËÁÔÚ›· ·ÛıÂÓÒÓ, ÂÎÙfi˜ ·fi ÙËÓ Î¿ı·ÚÛË Î·È ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ ÛÙË Ï‹„Ë ˘ÁÚÒÓ Î·È ÙÚÔÊ‹˜, ·ÓÙÈÌÂÙˆ›˙ÂÈ Û ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ÏËıÒÚ· ¿ÏÏˆÓ ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛÂˆÓ Ô˘ ÂÈ‚¿ÏÏÔ˘Ó Û¯ÔÏ·ÛÙÈ΋ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‰ÈÂÚ‡ÓËÛË Î·È Û˘Ó¯‹
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ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË. Δ· ·Ú·¿Óˆ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙȘ ȉȷÈÙÂÚfiÙËÙ˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜, ÙÔ˘ ·˘ÛÙËÚÔ‡ ˆÚÈ·›Ô˘ ÈÛÔ˙˘Á›Ô˘ ˘ÁÚÒÓ, Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È Î·Ù·ÁÚ·Ê‹˜ ÙˆÓ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ, Ù˘ „˘¯ÔÏÔÁÈ΋˜ ÛÙ‹ÚÈ͢ Î·È Âη›‰Â˘Û˘ Ô˘ ÂÈ‚¿ÏÏÂÙ·È Û οı ʿÛË Ù˘ ‰È·‰Èηۛ·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ·ÔÙ¤ÏÂÛ·Ó Â‰›Ô ¤Ú¢ӷ˜. OÈ ÓÔÛËÏÂ˘Ù¤˜, η٤¯ÔÓÙ·˜ ÁÓÒÛÂȘ Î·È ‰ÂÍÈfiÙËÙ˜, Ú¤ÂÈ Ó· ·Ú¤¯Ô˘Ó ÓÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰· ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË Î·ÙËÁÔÚ›· ·ÛıÂÓÒÓ ÛÙ·ıÂÚ‹˜ ÔÈfiÙËÙ·˜. °È· Ó· ÂÈÙ¢¯ı› ·˘Ùfi, ··ÈÙÂ›Ù·È Ë Ù˘ÔÔ›ËÛË Ù˘ ÊÚÔÓÙ›‰·˜ Î·È ÙÔ˘ ۯ‰ȷÛÌÔ‡ Ù˘ ÁÈ· οı ·ÛıÂÓ‹. ™¯¤‰ÈÔ ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ (care plan, clinical pathways η) ÔÓÔÌ¿˙Ô˘Ì ¤Ó· Û˘ÁÎÂÎÚÈ̤ÓÔ Î·È ÙÂÎÌËÚȈ̤ÓÔ Û¯Â‰È·ÛÌfi ÈÂÚ¿Ú¯ËÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ·Ó·ÁÎÒÓ Ô˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ¤Ó·˜ ·ÛıÂÓ‹˜. ∞ÔÙÂÏ› ÎÔÌÌ¿ÙÈ ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜ Û ¤Ó· Û‡ÛÙËÌ· ˘Á›·˜, ·ÏÏ¿ Û˘¯Ó¿ ÂÂȉ‹ ‰ÂÓ Á›ÓÂÙ·È Î·Ù·ÓÔËÙfi, ·Ú·ÌÂÏ›ٷÈ. ™ÙË ‰È·‰Èηۛ· ÙÔ˘ ۯ‰ȷÛÌÔ‡ Ù˘ ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ Ú¤ÂÈ Ó· Û˘ÌÌÂÙ¤¯Ô˘Ó fiÏÔÈ ÔÈ ÂÈÛÙËÌÔÓÈÎÔ› ÙÔÌ›˜, ÔÈ ÔÔ›ÔÈ ÂÌϤÎÔÓÙ·È ÛÙË ÊÚÔÓÙ›‰· ÙÔ˘ ·ÛıÂÓÔ‡˜ (Sox, 2007). ∏ ·Ó¿Ù˘ÍË Ù˘ÔÔÈËÌ¤ÓˆÓ Û¯Â‰›ˆÓ ÊÚÔÓÙ›‰·˜ ·ÎÔÏÔ˘ı› Û˘ÁÎÂÎÚÈ̤ÓË ·ÏÏËÏÔ˘¯›· ‚ËÌ¿ÙˆÓ. ∞Ú¯›˙ÂÈ Ì ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ·ÓÙÈÎÂÈ̤ÓÔ˘ ÂӉȷʤÚÔÓÙÔ˜ (Û˘ÁÎÂÎÚÈ̤ÓË Î·ÙËÁÔÚ›· ·ÛıÂÓÒÓ), Û˘Ó¯›˙ÂÈ Ì ÙË Û‡ÛÙ·ÛË ÔÌ¿‰·˜ ·Ó¿Ù˘Í˘ ÙÔ˘ ۯ‰›Ô˘ ÊÚÔÓÙ›‰·˜ Ô˘ Û˘ÏϤÁÂÈ Î·È ·Ó·Ï‡ÂÈ Ù· Û¯ÂÙÈο ÂÈÛÙËÌÔÓÈο ‰Â‰Ô̤ӷ, ·Ó·Ù‡ÛÛÂÈ ÙÔ Ù˘ÔÔÈË̤ÓÔ Û¯¤‰ÈÔ ÊÚÔÓÙ›‰·˜, ÙÔ ÂÊ·ÚÌfi˙ÂÈ ÈÏÔÙÈο, ÂϤÁ¯ÂÈ ÙËÓ Ù‹ÚËÛ‹ ÙÔ˘, ·ÍÈÔÏÔÁÒÓÙ·˜ Ù· ·ÔÙÂϤÛÌ·Ù·, ·Ó·ıˆÚÒÓÙ·˜ ·Ó¿ÏÔÁ· Î·È Ì ÓÂfiÙÂÚ· ‰Â‰Ô̤ӷ (∫·Ï·Ê¿ÙË Î·È Û˘Ó, 2007). O ۯ‰ȷÛÌfi˜ Ù˘ ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ ‚·-
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Û›˙ÂÙ·È ÛÙË ÓÔÛËÏ¢ÙÈ΋ ‰ÈÂÚÁ·Û›·, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ Û˘ÛÙËÌ·ÙÈ΋ ̤ıÔ‰Ô˜ Ô˘ ηÙ¢ı‡ÓÂÈ ÙÔ ÓÔÛËÏÂ˘Ù‹ Î·È ÙÔÓ ·ÛıÂÓ‹ ÛÙÔÓ ·ÌÔÈ‚·›Ô ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ·Ó·ÁÎÒÓ ÁÈ· ÓÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰·, ۯ‰ȷÛÌfi Î·È ÂÊ·ÚÌÔÁ‹ Ù˘ ÊÚÔÓÙ›‰·˜ Î·È ÂÎÙ›ÌËÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. μ·ÛÈÎfi˜ ÛÎÔfi˜ Ù˘ Â›Ó·È Ó· ‚ÔËı‹ÛÂÈ ÙÔ ÓÔÛËÏÂ˘Ù‹ Ó· ‰È·¯ÂÈÚ›˙ÂÙ·È ÙË ÊÚÔÓÙ›‰· οı ·ÛıÂÓÔ‡˜ Ì ÂÈÛÙËÌÔÓÈÎfi, ÔÏÈÛÙÈÎfi Î·È ‰ËÌÈÔ˘ÚÁÈÎfi ÙÚfiÔ. ∞ÔÙÂÏÂ›Ù·È ·fi ¤ÓÙ ÛÙ¿‰È·, ÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ÙË ‰È·Ù‡ˆÛË ÓÔÛËÏ¢ÙÈÎÒÓ ‰È·ÁÓÒÛˆÓ, ÙÔ Û¯Â‰È·ÛÌfi Ù˘ ÊÚÔÓÙ›‰·˜ (‰È·Ù‡ˆÛË ÛÎÔÒÓ Î·È Û¯Â‰È·ÛÌfi˜ ·ÚÂÌ‚¿ÛˆÓ), ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ Î·È ÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ÊÚÔÓÙ›‰·˜ (§ÂÌÔÓ›‰Ô˘ & ¶·ÙËÚ¿ÎË, 2003). ™ÙËÓ ÚÔÛ¿ıÂÈ· Ù˘ÔÔ›ËÛ˘ Ù˘ ÓÔÛËÏ¢ÙÈ-
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΋˜ ÊÚÔÓÙ›‰·˜, ¤¯Ô˘Ó ·Ó·Ù˘¯ı› ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· Ù·ÍÈÓfiÌËÛ˘ ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÛÙÔȯ›ˆÓ Ù˘ ÓÔÛËÏ¢ÙÈ΋˜ ‰ÈÂÚÁ·Û›·˜. ™˘ÁÎÂÎÚÈ̤ӷ, ¤¯ÂÈ ·Ó·Ù˘¯ı› Ë Ù·ÍÈÓfiÌËÛË ÓÔÛËÏ¢ÙÈÎÒÓ ‰È·ÁÓÒÛÂˆÓ Î·Ù¿ ¡∞NDA (North American Nursing Diagnosis Association), Ë Ù·ÍÈÓfiÌËÛË ÓÔÛËÏ¢ÙÈÎÒÓ ·ÚÂÌ‚¿ÛÂˆÓ (NIC – Nursing Interventions Classification) Î·È Ë Ù·ÍÈÓfiÌËÛË ÓÔÛËÏ¢ÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ (NOC – Nursing Outcome Classification). ªÂ ‚¿ÛË ÙȘ ·Ú·¿Óˆ Ù·ÍÈÓÔÌ‹ÛÂȘ, Û ÔÏϤ˜ ¯ÒÚ˜ Á›ÓÂÙ·È Ô Û¯Â‰È·ÛÌfi˜ Ù˘ ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ (NANDA, 2007). ™ÙË Û˘Ó¤¯ÂÈ·, ·ÎÔÏÔ˘ı› ·Ú¿ıÂÛË ÂÓfi˜ Ù˘ÔÔÈË̤ÓÔ˘ ÓÔÛËÏ¢ÙÈÎÔ‡ ۯ‰›Ô˘ ÊÚÔÓÙ›‰·˜ Ô˘ ·ÊÔÚ¿ Û˘ÁÎÂÎÚÈ̤ӷ ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ (Gulanick et al, 1998).
¡ÔÛËÏ¢ÙÈÎfi ™¯¤‰ÈÔ ºÚÔÓÙ›‰·˜ ¡ÔÛËÏ¢ÙÈ΋ ‰È¿ÁÓˆÛË: ∫›Ó‰˘ÓÔ˜ ∂ÏÏ›ÌÌ·ÙÔ˜ ‹ ¶ÂÚ›ÛÛÂÈ·˜ ŸÁÎÔ˘ ÀÁÚÒÓ ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘: ªÂÙ·‚ÏËÙfi˜ ¯ÚfiÓÔ˜ ·Ú¯È΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜: ∞̤ۈ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ô ·ÛıÂÓ‹˜ ÌÔÚ› Ó· Ù·Ï·ÓÙ¢Ù› ÌÂٷ͇ Ì›ˆÛ˘ Î·È ·‡ÍËÛ˘ ˘ÁÚÒÓ. ¶·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ ÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË. ∞fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜. ∞ÈÌÔÚÚ·Á›· ·fi ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ÙÔÌ‹. ∞Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·: O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ ˘ÂÚÊfiÚÙˆÛ˘ ‹ ÂÏÏ›ÌÌ·ÙÔ˜ ÌÂÈÒÓÂÙ·È Ì ÚÔ‚ÏÂfiÌÂÓ˜ ÂÎÙÈÌ‹ÛÂȘ Î·È ¤ÁηÈÚ˜ ·ÚÂÌ‚¿ÛÂȘ. ¶ÚÔԉ¢ÙÈ΋ ÂÎÙ›ÌËÛË ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ
∞ÈÙÈÔÏÔÁ›·
¶·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· ÁÈ· ΔÔ ÌfiÛ¯Â˘Ì· ÌÔÚ› ÏfiÁˆ ·Ú·ÙÂٷ̤Ó˘ ÈÛ¯·ÈÌ›·˜ Ó· ‚Ú›ÛΤÏÏÂÈÌÌ· fiÁÎÔ˘ ˘ÁÚÒÓ: ÔÏ˘Ô˘Ú›·, ·ÒÏÂÈ· ‚¿ÚÔ˘˜, Ù·È Û ʿÛË ·˘ÍË̤Ó˘ ‰ÈÔ‡ÚËÛ˘ ηٿ ÙËÓ ·Ó¿ÚÚˆÛË. ·‰˘Ó·Ì›· Î·È ‰›„·. ¶·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· ÛËÌ›· Î·È Û˘ÌÙÒÌ·Ù· ÂÚ›Û- ∏ ÔÍ›· ·fiÚÚÈ„Ë ¤¯ÂÈ ˆ˜ ·ÚÈÔ Û‡Ìو̷ ÙË Ì›ˆÛË Ù˘ ÛÂÈ·˜ fiÁÎÔ˘ ˘ÁÚÒÓ: Ô›‰ËÌ·, ·‡ÍËÛË ‚¿ÚÔ˘˜, Ì›ˆÛË ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ·Ô‚·ÏÏfiÌÂÓˆÓ Ô‡ÚˆÓ, Úfi‚ÏËÌ· ÛÙËÓ ·Ó·ÓÔ‹ Î·È ÙÚ›˙ÔÓÙ˜. ∫·ıËÌÂÚÈÓ‹ ˙‡ÁÈÛË Ì ÙË ¯Ú‹ÛË Ù˘ ›‰È·˜ ˙˘Á·ÚÈ¿˜. °È· ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ‰È·ÊÔÚÔÔÈ‹ÛÂˆÓ Î·Ù¿ ÙË ˙‡ÁÈÛË. ¶·Ú·ÎÔÏÔ‡ıËÛË ÂÈÛÂÚ¯fiÌÂÓˆÓ ˘ÁÚÒÓ Î·È ·Ô‚·ÏÏfiÌÂÓˆÓ Ô‡ÚˆÓ. £Âڷ¢ÙÈΤ˜ ¶·ÚÂÌ‚¿ÛÂȘ ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ ∞Ó·Ï‹ÚˆÛË Û ml ÙˆÓ ·Ô‚·ÏÏfiÌÂÓˆÓ Ô‡ÚˆÓ Ì ›ÛË ÔÛfiÙËÙ· ÚÔÛÏ·Ì‚·ÓÔÌ¤ÓˆÓ ˘ÁÚÒÓ Û˘Ó 30 ml ·Ó¿ ÒÚ·.
∞ÈÙÈÔÏÔÁ›·
°È· Ó· Î·Ï˘Êı› Ë ·Ó·›ÛıËÙË ·ÒÏÂÈ· ‹ Û‡Ìʈӷ Ì ÙÔ ÈÛ¯‡ÔÓ ÚˆÙfiÎÔÏÏÔ Ù˘ ÌÔÓ¿‰·˜. OÈ ·ÛıÂÓ›˜ Ì ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË ÌÔÚ› Ó· ·Ô‚¿ÏÏÔ˘Ó ÁÈ· ·ÚÎÂÙ¤˜ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË 200 Ì 400 ml ·Ó¿ ÒÚ·. ™Â ÂÚÈÙÒÛÂȘ Û˘ÁÁÂÓÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ë ‰ÈÔ‡ÚËÛË Â›Ó·È ·ÎfiÌ· ÌÂÁ·Ï‡ÙÂÚË Î·È ÙȘ ÚÒÙ˜ Ë̤Ú˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÊÙ¿ÓÂÈ Î·È Ù· 600 ml ÙËÓ ÒÚ·. Δ· ·Ô‚·ÏÏfiÌÂÓ· Ô‡Ú· ı· Ú¤ÂÈ Ó· ·Ó·ÏËÚÒÓÔÓÙ·È ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ·Ê˘‰¿ÙˆÛ˘. ™Â ÂÚ›ÙˆÛË ˘ÂÚÊfiÚÙˆÛ˘: ·) ÃÔÚËÁԇ̠‰ÈÔ˘ÚË- ¡· ‰È¢ÎÔÏ˘Óı› Ë Â·Ú΋˜ ·ÈÌ¿ÙˆÛË ÙˆÓ ÈÛÙÒÓ ÛÙȘ ÔȉËÌ·ÙÒÙÈο Î·È ÂÚÈÔÚ›˙Ô˘Ì ÙË Ï‹„Ë ÚÔÛÏ·Ì‚·ÓfiÌÂÓˆÓ ‰ÂȘ ÂÚÈÔ¯¤˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È Ó· Á›ÓÂÈ ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ˘ÁÚÒÓ ˘ÁÚÒÓ Î·È ‚) •ÂÎÈÓ¿Ì ÛÙ·‰È·Î‹ ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ Î·È Ó· ÌÂȈı› ÙÔ Ô›‰ËÌ·. ·ÛıÂÓÔ‡˜ ™Â ÂÚ›ÙˆÛË ·ÓÔ˘Ú›·˜ Ô ·ÛıÂÓ‹˜ οÓÂÈ Î¿ı·ÚÛË. ªÂÚÈΤ˜ ÊÔÚ¤˜ ÙÔ ÌfiÛ¯Â˘Ì· ‰ÂÓ ·Ú¿ÁÂÈ Ô‡Ú· ·Ì¤Ûˆ˜ Î·È Ë Î¿ı·ÚÛË ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË ¤ˆ˜ fiÙÔ˘ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÎÚÈı› ·ÚΛ˜
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A. ¶A¶A™HMAKO¶OY§OY ¡ÔÛËÏ¢ÙÈ΋ ‰È¿ÁÓˆÛË: ∫›Ó‰˘ÓÔ˜ ∂›Û¯ÂÛ˘
¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘: μÔ˘ÏˆÌ¤ÓÔ˜ Ô˘ÚÔηıÂÙ‹Ú·˜ ¢È·ÚÚÔ‹ ·fi ÙËÓ ·Ó·ÛÙfïÛË ∞Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·: O ΛӉ˘ÓÔ˜ ›ۯÂÛ˘ ÁÈ· ÙÔÓ ·ÛıÂÓ‹ ÌÂÈÒÓÂÙ·È fiˆ˜ ÙÂÎÌËÚÈÒÓÂÙ·È ·fi ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ô˘ÚÔηıÂÙ‹Ú· ‹ ÙËÓ ·Ó¿ÁÎË ÙÔ˘ ·ÛıÂÓ‹ ÁÈ· Ô‡ÚËÛË Î¿ı 1-2 ÒÚ˜. ¶ÚÔԉ¢ÙÈ΋ ÂÎÙ›ÌËÛË ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ
∞ÈÙÈÔÏÔÁ›·
§·Ì‚¿ÓÔ˘Ì ˘’fi„ÈÓ Ì·˜ ÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ·ÛıÂÓÔ‡˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Ô‡ÚËÛ‹ ÙÔ˘ ÚÔ Ù˘ ¤̂·Û˘.
∂¿Ó Ô ·ÛıÂÓ‹˜ ÚÔ Ù˘ ¤̂·Û˘ ·Ú‹Á·Á ÌÈÎÚ‹ ÔÛfiÙËÙ· Ô‡ÚˆÓ, Ë Ô˘ÚÔ‰fi¯Ô˜ ·ÛÙË ÙÔ˘ ÌÔÚ› Ó· ¤¯ÂÈ ·ÙÚÔÊ‹ÛÂÈ ‹ Î·È Ó· ¤¯ÂÈ ÌÂȈı› Û ̤ÁÂıÔ˜. ¶·Ú·ÙËÚԇ̠ٷ Ô‡Ú· fiÛÔÓ ·ÊÔÚ¿ ÙÔ ¯ÚÒÌ·, ÙËÓ Ô- ∏ ·Ú·ÌÔÓ‹ ÙÔ˘ Ô˘ÚÔηıÂÙ‹Ú· ı· ÂÍ·ÚÙËı› ·fi ÙË ¯ˆÚËÙÈÛfiÙËÙ·, ÙÔ ›˙ËÌ· Î·È ÙËÓ ·ÚÔ˘Û›· ‹ÁÌ·ÙÔ˜ ·›Ì·ÙÔ˜. ÎfiÙËÙ· Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜, ÙÔ Ì˘˚Îfi ÙfiÓÔ, ÙÔ ‚·ıÌfi Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ ¶·Ú·ÙËÚԇ̠ÙËÓ ÎÔÈÏȷ΋ ¯ÒÚ· Î·È ÙËÓ Î‡ÛÙË ÁÈ· ÛËÌ›· ‰È¿Ù·Û˘ ÏfiÁˆ ÊÚ·Á̤ÓÔ˘ ·fi ‹ÁÌ·Ù· Ô˘ÚÔηıÂÙ‹Ú· ‹ ‰È·ÚÚÔ‹ Ù˘ ·Ó·ÛÙfïÛ˘ ªÂÙÚ¿Ì ٷ ·Ô‚·ÏÏfiÌÂÓ· Ô‡Ú· Î·È Ù· ÚÔÛÏ·Ì‚·ÓfiÌÂÓ· ˘ÁÚ¿ ªÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ Ô˘ÚÔηıÂÙ‹Ú·, ·Ú·ÙËÚԇ̠∏ ·ÈÌ·ÙÔ˘Ú›· Î·È ÔÈ ÂӉ›ÍÂȘ ÌÔχÓÛˆ˜ Ú¤ÂÈ Ó· ·ÓÙÈÌÂوٷ ·Ô‚·ÏÏfiÌÂÓ· Ô‡Ú· (¯ÚÒÌ·, ‰È·‡ÁÂÈ·, ›˙ËÌ· Î·È ›˙ÔÓÙ·È ¿ÌÂÛ·. ·ÚÔ˘Û›· ·›Ì·ÙÔ˜). £Âڷ¢ÙÈΤ˜ ¶·ÚÂÌ‚¿ÛÂȘ ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ
∞ÈÙÈÔÏÔÁ›·
¢È·ÙËÚÂ›Ù·È Ë ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ Ô˘ÚÔηıÂÙ‹Ú· ∞˘Ù¿ ı· ÂÌfi‰È˙·Ó ÙË ‰È·‚·ÙfiÙËÙ· ÙÔ˘ Ô˘ÚÔηıÂÙ‹Ú·. ·ÔʇÁÔÓÙ·˜ ÙË Û˘ÛÙÚÔÊ‹ ∂¿Ó ·Ú·ÙËÚËı› ÛÔ‚·Ú‹ ·ÈÌ·ÙÔ˘Ú›·, ·ÛÎԇ̠›ÂÛË ∏ ·ÈÌÔÚÚ·Á›· ·fi ÙËÓ ·Ó·ÛÙfïÛË ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÙÔÓ Î·ıÂÙ‹Ú· ÁÈ· Ó· ·ÔÌ·ÎÚ‡ÓÔ˘Ì ٷ ‹ÁÌ·Ù· ·›Ì·- ‹ÁÌ·Ù· ·›Ì·ÙÔ˜ ÙÔ˜ Î·È Á›ÓÔÓÙ·È Ï‡ÛÂȘ Û‡Ìʈӷ Ì ȷÙÚÈ΋ Ô‰ËÁ›·. ªÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ Ô˘ÚÔηıÂÙ‹Ú·, ˙ËÙ¿Ì ·fi °È· Ó· ·ÔʇÁÔ˘Ì ÙË ‰È¿Ù·ÛË Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘. ∂¿Ó Ë ÙÔÓ ·ÛıÂÓ‹ Ó· Ô˘Ú› οı 1 Ì 2 ÒÚ˜ ¯ˆÚËÙÈÎfiÙËÙ· Ù˘ ·ÛÙ˘ ¤¯ÂÈ ÌÂȈı› ÛËÌ·ÓÙÈο, Ô ·ÛıÂÓ‹˜ ı· ·ÈÛı¿ÓÂÙ·È ¤ÓÙÔÓ· ÙËÓ ·Ó¿ÁÎË Ó· ÙËÓ ·‰ÂÈ¿˙ÂÈ ÈÔ Û˘¯Ó¿. ∏ ÁÂÌ¿ÙË Î‡ÛÙË ÚÔηÏ› ÂÈÚfiÛıÂÙË ‰È¿Ù·ÛË ÛÙËÓ ·Ó·ÛÙfïÛË ¢È‰¿ÛÎÔ˘Ì ÙÔÓ ·ÛıÂÓ‹ Ò˜ Ó· ÌÂÙÚ¿ Ù· ·Ô‚·ÏÏfiÌÂÓ· Ô‡Ú· ηıËÌÂÚÈÓ¿ Î·È Ó· ÂÓËÌÂÚÒÓÂÈ ÙË ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÔÌ¿‰· ÁÈ· ·ÏÏ·Á¤˜ ÛÙËÓ ÔÛfiÙËÙ·, ÙÔ ¯ÚÒÌ·, ÙË ‰È·‡ÁÂÈ· ‹ ÙȘ ›ÌÔÓ˜ ‰È·ÊÔÚÔÔÈ‹ÛÂȘ.
¡ÔÛËÏ¢ÙÈ΋ ‰È¿ÁÓˆÛË: ∫›Ó‰˘ÓÔ˜ §Ô›ÌˆÍ˘ ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘: ∏ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ Î·È ·ÓÙÈ·ÔÚÚÈÙÈ΋ ·ÁˆÁ‹. §‡ÛË Ù˘ Û˘Ó¤¯ÂÈ·˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÓÔÛÔÎÔÌÂȷ΋ Ïԛ̈ÍË ∞Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·: O ΛӉ˘ÓÔ˜ Ïԛ̈͢ ÌÂÈÒÓÂÙ·È Ì¤Ûˆ Ù˘ Û˘Ó¯ԇ˜ ·ÍÈÔÏfiÁËÛ˘ Î·È ÙˆÓ ¤ÁηÈÚˆÓ ·ÚÂÌ‚¿ÛˆÓ. O ·ÛıÂÓ‹˜ ‹ Ë ÔÈÎÔÁ¤ÓÂÈ· ÂÎÊÚ¿˙ÂÈ ÏÂÎÙÈο fiÙÈ ¤¯Ô˘Ó ηٷÓÔ‹ÛÂÈ ÙËÓ ·Ó¿ÁÎË ÁÈ· ·˘ÛÙËÚ¿ ̤ÙÚ· ÂϤÁ¯Ô˘ ÏÔÈÌÒÍÂˆÓ ¶ÚÔԉ¢ÙÈ΋ ÂÎÙ›ÌËÛË ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ ¶·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ¶·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ. . ¶·Ú·Ù‹ÚËÛË ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ÙÚ·‡Ì·ÙÔ˜ ÁÈ· ÙÔÈÎfi ÂÚ‡ıËÌ·, ˘Ò‰Ë ˘ÁÚ¿ ‹ ‰˘Û·ÓÂÍ›·. ∂ÓË̤ڈÛË ÙÔ˘ È·ÙÚÔ‡ Â¿Ó ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó. §‹„Ë Î·ÏÏȤÚÁÂÈ·˜ ·fi ÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ÙÚ·‡Ì· ÁÈ· ·ÂÚfi‚ÈÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜ Â¿Ó Ù· ˘ÁÚ¿ Â›Ó·È ˘Ò‰Ë, Ú¿ÛÈÓ· Î·È ‰‡ÛÔÛÌ·. §‹„Ë Î·ÏÏȤÚÁÂÈ·˜ Ô‡ÚˆÓ Â¿Ó Ô ·ÛıÂÓ‹˜ ·ÚÔ˘ÛÈ¿ÛÂÈ ˘ÚÂÙfi ‹ ‰˘ÛÔ˘Ú›·, ‹ Â¿Ó Ù· Ô‡Ú· Á›ÓÔ˘Ó ı·Ì¿.
∞ÈÙÈÔÏÔÁ›· ª›· ‰ÂηÙÈ΋ ˘ÚÂÙÈ΋ ΛÓËÛË ÌÔÚ› Ó· Â›Ó·È ¤Ó‰ÂÈÍË Ïԛ̈͢ ∞ÎfiÌ· Î·È Ì›· ÌÈÎÚ‹ ·‡ÍËÛË ÛÙ· ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ· ÌÔÚ› Ó· Â›Ó·È ¤Ó‰ÂÈÍË Ïԛ̈͢ ÂÍ ·ÈÙ›·˜ Ù˘ ·Ô‰˘Ó¿ÌˆÛ˘ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù· ¶·Ú·ÎÔÏÔ‡ıËÛË fiÏˆÓ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Î·ÏÏÈÂÚÁÂÈÒÓ ∞ÍÈÔÏfiÁËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ Û˘¯ÓfiÙËÙ·˜ Î·È ÙÔ˘ Ú˘ıÌÔ‡ Î·È ·ÍÈÔÏfiÁËÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÂÚÁÒ‰Ô˘˜ ·Ó·ÓÔ‹˜ ∞ÍÈÔÏfiÁËÛË ÙˆÓ Ó¢ÌfiÓˆÓ ÁÈ· ·Ó¿Ù˘ÍË ·ıÔÏÔÁÈÎÒÓ ·Ó·Ó¢ÛÙÈÎÒÓ ‹¯ˆÓ.
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∫·Ù·ÌÂÙÚÔ‡ÓÙ·È Î˘Ú›ˆ˜ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ. OÈ ÏÔÈÌÒÍÂȘ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Â›Ó·È Û˘¯Ó¤˜ Î·È ÛÔ‚·Ú¤˜ ÛÙÔ˘˜ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜.
£Âڷ¢ÙÈΤ˜ ¶·ÚÂÌ‚¿ÛÂȘ ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ
∞ÈÙÈÔÏÔÁ›·
¶Ï‡ÛÈÌÔ ÙˆÓ ¯ÂÚÈÒÓ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ Â·Ê‹ Ì ÙÔÓ ·ÛıÂÓ‹
μ·ÎÙ‹ÚÈ·, ÈÔ›, ̇ÎËÙ˜ Î·È ÚˆÙfi˙ˆ· Ô˘ ˘¿Ú¯Ô˘Ó ÛÙÔ˘˜ ÌË ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ÏËı˘ÛÌÔ‡˜ ÌÔÚ› Ó· ·ÔÙÂϤÛÔ˘Ó Î›Ó‰˘ÓÔ˘˜ ÏÔÈÌÒÍÂˆÓ ÛÙÔ˘˜ ÛÙÔ˘˜ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜. ΔÔ ÓÔÛÔÎÔÌÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÏËıÒÚ· ‚·ÎÙËÚ›ˆÓ Î·È ÈÒÓ. ªÂÙ¿ ÙËÓ ¤ÍÔ‰fi ÙÔ˘ ·fi ÙË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜, ‰È·Ù‹ÚË- °È· ÙËÓ ·ÔÊ˘Á‹ ÂÈÌfiÏ˘ÓÛ˘. ÛË È‰ÈˆÙÈÎÔ‡ ‰ˆÌ·Ù›Ô˘ ‹ ÌÂ Û˘ÁοÙÔÈÎÔ ¯ˆÚ›˜ Ïԛ̈ÍË. ¶ÂÚÈÔÚÈ OÈ ·ÛıÂÓ›˜ ‰Â ¯Ú‹˙Ô˘Ó ·ÔÌfiÓˆÛ˘. ÛÌfi˜ ÙˆÓ ÂÈÛÎÂÙÒÓ Î·È ÙˆÓ ÏÔ˘ÏÔ˘‰ÈÒÓ. ¶ÚÔÙÚÔ‹ ÁÈ· ‚·ıȤ˜ ·Ó·ÓÔ¤˜, ‚‹ÍÈÌÔ, Î·È Á‡ÚÈÛÌ·. °È· ÙËÓ ·ÔÊ˘Á‹ ·Ó·Ó¢ÛÙÈÎÒÓ ÂÈÏÔÎÒÓ. ∏ ·ÔÊ˘Á‹ ÌÈ·˜ ·Ó·Ó¢ÛÙÈ΋˜ Ïԛ̈͢ ‚ÔËı¿ ÛÙË ‰È¢ÎfiÏ˘ÓÛË Ù˘ ‰È·‰Èηۛ·˜ ·Ó¿ÚÚˆÛ˘. ¶ÚÔÙÚÔ‹ ÁÈ· ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ·Ó·Ó¢ÛÙÈΤ˜ ·Û΋ÛÂȘ °È· ÙËÓ ·ÔÊ˘Á‹ ·Ó·Ó¢ÛÙÈÎÒÓ ÂÈÏÔÎÒÓ. ∏ ·ÔÊ˘Á‹ ÌÈ·˜ ·Ó·Ó¢ÛÙÈ΋˜ Ïԛ̈͢ ‚ÔËı¿ ÛÙË ‰È¢ÎfiÏ˘ÓÛË Ù˘ ‰È·‰Èηۛ·˜ ·Ó¿ÚÚˆÛ˘. ÃÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·Ù¿ ÙȘ Ô‰ËÁ›Â˜ ¶ÚÔÙÚÔ‹ ÁÈ· Ï‹„Ë ÙÚÔÊ‹˜ ÏÔ‡ÛÈ· Û ıÂÚÌ›‰Â˜ Î·È ÚˆÙ½Ó˜ O ΛӉ˘ÓÔ˜ Ïԛ̈͢ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ·ÛıÂÛÙÔ ‚·ıÌfi ¿ÓÙ· Ô˘ ÙÔ ÂÈÙÚ¤ÂÈ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ó›˜ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Ô˘ ‹Ù·Ó ‹‰Ë ÂÍ·ÛıÂÓË̤ÓÔÈ ÚÈÓ ÙËÓ Â¤Ì‚·ÛË. ∂η›‰Â˘ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· Ó· ·ÔʇÁÂÈ Ù· Ï‹ıË Ô˘ OÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ηٷÓÔ‹ÛÔ˘Ó ÙÔ ÌÂÁ¿ÏÔ Î›Ó ÌÔÚ› Ó· Â›Ó·È ÊÔÚ›˜ ÏÔÈÌÒ͈Ó, Ó· ÚÔÛ¤¯ÂÈ ÙËÓ ·ÙÔÌÈ΋ ÙÔ˘ ‰˘ÓÔ ÚÔÛ‚ÔÏ‹˜ ·fi Ïԛ̈ÍË Î·È ÙË ÛÔ˘‰·ÈfiÙËÙ· ˘ÁÈÂÈÓ‹ Î·È Ó· ·Ó·ÁÓˆÚ›˙ÂÈ Û˘ÌÙÒÌ·Ù· Ïԛ̈͢. Ù˘ ÂÓË̤ڈÛ˘ Ù˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋˜ ÌÔÓ¿‰·˜ ÁÈ· ÙËÓ ·ÚÔ˘Û›· ÔÔÈÔ˘‰‹ÔÙ ÛËÌ›Ԣ Ïԛ̈͢ .
¡ÔÛËÏ¢ÙÈ΋ ‰È¿ÁÓˆÛË: ∫›Ó‰˘ÓÔ˜ ªË ∞ÔÙÂÏÂÛÌ·ÙÈ΋˜ ∞Ô‰Ô¯‹˜ Ù˘ ¡¤·˜ ∫·Ù¿ÛÙ·Û˘ ∞ÛıÂÓÔ‡˜ ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘: ∫›Ó‰˘ÓÔ˜ ·fiÚÚȄ˘ Î·È Ïԛ̈͢ ªÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ó¿ÁÎË ÁÈ· οı·ÚÛË. ∞ÓËÛ˘¯›· ÁÈ· ÙÔ ‰fiÙË ∞ÓËÛ˘¯›· ÁÈ· ÙË Ï‹„Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ÁÈ· ÙÔ ˘fiÏÔÈÔ Ù˘ ˙ˆ‹˜ ÙÔ˘. ∞ÓÙ›ÏË„Ë ÙˆÓ ·ÏÏ·ÁÒÓ ÛÙÔ ÛÒÌ· ∞ÏÏ·Á‹ ÛÙÔÓ ÙÚfiÔ ÏÂÈÙÔ˘ÚÁ›·˜ ∞Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·: O ·ÛıÂÓ‹˜ ÂȉÂÈÎÓ‡ÂÈ ·Ô‰Ô¯‹ Ù˘ ÚÔfi‰Ô˘ Ù˘ ‰È·‰Èηۛ·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. O ·ÛıÂÓ‹˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÛËÌ›· ·Ô‰Ô¯‹˜ Ù˘ ηٿÛÙ·Û˘ fiˆ˜ ÙÂÎÌËÚÈÒÓÂÙ·È ·fi Û˘ÌÂÚÈÊÔÚ¿ Û˘ÓÂÚÁ·Û›·˜, ‹ÚÂÌË ÂÌÊ¿ÓÈÛË Î·È ÂӉȷʤÚÔÓ ÁÈ· ÙÔ ÂÚÈ‚¿ÏÏÔÓ. ¶ÚÔԉ¢ÙÈ΋ ÂÎÙ›ÌËÛË ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ
∞ÈÙÈÔÏÔÁ›·
∞ÍÈÔÏfiÁËÛË ÛËÌ›ˆÓ ·Ó·ÔÙÂÏÂÛÌ·ÙÈ΋˜ ·Ô‰Ô¯‹˜: ·ÓË- ™˘Ó‹ıˆ˜ Ô ·ÛıÂÓ‹˜ ¯ÚÂÈ¿˙ÂÙ·È ÌÂÙÂÁ¯ÂÈÚËÙÈο οı·ÚÛË Û˘¯›·, ·›ÛıËÌ· ·Ó¿ÚÎÂÈ·˜, ÙÂÓو̤ӷ ¯·Ú·ÎÙËÚÈÛÙÈο ¤ˆ˜ fiÙÔ˘ ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·Ú¯›ÛÂÈ Ó· ÏÂÈÙÔ˘ÚÁ› ÈηÓÔÚÔÛÒÔ˘, Ó¢ÚÈÎfiÙËÙ·, Êfi‚Ô˜ ÔÈËÙÈο. ∞˘Ùfi ÚÔηÏ› ·›ÛıËÌ· ¿Á¯Ô˘˜ ÛÙÔÓ ·ÛıÂÓ‹. £· Ú¤ÂÈ Ó· ‰È·‚‚·Èˆı› fiÙÈ ·˘Ùfi ‰ÂÓ Â›Ó·È ·Û˘Ó‹ıÈÛÙÔ. OÈ ·ÛıÂÓ›˜ ÌÔÚÔ‡Ó Â›Û˘ Ó· ·ÓÙȉڿÛÔ˘Ó ·ÚÓËÙÈο ÛÙÔ Êfi‚Ô Èı·Ó‹˜ ·fiÚÚȄ˘. ∞ÍÈÔÏfiÁËÛË ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ˘ÔÛÙËÚÈÎÙÈÎÒÓ ‰ÈÎÙ‡ˆÓ Î·È ÃÚ‹ÛÈ̘ ÛÙÚ·ÙËÁÈΤ˜ ·ÓÙÈÌÂÙÒÈÛ˘ ‰‡ÛÎÔÏˆÓ Î·Ù·ÛÙ¿ÛÂÙˆÓ Ì˯·ÓÈÛÌÒÓ ·Ô‰Ô¯‹˜. ˆÓ ÛÙÔ ·ÚÂÏıfiÓ ÌÔÚ› ‹ fi¯È Ó· Â›Ó·È ¯Ú‹ÛÈ̘. ∞ÍÈÔÏfiÁËÛË Ù˘ ÈηÓfiÙËÙ·˜ ÙÔ˘ ·ÛıÂÓ‹ ÁÈ· ·Ô‰Ô¯‹ ∞˘Ùfi Â›Ó·È ÛËÌ·ÓÙÈÎfi, ·ÊÔ‡ Ô ·ÛıÂÓ‹˜ ı· Ï·Ì‚¿ÓÂÈ ·ÓÔÛÔÙ˘ ¢ı‡Ó˘ ÁÈ· ·˘ÙÔÊÚÔÓÙ›‰·. ηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙÔ ˘fiÏÔÈÔ Ù˘ ˙ˆ‹˜ ÙÔ˘ ÒÛÙ ӷ ·ÔÊ¢¯ı› Ë ·fiÚÚÈ„Ë ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∞ÍÈÔÏfiÁËÛË Ù˘ ›‰Ú·Û˘ Ù˘ ·Ûı¤ÓÂÈ·˜ Û ÚfiÏÔ˘˜ Î·È Û¯¤ÛÂȘ ∫·Ù¿ ÙËÓ ·Ó¿ÚÚˆÛË, ·ÍÈÔÏfiÁËÛË Ù˘ ·ÓÙ›‰Ú·Û˘ Û OÈ ·ÚÂÓ¤ÚÁÂȘ ÙˆÓ ÛÙÂÚÔÂȉÒÓ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ·ÏÏ·Á¤˜ ÛÙËÓ Â͈ÙÂÚÈ΋ ÂÌÊ¿ÓÈÛË. ·‡ÍËÛË ‚¿ÚÔ˘˜, ·‡ÍËÛË ÙÚȯÔÊ˘˝·˜ ÛÙÔ ÚfiÛˆÔ Î·È ÛÙÔ ÛÒÌ·, ÛÂÏËÓÔÂȉ¤˜ ÚÔÛˆÂ›Ô Î·È Â‡ıÚ·˘ÛÙÔ ‰¤ÚÌ·. ∫¿ÔÈ· ·fi ·˘Ù¿ Â›Ó·È È‰È·›ÙÂÚ· ÂÓÔ¯ÏËÙÈο ÁÈ· Á˘Ó·›Î˜.
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A. ¶A¶A™HMAKO¶OY§OY
£Âڷ¢ÙÈΤ˜ ¶·ÚÂÌ‚¿ÛÂȘ ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ
∞ÈÙÈÔÏÔÁ›·
¶·ÚÔ¯‹ ¯ÚfiÓÔ˘ ÛÙÔÓ ·ÛıÂÓ‹ Ó· ÂΉËÏÒÛÂÈ ÙÔ˘˜ Êfi‚Ô˘˜ Î·È ÙÔ ¿Á¯Ô˜ ÙÔ˘.
ªÂÙ¿ ÙËÓ Â¤Ì‚·ÛË, Ô ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˜ ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ‰È·ÙËÚ› Ù˘ ˘Á›· ÙÔ˘ ¯ˆÚ›˜ Ó· ‚·Û›˙ÂÙ·È ÛÙÔ ÚÔÛˆÈÎfi Ù˘ οı·ÚÛ˘. ∞˘Ù‹ Ë ·ÓÂÍ·ÚÙËÛ›·, ÔÏϤ˜ ÊÔÚ¤˜ ÚÔηÏ› Êfi‚Ô, ȉȷ›ÙÂÚ· ÏfiÁˆ Èı·Ó‹˜ ·fiÚÚȄ˘ ‹ Ïԛ̈͢. μÔ‹ıÂÈ· Ì ٷ ‰È·ı¤ÛÈÌ· ˘ÔÛÙËÚÈÎÙÈο ‰›ÎÙ˘· ¯ ÔÌ¿‰Â˜ OÈ Û¯¤ÛÂȘ Ì ·ÓıÚÒÔ˘˜ Ô˘ ¤¯Ô˘Ó ·ÚfiÌÔȘ ÂÌÂÈڛ˜ ˘ÔÛÙ‹ÚÈ͢ ‹ ¿ÏÏÔ˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˜ ·ÛıÂÓ‹˜ ÁÈ· Ó· Û˘- Î·È ÛÙfi¯Ô˘˜ ÌÔÚ› Ó· Â›Ó·È ˆÊ¤ÏÈ̘. ˙ËÙ‹ÛÂÈ Û¯ÂÙÈο Ì ÙȘ ·ÏÏ·Á¤˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ˙ˆ‹ ÙÔ˘. ¶·ÚÔ¯‹ „˘¯ÔÏÔÁÈ΋˜ ÛÙ‹ÚÈ͢. ∂¿Ó Ô ·ÛıÂÓ‹˜ ‰È·Î·Ù¤¯ÂÙ·È ·fi ¿Á¯Ô˜ ÂÍ·ÈÙ›·˜ Ù˘ ·Ó¿Á΢ ÁÈ· οı·ÚÛË ÌÂÙÂÁ¯ÂÈÚËÙÈο, ÙÔÓ ‰È·‚‚·ÈÒÓÔ˘Ì fiÙÈ ·˘Ùfi ‰ÂÓ Â›Ó·È ·Û˘Ó‹ıÈÛÙÔ È‰›ˆ˜ Û ϋÙ˜ و̷ÙÈÎÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ.
¡ÔÛËÏ¢ÙÈ΋ ‰È¿ÁÓˆÛË: ŒÏÏÂÈÌÌ· ÁÓÒÛ˘ ™¯ÂÙÈ˙fiÌÂÓÔÈ ·Ú¿ÁÔÓÙ˜ ¡¤Â˜ Û˘Óı‹Î˜ ª·ÎÚÔÚfiıÂÛÌÔ˜ ۯ‰ȷÛÌfi˜ ¶ÚÔÛ‰ÈÔÚÈÛÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο §ÂÎÙÈ΋ ¤ÎÊÚ·ÛË Ù˘ Û‡Á¯˘Û˘ Û¯ÂÙÈο Ì ÙË ıÂڷ›· ŒÏÏÂÈ„Ë ÂÚˆÙ‹ÛÂˆÓ ¶·Ú¿ÎÏËÛË ÁÈ· ÏËÚÔÊÔڛ˜ ∞Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·: O ·ÛıÂÓ‹˜ ‹ Ô ÊÚÔÓÙÈÛÙ‹˜ ÂÎÊÚ¿˙ÂÈ ÏÂÎÙÈο ÙËÓ Î·Ù·ÓfiËÛË Ù˘ Û˘ÓÔÏÈ΋˜ ‰È·‰Èηۛ·˜ ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·˜ Î·È ÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·˘ÙÔÊÚÔÓÙ›‰·. ¶ÚÔԉ¢ÙÈ΋ ÂÎÙ›ÌËÛË ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ
∞ÈÙÈÔÏÔÁ›·
∂ÎÙ›ÌËÛË Ù˘ ηٷÓfiËÛ˘ ·fi ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ªÂÙÂÁ¯ÂÈÚËÙÈο ÔÈ ·ÛıÂÓ›˜ ηٷÎχ˙ÔÓÙ·È ·fi ÔÏϤ˜ ÁÈ· ÙËÓ Â¤Ì‚·ÛË, ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÚ›·, Ê·Ú̷΢ÙÈ΋ ·ÁˆÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜ Ô˘ ·ÔÙÂÏÔ‡Ó Â˘ı‡ÓË ÙÔ˘˜ Á‹ Î·È ·ÚÂÓÂÚÁÂÈÒÓ Î·È ÙËÓ Èı·Ó‹ ·ÏÏ·Á‹ ÛÙÔÓ ÙÚfiÔ ˙ˆ‹˜. (Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ·Ó·ÁÓÒÚÈÛË ÛËÌ›ˆÓ Ïԛ̈͢ £Âڷ¢ÙÈΤ˜ ¶·ÚÂÌ‚¿ÛÂȘ ∂Ó¤ÚÁÂȘ / ¶·ÚÂÌ‚¿ÛÂȘ
∞ÈÙÈÔÏÔÁ›·
∂η›‰Â˘ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹ ÙÔ˘ ÊÚÔÓÙÈÛÙ‹ Û¯ÂÙÈο Ì ÙË Δ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ·ÎÔÏÔ˘ıÒÓÙ·˜ ÙȘ ·Ú·Î¿Ùˆ ÂÓ¤ÚÁÂȘ : ηıËÌÂÚÈÓ¿ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ∂η›‰Â˘ÛË ÁÈ· ÙË Ï‹„Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ηıË- ™ÙÂÚÔÂȉ‹, ·ÓÙÈÌÂÙ·‚Ôϛ٘ Î·È ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÌÂÚÈÓ¿ Î·È ÁÈ· ¿ÓÙ· (Gutch, 2003 & Thomas 2003) Ó˘ Â›Ó·È Ë Û˘Ó‹ı˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ô˘ ‰›ÓÂ1. ∞Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ Ù·È ÁÈ· Ó· ηٷÛÙ›ÏÂÈ ÙÔ ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ· ÁÈ· Ó· 2. ∞ÓÙÈÌÂÙ·‚Ôϛ٘ ·Ô‰Â¯ı› ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ∞˘Ù‹ Ë ·ÁˆÁ‹ ·˘Í¿ÓÂÈ 3. ™ÙÂÚÔÂȉ‹ ÙÔÓ Î›Ó‰˘ÓÔ Ïԛ̈͢ Î·È ·Ó¿Ù˘Í˘ ηÎÔËıÂÈÒÓ ÔÈ ∂η›‰Â˘ÛË ÁÈ· ÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ ··ÈÙ‹ÛÂȘ οı ʷÚÌ¿ÎÔ˘ Ôԛ˜ ÚÔηÏÔ‡ÓÙ·È ·fi ÙË ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ·ÓÔÛÔÔÈË(¯: Ï‹„Ë Î˘ÎÏÔÛÔÚ›Ó˘ Ì ¿‰ÂÈÔ ÛÙÔÌ¿¯È, ÛÙÂÚÔÂȉ‹ Ì ÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. Ê·ÁËÙfi) ∂η›‰Â˘ÛË Û¯ÂÙÈο Ì ÙȘ ·ÚÂÓ¤ÚÁÂȘ Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜ (¯ ˘¤ÚÙ·ÛË, ·ÏÏ·Á¤˜ ÛÙË ‰È¿ıÂÛË, ‡ıÚ·˘ÛÙ· ÔÛÙ¿). ∂η›‰Â˘ÛË Û¯ÂÙÈο ÌÂ Û˘ÌÙÒÌ·Ù·/ ÛËÌ›· ÙÔÈ΋˜ Î·È OÈ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·Ó¿Û˘ÛÙËÌ·ÙÈ΋˜ Ïԛ̈͢. Ù˘Í˘ ÏÔÈÌÒÍÂˆÓ ÂÍ·ÈÙ›·˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ıÂڷ›·˜ ∂η›‰Â˘ÛË Û¯ÂÙÈο ÌÂ Û˘ÌÙÒÌ·Ù·/ ÛËÌ›· ·fiÚÚȄ˘ OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ı· ‚ÈÒÛÔ˘Ó Î¿ÔÈÔ˘ Ù‡Ô˘ ÔÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜: ˘ÚÂÙfi˜, ·‡ÍËÛË ÛˆÌ·ÙÈÎÔ‡ ‚¿ÚÔ˘˜, Í›· ·fiÚÚÈ„Ë ·Ó·ÛÙÚ¤„ÈÌË Ì ıÂڷ›·. ∏ ¯ÚfiÓÈ· ·Ì›ˆÛ˘ Ô‡ÚˆÓ, ·‡ÍËÛË ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ÂÒ‰˘ÓË ‰ÈfiÁΈ- fiÚÚÈ„Ë Â¤Ú¯ÂÙ·È ‚·ıÌÈ·›· Î·È ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛË Î·Ù¿ ÙË „ËÏ¿ÊËÛË ÛÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ÙÔÌ‹, ·‡ÍËÛË ÎÚ·ÙÈÌË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ ÓÂÊÚÔ‡. ∏ ÔÍ›· ·fiÚÚÈ„Ë ·ÓÙÈÓ›Ó˘, ·‡ÍËÛË Ù˘ Ô˘Ú›·˜ ÛÙÔ ·›Ì·. ÌÂÙˆ›˙ÂÙ·È Ì ˘„ËϤ˜ ‰fiÛÂȘ ÛÙÂÚÔÂȉÒÓ, Î·È ·ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ (Gutch, 2003 & Thomas 2003) ∂Í·ÛÊ¿ÏÈÛË fiÙÈ Ô ·ÛıÂÓ‹˜ ÁÓˆÚ›˙ÂÈ ÙÈ Ó· οÓÂÈ Î·È ÔÈÔÓ Ó· ηϤÛÂÈ Û ÂÚ›ÙˆÛË ˘Ô„›·˜ ·fiÚÚȄ˘ ‹ Ïԛ̈͢. ∂η›‰Â˘ÛË Û¯ÂÙÈο Ì ÙËÓ ÚÔÙÂÈÓfiÌÂÓË ‰›·ÈÙ·. OÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÛıÂÓ›˜ ‰Â ¯ÚÂÈ¿˙ÂÙ·È Ó· ·ÎÔÏÔ˘ıÔ‡Ó ·˘ÛÙËÚ‹ ‰›·ÈÙ· ÓÂÊÚÔ·ıÔ‡˜. ¶·ÚfiÏ·’ ·˘Ù¿ Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ‰È·ÙËÚÔ‡Ó ÌÂȈ̤ӷ ›‰· Ó·ÙÚ›Ô˘ ÁÈ· Ó· ·ÔʇÁÔ˘Ó ÙËÓ Î·Ù·ÎÚ¿ÙËÛË ˘ÁÚÒÓ ÏfiÁˆ ÙˆÓ ÛÙÂÚÔÂȉÒÓ Î·È ·˘ÍË̤ӷ ›‰· ÚˆÙÂ˚ÓÒÓ ÁÈ·Ù› Ù· ÛÙÂÚÔÂȉ‹ ·Ô‰ÔÌÔ‡Ó ÙȘ ÚˆÙ½Ó˜.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù· ∂η›‰Â˘ÛË ÁÈ· ÙË ÛËÌ·ÓÙÈÎfiÙËÙ· Ù˘ ÛˆÛÙ‹˜ ·ÙÔÌÈ΋˜ ˘ÁÈÂÈÓ‹˜ ∂η›‰Â˘ÛË ·ÛıÂÓÔ‡˜ Ó· ¤¯ÂÈ ¿ÓÙÔÙ ̷˙› ÙÔ˘ οÚÙ· Ô˘ ı· ·Ó·Ê¤ÚÂÈ fiÙÈ Â›Ó·È ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˜ Î·È fiÙÈ Â›Ó·È Û ·ÓÙÈ·ÔÚÚÈÙÈ΋ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹.
™ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ Û¯¤‰ÈÔ ÊÚÔÓÙ›‰·˜ ηٷÁÚ¿ÊÔÓÙ·È ÔÈ Èı·Ó¤˜ ÓÔÛËÏ¢ÙÈΤ˜ ‰È·ÁÓÒÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó ¤Ó·Ó ·ÛıÂÓ‹ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ∂Í·ÙÔÌÈ·ÔÓÙ·˜ ÙË ÊÚÔÓÙ›‰· ÙÔ˘, Â›Ó·È ·Ó·Áη›· Ì›· ÂÎÙÂٷ̤ÓË ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ (ÓÔÛËÏ¢ÙÈÎfi ÈÛÙÔÚÈÎfi – Ê˘ÛÈ΋ ÂͤٷÛË – Û˘Ó¤ÓÙ¢ÍË ·fi ÔÈÎÔÁ¤ÓÂÈ·) ÒÛÙ ӷ ÂÓÙÔÈÛÙÔ‡Ó ÔÈ ·Ó¿ÁΘ Î·È Î·Ù’ ¤ÎÙ·ÛË ÔÈ ÓÔÛËÏ¢ÙÈΤ˜ ‰È·ÁÓÒÛÂȘ Ô˘ ÚÔ·ÙÔ˘Ó ÙfiÛÔ ·fi ÙË Û˘ÁÎÂÎÚÈ̤ÓË Î·Ù¿ÛÙ·ÛË (ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡) fiÛÔ Î·È ·fi ÙË Û˘ÓÔÏÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ (Û˘Ó˘¿Ú¯ÔÓÙ· ÓÔÛ‹Ì·Ù·, ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· η). ™ËÌ·ÓÙÈÎfi Â›Ó·È fiÙÈ ÙÔ ·Ú·¿Óˆ Û¯¤‰ÈÔ ÊÚÔÓÙ›‰·˜ ¤¯ÂÈ Î·È ·ÓÙ›ÛÙÔȯ· ¤ÓÙ˘· ÁÈ· ÙËÓ ÙÂÎÌËÚ›ˆÛË Ù˘ ÊÚÔÓÙ›‰·˜ Ô˘ ÙÂÏÈο ı· Ï¿‚ÂÈ ·ÙÔÌÈο Ô Î¿ı ·ÛıÂÓ‹˜. ∏ ÓÔÛËÏ¢ÙÈ΋ ‰ÈÂÚÁ·Û›· ˆ˜ ̤ıÔ‰Ô˜ ¤¯ÂÈ Î·È ÂÈÎÚÈÙ¤˜. ™˘ÁÎÂÎÚÈ̤ӷ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Û‡Á¯˘ÛË Û ÌË ¤ÌÂÈÚÔ˘˜ Î·È Î·Ù¿ÏÏËÏ· ÂÎ·È‰Â˘Ì¤ÓÔ˘˜ ÓÔÛËÏÂ˘Ù¤˜. ∂›Û˘, ÛÙËÓ ·ÓÙ›ıÂÙË ÂÚ›ÙˆÛË ÙˆÓ ÂÍÂȉÈÎÂ˘Ì¤ÓˆÓ ÓÔÛËÏ¢ÙÒÓ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÚÈÔÚÈÛÌfi Ù˘ ÓÔÛËÏ¢ÙÈ΋˜ Î·È ÎÚÈÙÈ΋˜ ÛΤ„˘ ‹ Î·È Û ÌË ·Ó·ÁÓÒÚÈÛË ÔÏÈÙÈÛÌÈÎÒÓ È‰È·ÈÙÂÚÔÙ‹ÙˆÓ ·ÛıÂÓÒÓ (§ÂÌÔÓ›‰Ô˘ & ¶·ÙËÚ¿ÎË, 2003). ¶·ÚfiÏ·˘Ù¿, Ë ¯Ú‹ÛË ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÙÚfiÔ˘ ۯ‰ȷÛÌÔ‡ Ù˘ ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· fiˆ˜ ÂÍ·ÙƠ̂΢ÛË Ù˘ ÊÚÔÓÙ›‰·˜, ÂÓË̤ڈÛË Î·È Û˘Ì-
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¡· ÌÂȈı› Ë Â›ÙˆÛË ÙˆÓ ÏÔÈÌÒ͈Ó.
ÌÂÙÔ¯‹ ·ÛıÂÓÒÓ, ÚÔÙ˘ÔÔÈË̤ÓË ÔÚÔÏÔÁ›· Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÈÎÔÈÓˆÓ›·˜ ÌÂٷ͇ ÓÔÛËÏ¢ÙÒÓ ·ÏÏ¿ Î·È ÙˆÓ ¿ÏÏˆÓ Â·ÁÁÂÏÌ·ÙÈÒÓ ˘Á›·˜, ÔÚÈÔı¤ÙËÛË ÓÔÛËÏ¢ÙÈÎÔ‡ ·ÁÁ¤ÏÌ·ÙÔ˜, ÓÔÛËÏ¢ÙÈ΋ Âη›‰Â˘ÛË.
∂§§∏¡π∫∏ μπμ§πO°ƒ∞ºπ∞ ∫·Ï·Ê¿ÙË ª., ªÂÏÏ¿ÏË £., ÷Ù˙ÔÔ‡ÏÔ˘ ª., º‡ÙÚÔ˘ ∂., ∫ÔÚ¤ÏË ∞., ∏ÏÈÔÔ‡ÏÔ˘ ∞. (2007), «ªÂıÔ‰ÔÏÔÁ›· ·Ó¿Ù˘Í˘ ÎÏÈÓÈÎÒÓ Î·Ù¢ı˘ÓÙËÚ›ˆÓ Ô‰ËÁÈÒÓ», ¡ÔÛËÏ¢ÙÈ΋, 46 (1): 31-37. §ÂÌÔÓ›‰Ô˘ Ã, ¶·ÙËÚ¿ÎË ∂. (2003) £ÂÌÂÏÈÒ‰ÂȘ ·Ú¯¤˜ Ù˘ ÓÔÛËÏ¢ÙÈ΋˜, ∂ΉfiÛÂȘ ¶·Û¯·Ï›‰Ë˜, ΔfiÌÔ˜ π, 21:350364 ™˘Ú¿ÎÔ˜ £. (1992).OÚÁ¿ÓˆÛË ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙË ¯ÒÚ· Ì·˜. ∂¡™ ªÂÙ·ÌfiÛ¯Â˘ÛË Î·È ¡ÔÛËÏ¢ÙÈ΋. 9-10 Gutch CF, Stoner MH, Corea AL. (2003) ∏ ·ÈÌÔοı·ÚÛË ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË, Ô ÚfiÏÔ˜ Ù˘ ˘ÁÂÈÔÓÔÌÈ΋˜ ÔÌ¿‰·˜. ∂È̤ÏÂÈ·: £.∫ ∞ÁÚ·ÊÈÒÙ˘, Ã.¢. ™˘ÚÁοÓ˘, ¶.¡. ∑ËÚÔÁÈ¿ÓÓ˘. ŒÎÙË ŒÎ‰ÔÛË. ∞ı‹Ó·, 15:276-279. Thomas N. (2003) ¡ÂÊÚÔÏÔÁÈ΋ ¡ÔÛËÏ¢ÙÈ΋. ªÂÙ¿ÊÚ·ÛË ∫·˘ÎÈ¿ ıÂÔ‰ÒÚ·. ¢Â‡ÙÂÚË ŒÎ‰ÔÛË. University Studio Press, £ÂÛÛ·ÏÔÓ›ÎË, 11, 541-545
•∂¡∏ μπμ§πO°ƒ∞ºπ∞ Gulanick M., Klopp A., Galanes S., Gratishar D., Puzas M. (1998), Nursing Care Plans, Mosby, St. Louis, USA. NANDA – π Nursing Diagnoses: Definitions & Classification 2007-2008. Sox H. (2007). What is a care plan? www.careplans.com, accessed 2/10/2007.
™˘¯ÓfiÙËÙ· Î·È ÂȉËÌÈÔÏÔÁ›· ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË
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™˘ÌÂÒÓ MÂÙ·ÏÏ›‰Ë˜
ÓÂÙ·È Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ÏÔÈÌÒÍÂˆÓ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ ·Ó¿ÏÔÁ· Ì ÙÔ Â›‰Ô˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÏÔÈÌÒÍÂȘ ÙÔÓ ÚÒÙÔ Ì‹Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ¯ÂÈÚÔ˘ÚÁ›Ô. ¶ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÌÈÎÚԂȷΤ˜ Î·È Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ. ∏ ÌfiÓË Û˘¯Ó‹ ÈÔÁÂÓ‹˜ Ïԛ̈ÍË Î·Ù¿ ÙËÓ ‰È¿ÚÎÂÈ· ÙÔ˘ 1Ô˘ Ì‹Ó· Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ ·fi ÙÔÓ ÈÔ ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ· (HSV). OÊ›ÏÔÓÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ Û ·ÓÂÚÁÔÔ›ËÛË. ∏ ÚÔÊ˘Ï·ÎÙÈ΋ ·ÁˆÁ‹ Ì ·Î˘ÎÏÔ‚›ÚË Û ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô ¤¯ÂÈ ÂÏ·ÙÙÒÛÂÈ ÛËÌ·ÓÙÈο ·˘Ù‹ ÙËÓ Â›ÙˆÛË. ¶·ıÔÁfiÓ· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ‰È·Ù·Ú·¯¤˜ Ù˘ ΢ÙÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ Û¿ÓÈ· ÂÌÊ·Ó›˙ÔÓÙ·È Û ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô. ΔËÓ ÂÚ›Ô‰Ô Ì¤¯ÚÈ ÙÔ˘˜ ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÌÊ·Ó›˙ÔÓÙ·È ÏÔÈÌÒÍÂȘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ù˘Èο Ì ÙËÓ ·ÓÔÛÔηٷÛÙÔÏ‹. ∂˘Î·ÈÚȷΤ˜ ÏÔÈÌÒÍÂȘ fiˆ˜ CMV, Pneumocystis carinii, Aspergillus spp., Nocardia spp., T. Gondii, Î·È Listeria monocytogenes ΢ÚÈ·Ú¯Ô‡Ó ÙËÓ ÂÚ›Ô‰Ô ·˘Ù‹.
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ Â›Ó·È ÌÈ· ıÂڷ¢ÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ÔÏÏ¿ ÓÔÛ‹Ì·Ù·. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·ÔÙÂÏ› ·Ó·ÁÓˆÚÈṲ̂ÓË ıÂڷ¢ÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ∏ ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÌÂÙ¿ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯Ô˘Ó ·˘ÍËı› ÛËÌ·ÓÙÈο ¯¿ÚË ÛÙËÓ ÚfiÔ‰Ô ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ, ÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂڷ›· Î·È ÙËÓ È·ÙÚÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ŸÌˆ˜ ÔÈ ÂÈÏÔΤ˜ fiˆ˜ ÔÈ ÏÔÈÌÒÍÂȘ Î·È Ë ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂڷ›· ·Ú·Ì¤ÓÔ˘Ó ÔÈ Î‡ÚȘ ·Èٛ˜ ıÓËÙfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË. À¿Ú¯Ô˘Ó ÙÚÂȘ ¯ÚÔÓÈΤ˜ ÂÚ›Ô‰ÔÈ, Ô˘ ÂËÚ¿˙ÔÓÙ·È ·fi ÙÔ ¯ÂÈÚÔ˘ÚÁ›Ô, ÙÔ ‚·ıÌfi Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È ÂÚÈ‚·Ï·ÓÙÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ηٿ ÙËÓ ‰È¿ÚÎÂÈ· ÙˆÓ ÔÔ›ˆÓ Û˘ÁÎÂÎÚÈ̤ÓÔÈ Ù‡ÔÈ ÏÔÈÌÒÍÂˆÓ Û˘Ì‚·›ÓÔ˘Ó ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔÓ ÚÒÙÔ Ì‹Ó·, ÙËӉ‡ÙÂÚË ÂÚ›Ô‰Ô Ì¤¯ÚÈ ÙÔ˘˜ ¤ÍÈ Ì‹Ó˜ Î·È ÙËÓ ÙÂÏÂ˘Ù·›· ÌÂÙ¿ ÙÔ˘˜ ¤ÍÈ Ì‹Ó˜. ™ÙÔ Û¯‹Ì· 1 Ê·›-
™¯‹Ì· 1. ∂›ÙˆÛË ÏÔÈÌÒÍÂˆÓ Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜.
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Hepatitis B, C CMV
121
CMV retinitis VZV
HSV
EBV HHV-6
JC/BK
Adenovirus
Transplant
Months posttransplant
™¯‹Ì· 2. ÃÚÔÓÈ΋ ηٷÓÔÌ‹ ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜.
ªÂÙ¿ ÙÔ˘˜ 6 Ì‹Ó˜ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ÂÌÊ·Ó›˙Ô˘Ó ÏÔÈÌÒÍÂȘ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Î·È ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∏ ÌfiÓË Â˘Î·ÈÚȷ΋ ÈÔÁÂÓ‹˜ Ïԛ̈ÍË Ô˘ ÂÌÊ·Ó›˙ÂÙ·È Û ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô Â›Ó·È Ë ÂÌÊ¿ÓÈÛË ¤ÚËÙ· ˙ˆÛÙ‹Ú·. ™¿ÓÈ· ÂÌÊ·Ó›˙ÂÙ·È ·ÌÊÈ‚ÏËÛÙÚÔÂȉ›Ùȉ· ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi. OÈ Î‡ÚÈÔÈ ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÏÔÈÌÒÍÂȘ Û ·˘Ù‹ ÙËÓ ÂÚ›Ô‰Ô Â›Ó·È Ù· Û˘¯Ó¿ ÂÂÈÛfi‰È· ·fiÚÚȄ˘ ÙËÓ ÚÔËÁÔ‡ÌÂÓË ÂÚ›Ô‰Ô Ù· ÔÔ›· ¯ÚÂÈ¿ÛÙËÎ·Ó ÂÈÚfiÛıÂÙË ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È Ë ¯ÚfiÓÈ· ·fiÚÚÈ„Ë Ô˘ ··ÈÙ› ·˘ÍË̤ÓË ·ÓÔÛÔηٷÛÙÔÏ‹. ™Â ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Â˘Î·ÈÚȷΤ˜ ÏÔÈÌÒÍÂȘ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ÂÚÈfi‰Ô˘. ™ÙÔ Û¯‹Ì· 2 Ê·›ÓÂÙ·È Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË.
∂ÚËÙÔ˚Ô› OÈ ÂÚËÙÔ˚Ô› fiˆ˜ Ô CMV, EBV, Herpes eimplex virus (HSV-1), HSV-2, varicella zoster (VZV), HHV-6, HHV-7 Î·È Ô HHV-8 Â›Ó·È Ù· ÈÔ ÛËÌ·ÓÙÈο ÈÔÁÂÓ‹ ·ıÔÁfiÓ· ÁÈ· ÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜. Œ¯Ô˘Ó ÙËÓ ‰˘Ó·ÙfiÙËÙ· Ó· ·Ú·Ì¤ÓÔ˘Ó Û ϷÓı¿ÓÔ˘Û· ηٿÛÙ·ÛË Û fiÏË ÙËÓ ˙ˆ‹ Î·È Ó· ·ӷÓÂÚÁÔÔÈËıÔ‡Ó Û ·¿ÓÙËÛË ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ, ȉȷ›ÙÂÚ· ÚÔÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÔΛÓ˜. °ÂÓÈο Ë ÚˆÙÔ·ı‹˜ Ïԛ̈ÍË Â›Ó·È ÈÔ ÛÔ‚·Ú‹ Û ۯ¤ÛË Ì ÙËÓ Â·Ó·ÓÂÚÁÔÔ›ËÛË. OÈ ÂÚËÙÔ˚Ô› Ú¤ÂÈ Ó· ıˆÚÔ‡ÓÙ·È ÔÁÎÔÁfiÓÔÈ Ì¤¯ÚÈ Ó· ·Ô‰ÂȯÙ› ÙÔ ·ÓÙ›ıÂÙÔ. ∂›Ó·È ÍÂοı·ÚË Ë Û˘Û¯¤ÙÈÛË ÌÂٷ͇ EBV Î·È (PTLD) Î·È ÌÂٷ͇ HHV-8 Î·È Û·ÚÎÒÌ·ÙÔ˜ Kaposi. ∏ Ïԛ̈ÍË ·fi CMV ·˘Í¿ÓÂÈ ÙÔ Î›Ó‰˘ÓÔ ÁÈ· PTLD ηٿ 7-10 ÊÔÚ¤˜.
∫˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜ (CMV) O CMV Â›Ó·È Ô ÈÔ ÛËÌ·ÓÙÈÎfi˜ Èfi˜ Ô˘ ÚÔ-
Û‚¿ÏÏÂÈ ÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜, ÙfiÛÔ ¿ÌÂÛ· fiÛÔ Î·È ¤ÌÌÂÛ· ̤ۈ ΢ÙÔÎÈÓÒÓ Î·È ¿ÏÏˆÓ ÌÂÛÔÏ·‚ËÙÒÓ Û ·¿ÓÙËÛË Ù˘ ÈÔÁÂÓÔ‡˜ ·ÓÙÈÁÚ·Ê‹˜ Î·È ÂÈÛ‚ÔÏ‹˜ ÛÙ· ·ÙÙ·Ú·. OÈ ÏÔÈÌÒÍÂȘ ·fi CMV Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÙÔ˘˜ 3 ÚÒÙÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiÙ·Ó Ë ·ÓÔÛÔηٷÛÙÔÏ‹ Â›Ó·È ¤ÓÙÔÓË. ∂ÌÊ·Ó›˙ÂÙ·È Û ÔÛÔÛÙfi ·fi 44-85% ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ™˘Ìو̷ÙÈ΋ ÓfiÛÔ˜ ·fi CMV Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ 8% ÙˆÓ ·ÛıÂÓÒÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, Û ۯ¤ÛË Ì ÙÔ 29% ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜.
πfi˜ ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ· (HSV) O HSV ΢ڛˆ˜ ÚÔηÏ› ÏÔÈÌÒÍÂȘ ·fi ·ӷÓÂÚÁÔÔ›ËÛË, ·ÏÏ¿ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î·È ÚˆÙÔ·ı‹ Ïԛ̈ÍË. ∞ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ HSV ·Ó¢ڛÛÎÔÓÙ·È ÛÙ· _ ÙˆÓ ÂÓËÏ›ÎˆÓ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È. ªÂÙ¿ ·fi ÙËÓ ÚˆÙÔ·ı‹ Ïԛ̈ÍË Ô Èfi˜ ·Ú·Ì¤ÓÂÈ Û ϷÓı¿ÓÔ˘Û· ηٿÛÙ·ÛË ÛÙ· ·ÈÛıËÙÈο Ó¢ÚÈο Á¿ÁÁÏÈ·. ∏ ·ӷÓÂÚÁÔÔ›ËÛË Û˘Ì‚·›ÓÂÈ Î‡ÚÈ· ÛÙË ÛÙÔÌ·ÙÈÎfi Î·È ÁÂÓÓËÙÈÎfi ‚ÏÂÓÓÔÁfiÓÔ Î‡ÚÈ· ηٿ ÙËÓ ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ Ì‹Ó· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÂÚ›Ô˘ 1/3 ÙˆÓ ÂÓËÏ›ÎˆÓ ·ÛıÂÓÒÓ Î·È 8% ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ (ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi Ï·Óı¿ÓÔ˘Û·˜ Ïԛ̈͢). ∏ ¯Ú‹ÛË ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ O∫Δ3 ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·ӷÓÂÚÁÔÔ›ËÛ˘.
πfi˜ ·ÓÂÌÔ‚ÏÔÁÈ¿˜ – ¤ÚËÙ· ˙ˆÛÙ‹Ú· ΔÔ 90% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Â›Ó·È ıÂÙÈÎÔ› ÚÔ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ı· ÂÌÊ·Ó›ÛÔ˘Ó ¤ÚËÙ· ˙ˆÛÙ‹Ú·. ΔÔ ˘fiÏÔÈÔ 10% Â›Ó·È ÔÚÔ·ÚÓËÙÈÎfi Î·È ‚Ú›ÛÎÂÙ·È ÛÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÚˆÙÔ·ıÔ‡˜ Ïԛ̈͢. ∂ÌÊ¿ÓÈÛË ¤ÚËÙ· ˙ˆÛÙ‹Ú· Û˘Ì‚·›ÓÂÈ ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ ÌÂÙ¿
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ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙÔ 5-13% ÙˆÓ ·ÛıÂÓÒÓ. ∏ ¯Ú‹ÛË ¯·ÌËÏ‹˜ ‰fiÛ˘ ·Î˘ÎÏÔ‚›Ú˘ ÁÈ· ÚÔʇϷÍË ·fi HSV Èı·Ó¿ Ó· ÚÔÛٷهÂÈ ·fi ·ӷÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÈÔ‡ ·ÓÂÌÔ‚ÏÔÁÈ¿˜ – ¤ÚËÙ· ˙ˆÛÙ‹Ú·. ¶·ÚfiϘ ÙȘ ÂÈÊ˘Ï¿ÍÂȘ ÁÈ· ÙËÓ ¯Ú‹ÛË ˙ÒÓÙˆÓ ÂÌ‚ÔÏ›ˆÓ Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÌÈ· ÚfiÛÊ·ÙË ÌÂϤÙË Î·Ù¤‰ÂÈÍ ÙËÓ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡.
ÎÔÓ‰˘ÏˆÌ¿ÙˆÓ, ·ÎfiÌ· Î·È Ô˘ÚËıÚÈÎÒÓ. O Èfi˜ JC Ô˘ ÚÔηÏ› ÙËÓ ÚÔԉ¢ÙÈ΋ ÔÏ˘ÂÛÙȷ΋ Ï¢ÎÔÂÁÎÂÊÏÔ¿ıÂÈ· ÙÔ˘ ∫ÂÓÙÚÈÎÔ‡ ¡Â˘ÚÈÎÔ‡ ™˘ÛÙ‹Ì·ÙÔ˜ ¤¯ÂÈ ·Ó‚ÚÂı› Û¿ÓÈ· Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. O Èfi˜ μ∫ ·ÔÌÔÓÒıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi Ù· Ô‡Ú· ·ÛıÂÓÔ‡˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ô˘ ›¯Â ÌÈ· Ô˘ÚËıÚÈ΋ ÛÙ¤ÓˆÛË Î·È ¤ÎÙÔÙÂ Û˘Ó‰¤ıËΠ̠ÙËÓ Û˘ÁÎÂÎÚÈ̤ÓË ÂÈÏÔ΋ Î·È Û ¿ÏϘ ·Ó·ÊÔÚ¤˜.
πfi˜ Epstein-Barr (EBV)
ÕÏÏÔÈ ÈÔ›
O Èfi˜ EBV ÌÔÚ› Ó· ÚÔηϤÛÂÈ ‹È· Û˘ÌÙÒÌ·Ù· fiˆ˜ ÎfiˆÛË, ˘ÚÂÙfi˜, ÎÂÊ·Ï·ÏÁ›·, ·ÏÏ¿ ÌÔÚ› Ó· Û˘Û¯ÂÙ›˙ÂÙ·È Î·È Ì ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈ΋ ÓfiÛÔ (PTLD) Ô˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ıÓËÙfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜ Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜. ∏ Û˘¯ÓfiÙËÙ· Ù˘ PTLD Î˘Ì·›ÓÂÙ·È ·fi 1% Û ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, 1,8-4,5% Û ηډȷ΋, 2,1% ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, 10% ÁÈ· Ó‡ÌÔÓ· Î·È 4,5-9% ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜-Ó‡ÌÔÓ·. ∏ ¯Ú‹ÛË ·ÓÙÈ˚ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÁÈ· ÚÔʇϷÍË ¤Ó·ÓÙÈ ÙÔ˘ CMV ÌÔÚ› Ó· ÂÏ·ÙÙÒÛÂÈ ÙËÓ Â›ÙˆÛË Ù˘ PTLD ÁÈ·Ù› ·˘ÙÔ› ÔÈ ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó ‰Ú·ÛÙÈÎfiÙËÙ· ¤Ó·ÓÙÈ ÙÔ˘ EBV Î·È ÂÍ·ÈÙ›·˜ Ù˘ Èı·Ó‹˜ Û˘Û¯¤ÙÈÛ˘ CMV Î·È EBV Ô˘ ̤ÓÂÈ Ó· ·Ô‰ÂȯÙ›.
¢È¿ÊÔÚÔÈ ÈÔ› ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ÓfiÛÔ Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂·Ó·ÓÂÚÁÔÔ›ËÛË ÙÔ˘ HHV-6 ¤¯ÂÈ ÚÔÙ·ı› Û ϋÙ˜ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ. O ·Ú‚Ô˚fi˜ μ19 ¤¯ÂÈ ÚÔÙ·ı› Û·Ó ·›ÙÈÔ ‚·ÚÈ¿˜ Ó¢ÌÔÓ›·˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜, Û·Ó ·›ÙÈÔ ·Ï·ÛÙÈ΋˜ ·Ó·ÈÌ›·˜ Î·È ÎÂÚ·˘ÓÔ‚fiÏÔ˘ Ë·Ù›Ùȉ·˜ Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. OÈ ÏÔÈÌÒÍÂȘ ·fi ·‰ÂÓÔ˚Ô‡˜ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ 7-19% ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∂›Û˘ ÌÔÚ› Ó· ÚÔηÏÔ‡Ó ·ÈÌÔÚÚ·ÁÈ΋ ΢ÛÙ›Ùȉ· Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ.
πÔ› papova (Papovaviruses) OÈ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‚Ú›ÛÎÔÓÙ·È Û ÌÂÁ¿ÏÔ Î›Ó‰˘ÓÔ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÏÔÈÌÒÍÂˆÓ ·fi anal human papillomavirus. À¿Ú¯ÂÈ ÌÈ· ·‡ÍËÛË 4-14 ÊÔÚ¤˜ ÛÙËÓ Â›ÙˆÛË ˘„ËÏÔ‡ ‚·ıÌÔ‡ ÂÓ‰ÔÂÈıËÏÈ·ÎÒÓ ‹ ‰ÈËıËÙÈÎÒÓ Î·ÚÎÈÓˆÌ¿ÙˆÓ ÙÔ˘ ÙÚ·¯‹ÏÔ˘ Ù˘ Ì‹ÙÚ·˜ Û Á˘Ó·›Î˜ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ papillomavirus ·Ó¢ڛÛÎÔÓÙ·È ÛÙ· Ô‡Ú· ÙˆÓ ·ÛıÂÓÒÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Û ÔÛÔÛÙfi 0,5% Î·È ·˘Ùfi Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·Ó¿Ù˘ÍË
μÈ‚ÏÈÔÁÚ·Ê›· 1. Patel R, Paya CV. Infections in solid organ transplantation recipients. Clin Micro Rev 1997; 10:86–124. 2. Rubin RH. Infectious disease complications of renal transplantation. Kidney Int 1993; 44:221–36. 3. Singh N, Carrigan DR. Human herpes virus–6 in transplantation: an emerging pathogen. Ann Intern Med 1996; 124:1065–71. 4. Preiksaitis JK, Diaz-Mitoma F, Mirzayans F, Roberts S, Tyrrell DLJ. Quantitative oropharyngeal EpsteinBarr virus shedding in renal and cardiac transplant recipients: relationship to immunosuppressive therapy, serologic responses, and the risk of posttransplant lymphoproliferative following disorder. J Infect Dis 1992; 166:986–94.
EÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó
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¢·Ó¿Ë ™ÔÊÈ·ÓÔ‡
ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi CMV ÛÙËÚ›˙ÂÙ·È ÛÙȘ οوıÈ ÌÂıfi‰Ô˘˜:
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› ¤Ó· ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ· ÂÈÙ‡ÁÌ·Ù· Ù˘ π·ÙÚÈ΋˜. ŸÌˆ˜, ·Ú¿ ÙË ‚ÂÏÙ›ˆÛË Ù˘ Ù¯ÓÈ΋˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Î·È ÙËÓ ·Ó¿Ù˘ÍË Ê·ÚÌ¿ÎˆÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙ· ÌÂÙ·ÌÔÛ¯Â˘Ì¤Ó· ¿ÙÔÌ·, Ô Î›Ó‰˘ÓÔ˜ Ïԛ̈͢ ·Ú·Ì¤ÓÂÈ ˘„ËÏfi˜ ·ÎfiÌ· Î·È Û‹ÌÂÚ·. Δ· ÌÂÙ·ÌÔÛ¯Â˘Ì¤Ó· ¿ÙÔÌ· ÎÈÓ‰˘ÓÂ‡Ô˘Ó ·fi ÏÔÈÌÒÍÂȘ ·fi ‚·ÎÙ‹ÚÈ·, ̇ÎËÙ˜ Î·È ÈÔ‡˜. ∞fi ÙÔ˘˜ ÈÔ‡˜, ÔÈ Û˘¯ÓfiÙÂÚÔÈ Â›Ó·È ÔÈ ÂÚËÙÔ˚Ô› ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÔÔ›ˆÓ ·Ó‹ÎÔ˘Ó Ô Èfi˜ ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ· (∏SV), Ô ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi˜ (CMV) Î·È Ô Èfi˜ Epstein Barr (EBV). T¤ÏÔ˜, ¿ÏÏÔÈ ÈÔ›, ÏÈÁfiÙÂÚ· Û˘¯ÓÔ›, fiˆ˜ Papovavirus Î·È Adenovirus ÂÓÔ¯ÔÔÈ‹ıËÎ·Ó ˆ˜ ·›ÙÈÔ Ïԛ̈͢. ∏ ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ ‰ÂÓ Â›Ó·È ¿ÓÙ· ‡ÎÔÏË Î·È ÛÙËÚ›˙ÂÙ·È ÛÙȘ οوıÈ Ù¯ÓÈΤ˜: 1. ·Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ ‹ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ÈÔ‡. 2. ηÏÏȤÚÁÂÈ· ÙÔ˘ ÈÔ‡. 3. ÔÚÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË, ÁÈ· ÙËÓ ·Ó‡ÚÂÛË ÂȉÈÎÒÓ IgG Î·È IgM ·ÓÙÈÛˆÌ¿ÙˆÓ ∂Âȉ‹ ÔÈ Ù¯ÓÈΤ˜ ·˘Ù¤˜ ‰È·Ê¤ÚÔ˘Ó ·fi Èfi Û Èfi ı· ·Ó·ÊÂÚıԇ̠ÌfiÓÔ ÛÙËÓ ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË ÙÔ˘ ÈÔ‡ CMV Ô ÔÔ›Ô˜ ·ÔÙÂÏ› ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ Ïԛ̈͢ ÙˆÓ ·ÙfiÌˆÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ Ì ıÓËÙfiÙËÙ· ˘„ËÏ‹ ·Ú¿ ÙËÓ ·Ó¿Ù˘ÍË ·ÓÙÈÈÈÎÒÓ Ê·Ú̿ΈÓ. O Èfi˜ CMV Â›Ó·È ¤Ó·˜ DNA Èfi˜ Ô˘ ·Ó‹ÎÂÈ ÛÙË ‚ ÔÌ¿‰· ÙˆÓ ÂÚËÙÔ˚ÒÓ. O ΛӉ˘ÓÔ˜ Ïԛ̈͢ ·fi ÙÔÓ Èfi Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ηٿ ÙÔ˘˜ 4 ÚÒÙÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÂÁÁ›˙ÂÈ ÙÔ ÔÛÔÛÙfi ÙÔ˘ 70% fiˆ˜ ÚÔ·ÙÂÈ ·fi Ù· ·ÔÙÂϤÛÌ·Ù· 16 ÌÂÏÂÙÒÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÂÚ›Ô˘ 1300 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡. ™Â ¤Ó· ÔÛÔÛÙfi 50% ÂÚ›Ô˘ ¢ı‡ÓÂÙ·È Ô ‰fiÙ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ fiÔ˘ Ô Èfi˜ ‚Ú›ÛÎÂÙ·È Û ϷÓı¿ÓÔ˘Û· ηٿÛÙ·ÛË ÛÙÔ ÌfiÛ¯Â˘Ì·. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰ÂÓ ÈÛ¯‡Ô˘Ó ÁÈ· ÙÔ˘˜ ·ÈÌ·ÙÔÏÔÁÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ ÂÚÁ·-
∞Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ ‹ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÙÔ˘: – ªÈÎÚÔÛÎfiËÛË Ì ÎÔÈÓfi ÌÈÎÚÔÛÎfiÈÔ. °›ÓÂÙ·È Û ›˙ËÌ· Ô‡ÚˆÓ ‹ ÈÛÙÔ‡˜ ‚ÈÔ„›·˜ ÌÂÙ¿ ·fi ¯ÚÒÛË: ·. Ì Giemsa ‹ ·ÈÌ·ÙÔÍ˘Ï›ÓË-ˆۛÓË fiÔ˘ ·Ó·˙ËÙÔ‡ÓÙ·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ‚·ÛÂfiÊÈÏ· ÂÓ‰Ô΢ÙÙ¿ÚÈ· ¤ÁÎÏÂÈÛÙ· Ù· ÔÔ›· ÂÚÈ‚¿ÏÏÔÓÙ·È ·fi Ì›· Ï¢΋ ¿Ïˆ Î·È ¤¯Ô˘Ó ÙËÓ ÂÈÎfiÓ· Ì·ÙÈÔ‡ ÎÔ˘ÎÔ˘‚¿ÁÈ·˜. ∏ ÌË ·Ó‡ÚÂÛË ÙˆÓ ÂÁÎÏ›ÛÙˆÓ ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË Ïԛ̈ÍË ÂÂȉ‹ Ô Èfi˜ ÌÔÚ› Ó· ÚÔÛ‚¿ÏÏÂÈ ÙÔ˘˜ ÈÛÙÔ‡˜ ¯ˆÚ›˜ Ó· ÚÔηÏ› Ù˘Èο ÌÂÁ·ÏÔ΢ÙÙ·ÚÈο ·ÙÙ·Ú· . ‚. Ì ÊıÔÚ›˙Ô˘Û˜ ¯ÚˆÛÙÈΤ˜ ¤Ó·ÓÙÈ ÙÔ˘ ÚÒÈÌÔ˘ ‹ fi„ÈÌÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÈÔ‡. ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ·Ú·ÙËÚÂ›Ù·È ÊıÔÚÈÛÌfi˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ʤÚÔ˘Ó ÙÔÓ Èfi. ∏ ̤ıÔ‰Ô˜ Â›Ó·È ÁÚ‹ÁÔÚË ·ÏÏ¿ ÛÙÂÚÂ›Ù·È Â˘·ÈÛıËÛ›·˜. ∂ÈϤÔÓ, ··ÈÙÂ›Ù·È ÂÌÂÈÚ›· ÏfiÁˆ ÙÔ˘ ÌË ÂȉÈÎÔ‡ ÊıÔÚÈÛÌÔ‡ Ô˘ ·Ú·ÙËÚÂ›Ù·È Î·Ù¿ ÙË ·Ú·Ù‹ÚËÛË ‚ÈÔÏÔÁÈÎÒÓ ˘ÏÈÎÒÓ. ∏ ¯ÚËÛÈÌÔÔ›ËÛË Ì›ÁÌ·ÙÔ˜ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ·˘Í¿ÓÂÈ ÙËÓ Â˘·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘. – ªÈÎÚÔÛÎfiËÛË Ì ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ. °›ÓÂÙ·È Î˘Ú›ˆ˜ Û ԇڷ Î·È Ê·Ú˘ÁÁÈο ‰Â›ÁÌ·Ù· Û ÂÚ›ÙˆÛË Û˘ÁÁÂÓÔ‡˜ Ïԛ̈͢ ∂›Ó·È ÁÚ‹ÁÔÚË, ·ÏÏ¿ ÛÙÂÚÂ›Ù·È Â˘·ÈÛıËÛ›·˜..∂›Û˘ ··ÈÙ› ÂȉÈÎfi ÂÍÔÏÈÛÌfi Î·È ÂÍÂȉÈÎÂ˘Ì¤ÓÔ ÚÔÛˆÈÎfi. – ∞ÓÙÈÁÔÓ·ÈÌ›· Ì ÙËÓ ·Ó‡ÚÂÛË Ù˘ pp65. ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ÚˆÙ½ÓË Ì ÌÔÚÈ·Îfi ‚¿ÚÔ˜ 65 kDa, Ë ÔÔ›· ÂÌÊ·Ó›˙ÂÙ·È Î·Ù¿ ÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÙÔ˘ ·ÎÏÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡. ∏ ·Ó‡ÚÂÛ‹ Ù˘ Û ·ÓȯÓ‡ÛÈÌ· ›‰· ÛÙ· ÂÚÈÊÂÚÈο Ï¢ÎÔ·ÙÙ·Ú· ·ÔÙÂÏ› ηÏfi ‰Â›ÎÙË ÚfiÛÊ·Ù˘ Ïԛ̈͢. ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹ ÌÔÚ› Ó· ·ÓȯÓ¢ı› Ô Èfi˜ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË
123
124
¢. ™OºIANOY
ÙˆÓ Û˘Ìو̿وÓ, Ë ‰Â ÔÛÔÙÈÎÔÔ›ËÛË ÙÔ˘ ÈÈÎÔ‡ ÊÔÚÙ›Ô˘ ÂÈÙÚ¤ÂÈ ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ CMV ÓfiÛÔ˘ Î·È ·Û˘Ìو̷ÙÈ΋˜ Ïԛ̈͢. Δ· ·ÔÙÂϤÛÌ·Ù· ÂÎÊÚ¿˙ÔÓÙ·È ˆ˜ Ô ·ÚÈıÌfi˜ ÙˆÓ ıÂÙÈÎÒÓ ÁÈ· ÙÔ ·ÓÙÈÁfiÓÔ Î˘ÙÙ¿ÚˆÓ ÚÔ˜ ÙÔÓ ÔÏÈÎfi ·ÚÈıÌfi ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ. Œ¯ÂÈ Â˘·ÈÛıËÛ›· 50-83% Î·È ÂȉÈÎfiÙËÙ· 71-83%. £ÂˆÚÂ›Ù·È ÈÔ Â˘·›ÛıËÙË ·fi ÙË Ù·¯Â›· ηÏÏȤÚÁÂÈ· ÙÔ˘ ÈÔ‡ ( shell vial assay) ·ÏÏ¿ ÏÈÁfiÙÂÚÔ ·fi ÙË PCR. ∏ ̤ıÔ‰Ô˜ Â›Ó·È ¯ÚÔÓÔ‚fiÚÔ˜, ··ÈÙ› Û¯ÂÙÈ΋ ÂÌÂÈÚ›· Î·È ‰ÂÓ ÌÔÚ› Ó· ÂÊ·ÚÌÔÛÙ› fiÙ·Ó ˘¿Ú¯ÂÈ ¤ÓÙÔÓË Ï¢ÎÔÂÓ›· . – À‚ÚȉÈÛÌfi˜ ÙÔ˘ DNA ÙÔ˘ ÈÔ‡ (dot-blot hybridization) Ì ÂȉÈÎÔ‡˜ ·ÓȯÓÂ˘Ù¤˜ (probes) ¤Ó·ÓÙÈ ÙÔ˘ DNA ÙÔ˘ ÈÔ‡. °›ÓÂÙ·È ÛÙ· Ô‡Ú·, ÛÙ· ÂÚÈÊÂÚÈο Ï¢ÎÔ·ÙÙ·Ú· ÙÔ˘ ·›Ì·ÙÔ˜ Î·È Û ÈÛÙÔÏÔÁÈο ·Ú·Û΢¿ÛÌ·Ù· Ó‡ÌÔÓÔ˜. ∞˘Ù‹ Ë in situ ˘‚ÚȉÔÔ›ËÛË ¤¯ÂÈ ÙÔ ÏÂÔÓ¤ÎÙËÌ· fiÙÈ Â›Ó·È ÁÚ‹ÁÔÚË, ·Ï‹, ·ÏÏ¿ ÛÙÂÚÂ›Ù·È Â˘·ÈÛıËÛ›·˜. – ªÔÚȷΤ˜ Ù¯ÓÈΤ˜. ∂ÈÙ˘Á¯¿ÓÂÙ·È Â›Ù ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ ÙÔ˘ CMV DNA ›Ù ·Ó›¯Ó¢ÛË ÙÔ˘ ·ÁÁÂÏÈÔÊfiÚÔ˘ RNA (mRNA) ÙÔ˘ ÈÔ‡ ÙË ÛÙÈÁÌ‹ Ù˘ ÌÂٿوÛ˘ ·fi ÙË Ï·Óı¿ÓÔ˘Û· ηٿÛÙ·ÛË ÛÙË Ê¿ÛË ÙÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡. ΔÔ ·ÔÙ¤ÏÂÛÌ· Â›Ó·È ıÂÙÈÎfi ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ÂÈÙÚ¤ÂÈ ÙË ÁÚ‹ÁÔÚË Ê·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ¢ÂÓ ÌÔÚ› fï˜ Ó· Á›ÓÂÈ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ ·Û˘Ìو̷ÙÈ΋˜ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ ÈÔ‡ Ë ÔÔ›· ‰ÂÓ ‰ËÌÈÔ˘ÚÁ› ‚Ï¿‚˜ ÛÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ÙÔ˘ ÂÓÂÚÁÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡ Ô˘ Ô‰ËÁ› Û ÓfiÛÔ. ™ÙȘ ÌÔÚȷΤ˜ Ù¯ÓÈΤ˜ ·Ó‹ÎÔ˘: a. ∏ ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË Ù˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR). ªÂ ÂȉÈÎÔ‡˜ ÂÎÎÈÓËÙ¤˜ (primers) ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ÈÔ‡ (¿ÌÂÛÔ ÚÒÈÌÔ ·ÓÙÈÁfiÓÔ, fi„ÈÌÔ ·ÓÙÈÁfiÓÔ, ÁÏ˘ÎÔÚˆÙ½Ó˜ ∏ & μ, ÙÔ ÙÌ‹Ì· EcoRI D) Ë PCR ·ÓȯÓ‡ÂÈ ÂÏ¿¯ÈÛÙ· ÔÛ¿ ÙÔ˘ DNA ÙÔ˘ ÈÔ‡ ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘. °›ÓÂÙ·È Û ÔÚfi ‹ Ï¿ÛÌ· Ì ¢·ÈÛıËÛ›· 50-100% Î·È ÂȉÈÎfiÙËÙ· 45-63% ‹ ÛÙ· ÂÚÈÊÂÚÈο Ï¢ÎÔ·ÙÙ·Ú· Ì ¢·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· 20-100% η 35-91%, ·ÓÙ›ÛÙÔȯ· . ¶ÚfiÎÂÈÙ·È ÁÈ· ̤ıÔ‰Ô ÂÍ·ÈÚÂÙÈο ¢·›ÛıËÙË fi¯È fï˜ ÂȉÈ΋ ÁÈ· Ïԛ̈ÍË. π‰È·›ÙÂÚ·, Ë ÔÈÔÙÈ΋ PCR ¤¯ÂÈ ÌÈÎÚ‹ ‰È·ÁÓˆÛÙÈ΋ ·Í›· ÂÂȉ‹ Ù· ·ÔÙÂϤÛÌ·Ù· ‰ÂÓ Û˘Ì‚·‰›˙Ô˘Ó Ì ÙË ÎÏÈÓÈ΋ ÂÈÎfiÓ·. ∏ ·Ó›¯Ó¢ÛË ÙÔ˘ DNA ÙÔ˘ ÈÔ‡ ÛÙ· Ï¢-
ÎÔ·ÙÙ·Ú· ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ‰ÂÓ Û˘Ó‰¤ÂÙ·È ¿ÓÙ· Ì ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ ‰ÈfiÙÈ Ô Èfi˜ ÌÔÚ› Ó· ‚Ú›ÛÎÂÙ·È Û ϷÓı¿ÓÔ˘Û· ηٿÛÙ·ÛË. ∏ ÔÛÔÙÈ΋ ‹ ËÌÈÔÛÔÙ΋ PCR ·Ó·Ù‡¯ıËΠÁÈ· Ó· ÂÈÙÚ¤„ÂÈ ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÌÂٷ͇ Ù˘ Ïԛ̈͢ Î·È Ù˘ ·Ó›¯Ó¢Û˘ ÙÔ˘ ÈÔ‡ Û ϷÓı¿ÓÔ˘Û· ηٿÛÙ·ÛË. ∏ ÔÛÔÙÈÎÔÔ›ËÛË ÙÔ˘ DNA ÙÔ˘ ÈÔ‡ Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Ì CªV Ïԛ̈ÍË ¤‰ÂÈÍ fiÙÈ Ù· ¿ÙÔÌ· ·˘Ù¿ ¤¯Ô˘Ó ÙÔ DNA ÙÔ˘ ÈÔ‡ Û ˘„ËÏfiÙÂÚ· ›‰· ÛÙ· ÂÚÈÊÂÚÈο Ï¢ÎÔ·ÙÙ·Ú· ‹ ÛÙÔ Ï¿ÛÌ· ·fi fiÙÈ ÔÈ ·ÛıÂÓ›˜ ¯ˆÚ›˜ ÓfiÛÔ. ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ··ÈÙ› ÂȉÈÎfi ÂÍÔÏÈÛÌfi Î·È ¤¯ÂÈ ÌÂÁ¿ÏÔ ÎfiÛÙÔ˜. b. Hybrid capture CMV DNA assay. ÃÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂȉÈÎÔ› RNA ·ÓȯÓÂ˘Ù¤˜ (probes) ÔÈ ÔÔ›ÔÈ Ì ÙË ¯Ú‹ÛË ÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÂÈÙÚ¤Ô˘Ó ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ÔÏÏÒÓ ·ÓÙÈÁÚ¿ÊˆÓ Ù˘ ·ÏÏËÏÔ˘¯›·˜-ÛÙfi¯Ô˘ (amplification). ∏ ÚÔÛı‹ÎË ÂȉÈÎÔ‡ ˘ÔÛÙÚÒÌ·ÙÔ˜ Î·È Ë ÂÎÔÌ‹ ¯ËÌÂÈÔʈٷ‡ÁÂÈ·˜ Â›Ó·È ·Ó¿ÏÔÁË ÙÔ˘ DNA ÛÙfi¯Ô˘. ª¤ıÔ‰Ô˜ ·Ï‹ Î·È ÁÚ‹ÁÔÚË ¯ˆÚ›˜ ÂÈÌÔχÓÛÂȘ. ∞·ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Û ·ÛıÂÓ›˜ Ì Ïԛ̈ÍË ·fi CMV Ì ¯·ÌËÏfi ÈÈÎfi ÊÔÚÙ›Ô. c. branched DNA signal amplification. ¶ÔÏÏ·ÏÔ› ÂȉÈÎÔ› ·ÓȯÓÂ˘Ù¤˜ Û¯ËÌ·Ù›˙Ô˘Ó ˘‚Ú›‰È· Ì ÙÔ DNA ÛÙfi¯Ô (60-300 ÌfiÚÈ· ÂÓ˙‡ÌÔ˘ ‰È· οı ÛÙfi¯Ô). ∏ ÚÔÛı‹ÎË Ùo˘ ηٿÏÏËÏÔ˘ ˘ÔÛÙÚÒÌ·ÙÔ˜ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÎÔÌ‹ ¯ËÌÂÈÔʈٷ‡ÁÂÈ·˜ Ë ÔÔ›· ÌÂÙÚ¿Ù·È Î·È Â›Ó·È ·Ó¿ÏÔÁË ÙÔ˘ ÛÙfi¯Ô˘. ∏ ÔÛÔÙÈ΋ ·˘Ù‹ ̤ÙÚËÛË ÙÔ˘ ÈÈÎÔ‡ ÊÔÚÙ›Ô˘ ÂÈÙÚ¤ÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ÛÙ· ÚÒÈÌ· ÛÙ¿‰È·. °›ÓÂÙ·È ÛÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì·, ∂¡À, Û¤ÚÌ·, Û ¤ÓÙÔÓË fï˜ Ï¢ÎÔÂÓ›· ‰ÂÓ ÌÔÚ› Ó· ÂÎÙÂÏÂÛı›. ∂›Ó·È ̤ıÔ‰Ô˜ ¯ÚÔÓÔ‚fiÚ· ·Ú·ÙËÚÔ‡ÓÙ·È fï˜ ÏÈÁfiÙÂÚ˜ ÂÈÌÔχÓÛÂȘ ·fi fiÙÈ Ì ÙË PCR. ∂›Ó·È ÈÔ Â˘·›ÛıËÙË ·fi ÙË Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ÈÔ‡ Î·È ¤¯ÂÈ ÙËÓ ›‰È· ¢·ÈÛıËÛ›· Ì ÙË pp65. d. NASBA (nucleic acid sequence-based amplification). ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ·ÓȯÓ‡ÂÈ ÙÔ pp67 fi„ÈÌÔ mRNA (pp67 late mRNA, messenger RNA) ÙÔ ÔÔ›Ô Îˆ‰ÈÎÔÔÈÂ›Ù·È ·fi ÙÔ ÁÔÓ›‰ÈÔ UL65 ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ Ù˘ pp67, ÌÈ·˜ ‰ÔÌÈ΋˜ ʈÛÊÔÚˆÙ½Ó˘ ÙÔ˘ ÈÔ‡ Ô˘ ·Ú¿ÁÂÙ·È Î·Ù¿ ÙË ÙÂÏÈ΋ Ê¿ÛË ÙÔ˘ ÔÏÏ·Ï·ÛÈ·-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÛÌÔ‡ ÙÔ˘. ¶·Ú·ÏÏ·Á‹ Ù˘ ÌÂıfi‰Ô˘ ·ÓȯÓ‡ÂÈ ÙÔ ¿ÌÂÛÔ-ÚÒÈÌÔ mRNA (immediate-early mRNA, ∂π1) ÙÔ ÔÔ›Ô Îˆ‰ÈÎÔÔÈÂ›Ù·È ·fi ÙÔ ÁoÓ›‰ÈÔ UL123. H ̤ıÔ‰Ô˜ ·˘Ù‹ ıˆÚÂ›Ù·È ÈÔ Â˘·›ÛıËÙË ·fi fiÙÈ Ë pp67 NASBA, ›Û˘ ıÂÙÈÎÔÔÈÂ›Ù·È ÓˆÚ›ÙÂÚ·. ∏ NASBA ‰Â›¯ÓÂÈ ÂÓÂÚÁfiÙËÙ· ÙÔ˘ ÈÔ‡ Î·È ÂÔ̤ӈ˜ ÓfiÛÔ Î·È ·ÔÙÂÏ› ÚÒÈÌÔ ‰Â›ÎÙË Ïԛ̈͢ ·fi ÙÔÓ Èfi. ∂›Ó·È Û¯ÂÙÈο ·Ï‹, ¤¯ÂÈ fï˜, ÌÂÁ¿ÏÔ ÎfiÛÙÔ˜.
∞ÔÌfiÓˆÛË ÙÔ˘ ÈÔ‡ – ∫·ÏÏȤÚÁÂÈ· ÙÔ˘ ÈÔ‡ Û ·ÙÙ·Ú· ÈÓÔ‚Ï¿ÛÙ˜. °›ÓÂÙ·È ·fi ·›Ì·, ÈÛÙÔ‡˜, Ô‡Ú·, BAL Î·È ∂¡À. ª¤ıÔ‰Ô˜ ¯ÚÔÓÔ‚fiÚ· - ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ·fi 20 ̤Ú˜ ÁÈ· ÙËÓ ·ÔÌfiÓˆÛË Î·È Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ÈÔ‡- ¯ÚÂÈ¿˙ÂÙ·È ÂȉÈο ÂÍÔÏÈṲ̂ÓÔ ÂÚÁ·ÛÙ‹ÚÈÔ. ∂›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËıÔ‡Ó „¢‰Ò˜-ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ·fi ÙË Î·ÏÏȤÚÁÂÈ· ÙˆÓ Ô‡ÚˆÓ ÏfiÁˆ ·Ú·ÌÔÓ‹˜ ÙÔ˘ ÈÔ‡ ÁÈ· ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. ∂›Û˘, ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ·Ó¿Ù˘Í˘ ¿ÏÏˆÓ ÈÒÓ ‹ ÂÈÌfiÏ˘ÓÛ˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ·fi ‚·ÎÙ‹ÚÈ·. – Shell vial assay Î·È ·ÓÔÛÔÊıÔÚÈÛÌfi˜ ¤Ó·ÓÙÈ ÙÔ˘ ÚÒÈÌÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÈÔ‡ Ì ÊıÔÚ›˙ÔÓ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷. ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· Ù·¯Â›· ̤ıÔ‰Ô Î·ÏÏȤÚÁÂÈ·˜ Î·È Â›Ó·È Û˘Ó‰˘·ÛÌfi˜ Ù˘ ηÏÏȤÚÁÂÈ·˜ ΢ÙÙ¿ÚˆÓ Î·È Ù˘ ·Ó›¯Ó¢Û˘ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ÈÔ‡. ∏ ̤ıÔ‰Ô˜ ·˘Ù‹ ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙÔ ¯ÚfiÓÔ ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ Û 1-2 Ë̤Ú˜. Œ¯ÂÈ Â˘·ÈÛıËÛ›· 8-63% Î·È ÂȉÈÎfiÙËÙ· 86-88%, Ë Î·ı˘ÛÙ¤ÚËÛË fï˜ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ ÁÈ· ‰È¿ÛÙËÌ· > 24h ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ Â˘·ÈÛıËÛ›·.. OÚÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË. ∏ ÔÚÔÌÂÙ·ÙÚÔ‹ Â›Ó·È Û˘Ó‹ıˆ˜ ¤Ó·˜ ηÏfi˜ ‰Â›ÎÙ˘ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ù· ÂȉÈο IgM ·ÓÙÈÛÒÌ·Ù· ·Ó·Ù‡ÛÛÔÓÙ·È Î·Ù¿ ÙËÓ ÚfiÛÊ·ÙË Ïԛ̈ÍË. ŸÌˆ˜, IgM ·ÓÙÈÛÒÌ·Ù· ÌÔÚÔ‡Ó Ó· ÂÌÊ·ÓÈÛıÔ‡Ó Û ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Ï·Óı¿ÓÔÓÙÔ˜ ÈÔ‡. ∂Ô̤ӈ˜, Ù· IgM ‰ÂÓ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË ÚfiÛÊ·Ù˘ ‹ ÂÓÂÚÁÔ‡ ÚˆÙÔ·ıÔ‡˜ Ïԛ̈͢. ∂›-
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Û˘, Ë ÙÂÙÚ·Ï¿ÛÈ· ·‡ÍËÛË ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgG ‰ÂÓ Â›Ó·È ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ Ïԛ̈͢. OÈ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÏfiÁˆ Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜, Û˘¯Ó¿ ‰ÂÓ ·Ó·Ù‡ÛÛÔ˘Ó ·ÓÙÈÛÒÌ·Ù· ÁÈ’ ·˘Ùfi Î·È Ë ÔÚÔÏÔÁÈ΋ ̤ıÔ‰Ô˜ ‰ÂÓ ‚ÔËı¿ ÛÙË ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË Ù˘ CMV Ïԛ̈͢. ™˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ ÙˆÓ ÌÔÚÈ·ÎÒÓ Ù¯ÓÈÎÒÓ Ô˘ Â›Ó·È Î·È ÔÈ ÈÔ Â˘·›ÛıËÙ˜ ÁÈ· ÙË ÚÒÈÌË ‰È¿ÁÓˆÛË Ù˘ CMV Ïԛ̈͢ Î·È ÙËÓ ¤Ó·ÚÍË Ù˘ ηٿÏÏËÏ˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜ ‰›ÓÔ˘Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. ŒÓ· ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ‰ÂÓ ÛËÌ·›ÓÂÈ ¿ÓÙ· ÓfiÛÔ Î·È ¤Ó· ·ÚÓËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ‰ÂÓ ·ÔÎÏ›ÂÈ ÙË ÓfiÛÔ. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë PCR Â›Ó·È Ë ÈÔ Â˘·›ÛıËÙË Ì¤ıÔ‰Ô˜ („¢‰Ò˜-·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù· 0.6-3.6%) ·ÏÏ¿ ÛÙÂÚÂ›Ù·È ÂȉÈÎfiÙËÙ·˜. ªÂ ÙË Ì¤ıÔ‰Ô ¡∞SBA „¢‰Ò˜ ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó Û 2.5% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÓÒ Ù· ÔÛÔÛÙ¿ ·˘Ù¿ ‹Ù·Ó ˘„ËÏfiÙÂÚ· Ì ÙË pp65 (19.8%) ÏfiÁˆ Ù˘ Ï¢ÎÔÂÓ›·˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, CMV Ïԛ̈ÍË ıˆÚÂ›Ù·È fiÙ·Ó ˘¿Ú¯Ô˘Ó Ù· ÎÏÈÓÈο ÎÚÈÙ‹ÚÈ· + Ë ·Ó›¯Ó¢ÛË Ù˘ pp65/ ‹ ıÂÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ‰È·ÊÔÚÂÙÈÎÒÓ ÌÔÚÈ·ÎÒÓ Ù¯ÓÈÎÒÓ.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Szczepura A.,Westmoreland D., Vinogradova Y., Fox J., Clark M. Evaluation of molecular techniques in prediction and diagnosis of cytomegalovirus disease in immunocomrpomised patients. Health Technology Assessment, 2006, vol 10, no 10 2. Preiser W., Bräuninger S., et al. Evaluation of diagnostic methods for the detection of cytomegalovirus in recipients of allogeneic stem cell transplants. J. Clin. Virol., 2001, 20, 59-70 3. Diaz-Mitoma F., Leger C., et al. Comparison of DNA amplification, mRNA amplification and NA hybridization techniques for detection of cytomegalovirus in bone marrow transplant recipients. J. Clin. Microbiol. 2003, 41, 5159-66 4. Meyer-Koening U., Romberg I., et al. Diagnostic value of reverse transcription-PCR for detection of cytomegalovirus pp67 in samples from solid-organ transplant recipients. J. Clin. Microbiol., 2006, 44, 3394-96
AÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÈÔÁÂÓÒÓ ÏÔÈÌÒ͈Ó
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B›‚È·Ó °ÂˆÚÁÔÔ‡ÏÔ˘
ÓÈÛ˘ ¢ηÈÚȷ΋˜ Ïԛ̈͢, ηıÒ˜ Î·È Ô ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ·fiÚÚȄ˘ Î·È ÔÁÎÔÁ¤ÓÂÛ˘. ∏ Ïԛ̈ÍË ·fi ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi ÂΉËÏÒÓÂÙ·È Î˘Ú›ˆ˜ Ì ÙË ÌÔÚÊ‹ Ù˘ Ó¢ÌÔÓ›·˜ (2). ªÂ ÙË Û˘ÛÙËÌ·ÙÈ΋ ¯Ú‹ÛË ·ÓÙÈ˚ÎÒÓ ÚÔÊ˘Ï·ÎÙÈÎÒÓ Ì¤ÙÚˆÓ Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ CMV Ó¢ÌÔÓ›·˜ ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÔ‡˜ ÔÚÁ¿ÓÔ˘ ‹ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ¤¯ÂÈ ÂÏ·ÙÙˆı› ÛËÌ·ÓÙÈο. ∂ȉÈÎfiÙÂÚ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ë Û˘¯ÓfiÙËÙ· Â›Ó·È < 1%, Ì ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ ~ 20% (1). ∏ ·Ï‹ ·/· ıÒÚ·ÎÔ˜ ·ÔÙÂÏ› ÙËÓ ÚÒÙË ·ÂÈÎÔÓÈÛÙÈ΋ ÂͤٷÛË ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ Û˘Ìو̷ÙÈÎÔ‡ ·ÛıÂÓÔ‡˜. Δ· ÈÔ Û˘¯Ó¿ Â˘Ú‹Ì·Ù· Â›Ó·È ÔÈ ÂÚÈÔ¯¤˜ ·˘ÍË̤Ó˘ ıÔÏÂÚfiÙËÙ·˜ Î·È ÔÈ ‰ÈÎÙ˘ÔÔ˙Ò‰ÂȘ ‰ÈËı‹ÛÂȘ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË – ηٿ ηÓfiÓ· –ηٷÓÔÌ‹ (5). ∞Ú¯Èο ÂÓÙÔ›˙ÔÓÙ·È ÛÙËÓ ÂÚÈʤÚÂÈ· Î·È ÛÙ· οو Ó¢ÌÔÓÈο ‰›·, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ÂÂÎÙ›ÓÔÓÙ·È ÚÔ˜ ÙȘ ‡Ï˜,
OÈ ÏÔÈÌÒÍÂȘ Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÔ‡˜ ÔÚÁ¿ÓÔ˘ ‹ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ·ÔÙÂÏÔ‡Ó ÛÔ‚·Ú‹ ÂÈÏÔ΋ Î·È ÛËÌ·ÓÙÈÎfi ·›ÙÈÔ ·˘ÍË̤Ó˘ ıÓËÙfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ·ÎfiÌË Î·È ÌÂÙ¿ ÙË Û˘ÛÙËÌ·ÙÈ΋ ¯Ú‹ÛË ÚÔÊ˘Ï·ÎÙÈÎÒÓ Ì¤ÙÚˆÓ Î·È ÙË ¯ÔÚ‹ÁËÛË Ó¤ˆÓ “‚ÂÏÙȈ̤ӈӔ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ (1). OÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ¤Ú¯ÔÓÙ·È ÚÒÙ˜ ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜ Ì ·ÚÈÔ˘˜ ÂÎÚÔÛÒÔ˘˜ ÙȘ ÏÔÈÌÒÍÂȘ ·fi ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi, ·Ïfi ¤ÚËÙ·, ¤ÚËÙ· ˙ˆÛÙ‹Ú· – ·ÓÂÌÔ‚ÏÔÁÈ¿, ÏÔÈÌÒ‰Ë ÌÔÓÔ˘Ú‹ÓˆÛË Î·È ÎÔÈÓÔÙÈÎÔ‡˜ ·Ó·Ó¢ÛÙÈÎÔ‡˜ ÈÔ‡˜ (2,3). ∞ÎÔÏÔ˘ıÔ‡Ó ÔÈ ÌÈÎÚԂȷΤ˜, Ì˘ÎËÙÈ·ÛÈΤ˜ Î·È Ë Ïԛ̈ÍË ·fi Ó¢ÌÔÓÔ·ÛÙË Carinii. OÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È 1-6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ηٿ ÙÔ ÔÔ›Ô ÂÈÙ˘Á¯¿ÓÂÙ·È Ë Ì¤ÁÈÛÙË ·ÓÔÛÔηٷÛÙÔÏ‹ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·fiÚÚȄ˘ (2). ∏ ÈÔ Û˘¯Ó‹ ·ÏÏ¿ Î·È ÈÔ ÛËÌ·ÓÙÈ΋ Â›Ó·È Ë Ïԛ̈ÍË ·fi ÙÔÓ ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô ( CMV) (4). O ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô˜ ·ÔÙÂÏ› ÙÔÓ ÈÔ ÌÂÁ¿ÏÔ ÁÓˆÛÙfi DNA Èfi ‰ÈÏ‹˜ ·Ï‡ÛÔ˘ Ô‡ ÚÔÛ‚¿ÏÏÂÈ ÙÔÓ ¿ÓıÚˆÔ. ª·˙› Ì ÙÔÓ ·Ïfi ¤ÚËÙ· 1, ÙÔÓ Èfi Ù˘ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘, ÙÔÓ Èfi ¤ÚËÙÔ˜ ˙ˆÛÙ‹ÚÔ˜ – ·ÓÂÌÔ‚ÏÔÁÈ¿˜ ·Ó‹ÎÂÈ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ‚-ÂÚËÙÔ˚ˆÓ. ªÂÙ¿ ÙËÓ Â›ÛÔ‰Ô Î·È ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙÔ˘ ÛÙÔ Î‡ÙÙ·ÚÔ ‰ËÌÈÔ˘ÚÁ› ¯·Ú·ÎÙËÚÈÛÙÈο ÌÂÁ¿Ï· ¤ÁÎÏÂÈÛÙ· ‰›ÎËÓ “ÔÊı·ÏÌÔ‡ ÎÔ˘ÎÔ˘‚¿ÁÈ·˜” ÛÙÔ ˘Ú‹Ó· Î·È ÌÈÎÚfiÙÂÚ· ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ·. ∏ Ïԛ̈ÍË ·fi ÙÔÓ ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô Â›Ó·È ÛËÌ·ÓÙÈ΋ ÙfiÛÔ ÁÈ· ÙȘ ¿ÌÂÛ˜ fiÛÔ Î·È ÁÈ· ÙȘ ¤ÌÌÂÛ˜ ÂȉڿÛÂȘ ÛÙÔÓ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ ·ÛıÂÓ‹ (2). ∏ Ô˘‰ÂÙÂÚÔÂÓ›·, Ë ·Ó΢ÙÙ·ÚÔÂÓ›· Ô ˘ÚÂÙfi˜, ÔÈ Ì˘·ÏÁ›Â˜ Î·È Ë “‰ÈËıËÙÈ΋ ÓfiÛÔ˜” Ì ÙË ÌÔÚÊ‹ Ó¢ÌÔÓ›·˜, ÂÁÎÂÊ·Ï›ÙȉԘ, ÎÔÏ›ÙȉԘ, Ë·Ù›ÙȉԘ ÂÓÙ¿ÛÛÔÓÙ·È ÛÙȘ ¿ÌÂÛ˜ ÂȉڿÛÂȘ. ŒÌÌÂÛ˜ ÂȉڿÛÂȘ ıˆÚÔ‡ÓÙ·È Ë Âȉ›ӈÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿-
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ù· ̤۷ Î·È ¿Óˆ Ó¢ÌÔÓÈο ‰›·. ™˘¯Ó¿ Â˘Ú‹Ì·Ù· ·ÔÙÂÏÔ‡Ó Â›Û˘ ÔÈ ·ÌÊÔÙÂÚfiÏ¢Ú˜ ˘ÎÓˆÙÈΤ˜ ÂÛٛ˜ ÛÙ· ̤۷ Î·È Î¿Ùˆ Ó¢ÌÔÓÈο ‰›· ηıÒ˜ Î·È ÔÈ ‰È¿Û·ÚÙ˜ ÌÈÎÚÔÔ˙Ò‰ÂȘ ‰ÈËı‹ÛÂȘ ‰È·Ì¤ÙÚÔ˘ 2-4 mm, Ô‡ ıˆÚÔ‡ÓÙ·È ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ Ù˘ ÓfiÛÔ˘ (ÂÈÎ. 1). ™¿ÓÈ· ·Ú·ÙËÚÔ‡ÓÙ·È ÌÔÓ‹ÚÂȘ ˘ÎÓˆÙÈΤ˜ ÂÛٛ˜ ‹ ÌÔÓ‹ÚÂȘ ÌÂÁ¿ÏÔÈ fi˙ÔÈ. ªÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ ÌÈÎÚ‹ ÔÛfiÙËÙ· ˘Â˙ˆÎÔÙÈ΋˜ Û˘ÏÏÔÁ‹˜. ∏ ·Ï‹ ·/· ıÒÚ·ÎÔ˜ ‰ÂÓ ·ÔÙÂÏ› ·ÍÈfiÈÛÙË ‰È·ÁÓˆÛÙÈ΋ ÂͤٷÛË, ηıÒ˜ ¤¯ÂÈ ¯·ÌËÏ‹ ‰È·ÁÓˆÛÙÈ΋ ·Í›·, ȉ›ˆ˜ ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÓfiÛÔ˘. ∏ ·ÂÈÎÔÓÈÛÙÈ΋ ̤ıÔ‰Ô˜ ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ‰ÈÂÚ‡ÓËÛË Ó¢ÌÔÓÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Â›Ó·È Ô ·ÍÔÓÈÎfi˜ ÙÔÌÔÁÚ¿ÊÔ˜ ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜ (HRCT).∏ ¢·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ Â›Ó·È È‰È·›ÙÂÚ· ˘„ËÏ‹, ηıÒ˜ ·Ó·‰ÂÈÎÓ‡ÔÓÙ·È ·ÏÏÔÈÒÛÂȘ ÌË ÔÚ·Ù¤˜ Ì ÙËÓ ·/· ıÒÚ·ÎÔ˜. Δ· ÈÔ Û˘¯Ó¿ Â˘Ú‹Ì·Ù· Â›Ó·È ÔÈ ÂÚÈÔ¯¤˜ “ıÔÏ‹˜ ˘¿ÏÔ˘”, Ù· ÔÏÏ·Ï¿ ÌÈÎÚ¿ Ô˙›‰È· ‰È·Ì¤ÙÚÔ˘ < 7 mm Î·È ÔÈ ˘ÎÓˆÙÈΤ˜ ÂÛٛ˜ ΢„ÂÏȉÈÎÔ‡ Ù‡Ô˘ (ÂÈÎ. 2). ø˜ ÂÚÈÔ¯¤˜ “ıÔÏ‹˜ ˘¿ÏÔ˘” ÔÚ›˙ÔÓÙ·È ÂÚÈÔ¯¤˜ Ì ·˘ÍË̤ÓË ıÔÏÂÚfiÙËÙ· ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÂÓÙfi˜ ÙˆÓ ÔÔ›ˆÓ ‰È·ÎÚ›ÓÔÓÙ·È ÔÈ ˘ÔΛÌÂÓ˜ ·ÁÁÂȷΤ˜ ‰Ô̤˜, Û ·ÓÙȉȷÛÙÔÏ‹ Ì ÙȘ ÂÚÈÔ¯¤˜ ‡ÎÓˆÛ˘ – ηٿÏ˄˘ ÙˆÓ Î˘„ÂÏ›‰ˆÓ, fiÔ˘ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ Ë ‰È¿ÎÚÈÛË ÙˆÓ ˘ÔΛÌÂÓˆÓ ·ÁÁÂÈ·ÎÒÓ ‰ÔÌÒÓ. OÈ ÂÚÈÔ¯¤˜ “ıÔÏ‹˜ ˘¿ÏÔ˘” Â›Ó·È Û˘Ó‹ıˆ˜ ·ÌÊÔÙÂÚfiÏ¢Ú˜, ·Û‡ÌÌÂÙÚ˜,ÂÓÙÔ›˙ÔÓÙ·È Î·Ù¿ ÙfiÔ˘˜ ‹ Â›Ó·È ‰È¿¯˘Ù˜ Î·È Î·Ù·Ó¤ÌÔÓÙ·È ÈÛfiÙÈÌ· Û fiÏ· Ù· Ó¢ÌÔÓÈο ‰›· (6). OÈ ˘ÎÓˆÙÈΤ˜ ÂÛٛ˜ ·ÔÙÂÏÔ‡Ó ÙÌËÌ·ÙÈΤ˜ ‹ ˘ÔÙÌËÌ·ÙÈΤ˜ ‰ÈËı‹ÛÂȘ ΢„ÂÏȉÈÎÔ‡ Ù‡Ô˘, Ô˘
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ηٷӤÌÔÓÙ·È Î˘Ú›ˆ˜ ÛÙË ÂÚÈʤÚÂÈ· Î·È ÛÙ· οو Ó¢ÌÔÓÈο ‰›· (7). OÈ ÂÚÈÔ¯¤˜ “ıÔÏ‹˜ ˘¿ÏÔ˘” Î·È ÔÈ ˘ÎÓˆÙÈΤ˜ ÂÛٛ˜ ΢„ÂÏȉÈÎÔ‡ Ù‡Ô˘ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ¿ÏÏÔÙ ¿ÏÏÔ˘ ‚·ıÌÔ‡ ‰È¿¯˘ÙË ‚Ï¿‚Ë ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ Û ÂÍȉڈ̷ÙÈÎfi Î·È ˘ÂÚÏ·ÛÙÈÎfi ÛÙ¿‰ÈÔ. ∂ÓÙfi˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ ·Ó¢ڛÛÎÔÓÙ·È ÂÍȉÚÒÌ·Ù·, Û¯ËÌ·ÙÈÛÌfi˜ ˘·Ï›Ó˘ ÌÂÌ‚Ú¿Ó˘ Î·È ˘ÂÚÏ·Û›· ÙÔ˘ Ù‡Ô˘ II Ó¢ÌÔÓÔ΢ÙÙ¿ÚˆÓ. ∂›Û˘ ·Ú·ÙËÚÂ›Ù·È ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ‰È‹ıËÛË Î·È ÈÓÔ‚Ï·ÛÙÈ΋ ·ÓÙ›‰Ú·ÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ÈÛÙÔ‡. ™ÙȘ ÂÚÈÔ¯¤˜ ·˘Ù¤˜ Û˘Ó˘¿Ú¯Ô˘Ó ÚÔۂ‚ÏË̤ӷ – ·fi ÙÔÓ Èfi- ΢„ÂÏȉÈο Ì·ÎÚÔÊ¿Á· Ì ¯·Ú·ÎÙËÚÈÛÙÈο ÂÓ‰Ô˘ÚËÓÈο ¤ÁÎÏÂÈÛÙ·(8). ¶ÔÏÏ·Ï¿ ÌÈÎÚ¿ Ô˙›‰È· ‰È·Ì¤ÙÚÔ˘ 2-4 mm (‹ < 7mm ηٿ ¿ÏÏÔ˘˜ Û˘ÁÁÚ·Ê›˜) Ì ·Û·Ê‹ fiÚÈ· Â›Ó·È Â›Û˘ Ôχ Û˘¯Ófi ‡ÚËÌ·. Δ· Ô˙›‰È· ·˘Ù¿ Â›Ó·È Î˘Ú›ˆ˜ ÎÂÓÙÚÔÏԂȉȷÎÔ‡ Ù‡Ô˘, ÂÓÙÔ›˙ÔÓÙ·È ‰ËÏ·‰‹, ÛÙÔ Î¤ÓÙÚÔ ÙÔ˘ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ Ó¢ÌÔÓÈÎÔ‡ ÏԂȉ›Ô˘ ÂÓÒ, Û·ÓÈfiÙÂÚ· ¤¯Ô˘Ó ˘Ô˘Â˙ˆÎÔÙÈ΋ ‹ Ù˘¯·›· ηٷÓÔÌ‹. ∂›Ó·È Û˘Ó‹ıˆ˜ ·ÌÊÔÙÂÚfiÏ¢ڷ Î·È ÌÔÚ› Ó· Û˘ÚÚ¤Ô˘Ó Î·Ù¿ ÙfiÔ˘˜ (ÛËÌÂ›Ô ÙÔ˘ ·ÓıÈṲ̂ÓÔ˘ ‰¤Ó‰ÚÔ˘) (9). ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ÂÓ‰Ô΢„ÂÏȉÈΤ˜ ÂÓ·Ôı¤ÛÂȘ Ì·ÎÚÔÊ¿ÁˆÓ, ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È ÈÓÈ΋˜. ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÔÈ ÌÈÎÚÔÔ˙ȉȷΤ˜ ·ÏÏÔÈÒÛÂȘ ÂÚÈ‚¿ÏÏÔÓÙ·È ·fi ¿Ïˆ “ıÔÏ‹˜ ˘¿ÏÔ˘”, Ô˘ ·ÓÙÈÛÙÔȯ› Û ÌÈÎÚfiÙÂÚÔ˘ ‚·ıÌÔ‡ ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË ‹ ·ÈÌÔÚÚ·Á›· (8). ∫·Ù¿ ηÓfiÓ· ·Ú·ÙËÚÂ›Ù·È Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ·ÓˆÙ¤ÚˆÓ ¢ÚËÌ¿ÙˆÓ. ™˘¯Ófi ‡ÚËÌ· ·ÔÙÂÏ› ›Û˘ Ë ¿¯˘ÓÛË ÙˆÓ ÌÂÛÔÏԂȉ›ˆÓ Î·È ÂÓ‰ÔÏԂȉ›ˆÓ ‰È·ÊÚ·ÁÌ·Ù›ˆÓ Ô˘ ·ÓÙÈÛÙÔȯ› Û ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ‰È‹ıËÛË ·˘-
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B. °EøP°O¶OY§OY
ÙÒÓ. ŸÙ·Ó Ë ¿¯˘ÓÛË ÙˆÓ ‰È·ÊÚ·ÁÌ·Ù›ˆÓ Û˘Ó‰˘¿˙ÂÙ·È Ì ·ÏÏÔÈÒÛÂȘ “ıÔÏ‹˜ ˘¿ÏÔ˘”, ‰È·ÌÔÚÊÒÓÂÙ·È Ë ÂÈÎfiÓ· ÙÔ˘ “ÏÈıfiÛÙÚˆÙÔ˘”. ªÔÚ› Ó· ·Ó¢ڛÛÎÂÙ·È ÌÈÎÚ‹ ÔÛfiÙËÙ· ˘Â˙ˆÎÔÙÈ΋˜ Û˘ÏÏÔÁ‹˜ . ™·ÓÈfiÙÂÚ· ·Ú·ÙËÚÔ‡ÓÙ·È ÌÈÎÚ¤˜ ΢ÛÙÈΤ˜ ‚ÚÔÁ¯ÂÎٷۛ˜, ¿¯˘ÓÛË ÙÔ˘ ‚ÚÔÁ¯Ô·ÁÁÂÈ·ÎÔ‡ ‰ÈÎÙ‡Ô˘, ¢ÌÂÁ¤ıÂȘ ˘ÎÓˆÙÈΤ˜ ÂÛٛ˜ ‹ ÌÈÎÚ¤˜ Ô˙Ò‰ÂȘ ‰ÈËı‹ÛÂȘ Ì ÙË ÌÔÚÊ‹ ÙÔ˘ “ίÚÔÂȉԇ˜” ÚfiÙ˘Ô˘(10). ∏ ÚÔηÏÔ‡ÌÂÓË ·fi ÙÔÓ ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi ÙÚÔÔÔ›ËÛË ÙˆÓ Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È Ë Ô˘‰ÂÙÂÚÔÂÓ›· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ۇÁ¯ÚÔÓË ·Ó¿Ù˘ÍË ¿ÏÏ˘ ÂÈıÂÙÈ΋˜ Ïԛ̈͢, fiˆ˜ Ó¢ÌÔÓ›·˜ ·fi Ó¢ÌÔÓÔ·ÛÙË Carinii, ‰ÈËıËÙÈ΋˜ ·ÛÂÚÁ›ÏψÛ˘,¿ÏÏ˘ ÈÔÁÂÓÔ‡˜ Ó¢ÌÔÓ›·˜ ‹ ·ÎfiÌË Î·È Ê˘Ì·ÙÈÒ‰Ô˘˜ Ó¢ÌÔÓ›·˜ (11) (ÂÈÎ. 3). ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ CMV Ó¢ÌÔÓ›·˜ Â›Ó·È Â˘Ú›· Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ¿ÏϘ ÈÔÁÂÓ›˜ Ó¢ÌÔӛ˜ (fiˆ˜ Ó¢ÌÔÓ›· ·fi ÈÔ‡˜ HSV, VZV, Epstein-Barr Î·È ÎÔÈÓÔÙÈÎÔ‡˜ ·Ó·Ó¢ÛÙÈÎÔ‡˜ ÈÔ‡˜), Ì˘ÎËÙÈ·ÛÈΤ˜ Ó¢ÌÔӛ˜ (΢ڛˆ˜ ÙËÓ ‰ÈËıËÙÈ΋ ·ÛÂÚÁ›ÏψÛË), ÙËÓ Ó¢ÌÔÓ›· ·fi Ó¢ÌÔÓÔ·ÛÙË Carinii Î·È ‚·ÎÙËÚȷΤ˜ Ó¢ÌÔӛ˜ (12,13). ™ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Â›Û˘ ÙÔ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·, Ë Ó¢ÌÔÓÈ΋ ·ÈÌÔÚÚ·Á›·, ÙÔ Û‡Ó‰ÚÔÌÔ ÔÍ›·˜ ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (ARDS), ÔÈ ÂΉËÏÒÛÂȘ ‰È·Ù·Ú·¯‹˜ ·Ó··Ú·ÁˆÁ‹˜ ÙÔ˘ ÏÂÌÊÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (PTLD) Î·È Ë ÙÔÍÈÎfiÙËÙ· ÔÚÈÛÌ¤ÓˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (.¯. Sirolimus). ∏ ‰È¿ÁÓˆÛË Ù˘ Ó¢ÌÔÓ›·˜ ·fi ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi Ù›ıÂÙ·È Ì ·ÍÈÔÈÛÙ›· ›Ù Ì ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ Û ÈÛÙÔÙÂÌ¿¯ÈÔ Ó‡ÌÔÓÔ˜ ÌÂÙ¿ ‚ÈÔ„›· ›Ù Ì ¿ÏϘ ÏÈÁfiÙÂÚÔ ÂÂÌ‚·ÙÈΤ˜ ÌÂıfi‰Ô˘˜, fiˆ˜ ·Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ Û ‚ÚÔÁ¯Ô΢„ÂÏȉÈÎfi ¤ÎÏ˘Ì·, ÔÛÔÙÈ΋ ̤ÙÚËÛË (PCR) ‹ ·Ó›¯Ó¢ÛË ·ÓÙÈÁfiÓˆÓ (pp65 ·ÓÙÈÁÔÓ·ÈÌ›·) ·˘ÙÔ‡, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, Ù· Â˘Ú‹Ì·Ù· ·fi ÙËÓ HRCT ıÒÚ·ÎÔ˜ Î·È ÙÔÓ ·ÔÎÏÂÈÛÌfi ¿ÏÏˆÓ ·ıÔÁfiÓˆÓ ·ÈÙ›ˆÓ (1). ∏ ÚÔÛ‚ÔÏ‹ ¿ÏÏˆÓ Û˘ÛÙËÌ¿ÙˆÓ, fiˆ˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Î·È ÙÔ˘ ÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·ÔÙÂÏÔ‡Ó Û¯ÂÙÈο Û¿ÓȘ ÂΉËÏÒÛÂȘ Ô‡ ÂÌÊ·Ó›˙ÔÓÙ·È Û ·ÒÙÂÚÔ ÛÙ¿‰ÈÔ,6-12 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË (1). ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÂΉËÏÒÓÂÙ·È ˆ˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉ›Ùȉ·, Ì˘ÂÏ›Ùȉ· / ÔÏ˘ÚÈ˙›Ùȉ·, ‰È¿¯˘ÙË ÌÈÎÚÔÔ˙Ò‰Ë ÂÁÎÂÊ·-
Ï›Ùȉ·, ÂÂÓ‰˘ÌÔÂÁÎÂÊ·Ï›Ùȉ· Î·È ÔÏÏ·Ï‹ ÌÔÓÔÓ¢ڛÙȉ· (14,15,16). ∞ÛıÂÓ›˜ Ì ·ÌÊÈ‚ÏËÛÙÚÔÂȉ›Ùȉ· ÂÌÊ·Ó›˙Ô˘Ó 10 ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚ· ·ÏÏÔÈÒÛÂȘ ÂÁÎÂÊ·Ï›ÙȉԘ. ∏ Ì˘ÂÏ›Ùȉ· / ÔÏ˘ÚÈ˙›Ùȉ· ÎÏÈÓÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÚÔԉ¢ÙÈ΋ ·ÓÈÔ‡Û· ¿ÚÂÛË Î·ıÒ˜ Î·È ‰È·Ù·Ú·¯¤˜ ·ÈÛıËÙÈÎfiÙËÙ·˜ Î·È Ô‡ÚËÛ˘. O Ì·ÁÓËÙÈÎfi˜ Û˘ÓÙÔÓÈÛÌfi˜ Î·È ÂȉÈÎfiÙÂÚ· Ë Δ1 ·ÎÔÏÔ˘ı›· ÌÂÙ¿ Â.Ê. ¤Á¯˘ÛË ÛÎÈ·ÛÙÈÎÔ‡ ·Ó·‰ÂÈÎÓ‡ÂÈ ¿¯˘ÓÛË Î·È Û˘ÚÚÔ‹ ÙˆÓ Ó¢ÚÈÎÒÓ ÚÈ˙ÒÓ, ηıÒ˜ Î·È ·ıÔÏÔÁÈÎfi ÁÚ·ÌÌÔÂȉ‹, Ô˙Ò‰Ë ‹ Î·È ‰È¿¯˘ÙÔ ÂÌÏÔ˘ÙÈÛÌfi ÙÔ˘ Ì˘ÂÏÈÎÔ‡ ÎÒÓÔ˘ Î·È ÙÔ˘ ÙÂÏÈÎÔ‡ ÓËÌ·Ù›Ô˘. ∞ÂÈÎÔÓÈÛÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ÂÁÎÂÊ·Ï›ÙȉԘ Â›Ó·È Ë ÊÏÔÈ˚΋ ·ÙÚÔÊ›·, ÔÈ ‰È¿¯˘Ù˜ ·ÏÏÔÈÒÛÂȘ Ù˘ Ï¢΋˜ Ô˘Û›·˜ Î·È Ë ¿¯˘ÓÛË ÙÔ˘ ÂÂÓ‰‡Ì·ÙÔ˜ ÙˆÓ ÎÔÈÏÈÒÓ Ì ·ıÔÏÔÁÈο ·˘ÍË̤ÓÔ Û‹Ì· ÛÙȘ Δ2 ·ÎÔÏÔ˘ı›Â˜ (ÂÈÎ. 4). ªÔÚ› Ó· ˘¿Ú¯ÂÈ Î·È ÚÔÛ‚ÔÏ‹ ÙÔ˘ ¯ÔÚÈÔÂȉԇ˜ ϤÁÌ·ÙÔ˜. ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ÔÈ ·ÏÏÔÈÒÛÂȘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÌÈÎÚÔ- ÁÏÔÈÔÙÈο Ô˙›‰È·, ÌÈÎÚ¤˜ ÂÛٛ˜ Ó¤ÎÚˆÛ˘ - ÈÛ¯·ÈÌ›·˜ Î·È ÁÈÁ·ÓÙÔ·ÙÙ·Ú· Ì ÂÓ‰Ô˘ÚËÓÈο ¤ÁÎÏÂÈÛÙ·. ∂ΉËÏÒÛÂȘ ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· ·ÔÙÂÏÔ‡Ó Ë Ë·Ù›Ùȉ·, Ë ÔÈÛÔÊ·Á›Ùȉ·, Ë ÎÔÏ›Ùȉ· Î·È Û·ÓÈfiÙÂÚ· Ë ¯ÔÏ·ÁÁÂÈ›Ùȉ· Î·È Ë ·ÁÎÚ·ٛÙȉ· (2). ∏ ÔÈÛÔÊ·Á›Ùȉ· ·Ú¯Èο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÈÎÚ¿ ·‚·ı‹ ¤ÏÎË Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·fi ¤ÓÙÔÓ˜ ÂÍÂÏÎÒÛÂȘ ΢ڛˆ˜ ÛÙÔ Î¿Ùˆ ÙÚÈÙËÌfiÚÈÔ ÙÔ˘ ÔÈÛÔ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
∂ÈÎfiÓ· 4. T2 ·ÎÔÏÔ˘ı›· ÛÙÔ Â›Â‰Ô ÙˆÓ ÌÂوȷ›ˆÓ ÎÂÚ¿ÙˆÓ. ¶·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓÔ Û‹Ì· ÛÙÔ Â¤Ó‰˘Ì· Î·È Á‡Úˆ ·fi ÙÔ ÙÔ›¯ˆÌ· Ù˘ 3˘ ÎÔÈÏ›·˜.
Ê¿ÁÔ˘ ÎÔÓÙ¿ ÛÙË Á·ÛÙÚÔ-ÔÈÛÔÊ·ÁÈ΋ Û˘Ì‚ÔÏ‹ (17). ∏ CMV ÎÔÏ›Ùȉ· ÚÔÛ‚¿ÏÏÂÈ Î˘Ú›ˆ˜ ÙÔ Ù˘ÊÏfi Î·È ·ÓÈfiÓ ÎfiÏÔ, ÌÔÚ›, fï˜ Ó· ÂÍÂÏȯı› Û ·ÓÎÔÏ›Ùȉ· ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ÙÂÏÈÎÔ‡ ÂÈÏÂÔ‡. ∞Ú¯Èο ·Ú·ÙËÚÔ‡ÓÙ·È ·ÊıÒ‰Ë ¤ÏÎË Û ÎÔÎÎÈÔÌ·ÙÒ‰Ë ‚ÏÂÓÓÔÁfiÓÔ. ™Â ÚÔ¯ˆÚË̤ÓÔ ÛÙ¿‰ÈÔ ·Ú·ÙËÚÔ‡ÓÙ·È ÂÍÂÏÎÒÛÂȘ, ‰È·ÙÈÙÚ·›ÓÔÓÙ· ¤ÏÎË Î·È ¤ÓÙÔÓÔ Ô›‰ËÌ· ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜. ∏ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ó·‰ÂÈÎÓ‡ÂÈ ·ıÔÏÔÁÈ΋ ¿¯˘ÓÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ ÌÂ Û˘ÓÔ‰fi Ô›‰ËÌ· ÙÔ˘ ·Ú·Î›ÌÂÓÔ˘ ÂÚÈÙÔÓ·˚ÎÔ‡ Ï›Ô˘˜. ™ÙȘ ‚·ÚȤ˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ ÙÔ ÙÔ›¯ˆÌ· ÙÔ˘ ÂÓÙ¤ÚÔ˘ Â›Ó·È ·ÈÌÔÚÚ·ÁÈÎfi – ˘¤Ú˘ÎÓÔ, ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ÂÓ‰ÔÙÔȯˆÌ·ÙÈÎfi˜ ·¤Ú·˜, ÈÛ¯·ÈÌÈ΋ Ó¤ÎÚˆÛË ‹ / Î·È ‰È¿ÙÚËÛË ·˘ÙÔ‡ (18). ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ °.∂.™. ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÁÁÂÈ›Ùȉ· ÙˆÓ ˘Ô‚ÏÂÓÓÔÁfiÓÈˆÓ ÙÚȯÔÂȉÒÓ Ì ·ÔÙ¤ÏÂÛÌ· ÙË ıÚfiÌ‚ˆÛË, ÈÛ¯·ÈÌ›· Î·È Ó¤ÎÚˆÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜. ∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi ÙÔ˘ ·ÏÔ‡ ¤ÚËÙÔ˜ ·ÔÙÂÏ› ÈÔ Û¿ÓÈ· ¢ηÈÚȷ΋ Ïԛ̈ÍË, Ô˘ ÂÌÊ·Ó›˙ÂÙ·È 1-2 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂ΉËÏÒÓÂÙ·È Î˘Ú›ˆ˜ Ì ÂÍÂÏÎÒÛÂȘ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘ ÛÙfiÌ·ÙÔ˜, ÙˆÓ ¯ÂÈÏÒÓ, ÙˆÓ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ ‹ ÙÔ˘ ÚˆÎÙÈÎÔ‡ ‰·ÎÙ˘Ï›Ô˘(2). ªÔÚ› ›Û˘ Ó· ÂΉËψı› Ì ÙË ÌÔÚÊ‹ ÔÈÛÔÊ·Á›ÙȉԘ, ÂÁÎÂÊ·Ï›ÙȉԘ ‹ ‰È·Ì¤ÛÔ˘ Ó¢ÌÔÓ›·˜. ∏ ÔÏ˘Û˘-
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ÛÙËÌ·ÙÈ΋ ÓfiÛÔ˜ ¤¯ÂÈ È‰È·›ÙÂÚ· ·˘ÍË̤ÓË ıÓËÛÈÌfiÙËÙ·. ∏ ÔÈÛÔÊ·Á›Ùȉ· ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ Ïԛ̈͢, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÔÏÏ·Ï¿ ÌÈÎÚ¿ ¤ÏÎË Ô˘ Û˘ÚÚ¤Ô˘Ó Û˘Ó‹ıˆ˜ ÛÙË ÌÂÛfiÙËÙ· ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, ¢ÌÂÁ¤ıÂȘ ÂÏΈÙÈΤ˜ ϿΘ Î·È ‰È¿¯˘Ù· ·ÓÒÌ·ÏË ·Ú˘Ê‹ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ (17). ™·ÓÈfiÙÂÚ· ·Ú·ÙËÚÔ‡ÓÙ·È ‰È¿ÙÚËÛË ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ Î·È ·Ó¿Ù˘ÍË ÙÚ·¯ÂÈÔÔÈÛÔÊ·ÁÈÎÔ‡ Û˘ÚÈÁÁ›Ô˘. ∏ ÂÚËÙÈ΋ ÌËÓÓÈÁÁÔ-ÂÁÎÂÊ·Ï›Ùȉ· ·ÔÙÂÏ› ÙË ÈÔ Û˘¯Ó‹ ÌÔÚÊ‹ ÂÁÎÂÊ·Ï›ÙȉԘ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ˜ ·ÛıÂÓ›˜ (19). ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›·, ηıÒ˜ Ë ıÓËÙfiÙËÙ· ·˘Ù‹˜ Êı¿ÓÂÈ ÙÔ 70%.¶ÚfiÎÂÈÙ·È ÁÈ· ÓÂÎÚˆÙÈ΋ ÂÁÎÂÊ·Ï›Ùȉ· Ô˘ ÁÚ‹ÁÔÚ· ÂÍ·ÏÒÓÂÙ·È ÛÙÔ ÂÁÎÂÊ·ÏÈÎfi ·Ú¤Á¯˘Ì·, ÚÔηÏÒÓÙ·˜ Ô›‰ËÌ· Î·È ÂÙ¯ÈÒ‰ÂȘ ·ÈÌÔÚÚ·Á›Â˜. ¶ÚÔÛ‚¿ÏÏÂÈ Î·Ù¿ ÚÔÙ›ÌËÛË ÙÔÓ Î¿Ùˆ Î·È Ì¤ÛÔ ÎÚÔÙ·ÊÈÎfi ÏÔ‚fi Ì ¤ÎÙ·ÛË ÚÔ˜ ÙË Ó‹ÛÔ ÙÔ˘ Reil, ¯ˆÚ›˜ Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ‚·ÛÈÎÒÓ Á·ÁÁÏ›ˆÓ. Œ¯ÂÈ Û˘Ó‹ıˆ˜ ·ÌÊÔÙÂÚfiÏ¢ÚË Î·Ù·ÓÔÌ‹. ªÂ ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ·ÍÔÓÈÎÔ‡ ÙÔÌÔÁÚ¿ÊÔ˘ ·Ó·‰ÂÈÎÓ‡ÔÓÙ·È ˘fi˘ÎÓ˜ ÂÛٛ˜ ÛÙȘ ÚÔۂ‚ÏË̤Ó˜ ÂÚÈÔ¯¤˜. ∏ ·ÂÈÎÔÓÈÛÙÈ΋ ÂͤٷÛË ÂÎÏÔÁ‹˜ Â›Ó·È Ô Ì·ÁÓËÙÈÎfi˜ Û˘ÓÙÔÓÈÛÌfi˜, fiÔ˘ ÛÙË Δ1 ·ÎÔÏÔ˘ı›· ·Ú·ÙËÚÔ‡ÓÙ·È ÂÛٛ˜ ¯·ÌËÏÔ‡ Û‹Ì·ÙÔ˜ Î·È ÛÙȘ Δ2 Î·È FLAIR ·-
∂ÈÎfiÓ· 5. ∂ÚËÙÈ΋ ÂÁÎÂÊ·Ï›Ùȉ·, FLAIR ·ÎÔÏÔ˘ı›· ¶·ıÔÏÔÁÈ΋ ÂÛÙ›· _ Û‹Ì·ÙÔ˜ ÛÙÔ Ì¤ÛÔ Î·È ÚfiÛıÈÔ ÎÚ·ÓÈ·Îfi ÏÔ‚fi ∞ƒ ( ‚¤ÏË). ¶·ıÔÏÔÁÈ΋ ÚfiÛÏË„Ë ÙˆÓ ÌËÓ›ÁÁˆÓ Î·È ÙˆÓ ÂÏ›ÎˆÓ ÙÔ˘ ÊÏÔÈÔ‡ ·Ú·ÙËÚÂ›Ù·È ÌÂÙ¿ ÙËÓ 2Ë Â‚‰ÔÌ¿‰·.
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ÎÔÏÔ˘ı›Â˜ ·Ó·‰ÂÈÎÓ‡ÔÓÙ·È ÂÛٛ˜ ˘„ËÏÔ‡ Û‹Ì·ÙÔ˜ ÂÓÙfi˜ 48h ‹ Î·È ÓˆÚ›ÙÂÚ·. ™ÙË ÚÒÈÌË Ê¿ÛË, ȉȷ›ÙÂÚ· ¢·›ÛıËÙË Ì¤ıÔ‰Ô˜ Â›Ó·È Ë Ù¯ÓÈ΋ ‰È¿¯˘Û˘ (DWI) (ÂÈÎ. 5). ∏ Ó¢ÌÔÓ›· ·fi ÙÔÓ ·Ïfi ÂÚËÙÔ˚fi ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÔÏϷϤ˜ ÂÌ‚·ÏÔÌ·ÙÔÂȉ›˜ ÂÚÈÔ¯¤˜ “ıÔÏ‹˜ ˘¿ÏÔ˘” ηıÒ˜ Î·È ˘ÎÓˆÙÈΤ˜ ÂÛٛ˜ Ì ÎÂÓÙÚÈ΋ Î·È ÂÚÈÊÂÚÈ΋ ηٷÓÔÌ‹. πÛÙÔÏÔÁÈο ÔÈ ÂÚÈÔ¯¤˜ ·˘Ù¤˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi Ó¤ÎÚˆÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙˆÓ Î˘„ÂÏ›‰ˆÓ Î·È ÚˆÙÂ˚ÓÈο ÂÍȉÚÒÌ·Ù· Ì ÔÏ˘ÌÔÚÊÔ˘ÚËÓÈ΋ ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË (8). ∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ ·ÓÂÌÔ‚ÏÔÁÈ¿˜ – ¤ÚËÙÔ˜ ˙ˆÛÙ‹ÚÔ˜ (VZV) Â›Ó·È Û¯ÂÙÈο Û¿ÓÈ· ÂÈÏÔ΋, ηıÒ˜ ·ÊÔÚ¿ ~ ÙÔ 7,4% ÙˆÓ ·ÛıÂÓÒÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰ÂÚÌ·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ, Ô˘ ÌÔÚ› Ó· Û˘Óԉ‡ÔÓÙ·È ·fi Û˘ÛÙËÌ·ÙÈ΋ ÓfiÛÔ, fiˆ˜ ‰È¿¯˘ÙË ÂÓ‰Ô·ÁÁÂȷ΋ ‹ÍË, Ë·Ù›Ùȉ·, Ó¢ÌÔÓ›·, ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›Ùȉ· Î·È ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·. ™ÙȘ ÂÚÈÙÒÛÂȘ Û˘ÛÙËÌ·ÙÈ΋˜ ÚÔÛ‚ÔÏ‹˜ ÙÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙÔ˜ ·Ó¤Ú¯ÂÙ·È Û ~34%(2). ∞ÎÙÈÓÔÏÔÁÈο Ë Ó¢ÌÔÓ›· ·fi ÙÔÓ Èfi Ù˘ ·ÓÂÌÔ‚ÏÔÁÈ¿˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÚÈÔ¯¤˜ “ıÔÏ‹˜ ˘¿ÏÔ˘” ÁˆÁÚ·ÊÈ΋˜ ηٷÓÔÌ‹˜ Î·È ÔÏÏ·Ï¿ ÌÈÎÚ¿ Ô˙›‰È· ‰È·Ì¤ÙÚÔ˘ 1-10mm ‰È¿Û·ÚÙ· Û fiÏË ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ Ó¢ÌÔÓÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ (8). Δ· Ô˙›‰È· ·˘Ù¿ ÌÔÚ› Ó· ÂÚÈ‚¿ÏÏÔÓÙ·È ·fi ¿Ïˆ “ıÔÏ‹˜ ˘¿ÏÔ˘” ‹ ÌÔÚ› ηٿ ÙfiÔ˘˜ Ó· Û˘ÚÚ¤Ô˘Ó . ™˘Ó‹ıˆ˜ ˘ÔÛÙÚ¤ÊÔÓÙ·È Û 1 ‚‰ÔÌ¿‰· . ™ÙȘ ‚·ÚȤ˜ fï˜ ÌÔÚʤ˜ Ù˘ ÓfiÛÔ˘ ·Ú·Ì¤ÓÔ˘Ó ÁÈ· Ì‹Ó˜,ÂÓÒ ÌÔÚ› Ó· ·ۂÂÛÙˆıÔ‡Ó Î·È Ó· ·Ú·Ì›ÓÔ˘Ó ˆ˜ ÌÈÎÚ¤˜ ‰È¿Û·ÚÙ˜ ÌÈÎÚÔ·ۂÂÛÙÒÛÂȘ (∂ÈÎ. 6). ∏ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·fi ÙÔÓ Èfi Ù˘ ·ÓÂÌÔ‚ÏÔÁÈ¿˜ Î·È ·fi ÙÔÓ Èfi ÙÔ˘ ¤ÚËÙÔ˜ ˙ˆÛÙ‹ÚÔ˜ ÂΉËÏÒÓÂÙ·È ˆ˜ ÂÁοÚÛÈ· Ì˘ÂÏ›Ùȉ·, ÌËÓÈÁÁÔÂÁÎÂÊ·Ï›Ùȉ·, ·ÚÂÁÎÂÊ·ÏȉÈ΋ ·Ù·Í›· Î·È ˆ˜ ÂÁÎÂÊ·ÏÈÙȉ·, Ó¢ڛÙȉ·, Ì˘ÂÏ›Ùȉ·, ÂÚËÙÈ΋ ÔÊı·ÏÌÔ¿ıÂÈ· ·ÓÙ›ÛÙÔȯ·. ∞ÂÈÎÔÓÈÛÙÈο Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ Ì·ÁÓËÙÈÎÔ‡ Û˘ÓÙÔÓÈÛÌÔ‡, ·Ú·ÙËÚÔ‡ÓÙ·È ÔÏ˘ÂÛÙȷΤ˜ ‚Ï¿‚˜ ÛÙÔ ÊÏÔÈfi Î·È ÛÙÔ Û٤ϯԘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘,·˘ÍË̤ÓÔ˘ Û‹Ì·ÙÔ˜ ÛÙË Δ2 ·ÎÔÏÔ˘ı›· (19). ∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ (EBV) ÂΉËÏÒÓÂÙ·È Û˘Ó‹ıˆ˜ Ì ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË Î·È Û˘ÓÔ‰fi ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· – Ê·Ú˘ÁÁ›Ùȉ· (2). ¶ÈÔ Û¿ÓȘ ÂΉËÏÒÛÂȘ ·ÔÙÂÏÔ‡Ó Ë Ó¢ÌÔÓ›·, Ë ÌËÓÈÁÁ›Ùȉ·, Ë Ë·Ù›Ùȉ· Î·È Ë ·-
ÁÎÚ·ٛÙȉ·. ∞ÎÙÈÓÔÏÔÁÈο Ë EBV Ó¢ÌÔÓ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È Î˘Ú›ˆ˜ ·fi ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ· ÌÂÛÔıˆÚ·Î›Ô˘ Î·È Û·ÓÈfiÙÂÚ· ·fi ‰ÈËı‹ÛÂȘ ÙÔ˘ ‰È¿ÌÂÛÔ˘ Ó¢ÌÔÓÈÎÔ‡ ‰ÈÎÙ‡Ô˘. O Èfi˜ Ù˘ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ·ıÔÁ¤ÓÂÈ· Ù˘ ‰È·Ù·Ú·¯‹˜ ·Ó··Ú·ÁˆÁ‹˜ ÙÔ˘ ÏÂÌÊÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË (PTLD), ηıÒ˜ ¤¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ Â¿ÁÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙˆÓ μ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ë ÔÔ›· Û ¤‰·ÊÔ˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜–·‰Ú¿ÓÂÈ·˜ ÙˆÓ Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·ı›ÛÙ·Ù·È ·ÓÂͤÏÂÁÎÙË (1). ∞ÛıÂÓ›˜ Ì ڈÙÔ·ı‹ EBV Ïԛ̈ÍË ¤¯Ô˘Ó 10-76 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ PTLD. ∞·ÓÙ¿Ù·È Î˘Ú›ˆ˜ Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó¢ÌfiÓˆÓ (4-10%) ‹ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (ˆ˜ 20%) Î·È Û·ÓÈfiÙÂÚ· Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ‹ ÓÂÊÚÒÓ (~ 1-2%).∂ÌÊ·Ó›˙ÂÙ·È 6-17 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ PTLD Î˘Ì·›ÓÂÙ·È ·fi ηÏÔ‹ıË ·ÓÙȉڷÛÙÈ΋ Ï·ÛÌ·ÙÔ΢ÙÙ·ÚÈ΋ ˘ÂÚÏ·Û›· ¤ˆ˜ ÌÔÓÔÎψÓÈ΋ ηÎÔ‹ıË ÓfiÛÔ, Ô˘ ÈÛÔ‰˘Ó·Ì› Ì ηÎfiËı˜ Non-Hodgkin ϤÌʈ̷. ∏ ÂÓÙfiÈÛË Ù˘ PTLD Â›Ó·È Î˘Ú›ˆ˜ Â͈ÏÂÌÊ·‰ÂÓÈ΋ Î·È ·ÊÔÚ¿ ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· (∂ÈÎ. 7). OÈ ÏÔÈÌÒÍÂȘ ·fi ÙÔ˘˜ ÎÔÈÓÔÙÈÎÔ‡˜ ·Ó·Ó¢ÛÙÈÎÔ‡˜ ÈÔ‡˜ (Èfi˜ Ù˘ ÈÓÊÏÔ˘¤ÓÙ˙·˜, ·Ú·ÈÓÊÏÔ˘¤ÓÙ˙·˜, ·‰ÂÓÔ˚fi˜, ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜) Â›Ó·È Û˘¯Ó¤˜ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∫·Ù¿ Û˘Ó¤ÂÈ· Ô ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˜ – ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË – ·ÛıÂÓ‹˜ ‚Ú›ÛÎÂÙ·È Û˘¯Ó¿ ÂÎÙÂıÂÈ̤ÓÔ˜ Û ·˘Ù¤˜ (1). ¶ÈÔ Û˘¯Ó¿ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÂ
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΢ÙÙ·ÚÔÙÔÍÈÎÒÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ô˘ ·Ó·ÁÓˆÚ›˙Ô˘Ó Ù· ÌÔÏ˘Ṳ̂ӷ ·ÙÙ·Ú· Î·È Ù· ηٷÛÙÚ¤ÊÔ˘Ó. ΔÔ ÂÚ›‚ÏËÌ· Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙË ÏÔÈÌÔÁfiÓÔ ‰‡Ó·ÌË ÙÔ˘ ÈÔ‡. ¶ÂÚȤ¯ÂÈ ÁÏ˘ÎÔÚˆÙ½Ó˜ Ô˘ ¯ÚËÛÈÌÂ‡Ô˘Ó ÁÈ· ÙËÓ ÚÔÛÎfiÏÏËÛË ÙÔ˘ ۈ̷Ùȉ›Ô˘ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ÍÂÓÈÛÙ‹, ÙËÓ Â›ÛÔ‰fi ÙÔ˘ Û ·˘Ù¿ Î·È ÙËÓ ·Ú·ÁˆÁ‹ ÂÍÔ˘‰ÂÙÂÚˆÙÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ·fi ÙÔ ÍÂÓÈÛÙ‹. ¶·ÚfiÙÈ Ë ·ÓÔÛ›· ¤Ó·ÓÙÈ ÙÔ˘ ΢ÙÙ·ÚÔÌÂÁ·ÏÔÈÔ‡ Â›Ó·È Î˘ÙÙ·ÚÈ΋ Î·È ÏÈÁfiÙÂÚÔ ¯˘ÌÈ΋ ‰‡Ô ÁÏ˘ÎÔÚˆÙ½Ó˜ ÙÔ˘ ÂÚÈ‚Ï‹Ì·ÙÔ˜ ÔÈ gμ Î·È gH ÂÎÊÚ¿˙ÔÓÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ÌÔÏ˘ÛÌ¤ÓˆÓ Î˘ÙÙ¿ÚˆÓ Î·È ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ·fi Ù· ·ÓÙÈÛÒÌ·Ù· ÔÚÔıÂÙÈÎÒÓ ·ÛıÂÓÒÓ. ¶Èı·ÓfiÓ Û’ ·˘Ù‹ ÙËÓ ÂÍÔ˘‰ÂÙÂÚˆÙÈ΋ ÈηÓfiÙËÙ· ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÔÊ›ÏÂÙ·È Ë ‰Ú¿ÛË Ù˘ ˘ÂÚ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ Ô˘ ¯ÔÚËÁÂ›Ù·È Û ÓÔÛÔ‡ÓÙ˜ ·fi ÙË Ïԛ̈ÍË. ∏ ‡·ÚÍË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ ÚˆÙÂ˚ÓÒÓ ·˘ÙÒÓ ÂÍËÁ› ›Û˘ ÁÈ·Ù› ÔÚÔıÂÙÈÎÔ› ·ÛıÂÓ›˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ·Ó·Ù‡ÛÛÔ˘Ó Û·ÓÈfiÙÂÚ· Ïԛ̈ÍË (2,3). ΔÔ Î˘ÙÙ·ÚÈÎfi ÛΤÏÔ˜ Ù˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ ÙÔ˘ ÍÂÓÈÛÙ‹ Â›Ó·È ÛËÌ·ÓÙÈÎfiÙÂÚÔ ·fi ÙÔ ¯˘ÌÈÎfi. Δ· CD8 ΢ÙÙ·ÚÔÙÔÍÈο ÏÂÌÊÔ·ÙÙ·Ú· ·Ó·ÁÓˆÚ›˙Ô˘Ó Ù· ÌÔÏ˘Ṳ̂ӷ ·ÙÙ·Ú· Î·È Ù· ηٷÛÙÚ¤ÊÔ˘Ó Î·È Ù· CD4 ‚ÔËıËÙÈο ·Ó·ÁÓˆÚ›˙Ô˘Ó Ù· CMV ·ÓÙÈÁfiÓ· Û ¤Ó· Û‡ÌÏÂÁÌ· Ì ٷ Ì›˙ÔÓ· ·ÓÙÈÁfiÓ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Î·È ‰ÈÂÁ›ÚÔ˘Ó Ì¤Ûˆ ΢ÙÙÔÎÈÓÒÓ ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ CD8 Î·È ÙËÓ ¯˘ÌÈ΋ ·ÓÔÛ›·. °È· ÙÔ ÏfiÁÔ ·˘Ùfi Ê¿Ú̷η fiˆ˜ ·ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈÎfi˜ ÔÚfi˜ Î·È ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Ô˘ ηٷÛÙ¤ÏÏÔ˘Ó ÙËÓ ·Ú·ÁˆÁ‹ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Û˘Ó‰¤ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ CMV Ïԛ̈͢.
ŒÓ· ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Ù˘ ÎÏÈÓÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 30 ¤ÙË, Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ Ì ÙÔÓ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi. O Èfi˜ Û ¿ÙÔÌ· ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ· Û¿ÓÈ· ÚÔηÏ› ÓfiÛÔ, Ô˘ ÔÌÔÈ¿˙ÂÈ Û’·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Ì ÁÚÈÒ‰Ë Û˘Ó‰ÚÔÌ‹. ¢˘ÛÙ˘¯Ò˜ Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Ë CMV Ïԛ̈ÍË ÂΉËÏÒÓÂÙ·È Ì ˘ÚÂÙfi, Ï¢ÎÔÂÓ›· Î·È Û˘¯Ó¿ ÂÈϤÎÂÙ·È Ì ÚÔÛ‚ÔÏ‹ ÙˆÓ ÈÛÙÒÓ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÚÔηÏÒÓÙ·˜ ÓÂÊÚ›Ùȉ·, Ó¢ÌÔÓ›·, Ë·Ù›Ùȉ·, Ì˘Ôηډ›Ùȉ·, ÂÓÙÂÚ›Ùȉ· ‹ ¯ÔÏ·ÁÁÂÈ›Ùȉ·, ÂÈ‚·Ú‡ÓÔÓÙ·˜ ÛËÌ·ÓÙÈο ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ.
πÔÏÔÁÈο Î·È ·ÓÔÛÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÈÔ‡ O ΢ÙÙ·ÚÔÌÂÁ·ÏÔÈfi˜ Â›Ó·È ¤Ó·˜ ÂÚËÙÔÈfi˜, Ô˘ ·Ó‹ÎÂÈ ÛÙËÓ ˘ÔÔÌ¿‰· ÙˆÓ ‚‹Ù· ÂÚËÙÔÈÒÓ. O ÂÚȤ¯ÂÈ ¤Ó· ‰›ÎψÓÔ DNA Î·È ÙÔ ÛˆÌ·Ù›‰ÈÔ ¤¯ÂÈ ÂÈÎÔۿ‰ÚË Û˘ÌÌÂÙÚ›·. ∞ÔÙÂÏÂ›Ù·È ·fi ¤Ó· ÚˆÙÂ˚ÓÈÎfi η„›‰ÈÔ, 162 η„ÔÌÂÚȉ›ˆÓ, ·fi ÙËÓ Â͈ÙÂÚÈ΋ ÚˆÙÂ˚ÓÈ΋ ÛÙÔÈ‚¿‰· Î·È ÙÔ ÂÚ›‚ÏËÌ·(1). ΔÔ ÚˆÙÂ˚ÓÈÎfi η„›‰ÈÔ ÂÈÛ¯ˆÚ› Î·È Î·Ù·Ï·Ì‚¿ÓÂÈ ÙÔÓ ˘Ú‹Ó· ÙÔ˘ ÌÔÏ˘Ṳ̂ÓÔ˘ ΢ÙÙ¿ÚÔ˘, fiÔ˘ Î·È ·Ó·Ù‡ÛÛÂÙ·È Ô Èfi˜. ∞ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ ÙÚÈÒÓ Ì›˙ÔÓˆÓ ÚˆÙÂ˚ÓÒÓ ÙÔ˘ η„ȉ›Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÙËÓ ÈηÓfiÙËÙ· Ó· ÂÍÔ˘‰ÂÙÂÚÒÛÔ˘Ó ÙÔÓ Èfi. °È· ÙÔ ÏfiÁÔ ·˘Ùfi ÔÈ ÚˆÙ½Ó˜ ÙÔ˘ η„ȉ›Ô˘ ‰ÂÓ Â›Ó·È ÛËÌ·ÓÙÈΤ˜ ÁÈ· ÙË ‰È¿ÁÓˆÛË ‹ ÙË ıÂڷ›· Ù˘ Ïԛ̈͢. ∏ ÚˆÙÂ˚ÓÈ΋ ÛÙÔÈ‚¿‰· ·ÔÙÂÏÂ›Ù·È ·fi 7 ÚˆÙ½Ó˜, ÔÈ Ôԛ˜ fiˆ˜ Î·È ·˘Ù¤˜ ÙÔ˘ η„ȉ›Ô˘, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ȉȷ›ÙÂÚË ÛËÌ·Û›· ÛÙËÓ ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË ÙÔ˘ ÍÂÓÈÛÙ‹. ¶·ÚfiÏ· ·˘Ù¿ Ë ÚˆÙ½ÓË pp65 Ù˘ ÛÙÔÈ‚¿‰·˜, ÂÎÊÚ¿˙ÂÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÌÔÏ˘Ṳ̂ÓÔ˘ ΢ÙÙ¿ÚÔ˘ ÚÈÓ Î·È ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡. ∏ ÚˆÙ½ÓË ·˘Ù‹ ·ÔÙÂÏ› ·ÓÙÈÁÔÓÈÎfi ÛÙfi¯Ô ÙˆÓ
∂ȉËÌÈÔÏÔÁ›· ÷ڷÎÙËÚÈÛÙÈÎfi ÙÔ˘ ÈÔ‡ Â›Ó·È Ë ÚfiÎÏËÛË Ï·Óı¿ÓÔ˘Û·˜ Ïԛ̈͢, Ë Â’ ·fiÚÈÛÙÔÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi Î·È Ë ·Ó·˙ˆ‡ÚˆÛË È‰È·›ÙÂÚ· Û ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜. ∏ ÔÓÔÌ·-
133
134
¢. OIKONOMI¢OY
Û›· ÙÔ˘ ÔÊ›ÏÂÙ·È ÛÙÔ Û¯ËÌ·ÙÈÛÌfi ÌÂÁ¿ÏˆÓ ΢ÙÙ¿ÚˆÓ Î·È ÂÁÎÏ›ÛÙˆÓ ÛˆÌ·Ù›ˆÓ ÛÙÔÓ ˘Ú‹Ó· Î·È ÛÙÔ ÚˆÙfiÏ·ÛÌ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ÚÔÛ‚¿ÏÏÂÈ. O Èfi˜ ·Ó·Ù‡ÛÛÂÙ·È Û ηÏÏȤÚÁÂȘ ÈÓÔ‚Ï·ÛÙÒÓ ·ÓıÚÒÔ˘ Ì ÙËÓ ÂÌÊ¿ÓÈÛË Î˘ÙÙ·ÚÔ·ıÔÏÔÁÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ ÌÂÙ¿ ·fi 1-6 ‚‰ÔÌ¿‰Â˜. ÷ڷÎÙËÚÈÛÙÈÎfi ÙÔ˘ Â›Ó·È fiÙÈ ÚÔÛ‚¿ÏÏÂÈ ÌfiÓÔ ÙÔÓ ¿ÓıÚˆÔ Î·È ‰ÂÓ ·Ó·Ù‡ÛÛÂÙ·È Û ÂÈÚ·Ì·Ùfi˙ˆ· (1,4). O Èfi˜ Â›Ó·È Â˘Î·ÈÚȷο ·ıÔÁfiÓÔ˜ ÁÈ· ÙÔÓ ¿ÓıÚˆÔ Î·È Ë ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ Î˘Ì·›ÓÂÙ·È ·fi 50-100% ·Ó¿ÏÔÁ· Ì ÙË ÁˆÁÚ·ÊÈ΋ ηٷÓÔÌ‹ Î·È ÙËÓ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ÏËı˘ÛÌÔ‡. ∏ ÌÂÙ¿‰ÔÛ‹ ÙÔ˘ Á›ÓÂÙ·È ·fi ¿ÙÔÌÔ Û ¿ÙÔÌÔ Ì¤Ûˆ ÂÎÎÚ›ÛˆÓ, ÌÂÙ·ÁÁ›ÛÂˆÓ ·›Ì·ÙÔ˜ ‹ Ì ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÚÁ¿ÓˆÓ. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ 50-70% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·Ó·Ù‡ÛÛÔ˘Ó CMV Ïԛ̈ÍË Î·È 15-20% ÓfiÛÔ. ∂›Û˘ Ë ÓfiÛÔ˜ Û ÔÛÔÛÙfi ÂÚ›Ô˘ 30% ˘ÔÙÚÔÈ¿˙ÂÈ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜(5). CMV Ïԛ̈ÍË ‹ ÓfiÛÔ˜ ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ ÙÔ ÚÒÙÔ ÂÍ¿ÌËÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiÙ·Ó ˘Ê›ÛÙ·Ù·È ÙÔ Ì¤ÁÈÛÙÔ Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜, ·ÏÏ¿ ‰ÂÓ ·ÔÎÏ›ÂÙ·È Ó· ÂΉËψı› Î·È ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ·)ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓÔ˘ ·fi ÔÚÔıÂÙÈÎfi ‰fiÙË (D+) Û ÔÚÔ·ÚÓËÙÈÎfi Ï‹ÙË (R-), Ô Î›Ó‰˘ÓÔ˜ ·Ó¿Ù˘Í˘ Ïԛ̈͢ Ûã·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Â›Ó·È 5 Ì 7 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜, ‚) ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi و̷ÙÈÎfi ‰fiÙË, Á) ·ÓÙÈ·ÔÚÚÈÙÈ΋ ıÂڷ›· Ì ·ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈÎfi ÔÚfi,‰) ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜. ∂›Ó·È ÂÌÊ·Ó¤˜ fiÙÈ ÔÈ ·Ú¿ÁÔÓÙ˜ ‚,Á Î·È ‰ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Ô Î›Ó‰˘ÓÔ˜ ÂÈÏԛ̈͢ Ì ¿ÏÏÔ Èfi ‹ ̇ÎËÙ· Â›Ó·È Â›Û˘ ˘„ËÏfi˜ (5).
÷ڷÎÙËÚÈÛÙÈο Ù˘ ÓfiÛÔ˘ ∫ÏÈÓÈο Û‡Ó‰ÚÔÌ· ∏ CMV Ïԛ̈ÍË ÌÔÚ› Ó· Â›Ó·È ÚˆÙÔ·ı‹˜, ‰Â˘ÙÂÚÔ·ı‹˜ Î·È ÂÈÏԛ̈ÍË. ¶ÚˆÙÔ·ı‹˜ Ïԛ̈ÍË ·Ú·ÙËÚÂ›Ù·È Û ¿ÙÔÌ· Ô˘ ‰ÂÓ ¤¯Ô˘Ó ·ÓÙÈÛÒÌ·Ù· Î·È ÌÔχÓÔÓÙ·È Ì ÙÔÓ Èfi ›Ù Ì ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜ ›Ù Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓÔ˘ ·fi ÔÚÔıÂÙÈÎfi Ï‹ÙË. ™’ ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Ë Èı·ÓfiÙËÙ· ÓfiÛÔ˘ ·fi ÙÔÓ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi Â›Ó·È ˘„ËÏ‹ Î·È ÏËÛÈ¿˙ÂÈ ÛÙÔ 70%. ™˘Ó‹ıˆ˜ Ë ÓfiÛÔ˜ ÂΉËÏÒÓÂÙ·È Ì ‚·ÚÈ¿ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, Ë ÚfiÏË„‹ Ù˘ Â›Ó·È ‰‡ÛÎÔÏË Î·È Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÂÈ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜,
ÂÈ‚·Ú‡ÓÔÓÙ·˜ ÙËÓ ÚfiÁÓˆÛ‹ Ù˘ (6,7). ∏ ‰Â˘ÙÂÚÔ·ı‹˜ Ïԛ̈ÍË ÂÌÊ·Ó›˙ÂÙ·È Û ¿ÙÔÌ· ÛÙ· ÔÔ›· Ô Èfi˜ ¢ڛÛÎÂÙ·È Û ϷÓı¿ÓÔ˘Û· ηٿÛÙ·ÛË ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ÙÔ˘˜ ÌÂÙ¿ ·fi Ïԛ̈ÍË. ∏ ÂÏ¿ÙÙˆÛË Ù˘ ¿Ì˘Ó·˜ ÙÔ˘ ÍÂÓÈÛÙ‹ Ì ÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂڷ›· Ô‰ËÁ› Û ·Ó·˙ˆ‡ÚˆÛË Ù˘ Ïԛ̈͢. ∂ÈÏԛ̈ÍË Û˘Ì‚·›ÓÂÈ fiÙ·Ó Ô ÍÂÓÈÛÙ‹˜ Ô˘ ¤¯ÂÈ ÓÔÛ‹ÛÂÈ ·fi ¤Ó· Û٤ϯԘ ÙÔ˘ ÈÔ‡ ÂÌÊ·Ó›ÛÂÈ Ïԛ̈ÍË ·fi ¿ÏÏÔ Û٤ϯԘ. ∂¿Ó ·˘Ùfi ÙÔ Û٤ϯԘ ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ·fi ÙÔ ÚÒÙÔ Î·È Ë ¿Ì˘Ó· ÙÔ˘ ÍÂÓÈÛÙ‹ Â›Ó·È ·ÚÎÂÙ¿ ηÙÂÛÙ·Ï̤ÓË ÙfiÙÂ Ë Èı·ÓfiÙËÙ· ·ӷÏԛ̈͢ Â›Ó·È ˘„ËÏ‹. ¶ÂÚ›Ô˘ 10-20% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ÂÌÊ·Ó›˙Ô˘Ó ‰Â˘ÙÂÚÔ·ı‹ Ïԛ̈ÍË ‹ ·ӷÏԛ̈ÍË, ·ÏÏ¿ Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Ù· Û˘ÌÙÒÌ·Ù· Ù˘ ÓfiÛÔ˘ Â›Ó·È ËÈfiÙÂÚ· ·fi fiÙÈ ÛÙËÓ ÚˆÙÔ·ı‹ Ïԛ̈ÍË. ∏ ÂÌÊ¿ÓÈÛË Ïԛ̈͢ ·fi ÔÚÔıÂÙÈÎfi ‰fiÙË Û ÔÚÔıÂÙÈÎfi Ï‹ÙË Â›Ó·È ‰‡Ô ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ·fi fiÙÈ ·fi ÔÚÔ·ÚÓËÙÈÎfi ‰fiÙË Û ÔÚÔıÂÙÈÎfi Ï‹ÙË ˘Ô‰ËÏÒÓÔÓÙ·˜ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÂÈÏԛ̈͢ ·fi ¿ÏÏÔ Û٤ϯԘ ‰ÂÓ Â›Ó·È Û¿ÓÈ· (8,9). ∏ CMV Û‡Ó‰ÚÔÌÔ ÂΉËÏÒÓÂÙ·È Ì ‹È· Û˘Ìو̷ÙÔÏÔÁ›· ‰ËÏ. ˘ÚÂÙfi, Ì˘·ÏÁ›Â˜, ηÎÔ˘¯›· ¯ˆÚ›˜ Ó· ÚÔÛ‚¿ÏÏÂÈ Î¿ÔÈÔ fiÚÁ·ÓÔ. ∏ CMV ÓfiÛÔ˜ ¤¯ÂÈ ‚·Ú‡ÙÂÚË ÂÈÎfiÓ· Ì ÚÔÛ‚ÔÏ‹ ÔÚÁ¿ÓˆÓ Î·È Û˘Ó‹ıˆ˜ Ô Èfi˜ ÚÔÛ‚¿ÏÏÂÈ ÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ÈÛÙÔ‡˜, ‰ËÏ. ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÚÔηÏ› Û˘¯ÓfiÙÂÚ· ÓÂÊÚ›Ùȉ·, ÛÙÔ ‹·Ú Ë·Ù›Ùȉ·, ÛÙÔ Ì˘ÔοډÈÔ ·ÚÙËÚÈ›Ùȉ· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ, ÛÙÔ ¿ÁÎÚ·˜ ·ÁÎÚ·ٛÙȉ· Î·È ÛÙÔ ¤ÓÙÂÚÔ ÂÓÙÂÚ›Ùȉ·. ¢ÂÓ Â›Ó·È ·›ı·ÓÔ Ó· ·Ú·ÙËÚÂ›Ù·È ÚÔÛ‚ÔÏ‹ ‰‡Ô ‹ Î·È ÂÚÈÛÛÔÙ¤ÚˆÓ ÔÚÁ¿ÓˆÓ ¿Û¯ÂÙ· Ì ÙÔ ÌfiÛ¯Â˘Ì·. ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ÂÂȉ‹ Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ì ÙËÓ ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ‰‡ÛÎÔÏË ı· Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È ‚ÈÔ„›· Î·È ÈÛÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË. Δ¤ÏÔ˜ ‚·Ú‡ÙÂÚË ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë Ó¢ÌÔÓ›· Ô˘ Ô‰ËÁ› Û ˘Ô͢ÁÔÓ·ÈÌ›·, ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·, ˘fiÙ·ÛË, ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË Î·È Ù¤ÏÔ˜ ·Ó¿ÚÎÂÈ· ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ. ∏ ηٿÏËÍË Û’ ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Â›Ó·È ÌÔÈÚ·›· (10). ™Â οı ÌÔÚÊ‹ Ïԛ̈͢ Ì ÙÔÓ Èfi ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ Ë Èı·ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜, Ô ÔÔ›Ô˜ ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Û οı ÂÚ›ÙˆÛË, ‰ÈfiÙÈ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û هÊψÛË. ¶ÚÈÓ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ·ÓÙ›-ÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙË ıÂڷ›· Ù˘ Ïԛ̈͢ Ë ÚfiÁÓˆÛ‹ Ù˘ ‹Ù·Ó
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
η΋ Û˘Ó‰ÂfiÌÂÓË Ì ¯·ÌËÏ‹ ÂÈ‚›ˆÛË ÙfiÛÔ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ fiÛÔ Î·È ÙˆÓ ·ÛıÂÓÒÓ. Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ì ÙËÓ ÚfiÏË„Ë Î·È ÙË ıÂڷ›· Ì ·ÓÙÈÈο Ê¿Ú̷η Ë ÚfiÁÓˆÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ¤¯ÂÈ ‚ÂÏÙȈı› ÛËÌ·ÓÙÈο .
∂ÈÙÒÛÂȘ Ù˘ Ïԛ̈͢ Ì ΢ÙÙ·ÚÔÌÂÁ·ÏÔÈfi ∂ÎÙfi˜ ·fi ÙȘ ¿ÌÂÛ˜ ÂΉËÏÒÛÂȘ, Ë Ïԛ̈ÍË Ì ÙÔÓ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi ÌÔÚ› Ó· ¤¯ÂÈ ¤ÌÌÂÛ˜ ÂΉËÏÒÛÂȘ. OÈ ÂΉËÏÒÛÂȘ ·˘Ù¤˜ ‰ÂÓ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙÔ ÈÈÎfi ÊÔÚÙ›Ô, fiˆ˜ Û˘Ì‚·›ÓÂÈ ÛÙË ÓfiÛÔ ·ÏÏ¿ Ì ÙËÓ ·ÓÙ›‰Ú·ÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ÍÂÓÈÛÙ‹. ∞ÓÙÈı¤Ùˆ˜ Ì¿ÏÈÛÙ· Èı·ÓfiÓ ÚfiÎÂÈÙ·È ÁÈ· ·¿ÓÙËÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û ¯·ÌËÏfi ÈÈÎfi ÊÔÚÙ›Ô Ô˘ ˘Ê›ÛÙ·Ù·È ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·. OÈ ÂÈÙÒÛÂȘ ·˘Ù¤˜ ÌÔÚ› Ó· ›ӷÈ: ·) ∞fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∫ÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ·ÛıÂÓ›˜ Ì ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ CMV Ïԛ̈͢ fiÙ·Ó ÂÏ¿Ì‚·Ó·Ó ·ÓÙ›-CMV-·ÁˆÁ‹ ›¯·Ó ÌÈÎÚfiÙÂÚÔ Î›Ó‰˘ÓÔ ·fiÚÚȄ˘ . ∂›Û˘ ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ¤‰ÂÈÍ·Ó ÎÈÓËÙÔÔ›ËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ ·fiÚÚȄ˘ ÌÂÙ¿ ·fi Ïԛ̈ÍË ·fi ÙÔÓ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi. ΔfiÛÔ Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ fiÛÔ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ Ó¢ÌfiÓˆÓ, Ê¿ÓËΠfiÙÈ ÔÈ ÏÔÈÌÒÍÂȘ ·˘Ù¤˜ ¿ÁÔ˘Ó ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ·fiÚÚȄ˘ Î·È ÙfiÛÔ Ë ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ fiÛÔ Î·È ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È ÂÏ·Ùو̤ÓË(11,12). ‚) ÃÚfiÓÈ· ·fiÚÚÈ„Ë. ∏ Ïԛ̈ÍË Ì ÙÔÓ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi ÚÔηÏ› ÙËÓ ¤ÎÊÚ·ÛË ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Î˘ÙÙ·ÚÔÎÈÓÒÓ, ÔÈ Ôԛ˜ Ì ÛÂÈÚ¿ ÙÔ˘˜ ÚÔ¿ÁÔ˘Ó ÙËÓ ¤ÎÊÚ·ÛË ÙˆÓ ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘ Î·È ÙˆÓ ·ÓÙÈÁfiÓˆÓ Ì›˙ÔÓÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜. OÈ Ì˯·ÓÈÛÌÔ› ·˘ÙÔ› ‰ÈÂÁ›ÚÔ˘Ó Ì˯·ÓÈÛÌÔ‡˜ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘, Ô˘ ÂΉËÏÒÓÔÓÙ·È Ì ·ÚÙËÚÈ›Ùȉ·, ¯ÚfiÓÈ· ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ‹ ¯ÔÏ·ÁÁÂÈ›Ùȉ· ÛÙ· ·ÓÙ›ÛÙÔȯ· ÌÔۯ‡̷ٷ (13,14). Á) ∫·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ˜. ∏ ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ Â›Ó·È ÛÔ‚·Úfi Úfi‚ÏËÌ·. ™ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·˘Ù¤˜ Ê¿ÓËΠfiÙÈ ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó ÚÔÊ˘Ï·ÎÙÈο ·ÁˆÁ‹ Ì Á·Ó΢ÎÏÔ‚›ÚË Î·È ˘ÂÚ¿ÓÔÛÔ Á-ÛÊ·ÈÚ›ÓË Â›¯·Ó ÏÈÁfiÙÂÚ˜ Èı·ÓfiÙËÙ˜ Ó· ·Ó·Ù‡ÍÔ˘Ó ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ·fi fiÙÈ ÔÈ ·ÛıÂÓ›˜ ¯ˆÚ›˜ ÚÔÏËÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙÔÓ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi (15,16). ‰) ∂ÈÏÔÈÌÒÍÂȘ ·fi ̇ÎËÙ˜, ‚·ÎÙËÚ›‰È·, ÚˆÙfi˙ˆ· Î·È ÈÔ‡˜. O ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜ ÌÔÚ›
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Ó· ÚÔηϤÛÂÈ Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™Â ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜ ¤¯ÂÈ ·Ú·ÙËÚËı› ÌÂÙ¿ ÙË Ïԛ̈ÍË Ì ÙÔÓ Èfi ÂÌÊ¿ÓÈÛË ‚·ÎÙËÚÈ·ÎÒÓ ÏÔÈÌÒ͈Ó, Ë·Ù›Ùȉ· C ·ÏÏ¿ Î·È Ì˘ÎËÙÈ¿ÛÂȘ. ∂›Û˘ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÔÈ ÏÔÈÌÒÍÂȘ Û˘Ó‰¤ÔÓÙ·È Ì ‚·Ú›˜ ÂÈÏÔÈÌÒÍÂȘ Ô˘ ÂÈ‚·Ú‡ÓÔ˘Ó ÛËÌ·ÓÙÈο ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ.
¶ÚÔʇϷÍË- £Âڷ›· Ù˘ Ïԛ̈͢ Œ¯Ô˘Ó ÚÔÙ·ı› ÔÏÏ¿ Î·È ‰È·ÊÔÚÂÙÈο Û¯‹Ì·Ù· ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘, ¯ˆÚ›˜ ̤¯ÚÈ ÙÒÚ· Ó· ηıÈÂÚˆı› οÔÈÔ Û¯‹Ì· ˆ˜ ȉ·ÓÈÎfi O ÂÌ‚ÔÏÈ·ÛÌfi˜ ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡, ı· ‹Ù·Ó Ë È‰·ÓÈ΋ ÚfiÏË„Ë Û ·ÛıÂÓ›˜ Ô˘ ÚfiÎÂÈÙ·È Ó· ÌÂÙ·ÌÔÛ¯Â˘ıÔ‡Ó. O ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÂÍ·ÛıÂÓË̤ÓÔ Û٤ϯԘ Towne Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠÙË ‰ÂηÂÙ›· ÙÔ˘ ‘80 ‰ÂÓ ¤‰ÂÈÍ ӷ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘, Û·ÊÒ˜ fï˜ ÙË ‚·Ú‡ÙËÙ¿ Ù˘. ∂›Û˘ ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ·ÓÙÈÁfiÓ· ÙÔ˘ ÈÔ‡, fiˆ˜ Ë gH ÚˆÙ½ÓË ÙÔ˘ ÂÚÈ‚Ï‹Ì·ÙÔ˜, ‰ÈÂÁ›ÚÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ·ÓÙÈÛˆÌ¿ÙˆÓ Û ˘ÁÈ‹ ¿ÙÔÌ· (17). ∏ ÂÌÂÈÚ›· ·fi ÙË ¯Ú‹ÛË ÙÔ˘ Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ‰ÂÓ Â›Ó·È ÌÂÁ¿ÏË. ∏ ¯Ú‹ÛË ÔÏ˘‰‡Ó·ÌÔ˘ ÂÌ‚ÔÏ›Ô˘ Ô˘ ı· ηχÙÂÈ ÂÚÈÛÛfiÙÂÚ· ÙÔ˘ ÂÓfi˜ ÛÙÂϤ¯ÔÈ ÙÔ˘ ÈÔ‡ ›Ûˆ˜ ·Ú¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË ÚÔÛÙ·Û›·. ∏ ·ıËÙÈ΋ ·ÓÔÛÔÔ›ËÛË Ì ¯ÔÚ‹ÁËÛË ÌÂÁ¿Ï˘ Û˘ÁΤÓÙÚˆÛ˘ ·ÓÙÈÛˆÌ¿ÙˆÓ Ê·›ÓÂÙ·È Ó· ·Ú¤¯ÂÈ ÚÔÛÙ·Û›· Û ÔÚÔ·ÚÓËÙÈÎÔ‡˜ Ï‹Ù˜ Î·È ¤¯ÂÈ ¤Ó‰ÂÈÍË ·fi ÙËÓ US Food and Drug Administration (FDA) ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ Ïԛ̈͢. ™˘Ìʈӛ· ˘¿Ú¯ÂÈ ˆ˜ ÚÔ˜ ÙËÓ ÚÔÏËÙÈ΋ ¯ÔÚ‹ÁËÛË ¯ÔÚ‹ÁËÛË ·ÓÙÈÈÎÒÓ Ê·Ú̿ΈÓ. Δ· Ê¿Ú̷η Ô˘ ¤¯Ô˘Ó ¯ÔÚËÁËı›, ÌfiÓ· ÙÔ˘˜ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·ÓÔÛÔÛÊ·ÈÚ›ÓË Â›Ó·È ·Î˘ÎÏÔ‚›ÚË, ‚·Ï·Î˘ÎÏÔ‚›ÚË, Á·Ó΢ÎÏÔ‚›ÚË Î·È ‚·ÏÁ·Ó΢ÎÏÔ‚›ÚË. ªÂ fiÏ· Ù· ıÂڷ¢ÙÈο Û¯‹Ì·Ù· Ë ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ ‹Ù·Ó Û ˘„ËÏfi ÔÛÔÛÙfi. ΔÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ¯ÔÚ‹ÁËÛ˘ ‹Ù·Ó ·fi 3-6 Ì‹Ó˜, ·fi ÙȘ ÌÂϤÙ˜ fï˜ ‰È·Ê·›ÓÂÙ·È fiÙÈ fiÛÔ ÓˆÚ›ÙÂÚ· ‰È·ÎÔ› Ë ·ÁˆÁ‹ ÙfiÛÔ ˘„ËÏfiÙÂÚÔ Â›Ó·È ÙÔ ÔÛÔÛÙfi Ïԛ̈͢ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ·ÁˆÁ‹˜. ∏ ‰È¿ÚÎÂÈ· Ù˘ ·ÁˆÁ‹˜ ‰ÂÓ ¤¯ÂÈ ÚÔÛ‰ÈÔÚÈÛÙ› ·ÎfiÌË ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Û’ ·˘Ù‹ ÙËÓ ·fiÊ·ÛË ‰È·‰Ú·Ì·Ù›˙ÂÈ Î·È ÙÔ ÎfiÛÙÔ˜ Ù˘ ıÂڷ›·˜ ÙÔ ÔÔ›Ô Â›Ó·È Ôχ ˘„ËÏfi(18,19,20). ∂›Û˘ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ fiÛÔ ·Ú·Ù›ÓÂÙ·È ÙÔ ‰È¿ÛÙËÌ· Ù˘ ÚÔÊ˘Ï·ÎÙÈ΋˜ ·ÁˆÁ‹˜.
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∏ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ·ÓÙÈ-ÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙË ıÂڷ›· Ù˘ CMV ÓfiÛÔ˘ ¤¯ÂÈ ‚ÂÏÙÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ. ΔËÓ ‰Âηٛ· ÙÔ˘ ’70 Î·È ’80 Ë Ïԛ̈ÍË Ì ÙÔÓ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi ›¯Â η΋ ÚfiÁÓˆÛË Î·È Ë ¤Î‚·ÛË ‹Ù·Ó Û˘¯Ó¿ ÌÔÈÚ·›·. ªÂÁ¿ÏË ÛËÌ·Û›· ‰›ÓÂÙ·È Ï¤ÔÓ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘, Ë ÔÔ›· ·ÊÂÓfi˜ ÂÏ·ÙÙÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Ïԛ̈͢, ·ÊÂÙ¤ÚÔ˘ ·ÎfiÌ· Î·È Û ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ Ë ¤Î‚·Û‹ Ù˘ Â›Ó·È Î·Ï‡ÙÂÚË Î·È ÔÈ ÂÈÏÔΤ˜ Ôχ ÏÈÁfiÙÂÚ˜. §fiÁˆ ÙÔ˘ ˘„ËÏÔ‡ ÎfiÛÙÔ˘˜ Ù˘ ÚÔÏËÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ·ÓÙÈÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ·ÚÎÂÙ¿ ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ¤¯Ô˘Ó ˘ÈÔıÂÙ‹ÛÂÈ ÙËÓ Ù·ÎÙÈ΋ Ù˘ preemptive ıÂڷ›·˜. ∏ Ù·ÎÙÈ΋ ·˘Ù‹ ··ÈÙ› ÙËÓ ÛÙÂÓ‹ ÔÚÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ·Ó¿Ù˘ÍË È·ÈÌ›·˜ Î·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ¯·ÌËÏÔ‡ Ù›ÙÏÔ˘ ÈÒÓ, ¯ˆÚ›˜ Ó· ˘¿Ú¯Ô˘Ó ÂΉËÏÒÛÂȘ ÈÔÁÂÓÔ‡˜ Û˘Ó‰ÚÔÌ‹˜ ‹ ÓfiÛÔ˘, ÙËÓ ¿ÌÂÛË ¯ÔÚ‹ÁËÛË ·ÓÙÈ-ÈÈ΋˜ ·ÁˆÁ‹˜. ∏ Ù·ÎÙÈ΋ ·˘Ù‹ ÚÔÏ·Ì‚¿ÓÂÈ Û·ÊÒ˜ ÙËÓ ÂΉ‹ÏˆÛË ÓfiÛÔ˘, ·ÏÏ¿ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ÙfiÛÔ Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· ˆ˜ ÚÔ˜ ÙËÓ ÚfiÏË„Ë ÙˆÓ ¤ÌÌÂÛˆÓ ÂÈÏÔÎÒÓ. ∂›Û˘ ·˘Í¿ÓÂÈ Î·Ù¿ Ôχ ÙÔ ÎfiÛÙÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È ıÂڷ›·˜, ÂÂȉ‹ ··ÈÙ› Ôχ Û˘¯ÓÔ‡˜ ÔÚÔÏÔÁÈÎÔ‡˜ ÂϤÁ¯Ô˘˜ Ì Ù¯ÓÈΤ˜ ˘„ËÏ‹˜ ·ÍÈÔÈÛÙ›·˜. ΔÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ È·ÈÌ›·˜ Â›Ó·È ˘„ËÏfi Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È ÊÙ¿ÓÂÈ ÙÔ 70% ÙˆÓ ·ÛıÂÓÒÓ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ˘„ËÏfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ, ¯ÚÂÈ¿˙ÂÙ·È Ó· ¿ÚÂÈ ·ÁˆÁ‹, Ô˘ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· Â›Ó·È ÂÓ‰ÔÊϤ‚È· Á·Ó΢ÎÏÔ‚›ÚË Ì¤¯ÚÈ Î·Ù·ÛÙÔÏ‹˜ Ù˘ È·ÈÌ›·˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·fi ÙÔ ÛÙfiÌ· ÁÈ· ‰È¿ÛÙËÌ· 8-12 ‚‰ÔÌ¿‰Â˜ (21,22,23). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Ïԛ̈ÍË ÚÔηÏ› ÓfiÛÔ Ì ÚÔÛ‚ÔÏ‹ ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ Î·È Î·Î‹ ¤Î‚·ÛË. ∏ Ï·Óı¿ÓÔ˘Û· ›ÌÔÓË È·ÈÌ›· ¢ı‡ÓÂÙ·È ÁÈ· ÔÏϤ˜ Î·È ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiˆ˜ ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÓÂÔÏ¿ÛÌ·Ù·, ÂÈÌÔχÓÛÂȘ Î·È Î·Ú‰È·ÁÁÂȷο ÓÔÛ‹Ì·Ù·. ∏ ÚÔÏËÙÈ΋ ·ÁˆÁ‹ Ì ·ÓÙ›-ÈÈο Ê¿Ú̷η ¤¯ÂÈ ‚ÂÏÙÈÒÛÂÈ ÛËÌ·ÓÙÈο ÙfiÛÔ ÙËÓ ÚfiÁÓˆÛË Ù˘ CMV ÓfiÛÔ˘ fiÛÔ Î·È ÙȘ ¤ÌÌÂÛ˜ ÂÈÏÔΤ˜ Ù˘ Ïԛ̈͢. ªÂϤÙ˜ ÛÙÔ Ì¤ÏÏÔÓ ı· ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ Î·Ù·ÓfiËÛË ÙˆÓ Ì˯·ÓÈÛÌÒÓ ÚfiÎÏËÛ˘ ¤ÌÌÂÛˆÓ ÂΉËÏÒÛÂˆÓ Ù˘ ÓfiÛÔ˘, ÛÙËÓ ·Ó‡ÚÂÛË ‰È·ÁÓˆÛÙÈÎÒÓ ÌÂıfi‰ˆÓ ÁÈ· ÙËÓ Ù·¯Â›· Î·È ·ÍÈfiÈÛÙË ‰È¿ÁÓˆÛË Ù˘ ·ÏÏ¿ Î·È ÙÔ ·ÛʷϤ˜ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ ıÂڷ›· Ù˘ Ïԛ̈͢.
μÈ‚ÏÈÔÁÚ·Ê›· 1) ¶···Ó·ÁÈÒÙÔ˘ π∫, ∫˘ÚÈ·˙ÔÔ‡ÏÔ˘-¢·Ï·˚Ó· μ. πÔ› ÔÌ¿‰·˜ ¤ÚËÙ·. ™Â π·ÙÚÈ΋ ÌÈÎÚÔ‚ÈÔÏÔÁ›· Î·È ÈÔÏÔÁ›·. ÂΉ University Studio £ÂÛ/Ó›ÎË 2001 311-328. 2) McLaughlin-Taylor E, Pande H, Foreman SJ, et al. Indentification of the major late human CMV matrix protein pp65 as a target antigen for CD8+ virus-specific cytotoxic T lymphocytes. J Med Virol 1994; 43 103108. 3) Emery VC, Cope AV, Browen EF, et al. The dynamics of human cytomegalovirus replication in vivo. J Exp Med 1999;190:177-182. 4) Humar A, Uknis M,Carlone-Jambor C, et al. Cytomegalovirus disease recurrence after ganciclovir treatment in kidney and kidney pancreas recipients. Transplantation 1999;67: 94-97. 5) Dunn DL, Acton RD. Solid organ transplantation, in Armstrong D, Cohen J(eds): Infectious Diseases. London, Mosby Int 1999; 3-15. 6) Brennan D. Cytomagalovirus in renal transplantation. J Am Soc Nephrol 2001;12:848-855 7) Ulkins ME, Dunn DL. Cytomegalovirus infection and disease after solid organ transplantation: Epidemiology, prevention, and therapy. Transplant Reviews 2000;14: 199-209. 8) Fishman JA, Rubin RH. Infection in organ transplant recipients. N Engl J Med 1998;338: 1741-1751. 9) Fishman JA, Emery V, Freeman R, et al. Cytomegalovirus in transplatation-challenging the status quo. Clin Transplant 2006;21:149-158. 10) Paya cv. Defining an optimal regimen for cytomegalovirusprophylaxis in organ transplantation. Transplant Proc 1996; 28(Suppl 2):9-11. 11) Unantue ER. Viral infections and nonspecific protection-good or bad? N Engl J Med 2007;1345-1346. 12) Vester U, Wingen AM, Nadalin S, Paul A,Broelsch CE. Acute rejection episodes in pediatric renal transplant recients with cytomegalovirus infection. Pediatr Transplant 2007 DOI 10.1111/ J.1399-3046. 2007. 00781X 13) Helantera I, Koskinen P, Finne P,et al. Persistent cytomegalovirus infection in kidney allografts is associated with inferior graft fuction and survival. Transpl Int 2006; 19:893-900 14) Humar A, Gillingham K, Payne W, Dunn D, Matas A. Association between cytomegalovirus disease and chronic rejection in kidney transplant recipients. Transplantation 1999;68: 1879-1883. 15) Hodson E, Jones C, Webster A, et al. Antiviral medications to prevent cytomegalovirus diese and early death in recipients of solid-organ transplants: a systemic review of randomized controlled trials. The Lancet 2005; 365: 2105-2115. 16) Sagedal S, Rollag H, Hartmann A. Cytomegalovirus
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17) Marker SC, Simmons RL, Balfour HH Jr. Cytomegalovirus vaccine in renal allograft recipients. Transpl Proc 1981;13: 117-119.
21) Dmitrienko S, Yu A, Balshaw R, Shapiro RJ, Keown PA, for the genome Canada biomarkers in Transplantation Group. The use of consensus guidelines for management of cytomegalovirus infaction in renal transplantation. Kidney Int 2007; 72:1014-1022.
18) Opelz G, Dohler B, Ruhenstroth A. Cytomegalovirus prophylaxis and graft outcome in solid organ transplantation: A collaborative transplant study report. Am J Transplant 2004; 4:928-936 19) Taber DJ, Ashcraft E, Baillie GM, et al. Valganciclovir prophylaxis in patients at high risk for the development of cytomegalovirus disease. Transpl Infect Dis 2004; 6:1001-109 20) Lowance D, Neumayer HH, Legendre CM, et al. Vala-
22) Robin HA. Management of late, recurrent, and resistant cytomegalovirus in transplant patients. Transplan Reviews 2007;21;65-76. 23) Freeman RB, Paya C, Pescovitz MD, et al. Risk factors for cytomegalovirus viremia and disease developing after prophylaxis in high-risk solid-organ transplant recipients. Clin Transplan 2004; 78:1765-1773.
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χÊıËΠ۠΢ÙÙ·ÚÈΤ˜ ÛÂÈÚ¤˜ ·fi Èı‹ÎÔ˘˜ Rhesus Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ÙËÓ ·Ú·Û΢‹ ÂÌ‚ÔÏ›ˆÓ ηٿ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜. ΔÔ Î·„›‰ÈÔ ÙˆÓ ÈÒÓ Polyoma ·ÔÙÂÏÂ›Ù·È ·fi ÙÚÂȘ ÚˆÙ½Ó˜ Ô˘ Έ‰ÈÎÔÔÈÔ‡ÓÙ·È ·fi ÙÔ ÈÈÎfi ÁÔÓȉ›ˆÌ·, ÙËÓ ÈÈ΋ ÚˆÙ½ÓË 1 (viral protein 1, VP1), ÙËÓ ÈÈ΋ ÚˆÙ½ÓË 2 (viral protein 2, VP2) Î·È ÙËÓ ÈÈ΋ ÚˆÙ½ÓË 3 (viral protein 3, VP3), ÔÈ Ôԛ˜ Î·È ÂÚÈ‚¿ÏÔ˘Ó ÙÔ ‰ÈÏ‹˜ ¤ÏÈη˜ ‰ÂÛfi͢ÚÈ‚ÔÓÔ˘ÎÏÂ˚ÎÔ‡ ÔͤԘ (deoxyribonucleic acid, DNA). OÈ ÙÚÂȘ ·˘Ù¤˜ ÚˆÙ½Ó˜ Û¯ËÌ·Ù›˙Ô˘Ó ¤Ó· ÂÈÎÔۿ‰ÚÔ Î·„›‰ÈÔ, ÙÔ ÔÔ›Ô ÂÚȤ¯ÂÈ 360 ÌfiÚÈ· Ù˘ VP1 Î·È ÂÚ›Ô˘ 30-60 ÌfiÚÈ· ·fi ÙȘ VP2 Î·È VP3. ΔÔ ÛˆÌ·Ù›‰ÈÔ ÙÔ˘ ÈÔ‡ ÂÚȤ¯ÂÈ Î·Ù¿ 88% ÚˆÙ½Ó˜ Î·È 12% ÁÂÓÂÙÈÎfi ˘ÏÈÎfi DNA. Δ· ÈÈο ۈ̷ٛ‰È· Â›Ó·È ·ÓıÂÎÙÈο Û ÏÈfiÊÈÏ· ‰È·Ï‡Ì·Ù·, ÁÂÁÔÓfi˜ Ô˘ ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ ÛÙÂÚÔ‡ÓÙ·È ÈÈÎÔ‡ ʷΤÏÔ˘. ∂›Û˘ ıˆÚÔ‡ÓÙ·È ·ÓıÂÎÙÈο ÛÙËÓ ·ÂÓÂÚÁÔÔ›ËÛË Ì ıÂÚÌfiÙËÙ·. ΔÔ ÁÔÓȉ›ˆÌ· ÙÔ˘ μ∫ ·ÚÔ˘ÛÈ¿˙ÂÈ 75% ÔÌÔÏÔÁ›· Ì ÙÔ ÁÔÓȉ›ˆÌ· ÙÔ˘ JC Î·È 70% ÔÌÔÏÔÁ›· Ì ÙÔÓ Èfi SV401. O Èfi˜ μ∫ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1970 ·fi ÙË Sylvia Gardner Û ϋÙË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜2. ΔÔ fiÓÔÌ· μ∫ ·Ô‰›‰ÂÙ·È ÛÙ· ·Ú¯Èο ÙÔ˘ ÔÓfiÌ·ÙÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ô˘ ·Ó·Î·Ï‡ÊıËÎÂ. ∂ÚfiÎÂÈÙÔ ÁÈ· ¤Ó· ™Ô˘‰·Ófi ¿Ó‰Ú· 39 ÂÙÒÓ Ô ÔÔ›Ô˜ ¤Ï·‚ ÌfiÛ¯Â˘Ì· ·fi ˙ÒÓÙ· ‰fiÙË Î·È Ù¤ÛÛÂÚȘ Ì‹Ó˜ ·ÚÁfiÙÂÚ· ·ÚÔ˘Û›·Û ÚÔԉ¢ÙÈ΋ ·ÓÔ˘Ú›· Î·È ÙÒÛË Ù˘ οı·ÚÛ˘ Ù˘ ÎÚ·ÙÈÓ›Ó˘, Ô˘ ÔÊ›ÏÂÙÔ Û ÛÙ¤ÓˆÛË ÙÔ˘ Ô˘ÚËÙ‹Ú· Ì ›ÓˆÛË, ÈÛ¯·ÈÌ›· Î·È ‰ËÌÈÔ˘ÚÁ›· ÎÔÎÎȈ̷ÙÒ‰Ô˘˜ ÈÛÙÔ‡ ÂÚ›Ô˘ 5 ÂÎ. οوıÂÓ Ù˘ ˘ÂÏÔÔ˘ÚËÙÈ΋˜ Û˘Ì‚ÔÏ‹˜. ∏ ΢ÙÙ·ÚÔÏÔÁÈ΋ ·Ó¿Ï˘ÛË Î·È Ë Î·ÏÏȤÚÁÂÈ· Ù˘ ‚ÈÔ„›·˜ ÙÔ˘ Ô˘Ú‹ÙËÚ· Ô‰‹ÁËÛ·Ó ÛÙËÓ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ÈÔ‡.
Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈ ÏÔÈÌÒÍÂȘ ·fi ÈÔ‡˜ Ù˘ ÔÌ¿‰·˜ polyoma virus Î·È È‰È·›ÙÂÚ· ·fi ÙÔÓ ÙÔÓ Èfi μ∫ Î·È ÙÔ‡ÙÔ ‰ÈfiÙÈ ¤¯ÂÈ Î·Ù·‰Âȯı› Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘ Ì ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÂÔÓÔÌ·˙fiÌÂÓ˘ μ∫ ÓÂÊÚÔ¿ıÂÈ·˜ Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ¯ÚÔÓ›· ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ Papovaviridae ÂÚÈÏ·Ì‚¿ÓÂÈ ÌÈÎÚÔ‡˜ DNA ÈÔ‡˜ ¯ˆÚ›˜ Ê¿ÎÂÏÔ Ô˘ ¤¯Ô˘Ó ÂÈÎÔۿ‰ÚÔ Î·„›‰ÈÔ. ΔÔ fiÓÔÌ¿ Ù˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ÚÒÙË Û˘ÏÏ·‚‹ ÙˆÓ ÙÚÈÒÓ ÚˆÙfiÙ˘ˆÓ ÈÒÓ: ·) rabbit papilloma virus (pa), ‚) mouse polyoma virus (po), Î·È Á) simian virus 40 (SV40) Ô˘ ·Ú¯Èο ›¯Â ÔÓÔÌ·Ûı› vacuolating virus (va). ∞ÔÙÂÏÂ›Ù·È ·fi ‰‡Ô ˘Ô-ÔÈÎÔÁ¤ÓÂȘ ÙËÓ Polyomaviridae Î·È ÙËÓ Papillomaviridae. ∏ ˘Ô-ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ Polyomaviridae ‰È·Ê¤ÚÂÈ ·fi ÙËÓ ˘ÔÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ Papillomaviridae ÛÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ η„ȉ›Ô˘, ÙÔ ÔÔ›Ô Â›Ó·È Û˘Ó‹ıˆ˜ 45 nm Û˘ÁÎÚÈÙÈο Ì 55 nm ÙˆÓ Papillomaviridae, ÛÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜, ÙÔ ÔÔ›Ô ·ÔÙÂÏÂ›Ù·È ÂÚ›Ô˘ ·fi 5000 bp ÂÓÒ ÙˆÓ Papillomaviridae ·ÔÙÂÏÂ›Ù·È ·fi 8000 bp ηıÒ˜ ›Û˘ Î·È ÛÙËÓ ÔÚÁ¿ÓˆÛË ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜. º·›ÓÂÙ·È fiÙÈ Î·È ÔÈ ‰‡Ô ¤ÏÈΘ ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ ÙˆÓ Polyomaviridae Έ‰ÈÎÔÔÈ› ÏËÚÔÊÔڛ˜ ÂÓÒ ÛÙÔ˘˜ Papillomaviridae ÌfiÓÔ Ë Ì›· ¤ÏÈη ʤÚÂÈ ÏËÚÔÊÔڛ˜. ∂›Û˘ ÔÈ Papillomaviridae ¤¯Ô˘Ó ·Ô‰Â‰ÂÈÁ̤ÓË ÔÁÎÔÁfiÓÔ È‰ÈfiÙËÙ· ÛÙÔÓ ¿ÓıÚˆÔ Î·È Û˘ÁÎÂÎÚÈ̤ӷ Ô Èfi˜ human papilloma virus (HPV) ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÙÔÓ Î·ÚΛÓÔ ÙÔ˘ ÙÚ·¯‹ÏÔ˘ ÙË Ì‹ÙÚ·˜ ÂÓÒ Ë ÔÁÎÔÁÔÓÈÎfiÙËÙ· ÙˆÓ Polyomaviridae ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ÌÂϤÙ˘. OÈ ÈÔ› Polyoma ·Ó‹ÎÔ˘Ó ÛÙËÓ ˘Ô-ÔÈÎÔÁ¤ÓÂÈ· Polyomavirinae Î·È Ì¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó ·Ó·ÁÓˆÚÈÛı› ‰Ò‰Âη ̤ÏË ÈÒÓ polyoma. ∞fi ·˘ÙÔ‡˜ ‰‡Ô ¤¯Ô˘Ó ·Ó·ÁÓˆÚÈÛı› fiÙÈ ÚÔÛ‚¿ÏÔ˘Ó ÙÔÓ ¿ÓıÚˆÔ, Ô Èfi˜ JC Î·È Ô Èfi˜ μ∫. O Èfi˜ SV40 ·Ó·Î·-
∂ȉËÌÈÔÏÔÁÈο ÛÙÔȯ›· OÚÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ÂÈÛËÌ·›ÓÔ˘Ó fiÙÈ Ô ¿ÓıÚˆÔ˜ ÓÔÛ› ÁÈ· ÚÒÙË ÊÔÚ¿ ηٿ ÙË ‰È¿ÚÎÂÈ·
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ΢ڛˆ˜ ÌÂٷ͇ ÙˆÓ ËÏÈÎÈÒÓ 1 Î·È 6 ÂÙÒÓ, ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· ‹ ÛËÌ›·. ∏ ·Ú¯È΋ ÌfiÏ˘ÓÛË ·fi ÙÔÓ Èfi μ∫ Â›Ó·È ·ÓÂÍ¿ÚÙËÙË ·fi ÙË ÌfiÏ˘ÓÛË ·fi ÙÔÓ Èfi JC, Ô˘ ›Û˘ Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ηٿ Ù· ÚÒÙ· ¤ÙË Ù˘ ˙ˆ‹˜3. ™Â Ì›· ÎÔÈÓ‹ ÌÂϤÙË ÙˆÓ ÂÚÁ·ÛÙËÚ›ˆÓ ªÈÎÚÔ‚ÈÔÏÔÁ›·˜ Ù˘ ™Ô˘Ë‰›·˜ Î·È Ù˘ ºÈÏ·Ó‰›·˜, ÌÂÏÂÙ‹ıËÎ·Ó 290 ·È‰È¿ ËÏÈΛ·˜ 1-13 ÂÙÒÓ Ì ·Ó›¯Ó¢ÛË ÛÙÔÓ ÔÚfi ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ μ∫ Î·È ÙÔ˘ ÈÔ‡ JC4. ∏ ÔÚÔıÂÙÈÎfiÙËÙ· ÁÈ· ÙÔÓ Èfi μ∫ ·˘Í·ÓfiÙ·Ó Úԉ¢ÙÈο ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 1-3 ÂÙÒÓ Ô˘ Î˘Ì·ÈÓfiÙ·Ó Î¿Ùˆ ÙÔ˘ 20% Û 98% ÛÙËÓ ËÏÈΛ· ÙˆÓ 7-9 ÂÙÒÓ. ∏ ÔÚÔıÂÙÈÎfiÙËÙ· ÛÙÔÓ ÂÓ‹ÏÈÎÔ ÏËı˘ÛÌfi ˘ÔÏÔÁ›˙ÂÙ·È ÂÚ›Ô˘ 90%, ·Ó Î·È ÔÈΛÏÂÈ ·Ó·ÏfiÁˆ˜ Ì ÙË ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ ÛËÌÂÈÒÓÔÓÙ·˜ ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ Û ÂÚÈÔ¯¤˜ Ù˘ ¡fiÙÈ·˜ ∞ÌÂÚÈ΋˜ Î·È Ù˘ ∞Û›·˜5. O ÙÚfiÔ˜ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ ÈÔ‡ μ∫ ‰ÂÓ ¤¯ÂÈ ÂÍ·ÎÚÈ‚ˆı›. ¶Èı·ÓÔÏÔÁÂ›Ù·È fiÙÈ ÌÂÙ·‰›‰ÂÙ·È Ì¤Ûˆ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÙfiÛÔ Ë ÔÚÔÌÂÙ·ÙÚÔ‹ fiÛÔ Î·È Ë ıÂÙÈÎÔÔ›ËÛË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ ·Ú·ÙËÚÔ‡ÓÙ·È ÌÂÙ¿ ·fi Ïԛ̈ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡. ΔÔ 1981 ·ÔÌÔÓÒıËÎÂ Ô Èfi˜ μ∫ ÛÙ· Ô‡Ú· ·È‰ÈÔ‡ Ì ÔÍ›· ·Ì˘Á‰·Ï›Ùȉ· Î·È ¤ÂÈÙ· ·Ú·ÙËÚ‹ıËΠÔÚÔÌÂÙ·ÙÚÔ‹, ‰ËÏ·‰‹ Ù· ·È‰È¿ Ô˘ ÂÍÂÙ¿ÛıËÎ·Ó Ì ÙË Ïԛ̈ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ÂÌÊ¿ÓÈÛ·Ó ·ÓÔÛÔÛÊ·ÈÚ›ÓË ª (immunoglobulin M, IgM) ÂȉÈο ÁÈ· ÙÔÓ Èfi μ∫6. OÌÔ›ˆ˜ Û ̛· ÌÂÁ·Ï‡ÙÂÚË ÌÂϤÙË Ê¿ÓËΠfiÙÈ Û ·È‰È¿ Ô˘ ÓfiÛËÛ·Ó ·fi ÏÔÈÌÒÍÂȘ ΢ڛˆ˜ ÙÔ˘ ·ÓÒÙÂÚÔ˘ Î·È ÏÈÁfiÙÂÚÔ ÙÔ˘ ηÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·Ú·ÙËÚÂ›Ù·È ·Ó¿Ù˘ÍË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ μ∫ Î·È ·Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ ÛÙ· Ô‡Ú·7. ŒÙÛÈ ·Ó Î·È Ë ·ÔÌfiÓˆÛË ÙÔ˘ ÈÔ‡ ·fi ÂÎÎڛ̷ٷ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ·fi ÈÛÙfi Ê·Ú˘ÁÁÈÎÒÓ ·Ì˘Á‰·ÏÒÓ Â›Ó·È Ôχ ‰‡ÛÎÔÏÔ Î·È Û¿ÓÈÔ Â‡ÚËÌ·, ÈÛÙ‡ÂÙ·È Î·È ÂÓÈÛ¯‡ÂÙ·È Ë ˘fiıÂÛË Ù˘ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ ÈÔ‡ ̤ۈ ÙÔ˘ ·¤Ú· Ì ÌÔÏ˘Ṳ̂ӷ ۈ̷ٛ‰È· Ô˘ ÂÚȤ¯Ô˘Ó ÙÔÓ Èfi. ΔÔ ÁÂÁÔÓfi˜ fiÙÈ Ô Èfi˜ ·ÓȯÓ‡ÂÙ·È Î˘Ú›ˆ˜ ÛÙ· Ô‡Ú· ÌÂÙ¿ ÙËÓ ÚˆÙÔÌfiÏ˘ÓÛË ı· ÌÔÚÔ‡Û ӷ ·ÔÙÂϤÛÂÈ Û˘ÓËÁÔÚËÙÈÎfi ÛÙÔÈ¯Â›Ô ˘¤Ú Ù˘ ÌÂÙ¿‰ÔÛ˘ ̤ۈ ÌÔÏ˘Ṳ̂ÓÔ˘ ÓÂÚÔ‡ ‹ Î·È ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ·ÂÎÎÚÈÌ¿ÙˆÓ8. ∏ ÌÂÙ¿‰ÔÛË ÙÔ˘ ÈÔ‡ μ∫ ̤ۈ ÙÔ˘ Ï·ÎÔ‡ÓÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ ·Ú·Ì¤ÓÂÈ ·ÌÊÈÛ‚ËÙ‹ÛÈÌË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ IgM ÌËÙÚÈ΋˜ ÚÔ¤Ï¢Û˘ ·Ó¢ڛÛÎÔÓÙ·È Û ÓÂÔÁ¤ÓÓËÙ· ·ÏÏ¿ ÛÙË Û˘Ó¤¯ÂÈ· ¯¿ÓÔÓÙ·È. ¶·Ú¿ Ù·‡Ù·
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Û ‚ÈÔ„ÈÎfi ˘ÏÈÎfi ÂÌ‚Ú‡ˆÓ ·fi ÌË ÔÏÔÎÏËڈ̤Ó˜ ΢‹ÛÂȘ ·ÓȯÓ‡ıËÎ·Ó Ì ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ (polymerase chain reaction, PCR) ·ÏÏËÏÔ˘¯›Â˜ ÙÔ˘ ÈÔ‡ μ∫ Ô˘ ‹Ù·Ó ÎÔÈÓ¤˜ ÙfiÛÔ ÛÙÔ ¤Ì‚Ú˘Ô fiÛÔ Î·È ÙË ÌËÙ¤Ú·9. ™ËÌÂÈÒÓÂÙ·È Â›Û˘ fiÙÈ Ô ·ÓÙ›ÛÙÔȯԘ ¤ÏÂÁ¯Ô˜ ÁÈ· ‡·ÚÍË fiÌÔÈˆÓ ·ÏÏËÏÔ˘¯ÈÒÓ ÁÈ· ÙÔÓ Èfi JC ÌÂٷ͇ ÙˆÓ ÂÌ‚Ú˘ÈÎÒÓ Î·È ÙˆÓ ÌËÙÚÈÎÒÓ ÈÛÙÒÓ ·¤‚Ë ·ÚÓËÙÈÎfi˜. ªÂÙ¿‰ÔÛË ÙÔ˘ ÈÔ‡ μ∫ ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È Ì¤Ûˆ ÌÂÙ·ÁÁ›Ûˆ˜ ·Ú·ÁfiÓÙˆÓ ·›Ì·ÙÔ˜ Î·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ, Û˘ÁÎÂÎÚÈ̤ӷ ÌÂÙ¿‰ÔÛË Ì¤Ûˆ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ‰fiÙË Û ϋÙË10. ªÂÙ¿ ÙËÓ ÚÒÙË ÌfiÏ˘ÓÛË Ô Èfi˜ μ∫ ·Ú·Ì¤ÓÂÈ Û ϷÓı¿ÓÔ˘Û· ηٿÛÙ·ÛË Î·È ÂÓÙÔ›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ÓÂÊÚfi Î·È Ù· ·ÙÙ·Ú· ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜11,12. ∏ ·ÓÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÈÔ‡ μ∫ Î·È Ë Â·ÎfiÏÔ˘ıË ·Ô‚ÔÏ‹ ÙÔ˘ ÛÙ· Ô‡Ú· ˘ÁÈÒÓ ÂÓËÏ›ÎˆÓ ˘ÔÏÔÁ›˙ÂÙ·È ÂÚ›Ô˘ ÛÙÔ 5% ·Ó Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿ÏË ‰È·Î‡Ì·ÓÛË ÌÂٷ͇ ‰È·ÊÔÚÂÙÈÎÒÓ ÌÂÏÂÙÒÓ, Ê˘ÛÈÔÏÔÁÈο fï˜ ‰ÂÓ ·Ó·Ì¤ÓÔÓÙ·È ıÂÙÈο Â˘Ú‹Ì·Ù· fiÙ·Ó ÂϤÁ¯ÔÓÙ·È ·ÓÔÛÔ·Ú΋ ¿ÙÔÌ·13. ∂ÓÙÔ‡ÙÔȘ ı· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ·Ó Î·È Ë μ∫ ÈÔ˘Ú›· Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó‹ Û˘ÁÎÚÈÙÈο Ì ÙËÓ JC ÈÔ˘Ú›·, Î·È ÁÈ· ÙÔ˘˜ ‰‡Ô polyoma ÈÔ‡˜ ·Ú·ÙËÚÂ›Ù·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ·‡ÍËÛË Ù˘ ·ÓÂÓÂÚÁÔÔ›ËÛ˘ Û ËÏÈÎȈ̤ӷ ¿ÙÔÌ· Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘14. ™˘Ó‹ıˆ˜ Ë Â·ÓÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÈÔ‡ Û¯ÂÙ›˙ÂÙ·È Î˘Ú›ˆ˜ Ì ·ı‹ÛÂȘ ‹ Ì ۇӉÚÔÌ· ·ÓÔÛÔηٷÛÙ·ÛÙÔÏ‹˜, fiˆ˜ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ, ΢ڛˆ˜ ÓÂÊÚÔ‡ ·ÏÏ¿ Î·È ‹·ÙÔ˜, ·ÁÎÚ¤·ÙÔ˜, Ó¢ÌfiÓˆÓ Î·È Î·Ú‰È¿˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ÙÔ Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (acquired immunodeficiency syndrome, AIDS), ÓÂÔÏ¿ÛÌ·Ù· ·ÈÌÔÔÈËÙÈÎÔ‡ ÈÛÙÔ‡, ¯ËÌÂÈÔıÂڷ›· ÁÈ· ηÎÔ‹ıÂȘ, Û˘ÁÁÂÓ‹ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·5.
¶·ıÔÁ¤ÓÂÈ· Ù˘ Ïԛ̈͢ ∏ ÚÒÙË Â·Ê‹ Ì ÙÔÓ Èfi μ∫, Ô˘ Û˘Ó‹ıˆ˜ Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, Û˘ÓÈÛÙ¿ ÌfiÏ˘ÓÛË ·fi ÙÔÓ Èfi Î·È ÛËÌ·ÙÔ‰ÔÙ› ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ÛÙ·‰›Ô˘ Ù˘ ·Ú·ÁˆÁÈ΋˜ ÊÏÂÁÌÔÓ‹˜ (productive infection), fiÔ˘ Ô Èfi˜ μ∫ ÂÈÛ¤Ú¯ÂÙ·È ÛÙ· ·ÙÙ·Ú·. O ΢ÙÙ·ÚÈÎfi˜ ˘Ô‰Ô¯¤·˜ ÛÙÔÓ ÔÔ›Ô ÚÔÛÎÔÏÏ¿Ù·È Ô Èfi˜ ÁÈ· ÙËÓ Â›ÛÔ‰fi ÙÔ˘ ÛÙÔ Î‡ÙÙ·ÚÔ Â›Ó·È Ù· ÛÈ·ÏÈο Ôͤ· Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ªÂÙ¿ ÙËÓ Â›ÛÔ‰fi ÙÔ˘ ÌÂٷʤÚÂÙ·È
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M. KOYKOY§AKH
ÁÚ‹ÁÔÚ· ÛÙÔÓ Î˘ÙÙ·ÚÈÎfi ˘Ú‹Ó·, fiÔ˘ ÍÂÎÈÓ¿ÂÈ Ë ‰È·‰Èηۛ· ÙÔ˘ ÈÈÎÔ‡ ·Ó·‰ÈÏ·ÛÈ·ÛÌÔ‡. ∞ÊÔ‡ ‰ËÌÈÔ˘ÚÁËıÔ‡Ó Ù· ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÈÔ‡, Ô˘ ÂÓÙÔ›˙ÔÓÙ·È ÛÙÔÓ Î˘ÙÙ·ÚÈÎfi ˘Ú‹Ó·, Ô Èfi˜ ·ÂÏ¢ıÂÚÒÓÂÙ·È ÛÙËÓ Î˘ÎÏÔÊÔÚ›· Èı·ÓÒ˜ Ì ÙËÓ Î˘ÙÙ·ÚÈ΋ χÛË, Ô˘ Ô‰ËÁ› Û ηٷÛÙÚÔÊ‹ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Î·È ÊÏÂÁÌÔÓ‹. ¶ÈÛÙ‡ÂÙ·È fiÙÈ Ù· ·ÙÙ·Ú· Ô˘ ÌÔχÓÔÓÙ·È ÁÈ· ÚÒÙË ÊÔÚ¿ Â›Ó·È Ù· ·ÙÙ·Ú· ÙˆÓ Ê·Ú˘ÁÁÈÎÒÓ ·Ì˘Á‰·ÏÒÓ Î·ıÒ˜ Î·È Ù· ·ÙÙ·Ú· ÙÔ˘ ÙÚ·¯ÂÈÔ‚ÚÔÁ¯ÈÎÔ‡ ‰¤ÓÙÚÔ˘7. ∏ ÚˆÙÔ-ÌfiÏ˘ÓÛË Û˘Ó‹ıˆ˜ ‰ÂÓ ÂΉËÏÒÓÂÙ·È ÎÏÈÓÈο ÌÂ Û˘Ìو̷ÙÔÏÔÁ›·, ÂÓÙÔ‡ÙÔȘ ÂȉËÌÈÔÏÔÁÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ÔÚÔÌÂÙ·ÙÚÔ‹˜ ηÙfiÈÓ ‹ÈˆÓ ÏÔÈÌÒÍÂˆÓ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ ‰È·‰Ú¿ÌÔ˘Ó Ì ÂÏÂÁ¯fiÌÂÓË ˘ÚÂÙÈ΋ ΛÓËÛË Î·È Û˘ÌÙÒÌ·Ù· ÎÚ˘ÔÏÔÁ‹Ì·ÙÔ˜. ∂Ó Û˘Ó¯›· ̤ۈ Ù˘ ·ÈÌ·ÙÔÁÂÓÔ‡˜ Ô‰Ô‡ Ô Èfi˜ ÂÁηı›ÛÙ·Ù·È ÛÙÔ ÓÂÊÚfi Î·È ÙÔ Ô˘ÚÔı‹ÏÈÔ11, 12. ΔÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ÈÈÎfi DNA ¤¯ÂÈ ·ÓȯÓ¢ı› ·ÎfiÌ· Î·È ÛÙÔ ‹·Ú, ÙÔÓ ÂÁΤʷÏÔ Î·È ÙÔ˘˜ Ó‡ÌÔÓ˜ ÂÓÈÛ¯‡ÂÈ ÙËÓ ˘fiıÂÛË Ù˘ ·ÈÌ·ÙÔÁÂÓÔ‡˜ ‰È·ÛÔÚ¿˜ ̤ۈ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, Ô˘ ¯ÚËÛÈÌÂ‡Ô˘Ó ÙfiÛÔ ÁÈ· ÙË ‰È·Ù‹ÚËÛË fiÛÔ Î·È ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ÈÔ‡. ™ÙË Û˘Ó¤¯ÂÈ· Ë ÂͤÏÈÍË Ù˘ ÊÏÂÁÌÔÓ‹˜ ÂÚÓ¿ÂÈ ÛÙÔ ÛÙ¿‰ÈÔ Ù˘ «ÂÎÙÚˆÙÈ΋˜ ÊÏÂÁÌÔÓ‹˜» ‹ ÂÎÙÚˆÙÈ΋˜ ÌÂÙ·ÙÚÔ‹˜ (abortive infection ‹ abortive transform)15. ™ÙÔ ÛÙ¿‰ÈÔ ·˘Ùfi Ô˘ ·ÎÔÏÔ˘ı› ÙËÓ ÚÒÙË ÌfiÏ˘ÓÛË, Ô Èfi˜ ÂÈÛ¤Ú¯ÂÙ·È ÛÙ· ·ÙÙ·Ú· Î·È ÙÔ ÈÈÎfi DNA ‰ÂÓ ·Ú¿ÁÂÈ ·ÓÙ›ÁÚ·Ê· Ô˘ ı· Ô‰ËÁ‹ÛÔ˘Ó ÛÙË ‰ËÌÈÔ˘ÚÁ›· Ó¤ˆÓ ÈÒÓ. ¶ÈÛÙ‡ÂÙ·È fiÙÈ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ·ÙÙ·Ú· Ô˘ ¤¯Ô˘Ó ÌÔÏ˘Óı› Ì ÙÔÓ Èfi, ÙÔ ÈÈÎfi DNA ÙÂÏÈο ¯¿ÓÂÙ·È Î·È Ù· ·ÙÙ·Ú· ·ӤگÔÓÙ·È ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ηٿÛÙ·ÛË16. ™Â ÌÈÎÚfi ÔÛÔÛÙfi ÙÔ ÈÈÎfi DNA ÂÓۈ̷ÙÒÓÂÙ·È Ì ÙÔ DNA ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÍÂÓÈÛÙ‹ ·Ú·Ì¤ÓÔÓÙ·˜ Û ϷÓı¿ÓÔ˘Û· ηٿÛÙ·ÛË (latency). Àfi ηٿÏÏËϘ Û˘Óı‹Î˜, ÂӉ¯Ô̤ӈ˜ ÌÂȈ̤Ó˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·fiÎÚÈÛ˘ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ηı›ÛÙ·Ù·È ‰˘Ó·Ù‹ Ë Â·ÓÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÈÔ‡. ∏ ·ÓÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÈÔ‡ ‰È·ÈÛÙÒÓÂÙ·È ·fi ÙËÓ ·Ó›¯Ó¢ÛË Ì ÌÔÚȷΤ˜ ÌÂıfi‰Ô˘˜ (PCR) Û ‚ÈÔÏÔÁÈο ˘ÁÚ¿ (Ô‡Ú·, ·›Ì·, ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi) ÙÔ˘ ÈÈÎÔ‡ DNA ‹ Ì ÙË Ì¤ıÔ‰Ô Ù˘ ΢ÙÙ·ÚÔÏÔÁ›·˜ Û ‰Â›ÁÌ·Ù· Ô‡ÚˆÓ ·Ó‡ÚÂÛË Î˘ÙÙ¿ÚˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ·fi ÙÔÓ Èfi μ∫ ηıÒ˜ Î·È ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÈÛÙÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û ‚ÈÔ„›· ÙÔ˘ ÚÔۂ‚ÏË̤ÓÔ˘ ÔÚÁ¿ÓÔ˘ Ô˘ ‰ËÏÒÓÂÈ ÙÔÓ ·Ó·‰ÈÏ·ÛÈ·ÛÌfi ÙÔ˘ μ∫ (BK virus replication)13.
™ÙËÓ Â·ÓÂÓÂÚÁÔÔ›ËÛË ‰ÂÓ ·Ó·Ì¤ÓÂÙ·È Ó· ·ÓȯÓ¢ıÔ‡Ó ·ÓÙÈÛÒÌ·Ù· IgM ·Ú¿ ÌfiÓÔ IgG (immunoglobulin G, IgG, ·ÓÔÛÔÛÊ·ÈÚ›ÓË G). ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ô ·Ó·‰ÈÏ·ÛÈ·ÛÌfi˜ ÙÔ˘ ÈÔ‡ ÚÔηÏ› ÔÚÁ·ÓÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÔÚÁ¿ÓÔ˘ Ô˘ ¤¯ÂÈ ÂÁηٷÛÙ·ı› ÙfiÙ ÔÚ›˙ÂÙ·È ˆ˜ ÂΉËÏÒÓÂÙ·È ÓfiÛÔ˜ ·fi ÙÔÓ Èfi μ∫ (BK virus disease). ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂͤÏıÂÈ Ô Èfi˜ μ∫ ·fi ÙË Ï·Óı¿ÓÔ˘Û· ηٿÛÙ·ÛË Î·È Ó· ÚÔηϤÛÂÈ ÔÚÁ·ÓÈ΋ ‚Ï¿‚Ë, Â›Ó·È ··Ú·›ÙËÙÔ Ó· Û˘Ó˘¿ÚÍÔ˘Ó ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ ı· ¢ÓÔ‹ÛÔ˘Ó ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÈÔ‡. O ÙÚfiÔ˜ Ì ÙÔÓ ÔÔ›Ô ‰ÚÔ˘Ó ÔÈ ‰È¿ÊÔÚ˜ ·Ú¿ÌÂÙÚÔÈ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ˜ Î·È ÔÏÏ¿ Û˘ÌÂÚ¿ÛÌ·Ù· ¤¯Ô˘Ó ‰È·Ù˘ˆı› ‚·ÛÈṲ̂ӷ Û ÌÈÎÚ¤˜ ÌÂϤÙ˜ ¯ˆÚ›˜ Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â·Ó·ÏË„ËÌfiÙËÙ· ‹ ÂȂ‚·›ˆÛË Ù·˘Ùfi¯ÚÔÓ· Û ÎÏÈÓÈο Î·È ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ. °È· ÙÔ˘˜ ÛÎÔÔ‡˜ Ù˘ ·ÚÔ‡Û·˜ ‰È·ÙÚÈ‚‹˜ ı· ·Ó·Ù˘¯ıÔ‡Ó ÔÈ ‰˘ÓËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ΛӉ˘ÓÔ˘ Ô˘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛı› Û ÙË ÚfiÎÏËÛË ÓÂÊÚÔ¿ıÂÈ·˜ Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ÙÔÓ Èfi μ∫. ∞‰Ú¿ ÌÔÚÔ‡Ó Ó· ‰È·¯ˆÚÈÛÙÔ‡Ó Û ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ‰fiÙË ‹ ÙÔ ÌfiÛ¯Â˘Ì· Î·È ÂÓ‰ÔÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ ÙÔ˘ Ï‹ÙË17. ¶·Ú¿ÌÂÙÚÔÈ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ‰fiÙË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ÙËÓ ÔÚÔıÂÙÈÎfiÙËÙ· ÁÈ· ÙÔÓ Èfi μ∫ Î·È ÙÔÓ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi (Cytomegalovirus, CMV), Ù· ÎÔÈÓ¿ ·ÓÙÈÁfiÓ· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (human leukocyte antigens, HLA) ÌÂٷ͇ ÙÔ˘ ‰fiÙË Î·È ÙÔ˘ Ï‹ÙË, Ë ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË Î·È Ë Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜18. ¶Èı·ÓÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ Ï‹ÙË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·ÊÔÚÔ‡Ó ÙÔ ·Ó‰ÚÈÎfi ʇÏÔ, ÙË Û˘Ó‡·ÚÍË ‰È·‚‹ÙË, ÙËÓ ·˘ÍË̤ÓË ËÏÈΛ· ¿Óˆ ÙˆÓ 50 ÂÙÒÓ, ÙË Î·˘Î·ÛÈ·Ó‹ Ê˘Ï‹ Î·È ÙËÓ ÔÚÔ·ÚÓËÙÈÎfiÙËÙ· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË19. π‰È·›ÙÂÚË ÛËÌ·Û›· ÚÔÛ‰›‰ÂÙ·È ÛÙËÓ ·Ô˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ μ∫ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ·Ú·ÙËÚ‹ıËΠfiÙÈ ·ÓÂÍ·Úًو˜ Ù˘ ÔÚÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ‰fiÙË, Ù· ·È‰È¿ Ô˘ ‰ÂÓ ‹Ù·Ó ÔÚÔıÂÙÈο ÁÈ· ÙÔÓ Èfi ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›¯·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ΛӉ˘ÓÔ Ó· ·Ó·Ù‡ÍÔ˘Ó ÓfiÛÔ20. ∏ ·ÓÔÛÔηٷÛÙÔÏ‹, ˆ˜ ·Ú¿ÁˆÓ Ô˘ ηٷÛÙ¤ÏÏÂÈ ÙËÓ ¿Ì˘Ó· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Î·È ÙÚÔÔÔÈ› ÙËÓ ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ Â·ÓÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÈÔ‡ μ∫. ∂›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi fiÙÈ ·Ó Î·È Ô Èfi˜ ÚˆÙÔ·Ú·ÙËÚ‹ıËÎÂ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙÔ 1971 ÁÈ· ÂÚ›Ô˘ 25 ¯ÚfiÓÈ· ‰ÂÓ Â›¯Â ÚÔηϤÛÂÈ ÙÔ ÎÏÈÓÈÎfi ÂӉȷʤÚÔÓ ÂÚ¢ÓËÙÒÓ. ¶·Ú¿ ÌfiÓÔ ÌÂÙ¿ ÙËÓ Â›ÛÔ‰Ô ÙˆÓ Ó¤ˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ (tacrolimus, mycophenolate mofetil) ·Ú·ÁfiÓÙˆÓ ÙÔ 1995 ¿Ú¯ÈÛÂ Ë Â·ÓÂÌÊ¿ÓÈÛË ÙÔ˘ ÈÔ‡ Û ·˘Í·ÓfiÌÂÓÔ ·ÚÈıÌfi ÏËÙÒÓ Î·È Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘ Ì ٷ Ó¤· Ê¿Ú̷η. ™˘ÁÎÚ›ÓÔÓÙ·˜ ıÂڷ¢ÙÈο Û¯‹Ì·Ù· Ì ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Î·È ·ÓÙÈÌÂÙ·‚Ôϛ٘, ·Ó·‰ÂÈÎÓ‡ÂÙ·È fiÙÈ ÙÔ tacrolimus Î·È ÙÔ mycophenolate mofetil ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙËÓ ¤Ó·ÚÍË ·Ó·‰ÈÏ·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡ Î·È ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ μ∫ ÓÂÊÚÔ¿ıÂÈ·˜21. ∂ÓÙÔ‡ÙÔȘ ˘¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ ÁÈ· ·Ó¿Ù˘ÍË ÓÂÊÚ›Ùȉ·˜ ·fi μ∫ Î·È ˘fi ·ÁˆÁ‹ Ì ¿ÏÏ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η fiˆ˜ Ë ·˙·ıÂÈÔÚ›ÓË, Ë Î˘ÎÏÔÛÔÚ›ÓË Î·È ÙÔ sirolimus22. ¶·Ú·Ïϋψ˜ Ï‹Ù˜ Ì ÚÔËÁÔ‡ÌÂÓÔ ÈÛÙÔÚÈÎfi ÔÍ›·˜ ·fiÚÚȄ˘ ÁÈ· ÙËÓ ÔÔ›· ¤Ï·‚·Ó ·ÓÙÈ-·ÔÚÚÈÙÈ΋ ·ÁˆÁ‹ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ ÈÔ‡ μ∫.
∫ÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ÿˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËÎÂ Ô ¿ÓıÚˆÔ˜ Á›ÓÂÙ·È ÊÔÚ¤·˜ ÙÔ˘ ÈÔ‡ μ∫ ‹‰Ë ·fi ÙËÓ ·È‰È΋ ËÏÈΛ·. ∏ Ïԛ̈ÍË ·fi ÙÔÓ Èfi ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ· Û˘Ó‹ıˆ˜ ‰È·‰Ú¿ÌÂÈ ·Û˘ÙˆÌ·ÙÈο ‹ Ì ÂÏ·ÊÚ¿ Û˘Ìو̷ÙÔÏÔÁ›· ÂÎ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ ‰ÂÓ ¯Ú‹˙ÂÈ ÓÔÛÔÎÔÌÂȷ΋˜ ÂÚ›ı·Ï„˘. À¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ ÁÈ· ÚˆÙÔÁÂÓ‹ Ïԛ̈ÍË ·fi μ∫ Ô˘ ÂΉËÏÒıËΠˆ˜ ΢ÛÙ›Ùȉ· Ì ‹ ¯ˆÚ›˜ ·ÈÌ·ÙÔ˘Ú›· Î·È ˆ˜ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ23. O μ∫ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÂÁÎÂÊ·Ï›Ùȉ· Û ·È‰È¿ ËÏÈΛ·˜ 2-5 ÂÙÒÓ Ì ·Ó›¯Ó¢ÛË ÈÈÎÔ‡ DNA ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi Û 2.1% › Û˘ÓfiÏÔ˘ 266 ÂÍÂÙ·Ûı¤ÓÙˆÓ ·È‰ÈÒÓ24. ∞ӷʤÚÂÙ·È Â›Û˘ fiÙÈ Ë Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙˆÓ Ô‡ÚˆÓ Â›Ó·È ıÂÙÈ΋ ÁÈ· μ∫ Û ·ÛıÂÓ›˜ Ì ‰È¿ÊÔÚ· Ô˘ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· Û ÔÛÔÛÙfi 0.3%25. ™Â ˘ÁÈ‹ ÂÔ̤ӈ˜ ¿ÙÔÌ· ‰ÂÓ ·Ó·Ì¤ÓÔÓÙ·È ÂΉËÏÒÛÂȘ Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ÓÔ˘˜ ‹ ·ÓÔÛÔ·Ó·ÚΛ˜ ·ÛıÂÓ›˜. OÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ Ïԛ̈͢ ·fi ÙÔÓ Èfi μ∫ ÛÙÔ˘˜ Ï‹Ù˜ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û˘Ó›ÛÙ·Ù·È Î˘Ú›ˆ˜ ÛÙËÓ ·Ó¿Ù˘ÍË ÓÂÊÚÔ¿ıÂÈ·˜, Ë ÔÔ›· ·Ú·ÙËÚÂ›Ù·È ·fi 2 Ì‹Ó˜ ̤¯ÚÈ 60 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ì ̤ÛÔ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘˜ 9 Ì‹Ó˜18. μ¿ÛÂÈ ÙˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ 1-7% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ı· ÂΉËÏÒÛÔ˘Ó μ∫ ÓÂÊÚÔ¿ıÂÈ·˜ Î·È ·fi ·˘ÙÔ‡˜
141
30%-50% ı· ηٷϋÍÔ˘Ó Û ÚÒÈÌË ·ÒÏÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜26. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ Â›Ó·È ·Û˘ÙˆÌ·ÙÈÎÔ› ÂÓÒ ÛËÌÂÈÒÓÂÙ·È ‰È·ÊfiÚÔ˘ ‚·ıÌÔ‡ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÛÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, ÁÈ· ·Ú¿‰ÂÈÁÌ·, ÌÔÚ› Ó· ·Ú·ÙËÚËı› ̤ÙÚÈ· ·‡ÍËÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÔÚfi ÙÔ˘ ·›Ì·ÙÔ˜. ™ËÌ›· ÁÂÓÈÎÂ˘Ì¤Ó˘ Ïԛ̈͢ ‰ÂÓ ·Ú·ÙËÚÔ‡ÓÙ·È. ∏ ·ÈÙ›· Ù˘ ‚·ıÌÈ·›·˜ ¤ÎÙˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ı· ÚÔÛ‰ÈÔÚÈÛı› Ì ÙË ‚Ô‹ıÂÈ· Ù˘ ‚ÈÔ„›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ ÂÈÎfiÓ· Ù˘ ‰È¿ÌÂÛ˘ ÓÂÊÚ›Ùȉ·˜ Î·È Ù˘ ÂÛÙȷ΋˜ ÛˆÏËÓ·Ú›Ùȉ·˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙËÓ μ∫ ÓÂÊÚÔ¿ıÂÈ· ı· Ú¤ÂÈ Ó· ‰È·ÊÔÚԉȷÁÓˆÛı› ·fi ÙËÓ ·ÓÙ›‰Ú·ÛË ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜27. ∂ÎÙfi˜ ·fi ÙË ÓÂÊÚÔ¿ıÂÈ· Ô Èfi˜ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· Ô˘ÚËÙËÚÈ΋ ÛÙ¤ÓˆÛË, fiˆ˜ Î·È ÛÙÔ Ï‹ÙË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ô˘ ·Ó·Î·Ï‡ÊıËÎÂ, Ô˘ ÔÊ›ÏÂÙ·È Û ‚Ï¿‚Ë ÙÔ˘ ÂÈıËÏ›Ô˘ ÙˆÓ Ô˘ÚÔÊfiÚˆÓ Ô‰ÒÓ Î·È ÛÙ¤ÓˆÛË ÙÔ˘ ·˘ÏÔ‡ Ô˘ Ô‰ËÁ› ›Ù Û ·Ó¿Ù˘ÍË ‹ ÊÏÂÁÌÔÓÒ‰Ë ‰ÈfiÁΈÛË ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ ÛÙËÓ Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·Ó·ÛÙfïÛË2. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ÂÓÒ Ô Èfi˜ μ∫ ÂÚÈÁÚ¿ÊËΠ۠ϋÙË Ô˘ ·Ó¤Ù˘Í ÛÙ¤ÓˆÛË ÙÔ˘ Ô˘ÚËÙ‹Ú·, ‰ÂÓ ¤¯Ô˘Ó ˘¿ÚÍÂÈ ÛÂÈÚ¤˜ ÔÏÏÒÓ ÂÚÈÛÙ·ÙÈÎÒÓ Ì fiÌÔÈ· ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË, ·ÚfiÏÔ Ô˘ Ë Ô˘ÚËÙËÚÈ΋ ÛÙ¤ÓˆÛË ··ÓÙ¿ ÂÚ›Ô˘ ÛÙÔ 4% ÙˆÓ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜.
¢È¿ÁÓˆÛË ΔfiÛÔ ÁÈ· ÙË ‰È¿ÁÓˆÛË fiÛÔ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÔÚ›·˜ Ù˘ Ïԛ̈͢ Î·È Ù˘ ÓÂÊÚÔ¿ıÂÈ·˜ ·fi ÙÔÓ Èfi μ∫ Â›Ó·È ··Ú·›ÙËÙË Ë Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙˆÓ Ô‡ÚˆÓ, ÌÔÚȷΤ˜ ̤ıÔ‰ÔÈ ·Ó›¯Ó¢Û˘ ÙÔ˘ ÈÔ‡ ÛÙ· Ô‡Ú·, ÛÙÔ ·›Ì· Î·È ÛÙÔ ÓÂÊÚÈÎfi ÈÛÙfi ηıÒ˜ Î·È Ë ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ‚ÈÔ„ÈÎÔ‡ ˘ÏÈÎÔ‡ ÙÔ˘ ÚÔÛ‚·ÏÏfiÌÂÓÔ˘ ÔÚÁ¿ÓÔ˘. ∏ ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈ÍË ·fi ÙÔÓ Èfi μ∫ Â›Ó·È ÂÚÁ·ÛÙËÚȷ΋ Î·È Û˘Ó‹ıˆ˜ ηÙ¢ı‡ÓÂÙ·È ·fi ÙËÓ ÎÏÈÓÈ΋ ˘Ô„›· ÙÔ˘ È·ÙÚÔ‡.
∞Ó·˙‹ÙËÛË ÙÔ˘ ÈÔ‡ μ∫ ÛÙ· Ô‡Ú· ‰È· Ù˘ ΢ÙÙ·ÚÔÏÔÁÈ΋˜ ÂͤٷÛ˘ ÷ڷÎÙËÚÈÛÙÈÎfi ‡ÚËÌ· ÛÙË Ïԛ̈ÍË ·fi ÙÔÓ Èfi μ∫ ηٿ ÙËÓ Î˘ÙÙ·ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙˆÓ Ô‡ÚˆÓ Â›Ó·È Ù· ÂÔÓÔÌ·˙fiÌÂÓ· “decoy cells” ‹ ·ÙÙ·Ú· «ÂÓ Â›‰Ë ‰ÔÏÒÌ·ÙÔ˜». Δ· “decoy cells” ·ÔÙÂÏÔ‡Ó ÂÈıËÏȷο ·ÙÙ·Ú· Ô˘ ÌÔχÓıËÎ·Ó ·fi ÙÔÓ Èfi, ˘¤ÛÙËÛ·Ó ·fiÙˆÛË, ÂÓÙÔ›˙ÔÓÙ·È ÛÙ·
142
M. KOYKOY§AKH
Ô‡Ú· Î·È ÚÔ¤Ú¯ÔÓÙ·È ·fi Ù· ÓÂÊÚÈο ÛˆÏËÓ¿ÚÈ· (΢ڛˆ˜ Ù· ¿ˆ ÂÛÂÈڷ̤ӷ ÛˆÏËÓ¿ÚÈ· Î·È Ù· ·ıÚÔÈÛÙÈο ÛˆÏËÓ¿ÚÈ·) Î·È ÙÔ ÂÈı‹ÏÈÔ ÙˆÓ Ô˘ÚÔÊfiÚˆÓ Ô‰ÒÓ28. Δ· ·ÙÙ·Ú· ·˘Ù¿ ÂÚȤ¯Ô˘Ó ˘ÚËÓÈο ÈÈο ۈ̷ٛ‰È· ÙÔ˘ ÈÔ‡ ‹ ·ÎfiÌ· Î·È ÔÏfiÎÏËÚÔ ÙÔ ÈÈÎfi ۈ̿ÙÈÔ. Δ· “decoy cells” ·ÓȯÓ‡ÔÓÙ·È Ì ÙË ¯ÚÒÛË ¶··ÓÈÎÔÏ¿Ô˘ Î·È Á›ÓÂÙ·È Î·Ù·Ì¤ÙÚËÛË Î·Ù¿ ÔÙÈÎfi ‰›Ô. ªÔÚÊÔÏÔÁÈο ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ·ÏÏÔÈÒÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ÙÔÓ ˘Ú‹Ó· ÙÔ˘ ΢ÙÙ¿ÚÔ˘. Δ¤ÛÛÂÚȘ ‰È·ÊÔÚÂÙÈÎÔ› Ù‡ÔÈ ÂÓ‰Ô˘ÚËÓÈÎÒÓ ÂÁÎÏ›ÛÙˆÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËıÔ‡Ó: ·) Ô Ù‡Ô˜ 1. ∂›Ó·È ¤Ó· ¿ÌÔÚÊÔ, ‚·ÛÂfiÊÈÏÔ ¤ÁÎÏÂÈÛÙÔ ‰›ÎËÓ «ÙÚÈÌ̤ÓË ‡·ÏÔ» Î·È Â›Ó·È ·˘Ùfi˜ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÈÔ Û˘¯Ó¿. ‚) Ô Ù‡Ô˜ 2. ∂›Ó·È ¤Ó· ˈÛÈÓfiÊÈÏÔ ÎÔÎÎ҉˜ ¤ÁÎÏÂÈÛÙÔ, Ô˘ ÂÚÈ‚¿ÏÏÂÙ·È ·fi Ì›· (Û˘Ó‹ıˆ˜ ÌË Ï‹ÚË) ¿Ïˆ. Á) Ô Ù‡Ô˜ 3. Œ¯ÂÈ ÌÈÎÚÔÎÔÎÎÒ‰Ë ÌÔÚÊÔÏÔÁ›· ¯ˆÚ›˜ ¿Ïˆ Î·È ‰) Ô Ù‡Ô˜ 4. Œ¯ÂÈ Ê˘Û·ÏÏÈ‰Ò‰Ë ÌÔÚÊÔÏÔÁ›· Î·È Û˘Óԉ‡ÂÙ·È ·fi ÌÂÁ¤ı˘ÓÛË ÙÔ˘ ˘Ú‹Ó· Î·È ·ÓÒÌ·ÏË Î·Ù·ÓÔÌ‹ Ù˘ ¯ÚˆÌ·Ù›Ó˘27. ªÂ ÙÔ ·Ïfi ÌÈÎÚÔÛÎfiÈÔ ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔÛ‰ÈÔÚÈÛı› Ë ÚԤϢÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ·fi Ù· ÓÂÊÚÈο ÛˆÏËÓ¿ÚÈ· ‹ ÙÔ ÌÂÙ·‚·ÙÈÎfi ÂÈı‹ÏÈÔ. ∂›Û˘ ‰ÂÓ Î·ı›ÛÙ·Ù·È ÂÊÈÎÙfi Ó· ‰È·ÊÔÚÔÔÈËı› Ô Èfi˜ μK ·fi ÙÔÓ Èfi JC ηıÒ˜ Î·È ·fi ¿ÏÏÔ˘˜ ·‰ÂÓÔ˚Ô‡˜. ¶·Ú¿ÏÏËÏ· ÛËÌÂÈÒÓÂÙ·È fiÙÈ Ë ·Ú·Ì¤ÏËÛË Î·È ÌË ¤ÁηÈÚË ÌÔÓÈÌÔÔ›ËÛË ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ Ô‡ÚˆÓ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÏÏÔ›ˆÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. O ·ÚÈıÌfi˜ ÙˆÓ decoy ΢ÙÙ¿ÚˆÓ ¯ÚËÛÈ̇ÂÈ ÁÈ· ÙÔ ¯·Ú·ÎÙËÚÈÛÌfi ÙˆÓ ıÂÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ 29. ™˘Ó‹ıˆ˜ ¿Óˆ ÙˆÓ 10 ΢ÙÙ¿ÚˆÓ ıˆÚÔ‡ÓÙ·È ·Ôχو˜ ıÂÙÈο Î·È ÏÈÁfiÙÂÚ· ·fi 10 ·ÙÙ·Ú· ıˆÚÔ‡ÓÙ·È Èı·ÓÒ˜ ıÂÙÈο. Δ· ·ÙÙ·Ú· decoy ÌÔÚÔ‡Ó Â‡ÎÔÏ· Ó· ·Ó·ÁÓˆÚÈÛıÔ‡Ó ¯ˆÚ›˜ ¯ÚÒÛË ÛÙÔ ·ÓÙÈı¤ÙÔ˘ Ê¿Ûˆ˜ ÌÈÎÚÔÛÎfiÈÔ (phase-contrast microscopy). ÷ڷÎÙËÚ›˙ÔÓÙ·È ·fi ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ˘Ú‹Ó·, Ô ÔÔ›Ô˜ ηχÙÂÙ·È ·fi ¤Ó· ‚·ÛÂfiÊÈÏÔ Û¯ËÌ·ÙÈÛÌfi, Ô˘ ÂÚÈ‚¿ÏÏÂÙ·È ·fi ¯ÚˆÌ·Ù›ÓË Î·È Ï¤ÔÓ ·›ÚÓÂÈ ÙË ÌÔÚÊ‹ Û·Ṳ̂ÓÔ˘ Á˘·ÏÈÔ‡)30. Δ· ‰Â›ÁÌ·Ù· ÙˆÓ Ô‡ÚˆÓ Ì ·ÙÙ·Ú· decoy ÌÔÚÔ‡Ó Ó· ·Ú·ÙËÚËıÔ‡Ó Ì ÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ ÔfiÙ ÂÓÙÔ›˙ÔÓÙ·È Û¯ËÌ·ÙÈÛÌÔ› ÎÚ˘ÛÙ¿ÏÏˆÓ ·fi ÙË Û˘ÁΤÓÙÚˆÛË ÙˆÓ Î·„ȉ›ˆÓ ÙÔ˘ ÈÔ‡ BK Ô˘ οı ¤Ó· ¤¯ÂÈ ‰È¿ÌÂÙÚÔ 45 nm, ÂÓÒ Ë ‰È¿ÌÂÙÚÔ˜ ÙÔ˘ CMV Î·È ÙˆÓ ÂÚËÙÔ˚ÒÓ Â›Ó·È 160nm Î·È ÙˆÓ ·‰ÂÓÔ˚ÒÓ Â›Ó·È 70nm31. Δ· “decoy cells” ı· Ú¤ÂÈ Î˘Ú›ˆ˜ Ó· ‰È·ÊÔ-
ÚԉȷÁÓˆÛıÔ‡Ó ·fi ηÎÔ‹ıË Î‡ÙÙ·Ú·, ȉȷ›ÙÂÚ· fiÙ·Ó ·Ú·ÙËÚÂ›Ù·È ÌÂÁ¿ÏÔ˜ ˘Ú‹Ó·˜ ÌÂ Ê˘Û·ÏÏÈ‰Ò‰Ë ÌÔÚÊ‹ (vesicular aspect).
ªÔÚȷΤ˜ Ù¯ÓÈΤ˜ ·Ó·˙‹ÙËÛ˘ ÙÔ˘ ÈÔ‡ μ∫ ÛÙÔ Ï¿ÛÌ· Î·È Ù· Ô‡Ú· ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÓÙfiÈÛË ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ ÈÔ‡ ÛÙ· Ô‡Ú· ‹ ÙÔ ·›Ì·, ÌÂÁ¿ÏË ÚfiÔ‰Ô˜ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÂͤÏÈÍË Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ (polymerase chain reaction, PCR), Ô˘ ‹‰Ë ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ì ÌÂÁ¿ÏË ‰È·ÁÓˆÛÙÈ΋ ·ÍÈÔÈÛÙ›· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ¿ÏÏˆÓ ÈÒÓ (.¯. ÙÔ˘ ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚Ô‡). °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰ÔÎÈÌ¿˙ÔÓÙ·È ‰È¿ÊÔÚ˜ ·Ú·ÏÏ·Á¤˜ Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ Ú·ÁÌ·ÙÈÎÔ‡ ¯ÚfiÓÔ˘ (real-time PCR) fiˆ˜ Â›Ó·È Ë lightcycler PCR Î·È Ë semi nested PCR ÁÈ· ÙËÓ ÔÈÔÙÈ΋ ·Ó›¯Ó¢ÛË ÙÔ˘ ÈÔ‡ μ∫ ηıÒ˜ Î·È Ë TaqMan PCR ÁÈ· ÙËÓ ÔÛÔÙÈ΋ ̤ÙÚËÛË ÙÔ˘ ÈÈÎÔ‡ ÊÔÚÙ›Ô˘32. OÈ Ù¯ÓÈΤ˜ ·˘Ù¤˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·Ó·˙‹ÙËÛË ÙÔ˘ ÈÔ‡ μ∫ ÙfiÛÔ Û ‰Â›ÁÌ·Ù· Ô‡ÚˆÓ fiÛÔ Î·È ‰Â›ÁÌ·Ù· ÔÚÔ‡ ·›Ì·ÙÔ˜.
∞Ó·˙‹ÙËÛË ÙÔ˘ ÈÔ‡ μ∫ Û ˘ÏÈÎfi ‚ÈÔ„ÈÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ∏ ÔÚÈÛÙÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓÂÊÚÔ¿ıÂÈ·˜ ·fi ÙÔÓ Èfi μ∫ Ù›ıÂÙ·È Ì ÙË ‚ÈÔ„›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ¢‡Ô ·ÚÈ· ÌÔÚÊÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÔÚ›˙Ô˘Ó ÙË μ∫ ÓÂÊÚÔ¿ıÂÈ· ·Ê’ ÂÓfi˜ ÌÂÓ Ë ·ÚÔ˘Û›· ÂÓ‰Ô˘ÚËÓÈÎÒÓ ÈÈÎÒÓ ÂÁÎÏ›ÛÙˆÓ, Ô˘ ·Ó¢ڛÛÎÔÓÙ·È ·ÔÎÏÂÈÛÙÈο Î·È ÌfiÓÔ ÛÙ· ÂÈıËÏȷο ·ÙÙ·Ú· ·ÊÂÙ¤ÚÔ˘ ‰Â Ë ÂÛÙȷ΋ χÛË ÙˆÓ ÂÈıËÏÈ·ÎÒÓ ÛˆÏËÓ·ÚÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ·fi ÙËÓ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ÈÔ‡27. O Èfi˜ μ∫ ¯ÚËÛÈÌÔÔÈ› ÙÔ Ì˯·ÓÈÛÌfi ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÍÂÓÈÛÙ‹, ÂÓ ÚÔÎÂÈ̤ÓÔ˘ ÙÔ˘ ÂÈıËÏÈ·ÎÔ‡ ΢ÙÙ¿ÚÔ˘, ÁÈ· ÙÔÓ ·Ó·‰ÈÏ·ÛÈ·ÛÌfi ÙÔ˘ Î·È ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ÂÓ‰Ô˘ÚËÓÈÎÒÓ ÂÁÎÏ›ÛÙˆÓ ÛÙ· ÂÈıËÏȷο ÛˆÏËÓ·Úȷο ·ÙÙ·Ú· Ô˘ ·ÔÙÂÏÔ‡Ó ÙÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÁÓÒÚÈÛÌ· Ù˘ ·Ú·ÁˆÁÈ΋˜ ÊÏÂÁÌÔÓ‹˜. ¶ÚÔԉ¢ÙÈο Ô ÈÈÎfi˜ ·Ó·‰ÈÏ·ÛÈ·ÛÌfi˜ ηٷϋÁÂÈ Û χÛË Î·È Ó¤ÎÚˆÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ¤¯Ô˘Ó ÚÔÛ‚ÏËı› Î·È ·ÔÁ‡ÌÓˆÛË Ù˘ ÛˆÏËÓ·Úȷ΋˜ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘33. ∏ ΢ÙÙ·ÚÔÙÔÍÈÎfiÙËÙ· ÙÔ˘ ÈÔ‡ ÌÔÚ› Ó· ·Ú·ÙËÚËı› Û ÔÏfiÎÏËÚÔ ÙÔ ÓÂÊÚÒÓ·, Â›Ó·È fï˜ ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó‹˜ ÛÙ· ¿ˆ ÂÛÂÈڷ̤ӷ ÛˆÏËÓ¿ÚÈ· Î·È ÛÙ· ·ıÚÔÈÛÙÈο ÛˆÏËÓ¿ÚÈ·. ¶Ôχ Û¿ÓÈ· ÚÔۂ‚ÏË̤ӷ ·ÙÙ·Ú· ÌÔÚ› Ó· ·Ú·ÙËÚËıÔ‡Ó ÛÙÔ ÙÔȯˆÌ·ÙÈÎfi ÂÈı‹ÏÈÔ, Ô˘ ÂÂÓ‰‡ÂÈ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙËÓ Î¿„· ÙÔ˘ Bowman, ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ÂÓ›ÔÙ ÌÈÎÚ¿ ·ıÚÔ›ÛÌ·Ù· ‰›ÎËÓ ËÌÈÛÂÏ‹ÓÔ˘. ™ÙË ÓÂÊÚÈ΋ ‡ÂÏÔ Î·È ÙÔ˘˜ Ô˘ÚËÙ‹Ú˜ ÌÔÚ› Ó· ·Ú·ÙËÚËıÔ‡Ó ˘ÚËÓÈο ¤ÁÎÏÂÈÛÙ· ÛÙ· ÂÈÊ·ÓÂȷο (‰È·ÊÔÚÔÔÈË̤ӷ) ·ÙÙ·Ú· ÙÔ˘ ÌÂÙ·‚·ÙÈÎÔ‡ ÂÈıËÏ›Ô˘ Î·È Ôχ Û¿ÓÈ· ÛÙË ‚·ÛÈ΋ ÛÙÈ‚¿‰·. Δ· Ô‰Ô·ÙÙ·Ú·, Ù· ÂÓ‰ÔıËÏȷο Î·È Ù· ÌÂÛÂÁ¯˘Ì·ÙÈο ·ÙÙ·Ú· Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ ÚÔÛ‚¿ÏÏÔÓÙ·È ·fi ÙÔÓ Èfi μ∫ ÛÙ· ·ÓıÚÒÈÓ· ÓÂÊÚÈο ÌÔۯ‡̷ٷ. ∏ μ∫ ÓÂÊÚÔ¿ıÂÈ· ·ÚÔ˘ÛÈ¿˙ÂÈ ‰È¿ÊÔÚ· ÛÙ¿‰È· ÂͤÏÈ͢ Î·È Â›Ó·È ‰˘Ó·Ùfi Ó· ‰È·ÁÓˆÛı› ÙfiÛÔ Ì ÚÒÈÌ· fiÛÔ Î·È Ì ÚÔ¯ˆÚË̤ӷ ÛËÌ›· Ù˘ ‚Ï¿‚˘. ™‹ÌÂÚ· Ë ÈÛÙÔÏÔÁÈ΋ Ù·ÍÈÓfiÌËÛË Ù˘ μ∫ ÓÂÊÚÔ¿ıÂÈ·˜ ‚·Û›˙ÂÙ·È ÛÙË Û˘Ó·›ÓÂÛË Ô˘ η٤ÏËÍ ÔÌ¿‰· ÂÈÛÙËÌfiÓˆÓ Ì ȉȷ›ÙÂÚÔ ¤ÚÁÔ ÛÙË ÌÂϤÙË ÙˆÓ ÈÒÓ polyoma ÙÔÓ OÎÙÒ‚ÚÈÔ 2003 ÛÙË μ·ÛÈÏ›· Ù˘ ∂Ï‚ÂÙ›·˜34.
μ∫ ÓÂÊÚÔ¿ıÂÈ· - ™Ù¿‰ÈÔ ∞ (¶ÂÚÈÔÚÈṲ̂Ó˘ ‹ ÚÒÈÌ˘ ‚Ï¿‚˘) – Pattern A (Limited – early stage) ™ËÌ›· ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ ÈÔ‡ ÂÓÙÔ›˙ÔÓÙ·È ÛÙ· ÛˆÏËÓ¿ÚÈ· ÙfiÛÔ Ù˘ ÊÏÔÈÒ‰Ô˘˜ ÌÔ›Ú·˜ fiÛÔ Î·È Ù˘ Ì˘ÂÏÒ‰Ô˘˜ ÌÔ›Ú·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ÷ڷÎÙËÚÈÛÙÈÎfi ÙÔ˘ ÛÙ·‰›Ô˘ ·˘ÙÔ‡ ·ÔÙÂÏ› Ë ·Ô˘Û›· ÂÈıËÏȷ΋˜ χÛ˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÓÂÚÁ¿ ÛËÌ›· ÈÈÎÔ‡ ·Ó·‰ÈÏ·ÛÈ·ÛÌÔ‡ ÂÓÒ Ë ·ÔÁ‡ÌÓˆÛË Ù˘ ÛˆÏËÓ·Úȷ΋˜ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Â›Ó·È ‰˘Û‰È¿ÎÚÈÙË. ∞Ô˘ÛÈ¿˙ÂÈ Ë ÊÏÂÁÌÔÓ‹ ÙÔ˘ ‰È¿ÌÂÛÔ˘ ÈÛÙÔ‡ ÂÓÒ Ë ÛˆÏËÓ·Úȷ΋ ·ÙÚÔÊ›· Î·È Ë ‰È¿ÌÂÛË ›ÓˆÛË ÂÚÈÔÚ›˙ÂÙ·È Û ÏÈÁfiÙÂÚÔ ·fi 10% ÙÔ˘ ÂÍÂÙ·˙fiÌÂÓÔ˘ ˘ÏÈÎÔ‡. ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÙÔ˘ ÛÙ·‰›Ô˘ ∞ ÌÔÚ› Ó· ·ÓÙ·ÔÎÚÈı› ÈηÓÔÔÈËÙÈο Û ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ì ·Ó·ÛÙÚ¤„ÈÌË ÔÚ›· ÙˆÓ ‚Ï·‚ÒÓ. ∞Ó ‰Â ‰È·ÁÓˆÛı› Î·È ·ÓÙÈÌÂÙˆÈÛı› ÂÈÙ˘¯Ò˜, Ë μ∫-ÓÂÊÚÔ¿ıÂÈ· ÛÙ·‰›Ô˘ ∞ ÌÔÚ› Ó· ÂÍÂÏȯı› Û ÛÙ·‰›Ô˘ μ ‹ Î·È °.
μ∫ ÓÂÊÚÔ¿ıÂÈ· - ™Ù¿‰ÈÔ μ (μ1-μ3, ƒÔ‰·Ïfi ÛÙ¿‰ÈÔ) – Pattern B (Florid stage) ™ÙÔ ÛÙ¿‰ÈÔ ·˘Ùfi ·Ú·ÙËÚÔ‡ÓÙ·È ÛËÌ›· ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ ÈÔ‡ ÛÙ· ÛˆÏËÓ¿ÚÈ· Ù˘ ÊÏÔÈÒ‰Ô˘˜ Î·È Ù˘ Ì˘ÂÏÈ΋˜ ÌÔ›Ú·˜, χÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ Ô˘ ¤¯Ô˘Ó ÚÔÛ‚ÏËı›, ·ÔÁ‡ÌÓˆÛË Ù˘ ÛˆÏËÓ·Úȷ΋˜ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Î·È ‰È¿ÌÂÛÔ Ô›‰ËÌ·. ™˘¯Ófi ‡ÚËÌ· Û˘ÓÈÛÙ¿ Ë ‰È‹ıËÛË ·fi ÊÏÂÁÌÔÓÒ‰Ë ÌÔÓÔ·ÙÙ·Ú· ·ÏÏ¿ Î·È Ï·ÛÌ·ÙÔ·ÙÙ·Ú· Î·È ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·. ∏ ‰È¿ÌÂÛË ›ÓˆÛË
143
Î·È Ë ·ÙÚÔÊ›· ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÏ¿¯ÈÛÙË Ì¤¯ÚÈ Ì¤ÙÚÈ· Ì ÏÈÁfiÙÂÚÔ ·fi ÙÔ 50% ÙÔ˘ ÂÍÂÙ·˙fiÌÂÓÔ˘ ‚ÈÔ„ÈÎÔ‡ ˘ÏÈÎÔ‡ Ó· ·ÚÔ˘ÛÈ¿˙ÂÈ ‚Ï¿‚˜. ∞ÏÏÔÈÒÛÂȘ ÙÔ˘ ÛÙ·‰›Ô˘ μ ÌÔÚÔ‡Ó Ó· ·Ó¢ÚÂıÔ‡Ó ÛÙÔ ÓÂÊÚÈÎfi ÊÏÔÈfi Î·È ÙÔ Ì˘ÂÏfi Î·È ÂÚ·ÈÙ¤Úˆ Ù·ÍÈÓÔÌÔ‡ÓÙ·È ‚¿ÛÂÈ Ù˘ ‚Ï¿‚˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ ·fi ÙÔÓ Èfi μ∫ Î·È Ù˘ ÊÏÂÁÌÔÓ‹˜ Û ·) ™Ù¿‰ÈÔ μ1: ‚Ï¿‚˜ Û ÏÈÁfiÙÂÚÔ ·fi 25% ÙÔ˘ ÂÍÂÙ·˙fiÌÂÓÔ˘ ‚ÈÔ„ÈÎÔ‡ ˘ÏÈÎÔ‡, ‚) ™Ù¿‰ÈÔ μ2: ‚Ï¿‚˜ Û ÏÈÁfiÙÂÚÔ ·fi 26-49%% ÙÔ˘ ÂÍÂÙ·˙fiÌÂÓÔ˘ ‚ÈÔ„ÈÎÔ‡ ˘ÏÈÎÔ‡, Î·È Á) ™Ù¿‰ÈÔ μ3: ‚Ï¿‚˜ Û ÏÈÁfiÙÂÚÔ ·fi 50% ÙÔ˘ ÂÍÂÙ·˙fiÌÂÓÔ˘ ‚ÈÔ„ÈÎÔ‡ ˘ÏÈÎÔ‡. ∂Í ÔÚÈÛÌÔ‡ ÛÙÔ ÛÙ¿‰ÈÔ ·˘Ùfi Ë ›ÓˆÛË Î·È Ë ÛˆÏËÓ·Úȷ΋ ·ÙÚÔÊ›· ·ÊÔÚ¿ ÏÈÁfiÙÂÚÔ ·fi 50% ÙÔ˘ ÂÍÂÙ·˙fiÌÂÓÔ˘ ‰Â›ÁÌ·ÙÔ˜ .
μ∫ ÓÂÊÚÔ¿ıÂÈ· - ™Ù¿‰ÈÔ ° (Ÿ„ÈÌÔ ÛÙ¿‰ÈÔ ›ÓˆÛ˘) – Pattern C (Late, sclerosing stage) ¶·Ú·ÙËÚÔ‡ÓÙ·È ÂÎÛÂÛËÌ·Ṳ̂ӷ ÛËÌ›· ÂÓÂÚÁÔ‡ ·Ó·‰ÈÏ·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡ μ∫ ÌÂ Û˘ÓÔ‰¤˜ ‚Ï¿‚˜ ÛÙ· ÓÂÊÚÈο ÛˆÏËÓ¿ÚÈ·. ∏ ‰È¿ÌÂÛË ›ÓˆÛË ÌÔÚ› Ó· ÔÈΛÏÂÈ ·fi ÂÏ·¯›ÛÙÔ˘ ̤¯ÚÈ ÂÎÙÂٷ̤ÓÔ˘ ‚·ıÌÔ‡. ∏ ›ÓˆÛË Î·È Ë ÛˆÏËÓ·Úȷ΋ ·ÙÚÔÊ›·, Û˘Ó›· Ù˘ ÈÈ΋˜ ηٷÛÙÚÔÊ‹˜ ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ, ·Ú·ÙËÚÂ›Ù·È Û ¿Óˆ ÙÔ˘ 50% ÙÔ˘ ÂÍÂÙ·˙fiÌÂÓÔ˘ ‚ÈÔ„ÈÎÔ‡ ˘ÏÈÎÔ‡. ™˘Ó‹ıˆ˜ ÔÈ ·ÏÏÔÈÒÛÂȘ ÙÔ˘ ÛÙ·‰›Ô˘ ·˘ÙÔ‡ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÛÙË ÊÏÔÈÒ‰Ë ÌÔ›Ú· Î·È ÏÈÁfiÙÂÚÔ ÛÙÔ Ì˘ÂÏfi ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. OÈ ·ÏÏÔÈÒÛÂȘ ÙÔ˘ ÛÙ·‰›Ô˘ ·˘ÙÔ‡ ıˆÚÔ‡ÓÙ·È ÌË ·Ó·ÛÙÚ¤„È̘.
¢È·ÊÔÚÈ΋ ¢È¿ÁÓˆÛË μ∫ ÓÂÊÚÔ¿ıÂÈ·˜ ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ μ∫-ÓÂÊÚÔ¿ıÂÈ·˜ Î·È Ù˘ ·fiÚÚȄ˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Î·ıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜ ÏfiÁˆ Ù˘ ‰È·ÊÔÚÂÙÈ΋˜ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘. ∏ ÓÂÊÚ›Ùȉ· ·fi Èfi μ∫ Û˘Óԉ‡ÂÙ·È ·fi ¤Ó· ÂÙÂÚÔÁÂÓ¤˜ ÊÏÂÁÌÔÓ҉˜ ‰È‹ıËÌ· ·ÔÙÂÏÔ‡ÌÂÓÔ ·fi ÏÂÌÊÔ·ÙÙ·Ú·, Ì·ÎÚÔÊ¿Á· Î·È ÔÚÈṲ̂ӷ Ï·ÛÌ·ÙÔ·ÙÙ·Ú·. ∂›Û˘, ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÌË ÂȉÈ΋ ÊÏÂÁÌÔÓ‹ ÌÂ Û˘ÌÌÂÙÔ¯‹ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ, ÂÓÒ ÔÈ ·ÏÏÔÈÒÛÂȘ ÛˆÏËÓ·Ú›Ùȉ·˜, fiÙ·Ó ˘¿Ú¯Ô˘Ó, Â›Ó·È Û˘Ó‹ıˆ˜ Ôχ ‹È˜. ™Â ÂÚÈÙÒÛÂȘ Û˘Ó‡·Ú͢ ÓÂÊÚ›Ùȉ·˜ ·fi μ∫ Î·È ÔÍ›·˜ ΢ÙÙ·ÚÈ΋˜ ·fiÚÚȄ˘ ÙÔ ÌÔÓÔ΢ÙÙ·ÚÈÎfi ÊÏÂÁÌÔÓ҉˜ ‰È‹ıËÌ· Î·È ÔÈ ·ÏÏÔÈÒÛÂȘ ÛˆÏËÓ·Ú›Ùȉ·˜ Â›Ó·È ÈÔ ¤ÓÙÔÓ˜ Û ÂÚÈÔ¯¤˜ ¯ˆÚ›˜ ·ÚÔ˘Û›· ˘ÚËÓÈÎÒÓ ÂÁÎÏ›ÛÙˆÓ, οÙÈ Ô˘ ηıÈÛÙ¿ ·›ı·ÓË ÙË ‰È¿ÌÂÛË ÓÂÊÚ›Ùȉ· ÈÔÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜. ∏
144
M. KOYKOY§AKH
¯ÚÔÓ›· ·fiÚÚÈ„Ë Ô˘ ‚·ıÌÈ·›· Ô‰ËÁ› Û ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÛÎÏ‹Ú˘ÓÛË ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ, ÛˆÏËÓ·Úȷ΋ ·ÙÚÔÊ›·, ‰È·¯ˆÚÈÛÌfi Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜ Î·È ‰È¿ÌÂÛË ›ÓˆÛË. ∏ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ¯ÚÒÛË ÁÈ· Δ-΢ÙÙ·ÚÔÙÔÍÈο Î·È μ- ÏÂÌÊÔ·ÙÙ·Ú· Ì ٷ ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ CD3 Î·È ÙÔ˘ CD20 ·ÓÙÈÛÙÔ›¯ˆ˜ ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÙË ‰È·ÊÔÚԉȿÁÓˆÛË. ™ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÓÂÊÚ›Ùȉ·˜ ·fi μ∫ Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏËÊı› Ë Ïԛ̈ÍË ·fi ¿ÏÏÔ˘˜ ÈÔ‡˜, fiˆ˜ Ô Èfi˜ ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ·, Ô ·‰ÂÓÔ˚fi˜ Î·È Ô Î˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜. ∏ ‰È¿ÎÚÈÛË ·˘Ù‹ ÌÔÚ› ‡ÎÔÏ· Ó· Á›ÓÂÈ Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ËÏÂÎÙÚÔÓÈÎÔ‡ ÌÈÎÚÔÛÎÔ›Ô˘, Ù˘ ·ÓÔÛÔ˚ÛÙÔ¯ËÌ›·˜ Î·È Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜. ™ÙÔ ËÏÂÎÙÚÔÓÈÎfi ÌÈÎÚÔÛÎfiÈÔ Â› Ïԛ̈͢ Ì μ∫ ·Ú·ÙËÚÔ‡ÓÙ·È ÛˆÌ·Ù›‰È· Ì ‰È¿ÌÂÙÚÔ ÌÂٷ͇ 30 Î·È 50nm Ô˘ ÂÓ›ÔÙ ۯËÌ·Ù›˙Ô˘Ó ÎÚ˘ÛÙ·ÏÏÔÂȉ›˜ ‰Ô̤˜.
£Âڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ¤Ó·ÚÍË ıÂڷ›·˜ ÁÈ· ÙË μ∫-ÓÂÊÚÔ¿ıÂÈ· ıˆÚÂ›Ù·È ˆ˜ Î·Ù·Ï˘ÙÈ΋ ·Ú¿ÌÂÙÚÔ˜ Ù˘ ÚfiÁÓˆÛ˘ Ù˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. Ÿˆ˜ ÂÚÈÁÚ¿ÊËÎÂ Î·È ·ÓˆÙ¤Úˆ ÛÙÔÓ ·ÏÁfiÚÈıÌÔ Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ Ïԛ̈͢ ·fi ÙÔÓ Èfi μ∫, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ ÓÂÊÚÔ¿ıÂÈ·˜ Î·È ‰Â‰Ô̤ÓÔ˘ ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÔÛÔÛÙÔ‡ ·ÒÏÂÈ·˜ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ fiÙ·Ó ·˘Ù‹ ÂΉËψı›, ÔÈ Ì¤ıÔ‰ÔÈ Ù˘ ΢ÙÙ·ÚÔÏÔÁ›·˜ Î·È Ù˘ PCR ·ÔÙÂÏÔ‡Ó Û˘ÓÂÈÎÔ˘ÚÈο ̤۷ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ Î·È ÙË ‰È¿ÁÓˆÛË Ù˘ ÓÂÊÚÔ¿ıÂÈ·˜ ·ÏÏ¿ ÌÔÚÔ‡Ó Ó· ηÙ¢ı‡ÓÔ˘Ó ÙÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì·. ŸÛÔÓ ·ÊÔÚ¿ ÙË ıÂڷ›· Ù˘ μ∫-ÓÂÊÚÔ¿ıÂÈ·˜, ‰‡Ô Â›Ó·È ÔÈ Î‡ÚȘ ÛÙÚ·ÙËÁÈΤ˜ ıÂڷ›·˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ·) Ë ÙÚÔÔÔ›ËÛË Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ Î·È ‚) Ë ¯ÔÚ‹ÁËÛË Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜34.
ΔÚÔÔÔ›ËÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ∏ ÙÚÔÔÔ›ËÛË Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Â›Ù ÙË Ì›ˆÛË ÙˆÓ ‰fiÛÂˆÓ Â›Ù ÙËÓ ·ÓÙÈηٿÛÙ·ÛË ÂÓfi˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡ Ì ¿ÏÏÔ, (fiˆ˜ ÙÔ˘ tacrolimus Ì ΢ÎÏÔÛÔÚ›ÓË ‹ ÙÔ˘ mycophenolate mofetil Ì ·˙·ıÂÈÔÚ›ÓË). ™ÎÔfi ¤¯ÂÈ ÙË ‰È·ÎÔ‹ Ù˘ ηٷÛÙÔÏ‹˜ Ù˘ ¿Ì˘Ó·˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ì ÙËÓ ¤ÎÏ˘ÛË ÈηÓÔÔÈËÙÈ΋˜ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ Ô˘ ı· Ô‰ËÁ‹ÛÂÈ
ÛÙË Ì›ˆÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ ÈÔ‡ Ì ΛӉ˘ÓÔ fï˜ ¿ÓÙ· ÙËÓ ÂΉ‹ÏˆÛË ·ÔÚÚÈÙÈÎÒÓ ÎÚ›ÛˆÓ. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÚÔÎÂÈ̤ÓÔ˘ Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Ë ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ı· Ú¤ÂÈ Ë ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ Ó· Á›ÓÂÈ ÚÈÓ ÙËÓ ÂÌÊ¿ÓÈÛË ÌË ·Ó·ÛÙÚ¤„ÈÌˆÓ ‚Ï·‚ÒÓ ÛÙ· ÓÂÊÚÈο ÛˆÏËÓ¿ÚÈ· Î·È Ó· ¤¯ÂÈ ·ÔÎÏÂÈÛı› Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ¯ÚÔÓ›·˜ ·fiÚÚȄ˘. ªÂ ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜ Ë ÂͤÏÈÍË Ù˘ ÔÚ›·˜ Ù˘ ÏÔÈÌÒ͈˜ ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο35. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› Û¯ÂÙÈο Ì ÙËÓ ÙÚÔÔÔ›ËÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ μ∫ ÓÂÊÚÔ¿ıÂÈ·˜ ‚·Û›ÛÙËÎ·Ó Û ڈÙfiÎÔÏÏ· ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ μ∫ È·ÈÌ›·˜, ÈÔ˘Ú›·˜ Î·È Ù˘ ·ÚÔ˘Û›·˜ ΢ÙÙ¿ÚˆÓ decoy ÛÙ· Ô‡Ú· ›Ù Û ڈÙfiÎÔÏÏÔ Â·Ó·Ï·Ì‚·ÓfiÌÂÓˆÓ ‚ÈÔ„ÈÒÓ20, 21, 36, 37. ∏ ÌÂÁ·Ï‡ÙÂÚË ÚÔÔÙÈ΋ ÌÂϤÙË ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ ÈÔ‡ μ∫ ÛÙ· Ô‡Ú· Î·È ÙÔ Ï¿ÛÌ· Ì ·ÎfiÏÔ˘ıË ·ÏÏ·Á‹ Ù˘ ·ÓÔÛÔηÛÙÔÏ‹˜ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ˘˜ Brennan et al., ÔÈ ÔÔ›ÔÈ ÂÈÛËÁ‹ıËÎ·Ó ÙËÓ ÚÔÏËÙÈ΋ (pre-emptive) Ì›ˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Û ϋÙ˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ì ÛËÌ·ÓÙÈ΋ Î·È ·Ú·ÙÂÈÓfiÌÂÓË μ∫ ÈÔ˘Ú›· Î·È μ∫ È·ÈÌ›·21. μ¿ÛÂÈ ÙÔ˘ ۯ‰ȷÛÌÔ‡ Ù˘ ÌÂϤÙ˘ Ë ·Ó›¯Ó¢ÛË μ∫ È·ÈÌ›·˜ Ô‰ËÁÔ‡Û Û ‰È·ÎÔ‹ Ù˘ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ·ÓÙÈÌÂÙ·‚ÔÏ›ÙË (Ù˘ ·˙·ıÂÈÔÚ›Ó˘ ‹ ÙÔ˘ mycophenolate mofetil) Î·È ·ÔÙ˘¯›· ·ÚÓËÙÈÎÔÔ›ËÛ˘ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ ·›Ì·ÙÔ˜ ÁÈ· ÙÔÓ Èfi μ∫ ÂÓÙfi˜ ÙÂÛÛ¿ÚˆÓ Â‚‰ÔÌ¿‰ˆÓ Ô‰ËÁÔ‡Û Û ÂÚ·ÈÙ¤Úˆ Ì›ˆÛË Ù˘ ‰fiÛ˘ ÙÔ˘ ·Ó·ÛÙÔϤ· Ù˘ ηÏÛÈÓ¢ڛÓ˘ Ì ›‰· Û˘ÁΤÓÙÚˆÛ˘ ΢ÎÏÔÛÔÚ›Ó˘ ÛÙÔ ·›Ì· ÚÈÓ ÙË Ï‹„Ë 100-200 ng/mL Î·È Â›Â‰· Û˘ÁΤÓÙÚˆÛ˘ tacrolimus ÛÙÔ ·›Ì· ÚÈÓ ÙË Ï‹„Ë 3-5 ng/ml. ∞fi ÙÔ˘˜ 200 Ï‹Ù˜ Ô˘ ÌÂÏÂÙ‹ıËηÓ, 23 ·ÚÔ˘Û›·Û·Ó μ∫ È·ÈÌ›· ÂÎ ÙˆÓ ÔÔ›ˆÓ ÔÈ 22 (95%) ·ÓÙ·ÔÎÚ›ıËÎ·Ó ÛÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ Ì ÛÙ·‰È·Î‹ Ì›ˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ì ·Ô‰ÚÔÌ‹ Ù˘ È·ÈÌ›·˜ ¯ˆÚ›˜ ‚¤‚·È· Ó· ·Ú·ÙËÚËı› ·ÒÏÂÈ· ÌÔۯ‡̷ÙÔ˜ ÏfiÁˆ μ∫-ÓÂÊÚÔ¿ıÂÈ·˜. ∏ ÂÈÙ˘¯›· Ù˘ Ì›ˆÛ˘ Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ÛÙ¿‰ÈÔ Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ μ∫-ÓÂÊÚÔ¿ıÂÈ·˜. OÈ Â·ÓÂÈÏËÌ̤Ó˜ ‚ÈÔ„›Â˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÚÔÙ›ÓÂÙ·È ·fi ÙÔ˘˜ Buehrig et al., ÛÙԯ‡ÂÈ ÛÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË Ù˘ ÓÂÊÚÔ¿ıÂÈ·˜ Î·È ·Ó¿ÏÔÁË ÙÚÔÔÔ›ËÛË Ù˘ ·ÁˆÁ‹˜. ∏ ÌÂϤÙË Î·Ù·Ï‹ÁÂÈ fiÙÈ ·-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙÔ˘˜ Ï‹Ù˜ Ô˘ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó Ì ڈÙfiÎÔÏÏÔ ‚ÈÔ„ÈÒÓ Û˘ÁÎÚÈÙÈο Ì ·˘ÙÔ‡˜ Ô˘ ‰ÂÓ Â›¯·Ó Û˘ÛÙËÌ·ÙÈΤ˜ ‚ÈÔ„›Â˜37. Ÿˆ˜ ¤¯ÂÈ ‹‰Ë ÙÔÓÈÛı› Ë Ì›ˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÂÓ¤¯ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÔÍ›·˜ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. Œ¯ÂÈ ÚÔÙ·ı› Ë ·ÓÙÈηٿÛÙ·ÛË ÙÔ˘ ·Ú¿ÁÔÓÙ· tacrolimus Ì ÙÔ sirolimus, ÙÔ ÔÔ›Ô Â›Ó·È ·Ó·ÛÙÔϤ·˜ Ù˘ Ú··Ì˘Î›Ó˘ ÙˆÓ ıËÏ·ÛÙÈÎÒÓ (mammalian target of rapamycin, mTOR) Û ·ÛıÂÓ›˜ Ì μ∫-ÓÂÊÚÔ¿ıÂÈ·˜38. ∞Ó Î·È ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Û ÂÚÈÔÚÈṲ̂ÓÔ ·ÚÈıÌfi ÏËÙÒÓ Ì ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÏfiÁˆ μ∫-ÓÂÊÚÔ¿ıÂÈ·˜ ̤¯ÚÈ Û‹ÌÂÚ·, ÂÂÙ‡¯ıË ·Ê’ÂÓfi˜ ÌÂÓ Û χÛË Ù˘ È·ÈÌ›·˜ ·ÊÂÙ¤ÚÔ˘ ‰Â Û ÛÙ·‰È·Î‹ ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜.
ÃÔÚ‹ÁËÛË Ê·ÚÌ¿ÎˆÓ ∞Ó Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ÂÁÎÂÎÚÈ̤ÓË ·ÓÙÈ-ÈÈ΋ ‹ ÈÔÛÙ·ÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ μ∫ Ïԛ̈͢, ‰È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› in vitro Î·È in vivo Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù·. ∂Âȉ‹ Ë ÌÈÎÚ‹ ›وÛË Ù˘ ÓfiÛÔ˘ ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙË ‰ÈÂÍ·ÁˆÁ‹ ÎÏÈÓÈÎÒÓ ‰ÔÎÈÌÒÓ Û ÌÂÁ¿Ï˜ ÛÂÈÚ¤˜ ·ÛıÂÓÒÓ, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÌÂÏÂÙÒÓ ÂÚÈÔÚ›˙ÂÙ·È Û ÌÈÎÚfi ·ÚÈıÌfi Û˘ÌÌÂÙ¯fiÓÙˆÓ. ΔÔ cidofovir ·ÔÙÂÏ› ¤Ó· ÓÔ˘ÎÏÂÔÙȉÈÎfi ·Ó¿ÏÔÁÔ Ù˘ ΢ÙÔÛ›Ó˘ [ (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl) cytosine, Vistide®] Î·È ¤¯ÂÈ ¤Ó‰ÂÈÍË ¯ÔÚ‹ÁËÛ˘ ÛÙËÓ ·ÌÊÈ‚ÏËÛÙÚÔÂȉ›Ùȉ· ·fi CMV Û ·ÛıÂÓ›˜ Ì ÓfiÛÔ AIDS. ¶ÂÈÚ¿Ì·Ù· in vitro, Ô˘ ¤‰ÂÈÍ·Ó ÈÔÛÙ·ÙÈΤ˜ ȉÈfiÙËÙ˜ ·Ú¯Èο ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ polyoma ÙÔ˘ Â›Ì˘Ô˜ Î·È ÙÔ˘ ÈÔ‡ SV40 Ô˘ ÚÔÛ‚¿ÏÂÈ Ù· ÚˆÙ‡ÔÓÙ· ›‰Ë Î·È ÛÙË Û˘Ó¤¯ÂÈ· ·Â‰Â›¯ıÂÈ Î·È Ë ·Ó·ÛÙÔÏ‹ ÙÔ˘ ·Ó·‰ÈÏ·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡ μ∫, ·ÔÙ¤ÏÂÛ·Ó ÙÔ ¤ÚÂÈÛÌ· ÁÈ· ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ cidofovir ÁÈ· ÙË ıÂڷ›· Ù˘ μ∫-ÓÂÊÚÔ¿ıÂÈ·˜. ∏ ΢ÚÈfiÙÂÚË ·ÓÂÈı‡ÌËÙË ÂÓ¤ÚÁÂÈ· Â›Ó·È Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·, Ë ÔÔ›· ÌÔÚ› Ó· ÂÚÈÔÚÈÛı› Ì ÙË Ì›ˆÛË Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ‰fiÛ˘ ηٿ 10-25% Ù˘ ‰fiÛ˘ ÙÔ˘ ¯ÔÚËÁÂ›Ù·È Û Ïԛ̈ÍË ·fi CMV. ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ÂÚÈÁÚ¿ÊÔÓÙ·È 29 Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Î·È ¤ÓÙ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÁÎÚ¤·ÙÔ˜-ÓÂÊÚÔ‡ Ô˘ ¤¯Ô˘Ó Ï¿‚ÂÈ Û˘ÌÏËڈ̷ÙÈ΋ ıÂڷ›· Ì cidofovir ÁÈ· μ∫-ÓÂÊÚÔ¿ıÂÈ·39. ∏
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ÌÂÁ·Ï‡ÙÂÚË ÂÎ ÙˆÓ ÌÂÏÂÙÒÓ ÂÚÈÏ·Ì‚¿ÓÂÈ 8 ÌfiÏȘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ (¤Ó·˜ ÂÎ ÙˆÓ ÔÔ›ˆÓ ‹Ù·Ó Ï‹Ù˘ ·ÁÎÚ¤·ÙÔ˜-ÓÂÊÚÔ‡) ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÎÙfi˜ ·fi ÙË ÙÚÔÔÔ›ËÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ‰fiıË ¯·ÌËÏ‹ ‰fiÛË cidofovir 0.5-1 mg/kgr ÁÈ· ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· 4-10 ‚‰ÔÌ¿‰ˆÓ. ∏ ÔÌ¿‰· ·˘Ù‹ Û˘ÓÂÎÚ›ıËΠ̛̠· ÔÌ¿‰· 13 ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË Ù˘ μ∫ ÓÂÊÚÔ¿ıÂÈ·˜ ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó ÌfiÓÔ Ì Ì›ˆÛË Ù˘ ·ÓÔÛÔηÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜. OÈ Ï‹Ù˜ Ô˘ ¤Ï·‚·Ó cidofovir ›¯·Ó ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (100% ÂÈ‚›ˆÛË Û˘ÁÎÚÈÙÈο Ì 30%)39. ∏ ÏÂÊÏÔ˘ÓÔÌ›‰Ë Â›Ó·È ¤Ó·˜ ·Ó·ÛÙÔϤ·˜ Ù˘ Û‡ÓıÂÛ˘ Ù˘ ˘ÚÈÌȉ›Ó˘ [N-(4_-trifluoromethylphenyl)-5-methylisoxazole-4-carboxamide, Arava®], ‰Ú· ·Ó·ÛÙ¤ÏÏÔÓÙ·˜ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ Î˘ÙÙ¿ÚˆÓ (antiprolifarative agent) Î·È ¤¯ÂÈ ÂÈÛ·¯ı› ÛÙË ıÂڷ›· Ù˘ ÚÂ˘Ì·ÙÔÂȉԇ˜ ·ÚıÚ›Ùȉ·˜. ∞Ó Î·È Ë ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ ÏÂÊÏÔ˘ÓÔÌ›‰Ë˜ ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ μ∫ ‰ÔÎÈÌ¿ÛıËΠin vitro Ì ̤ÙÚÈ· ·ÔÙÂϤÛÌ·Ù·, ÎÏÈÓÈ΋ ¯ÔÚ‹ÁËÛË Û ·ÛıÂÓ›˜ Ì μ∫-ÓÂÊÚÔ¿ıÂÈ· ›¯Â ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·40. ™ÙË ÌÂϤÙË ÙˆÓ Williams et al., ‰È·ÎfiËÎÂ Ë ¯ÔÚ‹ÁËÛË MMF, ÌÂÈÒıËÎ·Ó ÔÈ ‰fiÛÂȘ tacrolimus Î·È ·Ú¿ÏÏËÏ· ¯ÔÚËÁ‹ıËΠÏÂÊÏÔ˘ÓÔÌ›‰Ë Û ‰fiÛË ÊfiÚÙÈÛ˘ 100 mg ÙËÓ Ë̤ڷ ÁÈ· 5 Ë̤Ú˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‰fiÛË Û˘ÓÙ‹ÚËÛ˘ 20-60 mg/Ë̤ڷ41. ∏ ‰ÔÛÔÏÔÁ›· ηıÔÚ›˙ÂÙÔ ·fi Ù· ›‰· ÙÔ˘ ∞771726, ÙÔ˘ ÂÓÂÚÁÔ‡ ÌÂÙ·‚ÔÏ›ÙË Ù˘ ÏÂÊÏÔ˘ÓÔÌ›‰Ë˜, ÛÙÔ ·›Ì· Ô˘ ¤¯ÂÈ ıÂڷ¢ÙÈÎfi ‡ÚÔ˜ ÌÂٷ͇ 50-100 mg/mL. ¶·Ú·ÙËÚ‹ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ÈÈÎÔ‡ ÊÔÚÙ›Ô˘ ÛÙÔ ·›Ì· Î·È Ù· Ô‡Ú· ÛÙÔ 88% (15/17 ·ÛıÂÓ›˜) Ô˘ ·ÓÙ·ÔÎÚ›ıËΠÛÙË ıÂڷ›· Ì ÏÂÊÏÔ˘ÓÔÌ›‰Ë Î·È ·ÚÔ˘Û›·Û ›‰· ∞77 1726 ¿Óˆ ÙˆÓ 40 mg/mL. ™Â ‰‡Ô ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ÂÂÙ‡¯ıËÛ·Ó ıÂڷ¢ÙÈο ›‰· ÏÂÊÏÔ˘ÓÔÌ›‰Ë˜ ·Ú¿ ÙË Ì¤ÁÈÛÙË ¯ÔÚËÁÔ‡ÌÂÓË ‰fiÛË, ‰Â ÛËÌÂÈÒıËΠ‚ÂÏÙ›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ÙÔ˘˜ ηٿÛÙ·Û˘ Î·È ÙÔ˘ ·Ó·‰ÈÏ·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡. ™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË Ù˘ Û˘Ó¯ÔÚ‹ÁËÛ˘ ÏÂÊÏÔ˘ÓÔÌ›‰Ë˜ Î·È cidofovir Ì ÙË ¯ÔÚ‹ÁËÛË Ù˘ ÏÂÊÏÔ˘ÓÔÌ›‰Ë˜ ÌfiÓ˘ Ù˘ ‰ÂÓ ¤‰ÂÈÍ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ ·Ô‰ÚÔÌ‹ Ù˘ μ∫ ÈÔ˘Ú›·˜ Î·È È·ÈÌ›·˜40. O ÙÚfiÔ˜ ‰Ú¿Û˘ Ù˘ ˘ÂÚ¿ÓÔÛ˘ ÛÊ·›ÚÈÓ˘ ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜, ¤¯ÂÈ fï˜ ¯ÚËÛÈÌÔÔÈËı› Ì ÂÈÙ˘¯›· Û ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù·
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Î·È Û ·Û‡Ì‚·Ù˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÚÁ¿ÓˆÓ ‹ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì ˘„ËÏfi Ù›ÙÏÔ Î˘ÙÙ·ÚÔÙÔÍÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·ıÒ˜ Î·È Û ÔÍ›· ·fiÚÚÈ„Ë Î·È Û ÈÈΤ˜ ÏÔÈÌÒÍÂȘ ·ÓÔÛÔηÙÂÛÙ·Ï̤ӈÓ42. ¶ÈÛÙ‡ÂÙ·È fiÙÈ Ù· ·ÓÙÈÛÒÌ·Ù· Ô˘ ÂÚȤ¯ÂÈ ‰È·ı¤ÙÔ˘Ó Â˘Ú‡ Ê¿ÛÌ· ÂȉÈÎfiÙËÙ·˜ ¤Ó·ÓÙÈ ‚·ÎÙËÚÈ·ÎÒÓ, ÈÈÎÒÓ, ·Ú·ÛÈÙÈÎÒÓ Î·È Ì˘ÎÔÏ·ÛÌ·ÙÈÎÒÓ ·ÓÙÈÁfiÓˆÓ, Ô˘ ÙÔ˘˜ ÂÈÙÚ¤ÂÈ ÙËÓ Ô„ÔÓÔÔ›ËÛË Î·È Ô˘‰ÂÙÂÚÔÔ›ËÛË ÌÈÎÚÔ‚›ˆÓ Î·È ÙÔÍÈÓÒÓ43. π‰È·›ÙÂÚÔ˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ˘¿Ú¯ÂÈ ÛÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ μ∫ ÏÔÈÌÒ͈˜ fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ Î·È ·fiÚÚÈ„Ë ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∫·È ÙÔ‡ÙÔ ÁÈ·Ù› Ë ·‡ÍËÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ô˘ ı· ·ÔÙÚ¤„ÂÈ ÙËÓ ·fiÚÚÈ„Ë, ı· ÂȉÂÈÓÒÛÂÈ ÙËÓ ÈÈ΋ Ïԛ̈ÍË ·ÊÔ‡ ı· ·˘ÍËı› Ô Ú˘ıÌfi˜ ·Ó·‰ÈÏ·ÛÈ·ÛÌÔ‡ ÙÔ˘ ÈÔ‡ ÂÓÒ Ë Ì›ˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ı· ÂÈÙ›ÓÂÈ ÙË ‰ÈÂÚÁ·Û›· Ù˘ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ™˘ÓÂÒ˜ Ë ‡·ÚÍË ·ÓÙÈÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ı· ‰È¢ÎfiÏ˘Ó ÙËÓ ‰ÈÂÎÂÚ·›ˆÛË Ù¤ÙÔÈˆÓ ÂÚÈÙÒÛˆÓ.
10. Rubio LA, Vera-Sempere FJ. BK viral genotype identification of a renal donor and their recipient pair. Transplantation 2006;82(7):986-7.
μÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ∞Ó·ÊÔÚ¤˜
17. Trofe J, Gordon J, Roy-Chaudhury P, et al. Polyomavirus nephropathy in kidney transplantation. Prog Transplant 2004;14(2):130-40; quiz 41-2.
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11. Heritage J, Chesters PM, McCance DJ. The persistence of papovavirus BK DNA sequences in normal human renal tissue. J Med Virol 1981;8(2):143-50. 12. Chesters PM, Heritage J, McCance DJ. Persistence of DNA sequences of BK virus and JC virus in normal human tissues and in diseased tissues. The Journal of infectious diseases 1983;147(4):676-84. 13. Hirsch HH. BK virus: opportunity makes a pathogen. Clin Infect Dis 2005;41(3):354-60. 14. Zhong S, Zheng HY, Suzuki M, et al. Age-related urinary excretion of BK polyomavirus by nonimmunocompromised individuals. J Clin Microbiol 2007; 45(1): 193-8. 15. Mylonakis E, Goes N, Rubin RH, Cosimi AB, Colvin RB, Fishman JA. BK virus in solid organ transplant recipients: an emerging syndrome. Transplantation 2001;72(10):1587-92. 16. White MK, Khalili K. Polyomaviruses and human cancer: molecular mechanisms underlying patterns of tumorigenesis. Virology 2004;324(1):1-16.
18. Hirsch HH, Knowles W, Dickenmann M, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med 2002;347(7):488-96. 19. Trofe J, Gaber LW, Stratta RJ, et al. Polyomavirus in kidney and kidney-pancreas transplant recipients. Transpl Infect Dis 2003;5(1):21-8. 20. Ginevri F, De Santis R, Comoli P, et al. Polyomavirus BK infection in pediatric kidney-allograft recipients: a single-center analysis of incidence, risk factors, and novel therapeutic approaches. Transplantation 2003; 75(8):1266-70. 21. Brennan DC, Agha I, Bohl DL, et al. Incidence of BK with tacrolimus versus cyclosporine and impact of preemptive immunosuppression reduction. Am J Transplant 2005;5(3):582-94. 22. Binet I, Nickeleit V, Hirsch HH, et al. Polyomavirus disease under new immunosuppressive drugs: a cause of renal graft dysfunction and graft loss. Transplantation 1999;67(6):918-22. 23. Saitoh K, Sugae N, Koike N, Akiyama Y, Iwamura Y, Kimura H. Diagnosis of childhood BK virus cystitis by electron microscopy and PCR. J Clin Pathol 1993; 46(8):773-5. 24. Behzad-Behbahani A, Klapper PE, Vallely PJ, Cleator GM. BK virus DNA in CSF of immunocompetent and immunocompromised patients. Arch Dis Child 2003; 88(2):174-5. 25. Kahan AV, Coleman DV, Koss LG. Activation of
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human polyomavirus infection-detection by cytologic technics. Am J Clin Pathol 1980;74(3):326-32.
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35. Mayr M, Nickeleit V, Hirsch HH, Dickenmann M, Mihatsch MJ, Steiger J. Polyomavirus BK nephropathy in a kidney transplant recipient: critical issues of diagnosis and management. Am J Kidney Dis 2001; 38(3):E13.
27. Nickeleit V, Hirsch HH, Binet IF, et al. Polyomavirus infection of renal allograft recipients: from latent infection to manifest disease. J Am Soc Nephrol 1999; 10(5):1080-9. 28. Nickeleit V, Hirsch HH, Zeiler M, et al. BK-virus nephropathy in renal transplants-tubular necrosis, MHCclass II expression and rejection in a puzzling game. Nephrol Dial Transplant 2000;15(3):324-32. 29. Thamboo TP, Jeffery KJ, Friend PJ, Turner GD, Roberts IS. Urine cytology screening for polyoma virus infection following renal transplantation: the Oxford experience. J Clin Pathol 2006. 30. Fogazzi GB, Cantu M, Saglimbeni L. ‘Decoy cells’ in the urine due to polyomavirus BK infection: easily seen by phase-contrast microscopy. Nephrol Dial Transplant 2001;16(7):1496-8. 31. Singh HK, Madden V, Shen YJ, Thompson BD, Nickeleit V. Negative-staining electron microscopy of the urine for the detection of polyomavirus infections. Ultrastruct Pathol 2006;30(5):329-38. 32. Vats A, Shapiro R, Singh Randhawa P, et al. Quantitative viral load monitoring and cidofovir therapy for the management of BK virus-associated nephropathy in children and adults. Transplantation 2003;75(1):10512. 33. Drachenberg CB, Papadimitriou JC, Wali R, Cubitt CL, Ramos E. BK polyoma virus allograft nephropathy: ultrastructural features from viral cell entry to lysis. Am J Transplant 2003;3(11):1383-92. 34. Hirsch HH, Brennan DC, Drachenberg CB, et al. Polyomavirus-associated nephropathy in renal trans-
36. Vasudev B, Hariharan S, Hussain SA, Zhu YR, Bresnahan BA, Cohen EP. BK virus nephritis: risk factors, timing, and outcome in renal transplant recipients. Kidney international 2005;68(4):1834-9. 37. Buehrig CK, Lager DJ, Stegall MD, et al. Influence of surveillance renal allograft biopsy on diagnosis and prognosis of polyomavirus-associated nephropathy. Kidney international 2003;64(2):665-73. 38. Wali RK, Drachenberg C, Hirsch HH, et al. BK virusassociated nephropathy in renal allograft recipients: rescue therapy by sirolimus-based immunosuppression. Transplantation 2004;78(7):1069-73. 39. Kuypers DR, Vandooren AK, Lerut E, et al. Adjuvant low-dose cidofovir therapy for BK polyomavirus interstitial nephritis in renal transplant recipients. Am J Transplant 2005;5(8):1997-2004. 40. Josephson MA, Gillen D, Javaid B, et al. Treatment of renal allograft polyoma BK virus infection with leflunomide. Transplantation 2006;81(5):704-10. 41. Williams JW, Javaid B, Kadambi PV, et al. Leflunomide for polyomavirus type BK nephropathy. N Engl J Med 2005;352(11):1157-8. 42. Jordan SC, Vo AA, Peng A, Toyoda M, Tyan D. Intravenous gammaglobulin (IVIG): a novel approach to improve transplant rates and outcomes in highly HLA-sensitized patients. Am J Transplant 2006; 6(3): 459-66. 43. Samuelsson A, Towers TL, Ravetch JV. Anti-inflammatory activity of IVIG mediated through the inhibitory Fc receptor. Science 2001;291(5503):484-6.
Proliferation signal inhibitors (PSI) for prevention of chronic allograft nepropathy (CAN)
19
Erich Pohanka
but further attempts will be required to identify those patients, that will most likely benefit from PSI-based immunosuppression. While the long term benefit on transplant survival is currently under investigation in several controlled studies, this drug class appears to offer additional advantages in the immunosuppressive maintenance therapy such as prevention of malignancies or reduction of some types of infections. PSIs have a place to achieve the desired goals of immunosuppressant therapy by targeting a balance between maximizing graft and patient survival, while minimizing the risks of adverse events and long-term complications. Although many questions still have to be answered before the optimal use of PSIs can be defined following solid organ transplantation, the current evidence supports the potential for PSIs to augment modern transplant management.
Advances in immunosuppressive therapy now allow sufficient control of acute allograft rejection, but there is still a need to improve long-term graft and patient survival. Chronic allograft dysfunction caused by chronic allograft nephropathy (CAN) and cardiac allograft vasculopathy (CAV) are well recognized barriers against long-term organ survival in kidney and heart transplantation, respectively, and are associated with both, increased patient morbidity and mortality. Early evidence suggests that proliferation signal inhibitors (PSIs) not only express effective immunosuppressive activity - allowing their safe use in de novo patients and for conversion strategies - but also offer antiproliferative effects that may address some of the unmet needs in the long term therapeutic management of posttransplant patients. PSIs have been successfully used in several protocols for CNI minimization or withdrawal resulting in improved renal function,
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Maintaining total immunosuppression during CNI minimisation or withdrawal: The importance of MPA-monitoring
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Johan W. de Fijter
transplantation resulted in low early acute rejection rates and prevented the occurrence of late acute rejection, despite a high variability in MPA exposure both in the CsA- and Tac-based regimens12. It appears critically important, especially during CNI minimisation or withdrawal, that dosing and concentrations of each immunosuppressant must be chosen such that adequate overall immunosuppression is achieved and maintained. The CAESAR study examined the effects of CsA minimisation on renal function and acute rejection 12 months post-transplantation in de novo renal transplant patients receiving 2 g MMF (n= 536)13. Disappointingly, renal function was not significantly different between the standard-dose and CsAsparing regimens. In the CsA withdrawal arm, this could be attributed to the high number of rejections. The Symphony study compared standard-dose CsA immunosuppression with three low-dose regimens (CsA, Tac and sirolimus) over 12 months in de novo renal transplant patients receiving 2 g MMF and steroids (n=1645)14. Renal function and acute rejection were both significantly better for the low-dose Tac group compared with all other groups (p<0.002). The results of these CNI-minimisation trials with IL-2 receptor blocker prophylaxis and MMF indicate that somewhat lower levels of CNI exposure along with fixed-dose of MMF are sufficient to provide adequate rejection prophylaxis in de novo kidney transplant recipients. In the CAESAR study, however, CsA withdrawal, which was performed between month 4 and 6, resulted in a significant increase in acute rejection13. This increase of around 50% was in the same order as previous withdrawal studies, in which CsA was tapered and eliminated at month 3, 6 or between 12â&#x20AC;&#x201C;30 months after transplantation79. The results of a post-hoc analysis indicated that
Earlier detection and intervention of chronic allograft nephropathy (CAN) remains a key challenge for transplant physicians. Tubular atrophy and interstitial fibrosis develop early after transplantation and are the consequence of the summated effects of tissue injury from acute rejection and calcineurin inhibitor (CNI)-related nephrotoxicity1. Over time, progressive glomerular sclerosis and vasculopathy, including obliteration of peritubular capillaries, become increasingly important2,3. Minimisation or elimination of CNIs appears to be a key decision to potentially modify long-term outcomes4,5. Maintenance dual therapy with steroids and azathioprine or later mycophenolate mofetil (MMF) has not become routine practice, mainly due to concerns about acute rejection after CNI discontinuation6-9. Currently, early intervention strategies focus on developing immunosuppressive regimens that allow CNI minimisation or withdrawal in order to eliminate CNI-associated toxicities, while maintaining the current low acute rejection rates. A retrospective analysis of cardiac transplant recipients (n=215) found a decreased incidence of acute rejection associated with high plasma trough levels of mycophenolic acid (MPA, the active metabolite of MMF), only if cyclosporine (CsA) or tacrolimus (Tac) levels were within their therapeutic ranges10. In renal transplant patients (n=59), lower acute rejection rates were observed when MPA and Tac levels were both above a certain threshold by day 7 post-transplantation compared with patients in whom neither or only one drug level was above the threshold11. In our own experience (n=126), an IL-2 receptor blocker, fixeddose MMF and concentration-controlled CNI exposure followed by early tapering to 3250 ng_h/ml CsA or 125 ng_h/ml Tac 6 weeks after renal
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the risk of rejection was higher in patients with lower MPA exposures 15 , and that the optimal range of MPA exposures in patients on reduced or no CsA was higher than the 30–60 _g_h/ml range that is targeted when standard CNI doses are used. This observation compares well with a study of renal transplant patients (n=218) that compared the incidence of acute rejection following withdrawal of CsA or MMF 3 months after renal transplantation16. Patients who had CsA withdrawn had improved renal function compared with those who had MMF withdrawn (p=0.023). The probability of acute rejection, however, was higher in those patients with CsA withdrawal (p=0.045). Multivariate analysis in these patients revealed low MPA exposure before CsA withdrawal as one of the significant risk factors for acute rejection (p=0.028). In our ongoing study, therapeutic drug monitoring was used to adjust the dose of MPA or CsA to the desired target levels in stable renal transplant patients (n=180) before withdrawing (3.2 ± 2.2 years) one of the drugs from the triple therapy regimen17. The target exposures were 3250 ng_h/ml for CsA and 75 Ìg_h/ml for MPA. Only 4 patients experienced acute rejection during a mean followup of 1.7 ± 0.8 years despite adequate exposure. MPA exposure was well tolerated and withdrawal of CNIs led to an improvement in renal function. In summary, early CNI minimisation or late withdrawal can be safely implemented in the large majority of renal transplant recipients. At present, we lack a reliable immunologic metric to guide the optimal timing of this strategy. In order to ensure adequate immunosuppression, MMF and CNI doses should be adjusted based upon exposure measurements. Maintaining low toxicity and an adequate overall level of immunosuppression may lead to improved graft and patient outcomes.
References 1. Solez K et al. Histopathologic findings from 2-year protocol biopsies from a U.S. multicenter kidney transplant trial comparing tacrolimus versus cyclosporine: a report of the FK506 Kidney Transplant Study Group. Transplantation 1998; 66:1736-40. 2. Nankivell BJ et al. Calcineurin inhibitor nephrotoxicity: longitudinal assessment by protocol histology. Transplantation 2004; 78:557-65. 3. Ishii Y et al. Injury and progressive loss of peritubular capillaries in the development of chronic allograft nephropathy. Kidney Int 2005; 67:321-32.
4. Bakker RC et al. Conversion from cyclosporine to azathioprine at three months reduces the incidence of chronic allograft nephropathy. Kidney Int 2003; 64:1027-3. 5. Gallagher MP et al. A randomized controlled trial of cyclosporine withdrawal in renal-transplant recipients: 15-year results. Transplantation 2004; 78:1653-60. 6. Kasiske BL et al. A meta-analysis of immunosuppression withdrawal trials in renal transplantation. J Am Soc Nephrol 2000; 11:1910-7. 7. Schnuelle P et al. Open randomized trial comparing early withdrawal of either cyclosporine or mycophenolate mofetil in stable renal transplant recipients initially treated with a triple drug regimen. J Am Soc Nephrol 2002; 13:536-43. 8. Abramowicz D et al. Cyclosporine withdrawal from a mycophenolate mofetil-containing immunosuppressive regimen in stable kidney transplant recipients: a randomized, controlled study. Transplantation 2002; 74:1725-34. 9. Smak Gregoor PJ et al. Withdrawal of cyclosporine or prednisone six months after kidney transplantation in patients on triple drug therapy: a randomized, prospective, multicenter study. J Am Soc Nephrol 2002; 13:1365-73. 10. Yamani MH et al. The impact of routine mycophenolate mofetil drug monitoring on the treatment of cardiac allograft rejection. Transplantation 2000; 69:2326-30. 11. Kuypers DR et al. Clinical efficacy and toxicity profile of tacrolimus and mycophenolic acid in relation to combined long-term pharmacokinetics in de novo renal allograft recipients. Clin Pharmacol Ther 2004; 75:434-47. 12. Scholten EM et al. Untreated rejection in 6-month protocol biopsies is not associated with fibrosis in serial biopsies or with loss of graft function. J Am Soc Nephrol 2006; 17:2622-32. 13. Ekberg H et al. Cyclosporine sparing with mycophenolate mofetil, daclizumab and corticosteroids in renal allograft recipients: the CAESAR Study. Am J Transplant 2007; 7:560-70. 14. Ekberg H et al. SYMPHONY: comparing standard immunosuppression to low-dose cyclosporine, tacrolimus or sirolimus in combination with MMF, daclizumab and corticosteroids in renal transplantation. Presented at the World Transplant Congress, Boston, July 2006. Abstract 49. 15. van Gelder T et al. Therapeutic drug monitoring of mycophenolate mofetil in transplantation. Ther Drug Monit 2006; 28:145-54. 16. Hazzan M et al. Predictive factors of acute rejection after early cyclosporine withdrawal in renal transplant recipients who receive mycophenolate mofetil: results from a prospective, randomized trial. J Am Soc Nephrol 2005; 16:2509-16. 17. de Fijter JW et al. Concentration-controlled systemic exposure provides improved safety after CNI or MMF withdrawal. Presented at the American Transplant Congress, San Francisco, May 2007, Abstract 238.
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∂ÈÎfiÓ· 2. ¶¿Óˆ. ∞ÍÈÔÔÈËı¤ÓÙ˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ› ‰fiÙ˜ ·Ó¿ ÂηÙÔÌ̇ÚÈÔ ÏËı˘ÛÌÔ‡ (Global Observatory on Donation and Transplantation (WHO) and Spanish National Transplant Organization, ONT). ∫¿Ùˆ. ªÂÙ·ÌÔÛ¯Â˘ÙÈÎË ‰Ú·ÛÙËÚÈÔÙËÙ· Û˘Ì·ÁˆÓ ÔÚÁ·ÓˆÓ ÛÙËÓ ∂ÏÏ·‰· 2001-2005 (∂ıÓÈÎfi˜ OÚÁ·ÓÈÛÌfi˜ ªÂÙ·ÌÔۯ‡ÛˆÓ).
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Yanaga et al
1989
132
Greig et al Mor et al Ploeg et al
1990 1992 1993
365 323
Gruenberger et al 1994
255
Gonzalez et al Markmann et al
1994 2001
168 1393
Briceno et al
2002
400
Rull et al Cuende et al
2003 2005
228 5150
Busuttil et al
2005
3200
Cameron et al
2006
1000
Feng et al
2006
20023
™Ù·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∏ÏÈΛ· ÙÔ˘ ‰fiÙË, Ë̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙË ª∂£, ·ıÔÏÔÁÈ΋ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ∏ÏÈΛ· ÙÔ˘ ‰fiÙË, Ë̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙÔ ¡ÔÛÔÎÔÌ›Ô, ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ μ¿ÚÔ˜ ‰fiÙË, Ë̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙË ª∂£ ∏ÏÈΛ· ÙÔ˘ ‰fiÙË (> 49), Ë̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (> 3), ÛÙ¿وÛË, ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ (> 18 h), ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ÙÔ˘ Ï‹ÙË ∫Ú·ÙÈÓ›ÓË ‰fiÙË, Ë̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙË ª∂£, ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ÏfiÁÔ˜ GW/BW, ·ÓË·ÙÈ΋ ÂÚ›Ô‰Ô˜, ÌÂÙ·ÁÁ›ÛÂȘ Na+ ‰fiÙË, ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ÌÂÙ·ÁÁ›ÛÂȘ ·ÈÌÔÂÙ·Ï›ˆÓ, PT Ï‹ÙË ∏ÏÈΛ· ÙÔ˘ ‰fiÙË, Na+ ‰fiÙË, ËÏÈΛ· ÙÔ˘ Ï‹ÙË, ÎÚ·ÙÈÓ›ÓË Ï‹ÙË, ÓÔÛËÏ›· ÙÔ˘ Ï‹ÙË ÛÙË ª∂£ ∏ÏÈΛ· ÙÔ˘ ‰fiÙË, ÈÓfiÙÚÔ·, Ì·ÎÚÔÊ˘ÛÛ·Ïȉ҉˘ ÛÙ¿وÛË, Ë̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙË ª∂£, ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ∏ÏÈΛ· ÙÔ˘ ‰fiÙË, ÛÙ¿وÛË, ∏ÏÈΛ· ÙÔ˘ ‰fiÙË, ˘¤ÚÙ·ÛË ÙÔ˘ ‰fiÙË, ›‰· ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ, Ë̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙË ª∂£ ∏ÏÈΛ· ÙÔ˘ ‰fiÙË, Ë̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ËÏÈΛ· ÙÔ˘ Ï‹ÙË, ›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË, ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ¯ÚfiÓÔ˜ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜, ‰È¿ÁÓˆÛË Ï‹ÙË ∏̤Ú˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ¯ÚfiÓÔ˜ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜, ËÏÈΛ· ÙÔ˘ Ï‹ÙË, ›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË ∏ÏÈΛ· ÙÔ˘ ‰fiÙË (>60), Ê˘Ï‹, ‡„Ô˜, ·ÈÙ›· ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘, ‰fiÙ˘ Ì ÌË ¿ÏÏÔ˘Û· ηډ›·, ÙÌËÌ·ÙÈ΋ Ì ÂÙ·ÌfiÛ¯Â˘ÛË
‰È·ÎÚ›ÓÂÙ·È ÛÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ¤Ó·ÚÍË ÏÂÈÙÔ˘ÚÁ›·˜ (delayed graft function, DGF) Î·È ÛÙËÓ ÚˆÙÔ·ı‹ ÌË ÏÂÈÙÔ˘ÚÁ›· (primary non function, PNF). T· ÌÔۯ‡̷ٷ Ì ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· (DGF), ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ˙ˆ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ì ·Ú·ÙÂٷ̤ÓË ·Ó¿ÚÚˆÛË Î·È ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·, ÂÓÒ Î·Ù¿ ÙËÓ ÚˆÙÔ·ı‹ ÌË ÏÂÈÙÔ˘ÚÁ›· (PNF) ··ÈÙÂ›Ù·È Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË. Δ· ÔÚȷο ÌÔۯ‡̷ٷ (marginal grafts) ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· ÛÙËÓ ‚Ï¿‚Ë Û˘ÓÙËÚ‹Ûˆ˜ Î·È ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÚˆÙÔ·ıÔ‡˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ë ÔÔ›· ÌÔÚ› Ó· ·Ô‰Ôı›: ·) ÛÂ Ê˘ÛÈÔÏÔÁÈ΋ ȉÈfiÙËÙ· ÙÔ˘ ‰fiÙË (ËÏÈΛ· > 60 ÂÙÒÓ, ÌÂÁ·ÏÔÊ˘ÛÛ·Ïȉ҉˘ ÛÙ¿وÛË > 30%) ‚) Û ÂÈÏÔ΋ ηٿ ÙË ÓÔÛËÏ›· ÙÔ˘ ‰fiÙË ‹ ÙË Ï‹„Ë (˘ÂÚÓ·ÙÚÈ·ÈÌ›· > 155 mEq/lit, ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ > 12 ÒÚ˜, ·Ú·ÌÔÓ‹ ÛÙË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ (ª∂£) > 3 Ë̤Ú˜, ·˘ÍË̤ÓË ·Ó¿ÁÎË ÁÈ· ˘ÔÛÙ‹ÚÈÍË Ì ÈÓfiÙÚÔ· Ê¿Ú̷η) Î·È Á) ÛÙËÓ Ù¯ÓÈ΋ Ï‹„˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ [‰fiÙ˜ Ì ÌË ¿ÏÏÔ˘Û· ηډ›· (non heart beating donors, NHB), ‰È·¯ˆÚÈÛÌfi˜ ÙÔ˘ ‹·ÙÔ˜ Û ‰‡Ô ÌÔۯ‡̷ٷ (Split Liver Transplantation, SLTx) Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ˜ Û˘ÁÁÂÓ›˜ ‰fiÙ˜ (Living Donor Liver Transplantation, LDLTx)]6.
∏ÏÈΛ· ÙÔ˘ ‰fiÙË ΔÔ ·Ô‰ÂÎÙfi fiÚÈÔ ËÏÈΛ·˜ ÙÔ˘ ‰fiÙË Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·˘Í¿ÓÂÙ·È Û˘Ó¯Ҙ ÏfiÁˆ ÌÂÙ·‚ÔÏÒÓ ÛÙË ‰ËÌÔÁÚ·ÊÈ΋ Û‡ÓıÂÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ Î·È Ù˘ ÂÏÏ›„ˆ˜ ÔÚÁ¿ÓˆÓ. ∂ȉÈÎfiÙÂÚ·, ÔÈ ‰fiÙ˜ > 65 ÂÙÒÓ ·ÔÙÂÏÔ‡Ó ÙËÓ Ù·¯‡ÙÂÚ· ·˘Í·ÓfiÌÂÓË ˘Ô-ÔÌ¿‰· Ù˘ ‰Âͷ̤Ӌ˜ و̷ÙÈÎÒÓ ‰ÔÙÒÓ (∂ÈÎfiÓ· 3). ∏ ÂÈÙ˘¯‹˜ ·ÍÈÔÔ›ËÛË ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ‰ÔÙÒÓ ··ÈÙ› ÙËÓ ÁÓÒÛË ÙˆÓ È‰È·›ÙÂÚˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘˜. ª·ÎÚÔÛÎÔÈο, Ù· ÌÔۯ‡̷ٷ ·Ô ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ›ÓˆÛË Ù˘ ο„·˜ ÙÔ˘ ‹·ÙÔ˜, ÛÎÔÙÂÈÓfiÙÂÚÔ ¯ÚÒÌ·, ·˘ÍË̤ÓË ÛÙ¿وÛË, ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚÔ Ì¤ÁÂıÔ˜ Î·È ·ÚÙËÚÈÔÛÎÏ‹Ú˘ÓÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜6.Δo ÛË250% 200% Ηλικία 18-34 35-49 50-64 ≥ 65
150% 100% 50% 0% -50% 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05
™˘ÁÁÚ·Ê›˜
∂ÈÎfiÓ· 3. ¢ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ‰ÂÍ·ÌÂÓ‹˜ و̷ÙÈÎÒÓ ‰ÔÙÒÓ22.
156
I. ºOYZA™
Ì·ÓÙÈÎfiÙÂÚÔ Â›Ó·È fiÙÈ Ù· ÌÔۯ‡̷ٷ ·Ô ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂȈ̤ÓË ·ÓÙÔ¯‹ ÛÙËÓ „˘¯Ú‹ ÈÛ¯·ÈÌ›·6. ∏ ‚Ï¿‚Ë ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘, ÏfiÁˆ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ¤گÂÙ·È Ù·¯‡ÙÂÚ· ÛÙ· ÌÔۯ‡̷ٷ ·Ô ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜, ·˘Í¿ÓÔÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ ÊÏÂÁÌÔÓ‹˜, ıÚÔÌ‚ÒÛˆ˜ Î·È Î˘ÙÙ·ÚÈ΋˜ ·ÔÚÚ›„ˆ˜, ÌÂ Û˘ÓÂÂÈ· ÙË ÌÂȈ̤ÓË Û˘ÓıÂÙÈ΋ Î·È ·Ó·ÁÂÓÓËÙÈ΋ ÈηÓfiÙËÙ·4,20,21. ∏ Ï‹„Ë ÔÚÁ¿ÓˆÓ ·Ô ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜ ··ÈÙ› ÂÌÂÈÚ›· ÛÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ Î·È ·Ó·ÙÔÌÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·˘ÙÒÓ, ÛÙȘ ÌÂıfi‰Ô˘˜ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋˜ ˘ÔÛÙËڛ͈˜ Î·È ÛÙȘ ÂÁ¯ÂÈÚËÙÈΤ˜ Ù¯ÓÈΤ˜. OÈ ËÏÈÎȈ̤ÓÔÈ ‰fiÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÏ·Ùو̤Ó˜ ·ÓÙÔ¯¤˜ Î·È Û˘Ó˘¿Ú¯Ô˘Û˜ ·ı‹ÛÂȘ, fiˆ˜ ÂÎÙÂٷ̤ÓË ·ÚÙËÚÈÔÛÎÏ‹Ú˘ÓÛË, ·Ó¢ڇÛÌ·Ù·, ÚÔËÁÔ‡ÌÂÓ˜ ÂÓ‰ÔÎÔÈÏȷΤ˜ Î·È ÂÓ‰ÔıˆÚ·ÎÈΤ˜ ÂÂÌ‚¿ÛÂȘ, Ë Ôԛ˜ ηıÈÛÙÔ‡Ó ‰˘Û¯ÂÚ‹ ÙËÓ Ï‹„Ë Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ23. ∏ ·ÍÈÔÔ›ËÛË ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ‰ÔÙÒÓ ÚÔÛʤÚÂÈ ÙËÓ ‰˘Ó·ÙfiÙËÙ· ÁÈ· ¿ÌÂÛË ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ì ·ÓÙ¿ÏÏ·ÁÌ· ÙË ÌÂȈ̤ÓË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·˘ÙÒÓ. Δ· ÌÔۯ‡̷ٷ ·Ô ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ηı˘ÛÙÂÚË̤Ó˘ ¤Ó·Ú͢ ÏÂÈÙÔ˘ÚÁ›·˜ (delayed graft function, DGF) Î·È ·Ú·ÙÂٷ̤ÓË ¯ÔÏfiÛÙ·ÛË Ô˘ ·Ô‰›‰ÔÓÙ·È Û ÛÔ‚·Ú‹ ‚Ï¿‚Ë ÈÛ¯·ÈÌ›·˜ ·ӷÈÌ·ÙÒÛˆ˜ 5, 19. ∂ÈϤÔÓ, ÔÈ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜ ¤¯Ô˘Ó ÌÂȈ̤ÓË ·ÒÙÂÚË ÂÈ‚›ˆÛË19,24. ∏ ËÏÈΛ·, ¤Ú· ·fi ÙËÓ ÔÔ›· Ë ¤ÎÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηı›ÛÙ·Ù·È ÌË ·Ô‰ÂÎÙ‹ ¢ڛÛÎÂÙ·È ÌÂٷ͇ ÙˆÓ 60 Î·È 70 ÂÙÒÓ19,25. ∂ÈϤÔÓ, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Ë ¯Ú‹ÛË Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·Ô ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜ Û ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË ·fi Ë·Ù›Ùȉ· C Û˘Óԉ‡ÂÙ·È ·fi ‚·Ú‡ÙÂÚË ˘ÔÙÚÔ‹ Î·È ÌÈÎÚfiÙÂÚË ÂÈ‚›ˆÛË26-28.
§È҉˘ ÂÎʇÏÈÛË (ÛÙ¿وÛË) ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ∏ ÛÙ¿وÛË ·ÔÙÂÏ› Û˘¯Ófi Û¯ÂÙÈο ÈÛÙÔÏÔÁÈÎfi ‡ÚËÌ· ÛÙ· ÌÔۯ‡̷ٷ (~30%) Î·È ÔÊ›ÏÂÙ·È Û ·¯˘Û·ÚΛ·, ˘ÂÚÏÈȉ·ÈÌ›·, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ηٷӿψÛË ÔÈÓÔÓ‡̷ÙÔ˜ Î·È Ï‹„Ë Ê·ÚÌ¿ÎˆÓ ‹ ·ÚÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜29. ™ÙËÓ Ù·¯Â›· ‚ÈÔ„›· (ÌÈÎÚÔÛÎÔÈ΋ ÂͤٷÛË ÙÔÌÒÓ ÎÚ˘ÔÛÙ¿ÙË), ÙÔ Ï›Ô˜ ÛÙ· Ë·ÙÔ·ÙÙ·Ú· ÌÔÚ› Ó· ¤¯ÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ÔÏÏ·ÏÒÓ Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÒÓ ÏÈÔÛÙ·ÁÔÓȉ›ˆÓ (ÌÈÎÚÔÊ˘ÛÛ·Ïȉ҉˘ ÛÙ¿و-
ÛË), ‹ ÌÈ¿˜ ÌÂÁ¿Ï˘ ÏÈÔÛÙ·ÁfiÓ·˜ Ô˘ ·ÚÂÎÙÔ›˙ÂÈ ÙÔÓ ˘Ú‹Ó· ÛÙËÓ ÂÚÈʤÚÂÈ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘ (ÌÂÁ·ÏÔÊ˘ÛÛ·Ïȉ҉˘ ÛÙ¿وÛË). ∏ ÛÙ¿وÛË ‚·ıÌÔÏÔÁÂ›Ù·È ˆ˜: ·) ‹È·, fiÙ·Ó ·ÊÔÚ¿ ¤ˆ˜ 30% ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, ‚) ̤ÙÚÈ·, fiÙ·Ó ·ÊÔÚ¿ ÔÛÔÛÙfi 30-60% ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Î·È Á) ¤ÓÙÔÓË ‹ ÛÔ‚·Ú‹, fiÙ·Ó ·ÊÔÚ¿ ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ 60% ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ30. ∏ ÌÈÎÚÔÊ˘ÛÛ·Ïȉ҉˘ ÛÙ¿وÛË ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ Ù˘ Ê˘ÛÈÔÏÔÁ›·˜ ÙÔ˘ ‹·ÙÔ˜ ·fi Û‹„Ë, ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ‹ ·Ú·ÙÂٷ̤ÓË ÓÔÛËÏ›·. £ÂˆÚÂ›Ù·È ·Ó·ÛÙÚ¤„ÈÌË Î·Ù¿ÛÙ·ÛË Î·È ‰ÂÓ ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ (DGF) ‹ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (PNF)31. ∏ ÎÏÈÓÈ΋ Ù˘ ÛËÌ·Û›· Â›Ó·È fiÙÈ ·ÔÙÂÏ› ¤Ó‰ÂÈÍË ÁÈ· ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ÙÔ˘ ‰fiÙË Î·È fi¯È ÁÈ· ÌË ·Ô‰Ô¯‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞ÓÙ›ıÂÙ·, Ë ÌÂÁ·ÏÔÊ˘ÛÛ·Ïȉ҉˘ ÛÙ¿وÛË ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ·˘ÍË̤ӷ ÔÛÔÛÙ¿ DGF Î·È PNF. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ‹È· ÛÙ¿وÛË (< 30%), ¯ˆÚ›˜ ¿ÏÏÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È ÌÈÎÚfi ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ·Ô‰›‰ÂÈ ·ÔÙÂϤÛÌ·Ù· ·ÚfiÌÔÈ· Ì ÂΛӷ ÙˆÓ ÌË ÛÙ·وÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ29,32.∏ ¯Ú‹ÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ¤ÓÙÔÓË ÛÙ¿وÛË (> 60%) ı· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È ‰ÈfiÙÈ Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜ Â›Ó·È ·Úfi‚ÏÂÙË Î·È ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÔÛÔÛÙ¿ PNF ̤¯ÚÈ Î·È 60%10,30,33. Δ· ÌÔۯ‡̷ٷ Ì ̤ÙÚÈ· ÛÙ¿وÛË (30 - 60%) ·ÔÙÂÏÔ‡Ó ÎÏÈÓÈ΋ ÚfiÎÏËÛË32. ∂¯Ô˘Ó ·Ó·ÊÂÚı› ÔÛÔÛÙ¿ DGF ̤¯ÚÈ Î·È 35%, fiˆ˜ ·Ô‰ÂÈÎÓ‡ÂÙ·È ·fi Ù· ˘„ËÏ¿ ÌÂÙÂÁ¯ÂÈÚËÙÈο ›‰· ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ Î·È ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È ÙȘ ·˘ÍË̤Ó˜ ·Ó¿ÁΘ ÌÂÙ·ÁÁ›ÛÂˆÓ ·›Ì·ÙÔ˜10,35. ∏ Û‹„Ë Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÙˆÓ ÏËÙÒÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ̤ÙÚÈ· Ë ÛÔ‚·Ú‹ ÛÙ¿وÛË. ∏ ·fiÊ·ÛË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ‰˘Û¯ÂÚ‹˜ Î·È Ú¤ÂÈ Ó· ‚·ÛÈÛı› ÛÙËÓ ‚ÈÔ„›· Î·È ÛÙËÓ ÁÓÒÌË ÂÓfi˜ ¤ÌÂÈÚÔ˘ ÛÙȘ Ï‹„ÂȘ ¯ÂÈÚÔ˘ÚÁÔ‡, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ˘Ê‹ Î·È ÙÔ ¯ÚÒÌ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÙËÓ ÔÈfiÙËÙ· Ù˘ ÂÎχÛˆ˜ Î·È ÙËÓ ‡·ÚÍË ¿ÏÏˆÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ‰fiÙË. ∂ÈϤÔÓ, Ú¤ÂÈ ·ÔÊ¢¯ı› Ô ·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, Ë ¤Ó‰ÂÈÍË Ù˘ ΛÚÚˆÛ˘ ·fi Ë·Ù›Ùȉ· C Î·È ‹ ‰˘Ó·ÙfiÓ Ô ËÏÈÎȈ̤ÓÔ˜ Î·È Û ‚·ÚÂÈ¿ ηٿÛÙ·ÛË Ï‹Ù˘29.
ÀÂÚÓ·ÙÚÈ·ÈÌ›· ∏ ˘ÂÚÓ·ÙÚÈ·ÈÌ›· Â›Ó·È Û˘¯Ófi ‡ÚËÌ· ÛÙÔ˘˜
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜ Î·È ¤¯ÂÈ ·ÚÓËÙÈ΋ ›وÛË ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙfiÛÔ ÙˆÓ Ë·ÙÈÎÒÓ fiÛÔ Î·È ÙˆÓ Â͈˷ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ12. OÊ›ÏÂÙ·È ÛÙËÓ ÂÏ·Ùو̤ÓË ¤ÎÎÚÈÛË ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ÔÚÌfiÓ˘, ÏfiÁˆ ÂÁÎÂÊ·ÏÈ΋˜ ÈÛ¯·ÈÌ›·˜, ÛÙËÓ ÂÈıÂÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ‹ ÛÙËÓ ÏËÌÌÂÏ‹ ·ÔηٿÛÙ·ÛË ÙˆÓ ·ˆÏÂÈÒÓ ˘ÁÚÒÓ ÙÔ˘ ‰fiÙË. ∏ ›‰Ú·ÛË Ù˘ ˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜ ÛÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·Ô‰›‰ÂÙ·È ÛÙËÓ ·‡ÍËÛË Ù˘ ÂÓ‰Ô΢ÙÙ·Ú›Ô˘ ˆÛ̈ÙÈ΋˜ ȤÛˆ˜ ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, Ì ÙËÓ Â›ÛÔ‰Ô ÈfiÓÙˆÓ Ó·ÙÚ›Ô˘, ·ÌÈÓÔͤˆÓ, ÌÂı˘Ï·ÌÈÓÒÓ Î.·., ˆ˜ ·Ì˘ÓÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ ¤Ó·ÓÙÈ ÙˆÓ ÂÍˆÎ˘ÙÙ·Ú›ˆÓ ˘ÂÚˆÛ̈ÙÈÎÒÓ Û˘ÓıËÎÒÓ. ∞ÎÔÏÔ˘ı› Ù·¯Â›· ›ÛÔ‰Ô˜ ÌÔÚ›ˆÓ ‡‰·ÙÔ˜ ÌÂ Û˘Ó¤ÂÈ· ÙÔ Î˘ÙÙ·ÚÈÎfi Ô›‰ËÌ· Î·È ‚Ï¿‚Ë6,12. ∏ ˘ÂÚÓ·ÙÚÈ·ÈÌ›· ÙÔ˘ ‰fiÙË ·ÔÙÂÏ› ÈÛ¯˘Úfi ·ÓÂÍ¿ÚÙËÙÔ ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜10,36,37. ∂ȉÈÎfiÙÂÚ·, ÙÈÌ‹ Ó·ÙÚ›Ô˘ ÙÔ˘ ÔÚÔ‡ > 155 mEq/L Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ·ӷÌÂÙ·Ìfiۯ‡Ûˆ˜ Î·È ÂÏ·Ùو̤ÓË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜13,37. ∏ ‰ÈfiÚıˆÛË Ù˘ ˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜, ·ÎfiÌË Î·È Ì ηı˘ÛÙ¤ÚËÛË Ù˘ Ï‹„ˆ˜ ÔÚÁ¿ÓˆÓ, ÌˉÂÓ›˙ÂÈ ÙȘ ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜23.
ÃÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ΔÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ ÌÂÛÔÏ·‚› ·fi ÙËÓ ¤ÎÏ˘ÛË ÙÔ˘ ‹·ÙÔ˜ ÛÙÔÓ ‰fiÙË Ì¤¯ÚÈ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÛÙÔÓ Ï‹ÙË (¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜) ¤¯ÂÈ Î·ıÔÚÈÛÙÈ΋ ›وÛË ÛÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÈÛ¯·ÈÌ›· ÌÂÙ·ÙÚ¤ÂÈ ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ Î˘ÙÙ¿ÚˆÓ Û ·Ó·ÂÚfi‚ÈÔ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÍ¿ÓÙÏËÛË ÁÚ‹ÁÔÚ· ÙˆÓ ÂÓÂÚÁÂÈ·ÎÒÓ ·ÔıÂÌ¿ÙˆÓ Û ATP Î·È ÙËÓ ·‡ÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÂÓ˙˘ÌÈÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ Î·È ÙˆÓ ·ÓÙÏÈÒÓ ÂÓÂÚÁËÙÈ΋˜ ÌÂÙ·ÊÔÚ¿˜. ∞˘Ùfi ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚfiÎÏËÛË Ôȉ‹Ì·ÙÔ˜ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ·fi ÙËÓ ÂχıÂÚË ‰›Ô‰Ô ËÏÂÎÙÚÔÏ˘ÙÒÓ Î·È ÓÂÚÔ‡. ∏ ÌÈÙÔ¯ÔÓ‰Úȷ΋ ÏÂÈÙÔ˘ÚÁ›· ·Ó·ÛÙ¤ÏÏÂÙ·È Î·È ÂÌÊ·Ó›˙ÂÙ·È Á·Ï·ÎÙÈ΋ ÔͤˆÛË6 (∂ÈÎfiÓ· 4). ∂ÈϤÔÓ, ·ıÚÔ›˙ÔÓÙ·È ÚÔ˚fiÓÙ· ÙÔ˘ ηٷ‚ÔÏÈÛÌÔ‡ ÙÔ˘ ATP, fiˆ˜ Ë ˘ÔÍ·Óı›ÓË Ô˘ ·ÔÙÂÏ› ˘fiÛÙڈ̷ ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ ηٿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË6. ∏ ·ӷÈÌ¿ÙˆÛË ÌÂÙ¿ ·fi ·Ú·ÙÂٷ̤ÓË „˘¯Ú‹ ÈÛ¯·ÈÌ›· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Â·ÁˆÁ‹ ÏÈȉÈ΋˜ ˘ÂÚÔÍÂȉÒÛˆ˜ Î·È ÙËÓ ·Ó¿Ù˘ÍË ÌÈÎÚÔ΢ÎÏÔÊÔÚȷ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙȉڿÛˆ˜
157
∂ÈÎfiÓ· 4. ∏ ÈÛ¯·ÈÌ›·, ÚÔηÏ› ‰È·ÎÔ‹ Ù˘ ·ÚÔ¯‹˜ Ô͢ÁfiÓÔ˘, ıÚÂÙÈÎÒÓ Û˘ÛÙ·ÙÈÎÒÓ, Û˘ÓÂÓ˙‡ÌˆÓ, ÂÓÒ ·Ó·ÛÙ¤ÏÏÂÈ Î·È ÙËÓ ··ÁˆÁ‹ ÙˆÓ ÙÂÏÈÎÒÓ ÚÔ˚fiÓÙˆÓ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡. Δ· ·ÙÙ·Ú· ÌÂÙ·›ÙÔ˘Ó ·fi ÙÔÓ ·ÂÚfi‚ÈÔ ÛÙÔÓ ·Ó·ÂÚfi‚ÈÔ ÌÂÙ·‚ÔÏÈÛÌfi, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÍ¿ÓÙÏËÛË ÙˆÓ ÂÓÂÚÁÂÈ·ÎÒÓ ÙÔ˘˜ ·ÔıÂÌ¿ÙˆÓ (ÙÒÛË ÂȤ‰ˆÓ ATP ADP), ΢ÙÙ·ÚÈÎfi Ô›‰ËÌ·, ÏfiÁˆ ·Ó·ÛÙÔÏ‹˜ Ù˘ ·ÓÙÏ›·˜ K+-Na+, ÙÒÛË ÙÔ˘ pH, ÏfiÁˆ Ù˘ ·˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ ·fi ÙËÓ ·Ó·ÂÚfi‚È· ÁÏ˘ÎfiÏ˘ÛË, ·‡ÍËÛË ÙˆÓ ÂÓ‰Ô΢ÙÙ·Ú›ˆÓ ÂȤ‰ˆÓ ÙÔ˘ Ca++, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÊˆÛÊÔÏÈ·ÛÒÓ Î·È ‚Ï¿‚Ë Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ·Ó·ÛÙÔÏ‹˜ Ù˘ ÔÍÂȉˆÙÈ΋˜ ʈÛÊÔÚ˘Ï›ˆÛ˘ Î·È ÂÓÂÚÁÔÔ›ËÛ˘ ¿ÏÏˆÓ ÂÓ˙˘ÌÈÎÒÓ Ô‰ÒÓ Ì ‚Ï·ÙÈ΋ ›‰Ú·ÛË ÛÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ΢ÙÙ¿ÚÔ˘.
ÂÓÙfi˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙËÓ ¤ÎÎÚÈÛË ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÔÎÈÓÒÓ, ÂÈÎÔÛ·ÓÔÂȉÒÓ, ÓÈÙÚÈÎÔ‡ ÌÔÓÔÍÂȉ›Ô˘ Î·È ÂÓÂÚÁÔÔ›ËÛË ÚˆÙÂÔÏ˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‚Ï¿‚Ë ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙˆÓ ÎÔψ‰ÒÓ ÙÚȯÔÂȉÒÓ Î·È ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜6,38,39 (∂ÈÎfiÓ· 5). O ·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ·ÔÙÂÏ› ·ÓÂÍ¿ÚÙËÙÔ ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ·Ó¿Ù˘ÍË ‚Ï¿‚˘ Û˘ÓÙËÚ‹Ûˆ˜ Î·È ÂÌÊ¿ÓÈÛË Î·ı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (DGF). O ·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ·˘Í¿ÓÂÈ fi¯È ÌfiÓÔ ÙȘ ¿ÌÂÛ˜ ÂÈÏÔΤ˜, ÏfiÁˆ Ù˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ·ÏÏ¿ Î·È ÙȘ ·ÒÙÂÚ˜ ÂÈÏÔΤ˜ ·fi Ù· ¯ÔÏËÊfiÚ·40. ΔÔ ·Ô‰ÂÎÙfi fiÚÈÔ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ‰fiÙË. ™Â ˘ÁÈ›˜ ‰fiÙ˜, ËÏÈΛ·˜ < 60 ÂÙÒÓ, Ô ·ÛÊ·Ï‹˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Êı¿ÓÂÈ ÙȘ 14-16 ÒÚ˜41. ¶¤Ú· ·fi ÙÔ ÛËÌÂ›Ô ·˘Ùfi ·˘Í¿ÓÂÙ·È ÙÔ ÔÛÔÛÙfi ÚˆÙÔ·ıÔ‡˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÌÂÈÒÓÂÙ·È Ë ÂÈ‚›ˆÛË10,14,41. Δ· Ë·ÙÈο ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ > 60 ÂÙÒÓ Â›Ó·È Ôχ ÂÚÈÛÛfiÙÂÚÔ Â˘·›ÛıËÙ· ÛÙËÓ ‚Ï¿‚Ë Û˘ÓÙËÚ‹Ûˆ˜ Î·È Ô ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 8 ÒÚ˜42.
I. ºOYZA™
158
¢fiÙ˜ ¯ˆÚ›˜ ¿ÏÏÔ˘Û· ηډ›· OÈ ‰fiÙ˜ ¯ˆÚ›˜ ¿ÏÏÔ˘Û· ηډȿ (non-heartbeating donors, ¡HBD) Â›Ó·È Ì›· ȉȷ›ÙÂÚË Î·ÙËÁÔÚ›· و̷ÙÈÎÒÓ ‰ÔÙÒÓ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‹Ïı ηډȷ΋ ·Ó·ÎÔ‹ ÚÈÓ ·fi ÙË Ï‹„Ë ÔÚÁ¿ÓˆÓ43,44 (¶›Ó·Î·˜ 2). ∏ Ï‹„Ë ÙˆÓ ÔÚÁ¿ÓˆÓ Ú¤ÂÈ Ó· Á›ÓÂÈ Ù·¯‡Ù·Ù· ÁÈ· Ó· ÌÂȈıÔ‡Ó ÔÈ Û˘Ó¤ÂȘ Ù˘ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜. ∏ ¤Ú¢ӷ ÛÙÔÓ ÙÔ̤· ·˘Ùfi ηı˘ÛÙÂÚ› ÏfiÁˆ ÙˆÓ ÔÏÏÒÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÂÚÈÙÒÛˆÓ, ÙˆÓ ‰È·ÊˆÓÈÒÓ ÌÂٷ͇ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ ˆ˜ ÚÔ˜ ÙÔÓ ÔÚÈÛÌfi ÙÔ˘ ‰fiÙË ¯ˆÚ›˜ ¿ÏÏÔ˘Û· ηډȿ, ËıÈÎÒÓ Î·È ‰È·‰ÈηÛÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ Î·È ÙˆÓ ÌÂÁ¿ÏˆÓ ÂÂÓ‰‡ÛÂˆÓ Û ÚÔÛˆÈÎfi Î·È Ì¤Û· Ô˘ ··ÈÙÔ‡ÓÙ·È 43,44. À¿Ú¯Ô˘Ó fï˜ ·Ó·ÊÔÚ¤˜ Ô˘ ˘Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ, ÌÂÙ¿ ·fi ÚÔÛÂÎÙÈ΋ ÂÈÏÔÁ‹, Ù· Ë·ÙÈο ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ¯ˆÚ›˜ ¿ÏÏÔ˘Û· ηډȿ ÌÔÚÔ‡Ó Ó· ÚÔÛʤÚÔ˘Ó ·ÔÙÂϤÛÌ·Ù· Ô˘ ÏËÛÈ¿˙Ô˘Ó ÂΛӷ ÙˆÓ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÒÓ ‰ÔÙÒÓ, Ì ·˘ÍË̤ÓÔ, fï˜ ÔÛÔÛÙfi ÚˆÙÔ·ıÔ‡˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜43,44. ∂ÈϤÔÓ, ÈÛÙ‡ÂÙ·È fiÙÈ ÔÈ ‰fiÙ˜ ·˘ÙÔ› ÌÔÚÔ‡Ó Ó· ·˘Í‹ÛÔ˘Ó ÛËÌ·ÓÙÈο ÙÔÓ ·ÚÈıÌfi ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ43.
ÂÎÙÔÌ‹ ÙÌËÌ¿ÙˆÓ ÙÔ˘ ‹·ÙÔ˜ ·fi ˙ÒÓÙ˜ ‹ و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Î·È ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘˜ Û ϋÙ˜, ·È‰È¿ ‹ ÂÓ‹ÏÈΘ. B·Û›˙ÂÙ·È ÛÙË ÏÂÈÙÔ˘ÚÁÈ΋ ·Ó·ÙÔÌÈ΋ ÙÔ˘ ‹·ÙÔ˜ ηٿ Couinaud, Ë ÔÔ›· ÂÈÙÚ¤ÂÈ ÙÔÓ ‰È·¯ˆÚÈÛÌfi ÙÔ˘ Û ÂÈ̤ÚÔ˘˜ ÙÌ‹Ì·Ù·, Ì ·˘ÙfiÓÔÌË ·ÁÁ›ˆÛË Î·È Â·Ú΋ Ì¿˙· Ë·ÙÔ΢ÙÙ¿ÚˆÓ ÁÈ¿ ÙËÓ Î¿Ï˘„Ë ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ó·ÁÎÒÓ ÙfiÛÔ ÙÔ˘ ‰fiÙË fiÛÔ Î·È ÙÔ˘ Ï‹ÙË45 (∂ÈÎfiÓ· 6). ∞Ú¯Èο ·Ó·Ù‡¯ıËÎÂ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË
TÌËÌ·ÙÈο Ë·ÙÈο ÌÔۯ‡̷ٷ H ÙÌËÌ·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È Ì›· Ó¤· ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ Ë ÔÔ›· Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ¶›Ó·Î·˜ 2. ¢fiÙ˜ ¯ˆÚ›˜ ¿ÏÏÔ˘Û· ηډȿ ∫·ÙËÁÔÚ›· 1 2 3 4
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¡ÂÎÚÔ› ηٿ ÙËÓ ¿ÊÈÍË ÛÙÔ Δ∂¶ ∞ÓÂÈÙ˘¯‹˜ ·Ó¿ÓË„Ë ÌÂÙ¿ ∫∞ ™Â ·Ó·ÌÔÓ‹ ∫∞ ∂ÁÎÂÊ·ÏÈο ÓÂÎÚÔ› Ì ∫∞ ÚÈÓ ·fi ÙË Ï‹„Ë ÔÚÁ¿ÓˆÓ
ªË ÂÏÂÁ¯fiÌÂÓÔÈ ªË ÂÏÂÁ¯fiÌÂÓÔÈ ∂ÏÂÁ¯fiÌÂÓÔÈ ªË ÂÏÂÁ¯fiÌÂÓÔÈ
™¿ÓÈÔÈ ™˘¯ÓÔ› §ÈÁfiÙÂÚÔ Û˘¯ÓÔ› ™¿ÓÈÔÈ
∫∞: ηډȷ΋ ·Ó·ÎÔ‹, Δ∂¶: ÙÌ‹Ì· ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÌÂȈ̤ÓÔ˘ ÌÂÁ¤ıÔ˘˜ و̷ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÂÓËÏ›ÎˆÓ Û ·È‰È¿ (reduced-size liver transplantation, RLTx), Ë ÔÔ›· ÂÍÂÏ›¯ıËΠÛÙȘ Ù¯ÓÈΤ˜ ÙÔ˘ ex vivo Î·È ÙÔ˘ in situ ‰È·¯ˆÚÈÛÌÔ‡ ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (split liver transplantation, SLTx), Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ‹·ÙÔ˜ ˙ÒÓÙˆÓ ÂÓËÏ›ÎˆÓ ‰ÔÙÒÓ Û ·È‰È¿ (adult-to-pediatric living donor liver transplantation, pLDLTx) Î·È ÙÂÏÈο Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ‹·ÙÔ˜ ˙ÒÓÙˆÓ ÂÓËÏ›ÎˆÓ ‰ÔÙÒÓ Û ÂÓ‹ÏÈΘ (adult to adult living donor liver transplantation, aLDLTx). OÈ Ù‡ÔÈ ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙȘ ÙÌËÌ·ÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ Â›Ó·È (EÈÎfiÓ· 7): 1. TÔ ‰ÂÍÈfi ‹·Ú (ÙÌ‹Ì·Ù· V-VIII). 2. TÔ ·ÚÈÛÙÂÚfi ‹·Ú (ÙÌ‹Ì·Ù· II-IV), Ì ‹ ¯ˆÚ›˜ ÙÔ ÙÌ‹Ì· I 3. O ·ÚÈÛÙÂÚfi˜ ÏÔ‚fi˜ ‹ ·ÚÈÛÙÂÚfi ¤Íˆ Ï¿ÁÈÔ ÙÌ‹Ì· (ÙÌ‹Ì·Ù· II Î·È III) 4. O ‰ÂÍÈfi˜ ÏÔ‚fi˜ ‹ ‰ÂÍÈfi ÂÎÙÂٷ̤ÓÔ ÌfiÛ¯Â˘Ì· (ÙÌ‹Ì·Ù· I, IV, V-VIII). 5. O ‰ÂÍÈfi˜ Ô›ÛıÈÔ˜ ÙÔ̤·˜ (ÙÌ‹Ì·Ù· VI Î·È VII).
ΤΑΞΙΝΟΜΗΣΗ ΤΜΗΜΑΤΙΚΩΝ ΗΠΑΤΙΚΩΝ ΜΟΣΧΕΥΜΑΤΩΝ Αμερικανική βιβλιογραφία
Ευρωπαϊκή βιβλιογραφία (Couinaud)
ΔΕΞΙΟΣ ΛΟΒΟΣ
ΔΕΞΙΟ ΗΠΑΡ V, VI, VII, VII
ΑΡΙΣΤΕΡΟΣ ΛΟΒΟΣ
ΑΡΙΣΤΕΡΟ ΗΠΑΡ ΙΙ, ΙΙI, ΙV, ± I
ΑΡΙΣΤΕΡΟ ΕΞΩ ΠΛΑΓΙΟ ΤΜΗΜΑ
ΑΡΙΣΤΕΡΟΣ ΛΟΒΟΣ ΙΙ, ΙΙI
ΔΕΞΙΟ ΕΚΤΕΤΑΜΕΝΟ ΜΟΣΧΕΥΜΑ
ΔΕΞΙΟΣ ΛΟΒΟΣ Ι, IV, V, VI, VII, VIII
159
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ‹·ÙÔ˜, ·fi و̷ÙÈÎfi ‹ ˙ÒÓÙ· ‰fiÙË, Û˘Óԉ‡ÂÙ·È ·fi ÌÂȈ̤ÓË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· ÙÔ˘ Ï‹ÙË. ∏ ÂÈÙ˘¯‹˜ ÂÊ·ÚÌÔÁ‹ Ù˘ ÙÌËÌ·ÙÈ΋˜ ÌÂÙ·ÌÔۯ‡Ûˆ˜ ‹·ÙÔ˜ ··ÈÙ› ÙËÓ ·Ú·‰Ô¯‹ fiÙÈ Ù· ÌÔۯ‡̷ٷ ·˘Ù¿ Â›Ó·È ÔÚȷο Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ̛· ÛÂÈÚ¿ ÂȉÈÎÒÓ ÂÈÏÔÎÒÓ, ÏfiÁˆ ·Ó·ÙÔÌÈÎÒÓ ·Ú·ÏÏ·ÁÒÓ Î·È ‰È·Ù·Ú·¯ÒÓ Ù˘ Ê˘ÛÈÔÏÔÁ›·˜ ÙÔ˘ Ï‹ÙË Î·È ÙÔ˘ ‰fiÙË. OÈ ÂÁ¯ÂÈÚËÙÈΤ˜ Ù¯ÓÈΤ˜ Â›Ó·È È‰È·›ÙÂÚ· ‰˘Û¯ÂÚ›˜ ‰ÈfiÙÈ ··ÈÙÂ›Ù·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÚÎÂÙÔ‡ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÁÈ· ÙËÓ Î¿Ï˘„Ë ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ó·ÁÎÒÓ ÙÔ˘ Ï‹ÙË, ÔχÏÔΘ ÌÈÎÚÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ ·ÔηٿÛÙ¿ÛÂȘ ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ ·Ú·ÏÏ·ÁÒÓ ÙˆÓ ·ÁÁ›ˆÓ Î·È ÙˆÓ ¯ÔÏËÊfiÚˆÓ Î·È ÔÚı‹ ÙÔÔı¤ÙËÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÁÈ· Ó· ÂÍ·ÛÊ·ÏÈÛı› Ë ·ÚfiÛÎÔÙË ÚÔ‹ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È Ù˘ ¯ÔÏ‹˜. OÈ Û˘¯ÓfiÙÂÚ˜ ÂÈÏÔΤ˜ ÙˆÓ ÏËÙÒÓ ÙˆÓ ÙÌËÌ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÔÊ›ÏÔÓÙ·È Û ¯ÔÏfiÚÚÔÈ· ·fi ÙËÓ ÂÈÊ¿ÓÂÈ· ‰È·ÙÔÌ‹˜, ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜, Û˘ÌÊfiÚËÛË ·fi ÊÏ‚È΋ ÛÙ¿ÛË, Û‹„Ë ·fi Ó¤ÎÚˆÛË Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Î·È Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÏfiÁˆ ·Ó·ÚÎÔ‡˜ Ë·ÙÈÎÔ‡ fiÁÎÔ˘. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÂȈ̤ÓÔ˘ ÌÂÁ¤ıÔ˘˜ و̷ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (reduced-size liver transplantation, RLTx) ·Ó·Ù‡¯ıËΠ·Ú¯Èο ·fi ÙÔ˘˜ Bismuth45 and Broelsch46 ÁÈ· Ó· ·ÓÙÈÌÂÙˆÈÛı› Ë ¤ÏÏÂÈ„Ë ·È‰È·ÙÚÈÎÒÓ ÙˆÌ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ô˘ ¤ÊÂÚ ˘„ËÏ‹ ıÓËÙfiÙËÙ· ÛÙȘ Ï›ÛÙ˜ ·Ó·ÌÔÓ‹˜ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ (>40%). OÈ ·Ú¯ÈΤ˜ ÚÔÛ¿ıÂȘ ·ÚÔ˘Û›·Û·Ó ÔÏϤ˜ ÂÈÏÔΤ˜ ·ÏÏ¿ ÔÈ ÌÂÙ¤ÂÈÙ· ÛÂÈÚ¤˜ ›¯·Ó ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·47-49. ∏ ̤ıÔ‰Ô˜ ¤¯ÂÈ Û¯Â‰fiÓ ÂÁηٷÏÂÈÊı› ‰ÈfiÙÈ ÙÔ ı˘ÛÈ¿˙ÂÈ ÙÔ ‹ÌÈÛ˘ ÙÔ˘ ‹·ÙÔ˜ Î·È ‰ÂÓ ·˘Í¿ÓÂÈ ÙË ‰ÂÍ·ÌÂÓ‹ ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ50,51. ∏ Ù¯ÓÈ΋ ÙÔ˘ Ë·ÙÈÎÔ‡ ‰È·¯ˆÚÈÛÌÔ‡ (split liver transplantation, SLTx) ·ÔÛÎÔ› ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰‡Ô ÏËÙˆÓ Î·È ıˆÚËÙÈο ÌÔÚ› Ó· ·˘Í‹ÛÂÈ ÛËÌ·ÓÙÈο ÙËÓ ‰ÂÍ·ÌÂÓ‹ ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ̤ıÔ‰Ô˜ ¢ڛÛÎÂÙ·È ˘fi ÂͤÏÈÍË, ÂÓÒ ÔÈ ÔÏϤ˜ Ù¯ÓÈΤ˜ Î·È ÔÚÁ·ÓˆÙÈΤ˜ ‰˘ÛÎÔϛ˜ ‰ÂÓ ¤¯Ô˘Ó ÂÈÙÚ¤„ÂÈ ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ Û ¢Ú›· Îϛ̷η. OÈ ÚÒÙ˜ ÌÂÁ¿Ï˜ ÛÂÈÚ¤˜ ·fi ÙÔ King’s College, ÙÔ UCLA Î·È Ù· πÙ·ÏÈο ΤÓÙÚ· ‰Â›¯ÓÔ˘Ó fiÙÈ fiÙ·Ó Ë SLTx ÂÊ·ÚÌfi˙ÂÙ·È Ì ·˘ÛÙËÚ‹ ÂÈÏÔÁ‹ ÙˆÓ ‰ÔÙÒÓ Î·È ÙˆÓ ÏËÙÒÓ ¤¯ÂÈ Û˘ÁÎÚ›ÛÈÌ· ·ÔÙÂϤÛÌ·Ù· Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ‹·ÙÔ˜52-55.
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∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·Ô ˙ÒÓÙ˜ ‰fiÙ˜ (living donor liver transplantation, LDLTx) ‰È·‰›‰ÂÙ·È ÚÔԉ¢ÙÈο ÛÙȘ ∏¶∞ Î·È ÙËÓ ∂˘ÚÒË, ÂÓÒ ·ÔÙÂÏ› ÙÔÓ Î·ÓfiÓ· ÛÙȘ ¯ÒÚ˜ Ù˘ ∞ˆ ∞Ó·ÙÔÏ‹˜, ÏfiÁˆ ÌË ·Ô‰Ô¯‹˜ ·fi ÙËÓ ÎÔÈÓˆÓ›· Ù˘ ·Ú¯‹˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘. ¶ÏÂÔÓÂÎÙ‹Ì·Ù· Ù˘ LDLTx Â›Ó·È Ô ÌÈÎÚfi˜ ¯ÚfiÓÔ˜ ·Ó·ÌÔÓ‹˜, Ô Û¯Â‰È·ÛÌfi˜ Ù˘ ÂÂÌ‚¿Ûˆ˜ Ô˘ ÂÈÙÚ¤ÂÈ ÙËÓ ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ Ï‹ÙË Î·È Ë Ï‹„Ë ÌÔۯ‡̷ÙÔ˜ ·fi ˘ÁÈ‹ ‰fiÙË Ì ÂÏ¿¯ÈÛÙÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜56. ªÂÈÔÓÂÎÙ‹Ì·Ù· ıˆÚÔ‡ÓÙ·È Ë Ï‹„Ë ÌÈÎÚÔÙ¤ÚÔ˘ ÌÔۯ‡̷ÙÔ˜, ÙÔ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÏÔÎÒÓ ÛÙÔÓ Ï‹ÙË Î·È Ë ¤ÎıÂÛË ÙÔ˘ ‰fiÙË ÛÙÔÓ Î›Ó‰˘ÓÔ Ù˘ Ë·ÙÂÎÙÔÌ‹˜. Δ· ·ÔÙÂϤÛÌ·Ù· Ù˘ LDLTx Â›Ó·È Î·ÙÒÙÂÚ· ·fi ÂΛӷ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÔÏÈÎÔ‡ ‹·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì Ôχ ‚·ÚÂÈ¿ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·.
ªÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì ˷ٛÙȉ· ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi anti-HBc{+) ‰fiÙË Û anti-HBc(-) ‰¤ÎÙË Û˘Û¯ÂÙ›˙ÂÙ·È Ì Ïԛ̈ÍË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ μ Û ÔÛÔÛÙfi 35-80%, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ‰fiÙË, ÙÔÓ ÂÈÔÏ·ÛÌfi Ù˘ ∏μV Ïԛ̈͢ ÛÙË ¯ÒÚ· ÙÔ˘ ‰fiÙË Î·È ¿ÏÏÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∏ ¯oÚ‹ÁËÛË Ï·ÌÈ‚Ô˘‰›Ó˘ Î·È n Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ HBsAg (HBIG) ÌˉÂÓ›˙ÂÈ ÙÔ ÔÛÔÛÙfi Ïԛ̈͢ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔÈÔ˘ÙÔÙÚfiˆ˜ ÂÍ·ÛÊ·Ï›˙ÂÈ ÙËÓ ·ÍÈÔÔ›ËÛË ·˘ÙÒÓ ÙˆÓ ‰ÔÙÒÓ57. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi antiHCV(+) ‰fiÙ˜ ¤¯ÂÈ ı¤ÛË ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓÒÓ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ HCV ΛÚÚˆÛË. ªÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ n ˘oÙÚo‹ Ù˘ ÓfiÛÔ˘ Î·È n ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ ‰È·Ê¤ÚÂl ÌÂٷ͇ ·ÛıÂÓÒÓ Ô˘ ¤Ï·‚·Ó ÌÔۯ‡̷ٷ ·Ô anti_HCV (+) Î·È anti-HCV(-) ‰fiÙ˜57.
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2
E˘ÛÙ¿ıÈÔ˜ AÓÙˆÓ›Ô˘
ÂÈχÛÔ˘Ó. ¶ÈÔ Û˘¯Ó¿ Î·È ÈÔ Û‡ÓıÂÙ· Â›Ó·È Ù· ÚÔ‚Ï‹Ì·Ù· Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ì Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, Ô˘ ÚfiÎÂÈÙ·È Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ¶ÔÈÔ‡˜ fï˜ ıˆÚԇ̠·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘; ∂ÈÓ·È Û˘Ó‹ıˆ˜ ·ÛıÂÓ›˜ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·, Û˘¯Ó¿ Ì ڋÍË Ù˘ ·ÓÙÈÚÚfiËÛ˘ Î·È Û˘ÓÔ‰¿ ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ Û˘¯Ó¤˜ ‚·ÚÂȤ˜ ÂÁÎÂÊ·ÏÔ¿ıÂȘ, Û˘¯Ó¤˜ ÎÈÚÛÔÚÚ·Á›Â˜ ÔÈÛÔÊ¿ÁÔ˘, ·ÚÔ˘Û›· Ë·ÙÔÓÂÊÚÈÎÔ‡ ‹ Ë·ÙÔÓ¢ÌÔÓÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ıÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ ‹ ÎÏ¿‰Ô˘ ·˘Ù‹˜, ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 65 ÂÙÒÓ, ·ÚÔ˘Û›· ∏∫∫ ‹/Î·È Û‡Á¯ÚÔÓ˘ ηÎÔ‹ıÂÈ·˜, Î·È ¿ÏÏ·. °È· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ˘Ô„ËÊ›ˆÓ ·ÛıÂÓÒÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ηıÒ˜ Î·È ÁÈ· ÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· ÙÔ˘˜ ÙfiÛÔ ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÛÙËÓ Ï›ÛÙ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÏÏ¿ Î·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·˘Ù‹ ηı·˘Ù‹, ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ‰È¿ÊÔÚ· ÌÔÓ٤Ϸ. ΔÔ Û˘ÓËı¤ÛÙÂÚÔ ÌÔÓÙ¤ÏÔ ·ÍÈÔÏfiÁËÛ˘ ÙÒÓ ˘Ô„ËÊ›ˆÓ ·ÛıÂÓÒÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ÁÈ· Ù· ÂÚÈÛÛfiÙÂÚ· ÌÂÙÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ‹·ÙÔ˜ ·Ó· ÙÔÓ ÎfiÛÌÔ, ‹Ù·Ó ÙÔ ChildTurcotte-Pugh (CTP) Û‡ÛÙËÌ· ÁÈ· ¿Ú· ÔÏÏ¿ ¯ÚfiÓÈ·. ΔÔ Û‡ÛÙËÌ· Ù·ÍÈÓfiÌËÛ˘ ÙˆÓ Child Î·È Turcotte, ‰ËÌÔÛȇıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1964, Î·È Â›¯Â Á›ÓÂÈ Ë Î‡ÚÈ· ̤ıÔ‰Ô˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÚfiÁÓˆÛ˘ ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ. OÈ Û˘ÁÁÚ·Ê›˜ Ù·ÍÈÓÔÌÔ‡Û·Ó ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û ÂÁ¯Â›ÚËÛË ˘Ï·ÈÔ-Û˘ÛÙÂÌÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜ ÁÈ· ·Ó·ÎÔ‡ÊÈÛË Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ ·Ó¿ÏÔÁ· Ì ÙË ÛÔ‚·ÚfiÙËÙ· ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÙÔ˘˜. ∏ ÂÈÏÔÁ‹ ÙˆÓ ¤ÓÙ ·Ú·Ì¤ÙÚˆÓ ¤ÁÈÓ ÂÌÂÈÚÈο (ÏÂ˘ÎˆÌ·Ù›ÓË ÔÚÔ‡, ¯ÔÏÂÚ˘ıÚ›ÓË ÔÚÔ‡, ·ÚÔ˘Û›· ·ÛΛÙË, ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Î·È Â›Â‰Ô ıÚ¤„˘) ‚¿ÛÂÈ ‰Â ÙˆÓ ÔÔ›ˆÓ ÔÈ ·ÛıÂÓ›˜ ηٷ¯ˆÚÔ‡ÓÙ·Ó Û ¤Ó· ·fi Ù· ÙÚ›· ›‰· ÎÈÓ‰‡ÓÔ˘, ·ÏÔÔÈÒÓÙ·˜ ¤ÙÛÈ ÙÔ Û‡ÓıÂÙÔ Úfi‚ÏËÌ· Ù˘ ÚfiÁÓˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ΔÔ Úfi‚ÏËÌ· ‹Ù·Ó fiÙÈ ÔÈ ÙÚÂȘ ·fi
™ÙȘ 23 πÔ˘Ï›Ô˘ 1967, Ô Starzl Î·È Û˘Ó., ÛÙÔ Pittsburgh ÙˆÓ ∏¶∞, ÂÈÙ˘Á¯¿ÓÔ˘Ó ÙËÓ ÚÒÙË ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (Oª∏) Û ¿ÓıÚˆÔ, Ì ·Ú·ÙÂٷ̤ÓË ÂÈ‚›ˆÛË. ∂›¯·Ó ÚÔËÁËı› ·ÔÙ˘¯Ë̤Ó˜ ÚÔÛ¿ıÂȘ Oª∏ Û ¿ÓıÚˆÔ, ÙfiÛÔ ·fi ÙÔÓ ›‰ÈÔ fiÛÔ Î·È ·fi ¿ÏÏ· ‰‡Ô ΤÓÙÚ· –μÔÛÙÒÓ˘ Î·È ¶·ÚÈÛÈÔ‡–, ‹‰Ë ·fi ÙÔ ·fi ÙÔ 1963. ¶·Ú’ fiϘ ÙȘ Ù¯ÓÈΤ˜ ‚ÂÏÙÈÒÛÂȘ Û ÂÈÚ·Ì·ÙÈÎfi Â›Â‰Ô Î·È ÙȘ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ô˘ ›¯·Ó ·Ó·Ù‡ÍÂÈ Ù· ÙÚ›· ·˘Ù¿ ΤÓÙÚ· ¯ˆÚÈÛÙ¿, ηıÒ˜ Î·È ·ÚÎÂÙ¿ ¿ÏÏ· ΤÓÙÚ· ηÙfiÈÓ, ‚Ô‹ıËÛ·Ó Ó· ˘¿ÚÍÂÈ ÌfiÓÔ ÌÈ· ÌÈÎÚ‹ ‚ÂÏÙ›ˆÛË ÙfiÛÔ ÛÙËÓ ÂÈ‚›ˆÛË fiÛÔ Î·È ÛÙÔÓ ·ÚÈıÌfi ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ Ì ‹·Ú. ª¤¯ÚÈ ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’80, Ë ÎÏÈÓÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·Ú¤ÌÂÓ ·ÎfiÌË Û ÂÚ¢ÓËÙÈο ›‰· Î·È ÌfiÓÔ Û¯ÂÙÈο ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ Â›¯Â ÌÂÙ·ÌÔÛ¯Â˘ı›. ªÂ ÙË Û˘Ó¯‹ ÚÔÛ¿ıÂÈ· Î·È ÙËÓ ·‡ÍËÛË Ù˘ ÂÌÂÈÚ›·˜ Î·È ÙˆÓ ÈηÓÔÙ‹ÙˆÓ ÙˆÓ ÔÌ¿‰ˆÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·Ó Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ÙË ÊÚÔÓÙ›‰· Î·È ÙË ‰È·ıÂÛÈÌfiÙËÙ· ÙˆÓ ‰ÔÙÒÓ, ÙËÓ ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ‰È·Ù‹ÚËÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÙˆÓ Î·Ï‡ÙÂÚˆÓ ÂÁ¯ÂÈÚËÙÈÎÒÓ Î·È ·Ó·ÈÛıËÙÈÎÒÓ Ù¯ÓÈÎÒÓ, Ù˘ ‚ÂÏÙ›ˆÛ˘ Ù˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È Ù˘ ÈηÓfiÙËÙ·˜ ÁÈ· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·ÓÔÛÔηٷÛÙÔÏ‹, Ù· ·ÔÙÂϤÛÌ·Ù· ¿Ú¯ÈÛ·Ó Ó· ‚ÂÏÙÈÒÓÔÓÙ·È Î·È Ó· ·˘Í¿ÓÂÙ·È Ù·¯‡Ù·Ù· ÙfiÛÔ Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ fiÛÔ Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ, ·ÁÎÔÛÌ›ˆ˜. Δ· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÙÒÚ· È·, ·Ó·Ê¤ÚÔ˘Ó ÚÒÙÔ ¯ÚfiÓÔ ÂÈ‚›ˆÛ˘ Û ϋÙ˜ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 90%, Û ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ Î·È 75-83% ¤ÓÙ ¯ÚfiÓÈ· ÂÈ‚›ˆÛ˘. ¶·ÚfiϘ ·˘Ù¤˜ ÙȘ ÚÔfi‰Ô˘˜, ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù· ˘¿Ú¯Ô˘Ó Î·È ÔÈ ÁÈ·ÙÚÔ› Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û˘¯Ó¿ ‚Ú›ÛÎÔÓÙ·È ·ÓÙÈ̤وÔÈ Ì ·˘Ù¿ Î·È Î·ÏÔ‡ÓÙ·È Ó· Ó· Ù·
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E. ANTøNIOY
·˘ÙÔ‡˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ (·ÛΛÙ˘, ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Î·È ıÚ¤„Ë) ‹Ù·Ó Ôχ ˘ÔÎÂÈÌÂÓÈÎÔ›. ΔÔ 1972 Ô Pugh ÙÚÔÔÔ›ËÛ ÙËÓ Child-Turcotte Ù·ÍÈÓfiÌËÛË ÁÈ· Ó· ·ÔÎÙ‹ÛÂÈ ¤Ó· ÂÚÁ·ÏÂ›Ô Ô˘ ı· ÙÔ˘ ¤‰ÈÓ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ÚԂϤ„ÂÈ Î·Ï‡ÙÂÚ· Ù· ·ÔÙÂϤÛÌ·Ù· ÌÂÙ¿ ·fi ÂÁ¯Â›ÚËÛË ˘Ï·ÈÔ-Û˘ÛÙÂÌÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜. O Pugh ·ÓÙÈη٤ÛÙËÛ ÙÔ Â›Â‰Ô ıÚ¤„˘ Ì ÙÔ ¯ÚfiÓÔ ÚÔıÚÔÌ‚›Ó˘, ·Ú·Î¿ÌÙÔÓÙ·˜ ¤ÙÛÈ ÙÔÓ ÈÔ ˘ÔÎÂÈÌÂÓÈÎfi ·Ú¿ÁÔÓÙ·. ∞Ó Î·È Ë ·Ú¯ÈÎfi˜ ÛÎÔfi˜ ÙÔ˘ CTP Û˘ÛÙ‹Ì·ÙÔ˜ Ù·ÍÈÓfiÌËÛ˘, fiˆ˜ ·Ó·Ê¤ÚıËÎÂ, ‹Ù·Ó Ë ÂÎÙ›ÌËÛË ÙÔ˘ ÂÁ¯ÂÈÚËÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Û ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û ˘Ï·ÈÔ-Û˘ÛÙÂÌÈ΋ ÂÈÎÔÈÓˆÓ›·, Ë Ù·ÍÈÓfiÌËÛË ·˘Ù‹ ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ Ù·ÍÈÓfiÌËÛË ·ÛıÂÓÒÓ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ¶·ÚfiÏÔ, Ô˘ ÙÔ Û‡ÛÙËÌ· ·˘Ùfi Ù˘ Ù·ÍÈÓfiÌËÛ˘ ‰ÂÓ ¤¯ÂÈ ÔÙ¤ ·ÍÈÔÏÔÁËı› ›ÛËÌ· ÁÈ· ÙËÓ ÛÙ·ÙÈÛÙÈ΋ ÙÔ˘ ·ÎÚ›‚ÂÈ·, ¤¯ÂÈ Ê·Ó› Ó· Â›Ó·È ¯Ú‹ÛÈÌÔ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÚfiÁÓˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ì ΛÚÚˆÛË ÙÔ˘ ‹·ÙÔ˜. ŸÙ·Ó fï˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Û·Ó ‰Â›ÎÙ˘ ‚·Ú‡ÙËÙ·˜ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·Ó·‰Â›ÍÂÈ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È Ó· ηıÔÚ›ÛÂÈ ÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÙÔ CTP Û‡ÛÙËÌ· Ê¿ÓËΠӷ ¤¯ÂÈ ÂÚÈÔÚÈÛÌÔ‡˜ ˆ˜ ÚÔ˜ ÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÙÔ˘. °È· ÙÔ ÏfiÁÔ ·˘Ùfi ˘‹ÚÍ·Ó ÚÔÛ¿ıÂȘ ·Ó‡ÚÂÛ˘ ηχÙÂÚÔ˘ Î·È ÈÔ ·ÍÈfiÈÛÙÔ˘ ÌÔÓÙ¤ÏÔ˘ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÚfiÎÂÈÙÔ Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ŒÙÛÈ, ÙÔ 1999, Û ·ÓÙ·fiÎÚÈÛË ÙˆÓ Î·Ù¢ı˘ÓÙ‹ÚÈˆÓ ÁÚ·ÌÌÒÓ ÙÔ˘ Department of Health and Human Services Î·È ÙÔ˘ Institute of Medicine (IOM), Ë UNOS (United Network for Organ Sharing) ÚfiÙÂÈÓ ÙËÓ ·ÏÏ·Á‹ ÙˆÓ Î·ÓfiÓˆÓ Ô˘ ‰È¤Ô˘Ó ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÔÚÁ¿ÓˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ. OÈ Ó¤ÔÈ Î·ÓfiÓ˜ ÚÔÙ›ÓÔ˘Ó Ó· ·ÓÙÈηٷÛÙ·ı› Ë Child-Turcotte-Pugh ηٿٷÍË ˆ˜ Ë ‚¿ÛË ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ›ÁÔÓÙÔ˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Ì ¤Ó· Û‡ÛÙËÌ· ‚·ıÌÔÏfiÁËÛ˘ Ô˘ ·Ó·Ù‡¯ıËΠ·fi ÙË Mayo Clinic, ÙÔ Model for End-Stage Liver Disease (MELD). ΔÈ Â›Ó·È ÙÔ MELD; ΔÔ MELD Û‡ÛÙËÌ· ‚·ıÌÔÏfiÁËÛ˘, fiˆ˜ Ë Î·Ù¿ Child-Pugh ηٿٷÍË, ۯ‰ȿÛÙËΠÁÈ· Ó· ÚԂϤ„ÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û ·ÔÛ˘ÌÊÔÚËÙÈ΋ ıÂڷ›·
ÁÈ· ˘Ï·›· ˘¤ÚÙ·ÛË. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ ÁÈ· ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û ‰È·ÛÊ·ÁÈÙȉÈ΋ ÂÓ‰ÔË·ÙÈ΋ ˘Ï·ÈÔÛ˘ÛÙÂÌÈ΋ ÂÈÎÔÈÓˆÓ›· [transjugular intrahepatic portosystemic shunt (TIPS)], ÌÈ· ÔÌ¿‰· ·ÛıÂÓÒÓ Ì ¢ڇ Ê¿ÛÌ· ÛÔ‚·ÚfiÙËÙ·˜ Î·È ·ÈÙÈÔÏÔÁ›·˜ ·ÛıÂÓÂÈÒÓ. ∏ ‰È·ÊÔÚ¿ Â›Ó·È fiÙÈ ÙÔ MELD ÚÔÂÚ¯fiÙ·Ó ·fi ÚÔÔÙÈο Û˘ÏÏÂÁfiÌÂÓ· ‰Â‰Ô̤ӷ ·ÓÙ› ÙˆÓ ÂÌÂÈÚÈο ηٷÛ΢·ÛÌ¤ÓˆÓ ‰Â‰Ô̤ӈÓ. O ˘ÔÏÔÁÈÛÌfi˜ Ù˘ ‚·ıÌÔÏfiÁËÛ˘ MELD ‚·Û›˙ÂÙ·È ÛÙËÓ ¯ÔÏÂÚ˘ıÚ›ÓË ÙÔ˘ ÔÚÔ‡, ÛÙÔ ¯ÚfiÓÔ ÚÔıÚÔÌ‚›Ó˘ ˘ÔÏÔÁÈ˙fiÌÂÓÔ Û·Ó INR (International Normalized Ratio) Î·È ÛÙËÓ ÎÚ·ÙÈÓ›ÓË ÙÔ˘ ÔÚÔ‡. ∏ ‚·ıÌÔÏfiÁËÛË MELD ¤¯ÂÈ ÏÂÔÓÂÎÙ‹Ì·Ù· fiÙ·Ó Û˘ÁÎÚ›ÓÂÙ·È Ì ÙËÓ Child-Pugh ηٿٷÍË. ∫·Ù’ ·Ú¯‹Ó ¯ÚËÛÈÌÔÔÈ› ·ÓÙÈÎÂÈÌÂÓÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, ‰Â‡ÙÂÚÔ ÔÈ ·ÓÙÈÎÂÈÌÂÓÈΤ˜ ·Ú¿ÌÂÙÚÔÈ ÂËÚ¿˙ÔÓÙ·È ÏÈÁfiÙÂÚÔ ·fi ΤÓÙÚÔ Û ΤÓÙÚÔ ·fi fiÙÈ Ë Î·Ù¿Ù·ÍË Î·Ù¿ Child Î·È ÙÚ›ÙÔÓ, Ë ‚·ıÌÔÏfiÁËÛË MELD ·˘Í¿ÓÂÈ Î·ıÒ˜ ÔÈ Û˘ÛÙ·ÙÈÎÔ› ·Ú¿ÌÂÙÚÔÈ ¯ÂÈÚÔÙÂÚ‡ԢÓ, ÂÓÒ Ù· ȉȷ›ÙÂÚ· ÛÙÔȯ›· ·ÍÈÔÏfiÁËÛ˘ ÛÙË Child-Pugh ηٿٷÍË ·Ú·Ì¤ÓÔ˘Ó ÛÙ·ıÂÚ¿ ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ¤¯Ô˘Ó ÊÙ¿ÛÂÈ Û οÔÈÔ Î·ıÔÚÈṲ̂ÓÔ Â›Â‰Ô. ΔÔ MELD Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ Â›Ó·È ÂÏ·ÊÚ¿ ·ÏÏ·Á̤ÓÔ ·fi ÙÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ ÎÈÓ‰‡ÓÔ˘ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·Ú¯Èο ÁÈ· ÙÔ TIPS ÌÔÓÙ¤ÏÔ. °È· ¢ÎÔÏfiÙÂÚË ¯Ú‹ÛË Ë ÙÂÏÈ΋ ‚·ıÌÔÏfiÁËÛË ÔÏÏ·Ï·ÛÈ·˙fiÙ·Ó Â› 10 Î·È ÛÙÚÔÁÁ˘Ï¢fiÙ·Ó ÚÔ˜ ÙÔÓ ÏËÛȤÛÙÂÚÔ ·Î¤Ú·ÈÔ ·ÚÈıÌfi. ŒÙÛÈ Ô Ù‡Ô˜ ÛÙË MELD ‚·ıÌÔÏfiÁËÛË Â›Ó·È: 3,8 ÙÈÌ‹ ¯ÔÏÂÚ˘ıÚ›Ó˘ (mg/dl) + 11,2 ÙÈÌ‹ INR + 9,6 ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ (mg/dl) + 6,4 (·ÈÙÈÔÏÔÁ›·: 0 Â¿Ó Â›Ó·È ¯ÔÏÔÛÙ·ÙÈ΋ ‹ ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ‹ 1 ÏÔÈ‹˜ ·ÈÙÈÔÏÔÁ›·˜). O Ù‡Ô˜ ·˘Ùfi˜ ÌÔÚ› Ó· ˘ÔÏÔÁ›ÛÂÈ ÙË Û˘¯ÓfiÙËÙ· ıÓËÙfiÙËÙ·˜ ÁÈ· ÙÔ˘˜ ÂfiÌÂÓÔ˘˜ ÙÚÂȘ Ì‹Ó˜. ΔÔ score Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 6 - 40, Ì ÙÔ 40 Ó· ˘Ô‰ÂÈÎÓ‡ÂÈ ·ÛıÂÓ›˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÚÔı·Ó·ÙÈ·›· ηٿÛÙ·ÛË. ΔÔ Û‡ÛÙËÌ· ·˘Ùfi, ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·fi ÙÔ 2002 ÛÙȘ ∏¶∞, Î·È ¤¯ÂÈ ÂÏ·ÙÙˆı› ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¤ı·ÈÓ·Ó ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, ÔÈ ·ÛıÂÓ›˜ Ì ∏∫∫, Â›Ó·È ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ¿Û¯ÂÙ· ·Ó Ë ÎÏÈÓÈ΋ ÙÔ˘˜ ÂÈÎfiÓ· ÔÏϤ˜ ÊÔÚ¤˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙ÂÈ ÙËÓ Ú·ÁÌ·ÙÈ΋ ηٿÛÙ·ÛË. ŒÙÛÈ ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ ¢ÓÔËıÔ‡ÓÙ·È È‰È·›ÙÂÚ· ·fi ÙÔ Û‡ÛÙËÌ· ·˘Ùfi ·ÍÈÔÏfiÁËÛ˘, ηıÒ˜ Ï·Ì‚¿ÓÔ˘Ó ÌfiÚÈ· ·ÓÂÍ¿ÚÙËÙ· Ù˘ Ú·ÁÌ·ÙÈ΋˜ ‚·ıÌÔÏfiÁËÛ˘. ™Â ·ÛıÂÓ›˜ Ì ÛÙ·‰›Ô˘ Δ1 ∏∫∫ ‰›‰ÂÙ·È Ì›·
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
‚·ıÌÔÏfiÁËÛË MELD= 24, ÂÓÒ ÁÈ· ÛÙ·‰›Ô˘ Δ2 ∏∫∫ ‰›‰ÂÙ·È Ì›· ‚·ıÌÔÏfiÁËÛË MELD= 29. ŒÙÛÈ ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÙËÓ ‰˘Ó·ÙfiÙËÙ· Ó· ÌÂÙ·ÌÔÛ¯Â˘ÙÔ‡Ó ÓˆÚ›ÙÂÚ·, Î·È Ó· ÂÏ·ÙÙÒÓÂÙ·È ¤ÙÛÈ ÙÔ ÔÛÔÛÙfi ı·Ó¿ÙÔ˘ ÛÙÔ˘˜ ÂfiÌÂÓÔ˘˜ 3 ‹ 6 Ì‹Ó˜ ·Ó·ÌÔÓ‹˜ ÛÙËÓ Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. O Kamath Î·È ÔÈ Û˘Ó. ·ÚÔ˘Û›·Û·Ó ÌÈ· ÌÂϤÙË ÙÔ 2001, fiÔ˘ ÂÚ¢ÓÔ‡Û·Ó Ù¤ÛÛÂÚȘ ·ÓÂÍ¿ÚÙËÙ˜ ÔÌ¿‰Â˜ Ë·ÙÔ·ıÒÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË: (1) ÂÓ‰ÔÓÔÛÔÎÔÌÂÈ·ÎÔ› ·ÛıÂÓ›˜ Ì ÚÔ¯ˆÚË̤ÓË Ë·ÙÈ΋ ÓfiÛÔ, (2) ÂÚÈ·ÙËÙÈÎÔ› ·ÛıÂÓ›˜ Ì ÌË ¯ÔÏÔÛÙ·ÙÈ΋ ΛÚÚˆÛË, (3) ·ÛıÂÓ›˜ Ì ڈÙÔ·ı‹ ¯ÔÏÈ΋ ΛÚÚˆÛË, Î·È (4) ÌË ÂÈÏÂÁ̤ÓÔÈ ·ÛıÂÓ›˜ Ì ˷ÙÈ΋ ΛÚÚˆÛË ·fi ÙËÓ ‰ÂηÂÙ›· ÙÔ˘ ’80. μÚ‹Î·Ó fiÙÈ ÙÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ MELD ‹Ù·Ó ¯Ú‹ÛÈÌÔ ÛÙËÓ Î·Ù¿Ù·ÍË ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ Û ۯ¤ÛË ÚÔ˜ ÙÔÓ ı¿Ó·ÙÔ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ, ÂÌÊ·ÓÈ˙fiÌÂÓÔ ÙÚÂȘ ÊÔÚ¤˜ ÈÔ Û¯ÂÙÈÎfi Ì ÙËÓ ·fiÊ·ÛË Ô˘ ·ÈÚÓfiÙ·Ó ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË (Û 1 ‚‰ÔÌ¿‰·, 3 Ì‹Ó˜ Î·È 1 ¯ÚfiÓÔ). ◊Ù·Ó Ë ÚÒÙË ÊÔÚ¿ Ô˘ ÁÈÓfiÙ·Ó ·Ó·ÊÔÚ¿ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ MELD ÁÈ· ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÔ‡˜ ·ÛıÂÓ›˜. OÈ Û˘ÁÁÚ·Ê›˜ η٤ÏËÁ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ ÙÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ MELD Â›Ó·È ·ÍÈfiÈÛÙÔ ÌÂÙÚÒÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ ıÓËÙfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ Î·È Î·Ù¿ÏÏËÏÔ Ó· ¯ÚËÛÈÌÔÔÈËı› Û·Ó ‰Â›ÎÙ˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘, ÚÔÎÂÈ̤ÓÔ˘ Ó· ηıÔÚ›ÛÂÈ ÙȘ ÚÔÙÂÚ·ÈfiÙËÙ˜ ÁÈ· ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÔÚÁ¿ÓˆÓ. ΔÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ MELD Ê·›ÓÂÙ·È Ó· ÂËÚ·˙fiÙ·Ó ÂÏ¿¯ÈÛÙ·, ˆ˜ ÚÔ˜ ÙËÓ ÈηÓfiÙËÙ· Úfi‚Ï„˘, ·fi ÌÂÌÔӈ̤Ó˜ ÂÈÏÔΤ˜ ·fi ÙËÓ ˘Ï·›· ˘¤ÚÙ·ÛË. O Kamath ›Û˘ ·¤‰ÂÈÍ fiÙÈ Ë ÚfiÛıÂÛË ÎÏÈÓÈÎÒÓ Ê·ÈÓÔÌ¤ÓˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, fiˆ˜ Ô ·ÛΛÙ˘, Ë ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ë ÎÈÚÛÔÚÚ·Á›· ‹ ·˘ÙfiÌ·ÙË ‚·ÎÙËÚȉȷ΋ ÂÚÈÙÔÓ›Ùȉ·, ÛÙÔ MELD Û‡ÛÙËÌ·, ‰ÂÓ ‚ÂÏÙ›ˆÓ ÙËÓ ·ÎÚ›‚ÂÈ· ÙÔ˘ ÌÔÓÙ¤ÏÔ˘. ∞˘Ùfi ‰Â›¯ÓÂÈ fiÙÈ ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ Ë·ÙÈ΋ ÓfiÛÔ Â›Ó·È ÈÔ Èı·Ófi Ó· ÂÌÊ·Ó›ÛÔ˘Ó ÂÈÏÔΤ˜ ÏfiÁˆ Ù˘ ÓfiÛÔ˘ ÙÔ˘˜ Î·È ¤ÙÛÈ, ÔÈ ÂÈÏÔΤ˜ ‰ÂÓ Â›Ó·È ·ÓÂÍ¿ÚÙËÙÔÈ ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÂÈ‚›ˆÛ˘. ∂›Û˘, Ë Û˘ÌÂÚ›ÏË„Ë Â˘Ú¤ˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ Î·ÙËÁÔÚÈÒÓ, fiˆ˜ Ë ¯ÔÏÔÛÙ·ÙÈ΋ ‹ ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ¤Ó·ÓÙÈ ÙˆÓ ˘ÔÏÔ›ˆÓ, ÔÈ Ôԛ˜ ›¯·Ó ·Ú¯Èο Û˘ÌÂÚÈÏËÊı›, ‰ÂÓ Ê¿ÓËΠ··Ú·›ÙËÙÔ. ΔÔ ÙÂÏÈÎfi ÛËÌÂ›Ô ‹Ù·Ó fiÙÈ ÙÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ MELD ı· ÌÔÚÔ‡Û ӷ ÂÊ·ÚÌÔÛı› Û οı ÏËı˘ÛÌfi Ô˘ ÂÚ›ÌÂÓ ÌÂÙ·-
165
ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. μÏ¤Ô˘Ì ÏÔÈfiÓ fiÙÈ Ù· ÂÚÈÛÛfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Ô˘ ηıÈÛÙÔ‡Ó ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ˆ˜ ÚÔ˜ ÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· Ô˘ ÙÔ˘˜ ‰›ÓÂÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Ì ÙÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ MELD. À¿Ú¯Ô˘Ó fï˜ ÂÚÈÔÚÈÛÌÔ› ÛÙÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ MELD; 1. Δ· ÂÚÈÛÛfiÙÂÚ· ‰È·ı¤ÛÈÌ· ‰Â‰Ô̤ӷ ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ÂÊ‹ÚÌÔÛ·Ó ÙÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ MELD, ‹Ù·Ó ΢ڛˆ˜ ‚·ÛÈṲ̂ӷ Û ·ÛıÂÓ›˜ Ì ÚÔ¯ˆÚË̤ÓË Ë·ÙÈ΋ ÓfiÛÔ. ∂›Ó·È ¤ÙÛÈ ÛËÌ·ÓÙÈÎfi Ó· Á›ÓÂÈ ¿Ú· ¤Ú· ·ÍÈÔÏfiÁËÛË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ MELD Û ·ÛıÂÓ›˜ Ì ÚÒÈÌÔ ÛÙ¿‰ÈÔ Î›ÚÚˆÛ˘. 2. ¶¿Ú· ¤Ú· ›Û˘ ¤Ú¢ӷ ÌÔÚ› Ó· ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· ηχÙÂÚË Ì¤ÙÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÒÛÙ ӷ ˘ÔÛÙËÚȯı› fiÙÈ Ë Â›‰Ú·ÛË Ù˘ ËÏÈΛ·˜, ÙÔ˘ ʇÏÔ˘ Î·È Ù˘ Ì¿˙·˜ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÛÙÔ MELD Û‡ÛÙËÌ· Â›Ó·È ·›ı·ÓÔ Ó· Â›Ó·È ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋. ΔÔ MELD Û‡ÛÙËÌ· ¤¯ÂÈ ÂÓ Ùˆ ÌÂٷ͇ ÙÚÔÔÔÈËı› ·fi ÙËÓ UNOS, ÚÔÛı¤ÙÔÓÙ·˜ ÙËÓ ÂÚÒÙËÛË, Â¿Ó Ô ·ÛıÂÓ‹˜ ›¯Â ·ÈÌÔ‰È¿Ï˘ÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ÊÔÚ¤˜ ÙËÓ ÙÂÏÂ˘Ù·›· ‚‰ÔÌ¿‰·. ŒÙÛÈ ÙÔ Û‡ÛÙÌ· ·˘Ùfi ¤¯ÂÈ ‰È·ÌÔÚʈı› ˆ˜ ÂÍ‹˜: What is the INR? What is the bilirubin? What is the creatinine? Has the patient had dialysis at least twice in the past week?
(mg/dl) (mg/dl) No Yes
MELD score:
ÕÏϘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ, .¯. Ì ÌÂÚÈ΋ ‹ Ï‹ÚË ıÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ (¶º), ‰ÂÓ ÂÓÙ¿ÛÛÔÓÙ·È ¿ÌÂÛ· ÛÙÔ MELD Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘. ∞Ó Î·È ÙÔ ÔÛÔÛÙfi ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È Û¯ÂÙÈο ÌÈÎÚfi (10%), Â›Ó·È ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ÔÏÏ¿ ΤÓÙÚ· ÙÔ ıˆÚÔ‡Ó Û¯ÂÙÈ΋ ‹ ·fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ¶·ÚfiÏ· ·˘Ù¿, ÚfiÛÊ·ÙË ÌÂϤÙË ÙˆÓ H. Egawa Î·È Û˘Ó. ·Â ·ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·fi ˙ÒÓÙ· ‰fiÙË, ·˘ÙÔ› Ô˘ ›¯·Ó Ï‹ÚË ·fiÊÚ·ÍË Ù˘ ¶º, ›¯·Ó MELD score > 25 Î·È ÔÈ 3 ÛÙÔ˘˜ 4 ¤ı·Ó·Ó. ∂ÚˆÙ‹Ì·Ù· ›Û˘ Û˘Ó¯›˙Ô˘Ó Ó· ˘¿Ú¯Ô˘Ó ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ ‹ ÌË ÂÏÂÁ¯fiÌÂÓÔ ‰È·‚‹ÙË, ηıÒ˜ ·˘Ù‹ Ë ·Ú¿ÌÂÙÚÔ˜ ‰ÂÓ Ï·Ì‚¿ÓÂÙ·È ˘fi„ÈÓ ·fi ηӤӷ Û‡ÛÙËÌ· ·-
166
E. ANTøNIOY
ÍÈÔÏfiÁËÛ˘. Ÿˆ˜ ›Û˘ ‰ÂÓ Ï·Ì‚¿ÓÂÙ·È ˘fi„ÈÓ Î·È Ë ËÏÈΛ·, ηıÒ˜ ·ÛıÂÓ›˜ ÌÂÁ·Ï‡ÙÂÚÔÈ ÙˆÓ 65 ÂÙÒÓ ıˆÚÔ‡ÓÙ·È ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È Ë ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ıÓËÛÈÌfiÙËÙ· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÙÔ˘ 25%. ªÈ· ¿ÏÏË ÔÌ¿‰· ·ÛıÂÓÒÓ ˘Ô„ËÊ›ˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Â›Ó·È ·˘ÙÔ› Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÚÔËÁÔ‡ÌÂÓ˜ ÂÂÌ‚¿ÛÂȘ ÛÙËÓ ¿Óˆ ΢ڛˆ˜ ÎÔÈÏÈ¿. ∂Âȉ‹ Û˘Ó˘¿Ú¯ÂÈ ˘Ï·›· ˘¤ÚÙ·ÛË, Ë ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ fiˆ˜ Î·È Û ·˘ÙÔ‡˜ Ì ıÚfiÌ‚ˆÛË ¶º, ÌÔÚ› Ó· Â›Ó·È ÙÚÈÏ¿ÛÈ· ·fi ÙÔ˘˜ ¿ÏÏÔ˘˜ ·ÛıÂÓ›˜. ™˘ÓÔ„›˙ÔÓÙ·˜, ı· ÌÔÚÔ‡Û·Ì ӷ ԇ̠fiÙÈ ÙÔ MELD Û‡ÛÙËÌ· ¤¯ÂÈ ‚ÔËı‹ÛÂÈ Ôχ ÒÛÙ ӷ ‰›ÓÂÙ·È ÚÔÙÂÚ·ÈfiÙËÙ· Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ì ·ÓÙÈÎÂÈÌÂÓÈο ÎÚÈÙ‹ÚÈ·, Ó· ˘Ô‚¿ÏÏÔÓÙ·È ÙÔ Û˘ÓÙÔÌÒÙÂÚÔ ‰˘Ó·ÙfiÓ Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (Oª∏), Ì›ˆÓÔÓÙ·˜ ¤ÙÛÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ı·Ó¿ÙˆÓ ÛÙȘ Ï›ÛÙ˜ ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, ı· Ú¤ÂÈ Ó· ¤¯Ô˘Ì ˘fi„ÈÓ Ì·˜ ÙȘ ÂȉÈΤ˜ ·˘Ù¤˜ ηÙËÁÔڛ˜ ˘Ô„ËÊ›ˆÓ ÁÈ· Oª∏, ÔÈ Ôԛ˜ ı· Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁÔ‡ÓÙ·È Ì ‰È·ÊÔÚÂÙÈο ÎÚÈÙ‹ÚÈ·. ¶ÂÚÈÛÛfiÙÂÚ· ÛÙÔȯ›· Î·È ¤Ú¢ӷ ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· Ó· ηıÔÚÈÛıÔ‡Ó ÎÚÈÙ‹ÚÈ· Ô˘ ı· ÂÏ·ÙÙÒÓÔ˘Ó ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ ÙÔ˘ MELD Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Ó· ηıÔÚ›˙ÂÙ·È Ë ·ÓÙ›ÛÙÔÈ¯Ë ÚÔÙÂÚ·ÈfiÙËÙ· Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜.
μÈ‚ÏÈÔÁÚ·Ê›· ∞ÓÙˆÓ›Ô˘ ∂. ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ™ÙÔ ª∂Δ∞ªO™Ã∂À™∂π™ π™Δø¡ ∫∞π Oƒ°∞¡ø¡, ∞ÏÎ. ∫ˆÛÙ¿Î˘, ∂ΉfiÛÂȘ ¶∞ƒπ™π∞¡OÀ ∞.∂., ∞ı‹Ó· 2004. Durand F, Belghiti J. Liver transplantation for hepato-
cellular Carcinoma. Should we push the limits? Liver transplantation 2003; 9(7): 697-699. Forman LM, Lucey MR. Predicting the prognosis of chronic liver disease: An evolution from child to MELD. Hepatology. 2001; Feb33(2):473-475. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D’amico G, Dickson ER, Kim WR. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001; Feb 33(2): 464-470. Langer B, Taylor BR, Mackenzie DR, Gilas T, Stone RM, Blendis L. Further report of a prospective randomized trial comparing distal splenorenal shunt with end-toside portacaval shunt. An analysis of encephalopathy, survival, and quality of life. Gastroenterology 1985; 88:424-429. Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, Montalto F, Ammatuna M, Morabito A, Gennari L. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. New England Journal of Medicine 1996; 334, 11: 693-699. Wiesner RH, Freeman RB, Mulligan DC. Liver transplantation for hepatocellular cancer: the impact of the MELD allocation policy. Gastroenterology. 2004 Nov; 127(5 Suppl 1):S261-7. Egawa H, Tanaka K, Kasahara M, Takada Y, Oike F, Ogawa K, Sakamoto S, Kozaki K, and Ito T. Single centre experience of 39 patients with preoperative Portal Vein thrombosis among 404 adult living donor liver transplantation. Liver transplantation 2006; 12:15121518. Cholongitas E, Marelli L, Shusang V, SenzoloM, Rolles K, Patch David, and Burroughs A. A systemic review of the performance of the Model for End-Stage Liver Disease (MELD) in the setting of liver transplantation. Liver transplantation 2006; 12:1049-1061.
H ¯ÚËÛÈÌÔÔ›ËÛË OÚÔıÂÙÈÎÒÓ ¢ÔÙÒÓ E˘¿ÁÁÂÏÔ˜ XÔÏfiÁÎÈÙ·˜, °ÂÒÚÁÈÔ˜ ¶··ıÂÔ‰ˆÚ›‰Ë˜
3
HBV (3), ÂÓÒ, Û ¿ÏÏË ÌÂϤÙË ·fi ÙË °·ÏÏ›·, ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ 50% ÙˆÓ Ó¤ˆÓ (de novo) HBV ÏÔÈÌÒÍÂˆÓ ÛÙÔ ÌfiÛ¯Â˘Ì· ÌÔÚÔ‡Û·Ó Ó· ·Ô‰ÔıÔ‡Ó Û ÌÂÙ¿‰ÔÛË ÙÔ˘ HBV ·fi ÙÔ ‰fiÙË, ÏfiÁˆ ·ÚÔ˘Û›·˜ HBV DNA ÛÙÔÓ ÔÚfi ηÈ/‹ ÙÔ ‹·Ú ÙÔ˘ (4). ΔÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ‹Ù·Ó Û˘¯ÓfiÙÂÚÔ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜ ·’ fiÙÈ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÒÓ ‹ ηډȿ˜ (5). ∞˘Ù¿ Ù· Â˘Ú‹Ì·Ù· ›¯·Ó Ô‰ËÁ‹ÛÂÈ ÛÙÔÓ ·ÔÎÏÂÈÛÌfi Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ·ÚÎÂÙ¿ ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ·. ∂ÓÙÔ‡ÙÔȘ, ·˘Ù‹ Ë ÛÙÚ·ÙËÁÈ΋ Û˘Ó¿ÁÂÙ·È ÛËÌ·ÓÙÈÎfi ÂÚÈÔÚÈÛÌfi ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÂȉÈο Û ¯ÒÚ˜ Ì ˘„ËÏfi ÂÈÔÏ·ÛÌfi Ù˘ HBV Ïԛ̈͢. O ÁÂÓÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi anti-HBc ıÂÙÈÎÔ‡˜ ‰fiÙ˜ ı· ÌÔÚÔ‡Û ӷ ÂÚÈÔÚÈÛı› Ì ÙËÓ ·ÔÎ¿Ï˘„Ë ÙˆÓ ‰ÔÙÒÓ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ HBV ÛÙÔ Ï‹ÙË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÏÏ¿ Î·È ÙˆÓ ÏËÙÒÓ Ì ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÁÈ· HBV Ïԛ̈ÍË. Ÿˆ˜ ÌÔÚ› Ó· Á›ÓÂÈ Â‡ÎÔÏ· ·ÓÙÈÏËÙfi, Ë ÌÂÙ¿‰ÔÛË ÙÔ˘ HBV ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÔ‡˜ ÔÚÁ¿ÓÔ˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Û˘Ó‰˘·ÛÌfi ÙˆÓ ÔÚÔÏÔÁÈÎÒÓ HBV ‰ÂÈÎÙÒÓ ÙÔ˘ ‰fiÙË Î·È ÙÔ˘ Ï‹ÙË. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ de novo HBV Ïԛ̈ÍË ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û 38-100% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ·ÛıÂÓÒÓ ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓË ¤ÎıÂÛË ÛÙÔÓ HBV Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi ıÂÙÈÎfi anti-HBc ‰fiÙË ¤Ó·ÓÙÈ ÌfiÏȘ 0-2% ·ÚfiÌÔÈˆÓ ·ÛıÂÓÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi ·ÚÓËÙÈÎfi anti-HBc ‰fiÙË (6,7). Δ· ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙÔÓ Î›Ó‰˘ÓÔ ÌÂÙ¿‰ÔÛ˘ HBV Ïԛ̈͢ ·fi ÌÔۯ‡̷ٷ anti-HBc ıÂÙÈÎÒÓ ‰ÔÙÒÓ Û ·ÛıÂÓ›˜ Ì ÚÔËÁÔ‡ÌÂÓË ¤ÎıÂÛË ÛÙÔÓ HBV ÔÈΛÏÏÔ˘Ó Î·È ÂËÚ¿˙ÔÓÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ HBsAg (antiHBs) ÛÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓ›˜. °ÂÓÈο, Ê·›ÓÂÙ·È fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ·Ó¿Ù˘Í˘ HBV Ïԛ̈͢ ÌÂÙ¿ ·fi Ï‹„Ë ÌÔۯ‡̷ÙÔ˜ ·fi anti-HBc ıÂÙÈÎÔ‡˜ ‰fiÙ˜ Â›Ó·È Û¯ÂÙÈο ¯·ÌËÏfi˜
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È Û‹ÌÂÚ· Ë ıÂڷ›· ÂÎÏÔÁ‹˜ ÁÈ· ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ Ë Èı·ÓfiÙËÙ· ÂÙ‹ÛÈ·˜ ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË ·˘Í¿ÓÂÈ ·fi 60% Û 85-90% ·Ó ·˘ÙÔ› ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ¢˘ÛÙ˘¯Ò˜, ·ÚÎÂÙÔ› ÎÈÚÚˆÙÈÎÔ› ·ÛıÂÓ›˜ ‰ÂÓ ÚÔÏ·‚·›ÓÔ˘Ó Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÚfiÙÈ ÏËÚÔ‡Ó Ù· ηٿÏÏËÏ· ÎÚÈÙ‹ÚÈ· Î·È Ì·›ÓÔ˘Ó Û ϛÛÙ· ·Ó·ÌÔÓ‹˜, ηıÒ˜ Ù· ‰È·ı¤ÛÈÌ· ÌÔۯ‡̷ٷ ‹·ÙÔ˜ Â›Ó·È Î·Ù¿ Ôχ ÏÈÁfiÙÂÚ· Î·È ‰ÂÓ ÌÔÚÔ‡Ó Ó· ηχ„Ô˘Ó ÙË ‰È·ÚÎÒ˜ ·˘Í·ÓfiÌÂÓË ˙‹ÙËÛË (1). °È’ ·˘Ùfi Á›ÓÔÓÙ·È ‰È·ÚÎÒ˜ ÚÔÛ¿ıÂȘ ¯ÚËÛÈÌÔÔ›ËÛ˘ ÔÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (1). ™ÙȘ ÚÔÛ¿ıÂȘ ·˘Ù¤˜ ˘¿ÁÔÓÙ·È Î·È ÔÈ ¯Ú‹ÛÂȘ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ıÂÙÈÎÔ‡˜ ÔÚÔÏÔÁÈÎÔ‡˜ ‰Â›ÎÙ˜ ·ÚÂÏıÔ‡Û·˜ Ïԛ̈͢ Ì ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ μ (HBV) ‹ Ì ıÂÙÈÎÔ‡˜ ÔÚÔÏÔÁÈÎÔ‡˜ ‰Â›ÎÙ˜ Ïԛ̈͢ Ì ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ C (HCV), Ô˘ Û¯ÔÏÈ¿˙ÔÓÙ·È ÛÙË Û˘Ó¤¯ÂÈ·.
HBV ÔÚÔıÂÙÈÎÔ› ‰fiÙ˜ ™Â ÌÂϤÙ˜ ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’90 ·Ú·ÙËÚ‹ıËΠfiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ ·fi ‰fiÙ˜ Ì ıÂÙÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ˘ÚËÓÈÎÔ‡ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ HBV (anti-HBc) Î·È ·ÚÓËÙÈÎÔ‡˜ ÔÚÔÏÔÁÈÎÔ‡˜ ‰Â›ÎÙ˜ ÂÓÂÚÁÔ‡ HBV Ïԛ̈͢ [·ÚÓËÙÈÎfi ÂÈÊ·ÓÂÈ·Îfi ·ÓÙÈÁfiÓÔ ÙÔ˘ HBV (HBsAg)] ÂÓ›¯Â ΛӉ˘ÓÔ ÌÂÙ¿‰ÔÛ˘ HBV Ïԛ̈͢. ∏ ÌÂÙ¿‰ÔÛË ·Ô‰fiıËΠ۠ÎÚ˘ÙÈ΋ (occult) HBV Ïԛ̈ÍË ÙÔ˘ ‰fiÙË, ‰ËÏ·‰‹ Û ·ÚÔ˘Û›· ¯·ÌËÏÒÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ HBV DNA ÛÙÔÓ ÔÚfi ηÈ/‹ ÛÙÔ ‹·Ú ÙÔ˘ ‰fiÙË, ÔÈ Ôԛ˜ ·‡Í·Ó·Ó ÛÙÔ Ï‹ÙË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÂÍ·ÈÙ›·˜ Ù˘ ·Ó·˙ˆ‡ÚˆÛ˘ ÙÔ˘ HBV ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÏfiÁˆ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ (2). ™Â Ì›· ÌÂϤÙË, HBV DNA ·ÓȯÓ‡ıËΠ۠8% ÙˆÓ ‚ÈÔ„ÈÒÓ ‹·ÙÔ˜ ·fi ·ÛıÂÓ›˜ Ì ıÂÙÈÎfi anti-HBc Î·È ·ÚÓËÙÈÎÔ‡˜ ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ÔÚÔÏÔÁÈÎÔ‡˜ ‰Â›ÎÙ˜ ÙÔ˘
167
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Û ‰¤ÎÙ˜ Ì ıÂÙÈÎfi anti-HBc (13%) Î·È Ôχ ¯·ÌËÏfi˜ Û ‰¤ÎÙ˜ Ì ıÂÙÈÎfi anti-HBs (6,8). ™Â Ì›· ÌÂϤÙË ·fi ÙȘ ∏¶∞ (8) Î·È ‰‡Ô ÌÂϤÙ˜ ·fi ÙËÓ ∂˘ÚÒË, ηӤӷ˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ıÂÙÈÎfi anti-HBs ÏfiÁˆ Ê˘ÛÈ΋˜ ·ÓÔÛ›·˜ ‹ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ‰ÂÓ ·Ó¤Ù˘Í HBV Ïԛ̈ÍË ÌÂÙ¿ ·fi Ï‹„Ë ÌÔۯ‡̷ÙÔ˜ ·fi anti-HBc ıÂÙÈÎfi ‰fiÙË (9,10). ∂ÓÙÔ‡ÙÔȘ, ÂÚÈÙÒÛÂȘ HBV Ïԛ̈͢ Û antiHBs ıÂÙÈÎÔ‡˜ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi anti-HBc ıÂÙÈÎÔ‡˜ ‰fiÙ˜ ¤¯Ô˘Ó Û¿ÓÈ· ·Ó·ÊÂÚı› (6). H ·ÈÙÈÔÏÔÁ›· Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ Ê·›ÓÂÙ·È fiÙÈ ÂËÚ¿˙ÂÈ ÙËÓ ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi anti-HBc ıÂÙÈÎfi ‰fiÙË. ™‡Ìʈӷ Ì ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜, ÔÈ ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË ÌË-HBV ΛÚÚˆÛË Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi anti-HBc ıÂÙÈÎfi ‰fiÙË ¤¯Ô˘Ó ¯ÂÈÚfiÙÂÚË ÎÏÈÓÈ΋ ÔÚ›· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi anti-HBc ·ÚÓËÙÈÎfi ‰fiÙË, ·ÏÏ¿ ηχÙÂÚË ÔÚ›· Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÏfiÁˆ ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓ˘ HBV ΛÚÚˆÛ˘ (6). ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ 50% ÙˆÓ ·ÛıÂÓÒÓ Ì de novo HBV Ïԛ̈ÍË ¤¯Ô˘Ó Ê˘ÛÈÔÏÔÁÈΤ˜ ·ÌÈÓÔÙÚ·ÓÛÊÂÚ¿Û˜ Î·È 85% ·˘ÙÒÓ ¤¯Ô˘Ó ηıfiÏÔ˘ ‹ ‹È˜ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ 1 ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (6). ŸÌˆ˜, Û‡Ìʈӷ Ì ÌÂÁ·Ï‡ÙÂÚ˘ ‰È¿ÚÎÂÈ·˜ ÌÂϤÙ˜, Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÚfiÁÓˆÛË ›Ûˆ˜ ‰ÂÓ Â›Ó·È È‰È·›ÙÂÚ· ηϋ, ηıÒ˜ ·Ú·ÙËÚ‹ıËΠfiÙÈ 63% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ó¤Ù˘Í·Ó de novo HBV Ïԛ̈ÍË Â›¯·Ó ÛÔ‚·Ú‹ ‚Ï¿‚Ë ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È 21% ·’ ·˘ÙÔ‡˜ ›¯·Ó Âı¿ÓÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÂÈÏÔÎÒÓ Ù˘ HBV Ïԛ̈͢ ÂÓÙfi˜ 2 ÂÙÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË(11). OÈ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· HBV Ïԛ̈ÍË Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi anti-HBc ıÂÙÈÎfi ‰fiÙË Ê·›ÓÂÙ·È fiÙÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÔÙÚÔ‹ Ù˘ HBV Ïԛ̈͢ Û˘¯ÓfiÙÂÚ· Î·È ÂÓˆÚ›ÙÂÚ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi anti-HBc ·ÚÓËÙÈÎfi ‰fiÙË (12). ∂ÓÙÔ‡ÙÔȘ, Ë ¯ÚËÛÈÌÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi antiHBc ıÂÙÈÎÔ‡˜ ‰fiÙ˜ Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· HμV Ïԛ̈ÍË Ê·›ÓÂÙ·È fiÙÈ ‰ÂÓ ¤¯ÂÈ ·ÚÓËÙÈ΋ ›‰Ú·ÛË ÛÙËÓ ÔÚ›· Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ Î·È ÛÙË ÂÈ‚›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (12). ™˘ÓÔ„›˙ÔÓÙ·˜, ı· ÌÔÚÔ‡Û ӷ ÂȈı› fiÙÈ Ù· ÌÔۯ‡̷ٷ ·fi anti-HBc ıÂÙÈÎÔ‡˜ ‰fiÙ˜ ı· Ú¤ÂÈ Ó· ηÙ¢ı‡ÓÔÓÙ·È Î·Ù¿ ÚÔÙÂÚ·ÈfiÙËÙ· Û HBsAg ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Î·È ¤ÂÈÙ· Û ·ÛıÂÓ›˜ Ì ıÂÙÈÎfi anti-HBc Î·È anti-HBs ‹ ¤ÛÙˆ ÌfiÓÔ ıÂÙÈÎfi
anti-HBc, ÂÓÒ ı· Ú¤ÂÈ Ó· ·ÔÙÂÏÔ‡Ó ‡ÛÙ·ÙË ÂÈÏÔÁ‹ ÁÈ· ·ÛıÂÓ›˜ ¯ˆÚ›˜ ıÂÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ÚÔËÁÔ‡ÌÂÓ˘ ¤ÎıÂÛ˘ ÛÙÔÓ HBV. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÔÏÏ¿ ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi HBsAg ıÂÙÈÎÔ‡˜ ‰fiÙ˜, ·ÊÔ‡ Ù¤ÙÔȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ¤¯Ô˘Ó ·ÔÙÔÏÌËı› Û ÂÏ¿¯ÈÛÙ· ΤÓÙÚ·. ∞fi ÌÂÌÔӈ̤Ó˜ ÂÚÈÙÒÛÂȘ Ê·›ÓÂÙ·È fiÙÈ HBV Ïԛ̈ÍË ÂÌÊ·Ó›˙ÂÙ·È Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜, ·Ú¿ ÙËÓ ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈÈ΋ ·ÁˆÁ‹ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (13). OÈ ıÂڷ¢ÙÈΤ˜ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ÚfiÏË„Ë Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ HBV Ïԛ̈͢ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì HBV Ë·ÙÔ¿ıÂÈ· ‹Ù·Ó Ê˘ÛÈÎfi Ó· Ô‰ËÁ‹ÛÔ˘Ó ÛÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ Ì›ˆÛ˘ Ù˘ ÂÌÊ¿ÓÈÛ˘ HBV Ïԛ̈͢ Î·È Û ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ˜ ·ÛıÂÓ›˜ Ì Ìoۯ‡̷ٷ ·fi anti-HBc ıÂÙÈÎÔ‡˜ ‰fiÙ˜. ™ÙËÓ ÚÔÛ¿ıÂÈ· ·˘Ù‹ ‰ÔÎÈÌ¿˙ÔÓÙ·È ‰È¿ÊÔÚ· Û¯‹Ì·Ù· ˘ÂÚ·ÓfiÛÔ˘ ÛÊ·ÈÚ›Ó˘ ÁÈ· ÙËÓ Ë·Ù›Ùȉ· μ (HBIG) Î·È ·ÓÙÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (Û˘Ó‹ıˆ˜ Ï·ÌÈ‚Ô˘‰›Ó˘), Û˘¯Ó¿ Ì ‚¿ÛË ÙËÓ ·ÚÔ˘Û›· ‰ÂÈÎÙÒÓ ÂÓÂÚÁÔ‡ HBV Ïԛ̈͢ ÛÙÔÓ ÔÚfi ηÈ/‹ ÛÙÔ ‹·Ú ÙÔ˘ ‰fiÙË Î·È ÙËÓ ÔÚÔÏÔÁÈ΋ ÂÈÎfiÓ· ÙÔ˘ ‰¤ÎÙË (14). ™ÙÔ ¯ÂÈÚÈÛÌfi ÙˆÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· HBV Ïԛ̈ÍË Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi anti-HBc ıÂÙÈÎfi ‰fiÙË Ê·›ÓÂÙ·È fiÙÈ ¤¯ÂÈ ÂÈÙ¢¯ı› Û˘Ó·›ÓÂÛË Î·È fiÙÈ ÂÊ·ÚÌfi˙ÂÙ·È Ë ·ÁˆÁ‹ Ô˘ ¤ÙÛÈ Î·È ·ÏÏÈÒ˜ ¯ÔÚËÁÂ›Ù·È ÁÈ· ÚfiÏË„Ë Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ HBV Ïԛ̈͢ ÛÙÔ ÌfiÛ¯Â˘Ì·, ‰ËÏ·‰‹ HBIG (Û˘Ó‹ıˆ˜ Û ¯·ÌËϤ˜ ‰fiÛÂȘ) ηÈ/‹ Ï·ÌÈ‚Ô˘‰›Ó˘ (15,16). ∞ÓÙ›ıÂÙ·, ¯ÚÂÈ¿˙ÔÓÙ·È Î·Ï¿ ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ηıÈÂÚˆıÔ‡Ó Â˘Ú¤ˆ˜ ·Ô‰ÂÎÙ¤˜ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ ÁÈ· ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ (ÌË-HBV) Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi antiHBc ıÂÙÈÎfi ‰fiÙË. ™Ù· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› Ï·Ì‚¿ÓÔ˘Ó ∏μπG ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ (·ÓË·ÙÈ΋ Ê¿ÛË), ÂÓÒ Ë ÂÚ·ÈÙ¤Úˆ ·ÁˆÁ‹ ηıÔÚ›˙ÂÙ·È Î˘Ú›ˆ˜ ·fi ÙËÓ ·ÚÔ˘Û›· ‹ fi¯È ‰ÂÈÎÙÒÓ ÂÓÂÚÁÔ‡ HBV Ïԛ̈͢ ÛÙÔ ‹·Ú ηÈ/‹ ÛÙÔÓ ÔÚfi ÙÔ˘ ‰fiÙË. ∞Ó Î·È Ô Û˘Ó‰˘·ÛÌfi˜ HBIG Î·È Ï·ÌÈ‚Ô˘‰›Ó˘ ¤¯ÂÈ ‰ÒÛÂÈ ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÂÌÊ¿ÓÈÛ˘ HBV Ïԛ̈͢ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û ۯ¤ÛË Ì ٷ Û¯‹Ì·Ù· ÌÔÓÔıÂڷ›·˜ (∏μIG ‹ Ï·ÌÈ‚Ô˘‰›Ó˘) (17,18), ÙÔ ÎfiÛÙÔ˜ ·˘Ù‹˜ Ù˘ ÛÙÚ·ÙËÁÈ΋˜ Â›Ó·È È‰È·›ÙÂÚ· ˘„ËÏfi. ∂Ú¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÌÔÓÔıÂڷ›· Ì ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË Ï·ÌÈ‚Ô˘‰›Ó˘, Ô˘ ¤¯ÂÈ Ôχ ÌÈÎÚfiÙÂÚÔ ÎfiÛÙÔ˜ Û ۯ¤ÛË Ì ÙËÓ HBIG, ÌÔÚ› Ó· ‰ÒÛÂÈ ·ÚÎÂÙ¿ ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· (19,20), ·Ó Î·È ¿ÓÙ· ˘¿Ú¯ÂÈ Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË (21). ∂›Û˘, ¤¯ÂÈ ÌÂÏÂÙËı› Ë ÚÒÈÌË ‰È·ÎÔ‹ Ù˘ ÚÔÊ˘Ï·ÎÙÈ΋˜ ·ÁˆÁ‹˜ (710 ̤Ú˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‹·ÙÔ˜), ηıÒ˜ Î·È Ë ÌË ¯ÔÚ‹ÁËÛË ÔÔÈ·Û‰‹ÔÙ ·ÓÙÈÈ΋˜ ·ÁˆÁ‹˜, ȉȷ›ÙÂÚ· ·Ó Ô ‰fiÙ˘ ‹Ù·Ó HBV DNA ·ÚÓËÙÈÎfi˜ ÛÙÔÓ ÔÚfi Î·È ÛÙÔ ‹·Ú Î·È Ô Ï‹Ù˘ ›¯Â ÂӉ›ÍÂȘ ·ÚÂÏıÔ‡Û·˜ ¤ÎıÂÛ˘ ÛÙÔÓ HBV Ì ıÂÙÈÎfi anti-HBs (22). ªÈ· ·ÚÎÂÙ¿ ÂӉȷʤÚÔ˘Û· ÂÓ·ÏÏ·ÎÙÈ΋ ÚÔÛ¤ÁÁÈÛË Â›Ó·È Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÛÙfi¯Ô ÙËÓ ·Ó¿Ù˘ÍË ˘„ËÏÒÓ Ù›ÙÏˆÓ anti-∏μs ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈÈ΋ ·ÁˆÁ‹ Ì ϷÌÈ‚Ô˘‰›ÓË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (23,24). ŒÓ· ·ÚÈÔ Úfi‚ÏËÌ· Ù˘ ÙÂÏÂ˘Ù·›·˜ ÚÔÛ¤ÁÁÈÛ˘ ı· Â›Ó·È ‚¤‚·È· Ë Û¯ÂÙÈο ÌÈÎÚ‹ ·ÓÙ·fiÎÚÈÛË ÛÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi ¤Ó·ÓÙÈ ÙÔ˘ HBV ÙˆÓ ·ÛıÂÓÒÓ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÔ¿ıÂÈ·. ¶¿ÓÙˆ˜, Û οı ÂÚ›ÙˆÛË ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ Ì ÌfiÛ¯Â˘Ì· ·fi anti-HBc ıÂÙÈÎfi ‰fiÙË Î·È ·ÓÂÍ·Úًو˜ ÙÔ˘ ›‰Ô˘˜ Ù˘ ·ÁˆÁ‹˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ··ÈÙÂ›Ù·È ÚÔÛÂÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙÔ˜ ·ÛıÂÓÔ‡˜ Ì ÛÎÔfi, ÂÎÙfi˜ ÙˆÓ ¿ÏψÓ, Î·È ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ Èı·Ó‹˜ HBV Ïԛ̈͢ Î·È ÙËÓ ·Ó¿ÏÔÁË ÙÚÔÔÔ›ËÛË Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘.
HCV ÔÚÔıÂÙÈÎÔ› ‰fiÙ˜ ∏ ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË ÏfiÁˆ ¯ÚfiÓÈ·˜ HCV Ïԛ̈͢ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜. ¢˘ÛÙ˘¯Ò˜, Ë HCV Ïԛ̈ÍË Î·Ù¿ ηÓfiÓ· ˘ÔÙÚÔÈ¿˙ÂÈ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È Ë ÂͤÏÈÍË Ù˘ HCV Ïԛ̈͢ Â›Ó·È Ù·¯‡ÙÂÚË Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·’ fiÙÈ ÛÂ Û˘Ó‹ıÂȘ ·ÓÔÛÔ·ÚΛ˜ ·ÛıÂÓ›˜ (25). ™˘ÓÂÒ˜, Ë ÚfiÁÓˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÏfiÁˆ ¯ÚfiÓÈ·˜ HCV Ïԛ̈͢ Â›Ó·È Û˘¯Ó¿ ¯ÂÈÚfiÙÂÚË Û ۯ¤ÛË Ì ÙËÓ ÚfiÁÓˆÛË ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÁÈ· ¿ÏϘ ¯ÚfiÓȘ Ë·ÙÔ¿ıÂȘ. §fiÁˆ ÙÔ˘ ˘„ËÏÔ‡ ÂÈÔÏ·ÛÌÔ‡ Ù˘ HCV Ïԛ̈͢ Û ·ÚÎÂÙ¤˜ ¯ÒÚ˜ Ì ·Ó·Ù˘Á̤ӷ ÚÔÁÚ¿ÌÌ·Ù· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜, ‰ÂÓ Â›Ó·È Û¿ÓÈ· Ë ÚÔÛÊÔÚ¿ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ıÂÙÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ HCV (anti-HCV) Î·È Û˘Ó‹ıˆ˜ ÂÓÂÚÁfi HCV ÏÔ›-
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̈ÍË. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÛÙȘ ∏¶∞ ÙÔ 12% ÙˆÓ ÙˆÌ·ÙÈÎÒÓ ‰ÔÙÒÓ Â›Ó·È anti-HCV ıÂÙÈÎÔ› (26). Δ· ÌÔۯ‡̷ٷ ·˘Ù¿ ı· ÌÔÚÔ‡Û·Ó Ó· ηχ„Ô˘Ó ¤Ó· ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ ÙˆÓ ·Ó·ÁÎÒÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∂ÓÙÔ‡ÙÔȘ, Ë Ôχ ˘„ËÏ‹ Èı·ÓfiÙËÙ· ·Ó¿Ù˘Í˘ ¯ÚfiÓÈ·˜ HCV Ïԛ̈͢ Û HCV ·ÚÓËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌfiÛ¯Â˘Ì· ·fi HCV ıÂÙÈÎfi ‰fiÙË (27,28) Î·È Ë ‰˘ÛÌÂÓ‹˜ ÚfiÁÓˆÛË ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· HCV Ïԛ̈ÍË (25) ·ÔÎÏÂ›Ô˘Ó ÙË ¯Ú‹ÛË Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ˘Ô„‹ÊÈÔ˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓ›˜ ¯ˆÚ›˜ HCV Ïԛ̈ÍË. ∞ÓÙ›ıÂÙ·, Ê·›ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ÏÔÁÈ΋ Ë ¯Ú‹ÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi HCV ıÂÙÈÎÔ‡˜ ‰fiÙ˜ Û ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË HCV ΛÚÚˆÛË, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ¤ÙÛÈ Î·È ·ÏÏÈÒ˜ ·Ó·Ì¤ÓÂÙ·È Ë ·Ó¿Ù˘ÍË ¯ÚfiÓÈ·˜ HCV Ïԛ̈͢ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÏfiÁˆ ˘ÔÙÚÔ‹˜ Ù˘ Ïԛ̈͢ Ì ÙÔ ‰ÈÎfi ÙÔ˘˜ HCV Û٤ϯԘ. ¶ÔÏÏ¿ ‰Â‰Ô̤ӷ ¤¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ‰Â›ÍÂÈ fiÙÈ Ë ¯Ú‹ÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi HCV ÔÚÔıÂÙÈÎÔ‡˜ ‰fiÙ˜ Û ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË HCV ΛÚÚˆÛË ‰ÂÓ ¤¯ÂÈ ·ÚÓËÙÈ΋ ›‰Ú·ÛË ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ™Â ÌÈ· ·fi ÙȘ ÚÒÙ˜ ÌÂϤÙ˜, fiÔ˘ ÂÎÙÈÌ‹ıËÎÂ Ë ¤Î‚·ÛË Ù˘ ¯ÚËÛÈÌÔÔ›ËÛ˘ 31 ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÔÙÒÓ Ì ıÂÙÈο anti-HCV, ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ë·Ù›Ùȉ·˜ C ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÂ Î·Ó¤Ó·Ó ·fi ÙÔ˘˜ 6 anti-HCV ıÂÙÈÎÔ‡˜ Ï‹Ù˜, ·ÏÏ¿ ·Ú·ÙËÚ‹ıËÎ·Ó Û 6 ·fi ÙÔ˘˜ 25 anti-HCV ·ÚÓËÙÈÎÔ‡˜ Ï‹Ù˜ (28). ™Â ÂfiÌÂÓ˜ ÌÂϤÙ˜ ·Ú·ÙËÚ‹ıËΠfiÙÈ Ë ·ÚÔ˘Û›· ‹ fi¯È ıÂÙÈÎÔ‡ anti-HCV ÛÙÔ˘˜ ‰fiÙ˜ ‰ÂÓ ÂËÚ¿˙ÂÈ ÙË ‚Ú·¯˘¯ÚfiÓÈ· ‹ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÙˆÓ HCV ıÂÙÈÎÒÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ·ÛıÂÓÒÓ [ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË: 90% ÛÙÔ˘˜ 18 Ì‹Ó˜ (29) Î·È >75% ÛÙ· 4 ¤ÙË (30)]. ¶·ÚÔÌÔ›ˆ˜, ‰ÂÓ ˘‹Ú¯Â ›‰Ú·ÛË Ù˘ anti-HCV ÔÚÔıÂÙÈÎfiÙËÙ·˜ ÙˆÓ ‰ÔÙÒÓ ÛÙËÓ ÂÈ‚›ˆÛË ‹ ÙËÓ ˘ÔÙÚÔ‹ Ù˘ Ë·Ù›Ùȉ·˜ C ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ̷ÎÚÔ¯ÚfiÓÈ· ÛÂÈÚ¿ 59 HCV ıÂÙÈÎÒÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ·ÛıÂÓÒÓ ·fi ¤Ó· ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ (8ÂÙ‹˜ ÂÈ‚›ˆÛË: 70% Î·È 66% ÁÈ· ·ÛıÂÓ›˜ Ì ÌfiÛ¯Â˘Ì· ·fi antiHCV ıÂÙÈÎÔ‡˜ Î·È ·ÚÓËÙÈÎÔ‡˜ ‰fiÙ˜, ·ÓÙ›ÛÙÔȯ·) (31) Ô‡ÙÂ Î·È ÛÙË ÌÂÁ·Ï‡ÙÂÚË Ì¤¯ÚÈ ÙÒÚ· ÌÂϤÙË ÚÔÂÚ¯fiÌÂÓË ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÔȯ›ˆÓ Ù˘ ·ÚÈ·˜ ‚¿Û˘ ‰Â‰ÔÌ¤ÓˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÙˆÓ ∏¶∞ (UNOS, United Network for Organ Sharing) (3ÂÙ‹˜ ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜: 69% ÛÙÔ˘˜
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190 HCV ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÌfiÛ¯Â˘Ì· ·fi anti-HCV ıÂÙÈÎfi ‰fiÙË Î·È 73% ÛÙÔ˘˜ 5053 HCV ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÌfiÛ¯Â˘Ì· ·fi anti-HCV ·ÚÓËÙÈÎfi ‰fiÙË) (32). Δ¤ÏÔ˜, ˘¿Ú¯Ô˘Ó Î·È ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ Ê¿ÓËΠfiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË HCV ΛÚÚˆÛË Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi anti-HCV ‰fiÙË Â›¯·Ó ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ ˘ÔÙÚÔ‹ Ù˘ Ë·Ù›Ùȉ·˜ C ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ۯ¤ÛË Ì ·ÚfiÌÔÈÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi anti-HCV ·ÚÓËÙÈÎfi ‰fiÙË (33). O ·ÚÈÔ˜ ÂÓ‰ÔÈ·ÛÌfi˜ Ù˘ ¯ÔÚ‹ÁËÛ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi HCV ıÂÙÈÎÔ‡˜ ‰fiÙ˜ Û HCV ıÂÙÈÎÔ‡˜ ‰¤ÎÙ˜ ‹Ù·Ó Ë Èı·Ó‹ ·ÚÓËÙÈ΋ ›‰Ú·ÛË Ô˘ ı· ÌÔÚÔ‡Û ӷ ¤¯ÂÈ Ë ÂÈÏԛ̈ÍË Ì ¤Ó· ‰È·ÊÔÚÂÙÈÎfi HCV Û٤ϯԘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÏfiÁˆ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ HCV Ë·ÙÔ¿ıÂÈ·˜. ∂˘Ù˘¯Ò˜, Û‡ÓÙÔÌ· ÔÈ ÌÂϤÙ˜ ÂÍÔ˘‰ÂÙ¤ÚˆÛ·Ó ÙȘ ·Ú¯ÈΤ˜ ıˆÚËÙÈΤ˜ ·ÓËÛ˘¯›Â˜. ™ÙËÓ ÚÒÙË Û¯ÂÙÈ΋ ÌÂϤÙË 14 ·ÛıÂÓÒÓ, 6 ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ˜ ·ÛıÂÓ›˜ ›¯·Ó ›‰ÈÔ ÁÔÓfiÙ˘Ô Ì ÙÔ ÁÔÓfiÙ˘Ô ÙÔ˘ ‰fiÙË, ÂÓÒ Ô ÁÔÓfiÙ˘Ô˜ ÙÔ˘ ‰fiÙË ÂÈÎÚ¿ÙËÛ ۇÓÙÔÌ· ÛÙÔ˘˜ ˘fiÏÔÈÔ˘˜ 8 ·ÛıÂÓ›˜ (34). °ÂÓÈο, Ô ÁÔÓfiÙ˘Ô˜ 1b Ê¿ÓËΠӷ ÂÈÎÚ·Ù› ÙˆÓ ¿ÏÏˆÓ HCV ÁÔÓÔÙ‡ˆÓ ·ÓÂÍ¿ÚÙËÙ· ·Ó ÚÔÂÚ¯fiÙ·Ó ·fi ÙÔ ‰fiÙË ‹ ÙÔ Ï‹ÙË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (34). ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÔÈ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ÙÔ˘ ‹·ÙÔ˜ ‹Ù·Ó ÛÔ‚·ÚfiÙÂÚ˜ ÛÙÔ˘˜ 6 ·ÛıÂÓ›˜ Ô˘ ‰È·Ù‹ÚËÛ·Ó ÙÔ ‰ÈÎfi ÙÔ˘˜ HCV ÁÔÓfiÙ˘Ô Û ۯ¤ÛË Ì ÙÔ˘˜ 8 ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÈÎÚ¿ÙËÛÂ Ô ÁÔÓfiÙ˘Ô˜ ÙÔ˘ ‰fiÙË (34). Δ· ·Ú·¿Óˆ Â˘Ú‹Ì·Ù· ÂȂ‚·ÈÒıËÎ·Ó ÛÙË Û˘Ó¤¯ÂÈ· Û ÌÂÁ·Ï‡ÙÂÚÔ ‰Â›ÁÌ· ·ÛıÂÓÒÓ Ì ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘, fiÔ˘ ¿ÏÈ Ë ÂÈÎÚ¿ÙËÛË ÙÔ˘ HCV ÛÙÂϤ¯Ô˘˜ ÙÔ˘ ‰fiÙË ¤Ó·ÓÙÈ Ù˘ ‰È·Ù‹ÚËÛ˘ ÙÔ˘ HCV ÛÙÂϤ¯Ô˘˜ ÙÔ˘ Ï‹ÙË ‚Ú¤ıËΠӷ Û¯ÂÙ›˙ÂÙ·È Ì ۷ÓÈfiÙÂÚË ÈÛÙÔÏÔÁÈ΋ ˘ÔÙÚÔ‹ Ù˘ HCV Ïԛ̈͢ ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È Î·ÏÏ›ÙÂÚË ÂÈ‚›ˆÛË ÂχıÂÚ˘ ÓfiÛÔ˘ ÙˆÓ ·ÛıÂÓÒÓ (33). ™Â ¿ÏÏË ÌÂϤÙË Â›Û˘ ÂȂ‚·ÈÒıËÎÂ Ë Î˘ÚÈ·Ú¯›· ÙÔ˘ ÁÔÓÔÙ‡Ô˘ 1 ·ÓÂÍ¿ÚÙËÙ· ÚÔ¤Ï¢Û˘ (‰fiÙË ‹ ‰¤ÎÙË) ¤Ó·ÓÙÈ ÙˆÓ ¿ÏÏˆÓ ÁÔÓÔÙ‡ˆÓ Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ HCV ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi HCV ıÂÙÈÎfi ‰fiÙË (35). Δ· ·Ú·¿Óˆ ηϿ ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ¯Ú‹ÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ HCV ıÂÙÈÎÒÓ ‰ÔÙÒÓ Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· HCV Ë·ÙÔ¿ıÂÈ· ÚÔÛ¿ıËÛ·Ó Ó· ÌÂÙÚÈ¿ÛÔ˘Ó Ù· ‰Â‰Ô̤ӷ Ì›·˜ ÌÂϤÙ˘ Ù˘ ÈÛÙÔÏÔÁÈ΋˜ ÂͤÏÈ͢ Ù˘ HCV Ïԛ̈͢ Û ٤ÙÔÈ· ÔÌ¿‰· ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ. ™Â ·˘Ù‹
ÙË ÌÂϤÙË ‚Ú¤ıËΠfiÙÈ 39 HCV ıÂÙÈÎÔ› ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi HCV ıÂÙÈÎÔ‡˜ ‰fiÙ˜ ›¯·Ó Ù·¯‡ÙÂÚË Âȉ›ӈÛË Ù˘ ›ÓˆÛ˘ Û ۯ¤ÛË Ì 580 HCV ıÂÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi HCV ·ÚÓËÙÈÎÔ‡˜ ‰fiÙ˜, ÂÓÒ Â›¯·Ó Î·È ¯ÂÈÚfiÙÂÚË ÂÈ‚›ˆÛË fiÙ·Ó ÔÈ ‰fiÙ˜ ‹Ù·Ó ÌÂÁ¿Ï˘ ËÏÈΛ·˜ (36). ∞ÓÙ›ıÂÙ·, Û Ôχ ÚfiÛÊ·ÙË ·Ó·ÎÔ›ÓˆÛË ÌÈ· ÚÔÛÂÎÙÈ΋˜ ÂÏÂÁ¯fiÌÂÓ˘ ÌÂϤÙ˘, ÔÈ HCV ıÂÙÈÎÔ› ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi HCV ıÂÙÈÎfi ‰fiÙË ¤Ó·ÓÙÈ ÂÎÂ›ÓˆÓ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi HCV ·ÚÓËÙÈÎfi ‰fiÙË Â›¯·Ó ËÈfiÙÂÚË ÂͤÏÈÍË Ù˘ ›ÓˆÛ˘ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (‰È·ÊÔÚ¿ ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋) Î·È Ù¿ÛË ÁÈ· ηÏÏ›ÙÂÚË 3ÂÙ‹ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (ƒ=0.10) (37). ªÂ ‚¿ÛË fiÏ· Ù· ·Ú·¿Óˆ Ê·›ÓÂÙ·È fiÙÈ ÌÔۯ‡̷ٷ ·fi HCV ıÂÙÈÎÔ‡˜ ‰fiÙ˜ ÌÔÚ› Ó· ¯ÔÚËÁÔ‡ÓÙ·È ¯ˆÚ›˜ ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù· Û ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË HCV ΛÚÚˆÛË (38).
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20) Prakoso E, Strasser SI, Koorey DJ, Verran D, McCaughan GW. Long-term lamivudine monotherapy prevents development of hepatitis B virus infection in hepatitis B surface-antigen negative liver transplant recipients from hepatitis B core-antibody-positive donors. Clin Transplant 2006;20:369-73. 21) Yena RD, Bonattib H, Mendezc J. Case report of lamivudine-resistant hepatitis B virus infection post liver transplantation from a hepatitis B core antibody donor. Am J Transplant 2006;6:1077-83. 22) Nery JR, Nery-Avila C, Reddy KR, Cirocco R, Weppler D, Levi DM, et al. Use of liver grafts from donors positive for antihepatitis B-core antibody (antiHBc) in the era of prophylaxis with hepatitis-B immunoglobulin and lamivudine. Transplantation 2003; 75:1179-86. 23) Chen YS, Wang CC, deVilla VH, Wang SH, Cheng YF, Huang TL, et al. Prevention of de novo hepatitis B virus infection in living donor liver transplantation using hepatitis B core antibody positive donors. Clin Transplant 2002;16:405-9. 24) Lin CC, Chen CL, Concejero A, Wang CC, Wang SH, Liu YW, et al. Active immunization to prevent de novo hepatitis B virus infection in pediatric live donor liver recipients. Am J Transplant 2007;7:195-200. 25) Papatheodoridis GV, Patch D, Dusheiko GM, Burroughs AK. The outcome of hepatitis C virus infection after liver transplantation - Is it influenced by the type of immunosuppression? J Hepatol 1999;30:731-8. 26) Saab S, Ghobrial RM, Ibbrahim AB, Kunder G, Durazo F, Han S, et al. Hepatitis C positive grafts may be used in orthotopic liver transplantation: a matched analysis. Am J Transplant 2003;3:1167-72. 27) Pereira BJ, Milford EL, Kirkman RL, Quan S, Sayre KR, Johnson PJ, et al. Prevalence of hepatitis C virus RNA in organ donors positive for hepatitis C antibody and in the recipients of their organs. N Engl J Med 1992;327:910-5. 28) Shah G, Demetris AJ, Irish W, Scheffel J, Mimms L, Van Thiel DH. Frequency and severity of HCV infection following orthotopic liver transplantation. Effect of donor and recipient serology for HCV using a second generation ELISA test. J Hepatol 1993;18:279-83. 29) Mulligan DC, Goldstein RM, Crippin JS, Abouljoud MS, Levy MF, Husberg BS, et al. Use of anti-hepatitis C virus seropositive organs in liver transplantation. Transplant Proc 1995;27:1204-5. 30) Testa G, Goldstein RM, Netto G, Abbasoglu O, Brooks BK, Levy MF, et al. Long-term outcome of patients transplanted with livers from hepatitis Cpositive donors. Transplantation 1998;65:925-9. 31) Ghobrial RM, Steadman R, Gornbein J, Lassman C, Holt CD, Chen P, et al. 10-year experience of liver transplantation for hepatitis C: analysis of factors determining outcome in over 500 patients. Ann Surg 2001; 234:384-93.
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E. XO§O°KITA™, °. ¶A¶A£EO¢øPI¢H™
32) Marroquin CE, Marino G, Kuo P, Plotkin JS, Rustgi VK, Lu AD, et al. Transplantation of hepatitis C-positive livers in hepatitis C-positive patients is equivalent to transplanting hepatitis C-negative livers. Liver Transplant 2001;7:762-8. 33) Vargas HE, Laskus T, Wang LF, Lee R, Radkowski M, Dodson F, et al. Outcome of liver transplantation in hepatitis C virus-infected patients who received hepatitis C virus-infected grafts. Gastroenterology 1999; 117:149-53. 34) Laskus T, Wang LF, Rakela J, Vargas H, Pinna A, Tsamandas AC, et al. Dynamic behavior of hepatitis C virus in chronically infected patients receiving liver graft from infected donors. Virology 1996;220:171-6. 35) Fan X, Lang DM, Xu Y, Lyra AC, Yusim K, Everhart
JE, et al. Liver transplantation with hepatitis C virusinfected graft: interaction between donor and recipient viral strains. Hepatology 2003;38:25-33. 36) Khapra AP, Agarwal K, Fiel MI, Kontorinis N, Hossain S, Emre S, et al. Impact of donor age on survival and fibrosis progression in patients with hepatitis C undergoing liver transplantation using HCV allografts. Liver Transplant 2006;12:1496-503. 37) Wilson S, Mangus RS, Tector AJ, Fridell JA, Vianna R, Liangpunsakul S, et al. Use of hepatitis C-infected donors in liver transplantation: a case-control study. Gastroenterology 2007;132 (Suppl. 2):A-728. 38) Peek R, Reddy KR. Hepatitis C virus-infected donors in liver transplantation. Gastroenterology 2007; 133: 381-2.
NÂÊÚÈ΋ AÓ¿ÚÎÂÈ· Î·È MÂÙ·ÌfiÛ¯Â˘ÛË ◊·ÙÔ˜ M·ÓÒÏ˘ TÛfi¯·Ù˙˘, Iˆ¿ÓÓ˘ KÔÛΛӷ˜
4
ÙÔ‡Ó ÔÏϷϤ˜ ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜ 4) ΔÔÍÈ΋ ‚Ï¿‚Ë ÛÙ· ÓÂÊÚ¿ ·fi ‚·ÎÙËÚȷ΋ Ïԛ̈ÍË ‹ ¯Ú‹ÛË ÓÂÊÚÔÙÔÍÈÎÒÓ Ê·ÚÌ¿ÎˆÓ 5) ¢˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, Ë ÔÔ›· ·Ó Â›Ó·È ÛÔ‚·Ú‹ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÚÔԉ¢ÙÈ΋ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ 6) ¶ÚÔ˘¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ›Ù Ì ÙË ÌÔÚÊ‹ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ›Ù Ì ÙË ÌÔÚÊ‹ ÙÔ˘ Ë·ÙÔÓÂÊÚÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘. ∂ȉÈο ÁÈ· ÙÔ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ, Ê·›ÓÂÙ·È Ó· ·›˙ÂÈ ÚfiÏÔ ÙfiÛÔ Ô ¯ÚfiÓÔ˜ ÂÁηٿÛÙ·Û‹˜ ÙÔ˘ Ú›Ó ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË fiÛÔ Î·È Ô Ù‡Ô˜ ÙÔ˘, ‰ËÏ·‰‹ ·Ó Â›Ó·È Ù‡Ô˘ π ‹ ππ. ø˜ Ù‡Ô˜ π Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ ÔÚ›˙ÂÙ·È Ô ‰ÈÏ·ÛÈ·ÛÌfi˜ Ù˘ ·Ú¯È΋˜ ÙÈÌ‹˜ ÎÚ·ÂÙÈÓ›Ó˘ Û ÙÈÌ‹ >2.5 mg/dl ‹ Ë 50% ÂÏ¿ÙÙˆÛË Ù˘ 24-ˆÚ˘ οı·ÚÛ˘ ÎÚ·ÙÈÓ›Ó˘ Û ÙÈÌ‹ <20 ml/min Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÏÈÁfiÙÂÚÔ ÙˆÓ ‰‡Ô ‚‰ÔÌ¿‰ˆÓ, ÂÓÒ ÛÙÔÓ Ù‡Ô˜ ππ Ë·ÙÔÓÂÊÚÈÎfi Ë ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ·ÎÔÏÔ˘ı› ÌÈ· ÈÔ ·ÚÁ‹ Î·È ÚÔԉ¢ÙÈ΋ ÔÚ›·. OÈ ·ÛıÂÓ›˜ ÌÂ Ù‡Ô˘ π Ë·ÙÔÓÂÊÚÈÎfi ¤¯Ô˘Ó ÌÈ· ÈÔ Î·ı˘ÛÙÂÚË̤ÓË Â·Ó¿ÎÙËÛË Ê˘ÛÈÔÏÔÁÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ ÌÂ Ù‡Ô˘ ππ, ÏfiÁˆ ÛÔ‚·ÚfiÙÂÚ˘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜. ∏ Alessandria Î·È Û˘Ó. ¤‰ÂÈÍ fiÙÈ ÛÙÔ Ë·ÙÔÓÂÊÚÈÎfi Ù‡Ô˘ π Ë Ì¤ÛË ·ÚÙËÚȷ΋ ›ÂÛË Â›Ó·È ÂÏ·Ùو̤ÓË Î·È Ù· ›‰· ÔÚÔ‡ ÓÔÚÂÈÓÂÊÚ›Ó˘ Î·È ‚·˙ÔÚÂÛÛ›Ó˘ ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· Û ۯ¤Ë Ì ÙÔÓ Ù‡Ô ππ. ™Â ÌÈÎÚ‹ ÌÂϤÙË ·ÛıÂÓÒÓ ÌÂ Ù‡Ô˘ π Ë·ÙÔÓÂÊÚÈÎfi, Ë ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ˜ Î·È Ë ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ·Ó¿ÁÎË ·ÈÌÔοı·ÚÛ˘ ‹Ù·Ó ·ÓÂÍ¿ÚÙËÙÔÈ ·ÚÓËÙÈÎÔ› ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·Ó¿ÎÙËÛ˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ·ÛıÂÓ›˜ Ì ÚÒÈÌË ÌÂÙ·-ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ë ¯Ú‹ÛË ·Ó·ÛÙÔÏÂÒÓ Î·ÏÛÈÓ¢ڛ-
∞fi ÙËÓ ÚÒÙË ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÙÔ 1967 ·fi ÙÔÓ Starzl ̤¯ÚÈ Û‹ÌÂÚ·, Ë ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ¤¯ÂÈ ‚ÂÏÙȈı› ı·̷ÙÈο, Ì ÙËÓ 5-ÂÙ‹ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ó· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 80% Î·È ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ 71%. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÔÊ›ÏÔÓÙ·È ÛÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ, Ù˘ ‰È·Ù‹ÚËÛ˘ ÙˆÓ ÔÚÁ¿ÓˆÓ, Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ÌÂÙ·-ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ ÂÈÏÔÎÒÓ. ∏ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ÙfiÛÔ ÛÙËÓ ÂÚÈÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÂÚ›Ô‰Ô fiÛÔ Î·È ÛÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú·Ì¤ÓÂÈ ¤Ó· ȉȷ›ÙÂÚ· ‰‡ÛÎÔÏÔ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÎÏÈÓÈÎfi Úfi‚ÏËÌ·, Ì ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·.
¶∂ƒπª∂Δ∞ªO™Ã∂ÀΔπ∫∏ ¡∂ºƒπ∫∏ ¢À™§∂πΔOÀƒ°π∞ ∏ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·ÔÙÂÏ› Û¯ÂÙÈο Û˘¯Ó‹ ÂÈÏÔ΋ ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ ÚÒÈÌË ÌÂÙ·ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÂÚ›Ô‰Ô, Ì ÙËÓ Â›ÙˆÛË Ù˘ Ó· Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 12% Î·È 51%, ·Ó¿ÏÔÁ· Ì ٷ ÎÚÈÙ‹ÚÈ· ÔÚÈÛÌÔ‡ Ù˘. Δ· ·›ÙÈ· Ù˘ Â›Ó·È Û˘Ó‹ıˆ˜ ÔÏ˘·Ú·ÁÔÓÙÈο, ÂÓÒ Ë ıÓËÛÈÌfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ı· ¯ÚÂÈ·ÛÙÔ‡Ó ÚÒÈÌ· ·ÈÌÔοı·ÚÛË ÌÔÚ› Ó· ÊÙ¿ÛÂÈ ÙÔ 60%. ΔÔ ÔÛÔÛÙfi ·˘Ùfi ·Ó‚·›ÓÂÈ ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ, ·Ó Ë ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Û˘Ó‰˘¿˙ÂÙ·È Ì و¯‹ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ¶ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ·Ó·Ù˘Í‹ Ù˘ ·ÔÙÂÏÔ‡Ó: 1) ¶ÚÔ˘¿Ú¯Ô˘Û· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· Ô˘ ÂËÚ¿˙ÂÈ Ù· ÓÂÊÚ¿, fiˆ˜ Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘, Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË Î·È Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ 2) ¶ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ·, ηıÒ˜ Ô ÓÂÊÚfi˜ Â›Ó·È È‰È·›ÙÂÚ· ¢·›ÛıËÙÔ˜ Û ·Ó¿Ù˘ÍË ˘fiÙ·Û˘ ÂÚÈÂÁ¯ÂÈÚËÙÈο 3) ∂ÚÁÒ‰ÂȘ ¯ÂÈÚÔ˘ÚÁÈÎÔ› ¯ÂÈÚÈÛÌÔ› Ô˘ ··È-
173
174
M. T™OXATZH™, I. KO™KINA™
Ó˘ (΢ÎÏÔÛÔÚ›ÓË, tacrolimus) ˆ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ÌÔÚ› Ó· ÂȉÂÈÓÒÛÂÈ ÂÚ·ÈÙ¤Úˆ ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ ÚÒÈÌË ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ô˘ ÚÔηÏÔ‡Ó Ù· ·ÓˆÙ¤Úˆ Ê¿Ú̷η ÔÊ›ÏÂÙ·È ÛÙËÓ ÔÍ›· ·ÁÁÂÈÔÛ‡Û·ÛË Ô˘ ÚÔηÏÔ‡Ó ÛÙ· ÚÔÛ·ÁˆÁ¿ ·ÚÙËÚ›‰È· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÛÂÈÚ¿Ì·ÙÔ˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·˘ÍË̤ÓË ·ÁÁÂȷ΋ ·ÓÙ›ÛÙ·ÛË, ÙËÓ ÂÏ·Ùو̤ÓË ÓÂÊÚÈ΋ ·ÈÌ¿ÙˆÛË Î·È ÙÂÏÈο ÙË ÌÂȈ̤ÓË ÛÂÈÚ·Ì·ÙÈ΋ ‰È‹ıËÛË. ∏ ·ÓˆÙ¤Úˆ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË Î·È Û ÁÂÓÈΤ˜ ÁÚ·Ì̤˜ ·Ó·ÛÙÚ¤„ÈÌË, ·Ó Î·È ÌÔÚ› Ó· ÂÍÂÏȯı› Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ·Ó ‰Â ‰ÈÔÚıˆı› ¤ÁηÈÚ·. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÔÏÈÁÔ˘ÚÈ¿ Û˘Óԉ¢fiÌÂÓË ·fi ¯·ÌËÏ‹ ÎÏ·ÛÌ·ÙÈ΋ ·¤ÎÎÚÈÛË Ó·ÙÚ›Ô˘ ÛÙ· Ô‡Ú·, ÂÓÒ ÙÔ ›˙ËÌ· Ô‡ÚˆÓ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi. ªÂϤÙ˜ Û‡ÁÎÚÈÛ˘ ÔÍ›·˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ ¤‰ÂÈÍ·Ó ˘„ËÏfiÙÂÚË ÙÔÍÈÎfiÙËÙ· ·fi ÙË ¯Ú‹ÛË Î˘ÎÏÔÛÔÚ›Ó˘ Û ۯ¤ÛË Ì ÙË ¯Ú‹ÛË tacrolimus. ™Â ·ÛıÂÓ›˜ Ì ÚÒÈÌË ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ¤¯Ô˘Ó ÚÔÙ·ı› ÓÂÊÚÔÚÔÛٷ٢ÙÈο ·ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ·, Ù· ÔÔ›· ‚·Û›˙ÔÓÙ·È ÛÙËÓ ÂÏ¿ÙÙˆÛË ‹ Î·È ÙËÓ ÂÍ¿ÏÂÈ„Ë ¯Ú‹Û˘ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘. ∞˘Ù¿ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË ¯Ú‹ÛË ÂÏ·Ùو̤Ó˘ ‰fiÛ˘ ΢ÎÏÔÛÔÚ›Ó˘ ÛÂ Û˘Ó‰˘·ÛÌÔ Ì MMF ‹ ·ÓÙÈCD25, ÙËÓ fi„ÈÌË ¤Ó·ÚÍË Î˘ÎÏÔÛÔÚ›Ó˘ ‹ ÙË ¯Ú‹ÛË sirolimus ÛÂ Û˘Ó‰˘·ÛÌfi Ì MMF. ™Â ÁÂÓÈΤ˜ ÁÚ·Ì̤˜, ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÚÒÈÌ˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Û˘Ó›ÛÙ·Ù·È Ë ‚¤ÏÙÈÛÙË ÂÈÏÔÁ‹ ‰ÔÙÒÓ Î·È ÏËÙÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ë ·ÔÊ˘Á‹ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜ Û ÂÈ‚·Ú˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È Ë ÔÚıÔÏÔÁÈ΋ ¯Ú‹ÛË ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ ÛÙËÓ ÚÒÈÌË ÌÂÙ·-ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÂÚ›Ô‰Ô.
Oæπª∏ ¡∂ºƒπ∫∏ ¢À™§∂πΔOÀƒ°π∞ ∏ ‚ÂÙȈ̤ÓË ÂÈ‚›ˆÛË ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ ›وÛ˘ Ù˘ fi„ÈÌ˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜. ∏ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Ô‰ËÁ› Û ÛËÌ·ÓÙÈο ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜. Δ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·Ó¿Ï˘Û˘ ‚¿Û˘ ‰Â‰ÔÌ¤ÓˆÓ 36849 ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ Ë·ÙÔ·ıÒÓ ¤‰ÂÈÍ·Ó Â›ÙˆÛË ¯ÚÔÓ›·˜ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (ÛÂÈÚ·Ì·ÙÈ΋ ‰È‹ıËÛË <29 ml/min/1.73 m2 ۈ̷ÙÈ΋˜ ÂÈÊ¿ÓÂÈ·˜) Û 18.1% ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ 5ÂÙ›·. ∏ ÂÌÂÈÚ›· ÙÔ˘ πÔÎÚ·Ù›Ԣ ÓÔÛÔÎÔÌ›Ԣ ∞ıËÓÒÓ ·fi 71 ·ÛıÂÓ›˜ Ì ̤ÛË 6ÂÙ‹ ·Ú·ÎÔ-
ÏÔ‡ıËÛË, ¤‰ÂÈÍ 21% ›وÛË ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÛÙËÓ 5ÂÙ›·, Ë ÔÔ›· Û˘Û¯ÂÙ›ÛÙËΠ̠ÙË ¯Ú‹ÛË Î˘ÎÏÔÛÔÚ›Ó˘ Û·Ó Ì›˙ˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi. ∏ ÚÔԉ¢ÙÈ΋ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚ› Ó· ÚÔ‚ÏÂÊÙ› ·fi ÙËÓ Âȉ›ӈÛË ÙÔ˘˜ ÚÒÙÔ˘˜ 3-12 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ÕÏÏÔÈ ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ·ÔÙÂÏÔ‡Ó Ë ÚÔ¯ˆÚË̤ÓË ËÏÈΛ· ÙÔ˘ Ï‹ÙË, Ë ÚÔ-ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, ÙÔ ı‹Ï˘ ʇÏÔ, Ë ¯Ú‹ÛË Î˘ÎÏÔÛÔÚ›Ó˘ Û ۇÁÎÚÈÛË Ì tacrolimus, Ë Ïԛ̈ÍË Ì ¯ÚfiÓÈ· Ë·Ù›Ùȉ· C Ú›Ó ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ô ÚÔ¸¿Ú¯ˆÓ ۷ί·Ú҉˘ ‰È·‚‹Ù˘. ∏ á∞ Û˘Û¯ÂÙÈ˙fiÌÂÓË ·fi ¯Ú‹ÛË ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ ¤¯ÂÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ. ΔÔ ÚÒÙÔ ‚‹Ì· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ Ì á∞ Â›Ó·È Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ‰fiÛÂˆÓ ÙˆÓ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘. ∏ ÚÔÛı‹ÎË MMF Ì ·Ú¿ÏÏËÏË ÂÏ¿ÙÙˆÛË Ù˘ ‰fiÛ˘, ¤¯ÂÈ ÙËÓ ›‰È· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ì ¯·ÌËÏfiÙÂÚË ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·. ™Â ÂÏÂÁ¯fiÌÂÓË ÌÂϤÙË, ÔÈ ·ÛıÂÓ›˜ Ô˘ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û MMF ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¯·ÌËÏ‹ ‰fiÛË ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ (trough ›‰· ·›Ì·ÙÔ˜ <4 ÁÈ· tacrolimus Î·È <50 ÁÈ· ΢ÎÏÔÛÔÚ›ÓË) ¤È¯·Ó ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÙÔ˘ ÏÈȉ·ÈÌÈÎÔ‡ ÚÔÊ›Ï Û ۇÁÎÚÈÛË Ì ·˘ÙÔ‡˜ Ô˘ ¤Ï·‚·Ó ÙË ÎÏ·ÛÛÈ΋ ‰fiÛË ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘. ÕÏÏË ÂÓ·ÏÏ·ÎÙÈ΋ ÂÈÏÔÁ‹ ·ÔÙÂÏ› Ë ¯Ú‹ÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Ô˘ ‰ÂÓ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘. ¶·ÚfiÙÈ ˘¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ ıÂÙÈ΋˜ ¤Î‚·Û˘ Û ·ÛıÂÓ›˜ ˘fi ÌÔÓÔıÂڷ›· Ì MMF, ¿ÏϘ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ˘„ËÏ¿ ÔÛÔÛÙ¿ ·fiÚÚȄ˘ ‹ Î·È ·Ó¿ÚÎÂÈ·˜ ÌÔۯ‡̷ÙÔ˜. ∏ ÌÔÓÔıÂڷ›· Ì sirolimus ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ·ÛÊ·Ï‹ ÂÈÏÔÁ‹, ÂÓÙÔ‡ÙÔȘ Ë ˘¿Ú¯Ô˘Û· ÂÌÂÈÚ›· Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË Î·È ·ÚÂÓ¤ÚÁÂȘ fiˆ˜ Ë ˘ÂÚÏÈȉ·ÈÌ›· Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙÂÓ¿. Δ¤ÏÔ˜, οı ‰ÓËÙÈο ÓÂÊÚÔÙÔÍÈÎfi Ê¿ÚÌ·ÎÔ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÓÂÓ›˜, ÂÓÒ ÌÂÙ·‚ÔÏÈΤ˜ ÂÈÏÔΤ˜ fiˆ˜ Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘, Ë ˘¤ÚÙ·ÛË Î·È Ë ‰˘ÛÏÈȉ·ÈÌ›· Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÂÈıÂÙÈο ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÏ·¯ÈÛÙÔÔÈËı› Ë Â›‰Ú·Û‹ ÙÔ˘˜ ÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·.
™Àª¶∂ƒ∞™ª∞Δ∞ ∏ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
·Ú¿ÁÔÓÙ· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ Ë·ÙÔ·ıÒÓ Î·È ÌÔÚ› Ó· ‰È·ÎÚÈı› Û ÚÒÈÌË Î·È fi„ÈÌË. ∏ ÚÒÈÌË ¤¯ÂÈ Û·Ó Î‡ÚÈÔ˘˜ ÚԉȷıÂÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ·, ÚÔ˘¿Ú¯Ô˘Û· ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· Ô˘ ÂËÚ¿˙ÂÈ ÙÔ˘˜ ÓÂÊÚÔ‡˜ ‹ ÚÔ˘¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. ∏ fi„ÈÌË Û˘Ó‰˘¿˙ÂÙ·È ÌÂٷ͇ ¿ÏÏˆÓ Ì ÚÔ-ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, ÙË ¯Ú‹ÛË Î˘ÎÏÔÛÔÚ›Ó˘ Û ۇÁÎÚÈÛË Ì tacrolimus Î·È ÙË Ïԛ̈ÍË Ì ¯ÚfiÓÈ· Ë·Ù›Ùȉ· C Ú›Ó ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ÂÏ¿ÙÙˆÛË Ù˘ ‰fiÛ˘ ÙˆÓ ·ÓÙ·ÁˆÓÈÛÙÒÓ Î·ÏÛÈÓ¢ڛÓ˘ ¤¯ÂÈ Â˘ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù·˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙˆÓ ‰˘Ô ÌÔÚÊÒÓ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜.
∂Ó‰ÂÈÎÙÈ΋ BÈ‚ÏÈÔÁÚ·Ê›· 1. Varo E, Lopez A, Rivero C. Initial immunosuppression in liver transplant recipients with impaired renal function. Transplant Proc. 2005 ;37:3909-12. 2. Pham PT, Pham PC, Wilkinson AH. Renal function outcomes following liver transplantation and combined liver-kidney transplantation. Nat Clin Pract Nephrol. 2007;3:507-14.
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5. Pawarode A, Fine DM, Thuluvath PJ Independent risk factors and natural history of renal dysfunction in liver transplant recipients. Liver Transpl. 2003;9:741-7 6. Cohen AJ, Stegall MD, Rosen CB, et al. Chronic renal dysfunction late after liver transplantation. Liver Transpl 2002;8:916-21 7. Tsochatzis E, Koskinas J, Manesis EK, et al. Liver transplantation in Greek patients: epidemiological data, morbidity, and mortality of 71 patients from a single center with 6 years of mean follow-up. Transplant Proc 2007;39:1505-7 8. Beckebaum S, Cicinnati VR, Klein CG, et al. Impact of combined mycophenolate mofetil and low-dose calcineurin inhibitor therapy on renal function, cardiovascular risk factors, and graft function in liver transplant patients: preliminary results of an open prospective study. Transplant Proc. 2004;36:2671-4. 9. Herrero JI, Quiroga J, Sangro B, et al. Conversion of liver transplant recipients on cyclosporine with renal impairment to mycophenolate mofetil. Liver Transpl Surg 1999;5:414-20. 10. Stewart SF, Hudson M, Talbot D, et al. Mycophenolate mofetil monotherapy in liver transplantation. Lancet 2001;357:609-10.
3. Said A, Lucey MR.Liver transplantation: an update. Curr Opin Gastroenterol. 2006;22:272-8.
11. Alessandria C, Ozdogan O, Guevara M, et al. MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation. Hepatology 2005;41:1282-9
4. Ojo AO, Held PJ, Port FK, et al. Chronic renal failure after transplantation of a nonrenal organ. N Engl J Med. 2003;349:931-40
12. Nankivell BJ, Chapman JR, Bonovas G, et al. Oral cyclosporine but not tacrolimus reduces renal transplant blood flow. Transplantation 2004 ;77:1457-9.
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5
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ÓË ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ë ÛÙ¿وÛË ÂÌÊ·Ó›˙Ô˘Ó Ôχ Û˘¯Ó¿ (Û ÔÛÔÛÙfi Ô˘ Êı¿ÓÂÈ ‹ ˘ÂÚ‚·›ÓÂÈ ÙÔ 60%) ÚˆÙÔ·ı‹ ÌË ÏÂÈÙÔ˘ÚÁ›· (primary nonfunction) (3-5). ø˜ ÂÎ ÙÔ‡ÙÔ˘, Ë ¯ÚËÛÈÌÔÔ›ËÛË ·˘ÙÒÓ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÁÂÓÈÎÒ˜ ·ÔʇÁÂÙ·È. ∞ÓÙ›ıÂÙ·, ÌÔۯ‡̷ٷ Ì ‹È· ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ë ÛÙ¿وÛË ¤¯Ô˘Ó ·ÚfiÌÔÈ· ÂÈÙ˘¯›· Ì ٷ ÌÔۯ‡̷ٷ ¯ˆÚ›˜ ÛÙ¿وÛË, fiÛÔÓ ·ÊÔÚ¿ ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜ Î·È ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ (2,3). Δ· ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó Ù· ÌÔۯ‡̷ٷ Ì ̤ÙÚÈ· ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ë ÛÙ¿وÛË Â›Ó·È ÈÔ Û‡ÓıÂÙ· Î·È ı· ·Ó·Ï˘ıÔ‡Ó ·Ú·Î¿Ùˆ. ™Â Ì›· ÌÂϤÙË 120 Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÛÙ¿وÛË (6), ‰È·ÈÛÙÒıËΠfiÙÈ Ë ·ÚÔ˘Û›· ̤ÙÚÈ·˜ ‹ ¤ÓÙÔÓ˘ ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ô˘˜ ÛÙ¿وÛ˘ Û˘Ó‰ÂfiÙ·Ó Ì و¯‹ ·Ú¯È΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (initial poor function) Î·È ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¯ÚfiÓÔ˘ ÌÂÙ¿ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™ÙË ÌÂϤÙË ·˘Ù‹ (6), Ùˆ¯‹ ·Ú¯È΋ ÏÂÈÙÔ˘ÚÁ›· ·Ú·ÙËÚ‹ıËΠÛÙÔ 17% ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ‹È· ÛÙ¿وÛË Î·È ÛÙÔ 35% ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ̤ÙÚÈ· ‹ ¤ÓÙÔÓË ÛÙ¿وÛË. ∞ÒÏÂÈ· ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ‰È·ÈÛÙÒıËΠÛÙÔ 22,5% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¯ˆÚ›˜ ÛÙ¿وÛË, ÛÙÔ 23,5% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì ‹È· ÛÙ¿وÛË Î·È ÛÙÔ 37,5% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì ̤ÙÚÈ· ‹ ¤ÓÙÔÓË ÛÙ¿وÛË. ∏ ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ÌÂϤÙ˘ ¤‰ÂÈÍ fiÙÈ ÔÈ ‰‡Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¤Ó· Ì‹Ó· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹Ù·Ó Ô ‚·ıÌfi˜ Ù˘ ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ô˘˜ ÛÙ¿وÛ˘ Î·È Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË (status) ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ¿ÏÏË ÌÂϤÙË (7) ‰È·ÈÛÙÒıËΠfiÙÈ Ô Î›Ó‰˘ÓÔ˜ Ùˆ¯‹˜ ·Ú¯È΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó ·˘ÍË̤ÓÔ˜ ηٿ 3,7 ÊÔÚ¤˜ fiÙ·Ó ˘‹Ú¯Â ̤ÙÚÈ· ‹ ¤ÓÙÔÓË ÛÙ¿وÛË, Û ۇÁÎÚÈÛË Ì ÙËÓ ·ÚÔ˘Û›· ‹È·˜ ÛÙ¿وÛ˘. O ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Ùˆ¯‹˜ ·Ú¯È΋˜ ÏÂÈ-
∏ ÛÙ¿وÛË ‹ ÏÈ҉˘ ÂÎʇÏÈÛË ·ÔÙÂÏ› ·Ó·ÛÙÚ¤„ÈÌË ·ÏÏÔ›ˆÛË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Ô˘ Û˘Ó‹ıˆ˜ ÔÊ›ÏÂÙ·È Û ·¯˘Û·ÚΛ·, ˘ÂÚÏÈȉ·ÈÌ›·, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ηٷӿψÛË ÔÈÓÔÓ‡̷ÙÔ˜ Î·È Ï‹„Ë Ê·ÚÌ¿ÎˆÓ ‹ ·ÚÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜. ∫·Ù¿ ÙËÓ ÂͤٷÛË ÛÙÔ ÌÈÎÚÔÛÎfiÈÔ, ÙÔ Ï›Ô˜ ÛÙ· Ë·ÙÔ·ÙÙ·Ú· ÌÔÚ› Ó· ¤¯ÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ÔÏÏ·ÏÒÓ Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈÎÒÓ ÏÈÔÛÙ·ÁÔÓȉ›ˆÓ (ÛÙ¿وÛË ÌÈÎÚÔÎÂÓÔÙÔÈÒ‰Ô˘˜ Ù‡Ô˘), ‹ ÌÈ¿˜ ÌÂÁ¿Ï˘ ÏÈÔÛÙ·ÁfiÓ·˜ Ô˘ ·ÚÂÎÙÔ›˙ÂÈ ÙÔÓ ˘Ú‹Ó· ÛÙËÓ ÂÚÈʤÚÂÈ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘ (ÛÙ¿وÛË ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ô˘˜ Ù‡Ô˘). ∂Âȉ‹ Ë ÛÙ¿وÛË Â›Ó·È Û˘¯Ó‹ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi Î·È ÂÂȉ‹ ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ı· ·Ó·ÛÎÔ‹ÛÔ˘Ì ÌÂ Û˘ÓÙÔÌ›· ÙË Û¯ÂÙÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÔÛÔÛÙfi ¤ˆ˜ 30% ÙˆÓ ·ÙfiÌˆÓ Ô˘ ‰˘ÓËÙÈο ·ÔÙÂÏÔ‡Ó ‰fiÙ˜ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÂÌÊ·Ó›˙Ô˘Ó ÛÙ¿وÛË ‹·ÙÔ˜ (1,2). ΔÔ ÔÛÔÛÙfi ·˘Ùfi Ì¿ÏÈÛÙ· ÚԂϤÂÙ·È fiÙÈ ı· ·˘ÍËı›, ·ÎÔÏÔ˘ıÒÓÙ·˜ ÙËÓ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ·¯˘Û·ÚΛ·˜ Î·È ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∏ ÂÎÙ›ÌËÛË Ù˘ ·ÚÔ˘Û›·˜ ÛÙ¿وÛ˘ ÛÙÔ ÌfiÛ¯Â˘Ì· ηÙã·Ú¯‹Ó Á›ÓÂÙ·È Ì·ÎÚÔÛÎÔÈο ·fi ÙÔ˘˜ ¯ÂÈÚÔ˘ÚÁÔ‡˜ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡Ó ÙËÓ Â¤Ì‚·ÛË ÛÙÔ ‰fiÙË. ŒÓ·˜ ¤ÌÂÈÚÔ˜ ¯ÂÈÚÔ˘ÚÁfi˜ Û˘Ó‹ıˆ˜ ÌÔÚ› Ó· ·Ó·ÁÓˆÚ›ÛÂÈ ÙËÓ ·ÚÔ˘Û›· ¤ÓÙÔÓ˘ ÛÙ¿وÛ˘, fï˜ Ë ‹È· Î·È Ë Ì¤ÙÚÈ· ÛÙ¿وÛË Â‡ÎÔÏ· ‰È·Ê‡ÁÔ˘Ó Î·Ù¿ ÙË Ì·ÎÚÔÛÎÔÈ΋ ÂͤٷÛË (2,3). ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔÌÒÓ ÎÚ˘ÔÛÙ¿ÙË (Ù·¯Â›· ‚ÈÔ„›·) ÌÔÚ› Ó· ÚÔÛ‰ÈÔÚ›ÛÂÈ Â·ÎÚÈ‚Ò˜ ÙË ‚·Ú‡ÙËÙ· Ù˘ ÛÙ¿وÛ˘. ∏ ÛÙ¿وÛË ‚·ıÌÔÏÔÁÂ›Ù·È ˆ˜: ·) ‹È·, fiÙ·Ó ·ÊÔÚ¿ ¤ˆ˜ 30% ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, ‚) ̤ÙÚÈ·, fiÙ·Ó ·ÊÔÚ¿ ÔÛÔÛÙfi 30-60% ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Î·È Á) ¤ÓÙÔÓË ‹ ÛÔ‚·Ú‹, fiÙ·Ó ·ÊÔÚ¿ ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ 60% ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ (3). ◊‰Ë ·fi ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990, ‰È·ÈÛÙÒıËΠfiÙÈ Ù· Ë·ÙÈο ÌÔۯ‡̷ٷ Ì ¤ÓÙÔ-
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙÔ˘ÚÁ›·˜ ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ̤ÙÚÈ· ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ë ÛÙ¿وÛË ·ÔÙÂÏ› ‡ÚËÌ· Î·È ·Ï·ÈfiÙÂÚˆÓ ÌÂÏÂÙÒÓ, Û ÔÚÈṲ̂Ó˜ Ì¿ÏÈÛÙ· ·fi ÙȘ Ôԛ˜ ‰È·ÈÛÙÒıËΠ›Û˘ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÚˆÙÔ·ıÔ‡˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ (3-5). ø˜ ÂÎ ÙÔ‡ÙÔ˘, ·˘Ù¿ ıˆÚÔ‡ÓÙ·È ˆ˜ «ÔÚȷο» ÌÔۯ‡̷ٷ, ÁÈ·Ù› Û˘¯Ó¿ ÙÔ ÎÏÈÓÈÎfi ·ÔÙ¤ÏÂÛÌ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‰ÂÓ Â›Ó·È ÙÔ ÂÈı˘ÌËÙfi, ȉȷ›ÙÂÚ· fiÙ·Ó Û˘ÓÙÚ¤¯Ô˘Ó Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, fiˆ˜ Ô ·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ‹ Ë ÌÂÁ¿ÏË ËÏÈΛ· ÙÔ˘ ‰fiÙË (2,8). §fiÁˆ fï˜ Ù˘ ÌÂÁ¿Ï˘ ·Ó¿Á΢ Ô˘ ˘¿Ú¯ÂÈ ÁÈ· Ë·ÙÈο ÌÔۯ‡̷ٷ, Ë ¯ÚËÛÈÌÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ̤ÙÚÈ· ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ë ÛÙ¿وÛË ·ÔÙÂÏ› ¤Ó· Û‡Á¯ÚÔÓÔ ‰›ÏËÌÌ· ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (9,10). ™Ù·‰È·Î¿ ·Ó·Ù‡ÛÛÂÙ·È Ë Ù¿ÛË Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ù· ÌÔۯ‡̷ٷ ·˘Ù¿ Û ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ÌÂÙ¿ ·fi fiÛÔ ÙÔ ‰˘Ó·Ùfi ÌÈÎÚfiÙÂÚÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ (2,10). ∞ÓÙ›ıÂÙ· Ì ÙË ÛÙ¿وÛË ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ô˘˜ Ù‡Ô˘, Ë ÛÙ¿وÛË ÌÈÎÚÔÎÂÓÔÙÔÈÒ‰Ô˘˜ Ù‡Ô˘ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÚˆÙÔ·ıÔ‡˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ·ÎfiÌË Î·È fiÙ·Ó Â›Ó·È ¤ÓÙÔÓË (11). ™Â Ì›· ÛÂÈÚ¿ 40 ÂÚÈÙÒÛÂˆÓ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ Ì ̤ÙÚÈ· ‹ ¤ÓÙÔÓË ÌÈÎÚÔÎÂÓÔÙÔÈÒ‰Ë ÛÙ¿وÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ‰ÂÓ ·Ú·ÙËÚ‹ıËΠÂÏ·Ùو̤ÓË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ¤Ó· ¯ÚfiÓÔ ÌÂÙ¿ ·fi ÙËÓ Â¤Ì‚·ÛË (11). ∂ÈϤÔÓ, ÛÙȘ ‚ÈÔ„›Â˜ ‹·ÙÔ˜ Ô˘ ÂÏ‹ÊıËÛ·Ó ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·Ú·ÙËÚ‹ıËΠÂÏ¿ÙÙˆÛË Î·È Û˘¯Ó¿ ÂÍ¿ÏÂÈ„Ë Ù˘ ÛÙ¿وÛ˘. OÈ Ì˯·ÓÈÛÌÔ› ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÔÊ›ÏÂÙ·È Ë ‚Ï¿‚Ë ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ì ÛÙ¿وÛË ‚Ú›ÛÎÔÓÙ·È ˘fi ‰ÈÂÚ‡ÓËÛË. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ù· Ë·ÙÔ·ÙÙ·Ú· Ì ÛÙ¿وÛË ¤¯Ô˘Ó ÂÏ·Ùو̤ÓË ·Ú·ÁˆÁ‹ ATP, ÂÏ·Ùو̤ÓË ·ÓÔ¯‹ Û ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë Î·È ÂÏ·Ùو̤ÓË ÈηÓfiÙËÙ· ·Ó·Á¤ÓÓËÛ˘ (9). ∫·Ù¿ ÙË Ê¿ÛË Ù˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, Ù· ÌÔۯ‡̷ٷ Ì ÛÙ¿وÛË ÂÌÊ·Ó›˙Ô˘Ó ‰È·Ù·Ú·¯¤˜ Ô˘ ·ÊÔÚÔ‡Ó ÙfiÛÔ Ù· Ë·ÙÔ·ÙÙ·Ú·, fiÛÔ Î·È Ù· ·ÙÙ·Ú· Ô˘ ·Ï›ÊÔ˘Ó Ù· ÎÔÏÒ‰Ë ÙÚȯÔÂȉ‹ ·ÁÁ›·, ÔÈ Ôԛ˜ ÂΉËÏÒÓÔÓÙ·È ÎÏÈÓÈο ÌÂÙ¿ ·fi ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË (1215). ∏ Û˘ÛÛÒÚ¢ÛË ÂχıÂÚˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ ÛÙ· Ë·ÙÔ·ÙÙ·Ú· ‰È·Ù·Ú¿ÛÛÂÈ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÌÈÙÔ¯ÔÓ‰Ú›ˆÓ Î·È ÙË ‰È·‰Èηۛ· ÌÂÙ·ÊÔÚ¿˜ ËÏÂÎÙÚÔÓ›ˆÓ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÚ·ÈÙ¤Úˆ ÂÏ¿ÙÙˆÛË Ù˘ ·Ú·ÁˆÁ‹˜ ATP, ÂÓÒ Ë ˘ÂÚÔÍ›‰ˆÛË ÙˆÓ ÏÈ-
177
ȉ›ˆÓ ÚÔηÏ› ΢ÙÙ·ÚÈΤ˜ ‚Ï¿‚˜ ÏfiÁˆ ¤ÎÏ˘Û˘ ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ (15-17). ∂ÈϤÔÓ, ÔÈ Â˘ÌÂÁ¤ıÂȘ ÏÈÔÛÙ·ÁfiÓ˜ Ù˘ ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ô˘˜ ÛÙ¿وÛ˘ Ê·›ÓÂÙ·È fiÙÈ ·ÔÙÂÏÔ‡Ó ÂÌfi‰ÈÔ ÛÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ ̤۷ ÛÙ· ÎÔÏÒ‰Ë ÙÚȯÔÂȉ‹ ·ÁÁ›·, ÂÓÒ Ë ¤Î¯˘ÛË ÏÈȉ›ˆÓ ·fi Ù· Ë·ÙÔ·ÙÙ·Ú· ÏfiÁˆ ηٷÛÙÚÔÊ‹˜ ÙÔ˘˜ ηٿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ‰È·Ù·Ú¿ÛÛÂÈ ÂÚ·ÈÙ¤Úˆ ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ Î·È ·Ú¤¯ÂÈ ÂÈÚfiÛıÂÙÔ ˘fiÛÙڈ̷ ÁÈ· ÔÍÂȉˆÙÈΤ˜ ·ÓÙȉڿÛÂȘ (18,19). ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ڈÙÔ·ı‹ ÌË ÏÂÈÙÔ˘ÚÁ›· ÏfiÁˆ ÛÙ¿وÛ˘ ‰Â›¯ÓÂÈ ÙËÓ ·ÚÔ˘Û›· ¢ÌÂÁÂıÒÓ ÂÍˆÎ˘ÙÙ¿ÚÈˆÓ ÏÈÔÛÙ·ÁfiÓˆÓ, ȉȷ›ÙÂÚ· ÛÙȘ ˙ÒÓ˜ 2 Î·È 3 ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, Ô˘ ÚÔηÏÔ‡Ó ‰È·Ù·Ú·¯‹ Ù˘ ·Ú¯ÈÙÂÎÙÔÓÈ΋˜ ÙˆÓ ÎÔψ‰ÒÓ ÙÚȯÔÂȉÒÓ ·ÁÁ›ˆÓ Î·È Û˘Óԉ‡ÔÓÙ·È ·fi ·ÈÌÔÚÚ·Á›· Î·È ÂÛٛ˜ Ó¤ÎÚˆÛ˘ ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ (19,20). ∏ Û˘ÛÛÒÚ¢ÛË ÂÍˆÎ˘ÙÙ¿ÚÈˆÓ ÏÈÔÛÙ·ÁfiÓˆÓ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ۯËÌ·ÙÈÛÌfi ΢ÛÙÈÎÒÓ ¯ÒÚˆÓ Ô˘ ı˘Ì›˙Ô˘Ó ÙËÓ ÂÏ›ˆÛË ÙÔ˘ ‹·ÙÔ˜ («ÏÈÔÂÏ›ˆÛË») (21). ∏ ·Ó¿Ù˘ÍË Ó¤ˆÓ ÌÂıfi‰ˆÓ Û˘ÓÙ‹ÚËÛ˘ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ô˘ ı· ÂÈÙÚ¤„Ô˘Ó ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ̤ÙÚÈ· ‹ ¤ÓÙÔÓË ÛÙ¿وÛË ·ÔÙÂÏ› Ì›· Û‡Á¯ÚÔÓË ÚfiÎÏËÛË (1,2,15). ∏ ÛÙ¿وÛË ‚¤‚·È· Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë Î·È ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·fi ˙ÒÓÙ· ‰fiÙË. §fiÁˆ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÛÙÔ ‰fiÙË, Û ÔÏÏ¿ ÚÔÁÚ¿ÌÌ·Ù· ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ Ì¤ÁÈÛÙÔ ·Ô‰ÂÎÙfi fiÚÈÔ ÌÂÁ·ÏÔÎÂÓÔÙÔÈÒ‰Ô˘˜ ÛÙ¿وÛ˘ Ù›ıÂÙ·È Â› ÙÔ˘ ·ÚfiÓÙÔ˜ ÛÙÔ 20%, fiˆ˜ ÌÔÚ› Ó· ÚÔÛ‰ÈÔÚÈÛı› ηٿ ÙËÓ ÚÔÛÂÎÙÈ΋ ÈÛÙÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÚÔÂÁ¯ÂÈÚËÙÈ΋˜ ‚ÈÔ„›·˜ (2). ∂ÈϤÔÓ Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ÂÏ·ÙÙˆı› Ë ÛÙ¿وÛË ÙÔ˘ ‰fiÙË ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ‰›·ÈÙ·, ۈ̷ÙÈ΋ ¿ÛÎËÛË Î·È ·Ô¯‹ ·fi Ù· ÔÈÓÔÓÂ˘Ì·ÙÒ‰Ë ÔÙ¿ (22).
μÈ‚ÏÈÔÁÚ·Ê›· 1. Alwayn IPJ, Porte RJ. How to make steatotic livers suitable for transplantation. Liver Transpl 2007;13:480-2. 2. Nocito A, El-Badry AM, Clavien PA. When is steatosis too much for transplantation? J Hepatol 2006;45:483513. 3. Adam R, Reynes M, Johann M, et al. The outcome of steatotic grafts in liver transplantation. Transplant Proc 1991;23:1538-40. 4. D’Alessandro AM, Kalayoglu M, Sollinger HW, et al. The predictive value of donor liver biopsies on the development of primary nonfunction after orthotopic
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liver transplantation. Transplant Proc 1991;23:1536-7. 5. Ploeg RJ, D’Alessandro AM, Knechtle SJ, et al. Risk factors for primary dysfunction after liver transplantation – a multivariate analysis. Transplantation 1993; 55:807-13. 6. Verran D, Kusyk T, Painter D, et al. Clinical experience gained from the use of 120 steatotic donor livers for orthotopic liver transplantation. Liver Transpl 2003; 9:500-5. 7. Urena MAG, Ruiz-Delgado FC, Gonzalez EM, et al. Assessing risk of the use of livers with macro and microsteatosis in a liver transplant program. Tranplant Proc 1998;30:3288-91. 8. Briceno J, Ciria R, Pleguezuelo M, et al. Contribution of marginal donors to liver transplantation for hepatitis C virus infection. Transplant Proc 2007;39:2297-9. 9. Selzner M, Clavien PA. Fatty liver in liver transplantation and surgery. Semin Liver Dis 2001;21:105-13.
cold preservation. Transplantation 1999;67:195-200. 14. Angulo P. Nonalcoholic fatty liver disease and liver transplantation. Liver Transpl 2006;12:523-34. 15. Bessems M, Doorschodt BM, Kolkert JLP, et al. Preservation of steatotic livers: A comparison between cold storage and machine perfusion preservation. Liver Transpl 2007;13:497-504. 16. Hayashi M, Tokunaga Y, Fujita T, et al. The effects of cold preservation on steatotic graft viability in rat liver transplantation. Transplantation 1993;56:282-7. 17. George J, Pera N, Phung N, et al. Lipid peroxidation, stellate cell activation and hepatic fibrogenesis in a rat model of chronic steatohepatitis. J Hepatol 2003; 39: 756-64. 18. Seifalian AM, Piasecki C, Agarwal A, et al. The effect of graded steatosis on flow in the hepatic parenchymal microcirculation. Transplantation 1999;68:780-4.
10. Alkofer B, Samstein B, Guarrera JV, et al. Extendeddonor criteria liver allografts. Semin Liver Dis 2006; 26:221-33.
19. Huebscher SG, Portmann BC. Transplantation pathology. In: MacSween RNM, Burt AD, Portmann BC, et al (eds). Pathology of the liver. 4th ed. London: Churchill Livingstone 2002:885-941.
11. Fishbein TM, Fiel MI, Emre S, et al. Use of livers with microvesicular fat safely expands the donor pool. Transplantation 1997;64:248-51.
20. Todo S, Demetris AJ, Makowka L, et al. Primary nonfunction of hepatic allografts with preexisting fatty infiltration. Transplantation 1989;47:903-5.
12. Trevisani F, Colantoni A, Caraceni P, et al. The use of donor fatty liver for liver transplantation: a challenge or a quagmire? J Hepatol 1996;24:114-21.
21. Ferrell L, Bass N, Roberts J, et al. Lipopeliosis: fat induced sinusoidal dilatation in transplanted liver mimicking peliosis hepatis. J Clin Pathol 1992;45:1109-10.
13. Fukumori T, Ohkohchi N, Tsukamoto S, et al. The mechanism of injury in a steatotic liver graft during
22. McCormack L, Clavien PA. Understanding the meaning of fat in the liver. Liver Transpl 2005;11:137-9.
™˘ÓÙ‹ÚËÛË – BÏ¿‚˜ ÈÛ¯·ÈÌ›·˜/·ӷÈÌ¿ÙˆÛ˘ ‹·ÙÔ˜
6
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∂π™∞°ø°∏
ۛ˜ Ô˘ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È Î·È ÔÈ Ôԛ˜ ÂÌϤΈÓÙ·È ÛÙËÓ Ë·ÙÈ΋ ‚Ï¿‚Ë Â›Ó·È ÔÈ Î˘ÙÔΛÓ˜ (TNF·, IL-1‚, IL-6, IL-8), Ù· ÂÈÎÔÛ·ÓÔÂȉ‹ (PG∂2, TXμ2, LTμ4), ÔÈ ÂχıÂÚ˜ Ú›˙˜ Ô͢ÁfiÓÔ˘ (R.O.S.), ÙÔ ÓÈÙÚÈÎfi ÔÍ›‰ÈÔ (NO),Î·È Ù· ÚˆÙÂÔÏ˘ÙÈο ÂÓ˙‡Ì·. ∂›Û˘ ÂÓÂÚÁÔÔÈË̤ӷ ÙÌ‹Ì·Ù· ÙÔ˘ ÛËÌÏËÚÒÌ·ÙÔ˜ ÂÚÈÏ·Ì‚¿ÓˆÓÙ·È ÛÙË ‰ËÌÈÔ˘ÚÁ›· Ù˘ ‚Ï¿‚˘ ‰ÈÂÁ›ڈÓÙ·˜ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ ·Ú¿ÁÔÓÙ· ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (P.A.F.) fiˆ˜ ›Û˘ Î·È Ë ·˘Í‹ÌÂÓË Û‡ÓıÂÛË ÌÔÚ›ˆÓ ÚÔÛÎfiÏËÛ˘ (adhesion molecules), Ë ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ (PMN) Î.·. ∞fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ ¤¯ÂÈ ÚÔÙ·ı› Ë ¿Ô„Ë fiÙÈ Ë ·ÔÙÚÔ‹ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ Kupffer ı· ¤¯ÂÈ ıÂÙÈ΋ ›‰Ú·ÛË ÛÙË ÚÔÛÙ·Û›· ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜,ÏfiÁÔ Ì›ˆÛ˘ Ù˘ ·Ú·ÁˆÁ‹˜ ÙˆÓ ÌÂÛÔÏ·‚ËÙÒÓ Ù˘ ÊÏÂÁ-
O Ì˯·ÓÈÛÌfi˜ ‰ËÌÈÔ˘ÚÁ›·˜ Ë·ÙÈ΋˜ ‚Ï¿‚˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÌÂÙ¿ ·fi ÈÛ¯·ÈÌ›· Î·È Â·Ó·ÈÌ¿ÙˆÛË Â›Ó·È ¤Ó· ÛÔ‚·Úfi Î·È ÔχÏÔÎÔ Úfi‚ÏËÌ·. ∏ ÚÔÛÙ·Û›· ÙÔ˘ ‹·ÙÔ˜ ·›˙ÂÈ Ôχ ÛËÌ·ÙÈÎfi ÚfiÏÔ Û ÂÚÈÙÒÛÂȘ ΢ÎÏÔÊÔÚÈ΋˜ ηٷÏËÍ›·˜, Û ÂÎÙÔ̤˜ ÙÔ˘ ‹·ÙÔ˜, Û ÙÚ·‡Ì·Ù· ÙÔ˘ ‹·ÙÔ˜ Î·È ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ¶Èı·Ó¤˜ Û˘Ó¤ÂȘ Ù˘ ÈÛ¯·ÈÌÈ΋˜ ‚Ï¿‚˘ Â›Ó·È Ë Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È Ë ¤Ó·ÚÍË Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ (S.I.R.S.) Î·È ÛËÙÈÎÔ‡ Shock Ù· ÔÔ›· ÌÔÚÔ‡Ó Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ·Ó¿ÚÎÂÈ· ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ (M.O.F.) ‹ ·fiÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜,ηٷÛÙ¿ÛÂȘ Ô˘ Û˘Óԉ‡ÔÓÙ·È ·fi Ôχ ·˘Í‹ÌÂÓË ıÓËÙfiÙËÙ·. ∞fi ÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÂÚ¢ÓËÙ¤˜ ¤¯Ô˘Ó ÚÔÙ·ı› ·ÚÎÂÙÔ› Ì˯·ÓÈÛÌÔ› Ô˘ Ó· ÂÍËÁÔ‡Ó ÙÔ Ì˯·ÓÈÛÌfi Ù˘ Û˘ÁÎÂÎÚÈ̤Ó˘ ‚Ï¿‚˘ Ì ΢ÚÈfiÙÂÚÔ ·˘ÙfiÓ Ù˘ ·Ú·ÁˆÁ‹˜ ∂Ï¢ı¤ÚˆÓ ƒÈ˙ÒÓ O͢ÁfiÓÔ˘ (ROS), Ù˘ ·ÁˆÁ‹˜ ÏÈȉÈ΋˜ ˘ÂÚÔÍ›‰ˆÛ˘ Î·È Ù˘ ·ÎfiÏÔ˘ı˘ ‰ËÌÈÔ˘ÚÁ›·˜ Ì›·˜ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ Î·È Ù˘ ·fiÙˆÛ˘ (∂ÈÎfiÓ· 1). ∏ ·ÓÔÍ›· Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ÈÛ¯·ÈÌ›·, ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÛËÌ·ÓÙÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ (Kupffer, Ë·ÙÔ·ÙÙ·Ú·, Ito, Pit) ∂¤Ú¯ÂÙ·È ÙÒÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ cAMP, ·Ó·Ú΋˜ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ‰È·‡ÏˆÓ ·Û‚ÂÛÙ›Ô˘ Î·È ‰È·Ù·Ú·¯¤˜ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÌÈÙÔ¯ÔÓ‰Ú›ˆÓ.
ATP Cellular homeostatis failure
C5a
EC and hepatocytes activation
IL-6 IL-10 IL-13 SLPI
KC activation
X/XOD Mitochondria
ROS
NO ET Narrowing of sinusoidal lumen
KC and EC
GM-CSF INF CD4 + T-cells TNFβ
LTB4 PAF
recrultment and activation
ICAM VCAM
TNFα Chemokines IL-1
GM-CSF
Neutrophil activation and accumulation
ROS, Proteases
∂¡∂ƒ°O¶Oπ∏™∏ ∫ÀΔΔ∞ƒø¡ KUPFFER
Necrosis ATP
Cellular injury
∏ ÂÓÂÚÁÔÔÈ‹ÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ Kupffer ÏfiÁÔ Ù˘ ‚Ï¿‚˘ ·fi ÈÛ¯·ÈÌ›· Î·È Â·Ó·ÈÌ¿ÙˆÛË Î·È/‹ Ù˘ ‡·Ú͢ ÂÓ‰ÔÙÔ͛Ӣ Ô‰ËÁ› ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË Ô˘ÛÈÒÓ Ô˘ ÌÂÛÔÏ·‚Ô‡Ó Î·È/‹ Û˘Ì‚¿ÏÔ˘Ó ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÌÈÎÚÔ΢ÎÏÔÊÔÚȷ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ (microcirculation inflammatory response) ÛÙÔ ‹·Ú Î·È Û ¿ÏÏ· ·ÔÌ·ÎÚ‡ÛÌÂÓ· fiÚÁ·Ó·. ªÂÚÈΤ˜ ·fi ÙȘ ‚·ÛÈΤ˜ Ô˘-
Necrapoptosis ATP Apoptosis
179
¢. °IAKOY™TI¢H™
180
ÌÔÓ‹˜ (TNF·, IL-1‚, IL-6, PGE2, TXB2, LTB4 Î.·.) Î·È Ù˘ ÌÈÎÚÔ΢ÎÏÔÊÔÚȷ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ (M.I.R.), Ì›ˆÛ˘ Ù˘ ÏÈȉÈ΋˜ ˘ÂÚÔÍ›‰ˆÛ˘ ÏfiÁÔ Ì›ˆÛ˘ Ù˘ ·Ú·ÁˆÁ‹˜ R.O.S. Î·È ÚˆÙÂÔÏ˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ‰È·Ù‹ÚËÛ˘ Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ Î·È ÚÔÛÙ·Û›·˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙˆÓ ÎÔÏÔÂȉÒÓ ÙÚȯÔÂȉÒÓ ÙÔ˘ ‹·ÙÔ˜.
ª∂Δ∞¡∞™Δ∂À™∏ ∫∞𠶃O™∫O§§∏™∏ º∞°O∫ÀΔΔ∞ƒø¡ ∏ ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ê·ÁÔ΢ÙÙ¿ÚˆÓ ÛÙÔÓ ÙfiÔ Ù˘ ÊÏÂÁÌÔÓ‹˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ¤Ó· ÔχÏÔÎÔ ‰›ÎÙ˘Ô ÚˆÙÂ˚ÓÒÓ ÛÙ· Ô˘‰ÂÙÂÚfiÊÈÏ· ·ÏÏ¿ Î·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙˆÓ ·ÁÁ›ˆÓ (∂ÈÎfiÓ· 2). ¶Ôχ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÚÔÛÎfiÏÏËÛË ·›˙Ô˘Ó ÔÚÈṲ̂Ó˜ ÚˆÙ½Ó˜ ÔÈ Ôԛ˜ ÔÓÔÌ¿˙ÔÓÙ·È ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ (adhesion molecules). Àfi Ê˘ÛÈÔÏÔÁÈΤ˜ Û˘Óı‹Î˜ Ù· Ê·ÁÔ·ÙÙ·Ú· ‰È·ÙËÚÔ‡Ó Ì›· ¯·Ï·Ú‹ Û‡Ó‰ÂÛË Ì ÙÔ ÙÔ›¯ˆÌ· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘. ∏ Û‡Ó‰ÂÛË ·˘Ù‹ Á›ÓÂÙ·È ‰È·Ì¤ÛÔ˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÙˆÓ ™ÂÏÂÎÙÈÓÒÓ (Selectin family). OÈ ÛÂÏÂÎÙ›Ó˜ Â›Ó·È ÂÈÊ·ÓÂȷΤ˜ ÚˆÙ›Ó˜ Î·È ¯ˆÚ›˙ÔÓÙ·È ÛÙȘ L-Selectin, ÛÙËÓ P-Selectin Î·È ÛÙËÓ E-Selectin. ∏ L-Selectin (CD62L) ÂÎÊÚ¿˙ÂÙ·È ·fi Ù· Ê·ÁÔ·ÙÙ·Ú· Î·È Û˘Ó‰¤ÂÙ·È Ì ÁÏ˘ÎÔÚˆÙ›Ó˜ Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Ô˘ ˘¿Ú¯Ô˘Ó ÛÙÔÓ ÙfiÔ Ù˘ ÊÏÂÁÌÔÓ‹˜. ∏ P-Selectin (CD62P) Î·È Ë E-Selectin (CD62E) Û˘Ó‰¤ÔÓÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Ì ٷ Ô˘‰ÂÙÂÚfiÊÈÏ· Ì ÂȉÈΤ˜ ÁÏ˘ÎÔÚˆÙ›Ó˜ Î·È ÁÏ˘ÎÔÏÈ›‰È·.
CD44 LGA-1 Lymphocyte
sVCAM-1
Endothelial Cell Wall ICAM-1 ICAM-1 PECAM-1 LGA-1 LGA-1 sICAM-3 PECAM-1 Neutrophil sL-Selectin PECAM-1 L-Selectin L-Selectin PECAM-1 ICAM-1 sP-Selectin ICAM-2
L-Selectin
sPECAM-1
ICAM-3
VLA-4
VLA-4
Monocyte
CD44 ICAM-2
∏ ∂-Selectin ÂÎÎÚ›ÓÂÙ·È Û ·¿ÓÙËÛË ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙÔÎÈÓÒÓ fiˆ˜ ÔÈ TNF·, IL-1, ÂÓÒ Ë PSelectin ÌÂÙ¿ ·fi ÂÓÂÚÁÔÔ›ËÛË ·fi ÈÛÙ·Ì›ÓË Î·È ıÚÔÌ‚›ÓË. ∏ ¯·Ï·Ú‹ ·˘Ù‹ Û‡Ó‰ÂÛË ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Ì ٷ Ô˘‰ÂÙÂÚfiÊÈÏ· ÌÔÚ› Ó· ÌÂÙ·Ùڷ› Û ÈÛ¯˘Ú‹ fiÙ·Ó Á›ÓÂÈ ·Ó›¯Ó¢ÛË ¯ËÌÂÈÔÙ·ÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ì ÙËÓ ·Ú·ÁˆÁ‹ ÈÓÙÂÁÎÚÈÓÒÓ. OÈ ÈÓÙÂÁÎÚ›Ó˜ Â›Ó·È ‰ÈÌÂÚ‹ ÁÏ˘ÎÔÚˆÙ›Ó˜ ÔÈ Ôԛ˜ ·ÔÙÂÏÔ‡ÓÙ·È ·fi ‰‡Ô ˘ÔÔÌ¿‰Â˜, ÙËÓ · Î·È ÙË ‚. ∞fi ÙȘ ÈÔ ÛËÌ·ÓÙÈΤ˜ ÈÓÙÂÁÎÚ›Ó˜ Â›Ó·È ÔÈ LFA1 (lymphocyte function antigen – 1), Mac-1, VLA4 (very late antigen – 4), p150,95. OÈ LFA-1 Î·È Mac-1 Â›Ó·È ÔÈ Î˘Ú›·Ú¯Â˜ ÈÓÙÂÁÎÚ›Ó˜ ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ Î·È ·ÓÙȉÚÔ‡Ó Ì ÙÔ ICAM-1 (intercellular adhesion molecule – 1). ∂ÈϤÔÓ ÙÔ Mac-1 Â›Ó·È ÈηÓfi Ó· Û˘Ó‰¤ÂÙ·È Î·È Ì ÙÔ ÈÓÔ‰ÔÁÒÓÔ, ÙËÓ ·Ï‚Ô˘Ì›ÓË, ÙÌ‹Ì·Ù· ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜ ÎÏ. Ÿˆ˜ ‚Ï¤Ô˘Ì ÔÈ ÈÓÙÂÁÎÚ›Ó˜ Â›Ó·È ¤ÙÛÈ ÙÚÔÔÔÈË̤Ó˜ Î·È ÔÛÔÙÈο ·ÏÏ¿ Î·È ÏÂÈÙÔ˘ÚÁÈο Î·È ‰È·Ì¤ÛÔ˘ ÙˆÓ ‰ÂÛÌÒÓ ÙÔ˘˜ ÌÔÚÔ‡Ó Ó· ‰ÒÛÔ˘Ó ÙÔ ¤Ó·˘ÛÌ· ÛÙ· Ï¢ÎÔ·ÙÙ·Ú· ÁÈ· ÛËÌ·ÓÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜. ∏ ÂfiÌÂÓË Ôχ ÛËÌ·ÓÙÈ΋ ηÙËÁÔÚ›· ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘ Â›Ó·È Ë ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ immunoglobulin gene superfamily. OÓÔÌ¿˙ÔÓÙ·È ¤ÙÛÈ ÁÈ·Ù› ‰È·ı¤ÙÔ˘Ó domains Ô˘ ÚÔÛÔÌÔÈ¿˙Ô˘Ó ÛÙȘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ (Ig-like domain) ÛÙÔ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ÙÌ‹Ì· ÙÔ˘˜. OÈ ÈÔ ÛËÌ·ÓÙÈΤ˜ Â›Ó·È ICAM-1, ICAM-2 (intercellular adhesion molecule – 1,2), ÔÈ VCAM-1 (vascular cell adhesion molecule – 1), PECAM-1 (platelet endothelial cell
P-Selection
LGA-1
L-Selectin
VLA-4 VCAM-1
Endothelial Cell Wall sICAM-3 sVCAM-1 sPECAM-1 sL-Selectin sP-Selectin
Soluble Forms of Cellular Adhesion Molecules Detectable in Plasma
E-Selectin (activated endothelium only)
LGA-1
L-Selectin PECAM-1
ICAM-1 ICAM-3
CD44 Lymphocyte
VLA-4
∂ÈÎfiÓ· 2. ∏ ÌÂÙ·Ó¿ÛÙ¢ÛË Î·È ÚÔÛÎfiÏËÛË ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ Á›ÓÂÙ·È ‰È·Ì¤ÛÔ˘ ÙˆÓ ÌÔÚ›ˆÓ ÚÔÛÎfiÏËÛ˘ Ô˘ ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È Î·Ù¿ ÙË Ê¿ÛË Ù˘ ·ӷÈÌ¿ÙˆÛ˘.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
adhesion molecule – 1). PECAM-1 Î·È VECAM-1 ˘¿Ú¯Ô˘Ó ÛÙ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ·ÏÏ¿ Î·È ÛÙ· ÏÂÌÊÔ·ÙÙ·Ú· Î·È ÛÙÔ˘˜ ÈÓÔ‚Ï¿ÛÙ˜ Î·È ¯ÚËÛÈÌÂ‡Ô˘Ó Û·Ó ÂÓ‰ÔıËÏÈ·ÎÔ› ‰ÂÛÌÔ› Ì ٷ Ï¢ÎÔ·ÙÙ·Ú·. ΔÔ LFA-1 ÂÓÒÓÂÙ·È Ì ÙÔ ÚÒÙÔ Ig-like domain ÙÔ˘ ICAM-1 ÂÓÒ ÙÔ Mac-1 Ì ÙÔ ÙÚ›ÙÔ. ŒÓ·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·ÁˆÓÈÛÙÒÓ ÔÈ ÔÔ›ÔÈ ÂÓÂÚÁÔÔÈÔ‡Ó Ù· Ô˘‰ÂÙÂÚfiÊÈÏ· ‹ Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘. Δ· ¯ËÌÂÈÔÙ·ÎÙÈο Â›Ó·È Ôχ ÛËÌ·ÓÙÈο ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÈÓÙÂÁÎÚÈÓÒÓ Î·È ÛÙËÓ ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ô˘‰ÂÙÂÚfiÊÈÏˆÓ ÔÏ˘ÌÔÚÊÔ‡ÚËÓˆÓ. OÈ ¯ËÌÂÈÔÙ·ÎÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·Ú¿ÁÔÓÙ·È ÙÔÈο Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‰È·¯¤ÔÓÙ·È Ì ÁÔÚÁfi Ú˘ıÌfi Ì ÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·. Δ¤ÙÔÈÔÈ ·Ú¿ÁÔÓÙ˜ Â›Ó·È Ô ¶·Ú¿ÁÔÓÙ·˜ ∂ÓÂÚÁÔÔ›ËÛ˘ ÙˆÓ ∞ÈÌÔÂÙ·Ï›ˆÓ (PAF), Ô ÔÔ›Ô˜ ÌÔÚ› Ó· ·Ú·¯ı› ·fi Ù· ÂÓÂÚÁÔÔÈË̤ӷ ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÌÂÙ¿ ·fi ÂÚÂıÈÛÌfi Ì ÈÛÙ·Ì›ÓË, ıÚÔÌ‚›ÓË, Î·È Ï¢ÎÔÙÚȤÓÈ· (LTC 4 ). ÕÏÏÔ˜ ÛËÌ·ÓÙÈÎfi˜ ¯ËÌÂÈÔÙ·ÎÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È Ë IL-8 Ë ÔÔ›· ·Ú¿ÁÂÙ·È ·fi Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÌÂÙ¿ ·fi ÂÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘˜ ·fi TNF· Î·È IL-1. ∂›Û˘ Ôχ ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô MIP-1‚ (macrophage inflammatory protein – 1‚).
∫ÀΔΔ∞ƒπ∫O™ £∞¡∞ΔO™ O ΢ÙÙ·ÚÈÎfi˜ ı¿Ó·ÙÔ˜ ÌÔÚ› Ó· ¤ÏıÂÈ Ì ‰‡Ô Ì˯·ÓÈÛÌÔ‡˜: ·) ¡¤ÎÚˆÛË, ‚) ∞fiÙˆÛË. ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ì ¯·Ú·ÎÙËÚÈÛÙÈο Ô˘ ˘ÂÚηχÙÔ˘Ó ÙÔ˘˜ ‰‡Ô Ì˯·ÓÈÛÌÔ‡˜. ∫·È Ë Ó¤ÎÚˆÛË ·ÏÏ¿ Î·È Ë ·fiÙˆÛË ÌÔÚ› Ó· Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· ÂÓfi˜ ÔÍÂȉˆÙÈÎÔ‡ stress. ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ·Ó·‰˘ı› Ì›· ‰È¯ÔÁӈ̛· Û¯ÂÙÈο Ì ÙÔ ÔÈÔ˜ Ì˯·ÓÈÛÌfi˜ ‚Ï¿‚˘ ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, Ë ·fiÙˆÛË ‹ Ë Ó¤ÎÚˆÛË, Â›Ó·È Ô ÂÈÎÚ·Ù¤ÛÙÂÚÔ˜. ∞fi ÔÏÏÔ‡˜ Û˘ÁÚ·Ê›˜ ¤¯ÂÈ ÚÔÙ·ı› fiÙÈ Ë Ì·˙ÈΤ˜ ÓÂÎÚˆÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ·ÔÙÂÏÔ‡Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ Ù˘ ·ÚÂÁ¯˘Ì·ÙÈ΋˜ ‚Ï¿‚˘. ∞fi ¿ÏÏÔ˘˜ ¤¯ÂÈ ÚÔÙ·ı› fiÙÈ Ë ÂÎÏÂÎÙÈ΋ ·Ó·ÛÙÔÏ‹ Ù˘ ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ Ô‰Ô‡ Ù˘ ·fiÙˆÛ˘ Ô‰ËÁ› Û ÛËÌ·ÓÙÈ΋ ÚÔʇϷÍË Î·È Ì›ˆÛ˘ Ù˘ ‚Ï¿‚˘ ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. ∂›Û˘ ¤¯ÂÈ ÚÔÙ·ı› Î·È Ô ÂӉȿÌÂÛÔ˜ Ì˯·ÓÈÛÌfi˜ ‚Ï¿‚˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙÔ˘˜ ‰‡Ô Ì˯·ÓÈÛÌÔ‡˜ Î·È Â›Ó·È ÁÓˆÛÙfi˜ ˆ˜ ÓÂÎÚ·fiÙˆÛË. ¡∂∫ƒø™∏ ∏ Ó¤ÎÚˆÛË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙÔ ÚÒÈÌÔ Ô›-
181
‰ËÌ· ÙˆÓ ÔÚÁ·ÓÈÏ›ˆÓ, ÙËÓ ·ÒÏÂÈ· Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙˆÓ ÌÈÙÔ¯ÔÓ‰Ú›ˆÓ, Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, fiˆ˜ Î·È ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ ÙˆÓ ˘ÂÚÔÍ˘ÛˆÌ¿ÙˆÓ Î·È ÙˆÓ Ï˘ÛÔÛˆÌ¿ÙˆÓ Î·È ÙËÓ ÙÂÏÈ΋ ηٷÛÙÚÔÊ‹ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Ë ÔÔ›· Ô‰ËÁ› ÛÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ Ô˘ÛÈÒÓ ÙÔ˘ ΢ÙÙ¿ÚÔ˘. ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ ÂËÚ¿˙ÔÓÙ·È Î·È Ù· ÁÂÈÙÔÓÈο ·ÙÙ·Ú· ÁÈ·Ù› ·ÂÏ¢ıÂÚÒÓÔÓÙ·È Ô˘Û›Â˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›· (ηٷϿÛË, ·ÓÙÈÔÍÂȉˆÙÈο, SOD, GSH ÎÏ). ∞¶O¶Δø™∏ ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ ·fiÙˆÛ˘, Ù· ÚÒÙ· Û˘ÌÙÒÌ·Ù· Â›Ó·È Ë ÛÌ›ÎÚ˘ÓÛË ÙÔ˘ ΢ÙÙ¿ÚÔ˘, Ë Û‡ÌÙ˘ÍË Î·È Ô Î·Ù·ÎÂÚÌ·ÙÈÛÌfi˜ Ù˘ ¯ÚˆÌ·Ù›Ó˘ Î·È Û˘¯Ó¿ Û˘Ó‰¤ÂÙ·È Ì ‚Ï¿‚˜ ÛÙË ‰ÔÌ‹ ÙÔ˘ DNA. ÕÏÏ· ¯·Ú·ÎÙËÚÈÛÙÈο Ù˘ ·fiÙˆÛ˘ ·ÔÙÂÏÔ‡Ó, Ë Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÛÎÂÏÂÙÔ‡, ηٷÎÂÚÌ·ÙÈÛÌfi ÙÔ˘ ˘Ú‹Ó· Î·È ÙÂÏÈο ÙË Ï‹ÚË ‰È¿Û·ÛË ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Û ·ÔÙˆÙÈο ۈ̷ٛ‰È· ¯ˆÚ›˜ fï˜ ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÌÈÙÔ¯ÔÓ‰ÚÈ·ÎÒÓ Î·È Ï˘ÛÔۈ̷ÙÈÎÒÓ ÌÂÌ‚Ú·ÓÒÓ Î·È ¤ÍÔ‰Ô ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. Δ· ·ÔÙˆÙÈο ۈ̷ٛ‰È· Ê·ÁÔ΢ÙÙ·ÚfiÓˆÓÙ·È ·fi Ù· ÁÂÈÙÔÓÈο ·ÙÙ·Ú· ‹ ·fi Ê·ÁÔ·ÙÙ·Ú·. O Ì˯·ÓÈÛÌfi˜ Ù˘ ·fiÙˆÛ˘ Â›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi˜ ÁÈ· ÙËÓ ·Ô‚ÔÏ‹ «·ÓÂÈı‡ÌËÙˆÓ» ΢ÙÙ¿ÚˆÓ Î·È ÔÓÔÌ¿˙ÂÙ·È Â›Û˘ ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓÔ˜ ΢ÙÙ·ÚÈÎfi˜ ı¿Ó·ÙÔ˜. º·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ Û fiÏ· Ù· ·ÙÙ·Ú· Î·È ·Ú¿ÁÔÓÙ˜ Ô˘ ÙÔÓ ÂÓÂÚÁÔÔÈÔ‡Ó Â›Ó·È Î·Ù·ÛÙ¿ÛÂȘ stress ‹ ·fiÛ˘ÚÛË ÙÔ˘ «Û‹Ì·ÙÔ˜ Ù˘ ˙ˆ‹˜» (“life signals”). ∞fi Ù· Â͈ÙÂÚÈο ÂÚÂı›ÛÌ·Ù· Ô˘ ‰›ÓÔ˘Ó ¤Ó·˘ÛÌ· ÛÙËÓ ·fiÙˆÛË Â›Ó·È Ë ‰È·Ù·Ú·¯‹ ÙÔ˘ ÂÓÂÚÁÂÈ·ÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ (·Ó·ÛÙÔÏ‹ Ù˘ ÌÂÙ·ÊÔÚ¿˜ ËÏÂÎÙÚÔÓ›ˆÓ ·fi Ù· ÌÈÙÔ¯fiÓ‰ÚÈ·), ÙÔ ÔÍÂȉˆÙÈÎfi stress, Î·È Ë ¯ÔÚ‹ÁËÛË Ê·Ú̷΢ÙÈÎÒÓ Ô˘ÛÈÒÓ Ô˘ ηٷÛÙÚ¤ÊÔ˘Ó ÙÔDNA fiˆ˜ Ù· Ê¿Ú̷η ¯ËÌÂÈÔıÂڷ›·˜ ÁÈ· ηÚΛÓÔ. £· Ú¤ÂÈ Ó· ÙÔÓ›ÛÔ˘Ì fiÙÈ ÔÈ ·Ú·¿Óˆ ·Èٛ˜ ·ÔÙÂÏÔ‡Ó Î·È ·Èٛ˜ Ó¤ÎÚˆÛ˘ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Î·È Èı·ÓfiÓ Ô ‰ÚfiÌÔ˜ ÙÔ˘ ı·Ó¿ÙÔ˘ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Ó· ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÈÛ¯‡, ÙË Û˘¯ÓfiÙËÙ· Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ. ∏ ·fiÙˆÛË ÛÙ· ·ÙÙ·Ú· ÂϤÁ¯ÂÙ·È ÁÔÓȉȷο Î·È Ôχ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ·›˙ÂÈ ÙÔ ÁÔÓ›‰ÈÔ bcl-2 ÙÔ ÔÔ›Ô ¤¯ÂÈ ·ÓÙ›-·ÔÙˆÙÈ΋ ‰Ú¿ÛË. ∫ˆ‰ÈÎÔÔÈ› Ì›· ÚˆÙ›ÓË ÙËÓ Bcl-2 Ë ÔÔ›· ‰ÂÓ ¤¯ÂÈ ·ÓÙÈÔÍÂȉˆÙÈ΋ ‰Ú¿ÛË ·ÏÏ¿ Ù· ·ÙÙ·Ú· Ô˘ ÙËÓ ÂÚȤ¯Ô˘Ó ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓË ·ÓÙ›ÛÙ·ÛË ÛÙÔ ÔÍÂȉˆÙÈÎfi stress (∂ÈÎfiÓ· 3).
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Survival Factors: Growth Factors, Cytokines, etc.
TNF, FasL
Caspase-2 Ask1 DNA damage
Caspase-8, -10 ΕR Stress
PKC
SIR2
NIK
Cell ERK 1/2 Cycle PI3K Cdc2
JNK
p90RSK
p53
Ak1 [Ca++] Calpain
Bak
Bid
Bad
Bax NF-κB HtrA2 cIAP ub ub
ub
Smeo/ Diablo
Cyto c
Apaf1 Caspase-9
GSK-3 FKHR
AIF Endo G
Caspase-3,-6,-7
APP
Bcl-XL
Bcl-2
Caspase-12
DNA repair
Rock
FakL etc.
DNA fragmentation
Cell shrinkage Membrane blebbling
APOPTOSIS
∂ÈÎfiÓ· 3. ∏ Ú‡ıÌÈÛË Ù˘ ·fiÙˆÛ˘ Á›ÓÂÙ·È Ì ÔχÏÔÎÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ NF-kB, Ù˘ caspase-3, ÙÔ˘ JNK, ÙÔ˘ BCL-2 Î·È ¿ÏÏˆÓ ÌÂÙ·ÁÚ·ÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ.
STRESS ACTIVATING PROTEINS ∏ ·Ú·ÁˆÁ‹ ÙˆÓ TNFa Î·È IL-1 Ú˘ıÌ›˙ÂÙ·È ‰È·Ì¤ÛÔ˘ Ù˘ ·ÁˆÁ‹˜ ÙÔ˘ Û‹Ì·ÙÔ˜ (signal transduction) Î·È Ù˘ ¤ÎÊÚ·Û˘ ÌÂÙ·ÁÚ·ÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ fiˆ˜ Â›Ó·È Ô NF-kB (Nuclear Factor-kappa Beta) Î·È AP-1 (Activating Protein-1) ÔÈ ÔÔ›ÔÈ ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È Ì ÙËÓ π/∂. ∏ ·ӷÈÌ¿ÙˆÛË ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÂ Â›Ì˘Â˜ ÂÓÂÚÁÔÔÈ› ÔÏϷϤ˜ ÎÈÓ¿Û˜. EÈϤÔÓ Ë ÌÂÙ·ÁÚ·Ê‹ ÙÔ˘ NF-kB ·›˙ÂÈ ÔÏÏ·ÏÔ‡˜ ÚfiÏÔ˘˜ Ú˘ıÌ›˙ÔÓÙ·˜ Û˘Á¯ÚfiÓˆ˜ ÙËÓ ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË ÙÔ˘ ‹·ÙÔ˜ fiˆ˜ ›Û˘ Î·È ÙËÓ ·Ó·ÁÂÓÓËÙÈ΋ Î·È ·ÓÙÈ·ÔÙˆÙÈ΋ ·¿ÓÙËÛË (∂ÈÎfiÓ· 4). ∏ ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË Ú˘ıÌ›˙ÂÙ·È ·fi ¤Ó·Ó Û‡ÓıÂÙÔ Î·Ù·Ú¿ÎÙË ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙÔÎÈÓÒÓ. ¶ÔÏÏ·ÏÔ› ηٷڿÎÙ˜ ÛËÌ¿ÙˆÓ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ·ÁˆÁ‹˜ ÙÔ˘ Û‹Ì·ÙÔ˜, Ù˘ p38 MAPKs (mitogen-activated protein kinases), Ù˘ SAPK (stress-activated protein kinase) Î·È Ù˘ JNK (c-
Jun N-terminal kinase) ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÛÙË ‚Ï¿‚Ë ÙÔ˘ ‹·ÙÔ˜ ÌÂÙ¿ ·fi π/∂. AÓ¿ÌÂÛ· ÛÙÔ˘˜ ‰È¿ÊÔÚÔ˘˜ ÌÂÙ·ÁÚ·ÊÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Ô‰ËÁÔ‡Ó ÛÙËÓ ·fiÙˆÛË, ¤¯ÂÈ Ê·Ó› fiÙÈ Ë ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ JNK1/SAPK1 (c-Jun N-terminal kinase 1/ stress activated protein kinase 1), ̤ÏÔ˜ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÙˆÓ Stress Activated Protein Kinase, Â›Ó·È ÛËÌ·ÓÙÈ΋ Î·È Ô‰ËÁ› Û ÂÓÂÚÁÔÔ›ËÛË Ù˘ caspase 3. ∏ ÛÙ·ıÂÚfiÙËÙ· ÙˆÓ c-Jun Î·È c-Fos ÚˆÙÂ˚ÓÒÓ Ú˘ıÌ›˙ÂÙ·È ·fi ÙËÓ ÊˆÛÊÔÚ˘Ï›ˆÛË ÙÔ˘ JNK. ∞fi ÙË ‚È‚ÏÈÔÁÚ·Ê›· ˘¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ÂӉ›ÍÂȘ fiÙÈ Ë ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ JNK ı· ÌÔÚÔ‡Û ӷ ·˘Í‹ÛÂÈ ÙËÓ ÚÔηÏÔ‡ÌÂÓË ·fi ÙÔÓ TNF-a ·fiÙˆÛË.
μ§∞μ∏ ™À¡Δ∏ƒ∏™∏™ ∫¿ı ˷ÙÈÎfi ÌfiÛ¯Â˘Ì· Î·È Î¿ı ÌfiÛ¯Â˘Ì· ÁÂÓÈÎfiÙÂÚ·, ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ı· ·Ê·ÈÚÂı› ·fi ÙÔ ‰fiÙË Û˘ÓÙËÚËı› Û ‰È¿Ï˘Ì· Û˘ÓÙËÚ‹Û˘ ηÈ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
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NF-κB Pathway
IL-1Rs, TLRs
TNRF
GF-Rs
PLCγ2
Ras
IRAKs
TRAF6 dsRNA
PI(3)K
RIP
PKCe PKR
MEKK3
MAGUKs MALT1 Bcl10
JNK
β-TrCP
IKKβ ub
ub p65/ IκBα RetA NF-κB1 p50
Nuclear-cytoplasmic shuttling of nonphosphorylated forms
IKKα IKKγ/ NEMO
Proteasomal Degradation ΙΚΚα
Ak1 Cot
ub β-TrCP ub p65/ ΙκBα RetA NF-κΒ2 p52
PKCζ GSK-3β
NAK
Nucleus p65/ RetA NF-κB p50/52
NIK
Tax
Cp65/ RetA PKAc NF-κB CK p50/52 Cytoplasm
p65 RetA IκBα NF-κB1 p50
LTβR, CD-40, BR3 TRAF3
ZAP70
LT, CD40L, BAFF/BLyS
TRAF2
LCK
Stress: ROIs, UV, metals, ischemia, shear
Growth Factors: BMP, EGF, HGH, Insulin, NGF, TGFα
MYD88
TCR
TNF
TIRAP
Ag-MHC
IL-1, LPS, CpG, dsRNA, Taxol
IKKα IKKα ub RelB ub NF-κB2 p100 Proteasomal Processing RelB NF-κB2 p52
CBP p300 HDAC
Inflammation, Immune Regulation, Survival, Proliferation
RelB NF-κB2 p52 Lymphogenesis B Cell Maturation
∂ÈÎfiÓ· 4. ¶ÔÏÏ·Ï¿ Â͈ÙÂÚÈο ÂÚÂı›ÛÌ·Ù· Â›Ó·È ˘Â‡ı˘Ó· ÁÈ· ÙËÓ ÂÓÂÚÁÔÔ›ÛË ÙÔ˘ NF-kB Î·È Î˘ÚÈfiÙÂÚÔ ÛÙËÓ ÈÛ¯·ÈÌ›·/·ӷÈÌ¿ÙˆÛË ÙÔ˘ ‹·ÙÔ˜ Ó· ›ÓÈ Ô TNF-a.
̤¯ÚÈ Ó· ÌÂÙ·ÌÔÛ¯Â˘Ù› ÛÙÔÓ Ï‹ÙË, ˘fiÎÂÈÙ·È Û ‚Ï¿‚Ë „˘¯Ú‹˜ Î·È ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜. ∏ ¢ÂÓ‰ÔÙfiÙËÙ· ÛÙË „˘¯Ú‹ Î·È ıÂÚÌ‹ ÈÛ¯·ÈÌ›· Â›Ó·È ‰È·ÊÔÚÂÙÙÈ΋ ÁÈ· ÙÔ Î¿ı ›‰Ô˜ ΢ÙÙ¿ÚˆÓ. Δ· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÙˆÓ ÎÔÏÔÂȉÒÓ Â›Ó·È ÈÔ Â˘·›ÛıËÙ· ÛÙËÓ „˘¯Ú‹ ÈÛ¯·ÈÌ›· Û ۯ¤ÛË Ì ٷ Ë·ÙÔ·ÙÙ·Ú·, ÂÓÒ ÛÙË ıÂÚÌ‹ ÈÛ¯·ÈÌ›· ÚÔ¤¯ÂÈ Ë ·ÚÂÁ¯˘Ì·ÙÈ΋ ‚Ï¿‚Ë. Ÿˆ˜ ¤¯Ô˘Ì ·Ó·Ê¤ÚÂÈ Ô Ì˯·ÓÈÛÌfi˜ Ù˘ ÈÛ¯·ÈÌÈ΋˜ ‚Ï¿‚˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·ÒÏÂÈ· Ù˘ ÌÈÙÔ¯ÔÓ‰Úȷ΋˜ ·Ó·ÓÔ‹˜ Î·È ÙËÓ ¤ÏÏÂÈ„Ë Û ATP. ∂ÈϤÔÓ Â›Ó·È Èı·Ó‹ Ë Û˘ÌÌÂÙÔ¯‹ ÚˆÙ·ÛÒÓ ÛÙËÓ ‚Ï¿‚Ë ÏfiÁˆ ·ÓÔÍ›·˜ ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ. ŒÓ·˜ ·fi ÙÔ˘˜ ÏfiÁÔ˘˜ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Ù· ÌÔۯ‡̷ٷ Û˘ÓÙËÚÔ‡ÓÙ·È Û ˘ÔıÂÚÌ›·, Â›Ó·È Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ˘ÔıÂÚÌ›· ÌÂÈÒÓÂÈ ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·˘Í¿ÓÂÙ·È Ë ÂÚ›Ô‰Ô˜ ηٿ ÙËÓ ÔÔ›· Ù· ·ÙÙ·Ú· Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ·ÓÔ-
Í›· Ó· ÌÔÚÔ‡Ó Ó· ‰È·ÙËÚ‹ÛÔ˘Ó ‚·ÛÈΤ˜ ÌÂÙ·‚ÔÏÈΤ˜ ÈηÓfiÙËÙ˜. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿ fï˜ Ë ˘ÔıÂÚÌ›· ÂËÚ¿˙ÂÈ ÙËÓ ÔÌÔÈfiÛÙ·ÛË ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó¿Ù˘ÍË Ôȉ‹Ì·ÙÔ˜ Î·È ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ·˘ÙÔ‡. °È· ·˘Ùfi ÙÔ ÏfiÁÔ ÛÙ· ‰È·Ï‡Ì·Ù· Û˘ÓÙ‹ÚËÛ˘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ì›· ·fi ÙȘ ‚·ÛÈΤ˜ ÙÔ˘˜ ȉÈfiÙËÙ˜ Â›Ó·È Ó· ÚÔÛÙ·ÙÂ‡Ô˘Ó Î·È Ó· ÌÂÈÒÓÔ˘Ó ÙÔ Ô›‰ËÌ·. ŒÓ·˜ ¿ÏÏÔ˜ Ôχ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô ÔÔ›Ô˜ ÌÔÚ› Ó· ÌÂÙ·Ùڷ› Û ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙÔ ÌfiÛ¯Â˘Ì· Â›Ó·È Ë Î·Ù¿ÛÙ·ÛË ıÚ¤„˘ ÙÔ˘ ‰fiÙË. ™ÙË Ê¿ÛË Û˘ÓÙ‹ÚËÛ˘ ¤¯Ô˘Ì ÂÍ¿ÏÂÈ„Ë ÙˆÓ ·ÔıÂÌ¿ÙˆÓ ÁÏ˘ÎÔÁfiÓÔ˘ ÛÙÔ ‹·Ú. OÈ ÌÂϤÙ˜ Û ۯ¤ÛË Ì ÙËÓ Î·Ù¿ÛÙ·ÛË ıÚ¤„˘ Î·È Ù· ·Ôı¤Ì·Ù· ÁÏ˘ÎÔÁfiÓÔ˘ ¤¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. ∞fi ÙË Ì›· ÌÂÚÈ¿ ˘¿Ú¯ÂÈ Ë ˘fiıÂÛË fiÙÈ Ë ‰È·ıÂÛÈÌfiÙËÙ· ÁÏ˘ÎÔÁfiÓÔ˘ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ‰È·Ù‹ÚËÛË ÈηÓÒÓ ÂȤ‰ˆÓ ATP ÛÙÔ ‹·Ú
184
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ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÈÛ¯·ÈÌ›·˜ Î·È Â·ÎfiÏÔ˘ı· ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ηٿ ÙË Ê¿ÛË Ù˘ ·ӷÈÌ¿ÙˆÛ˘. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿ ˘¿Ú¯Ô˘Ó ÂÚÁ·Û›Â˜ Ô˘ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ë ÓËÛÙ›· ÌÔÚ› Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ÏÂÈÙÔ˘ÚÁ›· Î·È ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞˘Ùfi Á›ÓÂÙ·È Ì¤ÛÔ Ù˘ ÌÂȈ̤Ó˘ Ê·ÁÔ΢ÙÙ¿ÚˆÛ˘ Î·È Ù˘ ηٷÛÙÔÏ‹˜ Ù˘ ·Ú·ÁˆÁ‹˜ TNF·, ÏfiÁˆ Ù˘ ÌÂȈ̤Ó˘ ÂÓÂÚÁÔÔ›ËÛ˘ Î·È ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Kupffer.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Kerr JF, Wyllie AH, Currie AR. Apoptosis: a basic biological phenomenon with wide-ranging implications in tissue kinetics. Br J Cancer 1972; 26:239 – 257. 2. Kohli V, Selzner M, Madden JF, Bendley RC, Clavien PA. Endothelial cell and hepatocyte deaths occur by apoptosis after ischemia-reperfusion injury in the rat liver. Transplantation 1999; 67:1099 – 1105. 3. Natori S, Selzner M, Valentino KL, Fritz LC, Srinivasan A, Clavien PA, Gores GJ. Apoptosis of sinusoidal endothelial cells occurs during liver preservation injury by a caspase-dependent mechanism. Transplantation 1999 15; 68:89-96. 4. Bilzer M, Gerbes AL. Preservation injury of the liver: mechanisms and novel therapeutic strategies. J Hepatol 2000; 32:508 – 515. 5. Bzeizi KI, Jalan R, Plevris JN, Hays PC. Primary graft dysfunction after liver transplantation: From pathogenesis to prevention. Liver Transpl Surg 1997; 3:137 – 148. 6. Rudiger HA, Graf R, Clavien PA. Liver ischemia: Apoptosis as a Central Mechanism of Injury. J Invest Surg 2003; 16:149 – 159. 7. Contreras JL, Vilatoba M, Eckstein C, Bilbao G, Thompson JA Eckhoff DE. Caspase-8 and caspase-3 small interfering RNA decreases ischemia/reperfusion injury to the liver in mice. Surgery 2004; 136:390 – 400. 8. Crenesse D, Tornieri K, Laurens M, Heurteaux C, Cursio R, Gugenheim J, Schmid-Alliana A. Diltiazem reduces apoptosis in rat hepatocytes subjected to warm hypoxia-reoxygenation. Pharmacology 2002; 65:87 – 95. 9. Jaeschke H, Farhood A. Neutrophil and Kupffer cell induced oxidant stress and ischemia-reperfusion injury in rat liver. Am J Physiol 1991; 260:335–362. 10. Jaeschke H. Reactive oxygen and ischemia-reperfusion injury of the liver. Chem Biol Interactions 1991; 79: 115–136.
11. Crenesse D, Gugenheim J , Hornoy J, Tornieri K, Laurens M, Cambien B, et al. Protein kinase activation by warm and cold hypoxia-reoxygenation in primary-cultured rat hepatocytes-JNK1/SAPK1 involvement in apoptosis. Hepatology 2000; 32:1029-1036. 12. Clavien PA. Sinusoidal endothelial injury during hepatic preservation and reperfusion. Hepatology 1998; 28:281 – 285. 13. Schlossberg H, Zhang Y, Dudus L, Engelhardt JF. Expression of c-fos and c-jun during hepatocellular remodeling following ischemia/reperfusion in mouse liver. Hepatology 1996; 23:1546–1555. 14. Arii S, Teramoto K, Kawamura K. Current progress in the understanding of and therapeutic strategies for ischemia and reperfusion injury of the liver. J Hepatobiliary Pancreat Surg. 2003; 10:189-94. 15. Bradham CA, Stachlewitz RF, Gao W, Qian T, Jayadev S, Jenkins G, Hannun Y, Lemasters JJ, Thurman RG, Brenner DA. Reperfusion after liver transplantation in rats differently activates the mitogen-activated protein kinases. Hepatology 1997; 25:1128 – 1135. 16. Baeuerle PA, Henkel T Function and activation of NFkappa B in the immune system. Annu Rev Immunol. 1994; 12:141-79. 17. Luedde T, Trautwein C. Intracellular survival pathways in the liver. Liver Int. 2006; 26:1163-74. 18. Malhi H, Gores GJ, Lemasters JJ. Apoptosis and necrosis in the liver: a tale of two deaths? Hepatology. 2006; 43:S31-44 19. Matsui N, Kasajima K, Hada M, Nagata T, Senga N, Yasui Y, Fukuishi N, Akagi M. Inhibiton of NF-kappa B activation during ischemia reduces hepatic ischemia/ reperfusion injury in rats. J Toxicol Sci 2005; 30:103-10. 20. McCloskey CA, Kameneva MV, Uryash A, Gallo DJ, Billiar TR. Tissue hypoxia activates JNK in the liver during hemorrhagic shock. Shock 2004; 22:380-6. 21. Wullaert A, Heyninck K, Beyaert R. Mechanisms of crosstalk between TNF-induced NF-kappaB and JNK activation in hepatocytes. Biochem Pharmacol 2006; 30:1090-101. 22. Onishi I, Tani T, Hashimoto T, Shimizu K, Yagi M, Yamamoto K, Yoshioka K. Activation of c-Jun N-terminal kinase during ischemia and reperfusion in mouse liver. FEBS Lett. 1997; 29; 20:201-4. 23. Crenesse D, Schmid-Alliana A, Hornoy J, Rossi B, Gugenheim J.] Hypoxia-reoxygenation ifferentially stimulates stress-activated protein kinases in primarycultured rat hepatocytes. Transpl Int 2000; 13:S597-9.
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∏ ∫ÂÚ·˘ÓÔ‚fiÏÔ˜ ∏·ÙÈ΋ ∞Ó¿ÚÎÂÈ· (∫∏∞) ‹ OÍ›· ∏·ÙÈ΋ ∞Ó¿ÚÎÂÈ· (O∏∞) Â›Ó·È ÙÔ ÎÏÈÓÈÎfi Û‡Ó‰ÚÔÌÔ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ì·˙È΋˜ Ó¤ÎÚˆÛ˘ ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ‹ ·ÈÊÓ›‰È·˜ Î·È ÛÔ‚·Ú‹˜ Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ ‰˘ÛÏÂÈ-ÙÔ˘ÚÁ›·˜ Ô˘ Ô‰ËÁ› Û ‰È·Ù·Ú·¯‹ Ù˘ ‹Í˘ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È Ë·ÙÈ΋ ÂÁÎÂÊ·-ÏÔ¿ıÂÈ· Û ¤Ó· ¿ÙÔÌÔ Ì¤¯ÚÈ ÚfiÙÈÓÔ˜ ˘ÁȤ˜ Î·È ¯ˆÚ›˜ ÚÔ¸¿Ú¯Ô˘Û· Ë·ÙÈ΋ ÓfiÛÔ1. ∏ O∏∞ ÂÁηı›ÛÙ·Ù·È Û ‰È¿ÛÙËÌ· < 26 ‚‰ÔÌ¿‰ˆÓ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ ÚÒÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ‹ < 8 ‚‰ÔÌ¿‰ˆÓ ·fi ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ÈÎÙ¤ÚÔ˘. ø˜ ˘ÂÚÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÔÚ›˙ÂÙ·È Ë ÌÔÚÊ‹ Ù˘ O∏∞ ÛÙËÓ ÔÔ›· ÙÔ ‰È¿ÛÙËÌ· ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ÈÎÙ¤ÚÔ˘ ̤¯ÚÈ ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Â›Ó·È < 7 ËÌÂÚÒÓ. ŸÙ·Ó ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi Â›Ó·È 8-28 Ë̤Ú˜, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È fiÙ·Ó ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ‰È¿ÛÙËÌ· Â›Ó·È ÌÂٷ͇ 5-26 ‚‰Ô-Ì¿‰ˆÓ, ÙÔ Û‡Ó‰ÚÔÌÔ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ˘ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·2. ∏ ‰È¿ÎÚÈÛË ıˆڋıËΠfiÙÈ ¤¯ÂÈ È‰È·›ÙÂÚË ÎÏÈÓÈ΋ ÛËÌ·Û›·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ·ÛıÂÓ›˜ Ì ˘ÂÚÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ¤¯Ô˘Ó ηχÙÂÚË ÚfiÁÓˆÛË, ÂÓÒ ·ÛıÂÓ›˜ Ì ˘ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚË Èı·ÓfiÙËÙ· ·˘ÙfiÌ·Ù˘ ·Ó¿ÚÚˆÛ˘.
∂ȉËÌÈÔÏÔÁ›· – ∞ÈÙÈÔÏÔÁ›· ™ÙȘ ∏¶∞, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÂÙËÛ›ˆ˜ Û˘Ì‚·›ÓÔ˘Ó ÂÚ› ÙȘ 2300-2800 ÂÚÈ-ÙÒÛÂȘ O∏∞, ·fi ÙȘ Ôԛ˜ ÌfiÓÔ 200-300 ÂÚÈÙÒÛÂȘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ª∏)3. H ÂÎÙÈÌÒÌÂÓË ÂÙ‹ÛÈ· ›وÛË Ù˘ O∏∞ ÛÙÔÓ ÎfiÛÌÔ ÔÈΛÏÏÂÈ ·fi 1 ÂÚ›-ÙˆÛË ·Ó¿ 100.000 ÏËı˘ÛÌÔ‡ ÛÙȘ ‰˘ÙÈΤ˜ ¯ÒÚ˜ ̤¯ÚÈ 1 ÂÚ›ÙˆÛË ·Ó¿ 10.000 ÏËı˘ÛÌÔ‡ Û ÔÚÈṲ̂Ó˜ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜3·. ∏ ÈÔ ÎÔÈÓ‹ ·ÈÙ›·, ·ÁÎÔÛÌ›ˆ˜, ·Ú·Ì¤ÓÂÈ Ë HBV Ïԛ̈ÍË. ∞Ó¿ÏÔÁ· fï˜ Ì ÙË ÁˆÁÚ·ÊÈ΋ ÂÚÈÔ¯‹ ·Ú·ÙËÚÂ›Ù·È Î·È ÌÂÁ¿ÏË ‰È·ÊÔ-ÚÔÔ›ËÛË ˆ˜ ÚÔ˜ ÙËÓ ·ÈÙÈÔÏÔÁ›·4 (›Ó·Î·˜ 1). ∏ ·Ó·ÁÓÒÚÈÛË Ù˘ ·ÈÙ›·˜ (›Ó·Î·˜ 3) Ù˘ O∏∞5 Â›Ó·È ÂÍ·ÈÚÂÙÈο ÛËÌ·ÓÙÈ΋, ÂÂȉ‹ Ë ·ÈÙÈÔÏÔÁ›· ÂËÚ¿˙ÂÈ ÙËÓ ÚfiÁÓˆÛË ·ÏÏ¿ ‚¤‚·È· Î·È ÙËÓ ·ÓÙÈ-ÌÂÙÒÈÛË, ÂÂȉ‹ Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ3· Ë O∏∞ ¤¯ÂÈ ıÂڷ‡ÛÈÌË ·ÈÙÈÔÏÔÁ›· (›Ó·Î·˜ 2).
¶›Ó·Î·˜ 1. ∞ÈÙÈÔÏÔÁ›·* O∏∞ Û ‰È·ÊÔÚÂÙÈΤ˜ ¯ÒÚ˜
% HμV/HDV % HAV % HEV % º¿Ú̷η** %∞ÚÔÛ‰ÈfiÚÈÛÙË %ÕÏÏ·
∏ӈ̤ÓÔ μ·Û›ÏÂÈÔ 1987-93 (941)
∏¶∞ 1998-2001 (308)
°·ÏÏ›· 1986 (330)
πÓ‰›· 1992-98 (458)
π·ˆÓ›· 1998 (93)
ÃÔÁÎ-∫ÔÓÁÎ 1997 (14)
9 9 0 60 17 5
7 4 0 52 17 20
47 4 0 17 22 10
16 2 26 5 47 4
44 4 0 0 41 11
50 0 0 21 21 8
* ¶ËÁ‹: AASLD 2005 Postgraduate Course: Acute and Chronic Liver Diseases. R.J. Fontana. Changing Epidemiology of Acute Liver Failure: Implications for Prognosis and Management p: 171-181. ** 39% AÎÂÙ·ÌÈÓÔÊ·›ÓË, 13% ȉÈÔÛ˘ÁÎÚ·Ûȷ΋ ·ÓÙ›‰Ú·ÛË Û ¿ÏÏ· Ê¿Ú̷η.
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¶›Ó·Î·˜ 3. ∞›ÙÈ· O∏∞ ∞. πÔÁÂÓ‹˜ Ïԛ̈ÍË HAV, HBV±HDV, HEV, HSV, CMV, EBV, HVZ*, ·‰ÂÓÔ˚Ô›, ÈÔ› ÙÔ˘ ·ÈÌÔÚÚ·ÁÈÎÔ‡ ˘ÚÂÙÔ‡ μ. º¿Ú̷η Î·È ÙÔ͛Ә ¢ÔÛÔÂÍ·ÚÙÒÌÂÓË ÙÔÍÈÎfiÙËÙ· ∞ÎÂÙ·ÌÈÓÔÊ·›ÓË, CCl4, ΛÙÚÈÓÔ˜ ʈÛÊfiÚÔ˜, Amanita phaloides, Bacillus cereus toxin, ÛÔ˘ÏÊÔÓ·Ì›‰Â˜, ÙÂÙڷ΢ÎÏ›ÓË, ¤ÎÛÙ·ÛË, Ê˘ÙÈο Û΢¿ÛÌ·Ù· π‰ÈÔÛ˘ÁÎÚ·Ûȷ΋ ÙÔÍÈÎfiÙËÙ· ∞ÏÔı¿ÓË, π¡∏, ÚÈÊ·ÌÈΛÓË, ‚·ÏÚÔ˚Îfi Ô͇, ª™∞º, ‰ÈÛÔ˘ÏÊÈÚ¿ÌË °. ∞ÁÁÂȷο ¢ÂÍÈ¿ ηډȷ΋ ·Ó¿ÚÎÂÈ·, Û‡Ó‰ÚÔÌÔ Budd-Chiari, ÊÏ‚ԷÔÊÚ·ÎÙÈ΋ ÓfiÛÔ˜, ÈÛ¯·ÈÌÈ΋ Ë·Ù›ÙȘ, ıÂÚÌÈ΋ ηٷÛÙÚÔÊ‹ ¢. ªÂÙ·‚ÔÏÈο O͇ ÏÈ҉˜ ‹·Ú Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, Ó. Wilson, Û‡Ó‰ÚÔÌÔ Reye, Á·Ï·ÎÙÔ˙·ÈÌ›·, ÎÏËÚÔÓÔÌÈ΋ ‰˘Û·ÓÂÍ›· ÊÚÔ˘ÎÙfi˙˘, Ù˘ÚÔÛÈÓ·ÈÌ›· ∂. ¶ÔÈΛϷ ¡ÂÔÏ·ÛÌ·ÙÈ΋ ‰È‹ıËÛË (ÌÂÙ·ÛÙ¿ÛÂȘ ÛÙÔ ‹·Ú, ϤÌʈ̷) ·˘ÙÔ¿ÓÔÛË Ë·Ù›ÙȘ, ÛËÙÈ΋ ηٿÛÙ·ÛË ™Ù. ∞ÚÔÛ‰ÈfiÚÈÛÙ· (17%) *∏∞V: Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ ∞, HBV: Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ μ, HDV: Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ D, ∏∂V: Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ ∂, ∏SV: Èfi˜ ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ·, CMV: ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜, ∂μV: Èfi˜ ÙÔ˘ Epstein Barr, HVZ: Èfi˜ Ù˘ ·ÓÂÌ¢ÏÔÁÈ¿˜-˙ˆÛÙ‹Ú·, CCl4: ÙÂÙÚ·¯ÏˆÚ¿Óıڷη˜, INH: ÈÛÔÓÈ·˙›‰Ë, ª™∞º: ªË ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë Ê¿Ú̷η.
¢È¿ÁÓˆÛË – ∞Ú¯È΋ ÂÎÙ›ÌËÛË ΔÔ ÎÏÂȉ› ÛÙË ‰È¿ÁÓˆÛË Ù˘ O∏∞ Â›Ó·È Ë ·Ú¿Ù·ÛË ÙÔ˘ ƒΔ (¯ÚfiÓÔ˘ ÚÔ-ıÚÔÌ‚›Ó˘) Î·È Ë ÂÁÎÂÊ·ÏÔ¿ıÂÈ·6,7. °È’ ·˘Ùfi Û οı ·ÛıÂÓ‹ Ì ÔÍ›· Ë·Ù›Ùȉ· ÌÂÙÚ›Ô˘ ‹ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡, ı· Ú¤ÂÈ Ó· ÌÂÙÚ¿Ù·È Ô ƒΔ Î·È Ó· ÂÎÙÈÌ¿Ù·È ÚÔ-ÛÂÎÙÈο Ë fiÔÈ· ‰È·ÎÚÈÙ‹ ·ÏÏ·Á‹ ÛÙÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘. ∞Ó Ô ƒΔ Â›Ó·È ·Ú·ÙÂÙ·-̤ÓÔ˜ ~ 4-6 sec ‹ ÙÔ INR ≥ 1.5 Î·È ‰È·ÈÛÙˆı› ÔÔÈ·‰‹ÔÙ ·ÏÏ·Á‹ ÛÙË ÓÔËÙÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓ‹, ÙfiÙÂ Ë ‰È¿ÁÓˆÛË Ù˘ O∏∞ Â›Ó·È ‰Â‰Ô̤ÓË Î·È Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ÓÔÛËÏ¢Ù›8. ™ÙÔ ÈÛÙÔÚÈÎfi ‰›ÓÂÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹ ÁÈ· Èı·Ó‹ ¤ÎıÂÛË Û ÈÔÁÂÓ‹ Ïԛ̈ÍË, Ê¿Ú̷η Î·È ÙÔ͛Ә.
™ÙË Ê˘ÛÈ΋ ÂͤٷÛË Ë ÚÔÛÔ¯‹ ÂÓÙÔ›˙ÂÙ·È ÛÙÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘ ÙÔ˘ ·ÛıÂÓ‹ Î·È ÛÙËÓ ·ÚÔ˘Û›· ÛÙÈÁÌ¿ÙˆÓ ¯ÚfiÓÈ·˜ Ë·ÙÈ΋˜ ÓfiÛÔ˘. O ›ÎÙÂÚÔ˜ ÌÔÚ› Î·È Ó· ·Ô˘ÛÈ¿˙ÂÈ Î·Ù¿ ÙËÓ ÚÒÙË ÂͤٷÛË. ŒÓ· ‰ÈÔÁΈ̤ÓÔ „ËÏ·ÊËÙfi ‹·Ú ÌÔÚ› Ó· Â›Ó·È ¤Ó‰ÂÈÍË ÔͤԘ Û˘Ó‰ÚfiÌÔ˘ BuddChiari, Û˘ÌÊÔÚËÙÈ΋˜ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ ‹ ÓÂÔÏ·ÛÌ·ÙÈ΋˜ ‰È‹ıËÛ˘. Δ˘Èο ÔÈ ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù·¯˘Î·Ú‰›· Î·È ˘fiÙ·ÛË, ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÌÂȈ̤Ó˘ Û˘ÛÙËÌ·ÙÈ΋˜ ·ÁÁÂȷ΋˜ ·ÓÙ›ÛÙ·Û˘. ∏ ÂÈÎfiÓ· Â›Ó·È ‰˘Û‰È¿ÎÚÈÙË ·fi Ì›· ÛËÙÈ΋ ηٿÛÙ·ÛË. ∏ ·Ú¯È΋ ÂÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË (›Ó·Î·˜ 4) Ú¤ÂÈ Ó· Â›Ó·È ÂÎÙÂٷ̤ÓË ÁÈ· ÙËÓ ·Ó‡ÚÂÛË Ù˘ ·ÈÙ›·˜ ·ÏÏ¿ Î·È ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ O∏∞. μÈÔ„›· ‹·ÙÔ˜ (‰ÈÛÊ·ÁÈÙȉÈ΋) ÂӉ›ÎÓ˘Ù·È Û ÔÚÈṲ̂Ó˜ ηٷÛÙ¿ÛÂȘ, fiˆ˜ ·˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ· (ÔÍ›·), ÌÂÙ·ÛÙ·ÙÈ΋ Ë·ÙÈ΋ ÓfiÛÔ˜, ϤÌʈ̷ ‹ HSV. ¶›Ó·Î·˜ 4. ∞Ú¯È΋ ÂÚÁ·ÛÙËÚȷ΋ ÚÔÛ¤ÁÁÈÛË ƒΔ, INR μÈÔ¯ËÌ›·: ∫+, ¡·+, Cl-, HCO—3, Ca++ Mg++, ÁÏ˘Îfi˙Ë, ʈÛÊfiÚÔ˜, ∞ST, ALT, ∞ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ÁGT, ¯ÔÏÂÚ˘ıÚ›ÓË, ·Ï‚Ô˘Ì›ÓË, Ô˘Ú›·, ÎÚ·ÙÈÓ›ÓË °ÂÓÈ΋ ·›Ì·ÙÔ˜ ∞¤ÚÈ· ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ °·Ï·ÎÙÈο ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ OÌ¿‰· ·›Ì·ÙÔ˜, Rh ∂›Â‰· ·ÎÂÙ·ÌÈÓÔÊ·›Ó˘ ΔÔÍÈÎÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ŒÏÂÁ¯Ô˜ ÈÔÁÂÓÔ‡˜ Ë·Ù›Ùȉ·˜ Anti-HAV IgM, HBsAg, anti-HBc IgM, anti-HEV, anti-HCV ™ÂÚÔ˘ÏÔÏ·ÛÌ›ÓË ÔÚÔ‡* ΔÂÛÙ ÂÁ΢ÌÔÛ‡Ó˘ (Á˘Ó·›Î˜) ∞Ì̈ӛ· ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ ¢Â›ÎÙ˜ ·˘ÙÔ¿ÓÔÛ˘ Ë·ÙÔ¿ıÂÈ·˜: ∞¡∞, SMA, anti-LKM1, ∞ÓÔÛÔÛÊ·ÈÚ›Ó˜ HIV# ∞Ì˘Ï¿ÛË Î·È ÏÈ¿ÛË * › ˘Ô„›·˜ Ó. Wilson (.¯. ·ÛıÂÓ›˜ < 40 ÂÙÒÓ, ¯ˆÚ›˜ ¿ÏÏË ÂÌÊ·Ó‹ ·ÈÙ›· O∏∞) # ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ Èı·Ó‹˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘
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O∏∞ Î·È ·Ó¿ÚÎÂÈ· ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ – ¶·ıÔÁ¤ÓÂÈ· ∏ O∏∞ Â›Ó·È Ì›· ηٿÛÙ·ÛË Ô˘ ‰ÂÓ ·ÊÔÚ¿ ÌfiÓÔ ÙÔ ‹·Ú. ∏ ·‰˘Ó·Ì›· ÙˆÓ Ì˯·ÓÈÛÌÒÓ ·Ó·Á¤ÓÓËÛ˘ Ó· ·ÓÙÈÚÚÔ‹ÛÔ˘Ó ÙË Ì·˙È΋ Ë·ÙÔ΢ÙÙ·ÚÈ΋ ηٷÛÙÚÔ-Ê‹ Î·È ÙË ÛÔ‚·Ú‹ ¤ÎÙˆÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ı¤ÙÂÈ Û ΛÓËÛË ‰È·‰Èηۛ· Ô˘ Ô‰ËÁ› Û ÏÂÈÙÔ˘ÚÁÈ΋ ·Ó¿ÚÎÂÈ· ÔÏÏÒÓ ÔÚÁ¿ÓˆÓ (∞¶O)9. ∏ ∞¶O ·ÊÔÚ¿ ΢ڛˆ˜ ÙÔ˘˜ ÓÂÊÚÔ‡˜9, ÙÔ˘˜ Ó‡ÌÔÓ˜, ÙÔ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ, ÙÔ Î˘ÎÏÔÊÔÚÈÎfi Û‡ÛÙËÌ· Î·È ‚¤‚·È· ÙÔÓ ÂÁΤʷÏÔ. ∏ Û˘ÛÛÒÚ¢ÛË ÙÔÍÈÓÒÓ fiˆ˜ Â›Ó·È Ë ·Ì̈ӛ· Î·È Ù· Á·Ï·ÎÙÈο ηıÒ˜ Î·È Ë ÂÈ‚Ï·‚‹˜ ›‰Ú·ÛË ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Î˘ÙÔÎÈÓÒÓ, ÚÔ˚fiÓÙˆÓ Ù˘ Ë·ÙÔ΢ÙÙ·-ÚÈ΋˜ ‚Ï¿‚˘ ‹ ÂÈϷΛ۷˜ ÛËÙÈ΋˜ ηٿÛÙ·Û˘ ‹ Î·È ÙˆÓ ‰‡Ô, Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ 10. ŒÙÛÈ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ ÎÏÈÓÈο ‰Â‰Ô̤ӷ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ù· ·˘ÍË̤ӷ ›‰· Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘-6 (IL-6) Î·È IL-8 Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÛÏ·Á¯ÓÈ΋ Î·È Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹ Î·È Û˘ÛÙËÌ·ÙÈ΋ ˘fiÙ·ÛË Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙËÓ O∏∞11. ∂›Û˘ Ë ÊÏÔÈÔÂÈÓÂÊÚÈ-‰È·Î‹ ·Ó¿ÚÎÂÈ· ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÂÈ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ˘fiÙ·ÛË12, fiˆ˜ ·˘Ùfi Û˘Ì‚·›ÓÂÈ Î·È ÛÙË ÛÔ‚·Ú‹ Û‹„Ë13. ŒÌÊÚ·ÎÙ· ÛÙË ÌÈÎÚÔ΢ÎÏÔÊÔÚ›· ·fi ÙÔ Û¯ËÌ·-ÙÈÛÌfi ÌÈÎÚÔıÚfiÌ‚ˆÓ, ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÂÓÂÚÁÔÔ›ËÛ˘ Î·È Î·Ù·Ó¿ÏˆÛ˘ ·ÈÌÔÂÙ·-Ï›ˆÓ, Ì·˙› Ì ÙËÓ ·˘ÍË̤ÓË ÚÔÛÎfiÏÏËÛË Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ, Èı·ÓfiÓ Ó· ÂȉÂÈÓÒÓÔ˘Ó ÙËÓ ˘ÔÍ›· ÙˆÓ ÈÛÙÒÓ14. 줂·È·, ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ Ê˘ÛÈÔ-ÏÔÁÈ΋˜ ·Ó·ÏÔÁ›·˜ ˘ÚÔ˘‚ÈÎÒÓ - Á·Ï·ÎÙÈÎÒÓ ÛÙËÓ Ë·ÙÈ΋ ÊÏ‚È΋ ΢ÎÏÔÊÔÚ›·, ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ÂÈÙ·¯˘ÓfiÌÂÓË ÁÏ˘ÎfiÏ˘ÛË, ·Ú¿ Ë ÈÛÙÈ΋ ˘ÔÍ›· Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· ÙË Û˘ÛÛÒÚ¢ÛË ÙˆÓ Á·Ï·ÎÙÈÎÒÓ 15,16, Ù· ÔÔ›· ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÛÙËÓ O∏∞17. ∏ ·˘ÍË̤ÓË ÁÏ˘ÎfiÏ˘ÛË Â›Ó·È ÁÓˆÛÙfi ·ÎfiÏÔ˘ıÔ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·¿ÓÙËÛ˘ (SIRS: Systemic inflammatory response syndrome) Î·È Èı·ÓÒ˜ Ó· ·ÔÙÂÏ› ÙÔ ‚·ÛÈÎfi Ì˯·ÓÈÛÌfi Ô˘ ÂÍËÁ› ÙË Û˘Û¯¤ÙÈÛË Ù˘
187
ÛÔ‚·ÚfiÙËÙ·˜ ÙÔ˘ SIRS Ì ÙÔ ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (∏∂)18. ¶Èı·Ó‹ ›Û˘ Û˘ÌÌÂÙÔ¯‹ Ù˘ ·Ì̈ӛ·˜ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ∏∂, ·Ó·‰ÂÈÎÓ‡ÂÙ·È Û ÌÂϤÙË19, ÛÙËÓ ÔÔ›· Ê·›ÓÂÙ·È fiÙÈ Ù· ›‰· Ù˘ ·ÚÙËÚȷ΋˜ ·Ì̈ӛ·˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜. ∏ Û‹„Ë Â›Ó·È Ì›˙ˆÓ ·ÈÙ›· ÙÔ˘ SIRS ÛÙËÓ O∏∞18. Δo oÍÂȉˆÙÈÎfi stress, ÙÔ Û¯ÂÙÈ˙fiÌÂÓÔ Ì ÛËÙÈΤ˜ ηٷÛÙ¿ÛÂȘ20, ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ (ÛÙ· ÙÚˆÎÙÈο) ÚÔ¿ÁÂÈ ÙËÓ Ë·ÙÔ΢ÙÙ·ÚÈ΋ Ó¤ÎÚˆÛË, ·ÏÏ¿ Ù·˘Ùfi¯ÚÔÓ· ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ Ë·ÙÔ΢ÙÙ·ÚÈ΋ ·Ó·Á¤ÓÓËÛË21. ∏ ÂÈÏÂÁ̤ÓË O∏∞ Ì ۋ„Ë, ·˘Í¿ÓÂÈ ÙȘ ‹‰Ë ·˘ÍË̤Ó˜ ÂÓÂÚÁÂÈ·-Τ˜ ·Ó¿ÁΘ Ù˘ O∏∞22. ™˘¯Ó¿ ·Ú·ÙËÚÂ›Ù·È Ù·¯Â›· Âȉ›ӈÛË Ù˘ ıÚÂÙÈ΋˜ ηٿÛÙ·Û˘ Î·È ÂÍ¿ÓÙÏËÛË ÙˆÓ ·ÔıÂÌ¿ÙˆÓ ÙÔ˘ Ì˘˚ÎÔ‡ Î·È ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡. ∞˘Ùfi ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÈÙ·¯˘ÓfiÌÂÓË ÁÏ˘ÎfiÏ˘ÛË, ÙËÓ ÌÂȈ̤ÓË ‰˘Ó·ÙfiÙËÙ· ·Ôı‹Î¢Û˘ ÁÏ˘ÎÔÁfiÓÔ˘ Î·È ÙËÓ ·‰˘Ó·Ì›· ÓÂÔÁÏ˘ÎÔÁ¤ÓÂÛ˘, Ô‰ËÁ› Û ˘ÔÁÏ˘Î·ÈÌ›· Î·È ·˘ÍË̤ÓË ‰È¿Û·ÛË Ì˘˚ÎÔ‡ Î·È ÏÈÒ‰Ô˘˜ ÈÛÙÔ‡. ŒÙÛÈ, ÁÈ· ÙȘ ÂÓÂÚÁÂȷΤ˜ ·Ó¿ÁΘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÂÓ·ÏÏ·ÎÙÈο ϛԘ Î·È ÚˆÙ½ÓË22. ∏ ÌÂȈ̤ÓË Ë·ÙÈ΋ Û‡ÓıÂÛË ÙÔ˘ Insulin-like growth factor-1, (IGF-1) ÂȉÂÈ-ÓÒÓÂÈ ÙË ‰È¿Û·ÛË ÙˆÓ ÚˆÙÂ˚ÓÒÓ23.
∫ÏÈÓÈ΋ ÂÈÎfiÓ· – ∞ÓÙÈÌÂÙÒÈÛË °ÂÓÈο ∂ÓÒ ÔÈ ·ÛıÂÓ›˜ Ì O∏∞ Û˘ÓÈÛÙÔ‡Ó ÌÈ· ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰· ˆ˜ ÚÔ˜ Ù· ·›ÙÈ·, ÂÓÙÔ‡ÙÔȘ ¤¯Ô˘Ó ÛÙ·ıÂÚ¿ ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο. ¢ÂÓ ˘¿Ú¯Ô˘Ó fï˜ Ê·Ú̷΢-ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¯Ú‹ÛÈÌÔÈ ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜. Δ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ .¯. Â›Ó·È ·Ó·ÔÙÂÏÂÛÌ·ÙÈο24. °È· ÙËÓ ˘ÔÛÙ‹ÚÈÍË Ù˘ ΢ÎÏÔÊÔÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Ë ÚÔÛÙ·Î˘ÎÏ›ÓË Î·È ¿ÏϘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˜, ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·25,26,27 ÙˆÓ ÔÔ›ˆÓ ÔÚÈṲ̂Ó˜ ÂÚÁ·Û›Â˜ ·ÌÊÈÛ‚ËÙÔ‡Ó. °È· ÙÔÓ ›‰ÈÔ ÛÎÔfi ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·È Ë ¡-∞ÎÂÙ˘ÏÔ΢ÛÙ½ÓË (NAC), Ë ÔÔ›· ‚ÂÏÙÈÒÓÂÈ ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ Î·È ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÔÚÁ¿ÓˆÓ Û ηٷÛÙ¿ÛÂȘ ÛËÙÈÎÔ‡ shock28,29,30. M ‚¿ÛË Ù· ˘¿Ú¯ÔÓÙ· ‰Â‰Ô̤ӷ Ë ¯Ú‹ÛË Ù˘ ¡∞C ‰ÂÓ ‰ÈηÈÔÏÔÁÂ›Ù·È Û fiϘ ÙȘ ÌÔÚʤ˜ O∏∞. ◊‰Ë ¢ڛÛÎÂÙ·È Û ÂͤÏÈÍË ÌÂÁ¿ÏË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË, Ù˘¯·ÈÔÔÈË̤ÓË, ‰ÈÏ‹ Ù˘ÊÏ‹, ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ NAC ¤Ó·ÓÙÈ placebo ÛÙËÓ O∏∞
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188
·fi ·›ÙÈ· ¿ÏÏ· ÏËÓ Ù˘ ∞ÎÂÙ·ÌÈÓÔÊ·›Ó˘ (∞∫º). ∂ÎÙfi˜ Ù˘ ÂȉÈ΋˜ ıÂڷ›·˜ (.¯. NAC ÁÈ· O∏∞ ·fi ∞∫º), ÂΛӷ Ô˘ ¤¯Ô˘Ó ·‰È·ÌÊÈÛ‚‹ÙËÙË ·Í›· Â›Ó·È Ù· ̤ÙÚ· ÂÓÙ·ÙÈ΋˜ ˘ÔÛÙËÚÈÎÙÈ΋˜ ÊÚÔÓÙ›‰·˜. ∫¿ı ·ÛıÂÓ‹˜ Ì ̤ÙÚÈÔ˘ ‹ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÍ›· Ë·Ù›Ùȉ· Î·È ÔÔÈ·‰‹ÔÙ ·ÏÏ·Á‹ ÙÔ˘ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘ ı· Ú¤ÂÈ Ó· ÓÔÛËχÂÙ·È Û ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ (ª∂£), ÂÂȉ‹ Ë ÂͤÏÈÍË ÛÙ· ÂfiÌÂÓ· ÛÙ¿‰È· Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ-¿ıÂÈ·˜ (∏∂) ÌÔÚ› Ó· Â›Ó·È Ù·¯Â›·. ∏ ÚÔÛÔ¯‹ ÂÈÎÂÓÙÚÒÓÂÙ·È Î·Ù’ ·Ú¯‹Ó ÛÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ ÙˆÓ ˘ÁÚÒÓ, ÛÙË ‰ÈfiÚıˆÛË ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ Î·È ÌÂÙ·‚ÔÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Î·È ÛÙËÓ ÚÒÈÌË ·Ó·ÁÓÒÚÈÛË Î·È ıÂڷ›· ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È ·ÓÙÈÌÂÙÒÈÛË Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ·ÈÌÔÚÚ·Á›ˆÓ. ∂È‚¿ÏÏÂÙ·È Ô Û˘¯Ófi˜ ¤ÏÂÁ¯Ô˜ ÁÂÓÈ΋˜ ·›Ì·ÙÔ˜, ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡, ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Î·È ·ÂÚ›ˆÓ ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ (›Ó·Î·˜ 5)8. ¶›Ó·Î·˜ 5. O ·ÛıÂÓ‹˜ Ì O∏∞ ÛÙË ª∂£ • ∂ÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ·/ÂÓ‰ÔÎÚ¿ÓÈ· ˘¤ÚÙ·ÛË ∂ÁÎÂÊ·ÏÔ¿ıÂÈ· ÛÙ·‰›Ô˘ π Î·È ππ - ªÂÙ·ÊÔÚ¿ ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ΤÓÙÚÔ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ¤ÓÙ·ÍË Û ϛÛÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ - CT ÂÁÎÂÊ¿ÏÔ˘: ·ÔÎÏÂÈÛÌfi˜ ¿ÏÏˆÓ ·ÈÙÈÒÓ ‰È·Ù·Ú·¯‹˜ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘ ÌÈÎÚ‹ ¯ÚËÛÈÌfiÙËÙ· ÛÙËÓ ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ - ∞ÔÊ˘Á‹ ‰È¤ÁÂÚÛ˘, ·ÔÊ˘Á‹ ηٷÛÙÔÏ‹˜ - ∞ÓÙȂȈÙÈο: ÂÈÙ‹ÚËÛË Î·È ıÂڷ›· ÏÔÈÌÒÍÂˆÓ - §·ÎÙÔ˘Ïfi˙Ë: ¶Èı·ÓÒ˜ ¯Ú‹ÛÈÌË ∂ÁÎÂÊ·ÏÔ¿ıÂÈ· ÛÙ·‰›Ô˘ πππ Î·È IV -
¢È·ÛˆÏ‹ÓˆÛË Ù˘ ÙÚ·¯Â›·˜ (ηٷÛÙÔÏ‹ Ì propofol) ∫ÂÊ·Ï‹ Û ı¤ÛË 20-30 ÌÔ›Ú˜ ΔÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· ÁÈ· ·Ú·ÎÔÏÔ‡ıËÛË ∂¶* ÕÌÂÛË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏËÙÈÎÒÓ ÎÚ›ÛÂˆÓ (ÊÂÓ˘ÓÙÔ˝ÓË). ¶ÚÔʇϷÍË; - ª·ÓÓÈÙfiÏË: ¯ÔÚ‹ÁËÛË 0,5-1 g/kg IV bolus Û ÛÔ‚·Ú‹ ·‡ÍËÛË Ù˘ ∂¶ ‹ Ì ٷ ÚÒÙ· ÎÏÈÓÈο ÛËÌ›· ∂À • §ÔÈÌÒÍÂȘ - ∂ÈÙ‹ÚËÛË Î·È ¿ÌÂÛË ¯ÔÚ‹ÁËÛË ·ÓÙȂȈÙÈÎÒÓ Â› ÏÔÈÌÒÍÂˆÓ - ¶ÚÔÊ˘Ï·ÎÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙȂȈÙÈÎÒÓ Èı·ÓÒ˜ ¯Ú‹ÛÈÌË, ·ÏÏ¿ ·Ó·fi‰ÂÈÎÙË • ¢È·Ù·Ú·¯‹ Ù˘ ‹Í˘ ÙÔ˘ ·›Ì·ÙÔ˜ - μÈÙ·Ì›ÓË ∫: ¯ÔÚ‹ÁËÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÈ·˜ ‰fiÛ˘ - FFP: ¯ÔÚ‹ÁËÛË ÌfiÓÔ Â› ÂÓÂÚÁÔ‡ ·ÈÌÔÚÚ·Á›·˜ ‹ ÂÂÌ‚·ÙÈÎÒÓ Ú¿ÍÂˆÓ - ∞ÈÌÔÂÙ¿ÏÈ·: ¯ÔÚ‹ÁËÛË fiÙ·Ó PLT < 10.000/mm3 ‹ Û ÂÂÌ‚·ÙÈΤ˜ Ú¿ÍÂȘ - ∞Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˜ ÂÓÂÚÁÔÔÈË̤ÓÔ˜ ·Ú¿ÁˆÓ VII: Èı·ÓÒ˜ ‰Ú·ÛÙÈÎfi˜ Û ÂÂÌ‚·ÙÈΤ˜ Ú¿ÍÂȘ - ¶ÚÔʇϷÍË ÁÈ· ¤ÏÎË ·fi stress: ¯ÔÚ‹ÁËÛË H2-blockers ‹ ƒƒπ‘s
• ∞ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ / ¡ÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· - ∫·ıÂÙËÚÈ·ÛÌfi˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ - ∞ÔηٿÛÙ·ÛË ÂÏÏ›ÌÌ·ÙÔ˜ ˘ÁÚÒÓ - ÀÔÛÙ‹ÚÈÍË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (ÓÙÔ·Ì›ÓË, ·‰ÚÂÓ·Ï›ÓË, ÓÔÚ·‰ÚÂÓ·Ï›ÓË) - ∞ÔÊ˘Á‹ ÓÂÊÚÔÙÔÍÈÎÒÓ ·Ú·ÁfiÓÙˆÓ - ™˘Ó¯›˜ ·ÈÌԉȇÏÈÛË ·Ó ¯ÚÂÈ·ÛÙ› - NAC, ÚÔÛÙ·Î˘ÎÏ›ÓË: ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ¿ÁÓˆÛÙË - μ·˙ÔÚÂÛÛ›ÓË: fi¯È ¯Ú‹ÛÈÌË ÛÙËÓ O∏∞. ¶Èı·ÓÒ˜ ÂÈ˙‹ÌÈ· • ªÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ - ™˘¯Ó‹ ·Ú·ÎÔÏÔ‡ıËÛË: ÁÏ˘Îfi˙˘ Î·Ï›Ô˘, Ì·ÁÓËÛ›Ô˘, ʈÛÊfiÚÔ˘ - ∂ÓÙÂÚÈ΋ ‹ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ∂¶: ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË, ∂À: ÂÓ‰ÔÎÚ¿ÓÈ· ˘¤ÚÙ·ÛË, FFP: fresh frozen plasma, PLT: ·ÈÌÔ-ÂÙ¿ÏÈ·, ƒƒπ’s: Proton pump inhibitors. ∏epatology 2005; 41: 5: 1179-1197
∏·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· (∏∂) ΔÔ ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ· (∂O) Î·È Ë ÂÓ‰ÔÎÚ¿ÓÈ· ˘¤ÚÙ·ÛË (∂À) ıˆÚÔ‡ÓÙ·È ·fi ÙȘ ÈÔ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ Î·È ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ Ù˘ O∏∞31. O ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ Ù˘ ‰ËÌÈÔ˘ÚÁ›·˜ ∂O Î·È ∂À ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜. ¶Èı·ÓÒ˜ Ó· ÔÊ›ÏÂÙ·È Û ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ˆÛ̈ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ‰È·Ù·Ú·¯¤˜ Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜, ÊÏÂÁÌÔÓÒ‰ÂȘ ‰ÈÂÚÁ·Û›Â˜ ‹/Î·È ÏÔÈÌÒÍÂȘ32. OÈ ‰‡Ô ÈÔ Èı·ÓÔ› Ì˯·ÓÈÛÌÔ› ıˆÚÔ‡ÓÙ·È Ë ÂÍÔ›‰ËÛË ÙˆÓ ·ÛÙÚÔ΢ÙÙ¿ÚˆÓ (΢ÙÙ·ÚÔÙÔÍÈÎfi Ô›‰ËÌ·) Î·È Ë ‰È¿Û·ÛË ÙÔ˘ ·ÈÌ·ÙÔÂÁÎÂÊ·ÏÈÎÔ‡ ÊÚ·ÁÌÔ‡, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ‰È·Ê˘Á‹ Ï¿ÛÌ·ÙÔ˜ ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi (·ÁÁÂÈÔÁÂÓ¤˜ Ô›‰ËÌ·).
¶ÚfiÏË„Ë – ∞ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ˘¤ÚÙ·Û˘ (∂À) ∏ ÂΉ‹ÏˆÛË ∂O Î·È ∂À ÛÙËÓ O∏∞ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ÂÁÎÂÊ·-ÏÔ¿ıÂÈ·˜ (›Ó·Î·˜ 6). ¶›Ó·Î·˜ 6. ™Ù¿‰È· Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ π
∞ÏÏ·Á¤˜ ÛÙË Û˘ÌÂÚÈÊÔÚ¿ Ì ÂÏ¿¯ÈÛÙ˜ ·ÏÏ·Á¤˜ ÛÙÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘ ππ ¢È·Ù·Ú·¯‹ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡, ÓˆıÚfiÙ˘, Èı·ÓÒ˜ ÎÈÓËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ (asterixis), ·ÚfiÛÌÂÓË (‰È·Ù·Ú·Á̤ÓË) Û˘ÌÂÚÈÊÔÚ¿ πππ ∂ÎÛÂÛËÌ·Ṳ̂ÓË Û‡Á¯˘ÛË, ·Û˘Ó¿ÚÙËÙË ÔÌÈÏ›·, ˘ÓËÏ›·, ·ÏÏ¿ ¤ÁÂÚÛË Î·È ·¿ÓÙËÛË Û ˯ËÙÈο ÂÚÂı›ÛÌ·Ù· πV ∫ÒÌ·. ªË ·ÓÙ·fiÎÚÈÛË ÛÙ· ÂÒ‰˘Ó· ÂÚÂı›ÛÌ·Ù·. £¤ÛË ·ÂÁÎÂÊ·ÏÈÛÌÔ‡ Gastroenterology 1977; 72: 573-583
ΔÔ ∂O ۯ‰fiÓ ÔÙ¤ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ ÛÙ¿‰ÈÔ π-ππ Ù˘ ∏∂. O ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ∂O ·˘Í¿ÓÂÈ ÛÙÔ 25-30% Ì ÙËÓ ÂͤÏÈÍË Ù˘ ∏∂ ÛÙÔ ÛÙ¿‰ÈÔ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
πππ Î·È ÛÙÔ 65-75% Î·È Ï¤ÔÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÛÙ¿‰ÈÔ ∏∂ IV ‹ ÎÒÌ·33. ΔÔ ∂O Â›Ó·È Ë ÈÔ ÎÔÈÓ‹ ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙËÓ O∏∞. ΔÔ ∂O ÂΉËÏÒÓÂÙ·È ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË (ÎÚ›ÛÂȘ Û˘ÛÙÔÏÈ΋˜ ›ÂÛ˘ > 200 mmHg ‹ ÛÙ·ıÂÚ‹ Û˘ÛÙÔÏÈ΋ ›ÂÛË > 150 mmHg) Î·È ‚Ú·‰˘Î·Ú‰›· (Cushing’s reflex), ·˘ÍË̤ÓÔ Ì˘˚Îfi ÙfiÓÔ Î·È Ì˘ÔÎÏÔÓÈÎÔ‡˜ Û·ÛÌÔ‡˜, ÛÙ¿ÛË ·ÂÁÎÂÊ·ÏÈÛÌÔ‡ Î·È ·Î·Ì„›·˜, ÂÍ·Ûı¤ÓÈÛË ÙˆÓ ·ÓÙ·Ó·ÎÏ·ÛÙÈÎÒÓ Ù˘ ÎfiÚ˘ ÙÔ˘ ÔÊı·ÏÌÔ‡ Î·È Ù¤ÏÔ˜ ·Ó·Ó¢ÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ¿ÓÔÈ·. ∏ ÚÔÛ¤ÁÁÈÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∏∂ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ‚‹Ì· ÚÔ˜ ‚‹Ì·34. ™Ù¿‰ÈÔ ∏∂ π-ππ. ∂›Ó·È ÚÔÙÈÌfiÙÂÚË Ë ÓÔÛËÏ›· ÙÔ˘ ·ÚÚÒÛÙÔ˘ Û ª∂£. ™˘ÓÈÛÙ¿Ù·È (ÛÙ¿‰ÈÔ ππ) Ë ·ÂÈÎfiÓÈÛË (CT) ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÁÈ· Ó· ·ÔÎÏÂÈÛÙ› ¿ÏÏË ·ÈÙ›· ¤ÎÙˆÛ˘ ÙÔ˘ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘ (.¯. ÂÓ‰ÔÎÚ¿ÓÈ· ·ÈÌÔÚÚ·Á›·). ∞ÔÊ˘Á‹ Ù˘ ηٷÛÙÔÏ‹˜ fiÛÔ Â›Ó·È ‰˘Ó·ÙfiÓ Î·È Â› ÌË ÂÏÂÁ¯fiÌÂÓ˘ ‰È¤ÁÂÚÛ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ‚ÂÓ˙ԉȷ˙›Ó˜ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ Û ÌÈÎÚ¤˜ ‰fiÛÂȘ8. ¢Â‰Ô̤ÓÔ˘ fiÙÈ Â›Â‰· ·Ì̈ӛ·˜ > 200 Ìg/dl Û¯ÂÙ›˙ÔÓÙ·È Ì ÌË ·Ó·ÛÙÚ¤„È̘ ÂÁÎÂÊ·-ÏÈΤ˜ ‚Ï¿‚˜ (ÂÁÎÔÏ·ÛÌfi˜ ÛÙÂϤ¯Ô˘˜ – cerebral herniation) Î·È ı¿Ó·ÙÔ19, ÚÔÙ›-ÓÂÙ·È Ë ¯ÔÚ‹ÁËÛË Ï·ÎÙÔ˘Ïfi˙˘ per os ‹ Ì ¤ÓÂÌ· ÁÈ· ÙËÓ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ·Ì̈ӛ·˜ Î·È ÙËÓ ÚfiÏË„Ë ÙÔ˘ ∂.O. ™Ù¿‰ÈÔ ∏∂ πππ-πV. ŸÙ·Ó Ë ∏∂ ÂÍÂÏȯı› ÛÙÔ ÛÙ¿‰ÈÔ πππ ‹ IV Û˘ÓÈÛÙ¿Ù·È ‰È·ÛˆÏ‹ÓˆÛË Ù˘ ÙÚ·¯Â›·˜ ÁÈ· ÚÔÛÙ·Û›· ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ. ¶ÚÔÙ›ÓÂÙ·È Ë ¯Ú‹ÛË propofol ˆ˜ ηٷÛÙ·ÏÙÈÎÔ‡35 Î·È Û˘¯Ó‹ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ Î·È ÓÂÊÚÈÎÒÓ ‰˘ÛÏÂÈÙÔ˘ÚÁÈÒÓ. ™˘¯Ófi˜ ¤ÏÂÁ¯Ô˜ ÁÏ˘Îfi˙˘, ËÏÂÎÙÚÔ-Ï˘ÙÒÓ Î·È ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ ηıÒ˜ Î·È Û˘¯Ó‹ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÁÈ· ÚÒÈÌË ‰È·›ÛÙˆÛË ÛËÌ›ˆÓ ∂À. ∏ ÎÂÊ·Ï‹ ÙÔ˘ ·ÚÚÒÛÙÔ˘ ÙÔÔıÂÙÂ›Ù·È Û ı¤ÛË 20-30 ÌÔÈÚÒÓ36. ™˘ÓÈÛÙ¿Ù·È ¯Ú‹ÛË ÂÓ‰ÔÙÚ·¯Âȷ΋˜ ͢ÏÔη˝Ó˘ ÚÈÓ ·fi ·Ó·Ú-ÚfiÊËÛË. OÈ ÂÈÏËÙÈΤ˜ ÎÚ›ÛÂȘ (Û·ÛÌÔ›) Û˘ÓÈÛÙ¿Ù·È Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ÊÂÓ˘ÓÙÔ˝ÓË. ∏ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Ì ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· ÛÙÔÓ ÂÈÛÎÏËÚ›‰ÈÔ, ˘ÔÛÎÏËÚ›‰ÈÔ ¯ÒÚÔ ‹ ÛÙÔ ÂÁÎÂÊ·ÏÈÎfi ·Ú¤Á¯˘Ì· ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È ·ÌÊÈÛ‚ËÙÔ‡ÌÂÓË. ∂›Ó·È fï˜ Ô ÌfiÓÔ˜ ÙÚfiÔ˜ ·Ó›¯Ó¢Û˘ ∂À. Δ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· ÙÔÔıÂÙÔ‡Ó ÙÔÓ Î·ıÂÙ‹Ú· ÛÙÔ ÛÙ¿‰ÈÔ ∏∂ πππ. OÈ Î›Ó‰˘ÓÔÈ ·fi ÙÔÓ Î·ıÂÙ‹Ú· Â›Ó·È ‚¤‚·È· Ë ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· Î·È ÔÈ ÏÔÈÌÒÍÂȘ Û ·ÛıÂÓ›˜ Ô˘ ÂÍ ÔÚÈÛÌÔ‡ ¤¯Ô˘Ó ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿-
189
ıÂÛË. ™Â Û‡ÓÔÏÔ 262 ·ÛıÂÓÒÓ Û ÌÂÙ·-ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÛÙȘ ∏¶∞ ÛËÌÂÈÒıËÎ·Ó ÂÈÏÔΤ˜ ÛÙÔ 3,8% ÙˆÓ ·ÛıÂÓÒÓ (1% ı·Ó·ÙËÊfiÚÔ˜ ·ÈÌÔÚÚ·Á›·) Ì ÂÈÛÎÏËÚ›‰ÈÔ Î·ıÂÙ‹Ú· ÂÓÒ Ô Î›Ó‰˘ÓÔ˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ Ì ˘ÔÛÎÏËÚ›‰ÈÔ ‹ ÂÓ‰Ô·ÚÂÁ¯˘Ì·ÙÈÎfi ηıÂÙ‹Ú·. Δ· ϤÔÓ ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ‚¤‚·È· ‰ÂÓ ‰Â›¯ÓÔ˘Ó ‚ÂÏÙ›ˆÛË ÛÙËÓ ¤Î‚·ÛË ÂÎÂ›ÓˆÓ ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÙÔÔıÂÙ‹ıËÎ·Ó ÔÈ Î·ıÂÙ‹Ú˜ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘38. ™Ùfi¯Ô˜ Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Ú¤ÂÈ Ó· Â›Ó·È Ë ‰È·Ù‹ÚËÛË Ù˘ ›ÂÛ˘ ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (̤ÛË ·ÚÙËÚȷ΋ ›ÂÛË Ì›ÔÓ ÙËÓ ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË) > 50-60 mmHg Î·È Ë ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË < 20-25 mmHg39. ™Â ÔÚÈṲ̂ӷ ΤÓÙÚ· Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÓÙÂӉ›ÎÓ˘Ù·È fiÙ·Ó Ë ›ÂÛË ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ (¶∞∂) ·Ú·Ì¤ÓÂÈ < 40 mmHg ÁÈ· ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚ˜ ÒÚ˜5. ŸÙ·Ó ‰È·ÈÛÙˆı› ∂À ›Ù Ì ηıÂÙ‹Ú· ›Ù Ì ÂÌÊ·Ó‹ Ó¢ÚÔÏÔÁÈο ÛËÌ›· (ı¤ÛË ·ÂÁÎÂÊ·ÏÈÛÌÔ‡, ÌÂȈ̤ӷ ‹ ·ÓÒÌ·Ï· ·ÓÙ·Ó·ÎÏ·ÛÙÈο Ù˘ ÎfiÚ˘ ÙÔ˘ ÔÊı·ÏÌÔ‡) Û˘ÓÈÛÙ¿Ù·È ˆÛ̈ÙÈ΋ ‰ÈÔ‡ÚËÛË Ì ÂÓ‰ÔÊϤ‚È· (IV) ¯ÔÚ‹ÁËÛË Ì·ÓÓÈÙfiÏ˘ Û bolus ‰fiÛË 0,5-1 g/kg Î·È Â·Ó¿ÏË„Ë Ì›· ‹ ‰‡Ô ÊÔÚ¤˜ ·Ó ¯ÚÂÈ·ÛÙ› Î·È Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ Ë ˆÛ̈ÙÈÎfiÙËÙ· ÙÔ˘ ÔÚÔ‡ ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ Ù· 320 mosm/L. ¶ÚÔÛÔ¯‹ ¯ÚÂÈ¿˙ÂÙ·È Â› ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (ΛӉ˘ÓÔ˜ Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜).
¢È·Ù·Ú·¯¤˜ Ù˘ ‹Í˘ ÙÔ˘ ·›Ì·ÙÔ˜ ΔÔ ‹·Ú ¤¯ÂÈ ÎÂÓÙÚÈÎfi ÚfiÏÔ ÛÙË Û‡ÓıÂÛË Û¯Â‰fiÓ fiÏˆÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ù˘ ‹Í˘ ·ÏÏ¿ Î·È ·Ó·ÛÙÔϤˆÓ Ù˘ ‹Í˘ Î·È Ù˘ ÈÓÔ‰fiÏ˘Û˘40. OÈ Î‡ÚȘ ‰È·Ù·Ú·¯¤˜ Ù˘ ‹Í˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÏ¿ÙÙˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ (PLT) Û˘¯Ó¿ £ 100.000 mm3 (Î·È ÔÈÔÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·) Î·È Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘ Î·È ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ ππ, V, VII, πÃ Î·È X. ∞˘Ùfi Ô‰ËÁ› Û ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘ (ƒΔ), Ô ÔÔ›Ô˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú¤ˆ˜ ˆ˜ ‰Â›ÎÙ˘ Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. Δ· ›‰· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ‹Í˘ (·ÓÙÈıÚÔÌ‚›ÓË πππ, ÚˆÙ½ÓË C Î·È S) ·ÚfiÙÈ Â›Ó·È ÌÂȈ̤ӷ, ÂÓ ÙÔ‡ÙÔȘ ‰ÂÓ ¤¯Ô˘Ó ‰ÈÔÚıˆÙÈ΋ ›‰Ú·ÛË ÛÙËÓ ‹ÍË41. °ÂÓÈÎÒ˜, ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË ÈÓˆ‰fiÏ˘ÛË (·‡ÍËÛË ÙˆÓ ÚÔ˚fiÓÙˆÓ ‰È¿Û·Û˘ ÙÔ˘ ÈÓÒ‰Ô˘˜ Î·È ·‰˘Ó·Ì›· Û¯ËÌ·ÙÈÛÌÔ‡ ıÚfiÌ‚Ô˘) Î·È ‰È¿¯˘ÙË ÂÓ‰·ÁÂȷ΋ ‹ÍË (·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ ıÚÔÌ‚›ÓË-·ÓÙÈıÚÔÌ‚›ÓË πππ42.
190
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∂Âȉ‹ Ô ƒΔ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÛÙËÓ O∏∞, Û˘ÓÈÛÙ¿Ù·È ·ÔÊ˘Á‹ ¯ÔÚ‹ÁËÛ˘ FFP ÁÂÓÈÎÒ˜, ÂÎÙfi˜ ·fi ηٷÛÙ¿ÛÂȘ ·ÈÌÔÚÚ·Á›·˜ ‹ fiÙ·Ó ÚfiÎÂÈÙ·È Ó· Á›ÓÔ˘Ó ÂÂÌ‚·ÙÈΤ˜ Ú¿ÍÂȘ (.¯. ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· ÛÙÔÓ ˘ÔÛÎÏËÚ›‰ÈÔ ¯ÒÚÔ) Î·È Ë ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË Â›Ó·È ÂÌÊ·Ó‹˜ (π¡R >7). ∏ ÌÂÙ¿ÁÁÈÛË ·ÈÌÔÂÙ·Ï›ˆÓ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÁÂÓÈÎÒ˜. ∂› ·Ô˘Û›·˜ ·ÈÌÔÚÚ·Á›·˜ ·ÛʷϤ˜ ıˆÚÂ›Ù·È ¤Ó· fiÚÈÔ ƒLT: 10.000/mm 3 ‹ 15-20.000/ mm3 Û ηٷÛÙ¿ÛÂȘ Ïԛ̈͢ ‹ Û‹„˘43. ŸÙ·Ó ÚfiÎÂÈÙ·È Ó· Á›ÓÔ˘Ó ÂÂÌ‚·ÙÈΤ˜ Ú¿ÍÂȘ, ·ÛʷϤ˜ fiÚÈÔ ıˆÚ›ٷÈ43 ·ÚÈıÌfi˜ PLT: 5070.000/mm3. ∂›Û˘, fiÙ·Ó ˘¿Ú¯ÂÈ ·ÈÌÔÚÚ·Á›· Ì PLT ~ 50.000/mm3, ÙfiÙ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌÂÙ¿ÁÁÈÛË ƒLT. O ÚfiÏÔ˜ ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ ÂÓÂÚÁÔÔÈË̤ÓÔ˘ ·Ú¿ÁÔÓÙ· VII (rFVIIa) ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·fi ÌÂÁ¿Ï˜ ÌÂϤÙ˜, ›Ûˆ˜ fï˜ Â›Ó·È ¯Ú‹ÛÈÌË Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ › ·ÈÌÔÚÚ·Á›·˜8 Î·È INR ≥ 1,5.
§ÔÈÌÒÍÂȘ §ÔÈÌÒÍÂȘ, ȉȷ›ÙÂÚ· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÂΉËÏÒÓÔÓÙ·È ÂÚ›Ô˘ ÛÙÔ 80% ÙˆÓ ·ÚÚÒÛÙˆÓ Ì O∏∞5. ∏ ·ÈÙ›· ÙˆÓ ÏÔÈÌÒÍÂˆÓ ‚Ú›ÛÎÂÙ·È ÛÙË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‰ÈÎÙ˘ÔÂÓ‰ÔıËÏÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (¢∂™) Î·È ÛÙË ÌÂȈ̤ÓË Ô„ÔÓÈÓÔÔ›ËÛË44. Δ· Û˘¯ÓfiÙÂÚ· ·ıÔÁfiÓ· Â›Ó·È Ù· Gram+ (ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜, ÛÙÚÂÙfiÎÔÎÎÔ˜) ÌÈÎÚfi‚È·, Gram(-) ÌÈÎÚfi‚È· Î·È Ì‡ÎËÙ˜ (΢ڛˆ˜ candida albicans ÛÙÔ 30% Ù˘ O∏∞). ¶·Ú¿ ÙÔ fiÙÈ ‰ÂÓ ¤¯ÂÈ ·Ô‰ÂȯÙ› Ë ˆÊÂÏÈÌfiÙËÙ· Ù˘ ÚÔÊ˘Ï·ÎÙÈ΋˜ ¯Ú‹Û˘ ÙˆÓ ·ÓÙȂȈÙÈÎÒÓ, ÔÏÏ¿ ΤÓÙÚ· ¯ÔÚËÁÔ‡Ó ÚÔÊ˘Ï·ÎÙÈο ¢ڤˆ˜ Ê¿ÛÌ·ÙÔ˜ ·ÓÙÈ-ÌÈÎÚԂȷο Î·È ·ÓÙÈÌË΢ÙÈ·ÛÈο. O ÏfiÁÔ˜ Â›Ó·È fiÙÈ ÔÈ ÏÔÈÌÒÍÂȘ Û ÚÔ¯ˆÚË̤ӷ ÛÙ¿‰È· ∏∂, ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÂΉ‹ÏˆÛ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜, ÂÓÒ Ô ˘ÚÂÙfi˜ ÌÔÚ› Ó· ÂȉÂÈÓÒÛÂÈ ÙËÓ ÂÓ‰ÔÎÚ¿ÓÈ· ˘¤ÚÙ·ÛË45. ∂ΛÓÔ Ô˘ ‚‚·›ˆ˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È, Â›Ó·È Ë ÚÔÛÂÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· ¤ÁηÈÚË ‰È·›ÛÙˆÛË Ïԛ̈͢ (·/· ıÒÚ·ÎÔ˜, ÂÚÈÔ‰È΋ Ï‹„Ë Î·ÏÏÈÂÚÁÂÈÒÓ Ù˘¤ÏˆÓ, Ô‡ÚˆÓ, ·›Ì·ÙÔ˜ ÁÈ· ÌÈÎÚfi‚È· Î·È Ì‡ÎËÙ˜).
∞ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ – ¡ÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· ∫·Ú‰È·ÁÁÂȷΤ˜, ·ÈÌÔ‰˘Ó·ÌÈΤ˜, ·Ó·Ó¢ÛÙÈΤ˜ Î·È ÓÂÊÚÔÏÔÁÈΤ˜ ÂÈÏÔΤ˜, Â›Ó·È ÛËÌ·ÓÙÈ-
Τ˜ ÂΉËÏÒÛÂȘ Ù˘ O∏∞. ÷ڷÎÙËÚÈÛÙÈο Â˘Ú‹Ì·Ù·, Â›Ó·È Ë Û˘ÛÙË-Ì·ÙÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹, ÔÈ ÌÂȈ̤Ó˜ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ, Ë ˘fiÙ·ÛË Î·È Ë ·ÓÙÈÛÙ·ıÌÈÛÙÈ΋ ·‡ÍËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜. ™ËÌÂÈÒÓÂÙ·È Â›Û˘ ‰È·Ù·Ú·¯‹ ÛÙËÓ ÚfiÛÏË„Ë Î·È ¯Ú‹ÛË ÙÔ˘ Ô͢ÁfiÓÔ˘ ÛÙÔ˘˜ ÂÚÈÊÂÚÈÎÔ‡˜ ÈÛÙÔ‡˜ Ô˘ Ô‰ËÁ› Û ÈÛÙÈ΋ ˘ÔÍ›· Î·È Á·Ï·ÎÙÈ΋ ÔͤˆÛË5. ∏ ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· Swan-Ganz ÛÙËÓ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›· Â›Ó·È ·Ôχو˜ ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ˘ÂÚÊfiÚÙËÛ˘ Ì ˘ÁÚ¿ (Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·). ∏ ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ ÙˆÓ ˘ÁÚÒÓ Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· Á›ÓÂÙ·È Ì ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù· (·Ï‚Ô˘Ì›ÓË), ·Ú¿ Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù· (·Ï‚Ô˘Ì›ÓË), ·Ú¿ Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ (·Ï·ÙÔ‡¯·) Î·È Ó· Â›Ó·È ÂÌÏÔ˘ÙÈṲ̂ӷ Ì ÁÏ˘Îfi˙Ë, ÁÈ· ‰È·Ù‹ÚËÛË Â˘ÁÏ˘Î·ÈÌ›·˜. ¶¤Ú·Ó ÙÔ‡ÙÔ˘ fï˜, ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ̤Û˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÛÙ· 50-60 mmHg, ¯ÚÂÈ¿˙ÂÙ·È ›Ûˆ˜ Î·È ¯Ú‹ÛË ÈÓfiÙÚÔˆÓ Î·È ·ÁÁÂÈÛ˘Û·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ. ∂Í’ ·˘ÙÒÓ Ë ÓÙÔ·Ì›ÓË ·˘Í¿ÓÂÈ, ÂÓÒ Ë ·‰ÚÂÓ·Ï›ÓË Î·È ÓÔÚ·‰ÚÂÓ·Ï›ÓË ÂȉÂÈÓÒÓÔ˘Ó ÙËÓ ·Ô‰¤ÛÌ¢ÛË Ô͢ÁfiÓÔ˘ ÛÙÔ˘˜ ÂÚÈÊÂÚÈÎÔ‡˜ ÈÛÙÔ‡˜25,46. ∏ ÔÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (O¡∞) Â›Ó·È Û˘¯Ó‹ ÂÈÏÔ΋ Ù˘ O∏∞ Î·È ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ·Ê˘‰¿ÙˆÛË, Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ (∏¡™) Î·È ÔÍ›· ÛˆÏË-Ó·Úȷ΋ Ó¤ÎÚˆÛË (O™¡)47. ∏ Û˘¯ÓfiÙËÙ· (40-50%) Ù˘ O¡∞ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Ì ˘ÂÚ‰ÔÛÔÏÔÁ›· ·ÎÂÙ·ÌÈÓÔÊ·›Ó˘ ˆ˜ ·ÈÙ›·˜ O∏∞48. ™Â οı ÂÚ›ÙˆÛË ı· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ‰˘ÓËÙÈο ÓÂÊÚÔÙÔÍÈÎÔ› ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÔÈ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜, Ù· ÌË ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë (ª™∞º) Î·È Ù· ÛÎÈ·ÛÙÈο ÁÈ· ·ÂÈÎfiÓÈÛË. ŸÙ·Ó fï˜ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÛÎÈ·ÛÙÈο ı· Ú¤ÂÈ Ó· ÚÔËÁÂ›Ù·È Ë ¯ÔÚ‹ÁËÛË ¡∞C ·ÚfiÙÈ Ë ¯ÚËÛÈÌfiÙËÙ¿ Ù˘ Â›Ó·È ·ÌÊÈÛ‚ËÙÔ‡ÌÂÓË49,50. ∞Ó ¯ÚÂÈ·Ûı› ·ÈÌԉȇÏÈÛË ı· Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘Ó¯‹˜ ÊÏ‚Ô-ÊÏ‚È΋, ·Ú¿ ‰È·ÏÂ›Ô˘Û· ·ÈÌԉȇÏÈÛË, ‰ÈfiÙÈ ¤¯ÂÈ Ê·Ó› fiÙÈ ¤ÙÛÈ ÛÙ·ıÂÚÔÔÈÔ‡ÓÙ·È Î·È ÔÈ Î·Ú‰È·ÁÁÂȷΤ˜ fiˆ˜ Î·È ·Ú¿ÌÂÙÚÔÈ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘51. ∏ ÙÂÚÏÈÚÂÛÛ›ÓË Ô˘ ·Ô‰Â‰ÂÈÁ̤ӷ ‚ÂÏÙÈÒÓÂÈ ÙÔ ∏¡™ ÛÙËÓ ¯ÚfiÓÈ· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·, Â›Ó·È ·Î·Ù¿ÏÏËÏË ÛÙË ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ O∏∞ ÛÙËÓ ÔÔ›· Û ÚfiÛÊ·ÙË ÌÂϤÙË52 Ê¿ÓËΠfiÙÈ ·˘Í¿ÓÂÈ ÙËÓ ÂÁÎÂÊ·ÏÈ΋ ·ÈÌ¿ÙˆÛË Î·È ÙËÓ ÂÓ‰Ô-ÎÚ¿ÓÈ· ˘¤ÚÙ·ÛË (∂À).
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ªÂÙ·‚ÔÏÈΤ˜ – ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ OÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· (40-50%)53 Ë ÔÔ›· ÛÙÔ 70% ·Ô‰›‰ÂÙ·È ÛÙËÓ ·Ú·ÎÂÙ·ÌfiÏË54 Î·È ÔÍ›· ·ÁÎÚ·ٛÙȉ· (44% Û ÌÈ· ÌÂϤÙË)55 fiˆ˜ Î·È Ë ˘ÔÁÏ˘Î·ÈÌ›·56 (45%) Â›Ó·È Û˘¯Ó¤˜ ÂÈÏÔΤ˜ Ù˘ O∏∞. OͤˆÛË, ·ÏοψÛË, ÂÏ·Ùو̤ӷ ›‰· ʈÛÊfiÚÔ˘, Ì·ÁÓËÛ›Ô˘ Î·È Î·Ï›Ô˘ ÂÈ‚¿ÏÔ˘Ó ÙÔ Û˘¯Ófi ¤ÏÂÁ¯Ô Î·È ¤ÁηÈÚË ‰ÈfiÚıˆÛË ·˘ÙÒÓ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ. ™˘Ó¯‹˜ ¯ÔÚ‹ÁËÛË ÁÏ˘Îfi˙˘, ÂÍ‹ÓÙ· ÁÚ·ÌÌ¿ÚÈ·/ËÌÂÚËÛ›ˆ˜ ÚˆÙ½Ó˜ Î·È ÂÓÙÂÚÈ΋ ‹ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È Ì ÂÈ̤ÏÂÈ·8.
∂ȉÈ΋ ·ÓÙÈÌÂÙÒÈÛË O∏∞ ·fi ÂȉÈο ·›ÙÈ· O∏∞ ·fi ∞ÎÂÙ·ÌÈÓÔÊ·›ÓË (∞∫º) ∏ Ë·ÙÔÙÔÍÈÎfiÙËÙ· Ù˘ ∞∫º Â›Ó·È ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË. ΔÔÍÈ΋ ıˆÚÂ›Ù·È Ë ‰fiÛË ÙˆÓ 10 g Û ÂÊ¿·Í Ï‹„Ë ‹ Û·Ó›ˆ˜ ·ÎfiÌ· Î·È ‰fiÛÂȘ ÙˆÓ 3-4 g Û ηٷÛÙ¿ÛÂȘ ÓËÛÙ›·˜ ‹ Û ¿ÙÔÌ· Ô˘ οÓÔ˘Ó ¯ÚfiÓÈ· ηٿ¯ÚËÛË ·ÏÎÔfiÏ57. Δ· ›‰· ÙˆÓ ·ÌÈÓÔÙÚ·ÓÛÊÂÚ·ÛÒÓ Û˘¯Ó¿ ÍÂÂÚÓÔ‡Ó ÙȘ 3.000-4.000 IU/L. ∏ ÚÒÙË ıÂڷ¢ÙÈ΋ ÂÓ¤ÚÁÂÈ· Â›Ó·È Ë ¯ÔÚ‹ÁËÛË ÂÓÂÚÁÔ‡ ¿Óıڷη Û ‰fiÛË 1 g/kg per os, ÁÈ· ‰¤ÛÌ¢ÛË Ù˘ ∞∫º Î·È «·Ôχ̷ÓÛË» ÙÔ˘ ÂÙÈÎÔ‡ ۈϋӷ. ∂›Ó·È ϤÔÓ ‰Ú·ÛÙÈ΋ fiÙ·Ó ¯ÔÚËÁÂ›Ù·È Ì¤Û· Û ‰È¿ÛÙËÌ· ÌÈ·˜ ÒÚ·˜ ·fi ÙË Ï‹„Ë ‹ ·ÎfiÌ· Î·È ·Ó ·Ú¤ÏıÔ˘Ó 3-4 ÒÚ˜ ·fi ÙË Ï‹„Ë58,59. ∞ÎÔÏÔ˘ı› Ë ¯ÔÚ‹ÁËÛË ¡-acetylcysteine (NAC) ÂȉÈÎÔ‡ ·ÓÙ›‰ÔÙÔ˘, ÙÔ ÔÔ›Ô ·˘Í¿ÓÂÈ Ù· ÂÍ·ÓÙÏË̤ӷ ·fi ÙËÓ ∞∫º ·Ôı¤Ì·Ù· Ù˘ ÈÛ¯˘Ú‹˜ ·ÓÙÈÔÍÂȉˆÙÈ΋˜ Ô˘Û›·˜, ÁÏÔ˘Ù·ıÂÈfiÓË. ÃÔÚËÁÂ›Ù·È ÂÓ‰ÔÊÏ‚›ˆ˜ Û ‰fiÛË 150 mg/kg Û ¯ÚfiÓÔ 15 min Û 5% ‰È¿Ï˘Ì· Dextrose, ÙȘ ÂfiÌÂÓ˜ 4 ÒÚ˜ ¯ÔÚËÁÔ‡ÓÙ·È πV 50 mg/kg Î·È ÙȘ ˘fiÏÔȘ 16 ÒÚ˜ ¯ÔÚËÁÔ‡ÓÙ·È 100 mg/kg ÂÓ‰ÔÊÏ‚›ˆ˜, ¿ÓÙ· Û 5% ‰È¿Ï˘Ì· Dextrose (¶›Ó·Î·˜ 2).
O∏∞ ·fi Ì·ÓÈÙ¿ÚÈ· ¢ÂÓ ˘¿Ú¯ÂÈ ‰È·ı¤ÛÈÌË ÂÚÁ·ÛÙËÚȷ΋ ÂͤٷÛË ÂȂ‚·›ˆÛ˘ Ù˘ ·ÚÔ˘Û›·˜ Ù˘ ÙÔ͛Ӣ ∞manita phalloides. ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È ·fi ÙÔ ÈÛÙÔÚÈÎfi Ï‹„˘ Ì·ÓÈÙ·ÚÈÒÓ Î·È Ù· ÛÔ‚·Ú¿ Á·ÛÙÚÂÓÙÂÚÈο Û˘ÌÙÒÌ·Ù· (Ó·˘Ù›·, ¤ÌÌÂÙÔÈ, ‰È¿ÚÚÔȘ, ΈÏÈÎÔÂȉ‹ ÎÔÈÏȷο ¿ÏÁË). ∞̤ۈ˜ ÙÔÔıÂÙÂ›Ù·È ÚÈÓÔÁ·ÛÙÚÈÎfi˜ ηıÂÙ‹Ú·˜, Á›ÓÔÓÙ·È Ï‡ÛÂȘ ÛÙÔÌ¿¯Ô˘ Î·È ¯ÔÚËÁÂ›Ù·È ÂÓÂÚÁfi˜ ¿Óıڷη˜. ∏ O∏∞ ·fi Ì·ÓÈÙ¿ÚÈ· Ô‰ËÁ›
191
Û ı¿Ó·ÙÔ ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜60, ·Ó Î·È ÚfiÛÊ·Ù· ¤¯ÂÈ ÂÚÈÁÚ·Ê› Ï‹Ú˘ ·Ó¿ÚÚˆÛË Ì ˘ÔÛÙËÚÈÎÙÈο ̤ÙÚ· Î·È Ê·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË61. ∂ȉÈο ·ÓÙ›‰ÔÙ· ıˆÚÔ‡ÓÙ·È Ë Penicillin-G Î·È Ë Silibinin (Silymarin ‹ milk thistle – Á¿Ï· ·fi Á·˚‰Ô˘Ú¿Áηı·), ·ÚfiÙÈ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÂÏÂÁ¯fiÌÂÓ˜ ÌÂϤÙ˜ Ô˘ Ó· ÂȂ‚·ÈÒÓÔ˘Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜60, 62, 63. ∏ Penicillin-G ¯ÔÚËÁÂ›Ù·È IV Û ‰fiÛÂȘ 300.000-1.000.000 IU/kg/ËÌÂÚ. H Silibinin/Silymarin ¯ÔÚËÁÂ›Ù·È (per os ‹ πV) Û ‰fiÛÂȘ 30-40 mg/kg/ËÌÂÚ. ÁÈ· 3-4 Ë̤Ú˜. ™Â ÔÚÈṲ̂ӷ ΤÓÙÚ· ¯ÔÚËÁÂ›Ù·È Û˘ÌÏËڈ̷ÙÈο Î·È NAC64.
OHA ·fi ȉÈÔÛ˘ÁÎÚ·Ûȷ΋ Ê·Ú̷΢ÙÈ΋ Ë·ÙÔÙÔÍÈÎfiÙËÙ· ™·Ó›ˆ˜ Ê¿Ú̷η ·ÏÏ¿ ÏËÓ ÙËÓ ∞∫º, ÚÔηÏÔ‡Ó ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË Ë·ÙÔ-ÙÔÍÈÎfiÙËÙ·. ŒÙÛÈ Ë ÙÔÍÈÎfiÙËÙ· ÙˆÓ ˘ÔÏÔ›ˆÓ Ê·ÚÌ¿ÎˆÓ Â›Ó·È È‰ÈÔÛ˘ÁÎÚ·Ûȷ΋ Î·È Û˘Ì‚·›ÓÂÈ Ì¤Û· ÛÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ ·fi ÙË Ï‹„Ë ÙˆÓ Ê·Ú̿ΈÓ. ∂Λӷ ÙˆÓ Ê·ÚÌ¿ÎˆÓ Ô˘ Ï·Ì‚¿ÓÔÓÙ·È Û˘Ó¯Ҙ ÁÈ· 1-2 ¯ÚfiÓÈ·, Â›Ó·È ÂÍ·ÈÚÂÙÈο ·›ı·ÓÔ Ó· ÚÔηϤÛÔ˘Ó Ë·ÙÔÙÔÍÈÎfiÙËÙ·. ™ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÈÙ›·˜ Ù˘ O∏∞ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È Ù· Û˘ÌÏËÚÒÌ·Ù· ‰È·ÙÚÔÊ‹˜, fiˆ˜ Î·È ‰È¿ÊÔÚ· Ê˘ÙÈο Û΢¿ÛÌ·Ù·65 (.¯. ‚fiÙ·Ó· ÁÈ· ·‰˘Ó¿ÙÈÛÌ·). ¢ÂÓ ˘¿Ú¯Ô˘Ó ÂȉÈο ·ÓÙ›‰ÔÙ· ÁÈ· ÙËÓ È‰ÈÔÛ˘ÁÚ·Ûȷ΋ Ê·Ú̷΢ÙÈ΋ Ë·ÙÔÙÔÍÈÎfiÙËÙ·. O ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ·ÈÙ›·˜ Ù˘ O∏∞ ·fi Ê¿Ú̷η Â›Ó·È ¿ÓÙÔÙ ‰È¿ÁÓˆÛË ÂÍ ·ÔÎÏÂÈÛÌÔ‡. ΔÔ Ê¿ÚÌ·ÎÔ Ô˘ ÂÓÔ¯ÔÔÈ›ٷÈ, ·ÛÊ·ÏÒ˜ ‰È·ÎfiÙÂÙ·È ·Ì¤Ûˆ˜. π‰ÈÔÛ˘ÁÎÚ·Ûȷ΋ Ê·Ú̷΢ÙÈ΋ Ë·ÙÔÙÔÍÈÎfiÙËÙ· ÚÔηÏÔ‡Ó Î˘Ú›ˆ˜ ÙÚÂȘ ηÙËÁÔڛ˜ Ê¿Ú̿ΈÓ: Ù· ·ÓÙÈ‚ÈÔÙÈο Ù· ÌË-ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë (ª™∞º) Î·È Ù· ·ÓÙÈÂÈÏËÙÈο Ê¿Ú̷η, ·ÏÏ¿ Û·ÓÈfiÙÂÚ· Î·È ¿ÏÏ· Ê¿Ú̷η (›Ó·Î·˜ 7).
OHA ·fi ÈÔÁÂÓ‹ Ë·Ù›Ùȉ· ∂ȉÈ΋ ıÂڷ›· ÁÈ· ÙËÓ O∏∞ ·fi ÙÔ˘˜ ÈÔ‡˜ Ù˘ Ë·Ù›Ùȉ·˜ ∏∞V, HBV, HDV, HEV (Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÔÈ ÂÁ΢ÌÔÓÔ‡Û˜ Á˘Ó·›Î˜66, 67 Û ÂÓ‰˘ÌÈΤ˜ ¯ÒÚ˜-πÓ‰›·, ¶·ÎÈÛÙ¿Ó, ªÂÍÈÎfi, ƒˆÛÛ›·-) ∏CV (Û·ÓÈfiٷٷ ·ÈÙ›· O∏∞), ‰ÂÓ ˘¿Ú¯ÂÈ. ∂›Ó·È Èı·Ófi Ó· ÂӉ›ÎÓ˘ÓÙ·È Ù· ÓÔ˘ÎÏÂÔÛȉÈ-
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¶›Ó·Î·˜ 7. º¿Ú̷η Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó È‰ÈÔÛ˘ÁÎÚ·Ûȷ΋ Ë·ÙÔÙÔÍÈÎfiÙËÙ· Î·È O∏∞ πÛÔÓÈ·˙›‰Ë ™Ô˘ÏÊÔÓ·Ì›‰Â˜ º·ÈÓ˘ÓÙÔ˝ÓË ™Ù·Ù›Ó˜ ¶ÚÔ˘ÏıÂÈÔԢڷΛÏË ∞ÏÔı¿ÓË ¢ÈÛÔ˘ÏÊÈÚ¿ÌË μ·ÏÚÔ˚Îfi Ô͇ ∞ÌÈÔ‰·ÚfiÓË ¢·ÛfiÓË ªÂÙÊÔÚÌ›ÓË OÊÏÔÍ·Û›ÓË ¶˘Ú·˙ÈÓ·Ì›‰Ë ΔÚÔÁÏÈÙ·˙fiÓË ¢ÈÎÏÔÊÂÓ¿ÎË
§ÈÛÈÓÔÚ›ÏË ¡ÈÎÔÙÈÓÈÎfi Ô͇ πÌÈÚ·Ì›ÓË ∞ÌÊÂٷ̛Ә/ŒÎÛÙ·ÛË §·ÌÂÙ·ÏfiÏË ºÏÔ˘Ù·Ì›‰Ë ∞ÏÏÔÔ˘ÚÈÓfiÏË ªÂı˘ÏÓÙÔ· ∫ÂÙÔÎÔÓ·˙fiÏË μfiÙ·Ó·*
™˘Ó‰˘·ÛÌÔ› Ê·ÚÌ¿ÎˆÓ Ì ÂÓÈÛ¯˘Ì¤ÓË Èı·ÓfiÙËÙ· Ë·ÙÔÙÔÍÈÎfiÙËÙ·˜ ΔÚÈÌÂıÔÚ›ÌË – ™Ô˘ÏÊ·ÌÂıÔÍ·˙fiÏË ƒÈÊ·ÌÈΛÓË – πÛÔÓÈ·˙›‰Ë ∞ÌÔ͢ÛÈÏÏ›ÓË – ∫Ï·‚Ô˘Ï·ÓÈÎfi Ô͇ *μfiÙ·Ó· Î·È Û˘ÌÏËÚÒÌ·Ù· ‰È·ÙÚÔÊ‹˜ Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó Ë·ÙÔ-ÙÔÍÈÎfiÙËÙ· Î·È O∏∞ Kava – Kava Scullcap Pennyroyal Heliotrope Comfrey Senecio Greater Celandine He Shon Wu Lipokinetix
Chaparal Germander Rattleweed Sunnhemp Impila Gum Thistle Ma Huang Bai-Fang herbs Hepatology 2005: 41(5)1179-1197
ο ·Ó¿ÏÔÁ·, fiˆ˜ Ë Lamivudine Î·È ›Ûˆ˜ Ë adefovir - dipivoxil ÛÙËÓ ÔÍ›· Ë·Ù›Ùȉ· ·fi ∏μV, ·ÏÏ¿ Ë ·ÔÙÂ-ÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·fi ÂÏÂÁ¯fiÌÂÓ˜ ÌÂϤÙ˜68. ∂Ô̤ӈ˜, Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ O∏∞ ·fi ÈÔÁÂÓ‹ Ë·Ù›Ùȉ· Â›Ó·È Î˘Ú›ˆ˜ ˘ÔÛÙËÚÈÎÙÈ΋. ∂›Û˘ O∏∞ ÌÔÚ› Ó· ÚÔÎÏËı› Û ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ¿ÙÔÌ· ‹ ¢ÚÈÛÎfiÌÂÓ· Û ¯ËÌÂÈÔıÂڷ›· ÁÈ· ηÎÔ‹ıË ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù· Î·È Ù· ÔÔ›· Â›Ó·È HBsAg(+) ıÂÙÈο. ™Â ·˘Ù¿ Ù· ¿ÙÔÌ· Ú¤ÂÈ Ó· ÚÔËÁÂ›Ù·È ‹ Ó· ·Ú¯›˙ÂÈ Ù·˘Ùfi¯ÚÔÓ· Ì ÙË ¯ËÌÂÈÔıÂڷ›· Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈÈ΋˜ ıÂڷ›·˜ (.¯. Lamivudine) Ë ÔÔ›· Î·È Ú¤ÂÈ Ó· Û˘Ó¯›˙ÂÙ·È ¤ˆ˜ Î·È ¤ÍÈ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ¯ËÌÂÈÔ-ıÂڷ›·˜69. O Èfi˜ ÙÔ˘ ŒÚËÙ· Û¿ÓÈ· ÚÔηÏ› O∏∞. ™Â ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Â˘Ú›ÛÎÔÓÙ·È ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ¿ÙÔÌ· ‹ ¤ÁÎ˘Â˜ Á˘Ó·›Î˜ ÛÙÔ ÙÚ›ÙÔ ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘. Œ¯Ô˘Ó ·Ó·ÊÂÚı› ÌÂÌÔӈ̤ӷ ÂÚÈÛÙ·ÙÈο O∏∞ ·fi ÙÔÓ Èfi ÙÔ˘ ¤ÚËÙ· Î·È Û ˘ÁÈ‹ ¿ÙÔÌ·66, 70,71. ™ËÌÂÈÒÓÂÙ·È fiÙÈ Ù· ÁÓˆÛÙ¿ ‰ÂÚ-
Ì·ÙÈο ÂÍ·Óı‹Ì·Ù· ·Ú·ÙËÚÔ‡ÓÙ·È ÌfiÓÔ ÙÔ 50% ÙˆÓ ÂÚÈÙÒÛˆÓ. ∏ ‚ÈÔ„›· ‹·ÙÔ˜ ‚ÔËı¿ÂÈ ÛÙË ‰È¿ÁÓˆÛË. ∂ȉÈ΋ ıÂڷ›· ÛÙËÓ O∏∞ ·fi Èfi ÙÔ˘ ¤ÚËÙ· Â›Ó·È Ë ¯ÔÚ‹ÁËÛË Acyclovir70,71. O Èfi˜ ÙÔ˘ ¤ÚËÙ· ˙ˆÛÙ‹Ú· (∏V∑) Û·ÓÈfiٷٷ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ˆ˜ ·ÈÙ›· O∏∞72. ∂ȉÈ΋ ıÂڷ›· Î·È ¿ÏÈ Â›Ó·È Ë ¯ÔÚ‹ÁËÛË Acyclovir.
OHA ·fi ÓfiÛÔ Wilson ∏ ÓfiÛÔ˜ Wilson Â›Ó·È ·Û˘Ó‹ı˘ ·ÈÙ›· (2-3% ÛÙȘ ∏¶∞) O∏∞. ∏ ÚÒÈÌË ·Ó·ÁÓÒÚÈÛË Â›Ó·È ÛËÌ·ÓÙÈ΋, ÂÂȉ‹ ıˆÚÂ›Ù·È ÁÂÓÈÎÒ˜ ı·Ó·ÙËÊfiÚÔ˜ ηٿÛÙ·ÛË ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∏ ÎÂÚ·˘ÓÔ‚fiÏÔ˜ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘ Wilson Û˘Ì‚·›ÓÂÈ Ù˘Èο Û Ӥ· ¿ÙÔÌ· Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÈÊÓ›‰È· ÂÁηٿÛÙ·ÛË ·ÈÌÔÏ˘ÙÈ΋˜ ·Ó·ÈÌ›·˜ Ì ›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ Ô˘ ÍÂÂÚÓÔ‡Ó Ù· 20 mg/dL (ηı’ ˘ÂÚÔ¯‹Ó ¤ÌÌÂÛË). O ‰·ÎÙ‡ÏÈÔ˜ ∫ayser-Fleischer ·Ú·ÙËÚÂ›Ù·È ÛÙÔ 50% ÙˆÓ ÂÚÈÙÒÛˆÓ73. Δ· ›‰· Ù˘ ™ÂÚÔ˘ÏÔÏ·ÛÌ›Ó˘ ÔÚÔ‡ Â›Ó·È Ù˘Èο ¯·ÌËÏ¿ ·ÏÏ¿ ÛÙÔ 15% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÌÔÚ› Ó· Â›Ó·È ÛÙ· Ê˘ÛÈÔÏÔÁÈο Ï·›ÛÈ·. ∞˘ÍË̤ӷ ›‰· ¯·ÏÎÔ‡ ÔÚÔ‡ Î·È ¯·ÏÎÔ‡ Ô‡ÚˆÓ ÂȂ‚·ÈÒÓÔ˘Ó ÙË ‰È¿ÁÓˆ-ÛË. ¶Ôχ ¯·ÌËÏ¿ ›‰· ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ Î·È Ô˘ÚÈÎÔ‡ ÔͤԘ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÎÂÚ·˘ÓÔ‚fiÏÔ˘ ÂΉ‹ÏˆÛ˘ Ù˘ ÓfiÛÔ˘ Wilson. ∏ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È Û˘Ó‹ıˆ˜ ÂËÚ·Ṳ̂ÓË, ÏfiÁˆ Ù˘ ÓÂÊÚÔÛˆÏËÓ·Úȷ΋˜ ‚Ï¿‚˘ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ ¯·ÏÎÔ‡. ∏ ¯ÔÚ‹ÁËÛË Penicillamine ‰ÂÓ ÂӉ›ÎÓ˘Ù·È. ™˘ÓÈÛÙ¿Ù·È Ë ÂÊ·ÚÌÔÁ‹ ÌÂıfi‰ˆÓ Ì›ˆÛ˘ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ ¯·ÏÎÔ‡ fiˆ˜ Û˘Û΢‹ ª∞RS (Molecular Adsorbent Recirculating System) Û˘Ó¯‹˜ ·ÈÌԉȋıËÛË, Î·È Ï·ÛÌ·Ê·›ÚÂÛË73. ¶·Ú¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ·˘ÙÒÓ ÙˆÓ ÌÂıfi‰ˆÓ, Ë ·Ó¿ÚÚˆÛË ıˆÚÂ›Ù·È ÂÍ·ÈÚÂÙÈο ÌÈÎÚ‹˜ Èı·ÓfiÙËÙ·˜ ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜73,74. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ÎÂÚ·˘ÓÔ‚fiÏÔ ÂΉ‹ÏˆÛË ÓfiÛÔ˘ Wilson ¤¯Ô˘Ó ‹‰Ë ΛÚÚˆÛË ‹·ÙÔ˜, fiÙ·Ó ÚˆÙÔÂΉËÏÒÓÂÙ·È Ë ÓfiÛÔ˜, Ë ÔÔ›· fï˜ Â›Ó·È ¿ÁÓˆÛÙË Ì¤¯ÚÈ ÂΛÓË ÙË ÛÙÈÁÌ‹.
O∏∞ ·fi ·˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ· ∂›Ó·È Ë ÛÔ‚·ÚfiÙÂÚË ÌÔÚÊ‹ Ù˘ ∞˘ÙÔ¿ÓÔÛ˘ ∏·Ù›Ùȉ·˜ (∞∏). Δ· ÂȉÈο ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· ÌÔÚ› Ó· ·Ô˘ÛÈ¿˙Ô˘Ó Î·ıÈÛÙÒÓÙ·˜ ¤ÙÛÈ ‰‡ÛÎÔÏË ÙË ‰È¿ÁÓˆÛË. ∏ ‚ÈÔ„›· ÙÔ˘ ‹·ÙÔ˜ ÌÔÚ› Ó·
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
‚ÔËı‹ÛÂÈ ÛÙË ‰È¿ÁÓˆÛË, fiÙ·Ó ÛÙ· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÔ‚·Ú‹ Ë·ÙÔ΢ÙÙ·ÚÈ΋ Ó¤ÎÚˆÛË, Ï·ÛÌ·ÙÔ΢ÙÙ·ÚÈ΋ ‰È‹ıËÛË ÙˆÓ ˘Ï·›ˆÓ ‰È·ÛÙËÌ¿ÙˆÓ, ÚÔ˙ÂÙÔÂȉ‹˜ ‰È¿Ù·ÍË Ë·ÙÔ΢ÙÙ¿ÚˆÓ Î·È ‰È¿Û·ÛË Ù˘ ·ÊÔÚÈÛÙÈ΋˜ Ͽη˜. ™˘ÓÈÛÙ¿Ù·È Ë ¿ÌÂÛË ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ (Prednisone 40-60 mg/ËÌÂÚ) Î·È ¤ÓÙ·ÍË ÙÔ˘ ·ÛıÂÓ‹ Û ϛÛÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÂÂȉ‹ ÌfiÓÔ ¤Ó· ÔÛÔÛÙfi ·ÚÚÒÛÙˆÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙË Û˘ÓÙËÚËÙÈ΋ ıÂڷ›·75, 76, 77.
¶ÚfiÁÓˆÛË – ŒÎ‚·ÛË Ù˘ O∏∞ ∫ÚÈÙ‹ÚÈ· ∂ÈÏÔÁ‹˜ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ -ηıÔÚÈÛÌfi˜ ÙÔ˘ ¯ÚfiÓÔ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ OÈ ‰‡Ô ·Ú¿ÁÔÓÙ˜ Ô˘ ηْ ÂÍÔ¯‹Ó ηıÔÚ›˙Ô˘Ó ÙËÓ ÚfiÁÓˆÛË ÛÙËÓ O∏∞ Â›Ó·È Ë ¤ÎÙ·ÛË Ù˘ Ë·ÙÈ΋˜ ‚Ï¿‚˘ Î·È Ô Ú˘ıÌfi˜ Ù˘ Ë·ÙÈ΋˜ ·Ó·Á¤ÓÓËÛ˘. OÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ (ÎÏÈÓÈÎÔ›, ‚ÈÔ¯ËÌÈÎÔ› Î·È ·ÂÈÎÔÓÈÛÙÈÎÔ›) Ô˘ ˘¿Ú¯Ô˘Ó ÚÔÛ·ıÔ‡Ó ·ÎÚÈ‚Ò˜, Ó· ·ÍÈÔÏÔÁ‹ÛÔ˘Ó ·˘Ù¤˜ ÙȘ ‰‡Ô ·Ú·Ì¤ÙÚÔ˘˜. OÈ È‰·ÓÈÎÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ı· ¤Ú ӷ ·Ó·ÁÓˆÚ›˙Ô˘Ó ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ı· ¤¯Ô˘Ó ı·Ó·ÙËÊfiÚ· ηٿÏËÍË, ·ÏÏ¿ Ô˘ ¢ڛÛÎÔÓÙ·È ·ÎfiÌ· ÛÙÔ ÛÙ¿‰ÈÔ ∏∂ π ‹ ππ (Positive Predictive Value: PPV) Î·È ·ÚÔÌÔ›ˆ˜ Ó· ÌÔÚÔ‡Ó Ó· ·Ó·ÁÓˆÚ›˙Ô˘Ó ÂΛÓÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÙÂÏÈÎÒ˜ ı· ÂÈ˙‹ÛÔ˘Ó ·Ú¿ ÙËÓ ‡·ÚÍË ÚÔ¯ˆ-ÚË̤Ó˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (ÛÙ¿‰ÈÔ ∏∂ πππ Î·È πV) Ì ˘ÔÛÙËÚÈÎÙÈο ̤ÙÚ· ÌfiÓÔÓ Î·È ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (¡egative Predictive Value: NPV).
OÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ Ë·ÙÈ΋˜ ·Ó·Á¤ÓÓËÛ˘ ∂ȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Û˘Û¯ÂÙ›˙Ô˘Ó ÙËÓ ËÏÈΛ· > 40 Ì ÊÙˆ¯‹ ÚfiÁÓˆÛË Ù˘ O∏∞78. O ÚfiÏÔ˜ Ù˘ ËÏÈΛ·˜ ÛÙËÓ Ë·ÙÈ΋ ·Ó·Á¤ÓÓËÛË ¤¯ÂÈ ‰ÈÂÚ¢ÓËı› Û ÂÈÚ·Ì·Ùfi˙ˆ·. ∏ ÌÂÚÈ΋ Ë·ÙÂÎÙÔÌ‹, Û ÂÈÚ·Ì·Ùfi˙ˆ· Ó·ڋ˜ ËÏÈΛ·˜, Ô‰ËÁ› Ú·ÎÙÈο fiÏ· Ù· Ë·ÙÔ·ÙÙ·Ú· Û ÔÏÏ·Ï·ÛÈ·ÛÌfi, Û ·ÓÙ›ıÂÛË Ì ÙÔ 30% ÌfiÓÔ ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Û ÂÈÚ·Ì·Ùfi˙ˆ· ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜79. À‡ı˘Ó˜ ÁÈ· ÙÔ‡ÙÔ ıˆڋıËÎ·Ó ÔÈ ·˘ÍËÙÈΤ˜ ÔÚÌfiÓ˜, ÙˆÓ ÔÔ›ˆÓ Ù· ›‰· ÌÂÈÒÓÔÓÙ·È Ì ÙËÓ ËÏÈΛ·. ™ÙÔÓ ¿ÓıÚˆÔ, ÔÈ ÔÚÔÏÔÁÈÎÔ› ‰¤ÈÎÙ˜ ‰Â›ÓÔ˘Ó ¤ÌÌÂÛ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ¤ÎÙ·ÛË Ù˘ Ë·ÙÈ΋˜ ·Ó·Á¤ÓÓËÛ˘.
193
ŒÙÛÈ ¯·ÌËÏ¿ ›‰· ʈÛÊfiÚÔ˘ ¤¯Ô˘Ó Û¯ÂÙÈÛı› Ì ÚÔ˚Ô‡Û· Ë·ÙÈ΋ ·Ó·Á¤ÓÓËÛË ÛÙËÓ O∏∞ ·fi ∞∫º80. ŸÌˆ˜, ÙÔ ·ÓÙ›ıÂÙÔ, ‰ËÏ·‰‹ Ù· ˘„ËÏ¿ ›‰· ʈÛÊfiÚÔ˘ ‰ÂÓ Û˘Ó‰¤ÔÓÙ·È Î·Ù’ ·Ó¿ÁÎËÓ Ì ÊÙˆ¯‹ Ë·ÙÈ΋ ·Ó·Á¤ÓÓËÛË, ÂÂȉ‹ ·˘Ù¿ ÌÔÚ› Ó· ÔÊ›ÏÔÓÙ·È ÛÙË ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Ô˘ ÌÔÚ› Ó· ÚÔηÏ› Ë ∞∫º. Δ· ·˘Í·ÓfiÌÂÓ· ›‰· alpha-fetoprotein (AFP) ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Â›Û˘ Û ‰‡Ô ÌÂϤÙ˜81,82, ÁÈ· ÙËÓ Úfi‚ÏÂ„Ë ‰È¿ÎÚÈÛ˘ ÌÂٷ͇ ÂÈ˙ÒÓÙˆÓ Î·È ÌË ÂÈ˙ÒÓÙˆÓ ÛÙËÓ O∏∞ ·fi ∞∫º. ŒÙÛÈ, ›‰· ∞FP, Ù· ÔÔ›· ‰ÂÓ ·˘Í¿ÓÔÓÙ·È ÛÙ· 4 ng/mL, ÌÈ· ̤ڷ ÌÂÙ¿ ÙË Ì¤ÁÈÛÙË ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ALT, ¤¯Ô˘Ó 100% ·ÚÓËÙÈ΋ ÚÔ-ÁÓˆÛÙÈ΋ ·Í›· (Negative Predictive Value-NPV) ÁÈ· ı¿Ó·ÙÔ, ·ÏÏ¿ ÌfiÓÔ 45% ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (Positive Predictive Value-PPV).
OÈ ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ¤ÎÙ·Û˘ Ù˘ Ë·ÙÈ΋˜ ‚Ï¿‚˘ ∏ ‰È·‰Ô¯È΋ ÔÁÎÔÌÂÙÚÈ΋ ÂÎÙ›ÌËÛË Ù˘ Ë·ÙÈ΋˜ Ì¿˙·˜ Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·, ı· ‹Ù·Ó ›Ûˆ˜ ¯Ú‹ÛÈÌË, ·ÏÏ¿ Ú·ÎÙÈο Â›Ó·È ‰‡ÛÎÔÏÔ Ó· Á›ÓÂÙ·È Û ·ÛıÂÓ‹ Ì ÔÚȷ΋ ηٿÛÙ·ÛË. ∏ Ë·ÙÈ΋ ‚ÈÔ„›· (‰È·ÛÊ·ÁÈÙȉÈ΋) ÂÓ¤¯ÂÈ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi Ï¿ıÔ˘˜ ‰Â›ÁÌ·ÙÔ˜ ÏfiÁˆ Ù˘ ·ÓÔÌÔÈÔÁ¤ÓÂÈ·˜ Ù˘ Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ Ó¤ÎÚˆÛ˘83. ∏ ‰È·Ù·Ú·¯‹ Ù˘ ‹Í˘ ÙÔ˘ ·›Ì·ÙÔ˜, fiˆ˜ ÂÎÊÚ¿˙ÂÙ·È Ì ·Ú¿Ù·ÛË ÙÔ˘ π¡R, ÂÍ·ÎÔÏÔ˘ı›84, ·Ú¿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ÂÈÊ˘Ï¿ÍÂȘ85, Ó· ·ÔÙÂÏ› ÙÔ ÎÏÂȉ› – ‰Â›ÎÙË Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. OÈ ·Ú¿ÁÔÓÙ˜ ‹Í˘ V Î·È VIII, ¤¯Ô˘Ó ›Û˘ ¯ÚËÛÈÌÔÔÈËı› Û ÔÚÈṲ̂ӷ ΤÓÙÚ· ˆ˜ ‰Â›ÎÙ˜ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜, ·ÏÏ¿ Ë ‰˘ÛÎÔÏ›· ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÂÚÈfiÚÈÛ ÙËÓ ·Ô‰Ô¯‹ ÛÙË ¯Ú‹ÛË ÙÔ˘˜86. Δ· ·˘ÍË̤ӷ ›‰· ·Ì̈ӛ·˜ (NH3) Â›Ó·È ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ˘ÚÔ‰fiÙ˘ Ì˯·ÓÈÛÌÔ‡ Ô˘ Ô‰ËÁ› ÛÙÔ ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ· (∂O), ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ·Ú·ÁˆÁ‹ ÁÏÔ˘Ù·Ì›Ó˘ (·ÔÙ¤ÏÂÛÌ· Ù˘ ˘ÂÚ·Ì̈ÓÈ·ÈÌ›·˜) ̤۷ ÛÙ· ·ÛÙÚÔ·ÙÙ·Ú·, Â›Ó·È ÙÔ ÎÏÂȉ› ÁÈ· ÙËÓ ¤Ó·ÚÍË ÌÂÙ·‚ÔÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ (·Ó·ÂÚfi‚È· ÁÏ˘ÎfiÏ˘ÛË Î·È ÔÍÂȉˆÙÈÎfi stress) Ô˘ Ô‰ËÁÔ‡Ó Û ·˘ÍË̤ÓË ÂÁÎÂÊ·ÏÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹87. ŒÙÛÈ Û ÌÈ· ÌÂϤÙË 19 Ù· ›‰· ¡∏ 3 > 200 Ìg/dL, Û ·ÛıÂÓ›˜ Ì ∏∂ ÛÙ·‰›Ô˘ πππ-πV, Û¯ÂÙ›ÛÙËÎ·Ó Ì ÂÁÎÔÏ·ÛÌfi ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜, ÂÓÒ ·ÓÙ›ÛÙÔȯ· ›‰· ¡∏3 < 150 Ìg/dL ·Ú·ÙËÚ‹ıËÎ·Ó Û ·ÛıÂÓ›˜ Ì ηχÙÂÚË ¤Î‚·ÛË.
194
£. BA™I§EIA¢H™
™ÙËÓ ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ· (Ë·ÙÈ΋, ÓÂÊÚÈ΋, ΢ÎÏÔÊÔÚÈ΋ ·Ó¿ÚÎÂÈ· Î·È ÏÔÈÌÒÍÂȘ) Ù· ›‰· ÙˆÓ Á·Ï·ÎÙÈÎÒÓ (blood lactate) Â›Ó·È ·˘ÍË̤ӷ. ŒÙÛÈ ¤¯ÂÈ ÚÔÙ·ı› Ë Á·Ï·ÎÙÈ΋ ÔͤˆÛË ˆ˜ ÚÒÈÌÔ˜ ‰Â›ÎÙ˘ ¤Î‚·Û˘ Ù˘ O∏∞ ·fi ∞∫º88. ∂›Â‰· Á·Ï·ÎÙÈÎÒÓ 3 mmol/L ÌÂÙ¿ ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÔηٿÛÙ·ÛË, ¤¯Ô˘Ó 67% ¢·ÈÛıËÛ›· Î·È 97% ÂȉÈÎfiÙËÙ· ÛÙËÓ Úfi‚ÏÂ„Ë ÂÈ‚›ˆÛ˘89. ∏ O∏∞ Û˘Ó‰¤ÂÙ·È Ì ÔÛÔÛÙ¿ ıÓËÙfiÙËÙ·˜ Ô˘ ·ÁÁ›˙Ô˘Ó ÙÔ 80% ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂ ÙËÓ Ë·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ë ¤Î‚·ÛË Ù˘ O∏∞ ¤¯ÂÈ ·ÏÏ¿ÍÂÈ ÛËÌ·ÓÙÈο, ·ÊÔ‡ Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ·Ú·Ì¤ÓÂÈ ÂÏ·ÊÚ¿ ¯·ÌËÏfiÙÂÚË Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ªÂ ‰Â‰Ô̤ÓË ÙËÓ ÂÚÈÔÚÈṲ̂ÓË ‰È¿ıÂÛË ÔÚÁ¿ÓˆÓ, ÙËÓ ¤ÏÏÂÈ„Ë ÂÓ·ÏÏ·ÎÙÈÎÒÓ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÌÂıfi‰ˆÓ Î·È ÙˆÓ Èı·ÓÒÓ ÂÈÏÔÎÒÓ Ù˘ ÂÊfiÚÔ˘ ˙ˆ‹˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜, Ë ·ÎÚÈ‚‹˜ ÚfiÁÓˆÛË ÛÙËÓ O∏∞ ·ÔÙÂÏ› ÛÙfi¯Ô ÚÒÙ˘ ÚÔÙÂÚ·ÈfiÙËÙ·˜. O ÚÒÈÌÔ˜ ηıÔÚÈÛÌfi˜ Ù˘ ÚfiÁÓˆÛ˘ Î·È Ë Ù·¯Â›· Ï‹„Ë ·fiÊ·Û˘ ÁÈ· ÙËÓ Â›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈο ÛËÌ›· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÚÚÒÛÙˆÓ Ì O∏∞90-94. ¢‡Ô ÚÔÁÓˆÛÙÈο ÌÔÓ٤Ϸ ¤¯Ô˘Ó ·ÍÈÔÏÔÁËı› ÁÈ· ÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘˜ Ó· ÚԂϤ„Ô˘Ó ÙË ıÓËÙfiÙËÙ·, ÒÛÙ ӷ ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Ì ·ÛÊ¿ÏÂÈ· ÁÈ· ›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O∏∞, ÚÔÎÏËı›۷ ·fi ·›ÙÈ· ÂÎÙfi˜ ∞∫º (O∏∞-ª∞). ∞˘Ù¿ Ù· ÚÔÁÓˆÛÙÈο ÌÔÓ٤Ϸ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ Clichy Î·È Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ King’s College Hospital (KCH) (›Ó·Î·˜ 8). ∫·È Ù· ‰‡Ô Û˘ÛÙ‹Ì·Ù· ‰È·‚¿ıÌÈÛ˘ Ù˘ ÚfiÁÓˆÛ˘ (scoring system) ‚Ú¤ıËΠӷ ¤¯Ô˘Ó ¯·ÌËÏ‹ ·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· (Negative Predictive Value-NPV) < 60 ‰ËÏ·‰‹ ‰ÂÓ ·Ó·ÁÓˆÚ›˙Ô˘Ó ÙËÓ ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ ÔÈ ÔÔ›ÔÈ ·Ú¿ ÙËÓ Î·Î‹ ÚfiÁÓˆÛË ÙÂÏÈÎÒ˜ ı· ·Ó·ÚÚÒÛÔ˘Ó ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞˘Ùfi ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ Û ·¯Ú›·ÛÙË (ÂÚÈÙÙ‹) ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË95 Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ KCH Î·È ÙÔ˘ Clichy Û˘ÁÎÚ›ıËÎ·Ó Ì ÙÔ ª∂LD Score (Mondel of End Stage Liver Disease = 0,957 x log(creatinine) + 0,378 x log(bilirubin) + 1,12 x log(INR) Û ·ÛıÂÓ›˜ Ì O∏∞-ª∞ (ÚÔÎÏËı›-
Û· ·fi ·›ÙÈ· ¿ÏÏ· ÏËÓ Ù˘ ∞∫º) (¶›Ó·Î·˜ 9). ΔÔ Û˘Ì¤Ú·ÛÌ· Ù˘ ÌÂϤÙ˘ Â›Ó·È fiÙÈ ÙÔ ª∂LD Score>30 ·ÔÙÂÏ› ÂÍ·ÈÚÂÙÈÎfi ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ¤Î‚·Û˘, ÙfiÛÔ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, fiÛÔ Î·È ÛÙ· ·È‰È¿ Ì O∏∞95, Ì ‰È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· 95% Î·È C-statistic score 0,96. ™˘ÁÎÚÈÙÈο, ÏÔÈfiÓ, Ì ٷ ‰‡Ô ·Ô‰ÂÎÙ¿ Û˘ÛÙ‹Ì·Ù· ‚·ıÌÔÏfiÁËÛ˘ (KCH Î·È Clichy) ÙÔ MELD score Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÌÈÎÚfiÙÂÚË Èı·ÓfiÙËÙ· „¢‰Ò˜ ·ÚÓËÙÈÎÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ÛÙËÓ O∏∞-ª∞. Δ· Û˘ÌÂÚ¿ÛÌ·Ù· fï˜ ·˘Ù¿ Â›Ó·È ÚÒÈÌÔ Ó· Á›ÓÔ˘Ó ·Ô‰ÂÎÙ¿, ÂÂȉ‹ ÚÔ¤Ú¯ÔÓÙ·È ·fi ¤Ó· ÌfiÓÔ Î¤ÓÙÚÔ. ¶›Ó·Î·˜ 8. ¶ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ÊÙˆ¯‹˜ ¤Î‚·Û˘ ÛÙËÓ O∏∞1,8 ∞ÈÙÈÔÏÔÁ›· π‰ÈÔÛ˘ÁÎÚ·Ûȷ΋ Ê·Ú̷΢ÙÈ΋ Ë·ÙÔÙÔÍÈÎfiÙ˘ OÍ›· Ë·Ù›ÙȘ μ (Î·È ¿ÏϘ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, ÏËÓ ÙÔ˘ HAV) ∞˘ÙÔ¿ÓÔÛË Ë·Ù›ÙȘ ¢ËÏËÙËÚ›·ÛË ·fi Ì·ÓÈÙ¿ÚÈ· ¡fiÛÔ˜ Wilson ™‡Ó‰ÚÔÌÔ μudd-Chiari ∞ÚÔÛ‰ÈfiÚÈÛÙË ·ÈÙ›· ™Ù¿‰ÈÔ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ™Ù¿‰ÈÔ III ™Ù¿‰ÈÔ πV KÚÈÙ‹ÚÈ· ÙÔ˘ ∫ing’s College Hospital90 • OHA ·fi ∞∫º ∞ÚÙËÚÈ·Îfi pH < 7,3 (ÌÂÙ¿ ·Ú΋ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÔηٿÛÙ·ÛË) Î·È ·ÓÂÍ·Úًو˜ ÛÙ·‰›Ô˘ ∏∂ ‹ INR > 6,5 + ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ > 3,4 mg/dL Û ·ÛıÂÓ›˜ ÛÙ·‰›Ô˘ πππ/IV ∏∂ • O∏∞ fi¯È ·fi ∞∫º π¡R > 6,5 ·ÓÂÍ·Úًو˜ ÛÙ·‰›Ô˘ ∏∂ ‹ ÙÚ›· ·fi Ù· ·ÎfiÏÔ˘ı· ·ÓÂÍ·Úًو˜ ÛÙ·‰›Ô˘ ∏∂ - º·Ú̷΢ÙÈ΋ Ë·ÙÔÙÔÍÈÎfiÙ˘, ·ÚÔÛ‰ÈfiÚÈÛÙË ·ÈÙ›· - ∏ÏÈΛ· < 10 ¤ÙË ‹ > 40 ¤ÙË - ªÂÛԉȿÛÙËÌ· ÈÎÙ¤ÚÔ˘ ̤¯ÚÈ ÙÔ ÎÒÌ· > 7 Ë̤Ú˜ - πNR > 3,5 - ÃÔÏÂÚ˘ıÚ›ÓË ÔÚÔ‡ > 17,5 mg/dL ∫ÚÈÙ‹ÚÈ· ÙÔ˘ Paul Brousse-Clichy92 ∂ÁÎÂÊ·ÏÔ¿ıÂÈ· ÛÙ·‰›Ô˘ πππ-IV Factor V < 20% ÁÈ· ËÏÈΛ· < 30 ÂÙÒÓ Factor V < 30% ÁÈ· ËÏÈΛ· > 30 ÂÙÒÓ ª∂LD ÎÚÈÙ‹ÚÈ· ÛÙËÓ O∏∞ ªeld score > 30
™Â ÌÈ· ÈÔ ÚfiÛÊ·ÙË ÌÂϤÙË96, ÛÎÔfi˜ Ù˘ ÔÔ›· ‹Ù·Ó Ó· ‰ÈÂÚ¢ӋÛÂÈ ÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙÔ˘ MELD score ÛÙËÓ O∏∞ (US ALF Study Group Cohort) Û ۇÓÔÏÔ 729 ·ÛıÂÓÒÓ (∞∫º 330 ·ÛıÂÓ›˜, ÌË-∞∫º: 412). ΔÔ Û˘Ì¤Ú·ÛÌ· Ù˘ ÌÂϤÙ˘ Â›Ó·È fiÙÈ MELD score < 30 Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ÙË ÌÂÁ·Ï‡ÙÂÚË ÂÊ·ÚÌÔÁ‹ ÛÙËÓ Úfi‚ÏÂ„Ë ·˘ÙfiÌ·Ù˘ ·Ó¿ÚÚˆÛ˘ (NPV: 82%, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O∏∞ ·fi ∞∫º, ÂÓÒ MELD score > 30 ‰ÂÓ ÌÔÚ› ÂÎ ÙÔ˘ ·ÛÊ·ÏÔ‡˜ Ó· ÚԂϤ„ÂÈ ÙÔ˘˜ ·ÛıÂ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ó›˜ Ì O∏∞-ª∞ Ô˘ ı· ηٷϋÍÔ˘Ó Û ı¿Ó·ÙÔ ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (PPV: 81%). ∫·È ·˘Ù¿ fï˜ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Â›Ó·È ÚÒÈÌÔ Ó· Á›ÓÔ˘Ó ·Ô‰ÂÎÙ¿, ÂÂȉ‹ ÚÔ-¤Ú¯ÔÓÙ·È Î·È ¿ÏÈ ·fi ÌÈ· ÔÌ¿‰· ÂÚÁ·Û›·˜. ¶›Ó·Î·˜ 9. ™˘ÁÎÚÈÙÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ ÚfiÁÓˆÛ˘ ÛÙËÓ O∏∞* ªÔÓÙ¤ÏÔ KCH CLICHY MELD>30
PPV % 71 91 91
NPV% 84 72 100
DA% 78 78 95
C-statistic 0,78 0,76 0,96
™˘ÓÙÌ‹ÛÂȘ: ∫CH: King’s College Hospital PPV: Positive Predictive Value – £ÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· ¡PV: Negative Predictive Value – ∞ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›· DA: Diagnostic accuracy – ¢È·ÁÓˆÛÙÈ΋ ·ÎÚ›‚ÂÈ· ª∂LD: Model for End – Stage Liver Disease *Yantorno SET, Trentadue JJ, Ruf AE, et al. Liver Transplantation 2004; 10:C36
T· ÈÔ Û˘¯Ó¿ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ· Î·È Ù· ÂÚÈÛÛfiÙÂÚÔ ·Ô‰ÂÎÙ¿ ÎÚÈÙ‹ÚÈ·, ·Ú¿ Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù¿ ÙÔ˘˜, ·Ú·Ì¤ÓÔ˘Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ∫CH. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ·ÍÈÔÏÔÁ‹ÛÂÈ ·˘Ù¿ Ù· ÎÚÈÙ‹ÚÈ· Î·È ‚Ú‹Î·Ó ÔÛÔÛÙ¿ PPV: 70-100% Î·È ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ ¡PV: 25-94%97-101. A˘Ù¿ Ù· ÚÔÁÓˆÛÙÈο ‰Â‰Ô̤ӷ, Û˘ÓÔÏÈο, ¤¯Ô˘Ó ·Ô‰ÂÎÙ‹ ÂȉÈÎfiÙËÙ· ·ÏÏ¿ ¯·ÌËÏ‹ ¢·ÈÛıËÛ›· ÛÙÔ Ó· ÚԂϤ„Ô˘Ó ÙËÓ ¤Î‚·ÛË ÛÙËÓ O∏∞. ™Â ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË ÙÔ˘ Bailey Î·È Û˘Ó.102 (›Ó·Î·˜ 9) Û˘ÁÎÚ›ıËÎ·Ó Ù· ‰È¿ÊÔÚ· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Û ·ÛıÂÓ›˜ Ì O∏∞ ·fi ∞∫º, ÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ KCH Î·È ‰È·ÊfiÚˆÓ Û˘Ó‰˘·ÛÌÒÓ ·fi ·˘ÍË̤ӷ ›‰· ÎÚ·ÙÈÓ›Ó˘, ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜, π¡R, ÌÂÈˆÌ¤ÓˆÓ ÂȤ‰ˆÓ ÙÔ˘ ·Ú¿ÁÔÓÙ· V Ù˘ ‹Í˘, ÙÔ APACHE II score103 (Acute Physiology and Chronic Health Evaluation) Î·È Ë Gc ÛÊ·ÈÚ›ÓË (ÚˆÙ½ÓË Ô˘ Û˘Ó‰¤ÂÈ ÙË ‚ÈÙ·Ì›ÓË D104). ∞fi ÙËÓ ·Ó¿Ï˘ÛË ·˘Ù‹ Ê¿ÓËΠfiÙÈ Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ KCH Î·È pH < 7,30 ÌfiÓÔ ÙÔ˘ ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ÂȉÈÎfiÙËÙ· ÛÙÔ Ó· ÚԂϤ„Ô˘Ó ÊÙˆ¯‹ ÚfiÁÓˆÛË. ∂ÓÒ, fï˜, Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ KCH ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· ·fi fiÙÈ ÙÔ pH ˆ˜ ÌfiÓÔ ÎÚÈÙ‹ÚÈÔ (69% Vs 57% ¢·ÈÛıËÛ›·) Ë ¯ÚËÛÈÌÔÔ›ËÛË Î·È ÙˆÓ ‰‡Ô ÎÚÈÙËÚ›ˆÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÎfiÌ· ÙËÓ Èı·ÓfiÙËÙ· Ù˘ ·ÒÏÂÈ·˜ ·ÛıÂÓÒÓ, ÔÈ ÔÔ›ÔÈ ÙÂÏÈÎÒ˜ ı· ¤Ú ӷ ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ Û˘ÁÁÚ·Ê›˜ ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘102 ‚Ú‹Î·Ó fiÙÈ ¤Ó· APACHE II Score > 15 ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ ›¯Â ÂȉÈÎfiÙËÙ· 92% (Û˘ÁÎÚÈÓfiÌÂÓÔ Ì ٷ ÎÚÈÙ‹ÚÈ· ÙÔ˘ KCH) Î·È ·ÎfiÌ·
195
ÌÂÁ·Ï‡ÙÂÚË Â˘·ÈÛıËÛ›· (81%). ∫·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È ÚÒÈÌÔ Ó· Á›ÓÔ˘Ó ·Ô‰ÂÎÙ¿, ÂÊfiÛÔÓ Â›Ó·È ÚÔ˚fiÓ ÌÈ·˜ ÌfiÓÔ ÌÂϤÙ˘. °ÂÓÈÎÒ˜ ÔÈ ¿ÚÚˆÛÙÔÈ Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ˷ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· (∏∂) ÛÙ·‰›Ô˘ πππ ‹ πV Â›Ó·È ÏÈÁfiÙÂÚÔ Èı·Ófi Ó· ÂÈ‚ÈÒÛÔ˘Ó, Û˘ÁÎÚÈÓfiÌÂÓÔÈ Ì ÂΛÓÔ˘˜ Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ∏∂ ÛÙ·‰›Ô˘ π ‹ ππ, ¯ˆÚ›˜ Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ΔÔ Û˘Ì¤Ú·ÛÌ· ·˘Ùfi ÂÍ¿ÁÂÙ·È ·‚›·ÛÙ· ·fi ÙË ÌÂÁ·Ï‡ÙÂÚË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Ô˘ ‰ÈÂÍ‹¯ıË ÛÙȘ ∏¶∞, ÁÈ· ·ÛıÂÓ›˜ Ì O∏∞3. ∞fi ÙËÓ ›‰È· ÌÂϤÙË, Ô ÈÔ ÛËÌ·ÓÙÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ¤Î‚·Û˘ Ù˘ O∏∞, ·Ó·‰Â›¯ÙËÎÂ Ë ·ÈÙÈÔÏÔÁ›· Ù˘ O∏∞. ŒÙÛÈ ·ÛıÂÓ›˜ Ì O∏∞ ·fi ∞∫º, Ë·Ù›Ùȉ· ∞, ÈÛ¯·ÈÌÈ΋ Ë·Ù›Ùȉ· (shock liver) ‹ Û¯ÂÙÈ˙fiÌÂÓË Ì ÂÁ΢ÌÔÛ‡ÓË (Ô͇ ÏÈ҉˜ ‹·Ú, Û‡Ó‰ÚÔÌÔ HELLP-Elevated Liver Enzymes and Low Platelets), ·ÚÔ˘ÛÈ¿˙Ô˘Ó ≥ 50% ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÌÂÙ·-ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ÂÓÒ fiϘ ÔÈ ¿ÏϘ ·ÈÙÈÔÏÔÁ›Â˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó < 25% ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ΔÔ ª∂LD score, Ô˘ ÙÂÏÂ˘Ù·›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Â˘Ú‡Ù·Ù· ÁÈ· ÙËÓ Úfi‚ÏÂ„Ë ıÓËÙfiÙËÙ·˜ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È ·ÍÈÔÏfiÁËÛË ÁÈ· ÌÂÙ·-ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜105, Â›Ó·È ÚÒÈÌÔ Ó· ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Ì O∏∞. ™‡Ìʈӷ Ì ÙÔ United Network for Organ Sharing – UNOS – System ÙˆÓ ∏¶∞ ÔÈ ·ÛıÂÓ›˜ Ì O∏∞ Ô˘ ¢ڛÛÎÔÓÙ·È Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ (ª∂£) Î·È ¤¯Ô˘Ó ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ < 7 Ë̤Ú˜ (Status 1), ı· Ú¤ÂÈ Ó· ÏËÚÔ‡Ó Ù· ÂÍ‹˜ ÎÚÈÙ‹ÚÈ· ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÓÙ·¯ıÔ‡Ó Û Â›ÁÔ˘Û· Ï›ÛÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘: ·ÚÔ˘Û›· ˘Ï·ÈÔÛ˘ÛÙËÌ·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (ÛÙ¿‰ÈÔ ππ Î·È Ï¤ÔÓ), ¯ÔÏÂÚ˘-ıÚ›ÓË ≥15 mg/dL, π¡R >2,5 ‹ ˘ÔÁÏ˘Î·ÈÌ›·106.
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ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÓÙ›ÛÙÔȯ·. øÛÙfiÛÔ Ô ·ÚÈıÌfi˜ ÙˆÓ ÚÔÛÊÂÚÔÌ¤ÓˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, -·Ú¿ ÙËÓ ·‡ÍËÛË Ù˘ ‰ÂÍ·ÌÂÓ‹˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÌËÌ¿ÙˆÓ ÙÔ˘ و̷ÙÈÎÔ‡ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÔÚÈ·ÎÒÓ ‰ÔÙÒÓ ·ÏÏ¿ Î·È ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÌ‹Ì·ÙÔ˜ ‹·ÙÔ˜ ·Ô ˙ÒÓÙ˜ ‰fiÙ˜-, ·Ú·Ì¤ÓÂÈ ‰˘Û·Ó¿ÏÔÁ· ÌÈÎÚfi˜ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ·Ó·Ì¤ÓÔ˘Ó Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ªÂ ·˘Ù¿ Ù· ‰Â‰Ô̤ӷ ÌfiÓÔ ÙÔ 10% ÙˆÓ ·ÛıÂÓÒÓ Ì FHF ¤¯Ô˘Ó Èı·ÓfiÙËÙ· Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ™ÙÔ˘˜ ·Ú·¿Óˆ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ÚÔÛÙÂıÔ‡Ó Î·È ÂΛÓÔÈ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ¤¯Ô˘Ó ·ÚÔ˘ÛÈ¿ÛÂÈ ÚˆÙÔ·ı‹ ÌË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (Primary non function) ‹ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· (Dysfuction) ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηıÒ˜ Î·È fiÛÔÈ ˘Â‚Ï‹ıËÎ·Ó Û ˷ÙÂÎÙÔÌ‹ Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘ÌÙÒÌ·Ù· Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÏfiÁˆ ÏÂÈÙÔ˘ÚÁÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÙÔ˘ ÂÓ·ÔÌ›ӷÓÙÔ˜ Ë·ÙÈÎÔ‡ ÎÔÏÔ‚ÒÌ·ÙÔ˜(liver reservoir). OÈ ÚÔ·Ó·ÊÂÚı›Û˜ Û˘Óı‹Î˜ ηıÈÛÙÔ‡Ó ÂÈÙ·ÎÙÈ΋ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÂÓ·ÏÏ·ÎÙÈÎÒÓ ÌÂıfi‰ˆÓ ÁÈ· ÙËÓ ˘ÔÛÙ‹ÚËÍË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÒÛÙ ÔÈ ·ÛıÂÓ›˜ Ó· ·Ú·Ì›ÓÔ˘Ó ÂÓ ˙ˆ‹ Î·È ¯ˆÚ›˜ Ó¢ÚÔÏÔÁÈ΋ ‚Ï¿‚Ë, ¤ˆ˜ fiÙÔ˘ ·Ó¢ÚÂı› ÙÔ Î·Ù¿ÏÏËÏÔ ÌfiÛ¯Â˘Ì· ‹ ¤ˆ˜ fiÙÔ˘ ·Ó·Ó‹„ÂÈ ÙÔ Èı·ÁÂÓ¤˜ ‹·Ú. ∞˘Ùfi ÌÔÚ› Ó· ÂÈÙ¢¯ı› ̤¯ÚȘ ÂÓfi˜ ÔÚ›Ô˘, Ì ÙȘ Ù¯ÓÈΤ˜ Â͈ۈ̷ÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. OÈ Ù¯ÓÈΤ˜ ·˘Ù¤˜, ·Ô ÙËÓ ÂÌÊ¿ÓÈÛ‹ ÙÔ˘˜ ÛÙËÓ ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ ̤¯ÚÈ Û‹ÌÂÚ·, ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ∞Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛË Î·È ¶Ï·ÛÌ·Ê·›ÚÂÛË(Blood and blood componet treatments), Ù· ™˘ÛÙ‹Ì·Ù· ÌË Î˘ÙÙ·ÚÈ΋˜ ‰È‹ıËÛ˘ (Acellular filtration systems), Ù· μÈÔÏÔÁÈο (Biological) Î·È Ù· À‚ÚȉÈο (Hybrid devices) ∂͈ۈ̷ÙÈο ™˘ÛÙ‹Ì·Ù· ÀÔÛÙ‹ÚÈ͢ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜.
∏ ÌË ·Ó·ÛÙÚ¤„ÈÌË Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, Ù›ÓÂÈ Ó· ·ÔÙÂϤÛÂÈ Û‹ÌÂÚ· Ì›· ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ıÓËÙfiÙËÙÔ˜ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ™ÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ‰‡Ô ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ:ÔÈ ·ÛıÂÓ›˜ ÂΛÓÔÈ ¯ˆÚ›˜ ÚÔ¸¿Ú¯Ô˘Û· Ë·ÙÈ΋ ÓfiÛÔ ÔÈ ÔÔ›ÔÈ ÂΉËÏÒÓÔ˘Ó ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·(acute hepatic failure/ AHF) ˆ˜ Û˘Ó¤ÂÈ· ÓfiÛËÛ‹˜ ÙÔ˘˜ ·Ô Ë·ÙÔÙÚfiÔ˘˜ ÈÔ‡˜ ‹ ÙÔÍÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È Û ÂΛÓÔ˘˜ Ô˘ ÂΉËÏÒÓÔ˘Ó Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÔÍ›·˜ ÂÈ‚¿Ú˘ÓÛ˘ Ì›·˜ ¯ÚÔÓ›·˜ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜(acute decompensation on chronic liver disease/AoCHF). ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ,- ȉȷ›ÙÂÚ· Ù˘ ÚÒÙ˘ ÔÌ¿‰Ô˜ Ô˘ ·Ó·Ù‡ÛÔ˘Ó ÎÂÚ·˘ÓÔ‚fiÏÔ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·(fulminant hepatic failure/FHF)-, ¤¯Ô˘Ó η΋ ÚfiÁÓˆÛË Î·È Î·Ù·Ï‹ÁÔ˘Ó Û˘Ó‹ıˆ˜ ÂÍ ·ÈÙ›·˜ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜, Ô˘ ÔÊ›ÏÂÙ·È Û ·ÈÊÓ›‰È· Î·È ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Î·È ÛÙËÓ Â·ÎfiÏÔ˘ıË ÂÓÛÊ‹ÓˆÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÛÙÂϤ¯Ô˘˜. ∂ȉÈο ÛÙË ∞HF Ë ıÓËÙfiÙËÙ· Â›Ó·È È‰È·›ÙÂÚ· ˘„ËÏ‹, ÎÂÈÌÂÓfiÌÂÓË ·Ô 28%-90% ¯ˆÚȘ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ·Ô 10-40% ÂÊ fiÛÔÓ ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. OÈ ·ÛıÂÓ›˜ Ù˘ ‰Â‡ÙÂÚ˘ ÔÌ¿‰·˜ Â¿Ó ‰ÂÓ ··ÓÙ‹ÛÔ˘Ó ÛÙËÓ ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙÔ ·›ÙÈÔ Ù˘ ÂÈ‚¿Ú˘ÓÛ‹˜ ÙÔ˘˜, (·˘ÙfiÌ·ÙË ÂÚÈÙÔÓ›ÙȘ, ·ÈÌÔÚÚ·Á›·, ¯ÔÏÔ΢ÛÙ›ÙȘ ÎÏ), ηٷϋÁÔ˘Ó Î·È ÂÍ ·ÈÙ›·˜ Û‹„˘, ·ÈÌÔÚÚ·Á›·˜ Î·È ·Ó¿ÚÎÂÈ·˜ ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ. ¶·Ú¿ ÙËÓ ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô ÛÙË Î·Ù·ÓfiËÛË Ù˘ Ê˘ÛÈÔ·ıÔÏÔÁ›·˜ Ù˘ ÔÍ›·˜ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Î·È ÙȘ ηٷ ηÈÚÔ‡˜ ÚÔÙ·ı›Û˜ ÌÂıfi‰Ô˘˜ Û˘ÓÙËÚËÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ‹˜ Ù˘, Ë FHF ÂÍ·ÎÔÏÔ˘ı› Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ˘„ËÏ‹ ıÓËÛÈÌfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·Ú·Ì¤ÓÂÈ Ì¯ÚÈ Û‹ÌÂÚÔÓ Ë Ï¤ÔÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂڷ¢ÙÈ΋ ̤ıÔ‰Ô˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘, Ì ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ 68% Î·È 61% ÁÈ· ÙÔ 1Ô Î·È 5Ô ¤ÙÔ˜
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
∞º∞πª∞•Oª∂Δ∞°°π™∏ ∫∞𠶧∞™ª∞º∞πƒ∂™∏ ΔËÓ ‰ÂηÂÙ›· ÙÔ˘ 1960 Î·È È‰È·›ÙÂÚ· ÙÔ 1965 Î·È ÂÓÙ‡ıÂÓ, ÂÈÛÙ‡ÂÙÔ ÔÙÈ Ë ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ‹Ù·Ó ÌÂÙ·‚ÔÏÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Î·È ˆ˜ ıÂڷ›· Û˘ÓÈÛÙÔ‡Û·Ó ÙË ¯ÔÚ‹ÁËÛË per os ·ÓÙȂȈÙÈÎÒÓ, ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È ‰›·ÈÙ·˜ ÂχıÂÚ˘ ÚˆÙÂ˚ÓÒÓ ÛÂ Û˘Ó‰È·ÛÌfi Ì ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛË(whole blood exchange transfusion). ∏ ıÂڷ¢ÙÈ΋ ·˘Ù‹ ÚÔÛ¤ÁÁÈÛË, ‚·Û›ÛÙËΠÛÙ· ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ·˘Ù‹˜ Ù˘ ÌÂıfi‰Ô˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·ÈÌÔÏ˘ÙÈ΋˜ ÓfiÛÔ˘ ÙˆÓ ÓÂÔÁÓÒÓ, ÛÙËÓ ‰ËÏËÙËÚ›·ÛË Ì ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ¿Óıڷη Î·È Û ˆÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜. Δ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛ˘ ‰ÂÓ ‹Ù·Ó ‰ÈfiÏÔ˘ ÈηÓÔÔÈËÙÈο, Ë ‰Â ̤ıÔ‰Ô˜ Û˘Óԉ¢fiÙ·Ó ·Ô ÛËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜, fiˆ˜ ·Ó·Ê˘Ï·ÎÙÈΤ˜ ·ÓÙȉڿÛÂȘ, ˘fiÙ·ÛË, ‚ÚÔÁ¯fiÛ·ÛÌÔ Î.Ï.., ηıÒ˜ Î·È Ì ÂÍ¿ÓÙÏËÛË ÙˆÓ ·ÔıÂÌ¿ÙˆÓ Ù˘ ∞ÈÌÔ‰ÔÛ›·˜, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ··ÈÙÔ‡ÓÙÔ ·Ô 5 ¤ˆ˜ 50L ÔÏÈÎÔ‡ ·›Ì·ÙÔ˜. ª›· Û¿ÓÈ· Î·È ·ÎÚ·›· ̤ıÔ‰Ô˜ ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛ˘ ‹Ù·Ó Ë «ÔÏÈ΋ ¤ÎÏ˘ÛË ÛÒÌ·ÙÔ˜».™‡Ìʈӷ Ì ·˘Ù‹ ÙËÓ Ì¤ıÔ‰Ô ·ÛıÂÓ›˜ Ì ∞HF ˘Ô‚¿ÏÔÓÙ·Ó Û ϋÚË ·Ê·›Ì·ÍË Ì ۇÁ¯ÚÔÓË ˘ÔıÂÚÌÈ΋ ηډȷ΋ ·Ó·ÎÔ‹. ªÂÙ¿ ÙËÓ Â·Ó·ÊÔÚ¿ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÔÈ ˘ÔÛÙËÚÈÎÙ¤˜ Ù˘ ÌÂıfi‰Ô˘ ·Ó·Ê¤ÚÔ˘Ó ‚ÂÏÙ›ˆÛË ¯ˆÚ›˜ Ó¢ÚÔÏÔÁÈΤ˜ ÂÈÏÔΤ˜. ∏ Ï·ÛÌ·Ê·›ÚÂÛË (plasma exchange) ‹Ù·Ó Ë ÂͤÏÈÍË Ù˘ ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛ˘. ™·Ó ıÂڷ›· ÚԤ΢„ ˆ˜ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË, fiÙ·Ó ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô St Vincent Ù˘ ¡¤·˜ ÀfiÚ΢ ‰ÂÓ ‹Ù·Ó ‰È·ı¤ÛÈÌÔ ·›Ì· ÔÌ¿‰Ô˜ μ, Rh (-), Ô˘ ··ÈÙ›ÙÔ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ì ·Ê·ÈÌ·ÍÔÌÂÙ¿ÁÁÈÛË ·ÛıÂÓÔ‡˜ ·˘Ù‹˜ Ù˘ ÔÌ¿‰Ô˜ Ô˘ ¤·Û¯Â ·Ô FH. ™ÎÔfi˜ Ù˘ ÌÂıfi‰Ô˘ Â›Ó·È Ë ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ Î˘ÎÏÔÊÔÚÔ˘ÛÒÓ ÙÔÍÈÓÒÓ Î·È Ë ·Ó·Ï‹ÚˆÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ (¯, ·Ú¿ÁÔÓÙ˜ ‹Í˘) Ô˘ Û˘ÓÙ›ıÂÓÙ·È ·Ô ÙÔ ‹·Ú. Δ· ·ÔÙÂϤÛÌ·Ù· Ô˘ ÂȉÈÒÎÔÓÙ·È Ì ÙËÓ Ï·ÛÌ·Ê·›ÚÂÛË, fiˆ˜ Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È Ë ·Ó¿ÓË„Ë ·Ô ÙÔ ÎfiÌ·, Â›Ó·È ÌÈÎÚ‹˜ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Î·È Û˘Ó‹ıˆ˜ ÂÈÙ˘Á¯¿ÓÔÓÙ·È Û ·ÛıÂÓ›˜ Ì ʷÚ̷΢ÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·. OÈ ÂÈÏÔΤ˜ ·Ô ÙËÓ Ï·ÛÌ·Ê·›ÚÂÛË ‰ÂÓ Â›Ó·È ·ÌÈÏËÙ·›Â˜ Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ Ì¢ÌÔÓÈÎfi Ô›‰ËÌ·, ÏÔÈÌÒÍÂȘ, ˘ÔηÏÈ·ÈÌ›· ·Ô ÙËÓ ÙÔÍÈ΋ ‰Ú·ÛË ÙˆÓ ÎÈÙÚÈÎÒÓ ÂÓÒÛÂˆÓ Ô˘ ÂÚȤ¯ÔÓÙ·È ÛÙÔ˘˜
201
·ÛÎÔ‡˜ ·›Ì·ÙÔ˜, ·ÏÏ¿ Î·È ·ÔÌ¿ÎÚ˘ÓÛË Ë·ÙÔÙÚÔÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ·Ô ÙËÓ Î˘ÎÏÔÊÔÚ›·. ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ FHF Ë ÂÈ‚›ˆÛË ·Ú¤ÌÂÈÓ ηÙÒÙÂÚË ÙÔ˘ 50% ÂÓÒ ‹Ù·Ó ˘„ËÏfi ÙÔ ÔÛÔÛÙfi ÂÈÏÔÎÒÓ, fiˆ˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ·ÏÏ¿ Î·È ı·Ó¿ÙˆÓ ·Ô ÂÈÏÔΤ˜ ·Ô ÙÔ˘˜ Ó‡ÌÔÓ˜ Î·È ÙÔÓ ÂÁΤʷÏÔ. ¶·Ú¿ ÙËÓ ÔÚȷ΋ ¯ÚËÛÈÌfiÙËÙ¿ Ù˘ Î·È Ù· ·Ó·fi‰ÂÎÙ· ÚÔ˜ ÙÔ ·ÚfiÓ ·ÔÙÂϤÛÌ·Ù·, Ë Ì¤ıÔ‰Ô˜ ÂÍ·ÎÔÏÔ˘ı› Ó· ¤¯ÂÈ ıÈ·ÛÒÙ˜.
™À™Δ∏ª∞Δ∞ ª∏ ∫ÀΔΔ∞ƒπ∫∏™ ¢π∏£∏™∏™ ∞πªO¢πÀ§∏™∏, ∞πªO¢π∏£∏™∏ & ∞πªO¶ƒO™ƒOº∏™∏ ∏ ·ÈÌԉȇÏËÛË(hemodialysis) ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙËÓ ‰ÂηÂÙ›· 1960 Î·È 1970 ˆ˜ ̤ıÔ‰Ô˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ AHF ÛÙË ‚¿ÛË Ù˘ ÙfiÙ ·Ú·Ù‹ÚËÛ˘ fiÙÈ ÔÈ ÙÔ͛Ә Ô˘ ¢ı‡ÓÔÓÙ·Ó ÁÈ· ÙÔ ÎfiÌ· ‹Ù·Ó ÌÈÎÚÔÌÔÚȷΤ˜ (< 5kDa) ˘‰·ÙÔ‰È·Ï˘Ù¤˜ ÂÓÒÛÂȘ. ∏ ·Ì̈ӛ· ›¯Â ÂÓÔ¯ÔÔÈËı› ˆ˜ ÙÔ Î‡ÚÈÔ ÌfiÚÈÔ Ô˘ ¢ı‡ÓÔÓÙ·Ó ÁÈ· ÙËÓ Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ·ÏÏ¿ ·ÚfiÏË ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛ‹ Ù˘ Ì ÙËÓ ·ÈÌԉȇÏËÛË, Ù· ›‰¿ Ù˘ ‰ÂÓ ÂÏ·ÙÙÒÓÔÓÙ·Ó ·Ó¿ÏÔÁ· ÛÙÔ Ï¿ÛÌ· ÙÔ˘ ·ÈÌÔ‰È˘ıÔ‡ÌÂÓÔ˘. ΔÔ ÁÂÁÔÓfi˜ ·˘Ùfi ÛÂ Û˘Ó‰È·ÛÌfi Ì ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ÚfiÏÔ˘ ÌÂÛ·›ˆÓ ÌÔÚ›ˆÓ (< 15kDa), fiˆ˜ Ë ¯ÔÏÂÚ˘ıÚ›ÓË, Ù· ¯ÔÏÈο Ôͤ·, Ù· ‚·Ú‚ÈÙÔ˘ÚÈο ÎÏ, ηıÒ˜ Î·È ÙˆÓ Û˘Ó‰Â‰ÂÌ¤ÓˆÓ Ì ÏÂ˘ÎˆÌ·Ù›ÓË ÙÔÍÈÓÒÓ, Ô‰‹ÁËÛ·Ó ÛÙËÓ ·ÈÌԉȋıËÛË (hemofiltration) Ì Ù¯ÓËÙ¤˜ ÌÂÌ‚Ú¿Ó˜ Î·È ·ÈÌÔÚÔÛÚfiÊËÛË(hemadsorpion) Ì ÙËÓ ¯ÚËÛÈÌÔÔ›ÛË ÚÔÛÚÔÊËÙÈÎÔ‡ ̤ÛÔ˘, Ô˘ Û˘ÓËı¤Ûٷٷ ‹Ù·Ó Ô ¿Óıڷη˜, ÔÈ Û˘ÓıÂÙÈΤ˜ ÚËÙ›Ó˜ Î·È ÔÈ ÈÔÓÙÔ·ÓÙ·ÏÏ·ÎÙÈΤ˜ ÚËÙ›Ó˜. ªÂ›˙ÔÓ ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ ‰Â‡ÙÂÚ˘ ÌÂıfi‰Ô˘ ËÙ·Ó Ë ·ÒÏÂÈ· ·ÈÌÔÂÙ·Ï›ˆÓ, Ï¢ÎÔ΢ÙÙ¿ÚˆÓ, ·Ú·ÁfiÓÙˆÓ ‹Í˘ ·ÏÏ¿ Î·È ¿ÏÏˆÓ Û˘ÛÙ·ÙÈÎÒÓ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜, Ô˘ Û˘Ó¤‚·ÈÓ Ì ÙËÓ Â·Ê‹ ÙÔ˘ ·›Ì·ÙÔ˜ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÚÔ˜ ÙÔ ÚÔÛÚÔÊËÙÈÎfi ̤ÛÔ. ∞Ô ÙȘ ÌÂıfi‰Ô˘˜ ·ÈÌԉȋıËÛ˘ ¢ڇÙÂÚË ÂÊ·ÚÌÔÁ‹ ¤Ù˘¯Â Ë ·ÈÌԉȋıËÛË ¿ÓıÚ·ÎÔ˜(harcoal hemoperfusion) Ô˘ ÛÎfi¢ ÛÙËÓ Î¿ı·ÚÛË ÂÓÒÛÂˆÓ ·Ô 1.000-1.500 kDa, ¯ˆÚ›˜ fï˜ Ó· Â›Ó·È ÙfiÛÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË Ù˘ ·Ì̈ӛ·˜ Î·È ÙˆÓ ÌÔÚ›ˆÓ ÙˆÓ Û˘Ó‰Â‰ÂÌ¤ÓˆÓ Ì Ï¢ÎÒÌ·Ù· ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘ÙÒÓ ÙˆÓ ÌÂıfi‰ˆÓ, ·ÏÏ¿
°. IMBPIO™
202
Î·È ÂÚÈÛÙ·ÛÈ·ÎÒÓ Û˘Ó‰È·ÛÌÒÓ Ì ÔÌfiÏÔÁ˜ ηٷ ‚¿ÛË Ù¯ÓÈΤ˜(Û˘Ó‰È·ÛÌfi˜ ·ÈÌԉȇıËÛ˘ Î·È Ï·ÛÌ·Ê·›ÚÂÛ˘), ‰ÂÓ ·ÓÙÈηÙfiÙÚÈ˙·Ó ÙȘ ·Ú¯ÈΤ˜ ÚԂϤ„ÂȘ Î·È ‰ÂÓ Î·ÙfiÚıˆÛ·Ó Ó· ·Ó·ÛÙÚ¤„Ô˘Ó ÙËÓ Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Î·È Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ ÂÈ‚›ˆÛË Û ·ÛıÂÓ›˜ Ì AHF. ™À™Δ∏ª∞ ∞¡∞∫À∫§ø™∏™ ª∂ ªOƒπ∞∫OÀ™ ¶ƒO™ƒOº∏Δ∂™ Δ· ›‰· ÔÏÏÒÓ ÂÓ‰ÔÁÂÓÒÓ ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ ÌÔÚ›ˆÓ ·˘Í¿ÓÔÓÙ·È fiÙ·Ó ÔÍ›· ‹ ÔÍ›· ÂÈ ¯ÚÔÓ›·˜ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·, ÂÚÈÔÚ›˙Ô˘Ó ‹ Î·È ·Ó·ÛÙ¤ÏÔ˘Ó ÙËÓ Û‡ÓıÂÛË ÚˆÙÂ˚ÓÒÓ. ™ÙȘ ÂÓÒÛÂȘ ·˘Ù¤˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ¯ÔÏÈο Ôͤ·, Û˘Ó‰Â‰Â̤ÓË ¯ÔÏÂÚ˘ıÚ›ÓË, ·ÚˆÌ·ÙÈο ·ÌÈÓÔͤ· Î·È ÔÈ ÌÂÙ·‚ÔÏ‹Ù˜ ÙÔ˘˜, ̤Û˘ ·Ï‡ÛÛÔ˘ ÏÈ·Ú¿ Ôͤ·, ÌÂÚηٿÓ˜, ÚÔÛÙ·Î˘ÎϛӘ, ÙÚ˘ÙÔÊ¿ÓË, ΢ÙÔΛÓ˜ Î.Ï.., ÙÔÍÈο ÌfiÚÈ· Ô˘ ÛÙËÓ ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È ÏÈfiÊÈÏ· Î·È Û˘Ó‰Â‰Â̤ӷ Ì ÏÂ˘ÎˆÌ·Ù›ÓË. ∏ Û˘ÁΤÓÙÚˆÛË ·˘ÙÒÓ ÙˆÓ Ô˘ÛÈÒÓ ÚÔηÏ› ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÙˆÓ ÓÂÊÚÒÓ Î·È ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ, ÂÏ¿ÙÙˆÛË ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÙfiÓÔ˘ Î·È Â›Ù·ÛË Ù˘ ·fiÙˆÛ˘ Î·È Ó¤ÎÚˆÛ˘ ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ. ∏ ‰˘Ó·ÙfiÙËÙ· ‰¤ÛÌ¢Û˘ ·˘ÙÒÓ ÙˆÓ ÌÔÚ›ˆÓ ·ÔÙÂÏÔ‡Ó ÙÔ ˘fi‚·ıÚÔ Ù˘ ¯ÚËÛÈÌÔÔ›ËÛ˘ Ù˘ ·Ï‚Ô˘Ì›Ó˘ Û·Ó ‰È·Ï‡ÙË Ì ÛÎÔfi ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÔÍ›·˜ Î·È Ù˘ ÔÍ›·˜ › ¯ÚÔÓ›·˜ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ΔÔ Û‡ÛÙËÌ· ·Ó·Î‡ÎψÛ˘ Ì ÌÔÚÈ·ÎÔ‡˜ ÚÔÛÚÔÊ‹Ù˜(Molecular Adsorbent Recirculating System, MARS, ™¯. 1, 2) ·Ó·Ù‡¯ıËΠ·Ô ÙÔÓ Strange et al ÙÔ 1993. ∂›Ó·È ¤Ó· Û˘ÛÙËÌ· Ì‹ ΢ÙÙ·ÚÈ΋˜ ‰È‹ıËÛ˘ Ô˘ ¯ÚËÛÈÌÔÔÈ› Â͈ۈ̷ÙÈο ‰È‡ÏËÛË ·Ï‚Ô˘Ì›Ó˘ ÁÈ· ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙÔÍÈ-
ÓÒÓ, ÙfiÛÔ ˘‰·ÙÔ‰È·Ï˘ÙÒÓ fiÛÔ Î·È Û˘Ó‰Â‰ÂÌ¤ÓˆÓ Ì ڈÙÂ˚Ó˜. μ·Û›˙ÂÙ·È Û ·ÈÌÔοı·ÚÛË Ì ۇÛÙËÌ· ‰È·¯ˆÚÈÛÌÔ‡, Ì›· ÌÂÌ‚Ú¿ÓË ÔÏ˘ÛÔ˘ÏÊfiÓ˘ Ì ÎԛϘ ›Ó˜, ÙˆÓ ÔÔ›ˆÓ Ô ·˘Ïfi˜(fiÚÔÈ) ÂÈÙÚ¤Ô˘Ó ÙËÓ ÔÚȷ΋ ‰È¤Ï¢ÛË ÚˆÙÂ˚ÓÈο Û˘Ó‰Â‰ÂÌ¤ÓˆÓ ÌÔÚ›ˆÓ ·Ô 50 ¤ˆ 60 kd. ∏ ÌÂÌ‚Ú¿ÓË ·˘Ù‹ ÂÈÙÚ¤ÂÈ ÙËÓ ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ˘‰·ÙÔ‰È·Ï˘ÙÒÓ Î·È ÙˆÓ Û˘Ó‰Â‰ÂÌ¤ÓˆÓ Ì ڈÙÂ˚Ó˜ ÙÔÍÈÓÒÓ ·fi ÙÔ ·›Ì· ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙËÓ ‰¤ÛÌÂ˘Û‹ ÙÔ˘˜ ·fi ÙȘ ÚˆÙÂ˚Ó˜ ÙÔ˘ ‰È·Ï‡ÙÔ˘. ™ÙËÓ Â͈ÙÂÚÈ΋ ÂÈÊ¿ÓÂÈ· Ù˘ ÌÂÌ‚Ú¿Ó˘, ˆ˜ ‰È¿Ï˘Ì· ¤ÎÏ˘Û˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÏÂ˘ÎˆÌ·Ù›ÓË Û ÂÚÈÂÎÙÈÎfiÙËÙ· ̤¯ÚÈ 20%. OÈ ÙÔ͛Ә, ÂÍ ·ÈÙ›·˜ Ù˘ ‰È·ÊÔÚ¿˜ Û˘ÁΤÓÙÚˆΛευκωματίνη διαλύματος
Δεσμευτική θέση
Τοξικές ουσίες δεσμευμένες με λευκωματίνη Μεμβράνη
Ελεύθερες μικρού ΜΒ ουσίες
Λευκωματίνη πλάσματος
Πρωτεϊνική στιβάδα Άλλες δεσμευτικές πρωτεΐνες
™¯‹Ì· 1. ∏ ‰È·Î›ÓËÛË ÙˆÓ Ô˘ÛÈÒÓ Ì¤Ûˆ Ù˘ ÌÂÌ‚Ú¿Ó˘ MARS.
ΠΡΟΣΡΟΦΗΤΙΚΕΣ ΣΤΗΛΕΣ MARS Flux
ΚΥΚΛΟΦΟΡΙΑ ΑΙΜΑΤΟΣ
ΚΥΚΛΟΦΟΡΙΑ ΛΕΥΚΩΜΑΤΙΝΗΣ
ΤΕΧΝΗΤΟΣ ΝΕΦΡΟΣ
™¯‹Ì· 2. ™¯ËÌ·ÙÈ΋ ‰È¿Ù·ÍË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ MARS
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Û˘, ‰È·¯¤ÔÓÙ·È ÛÙËÓ ÂÛˆÙÂÚÈ΋ ÂÈÊ¿ÓÂÈ· ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ. ™Â Û˘Ó¤¯ÂÈ· ÔÈ ÚˆÙÂ˚Ó˜ ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ·Ï‚Ô˘Ì›Ó˘ ·ӷ‰ÂÛÌÂ‡Ô˘Ó ÙȘ ÙÔ͛Ә ·Ô ÙËÓ Â͈ÙÂÚÈ΋ ÂÈÊ¿ÓÂÈ· Ù˘ ÌÂÌ‚Ú¿Ó˘ ÌÂ Ê˘ÛÈÎÔ¯ËÌÈÎfi Ì˯·ÓÈÛÌfi, ÌÂ Û˘Ó¤ÂÈ· Ó· ‰ËÌÈÔ˘ÚÁÂ›Ù·È Ì›· Û˘Ó¯‹˜ ‰È·ÊÔÚ¿ Û˘ÁΤÓÙÚˆÛ˘ ÙˆÓ ÙÔÍÈÓÒÓ ·Ó¿ÌÂÛ· ÛÙȘ ‰‡Ô Ï¢ڤ˜ Ù˘ ÌÂÌ‚Ú¿Ó˘. OÈ ‰ÂÛÌÂ˘Ì¤Ó˜ ÛÙÔ ·Ï‚Ô˘ÌÈÓÈÎfi ϤÔÓ ‰È¿Ï˘Ì· ÙÔ͛Ә, Ô‰ËÁÔ‡ÓÙ·È Û ¤Ó· Û‡ÛÙËÌ· ÚÔÛÚÔÊËÙÈÎÒÓ Ì¤ÛˆÓ Ô˘ ·ÔÙÂÏÂ›Ù·È ·Ô ÛًϘ ÂÓÂÚÁÔ‡ ¿Óıڷη Î·È ÈÔ·ÓÙ·ÏÏ·ÎÙÈÎÒÓ ÚÈÙÈÓÒÓ, fiÔ˘ Î·È Î·ı·›ÚÔÓÙ·È. ªÂ ·˘Ùfi ÙÔÓ ÙÚfiÔ ·Ô‰ÂÛ̇ÔÓÙ·È ÔÈ ı¤ÛÂȘ Û‡Ó‰ÂÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ Ô˘ÛÈÒÓ Ì ÙȘ ÚˆÙÂ˚Ó˜ Î·È ÌÔÚ› Ó· ·ӷ¯ÚËÛÈÌÔÔÈı› Ë ·Ï‚Ô˘Ì›ÓË ÙÔ˘ ‰È·Ï‡ÙË. OÈ ÔÚÌfiÓ˜, ÔÈ ‚Èٷ̛Ә Î·È ÔÈ ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‰ÂÓ ‰ÈËÏ›˙ÔÓÙ·È, ÂÓÒ ÙÔ ÓÂÚfi Î·È ÔÈ ËÏÂÎÙÚÔχÙ˜ ‰ÈËÏ›˙ÔÓÙ·È Ì Ì˯·ÓÈÛÌfi ‰È¿¯˘Û˘ ‹ ÌÂÙ·ÊÔÚ¿˜. ΔÔ Û‡ÛÙËÌ· ·ÈÌԉȇÏËÛ˘ Ô˘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙÔ MARS, ÚÔÛı¤ÙÂÈ fiÏ· Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· Ù˘ ·ÈÌԉȇÏËÛ˘, ÂÂȉ‹ ÔÏÏÔ› ·Ô ÙÔ˘˜ ·ÛıÂÓ›˜ Ì AHF ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÓÂÊÚÈ΋ ‹ ·Ó¿ÚÎÂÈ· ÔÏÏ·ÏÒÓ ÔÚÁ¿ÓˆÓ. ™ÙÔ Û‡ÛÙËÌ· MARS, Ë Ì¤ÛË ‰È¿ÚÎÂÈ· ‰È¿ÚÎÂÈ· ıÂڷ›·˜ ÁÈ· ¤Ó·Ó ·ÛıÂÓ‹ ‚¿ÚÔ˘˜ 75kg Ì ̤ÛË ÚÔ‹ ·›Ì·ÙÔ˜ ÛÙÔ Â͈ۈ̷ÙÈÎfi ·Îψ̷ 200 mL/h, Â›Ó·È ÂÚ›Ô˘ 6 ÒÚ˜. ΔÔ Û‡ÛÙËÌ· MARS ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ AHF ÈÔÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜, Ù˘ AoCHF ·ÏÏ¿ Î·È ¿ÏÏˆÓ ÓfiÛˆÓ fiˆ˜ Ë ÓfiÛÔ˜ Wilson, Ë ÚˆÙÔ·ı‹˜ ¯ÔÏÈ΋ ΛÚÚˆÛË, Ë Î·ÏÔ‹ı˘ ˘ÔÙÚÔÔÈ¿˙Ô˘Û· ÂÓ‰ÔË·ÙÈ΋ ¯ÔÏfiÛÙ·ÛË, Ë Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ·Ô ‰ËÏËÙËÚ›·ÛË Ì ·Ú·ÎÂÙ·ÌfiÏË ‹ ·Ô Ì·ÓÈÙ¿ÚÈ·, Ë ÚˆÙÔ·ı‹˜ ÌË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ·Ô ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î.Ï. ∏ ̤¯ÚÈ Û‹ÌÂÚ· ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ ‰›ÓÂÈ ·ÔÙÂϤÛÌ·Ù· Ô˘ ÔÈΛÏÔ˘Ó Û ‚·ıÌfi ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙÔ˜. ∞ӷʤÚÂÙ·È ÙÒÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È Ù˘ ÎÚ·ÙÈÓ›Ó˘ Î·È ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ·ÓÙÈıÚÔÌ‚›Ó˘ πππ, Ù˘ ·Ï‚Ô˘Ì›Ó˘ Î·È ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘. ∂›Û˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ‚ÂÏÙ›ˆÛË Ë·ÙÔÓÂÊÚÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ (Ù‡Ô˜ π) Î·È Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Û ·ÛıÂÓ›˜ Ì AHF Î·È Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ. º·›ÓÂÙ·È fiÙÈ Ë Ì¤ıÔ‰Ô˜ ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ·Ú·Ù›ÓÂÈ ‚Ú·¯˘¯ÚfiÓÈ· ÙËÓ ÂÈ‚›ˆÛË, Û ·ÛıÂÓ›˜ Ì ÔÍ›· ÂÈ ¯ÚÔÓ›·˜ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·. øÛÙfiÛÔ ‰ËÌÔÛÈ¢-
203
̤ÓË ÂÌÂÈÚ›· ·ÌÊÈÛ‚ËÙ› ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘. ª›· ¿ÏÏË ÌÔÚÊ‹ Ù˘ ‰È‡ÏËÛ˘ Ì ·Ï‚Ô˘Ì›ÓË, ·ÔÙÂÏ› ÙÔ Û‡ÛÙËÌ· «¶ÚÔÌËı¤·˜»(PrÔmetheus system/Fresenium Medical Care AG). ™˘Ó‰È¿˙ÔÓÙ·˜ ÎÏ·ÛÌ·ÙÈÎfi ‰È·¯ˆÚÈÛÌfi ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ÚÔÛÚfiÊËÛË Ì ˘„ËÏ‹˜ ÚÔ‹˜ ·ÈÌÔ‰È‡Ï˘ÛË Ì ̛· 250 kd ËÌȉȷÂÚ·Ù‹ ÌÂÌ‚Ú¿ÓË, ÙÔ Û‡ÛÙËÌ· ·˘Ùfi ˘fiÛ¯ÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÚˆÙÂ˚ÓÈο Û˘Ó‰Â‰ÂÌ¤ÓˆÓ ÙÔÍÈÓÒÓ ·fiÙÈ ÙÔ MARS. ∞ÔÙÂÏ› fï˜ ̤ıÔ‰Ô Ô˘ ÂÊ·ÚÌfiÛÙËΠۯÂÙÈο ÚfiÛÊ·Ù· ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Î·È Û˘ÓÂÒ˜ ÂÚÈÔÚÈṲ̂Ó˘ ÂÌÂÈÚ›·˜.
μπO§O°π∫∞ ™À™Δ∏ª∞Δ∞ À¶O™Δ∏ƒπ•∏™ ™Â ·˘Ù‹ ÙËÓ Î·ÙËÁÔÚ›· ·Ó‹ÎÔ˘Ó Û˘ÛÙ‹Ì·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó Î·ÙÂÍÔ¯‹Ó ‚ÈÔÏÔÁÈο ̤۷, ˙ÒÓÙ· ÔÚÁ·ÓÈÛÌfi ‹ ·ÔÌÔӈ̤ӷ fiÚÁ·Ó¿ ÙÔ˘˜(‹·Ú), ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÈÙ‡¯Ô˘Ó ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÙÔÍÈÓÒÓ. OªO§O°∏ ∫∞π ∂Δ∂ƒO§O°∏ ¢π∞™Δ∞ÀƒOÀª∂¡∏ ∞πªO¢πÀ§∏™∏ ∏ ˘fiıÂÛË ÔÙÈ, Ë ÂÌÏÔ΋ ÂÓfi˜ ˘ÁÈÔ‡˜ ‹·ÙÔ˜ ÛÙËÓ ÁÂÓÈ΋ ΢ÎÏÔÊÔÚ›· ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ·Ô AHF ‹ AoCHF, ı· ÌÔÚÔ‡Û ӷ ·ÔÌ·ÎÚ‡ÓÂÈ ÙȘ ÙÔ͛Ә, Ô‰‹ÁËÛ ÛÙËÓ ¯ÚËÛËÌÔÔ›ËÛË Ù¯ÓÈÎÒÓ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÈÌԉȇÏËÛ˘(cross hemodialysis) Ì ˙ÒÓÙ· ˙Ò·. ∏ ÚÒÙË ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ ¤ÁÈÓ ·Ô ÙÔÓ ∫imoto ÙÔ 1959, Ì ˙ÒÔ Û·ÏÔ. ÃÚËÛÈÌÔÈ‹ıËÎ·Ó ‰‡Ô ͯˆÚÈÛÙ¿ ΢ÎÏÒÌ·Ù· ·›Ì·ÙÔ˜, ¤Ó· ÁÈ· οı ÔÚÁ·ÓÈÛÌfi, ηÈ, Ë ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ÙÔÍÈÓÒÓ ÛÙÔ ·›Ì· ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÚÔ˜ ÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÔ˘ Û·ÏÔ˘, Á›ÓÔÓÙ·Ó Ì¤Ûˆ Ì›·˜ ÌÂÌ‚Ú¿Ó˘ ÛÂÏÏÔÊ¿Ó˘. ∏ ̤ıÔ‰Ô˜ ‰ÂÓ ¤ÁÈÓ ·Ô‰ÂÎÙ‹ Î·È ÂÚÈıoÚÈÔÔÈ‹ıËÎÂ. ∂›Û˘ ¤¯ÂÈ ·Ó·ÊÂÚı› ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÈÌԉȇÏËÛË Ì ̷ÌÔ˘˚ÓÔ˘˜. ∏ ‚ÂÏÙ›ˆÛË Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ‹Ù·Ó ÂÚÈÔÚÈṲ̂ÓË Î·È ÛÙÔ ˙Ò· ·Ó·Ù‡ÛÛÔÓÙ·Ó ·Ó·ÈÌ›· Î·È ·ÚÔ˘ÛÈ¿˙ÔÓÙ·Ó ı¿Ó·ÙÔÈ ·Ô ηډȷ΋ ·Ó·ÎÔ‹, ·ÚÎÂÙ¤˜ Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ·ÈÌԉȇÏËÛË. ∏ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË Î˘ÎÏÔÊÔÚ›· Ì ˘ÁÈ›˜ ·ÓıÚÒÔ˘˜-ÂıÂÏÔÓÙ¤˜, ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËıÂÈ ·ÏÏ¿ ÂÁηٷϋÊıËΠٷ¯‡Ù·Ù· ÏfiÁˆ Ù˘ ÚÔÊ·ÓÔ‡˜ ÎÈÓ‰‡ÓÔ˘ Ó· ÌÂÙ·‰Ôı› ÛÙÔÓ ÂıÂÏÔÓÙ‹ Ë ÈÔÁÂÓ‹˜ Ë·Ù›ÙȘ ‹ ¿ÏÏÔ ·ÈÌ·ÙÔÁÂÓÒ˜ ÌÂÙ·‰È‰fiÌÂÓÔ ÓfiÛËÌ·.
°. IMBPIO™
204 ∂Δ∂ƒO§O°O™ & OªO§O°O™ ∂•ø™øª∞Δπ∫∏ ∏¶∞ΔO¢π∏£∏™∏
∞Ó Î·È Ë ¯Ú‹ÛË ÙÔ˘ ·ÔÌÔӈ̤ÓÔ˘ ‹·ÙÔ˜ ÁÈ· ¯Ú‹ÛË ÌÂÙ·‚ÔÏÈÎÒÓ ÂÈÚ·Ì·ÙÈÎÒÓ ÌÂÏÂÙÒÓ ‹Ù·Ó Û ¯Ú‹ÛË ‹‰Ë ·Ô ÙÔ 1855, Ë ¯ÚËÛËÌÔÔ›ËÛË ex vivo ÙÔ˘ ·ÔÌÔӈ̤ÓÔ˘ ‹·ÙÔ˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ¤ÁÈÓ ÙËÓ ‰ÂηÂÙ›· ÙÔ˘ 1960. ∏ ̤ıÔ‰Ô˜ (™¯. 3), Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ¿ÌÂÛË Û‡Ó‰ÂÛË ÂÓfi˜ ·ÔÌÔӈ̤ÓÔ˘ ‹·ÙÔ˜, ˙ÒÔ˘(ÂÙÂÚfiÏÔÁÔ˜ Ë·ÙԉȋıËÛË) ‹ ·ÓıÚÒÔ˘(ÔÌfiÏÔÁÔ˜ Ë·ÙԉȋıËÛË) ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÔ˘ ¿Û¯ÔÓÙÔ˜. ∞Ô Ù¯ÓÈ΋˜ ¿Ô„˘, ÙÔ ·ÚÙËÚÈ·Îfi ·›Ì· ÙÔ˘ ¿Û¯ÔÓÙÔ˜,Û˘Ó‹ıˆ˜ ·Ô ÙËÓ ÎÂÚÎȉÈ΋ ‹ ÚfiÛıÈ· ÎÓËÌÈ·›· ·ÚÙËÚ›·, Ô‰ËÁÂ›Ù·È Ì¤Ûˆ ÂÓfi˜ Â͈ÙÂÚÈÎÔ‡ ΢ÎÏÒÌ·ÙÔ˜ ÛÙËÓ ˘Ï·›· ÙÔ˘ ·Ô̈ÓÔ̤ÓÔ˘ ‹·ÙÔ˜ Î·È ·ÎÔÏÔ‡ıˆ˜ ÙÔ ·›Ì· ·Ô ÙËÓ ˘ÂÚË·ÙÈ΋ ÎÔ›ÏË ÊϤ‚· ·ӷʤÚÂÙ·È ÛÙÔÓ ·ÛıÂÓ‹, ‰ÈÔ¯ÂÙ¢fiÌÂÓÔ ÛÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô Ì ÙËÓ ·ÚÙËÚ›· Ï‹„˘, ÂÚÈÊÂÚÈÎfi ÊÏ‚ÈÎfi Û٤ϯԘ.∏ ‰È¿ÚÎÂÈ· Ì›·˜ Û˘Ó‰ڛ·˜ ˘ÔÏÔÁ›˙ÔÙ·Ó ÂÚ›Ô˘ ÛÙȘ 13 ¤ˆ˜ 16 ÒÚ˜. Œ¯Ô˘Ó ·Ó·ÊÂÚı› ÔÏϤ˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ˘ÔÛÙ‹ÚÈÍË ·ÛıÂÓÒÓ Ì AHF Ì ÙËÓ ¯ÚËÛÈÌÔÔ›ËÛË ·ÔÌÔӈ̤ÓÔ˘ ‹·ÙÔ˜ ›Ù ·Ô Ê˘ÏÔÁÂÓÓËÙÈÎÒ˜ ·ÚÔÌÔ›ˆÓ ˙ÒˆÓ fiˆ˜ ÔÈ Ì·ÌÔ˘›ÓÔÈ (concordant xenografts), ›Ù ·Ô ÊıÏÔÁÂÓÓËÙÈÎÒ˜ ·ÔÌ·ÎÚ˘Ṳ̂ӷ ›‰Ë (discordant xenografts), fiˆ˜,-΢ڛˆ˜-, ÔÈ ¯Ô›ÚÔÈ ·ÏÏ¿ Î·È Û·ÏÔÈ ‹ Î·È ÌÔ-
Û¯¿ÚÈ·. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·Ú·ÙËÚ‹ıËΠÌfiÓÔ ÚÔÛˆÚÈÓ‹ ‚ÂÏÙ›ˆÛË Ù˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Î·È ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ∂ÈÚÔÛı¤Ùˆ˜ ·Ú·ÙËÚ‹ıËΠ˘ÂÚÔÍ›· Î·È ÔÍ›· ·fiÚÚÈ„Ë ÙÔ˘ ÂÙÂÚfiÏÔÁÔ˘ ÔÚÁ¿ÓÔ˘, Ô˘ Ô‰‹ÁËÛ Û ¤ÎÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿˜ ÙÔ˘ Î·È ÂÓ‰ÔË·ÙÈ΋ ·ÈÌÔÚÚ·Á›·, ÂÓÒ ÂÈÛ˘Ó¤‚·ÈÓ ·ÈÌfiÏ˘ÛË Î·È ıÚÔÌÔ΢ÙÙ·ÚÔÂÓ›· ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ Û˘ÛÛÒÚ¢Û˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÂÓÙfi˜ ÙÔ˘ ÂÙÂÚfiÏÔÁÔ˘ ‹·ÙÔ˜. ΔÔ ·ÓÔÛÔÏÔÁÈÎfi Úfi‚ÏËÌ· ı· ÌÔÚÔ‡Û ӷ Ï˘ı› Ì ÙËÓ ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ ‹·ÙÔ˜ ‰È·ÁÔÓȉȷÎÒÓ ¯Ô›ÚˆÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·ÌËÏ‹ ·ÓÙÈÁÔÓÈÎfiÙËÙ·. ∏ ÂÙÂÚfiÏÔÁÔ˜ Ë·ÙԉȋıËÛË ··ÈÙ› ÙËÓ ·Ó¿Ù˘ÍË ÂÍÂȉÈÎÂ˘Ì¤Ó˘ ÔÌ¿‰Ô˜ ˙ÒˆÓ-‰ÔÙÒÓ ·ÏÏ¿ Î·È ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ·ÈÌÔ‰ÈËıÔ‡ÌÂÓÔ˘ ·Ô ÙËÓ ÌÂÙ¿‰ÔÛË ˙ˆÔÓfiÛÔ˘, fiˆ˜ Ô ÚÂÙÚÔ˚fi˜ ÙˆÓ ¯Ô›ÚˆÓ (Porcine Endogenous Retrovirus/PERV), Ô ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚fi˜ ÙˆÓ ¯Ô›ÚˆÓ (CMV), Ë ÓfiÛÔ˜ Crutzfeldt-Jakob ÎÏ. ∏ ÔÌfiÏÔÁË Ë·ÙԉȋıËÛË ÂÈÙ‡¯ıËΠ̠ÙËÓ ¯ÚËÛÈÌÔÔ›ËÛË ·ÓıÚˆ›ÓˆÓ و̷ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ‰ÂÓ ‹Ù·Ó ηٿÏÏËÏ· ÁÈ· Ó· ÌÂÙ·ÌÔÛ¯Â˘ıÔ‡Ó. ΔÔ ÂÚÒÙËÌ· Ô˘ ÚÔ·ÙÂÈ Â›Ó·È ˆ˜ Â›Ó·È ‰˘Ó·ÙfiÓ ¤Ó· ÌfiÛ¯Â˘Ì· Ô˘ ÌÔÚ› Ó· ÚÔÛʤÚÂÈ ÙËÓ ·Ó·Áη›· ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÁÈ· ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÙÔÍÈÓÒÓ, ·ÍÈÔÏÔÁÂ›Ù·È ˆ˜ ·Î·Ù¿ÏÏËÏÔ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. øÛÙfiÛÔ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Î·È “ηٿÏÏËÏ·” و̷ÙÈο Ë·ÙÈο ÌÔۯ‡-
ΗΑ
Προς την A-V παράκαμψη του "ασθενούς"
ΠΦ
Θερμόμετρο
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Πρωταμίνη Αναπνευστήρας
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Ασκιτικό υγρό
™¯‹Ì· 3. ¢È¿Ù·ÍË ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÂÙÂÚfiÏÔÁ˘ ‹ ÔÌfiÏÔÁ˘ Â͈ۈ̷ÙÈ΋˜ Ë·ÙԉȋıËÛ˘.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ì·Ù· ¯ˆÚ›˜ fï˜ ı·̷ÙÈο ·ÔÙÂϤÛÌ·Ù·. OÈ ‰ËÌÔÛÈ¢ı›Û˜ ÂÚÁ·Û›Â˜ ÛÙÔ ı¤Ì· ·˘Ùfi ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Ì¤ıÔ‰Ô˜ ·˘Ù‹, ÂÙÂÚfiÏÔÁÔ˜ ‹ ÔÌfiÏÔÁÔ˜, ÌÔÚ› Ó· Û˘ÓÂÈÛʤÚÂÈ ÛÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ÙÔÍÈÎÒÓ ÚÔ˚fiÓÙˆÓ ·Ô ÙÔÓ ¿Û¯ÔÓÙ·, ·ÏÏ¿ Ë ÂÏ·Ùو̤ÓË ‚ȈÛËÌfiÙËÙ· ÙÔ˘ ·ÔÌÔӈ̤ÓÔ˘ ‹·ÙÔ˜ ηıÈÛÙ· ÚÔ‚ÏËÌ·ÙÈ΋ ÙËÓ ˘ÈÔı¤ÙËÛË Ù˘ ÌÂıfi‰Ô˘. Àμƒπ¢π∫∞ ™À™Δ∏ª∞Δ∞ À¶O™Δ∏ƒπ•∏™ ™Â ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·Ó‹ÎÔ˘Ó ÔÈ Ì¤ıÔ‰ÔÈ fiÔ˘ Á›ÓÂÙ·È Û˘Ó‰È·ÛÌfi˜ ‚ÈÔÏÔÁÈÎÒÓ(ÔÌfiÏÔÁ· ‹ ÂÙÂÚfiÏÔÁ· Ë·ÙÔ·ÙÙ·Ú·) Î·È Ì‹ ‚ÈÔÏÔÁÈÎÒÓ Ì¤ÛˆÓ (ÌÂÌ‚Ú¿Ó˜). ™Ù· Û˘ÛÙ‹Ì·Ù· ·˘Ù¿ ·Ô‰›‰ÂÙ·È Ë ÁÂÓÈ΋ ÔÓÔÌ·Û›· «μÈÔÙ¯ÓËÙfi ◊·Ú» (Artificial Liver/AL, ™¯. 4), fiÚÔ˜ Ô˘ ÂÈÛ‹¯ıË ·Ô ÙÔÓ Sorrentino ÙÔ 1956, ÂÓÒ Ë ÚÒÙË ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ ·Ó·Ê¤ÚıËΠÙÔ 1959 ·Ô ÙÔÓ Kimoto (Tokyo). ∏ ̤ıÔ‰Ô˜ ÛÙËÚ›¯ıËΠÛÙËÓ È‰ÈfiÙËÙ· ÙÔ˘ ÚfiÛÊ·Ù· ÔÌÔÁÂÓÔÔÈË̤ÓÔ˘ Ë·ÙÈÎÔ‡ ÈÛÙÔ‡, Ó· ÌÂÙ·‚ÔÏ›˙ÂÈ ÎÂÙÔÓÈο ÛÒÌ·Ù·, ‚·Ú‚ÈÙÔ˘ÚÈο, Û·Ï˘ÎÈÏÈÎfi Ô͇ Î·È ·Ì̈ӛ·. ∞ÎÔÏÔ‡ıËÛ ̷ÎÚ¿ ¤Ú¢ӷ Ì ڈÙÔfiÚ˜ ÂÊ·ÚÌÔÁ¤˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ AHF, ΢ڛˆ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· (Kimoto 1959, Nose 1963, Hager 1978/1983, Uchino 1988, Gerlach 1994, Flendrig 1997 Î·È ¿ÏÏÔÈ), ·Ô ÙȘ Ôԛ˜ ‰È·ÈÛÙÒıËΠfiÙÈ, Ù· Ë·ÙÔ·ÙÙ·Ú· ·Ú¿ Ù‹Ó ·ÔÎÔ‹
™¯‹Ì· 4. ™¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË ÙÔ˘ μÈÔÙ¯ÓËÙÔ‡ ‹·ÙÔ˜
205
ÙÔ˘˜ ·Ô ÙÔ˘˜ Ú˘ıÌÈÛÙÈÎÔ‡˜ in vivo Ì˯·ÓÈÛÌÔ‡˜, ÌÔÚÔ‡Ó Ó· ‰È·ÙËÚ‹ÛÔ˘Ó in vitro ÛËÌ·ÓÙÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ fiˆ˜ ÙË Û‡ÓıÂÛË ÚˆÙÂ˚ÓÒÓ, ÙË ÓÂÔÁÏÔ˘ÎÔÎÔÁ¤ÓÓÂÛË, ÙË Û‡ÓıÂÛË Ù˘ Ô˘Ú›·˜ Î·È Ë ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ΢ÙÙÔ¯ÚÒÌ·ÙÔ˜ ƒ 450. ∏ ·Ó¿Ù˘ÍË ÂÓfi˜ AL ÁÈ· Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, ÔÊ›ÏÂÈ Ó· ÂÚȤ¯ÂÈ ¤Ó·Ó ÂÏ¿¯ÈÛÙÔ ·ÚÈıÌfi ÏÂÈÙÔ˘ÚÁÈο ÈηÓÒÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, ÒÛÙ ӷ Â›Ó·È ‰˘Ó·Ù‹ Ë ÂΉ‹ÏˆÛË ‚ÈÔÛ˘ÓıÂÙÈÎÒÓ Î·È ·ÔÙÔÍÈÓˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ. O Û˘ÓÔÏÈÎfi˜ ·ÚÈıÌfi˜ ÙˆÓ ·Ó·Áη›ˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ÁÈ· ÙËÓ ‰È·Ù‹ÚËÛË ÛÙË ˙ˆ‹ ÂÓfi˜ ÔÚÁ¿ÓÈÛÌÔ‡ Û ÂÚ›ÙˆÛË AHF, ˘ÔÏÔÁ›˙ÂÙ·È ÂÚ›Ô˘ ÛÙÔ 20-40% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ™˘Ó¤ÂÈ· ÙÔ˘ ·Ú·¿Óˆ Â›Ó·È ÔÙÈ Ô ·ÚÈıÌfi˜ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· Ó· Â›Ó·È ÏÂÈÙÔ˘ÚÁÈÎfi ÙÔ Û‡ÛÙËÌ· ÙÔ˘ AL, Â›Ó·È ÂÚ›Ô˘ 6á1010 ·ÙÙ·Ú·, ‹ ηٷ ÚÔÛ¤ÁÁÈÛË 300 gr ·ÔÌÔÓˆÌ¤ÓˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ. μ¿ÛÂÈ ÙˆÓ ·ÓˆÙ¤Úˆ, ·Ó·Ù‡¯ıËÎ·Ó ÙËÓ ‰ÂηÂÙ›· 1980 Ù· «™˘ÛÙ‹Ì·Ù· μÈÔ·ÓÙȉڷÛÙ‹ÚˆÓ», Ô˘ Â›Ó·È Û˘Û΢¤˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó ˆ˜ ˘fiÛÙڈ̷ ¤Ó· Û˘ÓıÂÙÈÎfi «·ÁÁÂÈ·Îfi» Û‡ÛÙËÌ· Ô˘ ·ÔÙÂÏÂ›Ù·È ·Ô ÙÚȯÔÂȉ›˜ ۈϋÓ˜, ¿Óˆ ÛÙÔ‡˜ ÔÔ›Ô˘˜ ÂÈοıÔÓÙ·È Ë·ÙÈο ·ÙÙ·Ú·. ∏ ÚÒÙË ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ ·˘ÙÔ‡ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ¤ÁÈÓ ÙÔ 1987 (Matsumura). ∞Ó¿ÏÔÁ· Ì ÙÔÓ ·ÚÈıÌfi Î·È Î˘Ú›ˆ˜ ÙËÓ ÚԤϢÛË ÙˆÓ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ·ÏÏ¿ Î·È Ì ÙÔÓ ÙÚfiÔ Ô˘ ÙÔÔıÂÙÔ‡ÓÙ·È ÛÙË Û˘Û΢‹, ·Ó·Ù‡¯ıËÎ·Ó ‰È¿ÊÔÚ· ÌÔÓ٤Ϸ. ∏ Û˘Û΢‹ Extrahepatic Liver Assist Device (ELAD), Ô˘ ·Ó·Ù‡¯ıËΠ‚·ÛÈṲ̂ÓË ÛÙȘ ÂÚÁ·Û›Â˜ ÙÔ˘ Sussman, 1992 (Huston), ÂÚȤ¯ÂÈ Ë·ÙÔ·ÙÙ·Ú· Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·Ô ·ÓıÚÒÈÓÔ Ë·ÙÔ-
™¯‹Ì· 5. μÈÔ·ÓÙȉڷÛÙ‹Ú·˜ ÙÔ˘ Gerlach
°. IMBPIO™
206
400 ml/min
Reservoir 50 ml/min 100 ml/min
Αντλία
Βιοαντιδραστήρας (με 5 εκ. ηπατοκύτταρα)
Ρύθμιση θερμοκρασίας Διαχωριστής πλάσματος/Άνθρακας Εμμόρφων
Οξυγονωτής
™¯‹Ì· 6. ™¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË ÙˆÓ ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÌÔÓ¿‰ˆÓ ÙÔ˘ μÈÔÙ¯ÓËÙÔ‡ ◊·ÙÔ˜.
‚Ï¿Ûو̷ (Hep G2C3A), Ù· ÔÔ›· ÂÈοıÔÓÙ·È ÛÙÔÓ Â͈ÙÚȯÔÂȉÈÎfi ¯ÒÚÔ ÙÔ˘ Ê›ÏÙÚÔ˘.∫¿ıÂ Û˘Û΢‹, ÂÚȤ¯ÂÈ Ë·ÙÔ·ÙÙ·Ú· Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û 200g Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‹·ÙÔ˜. ΔÔ fiÏÔ Û‡ÛÙËÌ· ÌÔÚ› Ó· ˘ÔÛÙËÚ›ÍÂÈ ÙÔÓ ·ÛıÂÓ‹ ÁÈ· 48 ¤ˆ˜ 72 ÒÚ˜, ¯ˆÚ›˜ ·ÏÏ·Á‹ Ù˘ Û˘Û΢‹˜ ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ. ΔÔ Û‡ÛÙËÌ· ·ÔÙÂÏ› Ì›· ÌÔÓ¿‰· Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜, ̤ۈ Ù˘ ÔÔ›·˜ ÙÔ ·›Ì· ÙÔ˘ ·ÛıÂÓÔ‡˜ ‰È¤Ú¯ÂÙ·È ·Ô ÙÔ Ê›ÏÙÚÔ Ì ٷ Ë·ÙÔ·ÙÙ·Ú·. ∏ ̤ıÔ‰Ô˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ Èı·Ó‹˜ ÂÈÛfi‰Ô˘ ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (Hep G2C3A) ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÔ˘ ·ÛıÂÓÔ‡˜. OÈ ·Ó·ÊÔÚ¤˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘Ù‹ ÙËÓ Ì¤ıÔ‰Ô, ÂÌÊ·Ó›˙Ô˘Ó ÌÈÎÙ¿ ·ÔÙÂϤÛÌ·Ù·, Ì ‚ÂÏÙ›ˆÛË ÛÙË Ó¢ÚÔÏÔÁÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· Û ·ÛıÂÓ›˜ Ì AHF ·ÏÏ¿ ¯ˆÚ›˜ ÂÌÊ·Ó‹ ‚ÂÏÙ›ˆÛË ÛÙËÓ ÂÈ‚›ˆÛË. H Û˘Û΢‹ HepatAssist 2000 Ô˘ ·Ó·Ù‡¯ıËΠ·Ô ÙÔÓ Demetriou, 1993 (Los Angeles), ¯ÚËÛÈÌÔÔÈ› Ë·ÙÈο ·ÙÙ·Ú· ¯Ô›ÚÔ˘ (5á109 ·ÙÙ·Ú·), ¿ӈ Û ÌÈÎÚÔÌÂÙ·ÊÔÚ›˜ ‰ÂÍÙÚ¿Ó˘, Ô˘ Â›Ó·È ÙÔÔıÂÙË̤ӷ ÛÙÔÓ Â͈ÙÚȯÔÂȉÈÎfi ¯ÒÚÔ Ê›ÏÙÚÔ˘ ÔÏ˘ÛÔ˘ÏÊfiÓ˘. ª¤Ûˆ ÙÔ˘ Ê›ÏÙÚÔ˘ ‰È¤Ú¯ÂÙ·È ÙÔ Ï¿ÛÌ· ÙÔ˘ ·ÛıÂÓÔ‡˜. (™¯. 4) Δ· ¯Ô›ÚÂÈ· Ë·ÙÔ·ÙÙ·Ú· ÌÔÚÔ‡Ó Ó· ÎÚ˘ÔÛ˘ÓÙËÚËıÔ‡Ó Î·È Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÔÔÙ‰‹ÔÙÂ, ¯ˆÚ›˜ Ó· ·ÏÏÔÈÒÓÔÓÙ·È ÔÈ È‰ÈfiÙËÙ¤˜ ÙÔ˘˜. ∏ ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ¢ÙÈ΋˜ Û˘Ó‰ڛ·˜ Â›Ó·È ÂÚ›Ô˘ 6 ÒÚ˜. øÛÙfiÛÔ ·Ú·Ì¤ÓÂÈ ÚÔ˜ ·¿ÓÙËÛË Î·Ù· fiÛÔ Â›Ó·È ‰˘Ó·Ù‹ Ë ÌÂÙ¿‰ÔÛË ÙÔ˘ ÂÓ‰ÔÁÂÓÔ‡˜ ÚÂÙÚÔ˚Ô‡ ÙˆÓ ¯Ô›ÚˆÓ (Porcine Endogenous Retrovirus/ PERV) ÛÙÔÓ ·ÛıÂÓ‹ Ô˘ ˘Ô‚¿ÏÏÂÙ·È Û ·˘Ù‹ ÙËÓ Ì¤ıÔ‰Ô. ¢È·ÊÔÚÂÙÈ΋ ÚÔÛÂÁÁÈÛË ÛÙË ‰È¿Ù·ÍË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ¤¯ÂÈ Ë Û˘Û΢‹ ÙÔ˘ Gerlach, 1996
(Berlin), fiÔ˘ Ë Î·ÏÏȤÚÁÂÈ· ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ¤¯ÂÈ ‰È·ÚÚ˘ıÌÈÛÙ› Ì ÙÚfiÔ ÒÛÙ ӷ ¤¯Ô˘Ó ‰ÔÌ‹ Ó¤Ô˘ ÔÚÁ¿ÓÔ˘. O ‚ÈÔ·ÓÙȉڷÛÙ‹Ú·˜ ·˘Ùfi˜ ÂÚȤ¯ÂÈ ÂÚÈÛÛfiÙÂÚÚÔ ÙÔ˘ 40% Ù˘ ΢ÙÙ·ÚÈ΋˜ Ì¿˙·˜ ÙÔ˘ ‹·ÙÔ˜ ·ÓıÚÒÔ˘, Ì ٷ Ë·ÙÔ·ÙÙ·Ú· Ó· ‰È·ÙËÚÔ‡Ó ÙË ÌÂÙ·‚ÔÏÈ΋ ÙÔ˘˜ ‰Ú·ÛÙËÚÈfiÙËÙ· ÁÈ· Ì‹Ó˜. O ‚ÈÔ·ÓÙȉڷÛÙ‹Ú·˜ ‚Ú›ÛÎÂÙ·È Û˘Ó‰Â̤ÓÔ˜ Ì ۇÛÙËÌ· Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜. ΔÔ Ï¿ÛÌ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÂٷʤÚÂÙ·È ÛÙÔ˘˜ ÙÚȯÔÂȉ›˜ ۈϋÓ˜ fiÔ˘ Î·È ÚÔÛ¿ÁÔÓÙ·È Î·È ·¿ÁÔÓÙ·È ÚÔ˚ÔÓÙ· ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Ô˘ ÂÚÈ‚¿ÏÔ˘Ó Ù· ÙÚȯÔÂȉ‹. Δ· ÙÚȯÔÂȉ‹ ÂÈÚfiÛıÂÙ· ·ÔÙÂÏÔ‡Ó ÊÚ·ÁÌfi ÁÈ· ·ÙÙ·Ú· Ô˘ Â›Ó·È ˘Â‡ı˘Ó· ÁÈ· ·ÓÔÛȷ΋ ·¿ÓÙËÛË. Δ· ·ÔÙÂϤÛÌ·Ù· ·Ô ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÌÂıfi‰Ô˘ Â›Ó·È ·ÈÛÈfi‰ÔÍ· Î·È ·Ó·Ê¤ÚÔÓÙ·È ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ ÙÈÌÒÓ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È Ù˘ ·ÌÈÓÔÙÚ·ÓÛÊÂÚ·ÛÒÓ, ·ÏÏ¿ Î·È ·ÍÈÔÛËÌ›ˆÙË ‚ÂÏÙ›ˆÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ Û˘Ìو̷ÙÔÏÔÁ›·˜. ∏ ̤ıÔ‰Ô˜ Â›Ó·È ‹‰Ë Û ¯Ú‹ÛË Ò˜ Á¤Ê˘Ú· ̤¯ÚÈ ÙËÓ Â‡ÚÂÛË ÙÔ˘ ηٷÏÏ‹ÏÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ı· ηٷÛÙ› Èı·ÓfiÓ ÂÚÈÛÛfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÂÊ fiÛÔÓ ÁÈÓÂÈ ÂÊÈÎÙ‹ Ë ·‡ÍËÛË Ù˘ ‚ÈÔÛÈÌfiÙËÙÔ˜ ÙˆÓ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ. ∏ ·Ó·ÛÎfiËÛË Ù˘ μÈ‚ÏÈÔÁÚ·Ê›·˜ Û¯ÂÙÈο Ì ٷ Û˘ÛÙ‹Ì·Ù· Â͈ۈ̷ÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ô‰ËÁ› ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘˜ ÂÏ·ÙÙÒÓÂÈ ÙËÓ ıÓËÙfiÙËÙ· Û ÂÚÈÙÒÛÂȘ ÔÍ›·˜ ÂÈ ¯ÚÔÓ›·˜ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜, ÂÓÒ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘˜ ÂÈ Ù˘ ÎÂÚ·˘ÓÔ‚fiÏÔ˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÚÔ˜ ÙÔ ·ÚfiÓ. øÛÙfiÛÔ, Ô ¯ÚfiÓÔ˜ Ô˘ ‰›‰ÂÙ·È ÁÈ· ÙËÓ ·Ó‡ÚÂÛË Ë·ÙÈÎÔ‡
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÌÔۯ‡̷ÙÔ˜ ·ÏÏ¿ Î·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ Ô˘ ·Ú¤¯ÂÙ·È ÛÙÔÓ ·ÛıÂÓ‹, ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ Û˘Ì‚ÔÏ‹ ÛÙÔÓ ˘Ô„‹ÊÈÔ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÒÛÙ ӷ ·ÓÙÈÂͤÏıÂÈ Ì ÂÈÙ˘¯›· ÙËÓ Ì¤ÛˆÓ ‰ÔÎÈÌ·Û›· Ù˘ Ë·ÙÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘.-
μÈ‚ÏÈÔÁÚ·Ê›· 1. ∞ÓÙˆÓÈ¿‰Ë˜ ∞∞. ™˘ÛÙ‹Ì·Ù· ˘ÔηٿÛÙ·Û˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∂ÏÏËÓÈ΋ π·ÙÚÈ΋ 1999;65:S11-S18. 2. ¶··‰ËÌËÙÚ›Ô˘ π¢. μÈÔÙ¯ÓËÙfi ‹·Ú. ∂ÏÏËÓÈ΋ π·ÙÚÈ΋ 1999;65:S72-S75. 3. Blei AT. Fulminant hepatic failure. In: Bacon BR, Di Bisceglie AM.Editors. Liver diseases, diagnosis and management, Chaur Liningston; 2000 p282. 4. Strange J, Mizzen SR, Klamath S, et al. Liver support by extracorporeal blood purification. A clinical observation. Transplantation 2000; 6:603-613. 5. Mizzen SR, Strange J, Klamath S, Riser t et al. Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized controlled clinical trial. Liver Transplantation 2000;6:277-286. 6. Ichai P, Aguilera V, Samuel D. Bioartificial liver systems. In Arroyo V, Bosch J Bruix J et al, Therapy in Hepatology, Ars Medica, Barcelona 2001; 167-174.
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7. Mizzen SR, Strange J, Klamath S, Schmidt R,NöldgeSchomburg G. Extracorporeal Detoxification using the molecular Absorbent Recirculating system for critically III patients with liver failure. J Am Soc Nephrol 2001; 12:S75-S82. 8. Allen JW, Hassanein T, Bhatia SN. Advances in bioartificial liver.Hepatology 2001;34:447-455. 9. ∫jaergrd LL, Liu J, Als-Nielsen B, Gluud C. Artificial and Bioartificial Support Systems for Acute and Acuteon-Chronic liver failure. American Medical Association, 2003;289.2:217-222. 10. ∞Úη‰fiÔ˘ÏÔ˜ ¡. ¡ÂfiÙÂÚ˜ ̤ıÔ‰ÔÈ ˘ÔÛÙ‹ÚÈ͢ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. πn AA ∫ˆÛÙ¿Î˘ (ed). ªÂÙ·ÌfiÛ¯Â˘ÛË ÈÛÙÒÓ Î·È ÔÚÁ¿ÓˆÓ. ∞ı‹Ó·: ¶·ÚÈ˙È¿ÓÔ˜; 2004 Û 357. 11. Demetriou AA, Brown RS Jr, Busuttil RW et al. Prospective, randomized,multicenter,controlled trial of a bioartificial liver in treating Acute Liver Failure.Annals of Surgery 2004;.235:660-670. 12. Cheung SW, Vacanti JP. Development of Biartificial liver.In Transplantation of the liver. Busuttil RW, Klintmalm GK. EdÈtors. Philadelphia: Elseviers Saunders; 2005 p1425 13. Rozga J, Demetreou AA. Suport of the failing liver.In, Surgery of the liver and biliary tract. Blumgart LH, Fong Y, Editors. New York: WB Saunders company LTD; 2005 p1839.
AÓ·ÈÛıËÛ›· ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜
9
EϤÓË K·Ùۛη
1. ∂π™∞°ø°∏ - ¢π∞Δ∏ƒ∏™∏ Δ∏™ ∞¡∞π™£∏™π∞™ ™∂ ª.∏
¯Âȷ΋ ‰È·ÛˆÏ‹ÓˆÛË Î·È Ë ÎÏÈÓÈ΋ ÂÌÂÈÚ›· ·Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ Ù˘ ‰ÂÓ ÂËÚ¿˙ÂÙ·È Ô˘ÛÈ·ÛÙÈο ·fi ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ¯ÔÏÈÓÂÛÙÂÚ¿Û˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ∞fi Ù· ÌË ·ÔÔψÙÈο Ì˘Ô¯·Ï·ÚˆÙÈο, ÙÔ ·ÙÚ·ÎÔ‡ÚÈÔ Î·È cis-·ÙÚ·ÎÔ‡ÚÈÔ ‰ÂÓ ¤¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ηډȷÁÁÂȷΤ˜ ÂȉڿÛÂȘ fiÙ·Ó ¯ÔÚËÁÔ‡ÓÙ·È Û ηÓÔÓÈΤ˜ ‰fiÛÂȘ Î·È Û ·ÓÙ›ıÂÛË Ì ٷ ¿ÏÏ· Ì˘Ô¯·Ï·ÚˆÙÈο, Ô ¯ÚfiÓÔ˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ ÙÔ˘˜ ‰ÂÓ ·Ú·Ù›ÓÂÙ·È Û ·ÛıÂÓ›˜ Ì ˷ÙÈ΋ ÓfiÛÔ. 1 ªÔÚ› Ó· ·Ú·ÙËÚËı› ·˘ÍË̤ÓË ··›ÙËÛË ÛÙȘ ‰fiÛÂȘ ¯ÔÚ‹ÁËÛ˘ Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ηٷÓÔÌ‹˜ Î·È Ù˘ οı·ÚÛ˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ÛÙË ÁÚ‹ÁÔÚË ·ÏÏ·Á‹ ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ ·›Ì·ÙÔ˜ ÏfiÁˆ Ù˘ ·ÈÌÔÚÚ·Á›·˜. °ÂÓÈο, Ê·›ÓÂÙ·È ÏÔÁÈ΋ ÂÈÏÔÁ‹ Ë ¯ÔÚ‹ÁËÛË ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ ÌË ·ÔÔψÙÈÎÒÓ Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ, ÂȉÈο fiÙ·Ó Û¯Â‰È¿˙ÂÙ·È ÁÚ‹ÁÔÚË ·Ô‰È·ÛˆÏ‹ÓˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∞fi Ù· ÔÈÔÂȉ‹, Ë ÊÂÓÙ·Ó‡ÏË ¤¯ÂÈ Î·ıÈÂÚˆı› ˆ˜ Ê¿ÚÌ·ÎÔ ÂÈÏÔÁ‹˜ ÁÈ· ÙË ª.∏.2 ∏ ÚÂÌÈÊÂÓÙ·Ó‡ÏË, ¤Ó· Ó¤Ô ÔÈÔÂȉ¤˜, Ì ¯ÚfiÓÔ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ 6,3 min, ÚÔÛʤÚÂÈ Î¿ÔÈ· ıˆÚËÙÈο ÏÂÔÓÂÎÙ‹Ì·Ù· ηıÒ˜ Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ Ù˘ ÂÏ¿¯ÈÛÙ· ÂËÚ¿˙ÂÙ·È ·fi ÙËÓ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ·ÏÏ¿ Ë ÂÌÂÈÚ›· ÛÙËÓ Ë·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË.3 To N2O Û˘Ó‹ıˆ˜ ·ÔʇÁÂÙ·È ÁÈ· Ú·ÎÙÈÎÔ‡˜ Î·È ıˆÚËÙÈÎÔ‡˜ ÏfiÁÔ˘˜. ∏ ‰È¿Ù·ÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Ô˘ ÚÔηÏ›, ÂÌÔ‰›˙ÂÈ ÙË Û‡ÁÎÏÂÈÛË ÙˆÓ ÎÔÈÏÈ·ÎÒÓ ÙÔȯˆÌ¿ÙˆÓ, ÂȉÈο fiÙ·Ó ÙÔ ÌfiÛ¯Â˘Ì· Â›Ó·È Û¯ÂÙÈο ÌÂÁ¿ÏÔ. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë Ë·ÙÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹ ÌÔÚ› ÛËÌ·ÓÙÈο Ó· ÂÏ·ÙÙˆı› Ì ¯ÔÚ‹ÁËÛË N2O3 ÏfiÁˆ Ù˘ Û˘Ì·ıËÙÈ΋˜ ·ÁÁÂÈÔÛ‡Û·Û˘ Ô˘ ÚÔηÏ›. ∞Ó Î·È ·˘Ùfi ‰ÂÓ ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÛÙË Ê¿ÛË Ù˘ Ë·ÙÂÎÙÔÌ‹˜, Ê·›ÓÂÙ·È ·ÓÂÈı‡ÌËÙÔ ÌfiÏȘ ÙÔ Ó¤Ô ‹·Ú ·ӷÈÌ·Ùˆı›. O ΛӉ˘ÓÔ˜ ·ÂÚÒ‰Ô˘˜ ÂÌ‚ÔÏ‹˜ Â›Ó·È ·˘ÍË̤ÓÔ˜ ÛÙËÓ Ë·ÙÈ΋ ÌÂÙ·Ìfi-
∏ ¯ÔÚ‹ÁËÛË ·Ó·ÈÛıËÛ›·˜ Û ·ÛıÂÓ‹ Ì ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Î·È ÂȉÈÎfiÙÂÚ· fiÙ·Ó ÚfiÎÂÈÙ·È Ó· ˘Ô‚ÏËı› Û ª∏ ·ÔÙÂÏ› ÚfiÎÏËÛË ÁÈ· ÙÔÓ ·Ó·ÈÛıËÛÈÔÏfiÁÔ ÁÈ·Ù› ¤¯ÂÈ Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ¤Ó·Ó ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ· ·ÛıÂÓ‹ Ô˘ Û˘Á¯ÚfiÓˆ˜ ¯ÚÂÈ¿˙ÂÙ·È Î·È ·Ó·ÈÛıËÛ›·. ∏ ¯ÔÚ‹ÁËÛË ÙˆÓ Ê·ÚÌ¿ÎˆÓ Ú¤ÂÈ Ó· Â›Ó·È Û¯ÔÏ·ÛÙÈο ÂÈÏÂÁ̤ÓË ÙfiÛÔ ˆ˜ ÚÔ˜ ÙËÓ Ê·ÚÌ·ÎÔÏÔÁÈ΋ ‰Ú¿ÛË Î·È ‰ÔÛÔÏÔÁ›· fiÛÔ Î·È ˆ˜ ÚÔ˜ ÙÔ ÛÙ¿‰ÈÔ Ù˘ ÂÁ¯Â›ÚËÛ˘. ø˜ ÚÔÓ¿ÚΈÛË ¯ÔÚËÁÔ‡ÓÙ·È ·fi ÙÔ ÛÙfiÌ· ÌÈ· ‚ÂÓ˙ԉȷ˙›ÓË ‚Ú·¯Â›·˜ ‰Ú¿Û˘ Î·È ¤Ó·˜ ∏2-·Ó·ÛÙÔϤ·˜. ™Â ·ÛıÂÓ›˜ Ì ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ‹ ÌÂÁ¿ÏË ÎÔÈÏȷ΋ ‰È¿Ù·ÛË ‰Â ¯ÔÚËÁÂ›Ù·È ÚÔÓ¿ÚΈÛË Î·ıÒ˜ Ô Î›Ó‰˘ÓÔ˜ ·Ó·Ó¢ÛÙÈ΋˜ ηٷÛÙÔÏ‹˜ Â›Ó·È ÌÂÁ¿ÏÔ˜. ∞·Ú·›ÙËÙË Â›Ó·È Ë Î·Ï‹ ÚÔÔ͢ÁfiÓˆÛË Î·È Ë Ù·¯Â›· ÂÈÛ·ÁˆÁ‹ ÛÙËÓ ·Ó·ÈÛıËÛ›·, ÁÈ·Ù› Ë ÏÂÈÙÔ˘ÚÁÈ΋ ˘ÔÏÂÈfiÌÂÓË ¯ˆÚËÙÈÎfiÙËÙ· (FRC) ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Â›Ó·È ÂÏ·Ùو̤ÓË Î·È Ô Î›Ó‰˘ÓÔ˜ ÂÈÛÚfiÊËÛ˘ ·˘ÍË̤ÓÔ˜ ÏfiÁˆ ÙÔ˘ ·ÛΛÙË, Ô˘ ÂÈ‚Ú·‰‡ÓÂÈ ÙËÓ Î¤ÓˆÛË ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ÂËÚ¿˙ÂÈ ÙË Û‡ÁÎÏÂÈÛË ÙÔ˘ ηÙÒÙÂÚÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ ÛÊÈÁÎÙ‹Ú·. Δ· Ê¿Ú̷η ÂÈÏÔÁ‹˜ ÁÈ· ÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È ÙË ‰È·Ù‹ÚËÛË Ù˘ ·Ó·ÈÛıËÛ›·˜ ηıÔÚ›˙ÔÓÙ·È Î˘Ú›ˆ˜ ·fi ÙËÓ ·Ó¿ÁÎË ÁÈ· ‰È·Ù‹ÚËÛË ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ÛÙ·ıÂÚfiÙËÙ·˜. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤̂·Û˘ ÌÔÚ› ‰Ú·Ì·ÙÈο Ó· ·ÏÏ¿ÍÔ˘Ó, ÙfiÛÔ ÙÔ ÚÔÊÔÚÙ›Ô fiÛÔ Î·È Ë Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÁÈã·˘Ùfi Ú¤ÂÈ Ó· ÂÏ·¯ÈÛÙÔÔÈËı› Ë Ì˘Ôηډȷ΋ ηٷÛÙÔÏ‹ ·fi ÙÔ˘˜ ·Ó·ÈÛıËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∏ ÂÙÔÌȉ¿ÙË ıˆÚÂ›Ù·È ÙÔ Ê¿ÚÌ·ÎÔ ÂÈÏÔÁ‹˜ ÁÈ· ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ ·Ó·ÈÛıËÛ›· ÏfiÁˆ Ù˘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ÛÙ·ıÂÚfiÙËÙ·˜ Ô˘ ÚÔÛʤÚÂÈ. ∞fi Ù· Ì˘Ô¯·Ï·ÚˆÙÈο, Ë ÛÔ˘ÎÈÓÈÏÔ¯ÔÏ›ÓË ÛÙȘ Û˘Ó‹ıÂȘ ‰fiÛÂȘ ÂÈÙÚ¤ÂÈ Ù·¯Â›· ÂÓ‰ÔÙÚ·-
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Û¯Â˘ÛË4 Î·È ·ÔÙÂÏ› ¤Ó·Ó ÂÈϤÔÓ ÏfiÁÔ ÁÈ· Ó· ·ÔʇÁÔ˘Ì ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ N2O. ∞fi Ù· ÙËÙÈο ·Ó·ÈÛıËÙÈο ÙÔ ÈÛÔÊÏÔ˘Ú¿ÓÈÔ ¤¯ÂÈ Î·ıÈÂÚˆı› ÛÙË ª.∏. ¡ÂÒÙÂÚÔÈ ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÙÔ ‰ÂÛÊÏÔ˘Ú¿ÓÈÔ Î·È Û‚ÔÊÏÔ˘Ú¿ÓÈÔ ÌÔÚÔ‡Ó Â›Û˘ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó, ÂÍ·ÛÊ·Ï›˙ÔÓÙ·˜ ÈηÓÔÔÈËÙÈÎfi ‚¿ıÔ˜ ·Ó·ÈÛıËÛ›·˜ Î·È ¿ÌÂÛË ·Ó¿ÓË„Ë ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜.5,6,7,8,9 ŸÏÔÈ ÔÈ ·ÏÔÁÔÓÔ̤ÓÔÈ ·Ú¿ÁÔÓÙ˜ ÚÔηÏÔ‡Ó ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË ÂÏ¿ÙÙˆÛË Ù˘ ̤Û˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (ª.∞.ƒ.) Î·È ÌÂÙ·‚ÔϤ˜ ÛÙÔÓ Î·Ú‰È·Îfi Ú˘ıÌfi Î·È ÙȘ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ˘ÔÙ·ÛÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, Â›Ó·È ÛÎfiÈÌË Ë ÂÏ¿ÙÙˆÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ ÙËÙÈÎÔ‡ ·Ó·ÈÛıËÙÈÎÔ‡ Î·È Ë Û˘ÌÏ‹ÚˆÛË Ù˘ ·Ó·ÈÛıËÛ›·˜ Ì ÔÈÔÂȉ‹. ∏ ›‰Ú·ÛË ÙˆÓ ÙËÙÈÎÒÓ ·Ó·ÈÛıËÙÈÎÒÓ ÛÙËÓ Ë·ÙÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹ Â›Ó·È ¯ˆÚ›˜ ÎÏÈÓÈ΋ ÛËÌ·Û›·, ÂÊfiÛÔÓ ‰È·ÙËÚÂ›Ù·È ÛÙ·ıÂÚ‹ Ë ·ÚÔ¯‹ O2 ÛÙÔ ‹·Ú (hepatic oxygen delivery).10
2. MONITORING ΔÔ monitoring ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ: • ∏∫° • ∫·ÓÔÁÚ¿ÊÔ (∂ΔCO2) • ¶·ÏÌÈÎfi Ô͢ÁÔÓfiÌÂÙÚÔ (SPO2) • ÕÌÂÛË Ì¤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (∞.¶.) Ì ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· 20G ÛÙËÓ ÎÂÚÎȉÈ΋ ·ÚÙËÚ›· • ΔÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· Swan-Ganz • SVO2/± CCO (continuous cardiac output) • ª¤ÙÚËÛË ıÂÚÌÔÎÚ·Û›·˜ ÛÒÌ·ÙÔ˜ • ŒÏÂÁ¯Ô˜ ·ÚÙËÚÈ·ÎÒÓ ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜ - ËÏÂÎÙÚÔÏ˘ÙÒÓ • (±) ¢ÈÔÈÛÔÊ¿ÁÈÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· • (±) ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÂÏԉȷÛÙÔÏÈÎÔ‡ fiÁÎÔ˘ Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ - ∫Ï¿ÛÌ· ÂÍÒıËÛ˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ • (±) ª¤ÙÚËÛË ÙÔ˘ pH ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ • Monitoring ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ (PT, PTT, £ÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ·Ê›·)
¢π∂°Ã∂πƒ∏Δπ∫∏ À¶O™Δ∏ƒπ•∏ 1. ¢π∂°Ã∂πƒ∏Δπ∫∞ ¶ƒOμ§∏ª∞Δ∞ ∞¡∞¶¡∂À™Δπ∫∏™ §∂πΔOÀƒ°π∞™ ∞Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤̂·Û˘ ‰ÂÓ Â›Ó·È Û˘¯Ó¿. ∞ÈÊÓ›‰È· ÂÏ¿ÙÙˆ-
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ÛË ÙÔ˘ ÎÔÚÂÛÌÔ‡ Ù˘ Hb Û O2 (SpO2) ÂÌÊ·Ó›˙ÂÙ·È ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ ·Ó·ÈÛıËÛ›·, ·ÎfiÌË Î·È ÌÂÙ¿ ·fi ηϋ ÚÔÔ͢ÁfiÓˆÛË, ηıÒ˜ Ë ÏÂÈÙÔ˘ÚÁÈ΋ ˘ÔÏÂÈfiÌÂÓË ¯ˆÚËÙÈÎfiÙËÙ· (FRC) ÂÏ·ÙÙÒÓÂÙ·È ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ Î·È ·˘Í¿ÓÂÈ Ë Î·Ù·Ó¿ÏˆÛË ÙÔ˘ O2.11 ΔÔ ‰ÈÂÁ¯ÂÚËÙÈÎfi Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· ıˆÚÂ›Ù·È Ë ÈÔ ÛÔ‚·Ú‹ ÂÈÏÔ΋ Ô˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·Ûı› ηٿ ÙË ‰È¿ÚÎÂÈ· Î·È ÌÂÙ¿ ÙË ª.H.12 ¢ÈÂÁ¯ÂÈÚËÙÈ΋ Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹. ¢ÈÂÁ¯ÂÈÚËÙÈο, ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·Ûı› Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹ ·fi ·¤Ú· ‹ ·fi ıÚfiÌ‚Ô. ∏ Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹ ·fi ·¤Ú· ‹ ıÚfiÌ‚Ô ¤¯ÂÈ ÂÚÈÁÚ·Ê› ˆ˜ ÂÈÏÔ΋ Ù˘ ¯Ú‹Û˘ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘.13,14,15,16 O ΛӉ˘ÓÔ˜ Ó¢ÌÔÓÈ΋˜ ıÚÔÌ‚ÔÂÌ‚ÔÏ‹˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÌÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË. ∞ÈÙ›· Â›Ó·È Ë ÂÍÂÛËÌ·Ṳ̂ÓË ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ ηٿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÂÓÒ Â›Ó·È Èı·Ófi Ë ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Ó· Â›Ó·È ‰˘Û·Ó¿ÏÔÁË Ù˘ ÈÓˆ‰ÔÏ˘ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜. ¢ÈÂÁ¯ÂÈÚËÙÈο ÌÔÚ› Ó· ÂÌÊ·ÓÈÛıÔ‡Ó ·ÙÂÏÂÎÙ·Û›· ‹ Ó¢ÌÔıÒڷη˜ ÂÈÏÔΤ˜ Û¿ÓȘ Î·È Â‡ÎÔÏ· ·ÓÙÈÌÂÙˆ›ÛÈ̘.
2. ¢π∂°Ã∂πƒ∏Δπ∫∞ ¶ƒOμ§∏ª∞Δ∞ ∫∞ƒ¢π∞°°∂π∞∫OÀ ™À™Δ∏ª∞ΔO™ OÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È Î·Ù¿ ÙË ª.∏. ÂËÚ¿˙ÔÓÙ·È, ÂÎÙfi˜ ÙˆÓ ¿ÏψÓ, ·fi ÙÔ ÛÙ¿‰ÈÔ Ù˘ ¤̂·Û˘ Î·È ·fi ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ Ô˘ ı· ÂÊ·ÚÌÔÛı› ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ Ë·ÙÂÎÙÔÌ‹˜.
2·. ™Δ∞¢π∞ Δ∏™ ∂¶∂ªμ∞™∏™ ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È ÌÈ· Ì·ÎÚ¿ ¤̂·ÛË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi 3 Ê¿ÛÂȘ: º¿ÛË π: ¶ÚÔ·ÓË·ÙÈ΋: ∂›Ó·È Ë ÂÚ›Ô‰Ô˜ ‰È·¯ˆÚÈÛÌÔ‡ ÙÔ˘ ‹·ÙÔ˜ ·fi ÙÔ Ì›Û¯Ô ÙÔ˘ Î·È ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚·. ∏ ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ÓÔÛÔ‡ÓÙÔ˜ ‹·ÙÔ˜ Â›Ó·È ›Ûˆ˜ ÙÔ ‰˘ÛÎÔÏfiÙÂÚÔ Ì¤ÚÔ˜ Ù˘ ¤̂·Û˘ Î·È ‰˘ÓËÙÈο Ë ÈÔ ÂÈΛӉ˘ÓË ÂÚ›Ô‰Ô˜ ÁÈ· ÛÔ‚·Ú‹ ·ÈÌÔÚÚ·Á›·. º¿ÛË ππ: ∞ÓË·ÙÈ΋: ∞Ú¯›˙ÂÈ ·fi ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ˘Ï·›·˜ Î·È Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ (∫∫º). ªÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ·ıÔÏÔÁÈÎÔ‡ ‹·ÙÔ˜, ÙÔÔıÂÙÂ›Ù·È ÛÙË ı¤ÛË ÙÔ˘ ÙÔ Ó¤Ô ÌfiÛ¯Â˘Ì· Î·È Á›ÓÔÓÙ·È ÔÈ ·ÁÁÂȷΤ˜ ·Ó·ÛÙÔÌÒÛÂȘ. º¿ÛË πππ: ¡ÂÔË·ÙÈ΋: ∞Ú¯›˙ÂÈ Ì ÙËÓ Â·-
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E. KAT™IKA
Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ú¯Èο Ì ·Ó·ÛÙfïÛË Ù˘ ˘Ï·›·˜ Î·È Î·ÙfiÈÓ Á›ÓÔÓÙ·È ÔÈ ·Ó·ÛÙÔÌÒÛÂȘ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ Î·È ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘.
2‚. Ã∂πƒOÀƒ°π∫∂™ Δ∂áπ∫∂™ 1) ¶Ï‹Ú˘ ·ÔÎÏÂÈÛÌfi˜ Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ (∫∫º) 2) ÃÚ‹ÛË ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘ 3) Piggyback ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋
i) ºÏ‚Ô-ÊÏ‚È΋ ·Ú¿Î·Ì„Ë ∏ ÛÔ‚·Ú‹ ˘fiÙ·ÛË Î·Ù¿ ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ∫∫º ÛÙËÓ ª.∏. ÛÙ· ÂÈÚ·Ì·Ùfi˙ˆ·, ¤Î·Ó ··Ú·›ÙËÙË ÙËÓ ·Ó¿Ù˘ÍË Ù¯ÓÈÎÒÓ ·Ú¿Î·Ì„˘ ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ÊÏ‚È΋˜ ÂÈÛÙÚÔÊ‹˜ ÛÙËÓ ·ÓË·ÙÈ΋ ÂÚ›Ô‰Ô. ∫·Ù¿ ÙË ÊÏ‚Ô-ÊÏ‚È΋ ·Ú¿Î·Ì„Ë, ÙÔ ·›Ì· ÌÂٷʤÚÂÙ·È Ì¤Ûˆ ÛˆÏ‹ÓˆÓ ·fi ÙËÓ ˘Ï·›· Î·È ÙË ‰ÂÍÈ¿ ÌËÚÈ·›· ÊϤ‚·, ÛÙËÓ ·ÚÈÛÙÂÚ‹ Ì·Û¯·ÏÈ·›· ÊϤ‚· Ì ÙËÓ ·ÚÂÌ‚ÔÏ‹ ÌÈ·˜ Ê˘ÁfiÎÂÓÙÚ˘ ·ÓÙÏ›·˜. ∏ ¯Ú‹ÛË Ë·ÚÈÓÈÛÌ¤ÓˆÓ ÛˆÏ‹ÓˆÓ, ÂÈÙÚ¤Ô˘Ó ÙËÓ ·ÛÊ·Ï‹ ÂÊ·ÚÌÔÁ‹ Ù˘ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘, ¯ˆÚ›˜ Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË Ë·Ú›Ó˘.17,18,19 OÈ ÚÔ¤˜, ÛÙÔ Î‡Îψ̷ Ù˘ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘ ÌÔÚÔ‡Ó Ó· Êı¿ÛÔ˘Ó 1,5-4 lit/min, ÁÈ· ·ÓË·ÙÈ΋ ÂÚ›Ô‰Ô, ·fi 40 ¤ˆ˜ 60 min.
ii) Piggyback Ù¯ÓÈ΋ ∫·Ù¿ ÙËÓ Piggyback Ù¯ÓÈ΋ ·ÔÎÏ›ÂÙ·È Ë ˘Ï·›· ÊϤ‚· ·ÏÏ¿ ‰È·ÙËÚÂ›Ù·È Ë ‚·ÙfiÙËÙ· Ù˘ ∫.∫.º. Ô˘ ·ÔÎÏ›ÂÙ·È Î·Ù’ ÂÊ·ÙÔ̤ÓË. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ô˘ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ë ·Ó·ÛÙfïÛË Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙÔ ÂÓÔÔÈË̤ÓÔ ÛÙfiÌÈÔ ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ ÙÔ˘ Ï‹ÙË, Ë ÊÏ‚È΋ ÂÈÛÙÚÔÊ‹ ‰È·ÙËÚÂ›Ù·È Ì¤Ûˆ Ù˘ ÌÂÚÈÎÒ˜ ·ÔÎÏÂÈṲ̂Ó˘ ∫.∫.º.
2Á. ∞πªO¢À¡∞ªπ∫∂™ ª∂Δ∞μO§∂™ OÈ ·ÛıÂÓ›˜ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·, ¤¯Ô˘Ó ˘ÂÚ‰˘Ó·ÌÈ΋ ΢ÎÏÔÊÔÚ›· Ì ‹È· ˘fiÙ·ÛË, ·Ú¿ ÙË ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ (C.O.) ÏfiÁˆ ÙˆÓ ¯·ÌËÏÒÓ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ (SVR) Î·È Ù˘ ‹È·˜ Ù·¯˘Î·Ú‰›·˜. ∏ ·ÈÙ›· ÙˆÓ ¯·ÌËÏÒÓ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ (SVR) Â›Ó·È ¿ÁÓˆÛÙË, ·ÏÏ¿ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Ê·›ÓÂÙ·È Ó· ·›˙ÂÈ Ô ÌË Ê˘ÛÈÔÏÔÁÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜ ÙˆÓ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ ‹/Î·È Ù˘ ÂÓ‰ÔıËÏ›Ó˘. ¢ÈÂÁ¯ÂÈÚËÙÈο,
Ë ˘fiÙ·ÛË ÌÔÚ› Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÂÈϤÔÓ ÂÏ¿ÙÙˆÛ˘ ÙˆÓ SVR ‹ ÂÏ¿ÙÙˆÛ˘ Ù˘ C.O. ÏfiÁˆ Ì›ˆÛ˘ ÙÔ˘ ÚÔÊÔÚÙ›Ô˘ (ÂÏ¿ÙÙˆÛË ÊÏ‚È΋˜ ÂÈÛÙÚÔÊ‹˜ ‹ ˘ÔÔÁηÈÌ›·) ‹ ‰È·Ù·Ú·Á̤Ó˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∏ ˘ÔÔÁηÈÌ›· Î·È Û˘ÓÂÒ˜ Ë ˘fiÙ·ÛË ÏfiÁˆ ·ÈÌÔÚÚ·Á›·˜, Â›Ó·È Ô ÌÂÁ·Ï‡ÙÂÚÔ˜ ΛӉ˘ÓÔ˜ Î·È ı· Ú¤ÂÈ Ó· ‰Ôı› ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ÛÙËÓ ÈηÓfiÙËÙ· ÁÈ· ÁÚ‹ÁÔÚË ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ ·ˆÏÂÈÒÓ ·›Ì·ÙÔ˜. ∏ ηډȷ΋ ÏÂÈÙÔ˘ÚÁ›· ÌÔÚ› Ó· ÂËÚ·ÛÙ› ηٿ ÙÔ ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÂÎÙÔÌ‹˜, ÏfiÁˆ ·ÈÊÓ›‰ÈÔ˘ ·ÔÎÏÂÈÛÌÔ‡ Ù˘ ÊÏ‚È΋˜ ÂÈÛÙÚÔÊ‹˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ ÛÙÔ ‹·Ú, ‹ ¿ÌÂÛ˘ ›ÂÛ˘ Ù˘ ‰È·ÊÚ·ÁÌ·ÙÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ Ù˘ ηډȿ˜. OÚÈṲ̂ӷ ·Ó·ÈÛıËÛÈÔÏÔÁÈο Ê¿Ú̷η Î·È Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ÈÔÓÈṲ̂ÓÔ˘ Ca++ ÂÓÈÛ¯‡Ô˘Ó ·˘Ù¿ Ù· ÚÔ‚Ï‹Ì·Ù·. ∏ ÂÚÌËÓ›· ÙˆÓ È¤ÛÂˆÓ Ï‹ÚˆÛ˘ ÌÔÚ› Ó· Â›Ó·È ‰‡ÛÎÔÏË Î·Ù¿ ÙÔ ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÂÎÙÔÌ‹˜ ηıÒ˜ Ô ·ÔÎÏÂÈÛÌfi˜ Ù˘ ∫.∫.º. ÔÈΛÏÏÂÈ Î·È ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ ÛÔ‚·Ú‹ ˘ÔÔÁηÈÌ›·. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· Û·Ê‹˜ Ë ·ÈÙ›· Ù˘ ÂÏ·Ùو̤Ó˘ ÊÏ‚È΋˜ ÂÈÛÙÚÔÊ‹˜, Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ‰›Ô˘ Î·È Ë Û˘ÓÂÓÓfiËÛË Ì ÙÔ ¯ÂÈÚÔ˘ÚÁfi, Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜. ∂› ·Ô˘Û›·˜ Ù˘ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘, Ô ·ÔÎÏÂÈÛÌfi˜ Ù˘ ∫.∫.º. ÛÙÔ ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÂÎÙÔÌ‹˜, ÚÔηÏ› ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË Ù˘ ÊÏ‚È΋˜ ÂÈÛÙÚÔÊ‹˜ Î·È Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜. ∞Ó Î·È ÔÈ SVR ·˘Í¿ÓÔÓÙ·È, ·Ó·Ì¤ÓÂÙ·È ÂÏ¿ÙÙˆÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ™ËÌ·ÓÙÈ΋ ˘fiÙ·ÛË (< 80mmHg) Â›Ó·È ·Û˘Ó‹ıÈÛÙË. ŸÙ·Ó ‰Â ۯ‰ȿ˙ÂÙ·È Ë ¯Ú‹ÛË Ù˘ ÊÏ‚ÔÊÏ‚È΋˜ ·Ú¿Î·Ì„˘, ÂȯÂÈÚÂ›Ù·È ‰ÔÎÈÌ·ÛÙÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜ Ù˘ ∫.∫.º. ÁÈ· Ó· ÂÎÙÈÌ‹ÛÔ˘Ì ÙËÓ ÈηÓfiÙËÙ· ÙÔ˘ ·ÛıÂÓÔ‡˜ Ó· ‰È·ÙËÚ‹ÛÂÈ Â·Ú΋ Û˘ÛÙËÌ·ÙÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË. ªfiÏȘ ·Ê·ÈÚÂı› ÙÔ ‹·Ú, Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ¯·ÌËÏfiÙÂÚ˜ ȤÛÂȘ Ï‹ÚˆÛ˘, ÂÊfiÛÔÓ Ë ∞.¶. Â›Ó·È ÈηÓÔÔÈËÙÈ΋. ∏ ˘ÂÚÌÂÙ¿ÁÁÈÛË Ûã·˘Ùfi ÙÔ ÛÙ¿‰ÈÔ, ΢ڛˆ˜ fiÙ·Ó ‰Â ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÊÏ‚ÔÊÏ‚È΋ ·Ú¿Î·Ì„Ë, Î·È ÔÈ ˘„ËÏfiÙÂÚ˜ ȤÛÂȘ Ï‹ÚˆÛ˘ Ô˘ Â›Ó·È ··Ú·›ÙËÙ˜ ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ÂÈΛӉ˘Ó· ˘„ËϤ˜ ȤÛÂȘ Ï‹ÚˆÛ˘ ηٿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË. ΔÔ ÁÂÁÔÓfi˜ ·˘Ùfi ÌÔÚ› Ó· ¤¯ÂÈ ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜, ÙËÓ ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ·ÂÚ›ˆÓ Î·È ÙËÓ Ë·ÙÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë ÊÏ‚Ô-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÊÏ‚È΋ ·Ú¿Î·Ì„Ë, Ë ÙÒÛË Ù˘ C.O. ÌÂÈÒÓÂÙ·È ·fi 40%-50% ÛÙÔ 20%-30%. ∏ ·ÚÙËÚȷ΋ ›ÂÛË ÂÍ·ÚÙ¿Ù·È ·fi ÙȘ ÚÔ¤˜ Ô˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È ÛÙÔ Î‡Îψ̷ Ù˘ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘. ¶·ÚfiÏ· ·˘Ù¿, ÚÔԉ¢ÙÈ΋ ÙÒÛË Ù˘ C.O. ÂÌÊ·Ó›˙ÂÙ·È Î·Ù¿ ÙËÓ ·ÓË·ÙÈ΋ Ê¿ÛË Î·È ·˘Ùfi ·ÓÙ·Ó·ÎÏ¿ ÌÈ· Âȉ›ӈÛË Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ÔͤˆÛ˘, ηıÒ˜ Î·È ·‡ÍËÛË Ù˘ ÎÔÏÏÔÂȉÔÛ̈ÙÈ΋˜ ›ÂÛ˘, ηıÒ˜ Ë ÊÏ‚È΋ ÛÙ¿ÛË Ô‰ËÁ› Û ÂÍ·ÁÁ›ˆÛË ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Î·È ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ. ¶ÚÔ˜ ÙÔ Ù¤ÏÔ˜ Ù˘ ·ÓË·ÙÈ΋˜ Ê¿Û˘, ÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· ÍÂϤÓÂÙ·È, ̤ۈ Ù˘ ˘Ï·›·˜ ÊϤ‚·˜, Ì 500-1000 ml Ringer’s Lactate ‹ ‰È¿Ï˘Ì· ÏÂ˘ÎˆÌ·Ù›Ó˘ 5%, ÁÈ· ·ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ ˘ÁÚÔ‡ Û˘ÓÙ‹ÚËÛ˘, ÙÔ˘ ∫+, Î·È ÙˆÓ ÈÛ¯·ÈÌÈÎÒÓ ÌÂÙ·‚ÔÏÈÎÒÓ ÚÔ˚fiÓÙˆÓ ÙÔ˘. ∞ÎÔÏÔ˘ı› ‰Â‡ÙÂÚÔ Í¤Ï˘Ì· Ì ·›Ì· ·fi ÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·, ¿ÏÈ Ì¤Ûˆ Ù˘ ˘Ï·›·˜ ÊϤ‚·˜, ÂÈÙÚ¤ÔÓÙ·˜ ·ÚÎÂÙ¤˜ ÂηÙÔÓÙ¿‰Â˜ mls ˘Ï·›Ô˘ ·›Ì·ÙÔ˜ Ó· ‰ÈËı‹ÛÔ˘Ó ÙÔ ‹·Ú Î·È ·ÚÔ¯ÂÙ‡ÔÓÙ¿˜ ÙÔ ·fi ÙËÓ ˘ÊË·ÙÈ΋ ∫.∫.º. ÙÔ˘ ÌÔۯ‡ÌÙÔ˜. ΔÔ ÁÂÁÔÓfi˜ ·˘Ùfi ÚÔηÏ› ÂÏ¿ÙÙˆÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ηıÒ˜ ÌÂÁ¿ÏÔ˜ fiÁÎÔ˜ ÛÏ·Á¯ÓÈÎÔ‡ ·›Ì·ÙÔ˜ ÁÂÌ›˙ÂÈ Ù· Ë·ÙÈο ·ÁÁ›· Î·È ÌÂÚÈ΋ ÔÛfiÙËÙ·, ¯¿ÓÂÙ·È ÛÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ÙÚ·‡Ì·. ¶ÚÈÓ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË, Ô ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ Ú¤ÂÈ Ó· Â›Ó·È Û ÂÙÔÈÌfiÙËÙ· ÁÈ· ¿ÌÂÛË Î·È Ù·¯Â›· ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∞˘Ùfi Â›Ó·È ÛÎfiÈÌÔ, ηıÒ˜ ηٿ ÙÔ ÛÙ¿‰ÈÔ Ù˘ ·ӷÈÌ¿ÙˆÛ˘ ÌÔÚ› Ó· ¤¯Ô˘Ì ÌÂÁ¿ÏË ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Ô˘ Ì·˙› Ì ÙÔ˘˜ ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÚÔηÏ› ¤ÓÙÔÓË ˘fiÙ·ÛË.20,21,22 ∏ ·ӷÈÌ¿ÙˆÛË ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ‹·ÙÔ˜, Û˘Óԉ‡ÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÌÂÙ·‚ÔϤ˜ ÙˆÓ Î·Ú‰È·ÎÒÓ Ûʇ͈Ó, Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÙÔ˘ ÂÚÈÊÂÚÈÎÔ‡ ·ÁÁÂÈ·ÎÔ‡ ÙfiÓÔ˘ ›Ù ÂÊ·ÚÌfi˙ÂÙ·È Ë ÊÏ‚Ô-ÊÏ‚È΋ ·Ú¿Î·Ì„Ë Â›Ù fi¯È.22 ∏ ·Ê·›ÚÂÛË ÙˆÓ Ï·‚›‰ˆÓ ·fi ÙËÓ ˘Ï·›· Î·È ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚· ÂÈÙÚ¤ÂÈ ÙË ÚÔ‹ Ô͈ÙÈÎÔ‡ ÌË Ô͢ÁÔӈ̤ÓÔ˘ ·›Ì·ÙÔ˜ ·fi ÙËÓ ·ÔÊÚ·¯ı›۷ ˘Ï·›· ΢ÎÏÔÊÔÚ›· Î·È ÙÔ ÏÔ‡ÛÈÔ Û ∫+ ÂÚȯfiÌÂÓÔ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ó· ‰ÈËı‹ÛÔ˘Ó ÙËÓ Î·Ú‰È¿. ™˘Ó‹ıˆ˜ ·Ú·ÙËÚÂ›Ù·È ‚Ú·‰˘Î·Ú‰›· ÏfiÁˆ Ù˘ ÔÍ›·˜ ˘ÂÚηÏÈ·ÈÌ›·˜. OÈ ÌÂÙ·‚ÔϤ˜ ·˘Ù¤˜ Â›Ó·È Û˘Ó‹ıˆ˜ ‹È˜ Î·È Û‡ÓÙÔ̘, ·ÏÏ¿ ÌÂÚÈΤ˜ ÊÔÚ¤˜ ·Ú·ÙËÚÔ‡ÓÙ·È ·Û˘ÙÔÏ›·, Ù·¯˘·ÚÚ˘ı̛˜ ·ÎfiÌË Î·È ÎÔÈÏȷ΋ Ì·ÚÌ·Ú˘Á‹. ∏ ·ÚÙËÚȷ΋ ›ÂÛË ÂÏ·ÙÙÒÓÂÙ·È Û¯Â‰fiÓ Û’ fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Î·È ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ÙÒÛ˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ
211
ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë ÊÏ‚Ô-ÊÏ‚È΋ ·Ú¿Î·Ì„Ë, Èı·ÓÒ˜ ÂÂȉ‹ Ë ·ÓÙÈÛÙ·ıÌÈÛÙÈ΋ ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔÛ‡Û·ÛË Î·Ù¿ ÙËÓ ·ÓË·ÙÈ΋ Ê¿ÛË Â›Ó·È ÏÈÁfiÙÂÚÔ ¤ÓÙÔÓË ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜. ∏ ˘fiÙ·ÛË ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÁÁÂÈԉȷÛÙÔÏ‹ ÙˆÓ ·ÚÙËÚÈÒÓ Ì ‹ ¯ˆÚ›˜ Ì˘Ôηډȷ΋ ηٷÛÙÔÏ‹. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ’ ·˘Ù¤˜ ÙȘ ÌÂÙ·‚ÔϤ˜ ›ӷÈ: ÊÏÂÁÌÔÓÒ‰ÂȘ ÌÂÛÔÏ·‚ËÙ¤˜ ·fi ÙÔ ÈÛ¯·ÈÌÈÎfi ‹·Ú, ÂÙ›‰È·, ·Ú¿ÁÔÓÙ˜ Ô˘ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È Î·Ù¿ ÙË ÛÏ·Á¯ÓÈ΋ ÛÙ¿ÛË Î·ıÒ˜ Î·È ·ÓÙȉڷÛÙÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹ ÏfiÁˆ ˘ÂÚηÏÈ·ÈÌ›·˜ ‹ ·ÈÊÓ›‰È·˜ ·‡ÍËÛ˘ Ù˘ ηډȷ΋˜ Ï‹ÚˆÛ˘. ÃÔÚ‹ÁËÛË CaCl2 Î·È ·ÚÔÙÈÓ›Ó˘ Ï›ÁÔ ÚÈÓ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË Ê·›ÓÂÙ·È Ó· ÌÂÙÚÈ¿˙ÂÈ ·˘Ù¿ Ù· Ê·ÈÓfiÌÂÓ· Î·È ·ÔÙÂÏ› Û˘¯Ó‹ Ú·ÎÙÈ΋ Ë ¯ÔÚ‹ÁËÛË ÌÈÎÚÒÓ ÂÊ’ ¿·Í ‰fiÛÂˆÓ ÈÓfiÙÚÔˆÓ Ê·ÚÌ¿ÎˆÓ (.¯. ÂÈÓÂÊÚ›ÓË 5-15Á bolus) fiÙ·Ó Ë ˘fiÙ·ÛË Â›Ó·È ¤ÓÙÔÓË. ™ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ Ë ∞.¶. Î·È Ë C.O. ·Ôηı›ÛÙ·ÓÙ·È Ì¤Û· Û ϛÁ· ÏÂÙ¿, ÛÙȘ ÚÔ Ù˘ ·ӷÈÌ¿ÙˆÛ˘ ÙÈ̤˜. ™Â ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ, Û˘Ó‹ıˆ˜ Û’ ·˘ÙÔ‡˜ Ì ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ·, Ë ·Ó¿ÓË„Ë ‰È·ÚΛ ÂÚÈÛÛfiÙÂÚÔ Î·È ¯ÚÂÈ¿˙ÂÙ·È ·Ú·ÙÂٷ̤ÓË ˘ÔÛÙ‹ÚÈÍË Ì ÈÓfiÙÚÔ· Ê¿Ú̷η. ∏ ηٿÛÙ·ÛË ·˘Ù‹ ·Ó·Ê¤ÚÂÙ·È ˆ˜ “Û‡Ó‰ÚÔÌÔ ÌÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË” (post-reperfusion syndrome). ∂›Ó·È Èı·ÓfiÓ Ó· ·Ú·ÙËÚËı› ·ÚÔ‰È΋ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ÌÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ·‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ ·›Ì·ÙÔ˜ ÌÂÙ¿ ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÛÙËÓ ∫.∫.º. ∞Ó Ë ›ÂÛË ÛÙËÓ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›· ˘Âڂ› Ù· 50mmHg Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÌÊ·ÓÈÛı› ·Ó¿ÚÎÂÈ· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ Ì ԛ‰ËÌ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Û˘ÛÙËÌ·ÙÈ΋ ˘Ô¿Ú‰Â˘ÛË. ∏ ηٿÛÙ·ÛË ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ¯ÔÚ‹ÁËÛË prostaglandin ∂1 ‹ ÓÈÙÚÔÁÏ˘ÎÂÚ›Ó˘, ÚÔÛı¤ÙÔÓÙ·˜ dobutamine ‹ ÓÔÚ·‰ÚÂÓ·Ï›ÓË ·Ó ÂÌÊ·ÓÈÛı› ·ÚÙËÚȷ΋ ˘fiÙ·ÛË. ΔÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ù˘ ª.∏. ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚfiÙËÙ· ÙÔ˘ ·ÛıÂÓÔ‡˜, ÂÏ¿¯ÈÛÙË ‹ ÌˉÂÓÈ΋ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Î·È ¿ÌÂÛË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.
3. ∞¡Δπª∂Δø¶π™∏ ¢π∞Δ∞ƒ∞Ãø¡ ∞πªO™Δ∞™∏™ - ÃOƒ∏°∏™∏ ∞πª∞ΔO™ ™ËÌ·ÓÙÈ΋ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·ÈÌÔÚÚ·Á›· Â›Ó·È Û˘¯Ó‹ ÛÙȘ ª.∏. ∏ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ, ÙËÓ Î·Ù¿ÛÙ·ÛË Ù˘ ˘Ï·›·˜
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E. KAT™IKA
΢ÎÏÔÊÔÚ›·˜, ÙËÓ ·ÚÔ˘Û›· Û˘ÌʇÛÂˆÓ Î·È ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋. O ̤ÛÔ˜ fiÚÔ˜ ¯ÔÚËÁÔ‡ÌÂÓÔ˘ ·›Ì·ÙÔ˜, Û ÂÓ‹ÏÈΘ, Â›Ó·È 8-12 ÌÔÓ¿‰Â˜. OÈ Â·ÓÂÈÏÏË̤Ó˜ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ Hct ηıÔÚ›˙Ô˘Ó ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ ·›Ì·ÙÔ˜ Ô˘ ¯ÔÚËÁÂ›Ù·È Î·È ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ÚÔ˚fiÓÙˆÓ ÁÈ· ·ÓÙÈηٿÛÙ·ÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ΔÈÌ‹ Hctª30%, ÂÈÙÚ¤ÂÈ ÙË ‚¤ÏÙÈÛÙË ÌÂÙ·ÊÔÚ¿ O2 ÛÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ÂÏ·ÙÙÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ıÚfiÌ‚ˆÛ˘ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜. ∏ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÈÌÔÂÙ·Ï›ˆÓ ηıÔÚ›˙ÂÙ·È ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È ÙËÓ ÎÏÈÓÈ΋ ·Ú·Ù‹ÚËÛË. ∏ Èı·ÓfiÙÂÚË ·ÈÙ›· ÂÏ¿ÙÙˆÛ˘ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Â›Ó·È Ë ·ÈÌÔ·Ú·›ˆÛË ÏfiÁˆ Ì·˙È΋˜ ÌÂÙ¿ÁÁÈÛ˘. ∏ ·ÂÏ¢ı¤ÚˆÛË fï˜ ·ÈÌÔÂÙ·Ï›ˆÓ ·fi ÙȘ ·Ôı‹Î˜ ÙÔ˘ ÛÏ‹Ó· Î·È ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÌÂÙÚÈ¿˙ÂÈ ÙÔ ÚÔ‚ÏÂfiÌÂÓÔ Ê·ÈÓfiÌÂÓÔ. ™Â ·ÛıÂÓ›˜ Ì ‚·ÚÈ¿ Ë·ÙÈ΋ ÓfiÛÔ ÙfiÛÔ Ô ·ÚÈıÌfi˜ fiÛÔ Î·È Ë ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Â›Ó·È ÂËÚ·Ṳ̂ÓË Î·È Ë ¯ÔÚ‹ÁËÛË ·ÈÌÔÂÙ·Ï›ˆÓ ÂӉ›ÎÓ˘Ù·È ·ÎfiÌË Î·È ·Ó ÔÈ ÙÈ̤˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈΤ˜ ·ÏÏ¿ ·Ú·ÙËÚÂ›Ù·È ÌÈÎÚÔ·ÁÁÂȷ΋ ‰È¿¯˘ÙË ·ÈÌÔÚÚ·Á›·. ∏ ¯ÔÚ‹ÁËÛË ·Ú·ÁfiÓÙˆÓ ‹Í˘ ÂÍ·ÚÙ¿Ù·È ·fi Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ Â·ÓÂÈÏËÌÌ¤ÓˆÓ ‰ÔÎÈÌ·ÛÈÒÓ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Î·È ÙËÓ ·Ú·Ù‹ÚËÛË ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ÙÚ·‡Ì·ÙÔ˜. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë·ÙÂÎÙÔÌ‹˜ Î·È Ù˘ ·ÓË·ÙÈ΋˜ Ê¿Û˘ ¯ÔÚËÁԇ̠ÊÚ¤ÛÎÔ Î·Ù„˘Á̤ÓÔ Ï¿ÛÌ· (FFP) ÚÔÛ·ıÒÓÙ·˜ Ó· ‰È·ÙËÚ‹ÛÔ˘Ì ÙÔ ¯ÚfiÓÔ ÚÔıÚÔÌ‚›Ó˘ (ƒΔ) Ì ·fiÎÏÈÛË 2sec ·fi ÙËÓ ÙÈÌ‹ ÂϤÁ¯Ô˘. O Ú˘ıÌfi˜ ¤Á¯˘Û˘ ·˘Í¿ÓÂÙ·È ·Ó ·Ú·ÙËÚËıÔ‡Ó ÎÏÈÓÈο ÛËÌ›· ‰È·Ù·Ú·¯‹˜ Ù˘ ‹Í˘, fiˆ˜ ·‰˘Ó·Ì›· ‰ËÌÈÔ˘ÚÁ›·˜ ıÚfiÌ‚Ô˘ ÛÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ÙÚ·‡Ì· Î·È ÁÂÓÈÎÂ˘Ì¤ÓË ·ÈÌÔÚÚ·Á›·, ·Ú¿ ÙËÓ ÚÔÛÂÎÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÈÌfiÛÙ·ÛË. ™ÙË Ê¿ÛË Ù˘ ·ӷÈÌ¿ÙˆÛ˘ Û˘¯Ó¿ ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÈϤÔÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ Î·È ÛËÌ›· ÈÓˆ‰fiÏ˘Û˘. ∏ ÂÏ¿ÙÙˆÛË Î·È Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÔÊ›ÏÔÓÙ·È ÛÙË Û˘ÛÛÒÚÂ˘Û‹ ÙÔ˘˜ ÛÙÔ Ó¤Ô ‹·Ú Î·È ÛÙË ‰Ú¿ÛË ÊÏÂÁÌÔÓˆ‰ÒÓ ÌÂÛÔÏ·‚ËÙÒÓ. ∏ ˘ÂÚÈÓˆ‰fiÏ˘ÛË Ù˘Èο ·Ú¯›˙ÂÈ Î·Ù¿ ÙËÓ ·ÓË·ÙÈ΋ Ê¿ÛË, fiÙ·Ó ·˘Í¿ÓÂÙ·È Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ tPA Ô˘ Ê˘ÛÈÔÏÔÁÈο ˘Ê›ÛÙ·Ù·È Î¿ı·ÚÛË ÛÙÔ ‹·Ú, ÂÓÒ ÂÏ·ÙÙÒÓÂÙ·È Ô ·Ó·ÛÙÔϤ·˜ ÙÔ˘ ‰ÈÂÁ¤ÚÙË ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘.24,25,26,27,28 ∏ ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒÓÂÙ·È Ì ÙÔ ÌÈÎÚfi ¯ÚfiÓÔ Ï‡Û˘ ÙÔ˘ ıÚfiÌ-
‚Ô˘ Î·È ÙÔ Ù˘ÈÎfi ıÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ¿ÊËÌ·. ∏ ·ÈÌfiÛÙ·ÛË Û˘Ó‹ıˆ˜ ‚ÂÏÙÈÒÓÂÙ·È Ì ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.
4. ∏§∂∫ΔƒO§ÀΔπ∫∂™ ª∂Δ∞μO§∂™ – ¢π∞Δ∞ƒ∞Ã∂™ O•∂Oμ∞™π∫∏™ π™OƒƒO¶π∞™ ∏ ¯ÔÚ‹ÁËÛË ÔÏÏÒÓ ÌÔÓ¿‰ˆÓ ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ ·˘ÙÔ‡ Î·È Ë Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÚÔηÏÔ‡Ó ÛËÌ·ÓÙÈΤ˜ ‚ÈÔ¯ËÌÈΤ˜ ÌÂÙ·‚ÔϤ˜. ™ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜, Ë ÁÏ˘Îfi˙Ë ÙÔ˘ ·›Ì·ÙÔ˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ ÚÈÓ ÙËÓ Â¤Ì‚·ÛË, ·ÏÏ¿ ·˘Í¿ÓÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ¿ Ù˘, ÏfiÁˆ ¯ÔÚ‹ÁËÛ˘ Û˘ÓÙËÚË̤ÓÔ˘ ·›Ì·ÙÔ˜ Ô˘ ÂÚȤ¯ÂÈ acid-citrate-dextrose Î·È Ù˘ ·˘ÍË̤Ó˘ ·ÓÔ¯‹˜ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË ÏfiÁˆ stress. ªfiÏȘ ÙÔ Ó¤Ô ‹·Ú ·Ú¯›ÛÂÈ Ó· ÏÂÈÙÔ˘ÚÁ›, Ë Û˘ÁΤÓÙÚˆÛË Ù˘ ÁÏ˘Îfi˙˘ ÙÔ˘ ·›Ì·ÙÔ˜ ÂÏ·ÙÙÒÓÂÙ·È. ÀÔÁÏ˘Î·ÈÌ›· Û¿ÓÈ· ·Ú·ÙËÚÂ›Ù·È ‰ÈÂÁ¯ÂÈÚËÙÈο, ·ÎfiÌË Î·È Î·Ù¿ ÙËÓ ·ÓË·ÙÈ΋ Ê¿ÛË Ô˘ ‰È·ÎfiÙÂÙ·È Ë Ê˘ÛÈÔÏÔÁÈ΋ ¤ÎÎÚÈÛË Ù˘ ÁÏ˘Îfi˙˘ ·fi ÙÔ ‹·Ú. ∏ ¯ÔÚ‹ÁËÛË ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜ (Ô˘ ÂÚȤ¯Ô˘Ó ÎÈÙÚÈÎfi Ó¿ÙÚÈÔ), ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ Î·È Ë ·ÒÏÂÈ· ‡‰·ÙÔ˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·‡ÍËÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ¡·+ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ∞‡ÍËÛË ÙÔ˘ ¡·+>12mmol/lt Û 24h, ÚÔηÏ› ÛÔ‚·Ú¤˜ Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜. ΔÔ Î¿ÏÈÔ (∫+) ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ·˘Í¿ÓÂÙ·È Î·Ù¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ‹·ÙÔ˜ ηıÒ˜ ·›Ì· ·fi ÙËÓ ˘Ï·›· ΢ÎÏÔÊÔÚ›·, ÏÔ‡ÛÈÔ Û ∫+ (·fi ÙÔ ÈÛ¯·ÈÌÈÎfi ‹·Ú Î·È ÙÔ ‰È¿Ï˘Ì· Û˘ÓÙ‹ÚËÛ˘) Ì·›ÓÂÈ ÛÙË Û˘ÛÙËÌ·ÙÈ΋ ΢ÎÏÔÊÔÚ›·. ™ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ Û‡ÓÙÔÌ· ·Ú·ÙËÚÂ›Ù·È ·Ó·Î·Ù·ÓÔÌ‹ Î·È ÚÔԉ¢ÙÈ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ∫+. ¶ÚÔ¸¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, ˘ÔÏÂÈÌÌ·ÙÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜ ·fi Ù· b-blockers Û ·ÛıÂÓ›˜ Ì ˘Ï·›· ˘¤ÚÙ·ÛË Î·È Û¯ÂÙÈο ÌÂÁ¿ÏÔ ‹ ÈÛ¯·ÈÌÈÎfi Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì·, ÚÔηÏÔ‡Ó ·Ú·ÙÂٷ̤ÓË Î·È ÂÈΛӉ˘ÓË ˘ÂÚηÏÈ·ÈÌ›·. ∏ ·ÓÙÈÌÂÙÒÈÛË Û˘Ó›ÛÙ·Ù·È ÛÙË ¯ÔÚ‹ÁËÛË CaCl2, ‰ÂÍÙÚfi˙˘ Ì ÈÓÛÔ˘Ï›ÓË, ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ ‹ Û·Ï‚Ô˘Ù·ÌfiÏ˘ Û ÂÈÛÓÔ¤˜. ™˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË ∫+ ÌÔÚ› Ó· ¯ÚÂÈ·Ûı› ÚÔ˜ ÙÔ Ù¤ÏÔ˜ Ù˘ ¤̂·Û˘, fiÙ·Ó Ë Â·Ó·ÚfiÛÏË„Ë ÙÔ˘ ∫+ ·fi ÙÔ Ó¤Ô ‹·Ú Ô‰ËÁ‹ÛÂÈ Û ˘ÔηÏÈ·ÈÌ›·. ∏ ‡·ÚÍË ÎÈÙÚÈÎÒÓ (trisodium citrate) ÛÙÔ Û˘ÓÙËÚË̤ÓÔ ÚÔ˜ ÌÂÙ¿ÁÁÈÛË ·›Ì· Î·È Ï¿ÛÌ·, ‰ÂÛÌÂ‡Ô˘Ó ÙÔ ÈÔÓÈṲ̂ÓÔ ·Û‚¤ÛÙÈÔ (Ca++). ™˘ÌÏËڈ̷ÙÈ΋ ¯ÔÚ‹ÁËÛË CaCl2 Â›Ó·È ··Ú·›ÙËÙË ÁÈ·
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙË ‰È·Ù‹ÚËÛË Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘. OÈ ··ÈÙ‹ÛÂȘ Û ·Û‚¤ÛÙÈÔ, ÂÍ·ÚÙÒÓÙ·È ·fi ÙÔ ¯ÔÚËÁÔ‡ÌÂÓÔ fiÁÎÔ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÙˆÓ ·Ú·ÁÒÁˆÓ ÙÔ˘ Î·È ÙËÓ ÈηÓfiÙËÙ· ÙÔ˘ ‹·ÙÔ˜ Ó· ÌÂÙ·‚ÔÏ›ÛÂÈ Ù· ÎÈÙÚÈο. ∂Ï¿ÙÙˆÛË Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ ÈÔÓÈṲ̂ÓÔ˘ Ì·ÁÓËÛ›Ô˘ (Mg) ·Ú·ÙËÚÂ›Ù·È ÛÙË ‰È¿ÚÎÂÈ· ÁÚ‹ÁÔÚ˘ ÌÂÙ¿ÁÁÈÛ˘ ÛÙËÓ ·Ó˘·ÙÈ΋ Ê¿ÛË Î·È ÛÙË Ê¿ÛË Â·Ó·ÈÌ¿ÙˆÛ˘. ∏ ¯ÔÚ‹ÁËÛË Mg ‰ÈÂÁ¯ÂÈÚËÙÈο, Û¿ÓÈ· ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË. ªÂÙ·‚ÔÏÈ΋ ÔͤˆÛË ·Ú·ÙËÚÂ›Ù·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ, Î·È ·Ô‰›‰ÂÙ·È ·) ÛÙÔÓ ÂÏ·Ùو̤ÓÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ Á·Ï·ÎÙÈÎÒÓ Î·È Ù˘ Ô˘Ú›·˜ Î·È ‚) Û Ô͈ÙÈÎÔ‡˜ ÌÂÙ·‚Ôϛ٘ Ô˘ Û˘ÛÛˆÚ‡ÔÓÙ·È ÛÙËÓ ˘Ï·›· ÊϤ‚·, ÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÔ˘ ηÙÒÙÂÚÔ˘ ÛÒÌ·ÙÔ˜ ÏfiÁˆ ÛÙ¿Û˘ Î·È ÛÙÔ ÌfiÛ¯Â˘Ì· ηٿ ÙË ÌÂÙ·ÊÔÚ¿ Î·È Û˘ÓÙ‹ÚËÛ‹ ÙÔ˘ Î·È ·ÂÏ¢ıÂÚÒÓÔÓÙ·È ÛÙË ÁÂÓÈ΋ ΢ÎÏÔÊÔÚ›· ηٿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË ‰ÈÔÚıÒÓÂÙ·È ·fi ÌfiÓË Ù˘ Ì ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ó¤Ô˘ ‹·ÙÔ˜.
5. ¡∂ºƒπ∫∏ §∂πΔOÀƒ°π∞ ∏ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ‰ÈÂÁ¯ÂÈÚËÙÈο, ÔÊ›ÏÂÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ Û ÌÂÙ·‚ÔϤ˜ Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ (C.O.) Î·È Ù˘ ÓÂÊÚÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜. ∏ ‰ÈÔ‡ÚËÛË ÂÏ·ÙÙÒÓÂÙ·È Î·Ù¿ ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ (∫∫º), ηıÒ˜ ÂÏ·ÙÙÒÓÂÙ·È Ë C.O. Î·È ·˘Í¿ÓÂÈ Ë ›ÂÛË ÛÙË ÓÂÊÚÈ΋ ÊϤ‚·. ∏ ·¿ÓÙËÛË ·˘Ù‹ ·Ì‚χÓÂÙ·È fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë ÊÏ‚Ô-ÊÏ‚È΋ ·Ú¿Î·Ì„Ë ‹ ÂÊ·ÚÌfi˙ÂÙ·È Ë piggyback Ù¯ÓÈ΋. ¶ÚÔ¸¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ÓfiÛÔ˜, ·Ú·ÙÂٷ̤ÓË ˘fiÙ·ÛË, ·˘ÍË̤ÓË ÌÂÙ¿ÁÁÈÛË Î·È ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯ÔÚ‹ÁËÛË Î˘ÎÏÔÛÔÚ›Ó˘ ∞ Î·È ·ÌÈÓÔÁÏ˘ÎÔÛȉÈÎÒÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ, ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ª¤ÙÚ· ÁÈ· ÙËÓ ÚÔʇϷÍË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ·ÔÙÂÏÔ‡Ó Ë ¯ÔÚ‹ÁËÛË Ì·ÓÓÈÙfiÏ˘ (0,2 gr/kgr/h) Î·È ÊÔ˘ÚÔÛÂÌ›‰Ë˜ (0,1-0,5 mgr/kgr/h). H ÔÏÈÁÔ˘Ú›·, Ô˘ ÔÊ›ÏÂÙ·È ÛÙËÓ ˘fiÙ·ÛË ÏfiÁˆ ÙˆÓ ¯·ÌËÏÒÓ SVR, ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛı› Ì ¯ÔÚ‹ÁËÛË ÓÔÚÂÈÓÂÊÚ›Ó˘ (0,05-0,5Á/kgr/min).
6. ¢π∞Δ∏ƒ∏™∏ Δ∏™ £∂ƒªO∫ƒ∞™π∞™ ΔOÀ ™øª∞ΔO™ ∏ ıÂÚÌÔÎÚ·Û›· ÙÔ˘ ˘Ú‹Ó· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÌÂÙ·‚¿ÏÏÂÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ª.∏. ¶·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó Û’ ·˘Ùfi Â›Ó·È Ë ÚÔ¸¿Ú-
213
¯Ô˘Û· η΋ ıÚ¤„Ë, Ë ¯ÔÚ‹ÁËÛË ÌÂÁ¿ÏÔ˘ fiÁÎÔ˘ ˘ÁÚÒÓ, Ë ¯Ú‹ÛË Ù˘ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘29 Î·È Ë ÙÔÔı¤ÙËÛË ÛÙËÓ ÎÔÈÏÈ¿ ÙÔ˘ „˘¯ÚÔ‡ Û˘ÓÙËÚË̤ÓÔ˘ ÌÔۯ‡̷ÙÔ˜ (ÛÙÔ˘˜ 2Ô-4Ô C). ∏ ˘ÔıÂÚÌ›· ÂËÚ¿˙ÂÈ ÙËÓ ·ÈÌfiÛÙ·ÛË, ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ Ê·Ú̿ΈÓ, ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÙËÓ ÈÛÙÈ΋ Ô͢ÁfiÓˆÛË ÙË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÂÏ·ÙÙÒÓÂÈ ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙȘ ÏÔÈÌÒÍÂȘ.30,31 ∞·Ú·›ÙËÙ· ̤ÙÚ· ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ˘ÔıÂÚÌ›·˜ Â›Ó·È Ë ¯Ú‹ÛË ıÂÚÌ·ÓÙÈÎÔ‡ ÛÙÚÒÌ·ÙÔ˜ (Ì ÓÂÚfi ‹ ·¤Ú·) Ë ÂʇÁÚ·ÛË Î·È ı¤ÚÌ·ÓÛË ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ·ÂÚ›ˆÓ Î·È Ë ÚÔı¤ÚÌ·ÓÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ˘ÁÚÒÓ.32
μÈ‚ÏÈÔÁÚ·Ê›· 1. De Wolf AM, Freeman JA, Scott VL, Tullock W, Smith DA, Kisor DF, et al. Pharmacokinetics and pharmacodynamics of cisatracurium in patients with end-stage liver disease undergoing liver transplantation. Br J Anaesth 1996;76:624-8. 2. Δegeder I, Lotsch J, Geisslinger G. Pharmacokinetics of opioids in liver disease. Clin Pharmacokinet 1999; 37:17-40. 3. Klinck J. Liver transplantation: anesthesia, in “Anesthesia and intensive care for organ transplantaion”. Ed by Klinck J, Lindop M 1st ed Chapman and Hall London-New York, 1998 pp.169-200. 4. Navalgund A, Kang Y: Massive pulmonary thromboembolism during liver transplantation. Anesth. Analg 1988;67:400-402. 5. O’Riordan J, O’Beirne HA, Young Y, Bellamy MC. Effects of desflurane and isoflurane on splanchnic microcirculation during major surgery. Br J Anaesth 1997;78:95-6. 6. Gatecel C, Losser MR, Payen D. The postoperative effects of halothane versus isoflurane on hepatic artery and portal vein blood flow in humans. Anesth Analg 2003;96(3):740-5. 7. Armbraster K, Noldge-Schomburg GF, Dressier IM, Fittkau AJ, Haberstroh J, Geiger K. The effects of desflurane on splachnic hemodynamics and oxygenation in the anesthetized pig. Anesth Analg 1997;84: 271-7. 8. Suttner SW, Schmidt CC, Boldt J, Huttner I, Kumle B, Piper SN. Low-flow desflurane and sevofiurane anesthesia minimally affect hepatic integrity and function in elderly patients.Anesth Analg 2000;91:206-12. 9. Frink Jr EJ. The hepatic effects of sevoflurane. Anesth Analg 1995;81:S46-50. 10. Kharasch ED, Frink Jr EJ, Artru A, Michalowski P, Rooke GA, Nogami W. Long-duration low-flow sevoflurane and isoflurane effects on postoperative renal and hepatic function. Anesth Analg 2001;93:1511-20. 11. O’ Brien J, Ettinger N. Pulmonary complications of
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liver transplantation. Clinics Chest Med , 1996; 17: 99114. 12. Yost S, Matthay M, Gropper M. Etiology of acute pulmonary edema during liver transplantation: a series of cases with analysis af the edema fluid. Chest 2001; 119:219-23. 13. Navalgund A, Kang Y. Massive pulmonary thromboembolism during liver transplanta tion. Anesth Analg 1988; 67: 400-2. 14. Khoury G, Mann M. Air embolism associated with veno-venous bypass during orthotopic liver transplantation. Anesthesiology 1987; 67: 848-51. 15. Manji M,. Isaac J, Bion J. Survival from massive intraoperative pulmonary thromboembolism during orthotopic liver transplantation Br J Anaesth, 1998;80: 685-7. 16. Adam B. Lerner, MD, Eswar S et al. Four cases of cardiopulmonary thromboembolism during liver transplantation without the use of antifibrinolytic drugs. Anesth Analg 2005;101: 1608-1612. 17. Shaw B. Some further notes on venous bypass for orthotopic transplantation of the liver. Transpl Proc 1987; 19: 13-6. 18. Paulsen AW, Whitten CW. Considerations for anesthetic management during venovenous bypass in adult hepatic transplantation. Anesth Analg 1989; 68: 489-96.
22. Paulsen AW, Valek TR. Effects of atropine pre-treatment on the revascularisation syndrome. Transplant Proc 1989; 21:2341-2. 23. Maurer J, Spence R. Transfusion requirements in liver transplantation. www.emedicine.com 2004:1-18. 24. Kang Y. Coagulopathies of hepatic disease. Critical care issues in liver transplantation 1999: 119-125 by AASLD - ILTS. 25. Steib A, Gengenwin N. Predictive factors of hyperfibrolytic activity during liver transplantation in cirrhotic patients. Br J Anaesth 1994; 73: 645-8. 26. Mallett SV, Cox D. Aprotinin and reduction of blood loss and transfusion requirements in orthotopic liver transplantation. Lancet 1990; 2: 886-7. 27. Soilleux H, Gillon MC. Comparative effects of small and large aprotinin doses on bleeding during orthotopic liver transplantation. Anesth. Analg 1995; 80: 34952. 28. Marcel RJ, Stegal WC. Continuous small-dose aprotinin controls fibrinolysis during orthotopic liver transplantation. Anesth Analg 1996; 82:1122-5. 29. Paulsen AW, Whitten CW. Considerations for anesthetic management during veno-venous bypass in adult hepatic transplantation Anesth. Analg 1989; 68: 489-96.
19. Shaw B, Martin D, Marquez J. Venous bypass in clinical liver transplantation. Ann Surg 1984; 200: 524-34.
30. Schmeid H, Kurz A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet 1996; 347: 289-92.
20. Aggarwal S, Kang YG, Freeman JA et al. Postreperfusion syndrome. Cardiovascular collapse following hepatic reperfusion during liver transplantation. Transpl Proc 1987;19:54-5.
31. Kurz A, Sessler DI. Perioperative normothermia to reduce the incidence of surgical - wound infection and shorten hospitalization. New Engl J Med 1996; 334: 1209-15.
21. Martin DJ, Marquez JM. Liver transplantation: hemodynamic and electrolyte changes seen immediately following revascularisation. Anesth Analg 1984;63:246 (S).
32. Russell SH, Freeman J. Prevention of hypothermia during orthotopic liver transplantation: comparison of three different intraoperative warming methods. Br. J. Anaesth 1995; 74: 415-18.
EÍÂÏ›ÍÂȘ ÛÙËÓ Ù¯ÓÈ΋ Ù˘ ÔÚıÔÙÔÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜
10
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ηٿ ÙË Ì¤ÛË ÁÚ·ÌÌ‹ ÚÔ˜ ÙË ÍÈÊÔÂȉ‹ ·fiÊ˘ÛË (ÙÔÌ‹ “Mercedes-benz”). ∫ÈÓËÙÔÔÈÂ›Ù·È Î·È ‰È·Ù¤ÌÓÂÙ·È Ô ÛÙÚÔÁÁ‡ÏÔ˜ Î·È ‰Ú·ÓÔÂȉ‹˜ Û‡Ó‰ÂÛÌÔ˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ô ·ÚÈÛÙÂÚfi˜ Î·È ‰ÂÍÈfi˜ ÙÚ›ÁˆÓÔ˜ Û‡Ó‰ÂÛÌÔ˜ ÙÔ˘ ‹·ÙÔ˜. ªÂÙ¿ ÙË ‰È¿ÓÔÈÍË ÙÔ˘ Ë·ÙÔÁ·ÛÙÚÈÎÔ‡ Û˘Ó‰¤ÛÌÔ˘ ·Ú·Û΢¿˙ÔÓÙ·È Î·È ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Ù· ÛÙÔȯ›· ÙÔ˘ Ë·ÙÔ‰ˆ‰Âη‰·ÎÙ˘ÏÈÎÔ‡ ÛÙÔ ‡„Ô˜ ÙˆÓ ˘ÏÒÓ ÙÔ˘ ‹·ÙÔ˜ (∂ÈÎ. 2). ∞ÔÏÈÓÒÓÂÙ·È Î·È ‰È·Ù¤ÌÓÂÙ·È Ô Î˘ÛÙÈÎfi˜ Î·È Ô ÎÔÈÓfi˜ Ë·ÙÈÎfi˜ fiÚÔ˜, ηıÒ˜ Î·È Ô ·ÚÈÛÙÂÚfi˜ Î·È ‰ÂÍÈfi˜ ÎÏ¿‰Ô˜ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜. Δ¤ÏÔ˜ ÙÔ Û٤ϯԘ Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ ÎÈÓËÙÔÔÈÂ›Ù·È ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ̤¯ÚÈ ÙÔ ‰ÂÍÈfi Î·È ·ÚÈÛÙÂÚfi ÎÏ¿‰Ô Ù˘. ∞Ó¿ÏÔÁ· Ì ÙÔ ‚·ıÌfi Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘, ÙËÓ ·ÈÌÔÚÚ·ÁÈÎfiÙËÙ· ÙÔ˘ ÂÁ¯ÂÈÚËÙÈÎÔ‡ ‰›Ô˘, ÙËÓ ‡·ÚÍË Û˘ÌʇÛÂˆÓ ·fi ÚÔËÁÔ‡ÌÂÓ˜ ÂÂÌ‚¿ÛÂȘ Î·È ÁÂÓÈο ÙÔÓ ÚÔ‚ÏÂfiÌÂÓÔ ¯ÚfiÓÔ ·ÔÎÏÂÈÛÌÔ‡ Ù˘ ˘Ï·›·˜ ΢ÎÏÔÊÔÚ›·˜ ·ÔÊ·Û›˙ÂÙ·È ‹ fi¯È Ë ¯ÚËÛÈÌÔÔ›ËÛË ˘Ï·ÈÔ – Û˘ÛÙËÌ·ÙÈ΋˜ ·Ú¿Î·Ì„˘. ΔÔ ÎÈÓËÙÔÔÈË̤ÓÔ Ï¤ÔÓ ‹·Ú ·Ê·ÈÚÂ›Ù·È ÁÚ‹ÁÔÚ· Ì·˙› Ì ÙÔ Ë·ÙÈÎfi ÙÌ‹Ì· Ù˘ οو ÎÔ›-
∏ Ù¯ÓÈ΋ Ù˘ ÎÏ·ÛÈ΋˜ ÔÚıÔÙÔÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ (Oª∏) Â›Ó·È ·˘Ù‹ Ì ÙËÓ ÔÔ›· Ú·ÁÌ·ÙÔÔÈ‹ıËÎÂ Ë ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙÔÓ ¿ÓıÚˆÔ ·fi ÙÔÓ Thomas Starzl ÙÔ 1963 ÛÙÔ Denver ÙÔ˘ Colorado ÙˆÓ ∏.¶.∞. ΔÔ ¿Û¯ÔÓ ‹·Ú ·Ê·ÈÚÂ›Ù·È (ÔÏÈ΋ Ë·ÙÂÎÙÔÌ‹) Î·È ÛÙË ı¤ÛË ÙÔ˘ ÙÔÔıÂÙÂ›Ù·È ÙÔ ˘ÁȤ˜ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì·. ∏ ÂÎÙÔÌ‹ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ‹·ÙÔ˜ Â›Ó·È ·fi ÙȘ ϤÔÓ ·ÈÌÔÚÚ·ÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Î·È ÁÈ ·˘Ùfi ··ÈÙÂ›Ù·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹ ÛÙËÓ ÚÔۤϷÛË Î·È ¯ÂÈÚÈÛÌfi ÙˆÓ ‰È·ÊfiÚˆÓ ÈÛÙÒÓ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ ·ÈÌfiÛÙ·Û˘ Û fiÏ· Ù· ÛÙ¿‰È· Ù˘ ¤̂·Û˘. ∏ ‡·ÚÍË ˘Ï·›·˜ ˘¤ÚÙ·Û˘ Î·È ÔÈ Û˘Ó˘¿Ú¯Ô˘Û˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ·ÚÈÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÔÈ ÔÔ›ÔÈ Â˘ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ·ÈÌÔÚÚ·ÁÈÎfiÙËÙ· Ù˘ ¤̂·Û˘. ∏ ηٿÏÏËÏË fï˜ ¯Ú‹ÛË ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘ (∂ÈÎ. 1) Î·È ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛËÌ·ÓÙÈο ÛÙË Ê¿ÛË ·˘Ù‹ Ù˘ ¤̂·Û˘ ÌÂÈÒÓÔÓÙ·˜ ·Ú¿ÏÏËÏ· Î·È Ù· ÔÛÔÛÙ¿ ÓÔÛËÚfiÙËÙ·˜. ∏ ÂÁ¯ÂÈÚËÙÈ΋ ÚÔۤϷÛË Á›ÓÂÙ·È Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ˘Ô¯fiÓ‰ÚÈ· ÙÔÌ‹, Ë ÔÔ›· ÂÂÎÙ›ÓÂÙ·È
∂ÈÎfiÓ· 1. ºÏ‚Ô-ÊÏ‚È΋ ·Ú¿Î·Ì„Ë Ù˘ οو ÎÔ›Ï˘ Î·È ˘Ï·›·˜ ÊϤ‚·˜ ÚÔ˜ ÙË Ì·Û¯·ÏÈ·›· ÊϤ‚·.
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B. ¶A¶ANIKO§AOY
∂ÈÎfiÓ· 2. ¶·Ú·Û΢‹ ÙˆÓ ÛÙÔȯ›ˆÓ ÛÙȘ ‡Ï˜ ÙÔ˘ ‹·ÙÔ˜.
Ï˘, Ë ÔÔ›· ‰È·Ù¤ÌÓÂÙ·È ˘Ô‰È·ÊÚ·ÁÌ·ÙÈο ·Ì¤Ûˆ˜ ¿Óˆ ·fi ÙËÓ Â΂ÔÏ‹ ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ Î·È ˘ÊË·ÙÈο ·Ì¤Ûˆ˜ ¿Óˆ ·fi ÙËÓ Â΂ÔÏ‹ ÙˆÓ ÓÂÊÚÈÎÒÓ ÊÏ‚ÒÓ (∂ÈÎ. 3). ∞ÎÔÏÔ˘ı› ÂÈÌÂÏ‹˜ ·ÈÌfiÛÙ·ÛË Ì ‰È·ıÂÚÌ›· ‹ Ì ·ÈÌÔÛÙ·ÙÈΤ˜ ڷʤ˜ Û fiÏË ÙËÓ ¤ÎÙ·ÛË Ù˘ ·ÔÁ˘Ìӈ̤Ó˘ ÂÚÈÔ¯‹˜ fiÈÛıÂÓ ÙÔ˘ ·Ê·ÈÚÂı¤ÓÙÔ˜ ‹·ÙÔ˜. OÈ ·ÛıÂÓ›˜ Ì ˷ÙÈ΋ ·Ó¿ÚÎÂÈ· Û˘¯Ó¿ ÂΉËÏÒÓÔ˘Ó ÛÔ‚·Ú‹ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· ·ÎfiÌ· Î·È fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ‰ÈÂÁ¯ÂÈÚËÙÈο. ™˘Ó‹ıˆ˜ ˘¿Ú¯ÂÈ ˘„ËÏ‹ ηډȷ΋ ·ÚÔ¯‹ Ì ¯·ÌËϤ˜ ÂÚÈÊÂÚÈΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ, Ô˘ ·fi ÔÏϤ˜ ·fi„ÂȘ ÚÔÛÔÌÔÈ¿˙Ô˘Ó Ì ÙȘ ‰È·Ù·Ú·¯¤˜ Ù˘ Û‹„˘ Î·È ÙÔ˘ ÛËÙÈÎÔ‡ shock. ™˘¯Ó¿ ÔÈ ÂÚÈÊÂÚÈΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ ¤ÊÙÔ˘Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤̂·Û˘ Î·È È‰È·›-
ÙÂÚ· ηٿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ·˘ÙÔ‡ Á›ÓÂÙ·È Ì ·‰ÚÂÓ·Ï›ÓË ‹ ÓÔÚ·‰ÚÂÓ·Ï›ÓË Î¿Ùˆ ·fi Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ì¤Ûˆ ηıÂÙ‹Ú· Swan-Ganz. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÂÍ¿ÏÏÔ˘ Ù˘ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘ (∂ÈÎ. 1) ηٿ ÙËÓ ·ÓË·ÙÈ΋ Ê¿ÛË ÂÍ·ÛÊ·Ï›˙ÂÈ ÛËÌ·ÓÙÈ΋ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚÔÔ›ËÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ·ÔÎÏÂÈÛÌÔ‡ Ù˘ ˘Ï·›·˜ ΢ÎÏÔÊÔÚ›·˜ Î·È Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÛÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚· (∫∫º), ÂÏ·ÙÙÒÓÂÈ ÙȘ ·ÒÏÂȘ ·›Ì·ÙÔ˜ Î·È ·ÔʇÁÂÙ·È Ë ÂÈ‚¿Ú˘ÓÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ·fi ÙË ÛÙ¿ÛË ÛÙȘ ÓÂÊÚÈΤ˜ ÊϤ‚˜. ΔÔ Ó¤Ô ‹·Ú ÙÔÔıÂÙÂ›Ù·È ÔÚıÔÙÔÈο Î·È ·Ó·ÛÙÔÌÒÓÂÙ·È ÚÒÙ· ÙÔ ˘ÂÚË·ÙÈÎfi ÎÔÏfi‚ˆÌ· Ù˘ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙÔ ˘Ô‰È·ÊÚ·ÁÌ·ÙÈÎfi ÎÔÏfi‚ˆÌ· Ù˘ ∫∫º ÙÔ˘ §‹ÙË (∂ÈÎ. 4) Î·È ·ÎÔÏÔ˘ı› Ë ·Ó·ÛÙfïÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙËÓ ˘Ï·›· ÊϤ‚· ÙÔ˘ §‹ÙË (∂ÈÎ. 5).
∂ÈÎfiÓ· 4. ∞Ó·ÛÙfïÛË ˘ÂÚË·ÙÈ΋˜ ∫∫º.
∂ÈÎfiÓ· 3. Δ· ÛÙ¿‰È· ·Ê·›ÚÂÛ˘ ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ‹·ÙÔ˜.
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§›ÁÔ ÚÈÓ ·fi ÙËÓ ÂÚ¿ÙˆÛË Ù˘ ÙÂÏÂ˘Ù·›·˜ ·Ó·ÛÙfïÛ˘ ÙÔ ‹·Ú ÂÎχÓÂÙ·È Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹, ‰È¿Ï˘Ì· ·Ï‚Ô˘Ì›Ó˘ ‹ ·›Ì· Ù˘ ÛÏ·Á¯ÓÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ ÁÈ· Ó· ·ÔÌ·ÎÚ˘ÓıÔ‡Ó Ù· ÚÔ˚fiÓÙ· ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡, ÙÔ Î¿ÏÈÔ Î·È Ô ·¤Ú·˜ ·fi ÙÔ ÌfiÛ¯Â˘Ì·. ∞Ê·ÈÚÔ‡ÓÙ·È ÛÙË Û˘Ó¤¯ÂÈ· ÔÈ ·ÁÁÂÈÔÏ·‚›‰Â˜ ·fi ÙËÓ ˘Ï·›· Î·È ÙËÓ ˘ÂÚË·ÙÈ΋ οو ÎÔ›ÏË Î·È ÙÔ ‹·Ú ·ӷÈÌ·ÙÒÓÂÙ·È, ÔfiÙ ÙÂÏÂÈÒÓÂÈ Î·È Ô ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ¤̂·ÛË Û˘Ó¯›˙ÂÙ·È Ì ÙËÓ ·Ó·ÛÙfïÛË Ù˘ ˘ÊË·ÙÈ΋˜ ∫∫º (∂ÈÎ. 6) Î·È Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ (∂ÈÎ. 7). Δ¤ÏÔ˜ ·Ê·ÈÚÂ›Ù·È Ë ¯ÔÏˉfi¯Ô˜ ·ÛÙË Î·È Ô ¯ÔÏˉfi¯Ô˜ fiÚÔ˜ ·Ó·ÛÙÔÌÒÓÂÙ·È ÙÂÏÈÎÔ-ÙÂÏÈο Ì ÙÔ ¯ÔÏˉfi¯Ô fiÚÔ ÙÔ˘ §‹ÙË. ∏ ÙÔÔı¤ÙËÛË ÛˆÏ‹Ó· Kehr ‰ÂÓ Â›Ó·È ¿ÓÙ· ··Ú·›ÙËÙË. ŸÙ·Ó, ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜, Ô ¯ÔÏˉfi¯Ô˜ fiÚÔ˜ ÙÔ˘
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∂ÈÎfiÓ· 6. ∞Ó·ÛÙfïÛË ˘ÊË·ÙÈ΋˜ ∫∫º.
∂ÈÎfiÓ· 7. Δ¯ÓÈΤ˜ ·Ó·ÛÙfïÛ˘ ∏∞.
§‹ÙË ‰ÂÓ ÚÔÛʤÚÂÙ·È, ÙfiÙÂ Ë ·Ó·ÛÙfïÛË Á›ÓÂÙ·È Ì ·ÔÌÔӈ̤ÓË ¤ÏÈη Ù˘ Ó‹ÛÙȉ·˜ Roux-enY (∂ÈÎ. 8).
∂ÈÎfiÓ· 8. ª¤ıÔ‰ÔÈ ·Ó·ÛÙfïÛ˘ ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘
∂ÍÂÏ›ÍÂȘ ÛÙËÓ ÂÁ¯ÂÈÚËÙÈ΋ Ù¯ÓÈ΋ Ù˘ Oª∏ Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÛÙȘ ÂÚÈÙÒÛÂȘ ÛÙȘ Ôԛ˜ ‰ÂÓ ÂÈ‚¿ÏÏÂÙ·È Ë Û˘Ó·Ê·›ÚÂÛË Î·È Ù˘ ∫∫º ÙÔ˘ §‹ÙË, ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë Ù¯ÓÈ΋ Piggyback ˆ˜ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË ÛÙË ÊÏ‚Ô-ÊÏ‚È΋ ·Ú¿Î·Ì„Ë Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓË·ÙÈ΋˜ Ê¿Û˘. O ÎÂÚÎÔÊfiÚÔ˜ ÏÔ‚fi˜ ·ÂÏ¢ıÂÚÒÓÂÙ·È ·fi ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÌÂÙ¿ ·fi ÚÔÛÂÎÙÈ΋ ·ÔϛӈÛË Î·È ‰È·ÙÔÌ‹ fiÏˆÓ ÙˆÓ ‚Ú·¯¤ˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ, ÔÈ Ôԛ˜ Â΂¿ÏÏÔ˘Ó ·Â˘ı›·˜ ÛÙËÓ ∫∫º Î·È ÙÔ ‹·Ú ·Ú·Ì¤ÓÂÈ Û˘Ó‰Â‰Â̤ÓÔ Ì ÙȘ 3 ÌfiÓÔ Î‡ÚȘ Ë·ÙÈΤ˜ ÊϤ‚˜. OÈ ÊϤ‚˜ ·˘Ù¤˜ ·ÔÎÏ›ÔÓÙ·È Ì ·ÁÁÂÈÔÏ·‚›‰· Î·È ÙÔ ‹·Ú ·Ê·ÈÚ›ٷÈ. ™ÙËÓ ·ÓË·ÙÈ΋ ϤÔÓ Ê¿ÛË ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ‹ fi¯È ÚÔÛˆÚÈÓ‹ ˘Ï·ÈÔ-ÎÔÈÏÈ΋ ÌfiÓÔ ·Ú¿Î·Ì„Ë, ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ∏ ˘ÂÚË·ÙÈ΋ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ó·ÛÙÔÌÒÓÂÙ·È Ì ÙÔÓ ÂÓÈ·ÈÔÔÈË̤ÓÔ ·˘Ïfi ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ, ÂÓÒ ‰È·ÙËÚÂ›Ù·È Ë Î˘ÎÏÔÊÔÚ›· ÛÙËÓ ∫∫º ÙÔ˘ §‹ÙË (∂ÈÎ. 9).
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∂ÈÎfiÓ· 9. ∂ÓÈ·ÈÔÔ›ËÛË ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ ÙÔ˘ §‹ÙË Î·È ·Ó·ÛÙfïۋ ÙÔ˘˜ Ì ÙËÓ ˘ÂÚË·ÙÈ΋ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.
∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë Â΂ÔÏ‹ Ù˘ ‰ÂÍÈ¿˜ Ë·ÙÈ΋˜ ÊϤ‚·˜ (¢∏º) ·ÎÔÏÔ˘ı› ‰È·ÊÔÚÂÙÈÎfi ¿ÍÔÓ· ·fi ÙËÓ Â΂ÔÏ‹ Ù˘ ̤Û˘ Î·È ·ÚÈÛÙÂÚ‹˜ Ë·ÙÈ΋˜ ÊϤ‚·˜ ηÈ, fiÙ·Ó ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ·fiÛÙ·ÛË ÌÂٷ͇ ÙÔ˘˜, ÔÏÏ¿ ΤÓÙÚ· ÙËÓ ·ÔÏÈÓÒÓÔ˘Ó, ÔfiÙÂ Ë ˘ÂÚË·ÙÈ΋ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ó·ÛÙÔÌÒÓÂÙ·È Ì ÙÔÓ ÂÓÈ·ÈÔÔÈË̤ÓÔ ·˘Ïfi Ù˘ ̤Û˘ ÌfiÓÔ Î·È ·ÚÈÛÙÂÚ‹˜ Ë·ÙÈ΋˜ ÊϤ‚·˜ (∂ÈÎ. 10∞ Î·È 10μ).
Δ· ˘fiÏÔÈ· ÛÙ¿‰È· Ù˘ ¤̂·Û˘ Â›Ó·È Ù· ›‰È· Ì ÙËÓ ÎÏ·ÛÈ΋ Ù¯ÓÈ΋ Ì ÙË ‰È·ÊÔÚ¿ fiÙÈ ÙÔ ÛÙfiÌÈÔ Ù˘ ˘ÊË·ÙÈ΋˜ ∫∫º ÙÔ˘ ¢fiÙË ·ÔÏÈÓÒÓÂÙ·È ÌÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ·›Ì· Ù˘ ˘Ï·›·˜ ΢ÎÏÔÊÔÚ›·˜. Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ï¤ÔÓ ·fi Ù· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Ë Ï·ÁÈÔ-Ï¿ÁÈ· ·Ó·ÛÙfïÛË Ù˘ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙËÓ ∫∫º ÙÔ˘ §‹ÙË, Ë ÔÔ›· ÂÍ·ÛÊ·Ï›˙ÂÈ
∂ÈÎfiÓ· 10 ∞ Î·È μ. ∂ÓÈ·ÈÔÔ›ËÛË ÙˆÓ ·˘ÏÒÓ Ù˘ ̤Û˘ Î·È ·ÚÈÛÙÂÚ‹˜ Ë·ÙÈ΋˜ ÊϤ‚·˜.
ŸÙ·Ó fï˜ ˘¿Ú¯ÂÈ ‰˘Û·Ó·ÏÔÁ›· ÌÂÁ¤ıÔ˘˜ ÛÙÔ˘˜ ·˘ÏÔ‡˜ Ô˘ ı· ·Ó·ÛÙÔ̈ıÔ‡Ó, ÙfiÙ ı· Ú¤ÂÈ Ó· ·˘ÍËı› ÙÔ Â‡ÚÔ˜ Ù˘ ·Ó·ÛÙfïÛ˘ Ì ÙË ‰È¿ÓÔÈÍË ÙÔ˘ ÚÔÛı›Ô˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ∫∫º ÙÔ˘ §‹ÙË ÚÔ˜ Ù· ‰ÂÍÈ¿ ̤¯ÚÈ ¿Óˆ ·fi ÙËÓ Â΂ÔÏ‹ Ù˘ ‰ÂÍÈ¿˜ Ë·ÙÈ΋˜ ÊϤ‚·˜ (∂ÈÎ. 11). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ··ÈÙÂ›Ù·È Ï‹Ú˘ ·ÔÎÏÂÈÛÌfi˜ Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÛÙËÓ ∫∫º Î·È ÂÔ̤ӈ˜ Ë ÂÊ·ÚÌÔÁ‹ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘ Â›Ó·È Î·È ¿ÏÈ ··Ú·›ÙËÙÔ˜.
∂ÈÎfiÓ· 11. ¢È‡ڢÓÛË ÙÔ˘ ·˘ÏÔ‡ Ì ÙË ‰È¿ÓÔÈÍË ÙÔ˘ ÚÔÛı›Ô˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ∫∫º ÙÔ˘ §‹ÙË.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
¿ÓÙÔÙ ÙË ‰ÈÂÓ¤ÚÁÂÈ· Ù˘ Oª∏, ¯ˆÚ›˜ ÙËÓ ·Ó¿ÁÎË ¯ÚËÛÈÌÔÔ›ËÛ˘ ÊÏ‚Ô-ÊÏ‚È΋˜ ·Ú¿Î·Ì„˘ (∂ÈÎ. 12).
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η, ·ÙÂÏÂÎÙ·Û›·˜, ·ÏÏ¿ Î·È Ó¢ÌÔÓ›·˜. ∏ ̤ıÔ‰Ô˜ Â›Ó·È ·ÛÊ·Ï‹˜ ›Û˘ ·fi ÓÂÊÚÔÏÔÁÈ΋˜ ÏÂ˘Ú¿˜ ÁÈ· ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· (Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ ÎÏ), ·ÏÏ¿ Î·È ·fi Á·ÛÙÚÂÓÙÂÚÔÏÔÁÈ΋˜ ÏÂ˘Ú¿˜ ÁÈ· ·ÛıÂÓ›˜ ¯ˆÚ›˜ ˘Ï·›· ˘¤ÚÙ·ÛË (ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·, ÎÂÚ·˘ÓÔ‚fiÏÔ˜ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÎÏ). ∏ Ï·ÁÈÔ-Ï¿ÁÈ· ·Ó·ÛÙfïÛË Ù˘ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙËÓ ∫∫º ÙÔ˘ §‹ÙË ÏÂÔÓÂÎÙ› ÂÌÊ·ÓÒ˜ ¤Ó·ÓÙÈ fiÏˆÓ ÙˆÓ ¿ÏÏˆÓ Ù¯ÓÈÎÒÓ Oª∏ ηÈ, Û‹ÌÂÚ· ϤÔÓ, ı· Ú¤ÂÈ Ó· ˘ÈÔıÂÙËı› Î·È Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·fi fiÏ· Ù· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÚÔ˜ fiÊÂÏÔ˜ ÙˆÓ ·ÛıÂÓÒÓ.
ΔÌËÌ·ÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜
∂ÈÎfiÓ· 12. ¶Ï·ÁÈÔ-Ï¿ÁÈ· ·Ó·ÛÙfïÛË Ù˘ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙËÓ ∫∫º ÙÔ˘ §‹ÙË.
ΔÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· ˘Ô‚¿ÏÏÂÙ·È Û ȉȷ›ÙÂÚË ÚÔÂÙÔÈÌ·Û›· ÛÙÔ «›Ûˆ ÙÚ·¤˙È» (back table). °›ÓÂÙ·È Û‡ÁÎÏÂÈÛË ÙÔ˘ ˘¤Ú Î·È ˘ÊË·ÙÈÎÔ‡ ÛÙÔÌ›Ô˘ Ù˘ οو ÎÔ›Ï˘ ÌÂ Û˘Ó¯‹ Ú·Ê‹ Î·È ÙÔ Ô›ÛıÈÔ ÙÔ›¯ˆÌ· Ù˘ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰È·ÓÔ›ÁÂÙ·È Î·Ù¿ ÙË Ì¤ÛË ÁÚ·ÌÌ‹ Û ̋ÎÔ˜ 6 ÂÚ›Ô˘ ÂÎ., ¤ÙÛÈ ÒÛÙÂ Ë ÊÏ‚È΋ ·Ô¯¤Ù¢ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ̤ۈ ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ Ó· Â›Ó·È ·ÚfiÛÎÔÙË. ªÂÙ¿ ·fi ÌÂÚÈÎfi ·ÔÎÏÂÈÛÌfi Ù˘ ∫∫º ÙÔ˘ §‹ÙË ÂÎÙÂÏÂ›Ù·È ·Ó¿ÏÔÁÔ˘ ÌÂÁ¤ıÔ˘˜ ‰È·ÙÔÌ‹ ÛÙÔ ÚfiÛıÈÔ ÙÔ›¯ˆÌ¿ Ù˘ Î·È ÂÍ·ÛÊ·Ï›˙ÂÙ·È Â˘Ú›· ·Ó·ÛÙfïÛË ÌÂٷ͇ ÙÔ˘ ÔÈÛı›Ô˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ∫∫º ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ ÚÔÛı›Ô˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ∫∫º ÙÔ˘ §‹ÙË (∂ÈÎ. 12). ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó·ÛÙfïÛ˘ ÙÔ ÌfiÛ¯Â˘Ì· ÂÎχÓÂÙ·È Ì „˘¯Úfi ‰È¿Ï˘Ì· ·Ï‚Ô˘Ì›Ó˘. ∞ÎÔÏÔ˘ı› Ë ‰ÈÂÓ¤ÚÁÂÈ· Ù˘ ·Ó·ÛÙfïÛ˘ Ù˘ ˘Ï·›·˜ ηÈ, ÚÈÓ ·˘Ù‹ ·ÎfiÌË ÔÏÔÎÏËÚˆı›, ·Ê·ÈÚÂ›Ù·È Ë ·ÁÁÂÈÔÏ·‚›‰· ·fi ÙËÓ ∫∫º. O ¯ÂÈÚÈÛÌfi˜ ·˘Ùfi˜ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó¿ÛÙÚÔÊË ¤ÎÏ˘ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙËÓ Ï‹ÚË ·ÔηٿÛÙ·ÛË Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÛÙËÓ ∫∫º. ∏ ¤̂·ÛË ÙÂÏÂÈÒÓÂÈ Ì ÙËÓ ·Ó·ÛÙfïÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ Î·È ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË Ù˘ ·ÚÔ¯¤Ù¢Û˘ ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ªÂ ÙËÓ Ù¯ÓÈ΋ ·˘Ù‹ ·ÔʇÁÂÙ·È Ë Û‡ÓıÏÈ„Ë ÙˆÓ ÊÚÂÓÈÎÒÓ Ó‡ڈÓ, Ë ÔÔ›· ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ·Ú¿Ù·ÛË Ù˘ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·Ó·ÓÔ‹˜ ÌÂÙÂÁ¯ÂÈÚËÙÈο, fiˆ˜ ›Û˘ ·ÔʇÁÂÙ·È Î·È Ë ‰ËÌÈÔ˘ÚÁ›· ˘‰ÚÔıÒÚ·-
∏ ¤ÏÏÂÈ„Ë Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ÙÔ ÌÂÁ¿ÏÔ Úfi‚ÏËÌ· Ù˘ Î¿Ï˘„˘ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ (ηٷϋÁÔ˘Ó ÛÙÔ ı¿Ó·ÙÔ >20% ÙˆÓ ÂÁÁÂÁÚ·ÌÌ¤ÓˆÓ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ ·Ó·ÌÔÓ‹˜) Ô‰‹ÁËÛ ÛÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ÙÌËÌ·ÙÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‹·ÙÔ˜, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙȘ Ù¯ÓÈΤ˜ ·) Ù˘ ÛÌ›ÎÚ˘ÓÛ˘ (reduced size), ‚) Ù˘ ‰È·›ÚÂÛ˘ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (Split grafts) Î·È Á) Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·fi ˙ÒÓÙ˜ Û˘ÁÁÂÓ›˜ ¢fiÙ˜ (living related donors). ∞) ∏ Ù¯ÓÈ΋ Ù˘ ÛÌ›ÎÚ˘ÓÛ˘ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (reduced size grafts) ÂÍ·ÛÊ·Ï›˙ÂÈ ÌÂÓ ÙÔ Î·Ù¿ÏÏËÏÔ Ì¤ÁÂıÔ˜ ÁÈ· ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ ÙÔ ˘fiÏÔÈÔ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ ·ÍÈÔÔÈÂ›Ù·È Î·È ‰ÂÓ ·˘Í¿ÓÂÙ·È ¤ÙÛÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. μ) ∏ ‰È·›ÚÂÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (Split grafts) ÂÍ·ÛÊ·Ï›˙ÂÈ ¤Ó· ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ÌfiÛ¯Â˘Ì· ÁÈ· ·È‰È·ÙÚÈÎfi §‹ÙË Î·È ¤Ó· ÌÂÁ·Ï‡ÙÂÚÔ ÁÈ· ÂÓ‹ÏÈη ·ÛıÂÓ‹. ∏ ‰È·›ÚÂÛË ÌÔÚ› Ó· Á›ÓÂÈ ex situ (ÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛ‹ ÙÔ˘ ·fi ÙÔÓ ¢fiÙË ÛÙÔ «›Ûˆ ÙÚ·¤˙È») ‹ in situ (ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ï‹„˘ ÙˆÓ ÔÚÁ¿ÓˆÓ Î·È ÚÈÓ ÙË ‰È·ÎÔ‹ Ù˘ ηډȷ΋˜ ΢ÎÏÔÊÔÚ›·˜). ™ËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· ÁÈ· ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ÙÂÏÂ˘Ù·›·˜ ·˘Ù‹˜ Ù¯ÓÈ΋˜ ·ÔÙÂÏ› Ô ‰È·ı¤ÛÈÌÔ˜ ¯ÚfiÓÔ˜ ¯ÂÈÚÔ˘ÚÁ›Ԣ ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ÙÔ˘ §‹ÙË, ·ÏÏ¿ ¤¯ÂÈ ÔÏÏ¿ ÏÂÔÓÂÎÙ‹Ì·Ù· Û ۯ¤ÛË Ì ÙÔÓ ex situ ‰È·¯ˆÚÈÛÌfi, ηıÒ˜ ÂÏ·ÙÙÒÓÂÙ·È Ô ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ÌÔÚ› Ó· ÂÎÙÈÌËı› Ë ‚ȈÛÈÌfiÙËÙ· ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ IV, ÂÚÈÔÚ›˙ÂÙ·È Ë ·ÈÌÔÚÚ·Á›· ηٿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË Î·È ‰È¢ÎÔχÓÂÙ·È Ë ‰È¿ıÂÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÂٷ͇ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ.
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∏ ‰È·›ÚÂÛË fï˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂÚÈΤ˜ ÊÔÚ¤˜ Â›Ó·È ·Ó¤ÊÈÎÙË, ÏfiÁˆ ÙˆÓ Û˘¯ÓÒÓ ·Ó·ÙÔÌÈÎÒÓ ·Ú·ÏÏ·ÁÒÓ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÛÙÔȯ›ˆÓ ÙÔ˘ ‹·ÙÔ˜ Î·È ÌfiÓÔ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ı· Ú¤ÂÈ Ï¤ÔÓ Û‹ÌÂÚ· Ó· ÂÊ·ÚÌfi˙ÂÙ·È Ë Ù¯ÓÈ΋ ÛÌ›ÎÚ˘ÓÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. °) ªÂÙ·ÌÔۯ‡ÛÂȘ ·fi ˙ÒÓÙ˜ Û˘ÁÁÂÓ›˜ ¢fiÙ˜ (living related donors). ∏ ÚÔËÁÔ‡ÌÂÓË ÂÌÂÈÚ›· Î·È Ù· ηϿ ·ÔÙÂϤÛÌ·Ù· ·fi ÙȘ ÙÌËÌ·ÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜, ΢ڛˆ˜ ÛÙ· ·È‰È¿, Ô‰‹ÁËÛ·Ó ÔÏÏ¿ ΤÓÙÚ· ÛÙËÓ ˘ÈÔı¤ÙËÛË Ù˘ ¯ÚËÛÈÌÔÔ›ËÛ˘ ˙ÒÓÙˆÓ ¢ÔÙÒÓ. ∞Ú¯Èο ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ù· ÙÌ‹Ì·Ù· II+III Ì Ôχ ηϿ ·ÔÙÂϤÛÌ·Ù·, ·ÏÏ¿ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË ·ÎfiÌË Ë ÂÌÂÈÚ›· ÁÈ· Ù· ÙÌ‹Ì·Ù· II+III+IV Î·È Ù· ÙÌ‹Ì·Ù· V+VI+VII+VIII. Δ· ÏÂÔÓÂÎÙ‹Ì·Ù· ·fi ÙË ¯ÚËÛÈÌÔÔ›ËÛË ·˘Ù‹˜ Ù˘ ËÁ‹˜ ÚÔ¤Ï¢Û˘ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È ÔÏÏ·Ï¿ Î·È Ë Â›Ï˘ÛË ÔÏÏÒÓ ·fi Ù· Ù¯ÓÈο ÚÔ‚Ï‹Ì·Ù· ÛÙÔ §‹ÙË Ô‰‹ÁËÛ Û ÂÓÙ˘ˆÛȷ΋ ÂÏ¿ÙÙˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ıÚfiÌ‚ˆÛ˘ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ Î·È ÙˆÓ ÂÈÏÔÎÒÓ ·fi Ù· ¯ÔÏËÊfiÚ·. ∏ ·ÛÊ¿ÏÂÈ· fï˜ ÙˆÓ ˙ÒÓÙˆÓ ¢ÔÙÒÓ, ÔÈ ÔÔ›ÔÈ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÈ· Ì›˙ÔÓ· ¤̂·ÛË, ‰ÂÓ ¤¯ÂÈ ·ÎfiÌ· Ï‹Úˆ˜ ÔÚÈÔıÂÙËı›. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ÛËÌ·ÓÙÈο ÔÛÔÛÙ¿ ÂÈÏÔÎÒÓ Î·È ·Ó·Ê¤ÚÔÓÙ·È Î·È ı¿Ó·ÙÔÈ ·ÎfiÌË, ÔÈ ÔÔ›ÔÈ ‰ÂÓ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı›. ÷ڷÎÙËÚÈÛÙÈ΋ Â›Ó·È Ë ÂÚ›ÙˆÛË ¢fiÙË, Ô˘ ˘Ô‚Ï‹ıËΠ۠Oª∏, ÁÈ·Ù› ÙÔ Ë·ÙÈÎfi ÙÌ‹Ì·, Ô˘ ·Ú¤ÌÂÈÓ ÌÂÙ¿ ÙËÓ Ë·ÙÂÎÙÔÌ‹, ‹Ù·Ó ·Ó·ÚΤ˜ ÁÈ· ÙÔÓ ›‰ÈÔ. ΔÔ Û‡Ó‰ÚÔÌÔ «ÌÈÎÚfi ÁÈ· ÙÔ Ì¤ÁÂıÔ˜» (small for size) Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ÛÔ‚·Úfi Úfi‚ÏËÌ·, ‰ÈfiÙÈ Û˘Ó‰¤ÂÙ·È Ì ÙÔÓ Î›Ó‰˘ÓÔ Ó· ÌËÓ Â·ÚΛ ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ÙÌ‹Ì· ÙÔ˘ ‹·ÙÔ˜ ÁÈ· ÙȘ ·Ó¿ÁΘ ÙÔ˘ §‹ÙË Î·È - fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ˙ÒÓÙ· ¢fiÙË - ÙÔ ÎÔÏfi‚ˆÌ· Ó· ÌËÓ ˘ÔÛÙËÚ›˙ÂÈ Â·ÚÎÒ˜ ÙȘ ·Ó¿ÁΘ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ÙÔ˘. ™˘ÌÂÚ·ÛÌ·ÙÈο ÏÔÈfiÓ 1) Ë Ù¯ÓÈ΋ Ù˘ ÛÌ›ÎÚ˘ÓÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¯ˆÚ›˜ Ó· ·˘Í¿ÓÂÈ ÙÔÓ
·ÚÈıÌfi ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ·Ó·Î·Ù·Ó¤ÌÂÈ Ù· ÌÔۯ‡̷ٷ ·fi ÂÓ‹ÏÈΘ Û ·È‰È¿ Î·È ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È ÌfiÓÔÓ fiÙ·Ó Ô ‰È·¯ˆÚÈÛÌfi˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ Â›Ó·È ÂÊÈÎÙfi˜ Î·È 2) Ô ‰È·¯ˆÚÈÛÌfi˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Î·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· Û˘ÁÁÂÓ‹ ¢fiÙË Ê·›ÓÂÙ·È fiÙÈ ÌÔÚÔ‡Ó Ó· ÚÔÛʤÚÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ¿Ì‚Ï˘ÓÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ¤ÏÏÂȄ˘ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Bussutil RW, Klintmalm GB, eds: Transplantation of the Liver. Philadelphia, Pa: WB Saunders; 1996. 2. Flye MW, ed: Principles of Organ Transplantation. Philadelphia, Pa: WB Saunders; 1989. 3. Patenaude YG, Dubois J, Sinsky AB, et al: Liver transplantation: review of the literature. Part 2: Vascular and biliary complications. Can Assoc Radiol J 1997 Aug; 48(4): 231-42 4. Reich D, Sharieff K, Behrend J, Manzarbeitia C: Venovenous bypass in liver transplantation. Graft Organ and Cell Transplantation 2000; 3: 81-5. 5. Otte JB, de Ville de Goyet J, Sokal E: Size reduction of the donor liver is a safe way to alleviate the shortage of size-matched organs in pediatric liver transplantation. Ann Surg 1990 Feb; 211(2): 146-57 6. Reyes J, Mazariegos GV: Pediatric transplantation. Surg Clin North Am 1999 Feb; 79(1): 163-89 7. Emond JC, Whitington PF, Thistlethwaite JR, et al: Transplantation of two patients with one liver. Analysis of a preliminary experience with ‘split-liver’ grafting. Ann Surg 1990 Jul; 212(1): 14-22 8. Broering DC, Wilms C, Bok P: Evolution of donor morbidity in living related liver transplantation: a single-center analysis of 165 cases. Ann Surg 2004 Dec; 240(6): 1013-24; discussions 1024-6 9. Jurim O, Shackleton CR, McDiarmid SV, et al: Livingdonor liver transplantation at UCLA. Am J Surg 1995 May; 169(5): 529-32 10. Tanaka K, Uemoto S, Tokunaga Y, et al: Surgical techniques and innovations in living related liver transplantation. Ann Surg 1993 Jan; 217(1): 82-91 11. Marcos A, Fisher RA, Ham JM, et al: Right lobe living donor liver transplantation. Transplantation 1999 Sep 27; 68(6): 798-803
Living related liver transplantation for pediatric recipients
11
Raymond Reding
Liver transplantation (LT) nowadays represents an efficient and broadly accepted therapy for patients with acute and chronic hepatic failure. Organ preservation, adequate surgical techniques and improvement in immunosuppression have extended the availability of LT to children and even infants, with however the continuing problem of limited access to size-matched organs from post-mortem pediatric donors. Out of necessity, several alternative surgical approaches have been designed to address this shortage, all of which use left segments of adult livers (segmental allografts), including reduced-size LT, split LT and livingdonor LT (LDLT). According to previous works from our centre, LDLT was found to reduce mortality among children on the waiting list, with improvement of post-transplant results through appropriate nutritional preparation of the recipient, better graft quality, shorter ischemic time, and putatively better immunological compatibility. Between March 1, 1984 and June 30, 2007, a total of 670 children (<15 years) received 782 LT at Saint-Luc University Hospital. Among them, the proportion of young recipients (<4 years) largely exceeded 70% of the total pediatric population, which required the use of reduced-size or split liver grafts retrieved from adult cadaveric donors. The latter technique paved the way for LDLT which was introduced at our centre in 1993. Since then, a total of 150 children received a left liver graft from a parental living donor. This experience was analysed in details, showing a significant advantage of patient and graft outcome when compared to liver grafts retrieved from postmortem donors, whatever the technique used. This advantage is particularly clear when considering recipients transplanted below 2 years, with 5 year patient and graft survival after LDLT now reaching 94% and 93%, respectively. With respect
to technical complications, LDLT were associated with a significantly lesser incidence of hepatic artery thrombosis, an incidence at 1% when compared to 13% after post-mortem donor LT (p<0.001). From an immunological perspective, however, it was rather paradoxical to observe a similar rate of acute rejection episodes in LDLT and post-mortem LT. Current investigations in this field include the validation of steroid-free, tacrolimus and anti-IL2R antibody based immunosuppressive protocols, with the aim to induce a prope tolerance status in the long-term. The mainstays of the pediatric liver transplant program at Saint-Luc University Hospital have been the multidisciplinary management organized in a specifically pediatric environment, the development of surgical alternatives to alleviate organ donor shortage, and the continuing search for the ideal immunosuppressive therapy. The introduction of LDLT since 1993 has provided a significant â&#x20AC;&#x153;boostingâ&#x20AC;? effect to our program, in terms of activity as well as of overall outcome. Along this experience, it clearly appeared that LDLT largely contributes to decrease the pressure on the post-mortem waiting list, allows better pretransplant survival by reducing the waiting time before LT, decreases ischemic injury to the donor graft, provides a lower incidence of vascular complications as well as better post-transplant outcomes in terms of patient and graft survival. Future development in LDLT may include the concept of crossover transplantation, in order to alleviate the problematic of ABO-incompatibility between recipients and living donor candidates.
Selected references 1. Evrard V, Otte JB, Sokal E, Rochet JS, Haccourt F, Gennari F, Latinne D, Jamart J, Reding R. Impact of Surgical and Immunological Parameters in Pediatric Liver Transplantation. A Multivariate Analysis in 500
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Consecutive Recipients of Primary Grafts. Annals of Surgery 239; 272-280, 2004. 2. Reding R. Steroid-free Organ Transplantation. The Lancet 363; 737-738, 2004. 3. Reding R. Is It Right to Promote Living Donor Liver Transplantation for Fulminant Hepatic Failure in Pediatric Recipients? American Journal of Transplantation 5; 1587-1591, 2005. 4. Cutillo L, Najimi M, Smets F, Janssen M, Reding R, de Ville de Goyet J, Sokal EM. Safety of Living-Related Liver Transplantation for Progressive Familial Intrahepatic Cholestasis. Pediatric Transplantation 10; 570574, 2006.
5. Darwish AA, Bourdeaux C, Kader HA, Janssen M, Sokal E, Lerut J, Ciccarelli O, Veyckemans F, Otte JB, de Ville de Goyet J, Reding R. Pediatric Liver Transplantation using Left Hepatic Segments from Living Related Donors: Surgical Experience in 100 Recipients at Saint-Luc University Clinics. Pediatric Transplantation 10; 345-353, 2006. 6. Bourdeaux C, Darwish A, Jamart J, Tri TT, Latinne D, Reding R. Living-Related versus Deceased Donor Pediatric Liver Transplantation: A Multivariate Analysis of Technical and Immunological Complications in 235 Recipients. American Journal of Transplantation 7; 440-447, 2007.
ICU treatment following liver transplantation
12
Fuat Hakan Saner
failure [2], which will last at least 3 weeks after successful liver transplantation. In 1953 Kowalski [3] et al. could show in a clinical trial, that patients with ESLD have a significant higher Cardiac output (CO) as compared with healthy volunteers. The high cardiac output is caused by nitric oxide (NO), which could be proved in animal trials [4], as well in clinical trials [5]. Moreover, patients with ESLD could develop an impaired contractility due to decreased number of adrenergic receptors [6]. The goal of our treatment should be the maintenance of a mean arterial pressure (MAP) of 70 mmHg, to preserve a safe organ perfusion, particularly the kidneys. In most cases this requires a volume challenge with colloids till a central venous pressure (CVP) of 10-12 mmHg is achieved, or if a right heart catheter is available a pulmonary capillary wedge pressure (PCWP) of 15 mbar should be adjusted. If a MAP of 70 mmHg could not be achieved a vasopressor like noradrenaline should be implemented in the therapy. For an optimal fluid and catecholamine management a right heart catheter should be placed. Briegel et al.
Despite liver transplantation is approved for more than 20 years as standard medical treatment for patients with end-stage liver disease (ESLD) only marginal data are available about liver transplantation and intensive care treatment [1]. The intensive care treatment for this patient population requires a high-end technical equipment and a very high skilled personal man power. The succeed of transplantation, we can also say the survival of the patient depends on a professional teamwork of all physicians (hepatologist, nephrologists, surgeons, anaesthesiologist, intensivist), who are involved in that case. Patients with ESLD have significant changes in their pathophysiology. For the best postoperative care we need a dedicated intensivist for liver transplantation, who is familiar with these changes. There are a lot of topics, which could be discussed, however, in this abstract we will highlight the main topics, changes in cardiovascular system, ventilation and kidney function.
1. Pathophysiology Hemodynamic Patients with ESLD develop a cardiovasculare
Figure 1. Due to increased translocation of bacteria and an impaired phagoctosis activity of the Kupffer cells in ESLD an increased cytokine production is evident. Inducible Nitric oxide synthase (iNOS) activity will be increased with huge amounts of nitric oxide. As a result the cGMP concentration is enlarged in the splanchnic area with a severe vasodilation, declining central and arterial blood volume, low Pulmonary capillary wedge pressure (PCWP), low central venous pressure (CVP), low systemic vascular resistance (SVR) and an increased cardiac output (CO).
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[7] showed that the use of hydrocortisone reduces the dose of catecholamine for maintain a stable MAP, the length of ventilation and stay on the ICU in septic patients. Recently a group from Taiwan [8] proved a higher mortality in patients with ESLD, sepsis and adrenal failure as compared with patients with ESLD, sepsis and without adrenal failure. From this point of view it is justified to use hydrocortisone to lower the catecholamine dose. There is an ongoing discussion about the CVP in liver transplant patients. Liverand transplant surgeons are scared about liver congestion if the CVP is higher than 5 mmHg. However, there are only a few prospective trails, which proved this topic. Jones et al. [9] showed that a CVP higher than 5 cm water! increases the blood loss. However, in this paper no data about kidney failure or patient outcome was mentioned. Schroeder et al [10] compared two different CVP policies, high vs. low (CVP above 5 mmHg or lower than 5 mmHg). The rate of kidney failure and mortality was significantly higher in the lower CVP group as compared in the higher group. These data are supported by our own investigation. Our group could show that even a CVP of 9 mmHg does not impair the liver outflow [11].
2. Lung Function Sixty to 120 minutes following reperfusion a very severe lung edema with hypoxemia can occur, which can cause an intraoperative death of the patient [12]. Increasing the inspiratory oxygen fraction would be only a symptomatic therapy and has only a very limited success [12]. A causative treatment would be an increase of the positiveend-expiratory pressure (PEEP). The functional residual capacity (FRC) could be restored with improving of the oxygenation. So far ventilation with PEEP levels higher than 5 mbar were considered as unsafe in liver transplant patients, since both animal- and clinical trials showed an impairment of liver outflow at PEEP levels higher than 5 mbar [13, 14]. Again our group [15] could show that a PEEP of 10 mbar does not impair the liver outflow in liver transplant patients. We recruited 65 patients following liver transplantation in our prospective study. All patients were studies within the first 4 postoperative hours postoperatively. At time of investigation all patients
were sedated, paralysed and controlled ventilated. To all patients 3 different PEEP levels (0, 5, 10 mbar) were applied, simultaneously the flow velocities of the hepatic artery(HA), the hepatic veins (HV), the portal vein (PV) and the hemodynamic data obtained from the right heart catheter were recorded. At all 3 PEEP levels we did not find a significant change of flow velocities HA, PV, and HV. Together with maintenance CO, it means that there is no impairment of liver outflow at a PEEP of 10 mbar.
3. Kidney function The kidney function of potential liver transplant recipients is impaired in up to 25% [16]. The hepatorenal syndrome (HRS) is a special kind of kidney failure at patients with ESLD [17]. It is associated with portal hypertension, tense ascites and intravascular hypovolemia [18]. As a result patients with HRS has an increased activity of renin, aldosterone and the sympathetic nervous system [17]. These vasopressor causes a vasoconstriction of the vas afferens and lowers the glomerular filtration rate (GFR). In the recent decade a couple of therapeutic options could be established for the treatment of HRS. The use of transjugularportosystemic-shunt (TIPPS) could remarkable improve kidney function [19, 20]. Another option is the use of V1 receptor agonist like Ornipressin [21] or terlipressin [22]. They induce a vasoconstriction in the splanchnic area. With simultaneous infusion of colloids they can reverse the HRS. Gonwa [23] could show in a retrospective study, that patients with HRS has the same outcome following liver transplantation as compared with patients without HRS. In a follow-up study 13 years later, Menon [16] could show that the requirement for dialyses is an independent predictor for mortality. Patients who needed dialyses pre-operatively had twofold higher mortality as compared with patients, who were transplanted without dialyses treatment. In conclusion, the successful intensive care treatment of liver transplant patients needs a stable hemodynamic with a MAP above 70 mmHg and a euvolemic volume status with a CVP between 6-10 mmHg. Oxygen impairment could be successful treated with an increased PEEP level up to 10 mbar without congestion of the liver.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
References 1. Saner, F., et al., Postoperative ICU management in liver transplant patients. Eur J Med Res, 2003. 8(11): p. 5116. 2. McGilvray, I.D. and P.D. Greig, Critical care of the liver transplant patient: an update. Curr Opin Crit Care, 2002. 8(2): p. 178-82. 3. Kowalski, The cardiac output in Laennec’s Cirrhosis. J Clin Invest, 1953. 32: p. 1025 - 1033. 4. Pizcueta, P., et al., Modulation of the hyperdynamic circulation of cirrhotic rats by nitric oxide inhibition. Gastroenterology, 1992. 103(6): p. 1909-15. 5. Albillos, A., et al., Enhanced endothelium-dependent vasodilation in patients with cirrhosis. Am J Physiol, 1995. 268(3 Pt 1): p. G459-64. 6. Ma, Z. and S.S. Lee, Cirrhotic cardiomyopathy: getting to the heart of the matter. Hepatology, 1996. 24(2): p. 451-9. 7. Briegel, J., et al., Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study. Crit Care Med, 1999. 27(4): p. 723-32. 8. Tsai, M.H., et al., Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock. Hepatology, 2006. 43(4): p. 673-81. 9. Jones, R.M., C.E. Moulton, and K.J. Hardy, Central venous pressure and its effect on blood loss during liver resection. Br J Surg, 1998. 85(8): p. 1058-60. 10. Schroeder, R.A., et al., Intraoperative fluid management during orthotopic liver transplantation. J Cardiothorac Vasc Anesth, 2004. 18(4): p. 438-41. 11. Saner FH, P.G., Gu Y, Gensicke J, Paul A, Radtke A, Bockhorn M, Fruhauf NR, Nadalin S, Malago M, Broelsch CE., Effects of positive end-expiratory pressure on systemic haemodynamics, with special interest to central venous and common iliac venous pressure in liver transplanted patients. Eur J Anaesthesiol., 2006. 23(9): p. 766-71. 12. Yost, C.S., M.A. Matthay, and M.A. Gropper, Etiology
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of acute pulmonary edema during liver transplantation: a series of cases with analysis of the edema fluid. Chest, 2001. 119(1): p. 219-23. 13. Brienza, N., et al., Effects of PEEP on liver arterial and venous blood flows. Am J Respir Crit Care Med, 1995. 152(2): p. 504-10. 14. Berendes, E., et al., Effects of positive end-expiratory pressure ventilation on splanchnic oxygenation in humans. J Cardiothorac Vasc Anesth, 1996. 10(5): p. 598602. 15. Saner FH, P.G., Gu Y, Fruhauf NR, Paul A, Radtke A, Nadalin S, Malago M, Broelsch CE., Does PEEP impair the hepatic outflow in patients following liver transplantation? Intensive Care Med., 2006. 32(10): p. 1584-90. 16. Narayanan Menon, K.V., et al., MELD and other factors associated with survival after liver transplantation. Am J Transplant, 2004. 4(5): p. 819-25. 17. Gines, P., et al., Hepatorenal syndrome. Lancet, 2003. 362(9398): p. 1819-27. 18. Cardenas, A., et al., Hepatorenal syndrome. Liver Transpl, 2000. 6(4 Suppl 1): p. S63-71. 19. Brensing, K.A., et al., Transjugular intrahepatic portosystemic stent-shunt for hepatorenal syndrome. Lancet, 1997. 349(9053): p. 697-8. 20. Guevara, M., et al., Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology, 1998. 28(2): p. 416-22. 21. Guevara, M., et al., Reversibility of hepatorenal syndrome by prolonged administration of ornipressin and plasma volume expansion. Hepatology, 1998. 27(1): p. 3541. 22. Uriz, J., et al., Terlipressin plus albumin infusion: an effective and safe therapy of hepatorenal syndrome. J Hepatol, 2000. 33(1): p. 43-8. 23. Gonwa, T.A., et al., Long-term survival and renal function following liver transplantation in patients with and without hepatorenal syndrome—experience in 300 patients. Transplantation, 1991. 51(2): p. 428-30.
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∂‰Ò ı· ·Û¯ÔÏËıԇ̠̠ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË, ÓÔÛËÏ›· Î·È ÊÚÔÓÙ›‰· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ·ÛıÂÓÔ‡˜ ÛÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô Î˘Ú›ˆ˜ ÛÙËÓ ª∂£. Δ· ‚È‚ÏÈÔÁÚ·ÊÈο ÛÙÔȯ›· ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ‹Ù·Ó ÂÚÈÔÚÈṲ̂ӷ (ÁÈ·Ù› Û˘Ó‹ıˆ˜ ÂÍ·ÈÚÔ‡ÓÙ·È ·fi ÙȘ ÌÂϤÙ˜ ÙˆÓ ª∂£) fï˜ Ì ÙËÓ ·‡ÍËÛË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÚÔÛÙ›ıÂÓÙ·È Î·ÈÓÔ‡ÚÁÈ· ÛÙÔȯ›· Î·È Ë ÚÔÛ¤ÁÁÈÛË ÙˆÓ ·ÚÚÒÛÙˆÓ ·˘ÙÒÓ Á›ÓÂÙ·È Â˘ÎÔÏfiÙÂÚË. ∏ ηχÙÂÚË ÁÓÒÛË Ù˘ Ê˘ÛÈÔ·ıÔÏÔÁ›·˜ Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (ESLD) Ô‰ËÁ› Û ηÈÓÔ‡ÚÁȘ ıÂڷ¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ fiÛÔÓ ·ÊÔÚ¿ ÙÔ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ (hepatorenal syndrome-HRS), ÙÔ Ë·ÙÔÓ¢ÌÔÓÈÎfi Û‡Ó‰ÚÔÌÔ (hepatopulmonary syndrome –HPS) Î·È ÙËÓ ˘Ï·ÈÔÓ¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË (portopulmonary hypertension- PPHTN), Î·È ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË ‰˘Ó·ÙfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘˜, ΢ڛˆ˜ Ì ÙËÓ ·‡ÍËÛË ÙˆÓ ˙ÒÓÙˆÓ ‰ÔÙÒÓ. ¢È¿ÊÔÚÔÈ ·Ú¿ÁÔÓÙ˜ fiˆ˜: Ë ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‰È¿ÁÓˆÛË, ÙÔ MELD score, Ë ‚·Ú‡ÙËÙ· Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙÔÓ ¯ÚfiÓÔ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, Û˘Ó˘¿Ú¯ÔÓÙ· ÓÔÛ‹Ì·Ù· Î·È Û˘Ì‚¿Ì·Ù· ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ÂËÚ¿˙Ô˘Ó ÙÔÓ ¯ÚfiÓÔ ·Ó¿Ó˄˘ ÙÔ˘ ·ÛıÂÓÔ‡˜. ∏ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ fiˆ˜ ÂÚÈÁÚ¿ÊÂÙ·È ·fi ÙÔ APACHE II score, ÙÔ UNOS Î·È ÙÔ MELD score, Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ‹ fi¯È ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÔÚÁ¿ÓˆÓ ÌÂÙÂÁ¯ÂÈÚËÙÈο, Ô˘ Ì ÙË ÛÂÈÚ¿ Ù˘ ÂËÚ¿˙ÂÈ ÙËÓ ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ.
¶›Ó·Î·˜ 1. Heart rate Mean arterial pressure Cardiac output Cardiac index Stroke volume Stroke volume index Central venous pressure Systemic vascular resistance Systemic vascular resistance index Pulmonary vascular resistance Pulmonary vascular resistance index Pulmonary arterial pressure (mean) Pulmonary arterial pressure (diastolic)
°›ÓÂÙ·È Î·Ù·Ì¤ÙÚËÛË Î·È Î·Ù·ÁÚ·Ê‹ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ˘ÁÚÒÓ ·ÏÏ¿ Î·È ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·Ô‚·ÏÏfiÌÂÓˆÓ ·fi ÙÔÓ ÚÈÓÔÁ·ÛÙÚÈÎfi ۈϋӷ, ÙȘ ·ÚÔ¯ÂÙ‡ÛÂȘ Î·È ÙÔ kehr – fiÙ·Ó ˘¿Ú¯ÂÈ – ÔÛÔÙÈο Î·È ÔÈÔÙÈο, ηıÒ˜ Î·È Ù˘ ‰ÈÔ‡ÚËÛ˘. ∂¿Ó ˘¿Ú¯ÂÈ Î·ıÂÙ‹Ú·˜ ̤ÙÚËÛ˘ Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ ( ÙÔÔıÂÙ›Ù ÚÔÂÁ¯ÂÈÚËÙÈο) ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ ÌÂÙ·‚ÔϤ˜ Ù˘ ICP Î·È Ù˘ CPP. ÕÌÂÛ· Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ·/· ıÒÚ·ÎÔ˜ Î·È ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ (›Ó·Î·˜ 2).
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù· ¶›Ó·Î·˜ 2. Complete blood count Arterial blood gases Coagulation profile Complete metabolic panel
O ˘ÔÏÔÁÈÛÌfi˜ ÙˆÓ Á·Ï·ÎÙÈÎÒÓ ÙÔ˘ ·›Ì·ÙÔ˜ ‚ÔËı¿ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ÈηÓfiÙËÙ·˜ ÙÔ˘ ‹·ÙÔ˜ fiÙ·Ó Ë Î·Ú‰È·Î‹ ·ÚÔ¯‹ Î·È Ë ¿Ú‰Â˘ÛË ÙˆÓ ÈÛÙÒÓ Â›Ó·È ÈηÓÔÔÈËÙÈ΋. ª¤ÙÚËÛË Ù˘ ÎÂÓÙÚÈ΋˜ ıÂÚÌÔÎÚ·Û›·˜ ÛÒÌ·ÙÔ˜ (ÂÈı˘ÌËÙ‹ > 37Æ C). ∏ ˘ÔıÂÚÌ›· ÂÈÙ›ÓÂÈ ÙȘ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. £ÂˆÚËÙÈο Ì ÙËÓ ÓÔÚÌÔıÂÚÌ›· ı· ÌÔÚÔ‡Û·Ó Ó· ÂÏ·ÙÙˆıÔ‡Ó ÔÈ ÌÂÙ·ÁÁ›ÛÂȘ ·Ú·ÁÒÁˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È Ó· ÂÈÙ¢¯ı› ηχÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ Ù˘ ·ÈÌÔÚÚ·Á›·˜. ™ËÌ·ÓÙÈ΋ Â›Ó·È Â›Û˘ Ë Ó¢ÚÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ·ÚÚÒÛÙÔ˘ – fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Û˘ÓÙÔÌfiÙÂÚ· – Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÂȤ‰Ô˘ ·ʋ˜, Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜, Ù˘ ·ÈÛıËÙÈÎfiÙËÙ·˜ Î·È ÙˆÓ ·ÓÙ·Ó·ÎÏ¿ÛˆÓ. ™ÙÔ ÔÚÈ·Îfi ‹·Ú Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ ÙˆÓ ·Ó·ÈÛıËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ·Ê‡ÓÈÛË ÌÂÙ¿ ÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô Î·ıÒ˜ Î·È Ô ‚·ıÌfi˜ Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Ô˘ ·Ú·Ì¤ÓÂÈ Î·È Ë ‡·ÚÍË ‹ fi¯È Û·ÛÌÒÓ (Û˘¯ÓÔ› ÌÂÙÂÁ¯ÂÈÚËÙÈο). ™ÙÔÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ· ¿ÚÚˆÛÙÔ ÌÂÙ¿ ·fi ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ·Ó·Áη›Ô Â›Ó·È ÙÔ monitoring Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ›ÂÛ˘ ‰È‹ıËÛ˘. ∞Ó¿ÏÔÁ· Ì ÙȘ ÎÏÈÓÈΤ˜ ÂӉ›ÍÂȘ Î·È ÙÔ ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ı· Â›Ó·È Î·È Ë ‰È·¯Â›ÚÈÛË ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ, ÌÂÙ·‚ÔÏÈÎÒÓ, ηډÈÔ·Ó·Ó¢ÛÙÈÎÒÓ Î·È ‰È·ÙÚÔÊÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ªÈ· Û·Ê‹˜ Ù·ÍÈÓfiÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÌÂÙÂÁ¯ÂÈÚËÙÈο, ÚÔÙ¿ıËΠۯÂÙÈο ÚfiÛÊ·Ù· (2001). ™‡Ìʈӷ Ì ·˘Ù‹ ÔÈ ·ÛıÂÓ›˜ Ù·ÍÈÓÔÌÔ‡ÓÙ·È Û 4 ÔÌ¿‰Â˜ – ηÙËÁÔڛ˜ Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„ÈÓ ÙËÓ ·ÚÔ˘Û›· Î·È ÙÔÓ ‚·ıÌfi Ù˘ ˘ÂÚ‰˘Ó·ÌÈ΋˜ ΢ÎÏÔÊÔÚ›·˜, Ù· ›‰· ÙÔ˘ ¡·, ÙËÓ
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‰È·Ù·Ú·¯‹ Ù˘ ıÚ¤„˘ (ÏÂ˘ÎˆÌ·Ù›ÓË ÔÚÔ‡), ÙËÓ ‡·ÚÍË ˘Ï·ÈÔÓ¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘ Î·È ÙËÓ Î·Ú‰È·Î‹ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· (fiˆ˜ ηıÔÚ›˙ÂÙ·È ·fi ÙÔ ÚÔÂÁ¯ÂÈÚËÙÈÎfi echo Î·È ÙÔ dobutamine stress echo) – (›Ó·Î·˜ 3). ∏ ηٿٷÍË ·˘Ù‹ ÂȯÂÈÚ› Ó· Ù·ÍÈÓÔÌ‹ÛÂÈ ÙÔ˘˜ ·ÛıÂÓ›˜ Û ÔÌ¿‰Â˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ÂÈ‚¿Ú˘ÓÛË Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Î·È Ó· ηÙ¢ı‡ÓÂÈ ÂÎ ÙˆÓ ÚÔÙ¤ÚˆÓ ÙËÓ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ÙËÓ ‰È·¯Â›ÚÈÛË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ™ÙËÓ Î·ÙËÁÔÚ›· π ·Ó·Ì¤ÓÂÙ·È ÔÈ ·ÛıÂÓ›˜ Ó· ··ÓÙÔ‡Ó Û¯Â‰fiÓ Ê˘ÛÈÔÏÔÁÈο ÛÙËÓ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È Ó· ··ÈÙÔ‡Ó ÏÈÁfiÙÂÚ· ˘ÁÚ¿ ·fi ÙËÓ Î·ÙËÁÔÚ›· ππ, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÂÁ·Ï‡ÙÂÚÔ ·ÛΛÙË, ·ÒÏÂÈ· ÚˆÙÂÈÓÒÓ Î·È ¤¯ÂÈ ·Ó¿ÁÎË ÈÔ ÂÈıÂÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ˘ÁÚÒÓ Î·È ÚˆÙÂÈÓÒÓ. ªÂ ÙËÓ ÂÈ‚¿Ú˘ÓÛË Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ‰ËÏ·‰‹ Ì ÙËÓ ·‡ÍËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ (CO) Î·È ÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ ÂÚÈÊÂÚÈÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ (SVR) - (˘ÂÚ‰˘Ó·ÌÈ΋ ΢ÎÏÔÊÔÚ›·) Ë ÂÚÌËÓ›· ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Î·ı›ÛÙ·Ù·È fiÏÔ Î·È ÈÔ ‰˘Û¯ÂÚ‹˜ Î·È ¯ÚÂÈ¿˙ÂÙ·È ÚÔÛÔ¯‹ Î·È ÏÂÙÔÌÂÚ‹˜ ηٷÁÚ·Ê‹ Ù˘ ÂÈ‚¿Ú˘ÓÛ˘ ¿ÏÏˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ fiˆ˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (‰ÈÔ‡ÚËÛË). ™ÙËÓ Î·ÙËÁÔÚ›· πππ Î·È IV Ô ·ÛıÂÓ‹˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ ·ÛΛÙË Î·È ÂÌÊ·Ó‹ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ‰È·ÊfiÚÔ˘ ‚·ıÌÔ‡. ∏ ÚÔÛ¤ÁÁÈÛË ÛÙËÓ ÔÏÈÁÔ˘Ú›· ‹ ÙËÓ ˘fiÙ·ÛË Ú¤ÂÈ Ó· Â›Ó·È ‰È·ÊÔÚÂÙÈ΋ ·fi ÙȘ ¿ÏϘ ÔÌ¿‰Â˜ (ηÙËÁÔÚ›· π Î·È ππ). ∏ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È ËÏÂÎÙÚÔÏ˘ÙÒÓ ··ÈÙ› ÚÔÛ¯ÙÈ΋ ‰È·¯Â›ÚÈÛË ÁÈ· ·ÔÊ˘Á‹ ˘ÂÚÊfiÚÙˆÛ˘ ·ÏÏ¿ Î·È ÂÏÏ›ÌÌ·ÙÔ˜ ˘ÁÚÒÓ. OÈ ·ÛıÂÓ›˜ ÌÂÙ¿ ÙËÓ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û˘¯Ó¿ ÂÌÊ·Ó›˙Ô˘Ó ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∏ ˘ÔÓ·ÙÚÈ·ÈÌ›· Â›Ó·È Û˘¯Ófi ‡ÚËÌ· ÛÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ¡· Ú¤ÂÈ Ó· Â›Ó·È Ôχ ÚÔÛ¯ÙÈ΋. ∏ ÂÈıÂÙÈ΋ ·ÓÙÈηٿÛÙ·ÛË ÙÔ˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÔÌ˘ÂϛӈÛË Ù˘ Á¤Ê˘Ú·˜ Î·È Ó¢ÚÔ„˘¯ÈΤ˜ ‰È·Ù·Ú·¯¤˜ (̤ÁÈÛÙË ¯ÔÚ‹ÁËÛË ¡· ª 0,5mEq/kg/h). ∏ ˘ÔÌ·ÁÓËÛÈ·ÈÌ›·, Ë ˘ÔʈÛÊ·Ù·ÈÌ›· Î·È Ë ˘Ôη-
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A. KAPA¶ANA°IøTOY
ÏÈ·ÈÌ›· ··ÈÙÔ‡Ó ‰ÈfiÚıˆÛË. OÊ›ÏÔÓÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ¯Ú‹ÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Î·È Û˘Óԉ‡ÔÓÙ·È ·fi ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË. ∏ ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË (ˆ˜ ·ÓÂÍ¿ÚÙËÙË ÌÂÙ·‚ÏËÙ‹ ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ·Ú¿Ù·ÛË ÓÔÛËÏ›·˜ ÛÙËÓ ª∂£) ÔÊ›ÏÂÙ·È ÂÓ Ì¤ÚÂÈ ÛÙȘ ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ·ÏÏ¿ Î·È ÛÙÔ ¤ÏÏÂÈÌÌ· fiÁÎÔ˘, ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ÎÈÙÚÈÎÒÓ ÙÔ˘ Û˘ÓÙËÚË̤ÓÔ˘ ·›Ì·ÙÔ˜ Û ‰ÈÙ·ÓıÚ·ÎÈο, ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ Á·Ï·ÎÙÈÎÒÓ (·fi ÙÔ ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì·) η› ÙËÓ ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ. ™Â ¤ÏÏÂÈÌÌ· ‚¿Û˘ > 6-7 mEq ‰ÈÙ·ÓıÚ·ÎÈο ÂÚÈÛÛfiÙÂÚ· ·fi 40mEq/l ¯ÔÚËÁÂ›Ù·È ·ÎÂÙ·˙ÔÏ·Ì›‰Ë. ŒÏÂÁ¯Ô˜ ÁÏ˘Îfi˙˘ ¤ÙÛÈ ÒÛÙ ٷ ›‰· ÙÔ˘ ·›Ì·ÙÔ˜ Ó· Î˘Ì·›ÓÔÓÙ·È ÛÙ· 4-6 mmol/l (Van der Berge et al NEJM 2001; 345:1359-67). ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· ·Ô‰›‰ÂÙ·È ÛÙÔ ÂÚÈÂÁ¯ÂÈÚËÙÈÎfi stress Î·È ÙËÓ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ (·Ó·Ú΋˜ Ë·ÙÈ΋ ÁÏ˘ÎÔÓÂÔÁ¤ÓÂÛË Î·È ·ÓÔ¯‹ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË ÏfiÁˆ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ). ∏ ˘ÔÁÏ˘Î·ÈÌ›· Â›Ó·È Î·Îfi ÚÔÁÓˆÛÙÈÎfi ÛËÌÂ›Ô Î·È ÌÔÚ› Ó· ÚÔËÁËı› Ù˘ ·Ó¿ÚÎÂÈ·˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∞πªO¢À¡∞ªπ∫∂™ ¢π∞Δ∞ƒ∞Ã∂™ ΔÔ monitoring, ·ÈÌ·ÙËÚfi ‹ ÌË, ¤¯ÂÈ ˆ˜ ÛÎÔfi ÙÔÓ ¤ÏÂÁ¯Ô Î·È ÙËÓ ‰È·Ù‹ÚËÛË Â·ÚÎÔ‡˜ ÌÂÙ·ÊÔÚ¿˜ Ô͢ÁfiÓÔ˘ ÛÙÔ˘˜ ÈÛÙÔ‡˜. ∂›Ó·È ‡ÎÔÏÔ Ó· ‰È·ÙËÚËı› ÂϤÁ¯ÔÓÙ·˜ ÙÔÓ ÎÔÚÂÛÌfi ÙÔ˘ ÌÈÎÙÔ‡ ÊÏÂ-
‚ÈÎÔ‡ ·›Ì·ÙÔ˜ (SvO2) Î·È ÙÔÓ ÎÔÚÂÛÌfi ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙÔÓ ‰ÂÍÈfi ÎfiÏÔ (ScvO2). M ÙȘ ÌÂÙÚ‹ÛÂȘ Ì ÙÔÓ Î·ıÂÙ‹Ú· Swan- Ganz ÙÈÙÏÔÔÈԇ̠ٷ ÈÓfiÙÚÔ· - ·ÁÁÂÈÔÛ˘Û·ÛÙÈο Ô˘ ··ÈÙÔ‡ÓÙ·È. Ÿˆ˜ ·Ó·Ê¤ÚıËÎÂ, Ë ˘ÂÚ‰˘Ó·ÌÈ΋ ΢ÎÏÔÊÔÚ›· Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÙÔ˘ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Ô˘ ·ӤگÂÙ·È ÛÙ· Ê˘ÛÈÔÏÔÁÈο ›‰· Û 2 ‚‰ÔÌ¿‰Â˜. ªÔÚ›, Û ÌÈÎÚ¿ ÔÛÔÛÙ¿, Ó· ·Ú·Ì›ÓÂÈ ¤ˆ˜ 2 ¯ÚfiÓÈ·.
∞ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ - º·›ÓÂÙ·È Ó· ·Ó·ÛÙÚ¤ÊÔÓÙ·È - OÈ Û˘ÛÙËÌ·ÙÈΤ˜ ÂÚÈÊÂÚÈΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ Î·È Ë Î·Ú‰È·Î‹ ·ÚÔ¯‹ ·ӤگÔÓÙ·È ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰· Û 2 ‚‰ÔÌ¿‰Â˜ – ÂÏ¿¯ÈÛÙ· ·Ú·Ì¤ÓÔ˘Ó ¤ˆ˜ 2 ¯ÚfiÓÈ· (Hepatol. 1993 _ 17 : 355) ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ Î·Ú‰È·Î‹ ÏÂÈÙÔ˘ÚÁ›·, ‰‡Ô ÎÏÈÓÈΤ˜ ÔÓÙfiÙËÙ˜ ·Í›˙ÂÈ Ó· ÛËÌÂȈıÔ‡Ó ÛÙÔÓ ¿ÚÚˆÛÙÔ Ì ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜: Ë ÎÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· Î·È Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜. ¶·Ú¿ ÙËÓ ˘ÂÚ‰˘Ó·ÌÈ΋ ΢ÎÏÔÊÔÚ›· Î·È ÙËÓ ·˘ÍË̤ÓË Î·Ú‰È·Î‹ ·ÚÔ¯‹, ÙËÓ ‰ÂηÂÙ›· ÙÔ˘ 1960 ·Ú·ÙËÚ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ ¿Ì‚Ï˘ÓÛË Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘. ∞Ú¯Èο ‚Ú¤ıËΠÛÙÔ˘˜ ·ÚÚÒÛÙÔ˘˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Î·È ¯·Ú·ÎÙËÚ›ÛÙËΠ·ÏÎÔÔÏÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·, ·Ô‰Â›¯ıËΠfï˜ Î·È Û ÌË ·ÏÎÔÔÏÈΤ˜ Ë-
∞ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ Û ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·(EDLD): ∞‡ÍËÛË Ù˘ ∫·Ú‰È·Î‹˜ ¶·ÚÔ¯‹˜ Î·È ÂÏ¿ÙÙˆÛË ÙˆÓ ¶ÂÚÈÊÂÚÈÎÒÓ ∞ÓÙÈÛÙ¿ÛˆÓ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
·ÙÈΤ˜ ·Ó¿ÚÎÂȘ Î·È ¯·Ú·ÎÙËÚ›ÛÙËΠˆ˜ ÎÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÂÏ·Ùو̤ÓË Û˘ÛÙ·ÏÙÈÎfiÙËÙ·: ÂÏ·Ùو̤ÓË ·¿ÓÙËÛË ÛÙȘ ηÙ¯ÔϷ̛Ә Î·È ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi stress, ·‡ÍËÛË ÙˆÓ È¤ÛÂˆÓ Ï‹ÚˆÛ˘ Ì ÌÈÎÚ‹ ÌÂÙ·‚ÔÏ‹ ÙÔ˘ fiÁÎÔ˘. ¶Èı·ÓÒ˜ ÔÊ›ÏÂÙ·È Û ›ÓˆÛË Î·È Ô›‰ËÌ· ÙˆÓ Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ, ‰È·Ù·Ú·¯‹ Ù˘ Ú¢ÛÙfiÙËÙ·˜ ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ Î·È ÙˆÓ ‚-˘Ô‰Ô¯¤ˆÓ, Û·Ó ·ÔÙ¤ÏÂÛÌ· ·˘ÍË̤Ó˘ ¤ÎÎÚÈÛ˘ ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ (¡O, ÂÓ‰ÔıËÏ›ÓË 1). ∏ÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο ÂÌÊ·Ó›˙ÔÓÙ·È ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÁˆÁÈÌfiÙËÙ·˜.
To Ì˘ÔοډÈÔ ÂÌÊ·Ó›˙ÂÈ ÂÏ·Ùو̤ÓË ·¿ÓÙËÛË ÛÙËÓ ÓÙÔ·Ì›ÓË Î·È ÓÙÔ‚Ô˘Ù·Ì›ÓË. ™Â ÔÏϤ˜ ÂÚÈÙÒÛÂȘ ÌÂÙ¿ ÙËÓ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ηډȷ΋ ·Ó¿ÚÎÂÈ·. ¶ÚÔÂÁ¯ÂÈÚËÙÈο Èı·ÓÒ˜ Ó· ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙÔ B-NP. À¿Ú¯Ô˘Ó fï˜ ÂÚÈÔÚÈṲ̂Ó˜ ÌÂϤÙ˜. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi 5-10% Î·È Û¯ÂÙ›˙ÂÙ·È Ì η΋ ¤Î‚·ÛË ·ÎfiÌË Î·È ·Ó ¤¯ÂÈ ·ÓÙÈÌÂÙˆÈÛÙ› (50% ıÓËÙfiÙËÙ· Û 1-3¯Ú. follow-up) Î·È ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÓÔÛËÚfiÙËÙ· 80%. ∏ ÂÓÂÚÁfi˜ ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ Â›Ó·È Û¯ÂÙÈ΋ ·ÓÙ¤Ó‰ÂÈÍË Î·È Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÚÔÂÁ¯ÂÈÚËÙÈο (stent, ·ÁÁÂÈÔÏ·ÛÙÈ΋). ¶ÚfiÛÊ·Ù· ¤¯Ô˘Ó ·Ó·ÊÂÚı› Î·È ÂÚÈÛÙ·ÙÈο
229
Ì ٷ˘Ùfi¯ÚÔÓË ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È μy pass.
ŒÏÂÁ¯Ô˜ Û ·ÚÚÒÛÙÔ˘˜ Ì ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ 1. test ÎfiˆÛ˘ 2. dobutamine stress echo (fi¯È ·ÍÈfiÈÛÙÔ – 60% „¢‰Ò˜ ıÂÙÈÎfi) K·È ÚÔÂÁ¯ÂÈÚËÙÈο ÛÙËÓ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ Î·Ù¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ ÁÈ· Ì›˙ÔÓ˜ ÌË Î·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ (∞CC/AHA) – JACC 2002 ; 39; 542 ™ÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô Û˘¯Ó¿ ÚÔ‚Ï‹Ì·Ù· ·ÔÙÂÏÔ‡Ó ÔÈ ·ÚÚ˘ı̛˜ fiˆ˜ Ë ÎÔÏÈ΋ Ì·ÚÌ·Ú˘Á‹. ∞Ô‰›‰ÔÓÙ·È Û˘¯Ó¿ Û ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜, ¯ÔÚ‹ÁËÛË ÈÓÔÙÚfiˆÓ Î·È ˘ÂÚÊfiÚÙˆÛË Ì ˘ÁÚ¿. ∏ ıÂڷ›· Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ¿ÚÛË ÙÔ˘ ˘ÔΛÌÂÓÔ˘ ·ÈÙ›Ô˘ Î·È ÙËÓ ¯Ú‹ÛË ·ÓÙÈ·ÚÚ˘ıÌÈÎÒÓ (fiˆ˜ ‚-·ÔÎÏÂÈÛÙÒÓ). H ˘¤ÚÙ·ÛË Î·Ù·ÁÚ¿ÊÂÙ·È Û ÔÛÔÛÙfi ÂÚ›Ô˘ 80% ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ™˘Û¯ÂÙ›˙ÂÙ·È Ì ÂÓ‰ÔÂÁÎÂÊ·ÏÈΤ˜ ·ÈÌÔÚÚ·Á›Â˜ Î·È Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ÒÛÙ ӷ Â›Ó·È Ë ™∞¶ >140 mmHg Î·È Ë ¢∞¶ <80 mmHg. ø˜ ·›ÙÈ· ·Ó·Ê¤ÚÔÓÙ·È ÙÔ ÚÔËÁÔ‡ÌÂÓÔ ÈÛÙÔÚÈÎfi, Ô fiÓÔ˜, Ë ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·, Ô ˘Ô·ÂÚÈÛÌfi˜, Ë ˘ÂÚÊfiÚÙˆÛË ‹ ·ÎfiÌË Î·È rebound Ù˘ ›ÂÛ˘ Â¿Ó ÛÙËÓ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô Â›¯·Ó ¯Ú‹ÛÈÌÔÔÈËı› ‚-·ÔÎÏÂÈÛÙ¤˜ Ë/Î·È ÎÏÔÓȉ›ÓË Ô˘ Â›Ó·È Î·È Ù· Ê¿Ú̷η ÂÎÏÔ-
A. KAPA¶ANA°IøTOY
230
Á‹˜ ÛÙÔ˘˜ ·ÚÚÒÛÙÔ˘˜ Ì ESLD. ∂ÈϤÔÓ Û ¤Ó· ÔÛÔÛÙfi Ë ˘¤ÚÙ·ÛË ÔÊ›ÏÂÙ·È Î·È ÛÙËÓ ¿ÌÂÛË ‰Ú¿ÛË ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ fiˆ˜ Ë Î˘ÎÏÔÛÔÚ›ÓË. ∂Ó·ÏÏ·ÎÙÈο ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·› ÔÈ ·Ó·ÛÙÔÏ›˜ ·Û‚ÂÛÙ›Ô˘. ∞¡∞¶¡∂À™Δπ∫O ™À™Δ∏ª∞ ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÂÈÏÔÎÒÓ ·Ó¤Ú¯ÂÙ·È Û ˘„ËÏfi ÔÛÔÛÙfi (75%) Î·È ¤¯Ô˘Ó ˘„ËÏfi ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜. ∏ ·ÙÂÏÂÎÙ·Û›·, ÔÈ Ï¢ÚÈÙÈΤ˜ Û˘ÏÏÔÁ¤˜ (Û˘¯ÓfiÙÂÚ· ‰ÂÍÈ¿ ·ÏÏ¿ Î·È ¿Ìʈ), Ë ÂÏ·Ùو̤ÓË FRC Ô˘ ·Ó¢ڛÛÎÔÓÙ·È ÚÔÂÁ¯ÂÈÚËÙÈο Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ ·ÛΛÙË. ∏ ¤̂·ÛË ÛÙËÓ ¿Óˆ ÎÔÈÏ›· Î·È Ô ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi˜ ÂÈÏÂfi˜ ÂÏ·ÙÙÒÓÔ˘Ó ÂÚ·ÈÙ¤Úˆ ÙËÓ ˙ˆÙÈ΋ ¯ˆÚËÙÈÎfiÙËÙ·. ∏ η΋ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ıÚ¤„Ë Î·È Ë Ùˆ¯‹ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ì˘ÒÓ ÂÏ·ÙÙÒÓÔ˘Ó ÙËÓ ÈηÓfiÙËÙ· ·ÔÌ¿ÎÚ˘ÓÛ˘ ÙˆÓ ÂÎÎÚ›ÛÂˆÓ ÛÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô. À¿Ú¯ÂÈ ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Ó¢ÌÔÓ›·˜ (Û˘Óԉ¢fiÌÂÓË Ì ·˘ÍË̤ÓË ıÓËÙfiÙËÙ·). ∂›Ó·È ÂÈı˘ÌËÙ‹ Ë fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Û˘ÓÙÔÌfiÙÂÚË ·Ô‰È·ÛˆÏ‹ÓˆÛË Î·È Ë ·Ô‰¤ÛÌ¢ÛË ·fi ÙÔÓ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi (·ÎfiÌË Î·È 3 ÒÚ˜ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË). ¶›Ó·Î·˜ 4. KÚÈÙ‹ÚÈ· ·Ô‰¤ÛÌ¢Û˘ Awake, alert, good muscle strength/tone Respiratory rate Tidal volume Arterial PO2 FiO2 Minute ventitation Metacholine inhalational challenge Peak inspiratory pressure Compliance
<30 breaths per minute >5 mL/kg >70 mmHg <0.4 <10 L/min >-25 cm H2O > 52 to 30 cm H2O > 30 mL/cm
¶Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· Û¯ÂÙÈ˙fiÌÂÓÔ Ì ÙȘ ÌÂÙ·ÁÁ›ÛÂȘ Â›Ó·È Û˘¯Ófi ÌÂÙÂÁ¯ÂÈÚËÙÈο. ∏ ıÂڷ›· Û˘Ó›ÛÙ·Ù·È Û ·‡ÍËÛË ÙÔ˘ FiO2 Î·È ÙÔ˘ PEEP Î·È Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ. ™˘Ó‹ıˆ˜ ˘Ô¯ˆÚ› ÌÂÙ¿ ÌÂÚÈΤ˜ ÒÚ˜. ΔÔ ARDS Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Û˘¯Ófi ÌÂÙ¿ ·fi ·ӷÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂÙÂÁ¯ÂÈÚËÙÈο ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ÂÌÊ·Ó›˙ÔÓÙ·È Ì ÂÚ›ÛÛÂÈ· ˘ÁÚÒÓ, ·Ó·Áη›· ‰ÈÂÁ¯ÂÈÚËÙÈο ·ÏÏ¿ Î·È ¿ÌÂÛ· ÌÂÙÂÁ¯ÂÈÚËÙÈο fiˆ˜ Î·È ·ÚÎÂÙ¤˜ ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ. ™˘¯Ó‹ Ë ÂÌÊ¿ÓÈÛË Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Û¯ÂÙÈ˙fiÌÂÓÔ˘ Ì ÙȘ ÌÂÙ·ÁÁ›ÛÂȘ (TRALI). £Âڷ¢ÙÈο ÂÊ·ÚÌfi-
˙ÂÙ·È PEEP Î·È ·˘Í¿ÓÂÙ·È ÙÔ FiO2. ÃÚÂÈ¿˙ÂÙ·È ÚÔÛ¯ÙÈ΋ ‰È·¯Â›ÚÈÛË ÙˆÓ ˘ÁÚÒÓ, ¤ÏÂÁ¯Ô˜ ÚÔÛÏ·Ì‚·ÓfiÌÂÓˆÓ Î·È ·Ô‚·ÏÏfiÌÂÓˆÓ ˘ÁÚÒÓ. ∏ ‰È·Î›ÓËÛË ÙˆÓ ˘ÁÚÒÓ ·fi ÙÔÓ ÙÚ›ÙÔ ¯ÒÚÔ Û˘Ó‹ıˆ˜ ·Ú·ÙËÚÂ›Ù·È ÙËÓ 3Ë Ì 4Ë Ë̤ڷ. §·Ì‚¿ÓÔÓÙ·˜ ˘’fi„ÈÓ ÙËÓ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· – Ô˘ ÌÔÚ› Ó· ÚÔ˘¿Ú¯ÂÈ ‹ Ó· Â›Ó·È ·fiÙÔÎÔ˜ ÂÏ·Ùو̤Ó˘ ›ÂÛ˘ ‰È‹ıËÛ˘ ‰ÈÂÁ¯ÂÈÚËÙÈο – ıˆÚÂ›Ù·È ·Ó·Áη›· Ë ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ ÒÛÙÂ Ë ˆÚÈ·›· ‰ÈÔ‡ÚËÛË Ó· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 150ml/h Î·È Ë ÎÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË Ó· ‰È·ÙËÚÂ›Ù·È ÌÂٷ͇ 4 Î·È 8 cm H2O. ∞‡ÍËÛË Ù˘ ÎÂÓÙÚÈ΋˜ ÊÏ‚È΋˜ ›ÂÛ˘ > 14cm H2O ÌÔÚ› Ó· ¤¯ÂÈ ‚Ï·ÙÈΤ˜ ÂȉڿÛÂȘ ÛÙÔ ‹·Ú Î·È ÌÔÚ› Ó· Û˘ÌÌÂÙ¤¯ÂÈ ˆ˜ ¤Ó· ‚·ıÌfi ÛÙËÓ ÚÒÈÌË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ‹·ÙÔ˜. ™˘¯Ó¤˜ ·Èٛ˜ ÌÂÙÂÁ¯ÂÈÚËÙÈο ·ÔÙÂÏÔ‡Ó Ë Ïԛ̈ÍË, Ë ·ÁÎÚ·ٛÙȉ· ·ÏÏ¿ Î·È Ë ÈÛ¯·ÈÌ›· ÙÔ˘ ‹·ÙÔ˜ ÌÂÙ¿ ·fi ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ ‹ ÔÍ›· ·fiÚÚÈ„Ë Î·ıÒ˜ Î·È Ë ¯Ú‹ÛË ÌÔÓÔÎÏÔÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ O∫Δ3. OÈ ÂÈÙÒÛÂȘ ÙÔ˘ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ‰ÂÓ Â›Ó·È ÔÌÔÈfiÌÔÚʘ fï˜ ÌÔÚ› Ó· Â›Ó·È ‰Ú·Ì·ÙÈΤ˜: 1. ΔÔ Ë·ÙÔÓ¢ÌÔÓÈÎfi Û‡Ó‰ÚÔÌÔ (hepatopulmonary syndrome –HPS) ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi 8-15% ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÁÁÂÈԉȷÛÙÔÏ‹ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ Û˘Óԉ¢fiÌÂÓË ·fi ˘Ô͢ÁÔÓ·ÈÌ›·, ‡·ÚÍË ‰ÂÍÈ¿ ÚÔ˜ ·ÚÈÛÙÂÚ¿ shunts, ·‡ÍËÛË Ù˘ ΢„ÂÏȉԷÚÙËÚȷ΋˜ ‰È·ÊÔÚ¿˜ ÙÔ˘ O2 Î·È ·Ô˘Û›· ÂÓ‰ÔÁÂÓÔ‡˜ ηډÈÔÓ¢ÌÔÓÈ΋˜ ÓfiÛÔ˘. ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì 3 ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜: ÙËÓ ˘ÂÚ˯ÔηډÈÔÁÚ·Ê›· ·ÓÙ›ıÂÛ˘, ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ·ÈÌ¿ÙˆÛ˘ Ì ̷ÎÚÔÌfiÚÈ· ·Ï‚Ô˘Ì›Ó˘ ÛÂÛËÌ·Ṳ̂ӷ Ì ڷ‰ÈÂÓÂÚÁfi Ù¯ӋÙÈÔ Î·È ÙËÓ Ó¢ÌÔÓÈ΋ ·ÁÁÂÈÔÁÚ·Ê›·. ™ÙÔ Ë·ÙÔÓ¢ÌÔÓÈÎfi Û‡Ó‰ÚÔÌÔ Ë ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË methylene blue, ·Ó·ÛÙÔϤ·˜ Ù˘ guanuylate cyclase, ·ÚÔ‰Èο ·˘Í¿ÓÂÈ ÙËÓ PaO2, ÙȘ Ó¢ÌÔÓÈΤ˜ Î·È ÙȘ Û˘ÛÙËÌ·ÙÈΤ˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ Û ·ÚÚÒÛÙÔ˘˜ Ì ˷ÙÔÓ¢ÌÔÓÈÎfi Û‡Ó‰ÚÔÌÔ. 2. ∏ ˘Ï·ÈÔÓ¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË (portopulmonary hypertension – PHTN) ÂÌÊ·Ó›˙ÂÙ·È Û ÔÛÔÛÙfi 5-10% ÙˆÓ ·ÚÚÒÛÙˆÓ Ô˘ Â›Ó·È ˘Ô„‹ÊÈÔÈ ÁÈ· ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∏ ·ıÔÁ¤ÓÂÛË Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÁÁÂÈÔÛ‡Û·ÛË Î·È ÙËÓ ıÚfiÌ‚ˆÛË, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘Ï·›· ˘¤ÚÙ·ÛË ÛÂ Û˘Ó‰È·ÛÌfi Ì ̤ÛË ›ÂÛË ÛÙËÓ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ó¢ÌÔÓÈ΋ (mPAP) ÌÂÁ·Ï‡ÙÂÚË ·fi 25mmHg ¯ˆÚ›˜ ÂӉ›ÍÂȘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ¿˜ (PCWP <15 mmHg Î·È PVR ≥120 dynes,s,cm5, (Mandell M Anesthesiology 1997; 87; 450). OÈ ·ÛıÂÓ›˜ ÂÌÊ·Ó›˙Ô˘Ó ˘„ËÏ¿ ÔÛÔÛÙ¿ ıÓËÛÈÌfiÙËÙ·˜. ŸÙ·Ó Ë PAP > 50 mmHg ·Ó¤Ú¯ÂÙ·È Û 100%. º·Ú̷΢ÙÈο ÁÈ· ÙËÓ PPHTN ÚÔÙ›ÓÂÙ·È Ë Û˘Ó¯‹˜ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ π2 0,6Ìg/kg/h ¤ÙÛÈ ÒÛÙ ӷ ÂÏ·ÙÙˆı› Ë mƒ∞ƒ Û ›‰· ·Ô‰ÂÎÙ¿ ÁÈ¿ Ó· ÌÔÚ¤ÛÂÈ Ó· ÚÔ¯ˆÚ‹ÛÂÈ Û ÌÂÙ·ÌfiÛ¯Â˘ÛË (ÙÈ̤˜ mPAP ÌÂÁ·Ï‡ÙÂÚ˜ ÙˆÓ 50mmHg ıˆÚÔ‡ÓÙ·È ··ÁÔÚ¢ÙÈΤ˜). H ¯ÔÚ‹ÁËÛË Û˘Ó¯›˙ÂÙ·È ‰ÈÂÁ¯ÂÈÚËÙÈο Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈο ÁÈ· ÌÂÚÈÎÔ‡˜ Ì‹Ó˜. £ÂˆÚËÙÈο Ì·ÎÚÔ¯ÚfiÓÈ· ¤ÎıÂÛË ÛÙËÓ ÚÔÛÙ·ÁÏ·Ó‰›ÓË π 2 ÌÔÚ› Ó· ÂȉÂÈÓÒÛÂÈ ÙËÓ ˘Ï·›· ˘¤ÚÙ·ÛË (ÂÓÒ ‚ÂÏÙÈÒÓÂÈ ÙËÓ Ó¢ÌÔÓÈ΋). Œ¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Ë ÂÈÛÓÔ‹ ¡O ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘ ÌÂÙÂÁ¯ÂÈÚËÙÈο Ì ηϿ ·ÔÙÂϤÛÌ·Ù·. ∏ ÂÈÛÓÂfiÌÂÓË ÚÔÛÙ·Î˘ÎÏ›ÓË (Iloprost) Ì ÈÔ ÈÛ¯˘Ú‹ ·ÁÁÂÈԉȷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË Û ۯ¤ÛË Ì ÙÔ ¡O ‰È·ÚΛ 45-60 ÏÂÙ¿. ΔÂÏÂ˘Ù·›· ‰ÔÎÈÌ¿˙ÂÙ·È Ë per os ¯ÔÚ‹ÁËÛË Siblenofil Ì ·ÚÎÂÙ¿ ηϿ ·ÔÙÂϤÛÌ·Ù·. OÈ ÌÂϤÙ˜ ·˘Ù¤˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ÔÈ ·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (ESLD) ÌÔÚ› Ó· Â›Ó·È ·Ó·ÛÙÚ¤„È̘. ¡∂ºƒπ∫∂™ ¢π∞Δ∞ƒ∞Ã∂™ ∏ ÌË Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È Û˘¯Ófi ‡ÚËÌ· ÌÂÙ¿ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ÔÊ›ÏÂÙ·È ·Ê’ÂÓfi˜ ÌÂÓ ÛÙÔÓ ·ÛΛÙË ·Ê’ÂÙ¤ÚÔ˘ ‰Â Û ÌÂÙ·‚ÔÏÈΤ˜ ‰È·Ù·Ú·¯¤˜ (ȉȷ›ÙÂÚ· ÙËÓ ˘ÔÓ·ÙÚÈ·ÈÌ›·). ™Â ÌÂÁ¿ÏÔ ‚·ıÌfi Ë ÂÏ¿ÙÙˆÛË Ù˘ GFR ·ÓÙ·Ó·ÎÏ¿ ÙËÓ ·ÓÙÈÛÙ¿ıÌÈÛË Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘. ΔÔ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ (hepatorenal syndrome – HPS) Â›Ó·È Ë ·ÎÚ·›· ÂΉ‹ÏˆÛË Ù˘ ·¿ÓÙËÛ˘ ÙˆÓ ÓÂÊÚÒÓ ÛÙËÓ ˘Ï·›· ˘¤ÚÙ·ÛË Î·È ÙËÓ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·. Œ¯ÂÈ Î·Ù·ÁÚ·Ê› ÛÙÔ 7-13% ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ Î·È ‰È·ÎÚ›ÓÂÙ·È Û ‰‡Ô Ù‡Ô˘˜: 1. Ù‡Ô˜ π Ì ÛÙ·‰È·Î‹ ·ÏÏ¿ Ù·¯Â›· ÂͤÏÈÍË Î·È Û¯ÂÙ›˙ÂÙ·È Ì ˘„ËÏ‹ ıÓËÙfiÙËÙ· 2. Ù‡Ô˜ ππ Ì ‹È· ·ÏÏ¿ ÛÙ·ıÂÚ‹ ÂÏ¿ÙÙˆÛË Ù˘ GFR ΔÔ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ Â›Ó·È Û˘Ó‹ıˆ˜ ·Ó·ÛÙÚ¤„ÈÌÔ ÌÂÙ¿ ÙËÓ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·Ó Î·È ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È ·fi ·ÚÔ-
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‰È΋ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÌÂÙÂÁ¯ÂÈÚËÙÈο. ªÂÙ¿ ÙËÓ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÙÔ 1/3 ¤¯ÂÈ ·Ó¿ÁÎË ·ÈÌÔοı·ÚÛ˘ ÁÈ· ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Î·È ÂÚ›Ô˘ 5% ¯ÚÂÈ¿˙ÂÙ·È ¯ÚfiÓÈ· ·ÈÌÔοı·ÚÛË. ™ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ë ·ÈÌÔοı·ÚÛË ‹ Û˘Ó¯ԇ˜ ·ÈÌԉȷ‰È‹ıËÛË ÂÊ·ÚÌfi˙ÂÙ·È Î·Ù¿ ÙËÓ ÓÔÛËÏ›· ÛÙËÓ ª∂£ ·Ú·Ù›ÓÂÙ·È Ë ·Ú·ÌÔÓ‹ ÛÙËÓ ÌÔÓ¿‰· Î·È ˘¿Ú¯ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ÂÈÏÔÎÒÓ. ¡ÂÊÚÔÙÔÍÈο Ê¿Ú̷η, ȉȷ›ÙÂÚ· ·fi Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ë Î˘ÎÏÔÛÔÚ›ÓË Î·È FK506 ı· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È Ì¤¯ÚÈ ÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ΔÂÏÂ˘Ù·›· Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ ıÂڷ›·˜ Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ·ÔÙڷ› Ë ÂÚ·ÈÙ¤Úˆ ‰Ú·ÛÙÈ΋ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ÏfiÁˆ Ù˘ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. º·Ú̷΢ÙÈÎfi ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·È Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· Ë ¯ÔÚ‹ÁËÛË terlipressin (0,04UI/ min) - ·Ó·ÏfiÁÔ˘ Ù˘ ‚·˙ÔÚÂÛÛ›Ó˘- Ì ÙËÓ ·ÁÁÂÈÔÛ‡Û·ÛË Ù˘ ÛÏ·Á¯ÓÈ΋˜ ΢ÎÏÔÊÔÚ›·˜, Û ·ÓÙ›ıÂÛË Ì ÙËÓ ·Ú·‰ÔÛȷ΋ ¯Ú‹ÛË ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÒÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ fiˆ˜ ÓÙÔ·Ì›ÓË Î·È ÚÔÛÙ·ÁÏ·Ó‰›ÓË. ∏ ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË (∞Δ¡) Ô˘ ·Ú·ÙËÚÂ›Ù·È Â›Û˘ ÛÙËÓ ª∂£ ÌÔÚ› Ó· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ‰ÈÂÁ¯ÂÈÚËÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ·ÈÌ¿ÙˆÛ˘, ÂȉÈο Û ·ÛıÂÓ›˜ Ì ÔÚȷ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ‹ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈο ÂÏ·Ùو̤ÓÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∞·ÈÙÂ›Ù·È ÚÔÛ¯ÙÈ΋ ‰È·¯Â›ÚËÛË ÙˆÓ ˘ÁÚÒÓ ÒÛÙ ӷ ·ÔʇÁÂÙ·È Ë Â͈ۈ̷ÙÈ΋ οı·ÚÛË. ŸÙ·Ó ¯ÚÂÈ¿˙ÂÙ·È, ÚÔÙÈÌ¿Ù·È Ë Û˘Ó¯‹˜ ·ÈÌԉȷ‰È‹ıËÛË. ¡∂ÀƒO§O°π∫∂™ ¢π∞Δ∞ƒ∞Ã∂™ ÕÌÂÛ· ÌÂÙÂÁ¯ÂÈÚËÙÈο (ÙËÓ 1Ë ‚‰ÔÌ¿‰·) ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Û·ÛÌÔ› (8,2%), Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· (11,8%), ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ· Î·È ÂÓ‰ÔÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·. ∞·ÈÙÂ›Ù·È fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ Û˘ÓÙÔÌfiÙÂÚ· ÂÎÙ›ÌËÛË Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ – ·ÈÛıËÙÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ÂȤ‰Ô˘ ·ʋ˜. ¶ÔÏÏÔ› ¿ÚÚˆÛÙÔÈ ÂÌÊ·Ó›˙Ô˘Ó Î¿ÔÈÔ ‚·ıÌfi Û‡Á¯˘Û˘ ÌÂÙ¿ ÙËÓ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‹·ÙÔ˜ Ô˘ Î˘Ì·›ÓÂÙ·È ·fi ·Ï‹ ·ÓËÛ˘¯›· Î·È Î·Ù·ÛÙÔÏ‹ ¤ˆ˜ Ú·ÁÌ·ÙÈΤ˜ ·Ú·ÈÛı‹ÛÂȘ Î·È ·Ú·Ï‹ÚËÌ·. Δ· ÂÚÈÛÛfiÙÂÚ· ˘Ô¯ˆÚÔ‡Ó ¯ˆÚ›˜ ȉȷ›ÙÂÚË ·ÁˆÁ‹. ∏ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ‹ Ù˘¯fiÓ ˘ÔÍÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ. OÈ Û·ÛÌÔ› Û˘¯Ó¿ ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛ-
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A. KAPA¶ANA°IøTOY
Ó˘ ·ÏÏ¿ Î·È ÌÂÙ¿ ·fi ˘„ËϤ˜ ‰fiÛÂȘ ÎÔÚÙÈ˙fiÓ˘. ™Â Ï‹Ù˜ ÌÂÙ¿ ·fi ÔÍ›· Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ›·Ó·È ÛËÌ·ÓÙÈÎfi ÙÔ monitoring Ù˘ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ›ÂÛ˘ Î·È Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ›ÂÛ˘ ‰ÈËı‹Ûˆ˜. OÈ ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È Î˘Ú›ˆ˜ Ë ˘ÔÌ·ÁÓËÛÈ·ÈÌ›· Î·È Ë ˘ÔÓ·ÙÚÈ·ÈÌ›· ÂËÚ¿˙Ô˘Ó ÙÔ Â›Â‰Ô ÂÁÚ‹ÁÔÚÛ˘ Î·È ÙËÓ ÂÌÊ¿ÓÈÛË Û·ÛÌÒÓ. ª˘Ô¿ıÂÈ· ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÌÂÙ¿ ·Ú·ÙÂٷ̤ÓÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. §Oπªø•∂π™ ∞ÔÙÂÏÔ‡Ó ÙËÓ ÈÔ Û˘¯Ó‹ ·ÈÙ›· ı·Ó¿ÙÔ˘ (2567%). ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÏÔÈÌÒÍÂˆÓ Â›Ó·È ·Ó¿ÏÔÁË Ù˘ ÈÛÔÚÚÔ›·˜ ÌÂٷ͇ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. OÈ ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ Ô˘ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È Î·Ù¿ ÙËÓ 1Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ‚‰ÔÌ¿‰· Û˘Ó‹ıˆ˜ ÔÊ›ÏÔÓÙ·È Û ÏÔÈÌÒÍÂȘ Ô˘ ÚÔ˘‹Ú¯·Ó Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ›Ù ¤¯Ô˘Ó ‰È·ÁÓˆÛÙ› ›Ù fi¯È. ¶ÚÔÂÁ¯ÂÈÚËÙÈΤ˜ Î·È ‰ÈÂÁ¯ÂÈÚËÙÈΤ˜ ηÏÏȤÚÁÂȘ Â›Ó·È ÂȂ‚ÏË̤Ó˜ ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢. ΔËÓ 1Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ‚‰ÔÌ¿‰· Û˘¯Ó‹ Â›Ó·È Ë Ó¢ÌÔÓ›·(25%) Î·È ÔÈ ÏÔÈÌÒÍÂȘ ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ (10%) ·ÏÏ¿ ΢ڛˆ˜ ÔÈ ÏÔÈÌÒÍÂȘ ÙˆÓ ¯ÔÏËÊfiÚˆÓ Ô‰ËÁÔ‡Ó Û ÌÈÎÚÔ‚È·ÈÌ›· ·fi gram·ÚÓËÙÈο ‚·ÎÙËÚ›‰È·. ∏ ‚·ÎÙËÚÈ·ÈÌ›· ·fi gram·ÚÓËÙÈο ‚·ÎÙËÚ›‰È· Â›Ó·È Û˘¯Ó‹ Û ·ÛıÂÓ›˜ Ì ™·Î¯·ÚÒ‰Ë ¢È·‚‹ÙË Î·È ˘ÔıÚ„›·. Δ· Û˘¯ÓfiÙÂÚ· ·Ô̈ÓÔı¤ÓÙ· ‚·ÎÙËÚ›‰È· ÛÙËÓ ª∂£ Â›Ó·È gram- ·ÚÓËÙÈο ÂÓÙÂÚÔ‚·ÎÙËÚÈÔÂȉ‹, pseudomonas ·ÏÏ¿ η› staphylococcus aureus. £ÂˆÚÂ›Ù·È ÂȂ‚ÏË̤ÓË Ë ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ (·ÌÈÎÈÏÏ›ÓË Î·È ÎÂÊ·ÏÔÛÔÚ›ÓË). ¶ÔÏÏ¿ ΤÓÙÚ· ¯ÔÚËÁÔ‡Ó ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋ ·ÁˆÁ‹ (amphotericin B ‹ caspofungin) Û ȉȷ›ÙÂÚ˜ ÂÚÈÙÒÛÂȘ. ªÂÙ¿ ÙÔÓ 1Ô Ì‹Ó· Û˘¯Ó¤˜ Â›Ó·È ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Ì ΢ÙÙ·ÚÔÌÂÁ·ÏÔÈfi, ¤ÚËÙ· ˙ˆÛÙ‹Ú·, ·‰ÂÓÔÈÔ‡˜ Î·È Epstein-barr.
5% Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ·, ÔͤˆÛË, ÌË ÂÏÂÁ¯fiÌÂÓ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡, ÛÔ‚·Ú‹ ˘ÔÁÏ˘Î·ÈÌ›· Î·È ˘ÂÚηÏÈ·Ì›· ·ÎfiÌ· Î·È ÛÙÔ ¯ÂÈÚÔ˘ÚÁ›Ô. ∏ ·fiÚÚÈ„Ë ‰È·ÊÔÚԉȷÁÈÁÓÒÛÎÂÙ·È ·fi ÙË Ïԛ̈ÍË Ì ‚ÈÔ„›· Î·È ··ÈÙ› ·˘ÍË̤ÓË ·ÓÔÛÔηٷÛÙÔÏ‹ (Û ·ÓÙ›ıÂÛË Ì ÙËÓ Ïԛ̈ÍË). OÈ Ù¯ÓÈΤ˜ ÂÈÏÔΤ˜ ¿ÌÂÛ· ÌÂÙÂÁ¯ÂÈÚËÙÈο ›ӷÈ: ∞. ∏ ·ÈÌÔÚÚ·Á›·, Û ÔÛÔÛÙfi 10-20%( Û‡Ìʈӷ Ì ٷ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ), Ì ·Ó¿ÁÎË ¿ÌÂÛ˘ ·ӷ‰È¿ÓÔÈ͢ Î·È ·ÚÔ¯¤Ù¢Û˘ ÙÔ˘ ·ÈÌÔÂÚÈÙÔÓ·›Ô˘ Î·È ÂÈÌÂÏ‹ ·ÈÌfiÛÙ·ÛË. O ΛӉ˘ÓÔ˜ ·ÈÌÔÚÚ·Á›·˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ·ӷÌÂÙ·ÌfiÛ¯Â˘ÛË, Û ·ÛıÂÓ›˜ Ì ÚÔËÁËı›Û˜ ÂÂÌ‚¿ÛÂȘ ÛÙËÓ ¿Óˆ ÎÔÈÏ›· ηıÒ˜ Î·È ÛÙËÓ ÚÒÈÌË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. μ. ∏ ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ ÂΉËÏÒÓÂÙ·È Ì ˘„ËÏfi ˘ÚÂÙfi Î·È Û˘Ó‹ıˆ˜ ·‡ÍËÛË ÙˆÓ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ. O ˘¤Ú˯Ԙ Â›Ó·È ‰È·ÁÓˆÛÙÈÎfi˜. °. ∏ ıÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ ¢. ∏ ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ÊϤ‚·˜ ∂. ∏ ÛÙ¤ÓˆÛË Ù˘ ÎÔ›Ï˘ ÊϤ‚·˜ ∑. ∏ ‰È·Ê˘Á‹ ¯ÔÏ‹˜ – ¯ÔÏÔÂÚÈÙfiÓ·ÈÔ ¢π∞ΔƒOº∏ ΔÔ 70-80% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ Â›Ó·È ˘ÔıÚÂÙÈÎÔ›. OÈ ıÂÚÌȉÈΤ˜ ·Ó¿ÁΘ ·Ó¤Ú¯ÔÓÙ·È ÛÙÔ 20-50% ÂÈϤÔÓ ÙˆÓ ‚·ÛÈÎÒÓ ·Ó·ÁÎÒÓ. OÈ ÚˆÙÂ˚ÓÈΤ˜ ·Ó¿ÁΘ ˘ÔÏÔÁ›˙ÔÓÙ·È ÛÙȘ 1,5g/ Kg ÙÔ˘ ȉ·ÓÈÎÔ‡ ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜. ™Â ÔÏÏ¿ ΤÓÙÚ· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¯ÔÚËÁÔ‡Ó ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹. ŒÙÛÈ ·˘Í¿ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ÏÔÈÌÒÍÂˆÓ ÂÓÒ Ì ÙËÓ ÂÓÙÂÚÈ΋ ‰È·ÙËÚÂ›Ù·È Ë ·ÎÂÚ·ÈfiÙËÙ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÔÁfiÓÔ˘ Î·È ÂÏ·ÙÙÒÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ·ÏÏfiıÂÛ˘ ÌÈÎÚÔ‚›ˆÓ. ∂¶π§O°O™
E¶π¶§O∫∂™ ∞¶O ΔO ∏¶∞ƒ ∏ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ‹·ÙÔ˜ ÌÔÚ› Ó· ÂËÚ·ÛÙ› Ì ¤Ó·Ó ·fi ÙÔ˘˜ οوıÈ ÙÚfiÔ˘˜ 1. ¶ÚˆÙÔ·ı‹˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ‹ ÌË ÏÂÈÙÔ˘ÚÁ›· 2. ∞fiÚÚÈ„Ë 3. Δ¯ÓÈΤ˜ ÂÈÏÔΤ˜ ∏ ÚÒÈÌË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· (Ì ·Ô˘Û›· ‹ ÂÏ·Ùو̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔÛ¯Â˘Ì·ÙÔ˜ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ) ÂÌÊ·Ó›˙ÂÙ·È Û ÔÛÔÛÙfi 3-
∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÊÚÔÓÙ›‰· ÛÙÔ˘˜ ·ÚÚÒÛÙÔ˘˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ··ÈÙ› ÙËÓ ÂÍ·ÙƠ̂΢ÛË Î·È ·Ó·ÁÓÒÚÈÛË ÙˆÓ È‰È·›ÙÂÚˆÓ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ÌÂÙ·‚ÔÏÒÓ ÛÙÔÓ Î¿ı ·ÛıÂÓ‹. OÈ ·ÛıÂÓ›˜ ı· Ú¤ÂÈ Ó· ÂÎÙÈÌÒÓÙ·È Â·ÎÚÈ‚Ò˜ fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Ì ȉȷ›ÙÂÚË ÚÔÛÔ¯‹ ÛÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÓÂÊÚÒÓ, ÙˆÓ Ó¢ÌfiÓˆÓ Î·È Ù˘ ηډȿ˜. ¶ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ··ÈÙÔ‡ÓÙ·È ÁÈ· Ó· ‰È¢ÎÚÈÓÈÛÙ› Ô Î·Ï‡ÙÂÚÔ˜ ÙÚfiÔ˜ ÚÔÛ¤ÁÁÈÛ˘ ÙˆÓ ‰˘ÓËÙÈο ·Ó·ÛÙÚ¤„ÈÌˆÓ ·-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ıÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ÌÂÙ·‚ÔÏÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·. ∂ÂÌ‚·ÙÈÎfi monitoring Î·È ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Â›Ó·È ·Ó·Áη›· ÛÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô.
μÈ‚ÏÈÔÁÚ·Ê›· 1) Critical Care of the liver transplant patient: an update Ian D.McGilvary,MD,Ph Current Opinion in critical Care 2002, 8:178-182 2) Cirrhotic cardiomyopathy and liver transplantation and liver transplantation Liver transplant 2000, 6(suppl); S44-S52 3) Liver failure,transplantation,and critical care Anatoli
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Krasko, MD, Crit. Care Clin. 19(2003) 155-183 4) Moller Heart 2002;87:9 5) Van der Berge et al NEJM 2001; 345:1359-67. 6) Murpy et al Hepatology 2004; 39(2):464-70 7) The role of Trans-Oesophageal Echocardiography for perioperative Cardiovascular Monitoring during Orthotopic Liver Transplantation Andrew J. Liver Transpl. 12:1577-1583 2006 8) Hepatopulmonary Syndrome Occuring after Orthotopic Liver Transplantation Christopher E. Avendano Liver Transplant. 2001; 7:1081-1084 9) Pulmonary Gas Exchange in Liver Transplant Candidates R.Mohamed Liver Transplant 2002; 8:802-808 10) Metabolic Alkalosis after Orthotopic Liver Transplantation Dominic Raj Amer J of Transplant 2003; 3:15661569
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ÂȂ‚·Èˆı› Ë ÛˆÛÙ‹ ı¤ÛË ÙÔ˘ ÂÓ‰ÔÙÚ·¯ÂÈ·ÎÔ‡ ۈϋӷ ÛÙËÓ ÙÚ·¯Â›· , Ë Â›ÛÔ‰Ô˜ ·ÚÎÔ‡˜ fiÁÎÔ˘ ·ÂÚ›ˆÓ ÛÙÔ˘˜ Ó‡ÌÔÓ˜ Î·È Ë ·ÈÌÔ‰˘Ó·ÌÈ΋ ÙÔ˘ ηٿÛÙ·ÛË. ∂ȉÈÎfiÙÂÚ· Û’ ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜: ¶·Ú·ÎÔÏÔ˘ıÂ›Ù·È Û˘Ó¯Ҙ Ë Î·Ú‰È·Î‹ Û˘¯ÓfiÙËÙ· Î·È Ô Ú˘ıÌfi˜ Ì monitor. H ·ÚÙËÚȷ΋ ›ÂÛË ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ì¤Ûˆ ηıÂÙ‹Ú· Ù˘ ÎÂÚÎȉÈ΋˜ ·ÚÙËÚ›·˜. ∫·Ù¿ ‰È·ÛÙ‹Ì·Ù· ÌÂÙÚ¿Ù·È Ë ›ÂÛË ÂÓÛÊ‹ÓˆÛ˘ ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ÙÚȯÔÂȉÒÓ (PCWP<15 cm H2O) Î·È Ë ÎÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË (CVP<10cm H2O). ¶·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ô ÎÔÚÂÛÌfi˜ ÙÔ˘ ÙÚȯÔÂȉÈÎÔ‡ ·›Ì·ÙÔ˜ (SpO2) Ì ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ Î·È Ô ÎÔÚÂÛÌfi˜ ÙÔ˘ ÌÈÎÙÔ‡ ÊÏ‚ÈÎÔ‡ ·›Ì·ÙÔ˜ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ (SvO2) ̤ۈ ÙÔ˘ ηıÂÙ‹Ú· Swan-Ganz. ∫·Ù·ÁÚ¿ÊÂÙ·È Ô Ù‡Ô˜ ·ÂÚÈÛÌÔ‡, Ë ·Ó·Ó¢ÛÙÈ΋ Û˘¯ÓfiÙËÙ·, Ë ÂÈÛÓÂfiÌÂÓË Û˘ÁΤÓÙÚˆÛË Ô͢ÁfiÓÔ˘ ÎÏ. OÈ ·Ó·ÚÚÔÊ‹ÛÂȘ ÙˆÓ ÂÎÎÚ›ÛÂˆÓ ·fi ÙÔÓ ÂÓ‰ÔÙÚ·¯ÂÈ·Îfi ۈϋӷ ‰ÂÓ Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È Ì ˘ÂÚ‚ÔÏ‹ ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ·ÈÌÔÚÚ·Á›·˜ ·fi ÙÔ˘˜ ‚ÚfiÁ¯Ô˘˜ ‹ ÙËÓ ÙÚ·¯Â›·, ‰ÈfiÙÈ Ô ‚ÚÔÁ¯ÈÎfi˜ ‚ÏÂÓÓÔÁfiÓÔ˜ Â›Ó·È ÔȉËÌ·Ù҉˘ Î·È ·ÈÌÔÚÚ·Á› ‡ÎÔÏ·, ÏfiÁˆ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ËÎÙÈÎfiÙËÙ·˜. ∂ϤÁ¯ÔÓÙ·È Ù·ÎÙÈο Ù· ·¤ÚÈ· ·›Ì·ÙÔ˜, Î·È Á›ÓÂÙ·È Û˘¯Ó‹ ·ÏÏ·Á‹ ı¤ÛÂˆÓ ÙÔ˘ ·ÚÚÒÛÙÔ˘ ÁÈ· Ó· ·ÔʇÁÔ˘ÌÂ Ù˘¯fiÓ ·ÙÂÏÂÎٷۛ˜. ∂·Ó·ıÂÚÌ·›ÓÔ˘Ì ÙÔÓ ·ÛıÂÓ‹ Ì ÙËÓ ¯ÚËÛÈÌÔÔ›ËÛË ıÂÚÌ·ÓÙÈ΋˜ ÎÔ˘‚¤ÚÙ·˜, ÙËÓ ı¤ÚÌ·ÓÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ˘ÁÚÒÓ Î·È ÙËÓ ÂʇÁÚ·ÓÛË Î·È ı¤ÚÌ·ÓÛË ÙˆÓ ÂÈÛÓÂfiÌÂÓˆÓ ·ÂÚ›ˆÓ. ∏ ̤ÙÚËÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÛÒÌ·ÙÔ˜ Á›ÓÂÙ·È Ì ˘‰Ú·ÚÁ˘ÚÈÎfi ıÂÚÌfiÌÂÙÚÔ ·fi ÙÔ ÔÚıfi Î·È Ì¤Ûˆ ÙÔ˘ ηıÂÙ‹Ú· Swan-Ganz. ∫·Ù·ÁÚ¿ÊÔ˘Ì ٷ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ· Î·È ·Ô‚·ÏÏfiÌÂÓ· ˘ÁÚ¿ (Ô‡Ú·, ¯ÔÏ‹, ·ÚÔ¯ÂÙ‡ÛÂȘ, Á·ÛÙÚÈο, ¿‰ËÏÔ˜ ·Ó·ÓÔ‹) οı 8 ÒÚ˜ Î·È Î¿ı 24 ÒÚ˜ Î·È ˘ÔÏÔÁ›˙Ô˘Ì ÙÔ ÈÛÔ˙‡ÁÈÔ ˘-
ΔȘ ÙÂÏÂ˘Ù·›Â˜ ‰‡Ô ‰ÂηÂٛ˜ Ë ÚfiÔ‰Ô˜ ÛÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÏÏ¿ Î·È ÛÙȘ ‚·ÛÈΤ˜ ÂÈÛً̘ ¤‰ˆÛ χÛË ÛÙÔ Úfi‚ÏËÌ· Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, ÌÈ·˜ ηٿÛÙ·Û˘ Ô˘ Ô‰ËÁ› ÛÙÔ ı¿Ó·ÙÔ. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙËÓ ·¿ÓÙËÛË Ù˘ π·ÙÚÈ΋˜ Û’ ·˘Ùfi ·ÎÚÈ‚Ò˜ ÙÔ Úfi‚ÏËÌ·. ™ÙËÓ ∂ÏÏ¿‰· Ë ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ¤ÁÈÓ ÙÔ 1990 ÛÙÔ πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¶ÂÚÈÊÂÚÂÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ ·fi ÙË ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£ Î·È Ì¤¯ÚÈ Û‹ÌÂÚ· ¤¯Ô˘Ó Á›ÓÂÈ 247 ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È Ë ‚·Ú‡ÙÂÚË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ÛÙÔÓ ¿ÓıÚˆÔ Î·È ··ÈÙ› ·ÁÚ‡ÓËÛË ·fi ÙÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi, ÙfiÛÔ ÛÙËÓ ¿ÌÂÛË fiÛÔ Î·È ÛÙËÓ ·ÒÙÂÚË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô. ªÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô ·ÛıÂÓ‹˜ ÌÂٷʤÚÂÙ·È Û ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ (ª∂£), Û˘Óԉ›· ·Ó·ÈÛıËÛÈÔÏfiÁÔ˘ Ô˘ ¤Ï·‚ ̤ÚÔ˜ ÛÙËÓ ·Ó·ÈÛıËÛ›·, Ì ÊÔÚËÙfi ·Ó·Ó¢ÛÙ‹Ú·, monitor Î·È ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ. ΔÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ¤¯ÂÈ ‹‰Ë ÂÙÔÈÌ¿ÛÂÈ Î·È ÂϤÁÍÂÈ ÙÔÓ ÂÍÔÏÈÛÌfi Ô˘ Â›Ó·È ··Ú·›ÙËÙÔ˜ ÁÈ· ÙËÓ ˘Ô‰Ô¯‹ ÙÔ˘ ·ÛıÂÓ‹. ∞˘Ùfi˜ ›ӷÈ: ∞Ó·ÚÚfiÊËÛË ¤ÙÔÈÌË Ì ηıÂÙ‹Ú· Monitor Ì ٷ ÂÍ·ÚÙ‹Ì·Ù· ¶·ÏÌÈÎfi Ô͇ÌÂÙÚÔ ƒÔfiÌÂÙÚ· Ì ÚÔÛˆ›‰· ¶ÈÂÛfiÌÂÙÚÔ Î·È ·ÎÔ˘ÛÙÈο º¿Ú̷η ηډÈÔÓ¢ÌÔÓÈ΋˜ ·Ó·˙ˆÔÁfiÓËÛ˘ Ambu ∞ÈÓȉˆÙ‹˜ ∞ÓÙϛ˜ ¯ÔÚ‹ÁËÛ˘ ˘ÁÚÒÓ Î·È Ê·ÚÌ¿ÎˆÓ ªfiÏȘ Ô ·ÛıÂÓ‹˜ ÙÔÔıÂÙËı› ÛÙÔ ÎÚ‚¿ÙÈ Î·È Û˘Ó‰Âı› Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú·, Ú¤ÂÈ Ó·
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÁÚÒÓ. ªÂ ‚¿ÛË ·˘Ùfi ηıÔÚ›˙ÂÙ·È Ô fiÁÎÔ˜ Î·È Ë Û‡ÛÙ·ÛË ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ‰È·Ï˘Ì¿ÙˆÓ. ªÂ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ·ÚÚÒÛÙÔ˘ ÛÙË ª∂£ ·ÎÔÏÔ˘ı› ·ÈÌÔÏË„›· ÁÈ· ·¤ÚÈ· ·›Ì·ÙÔ˜, ËÎÙÈÎfi Ì˯·ÓÈÛÌfi, ·ÈÌ·ÙÔÏÔÁÈÎfi Î·È ‚ÈÔ¯ËÌÈÎfi ¤ÏÂÁ¯Ô. Δ·˘Ùfi¯ÚÔÓ· ÂϤÁ¯ÔÓÙ·È ÔÈ ËÏÂÎÙÚÔχÙ˜, ÙÔ ÈÔÓÈṲ̂ÓÔ ·Û‚¤ÛÙÈÔ Î·È ÙÔ Û¿Î¯·ÚÔ. ∂›Û˘ Á›ÓÂÙ·È Î·È ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜. ™Â Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· Á›ÓÂÙ·È ¤Ó·˜ Ï‹Ú˘ ÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Î·È ¤ÏÂÁ¯Ô˜ ÁÈ· ̇ÎËÙ˜ (∏μV, ∏CV, CªV, ∂μV, Candida, ÎÏ.), ÂÓÒ 3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· Á›ÓÂÙ·È Ì¤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ∫˘ÎÏÔÛÔÚ›Ó˘ (Neoral) ‹ ÙÔ˘ Tacrolimus (Prograf) ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ËÌÂÚ‹ÛÈ·˜ ‰fiÛ˘. ∏ ̤ÙÚËÛË ÙˆÓ Ô‡ÚˆÓ Â›Ó·È ˆÚÈ·›· Î·È ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 0,5ml/kgr/h. ™Â Û˘Ó‰˘·ÛÌfi Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ (Ô˘Ú›·, ÎÚ·ÙÈÓ›ÓË) ÂϤÁ¯Ô˘Ì ÙËÓ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ™ÙÔÓ ·ÛıÂÓ‹ ÙÔÔıÂÙÂ›Ù·È Â›Û˘ ÚÈÓÔÁ·ÛÙÚÈÎfi˜ ۈϋӷ˜ (Levin). ∞˘Ùfi˜ ·Ê·ÈÚÂ›Ù·È ÌÂÙ¿ ÙËÓ ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ·Ú¯›˙ÂÈ Ë Û›ÙËÛË ÙÔ˘ ·ÛıÂÓ‹ ·fi ÙÔ ÛÙfiÌ·. ∂¿Ó ‰ÂÓ ·ÔηٷÛÙ·ı› Ë ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ÂÓÙ¤ÚÔ˘ ·Ú¯›˙ÂÈ ÙËÓ 2Ë-3Ë Ë̤ڷ Ë ¯ÔÚ‹ÁËÛË ·ÚÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜. ∏ ·‰˘Ó·Ì›· ·›ÙËÛ˘ ÙÔ˘ ·ÛıÂÓ‹ ·fi ÙÔ ÛÙfiÌ· (Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜, ¿ÚÓËÛË ÙÔ˘ ·ÛıÂÓ‹, ·Ô˘Û›· ·ʋ˜ Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÎÏ.), ÂÈ‚¿ÏÏÂÈ ÙËÓ ÙÔÔı¤ÙËÛË ÚÈÓÔ‰ˆ‰Âη‰·ÎÙÈÏÈÎÔ‡ ۈϋӷ ÛÈÏÈÎfiÓ˘ Î·È ÙËÓ ¤Ó·ÚÍË ÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜. °È· ÙËÓ ÚÔʇϷÍË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ¯ÔÚËÁÔ‡ÓÙ·È ·ÓÙÈfiÍÈÓ· ·fi ÙÔ Levin ‹ ÂÓ‰ÔÊϤ‚ÈÔÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ ∏+. ∏ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÀÁÚ¿ Û˘ÓÙ‹ÚËÛ˘: N/S 0,9%, D/W 5%, R/L - ∞›Ì· Î·È ·Ú¿ÁˆÁ·: ·Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ - πÓfiÙÚÔ·: ÁÈ· Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜. ÃÔÚËÁÔ‡ÓÙ·È Ì ·ÓÙϛ˜ Û˘Ó¯ԇ˜ ¤Á¯˘Û˘. - ¢ÈÔ˘ÚËÙÈο: ÊÔ˘ÚÂÛÂÌ›‰Ë, mannitol 20% - ∞ÓÙÈfiÍÈÓ· Î·È ·Ó·ÛÙÔÏ›˜ ∏+ - ÃËÌÂÈÔÚÔʇϷÍË: ÃÔÚËÁÔ‡ÓÙ·È ‰ÈÂÁ¯ÂÈÚËÙÈο (Ambicilline Î·È Cefotaxime) Î·È Û˘Ó¯›˙ÔÓÙ·È ‹ ÙÚÔÔÔÈÔ‡ÓÙ·È Û‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÙˆÓ Î·ÏÏÈÂÚÁÂÈÒÓ Î·È ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·. - ∞Ó·ÏÁËÙÈο Î·È Î·Ù·ÛÙ·ÏÙÈο: ÃÔÚËÁÔ‡ÓÙ·È Fentanyl (Ê·ÈÓÙ·Ó‡ÏË) Î·È Dormicum (Midazo-
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lam) Ì ·ÓÙϛ˜ Û˘Ó¯ԇ˜ ¤Á¯˘Û˘. - ∞ÓÔÛÔηٷÛÙ·ÏÙÈο: ¢ÈÏ‹ ‹ ÙÚÈÏ‹ ·ÓÔÛÔηٷÛÙÔÏ‹ (ªÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË, ∫˘ÎÏÔÛÔÚ›ÓË ‹ Tacrolimus, Mycophenolate Mofetil). ªfiÏȘ ·ÔÛˆÏËÓˆı› Ô ·ÛıÂÓ‹˜ Î·È ÂÊ’ fiÛÔÓ ÙÔ ÂÈÙÚ¤ÂÈ Ë ÁÂÓÈ΋ ÙÔ˘ ηٿÛÙ·ÛË, ÌÂٷʤÚÂÙ·È Û ı¿Ï·ÌÔ ·˘ÍË̤Ó˘ ÊÚÔÓÙ›‰·˜, fiÔ˘ Û˘Ó¯›˙ÂÙ·È Ë ÊÚÔÓÙ›‰· Ô˘ ‹‰Ë ›¯Â ·Ú¯›ÛÂÈ ÛÙËÓ ª∂£. ÃÔÚËÁÂ›Ù·È O2 Ì ̿Ûη. ∞Ó¿ 12 ÒÚ˜ ÚÔÛ‰ÈÔÚ›˙ÔÓÙ·È Ù· ·¤ÚÈ· ·›Ì·ÙÔ˜ Î·È ÔÈ ËÏÂÎÙÚÔχÙ˜. ¶·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ô ÎÔÚÂÛÌfi˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Ì ·ÏÌÈÎfi Ô͇ÌÂÙÚÔ. ∏ ̤ÙÚËÛË Ù˘ ∞¶ (Ì ˘‰Ú·ÚÁ˘ÚÈÎfi ÈÂÛfiÌÂÙÚÔ) Î·È ÙˆÓ ÛʇÍÂˆÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·ÚÚÒÛÙÔ˘ Î·È ÂÊ’ fiÛÔÓ ÛÙ·ıÂÚÔÔÈËı› ÂϤÁ¯ÔÓÙ·È 3 ÊÔÚ¤˜ ÙÔ 24ˆÚÔ. ∏ ̤ÙÚËÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÛÒÌ·ÙÔ˜ Î·È Ù˘ ∫º¶ (¤ÌÌÂÛË Ì¤ÙÚËÛË) Á›ÓÂÙ·È ·Ó¿ 3 ÒÚ˜. ŒÓÙÔÓË Ê˘ÛÈÔıÂڷ›· Î·È ÎÈÓËÛÈÔıÂڷ›·. ∫·ıËÌÂÚÈÓ¿ Á›ÓÂÙ·È ·ÏÏ·Á‹ ÙÚ·‡Ì·ÙÔ˜ Î·È ÂϤÁ¯Ô˘Ì ÙÔ ÙÚ·‡Ì· ÁÈ· ·ÈÌÔÚÚ·Á›·. OÈ ·ÚÔ¯ÂÙ‡ÛÂȘ Ô˘ ¤¯Ô˘Ó ÙÔÔıÂÙËı› ÛÙÔÓ ·ÛıÂÓ‹, Û˘Ó‰¤ÔÓÙ·È Ì ·ÔÛÙÂÈڈ̤ÓÔ˘˜ Û˘ÏϤÎÙ˜. ∞˘Ù¤˜ Â›Ó·È 2-3 Î·È ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ˘ÊË·ÙÈÎÔ‡ Î·È ÙÔ˘ ˘Ô‰È·ÊÚ·ÁÌ·ÙÈÎÔ‡ ¯ÒÚÔ˘. ¶Èı·ÓfiÓ Ó· ˘¿Ú¯ÂÈ Î·È ÛˆÏ‹Ó·˜ Δ ‹ ∫ehr. ∞Ê·ÈÚ›ٷÈ, Û˘Ó‹ıˆ˜, ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ ÙÔ˘ 3Ô˘ Ì‹Ó· Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Î·Ï‹ Î·È Ë ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· ‰ÂÓ ‰Â›¯ÓÂÈ ‰È·Ê˘Á‹ ·fi ÙËÓ ·Ó·ÛÙfïÛË ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘. ∂ϤÁ¯Ô˘ÌÂ Î·È Î·Ù·ÁÚ¿ÊÔ˘Ì ÙËÓ ÔÛfiÙËÙ· Î·È ÙËÓ Û‡ÛÙ·ÛË ÙÔ˘ ˘ÁÚÔ‡ ÙˆÓ ·ÚÔ¯ÂÙ‡ÛÂˆÓ (·ÈÌ·ÙËÚfi, ÔÚÔ·ÈÌ·ÙËÚfi, ·ÛÎËÙÈÎfi). OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ·Ú¿ÁÔ˘Ó ·ÛÎËÙÈÎfi ˘ÁÚfi ÁÈ· Ï›Á˜ Ë̤Ú˜ ÏfiÁˆ Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ Ô˘ ›¯·Ó ÚÔÂÁ¯ÂÈÚËÙÈο ‹ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›·. ¶ÚÔÛ¤¯Ô˘Ì ηٿ ÙȘ ÌÂÙ·ÎÈÓ‹ÛÂȘ ÙÔ˘ ·ÛıÂÓ‹ Ó· ÌËÓ ÌÂÙ·ÎÈÓËıÔ‡Ó ÔÈ ·ÚÔ¯ÂÙ‡ÛÂȘ, ΢ڛˆ˜ Ô ÛˆÏ‹Ó·˜ ∫EHR, ÁÈ·Ù› ·˘Ùfi ÛËÌ·›ÓÂÈ ¯ÔÏÔÂÚÈÙfiÓ·ÈÔ, Ô˘ ··ÈÙ› ¿ÌÂÛË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ·ÏÏÈÒ˜ Â›Ó·È ı·Ó·ÙËÊfiÚÔ. ∫·Ù·ÁÚ¿ÊÔ˘Ì ٷ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ· Î·È ·Ô‚·ÏÏfiÌÂÓ· ˘ÁÚ¿ οı 8 ÒÚ˜ Î·È Î¿ı 24 ÒÚ˜ Î·È ˘ÔÏÔÁ›˙Ô˘Ì ÙÔ ÈÛÔ˙‡ÁÈÔ ˘ÁÚÒÓ.
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∂ϤÁ¯Ô˘Ì ÙÔÓ ÚÈÓÔ‰ˆ‰Âη‰·ÎÙ˘ÏÈÎfi ۈϋӷ ÛÈÏÈÎfiÓ˘ ˆ˜ ÚÔ˜ ÙË ı¤ÛË Î·È ÙËÓ ‚·ÙfiÙËÙ· ÙÔ˘. ¶·Ú·ÎÔÏÔ˘ıԇ̠ÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘ (·ÚÈıÌfi˜ Î·È ÌÔÚÊ‹ ÎÂÓÒÛˆÓ). ∂›Û˘ οı ڈ› Ô ·ÛıÂÓ‹˜ ˙˘Á›˙ÂÙ·È. OÈ ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓÔ˘ Â›Ó·È È‰È·›ÙÂÚ· ÂÈÚÚ›˜ Û ÏÔÈÌÒÍÂȘ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi: ΔÔ ÂÈÛÎÂÙ‹ÚÈÔ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓÔ Î·È ¯ÚËÛÈÌÔÔÈ› Ì¿Ûη, Ô‰ÔÓ¿ÚÈ·, ÌÏÔ‡˙·. ∂¿Ó Ô ·fiÏ˘ÙÔ˜ ·ÚÈıÌfi˜ ÙˆÓ Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Â›Ó·È <3000mm3, Ô ·ÛıÂÓ‹˜ ·ÔÌÔÓÒÓÂÙ·È. ∞ÓÙÈηı›ÛÙ·ÓÙ·È Ì›· ÊÔÚ¿ ÙËÓ Â‚‰ÔÌ¿‰· Ô Î·ıÂÙ‹Ú·˜ ·ÛÙˆ˜, Ë ·ÚÙËÚȷ΋ ÁÚ·ÌÌ‹ Î·È Ô ÎÂÓÙÚÈÎfi˜ ÊÏ‚ÈÎfi˜ ηıÂÙ‹Ú·˜. ™‡Ìʈӷ Ì ڈÙfiÎÔÏÏ· ÂÍÂÙ¿ÛÂˆÓ Ô ÓÔÛËÏÂ˘Ù‹˜-ÙÚÈ· Ï·Ì‚¿ÓÂÈ Î·ÏÏȤÚÁÂȘ ÙÚ·¯ÂÈÔ‚ÚÔÁ¯ÈÎÒÓ ÂÎÎÚ›ÛˆÓ, ˘ÁÚÒÓ ·ÚÔ¯¤Ù¢Û˘, Ô‡ÚˆÓ, ·›Ì·ÙÔ˜ Î·È ÛÙ¤ÏÓÂÈ ÌÂÙ¿ ·fi οı ·Ê·›ÚÂÛË Î·ıÂÙ‹Ú· ‹ ·ÚÔ¯¤Ù¢Û˘ ÙÔ ¿ÎÚÔ ÙÔ˘ ÁÈ· ηÏÏȤÚÁÂÈ·. ∫·ıËÌÂÚÈÓ¿ ·ÏÏ¿˙ÔÓÙ·È fiÏ· Ù· Û˘ÛÙ‹Ì·Ù· ¯ÔÚ‹ÁËÛ˘ ˘ÁÚÒÓ, ̤ÙÚËÛ˘ ∫º¶ Î·È ∞¶. ∂›Û˘ ·ÏÏ¿˙ÔÓÙ·È ÔÈ Á¿˙˜ ÂÈÎ¿Ï˘„˘ ÛÙ· ÛËÌ›· ÂÈÛfi‰ˆÓ ÙˆÓ ÊÏ‚ÔηıÂÙ‹ÚˆÓ Î·È Ù˘ ·ÚÙËÚȷ΋˜ ÁÚ·ÌÌ‹˜. ∞ÏÏ¿˙ÂÙ·È Î·ıËÌÂÚÈÓ¿ ÙÔ Î‡Îψ̷ ÙÔ˘ ·Ó·Ó¢ÛÙ‹Ú· (ª∂£) °È· ÙËÓ Î·Ï‡ÙÂÚË ·Ú·ÎÔÏÔ‡ıËÛË ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ ÙÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ı· Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ ÙȘ ÂÈÏÔΤ˜ Ô˘ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó. ∞˘Ù¤˜ ›ӷÈ: ∞ÈÌÔÚÚ·Á›· ∂ÈÏÔΤ˜ ·fi Ù· ¯ÔÏËÊfiÚ· (·fiÊÚ·ÍË, ¯ÔÏ·ÁÁÂÈ›Ùȉ·, ‰È·Ê˘Á‹ ·fi ÙËÓ ·Ó·ÛÙfïÛË) £ÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ ‹ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ ∂ÈÏÔΤ˜ ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi (·ÙÂÏÂÎÙ·Û›·, ÏÔÈÌÒÍÂȘ, ˘‰ÚÔıÒڷη˜) ¡ÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ∞ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙË Ì¤ıÔ‰Ô Ù˘ Û˘Ó¯ԇ˜ ·ÈÌԉȋıËÛ˘. ∞fiÚÚÈ„Ë: ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·‡ÍËÛË ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜, Ì›ˆÛË Ù˘ ÔÛfiÙËÙ·˜ Ù˘ ¯ÔÏ‹˜ (·Ó ˘¿Ú¯ÂÈ ÛˆÏ‹Ó·˜ ∫ehr), ˘ÚÂÙfi, ¢·ÈÛıËÛ›·
ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÎÏ. ¢È·ÁÈÁÓÒÛÎÂÙ·È Ì ÙËÓ ‚ÈÔ„›· ÌÔۯ‡̷ÙÔ˜ Î·È ·Ú¯›˙ÂÈ ·Ì¤Ûˆ˜ ·ÓÙÈ·ÔÚÚÈÙÈ΋ ·ÁˆÁ‹. ∫¿ı ªÔÓ¿‰· ·ÎÔÏÔ˘ı› ‰ÈÎfi Ù˘ ·ÓÙÈ·ÔÚÚÈÙÈÎfi ÚˆÙfiÎÔÏÏÔ. ™˘Ó‹ıˆ˜ ¯ÔÚËÁÔ‡ÓÙ·È ÎÔÚÙÈÎÔÂȉ‹ Û ‰fiÛÂȘ ÙˆÓ 500mgr ÁÈ· 4 Ë̤Ú˜ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ˘Ô‰ÈÏ·ÛÈ¿˙ÂÙ·È Ë ‰fiÛË Î·ıËÌÂÚÈÓ¿ ̤¯ÚÈ Ù· 20mgr. ™ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ·ÓÙÈ·ÔÚÚÈÙÈ΋˜ ·ÁˆÁ‹˜, ·Ó·ÛÙÚ¤ÊÂÙ·È Ô Ì˯·ÓÈÛÌfi˜ Ù˘ ·fiÚÚȄ˘. OÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·ÔÙÂÏÔ‡Ó ÙËÓ ÌÔÓ·‰È΋ ÂÈÏÔÁ‹ ÁÈ· fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜ Î·È ‰›ÓÔ˘Ó ÂÏ›‰· Î·È ‰È¤ÍÔ‰Ô Û ¿ÙÔÌ· Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ·Ó¿ÚÎÂÈ·˜ ˙ˆÙÈÎÔ‡ ÔÚÁ¿ÓÔ˘. ∏ „˘¯ÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË ·˘ÙÒÓ ÙˆÓ ·ÙfiÌˆÓ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÂÈÙ˘¯‹ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∏ ‚·ÛÈ΋ ÓfiÛÔ˜, Ë Âȉ›ӈÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜, ÔÈ Û˘¯Ó¤˜ ÓÔÛËÏ›˜, ÂÈ‚·Ú‡ÓÔ˘Ó ÙËÓ „˘¯È΋ ˘Á›· ÙˆÓ ·ÛıÂÓÒÓ. Δ· ÚÔ‚Ï‹Ì·Ù· Î·È Ë ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ „˘¯ÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Û ·ÛıÂÓ›˜ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙË ‰È·‰Èηۛ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ··ÈÙÔ‡Ó ÛÙ‹ÚÈÍË ·fi ÙÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi. ∏ ÛˆÛÙ‹ ÓÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰· ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ Ú¤ÂÈ Ó· ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ÂÈÎÔÈÓˆÓ›·, Ë ÔÔ›· Â›Ó·È Ì›· ‰È·ÚÔÛˆÈ΋ Û¯¤ÛË Î·È ‰ÂÓ ÂÚÈÔÚ›˙ÂÙ·È Û ·Ï¤˜ Ù¯ÓÈΤ˜ ‰È·‰Èηۛ˜. ∞Ó·ÁÓˆÚ›˙ÔÓÙ·˜ ÙËÓ È‰È·ÈÙÂÚfiÙËÙ· ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ‰ËÌÈÔ˘ÚÁÔ‡ÌÂ Û˘Óı‹Î˜ ¿ÓÂÛ˘. ¢Â›¯ÓÔÓÙ·˜ ÂӉȷʤÚÔÓ ÚÔÛʤÚÔ˘Ì ηٷÓfiËÛË Î·È ˘ÔÌÔÓ‹. ¢È·ı¤ÙÔ˘Ì fiÛÔ Á›ÓÂÙ·È ÂÚÈÛÛfiÙÂÚÔ ¯ÚfiÓÔ ÁÈ· Û˘˙‹ÙËÛË Î·È Ï‡ÛË ÙˆÓ ÔÏÏ·ÏÒÓ Î·È ÂÍÂȉÈÎÂ˘Ì¤ÓˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ. ∞Ó·ÁÓˆÚ›˙Ô˘ÌÂ Î·È Û‚fiÌ·ÛÙ ÙȘ ÊÔ‚›Â˜ Î·È Ù· Û˘Ó·ÈÛı‹Ì·Ù· ÙÔ˘ ·ÚÚÒÛÙÔ˘, ÂÓÒ ÙÔÓ ÂÓı·ÚÚ‡ÓÔ˘Ì Ì ÂÚˆÙ‹ÛÂȘ Î·È ÙÔÓ Û˘Ì‚Ô˘Ï‡ԢÌ ÌfiÓÔ ·Ó ÙÔ ˙ËÙ‹ÛÂÈ. O ‰È¿ÏÔÁÔ˜ Â›Ó·È Ì›· ˘Â‡ı˘ÓË ÓÔÛËÏ¢ÙÈ΋ Ú¿ÍË Î·È ÌÔÚ› Ó· ¤¯ÂÈ ÏÂÙ‹ ·ÏÏ¿ ‰˘Ó·Ù‹ ›‰Ú·ÛË ÛÙÔ ¿ÏÏÔ ÚfiÛˆÔ. OÈ ·ÛıÂÓ›˜ Ô˘ ÏËÛÈ¿˙Ô˘Ó ÚÔ˜ ÙËÓ Ë̤ڷ Ù˘ ÂÍfi‰Ô˘ ÙÔ˘˜ ·fi ÙÔ ¡ÔÛÔÎÔÌÂ›Ô Âηȉ‡ÔÓÙ·È ·fi ÙËÓ ÓÔÛËχÙÚÈ·-ÙË. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ··ÈÙ› ¤Ó· ˘ÁÈÂÈÓfi ÙÚfiÔ ˙ˆ‹˜. ∞·ÈÙÂ›Ù·È ‰È·ÎÔ‹ ÙÔ˘ ηӛÛÌ·ÙÔ˜, ·Ô¯‹ ·fi ÙÔ ·ÏÎÔfiÏ ‹ Û¿ÓÈ· ¯Ú‹ÛË ÙÔ˘, ‰È·ÈÙËÙÈΤ˜ ·ÏÏ·Á¤˜, ·ÔÊ˘Á‹ ηıÈÛÙÈ΋˜ ˙ˆ‹˜ ‹ ¤ÓÙÔÓ˘ ÎfiˆÛ˘, ̤ÙÚÈ· ¿ÛÎËÛË. ∂›Ó·È ·Ó·Áη›· Ë ÌfiÓÈÌË Î·È Û˘Ó¯‹˜ ·ʋ ÌÂ
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ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ, ÔÈ Ù·ÎÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ, Ë Û˘ÌÌfiÚʈÛË Ì ÙË Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹. ™ÙËÓ ÂÈÙ˘¯‹ ÂͤÏÈÍË Ì›·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ Î·È ÙËÓ ÂÈÛÙÚÔÊ‹ ÙÔ˘ ·ÚÚÒÛÙÔ˘ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Î·È ‰ËÌÈÔ˘ÚÁÈ΋ ˙ˆ‹, Ô ÚfiÏÔ˜ Ô˘ ηÏÂ›Ù·È Ó· ‰È·‰Ú·Ì·Ù›ÛÂÈ Ô ÓÔÛËÏÂ˘Ù‹˜-ÙÚÈ· Â›Ó·È ÂÍ·ÈÚÂÙÈο ÛËÌ·ÓÙÈÎfi˜.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Wiesner H R.Curreent Indications, Contraintications and timing for Liver Transplantation. In: Transplantation of the Liver. Busuttil W R, Klintmalm B G(Eds), WB Saunders Company, Philadelphia 1996, 71-84 2. ∞ÛÎËÙÔÔ‡ÏÔ˘ ∂. ∂›ÁÔ˘Û· Î·È ∂ÓÙ·ÙÈ΋ π·ÙÚÈ΋, ∂ΉfiÛÂȘ §›ÙÛ·˜ 1991:503, 558-559 3. ÿÌ‚ÚÈÔ˜ °. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÓÔÛËÚfiÙËÙ· ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ˆ˜ ÙÚÔ¯Ô¤‰Ë ·ӤÓÙ·Í˘ ÙÔ˘˜. ªÂÙ·ÌfiÛ¯Â˘ÛË OÚÁ¿ÓˆÓ @ πÛÙÒÓ 1998, 3, 1-2:64-66
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4. ÿÌ‚ÚÈÔ˜ °. ªÂÙ·ÌÔۯ‡ÛÂȘ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ Ù˘ ÎÔÈÏ›·˜. πn: ∂›Î·ÈÚ· ÎÏÈÓÈο ı¤Ì·Ù· ÓÂÚ˘ÔÂÈÛÙËÌÒÓ. ∞. μȉ¿Ï˘ (∂d). ™‡Á¯ÚÔÓ˜ ∂ΉfiÛÂȘ 2001, £ÂÛÛ·ÏÔÓ›ÎË 5. μȉ¿Ï˘ ∞., ™˘ÁÁÂÏ¿Î˘ ª., °Ô˘ÏÈ·Ófi˜ ∞. Î·È Û˘Ó. æ˘¯È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È ˘ÔÛÙ‹ÚÈÍË ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ. ªÂÙ·ÌfiÛ¯Â˘ÛË OÚÁ¿ÓˆÓ @ πÛÙÒÓ, 1:4050, 1996 6. μȉ¿Ï˘ ∞., ∫·Ú›Ó˘ °, ºÂÛ·Ù›‰Ë˜ π., ∞ÚÁ˘ÚÔÔ‡ÏÔ˘ ¶. Î·È Û˘Ó. ™˘ÁÎÚÈÙÈ΋ ‰ÈÂÚ‡ÓËÛË „˘¯Ô·ıÔÏÔÁ›·˜ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ηډȿ˜, Ó¢ÌfiÓˆÓ Î·È ‹·ÙÔ˜. πÔÎÚ¿ÙÂÈ·: 1,2:93-97, 1997 7. ∂Ù·ÈÚ›· ∞Ó·ÈÛıËÛÈÔÏÔÁ›·˜ Î·È ∂ÓÙ·ÙÈ΋˜ π·ÙÚÈ΋˜ μÔÚ›Ԣ ∂ÏÏ¿‰Ô˜. ªÂÙÂÎ·È‰Â˘ÙÈο ª·ı‹Ì·Ù· ÁÈ· ¡ÔÛËÏÂ˘Ù¤˜ ∞Ó·ÈÛıËÛÈÔÏÔÁ›·˜ - ª∂£, 1991-1992 8. ªÔ˘Ì¿Ú˘ ∫., °ÂˆÚÁÈ¿‰Ô˘ ∂. π‰È·ÈÙÂÚfiÙËÙ˜ ÛÙËÓ ¡ÔÛËÏ¢ÙÈ΋ ºÚÔÓÙ›‰· ·ÛıÂÓÒÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ. 1Ô ¶·ÁÎÚ‹ÙÈÔ ¡ÔÛËÏ¢ÙÈÎfi ™˘Ó¤‰ÚÈÔ, ª¿ÚÙÈÔ˜ 2003
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∏ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ∏∫∫ Ì ÙȘ ÌÂıfi‰Ô˘˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1, Û˘¯Ó¿ ‰ÂÓ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂڷ›· (ÂÎÙÔÌ‹, ÌÂÙ·ÌfiÛ¯Â˘ÛË) ÛÙԯ‡ÂÈ ÛÙËÓ ›·ÛË. OÈ ÂÚÈÔ¯ÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ÌÔÚ› Ó· Â›Ó·È ¿ÎÚˆ˜ ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ Û ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ2,3,4,5,6. ΔÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ∏∫∫ Â›Ó·È Ë ‚·ÛÈÎfiÙÂÚË ÚÔÁÓˆÛÙÈ΋ ·Ú¿ÌÂÙÚÔ˜ ÁÈ· Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ıÂڷ›·˜. ¢˘ÛÙ˘¯Ò˜, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ηٿ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ∏∫∫ Â›Ó·È ·ÓÂÁ¯Â›ÚËÙÔÈ ÏfiÁˆ ¤ÎÙ·Û˘ ÙÔ˘ fiÁÎÔ˘, ˘ÔΛÌÂÓ˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ ‹/Î·È ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ™Â ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ÂȯÂÈÚÔ‡ÓÙ·È ÂÚÈÔ¯ÈΤ˜ (ÙÔÈΤ˜ ÛÙÔ ‹·Ú) ıÂڷ›˜ ‹ Û˘ÛÙËÌ·ÙÈ΋ ¯ËÌÂÈÔıÂڷ›·7,8,9. (¶›Ó·Î·˜ 2). ™ÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ (67% ÛÙȘ ∏¶∞) ‰ÂÓ ¯ÔÚËÁÂ›Ù·È Î·ÌÈ¿ ·ÁˆÁ‹ 10,11 . ŸÌˆ˜, Ì ÙË Û˘ÛÙËÌ·ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ, ÛÙo 30-40% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ∏∫∫ ÛÙË ¢‡ÛË Î·È ÛÙÔ 60% ÛÙËÓ π·ˆÓ›·, Ô ∏∫∫ ‰È·ÈÛÙÒÓÔÓÙ·È Û ÚÒÈÌË Ê¿ÛË ÔfiÙÂ Î·È Ù›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· Ù˘ ·ÓÙÈÌÂÙÒÈÛ‹˜ ÙÔ˘ Ì ÛÙfi¯Ô ÙËÓ ›·ÛË12. H ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‹·ÙÔ˜ ·ÔÙÂÏ› ηıÈÂڈ̤ÓË, ·ÔÙÂÏÂÛÌ·ÙÈ΋, Â˘Ú‡Ù·Ù· ÂÊ·ÚÌÔ˙fiÌÂÓË Ì¤ıÔ‰Ô ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ÙÔ˘ ÙÂÏÈÎÔ‡ ÛÙ¿‰ÈÔ˘ Ù˘ ΛÚÚˆÛ˘ ÙÔ˘ ‹·ÙÔ˜ Î·È Ù˘ ÔÍ›·˜ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. O ÌÂÙ·ÌÔۯ‡ÛÂȘ ·Ó¿ ¤ÙÔ˜ Î·È Ë ÂÈ‚›ˆÛË ·˘Í¿ÓÔ˘Ó ‰ÈÂıÓÒ˜. ™ÙȘ H¶A Á›ÓÔÓ·ÙÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi 3000 ÌÂÙ·ÌÔۯ‡ÛÂȘ ·Ó¿ ¤ÙÔ˜, Û ÂÚÈÛÛfiÙÂÚ· ·fi 100 ΤÓÙÚ·. ∏ ÂÙËÛ›· ÂÈ‚›ˆÛË Â›Ó·È > 85% Î·È Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË > 70%.
O Ë·ÙÔ΢ÙÙ·ÚÈÎfi˜ ηÚΛÓÔ˜ (HKK) Â›Ó·È Ô Î˘ÚÈfiÙÂÚÔ˜ (90%) ÚˆÙÔ·ı‹˜ ηÚΛÓÔ˜ ÙÔ˘ ‹·ÙÔ˜, ·fi ÙȘ Û˘¯ÓfiÙÂÚ˜ ÌÔÚʤ˜ ηÎÔ‹ıÔ˘˜ ÓÂÔÏ·Û›·˜ ÛÙËÓ ˘Ê‹ÏÈÔ (5% fiÏˆÓ ÙˆÓ Î·ÚΛӈÓ, Ì ÂÚÈÛÛfiÙÂÚ˜ ·fi 500.000 ÂÚÈÙÒÛÂȘ ÙÔ ¯ÚfiÓÔ)1. O ∏∫∫, Û˘Ó‹ıˆ˜ (90-95%), ·Ó·Ù‡ÛÛÂÙ·È Û ÎÈÚÚˆÙÈÎfi ‹·Ú ·ÔÙÂÏÒÓÙ·˜ ÙË Û˘¯ÓfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi ÙËÓ Â˘Ú›· ‰È¿‰ÔÛË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂΉËÏÒÛÂˆÓ Ù˘ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. H ¯ÚÔÓ›· ÊÏÂÁÌÔÓ‹ Î·È Ë Û˘Ó¯‹˜ ·Ó·Á¤ÓÓËÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ÚÔηÏÔ‡Ó ‚Ï¿‚Ë ÛÙÔ DNA ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Î·È ÙËÓ ·Ú¯‹ Ù˘ ÓÂÔÏ·ÛÌ·ÙÈ΋˜ ÂÎÙÚÔ‹˜. ∏ ÚfiÁÓˆÛË ÙÔ˘ ∏∫∫ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘ ηٿ ÙË ÛÙÈÁÌ‹ Ù˘ ‰È¿ÁÓˆÛ˘ Î·È ÙËÓ Â¿ÚÎÂÈ· Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ΔÔ 80-90% ÙˆÓ ·ÛıÂÓÒÓ Ì ∏∫∫ Î·È Î›ÚÚˆÛË ÛÙ¿‰ÈÔ˘ ∞ ηٿ Child Pugh ı· ˙‹ÛÂÈ 1 ¯ÚfiÓÔ, ÂÓÒ ÌfiÓÔ ÙÔ 20% ÂÎÂ›ÓˆÓ Ì ÛÙ¿‰ÈÔ C. TÔ 80-100% ÙˆÓ ·ÛıÂÓÒÓ Ì HKK ‰È·Ì¤ÙÚÔ˘ <5 ÂηÙÔÛÙÒÓ ı· ˙‹ÛÂÈ, ¯ˆÚ›˜ ıÂڷ›·, ÁÈ· 1 ¯ÚfiÓÔ Î·È ÙÔ 20% ÁÈ· 3 ¯ÚfiÓÈ·. ŸÌˆ˜, Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ÙÔ˘ ∏∫∫ Â›Ó·È < 5%. H ̤ÛË ÂÈ‚›ˆÛË ÙˆÓ Û˘Ìو̷ÙÈÎÒÓ ·ÛıÂÓÒÓ Â›Ó·È ÌfiÓÔ 6-8 Ì‹Ó˜. ÷ڷÎÙËÚÈÛÙÈÎfi ÙÔ˘ ∏∫∫ Â›Ó·È Ë ‰È‹ıËÛË ·ÁÁ›ˆÓ (˘Ï·›· ÊϤ‚·, Ë·ÙÈΤ˜ ÊϤ‚˜) Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÂÓ‰ÔË·ÙÈΤ˜ Î·È ·ÔÌÂÌ·ÎÚ˘Ṳ̂Ó˜ (ÔÛÙÈΤ˜, Ó¢ÌÔÓÈΤ˜, ÛÙÔ ÂÈÓÂÊÚ›‰ÈÔ ÎÏ) ÌÂÙ·ÛÙ¿ÛÂȘ. ¶›Ó·Î·˜ 1. M¤ıÔ‰ÔÈ ıÂڷ›·˜ HKK 1. ∞ÔÌ¿ÎÚ˘ÓÛË ÙÔ˘ fiÁÎÔ˘ ∂ÎÙÔÌ‹ MÂÙ·ÌfiÛ¯Â˘ÛË 2. K·Ù·ÛÙÚÔÊ‹ ÙÔ˘ fiÁÎÔ˘ ¶ÂÚÈÔ¯È΋ EÌ‚ÔÏÈÛÌfi˜ +/- ¯ËÌÂÈÔıÂڷ›· ŒÁ¯˘ÛË ·ÏÎÔfiÏ˘ ∂Ê·ÚÌÔÁ‹ Ú·ÛÈÔÛ˘¯ÓÔÙ‹ÙˆÓ ™˘ÛÙËÌ·ÙÈ΋ XËÌÂÈÔıÂڷ›·
2. ª∂Δ∞ªO™Ã∂À™∏ ∏¶∞ΔO™ ™ΔO¡ ∏∫∫ ∏ ·Ó¿Ù˘ÍË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ Ù· ÙÂÏÂ˘Ù·›· 30 ¯ÚfiÓÈ· ‰ËÌÈÔ‡ÚÁËÛ ÙËÓ ÂÏ›‰· ÁÈ· ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ∏∫∫. ∏ ÌÂ-
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¶›Ó·Î·˜ 2. ∞ÏÁfiÚÈıÌÔ˜ ·ÓÈÌÂÙÒÈÛ˘ ∏∫∫. ∞fi ÙÔ 8 ÙÚÔÔÈË̤ÓÔ
Ù·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È ıˆÚËÙÈÎÒ˜ Ë Ï¤ÔÓ ÂÏ΢ÛÙÈ΋ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ∏∫∫, ÁÈ·Ù› ÂÎÙfi˜ ·fi ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÓÂÔÏ¿ÛÌ·ÙÔ˜ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Î·È Ë Î›ÚÚˆÛË Ô˘ ·ÔÙÂÏ› ÚÔηÚÎÈÓÈ΋ ηٿÛÙ·ÛË ÁÈ· ÂΉ‹ÏˆÛË ÌÂÏÏÔÓÙÈÎÒÓ fiÁΈÓ, ÂÓÒ Ù·˘ÙÔ¯ÚfiÓˆ˜ ÚÔÏ·Ì‚¿ÓÔÓÙ·È Î·È ÔÈ ¿ÏϘ ÂÈÏÔΤ˜ Ù˘ (ÏfiÁˆ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ ‹/Î·È Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜)13. Δ· ·Ú¯Èο ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û ∏∫∫ ·fi ÙÔ˘˜ ÚˆÙÔfiÚÔ˘˜ ¯ÂÈÚÔ˘ÚÁÔ‡˜ Thomas Starzl14 Î·È Sir Roy Calne ‹Ù·Ó ·ÔÁÔËÙ¢ÙÈο, ΢ڛˆ˜ ÏfiÁˆ η΋˜ ÂÈÏÔÁ‹˜ ÙˆÓ ·ÛıÂÓÒÓ. ™ÙËÓ ·Ú¯È΋ ÂÚ›Ô‰Ô ÂÊ·ÚÌÔÁ‹˜ Ù˘, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÓÂÁ¯Â›ÚËÙˆÓ Ôχ ÌÂÁ¿ÏˆÓ fiÁÎˆÓ ÙÔ˘ ‹·ÙÔ˜ ‰Â‰Ô̤Ó˘ Ù˘ η΋˜ ÚfiÁÓˆÛ˘ Î·È Ù˘ ·‰˘Ó·Ì›·˜ ÁÈ· ÚÈ˙ÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ŸÌˆ˜, Û‡ÓÙÔÌ· ¤ÁÈÓ ·ÓÙÈÏËÙfi ÙÔ ˘„ËÏfi ÔÛÔÛÙfi ˘ÔÙÚÔÒÓ (80%) Î·È Ì¿ÏÈÛÙ· Û ۇÓÙÔÌÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·15,16,17,18,19 ÁÂÁÔÓfi˜ Ô˘ ·Ó·fiÊ¢ÎÙ· Ô‰‹ÁËÛ Û Ì›ˆÛË ÙÔ˘ ÂÓıÔ˘ÛÈ·ÛÌÔ‡ ÁÈ· ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ 20 . ™‡Ìʈӷ Ì ÙËÓ European Liver Transplant Registry, ÙÔ 1985 ÙÔ 38% ÙˆÓ Ë·ÙÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·ÊÔÚÔ‡Û ·ÛıÂÓ›˜ Ì ∏∫∫, ÂÓÒ ÙÔ 1996 ÙÔ ÔÛÔÛÙfi ·˘Ùfi ‹Ù·Ó ÌfiÏȘ 10%21. ΔÔ ÂfiÌÂÓÔ ‚‹Ì· ‹Ù·Ó Ë ·Ó·˙‹ÙËÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ˘ÔÙÚÔ‹˜ ÙÔ˘ ∏∫∫ Î·È Ë Î·ÏÏ›ÙÂÚË ÂÈÏÔÁ‹ ·ÛıÂÓÒÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ì ÛÙfi¯Ô ÙËÓ Â›Ù¢ÍË ÈηÓÔÔÈËÙÈÎfiÙÂÚˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ22.
3. ¶ƒO°¡ø™∏ ª∂Δ∞ Δ∏ ª∂Δ∞ªO™Ã∂À™∏ ¶ÔÏ˘¿ÚÈı̘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÛÂÈÚ¤˜ ·fi ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ‰ÈÂÚ‡ÓËÛ·Ó Î·È ·Ó¤Ï˘Û·Ó ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ˘ÔÙÚÔ‹ Î·È ¤ıÂÛ·Ó ÙȘ ÂӉ›ÍÂȘ ÂÈÏÔÁ‹˜ ·ÛıÂÓÒÓ Ì ∏∫∫ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË23,24,25,26,27,28,29,30,31. Δ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ (ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô˜ ¯ˆÚ›˜ ÓfiÛÔ Î·È ÂÈ‚›ˆÛË) Â›Ó·È Î·Ï‡ÙÂÚ· fiÙ·Ó Ô fiÁÎÔ˜ ¤¯ÂÈ Û˘ÁÎÂÎÚÈ̤ӷ ¯·Ú·ÎÙËÚÈÛÙÈο. ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ ·ÔʇÁÂÙ·È Ë Û·Ù¿ÏË ÌÔÛ¯Â˘Ì¿ÙˆÓ ÁÈ· ·ÛıÂÓ›˜ Ì η΋ ÚfiÁÓˆÛË32. O ˘ÔÙÚÔ¤˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙȘ ÎÏÈÓÈÎÒ˜ Î·È ·ÎÙÈÓÔÏÔÁÈÎÒ˜ ÌË ·ÓȯÓ‡ÛÈ̘ ÌÈÎÚÔÌÂÙ·ÛÙ¿ÛÂȘ, Ù· ‰È·Ê˘ÁfiÓÙ· ηÚÎÈÓÈο ·ÙÙ·Ú· ηٿ ÙËÓ ‰È¿ÚÎÂÈ· ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ ÛÙÔ ‹·Ú, ÙË ¯ÔÚËÁÔ‡ÌÂÓË ·ÓÔÛÔηٷÛÙÔÏ‹, ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ·Ú¯ÈÎÔ‡ fiÁÎÔ˘, ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ Û ÔÏ˘ÂÛÙȷ΋ ÂΉ‹ÏˆÛË ÙÔ˘ ∏∫∫, ÙË ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÈÛÙÔÏÔÁÈÎÒ˜ Î·È ÙËÓ ·ÁÁÂȷ΋ ‹/Î·È ÏÂÌÊ·‰ÂÓÈ΋ ‰È‹ıËÛË. O ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ HKK Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ÚÔ¯ˆÚË̤ӷ ÛÙ¿‰È· Ù˘ ΛÚÚˆÛ˘. ΔÔ 30% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÁÈ· ÌË–·ÓÙÈÚÚÔÔ‡ÌË HCV ΛÚÚˆÛË, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ∏∫∫ ÛÙÔ ÎÈÚÚˆÙÈÎfi ‹·Ú Ô˘ ·ÓÙÈηı›ÛٷٷÈ. H ÚfiÁÓˆÛË Â›Ó·È Ôχ ηϋ (5ÂÙ‹˜ ÂÈ‚›ˆÛË >70%) fiÙ·Ó Ô ∏∫∫ ‰È·ÈÛÙˆı› Ù˘¯·›ˆ˜ ηٿ ÙÔÓ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ¤ÏÂÁ¯Ô ÙÔ˘ ·Ê·ÈÚÂı¤ÓÙÔ˜ ‹·ÙÔ˜33,34. T· ·Ú·¿Óˆ, Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÛıÂÓÒÓ Ì ÚÔ¯ˆÚË̤ÓË
240
™. NTOYPAKH™
ΛÚÚˆÛË ‹·ÙÔ˜ ÚÈÓ ·fi ÙËÓ ·ÂÈÎÔÓÈÛÙÈ΋ ‹ ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË ÙÔ˘ HKK. ∏ ÛËÌ·ÓÙÈÎfiÙÂÚË ÚÔÁÓˆÛÙÈ΋ ·Ú¿ÌÂÙÚÔ˜ ˘ÔÙÚÔ‹˜ ÙÔ˘ ∏∫∫ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Ë ÌÈÎÚÔÛÎÔÈ΋ ‹ Ì·ÎÚÔÛÎÔÈ΋ ·ÁÁÂȷ΋ ‰È‹ıËÛË35. ∏ ‰È‹ıËÛË ‰È·ÙÚ¤¯ÂÈ ·Ú¿ÏÏËÏ· Ì ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ fiÁÎÔ˘ Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ fi˙ˆÓ Ô˘ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ΢ÚÈfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ˘ÔÙÚÔÒÓ Î·È ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÚÚÒÛÙˆÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË36, 37. OÈ ·ÛıÂÓ›˜ Ì fiÁÎÔ˘˜ ‰È·Ì¤ÙÚÔ˘ < 5 ÂηÙÔÛÙÒÓ ¤¯Ô˘Ó ÈηÓÔÔÈËÙÈ΋ ÂÈ‚›ˆÛË Î·È ÔÛÔÛÙfi ˘ÔÙÚÔ‹˜ < 20%. ∏ 3/ÂÙ‹˜ ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË ÁÈ· ∏∫∫ ‰È·Ì¤ÙÚÔ˘ < 3 ÂηÙÔÛÙÒÓ Â›Ó·È 83%38. ŒÙÛÈ, ÁÈ· ηχÙÂÚË ÚfiÁÓˆÛË ··ÈÙÂ›Ù·È ÂÚÈÔÚÈṲ̂ÓÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ∏∫∫ (‰È¿ÌÂÙÚÔ˜ < 5 ÂηÙÔÛÙÒÓ Û 1 ‚Ï¿‚Ë ‹ < 3 ÂηÙÔÛÙÒÓ Û 3 ‚Ï¿‚˜) ¯ˆÚ›˜ Ó· ‰È·ÈÛÙÒÓÔÓÙ·È ·ÁÁÂȷΤ˜ ‰ÈËı‹ÛÂȘ ‹ ÏÂÌÊ·‰ÂÓÈΤ˜ ‹ ·ÈÌ·ÙÔÁÂÓ›˜ ÌÂÙ·ÛÙ¿ÛÂȘ (∫ÚÈÙ‹ÚÈ· ÙÔ˘ ªπÏ¿ÓÔ˘)39. ™Â ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜, Ë ÂÈ‚›ˆÛË Â›Ó·È 75% ÛÙ· 4 ¯ÚfiÓÈ· Ì ΛӉ˘ÓÔ ˘ÔÙÚÔ‹˜ ÙÔ˘ ∏∫∫ ÂÚ›Ô˘ 10%. ∏ ÂÈ‚›ˆÛË ·˘Ù‹ ‰Â ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË ¯ˆÚ›˜ ∏∫∫40,41, 42,43,44. Δ· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ· ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ·ÔÙÂÏÔ‡Ó ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· ÚÔÁÓˆÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ·Ô˘Û›·˜ ÌÈÎÚÔÛÎÔÈ΋˜ ·ÁÁÂȷ΋˜ ‹ ÏÂÌÊ·ÁÁÂȷ΋˜ ‰È‹ıËÛ˘ Ô˘ ÚÔËÁÂ›Ù·È Ù˘ ÂÓ‰ÔË·ÙÈ΋˜ ‹ Â͈˷ÙÈ΋˜ ¤ÎÙ·Û˘ Ù˘ ÓfiÛÔ˘45. ΔÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ∏∫∫ ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÌÂÙ¿ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏfiÁˆ ÙˆÓ ÚÔ¸·Ú¯Ô˘ÛÒÓ ÌÈÎÚÔÛÎÔÈÎÒÓ ÌÂÙ·ÛÙ¿ÛÂˆÓ Î·È ÛÙ· Ï·›ÛÈ· Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜. ŸÌˆ˜, ‹‰Ë ÂȯÂÈÚÂ›Ù·È Û ÂȉÈο ΤÓÙÚ· Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ∏∫∫ Ì ÚfiÁÓˆÛË Ï›ÁÔ ¯ÂÈÚfiÙÂÚË Û ۯ¤ÛË Ì ٷ ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ (5ÂÙ‹˜ ÂÈ‚›ˆÛË 50% 46,47) Ô˘ Â›Ó·È ÁÂÓÈÎÒ˜ ·Ô‰ÂÎÙ‹48,49,50,51,52,53,54. ∏·ÙÔ΢ÙÙ·ÚÈÎÔ› ηÚΛÓÔÈ Ì ÌÂÁ·Ï‡ÙÂÚ˜ ·fi ÙȘ ÂÚÈÏ·Ì‚·ÓfiÌÂÓ˜ ÛÙ· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ ‰È·ÛÙ¿ÛÂȘ (‰È¿ÌÂÙÚÔ˜ ‚Ï¿‚˘ <6,5 ÂηÙÔÛÙÒÓ, ‹ 3 ‚Ï¿‚˜ Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ‰È·Ì¤ÙÚÔ˘ < 4,5 ÂηÙÔÛÙÒÓ Î·È Û˘ÓÔÏÈ΋ <8 ÂηÙÔÛÙÒÓ (∫ÚÈÙ‹ÚÈ· University of California at San Francisco-UCSF55) Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÙ‹ÛÈ· Î·È 5ÂÙ‹ ÂÈ‚›ˆÛË 90% Î·È 72% ·ÓÙÈÛÙÔ›¯ˆ˜56,57. ŸÌˆ˜, ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú·¤ÌÂÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ٷ ‰È¢ÚË̤ӷ ·˘Ù¿ ÎÚÈÙ‹ÚÈ· ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ ÙÔ 5% ÙˆÓ
ÂÈÏÂÁÌ¤ÓˆÓ Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘58. ∞fi ‰Â‰Ô̤ӷ ÙÔ˘ ∞ÌÂÚÈηÓÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÂϤÁ¯Ô˘ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ (United Network for Organ sharing-UNOS), Û 3 ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜ (1987-91, 1992-95 Î·È 1996-2001), Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÁÈ· ∏∫∫ ‹Ù·Ó 25, 47 Î·È 61% ·ÓÙÈÛÙÔ›¯ˆ˜, ÂÓÒ ÁÈ· ÌË ÓÂÔÏ·ÛÌ·ÙÈ΋ ·ÈÙ›· 71% Î·È ÁÈ· ÙȘ 3 ÂÚÈfi‰Ô˘˜59. ΔÔ ÁÂÁÔÓfi˜ Ì·ÚÙ˘Ú¿ fiÙÈ ÔÈ ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ Ô˘ ·Ú·ÙËÚ‹ıËΠ̠ÙÔ ¤Ú·ÛÌ· ÙÔ˘ ¯ÚfiÓÔ˘ ÔÊ›ÏÂÙ·È Û ηχÙÂÚË ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ∏∫∫ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È fi¯È Û ‚ÂÏÙ›ˆÛË Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Ù¯ÓÈ΋˜ ‹ Ù˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ÊÚÔÓÙ›‰·˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Â›Ó·È Ë ›‰È· Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ οı ·ÈÙÔÏÔÁ›·˜. ™˘Û¯¤ÙÈÛË Ì ÙËÓ ÂÈ‚›ˆÛË ¯ˆÚ›˜ ˘ÔÙÚÔ‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ∏∫∫ ÌÂÙ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÚÔ˘ÛÈ¿˙ÂÈ Î·È Ë ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ·ÏÏ¿ Ë ÂÎÙ›ÌËÛ‹ Ù˘ ··ÈÙ› ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË Ô˘ ‰ÂÓ ˘¿Ú¯ÂÈ ¿ÓÙÔÙÂ60,61,62. ∂ÈϤÔÓ, Ô ∏∫∫ ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘¯Ó¿ ÂÙÂÚÔÁ¤ÓÂÈ· ÛÙË ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘. ∏ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÌÂϤÙË ÙÔ˘ ·Ê·ÈÚÂı¤ÓÙÔ˜ ÎÈÚÚˆÙÈÎÔ‡ ‹·ÙÔ˜ Ì ÙÔÓ ∏∫∫ ÌÔÚ› Ó· ÚԂϤ„ÂÈ ÙËÓ Èı·Ó‹ ˘ÔÙÚÔ‹ ÏfiÁˆ ‰È·›ÛÙˆÛ˘ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÌÈÎÚÔ‰ÈËı‹ÛÂˆÓ Ô˘ ÌÔÚ› Ó· ˘Ô‰ËÏÒÓÔ˘Ó ÙËÓ ·Ú¯‹ ÌÈÎÚÔÌÂÙ·ÛÙ¿ÛˆÓ. ∏ ·Ó·˙‹ÙËÛË ÙÔ˘ ·ÁÁÂÏÈÔÊfiÚÔ˘ RNA Ù˘ ·1 ÂÌ‚Ú˘È΋˜ ÚˆÙÂ˚Ó˘ ÛÙËÓ ÔÛÙÈ΋ ‚ÈÔ„›· ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ÛÙÔ Ì¤ÏÏÔÓ ‰È·ÁÓˆÛÙÈÎfi ÎÚÈÙ‹ÚÈÔ ‡·Ú͢ ÌÈÎÚÔÌÂÙ·ÛÙ¿ÛˆÓ63. ∏ Û‡Á¯ÚÔÓË ¤Ú¢ӷ ηÙ¢ı‡ÓÂÙ·È ÚÔ˜ ÙËÓ ÂÍ‹ÁËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ fiÛˆÓ (10-20% ÙÔ˘ Û˘ÓfiÏÔ˘) ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Û‡Ìʈӷ Ì ٷ ‰ÈÂıÓÒ˜ ÎÚ·ÙÔ‡ÓÙ· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ Î·È ˘ÔÙÚÔÈ¿˙Ô˘Ó Û ·ÓÙ›ıÂÛË Ì ¿ÏÏÔ˘˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Ì ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ηÚΛÓÔ˘˜ Î·È ÂÈ‚ÈÒÓÔ˘Ó ¯ˆÚ›˜ ˘ÔÙÚÔ‹. ∂›Ó·È Èı·ÓfiÓ, Ô ‚ÈÔÏÔÁÈÎfi˜ Ê·ÈÓfiÙ˘Ô˜ ÙÔ˘ ∏∫∫, Ô˘ ÌÂÏÂÙ¿Ù·È Ì ÁÔÓȉȷΤ˜ Ù¯ÓÈΤ˜, Ó· ·ÔÙÂϤÛÂÈ ÛÙÔ Ì¤ÏÏÔÓ ÙÔÓ Ï¤ÔÓ Î·Ù¿ÏÏËÏÔ ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÂÈÙ˘¯›·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘64,65,66,67.
4. ∂¶π§O°∏ Δø¡ ∞™£∂¡ø¡ ªÂ ‚¿ÛË Ù· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ·, Û οı ·ÛıÂÓ‹ Ú¤ÂÈ Ó· ηıÔÚ›˙ÂÙ·È ÙÔ Ì¤ÁÂıÔ˜ Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ fiÁÎˆÓ Î·È Ó· ·ÔÎÏ›ÂÙ·È Ë ·ÁÁÂȷ΋ Î·È Â͈˷ÙÈ΋ ¤ÎÙ·ÛË ÙÔ˘ ∏∫∫. °È ·˘Ùfi, ‰ÈÂÓÂÚÁÔ‡ÓÙ·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, ·ÍÔÓÈ΋ Î·È Ì·ÁÓË-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙÈ΋ ÙÔÌÔÁÚ·Ê›· Î·È ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒÚ·ÎÔ˜. ∏ ·ÂÈÎÔÓÈÛÙÈ΋ ÌÂϤÙË Ì positron emission tomography (ƒ∂Δ) ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ68. ∏ ‚ÈÔ„›· ÙÔ˘ ∏∫∫ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË. ŸÌˆ˜, fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ÈÛÙÔÏÔÁÈ΋ ÂȂ‚·›ˆÛË, ··ÈÙÂ›Ù·È ‰È·ÁÓˆÛÙÈÎÒ˜ ηٿ‰ÂÈÍË Ù˘ ÂȉÈ΋˜ ·ÁÁÂÈÔÁÚ·ÊÈ΋˜ ÂÈÎfiÓ·˜ (ÓÂÔ·ÁÁ›ˆÛË) Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙËÓ ·ÂÈÎÔÓÈÛÙÈ΋ ‚Ï¿‚Ë Î·È ÙÈ̤˜ ·1 ÂÌ‚Ú˘È΋˜ ÚˆÙÂ˚Ó˘ >200ng/ml. ∞ÛıÂÓ›˜ Ì ·‡ÍËÛË Ù˘ ·1 ÂÌ‚Ú˘È΋ ÚˆÙÂ˚ÓË >500 ng/ml, ÂÓÙ¿ÛÛÔÓÙ·È Û ÚfiÁÚ·ÌÌ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ·ÎfiÌË Î·È Â¿Ó ‰ÂÓ ‰È·ÈÛÙÒÓÂÙ·È ·ÎÙÈÓÔÏÔÁÈÎÒ˜ ¯ˆÚÔηٷÎÙËÙÈ΋ ÂÍÂÚÁ·Û›·69. O ·ÛıÂÓ‹˜ Ì ‰È¿ÁÓˆÛË ∏∫∫ ÛÙË Ï›ÛÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ì ¢·›ÛıËÙË ·ÂÈÎÔÓÈÛÙÈ΋ ÂͤٷÛË ·Ó¿ 3ÌËÓÔ ÁÈ· Ó· ·ÓÂÎÙÈÌ¿Ù·È Â¿Ó Û˘Ó¯›˙ÂÈ Ó· ÏËÚ› Ù· ÎÚÈÙ‹ÚÈ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË70. ∂¿Ó ˘¿Ú¯ÂÈ ÂÚÒÙËÌ· ÁÈ· ÙËÓ ·ÚÔ˘Û›· ‰ÈËıËÌ¤ÓˆÓ ÏÂÌÊ·‰¤ÓˆÓ ‹ ÂÚÈÙÔÓ·˚΋˜ ‰È·ÛÔÚ¿˜, ÌÔÚ› Ó· ÂȯÂÈÚËı› ‰È·ÁÓˆÛÙÈ΋ Ï··ÚÔÛÎfiËÛË Ì ‹ ¯ˆÚ›˜ ÂÓ‰ÔÛÎÔÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌÌ· Ì ÛÎÔfi Ó· ·ÔÊ¢¯ı› Ë Ï··Ú·ÙÔÌ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Â¿Ó ˘¿Ú¯ÂÈ Â͈˷ÙÈ΋ ‰È·ÛÔÚ¿ ÙÔ˘ ∏∫∫71. ∞fiÏ˘Ù˜ ·ÓÙÂӉ›ÍÂȘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È ÔÈ ÂÓÂÚÁ›˜ ÂÎÙfi˜ ¯ÔÏËÊfiÚˆÓ ‚·ÎÙËÚȷΤ˜ ‹ Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ, Ë ÛÔ‚·Ú‹ ηډȷÁÁÂȷ΋ ‹ Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜, Ô ÌÂÙ·ÛÙ·ÙÈÎfi˜ ∏∫∫, Ë ÚfiÛÊ·ÙË ‰È¿ÁÓˆÛË Â͈˷ÙÈÎÔ‡ ηÚΛÓÔ˘, Ô ÂÓÂÚÁfi˜ ·ÏÎÔÔÏÈÛÌfi˜ ‹/Î·È ÂıÈÛÌfi˜ Û ÙÔÍÈΤ˜ Ô˘Û›Â˜ Î·È Ë ¤ÏÏÂÈ„Ë Û˘ÓÂÚÁ·Û›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹/Î·È ÙˆÓ Û˘ÁÁÂÓÒÓ ÙÔ˘. ™¯ÂÙÈΤ˜ ·ÓÙÂӉ›ÍÂȘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È Ë ËÏÈΛ· >75 ¯ÚÔÓÒÓ, Ë Û‹„Ë ÙˆÓ ¯ÔÏËÊfiÚˆÓ, ÙÔ ¯ÔÏ·ÁÁÂÈÔηÚΛӈ̷, ÙÔ ·ÈÌ·ÁÁÂÈÔÛ¿ÚΈ̷, Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ÌÂ Û˘ÓÔ‰fi ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, Ë ÓÔÛËÚ¿ ·¯˘Û·ÚΛ·, ÙÔ ÂÓÂÚÁfi „˘¯È·ÙÚÈÎfi ÓfiÛËÌ· Î·È Ë HIV Ïԛ̈ÍË.
5. ª∂πO¡∂∫ΔHª∞Δ∞ Δ∏™ ª∂Δ∞ªO™Ã∂À™∏™ ™Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÌÂٷ͇ ¿ÏÏˆÓ Û˘ÁηٷϤÁÔÓÙ·È: Ë ¤ÏÏÂÈ„Ë ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÙÔ ˘„ËÏfi ÎfiÛÙÔ˜, Ë Èı·ÓfiÙËÙ· ¤ÎÙ·Û˘ ÙÔ˘ fiÁÎÔ˘ ηٿ ÙÔÓ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË (Ô ÔÔ›Ô˜ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ˘ÂÚ‚·›ÓÂÈ ÙÔ˘˜ 6 Ì‹Ó˜), Ô ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ˘ÔÙÚÔ‹˜ ·fi Ù· ¯ÔÚËÁÔ‡ÌÂÓ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Î·È Ë ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· ·fi ¿ÏϘ ·Èٛ˜. ΔÔ Î‡ÚÈÔ Úfi‚ÏËÌ· Ù˘ ÌÂÙ·-
241
ÌfiÛ¯Â˘Û˘ Â›Ó·È fiÙÈ Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ÂÚÈ̤ÓÂÈ ·ÚÎÂÙÔ‡˜ Ì‹Ó˜ ÛÙË Ï›ÛÙ·, ÔfiÙ ÙÔ ÓÂfiÏ·ÛÌ· ÌÔÚ› Ó· ·˘ÍËı› Û ̤ÁÂıÔ˜ ‹ Ó· ÂȉÂÈÓˆı› Ë Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÌÂÈÒÓÔÓÙ·˜ Ù· ÔÛÔÛÙ¿ ›·Û˘72,73. ™ÙȘ ∏¶∞, Ë ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÌÔÚ› Ó· ˘Âڂ› Ù· 2 ¯ÚfiÓÈ·. ∏ ·ÔÌ¿ÎÚ˘ÓÛË ·fi ÙË Ï›ÛÙ· Û 12 Ì‹Ó˜ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙ· ÌÂÁ¿Ï· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÙˆÓ ∏¶∞ Û 15-30%, ÁÂÁÔÓfi˜ Ô˘ ÌÂÈÒÓÂÈ ÙËÓ Ú·ÁÌ·ÙÈ΋ 5ÂÙ‹ ÂÈ‚›ˆÛË Î·Ù¿ 10-15% 74,75,76. ∞ÛÊ·ÏÒ˜, Ù· ÓÔ‡ÌÂÚ· Â›Ó·È ÌÂÁ·Ï‡ÙÂÚ· (>50%) Â¿Ó ÂÚÈÏËÊıÔ‡Ó Î·È ∏∫∫ ÌÂÁ¤ıÔ˘˜ ÌÂÁ·Ï‡ÙÂÚÔ˘ ·fi ÙÔ ÎÏ·ÛÈÎÒ˜ Û˘ÓÈÛÙÒÌÂÓÔ˘ Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘77. ™ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÂÈ‚›ˆÛ˘ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÁÈ· ∏∫∫, ı· Ú¤ÂÈ Ó· ˘ÔÏÔÁ›˙ÔÓÙ·È ¿ÓÙÔÙ ÎÔÈ ÔÈ ·ÛıÂÓ›˜ Ô˘ ·ÔÌ·ÎÚ‡ÓıËÎ·Ó ·fi ÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÏfiÁˆ ¤ÎÙ·Û˘ ÙÔ˘ ÓÂÔÏ¿ÛÌ·ÙÔ˜.
6. Ã∂πƒOÀƒ°π∫H ∂∫ΔOªH ΔOÀ ∏∫∫ ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ ÚÔÙÈÌ¿Ù·È Û ·ÛıÂÓ›˜ ¯ˆÚ›˜ ΛÚÚˆÛË ‹ Û fiÛÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â¿ÚÎÂÈ· Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ª¤¯ÚÈ ÙÔ 75% ÙÔ˘ ÌË-ÎÈÚÚˆÙÈÎÔ‡ ‹·ÙÔ˜ ÌÔÚ› Ó· ·Ê·ÈÚÂı› Ì ¯ÂÈÚÔ˘ÚÁÈ΋ ıÓËÛÈÌfiÙËÙ· <5% 78, 79,80. ΔÔ ÂÓ·ÔÌÂ›Ó·Ó ÌË-ÎÈÚÚˆÙÈÎfi ‹·Ú ¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ·Ó·Á¤ÓÓËÛ˘81. ™Â ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÛÙ·‰›Ô˘ ∞ ηٿ Child-Pugh (¶›Ó·Î·˜ 3) ÌÔÚ› Ó· ·Ê·ÈÚÂı› ÙÔ 50% ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. ∏ ÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· Â›Ó·È < 6% Î·È Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ÛÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· 3050%82. ™Â ·ÛıÂÓ›˜ Ì ÌÂÁ¿ÏÔ˘˜ fiÁÎÔ˘˜ Î·È ·Ó·ÌÂÓfiÌÂÓÔ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÒ˜ ÌÈÎÚfi fiÁÎÔ ‹·ÙÔ˜, ÌÔÚ› Ó· ÂȯÂÈÚËı› ·ÙÚÔÊ›· ÙÔ˘ ∏∫∫ Ì ·ÓÙ›ÛÙÔÈ¯Ë ˘ÂÚÙÚÔÊ›· ÙÔ˘ ÌË ÓÂÔÏ·ÛÌ·ÙÈÎÔ‡ ‹·ÙÔ˜ Ì ÚÔÂÁ¯ÂÈÚËÙÈÎfi ‰È·‰ÂÚÌÈÎfi ‰ÈË·ÙÈÎfi ÂÌ‚ÔÏÈÛÌfi ‹ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔϛӈÛË ÙÔ˘ ‰ÂÍÈÔ‡ ‹ ·ÚÈÛÙÂÚÔ‡ ÎÏ¿‰Ô˘ Ù˘ ˘Ï·›·˜. ªÂ ÙËÓ ·Ú¤Ì‚·ÛË ¶›Ó·Î·˜ 3. K·Ù¿Ù·ÍË ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ Ì ‚¿ÛË Ù· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ηٿ Child-Δurcotte-Pugh KPITHPIA AÛΛÙ˘ EÁÎÂÊ·ÏÔ·ıÂÈ· XÔÏÂÚ˘ıÚ›ÓË mg/dl (™Â PBC) §Â˘ÎˆÌ·Ù›ÓË g/l ¶·Ú¿Ù·ÛË X. Quick Û sec B∞£ªOπ ™TA¢IO (‚·ıÌÔ›)
BA£MO§O°IA 1-2 1-4 >35 <4 1
+/I-II 2-3 4-10 28-35 4-6 2
+ III-IV >3 >10 <28 >6 3
A: 5-6
B: 7-9
C: >10
242
™. NTOYPAKH™
·˘Ù‹ ˘¿Ú¯Ô˘Ó ÌÈÎÚÔ› ΛӉ˘ÓÔÈ ÂÓ›Û¯˘Û˘ ÙÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙˆÓ Î·ÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È Ú‹Í˘ Ù˘ ·ÓÙÈÚÚfiËÛ˘ Ì ÚfiÎÏËÛË ‹ Âȉ›ӈÛË ÚÔ¸¿Ú¯Ô˘Û·˜ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ Î·È ÂÈÏÔ΋-¯ ÎÈÚÛÔÚÚ·Á›·. OÈ ·ÚÂÌ‚¿ÛÂȘ ÛÙÔ ˘Ï·›Ô Û‡ÛÙËÌ· ÌÔÚ› Ó· Û˘Ó‰˘·ÛıÔ‡Ó Ì ·ÚÙËÚÈ·Îfi ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi ÙÔ˘ ∏∫∫83,84. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ Á›ÓÂÙ·È 2-4 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈÛÌfi ÌfiÓÔÓ ÂÊ’fiÛÔÓ ·Ú·ÙËÚËı› ‚·ıÌfi˜ ·Ó·Á¤ÓÓËÛ˘ ÙÔ˘ ‹·ÙÔ˜85,86,87,88. ∏ ÂÎÙÔÌ‹ Û ÎÈÚÚˆÙÈÎfi ·ÛıÂÓ‹ ÚÔ¸Ôı¤ÙÂÈ ÈηÓÔÔÈËÙÈ΋ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ™Â ·ÛıÂÓ›˜ ÛÙ·‰›Ô˘ C ‰ÂÓ ‰ÈÂÓÂÚÁÂ›Ù·È ÂÎÙÔÌ‹ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. ∏ ÂÎÙ›ÌËÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚ› Ó· ÂȯÂÈÚËı› Ì ÙËÓ Î¿ı·ÚÛË ÙÔ˘ Ú¿ÛÈÓÔ˘ Ù˘ ÈÓ‰Ô΢·Ó›Ó˘. ∏ ¿ÚÎÂÈ· Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ Ú¿ÍË ÂÎÙÈÌ¿Ù·È Ì ÙËÓ ·Ô˘Û›· ÈÎÙ¤ÚÔ˘ Î·È ÛÔ‚·Ú‹˜ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ fiˆ˜ ÌÂÙÚ¿Ù·È Ì ÙË ›ÂÛË ÂÓÛÊ‹ÓˆÛ˘ ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ Î·È ˘Ï·ÈÔÛ˘ÛÙËÌ·ÙÈ΋ ‰È·ÊÔÚ¿ <10 mmHg. ∏ ·ÚÔ˘Û›· ÛÏËÓÔÌÂÁ·Ï›·˜, ıÚÔÌ‚ÔÂÓ›·˜ ‹/Î·È ÎÈÚÛÒÓ ÔÈÛÔÊ¿ÁÔ˘ ÛÙËÓ ÂÓ‰ÔÛÎfiËÛË ˘Ô‰ËÏÒÓÔ˘Ó ÙËÓ ·ÚÔ˘Û›· ˘Ï·›·˜ ˘¤ÚÙ·Û˘ Î·È ·ÓÙ¤Ó‰ÂÈÍË ÌÂÚÈ΋˜ Ë·ÙÂÎÙÔÌ‹˜ 89. °ÂÓÈÎÒ˜, ÙÔ 20-30% ÙˆÓ ∏∫∫ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛıÔ‡Ó ¯ÂÈÚÔ˘ÚÁÈÎÒ˜ Ì ÂÎÙÔÌ‹90. (¶›Ó·Î·˜ 4). Δ· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ‰›‰Ô˘Ó ∏∫∫ <5 ÂηÙÔÛÙÒÓ ‹ ÏÈÁfiÙÂÚÔ ·fi 3 ‰È·Ì¤ÙÚÔ˘ <3 ÂηÙÔÛÙÒÓ, ¯ˆÚ›˜ ·ÁÁÂȷ΋ ‰È‹ıËÛË. OÈ ÌÂÁ·Ï‡ÙÂÚÔÈ fiÁÎÔÈ ¤¯Ô˘Ó ‰˘ÛÌÂÓ¤ÛÙÂÚÔ ·ÔÙ¤ÏÂÛÌ·. ∏ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÛÙ·‰ÈÔÔ›ËÛË ÙÔ˘ ∏∫∫ Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋91,92. ŸÌˆ˜, Ô ÚÔÂÁ¯ÂÈÚËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ Î·Ï‹ ¢·ÈÛıËÛ›· Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÔÏÏ¿ „¢‰Ò˜ ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù·93. ™ÙÔ 10-15% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÙÔ˘Ï¿¯ÈÛÙÔÓ, ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ fiÁÎÔ˘ ˘ÔÏÔÁ›˙ÂÙ·È ÌÈÎÚfiÙÂÚÔ Ì ÙȘ ·ÂÈÎÔÓ›ÛÂȘ Û ۯ¤ÛË Ì ÙÔ ·ıÔÏÔÁÔ·Ó·ÙÔÌÈÎfi ˘ÏÈÎfi94. ΔÔ ÔÛÔÛÙfi ÌÔÚ› Ó· ·Ó¤ÏıÂÈ Î·È ÛÙÔ 20-30%95. ™ËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÂÈ‚›ˆÛ˘ ÚÔÂÁ¯ÂÈÚËÙÈÎÒ˜ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ıÚ¤„˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ë ·Ô˘Û›· ¿ÏÏˆÓ ÛËÌ·ÓÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ˘Á›·˜ (¯ ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜, ۷ί·Ú҉˘ ‰È·‚‹Ù˘ ÎÏ). ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂÁ¿Ï· ÔÛÔÛÙ¿ (50%) ˘ÔÙÚÔ‹˜, Û˘Ó‹ıˆ˜ Û ¿ÏÏË ı¤ÛË ·fi ÙËÓ ·Ï·ÈfiÙÂÚË ‚Ï¿‚Ë96. ΔÔ ÁÂÁÔÓfi˜ ·Ô‰›‰ÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ÔÏÏÒÓ ‰˘ÛÏ·ÛÙÈÎÒÓ Î·È ‰˘ÓËÙÈο ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ ‚Ï·‚ÒÓ (ÔÏ˘ÂÛÙȷ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ∏∫∫) ÛÙÔ ÎÈÚÚˆÙÈÎfi ‹·Ú ‹ Û ÂÓ‰ÔË·ÙÈ΋ ‰È·ÛÔÚ¿ ÚÔ Ù˘ ¤̂·Û˘.
¶›Ó·Î·˜ 4. AÏÁfiÚÈıÌÔ˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ ∏∫∫. ™Â ΛÚÚˆÛË ÛÙ·‰›Ô˘ B ‹ C ηٿ Child Pugh Î·È Û ·ÚÔ˘Û›· ˘Ï·›·˜ ˘¤ÚÙ·Û˘ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÎÙÔÌ‹. ∞fi ÙÔ 84 ÙÚÔÔÈË̤ÓÔ. ΗΚΚ Υπολειπόμενος όγκος ήπατος > 30% Σε κίρρωση > 50% (Στάδιο Α, χωρίς πυλαία υπέρταση) ΟΧΙ
ΝΑΙ
Εκτομή
Εμβολισμός πυλαίας φλέβας +/- αρτηριακός χημειοεμβολισμός ΝΑ
Ι
Υπολειπόμενο ήπαρ > 30% Σε κίρρωση > 50% ΟΧΙ Άλλη Θεραπεία
7. ™Y°∫ƒπ™∏ Ã∂πƒOÀƒ°π∫H™ ∂∫ΔOªH™ ª∂ ª∂Δ∞ªO™Ã∂À™∏ ∏ ·¿ÓÙËÛË ÛÙÔ ÂÚÒÙËÌ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹ ÌÂÚÈ΋ ÂÎÙÔÌ‹ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ∏∫∫ ‰ÂÓ Â›Ó·È Â‡ÎÔÏË, ·ÊÔ‡ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÚÔÔÙÈΤ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Û‡ÁÎÚÈÛ˘ ÙˆÓ ‰‡Ô ÌÂıfi‰ˆÓ97,98,99. °È· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ··ÈÙÂ›Ù·È ·Ó·ÌÔÓ‹, ÂÓÒ, ·ÓÙÈı¤Ùˆ˜, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ ÌÔÚ› Ó· Á›ÓÂÈ ¿ÌÂÛ·. Δ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÂÈÒÓÔÓÙ·È ·Ó·ÏfiÁˆ˜ ÙÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ÁÈ· ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜. ∏ ÂÈ‚›ˆÛË Â›Ó·È Î·Ï‡ÙÂÚË ÌÂÙ¿ ·fi ÂÎÙÔÌ‹ Û ۯ¤ÛË Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÁÈ· fiÛÔ˘˜ ÂÚÈ̤ÓÔ˘Ó ÁÈ· Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË >12 Ì‹Ó˜100. ∫·Ù¿ ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ Û˘ÁÁÚ·Ê›˜ 101, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ˘ÂÚ¤¯ÂÈ Û ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË ÙÔ˘ ‹·ÙÔ˜ Î·È Ì ÌÈÎÚÔ‡˜ Û ̤ÁÂıÔ˜ Î·È ÔÏ›ÁÔ˘˜ Û ·ÚÈıÌfi fiÁÎÔ˘˜102,103. O ∏∫∫ Ì ‰È¿ÌÂÙÚÔ <3 ÂηÙÔÛÙÒÓ ¤¯ÂÈ ÌÈÎÚ‹ Èı·ÓfiÙËÙ· Ó· Á›ÓÂÈ ·ÓÂÁ¯Â›ÚËÙÔ˜ ηٿ ÙËÓ ·Ó·ÌÔÓ‹75,104. ∏ ÂÁ¯ÂÈÚËÙÈ΋ ıÓËÛÈÌfiÙËÙ· (ÙȘ ÚÒÙ˜ 30Ë̤Ú˜ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÒ˜) Â›Ó·È < 5% › ÌÂÚÈ΋˜ Ë·ÙÂÎÙÔÌ‹˜ Î·È <10% › ÌÂÙ·ÌfiÛ¯Â˘Û˘102. ŸÌˆ˜, Ë 5/ÂÙ‹˜ Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔÒÓ ÙÔ˘ ∏∫∫ Â›Ó·È 55% ÁÈ· ÙËÓ
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÌÂÚÈ΋ ÂÎÙÔÌ‹ Î·È 20% ÁÈ· ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ¿ÏÏË ÌÂϤÙË, Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË Ì ÂÎÙÔÌ‹ ‚Ú¤ıËΠ26% Î·È Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË 69%105. ΔÔ 86% ÙˆÓ ı·Ó¿ÙˆÓ ÌÂÙ¿ ·fi ÌÂÚÈ΋ Ë·ÙÂÎÙÔÌ‹ ÔÊ›ÏÂÙ·È Û ˘ÔÙÚÔ‹ ÙÔ˘ ∏∫∫, ÂÓÒ ¤ˆ˜ ÙÔ 42% ÙˆÓ ı·Ó¿ÙˆÓ ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÊ›ÏÂÙ·È Û ˘ÔÙÚÔ‹ Ù˘ ˘ÔΛÌÂÓ˘ ¯ÚÔÓ›·˜ ÈÔÁÂÓÔ‡˜ Ïԛ̈͢ (·Ï·ÈfiÙÂÚ· Ë·Ù›Ùȉ· μ Î·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ë·Ù›Ùȉ· C) Û ¤‰·ÊÔ˜ ¯Ú‹Ûˆ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ. ∏ ÚÔÛ¤ÁÁÈÛË Ù˘ ıÂڷ›·˜ ÂÍ·ÚÙ¿Ù·È Ôχ ·fi ÙËÓ ÂÌÂÈÚ›· ÙÔ˘ ΤÓÙÚÔ˘, ÙËÓ ·ÚÔ˘Û›· ÂÌÂ›ÚˆÓ ¯ÂÈÚÔ˘ÚÁÒÓ ‹·ÙÔ˜ Î·È ÙË ‰˘Ó·ÙfiÙËÙ· ‰ÈÂÓ¤ÚÁÂÈ·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ (¿ÚÎÂÈ· ÌÔÛ¯Â˘Ì¿ÙˆÓ). ™Â ¯ÒÚ˜ fiÔ˘ ‰ÂÓ ‰ÈÂÓÂÚÁÂ›Ù·È ÌÂÙ·ÌfiÛ¯Â˘ÛË (¯ Õˆ ∞Ó·ÙÔÏ‹), ÁÈ· ıÚËÛ΢ÙÈÎÔ‡˜ Î·È ÔÈÎÔÓÔÌÈÎÔ‡˜ ÏfiÁÔ˘˜, Ë ‰È¿ÁÓˆÛË ÙÔ˘ ∏∫∫ Û ÚÒÈÌÔ ÛÙ¿‰ÈÔ Ì ÚÔÏËÙÈÎfi ¤ÏÂÁ¯Ô ÂÈÙÚ¤ÂÈ ÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ ÙÔ˘. ™ÙȘ ¢˘ÙÈΤ˜ ¯ÒÚ˜ Ô˘ ‰ÂÓ Â›Ó·È ÂÎÙÂٷ̤ÓË Ë ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÙÔ˘ ∏∫∫, Ë ÂÊ·ÚÌÔÁ‹ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÂÎÙÔÌ‹˜ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË (5%). °ÂÓÈÎÒ˜, ÁÈ· ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘, ı· Ú¤ÂÈ Ô fiÁÎÔ˜ Ó· ÌËÓ Â›Ó·È ¯ÂÈÚÔ˘ÚÁÈÎÒ˜ ÂÍ·ÈÚ¤ÛÈÌÔ˜ ‹ Ô ·ÛıÂÓ‹˜ Ó· ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Ô˘ ηıÈÛÙ¿ ·‰‡Ó·ÙË ÙËÓ ÂÎÙÔÌ‹ ÙÔ˘ ∏∫∫. ™Â ·ÛıÂÓ›˜ Ì ∏∫∫ ¯ˆÚ›˜ ΛÚÚˆÛË (·ÔÙÂÏÔ‡Ó ÙÔ 5% ÛÙË ¢‡ÛË Î·È Ì¤¯ÚÈ ÙÔ 40% ÛÙËÓ ∞Û›·) Ë ÌÂÚÈ΋ Ë·ÙÂÎÙÔÌ‹ Â›Ó·È ÚÔÙÈÌfiÙÂÚË, ÂÎÙfi˜ ·Ó Ë ı¤ÛË ÙÔ˘ fiÁÎÔ˘ ÙÔÓ Î·ıÈÛÙ¿ ÌË ÂÍ·ÈÚ¤ÛÈÌÔ, ÔfiÙÂ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ ı¤ÛË. ™Â ÌÂϤÙË 126 ·ÛıÂÓÒÓ ¯ˆÚ›˜ ΛÚÚˆÛË Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÏfiÁˆ ∏∫∫, Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û 16 ‰ËÌÔÛȇÛÂȘ Ù· ÙÂÏÂ˘Ù·›· 35 ¯ÚfiÓÈ·, ÙÔ 75% ÙˆÓ ˘ÔÙÚÔÒÓ ·ÚÔ˘ÛÈ¿ÛÙËΠٷ ÚÒÙ· 2 ¯ÚfiÓÈ· Î·È Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ‹Ù·Ó 39,4% Î·È 11,2% ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙÔÓ ÈÓÔÂÙ·ÏÔÂȉ‹ Î·È ÎÏ·ÛÈÎfi ∏∫∫106. ¶¿ÓÙˆ˜, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·˘ÙÒÓ ·ÊÔÚÔ‡Û·Ó ÚÔ¯ˆÚË̤ÓÔ˘˜ ÌÂÁ¿ÏÔ˘˜ fiÁÎÔ˘˜.
8. ∂∫ΔOª∏ ¶ƒπ¡ ∞¶O Δ∏ ª∂Δ∞ªO™Ã∂À™∏ °È· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ·Ó·ÌÔÓ‹˜ ÁÈ· ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜, ¤¯ÂÈ ÚÔÙ·ı› Ë ÂÎÙÔÌ‹ ÙÔ˘ fiÁÎÔ˘ Î·È ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì¤¯ÚÈ ÙËÓ ˘ÔÙÚÔ‹ ‹ ÙËÓ Âȉ›ӈÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜107,108,109,110. ªÂÚÈÎÔ› ·ÛıÂÓ›˜ ÌÔÚ› Ó· ÌËÓ ˘ÔÙÚÔÈ¿ÛÔ˘Ó ÔÙ¤111 Î·È ¿ÏÏÔÈ ÌÔÚ› Ó· ‚ÔË-
243
ıËıÔ‡Ó fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ ÙÔ˘˜ Ì ÙË ¯ÔÚ‹ÁËÛË ·ÈÙÈÔÏÔÁÈ΋˜ ıÂڷ›·˜ (·ÓÙÈÈ΋ ·ÁˆÁ‹, ‰È·ÎÔ‹ ÔÈÓÔÓ‡̷ÙÔ˜ ÎÏ)112. ∂ÈϤÔÓ, ÔÈ Û‡Á¯ÚÔÓ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ Ù¯ÓÈΤ˜ ÌÂÈÒÓÔ˘Ó (·ÏÏ¿ ‰ÂÓ ÌˉÂÓ›˙Ô˘Ó) Ù· ·Ï·ÈfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ·fi ÙËÓ ÚÔËÁÔ‡ÌÂÓË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË. ŸÌˆ˜, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ı· ˘ÔÙÚÔÈ¿ÛÔ˘Ó ‹ ı· ÂȉÂÈÓˆı› Ë Î›ÚÚˆÛ‹ ÙÔ˘˜ Î·È ı· ÌÂÙ·ÌÔÛ¯Â˘ıÔ‡Ó Ì ÓÔÛËÚfiÙËÙ· ‹/Î·È ıÓËÙfiÙËÙ·, ÎfiÛÙÔ˜ Î·È Ì¤ÁÂıÔ˜ ∏∫∫ ·˘ÍË̤ӷ Î·È Û˘ÓÂÒ˜ Ì ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ ›·Û˘113,114. ™Â ÂÚÈÙÒÛÂȘ Ô˘ Ë ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ ÙÔ˘˜ 6-12 Ì‹Ó˜115, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÚÔÙÈÌ¿Ù·È, ÂÓÒ fiÙ·Ó ˘ÂÚ‚·›ÓÂÈ ÙÔ˘˜ 18 Ì‹Ó˜, ÌÔÚ› Ó· ÂȯÂÈÚËı› Ë ÂÎÙÔÌ‹ ·Ê‹ÓÔÓÙ·˜ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÁÈ· ·ÓÙÈÌÂÙÒÈÛË Èı·Ó‹˜ ˘ÔÙÚÔ‹˜ ‹ Âȉ›ӈÛ˘ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ 116,117.
9. ª∂Δ∞ªO™Ã∂À™∏ ∞™£∂¡ø¡ ª∂ ∏∫∫ ∫∞ΔA ¶ƒOΔ∂ƒ∞πOΔ∏Δ∞ ¶ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ·ÔÌ¿ÎÚ˘ÓÛË ·fi ÙË Ï›ÛÙ· ·ÛıÂÓÒÓ Ì ∏∫∫ ‚Ú¤ıËÎ·Ó Ë ËÏÈΛ·, ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ∏∫∫, Ô ‰Â›ÎÙ˘ MELD (‚·ıÌÔÏÔÁ›· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘- Model for End-stage Liver Disease- Ì ‚¿ÛË ÙË ¯ÔÏÂÚ˘ıÚ›ÓË, ÙËÓ ÎÚ·ÙÈÓ›ÓË Î·È ÙÔ ¯ÚfiÓÔ ÚÔıÚÔÌ‚›Ó˘) Î·È ÔÈ ÙÈ̤˜ Ù˘ ·1 ÂÌ‚Ú˘È΋˜ ÚˆÙÂ˚Ó˘118. ªÂ ‚·ıÌÔÏÔÁ›· MELD <8, ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ (30 Ë̤Ú˜) ıÓËÙfiÙËÙ·˜ Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÎÙÔÌ‹ ÙÔ˘ ∏∫∫, ÂÓÒ Â¿Ó Ë ‰È¿ÌÂÙÚÔ˜ ÙÔ˘ fiÁÎÔ˘ Â›Ó·È <5 ÂηÙÔÛÙÒÓ, Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË Â›Ó·È 80%119. ªÂ ‚·ıÌÔÏÔÁ›· <10, ÔÈ ÂÚÈÔ¯ÈΤ˜ ıÂڷ›˜ ÌÔÚ› Ó· ‚ÔËı‹ÛÔ˘Ó. OÈ ·ÛıÂÓ›˜ Ì ∏∫∫ ÛÙȘ ∏¶∞ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Ì ‚¿ÛË ÙÔ Û‡ÛÙËÌ· MELD, ·ÏÏ¿ ÚÈÌÔ‰ÔÙÔ‡ÓÙ·È Ì ÌÔÓ¿‰Â˜, Ì ‚¿ÛË ÙÔ Ì¤ÁÂıÔ˜ Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ fi˙ˆÓ, ÁÈ· Ó· Û˘Û¯ÂÙÈÛı› Ë ‚·ıÌÔÏÔÁ›· ÙÔ˘˜ ηχÙÂÚ· Ì ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÈ‚›ˆÛ‹ ÙÔ˘˜120,121,122. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓÒÓ Ì ∏∫∫, ηٿ ÚÔÙÂÚ·ÈfiÙËÙ·, ÌÂÈÒÓÂÈ Ù· ÔÛÔÛÙ¿ ·ÔÌ¿ÎÚ˘ÓÛ˘ ·fi ÙË Ï›ÛÙ· ηٿ ÙËÓ ÔχÌËÓË ·Ó·ÌÔÓ‹ ÁÈ· ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜123. ŒÙÛÈ, fiÙ·Ó ÏËÚÔ‡ÓÙ·È Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘, Ï·Ì‚¿ÓÔ˘Ó 22 ÌÔÓ¿‰Â˜ Ô˘ ·˘Í¿ÓÔÓÙ·È ÁÈ· οı ÙÚ›ÌËÓÔ ·Ó·ÌÔÓ‹˜. ŸÌˆ˜, ÙÔ 1/5 fiÛˆÓ ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Ì ‚¿ÛË ÙÔ Û‡ÛÙËÌ· ·˘Ùfi ÂÈÏÔÁ‹˜ ÙˆÓ ·ÛıÂÓÒÓ, ‰ÂÓ Â›¯·Ó ∏∫∫, ÂÓÒ Û˘¯Ó¿ ÔÈ ·ÛıÂÓ›˜ Ì ∏∫∫ ÚÔÙÈÌÒÓÙ·È ¤Ó·ÓÙÈ ÂÎÂ›ÓˆÓ Ì ΛÚÚˆÛË Ì ÙË ‰ÈηÈÔÏÔÁ›· ÙÔ˘ ›ÁÔÓÙÔ˜124.
244
™. NTOYPAKH™
10. ª∂Δ∞ªO™Ã∂À™∏ ∞¶O ∑ø¡Δ∞ ¢OΔ∏ ΔÔ Úfi‚ÏËÌ· Ù˘ ·Ó·ÌÔÓ‹˜ ̤¯ÚÈ Ó· ·Ó¢ÚÂı› ÌfiÛ¯Â˘Ì·, ¤¯ÂÈ ÂȯÂÈÚËı› Î·È Ì ÙË ¯Ú‹ÛË ÌÔۯ‡̷ÙÔ˜ ·fi ‰fiÙË Ì ·Ì˘ÏÔ›‰ˆÛË, ¯ÚÔÓ›· ÈÔÁÂÓ‹ Ïԛ̈ÍË ¯ˆÚ›˜ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ Î·È ·fi ˙ÒÓÙ· ‰fiÙË125. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË Â›Ó·È Ôχ ÂÏ΢ÛÙÈ΋ ·ÊÔ‡ ·ÓÙÈÌÂÙˆ›˙ÂÈ ÙÔ Úfi‚ÏËÌ· Ù˘ ·Ó·ÌÔÓ‹˜ Î·È Ù˘ ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∂ÈϤÔÓ, Ô ·ÛıÂÓ‹˜ ‚Ú›ÛÎÂÙ·È Û ڈÈÌfiÙÂÚÔ ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘ ÁÈ·Ù› ‰ÂÓ ÂÚÈ̤ÓÂÈ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ Î·È ÙÔ ÌfiÛ¯Â˘Ì· (35-40% ÙÔ˘ ‹·ÙÔ˜) Â›Ó·È ·fi ˘ÁÈ‹ ‰fiÙË Î·È Â›Ó·È Î·Ï‡ÙÂÚ˘ ÔÈfiÙËÙ·˜ Î·È ÂÓ ‰˘Ó¿ÌÂÈ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ 126. ªÂÙ¿ ÙËÓ ÚÒÙË ÂÈÙ˘¯‹ ÚÔÛ¿ıÂÈ·127, ¤ÁÈÓ·Ó ÂÚÈÛÛfiÙÂÚ˜ ·fi 3000 ÌÂÙ·ÌÔۯ‡ÛÂȘ. ΔÔ 5% ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‹·ÙÔ˜ ÁÈ· ∏∫∫ ÛÙȘ ∏¶∞ Á›ÓÂÙ·È ·fi ˙ÒÓÙ· ‰fiÙË128,129,130,131. Δ· ·ÔÙÂϤÛÌ·Ù· ÁÂÓÈÎÒ˜ Â›Ó·È ·ÚfiÌÔÈ· Ì ÙË ¯Ú‹ÛË ÙˆÌ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÂÓÒ ÈÛ¯‡Ô˘Ó Î·È ÛÙËÓ ÌÔÚÊ‹ ·˘Ù‹ ÔÈ ÂÚÈÔÚÈṲ̂ÓÔÈ ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ ªÈÏ¿ÓÔ˘132, 133,134. ŸÌˆ˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË ·ÚÔ˘ÛÈ¿˙ÂÈ ıÓËÙfiÙËÙ· ÁÈ· ÙÔÓ ˘ÁÈ‹ ‰fiÙË 0,2-0,5% 135, 136,137,138. ∂ÈϤÔÓ, Ë ÓÔÛËÚfiÙËÙ· Â›Ó·È ÛËÌ·ÓÙÈ΋ (15-30%), ÛÙÔ 12-14,5% (π·ˆÓ›· Î·È ∏¶∞ ·ÓÙÈÛÙÔ›¯ˆ˜) ÛËÌ·ÓÙÈ΋ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÈÏÔ΋ Î·È ÛÙÔ 1% ··ÈÙÂ›Ù·È Â·ÓÂÁ¯Â›ÚËÛË ÁÈ· ÂÈÏÔΤ˜ ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜, ·ÔÊÚ·ÎÙÈÎfi ÂÈÏÂfi, ·ÈÌÔÚÚ·Á›· ‹ Û‹„Ë139,140. ™Â ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‰ÂÍÈÔ‡ ÏÔ‚Ô‡ ÙÔ˘ ‹·ÙÔ˜ (Â›Ó·È Ë Û˘ÓËı¤ÛÙÂÚË), ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û¯ÂÙÈÎÒ˜ ÌÂÁ·Ï‡ÙÂÚË ÓÔÛËÚfiÙËÙ· Î·È ·Ú¿Ù·ÛË Ù˘ ·Ú·ÌÔÓ‹˜ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ∏ ‚ÂÏÙ›ˆÛË ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙË ÓÔÛËÚfiÙËÙ· ÙˆÓ ‰ÔÙÒÓ, ·ÏÏ¿ Ë Èı·ÓfiÙËÙ· η΋˜ ÂͤÏÈ͢ ÛÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô ‰Â ÌÔÚ› Ó· ·ÔÎÏÂÈÛı›141. ŒÙÛÈ, Ù· ·ÔÙÂϤÛÌ·Ù· ÌÔÚ› Ó· Â›Ó·È Á›ÓÔ˘Ó ¯ÂÈÚfiÙÂÚ· ·fi ÙË ¯Ú‹ÛË ÙˆÌ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ 142,143. H ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË Û ·ÛıÂÓ›˜ Ì ÌÂÁ·Ï‡ÙÂÚÔ HKK ·fi ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ ªÈÏ¿ÓÔ˘, ¤‰ˆÛ ۯÂÙÈÎÒ˜ ηϿ ·ÔÙÂϤÛÌ·Ù· (3ÂÙ‹˜ ÂÈ‚›ˆÛË 50%144,145) Èı·ÓfiÓ ÏfiÁˆ Ù˘ ¿ÌÂÛ˘ ‰ÈÂÓ¤ÚÁÂÈ¿˜ Ù˘ Î·È ›Ûˆ˜ ·˘Ù‹ Ó· Â›Ó·È Ë Î‡ÚÈ· ¤Ó‰ÂÈÍ‹ Ù˘146. ∂ÈϤÔÓ, ÌÔÚ› Ó· ÌÂÙ·ÌÔÛ¯Â˘ıÔ‡Ó Î·È ¿ÙÔÌ· Ì ∏∫∫ η΋˜ ‚ÈÔÏÔÁÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ Ô˘ ‰ÂÓ ı· ÂÏ¿Ì‚·Ó·Ó ¿ÌÂÛ· و̷ÙÈÎfi ÌfiÛ¯Â˘Ì·. °ÂÓÈÎÒ˜, ·Ú·Ì¤ÓÂÈ Ï‡ÛË ÁÈ· ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ, ·ÊÔ‡ ÔÈ ‰fiÙ˜ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓÔÈ ÏfiÁˆ ·Û˘Ì‚·ÙfiÙËÙ·˜ ÔÌ¿‰ˆÓ ·›Ì·ÙÔ˜, È·ÙÚÈÎÒÓ ·ÓÙÂӉ›ÍÂˆÓ Î·È „˘¯ÔÎÔÈÓˆÓÈÎÒÓ ıÂÌ¿ÙˆÓ.
Œ¯ÂÈ ˘ÔÏÔÁÈÛı› fiÙÈ, Â¿Ó Û˘Ó˘ÔÏÔÁÈÛıÔ‡Ó Ë ·ÔÌ¿ÎÚ˘ÓÛË ·fi ÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ (4% ÙÔ Ì‹Ó·), Ë ·Ó·ÌÂÓfiÌÂÓË ÂÈ‚›ˆÛË (70% ÛÙ· 5 ¯ÚfiÓÈ·) Î·È Ë ıÓËÙfiÙËÙ· ÙÔ˘ ‰fiÙË (0,3-0,5%), Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË Â›Ó·È ¯Ú‹ÛÈÌË Â¿Ó Ë ·Ó·ÌÔÓ‹ ÁÈ· و̷ÙÈÎfi ÌfiÛ¯Â˘Ì· ˘ÂÚ‚·›ÓÂÈ ÙÔ˘˜ 7 Ì‹Ó˜147.
9. À¶OΔƒO¶H Δ∏™ ÃO¡IA™ πO°∂¡OY™ §OIªø•∏™ ™ΔO ªO™Ã∂Àª∞ ∏ ˘ÔÙÚÔ‹ Ù˘ ¯ÚÔÓ›·˜ ÈÔÁÂÓÔ‡˜ Ïԛ̈͢ ÛÙÔ ÌfiÛ¯Â˘Ì· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ٷ¯Â›· ·Ó¿Ù˘ÍË Î›ÚÚˆÛ˘ Ô˘ ÂËÚ¿˙ÂÈ ÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜148. ŒÙÛÈ, Ë ·ÓÙ›ÏË„Ë fiÙÈ Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ô ∏∫∫ Î·È Ë ˘ÔΛÌÂÓË Î›ÚÚˆÛË ÙÔ˘ ‹·ÙÔ˜ ‰ÂÓ ÈÛ¯‡ÂÈ ¿ÓÙÔÙÂ, fiˆ˜ Û˘Ì‚·›ÓÂÈ ÛÙË Û˘Ó‹ıË ÂÚ›ÙˆÛË Ù˘ Ïԛ̈͢ Ì ÙÔÓ HCV. ∏ ˘ÔÙÚÔ‹ Ù˘ Ë·Ù›Ùȉ·˜ C ÂËÚ¿˙ÂÈ Ù· Ì·ÎÚÔ¯ÚfiÓÈ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ 149,150,151,152. ∞ÎfiÌË Î·È Û Û fiÛÔ˘˜ ÌÔÚÔ‡Ó Ó· Ï¿‚Ô˘Ó ·ÁˆÁ‹ Ì ÈÓÙÂÚÊÂÚfiÓË Î·È ÚÈÌ·‚ÈÚ›ÓË, Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ¯ÂÈÚfiÙÂÚ· Û ۯ¤ÛË Ì ÂΛÓÔ˘˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ıÂڷ›· ÚÈÓ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË153. ΔÔ Úfi‚ÏËÌ· Ì ÙËÓ ˘ÔÙÚÔ‹ Ù˘ Ë·Ù›Ùȉ·˜ μ ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛı› Ì ÙË ¯ÔÚ‹ÁËÛË ÓÔ˘ÎÏÂÔÛȉÈÎÒÓ/ÓÔ˘ÎÏÂÔÙȉÈÎÒÓ ·Ú·ÁÒÁˆÓ Î·È ·ÓÙÈ-HBs ÛÊ·ÈÚ›Ó˘154.
10. ™À¡O¢O™ £∂ƒ∞¶Eπ∞ O ΛӉ˘ÓÔ˜ ‰È·ÛÔÚ¿˜ ηÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙËÓ Â¤Ì‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¢ÓÔ› ıˆÚËÙÈÎÒ˜ ÙËÓ ˘ÔÙÚÔ‹ ÙÔ˘ fiÁÎÔ˘ Î·È Û˘ÓÂÒ˜ ÂÓÈÛ¯‡ÂÈ ÙËÓ È‰¤· Ù˘ Û˘ÓÔ‰Ô‡ ¯ËÌÂÈÔıÂڷ›·˜ ÌÂÙ¿ ÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô155. ¶Ú¿ÁÌ·ÙÈ, Ô ¯ÚfiÓÔ˜ ‰ÈÏ·ÛÈ·ÛÌÔ‡ ÙÔ˘ fiÁÎÔ˘ Â›Ó·È Ôχ ÌÈÎÚfiÙÂÚÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ۯ¤ÛË Ì ÙÔÓ ∏∫∫ ¯ˆÚ›˜ ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË (40 ¤Ó·ÓÙÈ 270 Ë̤Ú˜)156. ™Â ÌË Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜, Ë Û˘ÓÔ‰fi˜ ¯ËÌÂÈÔıÂڷ›· Ê¿ÓËΠӷ ‚ÔËı¿157,158,159, 160,161,162,163. ŸÌˆ˜, ÛÙË ÌÔÓ·‰È΋ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË Ì ¯ÔÚ‹ÁËÛË ÓÙÔÍÔÚÔ˘‚ÈΛÓ˘, Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ¯ËÌÂÈÔıÂڷ›· ‰ÂÓ ÔʤÏËÛÂ164, ÂÓÒ Â˘ÓÔ› ÙËÓ ˘ÔÙÚÔ‹ Ù˘ ¯ÚÔÓ›·˜ ÈÔÁÂÓÔ‡˜ Ïԛ̈͢ fiÙ·Ó ·˘Ù‹ ˘¿Ú¯ÂÈ165. ∏ ¯Ú‹ÛË ·Ó·ÛÙÔϤˆÓ Ù˘ Ù˘ÚÔÛÈÓÈ΋˜ ÎÈÓ¿Û˘ ›Ûˆ˜ ·Ô‰Âȯı› ÛÙÔ Ì¤ÏÏÔÓ ‚ÔËıËÙÈ΋. ∏ ¯Ú‹ÛË Ú·‰ÈÔÛÂÛËÌ·Ṳ̂ÓÔ˘ ÌÔÓÔÎψÓÈÎÔ‡ ·ÓÙÈÛÒÌ·ÙÔ˜ (Licartin) ›Ûˆ˜ Ó· ‰ÒÛÂÈ Î·Ï¿ ·ÔÙÂϤÛÌ·Ù·, fiÙ·Ó ÌÂÏÂÙËı› ·ÚÎÒ˜166. H ¯ÔÚ‹ÁËÛË ÛˆÌ·ÙÔ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÛÙ·Ù›Ó˘ ‹ ÔÎÙÚÔÙȉ›Ô˘ ‰ÂÓ ‚ÔËı¿167.
11. º∞ƒª∞∫∞ ∞¡O™O∫∞Δ∞™ΔO§∏™ °È· ÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ˘ÔÙÚÔ‹˜, Ë ¯ÔÚËÁÔ‡ÌÂÓË ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂÈÒÓÂÙ·È Î·Ù¿ ÙÔ Ì¤ÁÈÛÙÔ ‰˘Ó·ÙfiÓ. ∏ ¯Ú‹ÛË ÙÔ˘ ÛÈÚfiÏÈÌÔ˘˜ ›Ûˆ˜ Ó· ˘ÂÚ¤¯ÂÈ, ·ÊÔ‡ ·ÚÔ˘ÛÈ¿˙ÂÈ ÂÈÚÔÛı¤Ùˆ˜ Î·È ·ÓÙÈÔÁÎÔÁfiÓÔ ‰Ú¿ÛË168,169,170,171, 172.
13. £∂ƒ∞¶∂π∞ «ø™ °EºÀƒA» ¶ƒO™ Δ∏ ª∂Δ∞ªO™Ã∂À™∏ O ÂÚÈÔÚÈṲ̂ÓÔ˜ ·ÚÈıÌfi˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·Ó¿ÁηÛ ӷ ÂȯÂÈÚËıÔ‡Ó ıÂڷ¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ ˆ˜ Á¤Ê˘Ú· ÚÔ˜ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì¤¯ÚÈ Ó· ·Ó¢ÚÂı› Ô Î·Ù¿ÏÏËÏÔ˜ ‰fiÙ˘ ÁÈ· Ó· ÚÔÏËÊı› Ë ÂͤÏÈÍË ÙÔ˘ fiÁÎÔ˘ Ì ·ÁÁÂȷ΋ ‰È‹ıËÛË ‹/Î·È Â͈˷ÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ. Δ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÂÎÙÔÌ‹˜ ·Ó·Ê¤ÚıËÎ·Ó ·Ú·¿Óˆ. ∏ ¯Ú‹ÛË ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌÔ‡, ¤Á¯˘Û˘ ·ÏÎÔfiÏ˘ ‹ ıÂÚÌÔη˘ÙËÚ›·Û˘ Ì ڷ‰ÈÔ·̷ٷ ÚÈÓ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ıˆÚËÙÈÎÒ˜ ı· ÌÔÚÔ‡Û ӷ ‚ÂÏÙÈÒÛÂÈ ÙËÓ ÂÈ‚›ˆÛË Ì¤Ûˆ ÙÔ˘ ÂϤÁ¯Ô˘ ·Ó¿Ù˘Í˘ ÙÔ˘ ∏∫∫ ηٿ ÙËÓ ÂÚ›Ô‰Ô ·Ó·ÌÔÓ‹˜ ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ô˘ Â›Ó·È ÛÙ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· ·ÚÎÂÙ¿ ÌÂÁ¿ÏË (6 Î·È Ï¤ÔÓ Ì‹Ó˜)173. OÈ ÛÙfi¯ÔÈ Â›Ó·È Ó· ÌÂȈı› ÙÔ Ì¤ÁÂıÔ˜ ÁÈ· Ó· ÂÚÈÏËÊı› ÛÙ· ÎÚÈÙ‹ÚÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘, Ó· ÌË ÌÂÁ·ÏÒÛÂÈ Ô ∏∫∫ fiÛÔ ·Ó·Ì¤ÓÂÙ·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ¿Óˆ ·’ fiÏ· Ó· ‚ÂÏÙȈıÔ‡Ó Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô˜ ¯ˆÚ›˜ ÓfiÛÔ Î·È Ë ÂÈ‚›ˆÛË174. OÈ ÛÙfi¯ÔÈ ·˘ÙÔ› ‰ÂÓ ÂÈÙ˘Á¯¿ÓÔÓÙ·È ¿ÓÙÔÙÂ175. O ÂÌ‚ÔÏÈÛÌfi˜ Ì ‹ ¯ˆÚ›˜ ÂÚÈÔ¯È΋ ¯ËÌÂÈÔıÂڷ›· Û˘ÓÈÛÙ¿Ù·È Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÛÙ·‰›Ô˘ Child Pugh ∞ fiÙ·Ó ‰ÂÓ ˘¿Ú¯ÂÈ ‰˘Ó·ÙfiÙËÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÂÎÙÔÌ‹˜ (Û˘Ó‹ıˆ˜ Û ‚Ï¿‚˜ ‰È·Ì¤ÙÚÔ˘ < 3ÂÎ), ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ fiÓÔ˘ ‹ Ù˘ ·ÈÌÔÚÚ·Á›·˜ ·fi Ú‹ÍË ÙÔ˘ HKK176. O ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi˜ ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÊ·ÚÌÔÛı› Û ÌË-·ÓÙÈÚÚÔÔ‡ÌÂÓÔ˘˜ ·ÛıÂÓ›˜ ÁÈ·Ù› ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂΉ‹ÏˆÛË ÔÍ›·˜ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜. Œ¯ÂÈ ÂȯÂÈÚËı› ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi˜ ÌÈÎÚÒÓ Î·È ÔÏ›ÁˆÓ Û ·ÚÈıÌfi fiÁÎÔ˘˜ ÚÈÓ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÈfiÙÈ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ fiÁÎÔ˘ ηٿ ÙËÓ ÂÚ›Ô‰Ô ·Ó·ÌÔÓ‹˜, ÌÂÈÒÓÂÈ ÙËÓ ·ÁÁÂÈÔ‚Ú›ıÂÈ· ÙÔ˘ fiÁÎÔ˘ Î·È ÂÏ·ÙÙÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ‰È·Ê˘Á‹˜ ηÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·Ù¿ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. O ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi˜ Â›Ó·È Û˘Ó‹ıˆ˜ ηÏÒ˜ ·ÓÂÎÙfi˜ Î·È Û˘-
245
Óԉ‡ÂÙ·È ·fi Ôχ ηϿ ·ÔÙÂϤÛÌ·Ù· Û ÂÈÏÂÁ̤ÓÔ˘˜ (ÎÏ·ÛÈο ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘) ·ÛıÂÓ›˜ (2/ÂÙ‹˜ ÂχıÂÚË – ÓfiÛÔ˘ ÂÈ‚›ˆÛË 84%)177, 178,179,180,181,182,183,184,185,186,187. ™Â ¿ÏϘ ÌÂϤÙ˜, Ô ÚÔÂÁ¯ÂÈÚËÙÈÎfi˜ ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi˜, ‰ËÌÈÔ˘ÚÁ› ÌÂÓ ·ÍÈÔÛËÌ›ˆÙË (·ÏÏ¿ Û˘Ó‹ıˆ˜ ÌÂÚÈ΋) Ó¤ÎÚˆÛË ÙÔ˘ fiÁÎÔ˘ ·ÏÏ¿ ‰ÂÓ ‚Ú¤ıËΠ۠ÌÂÙ·-·Ó·Ï‡ÛË Ó· ˆÊÂÏ› ÛÙËÓ ÂÈ‚›ˆÛË Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ÈÛÙÔÚÈÎÔ‡˜ ·ÛıÂÓ›˜, ÂÓÒ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ› ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ¿ÌÂÛˆÓ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÒÓ ÊÏÂÁÌÔÓˆ‰ÒÓ ÂÈÏÔÎÒÓ (¯. Ó¢ÌÔÓ›·)188. ¢ÂÓ ˘¿Ú¯Ô˘Ó ÚÔÔÙÈΤ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Ô˘ Ó· ı¤ÙÔ˘Ó Ì ۷ʋÓÂÈ· ÙË ı¤ÛË ÙÔ˘ ÂÌ‚ÔÏÈÛÌÔ‡ Ì ‹ ¯ˆÚ›˜ ÂÚÈÔ¯È΋ ¯ËÌÂÈÔıÂڷ›·. ∏ ηٷÛÙÚÔÊ‹ ÙÔ˘ fiÁÎÔ˘ (ablation) ÂȯÂÈÚÂ›Ù·È Î·È Ì ÙËÓ ÂÚÈÔ¯È΋ ¤Á¯˘ÛË ·ÏÎÔfiÏ˘189,190 ‹ ÙËÓ Î·˘ÙËÚ›·ÛË Ì ڷ‰ÈÔÛ˘¯ÓfiÙËÙ˜ (radiofrequencies)191,192. Δ· ·ÔÙÂϤÛÌ·Ù· Û ∏∫∫ ‰È·Ì¤ÙÚÔ˘ <4ÂÎ Â›Ó·È fiÌÔÈ· Ì ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ 193. ∏ ¤Á¯˘ÛË ·ÏÎÔfiÏ˘194,195,196 Ë Î·˘ÙËÚ›·ÛË197, 198,199,200,201 ÌÔÚ› Ó· ‚ÔËıÔ‡Ó ·ÚÔ‰ÈÎÒ˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ∏∫∫ ÂÓ ·Ó·ÌÔÓ‹ ÌÔۯ‡̷ÙÔ˜, ·ÏÏ¿ Ë ÂÈ‚›ˆÛË ‰Â ‚ÂÏÙÈÒÓÂÙ·È202. ∂ÈϤÔÓ, Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÂÚÈÔ¯ÈÎÒÓ ıÂÚ·ÂÈÒÓ, Ô ıˆÚËÙÈÎfi˜ ΛӉ˘ÓÔ˜ Â›Ó·È Ô ÂÓÔÊı·ÏÌÈÛÌfi˜ ηÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, fiˆ˜ Û˘Ì‚·›ÓÂÈ Û·Ó›ˆ˜ Î·È Ì ÙË ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· ÙÔ˘ ‹·ÙÔ˜. O ΛӉ˘ÓÔ˜ ·˘Ùfi˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ÌË-‰È·ÊÔÚÔÔÈË̤ÓÔ˘˜ fiÁÎÔ˘˜ Î·È Û ÂÚÈÊÂÚÈÎÒ˜ ¢ÚÈÛÎfiÌÂÓÔ˘˜203,204. ŸÌˆ˜, Ô Î›Ó‰˘ÓÔ˜ ·˘Ùfi˜ ‰ÂÓ Â›Ó·È ·Ô‰Â‰ÂÈÁ̤ÓÔ˜ Î·È Ë Ì¤ıÔ‰Ô˜ ·Í›˙ÂÈ Ó· ÌÂÏÂÙËı› ÂÓÙfi˜ ÚˆÙÔÎfiÏÏÔ˘205. O Û˘Ó‰˘·ÛÌfi˜ ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌÔ‡ Î·È ‰È·‰ÂÚÌÈ΋˜ ¤Á¯˘Û˘ ·ÏÎÔfiÏ˘ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË (Multimodal treatment) ‰ËÌÈÔ˘ÚÁ› Ó¤ÎÚˆÛË ÙÔ˘ fiÁÎÔ˘ Î·È Û˘Óԉ‡ÂÙ·È ·fi ‚ÂÏÙȈ̤ÓË ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË206.
14. ™Àª¶∂ƒ∞™ª∞Δ∞ ™ÙÔ˘˜ ÌË ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ∏∫∫ Î·È Û fiÛÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ¤¯Ô˘Ó ηϋ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ÂÎÙÔÌ‹ ·Ú·Ì¤ÓÂÈ Ë ıÂڷ›· ÂÎÏÔÁ‹˜. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÔÙÂÏ› ϤÔÓ ·Ô‰ÂÎÙ‹ ıÂڷ›· ·ÓÙÈÌÂÙÒÈÛ˘ ηÏÒ˜ ÂÈÏÂÁÌ¤ÓˆÓ ·ÛıÂÓÒÓ Ì ∏∫∫ Ì ÛÎÔfi ÙËÓ ›·ÛË. ™Â ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜, Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ·Ó¿ÏÔÁ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÏfiÁˆ ÌË-ÓÂÔÏ·ÛÌ·ÙÈ΋˜ Ë·ÙÈ΋˜ ÓfiÛÔ˘. Δ· Ù˘¯·›ˆ˜ ·Ó¢ÚÈÛÎfiÌÂÓ· ∏∫∫ Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏfiÁˆ ÂÈÏÔÎÒÓ Ù˘ ΛÚÚˆÛ˘
246
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ÙÔ˘ ‹·ÙÔ˜, ¤¯Ô˘Ó ÙËÓ Î·ÏÏ›ÙÂÚË ÚfiÁÓˆÛË. ™‡Ìʈӷ Ì ٷ Û‡Á¯ÚÔÓ· ‰Â‰Ô̤ӷ, ¢ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· ·fi ÏÂ˘Ú¿˜ ˘ÔÙÚÔ‹˜ Î·È ÂÈ‚›ˆÛ˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È ÛÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÏÈÁfiÙÂÚÔ˘˜ ·fi 3 fiÁÎÔ˘˜ (∏∫∫), ‰È·Ì¤ÙÚÔ˘ <3 ÂηÙÔÛÙÒÓ Î·È Û˘ÓÔÏÈ΋˜ ‰È·Ì¤ÙÚÔ˘ < 5 ÂηÙÔÛÙÒÓ, ¯ˆÚ›˜ ·ÁÁÂȷ΋ ‰È‹ıËÛË Î·È ¯ˆÚ›˜ ÏÂÌÊ·‰ÂÓÈΤ˜ ‹ ¿ÏϘ ÌÂÙ·ÛÙ¿ÛÂȘ. ∞ÎfiÌË, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ ı¤ÛË Û ·ÛıÂÓ›˜ ¯ˆÚ›˜ ΛÚÚˆÛË Ì ÌË ÂÍ·ÈÚ¤ÛÈÌÔ˘˜ ÏfiÁˆ ı¤Ûˆ˜ ∏∫∫. ∫·Ù¿ ÙËÓ ·Ó·ÌÔÓ‹ ÁÈ· ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜, Ú¤ÂÈ Ó· ÂÎÙÈÌ¿Ù·È ·Ó¿ 3ÌËÓÔ Â¿Ó Ô ∏∫∫ ·Ú·Ì¤ÓÂÈ ÛÙ· ÂÈÙÚÂÙ¿ fiÚÈ·. ™Â ΤÓÙÚ· Ô˘ Ë ·Ó·ÌÔÓ‹ ÁÈ· ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜ ˘ÂÚ‚·›ÓÂÈ ÙÔ˘˜ 6-12 Ì‹Ó˜, Ë Ï‹„Ë ÌÔۯ‡̷ÙÔ˜ ·fi ˙ÒÓÙ· ‰fiÙË ·ÔÙÂÏ› ·Ô‰ÂÎÙ‹ χÛË. ™Â ÔÏÏ¿ ΤÓÙÚ· ÂÊ·ÚÌfi˙ÂÙ·È ÂÚÈÔ¯È΋ ıÂڷ›· Ì ڷ‰ÈÔÛ˘¯ÓfiÙËÙ˜ ‹ Ì ÂÌ‚ÔÏÈÛÌfi Ì ÛÎÔfi ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ∏∫∫ ηٿ ÙÔ ¯ÚfiÓÔ Ù˘ ·Ó·ÌÔÓ‹˜ ÁÈ· ·Ó‡ÚÂÛË Ìۯ‡̷ÙÔ˜. ∂›Û˘, ›Ûˆ˜ ÌÂÏÏÔÓÙÈο, Ó· ‚ÔËı‹ÛÂÈ ÛÙË Ì›ˆÛË Ù˘ ·Ó·ÌÔÓ‹˜ Ë ¯Ú‹ÛË ÙˆÌ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÁÈ· 2 Ï‹Ù˜, ·ÊÔ‡ ÙÔ 40% ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‹·ÙÔ˜ ·ÚΛ ÁÈ· ÙÔÓ Î·ı¤Ó· (84).
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ÓÒÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰È·Ê¤ÚÔ˘Ó ·fi ÙÔ ¤Ó· ÛÙÔ ¿ÏÏÔ Î¤ÓÙÚÔ ÌÂÙ·ÌÔۯ‡ÛˆÓ, Â›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙfi fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Ú¤ÂÈ Ó· ·Ú·¤ÌÔÓÙ·È ÁÈ· ·ÍÈÔÏfiÁËÛË Î·È ¤ÓÙ·ÍË ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÂΉ‹ÏˆÛË ÂÈÏÔÎÒÓ fiˆ˜ Â›Ó·È Ë ÎÈÚÛÔÚÚ·Á›·, Ô ·ÛΛÙ˘ Î·È Ë Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. ∂›Û˘ Ô ˘ÂÚÛÏËÓÈÛÌfi˜ Ì ÙË ·ÚÔ˘Û›· ÌË ·ÓÙÈÚÚÔÔ˘Ì¤Ó˘ ΛÚÚˆÛ˘ ı· Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È ˆ˜ ¤Ó‰ÂÈÍË ÁÈ· ¤ÁηÈÚË ·Ú·ÔÌ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÚÔ˜ ¤ÓÙ·ÍË, ·ÊÔ‡ Û˘Óԉ‡ÂÙ·È ·fi ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·˘ÙfiÌ·Ù˘ ‚·ÎÙËÚȷ΋˜ ÂÚÈÙÔÓ›Ùȉ·˜ Î·È ·ÈÌÔÚÚ·Á›·˜ ·fi ˘Ï·›· ˘¤ÚÙ·ÛË. ∂›Ó·È ηχÙÂÚ· ÔÈ ·ÛıÂÓ›˜ Ó· ·Ú·¤ÌÔÓÙ·È Û ÚÒ˚ÌË Ê¿ÛË, ·Ú¿ fiÙ·Ó Â›Ó·È Û ‚·ÚÈ¿ ÁÂÓÈ΋ ηٿÛÙ·ÛË, fiÔ˘ Â¿Ó ÙÂÏÈο Á›ÓÂÈ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Èı·ÓfiÓ Ó· ÌËÓ ¤¯ÂÈ ÙËÓ Î·Ï‡ÙÂÚË ¤Î‚·ÛË. ΔÔ Î¤ÓÙÚÔ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¤¯ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Î·È ÙËÓ ÂÌÂÈÚ›· Ó· ÚÔÙ›ÓÂÈ Î·È ¿ÏϘ ıÂڷ¢ÙÈΤ˜ ÂÈÏÔÁ¤˜ ÏËÓ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜, fiˆ˜ ÙË ‰ËÌÈÔ˘ÚÁ›· ˘Ï·ÈÔÛ˘ÛÙËÌ·ÙÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜ (ÛÏËÓÔÓÂÊÚÈÎfi shunt, TIPS [transjugular intrahepatic portosystemic shunt]), ÒÛÙ ӷ ÂÍÔÈÎÔÓÔÌËı› ¯ÚfiÓÔ˜ Î·È Ó· Á›ÓÂÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË fiÙ·Ó Â›Ó·È ··Ú·›ÙËÙË Î·È ÛÙÔ Î·Ù·ÏÏËÏfiÙÂÚÔ ÁÈ· ÙÔÓ ·ÛıÂÓ‹ ¯ÚfiÓÔ3. μ·ÛÈÎfi ÎÚÈÙ‹ÚÈÔ ¤ÓÙ·Í˘ Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ‹·ÙÔ˜ ·ÔÙÂÏ› Ô ¯ÚfiÓÔ˜ ·Ô¯‹˜ ·fi ÙÔ ·ÏÎÔfiÏ. Δ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û ∂˘ÚÒË Î·È μ. ∞ÌÂÚÈ΋ ··ÈÙÔ‡Ó ÙËÓ ÂÍ¿ÌËÓË ·Ô¯‹ ·fi ÙÔ ·ÏÎÔfiÏ ˆ˜ ··Ú·›ÙËÙË ÚÔ˘fiıÂÛË ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË4. O ÂÚÈÔÚÈÛÌfi˜ ·˘Ùfi˜ ÛÙËÚ›˙ÂÙ·È ÛÙ· ·ÔÙÂϤÛÌ·Ù· ÌÂÏÂÙÒÓ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ, Ë ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÍ¿ÌËÓË ·Ô¯‹ ·fi ÙÔ ·ÏÎÔfiÏ ÚÈÓ ÙËÓ ¤ÓÙ·ÍË ÌÂÈÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ ÛÙË ¯Ú‹ÛË ·ÏÎÔfiÏ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË (ηÓfiÓ·˜ ÙˆÓ 6 ÌËÓÒÓ)5. øÛÙfiÛÔ Ë ¯ÚËÛÈÌfiÙËÙ· ÙÔ˘ ηÓfiÓ· ÙˆÓ 6 ˆ˜ ÚÔÁÓˆÛÙÈÎÔ‡ ‰Â›ÎÙË Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·Ô¯‹˜ ·fi ÙÔ ·ÏÎÔfiÏ ·ÌÊÈÛ‚ËÙÂ›Ù·È ·fi ¿ÏϘ ÌÂϤÙ˜6. ŒÓ·˜
O ·ÏÎÔÔÏÈÛÌfi˜ Î·È ÔÈ Û˘Ó¤ÂȤ˜ ÙÔ˘ Â›Ó·È ÛÔ‚·Úfi Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜. ªÔÏÔÓfiÙÈ ÙÔ ·ÏÎÔfiÏ ‰ÂÓ ÚÔηÏ› Ë·ÙÈ΋ ÓfiÛÔ Û fiÏÔ˘˜ ÙÔ˘˜ ¯ÚfiÓÈÔ˘˜ ·ÏÎÔÔÏÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÔÙÂÏ› ÙËÓ Î˘ÚÈfiÙÂÚË ·ÈÙ›· ΛÚÚˆÛ˘ ÛÙÔ ¢˘ÙÈÎfi ÎfiÛÌÔ Î·È ·fi ÙȘ ÈÔ Û˘¯Ó¤˜ ÂӉ›ÍÂȘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÁÎÔÛÌ›ˆ˜. ∏ ÂÓÙ·ÂÙ‹˜ Î·È 10ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Â›Ó·È 23% Î·È 7% ·ÓÙ›ÛÙÔȯ· Î·È Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ΛÚÚˆÛË ‹·ÙÔ˜ ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜1. ª¤¯ÚÈ ÙÔ 1983 Û¿ÓÈ· ÚÔÛÊÂÚfiÙ·Ó ÌfiÛ¯Â˘Ì· Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË, ÂÍ·ÈÙ›·˜ Ù˘ ·‚‚·ÈfiÙËÙ·˜ ÁÈ· ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ÙËÓ ÂÈʇϷÍË ÁÈ· ÙËÓ ˘ÔÙÚÔ‹ ÛÙË ¯Ú‹ÛË ·ÏÎÔfiÏ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ΔÔ 1983 ÌÂÙ¿ ·fi ÙÔ Ï·›ÛÈÔ Û˘Ìʈӛ·˜ ÙÔ˘ ¡π∏ (National Institute of Health) ÛÙË ¡¤· ÀfiÚÎË ÚÔÙ¿ıËÎÂ Ë ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ˆ˜ ηٿÏÏËÏË ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Ì ÙËÓ ÂÎÙ›ÌËÛË fiÙÈ Ô ·ÛıÂÓ‹˜ ı· ·ÂÍ·ÚÙËı› ·fi ÙÔ ·ÏÎÔfiÏ. ΔÔ 1988 Ô Starzl Î·È Û˘ÓÂÚÁ¿Ù˜ ·ÚÔ˘Û›·Û·Ó ÙËÓ ÚÒÙË ÛÂÈÚ¿ ·ÛıÂÓÒÓ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Î·È ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ™‡Ìʈӷ Ì ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ù· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó ÈηÓÔÔÈËÙÈο, Ì ˘ÔÙÚÔ‹ Ù˘ ηٿ¯ÚËÛ˘ ·ÏÎÔfiÏ ÌfiÏȘ ÛÙÔ 3% Î·È ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ÙÔ ÚÒÙÔ ¤ÙÔ˜ 73%2. ªÂÙ¿ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·Ú·¿Óˆ ÌÂϤÙ˘ Ë ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Î·ıÈÂÚÒıËΠˆ˜ ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û ∂˘ÚÒË Î·È μ. ∞ÌÂÚÈ΋, Ì ÚÔ˘fiıÂÛË ÙËÓ ·Ô¯‹ ·fi ÙÔ ·ÏÎÔfiÏ ÁÈ· ÌÈ· ÛËÌ·ÓÙÈ΋ ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Î·È ÙËÓ ‡·ÚÍË ‰È·ı¤ÛÈÌ˘ ÎÔÈÓˆÓÈ΋˜ ÛÙ‹ÚÈ͢ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŒÙÛÈ Û‹ÌÂÚ· Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È Ë ÔÚÈÛÙÈ΋ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ.
ŒÓÙ·ÍË ·ÛıÂÓÔ‡˜ ∞Ó Î·È Ù· ÂȉÈο ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙˆÓ ·ÛıÂ-
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O. °IOY§EME
¿ÏÏÔ˜ ÏfiÁÔ˜ ÁÈ· ÙÔÓ ÔÔ›Ô ··ÈÙÂ›Ù·È Ë ÂÍ¿ÌËÓË ·Ô¯‹ ÚÈÓ ÙËÓ ¤ÓÙ·ÍË ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ, Ë ‰È·ÎÔ‹ ÙÔ˘ ·ÏÎÔfiÏ Ô‰ËÁ› Û˘Ó‹ıˆ˜ Û ‚ÂÏÙ›ˆÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓ‹, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÌËÓ Â›Ó·È ··Ú·›ÙËÙË ¿ÓÙÔÙÂ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. O Veldt Î·È Û˘ÓÂÚÁ¿Ù˜ ˆÛÙfiÛÔ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ, ·Ó Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÌÂÙ¿ ÙË ¿ÚÔ‰Ô 3 ÌËÓÒÓ ·fi ÙË ‰È·ÎÔ‹ ÙÔ˘ ·ÏÎÔfiÏ Î·È ÙËÓ ˘ÔÛÙËÚÈÎÙÈ΋ Û˘ÓÙËÚËÙÈ΋ ıÂڷ›·, Ë Èı·ÓfiÙËÙ· ÁÈ· ÂÚ·ÈÙ¤Úˆ ·˘ÙfiÌ·ÙË ·Ó¿ÓË„Ë Â›Ó·È Ùˆ¯‹ Î·È ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ·Ú·¤ÌÔÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË7. H ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÔÍ›· ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ· Î·È Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Â›Ó·È ÙÔ ‰˘ÛÎÔÏfiÙÂÚÔ Î·È ·ÎfiÌË ¿Ï˘ÙÔ Úfi‚ÏËÌ· ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û ·ÏÎÔÔÏÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ ‚·Û›˙ÂÙ·È ÛÙÔ ‰Â›ÎÙË (Discriminant Function, DF) Ô˘ ÚÔÙ¿ıËΠ·fi ÙÔÓ Maddrey Î·È ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜ Î·È Ô˘ ÚÔ·ÙÂÈ ·fi ÙËÓ ·Ú·Î¿Ùˆ Â͛ۈÛË 4.6(¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ ·ÛıÂÓ‹ - ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ Ì¿ÚÙ˘Ú·) + ¯ÔÏÂÚ˘ıÚ›ÓË ÔÚÔ‡. ΔÈ̤˜ DF ‰Â›ÎÙË >32 Û¯ÂÙ›˙ÔÓÙ·È Ì ˘„ËÏ‹ ıÓËÙfiÙËÙ· 35%-46% Û ¤Ó· Ì‹Ó·. ∏ ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Î·È Ë ·Ó¿ÁÎË ÁÈ· ·ÈÌÔοı·ÚÛË Â›Ó·È ·fiÏ˘Ù· ηÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÂÈ‚›ˆÛ˘. ªÂ ÙË ıÓËÙfiÙËÙ· Ó· ·Ú·Ì¤ÓÂÈ Û ÙfiÛÔ ˘„ËÏ¿ ÂȤ‰· ÛÙÔ ÎÏÈÓÈÎfi Û‡Ó‰ÚÔÌÔ Ù˘ ÔÍ›·˜ ·ÏÎÔÔÏÈ΋˜ Ë·Ù›Ùȉ·˜, ·Ú¿ ÙË ÂÊ·ÚÌÔÁ‹ ‰È·ÊfiÚˆÓ Û˘ÓÙËÚËÙÈÎÒÓ ıÂڷ¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Ô˘ ¤¯Ô˘Ó ‰ÔÎÈÌ·Ûı› fiˆ˜: ÎÔÚÙÈÎÔÂȉ‹, Û˘ÌÏËÚÒÌ·Ù· ·ÌÈÓÔͤˆÓ, ÂÁ¯‡ÛÂȘ ÈÓÛÔ˘Ï›Ó˘ Î·È ÁÏԢηÁfiÓÔ˘, ÂÓÙÔÍ˘Ê˘ÏÏ›Ó˘, ÎÔϯÈΛÓ˘ Î·È ¿ÏψÓ, ·Ó·fiÊ¢ÎÙ· Ù›ıÂÙ·È ÙÔ ÂÚÒÙËÌ· Â¿Ó Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ı· ‚ÂÏÙ›ˆÓ ÙË ÚfiÁÓˆÛË Û ·ÛıÂÓ›˜ Ì ‚·ÚÈ¿ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ·8. ∂›Ó·È ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ÂÈÏÔΤ˜ Ù˘ ÔÍ›·˜ ·ÏÎÔÔÏÈ΋˜ Ë·Ù›Ùȉ·˜ -ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ- ·Ôηı›ÛÙ·ÓÙ·È Î·È Ë Î·Ù¿ÛÙ·ÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙ·ıÂÚÔÔÈÂ›Ù·È Ì ÙË ·Ú¤Ï¢ÛË ÙÔ˘ ¯ÚfiÓÔ˘ Î·È ÙËÓ ·Ô¯‹ ·fi ÙÔ ·ÏÎÔfiÏ Î·È ¤ÙÛÈ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË ¿ÓÙÔÙÂ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. øÛÙfiÛÔ Û‡Ìʈӷ Ì ÙÔÓ Veldt Î·È Û˘ÓÂÚÁ¿Ù˜, fiˆ˜ Î·È ÛÙËÓ ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË, Â¿Ó ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÌÂÙ¿ ÙË ¿ÚÔ‰Ô 3 ÌËÓÒÓ ·fi ÙË ‰È·ÎÔ‹ ÙÔ˘ ·ÏÎÔfiÏ Î·È ÙËÓ ˘ÔÛÙËÚÈÎÙÈ΋ Û˘ÓÙËÚËÙÈ΋ ıÂڷ›·, Ë Èı·ÓfiÙËÙ· ÁÈ· ÂÚ·ÈÙ¤Úˆ ·˘ÙfiÌ·ÙË ·Ó¿ÓË„Ë Â›Ó·È Ùˆ¯‹ Î·È ÔÈ ·ÛıÂÓ›˜ Ú¤-
ÂÈ Ó· ·Ú·¤ÌÔÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË7. À¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ì ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ, Ë ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÔÍ›· ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ· Ô˘ ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ¯ˆÚ›˜ ÙËÓ Û˘Ó‡·ÚÍË ·ÏÎÔÔÏÈ΋˜ Ë·Ù›Ùȉ·˜ Î·È ·˘ÙÒÓ Ì ÌË ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ9. ∂›Û˘ Ë ·ÚÔ˘Û›· Ù˘ ÔÍ›·˜ ·ÏÎÔÔÏÈ΋˜ Ë·Ù›Ùȉ·˜ Ê·›ÓÂÙ·È fiÙÈ ‰Â ÚÔ‰Èο˙ÂÈ ÙËÓ ˘ÔÙÚÔ‹ ÛÙË ¯Ú‹ÛË ·ÏÎÔfiÏ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶·Ú’fiÏ· ·˘Ù¿, Ë ı¤ÛË ÁÈ· ÙÔ Â¿Ó Ú¤ÂÈ ‹ ‰ÂÓ Ú¤ÂÈ ÔÈ ·ÛıÂÓ›˜ Ì ÔÍ›· ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ· Ó· ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ı· ·Ú·Ì›ÓÂÈ Û ·ÌÊÈÛ‚‹ÙËÛË Î·È Û˘Ó¯‹ ÚÔ‚ÏËÌ·ÙÈÛÌfi. ™‹ÌÂÚ· Ë Ù·ÎÙÈ΋ ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ Î¤ÓÙÚˆÓ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Â›Ó·È Ó· ·ÔÚÚ›ÙÔ˘Ó ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÔÍ›· ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ· Î·È ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·5.
∂ÈÏÔÁ‹ ÙÔ˘ ¯ÚfiÓÔ˘ ™Â ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ÛÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ȉ·ÓÈÎÔ‡ ¯ÚfiÓÔ˘ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ú¤ÂÈ Ó· Û˘Ó˘ÔÏÔÁ›˙ÂÙ·È Ì·˙› Ì ÙËÓ ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ Î·È Ë Ù˘¯fiÓ ·ÚÔ˘Û›· ÙÔ˘ ·ÏÎÔÔÏÈÛÌÔ‡ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘. °ÂÓÈο ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ¯ÚfiÓÔ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ù· ÎÚÈÙ‹ÚÈ· Ô˘ ÈÛ¯‡Ô˘Ó Î·È ÛÙÔ˘˜ ¿ÏÏÔ˘˜ ·ÛıÂÓ›˜ Ì ˷ÙÈ΋ ·Ó¿ÚÎÂÈ·. ∞fi ÙÔ 1997 ¤ˆ˜ ÙÔ 2002 Ë ÂÈÏÔÁ‹ ÙÔ˘ ¯ÚfiÓÔ˘ ÁÈÓfiÙ·Ó Û‡Ìʈӷ Ì ÙËÓ Î·Ù¿Ù·ÍË Î·Ù¿ ChildTurcotte-Pugh. O Poynard Î·È Û˘Ó ¤‰ÂÈÍ·Ó Ì ۷ʋÓÂÈ· ÙÔ fiÊÂÏÔ˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· Û ۯ¤ÛË Ì ÙËÓ ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™ÙȘ ÌÂϤÙ˜ ÙÔ˘˜ ÙÔ fiÊÂÏÔ˜ ·ÊÔÚÔ‡Û ÌfiÓÔ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË ‹·ÙÔ˜ ηٿ Child-Pugh C. ∞ÓÙ›ıÂÙ· ÔÈ ·ÛıÂÓ›˜ ηٿ Child-Pugh μ ‰ÂÓ ÂÌÊ¿ÓÈ˙·Ó ‰È·ÊÔÚ¿ ÛÙËÓ ÂÈ‚›ˆÛË Ì ‹ ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÂÓÒ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ηٿ Child-Pugh A Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô‰ËÁÔ‡Û Û ÌÈÎÚfiÙÂÚË ÂÈ‚›ˆÛË10,11. ∞fi ÙÔÓ ºÂ‚ÚÔ˘¿ÚÈÔ 2002 ÛÙȘ ∏¶∞ ηıÈÂÚÒıËΠÙÔ MELD score ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™ÙÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ MELD ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÌfiÓÔ ·ÓÙÈÎÂÈÌÂÓÈΤ˜ ·Ú¿ÌÂÙÚÔÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Û οı ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Î·È ¤ÙÛÈ Â›Ó·È ··ÏÏ·Á̤ÓÔ ·ÊãÂÓfi˜ ·fi ÙËÓ ˘ÔÎÂÈÌÂÓÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ıÂÚ¿ÔÓÙÔ˜ È·ÙÚÔ‡ Î·È ·ÊãÂÙ¤ÚÔ˘ ·fi ÙË ·Ú¿ÌÂÙÚÔ ÙÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ·fi ÙËÓ ¤ÓÙ·ÍË ÙÔ˘
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
·ÛıÂÓÔ‡˜ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. O ÏÔÁ¿ÚÈıÌÔ˜ ‰‡Ô ‰ÂÈÎÙÒÓ Ù˘ Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, -Ë ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘ Î·È Ù· ›‰· Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÛÙÔÓ ÔÚfi- Î·È ·˘Ùfi˜ ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ·ÔÙÂÏÔ‡Ó Ù· ÛÙÔȯ›· ÙÔ˘ Ì·ıËÌ·ÙÈÎÔ‡ Ù‡Ô˘ Ô˘ ˘ÔÏÔÁ›˙ÂÈ ÔÛÔÙÈο ÙË ‚·Ú‡ÙËÙ· Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÙÔÓ Î›Ó‰˘ÓÔ ıÓËÙfiÙËÙ·˜. R=(0,957 x Log e[ÎÚ·ÙÈÓ›ÓË(mg/dl)] + 0,378 x Log e [ÔÏÈ΋ ¯ÔÏÂÚ˘ıÚ›ÓË(mg/dl)] + 1,120 x LogeINR + 0.643) x 10 ΔÔ MELD score Û 80%-85% ÚÔÛ‰ÈÔÚ›˙ÂÈ Ì ·ÎÚ›‚ÂÈ· ÔÈÔÈ ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË ‹·ÙÔ˜ ı· ÂÈ‚ÈÒÛÔ˘Ó Î·È ÔÈÔÈ ‰ÂÓ ı· ÂÈ‚ÈÒÛÔ˘Ó ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞ÛıÂÓ›˜ Ì MELD score <16 Â›Ó·È Èı·ÓfiÙÂÚÔ Ó· ÂÈ‚ÈÒÛÔ˘Ó ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú¿ Â¿Ó ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË. O ¯ÂÈÚÔ˘ÚÁÈÎfi˜ ΛӉ˘ÓÔ˜ Î·È ÔÈ ÂÈÏÔΤ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯Ô˘Ó ˘„ËÏfiÙÂÚË ıÓËÙfiÙËÙ· ·fi 6%, Ô˘ Â›Ó·È Ë ÂÙ‹ÛÈ· ıÓËÙfiÙËÙ· Û ·ÛıÂÓ›˜ Ì MELD score <16. ∏ ıÓËÙfiÙËÙ· ‚·›ÓÂÈ ·˘Í·ÓfiÌÂÓË Ì ÙËÓ ·‡ÍËÛË ÙÔ˘ MELD score. ∂ÙÛÈ, ·ÛıÂÓ›˜ Ì score <9 ¤¯Ô˘Ó ıÓËÙfiÙËÙ· 1.9% Û ‰È¿ÛÙËÌ· 3 ÌËÓÒÓ, ÂÓÒ ·˘ÙÔ› Ì score <40 ¤¯Ô˘Ó ıÓËÙfiÙËÙ· 71% ·ÓÙ›ÛÙÔȯ·12,13. ªÂ ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ô Srikureja Î·È Û˘ÓÂÚÁ¿Ù˜ ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ MELD score Â›Ó·È Î·Ï‡ÙÂÚÔ ·fi ÙÔ DF (Discriminant Function) score ‹ ÙÔ CTP (Child-Turcotte-Pugh) score ÛÙË ÚfiÁÓˆÛË ÙˆÓ ÂÈÛ·ÁÔÌ¤ÓˆÓ Ì ÔÍ›· ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ· ·ÛıÂÓÒÓ ÚÔ˜ ÓÔÛËÏ›·. ¶Ú¿ÁÌ·ÙÈ, ÙÈ̤˜ MELD score >18 Î·È >20 ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È ÙË ÚÒÙË Â‚‰ÔÌ¿‰· Ù˘ ÓÔÛËÏ›·˜ ·ÓÙ›ÛÙÔȯ·, ‹ Âȉ›ӈÛË ÙÔ˘ MELD >2 Û ÌÈ· ‚‰ÔÌ¿‰·, ›¯Â ÛËÌ·ÓÙÈο Û˘Û¯ÂÙÈÛı› Ì ÙËÓ ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋ ıÓËÙfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ·. ÀÔÛÙËÚ›˙Ô˘Ó ·ÎfiÌË fiÙÈ ‡·ÚÍË MELD score >20 ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ÓÔÛËÏ›·˜ ¤¯ÂÈ ÙËÓ ˘„ËÏfiÙÂÚË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ÛÙË ÚfiÁÓˆÛË Ù˘ ıÓËÙfiÙËÙ·˜14.
¶ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ·ÛıÂÓÒÓ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË °È· ÙË ‰È·ÛÊ¿ÏÈÛË ÂÈÙ˘¯Ô‡˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ Û ·ÛıÂÓ‹ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ, Ú¤ÂÈ Ó· ÚÔËÁÂ›Ù·È ÏÂÙÔÌÂÚ‹˜ ÂÎÙ›ÌËÛË Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ˘Ô„ËÊ›Ô˘ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÚÈÓ ÎÚÈı› ηٿÏÏËÏÔ˜. ŒÙÛÈ, ÂϤÁ¯ÂÙ·È Î¿ıÂ Û˘Ó˘¿Ú¯ÔÓ Úfi‚ÏËÌ· Ô˘ ı· ÂËÚÂ-
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¿ÛÂÈ ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Î·È Ù˘ „˘¯È·ÙÚÈ΋˜ ·ÍÈfiÏÔÁËÛ˘, ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ·Ê’ÂÓfi˜ Ù˘ ·Ó·ÌÂÓfiÌÂÓ˘ ·Ô¯‹˜ Î·È ·ÂÍ¿ÚÙËÛ˘ ·fi ÙÔ ·ÏÎÔfiÏ Î·È ·ÊãÂÙ¤ÚÔ˘ Ù˘ Û˘ÌÌfiÚʈÛ˘ ÛÙÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ΔÔ ·ÏÎÔfiÏ ÂÈ‚·Ú‡ÓÂÈ ÔÏÏ¿ fiÚÁ·Ó· ¤Ú·Ó ÙÔ˘ ‹·ÙÔ˜. Ÿˆ˜ ÂÚȤÁÚ·„·Ó ÔÈ Keeffe, Neuberger Î·È Û˘ÓÂÚÁ¿Ù˜ Ë Î·Ù¿¯ÚËÛË ·ÏÎÔfiÏ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ‚Ï¿‚Ë ÙÔ˘ Ì˘Ôηډ›Ô˘, ÙˆÓ ÛÎÂÏÂÙÈÎÒÓ Ì˘ÒÓ, ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜, Ù˘ ıÚ¤„˘, ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Î·È ÂÚÈÊÂÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÙˆÓ ÔÛÙÒÓ ·ÏÏ¿ Î·È ÛÙËÓ ·Ó¿Ù˘ÍË ÓÂÔÏ·ÛÌ¿ÙˆÓ ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È ÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. OÈ ÂÈÏÔΤ˜ ·fi Ù· ¿ÏÏ· fiÚÁ·Ó· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ‰˘ÛÎÔϤ„Ô˘Ó ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È fi¯È Û¿ÓÈ· Ó· ·ÔÙÂϤÛÔ˘Ó ·ÓÙ¤Ó‰ÂÈÍË ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹ Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ÙÂÏÈ΋ ¤Î‚·ÛË Ù˘16,17. OÈ Û˘ÓËı¤ÛÙÂÚ˜ ÂÈÏÔΤ˜ ·Ó·Ê¤ÚÔÓÙ·È ·Ú·Î¿Ùˆ. ∫·Ú‰ÈÔÌ˘Ô¿ıÂÈ· ∂›Ó·È ÂÚÈÛÛfiÙÂÚÔ Û˘¯Ó‹ Û ·ÏÎÔÔÏÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÂÓÂÚÁfi ηٿ¯ÚËÛË ·ÏÎÔfiÏ Î·È ÏÈÁfiÙÂÚÔ Û ·˘ÙÔ‡˜ Ô˘ ·¤¯Ô˘Ó ·fi ÙÔ ·ÏÎÔfiÏ. °ÂÓÈÎÒ˜, ·ÔÙÂÏ› ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ·ÈÙ›· ·fiÚÚȄ˘ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ·ÚÔ˘Û›· ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Û˘¯Ó‹ ·fi ÙË Î·Ú‰ÈÔÌ˘Ô¿ıÂÈ·. ™ÙÔ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô Á›ÓÂÙ·È ÂÎÙ›ÌËÛË Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÌË ·ÚÂÌ‚·ÙÈΤ˜ ÌÂıfi‰Ô˘˜ fiˆ˜ ÙÔ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ·, ÙÔ ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ· Î·È Ë ‰ÔÎÈÌ·Û›· ÎÔÒÛˆ˜ Î·È Û·ÓÈfiÙÂÚ· Ë Ú·‰ÈÔ˚ÛÔÙÔÈ΋ ÎÔÈÏÈÔÁÚ·Ê›·. ªÔÏÔÓfiÙÈ, Ë ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ‰ÂÓ Â›Ó·È ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔηϤÛÂÈ ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù· Â¿Ó ‰ÂÓ ‰È·ÁÓˆÛı› Î·È ·ÓÙÈÌÂÙˆÈÛı› ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ª˘Ô¿ıÂÈ·. μÏ¿‚Ë ÙˆÓ ÛÎÂÏÂÙÈÎÒÓ Ì˘ÒÓ ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi ̤¯ÚÈ 42% ÙˆÓ ·ÏÎÔÔÏÈÎÒÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ Î·È ÙÔ 46% ÙˆÓ ·Ó‰ÚÒÓ Ì ÂÓÂÚÁfi ηٿ¯ÚËÛË ·ÏÎÔfiÏ ÂÌÊ·Ó›˙Ô˘Ó ·ÏÏ·Á¤˜ ÙˆÓ Ì˘˚ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ Â›Ó·È ÂÓ‰ÂÈÎÙÈΤ˜ Ì˘Ô¿ıÂÈ·˜. ∏ ηٿÛÙ·ÛË ÂΉËÏÒÓÂÙ·È ÌÂ Ì˘˚΋ ·‰˘Ó·Ì›·, Ì˘·ÏÁ›Â˜ Î·È ‰È·Ù·Ú·¯¤˜ Ì˘˚ÎÒÓ ÂÓ˙‡ÌˆÓ. ∏ ‚Ï·ÙÈ΋ ‰Ú¿ÛË ÙÔ˘ ·ÏÎÔfiÏ ÛÙÔ Ì˘ÈÎfi ·ÙÙ·ÚÔ Â›Ó·È ¿ÌÂÛË ‹/Î·È ¤ÌÌÂÛË ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ η΋˜ ıÚ¤„˘ Î·È Ù˘ Ó¢ÚÔ¿ıÂÈ·˜. ∏ ·ÚÔ˘Û›· Ì˘Ô¿ıÂÈ·˜ Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ Î·È ·Ó¿ÏÔÁË Ù˘ Û˘ÓÔÏÈ΋˜ ÔÛfiÙËÙ·˜ ·ÏÎÔfiÏ Ô˘ ηٷӿψ-
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O. °IOY§EME
Û·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜. ∏ ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ Ì˘Ô¿ıÂÈ· Â›Ó·È Û¿ÓÈ· Û ·ÛıÂÓ›˜ ˘Ô„‹ÊÈÔ˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ¶·ÁÎÚ·ٛÙȉ·. ∏ ¯ÚfiÓÈ· ·ÁÎÚ·ٛÙȉ· ÂÌÊ·Ó›˙ÂÙ·È Û·ÓÈfiÙÂÚ· Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ Û ۯ¤ÛË Ì ·ÏÎÔÔÏÈÎÔ‡˜ ¯ˆÚ›˜ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ‹·ÙÔ˜ Û ·Ó·ÏÔÁ›· 1:5. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÚÔηÏÔ‡Ó ·˘Ù‹ ÙËÓ ‰È·ÊÔÚ¿ ‰ÂÓ Â›Ó·È ÁÓˆÛÙÔ›. ∏ Û˘Ó‡·ÚÍË ‚·ÚÈ¿˜ ¯ÚfiÓÈ·˜ ·ÁÎÚ·ٛÙȉ·˜ ÂËÚ¿˙ÂÈ ·ÚÓËÙÈο ÙËÓ ·ÔÚÚfiÊËÛË ÙˆÓ ·ÓÔÛÔÙÚÔÔÔÈËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ù· ÔÔ›· Â›Ó·È ··Ú·›ÙËÙ· ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∂ÙÛÈ, ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ¯ÚfiÓÈ· ·ÁÎÚ·ٛÙȉ· Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÂӉ¯Ô̤ӈ˜ Ó· Ï·Ì‚¿ÓÔ˘Ó ·ÓÔÛÔηٷÛÙ·ÏÙÈο Û ˘„ËÏfiÙÂÚ˜ ‰fiÛÂȘ ÁÈ· ÙËÓ Â›Ù¢ÍË ‰Ú·ÛÙÈÎÒÓ ÂȤ‰ˆÓ ÛÙÔ ·›Ì·. ¢È·Ù·Ú·¯‹ ıÚ¤„˘ ·Ú·ÙËÚÂ›Ù·È Û ÔÏÏÔ‡˜ Â¿Ó fi¯È Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Ô‰ËÁÔ‡Ó ÛÙË ‰È·Ù·Ú·¯‹ Ù˘ ıÚ¤„˘ ›ӷÈ: Ë ÏËÌÌÂÏ‹˜ ‰È·ÙÚÔÊ‹, Ô ·˘ÍË̤ÓÔ˜ ηٷ‚ÔÏÈÛÌfi˜ ÙˆÓ ˘‰·Ù·ÓıڿΈÓ, ÙˆÓ ÚˆÙÂ˚ÓÒÓ Î·È ÙÔ˘ Ï›Ô˘˜ ÙÔ˘ ÛÒÌ·ÙÔ˜, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ‰˘Û·ÔÚÚfiÊËÛË ÙˆÓ ıÚÂÙÈÎÒÓ Ô˘Û›ˆÓ ÏfiÁˆ ‚Ï¿‚˘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘, ÙËÓ ˘ÂÚ·Ó¿Ù˘ÍË ÌÈÎÚÔ‚›ˆÓ, ÙË ¯ÔÏfiÛÙ·ÛË Î·È ÙËÓ ÂÏ·Ùو̤ÓË ·ÁÎÚ·ÙÈ΋ ¤ÎÎÚÈÛË. ∂ÈϤÔÓ, ÛÙÔ˘˜ ·ÏÎÔÔÏÈÎÔ‡˜ ·ÛıÂÓ›˜ ·Ú·ÙËÚÂ›Ù·È ·Ó¿ÚÎÂÈ· ‚ÈÙ·ÌÈÓÒÓ Î·È ÂȉÈο Ù˘ ıÂÈ·Ì›Ó˘ Ô˘ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ∏ η΋ ıÚ¤„Ë Â›Ó·È Î·Îfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ Î·È Û˘¯Ó¿ Â›Ó·È ÏfiÁÔ˜ ·Ó·‚ÔÏ‹˜ ̤¯ÚÈ Ó· ÂÈÙ¢¯ı› ηχÙÂÚÔ ÛÙ¿‰ÈÔ ıÚ¤„˘. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ıÚ¤„˘ Á›ÓÂÙ·È ÌÂ Û˘ÌÏËڈ̷ÙÈ΋ ÂÓÙÂÚÈ΋ Û›ÙÈÛË ÚÈÓ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Î·Ï‡ÙÂÚË ÚfiÁÓˆÛË. ¡Â˘ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙÔÓ ¯ÚfiÓÈÔ ·ÏÎÔÔÏÈÛÌfi ÚÔηÏÔ‡ÓÙ·È ·fi ¿ÌÂÛË ‚Ï·ÙÈ΋ ‰Ú¿ÛË ÙÔ˘ ·ÏÎÔfiÏ Î·È ÙˆÓ ÌÂÙ·‚ÔÏÈÙÒÓ ÙÔ˘ ÛÙÔÓ ÂÁΤʷÏÔ Î·È ÛÙ· ÂÚÈÊÂÚÈο Ó‡ڷ, Ô˘ Ô‰ËÁÔ‡Ó ÙÂÏÈο ÛÙËÓ ·Ó¿Ù˘ÍË ·ÙÚÔÊ›·˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È ÂÚÈÊÂÚÈ΋˜ Ó¢ڛÙȉ·˜. ∏ Û˘Ó‡·ÚÍË Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ‰˘Û¯¤ÚÂÈ· ÛÙË ‰È¿ÎÚÈÛË ˘ÔΛÌÂÓ˘ Ó¢ÚÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜ ·fi ÙÔÍÈÎfiÙËÙ· ÙÔ˘ ·ÏÎÔfiÏ. ∏ ·ÚÔ˘Û›· ÛÔ‚·Ú‹˜ Ó¢ÚÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜ Â›Ó·È ·ÓÙ¤Ó-
‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ·Ê’ ÂÓfi˜ ÏfiÁˆ ·ÓÈηÓfiÙËÙ·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· Ï‹ÚË Û˘ÌÌfiÚʈÛË ÛÙÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ·Ê’ ÂÙ¤ÚÔ˘ ÏfiÁˆ ÙÔ˘ ÂӉ¯Ô̤ÓÔ˘ Ù˘ ÌË ÛËÌ·ÓÙÈ΋˜ ‚ÂÏÙ›ˆÛ˘ ÛÙË ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜. ¶Ú¿ÁÌ·ÙÈ, Ù· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ÂÎÙÈÌÔ‡Ó Ì ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Î·È Ó¢ÚÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ ÙȘ ·Ó·ÙÔÌÈΤ˜ ‰Ô̤˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi ‚Ï·‚ÒÓ Ô˘ ı· ÂËÚ¿ÛÔ˘Ó ÙËÓ ÚfiÁÓˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÛÙÂÔÂÓ›· ·Ú·ÙËÚÂ›Ù·È Û 10%-42% ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË, ÏfiÁˆ Ù˘ ÌÂȈ̤Ó˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ ÔÛÙÂÔ‚Ï·ÛÙÒÓ Î·È ÙˆÓ ÁÔÓ¿‰ˆÓ Ô˘ ·Ú¿ÁÔ˘Ó ÔÚÌfiÓ˜ Î·È Ú˘ıÌ›˙Ô˘Ó ÙËÓ ÔÛÙÂÔÁ¤ÓÂÛË, ÙÔ˘ ÌÂȈ̤ÓÔ˘ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ Î·È Ù˘ ÌÂȈ̤Ó˘ ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘. ∏ Ì›ˆÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÔÛÙÂÔfiÚˆÛË Ì ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·˘ÙfiÌ·ÙˆÓ Î·Ù·ÁÌ¿ÙˆÓ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÂÚÈÔ‰ÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Î·È ÚÔÛ¿ıÂÈ· ıÂڷ¢ÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ì ÛÙfi¯Ô ÙËÓ ·Ó·ÛÙÔÏ‹ ‹/Î·È ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÛÙÈ΋˜ Ì¿˙·˜. ∫·ÎÔ‹ıÂȘ. ∫ÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·Ó·Ù‡ÛÛÔÓÙ·È ÓÂÔÏ¿ÛÌ·Ù· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡, ÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÏÂÌÊÒÌ·Ù· Û ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ·fi ·˘Ù‹ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û ÌË ·ÏÎÔÔÏÈÎÔ‡˜ ·ÛıÂÓ›˜18. °È· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ·ÚÔ˘Û›·˜ Û˘Ó˘¿Ú¯Ô˘Û·˜ ÓÂÔÏ·ÛÌ·ÙÈ΋˜ ÓfiÛÔ˘ ÛÙÔ ÎÈÚÚˆÙÈÎfi ‹·Ú ηٿ ÙËÓ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË Á›ÓÔÓÙ·È ÂȉÈΤ˜ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÙÔ˘ ‹·ÙÔ˜, fiˆ˜ Ë ÔÁÎÔÌÂÙÚÈ΋(spiral) ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· Î·È Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ‹·ÙÔ˜. ∂›Û˘ Á›ÓÂÙ·È ÏÂÙÔÌÂÚ‹˜ ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi ÓÂÔÏ·ÛÌ·ÙÈ΋˜ ÓfiÛÔ˘ ÛÙ· ˘fiÏÔÈ· fiÚÁ·Ó·, Ô˘ Û˘Ó¯›˙ÂÙ·È Î·È ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ٷÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·. æ˘¯È·ÙÚÈ΋ ÂÎÙ›ÌËÛË. ∂›Ó·È ‚·ÛÈÎfi ÁÈ· ÙËÓ Î·Ï‹ ÚfiÁÓˆÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜, ÔÈ ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ Ó· ·Ú·Ì¤ÓÔ˘Ó ÂχıÂÚÔÈ ·fi ÙÔ ·ÏÎÔfiÏ Î·È Ó· Û˘ÌÌÔÚÊÒÓÔÓÙ·È Ì ÙÔ ··ÈÙÔ‡ÌÂÓÔ ıÂڷ¢ÙÈÎfi Û¯‹Ì·. ∏ ÂÎÙ›ÌËÛË ÙÔ˘ οı ˘Ô„ËÊ›Ô˘ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓÔ‡˜ ·fi ÙÔÓ ÂȉÈÎfi „˘¯›·ÙÚÔ Ù˘ ÔÌ¿‰·˜
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÌÂÙ·ÌfiÛ¯Â˘Û˘, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ ·›ÙÈÔ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘, Û˘Ì‚¿ÏÏÂÈ ÛËÌ·ÓÙÈο ÛÙË Î·Ï‡ÙÂÚË ·Ô‰Ô¯‹ Ù˘ Ó¤·˜ Ú·ÁÌ·ÙÈÎfiÙËÙ·˜ Ô˘ ÂÈʤÚÂÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∞˘Ù‹ Á›ÓÂÙ·È ··Ú·›ÙËÙË fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË fiÔ˘ ÌÔÚ› Ó· ÚÔÛ‰ÈÔÚ›ÛÂÈ Â¿Ó Î¿ÔÈÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ı· ÏËÚÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· ÁÈ· ·Ô¯‹ Î·È ·ÂÍ¿ÚÙËÛË ·fi ÙÔ ·ÏÎÔfiÏ. ™ÙË „˘¯È·ÙÚÈ΋ ÂÎÙ›ÌËÛË ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÙÔ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ÙÔ˘ ·ÛıÂÓÔ‡˜, ηıÒ˜ Î·È ÔÈ ˘ÔΛÌÂÓ˜ „˘¯È·ÙÚÈΤ˜ ·ı‹ÛÂȘ, Ë Û¯¤ÛË ÂÚÁ·Û›·˜, ·ÚÈıÌfi˜ Î·È ‰È¿ÚÎÂÈ· ÚÔËÁÔ˘Ì¤ÓˆÓ ÚÔÛ·ıÂÈÒÓ ÁÈ· ·Ô¯‹ Î·È ·ÂÍ¿ÚÙËÛË ·fi ÙÔ ·ÏÎÔfiÏ, ηıÒ˜ Î·È Ë Û˘Ó¤ÓÙ¢ÍË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÙË ·ÚÔ˘Û›· ÂÓfi˜ ̤ÏÔ˘˜ Ù˘ ÔÈÎÔÁÂÓ›·˜ ÙÔ˘ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ˘ÔÙÚÔ‹˜ ÛÙË ¯Ú‹ÛË ÙÔ˘ ·ÏÎÔfiÏ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. °È· ÙËÓ ÚfiÁÓˆÛË Ù˘ ˘ÔÙÚÔ‹˜ ÛÙÔ ·ÏÎÔfiÏ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰È¿ÊÔÚ· ÌÔÓ٤Ϸ ·ÍÈÔÏfiÁËÛ˘ fiˆ˜ Ë Îϛ̷η ÂÎÙ›ÌËÛ˘ Michigan Alcoholism Prognosis Scale (MAPS) Î·È Ë Îϛ̷η High Risk Alcoolism Relapse (HRAR) Ì ·ÌÊÈÏÂÁfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·19,20.
ÀÔÙÚÔ‹ ÛÙË ¯Ú‹ÛË ·ÏÎÔfiÏ O ÔÚÈÛÌfi˜ Ù˘ ˘ÔÙÚÔ‹˜ ÛÙË ¯Ú‹ÛË ·ÏÎÔfiÏ Â›Ó·È ˘fi ·ÌÊÈÛ‚‹ÙËÛË Î·È ‰È·‚·ıÌ›˙ÂÙ·È ·fi ÙËÓ ÔÔÈ·‰‹ÔÙ ¯Ú‹ÛË ·ÏÎÔfiÏ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì¤¯ÚÈ ÙÔÓ ·ÏÎÔÔÏÈÛÌfi Ì ·Ó¿ÁÎË ÓÔÛËÏ›·˜21. Δ·ÎÙÈ΋ ¯Ú‹ÛË ·ÏÎÔfiÏ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÛÔ‚·Ú¿ ˘’ fi„ÈÓ, ÁÈ·Ù› Û˘ÓÈÛÙ¿ ÚÒ˚ÌÔ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙË Ì·ÎÚ¿ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜22. ∏ ÂÚÈÛÙ·Ûȷ΋ ¯Ú‹ÛË ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ ·ÏÎÔfiÏ ‰ÂÓ Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È ˆ˜ ˘ÔÙÚÔ‹ Î·È ‰ÂÓ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ·˘ÛÙËÚ¿, ·ÊÔ‡ Û˘Ó‹ıˆ˜ ‰ÂÓ ÌÂÙ·›ÙÂÈ Û ϋÚË ˘ÔÙÚÔ‹ ηٿ¯ÚËÛ˘ ·ÏÎÔfiÏ Ô˘ ÌÔÚ› Ó· Â›Ó·È ‚Ï·ÙÈ΋ ÁÈ· ÙÔ ÌfiÛ¯Â˘Ì·. ∏ ·‰˘Ó·Ì›· ÔÚÈÛÌÔ‡ Ù˘ ˘ÔÙÚÔ‹˜ ÛÙË ¯Ú‹ÛË ÙÔ˘ ·ÏÎÔfiÏ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ Â˘Ú¤ˆ˜ Î˘Ì·ÈÓfiÌÂÓË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ ¯Ú‹Û˘ ÛÙÔ ·ÏÎÔfiÏ. ∏ ̤¯ÚÈ Û‹ÌÂÚ· ÂÎÙ›ÌËÛË Ù˘ ˘ÔÙÚÔ‹˜ ‰ÂÓ ÂËÚ¿˙ÂÙ·È ÌfiÓÔ ·fi ÙËÓ ·‰˘Ó·Ì›· ÔÚÈÛÌÔ‡ Ù˘ ˘ÔÙÚÔ‹˜ ·ÏÏ¿ Î·È ·fi ÙÔÓ ÙÚfiÔ Ô˘ ηٷÁÚ¿ÊÂÙ·È Ë ˘ÔÙÚÔ‹. ∏ ÂÚÈÛÛfiÙÂÚÔ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓË Ì¤ıÔ‰Ô˜ ÙÂÎÌËÚ›ˆÛ˘ Ù˘ ˘ÔÙÚÔ‹˜ Â›Ó·È Ë ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Î·È Ë Û˘Ó¤ÓÙ¢ÍË ·fi ÙÔÓ „˘¯›·ÙÚÔ Ù˘ ÔÌ¿‰·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹ ÔÈ ··ÓÙ‹ÛÂȘ Û ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÚˆÙÔÎfiÏÏÔ˘. O
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·ÓÙÈÎÂÈÌÂÓÈÎfi˜ ÙÚfiÔ˜ ÙÂÎÌËÚ›ˆÛ˘ Ù˘ ˘ÔÙÚÔ‹˜, fiˆ˜ ›‰· ·ÏÎÔfiÏ ÛÙÔ ·›Ì·, ÛÙ· Ô‡Ú· ‹ ÛÙÔÓ ÂÎÓÂfiÌÂÓÔ ·¤Ú·, ÂȉÈο ¤Ó˙˘Ì· ‚Ï¿‚˘ ÙÔ˘ Ë·ÙÔ΢ÙÙ¿ÚÔ˘ ηÈ, Ù¤ÏÔ˜ Ë ‚ÈÔ„›· ‹·ÙÔ˜ ‰ÂÓ Â›Ó·È Û˘Ó‹ıˆ˜ ‰È·ı¤ÛÈÌ· Î·È ¤ÙÛÈ ‰ÂÓ Â›Ó·È Â‡ÎÔÏÔ Ó· ÚÔÛ‰ÈÔÚÈÛı› Ë ˘ÔÙÚÔ‹. °ÂÓÈÎÒ˜, Ë ˘ÔÙÚÔ‹ ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ Â›Ó·È ˘„ËÏfiÙÂÚË Î·È ÌÂÈÒÓÂÙ·È ÛÙË Û˘Ó¤¯ÂÈ·. Δ· ÚÒÙ· 2 ¯ÚfiÓÈ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· 95% ÙˆÓ ˘ÔÙÚÔÒÓ ÛÙË ¯Ú‹ÛË ·ÏÎÔfiÏ23. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ, Ù· ·ÔÙÂϤÛÌ·Ù· ÌÂÙ·-·Ó·Ï‡ÛÂˆÓ ¤‰ÂÈÍ·Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· ¯Ú‹Û˘ ·ÏÎÔfiÏ Û ·ÏÎÔÔÏÈÎÔ‡˜ Î·È ÌË ·ÏÎÔÔÏÈÎÔ‡˜ ·ÛıÂÓ›˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ·ÚfiÌÔÈ· 4% Î·È 5% ÛÙÔ˘˜ 6 Ì‹Ó˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ Î·È 17% Î·È 16% ÛÙÔ˘˜ 12 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·. ™Ù· 7 ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 32% ÙˆÓ ·ÛıÂÓÒÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Î¿ÓÔ˘Ó ¯Ú‹ÛË ·ÏÎÔfiÏ. ∏ Û˘¯ÓfiÙËÙ· fï˜ ÙˆÓ ‚·Ú¤ˆÓ ÔÙÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË-Ë ˘ÔÙÚÔ‹ fï˜ Ù˘ ·ÏÎÔÔÏÈ΋˜ Ë·ÙÈ΋˜ ÓfiÛÔ˘ Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó‹ Î·È ÏÈÁfiÙÂÚÔ ÛÔ‚·Ú‹ ·fi ÙȘ ¿ÏϘ ˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÚˆÙÔ·ı›˜ ·ı‹ÛÂȘ ÙÔ˘ ‹·ÙÔ˜24.
∂È‚›ˆÛË - ¶ÔÈfiÙËÙ· ˙ˆ‹˜ ∏ ÚÒÈÌË ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÏÎÔÔÏÈ΋ Ë·ÙÈ΋ ÓfiÛÔ Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È ÂÍ·ÈÚÂÙÈ΋ Î·È Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË Ù˘ ˘Á›·˜ Â›Ó·È ÂÍ ›ÛÔ˘ ηϋ Ì ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ÌË ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË. OÚÈṲ̂Ó˜ ·fi ÙȘ ÂÈÏÔΤ˜ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó Û˘¯Ó¿ ÙËÓ ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË fiˆ˜ Ë spur cells ·Ó·ÈÌ›· (·Î·ÓıÔ·ÙÙ·Ú·) Î·È Ë ÔÏ˘Ó¢ÚÔ¿ıÂÈ· ˘Ô¯ˆÚÔ‡Ó ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ÂÓÒ ·ÓÙ›ıÂÙ· Ô ˘ÂÚÛÏËÓÈÛÌfi˜ ÌÔÚ› Ó· ÂÈ̤ÓÂÈ. ∂›Û˘ Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ ·˘ÙÔÁÓˆÛ›·˜ Â›Ó·È Èı·ÓfiÓ Ó· ‚ÂÏÙȈı› ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·Ó Î·È Ë ÏÂÈÙÔ˘ÚÁ›· Ù˘ ÌÓ‹Ì˘ Û˘Ó‹ıˆ˜ ‰ÂÓ ‚ÂÏÙÈÒÓÂÙ·È. ∂ÈϤÔÓ, ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Ë ÂÌÊ¿ÓÈÛË ÔÍ›·˜ Û˘Á¯˘ÙÈ΋˜ ηٿÛÙ·Û˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô˘ ‰È·ÚΛ ÙÚÂȘ Ë̤Ú˜. ∏ Ó¢ÚÔÏÔÁÈ΋ ·˘Ù‹ ÂΉ‹ÏˆÛË ÂÌÊ·Ó›˙ÂÙ·È Û˘¯ÓfiÙÂÚ· Û ·ÛıÂÓ›˜ Ì ÌÈÎÚfiÙÂÚÔ ¯ÚfiÓÔ ·Ô¯‹˜ ·fi ÙÔ ·ÏÎÔfiÏ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Û ·ÛıÂÓ›˜ Ì ˘„ËÏfiÙÂÚ· ›‰· ·Ì̈ӛ·˜ ·›Ì·ÙÔ˜ ηٿ ÙÔ ¯ÚfiÓÔ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. O Ì˯·ÓÈÛÌfi˜ ‰ÂÓ Â›Ó·È Û·Ê‹˜, Û˘Ó‹ıˆ˜ ˘Ô¯ˆÚ› Ì ˘ÔÛÙËÚÈÎÙÈ΋
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ıÂڷ›· ·ÏÏ¿ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÓÔÛËÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ. OÈ ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ÂÌÊ·Ó›˙Ô˘Ó Û ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È Û˘¯Ó¿ ··ÈÙÂ›Ù·È ¤Ó·ÚÍË ·ÁˆÁ‹˜ Ì ÈÓÛÔ˘Ï›ÓË ÛÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ê¿ÛË. ∂›Û˘ ·Ú·ÙËÚ‹ıËΠfiÙÈ ÂÌÊ·Ó›˙Ô˘Ó Û˘¯ÓfiÙÂÚ· ‚·ÎÙËÚȷΤ˜ ÏÔÈÌÒÍÂȘ 25. À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ fiÙÈ Ë Ì·ÎÚfi¯ÚÔÓË ·Ô¯‹ ·fi ÙÔ ·ÏÎÔfiÏ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ›Ûˆ˜ ‚ÂÏÙÈÒÓÂÈ ÙË Ì·ÎÚ¿ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. øÛÙfiÛÔ, Û‡Ìʈӷ Ì ٷ ‰Â‰Ô̤ӷ Ù˘ UNOS, Ë ·ÒÙÂÚË ÂÈ‚›ˆÛË Â›Ó·È Ùˆ¯fiÙÂÚË Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌË ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË, ÁÂÁÔÓfi˜ Ô˘ ÂÍËÁÂ›Ù·È ·fi ÙË ÛÔ‚·ÚfiÙËÙ· ÙˆÓ Û˘Ó˘¿Ú¯Ô˘ÛˆÓ ·ı‹ÛÂˆÓ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ηıÒ˜ Î·È ·fi ÙËÓ ·˘ÍË̤ÓË Â›ÙˆÛË ÙˆÓ ·ÒÙÂÚˆÓ ÂÈÏÔÎÒÓ fiˆ˜ fiÁÎÔÈ, ÏÔÈÌÒÍÂȘ Î·È ·ı‹ÛÂȘ ÙÔ˘ Á‹Ú·ÙÔ˜. ∏ ÔÈfiÙËÙ· ˙ˆ‹˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È Û˘ÓÈÛٷ̤ÓË ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÂËÚ¿˙o˘Ó ÙÔ ˘ÔÎÂÈÌÂÓÈÎfi ·›ÛıËÌ· ÙÔ˘ “Â›Ì·È Î·Ï¿”. ∞˘ÙÔ› ÔÈ ·Ú¿ÁÔÓÙ˜ Â›Ó·È Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË Ù˘ ˘Á›·˜, Ë ÎÔÈÓˆÓÈ΋ ¤ÓÙ·ÍË, Ë ÂÚÁ·Û›· Î·È ÔÈ ÚÔÛˆÈΤ˜ Û¯¤ÛÂȘ. °ÂÓÈÎÒ˜, Ë ÔÈfiÙËÙ· ˙ˆ‹˜ ·fi ÏÂ˘Ú¿˜ Ê˘ÛÈ΋˜ Î·È „˘¯ÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ¿ÏÏ· ·›ÙÈ· Ë·ÙÈ΋˜ ÓfiÛÔ˘. ∞ÓÙ›ıÂÙ·, Û ·ÛıÂÓ›˜ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ˘ÔÙÚÔ‹ ηٿ¯ÚËÛ˘ ·ÏÎÔfiÏ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Ë ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘˜ ˘ÔÏ›ÂÙ·È ·fi ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‰ÂÓ Â›¯·Ó ˘ÔÙÚÔ‹26. ™Ù· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ·, ‰ÂÓ ÂӉ›ÎÓ˘Ù·È Ë Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË ·fi ˘ÔÙÚÔ‹ ÛÙË ¯Ú‹ÛË ·ÏÎÔfiÏ ÌÂÙ¿ ÙË ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ·Ó Î·È ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û ¤Ó· ·ÛıÂÓ‹ Ì ηϿ ·ÔÙÂϤÛÌ·Ù·27.
μÈ‚ÏÈÔÁÚ·Ê›· 1. McCullough A. Alcoholic liver disease In: Schiff E.R.; Sorrell M.F.; and Maddrrey W.C. eds. Schiff’s Diseases of the liver, 8th ed. Philadelphia: Lippincott Williams & Wilkins 1999:941-971 2. Starzl TE, Van Thiel D, Tzakis AG: Orthotopic liver transplantation for alcoholic cirrhosis. JAMA: Journal of the American Medical Association 1988;260:25422544 3. Zetterman R.K Liver Transplantation for Alcoholic Liver disease Clinics of Liver Disease 2005;9:171-181,
4. Lucey MR. Liver Transplantation in the alcoholic patient In:Maddrey WC, Sorrell M, Schiff E. Editors. Transplantation of the liver, 3nd ed Lippincott: Williams and Wilkins; 2001:319-326 5. Tome S., Lucey M.R. Timing of liver transplantation in alcoholic cirrhosis. J Hepatology 2003;39:302-307 6. Vaillant G.E.The natural history of alcoholism and its relationship to liver transplantation Liver Transpl Surg 1997;3:304-310. 7. Veldt BJ, Laine F, Guillygomarc’h A, et al. Indication for liver transplantation in severe alcoholic cirrhosis: quantitative evaluation and optimal timing. J Hepatology 2002;36:93-98. 8. Lucey MR. Editorial. Is liver transplantation an appropriate treatment for acute alcoholic hepatitis? J Hepatology 2002;36: 829-831 9. Dunn W, Jamil LH, Brown LS: MELD accurately predicts mortality in patients with alcoholic hepatitis. Hepatology 2005;41(2):353-8 10. Poynard T, Barthelemy P, Fratte S, et al. Evaluation of efficacy of liver transplantation in alcoholic cirrhosis by a case-control study and simulated controls. Lancet 1994;344(8921):502-507 11. Poynard T, Naveau S, Doffoel M, et al. Evaluation of efficacy of liver transplantation in alcoholic cirrhosis using matched and simulated controls:5-year survival. Multi-centre group. J Hepatology 1999;30(6): 11301137 12. Forman LM, Lucey MR: Predicting the prognosis of chronic liver disease: An evolution from Child to MELD Hepatology 2001;33(2):473-475 13. Wiesner R, Edwards E, Freeman R: Model for EndStage liver Disease (MELD) and Allocation of Donor Livers Gastroenterology 2003;124:91-96 14. Srikureja W: MELD score is a better prognostic model than Child-Turcotte-Pugh score or Discriminant Function score in patients with alcoholic hepatitis J Hepatology 2005;42:700-706. 15. Dunn W, Jamil LH, Brown LS: MELD accurately predicts mortality in patients with alcoholic hepatitis. Hepatology 2005;41(2):353-358 16. Keeffe EB. Comorbidities of alcoholic liver disease that affect outcome of orthotopic liver transplantation. Liver Transplantation aand Surgery 1997;3:251-257 17. Neuberger J, Schulz KH, Day C, et al Transplantation for alcoholic liver disease. J Hepatology 2002;36:130137 18. Kenngott S. Rapid development of esophageal squamous cell carcinoma after Lot for alcohol induced cirrhosis Transpl Int 2003;16:639-641 19. Beresford TP, Wilson D, Blow F.C, et al The shortterm psychological health of alcoholic and nonalcoholic liver traansplant recipients. Alcoholism: Clinical and Experimental Research 1992;16:996-1000 20. Yates W.R, Martin M, Labrecque D, et al A model to
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
examine the validity of the 6-month abstinence criterion for liver transplantation. Alcoholism:Clinical and Experimental Research 1998;22:513-517 21. Fuller RK, Difinition and diagnosis of relapse to drinking. Liver Transplantation and Surgery1997; 3:258-262 22. Beresford T.P. Overt and covert alcoholism. In: Lucey, M.R., Merion R.M., and Beresford T.P.;eds. Liver Transplantation and the Alcoholic Patient: Medical, Surgical and Psychosocial Issues. Cambridge, United Kingdom: Cambridge University Press 1994: pp.6-28 23. Platz K, Mueller AR, Spree E et al; Liver transplantation for alcoholic cirrhosis. Transplantation International 2000;13:127-130
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24. Burra P, Lucey M. Liver transplantation in alcoholic patients. Transplant International 2005;18:491-498 25. Farges O, Saliba F, Farhamant H, et al Incidence of rejection and infection after liver transplantation as a function of primary disease: possible influence of alcohol and polyclonal immunoglobulins. Hepatology 1996; 23:240-248. 26. Pereira SP,Howard LM, Muiesan P et al. Quality of life after liver transplantation for alcoholic liver disease. Liver Transplantation 2000;6:762-768 27. Bernard PH, Le Baill B, Carles J. Liver retransplantation for alcoholic cirrhosis reccuring within a 21month period. Transplantation International 1996; 9; 5: 524
IÔÁÂÓ›˜ Ë·Ù›Ùȉ˜: YÔÙÚÔ‹ ÛÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì·
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Iˆ¿ÓÓ˘ °Ô˘Ï‹˜
(HBV) ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋ ÓfiÛÔ˜ ·ÔÙÂÏÔ‡Û ÁÈ· ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ‰ÈfiÙÈ Û¯ÂÙÈ˙fiÙ·Ó Ì ··ÁÔÚ¢ÙÈο ÔÛÔÛÙ¿ ˘ÔÙÚÔ‹˜ ÛÙÔ ÌfiÛ¯Â˘Ì· (80-100%), Ù·¯‡Ù·ÙË ÂͤÏÈÍË Û ΛÚÚˆÛË Î·È ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ Ô˘ Û¿ÓÈ· ÍÂÂÚÓÔ‡Û·Ó ÙÔ 40%-50% ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ (1). ∏ ÂÊ·ÚÌÔÁ‹ Ù˘ ·ıËÙÈ΋˜ ·ÓÔÛÔÔ›ËÛ˘ (HBIG) ·ÔÙ¤ÏÂÛ ÙËÓ ÚÒÙË ÛËÌ·ÓÙÈ΋ ÚÔÛ¿ıÂÈ· Ô˘ Ì›ˆÛ ٷ ÔÛÔÛÙ¿ ˘ÔÙÚÔ‹˜ Î·È ·‡ÍËÛ ÙËÓ ÂÈ‚›ˆÛË ÛÙÔ 63% ÛÙËÓ 3ÂÙ›· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (1). °Ú‹ÁÔÚ· ¤ÁÈÓ ·ÓÙÈÏËÙfi fiÙÈ Ù· ÂÏȉÔÊfiÚ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÓÔÛÔÔ›ËÛ˘ ÌÂÈÒÓÔÓÙ·Ó ·fi ÙËÓ ‡·ÚÍË ÂÓÂÚÁÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (1,2,3). ∂ÙÛÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ù· ›‰· ÙÔ˘ HBV DNA Â›Ó·È <105 copies/ml, Ë ¯ÔÚ‹ÁËÛË HBIG ÂÓ‰ÔÊÏ‚›ˆ˜ Ì›ˆÛ ÙÔ ÔÛÔÛÙfi ·Ó·ÌfiÏ˘ÓÛ˘ Û 15% ÙÔÓ 1Ô ¯ÚfiÓÔ, 24% ÛÙ· 5 ¯ÚfiÓÈ· Î·È 25% ÛÙ· 10¯ÚfiÓÈ·. ∞ÓÙ›ıÂÙ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘„ËÏ¿ ›‰· HBV-DNA ÛÙÔÓ ÔÚfi ÙÔ ÔÛÔÛÙfi ·Ó·ÌfiÏ˘ÓÛ˘ ·ÓÂÚ¯fiÙ·Ó ÛÙÔ 89% ÛÙ· 10 ¯ÚfiÓÈ· (4). ∏ ·Ó¿Ù˘ÍË ÌÂÙ·ÏÏ·ÁÒÓ ÛÙÔ ÁÔÓ›‰ÈÔ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÈÊ·Ó›·˜ (HBsAg) ÙÔ˘ ÈÔ‡ ‹Ù·Ó Ë ‰Â‡ÙÂÚË ·ÈÙ›· ·ÛÙÔ¯›·˜ Ù˘ ·Ú¤Ì‚·Û˘ Ì ·ÓÔÛÔÚÔʇϷÍË (3). ∏ ¤Ï¢ÛË Ù˘ Ï·ÌÈ‚Ô˘‰›Ó˘ ·fi Ù· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ã90 ·ÏÏ¿ Î·È ·ÚÁfiÙÂÚ· Ù˘ ‰ÈÈ‚·ÏÈ΋˜ ·‰ÂÊÔ‚›Ú˘ ¿ÏÏ·Í ÚÈ˙Èο Ù· ‰Â‰Ô̤ӷ. ∏ Ï·ÌÈ‚Ô˘‰›ÓË Â›Ó·È ÓÔ˘ÎÏÂÔÛȉÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÂÈÒÓÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘ ÈÔ‡ ‰ÚÒÓÙ·˜ ÛÙËÓ ·Ó¿ÛÙÚÔÊË ÌÂÙ·ÁÚ·Ê¿ÛË Ù˘ ÔÏ˘ÌÂÚ¿Û˘ ÙÔ˘ ÈÔ‡. ∏ Ï·ÌÈ‚Ô˘‰›ÓË Â›Ó·È ¿ÚÈÛÙ· ·ÓÂÎÙ‹ Î·È ÌÔÚ› Ó· ¯ÔÚËÁËı› Û ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Ô˘ ·ÔÙÂÏÔ‡Ó Î·È ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ˘Ô„ËÊ›ˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓÒÓ. ∏ Ï·ÌÈ‚Ô˘‰›ÓË Û ËÌÂÚ‹ÛÈ· ‰fiÛË 100mg ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ÂÈʤÚÂÈ Ù·¯Â›· Î·È ‰Ú·ÛÙÈ΋ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘ HBV DNA, ¤-
∏ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÔÊÂÈÏfiÌÂÓË Û ¯ÚfiÓÈ· ÈÔÁÂÓ‹ Ë·Ù›Ùȉ· ·ÔÙÂÏ› ·ÁÎÔÛÌ›ˆ˜ ÙÔ Û˘¯ÓfiÙÂÚÔ ·›ÙÈÔ ÁÈ· ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜. ∏ ‚ÂÏÙ›ˆÛË ÛÙȘ ¯ÂÈÚÔ˘ÚÁÈΤ˜ Ù¯ÓÈΤ˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô ÛÙË Ê·Ú̷΢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·fiÚÚȄ˘ Ì ÈÛ¯˘Ú¿ Î·È ·ÛʷϤÛÙÂÚ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ·‡ÍËÛ·Ó ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂ›˙ÔÓ Úfi‚ÏËÌ· fï˜ ·Ú·Ì¤ÓÂÈ Ë ÚfiÏË„Ë Î·È Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ó·ÌfiÏ˘ÓÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÙÔ˘˜ Ë·ÙÔÙÚfiÔ˘˜ ÈÔ‡˜. OÈ ıÂڷ¢ÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜ Ô˘ Û‹ÌÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÊÂÓfi˜ ÙˆÓ ˘„ËÏÒÓ ÂȤ‰ˆÓ È·ÈÌ›·˜ ÚÈÓ ‹ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ·ÊÂÙ¤ÚÔ˘ Ì ÙËÓ ˘ÔÙÚÔ‹ ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È ‰È·ÎÚ›ÓÔÓÙ·È ˆ˜ ÂÍ‹˜: ∞) ∏ ÚÔ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÓÙÈÌÂÙÒÈÛË Ô˘ ¤¯ÂÈ ˆ˜ ·ÚÈÔ ÛÙfi¯Ô ÙËÓ Î·Ù·ÛÙÔÏ‹ ‹ ·ÎfiÌ· Î·È ÙËÓ ÂÍ¿ÏÂÈ„Ë ÙÔ˘ ÈÔ‡ ÚÈÓ ·fi ÙÔ ¯ÂÈÚÔ˘ÚÁ›Ô. μ) ∏ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ıÂڷ›·: ™ÙËÓ Ë·Ù›Ùȉ· B (HBV) Ë ıÂڷ›· ¯ÔÚËÁÂ›Ù·È ¿ÌÂÛ· Î·È ¤’ ·fiÚÈÛÙÔÓ Ì ÛÎÔfi Ó· ·ÔÙڷ› Ë Â·ÓÂÌÊ¿ÓÈÛË ÙÔ˘ ÈÔ‡. ™ÙȘ ÂÚÈÙÒÛÂȘ Ì Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ C (HCV) fiÔ˘ Ë Â·ÓÂÌÊ¿ÓÈÛË ÙÔ˘ ÈÔ‡ Â›Ó·È Û¯Â‰fiÓ Î·ıÔÏÈ΋, Ë ÚÒÈÌË, ÂÓÙfi˜ ÙˆÓ ÚÒÙˆÓ Â‚‰ÔÌ¿‰ˆÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ¯ÔÚ‹ÁËÛË ·ÓÙÈÈ΋˜ ·ÁˆÁ‹˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÂÈÒÛÔ˘Ì ٷ ›‰· Ù˘ È·ÈÌ›·˜ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ı· ÂÌÊ·Ó›ÛÂÈ ‚ÈÔ¯ËÌÈο Î·È ÈÛÙÔÏÔÁÈο ¯ÚfiÓÈ· Ë·Ù›Ùȉ· Î·È Î›ÚÚˆÛË. °) ∏ ıÂڷ›· ÌÂÙ¿ ·fi ÙÂÎÌËÚȈ̤ÓË ÈÛÙÔÏÔÁÈο ˘ÔÙÚÔ‹ Ù˘ Ë·Ù›Ùȉ·˜ Ì ·ÚÈÔ ÛÙfi¯Ô ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘.
∏·Ù›Ùȉ· μ ∏ ÚÔηÏÔ‡ÌÂÓË ·fi ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ μ
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙÛÈ ÒÛÙ ÛÙÔ 60-100% ÙˆÓ ·ÛıÂÓÒÓ Ó· ÌËÓ ·ÓȯÓ‡ÂÙ·È HBV DNA ÙÔ˘˜ ÚÒÙÔ˘˜ 2-3 Ì‹Ó˜ Ù˘ ıÂڷ›·˜ (5). ™Ô‚·Úfi ÌÂÈÔÓ¤ÎÙËÌ· ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Â›Ó·È Ë ·Ó¿Ù˘ÍË Ê·ÈÓÔ̤ÓÔ˘ ÈÈ΋˜ ‰È·Ê˘Á‹˜ Ô˘ ÔÊ›ÏÂÙ·È Û ÌÂÙ·ÏÏ·Á¤˜ ÙÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ÈÈ΋˜ ÔÏ˘ÌÂÚ¿Û˘. ∏ ·Ó¿Ù˘ÍË ÌÂÙ·ÏÏ·ÁÌ¤ÓˆÓ ·ÓıÂÎÙÈÎÒÓ ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË ÛÙÂϯÒÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‰È¿ÚÎÂÈ· ıÂڷ›·˜ Î·È ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ 15-20% ÁÈ· οı ¯ÚfiÓÔ ıÂڷ›·˜ (6-9). ¶ÔÏϤ˜ ÌÂϤÙ˜ ·Ó¤‰ÂÈÍ·Ó ÙË ‚ÂÏÙ›ˆÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÙË ¯ÔÚ‹ÁËÛË Ï·ÌÈ‚Ô˘‰›Ó˘ ÏfiÁˆ Ù˘ ÛËÌ·ÓÙÈ΋˜ ηٷÛÙÔÏ‹˜ ÙÔ˘ ÈÈÎÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡(6,7). ™˘Ó‹ıˆ˜ Ë ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË ·Ú·ÙËÚÂ›Ù·È 6 Ì‹Ó˜ ÂÚ›Ô˘ ÌÂÙ¿ ÙËÓ ÈÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË Î·È ¤ÙÛÈ ·ÛıÂÓ›˜ Ì ȉȷ›ÙÂÚ· ÛÔ‚·Ú‹ ·Ó¿ÚÎÂÈ· Èı·ÓfiÓ Ó· ÌËÓ ÚÔÏ¿‚Ô˘Ó Ó· ˆÊÂÏËıÔ‡Ó ·Ú¿ ÙËÓ ÈÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ Ê¿ÓËΠfiÙÈ Ë ·Ó¿Ù˘ÍË ÈÈ΋˜ ‰È·Ê˘Á‹˜ Û ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ Ì ÚÔ¯ˆÚË̤ÓË ÓfiÛÔ Û˘Óԉ‡ÂÙ·È ·fi Âȉ›ӈÛË Ù˘ ÓfiÛÔ˘, ÛÔ‚·Ú‹ ·ÔÚÚ‡ıÌÈÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ı¿Ó·ÙÔ. ∏ ‰ÈÈ‚·ÏÈ΋ ·‰ÂÊÔ‚›ÚË ¤Ó· ÓÔ˘ÎÏÂÔÙȉÈÎfi ·Ó¿ÏÔÁÔ Ù˘ ÌÔÓÔʈÛÊÔÚÈ΋˜ ·‰ÂÓÔÛ›Ó˘ ·ÔÙ¤ÏÂÛ ÙÔ ‰Â‡ÙÂÚÔ Ê¿ÚÌ·ÎÔ ¯ÚÔÓÔÏÔÁÈο ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ μ Ô˘ ¯ÔÚËÁÂ›Ù·È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ΔÔ Ê¿ÚÌ·ÎÔ Â›Ó·È ‰Ú·ÛÙÈÎfi ¤Ó·ÓÙÈ ÙÔ˘ Ê˘ÛÈÎÔ‡, ÙÔ˘ ÚÔ˘ÚËÓÈο ÌÂÙ·ÏÏ·Á̤ÓÔ˘ ·ÏÏ¿ Î·È ÙˆÓ ·ÓıÂÎÙÈÎÒÓ ÛÙË Ï·ÌÈ‚Ô˘ÓÙ›ÓË ÛÙÂϯÒÓ. ∂ÌÊ·Ó›˙ÂÈ ÂÍ·ÈÚÂÙÈ΋ ·ÓÔ¯‹ Î·È ·ÛÊ¿ÏÂÈ· Î·È ÙÔ ÏÂÔÓ¤ÎÙËÌ· Ó· ÂÌÊ·Ó›˙ÂÈ Û ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ·Ó¿Ù˘ÍË ÌÂÙ·ÏÏ·ÁÌ¤ÓˆÓ ÛÙÂϯÒÓ. ∞ÓıÂÎÙÈο ÛÙÂϤ¯Ë ·Ó¢ڛÛÎÔÓÙ·È ÛÙÔ 2% ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi 2 ¯ÚfiÓÈ· Î·È ÛÙÔ 18% ÌÂÙ¿ ·fi 4 ¯ÚfiÓÈ· (3). ™Â ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Ô˘ Û˘ÌÂÚȤϷ‚ 128 ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË HBV ΛÚÚˆÛË Î·È Ì ·ÓıÂÎÙÈο ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË ÛÙÂϤ¯Ë ¯ÚËÛÈÌÔÔÈ‹ıËΠ·‰ÂÊÔ‚›ÚË Û ‰fiÛË 10mg/ËÌÂÚËÛ›ˆ˜ ÁÈ· ÂӉȿÌÂÛÔ ¯ÚfiÓÔ 19 ‚‰ÔÌ¿‰Â˜. ∏ ÂӉȿÌÂÛË Ì›ˆÛË HBV DNA ·Ó‹Ïı ÛÙ· 4.1 log ·ÓÙ›ÁÚ·Ê·/ml ÙËÓ 48 ‚‰ÔÌ¿‰· ıÂڷ›·˜ Ì ÙÔ 81% ÙˆÓ ·ÛıÂÓÒÓ Ó· ¤¯ÂÈ ÌË ·ÓȯÓ‡ÛÈÌÔ HBV-DNA ÛÙÔÓ fiÚÔ Ì PCR (10). ∏ ÂÈ‚›ˆÛË ÛÙÔ ¤ÙÔ˜ ·Ó‹Ïı ÛÙÔ 84%, ÔÛÔÛÙfi ·ÚfiÌÔÈÔ ÌÂ ÙˆÓ ÈÛÙÔÚÈÎÒÓ Ì·ÚÙ‡ÚˆÓ. ∂ÙÛÈ ÌÂÙ¿ ·fi ·Ó¿Ù˘ÍË ·ÓıÂÎÙÈÎfiÙËÙ·˜ ÛÙËÓ Ï·ÌÈ‚Ô˘‰›ÓË Û˘ÛÙ‹ÓÂÙ·È Ë ¤Ó·ÚÍË ıÂڷ›·˜ Ì ‰ÈÈ‚·ÏÈ΋ ·‰ÂÊÔ‚›ÚË. §·Ì‚¿ÓÔÓÙ·˜ fï˜ ˘fi„Ë ÙȘ ÔϤıÚȘ Û˘Ó¤ÂȘ Ù˘ ÈÈ΋˜ ‰È·-
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Ê˘Á‹˜ Û ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË ÓfiÛÔ Î·È ÙÔ fiÙÈ Ù· ‰‡Ô Ê¿Ú̷η ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó ‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÓÙÔ¯‹ ÎÚ›ÓÂÙ·È ÛÎfiÈÌÔ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‰‡Ô Ê·ÚÌ¿ÎˆÓ ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Ì ÚÔ¯ˆÚË̤ÓË ÓfiÛÔ (3). ªÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ë ÌÔÓÔıÂڷ›· Ì ϷÌÈ‚Ô˘‰›ÓË ‰ÂÓ Ê¿ÓËΠӷ ·ÔÙÂÏ› ÈηÓÔÔÈËÙÈ΋ ÚÔÛ¤ÁÁÈÛË. ™ÙËÓ ÌÂϤÙË ÙˆÓ Perillo Î·È Û˘Ó. ÙÔ ÔÛÔÛÙfi ·Ó·ÌfiÏ˘ÓÛ˘ ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ ·Ó‹Ïı ÛÙÔ 40%. °È· ÙËÓ ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ˘„ËÏ¿ ›‰· HBV DNA (>10pg/ ml) Ù· ÔÛÔÛÙ¿ ·Ó·ÌfiÏ˘ÓÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÍÂÂÚÓÔ‡Û·Ó ÙÔ 80% (6). ÕÏϘ ÌÂϤÙ˜ ·Ó¤‰ÂÈÍ·Ó ·ÚfiÌÔÈ· ÔÛÔÛÙ¿ Ô˘ Û˘Óԉ‡ÔÓÙ·Ó Î·È ·fi ÛÔ‚·Ú‹ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ (9,11). ΔÂÏÈο ‚Ú¤ıËÎÂ Ë ¯Ú˘Û‹ ÙÔÌ‹, fiÙ·Ó ·Ô‰Â›¯ıËΠfiÙÈ Û˘Ó‰˘¿˙ÔÓÙ·˜ Ï·ÌÈ‚Ô˘‰›ÓË Ì HBIG >500 mIU/ml Ù· ÔÛÔÛÙ¿ ·Ó·ÌfiÏ˘ÓÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂÈÒıËÎ·Ó ÛÙÔ 10% ÛÙËÓ 2ÂÙ›· (4,12). ∞ÏÏ¿ Î·È ¯·ÌËÏfiÙÂÚ· ›‰· HBIG (>100 mIU/ml) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ϷÌÈ‚Ô˘‰›ÓË ¤‰ˆÛ·Ó ·ÓÙ›ÛÙÔȯ· ηϿ ·ÔÙÂϤÛÌ·Ù· (13,14). Œˆ˜ Û‹ÌÂÚ· ÙÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi ·Ô‰›‰ÂÙ·È ÛÙËÓ Èı·Ó‹ Û˘ÓÂÚÁÈ΋ ‰Ú¿ÛË Ù˘ ıÂڷ›·˜ Û ‰È·ÊÔÚÂÙÈο ÛËÌ›· Ô˘ ·ÔÙÚ¤ÂÈ ÙËÓ ÌÂÙ·ÏÏ·Á‹ ÙÔ˘ ÈÔ‡. §fiÁˆ ÙÔ˘ ȉȷ›ÙÂÚ· ˘„ËÏÔ‡ ÎfiÛÙÔ˘˜ Ù˘ Ì·ÎÚfi¯ÚÔÓ˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÂÓ‰ÔÊÏ‚›ˆ˜ (180.000$ ÂÙËÛ›ˆ˜) ¤¯Ô˘Ó ÚÔÙ·ı› ÂÓ·ÏÏ·ÎÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ fiˆ˜: ·) Ë ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË ·ÓÔÛÔÛÊ·ÈÚ›Ó˘, ‚) Ë ÌÔÓÔıÂڷ›· Ì ϷÌÈ‚Ô˘‰›ÓË Î·È Á) Ô ÂÌ‚ÔÏÈ·ÛÌfi˜(15). ∏ ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ϷÌÈ‚Ô˘‰›ÓË ÚÈÓ ·ÏÏ¿ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙËÚ›¯ıËΠ۠·Ú·ÙËÚ‹ÛÂȘ Ê·ÚÌ·ÎÔÎÈÓËÙÈÎÒÓ ÌÂÏÂÙÒÓ Ô˘ ·Ó¤‰ÂÈÍ·Ó ÈηÓÔÔÈËÙÈÎÔ‡˜ Ù›ÙÏÔ˘˜ anti-HBs ÛÙÔÓ ÔÚfi (>100IU/L) ÌÂÙ¿ ·fi ÂÓ‰ÔÌ˘˚΋ ¯ÔÚ‹ÁËÛË 1000IU HBIG(16). ∫ÏÈÓÈΤ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó ÔÛÔÛÙfi ·Ó·ÌfiÏ˘ÓÛ˘ 4%-10% ÌÂÙ¿ ·fi 15 -23 Ì‹Ó˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ (17,18). OÈ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ‰fiÛÂȘ ‹Ù·Ó ·fi 400 ¤ˆ˜ 2000IU ·Ó¿ÏÔÁ· Ì ÙÔ ÚˆÙfiÎÔÏÏÔ Î·È ¯ÔÚËÁÔ‡Ù·Ó ·Ó¿ ¤Ó· ‹ ‰‡Ô Ì‹Ó˜. ∏ ÂÓ‰ÔÌ˘È΋ ¯ÔÚ‹ÁËÛË Èı·ÓfiÓ Ó· Â›Ó·È Ë Î·Ï‡ÙÂÚË ÚÔÛ¤ÁÁÈÛË Ì ‚¿ÛË ÙË Û¯¤ÛË ÎfiÛÙÔ˘˜/·ÔÙÂϤÛÌ·ÙÔ˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ¯·ÌËÏ¿ ›‰· È·ÈÌ›·˜ ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó·ÌfiÏ˘ÓÛË ¤¯ÂÈ ‰ÔÎÈÌ·Ûı› Ì ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù· Ë ‰È·ÎÔ‹ Ù˘ Û˘Ó-
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I. °OY§H™
‰˘·Ṳ̂Ó˘ ıÂڷ›·˜ Î·È Ë Û˘Ó¤¯ÈÛË Ì ÌÔÓÔıÂڷ›· Ï·ÌÈ‚Ô˘‰›Ó˘ (5,19). ¢È·ÙËÚÔ‡ÓÙ·È fï˜ ÂÈÊ˘Ï¿ÍÂȘ ÏfiÁˆ ÙÔ˘ ÌÈÎÚÔ‡ ¯ÚfiÓÔ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ (18 Ì‹Ó˜). Δ¤ÏÔ˜ Ù· ÚÔÁÚ¿ÌÌ·Ù· ÂÌ‚ÔÏÈ·ÛÌÒÓ ÚÔÙ›ÓÔ˘Ó ÙË ¯Ú‹ÛË ÂÌ‚ÔÏ›ˆÓ Û ˘„ËÏfiÙÂÚ˜ ‰fiÛÂȘ (·fi 40-100Ìg/‰fiÛË) ÚÈÓ ‹ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ÙÔ˘ HBIG ÛÂ Û˘Ó‰˘·ÛÌfi fï˜ Ì ÙË Ì›ˆÛË ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ‰ÈfiÙÈ Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ˘„ËϤ˜ ‰fiÛÂȘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ÂÌÔ‰›˙ÂÈ ÙËÓ ·Ó¿Ù˘ÍË ˘„ËÏÒÓ Ù›ÙÏˆÓ ·ÓÙ›-HBs (20). ¢È¯ÔÁӈ̛· ˘¿Ú¯ÂÈ Û¯ÂÙÈο Ì ٷ ›‰· ÙˆÓ ÚÔÛٷ٢ÙÈÎÒÓ ÁÈ· ·Ó·ÌfiÏ˘ÓÛË Ù›ÙÏˆÓ (1,2,21). OÈ Bienzle Î·È Û˘Ó. ·Ó·Ê¤ÚÔ˘Ó ÔÛÔÛÙ¿ ÔÚÔÌÂÙ·ÙÚÔ‹˜ 80% ÁÈ· ›‰· anti HBs> 10 IU/L Ô˘ ‰È·ÙËÚ‹ıËÎ·Ó ¤ˆ˜ ÙÔ˘˜ 14Ì‹Ó˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ (21). ™Â ¿ÏϘ fï˜ ·Ó·ÊÔÚ¤˜ (22) Ù· ÔÛÔÛÙ¿ ÔÚÔÌÂÙ·ÙÚÔ‹˜ Â›Ó·È ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ· Î·È ‰ÂÓ ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 20% ÁÈ· ÂÈı˘ÌËÙ¿ ›‰· ·ÓÙ›-HBs >100IU/L. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ·ÛıÂÓÒÓ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ∏BV Ïԛ̈ÍË Ô˘ Â›Ó·È ˘Ô„‹ÊÈÔÈ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ú¤ÂÈ Ó· ÂÛÙÈ¿˙ÂÙ·È ÛÙÔÓ ÈÈÎfi ÔÏÏ·Ï·ÛÈ·ÛÌfi. OÈ Û˘ÛÙ¿ÛÂȘ ‰È·Ê¤ÚÔ˘Ó ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘„ËÏ¿ ›‰· HBV DNA ÛÙÔÓ ÔÚfi (>105 ·ÓÙ›ÁÚ/ml) ·fi ÂΛÓÔ˘˜ Ì ¯·ÌËÏfiÙÂÚ· ›‰·. OÈ ·ÛıÂÓ›˜ Ì ¯·ÌËÏ¿ ›‰· ‰ÂÓ ¯ÚÂÈ¿˙ÔÓÙ·È ·ÓÙÈÈ΋ ıÂڷ›· ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ·ÓÙÈÈ΋ ıÂڷ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ó· Û˘Ó¯›˙ÂÙ·È Â’ ·fiÚÈÛÙÔÓ. ∂›Û˘ ÂÈ‚¿ÏÏÂÙ·È Ó· Ï·Ì‚¿ÓÔ˘Ó 10.000 HBIG ÂÓ‰ÔÊÏ‚›ˆ˜ ηٿ ÙËÓ ·ÓË·ÙÈ΋ Ê¿ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, 10.000U HBIG ÂÓ‰ÔÊÏ‚›ˆ˜ ËÌÂÚËÛ›ˆ˜ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÛÙË Û˘Ó¤¯ÂÈ· οı 4-8 ‚‰ÔÌ¿‰Â˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÙËÚ‹ÛÔ˘Ó antiHBs Ù›ÙÏÔ˘˜ >100-150 IU/L. H ˘ÔÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ¯·ÌËÏ¿ ›‰· HBV DNA ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Î·Ù¿ÏÏËÏË, ÏfiÁˆ ÙÔ˘ Û¯ÂÙÈο ÌÈÎÚÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ˘ÔÙÚÔ‹ Ù˘ Ïԛ̈͢, Ó· ÌÂÏÂÙËı› Ì ÂÓ·ÏÏ·ÎÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ, fiˆ˜ ÂÌ‚ÔÏÈ·ÛÌfi Ì ·ÓÙÈÈο ‹ ÂÚÈÔÚÈṲ̂Ó˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÂÊfiÛÔÓ ÔÈ ·ÛıÂÓ›˜ ·Ú·Ì¤ÓÔ˘Ó ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÌË ·ÓȯÓ‡ÛÈÌÔ HBV DNA Ì ̤ıÔ‰Ô PCR. °È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘„ËÏ¿ ›‰· HBV DNA ÛÙÔÓ ÔÚfi ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô ‚·ÛÈÎfi˜ ÛÙfi¯Ô˜ Â›Ó·È Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ÈÈÎÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ Ì ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈÈ΋˜ ·ÁˆÁ‹˜. ∏ ‚·Ú‡ÙËÙ· Ù˘ Ë·ÙÈ΋˜ ·ÓÂ-
¿ÚÎÂÈ·˜ ·ÔÙÂÏ› ·ÚÈÔ ÎÚÈÙ‹ÚÈÔ ÚÔÙÂÚ·ÈfiÙËÙ·˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ÂÚÈÙÒÛÂȘ ·Ó¿Ù˘Í˘ ÈÈ΋˜ ·ÓÙÔ¯‹˜ ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ‰ÈÈ‚·ÏÈ΋ ·‰ÂÊÔ‚›ÚË, ÂÓÙÂη‚›ÚË ‹ ÙÂÓÔÊÔ‚›ÚË. ªÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔ˘Ó 10000πU HBIG ηıËÌÂÚÈÓ¿ ÙËÓ 1Ë Â‚‰ÔÌ¿‰· Î·È ·ÎÔÏÔ‡ıˆ˜ οı 4-8 ‚‰ÔÌ¿‰Â˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÙËÚËıÔ‡Ó Ù· ›‰· anti-HBs > 500 IU/L ÙÔÓ 1Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì‹Ó· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, > 250 IU/L ̤¯ÚÈ ÙÔÓ 3Ô Ì‹Ó· Î·È ·ÎÔÏÔ‡ıˆ˜ > 100-150UI/L. ∏ ·ÓÙÈÈ΋ ·ÁˆÁ‹ Ú¤ÂÈ Ó· Û˘Ó¯›˙ÂÙ·È Âã·fiÚÈÛÙÔÓ. ¢È·ÎÔ‹ Ù˘ ·ÓÔÛÔÚÔʇϷ͢ ‰ÂÓ Ú¤ÂÈ Ó· ÂȯÂÈÚÂ›Ù·È ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ·ÛıÂÓÒÓ Ì ¤ÓÙÔÓÔ ÈÈÎfi ÔÏÏ·Ï·ÛÈ·ÛÌfi ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ŸÏÔÈ ÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ÏfiÁˆ HBV ΛÚÚˆÛ˘ ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È Î¿ı 3 Ì‹Ó˜ ÁÈ· ¿ÓÔ‰Ô ÙÔ˘ HBsAg Î·È HBV DNA Ì ÌÂıfi‰Ô˘˜ PCR, ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÁÓˆÛı› ¤ÁηÈÚ· Ë ·Ó·ÌfiÏ˘ÓÛË ‹ Ë ·Ó¿Ù˘ÍË ÌÂÙ·ÏÏ·ÁÌ¤ÓˆÓ ÛÙÂϯÒÓ Î·È ÈÈ΋˜ ‰È·Ê˘Á‹˜.
¢È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔÙÚÔ‹˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ∏ ıÂڷ›· ·ÛıÂÓÒÓ Ì ·Ó·ÌfiÏ˘ÓÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙÔÓ HBV ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ¤Ó· ÏÈÁfiÙÂÚÔ ÛÔ‚·Úfi Úfi‚ÏËÌ· Û‹ÌÂÚ· ·fi fiÙÈ ÚÈÓ ·fi Ï›Á· ¯ÚfiÓÈ· ÏfiÁˆ Ù˘ ‰È·ıÂÛÈÌfiÙËÙ·˜ ÙˆÓ ÓÔ˘ÎÏÂÔÛ(Ù)ȉÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. OÈ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ·ÔÙÂÏÔ‡Ó ÌÈ· ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰·, ·ÊÔ‡ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·ÛıÂÓ›˜ Ì 1. ˘ÔÙÚÔ‹ ÏfiÁˆ ÏËÌÂÏÏÔ‡˜ ÚÔʇϷ͢, 2. ˘ÔÙÚÔ‹ ÏfiÁˆ ·ÔÙ˘¯›·˜ Ù˘ ÚÔʇϷ͢ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È 3. de novo Ïԛ̈ÍË. ∏ ÂÈÏÔÁ‹ Ù˘ ηٿÏÏËÏ˘ ıÂڷ›·˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Â›‰Ô˜ Ù˘ ÚÔËÁÔ‡ÌÂÓ˘ ıÂڷ›·˜ Î·È Ô Î‡ÚÈÔ˜ ÛÙfi¯Ô˜ Â›Ó·È Ë ·Ó·ÛÙÔÏ‹ Ù˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘. ∏ ‰È¿ÁÓˆÛË Ù˘ ˘ÔÙÚÔ‹˜ Á›ÓÂÙ·È fiÙ·Ó Â·ÓÂÌÊ·Ó›˙ÂÙ·È ÙÔ ·ÓÙÈÁfiÓÔ ÂÈÊ·Ó›·˜ (HBsAg) ÛÙÔÓ ÔÚfi, Î·È ·ÓȯÓ‡ÂÙ·È HBV-DNA ÛÙÔÓ ÔÚfi Ì PCR. Δ· ÈÛÙÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÛÙÔ ‹·Ú ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ÔÌÔÈ¿˙Ô˘Ó Ì ÂΛӷ ÙˆÓ ÌË ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ Ì ˷ٛÙȉ· (ÏԂȷ΋ ÊÏÂÁÌÔÓ‹, Ó¤ÎÚˆÛË Ë·ÙÔ΢ÙÙ¿ÚˆÓ ÌÂ Û˘ÌÌÂÙÔ¯‹ ΢ڛˆ˜ ÙˆÓ ˘Ï·›ˆÓ ‰È·ÛÙËÌ¿ÙˆÓ Î·È ›ÓˆÛË). ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Ë ÎÈÚÚˆÙÈ΋ ‰È·‰Èηۛ· ÂÍÂÏ›ÛÛÂÙ·È Û ۯÂÙÈο Û‡ÓÙÔÌÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· (¤ˆ˜ Î·È 2 ¯ÚfiÓÈ·) ÁÂÁÔÓfi˜ Ô˘ ·Ô‰›‰ÂÙ·È ÛÙË ¯ÔÚËÁÔ‡ÌÂ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÓË ·ÓÔÛÔηٷÛÙÔÏ‹. ™Â ÔÛÔÛÙfi 5% Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÌÊ·ÓÈÛÙ› Ë ÏÂÁfiÌÂÓË ÈÓ҉˘ ¯ÔÏÔÛÙ·ÙÈ΋ Ë·Ù›Ùȉ· (fibrosing cholestatic hepatitis) Ô˘ Û˘ÓÈÛÙ¿ ÌÈ· ÂÈıÂÙÈ΋ ÌÔÚÊ‹ ›ÓˆÛ˘ Ì ¯ÔÏfiÛÙ·ÛË Î·È ¤ÏÏÂÈ„Ë ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ Û˘Ó‰˘¿˙ÂÙ·È Ì ˘„ËÏ¿ ›‰· HBV DNA. °È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ Ï¿Ì‚·Ó·Ó ·ÓÙÈ˚ο Ê¿Ú̷η ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÚÔÙ›ÓÂÙ·È Ë ¿ÌÂÛË ¤Ó·ÚÍË Ï·ÌÈ‚Ô˘‰›Ó˘ 100mg/ËÌÂÚËÛ›ˆ˜ Î·È ÌÂÙ¿ ÙËÓ ÙÒÛË ÙÔ˘ HBV DNA Ë Â·Ó·¯ÔÚ‹ÛË ˘ÂÚ·ÓfiÛÔ˘ ÛÊ·ÈÚ›Ó˘ HBIG 10000IU i.v. ÌËÓÈ·›ˆ˜ Ì ÛÎÔfi ÙË ‰È·Ù‹ÚËÛË ÙÔ˘ anti-HBs >500IU/ L › ÌÔÓ›ÌÔ˘ ‚¿Ûˆ˜ (3,14). ¶Úfi‚ÏËÌ· Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÁˆÁ‹˜ Ì ÙË Ï·ÌÈ‚Ô˘‰›ÓË ·ÔÙÂÏ› Ë ·Ó¿Ù˘ÍË ÌÂÙ·ÏÏ·ÁÌ¤ÓˆÓ ÛÙÂϯÒÓ Ô˘ ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ 14-62% ÌÂÙ¿ ·fi ÂӉȿÌÂÛÔ ¯ÚfiÓÔ 1236 Ì‹Ó˜. ∏ ÈÈ΋ ‰È·Ê˘Á‹ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ˘ÔÙÚÔ‹ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô‰ËÁ› Û ÈÛÙÔÏÔÁÈ΋ Âȉ›ӈÛË Î·È ÚÔԉ¢ÙÈ΋ Ì›ˆÛË ÙˆÓ Ë·ÙÈÎÒÓ ÂʉÚÈÒÓ. ∏ ·Ó¿ÁÎË ÁÈ· Û˘Ó¯‹ ÈÈ΋ ηٷÛÙÔÏ‹ Ô‰ËÁ› Û‹ÌÂÚ· ÛÙËÓ ÚÔÛı‹ÎË ‰ÈÈ‚·ÏÈ΋˜ ·‰ÂÊÔ‚›Ú˘ 10mg/ËÌÂÚËÛ›ˆ˜ Ô˘ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ¤Ó·ÓÙÈ ÙÔ˘ ·ÓıÂÎÙÈÎÔ‡ ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË ÛÙÂϤ¯Ô˘˜ (3,10). ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÓıÂÎÙÈο ÛÙË ‰ÈÈ‚·ÏÈ΋ ·‰ÂÊÔ‚›ÚË ÛÙÂϤ¯Ë ÚÔÙ›ÓÂÙ·È ¤Ó·ÚÍË ıÂڷ›·˜ Ì ϷÌÈ‚Ô˘‰›ÓË ‹ ÂÓÙÂη‚›ÚË.
∏·Ù›Ùȉ· C ∏ ΛÚÚˆÛË ÔÊÂÈÏfiÌÂÓË Û ¯ÚfiÓÈ· Ë·Ù›Ùȉ· C ·ÔÙÂÏ› ÙË Û˘¯ÓfiÙÂÚË ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙËÓ ∂˘ÚÒË Î·È ÛÙËÓ ∞ÌÂÚÈ΋ Û ÔÛÔÛÙfi Ô˘ ÊÙ¿ÓÂÈ ÙÔ 50% Û ÔÚÈṲ̂ӷ ΤÓÙÚ·. ∏ ˘ÔÙÚÔ‹ Ù˘ È·ÈÌ›·˜ Â›Ó·È Î·ıÔÏÈÎfi Ê·ÈÓfiÌÂÓÔ ·fi ÙȘ ÚÒÙ˜ ÒÚ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. πÛÙÔÏÔÁÈο ÂȂ‚·ÈˆÌ¤ÓË ˘ÔÙÚÔ‹ ÛÙÔ ÌfiÛ¯Â˘Ì· ·Ó¢ڛÛÎÂÙ·È ÂÚ›Ô˘ ÛÙÔ 70% ÙˆÓ ·ÛıÂÓÒÓ ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜. ΔÔ 20% ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ı· ·Ó·Ù‡ÍÔ˘Ó Î›ÚÚˆÛË ÂÓÙfi˜ 5ÂÙ›·˜ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ·fi ·˘ÙÔ‡˜ ÔÈ ÌÈÛÔ› ÂÚ›Ô˘ Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÂÓÙfi˜ 12ÌËÓÔ˘. ™Â ÂΛÓÔ˘˜ Ô˘ ÙÂÏÈο ı· ÂÌÊ·ÓÈÛÙ› Ë·ÙÈ΋ ·Ó¿ÚÎÂÈ· ÙÔ 50% ‰ÂÓ ı· ÂÈ‚ÈÒÛÂÈ ¤Ú·Ó ÙÔ˘ ¤ÙÔ˘˜ Î·È ÙÔ 80% ÌÂÙ¿ Ù· ‰‡Ô ¯ÚfiÓÈ· (23). ÕÚ· Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈÈ΋˜ ıÂڷ›·˜ ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·Ó·¯·›ÙÈÛË Ù˘ ·ÓˆÙ¤Úˆ ‰˘Û¯ÂÚÔ‡˜ ÂͤÏÈ͢. ¶·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ¯Â›· ÂͤÏÈÍË Ù˘ ˘ÔÙÚÔ‹˜ ÛÙÔ ÌfiÛ¯Â˘Ì· Â›Ó·È ÙÔ È˚Îfi ÊÔÚÙ›Ô Û ÙÈ̤˜ ¿Óˆ ÙÔ˘ 1Meq/ml ÚÈÓ ·fi ÙËÓ ÌÂÙ·-
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ÌfiÛ¯Â˘ÛË ‹ ¿Óˆ ÙˆÓ 10Meq/ml 4 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË, Ë Ïԛ̈ÍË ·fi ÁÔÓfiÙ˘Ô 1b, Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË (>50 ÂÙÒÓ), Ë ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È ÔÈ ·fiÙÔ̘ ÙÚÔÔÔÈ‹ÛÂȘ ÛÙË ‰fiÛÂȘ ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ (.¯ Û ˘fiÓÔÈ· ·fiÚÚȄ˘ ÌÔۯ‡̷ÙÔ˜). ∂Ó‰ÂÈÎÙÈ΋ ÁÈ· ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È Î·È Ë ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· ÛÙÔ ÚÒÙÔ Î·È ÙÔ ÙÚ›ÙÔ ¤ÙÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÌÂÙ¿ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (23). °ÂÓÈο ÔÈ ·ÛıÂÓ›˜ Ì ˷ٛÙȉ· C Î·È Î›ÚÚˆÛË Ì Child-Pugh ÛÎÔÚ 7-9 ‹ ·ÓÙ›ÛÙÔȯ· MELD 18 ıˆÚÔ‡ÓÙ·È ˘Ô„‹ÊÈÔÈ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË (24). OÈ ÛÙfi¯ÔÈ Ù˘ ÚÔÙÂÈÓfiÌÂÓ˘ ÚÈÓ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁˆÁ‹˜ Ì ·ÓÙÈ˚ο Ê¿Ú̷η Â›Ó·È Ë Â›Ù¢ÍË ÌfiÓÈÌ˘ ÈÔÏÔÁÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘, Ë ÚfiÏË„Ë Ù˘ ˘ÔÙÚÔ‹˜ ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È Ë ‰È·ÎÔ‹/ ηı˘ÛÙ¤ÚËÛË Ù˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘. ∞Ó·ÊÔÚÈο Ì ÙËÓ Èı·ÓfiÙËÙ· ‰È·ÎÔ‹˜ / ηı˘ÛÙ¤ÚËÛ˘ Ù˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘ Ì ÙË ¯ÔÚ‹ÁËÛË Ù˘ ·ÓÙÈ˚΋˜ ·ÁˆÁ‹˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·Ú΋ ‰Â‰Ô̤ӷ Ô˘ Ó· ·ÊÔÚÔ‡Ó ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Û ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ Ê¿ÛË. ∞ÓÙ›ıÂÙ· Û ÎÈÚÚˆÙÈÎÔ‡˜ Ì ηϋ ·ÓÙÈÚÚfiËÛË Ê¿ÓËΠfiÙÈ Ë ¯Ú‹ÛË Ù˘ ÈÓÙÂÚÊÂÚfiÓ˘ ›Ù ˆ˜ ÌÔÓÔıÂڷ›·˜ ›Ù ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÚÈÌ·‚ÈÚ›ÓË ÌÔÚ› Ó· ·Ó·ÛÙ›ÏÂÈ ÙË ÊÏÂÁÌÔÓ‹, Ó· ÛÙ·ıÂÚÔÔÈ‹ÛÂÈ ÙËÓ ›ÓˆÛË Î·È Ó· ÚÔÏ¿‚ÂÈ ‹ Ó· ηı˘ÛÙÂÚ‹ÛÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ (25). O Û˘Ó‰˘·ÛÌfi˜ ÈÓÙÂÚÊÂÚfiÓ˘ Î·È ÚÈÌ·‚ÈÚ›Ó˘ ÚÈÓ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ÈηÓÔÔÈËÙÈ΋ Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· (̤ÛÔ Child-Pugh <8) ¤ÊÂÚ ÌfiÓÈÌË ÈÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË Û ÔÛÔÛÙfi ~ 23% (26,27). ∞ÓÙ›ıÂÙ· ¿ÏÏË ÌÂϤÙË Ô˘ ¤ÁÈÓ Û ·ÛıÂÓ›˜ Ì ‚·Ú‡ÙÂÚË ÓfiÛÔ ( Ì.Ô Child-Pugh 11) ÙÔ ÔÛÔÛÙfi ›Ù¢Í˘ ÈÔÏÔÁÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ ‹Ù·Ó ÌˉÂÓÈÎfi (28). ™˘ÓÂÒ˜ Ë ·ÓÙ·fiÎÚÈÛË ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ ÛÙËÓ ·ÓÙÈÈ΋ ıÂڷ›· Î·È Ë Â›Ù¢ÍË ÈÔÏÔÁÈ΋˜ οı·ÚÛ˘ ÌÂÈÒÓÂÙ·È, fiÛÔ ·˘Í¿ÓÂÙ·È Ë ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘. ø˜ ·Èٛ˜ Ù˘ Ùˆ¯‹˜ ·ÓÙ·fiÎÚÈÛ˘ ÛÙÔ˘˜ ÛÔ‚·ÚfiÙÂÚ· ¿Û¯ÔÓÙ˜ ·Ó·Ê¤ÚÔÓÙ·È Ô ÁÔÓfiÙ˘Ô˜ 1 Î·È Ë ‰˘ÛÎÔÏ›· ÛÙË ¯ÔÚ‹ÁËÛË ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ ‰fiÛÂˆÓ ÈÓÙÂÚÊÂÚfiÓ˘ Î·È ÚÈÌ·‚ÈÚ›Ó˘ ÏfiÁˆ ·Ó¿Ù˘Í˘ ÛÔ‚·ÚÒÓ ·ÚÂÓÂÚÁÂÈÒÓ (29). ªÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÈ ÛÙÚ·ÙËÁÈΤ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ Ïԛ̈͢ Â›Ó·È ‰‡Ô. OÈ ÚÒÙ˜ ·ÊÔÚÔ‡Ó ÙËÓ ÚÒÈÌË ÂÚ›Ô‰Ô (pre-emptive treatment), ‰ËÏ·‰‹ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiÔ˘ ¤¯Ô˘Ì ˘„ËÏ¿ ›‰· È·ÈÌ›·˜
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ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ ¯ˆÚ›˜ ˘ÔÙÚÔ‹ ÛÙÔ ÌfiÛ¯Â˘Ì· (30). ™Ùfi¯Ô˜ Ù˘ ·ÓÙÈÈ΋˜ ·ÁˆÁ‹˜ ÙËÓ ÂÚ›Ô‰Ô ·˘Ù‹ Â›Ó·È Ë Ì›ˆÛË ‹ Ë ÂÍ¿ÏÂÈ„Ë ÙÔ˘ ÈÔ‡, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÙÚ¤„Ô˘Ì ÌÂÏÏÔÓÙÈ΋ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÛÙÔ ÌfiÛ¯Â˘Ì·. ∏ ‰Â‡ÙÂÚË ÚÔÛ¤ÁÁÈÛË ·ÊÔÚ¿ ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ¤¯ÂÈ ·Ó·Ù˘¯ı› ˘ÔÙÚÔ‹ ÛÙÔ ÌfiÛ¯Â˘Ì· Ì ·ÚÈÔ ÛÙfi¯Ô ÙËÓ Î·ı˘ÛÙ¤ÚËÛË ‹ ‰È·ÎÔ‹ Ù˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘. ∏ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ı¤ÙÂÈ ÙË ‰È¿ÁÓˆÛË Ù˘ ˘ÔÙÚÔ‹˜ ÛÙÔ ÌfiÛ¯Â˘Ì· Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ ÙË ÌÔÚÊ‹ Ù˘ ÔÍ›·˜ (ÏԂȷ΋ ÊÏÂÁÌÔÓ‹ Î·È Ó¤ÎÚˆÛË) ‹ Ù˘ ¯ÚfiÓÈ·˜ Ë·Ù›Ùȉ·˜ (˘Ï·›· Î·È ÂÚÈ˘Ï·›· ÊÏÂÁÌÔÓ‹ Î·È ›ÓˆÛË) (30,31). ™ÙËÓ ÚÒÈÌË ıÂڷ›· Ì ÈÓÙÂÚÊÂÚfiÓË Î·È ÚÈÌ·‚ÈÚ›ÓË (32,33) ÙÔ ÔÛÔÛÙfi ÌfiÓÈÌ˘ ÈÔÏÔÁÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ ·Ó‹Ïı ÛÙÔ 33% Î·È Ù· ÔÛÔÛÙ¿ ‰È·ÎÔ‹˜ Ù˘ ıÂڷ›·˜ ÙÔ 50%. OÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ ‹Ù·Ó Ï¢ÎÔÂÓ›·, ıÚÔÌ‚ÔÂÓ›·, ÎÂÊ·Ï·ÏÁ›Â˜, Î·È ·Ó·ÈÌ›·. ™˘ÌÂÚ·ÛÌ·ÙÈο Ë ÚÒÈÌË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ıÂڷ›· ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÚÔÛʤÚÂÈ ÛËÌ·ÓÙÈο ÔʤÏË Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë fiÙÈ ÚÔÛٷهÂÈ ÌfiÓÔ ÙÔ˘˜ Ï›ÁÔ˘˜ ·ÛıÂÓ›˜ Ô˘ Èı·Ó¿ ı· ·Ó·Ù‡ÍÔ˘Ó ÛÔ‚·Ú‹ Ë·ÙÈ΋ ÓfiÛÔ Î·È ı· ·ÓÙ·ÔÎÚÈıÔ‡Ó ·Ú¿ÏÏËÏ· ÛÙË ıÂڷ›·, ÂÓÒ ÂÎı¤ÙÂÈ ÛÙÔ˘˜ ÚÔ·Ó·ÊÂÚı¤ÓÙ˜ ÎÈÓ‰‡ÓÔ˘˜ ‰˘ÓËÙÈο fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ (33). ∏ ıÂڷ›· ÌÂÙ¿ ·fi ÙÂÎÌËÚȈ̤ÓË ÈÛÙÔÏÔÁÈο ˘ÔÙÚÔ‹ ÛÙÔ ÌfiÛ¯Â˘Ì· Â›Ó·È Ë Â˘Ú‡ÙÂÚ· ÂÊ·ÚÌÔ˙fiÌÂÓË. ∂ÈϤÁÂÙ·È ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ‚·Ú‡ÙÂÚË ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Ì ¤ÓÙÔÓË ÊÏÂÁÌÔÓ‹, Ë·ÙÔ΢ÙÙ·ÚÈ΋ Ó¤ÎÚˆÛË Î·È ›ÓˆÛË. ∂Ó·ÏÏ·ÎÙÈο ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Î·È Û ·ÛıÂÓ›˜ Ì ÈÔ ‹È· ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Ì ¯·ÌËÏfiÙÂÚ· ›‰· HCV RNA Î·È Ïԛ̈ÍË ·fi ÁÔÓfiÙ˘Ô 2 ‹ 3. ¶Ú¤ÂÈ fï˜ Ó· ÙÔÓÈÛı› fiÙÈ Ù· ‰Â‰Ô̤ӷ Â›Ó·È Ï›Á· Ì ÌÂϤÙ˜ ηٿ ηÓfiÓ· ÌË Ù˘¯·ÈÔÔÈË̤Ó˜ Ô˘ Û˘ÌÂÚȤϷ‚·Ó ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ Î·È ÔÈΛϷ ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù·. ∏ ÎÏ·ÛÈ΋ ÈÓÙÂÚÊÂÚfiÓË ˆ˜ ÌÔÓÔıÂڷ›· Û¯ÂÙ›˙ÂÙ·È Ì ÌˉÂÓÈο ‹ Ôχ ¯·ÌËÏ¿ ÔÛÔÛÙ¿ ÌfiÓÈÌ˘ ÈÔÏÔÁÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ (7%) Î·È Ì ÛËÌ·ÓÙÈο ˘„ËÏfi ΛӉ˘ÓÔ ·fiÚÚȄ˘ ÌÔۯ‡̷ÙÔ˜ (35%) (33,34). Δ· ÔÛÔÛÙ¿ ·ÓÙ·fiÎÚÈÛ˘ ‹Ù·Ó ˘„ËÏfiÙÂÚ· Ì ÙÔ Û˘Ó‰˘·ÛÌfi ÈÓÙÂÚÊÂÚfiÓ˘ Î·È ÚÈÌ·‚ÈÚ›Ó˘ (7% - 56%) Ì ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ ÂÂÈÛÔ‰›ˆÓ ·fiÚÚȄ˘ ÌÔۯ‡̷ÙÔ˜ (3%). ¶Úfi‚ÏËÌ· ‹Ù·Ó Ë ·ÓÔ¯‹ ÛÙË ıÂڷ›·, ΢ڛˆ˜ ÏfiÁˆ Ù˘ Ì˘ÂÏÔÙÔÍÈÎfiÙËÙ·˜ ÁÂÁÔÓfi˜ Ô˘ Ô‰‹ÁËÛ ÙÔ 50% ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ ÛÙË Ì›ˆÛË Ù˘ ‰fiÛ˘ Î·È ÙÔ
26% ÛÙË ‰È·ÎÔ‹ Ù˘ ıÂڷ›·˜ (33,35,36). ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó ÂÍ›ÛÔ˘ ηϿ ·ÔÙÂϤÛÌ·Ù· Î·È Ì ÙÔ Û˘Ó‰˘·ÛÌfi ÂÁ΢ÏȈ̤Ó˘ ÈÓÙÂÚÊÂÚfiÓ˘ Î·È ÚÈÌ·‚ÈÚ›Ó˘ Ì ·ÓÙ›ÛÙÔȯ· ÔÛÔÛÙ¿ ·ÚÂÓÂÚÁÂÈÒÓ (39,40). ∏ ›Ù¢ÍË ÌfiÓÈÌ˘ ÈÔÏÔÁÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ Û˘Ó‰˘¿˙ÂÙ·È Î·È Ì ÈÛÙÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË. ™Â ÌÂϤÙË ·fi ÙÔ˘˜ Bizollon Î·È Û˘Ó. ÙÔ 93% ÙˆÓ ·ÛıÂÓÒÓ ‰È·Ù‹ÚËÛ·Ó ÈÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË, Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÙÚ·ÓÛ·ÌÈÓ·ÛÒÓ Î·È ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ÊÏÂÁÌÔÓ‹˜ Î·È ÙÔ˘ ÛÙ·‰›Ô˘ ›ÓˆÛ˘ ÛÙ· 3 ¯ÚfiÓÈ· ÂÚ›Ô˘ ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂڷ›·˜ (37). OÈ Abdelmalek Î·È Û˘Ó. ÂȂ‚·›ˆÛ·Ó ·˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· ÌÂÙ¿ ·fi Ì·ÎÚfiÙÂÚË Ì¤¯ÚÈ 5 ¤ÙË ·Ú·ÎÔÏÔ‡ıËÛË (38). Δ¤ÏÔ˜ Ú¤ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ ÔÈ ‰fiÛÂȘ ÙˆÓ Ê·ÚÌ¿ÎˆÓ Î·È Ë ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ ‰ÂÓ ¤¯Ô˘Ó ·ÎÚÈ‚Ò˜ ηıÔÚÈÛı›. OÈ Dumortier Î·È Û˘Ó. ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Û¯‹Ì· Ì ¯·ÌËϤ˜ ‰fiÛÂȘ ÈÓÙÂÚÊÂÚfiÓ˘ Î·È ÚÈÌ·‚ÈÚ›Ó˘ ÛÙËÓ ·Ú¯‹ Ô˘ ÚÔԉ¢ÙÈο ·˘Í·ÓfiÙ·Ó ·Ó·ÏfiÁˆ˜ Ì ÙËÓ ·ÓÔ¯‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ ·Ó·Ê¤ÚÔ˘Ó ÌfiÓÈÌË ÈÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË 45% Î·È ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ ‰È·ÎÔ‹˜ Ù˘ ıÂڷ›·˜ (20%) (40). ∞fi ÙËÓ ¿ÏÏË ‰ÂÓ ¤¯ÂÈ Ê·Ó› fiÙÈ ÙÔ 12ÌËÓÔ Û¯‹Ì· ÈÓÙÂÚÊÂÚfiÓ˘ Î·È ÚÈÌ·‚ÈÚ›Ó˘ ˘ÂÚÙÂÚ› ÙÔ˘ 6ÌËÓÔ˘. ¢ÂÓ ¤¯ÂÈ ÂȂ‚·Èˆı› Â¿Ó Ë ÂÈÌ‹Î˘ÓÛË Ù˘ ıÂڷ›·˜ ÁÈ· 12 Ì‹Ó˜ ‹ ÂÚÈÛÛfiÙÂÚÔ ÌÂÈÒÓÂÈ Ù· ÔÛÔÛÙ¿ ˘ÔÙÚÔÒÓ Ô˘ ·Ó¤Ú¯ÔÓÙ·È ÛÙÔ 80%-85% ÙˆÓ ·ÛıÂÓÒÓ. ∂›Û˘ ‰ÂÓ Â›Ó·È Â·ÚÎÒ˜ ÙÂÎÌËÚȈ̤ÓË Ë ·Í›· Ù˘ ̤ÙÚËÛ˘ ÙÔ˘ HCV RNA ÛÙÔ 3ÌËÓÔ ‹ 6ÌËÓÔ Ù˘ ıÂڷ›·˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· Ê·Ó› Ë Èı·ÓfiÙËÙ· ÌfiÓÈÌ˘ ·ÓÙ·fiÎÚÈÛ˘. ¶ÂÚÈÛÛfiÙÂÚ˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ··ÈÙÔ‡ÓÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ηıÔÚ›ÛÔ˘Ì ÙËÓ Î·Ù¿ÏÏËÏË ‰È¿ÚÎÂÈ· Î·È ‰fiÛË ÙˆÓ ·ÓÙÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ·ÏÏ¿ Î·È Ó· ‰ÈÂÚ¢ӋÛÔ˘Ì ÙÔ˘˜ ÙÚfiÔ˘˜ Ì›ˆÛ˘ ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ ÙÔ˘˜.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Samuel D, Muller R, Alexander G, Fassati L, Ducot B, Benhamou JP. et al. Liver transplantation in European patients with the hepatitis B surface antigen. N Engl J Med. 1993;329(25):1842–1847. 2. Terrault NA, Zhou S, Combs C, Hahn JA, Lake JR, Roberts JP. et al. Prophylaxis in liver transplant recipients using a fixed dosing schedule of hepatitis B immunoglobulin. Hepatology. 1996;24(6):1327–1333. 3. Terrault N, Roche B, Samuel D. Management of the hepatitis B virus in the liver transplantation setting: a European and an American perspective. Liver Transpl. 2005 Jul;11(7):716-32.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
4. Roche B, Feray C, Gigou M, Roque-Afonso AM, Arulnaden JL, Delvart V. et al. HBV DNA persistence 10 years after liver transplantation despite successful anti-HBS passive immunoprophylaxis. Hepatology. 2003;38(1):86–95. 5. Buti M, Mas A, Prieto M, Casafont F, Gonzalez A, Miras M. et al. A randomized study comparing lamivudine monotherapy after a short course of hepatitis B immune globulin (HBIg) and lamivudine with longterm lamivudine plus HBIg in the prevention of hepatitis B virus recurrence after liver transplantation. J Hepatol. 2003;38(6):811–817.
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18. Marzano A, Salizzoni M, Debernardi-Venon W, Smedile A, Franchello A, Ciancio A. et al. Prevention of hepatitis B virus recurrence after liver transplantation in cirrhotic patients treated with lamivudine and passive immunoprophylaxis. J Hepatol. 2001;34(6): 903–910.
8. Dienstag JL, Schiff ER, Wright TL, Perrillo R, Hann HWL, Goodman Z, Crowther L, et al. Lamivudine as initial treatment for chronic hepatitis B in the United States. N Engl J Med 1999;341:1256-1263. 9. Mutimer D, Pillay D, Shields P, Cane P, Ratcliffe D, Martin B, Buchan S, et al. Outcome of lamivudine resistant hepatitis B virus infection in the liver transplant recipient. Gut 2000;46:107-113. 10. Schiff ER, Lai CL, Hadziyannis S, Neuhaus P, Terrault N, Colombo M. et al. Adefovir dipivoxil therapy for lamivudine-resistant hepatitis B in pre- and post-liver transplantation patients. Hepatology. 2003;38(6): 1419–1427. 11. Mutimer D, Pillay D, Dragon E, et al. High pretreatment serum hepatitis B virus titer predicts failure of lamivudine prophylaxis and graft re-infection after liver transplantation. J Hepatol. 1999;30:715–721.
19. Naoumov NV, Lopes AR, Burra P, Caccamo L, Iemmolo RM, de Man RA. et al. Randomized trial of lamivudine versus hepatitis B immunoglobulin for longterm prophylaxis of hepatitis B recurrence after liver transplantation. J Hepatol. 2001;34(6):888–894. 20. Arslan M, Wiesner RH, Sievers C, Egan K, Zein NN. Double-dose accelerated hepatitis B vaccine in patients with end-stage liver disease. Liver Transpl 2001;7:314320. 21. Bienzle U, Gunther M, Neuhaus R, Vandepapeliere P, Vollmar J, Lun A. et al. Immunization with an adjuvant hepatitis B vaccine after liver transplantation for hepatitis B-related disease. Hepatology. 2003;38(4): 811–819. 22. Lo CM, Liu CL, Chan SC, et al. Failure of Hepatitis B vaccination in patients receiving lamivudine prophylaxis after liver transplantation for chronic hepatitis B. J Hepatol 2005;43:283-287
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27. Thomas RM, Brems JJ, Guzman-Hartman G, Yong S, Cavaliere P, Van Thiel DH. Infection with chronic hepatitis C virus and liver transplantation: A role for Interferon therapy before transplantation. Liver Transpl 2003;9:905–915. 28. Crippin JS, McCashland T, Terrault N, Sheiner P, Charlton MR. A pilot study of the tolerability and efficacy of antiviral therapy in hepatitis C virus-infected patients awaiting liver transplantation. Liver Transpl 2002;8:350–355. 29. Everson GT. Should we treat patients with chronic hepatitis C on the waiting list? J Hepatol 2005; 42: 448–479. 30. Ferrell L, Wright T, Roberts J, Ascher N, Lake J. Hepatitis C viral infection in liver transplant recipients. Hepatology 1992;16:865–876. 31. Berenguer M, Rayo_nM, Prieto M, Aguilera V, Nicola_s D, Ortiz V, et al. Are post-transplantation protocol liver biopsies useful in the longterm? Liver Transpl 2001. 32. Mazzaferro V, Tagger A, Schiavo M, Regalia E, Pulvirenti A, Ribero ML, et al. Prevention of recurrent hepatitis C after liver transplantation with early interferon and ribavirin treatment. Transplant Proc 2001; 33:1355–1357. 33. Morard I, Negro F. How should we treat recurrent hepatitis C after liver transplantation? J Hepatol 2005; 42: 448–479. 34. Feray C, Samuel D, Gigou M, Paradis V, David MF, Lemonnier C, et al. An open trial of interferon alfa recombinant for hepatitis C after liver transplantation: antiviral effects and risk of rejection. Hepatology 1995;22:1084. 35. Narayanan Menon KV, Poterucha JJ, El-Amin OM, Burgart LJ, Kremers WK, Rosen CB, et al. Treatment
of posttransplantation recurrence of hepatitis C with interferon and ribavirin: lessons on tolerability and efficacy. Liver Transpl 2002;8:623–629. 36. Samuel D, Bizollon T, Feray C, Roche B, Ahmed SN, Lemonnier C, Cohard M, Reynes M, Chevallier M, Ducerf C, Baulieux J, Geffner M, Albrecht JK, Bismuth H, Trepo C. Interferon-alpha 2b plus ribavirin in patients with chronic hepatitis C after liver transplantation: a randomized study. Gastroenterology. 2003 Mar;124(3):642-50. 37. Bizollon T, Ahmed SN, Radenne S, Chevallier M, Chevallier P, Parvaz P, Guichard S, Ducerf C, Baulieux J, Zoulim F, Trepo C.Long term histological improvement and clearance of intrahepatic hepatitis C virus RNA following sustained response to interferonribavirin combination therapy in liver transplanted patients with hepatitis C virus recurrence. Gut. 2003 Feb; 52(2):283-7. 38. Abdelmalek MF, Firpi RJ, Soldevila-Pico C, Reed AI, Hemming AW, Liu C, Crawford JM, Davis GL, Nelson DR. Sustained viral response to interferon and ribavirin in liver transplant recipients with recurrent hepatitis C. Liver Transpl. 2004 Feb;10(2):199-207. 39. Neff GW, O’Brien CB, Cirocco R, Montalbano M, de Medina M, Ruiz P, et al. Prediction of sustained virological response in liver transplant recipients with recurrent hepatitis C virus following combination pegylated interferon alfa-2b and ribavirin therapy using tissue hepatitis C virus reverse transcriptase polymerase chain reaction testing. Liver Transpl 2004;10: 595–598. 40. Dumortier J, Scoazec JY, Chevallier P, Boillot O. Treatment of recurrent hepatitis C after liver transplantation: a pilot study of peginterferon alfa-2b and ribavirin combination. J Hepatol 2004 Apr;40(4):669-74.
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∏·Ù›Ùȉ· C OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ (90%) Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÏfiÁˆ HCV ΛÚÚˆÛ˘ ÂÌÊ·Ó›˙Ô˘Ó ÈÔÏÔÁÈÎÔ‡˜ ‰Â›ÎÙ˜ ˘ÔÙÚÔ‹˜ Ù˘ Ïԛ̈͢.2 ∏ ·ӷÏԛ̈ÍË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÂÌÊ·Ó›˙ÂÙ·È Èı·Ófiٷٷ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ӷÈÌ¿ÙˆÛ˘ Î·È Ë ·Ó··Ú·ÁˆÁ‹ ÙÔ˘ ÈÔ‡ Ï›Á˜ ÒÚ˜ ÌÂÙ¿.3 Δ· ›‰· ÙÔ˘ È˚ÎÔ‡ ÊÔÚÙ›Ô˘ ÌÂÈÒ-
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πÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ-º˘ÛÈ΋ ÈÛÙÔÚ›· Ÿˆ˜ ‹‰Ë ÚԷӷʤÚıËÎÂ Ë ‰È¿ÎÚÈÛË ÌÂٷ͇ Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢ Î·È ¿ÏÏˆÓ ÌÂÙ¿-ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ ÂÈÏÔÎÒÓ ‰ÂÓ Â›Ó·È ‰˘Ó·Ù‹ › ÙË ‚¿ÛÂÈ ÙˆÓ ÎÏÈÓÈÎÒÓ Î·È ‚ÈÔ¯ËÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ ÌfiÓÔ. ∏ ‚ÈÔ„›· ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢.2,4 ∂ÈϤÔÓ Â›Ó·È ¯Ú‹ÛÈÌË ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ÓÂÎÚÔÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È ÙÔ˘ ÛÙ·‰›Ô˘ Ù˘ ÓfiÛÔ˘1,7, ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ Î·È ÙÔÓ ·ÔÎÏÂÈÛÌfi ¿ÏÏˆÓ ·ÈÙ›ˆÓ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.4 Δ˘Èο, Ë ˘ÔÙÚÔ‹ Ù˘ Ïԛ̈͢ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi 3 ΢ڛˆ˜ Ê¿ÛÂȘ. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú¯È΋˜ Ê¿Û˘ ‹ Ù˘ Ê¿Û˘ ·ӷÏԛ̈͢ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (0-2 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË), fiÙ·Ó Ù· ›‰· ÙÔ˘ HCV-RNA Â›Ó·È ˘„ËÏ¿, Ë ·ÈÙÈÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÈÛÙÔÏÔÁÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Â›Ó·È ‰‡ÛÎÔÏË ÂÍ·ÈÙ›·˜ Ù˘ Û˘¯Ó‹˜ ·ÚÔ˘Û›·˜ Î·È ¿ÏÏˆÓ ·ÈÙ›ˆÓ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ fiˆ˜ ÔÈ ‚Ï¿‚˜ Û˘ÓÙ‹ÚËÛ˘-·ӷÈÌ¿ÙˆÛ˘ Î·È Ë ÔÍ›· ·fiÚÚÈ„Ë. ∏ Ê¿ÛË ·˘Ù‹ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ÈÛÙÔÏÔÁÈο ·fi ÏԂȷ΋ ‰È·Ù·Ú·¯‹ ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, ‰È¿Ù·ÛË ÙˆÓ ÎÔψ‰ÒÓ ÙÚȯÔÂȉÒÓ, ÂÓ‰ÔÏԂȷ΋ ÊÏÂÁÌÔÓ‹, ÂÍÔ›‰ËÛË Ë·ÙÔ΢ÙÙ¿ÚˆÓ, ·ÚÔ˘Û›· ·ÔÙˆÙÈÎÒÓ ÛˆÌ·Ù›ˆÓ Î·È ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ ·˘ÍË̤ÓË ÌÈÙˆÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·. ™·ÓÈfiÙÂÚ· ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÂÛÙȷ΋ Î·È ‹È· Ë·ÙÔ΢ÙÙ·ÚÈ΋ ÛÙ¿وÛË Î·È ˘Ï·›· ÊÏÂÁÌÔÓ‹.1,4,7,15 ∏ ‰Â‡ÙÂÚË Ê¿ÛË Ù˘ ÂÁηÙÂÛÙË̤Ó˘ Ïԛ̈͢ (2-4 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÚÈÛÛfiÙÂÚÔ Ù˘ÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÔÍ›·˜ Ë·Ù›Ùȉ·˜. ∏ ÊÏÂÁÌÔÓ‹ Â›Ó·È ‹È·, ΢ڛˆ˜ ÂÓ‰ÔÏԂȷ΋ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ˛Ԣ ‚·ıÌÔ‡ ‰È·Ù·Ú·¯‹ Ù˘ ÏԂȷ΋˜ ·Ú¯ÈÙÂÎÙÔÓÈ΋˜, ÂÍÔ›‰ËÛË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ·ÚÔ˘Û›· ·ÔÙˆÙÈÎÒÓ ÛˆÌ·Ù›ˆÓ Î·È ˘ÂÚÏ·Û›· ÙˆÓ Î˘ÙÙ¿ÚˆÓ kupffer.1,7 ΔÔ ÊÏÂÁÌÔÓ҉˜ ‰È‹ıËÌ· ÙÔ˘ ÏÔ‚›Ô˘ ·ÔÙÂÏÂ›Ù·È ·fi CD8+ Δ-ÏÂÌÊÔ·ÙÙ·Ú· Î·È CD57+ ·ÙÙ·Ú· ÊÔÓ›˜.16 ∏ ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ Fas ·fi Ù· Ë·ÙÔ·ÙÙ·Ú·, Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘ ÈÔ‡, Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÏԂȷ΋ ÊÏÂÁÌÔÓ‹ Î·È ÙËÓ ·fiÙˆÛË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ HCV Ïԛ̈͢.17 ∏ ÙÚ›ÙË Ê¿ÛË Ù˘ ÚÔԉ¢ÙÈ΋˜ Ë·ÙÈ΋˜ ‚Ï¿‚˘ (>6 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ¯ÚfiÓÈ·˜ Ë·Ù›Ùȉ·˜, fiÌÔȘ Ì’ ·˘Ù¤˜ Ô˘ ·Ú·ÙËÚÔ‡-
ÓÙ·È ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi.4 ∏ Ê¿ÛË ·˘Ù‹ Û¯ÂÙ›˙ÂÙ·È Ì ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ TH1-ÊÏÂÁÌÔÓˆ‰ÒÓ, ÚÔ˚ÓˆÙÈÎÒÓ Î·È ÚÔ·ÔÙˆÙÈÎÒÓ ·ıÔÁÂÓÂÙÈÎÒÓ Ô‰ÒÓ.18 50% ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ 1 ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÌÊ·Ó›˙Ô˘Ó ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ¯ÚfiÓÈ·˜ Ë·Ù›Ùȉ·˜.1 ™ÙË ‚ÈÔ„›· ·Ú·ÙËÚÂ›Ù·È ÊÏÂÁÌÔÓ҉˘ ‰È‹ıËÛË ÙˆÓ ˘Ï·›ˆÓ ‰È·ÛÙËÌ¿ÙˆÓ ·fi ÌÔÓÔ‡ÚËÓ·, Ù˘Èο Ì ÌÔÚÊ‹ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ·ıÚÔ›ÛÂˆÓ Î·È ÂÛÙȷο ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ‰È‹ıËÛË ÙÔ˘ ÂÈıËÏ›Ô˘ ÔÚÈÛÌ¤ÓˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. ¶·Ú·ÙËÚÔ‡ÓÙ·È Â›Û˘ ‰È·‚ÚˆÙÈ΋ Ó¤ÎÚˆÛË, ÂÓ‰ÔÏԂȷ΋ ÊÏÂÁÌÔÓ‹, Ë·ÙÔ΢ÙÙ·ÚÈ΋ ÛÙ¿وÛË Î·È ÌÂÌÔӈ̤ӷ ·ÔÙˆÙÈο ۈ̿ÙÈ·.4,8 ™Â ÂÚÈÙÒÛÂȘ ¤ÓÙÔÓ˘ Î·È ÂÎÙÂٷ̤Ó˘ ‚Ï¿‚˘ ÙˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ Ë ‰È¿ÎÚÈÛË ·fi ÙËÓ ÔÍ›· ·fiÚÚÈ„Ë Â›Ó·È ‰‡ÛÎÔÏË.1 º·›ÓÂÙ·È fiÙÈ Ë HCV Ïԛ̈ÍË ÂÌÊ·Ó›˙ÂÈ ÂÈıÂÙÈÎfiÙÂÚË Û˘ÌÂÚÈÊÔÚ¿ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ ·’ fiÙÈ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ™Â ‚ÈÔ„›Â˜ ·ÛıÂÓÒÓ 1 ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘¯Ó¿ ·Ú·ÙËÚÂ›Ù·È ›ÓˆÛË Î·È ÙÔ ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘ ÚÔ‰Èο˙ÂÈ ÙËÓ ÂÚ·ÈÙ¤Úˆ ·Ó¿Ù˘ÍË ¤ÓÙÔÓ˘ ›ÓˆÛ˘ ‹ ΛÚÚˆÛ˘.19 ªÈÎÚfi˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ ı· ·Ó·Ù‡ÍÂÈ Î›ÚÚˆÛË 1-2 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, 10-30% ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi 5 ¯ÚfiÓÈ· Î·È 50% ÙˆÓ ·ÛıÂÓÒÓ 7-10 ¯ÚfiÓÈ· ÌÂÙ¿-ÌÂÙ·ÌÔÛ¯Â˘ÙÈο. 1 ªÂ ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈΤ˜ ÌÂıfi‰Ô˘˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ·ÓÙÈÁfiÓ· ÙÔ˘ ÈÔ‡ ·ÓȯÓ‡ÔÓÙ·È ÛÙÔ ‚ÈÔÙÈÎfi ˘ÏÈÎfi ·ÛıÂÓÒÓ, Ï›Á˜ ̤Ú˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, 30-50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÂÌÊ·Ó›˙Ô˘Ó ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈ΋ ıÂÙÈÎfiÙËÙ· ÙÔÓ 1Ô ÌÂÙ¿-ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi Ì‹Ó·. ¶·ÚfiÌÔÈ· Â˘Ú‹Ì·Ù· ÚԤ΢„·Ó Î·È Ì ÙË ¯Ú‹ÛË ¿ÏÏˆÓ Ï¤ÔÓ Â˘·›ÛıËÙˆÓ ÌÂıfi‰ˆÓ (in situ PCR-in situ ˘‚ÚȉÈÛÌfi˜).20-21 ∞fi ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ÚԤ΢„ ›Û˘ Û˘Û¯¤ÙÈÛË Ù˘ ÈÛÙÈ΋˜ ¤ÎÊÚ·Û˘ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ÈÔ‡, ÙˆÓ ˘„ËÏÒÓ Ù›ÙÏˆÓ ÙÔ˘ HCV-RNA ÛÙÔÓ ÔÚfi Î·È ÙˆÓ ÚÒÈÌˆÓ ÈÛÙÔÏÔÁÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ Ë·Ù›Ùȉ·˜ C ÛÙÔ ÌfiÛ¯Â˘Ì·.1 ∂ÎÙfi˜ ÙˆÓ Ù˘ÈÎÒÓ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Î·È ¿Ù˘Â˜ ÈÛÙÔÏÔÁÈΤ˜ ÌÔÚʤ˜ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢ ÛÙÔ ÌfiÛ¯Â˘Ì·. ŒÓ· ÌÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ ÈÓÔÔÈfi ¯ÔÏÔÛÙ·ÙÈ΋ Ë·Ù›Ùȉ· C Ë ÔÔ›· Èı·ÓfiÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Â˘ı›·˜ ΢ÙÙ·ÚÔÙÔÍÈ΋-΢ÙÙ·ÚÔÏ˘ÙÈ΋ ‰Ú¿ÛË ÙÔ˘ ÈÔ‡.22 ∏ ÌÔÚÊ‹ ·˘Ù‹ Â›Ó·È Û¿ÓÈ·, ÂÌÊ·Ó›˙ÂÙ·È 1-3 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û¯ÂÙ›˙ÂÙ·È Ì ˘„ËÏ¿ ›‰· È˚ÎÔ‡ ÊÔÚÙ›Ô˘ ÙfiÛÔ ÛÙÔÓ ÔÚfi fiÛÔ Î·È
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÛÙÔÓ ÈÛÙfi ηıÒ˜ Î·È Ì ·Ô˘Û›· ·ÓÔÛÔ·fiÎÚÈÛ˘ ̤ۈ ÙˆÓ CD4+Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (Δ∏1 Δ∏2). πÛÙÔÏÔÁÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÎÙÂٷ̤ÓË ÎÂÓÙÚÔÏԂȷ΋ ÂÍÔ›‰ËÛË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ, ¯ÔÏÂÚ˘ıÚÈÓfiÛÙ·ÛË, ÂÛÙȷ΋ ·fiÙˆÛË, ˘ÂÚÏ·Û›· ÙˆÓ Î˘ÙÙ¿ÚˆÓ kupffer, ‰È‡ڢÓÛË Î·È ›ÓˆÛË ÙˆÓ ˘Ï·›ˆÓ ‰È·ÛÙËÌ¿ÙˆÓ Î·È ‹È·/̤ÙÚÈ· ÊÏÂÁÌÔÓ‹ ÌÂ Û˘ÓÔ‰fi ·ÓÙ›‰Ú·ÛË ¯ÔÏ·ÁÁÂÈÔÏ›ˆÓ.1 ™˘¯Ó¿ ÌÈÌÂ›Ù·È ·ÏÏÔÈÒÛÂȘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ·fiÊÚ·ÍË ¯ÔÏËÊfiÚˆÓ fiÚˆÓ, ÙÔÍÈÎfiÙËÙ· Ê·ÚÌ¿ÎˆÓ ‹ Î·È ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜.7 OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ Ì ¯ÔÏÔÛÙ·ÙÈ΋ Ë·Ù›Ùȉ· Ô‰ËÁÔ‡ÓÙ·È Û‡ÓÙÔÌ· Û ·Ó¿ÚÎÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹ ı¿Ó·ÙÔ, Ï›ÁÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË.22 ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Ë ÂÏ¿ÙÙˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ô‰ËÁ› Û ‚ÈÔ¯ËÌÈ΋ Î·È ÈÛÙÔÏÔÁÈ΋ ‡ÊÂÛË. ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ¤¯ÂÈ Â›Û˘ ÂÚÈÁÚ·Ê› ·Û˘Ó‹ı˘ Ù‡Ô˜ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢, ÈÛÙÔÏÔÁÈο Ì ÌÔÚÊ‹ ÎÔÎÎȈ̷ÙÒ‰Ô˘˜ Ë·Ù›Ùȉ·˜.23
¢È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË HCV Ïԛ̈͢ Î·È ÔÍ›·˜ ·fiÚÚȄ˘ ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ ‰È·ÊfiÚˆÓ Ê¿ÛÂˆÓ ˘ÔÙÚÔ‹˜ Ù˘ Ë·Ù›Ùȉ·˜ C ·fi ¿ÏÏ· ·›ÙÈ· Ô˘ ÚÔηÏÔ‡Ó ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÛÙÔ ÌfiÛ¯Â˘Ì·, Î·È È‰È·›ÙÂÚ· ÙËÓ ÔÍ›· ·fiÚÚÈ„Ë, ·ÔÙÂÏ› ¤Ó· ·fi Ù· Û˘¯ÓfiÙÂÚ· Î·È ÂÍ·ÈÚÂÙÈ΋˜ ‰˘ÛÎÔÏ›·˜ ÚÔ‚Ï‹Ì·Ù· Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›˙ÂÈ Ô ·ıÔÏÔÁÔ·Ó·ÙfiÌÔ˜. ™˘¯Ó¿ ÙÔ ÔÛÔÛÙfi Û˘Ìʈӛ·˜, ·ÎfiÌË Î·È ÌÂٷ͇ ¤ÌÂÈÚˆÓ ·ıÔÏÔÁÔ·Ó·ÙfïÓ, ‰ÂÓ Â›Ó·È ÈηÓÔ-
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ÔÈËÙÈÎfi, fiˆ˜ ÚÔ·ÙÂÈ Î·È ·fi ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·.24-26 ∏ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Â›Ó·È ÂÍ·ÈÚÂÙÈο ÛËÌ·ÓÙÈ΋ ·ÊÂÓfi˜ ÌÂÓ ‰ÈfiÙÈ ·‡ÍËÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜, ÌË ··Ú·›ÙËÙË, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÈÙ·¯˘ÓfiÌÂÓË ÈÓÔÁ¤ÓÂÛË ÛÙË ¯ÚfiÓÈ· Ë·Ù›Ùȉ· C ‹ Ó· ˘ÚÔ‰ÔÙ‹ÛÂÈ ·Ó¿Ù˘ÍË ÈÓÔÔÈÔ‡ ¯ÔÏÔÛÙ·ÙÈ΋˜ Ë·Ù›Ùȉ·˜26, ·ÊÂÙ¤ÚÔ˘ ‰Â ‰ÈfiÙÈ ÔÍ›· ·fiÚÚÈ„Ë ¯ˆÚ›˜ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ¯ÚfiÓÈ· ·fiÚÚÈ„Ë, ȉȷ›ÙÂÚ· Û ϋÙ˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ¯ÔÚËÁÂ›Ù·È ÈÓÙÂÚÊÂÚfiÓË.27 ∫·È ÔÈ ‰‡Ô ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ÈÛÙÔÏÔÁÈο ·fi ÊÏÂÁÌÔÓ‹ ÙˆÓ ˘Ï·›ˆÓ ‰È·ÛÙËÌ¿ÙˆÓ Î·È ‚Ï¿‚Ë ÙˆÓ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ. ™ÙÔÓ ›Ó·Î· 1 ·Ó·Ê¤ÚÔÓÙ·È ÂÚÈÏËÙÈο Î·È Û˘ÁÎÚ›ÓÔÓÙ·È ÔÈ Î‡ÚȘ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ, ¯Ú‹ÛÈ̘ ÁÈ· ÙËÓ ·Ó·ÊÂÚfiÌÂÓË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. ∫·Ì›· ·fi ÙȘ ·ÏÏÔÈÒÛÂȘ ·˘Ù¤˜ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÂȉÈ΋ ‹ ·ıÔÁÓˆÌÔÓÈ΋ ÁÈ· ÙËÓ ÔÍ›· ·fiÚÚÈ„Ë ‹ ÙËÓ ˘ÔÙÚÔ‹ Ù˘ HCV Ïԛ̈͢. øÛÙfiÛÔ, ÚÔÛÂÎÙÈ΋ ÈÛÙÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ Ù‡Ô˘ Ù˘ ÊÏÂÁÌÔÓ‹˜ Î·È ÙˆÓ Û˘ÓÔ‰ÒÓ ·ÏÏÔÈÒÛÂˆÓ Ô˘ ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ›Ó·Î· ÂÈÙÚ¤ÂÈ ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ·ÚÈÔ˘ ·ÈÙ›Ô˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Û˘ÓÂÒ˜ ·ÛÊ·Ï‹ ÈÛÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛˆÓ. ∞Í›˙ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ Û ÌÈ· ÂӉȷʤÚÔ˘Û· ÌÂϤÙË ÙˆÓ Saxena Î·È Û˘Ó ‰È·ÈÛÙÒıËΠfiÙÈ Û ÈÛÙÔÏÔÁÈÎfi Â›Â‰Ô Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÔÙˆÙÈÎÒÓ ÛˆÌ·Ù›ˆÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ (2Ï¿ÛÈÔ˜ Î·È Ì ‰È¿¯˘ÙË Î·Ù·ÓÔÌ‹) ÛÙËÓ ˘ÔÙÚÔ‹ ·’ fiÙÈ ÛÙËÓ ·fiÚÚÈ„Ë (ÂÚÈ˘Ï·›· ηٷÓÔÌ‹). 28
¶›Ó·Î·˜ 1. ™‡ÁÎÚÈÛË ÈÛÙÔÏÔÁÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ HCV Ïԛ̈͢ Î·È ÔÍ›·˜ ·fiÚÚȄ˘ ÛÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· (∞) ¶˘Ï·›Â˜ Î·È ÂÚÈ˘Ï·›Â˜ ·ÏÏÔÈÒÛÂȘ ¶˘Ï·›· ÊÏÂÁÌÔÓ‹ ¶ÂÚÈ˘Ï·›· Ë·Ù›Ùȉ· ºÏÂÁÌÔÓ‹ ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ∞ÒÏÂÈ· ¯ÔÏËÊfiÚˆÓ fiÚˆÓ ∂Ó‰ÔıËÏÈ˝Ùȉ· ÿÓˆÛË
∏·Ù›Ùȉ· C
∞fiÚÚÈ„Ë
ªÔÓÔ‡ÚËÓ· ·ÙÙ·Ú· (ÏÂÌÊÔÂȉ›˜ ·ıÚÔ›ÛÂȘ) ¶ÔÈΛÏË ◊È· (ÏÂÌÊÔ΢ÙÙ·ÚÈ΋) Ÿ¯È ∞Ô‡Û·/◊È· ¡·È
ªÈÎÙfi˜ ÏËı˘ÛÌfi˜ (ÏÂÌÊÔ·ÙÙ·Ú·, Ì·ÎÚÔÊ¿Á·, Ô˘‰ÂÙÂÚfiÊÈÏ·, ˆÛÈÓfiÊÈÏ·) ◊È· ∂ÌÊ·Ó‹˜ (ÌÈÎÙfi˜ ÏËı˘ÛÌfi˜) ¶ÔÈΛÏË (Û ÂÚÈÙÒÛÂȘ ÂͤÏÈ͢ ÚÔ˜ ¯ÚfiÓÈ· ·fiÚÚÈ„Ë) ¡·È Ÿ¯È
∏·Ù›Ùȉ· C
∞fiÚÚÈ„Ë
°ÂÓÈο ‹È· ∂ÛÙȷ΋ Δ˘¯·›· §Ô‚ȷ΋ ‰È·Ù·Ú·¯‹ ™¿ÓÈ· (ÂÎÙfi˜ IXHC) ¡·È (Ì·ÎÚÔÊ˘Û·ÏÏȉ҉˘) ™˘¯Ó¿
¶ÔÈΛÏË ™˘ÚÚ¤Ô˘Û· ¶ÂÚÈÊÏ‚È΋ ºÏÂÁÌÔÓ‹ ÂÓ‰ÔıËÏ›Ô˘ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ ™˘¯Ó‹ Ÿ¯È §›Á·
(μ) ¶·ÚÂÁ¯˘Ì·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ¶·ÚÂÁ¯˘Ì·ÙÈ΋ ÊÏÂÁÌÔÓ‹ Δ‡Ô˜ ∫·Ù·ÓÔÌ‹ ÕÏϘ ‚Ï¿‚˜ ÃÔÏfiÛÙ·ÛË ™Ù¿وÛË ∞ÔÙˆÙÈο ۈ̿ÙÈ·
270
K. ¶AT™IAOYPA
¶ÚfiÛÊ·Ù· ‰È·ÈÛÙÒıËΠ›Û˘ fiÙÈ Ô ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈÎfi˜ ‰Â›ÎÙ˘ C4d ÂÎÊÚ¿˙ÂÙ·È Û ÂÚÈÙÒÛÂȘ ÔÍ›·˜ ·fiÚÚȄ˘ (ÂȉÈÎfiÙËÙ· 90%) Î·È ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ÌÈ· ÂÈϤÔÓ ·Ú¿ÌÂÙÚÔ˜ ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ ‰‡Ô ÔÓÙÔًوÓ.29 π‰È·›ÙÂÚ· ¯Ú‹ÛÈÌÔ ÛÙÔÈ¯Â›Ô ÁÈ· ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ·ÔÙÂÏ› Ô ¯ÚfiÓÔ˜ ÂÌÊ¿ÓÈÛ˘ Ù˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜. Δ· ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÙȘ ÚÒÙ˜ 30 Ë̤Ú˜ ÂÓÒ Û˘Ó‹ıˆ˜ Ë ˘ÔÙÚÔ‹ ÌÂٷ͇ Ù˘ 3˘ Î·È 8˘ ‚‰ÔÌ¿‰·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË 1,7. ™ËÌÂÈÒÓÂÙ·È Â›Û˘ fiÙÈ Ù· ›‰· ÙÔ˘ È˚ÎÔ‡ ÊÔÚÙ›Ô˘ ÛÙÔÓ ÔÚfi Â›Ó·È ˘„ËÏfiÙÂÚ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ·fi ÂΛÓÔ˘˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ·ÌÈÁÒ˜ ÔÍ›· ·fiÚÚÈ„Ë. Δ¤ÏÔ˜, Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Û˘Ó˘¿Ú¯Ô˘Ó Î·È ÔÈ ‰‡Ô ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ. 1,26 ™ÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ‰ÈÏ‹˜ ·ÈÙÈÔÏÔÁ›·˜ ÔÈ ‚Ï¿‚˜ Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ·fiÚÚÈ„Ë Â›Ó·È ‹È˜, ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È ÂÈϤÔÓ ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È ˆ˜ ˘ÂÚÈÛ¯‡Ô˘Û· ‰È¿ÁÓˆÛË ıˆÚÂ›Ù·È Ë ˘ÔÙÚÔ‹ Ù˘ Ïԛ̈͢.26 ∂ÈϤÔÓ ·ÓÔÛÔηٷÛÙÔÏ‹ ÚÔÙ›ÓÂÙ·È ˆ˜ ıÂڷ›· ÂÎÏÔÁ‹˜ fiÙ·Ó Ë ÔÍ›· ·fiÚÚÈ„Ë Â›Ó·È Ì¤ÙÚÈ·˜ ‚·Ú‡ÙËÙ·˜ ‹ ÔÈ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ Â›Ó·È ˘Ô‰ËψÙÈΤ˜ ÂͤÏÈ͢ Û ¯ÚfiÓÈ· ·fiÚÚÈ„Ë.1,7
μÈ‚ÏÈÔÁÚ·Ê›· 1. Hubscher SG, Portmann BC. Transplantation pathology. In: Burt AD, Portmann BC, Ferrell LD (eds). MacSween’s Pathology of the Liver. 5th ed. Churchill Livingstone 2007:815-879 2. Berenguez M, Lopez-Labrador FX, Wright TL. Hepatitis C and liver transplantation. J Hepatol 2001;35:666678 3. Garcia-Retortillo M, Forns X, Feliu A, et al. Hepatitis C virus kinetics during and immediately after liver transplantation. Hepatology 2002;35:680-687 4. Petrovic LM. Early recurrence of hepatitis C virus injection after liver transplantation. Liver Transpl 2006; 12:S32-S37 5. Gane E. The natural history and outcome of liver transplantation in hepatitis C virus-infected recipients. Liver Transpl 2003;9:S28-S34 6. Berenguez M. What determines the natural history of recurrent hepatitis C after liver transplantation? J Hepatol 2005;42:448-456 7. Demetris AJ, Nalesnik M, Randhawa P, Wu T, Minervini M, Lai C, Lu Z. Histological patterns of rejection and other causes of liver dysfunction. In: Busuttil and Klintmalm (eds). Transplantation of the Liver 2nd ed.
Elsevier Saunders;2005:1058-1128 8. Lassman CR. Pathology of recurrence of non-neoplastic disease after liver transplantation. In: Busuttil and Klintmalm (eds). Transplantation of the Liver 2nd ed. Elsevier Saunders;2005:1129-1148 9. Russo MW, Firpi RJ, Nelson DR, et al. Early hepatic stellate cell activation is associated with advanced fibrosis after liver transplantation in recipients with hepatitis C. Liver Transpl 2005;11:1235-1241 10. Gawrieh S, Papouchado BG, Burgart LJ. Early hepatic stellate cell activation predicts severe hepatitis C recurrence after liver transplantation. Liver Transpl 2005; 11:1207-1213 11. Pelletier SJ, Iezzoni JC, Crabtree TJ, et al. Prediction of liver allograft fibrosis after transplantation for hepatitis C virus: persistent elevation of serum transaminase levels versus necroinflammatory activity. Liver Transpl 2000;6:44-53 12. Seekumar R, Gonzalez-Koch A, Maor-Kndler Y, et al. Early identification of recipients with progressive histologic recurrence of hepatitis C after liver transplantation. Hepatology 2000;32:1125-1130 13. Guido M, Fagiuoli S, Tessari G, et al. Histology predicts cirrhotic evolution of post transplant hepatitis C. Gut 2002;50:697-700 14. Gordon FD, Pomfret EA, Pomposelli JJ, et al. Severe steatosis as the initial histologic manifestation of recurrent hepatitis C genotype 3. Hum Pathol 2004;35:636638 15. Lefkowitz JH. Diagnostic issues in liver transplantation pathology. Clin Liver Dis 2002;6:538-560 16. Ballardini G, De Raffele E, Groff P, et al. Timing of reinfection and mechanisms of hepatocellular damage in transplanted hepatitis C virus-reinfected liver. Liver Transpl 2002;8:10-20 17. Crespo J, Rivero M, Mayorga M, et al. Involvement of the fas system in hepatitis C virus recurrence after liver transplantation. Liver Transpl 2000;6:562-569 18. Rosen HR. Hepatitis C virus in the human liver transplantation model. Clin Liver Dis 2003;7:107-125 19. Firpi RJ, Abdelmalek MF, Soldevila-Pico C, et al. One-year protocol liver biopsy can stratify fibrosis progression in liver transplant recipients with recurrent hepatitis C infection. Liver Transpl 2004;10:1240-1247 20. Verslype C, Nevens F, Sinelli N, et al. Hepatic immunohistochemical staining with a monoclonal antibody against HCV-E2 to evaluate antiviral therapy and reinfection of liver grafts in hepatitis C viral infection. J Hepatol 2003;38:208-214 21. Nuovo GJ, Holly A, Wakely P, et al. Correlation of histology, viral load, and in situ viral detection in hepatic biopsies from patients with liver transplants secondary to hepatitis C infection. Hum Pathol 2002;33:277-284 22. Deshpande V, Burd E, Aardema KL, et al. High levels of hepatitis C virus RNA in native livers correlate with
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
the development of cholestatic hepatitis in liver allografts and a poor outcome. Liver Transpl 2001;7:118124 23. Barcena R, SanRoman AL, Del Campo S, et al. Posttransplant liver granulomatosis associated with hepatitis C? Transplantation 1998;65:1494-1495 24. Younossi ZM, Boparai N, Gramlich T, et al. Agreement in pathologic interpretation of liver biopsy speciments in posttransplant hepatitis C infection. Arch Path Lab Med 1999;123:143-145 25. Regev A, Molina E, Moura R, et al. Reliability of histopathologic assessment for the differentiation of recurrent hepatitis C from acute rejection after liver transplantation. Liver Transpl 2004;10:1233-1239 26. Demetris AJ, Eghtesad B, Marcos A, et al. Recurrent
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hepatitis C in liver allografts. Prospective assessment of diagnostic accuracy, identification of pitfalls, and observations about pathogenesis. Am J Surg Pathol 2004;28:658-669 27. Saab S, Kalmar D, Gajjar NA, et al. Outcomes of acute rejection after liver interferon therapy in liver transplant recipients. Liver Transpl 2004:859-867 28. Saxena R, Crawford JM, Navarro VJ, et al. Utilization of acidophil bodies in the diagnosis of recurrent hepatitis C infection after orthotopic liver transplantation. Mod Pathol 2002;15:897-903 29. Schmeding M, Dankof A, Krenn V, et al. C4d in acute rejection after liver transplantation-a valuable tool in differential diagnosis of hepatitis C recurrence. Am J Transpl 2006;6:523-530
AÓÔÛÔÔ›ËÛË ˆ˜ ̤ÙÚÔ ÚÔÛÙ·Û›·˜ ÚÈÓ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·È‰È¿
19
KÏÂÔ̤Ó˘ ™‡ÚÔÁÏÔ˘
∞ÓÔÛÔÔ›ËÛË ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË
OÈ ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ÌÈ· ·fi ÙȘ ÈÔ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‹·ÙÔ˜, ÏfiÁˆ ηٷÛÙÔÏ‹˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·ÓÔÛ›·˜ Ë ÔÔ›· Û¯ÂÙ›˙ÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ [1-3]. ΔÔ Úfi‚ÏËÌ· ·˘Ùfi Â›Ó·È È‰È·›ÙÂÚ· ÛÔ‚·Úfi ÁÈ· ‚Ú¤ÊË Ô˘ ‰ÂÓ ÚfiÏ·‚·Ó Ó· ÔÏÔÎÏËÚÒÛÔ˘Ó ÙÔ ÚfiÁÚ·ÌÌ· ÙˆÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ¤ÙÛÈ ‚Ú›ÛÎÔÓÙ·È Û ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ·Ó·Ù‡ÍÔ˘Ó ÏÔÈÌÒÍÂȘ ÔÈ Ôԛ˜ ˘fi ¿ÏϘ Û˘Óı‹Î˜ ÌÔÚÔ‡Ó Ó· ÚÔÏËÊıÔ‡Ó [4]. °È· ÙÔ ÏfiÁÔ ·˘Ùfi Û ÔÏÏ¿ ÎÚ¿ÙË Ù˘ ∂˘ÚÒ˘ ÚÔÙ›ÓÔÓÙ·È ‰È¿ÊÔÚ· ÚÔÁÚ¿ÌÌ·Ù· ÁÈ· ˘Ô„‹ÊÈÔ˘˜ Ï‹Ù˜ ‹·ÙÔ˜ Î·È ¿ÏÏˆÓ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ. Δ· ÚÔÁÚ¿ÌÌ·Ù· ·˘Ù¿ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ù· ÂÌ‚fiÏÈ· ‰ÈÊıÂÚ›Ùȉ·˜, ÙÂÙ¿ÓÔ˘, ÎÔΛÙË, ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜, ·ÈÌfiÊÈÏÔ˘ ÈÓÊÏÔ˘¤ÓÙÛ·˜, Ë·Ù›Ùȉ·˜ μ, ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ÈÏ·Ú¿˜, ÂÚ˘ıÚ¿˜ Î·È ·ÚˆÙ›Ùȉ·˜, ·ÏÏ¿ Î·È ÓÂfiÙÂÚ· ÂÌ‚fiÏÈ· Ô˘ ÚÔÙ›ÓÔÓÙ·È ÁÈ· ¿ÙÔÌ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ fiˆ˜ Ù· ÂÌ‚fiÏÈ· ÁÈ· ÙËÓ ·ÓÂÌÔ‚ÏÔÁÈ¿, ÙËÓ Ë·Ù›Ùȉ· ∞ Î·È ÙÔÓ ÛÙÚÂÙfiÎÔÎÎÔ Ó¢ÌÔÓ›·˜ [5-7]. øÛÙfiÛÔ, ·Ú¿ ÙȘ Û˘ÛÙ¿ÛÂȘ ·˘Ù¤˜, ÌÈ· ÚfiÛÊ·ÙË ÌÂϤÙË ·È‰ÈÒÓ ˘Ô„‹ÊÈˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÔ‡˜ ÔÚÁ¿ÓÔ˘, ¤‰ÂÈÍ fiÙÈ 70% ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ‰ÂÓ Â›¯·Ó ÂÌ‚ÔÏÈ·Ûı› Ì ٷ ·Ó¿ÏÔÁ· ÂÌ‚fiÏÈ· ηٿ ÙÔ ¯ÚfiÓÔ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ [8]. Δ· ·È‰È¿ ·˘Ù¿ Â›Ó·È ·ÚÔÛÙ¿ÙÂ˘Ù· ¤Ó·ÓÙÈ ÏÔÈÌÒÍÂˆÓ ÔÈ Ôԛ˜ ·ÚÂÌÔ‰›˙ÔÓÙ·È Ì ¤Ó· ÂÌ‚fiÏÈÔ ‹ ÌÔÚ› Ó· ·ÔÙ‡¯Ô˘Ó Ó· ·Ó·Ù‡ÍÔ˘Ó ·ÓÔÛ›· Â¿Ó ÂÌ‚ÔÏÈ·ÛıÔ‡Ó ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÚÔ‚Ï‹Ì·Ù· ΢ڛˆ˜ ÌÔÚ› Ó· ÚÔ·„Ô˘Ó Â¿Ó ¯ÔÚËÁËıÔ‡Ó ÂÌ‚fiÏÈ· Ì ˙ÒÓÙ˜ ÂÍËÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜. Δ· ̤¯ÚÈ Û‹ÌÂÚ· ‰Â‰Ô̤ӷ ÚÔÛÙ·Û›·˜ ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‚·Û›˙ÔÓÙ·È Û ‰È¿ÊÔÚ˜ ÂÚÁ·Û›Â˜ Ì ‰È·ÊÔÚÂÙÈο ÚˆÙfiÎÔÏÏ· ÌÂϤÙ˘ Î·È ÌÈÎÚfi ·ÚÈıÌfi ÂÚÈÛÙ·ÙÈÎÒÓ.
¶ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ë ÚÔÛÙ·Û›· ÂÓfi˜ ˘Ô„ËÊ›Ô˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·È‰ÈÔ‡ ÛÙËÚ›˙ÂÙ·È ÛÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Ì ٷ ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙËÓ ËÏÈΛ· ÂÌ‚fiÏÈ· (›Ó·Î·˜ 1) Î·È ÙË ¯ÔÚ‹ÁËÛË ÛÊ·ÈÚÈÓÒÓ Â› ÂȉËÌ›·˜ ‹ Èı·Ó‹˜ ·ʋ˜ Ì ¿Û¯ÔÓÙ· ÓÔÛ‹Ì·ÙÔ˜ ÁÈ· ÙÔ ÔÔ›Ô ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ›ÛÙÔÈ¯Ô ÂÌ‚fiÏÈÔ. ¶·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ ÙÚÈÒÓ ÂÙÒÓ, ÂÊfiÛÔÓ Â›Ó·È Û ϛÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ı· Ú¤ÂÈ Ó· ·›ÚÓÔ˘Ó Á ÛÊ·ÈÚ›ÓË Î¿ı ̋ӷ, ·fi ÙÔÓ ¡Ô¤Ì‚ÚÈÔ Ì¤¯ÚÈ ÙÔÓ ∞Ú›ÏÈÔ ÁÈ· ÚÔÛÙ·Û›· ·fi ÙÔÓ RSV Èfi. ∂›Û˘ Û ·È‰›· Ù˘ ›‰È·˜ ÔÌ¿‰·˜ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÂÌ‚ÔÏÈ·Ûı› ¤Ó·ÓÙÈ Ù˘ Ë·Ù›Ùȉ·˜ μ, Û ÂÚ›ÙˆÛË ‡ÔÙ˘ ·ʋ˜ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ˘ÂÚ¿ÓÔÛË Á ÛÊ·ÈÚ›ÓË Î·È ÂÊfiÛÔÓ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÓÙÂӉ›ÍÂȘ Ó· Á›ÓÂÙ·È ·Ú¿ÏÏËÏ· Î·È ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÂÌ‚fiÏÈÔ. ¶›Ó·Î·˜ 1. ∂Ì‚fiÏÈ· Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤Ó· ·È‰È¿ ΔÔ ·ÎfiÏÔ˘ıÔ Û¯‹Ì· ·Ú¯›˙ÂÈ 6 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ‹·ÙÔ˜ ¢ÈÊıÂÚ›Ùȉ·˜, ÙÂÙ¿ÓÔ˘, ™˘Ó¯›˙ÂÈ ÙÔ Î·ÓÔÓÈÎfi ÙÔ˘ ÎÔΛÙË (DT·P) ÚfiÁÚ·ÌÌ· ¶ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ™˘Ó¯›˙ÂÈ ÙÔ Î·ÓÔÓÈÎfi ÙÔ˘ ÚfiÁÚ·ÌÌ· ΔÔ ¿ÌÂÛÔ ÂÚÈ‚¿ÏÏÔÓ (ÁÔÓ›˜ Î·È ·‰¤ÏÊÈ·) ı· Ú¤ÂÈ Ó· ÂÌ‚ÔÏÈ·ÛıÔ‡Ó Â›Û˘ Ì ÙÔ ·‰Ú·ÓÔÔÈË̤ÓÔ ÂÌ‚fiÏÈÔ πÓÊÏÔ˘¤ÓÙÛ·˜ Ù‡Ô˘ b ™˘Ó¯›˙ÂÈ ÙÔ Î·ÓÔÓÈÎfi ÙÔ˘ ÚfiÁÚ·ÌÌ· πÏ·Ú¿˜, ÂÚ˘ıÚ¿˜, ΔÔÓ 7Ô Ì‹Ó· ·Ó ‰ÂÓ ¤¯ÂÈ ÂÌ‚ÔÏÈ·Ûı› ·ÚˆÙ›Ùȉ·˜ ÚÔËÁÔ˘Ì¤Óˆ˜ (Ó· Á›ÓÂÈ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ Ù›ÙÏÔ˘) ∏·Ù›Ùȉ·˜ ∞ ªÂÙ¿ ÙÔÓ 7Ô Ì‹Ó· Û ‰˘Ô ‰fiÛÂȘ ∏·Ù›Ùȉ·˜ μ Ton 7o, 9o & 12o ª‹Ó· ∞ÓÂÌÔ‚ÏÔÁÈ¿˜ ΔÔÓ 7Ô Ì‹Ó· ·Ó ‰ÂÓ ¤¯ÂÈ ÂÌ‚ÔÏÈ·Ûı› (Varicella) ÚÔËÁÔ˘Ì¤Óˆ˜ (Ó· Á›ÓÂÈ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ Ù›ÙÏÔ˘) Pneumovax °È· ·ÛıÂÓ›˜ Ì ÛÏËÓÂÎÙÔÌ‹ ‹ ·ÛÏËÓ›· Influenza ∂ÙËÛ›ˆ˜
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ÃÚfiÓÔ˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ·È‰ÈÔ‡ ΔÔ È‰Â҉˜ Â›Ó·È ÙÔ ·È‰› Ó· ¤¯ÂÈ ˘Ô‚ÏËı› Û fiÏ· Ù· ÂÌ‚fiÏÈ· ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÁÈ· ÙÔ˘˜ ÂÍ‹˜ ÙÚÂȘ ÏfiÁÔ˘˜: ·) Ë ·ÓÙ·fiÎÚÈÛË ÛÙÔ ÂÌ‚fiÏÈÔ Â›Ó·È Ù·¯‡ÙÂÚË ‚) ÂÌ‚fiÏÈ· ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ Û˘Ó‹ıˆ˜ ·ÓÙÂӉ›ÎÓ˘ÓÙ·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È 3) Ù· ÂÂÈÛfi‰È· ·fiÚÚȄ˘ may precipitate d by immunization [9]. °ÂÓÈο ÂÊfiÛÔÓ ÙÔ ·È‰› ‰ÂÓ ¤¯ÂÈ ÂÌ‚ÔÏÈ·Ûı› Ï‹Úˆ˜ ‹ ¯ÚÂÈ¿˙ÂÙ·È Â·Ó·ÏËÙÈΤ˜ ‰fiÛÂȘ οÔÈˆÓ ÂÌ‚ÔÏ›ˆÓ, ·˘Ù¿ ¯ÔÚËÁÔ‡ÓÙ·È ÌÂÙ¿ ÙÔÓ 6Ô Ì‹Ó· ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.
∂Ì‚fiÏÈ· ·fi ÓÂÎÚÔ‡˜ ÈÔ‡˜ ‹ Û˘ÛÙ·ÙÈο ·˘ÙÒÓ Δ· ÂÌ‚fiÏÈ· ·˘Ù¿ ıˆÚËÙÈο ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÎÈÓ‰‡ÓÔ˘˜ ÁÈ· ÌÂÙ·ÌÔÛ¯Â˘Ì¤Ó· ·È‰È¿. Δ· ‰Â‰Ô̤ӷ Ô˘ ˘¿Ú¯Ô˘Ó ÁÈ· Ù· ·È‰È¿ ·˘Ù¿, ·ÚfiÏÔ Ô˘ Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ Î·È ·ÊÔÚÔ‡Ó ÌÂϤÙ˜ Ì ÌÈÎÚfi ·ÚÈıÌfi ÂÚÈÛÙ·ÙÈÎÒÓ Î·È ‰È·ÊÔÚÂÙÈο ÚˆÙÔÎfiÏÏ· Â›Ó·È Ì¿ÏÏÔÓ ÈηÓÔÔÈËÙÈο Î·È Ù· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· Û˘ÓÈÛÙÔ‡Ó ÙË Û˘Ó¤¯ÈÛË ÙˆÓ ÂÌ‚ÔÏ›ˆÓ ·˘ÙÒÓ ‹ ·ÎfiÌË Î·È ·Ú¯ÈÎfi ÂÌ‚ÔÏÈ·ÛÌfi.
∂Ì‚fiÏÈ· ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ ∞Ó Î·È Ù· ÂÌ‚fiÏÈ· ·˘Ù¿ ·Ú¿ÁÔÓÙ·È ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜, Ù· ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ·È‰È¿ ‰ÂÓ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔ˘Ó Ù¤ÙÔÈ· ÂÌ‚fiÏÈ·, Ì ÙÔ ÛÎÂÙÈÎfi fiÙÈ Ô ÂÍ·ÛıÂÓË̤ÓÔ˜ Èfi˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÓÙ›ÛÙÔÈ¯Ë ÓfiÛÔ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi Û˘ÓÈÛÙ¿Ù·È fiˆ˜ Ù· ÂÌ‚fiÏÈ· ·˘Ù¿ ¯ÔÚËÁÔ‡ÓÙ·È 2-4 ‚‰ÔÌ¿‰Â˜ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË [10]. ∞Ó Î·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÔÚÈṲ̂ӷ ÌÂÁ¿Ï· ¤¯Ô˘Ó ·Ú¯›ÛÂÈ Ó· ¯ÔÚËÁÔ‡Ó Ù¤ÙÔÈ· ÂÌ‚fiÏÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ù· ‰Â‰Ô̤ӷ Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ Î·È ‚·Û›˙ÔÓÙ·È Î˘Ú›ˆ˜ Û ·ÓÙ›ÛÙÔȯ˜ ÌÂϤÙ˜ ·fi ·ÛıÂÓ›˜ Ì AIDS Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ.
∂Ì‚fiÏÈ· Ô˘ Û˘ÓÈÛÙÒÓÙ·È ÁÈ· ¯ÚfiÓȘ ·ı‹ÛÂȘ ÙÔ˘ ‹·ÙÔ˜ ™ÙËÓ ÔÌ¿‰· ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÙÔ ÂÌ‚fiÏÈÔ ¤Ó·ÓÙÈ Ù˘ Ë·Ù›Ùȉ·˜ ∞[11]. ∏ ¿ÚÎÂÈ· ÙÔ˘ ÂÌ‚ÔÏ›Ô˘ ·˘ÙÔ‡ ‰ÂÓ ¤¯ÂÈ ÌÂÏÂÙËı› Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤Ó· ¿ÙÔÌ·, ¤¯ÂÈ fï˜ ‰Âȯı› fiÙÈ Û ·ÛıÂÓ›˜ Ì AIDS Ë ·ÓÙÈۈ̷ÙÈ΋ ÈηÓfiÙËÙ· ¤Êı·Û ÙÔ 80% Î·È Ï¤ÔÓ [12]. ∞Ó Î·È Ù· ÂÌÔÚÈο ‰È·ÁÓˆÛÙÈο
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ÙÂÛÙ ÌÔÚ› Ó· ÌËÓ ·ÓȯÓÂ‡Ô˘Ó ¯·ÌËÏÔ‡˜ ·ÏÏ¿ ÚÔÛٷ٢ÙÈÎÔ‡˜ Ù›ÙÏÔ˘˜, Û˘ÓÈÛÙ¿Ù·È ÌÂÙ¿ ÙÔÓ ÂÌ‚ÔÏÈ·ÛÌfi Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ [13].
∞ÓÔÛÔÔ›ËÛË ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ O ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ·ÙfiÌˆÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ·Ú¤¯ÂÈ ‰Â˘ÙÂÚÔ·ı‹ ÚÔÛÙ·Û›· ÁÈ· Ù· ÌÂÙ·ÌÔÛ¯Â˘Ì¤Ó· ·È‰È¿. O ÂÌ‚ÔÏÈ·ÛÌfi˜ ÙˆÓ ·ÙfiÌˆÓ ·˘ÙÒÓ Ì ÓÂÎÚ¿ ÂÌ‚fiÏÈ· ‰ÂÓ ÂÁ΢ÌÔÓ› ηӤӷ ΛӉ˘ÓÔ ÁÈ· ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ·È‰› [14]. ∂›Û˘ Ì ÂÍ·›ÚÂÛË ÙÔ ÂÌ‚fiÏÈÔ Ù˘ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ ÙÔ ¯ÔÚËÁÔ‡ÌÂÓÔ Ôfi ÙÔ ÛÙfiÌ·, ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ÌÔÚ› Ó· ÂÌ‚ÔÏÈ·Ûı› Ì fiÏ· Ù· ÂÌ‚fiÏÈ· ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ Ì Ôχ ÌÈÎÚfi ΛӉ˘ÓÔ ÁÈ· Ù· ÌÂÙ·ÌÔÛ¯Â˘Ì¤Ó· ·È‰È¿ [1].
™˘ÌÂÚ¿ÛÌ·Ù· Δ· ·È‰È¿ Ô˘ ÚfiÎÂÈÙ·È Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ı· Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È ÛÙÔ˘˜ ··Ú·›ÙËÙÔ˘˜ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘˜ ÂÌ‚ÔÏÈ·ÛÌÔ‡˜ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·Ó Î·È Ù· ‰Â‰Ô̤ӷ Â›Ó·È ÂÚÈÔÚÈṲ̂ӷ Î·È ‚·Û›˙ÔÓÙ·È Î˘Ú›ˆ˜ Û ÌÂϤÙ˜ ·fi ·ÛıÂÓ›˜ Ì AIDS Î·È Ï¢¯·ÈÌ›· ÚÔÙ›ÓÂÙ·È Î˘Ú›ˆ˜ Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì ÓÂÎÚ¿ ÂÌ‚fiÏÈ· 6 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂Ì‚fiÏÈ· ·fi ˙ÒÓÙ˜ ÂÍ·ÛıÂÓË̤ÓÔ˘˜ ÈÔ‡˜ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Ì ÂÈÊ˘Ï¿ÍÂȘ.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Fulginity VA, Scribner R, Groth CG, et al. Infections in recipients of liver homografts. N Engl J Med 1968; 279:619 2. Busuttil RW, Golstein LI, Donavitch G, et al. Liver transplantation today. Ann Intern Med 1986;104:377 3. Carey WD, Vogt D, Broughan T et al. Liver transplantation at Cleveland Clinic: early results. Cleve Clin J Med 1987;54:83 4. Pacini-Edelstein SJ, Mehra M, Ament ME, Vargas JH, Martin MG, McDiarmid SV. Varicella in pediatric liver transplant patients: a perspective analysis of treatment and outcome. J Pediatr Gastro Nutr 2003;37:183186 5. Pinot DM, Nardone A. Varicella zoster virus vaccination policies and surveillance strategies in Europe. Euro Surveill 2005;10:43-45 6. Reinert RR. Pneumococcal conjugate vaccines – a European perspective. Int J Med Med Microbiol 2004; 294:277-294 7. Franco E, Vitiello G. Vaccination strategies against HAV in southern Europe. Vaccine 2003;21:696-697
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8. Burroughs M, Moscona A. Immunization of pediatric solid organ transplant candidates and recipients. Clin Infect Dis 2000;30:857-869 9. Blumberg E, Fitzpatrick J, Stutman P, Hayden F, Brozena S. Safety of influenza vaccine in heart transplant recipients. J Heart Lung Transplant 1998;17:1075-80 10. Burrough M, Moscona A. Immunization pof pediatric solid organ transplant candidates and recipients. Clin Infect Dis 2000;30:857-69 11. Prevention of hepatitis A infections: guidelines for use of hepatitis A vaccine and immune globulin. American Academy of Pediatrics Committee on Infectious Diseases. Pediatrics 1996;98:1207-15 12. Neilsen G, Bodsworth N, Watts N. Response to hepatitis A vaccination in human immunodeficiency
virus-infected and –uninfected homosexual men. J Infect Dis 1997;176:1064-67 13. American Academy of Pediatrics. Hepatitis A. In Georges MP, ed. 1997 Red Book: report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Illinois: American Academy of Pediatrics, 1997:237-46 14. American Academy of Pediatrics. Influenza. In: Georges MP, ed. 1997 Red Book: report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Illinois: American Academy of Pediatrics, 1997:307-15 15 Fitts S, Green M, Reyes J, Nour B, Tzakis A, Kochosis S. Clinical features of nosocomial rotavirus infection in pediatric liver transplant recipients. Clin Transplant 1995;9:201-4
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1. ∂ÈÛ·ÁˆÁ‹
Û¤˜ ·˘ÙÒÓ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙËÓ ∂˘ÚÒË (1,2). ™‹ÌÂÚ· ÛÙË μ. ∞ÌÂÚÈ΋ ˘¿Ú¯Ô˘Ó 131 ΤÓÙÚ· Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡Ó ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜. ªfiÓÔ ÙÔ 15% ·˘ÙÒÓ Ú·ÁÌ·ÙÔÔÈÔ‡Ó ÂÚÈÛÛfiÙÂÚ˜ ·fi 20 ÙÔ ¯ÚfiÓÔ. OÈ ÌÈÛ¤˜ ·fi ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·˘Ù¤˜ Á›ÓÔÓÙ·È ÛÙ· 19 ÌÂÁ·Ï‡ÙÂÚ· ΤÓÙÚ· (1). ∂›Û˘, ·ÁÎÔÛÌ›ˆ˜ ˘¿Ú¯Ô˘Ó 47 ΤÓÙÚ· Ô˘ ‰ÈÂÓÂÚÁÔ‡Ó ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓËÛȉ›ˆÓ (18 ·fi ·˘Ù¿ Î·È ·˘ÙÔÌÂÙ·ÌÔۯ‡ÛÂȘ). ¶ÂÚÈÛÛfiÙÂÚ˜ ·fi 20 ÙÔ ¯ÚfiÓÔ ‰ÈÂÓÂÚÁÔ‡ÓÙ·È Û 11 ΤÓÙÚ· (7 ÛÙËÓ ∂˘ÚÒË, 4 ÛÙË μ. ∞ÌÂÚÈ΋). ∞˘Ù¿ Ù· 11 ΤÓÙÚ· ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈ‹ÛÂÈ Û˘ÓÔÏÈο ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ÌÈÛ¤˜. ¶ÚfiÛÊ·Ù· Ù· ΤÓÙÚ· ÙÔ˘ °Î›ÛÂÓ Î·È ÙÔ˘ ŒÓÙÔÌÓÙÔÓ ÍÂ¤Ú·Û·Ó ÙȘ 100 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓËÛȉ›ˆÓ ¤Î·ÛÙÔ (3). ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ηÙËÁÔÚÈÔÔÈÂ›Ù·È Ì ‚¿ÛË ÙË Û˘Ó‡·ÚÍË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÛÂ Û˘Ó‰˘·Ṳ̂ÓË ·ÁÎÚ¤·ÙÔ˜-ÓÂÊÚÔ‡ (SPK), Û ·ÁÎÚ¤·ÙÔ˜ ‡ÛÙÂÚ· ·fi ÓÂÊÚÔ‡ (PAK) Î·È Û ·ÁÎÚ¤·ÙÔ˜ ÌfiÓÔ (PTA). ∂›Û˘ ηÙËÁÔÚÈÔÔÈÂ›Ù·È Ì ‚¿ÛË ÙËÓ ·ÚÔ¯¤Ù¢ÛË Ù˘ Â͈ÎÚÈÓÔ‡˜ ÌÔ›Ú·˜ Û ÂÓÙÂÚÈ΋ (ED) ‹ ΢ÛÙÈ΋ (BD). Δ¤ÏÔ˜ ηÙËÁÔÚÈÔÔÈÂ›Ù·È Ì ‚¿ÛË ÙË ÊÏ‚È΋ ·ÔÚÚÔ‹ ÛÂ Û˘ÛÙËÌ·ÙÈ΋ (™∫) ‹ ˘Ï·›· (¶º). ∏ Û˘¯ÓfiÙÂÚË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ Â›Ó·È Ë SPK/ED (81%, n = 18322), 5 ÛÙȘ 6 ·fi ÙȘ Ôԛ˜ ¤¯Ô˘Ó Û˘ÛÙËÌ·ÙÈ΋ ÊÏ‚È΋ ·ÔÚÚÔ‹ (4). ΔfiÛÔ ÔÈ ·Ú¯ÈΤ˜ ÂÈ‚ÈÒÛÂȘ ÌÔÛ¯Â˘Ì¿ÙˆÓ (5) fiÛÔ Î·È ÔÈ ÂÈÏÔΤ˜ (4) ÌÂÙ·˙‡ ÙˆÓ ‰È·ÊfiÚˆÓ Î·ÙËÁÔÚÈÒÓ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ Â›Ó·È ·ÚfiÌÔȘ. ŒÙÛÈ, ÁÈ· ÏfiÁÔ˘˜ ¢ÎÔÏ›·˜, ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Ù· ‰Â‰Ô̤ӷ Ù˘ ÔÏ˘ÏËı¤ÛÙÂÚ˘ ηÙËÁÔÚ›·˜ (SKP/ED) ÛÙË Û‡ÁÎÚÈÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ Ì ·˘Ù‹ ÙˆÓ ÓËÛȉ›ˆÓ. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ ·ÁÎÚ¤·ÙÔ˜ ηÙËÁÔÚÈÔÔÈÂ›Ù·È Ì ‚¿ÛË ÙÔ Â›‰Ô˜ ÙÔ˘ ‰fiÙË Û ·ÏÏÔÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Û ·˘ÙÔÌÂÙ·ÌfiÛ¯Â˘ÛË (2). ∂›Û˘, ηÙËÁÔÚÈÔÔÈÂ›Ù·È Ì ‚¿ÛË ÙË Û˘Ó‡·ÚÍË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÛÂ Û˘Ó‰˘·Ṳ̂ÓË ÓËÛȉ›ˆÓÓÂÊÚÔ‡ (SπK), Û ÓËÛȉ›ˆÓ ‡ÛÙÂÚ· ·fi ÓÂÊÚÔ‡
∏ ¤ÎÚËÍË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ô˘ Û˘ÓÙÂϤÛÙËΠÙËÓ ÙÂÏÂ˘Ù·›· 25ÂÙ›·, ÂËÚ¤·ÛÂ Î·È ÙÔÓ ÙÔ̤· Ù˘ ıÂڷ›·˜ ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂÈÏÂÁ̤ÓÔ ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ ‰È·‚‹ÙË ÚÔÙ›ÓÔÓÙ·È, οو ·fi Û˘ÁÎÂÎÚÈ̤Ó˜ ÂӉ›ÍÂȘ, ‰‡Ô ›‰Ë ÌÂÙ·ÌfiÛ¯Â˘Û˘: ·) ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜. ‚) ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ ·ÁÎÚ¤·ÙÔ˜. ªÔÈÚ·›· ÔÈ ‰‡Ô ·˘Ù¤˜ ıÂڷ¢ÙÈΤ˜ χÛÂȘ Û˘ÁÎÚ›ÓÔÓÙ·È ‰È·ÚÎÒ˜. ªÂ ‚¿ÛË ÙȘ ̤¯ÚÈ Û‹ÌÂÚ· ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ô‰Â›ÍÂȘ (evidence based) ÔÈ Ôԛ˜ ·Ó·Ï‡ÔÓÙ·È ·Ú·Î¿Ùˆ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ı· Ú¤ÂÈ Ó· ·ÔÙÂÏ› ÙË ıÂڷ›· ·Ó·ÊÔÚ¿˜ (gold standard). ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ, ·Ó Î·È ÂÏ΢ÛÙÈÎfiÙÂÚË ÂÂȉ‹ Â›Ó·È ÏÈÁfiÙÂÚÔ ÂÂÌ‚·ÙÈ΋, Â›Ó·È ·ÎfiÌ· ˘Ô‰Â¤ÛÙÂÚË.
2. ¶ËÁ¤˜ ‰Â‰ÔÌ¤ÓˆÓ ΔÔ ·ÁÎfiÛÌÈÔ Î¤ÓÙÚÔ ·Ó·ÊÔÚ¿˜ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ‚Ú›ÛÎÂÙ·È ÛÙË ªÈÓÂÛfiÙ· ÙˆÓ ∏¶∞. O ‰ÈÎÙ˘·Îfi˜ ÙÔ˘˜ ÙfiÔ˜ ›ӷÈ: www.iptr.umn.edu. ΔÔ ·ÁÎfiÛÌÈÔ Î¤ÓÙÚÔ ·Ó·ÊÔÚ¿˜ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÓËÛȉ›ˆÓ ‚Ú›ÛÎÂÙ·È ÛÙÔ °Î›ÛÂÓ Ù˘ °ÂÚÌ·Ó›·˜. O ‰ÈÎÙ˘·Îfi˜ ÙÔ˘˜ ÙfiÔ˜ ›ӷÈ: www.med.uni-giessen.de/itr. ∏ ·Ó·˙‹ÙËÛË ÛÙÔ medline (Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ Î·È ÙÔ˘ ¤ÙÔ˘˜ 2007) ·ÔʤÚÂÈ 295 (90 Ù˘¯·ÈÔÔÈË̤Ó˜) Î·È 63 (10 Ù˘¯·ÈÔÔÈË̤Ó˜) ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ Î·È ÓËÛȉ›ˆÓ ·ÓÙ›ÛÙÔȯ· (65% ·ÓÔÛÔÏÔÁÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ Î·È 35% Ù¯ÓÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘).
3. μ·ÛÈο ÛÙÔȯ›· Œˆ˜ ÙÔ 2007 ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› Û˘ÓÔÏÈο 29000 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜. OÈ 21500 ·fi ·˘Ù¤˜ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙË μ. ∞ÌÂÚÈ΋. ∂ÈϤÔÓ, ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› 1500 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓËÛȉ›ˆÓ. ¶ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙȘ ÌÈ-
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¢. BPOXI¢H™
(π∞∫) Î·È Û ÓËÛȉ›ˆÓ ÌfiÓÔ (πΔ∞). ™˘¯ÓfiÙÂÚ˜ Â›Ó·È ÔÈ ·ÏÏÔÌÂÙ·ÌÔۯ‡ÛÂȘ (73% n = 1200), ·fi ÙȘ Ôԛ˜ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ (n = 700) ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ ÙÔ˘ ŒÓÙÌÔÓÙÔÓ. ΔÔ ÚˆÙfiÎÔÏÏÔ ŒÓÙÌÔÓÙÔÓ ‚ÂÏÙ›ˆÛ ‰Ú·Ì·ÙÈο Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓËÛȉ›ˆÓ (6). ŒÙÛÈ, ÁÈ· ÏfiÁÔ˘˜ ·ÓÙÈÎÂÈÌÂÓÈÎfiÙËÙ·˜, ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ‰Â‰Ô̤ӷ ·ÏÏÔÌÂÙ·ÌÔۯ‡ÛÂˆÓ Î¿Ùˆ ·fi ÙÔ ÚˆÙfiÎÔÏÏÔ ŒÓÙÔÌÓÙÔÓ ÛÙË Û‡ÁÎÚÈÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓËÛȉ›ˆÓ Ì ·˘Ù‹ ÙÔ˘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜. ™˘ÓÔÙÈο, ÙÔ ÚˆÙfiÎÔÏÏÔ ŒÓÙÌÔÓÙÔÓ Û˘Ó›ÛÙ·Ù·È ÛÙË: ·) ∂Ï·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ (< 8 hr). ‚) ™ÙË ¯Ú‹ÛË Ù˘ ËÌÈ·˘ÙfiÌ·Ù˘ ÌÂıfi‰Ô˘ ·ÔÌfiÓˆÛ˘ ηٿ Ricordi. Á) ™ÙËÓ ·ÔÊ˘Á‹ ˙ˆÈÎÒÓ ·ÓÙȉڷÛÙËÚ›ˆÓ. ‰) ™ÙË ¯Ú‹ÛË ÙÔ˘Ï¿Á¯ÈÛÙÔÓ 11000 IEQ/kgr ‚¿ÚÔ˘˜ Ï‹ÙË (ÂÚÈÛÛfiÙÂÚÔÈ ÙÔ˘ ÂÓfi˜ ‰fiÙ˜). Â) ™ÙË ÌË ¯Ú‹ÛË ÛÙÂÚÔÂȉÒÓ ÛÙÔ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Û¯‹Ì· (6).
4. ∂È‚›ˆÛË ·ÛıÂÓÒÓ ∏ ÂÈ‚›ˆÛË ÙˆÓ ÏËÙÒÓ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ·Ó¤Ú¯ÂÙ·È Û 95% Î·È 85% ÛÙÔ ÚÒÙÔ Î·È ÛÙÔ ¤ÌÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÓÙ›ÛÙÔȯ· (1). ∂Ï¿¯ÈÛÙ˜ ·fi ÙȘ ÂÚÁ·Û›Â˜ ÓËÛȉ›ˆÓ ·Ó·Ê¤ÚÔÓÙ·È Û ÂÈ‚›ˆÛË ÏËÙÒÓ. ™Â Ì›· Û¯ÂÙÈο ÌÈÎÚ‹ ÌÂϤÙË (n = 11) Ë ÂÈ‚›ˆÛË ·Ó¤Ú¯ÂÙ·È Û 100% ÛÙÔ ‰Â‡ÙÂÚÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (7). ∞ÎfiÌ· Î·È ÛÙȘ ‰ËÌÔÛȇÛÂȘ Ô˘ ¤Ú¯ÔÓÙ·È ·fi ÙÔ ÚˆÙÔfiÚÔ Î¤ÓÙÚÔ ÙÔ˘ ŒÓÙÌÔÓÙÔÓ, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· ÁÈ· ÙȘ ÂÈ‚ÈÒÛÂȘ ÙˆÓ ÏËÙÒÓ. ŒÙÛÈ, ·fi Ì›· ÔÌ¿‰· 65 ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Ì ÓËÛ›‰È·, ÛÙÔ Ù¤ÏÔ˜ Ù˘ ÂÓÙ·ÂÙ›·˜ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·Ó ·ÎfiÌË ÌfiÓÔ 44 ·ÛıÂÓ›˜. øÛÙfiÛÔ, ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ ÙÈ Û˘Ó¤‚Ë ÛÙÔ˘˜ ˘fiÏÔÈÔ˘˜ 21 Ï‹Ù˜ ‰Â ‰›ÓÔÓÙ·È (8).
5. ∂È‚›ˆÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ∏ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ·Ó¤Ú¯ÂÙ·È Û 90%, 70% Î·È 45% ÛÙÔ ÚÒÙÔ, ¤ÌÙÔ Î·È ‰¤Î·ÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÓÙ›ÛÙÔȯ· (1). ∏ ÈÓÛÔ˘ÏÈÓÔ·ÓÂÍ·ÚÙËÛ›· Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È ·fi fiÏ· Ù· Û˘ÌÌÂÙ¤¯ÔÓÙ· ΤÓÙÚ· ÛÙË ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ °Î›ÛÂÓ ·Ó¤Ú¯ÂÙ·È Û 44% ÛÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (2). ∞Ó ıˆÚËıÔ‡Ó ˆ˜ ÏÂÈÙÔ˘ÚÁÔ‡ÓÙ· ÓËÛ›‰È· Ì ٷ ÔÔ›·, ·Ó Î·È ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÈÓÛÔ˘ÏÈÓÔ·ÓÂÍ·ÚÙËÛ›·, ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÓȯÓ‡ÂÙ·È ÂÙ›‰ÈÔ- C ÛÙÔ Ï‹ÙË, ÙfiÙ ÙÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ó¤Ú¯ÂÙ·È Û 80% ÛÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·-
ÌfiÛ¯Â˘ÛË (2). Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÂȂ‚·ÈÒıËÎ·Ó ÚfiÛÊ·Ù· Î·È ·fi ÌÂϤÙË ÛÙËÓ ÔÔ›· Û˘ÌÌÂÙ›¯·Ó Ù· 9 ÌÂÁ·Ï‡ÙÂÚ· ΤÓÙÚ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓËÛȉ›ˆÓ ÛÙÔÓ ÎfiÛÌÔ (9). ∂ÈϤÔÓ, Ë ÈÓÛÔ˘ÏÈÓÔ·ÓÂÍ·ÚÙËÛ›· Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È ÛÙÔ ŒÓÙÌÔÓÙÔÓ ÙÔ ¤ÌÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ ·Ó¤Ú¯ÂÙ·È ÌfiÏȘ ÛÙÔ 10% (10). Δ¤ÏÔ˜, ÛÙË ÌÔÓ·‰È΋ ÌÂϤÙË Ô˘ Û˘Ó¤ÎÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ Ì ·˘Ù‹ ÙˆÓ ÓËÛȉ›ˆÓ ÔÈ ÂÈ‚ÈÒÛÂȘ ÛÙÔ ‰Â‡ÙÂÚÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹Ù·Ó 65%, 55% Î·È 20% ÁÈ· ÙÔ ÔÏÈÎfi ¿ÁÎÚ·˜, Ù· ÓËÛ›‰È· Ì ·Ú·ÁˆÁ‹ ÂÙȉ›Ô˘-C ÌfiÓÔ Î·È Ù· ÓËÛ›‰È· Ì ÈÓÛÔ˘ÏÈÓÔ·ÓÂÍ·ÚÙËÛ›· (7).
6. ∂ÈÏÔΤ˜ ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÂÈÏÔΤ˜. OÈ Î˘ÚÈfiÙÂÚ˜ ·fi ·˘Ù¤˜ Â›Ó·È ÔÈ Ù¯ÓÈΤ˜ (ıÚfiÌ‚ˆÛË, ·ÈÌÔÚÚ·Á›·, ‰È·Ê˘Á‹) Ô˘ ·Ó¤Ú¯ÔÓÙ·È Û 6,5%, ÔÈ ·ÔÚÚ›„ÂȘ ̤۷ ÛÙËÓ ÚÒÙË ÂÓÙ·ÂÙ›· Ô˘ ·Ó¤Ú¯ÔÓÙ·È Û 12% Î·È ÔÈ CMV ÏÔÈÌÒÍÂȘ Ô˘ ·Ó¤Ú¯ÔÓÙ·È Û 10% (4). øÛÙfiÛÔ, ·Ú¿ ÙËÓ ÂÚ› ÙÔ˘ ·ÓÙ›ıÂÙÔ˘ ·ÓÙ›ÏË„Ë, Î·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ ‰ÂÓ Â›Ó·È ¿ÌÔÈÚË ÂÈÏÔÎÒÓ. ™˘ÁÎÂÎÚÈ̤ӷ, ¤¯Ô˘Ó ηٷÁÚ·Ê› ˘Ï·›· ıÚfiÌ‚ˆÛË, ·ÈÌÔÚÚ·Á›·, ›ÁÔ˘Û· Ï··ÚÔÙÔÌ›· , Ë·ÙÈ΋ ÛÙ¿وÛË Î·È ÛÙÔÌ·ÙÈο ¤ÏÎË ·fi ÙË Ú··Ì˘Î›ÓË Û ÔÛÔÛÙfi 5%, 14% 8%, 23% Î·È 77% ·ÓÙ›ÛÙÔȯ· (11).
7. ∫fiÛÙÔ˜ Δ· ÓÔÛ‹ÏÈ· ÁÈ· Ì›· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ·Ó¤Ú¯ÔÓÙ·È Û 20000 ‰ÔÏÏ¿ÚÈ·. ΔÔ ÎfiÛÙÔ˜ Ï‹„˘ ÂÓfi˜ ·ÁÎÚ¤·ÙÔ˜ ·Ó¤Ú¯ÂÙ·È Û 20000 ‰ÔÏÏ¿ÚÈ·. ∂Ô̤ӈ˜, ÙÔ Û˘ÓÔÏÈÎfi ÎfiÛÙÔ˜ Ì›·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ Â›Ó·È ÂÚ›Ô˘ 40000. Δ· ÓÔÛ‹ÏÈ· ÁÈ· Ì›· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ ·Ó¤Ú¯ÔÓÙ·È Û 5000 ‰ÔÏÏ¿ÚÈ·. ΔÔ ÎfiÛÙÔ˜ Ï‹„˘ ÂÓfi˜ ·ÁÎÚ¤·ÙÔ˜ ·Ó¤Ú¯ÂÙ·È Û 20000 ‰ÔÏÏ¿ÚÈ·. ∏ ÂÓ˙˘ÌÈ΋ ÂÂÍÂÚÁ·Û›· ÙÔ˘ ÔÚÁ¿ÓÔ˘ ÎÔÛÙ›˙ÂÈ ÂÚ›Ô˘ 20000 ‰ÔÏÏ¿ÚÈ·. ∞ÚÎÂÙ¤˜ (1/3) ÂÓ˙˘ÌÈΤ˜ ÂÂÍÂÚÁ·Û›Â˜ ‰ÂÓ Â›Ó·È ÎÏÈÓÈο ¯ÚËÛÈÌÔÔÈ‹ÛÈ̘. ∂ÈϤÔÓ, ¤Ó·˜ Ï‹Ù˘ ÓËÛȉ›ˆÓ ··ÈÙ› Û˘Ó‹ıˆ˜ 2 ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ ‰fiÙ˜. ΔÂÏÈο, ÙÔ Û˘ÓÔÏÈÎfi ÎfiÛÙÔ˜ ÌÈ·˜ ÂÈÙ˘¯Ô‡˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓËÛȉ›ˆÓ ·Ó¤Ú¯ÂÙ·È Û ¿Óˆ ·fi 120000 ‰ÔÏÏ¿ÚÈ·, ‰ËÏ·‰‹ ÙÚÈÏ¿ÛÈÔ ·fi ·˘Ù‹ ÙÔ˘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ (7).
8. μÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ¶Ï¿Ó˜ ∏ ÚÒÙË Ï¿ÓË ·ÊÔÚ¿ ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfi-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÙËÙ· Ù˘ ƒ∞∫ Î·È Ù˘ ƒ∞Δ. ∞fi Ì›· ·Ó¿Ï˘ÛË ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ UNOS ·fi ÙÔ˘˜ Venstrom J, et al ÙÔ 2003 ÚԤ΢„ ˆ˜ ÔÈ Ï‹Ù˜ ƒ∞∫ ‹ ƒ∞Δ ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÂÚÈ̤ÓÔ˘Ó ÛÙË Ï›ÛÙ· Ì 1.57 (p<.001) ÌÂÁ·Ï‡ÙÂÚÔ Û¯ÂÙÈÎfi ΛӉ˘ÓÔ ı·Ó¿ÙÔ˘ (12). øÛÙfiÛÔ, ÌÂÙ·ÁÂÓ¤ÛÙÂÚË ·Ó¿Ï˘ÛË ÙˆÓ ›‰ÈˆÓ ‰Â‰ÔÌ¤ÓˆÓ (13) η٤‰ÂÈÍ fiÙÈ ÔÈ Ï‹Ù˜ ƒ∞∫ Î·È ƒ∞Δ ¤¯Ô˘Ó ηχÙÂÚË ÂÈ‚›ˆÛË (90,5%) ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÂÚÈ̤ÓÔ˘Ó ÛÙË Ï›ÛÙ· (87,3%). ∏ ‰Â‡ÙÂÚË Ï¿ÓË ·ÊÔÚ¿ ÛÙËÓ Â›Ù¢ÍË ˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ (80%) ÈÓÛÔ˘ÏÈÓÔ·ÓÂÍ·ÚÙËÛ›·˜ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ, ÂÊfiÛÔÓ ¯ÚËÛÈÌÔÔÈËı› ÙÔ ÚˆÙfiÎÔÏÏÔ ŒÓÙÌÔÓÙÔÓ (14). ∏ ·Ï‹ıÂÈ· Â›Ó·È ˆ˜ ·˘Ùfi ÙÔ ÔÛÔÛÙfi ‰ÂÓ ·Ó··Ú¿ÁÂÙ·È Â‡ÎÔÏ·. ™˘ÁÎÂÎÚÈ̤ӷ, ÌfiÓÔ 3 ·fi Ù· 9 ÌÂÁ¿Ï· ΤÓÙÚ· Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙËÓ ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË ¤Ù˘¯·Ó ÈÓÛÔ˘ÏÈÓÔ·ÓÂÍ·ÚÙËÛ›· Û ÔÛÔÛÙfi > 65% ¤Ó· ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ (15). ∏ ÙÚ›ÙË Ï¿ÓË ·ÊÔÚ¿ ÛÙËÓ ÂÔ›ËıÛË fiÙÈ ÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ Ì ÓËÛ›‰È· ·ÛıÂÓ›˜ ‰ÂÓ ¤¯Ô˘Ó ˘ÔÁÏ˘Î·ÈÌÈ΋ ·ÁÓˆÛ›· Î·È ·Úfi‚ÏÂÙË ÁÏ˘Î·ÈÌÈ΋ ‰È·Î‡Ì·ÓÛË, ·ÎfiÌ· Î·È ·Ó ‰ÂÓ ÂÈÙ¢¯ı› ÈÓÛÔ˘ÏÈÓÔ·ÓÂÍ·ÚÙËÛ›·, ÂÊfiÛÔÓ ·ÓȯÓ‡ÂÙ·È ÂÙ›‰ÈÔ-C. ∏ ·Ï‹ıÂÈ· Â›Ó·È fiÙÈ, ÛÙÔ˘˜ ÌË ÈÓÛÔ˘ÏÈÓÔ·ÓÂÍ¿ÚÙËÙÔ˘˜ ·ÏÏ¿ ·Ú¿ÁÔÓÙ˜ ·ÎfiÌ· ÂÙ›‰ÈÔ-C ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜, Ë ¤ÎÎÚÈÛË ÙÔ˘ ÁÏԢηÁfiÓÔ˘ ·Ú·Ì¤ÓÂÈ ·Ì‚Ï˘Ì¤ÓË Î·È ·˘Ùfi ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÚÔ˘Û›· οÔÈˆÓ ˘ÔÁÏ˘Î·ÈÌÈÎÒÓ Î·È ˘ÂÚÁÏ˘Î·ÈÌÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ (10).
9. ∏ ÈÛ¯‡Ô˘Û· ηٿÛÙ·ÛË ÛÙË μ. ∞ÌÂÚÈ΋ OÈ ‰fiÙ˜ ÌÈÎÚfiÙÂÚÔÈ ÙˆÓ 50 ÂÙÒÓ Â›Ó·È Î·Ù·ÏÏËÏfiÙÂÚÔÈ ÁÈ· ÔÏÈÎfi ¿ÁÎÚ·˜ (1) ÁÈ·Ù› Ô‰ËÁÔ‡Ó Û ÏÈÁfiÙÂÚ˜ Ù¯ÓÈΤ˜ ÂÈÏÔΤ˜ (RR ¤ˆ˜ Î·È 3.62, p = .007). ∞ÓÙ›ıÂÙ·, ÔÈ ‰fiÙ˜ ÌÂÁ·Ï‡ÙÂÚÔÈ ÙˆÓ 50 ÂÙÒÓ Î·ıÒ˜ Î·È ÔÈ ·¯Â›˜ ‰fiÙ˜ Â›Ó·È Î·Ù·ÏÏËÏfiÙÂÚÔÈ ÁÈ· ÓËÛ›‰È·, ÁÈ·Ù› Û ·˘ÙÔ‡˜ Â›Ó·È Â˘ÎÔÏfiÙÂÚÔÈ Ë ÂÓ˙˘ÌÈ΋ ‰È¿Û·ÛË ÙÔ˘ ÔÚÁ¿ÓÔ˘ (4). ªÂ ‚¿ÛË ·˘Ù¤˜ ÙȘ ·Ú·ÙËÚ‹ÛÂȘ, ÛÙÈË μ. ∞ÌÂÚÈ΋, ÙÔ ¿ÁÎÚ·˜ οı Ó·ÚÔ‡ Î·È ÏÂÙÔ‡ ‰fiÙË ÚÔÛʤÚÂÙ·È Î·Ù¿ ÚÔÙÂÚ·ÈfiÙËÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜, ÂÓÒ fiÏ· Ù· ˘fiÏÔÈ· ÚÔÛʤÚÔÓÙ·È ÁÈ· ÓËÛ›‰È· (7).
10. ∏ ∂ÏÏËÓÈ΋ Ú·ÁÌ·ÙÈÎfiÙËÙ· ™ÙËÓ ∂ÏÏ¿‰· ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› 11 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ÛÙȘ ·Ú¯¤˜ ÙÔ˘ ’90
279
Î·È 3 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓËÛȉ›ˆÓ ÛÙ· Ù¤ÏË ÙÔ˘ ’90 ·fi ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ ÙÔ˘ πÔÎÚ¿ÙÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ £ÂÛÛ·ÏÔӛ΢ (16). øÛÙfiÛÔ, Û ·˘Ùfi ÙÔÓ ÙÔ̤· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ, ·Ú·ÙËÚÂ›Ù·È ÛÙË ¯ÒÚ· Ì·˜ Ù· ÙÂÏÂ˘Ù·›· 5 ¯ÚfiÓÈ· ÎÏÈÓÈ΋ ·ÎÈÓËÛ›·. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ô‰Â›ÍÂȘ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ı· Ú¤ÂÈ Ó· ·ÔÙÂÏ› ÙË ıÂڷ›· ·Ó·ÊÔÚ¿˜. ∂ÈϤÔÓ, ÌÈ· Î·È ÔÈ ‰fiÙ˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÔÏÈÎfi ¿ÁÎÚ·˜ ‰Â ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÓËÛ›‰È·, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ ÌÔÚ› Ó· ‰Ú¿ÛÂÈ ÂÈÎÔ˘ÚÈο ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ÔÚÁ¿ÓÔ˘. ªÂ ‚¿ÛË Ù· ÚÔËÁÔ‡ÌÂÓ·, ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ ∂ÏÏËÓÈÎfi ªÔÓÙ¤ÏÔ ªÂÙ·ÌfiÛ¯Â˘Û˘ OÏÈÎÔ‡ ¶·ÁÎÚ¤·ÙÔ˜ Î·È ¡ËÛȉ›ˆÓ ¤¯ÂÈ Ù· ·ÎfiÏÔ˘ı· ‚·ÛÈο ÛËÌ›·: ·) ∫ÔÈÓ‹ Ï›ÛÙ·. ‚) ŒÓ· ΤÓÙÚÔ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜. Á) ŒÓ· ΤÓÙÚÔ ÓËÛȉ›ˆÓ ·ÁÎÚ¤·ÙÔ˜. ‰) ¢fiÙ˘ ÌÈÎÚfiÙÂÚÔ˜ ·fi 40 ÂÙÒÓ, Ì μªπ < 25, ÚÔÛʤÚÂÙ·È ÁÈ· ÔÏÈÎfi. Â) ¢fiÙ˘ ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi 40 ÂÙÒÓ ‹ Ì μªπ > 25 ÚÔÛʤÚÂÙ·È ÁÈ· ÓËÛ›‰È·. ÛÙ) OÈ ÓÂÊÚÔ·ı›˜ ‰È·‚ËÙÈÎÔ› (ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ‹ ÌË) Ï·Ì‚¿ÓÔ˘Ó ÔÏÈÎfi +/- ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ˙) OÈ ˘fiÏÔÈÔÈ ‰È·‚ËÙÈÎÔ› Ï·Ì‚¿ÓÔ˘Ó ÓËÛ›‰È· ·Ó ¤¯ÂÈ ÚÔËÁËı› ¿ÏÏË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓËÛȉ›ˆÓ (Ì ·ÓȯÓ‡ÛÈÌÔ ÂÙ›‰ÈÔ-C), ÓËÛ›‰È· ·Ó ÚÔ·„Ô˘Ó ÚÈÓ ·fi ÔÏÈÎfi, ÔÏÈÎfi ·Ó ÚÔ·„ÂÈ ÚÈÓ ·fi ÓËÛ›‰È·. ΔÔ ÚÔÙÂÈÓfiÌÂÓÔ ∂ÏÏËÓÈÎfi ªÔÓÙ¤ÏÔ ªÂÙ·ÌfiÛ¯Â˘Û˘ OÏÈÎÔ‡ ¶·ÁÎÚ¤·ÙÔ˜ Î·È ¡ËÛȉ›ˆÓ ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌÔÛÙ› ¿ÌÂÛ·.
μÈ‚ÏÈÔÁÚ·Ê›· 1. IPTR. In: http://www.iptr.umn.edu; 2007. 2. ITR. In: http://www.med.uni-gissen.de/itr; 2007. 3. Bretzel R, et al. Langenbecks Arch Surg 2007 ; 392 : 239. 4. Gruessner A, et al. Clin Transplant 2005 ; 19 : 433. 5. Sutherland D, et al. Ann Surg 2001 ; 233 : 463. 6. Shapiro A, et al. N Engl J Med 2000 ; 343 : 230. 7. Frank A, et al. Ann Surg 2004 ; 240 : 631. 8. Ryan E, et al. Diabetes 2005 ; 54 : 2050. 9. Shapiro A, et al. N Engl J Med 2006 ; 355 : 1318. 10. Rickels M, et al. Diabetes 2005 ; 54 : 3205. 11. Ryan E, et al. Diabetes 2002 ; 51 : 2148. 12. Venstrom J, et al. JAMA 2003 ; 290 : 2817. 13. Gruessner R, et al. Am J Transplant 2004 ; 4 : 2018. 14. Shapiro A, et al. Lancet 2003 ; 362 : 1242. 15. Ault A. Lancet 2003 ; 361 : 2054. 16. Papanikolaou V, et al. Organ Tissue Transpl 2000; 5: 9.
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ÍÂÓÈÛÙ‹ (graft vs host disease GVHD). ∏ ÌÈÎÚ‹ ‰fiÛË Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿ ·ÔÙÂÏ› ÙÔÓ Ì›˙ÔÓ· ÊÚ·ÁÌfi Î·È ÎÚÈÙÈÎfi ÛËÌÂ›Ô ÁÈ· ÙËÓ ·ÈÌ·ÙÔÏÔÁÈ΋ ·Ó¿Î·Ì„Ë Î·È ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ŒÙÛÈ ‰ÈηÈÔÏÔÁÂ›Ù·È Ë ÌË Â˘Ú›· ÂͿψÛË Ù˘ UCBT Û ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ·ÛıÂÓ›˜ Ì ۈ̷ÙÈÎfi ‚¿ÚÔ˜ ¿Óˆ ÙˆÓ 40kg.∞Ó Î·È Ë 1Ë ÂÈÙ˘¯‹˜ UCB ·ÏÏÔÁÂÓ‹˜ HCT ‰ÈÂÓÂÚÁ‹ıËΠ·fi E. Gluckman et al ÙÔ ¤ÙÔ˜ 1989 Û ·È‰› Ì ·Ó·ÈÌ›· Fanconi, ¤¯Ô˘Ó ‰ÈÂÓÂÚÁËı› 5.800 ·Ó¿ÏÔÁ˜ UCμT ΢ڛˆ˜ Û ·È‰È¿ Î·È Û ÌÈÎÚfi ÔÛÔÛÙfi Û ÂÓ‹ÏÈΘ. To ÂÚÒÙËÌ· Â¿Ó ÔÈ ΔÚ¿Â˙˜ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È Ì‡ıÔ˜ ‹ Ú·ÁÌ·ÙÈÎfiÙËÙ· ··ÓÙ¿Ù·È ·Ó¿ÏÔÁ· Ì ÙÔÓ ÛÙfi¯Ô: ·) ·˘ÙfiÏÔÁË ¯Ú‹ÛË (ÚÔÏËÙÈ΋ private banking) ‚) ¯Ú‹ÛË Û ·‰ÂÏÊÔ‡˜ Ì ÓfiÛËÌ· ıÂڷ¢fiÌÂÓÔ Ì ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (directed donation) Á) ¯Ú‹ÛË Û ÌË Û˘ÁÁÂÓ‹ (·È‰È¿ – ÂÓ‹ÏÈΘ) ˆ˜ ÌfiÛ¯Â˘Ì· ÁÈ· ·ÏÏÔÁÂÓ‹ HCT (donation public banking). ∏ ·˘ÙfiÏÔÁË ¯Ú‹ÛË ·ÔÙÂÏ› ¤Ó·Ó ̇ıÔ ÂÂȉ‹ ÛÙȘ ÌÂÓ Ï¢¯·È̛˜ ·È‰È΋˜ ËÏÈΛ·˜ ‰ÂÓ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË, ÛÙ· ‰Â ÌÂÙ·‚ÔÏÈο – ÁÂÓÂÙÈο ÓÔÛ‹Ì·Ù· ›Ûˆ˜ ÛÙÔ Ì¤ÏÏÔÓ ÌÂÙ¿ ÁÔÓȉȷ΋ ıÂڷ›· ·ÔÙÂϤÛÂÈ ÂӉ‰ÂÈÁ̤ÓË ıÂڷ›·. ŸÛÔ ‰Â ÁÈ· Ù· ÓÔÛ‹Ì·Ù· ÂÓËÏ›ÎˆÓ (ÓfiÛÔ Alzheimer, ÓfiÛÔ Parkinson, ηډȷΤ˜ ·ı‹ÛÂȘ) ›Ûˆ˜ ·ÔÙÂÏ› ıˆÚËÙÈ΋, ÌÂÏÏÔÓÙÈ΋ ÂÊ·ÚÌÔÁ‹. ∞ÓÙ›ıÂÙ·, ÙÔ UCB ˆ˜ ÌfiÛ¯Â˘Ì· ÁÈ· ÂÊ·ÚÌÔÁ‹ ·ÏÏÔÁÂÓÔ‡˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¤¯ÂÈ ¿ÌÂÛË ¯Ú‹ÛË ÛÂ Û˘ÁÁÂÓ›˜ Ì ‹‰Ë ˘¿Ú¯ÔÓ ÓfiÛËÌ· Î·È Û ÌË Û˘ÁÁÂÓ›˜ ·ÛıÂÓ›˜ Ì ÓfiÛËÌ· ıÂڷ¢fiÌÂÓÔ Ì ·ÏÏÔÁÂÓ‹ HCT. ΔfiÙÂ Â›Ó·È ÌÈ· Ú·ÁÌ·ÙÈÎfiÙËÙ· ‚·ÛÈṲ̂ÓË Û ‰Â‰Ô̤ӷ: 1) ‡ÎÔÏ˘ Û˘ÏÏÔÁ‹˜ ¯ˆÚ›˜ ΛӉ˘ÓÔ ÁÈ· ÓÂÔÁÓfi Î·È ÌËÙ¤Ú· › ·Ó›ÏÂÎÙÔ˘ ÙÔÎÂÙÔ‡
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÏÏÔÁÂÓÒÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (hematopoietic cell transplantation HCT) ·ÔÙÂÏ› ıÂڷ›· ÂÎÏÔÁ‹˜ Ì ‰˘Ó·ÙfiÙËÙ· ›·Û˘ ÔÈÎ›ÏˆÓ ·ÈÌ·ÙÔÏÔÁÈÎÒÓ Î·ÎÔ‹ıˆÓ ‹ ÌË ÓfiÛˆÓ. ∂Ó ÙÔ‡ÙÔȘ, Ë ¤ÏÏÂÈ„Ë Î·Ù¿ÏÏËÏÔ˘ ‰fiÙË Â›Ó·È Ô Ì¤ÁÈÛÙÔ˜ ÊÚ·ÁÌfi˜ ÂÂȉ‹ ÔÈ ÌÈÛÔ› ·ÛıÂÓ›˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ ‚Ú›ÛÎÔ˘Ó ‰fiÙË. OÈ ÌË Û˘ÁÁÂÓ›˜ HLA Û˘Ì‚·ÙÔ› ‰fiÙ˜ ·ÔÙÂÏÔ‡Ó ÙËÓ ÚÒÙË ÂÈÏÔÁ‹ › ÌË ‡·Ú͢ Û˘Ì‚·ÙÔ‡ ·‰ÂÏÊÔ‡.∂ÓÒ Ë ‰ÈÂıÓ‹˜ ‰ÂÍ·ÌÂÓ‹ ‰È·ı¤ÙÂÈ 10 ÂηÙÔÌ̇ÚÈ· ‰fiÙ˜ ·Ó¿ ÙÔÓ ÎfiÛÌÔ,Ë Â͇ÚÂÛË HLA Û˘Ì‚·ÙÔ‡ ‰fiÙË ÂÍ·ÚÙ¿Ù·È ·fi ÂıÓÈÎfiÙËÙ· Î·È Ê˘Ï‹ Î·È Î˘Ì·›ÓÂÙ·È ·fi 30-70% Û ÌÈ· ‰È·‰Èηۛ· Ô˘ ÌÔÚ› Ó· Êı¿ÛÂÈ ÙÔ˘˜ 2-4 Ì‹Ó˜. ∫·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ·˘Ùfi ‰È¿ÛÙËÌ· ÌÔÚ› Ó· ÂÍÂÏȯı› Ë ÓfiÛÔ˜, ÔfiÙÂ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ Â›Ó·È Ï¤ÔÓ ÂÊÈÎÙ‹ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ∞ÎÚÈ‚Ò˜ ÁÈ· Ó· ÂÌÏÔ˘ÙÈÛı› Ë ‰ÂÍ·ÌÂÓ‹ ‰ÔÙÒÓ, ÙÔ ÌË Û˘ÁÁÂÓ¤˜ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì· (umbilical cord blood UCB) ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Û·Ó ÂÓ·ÏÏ·ÎÙÈ΋ ËÁ‹ Û ¿ÌÂÛË Î·È Â˘¤ÏÈÎÙË ‰È¿ıÂÛË. ΔÔ UCB Â›Ó·È ÙÔ ·›Ì· Ô˘ ·Ú·Ì¤ÓÂÈ ÛÙÔÓ Ï·ÎÔ‡ÓÙ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ÌÔÚ› Ó· Û˘ÏÏÂÁ› Î·È Ó· ‰È·ÙËÚËı› ηٷ„˘Á̤ÓÔ Â› ÔÏÏ¿ ¤ÙË. ΔÔ ÌË Û˘ÁÁÂÓ¤˜ UCB ¤¯ÂÈ ·Ô‰Â›ÍÂÈ Û ·È‰È¿ Ì ·ÈÌ·ÙÔÏÔÁÈ΋ ÓfiÛÔ fiÙÈ ÂÚȤ¯ÂÈ Èηӿ ·ÈÌÔÔÈËÙÈο ·ÙÙ·Ú· Ó· ·Ó·Ù‡ÍÔ˘Ó Ì·ÎÚfi¯ÚÔÓË ÛÙ·ıÂÚ‹ ÂÌʇÙ¢ÛË Î·È ·ÈÌ·ÙÔÏÔÁÈ΋ ·Ó¿Î·Ì„Ë ÌÂÙ¿ ·fi ˘„ËϤ˜ ‰fiÛÂȘ ¯ËÌÂÈÔ±·ÎÙÈÓÔıÂڷ›·˜. ∂Ô̤ӈ˜ ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì· ÚÔÂÚ¯fiÌÂÓÔ ·fi ÌË Û˘ÁÁÂÓ‹ ıˆÚÂ›Ù·È ÂÓ·ÏÏ·ÎÙÈ΋ ËÁ‹ ÌÔۯ‡̷ÙÔ˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÏÏÔÁÂÓÒÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (UCBT). ∂¿Ó Û˘ÁÎÚÈı› ‰Â Ì ÌfiÛ¯Â˘Ì· Ì˘ÂÏÈÎfi ‹ ÂÚÈÊÂÚÈÎfi ·ÈÌ·ÙÈÎfi ·fi ÌË Û˘ÁÁÂÓ‹ ‰fiÙË ¤¯ÂÈ Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· ·) Ù˘ ¿ÌÂÛ˘ ‰È¿ıÂÛ˘ ‚) Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ·Ô‰ÂÎÙ‹˜ HLA ·Û˘Ì‚·ÙfiÙËÙ·˜ ÏfiÁˆ ‡·Ú͢ naive ΢ÙÙ¿ÚˆÓ Î·È Á) Ù˘ ¯·ÌËÏfiÙÂÚ˘ Û˘¯ÓfiÙËÙ·˜ ‚·Ú›·˜ ÓfiÛÔ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ
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2) ÌÈÎÚfiÙÂÚ˘ Èı·ÓfiÙËÙ·˜ ÈÔÁÂÓÔ‡˜ ÂÈÌfiÏ˘ÓÛ˘ Û ۇÁÎÚÈÛË Ì ÂÓ‹ÏÈÎÔ˘˜ ‰fiÙ˜ 3) ‰˘Ó·ÙfiÙËÙ·˜ ÎÚ˘ÔÛ˘ÓÙ‹ÚËÛ˘ ÁÈ· ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ· 4) ¿ÌÂÛ˘ ‰È·ıÂÛÈÌfiÙËÙ·˜ 5) ‰˘Ó·ÙfiÙËÙ·˜ ¯ÔÚ‹ÁËÛ˘ ÌÂÚÈÎÒ˜ HLA Û˘Ì‚·ÙÔ‡ UCB ÏfiÁˆ ¯·ÌËÏ‹˜ ›وÛ˘ GVHD 6) ‰Â‰Ô̤ÓÔ˘ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ΢ÙÙ¿ÚˆÓ Î·È ÌË ‰˘Ó·ÙfiÙËÙ·˜ ¤Á¯˘Û˘ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ‰fiÙË Â› ˘ÔÙÚÔ‹˜ 7) ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ UCBT ÂÊ¿ÌÈÏÏ˘ Ì Bone Marrow Transplantation (BMT) ÛÙ· ·È‰È¿. ∏ ·Ô‰ÂÎÙ‹ ¯Ú‹ÛË ÙÔ˘ Â›Ó·È ˆ˜ ËÁ‹ ΢ÙÙ¿ÚˆÓ ÁÈ· ·ÏÏÔÁÂÓ‹ UCBT Û ϋÙ˜ ·‰ÂÏÊÔ‡˜ ‹ ÌË Û˘ÁÁÂÓ›˜. OÈ Â›ÙÔΘ ÌËÙ¤Ú˜ ·ÏÙÚÔ˘˚ÛÙÈο ÚÔÛʤÚÔ˘Ó UCB Û ‰ËÌfiÛȘ ÙÚ¿Â˙˜. ∏ ‰ËÌÈÔ˘ÚÁ›· ‰ËÌÔÛ›ˆÓ ÙÚ·Â˙ÒÓ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÛÙ·ıÌfi ÛÙËÓ ›·ÛË ·È‰ÈÒÓ Ì ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù·. ∂Ó ÙÔ‡ÙÔȘ Ì ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ȉȈÙÈÎÒÓ ÙÚ·Â˙ÒÓ ÔÈ ÁÔÓ›˜ ¤¯Ô˘Ó ÙËÓ Â˘Î·ÈÚ›· Ó· ηٷ„‡ÍÔ˘Ó ÙÔ UCB ÙÔ˘ ·È‰ÈÔ‡ ÁÈ· Èı·Ó‹ ÌÂÏÏÔÓÙÈ΋ ¯Ú‹ÛË ÛÙÔ ›‰ÈÔ ·È‰› (·˘ÙfiÏÔÁË HCT). H ·Í›· Ù˘ ȉȈÙÈ΋˜ „‡Í˘ UCB ¤¯ÂÈ ·ÌÊÈÛ‚ËÙËı› ·fi ÔÏϤ˜ ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ Î·È ÌÈ· ·Ó·ÊÔÚ¿ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘ ·Ó·Ï‡ÂÈ Ù· ËıÈο ÚÔ‚Ï‹Ì·Ù·, Ô˘ ·Ó·Î‡ÙÔ˘Ó ·fi ÙËÓ ÒÏËÛË ÌÈ· ˘ËÚÂÛ›·˜ ¯ˆÚ›˜ Ú·ÁÌ·ÙÈ΋ ¯Ú‹ÛË. ∏ Èı·ÓfiÙËÙ· ¯Ú‹Û˘ ÙÔ˘ UCB Â›Ó·È <1/20000. ∂› ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ ‰ÂÓ ı· ‰ÈÂÓÂÚÁËı› ·˘ÙfiÏÔÁË UCB ÏfiÁˆ Èı·ÓÒÓ ÚÔ¸·Ú¯Ô˘ÛÒÓ ÌÂÙ·ÏÏ¿ÍÂˆÓ ÛÙÔ „˘¯ı¤Ó UCB ‹ Î·È ÌÂÁ¿Ï˘ ˘ÔÙÚÔ‹˜ Û ·ÓÙ›ıÂÛË Ì ÙËÓ ·ÏÏÔÁÂÓ‹ UCBT. E› Û˘Ì·ÁÒÓ fiÁΈÓ, ÏÂÌÊˆÌ¿ÙˆÓ ‹ ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ Ë ·˘ÙfiÏÔÁË UCB ¯Ú‹ÛË Â›Ó·È ·ÌÊ›‚ÔÏË ÏfiÁˆ ¯·ÌËÏÔ‡ ·ÚÈıÌÔ‡ ÚÔÁÔÓÈÎÒÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·Ê’ ÂÓfi˜ Î·È ÏfiÁˆ ÂÊÈÎÙ‹˜ Û˘ÏÏÔÁ‹˜ ·˘ÙfiÏÔÁÔ˘ Ì˘ÂÏÔ‡ ‹ ÎÈÓËÙÔÔÈË̤ÓÔ˘ Ì ·˘ÍËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÂÚÈÊÂÚÈÎÔ‡ ·›Ì·ÙÔ˜ ·Ê’ ÂÙ¤ÚÔ˘. ΔÔ UCB ·Ú¿ ÙË ÌÔÓ·‰ÈÎfiÙËÙ¿ ÙÔ˘, Û˘ÏϤÁÂÙ·È ÌÈ· ÌfiÓÔ ÛÙÈÁÌ‹ ÛÙË ˙ˆ‹ ÙÔ˘ ·ÓıÚÒÔ˘, ÛÒ˙ÂÈ ˙ˆ¤˜ ¿ÏÏˆÓ ·È‰ÈÒÓ Î·È ÂÓËÏ›ÎˆÓ ·ÏÏ¿ Â›Ó·È Ì¿ÏÏÔÓ ¿¯ÚËÛÙÔ ÁÈ· ·˘ÙfiÏÔÁË ¯Ú‹ÛË. O ÚÒÙÔ˜ ÏfiÁÔ˜ Â›Ó·È Ô ·ÔÎÏÂÈÛÌfi˜ Ù˘ ¯Ú‹Û˘ ÙÔ˘ ÁÈ· ÎÏËÚÔÓÔÌÈΤ˜ ÓfiÛÔ˘˜ (‚-ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· ‹ ÎÏËÚÔÓÔÌÈο Û‡Ó‰ÚÔÌ· Ì˘ÂÏÈ΋˜ ·Ó¿ÚÎÂÈ·˜). O ‰Â‡ÙÂÚÔ˜ ÏfiÁÔ˜ Â›Ó·È Ô ·ÔÎÏÂÈÛÌfi˜ ÙÔ˘ › Ï¢-
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¯·ÈÌÈÒÓ ÏfiÁˆ ÙÔ˘ ÁÔÓȉȷÎÔ‡ ˘ÏÈÎÔ‡ ÌÂÙ·ÏÏ¿ÍÂˆÓ Ô˘ ›Ûˆ˜ ÌÂٷʤÚÂÈ. O ÙÚ›ÙÔ˜ ÏfiÁÔ˜ Â›Ó·È Ë ÌË ÛˆÛÙ‹ ‰È¿ıÂÛ‹ ÙÔ˘ Û ‰ËÌfiÛȘ ÙÚ¿Â˙˜ fiÔ˘ Ì ÙË ¯Ú‹ÛË ÙÔ˘ ÛÒ˙ÂÈ ˙ˆ¤˜. OÈ È‰ÈˆÙÈΤ˜ ÙÚ¿Â˙˜ ÛÙÔ¯Â‡Ô˘Ó ÙÔ˘˜ ÁÔÓ›˜ Û ÌÈ· ¢·›ÛıËÙË ÂÚ›Ô‰Ô Î·È Ô˘ÛÈ·ÛÙÈο ÙÔ˘˜ Ô‰ËÁÔ‡Ó Û ϷÓı·Ṳ̂Ó˜ ·ÔÊ¿ÛÂȘ ÌÂ Û˘Óı‹Ì·Ù· «Ë Ì›· ¢ηÈÚ›· Û’ ÔÏfiÎÏËÚË ÙË ˙ˆ‹ Ó· ‰È·ÙËÚ‹ÛÂȘ Ù· ÛÙÔȯ›· ÎÏÂȉȿ ÁÈ· ÌÂÏÏÔÓÙÈ΋ È·ÙÚÈ΋ ‚Ô‹ıÂÈ· Ô˘ ı· ÛÒÛÂÈ Ù˘ ˙ˆ‹ ÙÔ˘ ·È‰ÈÔ‡ ÛÔ˘, ı· ÙÔ˘ ¯·Ú›ÛÂÈ ¤Ó· Ó¤Ô ·ÓÔÛÔÔÈËÙÈÎfi Û‡ÛÙËÌ·, ı· ÙÔ ÛÒÛÂÈ ·fi Parkinson, ‰È·‚‹ÙË, ηÚΛÓÔ, ηډȷÁÁÂȷ΋ ÓfiÛÔ». O˘ÛÈ·ÛÙÈο ÂÁ›ÚÔ˘Ó ÂÏ›‰Â˜ Û ÌÈ· Ô˘ÙÔ›· ‚·ÛÈ˙fiÌÂÓË ÛÙË Û‡Á¯ÚÔÓË ÂÈÛÙËÌÔÓÈ΋ ÁÓÒÛË Ù˘ Ï·ÛÙÈÎfiÙËÙ·˜ ÙÔ˘ ÔÏ˘‰‡Ó·ÌÔ˘ ·ÈÌÔÔÈËÙÈÎÔ‡ ΢ÙÙ¿ÚÔ˘ Ô˘ ÌÂÙ·ÙÚ¤ÂÙ·È Û ·ÙÙ·Ú· ¿ÏÏˆÓ ÈÛÙÒÓ ˘fi ·‰È¢ÎÚ›ÓÈÛÙ˜ ¿ÁÓˆÛÙ˜ ·ÎfiÌË Û˘Óı‹Î˜. ŸÏ˜ ÔÈ ·ÓÙ›ÛÙÔȯ˜ ÌÂϤÙ˜ Â›Ó·È ÂÈÚ·Ì·ÙÈΤ˜, Ù· ·ÔÙÂϤÛÌ·Ù· ‰ÂÓ Â›Ó·È ÛÙ·ıÂÚ¿ Î·È ··ÈÙÂ›Ù·È ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ÔÏ˘‰‡Ó·ÌˆÓ stem cells Ô˘ ‰ÂÓ ÂÚȤ¯ÂÈ ÙÔ UCB. Δ· ·ÓıÚÒÂÈ· ÂÌ‚Ú˘ÔÓÈο stem cells (ESC), Ù· ÔÔ›· Û˘ÏϤÁÔÓÙ·È ·fi ¤Ì‚Ú˘· ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÁÔÓÈÌÔÔ›ËÛË ¤¯Ô˘Ó ηχÙÂÚ˜ ȉÈfiÙËÙ˜ ÁÈ· ·Ó·ÁÂÓÓËÙÈ΋ È·ÙÚÈ΋ ·ÏÏ¿ Â›Ó·È ÌË ‰˘Ó·Ù‹ Ë ¯Ú‹ÛË ÙÔ˘˜ ÏfiÁˆ ËıÈÎÒÓ ÂÚÈÔÚÈÛÌÒÓ Î·È ‰Â‰ÔÌ¤ÓˆÓ ÁÈ· ÙË ÌË Â›Ù¢ÍË ·ÓÔÛÔÏÔÁÈ΋˜ ·ÓÔ¯‹˜. ∂Ô̤ӈ˜ ÙÔ UCB ·Ó·‰‡ÂÙ·È ˆ˜ ÏÔÁÈ΋ ÚÒÙË ÂÈÏÔÁ‹ ÛÙÔ Â‰›Ô Ù˘ ·Ó·ÁÂÓÓËÙÈ΋˜ È·ÙÚÈ΋˜. ΔÔ UCB ¤¯ÂÈ ‰‡Ô Ù‡Ô˘˜ ÔÏ˘‰‡Ó·ÌˆÓ ÚÔÁÔÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ – Ù· ·ÈÌÔÔÈËÙÈο Î·È Ù· ÌÂÛÂÁ¯˘Ì·ÙÈο Ì ‰È·ÊÔÚÂÙÈÎÔ‡˜ ΢ÙÙ·ÚÈÎÔ‡˜ ‰Â›ÎÙ˜ ÂÈÊ·Ó›·˜. Δ· ·ÈÌÔÔÈËÙÈο ηıÒ˜ Î·È Ù· ÌÂÛÂÁ¯˘Ì·ÙÈο ÌÔÚÔ‡Ó Ó· ‰È·ÊÔÚÔÔÈËıÔ‡Ó in vivo Û ·ÙÙ·Ú· Ë·ÙÈο, ÓÂÊÚÈο, ÂÁÎÂÊ·ÏÈο, ÔÛÙÈο, ÛÎÂÏÂÙÈο Î·È Î·Ú‰È·Î¿ Ì˘˚ο. ∏ Â˘Úˆ·˚΋ Ô‰ËÁ›· ··ÈÙ› ÙËÓ Ï‹ÚË ÂÓË̤ڈÛË ÁÈ· ÙË ‰˘Ó·ÙfiÙËÙ· ¯Ú‹Û˘ ÙÔ˘ ·˘ÙfiÏÔÁÔ˘ UCB ÁÈ· ÙȘ ÙÚ¤¯Ô˘Û˜ ÂӉ›ÍÂȘ Î·È ÁÈ· ÙËÓ Ôχ ˘ÔıÂÙÈ΋ ıÂڷ¢ÙÈ΋ ¯Ú‹ÛË ÙÔ˘ ÛÙȘ ¿ÏϘ ·ı‹ÛÂȘ Ì ¯Ú‹ÛË ‚ÈÔÙ¯ÓÔÏÔÁ›·˜ ·Ó·ÁÂÓÓËÙÈ΋ ÈηÓfiÙËÙ· Ó¤ˆÓ ΢ÙÙ¿ÚˆÓ Î·È ÈÛÙÒÓ. ªÂ ÙËÓ ·˘Í·ÓfiÌÂÓË ÂÌÂÈÚ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÏÏÔÁÂÓÔ‡˜ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ·›Ì·ÙÔ˜ Û ·È‰È¿ ˆ˜ ηÙÒÙÂÚË ‰fiÛË Â̇ÚËÓˆÓ Î˘ÙÙ¿ÚˆÓ ÈηÓÒÓ ÁÈ· ÂÈÙ˘¯‹ ÂÌʇÙ¢ÛË Î·È ¤Î‚·ÛË ıˆÚÂ›Ù·È Ô ·ÚÈıÌfi˜ >2,5 á 10^7/kg Ï‹ÙË, ÂÂȉ‹ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË ·ÓÂ-
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I. ™AKE§§APH
¿ÚÎÂÈ· ÌÔۯ‡̷ÙÔ˜ Î·È ıÓËÙfiÙËÙ· Û¯ÂÙÈ˙fiÌÂÓË Ì ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ¯·ÌËÏfiÙÂÚË ‰fiÛË Î˘ÙÙ¿ÚˆÓ. ¢˘ÛÙ˘¯Ò˜ ÌfiÓÔ 25% ÙˆÓ ÂÓËÏ›ÎˆÓ ÏfiÁˆ ‚¿ÚÔ˘˜ ÌÔÚÔ‡Ó Ó· Ï¿‚Ô˘Ó ·˘Ù‹ ÙË ‰fiÛË Ì ¤Á¯˘ÛË 1 ÌÔÓ¿‰·˜ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÂÔ̤ӈ˜ Ë ÏÂÈÔÓfiÙËÙ· ‰ÂÓ Â›Ó·È ÂÈϤÍÈÌÔÈ ÁÈ· UCB Transplantation. ∏ ÂÈÏÔÁ‹ ÙÔ˘ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Û˘Ó¿ÚÙËÛË Ù˘ HLA Û˘Ì‚·ÙfiÙËÙ·˜ Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Â̇ÚËÓˆÓ Î˘ÙÙ¿ÚˆÓ ·Ó¿ ÎÈÏfi Ï‹ÙË. ∞ÌÊfiÙÂÚÔÈ ÔÈ ·Ú¿ÁÔÓÙ˜ ÂËÚ¿˙Ô˘Ó ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È fiÛÔ ÌÂÁ·Ï‡ÙÂÚË Ë ·Û˘Ì‚·ÙfiÙËÙ· ÙfiÛÔ˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ΢ÙÙ¿ÚˆÓ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ ÂÈÙ˘¯‹ ÂÌʇÙ¢ÛË Û‡Ìʈӷ Ì ÙËÓ ÂÌÂÈÚ›· ÛÙ· ·È‰È¿. ∏ Ì·ÎÚfi¯ÚÔÓË 10ÂÙ‹˜ ÔÏÈ΋ ÂÈ‚›ˆÛË Î˘Ì·›ÓÂÙ·È ·fi 30% › ‰fiÛ˘ Â̇ÚËÓˆÓ 0,7 – 2,4 á 10^7/kg Ï‹ÙË Ì¤¯ÚÈ 63% › ‰fiÛ˘ >10 á 10^7/kg Ï‹ÙË (New York Blood Center). ∂›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ ‰ÂÓ ÂËÚ¿˙ÂÙ·È Ë ÔÏÈ΋ ÂÈ‚›ˆÛË ·fi ÙËÓ ·Û˘Ì‚·ÙfiÙËÙ·, Ë 5/6 ·ÓÙÈÁfiÓ· Û˘Ì‚·ÙfiÙËÙ· Î·È Ë 4/6 ·ÓÙÈÁfiÓ· Û˘Ì‚·ÙfiÙËÙ· ·Ó ‰Ôı› ÌfiÛ¯Â˘Ì· Ì Â̇ÚËÓ· 10 á 10 ^7/kg Ô˘ ıˆÚÂ›Ù·È Ì¤ÁÈÛÙË ‰fiÛË ŒÓ·˜ ·ÚÈıÌfi˜ ‰È·ÊÔÚÂÙÈÎÒÓ ÚÔÛÂÁÁ›ÛÂˆÓ ÌÂÏÂÙ‹ıËÎ·Ó ÁÈ· Ó· ˘ÂÚˉËı› Ô ÂÌfi‰ÈÔ Ù˘ ÌÈÎÚ‹˜ ‰fiÛ˘ ÚÔÁÔÓÈÎÒÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ fiˆ˜ Ë ex vivo ¤ÎÙ˘Í‹ ÙÔ˘˜ Û ηÏÏȤÚÁÂȘ, Ë ÂÓ‰ÔÔÛÙÈ΋ ¤Á¯˘ÛË UCB Î·È Ë ¤Á¯˘Û‹ ÔÏÏ·ÏÒÓ UCB ÌÔÓ¿‰ˆÓ. ∏ Û˘Á¯ÔÚ‹ÁËÛË 2 ‹ ÔÏÏÒÓ ÌÂÚÈÎÒÓ HLA Û˘Ì‚·ÙÒÓ UCB ÌÔÓ¿‰ˆÓ Â›Ó·È ˘fi ÌÂϤÙË ·Ó¿ ÙÔÓ ÎfiÛÌÔ Ì ڈÙÔfiÚÔ ÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ Ù˘ Minessota (Barker et al). OÈ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ô˘ ‰ÈÂÓÂÚÁÔ‡ÓÙ·È Ï¤ÔÓ Û ÂÓ‹ÏÈΘ ·ÊÔÚÔ‡Ó ÛÙËÓ ¤Á¯˘ÛË 2 ÌÔÓ¿‰ˆÓ ‰È·ÊÔÚÂÙÈÎÔ‡ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ Ì˘ÂÏÔηٷÛÙÚÔÊÈÎfi Û¯‹Ì· ÚÔÂÙÔÈÌ·Û›·˜. ∞fi ÙËÓ ÂÌÂÈÚ›· Ù˘ UCBT ÛÙ· ·È‰È¿ ˆ˜ ÛÙfi¯Ô˜ Î·È cutoff ·ÚÈıÌÔ‡ ÂÌ˘Ú‹ÓˆÓ ÙÔ˘ ‰ÈÏÔ‡ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ıˆÚÂ›Ù·È Ô ·ÚÈıÌfi˜ 3 á 10^7/kg. OÈ ÌÂϤÙ˜ Â›Ó·È ÌÈÎÚ¤˜, ¤¯Ô˘Ó ‹‰Ë ˘Ô‚ÏËı› Û UCBT Ì ¤Á¯˘ÛË 2 ÌÔÓ¿‰ˆÓ ‰È·ÊÔÚÂÙÈÎÔ‡ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜ 200 ·ÛıÂÓ›˜ ·Ó¿ ÙÔÓ ÎfiÛÌÔ(‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜). ∏ ‰fiÛË ÙÔ˘ ‰ÈÏÔ‡ ÌÔۯ‡̷ÙÔ˜ ÂÏ·ÙÙÒÓÂÈ ÙËÓ ·ÔÙ˘¯›· ÂÌʇÙ¢Û˘ Î·È Ù˘ ıÓËÙfiÙËÙ·˜ Û¯ÂÙÈ˙fiÌÂÓ˘ Ì ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÂÔ̤ӈ˜ ·˘Í¿ÓÂÈ ÙËÓ ÔÏÈ΋ ÂÈ‚›ˆÛË ÙˆÓ ÂÓËÏ›ÎˆÓ ·ÛıÂÓÒÓ.∏ Ì›· ÂÎ ÙˆÓ
‰‡Ô ÌÔÓ¿‰ˆÓ ·ÔÚÚ›ÙÂÙ·È ÂÓÙfi˜ 100 ËÌÂÚÒÓ ¯ˆÚ›˜ Ó· Â›Ó·È ÁÓˆÛÙfi˜ Ô ·Ú¿ÁˆÓ ·fiÚÚȄ˘ Î·È ÈÛ¯‡Ô˜. ªÂÏÂÙ‹ıËÎ·Ó ÔÈ ‰fiÛÂȘ ΢ÙÙ¿ÚˆÓ, Ë HLA Û˘Ì‚·ÙfiÙ˘ Î·È Ë ·ÓÙÈÁÔÓÈ΋ ‰È·ÊÔÚ¿ ÙÔ˘˜, Ë ÛÂÈÚ¿ ¤Á¯˘Û˘, Ë ∞μO ·Û˘Ì‚·ÙfiÙËÙ· Î·È Ë ·Û˘Ì‚·ÙfiÙËÙ· ʇÏÔ˘ ·ÏÏ¿ ηӤӷ˜ ·Ú¿ÁÔÓÙ·˜ ‰ÂÓ ÚÔ‰Èο˙ÂÈ ÔÈ· ÌÔÓ¿‰· ı· ÂÌÊ˘Ù¢ı›.¢ÂÓ ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË GVHD, ÂΛÓÔ Ô˘ ‰È·Ê¿ÓËΠ‹Ù·Ó Ë ÂÏ¿ÙÙˆÛË Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ ‚·ÛÈ΋˜ ÓfiÛÔ˘ Ì ‰ÈÏfi ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ÌfiÛ¯Â˘Ì· ˘ÔÓÔÒÓÙ·˜ ÈÛ¯˘ÚfiÙÂÚË ¿ÓÔÛË ·ÓÙ›‰Ú·ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ Ù˘ ηÎÔ‹ıÂÈ·˜. ∞˘Ù‹ Ë graft versus leukemia (GVL) ‰Ú¿ÛË ÚÔ‰Èο˙ÂÈ ·‡ÍËÛË Ù˘ ÂÈ‚›ˆÛ˘ ¯ˆÚ›˜ ÓfiÛÔ. ΔÔ ·ÁÎfiÛÌÈÔ ‰›ÎÙ˘Ô Ô˘ ˘ÔÛÙËÚ›˙ÂÈ ÙȘ ·ÏÏÔÁÂÓ›˜ UCB ÌÂÙ·ÌÔۯ‡ÛÂȘ Â›Ó·È ÙÔ NETCORD Ì 23 ÙÚ¿Â˙˜ ·Ó¿ ÙÔÓ ÎfiÛÌÔ Î·È Û˘ÓÔÏÈÎfi ·ÚÈıÌfi ÌÔÛ¯Â˘Ì¿ÙˆÓ 148.000. Œ¯Ô˘Ó ‹‰Ë Ú·ÁÌ·ÙÔÔÈËı› 5.800 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÌÊÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ·›Ì·ÙÔ˜ (3.100 ÂÍ ·˘ÙÒÓ Û ·È‰È¿) ΔÔ NETCORD ÏÂÈÙÔ˘ÚÁ› Ì ·˘ÛÙËÚÔ‡˜ ηÓfiÓ˜ Î·È ¯ÔÚËÁ› ÂȉÈ΋ ‰È·›ÛÙ¢ÛË ÛÙȘ ΔÚ¿Â˙˜. ∏ ∂˘Úˆ·˚΋ ŒÓˆÛË Ì ÙËÓ Ô‰ËÁ›· 2004/23/ EC ¤¯ÂÈ Î·ıÔÚ›ÛÂÈ ÙȘ ·Ú¯¤˜ Î·È ‰È·‰Èηۛ˜ ˆ˜ ÚÔ˜ ÙÔ ÌfiÛ¯Â˘Ì· (Û˘ÏÏÔÁ‹ – ÂÂÍÂÚÁ·Û›· – „‡ÍË – ·Ôı‹Î¢ÛË – ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ÁÈ· ¤ÏÂÁ¯Ô ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Î·È ÏÔÈ̈‰ÒÓ ÓfiÛˆÓ) Î·È ˆ˜ ÚÔ˜ ÙÔ ËıÈÎfi Î·È ÓÔÌÈÎfi Ï·›ÛÈÔ Ù˘ ‰ˆÚ¿˜ (ÂÓË̤ڈÛË – Û˘Ó·›ÓÂÛË ÌËÙ¤Ú·˜ Î·È ·Ú¯Â›Ô ‰Â‰Ô̤ӈÓ, Û˘ÛÙ‹Ì·Ù· ·ÛÊ·Ï›·˜ Î·È ¤ÏÂÁ¯Ô˜ ÔÈfiÙËÙ·˜). OÈ ‰È·‰Èηۛ˜ ·ÊÔÚÔ‡Ó: 1) ™˘ÏÏÔÁ‹ ÛÙËÓ ·›ıÔ˘Û· ÙÔÎÂÙÔ‡ ·fi ÂȉÈÎÂ˘Ì¤ÓÔ ÚÔÛˆÈÎfi Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ‰˘Ó·Ù‹˜ ÔÛfiÙËÙ·˜ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ·›Ì·ÙÔ˜ ›Ù ex utero ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi ·fi ÙËÓ ÔÌÊ·ÏÈ΋ ÊϤ‚· ›Ù in utero ÌÂ Û˘ÏÏÔÁ‹ ÎÏÂÈÛÙÔ‡ ΢ÎÏÒÌ·ÙÔ˜ ÌÂÙ¿ ·Ú·Î¤ÓÙËÛË Ù˘ ÔÌÊ·ÏÈ΋˜ ÊϤ‚·˜ Ì ÙËÓ ÂȉÈ΋ ‚ÂÏfiÓË ÙÔ˘ ·ÛÎÔ‡ Ù˘ Û˘ÏÏÔÁ‹˜. ¶ÚÔ¸fiıÂÛË ·ÔÙÂÏÔ‡Ó ÔÈ ¿ÛËÙ˜ Û˘Óı‹Î˜ Û˘ÏÏÔÁ‹˜. 2) ∂ÂÍÂÚÁ·Û›· ÛÙËÓ ÙÚ¿Â˙· ÁÈ· ÙËÓ Ì›ˆÛË ÙÔ˘ fiÁÎÔ˘ ÙÔ˘ ÛÙ· 20cc ÌÂÙ¿ ÙËÓ Ê˘ÁÔΤÓÙÚËÛË Î·È ·Ê·›ÚÂÛË ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ Î·È Ï¿ÛÌ·ÙÔ˜. 3) ∏ ηٿ„˘ÍË ÌÂÙ¿ ÚÔÛı‹ÎË ÎÚ˘ÔÚÔÛٷ٢ÙÈ΋˜ Ô˘Û›·˜ DMSO Á›ÓÂÙ·È Ì ÂȉÈ΋ ‰È·‰Èηۛ· ÛÙ·‰È·Î‹˜ „‡Í˘ ̤۷ Û ·ÛÎÔ‡˜ Ô˘ ÙÔ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÔıÂÙÔ‡ÓÙ·È Û ˘ÁÚfi ¿˙ˆÙÔ ÛÙÔ˘˜ –196Ô C. ∞˘Ùfi˜ Â›Ó·È Ô Î·ıÈÂڈ̤ÓÔ˜ ÙÚfiÔ˜ ηٿ„˘Í˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ ¯ˆÚ›˜ ÂËÚ·ÛÌfi Ù˘ ‚ȈÛÈÌfiÙËÙ·˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ. 4) O ¤ÏÂÁ¯Ô˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ·fi ÂÁÎÂÎÚÈ̤ӷ ÂıÓÈο ·ÓÙ›ÛÙÔȯ· ÂÚÁ·ÛÙ‹ÚÈ· ηıÒ˜ Î·È ÔÈ ÌÂÙÚ‹ÛÂȘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ, Â̇ÚËÓˆÓ Î·È CD34+ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Î·ıÔÚÈÛÙÈο Ù˘ Ù·˘ÙfiÙËÙ¿˜ ÙÔ˘. 5) O ¤ÏÂÁ¯Ô˜ Ô˘ ÚԂϤÂÙ·È ÁÈ· ÙË ÌË ÌÂÙ¿‰ÔÛË ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ ‰ÈÂÓÂÚÁÂ›Ù·È Î·È ÛÙË ÌËÙ¤Ú· Î·È ÛÙÔ ÌfiÛ¯Â˘Ì·: HBV, HCV, HIV, CMV, HTLV1, Û‡ÊÈÏË. 6) ªÂ›˙ÔÓ ı¤Ì· ·ÔÙÂÏ› Ë ¤ÁηÈÚË ÂÓË̤ڈÛË Î·È Û˘Ó·›ÓÂÛË Ù˘ ÌËÙ¤Ú·˜ Ë ÔÔ›· ‰ˆÚ›˙ÂÈ ÙÔ ÌfiÛ¯Â˘Ì· ¯ˆÚ›˜ η̛· ··›ÙËÛË Î·È Ù·˘Ùfi¯ÚÔÓ· ÁÓˆÛÙÔÔÈ› ÙÔ È·ÙÚÈÎfi ÈÛÙÔÚÈÎfi Ù˘. 7) Δ· ·Ú¯Â›· Ù˘ ΔÚ¿Â˙·˜ Â›Ó·È ÛËÌ·ÓÙÈο Î·È ·ÊÔÚÔ‡Ó ÙfiÛÔ Ù· ‰Â‰Ô̤ӷ ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ÙÔ˘ ÙÔÎÂÙÔ‡ Î·È ÙˆÓ ÂȉÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ fiÛÔ Î·È ÙËÓ ÂȉÈ΋ ÂÙÈΤٷ Ô˘ Û˘Óԉ‡ÂÈ ÙÔ ÌfiÛ¯Â˘Ì· ·fi ÙË Û˘ÏÏÔÁ‹ ̤¯ÚÈ ÙËÓ ¤Á¯˘Û‹ ÙÔ˘ ÛÙÔÓ Ï‹ÙË. 8) μ·ÛÈÎfi˜ Ù¤ÏÔ˜ Â›Ó·È Î·È Ô ¤ÏÂÁ¯Ô˜ ÔÈfiÙËÙ·˜ fiÏˆÓ ÙˆÓ ‰È·‰ÈηÛÈÒÓ ·fi ÂÈÙÚÔ‹ ÂȉÈÎÒÓ Â› ÙÔ˘ ·ÓÙÈÎÂÈ̤ÓÔ˘. ∞˘Ù‹ ÙË ÛÙÈÁÌ‹ ÛÙËÓ ∂ÏÏ¿‰· ÏÂÈÙÔ˘ÚÁÔ‡Ó ÔÏϤ˜ ȉȈÙÈΤ˜ ÙÚ¿Â˙˜ Ì ÔÈÎÔÓÔÌÈÎfi ·ÎÏÔ ÂÚÁ·ÛÈÒÓ 50.000.000 _ ÙÔ 2006 ÁÈ· Ó· Â͢ËÚÂÙ‹ÛÔ˘Ó ÙÔ Ì‡ıÔ ÙÔ˘ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ·›Ì·ÙÔ˜. ∞ÓÙ›ıÂÙ·, ÏÂÈÙÔ˘ÚÁ› ÌÈ· ‰ËÌfiÛÈ· ΔÚ¿Â˙· ÛÙËÓ ∞η‰ËÌ›· ∞ıËÓÒÓ Ì ηٷ¯ˆÚË̤ӷ ÛÙÔ NETCORD 450 ÌÔۯ‡̷ٷ, ÂÓÒ ·fi ÙËÓ ∞ÈÌ·ÙÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ – ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ «°. ¶··ÓÈÎÔÏ¿Ô˘» Á›ÓÂÙ·È Û˘ÏÏÔÁ‹ Î·È Û˘ÓÙ‹ÚËÛË UCB ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ¯Â˘Ì¤ÓË Û ·‰ÂÏÊÔ‡˜ ·Û¯fiÓÙˆÓ ·fi ·ÈÌ·ÙÔÏÔÁÈ΋ ηÎÔ‹ıÂÈ·. ™ÙËÓ ∂ÏÏ¿‰· Ì ·˘ÙfiÓ ÙÔ ÂÏ¿¯ÈÛÙÔ Ú˘ıÌfi ·Ó¿Ù˘Í˘ Â͢ËÚÂÙÂ›Ù·È Ë Ú·ÁÌ·ÙÈÎfiÙËÙ· Ù˘ ¯Ú‹Û˘ ÙÔ˘ UCB Ô˘ ·ÔÙÂÏ› ·ÍÈfiÈÛÙË ËÁ‹ ÂÓ·ÏÏ·ÎÙÈ΋ ‰ÈÂıÓÒ˜ ÁÈ· ·ÏÏÔÁÂÓ›˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì Èı·ÓfiÙËÙ· ›·Û˘. Ÿˆ˜ ‰È·Ê·›ÓÂÙ·È, Ù· ‰›· ‰È¢ڇÓÔÓÙ·È Ì Ӥ˜ ÂÈÛÙËÌÔÓÈο ÙÂÎÌËÚȈ̤Ó˜ ÌÂϤÙ˜ ÁÈ· ÙË ¯Ú‹ÛË ÙÔ˘ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜
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ÛÙËÓ ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ıˆÚÂ›Ù·È ıÂڷ›· ÂÎÏÔÁ‹˜ Ì ˘„ËÏ‹ Èı·ÓfiÙËÙ· ›·Û˘ Û Ï›ÛÙ˜ fiÛ˜ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ·ı‹ÛÂȘ.∏ ÂÈÛÙËÌÔÓÈ΋ ÚfiÎÏËÛË Ù˘ ¢Ú›·˜ ¯Ú‹Û˘ ÙÔ˘ UCB Û’ ·˘Ùfi ÙÔ Â‰›Ô ·ÔÙÂÏ› ‚¿ÛË ÁÈ· ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ·Ó›·ÙˆÓ ·˘ÙÒÓ ·ÛıÂÓÂÈÒÓ. ∞˘Ù‹ Ë Ú·ÁÌ·ÙÈÎfiÙËÙ· Ú¤ÂÈ Ó· ˘ÚÔ‰ÔÙ‹ÛÂÈ ÙËÓ ÛˆÛÙ‹ ÂÓË̤ڈÛË ÙÔ˘ ÎÔÈÓÔ‡ ÁÈ¿ ‰ˆÚ¿ ÙÔ˘ UCB Û ‰ËÌfiÛȘ ÙÚ¿Â˙˜ ÂΠ̤ÚÔ˘˜ Ù˘ ÂÈÛÙËÌÔÓÈ΋˜ ÎÔÈÓfiÙËÙ·˜.
μÈ‚ÏÈÔÁÚ·Ê›· 1) American Academy of Pediatrics Section on Hematology/Oncology; American Academy of Pediatrics Section on Allergy/Immunology, Lubin BH, Shearer WT. Cord blood banking for potential future transplantation. Pediatrics. 2007 Jan;119(1):165-70 2) Barker JN, Weisdorf DJ, DeFor TE, Blazar BR, McGlave PB, Miller JS, Verfaillie CM, Wagner JE. Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood. 2005 Feb 1;105(3): 1343-7. 3) Fisk NM, Roberts IA, Markwald R, Mironov V. Can routine commercial cord blood banking be scientifically and ethically justified? PLoS Med. 2005 Feb; 2(2):e44. 4) Fox NS, Stevens C, Ciubotariu R, Rubinstein P, McCullough LB, Chervenak FA. Umbilical cord blood collection: do patients really understand? J Perinat Med. 2007;35(4):314-21 5) Majhail NS, Brunstein CG, Wagner JE. Double umbilical cord blood transplantation. Curr Opin Immunol. 2006 Oct;18(5):571-5. 6) Michel G, Rocha V, Chevret S, Arcese W, Chan KW, Filipovich A, Takahashi TA, Vowels M, Ortega J, Bordigoni P, Shaw PJ, Yaniv I, Machado A, Pimentel P, Fagioli F, Verdeguer A, Jouet JP, Diez B, Ferreira E, Pasquini R, Rosenthal J, Sievers E, Messina C, Iori AP, Garnier F, Ionescu I, Locatelli F, Gluckman E; Eurocord Group. Unrelated cord blood transplantation for childhood acute myeloid leukemia: a Eurocord Group analysis. Blood. 2003 Dec 15;102(13):4290-7. 7) Smythe J, Armitage S, McDonald D, Pamphilon D, Guttridge M, Brown J, Green A, Brown C, Warwick RM, Lankester A, Fehily D, Contreras M, Navarrete C, Watt SM. Directed sibling cord blood banking for transplantation: the 10-year experience in the national blood service in England. Stem Cells. 2007 Aug; 25(8): 2087-93.
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Iˆ¿ÓÓ˘ AÔÛÙÔÏ›‰Ë˜
™ÙÔÓ ¶›Ó·Î· 1 ·Ó·Ê¤ÚÔÓÙ·È ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ‰Â‡ÙÂÚˆÓ Î·ÎÔËıÂÈÒÓ ÌÂÙ¿ ·fi ª∞∫.
∂ÈÛ·ÁˆÁ‹ ∏ ÚfiÔ‰Ô˜ ÛÙÔ Â‰›Ô Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (ª∞∫) ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ Û ·˘Í·ÓfiÌÂÓÔ ·ÚÈıÌfi ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ Î·È ÌË ÓÂÔÏ·ÛÌ·ÙÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ.1 ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ·ÁÎÔÛÌ›ˆ˜ Û ÂÙ‹ÛÈ· ‚¿ÛË ÂÎÙÂÏÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ·fi 45.000 ª∞∫ Î·È Ï¤ÔÓ ˘¿Ú¯Ô˘Ó È·ı¤ÓÙ˜ ·ÛıÂÓ›˜ Ô˘ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÁÈ· ‰‡Ô Î·È ÙÚÂȘ ‰ÂηÂٛ˜. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË fï˜ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÂÌÊ¿ÓÈÛË fi„ÈÌˆÓ ÂÈÏÔÎÒÓ. OÈ ‰Â‡ÙÂÚ˜ ηÎÔ‹ıÂȘ, ·ÔÙ¤ÏÂÛÌ· Û‡ÓıÂÙˆÓ ·ÏÏËÏÂȉڿÛÂˆÓ ÌÂٷ͇ ‰È·ÊfiÚˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘, ·ÔÙÂÏÔ‡Ó ÌÈ· ÛËÌ·ÓÙÈ΋ ·ÒÙÂÚË ÂÈÏÔ΋ Ù˘ ª∞∫. ∏ ›وÛË ÙˆÓ Î·ÎÔËıÂÈÒÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi ·˘Ù‹ Ô˘ Û˘Ó·ÓÙ¿Ì ÛÙÔÓ ˘ÁÈ‹ ÏËı˘ÛÌfi Î·È Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. ™ÙËÓ ·Ó·ÛÎfiËÛË ·˘Ù‹ ı· ÂÍÂÙ¿ÛÔ˘Ì ÙȘ ηÙËÁÔڛ˜ ÙˆÓ ‰Â‡ÙÂÚˆÓ Î·ÎÔËıÂÈÒÓ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË Î·È ·ÏÏÔÁÂÓ‹ ª∞∫, ÙËÓ Â›ÙˆÛ‹ ÙÔ˘˜, ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛ‹ ÙÔ˘˜, Î·È ÙÔ˘˜ ÙÚfiÔ˘˜ ÚfiÏË„‹˜ ÙÔ˘˜.
¢Â‡ÙÂÚ˜ ηÎÔ‹ıÂȘ ÌÂÙ¿ ·fi ª∞∫ ΔÚÂȘ ηÙËÁÔڛ˜ ‰Â‡ÙÂÚˆÓ Î·ÎÔËıÂÈÒÓ ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÙ¿ ·fi ª∞∫ (¶›Ó·Î·˜ 2). OÈ Î·ÎÔ‹ıÂȘ ÙÔ˘ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ Î·È ÔÈ Û˘Ì·Á›˜ fiÁÎÔÈ ÂÌÊ·Ó›˙ÔÓÙ·È Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ª∞∫, ÂÓÒ ÔÈ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ª∞∫.
¢Â‡ÙÂÚ˜ ηÎÔ‹ıÂȘ ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ª∞∫ ∫·ÎÔ‹ıÂȘ ÙÔ˘ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ Δ· ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù· ÌÂÙ¿ ·fi ª∞∫ (posttransplant lymphoproliferative disorders, PTLD) Â›Ó·È ÔÈ Û˘¯ÓfiÙÂÚ˜ ‰Â‡ÙÂÚ˜ ηÎÔ‹ıÂȘ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜ ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ª∞∫ ÛÙËÓ ÔÔ›· ¤¯ÂÈ Á›ÓÂÈ ·Ê·›ÚÂÛË ÙˆÓ Δ-΢ÙÙ¿ÚˆÓ ·fi ÙÔ ÌfiÛ¯Â˘Ì·. ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ PTLD Â›Ó·È μ-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ Î·È Û¯ÂÙ›˙ÔÓÙ·È Ì EBV Ïԛ̈ÍË, ÂÓÒ Ù· Δ-΢ÙÙ·ÚÈο PTLD Â›Ó·È Û¿ÓÈ·.
¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË ‰Â‡ÙÂÚˆÓ Î·ÎÔËıÂÈÒÓ
·) μ ΢ÙÙ·ÚÈο ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù·
◊Ù·Ó ‹‰Ë ÁÓˆÛÙfi ·fi ÙȘ ‰ÂηÂٛ˜ ÙÔ˘ 1970 Î·È 1980 fiÙÈ ˘‹Ú¯Â ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ›وÛ˘ ÙˆÓ ‰Â‡ÙÂÚˆÓ Î·ÎÔËıÂÈÒÓ Û ÂÈÚ·Ì·Ùfi˙ˆ· Ô˘ ›¯·Ó ·ÎÙÈÓÔ‚ÔÏËı› ÌÂ Ì˘ÂÏÔ·Ê·ÓÈÛÙÈΤ˜ ‰fiÛÂȘ ÔÏfiÛˆÌ˘ ·ÎÈÓÔ‚ÔÏ›·˜ (TBI) Î·È Ô˘ ›¯·Ó ‰È·Ûˆı› Ì ·˘ÙfiÏÔÁ· ‹ ·ÏÏÔÁÂÓ‹ Ì˘ÂÏÈο ·ÙÙ·Ú·. ™‡ÓÙÔÌ· Ê¿ÓËΠfiÙÈ ‰Â‡ÙÂÚ˜ ηÎÔ‹ıÂȘ ÂÌÊ·Ó›˙ÔÓÙ·Ó Û ·ÛıÂÓ›˜ Ô˘ ›¯·Ó Ï¿‚ÂÈ Û˘Ì‚·ÙÈ΋ ¯ËÌÂÈÔıÂڷ›· ‹ ¯ËÌÂÈÔ·ÎÙÈÓÔıÂڷ›· ÁÈ· ÏÂÌÊÒÌ·Ù· Hodgkin Î·È non-Hodgkin.2 ªÂ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·Ó·‰Â›¯ıËÎÂ Î·È Ë ·˘ÍË̤ÓË Â›ÙˆÛË ‰Â‡ÙÂÚˆÓ Î·ÎÔËıÂÈÒÓ ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ‹ ·ÏÏÔÁÂÓ‹ ª∞∫. 3
∞ÔÙÂÏÔ‡Ó ÌÈ· ÎÏÈÓÈ΋ Î·È ÈÛÙÔ·ıÔÏÔÁÈ΋ ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰· ÓÔÛËÌ¿ÙˆÓ Ô˘ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÓÙfi˜ ÙˆÓ ÚÒÙˆÓ 6 ÌËÓÒÓ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË PTLD ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∏ ·ıÚÔÈÛÙÈ΋ ›وÛË Î˘Ì·›ÓÂÙ·È ·fi 1% ˆ˜ 2% ÛÙ· 10 ¤ÙË, Ì ÙÔ 80% ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ÂÓÙfi˜ ÙˆÓ 2-5 ÌËÓÒÓ ·fi ÙËÓ ª∞∫. ∏ ˘„ËÏfiÙÂÚË Â›ÙˆÛË ·Ó¢ڛÛÎÂÙ·È Û ‰¤ÎÙ˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÌÂÚÈÎÒ˜ Û˘Ì‚·ÙÔ‡˜ Û˘ÁÁÂÓ›˜ ‰fiÙ˜ Î·È Û˘Ì‚·ÙÔ‡˜ ÌË Û˘ÁÁÂÓ›˜ ‰fiÙ˜, ȉȷ›ÙÂÚ·
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
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¶›Ó·Î·˜ 1. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ‰Â‡ÙÂÚˆÓ Î·ÎÔËıÂÈÒÓ Δ‡Ô˜ ª∞∫
Δ‡Ô˜ ‰Â‡ÙÂÚ˘ ηÎÔ‹ıÂÈ·˜
¶·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘
∞ÏÏÔÁÂÓ‹˜
PTLD
EBV+ ‰fiÙ˘ EBV- ·ÛıÂÓ‹˜ HLA ·Û˘Ì‚·ÙfiÙËÙ· ∞Ê·›ÚÂÛË Δ Î˘ÙÙ¿ÚˆÓ ∞ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈÎfi˜ ÔÚfi˜ (ATG) ∞ÎÙÈÓÔ‚ÔÏ›· GVHD - ÔÍ›· - ¯ÚfiÓÈ· (·ÚÔÛ‰ÈfiÚÈÛÙÔÈ) ∞ÎÙÈÓÔ‚ÔÏ›· ÃÚfiÓÈ· GVHD ÕÚÚÂÓ Ê‡ÏÔ ¡ÂfiÙÂÚË ËÏÈΛ· ·ÛıÂÓÔ‡˜ ∞Ê·›ÚÂÛË Δ Î˘ÙÙ¿ÚˆÓ ∞ÎÙÈÓÔ‚ÔÏ›· πÔ› ŒÓÙ·ÛË/‰È¿ÚÎÂÈ· ÚÔËÁÔ‡ÌÂÓ˘ ıÂڷ›·˜ ŒÎıÂÛË Û ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜ ™¯‹Ì· ÚÔÂÙÔÈÌ·Û›·˜ ¶ËÁ‹ ÚÔÁÔÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ™¯‹Ì· ÎÈÓËÙÔÔ›ËÛ˘ ªÂÁ·Ï‡ÙÂÚË ËÏÈΛ· ·ÛıÂÓÔ‡˜
∞ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ™˘Ì·Á›˜ fiÁÎÔÈ
∞˘ÙfiÏÔÁË
™˘Ì·Á›˜ fiÁÎÔÈ ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ
fiÙ·Ó ÙÔ ÌfiÛ¯Â˘Ì· ˘Ô‚¿ÏÏÂÙ·È Û ÂÂÍÂÚÁ·Û›· Ì ·ÓÙÈÛÒÌ·Ù· ÁÈ· ÙËÓ ÂÈÏÂÎÙÈ΋ ·Ê·›ÚÂÛË ÙˆÓ Δ Î˘ÙÙ¿ÚˆÓ Ì ÛÎÔfi ÙËÓ GVHD ÚÔʇϷÍË.4 ™Â ·˘Ù‹ ÙË Î·ÙËÁÔÚ›· ·ÛıÂÓÒÓ Ë Â›ÙˆÛË Î˘Ì·›ÓÂÙ·È ·fi 12% ̤¯ÚÈ 25% (Ê·ÈÓfiÌÂÓÔ ·ıÚÔÈÛÙÈ΋˜ ‹ Û˘ÓÂÚÁÂÈÛÙÈ΋˜ ›وÛ˘ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘). ∞ÓÙÈı¤Ùˆ˜, ·Ó ·Ê·ÈÚÂıÔ‡Ó Î·È Ù· μ ·ÙÙ·Ú· ·fi ÙÔ ÌfiÛ¯Â˘Ì· (¯Ú‹ÛË ·ÓÙÈ-CD52 ÌÔÓÔÎψÓÈÎÔ‡ ·ÓÙÈÛÒÌ·ÙÔ˜, campath 1-H) Ë Â›ÙˆÛË ÌÂÈÒÓÂÙ·È Û ÏÈÁfiÙÂÚÔ ·fi 2%. ∏ ÓfiÛÔ˜ Û˘Ó‹ıˆ˜ ÂΉËÏÒÓÂÙ·È Ì ˘ÚÂÙfi (ηÌÈ¿ ÊÔÚ¿ Ë ÂÈÎfiÓ· Û˘Á¯¤ÂÙ·È Ì ۋ„Ë), ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·. ™˘¯Ó¿ ÚÔÛ‚¿ÏÏÔÓÙ·È ÔÈ Ó‡ÌÔ¶›Ó·Î·˜ 2. ¢Â‡ÙÂÚ˜ ηÎÔ‹ıÂȘ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ 1. ∫·ÎÔ‹ıÂȘ ÙÔ˘ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ ·) μ-΢ÙÙ·ÚÈο ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù· (PTLD) ‚) Δ-΢ÙÙ·ÚÈο ÏÂÌÊÒÌ·Ù· Á) §¤Ìʈ̷ Hodgkin Î·È ¿ÏÏ· fi„ÈÌ· ÏÂÌÊÒÌ·Ù· 2. ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ·) *ªÂÙ¿‰ÔÛË Î·ÎÔ‹ıÂÈ·˜ ·fi ÙÔÓ ‰fiÙË ÛÙÔ Ï‹ÙË ‚) *∞Ó¿Ù˘ÍË Ó¤·˜ ηÎÔ‹ıÂÈ·˜ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ ‰fiÙË Á) *∞Ó¿Ù˘ÍË Ó¤·˜ ηÎÔ‹ıÂÈ·˜ ÛÙ· ·ÙÙ·Ú· ÙÔ˘ Ï‹ÙË ‰) †ª˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ/Oª§ 3. ™˘Ì·Á›˜ fiÁÎÔÈ ·) ∫·ÚΛÓÔÈ ‚) ™·ÚÎÒÌ·Ù· Á) ŸÁÎÔÈ ∫¡™ *∞ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÏÏÔÁÂÓ‹ ª∞∫ †∞ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·˘ÙfiÏÔÁË ª∞∫
Ó˜, ÓÂÊÚÔ›, Î·È ∫¡™. Δ· μ-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ PTLD ¤¯Ô˘Ó ¿ÓÙ· ÚԤϢÛË ·fi μ-·ÙÙ·Ú· ÙÔ˘ ‰fiÙË Î·È ÙÔ ÈÛÙÔÏÔÁÈÎfi ÙÔ˘˜ Ê¿ÛÌ· Â›Ó·È Â˘Ú‡ Î˘Ì·ÈÓfiÌÂÓÔ ·fi ÔÏ˘ÎψÓÈ΋ ÔÏ˘ÌÔÚÊÈ΋ ÏÂÌÊÔ¸ÂÚÏ·Û›· ˆ˜ Ù· ÂÈıÂÙÈο ·ÓÔÛÔ‚Ï·ÛÙÈÎÔ‡ Ù‡Ô˘ ÏÂÌÊÒÌ·Ù·. Δ· μ ·ÙÙ·Ú· ÌÓ‹Ì˘ Â›Ó·È Ô ÙfiÔ˜ fiÔ˘ ʈÏÈ¿˙ÂÈ Ô ∂μV ÁÈ· ÙÔ ˘fiÏÔÈÔ Ù˘ ˙ˆ‹˜ ÌÂÙ¿ ·fi Ïԛ̈ÍË. ΔÔ ÁÔÓȉ›ˆÌ· ÙÔ˘ ∂μV ·fi ÁÚ·ÌÌÈÎfi Á›ÓÂÙ·È Î˘ÎÏÈÎfi Û¯ËÌ·Ù›˙ÔÓÙ·˜ ›ۈ̷, Î·È ·Ú·Ì¤ÓÂÈ Û ϷÓı¿ÓÔ˘Û· Ê¿ÛË Ì¤Û· ÛÙ· ·ÙÙ·Ú· ·˘Ù¿. ∞ÓÙÈÁÚ·Ê‹ ÙÔ˘ ÈÔ‡ Û˘Ì‚·›ÓÂÈ Ù˘¯·›· ÌfiÓÔ Û ÌÈÎÚfi ÔÛÔÛÙfi Ï·Óı·ÓfiÓÙˆÓ ÌÔÏ˘ÛÌ¤ÓˆÓ μ ΢ÙÙ¿ÚˆÓ. ™Â ˘ÁÈ›˜ ·ÓıÚÒÔ˘˜ 1 – 50 μ- ·ÙÙ·Ú· ·Ó¿ 10 6 ÛÙË Î˘ÎÏÔÊÔÚ›· Â›Ó·È ÌÔÏ˘Ṳ̂ӷ Ì ∂μV. ∏ ¿ÁÚ˘ÓË ·ÓÔÛÔÏÔÁÈ΋ ÂÈÙ‹ÚËÛË Ì ٷ EBV-ÂȉÈο ΢ÙÙ·ÚÔÙÔÍÈο Δ-ÏÂÌÊÔ·ÙÙ·Ú· (CTL) ·ÚÂÌÔ‰›˙ÂÈ ÙÔÓ ·ÓÂͤÏÂÁÎÙÔ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ EBV-ÌÔÏ˘ÛÌ¤ÓˆÓ μ-΢ÙÙ¿ÚˆÓ. ∏ ‰È·Ù¿Ú·ÍË Ù˘ ÈÛÔÚÚÔ›·˜ ·˘Ù‹˜, ·fiÙÔÎË Ù˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Ù˘ ÛÙ¤ÚËÛ˘ ÙˆÓ ∂μV-ÂȉÈÎÒÓ CTL, ·ÔÙÂÏ› Î·È ÙÔÓ ·ıÔÁÂÓÂÙÈÎfi Ì˯·ÓÈÛÌfi ·Ó¿Ù˘Í˘ ÙˆÓ PTLD ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ª∞∫. πÛÙÔÚÈο, Ë Î˘ÙÙ·ÚÔıÂڷ›· Ì ÂÁ¯‡ÛÂȘ ÌË ÂȉÈÎÒÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ‰fiÙË (donor lymphocyte infusions, DLI) ·ÂÙ¤ÏÂÛ ÙËÓ ıÂڷ›· ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ıÂڷ›· ÙˆÓ PTLD, ·ÏÏ¿ Ô Î›Ó-
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I. A¶O™TO§I¢H™
‰˘ÓÔ˜ ı·Ó¿ÙÔ˘ ·fi GVHD ‹Ù·Ó ÛËÌ·ÓÙÈÎfi˜. 5 ªÈ· ̤ıÔ‰Ô˜ Ô˘ ··ÏÏ¿ÛÛÂÈ ·fi ÙȘ ÂÈÏÔΤ˜ Ù˘ GVHD Â›Ó·È Ë ıÂڷ›· Ì EBV-ÂȉÈο CTL, ·Ú·ÁfiÌÂÓ· ·fi EBV ÌÂÙ·ÌÔÚʈ̤Ó˜ B ÏÂÌÊÔ‚Ï·ÛÙÔÂȉ›˜ ΢ÙÙ·ÚÈΤ˜ ÛÂÈÚ¤˜ ÙÔ˘ ‰fiÙË (lymphoblastoid cell lines, LCL) Ô˘ ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó È‰·ÓÈο ·ÓÙÈÁÔÓÔ·ÚÔ˘ÛÈ·ÛÙÈο ·ÙÙ·Ú·.6 ΔÔ ÌÂÁ¿ÏÔ ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ ÌÂıfi‰Ô˘ ·˘Ù‹˜ Â›Ó·È fiÙÈ Ë ·Ú·ÁˆÁ‹ EBV-ÂȉÈÎÒÓ CTL ··ÈÙ› 8 Ì 12 ‚‰ÔÌ¿‰Â˜, ·fi ÙȘ Ôԛ˜ 4 Ì 6 ‚‰ÔÌ¿‰Â˜ Â›Ó·È ··Ú·›ÙËÙ˜ ÁÈ· ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ·ÚÎÔ‡˜ ·ÚÈıÌÔ‡ LCL ÁÈ· ÙËÓ ‰È¤ÁÂÚÛË ÙˆÓ CTL. ∞Ó Î·È Ë ıÂڷ›· Ì EBV-ÂȉÈο CTL Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋, Ë ‰È·‰Èηۛ· ·Ú·ÁˆÁ‹˜ ΢ÙÙ·ÚÈÎÒÓ ÛÂÈÚÒÓ Â›Ó·È ¯ÚÔÓÔ‚fiÚ·, ÂÚÁ҉˘ Î·È ··ÈÙ› ÂÍÂȉÈÎÂ˘Ì¤ÓË ÂÚÁ·ÛÙËÚȷ΋ ˘Ô‰ÔÌ‹, ÁÂÁÔÓfi˜ Ô˘ ¤¯ÂÈ ÂÚÈÔÚ›ÛÂÈ ÙËÓ Â˘Ú›· ·Ô‰Ô¯‹ Ù˘ ÛÙË ÎÏÈÓÈ΋ Ú¿ÍË. ™ËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ Ì PTLD (70%-80%) ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ-CD20 ÌÔÓÔÎψÓÈÎÔ‡ ·ÓÙÈÛÒÌ·ÙÔ˜ (rituximab), ··ÏÏ¿ÛÛÔÓÙ¿˜ ÙÔ˘˜ ·fi ÙËÓ ·Ó·ÁηÈfiÙËÙ· ¯ÔÚ‹ÁËÛ˘ EBV-ÂȉÈÎÒÓ CTL.7 ∏ ÚfiÏË„Ë Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋, Î·È Ì ÙËÓ Â˘Ú›· ¯Ú‹ÛË Ù˘ ÔÛÔÙÈ΋˜ PCR ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ È˚ÎÔ‡ ÊÔÚÙ›Ô˘ ÙÔ˘ EBV ÌÔÚԇ̠ϤÔÓ Ó· ÚԂϤ„Ô˘Ì ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ PTLD, Î·È Ó· ¯ÔÚËÁ‹ÛÔ˘Ì ÚÔÏËÙÈ΋ (preemptive) ıÂڷ›· › ÌÂÙ·‚ÔÏÒÓ ÙÔ˘ EBV È˚ÎÔ‡ ÊÔÚÙ›Ô˘.8
‚) Δ-΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù· Î·È fi„ÈÌ· ÏÂÌÊÒÌ·Ù· ™¿ÓÈ· ÂÚÈÁÚ¿ÊÔÓÙ·È Δ-ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù· ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ª∞∫, Ë ‰Â ÂÌÊ¿ÓÈÛ‹ ÙÔ˘˜ Â›Ó·È fi„ÈÌË Û ۯ¤ÛË Ì ٷ EBV-Û¯ÂÙÈ˙fiÌÂÓ· μ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈο ÓÔÛ‹Ì·Ù·. ¢ÂÓ ˘¿Ú¯ÂÈ ·ıÔÁÂÓÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙÔ˘˜ ÈÔ‡˜ EBV, HTLV1, ‹ HHV6. Ÿ„ÈÌË ÂÌÊ¿ÓÈÛË μ ΢ÙÙ·ÚÈ΋˜ ÚÔ¤Ï¢Û˘ non-Hodgkin ÏÂÌÊˆÌ¿ÙˆÓ ÂÚÈÁÚ¿ÊÂÙ·È ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ª∞∫, ·ÏÏ¿ Â›Ó·È Û¿ÓÈ·. O ÌfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ÂÌÊ¿ÓÈÛ‹ ÙÔ˘˜ Â›Ó·È Ë ¯ÚfiÓÈ· GVHD. §ÂÌÊÒÌ·Ù· Hodgkin Â›Ó·È Â›Û˘ Û¿ÓÈ·, Û˘Ó‹ıˆ˜ ÙÔ˘ ÈÛÙÔÏÔÁÈÎÔ‡ ˘fiÙ˘Ô˘ Ù˘ ÌÂÈÎÙ‹˜ ΢ÙÙ·ÚÔ‚Ú›ıÂÈ·˜, Î·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ·Ó¢ڛÛÎÂÙ·È ÙÔ ÁÔÓȉ›ˆÌ· ÙÔ˘ EBV.9 ∏ ›وۋ ÙÔ˘˜ ‰ÂÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ Û˘Ó·ÓÙ¿Ì ÛÙ· PTLD, ÂÓÒ ÂÌÊ·Ó›˙ÔÓÙ·È fi„ÈÌ· (>2.5 ¤ÙË) Û˘ÁÎÚÈÙÈο Ì ٷ PTLD Î·È ¤¯Ô˘Ó Û¯Â-
ÙÈο ηϋ ¤Î‚·ÛË.
∞ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ OÍ›· Ï¢¯·ÈÌ›· (Ì˘ÂÏÔÁÂÓ‹˜ ‹ ÏÂÌÊÔ‚Ï·ÛÙÈ΋) ˆ˜ ‰Â‡ÙÂÚË Î·ÎÔ‹ıÂÈ· ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ª∞∫ Â›Ó·È Û¿ÓÈ·. Œ¯ÂÈ ÂÚÈÁÚ·Ê› Ë ÂÌÊ¿ÓÈÛ‹ Ù˘ Û ·ÙÙ·Ú· ÙÔ˘ ·ÛıÂÓÔ‡˜ ·ÏÏ¿ Û·ÓÈfiÙÂÚ· Î·È Û ·ÙÙ·Ú· ÙÔ˘ ‰fiÙË.10 ∂›Û˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚÈÛÙ·ÙÈο ÌÂÙ¿‰ÔÛ˘ ·ÈÌ·ÙÔÏÔÁÈ΋˜ ηÎÔ‹ıÂÈ·˜ ·fi ÙÔÓ ‰fiÙË ÛÙÔÓ Ï‹ÙË11. Δ· ·›ÙÈ· ·Ú·Ì¤ÓÔ˘Ó ¿ÁÓˆÛÙ·, ·Ó Î·È ¤¯Ô˘Ó ÚÔÙ·ı› ˆ˜ ‰˘ÓËÙÈÎÔ› ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ô ÌÂÙ·Û¯ËÌ·ÙÈÛÌfi˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ‰fiÙË Ì¤Ûˆ ·ÓÙÈÁÔÓÈÎÔ‡ ÂÚÂıÈÛÌÔ‡ ·fi ÙÔ Ï¢¯·ÈÌÔÁfiÓÔ ÌÈÎÚÔÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·ÛıÂÓÔ‡˜, Û‡ÓÙËÍË Ê˘ÛÈÔÏÔÁÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ‰fiÙË Ì ˘ÔÏÂÈÌÌ·ÙÈο Ï¢¯·ÈÌÈο ·ÙÙ·Ú· ÙÔ˘ Ï‹ÙË, ‰È·ÌfiÏ˘ÓÛË Ì ÔÁÎÔÁÔÓ›‰È· ÙÔ˘ Ï‹ÙË, Î·È Ë ÂÈÙ·¯˘ÓfiÌÂÓË ‚Ú¿¯˘ÓÛË ÙˆÓ ÙÂÏÔÌÂÚÒÓ ÛÙ· ·ÈÌÔÔÈËÙÈο ·ÙÙ·Ú· ÙÔ˘ ‰fiÙË.12
™˘Ì·Á›˜ fiÁÎÔÈ ∞fi ÌÈ· ÌÂÁ¿ÏË Û˘ÓÂÚÁ·ÙÈ΋ ÌÂϤÙË Â› 20.000 ·ÛıÂÓÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ·ÏÏÔÁÂÓ‹ ª∞∫ Ô Î›Ó‰˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ Û˘Ì·ÁÔ‡˜ fiÁÎÔ˘ ‹Ù·Ó 2.2% ÛÙ· 10 ¤ÙË Î·È 6.7% ÛÙ· 15 ¤ÙË. ¶·Ú·ÙËÚ‹ıËÎ·Ó 80 Û˘Ì·Á›˜ fiÁÎÔÈ Ì ·Ú·ÙËÚÔ‡ÌÂÓË/·Ó·ÌÂÓfiÌÂÓË (O/∂) ·Ó·ÏÔÁ›· 2.7.13 O ΛӉ˘ÓÔ˜ ‹Ù·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÌÂÏ·ÓÒÌ·ÙÔ˜ (O/∂ 5.0), ηÚΛÓÔ Ù˘ ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ (11.1), ‹·ÙÔ˜ (7.5), ∫¡™ (7.6), ı˘ÚÂÔÂȉԇ˜ (6.6), ÔÛÙÔ‡ (13.4), Î·È Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡ (8.0). OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Û˘Ì·ÁÒÓ fiÁÎˆÓ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. O ΛӉ˘ÓÔ˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÁÈ· ÓÂfiÙÂÚ˘ ËÏÈΛ·˜ ·ÛıÂÓ›˜ Î·È ÌÂÈÔ‡ÌÂÓÔ˜ Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ ÛÙËÓ ª∞∫. ∏ TBI ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ fi„ÈÌË ÂÌÊ¿ÓÈÛË Î·ÚΛÓÔ˘ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜, fiÁÎˆÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ÔÛÙÂÔÁÂÓÔ‡˜ Û·ÚÎÒÌ·ÙÔ˜, Î·È ÓÂÔÏ·ÛÌ¿ÙˆÓ ÙˆÓ Ì·Ï·ÎÒÓ ÈÛÙÒÓ.14 ∏ ¯ÚfiÓÈ· GVHD Î·È Ë ·Ú·ÙÂٷ̤ÓË ·ÓÔÛÔηٷٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ì ·˙·ıÂÈÔÚ›ÓË, ȉȷ›ÙÂÚ· fiÙ·Ó Û˘Ó‰˘¿˙ÂÙ·È Ì ΢ÎÏÔÛÔÚ›ÓË Î·È ÎÔÚÙÈÎÔÂȉ‹ ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› ˆ˜ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ï·ÎÒ‰Ô˘˜ ηÚΛÓÔ˘ Ù˘ ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Î·È ÙÔ˘ ‰¤ÚÌ·ÙÔ˜.15 Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ·Ó¿Ù˘Í˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚˆÓ Î·È ÏÈÁfiÙÂÚÔ Î·ÚÎÈÓÔÁfiÓˆÓ ıÂÚ·ÂÈÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¯ÚfiÓÈ·˜ GVHD. ∂›Û˘, ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ·ÏÏÔÁÂÓ‹ ª∞∫
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Î·È È‰È·›ÙÂÚ· ·˘ÙÔ› Ì ÂÌ̤ÓÔ˘Û· ¯ÚfiÓÈ· GVHD ‹ ˘fi ¯ÚfiÓÈ· ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÚÈÔ‰ÈÎfi ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ‰Â‡ÙÂÚˆÓ Î·ÎÔËıÂÈÒÓ.
¢Â‡ÙÂÚ˜ ηÎÔ‹ıÂȘ ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ª∞∫ ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ηÎÔ‹ıÂȘ ¢Â˘ÙÂÚÔ·ı¤˜ Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈÎfi Û‡Ó‰ÚÔÌÔ (s-MDS) Î·È ÔÍ›· Ì˘ÂÏÔÁÂÓ‹˜ Ï¢¯·ÈÌ›· (sAML) ·ÔÙÂÏÔ‡Ó Ì›˙ˆÓ ÂÈÏÔ΋ ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ª∞∫. ∏ ÚfiÁÓˆÛË ÙˆÓ s-MDS/s-AML Â›Ó·È ÂÍ·ÈÚÂÙÈο Ùˆ¯‹, Ì ‰È¿ÌÂÛË ÂÈ‚›ˆÛË ÙÔ˘˜ 6 Ì‹Ó˜. ∞ÔÙÂÏÔ‡Ó ÙËÓ ‰Â‡ÙÂÚË Û˘¯ÓfiÙÂÚË ÂÈÏÔ΋ ÌÂÙ¿ ÙËÓ ˘ÔÙÚÔ‹ ÙÔ˘ ‚·ÛÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ Û ·ÛıÂÓ›˜ Ì ϤÌʈ̷ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ·˘ÙfiÏÔÁË ª∞∫.16 ∏ ·ıÚÔÈÛÙÈ΋ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ s-MDS/s-AML Î˘Ì·›ÓÂÙ·È ·fi 1.1% ÛÙÔ˘˜ 20 Ì‹Ó˜ ¤ˆ˜ 24.3% ÛÙÔ˘˜ 43 Ì‹Ó˜, Ì ‰È¿ÌÂÛÔ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘˜ 12-24 Ì‹Ó˜ (‡ÚÔ˜, 6 Ì‹Ó˜ – 8 ¤ÙË).16,17 ™Â ÌÈ· ÚfiÛÊ·ÙË ÌÂϤÙË Û ·ÛıÂÓ›˜ Ì Ô˙҉˜ ϤÌʈ̷ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ·˘ÙfiÏÔÁË ª∞∫ ¤Ú·Ó Ù˘ 1˘ ‡ÊÂÛ˘ Ì ÛËÌ·ÓÙÈ΋ ¤ÎıÂÛË Û ·Ï΢ÎÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ì ÚÔ·Ú·Û΢ÛÙÈÎfi Û¯‹Ì· CY/TBI ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ·ıÚÔÈÛÙÈ΋ ›وÛË sMDS/s-AML ‹Ù·Ó 26% ÌÂÙ¿ ·fi ‰È¿ÌÂÛË ·Ú·ÎÔÏÔ‡ıËÛË 13.5 ¤ÙË.18 OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË s-MDS/s-AML ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ¶·Ú·Ì¤ÓÂÈ ·Û·Ê¤˜ ·Ó ÙÔ s-MDS ·Ó·‰‡ÂÙ·È ·fi Ù· ÂÁ¯˘fiÌÂÓ· ·ÈÌÔÔÈËÙÈο ·ÙÙ·Ú· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹ ·fi ˘ÔÏÂÈÌÌ·ÙÈο ·ÙÙ·Ú· Ô˘ ¤¯Ô˘Ó ÂÎÙÂı› ÛÙÔ ÚÔ·Ú·Û΢·ÛÙÈÎfi Û¯‹Ì· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∂›Ó·È ÁÂÁÔÓfi˜ fï˜ fiÙÈ ÔÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ηڢÔÙ˘ÈΤ˜ ‚Ï¿‚˜ (-7, +8, 7q-, 20q-, 11q23) ¤¯Ô˘Ó ·Ó¢ÚÂı› ·Ó·‰ÚÔÌÈο Ì FISH Û ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈο ‰Â›ÁÌ·Ù· Ì˘ÂÏÔ‡ ·ÛıÂÓÒÓ Ô˘ ·Ó¤Ù˘Í·Ó sMDS ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ª∞∫.19 ∂Ô̤ӈ˜, Â›Ó·È Èı·ÓfiÓ Ù¤ÙÔÈÔÈ ÎÏÒÓÔÈ Ó· ˘Ê›ÛÙ·ÓÙ·È ÚÈÓ ÙËÓ ª∞∫ Î·È ¤Ó· ‘‰Â‡ÙÂÚÔ ¯Ù‡ËÌ·’ Ó· ÂÈÛ˘Ì‚·›ÓÂÈ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞fi Ù· ‰Â‰Ô̤ӷ ·˘Ù¿ Û˘Ó¿ÁÂÙ·È fiÙÈ Ë ¤ÎıÂÛË Û ¯ËÌÂÈÔ·ÎÙÈÓÔıÂڷ›· ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÙÔ ÚÔ·Ú·ÛÎÂ˘Û·ÙÈÎfi Û¯‹Ì· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û˘ÓÂÈÛʤÚÔ˘Ó ÛÙËÓ ·Ó¿Ù˘ÍË s-MDS/s-AML. ∏ ÚfiÁÓˆÛË ÙˆÓ s-MDS/s-AML Â›Ó·È ÂÍ·ÈÚÂÙÈο Ùˆ¯‹ Î·È Ë ·ÏÏÔÁÂÓ‹˜ ª∞∫ ·ÔÙÂÏ› ÙËÓ ÌfiÓË ıÂڷ›· Ô˘ ÚÔÛʤÚÂÈ ÙËÓ ‰˘Ó·ÙfiÙËÙ· ›·Û˘.20 ∏ Ê¿ÛË Ù˘ ÓfiÛÔ˘ Î·È Ô Î·Ú˘fiÙ˘Ô˜ ·ÔÙÂÏÔ‡Ó
287
ÙÔ˘˜ ÈÛ¯˘ÚfiÙÂÚÔ˘˜ ÚÔÁÓˆÛÙÈÎÔ‡˜ ‰Â›ÎÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ¤Î‚·ÛË ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ. ∏ ÌÂȈ̤ÓË ¤ÎıÂÛË Û ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜, ·Ó·ÛÙÔÏ›˜ Ù˘ ÙÔÔ˚ÛÔÌÂÚ¿Û˘, ·ÎÙÈÓÔ‚ÔÏ›·, ηıÒ˜ Î·È Ë ‚Ú¿¯˘ÓÛË Ù˘ ‰È¿ÚÎÂÈ·˜ Ù˘ ıÂڷ›·˜ ı· Û˘ÓÙÂϤÛÔ˘Ó ·Ó·ÌÊ›‚ÔÏ· ÌÂÏÏÔÓÙÈο ÛÙË Ì›ˆÛË Ù˘ ›وÛ˘ ÙˆÓ s-MDS/s-AML. ŸÙ·Ó Â›Ó·È ÂÊÈÎÙfi ÔÈ ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜ Î·È ÔÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ÙÔÔ˚ÛÔÌÂÚ¿Û˘ ı· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÁÈ· ÙËÓ ÎÈÓËÙÔÔ›ËÛË ÚÔÁÔÓÈÎÒÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ™ÙÔÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô Ô Î·Ú˘fiÙ˘Ô˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ·ÚΛ ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi ·ÛıÂÓÒÓ Ì ΛӉ˘ÓÔ ·Ó¿Ù˘Í˘ s-MDS/s-AML ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ª∞∫. ™˘ÓÈÛÙ¿Ù·È Û ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·ÛıÂÓ›˜ ÛÙÔÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô ÏËÓ ÙÔ˘ ηڢfiÙ˘Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë FISH ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ¯ÚˆÌÔÛˆÌÈÎÒÓ ‚Ï·‚ÒÓ Ô˘ Û˘Ó·ÓÙ¿Ì ÛÙ· sMDS. ∏ ÂÊ·ÚÌÔÁ‹ ÓÂfiÙÂÚˆÓ ÌÔÚÈ·ÎÒÓ Ù¯ÓÈÎÒÓ (gene expression profiling, genome wide analysis) ›Ûˆ˜ ÂÈÙÚ¤„ÂÈ ÌÂÏÏÔÓÙÈο ÙÔÓ ÂÓÙÔÈÛÌfi ÙˆÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·ÛıÂÓÒÓ Ì ÚԉȿıÂÛË ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË s-MDS/s-AML.21
™˘Ì·Á›˜ fiÁÎÔÈ ∏ ›وÛË ÙˆÓ Û˘Ì·ÁÒÓ fiÁÎˆÓ ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ª∞∫ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 5%-10% ÛÙ· 5-10 ¤ÙË, ·Ó¿ÏÔÁ· Ì ÙȘ ÛÂÈÚ¤˜ Ô˘ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢Ù›.13,22 OÈ Ù‡ÔÈ ÙˆÓ Û˘Ì·ÁÒÓ fiÁÎˆÓ ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó Ô˘ÛÈ·ÛÙÈο ·fi ·˘ÙÔ‡˜ Ô˘ Û˘Ó·ÓÙ¿Ì ÌÂÙ¿ ·fi ·ÏÏÔÁÂÓ‹ ª∞∫, ·ÏÏ¿ ÔÈ ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› ‰È·Ê¤ÚÔ˘Ó. O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi Â›Ó·È 2-4. OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÂÈ‚ÈÒÓÔ˘Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ 2 ¤ÙË ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ª∞∫, ÙÔ 25% ÙˆÓ fi„ÈÌˆÓ ı·Ó¿ÙˆÓ ÔÊ›ÏÔÓÙ·È Û ‰Â‡ÙÂÚË Î·ÎÔ‹ıÂÈ·. 23 ∏ ¯Ú‹ÛË TBI Î·È Ë ¤ÎıÂÛË Û ÈÔ‡˜ (HPV, HHV8) ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓË Â›ÙˆÛË. ¢ÂÓ ˘¿Ú¯ÂÈ plateau ÛÙËÓ Â›ÙˆÛË Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘, ÁÂÁÔÓfi˜ Ô˘ ÂÈ‚¿ÏÂÈ ÙËÓ ‰È· ‚›Ô˘ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÚÔÏËÙÈÎfi ¤ÏÂÁ¯Ô.
™˘ÌÂÚ¿ÛÌ·Ù· ∞ÛıÂÓ›˜ Ô˘ ÂÈ‚ÈÒÓÔ˘Ó ÙÔ˘ ‚·ÛÈÎÔ‡ ÙÔ˘˜ ÓÔÛ‹Ì·ÙÔ˜ ÌÂÙ¿ ·fi ª∞∫ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ‰Â‡ÙÂÚ˘ ηÎÔ‹ıÂÈ·˜ Û ۯ¤ÛË Ì ÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∏ ›وÛË ·˘Í¿ÓÂÈ ‰Ú·Ì·ÙÈο Û ÂÚÈÙÒÛÂȘ fiÔ˘ ˘¿Ú¯Ô˘Ó ÔÏÏ·ÏÔ› ·Ú¿-
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ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ (·ıÚÔÈÛÙÈ΋ ›وÛË). ∞Ó Î·È ¯ÚÂÈ¿˙ÂÙ·È Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ÁÈ· Ó· ηٷÁÚ·Ê› Ë Ï‹Ú˘ ‰È¿ÛÙ·ÛË Ù˘ ÂÈÏÔ΋˜ ·˘Ù‹˜, ··ÈÙÔ‡ÓÙ·È ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ Û˘ÛÙËÌ·ÙÈ΋˜ ÎÏÈÓÈ΋˜ Î·È ÁÂÓÂÙÈ΋˜/ÌÔÚȷ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ÙËÓ Î·Ù·ÓfiËÛË Î·È Î·Ù·ÁÚ·Ê‹ ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙË ·ıÔÁ¤ÓÂÈ· ÙˆÓ Î·ÎÔËıÂÈÒÓ ·˘ÙÒÓ, Ì ·ÒÙÂÚÔ ÛÙfi¯Ô ÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ ÚfiÏ˄˘ Î·È Ù˘ ıÂڷ›·˜ ÙˆÓ ÓÔÛËÌ¿ÙˆÓ ·˘ÙÒÓ.
13. Curtis RE, Rowlings PA, Deeg HJ, et al. Solid cancers after bone marrow transplantation. N Engl J Med 1997; 336: 897-904.
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16. Micallef INM, Lillington D, Apostolidis J, et al. Myelodysplasia and acute myelogenous leukemia following high dose therapy with aut;ologous haematopoietic progenitor cell support for lymphoid malignancies. J Clin Oncol 2000; 18: 947-955.
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4
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ÙÔ ÙÂÏÈÎfi ‡„Ô˜1. °È· Ù· ·È‰È¿ Ô˘ ÙÔ˘˜ ¯ÔÚËÁÂ›Ù·È Ô Û˘Ó‰˘·ÛÌfi˜ ‚Ô˘ÛÔ˘ÏÊ¿Ó˘ Ì ΢ÎÏÔʈÛÊ·Ì›‰Ë (Bu-Cy)Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÚÈÛÛÔÙ¤ÚˆÓ ÌÂÏÂÙÒÓ ‰Â›¯ÓÔ˘Ó fiÙÈ ÙÔ ÙÂÏÈÎfi ÙÔ˘˜ ‡„Ô˜ ‰ÂÓ ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο ·fi ÙÔ ÁÂÓÂÙÈο ·Ó·ÌÂÓfiÌÂÓÔ2. ªÂ›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ·Ó¿Ù˘Í˘ ·Ó·Ê¤ÚÂÙ·È ÌfiÓÔ Û ·È‰È¿ 10 -12 ÂÙÒÓ Ì ªÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ª∞∫ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ Bu-Cy, ·ÏÏ¿ ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ú¤ÂÈ Ó· ÏËÊı› ˘’ fi„ÈÓ Î·È Ë Û˘ÌÌÂÙÔ¯‹ ÂӉ¯fiÌÂÓ˘ ‚Ï¿‚˘ ˘fiÊ˘Û˘ Î·È ÁÔÓ¿‰ˆÓ ÏfiÁˆ Ù˘ ˘ÂÚÊfiÚÙˆÛ˘ Ì ۛ‰ËÚÔ, ηıÒ˜ Î·È Ë ÔÛÙÈ΋ ‰˘ÛÏ·Û›· Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙË ‰ÂÛÊÂÚÈÔÍ·Ì›ÓË3. ∞‰È·ÌÊÈÛ‚‹ÙËÙÔ ÚfiÏÔ ÛÙËÓ Ì›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ·Ó¿Ù˘Í˘ Î·È ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ·›˙ÂÈ Ë ¯ÔÚ‹ÁËÛË ·ÎÙÈÓÔ‚ÔÏ›·˜. ™Â Ì›· °·ÏÏÈ΋ ÌÂϤÙË, ÙÔ ÙÂÏÈÎfi ‡„Ô˜ Û 58% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ›¯·Ó ˘Ô‚ÏËı› Û ÔÏfiÛˆÌË ·ÎÙÈÓÔ‚fiÏËÛË (TBI) ÚÔ Ù˘ ª∞∫, ‹Ù·Ó ¯·ÌËÏfiÙÂÚÔ Î·Ù¿ ÂÚÈÛÛfiÙÂÚÔ ·fi 2 ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ (SD) Û ۯ¤ÛË Ì ÙÔ ·Ó·ÌÂÓfiÌÂÓÔ4. ΔË ÌÂÁ·Ï‡ÙÂÚË ·ÚÓËÙÈ΋ ›‰Ú·ÛË ‰¤¯ÔÓÙ·È ÔÈ ·ÛıÂÓ›˜ ̠Ϣ¯·ÈÌ›· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÎÙÈÓÔ‚ÔÏ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ ÚÒÙ˘ ÁÚ·ÌÌ‹˜, Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ï·Ì‚¿ÓÔ˘Ó TBI Û ̛· ‰fiÛË, ˆ˜ ÚÔÂÙÔÈÌ·Û›· ÁÈ· ª∞∫. ŸÙ·Ó ·È‰È¿ Ô˘ ·Ú·¤ÌÔÓÙ·È ÁÈ· ª∞∫ ¤¯Ô˘Ó ‹‰Ë ·ÎÙÈÓÔ‚ÔÏËı› Ì 18-24 Gy ÛÙÔ ∫¡™, Î·È ÛÙË Û˘Ó¤¯ÂÈ· ˘Ô‚¿ÏÏÔÓÙ·È Û TBI, Ë Û˘ÓÔÏÈ΋ ‰fiÛË ·ÎÙÈÓÔ‚fiÏËÛ˘ ÙÔ˘ ∫¡™ ˘ÂÚ‚·›ÓÂÈ Ù· 30 Gy Ô˘ ÂÎÙÈÌ¿Ù·È fiÙÈ Â›Ó·È ÙÔ fiÚÈÔ ÁÈ· ·Ó¿Ù˘ÍË ¤ÏÏÂȄ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (GH). H ¤ÏÏÂÈ„Ë ·˘Ù‹ ·Ó·Ù‡ÛÛÂÙ·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ 2-3 ¯ÚfiÓÈ· ·fi ÙË ¯ÔÚ‹ÁËÛË Ù˘ TBI, ‹ Î·È ·ÚÁfiÙÂÚ· Â¿Ó Ë Û˘ÓÔÏÈ΋ ‰fiÛË Â›Ó·È ÌÈÎÚfiÙÂÚË, Û˘ÓÂÒ˜ Ù· ·È‰È¿ Ô˘ ·ÎÙÈÓÔ‚ÔÏÔ‡ÓÙ·È Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· (ÌÂÙ¿ Ù· 10 ¯ÚfiÓÈ·) ÌÔÚ› Ó· ·Ó·Ù‡ÍÔ˘Ó ¤ÏÏÂÈ„Ë GH ÌÂÙ¿ ÙË Û˘ÌÏ‹ÚˆÛË Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘˜. ∏ ¯ÔÚ‹ÁËÛË Ù˘ ·ÎÙÈÓÔ‚ÔÏ›·˜ Û ÌÈÎÚ‹ ËÏÈΛ· (< ÙˆÓ 6 ÂÙÒÓ), Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ‚Ï·ÙÈ΋. ∏ ‰fiÛË Ù˘ ·ÎÙÈÓÔ-
™Â ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (ª∞∫) ˘Ô‚¿ÏÏÔÓÙ·È ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚ·, Ó¤· ΢ڛˆ˜ ¿ÙÔÌ·, Ì ÁÂÓÂÙÈο Î·È ÓÂÔÏ·ÛÌ·ÙÈο ÓÔÛ‹Ì·Ù·, ÈÒÓÙ·È Û ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi, ·ÏÏ¿ Û˘¯Ó¿ ¤¯Ô˘Ó Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó ÙȘ Ì·ÎÚÔ¯ÚfiÓȘ Û˘Ó¤ÂȘ ·˘Ù‹˜ Ù˘ Û˘Ó‰˘·Ṳ̂Ó˘ ΢ÙÙ·ÚÔÙÔÍÈ΋˜ Î·È ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ıÂڷ›·˜. ∞ÚÎÂÙ¿ Û˘¯Ó¤˜ Â›Ó·È ÔÈ ÂÈÏÔΤ˜ ·fi ÙÔ ÂÓ‰ÔÎÚÈÓÈÎfi Û‡ÛÙËÌ·, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î˘Ú›ˆ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜, ÙˆÓ ÁÔÓ¿‰ˆÓ, Ù˘ ·‡ÍËÛ˘/·Ó¿Ù˘Í˘, Î·È ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÁÏ˘Îfi˙˘ Î·È ÙˆÓ ÏÈȉ›ˆÓ. ∏ ·Ó·ÁÓÒÚÈÛË, ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ ·˘ÙÒÓ ‚ÔËı¿ Ù· ¿ÙÔÌ· Ô˘ ıÂڷ‡ÔÓÙ·È ·fi ÙÔ ‚·ÛÈÎfi ÙÔ˘˜ ÓfiÛËÌ· Ì ÙË ª∞∫, Ó· ¤¯Ô˘Ó ηχÙÂÚË ˘Á›· Î·È ÔÈfiÙËÙ· ˙ˆ‹˜.
∞‡ÍËÛË Î·È ·˘ÍËÙÈ΋ ÔÚÌfiÓË ∏ Ê˘ÛÈÔÏÔÁÈ΋ ·˘ÍËÙÈ΋ ‰È·‰Èηۛ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ·ÓÙ·Ó·ÎÏ¿ ÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·Ï‹˜ ˘Á›·˜ ÙÔ˘ ·ÙfiÌÔ˘, Î·È Ú˘ıÌ›˙ÂÙ·È ·fi ÙËÓ ·ÏÏËÏ›‰Ú·ÛË ÁÂÓÂÙÈÎÒÓ, ‰È·ÙÚÔÊÈÎÒÓ, ÌÂÙ·‚ÔÏÈÎÒÓ Î·È ÔÚÌÔÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ ·Ó¿Ù˘ÍË ‰ÂÓ Â›Ó·È ¿ÓÙ· ÁÚ·ÌÌÈ΋, Î·È ÌÔÚ› Ó· ·Ó·ÛÙ¤ÏÏÂÙ·È Û ÂÚÈfi‰Ô˘˜ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·Ûı¤ÓÂÈ·˜ ‹ ˘Ô‚ÔÏ‹˜ Û ÙÔÍÈΤ˜ ıÂڷ›˜. O ÈÔ ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘ ÙÔÍÈÎfiÙËÙ·˜ ÌÈ·˜ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙËÓ ·‡ÍËÛË, Â›Ó·È ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÙÔ˘ ·ÙfiÌÔ˘, ÙÔ ‡„Ô˜ ‰ËÏ·‰‹ Ô˘ ¤¯ÂÈ Êı¿ÛÂÈ ÌÂÙ¿ ÙË Û‡ÁÎÏÈÛË ÙˆÓ ÂÈʇÛˆÓ, Î·È ÙË Ì›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ηı’ ‡„Ô˜ ·‡ÍËÛ˘ Û ÏÈÁfiÙÂÚÔ ·fi 1 cm ÙÔ ¯ÚfiÓÔ. ¶·Ú’ fiÙÈ Ë ·‡ÍËÛË ·Ó·ÛÙ¤ÏÏÂÙ·È Û ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ª∞∫, ÙÔ ÙÂÏÈÎfi ‡„Ô˜ ÂÍ·ÚÙ¿Ù·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙÔ Û¯‹Ì· ÚÔÂÙÔÈÌ·Û›·˜, Î·È Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ‰ÂÓ ÂËÚ¿˙ÂÙ·È ÛËÌ·ÓÙÈο. ∏ ¯ÔÚ‹ÁËÛË .¯. ÌfiÓÔ Î˘ÎÏÔʈÛÊ·Ì›‰Ë˜ ÚÔ Ù˘ ª∞∫ ÁÈ· ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›· ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ·ÚÓËÙÈο
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I. ¶EPI™TEPH
‚ÔÏ›·˜ (> 7 Gy) ·›˙ÂÈ ÎÚ›ÛÈÌÔ ÚfiÏÔ, ÂÓÒ Ë ¯ÔÚ‹ÁËÛ‹ Ù˘ Û ÎÏ¿ÛÌ·Ù· ‰ÂÓ Ê·›ÓÂÙ·È Ó· ‚ÂÏÙÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ·. OÈ Holm et al ·Ó¤ÊÂÚ·Ó fiÙÈ Ë Ì›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ‹Ù·Ó 8,6 ÂηÙÔÛÙ¿ ÛÙÔ˘˜ ¿Ó‰Ú˜ Î·È 7,9 ÂηÙÔÛÙ¿ ÛÙȘ Á˘Ó·›Î˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û TBI Û ̛· ‹ ÂÚÈÛÛfiÙÂÚ˜ ‰fiÛÂȘ5. O Ù‡Ô˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ (·˘ÙfiÏÔÁË, ·ÏÏÔÁÂÓ‹˜) ‰ÂÓ ÂËÚ¿˙ÂÈ ÙÔ ÙÂÏÈÎfi ‡„Ô˜, ·Ó Î·È Û ÌÂÚÈΤ˜ ÌÂϤÙ˜, ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ ¯ÚfiÓÈ· ÓfiÛÔ ÌÔۯ‡̷ÙÔ˜ ηٿ ÍÂÓÈÛÙ‹ (cGVHD) Ê·›ÓÂÙ·È Ó· ÂÌÊ·Ó›˙Ô˘Ó Ù¿ÛË ÁÈ· ÌÂȈ̤ÓË ·Ó¿Ù˘ÍË Î·È ¯·ÌËÏfiÙÂÚÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· (Èı·ÓÒ˜ ÏfiÁˆ ‚·ÚÈ¿˜ Û˘ÛÙËÌ·ÙÈ΋˜ ÓfiÛÔ˘ Î·È ·Ú·ÙÂٷ̤Ó˘ ıÂڷ›·˜ Ì ÛÙÂÚÔÂȉ‹). ∏ TBI ÌÔÚ› Ó· ÚÔηϤÛÂÈ ‚Ú·¯‡ ·Ó¿ÛÙËÌ· Ì 2 ÙÚfiÔ˘˜: Ì›ˆÛË Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÏfiÁˆ Ù˘ ·ÎÙÈÓÔ‚fiÏËÛ˘ ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘ Î·È Ù˘ ˘ÔʇÛˆ˜, Î·È ‚Ï¿‚Ë ÙˆÓ ÔÛÙÒÓ Î·È ÙˆÓ ¯fiÓ‰ÚˆÓ. ∏ Ì›ˆÛË Ù˘ GH Û˘Ó‰˘¿˙ÂÙ·È ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÛÎÂÏÂÙÈΤ˜ ·Ó·ÏÔÁ›Â˜, ÂÓÒ Ë ·ÎÙÈÓÔ‚fiÏËÛË fiÏÔ˘ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÚÔηÏ› ÂÓ›ÔÙ ÛÎÂÏÂÙÈ΋ ‰˘Û·Ó·ÏÔÁ›· Ì Ì›ˆÛË ÙÔ˘ ‡„Ô˘˜ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘, Î·È ÙÔ˘ ÏÂÁfiÌÂÓÔ˘ «Î·ıÈÛÙÔ‡» ·Ó·ÛÙ‹Ì·ÙÔ˜5. ∏ ¯ÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÁÈ· ‚ÂÏÙ›ˆÛË ÙÔ˘ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÌÂÙ¿ ª∞∫ Û˘ÓÈÛÙ¿Ù·È Ì ÂÈʇϷÍË Î·È ÁÈ· ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ ·fi ÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ Û˘ÁÁÚ·Ê›˜. ¶ÚfiÛÊ·ÙË ÌÂϤÙË ‰Â›¯ÓÂÈ fiÙÈ ·È‰È¿ 2-10 ¯ÚÔÓÒÓ, Ô˘ ›¯·Ó ¤ÏÏÂÈ„Ë GH, Î·È ¤Ï·‚·Ó ıÂڷ›· ˘ÔηٿÛÙ·Û˘, ›¯·Ó ηχÙÂÚÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, ·fi ·È‰È¿ Ù˘ ›‰È·˜ ËÏÈΛ·˜ Ô˘ ‰ÂÓ ‹Ú·Ó GH6. ∞ÓÙ›ıÂÙ·, ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 10 ÂÙÒÓ ‰ÂÓ Â›¯·Ó ÛËÌ·ÓÙÈ΋ ˆÊ¤ÏÂÈ· ·fi ÙË ıÂڷ›· Ì GH. Δ· ·È‰È¿ ·˘Ù¿ Û˘ÓÈÛÙ¿Ù·È Ó· Ï·Ì‚¿ÓÔ˘Ó GH ÌfiÓÔÓ fiÙ·Ó ¤¯Ô˘Ó Ôχ ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ‹ Ôχ ¯·ÌËϤ˜ ÙÈ̤˜ GH7. Δ· ·ÁfiÚÈ· ˆÊÂÏÔ‡ÓÙ·È ÏÈÁfiÙÂÚÔ ·fi Ù· ÎÔÚ›ÙÛÈ·.
¢È·Ù·Ú·¯¤˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ·‰¤ÓÔ˜ OÈ ı˘ÚÂÔÂȉÈΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó¤˜ ÌÂÙ¿ ÙË ª∞∫. ∂ȉÈο Ë ·ÎÙÈÓÔ‚fiÏËÛË ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ·Ó¿Ù˘ÍË ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡, ·Ú¯Èο Û˘Ó‹ıˆ˜ ·ÓÙÈÚÚÔo‡ÌÂÓÔ˘, ÌÂ Ê˘ÛÈÔÏÔÁÈο ›‰· ı˘ÚÔ͛Ӣ ÔÚÔ‡, ·ÏÏ¿ ·˘ÍË̤Ó˜ ÙÈ̤˜ TSH, Ô ÔÔ›Ô˜ ÌÔÚ›, ÌÂÚÈΤ˜ ÊÔÚ¤˜ Î·È ÌÂÙ¿ ·fi ‰ÂηÂٛ˜ Ó· ÂÍÂÏȯı› Û ÎÏÈÓÈÎfi ˘Ôı˘ÚÂÔÂȉÈÛÌfi. £˘ÚÂÔÂȉ›Ùȉ· Î·È ı˘ÚÂÔÂȉÈο ÓÂÔÏ¿ÛÌ·Ù· ··ÓÙÒÓÙ·È Â›Û˘ Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Û ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó οÓÂÈ ÌÂÙ·Ìfi-
Û¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ™Â Ì›· ∂ıÓÈ΋ °·ÏÏÈ΋ ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û 388 ·È‰È¿ Ì ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (O§§) Ô˘ ›¯·Ó ˘Ô‚ÏËı› Û ª∞∫ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰ÂηÂÙ›·˜ 1984 - 1994, ÂÍÂÙ¿ÛÙËÎÂ Ë ‰ÔÌ‹ Î·È ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ·‰¤ÓÔ˜ Û 153 ¿ÙÔÌ· Ô˘ ›¯·Ó ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ ¿Óˆ ÙˆÓ 5 ÂÙÒÓ8. ™ÙËÓ ÔÌ¿‰· ·˘Ù‹, 16 ·ÛıÂÓ›˜ (9%) ·Ó¤Ù˘Í·Ó ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓÔ ˘Ôı˘ÚÂÔÂȉÈÛÌfi, Î·È 46 (31,4%) ·ÓÙÈÚÚÔÔ‡ÌÂÓÔ Ì ‰È¿ÌÂÛÔ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ‹˜ ÙÔ˘˜ 2,9 Î·È 2,7 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ª∞∫. ¶¤ÓÙ ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ª∞∫, 73,2% ÙˆÓ ·ÙfiÌˆÓ Ô˘ ‚›ˆÓ·Ó ‰ÂÓ Â›¯·Ó ı˘ÚÂÔÂȉÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ÔÛÔÛÙfi Ô˘ ¤ÂÊÙ ÛÙÔ 59,2 ‰¤Î· ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ª∞∫. O ·ÚÈÔ˜ ·Ú¿ÁˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ˘ÔÎÏÈÓÈÎÔ‡ Î·È ÎÏÈÓÈÎÔ‡ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ ‹Ù·Ó Ë ÔÏfiÛˆÌË ·ÎÙÈÓÔ‚fiÏËÛË, Î·È È‰›ˆ˜ fiÙ·Ó ·˘Ù‹ ¯ÔÚËÁ›ÙÔ Û ̛· ‰fiÛË, Î·È fi¯È Û ÎÏ¿ÛÌ·Ù·. ∏ ›‰Ú·ÛË ÙÔ˘ ‰ÔÛÔÏÔÁÈÎÔ‡ Û¯‹Ì·ÙÔ˜ Ù˘ TBI ÛÙËÓ ·Ó¿Ù˘ÍË ı˘ÚÂÔÂȉÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ê·›ÓÂÙ·È Î·È ÛÙË ÌÂϤÙË ÙˆÓ Sanders et al fiÔ˘ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó TBI Û ̛· ‰fiÛË Â›¯·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚË ı˘ÚÂÔÂȉԿıÂÈ· (4648%) Û ۯ¤ÛË Ì fiÛÔ˘˜ ›¯·Ó Ï¿‚ÂÈ TBI Û ÎÏ¿ÛÌ·Ù· (15-16%)9. ∞ÓÙ›ıÂÙ·, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¤Ï·‚ ۯ‹Ì· ÚÔÂÙÔÈÌ·Û›·˜ ÌfiÓÔ Ì ¯ËÌÂÈÔıÂڷ›·, ›¯Â Ê˘ÛÈÔÏÔÁÈ΋ ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ‹Ù·Ó Ë Ó·ڋ ËÏÈΛ· ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ë ª∞∫ Û 2Ë ‡ÊÂÛË. Ÿ˙Ô˘˜ ÛÙÔ ı˘ÚÂÔÂȉ‹ ›¯·Ó 10 ·fi ÙÔ˘˜ 35 ·ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô O ‰È¿ÌÂÛÔ˜ ¯ÚfiÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ÙˆÓ fi˙ˆÓ ‹Ù·Ó 7,8 ¤ÙË ·fi ÙË ª∞∫. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË Ù˘ ∂˘Úˆ·˚΋˜ OÌ¿‰·˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (EBMT Group), Û 68.936 ¿ÙÔÌ· Ô˘ ›¯·Ó ˘Ô‚ÏËı› Û ª∞∫, ηٿ ÙËÓ ÂÚ›Ô‰Ô 1985 ¤ˆ˜ 2003, ÂÓÙÔ›ÛıËÎ·Ó 32 ·ÛıÂÓ›˜ Ô˘ ·Ó¤Ù˘Í·Ó ηÚΛÓÔ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜10. ™Â Û‡ÁÎÚÈÛË Ì ¿ÙÔÌ· ÙÔ˘ ȉ›Ô˘ ʇÏÔ˘ Î·È ËÏÈΛ·˜ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi, ÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÛıÂÓ›˜ ›¯·Ó ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ηÚΛÓÔ˘ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ (ËÏ›ÎÔ ·Ú·ÙËÚÔ‡ÌÂÓˆÓ/·Ó·ÌÂÓfiÌÂÓˆÓ ÂÚÈÙÒÛˆÓ: 3,26). O ΛӉ˘ÓÔ˜ ·˘Ùfi˜ ‹Ù·Ó ÂÍ·ÈÚÂÙÈο ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ¿ÙÔÌ· Ô˘ ›¯·Ó ˘Ô‚ÏËı› Û ª∞∫ Û ËÏÈΛ· ÌÈÎÚfiÙÂÚË ÙˆÓ 10 ÂÙÒÓ (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜, RR: 24,61). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ‹Ù·Ó Ë ·ÎÙÈÓÔ‚ÔÏ›·, ÙÔ Á˘Ó·ÈÎÂ›Ô Ê‡ÏÔ, Î·È Ë ‡·ÚÍË ¯ÚfiÓÈ·˜ ÓfiÛÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ ÍÂÓÈ-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÛÙ‹ (cGVHD). Àfi ÙÔ Êˆ˜ ·˘ÙÒÓ ÙˆÓ ‰Â‰Ô̤ӈÓ, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ÂÓ‰ÔÎÚÈÓÔÏfiÁÔÈ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÌÂÈÒÛÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ı˘ÚÂÔÂȉÈÎÔ‡ ηÚΛÓÔ˘ Û ¿ÙÔÌ· Ô˘ ÂÎÙ¤ıËÎ·Ó Û ·ÎÙÈÓÔ‚ÔÏ›· Û Ó·ڋ ËÏÈΛ·, ¯ÔÚËÁÔ‡Ó Û ·ÛıÂÓ›˜ Ì ·˘ÍË̤ӷ ›‰· TSH , Ê·Ú̷΢ÙÈ΋ ˘ÔηٿÛÙ·ÛË Ì ı˘ÚÔÍ›ÓË,
¢˘ÛÏÂÈÙÔ˘ÚÁ›· ÁÔÓ¿‰ˆÓ ªÂÙ¿ ÙË ª∞∫ ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ (92% ÙˆÓ ·Ó‰ÚÒÓ Î·È 99% ÙˆÓ Á˘Ó·ÈÎÒÓ) ı· ÂÌÊ·Ó›ÛÂÈ ÁÔÓ·‰È΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ë ÔÔ›· Û˘¯Ó¿ ı· ÂÍÂÏȯı› Û ÌË ·Ó·ÛÙÚ¤„ÈÌË ·Ó¿ÚÎÂÈ·11. ∫·È ÔÈ ‰‡Ô ÏÂÈÙÔ˘ÚÁ›Â˜ ÙˆÓ ÁÔÓ¿‰ˆÓ, Ë Á·ÌÂÙÔÁ¤ÓÂÛË (ˆÔÁ¤ÓÂÛË, ÛÂÚÌ·ÙÔÁ¤ÓÂÛË) ·ÏÏ¿ Î·È Ë ·Ú·ÁˆÁ‹ ÙˆÓ Ê˘ÏÂÙÈÎÒÓ ÛÙÂÚÔÂȉÒÓ ÔÚÌÔÓÒÓ (ÔÈÛÙÚÔÁfiÓ·, ÚÔÁÂÛÙÂÚfiÓË, ÙÂÛÙÔÛÙÂÚfiÓË) ÂËÚ¿˙ÔÓÙ·È, Ì ·ÔÙ¤ÏÂÛÌ· ÛÙÂÈÚfiÙËÙ· Î·È ÛÂÍÔ˘·ÏÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. OÈ ÂÈÏÔΤ˜ ·˘Ù¤˜ ÂËÚ¿˙Ô˘Ó ÛËÌ·ÓÙÈο ÙËÓ „˘¯ÔÏÔÁ›· Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÈ‚ÈÒÓÔ˘Ó ÌÂÙ¿ ª∞∫, Î·È Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ¤ÁηÈÚ· ÚÔÏËÙÈο Î·È ıÂڷ¢ÙÈο ̤ÙÚ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜. ∏ ‚Ï¿‚Ë ÙˆÓ ÁÔÓ¿‰ˆÓ Â›Ó·È ¤Ó· ˆ˜ › ÙÔ Ï›ÛÙÔÓ Ô͇ Ê·ÈÓfiÌÂÓÔ Ô˘ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ ÚÔ·Ú·Û΢·ÛÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ (¤¯ÂÈ ·Ó·ÊÂÚı› Ì›ˆÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ fiÚ¯ÂˆÓ Î·Ù¿ 50% ÂÓÙfi˜ 24 ˆÚÒÓ ·fi ÙË ¯ÔÚ‹ÁËÛË Ù˘ ¯ËÌÂÈÔıÂڷ›·˜, ·˙ˆÔÛÂÚÌ›· Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ 2 Ì‹Ó˜ ÌÂÙ¿ ÙË ª∞∫, ·ÏÏ¿ Î·È Ì›ˆÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ ˆÔıËÎÒÓ Î·È ÂÍ·Ê¿ÓÈÛË ÙˆÓ ˆÔı˘Ï·Î›ˆÓ ÛÙȘ Á˘Ó·›Î˜)12. ∏ ÁÔÓ·‰È΋ ‚Ï¿‚Ë ‰È·ÈÛÙÒÓÂÙ·È Î·È ·fi ÙȘ Ôχ ˘„ËϤ˜ ÙÈ̤˜ ÁÔÓ·‰ÔÙÚÔÊÈÓÒÓ 24 ÒÚ˜ ÌÂÙ¿ ÙË ª∞∫. ¶ÏËÓ ÙˆÓ ÁÔÓ¿‰ˆÓ, ‚Ï¿ÙÔÓÙ·È Î·È Ô ˘Ôı·Ï·ÌÔ-˘ÔÊ˘ÛÈ·Îfi˜ ¿ÍÔÓ·˜, ȉȷ›ÙÂÚ· ÌÂÙ¿ ·ÎÙÈÓÔ‚fiÏËÛË ÙÔ˘ ÎÚ·Ó›Ô˘, Î·È Ù· fiÚÁ·Ó· ÛÙfi¯ÔÈ fiˆ˜ ÙÔ ÂÓ‰ÔÌ‹ÙÚÈÔ Î·È Ô ÎfiÏÔ˜. ∏ ‚Ï¿‚Ë ÙˆÓ ÁÔÓ¿‰ˆÓ ¿ÓÙˆ˜ ÌÔÚ› Ó· Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË Î·È Ë ‚·Ú‡ÙËÙ¿ Ù˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ˘˜ ·ÎfiÏÔ˘ıÔ˘˜ ·Ú¿ÁÔÓÙ˜: – ÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ˜ Î·È ÙËÓ ÚÔËÁÔ‡ÌÂÓË ¯ËÌÂÈÔıÂڷ›·. ¶ÔÏÏ·ÏÔ› ·ÎÏÔÈ ÁÔÓ·‰ÔÙÔÍÈÎÒÓ ıÂÚ·ÂÈÒÓ (·ÎÙÈÓÔ‚ÔÏ›·, ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜) Î·È ‡·ÚÍË ·ÈÌ·ÙÔÏÔÁÈ΋˜ ηÎÔ‹ıÂÈ·˜ (ÏfiÁˆ Ù‡Ô˘ ıÂڷ›·˜ ‹ Ù¿Û˘ ‰È‹ıËÛ˘ ÙˆÓ ÁÔÓ¿‰ˆÓ) ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ. – ΔÔ Ê‡ÏÔ Î·È Ë ËÏÈΛ·. º·›ÓÂÙ·È fiÙÈ Ë ‚Ï¿‚Ë Ô˘ ÚÔηÏ› Ë ·ÎÙÈÓÔ‚ÔÏ›· ÛÙȘ ÁÔÓ¿‰Â˜ ηٿ ÙËÓ
291
ÚÔÂÊË‚È΋ ËÏÈΛ· Â›Ó·È ÌÈÎÚfiÙÂÚË, ·fi fiÙÈ ÌÂÙ¿ ÙËÓ ÂÓ‹‚ˆÛË. ∞ÁfiÚÈ· Î·È ¤ÊË‚ÔÈ Ô˘ ‹Ú·Ó Û¯‹Ì·Ù· ÚÔÂÙÔÈÌ·Û›·˜ Ô˘ ÂÚÈÂÏ¿Ì‚·Ó·Ó ›Ù ΢ÎÏÔʈÛÊ·Ì›‰Ë ÌfiÓÔ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì TBI, ›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Leydig, fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÙÂÛÙÔÛÙÂÚfiÓ˘ ÔÚÔ‡, ›¯·Ó fï˜ ÂӉ›ÍÂȘ ‚Ï¿‚˘ Ù˘ ÛÂÚÌ·ÙÔÁ¤ÓÂÛ˘ Ì ·˘ÍË̤Ó˜ ÙÈ̤˜ FSH Î·È ÌÂȈ̤ÓÔ fiÁÎÔ fiگˆÓ. Δ· ·ÙÙ·Ú· Leydig Â›Ó·È Ú¿ÁÌ·ÙÈ ÏÈÁfiÙÂÚÔ Â˘·›ÛıËÙ· ÛÙË ¯ËÌÂÈÔıÂڷ›· ·fi Ù· ·ÙÙ·Ú· ÙÔ˘ ÛÂÚÌ·ÙÈÎÔ‡ ÂÈıËÏ›Ô˘, Ô ·ÚÈıÌfi˜ ÙÔ˘˜ fï˜ ÌÂÈÒÓÂÙ·È ÌÂÙ¿ ÙË ª∞∫, Î·È ¿Ó‰Ú˜ ¿Óˆ ÙˆÓ 40 ÂÙÒÓ ÂÓ‰¤¯ÂÙ·È Ó· ¤¯Ô˘Ó ·Ó¿ÚÎÂÈ· ÙÂÛÙÔÛÙÂÚfiÓ˘ Î·È ÛÂÍÔ˘·ÏÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. ™Â ÌÂϤÙË ·fi ÙÔ ªemorial-Sloan Kettering CC, Û ÚÔÂÊË‚Èο ·È‰È¿ Ì ÔÍ›· Ï¢¯·ÈÌ›· Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÌÂÙ¿ ÚÔÂÙÔÈÌ·Û›· Ì ˘ÂÚ-ÎÏ·ÛÌ·ÙÔÔÈË̤ÓË TBI ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¯ËÌÂÈÔıÂڷ›· (΢ÎÏÔʈÛÊ·Ì›‰Ë ‹ Ara-C) ‰È·ÈÛÙÒıËΠfiÙÈ Ù· ÂÚÈÛÛfiÙÂÚ· ·ÁfiÚÈ· ÂÌÊ¿ÓÈÛ·Ó Î·ÓÔÓÈ΋ ‹‚Ë, ÂÓÒ Ù· ÌÈÛ¿ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÎÔÚ›ÙÛÈ· ‰È·Ù‹ÚËÛ·Ó ·ÚÎÂÙ‹ ˆÔıËÎÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÒÛÙ ӷ ÂÌÊ·Ó›ÛÔ˘Ó ÔÌ·Ï‹ ‹‚Ë Î·È ¤ÌÌËÓÔ Ú‡ÛË13. º·›ÓÂÙ·È fiÙÈ ÔÈ ˆÔı‹Î˜ ÙˆÓ Ó·ÚÒÓ ·ÛıÂÓÒÓ Â›Ó·È ÈÔ ·ÓıÂÎÙÈΤ˜ ÛÙËÓ ·ÎÙÈÓÔ‚ÔÏ›·, Î·È Ù· ÂÓ·ÔÌ›ӷÓÙ· ¿ıÈÎÙ· ˆÔı˘Ï¿ÎÈ· ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ·ÚÁfiÙÂÚ· ÛÙȘ ·˘ÍË̤Ó˜ ÁÔÓ·‰ÔÙÚÔʛӘ. ∞ÓÙ›ıÂÙ·, fiϘ ۯ‰fiÓ ÔÈ Á˘Ó·›Î˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó Û ËÏÈΛ· ¿Óˆ ÙˆÓ 12 ÂÙÒÓ ÂÌÊ¿ÓÈÛ·Ó ˆÔıËÎÈ΋ ·Ó¿ÚÎÂÈ·. – ΔÔ ¯ÔÚËÁÔ‡ÌÂÓÔ Û¯‹Ì· ÚÔÂÙÔÈÌ·Û›·˜. ∂ÓÒ Ë Â›‰Ú·ÛË Ù˘ TBI ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙË ª∞∫, ÔÈ ·Ï΢ÏÈÔ‡ÓÙ˜ ·Ú¿ÁÔÓÙ˜ Î·È ‰Ë ÙÔ Busulfan ‰ÚÔ˘Ó ‚Ï·ÙÈο ÛÙȘ ÁÔÓ¿‰Â˜ ÙfiÛÔ Û ·È‰È¿ fiÛÔ Î·È Û ÂÓ‹ÏÈΘ. ™ÙË ÌÂϤÙË ÙˆÓ Sanders Î·È Û˘ÓÂÚÁ·ÙÒÓ Ì›· ÌfiÓÔ Á˘Ó·›Î· ·fi ÙȘ 73, ËÏÈΛ·˜ 14-57 ÂÙÒÓ Ô˘ ‹Ú·Ó busulfan (16 mg/kg) Î·È cyclophosphamide (200 mg/kg), ·ӤÎÙËÛÂ Ê˘ÛÈÔÏÔÁÈ΋ ˆÔıËÎÈ΋ ÏÂÈÙÔ˘ÚÁ›·14, ÂÓÒ Û ¿ÏϘ ÌÂϤÙ˜ Ê·›ÓÂÙ·È fiÙÈ ÙÔ Busulfan ÚÔηÏ› ˆÔıËÎÈ΋ ·Ó¿ÚÎÂÈ· ۯ‰fiÓ Û fiϘ ÙȘ Á˘Ó·›Î˜, ·ÎfiÌË Î·È fiÙ·Ó ¯ÔÚËÁÂ›Ù·È Û ÚÔÂÊË‚È΋ ÂÚ›Ô‰Ô15,16,17. ΔÔ Û˘¯Ófi Úfi‚ÏËÌ· Ù˘ ÁÔÓ·‰È΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ÙË ª∞∫ Ú¤ÂÈ Ó· ÁÓˆÛÙÔÔÈÂ›Ù·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÚfiÎÂÈÙ·È Ó· ˘Ô‚ÏËıÔ‡Ó Û ª∞∫ ‹ ÛÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘˜, Ó· ÚÔÙ›ÓÔÓÙ·È Î·È Ó· Ï·Ì‚¿ÓÔÓÙ·È Ì¤ÙÚ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘.
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I. ¶EPI™TEPH
∏ ¯Ú‹ÛË ÁÔÓ·‰ÔÙÔÍÈÎÒÓ Û¯ËÌ¿ÙˆÓ ÚÔÂÙÔÈÌ·Û›·˜ ı· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È fiÙ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ. ∏ ¯ÔÚ‹ÁËÛË ÔÚÌÔÓÈ΋˜ ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ ‚ÔËı¿ Ôχ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÛÂÍÔ˘·ÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Û ¿Ó‰Ú˜ Î·È Á˘Ó·›Î˜ (‰˘ÛÎÔÏ›· ÛÙ‡Ûˆ˜ Î·È ÂÎÛÂÚÌ·ÙÒÛˆ˜, ÌÂȈ̤ÓË libido, ·ÙÚÔÊ›· ¤Íˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ, ÍËÚfiÙËÙ· ÎfiÏÔ˘, ‰˘Û·Ú‡ÓÈ·), ·ÏÏ¿ Î·È Ù˘ ÔÛÙÂÔfiÚˆÛ˘, ȉ›ˆ˜ ÛÙȘ Á˘Ó·›Î˜. π‰È·›ÙÂÚË Ì¤ÚÈÌÓ· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÁÈ· ÙÔ˘˜ Ó¤Ô˘˜ ·ÛıÂÓ›˜ Ô˘ ÂÈı˘ÌÔ‡Ó Ó· ‰È·ÙËÚ‹ÛÔ˘Ó ÙË ÁÔÓÈÌfiÙËÙ¿ ÙÔ˘˜.
∫Ú˘ÔÛ˘ÓÙ‹ÚËÛË Û¤ÚÌ·ÙÔ˜ O ηıÈÂڈ̤ÓË Ì¤ıÔ‰Ô˜ ‰È·Ù‹ÚËÛ˘ Ù˘ Èı·ÓfiÙËÙ·˜ ÁÈ· ÙÂÎÓÔÔ›ËÛË ÛÙÔ˘˜ ¿Ó‰Ú˜ Î·È ÛÂÍÔ˘·ÏÈο ÒÚÈÌÔ˘˜ ¤ÊË‚Ô˘˜ Â›Ó·È Ë Ê‡Ï·ÍË ÎÚ˘ÔηÙ„˘Á̤ÓÔ˘ Û¤ÚÌ·ÙÔ˜. ªÂ ÙËÓ ·Ó¿Ù˘ÍË Ó¤ˆÓ Ù¯ÓÈÎÒÓ, fiˆ˜ Ë in vitro ÁÔÓÈÌÔÔ›ËÛË Î·È Ë ÂÓ‰Ô΢ÙÙÔÏ·ÛÌÈ΋ ÛÂÚÌ·Ù¤Á¯˘ÛË, ·ÎfiÌË Î·È Û¤ÚÌ· ¯·ÌËÏ‹˜ ÔÈfiÙËÙ·˜ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ÂÈÙ˘¯Ò˜ Î·È Ó· ÚÔ·„Ô˘Ó Î˘‹ÛÂȘ. ™˘ÓÂÒ˜, ÏËÓ ÂÚÈÙÒÛÂˆÓ ·˙ˆÔÛÂÚÌ›·˜, ÙÔ Û¤ÚÌ· Ú¤ÂÈ Ó· Ê˘Ï¿ÛÛÂÙ·È ¿ÓÙ· fiÙ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, ȉ·ÓÈο ÚÔ Ù˘ ¤Ó·Ú͢ ¯ËÌÂÈÔıÂڷ›·˜. ™Â ·ÛıÂÓ›˜ Ì ·˙ˆÔÛÂÚÌ›· ‹ ·‰˘Ó·Ì›· Ï‹„˘ Û¤ÚÌ·ÙÔ˜, ˘¿Ú¯ÂÈ Î·È Ë ‰˘Ó·ÙfiÙËÙ· ÎÚ˘Ôηٿ„˘Í˘ ÔÚ¯ÈÎÔ‡ ÈÛÙÔ‡, ‹ ·ÔÌfiÓˆÛ˘ Î·È Î·Ù¿„˘Í˘ ΢ÙÙ¿ÚˆÓ ÛÂÚÌ·ÙÈÎÔ‡ ÂÈıËÏ›Ô˘18.
∫Ú˘ÔÛ˘ÓÙ‹ÚËÛË ÂÌ‚Ú‡Ô˘- ˆÔıËÎÈÎÔ‡ ÈÛÙÔ‡ ™Â ·ÓÙ›ıÂÛË Ì ÙËÓ ÎÚ˘ÔÛ˘ÓÙ‹ÚËÛË ÙÔ˘ Û¤ÚÌ·ÙÔ˜, Ë ÎÚ˘ÔÛ˘ÓÙ‹ÚËÛË ˆ·Ú›ˆÓ ‰ÂÓ Â›Ó·È ·ÎfiÌË Ù¯ÓÈο ÂÊÈÎÙ‹. ™‡Ìʈӷ Ì ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ, ·ÎfiÌË Î·È Ù· ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ˆ·Ú›ˆÓ Ô˘ ÂÈÙ˘Á¯¿ÓÔÓÙ·È Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÈÔ ÂÍÂÏÈÁÌ¤ÓˆÓ ÚˆÙÔÎfiÏÏˆÓ ÎÚ˘ÔÛ˘ÓÙ‹ÚËÛ˘ (·ÚÁfi˜ Ú˘ıÌfi˜ „‡Í˘, ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÔ˘ÎÚfi˙˘), ‰ÂÓ ÂÁÁ˘ÒÓÙ·È ÎÏÈÓÈ΋ ÂÈÙ˘¯›·. Δ· ÔÛÔÛÙ¿ ›Ù¢Í˘ ·ËÛ˘ ÁÈ· οı ·Ô„˘Á̤ÓÔ ˆ¿ÚÈÔ ‰ÂÓ ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 1,8%19. ∏ ÈÔ ‰ÔÎÈÌ·Ṳ̂ÓË Ì¤ıÔ‰Ô˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ÛÙÂÈÚfiÙËÙ·˜ Û Á˘Ó·›Î˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ª∞∫ Â›Ó·È Ë in vitro ÁÔÓÈÌÔÔ›ËÛË Î·È ÎÚ˘ÔÛ˘ÓÙ‹ÚËÛË ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÁÈ· ÌÂÏÏÔÓÙÈ΋ ÂÌ‚Ú˘ÔÌÂÙ·ÊÔÚ¿. ∞·ÈÙÂ›Ù·È Ì›· ÏÂÈÙÔ˘ÚÁÈ΋ ˆÔı‹ÎË, ÛÙ·ıÂÚfi˜ Û‡ÓÙÚÔÊÔ˜, Î·È Â·Ú΋˜ ¯ÚfiÓÔ˜ (·ÚÎÂÙ¤˜ ‚‰ÔÌ¿‰Â˜) ÁÈ· ÚfiÎÏËÛË ˆÔÚÚËÍ›·˜ Î·È Û˘ÏÏÔÁ‹˜ ÙˆÓ ˆ·Ú›ˆÓ ÚÔ Ù˘ ¤Ó·Ú͢ ÙÔ˘ ΢ÙÙ·ÚÔÙÔÍÈÎÔ‡ Û¯‹Ì·-
ÙÔ˜. ∂Ó·ÏÏ·ÎÙÈο, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ηٷ„˘¯ı› ˆÔıËÎÈÎfi˜ ÈÛÙfi˜, Ô˘ ÂÚȤ¯ÂÈ ˆÔı˘Ï¿ÎÈ·, Ó· Ê˘Ï·¯ı›, Î·È Ó· ·ÓÂÌÊ˘Ù¢ı› ÌÂÙ¿ ÙË ª∞∫ ›Ù ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ˆÔı‹Î˘, ›Ù ÂÙÂÚfiÙÔ·. ¶ÚÔ Ù˘ ÂÌÊ˘Ù‡Ûˆ˜ Ô ˆÔıËÎÈÎfi˜ ÈÛÙfi˜ Ú¤ÂÈ Ó· ÂÏÂÁ¯ı› ÁÈ· ‰È‹ıËÛË ·fi ÓÂÔÏ·ÛÌ·ÙÈο ·ÙÙ·Ú·.
∫˘‹ÛÂȘ ∞ÚÎÂÙ¤˜ ÛÔÚ·‰ÈΤ˜ ·Ó·ÊÔÚ¤˜ ÁÈ· ÂÈÙ˘¯Â›˜ ΢‹ÛÂȘ ÌÂÙ¿ ª∞∫ ˘¿Ú¯Ô˘Ó ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ fï˜ ÏËÚÔÊÔڛ˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi 2 ÌÂÁ¿Ï˜ ÌÂϤÙ˜, Ì›· AÌÂÚÈηÓÈ΋14 Î·È Ì›· ∂˘Úˆ·˚΋20. ™ÙËÓ ∂˘Úˆ·˚΋ ÌÂϤÙË Û ÛÂÈÚ¿ 37.362 ·ÛıÂÓÒÓ, ηٷÁÚ¿ÊËÎ·Ó 312 ΢‹ÛÂȘ Û 232 (0,6%) ·ÛıÂÓ›˜ ‹ Û˘ÓÙÚfiÊÔ˘˜ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi ª∞∫. ΔÔ ÂÙ‹ÛÈÔ ÔÛÔÛÙfi ÁÂÓÓ‹ÛÂˆÓ ÛÙËÓ ÔÌ¿‰· ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 1,7 Û 1000 ¿ÙÔÌ·, Ôχ ¯·ÌËÏfiÙÂÚÔ ÙÔ˘ ÂÙ‹ÛÈÔ˘ ÂıÓÈÎÔ‡ ÔÛÔÛÙÔ‡ ÙˆÓ μÚÂÙ·ÓÒÓ (12,5). OÈ Û‡ÓÙÚÔÊÔÈ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·Ó‰ÚÒÓ Â›¯·Ó ·Ó›ÏÂÎÙ˜ ΢‹ÛÂȘ Î·È Ê˘ÛÈÔÏÔÁÈο ·È‰È¿, ÂÓÒ ÔÈ Á˘Ó·›Î˜ Ô˘ ›¯·Ó ˘Ô‚ÏËı› Û ª∞∫ ›¯·Ó ÈÔ Û˘¯Ó¿ ·Ô‚ÔϤ˜, ÚfiˆÚÔ˘˜ ÙÔÎÂÙÔ‡˜, ÏÈÔ‚·Ú‹ ̈ڿ Î·È ˘¤ÚÙ·ÛË. ∏ Û˘¯ÓfiÙËÙ· Û˘ÁÁÂÓÒÓ ·ÓˆÌ·ÏÈÒÓ, ‰È·Ù·Ú·¯ÒÓ Ù˘ ·Ó¿Ù˘Í˘ Î·È Î·ÎÔ‹ıÔ˘˜ ÓÔÛ‹Ì·ÙÔ˜ ÛÙ· ·È‰È¿ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ‰ÂÓ ‰È¤ÊÂÚ ·fi ·˘Ù‹Ó ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡. ª˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ. ª›· ·ÚÔÛ‰fiÎËÙË ËÁ‹ ˆÔ΢ÙÙ¿ÚˆÓ; ™Â ·ÓÙ›ıÂÛË Ì ÙÔÓ fiÚ¯È, Ô˘ Û˘Ó¯›˙ÂÈ ÙËÓ ·Ú·ÁˆÁ‹ Á·ÌÂÙÒÓ Û fiϘ ÙȘ ËÏÈ˘, Ë ˆÔı‹ÎË ÙˆÓ ıËÏ·ÛÙÈÎÒÓ ÈÛÙ‡ÂÙ·È fiÙÈ ‰È·ı¤ÙÂÈ ¤Ó· ÂÚÈÔÚÈṲ̂ÓÔ ·fiıÂÌ· ˆÔı˘Ï·Î›ˆÓ Ô˘ ‰ÂÓ ·Ó·ÓÂÒÓÂÙ·È ÌÂÙ¿ ÙË Á¤ÓÓËÛË.To 2004 Ì›· ÌÂϤÙË Ô˘ ‰ËÌÔÛȇÙËΠÛÙÔ ÂÚÈÔ‰ÈÎfi Nature ·fi ÙÔ˘˜ Tilly Î·È Û˘ÓÂÚÁ¿Ù˜, ·ÌÊÈÛ‚‹ÙËÛ ÙËÓ ÈÛ¯‡ ÙÔ˘ ‰fiÁÌ·ÙÔ˜ ·˘ÙÔ‡21. ∂Ó Ì¤Ûˆ ÁÂÓÈÎÔ‡ ÛÎÂÙÈÎÈÛÌÔ‡ Î·È ÎÚÈÙÈ΋˜, Ë ›‰È· ÔÌ¿‰· ¤Ó· ¯ÚfiÓÔ ·ÚÁfiÙÂÚ· ·ӋÏı Ì Ӥ· ÌÂϤÙË ‹ ÔÔ›· ÂÓÙfiÈÛ ·ÙÙ·Ú· ÛÙÔ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ Î·È ÙÔ ·›Ì· ıËÏ˘ÎÒÓ ÔÓÙÈÎÒÓ Ù· ÔÔ›· ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔÚÔ‡Û·Ó Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó ˆÔ·ÙÙ·Ú· ̤۷ Û ¿ˆÚ· ˆÔı˘Ï¿ÎÈ· ÛÙȘ ˆÔı‹Î˜ ÔÓÙÈÎÒÓ Ô˘ ›¯·Ó ˘Ô‚ÏËı› Û ¯ËÌÂÈÔıÂڷ›·22. ∞ÚÁfiÙÂÚ·, Ó¤· ÂÈÚ¿Ì·Ù· ¤‰ÂÈÍ·Ó fiÙÈ Ú¿ÁÌ·ÙÈ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‚ÂÏÙ›ˆÓ ÛËÌ·ÓÙÈο ÙË ÁÔÓÈÌfiÙËÙ· ÔÓÙÈÎÒÓ Ô˘ ›¯·Ó Ï¿‚ÂÈ ¯ËÌÂÈÔıÂڷ›·, ·ÏÏ¿ fiÏÔÈ ÔÈ ·fiÁÔÓÔÈ Â›¯·Ó ÙË ÁÂÓÂÙÈ΋ Ù·˘ÙfiÙËÙ· ÙÔ˘ Ï‹ÙË23. OÈ Û˘ÁÁÚ·Ê›˜ ÚÔÂÎÙ›ÓÔÓÙ·˜ Ù· Â˘Ú‹Ì·Ù¿ ÙÔ˘˜, Ù·
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Û˘Ó‰¤Ô˘Ó Ì ÙËÓ ·˘ÙfiÌ·ÙË Â¿ÓÔ‰Ô Ù˘ ÂÌÌ‹ÓÔ˘ Ú‡Ûˆ˜ Î·È Ù˘ Ê˘ÛÈ΋˜ ÁÔÓÈÌfiÙËÙ·˜ Ô˘ ¤گÂÙ·È Û ÌÂÚÈΤ˜ Á˘Ó·›Î˜ ÌÂÙ¿ ·fi ª∞∫, ·Ú’ fiÙÈ ·˘Ù¤˜ ÂÌÊ¿ÓÈ˙·Ó ÂÌÌËÓfi·˘ÛË ÁÈ· ·ÚÎÂÙ¿ ¯ÚfiÓÈ·. ∏ ˘fiıÂÛË ·˘Ù‹, ·Ó ·ÏËı¢ı›, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û Ӥ˜ ÛÙÚ·ÙËÁÈΤ˜ ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ÁÔÓÈÌfiÙËÙ·˜ ÌÂÙ¿ ª∞∫, Ë ÔÔ›· fï˜ ÚÔ˜ ÙÔ ·ÚfiÓ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È Î¿ı ̤ÚÈÌÓ· ÒÛÙ ӷ ‰È·ÛÊ·Ï›˙ÂÙ·È Ì ÙËÓ ˘¿Ú¯Ô˘Û· ‰È·‰Èηۛ· ÎÚ˘ÔÛ˘ÓÙ‹ÚËÛ˘.
¢È·‚‹Ù˘-ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ OÈ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÁÏ˘Îfi˙˘ Î·È ÙˆÓ ÏÈȉ›ˆÓ ÌÂÙ¿ ÙË ª∞∫ ‰ÂÓ ¤¯Ô˘Ó ·ÚÎÒ˜ ÌÂÏÂÙËı›, Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ·fi ÙȘ ¿ÏϘ ÂÓ‰ÔÎÚÈÓÈΤ˜ ‰È·Ù·Ú·¯¤˜, ¤¯Ô˘Ó fï˜ ÛËÌ·Û›·, ‰ÈfiÙÈ Ë ÂΉ‹ÏˆÛ‹ ÙÔ˘˜ ÂÎı¤ÙÂÈ ÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Û ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂÈ·ÎÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÚfiˆÚÔ˘ ı·Ó¿ÙÔ˘. ™Â ºÈÏ·Ó‰È΋ ÌÂϤÙË Ô˘ ‰ËÌÔÛȇÙËΠÛÙÔ Lancet ÙÔ 2000, ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ (52%) ·Ó·Ù‡ÛÛÂÈ ·ÓÙÔ¯‹ ÛÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È ˘ÂÚÈÓÛÔ˘ÏÈÓ·ÈÌ›· ÌÂÙ¿ ª∞∫24. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ·˘ÙÔ‡˜ ÂÌÊ·Ó›˙Ô˘Ó Â›Û˘ ‰˘Û·ÓÂÍ›· ÛÙË ÁÏ˘Îfi˙Ë ‹ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2, ‰˘ÛÏÈȉ·ÈÌ›·, ˘¤ÚÙ·ÛË Î·È ÎÔÈÏȷ΋ ·¯˘Û·ÚΛ·. Δ· ÛËÌ›· ·˘Ù¿ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÏÂÁfiÌÂÓÔ˘ «ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘», Ô˘ Û˘Ó‰¤ÂÙ·È Ì ·ıËÚÔÁ¤ÓÂÛË Î·È ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚÒÈÌˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂΉËÏÒÛˆÓ. ÕÏϘ ÌÈÎÚ¤˜ ÌÂϤÙ˜ ÂȂ‚·›ˆÛ·Ó ÙËÓ ·˘ÍË̤ÓË Â›ÙˆÛË ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ Û ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ˘Ô‚ÏËı› Û ª∞∫. ™ÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÈÓÛÔ˘Ï›Ó˘ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ Ê·›ÓÂÙ·È fiÙÈ ·›˙ÂÈ ÚfiÏÔ Ë ¤ÏÏÂÈ„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È Ô ˘ÔÁÔÓ·‰ÈÛÌfi˜ Ô˘ ¤¯Ô˘Ó ·ÚÎÂÙ¿ Û˘¯Ó¿ ÔÈ ·ÛıÂÓ›˜ ÌÂÙ¿ ª∞∫. ™˘¯Ó¿ ÔÈ ·ÛıÂÓ›˜ Ì ÙË ‰È·Ù·Ú·¯‹ ·˘Ù‹ ÂÌÊ·Ó›˙Ô˘Ó Î·È ¯ÚfiÓÈ· GVHD, ·Ó Î·È ·ÈÙÈÔ·ıÔÁÂÓÂÙÈ΋ Û¯¤ÛË ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı›. ∏ ÙÚ¤¯Ô˘Û· ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Û ·ÛıÂÓ›˜ Ì ÌÂÙ·‚ÔÏÈÎfi Û‡Ó‰ÚÔÌÔ Û˘Ó›ÛÙ·Ù·È Û ·ÏÏ·Á‹ ÙÔ˘ ÙÚfiÔ˘ ˙ˆ‹˜ (¿ÛÎËÛË, ·ÏÏ·Á‹ ‰È·ÙÚÔÊ‹˜) ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¤ÏÂÁ¯Ô Ù˘ ˘¤ÚÙ·Û˘, ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÂÚÏÈȉ·ÈÌ›·˜, Î·È ÂӉ¯Ô̤ӈ˜ Ï‹„Ë ·ÓÙÈ·ÈÌÔÂÙ·ÏÈ·ÎÒÓ Ê·Ú̿ΈÓ. ÕÙÔÌ· Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ª∞∫ Û˘ÓÈÛÙ¿Ù·È Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ٷÎÙÈ΋ ̤ÙÚËÛË ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜, ÏÈ-
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ȉ›ˆÓ, Î·È ÈÓÛÔ˘Ï›Ó˘. ∂› ÂÌÊ·Ó›Ûˆ˜ ÛÙÔȯ›ˆÓ ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘, ÌÔÚÔ‡Ó ›Ûˆ˜ Ì ÙȘ ˆ˜ ¿Óˆ ·ÚÂÌ‚¿ÛÂȘ Ó· ηı˘ÛÙÂÚ‹ÛÔ˘Ó ‹ Ó· ·ÔʇÁÔ˘Ó ÙËÓ ÂÌÊ¿ÓÈÛË ‰È·‚‹ÙË, ‹ ÂÈΛӉ˘ÓˆÓ ηډȷÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ. ∏ ‰È‡ڢÓÛË ÙˆÓ ÂӉ›ÍÂˆÓ ÁÈ· ª∞∫, ÔÈ Ó¤Â˜ Ù¯ÓÈΤ˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È Ë ‚ÂÏÙ›ˆÛË Ù˘ ˘ÔÛÙËÚÈÎÙÈ΋˜ ·ÁˆÁ‹˜ ¤¯ÂÈ Û˘ÓÙÂϤÛÂÈ ÛÙËÓ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÔÏÏÒÓ ·ÙfiÌˆÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó ÛÙË ıÂڷ›· ·˘Ù‹. ¶ÂÚ›Ô˘ 30.000 – 40.000 ÌÂÙ·ÌÔۯ‡ÛÂȘ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÂÙËÛ›ˆ˜, Ì ٿÛË ·‡ÍËÛ˘ ηٿ 10% ÂÚ›Ô˘ ηْ ¤ÙÔ˜. ∫·ıÒ˜ Û˘Ó¯Ҙ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ÂÈ‚ÈÒÓÔ˘Ó Èı·ÓÒ˜ ÔÚÈÛÙÈÎÒ˜ È·ı¤ÓÙ˜, ÂÚÈÛÛfiÙÂÚË ÛËÌ·Û›· ‰›‰ÂÙ·È ÛÙËÓ Â·ÁÚ‡ÓËÛË ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·ı˘ÛÙÂÚËÌ¤ÓˆÓ ÂÈÏÔÎÒÓ, fiˆ˜ ÔÈ ÂÓ‰ÔÎÚÈÓÔ¿ıÂȘ Ô˘ ÌÔÚ› Ó· ·ÂÈÏ‹ÛÔ˘Ó ÙËÓ ˘Á›·, ·ÏÏ¿ Î·È ÙÔÓ Ê˘ÛÈÔÏÔÁÈÎfi ÙÚfiÔ ˙ˆ‹˜ Ô˘ ÂÈı˘ÌÔ‡Ó Ï¤ÔÓ Ù· ¿ÙÔÌ· ·˘Ù¿. Δ·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È Û˘ÓÂÚÁ·Û›· ÙˆÓ Û¯ÂÙÈÎÒÓ ÂȉÈÎÔÙ‹ÙˆÓ Â›Ó·È ··Ú·›ÙËÙ˜ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÈÏÔÎÒÓ ·˘ÙÒÓ Î·È ÙËÓ Ì›ˆÛË ÙˆÓ ÂÈÙÒÛÂÒÓ ÙÔ˘˜.
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poietic cell transplant in children. Bone Marrow Transplantation 2007 Oct 8 8. C Berger, B Le-Gallo, J Donadieu. Late thyroid toxicity in 153 long-term survivors of allogeneic bone marrow transplantation for acute lymphoblastic leukaemia. Bone Marrow Transplantation 2005; 35, 991–995 9. Sanders JE, The Long-Term Follow-Up Team. Endocrine problems in children after bone marrow transplant for hematologic malignancies. Bone Marrow Transplant 1991; 8: 2–4 10. Cohen ∞, Rovelli A, Merlo DF et al. Risk for Secondary Thyroid Carcinoma After Hematopoietic StemCell Transplantation: An EBMT Late Effects Working Party Study. Journal of Clinical Oncology, 2007;25,17: 2449-2454 11. Mertens, A.C., Ramsay, N.K.C., Kouris, S. et al. Patterns of gonadal dysfunction following bone marrow transplantation. Bone Marrow Transplantation, 1998; 22, 345–350 12. Chatterjee R and Kottarides PD. Treatment of gonadal damage in recipients of allogeneic or autologous transplantation for haematological malignancies. Bone Marrow Transplantation 2002;30:629-635 13. Boulad F, Bromley M, Black P, et al. Thyroid dysfunction following bone marrow transplantation using hyperfractionated radiation. Bone Marrow Transplant 1995; 15: 71–76 14. Sanders J, Hawley J, Levy W et al. Pregnancies following high-dose cyclophosphamide with or without high-dose busulfan or total-body irradiation and bone marrow transplantation.Blood 1996; 87: 3045–3052 15. Teinturier C, Hartmann O, Valteau-Couanet D et al. Ovarian function after autologous bone marrow transplantation in childhood: high-dose busulfan is a major cause of ovarian failure. Bone Marrow Transplanta-
tion, 1998; 22: 989–994 16. Sarafoglou K, Boulad F, Gilio A, et al. Gonadal function after bone marrow transplantation for acute leukemia during childhood. J. Pediatr 1997;130(2):210-6 17. Vlachopapadopoulou E, Kitra V, Peristeri J,et al Gonadal function of young patients with beta-thalassemia following bone marrow transplantation J Pediatr Endocrinol Metab 2005;18(5): 477-483 18. Tournay H. Storing reproduction for oncological patients: some points for discussion. Mol Cell Endocrinol 2000;169:133-136 19. Borini A, Sciajno R, Bianchi V, et al. Clinical outcome of oocyte cryopreservation after slow cooling with a protocol utilizing a high sucrose concentration. Hum Reprod 2006;21,512–517 20. Salooja N, Szydlo RM, Socie G et al. Pregnancy outcomes after peripheral blood or bone marrow transplantation: a retrospective survey. Lancet 2001; 358: 271276 21. Johnson J, Canning J, Kaneko T, Pru JK, Tilly JL. Germline stem cells and follicular renewal in the postnatal mammalian ovary. Nature. 2004;428:145–150 22. Johnson J, Bagley J, Skaznik-Wikiel M et al..Tilly JL. Oocyte generation in adult mammalian ovaries by putative germ cells in bone marrow and peripheral blood. Cell. 2005;122:303–315 23. Lee H-J, Selesniemi K, Niikura Y, et al: Bone marrow transplantation generates immature oocytes and rescues long-term fertility in a preclinical mouse model of chemotherapy-induced premature ovarian failure. J Clin Oncol 2007;25:3198-3204, 24. Taskinen M, Saarinen-Pihkala UM, Hovi L, et al. Impaired glucose tolerance and dyslipidemia as late effects after bone-marrow transplantation in childhood. Lancet 2000;356:993–997
AÒÙÂÚ˜ ÂÈÏÔΤ˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (MAK) ÏËÓ ÂÓ‰ÔÎÚÈÓÈÎÒÓ Î·È ‰Â˘ÙÂÚÔ·ıÒÓ ÓÂÔÏ·ÛÈÒÓ
5
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∂ÈÛ·ÁˆÁ‹
Ï‹˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ¢ηÈÚÈ·ÎÒÓ ÏÔÈÌÒ͈Ó. ΔËÓ ˘ÂÚÊfiÚÙˆÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ì ۛ‰ËÚÔ ÙfiÛÔ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈο (·ÈÌÔÛÊ·ÈÚÈÓÔ¿ıÂȘ, ·Ï·ÛÙÈ΋ ·Ó·ÈÌ›·, Ì˘ÂÏÔ‰˘ÛÏ·ÛÙÈο Û‡Ó‰ÚÔÌ· Ì ˘ÂÚÌÂÙ·ÁÁ›ÛÂȘ), fiÛÔ Î·È ÌÂÙ¿ ÙËÓ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂ ‰Â‰Ô̤ÓÔ˘˜ ÙÔ˘˜ ·ÓˆÙ¤Úˆ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÚÔ·ÙÂÈ fiÙÈ Â›Ó·È ·Ó·Áη›· Ë ÁÓÒÛË Î·È Ë ·Ó·˙‹ÙËÛË fiÏˆÓ ÙˆÓ ÂÈÏÔÎÒÓ Ô˘ Â›Ó·È ‰˘Ó·Ùfi Ó· ÂÌÊ·ÓÈÛıÔ‡Ó. O ÚÔÏËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜, Ë ¿ÌÂÛË ‰È¿ÁÓˆÛË Î·È Ë ÁÚ‹ÁÔÚË Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ·ÔÙÂÏ› ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ÚÔ¿ÛÈÛË Ù˘ ˘Á›·˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ·ÛıÂÓÒÓ.
™ÙȘ ̤Ú˜ Ì·˜ ÂÚÈÛÛfiÙÂÚÔÈ ·fi 40000 ·ÛıÂÓ›˜ ˘Ô‚¿ÏÏÔÓÙ·È Î¿ı ¯ÚfiÓÔ Û ª∞∫ (·ÏÏÔÁÂÓ‹ Ë ·˘ÙfiÏÔÁË) Û fiÏÔ ÙÔÓ ÎfiÛÌÔ. O ·ÚÈıÌfi˜ ÙˆÓ Ì·ÎÚÔ¯ÚÔÓ›ˆ˜ ÂÈ˙ÒÓÙˆÓ ÌÂÙ¿ ª∞∫ ·˘Í¿ÓÂÙ·È Û˘Ó¯Ҙ ηıÒ˜ ‰È·Ù˘ÒÓÔÓÙ·È Ó¤Â˜ ÂӉ›ÍÂȘ ª∞∫, ÂÓÒ ·Ú¿ÏÏËÏ· ‰È¢ڇÓÂÙ·È Û˘Ó¯Ҙ Ë ‰ÂÍ·ÌÂÓ‹ ·ÏÏÔÁÂÓÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi: -Û˘ÁÁÂÓ›˜ Û˘Ì‚·ÙÔ‡˜ ‰fiÙ˜ Û˘ÁÁÂÓ›˜ Û˘Ì‚·ÙÔ‡˜ ‰fiÙ˜ Ì ·ÓÙÈÁÔÓÈΤ˜ ‰È·ÊÔÚ¤˜ ÌË Û˘ÁÁÂÓ›˜ Û˘Ì‚·ÙÔ‡˜ ‰fiÙ˜ Ù˘ ·ÁÎfiÛÌÈ·˜ ÙÚ¿Â˙·˜ ‰ÔÙÒÓ ·ÏÔÙ·˘ÙfiÛËÌÔ˘˜ ‰fiÙ˜ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙȷο ÌÔۯ‡̷ٷ ȉȷ›ÙÂÚ· Û ·È‰È¿. ŒÓ· ÛËÌ·ÓÙÈÎfi ̤ÚÔ˜ Ù˘ ‰È‡ڢÓÛ˘ ·ÊÔÚ¿ ΢ڛˆ˜ ·ÓıÚÒÔ˘˜ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÌË Ì˘ÂÏÔ·Ê·ÓÈÛÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ ÚÔÂÙÔÈÌ·Û›·˜. ∏ ·ÚÔ˘Û›· ÙÔ˘ ÌÂÁ¿ÏÔ˘ ·˘ÙÔ‡ ·ÚÈıÌÔ‡ ÂÈ˙ÒÓÙˆÓ ·Ó¤‰ÂÈÍ ٷ ·ÒÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ÙfiÛÔ Ì ÙÔÓ Î›Ó‰˘ÓÔ ÚÔÛ‚ÔÏ‹˜ Û˘ÛÙËÌ¿ÙˆÓ Î·È ÔÚÁ¿ÓˆÓ ÙˆÓ ·ÛıÂÓÒÓ, fiÛÔ Î·È Ì ÙÔÓ ÂËÚ·ÛÌfi Ù˘ „˘¯È΋˜ Î·È ÓÔËÙÈ΋˜ ÙÔ˘˜ ÛÊ·›Ú·˜ Ì ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘˜, Û ÔÚÈṲ̂Ó˜ ‰Â ÂÚÈÙÒÛÂȘ ı¤ÙÔÓÙ·˜ Û ΛӉ˘ÓÔ ÙËÓ ˙ˆ‹ ÙÔ˘˜. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙËÓ ÂÌÊ¿ÓÈÛË ÙˆÓ ÂÈÏÔÎÒÓ ·ÊÔÚÔ‡Ó: Δ· ÚÔ·Ú·Û΢·ÛÙÈο Û¯‹Ì·Ù· ÚÔÂÙÔÈÌ·Û›·˜ Ù˘ ÌÂÁ·ıÂڷ›·˜ {¯ËÌÂÈÔıÂڷ›·, ÔÏÔۈ̷ÙÈ΋ ·ÎÙÈÓÔ‚ÔÏ›· (Total Body iradiation- TBI)}. Δ· Û¯‹Ì·Ù· ¯ËÌÂÈÔıÂڷ›·˜ Ë ·ÎÙÈÓÔıÂڷ›·˜ ÚÈÓ ÙËÓ ª∞∫ ȉȷ›ÙÂÚ· fiÙ·Ó ·ÊÔÚÔ‡Ó ·Óıڷ΢ÎϛӘ Ë fiÙ·Ó ÔÈ ÚÔËÁËı›Û˜ ÁÚ·Ì̤˜ ıÂڷ›·˜ ‹Ù·Ó ÔÏϤ˜. ΔËÓ ·ÚÔ˘Û›· Ù˘ ÓfiÛÔ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ˘ ÍÂÓÈÛÙ‹ GVHD (Graft Versus Host Desease)Î·È È‰È·›ÙÂÚ· Ù˘ ·ÓıÂÎÙÈ΋˜ ÌÔÚÊ‹˜ Ë ÔÔ›· ··ÈÙ› Ì·ÎÚÔ¯ÚfiÓÈ· ıÂڷ›· ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ Ì¿ÏÈÛÙ· Ì ÙËÓ ¯Ú‹ÛË ÎÔÚÙÈÎÔÂȉÒÓ Û ÈηӤ˜ ‰fiÛÂȘ. ΔËÓ ·ÚÔ˘Û›· Û ¿ÏÏÔÙ ¿ÏÏÔ ‚·ıÌfi ÛËÌ·ÓÙÈ΋˜ ·ÓÔÛÔηٷÛÙÔ-
¶Ó¢ÌÔÓÈΤ˜ ÂÈÏÔΤ˜ ∞ÚÎÂÙÔ› ·ÛıÂÓ›˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛËÌ·ÓÙÈο Â˘Ú‹Ì·Ù· ÛÙȘ ÂȉÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÂϤÁ¯Ô˘ Ù˘ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ –ÛÂÈÚÔ̤ÙÚËÛË-¯ˆÚ›˜ ÛÔ‚·Ú¿ ÎÏÈÓÈο ÚÔ‚Ï‹Ì·Ù· ·fi ÙÔ˘˜ Ó‡ÌÔÓ˜. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙËÓ ÂÌÊ¿ÓÈÛË ÂÚÈÔÚÈÛÙÈÎÔ‡ Ù‡Ô˘ Ó¢ÌÔÓÔ¿ıÂÈ·˜ ›ӷÈ: Δ· Ê¿Ú̷η ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ ÚÔÂÙÔÈÌ·Û›·˜ (Busulphan ηٿ ·ÚÈÔ ÏfiÁÔ Î·È Thiotepa ‰Â˘ÙÂÚ¢fiÓÙˆ˜) Î·È Ë ÔÏÔۈ̷ÙÈ΋ ·ÎÙÈÓÔıÂڷ›· (Δμπ) ȉȷ›ÙÂÚ· fiÙ·Ó ‰ÂÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û ÎÏ·ÛÌ·ÙÈ΋ ‰fiÛË Û¯ÂÙ›˙ÔÓÙ·È Ì Ó¢ÌÔÓÈ΋ ›ÓˆÛË. ΔÔÈÎÔ› ·Ú¿ÁÔÓÙ˜ fiˆ˜ Ë ·ÚÔ˘Û›· ·ʈÛ˘, ÛÎÔÏ›ˆÛ˘, ıˆÚ·ÎÔÙÔÌ‹˜. ¶·ÚÔ˘Û›· ¯ÚfiÓÈ·˜ ÓfiÛÔ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ˘ ÍÂÓÈÛÙ‹ (cGVHD) Î·È Ë Û¯ÂÙÈ˙fiÌÂÓË Ì ·˘Ù‹Ó ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯ÈÔÏ›ÙȘ. O Ì˯·ÓÈÛÌfi˜ Ù˘ ÌË ÏÔÈÌÒ‰Ô˘˜ Ó¢ÌÔÓÈ΋˜ ‰È·Ù·Ú·¯‹˜ Ê·›ÓÂÙ·È ˆ˜ Â›Ó·È ·ÓÔÛÔÏÔÁÈÎfi˜ ·ÚfiÌÔÈÔ˜ Ì ·˘ÙfiÓ Ù˘ GVHD. ∏ ‚·Ú‡ÙËÙ¿ ÙÔ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙȘ ·ÏÏÔÁÂÓ›˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ηıÒ˜ Î·È Û ÚÔ¯ˆÚË̤ӷ ÛÙ¿‰È· Ù˘ ‚·ÛÈ΋˜ ÓfiÛÔ˘. ∂ÌÊ·Ó›˙ÂÙ·È Â›Ù Ì ÙËÓ ÌÔÚÊ‹ Ù˘ BOOP( Bronchiolitis Obliterans Organiging Pneumonia) ›Ù Ì ÙËÓ ÌÔÚÊ‹ Ù˘ ·ÔÊÚ·ÎÙÈ΋˜
295
296
X. ™MIA™
‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ (Bronchiolitis Obliterans). ∏ BOOP ÂÌÊ·Ó›˙ÂÙ·È Û ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ Ô˘ ÛÙ·‰È·Î¿ Î·È ·˘Ù¿ ÌÂÈÒÓÔÓÙ·È Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÚˆÙÔÎfiÏÏˆÓ Ì ÌË Ì˘ÂÏÔ·Ê·ÓÈÛÙÈο Û¯‹Ì·Ù· ÚÔÂÙÔÈÌ·Û›·˜ RIC (Reduced indensity Conditioning) Ì ·Ó·ÊÂÚfiÌÂÓ· ÔÛÔÛÙ¿ ›وÛ˘ 17% ¤Ó·ÓÙÈ 2,3 Û˘Ì‚·ÙÈÎÒÓ ·ÏÏÔÁÂÓÒÓ ¤Ó·ÓÙÈ RIC. ¶ÚÒÈÌË ÂÌÊ¿ÓÈÛË Ù˘ BOOP ÚÈÓ ÙËÓ 200Ë Ë̤ڷ ¤¯ÂÈ Ôχ ¯ÂÈÚfiÙÂÚË ÚfiÁÓˆÛË ·fi ÂΛÓË ÙˆÓ ·ˆÙ¤ÚˆÓ ÛÙ·‰›ˆÓ Ë ÔÔ›· Â›Ó·È Î·È Û˘¯ÓfiÙÂÚË. ∏ ·ÔÊÚ·ÎÙÈ΋ ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ·ÚÔ˘ÛÈ¿˙ÂÈ ˘„ËÏ‹ ıÓËÙfiÙËÙ· Ô˘ Êı¿ÓÂÈ Ì¤¯ÚÈ 50% Û ·ÛıÂÓ›˜ Ì ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ì ‚‹¯· ‰‡ÛÓÔÈ· Ì ÙËÓ ÎfiˆÛË Î·È ÂÈϤÎÂÙ·È ÌÂ Û˘¯Ó¤˜ ÏÔÈÌÒÍÂȘ ·Ó·Ó¢ÛÙÈÎÔ‡. ∏ ·/· Î·È Ë CT ıÒÚ·ÎÔ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â˘Ú‹Ì·Ù· Ó¢ÌÔÓÈÎÒÓ ‰ÈËı‹ÛÂˆÓ Ì ÛÙÔȯ›· ‰È¿ÌÂÛ˘ ›ÓˆÛ˘. ∏ ‰È¿ÁÓˆÛË ı· ÙÂı› Ì ‚ÚÔÁ¯ÔÛÎfiËÛË Î·È ‰È·‚ÚÔÁ¯È΋ ‚ÈÔ„›·. ∏ ıÂڷ›· ÙÔ˘˜ ‚·Û›˙ÂÙ·È ÛÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ì ÎÔÚÙÈÎÔÂȉ‹ Î·È Cell Cept Ë ·˙·ıÂÈÔÚ›ÓË. ∞ӷʤÚÔÓÙ·È ÙÂÏÂ˘Ù·›· ηϿ ·ÔÙÂϤÛÌ·Ù· Ì ÙËÓ ¯ÔÚ‹ÁËÛË ÙÔ˘ ÌÔÓÔÎψÓÈÎÔ‡ ·ÓÙÈÛÒÌ·ÙÔ˜ Mab Thera ÂÓÒ ÛÙÔ Î·Ïfi ·ÔÙ¤ÏÂÛÌ· Ê·›ÓÂÙ·È ˆ˜ Û˘Ì‚¿ÏÂÈ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÚÔʇϷÍË ·fi ÙȘ ÏÔÈÌÒÍÂȘ.
∫·Ú‰È·Î¤˜ ÂÈÏÔΤ˜ O ÌÂÁ·Ï‡ÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ηډÈÔÙÔÍÈÎfiÙËÙ·˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ÙˆÓ ·Óıڷ΢ÎÏÈÓÒÓ ÛÙ· ¯ËÌÂÈÔıÂڷ¢ÙÈο ÚˆÙfiÎÔÏÏ· ÙˆÓ ·Ú¯ÈÎÒÓ Û¯ËÌ¿ÙˆÓ ıÂڷ›·˜ Ë ÛÙËÓ ·ÚÔ˘Û›· ΢ÎÏÔʈÛÊ·Ì›‰Ë˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙÔ Û˘ÓËı¤ÛÙÂÚÔ ÚˆÙfiÎÔÏÏÔ ÚÔ·Ú·Û΢·ÛÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ÚÔÂÙÔÈÌ·Û›·˜ BuCy. ™ËÌ·ÓÙÈ΋ ›Û˘ ηډÈÔÙÔÍÈÎfiÙËÙ· ÌÔÚ› Ó· ÂÌÊ·ÓÈÛı› Ì ÚÔËÁËı›۷ ·ÎÙÈÓÔıÂڷ›· ÌÂÛÔıˆÚ·Î›Ô˘ Ë Ì ¯Ú‹ÛË Δμπ ÛÙÔ ÚˆÙfiÎÔÏÏÔ ÚÔÂÙÔÈÌ·Û›·˜ ȉȷ›ÙÂÚ· Û ÌË ÎÏ·ÛÌ·ÙÔÔÈË̤ÓË ¯ÔÚ‹ÁËÛ‹ Ù˘. ™˘Ó‰˘·ÛÌfi˜ ηډÈÔÙÔÍÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈο Ì ¯Ú‹ÛË ÙÔ˘˜ Î·È ÛÙÔ ÚˆÙfiÎÔÏÏÔ ÚÔÂÙÔÈÌ·Û›·˜ ·˘Í¿ÓÂÈ ÙËÓ Î·Ú‰ÈÔÙÔÍÈÎfiÙËÙ·. ™ËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÎÏ¿ÛÌ·ÙÔ˜ ÂÍÒıËÛ˘ ¯ˆÚ›˜ fï˜ Ó· ÂËÚ¿˙ÂÙ·È ÛËÌ·ÓÙÈο Ë ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ. ∏ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·˘Ù‹ Á›ÓÂÙ·È ÂÌÊ·Ó‹˜ ÌfiÓÔ ÛÂ Û˘Óı‹Î˜ ¿ÛÎËÛ˘ Ì ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ô˘ ÚÔÛÂÁÁ›˙Ô˘Ó ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ. ªfiÓÔ ÙÔ 10% fï˜ ·˘ÙÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Û ECHO ηډȿ˜ ÂÓ ËÚÂÌ›·. ™Â ·ÛıÂÓ›˜ Ì ÂÈÌ‹-
΢ÓÛË ÙÔ˘ QT ‰È·ÛÙ‹Ì·ÙÔ˜ ‚Ú¤ıËÎ·Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜, ÂÓÒ Ì ٷ Û˘Ì‚·ÙÈο ÚˆÙfiÎÔÏÏ· ÚÔÂÙÔÈÌ·Û›·˜ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·ÈÌÔÚÚ·ÁÈ΋˜ Ì˘Ôηډ›Ùȉ·˜. ¶·Ú·ÙËÚ‹ıËΠfiÙÈ ÔÈ Î·Ú‰È·Î¤˜ ·ÓˆÌ·Ï›Â˜ –¯ˆÚ›˜ ÙËÓ ÂÈϤÔÓ ÂÈ‚¿Ú˘ÓÛË ·fi ¿ÏÏ· ηډÈÔÙÔÍÈο Ê¿Ú̷η –·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ÙËÓ ·Ú¤Ï¢ÛË ÙÚÈÂÙ›·˜ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. º·›ÓÂÙ·È ˆ˜ Ë Û ‚¿ıÔ˜ ¯ÚfiÓÔ˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ηډȷÎÔ‡ Ì˘fi˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÓÙÔÓfiÙÂÚË Ì ÙËÓ ·ÒÏÂÈ· ÂʉÚÂÈÒÓ ÙÔ˘. ¶Èı·Ó¿ Î·È Ë ·ÚÔ˘Û›· Ù˘ cCVHD ÂÈ‚·Ú‡ÓÂÈ ÙËÓ Î·Ú‰È·Î‹ ÏÂÈÙÔ˘ÚÁ›· ·ÊÂÓfi˜ ÌÂÓ Ì ÙËÓ ‰ËÌÈÔ˘ÚÁÔ‡ÌÂÓË ˘ÂÚÏÈȉ·ÈÌ›· Î·È ·ÊÂÙ¤ÚÔ˘ ‰Â Ì ÙËÓ ˘ÂÚÊfiÚÙˆÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ì ۛ‰ËÚÔ Ô˘ Ë ÙÔÍÈ΋ ÙÔ˘ ›‰Ú·ÛË ÛÙÔ Ì˘ÔοډÈÔ Â›Ó·È ‰Â‰Ô̤ÓË. ¶ÚÔÛ‚ÔÏ‹ ÙÔ˘ Ì˘ÔηډȷÎÔ‡ ·fi GVHD Â›Ó·È Ôχ Û¿ÓÈ· ÂÓÒ ·ÓÙ›ıÂÙ· ÂÚÈηډ›Ùȉ· ÛÙ· Ï·›ÛÈ· ÔÚÔÁÔÓ›Ùȉ·˜ ·fi cGVHD ·Ú·ÙËÚÂ›Ù·È Û ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ. ∏ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ ÌÂ Ë ¯ˆÚ›˜ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë Â›Ó·È Û˘Ó‹ıˆ˜ ·Ú΋˜. ∂› ·ÔÙ˘¯›·˜ Ì ʷÈÓfiÌÂÓ· ÂȈ̷ÙÈÛÌÔ‡ ÙÔÔı¤ÙËÛË ·ÚÔ¯¤Ù¢Û˘ ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË.
∏·ÙÈΤ˜ ÂÈÏÔΤ˜ ∏ Ù·˘ÙÔÔ›ËÛË Ù˘ ·ÈÙÈÔÏÔÁ›·˜ Ù˘ Ë·ÙÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ô˘ ·ÎÔÏÔ˘ı› ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ‰‡ÛÎÔÏË. ÃÚ‹ÛÈ̘ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ‰È·ÎÚ›‚ˆÛË Ù˘ ÌÔÚ› Ó· Ì·˜ ‰ÒÛÔ˘Ó: O ¯ÚfiÓÔ˜ ÙÔ˘ Ë·ÙÈÎÔ‡ Û˘Ì‚¿ÓÙÔ˜ ΔÔ ÈÛÙÔÚÈÎfi Ë·ÙÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜. ∏ ·ÚÔ˘Û›· cGVHD Û ¿ÏÏ· fiÚÁ·Ó·. ∏ ÂÍ·ÎÚ›‚ˆÛË Ù˘ ·ÚÔ˘Û›·˜ cGVHD ÛÙÔ ‹·Ú Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ·ÈÙÈÔÏÔÁÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ Ë·ÙÈ΋˜ ‰È·Ù·Ú·¯‹˜. ∏ ·ÚÔ˘Û›· ¯ÔÏfiÛÙ·Û˘ Ô˘ ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ Ì ·‡ÍËÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ Â›Ó·È Ù· Û˘Ó‹ıË Â˘Ú‹Ì·Ù· Î·È Ë ÙÂÎÌËÚ›ˆÛË Ù˘ ıÂÌÂÏÈÒÓÂÙ·È Ì ÙËÓ Ë·ÙÈ΋ ‚ÈÔ„›·. ∏ ¯ÔÚ‹ÁËÛË ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ì·˙› Ì ԢÚÛÔ‰ÈfiÏË Â›Ó·È Ù· Ê¿Ú̷η ÂÎÏÔÁ‹˜. ∏ ¯ÔÚËÁÔ‡ÌÂÓË ·ÓÔÛÔηٷÛÙÔÏ‹ -·ÚÈ· ‰Â Ù· ÎÔÚÙÈÎÔÂȉ‹- ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·Ó·˙ˆ‡ÚˆÛË Ë·Ù›Ùȉ·˜ μ Û ·ÛıÂÓ›˜ Ì ·Ô‰Ú·ÌÔ‡Û· Ë·Ù›Ùȉ· Î·È ·ÚÔ˘Û›· ·ÓÙÈ∏μc ηٿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™˘¯ÓfiÙÂÚ· ·ÛıÂÓ›˜ Ì ˷ٛÙȉ· ·fi HCV ÌÔÚÔ‡Ó Â·ÓÂÓÂÚÁÔÔÈÒÓÙ·˜ ÙÔÓ Èfi Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó ÛÔ‚·Ú‹ Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ô˘ ÌÔÚ› Ó· Êı¿ÛÂÈ Ì¤¯ÚÈ ÙËÓ Ë·ÙÈ΋ ΛÚÚˆÛË Ë ÙËÓ ·ÚÔ˘Û›· Ë·ÙÒÌ·ÙÔ˜ Û ÔÛÔÛÙ¿ ̤¯ÚÈ ÙÔ 25%. ∏ ¿ÌÂÛË ‰È¿ÁÓˆÛË Î·È Ë ¯Ô-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ú‹ÁËÛË Ù˘ ηٿÏÏËÏ˘ ·ÓÙÈÈ΋˜ ıÂڷ›·˜ ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÂÈ ·ÔÊ·ÛÈÛÙÈο ÛÙËÓ ÔÚ›· ÂͤÏÈ͢ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∏ ¯ÔÚ‹ÁËÛË Ï·ÌÈ‚Ô˘‰›Ó˘ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ Î·Ù·ÔϤÌËÛË Ù˘ ·Ó·˙ˆ‡ÚˆÛ˘ Ù˘ Ë·Ù›Ùȉ·˜ ·fi ÙÔÓ HBV ·ÏÏ¿ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·È ˆ˜ ÚÔÊ˘Ï·ÎÙÈ΋ ıÂڷ›·˜ Û ÊÔÚ›˜ ÙÔ˘ ÈÔ‡. ∞Ó¿ÏÔÁ· Î·È Ë ÚÈÌ·‚ÈÚ›ÓË ÌÂ Ë ¯ˆÚ›˜ ÈÓÙÂÚÊÂÚfiÓË (› ·ÚÔ˘Û›·˜ GVHD ˘¿Ú¯ÂÈ ·fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ¯ÔÚ‹ÁËÛ˘) ÌÔÚ› Û ÛËÌ·ÓÙÈÎfi ‚·ıÌfi Ó· ÚÔÏ¿‚ÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ Ë·Ù›Ùȉ·˜ C Û ΛÚÚˆÛË. ∏ ÛËÌ·ÓÙÈ΋ ·ÚÔ˘Û›· ·ÛıÂÓÒÓ Ì ¿ÏÏÔÙ ¿ÏÏÔ˘ ‚·ıÌÔ‡ ˘ÂÚÊfiÚÙˆÛË Ì ۛ‰ËÚÔ Ô˘ ÛËÌ·›ÓÂÈ Î·È ·˘ÍË̤ÓË ·ÚÔ˘Û›· ÙÔ˘ ÛÙÔ ‹·Ú ‰ÂÓ Â›Ó·È Û¿ÓÈ·. ∏ ÙÂÎÌËÚ›ˆÛË Ù˘ Á›ÓÂÙ·È Ì ÙËÓ Ì¤ÙÚËÛË ÙˆÓ ÂȤ‰ˆÓ ÊÂÚÚÈÙ›Ó˘ ÛÙÔÓ ÔÚfi Î·È Û˘ÌÏËÚÒÓÂÙ·È Ì ÙËÓ Ë·ÙÈ΋ ‚ÈÔ„›·. ∏ ˘ÂÚÊfiÚÙˆÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ Ì ۛ‰ËÚÔ ÛÂ Û˘Ó‡·ÚÍË Ì ÈÔÁÂÓ‹ Ë·Ù›Ùȉ· ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο ÙÔÓ Î›Ó‰˘ÓÔ Ë·ÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜ Î·È ÙËÓ ÂͤÏÈÍË Ù˘ Û ΛÚÚˆÛË. ∏ ¿ÌÂÛË ¤Ó·ÚÍË ıÂڷ›·˜ ·ÔÛȉ‹ÚˆÛ˘ Ì ¯ËÏÈο (˘Ô‰ÔÚ›ˆ˜, ÂÓ‰ÔÊÏ‚›ˆ˜ Î·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜) ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ·ÒÙÂÚˆÓ Ë·ÙÈÎÒÓ ÂÈÏÔÎÒÓ.
¡ÂÊÚÈΤ˜ ÂÈÏÔΤ˜ ¶ÔÛÔÛÙfi 10% ÙˆÓ ·ÛıÂÓÒÓ ÂÓÒ ·ÚÔ˘ÛÈ¿˙ÂÈ Ê˘ÛÈÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ Ô˘Ú›·˜ – ÎÚ·ÙÈÓ›Ó˘ ÂÌÊ·Ó›˙ÂÈ ·ıÔÏÔÁÈ΋ οı·ÚÛË ÎÚ·ÙÈÓ›Ó˘. OÈ Û˘ÓËı¤ÛÙÂÚ˜ ·ÒÙÂÚ˜ ÂÈÏÔΤ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÚÔ˘Û›· cGVHD ÛÙÔ˘˜ ÓÂÊÚÔ‡˜ Î·È ÂÌÊ·Ó›˙ÔÓÙ·È Â›Ù Ì ÙËÓ ÌÔÚÊ‹ á∞ ›Ù ˆ˜ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ. £Âڷ¢ÙÈο ¯ÔÚËÁÂ›Ù·È Û˘Ó‰˘·ÛÌfi˜ ÎÔÚÙÈÎÔÂȉÒÓ Ì cell cept. ™Â ·ÔÙ˘¯›· Û˘ÓÈÛÙ¿Ù·È ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡.
OÛÙÈΤ˜ ÂÈÏÔΤ˜ OÛÙÂÔÂÓ›· Î·È ÔÛÙÂÔfiÚˆÛË: ·ÔÙÂÏÔ‡Ó Û˘¯Ó¿ Â˘Ú‹Ì·Ù· Î·È ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ÔÛÙÈ΋˜ Ì¿˙·˜ Ë ÔÔ›· ηٷÁÚ¿ÊÂÙ·È Ì ÙȘ ÂȉÈΤ˜ ÂÍÂÙ¿ÛÂȘ. ∏ Û˘ÓÔÏÈ΋ ‰fiÛË Î·È Ë ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Î·È ‰Â˘ÙÂÚ¢fiÓÙˆ˜ ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Û¯ÂÙ›˙ÔÓÙ·È ¿ÌÂÛ· Ì ÙËÓ ·ÒÏÂÈ· ÔÛÙÈ΋˜ Ì¿˙·˜. ∏ ‰˘ÛÌÂÓ‹˜ ·˘Ù‹ ›‰Ú·ÛË ÌÔÚ› Ó· ‚ÂÏÙȈı› Ì ÙËÓ ·‡ÍËÛË Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ë ÔÔ›· Û˘Ó‹ıˆ˜ ÏfiÁˆ Û˘Ó˘·Ú¯Ô‡Û˘ Ì˘Ô¿ıÂÈ·˜ Â›Ó·È ÂÏ¿¯ÈÛÙË. ∏ ¯ÔÚ‹ÁËÛË ·Û‚ÂÛÙ›Ô˘, ‚ÈÙ·Ì›Ó˘ D Î·È ‰ÈʈÛÊÔÓÈÎÒÓ Â›Ó·È ··Ú·›ÙËÙË. ∏ ÂÏ¿ÙÙˆÛË
297
–fiÔ˘ Â›Ó·È ‰˘Ó·ÙfiÓ- Ù˘ ‰fiÛ˘ ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ Î·Ù·ÔϤÌËÛË Ù˘ cGVHD ¤¯ÂÈ Â˘ÓÔ˚΋ ›‰Ú·ÛË. ÕÛËÙË Ó¤ÎÚˆÛË: ∏ ›وۋ Ù˘ ÌÂÙ¿ ·ÏÏÔÁÂÓ‹ ª∞∫ ·Ó¤Ú¯ÂÙ·È Û ÔÛÔÛÙfi 4-10%. ΔÔ Î‡ÚÈÔ ÛËÌÂ›Ô ÂÓÙfiÈÛ˘ Ù˘ ·ÔÙÂÏ› Ë ÎÂÊ·Ï‹ ÙˆÓ ÌËÚÈ·›ˆÓ (80%),Ì ÙÔ 60% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ó· ·ÊÔÚ¿ ·ÌÊÔÙÂÚfiÏ¢ÚË ÂÓÙfiÈÛË. ∂ÌÊ·Ó›˙ÂÙ·È ·Ú¯Èο ˆ˜ ÙÔÈÎfi ¿ÏÁÔ˜ ÛÙÔ ÛËÌÂ›Ô ÂÓÙfiÈÛ˘ ∞ÚÎÂÙ¤˜ ÊÔÚ¤˜ Ô ¤ÏÂÁ¯Ô˜ Ì ·/· ‰ÂÓ Â›Ó·È ·ÔÎ·Ï˘ÙÈÎfi˜ Î·È Ë ÂͤٷÛË ÂÎÏÔÁ‹˜ Â›Ó·È Ë MRI. ¶ÚÔÛ‚ÔÏ‹ Ù˘ ηٿ ÁfiÓ˘ ¿ÚıÚˆÛ˘ ·Ó·Ê¤ÚÂÙ·È ÛÙÔ 10% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·È ¤ÂÙ·È Ë ÂÚÈÔ¯‹ Ù˘ ˯ÂÔηÚÈ΋˜ Î·È ÙÔ˘ ·ÛÙÚ·Á¿ÏÔ˘. ™ËÌ·ÓÙÈ΋ ·Ó·ÎÔ‡ÊÈÛË ÛÙÔÓ fiÓÔ Û˘ÓÈÛÙ¿ Ë ÔÚıԷȉÈ΋ ¤̂·ÛË ÂÏ¿ÙÙˆÛ˘ Ù˘ ›ÂÛ˘ ÛÙËÓ ¿ÚıÚˆÛË Ì ÙËÓ ¯Ú‹ÛË ÂȉÈÎÒÓ ‚·ÎÙËÚÈÒÓ (·ÙÂÚ›ÙÛ˜). ∂ȉÈο ÁÈ· ÙËÓ ÂÓÙfiÈÛË ÛÙËÓ ÎÂÊ·Ï‹ ÙÔ˘ ÌËÚÈ·›Ô˘ –ÙËÓ Û˘ÓËı¤ÛÙÂÚË ÙˆÓ ÂÓÙÔ›ÛˆÓ-ÙÔ Â›‰Ô˜ Ù˘ ·Ú¤Ì‚·Û˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔÓ ‚·ıÌfi ÂͤÏÈ͢ Ù˘ ¿ÛËÙ˘ Ó¤ÎÚˆÛ˘ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ÛÙ· ÚÒÙ· ÛÙ¿‰È· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÁÂÈÔ‡ÌÂÓˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ϤÔÓ ÚÔ¯ˆÚË̤ӷ ‰Â ÙËÓ ·Ê·›ÚÂÛË ·Û¯fiÓÙˆÓ ÙÌËÌ¿ÙˆÓ Î·È ÙËÓ ÚÔÛı‹ÎË Û˘ÓıÂÙÈÎÒÓ ÙÌËÌ¿ÙˆÓ. ∞ӷʤÚÔÓÙ·È Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· ÔÊ›ÏÔ˘Ó fï˜ ÔÈ ·ÛıÂÓ›˜ –ȉȷ›ÙÂÚ· ÔÈ ÓÂÒÙÂÚÔÈ-Ó· ‚Ú›ÛÎÔÓÙ·È Û ̷ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË.
™ÙÔÌ·ÙÈΤ˜-O‰ÔÓÙÈΤ˜ ÂÈÏÔΤ˜ ∏ ·ÎÙÈÓÔıÂڷ›· ›Ù ˆ˜ ̤ÚÔ˜ ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ ÚÔÂÙÔÈÌ·Û›·˜ (Δμπ) ›Ù ˆ˜ ıÂڷ›· ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ·ÈÙ›· ÂÏ¿ÙÙˆÛ˘ Ù˘ ·Ú·ÁˆÁ‹˜ ÛȤÏÔ˘. ¶·ÚfiÌÔÈ· ÂÏ¿ÙÙˆÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÙÔ˘ Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔηϤÛÂÈ Ë ·ÚÔ˘Û›· cGVHD ‰ÚÒÓÙ·˜ ‚Ï·ÙÈο ÛÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÛÈÂÏÔÁfiÓˆÓ ·‰¤ÓˆÓ. ∏ ÂÏ¿ÙÙˆÛË Ù˘ ·Ú·ÁˆÁ‹˜ ÛȤÏÔ˘ ¤Ú·Ó ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÍËÚÔÛÙÔÌ›·˜ ‰ËÌÈÔ˘ÚÁ› Û˘Óı‹Î˜ ‡ÎÔÏ˘ ‰Ú¿Û˘ ÙÔÈο ÙˆÓ ‚·ÎÙËÚ›ˆÓ-Ì˘Î‹ÙˆÓ Î·ıfiÙÈ ·ÔÙÂÏ› ÙÔ ÎÏÂȉ› Ù˘ ¿Ì˘Ó·˜ Ù˘ ÛÙÔÌ·ÙÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Î·È ÙˆÓ Ô‰fiÓÙˆÓ. ∫·Ù·ÔϤÌËÛË Ù˘ cGVHD ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‚ÂÏÙ›ˆÛË Ù˘ ÛÙÔÌ·ÙÈ΋˜ ˘ÁÈÂÈÓ‹˜ Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÙÔÈ΋ ¿Ì˘Ó·. ¶¤Ú·Ó Ù˘ ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÛÈÂÏÔÁfiÓˆÓ ·‰¤ÓˆÓ Ë ·ÚÔ˘Û›· Ù˘ cGVHD ÛÙËÓ ÛÙÔÌ·ÙÈ΋ ÎÔÈÏfiÙËÙ· Â›Ó·È ‰˘Ó·Ùfi Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÙÔÈΤ˜ ÂÍÂÏÎÒÛÂȘ Ì ·ÔÙ¤ÏÂÛÌ· fiÓÔ Î·È ÏÔÈÌÒ‰ÂȘ ÂÈÏÔΤ˜. OÈ Ô‰ÔÓÙÈΤ˜ ÂÈÏÔΤ˜ ‰ÂÓ Â›Ó·È ·Û˘Ó‹ıÂȘ ÛÙ· ·È-
298
X. ™MIA™
‰È¿. ∞ӷʤÚÂÙ·È ÂÚÈÔ‰ÔÓÙ›Ùȉ· ÛÙÔ 60% ÙˆÓ ·È‰ÈÒÓ ÂÓÒ ÛÙÔ 4% ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È Ô‰ÔÓÙÔÚÔÛˆÈΤ˜ ·ÓˆÌ·Ï›Â˜. ™Â ˘„ËÏ¿ ÔÛÔÛÙ¿ ·Ó·Ê¤ÚÔÓÙ·È Ô‰ÔÓÙÈΤ˜ ·ÁÂÓÂۛ˜ Ë ˘ÔÏ·Û›· Ô‰ÔÓÙÈÎÒÓ ÚÈ˙ÒÓ. ∂›Ó·È Û˘¯ÓfiÙÂÚ˜ Û ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ·ÎÙÈÓÔıÂڷ›·. ∏ ¤ÎÎÚÈÛË ÛȤÏÔ˘ Î·È Ë Î·Ï‹ ÛÙÔÌ·ÙÈ΋ ÊÚÔÓÙ›‰· ÌÔÚ› Ó· ÂÚÈÔÚ›ÛÔ˘Ó ÙȘ ÙÔÈΤ˜ ÏÔÈÌÒÍÂȘ Î·È Ó· Û˘Ì‚¿ÏÔ˘Ó Û ̛· ηχÙÂÚË Ô‰ÔÓÙÔÛÙÔÌ·ÙÔÏÔÁÈ΋ ˘ÁÈÂÈÓ‹.
OÊı·ÏÌÈΤ˜ ÂÈÏÔΤ˜ ΔËÓ Û˘ÓËı¤ÛÙÂÚË ÂÈÏÔ΋ ·ÔÙÂÏ› Ô Î·Ù·ÚÚ¿ÎÙ˘ Ô˘ ÌÔÚ› Ó· Â›Ó·È ˘Ôη„ÈÎfi˜ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÎÙÈÓÔıÂڷ›· Ë ‰Â˘ÙÂÚÔ·ı‹˜ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ¯Ú‹ÛË ÎÔÚÙÈÎÔÂȉÒÓ ÁÈ· ·ÓÙÈÌÂÙÒÈÛË Ù˘ GVHD. ∏ ›وÛË ÙÔ˘ ηٷÚÚ¿ÎÙË ·fi ·ÎÙÈÓÔıÂڷ›· ÂÏ·ÙÙÒÓÂÙ·È Ì ÙËÓ ÎÏ·ÛÌ·ÙÔÔÈË̤ÓË ¯ÔÚ‹ÁËÛË Ù˘ Δμπ. ∏ ÍËÚÔÊı·ÏÌ›· Â›Ó·È Â›Û˘ Û‡ÓËı˜ Úfi‚ÏËÌ· ÙˆÓ ·ÏÏÔÁÂÓÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙ· Ï·›ÛÈ· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ‰·ÎÚ˘˚ÎÒÓ ·‰¤ÓˆÓ ·fi cGVHD Î·È ÂϤÁ¯ÂÙ·È Ì ÂȉÈ΋ ÂͤٷÛË ÙÔ Shiermer test. ∏ ıÂڷ›· Ù˘ Â›Ó·È ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È ¯ÔÚ‹ÁËÛË Ù¯ÓËÙÒÓ ‰·ÎÚ‡ˆÓ Δ¤ÏÔ˜ ·Ó·Ê¤ÚÂÙ·È Ë ÌÈÎÚÔ·ÁÁÂȷ΋ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ô˘ ·Ô‰›‰ÂÙ·È Â›Ù Û ‚Ï¿‚Ë ·fi ΢ÎÏÔÛÔÚ›ÓË, ›Ù Û ¿ÓÔÛË ·ÓÙ›‰Ú·ÛË ÌÂÙ¿ ·fi ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ ·fi ÙÔÓ ÌÂÁ·ÏÔ΢ÙÙ·ÚÔÈfi (CMV).
¡Â˘ÚÔÏÔÁÈΤ˜ ÂÈÏÔΤ˜ ∏ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÌÂÙ¿ ª∞∫ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È ÌÂ: ÙËÓ Ï‹„Ë ·ÎÙÈÓÔıÂڷ›·˜ Ë ¯ËÌÂÈÔıÂڷ›·˜ Ì ʿÚ̷η Ô˘ ‰È·ÂÚÓÔ‡Ó ÙÔÓ ·ÈÌ·ÙÂÁÎÂÊ·ÏÈÎfi ÊÚ·ÁÌfi. AÔ‰Ú·ÌÔ‡Û˜ ÏÔÈÌÒÍÂȘ ∫¡™ Ë Î·Ù·ÛÙ¿ÛÂȘ Ô˘ ‰ËÌÈÔ‡ÚÁËÛ·Ó Û˘Óı‹Î˜ ·Ú·ÙÂٷ̤Ó˘ ˘ÔÍ›·˜ ÂÁÎÂÊ¿ÏÔ˘. TÔÍÈ΋ ›‰Ú·ÛË ·fi Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η ΢ÎÏÔÛÔÚ›ÓË Î·È Ù·ÎÚfiÏÈÌÔ˘˜. ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ fiˆ˜ Û ·Ú¿Ù·ÛË Ù˘ ˘ÔÍ›·˜ Ë ‚Ï¿‚Ë ÌÔÚ› Ó· ÂÍÂÏȯı› Û ÌfiÓÈÌÔ Ó¢ÚÔÏÔÁÈÎfi Úfi‚ÏËÌ· ¯. ¿ÓÔÈ·. ∏ MRI ÂÁÎÂÊ¿ÏÔ˘ Î·È Ë Î·Ù¢ı˘ÓfiÌÂÓË ÛÙÂÚÂÔÙ·ÎÙÈ΋ ‚ÈÔ„›· ‚ÔËıÔ‡Ó ÛÙËÓ Ù·˘ÙÔÔ›ËÛË Ù˘ ÓfiÛÔ˘. ∏ ÂÚÈÊÂÚÈ΋ ÔÏ˘Ó¢ÚÔ¿ıÂÈ· ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Â›‰Ú·ÛË Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ Ë Ó· Â›Ó·È ·fiÙÔÎÔ˜ ·Ô‰Ú·ÌÔ‡Û˘ ˘ÔÍ›·˜. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ·ÛıÂÓ‹ ÔÏϤ˜ ÊÔÚ¤˜ › Ì‹Ó˜.
ª˘˚Τ˜ ÂÈÏÔΤ˜ O ·ÚÈÔ˜ ·Ú¿ÁÔÓÙ·˜ Ì˘˚΋˜ ÚÔÛ‚ÔÏ‹˜ Â›Ó·È Ë ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÂȉÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ GVHD. ∏ ‚·Ú‡ÙËÙ· ·ÊÔÚ¿ ÙfiÛÔ ÙÔ Û‡ÓÔÏÔ Ù˘ ¯ÔÚËÁËı›Û˘ ‰fiÛ˘ fiÛÔ Î·È ÙÔ ‡„Ô˜ Ù˘ ηıËÌÂÚÈÓ‹˜. ∏ ¯Ú‹ÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ ÂÈʤÚÂÈ ·ÒÏÂÈ· Ì˘˚΋˜ Ì¿˙·˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ù‡Ô˘ ππ ·ÙÚÔÊ›· ÙˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ. ∏ ÚÔÛ‚ÔÏ‹ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÛÙ· οو ¿ÎÚ·. ∏ Ì˘˚΋ ·ÒÏÂÈ· ÌÔÚ› Ó· ÂÏ·ÙÙˆı› ÌÂ Ê˘ÛÈÔıÂڷ›· Î·È ÂȉÈΤ˜ ηıËÌÂÚÈÓ¤˜ ·Û΋ÛÂȘ ÂÓ‰˘Ó¿ÌˆÛ˘. ∞ӷʤÚÔÓÙ·È ÂȉÈο ÚÔÛ·ÚÌÔṲ̂ӷ ÚÔÁÚ¿ÌÌ·Ù· ¿ÛÎËÛ˘-Ê˘ÛÈÔıÂڷ›·˜ Ô˘ ‚ÂÏÙÈÒÓÔ˘Ó ÛËÌ·ÓÙÈο ÙȘ Ê˘ÛÈΤ˜ ‰˘Ó¿ÌÂȘ ÙˆÓ ·ÛıÂÓÒÓ. ∏ ÂÏ¿ÙÙˆÛË ÛÙË ÌÈÎÚfiÙÂÚË ·Ó·Áη›·-Ì ÌÂÁ¿ÏË ÚÔÛÔ¯‹‰fiÛË ÎÔÚÙÈÎÔÂȉÒÓ ÌÔÚ› Ó· Û˘Ì‚¿ÏÂÈ ÛÙËÓ ËÈfiÙÂÚË Â›‰Ú·Û‹ ÙÔ˘˜ ÛÙÔ Ì˘˚Îfi Û‡ÛÙËÌ·. Œ¯ÂÈ ·ÎfiÌ· ·Ó·ÊÂÚı› fiÙÈ ›‰È· Û˘ÓÔÏÈ΋ ‰fiÛË ÎÔÚÙÈÎÔÂȉÒÓ Û ·Ú’ Ë̤ڷ ÚfiÁÚ·ÌÌ· ¯ÔÚ‹ÁËÛ˘ ÌÔÚ› Ó· ÂȉڿÛÂÈ ıÂÙÈο ÛÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ Ì˘Ô¿ıÂÈ·˜.
æ˘¯ÔÏÔÁÈΤ˜ Î·È ÓÔËÙÈΤ˜ ÂÈÏÔΤ˜ ∂›Ó·È Û˘¯ÓfiÙÂÚ˜ ÛÙ· ·È‰È¿ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ‹˜ ÙÔ˘˜ ÌÂÙ¿ ª∞∫ Î·È Û˘Ó‰¤ÔÓÙ·È Û˘Ó‹ıˆ˜ ÌÂ: ‚Ï·ÙÈ΋ ›‰Ú·ÛË Ù˘ ¯ËÌÂÈÔıÂڷ›·˜ Ë ·ÎÙÈÓÔıÂڷ›·˜. AÔ‰Ú·ÌÔ‡Û· Ïԛ̈ÍË ÙÔ˘ ∫¡™ Ë ·Ú·ÙÂٷ̤ÓË ÂÁÎÂÊ·ÏÈ΋ ˘ÔÍ›· ÌÔÚÔ‡Ó Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó ÛÔ‚·Ú¤˜ ÓÔËÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ (fiˆ˜ ÙÒÛË ÙÔ˘ IQ, ‚Ú·‰˘„˘¯ÈÛÌfi). ∂Í ¿ÏÏÔ˘ Ë Â› Ì·ÎÚfiÓ ‰È·‚›ˆÛË ¤Íˆ ·fi ÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÛÔ‚·Ú¿ „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ȉȷ›ÙÂÚ· ÛÙ· ·È‰È¿. ™˘¯Ó‹-Ù·ÎÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·ÛıÂÓÒÓ Î·È ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ·ÚÔ˘Û›· ‰·ÛÎ¿ÏˆÓ ÛÙ· ·È‰È¿ ÁÈ· ·Ó·Ï‹ÚˆÛË ÙÔ˘ Û¯ÔÏ›Ԣ, Â›Ó·È Û‹ÌÂÚ· ·Ó·Áη›Â˜ ÚÔ¸Ôı¤ÛÂȘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ·˘ÙÒÓ Ì·˙› Ì ÙËÓ fiÔÈ· Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹. ™˘ÌÂÚ·ÛÌ·ÙÈο ·Ó·Ê¤ÚÔ˘Ì fiÙÈ ¤Ó· Ó¤Ô ÙÔ›Ô ¤¯ÂÈ ‰È·ÌÔÚʈı› ÛÙÔÓ ¯ÒÚÔ ÙˆÓ Ì·ÎÚÔ¯ÚÔÓ›ˆ˜ ÂÈ˙ÒÓÙˆÓ ÌÂÙ¿ ª∞∫. ø˜ ÂÎ ÙÔ‡ÙÔ˘ Â›Ó·È ·Ó·Áη›· Ë Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜ ÁÈ· ÙËÓ ÚfiÏË„Ë Ë ¿ÌÂÛË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÌÊ·ÓÈ˙ÔÌ¤ÓˆÓ ÂÈÏÔÎÒÓ. ∏ ÁÓÒÛË Î·È ·Ó·˙‹ÙËÛ‹ ÙÔ˘˜ ÌÔÚ› Ó· Û˘Ì‚¿ÏÂÈ ÙfiÛÔ ÛÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ ·ÏÏ¿ Î·È ÛÙËÓ ¤ÁηÈÚË ·ÓÙÈÌÂÙÒÈÛË ÂÎÂ›ÓˆÓ Ô˘ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ı¤ÛÔ˘Ó Û ΛӉ˘ÓÔ ÙËÓ ˙ˆ‹ ÙÔ˘˜.
NÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰· ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ¢¤ÛÔÈÓ· AÓ·ÁÓÒÛÙÔ˘, °ÂˆÚÁ›· °Ú·ÌÌ¿‰·, ÕÓÓ· MÔ‡¯ÏÈ·
6
¯·ÈÌÈ΋˜ ‰Ú¿Û˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ô fiÚÔ˜ «˘ÈÔıÂÙÔ‡ÌÂÓË ·ÓÔÛÔıÂڷ›·» Ô˘ ·Ó¿ÁÔÓÙ·È ÛÙÔ Mathé ˘Ô‰ÂÈÎÓ‡Ô˘Ó ÙËÓ ÈηÓfiÙËÙ· ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÌÊ˘Ù¢ı¤ÓÙÔ˜ ÌÔۯ‡̷ÙÔ˜ Ó· ·ÓÙȉÚÔ‡Ó ÂÓ·ÓÙ›ÔÓ ÙˆÓ Î·ÎfiËıˆÓ ΢ÙÙ¿ÚˆÓ ÙÔ˘ ·ÛıÂÓ‹ .OÈ Weiden et al ¤‰ÂÈÍ·Ó fiÙÈ fiÛÔ ÛÔ‚·ÚfiÙÂÚË GVHD ÙfiÛÔ ÏÈÁfiÙÂÚË ˘ÔÙÚÔ‹ Ù˘ Ï¢¯·ÈÌ›·˜ ˘‹Ú¯Â. ™ÙË ‰ÂηÂÙ›· ÙÔ˘ 1970 ˘‹Ú¯Â ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ÛÙËÓ ·Ó‡ÚÂÛË ‰ÔÙÒÓ ÂÂȉ‹ ÌfiÓÔ ÙÔ 25-30 % ÙˆÓ ·ÛıÂÓÒÓ ¤¯Ô˘Ó Ù·˘ÙfiÛËÌÔ ·‰ÂÏÊfi. ΔÔ 1779 Ú·ÁÌ·ÙÔÔÈ‹ıËÎÂ Ë ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ÌË Û˘ÁÁÂÓ‹ HLA Û˘Ì‚·Ùfi ‰fiÙË. ∞fi ÙfiÙ ȉڇıËΠÙÔ MNDP (National Marrow Donor Program) Ô˘ ÙÔÓ 11/2005 ·ÚÈıÌÔ‡Û 10 ÂηÙÔÌ̇ÚÈ· ÂıÂÏÔÓÙ¤˜ ‰fiÙ˜ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ‰ÈÂÓÂÚÁÔ‡ÓÙ·È 1400 ÌÂÙ·ÌÔۯ‡ÛÂȘ ·Ó¿ ¤ÙÔ˜ ÛÙȘ ∏¶∞. ªÂÙ¿ ÙÔ 1980 ˘¿Ú¯Ô˘Ó ÛËÌ·ÓÙÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ô˘ ÂËÚ¤·Û·Ó ÙËÓ ÂͤÏÈÍË ÙÔ˘˜. 1. ø˜ ËÁ‹ ÌÔۯ‡̷ÙÔ˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·È ÙÔ ÂÚÈÊÂÚÈÎfi ·›Ì· ÌÂÙ¿ ·fi ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ÚÔÁÔÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ì ·˘ÍËÙÈÎfi ·Ú¿ÁÔÓÙ· Î·È ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì· ÁÈ· ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ΢ڛˆ˜. O fiÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ (BMT) ·ÓÙÈηٷÛÙ¿ıËΠ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (HCT). 2. O Û˘Ó‰˘·ÛÌfi˜ ΢ÎÏÔÛÔÚ›Ó˘ + ÌÂıÔÙÚÂÍ¿Ù˘ ·fi Ù· ̤۷ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1980 ·Ó·‰Â›¯ıËÎÂ Ë ÛÙ·ıÂÚ‹ ÚÔʇϷÍË ¤Ó·ÓÙÈ ÔÍ›·˜ ÓfiÛÔ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ˘ ÍÂÓÈÛÙ‹ (GVHD). ∏ ·Ê·›ÚÂÛË ÙˆÓ Δ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Ë ÂÓ·ÏÏ·ÎÙÈ΋ ̤ıÔ‰Ô˜. 3. ÀÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹: ∏ ¯Ú‹ÛË ÙˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÁÈ· ÙËÓ ÂÈÙ¿¯˘ÓÛË ·ÈÌ·ÙÔÏÔÁÈ΋˜ ·ÔηٿÛÙ·Û˘ ÌÂÙ¿ ·fi ·˘ÙfiÏÔÁË ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ Ì¤ıÔ‰ÔÈ ·ÔÊ˘Á‹˜ CMV ÓfiÛÔ˘ Ì ÙË ¯Ú‹ÛË ÔÚÔ·ÚÓËÙÈÎÒÓ ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÏÏÔÁÂÓÒÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ (allo-HCT) ·ÔÙÂÏ› Û‹ÌÂÚ· ÙËÓ Ï¤ÔÓ ·ÍÈfiÈÛÙË ıÂڷ¢ÙÈ΋ ÂÈÏÔÁ‹ ›·Û˘ ÁÈ· ÂÈÏÂÁ̤ÓÔ˘˜ ·ÛıÂÓ›˜ Ì ηÎÔ‹ıË Î·È ÌË Î·ÎÔ‹ıË ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù·. ∏ ıÂڷ¢ÙÈ΋ Ù˘ ‰Ú¿ÛË ÛÙËÚ›˙ÂÙ·È: 1. ÛÙËÓ ÈÛ¯˘Ú‹ Ì˘ÂÏÔ·Ê·ÓÈÛÙÈ΋ ¯ËÌÂÈÔ/·ÎÙÈÓÔıÂڷ›· Ô˘ ¤¯ÂÈ ÛÙfi¯Ô, ·ÊÂÓfi˜ ÙËÓ Î·Ù·ÛÙÔÏ‹ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ Ï‹ÙË Î·È ·ÊÂÙ¤ÚÔ˘ ÙËÓ ÂÎÚ›˙ˆÛË Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘. 2. ÛÙÔ ÌfiÛ¯Â˘Ì· Ô˘ ÂÎÙfi˜ ·fi ÙËÓ ·ÈÌ·ÙÔÏÔÁÈ΋ ·ÔηٿÛÙ·ÛË ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Û˘Ì‚¿ÏÏÂÈ ÚˆÙÔÁÂÓÒ˜ ̤ۈ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÛÙËÓ ÂÎÚ›˙ˆÛË Ù˘ ÓfiÛÔ˘. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÔÚ›˙ÂÙ·È ˆ˜ Ë ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË ÚÔÁÔÓÈÎÒÓ ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ Â›Ó·È Èηӿ Ó· ‰ڷÈÒÛÔ˘Ó Ì·ÎÚfi¯ÚÔÓË ÛÙ·ıÂÚ‹ Ì˘ÂÏÈ΋ ,·ÈÌ·ÙÔÏÔÁÈ΋ Î·È ·ÓÔÛÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›·. •ÂΛÓËÛÂ Û·Ó È‰¤· ηٿ Ù· ÙÂÏÂ˘Ù·›· ¤ÙË ÙÔ˘ ÚÔËÁÔ‡ÌÂÓÔ˘ ·ÈÒÓ·. OÈ ÚÒÙ˜ ÚÔÛ¿ıÂȘ ‹Ù·Ó ÁÂÓÈο ·ÓÂÈÙ˘¯Â›˜ ΢ڛˆ˜ ÁÈ· ÙÔ˘˜ ÂÍ‹˜ ÏfiÁÔ˘˜: • Δ· Û˘ÛÙ‹Ì·Ù· ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ‹Ù·Ó ¿ÁÓˆÛÙ·. • ¢ÂÓ Â›¯Â ÂÎÙÈÌËı› ·ÚÎÂÙ¿ Ë ·Ó¿ÁÎË ÚÔÂÙÔÈÌ·Û›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ì ·ÔÙ¤ÏÂÛÌ· Ë ·fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜ Ó· Â›Ó·È ÙÔ ÛÔ‚·ÚfiÙÂÚÔ Úfi‚ÏËÌ·. • OÈ ·ÛıÂÓ›˜ ·ÓÙÈÌÂÙÒÈ˙·Ó ÙÔ Úfi‚ÏËÌ· Ù˘ ·ÓÛÔηٷÛÙÔÏ‹˜ Î·È ·Ó΢ÙÙ·ÚÔÂÓ›·˜, ¯ˆÚ›˜ ÙËÓ ··Ú·›ÙËÙË ÂÓÙ·ÙÈ΋ Û˘Ìو̷ÙÈ΋ ÊÚÔÓÙ›‰·. OÈ Ù¯ÓÈΤ˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ÈÛÙÈÎÒÓ ·ÓÙÈÁfiÓˆÓ ¤ıÂÛ·Ó ÙÔ ıÂ̤ÏÈÔ Ï›ıÔ ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ. ∏ ηıȤڈÛË Ù˘ Ù¯ÓÈ΋˜ ÂϤÁ¯Ô˘ HLA ¤ÁÈÓ ·fi ÙÔ˘˜ Terasaki Î·È McLelland ÙÔ 1964.∏ ÈηÓfiÙËÙ· ÂÈÏÔÁ‹˜ ÙˆÓ HLA Û˘Ì‚·ÙÒÓ Ù·˘ÙfiÛËÌˆÓ ·‰ÂÏÊÒÓ ˆ˜ ‰fiÙ˜ Ì˘ÂÏÔ‡ ‹Ù·Ó Ë Ì¤ÁÈÛÙË ÚfiÔ‰Ô˜ ÛÙËÓ ÔÚ›· Ù˘ ·ÏÏÔÁÂÓÔ‡˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. ∏ ¤ÓÓÔÈ· Ù˘ ·ÓÙÈÏ¢-
299
300
¢. ANA°Nø™TOY, °. °PAMMA¢A, A. MOYX§IA
Û ÔÚÔ·ÚÓËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ηıÒ˜ Î·È Ë ÚÔÏËÙÈ΋-ÚÔÊ˘Ï·ÎÙÈ΋ ¯Ú‹ÛË ÂȉÈÎÒÓ ·ÓÙ› CMV Ê·Ú̿ΈÓ.∏ ÚÔÊ˘Ï·ÎÙÈ΋ ¯Ú‹ÛË ·ÓÙÈÌ˘ÎËÙÈ·ÛÈÎÒÓ ‚ÂÏÙ›ˆÛ ÙËÓ ÔÏÈ΋ ÂÈ‚›ˆÛË. 4. ∏ HCT ·fi Û˘ÁÁÂÓ›˜ ‰fiÙ˜ ·ÏÔÙ·˘ÙfiÛËÌÔ˘˜ ·ÔÙÂÏ› ϤÔÓ ÙÔ 10% ÙˆÓ ‰ÈÂÓÂÚÁÔ˘Ì¤ÓˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ì ÈÛ¯˘Úfi Ì˘ÂÏÔ-·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi ÚÔ·Ú·Û΢·ÛÙÈÎfi Û¯‹Ì· Î·È ÌfiÛ¯Â˘Ì· Ô˘ ¤¯ÂÈ ˘„ËÏfi ·ÚÈıÌfi CD34+ ΢ÙÙ¿ÚˆÓ ÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙˆÓ Δ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. 5. ∏ ¯Ú‹ÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ‰fiÙË (DLI Donor Lymphocyte Infusion ) Î·È Ë ¯Ú‹ÛË ÌË Ì˘ÂÏÔηٷÛÙÚÔÊÈÎÒÓ –ÂÏ·Ùو̤Ó˘ ÈÛ¯‡Ô˜ Û¯ËÌ¿ÙˆÓ (RIC - Reduced Intensity Contditioning) ·ÔÙÂÏÔ‡Ó ÙËÓ ÙÂÏÂ˘Ù·›· ÂͤÏÈÍË ÛÙËÓ BMT Ì ‚¿ÛË ÙËÓ ÚfiÛÊ·ÙË ÁÓÒÛË ÛÙËÓ ÎÏÈÓÈ΋ ·ÓÔÛÔÏÔÁ›·.
∞ÏÔÙ·˘ÙfiÛËÌË HCT ∏ ·ÏÔÙ·˘ÙfiÛËÌË HCT ÂÌÂÚȤ¯ÂÈ ˆ˜ ‚¿ÛË ÙËÓ ¤Á¯˘ÛË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÚÔÁÔÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÌÂÙ¿ ÙËÓ ·ÔÌ¿ÎÚ˘ÓÛË Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÌÔۯ‡̷ÙÔ˜ ·fi ‰fiÙË ·‰ÂÏÊfi ‹ ÁÔÓ¤·, Û˘Ì‚·Ùfi ηٿ ÙÔ ‹ÌÈÛ˘ Ì ÙÔÓ ·ÛıÂÓ‹. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ú¤ÂÈ Ó· ˘Ô‚ÏËıÔ‡Ó Û ·ÏÏÔÁÂÓ‹ ·fi ͤÓÔ ‰fiÙË (VUD Volunteer Unrelated Donor) ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ 50% ÂÚ›Ô˘ ı· ¤¯ÂÈ ¤Ó· Ï‹Úˆ˜ Û˘Ì‚·Ùfi ‰fiÙË. ∞Ó ÏËÊı› ˘fi„Ë fiÙÈ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·Ó‡ÚÂÛ˘ ÂÓfi˜ VUD ˆ˜ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÂÛÔÏ·‚Ô‡Ó ÂÚ›Ô˘ 3 Ì‹Ó˜, οÔÈÔÈ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·˘Ùfi ÙÔ ‰È¿ÛÙËÌ· Â›Ó·È ‰˘Ó·Ùfi Ó· ˘ÔÙÚÔÈ¿ÛÔ˘Ó. O ·ÏÔÙ·˘ÙfiÛËÌÔ˜ ‰fiÙ˘ ·ÔÙÂÏ› ÌÈ· ¿ÌÂÛ· ‰È·ı¤ÛÈÌË ËÁ‹ ÌÔۯ‡̷ÙÔ˜ ÁÈ· ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¤¯Ô˘Ó ηٷگ‹Ó ¤Ó‰ÂÈÍË ÁÈ· ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂÙ·ÌÔۯ‡ÛÂȘ Ì ‰fiÙ˜ Û˘ÁÁÂÓ›˜, ÔÈ ÔÔ›ÔÈ ¤¯Ô˘Ó ¤Ó· ÌfiÓÔ ÎÔÈÓfi HLA·ÏfiÙ˘Ô Ì ÙÔ˘˜ ·ÛıÂÓ›˜, ¿Ú¯ÈÛ·Ó Ó· ÂȯÂÈÚÔ‡ÓÙ·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ Ì ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÔÍ›· Ì˘ÂÏÔÁÂÓ‹ Ï¢¯·ÈÌ›·, ÛÙ· Ï·›ÛÈ· ÂȉÈÎÒÓ ÚˆÙÔÎfiÏψÓ. ªÂ ÙË ¯ÚËÛÈÌÔÔ›ËÛË ‚ÂÏÙÈˆÌ¤ÓˆÓ Ù¯ÓÈÎÒÓ ÂÂÍÂÚÁ·Û›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÚÔÊ˘Ï·ÎÙÈÎÒÓ ıÂÚ·ÂÈÒÓ, Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ÍÂÂÚ·ÛÙ› Ô ÊÚ·ÁÌfi˜ Ù˘ HLA-ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Î·È Ó· ¢ÂÚÁÂÙËıÔ‡Ó ÔÈ ·ÛıÂÓ›˜ ÌÈ·˜ Ù¤ÙÔÈ·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ë ÔÔ›· ʤÚÂÈ Ù· ÂÍ‹˜ ÏÂÔÓÂÎÙ‹Ì·Ù·: • ⁄·ÚÍË ‰fiÙË ÁÈ· ÙÔ 95% ÙˆÓ ÛıÂÓÒÓ • ÕÌÂÛ· ‰È·ı¤ÛÈÌÔ˜ ‰fiÙ˘
• ¢˘Ó·ÙfiÙËÙ· ÂÈÏÔÁ‹˜ ·Ó¿ÌÂÛ· Û ÔÏÏÔ‡˜ ‰˘ÓËÙÈÎÔ‡˜ ‰fiÙ˜ Ì ‰˘Ó·ÙfiÙËÙ· ÂÈÏÔÁ‹˜ ʇÏÔ˘, ËÏÈΛ·˜, CMV • ∫·Ó¤Ó·˜ ÂıÓÈÎfi˜ ‹ Ê˘ÏÂÙÈÎfi˜ ÂÚÈÔÚÈÛÌfi˜ • ™˘Ó¯›˜ ÚfiÛ‚·ÛË ÛÙÔ ‰fiÙË ÁÈ· ΢ÙÙ·ÚÈΤ˜ ıÂڷ›˜ • ¶ÂÚÈÔÚÈÛÌfi˜ ÂÍfi‰ˆÓ ·fi ÙËÓ HLA Ù˘ÔÔ›ËÛË
ºÚ·ÁÌÔ› Î·È ‰˘ÓËÙÈΤ˜ χÛÂȘ ÛÙȘ ·ÏÔÙ·˘ÙfiÛË̘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ∏ HLA- ·Û˘Ì‚·ÙfiÙËÙ· ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ·: • ∞˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·fiÚÚȄ˘ • ∞˘ÍË̤ÓÔ ÔÛÔÛÙfi ÂΉ‹ÏˆÛ˘ Ù˘ ÓfiÛÔ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ˘ ÍÂÓÈÛÙ‹ (GVHD) °È· Ó· ÍÂÂÚ·ÛÙÔ‡Ó ·˘ÙÔ› ÔÈ ÊÚ·ÁÌÔ› Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¤¯Ô˘Ó ÚÔÙ·ı› ‰È¿ÊÔÚ˜ ‰˘ÓËÙÈΤ˜ χÛÂȘ. ŒÙÛÈ Ô ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Ù˘ GVHD ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì ¯ÔÚ‹ÁËÛË ÌÔۯ‡̷ÙÔ˜ ÎÂηı·Ṳ́ÓÔ˘ ·fi Ù· Δ-ÏÂÌÊÔ·ÙÙ·Ú· ÂÓÒ Ô Î›Ó‰˘ÓÔ˜ Ù˘ ·fiÚÚȄ˘ Ì ÙË ¯ÔÚ‹ÁËÛË CD34+ ΢ÙÙ¿ÚˆÓ, ηıÒ˜ Î·È Ì ÈÛ¯˘Úfi ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi ÚÔ·Ú·Û΢·ÛÙÈÎfi ÂÎÏÂÎÙÈο Ì˘ÂÏÔ·Ê·ÓÈÛÙÈÎfi Û¯‹Ì·. ∂·ÎfiÏÔ˘ıÔ ÙˆÓ ·ÓˆÙ¤Úˆ ¯ÂÈÚÈÛÌÒÓ Â›Ó·È: • ªÂȈ̤ÓË GVL (·ÓÙÈÏ¢¯·ÈÌÈ΋ ‰Ú¿ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜) • ∫·ı˘ÛÙÂÚË̤ÓË ·ÓÔÛÔÏÔÁÈ΋ ·ÔηٿÛÙ·ÛË (6-16 Ì‹Ó˜). ∏ ·Ó·ÌÂÓfiÌÂÓË ·fi ÙËÓ ·Ô˘Û›· Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÌÂȈ̤ÓË ·ÏÏÔ·ÓÙȉڷÛÙÈÎfiÙËÙ· ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ì ‰Ú¿ÛË ÙˆÓ ¡∫ ΢ÙÙ¿ÚˆÓ ·fi ÙËÓ ÂÈÏÔÁ‹ ‰ÔÙÒÓ Ì HLA ·Û˘Ì‚·ÙfiÙËÙ· Î·È Ó· ÂÈʤÚÂÈ ÈÛ¯˘Ú‹ ·ÓÙÈÏ¢¯·ÈÌÈ΋ ‰Ú¿ÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÈ· ÔÚÈṲ̂ÓÔ Ù‡Ô Ï¢¯·ÈÌÈÒÓ (Oª§). Δ¤ÏÔ˜ ÛÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ·ÓÔÛÔÏÔÁÈ΋ ·ÔηٿÛÙ·ÛË ÚÔÙ›ÓÔÓÙ·È ¯ÂÈÚÈÛÌÔ› Ì ΢ÙÙ·ÚÔΛÓ˜ ηıÒ˜ Î·È Ë ¯Ú‹ÛË ·ÏÏÔ·ÓÙȉڷÛÙÈÎÒÓ Δ- ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ‰È·ÌÔÏ˘ÛÌ¤ÓˆÓ Ì ÁÔÓ›‰È· ÒÛÙ ӷ Â›Ó·È Â˘·›ÛıËÙ· ÛÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈÈÎÒÓ Ê·Ú̿ΈÓ.
ªÂÙ·ÌÔۯ‡ÛÂȘ Ì ÌÂȈ̤Ó˘ ¤ÓÙ·Û˘ Û¯‹Ì·Ù· ÚÔÂÙÔÈÌ·Û›·˜ ¶·Ú¿ ÙȘ ÛËÌ·ÓÙÈΤ˜ ‚ÂÏÙÈÒÛÂȘ ÛÙËÓ ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹, Ë ÙÔÍÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ ÂÍ·ÎÔÏÔ˘ı› Ó· ·ÔÙÂÏ› ÊÚ·ÁÌfi ÁÈ· ·ÛıÂÓ›˜ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 55 ÂÙÒÓ Î·È ÁÈ· ·˘ÙÔ‡˜ Ô˘ ÙË ÁÂÓÈ΋ ÙÔ˘˜ ηٿÛÙ·ÛË ‰ÂÓ Â›Ó·È ÈηÓÔÔÈËÙÈ΋. ∞fi ÙÔ 1976 ÔÈ Slavin Î·È ÔÈ Û˘Ó. ÙÔ˘ Î·È ·ÚÁfiÙÂÚ· ÔÈ Yu Î·È Û˘Ó. η٤‰ÂÈÍ·Ó Û ÂÈÚ·Ì·ÙÈο
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
ÌÔÓ٤Ϸ fiÙÈ Â›Ó·È ‰˘Ó·Ù‹ Ë ÂÌʇÙ¢ÛË ÌÔۯ‡̷ÙÔ˜ Î·È Ë Â›Ù¢ÍË ·ÈÌÔÔÈËÙÈ΋˜ ¯›Ì·ÈÚ·˜ ÙÔ˘ ‰fiÙË ÈηӋ˜ Ó· ·Ó·Ù‡ÍÂÈ ·ÓÙÈÏ¢¯·ÈÌÈ΋ ‰Ú¿ÛË, ¯ˆÚ›˜ ÙËÓ ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ÈÛ¯˘ÚÔ‡ ÚÔ·Ú·Û΢·ÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ∂› ϤÔÓ Ë ÎÏÈÓÈ΋ ÂÌÂÈÚ›· ÙˆÓ «Û˘Ì‚·ÙÈÎÒÓ», ÎÏ·ÛÛÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·¤‰ÂÈÍ fiÙÈ Ë ÂÓÙ·ÙÈÎÔÔ›ËÛË ÙÔ˘ ÚÔ·Ú·Û΢·ÛÙÈÎÔ˘ Û¯‹Ì·ÙÔ˜ ‰ÂÓ Â›Ó·È ÈηӋ Ó· ÂÍ·Ï›„ÂÈ ÙËÓ Èı·ÓfiÙËÙ· Ù˘ ˘ÔÙÚÔ‹˜. ∏ ›·ÛË ÌÔÚ› Ó· ÂÈÙ¢¯ı› ̤ۈ GvL ‰Ú¿Û˘, ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ˘ÔÏËı˘ÛÌfi Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ô˘ Â›Ó·È ˘Â‡ı˘ÓÔ˜ ÙfiÛÔ ÁÈ· ÙË ‰Ú¿ÛË ÙÔ˘ ÍÂÓÈÛÙ‹ ¤Ó·ÓÙÈ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (HvG) fiÛÔ Î·È ÁÈ· ÙË ‰Ú¿ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¤Ó·ÓÙÈ ÙÔ˘ ÍÂÓÈÛÙ‹ (GvH). ∞˘Ù¿ Ù· ÂÈÚ·Ì·ÙÈο Î·È ÎÏÈÓÈο ‰Â‰Ô̤ӷ ·ÔÙ¤ÏÂÛ·Ó ÙÔ ¤Ó·˘ÛÌ· ÁÈ· Ì›· Ó¤· ÛÙÚ·ÙËÁÈ΋ ÛÙÔÓ ÙÔ̤· Ù˘ alloHCT Ô˘ ¯ÚËÛÈÌÔÔÈ› ÏÈÁfiÙÂÚÔ ÂÓÙ·ÙÈÎÔÔÈË̤ÓÔ ÚÔ·Ú·Û΢·ÛÙÈÎfi Û¯‹Ì·. ∏ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ·˘ÙÔ‡ ÙÔ˘ Û¯‹Ì·ÙÔ˜ Â›Ó·È ÈηӋ ÒÛÙ ӷ ÂÈÙÚ¤„ÂÈ ÙËÓ ÂÌʇÙ¢ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ηٷگ‹Ó ÌÈÎÙ‹˜ ·ÈÌÔÔÈËÙÈ΋˜ ¯›Ì·ÈÚ·˜. ΔÔ ÚÔÛ‰ÔÎÒÌÂÓÔ ·ÔÙ¤ÏÂÛÌ· Â›Ó·È Ë Ì›ˆÛË Ù˘ ÙÔÍÈÎfiÙËÙ·˜ ̤ۈ ÏÈÁfiÙÂÚÔ ÈÛ¯˘ÚÔ‡ ÚÔ·Ú·Û΢·ÛÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ Î·È Ë ·ÍÈÔÔ›ËÛË Ù˘ GvL ‰Ú¿Û˘ ̤ۈ Ù˘ ÚÔԉ¢ÙÈ΋˜ ÂÁηٿÛÙ·Û˘, ·ÓÔÛÔÏÔÁÈ΋˜ ·ÓÔ¯‹˜ ÌÂٷ͇ ÌÔۯ‡̷ÙÔ˜ - Ï‹ÙË Î·È ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ (.¯. ¯ÔÚ‹ÁËÛË ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ‰fiÙË) ÒÛÙ ÙÂÏÈο ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ Ó· ˆÊÂÏËıÔ‡Ó ·fi ÙË Ì¤ıÔ‰Ô. OÈ allo-HCT Ì ÌÂȈ̤Ó˘ ¤ÓÙ·Û˘ ÚÔ·Ú·Û΢·ÛÙÈÎfi Û¯‹Ì· ÂÊ·ÚÌfi˙ÔÓÙ·È Û ÎÏÈÓÈÎfi Â›Â‰Ô Ï¤ÔÓ, ۯ‰fiÓ ÌÈ· ‰ÂηÂÙ›·. ∏ ıÂڷ¢ÙÈ΋ ‰Ú¿ÛË ÛÙËÚ›˙ÂÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÛÙ· ·ÓÔÛÔÈηӿ ·ÙÙ·Ú· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÂÔ̤ӈ˜ ÌfiÓÔ ·ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù· ¢·›ÛıËÙ· ÛÙËÓ GvL ‰Ú¿ÛË Â›Ó·È Î·Ù¿ÏÏËÏ· Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Ì ÙË Û˘ÁÎÂÎÚÈ̤ÓË ıÂڷ¢ÙÈ΋ Ù·ÎÙÈ΋. ™˘Ì·Á›˜ fiÁÎÔÈ Ì ‰Â‰Ô̤ÓË ·ÓÙÈÁÔÓÈÎfiÙËÙ· (Ca ÓÂÊÚÔ‡) ÌÔÚ› ›Û˘ Ó· ·ÓÙÈÌÂÙˆÈÛÙÔ‡Ó Ì ÙËÓ ›‰È· Ù·ÎÙÈ΋. ∂ÈϤÔÓ Ë Â›Ù¢ÍË ÛÙ·ıÂÚ‹˜ ÌÈÎÙ‹˜ ·ÈÌÔÔÈËÙÈ΋˜ ¯›Ì·ÈÚ·˜ ÌÔÚ› Ó· ·Ô‚› ÂÈÙ˘¯‹˜ ıÂڷ›· Û ÌÈ· ÛÂÈÚ¿ ·fi ÌË Î·Ô‹ıË ÁÂÓÂÙÈο ÓÔÛ‹Ì·Ù·.
∂˘·›ÛıËÙ· ÓÔÛ‹Ì·Ù· ÃÚfiÓÈ· ª˘ÂÏÔÁÂÓ‹˜ §Â˘¯·ÈÌ›· ÷ÌËÏ‹˜ ∫·ÎÔ‹ıÂÈ·˜ §¤Ìʈ̷ §¤Ìʈ̷ ·fi ·ÙÙ·Ú· Ì·Ó‰‡· ÃÚfiÓÈ· §ÂÌÊÔ΢ÙÙ·ÚÈ΋ §Â˘¯·ÈÌ›·
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∂ӉȿÌÂÛ˘ ∂˘·ÈÛıËÛ›·˜ ¡ÔÛ‹Ì·Ù· OÍ›· ª˘ÂÏÔÁÂÓ‹˜ §Â˘¯·ÈÌ›· ∂ӉȿÌÂÛ˘ ∫·ÎÔ‹ıÂÈ·˜ §¤Ìʈ̷ ¶ÔÏÏ·ÏÔ‡Ó ª˘¤ÏˆÌ· ¡fiÛÔ˜ Hodgkin Ca ¡ÂÊÚÔ‡ Ca Ì·ÛÙÔ‡
ªË ¢·›ÛıËÙ· ¡ÔÛ‹Ì·Ù· OÍ›· §ÂÌÊÔ‚Ï·ÛÙÈ΋ §Â˘¯·ÈÌ›· À„ËÏ‹˜ ηÎÔ‹ıÂÈ·˜ §¤Ìʈ̷
¶ÚÔ·Ú·Û΢·ÛÙÈο Û¯‹Ì·Ù· OÈ È‰·ÓÈΤ˜ ‰fiÛÂȘ Î·È Û¯‹Ì· ‰ÂÓ ¤¯Ô˘Ó ηıÔÚÈÛÙ› Î·È Èı·Ó¿ ‰ÂÓ Â›Ó·È fiÌÔÈ· ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Î·È ÓÔÛ‹Ì·Ù· Î·È ÂÈϤÔÓ Ë ÂÈÏÔÁ‹ ÙÔ˘ Û¯‹Ì·ÙÔ˜ ÂËÚ¿˙ÂÙ·È ·fi ÙȘ Èı·Ó¤˜ HLA ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ‰fiÙË Î·È Ï‹ÙË. ªÂ ‚¿ÛË ÙËÓ ÈÛ¯‡ ÙÔ˘˜ ¤¯Ô˘Ó Ù·ÍÈÓÔÌËı›: 1. ∞ÌÈÁÒ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈο – ÌË Ì˘ÂÏÔηٷÛÙ·ÏÙÈο Û¯‹Ì·Ù· Ô˘ ÏËÚÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· ·) ÌË ÂÎÚ›˙ˆÛË Ù˘ ·ÈÌÔÔÈ˚·˜ Ï‹ÙË ‚) ¿ÌÂÛË ·ÈÌ·ÙÔÏÔÁÈ΋ ·Ó¿Î·Ì„Ë (4 ‚‰ÔÌ¿‰Â˜) ¯ˆÚ›˜ ¯ÔÚ‹ÁËÛË ÌÔۯ‡̷ÙÔ˜ Á) ·Ú¯È΋ ·ÚÔ˘Û›· ÌÈÎÙ‹˜ ¯›Ì·ÈÚ·˜ (Û˘Ó‡·ÚÍË ·ÈÌÔÔÈËÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ‰fiÙË, Ï‹ÙË) ηٿ ÙËÓ ÂÌʇÙ¢ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Â›Ù¢ÍË Ï‹ÚÔ˘˜ ¯›Ì·ÈÚ·˜ Û 3-6 Ì‹Ó˜. 2. ªÂȈ̤Ó˘ ¤ÓÙ·Û˘ Ì˘ÂÏÔηٷÛÙ·ÏÙÈο Û¯‹Ì·Ù· Ù· ÔÔ›· ÚÔηÏÔ‡Ó ·Ó΢ÙÙ·ÚÔÂÓ›·, Ì Èı·Ó‹ ·Ó¿Î·Ì„Ë Ù˘ ·ÈÌÔÔÈ˚·˜ ÙÔ˘ ‰fiÙË Î·È Â›Ù¢ÍË Ï‹ÚÔ˘˜ ¯›Ì·ÈÚ·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ Ù˘ ÎÔÎÎÈÒ‰Ô˘˜ ÛÂÈÚ¿˜ ÂÓÙfi˜ ÂÓfi˜ ÌËÓfi˜. Δ· Û˘ÁÎÚÈÙÈο ÔʤÏË ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ˘ÔΛÌÂÓË ÓfiÛÔ, ÙÔ ÛÙ¿‰ÈÔ Î·È ÙË Ê¿ÛË Ù˘ ÓfiÛÔ˘ ηıÒ˜ Î·È ÙËÓ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ™Â ·ÛıÂÓ›˜ Ô˘ ‰Â›¯ÓÔ˘Ó Â˘·ÈÛıËÛ›· ÛÙËÓ ·ÓÙÈÏ¢¯·ÈÌÈ΋ ‰Ú¿ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, fiˆ˜ ·˘Ù‹ ·Ô‰Â›¯ıËΠÌÂÙ¿ ÙË ‰Ú¿ÛË Ù˘ ¤Á¯˘Û˘ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ‰fiÙË (ê§, ç§, ϤÌʈ̷ ¯·ÌËÏ‹˜ ηÎÔ‹ıÂÈ·˜), Ù· ·ÌÈÁÒ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê·›ÓÔÓÙ·È ÈηÓÔÔÈËÙÈο ÛÙËÓ Â›Ù¢ÍË ÂÌʇÙ¢Û˘. ∏ ‰Â ÎÈÓËÙÈ΋ ÙÔ˘ fiÁÎÔ˘ ·Ê‹ÓÂÈ ¯ÚÔÓÈο ÂÚÈıÒÚÈ· ÁÈ· ÙËÓ ·ÓÙÈÏ¢¯·ÈÌÈ΋ ‰Ú¿ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞ÓÙ›ıÂÙ· Û ÚÔ˚Ô‡Û· ÓfiÛÔ ‹ Û ÓfiÛÔ Ì ÌÂÁ¿ÏË ÎÈÓËÙÈ΋ ÙÔ˘ fiÁÎÔ˘ (ϤÌʈ̷ ˘„ËÏ‹˜ ηÎÔ‹ıÂÈ·˜, ¡. Hodgkin, ÔÏÏ·ÏÔ˘Ó Ì˘¤ÏˆÌ·, Ô-
302
¢. ANA°Nø™TOY, °. °PAMMA¢A, A. MOYX§IA
Í›· Ì˘ÂÏÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·) ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ù· ÌÂȈ̤Ó˘ ¤ÓÙ·Û˘. ∏ ·ÓÔÛÔηٷÛÙÔÏ‹ ÚÈÓ ÙËÓ ¯ÔÚ‹ÁËÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¤¯ÂÈ Û·Ó ÛÙfi¯Ô ·ÊÂÓfi˜ ÙËÓ ·‡ÍËÛË Ù˘ GvL ‰Ú¿Û˘ Î·È ·ÊÂÙ¤ÚÔ˘ ÙËÓ ·ÔÊ˘Á‹ Ù˘ GVHD. ø˜ ·ÌÈÁÒ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·ÓÙÈı˘ÌÔ΢ÙÙ·ÚÈÎË ÛÊ·ÈÚ›ÓË (ATG), ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· (mab campath), ÙÔÈ΋ ·ÎÙÈÓÔ‚fiÏËÛË ÙÔ˘ ı‡ÌÔ˘ ·‰¤Ó·, Î.·. ∏ ¯Ú‹ÛË ÂÏ·Ùو̤Ó˘ ÈÛ¯‡Ô˜ ÚÔ·Ú·Û΢·ÛÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ¤¯ÂÈ Î·Ù·ÛÙ‹ÛÂÈ ÙËÓ ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰˘Ó·Ù‹, ÂÊÈÎÙ‹ ıÂڷ¢ÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ·ÛıÂÓ›˜ Ì ·ÈÌ·ÙÔÏÔÁÈ΋ ηÎÔ‹ıÂÈ· Ô˘ ‰ÂÓ ·ÓÙ¤¯Ô˘Ó ÙËÓ Û˘Ì‚·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÙȘ Ì˘ÂÏÔηٷÛÙÚÔÊÈΤ˜ ¯ËÌÂÈÔ –·ÎÙÈÓÔıÂڷ›˜ ÂÍ ·ÈÙ›·˜ Ù˘ ÌÂÁ¿Ï˘ ËÏÈΛ·˜, Ù˘ ÚÔËÁËı›Û˘ ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜, Ù˘ ‰È·Ù·Ú·Á̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ˙ˆÙÈÎÒÓ ÔÚÁ¿ÓˆÓ ‹ Ù˘ ÂÓÂÚÁÔ‡ Ïԛ̈͢. ∞Ó Î·È ÂÚ›Ô˘ 1500 ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó ¤ˆ˜ ÙÒÚ· Û ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÌÂȈ̤Ó˘ ¤ÓÙ·Û˘ ÚÔ·Ú·Û΢·ÛÙÈÎfi Û¯‹Ì·, ÔÈ ·ÎÚȂ›˜ ÂӉ›ÍÂȘ ‰ÂÓ ¤¯Ô˘Ó ·ÔÛ·ÊËÓÈÛı›. ¢È¢ڇÓÂÈ ÙȘ ËÏÈÎȷΤ˜ ÔÌ¿‰Â˜, Ê·›ÓÂÙ·È fï˜ Ó· ·Ú¤¯ÂÈ Î·Ï‡ÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Û ·ÛıÂÓ›˜ Ì ¯·ÌËÏfi ÊÔÚÙ›Ô ÓfiÛÔ˘. ∞fi ‰È¿ÊÔÚ˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Û˘ÌÂÚ·›ÓÔÓÙ·È Ù· ÂÍ‹˜: ™˘ÓÔÏÈο Ë ÂÌʇÙ¢ÛË ‹Ù·Ó ÂÈÙ˘¯‹˜ Û ÔÛÔÛÙfi 94%. ∏ ·ÈÌ·ÙÔÏÔÁÈ΋ ·Ó¿Î·Ì„Ë ‹Ù·Ó Ù·¯Â›· ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ Â›‰Ô˜ ÙÔ˘ ÚÔ·Ú·Û΢·ÛÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ∏ ÓfiÛÔ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ˘ ÍÂÓÈÛÙ‹ Î·È È‰È·›ÙÂÚ· Ë ¯ÚfiÓÈ· ÌÔÚÊ‹ Ù˘ ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· Â›Ó·È Ì›˙ÔÓ Úfi‚ÏËÌ· fiˆ˜ Î·È ÛÙËÓ Û˘Ì‚·ÙÈ΋ allo-HCT. ∏ ÙÔÍÈÎfiÙËÙ· Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÎÙÈÌËı› ÙfiÛÔ ÏfiÁˆ Ù˘ ÂÙÂÚÔÁ¤ÓÂÈ·˜ ÙˆÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙˆÓ ÚÔ·Ú·Û΢·ÛÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Ô˘ ¯ÔÚËÁ‹ıËÎ·Ó fiÛÔ Î·È ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ ·ÍÈÔÏfiÁËÛ˘ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËηÓ, Â›Ó·È fï˜ ·Ô‰ÂÎÙ‹ ·ÎfiÌË Î·È Û ·ÛıÂÓ›˜ ÌÂÁ¿Ï˘ ËÏÈΛ·˜ Î·È Ì ÁÂÓÈ΋ ηٿÛÙ·ÛË Ô˘ ·ÔÙÚ¤ÂÈ ÙËÓ Û˘Ì‚·ÙÈ΋ allo-HCT. ∏ ıÓËÙfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ (TRM) ·Ó¤Ú¯ÂÙ·È Ì¤¯ÚÈ ÙÔ 20%. ∏ ÈÔ Û˘¯Ó‹ ·ÈÙ›· TRM ‹Ù·Ó ÔÈ ÏÔÈÌÒÍÂȘ (45%) Î·È Ë ÔÍ›· ‹ ¯ÚÔÓ›· GVHD (37%).
¡ÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰· ΔÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ·Ú·ÎÔÏÔ˘ı› ηÈ
ÊÚÔÓÙ›˙ÂÈ ÙÔÓ ·ÛıÂÓ‹ ‰È‰¿ÛÎÔÓÙ·˜ ÙÔÓ, ¯ÔÚËÁÒÓÙ·˜ Ê¿Ú̷η, ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·˜ Ù· Û˘ÌÙÒÌ·Ù· ÂÚ¯fiÌÂÓÔ˜ Û ÂÈÎÔÈÓˆÓ›· Ì ٷ ˘fiÏÔÈ· ¿ÙÔÌ· Ù˘ ÔÌ¿‰·˜ ˘Á›·˜. ∏ ÁÓÒÛË Â›Ó·È ÙÔ ‚·ÛÈÎfiÙÂÚÔ ÁÓÒÚÈÛÌ· Ù˘ ÓÔÛËχÙÚÈ·˜ ÁÈ· Ó· ‰È‰¿ÛÎÂÈ ·ÔÙÂÏÂÛÌ·ÙÈο, Ó· ·Ú·ÙËÚ› Ù· Û˘ÌÙÒÌ·Ù· ÛÙË ·Ú¯‹ Î·È Ó· ÂÂÌ‚·›ÓÂÈ ÛÙÔÓ Î·Ù¿ÏÏËÏÔ ¯ÚfiÓÔ. OÈ ·ÛıÂÓ›˜ Ù˘ ÌÔÓ¿‰·˜ ÓÔÛËχÔÓÙ·È ÛÂ Û˘Óı‹Î˜ ·ÔÌfiÓˆÛ˘ Ì ÂȉÈο ‰È·ÌÔÚʈ̤ÓÔ˘˜ ¯ÒÚÔ˘˜ ˘fi Û˘Ó¯‹ ÓËÌ·ÙÔÂȉ‹ ÚÔ‹ ÊÈÏÙÚ·ÚÈṲ̂ÓÔ˘ ·¤Ú·, (Ê›ÏÙÚ· Hepa), ÁÂÁÔÓfi˜ Ô˘ Ê·›ÓÂÙ·È Ó· ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙÔ ÔÛÔÛÙfi ÙˆÓ ÏÔÈÌÒÍÂˆÓ Î·È Î˘Ú›ˆ˜ ·˘ÙÒÓ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ·. ∏ ÏÂÈÙÔ˘ÚÁ›· οı ÌÔÓ¿‰·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ı· Ú¤ÂÈ Ó· ÛÙËÚ›˙ÂÙ·È Û ÂȉÈο ÚˆÙfiÎÔÏÏ· Ù· ÔÔ›· ı· ηıÔÚ›˙Ô˘Ó Â·ÎÚÈ‚Ò˜ ÙÔÓ ÙÚfiÔ ÂÎÙ¤ÏÂÛ˘ fiÏˆÓ ÙˆÓ ‰ÈÂÚÁ·ÛÈÒÓ Î·È ı· ÙËÚÔ‡ÓÙ·È ·fi fiÏ· Ù· ¿ÙÔÌ· Ù˘ ÔÌ¿‰·˜ ˘Á›·˜ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ÊÚÔÓÙ›‰· ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ. ∏ ÚfiÔ‰Ô˜ Ù˘ ÂÈÛÙ‹Ì˘ Î·È Ù˘ Ù¯ÓÔÏÔÁ›·˜ ¿Óˆ ÛÙ· ı¤Ì·Ù· Ù˘ ˘Á›·˜, ¤¯ÂÈ Î¿ÓÂÈ ÈÔ ÂÚ›ÏÔÎÔ ÙÔ ÎÏÈÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ Î·È ÙȘ ‰È·‰Èηۛ˜ ÊÚÔÓÙ›‰·˜ ÙˆÓ ·ÛıÂÓÒÓ. ΔÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi ı· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÙÈ· ÂÎ·È‰Â˘Ì¤ÓÔ Ì ÁÓÒÛÂȘ Î·È ÂÌÂÈÚ›· ÁÈ· Ó· ÌÔÚ¤ÛÂÈ Ó· Û˘Ì‚¿ÏÂÈ Ô˘ÛÈ·ÛÙÈο ÛÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ OÈ ÏÔÈÌÒÍÂȘ Â›Ó·È ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì˘ÂÏÔ‡. OÈ ·ıÔÁfiÓÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ÚÔ¤Ú¯ÔÓÙ·È Â›Ù ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ (Â͈ÁÂÓ›˜) ›Ù ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi ۈϋӷ Î·È ÙÔ ‰¤ÚÌ· (ÂÓ‰ÔÁÂÓ›˜). Δ· ̤ÙÚ· Ô˘ Ï·Ì‚¿ÓÔÓÙ·È ÁÈ· ÙËÓ ÚÔʇϷÍË ·fi ÙȘ ÏÔÈÌÒÍÂȘ ›ӷÈ: • ¡ÔÛËÏ›· ˘fi Û˘Óı‹Î˜ ·ÔÌfiÓˆÛ˘ Û ÂȉÈÎÔ‡˜ ı·Ï¿ÌÔ˘˜ LAF ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÙËÚÔ‡ÓÙ·È ·˘ÛÙËÚ¿ ÔÈ Î·ÓfiÓ˜ ηı·ÚÈfiÙËÙ·˜ Î·È ÛˆÛÙ‹˜ Û˘ÓÙ‹ÚËÛ˘ ÙˆÓ ÂÁηٷÛÙ¿ÛˆÓ. ∞·ÁfiÚ¢ÛË Ê˘ÙÒÓ Î·È ÏÔ˘ÏÔ˘‰ÈÒÓ ÛÙÔ˘˜ ı·Ï¿ÌÔ˘˜ (·Û¤ÚÁÈÏÔ˜, „¢‰ÔÌÔÓ¿‰·) • ÕÛËÙË Ù¯ÓÈ΋ Û οı ¯ÂÈÚÈÛÌfi, Û¯ÔÏ·ÛÙÈÎfi χÛÈÌÔ ¯ÂÚÈÒÓ ÚÈÓ Î·È ÌÂÙ¿ ·fi οı ÂÚÁ·Û›· Î·È ¯Ú‹ÛË Á·ÓÙÈÒÓ Î·È ÚÔÛٷ٢ÙÈ΋˜ Ì¿Ûη˜. • ª¤ÙÚ· ÁÈ· ÙËÓ Û¯ÔÏ·ÛÙÈ΋ ·ÙÔÌÈ΋ ˘ÁÈÂÈÓ‹ Î·È Û˘¯Ófi˜ ÌÈÎÚÔ‚ÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Î·È Ù˘ ¯ÏˆÚ›‰·˜ ÙÔ˘ ·ÚÚÒÛÙÔ˘.
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
• Δ‹ÚËÛË Î·ÓfiÓˆÓ ·ÛÊ·ÏÔ‡˜ ·Ú·Û΢‹˜ ,ÌÂÙ·ÊÔÚ¿˜, Û˘ÓÙ‹ÚËÛ˘ ÙÚÔÊ›ÌˆÓ ·fi fiÏÔ˘˜ fiÛÔ˘˜ ÂÌϤÎÔÓÙ·È (ÚÔÛˆÈÎfi ÔÈΛÔÈ). • Δ‹ÚËÛË ÚˆÙÔÎfiÏÏˆÓ ÊÚÔÓÙ›‰·˜ Î·È ¯Ú‹Û˘ ÙˆÓ ÂÓ‰·ÁÁÂÈ·ÎÒÓ Î·ıÂÙ‹ÚˆÓ ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ‚·ÙfiÙËÙ·˜ Î·È ÙËÓ ·ÔÊ˘Á‹ ÂÈÌfiÏ˘ÓÛ˘ ÙÔ˘˜. • ™˘ÛÙËÌ·ÙÈ΋ ÚÔʇϷÍË Ì ·ÓÙÈ‚ÈÔÙÈο ‹ Ê¿Ú̷η ηٿ ÙˆÓ ÈÒÓ Î·È Ì˘Î‹ÙˆÓ. • ÃÔÚ‹ÁËÛË Á-ÛÊ·ÈÚÈÓÒÓ Î·È ÂÌ‚ÔÏ›ˆÓ. ∞Ó Î·È Û·Ê‹˜ ·fi‰ÂÈÍË Ù˘ ¯ÚËÛÈÌfiÙËÙ·˜ ÙˆÓ ÔÏ˘‰‡Ó·ÌˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ‰ÂÓ ˘¿Ú¯ÂÈ, ÂÓ ÙÔ‡ÙÔȘ ¯ÔÚËÁÔ‡ÓÙ·È ÚÔÊ˘Ï·ÎÙÈο ÂÂȉ‹ ÙÔ Â›Â‰Ô ÙˆÓ ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ ÛÙÔ ·›Ì· ·Ú·Ì¤ÓÂÈ ¯·ÌËÏfi ÁÈ· 3 Ì‹Ó˜ ÂÚ›Ô˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ˘ÂÚ¿ÓÔÛË ÛÊ·ÈÚ›ÓË Î·Ù¿ ÙÔ˘ ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚Ô˘ ÂÏ·ÙÙÒÓÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ‚·ÚÈÒÓ ÏÔÈÌÒÍÂˆÓ ·fi CMV Î·È Ê·›ÓÂÙ·È Ó· ÂÏ·ÙÙÒÓÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ GVHD. ΔÔ ÂÌ‚fiÏÈÔ Î·Ù¿ ÙÔ˘ Ó¢ÌÔÓÈfiÎÔÎÎÔ˘ ¤¯ÂÈ ÚÔÊ˘Ï·ÎÙÈ΋ ·Í›· fiÙ·Ó ‰ÈÂÓÂÚÁÂ›Ù·È Ôχ ÓˆÚ›˜, ¿Óˆ ·fi 6 Ì‹Ó˜ ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ª¤ÚÈÌÓ· ÁÈ· ÈÛ¯˘Ú‹ ·ÓÙÈÂÌÂÙÈ΋ ·ÁˆÁ‹, ÒÛÙÂ Ô ·ÛıÂÓ‹˜ Ó· ÌËÓ Ù·Ï·ÈˆÚËı› ·fi Ó·˘Ù›Â˜ ‹ ÂÌ̤ÙÔ˘˜. ¶Ú¤ÂÈ Ó· ÁÓˆÚ›˙ÂÈ fiϘ ÙȘ ÏÂÙÔ̤ÚÂȘ ÁÈ· ÙÔ Î¿ı ʿÚÌ·ÎÔ Î·È ¤ÙÛÈ Ó· Â›Ó·È Û ı¤ÛË Ó· ·Ú¤Ì‚ÂÈ fiÔÙ ¯ÚÂÈ·ÛÙ›, ÚÔÏ·Ì‚¿ÓÔÓÙ·˜ Ù˘¯fiÓ ·ÚÂÓ¤ÚÁÂȘ. °È· ·Ú¿‰ÂÈÁÌ·, ÂÊfiÛÔÓ ¯ÔÚËÁËı› Busulfan ÛÙÔÓ ·ÛıÂÓ‹, ı· Ú¤ÂÈ ¤ÁηÈÚ· Ó· ‰Ôı› ·ÓÙÈÂÈÏËÙÈ΋ ·ÁˆÁ‹ ÚÔÊ˘Ï·ÎÙÈο. ∫˘ÎÏÔÊÔÛÊ·Ì›‰Ë: ÂÈ‚¿ÏÏÂÙ·È ·˘ÛÙËÚ‹ ηٷ̤ÙÚËÛË ÈÛÔ˙˘Á›Ô˘, ηϋ ÂÓ˘‰¿ÙˆÛË Î·È ¤ÓÙÔÓË ‰ÈÔ‡ÚËÛË. ¶·Ú·ÎÔÏÔ˘ıԇ̠ηٿ ÙË ¯ÔÚ‹ÁËÛË ÙÔÓ ·ÛıÂÓ‹ ÁÈ· ÛËÌ›· ηډȷ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ (‰‡ÛÓÈ·, ‰˘ÛÊÔÚ›·, ÌÂÙ·‚ÔÏ‹ ηډȷÎÔ‡ Ú˘ıÌÔ‡). ¶ÚÔÊ˘Ï·ÎÙÈο ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ‚ÏÂÓÔÁfiÓÔ˘ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ ÔˆÛ‰‹ÔÙ ¯ÔÚËÁԇ̠MESNA Ô˘ ¤¯ÂÈ ÙËÓ ÈηÓfiÙËÙ· Ó· ‰ÂÛ̇ÂÈ ÙÔ˘˜ ÙÔÍÈÎÔ‡˜ ÌÂÙ·‚Ôϛ٘ Ù˘ ΢ÎÏÔÊÔÛÊ·Ì›‰Ë˜ ÛÙ· Ô‡Ú· Î·È ¤ÙÛÈ Ó· ÚÔÏ¿‚Ô˘Ì ›Ûˆ˜ Ì›· ·ÈÌÔÚÚ·ÁÈ΋ ΢ÛÙ›Ùȉ·. ∏ ΢ÎÏÔÛÔÚ›ÓË ·ÚÂÌ‚·›ÓÂÈ ÂȉÈο ÛÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ¿Ì˘Ó·˜ Î·È ÛÙȘ ·ÓÙȉڿÛÂȘ ˘ÂÚ¢·ÈÛıËÛ›·˜ Ô˘ ·Ó·Ù‡ÛÛÔÓÙ·È Ê˘ÛÈÔÏÔÁÈο ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi Û·Ó ·ÓÙ›‰Ú·ÛË ÛÙËÓ ·ÚÔ˘Û›· Û «Í¤ÓˆÓ» ÈÛÙÒÓ. μÔËı¿ÂÈ ÙÔ Í¤ÓÔ fiÚÁ·ÓÔ/ÌfiÛ¯Â˘Ì· Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ Ó· ·ÔÎÙ‹ÛÂÈ ÌfiÓÈÌË ÂÁηٿÛÙ·ÛË. ¶ÚÔÛÔ¯‹ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ IV ¯ÔÚ‹ÁËÛË.
303
Δ· ‰È·Ï‡Ì·Ù· Ì·›ÓÔ˘Ó Û ·ÛÎÔ‡˜ Ô˘ ‰È¤Ô˘Ó ÙȘ ÚԉȷÁڷʤ˜ ·ÛÎÒÓ ÁÈ· ·Ú¿ÁˆÁ· ·›Ì·ÙÔ˜ (ÙÔ ÔÏ˘Ô͢·Èı˘ÏȈ̤ÓÔ Î·ÛÙÔڤϷÈÔ Ô˘ ÂÚȤ¯ÂÙ·È ÛÙÔ Û˘Ì‡Îӈ̷ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·Ó·Ê˘Ï·ÎÙÈΤ˜ ·ÓÙȉڿÛÂȘ ÂÍ·ÈÙ›·˜ ÙÔ˘ È˙‹Ì·ÙÔ˜ Ô˘ ‰ËÌÈÔ˘ÚÁÂ›Ù·È ·fi ÙËÓ ·ÏÏÔ›ˆÛË ÙˆÓ ÎÔÈÓÒÓ Ï·ÛÙÈÎÒÓ ÊÈ·ÏÒÓ). ¶ÚÔÛÔ¯‹: ·Ó Ë ÎÚ·ÙÈÓ›ÓË Â›Ó·È ¿Óˆ ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi, ÂÏ¿ÙÙˆÛË Ù˘ CSP ηٿ 50%. ∂¿Ó Ë ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ Â›Ó·È ¿Óˆ ·fi 2mg/dL, Á›ÓÂÙ·È ‰È·ÎÔ‹ ̤¯ÚÈ ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∂›Â‰· CSP ÌÂÙÚÒÓÙ·È 3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰·. º˘ÛÈÔÏÔÁÈο ›‰· 400800ng/ml. ∏ ΢ÎÏÔÛÔÚ›ÓË Û·Ó Ê¿ÚÌ·ÎÔ ¤¯ÂÈ ÔÏϤ˜ ·ÚÂÓ¤ÚÁÂȘ Î·È ı· Ú¤ÂÈ ÙÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi Ó· ÙȘ ÁÓˆÚ›˙ÂÈ ÁÈ· Ó· ÌÔÚ› ¿ÌÂÛ· Ó· ·ÓÙÈÏËÊı› Î·È Ó· Û˘Ì‚¿ÏÂÈ Ô˘ÛÈ·ÛÙÈο ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ.
∞ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈÎfi˜ ÔÚfi˜ ¢Ú· ηٷÛÙÚ¤ÊÔÓÙ·˜ Ù· Δ-ÏÂÌÊÔ·ÙÙ·Ú· Ù· ÔÔ›· Â›Ó·È ˘Â‡ı˘Ó· ÁÈ· ÔÍ›· ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹ ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ GVHD .
OÏfiÛˆÌË ·ÎÙÈÓÔ‚fiÏËÛË (Δμπ) OÈ Û˘ÓËı¤ÛÙÂÚ˜ ÂÈÏÔΤ˜ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÙÔ ÚÒÙÔ ‰È¿ÛÙËÌ· ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘ TBI ›ӷÈ: Ó·˘Ù›·, ¤ÌÂÙÔÈ, ‰È¿ÚÚÔȘ, ·ÚˆÙ›Ùȉ·, ‰ÂÚÌ·ÙÈÎfi ÂÍ¿ÓıËÌ·, ·ÏˆÂΛ·, ÎfiˆÛË. ¡·˘Ù›· Î·È ¤ÌÂÙÔÈ ·Ú·ÙËÚÔ‡ÓÙ·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ÙÔ ÚÒÙÔ ÎÏ¿ÛÌ· ·ÎÙÈÓÔ‚fiÏËÛ˘ Î·È ˘Ô¯ˆÚÔ‡Ó ÁÚ‹ÁÔÚ· ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ TBI Ì ·Ú¿ÏÏËÏË ¯ÔÚ‹ÁËÛË ·ÓÙÈÂÌÂÙÈÎÒÓ. μÏ¿‚Ë ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÈı‹ÏÈÔ˘ ÚÔηÏÂÈ ‰È¿ÚÚÔȘ Î·È ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ Ô˘ ˘Ô¯ˆÚ› Ì ÙËÓ ·Ó·Á¤ÓÓËÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ (ÂÚ›Ô˘ 10 ̤Ú˜ ·fi ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂڷ›·˜). ∞ÌÊÔÙÂÚfiÏ¢ÚË ·ÚˆÙ›Ùȉ· ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› Ô˘ ˘Ô¯ˆÚ› Û˘Ó‹ıˆ˜ Û 6 ̤Ú˜. ∏ ·ÏˆÂΛ· Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË ÂÓÒ Ë ÂÌÊ¿ÓÈÛË ÙÔ˘ ‰ÂÚÌ·ÙÈÎÔ‡ ÂÍ·Óı‹Ì·ÙÔ˜ Â›Ó·È ÈÔ Û˘¯Ó‹ Î·È ¤ÓÙÔÓË Ì ÙËÓ Û˘Á¯ÔÚ‹ÁËÛË ARA-C ‹ VP16.
ÃÔÚ‹ÁËÛË ÌÔۯ‡̷ÙÔ˜ ŒÏÂÁ¯Ô˜ Ù˘ ‚·ÙfiÙËÙ·˜ Î·È ÙˆÓ ‰‡Ô ·ÚÔ¯ÒÓ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ÊÏ‚ÔηıÂÙ‹Ú·, Ë·ÚÈÓ›˙Ô˘Ì ÙȘ ÁÚ·Ì̤˜ Î·È ÙȘ ÎÚ·Ù¿Ì ·ÓÔȯ٤˜ Ì Normal Saline 9ÅÒ.
304
¢. ANA°Nø™TOY, °. °PAMMA¢A, A. MOYX§IA
∫·Ù·ÛÙÔÏ‹ ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· ·ÏÏÂÚÁÈ΋˜ ·ÓÙ›‰Ú·Û˘. ÃÔÚËÁԇ̠tab Tavor 0.1mg – 1 amp ÈÛ¯˘ÚÔ‡ ·ÓÙÈÂÌÂÙÈÎÔ‡ 1 1/2 amp Promethazine 1amp ¶·Ú·ÎÂÙ·ÌfiÏ˘ Î·È ± 1 amp Pethidine. §‹„Ë ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Û’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤Á¯˘Û˘ , Î·È ·˘ÛÙËÚ‹ ηٷ̤ÙÚËÛË ÈÛÔ˙˘Á›Ô˘. O Ì˘ÂÏfi˜ ¯ÔÚËÁÂ›Ù·È Ì ·Ïfi Û‡ÛÙËÌ· ÔÚÔ‡ ‰ÈfiÙÈ ÛÙÔ Û‡ÛÙËÌ· ÌÂÙ¿ÁÁÈÛ˘ ·Áȉ‡ÔÓÙ·È ÔÏÏ¿ ÌËÙÚÈο Ì˘ÂÏÈο ·ÙÙ·Ú·. ∏ ‰È¿ÚÎÂÈ· Ù˘ ¤Á¯˘Û˘ ÔÈΛÏÂÈ. ¶·Ú·ÎÔÏÔ˘ıÂ›Ù·È Ô ·ÛıÂÓ‹˜ ÁÈ· Ù˘¯fiÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·Î‹˜ ο̄˘ (˘ÂÚÊfiÚÙˆÛË) Î·È ÂÊ’ fiÛÔÓ ÎÚ›ÓÂÙ·È ·˘Í¿ÓÂÙ·È Ë ‰ÈÔ‡ÚËÛË (Lasix IV) ‹ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› Ó· ‰È·Îfi„Ô˘Ì ÙËÓ ¤Á¯˘ÛË Ì¤¯ÚÈ ÙËÓ ·ÔηٿÛÙ·ÛË ÙˆÓ Ù˘¯fiÓ ÚÔ‚ÏËÌ¿ÙˆÓ. ¶ÚÔÛÔ¯‹ ¯ÚÂÈ¿˙ÂÙ·È fiÙ·Ó ¯ÔÚËÁԇ̠ηÙ„˘Á̤ÓÔ ÌfiÛ¯Â˘Ì· ÛÙÔ ¯ÚfiÓÔ ¯ÔÚ‹ÁËÛ˘. ªÂÙ¿ ÙËÓ ·fi„˘ÍË Ù· ·ÙÙ·Ú· Ú¤ÂÈ Ó· ¯ÔÚËÁËıÔ‡Ó Ù·¯‡Ù·Ù·. Δ· ·ÙÙ·Ú· ÌÂÙ¿ ÙËÓ ¤Á¯˘ÛË ·Ú·Ì¤ÓÔ˘Ó ÛÙÔ˘˜ Ó‡ÌÔÓ˜ ÌÈÛ‹ ÒÚ· Î·È Î·ÙfiÈÓ ÌÂÙ·Ó·ÛÙÂ‡Ô˘Ó ÛÙȘ ÔÛÙÈΤ˜ Ì˘ÂÏÔ΢„¤Ï˜ fiÔ˘ Î·È ·Ó·Ù‡ÛÛÔÓÙ·È. OÈ ·ÚÂÓ¤ÚÁÂȘ Ô˘ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó Â›Ó·È Ú›ÁÔ˜, ˘ÂÚ˘ÚÂÍ›·, ÂÌÂÙfi˜, ÎÔÈÏȷο ¿ÏÁË, ‰È¿ÚÚÔÈ·, ÎÂÊ·Ï·ÏÁ›·, ˘¤ÚÙ·ÛË Î·È ‚Ú·‰˘Î·Ú‰›·. ªÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ·ÈÌÔÛÊ·ÈÚÈÓÔ˘Ú›·, Ô˘ ··ÈÙ› ÂÍÒıËÛË Ù˘ ‰ÈÔ‡ÚËÛ˘ ÒÛÙ ӷ ·ÔʇÁÔ˘Ì ÙËÓ ÛˆÏËÓ·Úȷ΋ ·fiÊÚ·ÍË Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÔÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·. ¢Â›ÁÌ·Ù· Ì˘ÂÏÔ‡ ÁÈ· ηÏÏȤÚÁÂȘ, ηıÒ˜ ›Û˘ Î·È Î·Ù·Ì¤ÙÚËÛ˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ, ·ÔÛÙ¤ÏÏÔÓÙ·È ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ·fi οı ·ÛÎfi Ô˘ ¯ÔÚËÁÔ‡ÌÂ.
ªÂÙ·ÁÁ›ÛÂȘ ∏ ∞μO ·Û˘Ì‚·ÙfiÙËÙ· ‰ÂÓ Â›Ó·È ÊÚ·ÁÌfi˜ ÛÙËÓ ·ÏÏÔÁÂÓ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ,fiˆ˜ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ Î·È Ù· ·Ú¿ÁˆÁ· ·›Ì·ÙÔ˜ ÛÙȘ ÌÂÙ·ÁÁ›ÛÂȘ ‰›ÓÔÓÙ·È ·Ó¿ÏÔÁ·. ŒÏÂÁ¯Ô˜ ·ÈÌÔÛ˘ÁÎÔÏÏËÙÈÓÒÓ Î·È Coombs (ABO ·Û˘Ì‚·ÙfiÙËÙ· - ·ÏÏ·Á‹ ÔÌ¿‰·˜ ·›Ì·ÙÔ˜). ¢ÂÓ ÚÔÙÈÌÒÓÙ·È ÁÈ· ‰fiÙ˜ ÔÈ ÛÙÂÓÔ› Û˘ÁÁÂÓ›˜ (ÁÔÓ›˜, ·‰¤ÏÊÈ·) ‰ÈfiÙÈ ÛÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ ·˘Í¿ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ ·ÏÏÔ·ÓÔÛÔÔ›ËÛ˘. °È· Ó· ·ÔʇÁÔ˘Ì ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ·fi ÙȘ ÌÂÙ·ÁÁ›ÛÂȘ, ÚÔÛ·ıԇ̠ӷ ÂÚÈÔÚ›ÛÔ˘Ì ÙȘ ÌÂÙ·ÁÁ›ÛÂȘ. Δ· ·Ú¿ÁˆÁ· ÙÔ˘ ·›Ì·ÙÔ˜ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÛÙËÓ ÂÚ›Ô‰Ô Ù˘ ·Ï·Û›·˜ ·ÎÙÈÓÔ‚ÔÏÔ‡ÓÙ·È ÛÂ
‰fiÛË 2500 – 4000 rads, Ì ÛÎÔfi ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ô˘ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ·ÓÙ›‰Ú·ÛË ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ˘ ÍÂÓÈÛÙ‹ (GVHD). ∂›Û˘ ı· Ú¤ÂÈ Ó· ¤¯Ô˘Ó ··ÏÏ·Á› ·fi Ù· ÏÂÌÊÔ·ÙÙ·Ú· ÏfiÁˆ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ù˘ ·ÓÙÈ-HLA ·ÏÏÔ·ÓÔÛÔÔ›ËÛ˘ Ô˘ ÚÔηÏÔ‡Ó. ∞˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ¯Ú‹ÛË ÂȉÈÎÒÓ Ê›ÏÙÚˆÓ Î·Ù·ÎÚ¿ÙËÛ˘ Ï¢ÎÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·Ù¿ ÙË ÌÂÙ¿ÁÁÈÛË. ™‹ÌÂÚ· Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· ·fi ÙËÓ ·ÈÌÔ‰ÔÛ›· Ë ÏÂ˘Î·Ê·›ÚÂÛË Ô˘ Á›ÓÂÙ·È ÛÙÔ˘˜ ·ÛÎÔ‡˜ ·ÈÌÔÂÙ·Ï›ˆÓ ·fi ‰fiÙ˜, Ó· Á›ÓÂÙ·È Î·È ÛÙ· Û˘Ì˘Îӈ̤ӷ ÂÚ˘ıÚ¿. ΔÔ ÎfiÛÙÔ˜ ‚¤‚·È· ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ Ê›ÏÙÚˆÓ ·fi Ù· ·Ú¿ ÙË ÎÏ›ÓË Â›Ó·È ˘„ËÏfiÙÂÚÔ ·ÏÏ¿ ·Ó Ï¿‚Ô˘Ì ˘fi„Ë fiÙÈ Ì ÙÔÓ ÙÚfiÔ ·˘Ùfi ·ÊÂÓfi˜ ÂÏ·¯ÈÛÙÔÔÈÂ›Ù·È Ô Î›Ó‰˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ÏÔÈÌÒÍÂˆÓ ·fi Ï¿ıÔ˜ ¯ÂÈÚÈÛÌÔ‡˜ ÙÔ˘ ÓÔÛËÏ¢ÙÈÎÔ‡ ÚÔÛˆÈÎÔ‡, ·ÊÂÙ¤ÚÔ˘ ‰Â ÂÍÔÈÎÔÓÔÌÂ›Ù·È ¯ÚfiÓÔ˜ ÁÈ· Ó· ·ÍÈÔÔÈËı› ˘¤Ú Ù˘ ÓÔÛËÏ¢ÙÈ΋˜ ÊÚÔÓÙ›‰·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë. Δ· ·Ú¿ÁˆÁ· ÂϤÁ¯ÔÓÙ·È, ÂÎÙfi˜ ÙˆÓ ¿ÏψÓ, ÁÈ· CMV (΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi) Î·È ı· Ú¤ÂÈ Ó· Â›Ó·È ·ÚÓËÙÈο ÂÍ·ÈÙ›·˜ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÏÔÈÌÒ͈Ó. ∂Èı˘ÌËÙfi Â›Â‰Ô Ht > 30%. Δ· ·ÈÌÔÂÙ¿ÏÈ· Ô˘ ¯ÔÚËÁԇ̠ÚÔÛ·ıԇ̠ӷ Â›Ó·È Ù˘ ›‰È·˜ ÔÌ¿‰·˜ (·ÔÊ˘Á‹ ¢·ÈÛıËÙÔÔ›ËÛ˘). ∂Èı˘ÌËÙfi Â›Â‰Ô ·ÈÌÔÂÙ·Ï›ˆÓ > = 30000. ÀÂÓı˘Ì›˙ÂÙ·È fiÙÈ 1 ‰ÈÂıÓ›˜ ÌÔÓ¿‰· ·Ó¿ 7kgr (·Ó¿ 5kgr Û ·È‰È¿) ·Ó‚¿˙ÂÈ Ù· ·ÈÌÔÂÙ¿ÏÈ· ·fi 50000 Û 100000. ΔÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi Â›Ó·È ·˘Ùfi Ô˘ Â›Ó·È fiÏÔ ÙÔ 24ˆÚÔ ‰›Ï· ÛÙÔÓ ·ÛıÂÓ‹ Î·È Â›Ó·È ÛËÌ·ÓÙÈ΋ Ë Û˘Ì‚ÔÏ‹ ÙÔ˘ ÛÙËÓ ¿ÚÙÈ· Î·È ÔÈÔÙÈ΋ ÓÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰· ηıÒ˜ Î·È ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÈÏÔÎÒÓ. ∏ ·Ú·ÎÔÏÔ‡ıËÛË, Ë Î·Ù·ÁÚ·Ê‹ Î·È ·ÍÈÔÏfiÁËÛË ÔÔÈÔ˘‰‹ÔÙ ÚÔ‚Ï‹Ì·ÙÔ˜ Ô˘ ·Ó·Ê¤ÚÂÈ Ô ·ÛıÂÓ‹˜ ı· ‚ÔËı‹ÛÂÈ ÛÙÔ Ó· Á›ÓÂÈ ¤ÁηÈÚ· Ë ‰È¿ÁÓˆÛË Î·È Ó· ·ÓÙÈÌÂÙˆÈÛÙ› ηٿÏÏËÏ· Î·È ¿ÌÂÛ· Ë ÔÔÈ·‰‹ÔÙ ÂÈÏÔ΋. ¶·Ú¿ÏÏËÏ· fï˜ ‰ÂÓ Ú¤ÂÈ Ó· ͯӿÌ fiÙÈ Â›Ó·È ¯Ú¤Ô˜ ÙÔ˘ οı ̤ÏÔ˘˜ Ù˘ ÔÌ¿‰·˜ ˘Á›·˜ Ó· ÙËÚ› ·˘ÛÙËÚ¿ ÙÔ˘˜ ηÓfiÓ˜ ÚÔÛÙ·Û›·˜ Î·È ·ÛÊ¿ÏÂÈ·˜ ÙˆÓ ÂÚÁ·˙ÔÌ¤ÓˆÓ ÒÛÙ ӷ ÚÔÊ˘Ï¿ÛÛÂÙ·È Î·È Ó· ÌÔÚ› Ó· ÚÔÛʤÚÂÈ Î·È Ó· ·Ô‰›‰ÂÈ Ù· ̤ÁÈÛÙ· ÚÔ˜ fiÊÂÏÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÂÓÒ Ë Û˘Ó¯‹˜ Âη›‰Â˘ÛË Î·È ÂÓË̤ڈÛË ı· ÙÔÓ Î·Ù·ÛÙ‹ÛÔ˘Ó ÈηÓfi
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ó· ·ÓÙÈÌÂÙˆ›˙ÂÈ Î·È Ó· ·ÓÙÂÂͤگÂÙ·È Ì ¿ÓÂÛË ÛÙÔ ‰‡ÛÎÔÏÔ Ú·ÁÌ·ÙÈο Î·È Ôχ ›ÔÓÔ ¤ÚÁÔ ÙÔ˘.
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EÏÏËÓÈ΋ TÚ¿Â˙· OÊı·ÏÌÒÓ: AÚ¯¤˜ ÏÂÈÙÔ˘ÚÁ›·˜
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∏ ÈÛÙÔÚ›· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙËÓ OÊı·ÏÌÔÏÔÁ›· ÍÂÎÈÓÒ ÙÔ 1906 ÔÙ·Ó ÚÒÙÔ˜ Ô Eduard Zirm οÓÂÈ ÙËÓ ÚÒÙË ·˘ÙÔÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·ÛıÂÓ‹. ΔÔ 1930 Ô Filatov ÚÔÙ›ÓÂÈ ÙËÓ ¯Ú‹ÛË ÙˆÌ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∞˘Ùfi ı· ‘¯·Ú›ÛÂÈ’ ÂÚÈÛÛfiÙÂÚ· ÌÔۯ‡̷ٷ ·ÏÏ¿ Î·È ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚfiÓÔ ÁÈ· Â͇ÚÂÛË Î·È ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ ‰¤ÎÙË. ΔÔ Úfi‚ÏËÌ· fï˜ Ù˘ ¶·Ú’fiÏ· ·˘Ù¿ fï˜ ˘‹Ú¯Â Úfi‚ÏËÌ· ÂÈÙ˘¯›·˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÁÂÁÔÓfi˜ Ô˘ Ô‰ËÁÔ‡Û ÛÙËÓ ·Ó¿ÁÎË ÂϤÁ¯Ô˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÒÛÙ ϤÔÓ Ó· ÌÂÙ·ÌÔۯ‡ÔÓÙÔ ÌÔۯ‡̷ٷ ηٿÏÏËÏ· Î·È ·ÛÊ·Ï‹. ∏ χÛË ·˘ÙÔ‡ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ‰fiıËΠ̠ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ÙÔ 1945 ·fi ÙÔÓ Paton Ù˘ ÚÒÙ˘ ΔÚ¿Â˙·˜ OÊı·ÏÌÒÓ. ™ÎÔfi˜ Ù˘ ΔÚ¿Â˙·˜ OÊı·ÏÌÒÓ ‹Ù·Ó Ë Û˘ÏÏÔÁ‹, Ô ¤ÏÂÁ¯Ô˜, Ë Û˘ÓÙ‹ÚËÛË Î·È Ë ‰È·ÓÔÌ‹ ÌfiÓÔÓ ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŒÎÙÔÙ ‰ËÌÈÔ˘ÚÁ‹ıËÎ·Ó Î·È ÏÂÈÙÔ˘ÚÁÔ‡Ó ΔÚ¿Â˙˜ OÊı·ÏÌÒÓ Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ. O ·ÚÈıÌfi˜ ÙÔ˘˜ ·˘Í¿ÓÂÙ·È Û˘Ó¯Ҙ ÂÓÒ ˘¿Ú¯Ô˘Ó Û˘Ó¯›˜ ÂÍÂÏ›ÍÂȘ fiÛÔÓ ·ÊÔÚ¿ ÙÔ˘˜ ηÓÔÓÈÛÌÔ‡˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜ Î·È ÙˆÓ È·ÙÚÈÎÒÓ standards Ù· ÔÔ›· ·˘Ù¤˜ ·ÎÔÏÔ˘ıÔ‡Ó. OÈ ÛÙfi¯ÔÈ ÙˆÓ Û‡Á¯ÚÔÓˆÓ ΔO ·Ú·Ì¤ÓÔ˘Ó ÔÈ ›‰ÈÔÈ, Ë ·‡ÍËÛË ‰ËÏ·‰‹ Ù˘ ·ÛÊ¿ÏÂÈ·˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙÔ˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·ıÒ˜ Î·È ÈηÓfi ·fiıÂÌ· ·˘ÙÒÓ ÒÛÙ ӷ ηχÙÔÓÙ·È ÔÈ ·Ó¿ÁΘ ÙˆÓ ÏËı˘ÛÌÒÓ. ∏ ‰È·ÓÔÌ‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Á›ÓÂÙ·È Ì¤Û· ·fi Ù· ‰›ÎÙ˘· ÙˆÓ Δ.O. Ô˘, ·ÏˆÌ¤Ó· Û fiÏÔ ÙÔÓ ÎfiÛÌÔ, ˘ÂÚ‚·›ÓÔ˘Ó Ù· Û‡ÓÔÚ· ÙÔ˘ ÎÚ¿ÙÔ˘˜ ÛÙ· ÔÔ›· ·Ó‹ÎÔ˘Ó. ™‹ÌÂÚ· 100 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÎÂÚ·ÙÔ‰ȉԇ˜ Î·È ÙËÓ ¯Ú‹ÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ¯ˆÚ›˜ ηӤӷ ÔÈÔÙÈÎfi ¤ÏÂÁ¯Ô ηٷÏÏËÏfiÙËÙÔ˜ Î·È ·ÛÊ·Ï›·˜, Ù›ıÂÓÙ·È ÔÈ Ó¤ÔÈ ÛÙfi¯ÔÈ ÒÛÙ ηÌÌ›· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó· ÌËÓ Â›Ó·È ‰˘Ó·Ù‹ ÛÙÔ Ì¤ÏÏÔÓ ¯ˆÚ›˜ ÙÔ ÌfiÛ¯Â˘Ì· Ó· ¤¯ÂÈ ÈÛÙÔÔÈËÙÈÎfi ηٷÏÏËÏfiÙËÙÙÔ˜ ÙÔ ÔÔ›Ô ı· ·Ú¤¯ÂÙ·È ·fi ÙÔ ÂȉÈÎfi ΤÓÙÚÔ ÂϤÁ¯Ô˘, ‰ËÏ·‰‹, ÙËÓ ÈÛÙÔÔÈË̤ÓË ΔÚ¿Â˙· OÊı·ÏÌÒÓ (Δ.O.) Î·È ÌfiÓÔÓ. ™ÙËÓ ÛËÌÂÚÈÓ‹ ∂˘Úˆ·˚΋ ∂ÓˆÛË ıÂÛ›˙ÔÓÙ·È
Ó¤ÔÈ ÎÔÈÓÔ› ÓfiÌÔÈ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ‰È·‰Èηۛ· Û˘ÏÏÔÁ‹˜, ÂϤÁ¯Ô˘ ηٷÏÏËÏfiÙËÙÔ˜, Î·È ‰È¿ıÂÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜. ŸÏ˜ ÔÈ Δ.O. ÙˆÓ ÎÚ·ÙÒÓ Ù˘ ∂˘Úˆ·˚΋˜ ∂ÓÒÛˆ˜ ÁÈ· Ó· Á›ÓÔ˘Ó Ì¤ÏË Ù˘ ∂˘Úˆ·È΋˜ ŒÓˆÛ˘ ΔÚ·Â˙ÒÓ (∂∂μ∞) ı· Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡Ó ÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ ‰È·‰Èηۛ˜ Î·È Ó· ˘fiÎÂÈÓÙ·È ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ ÓÔÌÈΤ˜ ‰È·Ù¿ÍÂȘ Ô˘ ·ÊÔÚÔ‡Ó ÙÔÓ ÙÚfiÔ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜. ΔÔ ÏÂÔÓ¤ÎÙËÌ· ÙˆÓ ÂÓÔÔÈËÌ¤ÓˆÓ ÎÔÈÓÒÓ Ô‰ËÁÈÒÓ Â›Ó·È Ë ·ÚÔ¯‹ Û fiÏË Ù˘ ÂÈÎÚ¿ÙÂÈ· Ù˘ ∂.∂. ÈÛÙÒÓ Î·Ù¿ÏÏËÏˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÏÏ¿ Î·È Ï‹Úˆ˜ ÂÏÂÁÌ¤ÓˆÓ ·fi ¿Ô„Ë ·ÛÊ¿ÏÂÈ·˜. ∞fi ÙËÓ ÛÙÈÁÌ‹ Ô˘ Ô ÎÂÚ·ÙÔÂȉ‹˜ Â›Ó·È ÈÛÙfi˜ Ô˘ ÌÔÚ› Ó· ‰È·ÙËÚËı› ÁÈ· ̤Ú˜ Ú›Ó Ó· ÌÂÙ·ÌÔÛ¯Â˘ı› Â›Ó·È ÏÔÁÈÎfi Ó· ˘¿Ú¯ÂÈ ÙÔ ¯ÚÔÓÈÎfi ÂÚÈıÒÚÈÔ ÁÈ· ÙËÓ Ï‹ÚË ·ÍÈÔÏfiÁËÛ‹ ÙÔ˘ Î·È ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ηٷÏÏËÏfiÙËÙfi˜ ÙÔ˘. ∏ ¢ı‡ÓË fiÏˆÓ ÙˆÓ ÓÔÌ›ÌˆÓ Δ.O. ı· Â›Ó·È Ë Ï‹„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ηٿÏÏËÏÔ˘˜ ‰fiÙ˜ Î·È Ë ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÌË Î·Ù¿ÏÏËψÓ, Ô ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ‰fiÙÔ˘ ÒÛÙ ӷ ·ÔÎÏÂÈÛÙ› Ë Èı·ÓfiÙËÙ· ÌÂÙ·‰ÔÙÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ Ì ÛÎÔfi Ó· ·ÔÊ¢¯ı› Ô ˘ÊÈÛÙ¿ÌÂÓÔ˜ ΛӉ˘ÓÔ˜ ÌÔχÓÛˆ˜ ÙÔ˘ ‰¤ÎÙÔ˘, Ë ‰È·Ù‹ÚËÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙ· ϤÔÓ Î·Ù¿ÏÏËÏ· ıÚÂÙÈο ˘ÏÈο, Ô ¤ÏÂÁ¯Ô˜ Ù˘ ηٷÏÏËÏfiÙËÙÔ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ë ÈÛÙÔÔ›ËÛ‹ ÙÔ˘ Î·È Ù¤ÏÔ˜ Ë ‰È·ÓÔÌ‹. ∫¿ı ÓfiÌÈÌË Δ.O. ı· ÏÂÈÙÔ˘ÚÁ› οو ·fi ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÂÓÓÈ·›Ô ÓÔÌÈÎfi Ï·›ÛÈÔ ÙÔ ÔÔ›Ô Î·È ÙÂÏÈο ı· Ú˘ıÌ›˙ÂÈ fiÏ· Ù· ı¤Ì·Ù· ÏÂÈÙÔ˘ÚÁ›·˜ ·ÏÏ¿ Î·È ËıÈο ˙ËÙ‹Ì·Ù· Ô˘ ÚÔ·ÙÔ˘Ó Û ۯ¤ÛË Ì ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÈÛÙÒÓ. ∂ÈÚfiÛıÂÙ· ÙÔ ÚÔÛˆÈÎfi Ô˘ ÂÚÁ¿˙ÂÙ·È ÛÙȘ Δ.O. ı· Ú¤ÂÈ Ó· ¤¯ÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂȉÈ΋ ·Ú¯È΋ Âη›‰Â˘ÛË ·Ó¿ÏÔÁ· Ì ÙÔ Â‰›Ô ÛÙÔ ÔÔ›Ô ı· ··Û¯ÔÏ›ٷÈ. H ÚÔÛ¿ıÂÈ· ·˘Ù‹ Ô˘ Á›ÓÂÙ·È ·fi ÙËÓ ∂.∂. ¤¯ÂÈ Î·È ÙÔÓ ·ÓÙ›ÏÔÁfi Ù˘. ¶ÈÛÙ‡ÂÙ·È ÔÙÈ ·Ú¿ ÙȘ ıÂÙÈΤ˜ ηÙ¢ı‡ÓÛÂȘ Î·È ÛÙfi¯Ô˘˜ Ô˘ ¤¯ÂÈ ı¤ÛÂÈ,, ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο ÙÔ ÎfiÛÙÔ˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÈ·˜
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Δ.O,. ··›Ù› ÂÍÂȉÈÎÂ˘Ì¤ÓÔ ÚÔÛˆÈÎfi Î·È ·˘Í¿ÓÂÈ Î·Ù·ÎfiÚ˘Ê· ÙÔ ÁÚ·ÊÂÈÔÎÚ·ÙÈÎfi ÊÔÚÙ›Ô ÙˆÓ ÁÈ·ÙÚÒÓ Ô˘ ÏÂÈÙÔ˘ÚÁÔ‡Û·Ó ÙȘ Δ.O Ì ÔÈfi ÂϤ˘ıÂÚÔ ÙÚfiÔ. ™ÙË ¯ÒÚ· Ì·˜ ·fi ÙÔ 1983 ÏÂÈÙÔ˘ÚÁ› ÛÙËÓ OÊı·ÏÌÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞ÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢, Ë ªÔÓ¿‰· ªÂÙ·ÌfiÛ¯Â˘Û˘ ∫ÂÚ·ÙÔÂȉԇ˜ Î·È Ë ÚÒÙË Î·È ÌfiÓË Ì¤¯ÚÈ Û‹ÌÂÚ· ∂ÏÏËÓÈ΋ ΔÚ¿Â˙· OÊı·ÏÌÒÓ, Ë ÔÔ›· ·Ó·ÁÓˆÚ›ÛÙËΠ›ÛËÌ· ·fi ÙÔ ∂ÏÏËÓÈÎfi ∫Ú¿ÙÔ˜ ÙÔ 1992. ΔÔ ÀÔ˘ÚÁÂ›Ô ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ‰ËÌÔÛȇÂÈ ÛÙËÓ ÂÊËÌÂÚ›‰· Ù˘ ΢‚ÂÚÓ‹Ûˆ˜ (º∂∫ 708/μ/1-12-1992) ÙËÓ ›‰Ú˘ÛË Î·È ÏÂÈÙÔ˘ÚÁ›· Ù˘ ∂ÏÏËÓÈ΋˜ ΔÚ¿Â˙·˜ OÊı·ÏÌÒÓ (∂.Δ.O.) Ì ¤‰Ú· ÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ OÊı·ÏÌÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞.¶.£. ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞. ΔÔ ›‰ÈÔ ¤ÙÔ˜, 1992, Ë ∂.Δ.O. ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô Ù˘ ¢ÈÂıÓÔ‡˜ ŒÓˆÛ˘ ΔÚ·Â˙ÒÓ OÊı·ÏÌÒÓ ÂÓÙ¿ÛÛÂÙ·È ˆ˜ Ï‹Ú˜ ̤ÏÔ˜ Ù˘ ∂ÓˆÛ˘ (πF∂EB: International Federation of Eye Banks) ÁÈ·Ù› ‹‰Ë ·fi ÙÔ 1985 Ë ∂.Δ.O. ›¯Â ÔÚÁ·Óˆı› Î·È ÏÂÈÙÔ˘ÚÁÔ‡Û ۇÌʈӷ Ì ÙȘ ‰ÈÂıÓ›˜ ÚԉȷÁڷʤ˜.. Δ¤ÏÔ˜ ÙÔ 1996 Ë ∂.Δ.O. Á›ÓÂÙ·È Ì¤ÏÔ˜ Ù˘ ∂˘Úˆ·˚΋˜ ∂ÓˆÛ˘ ΔÚ·Â˙ÒÓ OÊı·ÏÌÒÓ. OÈ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ù˘ ∂.Δ.O. ‰È·ÈÚÔ‡ÓÙ·È Û ‰‡Ô ÌÂÁ¿Ï˜ ηÙËÁÔڛ˜. ΔËÓ ‰È·‰Èηۛ· ·fi ÙËÓ Ï‹„Ë ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È Ì¤¯ÚÈ ÙË ÌÂÙ·ÊÔÚ¿ ÙÔ˘˜ ÛÙÔÓ ¯ÒÚÔ Ù˘ ∂.Δ.O. Î·È ÔÈ ÂÚ·ÈÙ¤Úˆ ‰È·‰Èηۛ˜ ̤¯ÚÈ ÙËÓ ÙÂÏÈ΋ ·ÔÛÙÔÏ‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∫·Ó¤Ó· ÌfiÛ¯Â˘Ì· ‰ÂÓ ÌÔÚ› Ó· ÏËÊı› Â¿Ó ÚÒÙ· ‰ÂÓ ˘ÔÁÚ·Ê› ‹ ‰‹ÏˆÛË Û˘ÁηٿıÂÛ˘ ‰ˆÚ¿˜. ∏ ‰‹ÏˆÛË ‰ˆÚ¿˜ ·fi ÙÔ˘ Û˘ÁÁÂÓ›˜ ÙÔ˘ ‰fiÙÔ˘ Â›Ó·È ··Ú·›ÙËÙË ·ÎfiÌË Î·È Â¿Ó Ô ‰fiÙ˘ Â›Ó·È ‰ˆÚËÙ‹˜ ÔÚÁ¿ÓˆÓ. ªÂÙ¿ ÙËÓ Ï‹„Ë, Ù· ÌÔۯ‡̷ٷ ÌÂٷʤÚÔÓÙ·È ÛÙÔ ¯ÒÚÔ Ù˘ Δ.O.. ∂Λ ·ÎÔÏÔ˘ıÔ‡ÓÙ·È Û˘ÁÎÂÎÚÈ̤Ó˜ ‰È·‰Èηۛ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ Ù·˘ÙÔÔ›ËÛË, ÂÂÍÂÚÁ·Û›· Î·È Û˘ÓÙ‹ÚËÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÙËÓ ÚÔÂÙÔÈÌ·Û›· Ù˘ ·ÔÛÙÔÏ‹˜ Î·È Ù¤ÏÔ˜ ÙËÓ ÌÂÙ·ÊÔÚ¿ Î·È ·Ú¿‰ÔÛ‹ ÙÔ˘˜ ÚÔ˜ ¯Ú‹ÛË ÛÙ· ηٿÏÏËÏ· ΤÓÙÚ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ∂.Δ.O. ˘Ô¯ÚÂÔ‡Ù·È Î·È ·ÎÔÏÔ˘ı› ÙËÓ ‰È·‰Èηۛ· tracking, ·Ú·ÎÔÏÔ‡ıËÛ˘ ‰ËÏ·‰‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ‰fiÙË ÛÙÔ ‰¤ÎÙË Î·È ‰È·ÙËÚ› ·Ú¯Â›· Ù· ÔÔ›· Â›Ó·È ÂÌÈÛÙ¢ÙÈο. Δ· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙÔ˘ ‰fiÙÔ˘ Â›Ó·È ·˘ÛÙËÚ¿ Î·È ¤¯Ô˘Ó ˆ˜ ÛÎÔfi ÙËÓ ·ÚÔ¯‹ ·ÛÊ·ÏÔ‡˜ ÌÔۯ‡̷ÙÔ˜ ÙfiÛÔ ÁÈ· ÙÔÓ ‰fiÙË fiÛÔ Î·È ÁÈ· ÙÔ ··Û¯ÔÏÔ‡ÌÂÓÔ ÚÔÛˆÈÎfi. ™Ù· Ï·›ÛÈ· ·˘Ù¿ Á›ÓÂÙ·È ÏÂÙÔÌÂÚ‹˜ ηٷÁÚ·Ê‹ ÙÔ˘ È·ÙÚÈÎÔ‡ Î·È ÎÔÈÓˆÓÈÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ÙÔ˘ ‰fiÙÔ˘. ∂·Ó ÚÔ·„Ô˘Ó Â˘Ú‹Ì·-
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Ù· Ô˘ ·ÔÙÂÏÔ‡Ó ‰˘ÓËÙÈÎfi ΛӉ˘ÓÔ ÁÈ· ÙÔ ÚÔÛˆÈÎfi Ù˘ ΔÚ¿Â˙·˜ Ù· ÌÔۯ‡̷ٷ ·ÔÚÚ›ÙÔÓÙ·È. ™ÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹ ·Ó‹ÓÂÈ Ë ÂÓÂÚÁfi˜ ÈÔÁÂÓ‹˜ Ë·Ù›ÙȘ, ÙÔ Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·Ó¿ÚÎÂÈ·˜ (AIDS) ‹ ÔÚÔıÂÙÈ΋ ·ÓÙ›‰Ú·ÛË HIV, Ë ÂÓÂÚÁfi˜ ÈÔÁÂÓ‹˜ ÂÎÂÊ·Ï›Ùȉ· ‹ ÂÁÎÂÊ·Ï›Ùȉ· ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜, Ë ÓfiÛÔ˜ Cruetzfeldt – Jacob, Ë Ï‡ÛÛ·.. ¢fiÙ˜ Ì ÙȘ ·ÎfiÏÔ˘ı˜ ηٷÛÙ¿ÛÂȘ Ô˘ ·ÔÙÂÏÔ‡Ó ‰˘ÓËÙÈÎfi ΛӉ˘ÓÔ ÁÈ· ÙÔ˘˜ ‰¤ÎÙ˜ ‹ ı¤ÙÔ˘Ó Û ΛӉ˘ÓÔ ÙËÓ ÂÈÙ˘¯›· Ù˘ ¤̂·Û˘ ‰ÂÓ ı· Ú¤ÂÈ Ó· ‰È·Ù›ıÂÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. £¿Ó·ÙÔ˜ ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜, ·ı‹ÛÂȘ ∫.¡.™. ‰˘Ó¿ÌÂÓ˜ Ó· ÌÂÙ·‰ÔıÔ‡Ó (¡fiÛÔ˜ Cruetzfeldt – Jacob, ˘ÔÍ›· ÛÎÏËÚ˘ÓÙÈ΋ ·ÓÂÁÎÂÊ·Ï›Ùȉ·, ÚÔ˚Ô‡Û· ÔÏ˘ÂÛÙȷ΋ Ï¢ÎÔÂÁÎÂÊ·ÏÔ¿ıÂÈ·, ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜ ÂÎÊ˘ÏÈÛÙÈ΋ ÓfiÛÔ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. §‹„Ë ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ·ÓıÚÒÈÓ˘ ÚÔ¤Ï¢Û˘ (pit-hGH) ηٿ ÙËÓ ‰È¿ÚÎÂÈ· 1963-1985, Ï‹„Ë ÛÎÏËÚ¿˜ Ì‹ÓÈÁÁÔ˜). §ÔÈÌÒÍÂȘ ÌË ÂÏÂÁ¯fiÌÂÓ˜ ηٿ ÙÔÓ ¯ÚfiÓÔ Ù˘ ‰ˆÚ¿˜, Û‡Ó‰ÚÔÌÔ ∂›ÎÙËÙ˘ ∞ÓÔÛÔ·Ó¿ÚÎÂÈ·˜ (AIDS), ¤ÓÂÛË ‹ ¤ÎıÂÛË Û ÙÔÍÈ΋ Ô˘Û›· Ô˘ ÌÔÚ› Ó· ÌÂÙ·‰Ôı› Û ÙÔÍÈ΋ ‰fiÛË ÛÙÔÓ ‰¤ÎÙË, Û˘ÁÁÂÓ‹˜ ÂÚ˘ıÚ¿, Û‡Ó‰ÚÔÌÔ Reyes, ÓÂÔÏ¿ÛÌ·Ù· ·ÈÌÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∂›Û˘, ÈÛÙÔÚÈÎfi, ÎÏÈÓÈΤ˜ ÂӉ›ÍÂȘ ‹ ıÂÙÈΤ˜ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ÁÈ· HIV (ÂӉ›ÍÂȘ ÌfiÏ˘ÓÛ˘ HIV-I ‹ HIV-II, HIV ÔÚÔıÂÙÈÎÔ›. ¶·È‰È¿ (οو ÙˆÓ 13 ÂÙÒÓ) ‹ ‚Ú¤ÊË ·fi ÌËÙ¤Ú· Ì AIDS ‹ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÌfiÏ˘ÓÛ˘ Ì HIV), OÍ›· ‹ ¯ÚfiÓÈ· Ë·Ù›Ùȉ·. (¢fiÙ˜ ıÂÙÈÎÔ› ÛÙÔ ÂÈÊ·ÓÂÈ·Îfi ·ÓÙÈÁfiÓÔ Ù˘ Ë·Ù›ÙȉԘ μ, ÔÚÔıÂÙÈÎÔ› Û ˷ٛÙȉ· C). ø˜ ÂÎ ÙÔ‡ÙÔ˘ Â›Ó·È ··Ú·›ÙËÙ˜ ÔÈ ÔÚÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÙÔ˘ ‰fiÙÔ˘. OÈ ¤ÏÂÁ¯ÔÈ Á›ÓÔÓÙ·È ·fi ÙÔ ÂȉÈÎfi Û˘ÓÂÚÁ·˙fiÌÂÓÔ ÂÚÁ·ÛÙ‹ÚÈÔ Ù˘ ∂.Δ.O. Ô˘ ÏËÚ› Ù· ·ÓÙ›ÛÙÔȯ· ÎÚÈÙ‹ÚÈ· Î·È ÎÚÈÙ‹ÚÈ· ÂϤÁ¯Ô˘ Ù˘ ·ÍÈÔÈÛÙ›·˜ Î·È Î·Ù·ÏÏËÏfiÙËÙ·˜ ÙˆÓ ·ÓÙȉڷÛÙËÚ›ˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È. OÈ ÔÚÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ Á›ÓÔÓÙ·È ·ÔÎÏÂÈÛÙÈο ·fi ÙÔÓ ÔÚfi ‹ ÙÔ Ï¿ÛÌ· ÙÔ˘ ‰fiÙÔ˘. ™Â ıÂÙÈÎfi ÔÚÔÏÔÁÈÎfi ·ÔÙ¤ÏÂÛÌ· ·ӷϷ̂¿ÓÂÙ·È ‰È˜ Ë ›‰È· ‰È·‰Èηۛ· ÂϤÁ¯Ô˘ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Ù· ›‰È· ·ÓÙȉڷÛÙ‹ÚÈ·. ∞Ó Ù· 2 ÙÂÛÙ Â›Ó·È ·ÚÓËÙÈο Ô ‰fiÙ˘ Á›ÓÂÙ·È Î·Ù¿ÏÏËÏÔ˜, ·Ó ÙÔ ¤Ó· Â›Ó·È ıÂÙÈÎfi Î·È ÙÔ ¿ÏÏÔ ·ÚÓËÙÈÎfi ıˆÚÂ›Ù·È ıÂÙÈÎfi˜ ÁÈ· ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ‰Â›ÎÙË. ∫¿ı ‰fiÙ˘ ÂϤÁ¯ÂÙ·È ÁÈ· Ù· οوıÈ: Anti-HBc EIA, AntiHTLV I/II, EIA, Anti- HIV-1/ HIV-2, CMV, HBsAg, Anti-HCV, RPR (rapid plasma reagin), Syphillis G, EIA.
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X. TEPZI¢OY
∏ ÈÛÙÔÔ›ËÛË Î·Ù·ÏÏËÏfiÙËÙÔ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Á›ÓÂÙ·È ÌÂÙ¿ ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙÔÓ ÂȉÈÎfi ¯ÒÚÔ Ù˘ ∂.Δ.O. οو ·fi ·˘ÛÙËÚ¤˜ Û˘Óı‹Î˜ ·ÛË„›·˜ ÙÔ˘ ¯ÒÚÔ˘ Î·È ¿ÛËÙ˜ Û˘Óı‹Î˜ ¯ÂÈÚÈÛÌÔ‡ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ΔÔ ÌfiÛ¯Â˘Ì· ÂϤÁ¯ÂÙ·È Ì·ÎÚÔÛÎÔÈο ÛÙË Û¯ÈÛÌÔÂȉ‹ Ï˘¯Ó›· Î·È ÌÈÎÚÔÛÎÔÈο °È· ÙÔÓ ÌÈÎÚÔÛÎÔÈÎfi ¤ÏÂÁ¯Ô ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ Ë ∂.Δ.O. ¯ÚËÛÈÌÔÔÈ› ÂȉÈ΋ ¯ÚÒÛË Î·È ÂÓ‰ÔıËÏÈÔÛÎfiÈÔ. ∫¿ı ÌfiÛ¯Â˘Ì· ÈÛÙÔÔÈÂ›Ù·È Î·È Î·Ù·Ù¿ÛÛÂÙ·È Û ̛· ·fi ÙȘ 5 ηÙËÁÔڛ˜ ¿ÚÈÛÙÔ. Ôχ ηÏfi, ηÏfi, ̤ÙÚÈÔ Î·È ·Î·Ù¿ÏÏËÏÔ ·Ó¿ÏÔÁ· Ì ÙËÓ ˘ÎÓfiÙËÙ· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î·È Ù· Â˘Ú‹Ì·Ù· ÙˆÓ ÏÔÈÒÓ ÛÙÚˆÌ¿ÙˆÓ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ fiˆ˜ ÙËÓ ·ÚÔ˘Û›· ‹ Ô¯È ÂÈıËÏÈ·ÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ, ÙËÓ ‡·ÚÍË ÁÂÚÔÓÙfiÙÔÍÔ˘ Î·È ÙËÓ ¤ÎÙ·Û‹ ÙÔ˘, ÙËÓ ·ÚÔ˘Û›· ‹ Ô¯È Î·È ÙËÓ ‚·Ú‡ÙËÙ· Ù˘¯ÒÓ Ù˘ ¢ÂÛÎÂÌÂÓÙ›Ԣ. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ˘ÎÓfiÙËÙ· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ ÌfiÛ¯Â˘Ì· ıˆÚÂ›Ù·È ¿ÚÈÛÙÔ Ì ˘ÎÓfiÙËÙ· >3000 ·ÙÙ·Ú· ·Ó¿ mm2, Ôχ ηÏfi Ì 2500-3000mm2, ηÏfi 2000-2500mm2, ̤ÙÚÈÔ 1500-2000mm 2 ÂÓÒ ˘ÎÓfiÙËÙ· ΢ÙÙ¿ÚˆÓ <1500mm2 ·ÔÚÚ›ÙÂÙ·È ˆ˜ ·Î·Ù¿ÏÏËÏÔ. ∂¿Ó ¤Ó·˜ ÎÂÚ·ÙÔÂÈȉ‹˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ˘ÎÓfiÙËÙ· ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ <2000 ·ÙÙ·Ú·/mm2, Î·È Â¿Ó ·Ú·ÙËÚÂ›Ù·È ·ÎÚ·›Ô˜ ÔÏ˘ÌÂÁÂıÈÛÌfi˜ Î·È ÏÂÈÔÌÔÚÊÈÛÌfi˜, ‹ ·ÚÔ˘Û›· ÛËÌ·ÓÙÈ΋˜ guttata, ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ¿ÚˆÓ ‹ ‚·ÎÙËÚ›ˆÓ ÛÙËÓ ÂÓ‰ÔıËÏȷ΋ ÂÈÊ¿ÓÂÈ·, ‹ ·ÁÁ›ˆÓ Ê·ÓÙ·ÛÌ¿ÙˆÓ ÛÙÔ ÛÙÚÒÌ· ‹ ·ÚÔ˘Û›· >2% ÓÂÎÚÒÓ Î˘ÙÙ¿ÚˆÓ ÂȉÈο fiÙ·Ó ‚Ú›ÛÎÔÓÙ·È Û˘ÁÎÂÓÙڈ̤ӷ ÛÙÔ ÎÂÓÙÚÈÎfi ÙÌ‹Ì· ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜, ıˆÚÂ›Ù·È ·Î·Ù¿ÏÏËÏÔ˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ·ÔÚÚ›ÙÂÙ·È. ∞˘Ù¿ Ù· ·Î·Ù¿ÏÏËÏ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔۯ‡̷ٷ ÌÔÚÔ‡Ó Ó· Ù·˘ÙÔÔÈËıÔ‡Ó, Ó· Û˘ÓÙËÚËıÔ‡Ó Î·È Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Î·È ÁÈ· ¿ÏÏÔ˘˜ ÛÎÔÔ‡˜ fiˆ˜ ۠›ÁÔ˘Û˜ ÂÚÈÙÒÛÂȘ ·ÂÈÏÔ‡ÌÂÓ˘ ‰È¿ÙÚËÛ˘ ÎÂÚ·ÙÔÂȉԇ˜, ÁÈ· ÙËÓ ·Ó·ÙÔÌÈ΋ ·ÔηٿÛÙ·ÛË Î·È ÚÔʇϷÍË ÙÔ˘ ‚ÔÏ‚Ô‡, ÁÈ· ÙËÓ Ï‹„Ë ÎÂÚ·ÙÔÛÎÏËÚÈÎÔ‡ ‰·ÎÙ˘Ï›Ô˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ™∫O ηıÒ˜ Î·È ÁÈ· ÂÚ¢ÓËÙÈÎÔ‡˜ ÛÎÔÔ‡˜. ∞fi ·˘Ù¿ ÂÍ·ÈÚÔ‡ÓÙ·È Ù· ÌÔۯ‡̷ٷ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ‹ ˘¿Ú¯ÂÈ ˘Ô„›· ÂÈÌfiÏ˘ÓÛ˘. Δ· ÌÔۯ‡̷ٷ Û˘ÓÙËÚÔ‡ÓÙ·È ·ÊÔ‡ ÙÔÔıÂÙËıÔ‡Ó Û ÂȉÈÎfi ‰Ô¯Â›Ô Ô˘ ÂÚȤ¯ÂÈ Î·Ù¿ÏÏËÏÔ Û˘ÓÙËÚËÙÈÎfi ˘ÁÚfi, Û „‡ÍË 4o C ̤¯ÚÈ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó. O ¯ÚfiÓÔ˜ Û˘ÓÙ‹ÚËÛ˘ ηıÔÚ›˙ÂÙ·È ·fi ÙËÓ ÔÈfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙËÓ ÌÂÏÏÔÓÙÈ΋ ÙÔ˘ ¯Ú‹ÛË. °È· ÙËÓ ·ÛÊ¿ÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙËÓ ·-
ÔÊ˘Á‹ ÂÈÌÔχÓÛÂˆÓ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÙÚÂȘ ÌÈÎÚÔ‚ÈÔÏÔÁÈÎÔ› ¤ÏÂÁ¯ÔÈ. ¶ÚÈÓ ·fi ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ‚ÔÏ‚Ô‡, fiÔ˘ Ï·Ì‚¿ÓÔÓÙ·È ‰Â›ÁÌ·Ù· ·fi ÙËÓ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ‚ÔÏ‚Ô‡ Î·È Ù· ÎÔÏÒÌ·Ù· ¶ÚÈÓ ·fi ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÎÂÚ·ÙÔÛÎÏËÚÈÎÔ‡ ‰·ÎÙ˘Ï›Ô˘: Ï·Ì‚¿ÓÔÓÙ·È ‰Â›ÁÌ·Ù· ·fi ÙËÓ ÚfiÛıÈ· ÂÈÊ¿ÓÂÈ· ÙÔ˘ ‚ÔÏ‚Ô‡ Î·È ÂȉÈÎfiÙÂÚ· ·fi ÙÔ ÎÂÚ·ÙÔÛÎÏËÚÈÎfi fiÚÈÔ Î·È Ù¤ÏÔ˜ ·Ó·ÚÚÔÊ¿Ù·È ÌÈÎÚ‹ ÔÛfiÙËÙ· ·fi ÙÔ Û˘ÓÙËÚËÙÈÎfi ˘ÏÈÎfi ÚÈÓ ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ·˘Ùfi. ∏ ∂.Δ.O. ÂÎÙfi˜ ·fi ÙÔ˘˜ ÎÂÚ·ÙÔÂȉ›˜ Î·È ÙÔ˘˜ ÛÎÏËÚÔÎÂÚ·ÙÔÂȉÈÎÔ‡˜ ‰·ÎÙ˘Ï›Ô˘˜ Û˘ÓÙËÚ› ÙÔÓ ÛÎÏËÚfi, ·ÊÔ‡ ·Ê·ÈÚÂı› ÙÔ ÛÎÏËÚÔÎÂÚ·ÙÔÂȉÈÎfi ÌfiÛ¯Â˘Ì·, Û ·fiÏ˘ÙË ·ÏÎÔfiÏË Ì¤Û· Û ÂȉÈο ÊÈ·Ï›‰È· Î·È Â›Û˘ ·Ú·Û΢¿˙ÂÈ Î·È Û˘ÓÙËÚ› ÌÔۯ‡̷ٷ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘. °È· ÙËÓ Ï‹„Ë Î·È ÂÂÍÂÚÁ·Û›· Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ Ï·Ì‚¿ÓÔÓÙ·È ˘’fi„ÈÓ fiÏ· Ù· ÎÚÈÙ‹ÚÈ· Ô˘ ÈÛ¯‡Ô˘Ó ÁÈ· ÙËÓ ÂÈÏÔÁ‹ Î·È Û˘ÓÙ‹ÚËÛË ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜. ∏ ·ÌÓȷ΋ ÌÂÌ‚Ú¿ÓË ·ÊÔ‡ ÙÂÌ·¯ÈÛÙ› Û ÙÂÌ¿¯È· 5á5 cm Û˘ÓÙËÚÂ›Ù·È Û ηٿÏÏËÏÔ Û˘ÓÙËÚËÙÈÎfi ˘ÏÈÎfi, Û ÂȉÈο ‰Ô¯Â›·, ÛÙÔ˘˜ –80Ô C. ∫¿ı ‰Ô¯Â›Ô ÂÈÁÚ¿ÊÂÙ·È Ì ÙËÓ ËÌÂÚÔÌËÓ›· ÂÂÍÂÚÁ·Û›·˜ Î·È ÙÔÓ Îˆ‰ÈÎfi ·ÚÈıÌfi. ∏ ·ÔÛÙÔÏ‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Á›ÓÂÙ·È Ì ÂȉÈ΋ Û˘Û΢·Û›·, ÂÍ·ÛÊ·Ï›˙ÔÓÙ·˜ ÙËÓ ·ÎÂÚ·ÈfiÙËÙ· Î·È ‚ȈÛÈÌfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∫¿ı ÌfiÛ¯Â˘Ì· Û˘Óԉ‡ÂÙ·È ·fi ¤ÁÁÚ·Ê· Ô˘ ·Ú¤¯Ô˘Ó ÙȘ ηٿÏÏËϘ ÏËÚÔÊÔڛ˜ ÁÈ· ÙÔ ÌfiÛ¯Â˘Ì· Î·È ÙÔÓ ‰fiÙË fiˆ˜ ËÏÈΛ·, ¯ÚfiÓÔ˜ ı·Ó¿ÙÔ˘ ÂÍfiڢ͢, ÂÍfiڢ͢ Û˘ÓÙ‹ÚËÛ˘, ·ÔÙÂϤÛÌ·Ù· ÔÚÔÏÔÁÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ ÙÔ˘ ‰fiÙÔ˘, ÈÛÙÔÔ›ËÛË ÌÔۯ‡̷ÙÔ˜ ηıÒ˜ Î·È Ô‰ËÁ›Â˜ ¯Ú‹Û˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ¤ÓÙ˘Ô ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ ‹ ¿ÏÏˆÓ Î·Ù·ÛÙ¿ÛÂˆÓ Û¯ÂÙÈ˙fiÌÂÓˆÓ Ì ÙÔ ÌfiÛ¯Â˘Ì·, fiˆ˜ ÛÙÔȯ›· ÙÔ˘ ‰¤ÎÙÔ˘, ·›ÙÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÚÔ‚Ï‹Ì·Ù· ηٿ ÙËÓ Â¤Ì‚·ÛË Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÔÈfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÔÈ Ôԛ˜ ı· Ú¤ÂÈ Ó· ·Ó·ÊÂÚıÔ‡Ó Ì ÙËÓ ÂÈÛÙÚÔÊ‹ ÙÔ˘ ÂȉÈÎÔ‡ ÂÓÙ‡Ô˘. ∏ ·ÚÔ˘Û›· ÏÔÈfiÓ Ù˘ ΔÚ¿Â˙·˜ OÊı·ÏÌÒÓ ÔÚÁ·ÓˆÌ¤ÓË Î·È ÏÂÈÙÔ˘ÚÁÔ‡Û· Û‡Ìʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘ Î·È ·ÎÔÏÔ˘ıÒÓÙ·˜ ÙÔ˘˜ ¢ÈÂıÓ›˜ ηÓÔÓÈÛÌÔ‡˜ ·Ú¤¯ÂÈ ÈÛÙÔÔÈË̤ӷ ÌÔۯ‡̷ٷ Û˘Ì‚¿ÏÏÔÓÙ·˜ ¿ÌÂÛ· ÛÙËÓ ÂÈÙ˘¯›· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ. ª¤Û· ÛÙÔ˘˜ ÛÙfi¯Ô˘˜ Î·È ÙȘ ÚÔÛ¿ıÂȤ˜ Ù˘ ı¤ÛË ÛËÌ·ÓÙÈ΋ η٤¯ÂÈ Î·È Ë ÂÓË̤ڈÛË Î·È Â˘·ÈÛıËÙÔÔ›ËÛË ÙÔ˘ ÎÔÈÓÔ‡ ÁÈ· ÙËÓ ·Í›· Ù˘ ‰ˆÚ¿˜ ̤۷ ·fi ÔÌÈϛ˜ Î·È ¤ÓÙ˘Ô ˘ÏÈÎfi, Ì ÙËÓ ˘ÔÛÙ‹ÚÈÍË ÎÔÈÓˆÊÂÏÒÓ Î·È ÎÔÈÓˆÓÈÎÒÓ ÔÚÁ·ÓÒÛˆÓ.
MÂÙ·ÌfiÛ¯Â˘ÛË ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜
8
NÈÎfiÏ·Ô˜ Zȿη˜
∂ÈÛ·ÁˆÁ‹
¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ÂͿψÛË ‚Ï·ÛÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ™∫O (stem cells) Î·È ÁÈ·Ù› ‰È¢ÎÔχÓÂÈ ÙËÓ ÂÈıËÏÈÔÔ›ËÛË ÙˆÓ ˘ÔÙÚÔÈ·˙Ô˘ÛÒÓ Î·È ¯ÚfiÓÈˆÓ ÂÈıËÏÈ·ÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ ‰È·ÙËÚÒÓÙ·˜ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÓ Ê·ÈÓfiÙ˘Ô ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ ·Ó·Ù‡ÛÛÔÓÙ·È Â¿Óˆ ÛÙËÓ ÂÈÊ¿ÓÂÈ¿ Ù˘. ªÂÈÒÓÂÈ ÙËÓ ÊÏÂÁÌÔÓ‹, Ô˘ÏÔÔ›ËÛË Î·È ÓÂÔ·ÁÁ›ˆÛË Ù˘ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ ηٷÛÙ¤ÏÏÔÓÙ·˜ ÙÔ ÌÂÙ·ÙÚÂÙÈÎfi ·˘ÍËÙÈÎfi ·Ú¿ÁÔÓÙ· ‚ (TGF-‚) Î·È ÔÌ·ÏÔÔÈÒÓÙ·˜ ÙËÓ ‰Ú¿ÛË ÙˆÓ ÈÓÔ‚Ï·ÛÙÒÓ. ∏ ÌÂÌ‚Ú¿ÓË ·ÔÙÂÏÂ›Ù·È ·fi ‰‡Ô ÛÙÚÒÌ·Ù·, ÙÔ ¯fiÚÈÔ ·fi ÙËÓ Ì›· ÌÂÚÈ¿ Î·È ÙËÓ ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË Ì ¤Ó·Ó ÛÙ›¯Ô ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ·fi ÙËÓ ¿ÏÏË. ŸÙ·Ó Ë ÌÂÌ‚Ú¿ÓË ÌÂÙ·ÌÔۯ‡ÂÙ·È Ì ÙÔ ÂÈı‹ÏÈÔ ÚÔ˜ ÙÔ Â͈ÙÂÚÈÎfi ÂÚÈ‚¿ÏÏÔÓ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ÌfiÛ¯Â˘Ì· ·Ó·Ì¤ÓÔÓÙ·˜ ÙÔ Ó¤Ô ÂÈı‹ÏÈÔ Ó· ·Ó·Ù˘¯ı› ÛÙËÓ ÂÈÊ¿ÓÂÈ¿. ŸÙ·Ó ÙÔÔıÂÙÂ›Ù·È Ì ÙÔ ÂÈı‹ÏÈÔ Û ·ʋ Ì ÙÔ˘˜ ÈÛÙÔ‡˜ ÙfiÙ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ Î¿Ï˘ÌÌ· ·Ó·Ì¤ÓÔÓÙ·˜ ÙÔ ÂÈı‹ÏÈÔ Ó· ·Ó·Ù˘¯ı› οو ·fi ÙËÓ ÌÂÌ‚Ú¿ÓË ·Ó¿ÏÔÁ· Ì ÙȘ ··ÈÙ‹ÛÂȘ Ù˘ ·ÔηٿÛÙ·Û˘ ÈÛÙÒÓ. ™ÙËÓ ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ˘¿Ú¯ÂÈ Ï‹ıÔ˜ ‰ËÌÔÛȇÛÂˆÓ ÁÈ· fiϘ ÙȘ Èı·Ó¤˜ ÂÊ·ÚÌÔÁ¤˜ Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ÛÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜, ı· ·Ó·Ù‡ÍÔ˘Ì fï˜ Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ Ì·ÎÚfi¯ÚÔÓË ÂÌÂÈÚ›· Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ÛÙȘ ·Ú·Î¿Ùˆ ÂÊ·ÚÌÔÁ¤˜: ·) ∂ÏÏ›ÌÌ·Ù· ÙÔ˘ ÎÂÚ·ÙÔÂȉÈÎÔ‡ ÂÈıËÏ›Ô˘ ·fi Ê˘Û·Ïȉ҉˘ ÎÂÚ·ÙÔ¿ıÂÈ·, ¯ËÌÈο ÂÁη‡Ì·Ù· Î·È ¤ÏÎË ÎÂÚ·ÙÔÂȉԇ˜. ‚) ¶ÙÂÚ‡ÁÈÔ, ¯¿Ï·ÛË ÙÔ˘ ÂÈÂÊ˘ÎfiÙ·, ÂÏÏ›ÌÌ·Ù· ÂÈÂÊ˘ÎfiÙ· ·fi ·Ê·›ÚÂÛË fiÁΈÓ, Û˘Ì‚Ï¤Ê·ÚÔ Î·È ·ÔηٿÛÙ·ÛË ‚ÏÂÊ·ÚÈÎÒÓ ÎÔψ̿وÓ.
∏ Û˘ÓÙËÚË̤ÓË ·ÓıÚÒÈÓË ·ÌÓȷ΋ ÌÂÌ‚Ú¿ÓË ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Ì ÂÈÙ˘¯›· Û ÔÏϤ˜ ÂÊ·ÚÌÔÁ¤˜ ·ÔηٿÛÙ·Û˘ Ù˘ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ ‰ËÏ·‰‹ ÙÔ˘ ÂÈıËÏ›Ô˘ Ô˘ Û˘ÓÈÛÙ¿ ÙÔÓ ‚ÏÂÊ·ÚÈÎfi Î·È ‚ÔÏ‚ÈÎfi ÂÈÂÊ˘ÎfiÙ· ηıÒ˜ Î·È ÙÔ ÂÈı‹ÏÈÔ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜. ™ÙËÓ OÊı·ÏÌÔÏÔÁ›· ÚÒÙÔ˜ Ô Roth to 1940 ·Ó·ÎÔ›ÓˆÛ ÙË ¯Ú‹ÛË Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË Û˘Ì‚Ï¤Ê·ÚÔ˘ Î·È ÂÏÏÂÈÌÌ¿ÙˆÓ ÂÈÂÊ˘ÎfiÙ·. H ·ÌÓȷ΋ ÌÂÌ‚Ú¿ÓË ‹ ¿ÌÓÈÔ Â›Ó·È Ô ÂÛˆÙÂÚÈÎfi˜ ¯ÈÙÒÓ·˜ ÙÔ˘ Ï·ÎÔ‡ÓÙ· Î·È ·ÔÙÂÏÂ›Ù·È ·fi ·¯ÂÈ¿ ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË Î·È ·Ó¿ÁÁÂÈÔ ÛÙÚÒÌ·, Ï·Ì‚¿ÓÂÙ·È ‰Â ηٿ ÙÔ Ù¤ÏÔ˜ ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˘ ηÈÛ·ÚÈ΋˜ ÙÔÌ‹˜, ∫¿Ùˆ ·fi ¿ÛËÙ˜ Û˘Óı‹Î˜ Û ı¿Ï·ÌÔ ÓËÌ·ÙÈ΋˜ ÚÔ‹˜ ÍÂϤÓÂÙ·È ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi ̤۷ ÛÙÔÓ ÔÔ›Ô ¤¯ÂÈ ÚÔÛÙÂı› Ì›ÁÌ· ·ÓÙÈ‚ÈÔÙÈÎÒÓ (ÂÓÈÎÈÏ›ÓË, ÛÙÚÂÙÔÌ˘Î›ÓË, ÓÂÔÌ˘Î›ÓË Î·È ·ÌÊÔÙÂÚÈΛÓË). ΔÔ ¿ÌÓÈÔ ¯ˆÚ›˙ÂÙ·È ·fi ÙÔ ¯fiÚÈÔ Î·È Ë ·ÌÓȷ΋ ÌÂÌ‚Ú¿ÓË ÂÓ ÂÎÙ¿ÛÂÈ ÙÔÔıÂÙÂ›Ù·È ¿Óˆ Û ʇÏÏÔ ÓÈÙÚÔÛÂÏÔ˘Ïfi˙˘ Ì ÙËÓ ÂÈıËÏȷ΋ ÏÂ˘Ú¿ ÚÔ˜ Ù· ¿ӈ. ΔÔÔıÂÙÂ›Ù·È Û ÊÈ·Ï›‰È· Ô˘ ÂÚȤ¯Ô˘Ó Ì›ÁÌ· Dulbecco modified Eagle medium Î·È ÁÏ˘ÎÂÚfiÏË 1:1 Î·È Ê˘Ï¿ÛÛÂÙ·È Û „˘ÁÂ›Ô ıÂÚÌÔÎÚ·Û›·˜ –80Ô C. ∏ ·ÌÓȷ΋ ÌÂÌ‚Ú¿ÓË ¤¯ÂÈ ÔÚÈṲ̂Ó˜ ÌÔÓ·‰ÈΤ˜ ‚ÈÔÏÔÁÈΤ˜ ȉÈfiÙËÙ˜ Ô˘ ÙËÓ Î·ıÈÛÙÔ‡Ó È‰·ÓÈÎfi ÌfiÛ¯Â˘Ì· ÁÈ· ·ÔηٿÛÙ·ÛË ÂÈıËÏ›Ô˘. ¢ÂÓ ¤¯ÂÈ ¤ÎÊÚ·ÛË HLA-A, B ·ÓÙÈÁfiÓˆÓ ÔfiÙ ‰ÂÓ ÚÔηÏ› ·ÓÙÈÁÔÓÈ΋ ·ÓÙ›‰Ú·ÛË ÂÓÒ ¤¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ˘˜ ·ÓÔÛÔÚ˘ıÌÈÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∂¿ÁÂÈ ÙËÓ ÂÈıËÏÈÔÔ›ËÛË ·Ú¤¯ÔÓÙ·˜ Ì›· Ó¤· ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË Î·È ·ÂÏ¢ıÂÚÒÓÔÓÙ·˜ ·Ú¿ÁÔÓÙ˜ ·Ó¿Ù˘Í˘ ΢ÙÙ¿ÚˆÓ ÂÓÒ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ‰Ú¿ÛË ÙˆÓ ÚˆÙ·ÛÒÓ. ∏ ‚·ÛÈ΋ Ù˘ ÌÂÌ‚Ú¿ÓË Â›Ó·È ·ÚfiÌÔÈ· Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÂÈÂÊ˘ÎfiÙ· Î·È È‰·ÓÈÎfi ˘fiÛÙڈ̷ ¿Óˆ ÛÙËÓ ÔÔ›· ÌÔÚÔ‡Ó Ó· ·Ó·Ù˘¯ıÔ‡Ó ·ÎfiÌ· Î·È ÂÈıËÏȷο ÚÔÁÔÓÈο ·ÙÙ·Ú·. ∞˘Ù‹ Ë ‰Ú¿ÛË Ù˘ ÂÍËÁ› ˆ˜ ÌÔÚ› Ó·
º˘Û·Ïȉ҉˘ ÎÂÚ·ÙÔ¿ıÂÈ· ΔÔ Û·ıÚfi ÂÈı‹ÏÈÔ Ì ÙȘ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ Ê˘-
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N. ZIAKA™
Û·Ï›‰Â˜ Î·È ÙËÓ Â·ÎfiÏÔ˘ıË ÊÏÂÁÌÔÓ‹ fiÏ˘ Ù˘ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ ·ÔÙ¤ÏÂÛ·Ó Â‰›Ô ÂÊ·ÚÌÔÁ‹˜ Ù˘ ÌÂÌ‚Ú¿Ó˘ ·fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ ÌÂÙ·ÌÔۯ‡ÔÓÙ¿˜ ÙËÓ Û·Ó ÌfiÛ¯Â˘Ì· ÛÙÔ ÎÂÚ·ÙÈÎfi ÂÈı‹ÏÈÔ ÂÓÙfi˜ ÙÔ˘ ÛÎÏËÚÔÎÂÚ·ÙÔÂȉԇ˜ ÔÚ›Ô˘ (™∫O) Û ̿ÙÈ· Ì ÛËÌ·ÓÙÈο ÌÂȈ̤ÓË fiÚ·ÛË. ™ÙËÓ ÎÏÈÓÈ΋˜ Ì·˜ Ë ÌÂÌ‚Ú¿ÓË ÂÊ·ÚÌfiÛıËΠÛÙ· ÂÚÈÛÙ·ÙÈο ·˘Ù¿ Û·Ó Î¿Ï˘ÌÌ· ¿ӈ ·fi ÔÏfiÎÏËÚË ÙËÓ ÎÂÚ·ÙÔÂȉÈ΋ ÂÈÊ¿ÓÂÈ· Û ̿ÙÈ· Ì ηϋ ÔÙÈ΋ Ô͇ÙËÙ· (>5/10). (∂ÈÎfiÓ· 1) ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ Â›Ó·È ÎÔÈÓ‹ ÁÈ· ÔÏϤ˜ ÂÊ·ÚÌÔÁ¤˜ Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ Î·È ·Ú¯›˙ÂÈ Ì ·fiÍÂÛË ÙÔ˘ Û·ıÚÔ‡ ÂÈıËÏ›Ô˘, 360Ô ÂÚÈÙÔÌ‹ ÙÔ˘ ÂÈÂÊ˘ÎfiÙ· ÂÚÈÊÂÚÈο ÙÔ˘ ™∫O, ÙÔÔı¤ÙËÛË Ù˘ ÌÂÌ‚Ú¿Ó˘ Ì Ù˘ ÂÈıËÏȷ΋ ÂÈÊ¿ÓÂÈ· Û ·ʋ Ì ÙÔ ÛÙÚÒÌ· ÙÔ˘ ÎÂÚ·ÙÔÂȉ‹ Î·È Û˘ÚÚ·Ê‹ ÌÂ Û˘Ó¯fiÌÂÓÔ Ú¿ÌÌ· nylon 9.0 ÛÙ· ÂχıÂÚ· ¿ÎÚ· ÙÔ˘ ÂÈÂÊ˘ÎfiÙ·. ™ÙÔ Ù¤ÏÔ˜ Ù˘ ¤̂·Û˘ ÙÔÔıÂÙÂ›Ù·È ıÂڷ¢ÙÈÎfi˜ Ê·Îfi˜ ·ʋ˜ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜. ªÂ ÂÏ¿¯ÈÛÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË 12 ÌËÓÒÓ ‰È·ÈÛÙÒÛ·Ì 87,6% ÙˆÓ ·ÛıÂÓÒÓ Ó· ¤¯Ô˘Ó ÔÌ·Ïfi Î·È ˘ÁȤ˜ ÂÈı‹ÏÈÔ Ì ÌÂȈ̤ÓË ÊÏÂÁÌÔÓ‹ ÙÔ˘ ÂÈÂÊ˘ÎfiÙ· Î·È ‚ÂÏÙȈ̤ÓË ÔÙÈ΋ Ô͇ÙËÙ·. ™ÙËÓ ·Ú·¿Óˆ Ù¯ÓÈ΋
ÙÔ Ó¤Ô ÂÈı‹ÏÈÔ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ ÚÔ¤Ú¯ÂÙ·È ·fi Ù· ·Ú¯¤ÁÔÓ· ·ÙÙ·Ú· ÙÔ˘ ™∫O Ù· ÔÔ›· ·Ó·Ù‡ÛÛÔÓÙ·È Î¿Ùˆ ·fi ÙËÓ ÌÂÌ‚Ú¿ÓË. ∂›Ó·È Ë ÌfiÓË ÛÂÈÚ¿ ·ÛıÂÓÒÓ ÛÙËÓ ÔÔ›· ÂÚÈÁÚ¿ÊÂÙ·È ‚ÂÏÙ›ˆÛË Ù˘ ÔÙÈ΋˜ Ô͇ÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ
ÃËÌÈο ÂÁη‡Ì·Ù· ™Ù· ¯ËÌÈο ÙÚ·‡Ì·Ù· ÙÔ˘ ÔÊı·ÏÌÔ‡ Î·È È‰›ˆ˜ ·fi ·ÏοÏ· ·Ú·ÙËÚÂ›Ù·È ¤ÓÙÔÓË ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË Î·È Î·Ù·ÛÙÚÔÊ‹ Ù˘ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ ηıÒ˜ Î·È Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÂÈıËÏ›Ô˘ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ Î·È ÛÙËÓ Û˘Ó¤¯ÂÈ· Ù‹ÍË ÙÔ˘ Ì ·Ú¿ÏÏËÏË Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ·Ú¯¤ÁÔÓˆÓ Î˘ÙÙ¿ÚˆÓ ÛÙÔ˘ ™∫O Û ÚÔ¯ˆÚË̤Ó˜ ÂÚÈÙÒÛÂȘ. (∂ÈÎfiÓ· 2) ∂Ê·ÚÌfiÛ·Ì ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ Û ¯ËÌÈο ÂÁη‡Ì·Ù· ‰Â‡ÙÂÚÔ˘ Î·È ÙÚ›ÙÔ˘ ÛÙ·‰›Ô˘ Û ·˘Ù¿ ‰ËÏ·‰‹ Ô˘ ‰ÂÓ ¤¯ÂÈ ÂÈÙÂÏÂÛÙ› Ë Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ·Ú¯¤ÁÔÓˆÓ Î˘ÙÙ¿ÚˆÓ. ™Ù· ÂÁη‡Ì·Ù· ÁÈÓfiÙ·Ó ·Ê·›ÚÂÛË ÙÔ˘ ÓÂÔ·ÁÁÂÈ·ÎÔ‡ ¿ÓÔ˘ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ Ì·˙› Ì ÙÔÓ ˘ÂÚÏ·ÛÙÈÎfi ÂÈÂÊ˘ÎfiÙ· Î·È Ï‡ÛË ÙˆÓ Û˘ÌʇÛÂˆÓ Î·È ÙÔ˘ Ù˘¯fiÓ ˘¿Ú¯ÔÓÙÔ˜ Û˘Ì‚Ï¤Ê·ÚÔ˘ ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ Â›Ó·È fiÌÔÈ· Ì ÙËÓ Ù¯ÓÈ΋ Ô˘
∂ÈÎfiÓ· 1. ¶ÚÔ¯ˆÚË̤ÓË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ê˘Û·Ïȉ҉˘ ÎÂÚ·ÙÔ¿ıÂÈ· (¿Óˆ ·ÚÈÛÙÂÚ¿). OÌ·Ï‹ ÂÈÊ¿ÓÂÈ· ÔÎÙÒ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ (¿Óˆ ‰ÂÍÈ¿). º˘Û·Ïȉ҉˘ ÎÂÚ·ÙÔ¿ıÂÈ· Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÎÂÚ·ÙÔÂȉԇ˜ Î·È ·ÔηٿÛÙ·ÛË Ù˘ ‰È·‡ÁÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ 6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË.
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∂ÈÎfiÓ· 2. ÃËÌÈο ÂÁη‡Ì·Ù· ‰Â‡ÙÂÚÔ˘ Î·È ÙÚ›ÙÔ˘ ‚·ıÌÔ‡ (·ÚÈÛÙÂÚ¿) Î·È ÔÌ·Ï‹˜ ÔÊı·ÏÌÈ΋ ÂÈÊ¿ÓÂÈ· ¯ˆÚ›˜ ÛËÌ›· ÊÏÂÁÌÔÓ‹˜ 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË (‰ÂÍÈ¿).
ÂÚÈÁÚ¿ÊËΠÁÈ· ÙËÓ Ê˘Û·ÏÈ‰Ò‰Ë ÎÂÚ·ÙÔ¿ıÂÈ· Ì ÙËÓ ÌÂÌ‚Ú¿ÓË Ó· ÙÔÔıÂÙÂ›Ù·È Û·Ó Î¿Ï˘ÌÌ· ¤ÙÛÈ ÒÛÙ ÙÔ ÂÈı‹ÏÈÔ Ó· ·Ó·Ù˘¯ı› οو ·fi ÙËÓ ÌÂÌ‚Ú¿ÓË ÂÓÒ ÙÔ Î‡ÚÈÔ fiÊÂÏÔ˜ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·˘Ù¿ Ù· ÂÚÈÛÙ·ÙÈο ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ˘˜ ‚ÈÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ηٷÛÙ¤ÏÏÔ˘Ó ÙËÓ ÊÏÂÁÌÔÓ‹˜ Î·È Ô˘ÏÔÔ›ËÛË. ™Ù· ÂÚÈÛÙ·ÙÈο ÂÁη˘Ì¿ÙˆÓ ·fi ·ÏοÏ· Ô˘ ÂÊ·ÚÌfiÛ·Ì ÙËÓ Ù¯ÓÈ΋ ·˘Ù‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂȂ‚ÏË̤ÓË Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ ·Ú·ÙËÚ‹ıËΠÛËÌ·ÓÙÈο Ù·¯‡ÙÂÚË ÂԇψÛË ÙÔ˘ ÎÂÚ·ÙÔÂȉÈÎÔ‡ ÂÈıËÏ›Ô˘, ‰È·‡Á·ÛË ÙÔ˘ ÛÙÚÒÌ·ÙÔ˜ Î·È Ù·¯‡ÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ Ù˘ ηٷÛÙÚÔÊÈ΋˜ ÊÏÂÁÌÔÓ‹˜ Ù˘ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ Û ۯ¤ÛË Ì ٷ ÂÚÈÛÙ·ÙÈο ÛÙ· ÔÔ›· ÂÊ·ÚÌfiÛıËΠ·ÔÎÏÂÈÛÙÈο Ë ÂӉ‰ÂÈÁ̤ÓË Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹.
ŒÏÎË ÎÂÚ·ÙÔÂȉԇ˜ ™Â ›ÌÔÓ· ÂÏÏ›ÌÌ·Ù· ÙÔ˘ ÂÈıËÏ›Ô˘ ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ ‹ ‚·ı‡ÙÂÚ· ¤ÏÎË Î·È Î˘Ú›ˆ˜ Ó¢ÚÔÙÚÔÊÈο Ù· ÔÔ›· ‰ÂÓ ··ÓÙÔ‡Ó ıÂÙÈο ÛÙËÓ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ ÂÊ·ÚÌfiÛ·Ì ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ·ÓÙ› Ù˘ ÂÈÎ¿Ï˘„˘ Ì ÂÈÂÊ˘ÎfiÙ· fiˆ˜ Û˘ÛÙ‹ÓÂÙ·È Û ÚÔ¯ˆÚË̤Ó˜ ÂÚÈÙÒÛÂȘ. (∂ÈÎfiÓ· 3)
™Ù· ÂÚÈÛÙ·ÙÈο ·˘Ù¿ Á›ÓÂÙ·È ·fiÍÂÛË ÙÔ˘ Û·ıÚÔ‡ ÂÈıËÏ›Ô˘ ‹ Î·È ÙÔ˘ ÓÂÎÚˆÙÈÎÔ‡ ˘ÏÈÎÔ‡ ·fi ÙÔÓ ÎÚ·Ù‹Ú· ÙÔ˘ ¤ÏÎÔ˘˜ Î·È ÙÔÔıÂÙÔ‡ÓÙ·È ÌÈÎÚ¿ ÙÂÌ¿¯È· Ù˘ ÌÂÌ‚Ú¿Ó˘ ÂÓÙfi˜ ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ ¤ÙÛÈ ÒÛÙ ӷ Î·Ï˘Êı› Ô ÎÚ·Ù‹Ú·˜ ÙÔ˘ ¤ÏÎÔ˘˜ Î·È Ó· ÔÌ·ÏÔÔÈËı› Ë ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜. ∏ ÙÂÏÈ΋ ÛÙÔÈ‚¿‰· Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔÔıÂÙÂ›Ù·È Û·Ó ÌfiÛ¯Â˘Ì· ÂÓÙfi˜ ÙˆÓ ÔÚ›ˆÓ ÙÔ˘ ™∫O ÌÂ Û˘ÚÚ·Ê‹ ÛÙÔ ÛÙÚÒÌ· ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜ ‹ Û·Ó Î¿Ï˘ÌÌ· ηٿ ·ÓÙ›ÛÙÔÈ¯Ô ÙÚfiÔ Ì ÙËÓ Ù¯ÓÈ΋ Ô˘ ÂÚÈÁÚ¿ÊËΠ·Ú·¿Óˆ ÛÙË Ê˘Û·ÏÈ‰Ò‰Ë ÎÂÚ·ÙÔ¿ıÂÈ·. ™Â ›ÌÔÓ· ¤ÏÎË Ë Ù¯ÓÈ΋ ÌÔÚ› Ó· ·ӷÏËÊı› ÔÏϤ˜ ÊÔÚ¤˜ Û ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ ÎÚËÌÓÔ‡˜ ÂÈÂÊ˘ÎfiÙ·.
¶ÙÂÚ‡ÁÈÔ Œ¯ÂÈ ‚È‚ÏÈÔÁÚ·ÊÈο ÙÂÎÌËÚȈı› fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ÁÈ· ÙËÓ Î¿Ï˘„Ë ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ Ô˘ ÚÔ·ÙÂÈ ·fi ÙËÓ ·Ê·›ÚÂÛË ÂÎÙÂÙ·Ì¤ÓˆÓ Î·È ˘ÔÙÚÔÈ·˙fiÓÙˆÓ ÙÂÚ˘Á›ˆÓ ¤¯ÂÈ Ù· ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ÂÈÙ˘¯›·˜ ÌÂÙ¿ ÙËÓ ·˘ÙÔÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÈÂÊ˘ÎfiÙ·. ¶¤Ú· ·fi ÙËÓ Â˘ÎÔÏ›· ·ÔηٿÛÙ·Û˘ ÔÔÈ·Û‰‹ÔÙ ¤ÎÙ·Û˘ ÂÏÏ›ÌÌ·ÙÔ˜ Ì ÙËÓ ÌÂÌ‚Ú¿ÓË Ó· ÙÔÔıÂÙÂ›Ù·È Û·Ó ÌfiÛ¯Â˘Ì· ‰ËÏ·‰‹ Ì ÙËÓ ÂÈıËÏȷ΋ ÂÈÊ¿-
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∂ÈÎfiÓ· 3. ¶·Ú·ÎÂÓÙÚÈÎfi Ó¢ÚÔÙÚÔÊÈÎfi ¤ÏÎÔ˜ ÎÂÚ·ÙÔÂȉԇ˜ Î·È ÙÚ›· ÛÙ¿‰È· ÂԇψÛ˘ ¤ÂÈÙ· ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘. ¢È·ÙËÚÂ›Ù·È Ë Ô˘ÏÔÔ›ËÛË Î·È ıfiψÛË ÙÔ˘ ÛÙÚÒÌ·ÙÔ˜ Î·È ¤ÂÈÙ· ·fi ÙËÓ ÂԇψÛË Ù˘ ÂÈÊ¿ÓÂÈ·˜.
ÓÂÈ· ÚÔ˜ ÙÔ Â͈ÙÂÚÈÎfi ÂÚÈ‚¿ÏÏÔÓ, ÔÈ ‚ÈÔÏÔÁÈΤ˜ ȉÈfiÙËÙ˜ Ù˘ ÌÂÌ‚Ú¿Ó˘ ÌÂÈÒÓÔ˘Ó ÙËÓ Ô˘ÏÔÔ›ËÛË Î·È ÓÂÔ·ÁÁ›ˆÛË ÌÂÈÒÓÔÓÙ·˜ ¤ÙÛÈ ‰Ú·ÛÙÈο Ù· ÔÛÔÛÙ¿ ˘ÔÙÚÔ‹˜. Δ· ÔÛÔÛÙ¿ ˘ÔÙÚÔ‹˜ Ù˘ ÌÂıfi‰Ô˘ ÁÈ· ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÙÂÚ‡ÁÈ· ‹Ù·Ó 26, 3% ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜. ∏ ¯Ú‹ÛË Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ÂÈÙÚ¤ÂÈ ÙËÓ Â·Ó¿ÏË„Ë Ù˘ ¤̂·Û˘ ¯ˆÚ›˜ ÙÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ Ô˘ Ë ¯Ú‹ÛË ·˘ÙÔÌÔۯ‡̷ÙÔ˜ ÂÈÂÊ˘ÎfiÙ· ÂÈ‚¿ÏÏÂÈ. (∂ÈÎfiÓ· 4)
∂ÏÏ›ÌÌ·Ù· ÂÈÂÊ˘ÎfiÙ· Δ· ÂÏÏ›ÌÌ·Ù· Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ÂÈÂÊ˘ÎfiÙ· ‹ Î·È ÙÔ˘ ÎÂÚ·ÙÔÂȉÈÎÔ‡ ÂÈıËÏ›Ô˘ ¤ÂÈÙ· ·fi ·Ê·›ÚÂÛË ÂÈÊ·ÓÂÈ·ÎÒÓ fiÁÎˆÓ ÚÔÛʤÚÔ˘Ó ÙÔ È‰·ÓÈÎfi ‰›Ô ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘. ∫·Ù¿ ·ÓÙ›ÛÙÔÈ¯Ô ÙÚfiÔ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÛÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÙÂÚ˘Á›Ô˘ Ë ÌÂÌ‚Ú¿ÓË Î·Ï‡ÙÂÈ ¿ÚÈÛÙ· ÔÔÈ·‰‹ÔÙ ¤ÎÙ·ÛË ÂÏÏ›ÌÌ·ÙÔ˜, ÂÚÈÔÚ›˙ÂÈ ÙËÓ ÓÂÔ·ÁÁ›ˆÛË ÂÓÒ ÚÔÛʤÚÂÈ ¿ÚÈÛÙË ‰˘Ó·ÙfiÙËÙ· ·Ú·Ù‹ÚËÛ˘ Ù˘ ÂÚÈÔ¯‹˜ ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Èı·ÓÒÓ ˘ÔÙÚÔÒÓ. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ÌÂÌ‚Ú¿ÓË ÙÔÔıÂÙÂ›Ù·È Ì ÙËÓ ÂÈıËÏȷ΋ ÏÂ˘Ú¿ ÚÔ˜ Ù· ¤Íˆ ¤ÙÛÈ ÒÛÙ ÙÔ Ó¤Ô ÂÈı‹ÏÈÔ Ó· ·Ó·Ù˘¯ı› ¿ӈ ·fi ÙËÓ ÌÂÌ‚Ú¿ÓË.
ÿϷÛË ÂÈÂÊ˘ÎfiÙ· ∏ ¯¿Ï·ÛË ÙÔ˘ ÂÈÂÊ˘ÎfiÙ· ¤¯ÂÈ ÂÚÈÁÚ·Ê› Û·Ó ·›ÙÈÔ ‹ ·ÔÙ¤ÏÂÛÌ· ÍËÚÔÊı·ÏÌ›·˜ ÂÓÒ Ë Ù‡¯ˆÛË Ù˘ ÂÚ›ÛÛÂÈ·˜ ÂÈÂÊ˘ÎfiÙ· ÛÙÔ ÚÈÓÈÎfi ÌÈÛfi ÙÔ˘ οو ‚ÏÂÊ·ÚÈÎÔ‡ ¯Â›ÏÔ˘˜ ÂÈÙ›ÓÂÈ Ù· Û˘ÌÙÒÌ·Ù· Ù˘ ·ÓÙ·Ó·ÎÏ·ÛÙÈ΋˜ ·›ÛıËÛ˘ ÂÈÊÔÚ¿˜ ÛÙ· ÂÚÈÛÙ·ÙÈο ·˘Ù¿. (∂ÈÎfiÓ· 5) ∏ ÂÈÎÚ·Ù¤ÛÙÂÚË ·ÈÙÈÔÏÔÁ›· ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Â›Ó·È Ë ·ÚÔ˘Û›· ˘ÔÎÏÈÓÈ΋˜ ¯ÚfiÓÈ·˜ ÊÏÂÁÌÔÓ‹˜ Èı·Ófiٷٷ ·fi ÙËÓ ÍËÚÔÊı·ÏÌ›· Î·È Ë ‰ËÌÈÔ˘ÚÁ›· ÏÂÌÊÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÛÙÔ˘˜ ÈÛÙÔ‡˜ ˘fi ÙÔÓ ÂÈÂÊ˘ÎfiÙ·. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË Ù˘ ÂÚ›ÛÛÂÈ·˜ ÙÔ˘ ÂÈÂÊ˘ÎfiÙ· Î·È Ë ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ ηٿ ·ÓÙ›ÛÙÔÈ¯Ô ÙÚfiÔ Ì ·˘ÙfiÓ ÙÔ˘ ÙÂÚ˘Á›Ô˘ ÚÔÛʤÚÂÈ Ù· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÁÈ· ÙËÓ ÂÍ¿ÏÂÈ„Ë ÙˆÓ ÛËÌ›ˆÓ Î·È Û˘Ìو̿وÓ.
∞ÔηٿÛÙ·ÛË ‚ÏÂÊ·ÚÈÎÒÓ ÎÔÏˆÌ¿ÙˆÓ ∏ χÛË Û˘Ì‚ÏÂÊ¿ÚˆÓ Î·È Ë ·ÔηٿÛÙ·ÛË ÙˆÓ ‚ÏÂÊ·ÚÈÎÒÓ ÎÔÏˆÌ¿ÙˆÓ Á›ÓÂÙ·È ·Ú·‰ÔÛȷο Ì ÙËÓ ¯Ú‹ÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔÌ·ÙÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘. ΔÂÏÂ˘Ù·›· ¤¯ÂÈ ÂÊ·ÚÌÔÛÙ› ÂÎÙÂٷ̤ӷ Ë ¯Ú‹ÛË Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ÛÙȘ Ù¯ÓÈΤ˜ ·˘Ù¤˜. (∂ÈÎfiÓ· 6)
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∂ÈÎfiÓ· 4. ∞Ê·›ÚÂÛË ÙÂÚ˘Á›Ô˘ (¿Óˆ) Î·È fiÁÎÔ˘ ÂÈÂÊ˘ÎfiÙ· ÛÙÔ Â›Â‰Ô ÙÔ˘ ™∫O (οو) Î·È Ë Î¿Ï˘„Ë ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ ÂÈÂÊ˘ÎfiÙ· Ì· ·ÌÓȷ΋ ÌÂÌ‚Ú¿ÓË (‰ÂÍÈ¿).
∂ÈÎfiÓ· 5. ÿϷÛË ÂÈÂÊ˘ÎfiÙ·, ·Ê·›ÚÂÛË Ù˘ ÂÚ›ÛÛÂÈ·˜ Î·È Î¿Ï˘„Ë ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ Ì ·ÌÓȷ΋ ÌÂÌ‚Ú¿ÓË ¢È·ÎÚ›ÓÂÙ·È (οو ‰ÂÍÈ¿) Ë ÔÌ·Ï‹ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ‚ÔÏ‚ÈÎÔ‡ ÂÈÂÊ˘ÎfiÙ· ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË.
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∂ÈÎfiÓ· 6. ƒ›ÎÓˆÛË ÎÔÏˆÌ¿ÙˆÓ (·ÚÈÛÙÂÚ¿) Î·È Ë ÈηÓÔÔÈËÙÈ΋ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÈÎfiÓ· ÛÙÔ˘˜ 6 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ·ÔηٿÛÙ·ÛË (‰ÂÍÈ¿).
∏ ·ÔηٿÛÙ·ÛË ÙÔ˘ ‚ÔÏ‚ÈÎÔ‡ ÂÈÂÊ˘ÎfiÙ· Á›ÓÂÙ·È Ì ¢ÎÔÏ›· Ì ÙËÓ ¯Ú‹ÛË Ù˘ ÌÂÌ‚Ú¿Ó˘ Ë ÔÔ›· Â›Ó·È ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙËÓ ·ÔηٿÛÙ·ÛË ÙÔ˘ ‚ÏÂÊ·ÚÈÎÔ‡ ÂÈÂÊ˘ÎfiÙ·. ∏ ÏÂÙ‹ Î·È Â‡ıÚ˘ÙË ·ÌÓȷ΋ ÌÂÌ‚Ú¿ÓË ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙËÓ Â‡ÎÔÏË ¯Ú‹ÛË Ú·ÌÌ¿ÙˆÓ ·Ó·Î·Ù·Û΢‹˜ ÙˆÓ ÎÔÏˆÌ¿ÙˆÓ Î·È Ë ¯Ú‹ÛË Ù˘ ÂӉ›ÎÓ˘Ù·È Û ÂÚÈÛÙ·ÙÈο ̤Û˘ ‚·Ú‡ÙËÙ·˜, ÂÓÒ ÁÈ· ÈÔ ÚÔ¯ˆÚË̤Ó˜ ηٷÛÙ¿ÛÂȘ ··ÈÙÂ›Ù·È Ë ¯Ú‹ÛË ÛÙÔÌ·ÙÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Ô˘ ÚÔÛʤÚÂÈ ·¯‡ÙÂÚÔ Î·È ÛÎÏËÚfiÙÂÚÔ ÌfiÛ¯Â˘Ì·. ∂ÈÚfiÛıÂÙ· Î·È Û ·ÓÙ›ıÂÛË Ì ÙÔÓ ÛÙÔÌ·ÙÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, Ë ÌÂÌ‚Ú¿ÓË ‰ÂÓ Î·Ï‡ÙÂÙ·È ·fi ÛÙÔÈ‚¿‰· ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È ‰ÂÓ ÂÚȤ¯ÂÈ ÂÎÎÚÈÙÈο ·ÙÙ·Ú· ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ ‚ϤÓÓ˘ ‹ ‰·ÎÚ‡ˆÓ. OÈ ·Ú·¿Óˆ ÂÊ·ÚÌÔÁ¤˜ ‰Â›¯ÓÔ˘Ó ÙÔ Â˘Ú‡ ‰›Ô ¯Ú‹Û˘ Ù˘ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ÛÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜. ∏ ÂÚÈÔÚÈÛÌÔ› Ù˘ ¯Ú‹Û˘ Ù˘ ÔÚ›˙ÔÓÙ·È ·fi ÙËÓ ·‰˘Ó·Ì›· ·Ó·Á¤ÓÓËÛ˘ ÙˆÓ ÌËÙÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ¿Ú· Û ÂÚÈÙÒÛÂȘ fiÔ˘ Ë ‚Ï¿‚Ë Â›Ó·È ÙfiÛÔ ÂÎÙÂٷ̤ÓË ··ÈÙÂ›Ù·È Ë Û˘Ó‰˘·Ṳ̂ÓË Â¤Ì‚·ÛË Ì ¯Ú‹ÛË ÌÔۯ‡̷ÙÔ˜ ™∫O. OÈ ÂÊ·ÚÌÔÁ¤˜ ·˘Ù¤˜ ¤‚·ÏÏ·Ó Î·È ÙËÓ ‰È‡ڢÓÛË Ù˘ ÚÔÛÊÔÚ¿˜ ‰È·ÊfiÚˆÓ
ÌÔÚÊÒÓ ·ÌÓȷ΋˜ ÌÂÌ‚Ú¿Ó˘ ·fi ‰È¿ÊÔÚ˜ ÂÙ·ÈÚ›˜ ‹ ÙÚ¿Â˙˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Lee SH, Tseng SC. Amniotic membrane transplantation for persistent epithelial defects with ulceration. American journal of ophthalmology 1997; 123: 303-12. 2. Azuara-Blanco A, Pillai CT, Dua HS. Amniotic membrane transplantation for ocular surface reconstruction. The British journal of ophthalmology 1999; 83: 399-402. 3. Dua HS, Azuara-Blanco A. Amniotic membrane transplantation. The British journal of ophthalmology 1999; 83: 748-52. 4. Kim JC, Tseng SC. Transplantation of preserved human amniotic membrane for surface reconstruction in severely damaged rabbit corneas. Cornea 1995; 14: 47384. 5. Mejia LF, Acosta C, Santamaria JP. Use of nonpreserved human amniotic membrane for the reconstruction of the ocular surface. Cornea 2000; 19: 288-91. 6. Prabhasawat P, Barton K, Burkett G, Tseng SC. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology 1997; 104: 974-85. 7. Prabhasawat P, Tseng SC. Impression cytology study of epithelial phenotype of ocular surface reconstructed by
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
preserved human amniotic membrane. Archives of ophthalmology 1997; 115: 1360-7. 8. Shimazaki J, Shinozaki N, Tsubota K. Transplantation of amniotic membrane and limbal autograft for patients with recurrent pterygium associated with symblepharon. The British journal of ophthalmology 1998; 82: 235-40. 9. Shimazaki J, Yang HY, Tsubota K. Amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns. Ophthalmology 1997; 104: 2068-76. 10. Tseng SC, Prabhasawat P, Barton K, Gray T, Meller D. Amniotic membrane transplantation with or without limbal allografts for corneal surface reconstruction in patients with limbal stem cell deficiency. Archives of ophthalmology 1998; 116: 431-41. 11. Tseng SC, Prabhasawat P, Lee SH. Amniotic mem-
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brane transplantation for conjunctival surface reconstruction. American journal of ophthalmology 1997; 124: 765-74. 12. Tsubota K, Satake Y, Ohyama M, Toda I, Takano Y, Ono M, Shinozaki N, Shimazaki J. Surgical reconstruction of the ocular surface in advanced ocular cicatricial pemphigoid and Stevens-Johnson syndrome. American journal of ophthalmology 1996; 122: 38-52. 13. Mejia LF, Santamaria JP, Acosta C. Symptomatic management of postoperative bullous keratopathy with nonpreserved human amniotic membrane. Cornea 2002; 21: 342-5. 14. Pires RT, Tseng SC, Prabhasawat P, Puangsricharern V, Maskin SL, Kim JC, Tan DT. Amniotic membrane transplantation for symptomatic bullous keratopathy. Archives of ophthalmology 1999; 117: 1291-7.
EӉ›ÍÂȘ Î·È ·ÔÙÂϤÛÌ·Ù· ‰È·ÌÂÚÔ‡˜ Î·È lamellar ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÎÂÚ·ÙÔÂȉԇ˜
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(HLA A, B, C, DR ‹ Î·È Û˘ÛÙ‹Ì·ÙÔ˜ ABO) ‰Â ÌÂÈÒÓÂÈ Ù· ÔÛÔÛÙ¿ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙȘ ÎÂÚ·ÙÔÏ·ÛÙÈΤ˜ ÚÔ˘Ù›Ó·˜.
∂Ӊ›ÍÂȘ √ √ √ √ √ √ √
∫ÂÚ·ÙfiΈÓÔ˜ 31% º˘Û·ÏÏȉ҉˘ ÎÂÚ·ÙÔ¿ıÂÈ· 26% ∂·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË (regrafts) 19% ¢˘ÛÙÚÔʛ˜ ÎÂÚ·ÙÔÂȉԇ˜ 7% ∂ÚËÙÈ΋ ÎÂÚ·Ù›Ùȉ· 5% ªÂÙ·ÙÚ·˘Ì·ÙÈΤ˜ Ô˘Ï¤˜ ÎÂÚ·ÙÔÂȉԇ˜ 3% ªÂÙ¿ ÌÈÎÚԂȷ΋ ÎÂÚ·Ù›Ùȉ· Ô˘Ï¤˜ ÎÂÚ·ÙÔÂȉԇ˜ 2% √ ¢È¿ÌÂÛË ÎÂÚ·Ù›Ùȉ· √ ¢ÂÛÎÂÌÂÙÔ΋ÏË √ ™˘ÁÁÂÓ›˜ ÎÂÚ·ÙÔ¿ıÂȘ
ªÂÙÂÁ¯ÂÈÚËÙÈ΋ ·ÁˆÁ‹ ∏ Û˘Ó‹ı˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÈ΋ ¯ÔÚ‹ÁËÛË ÎÔÚÙÈ˙ÔÓÔ‡¯ˆÓ ÛÙ·ÁfiÓˆÓ ÁÈ· ÂÚ›Ô‰Ô 6 Ì‹ÓˆÓ ÛÙ·‰È·Î¿ ÌÂÈÔ‡ÌÂÓˆÓ. ™Â ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÎÂÚ·ÙÔÏ·ÛÙÈΤ˜ ··ÈÙÂ›Ù·È Ë ¯ÔÚ‹ÁËÛË Û˘ÛÙËÌ·ÙÈ΋˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ (ÎÔÚÙÈ˙fiÓË ¿ÌÂÛ· ÌÂÙÂÁ¯ÂÈÚËÙÈο, ΢ÎÏÔÛÔÚ›ÓË ‹ Cellcept ÁÈ· Ì·ÎÚÔ¯ÚfiÓÈ· ıÂڷ›·).
1Tan et al. Singapore Cornea Transplant Study Ophthalmology 2007, 2Australian Cornea Graft Registry 2004
∫‡ÚȘ ·Èٛ˜ ·ÔÙ˘¯›·˜ ÌÔۯ‡̷ÙÔ˜ ÛÙË ‰È·ÌÂÚ‹ ÎÂÚ·ÙÔÏ·ÛÙÈ΋ √ √ √ √ √ √ √
∂È‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ ÛÙË ‰È·ÌÂÚ‹ ÎÂÚ·ÙÔÏ·ÛÙÈ΋ (penetrating keratoplasty, PK) ™˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË PK 86% at 1yr 73% at 5yrs 62% at 10yrs 55% at 15yrs EÈ‚›ˆÛË PK ÁÈ· ÎÂÚ·ÙfiΈÓÔ 98% at 1yr 97% at 5 yrs 92% at 10yrs 84% at 15 yrs
∞fiÚÚÈ„Ë Ÿ„ÈÌË ·Ó¿ÚÎÂÈ· ÂÓ‰ÔıËÏ›Ô˘ ªfiÏ˘ÓÛË °Ï·‡ÎˆÌ· ¶ÚˆÙÔ·ı‹˜ ·Ó¿ÚÎÂÈ· O˘ÏÔÔ›ËÛË - ÓÂÔ·ÁÁ›ˆÛË À„ËÏfi˜ ·ÓÒÌ·ÏÔ˜ ·ÛÙÈÁÌ·ÙÈÛÌfi˜ ÌÂÙÂÁ¯ÂÈÚËÙÈο - ¶Ùˆ¯¿ ÔÙÈο ·ÔÙÂϤÛÌ·Ù·
™˘ÌÂÚ·ÛÌ·ÙÈο Ë ‰È·ÌÂÚ‹˜ ÎÂÚ·ÙÔÏ·ÛÙÈ΋ Â›Ó·È ·ÎfiÌË Î·È Û‹ÌÂÚ· ÙÔ Gold Standard √ √ √ √ √
∂È‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜: Ë ÓÂÔ·ÁÁ›ˆÛË ÙÔ˘ ÎÂÚ·ÙÔÂȉԇ˜, Ë ·ÚÔ˘Û›· ÊÏÂÁÌÔÓ‹˜ ηٿ ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô, Ë ·˘ÍË̤ÓË ÂÓ‰ÔÊı¿ÏÌÈ· ›ÂÛË. ∏ ÂÈ‚›ˆÛË ÛÙÔÓ ÎÂÚ·ÙfiΈÓÔ Î·È ÙȘ ‰˘ÛÙÚÔʛ˜ ÎÂÚ·ÙÔÂȉԇ˜ Â›Ó·È Ôχ ηϋ. ∞ÓÙ›ıÂÙ· Ùˆ¯fiÙÂÚË Ë ÂÈ‚›ˆÛË ÛÙË Ê˘Û·ÏÏÈ‰Ò‰Ë ÎÂÚ·ÙÔ¿ıÂÈ· Î·È ÙËÓ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÌÂϤÙË ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜
∞ÏÏ¿: ∞fiÚÚÈ„Ë Ÿ„ÈÌË ·Ó¿ÚÎÂÈ· ÂÓ‰ÔıËÏ›Ô˘ ƒ¿ÌÌ·Ù· ∞ÚÁ‹ ÔÙÈ΋ ·ÔηٿÛÙ·ÛË – ·ÛÙÈÁÌ·ÙÈÛÌfi˜ ∂ÈÏÔΤ˜ open sky ¯ÂÈÚÔ˘ÚÁ›Ԣ
¶ÚfiÁÓˆÛË ‰È·ÌÂÚÔ‡˜ ÎÂÚ·ÙÔÏ·ÛÙÈ΋˜ 60% ÂÈ‚›ˆÛË Û˘ÓÔÏÈο ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙ· 10 ¤ÙË (ACGR, 2001 Î·È SCTS, 2007)1,2
316
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
60% ÙˆÓ ·ÔÙ˘¯ËÌ¤ÓˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÔÊ›ÏÔÓÙ·È Û ·fiÚÚÈ„Ë ‹ fi„ÈÌË ·Ó¿ÚÎÂÈ· ÂÓ‰ÔıËÏ›Ô˘1,3 ∂ÎıÂÙÈ΋ Ì ٷ ¯ÚfiÓÈ· ·ÒÏÂÈ· ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÌÂÙ¿ ·fi ‰È·ÌÂÚ‹ PK, 4-8% οı ¯ÚfiÓÔ4 ª¤ÛÔ˜ ·ÛÙÈÁÌ·ÙÈÛÌfi˜ ÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË Ú·ÌÌ¿ÙˆÓ 3-4 D – 35% ·ÛıÂÓÒÓ ··ÈÙÔ‡Ó RGP º.∂5 15-20% ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·ÔÙ˘Á¯¿ÓÔ˘Ó ÏfiÁˆ ÚÔ‚ÏËÌ¿ÙˆÓ ÔÊı·ÏÌÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ ÙÔ 1Ô ¤ÙÔ˜6 1Tan et al. Singapore Cornea Transplant Study Ophthalmology 2007, 2Australian Cornea Graft Registry 2004, 3Price et al Arch Ophthalmol 2003, 4Patel and Bourne Am J Ophthalmol 2005, 5Claesson 2002, 6Thompson et al Ophthalmology 2003
Lamellar ÎÂÚ·ÙÔÏ·ÛÙÈΤ˜ ™ÙÔ¯Â˘Ì¤ÓË ·ÓÙÈηٿÛÙ·ÛË ¿Û¯ÔÓÙÔ˜ ÈÛÙÔ‡ ¶¿Û¯ÔÓ ÛÙÚÒÌ· Superficial ∞nterior lamellar Keratoplasty – SALK Deep Anterior Lamellar Keratoplasty - DALK
¶¿Û¯ÔÓ ÂÓ‰Ôı‹ÏÈÔ Posterior Lamellar Keratoplasty – PLK ‹ Endothelial Keratoplasty – EK Deep Endothelial Lamellar Keratoplasty – DLEK Descemet Stripping Endothelial Keratoplasty – DSEK Descemet Stripping Automated Endothelial Keratoplasty - DSAEK
∂ͤÏÈÍË ∏¶∞ 2000 10% ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ lamellar 2006 41% lamellar OÏÏ·Ó‰›· 2000 10% lamellar 2006 30% lamellar
∂Ӊ›ÍÂȘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÛÙÚÒÌ·ÙÔ˜ SALK, DALK ∫ÂÚ·ÙfiΈÓÔ˜ ∂ÚËÙÈΤ˜ ÎÂÚ·Ù›Ùȉ˜ ªÂÙ¿ LASIK ÂÎÙ·Û›· ªÂÙ¿ ÌÈÎÚԂȷΤ˜ ÎÂÚ·Ù›Ùȉ˜
317
∂ÈÔÏ‹˜ ıÔÏÂÚfiÙËÙ˜ (‰˘ÛÙÚÔʛ˜ .¯. ReisBucklers, granular, post PRK haze) À„ËÏÔ‡ Ú›ÛÎÔ˘ ÎÂÚ·ÙÔÏ·ÛÙÈΤ˜ (ÓÂÔ·ÁÁÂÈÒÛÂȘ)
Δ¯ÓÈΤ˜ DALK
™˘Ì‚·ÙÈ΋ Δ¯ÓÈ΋ Big bubble ÙÔ˘ Anwar Δ¯ÓÈ΋ Melles ALTK (Moria system) Femtosecond laser
DALK vs PK πÛfiÙÈ̘ ÛÂ: ∞ÛÙÈÁÌ·ÙÈÛÌfi OÙÈ΋ Ô͇ÙËÙ· – Contrast sensitivity? ∞ÒÏÂÈ· ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔÓ 1Ô ¯ÚfiÓÔ ŸÌˆ˜ ÛÙËÓ DALK Ÿ¯È ·fiÚÚÈ„Ë ÂÓ‰ÔıËÏ›Ô˘ Ÿ¯È Û˘Ó¯È˙fiÌÂÓË ·ÒÏÂÈ· ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÃÂÈÚÔ˘ÚÁÂ›Ô Û «ÎÏÂÈÛÙfi» ÔÊı·ÏÌfi (Â͈ıËÙÈ΋ ·ÈÌÔÚÚ¿ÁÈ·, ηٷÚÚ¿ÎÙ˘, ÁÏ·‡ÎˆÌ·, ÂÓ‰ÔÊı·ÏÌ›Ùȉ·) (ªÈÎÚÔ)-¢È·ÙÚ‹ÛÂȘ ‰ÂÛÎÂÌÂÙ›Ԣ 22% Watson et al 0phthalmology 2004; 111: 1676, Panda A et al. Cornea 1999; 18: 172
¶ÚÔ‚Ï‹Ì·Ù· DALK Δ¯ÓÈο ‰˘ÛÎÔÏfiÙÂÚË – ÃÚÔÓÔ‚fiÚÔ˜, ‰È·ÙÚ‹ÛÂȘ ‰ÂÛÎÂÌÂÙ›Ԣ Ÿ¯È Û ÚÔ¯ˆÚË̤ÓÔ˘˜ ÎÒÓÔ˘˜ (Ôχ ÏÂÙÔ›, Ôχ ΢ÚÙÔ› ÎÂÚ·ÙÔÂȉ›˜) Î·È Û ÂÓ Ùˆ ‚¿ıÂÈ ¤ˆ˜ ÙË ‰ÂÛÎÂ̤ÙÂÈÔ Ô˘Ï¤˜ Interface haze – contrast sensitivity? ALTK – ÌË ·ÎÚÈ‚‹˜ ηıÔÚÈÛÌfi˜ ‚¿ıÔ˘˜ ÂÎÙÔÌ‹˜ Î·È ‰È·Ì¤ÙÚÔ˘ Femtosecond Û ʿÛË ‚ÂÏÙ›ˆÛ˘ ·Ú·Ì¤ÙÚˆÓ software
∂Ӊ›ÍÂȘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÂÓ‰ÔıËÏ›Ô˘ PLK ‹ EK (DLEK, DSEK, DSAEK -Descemet Stripping Automated Endothelial Keratoplasty-, FS-DSAEK) º˘Û·ÏÏȉ҉˘ ÎÂÚ·ÙÔ¿ıÂÈ· ¢˘ÛÙÚÔÊ›· Fuchs ¶ÚÔËÁËı›۷ ·ÔÚÚÈÊı›۷ PKP ‹ DSEK
318
M. ¶A¶A£ANA™IOY
¶ÏÂÔÓÂÎÙ‹Ì·Ù· PLK
¶ÚÔ‚Ï‹Ì·Ù· DSAEK
Δ·¯Â›· ·ÔηٿÛÙ·ÛË fiÚ·Û˘ (1-2 Ì‹Ó˜ vs 12 ¤ÙË ÛÙËÓ PK) ∞ÔÊ˘Á‹ ÂÈÏÔÎÒÓ Ú·ÌÌ¿ÙˆÓ (ÌÔχÓÛÂȘ, ÓÂÔ·ÁÁ›ˆÛË, ·fiÚÚÈ„Ë) ∞ÛÙÈÁÌ·ÙÈÛÌfi˜ – ∞ÔÊ˘Á‹ RGP Ê·ÎÒÓ Â·Ê‹˜ ¢È·Ù‹ÚËÛË ‰È·ıÏ·ÛÙÈ΋˜ ‰‡Ó·Ì˘ ¢ÔÌÈο ÛÙ·ıÂÚfi˜ ÔÊı·ÏÌfi˜ (ÙÚ·˘Ì·ÙÈ΋ ‰È¿ÛÙ·ÛË Û PKP)
¶·ÚÂÎÙfiÈÛË ÌÔۯ‡̷ÙÔ˜ ÂÓ‰ÔıËÏ›Ô˘ 9 – 27% 1, 2 ∞ÒÏÂÈ· ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙÔÓ 1Ô ¯ÚfiÓÔ 22-55% 3, 4,5 Î·È ÚˆÙÔ·ı‹˜ ·ÔÙ˘¯›· ÌÔۯ‡̷ÙÔ˜ (6-45%) (·Ó·‰›ÏˆÛË ÌÔۯ‡̷ÙÔ˜ ÁÈ· ¤ÓıÂÛË ·fi ÌÈÎÚ‹ ÙÔÌ‹)
Δ¯ÓÈ΋ PLK 1Ô: ∞ÔÌfiÓˆÛË ÂÓ‰ÔıËÏ›Ô˘ ·fi ‰fiÙË ¢È·¯ˆÚÈÛÌfi˜ manual Û Ù¯ÓËÙfi ¶.£. ¢È·¯ˆÚÈÛÌfi˜ Ì ALTK Precut ÌÔۯ‡̷ٷ ·fi ÙÚ¿Â˙· Femtosecond laser 2Ô: ∞fiÍÂÛË (Stripping), ·Ê·›ÚÂÛË ‰ÂÛÎÂÌÂÙ›Ԣ–ÂÓ‰ÔıËÏ›Ô˘ ·fi ·ÛıÂÓ‹ 3Ô: ŒÓıÂÛË ÌÔۯ‡̷ÙÔ˜ ÂÓ‰ÔıËÏ›Ô˘ ÂÓ‰Èψ̤ÓÔ ·fi ÌÈÎÚ‹ ÙÔÌ‹ Î·È ÛÙ·ıÂÚÔÔ›ËÛ‹ ÙÔ˘ Ì ·¤Ú·
¶ÚÔ‚Ï‹Ì·Ù· ÚÔ˜ Â›Ï˘ÛË Δ¯ÓÈΤ˜ ˘fi ÂͤÏÈÍË ™Ùfi¯ÔÈ: ªÈÎÚfiÙÂÚË ·ÒÏÂÈ· ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Û DSAEK (ÙÚfiÔÈ ÂÓı¤Ûˆ˜) ªÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ‰È·ÙÚ‹ÛÂˆÓ ‰ÂÛÎÂÌÂÙ›Ԣ Û DALK ™ËÌ·ÓÙÈ΋ ‚Ô‹ıÂÈ· ·fi: ™‡ÛÙËÌ· ALTK ¢ÂÓ ··ÈÙ› ȉȷ›ÙÂÚË ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÂÍÈfiÙËÙ· – ηϋ ÔÈfiÙËÙ· ÂÎÙÔÌ‹˜ Femtosecond laser – ¿ÚÈÛÙË ÔÈfiÙËÙ· Î·È ¿¯Ô˜ ÂÎÙÔÌ‹˜ ÃÚ‹ÛË precut ÌÔÛ¯Â˘Ì¿ÙˆÓ ÂÓ‰ÔıËÏ›Ô˘ ·fi ÙÚ¿Â˙˜
¢ˆ‰ÂηÂÙ‹˜ ÂÌÂÈÚ›· ÂÓfi˜ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜
10
§Ô˘Î¿˜ ¶. TÛÔ˘Ú¤Ï˘
‰Ô·ÔÚÙÈ΋˜ ·ÓÙÏ›·˜ (IABP), ¤ˆ˜ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. Δ¤ÏÔ˜ Û 23 ·ÛıÂÓ›˜ ÙÔÔıÂÙ‹ıËΠۇÛÙËÌ· ˘ÔÛÙ‹ÚÈ͢ Ù˘ ΢ÎÏÔÊÔÚ›·˜ (VAD), ·Ô ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ 8 ·ÎÔÏÔ‡ıˆ˜ ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó Ì ÂÈÙ˘¯›·. ŒÁÈÓ ·Ô‰Ô¯‹ ηډȷÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·Ô ‰fiÙ˜, ηٿ ÚÔÙ›ÌËÛË ÓÂÒÙÂÚÔ˘˜ ÙˆÓ 35 ÂÙÒÓ, Ì ·ÈÙ›· ı·Ó¿ÙÔ˘ ·˘ÙfiÌ·ÙË ÂÓ‰ÔÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ‹ ÙÚÔ¯·›Ô ·Ù‡¯ËÌ·. ∏ Û˘ÓÙ‹ÚËÛË ÙÔ˘ ηډȷÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤ÁÈÓ Ì ÙËÓ ¯ÔÚ‹ÁËÛË „˘¯Ú‹˜ ηډÈÔÏËÁ›·˜ «HTK» ıÂÚÌÔÎÚ·Û›·˜ 4 ‚·ıÌÒÓ ∫ÂÏÛ›Ô˘. ™Â fiϘ ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÂÊ·ÚÌfiÛÙËÎÂ Ë ÎÏ·ÛÛÈ΋ Ù¯ÓÈ΋ Ô˘ ÂÚȤÁÚ·„·Ó ÔÈ Lower & Shumway (1960), ÂÓÒ Ô Ì¤ÛÔ˜ ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó 158.5 – 259 min. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·ÓÔÛÔηٷÛÙÔÏ‹ ÂÚÈÂÏ¿Ì‚·ÓÂ, ıÂڷ›· «ÂÈÛ·ÁˆÁ‹˜» Ì ·ÓÙÈı˘ÌÔ΢ÙÙ·ÚÈ΋ ÛÊ·ÈÚ›ÓË (A.T.G.), Î·È ÛÙËÓ Û˘Ó¤¯ÂÈ· ÙÚÈÏfi ıÂڷ¢ÙÈÎfi Û¯‹Ì· Û˘ÓÙ‹ÚËÛ˘, Ì ΢ÎÏÔÛÔÚ›ÓË – ÛÙÂÚÔÂȉ‹ – ·ÓÙÈÌÂÙ·‚ÔÏ›ÙË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (M.M.F.). ªÂÙ¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ÔÈ ·ÛıÂÓ›˜ ·ÎÔÏÔ˘ıÔ‡Ó ÚÔηıÔÚÈṲ̂ÓÔ ÚˆÙfiÎÔÏÏÔ ‚ÈÔ„ÈÒÓ ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂڷ›· Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ŸÏÔÈ ÔÈ ·ıÂÓ›˜ ˘Ô‚¿ÏÏÔÓÙ·È Û ÛÙÂÊ·ÓÈÔÁÚ·Ê›· ¤Ó· Ì‹Ó· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ, ÂÓÒ Ù· ÙÂÏÂ˘Ù·›· ¤ÙË Ì·˙› Ì ÙËÓ ÂÙ‹ÛÈ· ÛÙÂÊ·ÓÈÔÁÚ·Ê›· ‰ÈÂÓÂÚÁÂ›Ù·È Î·È ÂÓ‰ÔÛÙÂÊ·ÓÈ·›· ˘ÂÚ˯ÔÁÚ·Ê›· (IVUS). ∏ Û˘ÓÔÏÈ΋ ıÓËÙfiÙËÙ· ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÙÔ˘ ø.∫.∫. Â›Ó·È 11.9% (7 ·Ûı.), Ë ÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· Â›Ó·È 5.8% (3 ·Ûı.), Î·È Ë ·ÒÙÂÚË 6.8% (4 ·Ûı.). ∏ ÂÈ‚›ˆÛË ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Â›Ó·È 95%, ÙÔÓ ¤ÌÙÔ ¯ÚfiÓÔ 92%, Î·È ÙÔÓ ‰¤Î·ÙÔ ¯ÚfiÓÔ 70%. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ·ÔÏ·Ì‚¿ÓÔ˘Ó ÂÍ·›ÚÂÙË ÔÈfiÙËÙ· ˙ˆ‹˜.
∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ ·ÔÙÂÏ› ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ıÂڷ›· ·ÛıÂÓÒÓ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ηډȷ΋ ·Ó¿ÚÎÂÈ·, ÚÔÛʤÚÔÓÙ·˜ ÙËÓ Ï¤ÔÓ Ì·ÎÚÔ‚ÈfiÙÂÚË Î·È ÔÈÔÙÈÎfiÙÂÚË Â·Ó¤ÓÙ·Í‹ ÙÔ˘˜ ÛÙË ˙ˆ‹. ∞·Ú·›ÙËÙË ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÂÓfi˜ ·ÛıÂÓÔ‡˜ ÛÙË «Ï›ÛÙ· ·Ó·ÌÔÓ‹˜» ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â›Ó·È Ë ÂÍ¿ÓÙËÛË fiÏˆÓ ÙˆÓ Û˘Ì‚·ÙÈÎÒÓ Ê·Ú̷΢ÙÈÎÒÓ Î·È ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ıÂڷ¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ, Ë ¯·ÌËÏ‹ ÏÂÈÙÔ˘ÚÁÈ΋ Ù¿ÍË (III & IV ηٿ NYHA) Î·È ÙÔ Ùˆ¯fi ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘. Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë ¯Ú‹ÛË Û˘Û΢ÒÓ ˘ÔÛÙ‹ÚÈ͢ ÙˆÓ ÎÔÈÏÈÒÓ (VADs), ¤¯ÂÈ ·ÏÏ¿ÍÂÈ ı·̷ÙÈο ÙÔÓ ÙÔ̤· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Î·Ú‰È¿˜, ‰È·ÙËÚÒÓÙ·˜ ÛÙË ˙ˆ‹ ·ÓıÚÒÔ˘˜, ÔÈ ÔÔ›ÔÈ ·Ï·ÈfiÙÂÚ· ı· ›¯·Ó ·Ô‚ÈÒÛÂÈ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜. ∏ ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÌÔÓ¿‰· ÙÔ˘ ø.∫.∫. ÂÊ·ÚÌfi˙ÂÈ ÙȘ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ Ù˘ International Society for Heart Lung Transplantation (I.S.H.L.T.) ηıÒ˜ Î·È ÙˆÓ ∞ÌÂÚÈηÓÈÎÒÓ ∫Ú‰ÈÔÏÔÁÈÎÒÓ ∂Ù·ÈÚÂÈÒÓ (AHA/ACC). ∞Ô Ù· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ȉȷ›ÙÂÚË ÛËÌ·Û›· ¤¯ÂÈ Ë ÂÎÙ›ÌËÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ΢ÎÏÔÊÔÚ›·˜,Ô˘ ·ÔÙÂÏ› ¤Ó· ·Ô ÙÔ˘˜ ÚÒÙÔ˘˜ ÛÙfi¯Ô˘˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Ù˘ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜, ÛÙÔ ÙÂÏÈÎfi ÛÙ¿‰Èfi Ù˘. ∏ ‰È·›ÛÙˆÛË ÌË ·Ó·ÛÙÚ¤„ÈÌ˘ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘ (> 4 w.un. / T.P.G.>15 mmHg) ·ÔÙÂÏ› ·fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ Î·È Û˘Ó‰¤ÂÙ·È Ì ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ¿ÌÂÛ˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Èı·Ó¿ ÌË ·Ó·ÛÙÚ¤„ÈÌ˘. ™ÙÔ ø.∫.∫. ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó Û˘ÓÔÏÈο 58 ·ÛıÂÓ›˜ ,·Ô ÙÔ˘˜ ÔÔ›Ô˘˜ 51 ¤¯Ô˘Ó Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË. ™Â 19 ·ÛıÂÓ›˜ ÙÔ˘ ¶ÚÔÁÚ¿ÌÌ·Ùfi˜ Ì·˜, ˘‹ÚÍ ·Ó¿ÁÎË ÚÔÂÁ¯ÂÈÚËÙÈ΋˜ ÙÔ˘˜ ˘ÔÛÙ‹ÚÈ͢ Ì ÈÓfiÙÚÔ· Ê¿Ú̷η (‰Ô‚Ô˘Ù·Ì›ÓË/ÌÈÏÚÈÓfiÓË), ̤ۈ ÌfiÓÈÌÔ˘ ηıÂÙ‹Ú· Hickman Î·È ÊÔÚËÙ‹˜ ·ÓÙÏ›·˜ Û˘Ó¯ԇ˜ ¤Á¯˘Û˘. ∂›Û˘ 6 ·ÛıÂÓ›˜ ‹Ù·Ó ÛÙËÓ ª.∂.£. Ì ÙËÓ ˘ÔÛÙ‹ÚÈÍË ÈÓÔÙÚfiˆÓ Î·È ÂÓ-
319
AÓ·ÈÛıËÛ›· ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ηډȿ˜ – Ó¢ÌfiÓˆÓ
11
AfiÛÙÔÏÔ˜ £·ÓfiÔ˘ÏÔ˜
AÓ·ÈÛıËÛ›· ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ηډȿ˜
(0.3mg/kg), fentanyl (10Ìg/kg), succinylcholine (1.5mg/kg) Â›Ó·È Ë ÈÔ ‰ËÌÔÊÈÏ‹˜ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ ·Ó·ÈÛıËÛ›·. ™ÙË Û˘Ó¤¯ÂÈ· ‰ÈÂÓÂÚÁÂ›Ù·È ¤Ó·˜ Ï‹Ú˘ ˘ÂÚ˯ÔηډÈÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜, Ô ÔÔ›Ô˜ ı· Ì·˜ ‰ÒÛÂÈ ÏËÚÔÊÔڛ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙË Û˘Û·ÛÙÈÎfiÙËÙ· Ù˘ ·ÚÈÛÙÂÚ‹˜ Î·È Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜, ÛÙË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·ıÒ˜ Î·È ÛÙËÓ ‡·ÚÍË ‹ ÌË Î·Ú‰È·ÎÒÓ ıÚfiÌ‚ˆÓ. ª¤¯ÚÈ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙËÓ Â͈ۈ̷ÙÈ΋ ΢ÎÏÔÊÔÚ›· Ù· ÚÔ‚Ï‹Ì·Ù· Ô˘ ÂÓ‰¤¯ÂÙ·È Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘ÌÂ Â›Ó·È Ë ˘fiÙ·ÛË Î·È ÔÈ ·ÚÚ˘ı̛˜ ·fi ÙÔ˘˜ ¯ÂÈÚÔ˘ÚÁÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜ ÁÈ· ÙÔ cannulation. ÃÔÚËÁÂ›Ù·È Ë·Ú›ÓË Î·È Ô ·ÛıÂÓ‹˜ Ì·›ÓÂÈ ÛÙËÓ Â͈ۈ̷ÙÈ΋ ΢ÎÏÔÊÔÚ›·. ªÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË ÙˆÓ ·Ó·ÛÙÔÌÒÛÂˆÓ Î·È ÚÈÓ ÙÔ ¿ÓÔÈÁÌ· Ù˘ ·ÔÚÙ‹˜ ¯ÔÚËÁÂ›Ù·È ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË 500mg. ∫·ÙfiÈÓ ·ÓÔ›ÁÂÈ Ë ·ÔÚÙ‹ Î·È ·Ú¯›˙ÂÈ Ë ¯ÔÚ‹ÁËÛË ÈÓÔÙÚfiˆÓ Ê·Ú̿ΈÓ. ™Â ·˘Ù‹ ÙË Ê¿ÛË ÙÔ Δ∂∂ Ì·˜ ‰›ÓÂÈ ÏËÚÔÊÔڛ˜ fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ de-airing ÚÈÓ ‚Áԇ̠·fi Â͈ۈ̷ÙÈ΋. OÈ ·ÛıÂÓ›˜ Ì ·˘ÍË̤Ó˜ Ó¢ÌÔÓÈΤ˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· οÓÔ˘Ó ÔÍ›· ·Ó¿ÚÎÂÈ· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜. ∞˘Ùfi ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ¡O ‹ Î·È PGE Ô˘ ÚÔηÏÔ‡Ó ·ÁÁÂÈԉȷÛÙÔÏ‹ ÛÙÔ Ó¢ÌÔÓÈÎfi ‰›ÎÙ˘Ô. ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË ÙÔ Δ∂∂ Ì·˜ ‰›ÓÂÈ ÂÈϤÔÓ ÏËÚÔÊÔڛ˜ ÁÈ· ÙË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ‰ÂÍÈ¿˜ Î·È ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜. ªÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ·fi ÙËÓ Â͈ۈ̷ÙÈ΋ ΢ÎÏÔÊÔÚ›· ¯ÔÚËÁÂ›Ù·È ÚˆÙ·Ì›ÓË ÁÈ· ÙËÓ Ï‹ÚË ·Ó·ÛÙÚÔÊ‹ Ù˘ Ë·Ú›Ó˘. ¢È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜ ÂÈÓ·È Û˘¯Ó¤˜ ÂȉÈο ÛÙÔ‡˜ ·ÛıÂÓ›˜ Ì ÚÔËÁÔ‡ÌÂÓË Â¤Ì‚·ÛË Î·Ú‰È¿˜. ŒÙÛÈ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÏÂÙÔÌÂÚ‹˜ ·ÈÌfiÛÙ·ÛË Î·È ·Ó¿ÏÔÁ· ÙÔÓ ËÎÙÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Ó· ¯ÔÚËÁÔ‡ÓÙ·È ·ÈÌÔÂÙ¿ÏÈ·, Ï¿ÛÌ·Ù· ‹ ·ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ (¯. ÈÓˆ‰ÔÁfiÓÔ). ŸÙ·Ó Ô ·ÛıÂÓ‹˜ ÛÙ·ıÂÚÔÔÈËı› ÎÏ›ÓÂÙ·È ÙÔ ÙÚ·‡Ì· Î·È ÌÂٷʤÚÂÙ·È ÛÙËÓ ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜.
OÈ ˘Ô„‹ÊÈÔÈ Ï‹Ù˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ· ÌÂ Û˘Ìو̷ÙÔÏÔÁ›· NYHA IV, LVEF<20% Î·È ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 60Ô ¤ÙÔ˜ Ù˘ ËÏÈΛ·˜ ÙÔ˘˜. OÈ ··Ú·›ÙËÙ˜ ÂÍÂÙ¿ÛÂȘ Ô˘ Ú¤ÂÈ Ó· Á›ÓÔÓÙ·È ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ ηډȷ΋˜ ÓfiÛÔ˘ ·ÏÏ¿ Î·È ÁÈ· Ó· ·ÔÎÏÂÈÛÙÔ‡Ó ¿ÏϘ ÓfiÛÔÈ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÚÔηϤÛÔ˘Ó ÂÈÏÔΤ˜ ›ӷÈ: Ê˘ÛÈ΋ ÂͤٷÛË, Ï‹Ú˜ ÈÛÙÔÚÈÎfi, ·ÈÌ·ÙÔÏÔÁÈÎfi˜-ÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜, Ó¢ÌÔÓÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË, ÛÙÂÊ·ÓÈÔÁÚ·Ê›·, ˘¤Ú˯Ԙ ηډȿ˜. ∂›Ó·È ›Û˘ ÛËÌ·ÓÙÈÎfi Ó· ÁÓˆÚ›˙Ô˘ÌÂ Â¿Ó ˘¿Ú¯ÂÈ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ÁÈ·Ù› Ë ıÓËÙfiÙ˘ Û ·ÛıÂÓ›˜ Ì TPG>15mmHg Â›Ó·È ÙÚ›˜ ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ‰fiÙË Ë ËÏÈΛ· ÙÔ˘ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙÔ 35Ô ¤ÙÔ˜, Ó· ˘¿Ú¯ÂÈ Û˘Ì‚·ÙfiÙËÙ· ∞μO, Ó· ÌËÓ Â›Ó·È ÛËÙÈÎfi˜, Ó· ÌËÓ ¤¯ÂÈ Î¿ÓÂÈ ·Ó·ÎÔ‹ ÌÂÁ¿Ï˘ ‰È¿ÚÎÂÈ·˜, Ó· ÌËÓ ¤¯ÂÈ ÙÚ·‡Ì· ıÒÚ·ÎÔ˜ Î·È Ó· ÌËÓ Ï·Ì‚¿ÓÂÈ ˘„ËϤ˜ ‰fiÛÂȘ ÈÓÔÙÚfiˆÓ. O ̤ÁÈÛÙÔ˜ ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 4 Ì 6 ÒÚ˜. ¶ÚÔÂÁ¯ÂÈÚËÙÈο Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È Ï‹Ú˜ ÈÛÙÔÚÈÎfi ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Â›Ó·È ··Ú·›ÙËÙÔ Ô ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ Ó· ÁÓˆÚ›˙ÂÈ ·ÎÚÈ‚Ò˜ ÙË ıÂڷ›· Ô˘ Ï·Ì‚¿ÓÔ˘Ó ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ (‰ÈÔ˘ÚËÙÈο, ·ÓÙÈËÎÙÈο, ÈÓfiÙÚÔ·, ACE inhibitors, π∞μƒ, bblockers), Ô‡Ùˆ˜ ÒÛÙ ӷ ÌÔÚ› Ó· οÓÂÈ ¤Ó· Ï¿ÓÔ ¯ÂÈÚÔ˘ÚÁ›Ԣ Î·È Ó· Â›Ó·È Û ı¤ÛË Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ Ù˘¯fiÓ ‰ÈÂÁ¯ÂÈÚËÙÈΤ˜ ‰˘ÛÎÔϛ˜. OÈ ÎÂÓÙÚÈΤ˜ ÁÚ·Ì̤˜ ÙÔÔıÂÙÔ‡ÓÙ·È ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ Ì ÙÔÈ΋ ·Ó·ÈÛıËÛ›·. ΔÔ ··Ú·›ÙËÙÔ monitoring Ô˘ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ ‰È·ı¤ÛÈÌÔ Â›Ó·È Î·ıÂÙ‹Ú·˜ ƒ∞, CCO, SVO2, TEE. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÛÙfi¯Ô˜ Â›Ó·È Ë ÁÚ‹ÁÔÚË ÂÍ·ÛÊ¿ÏÈÛË ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡ Î·È Ë ·ÔÊ˘Á‹ ηٷÛÙÔÏ‹˜ ÙÔ˘ Ì˘Ôηډ›Ô˘. ∏ ¯ÔÚ‹ÁËÛË etomidate
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METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
AÓ·ÈÛıËÛ›· ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ó¢ÌfiÓˆÓ OÈ ˘Ô„‹ÊÈÔÈ Ï‹Ù˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó¢ÌfiÓˆÓ Â›Ó·È ·ÛıÂÓ›˜ Ì Ó¢ÌÔÓÈ΋ ÓfiÛÔ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (NYHA class III-IV). OÈ ··Ú·›ÙËÙ˜ ÂÍÂÙ¿ÛÂȘ Ô˘ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Â›Ó·È: - ™ÂÈÚÔ̤ÙÚËÛË - ∞ÎÙÈÓÔÁÚ·Ê›· Î·È ∞ÍÔÓÈ΋ ıÒÚ·ÎÔ˜ - À¤Ú˯Ԙ ηډȿ˜ - ™ÙÂÊ·ÓÈÔÁÚ·Ê›· ÛÙÔ˘˜ ·ÛıÂÓ›˜ ¿Óˆ ÙˆÓ 40 ÂÙÒÓ ÁÈ· Ó· ·ÔÎÏÂÈÛÙ› οÔÈ· ÛÔ‚·Ú‹ ÛÙ¤ÓˆÛË ‹ Ë ‡·ÚÍË ÂÓ‰ÔηډȷÎÔ‡ shunt. ŸÛÔÓ ·ÊÔÚ¿ ÛÙȘ ¯ÂÈÚÔ˘ÚÁÈΤ˜ Ù¯ÓÈΤ˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÓfi˜ Ó‡ÌÔÓ· Â›Ó·È Ë Â¤Ì‚·ÛË ÂÈÏÔÁ‹˜ ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ Ï‹Ù˜, ÂÎÙfi˜ Î·È ·Ó Ë ·Ú·ÌÔÓ‹ ÙÔ˘ ¿ÏÏÔ˘ Ó‡ÌÔÓ· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÈÏÔΤ˜ (¯. Û ·ÛıÂÓ›˜ Ì ‚ÚÔÁ¯ÈÂÎٷۛ˜, ÔÈ ÔÔ›ÔÈ ¤¯Ô˘Ó ¯ÚfiÓȘ ÏÔÈÌÒÍÂȘ Ô ·Ú·Ì¤ÓˆÓ ÓÂ‡ÌˆÓ ı· ÏÂÈÙÔ˘ÚÁÔ‡Û ˆ˜ reservoir ÏÔÈÌÒ͈Ó). O ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ ÂÎÙfi˜ ·fi ÙÔ ÈÛÙÔÚÈÎfi Ô˘ ¿ÓÙ· Ú¤ÂÈ Ó· ¤¯ÂÈ ÛÙËÓ ‰È¿ıÂÛË ÙÔ˘, Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁ› ÙËÓ ·ÚÔ‡Û· ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÏfiÁˆ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ¯ÚÔÓÈÎÔ‡ ‰È·ÛÙ‹Ì·ÙÔ˜ Ô˘ ÌÂÛÔÏ·‚› ·fi ÙËÓ ÚÒÙË ÙÔ˘ ·ʋ Ì ÙÔÓ ·ÛıÂÓ‹ ·˘ÙfiÓ, ‰ËÏ·‰‹: - ·Ó ¤¯ÂÈ ÌÂȈı› Ë Ê˘ÛÈ΋ ÙÔ˘ ‰Ú·ÛÙËÚÈfiÙ˘ - ·Ó ¤¯ÂÈ ˘ÔÍ·ÈÌ›·, ‚ÚÔÁ¯fiÛ·ÛÌÔ - ·Ó οÓÂÈ ·‡ÛÂȘ ÂÓÒ ÌÈÏ¿ÂÈ ÁÈ· Ó· ·Ó·Ó‡ÛÂÈ, Â›Ó·È ‰Â›ÁÌ·Ù· Èı·ÓÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ. OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¤Ú¯ÔÓÙ·È ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ¯ˆÚ›˜ ÚÔÓ¿ÚΈÛË ÏfiÁˆ ÙÔ˘ fiÙÈ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ·Ó·Ó¢ÛÙÈ΋˜ ηٷÛÙÔÏ‹˜. ∏ ÙÔÔı¤ÙËÛË ÎÂÓÙÚÈÎÒÓ ÁÚ·ÌÌÒÓ Á›ÓÂÙ·È Ì ÙÔÈ΋ ·Ó·ÈÛıËÛ›· ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹. ™ÙË ‰È¿ıÂÛË ÙÔ˘ ·Ó·ÈÛıËÛÈÔÏfiÁÔ˘ Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ: ÙÚ·¯ÂÈÔۈϋӷ˜ ‰ÈÏÔ‡ ·˘ÏÔ‡, ·Ó·Ó¢ÛÙ‹Ú·˜ Ì ÈηÓfiÙËÙ· pressure control ventilation, ¤Ó·˜ ‰Â‡ÙÂÚÔ˜ ·Ó·Ó¢ÛÙ‹Ú·˜ ÁÈ· ÙËÓ ÂÚ›ÙˆÛË ·ÓÂÍ¿ÚÙËÙÔ˘ ·ÂÚÈÛÌÔ‡ ÙˆÓ Ó¢ÌfiÓˆÓ, ηıÂÙ‹Ú·˜ PA, SVO2, TEE. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ ·Ó·ÈÛıËÛ›· Ú¤ÂÈ Ó· ‰›ÓÂÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹ ÛÙËÓ : - ÂÍ·ÛÊ¿ÏÈÛË ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡ - ·ÔÊ˘Á‹ ηٷÛÙÔÏ‹˜ ÙÔ˘ Ì˘Ôηډ›Ô˘, ÂȉÈο Û ·ÛıÂÓ›˜ Ì ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ - ·ÔÊ˘Á‹ ˘ÂډȿٷÛ˘ ÙˆÓ Ó¢ÌfiÓˆÓ ÁÈ·Ù›
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ÌÔÚ› Ó· ÚÔÎÏËı› Ó¢ÌÔıÒڷη˜. ¢ÈÂÁ¯ÂÈÚËÙÈο ÁÈ· Ó· Á›ÓÂÈ Ë Ó¢ÌÔÓÂÎÙÔÌ‹ Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛı› Ô ¤Ó·˜ Ó‡̈Ó. O ·ÂÚÈÛÌfi˜ ÂÓfi˜ Ó‡ÌÔÓÔ˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· Î·È ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ·ÂÚ›ˆÓ. ∏ ÌÂÁ¿ÏË ˘ÔÍ·ÈÌ›· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È: - CPAP ÛÙÔÓ ÌË ·ÂÚÈ˙fiÌÂÓÔ Ó‡ÌÔÓ·. - PEEP ÙÔ ÔÔ›Ô fï˜ ÌÔÚ› Ó· ·˘Í‹ÛÂÈ ÙÔ shunt. - PA Clamping. ΔÔ PA Clamping fï˜ ‰ÂÓ Â›Ó·È Î·Ï¿ ·ÓÂÎÙfi ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË Î·È ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÔÍ›· ·Ó¿ÚÎÂÈ· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜. ∞Ó ·˘Ùfi ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛı› Ì ÙË ¯ÔÚ‹ÁËÛË ÈÓÔÙÚfiˆÓ ÙfiÙÂ Ë Â¤Ì‚·ÛË Û˘Ó¯›˙ÂÙ·È Ì ÙË ‚Ô‹ıÂÈ· Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜. ªÂÙ¿ ÙÔ ¤Ú·˜ ÙˆÓ ·Ó·ÛÙÔÌÒÛÂˆÓ Î·È ·ÊÔ‡ ¤¯ÂÈ ¯ÔÚËÁËı› ÌÂı˘ÏÚ‰ÓÈ˙ÔÏfiÓË 500mg, Ë Â·Ó·ÈÌ¿ÙˆÛË ÌÔÚ› Ó· ÚÔηϤÛÂÈ: - ÀfiÙ·ÛË ÏfiÁˆ ÙˆÓ ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ Ô˘ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È ‹ Ô˘ Û¯ËÌ·Ù›˙ÔÓÙ·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÈÛ¯·ÈÌ›·˜. - ¢È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜. - ¢È·Ù·Ú·¯¤˜ ·ÂÚÈÛÌÔ‡. °È· ·Ú¿‰ÂÈÁÌ· Û ·ÛıÂÓ›˜ Ì ·ÔÊÚ·ÎÙÈ΋ ÓfiÛÔ Ô Ó¤Ô˜ ÓÂ‡ÌˆÓ ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ÂÓ‰ÔÙÈÎfiÙËÙ· ÂÓÒ Ô ·Ï·Èfi˜ ·˘ÍË̤ÓË. ∞˘Ùfi ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ˘ÂډȿٷÛË ÙÔ˘, ÂÓÒ Ô Ó¤Ô˜ ˘Ô·ÂÚ›˙ÂÙ·È. ∏ ˘ÂډȿٷÛË ÂÎÙfi˜ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ·ÂÚÈÛÌÔ‡ ·ÈÌ¿ÙˆÛ˘ ÚÔηÏ› Î·È ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ·. ∏ χÛË Û ·˘Ùfi ÙÔ Úfi‚ÏËÌ· Â›Ó·È Ë ¯ÚËÛÈÌÔÔ›ËÛË ‰‡Ô ·Ó·Ó¢ÛÙ‹ÚˆÓ, ¤Ó·˜ ÁÈ· οı Ó‡ÌÔÓ·. - ∫¿Ì„Ë Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜. - ¶Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·. ∏ ÈÛ¯·ÈÌ›· Î·È Ë Â·Ó·ÈÌ¿ÙˆÛË ÚÔηÏÔ‡Ó ‚Ï¿‚˜ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÏÏÔ›ˆÛË Ù˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ Ù˘ ÌÂÌ‚Ú¿Ó˘ ηıÒ˜ Î·È ÙËÓ ·‡ÍËÛË ÙˆÓ PVR. ¶¿ÓÙ· ˘¿Ú¯ÂÈ ¤Ó·˜ ‚·ıÌfi˜ Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜, ÙÔ ÔÔ›Ô fiÙ·Ó Â›Ó·È ‚·ÚÂÈ¿˜ ÌÔÚÊ‹˜ ÂÌÊ·Ó›˙ÂÙ·È Ì ÛÔ‚·Ú‹ ˘ÔÍ·ÈÌ›·, ·˘ÍË̤ÓË compliance Î·È ÌÂÁ¿Ï˜ ·ÊÚÒ‰ÂȘ ÂÎÎÚ›ÛÂȘ Ô˘ ¯Ú‹˙Ô˘Ó Û˘Ó¯ÒÓ ·Ó·ÚÚÔÊ‹ÛˆÓ. ∏ ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È: ¯ÔÚ‹ÁËÛË ¡O ‹ Î·È ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ, ƒ∂∂ƒ, ‰ÈÔ˘ÚËÙÈο, Ì›ˆÛË ˘ÁÚÒÓ, surfactant. ∞Ó fiÏ· ·˘Ù¿ ·ÔÙ‡¯Ô˘Ó, ÙÔ ÂfiÌÂÓÔ ‚‹Ì· Â›Ó·È Ë ¯ÚËÛÈÌÔÔ›ËÛË ECMO.
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μÈ‚ÏÈÔÁÚ·Ê›· 1. Bailey PL, Mc Gowan F.: Anesthesia for Heart/HeartLung/Lung Transplants, in: ANESTHETIC PRINCIPLES FOR ORGAN TRANSPLANTATION, DR COOK, PJ DAVIS, eds, Raven Press 1994. 2. Christie JM : Inhaled selective pulmonary vasodilators: Seminar in anesthesia. Perioperative medicine and pain 1999, 18-3:231-8.
3. Pulmonary vascular impedance and Recipient Chronic pulmonary hypertension following cardiac transplantation. Ep Chen, HB Bittner, RD Davis Chest 1997; 112; 1622-1629 4. Perioperative management of patients undergoing lung transplantation. Joseph Briegel, Joachim Groh and Mathias Haller. Anaesthesiology 1998, 11:51-59. 5. Cheng DCH, Demajo W, Sandler AN. Lung transplantation. Anesthesiol Clin North Am 1994; 12:749-765.
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Ë ˘ÔÛÙ‹ÚÈÍË Ì ÈÛÔÚÔÙÂÚÂÓfiÏË ‹ ¿ÏÏ· ·ÁÁÂÈÔ‰Ú·ÛÙÈο Ê¿Ú̷η fiˆ˜ ‰Ô‚Ô˘Ù·Ì›ÓË, ÂÈÓÂÊÚ›ÓË Î·È ÓÔÚÂÈÓÂÊÚ›ÓË ·ÔÙÂÏ› ıÂڷ›· ÚÔ˘Ù›Ó·˜ ÙȘ ÚÒÙ˜ 48-72 ÒÚ˜. ™Â ÔÏÏ¿ ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Ë ÈÛÔÚÔÙÂÚÂÓfiÏË ıˆÚÂ›Ù·È Ë ıÂڷ›· ÂÎÏÔÁ‹˜ Î·È Û˘¯Ó¿ ¯ÔÚËÁÂ›Ù·È ‹‰Ë ·fi ÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ÁÈ·Ù› ¤¯ÂÈ ıÂÙÈ΋ ÈÓfiÙÚÔË Î·È ¯ÚÔÓfiÙÚÔË ‰Ú¿ÛË, ÂÓÒ ·Ú¿ÏÏËÏ· ÚÔηÏ› ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹, ÂÏ·ÙÙÒÓÂÈ ÙȘ Ó¢ÌÔÓÈΤ˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ Î·È ‚ÂÏÙÈÒÓÂÈ ÙË ‰È·ÛÙÔÏÈ΋ ¯¿Ï·ÛË ÙˆÓ ÎÔÈÏÈÒÓ. ∂¿Ó Ë ÈÓfiÙÚÔË ˘ÔÛÙ‹ÚÈÍË ‰ÂÓ Â›Ó·È Â·Ú΋˜ ÁÈ· Ó· ÂÍ·ÛÊ·Ï›ÛÂÈ ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚfiÙËÙ·, ÙfiÙ ÂÍÂÙ¿˙ÂÙ·È Ë ÙÔÔı¤ÙËÛË ÂÓ‰Ô·ÔÚÙÈ΋˜ ·ÓÙÏ›·˜, ‹ ¿ÏÏˆÓ Û˘Û΢ÒÓ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ΢ÎÏÔÊÔÚ›·˜. ∂› ÛËÌ·ÓÙÈ΋˜ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÈÓfiÙÚÔ· fiˆ˜ Ë ÌÈÏÚÈÓfiÓË Î·È ·ÁÁÂÈԉȷÛÙ·ÏÙÈο ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁ›ˆÓ (ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘, ÓÈÙÚÔÁÏ˘ÎÂÚ›ÓË, ÓÈÙÚÔÚˆÛÛÈÎfi Ó¿ÙÚÈÔ Î·È ÚÔÛÙ·ÁÏ·Ó‰›ÓË ∂1). Δ¤ÏÔ˜, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÊÏ‚fiÎÔÌ‚Ô˘ Â›Ó·È Û˘¯Ó‹ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜. ∏ ηډȷ΋ Û˘¯ÓfiÙËÙ· Ú¤ÂÈ Ó· ‰È·ÙËÚÂ›Ù·È ÛÙȘ 100 ÂÚ›Ô˘ ÛʇÍÂȘ ·Ó¿ ÏÂÙfi, Ì ÙË ¯Ú‹ÛË ÚÔÛˆÚÈÓÔ‡ ÂÈοډÈÔ˘ ‚ËÌ·ÙÔ‰fiÙË. ∂›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÁÓˆÚ›˙Ô˘Ì fiÙÈ Ë ·ÔÓÂ˘ÚˆÌ¤ÓË Î·Ú‰È¿ ‰ÂÓ ··ÓÙ¿ ÛÙËÓ ·ÙÚÔ›ÓË. ∏ ·ÌÈÓÔÊ˘ÏÏ›ÓË Â›Ó·È Û˘¯Ó¿ ¯Ú‹ÛÈÌË Û ·ÛıÂÓ›˜ Ì ‚Ú·‰˘Î·Ú‰›·. ∂Âȉ‹ Â›Ó·È ÁÓˆÛÙfi fiÙÈ Ô ÊÏ‚fiÎÔÌ‚Ô˜ ÌÔÚ› Ó· ¯ÚÂÈ·Ûı› ‚‰ÔÌ¿‰Â˜ ÁÈ· Ó· ·Ó·ÎÙ‹ÛÂÈ ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘, ÙÔÔı¤ÙËÛË ÌfiÓÈÌÔ˘ ‚ËÌ·ÙÔ‰fiÙË ‰ÂÓ Ú¤ÂÈ Ó· ·ÔÊ·Û›˙ÂÙ·È ÁÈ· ÙȘ ÚÒÙ˜ 4 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.
∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÊÚÔÓÙ›‰· ÙˆÓ ·ÛıÂÓÒÓ Ì ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ Â›Ó·È ·Ó¿ÏÔÁË ÂΛӢ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÔÔÈ·‰‹ÔÙ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË. OÈ Î‡ÚÈÔÈ ÛÙfi¯ÔÈ Ù˘ ¿ÌÂÛ˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ÂÚÈfi‰Ô˘ Â›Ó·È ·) Ë Â›Ù¢ÍË ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ÛÙ·ıÂÚfiÙËÙ·˜ Ô˘ ı· ÂÍ·ÛÊ·Ï›˙ÂÈ ÙËÓ Â·Ú΋ ·ÈÌ¿ÙˆÛË fiÏˆÓ ÙˆÓ ÔÚÁ¿ÓˆÓ ‚) Ë Â›Ù¢ÍË ÈηÓÔÔÈËÙÈ΋˜ ·ÓÙ·ÏÏ·Á‹˜ ÙˆÓ ·ÂÚ›ˆÓ Î·È Á) Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘¯fiÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ÂȉÈο Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiˆ˜ Ë ¤ÁηÈÚË ·Ó·ÁÓÒÚÈÛË Ù˘ ·ÈÌÔÚÚ·Á›·˜, Ë ıÂڷ›· ÙˆÓ ·ÚÚ˘ıÌÈÒÓ, Ë ÚfiÏË„Ë Ù˘ ‰ÂÍÈ¿˜ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜, Ë ‰È¿ÁÓˆÛË Ù˘¯fiÓ ·fiÚÚȄ˘, Ë ÂÈÏÔÁ‹ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È Ë ‰È·›ÛÙˆÛË Ù˘¯fiÓ ·ÚÂÓÂÚÁÂÈÒÓ Ù˘, Ë ÚÔʇϷÍË Î·È Ô ¤ÏÂÁ¯Ô˜ ÙˆÓ ÏÔÈÌÒ͈Ó, Î·È Ë Âη›‰Â˘ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜.
∞ÈÌÔ‰˘Ó·ÌÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ΔÔ ÌfiÛ¯Â˘Ì· Û˘¯Ó¿ ÂΉËÏÒÓÂÈ ÛËÌ›· Ì˘Ôηډȷ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜, ÏfiÁˆ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜ ÙÔ˘ ‰fiÙÔ˘, ·˘ÍË̤ÓÔ˘ ¯ÚfiÓÔ˘ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ˘ÔıÂÚÌ›·˜ ‹ ÏfiÁˆ ‚Ï¿‚˘ ÈÛ¯·ÈÌ›·˜-·ӷÈÌ¿ÙˆÛ˘. ∂ÈÚfiÛıÂÙ·, ·Ó Î·È Ë ÚÔ¸¿Ú¯Ô˘Û· ÌË ·Ó·ÛÙÚ¤„ÈÌË Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË (> 5 Wood Units ‹ ‰È·Ó¢ÌÔÓÈ΋ ÎÏ›ÛË ›ÂÛ˘ > 15mmHg) ıˆÚÂ›Ù·È ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜, ‹È· ‹ ̤ÙÚÈ· Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ·Ú·ÙËÚÂ›Ù·È Û˘¯Ó¿ ÛÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô ·ÛıÂÓÒÓ Ì ·Ô‰ÂÎÙ¤˜ ÚÔÂÁ¯ÂÈÚËÙÈΤ˜ Ó¢ÌÔÓÈΤ˜ ȤÛÂȘ, Ë ‰Â ‰ÂÍÈ¿ ηډȷ΋ ·Ó¿ÚÎÂÈ· ·Ú·Ì¤ÓÂÈ ÌÈ· ·fi ÙȘ ·ÚȘ ·Èٛ˜ ÚÒÈÌ˘ ıÓËÙfiÙËÙ·˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ. ¢ÈÂÁ¯ÂÈÚËÙÈ΋ ‰ÈÔÈÛÔÊ¿ÁÂÈÔ˜ ˘ÂÚ˯ÔÁÚ·Ê›· Î·È Û˘ÛÙËÌ·ÙÈ΋ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ì ηıÂÙ‹Ú· Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ Â›Ó·È ··Ú·›ÙËÙ˜ ÁÈ· ÙËÓ ¤ÁηÈÚË ·Ó›¯Ó¢ÛË ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ∂Ó‰ÔÊϤ‚È· ÈÓfiÙÚÔ-
¶Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· ∞ÛıÂÓ›˜ Ì ÛËÌ·ÓÙÈ΋ Ó¢ÌÔÓÈ΋ Û˘ÌÊfiÚËÛË ÌÔÚ› Ó· ¯ÚÂÈ·Ûı› Ó· ·Ú·Ì›ÓÔ˘Ó Û Ì˯·ÓÈ΋ ·Ó·ÓÔ‹ ÁÈ· ̤Ú˜ ̤¯ÚÈ Ó· ·Ô‚ÏËıÔ‡Ó Ù· ÏÂÔÓ¿˙ÔÓÙ· ˘ÁÚ¿. ∏ ·Ó¿ÁÎË ·Ú¿Ù·Û˘ ÙÔ˘ ÌË-
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K. MAPA£IA
¯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ·˘Í¿ÓÂÈ ÙË ıÓËÙfiÙËÙ· ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜. ∏ ·ÓÙȉڷÛÙÈ΋ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ˘Ô¯ˆÚ› ÛÈÁ¿ ÛÈÁ¿ ÌÂÙ¿ ÙÔ ¯ÂÈÚÔ˘ÚÁ›Ô, ·ÏÏ¿ ÌÔÚ›, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ˘ÂÚÊfiÚÙˆÛË Ì ˘ÁÚ¿ Î·È ÙÔ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ıÂÙÈ΋˜ ›ÂÛ˘ Ó· ÂȉÂÈÓÒÛÂÈ ÙË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜.
¡ÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ¶ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ¿ÓÔ‰Ô˜ Ù˘ ÎÚ·ÙÈÓ›Ó˘ Â›Ó·È Û˘¯Ó‹ Û ·ÛıÂÓ›˜ Ì ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ‹ Û‡Ó‰ÚÔÌÔ ¯·ÌËÏ‹˜ ηډȷ΋˜ ·ÚÔ¯‹˜. ∏ ‚ÂÏÙÈÛÙÔÔ›ËÛË Ù˘ Ì˘Ôηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÂÚÈÔÚ›˙ÂÈ ÙËÓ Èı·ÓfiÙËÙ· ·Ó¿Ù˘Í˘ ÛËÌ·ÓÙÈ΋˜ ÓÂÊÚÈ΋˜ ·Ó¿ÚÎÂÈ·˜. ∏ ΢ÎÏÔÛÔÚ›ÓË Â›Ó·È ÓÂÊÚÔÙÔÍÈ΋, ȉ›ˆ˜ ÛÙËÓ ÂÓ‰ÔÊϤ‚È· ÌÔÚÊ‹ Ù˘, ÁÈ ·˘Ùfi Ë ¯Ú‹ÛË Ù˘ ·Ó·‚¿ÏÏÂÙ·È Ì¤¯ÚÈ ÙËÓ ÚÒÙË ‹ ‰Â‡ÙÂÚË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ Î·È ¯ÔÚËÁÂ›Ù·È Î·Ù¿ ÚÔÙ›ÌËÛË ·fi ÙÔ ÛÙfiÌ·. ∂Ó·ÏÏ·ÎÙÈο, ·ÓÙ› Ù˘ ΢ÎÏÔÛÔÚ›Ó˘, ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› FK506 (tacrolimus) ‹ Ó· ÂÏ·¯ÈÛÙÔÔÈËı› Ë ‰fiÛË Ù˘ Î·È Ó· ·˘ÍËıÔ‡Ó Ù· ˘fiÏÔÈ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η. ªÂÙÂÁ¯ÂÈÚËÙÈ΋ ˘¤ÚÙ·ÛË ·Ó·Ù‡ÛÛÂÙ·È ÛÙÔ 75% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ. Δ· ΢ÚÈfiÙÂÚ· ·›ÙÈ· Â›Ó·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÁÁÂȷ΋˜ ·ÓÙȉڷÛÙÈÎfiÙËÙ·˜ ÏfiÁˆ ΢ÎÏÔÛÔÚ›Ó˘ Î·È Ë Î·Ù·ÎÚ¿ÙËÛË ˘ÁÚÒÓ ÏfiÁˆ ÛÙÂÚÔÂȉÒÓ. OÈ ·Ó·ÛÙÔÏ›˜ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ Î·È ÔÈ ·Ó·ÛÙÔÏ›˜ ÙˆÓ ‰È·‡ÏˆÓ ·Û‚ÂÛÙ›Ô˘ Â›Ó·È Ë ıÂڷ›· ÂÎÏÔÁ‹˜, ·Ó Î·È ÔÈ ÚÒÙÔÈ Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Ì ÚÔÛÔ¯‹ ÏfiÁˆ Ù˘ Èı·Ó‹˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ·fi ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË.
∞fiÚÚÈ„Ë - ∞ÓÔÛÔηٷÛÙÔÏ‹ O ·ÚÈÔ˜ ÛÙfi¯Ô˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ Â›Ó·È ·Ê ÂÓfi˜ Ë ÙÚÔÔÔ›ËÛË Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ·ÛıÂÓÔ‡˜ ÒÛÙ ӷ ÂÈÙ˘Á¯¿ÓÂÙ·È Ë ÚfiÏË„Ë Ù˘ ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ì ·Ú¿ÏÏËÏË ‰È·Ù‹ÚËÛË ÙˆÓ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÂÓ¿ÓÙÈ· Û ÏÔÈÌÒÍÂȘ Î·È ÓÂÔϷۛ˜ Î·È ·Ê ÂÙ¤ÚÔ˘ Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË Ù˘ ÙÔÍÈÎfiÙËÙ·˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ¯Ú‹ÛË ÙˆÓ Ê·ÚÌ¿ÎˆÓ ·˘ÙÒÓ. ∞Ó Î·È Ô Î›Ó‰˘ÓÔ˜ ·fiÚÚȄ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙÔ˘˜ ÚÒÙÔ˘˜ 3 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ‰È· ‚›Ô˘ ·Ó·ÛÔηٷÛÙÔÏ‹ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· Ó· ÚÔÊ˘Ï¿ÍÂÈ ÙË ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓË Î·Ú‰È¿ ·fi ÙËÓ ÔÍ›· ·fiÚÚÈ„Ë. Δ· ÙÂÏÂ˘Ù·›· 20
¯ÚfiÓÈ· Ù· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ¯ÚËÛÈÌÔÔÈÔ‡Ó ·ÚfiÌÔÈ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· Ì ΢ÎÏÔÛÔÚ›ÓË, Ú‰ÓÈ˙fiÓË Î·È ·˙·ıÂÈÔÚ›ÓË ‹ mycophenolate mofetyl (cellcept). ∞ÚÎÂÙ¿ ΤÓÙÚ· ¯ÚËÛÈÌÔÔÈÔ‡Ó ·Ú¯Èο ıÂڷ›· ·ÁˆÁ‹˜ Ì ·ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ȉ›ˆ˜ Â¿Ó Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙËÓ ¿ÌÂÛË ¯Ú‹ÛË ÓÂÊÚÔÙÔÍÈÎÒÓ Ê·Ú̿ΈÓ. °È· ÙË ıÂڷ›· Ù˘ ·fiÚÚȄ˘ ÎÏ·ÛÛÈο ¯ÔÚËÁÔ‡ÓÙ·È ˘„ËϤ˜ ‰fiÛÂȘ ÛÙÂÚÔÂȉÒÓ ‹ ·ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ·Ú¿ÁÔÓÙ˜. ∂¿Ó Ô ·ÛıÂÓ›˜ ‰ÂÓ ÂÌÊ·Ó›˙ÂÈ ÂÂÈÛfi‰È· ·fiÚÚȄ˘, ÂȯÂÈÚÂ›Ù·È ‰È·ÎÔ‹ ÙˆÓ ÛÙÂÚÔÂȉÒÓ 6-12 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ Î‡ÚȘ ·ÚÂÓ¤ÚÁÂȘ ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·›ÓÔÓÙ·È ÛÙÔÓ ›Ó·Î· 1. ¶›Ó·Î·˜ 1. ∫‡ÚȘ ·ÚÂÓ¤ÚÁÂȘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ∞ÓÔÛÔηٷÛÙ·ÏÙÈÎfi˜ ¶·ÚÂÓ¤ÚÁÂȘ ·Ú¿ÁˆÓ ∫·Ù·ÎÚ¿ÙËÛË ˘ÁÚÒÓ (·‡ÍËÛË ‚¿ÚÔ˘˜, ˘¤ÚÙ·ÛË), ‰˘Û·ÓÂÍ›· ÛÙË ÁÏ˘Îfi˙Ë, Û‡Ó‰ÚÔÌÔ Cushing, ÂÙÈÎfi ¤ÏÎÔ˜, ÔÛÙÂÔfiÚˆÛË, Ì˘Ô¿ıÂÈ·, ηٷÚÚ¿ÎÙ˘, ¿ÛËÙ˜ ÓÂÎÚÒÛÂȘ, ˘ÂÚÏÈȉ·ÈÌ›·, „‡¯ˆÛË, η΋ ÂԇψÛË ÙÚ·˘Ì¿ÙˆÓ ∫˘ÎÏÔÛÔÚ›ÓË ¡ÂÊÚÔÙÔÍÈÎfiÙËÙ·, ˘¤ÚÙ·ÛË, Ë·ÙÔÙÔÍÈÎfiÙËÙ·, Ó¢ÚÔÙÔÍÈÎfiÙËÙ·, ¯ÔÏÔÏÈı›·ÛË, ˘ÂÚÙÚÔÊ›· ԇψÓ, ˘ÂÚÙÚ›¯ˆÛË, ˘ÂÚÔ˘Úȯ·ÈÌ›·, ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹ Cellcept ∞ÈÌ·ÙÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜, ˘¤ÚÙ·ÛË – Ù·¯˘Î·Ú‰›·, ÂÚÈÊÂÚÈÎfi Ô›‰ËÌ·, ˘ÚÂÙfi˜ Á·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜, ·¸Ó›·, ·ÓËÛ˘¯›·, ÎÂÊ·Ï·ÏÁ›·, ·‰˘Ó·Ì›·, ÙÚfiÌÔ˜, ·Ú·ÈÛıËۛ˜ A˙·ıÂÈÔÚ›ÓË ∫·Ù·ÛÙÔÏ‹ ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ, ·ÁÎÚ·ٛÙȉ·, Ë·Ù›Ùȉ·, Á·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ (Ó·˘Ù›·, ¤ÌÂÙÔ˜, ‰È¿ÚÚÔÈ·, ÎÔÈÏȷο ¿ÏÁË), ¯ÔÏÔÛÙ·ÙÈÎfi˜ ›ÎÙÂÚÔ˜, ·ÏˆÂΛ· ∞ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈ΋- ¶˘ÚÂÙfi˜ Î·È Ú›ÁÔ˜, ıÚÔÌ‚Ô΢ÙÙÔÂÓ›·, ÛÊ·ÈÚ›ÓË (∞ΔG) Á·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜, ·Ó·ÈÌ›·, Ï¢ÎÔÂÓ›·, ·ÚıÚ·ÏÁ›Â˜, ÂÍ¿ÓıËÌ·, ·ÏˆÂΛ· O∫Δ3 ¶˘ÚÂÙfi˜, Ú›ÁÔ˜, Ï¢ÎÔÂÓ›·, ‰‡ÛÓÔÈ·, ‚ÚÔÁ¯fiÛ·ÛÌÔ˜, ηÎÔ˘¯›·, Á·ÛÙÚÂÓÙÂÚÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÎÂÊ·Ï·ÏÁ›·, ÙÚfiÌÔ˜ Î·È Û·ÛÌÔ›, Ì‹ ηډÈÔÁÂÓ¤˜ Ó. Ô›‰ËÌ·, ˘fiÙ·ÛË, ÂÍ¿ÓıËÌ· ™ÙÂÚÔÂȉ‹
∂Ó‰ÔÌ˘Ôηډȷ΋ ‚ÈÔ„›· ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË Èı·Ó‹˜ ˘ÔÎÏÈÓÈ΋˜ ÔÍ›·˜ ·fiÚÚȄ˘ Á›ÓÂÙ·È ÌÈ· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Î·È ÛÙË Û˘Ó¤¯ÂÈ· Û‡Ìʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ ÙÔ˘ οı ∫¤ÓÙÚÔ˘. ªÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ÛÙËÓ ·Ó·ÛÔηٷÛÙ·ÏÙÈ΋ Ê·Ú¤ÙÚ· Ù· ÎÏÈÓÈο ÛË-
METAMO™XEY™EI™ 2007: ™‡Á¯ÚÔÓ˜ ··ÓÙ‹ÛÂȘ Û ·Ï·È¿ ÂÚˆÙ‹Ì·Ù·
Ì›· ·fiÚÚȄ˘ ‰ÂÓ Â›Ó·È È‰È·›ÙÂÚ· Û˘¯Ó¿. ∂ÂÈÛfi‰È· ÂÈ̤ÓÔ˘Û·˜ ‚Ú·‰˘Î·Ú‰›·˜, ‹ ÂΉ‹ÏˆÛË Û˘Ó‰ÚfiÌÔ˘ ¯·ÌËÏ‹˜ ηډȷ΋˜ ·ÚÔ¯‹˜ ÛËÌ·ÙÔ‰ÔÙÔ‡Ó Û˘¯Ó¿ ÔÍ›· ·fiÚÚÈ„Ë Î·È Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁÔ‡ÓÙ·È ÁÈ· ¿ÌÂÛË ‚ÈÔ„›·. ∞ÓÙ›ıÂÙ·, ÔÈ ÎÔÏÈΤ˜ ·ÚÚ˘ı̛˜ Â›Ó·È ·ÚÎÂÙ¿ Û˘¯Ó¤˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜ Î·È Â›Ó·È ÏÈÁfiÙÂÚÔ ·ÓËÛ˘¯ËÙÈΤ˜.
§ÔÈÌÒÍÂȘ O ΛӉ˘ÓÔ˜ ÏÔÈÌÒÍÂˆÓ ÛÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ·ÛıÂÓ‹ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô Î·ıÒ˜ Î·È ÛÙȘ ÂÚÈfi‰Ô˘˜ Ù˘ ·˘ÍË̤Ó˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜, Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙË ıÂڷ›· Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘. OÈ ÏÔÈÌÒÍÂȘ Â›Ó·È ÈÔ Û˘¯Ó¤˜ ÛÙÔ˘˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ·ÛıÂÓ›˜, Û ·˘ÙÔ‡˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÚÔÂÁ¯ÂÈÚËÙÈο Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ ‹ Ù˘ ΢ÎÏÔÊÔÚ›·˜, Î·È fiÙ·Ó Ô ‰fiÙ˘ Â›Ó·È CMV ıÂÙÈÎfi˜ ‹ Á˘Ó·›Î·. ¶ÈÔ Û˘¯Ó¤˜ Â›Ó·È ÔÈ ‚·ÎÙËÚȷΤ˜ Î·È ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ, ·Ó Î·È Ì˘ÎËÙÈ¿ÛÂȘ Î·È ÚˆÙÔ˙ˆÈΤ˜ ÏÔÈÌÒ-
325
ÍÂȘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙÔ 10% ÙˆÓ ·ÛıÂÓÒÓ. ∂ÈıÂÙÈ΋ ÚÔÛ¤ÁÁÈÛË Î·È ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ˘ÚÂÙÔ‡, Ù˘ Ï¢ÎÔ΢ÙÙ¿ÚˆÛ˘, Ù˘¯fiÓ ‰ÈËıËÌ¿ÙˆÓ ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜, ÙÔ˘ ÔÓÔÎÂÊ¿ÏÔ˘, ·ÏÏ·ÁÒÓ ÙÔ˘ ÂȤ‰Ô˘ Û˘Ó›‰ËÛ˘ ‹ ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ¿ÏÁÔ˘˜ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰È¿ÁÓˆÛË Î·È ıÂڷ›· Ù˘¯fiÓ ÏÔÈÌÒ͈Ó. ¶ÚÔÊ˘Ï·ÎÙÈ΋ ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ ¯ÔÚËÁÂ›Ù·È Û·Ó ÚÔ˘Ù›Ó· ÙȘ ÚÒÙ˜ 48 ÒÚ˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜. ΔÔ ÚÔÛˆÈÎfi Ô˘ ÊÚÔÓÙ›˙ÂÈ ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ·ÛıÂÓ‹ Ú¤ÂÈ Ó· Â›Ó·È Û¯ÔÏ·ÛÙÈÎfi ÛÙÔ Ï‡ÛÈÌÔ ÙˆÓ ¯ÂÚÈÒÓ. ™Ù· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Ë ·ÔÌfiÓˆÛË ÙˆÓ ·ÛıÂÓÒÓ ‰ÂÓ ıˆÚÂ›Ù·È ·fiÏ˘Ù· ··Ú·›ÙËÙË.
μÈ‚ÏÈÔÁÚ·Ê›· 1. Bethea BT, Yuh DD, Conte JV, Baumgartner WA. Heart Transplantation. In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003:1427-1460. 2. Kirklin JK, Young JB, McGiffin DC eds. Heart Transplantation. Churchill Livingstone, 2002: 375-583