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9

™Y°°PAºEI™ •¤ÓÔÈ ™˘ÁÁÚ·Ê›˜: 1. Reding Raymond, Professeur, Hôpital Saint Luc, Unité de chirurgie pédiatrique abdominale et générale, Brussels, Belgium

ŒÏÏËÓ˜ ™˘ÁÁÚ·Ê›˜: 1. ∞ÓÙˆÓÈ¿‰Ë˜ ¡ÈÎfiÏ·Ô˜, §¤ÎÙÔÚ·˜ ÃÂÈÚÔ˘ÚÁÈ΋˜-ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛˆÓ, °¡£ «πÔÎÚ¿ÙÂÈÔ» 2. μÚÔ¯›‰Ë˜ ¢ÈÔÓ‡ÛÈÔ˜, ÃÂÈÚÔ˘ÚÁfi˜, ∂ÈÛÙËÌÔÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ ÃÂÈÚÔ˘ÚÁÈ΋˜ ∫ÏÈÓÈ΋˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 3. °ÂˆÚÁ¿Î˘ πˆ¿ÓÓ˘, ¶·È‰Ô¯ÂÈÚÔ˘ÚÁfi˜, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 4. °Ô˘Ï‹˜ πˆ¿ÓÓ˘, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜-°·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ∞¶£, ¢’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ» 5. °Ô‡ÌÂÓÔ˜ ¢ËÌ‹ÙÚÈÔ˜, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜-¡ÂÊÚÔÏÔÁ›·˜, ¢È¢ı˘ÓÙ‹˜ ¡ÂÊÚÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ˘ ¶·ÙÚÒÓ 6. ¢Ú·ÎfiÔ˘ÏÔ˜ ™˘Ú›‰ˆÓ, ÃÂÈÚÔ˘ÚÁfi˜, ¢È¢ı˘ÓÙ‹˜ ∞’ ÃÂÈÚÔ˘ÚÁÈÎÔ‡ ΔÌ‹Ì·ÙÔ˜ Î·È ∂ÈÛÙËÌÔÓÈÎfi˜ À‡ı˘ÓÔ˜ ªªO, °¡∞ «O ∂˘·ÁÁÂÏÈÛÌfi˜» 7. £ÂÔ‰ˆÚ›‰Ë˜ ª¿ÚÈÔ˜, ¡ÂÊÚÔÏfiÁÔ˜, ∂ÈÌÂÏËÙ‹˜ μ’, ¡ÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, π·ÙÚÈ΋ ™¯ÔÏ‹ ¢¶£, ¶°¡ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 8. ÿÌ‚ÚÈÔ˜ °ÂÒÚÁÈÔ˜, ÃÂÈÚÔ˘ÚÁfi˜, ¢È¢ı˘ÓÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛˆÓ, °¡£ «πÔÎÚ¿ÙÂÈÔ» 9. ∫ÔÛΛӷ˜ πˆ¿ÓÓ˘, ∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜-∏·ÙÔÏÔÁ›·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ∞ıËÓÒÓ, ¶·ÓÂÈÛÙËÌȷ΋ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡∞ «πÔÎÚ¿ÙÂÈÔ» 10. §·Ì·‰·Ú›Ô˘ ∫·ÙÂÚ›Ó·, ∞Ó·ÈÛıËÛÈÔÏfiÁÔ˜, ∞Ó·ÏËÚÒÙÚÈ· ¢È¢ı‡ÓÙÚÈ·, ∞Ó·ÈÛıËÛÈÔÏÔÁÈÎfi ΔÌ‹Ì·, °¡∞ «§·˚Îfi» 11. ª·ÚÈÓ¿ÎË ™Ì·Ú·Á‰‹, ¡ÂÊÚÔÏfiÁÔ˜, ∂ÈÌÂÏ‹ÙÚÈ· B’, ¡ÂÊÚÔÏÔÁÈÎfi ΔÌ‹Ì·, °.N.A. «§·˚Îfi» 12. ªÔ‡ÙÛÈ·ÓÔ˜ °ÂÒÚÁÈÔ˜, ∞Ó·ÈÛıËÛÈÔÏfiÁÔ˜, ∂ÈÌÂÏËÙ‹˜ ∞’, ∞Ó·ÈÛıËÛÈÔÏÔÁÈÎfi ΔÌ‹Ì·, °¡£ «πÔÎÚ¿ÙÂÈÔ» 13. ª¿ÚÏ·˜ ∞ϤͷӉÚÔ˜, ÃÂÈÚÔ˘ÚÁfi˜, ∂ÈÌÂÏËÙ‹˜ B’, ªª¡, °¡∞ «§·˚Îfi» 14. ªÔϤÙ˘ πˆ¿ÓÓ˘, ¡ÂÊÚÔÏfiÁÔ˜, ¢È¢ı˘ÓÙ‹˜, ¡ÂÊÚÔÏÔÁÈÎfi ΔÌ‹Ì· Î·È MÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ∫¤ÓÙÚÔ, °.N.A. «§·˚Îfi» 15. ª˘ÛÂÚÏ‹˜ °ÚËÁfiÚÈÔ˜, ¡ÂÊÚÔÏfiÁÔ˜, ¢È¢ı˘ÓÙ‹˜, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 16. Deutsch Melanie, ¶·ıÔÏfiÁÔ˜-∏·ÙÔÏfiÁÔ˜, ∂ÈÌÂÏ‹ÙÚÈ· ∞’, °¡∞ «πÔÎÚ¿ÙÂÈÔ» 17. ¶··ÓÈÎÔÏ¿Ô˘ μ·Û›ÏÂÈÔ˜, ∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜-ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛˆÓ, °¡£ «πÔÎÚ¿ÙÂÈÔ» 18. ¶·Û·‰¿Î˘ ¶ÏÔ˘Ì‹˜, ∫·ıËÁËÙ‹˜ ¡ÂÊÚÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¢¶£, ¡ÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, ¶°¡ ∞ÏÂÍ·Ó‰ÚÔ‡ÔÏ˘ 19. ™·ÌˆÓ¿Î˘ ¢ËÌ‹ÙÚÈÔ˜, °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜, ∂ÈÌÂÏËÙ‹˜ ∞’, °·ÛÙÚÂÓÙÂÚÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜, ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∏Ú·ÎÏ›Ԣ ∫Ú‹Ù˘ 20. ™È‰ËÚÔÔ‡ÏÔ˘ Δ·ÙÈ·Ó‹, §¤ÎÙÔÚ·˜ ∞Ó·ÈÛıËÛÈÔÏÔÁ›·˜, ∞Ó·ÈÛıËÛÈÔÏÔÁÈÎfi ΔÌ‹Ì·, ¶°¡ «∞ÙÙÈÎfiÓ» 21. ™Ù¿ÁÎÔ˘ ª·Ú›·, ¡ÂÊÚÔÏfiÁÔ˜, ∂ÈÌÂÏ‹ÙÚÈ·, ¡ÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ» 22. Δ·ÎÔ‡‰·˜ ¢ËÌ‹ÙÚÈÔ˜, ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ¢/ÓÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ∫ÏÈÓÈ΋˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£ 23. ΔÚÈ¿ÓÙÔ˜ ÃÚ‹ÛÙÔ˜, °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜, ∂ÈÌÂÏËÙ‹˜ ∞’, ¶¶°¡ ¶·ÙÚÒÓ 24. ΔÛԇη °Ï˘ÎÂÚ›·, ¡ÂÊÚÔÏfiÁÔ˜, ∂ÈÎÔ˘ÚÈ΋ π·ÙÚfi˜, ¡ÂÊÚÔÏÔÁÈÎfi ΔÌ‹Ì· Î·È ªªO, °¡∞ «O ∂˘·ÁÁÂÏÈÛÌfi˜» 25. ºÔ‡˙·˜ πˆ¿ÓÓ˘, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 26. ÃÔÏÔÁΛٷ˜ ∂˘¿ÁÁÂÏÔ˜, §¤ÎÙÔÚ·˜ ¶·ıÔÏÔÁ›·˜ ∞¶£, ¢’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ»

11

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¶·ıÔÁ¤ÓÂÈ· Ù˘ ¢È·‚ËÙÈ΋˜ NÂÊÚÔ¿ıÂÈ·˜ ª¿ÚÈÔ˜ £. £ÂÔ‰ˆÚ›‰Ë˜ ∂ÈÛ·ÁˆÁ‹

Ó˘, ∂Ó‰ÔıËÏ›Ó˘) Ô˘ ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ¤ÎÎÚÈÛË Î˘ÙÔÎÈÓÒÓ Ô˘ ÚÔ¿ÁÔ˘Ó ÙËÓ ›ÓˆÛË fiˆ˜ Ô Transforming Growth Factor ‚1 (TGF-‚1) ÚÔηÏÒÓÙ·˜ ÂÚ·ÈÙ¤Úˆ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ fiˆ˜ Ë ¿ÓÔ‰Ô˜ Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ Î·È Ù˘ ÂÓ‰ÔÛÂÈÚ·Ì·ÙÈ΋˜ ›ÂÛ˘. OÈ ÌÂÙ·‚ÔÏÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ÌË ÂÓ˙˘Ì·ÙÈ΋ ÁÏ˘ÎÔ˙˘Ï›ˆÛË, ÙËÓ ·˘ÍË̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÚˆÙÂ˚ÓÈ΋˜ ÎÈÓ¿Û˘ C (PKC) ηıÒ˜ Â›Û˘ Î·È ÙÔÓ ·ıÔÏÔÁÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ÔÏ˘ÔÏÒÓ. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙÔÓ Û˘Û¯ÂÙÈÛÌfi Ù˘ ·˘ÍË̤Ó˘ ¤ÎÎÚÈÛ˘ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ ÌÔÚ›ˆÓ (΢ÙÔÎÈÓÒÓ) ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÌÂÙ·ÏÏÔÚˆÙÂÈÓ·ÛÒÓ Î·ıÒ˜ Â›Û˘ Î·È ÙÔ˘ ÔÍÂȉˆÙÈÎÔ‡ stress ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ¢¡.

∏ ¢È·‚ËÙÈ΋ ¡ÂÊÚÔ¿ıÂÈ· (¢¡) ·ÔÙÂÏ› ·ÁÎÔÛÌ›ˆ˜ ÙËÓ ÚÒÙË ·ÈÙ›· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (ESRD).ΔÔ ÔÛÔÛÙfi ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ô˘ ·Ó·Ù‡ÛÛÔ˘Ó ¢¡ Î˘Ì·›ÓÂÙ·È ·fi 20-40 % Ì ¿ÁÓˆÛÙÔ˘˜ ̤¯ÚÈ Î·È Û‹ÌÂÚ· ÙÔ˘˜ ÏfiÁÔ˘˜ ÌË ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰È·‚ËÙÈÎÒÓ. ∏ ¢¡ ·ÔÙÂÏ› ÌÈ· ÌÈÎÚÔ·ÁÁÂȷ΋ ÂÈÏÔ΋ ÙÔ˘ ‰È·‚‹ÙË (fiˆ˜ Ë ‰È·‚ËÙÈ΋ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·) Î·È ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ·fi ¤ÓÙ ÙÔ˘Ï¿¯ÈÛÙÔÓ ¯ÚfiÓÈ· ‰È¿ÚÎÂÈ·˜ ÙÔ˘ ‰È·‚‹ÙË. ∏ Ê˘ÛÈ΋ ÔÚ›· Ù˘ ÓfiÛÔ˘ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÛÙ¿‰È· Ù˘ ÀÔÎÏÈÓÈ΋˜ ¡ÂÊÚÔ¿ıÂÈ·˜ ,Ù˘ ∫ÏÈÓÈ΋˜ ¡ÂÊÚÔ¿ıÂÈ·˜ Î·È ÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ¡ÂÊÚÈ΋˜ ∞ÓÂ¿ÚÎÂÈ·˜. O ‰È·¯ˆÚÈÛÌfi˜ ÙˆÓ ÛÙ·‰›ˆÓ Á›ÓÂÙ·È Ì ‚¿ÛË ÙÔ Ú˘ıÌfi ¤ÎÎÚÈÛ˘ (·Ô‚ÔÏ‹˜) ÏÂ˘ÎˆÌ·Ù›Ó˘ ÛÙ· Ô‡Ú· (UAER). ΔÔ ÛÙ¿‰ÈÔ Ù˘ ÀÔÎÏÈÓÈ΋˜ ¡ÂÊÚÔ¿ıÂÈ·˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ô‚ÔÏ‹ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÛÙ· Ô‡Ú· ·fi 30 ¤ˆ˜ 300 mg/24ˆÚÔ (Ê.Ù <30 mg/24ˆÚÔ) ÂÓÒ ÂÚ·ÈÙ¤Úˆ ·‡ÍËÛË Ù˘ ·Ô‚ÔÏ‹˜ Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ Û Â›‰· ÛÙ·ıÂÚ¿ >300 mg/24ˆÚÔ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙÔ ÛÙ¿‰ÈÔ Ù˘ ∫ÏÈÓÈ΋˜ ¡ÂÊÚÔ¿ıÂÈ·˜. ΔÔ 1/3 ÂÚ›Ô˘ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ ı· ÂÈÛ¤ÏıÂÈ ÛÙÔ ÛÙ¿‰ÈÔ Ù˘ ÀÔÎÏÈÓÈ΋˜ ¡ÂÊÚÔ¿ıÂÈ·˜ Î·È ·fi ·˘ÙÔ‡˜ ¤Ó· ÔÛÔÛÙfi ÂÚ› ÙÔ˘ 80% Û 10 ˆ˜ 15 ¯ÚfiÓÈ· ı· ÂÈÛ¤ÏıÔ˘Ó ÛÙÔ ÛÙ¿‰ÈÔ Ù˘ ∫ÏÈÓÈ΋˜ ¡ÂÊÚÔ¿ıÂÈ·˜. ™ÙË ¢¡ ÌÔÚÔ‡Ó Ó· ·Ú·ÙËÚËıÔ‡Ó ÏÂÈÙÔ˘ÚÁÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÛÙÔ Â›Â‰Ô ÙÔ˘ ÓÂÊÚÒÓ· (ÛÂÈÚ·Ì·ÙÈ΋ ˘ÂډȋıËÛË) Ôχ ÚÈÓ ÙËÓ ·Ó›¯Ó¢ÛË ÎÏÈÓÈÎÒÓ ÌÂÙ·‚ÔÏÒÓ ÛÙÔÓ ·ÛıÂÓ‹.

OÈ Ì˯·ÓÈÛÌÔ› Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÛÙËÓ ¤Î‚·ÛË Ù˘ ¢¡ Â›Ó·È ÔÏÏ·ÏÔ› Î·È ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ÙËÓ ·ÏÏËÏÂ›‰Ú·ÛË ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ Î·È ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ÌÂÙ·‚ÔÏÒÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ˘ÂÚÁÏ˘Î·ÈÌ›· ηıÒ˜ Â›Û˘ Î·È ·fi ÙËÓ ÁÂÓÂÙÈ΋ ÚԉȿıÂÛË ÙÔ˘ οı ·ÛıÂÓ‹ ͯˆÚÈÛÙ¿. OÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ ·ÊÔÚÔ‡Ó ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Û˘ÛÙËÌ¿ÙˆÓ (ƒÂÓ›Ó˘-∞ÁÁÂÈÔÙÂÓÛ›Ó˘-∞ωÔÛÙÂÚfi-

∞ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ ∏ ÛÂÈÚ·Ì·ÙÈ΋ ˘ÂډȋıËÛË ·ÔÙÂÏ› ÙÔ ÚˆÈÌfiÙÂÚÔ ÛËÌÂ›Ô Ù˘ ¢¡ Î·È Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ÌÂȈ̤Ó˘ ·ÓÙ›ÛÙ·Û˘ ÙÔ˘ ÚÔÛ·ÁˆÁÔ‡ Î·È ÙÔ˘ ··ÁˆÁÔ‡ ·ÚÙËÚȉ›Ô˘ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜ (ÙÔ ··ÁˆÁfi ·ÚÙËÚ›‰ÈÔ ÂÌÊ·Ó›˙ÂÈ ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi ·ÁÁÂÈԉȷÛÙÔÏ‹˜). OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ·˘Ù‹ ÙËÓ ‰È·Ù·Ú·¯‹ ÛÙËÓ ·˘ÙÔÚÚ‡ıÌÈÛË ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ù· ÚÔÛÙ·ÓÔÂȉ‹, ÙÔ ÓÈÙÚÈÎfi ÔÍ›‰ÈÔ, ÙÔÓ vascular endothelial growth factor (VEGF), ÙÔÓ TGF-‚1 Î·È ÙÔ Û‡ÛÙËÌ· ƒÂÓ›Ó˘ ∞ÁÁÂÈÔÙÂÓÛ›Ó˘ ∞ωÔÛÙÂÚfiÓ˘ (ƒ∞∞). OÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ·˘Ù¤˜ ÌÂÙ·‚ÔϤ˜ ÚÔ¿ÁÔ˘Ó ‰È·Ù·Ú·¯¤˜ fiˆ˜ ÙËÓ ·ÒÏÂÈ· ·Ï‚Ô˘Ì›Ó˘ ·fi Ù· ÛÂÈÚ·Ì·ÙÈο ÙÚȯÔÂȉ‹, ÙËÓ ˘ÂÚÏ·Û›· Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ÌÂÛ¿ÁÁÂÈÔ˘ Ô˘Û›·˜, ÙË ‚Ï¿‚Ë ÙˆÓ Ô‰Ô΢ÙÙ¿ÚˆÓ Î·È ÙËÓ ¿¯˘ÓÛË Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ∂ÈÚfiÛıÂÙ· ÙÔ ·˘ÍË̤ÓÔ Ì˯·ÓÈÎfi stress ÂÓ‰ÔÛÂÈÚ·Ì·ÙÈο ÚÔηÏ› ÙËÓ ÙÔÈ΋ ·ÂÏ¢ı¤ÚˆÛË Î˘ÙÔÎÈÓÒÓ Î·È ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ.

OÈ ÓÂÊÚÈΤ˜ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÔÊ›ÏÔÓÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÛÙȘ ·ÁÁÂÈÔ‰Ú·ÛÙÈΤ˜ ÔÚÌfiÓ˜ fiˆ˜ Ë angiotensin II (∞ππ) Î·È Ë ÂÓ‰ÔıËÏ›ÓË. ∏ ÂÓ‰ÔÛÂÈÚ·Ì·ÙÈ΋ ˘¤ÚÙ·ÛË Î·È Ë ˘ÂډȋıËÛË Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ÛËÌ·›ÓÔÓÙ· ÚfiÏÔ ÛÙËÓ ·-

15

16

M. £∂√¢øƒπ¢∏™

ıÔÁ¤ÓÂÈ· Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÁÈ·Ù› Ë ·Ó·ÛÙÔÏ‹ ÙÔ˘ ¿ÍÔÓ· ƒ∞∞ ÚÔÊ˘Ï¿ÛÛÂÈ ÙËÓ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ·Ó·ÛÙ¤ÏÏÔÓÙ·˜ ÙȘ ˘ÂÚÏ·ÛÙÈΤ˜ Î·È ÛÎÏËÚ˘ÓÙÈΤ˜ ‰Ú¿ÛÂȘ ÙȘ ∞ππ (ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙËÓ ·Ú·ÁˆÁ‹ ÙÔ˘ TGF-‚1).

ÀÂÚÁÏ˘Î·ÈÌ›· Î·È AGEs (ΔÂÏÈο ÚÔ˚fiÓÙ· ÁÏ˘ÎÔ˙˘Ï›ˆÛ˘) ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· ·ÔÙÂÏ› ‚·ÛÈÎfi ·Ú¿ÁÔÓÙ· ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÏfiÁˆ Ù˘ Â›‰Ú·Û˘ Ù˘ ÛÙ· ÌÂÛ·ÁÁÂȷο ·ÙÙ·Ú· Î·È ÛÙ· ÛÂÈÚ·Ì·ÙÈο ÙÚȯÔÂȉ‹. Δ· ÌÂÛ·ÁÁÂȷο ·ÙÙ·Ú· Â›Ó·È ˘‡ı˘Ó· ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ‰ÔÌ‹˜ ÙˆÓ ÛÂÈÚ·Ì·ÙÈÎÒÓ ÙÚȯÔÂȉÒÓ Î·È ÙËÓ Ú‡ıÌÈÛË Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ ̤ۈ Ú‡ıÌÈÛ˘ ÙÔ˘ ÙfiÓÔ˘ ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ. ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· Û¯ÂÙ›˙ÂÙ·È Ì ˘ÂÚÏ·Û›· Î·È ˘ÂÚÙÚÔÊ›· ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·ıÒ˜ Â›Û˘, Ì ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ÌÂÛ¿ÁÁÂÈÔ˘ Ô˘Û›·˜ Î·È ¿¯˘ÓÛË Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜. ∏ ˘ÂÚÏ·Û›· ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÔÊ›ÏÂÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÛÙËÓ ·˘ÍË̤ÓË ÂÓ‰Ô΢ÙÙ¿ÚÈ· Û˘ÁΤÓÙÚˆÛË Ù˘ ÁÏ˘Îfi˙˘. ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· ·˘Í¿ÓÂÈ ÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ VEGF ÛÙ· Ô‰Ô·ÙÙ·Ú· Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ‰È·‚·ÙfiÙËÙ· ÙˆÓ ÛÂÈÚ·Ì·ÙÈÎÒÓ ÙÚȯÔÂȉÒÓ.

OÈ Ì˯·ÓÈÛÌÔ› Ô˘ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ‚Ï·ÙÈ΋ Â›‰Ú·ÛË Ù˘ ˘ÂÚÁÏ˘Î·ÈÌ›·˜ ÛÙÔ ÓÂÊÚfi Â›Ó·È ÌË ÂÓ˙˘Ì·ÙÈ΋ ÁÏ˘ÎÔ˙˘Ï›ˆÛË (AGEs), Ë ÂÓÂÚÁÔÔ›ËÛË Ù˘ PKC Î·È ‰È¤ÁÂÚÛË ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ ‰ÚfiÌÔ˘ Ù˘ ·Ó·ÁˆÁ¿Û˘ Ù˘ ·Ï‰fi˙˘. ΔÔ ÔÍÂȉˆÙÈÎfi stress ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Î·È ÛÙÔ˘˜ ÙÚ›˜ Ì˯·ÓÈÛÌÔ‡˜.

°Ï˘ÎÔ˙˘Ï›ˆÛË ¶ÚˆÙÂ˚ÓÒÓ ∏ ÁÏ˘ÎÔ˙˘Ï›ˆÛË ÙˆÓ ÈÛÙÈÎÒÓ ÚˆÙÂ˚ÓÒÓ Û˘Ì‚¿ÏÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ Î·È ¿ÏÏˆÓ ÌÈÎÚÔ·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ ÙÔ˘ ‰È·‚‹ÙË. ™ÙË ¯ÚfiÓÈ· ˘ÂÚÁÏ˘Î·ÈÌ›· Ë ÂÚ›ÛÛÂÈ· Ù˘ ÁÏ˘Îfi˙˘ Û˘Ó‰¤ÂÙ Ì ÂχıÂÚ· ·ÌÈÓÔͤ· ΢ÎÏÔÊÔÚÔ‡ÓÙˆÓ ‹ ÈÛÙÈÎÒÓ ÚˆÙÂ˚ÓÒÓ. ∏ ÌË ÂÓ˙˘Ì·ÙÈ΋ ÁÏ˘ÎÔ˙˘Ï›ˆÛË, ·Ú¯Èο ·Ó·ÛÙÚ¤„ÈÌË Î·È ·ÚÁfiÙÂÚ· fi¯È (∞GEs), ÚÔηÏ› ‰È·Ù·Ú·¯‹ ÛÙË ‰ÔÌ‹ Î·È ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Î˘ÙÙ¿ÚˆÓ (ÌÂÙ¿‰ÔÛË ÛËÌ¿ÙˆÓ ·fi ÔÚÌfiÓ˜/΢ÙÔΛÓ˜ ÎÏ). Δ· AGEs ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛı› ̤ۈ Â›‰Ú·Û˘ ÛÙÔÓ ˘Ô‰Ô¯¤· ÙÔ˘˜ Ì ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË ÂÏ¿ÙÙˆÛË ÙÔ˘ ÓÈÙÚÈÎÔ‡ ÔÍÂȉ›Ô˘.

¶ÚˆÙÂ˚ÓÈ΋ ∫ÈÓ¿ÛË C ∏ ÂÓÂÚÁÔÔ›ËÛË Ù˘ PKC ÚÔ¿ÁÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ·ÁÁÂÈԉȷÛÙ·ÏÙÈÎÒÓ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÓ‰ÔÛÂÈÚ·Ì·ÙÈ΋ ˘¤ÚÙ·ÛË Î·È ˘ÂډȋıËÛË Î·ıÒ˜ Â›Û˘ Û¯ÂÙ›˙ÂÙ·È Ì ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ TGF-‚ Î·È ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ÌÂÛ·ÁÁ›Ԣ Ô˘Û›·˜. O Ì˯·ÓÈÛÌfi˜ ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ PKC ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ de novo Û¯ËÌ·ÙÈÛÌfi ‰È·ÁÏ˘ÎÂÚfiÏ˘ Î·È ÙÔ ÔÍÂȉˆÙÈÎfi stress.

ªÂÙ·‚ÔÏÈÎfi˜ ¢ÚfiÌÔ˜ Ù˘ ∞Ó·ÁˆÁ¿Û˘ Ù˘ ∞ωfi˙˘ O ÌÂÙ·‚ÔÏÈÎfi˜ ‰ÚfiÌÔ˜ ÙˆÓ ÔÏ˘ÔÏÒÓ ÂÓÔ¯ÔÔÈÂ›Ù·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ¢¡. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ·Ó·Ê¤ÚÔ˘Ó Ì›ˆÛË ÙÔ˘ UAER Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÛÙÔϤˆÓ Ù˘ ·Ó·ÁˆÁ¿Û˘ Ù˘ ·Ï‰fi˙˘ ¯ˆÚ›˜ ·˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· Ó· ¤¯Ô˘Ó ÂȂ‚·Èˆı› Û ·ÓıÚÒÔ˘˜.

¶ÚÔÚÂÓ›ÓË ∞ÚÎÂÙ¤˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ë ·˘ÍË̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ ÚÔÚÂÓ›Ó˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Â›Ó·È ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ·Ó¿Ù˘Í˘ ¢¡. O ˘Ô‰Ô¯¤·˜ ÚÔÚÂÓ›Ó˘ ÛÙÔ ÓÂÊÚfi ‚Ú›ÛÎÂÙ·È ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ Î·È ÛÙ· Ô‰Ô·ÙÙ·Ú·, Ô ·ÔÎÏÂÈÛÌfi˜ ÙÔ˘ ÔÔ›Ô˘ ·Ú¤¯ÂÈ ÓÂÊÚÔÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË ÙfiÛÔ Û ÂÈÚ·Ì·ÙÈΤ˜ ·ÏÏ¿ Î·È ÎÏÈÓÈΤ˜ ÌÂϤÙ˜. ∏ ‰È¤ÁÂÚÛË ÙÔ˘ ˘Ô‰Ô¯¤· ·fi ÙËÓ ÚÔÚÂÓ›ÓË ÚÔ¿ÁÂÈ ÙËÓ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ÌÂÙ·ÊÔÚ¿ ÛËÌ¿ÙˆÓ Ô˘ ÂÓÂÚÁÔÔÈÔ‡Ó ÙËÓ p44/p42 mitogenactivated protein kinase (MAPK – ÌÂÙ·‚ÔÏÈÎfi˜ ‰ÚfiÌÔ˜ ÂÓÂÚÁÔÔ›ËÛ˘ PKC)

∫˘ÙÔΛÓ˜ ∏ ÂÓÂÚÁÔÔ›ËÛË Î˘ÙÔÎÈÓÒÓ, ·˘ÍËÙÈÎÒÓ Î·È ·ÁÁÂÈÔÁÂÓÂÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Û¯ÂÙ›˙ÂÙ·È Èı·ÓÒÓ Ì ÙËÓ ÂÓ·fiıÂÛË ÂÍˆÎ˘ÙÙ·Ú›Ô˘ Ô˘Û›·˜ ,Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙË ¢¡, ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ Î·È ÛÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜. ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· ÚÔ¿ÁÂÈ ÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ VEGF Ô ÔÔ›Ô˜ ¢ı‡ÓÂÙ·È ÁÈ· ÂÓ‰ÔıËÏȷ΋ ‚Ï¿‚Ë ÛÙ· ÛÂÈÚ·Ì·ÙÈο ÙÚȯÔÂȉ‹ ηıÒ˜ Â›Û˘ Î·È ÁÈ· ÙËÓ ·˘ÍË̤ÓË ‰È·‚·ÙfiÙËÙ· ÙÔ˘ ÊÚ·ÁÌÔ‡ ‰È‹ıËÛ˘. ∞ÔÙÂϤÛÌ·Ù· ·fi ÌÂϤÙ˜ ηıÔÚ›˙Ô˘Ó ÙÔ Â›Â‰Ô Ù˘ ‚Ï¿‚˘ ÛÙË Ì›ˆÛË Ù˘ ‰ÈÂÓ‰ÔıËÏȷ΋˜ ËÏÂÎÙÚÈ΋˜ ·ÓÙ›ÛÙ·Û˘. O ¯ÔÚ‹ÁËÛË ·ÔÎÏÂÈÛÙÒÓ ÙÔ˘ VEGF Ê·›ÓÂÙ·È fiÙÈ Ô‰‹ÁËÛ Û Ì›ˆÛË ÙËÓ ˘ÂÚÙÚÔÊ›·˜ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜ Î·È ÙÔ˘ UAER, Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ¢¡.

METAMO™XEY™Eπ™ 2010

∏ ˘ÂÚÁÏ˘Î·ÈÌ›·, Ô TGF-‚1 Î·È Ë ∞ππ ÚÔ¿ÁÔ˘Ó ÙËÓ ·‡ÍËÛË ÙÔ˘ VEGF, ÁÂÁÔÓfi˜ Ô˘ Ô‰ËÁ› Û ·˘ÍË̤ÓË Û‡ÓıÂÛË ·fi ÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙÔ˘ ÓÈÙÚÈÎÔ‡ ÔÍÂȉ›Ô˘ (¡O). ∏ ·‡ÍËÛË ÙÔ˘ ¡O ÚÔηÏ› ·ÁÁÂÈԉȷÛÙÔÏ‹, ÂÓ‰ÔÛÂÈÚ·Ì·ÙÈ΋ ˘¤ÚÙ·ÛË Î·È ˘ÂډȋıËÛË. ∂ÈϤÔÓ Ô VEGF ÚÔ¿ÁÂÈ ÙËÓ Û‡ÓıÂÛË Ù˘ ·Ï‡ÛÔ˘ ·3 ÙÔ˘ ÎÔÏÏ·ÁfiÓÔ˘ Ù‡Ô˘ IV (Û˘ÛÙ·ÙÈÎfi Ù˘ μ·ÛÈ΋˜ ªÂÌ‚Ú¿Ó˘ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜) ÁÂÁÔÓfi˜ Ô˘ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ¿¯˘ÓÛË Ù˘ μª ÛÙË ¢¡. ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· ·˘Í¿ÓÂÈ ÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ TGF-‚1 Î·È ¤ÌÌÂÛ· Û˘Ó‰Ú¿ÌÂÈ ÛÙËÓ ·Ó¿Ù˘ÍË ›ÓˆÛ˘ ÛÙÔ Û›ڷ̷ ̤ۈ ΢ÙÙ·ÚÈ΋˜ ˘ÂÚÏ·Û›·˜ Î·È ·˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ ÎÔÏÏ·ÁfiÓÔ˘. ∂ÈÚfiÛıÂÙ· Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Û¯ÂÙ›˙ÂÙ·È Ì ¯·ÌËÏfiÙÂÚ· Â›‰· Ù˘ ÌÔÚÊÔÁÂÓÂÙÈ΋˜ ÚˆÙ½Ó˘ 7 Ô˘ ‰Ú· ·ÓÙ·ÁˆÓÈÛÙÈο ÛÙȘ ÛÎÏËÚ˘ÓÙÈΤ˜ ‰Ú¿ÛÂȘ ÙÔ˘ TGF-‚1. ∏ ¯ÔÚ‹ÁËÛË Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Û ÂÈÚ·Ì·Ùfi˙ˆ·, Ô ÔÔ›Ô˜ ·Ó·ÛÙ¤ÏÏÂÈ ÙȘ ÛÎÏËÚ˘ÓÙÈΤ˜ ‰Ú¿ÛÂȘ ÙÔ˘ TGF-‚1, ÂÈ‚Ú·‰‡ÓÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ ¢¡.

OÈ ÚÔÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÔΛÓ˜ ÂÓÔ¯ÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ¢¡ Î·È È‰È·›ÙÂÚ· Ë ÈÓÙÂÚÏ¢ΛÓË 1 (IL-1) Ë IL-6 Ë IL-18 Î·È Ô tumor necrosis factor Ë Î¿ı ÌÈ· Ì ‰È·ÊÔÚÂÙÈÎfi ÙÚfiÔ ‰Ú¿Û˘ ∏ IL-1 ·ÏÏÔÈÒÓÂÈ ÙËÓ ¤ÎÊÚ·ÛË ¯ËÌÂÈÔÙ·ÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘ , ÌÂÙ·‚¿ÏÏÂÈ ÙËÓ ÂÓ‰ÔÛÂÈÚ·Ì·ÙÈ΋ ·ÈÌÔ‰˘Ó·ÌÈ΋ (ÂËÚ¿˙ÂÈ ÙËÓ Û‡ÓıÂÛË ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ ·fi ÙÔ ÌÂÛ¿ÁÁÂÈÔ) Î·È Èı·ÓÒÓ Ó· ·˘Í¿ÓÂÈ ÙËÓ ‰È·‚·ÙfiÙËÙ· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∏ IL-6 ·ÚÔ˘ÛÈ¿˙ÂÈ ÈÛ¯˘Úfi Û˘Û¯ÂÙÈÛÌfi Ì ÙËÓ ¿¯˘ÓÛË Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Î·È Èı·ÓÒÓ Ó· ÚÔηÏ› ·˘ÍË̤ÓË ‰È·‚·ÙfiÙËÙ· ÛÙ· ÛÂÈÚ·Ì·ÙÈο ÙÚȯÔÂȉ‹ ηıÒ˜ Â›Û˘ Î·È ˘ÂÚÏ·Û›· ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ. ∏ IL-18 ÚÔ¿ÁÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÚÔÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÔÎÈÓÒÓ fiˆ˜ Ë IL-1, Ë interferon Á, Ô tumor necrosis factor Î·È Èı·ÓÒÓ Ó· Û¯ÂÙ›˙ÂÙ·È Ì ·fiÙˆÛË ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. O Tumor Necrosis Factor ‰Ú· ¿ÌÂÛ· ˆ˜ ÓÂÊÚÈ΋ ΢ÙÔÙÔÍ›ÓË, ÂËÚ¿˙ÂÈ ÙËÓ ·fiÙˆÛË, ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜, ÙËÓ ÂÓ‰ÔıËÏȷ΋ ‰È·ÂÚ·ÙfiÙËÙ· Î·È ÙȘ ΢ÙÙ·ÚÔ-΢ÙÙ·ÚÈΤ˜ Û˘Ó‰¤ÛÂȘ.

ªÂÛÔÏ·‚ËÙ¤˜ ÏÈȉ›ˆÓ Δ· ÌÈÎÚÔÏÈ›‰È· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇ Î·È ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ¢¡. ∏ Cyclooxygenase 2 ‰È·Û¿ ÙÔ ·Ú·¯È‰ÔÓÈÎfi Ô͇ Û ÌÈÎÚfiÙÂÚ· ÚÔÛÙ·ÓÔÂȉ‹. ™Â ÂÈ-

17

Ú·Ì·ÙÈο ÌÔÓ٤Ϸ ¢¡ ¤¯Ô˘Ó ·Ó¢ÚÂı› ·˘ÍË̤ӷ Â›‰· Ù˘ cyclooxygenase 2 Î·È ÙˆÓ ÚÔÊÏÂÁÌÔÓ‰ÒÓ ÚÔÛÙ·ÓÔÂȉÒÓ fiˆ˜ Ë ÚÔÛÙ·ÁÏ·Ó‰›Ó˜ E2 Î·È I2. ∏ ·Ó·ÛÙÔÏ‹ Ù˘ cyclooxygenase 2 Ì›ˆÛ ÙË ÛÂÈÚ·Ì·ÙÈ΋ ˘ÂډȋıËÛË Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜.

OÍÂȉˆÙÈÎfi stress OÈ ÌÂÙ·‚ÔÏÈΤ˜ ‰Ú·ÛÙËÚÈfiÙËÙ˜ ÛÙÔ ÓÂÊÚfi ·Ú¿ÁÔ˘Ó ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ ÔÍÂȉˆÙÈÎÒÓ ÌÔÚ›ˆÓ Ù· ÔÔ›· ·ÔÌ·ÎÚ‡ÓÔÓÙ·È ·fi ·ÓÙÈÔÍÂȉˆÙÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜. Δ· ÔÍÂȉˆÙÈο ·˘Ù¿ ÌfiÚÈ· ‰˘ÓËÙÈο ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ·ıÔÏÔÁÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÛÙ· ÏÈ›‰È· Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜ Û ÚˆÙÂ˚ÓÈΤ˜ ‰Ô̤˜ Î·È ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛı› Ì ÂÓ‰ÔÓÂÊÚÈ΋ ·ÁÁÂÈÔÛ‡Û·ÛË. ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· ÚÔ¿ÁÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÔÍÂȉˆÙÈÎÒÓ ÌÔÚ›ˆÓ ΢ڛˆ˜ ·fi Ù· ÌÈÙÔ¯fiÓ‰ÚÈ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ. ™ÙË ‰È¤ÁÂÚÛË Ù˘ PKC Î·È ÛÙË ‰ËÌÈÔ˘ÚÁ›· AGEs Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ˘ÂÚÁÏ˘Î·ÈÌ›· Ê·›ÓÂÙ·È Ó· ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·›ÓÔÓÙ· ÚfiÏÔ Î·È ÙÔ ÔÍÂȉˆÙÈÎfi stress.

¡ÂÊÚ›ÓË Δ· Ô‰Ô·ÙÙ·Ú· (ÂÈıËÏȷο ·ÙÙ·Ú· ÙˆÓ ÛÂÈÚ·Ì·ÙÈÎÒÓ ÙÚȯÔÂȉÒÓ) Î·È Ë ÓÂÊÚ›ÓË (ÚˆÙ½ÓË ÛÙËÓ ÌÂÌ‚Ú¿ÓË ÙˆÓ Ô‰Ô΢ÙÙ¿ÚˆÓ) ·ÔÙÂÏÔ‡Ó ‚·ÛÈΤ˜ ‰Ô̤˜ ÙÔ˘ ÊÚ·ÁÌÔ‡ ‰È‹ıËÛ˘. ™ÙË ¢¡ Ë ÓÂÊÚÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÓÂÊÚ›Ó˘ Â›Ó·È ÛËÌ·ÓÙÈο ÂÏ·Ùو̤ÓË. ∂ÈϤÔÓ Ë ·Ô‚ÔÏ‹ Ù˘ ÓÂÊÚ›Ó˘ ÌÔÚ› Ó· ·ÔÙÂÏ› ÚÒÈÌÔ ÛËÌÂ›Ô ‚Ï¿‚˘ ÙˆÓ Ô‰Ô΢ÙÙ¿ÚˆÓ ÚÈÓ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·Ï‚Ô˘ÌÈÓÔ˘Ú›·˜. ∞Ó·ÛÙÔÏ‹ ÙÔ˘ ¿ÍÔÓ· ƒ∞∞ Èı·ÓÒÓ Ó· ÂÏ·ÙÙÒÓÂÈ ÙËÓ ·Ô‚ÔÏ‹ Ù˘ ÓÂÊÚ›Ó˘.

∫ÏËÚÔÓÔÌÈÎfiÙËÙ· O ÁÔÓfiÙ˘Ô˜ ÙˆÓ ·ÛıÂÓÒÓ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· Ù˘ ÂÌÊ¿ÓÈÛ˘ Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ¤ÎÊÚ·Û˘ Ù˘ ¢¡. ∏ ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ÂÌÊ·Ó›˙ÂÙ·È Û˘¯ÓfiÙÂÚ· Û ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ÓÂÊÚÔ¿ıÂÈ·˜ Û ÁÔÓ›˜ ‹ ·‰¤ÏÊÈ·. ªÂϤÙ˜ Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Pima Indians ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËÛÂÈ Ù· ¯ÚˆÌ·ÙÔÛÒÌ·Ù· 3, 7, 9 Î·È 20 ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ¢¡. ™Â ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ù‡Ô˘ ππ ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ô DD ÔÏ˘ÌÔÚÊÈÛÌfi˜ ÁÈ· ÙÔ ACE Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ¢¡, ‚·ÚÈ¿˜ ÚˆÙÂÈÓÔ˘Ú›·˜ ηıÒ˜ Â›Û˘ Î·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ıÓËÙfiÙËÙ·˜ ηٿ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ οı·ÚÛ˘.

M. £∂√¢øƒπ¢∏™

18 ™˘ÌÂÚ¿ÛÌ·Ù·

ΔËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯Ô˘Ó Á›ÓÂÈ ÂÚÈÛÛfiÙÂÚÔ Î·Ù·ÓÔËÙÔ› ÔÈ Ì˯·ÓÈÛÌÔ› Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜. OÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ Î·È Ë ÛÂÈÚ·Ì·ÙÈ΋ ˘‰ȋıËÛË ÂÌÊ·Ó›˙ÔÓÙ·È ÓˆÚ›ÙÂÚ· ·fi ÔÔÈ·‰‹ÔÙ ÎÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ ¯ˆÚ›˜ fï˜ Î·È Ó· ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ ÔÚ›· ÂͤÏÈ͢ Ù˘ ¢¡. OÈ ‰ÔÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÚÒÈÌ· ÛÙÔ Û›ڷ̷ Â›Ó·È Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ Ô‰Ô΢ÙÙ¿ÚˆÓ, Ë ¿¯˘ÓÛË Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Î·È Ë ˘ÂÚÏ·Û›· ÙÔ˘ ÌÂÛ·ÁÁ›Ԣ. ∏ ˘ÂÚÁÏ˘Î·ÈÌ›· ·ÛΛ ÎÂÓÙÚÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó¿Ù˘ÍË Ù˘ ¢¡ ÚÔηÏÒÓÙ·˜ ¤Ó· ηٷÚÚ¿ÎÙË ÌÂÙ·‚ÔÏÒÓ ÛÙËÓ ¤ÎÊÚ·ÛË Î˘ÙÔÎÈÓÒÓ, ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÔÍÂȉˆÙÈÎÔ‡ ÛÙÚ˜, ÚÔ¿ÁÂÈ ÙË ‰ËÌÈÔ˘ÚÁ›· ÙˆÓ AGEs ÌÂÙ·‚¿ÏÏÔÓÙ·˜ ÙËÓ ‰ÔÌ‹ ÚˆÙÂ˚ÓÒÓ Î·È ÙËÓ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ÌÂÙ¿‰ÔÛË ÛËÌ¿ÙˆÓ. ∏ ·fiÎÙËÛË Ù˘ ÁÓÒÛ˘ Ô˘ ·ÊÔÚ¿ ÙËÓ Â›-

Diabetes duration Age at onset

‰Ú·ÛË Ù˘ ÎÏËÚÔÓÔÌÈÎfiÙËÙ·˜ Î·È ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ¢¡ Èı·ÓÒÓ ÛÙÔ Ì¤ÏÏÔÓ Ó· ‚ÔËı‹ÛÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ Ì›ˆÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÓfiÛÔ˘.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Ziyadeh FN. (2004). Mediators of diabetic renal disease: the case for TGF-‚ as the major mediator. J Am Soc Nephrol 15 (Suppl 1): S55-S57.

2. Ichinose K et al. (2007). Recent advancement of understanding pathogenesis of type 1 diabetes and potential relevance to diabetic nephropathy.Am J Nephrol 27: 554-564.

3. Raptis AE and Viberti G. (2001). Pathogenesis of diabetic nephropathy. Exp Clin Endocrinol Diabetes 109 (suppl 2): S424-S437.

4. Singh DK et al. (2008). Mechanisms of disease: the hypoxic tubular hypothesis of diabetic nephropathy.

Nat Clin Pract Nephrol 4: 216-226 5. Ziyadeh FN and Wolf G. (2008). Pathogenesis of the podocytopathy and proteinuria in diabetic glomerulopathy. Curr Diabetes Rev 4: 39-45.

Insulin resistance

Glycaemic control

Metabolic Factors Hyperglycaemia AGEs Polyol Hexosamine Oxidative stress

Genetic Factors

Environmental Factors Dietary protein intake Smoking

Activation of intracellular signalling pathways

ACE ID polymorphism Hyperlipidemia Oligonephropathy

Haemodynamic Factors

Growth factors Inflammatory mediators

Elevated systemic BP Glomerular hypertension Increased vasoactive hormones ECM accumulation

Altered vessel permeability Proteinuria

D i a b e t i c N e p h ro p at hy

∂ÈÎfiÓ· 1. ¶·ıÔÁ¤ÓÂÈ· ¢È·‚ËÙÈ΋˜ ¡ÂÊÚÔ¿ıÂÈ·˜.

METAMO™XEY™Eπ™ 2010

6. Wolf G et al. (2005). From the periphery of the glomerular capillary wall toward the center of disease: podocyte injury comes of age in diabeticnephropathy.

Diabetes 54: 1626-1634.

7. Mauer SM et al. (1983). The development of lesions in the glomerular basement membrane and mesangium after transplantation of normal kidneys to diabetic patients. Diabetes 32: 948-952.

8. Friedman EA. (1999). Advanced glycation endproducts in diabetic nephropathy. Nephrol Dial Transplant 14 (suppl 3): S1-S931.

9. Cooper ME. (1998). Pathogenesis prevention and treatment of diabetic nephropathy. Lancet 352: 213-219.

10. Yamagishi S et al. (2007). Molecular mechanisms of dia-

11.

12.

13.

14.

15.

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betic nephropathy and its therapeutic intervention. Curr Drug Targets 8: 952-95964 Vasavada N and Agarwal.

Role of oxidativestress in diabetic nephropathy. Adv Chronic Kidney Dis 12: 146–154 (2005).

Mundel P and Shankland SJ. (2002). Podocyte biology and response to injury. J Am Soc Nephrol 13: 3005-3015.

Benigni A et al. (2004). Selective impairment of gene expression and assembly of nephrin in human diabetic nephropathy. Kidney Int 65: 2193-2200.

Adler S. (2004). Diabetic nephropathy: Linking histology, cell biology, and genetics. Kidney Int 66: 2095-2106.

Trevisan R and Viberti G. (1995). Genetic factors in the development of diabetic nephropathy. J Lab Clin Med 126: 342–349.

KÏÈÓÈ΋ ÂÈÎfiÓ·, EͤÏÈÍË Ù˘ ¢È·‚ËÙÈ΋˜ NÂÊÚÔ¿ıÂÈ·˜ ¶ÏÔ˘Ì‹˜ ™. ¶·Û·‰¿Î˘ O ۷ί·Ú҉˘ ‰È·‚‹Ù˘ (™¢) ·ÔÙÂÏ› Ì›· ·ÚÎÂÙ¿ Û˘¯Ó‹ ‰È·Ù·Ú·¯‹ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÏ·Ùو̤ÓË ¤ÎÎÚÈÛË ÈÓÛÔ˘Ï›Ó˘ ‹ ÂÏ¿ÙÙˆÛË Ù˘ ¢·ÈÛıËÛ›·˜ ÙˆÓ ÈÛÙÒÓ ÙÔ˘ ÛÒÌ·ÙÔ˜ ÛÙË ‰Ú¿ÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘ (·ÓÙ›ÛÙ·ÛË), Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ÁÏ˘Îfi˙Ë (ۿί·ÚÔ) ·›Ì·ÙÔ˜. ¢È·ÎÚ›ÓÂÙ·È Û هÔ 1, Ô˘ ·ÔÙÂÏ› ÙÔ 5-10% Î·È ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û˘Ó‹ıˆ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ· fiÙ·Ó ÙÔ ¿ÁÎÚ·˜ ‰ÂÓ ·Ú¿ÁÂÈ ÈÓÛÔ˘Ï›ÓË Î·È ÙÔÓ Ù‡Ô 2, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÏ·Ùو̤ÓË ¤ÎÎÚÈÛË ÈÓÛÔ˘Ï›Ó˘ Î·È ·ÓÙ›ÛÙ·ÛË Ù˘ ‰Ú¿Û˘ Ù˘ ÛÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ·ÊÔÚ¿ ÛÙÔ 90-95% ÙˆÓ ‰È·‚ËÙÈÎÒÓ. Δ· ¿ÙÔÌ· Ô˘ ·Ó·Ù‡ÛÛÔ˘Ó ‰È·‚‹ÙË Ù‡Ô˘ 2 Â›Ó·È Û˘Ó‹ıˆ˜ ˘¤Ú‚·Ú· (BMI>25 kg/m2), ÁÂÁÔÓfi˜ Ô˘ ·ÔÙÂÏ› Û·Ê‹ ¤Ó‰ÂÈÍË Ù˘ Û˘Û¯¤ÙÈÛ˘ Ù˘ ÓfiÛÔ˘ Ì ÙÔ Û‡Á¯ÚÔÓÔ ÙÚfiÔ ˙ˆ‹˜ Î·È ÙȘ ‰È·ÙÚÔÊÈΤ˜ Ì·˜ Û˘Ó‹ıÂȘ. ™ÙË ¯ÒÚ· Ì·˜, ÙÔ 6% ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ ¿Û¯ÂÈ ·fi ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ÂÓÒ Û‡Ìʈӷ Ì ÙÔÓ ¶·ÁÎfiÛÌÈÔ OÚÁ·ÓÈÛÌfi ÀÁ›·˜, ̤¯ÚÈ ÙÔ 2030 ÂÚÈÛÛfiÙÂÚ· ·fi 300 ÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ ı· ¤¯Ô˘Ó ÂΉËÏÒÛÂÈ ™¢ Ù‡Ô˘ 2. ∞˘Ùfi ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÂÊfiÛÔÓ Ô ™¢ ‚Ú›ÛÎÂÙ·È ·ÁÎÔÛÌ›ˆ˜ ÛÙËÓ ÚÒÙË ı¤ÛË ÙˆÓ ·ÈÙ›ˆÓ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (á∞), ÂÓÒ ·ÎÔÏÔ˘ıÔ‡Ó Ë ˘¤ÚÙ·ÛË, ÔÈ ÛÂÈÚ·Ì·ÙÔ¿ıÂȘ Î·È Ë Î˘ÛÙÈ΋ ÓÂÊÚÔ¿ıÂÈ·. ™ÙȘ ∏¶∞ ÙÔ ÔÛÔÛÙfi ÙˆÓ Ó¤ˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú¯›˙Ô˘Ó ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ ÏfiÁˆ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ (¢¡) Â›Ó·È 45%. ™ÙËÓ ∂ÏÏ¿‰· ÙÔ ÔÛÔÛÙfi ÙˆÓ Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ Ì á¡ Û˘ÓÂ›· ¢¡ ·˘Í‹ıËΠ·fi 18% ÙÔ 2001 Û 28% ÙÔ 2008. ÀÔΛÌÂÓË ‚¿ÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ÂÈÏÔÎÒÓ Î·È Ù˘ ¢¡, ·ÔÙÂÏ› Ë Ì·ÎÚfi¯ÚÔÓË ˘ÂÚÁÏ˘Î·ÈÌ›·, fiˆ˜ ·ԉ›¯ıËΠ·fi Ù· ÔÚÈÛÙÈο ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÏÂÙÒÓ, Ù˘ DCCT (Diabetes Control and Complications Trial) ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ 11 Î·È ÙËÓ UKPDS (Prospective Diabetes Study) ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ 22. ¶Ú¿ÁÌ·ÙÈ Ô ™¢ ÛÙË Ì·ÎÚ¿ ‰È·‰ÚÔÌ‹ Ù˘ ˘ÂÚÁÏ˘Î·ÈÌ›·˜ ÂÌÊ·Ó›˙ÂÈ Ì·ÎÚÔ·ÁÁÂȷΤ˜ (·ÁÁÂÈÔÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ, ηډȷ΋ ÓfiÛÔ, ˘¤ÚÙ·ÛË, ÂÚÈÊÂÚÈ΋ ·Á-

ÁÂȷ΋ ÓfiÛÔ) Î·È ÌÈÎÚÔ-·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ (·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·, ÓÂÊÚÔ¿ıÂÈ·, Ó¢ÚÔ¿ıÂÈ·). ∏ Û¯¤ÛË ÙÔ˘ ™¢ Ì ÙÔ˘˜ ÓÂÊÚÔ‡˜ ·ÔηχÊıËΠ·ÚÎÂÙ¿ ÓˆÚ›˜, ÂÓÒ ÙÔ 1936 ÔÈ Kimmelstiel Î·È Wilson ÂÚȤÁÚ·„·Ó ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ Ô˙ˆ‰ÒÓ ÛÂÈÚ·Ì·ÙÈÎÒÓ ÌÂÛÔÙÚȯÔÂȉÒÓ ‚Ï·‚ÒÓ, Û ·ÛıÂÓ›˜ Ì ·fi Ì·ÎÚÔ‡ ™¢ Ù‡Ô˘ 2, Ô˘ ›¯·Ó ÙÔ ÎÏÈÓÈÎfi Û‡Ó‰ÚÔÌÔ Ù˘ ‚·ÚÈ¿˜ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Î·È Ù˘ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Û˘Óԉ¢fiÌÂÓ· ·fi ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË.

O Ì˯·ÓÈÛÌfi˜ Ì ÙÔÓ ÔÔ›Ô Ë ·Ú·ÙÂٷ̤ÓË ˘ÂÚÁÏ˘Î·ÈÌ›· ÚÔηÏ› ÈÛÙÔÏÔÁÈΤ˜ ÌÂÙ·‚ÔϤ˜ Î·È ÙȘ ÂÈÏÔΤ˜ ÙÔ˘ ™¢ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ Û˘ÛÛÒÚ¢ÛË ÂÍˆÎ˘ÙÙ·Ú›Ô˘ Ô˘Û›·˜ (ECM) ÛÙÔ Û›ڷ̷ Î·È ÙÔÓ ‰È¿ÌÂÛÔ ÈÛÙfi, ÙË ÁÏ˘ÎÔ˙˘Ï›ˆÛË ÙˆÓ ÚˆÙÂ˚ÓÒÓ Ì ÂÓ·fiıÂÛË ÙˆÓ ·Ú·ÁÔÌ¤ÓˆÓ ÙÂÏÈÎÒÓ ÁÏ˘ÎÔ˙˘ÏÈˆÌ¤ÓˆÓ ÚÔ˚fiÓÙˆÓ (advanced glycosylation end products (AGEs))3,4. ∫Ú›ÛÈÌÔ ÂӉȿÌÂÛÔ ‰È·‚È‚·ÛÙ‹ Ù˘ ÁÏ˘ÎÔÙÔÍÈ΋˜ Â›‰Ú·Û˘ ÛÙË Û˘ÛÛÒÚ¢ÛË Ù˘ ÌÂÛ·ÁÁÂȷ΋˜ Ô˘Û›·˜, ·ÔÙÂÏ› Ë Î˘ÙÔΛÓË TGF-‚ (Transforming Growth Factor-‚), ̤ۈ Ù˘ ÚÔ˜ Ù· ¿Óˆ Ú‡ıÌÈÛ˘, ÙÔ˘ ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ˘ ˘Ô‰Ô¯¤· ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Glu-15, Ì ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÂÈÛfi‰Ô˘ ÁÏ˘Îfi˙˘ Î·È ÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ÚˆÙÂ˚ÓÈ΋˜ ÎÈÓ¿Û˘ (PKC). ∂›Û˘ Ë ÂÓ‰ÔÛÂÈÚ·Ì·ÙÈ΋ ˘¤ÚÙ·ÛË, ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË, Ì ·‡ÍËÛË Ù˘ ‰È·ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È·Î›ÓËÛ˘ Ì·ÎÚÔÌÔÚ›ˆÓ, Ë ÔÔ›· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ˘ÂÚÊfiÚÙˆÛË ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∏ ÛËÌ·Û›· Ù˘ ÂÓ‰ÔÛÂÈÚ·Ì·ÙÈ΋˜ ›ÂÛ˘ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ¢¡, ÌÔÚ› Ó· ÂÍËÁ‹ÛÂÈ ÁÈ·Ù› Ë Û˘ÛÙËÌ·ÙÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ·Ó¿Ù˘Í˘ ¢¡. ∏ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ‹˜ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÂÁÎÂÊ·ÏÈÎÒÓ Î·È Î·Ú‰È·ÎÒÓ ÂÂÈÛÔ‰›ˆÓ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Â›Ó·È ‰ÈÏ¿ÛÈ· ·fi ·˘Ù‹ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡, ÂÓÒ Ë ÂÌÊ¿ÓÈÛË Ã¡∞ Â›Ó·È 23 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË. ∂›Û˘ Ë ÁÂÓÈ΋ ıÓËÙfiÙËÙ· ÙˆÓ ‰È·‚ËÙÈÎÒÓ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· (¢¡) Â›Ó·È 40 ÊÔÚ¤˜ ÂÚÈÛÛfiÙÂÚË ·fi ·˘Ù‹ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ¯ˆÚ›˜ ÙËÓ ·Ó¿Ù˘ÍË ¢¡.

20

METAMO™XEY™Eπ™ 2010

∏ ¢¡ ·ÔÙÂÏ› ÌÈ· ÌÈÎÚÔ·ÁÁÂÈÔ·ıËÙÈ΋ ÂÈÏÔ΋ ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· (>300 mg/24), Û˘Ó¯‹ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ̤¯ÚÈ ÙËÓ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (ÂÏ¿ÙÙˆÛË Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR) 2-20 ml/min/¤ÙÔ˜), ·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ·ÚÔ˘Û›· ‰È·‚ËÙÈ΋˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·˜. ∞fi ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÌfiÓÔ ÙÔ 35-40% ı· ÂÌÊ·Ó›ÛÔ˘Ó ¢¡, ÔÛÔÛÙfi ·ÚfiÌÔÈÔ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ù‡Ô˘ 1 Î·È 2. ∂˘Ù˘¯Ò˜ ÌfiÓÔ ÛÙÔ 35% ÙˆÓ ·ÛıÂÓÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂΉËÏÒÓÂÙ·È Ë ¢¡, Ë ÓfiÛÔ˜ ı· ÂÍÂÏȯı› Û á¡ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ¢ÂÓ Â›Ó·È ÁÓˆÛÙfi ÁÈ·Ù› ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó fiÏÔÈ ÔÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ ¢¡, Ô‡Ù ÔÈÔ› Â›Ó·È ÔÈ Î˘Ú›ˆ˜ ˘‡ı˘ÓÔÈ ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÁÂÓÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (ÔÈÎÔÁÂÓ¤˜ ÈÛÙÔÚÈÎfi ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘, ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘, ˘‡ı˘Ó· ÁÔÓ›‰È·), Â›ÎÙËÙÔÈ Î·È ÂÚÈ‚·ÏÏÔÓÙ·ÈÎÔ› ·Ú¿ÁÔÓÙ˜, Ô ÙÚfiÔ˜ ˙ˆ‹˜ (οÓÈÛÌ·), Ë ÈηÓfiÙËÙ· ÂϤÁ¯Ô˘ Ù˘ ÓfiÛÔ˘ Î·È Ù¤ÏÔ˜ Èı·ÓÔ› ΢ÎÏÔÊÔÚÔ‡ÓÙ˜ ‹ ÈÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜. ∞fi ÙÔ˘˜ Â›ÎÙËÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ¢¡ ÌÂÁ¿ÏË ÛËÌ·Û›· ¤¯ÂÈ ·Ô‰Ôı› ÛÙËÓ ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË Î·È ÙËÓ Ú‡ıÌÈÛË ÙÔ˘ ۷ί¿ÚÔ˘, ȉ›ˆ˜ ÛÙ· ·Ú¯Èο ÛÙ¿‰È· ÙÔ˘ ™¢. ªÂϤÙ˜ Û ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ‹ ‰ÂÓ ¤¯Ô˘Ó ÎÏÈÓÈÎÒ˜ ÂÌÊ·Ó‹ ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ·, ÂÓÙfiÈÛ·Ó ¤Ó·Ó ·ÚÈıÌfi ·Ú·ÁfiÓÙˆÓ ÔÈ ÔÔ›ÔÈ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÓÂÊÚÈ΋˜ ÚÔÛ‚ÔÏ‹˜6,7.

∫ÏÈÓÈ΋ ÂÈÎfiÓ· – ™Ù¿‰È· ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ∞Ú¯ÈÎÒ˜ (ÛÙ¿‰ÈÔ 1) Ë ˘ÂÚÙÚÔÊ›· ÙÔ˘ ÓÂÊÚÔ‡ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ÌÂ Û˘ÓÔÏÈ΋ ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÓÂÊÚÔ‡ Î·È Ù˘ ÂÈÊ¿ÓÂÈ·˜ ‰È‹ıËÛ˘ (∂ÈÎfiÓ· 1). ∏ ·‡ÍËÛË Ù˘ GFR ÔÊ›ÏÂÙ·È ÛÙËÓ ·˘ÍË̤ÓË ÂÈÊ¿ÓÂÈ· ‰È‹ıËÛ˘, ÙÔÓ ·˘ÍË̤ÓÔ Ú˘ıÌfi ÓÂÊÚÈ΋˜ ÚÔ‹˜ Ï¿ÛÌ·ÙÔ˜ (RPF) Î·È ÛÙËÓ ·˘ÍË̤ÓË ‰È·ÛÂÈÚ·Ì·ÙÈ΋ ›ÂÛË ‰È‹ıËÛ˘ Î·È ıˆÚÂ›Ù·È fiÙÈ ÌÔÚ› Ó· ˘Ô¯ˆÚ‹ÛÂÈ ÌÂÚÈÎÒ˜ Ì ÙËÓ Î·Ï‹ Ú‡ıÌÈÛË ÙÔ˘ ™.¢. ™ÙÔÓ ™¢ Ù‡Ô 1 ÔÈ ÌÈÛÔ› ·ÛıÂÓ›˜ ÛÙËÓ 5ÂÙ›· ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ GFR 25-50% ¿Óˆ ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi, ÂÓÒ ·˘Ùfi Û˘Ì‚·›ÓÂÈ Û ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi Î·È ÌÈÎÚfiÙÂÚË ¤ÓÙ·ÛË Û ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ 2, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· Î·È Ë

21 Φυσική πορεία ΔΝ

ΛΕΙΤΟΥΡΓΙΚΕΣ ΜΕΤΑΒΟΛΕΣ νεφροί GFR

ΔΟΜΙΚΕΣ ΜΕΤΑΒΟΛΕΣ πάχυνση ΒΜ διάταση μεσαγείου

YΠΟΚΛΙΝΙΚΗ ΝΕΦΡΟΠΑΘΕΙΑ ΠΡΟΔΙΑΘΕΣΙΚΟΙ ΠΑΡΑΓΟΝΤΕΣ • υπερδιήθηση • ατελής έλεγχος σακχάρου • υπέρταση • micro albuminuria χρόνια

0

2

5

11-23

Δ μ κω

υ

Λε

15-27

ς ρία ίνη ου τιν n/y XNA ατ εα l/mi ρ Κ m 2 R1 GF ΝΕΦΡΟΠΑΘΕΙΑ

ηΣ

ξ αρ

Έν

13-25

∂ÈÎfiÓ· 1. ∏ Ê˘ÛÈ΋ ÔÚ›· Ù˘ ¢¡ ·Ú¯›˙ÂÈ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ™¢. ªÂÙ¿ ·fi ¿ÚÔ‰Ô ÌÂÚÈÎÒÓ ÂÙÒÓ, ÔÈ ÏÂÈÙÔ˘ÚÁÈΤ˜ Î·È ‰ÔÌÈΤ˜ ‰È·Ù·Ú·¯¤˜, ÌÔÚ› Ó· ÂÍÂÏȯıÔ‡Ó Û ÎÏÈÓÈο ¤Î‰ËÏË ÓÂÊÚÔ¿ıÂÈ·, Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Î·È ÙËÓ Û˘Ó¯‹ ÂÏ¿ÙÙˆÛË ÙÔ˘ GFR (áN).

Û˘¯ÓfiÙÂÚË ·Ó‡ÚÂÛË ·ÚÙËÚÈÔÛÎÏËÚ˘ÓÙÈ΋˜ ÓfiÛÔ˘, Èı·ÓfiÓ Ó· ÂÚÈÔÚ›˙ÂÈ ÙËÓ ·˘ÍË̤ÓË ˘ÂډȋıËÛË Î·È ÙËÓ ·‡ÍËÛË ÙÔ˘ ÛÂÈÚ·Ì·ÙÈÎÔ‡ ÌÂÁ¤ıÔ˘˜. ªÂÙ¿ ·fi 2-3 ¤ÙË (ÛÙ¿‰ÈÔ 2) ·Ú·ÙËÚÔ‡ÓÙ·È ÔÈ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ‰ÔÌÈΤ˜ ÌÂÙ·‚ÔϤ˜: ·) ¿¯˘ÓÛË Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ‚) ·‡ÍËÛË ÙÔ˘ ÌÂÛ·ÁÁ›Ԣ (˘ÂÚÏ·Û›· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Î·È ·‡ÍËÛË Ù˘ ıÂ̤ÏÈ·˜ Ô˘Û›·˜ (matr›x), Ì ÂÏ¿ÙÙˆÛË Ù˘ ÂÈÊ¿ÓÂÈ·˜ ‰È‹ıËÛ˘ Î·È Á) ·ÚÙËÚÈÔÛÎÏ‹Ú˘ÓÛË ÙˆÓ ÚÔÛ·ÁˆÁÒÓ Î·È ··ÁˆÁÒÓ ·ÚÙËÚȉ›ˆÓ. OÙ·Ó Ë ÂÓ·fiıÂÛË ˘ÏÈÎÔ‡ ÛÙÔ ÌÂÛ¿ÁÁÂÈÔ ·›ÚÓÂÈ ÙËÓ ÌÔÚÊ‹ fi˙ˆÓ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ¯·Ú·ÎÙËÚÈÛÙÈ΋˜ ÛÎÏ‹Ú˘ÓÛ˘ ÙˆÓ Kimmest›elW›lson. ¶·Ú¿ÏÏËÏ· ·Ú·ÙËÚÔ‡ÓÙ·È Î·È ·ÏÏÔÈÒÛÂȘ ÛÙ· Ô˘ÚÔÊfiÚ· ÛˆÏËÓ¿ÚÈ· Î·È ÙÔ ‰È¿ÌÂÛÔ ÓÂÊÚÈÎfi ÈÛÙfi. ∞fi ÌÂϤÙ˜ Ê·›ÓÂÙ·È fiÙÈ Ô Ôχ ηÏfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ‰È·‚‹ÙË ÌÔÚ› Ó· ·Ó·ÛÙÚ¤„ÂÈ ÂÓ Ì¤ÚÂÈ ÙËÓ ¿¯˘ÓÛË Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Î·È ÙËÓ ÌÂÛ·ÁÁÂȷ΋ ˘ÂÚÏ·Û›·. ∞ÎÔÏÔ˘ı› ÙÔ ˘ÔÎÏÈÓÈÎfi ÛÙ¿‰ÈÔ (ÛÙ¿‰ÈÔ 3) Ô˘ ‰È·ÚΛ 10-15 ¯ÚfiÓÈ· ÛÙÔ ÔÔ›Ô Ë ¢¡ ·ÚÔ˘ÛÈ¿˙ÂÈ ·‡ÍËÛË Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ Û ڢıÌfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 20 Ìg/min ÁÂÁÔÓfi˜ Ô˘ Û˘ÓÂ¿ÁÂÙ·È ÙËÓ ·‡ÍËÛË Ù˘ ËÌÂÚ‹ÛÈ·˜ ÓÂÊÚÈ΋˜ ¤ÎÎÚÈÛ‹˜ Ù˘ (urinary albumin excretion (UAE)), Û ÔÛfiÙËÙ· ÌÂÁ·Ï‡ÙÂÚË ·fi 30 mg. ∏ ÌÈÎÚ‹ ·˘Ù‹ ÔÛfiÙËÙ· ·ÔÙÂÏ› ÙËÓ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· Î·È Î˘Ì·›ÓÂÙ·È ·fi 30-300 mg/24h (20-200 Ìg/min),

22

¶. ¶∞™∞¢∞∫∏™

ÂÓÒ ‰ÂÓ ‰‡Ó·Ù·È Ó· ·ÓȯÓ¢ı› Ì ÙȘ Û˘Ó‹ıÂȘ ÂÚÁ·ÛÙËÚȷΤ˜ Ù¯ÓÈΤ˜ (‰ÔÎÈÌ·ÛÙÈΤ˜ Ù·Èӛ˜). ∫·ıÒ˜ Ë ÓfiÛÔ˜ ÂÍÂÏ›ÛÛÂÙ·È, ÌÂÙ¿ ·fi 5-10 ¯ÚfiÓÈ·, ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË Ù˘ ¤ÎÎÚÈÛ˘ Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÛÙ· Ô‡Ú·, Ì ·Ó‡ÚÂÛË ÔÛfiÙËÙ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ·fi 300 mg ·Ó¿ 24 ÒÚ˜ (‹ 200 Ìg/min). ∏ ÔÛfiÙËÙ· ·˘Ù‹ ·ÔÙÂÏ› ÙË ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· Î·È ¯·Ú·ÎÙËÚ›˙ÂÈ ÙËÓ ÎÏÈÓÈο ¤Î‰ËÏË ÓÂÊÚÔ¿ıÂÈ·, Ì ÙËÓ ‚·ıÌÈ·›· ϤÔÓ ÂÏ¿ÙÙˆÛË Ù˘ GFR, (ÛÙ¿‰ÈÔ 4 Ù˘ ÎÏÈÓÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ‹ Ù˘ Ì·ÎÚÔÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜). ™ÙË ¢¡ Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ GFR ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ·ÓÙ›ÛÙÔÈ¯Ë ÂÏ¿ÙÙˆÛË Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜. ΔÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ù˘ ∏ ‚·ÚÈ¿ ¢¡ (ÙÂÏÈÎfi ÛÙ¿‰ÈÔ) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÓÂÊÚÔ‡˜ Ì ‰È¿¯˘ÙË ‹ Ô˙Ò‰Ë ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË. ™ÙÔ ÛÙ¿‰ÈÔ ·˘Ùfi ·Ú¯›˙ÂÈ Û˘Ó‹ıˆ˜ Ë ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÂÓÒ ıˆÚÂ›Ù·È Èı·ÓfiÓ fiÙÈ Ë ÌÂÙ¿‚·ÛË ·fi ÙÔ ÛÙ¿‰ÈÔ 4 ÛÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÌÔÚ› Ó· ηı˘ÛÙÂÚ‹ÛÂÈ Ì ÙËÓ Î·Ï‹ Ú‡ıÌÈÛË Ù˘ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘. °ÂÓÈο Ê·›ÓÂÙ·È Ó· ··ÈÙÂ›Ù·È ·ÚfiÌÔÈÔ˜ ¯ÚfiÓÔ˜ ·fi ÙËÓ ¤Ó·ÚÍË ÙÔ˘ ™¢ ̤¯ÚÈ ÙËÓ ÂÌÊ¿ÓÈÛË ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Î·È ·fi ÙË ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ̤¯ÚÈ ÙËÓ ÂÌÊ¿ÓÈÛË Ã¡¡ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. Ÿˆ˜ Ê·›ÓÂÙ·È Ë ¢¡ ¤¯ÂÈ Ù·ÍÈÓÔÌËı› Û ÛÙ¿‰È· Ì ‚¿ÛË Î˘Ú›ˆ˜ ÙȘ ÙÈ̤˜ Ù˘ ÓÂÊÚÈ΋˜ ¤ÎÎÚÈÛ˘ ÏÂ˘ÎˆÌ·Ù›Ó˘. ∏ ÓÔÚÌÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· (UAE<20 mg/24h (‹ 15 Ìg/min)), ·ÎÔÏÔıÂ›Ù·È ·fi ÙËÓ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· (UAE>30 mg/24h (‹ 20 Ìg/min) Î·È UAE<300 mg/24h (‹ 200 Ìg/min)), ÂÓÒ Ë ÎÏÈÓÈ΋ ÓÂÊÚÔ¿ıÂÈ· ·ÊÔÚ¿ ÛÙËÓ ÌÂÙ·ÙÚÔ‹ Ù˘ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜ Û ̷ÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· (UAE>300mg/24h (‹ 200 Ìg/min). OÈ ÙÈ̤˜ ·˘Ù¤˜ (cut-points) ¤¯Ô˘Ó ÙÂı› „ËÏfiÙÂÚ· ·fi ÙÔ Ì¤ÛÔ fiÚÔ Ù˘ ̤Û˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ÙÈÌ‹˜, ÁÈ· Ó· ·˘ÍËı› Ë ÂȉÈÎfiÙËÙ· Î·È Ó· ·ÔÊ¢¯ı› Ë ·Ó‡ÚÂÛË „¢‰Ò˜ ıÂÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ, ÚÔηÏÒÓÙ·˜ fï˜ ¯·ÌËÏ‹ ¢·ÈÛıËÛ›· („¢‰Ò˜ ·ÚÓËÙÈο ‰Â›ÁÌ·Ù·). ™ËÌÂÈÒÓÂÙ·È Â‰Ò fiÙÈ ÂÎÙfi˜ ·fi ÙËÓ 24ˆÚË Û˘ÏÏÔÁ‹ Ô‡ÚˆÓ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Úˆ˚Ófi ‰Â›ÁÌ· Ô‡ÚˆÓ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ÏfiÁÔ˘ ÏÂ˘ÎˆÌ·Ù›Ó˘/ÎÚ·ÙÈÓ›ÓË (Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ <30 Ìg/mg), ÂÓÒ Ë ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· ÙÂÎÌËÚÈÒÓÂÙ·È fiÙ·Ó ÚÔ·„Ô˘Ó ÙÈ̤˜ ÌÂٷ͇ 30-300 Ìg/mg Û ‰‡Ô ·fi 3 ‰Â›ÁÌ·Ù· Û ‰È¿ÛÙËÌ· 3-6 ÌËÓÒÓ, Û ÂÚÈfi‰Ô˘˜ Û¯ÂÙÈο ÛÙ·ıÂÚÔ‡ ÌÂÙ·‚ÔÏÈÎÔ‡ ÂϤÁ¯Ô˘. ∏ ÂͤÏÈÍË Ù˘ ¢¡ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·ÚÔ˘Û›· Ù˘ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜, Ë ÔÔ›· ·ÔÙÂÏ› ÈÛ¯˘Ú‹ ¤Ó‰ÂÈÍË ÂÌÊ¿ÓÈÛ˘ ¢¡ ÙfiÛÔ Û ™¢ Ù‡Ô˘ 1

fiÛÔ Î·È Û ™¢ Ù‡Ô˘ 2. ∏ ÚÔÁÓˆÛÙÈ΋ Ù˘ ·Í›· ÛÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ¢¡ ÛÙË ‰ÂηÂÙ›· ÙÔı 1980 ¤Êı·Ó ÙÔ 80%, ÛÙÔ˘˜ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘ÚÈÎÔ‡˜ Ù‡Ô˘ 1, Û ‰È¿ÛÙËÌ· 6-14 ÂÙÒÓ. ™Â ÈÔ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÌfiÓÔ ÙÔ 30-45% ÙˆÓ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘ÚÈÎÒÓ ·ÛıÂÓÒÓ, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ô‰ËÁÔ‡ÓÙ·È Û ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· ÂÓÙfi˜ 10 ÂÙÒÓ8, Èı·ÓfiÓ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ ¤ÓÙÔÓÔ˘ ÁÏ˘Î·ÈÌÈÎÔ‡ ÂϤÁ¯Ô˘ Î·È Ù˘ Ú‡ıÌÈÛ˘ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ™¯ÂÙÈο Ì ÙÔ ÔÛÔÛÙ¿ ÂÌÊ¿ÓÈÛ˘ Ù˘ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜, Û ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ 1, ·˘Ù‹ ‰È·ÈÛÙÒÓÂÙ·È Û˘Ó‹ıˆ˜ ·ÚÎÂÙ¿ ¯ÚfiÓÈ· (>5) ÌÂÙ¿ ÙËÓ ‰È¿ÁÓˆÛË. ™ÙÔ 20-30% Ë ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· ı· ÂÌÊ·ÓÈÛı› Û 15 ¯ÚfiÓÈ· Î·È ·Ó ‰ÂÓ Á›ÓÂÈ Û˘ÁÎÂÎÚÈ̤ÓË ·Ú¤Ì‚·ÛË (ÁÏ˘Î·ÈÌÈÎfi˜ ¤ÏÂÁ¯Ô˜, ¤ÏÂÁ¯Ô˜ ˘¤ÚÙ·Û˘), ı· ÛÙ·ıÂÚÔÔÈËı› ÛÙÔ 80% ÙˆÓ ·ÛıÂÓˆÓ, ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË Ù˘ ÏÂ˘ÎˆÌ·Ù›Ó˘ ÙˆÓ Ô‡ÚˆÓ Ì ÂÌÊ¿ÓÈÛË Ù˘ ÎÏÈÓÈο ¤Î‰ËÏ˘ ÓÂÊÚÔ¿ıÂÈ·˜, Û ÔÛÔÛÙfi 10-20% ηٿ ¤ÙÔ˜. ™Â 10 ¯ÚfiÓÈ· ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Ì ™¢ Ù‡Ô˘ 1 Î·È ¢¡ ı· ÂÌÊ·Ó›ÛÂÈ XNN ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, Û 20 ¯ÚfiÓÈ· ÙÔ ÔÛÔÛÙfi ·˘Ùfi ·˘Í¿ÓÂÙ·È Û 75%, ÂÓÒ ·Ó ÌÂÙ¿ ·fi 20-25 ¯ÚfiÓÈ· ‰ÂÓ ¤¯ÂÈ ÂÌÊ·ÓÈÛÙ› ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·, Ô Î›Ó‰˘ÓÔ˜ ÎÏÈÓÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ·Ó¤Ú¯ÂÙ·È Û 1% ÂÙËÛ›ˆ˜8. ™ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Ë ˘¤ÚÙ·ÛË Û˘Ó‹ıˆ˜ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ˘ÔΛÌÂÓË ¢¡ Î·È Ù˘Èο ÂÌÊ·Ó›˙ÂÙ·È ÙËÓ ÂÚ›Ô‰Ô ÂÌÊ¿ÓÈÛ˘ Ù˘ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜9. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·, ÔÛÔÛÙfi 2040% ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÂÈ ÓÔÚÌÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· (˘ÔÛÙÚÔÊ‹) Û 5-18 ¯ÚfiÓÈ·. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ Î˘Ú›ˆ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ηÏfi ÁÏ˘Î·ÈÌÈÎfi ¤ÏÂÁ¯Ô, ¯·ÌËÏ‹ ·ÚÙËÚȷ΋ ›ÂÛË Î·È ¯·ÌËÏ¿ Â›‰· ¯ÔÏËÛÙÂÚfiÏ˘10,11. ∂ÈÚfiÛıÂÙ· Ì ÙË ÛËÌ·Û›· ÙÔ˘ ÁÏ˘Î·ÈÌÈÎÔ‡ ÂϤÁ¯Ô˘, Ë ÈÔ ÂÈıÂÙÈ΋ Ì›ˆÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Ë ¯Ú‹ÛË ÙˆÓ ·-ª∂∞ ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÌÂÈÒÓÔ˘Ó ÙÔÓ Ú˘ıÌfi Ù˘ ÂͤÏÈ͢ Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜. ∂ÓÒ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ 1 Â›Ó·È Û¯ÂÙÈο ‡ÎÔÏË Ë ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ÔÚ›·˜ ÌÂÙ¿ ÙËÓ ‰È¿ÁÓˆÛË ÙÔ˘ ™¢, ·˘Ùfi ‰ÂÓ Û˘Ì‚·›ÓÂÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ™¢ Ù‡Ô˘ 2, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Â›Ó·È ¿ÁÓˆÛÙË ¯ÚÔÓÈο Ë ¤Ó·ÚÍË ÙÔ˘ ™¢ Û ۯ¤ÛË Ì ÙË ‰È¿ÁÓˆÛË. ∞ÚÎÂÙ¿ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì ™¢ Ù‡Ô˘ 2, ÙËÓ ÛÙÈÁÌ‹ Ù˘ ‰È¿ÁÓˆÛ˘ ÂÌÊ·Ó›˙ÂÈ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· ›Ù ¢¡, ÂÓÒ ÛÙÔ 1/3 ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ ·Ó¢ڛÛÎÂÙ·È Î·È ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË. ∏ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· ÛÙÔ 20-40%

METAMO™XEY™Eπ™ 2010

ÙˆÓ ·ÛıÂÓÒÓ ı· ÂÍÂÏȯı› Û ¢¡ Û 10 ¯ÚfiÓÈ·, ÂÓÒ ÛÙ· ÂfiÌÂÓ· 20 ¯ÚfiÓÈ· ÙÔ 20% ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ı· ¤¯ÂÈ ·Ó¿ÁÎË ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜12. ∫‡ÚÈÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ¢ÓÔÔ‡Ó ÙËÓ ÚfiÔ‰Ô Û á¡ Â›Ó·È Ë ˘ÂÚÁÏ˘Î·ÈÌ›·, Ë ˘¤ÚÙ·ÛË, Ë ÂıÓÈÎfiÙËÙ· Î·È ÙÔ Î¿ÓÈÛÌ·. ∏ ˘¤ÚÙ·ÛË Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ˘ÔΛÌÂÓË ¢¡, ÂÓÒ ÌÔÚ› Ó· ·ÊÔÚ¿ Û ȉÈÔ·ı‹ ›Ù ‰Â˘ÙÂÚÔ·ı‹ ˘¤ÚÙ·ÛË. ™ÂÙÈο Ì ÙËÓ ˘ÔÛÙÚÔÊ‹ Ù˘ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜ Û ÓÔÚÌÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›· ·˘Ù‹ ·ÊÔÚ¿ Û ÌÈÎÚfi ÔÛÔÛÙfi ȉ·›ÙÂÚ· ·˘ÙÔ‡˜ Ì ηÏfi ÁÏ˘Î·ÈÌÈÎfi ¤ÏÂÁ¯Ô13. ∂›Û˘ Ë ¯Ú‹ÛË ÙˆÓ Û‡Á¯ÚÔÓˆÓ ıÂÚ·ÂÈÒÓ ÌÂÈÒÓÂÈ ÙËÓ Â›ÙˆÛË Ù˘ á¡, ·ÎfiÌË Î·È Û ÔÌ¿‰Â˜ ȉȷ›ÙÂÚ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ fiˆ˜ Â›Ó·È ÔÈ Pima Indians. ™Â ÌÈ· ÚfiÛÊ·ÙË Û¯ÂÙÈο ÌÂϤÙË, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ì ¢¡ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÌÂÈÒıËΠÛËÌ·ÓÙÈο ÌÂٷ͇ 1991-1994 Î·È 1999-2002, ·fi 32 Û 15 ÂÚÈÙÒÛÂȘ ·Ó¿ 1000 ¤ÙË-·ÛıÂÓ‹, ·ÓÙ›ÛÙÔȯ·14. °ÂÓÈο Ë ˘¤ÚÙ·ÛË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ™¢ Û˘Óԉ‡ÂÙ·È ·fi ·˘ÍË̤ÓÔ fiÁÎÔ Ï¿ÛÌ·ÙÔ˜, ·˘ÍË̤Ó˜ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ, ·˘ÍË̤ÓË ·ÚÙËÚȷ΋ ‰˘Ûη̄›· Î·È ¯·ÌËÏ‹ ‰Ú·ÛÙËÚÈfiÙËÙ· ÚÂÓ›Ó˘. ∞fi ÙÔ ÛÙ¿‰ÈÔ Ù˘ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜ ·Ú·ÙËÚÂ›Ù·È ¿ÓÔ‰Ô˜ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ȉ›ˆ˜ Ë ‰È·ÛÙÔÏÈ΋ ·ÚÙËÚȷ΋ ›ÂÛË, Ë ÔÔ›· ·Ú¯Èο ÌÔÚ› Ó· Â›Ó·È ÔÚȷ΋ ‹ Ê˘ÛÈÔÏÔÁÈ΋. ∂›Û˘ ¯¿ÓÂÙ·È Î·È o Ê˘ÛÈÔÏÔÁÈÎfi˜ Ú˘ıÌfi˜ Ù˘ 24ˆÚ˘ ‰È·Î‡Ì·ÓÛ˘ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (·‡ÂÈ Ë Ê˘ÛÈÔÏÔÁÈ΋ ÙÒÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Ô˘ ·Ú·ÙËÚÂ›Ù·È Î·Ù¿ ÙË Ó‡ÎÙ·). ∏ ·ÚÔ˘Û›· ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ ·ÔÎÙ¿ ȉȷ›ÙÂÚË ÛËÌ·Û›· Û ·ÛıÂÓ›˜ Ì Ùˆ¯fi ÁÏ˘Î·ÈÌÈÎfi ¤ÏÂÁ¯Ô (HbA1c>12%), ÔÈ ÔÔ›ÔÈ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÎÏÈÓÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÛÙËÓ 20ÂÙ›·15, ÂÓÒ Ì ηχÙÂÚÔ ÁÏ˘Î·ÈÌÈÎfi ¤ÏÂÁ¯Ô Ô Î›Ó‰˘ÓÔ˜ ·Ú·Ì¤ÓÂÈ ÌÂÁ¿ÏÔ˜ ·ÏÏ¿ Ë ¢¡ Ê·›ÓÂÙ·È fiÙÈ Î·ı˘ÛÙÂÚ›16. ¶·Ú·ÙËÚÂ›Ù·È Â›Û˘ ÂÏ¿ÙÙˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR) Î·È ¿ÓÔ‰Ô˜ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡, Ë ÔÔ›· ÙÂÏÈο ηٷϋÁÂÈ Û Ã.¡.∞. ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ∞˘Ùfi Á›ÓÂÙ·È ÌÂÙ¿ ¿ÚÔ‰Ô 5-10 ÂÙÒÓ ÔfiÙ Â¤Ú¯ÂÙ·È ÛÙ·‰È·Î¿ ÛÙÚ·ÁÁ·ÏÈÛÌfi˜ ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ÌÂÛ·ÁÁ›Ԣ Î·È Ù˘ ÛÎÏ‹Ú˘ÓÛ˘ ÙˆÓ ·ÚÙËÚȉ›ˆÓ (ÈÛ¯·ÈÌ›·). ∏ ‰È¿ÁÓˆÛË Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ Á›ÓÂÙ·È ·fi ÙËÓ ‰È·›ÛÙˆÛË ÛÙ·ıÂÚ‹˜ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ >300mg/24h, (‹ >200 Ìg/min), ¯ˆÚ›˜ ÎÏÈÓÈο

23

Â˘Ú‹Ì·Ù· ÓÂÊÚÔ¿ıÂÈ·˜ ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜. °È· ÙËÓ ‡·ÚÍË ¢¡ Û˘ÓËÁÔÚÔ‡ÓÙ· Â˘Ú‹Ì·Ù· ıˆÚÔ‡ÓÙ·È: ·) ‡·ÚÍË ‰È·‚ËÙÈ΋˜ ·ÌÊÈ‚ÏËÛÙÚ/ıÂÈ·˜, ˘¤ÚÙ·Û˘, ·˘ÍË̤ÓÔ˘ ÌÂÁ¤ıÔ˘˜ ÓÂÊÚÔ›. ∞Ô˘Û›· ÙÔ˘˜ ··ÈÙÂ›Ù·È ÓÂÊÚÈ΋ ‚ÈÔ„›· ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË Ù˘ ‰È¿ÁÓˆÛ˘. ™ÙÔÓ ‰È·‚‹ÙË Ù‡Ô˘ 1 ¤ÏÂÁ¯Ô˜ (screening) ÁÈ· ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›· Ú¤ÂÈ Ó· Á›ÓÂÙ·Ô ÂÙËÛ›ˆ˜, ÍÂÎÈÓÒÓÙ·˜ 5 ¤ÙË ÌÂÙ¿ ÙË ‰È¿ÁÓˆÛË ‹ Î·È ÓˆÚ›ÙÂÚ· Û ÂÚ›ÙˆÛË ÂÊ‹‚ˆÓ ‹ ηÎÔ‡ ÌÂÙ·‚ÔÏÈÎÔ‡ ÂϤÁ¯Ô˘. ™Â ·ÛıÂÓ›˜ Ô˘ ¿Û¯Ô˘Ó ·fi ‰È·‚‹ÙË Ù‡Ô˘ 2, Ô ¤ÏÂÁ¯Ô˜ ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÙË ‰È¿ÁÓˆÛË Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÂÙ‹ÛÈ·. OÈ ·ÛıÂÓ›˜ Ì ÌÈÎÚÔ- Î·È macroalbuminuria ı· Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ÎÏÈÓÈ΋ ¤ÏÂÁ¯Ô fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÚÔ˘Û›· Û˘Ó˘¿Ú¯Ô˘Û·˜ ÓÔÛËÚfiÙËÙ·˜, ȉ›ˆ˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·˜ ‹ Ì·ÎÚÔ·ÁÁÂÈÔ¿ıÂÈ·˜. ªÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ Ì·ÎÚÔÏÂ˘ÎˆÌ·ÙÈÓÔ˘Ú›·˜ Ô Î›Ó‰˘ÓÔ˜ ı·Ó¿ÙÔ˘ ÙˆÓ ‰È·‚ËÙÈÎÒÓ Â›Ó·È 100 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÙˆÓ ÌË ‰È·‚ËÙÈÎÒÓ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡, Ô Î›Ó‰˘ÓÔ˜ ·Ó¿Ù˘Í˘ ÎÏÈÓÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜ 20 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚÔ˜, ÂÓÒ ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚÔ˜ ΛӉ˘ÓÔ˜ ı·Ó¿ÙÔ˘ ·fi ηډȷÁÁÂȷ΋ ÓfiÛÔ.

μÈ‚ÏÈÔÁÚ·Ê›· 1. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.

N Engl J Med 329: 977-86, 1993.

2. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352: 837-53, 1998.

3. Steffes MW, Bilous RW, Sutherland DER, Mauer SM. Cell and matrix components of the glomerular mesangium in type I diabetes mellitus. Diabetes 41: 679-684, 1992.

4. Lane PH, Steffes MW, Fioretto P, Mauer SM: Renal interstitial expansion in insulin-dependent diabetes mellitus. Kidney Int 43: 661-667, 1993.

5. Mogyorosi A, Ziyadeh FN. GLUT1 and TGF-beta: The link between hyperglycaemia and diabetic nephropathy: Nephrol Dial Transplant 14: 2827–2829, 1999.

6. Fioretto P, Steffes MW, Brown DM, Mauer SM. An overview of renal pathology in insulin-dependent diabetes mellitus in relationship to altered glomerular hemodynamics. Am J Kidney Dis 1992 Dec; 20(6): 549-58.

7. Mogensen CE. Prediction of clinical diabetic nephropathy in IDDM patients. Alternatives to microalbuminuria? Diabetes 1990 Jul; 39(7): 761-7.

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¶. ¶∞™∞¢∞∫∏™

8. Caramori ML, Fioretto P, Mauer M. The need for early predictors of diabetic nephropathy risk: is albumin excretion rate sufficient? Diabetes 49:1399-1408, 2000.

12. American Diabetes Association, Nephropathy in Diabetes, Position Statements Original Article Diabetes Care 27: S79-S83, 2004.

8. Newman DJ, Mattock MB, Dawnay AB, et al. Systematic review on urine albumin testing for early detection of diabetic complications. Health Technol Assess 2005; 9:

13. Araki S, Haneda M, Sugimoto T, et al. Factors associated with frequent remission of microalbuminuria in patients with type 2 diabetes. Diabetes 2005; 54: 2983.

9. Costacou T, Ellis D, Fried L. Orchard TJ Sequence of progression of albuminuria and decreased GFR in persons with type 1 diabetes: a cohort study.Am J Kidney Dis. 2007 Nov; 50(5): 721-32.

10. Hovind P, Tarnow L, Rossing P, et al. Predictors for the development of microalbuminuria and macroalbuminuria in patients with type 1 diabetes: inception cohort study. BMJ 2004; 328:1105.

11. Perkins BA, Ficociello LH, Silva KH, Finkelstein DM. Regression of microalbuminuria in type 1 diabetes. N Engl J Med 2003; 348:2285.

14. Pavkov ME, Knowler WC, Bennett PH, Looker HC, Krakoff J, Nelson RG. Increasing incidence of proteinuria and declining incidence of end-stage renal disease in diabetic Pima Indians.Kidney Int. 2006 Nov; 70(10):1840-6. Epub 2006 Sep 27.

15. Barzilay J, Warram JH, Bak M, et al. Predisposition to hypertension: Risk factor for nephropathy and hypertension in IDDM. Kidney Int 1992; 41:723.

16. Yoshida H, Kuriyama S, Atsumi Y, et al. Angiotensin I converting enzyme gene polymorphism in non-insulindependent diabetes mellitus. Kidney Int 1996; 50:657.

£ÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ ¢È·‚ËÙÈ΋˜ NÂÊÚÔ¿ıÂÈ·˜ ™Ù¿ÁÎÔ˘ ª·Ú›· ·Ó¿Ù˘ÍË ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ Î·È ›ÓˆÛ˘ ÙÔ˘ ‰È¿ÌÂÛÔ˘ ÈÛÙÔ‡4. ∏ ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ ¢¡ Û˘Ó›ÛÙ·Ù·È ÛÂ: 1. ¶ÚfiÏË„Ë Ù˘ ÂÌÊ¿ÓÈÛ˘ Ù˘ ¢¡ Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ 2. ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· 3. ∂ÈÏÔÁ‹ ÌÂıfi‰Ô˘ ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜

O ™·Î¯·Ú҉˘ ¢È·‚‹Ù˘ (™¢) Ù‡Ô˘ ππ ·ÔÙÂÏ› ¤Ó· ·fi Ù· ÛÔ‚·ÚfiÙÂÚ· È·ÙÚÈο Î·È ÎÔÈÓˆÓÈÎÔ-ÔÈÎÔÓÔÌÈο ÚÔ‚Ï‹Ì·Ù· ·ÁÎÔÛÌ›ˆ˜. ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘ ·ÚÔ˘ÛÈ¿˙ÂÈ Ú·Á‰·›· ·‡ÍËÛË Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ΢ڛˆ˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜, ÂÓÒ ·Ó·Ì¤ÓÂÙ·È Ó· ÂÍ·ψı› ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ÙȘ ÂfiÌÂÓ˜ ‰ÂηÂٛ˜. ™‡Ìʈӷ Ì ÙËÓ ¶·ÁÎfiÛÌÈ· OÚÁ¿ÓˆÛË ÀÁ›·˜ Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ™¢ Ù‡Ô˘ ππ ÛÙÔ 2007 ˘ÔÏÔÁ›˙ÂÙ·È ÂÚ›Ô˘ ÛÙ· 246 ÂηÙÔÌ̇ÚÈ· ·ÁÎÔÛÌ›ˆ˜, ÂÓÒ ÔÈ ÚԂϤ„ÂȘ ÁÈ· ÙÔ 2025 ·Ó‚¿˙Ô˘Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÛıÂÓÒÓ ÛÙ· 380 ÂηÙÔÌ̇ÚÈ·1. ™Ù· ÙÂÏÂ˘Ù·›· 25 ¯ÚfiÓÈ· Ô ·ÚÈıÌfi˜ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ ¤¯ÂÈ ‰ÈÏ·ÛÈ·ÛÙ› ÛÙȘ ∏¶∞, ÂÓÒ ¤¯ÂÈ ÙÚÈ- ‹ ÙÂÙÚ·Ï·ÛÈ·ÛÙ› Û πÓ‰›·, ∫›Ó·, Δ·˚Ï¿Ó‰Ë, ∫ÔÚ¤·2. ∏ ¢È·‚ËÙÈ΋ ¡ÂÊÚÔ¿ıÂÈ· (¢¡) ·ÔÙÂÏ› ÌÈ· ·fi ÙȘ ÛÔ‚·ÚfiÙÂÚ˜ ÂÈÏÔΤ˜ ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË, ÂÓÒ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ì ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ ÏfiÁˆ ™¢ ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘Ó¯Ҙ ·‡ÍËÛË3. ™ÙËÓ ·ıÔÁ¤ÓÂÈ¿ Ù˘ ÂÌϤÎÔÓÙ·È ÌÂÙ·‚ÔÏÈÎÔ› ·Ú¿ÁÔÓÙ˜4 Î·È ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜5 Î·È ÊÏÂÁÌÔÓÒ‰ÂȘ ‰ÈÂÚÁ·Û›Â˜6. ∏ in-vitro ·¿ÓÙËÛË ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙËÓ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË ÁÏ˘Îfi˙˘ Î·È ÛÙËÓ Â›‰Ú·ÛË ÁÏ˘ÎÔ˙˘ÏÈˆÌ¤ÓˆÓ ÚˆÙÂ˚ÓÒÓ, Û˘Ó›ÛÙ·Ù·È Û ·‡ÍËÛË ¤ÎÊÚ·Û˘ ÙÔ˘ ÁÔÓȉ›Ô˘ ÙÔ˘ ·˘ÍËÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÙÔ˘ Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡, (connective tissue growth factor, CTGF)7, ·‡ÍËÛË Ù˘ ¤ÎÊÚ·Û˘ ÚˆÙÂ˚ÓÒÓ fiˆ˜ Ë ÈÓÈ΋, ÙÔ ÎÔÏÏ·ÁfiÓÔ Ù‡Ô˘ π, πππ, πV Î·È ÔÈ ÌÂÙ·ÏÔÚˆÙÂ˚Ó¿Û˜ (MMPs)8,9. ∂›Û˘, Û ηÏÏȤÚÁÂȘ ÛÂÈÚ·Ì·ÙÈÎÒÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î·È ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ‰È·ÈÛÙÒıËΠ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ÎÔÏÏ·ÁfiÓÔ˘ IV, ÈÓÈ΋˜ Î·È ·˘ÍËÙÈÎÔ‡ ÌÂÙ·ÌÔÚʈÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (transforming growth factor, TGF-‚1) ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ÁÏ˘Îfi˙Ë9,10.

In vivo ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë Â›‰Ú·ÛË Ù˘ ·˘ÍË̤Ó˘ Û˘ÁΤÓÙÚˆÛ˘ ÁÏ˘Îfi˙˘ Î·È ÙˆÓ AGEs Ô‰ËÁ› Û ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÓÂÊÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ‰È‹ıËÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ ·fi ÌÔÓÔ·ÙÙ·Ú· Ì·ÎÚÔÊ¿Á·3,4, ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ Î·È ÚˆÙÂ˚ÓÒÓ Ù˘ ÂÍˆÎ˘ÙÙ¿ÚÈ·˜ Ô˘Û›·˜, Î·È ÙÂÏÈο

¶ÚfiÏË„Ë Ù˘ ÂÌÊ¿ÓÈÛ˘ Ù˘ ¢¡ Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ΔÔ Î‡ÚÈÔ Ì¤ÚÔ˜ Ù˘ ıÂÚ·¢ÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ Ù˘ ¢¡ ı· Ú¤ÂÈ Ó· ÚÔÛ·Ó·ÙÔÏ›˙ÂÙ·È ÛÙËÓ ÚfiÏË„Ë Î·È ·ÔÊ˘Á‹ Ù˘ ·Ó¿Ù˘Í˘ ÓÂÊÚÈ΋˜ ÚÔÛ‚ÔÏ‹˜ ÛÙÔ ™¢. ¶·Ú¿ÁÔÓÙ˜ Ô˘ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÂÌÊ¿ÓÈÛË Î·È ÂͤÏÈÍË Ù˘ ¢¡ ›ӷÈ: Ë ÌÈÎÚÔÎ·È Ì·ÎÚÔ-ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·, Ë ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, Ë ÌË ÛˆÛÙ‹ Ú‡ıÌÈÛË ÙÔ˘ ™¢, Î·È Ë ÂÌÊ¿ÓÈÛË ‰È·‚ËÙÈ΋˜ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·˜1-3. ªÂÁ¿Ï˜ ÚÔÔÙÈΤ˜ ÌÂϤÙ˜, fiˆ˜ Ë UKPDS, RENAAL, ADVANCE, STENO-2, ¤¯Ô˘Ó ‰Â›ÍÂÈ ·fi ·ÚÎÂÙ¿ ¯ÚfiÓÈ· ÚÈÓ fiÙÈ Ë Ú‡ıÌÈÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÁÏ˘Îfi˙˘ ÛÙÔÓ ÔÚfi, Ë Ú‡ıÌÈÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ÏÈȉ›ˆÓ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂͤÏÈÍË Ù˘ ‰È·‚ËÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜. ∏ ‡·ÚÍË Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Ê·›ÓÔÓÙ·È Ó· ·›˙Ô˘Ó ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ÚfiÏÔ ÛÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘. O Ú˘ıÌfi˜ ¤ÎÙˆÛ˘ Ù˘ GFR Û ™¢ Ù‡Ô˘ ππ ¯ˆÚ›˜ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· Â›Ó·È 0,96ml/min/yr Î·È ·˘Í¿ÓÂÈ ÛÙ· 2,4ml/min/yr Û ÂÚ›ÙˆÛË ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜, ÂÓÒ Ë ÂÌÊ¿ÓÈÛË Ì·ÎÚÔÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Û˘Óԉ‡ÂÙ·È ·fi ÌÈ· ÂÚÂÙ·›Úˆ ·‡ÍËÛË ÛÙ· 57ml/min/yr. ∏ ·Ó·ÛÙÔÏ‹ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÚÂÓ›Ó˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ·Ï‰ÔÛÙÂÚfiÓ˘ ¤¯ÂÈ ¿ÌÂÛË Â›‰Ú·ÛË ÛÙËÓ ¤ÎÙˆÛË ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Û ‰È·‚ËÙÈÎÔ‡˜ Î·È ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ ¯ÔÚ‹ÁËÛË ·Ó·ÛÙÔϤˆÓ ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ (·-ª∂∞) Î·È ÙˆÓ ·ÓÙ·-

25

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ª. ™Δ∞°∫OÀ

ÁˆÓÈÛÙÒÓ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ÁÁÁÂÈÔÙÂÓÛ›Ó˘ ππ Û ÌÂÁ¿Ï˜ ÚÔÔÙÈΤ˜ ÌÂϤÙ˜, fiˆ˜ Ë REIN, RENAAL, IDNT, IRMA-2, BENEDICT, Ê¿ÓËΠӷ ÂÏ·ÙÙÒÓÂÈ ÙË ‚·Ú‡ÙËÙ· Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜, Ó· ÚÔÏ·Ì‚¿ÓÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ ÌÈÎÚÔ- Û ̷ÎÚÔÏÂ˘ÎˆÌ·ÙÔ˘Ú›· Î·È ·ÎfiÌË Ó· ηı˘ÛÙÂÚ› ‹ Î·È Ó· ·ÔÙÚ¤ÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÌÈÎÚÔÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜. ∏ ‰Ú¿ÛË ·˘Ù‹ ÙˆÓ ·Ú·¿Óˆ Û΢·ÛÌ¿ÙˆÓ ‹Ù·Ó ¿Û¯ÂÙË ·fi ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Ô˘ Û˘Ófi‰Â˘Â ÙË ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜11-14. ∂Ô̤ӈ˜ ÛÙÔ ™¢ Ë ÚfiÏË„Ë ‹ ÂÏ¿ÙÙˆÛË Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ Ì ÙË ¯ÔÚ‹ÁËÛË ·Ó·ÛÙÔϤˆÓ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ RAAS ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ú‡ıÌÈÛË ÙˆÓ ÂÈ¤‰ˆÓ ÁÏ˘Îfi˙˘ ÛÙÔ ·›Ì· Î·È ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË, ·ÔÙÂÏÔ‡Ó ·‰È·ÌÊÈÛ‚‹ÙËÙ· ÙÔ ıÂÌÂÏÈÒ‰Ë Ï›ıÔ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¢¡. øÛÙfiÛÔ, Â›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ ÓÂfiÙÂÚ˜ ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ı¤ÙÔ˘Ó ˘fi ·ÌÊÈÛ‚‹ÙËÛË Ù· ·Ú·¿Óˆ ‰Â‰Ô̤ӷ. ™ÙȘ ÌÂϤÙ˜ DIRECT Î·È RASS ‰ÂÓ ‰È·ÈÛÙÒıËΠÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË Ù˘ ÏÂ˘ÎˆÌ·ÙÔ˘Ú›·˜ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ·ª∂∞ ‹ ·Ó·ÛÙÔϤˆÓ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ÁÈ· 5 ÂÚ›Ô˘ ¯ÚfiÓÈ·15. øÛÙfiÛÔ, Ë ·ıÔÁ¤ÓÂÈ· ÙˆÓ ÈÛÙÔÏÔÁÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙË ¢¡ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÌÈ·˜ ÔχÏÔ΢ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰ÈÂÚÁ·Û›·˜, ηٿ ÙËÓ ÔÔ›· Ï·Ì‚¿ÓÂÈ ¯ÒÚ· ÂÓÂÚÁÔÔ›ËÛË ÓÂÊÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ, ·Ú·ÁˆÁ‹ ΢ÙÙ·ÚÔÎÈÓÒÓ, Î·È ‰È‹ıËÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ·fi ÊÏÂÁÌÔÓÒ‰Ë Î‡ÙÙ·Ú·. ∞˘Ùfi ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ‡·ÚÍË ÂÚÈÙÒÛÂˆÓ ·ÛıÂÓÒÓ Ô˘ ‰ÂÓ ··ÓÙÔ‡Ó ÈηÓÔÔÈËÙÈο ÛÙȘ ·Ú·¿Óˆ ·ÚÂÌ‚¿ÛÂȘ, ηıÈÛÙÔ‡Ó ·Ó·Áη›· ÙËÓ ÂÊ·ÚÌÔÁ‹ Ó¤ˆÓ ıÂÚ·¢ÙÈÎÒÓ ÌÂıfi‰ˆÓ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¢¡16,17. ™Â ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ 5/6 ÓÂÊÚÂÎÙÔÌ‹˜13 fiˆ˜ Î·È Û ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ¢¡14-16 ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Ë ¯ÔÚ‹ÁËÛË ÂÛÙ¤Ú· ÙÔ˘ Ì˘ÎÔÊ·ÈÓÔÏÈÎÔ‡ ÔͤԘ (MMF). ∏ ¯ÔÚ‹ÁËÛË MMF Û ÔÓÙ›ÎÈ· Ì ¢¡ ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÂÏ¿ÙÙˆÛË ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘, ÂÏ¿ÙÙˆÛË Ù˘ ‰È‹ıËÛ˘ ·fi Ì·ÎÚÔÊ¿Á·, Î·È Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ¤ÎÊÚ·Û˘ ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ ÌÔÚ›Ô˘ ÚÔÛÎfiÏÏËÛ˘ (Intercellular adhesion molecule, ICAM-1), ÙÔ˘ ¯ËÌÂÈÔÙ·ÎÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÙˆÓ ÌÔÓÔ΢ÙÙ¿ÚˆÓ, (Monocyte chemotactic protein, MCP-1) Î·È ÙÔ˘ TGF-‚114,15. ÕÏÏÔÈ ÂÚ¢ÓËÙ¤˜ ¤¯Ô˘Ó ÂÚÈÁÚ¿„ÂÈ Â˘ÓÔ˚΋ Â›‰Ú·ÛË ÙÔ˘ MMF, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ACEI ÛÙËÓ ·ÒÏÂÈ· ÙˆÓ Ô‰Ô΢ÙÙ¿ÚˆÓ Î·È ÛÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ MCP-1, ÛÙËÓ ¢¡16.

∏ Èı·Ó‹ Â›‰Ú·ÛË ÙÔ˘ MMF ÛÙË ¢¡ ÛÙÔÓ ¿ÓıÚˆÔ ‰ÂÓ ¤¯ÂÈ ÌÂÏÂÙËı› ·ÎfiÌË. ∂›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙfi fiÙÈ Ë ·Ó¿Ù˘ÍË ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ Î·È ›ÓˆÛ˘ ÛÙÔ ‰È¿ÌÂÛÔ ÈÛÙfi, ÔÈ Ôԛ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ·ÔÙÂÏÔ‡Ó ÚÔ¯ˆÚË̤Ó˜ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ, Ô˘ ‰ÂÓ Âȉ¤¯ÔÓÙ·È Î¿ÔÈ· ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ∂Ô̤ӈ˜, Ë ÔÔÈ·‰‹ÔÙ ·Ú¤Ì‚·ÛË ı· Ú¤ÂÈ Ó· Á›ÓÂÈ Û ÚÒÈÌ· ÛÙ¿‰È·, ηٿ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ‰ÈÂÚÁ·Û›·˜.

∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· OÈ ·ÛıÂÓ›˜ Ì ¢¡ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÚÈṲ̂Ó˜ ÎÚÈÙÈΤ˜ ‰È·ÊÔÚ¤˜ ·fi ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ·ÚfiÌÔÈÔ˘ ‚·ıÌÔ‡ á∞, fiˆ˜ Â›Ó·È Ë Ù·¯‡ÙÂÚË Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, Ë Û˘¯ÓfiÙÂÚË ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ, Ë ÈÔ ¤ÓÙÔÓË ·Ó·ÈÌ›· Î·È Ù· ¯·ÌËÏfiÙÂÚ· Â›‰· ·Ú·ıÔÚÌfiÓ˘ ÔÚÔ‡ Ù· ÔÔ›· Û˘Óԉ‡ÔÓÙ·È ·fi ·‰˘Ó·ÌÈ΋ ÓfiÛÔ ÙˆÓ ÔÛÙÒÓ. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ó·ÈÌ›·˜ ÛÙË ¢¡ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ¯ÔÚ‹ÁËÛË Ûȉ‹ÚÔ˘ Î·È ÂÚ˘ıÚÔÔÈËÙ›Ó˘. Δ· Â›‰· Hb Û‡Ìʈӷ Ì ÙȘ ÙÂÏÂ˘Ù·›Â˜ Ô‰ËÁ›Â˜ ÙÔ˘ NKF ı· Ú¤ÂÈ Ó· Î˘Ì·›ÓÔÓÙ·È 11-12g/dl, Ì ÛÙfi¯Ô ΢ڛˆ˜ ÙËÓ ·ÔÊ˘Á‹ ηډȷÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Î·È ‚ÂÏÙ›ˆÛ˘ Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜.

OÈ ·ÛıÂÓ›˜ Ì ¢¡ ·Ó·Ù‡ÛÔ˘Ó ¯·Ú·ÎÙËÚÈÛÙÈο ·‰˘Ó·ÌÈ΋ ÓfiÛÔ ÙˆÓ ÔÛÙÒÓ, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÏ·Ùو̤ÓË ÔÛÙÈ΋ ˘ÎÓfiÙËÙ· Î·È ÂÏ¿ÙÙˆÛË Ù˘ ÔÛÙÂÔηÏÛ›Ó˘. OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ ¯·ÌËÏ¿ Â›‰· ·Ú·ıÔÚÌfiÓ˘ ÛÙÔÓ ÔÚfi, ÂÓÒ ˘¿Ú¯ÂÈ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ·Ú·ıÔÚÌfiÓ˘ Î·È Ù˘ ÁÏ˘ÎÔ˙ÈÏȈ̤Ó˘ ÚˆÙÂ˚Ó˘ ÙÔ˘ ÔÚÔ‡. °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·‰˘Ó·ÌÈ΋˜ ÓfiÛÔ˘ ··ÈÙÂ›Ù·È ÛˆÛÙ‹ Ú‡ıÌÈÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÁÏ˘Îfi˙˘, ۈ̷ÙÈ΋ ¿ÛÎËÛË, Ú‡ıÌÈÛË ÙˆÓ ÂÈ¤‰ˆÓ ·Û‚ÂÛÙ›Ô˘20-23.

∂ÈÏÔÁ‹ ÌÂıfi‰Ô˘ ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ∏ ÂÓ‰ÂÈÎÓ˘fiÌÂÓË Ì¤ıÔ‰Ô˜ ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Â›Ó·È Ë ÂÚÈÙÔÓ·˚΋ οı·ÚÛË24. ª¤Û· ÛÙ· ÚÒÙ· 2 ¯ÚfiÓÈ· Ù˘ ÂÊ·ÚÌÔÁ‹˜ Ù˘, Ë ÂÚÈÙÔÓ·˚΋ οı·ÚÛË Û¯ÂÙ›˙ÂÙ·È Ì ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ı·Ó¿ÙˆÓ Û ۯ¤ÛË Ì ÙËÓ ·ÈÌÔοı·ÚÛË. ∞˘Ùfi ·Ô‰›‰ÂÙ·È ÛÙÔ ¯·ÌËÏfiÙÂÚÔ ÔÛÔÛÙfi ÏÔÈÌÒ͈Ó, ÛÙËÓ «ÚÔÛÙ·-

METAMO™XEY™Eπ™ 2010

Ù¢ÙÈ΋» Ù˘ ‰Ú¿ÛË ¤Ó·ÓÙÈ Ù˘ Û˘ÌÊÔÚËÙÈ΋˜ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ÙËÓ ‰È·Ù‹ÚËÛË Î¿ÔÈ·˜ ˘ÔÏÂÈfiÌÂÓ˘ ‰ÈÔ‡ÚËÛ˘. ∏ ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ·ÔÙÂÏ› ÛÔ‚·Ú‹ ÂÈÏÔ΋ ÙÔ˘ ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË, Ë ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ ··ÈÙ› ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÛÙԯ‡ÂÈ Î˘Ú›ˆ˜ ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘. OÈ ÂÈÏÔΤ˜ Ô˘ Û˘ÓÔ‰Â‡Ô˘Ó ÙË ¢¡ ¤¯Ô˘Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙÔ ‰È·¯ˆÚÈÛÌfi Ù˘ ¿ıËÛ˘ ۠ͯˆÚÈÛÙ‹ ÔÓÙfiÙËÙ· ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Ë ÔÔ›· ¤¯ÂÈ Ù· ‰Èο Ù˘ ¯·Ú·ÎÙËÚÈÛÙÈο Î·È ··ÈÙ› ‰È·ÊÔÚÂÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030 Diabetes Care 2004; 27: 1047-1053.

2. Atkins RC, Zimmet P. Diabetic kidney disease: act now or pay later. Saudi J Kidney Dis Transpl 2010; 21(2): 217-221.

3. Ritz E, Rychlík I, Locatelli F, Halimi S. End-stage renal failure in type 2 diabetes: A medical catastrophe of worldwide dimensions. Am J Kidney Dis. 1999; 34(5): 795-808.

4. The diabetes control and complications trial research group. The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin dependent diabetes mellitus. N Engl J Med 1993; 329: 977-986.

5. Zatz R, Dunn BR, Meyer TW, et al. Prevention of diabetic glomerulopathy by pharmacological amelioration of glomerular capillary hypertension. J Clin Invest 1986; 77: 1925-1930.

7. The role of inflammatory cytokines in diabetes and its complications. King GL. J Periodontol. 2008; 79:15271534.

8. Blom I, van Dijk A, Wieten L, et al. In vitro evidence for differential involvement of CTGF, TGFbeta and PDGF in mesangial response to injury. Nephrol Dial Transplant 2001; 16: 1139-1148.

7. Di Paolo S, Gesualdo L, Ranieri E, Grandaliani G, Schena FP. High glucose concentration induces the overexpression of TGF-beta through the activation of PDGF loop in human mesangial cells. Am J Pathol 1996; 149: 2095-2106.

8. Mason RM, Wahab NA. Extracellular matrix metabolism in diabetic nephropathy. J Am Soc Nephrol 2003; 14: 1358-1373.

9. Cohen MP, Wu VY, Cohen JA. Glycated albumin stimulates fibronectin and collagen IV production by glomerular endothelial cells under normoglycemic conditions. Biochem Biophys Res Commun 1997; 239: 91-94.

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10. Inglesias-de la Crouz MC, Ziyadeh FN, Isono M, et al.

Effects of high glucose and TGF-beta1 in the expression of collagen IV and vascular endothelial growth factor in mouse podocytes. Kidney Int 2002; 62: 901-913.

11. Zeeuw D. Albuminuria: A Target for Treatment of Type 2 Diabetic Nephropathy. Seminars in Nephrology 2007; 27: 172-181.

12. Ruggenenti P, Fassi A, Ilieva AP, et al. Preventing microalbuminuria in type 2 diabetes. N Engl J Med. 2004; 351: 1941-1951.

13. de Zeeuw D, Remuzzi G, Parving HH, et al. Proteinuria, a target for renoprotection in patients with type 2 diabetic nephropathy: lessons from RENAAL. Kidney Int 2004; 65: 2309-2320.

14. Fioretto P, Bruseghin M, Berto I, Gallina P, Manzato E, Mussap M. Renal protection in diabetes: role of glycemic control. J Am Soc Nephrol. 2006; 17: S86-89.

15. Bilous R, Chaturvedi N, Sjølie AK, Fuller J, Klein R, Orchard T, Porta M, Parving HH. Effect of candesartan on microalbuminuria and albumin excretion rate in diabetes: three randomized trials. Ann Intern Med. 2009; 151: 11-20.

16. Hostetter TH. Prevention of end-stage renal disease due to type 2 diabetes. N Engl J Med 2001; 345: 910-912.

17. Williams ME, Tuttle K. The next generation of diabetic nephropathy therapies: An update. Adv Chronic Kidney Dis 2005; 12: 212-222.

18. Romero F, Rodriguez-Iturbe B, Parra G, et al. Mycophenolate mofetil prevents the progressive renal failure induced by 5/6 renal ablation in rats. Kidney Int 1999; 55: 945-955.

19. Utimura R, Fujihara CK, Mattar AL, Costa- Malheiros DMA, Noronha IL, Zatz R. Mycophenolate mophetil prevents the development of glomerular injury in experimental diabetes. Kidney Int 2003; 63: 209-216.

20. Kumeda Y, Inaba M, Ishimura E. Renal osteodystrophy with diabetic bone disease Clin Calcium. 2003; 13: 299309.

21. Murakami R, Murakami S, Tsushima R, et al. Glycaemic control and serum intact parathyroid hormone levels in diabetic patients on haemodialysis therapy. Nephrol Dial Transplant. 2008; 23(1): 315-320.

22. Rossert J. The diabetic patient: renal insufficiency like other kidney failures? Nephrol Ther. 2006; 2: S187-189.

23. Pei Y, Hercz G, Greenwood C, Segre G, Manuel A, Saiphoo C, Fenton S, Sherrard D. Renal osteodystrophy in diabetic patients. Kidney Int. 1993; 44: 159-164.

24. Chung SH, Noh H, Ha H, Lee HB. Optimal use of peritoneal dialysis in patients with diabetes. Perit Dial Int. 2009; 29 Suppl 2: S132-134.

ÃÂÈÚÔ˘ÚÁÈο ÚÔ‚Ï‹Ì·Ù· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÃÚfiÓÈ· ¢È·‚ËÙÈ΋ NÂÊÚÔ¿ıÂÈ· ¡. ∞ÓÙˆÓÈ¿‰Ë˜, ¢. Δ·ÎÔ‡‰·˜

™ÙË ¯ÒÚ· Ì·˜ ÙÔ 30% ÙˆÓ ·ÈÌÔηı·ÈÚÔÌ¤ÓˆÓ ·ÛıÂÓÒÓ ¿Û¯Ô˘Ó ·fi ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ÔÛÔÛÙfi Ô˘ ‰Â›¯ÓÂÈ ·ÓËÛ˘¯ËÙÈ΋ ·‡ÍËÛË Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. §fiÁˆ Ù˘ ·ÁÁÂÈÔ¿ıÂÈ·˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó, ÔÈ ·ÛıÂÓ›˜ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ıˆÚÔ‡ÓÙ·È ˘„ËÏÔ‡ ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ÂȉÈÎfiÙÂÚ· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ÂÈÏÔÎÒÓ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ‹/Î·È ·ÁÎÚ¤·ÙÔ˜.1,2 ŸÌˆ˜ ÔÈ ÌÂϤÙ˜ Ô˘ ÂÈÎÂÓÙÚÒÓÔÓÙ·È ÛÙ· ȉȷ›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ‰È·‚ËÙÈÎÒÓ, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ Î·Ú‰ÈÔ·ÁÁÂȷ΋ ÓfiÛÔ, ÙËÓ ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔ¿ıÂÈ· Î·È ÙË Ó¢ÚÔ¿ıÂÈ·, ˘Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› Ì ÙËÓ Î·Ù¿ÏÏËÏË ·ÓÙÈÌÂÙÒÈÛË ÌÔÚÔ‡Ó Ó· ÂÈϤÁÔÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ٷ ›‰È· ÎÚÈÙ‹ÚÈ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜.3 ™ËÌ·ÓÙÈÎfi ¯ÂÈÚÔ˘ÚÁÈÎfi Úfi‚ÏËÌ· ·ÔÙÂÏ› Ë ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔ¿ıÂÈ·. ™Ù· ¿Óˆ ¿ÎÚ·, ÔÈ ·ıËÚÔÛÎÏËÚˆÙÈΤ˜ ‚Ï¿‚˜ ÛÙËÓ ·ÚÙËÚȷ΋ ·ÚÔ¯‹ Î·È Ë ·ÓÂ·Ú΋˜ ÊÏ‚È΋ ·Ô¯¤Ù¢ÛË Î·ıÈÛÙÔ‡Ó ÚÔ‚ÏËÌ·ÙÈ΋ ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ·ÁÁÂȷ΋˜ ÚÔÛ¤Ï·Û˘ ÁÈ· ·ÈÌÔοı·ÚÛË Î·È Û οÔȘ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· Â›Ó·È Ô ÏfiÁÔ˜ ÁÈ· Â›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ™Ù· οو ¿ÎÚ·, ÛÙ· Ï·›ÛÈ· Ù˘ Ê˘ÛÈ΋˜ ÂͤٷÛ˘, Â›Ó·È ÚÔÙÂÚ·ÈfiÙËÙ· Ë ÂÎÙ›ÌËÛË ÙˆÓ ·ÚÙËÚÈ·ÎÒÓ ÛʇÍÂˆÓ Î·È ÙˆÓ Èı·ÓÒÓ ÈÛ¯·ÈÌÈÎÒÓ ÂÏÎÒÓ. πÛ¯·ÈÌÈο ¤ÏÎË ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·ÛıÂÓ›˜ ÛʇÍÂȘ Ú¤ÂÈ Ó· ‰ÈÂÚ¢ÓÒÓÙ·È Ì ·ÁÁÂÈÔÁÚ·Ê›· ÒÛÙ fiÙ·Ó ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ‹ ÂÓ‰Ô·˘ÏÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Ó· Á›ÓÂÙ·È ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÊÔ‡ ·ÎfiÌË Î·È Ù· ÍËÚ¿ ·Û˘Ìو̷ÙÈο ¤ÏÎË ÌÔÚÔ‡Ó ÁÚ‹ÁÔÚ· Ó· ÂÍÂÏȯÙÔ‡Ó ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÂÈΛӉ˘Ó˜ ÛËÙÈΤ˜ ÂÛٛ˜. ™ÙË ‰ÂηÂÙ›· ÙÔ˘ ’70 Î·È ÛÙȘ ·Ú¯¤˜ ÙÔ˘ ’80, ÔÏÏ¿ ÚÔÁÚ¿ÌÌ·Ù· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·¤ÎÏÂÈ·Ó ÙË ‰ÈÂÓ¤ÚÁÂÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ Û ‰È·‚ËÙÈÎÔ‡˜. ∏ ÊÙˆ¯‹ ÚfiÁÓˆÛË ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ ·ÌÔοı·ÚÛË, Ë Î·Î‹ Ê˘ÛÈ΋ ÙÔ˘˜ ηٿÛÙ·-

ÛË ÏfiÁˆ ÙˆÓ Û˘ÓÔ‰ÒÓ ÂÈÏÔÎÒv ÙÔ˘ ‰È·‚‹ÙË (·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·, Ó¢ÚÔ¿ıÂÈ· Î·È Î·Ú‰ÈÔ·ÁÁÂȷ΋ ÓfiÛÔ) Î·È Ô ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÂÈÏÔÎÒÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú·ı¤ÙÔÓÙ·Ó ˆ˜ ÔÈ ÏfiÁÔÈ Ô˘ ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ÂÈϤÁÔÓÙ·Ó ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡.4,5 ™Ù· ΤÓÙÚ· Ô˘ ÂȯÂÈÚÔ‡Û·Ó ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡ Û ‰È·‚ËÙÈÎÔ‡˜, Ë ÂÈ‚›ˆÛË ˘ÂÚ¤‚·ÈÓÂ ÙˆÓ ‰È·‚ËÙÈÎÒÓ Ô˘ ·Ú¿ÌÂÓ·Ó ÛÙËÓ ·ÈÌÔοı·ÚÛË. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ‚ÂÏÙ›ˆÛË Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ‰È·‚ËÙÈÎÒÓ Î·È Ô˘Ú·ÈÌÈÎÒÓ ÂÈÏÔÎÒÓ, ¤¯Ô˘Ó οÓÂÈ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÈ· ¢ڤˆ˜ ·Ô‰ÂÎÙ‹ ıÂÚ·¢ÙÈ΋ ̤ıÔ‰Ô ÁÈ· ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜.6 ¶·ÚfiÏ· ·˘Ù¿ Û ·ÚÎÂÙ¤˜ ÛÂÈÚ¤˜ ·ÛıÂÓÒÓ Ë ÂÈ‚›ˆÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È 10-20% ¯·ÌËÏfiÙÂÚË ·’ fiÙÈ ÙˆÓ ÏËÙÒÓ Ì ÌË ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ·, ÛÙ· 3-5 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.7,8 ∏ ηډÈÔ·ÁÁÂȷ΋ ÓfiÛÔ˜ ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· ÙˆÓ ‰È·‚ËÙÈÎÒÓ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ì ÙË ıÓËÙfiÙËÙ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó· Â›Ó·È ˘„ËÏfiÙÂÚË ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì هÔ˘ 2 ·’ fiÙÈ Ì هÔ˘ 1 ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË.9 ∞˘Ùfi Èı·ÓÒ˜ ÔÊ›ÏÂÙ·È ÛÙË ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· Î·È ÛÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi Û˘ÓÔ‰ÒÓ ·ı‹ÛÂˆÓ Ô˘ ¤¯Ô˘Ó ÔÈ ·ÛıÂÓ›˜ Ì هÔ˘ 2 ‰È·‚‹ÙË. ŸÙ·Ó ‰ÂÓ Ï·Ì‚¿ÓÔÓÙ·È ˘’ fi„ÈÓ ÔÈ ÂÚÈÙÒÛÂȘ ·ÒÏÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ ÏfiÁˆ ı·Ó¿ÙÔ˘, Ê·›ÓÂÙ·È Ó· ÌËÓ ˘¿Ú¯ÂÈ ‰È·ÊÔÚ¿ ÛÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÌÂٷ͇ ·ÛıÂÓÒÓ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· Î·È ·ÛıÂÓÒÓ Ì ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·: Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ‹Ù·Ó 57,3% ÁÈ· ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Î·È 59% ÁÈ· ÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜.10

∞ÁÁÂȷ΋ ÚÔÛ¤Ï·ÛË ÁÈ· ·ÈÌÔοı·ÚÛË ∏ ·ÁÁÂÈÔ¿ıÂÈ· ÙˆÓ ·ÛıÂÓÒÓ Ì ‰È·‚‹ÙË ÌÔÚ› Ó· οÓÂÈ ÚÔ‚ÏËÌ·ÙÈ΋ ÙË ‰ÈÂÓ¤ÚÁÂÈ· Î·È ÙËÓ ˆÚ›Ì·ÓÛË Ù˘ ·ÚÙËÚÈÔÊÏ‚È΋˜ ÂÈÎÔÈÓˆÓ›·˜ ÁÈ· ·ÈÌÔοı·ÚÛË, οÓÔÓÙ·˜ ·Ó·Áη›· ÙËÓ ÙÔÔı¤ÙËÛË Û˘ÓıÂÙÈÎÔ‡ ·ÁÁÂÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ ÚÔÙÈ-

28

METAMO™XEY™Eπ™ 2010

29

ÌÒÌÂÓË ·ÁÁÂȷ΋ ÚÔÛ¤Ï·ÛË Â›Ó·È Ë ·˘ÙfiÏÔÁË ·ÚÙËÚÈÔÊÏ‚È΋ ÂÈÎÔÈÓˆÓ›·, Ì ÏÈÁfiÙÂÚ˜ ÂÈÏÔΤ˜ Ïԛ̈͢ ‹ ıÚfiÌ‚ˆÛ˘ ·’ fiÙÈ Ù· Û˘ÓıÂÙÈο ÌÔۯ‡̷ٷ.11 ∂ÓÒ Î¿ÔȘ ÌÂϤÙ˜ ‚Ú‹Î·Ó fiÙÈ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ù· ÔÛÔÛÙ¿ ÂÈÏÔÎÒÓ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÚÔÛÂÏ¿ÛÂˆÓ Â›Ó·È ˘„ËÏfiÙÂÚ· Î·È Ë ‰È¿ÚÎÂÈ· ÏÂÈÙÔ˘ÚÁÈ΋˜ ‚·ÙfiÙËÙ·˜ ÙÔ˘˜ Â›Ó·È ÌÈÎÚfiÙÂÚË,12-14 ¿ÏϘ ÌÂϤÙ˜ ‰ÂÓ ‰È¤ÎÚÈÓ·Ó Ù¤ÙÔȘ ‰È·ÊÔÚ¤˜ Û ۯ¤ÛË Ì ÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜ ÌÂ Δ™¡∞.15-17 ∏ ·ÓÂ·Ú΋˜ ·ÚÙËÚȷ΋ ·ÚÔ¯‹, ȉȷ›ÙÂÚ· ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜, ıˆÚÂ›Ù·È ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÙËÚÈÔÊÏ‚È΋˜ ÂÈÎÔÈÓˆÓ›·˜.11 OÈ ÎÂÚÎȉÈΤ˜ ·ÚÙËڛ˜ ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ ·ıËÚÔÛÎÏËÚˆÙÈΤ˜ ‚Ï¿‚˜ Î·È ‰ÂÓ ÌÔÚÔ‡Ó Ó· ‰È·ÛÙ·ÏÔ‡Ó ÌÂÙ¿ ÙËÓ ·ÚÙËÚÈÔÊÏ‚È΋ ·Ó·ÛÙfïÛË ÁÈ· ÂÈÙÚ¤„Ô˘Ó ÙËÓ ·‡ÍËÛË Ù˘ ·ÚÔ¯‹˜ ·›Ì·ÙÔ˜ ·fi 10-20 ml/min Û 600-1200 ml/min.11 ∏ ·Ó·ÛÙfïÛË ÚÔÙÈÌ¿Ù·È Ó· Á›ÓÂÙ·È ÎÂÓÙÚÈÎfiÙÂÚ·, Ì ÚÒÙË ÂÈÏÔÁ‹ Ù· ·˘ÙfiÏÔÁ· ·ÁÁ›· ÙÔ˘ ·ÛıÂÓ‹. OÈ ·ıËÚÔÛÎÏËÚˆÙÈΤ˜ ‚Ï¿‚˜ Â›Ó·È ÂÈÛ˘ ·ÈÙ›· ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Ê·ÈÓÔ̤ÓÔ˘ ˘ÔÎÏÔ‹˜, Ì ÈÛ¯·ÈÌÈÎfi fiÓÔ ÙÔ˘ ¯ÂÚÈÔ‡ ‹ Á¿ÁÁÚ·ÈÓ· ‰·ÎهψÓ, Û‡ÛÙÔȯ· Ì ÙËÓ ·ÚÙËÚÈÔÊÏ‚È΋ ÂÈÎÔÈÓˆÓ›·. ∞fi ÙÔ˘˜ ·ÈÌÔηı·ÈÚfiÌÂÓÔ˘˜ ·ÛıÂÓ›˜ ۯ‰fiÓ ·ÔÎÏÂÈÛÙÈο ÔÈ ‰È·‚ËÙÈÎÔ› Â›Ó·È ·˘ÙÔ› Ô˘ ı· ÂÌÊ·Ó›ÛÔ˘Ó ÈÛ¯·ÈÌ›· ‹ Á¿ÁÁÚ·ÈÓ· ¯ÂÚÈÔ‡ Ô˘ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› ¤ˆ˜ Î·È ·ÎÚˆÙËÚÈ·ÛÌfi ‰·ÎهψÓ.18 °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔÎÏÔ‹˜ ÌÔÚ› Ó· Á›ÓÂÈ ‰È·‰ÂÚÌ΋ ·ÁÁÂÈÔÏ·ÛÙÈ΋ ÛÙÂÓˆÌ¤ÓˆÓ ·ÚÙËÚÈÒÓ, ·ÔϛӈÛË Ù˘ ·ÚÙËÚÈÔÊÏ‚È΋˜ ÂÈÔÈÓˆÓ›·˜ ‹ Ì ÈÔ ÔχÏÔΘ Ù¯ÓÈΤ˜ Ë ·‡ÍËÛË Ù˘ ·ÈÌ¿ÙˆÛ˘ Ù˘ ÈÛ¯·ÈÌÈ΋˜ ÂÚÈÔ¯‹˜.19

ÈÛ¯·ÈÌ›·, Ë Ó¢ÚÔ¿ıÂÈ· Î·È Ë Ïԛ̈ÍË Â›Ó·È ÔÈ ÙÚÂȘ Ì·˙› ·ıÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Ô‰ËÁÔ‡Ó ÛÙȘ ÂÈÏÔΤ˜ ÙÔ˘ «‰È·‚ËÙÈÎÔ‡ Ô‰ÈÔ‡». ∏ Ïԛ̈ÍË ÙÔ˘ ¿ÎÚÔ˘ Ô‰fi˜ Â›Ó·È Ë ÂÈÏÔ΋ Ô˘ ·ÔÙÂÏ› Úfi‰ÚÔÌË Î·Ù¿ÛÙ·ÛË Î·Ù¿ÏË͢ Û ·ÎÚˆÙËÚÈ·ÛÌfi.24 ™Â ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ÙÔ 25-50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì Ïԛ̈ÍË ‰È·‚ËÙÈÎÔ‡ Ô‰ÈÔ‡ ˘Ô‚Ï‹ıËÎ·Ó Û ÂÏ¿ÛÛˆÓ· ·ÎÚˆÙËÚÈ·ÛÌfi, Ì ÙÔ 40% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ó· ¯ÚÂÈ¿˙ÔÓÙ·È ÂÎÙÂٷ̤ÓÔ ·ÎÚˆÙËÚÈ·ÛÌfi. O ıÂÚ¿ˆÓ È·ÙÚfi˜ Ú¤ÂÈ Ó· ‰È·ÎÚ›ÓÂÈ ÔÈ· Ïԛ̈ÍË Â›Ó·È ÂÈΛӉ˘ÓË ·Ó·Áο˙ÔÓÙ·˜ ¿ÌÂÛË ·ÓÙÈÌÂÙˆÈÛË Ì ¢Ú›· ·ÓÙȂȈÙÈ΋ ·ÁˆÁ‹ Î·È ¯ˆÚ›˜ ηı˘ÛÙ¤ÚËÛË ‰ÈÂÓ¤ÚÁÂÈ· ·ÎÚˆÙËÚÈ·ÛÌÔ‡, ÔÈ· ηٿÛÙ·ÛË ÌÔÚ› Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Û˘ÓÙËÚËÙÈÎfiÙÂÚ· Ì ¯ÂÈÚÔ˘ÚÁÈÎÔ‡˜ ηı·ÚÈÛÌÔ‡˜ Î·È ·ÓÙÈ‚›ˆÛË Î·È Ù¤ÏÔ˜ ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ Ó· ·ÔÊ·Û›ÛÂÈ ÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ ‹ ·ÚÂÌ‚·ÙÈ΋ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÛΤÏÔ˘˜. ∏ ÂͤٷÛË Ô˘ ηıÔÚ›˙ÂÈ ÙȘ ·Ú·¿Óˆ ıÂÚ·¢ÙÈΤ˜ ÂÈÏÔÁ¤˜ Â›Ó·È Ë ·ÁÁÂÈÔÁÚ·Ê›· Î·È ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ¤Ó‰ÂÈÍË ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ÂÚÈÊÂÚÈ΋˜ ·ÔÊÚ·ÎÙÈ΋˜ ·ÁÁÂÈÔ¿ıÂÈ·˜ Ë ÂÈÏÔÁ‹ Ù˘ ıÂÚ·¢ÙÈ΋˜ ÌÂıfi‰Ô˘ Á›ÓÂÙ·È ÌÂٷ͇ Ù˘ ÎÏ·ÛÛÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÔηٿÛÙ·Û˘ ‹ Ù˘ ÏÈÁfiÙÂÚÔ ÂÂÌ‚·ÙÈ΋˜ ÂÓ‰Ô·ÁÁÂȷ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘. ªÂϤÙ˜ Ô˘ Û˘ÁÎÚ›ÓÔ˘Ó ÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜ ‰ÂÓ ¤‰ÂÈÍ·Ó È‰È·›ÙÂÚ˜ ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙÔ˘˜ ÛÙ· ÔÛÔÛÙ¿ ÂÈÙ˘¯›·˜.25 OÈ ·ÔÊÚ·ÎÙÈΤ˜ ‚Ï¿‚˜ ˘¤˘ı˘Ó˜ ÁÈ· ÙȘ ÈÛ¯·ÈÌÈΤ˜ ÂÈÏÂÁ̤Ó˜ ‚Ï¿‚˜ ÙÔ˘ ‰È·‚ËÙÈÎÔ‡ Ô‰ÈÔ‡ Ú¤ÂÈ Ó· ‰ÈÚıÒÓÔÓÙ·È ÚÒÙ· Î·È ÌÂÙ¿ Ó· Â·ÓÂÎÙÈÌ¿Ù·È Ë Èı·ÓfiÙËÙ· ÙÔ˘ ·ÎÚˆÙËÚÈ·ÛÌÔ‡ Ô˘ Â›Ó·È Î·È Ë ‡ÛÙ·ÙË ıÂÚ·¢ÙÈ΋ ÂÈÏÔÁ‹.

¢È·‚ËÙÈÎfi fi‰È – ¶ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔ¿ıÂÈ·

ªÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ - ·ÁÎÚ¤·ÙÔ˜

∏ ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔ¿ıÂÈ· Â›Ó·È ÙÚÂȘ ÊÔÚ¤˜ Û˘¯ÓfiÙÂÚË ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·’ fiÙÈ ÛÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜.20 OÈ ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË Î·È ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÂÌÊ·Ó›˙Ô˘Ó ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÂÈÏÔÎÒÓ ·fi ÈÛ¯·ÈÌÈΤ˜ ‚Ï¿‚˜ ÛÙ· fi‰È· (25%) ·’fiÙÈ ÔÈ ‰È·‚ËÙÈÎÔ› ¯ˆÚ›˜ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (10%).21 ™ÙÔ 15% ÙˆÓ ·ÛıÂÓÒÓ Ù· ÈÛ¯·ÈÌÈο ¤ÏÎË ı· Ô‰ËÁ‹ÛÔ˘Ó Û ·ÎÚˆÙËÚÈ·ÛÌfi.22 Δ· ÔÛÔÛÙ¿ ÙˆÓ ÂÈÏÔÎÒÓ ‰Â›¯ÓÔ˘Ó Ó· Â›Ó·È ·ÚfiÌÔÈ· ÌÂٷ͇ ·ÛıÂÓÒÓ Ì ‰È·‚‹ÙË Ù‡Ô˘ 1 Î·È Ù‡Ô˘ 2. ŸÌˆ˜ Ì›· ÁÂÚÌ·ÓÈ΋ ÌÂϤÙË ¤‰ÂÈÍ ¯ÂÈÚfiÙÂÚ· ÔÛÔÛÙ¿ ÁÈ· ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ù‡Ô˘ 2 ˘fi ·ÈÌÔοı·ÚÛË, Ì 16% ·˘ÙÒÓ Ó· ¤¯Ô˘Ó ÈÛÙÔÚÈÎfi ·ÎÚˆÙËÚÈ·ÛÌÔ‡, ÂÓÒ ÙÔ 44% ›¯·Ó Â˘Ú‹Ì·Ù· ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈÔ¿ıÂÈ·˜.23 ∏

ªÔÏÔÓfiÙÈ Ë ÂÈ‚›ˆÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Î·ÙÒÙÂÚË ·fi ·˘Ù‹ ÙˆÓ ÌË ‰È·‚ËÙÈÎÒÓ ÏËÙÒÓ, Ë ·‡ÍËÛË ÙÔ˘ ÚÔÛ‰fiÎÈÌÔ˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ÏËÙÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ۯ¤ÛË Ì ÙÔ ÚÔ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÚÈ̤ÓÔ˘Ó ÁÈ· ÌfiÛ¯Â˘Ì· ÛÙËÓ ·ÈÌÔοı·ÚÛË Â›Ó·È ·ÚÎÂÙ¿ ÌÂÁ·Ï‡ÙÂÚË ·fi ·˘Ù‹ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜.26 ∏ ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· Î·È Ë ¯·ÌËÏfiÙÂÚË Â›‚›ˆÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜, Û ۯ¤ÛË Ì ÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ Ìԯ‡̷ÙÔ˜, ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ÚÔ¸¿Ú¯Ô˘Û· ηډÈÔ·ÁÁÂȷ΋ ÓfiÛÔ. ∂›Û˘ Â›Ó·È ÁÓˆÛÙfi fiÙÈ Ô ÂÚÈÂÁ¯ÂÈÚËÙÈÎfi˜ ΛӉ˘ÓÔ˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ Ï·Ì‚¿ÓÙ·È

30

¡. ∞¡Δø¡π∞¢∏™, ¢. Δ∞∫√À¢∞™

˘’fi„ÈÓ fiÙÈ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ‚Ú¤ıËΠӷ Â›Ó·È ÌfiÓÔ 8 ¯ÚfiÓÈ· ÂÓÒ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÚÈÛÛfiÙÂÚÔ ·fi 19 ¯ÚfiÓÈ·. ™Â ÔÏÏ¿ ΤÓÙÚ· Ë ·ÁÁÂÈÔÁÚ·Ê›· ÛÙÂÊ·ÓÈ·›ˆÓ Á›ÓÂÙ·È Û fiÏÔ˘˜ ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ÛÙÔÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô. ∏ ·ÂÈÎfiÓÈÛË ÙˆÓ Ï·ÁfiÓÈˆÓ Î·È ÌËÚÈ·›ˆÓ ·ÁÁ›ˆÓ Â›Ó·È ··Ú·›ÙËÙË Î·È fiÔ˘ ˘¿Ú¯ÂÈ ¤Ó‰ÂÈÍË ‰ÈÂÓÂÚÁÂ›Ù·È ·ÁÁÂÈÔÁÚ·Ê›·, Ì ÚÔÙÈÌÔ‡ÌÂÓË ϤÔÓ ÙËÓ MDCT ·ÁÁÂÈÔÁÚ·Ê›·. ∞Ó Î·È ‰ÂÓ ·ÔÙÂÏ› ·fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡, ÙÔ ÈÛÙÔÚÈÎfi ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈÔ¿ıÂÈ·˜ Ê·›ÓÂÙ·È fiÙÈ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ıÓËÙfiÙËÙ·˜ Î·È ·ÓÂ¿ÚÎÂÈ·˜ ÌÔۯ‡̷ÙÔ˜. Δ· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ·ÔʇÁÔ˘Ó Ó· ÌÂÙ·ÌÔۯ‡ÛÔ˘Ó ·ÛıÂÓ›˜ Ì ·ÌÊÔÙÂÚfiÏ¢Ú˜ ‰È¿¯˘Ù˜ Î·È ÂÚÈÌÂÙÚÈΤ˜ Â·Û‚ÂÛÙÒÛÂȘ Ì ÛÙÂÓÒÛÂȘ Ï·ÁÔÓ›ˆÓ ·ÁÁ›ˆÓ. ª›· ÂÓÙÔÈṲ̂ÓË ·ÚÙËÚȷ΋ ÛÙ¤ÓˆÛË Ô˘ ÌÔÚ› Ó· ·ÔηٷÛÙ·ı› Ì ÂÓ‰Ô·ÁÁÂȷ΋ ̤ıÔ‰Ô ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™ÙÔ˘˜ Ï‹Ù˜ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ÔÈ ÂÈÏÔΤ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Â›Ó·È ·ÚfiÌÔȘ Ì ·˘Ù¤˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈ Ï‹Ù˜ Ì ¿ÏϘ ÚˆÙÔ·ı›˜ ·Èٛ˜ Δ™¡∞.3 OÈ ÏÔÈÌÒÍÂȘ ÙÚ·‡Ì·ÙÔ˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È È‰È·›ÙÂÚ· Û˘¯ÓfiÙÂÚ˜ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ï‹Ù˜, ·Ó Î·È Ë ‡·ÚÍË ·¯˘Û·ÚΛ·˜ Û ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·ÛıÂÓÒÓ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ·˘Ù‹˜ Ù˘ ÂÈÏÔ΋˜.27,28 OÈ ÂÈÏÔΤ˜ Ù˘ ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈÔ¿ıÂÈ·˜ Ô˘ Ô‰ËÁÔ‡Ó Û ·ÎÚˆÙËÚÈ·ÛÌfi Â›Ó·È ·fi ÙȘ Û˘¯Ó¤˜ ÂÏÔΤ˜ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ì ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ÛÙÔ 13-25% ÙˆÓ ·ÛıÂÓÒÓ. ŒÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘ ·Ú·Ô˘ÛÈ¿˙ÂÙ·È ÛÙÔ 14-22% ÙˆÓ ·ÛıÂÓÒÓ Î·È ¤ˆ˜ Î·È 19% ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÁÎÂÊ·ÏÈο ·ÁÁÂȷο ÂÂÈÛfi‰È·.29 OÈ ·ÛıÂÓ›˜ Ì ÚÔ¸¿Ú¯Ô˘Û· ·ÁÁÂȷ΋ ÓfiÛÔ ¤¯Ô˘Ó ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ Ù¤ÙÔÈˆÓ ÂÈÏÔÎÒÓ.30,31 ¢È·‚ËÙÈÎÔ› ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ì ≥75% ÛÙ¤ÓˆÛË Û ¤Ó· ‹ ÂÚÈÛÛfiÙÂÚ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· ›¯·Ó ÂÙ·Ï¿ÛÈÔ Î›Ó‰˘ÓÔ ·ÎÚˆÙËÚÈ·ÛÌÔ‡ Î·È ÙÂÙÚ·Ï¿ÛÈÔ Î›Ó‰˘ÓÔ ÂÌÊÚ¿ÁÌ·ÙÔ˜ Ì˘Ôηډ›Ô˘ 3 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.32 ∂›Û˘ ¯ÂÈÚÔ˘ÚÁÈÎfi Úfi‚ÏËÌ· ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ Û˘Ó¤ÂÈ· Ù˘ ÛÏ·Á¯ÓÈ΋˜ Ó¢ÚÔ¿ıÂÈ·˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜. OÈ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ›Ûˆ˜ ¤¯Ô˘Ó η΋ ÔÈfiÙËÙ· ÙÔ˘ Â͈ÛÙ‹Ú· Ì˘

Ù˘ ·ÛÙ˘ οÓÔÓÙ·˜ Ù¯ÓÈο ‰˘ÛÎÔÏfiÙÂÚË ÙËÓ ÂÌʇÙ¢ÛË ÙÔ˘ Ô˘ÚËÙ‹Ú· ÛÙËÓ Î‡ÛÙË.

OÈ ·ÛıÂÓ›˜ ÌÂ Δ™¡™ Î·È ‰È·‚‹ÙË Ù‡Ô˘ 1 ÌÔÚ› Ó· Â›Ó·È ˘Ô„‹ÊÈÔÈ Î·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ÌÔÚ› Ó· Á›ÓÂÈ ÛÂ Û˘Ó‰˘·ÛÌfi (Û‡Á¯ÚÔÓ·) Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ‹ Û ÌÂÙ·ÁÂÓ¤ÛÙÂÚÔ ¯ÚfiÓÔ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ™ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ÔÈ Û˘ÓÔ‰¤˜ ·ı‹ÛÂȘ (.¯. ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜) Î·È Ë ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 55 ¯ÚÔÓÒÓ ÂÚÈÔÚ›˙Ô˘Ó ÙËÓ ÂÈÏÔÁ‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÌfiÓÔ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ·ÊÔ‡ Ô Î›Ó‰˘ÓÔ˜ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÒÓ ÂÈÏÔÎÒÓ ·fi ÙË Û˘Ó‰˘·Ṳ̂ÓË ‹ ÌÂÙ·ÁÂÓ¤ÛÙÂÚË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ Â›Ó·È ÌÂÁ¿ÏÔ˜ Î·È ‰ÂÓ ÚÔÛʤÚÂÈ ÛÙË Û˘ÓÔÏÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙÔ˘˜.33,34 ∂›Û˘ ÔÈ ·ÚÙËÚÈÔÛÎÏËÚ˘ÓÙÈΤ˜ ‚Ï¿‚˜ ·ÔÚÙ‹˜ Î·È Ï·ÁÔÓ›ˆÓ ·˘Í¿ÓÔ˘Ó ··ÁÔÚ¢ÙÈο ÙËÓ Èı·ÓfiÙËÙ· Ù¯ÓÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ Î·È ÂÈÏÔÎÒÓ. °ÂÓÈο Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ¤¯ÂÈ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÏÔÎÒÓ ·’ fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. Œ¯Ô˘Ó ÂÚÈÁÚ¿„ÂÈ ÔÛÔÛÙfi Â·ÓÂ¤Ì‚·Û˘ 32% ÏfiÁˆ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÈÏÔÎÒÓ.35 ™Â ÓÂfiÙÂÚ˜ ·Ó·ÊÔÚ¤˜ ·˘Ùfi ÙÔ ÔÛÔÛÙfi Â›Ó·È ÌÈÎÚfiÙÂÚÔ.36 ™˘ÁÎÂÎÚÈ̤ӷ, Ù· ÔÛÔÛÙ¿ Â·ÓÂ¤Ì‚·Û˘ ÁÈ· ıÚfiÌ‚ˆÛË ÌÔۯ‡̷ÙÔ˜ ‹ ÁÈ· ÙËÓ ·ÚÔ¯¤Ù¢ÛË ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ ·ÔÛÙ‹Ì·ÙÔ˜ ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó ÌÂȈ̤ӷ ·fi 10% Û 5,6% Î·È ·fi 12% Û 3,8% ·ÓÙ›ÛÙÔȯ·. ∏ ÌÂÁ¿ÏË ËÏÈΛ· Î·È Ë ·¯˘Û·ÚΛ· ÙÔ˘ ‰fiÙË ¤¯Ô˘Ó Â›Û˘ Û˘Û¯ÂÙÈÛÙ› Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÈÏÔÎÒÓ. ∏ ‚ÂÏÙ›ˆÛË ÙˆÓ ÔÛÔÛÙÒÓ ÂÈÏÔÎÒÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ÚÔÊ˘Ï·ÎÙÈ΋ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ıÚfiÌ‚ˆÛ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ·Ó¿Ù˘ÍË Ïԛ̈͢, ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Ù¯ÓÈ΋˜ Î·È Ù˘ ·Ó·ÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜. ªÔÏ·Ù·‡Ù·, Ë ·ÁÁÂȷ΋ ıÚfiÌ‚ˆÛË ÌÔۯ‡̷ÙÔ˜ ÂÚÈÁÚ¿ÊÂÙ·È fiÙÈ ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û ÔÛÔÛÙfi 10-35% Î·È Â›Ó·È ˘¤˘ı˘ÓË ÁÈ· ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·ÒÏÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ fiÔ˘ ‰ÂÓ Û˘ÌÌÂÙ¤¯ÂÈ Ë ·ÓÔÛÔÏÔÁÈ΋ ·ÈÙ›·.36 ÕÏϘ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÈÏÔΤ˜ Ô˘ ··ÈÙÔ‡Ó Â·ÓÂ¤Ì‚·ÛË ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÈÌÔÚÚ·Á›· Î·È ÙË ‰È·Ê˘Á‹ ·ÁÎÚ·ÙÈÎÒÓ ˘ÁÚÒÓ. ŸÛÔ ·Ó·ÊÔÚ¿ ÙȘ ‰‡Ô Ù¯ÓÈΤ˜ ·ÚÔ¯¤Ù¢Û˘ Ù˘ Â͈ÎÚÈÓÔ‡˜ ÌÔ›Ú·˜ ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (·ÁÎÚ·ÙÈÎfi˜ fiÚÔ˜), ‰ÂÓ Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ‰È·ÊÔÚ¿ ÛÙË Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ·ÁÎÚ¤·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÛÙÔ ¤ÓÙÂÚÔ Î·È Ì ·ÚÔ¯¤Ù¢ÛË ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË. ∏ ·ÚÔ¯¤Ù¢ÛË Ù˘ Â͈-

METAMO™XEY™Eπ™ 2010

ÎÚÈÓÔ‡˜ ÌÔ›Ú·˜ ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÛÙÔ ¤ÓÙÂÚÔ Û¯ÂÙ›˙ÂÙ·È Ì ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÏÔÈÌÒÍÂˆÓ Î·È ·ÁÁÂÈ·ÎÒÓ ıÚÔÌ‚ÒÛÂˆÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ŸÌˆ˜ Ë ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË ¤¯ÂÈ Û˘ÓÔÏÈο ÙÔ ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÂÈÏÔÎÒÓ, ¤ˆ˜ Î·È 5060% ÙˆÓ ·ıÂÓÒÓ ¤¯Ô˘Ó οÔÈ· Ô˘ÚÔÏÔÁÈ΋ ÂÈÏÔ΋.37,38 ªÂÙ·ÙÚÔ‹ Ù˘ ·ÚÔ¯¤Ù¢Û˘ ·fi ÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË ÛÙÔ ¤ÓÙÂÚÔ ¯ÚÂÈ¿˙ÂÙ·È ÛÙÔ 1020% ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÈÏÔΤ˜ Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙËÓ ·ÚÔ¯¤Ù¢ÛË ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË.39 ∂ÎÛÂÛËÌ·Ṳ̂ÓË ·ÈÌ·ÙÔ˘Ú›· Î·È ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ô˘ÚÔÏÔÈÌÒÍÂȘ Â›Ó·È Ô Û˘¯ÓfiÙÂÚ˜, Ì ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ÂÚ›Ô˘ 30%. ™ÙȘ ·Èٛ˜ Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ÊÏÂÁÌÔÓ‹ ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, Ë Ïԛ̈ÍË, ÔÈ Ï›ıÔÈ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙË Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ·fi Ù· Ú¿ÌÌ·Ù· Ô˘ ÙÔÔıÂÙÔ‡ÓÙ·È, Ë ·ÈÌÔÚÚ·Á›· ·fi ÙËÓ ·Ó·ÛÙfïÛË, Ë ÔÍ›· ·fiÚÚÈ„Ë, Ë Ó¤ÎÚˆÛË ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ˘ÏÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÔÈ ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ·ÚÙËÚÈÔÊÏ‚ÈΤ˜ ÂÈÎÔÈӈӛ˜. ∏ ΢ÛÙÂÔÛÎfiËÛË Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰È¿ÁÓˆÛË ·ÏÏ¿ Î·È ÁÈ· ÙËÓ ·Ú¯È΋ ·ÓÙÈÌÂÙÒÈÛË. ¶·ÁÎÚ·ٛÙȉ· ÌÔۯ‡̷ÙÔ˜ ·fi ·ÏÈÓ‰ÚfiÌËÛË Ô‡ÚˆÓ ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ 11-17% ÙˆÓ ÏËÙÒÓ Ì ·ÚÔ¯¤Ù¢ÛË ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Ì ˘ÂÚ·Ì˘Ï·Û·ÈÌ›· Î·È fiÓÔ ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È Ú¤ÂÈ Ó· ‰È·ÊÔÚԉȷÁÓˆÛÙ› ·fi ÛÔ‚·ÚfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· fiˆ˜ Ë ‰È·Ê˘Á‹ ·ÁÎÚ·ÙÈÎÒÓ ˘ÁÚÒÓ Î·È ÙÔ ·fiÛÙËÌ·. ºÏÂÁÌÔÓ‹ Î·È Ïԛ̈ÍË Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ ÌÔÚ› Ó· Û˘Ì‚Ô‡Ó ·fi ÙÔÓ ÂÚÂıÈÛÌfi ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Ù˘ ·fi ÙËÓ ·ÏÏ·Á‹ ÙÔ˘ pH ÙˆÓ Ô‡ÚˆÓ ÏfiÁˆ ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÎÎÚ›ÛˆÓ. OÈ Ï‹Ù˜ ·ÁÎÚ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ·ÚÔ¯¤Ù¢ÛË ÛÙËÓ Î‡ÛÙË ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Û˘Ìو̷ÙÈ΋ ˘ÔÔÁηÈÌ›· Î·È ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÒÏÂÈ·˜ ·ÁÎÚ·ÙÈÎÒÓ ÂÎÎÚ›ÛÂˆÓ Ô˘ ÂÚȤ¯Ô˘Ó ‰ÈÙÙ·ÓıÚ·ÎÈο.40 ¶·Ú¿ ÙȘ ÂӉ›ÍÂȘ fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ¤¯ÂÈ ıÂÙÈ΋ Â›‰Ú·ÛË ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ù˘ ·ıËÚÔÛÎÏ‹ÚˆÛ˘, Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙȘ ÌÂϤÙ˜ ÁÈ· ÙËÓ ÂͤÏÈÍË Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ‰ÈÊÔÚÔ‡ÌÂÓ·. º·›ÓÂÙ·È fiÙÈ ÔÈ ÂÎÙÂٷ̤Ó˜ ηڈÙȉÈΤ˜ ·ÁÁÂȷΤ˜ ‚Ï¿‚˜ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ‹ Ó· ÂÍÂÏ›ÛÛÔÓÙ·È Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜.41 ∂›Û˘ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ‰ÂÓ ÛÙ·Ì·Ù¿ÂÈ ÙȘ ‚Ï¿‚˜ ÛÙ· ÌÂÁ¿Ï· ·Á-

31

Á›· Î·È fiÙÈ ÔÈ Ï‹Ù˜ ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ÂÈÏÔÎÒÓ ÏfiÁˆ ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈÔ¿ıÂÈ·˜ (Ì ·ÎÚˆÙËÚÈ·ÛÌÔ‡˜ Î·È ·ÁÁÂȷΤ˜ ·Ú·Î¿Ì„ÂȘ) ·’ fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó ÌfiÓÔ Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ·ÚfiÙÈ ÔÈ ‰‡Ô ÔÌ¿‰˜ ·ÛıÂÓÒÓ Â›¯·Ó Û˘ÁÎÚ›ÛÈÌ· ÔÛÔÛÙ¿ ÂÈÏÔÎÒÓ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.42,43

μÈ‚ÏÈÔÁÚ·Ê›· 1. Fryd DS, Migliori R, Simmons RL, Chavers B, Dunn D, Payne W, Canafax DM, Sutherland DE, So SS, Mauer SM, et al. Renal transplantation at the University of Minnesota during the 1980s. Clin Transpl. 1987:167-81.

2. Larsson O, Attman PO, Aurell M, Frisk B, Brynger H. Survival in end-stage diabetic renal disease. A prospective study of 100 kidney transplant patients. Acta Med Scand. 1984; 216:393-402.

3. Rohrer RJ, Madras PN, Sahyoun AI, Monaco AP. Renal transplantation in the diabetic. World J Surg. 1986; 10:397-403.

4. Najarian J, Kjellstrand C, Simmons R et al. Renal transplantation for diabetic glomerulosclerosis. Ann Surg.

1973; 178: 477–84.

5. Kjellstrand C, Simmons R, Goetz F et al. Renal transplantation in patients with insulin-dependent diabetes.

Lancet 1973; 2:4-8.

6. Veenstra DL, Best JH, Hornberger J, Sullivan SD, Hricik DE. Incidence and long-term cost of steroid-related side effects after renal transplantation. Am J Kidney Dis. 1999; 33:829-39.

7. Munson J, Bennett W, Barry J et al. A case control study of renal transplantation in patients with type I diabetes.

Clin Transplant 1992; 6:306-11.

8. Bleyer A, Donaldson L, McIntosh M et al. Relationship between underlying renal disease and renal transplantation outcome. Am J Kidney Dis 2001; 37:1152-61.

9. Kronson J, Gillingham K, Sutherland D et al. Renal transplantation for type II diabetic patients compared with type I diabetic patients and patients over 50 years old: a single center experience. Clin Transplant 2000; 14:226-34.

10. United States Renal Data System (USRDS) Annual Data Report. Vol. 2001: National Institute of Diabetes and Digestive and Kidney Diseases (2000).

11. Konner K. Primary vascular access in diabetic patients: an audit. Nephrol Dial Transpl 2000; 15:1317-1325.

12. Roy-Chaudhury P, Kelly BS, Miller MA et al. Venous neointimal hyperplasia in polytetrafluroethylene dialysis graft. Kidney Int 2001; 59:2325-34.

13. Goldwasser P, Avram MM, Collier JT et al. Correlates of vascular access occlusion in hemodialysis. Am J Kidney Dis 1994; 24:785-94.

14. Windus DW, Jendrisak MD, Delmez JA. Prosthetic fistula survival and complications in hemodialysis

32

¡. ∞¡Δø¡π∞¢∏™, ¢. Δ∞∫√À¢∞™

patients-effects of diabetes and age. Am J Kidney Dis 1992; 19:448-52.

15. Lay JP, Ashleigh RJ, Tranconi L et al. Result of angioplasty of Brescia-Cimino haemodialysis fistulae. Clin Radiol 1998; 53:608-11.

16. Mayers JD, Markell MS, Cohen LS et al. Vascular access surgery for maintenance hemodialysis. Variables in hospital stay. ASAIO J 1992; 38:113-15.

17. Chazan JA, London MR, Pono LM. Long term survival of vascular access in a large chronic hemodialysis population. Nephron 1995; 69:228-33.

18. Caroll LL, Tzamaloukas AH, Scremin AE et al. Hand dysfunction in patients on chronic hemodialysis. Int J Artif Organs 1993; 16:694-9.

19. Valji K, Hye RJ, Roberts AC et al. Hand ischemia in patients with hemodialysis access graft. Angiographic diagnosis and treatment. Radiology 1995; 196:697-701.

20. Beks PJ, Mackay AJ, De Neeling JN et al. Peripheral arterial disease in relation to glycaemic control in an elderly Caucasian population. The Hoorn Study.

Diabetologia 1995; 38:86-96.

21. Hill MN, Feldman HI, Hilton SC et al. Risk of foot complications in long-term diabetic patients with and without ESRD: a preliminary study. ANNA J 1996; 23:381-6.

22. Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Reiber GE, Wagner EH. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 1999; 22:382-7.

23. Wannner C, Krane V, Ruf G et al. for Die Deutsch Diabetes Dialyse Studie Investigators. Rationale and design of a trial improving outcome of type 2 diabetes on haemodialysis.

Kidney Int 1999; 56 (Suppl 71):S222-6.

24. Eneroth M, Apelqvist J, Stenstrom A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections. Foot Ankle Int 1997; 18:716-22.

25. Stephenson BM, Shute K, Shandall AA. Diabetic tibial disease: the case for revascularisation. Ann R Coll Surg Engl 1993; 75:133-6.

26. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999; 341:1725-1730.

27. Stephan R, Munschauer C, Kumar M. Surgical wound infection in renal transplantation: outcome data of 102 consecutive patients without perioperative systemic antibiotic coverage. Arch Surg 1997; 132:1315-18.

28. Drafts H, Anjum M, Wynn J et al. The impact of pretransplant obesity on renal transplant outcome, Clin Transplant 1997; 11: 493-6.

29. Sung R, Althoen M, Howell T et al. Peripheral vascular occlusive disease in renal transplant recipients: risk factors and impact on kidney allograft survival, Transplantation 2000; 70:1049-54.

30. Rao K, Andersen R. The impact of diabetes on vascular com-plications following cadaver renal transplantation.

Transplantation 1987; 43:193-7.

31. Carlstrom J, Norden G, Mjornstedt L et al. Increasing prevalence of cardiovascular disease in kidney transplant patients with type I diabetes. Transpl Int 1999; 12:176-81.

32. Manske C, Wilson R, Wang Y et al. Atherosclerotic vascular complications in diabetic transplant candidates, Am J Kidney Dis 1997; 29:601-7.

33. Ojo A, Meier-Kriesche H, Hanson J et al. The impact of simultaneous pancreas-kidney transplantation on longterm patient survival. Transplantation 2001; 71:82-90.

34. Becker B, Brazy P, Becker Y et al. Simultaneous pancreas-kidney transplantation reduces excess mortality in type I diabetic patients with end-stage renal disease, Kidney Int 2000; 57: 2129-35.

35. Gruessner R, Sutherland D, Troppmann C et al. The surgical risk of pancreas transplantation in the cyclosporine era: an overview. J Am Coll Surg 1997; 185:128-44.

36. Humar A, Kandaswamy R, Granger D et al. Decreased surgical risks of pancreas transplantation in the modern era. Ann Surg 2000; 231:269-75.

37. Hickey D, Bakthavatsalam R, Bannon C et al. Urologic complications of pancreatic transplantation. J Urol 1997; 157:2042-8.

38. Del Pizzo JJ, Jacobs S, Bartlett S et al. Urologic complications of bladder-drained pancreatic allografts. Br J Urol 1998; 81: 543-7.

39. Sollinger H, Odorico J, Knechtle S et al. Experience with 500 simultaneous pancreas-kidney transplants. Ann Surg 1998; 228:284-96.

40. Hurst G, Somerville K, Alloway R et al. Preliminary experience with midodrine in kidney-pancreas transplant patients with orthostatic hypotension. Clin Transpl 2000; 14:42-7.

41. Nankivell B, Lau S, Chapman J et al. Progression of macrovascular disease after transplantation. Transplantation 2000; 69: 574-81.

42. Biesenbach G, Margreiter R, Konigsrainer A et al. Comparison of progression of macrovascular diseases after kidney or pancreas and kidney transplantation in diabetic patients with end-stage renal disease. Diabetologia 2000; 43:231-4.

43. Morrissey P, Shaffer D, Monaco A et al. Peripheral vascular disease after kidney-pancreas transplantation in diabetic patients with end-stage renal disease. Arch Surg 1997; 132: 358-61.

¶ÚfiÛÊ·Ù˜ ÂÍÂÏ›ÍÂȘ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜: EÏÏËÓÈ΋ Ú·ÁÌ·ÙÈÎfiÙËÙ· μ·Û›ÏÂÈÔ˜ ¶··ÓÈÎÔÏ¿Ô˘, ¢ËÌ‹ÙÚÈÔ˜ Δ·ÎÔ‡‰·˜ ÛË ÓÂÊÚÔ‡, Ë Û˘Ó‰˘·Ṳ̂ÓË Ì ÓÂÊÚfi ‹ Û ‰Â‡ÙÂÚÔ ¯ÚfiÓÔ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ (ª¶) Â›Ó·È Û‹ÌÂÚ· Ï‹Úˆ˜ ·Ô‰ÂÎÙ‹, ÁÈ·Ù› Ô ˘Ô„‹ÊÈÔ˜ Ï‹Ù˘ ı· Â›Ó·È ‹ Â›Ó·È ‹‰Ë ÂÎÙÂıÂÈ̤ÓÔ˜ ÛÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ù˘ ¯ÚfiÓÈ·˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÁÈ· Ó· ÌËÓ ·ÔÚÚ›„ÂÈ ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ¢ÂÓ ÈÛ¯‡ÂÈ fï˜ ÙÔ ›‰ÈÔ Î·È ÁÈ· ÙÔ˘˜ ÌË Ô˘Ú·ÈÌÈÎÔ‡˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ì ÙË ı·̷ÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÛÙȘ ª¶ ˘Ô„‹ÊÈÔÈ ıˆÚÔ‡ÓÙ·È Î·È ÂΛÓÔÈ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ ÂÈÏÔΤ˜ ÙÔ˘ ‰È·‚‹ÙË Â›Ó·È ‹ ·Ó·Ì¤ÓÂÙ·È Ó· Â›Ó·È ÛÔ‚·ÚfiÙÂÚ˜ ·fi ÙȘ Èı·Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ Ù˘ ¯ÚfiÓÈ·˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜. ∏ ηÎÔ‹ı˘ ‹ ˘ÂÚÏ·ÛÙÈ΋ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·, Ë ‚·ÚÂÈ¿ Ó¢ÚÔ¿ıÂÈ·, Ë ·Ú¯fiÌÂÓË ÚÒÈÌË ÓÂÊÚÔ¿ıÂÈ· (ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡<2 mg/dl, οı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ >50 ml/min, ÌÈÎÚÔ- ‹ Ì·ÎÚÔÏÂ˘ÎˆÌ·ÙÔ˘Ú›·), Ë ¤ÓÙÔÓË ‰˘Û¯¤ÚÂÈ· ÛÙË Ú‡ıÌÈÛË ÙÔ˘ ‰È·‚‹ÙË ‹ Î·È Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ·Ú·¿Óˆ ·ÔÙÂÏÔ‡Ó ÙȘ ·ÚȘ ÂӉ›ÍÂȘ ÌÂÌÔÓˆÌ¤ÓˆÓ ª¶ Û ÂÏ¿¯ÈÛÙ· fï˜ ÚˆÙÔÔÚȷο ΤÓÙÚ· Û’ fiÏÔ ÙÔÓ ÎfiÛÌÔ. ΔÔ ÁÂÓÈÎfiÙÂÚÔ ÛÎÂÙÈÎfi Ù˘ ‰È‡ڢÓÛ˘ ÙˆÓ ÂӉ›ÍÂˆÓ ·˘ÙÒÓ ÂÈÏÔÁ‹˜ ˘Ô„ËÊ›ˆÓ ÁÈ· ª¶ Â›Ó·È fiÙÈ ÌfiÓÔÓ fiÙ·Ó Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Á›ÓÂÈ ÓˆÚ›˜ ÛÙËÓ ÔÚ›· Ù˘ ÓfiÛÔ˘, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÈÙ¢¯ı› Ô Î‡ÚÈÔ˜ ÛÙfi¯Ô˜ Ù˘, Ë ÚfiÏË„Ë ‰ËÏ·‰‹, ·Ó·ÛÙÚÔÊ‹ ‹ ·Ó¿Û¯ÂÛË Ù˘ ÂͤÏÈ͢ ÙˆÓ ‰Â˘ÙÂÚÔ·ıÒÓ ‚Ï·‚ÒÓ ÙÔ˘ ‰È·‚‹ÙË. ∂Âȉ‹ fï˜ ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ Ï‹Ù˜ ·ÁÎÚ¤·ÙÔ˜ Û‹ÌÂÚ· ÔÈ ÂÈÏÔΤ˜ ·˘Ù¤˜ Â›Ó·È ‹‰Ë ÚÔ¯ˆÚË̤ÓÔ˘ ÛÙ·‰›Ô˘, Â›Ó·È Ôχ ‰‡ÛÎÔÏÔ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Ó· ÂÎÙÈÌËı› Ô ‚·ıÌfi˜ ÛÙÔÓ ÔÔ›Ô ÂËÚ¿˙ÔÓÙ·È. øÛÙfiÛÔ ÛÙËÓ ˘¿Ú¯Ô˘Û· ‚È‚ÏÈÔÁÚ·Ê›· Ê·›ÓÂÙ·È Î·ı·Ú¿ ϤÔÓ ˆ˜ Ë ª¶ ÚÔÊ˘Ï¿ÛÛÂÈ ·fi ÙËÓ ÂΉ‹ÏˆÛË ‰È·‚ËÙÈÎÒÓ ‚Ï·‚ÒÓ Û ٷ˘Ùfi¯ÚÔÓ· ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ÓÂÊÚfi, ÔÈ Ôԛ˜ ı· ÂΉËÏÒÓÔÓÙ·Ó Ì¤Û· Û ‰‡Ô (2) ¯ÚfiÓÈ· ÌÂÙ¿ ·fi ÓÂÊÚÈ΋ ÌfiÓÔÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶ÚÔ¸¿Ú¯Ô˘Û˜ Â›Û˘ ÓÂÊÚÈΤ˜ ‚Ï¿‚˜ Û ÚÔËÁËı›۷ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹ ‚Ï¿-

O ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Ù‡Ô˘ 1 Â›Ó·È Ë ÙÚ›ÙË Û ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜ ÓfiÛÔ˜ ÙÔ˘ ÂÓ‹ÏÈÎÔ˘ ÏËı˘ÛÌÔ‡ ÛÙÔ ¢˘ÙÈÎfi ÎfiÛÌÔ Î·È ·fi Ù· ÈÔ Û˘¯Ó¿ ¯ÚfiÓÈ· ÓÔÛ‹Ì·Ù· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÔχÏÔÎˆÓ Û¯ËÌ¿ÙˆÓ ÈÓÛÔ˘ÏÈÓÔıÂÚ·›·˜ ÂÏ·ÙÙÒÓÂÈ ÙË Û˘¯ÓfiÙËÙ· Î·È ‚·Ú‡ÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ ÙÔ˘ ‰È·‚‹ÙË, ·ÏÏ¿ ¿ÓÙ· Ì ·ÓÙ¿ÏÏ·ÁÌ· ÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ˘ÔÁÏ˘Î·ÈÌÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ, ÂÓÒ ÔÈ ÙÈ̤˜ Ù˘ ÁÏ˘ÎÔ˙˘ÏȈ̤Ó˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ (HbA1c) ‰È·ÙËÚÔ‡ÓÙ·È ÛÙ·ıÂÚ¿ ¿Óˆ ·fi Ù· Ê˘ÛÈÔÏÔÁÈο Â›‰·. OÈ ÂÈÏÔΤ˜ fï˜ ·˘Ù¤˜ ÂΉËÏÒÓÔÓÙ·È ·ÎfiÌË Î·È Ì ÌÂÙÚ›ˆ˜ ·˘ÍË̤ÓË HbA1c, Ô˘ ÛËÌ·›ÓÂÈ fiÙÈ “ηϋ” Ú‡ıÌÈÛË ÙÔ˘ ۷ί¿ÚÔ˘ ‰ÂÓ Â›Ó·È ¿ÓÙ· «·ÚÎÂÙ¿ ηϋ» ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜. ∂›Ó·È ϤÔÓ ÁÓˆÛÙfi fiÙÈ ÙÔ ‰È·‚ËÙÈÎfi Û‡Ó‰ÚÔÌÔ ‰ÂÓ ıÂÚ·‡ÂÙ·È Ì ÙËÓ ÈÓÛÔ˘Ï›ÓË Î·È ÌfiÓÔ Ë ·ÓÙÈηٿÛÙ·ÛË Ù˘ ¿Û¯Ô˘Û·˜ ÂÓ‰ÔÎÚÈÓÔ‡˜ ÌÔ›Ú·˜ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ·ÔÙÂÏ› Û‹ÌÂÚ· ÙÔÓ ϤÔÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfi ÙÚfiÔ Â›Ù¢Í˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÁÏ˘Îfi˙˘. ΔÔ Ù›ÌËÌ· ‚¤‚·È· Ù˘ ıÂÚ·¢ÙÈ΋˜ ·˘Ù‹˜ ·ÓÙÈÌÂÙÒÈÛ˘ Â›Ó·È Ë ·Ó¿ÁÎË ¯ÔÚ‹ÁËÛ˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏfiÎÏËÚÔ˘ ÙÔ˘ ÔÚÁ¿ÓÔ˘, Ë ÔÔ›· Â›Ó·È ÌÈ· ÌÂÁ¿ÏË Â¤Ì‚·ÛË, ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÂÈϤÔÓ ÂÁ¯ÂÈÚËÙÈÎfi˜ ΛӉ˘ÓÔ˜ Î·È ÔÈ ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜. øÛÙfiÛÔ, fiÙ·Ó ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·˘Ù¤˜ Â›Ó·È ÂÈÙ˘¯Â›˜, ÂÁηıÈÛÙÔ‡Ó ·fiÏ˘ÙË Â˘ÁÏ˘Î·ÈÌ›· Î·È Ë HbA1c ‰È·ÙËÚÂ›Ù·È Ê˘ÛÈÔÏÔÁÈ΋ ÁÈ· fiÛÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÙÔ ÌfiÛ¯Â˘Ì· ÏÂÈÙÔ˘ÚÁ›.

OÈ Kelly Î·È Û˘Ó. (1967) fiÙ·Ó ‰ËÌÔÛ›Â˘Û·Ó ÙËÓ ÚÒÙË ÎÏÈÓÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÁÎÚ¤·ÙÔ˜ ÚÔÛ‰ÈfiÚÈÛ·Ó Û˘Á¯ÚfiÓˆ˜ Î·È ÙËÓ Î‡ÚÈ· ÔÌ¿‰· ˘Ô„ËÊ›ˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. «...OÈ ·ÛıÂÓ›˜ ÂΛÓÔÈ Ô˘ ¿Û¯Ô˘Ó ·fi Ó·ÓÈÎfi ‰È·‚‹ÙË Î·È ¤¯Ô˘Ó ηٷϋÍÂÈ Û ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Â›Ó·È Î·Ù¿ÏÏËÏÔÈ ˘Ô„‹ÊÈÔÈ ÁÈ· Û‡Á¯ÚÔÓË ÓÂÊÚÈ΋ Î·È ·ÁÎÚ·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË...». ™ÙÔÓ Ô˘Ú·ÈÌÈÎfi ‚¤‚·È· ‰È·‚ËÙÈÎfi ·ÛıÂÓ‹, ÁÈ· ÙÔÓ ÔÔ›Ô ıÂÚ·›· ÂÎÏÔÁ‹˜ Â›Ó·È Ë ÌÂÙ·ÌfiÛ¯Â˘-

33

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‚˜ ÛÙÔ˘˜ Èı·ÁÂÓ›˜ (native) ÓÂÊÚÔ‡˜ ÌË Ô˘Ú·ÈÌÈÎÒÓ ‰È·‚ËÙÈÎÒÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ª¶ Ê·›ÓÂÙ·È fi¯È ÌfiÓÔ Ó· ÌËÓ ÂÍÂÏ›ÛÛÔÓÙ·È, ·ÏÏ¿ ·ÓÙ›ıÂÙ· ¤¯ÂÈ ·Ú·ÙËÚËı› Î·È ÛËÌ·ÓÙÈ΋ ˘Ô¯ÒÚËÛ‹ ÙÔ˘˜. ∞ÓÙÈÎÂÈÌÂÓÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ Ó¢ÚÔ¿ıÂÈ·˜ Â›Ó·È Û˘Ó‹ı˘ ÙfiÛÔ ÛÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ Ì ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ã¡∞ fiÛÔ Î·È ÛÙÔ˘˜ ÌË Ô˘Ú·ÈÌÈÎÔ‡˜. ∞ÏÏ¿ Î·È ÛÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ ·˘ÙÔ‡˜ ·ÛıÂÓ›˜ Ë Ó¢ÚÔ¿ıÂÈ· Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Ôχ ÚÔ¯ˆÚË̤ÓË ÁÈ· Ó· Â›Ó·È Ï‹Úˆ˜ ·Ó·ÛÙÚ¤„ÈÌË. ∏ ÔÌ¿‰· ¿ÓÙˆ˜ ÙÔ˘ Michigan ıˆÚ› ÙË Ó¢ÚÔ¿ıÂÈ· ÙÔ˘ ∞˘ÙfiÓÔÌÔ˘ ¡Â˘ÚÈÎÔ‡ ™˘ÛÙ‹Ì·ÙÔ˜ Û·Ó ·ÓÂÍ¿ÚÙËÙË ¤Ó‰ÂÈÍË ª¶. ™ÙË ÌÂÁ¿ÏË ÙÔ˘˜ Â›Û˘ ÏÂÈÔÓfiÙËÙ· ÔÈ Ï‹Ù˜ ·ÁÎÚ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È ‹‰Ë Ù˘ÊÏÔ› ‹ ¿Û¯Ô˘Ó ·fi ÚÔ¯ˆÚË̤ÓÔ˘ ÛÙ·‰›Ô˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·, Ë ÔÔ›· Èı·ÓfiÓ ÛÙË Ê¿ÛË ·˘Ù‹ Ó· Â›Ó·È fi¯È ÌfiÓÔ ÌË ·Ó·ÛÙÚ¤„ÈÌË, ·ÏÏ¿ Î·È ·˘ÙÔÂÍÂÏÈÛÛfiÌÂÓË. ¶·Ú’ fiÏ· ·˘Ù¿ Û ÚfiÛÊ·ÙË Ôχ ηϿ ÙÂÎÌËÚȈ̤ÓË ÂÚÁ·Û›· ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ì¤Û· ÛÙ· 2-3 ÚÒÙ· ¯ÚfiÓÈ· ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ù· ÔÛÔÛÙ¿ ÛÙ·ıÂÚÔÔ›ËÛ˘ ‹ ÂÚ·ÈÙ¤Úˆ ÂͤÏÈ͢ Ù˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ·˜ Â›Ó·È ·ÚfiÌÔÈ· ÁÈ· ÙÔ˘˜ ·ÚÚÒÛÙÔ˘˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ‹ fi¯È ÌfiÛ¯Â˘Ì·. ªÂÙ¿ Ù· 3 fï˜ ¯ÚfiÓÈ· Ë ·ÌÊÈ‚ÏËÛÙÚÔÂȉÔ¿ıÂÈ· ·Ú¤ÌÂÈÓ ÛÙ·ıÂÚ‹ ÛÙÔ˘˜ ·ÚÚÒÛÙÔ˘˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì·, ÂÓÒ Û˘Ó¤¯ÈÛ ӷ ÂÍÂÏ›ÛÛÂÙ·È ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ÙÔ ÌfiÛ¯Â˘Ì· ›¯Â ÛÙ·Ì·Ù‹ÛÂÈ Ó· ÏÂÈÙÔ˘ÚÁ›.

™Â ·ÁÎfiÛÌÈÔ Â›Â‰Ô ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› ̤¯ÚÈ Û‹ÌÂÚ· ÂÚÈÛÛfiÙÂÚ˜ ·fi 30000 ª¶. ªÂÙ·ÌÔۯ‡ÛÂȘ ÙÔ˘ ÔÚÁ¿ÓÔ˘ Á›ÓÔÓÙ·È Û 200 ÂÚ›Ô˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Î·È Ù· ÌÈÛ¿ ۯ‰fiÓ ‚Ú›ÛÎÔÓÙ·È ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ Ù˘ ∞ÌÂÚÈ΋˜, fiÔ˘ Î·È ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› Ù· 3/4 ÂÚ›Ô˘ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ (∂ÈÎ. 1). ∏ ›ÛÔ‰Ô˜ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË ÙˆÓ ÓÂfiÙÂÚˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Â›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÓÙ˘ˆÛȷ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ ·ÔÚÚÈÙÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ Î·È ÙË ‰ËÌÈÔ˘ÚÁ›· ‰‡Ô Ó¤ˆÓ Ù¿ÛÂˆÓ ÛÙȘ ª¶, Ô˘ ¿Ú¯ÈÛ·Ó Ó· ÂΉËÏÒÓÔÓÙ·È ÌÂÙ¿ ÙÔ 1994. ¶ÚÒÙÔÓ ·˘Í‹ıËÎÂ Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÌÔÓˆÌ¤ÓˆÓ ª¶ Î·È ‰Â‡ÙÂÚÔÓ Ë ·ÚÔ¯¤Ù¢ÛË Ù˘ ¤Íˆ ¤ÎÎÚÈÛ˘ ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË, Ô˘ ÚÔÛ¤ÊÂÚ ÙË ‰˘Ó·ÙfiÙËÙ· ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ·Ì˘Ï¿Û˘ ÛÙ· Ô‡Ú· (ÚÒÈÌÔ˜ ‰Â›ÎÙ˘ ·fiÚÚȄ˘), ¤ÁÈÓ ÏÈÁfiÙÂÚÔ ‰ËÌÔÊÈÏ‹˜ Î·È Ù· ÂÚÈÛÛfiÙÂÚ· ϤÔÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ·Ú¯›˙Ô˘Ó Ó· ÚÔÙÈÌÔ‡Ó ÙËÓ ·ÚÔ¯¤Ù¢ÛË ÛÙÔ ¤ÓÙÂÚÔ.

OÈ ·ÓÔÛÔÏÔÁÈΤ˜ ·ÒÏÂȘ ÌÂÈÒıËÎ·Ó ÛËÌ·ÓÙÈο ·fi 6% ÛÙÔ 2% ÁÈ· ÙȘ Û˘Ó‰˘·Ṳ̂Ó˜ Ì ÓÂÊÚfi ª¶ (™¡ª¶), ·fi 23% ÛÙÔ 7% ÁÈ· ÙȘ ÌÂÙ¿ ·fi ÓÂÊÚfi ª¶ (ª¡ª¶) Î·È ·fi 35% ÛÙÔ 9% ÁÈ· ÙȘ ·ÌÈÁ›˜ ª¶ (∞ª¶), ηıÒ˜ Â›Û˘ Î·È ÔÈ ·ÒÏÂȘ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÛÊ¿ÏÌ·Ù· ÂÁ¯ÂÈÚËÙÈ-

∂ÈÎfiÓ· 1. ∏ ÙÂÏÂ˘Ù·›· ·Ó¿Ï˘ÛË (2007) ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ ¢ÈÂıÓÔ‡˜ ∞Ú¯Â›Ô˘ ªÂÙ·ÌfiÛ¯Â˘Û˘ ¶·ÁÎÚ¤·ÙÔ˜ (International Pancreas Transplant Registry 2007) ·ÊÔÚ¿ Û ÂÚÈÛÛfiÙÂÚ˜ ·fi 29000 ª¶, ·fi ÙȘ Ôԛ˜ ÔÈ 21500 ÂÚ›Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙȘ ∏¶∞.

METAMO™XEY™Eπ™ 2010

΋˜ Ù¯ÓÈ΋˜ (·fi 16% ÛÙÔ 8%). ∞ÔÙ¤ÏÂÛÌ· ÙˆÓ ÂÍÂÏ›ÍÂˆÓ ·˘ÙÒÓ ‹Ù·Ó Ó· ·˘ÍËı› Ë ÂÈ‚›ˆÛË ÙˆÓ ÏËÙÒÓ ·ÁÎÚ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (≥95% ¤Ó·ÓÙÈ 91% Ù˘ ÂÚÈfi‰Ô˘ 1987-95), ηıÒ˜ Î·È ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi 77% Û 84% ÁÈ· ÙȘ ™¡ª¶, ·fi 54% Û 74% ÁÈ· ÙȘ ª¡ª¶ Î·È ·fi 52% Û 76% ÁÈ· ÙȘ ∞ª¶. ∏ ‚ÂÏÙ›ˆÛË ·˘Ù‹ Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙȘ ÌÂÌÔӈ̤Ó˜ (ª¡ª¶ Î·È ∞ª¶) ª¶ Û˘Óԉ‡ÙËΠ‚¤‚·È· Î·È ·fi ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·˘ÙÒÓ (·fi 34 ∞ª¶ ÙÔ 1992 ¤ÁÈÓ·Ó 163 ÙÔ 2001 Î·È ·fi 27 ª¡ª¶ ÙÔ 1992 ¤ÁÈÓ·Ó 305 ÙÔ 2001), ÂÓÒ ÌÂÈÒıËΠÙÔ ÔÛÔÛÙfi ÙˆÓ ™¡ª¶ ·fi ÙÔ 89% ÛÙÔ 65% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ª¶

35

Ô˘ ¤ÁÈÓ·Ó ÙÔ 1992 Î·È ÙÔ 2001 ·ÓÙ›ÛÙÔȯ· (∂ÈÎ. 2). ∏ ·ÚÔ¯¤Ù¢ÛË Ù˘ ¤Íˆ ·ÁÎÚ·ÙÈ΋˜ ¤ÎÎÚÈÛ˘ ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË (∂ÈÎ. 3) ·ÔÙÂÏÔ‡Û ̤¯ÚÈ ÚfiÛÊ·Ù· ÙË Ì¤ıÔ‰Ô ÂÎÏÔÁ‹˜ (92% ÙˆÓ ª¶ ÛÙȘ ∏¶∞ Û‡Ìʈӷ Ì ÙËÓ ·Ó¿Ï˘ÛË ÙÔ˘ 1995). ™ÙËÓ ∂ÏÏ¿‰· Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó 11 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÏÈÎÔ‡ ·ÁÎÚ¤·ÙÔ˜ ÛÙȘ ·Ú¯¤˜ ÙÔ˘ ’90, ·fi ÙȘ Ôԛ˜ ÔÈ 4 Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ∞.¶.£. ÛÙÔ πÔÎÚ¿ÙÂÈÔ °ÂÓ. ¡ÔÛÔÎÔÌÂ›Ô £ÂÛ/ӛ΢ Ì ÙËÓ Ù¯ÓÈ΋ Ù˘ ·ÚÔ¯¤Ù¢Û˘ Ù˘ ¤Íˆ ¤ÎÎÚÈÛ˘ ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË. ™ÙËÓ ÂÚ›Ô‰Ô ˆÛÙfiÛÔ 1996-99 Ë ϤÔÓ Ê˘ÛÈÔÏÔÁÈ΋ ·ÚÔ¯¤Ù¢ÛË ÛÙÔÓ ÂÓÙÂÚÈÎfi ۈϋӷ (∂ÈÎ. 4)

Κατηγορίες παγκρεατικών μετ/σεων ΣΝΜΠ

ΜΝΜΠ

ΑΜΠ

1000 800 600 400 200 0 1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003 midyear update IPTR/UNOS

∂ÈÎfiÓ· 2. ΔÔ 79% ÙˆÓ ª¶ Ô˘ Á›ÓÔÓÙ·È ÂÙËÛ›ˆ˜ ÛÙȘ ∏¶∞ Â›Ó·È ™¡ª¶, ÙÔ 14% ª¡ª¶ Î·È ÙÔ 6% ∞ª¶. ™ÙȘ ÂÎÙfi˜ ∏¶∞ fï˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÈ ª¡ª¶ Î·È ÔÈ ∞ª¶ Á›ÓÔÓÙ·È Ì ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ· (5% Î·È 3% ·ÓÙ›ÛÙÔȯ·).

Λεπτό έντερο

Πάγκρεας

Λαγόνιος αρτηρία

Δωδεκαδάκτυλο

Πάγκρεας

Κοινή λαγόνιος Δότη

Αγγειακό μόσχευμα δότη

Δωδεκαδάκτυλο

Λαγόνιος αρτηρία και φλέβα Ουροδ. κύστη

∂ÈÎfiÓ· 3. Δ¯ÓÈ΋ ·ÚÔ¯¤Ù¢Û˘ Ù˘ ¤Íˆ ¤ÎÎÚÈÛ˘ ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË.

∂ÈÎfiÓ· 4. Δ¯ÓÈ΋ ·ÚÔ¯¤Ù¢Û˘ Ù˘ ¤Íˆ ¤ÎÎÚÈÛ˘ ÛÙÔ ¤ÓÙÂÚÔ.

μ. ¶∞¶∞¡π∫O§∞OÀ, ¢. Δ∞∫OÀ¢∞™

ÎÂÚ‰›˙ÂÈ ¤‰·ÊÔ˜ Î·È ÛÙÔ 50% ÂÚ›Ô˘ ÙˆÓ ™¡ª¶ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë Ù¯ÓÈ΋ ·˘Ù‹ Ì ·ÚfiÌÔÈ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (84% ¤Ó·ÓÙÈ 85%). ™ÙÔ 1/3 Ì¿ÏÈÛÙ· ·fi ÙȘ ™¡ª¶ Ì ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ fiÚÔ˘ ÛÙÔ ¤ÓÙÂÚÔ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ˘Ï·›· ÁÈ· ÙËÓ ·ÚÔ¯¤Ù¢ÛË Ù˘ ¤Ûˆ ¤ÎÎÚÈÛ˘ ·ÓÙ› Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ Ì ÔÛÔÛÙ¿ 1 ¤ÙÔ˘˜ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ 83% Î·È 84% ·ÓÙ›ÛÙÔȯ·. ∏ ¯ÚËÛÈÌÔÔ›ËÛË fï˜ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ ÂÍ·ÎÔÏÔ˘ı› Ó· ˘ÔÛÙËÚ›˙ÂÈ ÛËÌ·ÓÙÈο ηχÙÂÚË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙȘ ÌÂÌÔӈ̤Ó˜ ª¶. ∏ 1 ¤ÙÔ˘˜ ÂÈ‚›ˆÛË ¤Ó·ÓÙÈ Ù˘ ·ÚÔ¯¤Ù¢Û˘ ÛÙÔ ¤ÓÙÂÚÔ ‹Ù·Ó 80% Î·È 68% ·ÓÙ›ÛÙÔȯ· ÛÙȘ ª¡ª¶ Î·È 78% Î·È 63% ·ÓÙ›ÛÙÔȯ· ÛÙȘ ∞ª¶. ªÂÙ·ÙÚÔ‹ Ù˘ ·ÚÔ¯¤Ù¢Û˘ ÛÙËÓ Ô˘ÚÔ‰fi¯Ô ·ÛÙË Û ÂÓÙÂÚÈ΋ ·ÚÔ¯¤Ù¢ÛË ··ÈÙ‹ıËÎÂ, ÏfiÁˆ ÂÈÏÔÎÒÓ, ÛÙÔ 12% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì¤Û· Û ‰È¿ÛÙËÌ· 2 ÂÙÒÓ. ∏ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ· ‰ÂÓ Ê·›ÓÂÙ·È Ó· ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛÔ‚·Úfi ÚfiÏÔ ÛÙȘ ™¡ª¶, ÂÓÒ ÙÔ ·ÓÙ›ıÂÙÔ Û˘Ì‚·›ÓÂÈ ÛÙȘ ÌÂÌÔӈ̤Ó˜ ª¶ ȉȷ›ÙÂÚ· Ì¿ÏÈÛÙ· ˆ˜ ÚÔ˜ Ù· ·ÓÙÈÁfiÓ· HLA-A Î·È B. ªÂ Û˘Ì‚·ÙfiÙËÙ· ≥ 1 Î·È ÛÙ· ‰‡Ô ·ÓÙÈÁfiÓ· Ë 1 ¤ÙÔ˘˜ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó 85% ÁÈ· ÙȘ ª¡ª¶ Î·È 74% ÁÈ· ÙȘ ∞ª¶, ¤Ó·ÓÙÈ 70% Î·È 60% ·ÓÙ›ÛÙÔȯ· ÁÈ· ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì ÏÈÁfiÙÂÚÔ Î·Ï‹ Û˘Ì‚·ÙfiÙËÙ·. ∏ ÂÏ¿ÙÙˆÛË ÙˆÓ ·ˆÏÂÈÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi η΋ ÂÁ¯ÂÈÚËÙÈ΋ Ù¯ÓÈ΋ Î·È Ô ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚÔ˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÔÚÚ›„ÂˆÓ ·fi ÙË ¯Ú‹ÛË ÙˆÓ ÓÂfiÙÂÚˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ‚ÂÏÙ›ˆÛ·Ó ÂÓÙ˘ˆÛȷο Ù· ·ÔÙÂϤÛÌ·Ù· Û fiϘ ÙȘ ηÙËÁÔڛ˜ ÏËÙÒÓ ·ÁÎÚ¤·ÙÔ˜ Î·È Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È Û‹ÌÂÚ· ÂÊ¿ÌÈÏÏË Ì ÂΛÓË ÙˆÓ ¿ÏÏˆÓ Û˘Ì·ÁÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ™‡Ìʈӷ Ì ÌÈ· ÚfiÛÊ·ÙË ·Ó¿Ï˘ÛË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ‰È·‚ËÙÈÎÒÓ Ù‡Ô˘ 1 ·ÛıÂÓÒÓ Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ÔÈ Ï‹Ù˜ ™¡ª¶ ËÏÈΛ·˜ ≤ 50 ÂÙÒÓ ¤¯Ô˘Ó ηٿ 15 ¯ÚfiÓÈ· ÌÂÁ·Ï‡ÙÂÚÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ·fi ÂΛÓÔ ÙˆÓ ÂÁÁÂÁÚ·ÌÌ¤ÓˆÓ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ ·Ó·ÌÔÓ‹˜ ‰È·‚ËÙÈÎÒÓ Î·È 10 ÂÚ›Ô˘ ¯ÚfiÓÈ· ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÂΛÓÔ˘˜, ÔÈ ÔÔ›ÔÈ ˘Ô‚Ï‹ıËÎ·Ó Û ÓÂÊÚÈ΋ ÌfiÓÔ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi و̷ÙÈÎfi ‰fiÙË. ™‡Ìʈӷ Ù¤ÏÔ˜ Ì ÙËÓ ›‰È· ÌÂϤÙË Ë ™¡ª¶ ÂÍ·ÛÊ·Ï›˙ÂÈ ·ÚfiÌÔÈ· Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË Ì ÙÔ˘˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌfiÓÔ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ˙ÒÓÙ· ‰fiÙË, ÂÓÒ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ·˘Í¿ÓÂÈ, Û ۯ¤ÛË Ì ÙȘ ¿ÏϘ ÌÂıfi‰Ô˘˜ ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ ÛÙȘ ËÏÈ˘ ¿Óˆ ÙˆÓ 50 ÂÙÒÓ (∂ÈÎ. 5).

Aναμενόμενη επιβίωση σε έτη

36

25

23,4 20,9

20 15 10

12,9 8

5 0 ΕΛΑ

ΠΔΝΜ

ΣΝΜΠ

ΤΔΝΜ

∂ÈÎfiÓ· 5. ∞Ó·ÌÂÓfiÌÂÓË ÂÈ‚›ˆÛË ‰È·‚ËÙÈÎÒÓ Ù‡Ô˘-1 ·ÚÚÒÛÙˆÓ ËÏÈΛ·˜ ≤ 50 ÂÙÒÓ, ·Ó¿ÏÔÁ· Ì ÙȘ ϤÔÓ Û‡Á¯ÚÔÓ˜ ÌÂıfi‰Ô˘˜ ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜.

∏ ™¡ª¶ Î·È Ë ª¡ª¶ ·ÔÙÂÏÔ‡Ó ϤÔÓ ÙË ıÂÚ·›· ÂÎÏÔÁ‹˜ Û ÂÈÏÂÁ̤ÓÔ˘˜ Ô˘Ú·ÈÌÈÎÔ‡˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ ª¶ ı· ·Ú·Ì›ÓÂÈ Ë ÌÔÓ·‰È΋ Ú·ÎÙÈ΋ ̤ıÔ‰Ô˜ ÔÏÈ΋˜ ÂÓ‰ÔÎÚÈÓÈ΋˜ ·ÔηٿÛÙ·Û˘ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ Ì¤¯ÚȘ fiÙÔ˘ ¿ÏϘ Ù¯ÓÈΤ˜ ı· ÌÔÚÔ‡Ó Ó· ÚÔÛʤÚÔ˘Ó ·Ó¿ÏÔÁÔ ¤ÏÂÁ¯Ô ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ˘‰·Ù·ÓıÚ¿ÎˆÓ Ì ÏÈÁfiÙÂÚË ‹ ηıfiÏÔ˘ ·ÓÔÛÔηٷÛÙÔÏ‹ ‹ ·ÎfiÌË ÈÔ ÌÈÎÚ‹ Û˘ÓÔ‰fi ıÓËÙfiÙËÙ·.

μÈ‚ÏÈÔÁÚ·Ê›· 1. ADA. American Diabetes Association. Clinical Practice Recommendations 2000. Pancreas transplantation for patients with type 1 diabetes. Diabetes Care 2000; 23 (suppl 1): S85.

2. Sollinger HW, Odorico JS, Knechtle SJ, D’Alessandro AM, Kalayoglu M, Pirsch JD. Experience with 500 simultaneous pancreas-kidney transplants. Ann Surg 1998; 228: 284-96.

3. Sutherland DE, Gruessner RW, Dunn DL, Matas AJ, Humar A, Kandaswamy R, et al. Lessons learned from more than 1,000 pancreas transplants at a single institution. Ann Surg 2001; 233: 463-501.

4. Tyden G, Bolinder J, Solders G, Brattstrom C, Tibell A, Groth C-G. Improved survival in patients with insulindependent diabetes mellitus and end-stage diabetic nephropathy 10 years after combined pancreas and kidney transplantation. Transplantation 1999; 67 (5): 645.

5. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999; 341 (23): 1725.

6. Smets YFC, Westendorp RGJ, van der Pijl JW, de Charro FT, Ringers J, de Fijter JW. Effect of simultaneous-kidney pancreas transplantation on mortality of patients with type diabetes mellitus. Lancet 1999; 2: 1915.

7. Chang-Sheng Ming and Zhong-Hua Klaus Chen. Progress in pancreas transplantation and combined pancreas-kidney transplantation. Hepatobiliary Pancreat Dis Int 2007; 6: 17-23.

8. Meloche RM. Transplantation for the treatment of type 1 diabetes. World J Gastroenterol 2007; 13(47): 6347-6355.

A•πO¶Oπ∏™∏ ªO™ÃEYªAΔø¡ A¶O ¢OΔE™ ME ¢πEYƒYMENA KƒπΔ∏ƒπA

EÌÂÈÚ›· ·fi ÙËÓ ·ÍÈÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ÂÎÙfi˜ ÎÚÈÙËÚ›ˆÓ ™‡ÚÔ˜ ¢Ú·ÎfiÔ˘ÏÔ˜

ÓÔ˘ ˘¤ÚÙ·ÛË, ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ¿Óˆ 1.5 mg/dl Î·È ÛÙË ‰Â‡ÙÂÚË ÔÌ¿‰· (ÔÌ¿‰· μ) ÂÚÈÂÏ‹ÊıËÛ·Ó Ï‹Ù˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi ‰fiÙ˜ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 60 ÂÙÒÓ. ¢ËÌÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ηıÒ˜ Î·È ·ÓÔÛÔÏÔÁÈÎÔ› ·Ú¿ÌÂÙÚÔÈ Î·Ù·ÁÚ¿ÊËÎ·Ó ÁÈ· ÙÔ˘˜ ‰fiÙ˜ Î·È ÙÔ˘˜ Ï‹Ù˜. ∂ÚÁ·ÛÙËÚȷο ÛÙÔȯ›· Ô˘ ·ÊÔÚÔ‡Ó ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û˘ÏϤ¯ıËÎ·Ó ÁÈ· ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ·Ú·ÎÔÏÔ‡ıËÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡.

∏ ¤ÏÏÂÈ„Ë ÚÔÛÊÔÚ¿˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·Ú¿ÏÏËÏ· Ì ÙËÓ ÔÏÔ¤Ó· Î·È ÌÂÁ·Ï‡ÙÂÚË ˙‹ÙËÛË ÏfiÁˆ Ù˘ ÌÂÁ¿Ï˘ ·˘Í‹Ûˆ˜ ÙˆÓ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ ¤¯ÂÈ ˆı‹ÛÂÈ ÙË ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÎÔÈÓfiÙËÙ· ÛÙËÓ ·Ó‡ÚÂÛË Ó¤ˆÓ ËÁÒÓ ·˘ÙÒÓ. ª›· ·fi ÙȘ ËÁ¤˜ Â›Ó·È Ë ¯ÚËÛÈÌÔÔ›ËÛË ‰ÔÙÒÓ Ì ‰È‡ڢÓÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ηٷÏÏËÏfiÙËÙ·˜ (expanded criteria donors). ΔÔ 2002, Ô OÚÁ·ÓÈÛÌfi˜ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ ÁÈ· ÙȘ ªÂÙ·ÌÔۯ‡ÛÂȘ OÚÁ¿ÓˆÓ (Organ Procurement and Transplantation Network/United Network for Organ Sharing, OPTN/UNOS) fiÚÈÛ ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ηٷÏÏËÏfiÙËÙ·˜ ‰fiÙË Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ ÙËÓ ËÏÈΛ· ÙÔ˘ ‰fiÙË Î·È ÙËÓ ·ÚÔ˘Û›· ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘1. ™ÙÔ˘˜ ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ηٷÏÏËÏfiÙËÙ·˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ˘ÂÚ‹ÏÈΘ ‰fiÙ˜ (¿Óˆ ÙˆÓ 60 ÂÙÒÓ) ηıÒ˜ Î·È ‰fiÙ˜ ¿Óˆ ÙˆÓ 50 ÂÙÒÓ Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·fi ÙÔ˘˜ ·Ú·Î¿Ùˆ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ˘¤ÚÙ·ÛË, ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ¿Óˆ 1.5 mg/dl. ¢ÈÂıÓÒ˜ ÌÂÏÂÙ¿Ù·È Ë Î·Ù·ÏÏËÏfiÙËÙ· Ù¤ÙÔÈˆÓ ‰ÔÙÒÓ Î˘Ú›ˆ˜ fiÛÔÓ ·ÊÔÚ¿ ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿ ÙÔ˘˜ ηıÒ˜ Î·È ÙË Ì·ÎÚÔÚfiıÂÛÌË ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ Î·È Ï‹ÙÔ˘2,3. ™ÙËÓ ·ÚÔ‡Û· ÂÈÛ‹ÁËÛË ı· ·ÚÔ˘ÛÈ·ÛÙÔ‡Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ¤¯Ô˘Ó ÂÈÏÂÁ› Ì ٷ ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ηٷÏÏËÏfiÙËÙ·˜ ÛÙË ªÔÓ¿‰· ªÂÙ·ÌÔۯ‡ÛÂˆÓ OÚÁ¿ÓˆÓ ÙÔ˘ °.¡.∞. «O ∂˘·ÁÁÂÏÈÛÌfi˜».

∞ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ŸÏÔÈ ÔÈ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤Ï·‚·Ó ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂÚ·›· ÂÈÛ·ÁˆÁ‹˜ ÚÔÂÁ¯ÂÈÚËÙÈο Ì ÙÔ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ ¤Ó·ÓÙÈ ÙÔ˘ ˘Ô‰Ô¯¤· Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 2 ÙˆÓ Δ – ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (·ÓÙÈ – CD25) Basiliximab ‹ Daclizumab. Δo Basiliximab Â›Ó·È ¯ÈÌ·ÈÚÈÎfi (Â›Ì˘˜/¿ÓıÚˆÔ˜) ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Î·È ¯ÔÚËÁÂ›Ù·È ÂÓ‰ÔÊϤ‚È· 20 mg ÙËÓ Ë̤ڷ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ÙËÓ Ù¤Ù·ÚÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ ÂÓÒ ÙÔ Daclizumab Â›Ó·È ·ÓıÚÒÂÈÔ ÌÔÓÔÎψÓÈÎfi ·Óٛۈ̷ Ô˘ ¯ÔÚËÁÂ›Ù·È ÂÓ‰ÔÊϤ‚È· 1 mg/kgr ‚¿ÚÔ˘˜ ÙËÓ Ë̤ڷ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ·ÎÔÏÔ˘ıÔ‡Ó Ù¤ÛÛÂÚȘ ‚‰ÔÌ·‰È·›Â˜ Â·Ó·ÏËÙÈΤ˜ ‰fiÛÂȘ. ¢ÈÂÁ¯ÂÈÚËÙÈο fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ ¤Ï·‚·Ó 1 gr ÌÂı˘ÏÚ‰ÓÈÛÔÏfiÓ˘ ÂÓ‰ÔÊϤ‚È·. ªÂÙÂÁ¯ÂÈÚËÙÈο ¯ÔÚËÁ‹ıËΠ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂÚ·›· Û˘ÓÙ‹ÚËÛ˘ Ì ÙÚÈÏfi ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi Û¯‹Ì· Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ: ·) ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘: ΢ÎÏÔÛÔÚ›ÓË ‹ tacrolimus (FK506), ‚) ·ÓÙÈÌÂÙ·‚Ôϛ٘: mycophenolate mofetil (MMF) Î·È Á) ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜. ∏ ΢ÎÏÔÛÔÚ›ÓË ¯ÔÚËÁ‹ıËΠ۠‰fiÛÂȘ 3 mg/kgr ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ ¤ÙÛÈ ÒÛÙ ٷ Â›‰· ÛÙ· ·›Ì· ÌÂÙ¿ ‰‡Ô ÒÚ˜ (C2, trough levels) Ó· Â›Ó·È 600-800 ng/dl Î·È ·Ú¿ÏÏËÏ· ¯ÔÚËÁ‹ıËΠMMF 2 g/Ë̤ڷ Î·È Ú‰ÓÈÛÔÏfiÓË 200 mg/Ë̤ڷ Ì ÚÔԉ¢ÙÈ΋ ÂÏ¿ÙÙˆÛË Ì¤¯ÚÈ ‰fiÛË Û˘ÓÙ‹ÚËÛ˘ Ù· 5 mg/Ë̤ڷ. ΔÔ tacrolimus ¯ÔÚËÁ‹ıËΠ۠‰fiÛÂȘ 0.1 mg/kgr ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ Ì trough levels 510 ng/dl Î·È ·Ú¿ÏÏËÏ· ‰fiıË 1 gr/Ë̤ڷ MMF Î·È 20 mg/Ë̤ڷ Ú‰ÓÈÛÔÏfiÓË.

∞ÛıÂÓ›˜ Î·È Ì¤ıÔ‰Ô˜ ∫·Ù¿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ 20ÂÙ›·˜, 1990-2010, Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Û˘ÓÔÏÈο 480 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡ ÛÙË ªÔÓ¿‰· ªÂÙ·ÌÔۯ‡ÛÂˆÓ OÚÁ¿ÓˆÓ ÙÔ˘ °.¡.∞. «O ∂˘·ÁÁÂÏÈÛÌfi˜». ∞fi ÙËÓ ·Ó·ÛÎfiËÛË ÙˆÓ È·ÙÚÈÎÒÓ Ê·Î¤ÏˆÓ ÂÈϤÁËÛ·Ó ÔÈ Ï‹Ù˜, ÔÈ ÔÔ›ÔÈ Â›¯·Ó Ï¿‚ÂÈ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· Ô˘ ÚÔÂÚ¯fiÙ·Ó ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ Î·È Â›¯·Ó Û˘ÌÏËÚÒÛÂÈ ÙÚ›· ¤ÙË ·Ú·ÎÔÏÔ‡ıËÛ˘.

OÈ Ï‹Ù˜ ‰È·ÎÚ›ıËÎ·Ó Û ‰‡Ô ÔÌ¿‰Â˜, ÛÙËÓ ÚÒÙË ÔÌ¿‰· (ÔÌ¿‰· ∞) ÂÚÈÂÏ‹ÊıËÛ·Ó Ï‹Ù˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi ‰fiÙË ËÏÈΛ·˜ 50-59 Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô ·fi ÙÔ˘˜ ·Ú·Î¿Ùˆ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡-

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£· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ fiϘ ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹Ù·Ó Û˘Ì‚·Ù¤˜ ˆ˜ ÚÔ˜ ÙËÓ ÔÌ¿‰· ·›Ì·ÙÔ˜ Î·È Ô ÚÔÂÁ¯ÂÈÚËÙÈÎfi˜ ·ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ÙË ‰ÔÎÈÌ·Û›· Ù˘ ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ ‹Ù·Ó ·ÚÓËÙÈÎfi˜.

™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÔÈ ÔÛÔÙÈΤ˜ ‹ ‰È·Ù¿ÍÈ̘ ·Ú¿ÌÂÙÚÔÈ, Ô˘ ηٷӤÌÔÓÙ·È Î·ÓÔÓÈο ÂÚÈÁÚ¿ÊÔÓÙ·È ˆ˜ ̤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ¿ ·fiÎÏÈÛË. ∏ ‰ÔÎÈÌ·Û›· t test Î·È t test ηٿ ˙‡ÁË ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÔÛÔÙÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ, Ô˘ ·ÚÔ˘Û›·˙·Ó ηÓÔÓÈ΋ ηٷÓÔÌ‹ Î·È Ë ‰ÔÎÈÌ·Û›· Mann Whitney U ÂÊ·ÚÌfiÛıËΠ۠·Ú·Ì¤ÙÚÔ˘˜ Ì ÌË Î·ÓÔÓÈ΋ ηٷÓÔÌ‹.

∞ÔÙÂϤÛÌ·Ù· ¢ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ∂ÈϤÁËÛ·Ó Ó· ÌÂÏÂÙËıÔ‡Ó 60 Ï‹Ù˜, ÔÈ ÔÔ›ÔÈ Â›¯·Ó Ï¿‚ÂÈ ÌfiÛ¯Â˘Ì· ·fi ‰fiÙË ‚¿ÛÂÈ ÙˆÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ηٷÏÏËÏfiÙËÙ·˜. ∏ ÔÌ¿‰· ∞ ÂÚÈÂÏ¿Ì‚·Ó 21 Ï‹Ù˜ ËÏÈΛ·˜ 49.6±12.4 ÂÙÒÓ ÂÎ ÙˆÓ ÔÔ›ˆÓ ÔÈ 17 ‹Ù·Ó ¿Ó‰Ú˜ Î·È 4 Á˘Ó·›Î˜. OÈ Ï‹Ù˜ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi ‰fiÙ˜ ËÏÈΛ·˜ 54.67±2.1 ¤ÙË ÂÎ ÙˆÓ ÔÔ›ˆÓ ÔÈ 15 ‹Ù·Ó ¿Ó‰Ú˜ Î·È 6 ‹Ù·Ó Á˘Ó·›Î˜. ŸÏÔÈ ÔÈ ‰fiÙ˜ ·˘Ù‹˜ Ù˘ ÔÌ¿‰·˜ ›¯·Ó ·Ô‚ÈÒÛÂÈ ·fi ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ, ÛÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘˜ ·Ó·ÊÂÚfiÙ·Ó ˘¤ÚÙ·ÛË Î·È Ë Ì¤ÛË ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ‹Ù·Ó 1.08±0.34 mg/dl. O ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ‹Ù·Ó 17.1±6.4 ÒÚ˜ ÂÓÒ Û ÔÛÔÛÙfi 10% ÍÂÂÚÓÔ‡Û ÙȘ 24 ÒÚ˜. O ̤ÛÔ˜ fiÚÔ˜ ÎÔÈÓÒÓ ·ÓÙÈÁfiÓˆÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ ‹Ù·Ó 3.44±0.98. ™Â Ù¤ÛÛÂÚȘ ÂÚÈÙÒÛÂȘ ‰ÂÓ ˘‹Ú¯Â ÎÔÈÓfi ·ÓÙÈÁfiÓÔ HLA DR (Human Leukocyte Antigen, HL∞) ÂÓÒ ÛÙȘ ˘fiÏÔÈ˜ 17 ÂÚÈÙÒÛÂȘ ˘‹Ú¯Â Û˘Ì‚·ÙfiÙËÙ· Û ¤Ó· ·ÓÙÈÁfiÓÔ HLA DR. ™ÙËÓ ÔÌ¿‰· μ ÂÚÈÂÏ‹ÊıËÛ·Ó 39 Ï‹Ù˜ ËÏÈΛ·˜ 50.2±12.7 ÂÙÒÓ. ™ÙËÓ ÔÌ¿‰· μ, 31 Ï‹Ù˜ ‹Ù·Ó ¿Ó‰Ú˜ Î·È 8 ‹Ù·Ó Á˘Ó·›Î˜. ΔÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ÚÔÂÚ¯fiÙ·Ó ·fi ‰fiÙ˜ ̤Û˘ ËÏÈΛ·˜ 65.5±3.79 ¤ÙË, ÂÎ ÙˆÓ ÔÔ›ˆÓ ÔÈ 34 ‹Ù·Ó ¿Ó‰Ú˜ Î·È ÔÈ 5 Á˘Ó·›Î˜. ∏ ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ÚÈÓ ÙË Ï‹„Ë ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó 0.96±0.25 mg/dl. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ˘˜ Û˘Ó˘¿Ú¯ÔÓÙ˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘, ˘¤ÚÙ·ÛË Î·È Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË ·ÚÔ˘Û›·˙·Ó ·ÓÙ›ÛÙÔȯ· 76.9% (30/39) Î·È 28.2% (11/39) ÙˆÓ ‰ÔÙÒÓ. O ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜

‹Ù·Ó 15.5±7.3 ÒÚ˜ Î·È Û ÙÚÂȘ ÌfiÓÔ ÌÂÙ·ÌÔۯ‡ÛÂȘ ˘ÂÚ¤‚·ÈÓ ÙȘ 24 ÒÚ˜. Δ· ÎÔÈÓ¿ ·ÓÙÈÁfiÓ· HLA ‹Ù·Ó 3.08±0.75 ÂÓÒ Ì ÂÍ·›ÚÂÛË ¤ÓÙ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙȘ Ôԛ˜ ‰ÂÓ ˘‹Ú¯Â ÎÔÈÓfi HLA DR ÛÙȘ ˘fiÏÔÈ˜ ÂÚÈÙÒÛÂȘ ˘‹Ú¯Â ¤Ó· ÎÔÈÓfi ·ÓÙÈÁfiÓÔ HLA DR.

ªÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ˘ÂÚ‹ÏÈΘ ‰fiÙ˜ Û ˘ÂÚ‹ÏÈΘ Ï‹Ù˜ ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙË ªÔÓ¿‰· ªÂÙ·ÌÔۯ‡ÛÂˆÓ OÚÁ¿ÓˆÓ ÙÔ˘ °.¡.∞. «O ∂˘·ÁÁÂÏÈÛÌfi˜» ‰ÂÓ ˘¿Ú¯ÂÈ Û˘ÁÎÂÎÚÈ̤ÓÔ ÚfiÁÚ·ÌÌ· ÒÛÙ ÌÔۯ‡̷ٷ ·fi ˘ÂÚ‹ÏÈΘ ‰fiÙ˜ Ó· ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Û ˘ÂÚ‹ÏÈΘ Ï‹Ù˜, Ë ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÔȯ›ˆÓ ¤‰ÂÈÍ fiÙÈ Û ¤ÓÙ ÂÚÈÙÒÛÂȘ ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ¿Óˆ ÙˆÓ 70 ÂÙÒÓ ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Û ϋÙ˜ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ. ªfiÓÔ ¤Ó·˜ Ï‹Ù˘ ‰ÂÓ ·Ôη٤ÛÙËÛ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÂÓÒ ÛÙȘ ˘fiÏÔÈ˜ Ù¤ÛÛÂÚȘ ÂÚÈÙÒÛÂȘ ÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÚÔ˘Û›·Û·Ó ÈηÓÔÔÈËÙÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ì ηϋ ÔÈfiÙËÙ· ˙ˆ‹˜ ·Ú·Ì¤ÓÔÓÙ·˜ ÂÎÙfi˜ ÂÚÈÔ‰È΋˜ ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ·ÈÌÔοı·ÚÛË.

¡ÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ OÈ ‰È·‰Ô¯ÈΤ˜ ÙÈ̤˜ ÎÚ·ÙÈÓ›Ó˘ ·Ó¿ ¤ÙÔ˜ ÁÈ· ÙËÓ ÙÚÈÂÙ›· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÁÈ· ÙËÓ ÔÌ¿‰· ∞ ‹Ù·Ó ·ÓÙ›ÛÙÔȯ· 1.78±0.97 mg/dl, 1.68±1.03 mg/dl, 1.87±0.75 mg/dl. ∏ ‰ÔÎÈÌ·Û›· t test ηٿ ˙‡ÁË ÂϤÁ¯ÔÓÙ·˜ ÙË ÌÂÙ·‚ÔÏ‹ ÙȘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ηٿ ÙË ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÚÈÒÓ ÂÙÒÓ ¤‰ÂÈÍ ÛÙ·ıÂÚ‹ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·.

OÌÔ›ˆ˜ ÛÙËÓ ÔÌ¿‰· μ, ÔÈ ‰È·‰Ô¯ÈΤ˜ ÙÈ̤˜ ÎÚ·ÙÈÓ›Ó˘ ÙÔÓ ÚÒÙÔ, ‰Â‡ÙÂÚÔ Î·È ÙÚ›ÙÔ ¯ÚfiÓÔ ·ÓÙ›ÛÙÔȯ· ‹Ù·Ó 2.24±0.56 mg/dl, 2.37±0.45 mg/dl, 2.62±0.28 mg/dl. O ÛÙ·ÙÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ÙË ‰ÔÎÈÌ·Û›· t test ηٿ ˙‡ÁË ‰ÂÓ ¤‰ÂÈÍ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ¶ÂÚ·ÈÙ¤Úˆ ·Ó¿Ï˘ÛË ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ Ì ÙË ‰ÔÎÈÌ·Û›· Mann Whitney U ¤‰ÂÈÍ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÙˆÓ ÙÈÌÒÓ ÎÚ·ÙÈÓ›Ó˘ ÙfiÛÔ ÙÔ ‰Â‡ÙÂÚÔ fiÛÔ Î·È ÙÔÓ ÙÚ›ÙÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (p=0.027 Î·È p=0.018 ·ÓÙ›ÛÙÔȯ·). Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ Â›Ó·È ÂÓ‰ÂÈÎÙÈο fiÙÈ Ë Ì·ÎÚÔÚfiıÂÛÌË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ÌÂÓ ÈηÓÔÔÈËÙÈ΋ ·ÏÏ¿ ˘ÔÏ›ÂÙ·È Ù˘ ÚÒÙ˘ ÔÌ¿‰·˜.

METAMO™XEY™Eπ™ 2010

∂È‚›ˆÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ™ÙËÓ ÔÌ¿‰· ∞ Ë ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹Ù·Ó 90.5% (19/21). ™Â Ì›· ÂÚ›ÙˆÛË ÙË ‰Â‡ÙÂÚË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ ‰È·ÈÛÙÒıËΠıÚfiÌ‚ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜ Î·È ÙÔ ÌfiÛ¯Â˘Ì· ·Ê·ÈÚ¤ıËÎÂ Î·È ˘‹Ú¯Â ¤Ó· ÂÚÈÛÙ·ÙÈÎfi ÛÙÔ ÔÔ›Ô ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·ÚÔ˘Û›·Û ‰˘ÛÚ·Á›· (primary non-function), ¯ˆÚ›˜ Ó· ·ÔηٷÛÙ‹ÛÂÈ ‰ÈÔ‡ÚËÛË Î·È ¯ÚÂÈ¿ÛÙËΠ·Ê·›ÚÂÛË ÌÂÙ¿ ·fi 50 Ë̤Ú˜ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ÂÈ‚›ˆÛË ÙÔ ÙÚ›ÙÔ ¤ÙÔ˜ ‹Ù·Ó 85.7% (18/21). ŒÓ· Ï‹Ù˘ ·ÚÔ˘Û›·Û ¯ÚÔÓ›· ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÙÔÓ 28Ô Ì‹Ó· Î·È Â·ÓÂÓÙ¿¯ıËΠ۠ÚfiÁÚ·ÌÌ· ·ÈÌÔοı·ÚÛ˘. ™ÙË ‰Â‡ÙÂÚË ÔÌ¿‰·, Ë ÂÈ‚›ˆÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó 84.6% (33/39) ÁÈ· ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™˘ÓÔÏÈο ˘‹Ú¯·Ó ‰‡Ô ÂÚÈÙÒÛÂȘ ıÚfiÌ‚ˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜ (ÙËÓ ‰Â‡ÙÂÚË Î·È ÙÚ›ÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ ·ÓÙ›ÛÙÔȯ·) Î·È Ì›· ÂÚ›ÙˆÛË Ú‹Í˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÙËÓ ÚÒÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ. ΔÚ›· ÌÔۯ‡̷ٷ ·ÚÔ˘Û›·Û·Ó ‰˘ÛÚ·Á›· Î·È ·ÎÔÏÔ‡ıËÛ ·Ê·›ÚÂÛË ·˘ÙÒÓ. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ÙÚÈÒÓ ÂÙÒÓ ‰ÂÓ ‰È·ÈÛÙÒıËΠ·ÒÏÂÈ· ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, Û˘ÓÂÒ˜ Ë ÂÈ‚›ˆÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó 84.6% (33/39). ∏ Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÙÔ ÔÔ›Ô ÚÔÂÚ¯fiÙ·Ó ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ηٷÏÏËÏfiÙËÙ·˜ ‹Ù·Ó 86.7% (52/60) Î·È 85% (51/60) ÙÔ ÚÒÙÔ Î·È ÙÚ›ÙÔ ¤ÙÔ˜ ·ÓÙ›ÛÙÔȯ·.

∂È‚›ˆÛË ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ °È· ÙËÓ ÔÌ¿‰· ÙˆÓ ÏËÙÒÓ, ÔÈ ÔÔ›ÔÈ ¤Ï·‚·Ó ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ‰fiÙ˜ ËÏÈΛ·˜ 50-59 ¤ÙË ·ÚÔ˘Û›· ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ (ÔÌ¿‰· ∞) Ë ÂÈ‚›ˆÛË ‹Ù·Ó 95.2% (20/21) ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŒÓ·˜ Ï‹Ù˘ ·‚›ˆÛ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· ‰‡Ô Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏfiÁˆ ˘ÔÙÚÔ‹˜ ÂÌÊÈÁÔÂȉԇ˜ „ˆÚ›·Û˘ Ì ηıÔÏÈ΋ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ∏ ÂÈ‚›ˆÛË ÙÔÓ ÙÚ›ÙÔ ¯ÚfiÓÔ ‹Ù·Ó 90.5% (19/21). ΔÔÓ 30Ô Ì‹Ó· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤Ó·˜ Ï‹Ù˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ˘¤ÛÙË ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È Î·Ù¤ÏËÍÂ. °È· ÙËÓ ÔÌ¿‰· ÙˆÓ ÏËÙÒÓ, ÔÈ ÔÔ›ÔÈ ¤Ï·‚·Ó ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ‰fiÙ˜ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 60 ÂÙÒÓ (ÔÌ¿‰· μ) Ë ÂÈ‚›ˆÛË ‹Ù·Ó ÙÔ ÚÒÙÔ ¤ÙÔ˜ 94.9% (37/39), Î·È ÙÔ ÙÚ›ÙÔ ¤ÙÔ˜ 87.2% (34/39). Δ· ·›ÙÈ· ı·Ó¿ÙÔ˘ ‹Ù·Ó ÁÈ· ÙÚÂȘ ·ÛıÂÓ›˜ Ô͇ ¤Ì-

41

ÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘ (·ÓÙÈÛÙÔ›¯ˆ˜ ÙÔÓ 4Ô, 5Ô Î·È 15Ô Ì‹Ó· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË). ŒÓ·˜ Ï‹Ù˘ ‰ÈÂÁÓÒÛıË ¤Ó· ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÌËÌÈÎÚÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ Ó‡ÌÔÓÔ˜ ÂÓÒ Â›Û˘ ¤Ó·˜ ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ÎÔÏÈ΋ Ì·ÚÌ·Ú˘Á‹ Î·È ¯ÚÂÈ¿ÛÙËΠ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ÌÂ Û˘Ó¯‹ ¤Á¯˘ÛË ÎÏ·ÛÛÈ΋˜ Ë·Ú›Ó˘ Ô˘ ÂÂÏ¿ÎÂÈ Ì ·ÈÌÔÚÚ·Á›· ·ÓˆÙ¤ÚÔ˘ ÂÙÈÎÔ‡. ™˘ÓÔÏÈο Ë ÂÈ‚›ˆÛË ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‰È·‰Ô¯Èο ÁÈ· ÙÔ ÚÒÙÔ Î·È ÙÚ›ÙÔ ¤ÙÔ˜ ‹Ù·Ó 95% (57/60) Î·È 88.3% (53/60). ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÔÈ Ï‹Ù˜ Ô˘ ·‚›ˆÛ·Ó ‰È·ÙËÚÔ‡Û·Ó ÈηÓÔÔÈËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜.

™˘ÌÂÚ¿ÛÌ·Ù· ∞Ó Î·È Â›Ó·È Î·Ù·ÓÔËÙfi Î·È ·Ôχو˜ ÂÈı˘ÌËÙfi Ô Î¿ı ˘Ô„‹ÊÈÔ˜ Ï‹Ù˘ ·ÓÂÍ·Úًو˜ ËÏÈΛ·˜ Ó· Ï·Ì‚¿ÓÂÈ ÌfiÛ¯Â˘Ì· ·fi Ó¤Ô ‰fiÙË ÂÓÙÔ‡ÙÔȘ Ë Ú·ÁÌ·ÙÈÎfiÙËÙ· ÙfiÛÔ ÛÙÔÓ ÂÏÏËÓÈÎfi fiÛÔ Î·È ÙÔÓ ‰ÈÂıÓ‹ ¯ÒÚÔ ¤‰ÂÈÍ fiÙÈ Ù¤ÙÔȘ ¢ÓÔ˚Τ˜ ÂÚÈÙÒÛÂȘ Û·Ó›˙Ô˘Ó. ∞ÓÙ›ıÂÙ· ‰Â fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔÈ Î˘Ú›ˆ˜ ˘ÂÚ‹ÏÈΘ ˘Ô„‹ÊÈÔÈ Ï‹Ù˜ ÂÈÛ¤Ú¯ÔÓÙ·È ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ Ì ·ÔÙ¤ÏÂÛÌ· ÂÍ’ ·Ó¿Á΢ Ó· ¤¯Ô˘Ó ‰È¢ڢÓı› Ù· ËÏÈÎȷο ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÚÔ˜ Ù· ¿Óˆ. ∏ ËıÈ΋ ÓÔÌÈÌÔÔ›ËÛ˘ Ù¤ÙÔÈ·˜ ÂÈÏÔÁ‹˜ ‚·Û›˙ÂÙ·È ÛÙÔ fiÙÈ ·ÔÙÂϤÛÌ·Ù· ·fi ÔÏÏ¿ ‰ÈÂıÓ‹ ΤÓÙÚ· ¤‰ÂÈÍ·Ó fiÙÈ ÌÔۯ‡̷ٷ ÚÔÂÚ¯fiÌÂÓ· ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÚÔÛ¤ÊÂÚ·Ó ÈηÓÔÔÈËÙÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÛÙÔ˘˜ Ï‹Ù˜ ··ÏÏ¿ÛÛÔÓÙ¿˜ ÙÔ˘˜ ·fi ÙËÓ ·ÈÌÔοı·ÚÛË Î·È ‰›ÓÔÓÙ·˜ ÙËÓ Â˘Î·ÈÚ›· ηχÙÂÚ˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜. ŒÎÏËÍË ‰Â ÚÔηÏ› ÙÔ fiÙÈ ÓÂÊÚÈο ÌÔۯ‡̷ٷ ÚÔÂÚ¯fiÌÂÓ· ·fi ‰fiÙ˜ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 70 ÂÙÒÓ ‰›ÓÔ˘Ó ÂÍ›ÛÔ˘ ÈηÓÔÔÈËÙÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÛÙÔ˘˜ ·ÓÙ›ÛÙÔÈ¯Ô˘˜ Ï‹Ù˜. ΔÔ‡ÙÔ ‚¤‚·È· ‰Â ÛËÌ·›ÓÂÈ fiÙÈ Ë Â¤ÎÙ·ÛË ÙˆÓ ÔÚ›ˆÓ ËÏÈΛ·˜ Â›Ó·È ¿ÓÙÔÙ ·ÛÊ·Ï‹˜ Î·È fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ‰È·Î˘‚‡ÂÙ·È Û ٤ÙÔȘ ÂÈÏÔÁ¤˜ ‰ÂÓ Â›Ó·È ˘·ÚÎÙfi˜. ∏ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓË ˙‹ÙËÛË ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·Ú¿ÏÏËÏ· Ì ÙËÓ ¤ÏÏÂÈ„Ë ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ·Ô‚ÈÒÛ·ÓÙ˜ ‰fiÙ˜ ÒıËÛ ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ Î·È Ù˘ ÂÈ‚›ˆÛ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ô˘ ÏËÚÔ‡Ó Ù· ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ηٷÏÏËÏfiÙËÙ·˜. ™ÙË ÌÂϤÙË Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙË ªÔÓ¿‰· Ì·˜ ‰È·ÈÛÙÒıËΠfiÙÈ Ë Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË

42

™. ¢ƒ∞∫√¶√À§√™

‹Ù·Ó 86.7% (52/60) Î·È Ë Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÏËÙÒÓ ‹Ù·Ó 95% (57/60). Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ¯·ÌËÏfiÙÂÚË ·fi ·˘Ù‹ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÓÂfiÙÂÚÔ˘˜ ‰fiÙ˜ fï˜ ÙÔ Î‡ÚÈÔ ·›ÙÈÔ ·ÒÏÂÈ·˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È Ë ÌË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ primary non-function. ™ÙËÓ ÂÚ›Ô‰Ô ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ÙÚÈÒÓ ÂÙÒÓ ‰ÂÓ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÂÚÈÙÒÛÂˆÓ ¯ÚÔÓ›·˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÂÓı·ÚÚ‡ÓÔ˘Ó ÙËÓ ·ÍÈÔÔ›ËÛË ˘ÂÚ‹ÏÈÎˆÓ ‰ÔÙÒÓ ÁÈ· ÙËÓ ÚÔÛÊÔÚ¿ ÌÔÛ¯Â˘Ì¿ÙˆÓ. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ¿Óˆ ÙˆÓ 60 ÂÙÒÓ ·ÚÔ˘Û›·˙·Ó ˘ԉ¤ÛÙÂÚË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÌÔۯ‡̷ٷ ÓÂfiÙÂÚ· ·ÎfiÌ· Î·È ·Ó Û˘Ó˘‹Ú¯·Ó ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘. ¶·Ú’ fiÏ· ·˘Ù¿ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ¤ÛÙˆ Î·È Ì ÌfiÛ¯Â˘Ì· ÚÔÂÚ-

¯fiÌÂÓÔ ·fi ‰fiÙË Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ηٷÏÏËÏfiÙËÙ·˜ ·Ú¤¯ÂÈ Î·Ï‹ ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È ÌÂÁ·Ï‡ÙÂÚ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙˆÓ ÏËÙÒÓ Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÂÈ‚›ˆÛË Â¿Ó ·Ú¤ÌÂÓ·Ó Û ÚfiÁÚ·ÌÌ· Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003; 3 Suppl 4:114-25.

2. Woo YM, Gill JS, Johnson N, Pereira BJ, Hariharan S. The advanced age deceased kidney donor: current outcomes and future opportunities. Kidney Int 2005; 67(6): 2407-14.

3. Port FK, Bragg-Gresham JL, Metzger RA, Dykstra DM, Gillespie BW, Young EW, Delmonico FL, Wynn JJ, Merion RM, Wolfe RA, Held PJ. Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors. Transplantation 2002; 74(9): 1281-6.

AÍÈooÈËÛË و̷ÙÈÎÒÓ ÌoÛ¯Â˘Ì¿ÙˆÓ Ì ·˘ÍË̤ÓË ÎÚ·ÙÈÓ›ÓË oÚo‡ °Ï˘ÎÂÚ›· ΔÛo‡Î·

·Ú·Î¿Ùˆ ÎÚÈÙ‹ÚÈ·3,4: i. πÛÙÔÚÈÎfi ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ ii. ∞›ÙÈÔ ı·Ó¿ÙÔ˘ ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ iii. ΔÂÏÈ΋ (ÚÈÓ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜) ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ >1,5 mg/dl. ∏ Â›‰Ú·ÛË Ù˘ ·˘ÍË̤Ó˘ ÙÈÌ‹˜ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÙÔ˘ ‰fiÙË ÛÙËÓ ÚfiÁÓˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÍÈÔÏÔÁ‹ıËΠ·fi ÙÔÓ Port Î·È Û˘Ó. Û ̛· ÔÏ˘ÌÂÙ·‚ÏËÙ‹ ·Ó¿Ï˘ÛË ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ Scientific Registry of Transplant Recipients (SRTR) 29.068 ÏËÙÒÓ3. ΔÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ >1,5 mg/dl ·ÚÔ˘Û›·ÛÂ Û˘Û¯¤ÙÈÛË Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÔÙ˘¯›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ·ÓÂÍ·Úًو˜ Ù˘ ËÏÈΛ·˜ ÙÔ˘ ‰fiÙË, ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ Î·È ÙÔ˘ ı·Ó¿ÙÔ˘ ·fi ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ·›ÙÈÔ. ™˘ÁÎÂÎÚÈ̤ӷ, ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ >1,5 mg/dl Û¯ÂÙ›ÛÙËΠ·ÓÂÍ¿ÚÙËÙ· Ì 10% ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·ÔÙ˘¯›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ [Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (relative risk-RR)=1,10, p=0,04], Û˘ÁÎÚÈÙÈο Ì ÌfiÛ¯Â˘Ì· ‰fiÙË ËÏÈΛ·˜ 10-39 ÂÙÒÓ Ì ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ≤1,5 mg/dl ¯ˆÚ›˜ ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË ‹ ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi Û˘Ì‚¿Ó (›Ó·Î·˜ 1).

O ÂÙ‹ÛÈÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¿Û¯Ô˘Ó ·fi ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Î·È ÂÁÁÚ¿ÊÔÓÙ·È Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰È·ÚÎÒ˜ ·˘Í¿ÓÂÙ·È Î·È ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ·ÓÙ›ÛÙÔÈ¯Ë ·‡ÍËÛË Ù˘ ‰È·ıÂÛÈÌfiÙËÙ·˜ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ 1 . ¶·ÁÎÔÛÌ›ˆ˜, Ë ‰È¿ÛÙ·ÛË ·Ó¿ÌÂÛ· ÛÙË ˙‹ÙËÛË Î·È ÚÔÛÊÔÚ¿ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ ηıÈÛÙ¿ Ô˘ÛÈ·ÛÙÈ΋ ÙËÓ ·Ó¿ÁÎË ·ÊÂÓfi˜ ÁÈ· ·‡ÍËÛË Ù˘ ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ Î·È ·ÊÂÙ¤ÚÔ˘ ÁÈ· ̤ÁÈÛÙË ‰˘Ó·Ù‹ ·ÍÈÔÔ›ËÛË ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ¶ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË ·˘Ù‹ Î·È Ì ‰Â‰Ô̤ÓÔ ÙÔ ·˘ÍË̤ÓÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ Î·È ÙË ‚ÂÏÙȈ̤ÓË ÔÈfiÙËÙ· ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ¯ÚfiÓÈ· Â͈ÓÂÊÚÈ΋ οı·ÚÛË Î·È ‚Ú›ÛÎÔÓÙ·È Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË2, ÙÔ United Network for Organ Sharing (UNOS) Â·Ó·ÚÔÛ‰ÈfiÚÈÛ ٷ fiÚÈ· ·Ô‰Ô¯‹˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È Î·ıȤڈÛ ÙËÓ ¤ÓÓÔÈ· ÙÔ˘ ‰fiÙË ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ. ø˜ ‰fiÙ˘ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ÔÚ›ÛÙËÎÂ Ô و̷ÙÈÎfi˜ ‰fiÙ˘ ËÏÈΛ·˜ >60 ÂÙÒÓ Î·È ·˘Ùfi˜ ËÏÈΛ·˜ 50-59 ÂÙÒÓ Ô˘ ÏËÚ› ‰‡Ô ·fi Ù·

¶π¡∞∫∞™ 1: ™¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ·ÒÏÂÈ·˜ (RR) ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‚¿ÛÂÈ ÙÂÛÛ¿ÚˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ ‰fiÙË. ªÂ ¤ÓÙÔÓ· ÁÚ¿ÌÌ·Ù· ÙÔÓ›˙ÂÙ·È RR>1,7. ∞À: ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, ∞∂∂: ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ·›ÙÈÔ ı·Ó¿ÙÔ˘. ™¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (RR) ∏ÏÈΛ· (¤ÙË)

º˘ÛÈÔÏÔÁÈ΋ ÎÚ·ÙÈÓ›ÓË ÃˆÚ›˜ ∞À ªÂ ∞À

À„ËÏ‹ ÎÚ·ÙÈÓ›ÓË ÃˆÚ›˜ ∞À ªÂ ∞À

∞ÈÙ›· ı·Ó¿ÙÔ˘ ¿ÏÏË 0-9 10-39 40-49 50-59 60+

1,40 1,0 (·Ó·ÊÔÚ¿˜) 1,17 1,41 1,90

1,59 1,14 1,33 1,60 2,16

1,52 1,09 1,28 1,53 2,07

– 1,24 1,45 1,74 2,36

∞ÈÙ›· ı·Ó¿ÙÔ˘ ∞∂∂ 0-9 10-39 40-49 50-59 60+

1,60 1,14 1,34 1,61 2,17

1,82 1,30 1,52 1,83 2,47

1,74 1,24 1,46 1,75 2,37

1,98 1,41 1,66 1,99 2,69

43

44

°. Δ™OÀ∫∞

∂ӉȷʤÚÔ˘Û· ‹Ù·Ó Ë ‰È·›ÛÙˆÛË fiÙÈ ÙÈ̤˜ ÙÂÏÈ΋˜ ÎÚ·ÙÈÓ›Ó˘ ≥2 mg/dl ‰ÂÓ Û¯ÂÙ›ÛÙËÎ·Ó Ì ˘„ËÏ¿ ÔÛÔÛÙ¿ ·ÔÙ˘¯›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (RR=1,01, p=0,95). ∏ ·Í›· ÙˆÓ ·Ó·ÊÂÚı¤ÓÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Û·ÊÒ˜ ÂÚÈÔÚ›˙ÂÙ·È ·fi ÙËÓ ¤ÏÏÂÈ„Ë ÈÛÙÔÏÔÁÈ΋˜ ÂͤٷÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÁÈ· ÙË ‰È·›ÛÙˆÛË Ù˘ ¯ÚÔÓÈfiÙËÙ·˜ ‹ ÌË Ù˘ ¤ÎÙˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ¶Ú¿ÁÌ·ÙÈ, Û‡Ìʈӷ Ì ‰Â‰Ô̤ӷ ÙÔ˘ UNOS, ÌÂٷ͇ ÙÔ˘ 2000 Î·È 2004, ÙÔ˘Ï¿¯ÈÛÙÔÓ Ô ¤Ó·˜ ÓÂÊÚfi˜ 893 و̷ÙÈÎÒÓ ‰ÔÙÒÓ ·ÔÚÚ›ÊıËΠ۠ÙÔÈÎfi Â›Â‰Ô ÏfiÁˆ ·˘ÍË̤Ó˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ‹ ÌÂȈ̤Ó˘ ‰ÈÔ‡ÚËÛ˘. ∞fi Ù· ÌÔۯ‡̷ٷ ·˘Ù¿, ÙÔ 1/3 ÙÂÏÈο ÌÂÙ·ÌÔۯ‡ıËΠ۠¿ÏÏË ÂÚÈÔ¯‹, Ú¿ÁÌ· Ô˘ Â›Ó·È ÂÓ‰ÂÈÎÙÈÎfi Ù˘ ‰È·ÊÔÚÔÔ›ËÛ˘ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÌÂÏÏÔÓÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. °È· Ó· ··ÓÙËı› ÙÔ ÂÚÒÙËÌ· ÔÈ· ÌÔۯ‡̷ٷ ı· ÏÂÈÙÔ˘ÚÁ‹ÛÔ˘Ó ÈηÓÔÔÈËÙÈο ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â›Ó·È ÛÎfiÈÌÔ Ó· Ù·ÍÈÓÔÌËıÔ‡Ó ÔÈ ‰fiÙ˜ Ì ·˘ÍË̤ÓË ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ (Î·È Û˘ÓÂÒ˜ ÌÂȈ̤ÓË Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘) Û ‰‡Ô ˘ÔηÙËÁÔڛ˜: A. ¢fiÙ˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÔÍ›· ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ Ô˘ ÌÔÚ› Ó· ÍÂÂÚÓ¿ Ù· 2 mg/dl. ™˘Ó‹ıˆ˜ ÚfiÎÂÈÙ·È ÁÈ· Ó¤Ô˘˜ ‰fiÙ˜, Ô˘ ‰ÂÓ ·Ó‹ÎÔ˘Ó ÛÙËÓ ÔÌ¿‰· ÙˆÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ, ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘, ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË, ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ ‹ ÏÔÈÒÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ Î·È ˘ÔÏÔÁÈ˙fiÌÂÓÔ Ú˘ıÌfi ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜, ÔÈ ÔÔ›ÔÈ, Û ¤‰·ÊÔ˜ ÂÏ¿ÙÙˆÛ˘ ‰Ú·ÛÙÈÎÔ‡ fiÁÎÔ˘ ·›Ì·ÙÔ˜ (ÌÂı·ÈÌÔÚÚ·ÁÈ΋ ‹ ÛËÙÈ΋ ηٷÏËÍ›·) ‹ Â›‰Ú·Û˘ ÓÂÊÚÔÙÔÍÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (Ê¿Ú̷η, ÛÎÈ·ÁÚ·ÊÈΤ˜ Ô˘Û›Â˜, Ì˘ÔÛÊ·ÈÚÈÓÔ˘Ú›· Î.·.) ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË ‰˘ÓËÙÈο ·Ó·ÛÙÚ¤„ÈÌË Ì ÙËÓ ¿ÚÛË ÙÔ˘ ·ÈÙ›Ô˘.

B. ¢fiÙ˜ Ì ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ >1,5 mg/dl Î·È ÌÂȈ̤ÓÔ ˘ÔÏÔÁÈ˙fiÌÂÓÔ Ú˘ıÌfi ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘, ÔÈ ÔÔ›ÔÈ, ÏfiÁˆ Ù˘ ‡·Ú͢ ÂÈÚfiÛıÂÙˆÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (ÚÔ¯ˆÚË̤ÓË ËÏÈΛ·, ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, ·ÈÙ›· ı·Ó¿ÙÔ˘ ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi Û˘Ì‚¿Ó) Ù·ÍÈÓÔÌÔ‡ÓÙ·È ÛÙËÓ ÔÌ¿‰· ÙˆÓ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ‹ ‰fiÙ˜ Ì ·˘ÍË̤ÓË ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ ÌÔÚ› Ó· ·ÔÎÏÂÈÛÙ› Ì ·ÛÊ¿ÏÂÈ· Ë ¯ÚÔÓÈfiÙËÙ· Ù˘ ¤ÎÙˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÙÔ˘˜ ÏÂÈÙÔ˘ÚÁ›·˜.

∞. ¢fiÙ˜ Ì ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· OÈ Ugarte Î·È Û˘Ó. Ú·ÁÌ·ÙÔÔ›ËÛ·Ó ÙÔ 2005 Ì›· ·Ó·‰ÚÔÌÈ΋ ·Ó¿Ï˘ÛË 262 ÏËÙÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ì ηډȷ΋ ÏÂÈÙÔ˘ÚÁ›· ÂÈϯı¤ÓÙˆÓ ‚¿ÛÂÈ ÙˆÓ Î·ıÈÂÚˆÌ¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ, ÔÈ 65 ÙˆÓ ÔÔ›ˆÓ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· ·fi ‰fiÙË Ì ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ >2 mg/dl5. ¡ÂÊÚÈ΋ ‚ÈÔ„›· ‰ÈÂÓÂÚÁ‹ıËΠηٿ ÙË Ï‹„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌfiÓÔ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ‰ÔÙÒÓ Ì ·˘ÍË̤ÓË ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘. ∂ÚfiÎÂÈÙÔ ÁÈ· ‰fiÙ˜ ÓÂfiÙÂÚÔ˘˜ ÙˆÓ ˘ÔÏÔ›ˆÓ (Ë ÏÂÈÔÓfiÙËÙ¿ ÙÔ˘˜ <50 ÂÙÒÓ), ¿ÚÚÂÓ˜, Ì ÌÈÎÚfiÙÂÚË Û˘¯ÓfiÙËÙ· ı·Ó¿ÙÔ˘ ·fi ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ Î·È ·Ú·ÙÂٷ̤ÓÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, Ô˘ ÂÈϤ¯ıËÎ·Ó ÂÊfiÛÔÓ ˘‹Ú¯·Ó ÎÏÈÓÈΤ˜ ÂӉ›ÍÂȘ ·Ó·ÛÙÚ¤„ÈÌ˘ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘, ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘, ÈηÓÔÔÈËÙÈ΋ ‰ÈÔ‡ÚËÛË Î·È Â˘ÓÔ˚Τ˜ ·Ú¿ÌÂÙÚÔÈ ÛÙËÓ ·ÓÙÏ›· ÛÊ˘ÁÌÈ΋˜ ·ÚÔ¯‹˜. ∞Ó Î·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙÔ˘˜ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ˘„ËÏ‹ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡, ÙfiÛÔ Ë ÂÍ·ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ (97% ¤Ó·ÓÙÈ 88%) Î·È ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (67% ¤Ó·ÓÙÈ 65%) fiÛÔ Î·È Ë Û˘¯ÓfiÙËÙ· Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘ ÛÙÔ˘˜ 12 Ì‹Ó˜ (39% ¤Ó·ÓÙÈ 36%) ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚÔÔ›ËÛË, Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜. ∂›Û˘, ÙfiÛÔ Ë ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ fiÛÔ Î·È Ô ˘ÔÏÔÁÈ˙fiÌÂÓÔ˜ Ú˘ıÌfi˜ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ ‰ÂÓ Î·Ù¤ÁÚ·„·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙÔ˘˜ 6 Ì‹Ó˜, 1, 2, 3 ¤ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂÙ¿ ·fi ‰ÈfiÚıˆÛË ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ Ï‹ÙË, ÌÂÙÚ›·˜ ‹ ÛÔ‚·Ú‹˜ ÌÔÚÊ‹˜ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ¯ÚÔÓÈfiÙËÙ·˜ Û¯ÂÙ›ÛÙËÎ·Ó ·ÓÂÍ¿ÚÙËÙ· Ì ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ˘ÔÏÔÁÈ˙fiÌÂÓÔ˘ Ú˘ıÌÔ‡ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ ÛÙÔ˘˜ 12 Ì‹Ó˜ (-19,6 ml/min/1,73 m2, p<0,013) Î·È Û fiÏ· Ù· ¯ÚÔÓÈο ÛËÌ›· (-14,8 ml/min/1,73 m2, p<0,019). ∞fi ÙËÓ ÔÏ˘ÌÂÙ·‚ÏËÙ‹ ·Ó¿Ï˘ÛË ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ ÎÏÈÓÈÎfi ÎÚÈÙ‹ÚÈÔ Ù˘ ·˘ÍË̤Ó˘ ÙÂÏÈ΋˜ ÙÈÌ‹˜ ÎÚ·ÙÈÓ›Ó˘ Û و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ô˘ ÏËÚÔ‡Ó Ù· Ù˘Èο ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ (Ì ¿ÏÏ· ÏfiÁÈ· fiÙ·Ó ‰ÂÓ Û˘Ó˘¿Ú¯Ô˘Ó ¿ÏÏÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜), Û˘ÓÙ¤ÏÂÛ Û ÂÏ·ÊÚ¿ ·‡ÍËÛË ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÔÙ˘¯›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi 1 Û 1,14, fiÙ·Ó ·˘Ùfi˜ Â›Ó·È 1,7 Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ. ΔÔ 2006, ÔÈ Anil Kumar Î·È Û˘Ó. ·ÚÔ˘Û›·Û·Ó Ì›· ÚÔÔÙÈ΋ ÌÔÓÔÎÂÓÙÚÈ΋ Û˘ÁÎÚÈÙÈ΋ ·Ó¿Ï˘ÛË ÙÚÈÒÓ ÔÌ¿‰ˆÓ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ·ÛıÂÓÒÓ6. ™ÙËÓ

METAMO™XEY™Eπ™ 2010

ÚÒÙË ÔÌ¿‰· ÂÚÈÂÏ‹ÊıËÛ·Ó 55 ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÌfiÛ¯Â˘Ì· و̷ÙÈÎÒÓ ‰ÔÙÒÓ Ì ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∏ ‰Â‡ÙÂÚË ÔÌ¿‰· ·ÔÙÂÏÔ‡ÓÙ·Ó ·fi 55 ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ô˘ ÏËÚÔ‡Û·Ó Ù· ÎÏ·ÛÛÈο ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜, ÂÓÒ ÛÙËÓ ÙÚ›ÙË ÔÌ¿‰· ·Ó‹Î·Ó 55 ·ÛıÂÓ›˜ Ì ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ ÂÈϯı¤ÓÙ˜ Ì ٷ ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·. OÚ›ÛÙËÎ·Ó ·˘ÛÙËÚ¿ ÎÚÈÙ‹ÚÈ· ·Ô‰Ô¯‹˜ ÁÈ· ÙÔ˘˜ ‰fiÙ˜ Ì ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ŒÙÛÈ, ÂÚfiÎÂÈÙÔ ÁÈ· ‰fiÙ˜ ËÏÈΛ·˜ <50 ÂÙÒÓ, Ì ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ·ÚÓËÙÈÎfi ÁÈ· ÓÂÊÚÈ΋ ÓfiÛÔ, ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË ‹ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, Ì ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÂÈÛ·ÁˆÁ‹˜ <1,5 mg/dl Î·È Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ >100 ml/min, ÔÈ ÔÔ›ÔÈ ÂÌÊ¿ÓÈÛ·Ó Î·Ù¿ ÙË ÓÔÛËÏ›· ÔÍ›· ÔÏÈÁÔ·ÓÔ˘Ú›· Î·È ¿ÓÔ‰Ô Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔ ‰ÈÏ¿ÛÈÔ ‹ ÂÚÈÛÛfiÙÂÚÔ (̤ÛË ÙÈÌ‹ 4,6 mg/dl, Ì ÂÏ¿¯ÈÛÙÔ fiÚÈÔ ÙËÓ ÙÈÌ‹ ÙˆÓ 2,5 mg/dl), ¯ˆÚ›˜ Ù¿ÛË ‚ÂÏÙ›ˆÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ̤¯ÚÈ ÙËÓ Î·Ù¿ÏËÍ‹ ÙÔ˘˜. ∏ ·Ó¿Ï˘ÛË Û˘ÌÏËÚÒıËΠ·fi ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·Ù¿ ÙËÓ ·Ê·›ÚÂÛ‹ ÙÔ˘˜: ÓÂÊÚÔ› ‰ÔÙÒÓ Ì ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ·ÍÈÔÔÈ‹ıËÎ·Ó ÌfiÓÔÓ fiÙ·Ó ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ¯ÚfiÓȘ ‚Ï¿‚˜, ÂÓÒ ¤ÁÈÓ·Ó ·Ô‰ÂÎÙ¿ ÌÔۯ‡̷ٷ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Ì ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË <15%, ‹È· ‰È¿ÌÂÛË ›ÓˆÛË Î·È/‹ ‹È· ·ÚÙËÚÈÔÏÈÔÛÎÏ‹Ú˘ÓÛË. ¶·Ú¿ ÙËÓ ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ Û˘ÓÂ·ÁfiÙ·Ó ·˘ÍË̤Ó˜ Ë̤Ú˜ ÓÔÛËÏ›·˜, Ë ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ÔÍ›· ÓÂÊÚÈ΋ ‚Ï¿‚Ë ÛÙ· 3 ¤ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (90% Î·È 90% ·ÓÙ›ÛÙÔȯ·) ·¤‚Ë Û˘ÁÎÚ›ÛÈÌË Ì ÙËÓ ÔÌ¿‰· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÔÙÒÓ ÎÏ·ÛÛÈÎÒÓ ÎÚÈÙËÚ›ˆÓ (100% Î·È 89% ·ÓÙ›ÛÙÔȯ·) Î·È Û·ÊÒ˜ ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ (83% Î·È 66% ·ÓÙ›ÛÙÔȯ·). OÈ ÙÈ̤˜ Ù˘ ÎÚ·ÙÈÓ›Ó˘ Ù˘ ÔÌ¿‰·˜ ‰ÔÙÒÓ Ì ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÛÙÔ˘˜ 6 Î·È 36 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚÔÔ›ËÛË Û˘ÁÎÚÈÓfiÌÂÓ˜ Ì ÙËÓ ÔÌ¿‰· ÙˆÓ ‰ÔÙÒÓ ÎÏ·ÛÛÈÎÒÓ ÎÚÈÙËÚ›ˆÓ, ÂÓÒ ‹Ù·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈο ÌÂȈ̤Ó˜ ¤Ó·ÓÙÈ Ù˘ ÔÌ¿‰·˜ ÙˆÓ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ. ∂›Û˘, ·Ú¿ ÙËÓ ·˘ÍË̤ÓË Â›ÙˆÛË Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ë Û˘¯ÓfiÙËÙ· Ù˘ ÎÏÈÓÈ΋˜ Î·È ˘ÔÎÏÈÓÈ΋˜ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ‰ÔÙÒÓ Ì ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ‰ÂÓ ‰È¤ÊÂÚÂ

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·fi ·˘Ù‹ Ù˘ ÔÌ¿‰·˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ ÎÏ·ÛÛÈÎÒÓ ÎÚÈÙËÚ›ˆÓ. ª›· ÂӉȷʤÚÔ˘Û· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ú·ÁÌ·ÙÔÔÈ‹ıËΠÙÔ 2007 ·fi ÙÔ˘˜ Morgan Î·È Û˘Ó.7, ÔÈ ÔÔ›ÔÈ ·ÍÈÔÏfiÁËÛ·Ó Û˘ÁÎÚÈÙÈο ‰‡Ô ÔÌ¿‰Â˜ ÏËÙÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ̤ÁÈÛÙË Î·Ù¿ ÙË ÓÔÛËÏ›·˜ ÙÔ˘˜ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ >2 mg/dl: ÛÙËÓ ÚÒÙË ÔÌ¿‰· ÂÚÈÂÏ‹ÊıËÛ·Ó 24 Ï‹Ù˜ ·fi ‰fiÙ˜ ÙˆÓ ÔÔ›ˆÓ Ë ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ (̤ÛË ÙÈÌ‹ 3,2±1,3) ‰ÂÓ ‰È¤ÊÂÚ ·fi ÙË Ì¤ÁÈÛÙË (̤ÛË ÙÈÌ‹ 3,2±1,3), ‰ËÏ·‰‹ ‰ÂÓ ·ÚÔ˘Û›·˙ ٿÛË ·Ó¿Î·Ì„Ë˜Ø ·ÓÙÈı¤Ùˆ˜ ÔÈ ‰fiÙ˜ Ù˘ ‰Â‡ÙÂÚ˘ ÔÌ¿‰·˜ ·ÚÔ˘Û›·Û·Ó ÙÒÛË ≥0,2 mg/dl ÛÙËÓ ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘˜ (̤ÛË ÙÈÌ‹ 1,9±0,9) Û ۯ¤ÛË Ì ÙË Ì¤ÁÈÛÙË ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ (̤ÛË ÙÈÌ‹ 3,1±1,3). ∏ ÂÈÏÔÁ‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ‰ÔÙÒÓ Ì ÛÙ¿ÛÈÌË ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ¤ÁÈÓ ‚¿ÛÂÈ ÙˆÓ ·ÎfiÏÔ˘ıˆÓ ÎÚÈÙËÚ›ˆÓ ÂÈÏÔÁ‹˜: i. ¢ÈÔ‡ÚËÛË ≥30 cc/ÒÚ· ‹ ÛÙËÓ ÂÚ›ÙˆÛË ·fi‰ÔÛ˘ 0-29 cc/ÒÚ·, ÚÔ‹ ÛÙË Ì˯·ÓÈ΋ ·ÚÔ¯‹ ‰È·Ï‡Ì·ÙÔ˜ ≥100 ml/min Î·È ii. ∞Ô˘Û›· ·ÏÏÔÈÒÛÂˆÓ ÂÓ‰ÂÈÎÙÈÎÒÓ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ ‹ ÊÏÔÈÒ‰Ô˘˜ Ó¤ÎÚˆÛ˘ ÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË Ô˘ ÚÔËÁ‹ıËÎ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∂ÊfiÛÔÓ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÎÚÈÙ‹ÚÈÔ Ù˘ ‚ÈÔ„›·˜ ÁÈ· Ó· ÂÍ·ÎÚÈ‚ˆı› Ì ·ÛÊ¿ÏÂÈ· Ë ÔÈfiÙËÙ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡, ‰ÂÓ ÂÙ¤ıËÛ·Ó ÂÈÚfiÛıÂÙÔÈ ÂÚÈÔÚÈÛÌÔ› Û¯ÂÙÈÎÔ› Ì ÙËÓ ËÏÈΛ· ÙÔ˘ ‰fiÙË, Û˘Ì·ÚÔÌ·ÚÙÔ‡ÓÙ· ÓÔÛ‹Ì·Ù· ‹ ·›ÙÈ· ı·Ó¿ÙÔ˘. Δ· ‰ËÌÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο Î·È ÛÙÔȯ›· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‰ÔÙÒÓ Î·È ÏËÙÒÓ ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜, ÏËÓ Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Î·È Ù˘ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ ¯ÚfiÓÈˆÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙË ‚ÈÔ„›· ÓÂÊÚÔ‡ ÛÙÔ˘˜ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÙˆÙÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ (41% ¤Ó·ÓÙÈ 0%, p<0,0023). ∞Ó Î·È ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ̤¯ÚÈ ÙËÓ ÚÒÙË ÙÒÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ‹Ù·Ó ηٿ 1,5 Ë̤Ú˜ ÌÂÁ·Ï‡ÙÂÚÔ ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÓÔ‰È΋˜ ÎÚ·ÙÈÓ›Ó˘ Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÔÌ¿‰· Ù˘ ÙˆÙÈ΋˜ ÙÈÌ‹˜ (‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈÎÒ˜ ÌË ÛËÌ·ÓÙÈ΋), ÔÈ Û˘¯ÓfiÙËÙ˜ Ù˘ ÚˆÙÔ·ıÔ‡˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. ¢ÂÓ ‰È·ÈÛÙÒıËΠÂ›Û˘ ‰È·ÊÔÚ¿ ÛÙË Ì¤ÛË ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔÓ ÚÒÙÔ Î·È ÙÚ›ÙÔ Ì‹Ó· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂ ̤ÛË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 9,6 Ì‹Ó˜, Ë ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ë ÙÂÏÈ΋ ÙÈ-

46

°. Δ™OÀ∫∞

Ì‹ ÎÚ·ÙÈÓ›Ó˘ ·¤‚ËÛ·Ó Û˘ÁÎÚ›ÛÈ̘ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. ΔÔ 2009, ÔÈ Zuckerman J. Î·È Û˘Ó. ‰ËÌÔÛ›Â˘Û·Ó Ì›· ·Ó·‰ÚÔÌÈ΋ ÌÔÓÔÎÂÓÙÚÈ΋ ÌÂϤÙË Û˘ÁÎÚÈÙÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ 17 ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È 83 ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ô˘ ÏËÚÔ‡Û·Ó Ù· Ù˘Èο ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜8. ø˜ ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÔÚ›ÛÙËÎÂ Ô ‰ÈÏ·ÛÈ·ÛÌfi˜ Ù˘ ÙÈÌ‹˜ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÙÔ˘ ‰fiÙË Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÙÈÌ‹ ÂÈÛ·ÁˆÁ‹˜ Î·È Ë ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ >2 mg/dl Û ‰fiÙË ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓË ‰È¿ÁÓˆÛË ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘. ∂ÈϤ¯ıËÎ·Ó ·˘ÛÙËÚ¿ ‰fiÙ˜ ËÏÈΛ·˜ <50 ÂÙÒÓ, Ì ˘ÔÏÔÁÈ˙fiÌÂÓË Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ ÛÙËÓ ÂÈÛ·ÁˆÁ‹ >90 ml/min, ·fi ÙÔ ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi ÙˆÓ ÔÔ›ˆÓ ‰ÂÓ ÚԤ΢Ù ˘¤ÚÙ·ÛË ‰È¿ÚÎÂÈ·˜ >5 ÂÙÒÓ, ‹ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Î·È Ô ı¿Ó·ÙÔ˜ ‰ÂÓ ÚÔ‹Ïı ·fi ηډȷÎfi ‹ ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ. ¶ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ ·Ô‰Ô¯‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‹Ù·Ó Ë ˘ÂÚ˯ÔÁÚ·ÊÈ΋ Ê˘ÛÈÔÏÔÁÈ΋ ÌÔÚÊÔÏÔÁ›· Î·È Ì¤ÁÂıÔ˜ ÙˆÓ ÓÂÊÚÒÓ, Ë ·Ô˘Û›· ¯ÚÔÓ›ˆÓ ‚Ï·‚ÒÓ, ÌÈÎÚÔıÚfiÌ‚ˆÓ ‹ ÊÏÔÈÒ‰Ô˘˜ Ó¤ÎÚˆÛ˘ ÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡, ηıÒ˜ Î·È ·Ú¿ÌÂÙÚÔÈ Ù˘ Ì˯·ÓÈ΋˜ ·ÚÔ¯‹˜ (ÚÔ‹ >80 ml/min Î·È ·ÓÙ›ÛÙ·ÛË <0,4 mm Hg/ml ÌÂÙ¿ ·fi ‰È¿ÛÙËÌ· 6 ˆÚÒÓ). Δ· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ÙˆÓ ÏËÙÒÓ Î·È Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ‰ÂÓ ‰È¤ÊÂÚ·Ó Ô˘ÛÈ·ÛÙÈο ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. ¢ÂÓ ‰È·ÈÛÙÒıËΠÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ fiÛÔÓ ·ÊÔÚ¿ ÙfiÛÔ ÛÙËÓ ÚˆÙÔ·ı‹ ÌË ÏÂÈÙÔ˘ÚÁ›· Î·È ÛÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ fiÛÔ Î·È ÛÙËÓ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ˘˜ 12 Ì‹Ó˜. Δ· ÔÛÔÛÙ¿ ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘, Ïԛ̈͢, ËÌÂÚÒÓ ÓÔÛËÏ›·˜ Î·È ÂÚÈÂÁ¯ÂÈÚËÙÈÎÒÓ ÂÈÏÔÎÒÓ ‰ÂÓ ‰È·ÊÔÚÔÔÈ‹ıËÎ·Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. Δ¤ÏÔ˜, Û˘ÁÎÚ›ÛÈÌË ‹Ù·Ó Ë ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ Î·È Ù˘ οı·ÚÛ˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙÔ˘˜ 6 Ì‹Ó˜. ΔÚˆÙfi ÛËÌÂ›Ô Ù˘ ÌÂϤÙ˘ Â›Ó·È Ô ÂÚÈÔÚÈṲ̂ÓÔ˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ Î·È Ë ¤ÏÏÂÈ„Ë ÌÂÛÔ- Î·È Ì·ÎÚÔÚfiıÂÛÌ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÁÈ· ÂÍ·ÁˆÁ‹ ·ÛʷϤÛÙÂÚˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ. ™˘ÌÂÚ·ÛÌ·ÙÈο, ·fi ÙËÓ ·Ó·ÛÎfiËÛË Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ ÚÔ·ÙÂÈ fiÙÈ ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·˘ÛÙËÚ¿ ÂÈÏÂÁÌ¤ÓˆÓ ‰ÔÙÒÓ Ì ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ¯ˆÚ›˜ Û˘ÓÔ‰¿ ÓÔÛ‹Ì·Ù· (·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, ۷ί·Ú҉˘ ‰È·‚‹Ù˘,

ÈÛÙÔÚÈÎfi ÓÂÊÚÈ΋˜ ÓfiÛÔ˘), ¯ˆÚ›˜ ÏÔÈÔ‡˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (ËÏÈΛ·, ηٿÏËÍË ·fi ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ) Î·È ¯ˆÚ›˜ ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ¯ÚÔÓÈfiÙËÙ·˜ ÛÙË ‚ÈÔ„›· ÓÂÊÚÔ‡, ÂÍ·ÛÊ·Ï›˙Ô˘Ó ÌÂÏÏÔÓÙÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È Ì·ÎÚÔÚfiıÂÛÌË ¤Î‚·ÛË Û˘ÁÎÚ›ÛÈ̘ Ì ÓÂÊÚÔ‡˜ ‰ÔÙÒÓ ÎÏ·ÛÛÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. Δ· ˘„ËÏ¿ ÔÛÔÛÙ¿ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÔÙÒÓ Ì ˘„ËÏ‹ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Úԉȷı¤ÙÔ˘Ó Û ÌÂȈ̤ÓË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË. ΔÔ ÂÁÁ‡˜ ÂÛÂÈڷ̤ÓÔ ÛˆÏËÓ¿ÚÈÔ, ̤ۈ ÔχÏÔÎˆÓ ‰È·‰ÈηÛÈÒÓ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡, ΢ÙÙ·ÚÈ΋˜ ÌÂÙ·Ó¿ÛÙ¢Û˘, Î·È ˘ÂÚÙÚÔÊ›·˜ ÙˆÓ ÛˆÏËÓ·ÚÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ, ‰È·ı¤ÙÂÈ ¤ÓÙÔÓË ·Ó·ÁÂÓÓËÙÈ΋ ÈηÓfiÙËÙ· ÌÂÙ¿ ·fi ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË ÈÛ¯·ÈÌÈ΋˜ ‹ ¿ÏÏ˘ ·ÈÙÈÔÏÔÁ›·˜, ÂÊfiÛÔÓ ·Úı› ÙÔ ·›ÙÈÔ. ¶·ÚÂÌ‚¿ÛÂȘ Ô˘ “ÚÔÛٷهԢӔ ÙÔ ÓÂÊÚÈÎfi ÂÚ¤Á¯˘Ì· Â›Ó·È Ë Î·Ù¿ ÙÔ ‰˘Ó·Ùfi ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, Ë ·ÓÙÏ›· ÛÊ˘ÁÌÈ΋˜ ·ÚÔ¯‹˜, Ë Î·ı˘ÛÙÂÚË̤ÓË ¯ÔÚ‹ÁËÛË Î·È Ë ‰È·Ù‹ÚËÛË ÔÚȷο ¯·ÌËÏÒÓ ÂÈ¤‰ˆÓ ÙÔ˘ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘. ¶ÚfiÎÂÈÙ·È ÁÈ· Ì›· ηÙËÁÔÚ›· ‰ÔÙÒÓ Ô˘, Â¿Ó ·ÍÈÔÔÈËı› ηٿÏÏËÏ· Û ÙÔÈÎfi Â›‰Ô, ı· ÂÈÙ¢¯ıÔ‡Ó ÌÂȈ̤ÓÔÈ ¯ÚfiÓÔÈ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ı· ‚ÂÏÙȈıÔ‡Ó ÂÚÈÛÛfiÙÂÚÔ, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·‡ÍËÛË Ù˘ ÚÔÛÊÔÚ¿˜ ηٿÏÏËÏˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ.

μ. ¢fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Ì ˘„ËÏ‹ ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ™ÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ¤¯ÂÈ ·ÍÈÔÏÔÁËı› Ë Â›‰Ú·ÛË Ù˘ ·˘ÍË̤Ó˘ ÙÈÌ‹˜ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ‰fiÙË (‹ Ù˘ ÌÂȈ̤Ó˘ ˘ÔÏÔÁÈ˙fiÌÂÓ˘ οı·ÚÛ˘ ÎÚ·ÙÈÓ›Ó˘) ˆ˜ ·Ú¿ÁÔÓÙ· Ô˘ ÂËÚ¿˙ÂÈ ÙËÓ ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ȉȷ›ÙÂÚ· Û ÌÔۯ‡̷ٷ ÚÔÂÚ¯fiÌÂÓ· ·fi ‰fiÙ˜ ÚÔ¯ˆÚË̤Ó˘ ËÏÈΛ·˜ ‹ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ. ∂›Û˘, Ë Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ‰fiÙË ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Û ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· ÔÛÔÙÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ ‰fiÙË (Deceased Donor Score9, Donor Risk Score10). ™Â Ì›· ·Ó·‰ÚÔÌÈ΋ ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË Ì ‰Â‰Ô̤ӷ ÙÔ˘ UNOS, ÙÔ 2000 Ô Carter Î·È Û˘Ó. ÂÎÙ›ÌËÛ·Ó ÙËÓ Â›‰Ú·ÛË Ù˘ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ Î·È Ù˘ ÙÂÏÈ΋˜ οı·ÚÛ˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ‰fiÙË ÛÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜11. ¢È·ÈÛÙÒıËΠfiÙÈ Û 4.732 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÒÓ ·fi ‰fiÙ˜ ≥55 ÂÙÒÓ, Ë Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ <80 ml/min

METAMO™XEY™Eπ™ 2010

‹Ù·Ó ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙ· 1, 2 Î·È 3 ¤ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰ÈÂÚ¢ÓËı› Ë Â›‰Ú·ÛË ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÙÔ˘ ‰fiÙË ÛÙËÓ ¤Î‚·ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÔÈ Pessione Î·È Û˘Ó. ÌÂϤÙËÛ·Ó 7.209 ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙË °·ÏÏ›· ÌÂٷ͇ 1996 Î·È 200012. ∏ ·˘ÍË̤ÓË ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ‰fiÙË (>1,7 mg/dl) Û¯ÂÙ›ÛÙËΠÈÛ¯˘Ú¿ Ì Ùˆ¯‹ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ¤Ó· ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (87% ¤Ó·ÓÙÈ 91,6% Û ‰fiÙ˜ Ê˘ÛÈÔÏÔÁÈ΋˜ ÎÚ·ÙÈÓ›Ó˘, p<0,0002), ·ÏÏ¿ Ë ‰È·ÊÔÚ¿ ÂÏ·ÙÙÒıËΠÛÙ· 3 ¤ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (83,9% ¤Ó·ÓÙÈ 85,8% ·ÓÙ›ÛÙÔȯ·, p<0,04). ™ÙËÓ ÔÏ˘ÌÂÙ·‚ÏËÙ‹ ·Ó¿Ï˘ÛË Î·È ÌÂÙ¿ ·fi ‰ÈfiÚıˆÛË ÁÈ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Ï‹ÙË, ‰È·ÈÛÙÒıËΠfiÙÈ ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ‰fiÙË >1,7 mg/dl ·ÔÙÂÏÔ‡Û ·ÓÂÍ¿ÚÙËÙÔ Î·È ÈÛ¯˘Úfi ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· Ùˆ¯‹˜ ¤Î‚·Û˘, Ì ۯÂÙÈÎfi ΛӉ˘ÓÔ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ 1,3 (p<0,03). ÕÏÏÔÈ ·ÓÂÍ¿ÚÙËÙÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÙÔ˘ ‰fiÙË ‹Ù·Ó ÙÔ ÈÛÙÔÚÈÎfi ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ Î·È Ë Î·Ù¿ÏËÍË ·fi ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ. ∏ Â›‰Ú·ÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ·˘ÙÒÓ ‹Ù·Ó ·ıÚÔÈÛÙÈ΋ Î·È Ë Û˘Ó‡·ÚÍ‹ ÙÔ˘˜ ÛÙËÓ ˘ÔÔÌ¿‰· ÙˆÓ ‰ÔÙÒÓ >60 ÂÙÒÓ ÚÔÌ‹Ó˘Â È‰È·›ÙÂÚ· ‰˘ÛÌÂÓ¤˜ ·ÔÙ¤ÏÂÛÌ·.

OÈ Stratta Î·È Û˘Ó. ·ÍÈÔÏfiÁËÛ·Ó ÙÔ 2006 ·Ó·‰ÚÔÌÈο ÙË ÌÂÛÔÚfiıÂÛÌË ¤Î‚·ÛË 101 ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ΤÓÙÚÔ˘ ÙÔ˘˜ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ¤Ó·ÓÙÈ 143 ÎÏ·ÛÛÈÎÒÓ ÎÚÈÙËÚ›ˆÓ13. ¢fiÙ˜ Ì οı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ <40 ml/min, Ì ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ >2 mg/dl, Ì ·ÓÔ‰È΋ Ù¿ÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘, Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·ÏÏÔÈÒÛÂȘ ¯ÚÔÓÈfiÙËÙ·˜ ÛÙË ‚ÈÔ„›· Î·È Ì ‰˘ÛÌÂÓ›˜ ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ Ì˯·ÓÈ΋˜ ·ÚÔ¯‹˜ ·ÔÚÚ›ÊıËÎ·Ó ·fi ÙË ÌÂϤÙË, ÂÓÒ ‰ÈÂÓÂÚÁ‹ıËΠ‰ÈÏ‹ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË fiÙ·Ó Ë Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ‰fiÙË ‹Ù·Ó 40-65 ml/min. ™Ù·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈΤ˜ ‹Ù·Ó ÔÈ ‰È·ÊÔÚ¤˜ ÛÙËÓ Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ (̤ÛË 72,3 vs 92,9 ml/min, p<0,01) Î·È ÛÙËÓ ËÏÈΛ· (̤ÛË 61,6 vs 33,1 ¤ÙË, p<0,01) ÙˆÓ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ¤Ó·ÓÙÈ ·˘ÙÒÓ ÙˆÓ ÎÏ·ÛÛÈÎÒÓ ÎÚÈÙËÚ›ˆÓ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ Ï‹Ù˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ, ÂÚfiÎÂÈÙÔ ÁÈ· ¿ÙÔÌ· ¯·ÌËÏÒÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ó·ÁÎÒÓ (̤ÛË ËÏÈΛ· 57±10,8 ÂÙÒÓ ¤Ó·ÓÙÈ 49,2±12,7 ¤ÙË, p<0,01 Î·È ¯·ÌËÏfi ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜) Î·È ÌÈÎÚfiÙÂÚÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ·fiÚÚȄ˘. ∞Ó

47

Î·È Ë ˘ÔÏÔÁÈ˙fiÌÂÓË Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ ‹Ù·Ó ÌÂȈ̤ÓË Î·ı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘, ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ ÛÙ· ÔÛÔÛÙ¿ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÛÙȘ Ë̤Ú˜ Ô˘ ··ÈÙ‹ıËÎ·Ó ÁÈ· Ó· ÌÂȈı› Ë ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÛÙ· 3 mg/dl, ÛÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÚÈÂÁ¯ÂÈÚËÙÈÎÒÓ ÂÈÏÔÎÒÓ Î·È ÙˆÓ ÏÔÈÌÒ͈Ó. ∂›Û˘, Û˘ÁÎÚ›ÛÈ̘ ‹Ù·Ó Ë ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ˘˜ 12, 24 (93% ¤Ó·ÓÙÈ 93,7% ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ, p=1 Î·È 83% ¤Ó·ÓÙÈ 82,5% ÂÈ‚›ˆÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ, p=1) Î·È 48 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ë Û˘¯ÓfiÙËÙ· ÔÍ›·˜ ·fiÚÚȄ˘ (12% ¤Ó·ÓÙÈ 17%, p=0,36). ªÂ ÛÎÔfi Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ë ·ÛÊ¿ÏÂÈ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ·˘ÍË̤ÓË ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡, ÔÈ Kayler Î·È Û˘Ó. Ú·ÁÌ·ÙÔÔ›ËÛ·Ó ÙÔ 2009 Ì›· ÔÏ˘ÎÂÓÙÚÈ΋ ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ì 99.313 Ï‹Ù˜ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË14. OÈ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ˜ ·ÛıÂÓ›˜ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Ì ‰‡Ô ÎÚÈÙ‹ÚÈ·: i) ÙËÓ ÚԤϢÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ‰fiÙË ÎÏ·ÛÛÈÎÒÓ ‹ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Î·È ii) ÙËÓ ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÙÔ˘ ‰fiÙË. O Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÚÔ˘Û›·˙ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ٷ Â›‰· ÎÚ·ÙÈÓ›Ó˘, Û ÌÔۯ‡̷ٷ ÚÔÂÚ¯fiÌÂÓ· ÙfiÛÔ ·fi ‰fiÙ˜ Ù˘ÈÎÒÓ fiÛÔ Î·È ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ. ŸÌˆ˜, ÂÓÒ Ë ˘„ËÏ‹ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÙÔ˘ ‰fiÙË ‰ÂÓ ÂȉÚÔ‡Û ·ÚÓËÙÈο ÛÙË ÌÂÛÔ- Î·È Ì·ÎÚÔÚfiıÂÛÌË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ‰ÔÙÒÓ Ù˘ÈÎÒÓ ÎÚÈÙËÚ›ˆÓ, Û¯ÂÙÈ˙fiÙ·Ó Ì ‰˘ÛÌÂÓ‹ ¤Î‚·ÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ÚÔÂÚ¯ÔÌ¤ÓˆÓ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ, Ì 14% ·‡ÍËÛË ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ÙÈ̤˜ ÎÚ·ÙÈÓ›Ó˘ 1,6-2 mg/dl Î·È 17% Û ÙÈ̤˜ >2 mg/dl. ¶·Ú¿ ÙÔ ÌÂÁ¿ÏÔ ÛÙ·ÙÈÛÙÈÎfi ‰Â›ÁÌ· Î·È ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË, Ë ÌÂϤÙË ÂÚÈÔÚ›˙ÂÙ·È ·fi ÙËÓ ¤ÏÏÂÈ„Ë ÈÛÙÔ·ıÔÏÔÁÈ΋˜ ÂͤٷÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ÙËÓ ·Ô˘Û›· ÏËÚÔÊÔÚÈÒÓ ÁÈ· ÙËÓ ÔÚ›· Ù˘ ÙÈÌ‹˜ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÙˆÓ ‰ÔÙÒÓ (ÙÈÌ‹ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È Ì¤ÁÈÛÙË ÙÈÌ‹), ÙËÓ ÔÛfiÙËÙ· Ù˘ ‰ÈÔ‡ÚËÛ˘, ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ ·ÓÙÏ›·˜ ÛÊ˘ÁÌÈ΋˜ ·ÚÔ¯‹˜, ÛÙÔȯ›· Ô˘ ı· ÚÔÛ‰ÈfiÚÈ˙·Ó ÙË Ê‡ÛË Ù˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜. ŒÙÛÈ, Ë Ùˆ¯‹ Û˘ÓÔÏÈ΋ ¤Î‚·ÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Ì ·˘ÍË̤ÓË ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ Èı·ÓfiÓ Ó·

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°. Δ™OÀ∫∞

ÔÊ›ÏÂÙ·È Û ·˘ÍË̤ÓË Â›ÙˆÛË ¯ÚfiÓÈˆÓ ·ÚÂÁ¯˘Ì·ÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Î·È fi¯È Û ·ÚÓËÙÈ΋ Â›‰Ú·ÛË ÔÍ›·˜ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘. ™ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ ÙÔ˘ °.¡.∞. «∂˘·ÁÁÂÏÈÛÌfi˜» ÌÂٷ͇ 2007 Î·È 2009, ‰ÈÂÓÂÚÁ‹ıËÎ·Ó 13 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ Ì ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ >1,5 mg/dl. ¢‡Ô ·fi ÙÔ˘˜ ‰fiÙ˜ ‹Ù·Ó ËÏÈΛ·˜ ≥60 ÂÙÒÓ, ¤Ó·˜ 50-59 ÂÙÒÓ Î·È ‰¤Î· ≤49 ÂÙÒÓ. ∏ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ 1 ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹Ù·Ó 84% Î·È 69% ·ÓÙ›ÛÙÔȯ· Î·È ÙÔ ÔÛÔÛÙfi ÔÍ›·˜ ·fiÚÚȄ˘ 15%.

O ÚÔÁÓˆÛÙÈÎfi˜ ÚfiÏÔ˜ Ù˘ ‚ÈÔ„›·˜ ÓÂÊÚÔ‡ ÙÔ˘ “ÔÚÈ·ÎÔ‡” ‰fiÙË ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ·ÌÊÈÏÂÁfiÌÂÓÔ˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·. ∞ÏÏÔÈÒÛÂȘ ¯ÚÔÓÈfiÙËÙ·˜, fiˆ˜ ‰È¿ÌÂÛË ›ÓˆÛË, ÛˆÏËÓ·Úȷ΋ ·ÙÚÔÊ›·, ÂÓ·Ôı¤ÛÂȘ ˘·Ï›Ó˘, ·ÚÙËÚÈÔÏÈÔÛÎÏ‹Ú˘ÓÛË Î·È Î˘Ú›ˆ˜ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË >20% ÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË Û¯ÂÙ›˙ÔÓÙ·È ·ÚÓËÙÈο Ì ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ·Ó Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ·fiÏ˘ÙË Û˘Ìʈӛ·. º·›ÓÂÙ·È ˆ˜ Ë ‚ÈÔ„›· ÓÂÊÚÔ‡ ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¯Ú‹ÛÈÌÔ ·ÏÏ¿ fi¯È ·ÓÂÍ¿ÚÙËÙÔ ‰Â›ÎÙË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë Î·È ¿ÏÏ· ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο ÛÙÔȯ›·. ¶·ÚÂÌ‚¿ÛÂȘ “ÚÔÛٷ٢ÙÈΤ˜” ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Û ÌÔۯ‡̷ٷ Ì ·˘ÍË̤ÓË ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ Â›Ó·È Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, Ë Û˘ÓÙ‹ÚËÛË Ì Ì˯·ÓÈ΋ ÛÊ˘ÁÌÈ΋ ·ÚÔ¯‹ ‰È·Ï‡Ì·ÙÔ˜ 15,16 , Ë Â·Ú΋˜ ÚÔʇϷÍË ·fi ÏÔÈÌÒÍÂȘ Î·È Ë ÚÔÛ·ÚÌÔÁ‹ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË Ù˘ ÂÏ·¯ÈÛÙÔÔ›ËÛ˘ Ù˘ ÙÔÍÈÎfiÙËÙ·˜. Œ¯Ô˘Ó ÚÔÙ·ı› ‰‡Ô ÛÙÚ·ÙËÁÈΤ˜ ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘: i) Ë Î·ı˘ÛÙÂÚË̤ÓË ¤Ó·ÚÍË ÙÔ˘ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ ̤¯ÚÈ Ó· ÂÈÙ¢¯ı› Â·Ú΋˜ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜13,17, Î·È ii) Ë ·ÔÊ˘Á‹ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ Î·È Ë ·ÓÔÛÔηٷÛÙÔÏ‹ Ì mycophenolate mofetil18 Î·È sirolimus19, Ù·ÎÙÈ΋ Ù˘ ÔÔ›·˜ Ë ·ÛÊ¿ÏÂÈ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı› Â·ÚÎÒ˜ ·fi ÙËÓ ¤ˆ˜ Û‹ÌÂÚ· ‚È‚ÏÈÔÁÚ·Ê›·. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÌÔۯ‡̷ٷ ÚÔÂÚ¯fiÌÂÓ· ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ ÎÏ·ÛÛÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ˘ÂÚÙÂÚÔ‡Ó Û ÏÂÈÙÔ˘ÚÁ›· Î·È Ì·ÎÚfi¯ÚÔÓË ÂÈ‚›ˆÛË Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÌÔۯ‡̷ٷ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Ì ·˘ÍË̤ÓË ÙÂÏÈ΋ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ Î·È ÌÂȈ̤ÓË Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘.

ŸÌˆ˜, Û ÂÈÏÂÁ̤Ó˜ ˘ÔÔÌ¿‰Â˜ ·ÛıÂÓÒÓ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÌÔۯ‡̷ٷ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Ì ˘„ËÏ‹ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ˘ÂÚÙÂÚ› ¤Ó·ÓÙÈ Ù˘ ·Ú·ÌÔÓ‹˜ ÙÔ˘˜ Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ Î·È Ù˘ ÎÏ·ÛÛÈ΋˜ ıÂÚ·›·˜ ÙÔ˘˜ Ì ·ÈÌÔοı·ÚÛË, ‰ÈfiÙÈ ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙÔ Î›Ó‰˘ÓÔ ıÓËÙfiÙËÙ·˜ Û ̷ÎÚÔÚfiıÂÛÌË ‚¿ÛË. Δ¤ÙÔÈÔÈ ˘Ô„‹ÊÈÔÈ Â›Ó·È ·ÛıÂÓ›˜ Û ϛÛÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙˆÓ ÔÔ›ˆÓ ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ Â›Ó·È ÌÈÎÚfiÙÂÚÔ ·fi ÙÔÓ ÚÔ‚ÏÂfiÌÂÓÔ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÙÔ˘˜ ÁÈ· ÌfiÛ¯Â˘Ì·. ŒÙÛÈ, ˘Ô„‹ÊÈÔÈ >60 ÂÙÒÓ ‹ >40 ÂÙÒÓ Ì ÚÔ‚ÏÂfiÌÂÓÔ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 44 ÌËÓÒÓ, ‰È·‚ËÙÈÎÔ› >40 ÂÙÒÓ, ·ÛıÂÓ›˜ Ì Ùˆ¯‹ ÂÈ‚›ˆÛË ÛÙËÓ Â͈ÓÂÊÚÈ΋ οı·ÚÛË ‹ ¯ˆÚ›˜ ÚÔÛ¤Ï·ÛË ÁÈ· ·ÈÌÔοı·ÚÛË ı· ˆÊÂÏËıÔ‡Ó ÛËÌ·ÓÙÈο, fiÛÔÓ ·ÊÔÚ¿ ÛÙÔ ÚÔÛ‰fiÎÈÌÔ Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘˜, ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ‰fiÙË ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ. ∞fi ÙË ‚È‚ÏÈÔÁÚ·Ê›· ‰È·ÈÛÙÒÓÂÙ·È fiÙÈ Ë ˘„ËÏ‹ ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÙÔ˘ ‰fiÙË Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ÓË ÌÂÛÔ- Î·È Ì·ÎÚÔÚfiıÂÛÌË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ, ÂÓÒ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Âȉڿ ·ÚÓËÙÈο ÛÙËÓ ¤Î‚·ÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ÚÔÂÚ¯ÔÌ¤ÓˆÓ ·fi ‰fiÙ˜ ÎÏ·ÛÛÈÎÒÓ ÎÚÈÙËÚ›ˆÓ, ‰ÈfiÙÈ Èı·Ófiٷٷ ÛÙÔ˘˜ ÚÒÙÔ˘˜ ÔÊ›ÏÂÙ·È Û ¯ÚfiÓȘ ÌË ·Ó·ÛÙÚ¤„È̘ ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ‚Ï¿‚˜ Î·È Ì·ÚÙ˘Ú¿ “ÔÚȷ΋” ÓÂÊÚÈ΋ Ì¿˙·. ŒÙÛÈ, ·ÛıÂÓ›˜ <40 ÂÙÒÓ, ˘„ËÏÒÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ó·ÁÎÒÓ, Ì ·˘ÍË̤ÓÔ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜, ˘„ËÏÔ‡ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ·fiÚÚȄ˘ ‹ Û ·Ó·ÌÔÓ‹ ÁÈ· ‰Â‡ÙÂÚË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ Â˘ÓÔÔ‡ÓÙ·È ·fi ÙË Ï‹„Ë ·˘ÙÒÓ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∂Ô̤ӈ˜, ÁÈ· Ó· ·ÍÈÔÔÈËıÔ‡Ó ÛÙÔ Ì¤ÁÈÛÙÔ ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Ì ·˘ÍË̤ÓË ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ Î·È Ó· ÂÍ·ÛÊ·ÏÈÛÙ› Ë Î·Ù¿ ÙÔ ‰˘Ó·Ùfi ÈηÓÔÔÈËÙÈ΋ ¤Î‚·ÛË, ı· Ú¤ÂÈ Ó· ·ÍÈÔÏÔÁÔ‡ÓÙ·È Î·È Ó· Û˘ÓÂÎÙÈÌÒÓÙ·È ¯·Ú·ÎÙËÚÈÛÙÈο ÙfiÛÔ ÙÔ˘ ‰fiÙË fiÛÔ Î·È ÙÔ˘ Ï‹ÙË.

μÈ‚ÏÈÔÁÚ·Ê›· 1. United Network for Organ Sharing. National Data.

Available at: http://www.unos.org/data.

2. Merion RM, Ashby VB, Wolfe RA, Distant DA, HulbertShearon TE, Metzger RA, Ojo AO, Port FK. Deceaseddonor characteristics and the survival benefit of kidney transplantation. JAMA. 2005 Dec 7; 294(21): 2726-33.

3. Port FK, Bragg-Gresham JL, Metzger RA, Dykstra DM, Gillespie BW, Young EW, Delmonico FL, Wynn JJ,

METAMO™XEY™Eπ™ 2010

Merion RM, Wolfe RA, Held PJ. Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors. Transplantation.

2002 Nov 15; 74(9): 1281-6.

4. Metzger RA, Delmonico FL, Feng S, et al. Expanded criteria donors for kidney transplantation. Am J Transplantation. 2003; 3 (suppl. 4): 29-40.

5. Ugarte R, Kraus E, Montgomery RA, Burdick JF, Ratner L, Haas M, Hawxby AM, Karp SJ. Excellent outcomes after transplantation of deceased donor kidneys with high terminal creatinine and mild pathologic lesions.

Transplantation. 2005 Sep 27; 80(6): 794-800.

6. Anil Kumar MS, Khan SM, Jaglan S, Heifets M, Moritz MJ, Saeed MI, Fyfe B, Sustento-Reodica N, Kumar A. Successful transplantation of kidneys from deceased donors with acute renal failure: Three-year results.

Transplantation. 2006 Dec 27; 82(12): 1640-5.

7. Morgan C, Martin A, Shapiro R, Randhawa PS, Kayler LK. Outcomes after transplantation of deceased-donor kidneys with rising serum creatinine. HYPERLINK “file:///tmp/sv4dp.tmp/javascript:AL_get(this, ‘jour’, ‘Am J Transplant.’)%3B” Am J Transplant. 2007 May;7(5):1288-92.

8. Zuckerman JM, Singh RP, Farney AC, Rogers J, Stratta RJ, Single center experience transplanting kidneys from deceased donors with terminal acute renal failure. Surgery. 2009 Oct; 146(4): 686-94.

9. Nyberg SL, Matas AJ, Kremers WK, Thostenson JD, Larson TS, Prieto M, Ishitani MB, Sterioff S, Stegall MD. Improved scoring system to assess adult donors for cadaver renal transplantation. Am J Transplant. 2003 Jun; 3(6): 715-21.

10. Schold JD, Kaplan B, Baliga RS, Meier-Kriesche HU. The broad spectrum of quality in deceased donor kidneys. Am J Transplant. 2005 Apr; 5(4 Pt 1): 757-65.

11. Carter JT, Lee CM, Weinstein RJ, Lu AD, Dafoe DC, Alfrey EJ. Evaluation of the older cadaveric kidney donor: the impact of donor hypertension and creatinine clearance on graft performance and survival.

Transplantation. 2000 Sep 15; 70(5): 765-71.

12. Pessione F, Cohen S, Durand D, Hourmant M, Kessler M, Legendre C, Mourad G, Noël C, Peraldi MN, Pouteil-Noble

49

C, Tuppin P, Hiesse C. Multivariate analysis of donor risk factors for graft survival in kidney transplantation Transplantation. 2003 Feb 15; 75(3): 361-7.

13. Stratta RJ, Rohr MS, Sundberg AK, Farney AC, Hartmann EL, Moore PS, Rogers J, Iskandar SS, Gautreaux MD, Kiger DF, Doares W, Anderson TK, Hairston G, Adams PL. Intermediate-term outcomes with expanded criteria deceased donors in kidney transplantation: a spectrum or specter of quality? Ann Surg. 2006 May; 243(5): 594-601.

14. Kayler LK, Garzon P, Magliocca J, Fujita S, Kim RD, Hemming AW, Howard R, Schold JD. Outcomes and utilization of kidneys from deceased donors with acute kidney injury. Am J Transplant. 2009 Feb; 9(2): 367-73.

15. Schold JD, Kaplan B, Howard RJ, Reed AI, Foley DP, Meier-Kriesche HU. Are we frozen in time? Analysis of the utilization and efficacy of pulsatile perfusion in renal transplantation. Am J Transplant. 2005 Jul; 5(7): 1681-8.

16. Matsuoka L, Shah T, Aswad S, Bunnapradist S, Cho Y, Mendez RG, Mendez R, Selby R. Pulsatile perfusion reduces the incidence of delayed graft function in expanded criteria donor kidney transplantation. Am J Transplant. 2006 Jun; 6(6): 1473-8.

17. Segoloni GP, Messina M, Squiccimarro G, Mazzucco G, Torta E, Leonardi G, Fop F, Roggero S, Vigotti F, Piccoli GB. Preferential allocation of marginal kidney allografts to elderly recipients combined with modified immunosuppression gives good results. Transplantation. 2005 Oct 15; 80(7): 953-8.

18. Arbogast H, Hückelheim H, Schneeberger H, Illner WD, Tarabichi A, Fertmann J, Wimmer CD, Hillebrand GF, Mistry-Burchardi N, Thomae R, Acikgöz A, Land W. A calcineurin antagonist-free induction/maintenance strategy for immunosuppression in elderly recipients of renal allografts from elderly cadaver donors: long-term results from a prospective single centre trial. Clin Transplant. 2005 Jun; 19(3): 309-15.

19. Re LS, Rial MC, Guardia OE, Galdo MT, Casadei DH. Results of a calcineurin-inhibitor-free immunosuppressive protocol in renal transplant recipients of expanded criteria deceased donors. Transplant Proc.

2006 Dec; 38(10):3468-9.

AÓ·ÙÔÌÈΤ˜ ·Ú·ÏÏ·Á¤˜ Ù˘ ·ÁÁ›ˆÛ˘ ÙÔ˘ ÓÂÊÚÔ‡ ∞. ª¿ÚÏ·˜

¡ÂÊÚÈ΋ ·ÚÙËÚ›·

ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜, ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ÓÂÊÚ·ÁÁÂȷ΋˜ ˘¤ÚÙ·Û˘) Î·È Ô˘ÚËÙËÚÈÎÒÓ ÂÈÏÔÎÒÓ (Ô˘Ï҉˘ ÛÙ¤ÓˆÛË, Ó¤ÎÚˆÛË ÙÔ˘ Ô˘ÚËÙ‹Ú·, ˘ÂÏÔÎ·Ï˘ÎÈο Û˘Ú›ÁÁÈ·) ÛÙÔ Ï‹ÙË4,5. ŸÙ·Ó ˆÛÙfiÛÔ fiϘ ÔÈ ÓÂÊÚÈΤ˜ ·ÚÙËڛ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ¿Óˆ Û ¤Ó· ·ÔÚÙÈÎfi ÌfiÛ¯Â˘Ì· (Carrel patch) ·fi ÙÔ ‰fiÙË Î·È ÙÔ ÌfiÛ¯Â˘Ì· Â·Ó·ÁÁÂÈÒÓÂÙ·È Ì¤Ûˆ Ì›·˜ ·Ó·ÛÙfïÛ˘ (ÙÔ˘ patch) ÛÙÔ Ï‹ÙË, ·Ú·ÙËÚ‹ıËΠfiÙÈ Ë ‡·ÚÍË ÔÏÏÒÓ ·ÚÙËÚÈÒÓ ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤Ó˜ ÂÈÏÔΤ˜6. ∏ ÛˆÛÙ‹ ·ÍÈÔÔ›ËÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÔÏÏ·Ï¿ ·ÁÁ›· ÍÂÎÈÓ¿ ·fi ÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË ÛÙÔÓ ‰fiÙË.

OÈ Starzl Î·È Û˘Ó.7 ¤‰ÂÈÍ·Ó fiÙÈ Ë Î¿ÎˆÛË ÙˆÓ ·ÁÁ›ˆÓ ηٿ ÙËÓ Ï‹„Ë ‰‡Ó·Ù·È Ó· ÂÏ·¯ÈÛÙÔÔÈËı› Ì ÙËÓ en-bloc ·Ú·Û΢‹ Î·È ·Ê·›ÚÂÛË ÙˆÓ ÓÂÊÚÒÓ ÛÙÔÓ و̷ÙÈÎfi ‰fiÙË, fiˆ˜ ·Ú¯Èο ÂÚÈÁÚ¿ÊËΠ·fi ÙÔ˘˜ Ackerman Î·È Û˘Ó. ÙÔ 19688. ΔÔ ÏÂÔÓ¤ÎÙËÌ· ·˘Ù‹˜ Ù˘ Ù¯ÓÈ΋˜ Ô˘ ·ÔÙÂÏ› ÎÔÈÓ‹ Ú·ÎÙÈ΋ Ï‹„˘ ÛÙȘ ̤Ú˜ Ì·˜, Â›Ó·È fiÙÈ ÂÈÙ˘Á¯¿ÓÂÙ·È ¿ÌÂÛ· ¿Ú‰Â˘ÛË ÙˆÓ ÓÂÊÚÒÓ Ì „˘¯Úfi ‰È¿Ï˘Ì· ¤ÎÏ˘Û˘ (UW ‹ custodiol) ¯ˆÚ›˜ Ó· Á›ÓÂÙ·È Î·Ó¤Ó·˜ ¯ÂÈÚÈÛÌfi˜ ÛÙ· ÓÂÊÚÈο ·ÁÁ›·. ◊È· ¤ÏÍË ÙˆÓ ÓÂÊÚÒÓ ÌÂÙ·ÙÔ›˙ÂÈ ÙÔ˘˜ ÓÂÊÚÔ‡˜ ÌÂÙ¿ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ Î·È ÙˆÓ Ô˘ÚËÙ‹ÚˆÓ ÚfiÛıÈ·, ÒÛÙ ӷ ·ÔÌ·ÎÚ˘ÓıÔ‡Ó ·fi ÙÔ Â›Â‰Ô ‰È·ÙÔÌ‹˜ ÙˆÓ ÈÛÙÒÓ Î·È Ó· ·ÔÊ¢¯ıÔ‡Ó Î·ÎÒÛÂȘ. ∏ ‰È·›ÚÂÛË Ù˘ ·ÔÚÙ‹˜ ÛÙË Ì¤ÛË ÂÍ·ÛÊ·Ï›˙ÂÈ ÒÛÙ fiϘ ÔÈ ·ÚÙËڛ˜ ÂοÛÙÔ˘ ÓÂÊÚÔ‡ Ó· ÏËÊıÔ‡Ó en-bloc Ì·˙› Ì ÙÔ ÙÔ›¯ˆÌ· Ù˘ ·ÔÚÙ‹˜ ·fi ÙÔ ÔÔ›Ô ÂÎʇÔÓÙ·È ÔÈ ·ÚÙËڛ˜. ∫·Ù¿ ÙËÓ ÚÔÛÂÎÙÈ΋ ·Ú·Û΢‹ ÙÔ˘ ÔÚÁ¿ÓÔ˘ ÛÙÔÓ ¿ÁÔ (bench work ‹ back table work) ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Ù· ˘ÂÚ¿ÚÈıÌ· ·ÁÁ›· ÙÔ˘ Ì ÂÈ̤ÏÂÈ·. ™ÙÔÓ ˙ÒÓÙ· ‰fiÙË Ô ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi˜ ¤Ï¯Ԙ Ì ·ÁÁÂÈÔÁÚ·Ê›·( ÎÏ·ÛÛÈ΋ ÂÂÌ‚·ÙÈ΋ ÂÓ‰Ô·ÔÚÙÈ΋ ‹ 3D-spiral CT ‹ MRA) ÂÈÙÚ¤ÂÈ Ì ÌÂÁ¿ÏË ·ÎÚ›‚ÂÈ· ÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÂÈÎÔ˘ÚÈÎÒÓ ·ÁÁ›ˆÓ ηıÒ˜ Î·È ÙËÓ ÔÛÔÛÙÈ·›· ·ÈÌ¿ÙˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ·fi οı ·ÁÁÂ›Ô ¯ˆÚÈÛÙ¿. Δ· Â˘Ú‹Ì·Ù· Ù˘ ·ÁÁÂÈÔÁÚ·Ê›·˜ ¤¯Ô˘Ó η-

™Â ÔÛÔÛÙfi 23% ÙÔ˘ ÏËı˘ÛÌÔ‡ ·Ú·ÙËÚÔ‡ÓÙ·È ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ ÂÙÂÚfiÏ¢ڷ, ÂÓÒ ·ÌÊÔÙÂÚfiÏ¢ڷ Û ÔÛÔÛÙfi 10%.

OÈ ÂÈÎÔ˘ÚÈΤ˜ ·ÚÙËڛ˜ Â›Ó·È Û˘¯ÓfiÙÂÚ˜ ·ÚÈÛÙÂÚ¿ Î·È Û˘Ó‹ıˆ˜ ÂÈÛ¤Ú¯ÔÓÙ·È Â›Ù ÛÙÔÓ ¿Óˆ (¿Óˆ ÔÏÈ΋ ·ÚÙËÚ›·), ›Ù ÛÙÔÓ Î¿Ùˆ fiÏÔ (οو ÔÏÈ΋ ·ÚÙËÚ›·) ÙÔ˘ ÓÂÊÚÔ‡. OÈ ÂÈÎÔ˘ÚÈΤ˜ ·ÚÙËڛ˜ ÌÔÚ› Ó· ¤¯Ô˘Ó “·ÓÒÌ·ÏË” ÔÚ›· ¤ÌÚÔÛıÂÓ Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜, ·˘Í¿ÓÔÓÙ·˜ ÙËÓ Èı·ÓfiÙËÙ· οΈÛ˘ ηٿ ÙË Ï‹„Ë ÙˆÓ ÓÂÊÚÒÓ. ∏ Û˘¯ÓfiÙËÙ· ‡·Ú͢ Î·È ‰Â‡ÙÂÚ˘ ÚfiÛıÂÙ˘ ·ÚÙËÚ›·˜ Â›Ó·È Û¯Â‰fiÓ ›‰È· ‰ÂÍÈ¿ (4,7%) Î·È ·ÚÈÛÙÂÚ¿ (4,4%). Δ· Ì‹ÎË(cm) Î·È ÔÈ ‰È¿ÌÂÙÚÔÈ (cm) Ù˘ ÚÒÙ˘ Î·È ‰Â‡ÙÂÚ˘ ÂÈÎÔ˘ÚÈ΋˜ ·ÚÙËÚ›·˜ ¤¯Ô˘Ó ˘ÔÏÔÁÈÛÙ› 4.5, 0.4 Î·È 3.8, 0.3 (‰ÂÍÈ¿) Î·È 4.9, 0.3 Î·È 3.7 Î·È 0.3 (·ÚÈÛÙÂÚ¿), ·ÓÙ›ÛÙÔȯ·1. OÈ ÎÏ¿‰ÔÈ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ Â›Ó·È ÙÂÏÈÎÔ›.

¡ÂÊÚÈ΋ ÊϤ‚· OÈ ·Ó·ÙÔÌÈΤ˜ ·Ú·ÏÏ·Á¤˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ÊÏ‚ÒÓ Â›Ó·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¤˜ ·fi ·˘Ù¤˜ ÙˆÓ ·ÚÙËÚÈÒÓ. ÀÂÚ¿ÚÈı̘ ÓÂÊÚÈΤ˜ ÊϤ‚˜ ·Ú·ÙËÚÔ‡ÓÙ·È Û˘¯ÓfiÙÂÚ· ÛÙÔ ‰ÂÍÈfi ÓÂÊÚfi (¤ˆ˜ Î·È 28%), ÂÓÒ Û¿ÓȘ ·Ó·ÙÔÌÈΤ˜ ·Ú·ÏÏ·Á¤˜ (.¯. ÊϤ‚· Ì ÔÈÛıÔ·ÔÚÙÈ΋ ÔÚ›· ‹ Ì ΢ÎÏÔÙÂÚ‹ ¤ÚÈÍ Ù˘ ·ÔÚÙ‹˜ ÔÚ›·, ‰›ÎËÓ ÎÔÏÏ¿ÚÔ˘) ·Ú·ÙËÚÔ‡ÓÙ·È Û˘¯ÓfiÙÂÚ· ÛÙÔÓ ·ÚÈÛÙÂÚfi ÓÂÊÚfi.

OÈ ÓÂÊÚÈΤ˜ ÊϤ‚·˜ ÂÈÎÔÈÓˆÓÔ‡Ó Ì¤Ûˆ ·Ú¿Ï¢Ú˘ ΢ÎÏÔÊÔÚ›·˜ Û Â›Â‰Ô ·ÚÂÁ¯‡Ì·ÙÔ˜.

™‡ÓÙÔÌË ÈÛÙÔÚÈ΋ ·Ó·‰ÚÔÌ‹ OÈ ÚˆÙÔfiÚÔÈ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ Hume Î·È Murray ıˆÚÔ‡Û·Ó ·fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙËÓ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·ÁÁ›ˆÓ ÛÙÔ ˘Ô„‹ÊÈÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·2,3. °È· ÂÚÈÛÛfiÙÂÚÔ ·fi ‰˘Ô ‰ÂηÂٛ˜ ·fi ÙËÓ ÚÒÙË ÂÈÙ˘¯‹ ÎÏÈÓÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÔÈ ÓÂÊÚÔ› Ì ÔÏÏ·Ï¿ ·ÁÁ›· ıˆÚÔ‡ÓÙÔ ·Î·Ù¿ÏÏËÏ· ÌÔۯ‡̷ٷ ηıÒ˜ Ë ÌÂÙ·ÌfiÛ¯Â˘Û‹ ÙÔ˘˜ ›¯Â Û˘Û¯ÂÙÈÛı› Ì ˘„ËÏfi ÔÛÔÛÙfi ·ÁÁÂÈ·ÎÒÓ (ıÚfiÌ‚ˆÛË ·ÚÙËÚ›·˜ Î·È ÌÔۯ‡̷ÙÔ˜, ÛÙ¤ÓˆÛË

50

METAMO™XEY™Eπ™ 2010

ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙÔÓ Û¯Â‰È·ÛÌfi Ù˘ Â¤Ì‚·Û˘ ÛÙÔ ‰fiÙË Î·È ÛÙËÓ ÂÈÏÔÁ‹ ÌÂٷ͇ ‰ÂÍÈÔ‡ Î·È ·ÚÈÛÙÂÚÔ‡ ÓÂÊÚÔ‡ ˆ˜ ÌfiÛ¯Â˘Ì·. ªÂٷ͇ ÓÂÊÚÒÓ Ô˘ ‰È·Ê¤ÚÔ˘Ó ÏÂÈÙÔ˘ÚÁÈο ‹ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·Ó·ÙÔÌÈ΋ ·ıÔÏÔÁ›· (.¯. ·ÛÙÂȘ) ÚÔÙÈÌ¿Ù·È Ó· ·Ú·Ì›ÓÂÈ Ô ÏÂÈÙÔ˘ÚÁÈο Î·È ·Ó·ÙÔÌÈο ·ÚÙÈfiÙÂÚÔ˜ ÓÂÊÚfi˜ ÛÙÔ ‰fiÙË. ªÂٷ͇ ÓÂÊÚÒÓ ¯ˆÚ›˜ ÏÂÈÙÔ˘ÚÁÈ΋ ‹ ÌÔÚÊÔÏÔÁÈ΋ ‰È·ÊÔÚ¿, ÚÔÙÈÌ¿Ù·È Ô ÓÂÊÚfi˜ Ì ̛· ·ÚÙËÚ›· Î·È ÊϤ‚· ‹ Ô ·ÚÈÛÙÂÚfi˜ Â› ·ÚÔ˘Û›·˜ ÔÏÏ·ÏÒÓ ·ÁÁ›ˆÓ ¿Ìʈ, ‰ÈfiÙÈ ÛÙËÓ ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì‹ÎÔ˜ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÊϤ‚·˜ ηıÈÛÙ¿ ¢¯ÂÚ¤ÛÙÂÚË ÙËÓ Â¤Ì‚·ÛË ÛÙÔ Ï‹ÙË. ∂ÈÎÔ˘ÚÈΤ˜ ¿Óˆ ÔÏÈΤ˜ ·ÚÙËڛ˜ Ú¤ÂÈ Ó· ·ÍÈÔÔÈÔ‡ÓÙ·È. ∏ ·Ôϛӈۋ ÙÔ˘˜ fï˜ Â›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙ‹ Â¿Ó ·ÈÌ·ÙÒÓÔ˘Ó ÏÈÁfiÙÂÚÔ ·fi 510% ÙÔ˘ ÓÂÊÚÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜. ∞˘Ùfi ‰È·ÈÛÙÒÓÂÙ·È Î·È Ì ¤Á¯˘ÛË ·Ú·ÈˆÌ¤Ó˘ (1:1000) ¯ÚˆÛÙÈ΋˜ methylene blue ÛÙÔ back table9. ¶ÚfiÛıÂÙ˜ οو ÔÏÈΤ˜ ·ÚÙËڛ˜ ‰ÂÓ Ú¤ÂÈ ÔÙ¤ Ó· ·ÔÏÈÓÒÓÔÓÙ·È ‰ÈfiÙÈ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ·ÈÌ¿ÙˆÛË ÙÔ˘ Ô˘ÚËÙ‹Ú· Î·È ·Ôϛӈۋ ÙÔ˘˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ԢÚËÙËÚÈΤ˜ ÂÈÏÔΤ˜, ·ÎfiÌË Î·È Ó¤ÎÚˆÛ‹ ÙÔ˘. ¢›ÏÏËÌ· ÛÙËÓ ÂÈÏÔÁ‹ ·ÔÙÂÏ› Ë ·ÚÔ˘Û›· ÂÈÎÔ˘ÚÈ΋˜ οو ÔÏÈ΋˜ ·ÚÈÛÙÂÚ¿ Î·È ¿Óˆ ÔÏÈ΋˜ ‰ÂÍÈ¿ ÌÂٷ͇ ÓÂÊÚÒÓ Ì ‰‡Ô ·ÚÙËڛ˜ ¿Ìʈ. ™ÙËÓ ˘ÔıÂÙÈ΋ ·˘Ù‹ ÂÚ›ÙˆÛË, ÙÔ ÌÂÈÔÓ¤ÎÙËÌ· ·ÚÈÛÙÂÚ¿ Â›Ó·È Ô Î›Ó‰˘ÓÔ˜ οΈÛ˘ Ù˘ οو ÔÏÈ΋˜ ηٿ ÙË Ï‹„Ë, ÂÓÒ ‰ÂÍÈ¿, Ë ‚Ú·¯Â›· ÓÂÊÚÈ΋ ÊϤ‚· ·˘Í¿ÓÂÈ ÙËÓ ÂÁ¯ÂÈÚËÙÈ΋ ‰˘ÛÎÔÏ›·. ∞ÚÎÂÙ¿ ΤÓÙÚ·, ·ÎfiÌ· Î·È Û‹ÌÂÚ·, ·ÔʇÁÔ˘Ó Ó· ¯ÚËÛÈÌÔÔÈ‹ÛÔ˘Ó ÓÂÊÚÔ‡˜ Ì ÂÚÈÛÛfiÙÂÚ˜ ·fi ‰‡Ô ·ÚÙËڛ˜.

51

∂ÈÎfiÓ· 1.

ÛÙÔ ·ÔÚÙÈÎfi patch ··ÈÙ› ÂÎÙÔÌ‹ ÙÔ˘ ÂӉȷ̤ÛÔ˘ ÙÌ‹Ì·ÙÔ˜ Î·È Â·Ó·Û˘ÚÚ·Ê‹ ÒÛÙ ӷ ‰ËÌÈÔ˘ÚÁËı› ¤Ó· Ó¤Ô ·ÔÚÙÈÎfi ÌfiÛ¯Â˘Ì· (neo-patch) ÌÈÎÚfiÙÂÚÔ˘ ÌÂÁ¤ıÔ˘˜ (∂ÈÎ. 1c). ∞˘Ùfi Á›ÓÂÙ·È ÛÙÔ back table Ì ÙÔ ÌfiÛ¯Â˘Ì· ÛÙÔ „˘¯Úfi ‰È¿Ï˘Ì· ÒÛÙ ӷ ÌËÓ ÂËÚ·ÛÙ› Ô ¯ÚfiÓÔ˜ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜. ∞ÎÔÏÔ˘ı› ·Ó·ÛÙfïÛË ÙÔ˘ Ó¤Ô˘ patch ÛÙÔ Ï‹ÙË.

3. ∂¿Ó Ë ·fiÛÙ·ÛË Ù˘ ¤ÎÊ˘Û˘ ÂÈÎÔ˘ÚÈ΋˜ ·ÚÙËÚ›·˜ ¯ οو ÔÏÈ΋˜ ·¤¯ÂÈ ÙfiÛÔ ·fi ·˘Ù‹ Ù˘ ·ÚÈ·˜ ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ ÒÛÙÂ Ë ‰ËÌÈÔ˘ÚÁ›· ÓÂÔ-patch ÚÔηÏ› Ù¿ÛË ‹ ÁˆÓ›ˆÛË ÙˆÓ ·ÚÙËÚÈÒÓ, Â›Ó·È ‰˘Ó·Ùfi Ó· ‰È·ÙËÚ‹ÛÔ˘Ì οı ·ÚÙËÚ›· ۠ͯˆÚÈÛÙfi patch Î·È Ó· ·Ó·ÛÙÔÌÒÛÔ˘Ì οı patch ͯˆÚÈÛÙ¿ ÛÙËÓ ¤Íˆ Ï·ÁfiÓÈÔ ·ÚÙËÚ›· ÙÔ˘ ‰fiÙË (EÈÎ. 2).

T¯ÓÈΤ˜ Â·Ó·ÁÁ›ˆÛ˘ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ ∞) ªÔۯ‡̷ٷ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ ™ËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· ÛÙÔ ÓÂÊÚfi ·fi و̷ÙÈÎfi ‰fiÙË ·ÔÙÂÏ› Ë ·ÚÔ˘Û›· ÌÔۯ‡̷ÙÔ˜ ·fi ÙÔ ÙÔ›¯ˆÌ· Ù˘ ·ÔÚÙ‹˜ ÙÔ˘ ‰fiÙË (Carrel patch) Ì fiÏ· Ù· ÛÙfiÌÈ· ¤ÎÊ˘Û˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ Û ·˘Ùfi.

1. H ·Ó·ÛÙfïÛË ÔÏÏ·ÏÒÓ ·ÚÙËÚÈÒÓ و̷ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ô˘ ¤¯Ô˘Ó ÏËÊı› Ì ÎÔÈÓfi ·ÔÚÙÈÎfi patch ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ̛· ÌfiÓÔ ·Ó·ÛÙfïÛË ÙÔ˘ patch ÙÂÏÈÎÔ-Ï¿ÁÈ· ÛÙËÓ ¤Íˆ Ï·ÁfiÓÈÔ ·ÚÙËÚ›· ÙÔ˘ Ï‹ÙË (∂ÈÎ. 1a).

2. ªÂÁ¿ÏË ·fiÛÙ·ÛË (>2.5cm) ÌÂٷ͇ ÙˆÓ ÛÙÔÌ›ˆÓ ¤ÎÊ˘Û˘ ‰‡Ô ‹ ÂÚÈÛÛfiÙÂÚˆÓ ·ÚÙËÚÈÒÓ

∂ÈÎfiÓ· 2.

B) ªÔۯ‡̷ٷ ·fi ˙ÒÓÙ˜ ‰fiÙ˜ OÈ Ù¯ÓÈΤ˜ Â·Ó·ÁÁ›ˆÛ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ ·fi ˙ÒÓÙ· ‰fiÙË ‰È·Ê¤ÚÔ˘Ó ‰ÈfiÙÈ ÛÙÔ ˙ÒÓÙ· ‰fiÙË ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· ¤¯Ô˘Ì Carrel patch. ø˜ ÂÎ ÙÔ‡ÙÔ˘ ÛÙ· ÌÔۯ‡̷ٷ Ì ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ ÔÈ ·Ó·ÛÙÔÌÒÛÂȘ Â›Ó·È ÂÚÈÛÛfiÙÂÚ˜ Î·È Ù¯ÓÈο ÈÔ ··ÈÙËÙ¤˜.

∞. ª¶∞ƒ§∞™

52

μ·) ¶ÂÚÈÛÛfiÙÂÚ˜ Ù˘ Ì›·˜ ·Ó·ÛÙfïÛ˘ ÛÙÔ Ï‹ÙË (in vivo). ∫·Ì›· ÛÙÔ back table 1. ¢È·‰Ô¯ÈΤ˜ ·Ó·ÛÙÔÌÒÛÂȘ ÙˆÓ ÔÏÏ·ÏÒÓ ·ÚÙËÚÈÒÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÙÂÏÈÎÔ-Ï¿ÁÈ· ÛÙË ¤Íˆ Ï·ÁfiÓÈ· ·ÚÙËÚ›· ·ÚÙËÚ›· ÙÔ˘ Ï‹ÙË. £ÂˆÚËÙÈÎfi ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ Ù¯ÓÈ΋˜ ·˘Ù‹˜ Â›Ó·È Ë Èı·Ó‹ ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ Ù¯ÓÈ΋ ·˘Ù‹ ·ÔÙÂÏ› ÙË ÌÔÓ·‰È΋ ÂÈÏÔÁ‹ fiÙ·Ó ÔÈ ·ÚÙËڛ˜ ¤¯Ô˘Ó ‚Ú·¯‡ Ì‹ÎÔ˜ Î·È Û ۯÂÙÈο ÌÂÁ¿ÏË ·fiÛÙ·ÛË ÌÂٷ͇ ÙÔ˘˜. ∞ÔÙÂÏ› ÙÔ gold standard ÁÈ· ÙËÓ Â·Ó·ÁÁ›ˆÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ˙ÒÓÙ· ‰fiÙË Ì ÔÏÏ·Ï¿ ·ÁÁ›· ·fi ÙÔ˘˜ V. Papalois Î·È N. Hakim ÛÙÔ West London Transplant Center ÛÙÔ Hammersmith Hospital (ÚÔÛˆÈ΋ ÂÌÂÈÚ›·). ∏ Û˘Ó¯‹˜ Ú‹„Ë „˘¯ÚÔ‡ ‰È·Ï‡Ì·ÙÔ˜ ‰È·Ù‹ÚËÛ˘ ÙˆÓ ÔÚÁ¿ÓˆÓ ÛÙÔ ÌfiÛ¯Â˘Ì· ÌÂÈÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ·‡ÍËÛ˘ Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÙÔ˘ (EÈÎ. 3).

2. ¢È·‰Ô¯ÈΤ˜ ·Ó·ÛÙÔÌÒÛÂȘ οı ·ÚÙËÚÈ·ÎÔ‡

∂ÈÎfiÓ· 3.

ÎÏ¿‰Ô˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ̠ͯˆÚÈÛÙfi ÎÏ¿‰Ô Ù˘ ¤Ûˆ Ï·ÁÔÓ›Ô˘ ÙÂÏÈÎÔ-ÙÂÏÈο (΢ڛˆ˜ Ù˘ ¿Óˆ ΢ÛÙÈ΋˜ Î·È Ù˘ ·È‰ÔÈ˚΋˜) (∂ÈÎ. 4). ∏ Ù¯ÓÈ΋ ·˘Ù‹ ‰ÂÓ Â›Ó·È ÂÊÈÎÙ‹ Û ‰È·‚ËÙÈÎÔ‡˜ Î·È Û ϋÙ˜ ÌÂÁ¿Ï˘ ËÏÈΛ·˜ Ì ¤ÓÙÔÓË ·ıËڈ̷ÙÈ΋ ÓfiÛÔ ÛÙÔ˘˜ ÂÚÈÊÂÚÈÎÔ‡˜ ÎÏ¿‰Ô˘˜ Ù˘ ¤Ûˆ Ï·ÁÔÓ›Ô˘.

∂ÈÎfiÓ· 4.

3. ÃÚËÛÈÌÔÔ›ËÛË ÙfiÛÔ Ù˘ ¤Íˆ, fiÛÔ Î·È Ù˘ ¤Ûˆ Ï·ÁÔÓ›Ô˘ ·ÚÙËÚ›·˜ ÙÔ˘ Ï‹ÙË ÁÈ· ÙËÓ ·Ó·ÛÙfïÛË Î¿ı ·ÚÙËÚ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (∂ÈÎ. 5). ∞Ó·ÛÙÔÌÒÓÂÙ·È Û˘Ó‹ıˆ˜ Ë Î‡ÚÈ· ·ÚÙËÚ›·, ÌÂÁ·Ï‡ÙÂÚ˘ ‰È·Ì¤ÙÚÔ˘ ÙÂÏÈÎÔ-ÙÂÏÈο ÛÙËÓ ¤Ûˆ Ï·ÁfiÓÈÔ Î·È Ë/ÔÈ ÌÈÎÚfiÙÂÚË/˜ ÙÂÏÈÎÔ-Ï¿ÁÈ· ÛÙËÓ ¤Íˆ Ï·ÁfiÓÈÔ ÙÔ˘ Ï‹ÙË.

∂ÈÎfiÓ· 5.

4. ÃÚËÛÈÌÔÔ›ËÛË Ù˘ ÂÓ Ùˆ ‚¿ıÂÈ Î¿Ùˆ ÂÈÁ·ÛÙÚ›Ô˘ ·ÚÙËÚ›·˜ ÙÔ˘ Ï‹ÙË ÁÈ· ÙËÓ ÙÂÏÈÎÔ-ÙÂÏÈ΋ ·Ó·ÛÙfïÛË ÚfiÛıÂÙ˘ ·ÚÙËÚ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (Û˘ÓËı¤ÛÙÂÚ· οو ÔÏÈ΋˜ Î·È Û·Ó›ˆ˜ ¿Óˆ ÔÏÈ΋˜) (∂ÈÎ. 6).H ·Ó·ÛÙfïÛË Á›ÓÂÙ·È ÙÂÏÈÎÔÙÂÏÈο Ì ÌÂÌÔӈ̤ӷ Ú¿ÌÌ·Ù· 7-0 Polypropylene Î·È fi¯È Û˘Ó¯ԇ˜ Ú·Ê‹˜ ÚÔ˜ ·ÔÊ˘Á‹ ÛÙ¤ÓˆÛ˘ Ù˘ ·Ó·ÛÙÔ̈ÙÈ΋˜ ÁÚ·ÌÌ‹˜ (pursestring effect). ∂›Ó·È ‰˘Ó·Ù‹ Ë Â·Ó·ÁÁ›ˆÛË ÙÔ˘ ÓÂÊÚÔ‡ ‰È· Ù˘ ·ÚÈ·˜ ·ÚÙËÚ›·˜-¤Ûˆ Ï·ÁÔÓ›Ô˘ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ·Ó·ÛÙfïÛ˘ ·˘Ù‹˜ Î·È ·ÎÔÏÔ‡ıˆ˜ Ó· Ú·ÁÌ·ÙÔÔÈËı› Ë ·Ó·ÛÙfïÛË Ù˘ ÂÈÎÔ˘ÚÈ΋˜ ·ÚÙËÚ›·˜ ÛÙËÓ ¤Íˆ Ï·ÁfiÓÈÔ Ì ÛÙfi¯Ô ÙË ‰È·Ù‹ÚËÛË ÌÈÎÚÔ‡ ¯ÚfiÓÔ˘ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜10.

∂ÈÎfiÓ· 6.

METAMO™XEY™Eπ™ 2010

53

B‚) ∞Ó·ÛÙÔÌÒÛÂȘ ÔÏÏ·ÏÒÓ ·ÚÙËÚÈÒÓ ÌÂٷ͇ ÙÔ˘˜ ÛÙÔ back table Î·È ·ÎÔÏÔ‡ıˆ˜ Ì›· ·Ó·ÛÙfïÛË ÛÙÔ Ï‹ÙË ¶·Ú¿ ÙËÓ ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Ì ·˘Ù¤˜ ÙȘ ÌÂıfi‰Ô˘˜, ηı›ÛÙ·Ù·È Ù¯ÓÈο ¢ÎÔÏfiÙÂÚË Ë ÙÔÔı¤ÙËÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙÔÓ Ï‹ÙË Ì ¤ÓÙÔÓË ·ıËڈ̿وÛË ÙˆÓ Ï·ÁÔÓ›ˆÓ ·ÁÁ›ˆÓ,Ô˘ ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙË ‰ËÌÈÔ˘ÚÁ›· ÔÏÏ·ÏÒÓ ·Ó·ÛÙÔÌÒÛˆÓ.

1. ∂ÈÌ‹Î˘ ‰È·ÙÔÌ‹ οı ·ÚÙËÚ›·˜ Î·È Ï·ÁÈÔ-Ï·Á›· ·Ó·ÛÙfïۋ ÌÂٷ͇ ÙÔ˘˜ ÌÂ Û˘Ó¯‹ Ú·Ê‹ Ì 7-0 ‹ 8-0 Ú¿ÌÌ· Polypropelene Ì ‰ËÌÈÔ˘ÚÁ›· ÂÓfi˜ Â˘Ú¤Ô˜ ·˘ÏÔ‡ Î·È ÂÓfi˜ Â˘Ú¤Ô˜ ÛÙÔÌ›Ô˘ (∂ÈÎ. 1b) ÙÔ ÔÔ›Ô ·Ó·ÛÙÔÌÒÓÂÙ·È Â›Ù ÙÂÏÈÎÔ-ÙÂÏÈο ÛÙËÓ ¤Ûˆ Ï·ÁfiÓÈ· ·ÚÙËÚ›· ÙÔ˘ Ï‹ÙË, ›Ù ÙÂÏÈÎÔ-Ï¿ÁÈ· ÛÙËÓ ¤Íˆ Ï·ÁfiÓÈ· ·ÚÙËÚ›· ÙÔ˘ Ï‹ÙË (∂ÈÎ. 7). ∞˘Ù‹ Ë Ù¯ÓÈ΋ ÂÚÈÁÚ¿ÊÂÙ·È ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ˆ˜ “double-barrel” ‹ “syndactylization”. OÈ Aulakh Î·È Û˘Ó ·Ó·ÛÙfiÌˆÛ·Ó ÙÚÂȘ ·ÚÙËڛ˜ Û ̛· ηÙ` ·˘Ùfi ÙÔÓ ÙÚfiÔ Î·È ÙËÓ ÔÓfiÌ·Û·Ó “three-legged pair of pants”.

H Ù¯ÓÈ΋ ·˘Ù‹ Â›Ó·È Ì›· ·fi ÙȘ Û˘¯ÓfiÙÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜. ∂›Ó·È ȉ·ÓÈ΋ fiÙ·Ó ÔÈ ·ÚÙËڛ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¤¯Ô˘Ó ·ÚfiÌÔÈÔ Ì‹ÎÔ˜ Î·È ‰È¿ÌÂÙÚÔ, ·Ú¿ÏÏËÏË ÔÚ›· Î·È ‚Ú›ÛÎÔÓÙ·È Û ÁÂÈÙÓ›·ÛË.

∂ÈÎfiÓ· 8.

∂ÈÎfiÓ· 9.

∂ÈÎfiÓ· 7.

2. ∂Ó·ÏÏ·ÎÙÈο Ù˘ ÚÔËÁÔ‡ÌÂÓ˘, ¤¯ÂÈ ÂÚÈÁÚ·Ê› Ë Ù¯ÓÈ΋ Ù˘ ·Ï‹˜ Ï·ÁÈÔ-Ï·Á›·˜ ·Ó·ÛÙfïÛ˘ ‰‡Ô ·ÚÙËÚÈÒÓ, Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ ¤Ó· ÙÚ›ÙÔ Ù˘ ÂÚÈ̤ÙÚÔ˘ ÙÔ˘ ÛÙÔÌ›Ô˘ οı ·ÚÙËÚ›·˜. ΔÔ ÎÔÈÓfi ÛÙfiÌÈÔ ·Ó·ÛÙÔÌÒÓÂÙ·È ÙÂÏÈÎÔ-Ï¿ÁÈ· ÛÙËÓ ¤Íˆ Ï·ÁfiÓÈÔ ·ÚÙËÚ›· ÙÔ˘ Ï‹ÙË (∂ÈÎ. 8).

3. ΔÂÏÈÎÔ-Ï·Á›· ·Ó·ÛÙfïÛË ÌÈ·˜ ·ÚÙËÚ›·˜ ÛÙËÓ ¿ÏÏË Ì ڿÌÌ· 7-0 ‹ 8-0 Polypropylene Î·È ·ÎÔÏÔ‡ıˆ˜ ‰ËÌÈÔ˘ÚÁ›· Ì›·˜ ·Ó·ÛÙfïÛ˘ ÛÙÔ Ï‹-

∂ÈÎfiÓ· 10.

ÙË, ›Ù ÛÙËÓ ¤Ûˆ (∂ÈÎ. 9), ›Ù ÛÙËÓ ¤Íˆ Ï·ÁfiÓÈÔ ·ÚÙËÚ›· (∂ÈÎ. 10). ∂Ӊ›ÎÓ˘Ù·È fiÙ·Ó Ì›· ÂÈÎÔ˘ÚÈ΋ ·ÚÙËÚ›· Â›Ó·È ‚Ú·¯‡ÙÂÚË ‹/Î·È ÌÈÎÚfiÙÂÚ˘ ‰È·Ì¤ÙÚÔ˘ Ù˘ ·ÚÈ·˜ ·ÚÙËÚ›·˜.

∞. ª¶∞ƒ§∞™

54 ªÔۯ‡̷ٷ Ì ÔÏÏ·Ϥ˜ ÊϤ‚˜

Ÿˆ˜ ÚԷӷʤÚıËÎÂ Ë ‡·ÚÍË ÔÏÏ·ÏÒÓ ÊÏ‚ÒÓ Â›Ó·È Û¿ÓÈ·. §fiÁˆ ÂÓ‰Ô-ÂÈÎÔÈÓˆÓ›·˜ Â›Ó·È ·ÛÊ·Ï‹˜ Ë ·ÔϛӈÛË Ù˘ ÌÈÎÚfiÙÂÚ˘ Û ‰È¿ÌÂÙÚÔ ÊϤ‚· Î·È Ë ·Ó·ÛÙfïÛË Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ÛÙÔ Ï‹ÙË. ™ÙÔÓ و̷ÙÈÎfi ÓÂÊÚfi Ë Ï‹„Ë ÙˆÓ ÊÏ‚ÒÓ Û ÎÔÈÓfi patch ·fi ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚· ÙÔ˘ ‰fiÙË ·ÏÔ˘ÛÙ‡ÂÈ ÙËÓ ÙÔÔı¤ÙËÛ‹ ÙÔ˘ ÛÙÔ Ï‹ÙË. ∂¿Ó ‰ÂÓ ¤¯ÂÈ ÏËÊı› patch ÔÈ ‰‡Ô ÌÂÁ·Ï‡ÙÂÚ˜ Û ‰È¿ÌÂÙÚÔ ÊϤ‚˜ ÌÔÚÔ‡Ó Ó· ·Ó·ÛÙÔ̈ıÔ‡Ó Ì ¤Ó· ·Ó¿ÛÙÚÔÊÔ “À” ÌfiÛ¯Â˘Ì· ·fi ÙËÓ ÎÔÈÓ‹ Î·È ÙÔ ‰È¯·ÛÌfi Ù˘ Û ¤Ûˆ Î·È ¤Íˆ Ï·ÁfiÓÈÔ ÊϤ‚· ÙÔ˘ ‰fiÙË ÛÙÔ back table, ÒÛÙ ӷ ¯ÚÂÈ·ÛÙ› ÌfiÓÔ Ì›· ·Ó·ÛÙfïÛË ÛÙÔ Ï‹ÙË (∂ÈÎ. 11). ÀÂÚ¿-

∂ÈÎfiÓ· 11.

ÚÈıÌÔ˜ ÎÏ¿‰Ô˜ ÌÔÚ› Ó· ·ÔÏÈÓˆı› ¯ˆÚ›˜ ÂÈÙÒÛÂȘ. ™ÙÔÓ ÓÂÊÚfi ·fi ˙ÒÓÙ· ‰fiÙË ··ÈÙÂ›Ù·È Í¯ˆÚÈÛÙ‹ ·Ó·ÛÙfïÛË Î¿ı ÊϤ‚·˜ ÛÙÔ Ï‹ÙË.

ªÔۯ‡̷ٷ Ì ÔÏÏ·Ï¿ ·ÁÁ›· Î·È Î¿ÎˆÛË Î·Ù¿ ÙË Ï‹„Ë ∏ Û˘¯Ó‹ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·ÁÁ›ˆÓ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (>20%) ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· È·ÙÚÔÁÂÓÔ‡˜ ·ÁÁÂȷ΋˜ οΈÛ˘. O ΛӉ˘ÓÔ˜ οΈÛ˘ ·˘Í¿ÓÂÙ·È ÂÚ·ÈÙ¤Úˆ fiÙ·Ó Ô ¯ÂÈÚÔ˘ÚÁfi˜ ηٿ ÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË ÛÙÔÓ ‰fiÙË Û‡‰ÂÈ ‰ÈfiÙÈ Ô ‰fiÙ˘ Â›Ó·È ‹ ηı›ÛÙ·Ù·È ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı‹˜ Î·È fiÙ·Ó Ô ¯ÂÈÚÔ˘ÚÁfi˜ ÙÔ˘ ‰fiÙË ÛÙÂÚÂ›Ù·È ÂÌÂÈÚ›·˜11. ∞Ï‹ Û˘ÚÚ·Ê‹ ÛÙËÓ ÂÚ›ÙˆÛË ‰È·ÙÔÌ‹˜ Î·È ‰È·ÎÔ‹˜ Ù˘ Û˘Ó¤¯ÂÈ·˜ ÙÔ˘ ·ÁÁ›Ԣ ÌÔÚ› Ó· Â›Ó·È Â·Ú΋˜,ÂÓÒ ·ÒÏÂÈ· ÙÌ‹Ì·ÙÔ˜ ·ÁÁ›Ԣ ‰˘Ó·ÙfiÓ Ó· ·ÔηٷÛÙ·ı› Ì “Á¤Ê˘Ú·” ·ÁÁÂÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ Û·ÊËÓ‹˜ ÊϤ‚·, Ë ÂÓ Ùˆ ‚¿ıÂÈ

οو ÂÈÁ·ÛÙÚÈ΋ ·ÚÙËÚ›· Î·È ÊϤ‚·, Ë ÁÔÓ·‰È΋ ÊϤ‚·, Ë ÂÙÂÚfiÏ¢ÚË ÂÈÔÏ‹˜ ÌËÚÈ·›· ÊϤ‚· ÙÔ˘ Ï‹ÙË Î·ıÒ˜ Î·È Û˘ÓıÂÙÈο ÌÔۯ‡̷ٷ PTFE ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ·ÁÁÂȷο ÌÔۯ‡̷ٷ Ì ηϿ ·ÔÙÂϤÛÌ·Ù·12. ∂Âȉ‹ Ë Î¿ÎˆÛË ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ و̷ÙÈÎÔ‡ ‰fiÙË Ô˘ Á›ÓÂÙ·È Î·Ù¿ ÙË Ï‹„Ë ‰È·ÈÛÙÒÓÂÙ·È Û˘Ó‹ıˆ˜ ηٿ ÙËÓ ·Ú·Û΢‹ ÙˆÓ ÔÚÁ¿ÓˆÓ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ÙÔ˘ Ï‹ÙË Î·È Û˘Ó‹ıˆ˜ ·¤¯Ô˘Ó ‰Âο‰Â˜ ¯ÈÏÈfiÌÂÙÚ· ÌÂٷ͇ ÙÔ˘˜, Â›Ó·È ÂȂ‚ÏË̤ÓË Ë “ÚÔÊ˘Ï·ÎÙÈ΋” Ï‹„Ë ·ÁÁÂÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÙÔ ‰fiÙË (.¯. ÙÌ‹Ì· ÙˆÓ Ï·ÁÔÓ›ˆÓ ·ÁÁ›ˆÓ) ÛÂ Û˘ÛÙËÌ·ÙÈ΋ ‚¿ÛË.

∞ÔÙÂϤÛÌ·Ù· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÒÓ Ì ÔÏÏ·Ï¿ ·ÁÁ›· ·fi و̷ÙÈÎÔ‡˜ Î·È ˙ÒÓÙ˜ ‰fiÙ˜ ÛÙËÓ ÂÔ¯‹ ÚÈÓ ÙË ÂÈÛ·ÁˆÁ‹ Ù˘ Ï··ÚÔÛÎÔÈ΋˜ ÓÂÊÚÂÎÙÔÌ‹˜ ‰fiÙË ∫·Ï‹ ·Ó¿Ï˘ÛË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÌÔÛ¯Â˘Ì¿ÙˆÓ (n=998) Î·È ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û‹˜ ÙÔ˘˜ (1985-1993) ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ University of Minnesota ÛÙË Minneapolis USA. OÈ Matas, Najarian Î·È Û˘Ó ‰ÂÓ ‚Ú‹Î·Ó ‰È·ÊÔÚ¿ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ˆ˜ ÚÔ˜ ÙȘ ÙÈ̤˜ ÎÚ·ÙÈÓ›Ó˘, ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ Ï‹ÙË Î·È ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (∂ÈÎ. 12), ÙȘ Ô˘ÚËÙËÚÈΤ˜ ÂÈÏÔΤ˜ Î·È ÙȘ ¿ÌÂÛ˜ ·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜ ÌÂٷ͇ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ̛· ·ÚÙËÚ›· (n=835), ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ ·ÏÏ¿ Ì›· ·Ó·ÛÙfïÛË ÛÙÔ Ï‹ÙË (n=112) Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ Î·È ÂÚÈÛÛfiÙÂÚ˜ Ù˘ Ì›·˜ ·Ó·ÛÙfïÛ˘ ÛÙÔ Ï‹ÙË (n=51) (∂ÈÎ. 12). ∏ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·ÚÙËÚÈÒÓ ‹Ù·Ó ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·ÒÙÂÚË ÛÙ¤ÓˆÛË Ù˘ ·ÚÙËÚ›·˜ ΢ڛˆ˜ ÛÙ· ÌÔۯ‡̷ٷ Ì ·Ú·ÙÂٷ̤ÓÔ ¯ÚfiÓÔ Û˘ÓÙ‹ÚËÛ˘13.

∞ÔÙÂϤÛÌ·Ù· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÒÓ Ì ÔÏÏ·Ï¿ ·ÁÁ›· ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ Ù˘ Ï··ÚÔÛÎÔÈ΋˜ ÓÂÊÚÂÎÙÔÌ‹˜ ‰fiÙË ∏ Ï··ÚÔÛÎÔÈ΋ ÓÂÊÚÂÎÙÔÌ‹ ‰fiÙË ÂÈÛ‹¯ıË ÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔ˘˜ Ratner Î·È Kavoussi ÛÙÔ John Hopkins ÛÙË μ·ÏÙÈÌfiÚË USA ÙÔ 1995, ·ÊÔÚÔ‡Û Û ·ÚÈÛÙÂÚfi ÓÂÊÚfi. ™Ù·‰È·Î¿ ˘ÈÔıÂÙ‹ıËΠ·fi ÂÚÈÛÛfiÙÂÚÔ ·fi 100 ÌÂÁ¿Ï· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Û ·ÁÎfiÛÌÈÔ Â›‰Ô, ÒÛÙ ۋÌÂÚ· Ó· ·ÔÙÂÏ› ÙË Ì¤ıÔ‰Ô ÂÎÏÔÁ‹˜ ÁÈ· ÙË ÓÂÊÚÂÎÙÔÌ‹ ÛÙÔ ˙ÒÓÙ· ‰fiÙË ‰Â‰Ô̤ÓÔ˘ fiÙÈ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÌÈÎÚfiÙÂÚÔ ¯ÚfiÓÔ ÓÔÛËÏ›·˜, ÏÈÁfiÙÂÚÔ ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi ¿ÏÁÔ˜, ·ÓÒÙÂÚÔ ÎÔÛÌËÙÈÎfi

METAMO™XEY™Eπ™ 2010

55

∂ÈÎfiÓ· 12.

·ÔÙ¤ÏÂÛÌ·, Ù·¯‡ÙÂÚË ÂÈÛÙÚÔÊ‹ ÛÙËÓ ÂÚÁ·Û›· Î·È ÁÂÓÈο ÌÂÁ·Ï‡ÙÂÚË ÈηÓÔÔ›ËÛË ÙÔ˘ ‰fiÙË Û ۯ¤ÛË Ì ÙËÓ ·ÓÔȯً. §fiÁˆ Ù¯ÓÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ë Ï··ÚÔÛÎÔÈ΋ ·Ê·›ÚÂÛË ‰ÂÍÈÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û˘Û¯ÂÙ›ÛÙËΠ̠˘„ËÏfi ÔÛÔÛÙfi ÊÏ‚È΋˜ ıÚfiÌ‚ˆÛ˘ Î·È ·ÒÏÂÈ·˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·˘ÙÒÓ. ∞˘Ùfi ›¯Â ˆ˜ Û˘Ó¤ÂÈ· fi¯È ÌfiÓÔ ÛÙÔ John Hopkins ·ÏÏ¿ Î·È ·ÚÎÂÙ¿ ¿ÏÏ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Ó· ·ÔÙÂÏ› Ô ·ÚÈÛÙÂÚfi˜ ÓÂÊÚfi˜ ÙÔ ÌfiÛ¯Â˘Ì· ÂÎÏÔÁ‹˜ ·Ú¿ ÙËÓ ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÔÏÏ·ÏÒÓ ·ÚÙËÚÈÒÓ Û ۯ¤ÛË Ì ÙÔÓ ‰ÂÍÈfi. ¶·Ú·ÙËÚ‹ÛÂȘ ‰Â Ô˘ Û˘ÓËÁÔÚÔ‡Û·Ó ˘¤Ú Ù˘ ·‡ÍËÛ˘ Ù˘ ÚÔÛÊÔÚ¿˜ ÔÚÁ¿ÓˆÓ ·fi ˙ÒÓÙ˜ ‰fiÙ˜ ¯¿ÚË ÛÙËÓ ÚfiÔ‰Ô Ù˘ Ï··ÚÔÛÎÔÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÔÌ¿ÎÚ˘Ó·Ó ÙÔ˘˜ ¯ÂÈÚÔ˘ÚÁÔ‡˜ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi ÙËÓ ·Ú·‰ÔÛȷ΋ ·ÓÔȯً ÓÂÊÚÂÎÙÔÌ‹ ÙÔ˘ ‰fiÙË.

OÈ Ratner Î·È Û˘Ó ‰ËÏÒÓÔ˘Ó ¯·Ú·ÎÙËÚÈÛÙÈο: “… multiple left renal arteries are less problematic than a right kidney”14.

OÈ Ratner Î·È Û˘Ó ÌÂϤÙËÛ·Ó ·Ó·‰ÚÔÌÈο Ù· ·ÔÙÂϤÛÌ·Ù· ÌÂÙ·ÌfiÛ¯Â˘Û˘ 353 ·ÚÈÛÙÂÚÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ÂÏ‹ÊıËÛ·Ó Ï··ÚÔÛÎÔÈο ÛÙÔ John Hopkins ÌÂٷ͇ 1995-2001. ∞fi ·˘Ù¿ 277 (78,5%)ÌÔۯ‡̷ٷ ›¯·Ó Ì›· ·ÚÙËÚ›·, 71 (20,1%) ‰‡Ô ·ÚÙËڛ˜ Î·È 5 (1,4%) 3 ·ÚÙËڛ˜. ™ÙÔ˘˜ ‰fiÙ˜ Ì ÂÚÈÛÛfiÙÂÚ˜ Ù˘ Ì›·˜ ·ÚÙËڛ˜ Ô ÂÁ¯ÂÈÚËÙÈÎfi˜ ¯ÚfiÓÔ˜ Î·È Ô ¯ÚfiÓÔ˜ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó ·˘ÍË̤ÓÔ˜ ·ÏÏ¿ Ë ‰È·ÊÔÚ¤˜ ‰ÂÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜. ∏ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·ÒÏÂÈ· ·›Ì·ÙÔ˜, ÔÈ ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜ Î·È Ô ¯ÚfiÓÔ˜ ÓÔÛËÏ›·˜ ÙÔ˘ ‰fiÙË ‰ÂÓ ÂËÚ¿ÛÙËΠÛËÌ·ÓÙÈο ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ Ï‹Ù˜, ÔÈ ÌÂÙ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜, ÔÈ ÙÈ̤˜ οı·ÚÛ˘ ÎÚ·ÙÈÓ›Ó˘ ÙËÓ 1Ë,2Ë Î·È 3Ë Ë̤ڷ ÌÂÙ¿ ÙËÓ ÌÂ-

Ù·ÌfiÛ¯Â˘ÛË Î·ıÒ˜ Î·È 3,6 Î·È 12 Ì‹Ó˜ ÌÂÙ¿, ‰ÂÓ ÂËÚ¿ÛÙËÎ·Ó Û ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ‚·ıÌfi ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ15. OÈ Î˘ÚÈfiÙÂÚ˜ ̤ıÔ‰ÔÈ ¯ÂÈÚÈÛÌÔ‡ ÙˆÓ ÔÏÏ·ÏÒÓ ·ÚÙËÚÈÒÓ ‹Ù·Ó Ë ÙÂÏÈÎÔ-Ï·Á›· ·Ó·ÛÙfïÛË Ù˘ ÂÈÎÔ˘ÚÈ΋˜ ·ÚÙËÚ›·˜ ÛÙËÓ Î‡ÚÈ· ÓÂÊÚÈ΋ ·ÚÙËÚ›· Î·È Ë Ï·ÁÈÔ-Ï·Á›· ·Ó·ÛÙfïÛË ÙˆÓ ·ÚÙËÚÈÒÓ ÌÂٷ͇ ÙÔ˘˜ ÛÙÔ back table. ∞ÎÔÏÔ˘ıÔ‡Û ̛· ·ÚÙËÚȷ΋ ·Ó·ÛÙfïÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙÔ Ï‹ÙË. ªË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ ÌÔÓÔÂÙ‹ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ú·ÙËÚ‹ıËΠ·fi ÙÔ˘˜ Kuo Î·È Û˘Ó ÛÙÔ Georgetown University Medical Center, Washington DC Â› 124 ·ÚÈÛÙÂÚÒÓ ÓÂÊÚÒÓ Ô˘ Ï‹ÊıËÛ·Ó Ï··ÚÔÛÎÔÈο. ∞fi ·˘ÙÔ‡˜ 83 ÌÔۯ‡̷ٷ ›¯·Ó Ì›· ·ÚÙËÚ›·, 33 ‰‡Ô Î·È 8 ÙÚÂȘ ·ÚÙËڛ˜. ∏ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ‹Ù·Ó 96,1%, 90,9% Î·È 90,0% ·ÓÙ›ÛÙÔȯ·16. ™Â ÌÂÁ¿ÏË ÛÂÈÚ¿ ·fi ÙÔ ªassachussets General Hospital ÛÙË μÔÛÙÒÓË Ì 350 ÌÔۯ‡̷ٷ ·fi ˙ÒÓÙ˜ ‰fiÙ˜ (ÂÚ›Ô‰Ô˜ 2000-2007), 319 (91,1%), ›¯·Ó Ì›· ·ÚÙËÚ›· Î·È 31 (8,9%) ›¯·Ó ÂÚÈÛÛfiÙÂÚ˜ Ù˘ Ì›·˜ ·ÚÙËÚ›·˜ (21 ›¯·Ó ‰‡Ô, 6 ÙÚÂȘ Î·È 4 Ù¤ÛÛÂÚȘ ·ÚÙËڛ˜). ∞fi Ù· ÌÔۯ‡̷ٷ Ì ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ ‰¤Î· ›¯·Ó ÏËÊı› ·ÓÔȯٿ Î·È ¤ÓÙÂη Ï··ÚÔÛÎÔÈο. ∏ ÌÔÓÔÂÙ‹˜ Î·È ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‹Ù·Ó Û˘ÁÎÚ›ÛÈÌË Ì·͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ (98,4% Î·È 91,5% ÛÙËÓ ÔÌ¿‰· Ì ̛· ·ÚÙËÚ›· Î·È 96,8% Î·È 87,1% ÛÙËÓ ÔÌ¿‰· Ì ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ ·ÓÙ›ÛÙÔȯ·). ™˘¯ÓfiÙÂÚË Ì¤ıÔ‰Ô˜ Â·Ó·ÁÁ›ˆÛ˘ ÛÙÔ ˘ÏÈÎfi ·˘Ùfi ‹Ù·Ó Ë ‰ËÌÈÔ˘ÚÁ›· Ì›·˜ ·ÚÙËÚ›·˜ Ì ÙËÓ Ù¯ÓÈ΋ “Double-barrel” (71%). ∞ÎÔÏÔ˘ı› Ë Ù¯ÓÈ΋ Ù˘ ex vivo ÙÂÏÈÎÔ-Ï·Á›·˜ ·Ó·ÛÙfïÛ˘ Ù˘ ÂÈÎÔ˘ÚÈ΋˜ ÛÙËÓ Î‡ÚÈ· ·ÚÙËÚ›·17.

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∞. ª¶∞ƒ§∞™

OÈ Carter J, Posselt Î·È Û˘Ó. (San Francisco, California, USA) ·Ó·Ï‡ÔÓÙ·˜ 361 ÌÔۯ‡̷ٷ (49 Ì ÂÚÈÛÛfiÙÂÚ˜ Ù˘ Ì›·˜ ·ÚÙËڛ˜) Ô˘ ¤¯Ô˘Ó ÏËÊı› Ï··ÚÔÛÎÔÈο ÌÂٷ͇ 1999 Î·È 2003, ηٷϋÁÔ˘Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë Ï··ÚÔÛÎÔÈ΋ Ï‹„Ë ÓÂÊÚÒÓ Ì ÔÏÏ·Ϥ˜ ·ÚÙËڛ˜ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Ô˘ÚËÙËÚÈÎÒÓ ÂÈÏÔÎÒÓ ÙÔ˘ Ï‹ÙË. ø˜ ÂÎ ÙÔ‡ÙÔ˘ ÔÈ Û˘ÁÁÚ·Ê›˜ ·˘ÙÔ› ηٷϋÁÔ˘Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ô ·ÚÈıÌfi˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ ÛÙÔ ˙ÒÓÙ· ‰fiÙË Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ı· ÏËÊı› Ï··ÚÔÛÎÔÈο18. ∏ ÚfiÔ‰Ô˜ ÙˆÓ Ï··ÚÔÛÎÔÈÎÒÓ ÂÚÁ·Ï›ˆÓ (ultracision, ligasure, vascular TA stapler, locking clips) ·fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿ η٤ÛÙËÛ ÂÊÈÎÙ‹ ÙËÓ ·ÍÈÔÔ›ËÛË Î·È ÙˆÓ ‰ÂÍÈÒÓ ÓÂÊÚÒÓ, Ì Ï‹Úˆ˜ Ï··ÚÔÛÎÔÈ΋ Ù¯ÓÈ΋ Î·È ¯ˆÚ›˜ ˘„ËÏfi ÔÛÔÛÙfi ·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ ÛÙÔ Ï‹ÙË. ∞ÚÎÂÙ¿ ΤÓÙÚ· Û‹ÌÂÚ· Ô˘ οÓÔ˘Ó Û˘ÛÙËÌ·ÙÈο Ï··ÚÔÛÎÔÈ΋ Ï‹„Ë ÓÂÊÚÔ‡, ÚÔÙÈÌÔ‡Ó ÙÔ ÓÂÊÚfi Ì ̛· ·ÚÙËÚ›· ÌÂٷ͇ ÓÂÊÚÒÓ ÏÂÈÙÔ˘ÚÁÈο ÈÛfiÙÈ̈Ó19.

ªÔۯ‡̷ٷ Ì ÔÏÏ·Ï¿ ·ÁÁ›· Î·È ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ Ï‹ÙË ™ÙÔ Â‡ÏÔÁÔ ÂÚÒÙËÌ· Â¿Ó Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈËÎÙÈ΋˜ ·ÁˆÁ‹˜ ÛÙÔ Ï‹ÙË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ì ÔÏÏ·Ï¿ ·ÁÁ›· ÌÂÈÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ıÚfiÌ‚ˆÛ˘ Î·È Û˘Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó Â·Ú΋ ‰Â‰Ô̤ӷ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ÁÈ· Ó· ÛÙËÚȯı› ‹ ·ÔÚÈÊı› Ì›· Ù¤ÙÔÈ· ÚÔÛ¤ÁÁÈÛË. ™Â ‰ËÌÔÛÈÂ˘Ì¤ÓË ÛÂÈÚ¿ ·fi ÙÔ Massachussets General Hospital ÛÙË μÔÛÙÒÓË Û fiÏÔ˘˜ ÙÔ˘˜ Ï‹Ù˜ ÓÂÊÚÒÓ Ì ÔÏÏ·Ï¿ ·ÁÁ›· (31 ·fi Û‡ÓÔÏÔ 350) ¯ÔÚËÁ‹ıËΠ‰ÂÍÙÚ¿ÓË ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ ¿ÌÂÛ· ÌÂÙÂÁ¯ÂÈÚËÙÈο ÁÈ· ¤ÓÙ Ë̤Ú˜ Î·È ¯·ÌËÏ‹ ‰fiÛË ·ÛÈÚ›Ó˘ ‰È· ‚›Ô˘17.

ÛÙÔÓ ÔÚÈÛÌfi ÙÔ˘ ‰fiÙË Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·. ∂Ô̤ӈ˜ ‰fiÙ˜ Ì ÌÔۯ‡̷ٷ Ì ÔÏÏ·Ï¿ ·ÁÁ›· ‰ÂÓ ·ÔÙÂÏÔ‡Ó ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ ·Ó ‰ÂÓ Û˘Ó˘¿Ú¯Ô˘Ó ÔÈ ·Ú·¿Óˆ ·Ú¿ÁÔÓÙ˜20.

™¿ÓȘ ÂÚÈÙÒÛÂȘ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÔÏÏ·Ï¿ ·ÁÁ›· O ¶ÂÙ·ÏÔÂȉ‹˜ ÓÂÊÚfi˜ ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÂÙ·ÏÔÂȉ‹ ÓÂÊÚÔ‡ Â›Ó·È 1:600 ¤ˆ˜ 1:800. OÈ ·ÚÙËڛ˜ Î·È ÔÈ ÊϤ‚˜ ÙÔ˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ¿ÏË ÔÈÎÈÏ›· ˆ˜ ÚÔ˜ ÙËÓ ¤ÎÊ˘Û‹ ÙÔ˘˜, ÙÔÓ ·ÚÈıÌfi Î·È ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜. ø˜ ÂÎ ÙÔ‡ÙÔ˘ Ë ÌÂÙ·ÌfiÛ¯Â˘Û‹ ÙÔ˘ ·ÔÙÂÏ› ¯ÂÈÚÔ˘ÚÁÈ΋ ÚfiÎÏËÛË. O ÂÙ·ÏÔÂȉ‹˜ ÓÂÊÚfi˜ ÌÔÚ› Ó· ÌÂÙ·ÌÔÛ¯Â˘ı› ›Ù en bloc, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙËÓ ÂÚÈÊÂÚÈ΋ ÎÔÈÏȷ΋ ·ÔÚÙ‹ Î·È Î¿Ùˆ ÎÔ›ÏË ÊϤ‚·, ›Ù ÌÂÙ¿ ‰È·›ÚÂÛ‹ ÙÔ˘ ÛÙÔÓ ÈÛıÌfi. ∞Ó¿ÛÙÚÔÊË ˘ÂÏÔÁÚ·Ê›· ÁÈ· ¯·ÚÙÔÁÚ¿ÊËÛË Ù˘ ·Ó·ÙÔÌÈ΋˜ Ù˘ ·Ô¯ÂÙ¢ÙÈ΋˜ ÌÔ›Ú·˜ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÈÛıÌÔ‡ Â›Ó·È ··Ú·›ÙËÙË ÚÔ˜ ·ÔÊ˘Á‹Ó ÙÚ·˘Ì·ÙÈÛÌÔ‡ Ù˘ ηٿ ÙË ‰È·›ÚÂÛË ÙÔ˘ ÈÛıÌÔ‡. ™‡Ìʈӷ Ì ÙȘ ÙÚ¤¯Ô˘Û˜ ·fi„ÂȘ Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ¯ÂÈÚÔ˘ÚÁÒÓ ÛÙ· Ï·›ÛÈ· Ù˘ ∂SOT ıˆÚÔ‡Ó fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ ÂÙ·ÏÔÂȉԇ˜ ÓÂÊÚÔ‡ ¤¯ÂÈ Ù· ›‰È· ·ÔÙÂϤÛÌ·Ù· Ì ·˘Ù¿ ÙˆÓ ·Ó·ÙÔÌÈο Ê˘ÛÈÔÏÔÁÈÎÒÓ ÓÂÊÚÒÓ21.

O ¶˘ÂÏÈÎfi˜ ÓÂÊÚfi˜ O ˘ÂÏÈÎfi˜ ÓÂÊÚfi˜ Â›Ó·È Û¿ÓÈ· Û˘ÁÁÂÓ‹˜ ·ÓˆÌ·Ï›· ÙÔ˘ ÓÂÊÚÔ‡ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·ÁÁ›ˆÓ Î·È ·˘ÍË̤ÓË ÚԉȿıÂÛË ÁÈ· ÓÂÊÚÔÏÈı›·ÛË. OÈ ˘ÂÏÈÎÔ› ÓÂÊÚÔ› ÌÔÚ› Ó· Â›Ó·È ‰˘ÛÏ·ÛÙÈÎÔ› Ì ÂËÚ·Ṳ̂ÓË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ¶¿Ú·˘Ù·, ˘ÂÏÈÎÔ› ÓÂÊÚÔ› ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ÌÔۯ‡̷ٷ ·fi ˙ÒÓÙ˜ ‰fiÙ˜22.

ªÔۯ‡̷ٷ Ì ÔÏÏ·Ï¿ ·ÁÁ›· Î·È ÔÚÈ·ÎÔ› ‰fiÙ˜

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ø˜ ÔÚÈ·ÎÔ› ‰fiÙ˜ (marginal donors) ‹ ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· (ECDs-expanded or extended criteria donors) ÔÚ›˙ÔÓÙ·È ÔÈ و̷ÙÈÎÔ› ‰fiÙ˜ Ì ËÏÈΛ· ¿Óˆ ÙˆÓ 60 ‹ ÌÂٷ͇ 50-59 Î·È ‰‡Ô ·fi Ù· ÂÍ›˜ ÙÚ›· ÎÚÈÙ‹ÚÈ·: 1) ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘, 2) ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ ˆ˜ ·ÈÙ›· ı·Ó¿ÙÔ˘, Î·È 3) ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ¿Óˆ ÙÔ˘ 1,5 mg/dL ηٿ ÙËÓ Ï‹„Ë. Ÿˆ˜ ·Ú·ÙËÚÔ‡ÌÂ Ë ·ÚÔ˘Û›· ÌÔÓ‹ÚˆÓ ‹ ÔÏÏ·ÏÒÓ ·ÁÁ›ˆÓ ‰ÂÓ ˘ÂÈÛ¤Ú¯ÂÙ·È ˆ˜ ÎÚÈÙ‹ÚÈÔ

Δ· ÌÔۯ‡̷ٷ Ì ÔÏÏ·Ï¿ ·ÁÁ›· ‰ÂÓ Â›Ó·È ÔÚȷο. ∏ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·ÁÁ›ˆÓ ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÛÙËÓ ·ÍÈÔÔ›ËÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. O Û‡Á¯ÚÔÓÔ˜ ¯ÂÈÚÔ˘ÚÁfi˜ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‰È·ı¤ÙÂÈ Ì›· ÏËıÒÚ· ÂÚÁ·Ï›ˆÓ Î·È Ù¯ÓÈÎÒÓ ÙfiÛÔ ÁÈ· ÙËÓ ·ÛÊ·Ï‹ Ï‹„Ë fiÛÔ Î·È ÁÈ· ÙËÓ Â·Ó·ÁÁ›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·˘ÙÒÓ, Ì ·ÔÙÂϤÛÌ·Ù· ·ÚfiÌÔÈ· Ì ·˘Ù¿ ÙˆÓ ÓÂÊÚÒÓ Ì ÌÔÓ‹ÚË ·ÁÁ›·.

METAMO™XEY™Eπ™ 2010

μÈ‚ÏÈÔÁÚ·Ê›· 1. Skandalakis` Surgical Anatomy 2. Hume DM et al. Renal homotransplantation in man in modified recipients. Ann Surg 1963; 158: 608.

3. Murray JE et al. Surgical management of fifty patients with kidney transplants,including eighteen pairs of twins.Am J Surg 1963; 105: 205.

4. Roza AM et al. Living-related donors with bilateral multiple renal arteries: a twenty-year experience Transplantation 1988; 47: 397-399.

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12. Alcocer F et al. The superficial femoral vein: A valuable Conduit for a Short Renal Vein in Kidney Transplantation Transpl Proceedings 2009; 41: 1963-1965.

13. Benedetti E et al. Short-and Long-term outcomes of kidney transplants with Multiple Renal Arteries Ann Surg 1995; 4: 406-414.

14. Ratner LE et al. Laparoscopic live donor nephrectomy: technical considerations and allograft vascular length Transplantation 1998; 65: 1657-1658.

5. Loughlin KR et al. Urological complications in 718 renal transplant patients Surgery 1984; 95: 297-302.

15. Hsu T, Ratner LE et al. Impact of renal artery multiplicity on outcomes of renal donors and recipients in laparoscopic donor nephrectomy Urology 2003; 61: 323-327.

6. Bewick et al. The arterial complications of five hundred renal transplants Proc Eur Dial Transplant Assoc 1976; 13: 186-190.

16. Kuo P et al. Laparoscopic living donor nephrectomy and multiple renal arteries Am J Surg 1998; 176: 559563.

7. Starzl TE et al. A flexible procedure for multiple cadaveric organ procurement. Surg. Gynecol. Obstet. 1984; 158: 223-230.

17. Saidi R et al. Living donor kidney transplantation with multiple arteries Arch Surg 2009; 144(5): 472-475.

8. Ackerman JR. Cadaveric renal transplantation:a technique for donor kidney removal. Br J Urol 1968; 40: 515521.

9. Textbook “Principles and Practice of renal Transplantation” by Barry Kahan and C. Ponticelli 10. Kumar A et al. Sequential anastomosis of accessory renal artery to inferior epigastric artery in the management of multiple arteries in live related renal transplantation:a critical appraisal Clin Transpl 2001; 15: 131-135.

11. Andreas Tzakis et al Renal artery reconstruction for harvesting injuries in kidney transplantation with particular reference to the use of vascular allografts.

Transplant Int 1988; 1: 80-85.

18. Carter J et al. Laparoscopic procurement of kidneys with multiple renal arteries is associated with increased ureteral complications in the recipient Am J of Transplantation 2005; 5: 1312-1318.

19. Saad S et al. Laparoscopic live donor nephrectomy for right kidneys:experience in a German community hospital Surg Endosc 2008; 22: 674-678.

20. Textbook “Kidney Transplantation” by P.Morris and S. Knechtle 6th ed. 2008.

21. Stroosma O et al. Current opinions in horseshoe kidney transplantation Transpl Int 2002; 15: 196-199.

22. Goldsmith P et al. Kidney transplantation using the inferior epigastric vessels for multiple anastomoses from a pelvic kidney J Am Coll Surg 2009; 209(1): e3.

ªETAMO™XEY™H NEºƒOY ™E A™£ENEI™ Yæ∏§OY KIN¢YNOY

MÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Û ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜ °. ª˘ÛÂÚÏ‹˜, ¢. Δ·ÎÔ‡‰·˜ ∂ÈÛ·ÁˆÁ‹

ÌÔ‡ ·ÛıÂÓÒÓ ÌÂ Δ™Ã¡¡. ™ÙÔ Ï·›ÛÈÔ Ù˘ ÙÚ¤¯Ô˘Û·˜ ¤ÏÏÂȄ˘ fiÚÁ¿ÓˆÓ,ÔÈ ˘¤ÚÌ·¯ÔÈ Ù˘ ıˆڛ·˜ ·˘Ù‹˜ ÂÓ·ÓÙÈÒÓÔÓÙ·È ÛÙËÓ ‰ˆÚ¿ ¤Ófi˜ Û¿ÓÈÔ˘ و̷ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi Ó¤Ô ‰fiÙË Û ËÏÈÎȈ̤ÓÔ ˘Ô„‹ÊÈÔ Ï‹ÙË Ì ÂÚÈÔÚÈṲ̂ÓË ‰È¿ÚÎÂÈ· ˙ˆ‹˜ ÂÓÒ ·ÓÙ›ıÂÙ· ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ÓÂÊÚÒÓ ÛÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ Ï‹Ù˜7,8. ¶ÈÛÙÂ‡Ô˘Ó Â›Û˘ fiÙÈ Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi Ó¤Ô˘˜ ‰fiÙ˜ ÛÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ Ï‹Ù˜ fi¯È ÌfiÓÔ Ô‰ËÁ› Û Û·Ù¿ÏË Î·È Ì›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·ÏÏ¿ Î·È Û ·‰ÈΛ· ÙˆÓ ÓÂfiÙÂÚˆÓ ÏËÙÒÓ Ô˘ ›Ù ·›ÚÓÔ˘Ó ËÏÈÎȈ̤ӷ ÌÔۯ‡̷ٷ ‹ ÂÍ·ÓÙÏÔ‡Ó Ù· ÈÔ ·Ú·ÁˆÁÈο ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜ ÂÚÈ̤ÓÔÓÙ·˜ ÁÈ· οÔÈÔ ÌfiÛ¯Â˘Ì· ·fi Ó¤Ô ‰fiÙË. OÈ ÂÈÎÚÈÙ¤˜, ˆÛÙfiÛÔ, ÈÛÙÂ‡Ô˘Ó fiÙÈ ÌÈ· Ù¤ÙÔÈ· ÔÏÈÙÈ΋ ı· ‹Ù·Ó ÂȘ ‚¿ÚÔ˜ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ ÏfiÁˆ Ù˘ ¯·ÌËÏfiÙÂÚ˘ ÔÈfiÙËÙ·˜ ÙˆÓ ÓÂÊÚÒÓ ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ ÂÓÒ ·fi ÙËÓ ¿ÏÏË ı· ÌÔÚÔ‡Û ӷ ÂÚÈÔÚ›ÛÂÈ ÙËÓ ÚfiÛ‚·ÛË ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ·ÛıÂÓÒÓ Û ÌÔۯ‡̷ٷ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜9,10. À¿Ú¯ÂÈ fï˜ ¤Ó· ÏÂÔÓ¤ÎÙËÌ· Î·È ÁÈ· ÙȘ ‰‡Ô ·fi„ÂȘ. ŒÓ· ÌÔÓÙ¤ÏÔ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ËÏÈÎȈ̤ÓÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ËÏÈÎȈ̤ÓÔ Ï‹ÙË, ÌÔÏÔÓfiÙÈ ‰ÂÓ Â›Ó·È ÙÔ È‰·ÓÈÎfi, ¤¯ÂÈ ÚÔÙ·ı› ˆ˜ χÛË ÁÈ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ‰ÔÙÒÓ Î·È ÙˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ Î·È Ê·›ÓÂÙ·È fiÙÈ ı· ÌÔÚÔ‡Û ӷ Ô‰ËÁ‹ÛÂÈ ÛÙË Ì›ˆÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ∞ÓÙ›ıÂÙ· ÌÈ· Ù¤ÙÔÈ· ÔÏÈÙÈ΋ ÌÔÚ› Ó· ÌËÓ Â›Ó·È Î·Ù¿ÏÏËÏË ÁÈ· ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜ Ì ˘„ËÏfi ·ÓÔÛÔÏÔÁÈÎfi ΛӉ˘ÓÔ, ¤Î‰ËÏË ·¯˘Û·ÚΛ· Î·È ÔÏÏ·Ï‹ Û˘ÓÔÛËÚfiÙËÙ· fiˆ˜ ı· ·Ó·ÊÂÚı› Î·È ·ÚÁfiÙÂÚ·.

∏ ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ˘fi ·ÈÌÔοı·ÚÛË ·ÁÎÔÛÌ›ˆ˜ Î·È ÛÙȘ ∏¶∞ ¤¯ÂÈ ·˘ÍËı›. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·ÈÌÔηı·ÈÚfiÌÂÓˆÓ ·ÛıÂÓÒÓ Â›Ó·È Û‹ÌÂÚ· 58.8 ¤ÙË1. ¶·Ú¿ÏÏËÏ· Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (Δ™Ã¡¡),Ô ÏËı˘ÛÌfi˜ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ ¤¯ÂÈ Â›Û˘ ·˘ÍËı›. OÈ ·ÛıÂÓ›˜ ¿Óˆ ÙˆÓ 50 ÂÙÒÓ ·ÔÙÂÏÔ‡Ó Û‹ÌÂÚ· ۯ‰fiÓ ÙÔ 60% Î·È ÔÈ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 17% Ù˘ Ï›ÛÙ·˜ ÁÈ· و̷ÙÈ΋ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË2. Δ· ÔÛÔÛÙ¿ ·˘Ù¿ ÙÔ 1993 ‹Ù·Ó 34 Î·È 5%, ·ÓÙ›ÛÙÔȯ·3. ∏ ¯ÚÔÓÔÏÔÁÈ΋ ËÏÈΛ· ·˘Ù‹ ηı·˘Ù‹ ‰ÂÓ ıˆÚÂ›Ù·È ϤÔÓ ˆ˜ ÂÌfi‰ÈÔ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË4,5. øÛÙfiÛÔ, Ô Ú˘ıÌfi˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ·ÛıÂÓÒÓ ·Ú·Ì¤ÓÂÈ ÌÈÎÚfi˜. ΔÔ ¤ÙÔ˜ 2006 ÛÙȘ ∏¶∞, 178.739 ·ÛıÂÓ›˜ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ ‹Ù·Ó ÛÙËÓ ·ÈÌÔοı·ÚÛË1, Î·È ÌfiÓÔ 10.534 (6%) ·fi ·˘ÙÔ‡˜ ·ÚÈÏ·Ì‚¿ÓÔÓÙ·Ó ÛÙËÓ Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ΔÔ ›‰ÈÔ ¤ÙÔ˜ ÙÔ Û˘ÓÔÏÈÎfi ÂıÓÈÎfi ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ ÌÂ Δ™Ã¡¡ Ô˘ ‹Ù·Ó ÂÁÁÂÁÚ·Ì̤ÓÔÈ ÛÙË Ï›ÛÙ· ‹Ù·Ó 37%6. OÈ ÏfiÁÔÈ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó fi¯È ÌfiÓÔ ÙÔÓ ·˘ÛÙËÚfi ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ¤ÏÂÁ¯Ô, ·ÏÏ¿ Â›Û˘ Î·È ÙËÓ ·ÚÔı˘Ì›· ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ Ó· ÂÓÙ¿ÍÔ˘Ó ÛÙËÓ Ï›ÛÙ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÏfiÁˆ ÙÔ˘ ÌÂȈ̤ÓÔ˘ ÚÔÛ‰fiÎÈÌÔ˘ ÂÈ‚›ˆÛ‹˜ ÙÔ˘˜, Ù˘ ÌÂÁ¿Ï˘ ÙÔ˘˜ Û˘ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ™ÙÔ ·ÚfiÓ ¿ÚıÚÔ, ı· Û˘˙ËÙ‹ÛÔ˘Ì ÙȘ ‰È¿ÊÔÚ˜ ÎÏÈÓÈΤ˜ Î·È ‰ÂÔÓÙÔÏÔÁÈΤ˜ Ù˘¯¤˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ Û ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜ ηıÒ˜ Â›Û˘ Î·È ÙȘ ˘ÊÈÛÙ¿ÌÂÓ˜ Î·È ÚÔÙÂÈÓfiÌÂÓ˜ Ú·ÎÙÈΤ˜ Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ.

™˘ÛÙ‹Ì·Ù· ηٷÓÔÌ‹˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ËÏÈÎȈ̤ÓÔ˘˜ Ï‹Ù˜ (˘¤Ú Î·È Î·Ù¿)

∏ıÈο ÚÔ‚Ï‹Ì·Ù· ™ÙÔ Ï·›ÛÈÔ ÙÔ˘ ÈÛ¯‡ÔÓÙÔ˜ Û˘ÛÙ‹Ì·ÙÔ˜ ηٷÓÔÌ‹˜ ÔÚÁ¿ÓˆÓ Ô˘ ‚·Û›˙ÂÙ·È ÛÙËÓ ÎÔÈÓˆÓÈ΋ ÈÛfiÙËÙ· Î·È ÙËÓ ÎÏÈÓÈ΋ ˆÊ¤ÏÂÈ·, Ë ¤ÌÊ·ÛË ‰›ÓÂÙ·È ÏÔÁÈο ÙfiÛÔ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ (QoL) fiÛÔ Î·È ÛÙËÓ ÂÈ‚›ˆÛË ÌÂÁ·Ï‡ÙÂÚÔ˘ ·ÚÈı-

ΔÔ ∂urotransplant Senior Program (ESP) ÍÂΛÓËÛ ÛÙËÓ ∂˘ÚÒË ÙÔ 1999 ÛÙËÓ Ê¿ÛË Î·Ù¿ ÙËÓ ÔÔ›· ˘‹Ú¯Â ¤Ó·˜ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓÔ˜ ·ÚÈıÌfi˜ ËÏÈÎÈˆÌ¤ÓˆÓ ‰ÔÙÒÓ Î·È ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ

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°. ªÀ™∂ƒ§∏™, ¢. Δ∞∫OÀ¢∞™

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ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜11. μ·ÛÈο Û˘Ó›ÛÙ·Ù·È ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÓÂÊÚÒÓ ·fi و̷ÙÈÎfi ‰fiÙË ËÏÈΛ·˜ 65 ÂÙÒÓ Î·È ¿Óˆ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·ÚfiÌÔÈ·˜ ËÏÈΛ·˜. ∏ ÂÈÙ˘¯›· ÙÔ˘ ESP ¤¯ÂÈ ÂÌÓ‡ÛÂÈ ·ÚfiÌÔȘ ÚÔÛ¿ıÂȘ Î·È ÛÙȘ ∏¶∞. ΔÔ UNOS ÂÍÂÙ¿˙ÂÈ ÌÈ· Ó¤· ηٷÓÔÌ‹. To Û‡ÛÙËÌ· ÔÓÔÌ¿˙ÂÙ·È Life Years From Transplant (LYFT)12. LYFT Â›Ó·È Ô ·ÚÈıÌfi˜ ÙˆÓ ÂÈϤÔÓ ¯ÚfiÓˆÓ Ù˘ ˙ˆ‹˜ Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ˙‹ÛÂÈ ¤Ó·˜ Ï‹Ù˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Û ۇÁÎÚÈÛË Ì ·˘Ù¿ Ô˘ ı· ˙Ô‡Û ·Ú·Ì¤ÓÔÓÙ·˜ ÛÙËÓ ·ÈÌÔοı·ÚÛË.

ÀÂÚ ΔÔ Ó¤Ô Û‡ÛÙËÌ· ı· ÌÔÚÔ‡Û ӷ ·˘Í‹ÛÂÈ ÙËÓ ·˘ÙÔÓÔÌ›· ÙˆÓ ·ÛıÂÓÒÓ ÂÈÙÚ¤ÔÓÙ¿˜ ÙÔ˘˜ Ó· ηıÔÚ›˙Ô˘Ó ÙȘ LYFT ‚·ıÌÔÏÔÁ›Â˜ ÙÔ˘˜ on-line. ŒÓ·˜ Û˘Ó¯‹˜ ¢Â›ÎÙ˘ ÙÔ˘ ¶ÚÔÊÈÏ ÙÔ˘ ¢fiÙË (Donor Profile Index-DPI) ·ÓÙÈηıÈÛÙ¿ ÙËÓ Ù·ÍÈÓfiÌËÛË ÙfiÛÔ ÙÔ˘ ‰fiÙË ÛÙ·ıÂÚÒÓ ÎÚÈÙËÚ›ˆÓ (Standard Criteria Donor-SCD) fiÛÔ Î·È ÙÔ˘ ‰fiÙË ÂÎÙÂÙ·Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ (∂xtended Criteria Donor-ECD). O ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ DPI ı· ÌÔÚÔ‡Û ӷ ηıˆÚ›ÛÂÈ ÙÔÓ ‚·ıÌfi ÎÈÓ‰‡ÓÔ˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‚·ÛÈ˙fiÌÂÓÔ˜ ÛÙËÓ ÔÈfiÙËÙ¿ ÙÔ˘˜, ÂÈÙÚ¤ÔÓÙ·˜ ¤ÙÛÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ó· ÚÔÛ‰ÈÔÚ›ÛÔ˘Ó Û ÔÈÔ Â›Â‰Ô ÎÈÓ‰‡ÓÔ˘ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ı· ÌÔÚÔ‡Û·Ó Ó· ÂÎÙÂıÔ‡Ó. ªÂ ÙÔ Û‡ÛÙËÌ· LYFT ı· ÌÔÚÔ‡Û·Ì ӷ ·Ú¿Û¯Ô˘Ì ÌÈ· ÌÂÁ·Ï‡ÙÂÚË ÂÈ‚›ˆÛË Û ÓÂfiÙÂÚÔ˘˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, Ú¿ÁÌ· Ô˘ ı· Ô‰ËÁÔ‡Û Û Ì›ˆÛË Ù˘ ·Ó¿Á΢ ÁÈ· Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ Û ·˘ÙÔ‡˜ Î·È ÂÓ Û˘Ó¯›· Û ÂÚÈÛÛfiÙÂÚ· ‰È·ı¤ÛÈÌ· ÌÔۯ‡̷ٷ ÁÈ· ÙÔ˘˜ ˘fiÏÔÈÔ˘˜. ΔÔ ÔÛÔÛÙfi ÙˆÓ ÎÚÈÓÔÌ¤ÓˆÓ ˆ˜ ·Î·Ù¿ÏÏËÏˆÓ ÔÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ Â›Ó·È Û‹ÌÂÚ· ÂÚÈÛÛfiÙÂÚÔ ·fi 50%13, ı· ÌÔÚÔ‡Û ӷ ÂÏ·¯ÈÛÙÔÔÈËı› Ì ÌÈ· ηχÙÂÚË ·ÓÙÈÛÙÔ›¯ÈÛË ÙˆÓ ÂÙÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (graft years) Ì ÙÔÓ ÚÔÛ‰fiÎÈÌÔ ¯ÚfiÓÔ ÂÈ‚›ˆÛ˘ ÙˆÓ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ. ªÂÙ¿ ÙÔÓ Î·ıÔÚÈÛÌfi Î·È ÙËÓ ÂÍÈÛÔÚÚfiÈÛË Ù˘ Ï›ÛÙ·˜ ·Ó·ÌÔÓ‹˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÈÌÔοı·ÚÛ˘, ·Ô ÙÔÓ LYFT ÚÔÙ›ÓÂÙ·È Ë ÛÎfiÈÌË ·ÔÊ˘Á‹ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÛÙȘ ÂÚÈÙÒÛÂȘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú·Ì¤ÓÔ˘Ó ÏÈÁfiÙÂÚÔ ÛÙË Ï›ÛÙ· (΢ڛˆ˜ ÏfiÁˆ ·˘ÍË̤Ó˘ Û˘ÓÔÛËÚfiÙËÙ·˜) ÁÈ· Ó· ·ÔÊ¢¯ı› Ë ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË.

∫·Ù¿ ∏ ÙÚ¤¯Ô˘Û· Ú·ÎÙÈ΋ ÛÙȘ ∏¶∞ Â›Ó·È Ë ·Ú·-

¯ÒÚËÛË ÙˆÓ ÌÂÁ·Ï‡ÙÂÚˆÓ Û ËÏÈΛ· ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜ 10,14. ∏ Ó¤· ÔÏÈÙÈ΋ ı· Ô‰ËÁfi‡Û ̿ÏÏÔÓ Û ÌÈ· ηı·Ú‹ ·ÔÊ˘Á‹ ÙˆÓ ÓÂfiÙÂÚˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ËÏÈÎȈ̤ÓÔ˘˜ Ï‹Ù˜ Û ÂÚ›Ô˘ 12 ¤ˆ˜ 9% Ì ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ Û‡ÛÙËÌ· (LYFT). ∞˘Ù‹ Ë ÚÔÛ¤ÁÁÈÛË Â›Ó·È ÂȘ ‚¿ÚÔ˜ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ ÏfiÁˆ ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ·. ∞ÁÓÔÒÓÙ·˜ Ì¿ÏÈÛÙ· ÙËÓ HLA Ù·˘ÙÔÔ›ËÛË ÂÓ‰¤¯ÂÙ·È Ó· ı¤ÛÔ˘Ì ÙÔ˘˜ ÓÂÊÚÔ‡˜ Û ΛӉ˘ÓÔ ·fiÚÚȄ˘ fiˆ˜ ¤¯ÂÈ ·Ô‰Âȯı› ÛÙËÓ Â˘Úˆ·˚΋ ÂÌÂÈÚ›·11. §·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë ·˘Ù¿ Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù·, ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ ÎÚ›ÓÔÓÙ·È ··Ú·›ÙËÙ˜ ÚÔÎÂÈ̤ÓÔ˘ Ó· Á›ÓÂÈ ÈÔ ÂÈı˘ÌËÙfi ·fi ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜. ™‡Ìʈӷ Ì ÙÔ ÈÛ¯‡ÔÓ Û‡ÛÙËÌ·, ‰›ÓÔÓÙ·˜ ¤ÌÊ·ÛË ÛÙËÓ Â›‰ÔÛË ÙˆÓ ÌÂÌÔÓˆÌ¤ÓˆÓ Î¤ÓÙÚˆÓ, ÂÌÊ·Ó›˙ÂÙ·È ·ÎfiÌË ¤Ó· ‰˘ÓËÙÈÎfi ÂÌfi‰ÈÔ ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ·ÛıÂÓÒÓ. ΔÔ SRTR (Scientific Registry for Transplant Recipients) ηıÔÚ›˙ÂÈ ¤Ó· ·Ó·ÌÂÓfiÌÂÓÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘, ÙfiÛÔ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ fiÛÔ Î·È ÁÈ· Ù· ÌÔۯ‡̷ٷ, Û οı ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ Î·È ÂÚÈÔ‰Èο ÂÎı¤ÙÂÈ Ù· ·Ú·ÙËÚÔ‡ÌÂÓ· ‰Â‰Ô̤ӷ ÂÈ‚›ˆÛ˘. ΔÂÏÈο Ë Î·ÙÒÙÂÚË ÂÈ‚›ˆÛË ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÓÂÒÙÂÚÔ˘˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·˘Í¿ÓÂÈ ÙËÓ ‰È·ÊÔÚ¿ ÌÂٷ͇ ·Ú·ÙËÚÔ‡ÌÂÓ˘ Î·È ·Ó·ÌÂÓfiÌÂÓ˘ ıÓËÙfiÙËÙ·˜ Û ¤Ó· ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ. O ·Ú¿ÁÔÓÙ·˜ ·˘Ùfi˜ Â›Ó·È ¤Ó· ·ÓÙÈΛÓËÙÚÔ ÁÈ· Ù· ΤÓÙÚ· ÛÙÔ Ó· ·Ú¿Û¯Ô˘Ó ÚfiÛ‚·ÛË ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜, ÂȉÈο ÁÈ· ¿ÙÔÌ· Ì ÛËÌ·ÓÙÈο Û˘ÓÔ‰¿ ÓÔÛ‹Ì·Ù·.

∏ ηٷÏÏËÏfiÙËÙ· ÙˆÓ ˘Ô„ËÊ›ˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ÏËÙÒÓ ∏ÏÈÎȈ̤ÓÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÛıÂÓ›˜ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ¯ÚfiÓÔ ·ÈÌÔηı·ÈÚfiÌÂÓÔÈ ·fi fi, ÙÈ ÔÈ ·ÓÙ›ÛÙÔȯÔÈ ÓÂÒÙÂÚÔ› ÙÔ˘˜15. Δ· ÎÏÈÓÈο ÔʤÏË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ÂÚÈÔÚ›˙ÔÓÙ·È Û ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÈÌÔοı·ÚÛË ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·16,17. ø˜ ÂÎ ÙÔ‡ÙÔ˘, Â›Ó·È ÌÂÁ¿ÏÔ ˙‹ÙËÌ· Ë ·˘ÛÙËÚ‹ ÂÎÙ›ÌËÛË, ÂÈÏÔÁ‹ Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ·ÛıÂÓÒÓ Û ‡ıÂÙÔ ¯ÚfiÓÔ. ªÂÁ¿ÏÔÈ ÛÙËÓ ËÏÈΛ· ˘Ô„‹ÊÈÔÈ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ı· Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û Ï‹ÚË ÚÔÌÂÙÔÌÔÛ¯Â˘ÙÈ΋ È·ÙÚÈ΋ ·ÍÈÔÏfiÁËÛË, Ì ȉȷ›ÙÂÚË ÚÔÛÔ¯‹ ÛÙËÓ Î·Ú‰È·ÁÁÂȷ΋ ˘Á›·,

METAMO™XEY™Eπ™ 2010

Ô˘ÚÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË Î·È ¤ÏÂÁ¯Ô ÁÈ· ηÚΛÓÔ.

OÈ ·ÛıÂÓ›˜ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ Â›Ó·È Î·Ù¿ÏÏËÏË ıÂÚ·›· ÏfiÁˆ ÙÔ˘ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ¤Ó·ÓÙÈ ÙÔ˘ ÔʤÏÔ˘˜, Ú¤ÂÈ ÙÂÏÈο Ó· ·ÔÎÏ›ÔÓÙ·È. ∏ ·fiÊ·ÛË Â›Ó·È ‰‡ÛÎÔÏË Î·È ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë Ë ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜, Ù· Û˘ÓÔ‰¿ ÓÔÛ‹Ì·Ù·, ÙÔ ÚÔÛ‰fiÎÈÌÔ ˙ˆ‹˜, Ô ·Ó·ÌÂÓfiÌÂÓÔ˜ ¯ÚfiÓÔ˜ ÛÙËÓ و̷ÙÈ΋ Ï›ÛÙ· Î·È Ë ÔÈfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ı· Ï¿‚Ô˘Ó. ∏ ¢ηÈÚ›· ÁÈ· ‚ÂÏÙ›ˆÛË Ù˘ ‰È¿ÚÎÂÈ·˜ ˙ˆ‹˜ Î·È Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ (QOL) ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ú¤ÂÈ Ó· ÂÍÂÙ·ÛÙ› ÚÔÛÂÎÙÈο. OÈ ·ÛıÂÓ›˜ ı· Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÌÈ· ÏÔÁÈ΋ Èı·ÓfiÙËÙ· ÂÈ‚›ˆÛ˘ ηχÙÂÚ˘ ·fi ÙÔÓ ÙÚ¤¯ÔÓÙ· ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ·ÍÈÔÏfiÁËÛË Ù˘ ÎÔÈÓˆÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ηı›ÛÙ·Ù·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙÔ˘˜ ·Ó›Î·ÓÔ˘˜ Ó· ÊÚÔÓÙ›ÛÔ˘Ó ÙÔÓ Â·˘Ùfi ÙÔ˘˜, ›Ù ÏfiÁˆ ¿ÓÔÈ·˜ ‹ ۈ̷ÙÈ΋˜ ·Ó·ËÚ›·˜, Î·È ·Ôı·ÚÚ‡ÓÔÓÙ·È ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÎÙfi˜ ·Ó ˘¿Ú¯ÂÈ ÈÛ¯˘Ú‹ ÔÈÎÔÁÂÓÂȷ΋ ‹ ÎÔÈÓˆÓÈ΋ ˘ÔÛÙ‹ÚÈÍË.

H oÈÎÔÓÔÌÈ΋ ıÂÒÚËÛË ÙÔ˘ ˙ËÙ‹Ì·ÙÔ˜ Â›Ó·È Â›Û˘ ÛËÌ·ÓÙÈ΋. OÚÈṲ̂Ó˜ ·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜18,19 ¤‰ÂÈÍ·Ó fiÊÂÏÔ˜ ÙÔ˘ ÎfiÛÙÔ˘˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¤Ó·ÓÙÈ Ù˘ ·ÈÌÔοı·ÚÛ˘ Û ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜. ªÈ· ÚfiÛÊ·ÙË ·Ó¿Ï˘ÛË ÙˆÓ Jassal et al.16, ˆÛÙfiÛÔ, ¤‰ÂÈÍ fiÙÈ Û ·ÛıÂÓ›˜ ¿Óˆ ÙˆÓ 60 ÂÙÒÓ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÂÈ‚›ˆÛË, ·ÏÏ¿ Â›Ó·È ·˘ÍË̤ÓÔ˘ ÎfiÛÙÔ˘˜, ȉ›ˆ˜ ÁÈ· ÂΛÓÔ˘˜ Ì ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· (CVD) ‹ ‰È·‚‹ÙË. ªÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ECD ‹ ·fi ‰fiÙË ÔÚÁ¿ÓˆÓ ÌÂÙ¿ ÙÔÓ Î·Ú‰È·Îfi ı¿Ó·ÙÔ (DCD) ÚÔÛı¤ÙÂÈ Â›Û˘ ÛÙÔ ·˘ÍË̤ÓÔ ÎfiÛÙÔ˜20, ÏfiÁˆ ÙÔ˘ ˘„ËÏfiÙÂÚÔ˘ ÎÈÓ‰‡ÓÔ˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔۯ‡̷ÙÔ˜ (DGF), ηıÒ˜ Î·È Ù˘ ·Ú·ÙÂٷ̤Ó˘ ÓÔÛËÏ›·˜. ∏ ‰È·¯Â›ÚÈÛË Ù˘ Ï›ÛÙ·˜ ·Ó·ÌÔÓ‹˜ ı· Ú¤ÂÈ Ó· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ı¤Ì· ÁÈ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜. ∂ÙÛÈ fiÙ·Ó Ô ˘Ô„‹ÊÈÔ˜ Ï‹Ù˘ ÂÁÎÚÈı› ÁÈ· ¤ÓÙ·ÍË ÛÙËÓ Ï›ÛÙ· , ı· Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ÛÙÂÓ¿ ÁÈ· ÙȘ ·ÏÏ·Á¤˜ ÛÙËÓ Î·Ú‰È·ÁÁÂȷ΋ ÙÔ˘ ηٿÛÙ·ÛË ÏfiÁˆ Ù˘ ·Ú·ÙËÚÔ‡ÌÂÓ˘ ˘„ËÏ‹˜ ıÓËÛÈÌfiÙËÙ·˜21.

¢fiÙ˜ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ·ÛıÂÓÒÓ Ÿˆ˜ Î·È ÁÈ· ÙȘ ¿ÏϘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ ¤ÙÛÈ Î·È ÁÈ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜ ˘¿Ú¯Ô˘Ó ÔÏϤ˜ ηÙËÁÔڛ˜ ‰ÔÙÒÓ.

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ªÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ˙ÒÓÙ· ‰fiÙË (LDKT) ¶·ÚfiÏÔ Ô˘ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ˙ÒÓÙ· ‰fiÙË (LDKT) ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È Ë Î·Ï‡ÙÂÚË ÂÈÏÔÁ‹ Û ÔÔÈ·‰‹ÔÙ ËÏÈΛ·, Â›Ó·È Î˘Ú›ˆ˜ ÌÈ· ÂÏ΢ÛÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜16. Δ›ÓÂÈ Ó· ÌÂÙÚÈ¿ÛÂÈ ÙȘ ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ÛËÌ·ÓÙÈ΋˜ Û˘ÓÔÛËÚfiÙËÙ·˜ ÛÙËÓ ÂÈ‚›ˆÛË ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ22. ∂ȉÈο, ÔÈ ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ‹/Î·È Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ (CVD) ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ ı· Ú¤ÂÈ Ó· ÂÎÙÈÌÒÓÙ·È ÛÔ‚·Ú¿ ÁÈ· ÌÈ· LDKT. ªÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ô ˙ÒÓÙ· ‰fiÙË ÌÂÈÒÓÂÈ ÙÔÓ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜, ÂÈÙÚ¤ÂÈ ÙË ‚ÂÏÙÈÛÙÔÔ›ËÛË ÙˆÓ Û˘ÓÔ‰ÒÓ ÓÔÛËÌ¿ÙˆÓ ÚÈÓ ·fi ÙËÓ ÂÁ¯Â›ÚËÛË Î·È ÂÏ·¯ÈÛÙÔÔÈ› ÙȘ ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜ ÙÔ˘˜ Ì ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÌÂÛ˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞ÎfiÌ· ÎÈ ·Ó ÔÈ ÓÂfiÙÂÚÔÈ ‰fiÙ˜ ·Ú¤¯Ô˘Ó Ù· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ÁÈ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ 23, ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ Â›Ó·È ËıÈο ‰‡ÛÎÔÏÔ Ó· ¯ÚËÛÈÌÔÔÈ‹ÛÔ˘Ì ¤Ó· ÓÂÊÚfi ·fi ‰fiÙË Ô ÔÔ›Ô˜ ¤¯ÂÈ ÌÂÁ¿ÏË ‰È·ÊÔÚ¿ ËÏÈΛ·˜ ·fi ÙÔÓ ËÏÈÎȈ̤ÓÔ Ï‹ÙË. ∏ÏÈÎȈ̤ÓÔÈ ˙ÒÓÙ˜ ‰fiÙ˜ Û˘ÓÈÛÙÔ‡Ó ÙËÓ ÂfiÌÂÓË Î·Ï‡ÙÂÚË ÂÓ·ÏÏ·ÎÙÈ΋ χÛË23-25. ∑ÒÓÙ˜ ÌË Û˘ÁÁÂÓ›˜ ‰fiÙ˜ ·ÔÙÂÏÔ‡Ó ÙËÓ Ù·¯‡ÙÂÚ· ·Ó·Ù˘ÛÛfiÌÂÓË ËÁ‹ ‰fiÙÒÓ Ì ٷ ·ÔÙÂϤÛÌ·Ù· ۯ‰fiÓ Ù·˘ÙfiÛËÌ· Ì ·˘Ù¿ ÙˆÓ Û˘ÁÁÂÓÈÎÒÓ ‰ÔÙÒÓ26.

ªÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ‰fiÙË ÛÙ·ıÂÚÒÓ ÎÚÈÙËÚ›ˆÓ (SCD) ŒÓ·˜ و̷ÙÈÎfi˜ ‰fiÙ˘ ÓÂÊÚÔ‡ Ô˘ ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÂÙ·È ÛÙÔÓ ÔÚÈÛÌfi ÙÔ˘ ‰fiÙË ÂÎÙÂÙ·Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ (ECD) Ù·ÍÈÓÔÌÂ›Ù·È ˆ˜ ‰fiÙ˘ ÛÙ·ıÂÚÒÓ ÎÚÈÙËÚ›ˆÓ (SCD). ™‡Ìʈӷ Ì ÙÔ ÈÛ¯‡ÔÓ Û‡ÛÙËÌ· ηٷÓÔÌ‹˜, ¤Ó·˜ ÌÂÁ¿Ï˘ ËÏÈΛ·˜ ˘Ô„‹ÊÈÔ˜ Ï‹Ù˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ›Û˜ Èı·ÓfiÙËÙ˜ ÁÈ· Ï‹„Ë ÓÂÊÚÔ‡ ·fi SCD Û ۯ¤ÛË Ì ÓÂÔÙÂÚÔ Ï‹ÙË. ΔÔ LYFT fï˜ Û‡ÛÙËÌ· ηٷÓÔÌ‹˜ ı· ÌÔÚÔ‡Û Èı·Ófiٷٷ Ó· ηÙ¢ı‡ÓÂÈ Ù· ÌÔۯ‡̷ٷ ·Ô SCD ÛÙÔ˘˜ ÓÂfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜. ¶ÚÔÙ›ÓÔ˘Ì ÌÈ· ÂÈÏÔÁ‹ SCD ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÌfiÓÔ ÁÈ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ‰ÂÓ ¤¯Ô˘Ó ˙ÒÓÙ· ‰fiÙË Î·È ‚Ú›ÛÎÔÓÙ·È Û ˘„ËÏfi È·ÙÚÈÎfi ΛӉ˘ÓÔ ÁÈ· ÂÈÏÔΤ˜ ·fi ÙË Ï‹„Ë ÂÓfi˜ ÓÂÊÚÔ‡ ECD.

ªÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ‰fiÙË Ì ·‡ÛË Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (DCD) ø˜ ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ ÌÂÙ¿ ·‡ÛË Ù˘ ηډȷ΋˜

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°. ªÀ™∂ƒ§∏™, ¢. Δ∞∫OÀ¢∞™

ÏÂÈÙÔ˘ÚÁ›·˜ (DCD) ÔÚ›˙ÂÙ·È ÂΛÓË Ô˘ ¤ÁÈÓ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ·‡ÛË Ù˘ ηډÈÔÓ¢ÌÔÓÈ΋˜ ·Ó·˙ÔˆÁÒÓËÛ˘. ¶·Ú·Ì¤ÓÂÈ ÌÈ· ˘Ô¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓË ÂÓ·ÏÏ·ÎÙÈ΋ χÛË ÁÈ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ÂÂȉ‹ Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ DCD ÌÂÙ·ÌfiÛ¯Â˘Û˘ Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù¿ Ù˘ SCD ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÂÎÙfi˜ ·fi ÌÈ· ·˘ÍË̤ÓË ‚¤‚·È· Èı·ÓfiÙËÙ· ÁÈ· DGF27,28.

ªÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ‰fiÙË ÂÎÙÂÙ·Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ (ECD) ø˜ ‰fiÙ˘ ÂÎÙÂÙ·Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ (ECD) ÔÚ›˙ÂÙ·È ·˘Ùfi˜ Ì ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ Î·È ËÏÈΛ· ¿Óˆ ÙˆÓ 60 ÂÙÒÓ ‹ ·˘Ùfi˜ Ì ËÏÈΛ· 50 ¤ˆ˜ 60 ÂÙÒÓ Î·È Ì ‰‡Ô ·fi ÙȘ ·ÎfiÏÔ˘ı˜ ÚÔ¸Ôı¤ÛÂȘ: ˘¤ÚÙ·ÛË, ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ ˆ˜ ·ÈÙ›· ÙÔ˘ ı·Ó¿ÙÔ˘, ‹ ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ÂÚÈÛÛfiÙÂÚÔ ·fi 1,5 mg/dl. ¡ÂÊÚÔ› ·fi ECD ¤¯Ô˘Ó 70% ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ۯ¤ÛË Ì ÓÂÊÚÔ‡˜ ·fi SCD29. ¶ÚˆÙÔ·ı‹˜ ÌË ÏÂÈÙÔ˘ÚÁ›·, ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÌÔۯ‡̷ÙÔ˜ (DGF), Ùˆ¯‹ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ·Ú·ÙÂٷ̤ÓË ÂÓ‰ÔÓÔÛÔÎÔÌÂȷ΋ ÓÔÛËÏ›· Î·È Ë ÙÔÍÈÎfiÙËÙ· ÙˆÓ Ê·ÚÌ¿ÎˆÓ (·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘) Â›Ó·È ÈÔ Û˘¯Ó¤˜ Û ËÏÈÎȈ̤ÓÔ˘˜ Ï‹Ù˜ ·fi ECD29-32. ¡ÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ËÏÈÎȈ̤ÓÔ ‰fiÙË ·ÚÔ˘ÛÈ¿˙ÂÈ ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ ·fiÚÚȄ˘ ÏfiÁˆ Ù˘ DGF, Ù˘ ·‡ÍËÛ˘ Ù˘ ·ÓÔÛÔÁÔÓÈÎfiÙËÙ·˜33 Î·È ÌÈ· ÌÂÁ·Ï‡ÙÂÚË Ù¿ÛË ÁÈ· ÂÈÏÔΤ˜ ·fi ÙËÓ ›‰È· ÙËÓ ·fiÚÚÈ„Ë34. ¶·Ú¿ Ù· ·Ú·¿Óˆ ·Ôı·ÚÚ˘ÓÙÈο ·ÔÙ¤ÏÂÛÌ·Ù·, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ‰fiÙË ECD ·Ú·Ì¤ÓÂÈ ıÂÙÈ΋ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË Û ۯ¤ÛË Ì ÙËÓ ·ÈÌÔοı·ÚÛË ÁÈ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜. ΔÔ fiÊÂÏÔ˜ ÂÈ‚›ˆÛ˘ ·fi ECD ‰ÂÓ Â›Ó·È ›ÛÔ Ì ÂΛÓÔ ·fi SCD ̤¯ÚÈ 3,5 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË35. ªÂ ¿ÏÏ· ÏfiÁÈ·, ÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·ÔÎÔÌ›˙Ô˘Ó fiÊÂÏÔ˜ ÂÈ‚›ˆÛ˘ ·fi ECD ·Ó ‰ÂÓ ÂÈ‚ÈÒÓÔ˘Ó ÂÚÈÛÛfiÙÂÚÔ ·fi 3,5 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ¤ÛÙˆ Î·È ·Ó Ë QOL ÌÔÚ› Ó· ‚ÂÏÙÈÒÓÂÙ·È ÛËÌ·ÓÙÈο. ¡ÂÊÚÔ› ·fi ECD ·ÔÙÂÏÔ‡Ó ÂÚ›Ô˘ ÙÔ 20% ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ36. ∏ ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘˜ ··ÈÙ› ÙËÓ Û˘Ó·›ÓÂÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. Δ· ÎÚÈÙ‹ÚÈ· ·Ô‰Ô¯‹˜ Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÂÓ Â›Ó·È Û·ÊÒ˜ ηıÔÚÈṲ̂ӷ, ·ÏÏ¿ Ê·›ÓÂÙ·È Ó· ‰ÈηÈÔÏÔÁÔ‡ÓÙ·È ÁÈ· Ï‹Ù˜ ËÏÈΛ·˜ 40 ÂÙÒÓ Î·È ¿Óˆ, Ì ¯·ÌËÏfi ·ÓÔÛÔÏÔÁÈÎfi ΛӉ˘ÓÔ [ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ¯·ÌËÏfi Ù›ÙÏÔ Î˘ÙÙ·ÚÔÙÔÍÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (PRA),

˘„ËÏÔ‡ ‚·ıÌÔ‡ HLA Ù·˘ÙÔÔ›ËÛË ÌÂٷ͇ ‰fiÙËÏ‹ÙË], ¯·ÌËÏfi BMI (<25 kg/m2), Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Â›Ù ·Ú·ÙÂٷ̤ÓË ·ÈÌÔοı·ÚÛË ÏfiÁˆ ÌÂÁ¿ÏÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ· (>3,5 ÂÙË) ‹ ¤¯Ô˘Ó η΋ ·ÁÁÂȷ΋ ÚÔÛ¤Ï·ÛË ‹ Û˘Ó˘¿Ú¯Ô˘Û˜ ·Ûı¤ÓÂȘ (.¯., ‰È·‚‹Ù˘) Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÚÔÛ‰fiÎÈÌÔ ˙ˆ‹˜ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÈÎÚfiÙÂÚÔ ·fi ÙÔÓ ·Ó·ÌÂÓfiÌÂÓÔ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË29,35. ∞ÛıÂÓ›˜ ËÏÈΛ·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ 65 ÂÙÒÓ Î·È ¿Óˆ ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚË ÂÈ‚›ˆÛË fiÙ·Ó ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ·fi ECD ÂÓÙfi˜ 2 ÂÙÒÓ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË Δ™Ã¡¡ (5.6 ¤ÙË) Û ۇÁÎÚÈÛË Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi SCD (5.3 ¯ÚfiÓÈ·) ‹ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË (5.5 ¯ÚfiÓÈ·) ÌÂÙ¿ 4 ¯ÚfiÓÈ· ·ÈÌÔοı·ÚÛ˘37. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ÔÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÔÚ› Ó· ÌËÓ Â›Ó·È Î·Ù¿ÏÏËÏË ÁÈ· ·ÛıÂÓ›˜ Ì ˘„ËÏfi ·ÓÔÛÔÏÔÁÈÎfi ΛӉ˘ÓÔ38,39 ‹ ÌÂÁ¿ÏË ·¯˘Û·ÚΛ· (ÏfiÁˆ Ù˘ ·Ó·ÓÙÈÛÙÔȯ›·˜ ÌÂÁ¤ıÔ˘˜ Ï‹ÙË Î·È ÓÂÊÚÈ΋˜ Ì¿˙·˜). ∂¿Ó ¤Ó·˜ ·ÛıÂÓ‹˜ ·Ó·Ì¤ÓÂÈ Â›Ù ÁÈ· ¤Ó· Ë·Ù›Ùȉ·˜ C ‹ μ ıÂÙÈÎfi ÌfiÛ¯Â˘Ì· ‹ Â›Ó·È ÔÌ¿‰Ô˜ ·›Ì·ÙÔ˜ ∞μ, Â›Ó·È ÏÔÁÈÎfi Ó· ÂÚÈ̤ÓÔ˘Ì ÁÈ· ¤Ó· ÓÂÊÚfi ·fi SCD, ÏfiÁˆ ÙÔ˘ ·Ó·ÌÂÓfiÌÂÓÔ˘ ÌÈÎÚfiÙÂÚÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ·14. ∏ ¯Ú‹ÛÈÌÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ECD Û˘Ó‰¤ÂÙ·È Â›Û˘ Ì ÙËÓ Â¤ÎÙ·ÛË Ù˘ ‰ÂÍ·ÌÂÓ‹˜ ÙˆÓ ‰ÔÙÒÓ Î·È ÙˆÓ ÏËÙÒÓ40,41. ∏ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÈÛÙÔÏÔÁÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ÓÂÊÚÔ‡ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙÔÓ ¯·Ú·ÎÙËÚÈÛÌfi Ù˘ ηٷÏËÏfiÙËÙ¿˜ ÙÔ˘ Î·È ÌÔÚ› Ó· ·ÔÙÚ¤„ÂÈ Ù· ÔÛÔÛÙ¿ ÌË ·Ô‰Ô¯‹˜ ÙÔ˘ 42,43, ·ÏÏ¿ ‰ÂÓ ÌÔÚ› Ó· ÚԂϤ„ÂÈ ·ÎÚÈ‚Ò˜ ÙË Ì·ÎÚÔÚfiıÂÛÌË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜44. ∂Ó· Û‡ÛÙËÌ· ‚·ıÌÔÏfiÁËÛ˘ Î·È ·Ú¿ÏÏËÏ˘ ·ÍÈÔÏfiÁËÛ˘ ÙÔ˘ ‰fiÙË Î·È ÙÔ˘ Ï‹ÙË ¤¯ÂÈ ÚÔÙ·ı› ¤ÙÛÈ ÒÛÙ ӷ Û˘Ì‚¿ÏÂÈ ÛÙËÓ ‰ÈηÈfiÙÂÚË Î·Ù·ÓÔÌ‹ ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ÓÂÊÚÒÓ Î·È ÛÙËÓ Úfi‚ÏÂ„Ë Ù˘ ÚÒÈÌ˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜45. ∏ ·ÏÌÈ΋ Û˘Û΢‹ ÂÎχÛˆ˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û˘Ì‚¿ÏÂÈ ÛÙË Ì›ˆÛË Ù˘ DGF, ·˘Í¿ÓÂÈ ÙÔ ÔÛÔÛÙfi ¯ÚËÛÈÌÔÔ›ËÛ˘ ÙˆÓ ÔÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙÔ Ó· ·ÔÎÏ›ÛÔ˘Ì ÌÔۯ‡̷ٷ ·fi ECD Ì ‰È·Ù·Ú·¯‹ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ ÙÔ˘˜ (ÚÔ‹ ·ÓÙÏ›·˜ <70 ml / min Î·È ÓÂÊÚÈΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ>0.4)46,47.

¢ÈÏ‹ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË (DKT) ∏ ‰ÈÏ‹ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË (DKT) ÂÈÙÚ¤ÂÈ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰‡Ô ÓÂÊÚÒÓ ·fi ¤Ó· ËÏÈÎȈ̤ÓÔ ‰fiÙË (‹ Î·È ˘ÂÚ‹ÏÈη ‰fiÙË) - Ô˘ ‰È·-

METAMO™XEY™Eπ™ 2010

ÊÔÚÂÙÈο ı· ·ÔÚÚ›ÙÔÓÙ·Ó - ÁÈ· ÙËÓ ·ÚÔ¯‹ Â·ÚÎÔ‡˜ ÓÂÊÚÈ΋˜ Ì¿˙·˜ ÛÙÔÓ ˘Ô„‹ÊÈÔ Ï‹ÙË. ∂›Ó·È ÌÈ· ·ÛÊ·Ï‹˜ ÚÔÛ¤ÁÁÈÛË, ·ÏÏ¿ ¤¯ÂÈ ¤Ó· ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi Ù¯ÓÈÎÒÓ ÂÈÏÔÎÒÓ. O Ï‹Ù˘ Ú¤ÂÈ Ó· Â›Ó·È Û ηϋ ηٿÛÙ·ÛË ˘Á›·˜ ÒÛÙ ӷ ·Ó¯ı› ÌÈ· ÌÂÁ¿ÏË ¯ÂÈÚÔ˘ÚÁÈ΋ ‰È·‰Èηۛ·. Δ· ·Ó·ÊÂÚfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È Û˘ÁÎÚ›ÛÈÌ· Ì ·˘Ù¿ Ù˘ ·Ï‹˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·fi ECD48-50. OÈ Andres et al.51 ¤¯Ô˘Ó ÚÔÙ›ÓÂÈ ÌÈ· DKT Ó· ÂÎÙÂÏÂ›Ù·È ·fi ‰fiÙË Ì ËÏÈΛ· 75 ¤ÙÒÓ Î·È ¿Óˆ, ‹ fiÙ·Ó Ô ‰fiÙ˘ Â›Ó·È ÌÂٷ͇ 60 Î·È 74 ÂÙÒÓ Î·È ¤¯ÂÈ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË ÌÂٷ͇ 15% Î·È 50%. ∞ÓÙÈı¤Ùˆ˜, Ë ·Ï‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ı· Ú¤ÂÈ Ó· Ú·ÁÌ·ÙÔÔÈÂ›Ù·È fiÙ·Ó Ô ‰fiÙ˘ Â›Ó·È ÌÂٷ͇ 60 Î·È 74 ÂÙÒÓ, Ì ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË ÌÈÎÚfiÙÂÚË ÙÔ˘ 15%.

∂nblock ÌÂÙ·ÌfiÛ¯Â˘ÛË ·È‰ÈÎÒÓ ‹ ‚ÚÂÊÈÎÒÓ ÓÂÊÚÒÓ ªÂÙ·ÌfiÛ¯Â˘ÛË enblock ·È‰ÈÎÒÓ ‹ ‚ÚÂÊÈÎÒÓ ÓÂÊÚÒÓ Â›Ó·È ÌÈ· ¿ÏÏË ‚ÈÒÛÈÌË ÂÓ·Ï·ÎÙÈ΋ ÂÈÏÔÁ‹ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÁÈ· ÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜. Δ· ÓÂÊÚ¿ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È enblock ·fi ‰fiÙ˜ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ. OÈ Dharnidharka et al.52 ¤¯Ô˘Ó ·Ó·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο ηχÙÂÚË ¤Î‚·ÛË Û ۇÁÎÚÈÛË Ì ÙËÓ ·Ï‹ SCD ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ì ÙËÓ ¯Ú‹ÛË ·˘Ù‹˜ Ù˘ ÚÔÛ¤ÁÁÈÛ˘.

∞ÓÔÛÔηٷÛÙÔÏ‹ Û ËÏÈÎȈ̤ÓÔ˘˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ OÈ ËÏÈÎȈ̤ÓÔÈ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤¯Ô˘Ó ÌÂȈ̤ÓË ·ÓÔÛÔÏÔÁÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Ì ¯·ÌËÏfi ΛӉ˘ÓÔ ·fiÚÚȄ˘53,54 ˘„ËÏfi ΛӉ˘ÓÔ Î·ÎÔ‹ıÂÈ·˜55 Î·È ÏÔÈÌÒ͈Ó56, ÁÂÁÔÓfi˜ Ô˘ ˘Ô‰ËÏÒÓÂÈ fiÙÈ Ë ¯·ÌËÏfiÙÂÚ˘ ¤ÓÙ·Û˘ ·ÓÔÛÔηٷÛÙÔÏ‹, ÂӉ›ÎÓ˘Ù·È ÁÈ· ·˘Ù‹ ÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰·. øÛÙfiÛÔ, Û ÂÚÈÙÒÛÂȘ Ùˆ¯‹˜ HLA Û˘Ì‚·ÙfiÙËÙ·˜, ˘„ËÏfi ÔÛÔÛÙfi ·fiÚÚȄ˘ ¤¯ÂÈ ÂÚÈÁÚ·Ê›11, 41,57. ™˘Ó·ÎfiÏÔ˘ı·, ÛÙȘ ·Ú·¿Óˆ ÂÚÈÙÒÛÂȘ, ¤Ó· ˘„ËÏfiÙÂÚÔ ÔÛfi ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÌÔÚ› Ó· Â›Ó·È ¯Ú‹ÛÈÌÔ, ·ÏÏ¿ ÔÚÈṲ̂ÓÔÈ ÂÚ¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ÂÊ·ÚÌÔÁ‹ ηχÙÂÚ˘ HLA Û˘Ì‚·ÙfiÙËÙ·˜11. ∏ ÌÂȈ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ΢ÙÔ¯ÚÒÌ·ÙÔ˜ P450 Ì ÙË Á‹Ú·ÓÛË, Â›Û˘, ··ÈÙ› Èı·Ófiٷٷ Ì›ˆÛË ÙˆÓ ‰fiÛÂˆÓ Î·È ÙˆÓ ‰‡Ô ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ (CNI) Î·È ÙˆÓ ÛÙÂÚÔÂȉÒÓ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ·ÚÂÓÂÚÁÂÈÒÓ. ¢ÂÓ ˘¿Ú¯Ô˘Ó Û·Ê›˜ ηÙ¢ı˘ÓÙ‹ÚȘ ÁÚ·Ì̤˜ Û‹ÌÂÚ· fiÛÔÓ ·ÊÔÚ¿ ÙË ‚¤ÏÙÈÛÙË ÂÈÏÔÁ‹ ÙÔ˘ ·ÓÔÛÔηٷ-

65

ÛÙ·ÏÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜.OÈ Danovitch et al.58 Ù¿¯ıËÎ·Ó ˘¤Ú Ù˘ ·ÎfiÏÔ˘ı˘ ÚÔÛ¤ÁÁÈÛ˘: Û ¤Ó· ¯·ÌËÏÔ‡ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Ï‹ÙË: ·ÔÊ˘Á‹ ‹ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ÛÙÂÚÔÂȉÒÓ fiÙ·Ó ËÏÈÎȈ̤ÓÔÈ ·ÛıÂÓ›˜ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Ì ¤Ó· Ó¤Ô ÓÂÊÚfi Î·È ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ CNI fiÙ·Ó ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Ì ¤Ó·Ó ËÏÈÎȈ̤ÓÔ ÓÂÊÚfi.™Â ˘„ËÏÔ‡ ·ÓÔÛÔÏÔÁÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Ï‹ÙË, ¯ÚÂÈ¿˙ÂÙ·È ÙÂÏÈο ÙÂÙÚ·Ï‹ ÂÈÛ·ÁˆÁÈ΋ ·ÓÔÛÔηٷÛÙÔÏ‹ Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È IL-2 ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù·.

∂È‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ™ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980, ÔÈ ·ÛıÂÓ›˜ ËÏÈΛ·˜ ÙˆÓ 50 ÂÙÒÓ ‰ÂÓ ÂıˆÚÔ‡ÓÙÔ ˘Ô„‹ÊÈÔÈ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ηıÒ˜ ÔÏϤ˜ ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ ·¤Ù˘¯·Ó Ó· ‰Â›ÍÔ˘Ó fiÊÂÏÔ˜ ÂÈ‚›ˆÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ 59-61. øÛÙfiÛÔ, Ì ÙË ‚ÂÏÙ›ˆÛË Ù˘ ‰È·‰Èηۛ·˜ Ù˘ ÂÈÏÔÁ‹˜, ÙËÓ Î·Ï‡ÙÂÚË ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘, ¤¯ÂÈ Û‹ÌÂÚ· ·Ú·ÙËÚËı› Ô˘ÛÈ·ÛÙÈ΋ ‚ÂÏÙ›ˆÛË ÙfiÛÔ ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ fiÛÔ Î·È ·˘Ù‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞ÎfiÌË Ë ›‰È· ‚ÂÏÙȈÛË ÛÙȘ ÂÈ‚ÈÒÛÂȘ ·Ú·ÙËÚ‹ıËÎÂ Î·È Û ϋÙ˜ ÔÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ62-68. μÂÏÙȈ̤ÓË ÂÈ‚›ˆÛË ¤¯ÂÈ ·Ô‰Âȯı› Î·È Û ·ÛıÂÓ›˜ ¿Óˆ ·fi 70 ÂÙÒÓ69,70. ∞ÛıÂÓ›˜ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ ·ÔÏ·Ì‚¿ÓÔ˘Ó ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤Ó· ۯ‰fiÓ ·ËÏ·Á̤ÓÔ ·fi ÙËÓ ·ÈÌÔοı·ÚÛË ˘fiÏÔÈÔ ˙ˆ‹˜15. ∏ QÔL Î·È Ë ÌÓ‹ÌË Â›Û˘ ‚ÂÏÙÈÒÓÔÓÙ·È71-73. ¶·Ú¿ ÙËÓ ÛËÌ·ÓÙÈο ‚ÂÏÙȈ̤ÓË ÂÈ‚›ˆÛË Û ۇÁÎÚÈÛË Ì ÙËÓ ·ÈÌÔοı·ÚÛË, Ë ıÓËÛÈÌfiÙËÙ· ·Ú·Ì¤ÓÂÈ ˘„ËÏ‹ Û ËÏÈÎȈ̤ÓÔ˘˜ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ÓÂÒÙÂÚÔ˘˜74. ∏ CVD ¤¯ÂÈ ·Ô‰Âȯı› ˆ˜ Ë ÈÔ ÎÔÈÓ‹ ·ÈÙ›· ı·Ó¿ÙÔ˘ Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙȘ ÏÔÈÌÒÍÂȘ ηÈ, ÛÙË Û˘Ó¤¯ÂÈ· ·fi ÙȘ ηÎÔ‹ıÂȘ15,74. ªÂÚÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó, ˆÛÙfiÛÔ, ¤¯Ô˘Ó ·Ó·Ê¤ÚÂÈ ÙȘ ÏÔÈÌÒÍÂȘ ˆ˜ ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ı·Ó¿ÙÔ˘75,76. ∏ ÌÂÁ¿ÏË ÂÔ̤ӈ˜ ËÏÈΛ·, ·ÔÙÂÏ› ¤Ó·Ó ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ˘¤ÚÙ·ÛË, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË 77 Î·È Â·Û‚ÂÛÙÒÛÂȘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ78, Î·È ı¤ÙÂÈ ÙÔ˘˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Û ˘„ËÏfi ΛӉ˘ÓÔ Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘. ¶·Ú¿ÁÔÓÙ˜ fiˆ˜ Ô ‰È·‚‹Ù˘, ÙÔ Î¿ÓÈÛÌ·, Ë ·¯˘Û·ÚΛ· Î·È ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÈÌÔοı·ÚÛË ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ÌÂȈ̤ÓË ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ17,79.

OÈ ËÏÈÎȈ̤ÓÔÈ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ˘Ê›ÛÙ·ÓÙ·È ÏÈÁfiÙÂÚ˜ ·ÒÏÂȘ ÌÔۯ‡̷ÙÔ˜ ‰Â˘-

66

°. ªÀ™∂ƒ§∏™, ¢. Δ∞∫OÀ¢∞™

ÙÂÚÔ·ıÒ˜ ÏfiÁˆ ·fiÚÚȄ˘, Î·È Ô ı¿Ó·ÙÔ˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· Â›Ó·È Ë ÈÔ ÎÔÈÓ‹ ·ÈÙ›· Ù˘ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ Ù· 5 ÚÒÙ· ¤ÙË, ·ÓÙÈÚÔÛˆ‡ÔÓÙ·˜ ¿Óˆ ·fi ÙÔ 50% ÙˆÓ ı·Ó¿ÙˆÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË80.∞Ó ·ÁÓÔËı› Ô ı¿Ó·ÙÔ˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· ÙfiÙ ·Ó·Ê¤ÚÂÙ·È ·ÚfiÌÔÈÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂٷ͇ ÙˆÓ Ó¤ˆÓ Î·È ÙˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ÏËÙÒÓ15,81.

™˘Ì¤Ú·ÛÌ· °È· ÙÔ˘˜ ÚÔÛÂÎÙÈο ÂÈÏÂÁ̤ÓÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜ ·ÛıÂÓ›˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› ·ÍÈfiÏÔÁË ÂÈÏÔÁ‹. ¶ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ ÁÈ· ·‡ÍËÛË Ù˘ ¯ÚËÛÈÌÔÔ›ËÛ˘ ÙˆÓ ECD Î·È DCD ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÙË ‚ÂÏÙ›ˆÛË Ù˘ ‰È·¯Â›ÚÈÛ˘ Ù˘ Ï›ÛÙ·˜ ·Ó·ÌÔÓ‹˜, ÙË ‚ÂÏÙÈÛÙÔÔ›ËÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È ÙË ‚ÂÏÙ›ˆÛË Ù˘ ηډȷÁÁÂȷ΋˜ ÓÔÛËÚfiÙËÙ·˜ ı· Û˘Ì‚¿ÏÂÈ ÛÙËÓ Â›Ù¢ÍË ÙˆÓ ÛÙfi¯ˆÓ Ù˘ ·‡ÍËÛ˘ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Î·È ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ËÏÈÎÈˆÌ¤ÓˆÓ ·ÛıÂÓÒÓ.

11.

12.

13.

14.

15.

16.

17.

μÈ‚ÏÈÔÁÚ·Ê›· 1. US Renal Data System: Annual Data Report. Bethesda, MD: National Institute of Health, National Institutes of Diabetes and Digestive and Kidney Diseases; 2008. http://www.usrdsorg/adr.htm 2. Organ Procurement and Transplantation Network (OPTN) National data. http://www.optn.org/latestData/step2.asp?.

3. 2003 OPTN/SRTR. Annual Report 1993-2002.

HHS/HRSA//HSB/DOT; UNOS; Arbor Research Collaborative for Health. http://www.ustransplant. org/annual_reports/archives/2003/501_age_ki.htm 4. Cantarovich D, Baranger T, Tirouvanziam A, et al. Onehundred and _ve cadaveric kidney transplants with cyclosporine in recipients more than 60 years of age.

Transplant Proc 1993; 25:1323.

5. Ismail N, Hakim RM, Helderman JH. Renal replacement therapies in the elderly. Part II: Renal transplantation. Am J Kidney Dis 1994; 23:1-15.

6. 2007 OPTN/SRTR. Annual Report 2002-2006.

HHS/HRSA//HSB/DOT; UNOS; Arbor Research for Health. http://www.ustransplant.org/annual_rep orts/current/501b_age_ki.htm 7. Danovitch GM. A kidney for all ages. Am J Transplant 2006; 6:1267-1268.

8. Meier-Kriesche HU, Schold JD, Gaston RS, et al. Kidneys from deceased donors: maximizing the value of a scarce resource. Am J Transplant 2005; 5:1725-1730.

9. Curtis JJ. Ageism and kidney transplantation. Am J Transplant 2006; 6:1264-1266.

10. Saidi RF, Kennealey PT, Elias N, et al. Deceased donor kidney transplantation in elderly patients: is there a

18.

19.

20.

21.

22.

23.

24.

25.

26.

difference in outcomes? Transplant Proc 2008; 40: 3413–3417.

Frei U, Noeldeke J, Machold-Fabrizii V, et al. Prospective age-matching in elderly kidney transplant recipients – a 5-year analysis of the Eurotransplant Senior Program. Am J Transplant 2008; 8: 50-57.

Wolfe RA, McCullough KP, Schaubel DE, et al.

Calculating life years from transplant (LYFT): methods for kidney and kidney-pancreas candidates. Am J Transplant 2008; 8: 997-1011.

Rosengard BR, Feng S, Alfrey EJ, et al. Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor. Am J Transplant 2002; 2: 701–711.

Stratta RJ, Sundberg AK, Rohr MS, et al. Optimal use of older donors and recipients in kidney transplantation.

Surgery 2006; 139: 324-333.

Oniscu GC, Brown H, Forsythe JL. How old is old for transplantation? Am J Transplant 2004; 4: 2067–2074.

Jassal SV, Krahn MD, Naglie G, et al. Kidney transplantation in the elderly: a decision analysis. J Soc Nephrol 2003; 14: 187-196.

Cosio FG, Alamir A, Yim S, et al. Patient survival after renal transplantation. I: The impact of dialysis pretransplant. Kidney Int 1998; 53: 767–772.

Laupacis A, Keown P, Pus N, et al. A study of the quality of life and cost-utility of renal transplantation. Kidney Int 1996; 50: 235-242.

Eggers P. Comparison of treatment costs between dialysis and transplantation. Semin Nephrol 1992; 12: 284-289.

Saidi RF, Elias N, Kawai T, et al. Outcome of kidney transplantation using expanded criteria and donation after cardiac death kidneys: realities and costs. Am J Transplant 2007; 7: 2769-2774.

Rabbat CG, Thorpe KE, Russell JD, Churchill DN. Comparison of mortality risk for dialysis patients and cadaveric first renal transplant recipients in Ontario, Canada. J Am Soc Nephrol 2000; 11:917-922.

Wu C, Shapiro R, Tan H, et al. Kidney transplantation in elderly people: the influence of recipient comorbidity and living kidney donors. J Am Geriatr Soc 2008; 56: 231-238.

Gill J, Bunnapradist S, Danovitch GM, et al. Outcomes of kidney transplantation from older living donors to older recipients. Am J Kidney Dis 2008; 52: 541-552.

Gill JS, Gill J, Rose C, et al. The older living kidney donor: part of the solution to the organ shortage.

Transplantation 2006; 82: 1662-1666.

Sakai K, Okamoto M, Suzuki T, et al. The excellent results of spousal kidney transplantation: experience in a Japanese single center. Transplant Proc 2008; 40: 21182120.

Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 1995; 333: 333-336.

METAMO™XEY™Eπ™ 2010

27. Locke JE, Segev DL, Warren DS, et al. Outcomes of kidneys from donors after cardiac death: implications for allocation and preservation. Am J Transplant 2007; 7: 1797–1807.

28. D’Alessandro AM, Fernandez LA, Chin LT, et al.

Donation after cardiac death: the University of Wisconsin experience. Ann Transplant 2004; 9: 68-71.

29. Metzger RA, Delmonico FL, Feng S, et al. Expanded criteria donors for kidney transplantation. Am J Transplant 2003; 3 (Suppl 4): 114-125.

30. Pfaff WW, Howard RJ, Patton PR, et al. Delayed graft function after renal transplantation. Transplantation 1998; 65: 219-223.

31. Matas AJ, Gillingham KJ, Elick BA, et al. Risk factors for prolonged hospitalization after kidney transplants.

Clin Transplant 1997; 11: 259-264.

32. Shoskes DA, Cecka JM. Deleterious effects of delayed graft function in cadaveric renal recipients independent of acute rejection. Transplantation 1998; 66: 16971701.

33. Reutzel-Selke A, Filatenkov A, Jurisch A, et al. Grafts from elderly donors elicit a stronger in the early period posttransplantation: a study in a rat model. Transplant Proc 2005; 37:382-383.

34. Melk A, Schmidt BM, Braun H, et al. Effects of donor age and cell senescence on kidney allograft survival.

Am J Transplant 2009; 9: 114-123.

35. Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA 2005; 294:2726-2733.

36. Marks WH, Wagner D, Pearson TC, et al. Organ donation and utilization, 1995-2004: entering the collaborative era. Am J Transplant 2006; 6: 1101–1110.

37. Schold JD, Meier-Kriesche HU. Which renal transplant candidates should accept marginal kidneys in exchange for a shorter waiting time on dialysis? Clin J Am Soc Nephrol 2006; 1:532-538.

38. Sellers MT, Velidedeoglu E, Bloom RD, et al. Expandedcriteria donor kidneys: a single-center clinical and short-term financial analysis – cause for concern in retransplantation. Transplantation 2004; 78: 1670-1675.

39. Miles CD, Schaubel DE, Jia X, et al. Mortality experience in recipients undergoing repeat transplantation with expanded criteria donor and non-ECD deceased-donor kidneys. Am J Transplant 2007; 7: 1140–1147.

40. Stratta RJ, Rohr MS, Sundberg AK, et al. Increased kidney transplantation utilizing expanded criteria deceased organ donors with results comparable to standard criteria donor transplant. Ann Surg 2004; 239: 688-695; discussion 695-687.

41. Fritsche L, Horstrup J, Budde K, et al. Old-for-old kidney allocation allows successful expansion of the donor and recipient pool. Am J Transplant 2003; 3: 1434-1439.

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42. Delmonico FL, Burdick JF. Maximizing the success of transplantation with kidneys from older donors. N Engl J Med 2006; 354: 411-413.

43. Lopes JA, Moreso F, Riera L, et al. Evaluation of preimplantation kidney biopsies: comparison of Banff criteria to a morphometric approach. Kidney Int 2005; 67: 1595-1600.

44. Pokorna E, Vitko S, Chadimova M, et al. Proportion of glomerulosclerosis in procurement wedge renal biopsy cannot alone discriminate for acceptance of marginal donors. Transplantation 2000; 69: 36-43.

45. Nyberg SL, Matas AJ, Rogers M, et al. Donor scoring system for cadaveric renal transplantation. Am J Transplant 2001; 1: 162-170.

46. Tesi RJ, Elkhammas EA, Davies EA, et al. Pulsatile kidney perfusion for evaluation of high-risk kidney donors safely expands the donor pool. Clin Transplant 1994; 8:134-138.

47. Kusaka M, Kubota Y, Sasaki H, et al. Is pulsatile perfusion necessary for renal transplantation engrafting kidneys from cardiac death donors? Transplant Proc 2006; 38: 3388-3389.

48. Tan JC, Alfrey EJ, Dafoe DC, et al. Dual-kidney transplantation with organs from expanded criteria donors: a long-term follow-up. Transplantation 2004; 78:692696.

49. Remuzzi G, Grinyo J, Ruggenenti P, et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. Double Kidney Transplant Group (DKG). J Am Soc Nephrol 1999; 10: 2591-2598.

50. Gill J, Cho YW, Danovitch GM, et al. Outcomes of dual adult kidney transplants in the United States: an analysis of the OPTN/UNOS database. Transplantation 2008; 85: 62-68.

51. Andres A, Morales JM, Herrero JC, et al. Double versus single renal allografts from aged donors. Transplantation 2000; 69: 2060-2066.

52. Dharnidharka VR, Stevens G, Howard RJ. En-bloc kidney transplantation in the United states: an analysis of united network of organ sharing (UNOS) data from 1987 to 2003. Am J Transplant 2005; 5: 1513-1517.

53. Friedman AL, Goker O, Kalish MA, et al. Renal transplant recipients over aged 60 have diminished immune activity and a low risk of rejection. Int Urol Nephrol 2004; 36: 451-456.

54. Becker BN, Ismail N, Becker YT, et al. Renal transplantation in the older end stage renal disease patient.

Semin Nephrol 1996; 16: 353-362.

55. Stratta P, Morellini V, Musetti C, et al. Malignancy after kidney transplantation: results of 400 patients from a single center. Clin Transplant 2008; 22:424-427.

56. Meier-Kriesche HU, Ojo AO, Hanson JA, Kaplan B. Exponentially increased risk of infectious death in older renal transplant recipients. Kidney Int 2001; 59: 1539–1543.

68

°. ªÀ™∂ƒ§∏™, ¢. Δ∞∫OÀ¢∞™

57. Giessing M, Budde K, Fritsche L, et al. ‘Old-for-old’ cadaveric renal transplantation: surgical findings, perioperative complications and outcome. Eur Urol 2003; 44: 701-708.

58. Danovitch GM, Gill J, Bunnapradist S. Immunosuppression of the elderly kidney transplant recipient.

Transplantation 2007; 84: 285-291.

transplantation: analysis of Medicare payments. Transplantation 2000; 70: 755-760.

69. Rao PS, Merion RM, Ashby VB, et al. Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipients. Transplantation 2007; 83: 1069-1074.

59. Sommer BG, Ferguson RM, Davin TD, et al. Renal transplantation in patients over 50 years of age.

Transplant Proc 1981; 13: 33-35.

70. Buchler M, Halimi JM, Najjar AA, et al. Living with a functioning kidney transplant at 74 yr or older: a national epidemiological study. Clin Transplant 2004; 18: 681-685.

60. Lundgren G, Fehrman I, Gunnarsson R, et al. Cadaveric renal transplantation in patients over 55 years of age with special emphasis on immunosuppressive therapy.

Transplant Proc 1982; 14: 601-604.

71. Jofre R, Lopez-Gomez JM, Moreno F, et al. Changes in quality of life after renal transplantation. Am J Kidney Dis 1998; 32: 93-100.

61. Hutchinson TA, Thomas DC, Lemieux JC, Harvey CE. Prognostically controlled comparison of dialysis and renal transplantation. Kidney Int 1984; 26: 44-51.

72. Humar A, Denny R, Matas AJ, Najarian JS. Graft and quality of life outcomes in older recipients of a kidney transplant. Exp Clin Transplant 2003; 1: 69-72.

62. Roodnat JI, Zietse R, Mulder PG, et al. The vanishing importance of age in renal transplantation. Transplantation 1999; 67: 576-580.

73. Griva K, Thompson D, Jayasena D, et al. Cognitive functioning pre to postkidney transplantation – a prospective study. Nephrol Dial Transplant 2006; 21: 3275-3282.

63. Kappes U, Schanz G, Gerhardt U, et al. Influence of age on the prognosis of renal transplant recipients. Am J Nephrol 2001; 21: 259-263.

74. Ojo AO, Hanson JA, Wolfe RA, et al. Long-term survival in renal transplant recipients with graft function. Kidney Int 2000; 57: 307-313.

64. Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of renal cadaveric transplantation on survival in end-stage renal failure: evidence for reduced mortality risk compared with hemodialysis during long-term follow-up. J Am Soc Nephrol 1998; 9: 2135-2141.

75. Jassal SV, Opelz G, Cole E. Transplantation in the elderly: a review. Geriatr Nephrol Urol 1997; 7: 157-165.

65. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999; 341: 1725-1730.

66. Johnson DW, Herzig K, Purdie D, et al. A comparison of the effects of dialysis and renal transplantation on the survival of older uremic patients. Transplantation 2000; 69: 794-799.

67. Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol 2001; 12: 589-597.

68. Whiting JF, Woodward RS, Zavala EY, et al. Economic cost of expanded criteria donors in cadaveric renal

76. Sato K, Ogawa K, Onumata O, et al. Cause of death in renal transplant patients: a comparison between azathioprine and ciclosporin. Surg Today 2001; 31: 681-687.

77. Foo SM, Wong HS, Morad Z. Risk factors and incidence of posttransplant diabetes mellitus in renal transplant recipients. Transplant Proc 2004; 36: 2139-2140.

78. Rosas SE, Mensah K, Weinstein RB, et al. Coronary artery calcification in renal transplant recipients. Am J Transplant 2005; 5: 1942-1947.

79. Cardinal H, Hebert MJ, Rahme E, et al. Modifiable factors predicting patient survival in elderly kidney transplant recipients. Kidney Int 2005; 68: 345-351.

80. Cecka JM. The UNOS renal transplant registry. Clin Transpl 2001: 1-18.

81. Tesi RJ, Elkhammas EA, Davies EA, et al. Renal transplantation in older people. Lancet 1994; 343: 461-464.

MÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Û ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ Ï‹Ù˜ ™. ª·ÚÈÓ¿ÎË

2. ∞˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ·fiÚÚȄ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.

ª›· ·fi ÙȘ Û‡Á¯ÚÔÓ˜ ÚÔÎÏ‹ÛÂȘ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Â›Ó·È Ë ·Ó‡ÚÂÛË Û˘Ì‚·ÙÒÓ ‰ÔÙÒÓ ÁÈ· ·ÛıÂÓ›˜ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ˘„ËÏÔ‡˜ Ù›ÙÏÔ˘˜ ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (¢·ÈÛıËÙÔÔÈË̤ÓÔÈ Î·È ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ). ∂˘·ÈÛıËÙÔÔÈË̤ÓÔÈ ıˆÚÔ‡ÓÙ·È ÔÈ ˘Ô„‹ÊÈÔÈ Ï‹Ù˜ Ì ÚÔÛ¯ËÌ·ÙÈṲ̂ӷ ·ÓÙÈ-HLA ·ÓÙÈÛÒÌ·Ù· (PRA’s) Ì ٛÙÏÔ >20%. ø˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔÈ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ÔÈ ·ÛıÂÓ›˜ Ì ٛÙÏÔ PRA’s ·fi 65 ̤¯ÚÈ 80%. Δ· ·ÓÙÈ-HLA ·ÓÙÈÛÒÌ·Ù· ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ÌÂÙ¿ ·fi οÔÈÔ ÁÂÁÔÓfi˜ ¢·ÛıËÙÔÔ›ËÛ˘ fiˆ˜ Â›Ó·È Ë Î‡ËÛË, ÔÈ ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜ ‹ ÚÔËÁÔ‡ÌÂÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË. O ‚·ıÌfi˜ ·ÏÏ¿ Î·È Ë ‰È¿ÚÎÂÈ· ¢·ÈÛıËÙÔÔ›ËÛ˘ ÏfiÁˆ ·ËÛ˘ ‹ ÌÂÙ·ÁÁ›ÛÂˆÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ·ÚÈıÌfi Î·È ÙË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ ·˘ÙÒÓ ÙˆÓ ÁÂÁÔÓfiÙˆÓ, ÂÓÒ Ë Â˘·ÈÛıËÙÔÔ›ËÛË ·fi ÚÔËÁÔ‡ÌÂÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÌÊ·Ó›˙ÂÈ ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ·1. ∂˘·ÈÛıËÙÔÔ›ËÛË ÌÔÚ› Ó· ÚÔÎÏËı› Î·È ·fi Â͈ÁÂÓ›˜ ·Ú¿ÁÔÓÙ˜ .¯. ÏÔÈÌÒÍÂȘ ÁÂÁÔÓfi˜ Ô˘ ÂÓÈÛ¯‡ÂÙ·È Î·È ·fi ÙËÓ ‡·ÚÍË ÎÔÈÓ‹˜ ·ÏÏËÏÔ˘¯›·˜ ÌÂٷ͇ HLA Î·È ÌÈÎÚÔ‚È·ÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ Èı·ÓfiÙËÙ· ÚfiÎÏËÛ˘ ÚˆÙ·Ú¯È΋˜ ·ÓÔÛÔ·¿ÓÙËÛ˘ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ïԛ̈͢ ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı›, ·˘Ùfi fï˜ Ô˘ ÌÔÚ› Ó· Û˘Ì‚Â›, Â›Ó·È Ë Â·ÓÂÓÂÚÁÔÔ›ËÛË ÌÈ·˜ ηı˘ÛÙÂÚË̤Ó˘ ·ÏÏÔ·¿ÓÙËÛ˘ ‹ Ë ‰È·Ù‹ÚËÛË ÌÈ·˜ Û˘Ó¯È˙fiÌÂÓ˘ ·Ú·ÁˆÁ‹˜ ·ÓÙÈۈ̿وÓ2. Δ· ÚÔ‚Ï‹Ì·Ù· ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÙˆÓ ˘ÂÚ¢·ÈÛıËÙÔÔÈËÌ¤ÓˆÓ ÏËÙÒÓ Â›Ó·È

OÚÈÛÌfi˜ ¢·ÈÛıËÙÔÔ›ËÛ˘ O ÔÚÈÛÌfi˜ ÙÔ˘ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘ Ï‹ÙË ÛÙËÚ›˙ÂÙ·È ÛÙÔÓ Ù›ÙÏÔ ÙˆÓ PRA’s Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÈÎÚ¤˜ ‰È·ÊÔÚÔÔÈ‹ÛÂȘ ·Ó¿ÏÔÁ· Ì ÙË ¯ÒÚ·. ™ÙË ∂ÏÏ¿‰· ÙÔ fiÚÈÔ Â›Ó·È PRA’s>70%, ÛÙȘ ¯ÒÚ˜ Ù˘ Eurotransplant >85%, ÂÓÒ ÛÙËÓ ∞ÌÂÚÈ΋ > 80%. ∂ΛÓÔ Ô˘ Â›Ó·È ÛËÌ·ÓÙÈÎfi Â›Ó·È Ë Ì¤ıÔ‰Ô˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ‚·ıÌÔ‡ ¢·ÈÛıËÙÔÔ›ËÛ˘. OÈ Ì¤ıÔ‰ÔÈ ÛÙËÚ›˙ÔÓÙ·È ÛÙËÓ ·Ó›¯Ó¢ÛË ÛÙÔÓ ˘Ô„‹ÊÈÔ Ï‹ÙË ·ÓÙÈ-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÂÓfi˜ Ê¿ÛÌ·ÙÔ˜ ÁÓˆÛÙÒÓ ·ÓÙÈÁfiÓˆÓ ·fi ‰ÂÍ·ÌÂÓ‹ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ (PRA’s=panel reactive antibodies). ªÂ ÙË Ì¤ıÔ‰Ô CDC (complement dependent cytotoxicity), o ÔÚfi˜ ÙÔ˘ Ï‹ÙË ÚÔÛÙ›ıÂÙ·È Û ‰ÂÍ·ÌÂÓ‹ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ì ÁÓˆÛÙ¿, Ù·˘ÙÔÔÈË̤ӷ HLA ·ÓÙÈÁfiÓ· (panel) Î·È ·ÎÔÏÔ˘ı› Ë ÚÔÛı‹ÎË Û˘ÌÏËÚÒÌ·ÙÔ˜. ΔÔ ÔÛÔÛÙfi ÙˆÓ ıÂÙÈÎÒÓ (΢ÙÙ·ÚÔÙÔÍÈÎÒÓ) ·ÓÙȉڿÛÂˆÓ ÛÙÔ panel Â›Ó·È ÙÔ ÔÛÔÛÙfi ÙˆÓ PRA’s ÙÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË. ∂ÎÙfi˜ ·fi ÙËÓ ÎÏ·ÛÛÈ΋ ̤ıÔ‰Ô ÙÔ˘ CDC, PRA’s ÌÔÚÔ‡Ó Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó Ì Elisa, Ì ÙË Ì¤ıÔ‰Ô Luminex ‹ Ì ΢ÙÙ·ÚÔÌÂÙÚ›· ÚÔ‹˜. ∞Ó¿ÏÔÁ· Ì ÙË Ì¤ıÔ‰Ô, ·ÓȯÓ‡ÔÓÙ·È ‰È¿ÊÔÚÔÈ Ù‡ÔÈ ·ÓÙÈۈ̿وÓ, Ë ÎÏÈÓÈ΋ ÛËÌ·Û›· ÙˆÓ ÔÔ›ˆÓ ‰ÂÓ Â›Ó·È ¿ÓÙ· Û·Ê‹˜. Δ· ·ÓÙÈÛÒÌ·Ù· Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ¤Ó·Ó ·ÛıÂÓ‹ ˆ˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ Â›Ó·È fiÏ· Ù· IgG ·ÏÏÔ·ÓÙÈÛÒÌ·Ù· Ù¿Í˘ π Î·È ππ, Û˘Ó‰¤ÔÓÙ· Î·È ÌË Û˘Ó‰¤ÔÓÙ· in vitro ÙÔ Û˘Ìϋڈ̷, Ù· ÔÔ›· ·ÓȯÓ‡ıËÎ·Ó ÔÔÈ·‰‹ÔÙ ÛÙÈÁÌ‹ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ηıÒ˜ Î·È IgM ·ÏÏÔ·ÓÙÈÛÒÌ·Ù· Ô˘ ·ÓȯÓ‡ÔÓÙ·È ÏÈÁfiÙÂÚÔ ·fi 6 Ì‹Ó˜ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂Âȉ‹ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ PRA’s Ì ÙË Ì¤ıÔ‰Ô CDC Û ‰ÂÍ·ÌÂÓ‹ (panel) ÂÚÈÏ·Ì‚¿ÓÂÈ ÏÂÌÊÔ·ÙÙ·Ú· ·fi ‰ÂÍ·ÌÂÓ‹ ÂÚ›Ô˘ 50-100 Ù˘ÔÔÈËÌ¤ÓˆÓ ‰ÔÙÒÓ Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÈÎÚ‹ ·Ó··Ú·ÁˆÁÈÌfiÙËÙ· ˆ˜ ̤ıÔ‰Ô˜ (‰È·Î‡Ì·ÓÛË Ì¤¯ÚÈ Î·È 10-80% ÁÈ· ÙÔ ›‰ÈÔ ‰Â›ÁÌ· ÔÚÔ‡ ÙÔ˘ Ï‹ÙË) ¯ÚËÛÈÌÔÔÈÂ›Ù·È ‹‰Ë ÛÙȘ ¯ÒÚ˜ Ù˘ Eurotransplant

1. ¢˘Û¯¤ÚÂÈ· ·Ó‡ÚÂÛ˘ Û˘Ì‚·ÙÔ‡ ÌÔۯ‡̷ÙÔ˜ ÷ÌËÏfiÙÂÚÔ ÔÛÔÛÙfi ÌÂÙ·ÌÔÛ¯Â˘ÛÈÌfiÙËÙ·˜ ·fi ÙÔ˘˜ ÌË ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜. 6,5% ¤Ó·ÓÙÈ 14% ‚¿ÛÂÈ ÛÙÔȯ›ˆÓ ·fi ÙË USRDS (US Renal Data System) ÙÔ˘ 2003. ∞˘Ùfi Û˘ÓÂ¿ÁÂÙ·È ·˘ÍË̤ÓÔ ¯ÚfiÓÔ ·Ú·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· –΢ڛˆ˜ ·fi ηډȷÁÁÂȷο– Ô˘ ÚÔ·ÙÂÈ ·fi ÙË Ì·ÎÚ¿ ‰È¿ÚÎÂÈ· ·Ú·ÌÔÓ‹˜ Û ̤ıÔ‰Ô ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜.

69

70

™. ª∞ƒπ¡∞∫∏

Ë Ì¤ıÔ‰Ô˜ ÙÔ˘ ÂÈÎÔÓÈÎÔ‡ crossmatch (virtual crossmatch). ªÂ ÙË Ì¤ıÔ‰Ô ·˘Ù‹, ÔÈ ÂȉÈÎfiÙËÙ˜ ÙˆÓ ·ÓÙÈ-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ ÙÔ˘ Ï‹ÙË Î·ıÔÚ›˙ÔÓÙ·È Ì¤Ûˆ ÂÓfi˜ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ∏/À Ì panel Ù· HLA ·fi ‰ÂÍ·ÌÂÓ‹ ÂÚ›Ô˘ 30.000 Ù˘ÔÔÈËÌ¤ÓˆÓ ‰ÔÙÒÓ (PRA’s=Population Reactive Antibodies). Δ· ˘Ô¯ÚˆÙÈο Ù˘ÔÔÈÔ‡ÌÂÓ· HLA Â›Ó·È Ù· HLA A-B- Î·È DR-. Δ· HLA C-, DQ Î·È DP Ù˘ÔÔÈÔ‡ÓÙ·È ÚÔ·ÈÚÂÙÈο, ·Ó¿ÏÔÁ· Ì ÙÔ Î¤ÓÙÚÔ. ªÂÙ¿ ÙÔ ¯·Ú·ÎÙËÚÈÛÌfi ÂÓfi˜ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË ˆ˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘, ÔÈ ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ·Ó‡ÚÂÛË Û˘Ì‚·ÙÔ‡ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó Â›Ó·È: 1. ∏ ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙËÓ ÂÈÏÔÁ‹ ™ÙËÚ›˙ÂÙ·È ÛÙË Ì¤ıÔ‰Ô ÙˆÓ ·Ô‰ÂÎÙÒÓ ·Û‡Ì‚·ÙˆÓ ·ÓÙÈÁfiÓˆÓ (acceptable mismatches).

2. £ÂÚ·›˜ ·¢·ÈÛıËÙÔÔ›ËÛ˘.

3. ™˘ÌÌÂÙÔ¯‹ Û ÚÔÁÚ¿ÌÌ·Ù· ·ÓÙ·ÏÏ·Á‹˜ ˙¢Á·ÚÈÒÓ ‰fiÙË-Ï‹ÙË (paired exchange donation).

¶ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙËÓ ÂÈÏÔÁ‹ ∏ Ú·ÎÙÈ΋ ·˘Ù‹ ÂÊ·ÚÌfi˙ÂÙ·È ÛÙË Eurotransplant ·fi ÙÔ 1985 Î·È ·fi ÛÙËÓ ∂ÏÏ¿‰· ·fi ÙÔ 2004 Î·È ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË Ì ÙË Ì¤ıÔ‰Ô ÙˆÓ «·Ô‰ÂÎÙÒÓ ·Û‡Ì‚·ÙˆÓ ·ÓÙÈÁfiÓˆÓ» (acceptable mismatches). °›ÓÂÙ·È «ÚÔÂÈÏÔÁ‹» ÌfiÓÔ ÂÎÂ›ÓˆÓ ÙˆÓ ˘ÂÚ¢·ÈÛıËÙÔÔÈËÌ¤ÓˆÓ ÏËÙÒÓ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ΢ÎÏÔÊÔÚÔ‡ÓÙ· ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ HLA ·ÓÙÈÁfiÓˆÓ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ‰fiÙË3. ∏ ̤ıÔ‰Ô˜ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ÈÛÙÔÚÈ΋ ¢·ÛıËÙÔÔ›ËÛË (·ÓÔÛÔÏÔÁÈ΋ ÌÓ‹ÌË) ÙÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË.∏ ·Ó›¯Ó¢ÛË ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Á›ÓÂÙ·È Ì ·Ó¿Ï˘ÛË ÙˆÓ ·ÚÓËÙÈÎÒÓ Î˘ÙÙ·ÚÔÙÔÍÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ÛÙÔ panel, Ì ÌÂıfi‰Ô˘˜ Ôχ ¢·›ÛıËÙ˜, fiˆ˜ ·˘Ù‹ Ù˘ ΢ÙÙ·ÚÔÌÂÙÚ›·˜ ÚÔ‹˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ·˘Ù‹ ÙˆÓ single antigen beads.™ÙË Eurotransplant ¯ÚËÛÈÌÔÔÈÂ›Ù·È Î·È ÚfiÁÚ·ÌÌ· ∏/À (HLA Matchmaker) Ì Ôχ ˘„ËÏ‹ ¢·ÈÛıËÛ›· ·Ó·ÁÓÒÚÈÛ˘ ·ÏÏËÏÔ˘¯ÈÒÓ ·ÌÈÓÔͤˆÓ (triplets) ÙˆÓ HLA ·ÓÙÈÁfiÓˆÓ. ¶ÚÔ¸Ôı¤ÛÂȘ ÚÔÂÈÏÔÁ‹˜ ›ӷÈ: 1. ¡· ÌËÓ ·ÓȯÓ‡ÔÓÙ·È ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ‰fiÙË Û ÈÛÙÔÚÈÎÔ‡˜ ÔÚÔ‡˜ ÙÔ˘ Ï‹ÙË 2. ¡· ÌËÓ ˘¿Ú¯ÂÈ ¤ÎÊÚ·ÛË HLA ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ‰fiÙË Û ÌfiÛ¯Â˘Ì· ·ÔÚÚÈÊı¤Ó ·fi ÙÔÓ ˘Ô„‹ÊÈÔ Ï‹ÙË. ∫·ıÔÚÈÛÙÈÎfi˜ Â›Ó·È Ô Ù·ÎÙÈÎfi˜ ¤ÏÂÁ¯Ô˜, ·Ó¿ 3-

6 Ì‹Ó˜, ÌÂ Ù˘ÔÔ›ËÛË ·fi ÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ fiÏˆÓ ÙˆÓ ˘ÂÚ¢·ÈÛıËÙÔÔÈËÌ¤ÓˆÓ ·ÛıÂÓÒÓ Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂ ÙË Ì¤ıÔ‰Ô ÙÔ˘ acceptable mismatch Á›ÓÂÙ·È «ÂÎ ÙˆÓ ÚÔÙ¤ÚˆÓ» ·ÔÎÏÂÈÛÌfi˜ ÙˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ Ô˘ ¤¯Ô˘Ó Èı·ÓfiÙËÙ· Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ıÂÙÈÎfi crossmatch Ì ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ‰fiÙË. ∞ÔÙ¤ÏÂÛÌ· Â›Ó·È Ë ·ÔÊ˘Á‹ ÛËÌ·ÓÙÈÎÔ‡ ·ÚÈıÌÔ‡ «¿ÛÎÔˆÓ» crossmatches Î·È Ë Ì›ˆÛË ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜. ∞Ó Ô ˘Ô„‹ÊÈÔ˜ ÏËÚÔ› ÙȘ ÚÔ¸Ôı¤ÛÂȘ ÚÔÂÈÏÔÁ‹˜, ÛÙË Û˘Ó¤¯ÂÈ· ¤¯ÂÈ ÚÔÙÂÚ·ÈfiÙËÙ· ¤Ó·ÓÙÈ fiÏˆÓ ÙˆÓ ¿ÏÏˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ ÁÈ· ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÌfiÛ¯Â˘Ì·.

OÈ ÚÔ¸Ôı¤ÛÂȘ Ô˘ Ú¤ÂÈ ÂÈϤÔÓ Ó· ÏËÚÔ‡ÓÙ·È ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÓfi˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘ Ï‹ÙË Â›Ó·È: 1. ∏ ·fiÏ˘ÙË Û˘Ì‚·ÙfiÙËÙ· ÔÌ¿‰ˆÓ ·›Ì·ÙÔ˜ ÌÂٷ͇ ‰fiÙË-Ï‹ÙË.

2. ΔÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ÎÔÈÓfi HLA Ù¿Í˘ π (∞ ‹ μ) Î·È ¤Ó· ÎÔÈÓfi HLA Ù¿Í˘ ππ (DR).

3. ∞ÚÓËÙÈο Δ- Î·È μ- flow crossmatches ( ÂÎÙfi˜ ÙÔ˘ CDC). ªÂ ÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· ÂÈÏÔÁ‹˜ ·˘Í¿ÓÂÙ·È ÙÔ ÔÛÔÛÙfi ÌÂÙ·ÌÔÛ¯Â˘ÛÈÌfiÙËÙ·˜ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜. ™ÙȘ ¯ÒÚ˜ Ù˘ Eurotransplant, ˘ÔÏÔÁ›˙ÂÙ·È Û 60% ÙˆÓ ˘ÂÚ¢·ÈÛıËÙÔÔÈËÌ¤ÓˆÓ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Û ‰‡Ô ¯ÚfiÓÈ· ÂÓÒ ÚÈÓ ÙË Ì¤ıÔ‰Ô ÙÔ˘ acceptable mismatch Î·È ÙËÓ Î·ıȤڈÛË ÚÔÙÂÚ·ÈfiÙËÙ¿˜ ÙÔ˘˜ ‹Ù·Ó ÌfiÏȘ 20%4. ΔfiÛÔ Ù· ‚Ú·¯˘¯ÚfiÓÈ· fiÛÔ Î·È Ù· Ì·ÎÚÔ¯ÚfiÓÈ· ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›Ó·È ÂÍ·ÈÚÂÙÈο Î·È ·˘Ùfi ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ ÛÙÔÓ ÂÎ ÙˆÓ ÚÔÙ¤ÚˆÓ ·ÔÎÏÂÈÛÌfi ÙˆÓ ÏËÙÒÓ Ì «ÌË ·Ô‰ÂÎÙ¿» ·Û‡Ì‚·Ù· ·ÓÙÈÁfiÓ·. ∞ÓÙ›ÛÙÔÈ¯Ô ÚfiÁÚ·ÌÌ· ·fiÏ˘Ù˘ ÚÔÙÂÚ·ÈfiÙËÙ·˜ ÛÙËÓ ÂÈÏÔÁ‹ ˘ÂÚ¢·ÈÛıËÙÔÔËÌ¤ÓˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ ¤¯ÂÈ Î·ıÈÂÚˆı› Î·È ÛÙËÓ ∂ÏÏ¿‰· ·fi ÙÔ 2004. ™ÙÔ §·˚Îfi ¡ÔÛÔÎÔÌÂ›Ô ¤¯Ô˘Ó ÌÂÙ·ÌÔÛ¯Â˘ı› ·fi ÙfiÙ 27 ·ÛıÂÓ›˜ Ì ÙË Ì¤ıÔ‰Ô ÙˆÓ ·Ô‰ÂÎÙÒÓ ·Û‡Ì‚·ÙˆÓ ·ÓÙÈÁfiÓˆÓ. ŸÙ·Ó ·Ó·Ï‡Û·Ì ٷ ‚Ú·¯˘¯ÚfiÓÈ· (ÂÓfi˜ ¤ÙÔ˘˜) ·ÔÙÂϤÛÌ·Ù· Û 20 ·ÛıÂÓ›˜, ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ì ÎÚ·ÙÈÓ›ÓË 1,6±0,86 mg/dl, ¯ˆÚ›˜ ‰È·ÊÔÚ¿ Û˘ÁÎÚÈÙÈο Ì ÔÌ¿‰· ÂϤÁ¯Ô˘ 20 ÌË ˘ÂÚ¢·ÈÛıËÙÔÔÈËÌ¤ÓˆÓ ·ÛıÂÓÒÓ, ÂÓÒ ‰ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ Î·È ÏÔÈÌÒÍÂˆÓ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ. ∏ ÌfiÓË ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÌÂٷ͇ ÙˆÓ

METAMO™XEY™Eπ™ 2010

‰‡Ô ÔÌ¿‰ˆÓ ‹Ù·Ó Ô Ì¤ÛÔ˜ ¯ÚfiÓÔ˜ ·Ú·ÌÔÓ‹˜ Û ∞πª∫ ‹ ™ºO¶∂∫ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô˘ ‹Ù·Ó 7,7±3,8 ¯ÚfiÓÈ· ÁÈ· ÙÔ˘˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ Î·È 5,6±2,7 ¯ÚfiÓÈ· ÁÈ· ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘. º·›ÓÂÙ·È ÏÔÈfiÓ fiÙÈ Ë ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙËÓ ÂÈÏÔÁ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ì¤ıÔ‰Ô ÙˆÓ ·Ô‰ÂÎÙÒÓ ·Û‡Ì‚·ÙˆÓ ·ÓÙÈÁfiÓˆÓ ·ÔÙÂÏ› Ôχ ÛËÌ·ÓÙÈ΋ χÛË ÛÙËÓ ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜ ÁÈ· ÔÏÏÔ‡˜ ·fi ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜5. ¶·Ú’ fiÏ· ·˘Ù¿, ÛÙÔÓ ÏËı˘ÛÌfi Ù˘ Eurotransplant ¤¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ·Ú·Ì¤ÓÂÈ ¤Ó· ÔÛÔÛÙfi 30-40% ÙˆÓ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ӈÓ, ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ ı· ÌÔÚ› Ó· ‚ÚÂı› Û˘Ì‚·Ùfi˜ ‰fiÙ˘. À¿Ú¯ÂÈ ÚfiÁÚ·ÌÌ· ∏/À (donor frequency calculator) Ì ÙÔ ÔÔ›Ô ÌÔÚ› Ó· ÂÎÙÈÌËı› Ë Èı·ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ Û˘Ì‚·ÙÔ‡ ‰fiÙË ÂÈÛ¿ÁÔÓÙ·˜ ÙËÓ HLA Ù˘ÔÔ›ËÛË Î·È Ù· acceptable mismatches (AM’s) ÙÔ˘ ·ÛıÂÓ‹6. °È· ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ÔÈ ÂÓ·ÏÏ·ÎÙÈΤ˜ ÂÚÈÔÚ›˙ÔÓÙ·È ÛÂ:

£ÂÚ·›˜ (ÚˆÙfiÎÔÏÏ·) ·¢·ÈÛıËÙÔÔ›ËÛ˘ À¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ ·fi ΤÓÙÚ· ÛÙËÓ ∞ÌÂÚÈ΋, fiÔ˘ Á›ÓÂÙ·È ¯Ú‹ÛË Î˘Ú›ˆ˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì Ï·ÛÌ·Ê·›ÚÂÛË, ·ÓÙÈ-CD20 Rituximab Î·È ÈÛ¯˘Ú‹ ·ÓÔÛÔηٷÛÙÔÏ‹ ˆ˜ ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘ Ï‹ÙË. OÈ ·ÓÔÛÔÙÚÔÔÔÈËÙÈΤ˜ ȉÈfiÙËÙ˜ Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ Â›Ó·È ÁÓˆÛÙ¤˜ Â‰Ò Î·È 20 ¯ÚfiÓÈ· ·fi ÙË ¯Ú‹ÛË Ù˘ ÛÙ· ÊÏÂÁÌÔÓÒ‰Ë Î·È Ù· ·˘Ô¿ÓÔÛ· ÓÔÛ‹Ì·Ù·. ™ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ¤¯ÂÈ ‚ÚÂı› ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË Ì›ˆÛË Ù˘ ‚Ï¿‚˘ ÈÛ¯·ÈÌ›·˜-Â·Ó·ÈÌ¿ÙˆÛ˘, ÛÙË Ì›ˆÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È ÂȉÈο ÛÙÔ˘˜ ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ÚÔηÏ› Ì›ˆÛË ÙfiÛÔ ÙÔ˘ ·ÚÈıÌÔ‡ fiÛÔ Î·È ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ Î˘ÎÏÔÊÔÚÔ‡ÓÙˆÓ ·ÓÙÈ-HLA ·ÏÏÔ·ÓÙÈۈ̿وÓ.

1. ∏ ÚÒÙË ÌÂϤÙË ‹Ù·Ó Ë IGO2 ·fi ÙÔ ¡π∏ ¶ÔÏ˘ÎÂÓÙÚÈ΋, ÚÔÔÙÈ΋, Ù˘¯·ÈÔÔÈË̤ÓË ‰ÈÏ‹, Ù˘ÊÏ‹ ÌÂϤÙË Ì ÛÙfi¯Ô ÙË Û‡ÁÎÚÈÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ¤Ó·ÓÙÈ ÙÔ˘ placebo ÛÙË Ì›ˆÛË ÙˆÓ PRA’s Û ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. º¿ÓËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙÔ ÔÛÔÛÙfi Ì›ˆÛ˘ ÙˆÓ PRA’s, ˘„ËÏfiÙÂÚÔ ÔÛÔÛÙfi ÌÂÙ·ÌÔÛ¯Â˘ÛÈÌfiÙËÙ·˜ (33% ¤Ó·ÓÙÈ 17%) Î·È ÌÈÎÚfiÙÂÚÔ˜ ÚÔ‚ÏÂfiÌÂÓÔ˜ ¯ÚfiÓÔ˜ ·Ó·ÌÔÓ‹˜ (4,8 ¤Ó·ÓÙÈ 10,3 ¯ÚfiÓÈ·) ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘.

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2. ¶ÚˆÙfiÎÔÏÏÔ Johns Hopkins Hospital ¶ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ ˘Ô„‹ÊÈÔ˘ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘ Ì Ï·ÛÌ·Ê·ÈÚ¤ÛÂȘ Û ·Ú’ËÌÂÚÔ Û¯‹Ì· Î·È ¯ÔÚ‹ÁËÛË ¯·ÌËÏ‹˜ ‰fiÛ˘ ˘ÂÚ¿ÓÔÛ˘ CMV ÛÊ·ÈÚ›Ó˘ ÌÂÙ¿ ·fi οı Ï·ÛÌ·Ê·›ÚÂÛË. ΔËÓ Ë̤ڷ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¯ÔÚ‹ÁËÛË ÂÈϤÔÓ Rituximab, Campath-1H (anti-CD52 mAb).

3. ¶ÚˆÙfiÎÔÏÏÔ ÙÔ˘ Cedars-Sinai Hospital ¶ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË Ì ¯ÔÚ‹ÁËÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ Ì ‹ ¯ˆÚ›˜ Ï·ÛÌ·Ê·›ÚÂÛË.∞Ú¯Èο, ÁÈ· Ó· ÚÔ‚ÏÂÊı› ÔÈÔÈ ·ÛıÂÓ›˜ ı· ·ÓÙ·ÔÎÈıÔ‡Ó ÛÙËÓ ·ÓÔÛÔÛÊ·ÈÚ›ÓË, Á›ÓÂÙ·È in vitro ‰ÔÎÈÌ·Û›·. °›ÓÂÙ·È ÚÔÛı‹ÎË ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÛÙÔ PRA test Î·È ÚÔÛ‰ÈÔÚ›˙ÂÙ·È Ô ‚·ıÌfi˜ Ì›ˆÛ˘ Ù˘ ΢ÙÙ·ÚÔÙÔÍÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙfiÛÔ ÙˆÓ Δ- fiÛÔ Î·È ÙˆÓ μ-΢ÙÙ¿ÚˆÓ. ∞Ó ˘¿Ú¯ÂÈ ·ÓÙ·fiÎÚÈÛË, ¯ÔÚËÁÂ›Ù·È ·ÓÔÛÔÛÊ·ÈÚ›ÓË, Û ‰fiÛË 2mg/∫g ·Ó¿ Ì‹Ó· ÁÈ· 4 ‰fiÛÂȘ7. ∞Ó ‰ÂÓ ˘¿Ú¯ÂÈ in vitro ·Ó·ÛÙÔÏ‹, ÚÔËÁÔ‡ÓÙ·È 5 ·ÎÏÔÈ Ï·ÛÌ·Ê·›ÚÂÛ˘ Î·È ·ÎÔÏÔ‡ıˆ˜ ¯ÔÚËÁÂ›Ù·È ·ÓÔÛÔÛÊ·ÈÚ›ÓË Î·È Rituximab 375mg/m2 ¿·Í. ΔÔ ÚˆÙfiÎÔÏÏÔ ·˘Ùfi ÂÊ·ÚÌfiÛÙËΠ›Ù Û ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜ ˘Ô„‹ÊÈÔ˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË Â›Ù Ôχ ÂÈÏÂÎÙÈο Û ˘Ô„‹ÊÈÔ˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË, ÁÈ· >5 ¯ÚfiÓÈ· ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÌÂ Û˘¯Ó¤˜ ÚÔÛÊÔÚ¤˜, ηıfiÙÈ ÌÂÙ¿ ÙËÓ ·¢·ÈÛıËÙÔÔ›ËÛË ÛÙ¤ÏÓÂÙ·È ÔÚfi˜ ÙÔ˘ ·ÛıÂÓ‹ ÁÈ· cross match ¿ÌÂÛ· Î·È Ì ÚÔÙÂÚ·ÈfiÙËÙ· ÁÈ· fiÏÔ˘˜ ÙÔ˘˜ ‰˘ÓËÙÈο Û˘Ì‚·ÙÔ‡˜ ‰fiÙ˜ Î·È Â› ·ÚÓËÙÈÎÔ‡ crossmatch ·ÎÔÏÔ˘ı› Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÂ ·˘Ùfi ÙÔ ÚˆÙfiÎÔÏÏÔ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ·ÔÙÂϤÛÌ·Ù· Û 89 ·ÛıÂÓ›˜ (46 ·fi ˙ÒÓÙ· ‰fiÙË, 33 ·fi ·Ô‚ÈÒÛ·ÓÙ·), Ì ηϋ ÏÂÈÙÔ˘ÚÁ›· ÌÔۯ‡̷ÙÔ˜ ÛÙ· ÙÚ›· ¯ÚfiÓÈ· (ÎÚ =1,4mg/dl) Î·È ÔÛÔÛÙ¿ ÔÍ›·˜ ·fiÚÚȄ˘ 28%8.

4. ¶ÚˆÙfiÎÔÏÏÔ Ù˘ Mayo Clinic ªÂ ·ÚfiÌÔÈÔ ÚˆÙfiÎÔÏÏÔ ‰ËÌÔÛȇÙËÎ·Ó ÙÔ 2007 Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ Mayo clinic Û 20 ˘ÂÚ¢·ÈÛıËÙÔÔÈË̤ÓÔ˘˜ ·ÛıÂÓ›˜.∏ ÚÔÂÙÔÈÌ·Û›· ÂÚÈÂÏ¿Ì‚·Ó ¯ÔÚ‹ÁËÛË 2mg/∫g ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ ÙȘ Ë̤Ú˜ 0 Î·È 30 Î·È ¯ÔÚ‹ÁËÛË Rituximab 1g, ÙȘ Ë̤Ú˜ 7 Î·È 22. ∞fi ÙÔ˘˜ 20 ·ÛıÂÓ›˜ ÌÂÙ·ÌÔۯ‡ıËÎ·Ó ÔÈ 16 (80%), 10 ·fi ˙ÒÓÙ· Î·È 6 ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË. O ̤ÛÔ˜ ¯ÚfiÓÔ˜ ·Ú·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ· ‹Ù·Ó 12 (‡ÚÔ˜ 5-27) ¤ÙË. Δ· ÔÛÔÛÙ¿ ÙˆÓ PRA’s ÌÂÈÒıË-

72

™. ª∞ƒπ¡∞∫∏

Î·Ó ·fi 77±19% (ÚÔ) Û 44±30 ÌÂÙ¿ ÙË ıÂÚ·›·. O ̤ÛÔ˜ ¯ÚfiÓÔ˜ ·fi ÙËÓ ·¢·ÈÛıËÙÔÔ›ËÛË Ì¤¯ÚÈ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹Ù·Ó 5±6 Ì‹Ó˜. ¶·Ú¿ Ù· ˘„ËÏ¿ ÔÛÔÛÙ¿ ÔÍ›·˜ ·fiÚÚȄ˘ (50%) Ù· ·ÔÙÂϤÛÌ·Ù· ÛÙÔÓ ¤Ó· ¯ÚfiÓÔ Â›Ó·È Ôχ ηϿ Ì ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ 100%, ÌÔÛ¯Â˘Ì¿ÙˆÓ 94% Î·È ÎÚ=1,5mg/dl9. º·›ÓÂÙ·È ÏÔÈfiÓ fiÙÈ Î·È Ù· ÚˆÙfiÎÔÏÏ· ·¢·ÈÛıËÙÔÔ›ËÛ˘ ¤¯Ô˘Ó ÙË ı¤ÛË ÙÔ˘˜ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ˘ÂÚ¢·ÈÛıËÙÔÔÈËÌ¤ÓˆÓ ·ÛıÂÓÒÓ, ÚˆÙ›ÛÙˆ˜ ÁÈ· ·˘ÙÔ‡˜ Ì ˘Ô„‹ÊÈÔ ˙ÒÓÙ· ‰fiÙË Î·È, Û ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ, fiÔ˘ ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· ¿ÌÂÛ˘ ‰ÈÂÓ¤ÚÁÂÈ·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË. ΔÔ ÎfiÛÙÔ˜ Â›Ó·È ˘„ËÏfi, Ë ·ÓÔÛÔηٷÛÙÔÏ‹ ÈÛ¯˘Ú‹ Î·È Ù· ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ ˘„ËÏfiÙÂÚ·, ·ÏÏ¿ Ù· ‚Ú·¯˘¯ÚfiÓÈ· ·ÔÙÂϤÛÌ·Ù· ‰ÈηÈÒÓÔ˘Ó ÙËÓ ÚÔÛ¿ıÂÈ·. ™›ÁÔ˘Ú· Ë «∂˘Úˆ·È΋ Ô‰fi˜» Ì ÙË Ì¤ıÔ‰Ô ÙˆÓ ·Ô‰ÂÎÙÒÓ ·Û‡Ì‚·ÙˆÓ ·ÓÙÈÁfiÓˆÓ, ÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙËÓ ÂÈÏÔÁ‹ Î·È ÙÔÓ ÂÎ ÙˆÓ ÚÔÙ¤ÚˆÓ ·ÔÎÏÂÈÛÌfi Â›Ó·È ÈÔ ·ÛÊ·Ï‹˜, ¤¯ÂÈ ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ ·fiÚÚȄ˘, ÈÔ ÏÂÏÔÁÈṲ̂ÓË ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È ·ÔÙÂÏ› ÙËÓ È‰·ÓÈ΋ ̤ıÔ‰Ô ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·˘Ù‹˜ Ù˘ ‰‡ÛÎÔÏ˘ ÔÌ¿‰·˜ ·ÛıÂÓÒÓ. ¶ÚÔ¸fiıÂÛË Â›Ó·È Ë ÛÙÂÓ‹ Û˘ÓÂÚÁ·Û›· Ì ÙÔ ·ÓÔÛÔÏÔÁÈÎfi ÂÚÁ·ÛÙ‹ÚÈÔ Î·È Ë ÁÂÓÈÎfiÙÂÚË ÚÔÛ¿ıÂÈ· ÁÈ· ÌÂÁ·Ï‡ÙÂÚË ‰È¿ıÂÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÙÚ›ÙË Ì¤ıÔ‰Ô, ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì¤Ûˆ ·ÓÙ·ÏÏ·Á‹˜ ˙¢ÁÒÓ ‰fiÙË-Ï‹ÙË, ÂÊ·ÚÌfi˙ÂÙ·È ÚÔ˜ ÙÔ ·ÚfiÓ Û ϛÁ˜ ¯ÒÚ˜ (∏¶∞, OÏÏ·Ó‰›·) ··ÈÙ› ÔχÏÔÎÔ Û‡ÛÙËÌ· ÔÚÁ¿ÓˆÛ˘

Î·È Û˘ÓÙÔÓÈÛÌÔ‡, Â›Ó·È fï˜ Î·È ·˘Ùfi Ì›· ÂÓ·ÏÏ·ÎÙÈ΋, Û˘¯Ó¿ ÛÂ Û˘Ó‰˘·ÛÌfi Ì οÔÈ· ·fi ÙȘ ÌÂıfi‰Ô˘˜ ·¢·ÈÛıËÙÔÔ›ËÛ˘.

μÈ‚ÏÈÔÁÚ·Ê›· 1. 14th International HLA and Immunogenetics Workshop: Report on understanding antibodies in transplantation.

Zachary AA et al. Tissue Antigens 2007; 69:160.

2. Preformed cytotoxic antibodies in potential allograft recipients:recent data.

Cecka JM et al. Hum Immunol 2005; 66:343.

3. The acceptable mismatch Program as a fast tool for highly sensitized Patients Awaiting aCadaveric Kidney Transplantation: Short Waiting Time and excellent Graft outcome.

FH Claas et al. Transplantation 2004; 78:190.

4. A Virtual crossmatch Protocol Significantly Increases ∞ccess of Highly Sensitized Patients to Deceased Donor Kidney Transplantation.

Bingaman AW et al. Transplantation 2008; 86:1864.

5. Enhanced Kidney Allocation to Highly Sensitized Patients by The Acceptable Mismatch Program.

Claas FH et al. Transplantation 2009; 88:447.

6. Management of the highly sensitized patient.

FH Claas and IN Doxiadis. Curr Op Immun 2009; 21:569.

7. Presensitization: The problem and Its Management.

SC Jordan and MD Pescovitz. Clin J Am Soc Nephrol 2006; 1:421.

8. Desensitization Therapy with Intravenous Gammaglobulin (IVIG): Applications in Solid Organ Transplantation.

SC Jordan et al. Trans Am Cl Assoc 2006; 117:199.

9. Rituximab and Intravenous Immune Globulin for Desensitization during Renal Transplantation.

A. Vo et al. NEJM 2008; 359:242.

MÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Û ·ÛıÂÓ›˜ Ì ·ÓÒÌ·ÏÔ Î·ÙÒÙÂÚÔ Ô˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ· π. °ÂˆÚÁ¿Î˘, ¢. Δ·ÎÔ‡‰·˜ Ù˘ ·ÛÙ˘ Î·È ÌÂȈ̤ÓË ¯ˆÚËÙÈÎfiÙËÙ·. ªÈ· ·ÓÒÌ·ÏË Ô˘ÚÔ‰fi¯Ô˜ ·ÛÙË fï˜ ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ηıÒ˜ ÙÔ ·ÔÙ¤ÏÂÛÌ· ‰ÂÓ ÂËÚ¿˙ÂÙ·È ·ÚÓËÙÈο fiÙ·Ó Á›ÓÂÙ·È Û ¤‰·ÊÔ˜ ·Ó·Î·Ù·Û΢·Ṳ̂Ó˘ ·ÛÙ˘. ø˜ ÂÎ ÙÔ‡ÙÔ˘, Ì ÙËÓ Î·Ù¿ÏÏËÏË ÂÈÏÔÁ‹ ·ÛıÂÓÔ‡˜, ÙË ÛˆÛÙ‹ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ·ÍÈÔÏfiÁËÛË, ÔÚÈṲ̂Ó˜ ÙÚÔÔÔÈ‹ÛÂȘ ÛÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙËÓ Î·Ï‹ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ú·ÎÔ˘ÏÔ‡ıËÛË, Ë ‚ȈÛÈÌfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ ‰È·Ê¤ÚÂÈ ·fi ·˘Ù‹Ó ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ. To ÂÚÒÙËÌ· Â›Ó·È Â¿Ó ÂÈÏÂÁ› Ó· ¯ÚËÛÈÌÔÔÈËı› Ë Î‡ÛÙË ÙÔ˘ ·ÛıÂÓÔ‡˜ (·ÎfiÌË Î·È Â¿Ó ÚÔËÁÔ˘Ì¤Óˆ˜ ¤¯ÂÈ Á›ÓÂÈ ÂÎÙÚÔ‹ Ô‡ÚˆÓ) ‹ Ó· ÚÔÙÈÌËı› Ó· ·Ô¯ÂÙ‡ÔÓÙ·È Ù· Ô‡Ú· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ÓÂÊÚÔ‡ ̤ۈ ÌÈ·˜ ÌfiÓÈÌ˘ ˘ÂÚ΢ÛÙÈ΋˜ ÂÎÙÚÔ‹˜. ªÈ· Ô˘ÚÔ‰fi¯Ô˜ ·ÛÙË ÌÔÚ› Ó· Â›Ó·È ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋ ÂÍ·ÈÙ›·˜ ¿ıËÛ˘ ÙÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ·ÔÊÚ·ÎÙÈÎÒÓ ·ÈÙÈÒÓ Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ·‰˘Ó·Ì›· Ù˘ ·Ô¯¤Ù¢Û˘ ÙˆÓ Ô‡ÚˆÓ (‚·Ï‚›‰Â˜ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜, ÛÙÂÓÒÌ·Ù·), ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È ·fi ‰˘Û¯¤ÚÂÈ· ΤӈÛ˘ (™‡Ó‰ÚÔÌÔ Hinman), ·fi ‰È·Ù·Ú·¯¤˜ Ô˘ ·ÊÔÚÔ‡Ó ·ÏÏ·Á¤˜ ÛÙËÓ Û˘ÌÂÚÈÊÔÚ¿ Î·È ‰fiÌËÛ‹ Ù˘, ·fi ‰È¿ÌÂÛË Î˘ÛÙ›Ùȉ· ÌÂÙ¿ ·fi ·ÎÙÈÓÔıÂÚ·›·, ·fi ›ÓˆÛË ÌÂÙ¿ ·fi ·fi ÂÓ‰Ô΢ÛÙÈ΋ ¯ËÌÂÈÔıÂÚ·›· ‹ ÂÚÈ΢ÛÙÈ΋ Ô˘Ï‹ (˘ÂÏÈÎfi ·È̿و̷, ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ÛÙËÓ Î‡ÛÙË). ™˘¯Ó¤˜ ·Èٛ˜ ‚Ï¿‚˘ ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ô˘ Ô‰ËÁÔ‡Ó Û ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È ·Ó¿ÁÎË ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ ÌÔÚ› Ó· ›ӷÈ: ™˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ fiˆ˜ ¢Èۯȉ‹˜ Ú¿¯Ë (spina bifida, occult, cystical, ª˘ÂÏÔÌËÓÈÁÁÔ΋ÏË, ªËÓÈÁÁÔ΋ÏË, §ÈÔÌËÓÈÁÁÔ΋ÏË) Î·È ‚·Ï‚›‰Â˜ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜. ∫¿ÔÈ· Û‡Ó‰ÚÔÌ· (Prune belly, Vater, Denys-Drash, Bardet-Bield, Beckwith-Wiederman Î.·.) Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË Ó¢ÚÔÁÂÓÔ‡˜ ·ÛÙˆ˜ ·ÊÔÚÔ‡Ó ÌÈÎÚfi ·ÚÈıÌfi ÂÚÈÛÙ·ÙÈÎÒÓ Ì ÌÂÙ·ÌÔÛ¯Â˘ÛË ÓÂÊÚÔ‡. ÕÏϘ ·Èٛ˜ ÂÌÊ¿ÓÈÛ˘

OÈ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÂÍ·ÈÙ›·˜ ·ı‹ÛÂˆÓ ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ·Ó¤Ú¯ÔÓÙ·È ÛÙÔ 6% ÂÙËÛ›ˆ˜ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ. ª¿ÏÈÛÙ·, ÛÙ· ·È‰È¿ Ô˘ ˘Ô‚¿ÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ÔÈ ·ı‹ÛÂȘ ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û·Ó ·ÈÙ›· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ Û˘¯Ó¤˜ Î·È ÌÔÚÔ‡Ó Ó· ÍÂÂÚ¿ÛÔ˘Ó ÙÔ 20%.

OÈ ‚·ÛÈΤ˜ ÚÔ¸Ôı¤ÛÂȘ ÁÈ· Ì›· ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ›ӷÈ, Ë ‰È·Ù‹ÚËÛË ÙˆÓ Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ, Ë ÂȉÈfiÚıˆÛË Î¿ı ·Ó·ÙÔÌÈ΋˜ ·ÓˆÌ·Ï›·˜ Ë ÔÔ›· ÌÔÚ› Ó· ·ÔÙÂÏ› ÂÛÙ›· Ïԛ̈͢, Ë Â·Ó·ÏÂÈÙÔ˘ÚÁ›· Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ Ë ÔÔ›· ‹Ù·Ó ·ÔÌÔӈ̤ÓË ÁÈ· ·ÚÎÂÙfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, Ë ÂÎÙ›ÌËÛË Ù˘ ¯ˆÚËÙÈÎfiÙËÙ¿˜ Ù˘ Î·È Ë ·ÍÈÔÏfiÁËÛË Ù˘ ÂÁÎÚ¿ÙÂÈ·˜ Î·È Ù˘ ÈηÓfiÙËÙ·˜ ΤӈÛ˘ ηıÒ˜ Î·È Ë ·Ô˘Û›· ˘Ô΢ÛÙÈÎÔ‡ Έχ̷ÙÔ˜. ªÂ ·˘Ù¿ Ù· ‰Â‰Ô̤ӷ Û ¤Ó·Ó ·ÛıÂÓ‹ Ì ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋ ·ÛÙË, Ô ÔÔ›Ô˜ ÏËÛÈ¿˙ÂÈ Û ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, ··ÈÙÂ›Ù·È ÛˆÛÙ‹ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡, ÒÛÙ ӷ ÂÈÙ¢¯ıÔ‡Ó Î·Ï‡ÙÂÚ˜ ÚÔ˘Ôı¤ÛÂȘ ÁÈ· ÌÈ· ÂÈÙ˘¯Ë̤ÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ∏ ‰È·Ù‹ÚËÛË ÙˆÓ Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ, ÂÍ·ÛÊ·Ï›˙ÂÈ ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÁÈ· ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·Ó·ÌÔÓ‹˜ ̤¯ÚÈ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ‡·ÚÍ‹ ÙÔ˘˜ ‚ÔËı¿ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÚÔÛˆÚÈÓ‹˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÂÓÒ Ë ÌÈÎÚ‹ ‰ÈÔ‡ÚËÛË ‰È¢ÎÔχÓÂÈ ÙËÓ Î¿ı·ÚÛË Î·È ‰Ú¿ÛË Ù˘ ‚ÈÙ·Ì›Ó˘ D. Δ¤ÏÔ˜ ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· Ù˘ ¯Ú‹Û˘ ÙÔ˘˜ ÁÈ· ·ÓÙÈÌÂÙÒÈÛË Èı·ÓÒÓ ÂÈÏÔÎÒÓ È‰›ˆ˜ ·fi ÙÔ˘˜ Ô˘ÚËÙ‹Ú˜ ÙÔ˘ ‰fiÙË. ∏ ÂÎÙ›ÌËÛË Ù˘ ηٷÏÏËÏfiÙËÙ·˜ Ù˘ ˘¿Ú¯Ô˘Û·˜ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ ÁÈ· ÙËÓ ·Ô¯¤Ù¢ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ¤Ó· ÛËÌ·ÓÙÈÎfi ˙‹ÙËÌ·. ™˘¯Ó¿, ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë Î‡ÛÙË ·Ú·Ì¤ÓÂÈ Ì ÂÎÙÚÔ‹ Ô‡ÚˆÓ, ·ÏÏ¿ Î·È ·ÛıÂÓ›˜ Ì ÔÏÈÁÔ˘Ú›· Ë ·ÓÔ˘Ú›· Ô˘ ‰È·ÙËÚÔ‡Ó Î‡ÛÙË ÈηӋ Ó· ·Ô‚¿ÏÂÈ ·fi ÙËÓ Ô˘Ú‹ıÚ·, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‰˘ÛÏÂÈÙÔ˘ÚÁ›·

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π. °∂øƒ°∞∫∏™, ¢. Δ∞∫√À¢∞™

Ó¢ÚÔÁÂÓÔ‡˜ ·ÛÙ˘ Ú›Ó ·ÏÏ¿ Î·È ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÂÛË ÓÂÊÚÔ‡, Â›Ó·È ‰˘Ó·ÙÔÓ Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó ÌÂÙ· ·fi ÂÂÌ‚¿ÛÂȘ ÂÏ¿ÛÛÔÓÔ˜ ˘¤ÏÔ˘, ÊÏÂÁÌÔÓ¤˜, ÓÂÔÏ¿ÛÌ·Ù·, ‰È·‚ËÙÈ΋ ΢ÛÙÔ¿ıÂÈ·, Ó¢ڛÙȉ˜, Ê˘Ì·Ù›ˆÛË, ·ÎÙÈÓÈ΋ ΢ÛÙ›Ùȉ·, ηÏÔ‹ı˘ ˘ÂÚÏ·Û›· ÚÔÛÙ¿ÙÔ˘. OÚÈṲ̂ÓÔÈ ·ÛıÂÓ›˜ ¯ÚÂÈ¿ÛıËΠӷ Â·Ó·ÍÈÔÏfiÁËıÔ‡Ó ÏfiÁˆ ‰ËÌÈÔ˘ÚÁ›·˜ ˘‰ÚÔÓ¤ÊÚˆÛ˘, ˘ÔÙÚÔÔÈ·˙fiÓÙˆÓ Ô˘ÚÔÏÔÈÌÒÍÂˆÓ Î·È ·ÎÚ¿ÙÂÈ·˜.

∞ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ∏ ·fiÊ·ÛË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Û ¤Ó·Ó ·ÛıÂÓ‹ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Â¿Ó Ë Ô˘ÚÔ‰fi¯Ô˜ ·ÛÙË Â›Ó·È Î·Ù¿ÏÏËÏË ÁÈ· ¯Ú‹ÛË. ∏ ¢ÂÓ‰ÔÙfiÙËÙ·, Ë ÂÁÎÚ¿ÙÂÈ·, Ë Î¤ÓˆÛ‹ Ù˘ Î·È Ë ÚÔÔÙÈ΋ Ó· ‰Â¯ı› Â·Ú΋ fiÁÎÔ Ô‡ÚˆÓ Â›Ó·È ÛËÌ·ÓÙÈΤ˜ ·Ú¿ÌÂÙÚÔÈ. ∏ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ·Ó·Ï˘ÙÈÎfi ·ÙÔÌÈÎfi ÈÛÙÔÚÈÎfi ‰›ÓÔÓÙ·˜ ¤ÌÊ·ÛË ÛÙËÓ ¿ıËÛË ÙˆÓ Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ. ∏ ÂÎÙ›ÌËÛË ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Á›ÓÂÙ·È ÁÈ· Ó· ·ÍÈÔÏÔÁËı› Ë Î·Ù·ÏÏËÏfiÙËÙ· Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Î·È Ë ‚·ÙfiÙËÙ· ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡. ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ ı· ÂÍÂÙ·ÛÙ› Ë Èı·ÓfiÙËÙ· ·Ó·Î·Ù·Û΢‹˜ Ù˘ ·ÛÙ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÓÂÊÚÂÎÙÔÌ‹ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ÂÎÙ›ÌËÛË ·˘Ù‹ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ‡·ÚÍË Ô˘ÚÔÏÈıÈ¿ÛˆÓ, ÏÔÈÌÒ͈Ó, ΢ÛÙÂÔ˘ÚËÙËÚÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘, ÚÔËÁÔ‡ÌÂÓˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛˆÓ, ÚÔ‚ÏËÌ¿ÙˆÓ Ô‡ÚËÛ˘. ™ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ··ÈÙÂ›Ù·È ÁÂÓÈ΋ Ô‡ÚˆÓ, ηÏ/ÁÂȘ Ô‡ÚˆÓ, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÓÂÊÚÒÓ Î·È Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ (Ì ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ˘ÔÏÂÈfiÌÂÓÔ˘ fiÁÎÔ˘ Ô‡ÚˆÓ ÌÂÙ¿ ÙËÓ Î¤ÓˆÛË), Ô˘ÚÔ‰˘Ó·ÌÈ΋ ÌÂϤÙË, ΢ÛÙÂÔÛÎfiËÛË.

OÈ ÔÈfi Û˘¯Ó¤˜ ·Èٛ˜ Ô˘ Ô‰ËÁÔ‡Ó Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ·fi ‚Ï¿‚˜ ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ··ÈÙÔ‡Ó ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Â›Ó·È Ë Ó¢ÚÔÁÂÓ‹˜ ·ÛÙË, Ë Î˘ÛÙÂÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÓËÛË Î·È ÔÈ ‚·Ï‚›‰Â˜ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜ Ô˘ ‰ÂÓ ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Â·ÚÎÒ˜. ∏ ˘Ô„›· Ù˘ ‡·Ú͢ ‚·Ï‚›‰ˆÓ Î·È Ë ‰˘ÛÎÔÏ›· ÛÙËÓ Î¤ÓˆÛË Ù˘ ·ÛÙ˘, Ô‰ËÁÔ‡Ó ÛÙËÓ ‰ÈÂÓ¤ÚÁÂÈ· ΢ÛÙÂÔÁÚ·Ê›·˜ Î·È Ô˘ÚÔ‰˘Ó·ÌÈ΋˜ ÌÂϤÙ˘. ™ÙËÓ ‚È‚ÏÈÔÁÚ·Ê›· Ë ‡·ÚÍË ‚·Ï‚›‰ˆÓ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜ Ô‰ËÁ› Û ÔÛÔÛÙfi Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 10-47% ,Û ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È ·Ó¿ÁÎË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ™Â ˘Ô„‹ÊÈÔ Ï‹ÙË ·È‰È΋˜ ËÏÈΛ·˜ Ì ÈÛÙÔÚÈÎfi

ÏÔÈÌÒ͈Ó, ‰˘ÛÏ·ÛÙÈÎÒÓ ÓÂÊÚÒÓ, ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜, Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ‰ÈÂÓÂÚÁÂ›Ù·È Î˘ÛÙÂÔ˘ÚËıÚÔÁÚ·Ê›· ÁÈ· ÂÓÙÔÈÛÌfi ·ÔÊÚ·ÎÙÈ΋˜ Ô˘ÚÔ¿ıÂÈ·˜ Î·È ÁÂÓÈο ¿ıËÛ˘ ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡. ∏ ·˘Í·ÓfiÌÂÓË ›ÂÛË Ù˘ ·ÛÙ˘ ÛÙËÓ Ô˘ÚÔ‰˘Ó·ÌÈ΋ ÌÂϤÙË, ‹Ù·Ó ÙÔ Û˘¯ÓfiÙÂÚÔ Â‡ÚËÌ· Ú›Ó ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È, fiÙÈ ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÌÈ· ÌÈÎÚ‹ ¯ˆÚ›˜ ¢ÂÓ‰ÔÙfiÙËÙ· ·ÛÙË ÂÍ·ÈÙ›·˜ Ù˘ ·Ú·ÙÂٷ̤Ó˘ ·¯ÚËÛ›·˜, ÏfiÁˆ ·ÓÔ˘Ú›·˜ Ë ÔÏÈÁÔ˘Ú›·˜. ΔÔ Â‡ÚËÌ· ÏÔÈfiÓ Ù˘ ·˘Í·ÓfiÌÂÓ˘ ›ÂÛ˘ Â›Ó·È ·Ó·ÌÂÓfiÌÂÓÔ ÏfiÁˆ Ù˘ ·ÓÔ˘Ú›·˜ Î·È Ë ÂÎÙ›ÌËÛË ÌÈÎÚ‹˜ ¯ˆÚËÙÈÎfiÙËÙ·˜ ‰ÂÓ Î·ıÔÚ›˙ÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÁÈ· ÙÔ Ì¤ÏÏÔÓ. ∞fi ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ·Ô‰ÂÈÎÓ‡ÂÙ·È fiÙÈ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ˘¿Ú¯ÂÈ ÌÈ· ‚·ıÌÈ·›· ·‡ÍËÛË Ù˘ ¯ˆÚËÙÈÎfiÙËÙ·˜, ȉȷ›ÙÂÚ· Â¿Ó Ë Â˘ÂÓ‰ÔÙfiÙËÙ· ‰ÂÓ Â›Ó·È ÂËÚ·Ṳ̂ÓË ·fi ÙËÓ ›ÓˆÛË ÙˆÓ Ï›ˆÓ Ì˘ÈÎÒÓ ÈÓÒÓ ÏfiÁˆ ÌË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜, ÏfiÁˆ ÊÏÂÁÌÔÓÒÓ Ë ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛˆÓ. ¢˘ÛÏÂÈÙÔ˘ÚÁÈΤ˜ ·ÛÙÂȘ Ô˘ ¤¯Ô˘Ó ¯·ÌËϤ˜ ȤÛÂȘ ÛÙËÓ ‰È¿ÚÎÂÈ· Ù˘ Ê¿Û˘ Ï‹ÚˆÛ˘, Û˘ÌÂÚÈʤÚÔÓÙ·È Î·Ï¿ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŸÙ·Ó Ë Ô˘ÚÔ‰fi¯Ô˜ ·ÛÙË ¤¯ÂÈ ¯ˆÚËÙÈÎfiÙËÙ· ÏÈÁfiÙÂÚÔ ·fi 100 ml, ›ÂÛË Î¤ÓˆÛ˘ ÂÚÈÛÛfiÙÂÚÔ ·fi 100cm H2O ˘¿Ú¯ÂÈ ÚԉȿıÂÛË ÁÈ· ÂÈÏÔΤ˜ Î·È ¯ÚÂÈ¿˙ÂÙ·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË ÁÈ· ÙËÓ ÌÂÁ¤ı˘ÓÛ‹ Ù˘. ∏ η΋ ¢ÂÓ‰ÔÙfiÙËÙ· ··ÈÙ› ÙËÓ ·ÔηٿÛÙ·ÛË ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÒÛÙ ӷ ·ÔÊ¢¯ı› Ë ‚Ï¿‚Ë ÛÙÔ ÌfiÛ¯Â˘Ì·. ŸÙ·Ó Ô ÂÓ‰Ô΢ÛÙÈΤ˜ ȤÛÂȘ ˘ÂÚ‚·›ÓÔ˘Ó Ù· 40cm H20, Ë ÌÂÙ·ÊÔÚ¿ ÙˆÓ Ô‡ÚˆÓ Ì¤Ûˆ ÙÔ˘ Ô˘ÚËÙ‹Ú· ÛÙ·Ì·Ù¿. ∏ ÂÓ‰Ô΢ÛÙÈ΋ ›ÂÛË Ú¤ÂÈ Ó· ‰È·ÙËÚËı› ÏÈÁfiÙÂÚÔ ·fi 30cm H20 ηٿ ÙËÓ Ê¿ÛË Ï‹ÚˆÛ˘ ÁÈ· ÚÔÏËÊıÔ‡Ó Ù˘¯fiÓ ‚Ï¿‚˜ ÛÙÔ ÓÂÊÚfi. ªÔÚԇ̠ӷ ¯ÚËÛÈÌÔÔÈ‹ÛÔ˘Ì ·ÓÙȯÔÏÈÓÂÚÁÈο Ê¿Ú̷η ÁÈ· Ó· ÌÂÈÒÛÔ˘Ì ÙËÓ ›ÂÛË Ï‹ÚˆÛ˘ Î·È ÙȘ Ù˘¯fiÓ ·ÛÙ·ı›˜ Û˘Û¿ÛÂȘ. ∞ÚÎÂÙÔ› ·ÛıÂÓ›˜ Ì ·ıÔÏÔÁÈ΋ ·ÛÙË ÌÔÚ› Ó· ÌËÓ Â›Ó·È Û ı¤ÛË Ó· ÙËÓ ÎÂÓÒÓÔ˘Ó Î·È ı· ¯ÚÂÈ·Ûı› Ó· ηٷʇÁÔ˘Ó ÛÙÔ˘˜ ‰È·Ï›ÔÓÙ˜ ηıÂÙËÚÈ·ÛÌÔ‡˜. ªÂÚÈÎÔ› ¤¯Ô˘Ó ‹‰Ë ¯ÚËÛÈÌÔÔÈ‹ÛÂÈ ·˘Ù‹Ó ÙËÓ Ù¯ÓÈ΋ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ú¤ÂÈ Ó· ÙËÓ Â·Ó·Ï¿‚Ô˘Ó ÌÂÙ¿ ·fi ·˘Ù‹Ó. ŸÛÔÈ ‰ÂÓ ¤¯Ô˘Ó ÂÊ·ÚÌfiÛÂÈ ·˘Ù‹Ó ÙËÓ Ù¯ÓÈ΋ ı· Ú¤ÂÈ Ó· ÂÎ·È‰Â˘ÙÔ‡Ó Î·Ù¿ÏÏËÏ·. À¿Ú¯Ô˘Ó ‰Â‰Ô̤ӷ fiÙÈ Ô Î·ıÂÙËÚÈ·ÛÌfi˜ Î·È ÔÈ Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ‰È·ÛÙÔϤ˜ ‚ÂÏÙÈÒÓÔ˘Ó ÙËÓ ¯ˆÚËÙÈÎfiÙËÙ· Ù˘ ·ÛÙˆ˜. ∏ ̤ıÔ‰Ô˜ ÂÓ¤¯ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ·ÈÌ·ÙÔ˘Ú›·˜ Î·È Û οÔÈÔ˘˜ Â›Ó·È ÂÒ‰˘ÓË.

METAMO™XEY™Eπ™ 2010

∏ ÛΤ„Ë ÁÈ· ¯ÂÈÚÔ˘ÚÁÈο ÌÂÁ¤ı˘ÓÛË Ù˘ ·ÛÙ˘ ı· Ú¤ÂÈ Ó· Û˘˙ËÙËı› Â¿Ó Ë ¯ˆÚËÙÈÎfiÙËÙ¿ Ù˘ ‰ÂÓ ‚ÂÏÙȈı› ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∫·Ù¿ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ô Ô˘ÚËÙ‹Ú·˜ ·Ó·ÛÙÔÌÒÓÂÙ·È ÛÙËÓ Î‡ÛÙË ÙÔ˘ Ï‹ÙË. OÈ ÚÔ˘¿Ú¯Ô˘Û˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ ‹ οÔȘ ÚÔËÁÔ‡ÌÂÓ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, ÌÔÚÔ‡Ó Ó· ηٷÛÙ‹ÛÔ˘Ó ÙËÓ Î‡ÛÙË ·Î·Ù¿ÏÏËÏË ÚÔ˜ ¯Ú‹ÛË. ∏ ÂÌʇÙÂ˘Ë ÙÔ˘ Ô˘ÚËÙ‹Ú· Û ¤Ó· ÈÓ҉˜ Â·¯˘Ì¤ÓÔ ÙÔ›¯ˆÌ· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È, ÏfiÁˆ ÙÔ˘ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞Ó Î·È Û ٤ÙÔȘ ηٷÛÙ¿ÛÂȘ Ù· Ô‡Ú· ÌÔÚÔ‡Ó Ó· Â͈ÙÂÚÈ΢ıÔ‡Ó Ì¤Ûˆ ‰ÂÚÌ·ÙÈ΋˜ Ô˘ÚËÙËÚÔÛÙÔÌ›·˜ ‹ ÌÈ·˜ Ô˘ÚËÙËÚÔÂÈÏÂÔ‰ÂÚÌ·ÙÈ΋˜ ÛÙÔÌ›·˜ Î·È ÔÈ ‰‡Ô Ù¯ÓÈΤ˜ ÂÓ¤¯Ô˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ‚·ÎÙËÚȷ΋˜ ·Ô›ÎËÛ˘ Ë ¯ÚfiÓÈ·˜ ÌfiÏ˘ÓÛ˘. °È· Ó· ˘ÂÚÓÈÎËıÔ‡Ó ·˘Ù¿ Ù· ÚÔ‚Ï‹Ì·Ù· ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÈ Ë ·Ó·‰ËÌÈÔ˘ÚÁ›· Ù˘ ·ÛÙ˘ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â Û¿ÓȘ ÂÚÈÙÒÛÂȘ ··ÈÙÂ›Ù·È Ë ‰ËÌÈÔ˘ÚÁ›· ÓÂÔ·ÛÙ˘ ·fi ¿ÏÏÔ˘˜ ÛÏ·¯ÓÈÎÔ‡˜ ÈÛÙÔ‡˜. ∞˘Ù‹ Ë ÚÔÛ¤ÁÁÈÛË ‰ËÌÈÔ˘ÚÁ› ηχÙÂÚÔ ÂÚÈ‚¿ÏÏÔÓ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ô‰ËÁ› Û ηχÙÂÚË ·ÔηٿÛÙ·ÛË ·fi fiÙÈ Ì ÙËÓ ÂÎÙÚÔ‹ Ô‡ÚˆÓ. ∞ÚÎÂÙÔ› Û˘ÁÁÚ·Ê›˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÌÔÚ› Ó· Á›ÓÂÈ Î·È 10-12 ‚‰ÔÌ¿‰Â˜ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™ÙÔÓ ›‰ÈÔ ¯ÚfiÓÔ ÌÔÚÔ‡Ó Ó· ·Ê·ÈÚÂıÔ‡Ó Î·È Ù˘¯fiÓ ˘fiÓÂÊÚÔÈ. ¡ÂÊÚÔ› Î·È Ô˘ÚËÙ‹Ú˜ Ì ¤ÌÙÔ˘ ‚·ıÌÔ‡ ·ÏÈÓ‰ÚfiÌËÛË ·Ê·ÈÚÔ‡ÓÙ·È ÚÈÓ Ë Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∂¿Ó fï˜ Ë fiÔÈ· ·ÎÚ¿ÙÂÈ· ‰ÂÓ Â›Ó·È Úfi‚ÏËÌ·, ˘¿Ú¯ÂÈ ÏÂÈÙÔ˘ÚÁ›· ·Ôı‹Î¢Û˘ ‹ ·Ó·Ì¤ÓÂÙ·È Ó· ˘¿ÚÍÂÈ ‚ÂÏÙ›ˆÛË, ‰ÂÓ ˘¿Ú¯ÂÈ ·fiÊÚ·ÍË, ÙfiÙ ˘¿Ú¯ÂÈ Ë Èı·ÓfiÙËÙ· Ë Î¤ÓˆÛË Ó· Â¤ÏıÂÈ Â›Ù ·˘ıfiÚÌËÙ· ›Ù Ì ‰È·Ï›ÔÓÙ˜ ηıÂÙËÚÈ·ÛÌÔ‡˜. ∞ÛıÂÓ›˜ Ì ÚÔ˘¿Ú¯ÔÓ Î·ÚΛӈ̷ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ ¤¯Ô˘Ó ¤Ó· ÔÛÔÛÙfi ˘ÔÙÚÔ‹˜ 18-26% ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞˘ÙÔ› Ú¤ÂÈ Ó· ÂÚÈ̤ÓÔ˘Ó ÙÔ ÏÈÁfiÙÂÚÔ ‰‡Ô ¯ÚfiÓÈ· ·fi ÙËÓ ıÂÚ·›· ÙÔ˘ ηÚΛÓÔ˘ ÁÈ· Ó· ÌÂÙ·ÌÔÛ¯Â˘ıÔ‡Ó. ∏ ΢ÛÙÂÔÛÎfiËÛË Â›Ó·È Ë Ì¤ıÔ‰Ô˜ ·Ú·ÎÔÏÔ‡ıËÛ˘.

ª¤ıÔ‰ÔÈ ÂÎÙÚÔ‹˜ Ô‡ÚˆÓ Û ·ÛıÂÓ›˜ Ì ·ÓÒÌ·ÏÔ Î·ÙÒÙÂÚÔ O˘ÚÔÔÈËÙÈÎfi Û‡ÛÙËÌ· ™ÙÔ˘˜ ·ÛıÂÓ›˜ ÂΛÓÔ˘˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰ÂÓ ı· ¯ÚËÛÈÌÔÔÈËı› Ë Ê˘ÛÈÔÏÔÁÈ΋ ·ÛÙË ÁÈ· ·Ô¯¤Ù¢ÛË Ô‡ÚˆÓ ·fi ÙÔ ÌfiÛ¯Â˘Ì· ˘¿Ú¯Ô˘Ó ÔÈ ÂÍ‹˜ ÂÈÏÔÁ¤˜:

75

• ªË ÂÁÎÚ·Ù›˜ ÂÎÙÚÔ¤˜ • ∂ÁÎÚ·Ù›˜ ÂÎÙÚÔ¤˜ • ªÂÁ¤ı˘ÓÛË O˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘

ªË ÂÁÎÚ·Ù›˜ ÂÎÙÚÔ¤˜ ªË ÂÁÎÚ·Ù›˜ ÂÎÙÚÔ¤˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› Û˘¯ÓfiÙÂÚ· ÏfiÁˆ Ù˘ ÔÈfi ·Ï‹˜ Ù¯ÓÈ΋˜. ∏ Èfi Û˘¯Ó‹ Â›Ó·È Ë Ô˘ÚËÙËÚÔÂÈÏÂÔ‰ÂÚÌ·ÙÈ΋ ·Ó·ÛÙfïÛË fiÔ˘ Ù· Ô‡Ú· ·Ô¯ÂÙ‡ÔÓÙ·È ÛÙËÓ ÂÈÏ·΋ ¤ÏÈη Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó Û·Ó ·ÁˆÁfi Î·È ÂͤگÔÓÙ·È ·fi ÙÔ ÂÚÈÊÂÚÈÎfi ¿ÎÚÔ , Û ¤Ó· ¿ÓÔÈÁÌ· Ô˘ ‰È·ÌÔÚÊÒÓÂÙ·È ÛÙÔ ÎÔÈÏÈ·Îfi ÙÔ›¯ˆÌ· Ô˘ Û˘Ó‹ıˆ˜ Â›Ó·È Úfi˜ ÙÔ ÛËÌÂ›Ô Mc Burney. Δ· Ô‡Ú· Û˘ÏϤÁÔÓÙ·È Û ̛· ÂȉÈ΋ Û˘Û΢‹ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È Á‡Úˆ ·fi ÙËÓ ÛÙÔÌ›·. ∏ Ù¯ÓÈ΋ ·˘Ù‹ ·ÎfiÌ· ÂÎÙÂÏÂ›Ù·È Û ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Ì ηٿÏÏËÏË ÂӉ›ÍË ÙȘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Ì ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Û Ó¢ÚÔÁÂÓ‹ ·ÛÙË. ∏ Ô˘ÚËÙËÚÔÎÔÏÔ‰ÂÚÌ·ÙÈ΋ ·Ó·ÛÙfïÛË ¤¯ÂÈ ¤Ó‰ÂÈÍË Â›Û˘ Û ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ Û˘ÁÁÂÓ›˜ ‰È·Ì·Úٛ˜, Ó¢ÚÔÁÂÓ‹ ·ÛÙË Ì ¤ÓÙÔÓË Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È Û ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ˘Ô‚¿ÏÔÓÙ·È Û ·˘ÙÔηıÂÙËÚÈ·ÛÌÔ˘˜ Ô˘ ÂÈ‚¿ÏÏÔ˘Ó ÔÈ ÂÁÎÚ·Ù›˜ ÂÎÙÚÔ¤˜. ∏ ‰˘Ó·ÙfiÙËÙ· ·ÓÙÈ·ÏÓ‰ÚÔÌÈ΋˜ ÂÌʇÙ¢Û˘ ÙÔ˘ Ô˘ÚËÙ‹Ú· Â›Ó·È ÙÔ ÏÂÔÓ¤ÎÙËÌ· ·˘Ù‹˜ Ù˘ ÌÂıfi‰Ô˘ Ì ‰Â‰Ô̤ÓÔ fiÙÈ ÌÂÈÒÓÂÙ·È ÙÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜. ΔÔ ÓÂÊÚfi ÙÔÔıÂÙÂ›Ù·È ÂÙÂÚfiÙÔ· ÛÙËÓ ÏÂοÓË ,ÛÙËÓ ·ÓÙ›ıÂÙË ÏÂ˘Ú¿ ·fi ÙËÓ ÛÙÔÌ›·. ªÂ ·˘ÙfiÓ ÙÔÓ ÙÚfiÔ ‰ÂÓ ÂÌÔ‰›˙ÂÙ·È Ë Î·Ù¿ÏÏËÏË ÚÔÛ·ÚÌÔÁ‹ Ù˘ Û˘Û΢‹˜ (ÏfiÁˆ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ Ô˘Ï‹˜ , ‰ÈfiÁΈÛË ÎÔÈÏȷ΋˜ ¯ÒÚ·˜). ∂¿Ó Â›Ó·È ·Ó·Áη›Ô ÙÔ ÌfiÛ¯Â˘Ì· ÌÔÚ› Ó· ÙÔÔıÂÙËı› ·ÓÙ›ÛÙÚÔÊ· ÁÈ· Ó· Â͢ËÚÂÙ‹ÛÂÈ ÙËÓ ·Ô¯¤Ù¢ÛË ÙˆÓ Ô‡ÚˆÓ ÛÙÔÓ ·ÁˆÁfi. ∏ ÈÔ Û˘¯Ó‹ ÂÈÏÔ΋ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂÎÙÚÔ‹ Ô‡ÚˆÓ Ì¤Ûˆ ·ÁˆÁÔ‡ Â›Ó·È Ë Ô˘ÚÔÏԛ̈ÍË Û ÔÛÔÛÙfi 25% Î·È ¿Óˆ. ™ÂÈÚ¤˜ ÌÂÏÂÙÒÓ ÂÈÛËÌ·›ÓÔ˘Ó fiÙÈ Ë ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Û¿ÓÈ·. ªÂÙ·ÌÔۯ‡ÛÂȘ Ì ԢÚËÙËÚÔÂÈÏÂÔ‰ÂÚÌ·ÙÈ΋ ·Ó·ÛÙfïÛË ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ˘„ËÏfi ÔÛÔÛÙfi ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÈÏÔÎÒÓ (ÛÙ¤ÓˆÛË Ô˘ÚËÙ‹Ú·, ÛÙ¤ÓˆÛË ‹ ·ÓÂ¿ÚÎÂÈ· ÛÙÔÌ›·˜) ·ÏÏ¿ ηÏfi ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ·Ó·ÛÙfïÛË ı· Ú¤ÂÈ Ó· ‰ËÌÈÔ˘ÚÁËı› ¤ÍÈ Ì ÔÎÙÒ Ì‹Ó˜ Ú›Ó ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Î·Ï‹, ۯ‰fiÓ ›‰È· ÌÂ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ›¯·Ó Ê˘ÛÈÔÏÔÁÈΤ˜ ·ÛÙÂȘ.

76

π. °∂øƒ°∞∫∏™, ¢. Δ∞∫√À¢∞™

∂ÁÎÚ·Ù›˜ ÂÎÙÚÔ¤˜ ™Â ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ‰ÂÓ ı¤ÏÔ˘Ó Ó· ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ Û˘Ó¯‹ ·ÚÔ˘Û›· ÂÓfi˜ Û˘ÛÙ‹Ì·ÙÔ˜ Û˘ÏÏÔÁ‹˜ Ô‡ÚˆÓ Î·È Û ·˘ÙÔ‡˜ Ô˘ Ë ·‡ÍËÛË Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ ‰ÂÓ Â›Ó·È Èı·Ó‹, Ë ‰˘Ó·ÙfiÙËÙ· ÂÈÏÔÁ‹˜ Â›Ó·È ÔÈ ÂÁÎÚ·Ù›˜ ‰ÂÚÌ·ÙÈΤ˜ ÂÎÙÚÔ¤˜. Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯Ô˘Ó ·Ó·Ù˘¯ı› ¯ÂÈÚÔ˘ÚÁÈΤ˜ Ù¯ÓÈΤ˜ Ô˘ Ì ÙËÓ ¯Ú‹ÛË ÙÌ‹Ì·ÙÔ˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ۈϋӷ (ÏÂÙÔ‡ Ë ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘), ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÌÈ· ηÈÓÔ‡ÚÁÈ· ·ÛÙË ÈηÓÔ‡ ÌÂÁ¤ıÔ˘˜ Î·È ¯ˆÚËÙÈÎfiÙËÙ·˜. ¢‡Ô ÛËÌ›· Â›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ÂÈÛËÌ·ÓıÔ‡Ó, fiÙÈ Û ·˘Ù‹ ÙËÓ Î‡ÛÙË ‰ËÌÈÔ˘ÚÁÂ›Ù·È ¤Ó·˜ ÂÁÎÚ·Ù‹˜ Ì˯·ÓÈÛÌfi˜ ÁÈ· Ó· Û˘ÁÎÚ·Ù› ÙËÓ ¤ÍÔ‰Ô ÙˆÓ Ô‡ÚˆÓ, fiˆ˜ Î·È Ë ‰ËÌÈÔ˘ÚÁ›· ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋˜ Ù¯ÓÈ΋˜ ÂÌʇÙ¢Û˘ ÙÔ˘ Ô˘ÚËÙ‹Ú· ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÙËÓ ·ÏÈÓ‰ÚfiÌËÛË Ô‡ÚˆÓ. °È· ÙËÓ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ·˘ÙÒÓ ÙˆÓ Ù¯ÓÈÎÒÓ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë Ë ‰˘Ó·ÙfiÙËÙ· ÂÎÙ¤ÏÂÛ˘ ÙˆÓ ·˘ÙÔηıÂÙËÚÈ·ÛÌÒÓ Ì¤Ûˆ ÙÔ˘ ÂÁÎÚ·ÙÔ‡˜ Ì˯·ÓÈÛÌÔ‡. π‰È·›ÙÂÚ· ÛÙ· ·È‰È¿ Â›Ó·È ··Ú·›ÙËÙË Ë Û‡ÌʈÓË ÁÓÒÌË ÙˆÓ ÁÔÓ¤ˆÓ. ™Ù· ·È‰È¿ ÂӉ›ÍÂȘ ÁÈ· ‰ÈÂÓ¤ÚÁÂÈ· Ù¤ÙÔÈˆÓ Ù¯ÓÈÎÒÓ Â›Ó·È ÔÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Ù˘ ·ÛÙ˘ fiˆ˜ Ë ÂÎÛÙÚÔÊ‹ Î·È Ë ·ÚÔ˘Û›· Ó¢ÚÔÁÂÓÔ‡˜ ·ÛÙ˘ Û˘ÁÁÂÓÔ‡˜ Ë ÙÚ·˘Ì·ÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜ Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜. °È· ÙÔÓ ÛÎÔfi ·˘Ùfi ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ô ÙÂÏÈÎfi˜ ÂÈÏÂfi˜ Ì ÙÔ Ù˘ÊÏfi ¤ÓÙÂÚÔ, ·ÎfiÌË Î·È Ì ÙÌ‹Ì· ÙÔ˘ ·ÓÈfiÓÙÔ˜ ÎfiÏÔ˘. Δ· ·Ó·ÙÔÌÈο ÛÙÔȯ›· Ù˘ ‡·Ú͢ Ù˘ ÂÈÏÂÔÙ˘ÊÏÈ΋˜ ‚·Ï‚›‰·˜ Î·È ÙˆÓ ÎÔÏÈÎÒÓ Ù·ÈÓÈÒÓ, ‚ÔËıÔ‡Ó ÛÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ Ù¯ÓÈ΋˜ ÁÈ· Û¯ËÌ·ÙÈÛÌfi ÂÁÎÚ¿ÙÂÈ·˜ Î·È ÚÔʇϷ͢ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÙËÓ ·ÏÈÓ‰ÚfiÌËÛË o‡ÚˆÓ (Indiana pouch, Mainz pouch, Mainz pouch I, Penn pouch). ΔÔ ÛÈÁÌÔÂȉ¤˜ ÌÔÚ› Ó· ÂÈÏÂÁ› ÏfiÁˆ Ù˘ ‡ÎÔÏ˘ ÌÂٷΛÓËÛ‹˜ ÙÔ˘, fï˜ ÔÈ ¤ÓÙÔÓ˜ Û˘Û¿ÛÂȘ, Ë ·˘ÍË̤ÓË ÔÛfiÙËÙ· ·Ú·ÁˆÁ‹˜ ‚ϤÓÓ˘ Î·È Ë Èı·ÓfiÙËÙ· ڋ͢ ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÌÂÈÒÓÔ˘Ó ÙËÓ ‰˘Ó·ÙfiÙËÙ· ÂÈÏÔÁ‹˜ ÙÔ˘.

OÈ Ù¯ÓÈΤ˜ (Kock pouch, Hautmann, Abol Enein, w ÂÈÏ·΋ Î.·.), Ì ÙËÓ ¯Ú‹ÛË ÙÌ‹Ì·ÙÔ˜ ÂÈÏÂÔ‡ Â›Ó·È Èı·Ó¤˜ ÂÈÏÔÁ¤˜, fï˜ ‰ËÌÈÔ˘ÚÁÔ‡Ó ÚÔ‚Ï‹Ì·Ù· fiˆ˜ ‰˘ÛÛ·ÔÚfiÊËÛË Ô˘ÛÈÒÓ, ·‚ÈÙ·ÌÈÓÒÛÂȘ Î·È ‰È¿ÚÚÔȘ ηıÒ˜ Î·È ÚÔ‚Ï‹Ì·Ù· ·fi ÙËÓ ÌË ·ÓÙÈ·ÏÈÓ‰ÚÔÌÈ΋ ÚÔÛÙ·Û›· ÌÂÙ¿ ÙËÓ ÂÌʇÙ¢ÛË Ô˘ÚËÙ‹Ú·. ∏ ¯Ú‹ÛË Ù˘ Ó‹ÛÙȉ·˜ ·ÓÙÂӉ›ÎÓ˘Ù·È ÏfiÁˆ ÙˆÓ ÛÔ‚·ÚÒÓ ‰È·Ù·Ú·¯ÒÓ Ô˘ ÚÔηÏ› Ë ÌÂÁ·Ï‡ÙÂÚË ·ÔÚÚÔÊËÙÈÎfiÙËÙ¿ Ù˘.

∏ Ó¤· ·ÛÙË ÌÔÚ› Ó· Á›ÓÂÈ Ú›Ó ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤ÙÛÈ ÒÛÙ ӷ ·Ô¯ÂÙ‡ÂÈ ÔÌ·Ï¿ Ì ÙËÓ ·‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ Ô‡ÚˆÓ, ¤¯ÔÓÙ·˜ ‰˘Ó·ÌÈ΋ ·˘ÍË̤Ó˘ ¯ˆÚËÙÈÎfiÙËÙ·˜ Î·È Ó· ÎÂÓÒÓÂÈ ÙËÓ ‚ϤÓÓË. Δ· ΢ÚÈfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ÌÂÙ¿ ÙËÓ ÂÁÎÚ·Ù‹ ÂÎÙÚÔ‹ Â›Ó·È Ë Ô˘ÚÔÏԛ̈ÍË Î·È Ë ˘ÂگψڷÈÌÈ΋ ÔͤˆÛË Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ·ÓÙÈ‚›ˆÛË Î·È ¯ÔÚ‹ÁËÛË ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ. ™Â ·ÛıÂÓ›˜ Ì ÂËÚ·Ṳ̂ÓË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È Ì Èı·ÓfiÙËÙ· ÌÂÙ·‚ÔÏÈ΋˜ ÔͤˆÛ˘ ¯ÚÂÈ¿˙ÂÙ·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ‰È¿ÚÚÔÈ· ·Ó¿ÏÔÁ· Ì ÙÔÓ Ù‡Ô (ˆÛ̈ÙÈÎfi ‹ ÂÎÎÚÈÙÈÎfi) ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ʷÚ̷΢ÙÈ΋ ·ÁˆÁ‹ (·ÓÙȯÔÏÈÓÂÚÁÈο Ë Û·ÛÌÔÏ˘ÙÈο – ¯ÔÏÈο ¿Ï·Ù·). ¶ÚÔ‚Ï‹Ì·Ù· ÁÈ· Ù· ÔÔ›· ¯ÚÂÈ¿ÛıËΠÂ·ÓÂÁ¯Â›ÚËÛË, Û ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÂÁÎÚ·Ù‹ ‰ÂÚÌ·ÙÈ΋ ÂÎÙÚÔ‹, ‹Ù·Ó ‰˘ÛÎÔϛ˜ ÂÁÎÚ¿ÙÂÈ·˜, ‰ËÌÈÔ˘ÚÁ›· ÏÂÌÊÔ΋Ï˘, ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ÊϤ‚·˜, ‚·ÙfiÙËÙ·˜ ÙÔ˘ Ô˘ÚËÙ‹Ú·. ∂ΛÓÔ Ô˘ ÂÈÛËÌ·›ÓÂÙ·È Â›Ó·È fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙËÓ ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ Ì ÙË ¯Ú‹ÛË ÂÁÎÚ·ÙÔ‡˜ ·ÛÙ˘ Ë ÂÈÏÂÔ‰ÂÚÌ·ÙÈ΋˜ ·Ó·ÛÙfïÛ˘.

MÂÁ¤ı˘ÓÛË Ù˘ O˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ OÈ ·ıÂÓ›˜ Ô˘ ı· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÁ¤ı˘ÓÛË Î‡ÛÙˆ˜ ÂÎ·È‰Â‡ÔÓÙ·È ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ‰È·ÏÂÈfiÓÙˆÓ Î·ıÂÙËÚÈ·ÛÌÒÓ. ∏ ¯Ú‹ÛË ÙÔ˘˜ ¤‰ˆÛ ÙËÓ ‰˘Ó·ÙfiÙËÙ· Ó· ·Ó·Ù˘¯ıÔ‡Ó Î·ÈÓÔ‡ÚÁȘ Ù¯ÓÈΤ˜ ·ÊÔ‡ ¤Ï˘Û·Ó ÙÔ Úfi‚ÏËÌ· Ù˘ ΤӈÛ˘ Ù˘ ·ÛÙ˘. ™Ùfi¯Ô˜ Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ·˘ÙÒÓ ÙˆÓ Ù¯ÓÈÎÒÓ ÌÂÁ¤ı˘ÓÛ˘ Â›Ó·È Ó· ·˘ÍËı› Ë ¯ˆÚËÙÈÎfiÙËÙ· Ù˘ ·ÛÙ˘ Î·È Ó· ÌÂȈıÔ‡Ó ÔÈ ȤÛÂȘ ÛÙ· ÙÔȯÒÌ·Ù¿ Ù˘. OÈ Ó¢ÚÔÁÂÓ›˜ ·ÛÙÂȘ Ô˘ ¤¯Ô˘Ó ÌÈÎÚ‹ ¯ˆÚËÙÈÎfiÙËÙ· ‹ ÔÈ Î‡ÛÙÂȘ Ô˘ ¤¯Ô˘Ó ‰È·Ù·Ú·¯‹ Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÂÍ·ÈÙ›·˜ ÙˆÓ ‚·Ï‚›‰ˆÓ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜, ÌÔÚÔ‡Ó Ó· ÌÂÁÂı˘ÓıÔ‡Ó ÌÂÙ¿ ·fi ÙËÓ ·ÔÙ˘¯›· Ù˘ ¯Ú‹Û˘ ‰È·ÏÂÈfiÓÙˆÓ Î·ıÂÙËÚÈ·ÛÌÒÓ Î·È Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜. ∏ Ù¯ÓÈ΋ Ù˘ ÌÂÁ¤Óı˘ÓÛ˘ ÌÔÚ› Ó· Ú·ÁÌ·ÙÔÔÈËı› Ú›Ó ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÁÈ· ÙȘ ·ÛÙÂȘ Ô˘ ‰˘ÛÏÂÈÙÔ˘ÚÁÔ‡Ó ‹ ÌÂÙ¿ Â¿Ó Ë Î‡ÛÙË ‰ÂÓ ‰ÈÔÚıˆı› Ì ÙÔ˘˜ ηıÂÙËÚÈ·ÛÌÔ‡˜ Î·È ÙËÓ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ‹ ·ÎfiÌË ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ‰È·ÈÛÙÒıËΠ·ÊÔ‡ ¤ÁÈÓÂ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ì ηϿ ·ÔÙÂϤÛÌ·Ù·.

OÈ Ù¯ÓÈΤ˜ ÌÂÁ¤ı˘ÓÛ˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó: ÙÌ‹Ì· ÂÈÏÂÔ‡, ÙÔ ÛÈÁÌÔÂȉ¤˜, ÙÌ‹Ì· ÂÈÏÂÔ‡-Ù˘ÊÏÔ‡ Ì·˙› Ì ÙËÓ ÂÈÏÂÔÙ˘ÊÏÈ΋ ‚·Ï‚›‰· (̤ıÔ‰Ô˜ Mainz), ÙÌ‹Ì· ÛÙÔÌ¿¯Ô˘ ηıÒ˜ Î·È ÙÔ˘˜ ‰È·ÙÂٷ̤ÓÔ˘˜

METAMO™XEY™Eπ™ 2010

Ô˘ÚËÙ‹Ú˜ Ô˘ ÏÂÈÙÔ˘ÚÁÈο ‚Ú›ÛÎÔÓÙ·È Û ·¯ÚËÛ›·. ™˘Ó‰˘¿˙ÔÓÙ·˜ ÙËÓ Ù¯ÓÈ΋ ÌÂÁ¤ı˘ÓÛ˘ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Ì ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹ (·ÓÙȯÔÏÈÓÂÚÁÈο, ‰È·Ï›ÔÓÙ˜ ηıÂÙËÚÈ·ÛÌÔ›, ·ÓÙÈ‚ÈÔÙÈο) ·Î˘ÚÒÓÂÙ·È Ë ·Ó¿ÁÎË ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ Ì ·ÁˆÁÔ‡˜. ∏ ÌÂÁ¤Óı˘ÓÛË ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔÚ› Ó· ÌÂÙ·ÙÂı› ¯ÚÔÓÈο ̤¯ÚÈ Ó· ÌÂȈı› Ë ·ÓÔÛÔηٷÛÙÔÏ‹, ¤ÙÛÈ ÒÛÙ ӷ ÌËÓ ˘¿ÚÍÂÈ Úfi‚ÏËÌ· ÛÙËÓ ÂԇψÛË. ŸÏ˜ ÔÈ Ù¯ÓÈΤ˜ ¤¯Ô˘Ó ÏÂÔÓÂÎÙ‹Ì·Ù· Î·È ÌÂÈÔÓÂÎÙ‹Ì·Ù·. μ·ÛÈÎfi ÛÙÔÈ¯Â›Ô Â›Ó·È fiÙÈ ÙÔ ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËı›, ı· Ú¤ÂÈ Ó· ˘ÔÛÙ› ÙËÓ ÂÂÍÂÚÁ·Û›· Ù˘ ·ÔۈϋӈÛ˘ Î·È Ó· ÙÔÔıÂÙËı› ÛÙÔÓ ıfiÏÔ Ù˘ ·ÛÙ˘ ·Ê‹ÓÔÓÙ·˜ Ù· Ï¿ÁÈ· ÙÔȯÒÌ·Ù· ·‰È·Ù¿Ú·¯Ù·. ΔÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· Â›Ó·È Ë ·‡ÍËÛË Ù˘ ¯ˆÚËÙÈÎfiÙËÙ·˜ ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ‰›ÓÔÓÙ·˜ ÛÙËÓ Ó¤· ·ÛÙË ÛÊ·ÈÚÈ΋ ÌÔÚÊ‹ Î·È Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ÂÓ‰Ô·˘ÏÈÎÒÓ ȤÛÂˆÓ Û ·˘Ù‹Ó, ‰È·ÎfiÙÔÓÙ·˜ ÙÔÓ ÂÚÈÛÙ·ÏÙÈÛÌfi Î·È ·ÔÎÙÒÓÙ·˜ ηϋ ÚÔÛ·ÚÌÔÛÙÈÎfiÙËÙ·. μÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ó·ÊÔÚ¤˜ ȉ›ˆ˜ Û ·È‰È¿ ·Ó·Ê¤ÚÔ˘Ó ‰ÈÂÙ‹ ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ 100%, ÂÓÙ·ÂÙ‹ 84%, ‰ÂηÂÙ‹ 73%. ∏ ÂÈÏÔÁ‹ ÙÔ˘ ÛÈÁÌÔÂȉԇ˜ Û ·ÛıÂÓ›˜ Ì ‰Èۯȉ‹ Ú¿¯Ë Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÛÊÈÁÎÙËÚÈ·ÎÔ‡ Ì˯·ÓÈÛÌÔ‡ ÙÔ˘ ÚˆÎÙÔ‡, ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ ÌÂÙ·ÁÂÓ¤ÛÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ÛÙÔÓ ÙÚfiÔ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ∏ ÌÈÎÚÔ‚ÈÔ˘Ú›· Î·È ÔÈ Ô˘ÚÔÏÔÈÌÒÍÂȘ Â›Ó·È ÔÈ Èfi Û˘¯Ó¤˜ ÂÈÏÔΤ˜. ∏ ¯Ú‹ÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ۈϋӷ ‰È·ÙËÚ› ·Ì›ˆÙË ÙËÓ ·Ú·ÁˆÁ‹ ‚ϤÓÓ˘. °È· ÙÔÓ ÏfiÁÔ ·˘ÙfiÓ Â›Ó·È ··Ú·›ÙËÙË Ë Î·Ï‹ ÂÎ·›‰Â˘ÛË ÁÈ· χÛÂȘ Ì ÙËÓ ‚Ô‹ıÂÈ· ηıÂÙ‹ÚˆÓ, Èfi Û˘¯Ó¤˜ Û ·ÓÔ˘ÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ªÂ ÙȘ Ù·ÎÙÈΤ˜ χÛÂȘ ‰È·ÙËÚԇ̠۠ÈηÓÔÔÈËÙÈο Â›‰· ÙËÓ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· Ù˘ ·ÛÙ˘ (‰È¿Ù·ÛË – Û˘ÌÂÚÈÊÔÚ¿). OÈ ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ÔÈ ‰È¿ÚÚÔȘ Â›Ó·È Èfi Û˘¯Ó¤˜ Ì ÙËÓ ¯Ú‹ÛË ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ ÂÈÏÂÔ‡ – Ù˘ÊÏÔ‡ ÏfiÁˆ Ù˘ ÁÚ‹ÁÔÚ˘ ·ÚÔ¯¤Ù¢Û˘ ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ ÙÔ˘ ÂÈÏÂÔ‡ Úfi˜ ÙÔ Ù˘ÊÏfi ÂÍ·ÈÙ›·˜ Ù˘ ¤ÏÏÂȄ˘ Ù˘ ÂÈÏÂÔÙ˘ÊÏÈ΋˜ ‚·Ï‚›‰·˜. ∏ Èı·ÓfiÙËÙ· ÓÂÎÚˆÛ˘–ڋ͢ Â›Ó·È Û¿ÓÈ· ·ÏÏ¿ ·Ó·Ê¤ÚÂÙ·È È‰›ˆ˜ Û ·ÛıÂÓ›˜ Ô˘ ·›ÚÓÔ˘Ó ÛÙÂÚÔÂȉ‹. Δ¤ÏÔ˜ Ë ¯˘ÌÈ΋ ΢ÛÙ›Ùȉ· Î·È Ë Ô˘ÚËıÚ›Ùȉ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û·Ó ÂÈÏÔΤ˜ ÌÂÙ¿ Á·ÛÙÚÔ΢ÛÙÂÔÏ·ÛÙÈ΋ ȉȷ›ÙÂÚ· ÛÙÔ‡˜ ·ÓÔ˘ÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ Ì›ˆÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÂÌÊ¿ÓÈÛ˘ Ù˘ ˘ÂگψڷÈÌÈ΋˜ ÔͤˆÛ˘ οÓÂÈ ÙËÓ Á·ÛÙÚÔ΢ÛÙÂÔÏ·ÛÙÈ΋ ÂÏ΢ÛÙÈ΋ Û·Ó ÂÈÏÔÁ‹ Ù¯ÓÈ΋˜.

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∞Í›˙ÂÈ Ó· ÛËÌÂȈı› Ô Ì˯·ÓÈÛÌfi˜ ÂÁÎÚ¿ÙÂÈ·˜ ÙˆÓ Ô‡ÚˆÓ Ô˘ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ Ì¤ıÔ‰Ô ÙÔ˘ ªitrofanoff Ì ÙËÓ ÂÎÌÂÙ¿Ï¢ÛË Ù˘ ÛΈÏËÎÔÂȉԇ˜ ·fiÊ˘Û˘ fiÔ˘ ÙÔ ¤Ó· ¿ÎÚÔ ÂÌÊ˘Ù‡ÂÙ·È ÛÙÔ ÙÔ›¯ˆÌ· Ù˘ ·˘ÍË̤Ó˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Î·È ÙÔ ¿ÏÏÔ ¿ÎÚÔ Î·ıËÏÒÓÂÙ·È Û·Ó ÛÙÔÌ›·. ∏ ̤ıÔ‰Ô˜ ¯ÚËÛÈÌÔÔÈ‹Ù·È ÔÈÔ Û˘¯Ó¿ ÛÙ· ·È‰È¿, fiÔ˘ ‰ÂÓ ˘¿Ú¯ÂÈ ‰˘Ó·ÙfiÙËÙ· ÁÈ· ÙËÓ ÂÎÙ¤ÏÂÛË ‰È·ÏÂÈfiÓÙˆÓ Î·ıÂÙËÚÈ·ÛÌÒÓ.

ªÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ∫·È ÛÙȘ ÙÚ›˜ ÂÈÏÔÁ¤˜ ˘¿Ú¯ÂÈ ÙÔ Úfi‚ÏËÌ· ·Ô›ÎËÛ˘ Ì ‚·ÎÙ‹ÚÈ·. ∂¿Ó Ô ·ÛıÂÓ‹˜ Â›Ó·È ·Û˘Ìو̷ÙÈÎfi˜, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ıÂÚ·›·. ∂Í·›ÚÂÛË ·ÔÙÂÏ› Ë ·Ô›ÎËÛË Ì ÔÚÁ·ÓÈÛÌÔ‡˜ ‰È¿Û·Û˘ Ù˘ Ô˘Ú›·˜ fiˆ˜ Ô Proteas mirabilis Ô˘ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ Ï›ıÔ˘˜. ŒÓ· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi (>60%), ·ÚÔ˘ÛÈ¿˙ÂÈ Ô˘ÚÔÏԛ̈ÍË ÙÔ˘˜ ÚÒÙÔ˘˜ ÙÚ›˜ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ¿ÌÂÛË ÂÌÊ¿ÓÈÛË Ô˘ÚÔÏԛ̈͢ ÌÔÚ› Ó· Û˘Ì‚¿ÏÂÈ Û ·ÒÏÂÈ· ÌÔۯ‡̷ÙÔ˜ Î·È Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÚÔ‚ÏËÌ·ÙÈ΋ Ô˘ÚÔ‰fi¯Ô ·ÛÙË. Œ¯ÂÈ ÚÔÙ·ı› Ë ¯ËÌÂÈÔÚÔʇϷÍË ÁÈ· ¤ÍÈ Î·È Î·Ù’ ¿ÏÏÔ˘˜ ÁÈ· ‰Ò‰Âη Ì‹Ó˜. ™Â ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Ô˘ÚÔÏÔÈÌÒÍÂˆÓ ÌÈ· ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ı· ·ÂÈÎÔÓ›ÛÂÈ ÙËÓ Èı·ÓfiÙËÙ· ‡·Ú͢ Ï›ıˆÓ ÛÙÔ˘˜ Èı·ÁÂÓ›˜ ÓÂÊÚÔ‡˜, ÛÙÔ ÌfiÛ¯Â˘Ì·, ÛÙËÓ Î‡ÛÙË ‹ ÛÙËÓ ÂÎÙÚÔ‹.

OÈ ‰È·Ï›ÔÓÙ˜ ηıÂÙËÚÈ·ÛÌÔ› Â›Ó·È ·ÛÊ·Ï›˜ Î·È ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·fi ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó Ê˘ÛÈÔÏÔÁÈ΋ Ô˘Ú‹ıÚ·, ·ÏÏ¿ ·‰˘Ó·ÙÔ‡Ó Ó· ·‰ÂÈ¿ÛÔ˘Ó ÙËÓ Î‡ÛÙË. ¢ÂÓ ·˘Í¿ÓÔ˘Ó ÙËÓ Û˘¯ÓfiÙËÙ· ÙˆÓ Ô˘ÚÔÏÔÈÌÒÍÂˆÓ ¿Ó Î·È Ï·Ì‚¿ÓÔ˘Ó ·ÓÔÛÔηٷÛÙÔÏ‹. ∏ ÔͤˆÛË, Ë ·Ú·ÁˆÁ‹ ‚ϤÓÓ˘, Ë ÌÂÁ·ÏÔ‚Ï·ÛÙÈ΋ ·Ó·ÈÌ›· Î·È Ë ÂÌÊ¿ÓÈÛË Ï›ıˆÓ (¤ˆ˜ Î·È 50%) Â›Ó·È ÚÔ‚Ï‹Ì·Ù· Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È. ∏ Ù¯ÓÈ΋ Ì ÙËÓ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ ÂÓ¤¯ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ·‰ÂÓÔηÚÎÈÓÒÌ·ÙÔ˜ ÛÙËÓ ·Ó·ÛÙfïÛË. ÃÚÂÈ¿˙ÂÙ·È Û˘¯Ó‹ ·Ú·ÎÔÏÔ‡ıËÛË Ì ‰Â‰Ô̤ÓÔ fiÙÈ Ë ¯ÚfiÓÈ· ·ÓÔÛÔηٷÛÙÔÏ‹ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ

™˘Ì¤Ú·ÛÌ· 1. ªÈ· ‰˘ÛÏÂÈÙÔ˘ÚÁÈ΋ ·ÛÙË ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÙËÓ ‰ÈÂÓ¤ÚÁÂÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡.

2. ∞fi ÙȘ ÙÚ›˜ ÂÈÏÔÁ¤˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Ù¯ÓÈ΋˜ ÂÈϤÁÂÙ·È Ë ‰ËÌÈÔ˘ÚÁ›· ÂÚÈ‚¿ÏÏÔÓÙÔ˜ Ô˘ ı· ·Ô¯ÂÙ‡ÂÈ ÙÔ˘˜ ÓÂÊÚÔ‡˜, ηٿ ÚÔÙ›ÌËÛË Ù¯ÓÈΤ˜ ÌÂÁ¤Óı˘ÓÛ˘ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜.

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π. °∂øƒ°∞∫∏™, ¢. Δ∞∫√À¢∞™

3. ∏ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ¤‰·ÊÔ˜ ÚÔ‚ÏËÌ·ÙÈ΋˜ ·ÛÙˆ˜ Ô˘ ·Ó·Î·Ù·Û΢¿ÛÙËΠ‰ÂÓ ÂËÚ¿˙ÂÙ·È ·ÚÓËÙÈο.

4. OÈ ‰È·ÙÂٷ̤ÓÔÈ Ô˘ÚËÙ‹Ú˜ ‰È·ÙËÚÔ‡ÓÙ·È ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· ¯ÚËÛÈÌÔÔ›ËÛ˘ ÙÔ˘˜ (ÏfiÁˆ ÌË ¤ÎÎÚÈÛ˘ ‚ϤÓÓ˘).

5. OÈ ‰È·Ï›ÔÓÙ˜ ηıÂÙËÚÈ·ÛÌÔ› ‰ÂÓ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Ô˘ÚÔÏÔÈÌÒÍÂˆÓ ·Ú’ fiÏÔ Ô˘ ÔÈ ·ÛıÂÓ›˜ Ï·Ì‚¿ÓÔ˘Ó Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ ·ÓÔÛÔηٷÛÙÔÏ‹˜.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Adams J. et al. Renal transplantation in children with malformations of the urinary tract. Transplant Proc 2002; 34: 726-727.

2. Advanced, Urologic Surgery. Rudolf Hohenfellner, U Mainz Germany, J Fitzpatrick Dublin Ireland, J Mc Aninch San Francisco USA, 2005.

3. Al-Mousawi et al. Renal transplantation in patients with abnormal lower urinary tract.Transplant Proc 2001; 33: 2676-2677.

4. Aygun et al. Renal transplantation experience following endoscopic treatment of vesicoureteral reflux. Transplant Proc 2004; 36: 68-70.

5. Berry JM. et al. Kidney transplantation into patients with abnormal bladders. Transplantation 2004; 77: 1120-1123.

6. Capozza et al. Renal transplantation and congenital anomaly of the kidney and urinary tract. Paediatrics and child health 2009; 19: 51-52.

7. Capozza et al. Renal transplantation in avalve bladder: is bladder augmentation always necessary? J Paediatric Urology 2007; 3: 45.

8. Coosemans et al. Renal transplantation into abnormal urinary tract: ileal conduit urinary diversion. Transplant Proc 2001; 33: 2493-2494.

9. Crowe A. et al. Renal transplantation following renal failure due to urological disorders. Nephrol Dial Transplant 1998; 13: 2065-2069.

10. Defoor W. Successful renal transplantation in children with posterior urethral valves. J Urol 2003; 170: 1402.

11. Dharm S. et al. Kidney transplantation in patients with an abnormal lower urinary tract.Transplant 2002; 7: 161-165.

12. Ebert A. et al. Transplantation in children with congenital anomalies of the lower urinary tract. Act Urol 2001; 32: 266-272.

13. Errando C. et al. Urodynamic evaluation and management prior to renal transplantation. Eur Urol 2000; 38: 415-418.

14. Gill et al. Clean intemitten catheterization and urinary diversion in the management of renal transplants recipients with iower urinary tract dysfunction. J Urol 1992; 148: 1397-1400.

15. Hatch DA et al. Kidney transplantation in children with urinary diversion or bladder augmentatiom. J Urol 2001; 165: 2265-2268.

16. Hill J., Ransley P. The colonic conduit:a better method of urinary diversion. British J. Urol 2008; 55: 629-631.

17. Koo HP et al. Renal transplantation in children with severe lower urinary tract dysfunction. J Urol 1999; 161: 240-245.

18. Luke PP et al. Long term results of paediatric renal transplantation into a dysfunctioanal lower urinary tract. Transplantation 2003; 76: 1578-1582.

19. Marechal JM. et al. Continent cutaneous ileostomy (Kock pouch) prior to renal transplantation. Br J Urol 1990; 65: 317-321.

20. Nahas et al. End stage renal disease caused and bladder dysfunction:algorithm for renal transplantation.

Transplant Proc 2001; 33: 2984-2985.

21. Operative Urology at the Cleveland Clinic. Senior Editor Andrew C. Novick, MD-Associate Editor J Stephens Jones, MD. Cleveland Clinic foundation, 2006.

22. Pasquale Casale. Renal Transplantation In Children With Posterior Urethral Valves. Pediatric Nephrology 2006, 21(4): 566-571.

23. Power RE et all. Pre-transplant bilateral native nephrectomy for medically refractomy hypertension. Ir Med 2001; 94: 14-216.

24. Reconstructive Urologic Surgery. Edited by Drogo Montague et al, 2008. Cleveland, OH, USA. 25. Riedmiller M. et al. Continet urinary diversion in preparation of renal transplantation: a staged approach.

Transplantation 2000; 70: 1713-1717.

26. Shalow E., Kirsh A. Advances in bladder augmentation.

Current Ur Re 2007; 3: 125-130.

27. Sironvale et al. Endoscopic treatment of vesocoureteral reflux prior to renal transplantation. Tranplant 1992; 5: 231-233.

28. Wegner H. et al. Ileal conduit urinary diversion 16 months before renal transplantation in a case of non – functioning lower urinary tract. Internatinal Urology and Nephrology 1994; 26: 661-664.

Chronic allograft nephropathy – a clinical syndrome: early detection and the potential role of proliferation signal inhibitors Campistol JM, Boletis IN, Dantal J, de Fijter JW, Hertig A, Neumayer HH, Øyen O, Pascual J, Pohanka E, Ruiz JC, Scolari MP, Stefoni S, Serón D, Sparacino V, Arns W, Chapman JR.

Abstract

and recipient charac- teristics contribute to the pathogenesis of CAN4. For example, older donors, poor graft quality, recipient co-morbidities such as hypertension, hyperlipidemia, and CNI nephrotoxicity promote its development4.

To allow for improved management of CAN, there is a need for early detection, which may prompt earlier intervention, with changes in immunosuppressive therapies being targeted towards minimizing the risk factors associated with CAN8.

However, whether improved management strategies translate into improved long-term outcomes requires further investigation. In light of this, a workshop of nephrologists was held to discuss current practice for the identification and management of CAN and explore the potential role of early intervention strategies such as the use of proliferation signal inhibitors (PSIs)/mammalian target of rapamycin (mTOR) inhibitors. Here, we discuss the outcomes of this workshop, which were based on published data and also on the extensive clinical experience of a panel of transplant physicians.

Appropriate use of the term ‘‘CAN’’ is a hotly debated issue and has been discussed widely by the authors. The term was originally introduced as a histological grading of the extent of IF/TA present in renal biopsies8,9. However, other histological features may be associated with CAN: these can be defined as different subtypes, including transplant vasculopathy and transplant glomerulopathy6,8. Confining the term ‘‘CAN’’ to describe a constellation of signs and symptoms is clinically meaningful and promotes the concept that further diagnosis and intervention are required. However, popular misuse of ‘‘CAN’’ as a specific disease

Chronic allograft nephropathy (CAN) leads to the majority of late graft loss following renal transplantation. Detection of CAN is often too late to permit early intervention and successful management. Most current strategies for managing CAN rely on minimizing or eliminating calcineurin inhibitors (CNIs) once CAN has become established. The proliferation signal inhibitors everolimus and sirolimus have potent immunosuppressive and antiproliferative actions, with the potential to alter the natural history of CAN by reducing CNI exposure whilst avoiding acute rejection. Whilst data will be forthcoming from a number of clinical trials investigating this potential, we discuss early detection of CAN and the rationale for a role for this class of agent.

Late graft loss is one of the critical issues associated with renal transplantation today with a progressive decline in long-term graft survival1,2.

Indeed, chronic allograft nephropathy (CAN) and death with a functioning graft are the two major causes of graft loss1,3-5.

CAN is considered to be a late onset condition, but studies show significant prevalence of chronic histological damage from as early as a median of three months post-transplant. The condition is progressive, with interstitial fibrosis (IF) and tubular atrophy (TA) eventually resulting in chronic renal dysfunction6. Acute rejection episodes and calcineurin inhibitor (CNI) induced nephrotoxicity are two predictors for CAN 7 , although sub-acute and chronic rejection, as well as donor and recipient charac- teristics, also play a role in disease progression4,6,8. In addition, nonimmunological factors relating to specific donor

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entity has led to the decision to eliminate the term from the Banff classification, using instead a histological description based on IF/TA10. ‘‘CAN’’ cannot be replaced by the term ‘‘chronic rejection,’’ which implies that the pathology has an immune etiology. The term ‘‘chronic allograft dysfunction’’ also has limitations, as pathological change often precedes any deterioration in function. The revised Banff classification now recognizes the entity of chronic antibody-mediated rejection, in addition to IF/TA, broadening the underlying pathological lesions and pathophysiol- ogy of patients with ‘‘CAN.’’ As this workshop was undertaken prior to publication of the Banff report and with no suitable generic replacement terminology, the term ‘‘CAN’’ will be used throughout to describe the clinical syndrome encompassing all the above histological changes and their associated decline in renal function, while recognizing that this does not indicate a specific causality.

Renal function as a method of detecting CAN CAN is detected in protocol biopsies at one month, three months, and one yr post-transplant without significant decline in renal function8,11-13. As protocol biopsies are not routinely performed in many centers, there is a need to identify sensitive clinical markers of CAN. The decline in renal function associated with CAN is a late sign implying irreversible histological damage6,8. Changes in serum creatinine occur late during the progression of CAN and may be too late to allow successful intervention8.

Glomerular filtration rate (GFR) is accepted as the best overall measure of kidney function, since serum creatinine often underestimates the deterioration of renal function, especially at GFR levels between 30 and 70 mL/min8,14, and a single reference range for serum creatinine can be mis- leading15. Changes in GFR occur before obvious changes in serum creatinine, and it is only at GFR levels below approximately 30 mL/min that an increase in serum creatinine becomes a sensitive indication of underlying renal damage8.

Renal function can be assessed by creatinine clearance or by measured GFR (mGFR) through clearance of injected agents 8 . However, these techniques can be difficult and expensive to perform15 and are used in clinical trials more than in clinical practice. Estimated or calculated GFR

(eGFR) is more commonly used to indicate impaired renal function. Although mGFR is a more accurate measure of renal function than eGFR15,16, changes in eGFR may still correlate well with mGFR 16. However, recent data from Gera et al.17 suggest that the accuracy of eGFR varies with timepoint and is less accurate during the first post-transplant. There are a number of equations to estimate GFR that include additional variables14,15,18,19. These calculations have varying limitations in different ethnic groups and extreme body conditions16. Evolution of renal function at three months post-transplant, measured by eGFR, has been shown to be a more accurate indicator of graft loss than serum creatinine, with a deterioration in renal function of more than 10% at three months post-transplant being associated with a 2.5 times relative risk of 10-yr graft loss and predicting approximately 15% reduction in long-term graft survival 20. These variables can also be used in ‘‘slope analysis,’’ which is commonly used to determine the progression of renal function over time21.

Early detection of CAN Early identification of CAN is an essential component of successful intervention. A proposed strategy for early identification of CAN in renal transplant recipients is illustrated in Fig. 18,9,14,16,18-29. Absolute serum creatinine (>1.8 mg/dL or >130 lmol/L) or an irreversible rise in serum creatinine of 30% at six months post-transplant may be predictive of CAN25.

In a study of slope analysis21, there was a significant correlation between a low intercept (GFR<50 mL/ min) and a negative slope (p = 0.025). The reciprocal of serum creatinine also shows a greater decline in renal function over six months in patients with a low intercept (Fig. 2)21. These data suggest that renal transplant recipients with a negative slope exceeding that expected for normal ageing (loss of GFR of 1 mL/min/yr over the age of 40 [30]) or maximal posttransplant GFR of <50 mL/min should be monitored closely for CAN21. It should be noted, however, that these conclusions are based on population data, and do not necessarily reflect the situation of a single patient. It is recommended that an increase of 0.3 mg/dL (20 lmol/L) in serum creatinine, measured three times over three months, or a 15–20% rise in serum creatinine over one yr, is predictive of CAN and should prompt early intervention. However,

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All renal transplant recipients • Patients at high risk* Monitor every month during the first year post-transplant, then every 3 months

Gold standards used in research protocols Measured GFR (22) Protocol biopsy (23,24)

Absolute serum creatinine (25) Serum cratinine change (%) (8,20) Estimated GFR (14, 18, 19) Slope of change of calculated GFR (21,26) or1/serum creatinine (27)

Recognise the clinical syndrome

Other indicators of renal change – proteinuria (protein/urine creatinine ratio) (28) – deterioration of blood pressure control (28) Recurrent glomerulomephritis Histology + physiology

Test new noninterventional tests

Renal artery stenosis

Ultrasound± biopsy

Other causes Ureteric obstruction BK virus nephropathy

CAN (tubular atrophy + interstitial fibrosis) (9) DR CAN + CNI nephrotoxicity CAN + transplant vasculopathy CAN + sub clinical rejection CAN + chronic antibody-mediated rejection (including chronic transplant glomerulopathy) Test novel interventional strategies

THERAPEUTIC INTERVENTION

I (41%) > 50 II (28%)

< 50

Intervention necessary

III (15%)

IV (16%)

Unstable slope after month 6 Year post-transplantation

Stable slope after month 6

Fig. 2. Slope analysis may contribute to early detection of chronic allograft nephropathy. The initial intercept of GFR (endogenous creatinine clearance) at six months post-transplant and the subsequent rate of decline of GFR are used to calculate the slope. There is a significant correlation between a low intercept with GFR<50 mL/min and a negative slope (p = 0.025) and the reciprocal of serum creatinine shows a greater decline in renal function over six months in patients with a low intercept. Twenty-eight percent of patients had an initial intercept of GFR of >50 mL/min with an unstable slope over six months (II), 16% of patients had an initial GFR of <50 mL/min with an unstable slope, leading to earlier graft loss (IV). Reproduced with permission from Sage Publications21.

Renal function GFR at month 6 (mL/min)

Fig. 1. Early detection before chronic allograft nephropathy becomes established8,9,14,16,18-29. *Patients at a high risk of CAN include ‘‘old-for-old’’ transplant recipients (older recipients receiving a kidney from an older donor)29.

Calculated GFR can be measured by Cockroft-Gault18, Nankivell19 or Modification of Diet in Renal Disease14 equations. These equations have varying limitations in different ethnic groups and are often unreliable at extreme GFR values14,16,18,19. +New proteinuria or an increase of 0.5 g/24 h. ¨Biopsy if 10% change in GFR (or 20% change in serum creatinine). CTG, chronic transplant glomerulopathy; DSAb, donor-specific antibodies.

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serum creatinine must be measured repeatedly to observe any trend, and these measurements should be obtained from the same laboratory using the same methodology. A 10% deterioration in renal function, determined by mGFR or eGFR, over a threemonth period may also be predictive of CAN and signals the need for early intervention. The group consensus was that GFR values of <50 mL/min identify the need to monitor the patient more closely for CAN. Other early markers of CAN include proteinuria and hypertension25,28. Changes in these parameters tend to occur late but may be a useful indicator of CAN in combination with subtle changes in serum creatinine or creatinine clearance. Group experience from the clinical setting suggests that a confirmed proteinuria level of >0.3 g (in the absence of other pathologies) or an increase in proteinuria of >0.5 g/24 h may be predictive of CAN and signals the need for intervention. However, it should be noted that small changes in the quantity and quality of proteinuria (low or high molecular weight proteins) may also be an indicator of CAN. There are other causes of renal dysfunction including recurrent glomerulonephritis, renal artery stenosis, ureteric obstruction, or BK virus associated nephropathy (Fig. 1)8. Therefore, deterioration in renal function requires confirmatory diagnosis through ultrasound and/or biopsy to ensure appropriate management and review of immunosuppressive therapies. New non-interventional tests such as magnetic resonance imaging 31 and tissue pulsatility index 32 show promise for non-invasive detection of CAN. Furthermore, identification of biological markers of CAN through gene expression

microarrays (e.g., vascular endothelial growth factor, vimentin, and a-smooth muscle actin 33,34 ) are currently under investigation.

Immunosuppressive strategies for the early intervention of CAN Early intervention strategies are important in managing CAN in renal transplant recipients8,13,35.

Identification of risk factors for CAN may allow targeted early intervention strategies8,35. While no formal randomized controlled trials are available to illustrate a direct correlation between early intervention and decreased allograft deterioration, early intervention seems a logical step in decreasing the impact of nephropathy. Such strategies include both preventive and therapeutic measures that target the management and monitoring of CNI dose and comorbidities, avoiding acute rejection episodes, and monitoring patients on an individual basis taking into account donor and recipient factors (Fig. 3) 8,35 .

Minimizing the impact of CNI dose-induced nephrotoxicity is one of the favored approaches to manage CAN8,36,37.

One option for early intervention of CAN involves reducing or eliminating CNIs through the use of PSIs. While there is still no consensus on the role of PSIs in the treatment of CAN, both everolimus and sirolimus have immunosuppressive and antiproliferative actions that may provide a multifaceted approach to the management of CAN. This may involve minimizing CNI use, minimizing rejection episodes and reducing smooth muscle cell proliferation 38,39. Clinical studies with everolimus in

Review CNI dose to avoid nephrotoxicity

Avoid acute and subclinical rejection episodes

Early intervention for CAN

Tailor patient management considering donor, recipient and graft factors • HLA match • Reduce iscje,oc injury • Maximze graft function • Increase surveillance for older donor kidney

Manage and monitor co-morbidities • Hyperlipidemia • Hypertension • Diabetes

Fig. 3. Early intervention strategies and considerations for the management of chronic allograft nephropathy8,35.

HLA, human leukocyte antigen. Reproduced with permission from Oxford University Press.

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renal transplant recipients have demonstrated that it facilitates a halving in cyclo- sporine (CsA) exposure, with a 57% reduction in mean CsA trough blood levels38. This strategy using everolimus and low-dose CsA, has been shown to provide effective protection against rejection with good renal function40. Recent studies show that sirolimus can be used in combination with CNIs, lowering the incidence of CAN41, and that CNI minimization with sirolimus attenuates the progression of early stage CAN42,43. Sirolimus is indicated for use in CNI-elimination regimens, and there are substantial clinical trial data demonstrating that withdrawal of CsA from three months postransplant is associated with a reduction in histological features of CAN and improved renal function44-49.

However, early withdrawal of CNIs has drawbacks such as increased acute rejection and adverse events36,50, implying that withdrawal should not be considered before three months post-transplant.

Conversion to sirolimus has been successful in reducing later stage CAN and improving renal function51-55. However, some studies have revealed a population of non-responders in whom renal function continues to deteriorate54,55. CNI-minimization or elimination can also be achieved using mycophenolate mofetil (MMF)-based immunosuppressive regimens in maintenance renal transplant recipients with established CAN 56-58 . Evidence from these studies suggests that subsequent improvements in renal function may be due to both the withdrawal of CNIs and the introduction of MMF. The combination of PSIs and mycophenolic acid (MPA)based regimens may provide further improvements in patients with established CAN. The potential role of PSIs in intervention of CAN The PSIs work through inhibition of mTOR, which plays a key role in signal transduction pathways linking growth factor activity with increased protein production. As a result, everolimus and sirolimus block calcium-independent T cell activation and proliferation after cytokine stimulation and costimulatory interaction, as well as inhibiting the effector functions of CD4+ and CD8+ T cells and the activation of monocytes and macrophages 59 .

Thus, the PSIs not only provide potent immunosuppression but also offer antiproliferative effects.

Studies examining conversion from CNIs to sirolimus for the management of CAN have been explored51,55,60. For example, 18-month data from

83

the CONVERT study in 275 patients who continued CNI-based immunosuppression and 555 who were converted to sirolimus have been presented at the World Transplant Congress61. The results showed that rates of acute rejection (3.2% in the sirolimus group vs. 2.0% in the continued CNI group), graft survival (95.4% vs. 95.9%), and patient survival (97.4% vs. 98.4%) were not signif- icantly different between the two groups. In patients who receive immunosuppression with sirolimus and CsA, renal function should be closely monitored62,63. Indeed, the sirolimus label notes that patients should not be treated with CsA and sirolimus in combination beyond three months62. Taken together, there is a rationale for early rather than late conversion to PSIbased immunosuppression. In the absence of clinical trial data reporting conversion to everolimus in maintenance of renal transplant recipients with CAN, clinical guidance can only be based on current evidence and clinical experience (Fig. 4)64-69. CNI exposure should be reduced as soon as early signs of CAN or renal dysfunction are evident. However, CNI withdrawal before the third month post-transplantation may be associated with increased risk of acute rejection50, although a protocol of conversion to everolimus at seven wk is currently being explored70. CsA blood levels at two h post-dose (C2) of 350–450 ng/mL64 or tacrolimus trough blood levels of around 7 ng/mL should be targeted before conversion to everolimus71. Benefits obtained after conversion are questionable if estimated GFR is below 40 mL/min72 or if proteinuria is over 800 mg/d55, and the risk: benefit balance in these patients should thus be considered very carefully (Fig. 4).

The potential immunosuppressive strategies utilizing everolimus in maintenance renal transplant recipients include everolimus in combination with reduced CNI, everolimus and steroids in a CNI-free regimen, or everolimus with MPA and steroids, with the conversion strategy being dependent on the choice of immunosuppressive regimen (Fig. 4). Since there is a drug-drug interaction between everolimus and CsA66, it is important to anticipate a 2-3-fold increase in everolimus dose requirements following withdrawal of CsA. Conversely, because tacrolimus has a minimal effect on everolimus blood levels, a higher everolimus dose may be needed to achieve trough blood levels of 3-8 ng/mL when combined with tacrolimus as opposed to CsA73. Withdrawal of

84

I. BOLETIS

Fig. 4. Everolimus in the management of chronic allograft nephropathy64-69. For conversion from CNIs to sirolimus (a drug that has followed a different development pathway) see references51,55,60. *If converting from a double immunosuppressive regimen to an alternative double immunosuppressive regimen, care should be taken to avoid under-immunosuppression and overlap of treatment is recommended. If converting from a triple immunosuppressive regimen to an alternative triple immunosuppressive regimen, then there is no need to overlap therapies. +Everolimus + MPA without steroids (double IS) is also under investigation68. Reduce MPA dose when introducing PSIs67,69. ¨Lower MPA dose may be required when converting to everolimus from a CsA regimen.

MPA dose reduction is not required when converting from tacrolimus. ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blockers; IS, immunosuppression; MPA, mycophenolic acid; Tac, tacrolimus. **Anemia and proteinuria may occur with everolimus treatment. Treat severe cases of anemia with erythropoietin and avoid ACE inhibitors, reducing MPA dose may also reduce anemia. Treat cases of proteinuria with ACE inhibitors or ARB79, maintain everolimus trough blood levels of 3-8 ng/mL, and reduce CsA dose64.

CsA affects MPA pharmacokinetics67,69; therefore, it may be necessary to reduce MPA dose when withdrawing CsA and introducing everolimus. However, tacrolimus withdrawal from regimens containing

MPA can be achieved without MPA dose reduction74.

Monitoring of renal function is required following conversion to everolimus. Proteinuria is a common adverse event associated with conversion to

METAMO™XEY™Eπ™ 2010

PSI therapy 55,75-77 . Evidence suggests that proteinuria is correlated with structural changes, and that PSIs may induce these changes78-80. Lower levels of proteinuria may be managed successfully by a reduction in CsA dose rather than elimination of CsA, or through the introduction of ACE inhibitors or ARBs78. Renal biopsy to rule out acute rejection may be useful in patients with deteriorating renal function or increasing proteinuria. Other adverse events associated with everolimus include hematological and metabolic abnormalities, which may be exacerbated if used with MPA. Effects on hematological parameters may require MPA dose reduction, or in severe cases, treatment with erythropoietin while hyperlipidemia is usually managed by the introduction of statins64.

Conclusions Earlier detection and intervention of CAN remains a key challenge for transplant physicians.

Changes in serum creatinine levels and proteinuria often occur late in disease progression and may not accurately represent the underlying renal damage.

Deterioration of renal function over time, determined through slope analysis, is a more accurate indicator of CAN, and earlier identification of renal deterioration may prompt earlier changes in immunosuppressive therapies. Conversion to nonnephrotoxic immunosuppressants, such as PSIs, holds promise in reducing the impact of CAN by both avoiding and reducing the impact of CNIs and reducing smooth muscle cell proliferation in the kidney. While clinical trial evidence is needed for early detection and intervention in patients with CAN, this review represents the current knowledge upon which clinicians can base their strategies.

Acknowledgements The authors received an honorarium from Novartis Pharma AG for participation at workshops in Barcelona, November 2006, and Geneva, June 2007, on “Chronic allograft nephropathy in renal transplantation: diagnosis and early intervention”. Ogilvy 4D provided editorial assistance on behalf of Novartis Pharma AG.

References 1. Macdonald S, Chang S, Excell L, eds. ANZDATA Registry Report 2006. Adelaide, Australia: Australia and New Zealand Dialysis and Transplantation Registry, 2006.

85

2. Meier Kriesche HU, Schold JD, Srinivas TR, Kaplan B. Lack of improvement in renal allograft survival despite a marked decrease in acute rejection rates over the most recent era. Am J Transplant 2004: 4: 378.

3. Excell L, Chadban S, MacDonald S. Transplantation in ANZDATA Registry Report 2004. In Excell L, Macdonald S eds. Adelaide, Australia: Australia and New Zealand Dialysis and Transplantation Registry, http://www.anzdata.org.au/v1/index.html.

4. Pascual M, Theruvath T, Kawai T, Tolkoff-Rubin N, Cosimi AB. Strategies to improve long-term out-comes after renal transplantation. N Engl J Med 2002: 346: 580.

5. Sijpkens YWJ, Doxiadis N II, de Fijter JW et al. Sharing cross-reactive groups of MHC class I improves longterm graft survival. Kidney Int 1999: 56: 1920.

6. Nankivell BJ, Borrows RJ, Fung CL-S et al. The natural history of chronic allograft nephropathy. N Engl J Med 2003: 349: 2326.

7. Solez K, Vincenti F, Filo RS. Histopathologic findings from 2-year protocol biopsies from a US multicenter kidney transplant trial comparing tacrolimus versus cyclosporine: a report of the FK506 kidney transplant study group. Transplantation 1998: 66: 1736.

8. Chapman JR, O PJ, Nankivell BJ. Chronic renal allograft dysfunction. J Am Soc Nephrol 2005: 16: 3015.

9. Racusen LC, Solez K, Colvin RB et al. The Banff 97 working classification of renal allograft pathology.

Kidney Int 1999: 55: 713.

10. Solez K, Colvin RB, Racusen LC et al. Banff Meeting Report: differential diagnosis of chronic allograft injury and elimination of chronic allograft nephropathy (‘‘CAN’’). Am J Transplant 2007: 7: 518.

11. Nankivell BJ, Chapman JR. The significance of subclinical rejection and the value of protocol biopsies.

Am J Transplant 2006: 6: 2006.

12. Serfin D, Moreso F, Bover J et al. Early protocol renal allograft biopsies and graft outcome. Kidney Int 1997: 51: 310.

13. Nankivell BJ, Chapman JR. Chronic allograft nephropathy: current concepts and future directions. Transplantation 2006: 81: 643.

14. Levey AS, Bosch JP, Breyer Lewis J et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med 1999: 130: 461.

15. Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function – measured and estimated glomerular filtration rate. N Engl J Med 2006: 354: 2473.

16. Raju DL, Grover VK, Shoker A. Limitations of glomerular filtration rate equations in the renal transplant patient. Clin Transplant 2005: 19: 259.

17. Gera M, Slezak JM, Rule AD et al. Assessment of changes in kidney allograft function using creatininebased estimates of glomerular filtration rate. Am J Transplant 2007: 7: 880.

18. Cockroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976: 16: 31.

86

I. BOLETIS

19. Nankivell BJ, Gruenewald SM, Allen RDM, Chapman JR. Predicting glomerular filtration rate after kidney transplantation. Transplantation 1995: 59: 1683.

35.

20. Marqués GG, Goenaga PE, Royo FJL, Escolá JM, Fernández NG, Unanua AP. Evolution of the renal function is a better predictor of long-term survival than serum creatinine. Transplant Proc 2005: 37: 3701.

36.

21. Sijpkens YWJ, Zwinderman AH, Mallat MJK et al.

Intercept and slope analysis of risk factors in chronic renal allograft nephropathy. Graft 2002: 5: 108.

37.

22. Watson CJE, Firth J, Williams PF et al. A randomized controlled trial of late conversion from CNI-based to sirolimus-based immunosuppression following renal transplantation. Am J Transplant 2005: 5: 2496.

38.

23. Moreso F, Ibernon M, Gomà M et al. Subclinical rejection associated with chronic allograft nephropathy in protocol biopsies as a risk factor for late graft loss.

Am J Transplant 2006: 6: 747.

39.

24. Chapman JR. Longitudinal analysis of chronic allograft nephropathy: clinicopathologic correlations. Kidney Int 2005: 68(Suppl 99): 108.

40.

25 Lietz K, Lewandowski Z, Lao M, Paczek L, Gaciong Z. Pretransplant and early posttransplant predictors of chronic allograft nephropathy in cadaveric kidney allograft – a single-center analysis of 1112 cases.

Transpl Int 2004: 17: 78.

41.

26. Meyers CM, Kirk AD. Workshop on late renal allograft dysfunction. Am J Transplant 2005: 5: 1600.

27. Morath C, Lange U, Klein A, Zeier M, Arns W. High responder rate after calcineurin-inhibitor withdrawal and introduction of sirolimus therapy in patients with deteriorating renal function. Transplantation 2006: 82(Suppl 3): 498. Abstract 1280.

42.

43.

28. Arias M, Fernandez-Fresnedo G, Rodrigo E et al. Nonimmunologic intervention in chronic allograft nephropathy. Kidney Int Suppl 2005: 99: S118.

29. Arns W, Citterio F, Campistol JM. – New strategies for renal transplantation. Nephrol Dial Transplant 2007: 22: 336.

30. Lindeman RD, Tobin J, Shock NW. Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 1985: 33: 278.

31. Djamali A, Sadowski EA, Samaniego-Picota M et al.

Noninvasive assessment of early kidney allograft dysfunction by blood oxygen level-dependent magnetic resonance imaging. Transplantation 2006: 82: 621.

32. Scholbach T, Girelli E, Scholbach J. Tissue pulsatility index: a new parameter to evaluate renal transplant perfusion. Transplantation 2006: 81: 751.

33. Mas V, Maluf D, Archer K et al. Establishing the molecular pathways involved in chronic allograft nephropathy for testing new non-invasive diagnostic markers. Transplantation 2007: 83: 448.

34. Cheng OH, Kampen RL, Hoffmann SC, Kirk AD, Mannon RB. Look into the crystal ball: using gene expression

44.

45.

46.

47.

arrays to predict chronic allograft nephropathy.

Transplantation 2006: 82(Suppl 3): 239. Abstract 511.

Serfin D, Arns W, Chapman JR. Chronic allograft nephropathy – clinical guidance for early detection and early intervention strategies. Nephrol Dial Transplant 2008: 23: 2467.

Chapman JR, Nankivell BJ. Nephrotoxicity of ciclosporin A – short-term gain, long-term pain? Nephrol Dial Transplant 2006: 21: 2060.

Nankivell BJ, Borrows RJ, Fung CL-S, O PJ, Chapman JR, Allen RDM. Calcineurin inhibitor nephrotoxicity: longitudinal assessment by protocol histology. Transplantation 2004: 78: 557.

Pascual J. Concentration-controlled everolimus (Certican): combination with reduced dose calcineurin inhibitors. Transplantation 2005: 79(Suppl 3): S76.

Lutz J, Zou H, Liu S, Antus B, Heemann U. Apoptosis and treatment of chronic allograft nephropathy with everolimus. Transplantation 2003: 76: 508.

Vitko S, Tedesco H, Eris J et al. Everolimus with optimized cyclosporine dosing in renal transplant recipients: 6-month safety and efficacy results of two randomized studies. Am J Transplant 2004: 4: 626.

Kumar MSA, Heifets M, Fyfe B et al. Comparison of steroid avoidance in tacrolimus/mycophenolate mofetil and tacrolimus/sirolimus combination in kidney transplantation monitored by surveillance biopsy. Transplantation 2005: 80: 807.

Sumethkul V, Changsirikulchai S, Lothuvachai T, Chalermsanyakorn P. Sirolimus attenuates the rate of progression of early chronic allograft nephropathy. Transplantation 2006: 82(Suppl 3): 3470. Abstract 1134.

Changsirikulchai S, Chalermsanyakorn P, Watanapokasin R, Sumethkul V. Cyclosporine reduction and sirolimus or mycophenolate mofetil addition attenuate the progressive decline of graft function and stabilize TGFb1 levels in chronic allograft nephropathy. Am J Transplant 2006: 6(Suppl 2): 507.

Flechner SM, Kurian SM, Solez K et al. De novo kidney transplantation without the use of calcineurin inhibitors preserves renal structure and function at two years. Am J Transplant 2004: 4: 1776.

Oberbauer R, Segoloni G, Campistol JM et al. Early cyclosporine withdrawal from a sirolimus-based regimen results in better renal allograft survival and renal function at 48 months after transplantation. Transpl Int 2005: 18: 22.

Mota A, Arias M, Taskinen EI et al. Sirolimus-based therapy following early cyclosporine withdrawal provides significantly improved renal histology and function at 3 years. Am J Transplant 2004: 4: 953.

Ruiz JC, Campistol JM, Grinyfi JM et al. Early cyclosporine A withdrawal in kidney-transplant recipients receiving sirolimus prevents progression of chronic pathologic allograft lesions. Transplantation 2004: 78: 1312.

METAMO™XEY™Eπ™ 2010

48. Ruiz JC, Campistol JM, Mota A et al. Early elimination of cyclosporine in kidney transplant recipients receiving sirolimus prevents progression of chronic pathologic allo-graft lesions. Transplant Proc 2003: 35: 1669.

49. Stallone G, Di Paolo S, Schena A et al. Early withdrawal of cyclosporine A improves 1-year kidney graft structure and function in sirolimus-treated patients.

Transplantation 2003: 75: 998.

50. Mulay AV, Hussain N, Fergusson D, Knoll GA. Calcineurin inhibitor withdrawal from sirolimus-based therapy in kidney transplantation: a systemic review of randomized trials. Am J Transplant 2005: 5: 1748.

51. Fischereder M, Graeb C, Kruger B et al. Conversion from calcineurin inhibitors to sirolimus in patients with chronic renal allograft dysfunction. Transplant Proc 2006: 38: 1295.

52. Stallone G, Infante B, Schena A et al. Rapamycin for treatment of chronic allograft nephropathy in renal transplant patients. J Am Soc Nephrol 2005: 16: 3755.

53. Wali RK, Cooper M, Foster C et al. Early tacrolimus withdrawal and rescue therapy with sirolimus in highrisk renal transplant recipients with moderate to severe chronic allograft nephropathy. Transplantation 2006: 82(Suppl 3): 1572. Abstract 1715.

54. Ibañez J, Monteverde M, Diaz M, Goldberg J, Turconi A. Sirolimus effect on chronic allograft dysfunction in pediatric renal recipients. Am J Transplant 2006: 6(Suppl 2): 571. Abstract 1504.5.

55. Diekmann F, Budde K, Oppenheimer F et al. Predictors of success in conversion from calcineurin inhibitor to sirolimus in chronic allograft dysfunction. Am J Transplant 2004: 4: 1869.

56. Gonzalez Molina M, Serfin D, Garcia del Moral R et al.

Mycophenolate mofetil reduces deterioration of renal function in patients with chronic allograft nephropathy A follow-up study by the Spanish Cooperative Study Group of Chronic Allograft Nephropathy. Transplantation 2004: 77: 215.

57. Dudley C, Pohanka E, Riad H et al. Mycophenolate mofetil substitution for cyclosporine A in renal transplant recipients with chronic progressive allograft dysfunction: the ‘‘Creeping Creatinine’’ study. Transplantation 2005: 79: 466.

58. Pascual M, Williams WW, Cosimi AB, Delmonico FL, Farrell ML, Tolkoff-Rubin N. Chronic renal allograft dysfunction: a role for mycophenolate mofetil? Transplantation 2000: 69: 1749.

59. Neuhaus P, Klupp J, Langrehr JM. mTOR inhibitors: an overview. Liver Transpl 2001: 7: 473.

60. Diekmann F, Campistol JM. Conversion from calcineurin inhibitors to sirolimus in chronic allograft nephropathy: benefits and risks. Nephrol Dial Transplant 2006: 21: 562.

61. Schena FP, Vitko S, Wali R et al. Efficacy and Safety of Conversion from Calcineurin Inhibitors to Sirolimus Versus Continued Use of Calcineurin Inhibitors in Renal Allograft Recipients: 18-Month results from a

87

Randomized, Open-Label Comparative Trial. Poster presented at the World Transplant Congress, Boston, MA, USA: July 22–27, 2006. Abstract 1026.

62. Wyeth Europa Ltd. Rapamune Summary of Product Characteristics. Maidenhead: Wyeth Europa Ltd., 2007.

63. Wyeth Pharmaceuticals, Inc., Rapamune (Sirolimus) Oral Solution and Tablets. Prescribing Information.

Philadelphia, PA: Wyeth Pharmaceuticals, Inc., 2007.

64. Pascual J, Boletis IN, Campistol JM. Everolimus (Certican) in renal transplantation: a review of clinical trial data, current usage and future directions. Transplant Rev 2006: 20: 1.

65. Chan L, Cooper M, Leventhal J, Munir L. Excellent renal function at 6 months in de novo kidney transplant recipients treated with everolimus, basiliximab and reduced tacrolimus exposure. Transplantation 2006: 82(Suppl 3): 299. Abstract 689.

66. Kovarik JM, Figueiredo J, Rouilly M, O LF, Rordorf C. Differential of two cyclosporine formulations on everolimus pharmacokinetics: a clinically relevant pharmacokinetic interaction. J Clin Pharmacol 2002: 42: 95.

67. Pohanka E. Conversion to everolimus in maintenance patients – current clinical strategies. Nephrol Dial Transplant 2006: 21(Suppl 3): 24.

68. Lebranchu Y, Etienne I, Touchard E et al. Comparison of Efficacy and Safety of Cyclosporine (CsA) Discontinuation with Introduction of Sirolimus (SRL) at Week 12 to Standard Strategy in Renal Transplant Recipients receiving Mycophenolate Mofetil (MMF). Presented at the Am J Transplant 2007: 7(Suppl 2): 160. Abstract 53.

69. Budde K, Glander P, Schuhmann R et al. Conversion from cyclosporine to everolimus leads to better renal function and to profound changes in everolimus and mycophenolate metabolism. Transplantation 2006: 82(Suppl 3): 999. Abstract 2867.

70. Holdaas H, Pfeffer P, Bentdal Ø, Midtvedt K. Conversion from Cyclosporine to Everolimus at Week 7 after Renal Transplantation is Safe and Improves Renal Function. Presented at Am J Transplant 2007: 7(Suppl 2). Abstract 1709.

71. Ekberg H, Tedesco-Silva H, Demirbas A et al. Reduced exposure to calcineurin inhibitors in renal transplantation. New Engl J Med 2007: 357: 2562.

72. Campistol JM, Oberbauer R, Schena F et al. The Sirolimus CONVERT Trial Study Group. Univariate and Multivariate Analyses of Factors affecting Renal Allograft Function after Conversion from Calcineurin Inhibitor (CI)- to Sirolimus (SRL)-based Immunosuppression.

Am J Transplant 2006: 6(Suppl 2): 412.

73. Kovarik JM, Curtis JJ, Hricik DE, Pescovitz MD, Scantlebury V, Vasquez A. Differential pharmacokinetic interaction of tacrolimus and cyclosporine on everolimus.

Transplant Proc 2006: 38: 3456.

74. Arns W, Glander P, Schuhmann R et al. Conversion from Tacrolimus to Everolimus does not Influence the

88

I. BOLETIS

Pharmacokinetic but Increases Pharmacodynamic Response on Mycophenolate Sodium in Renal Transplant Patients. Am J Transplant 2006: 6(Suppl 2): 488.

75. Bumbea V, Kamar N, Ribes D et al. Long-term results in renal transplant patients with allograft dysfunction after switching from calcineurin inhibitors to sirolimus.

Nephrol Dial Transplant 2005: 20: 2517.

76. Ruiz JC, Campistol JM, Sรกnchez-Fructuoso A et al. Increase of proteinuria after conversion from calcineurin inhibitor to sirolimus-based treatment in kidney transplant patients with chronic allograft dysfunction.

Nephrol Dial Transplant 2006: 21: 3252.

77. Stracke S, Mayer JM, Henne-Bruns D, Keller F. Elevated

serum levels of vascular endothelial growth factor (VEGF) and proteinuria in renal allograft recipients treated with mTOR inhibitors. Am J Transplant 2006: 6 (Suppl 2): 299. Abstract 688.

78. Wilmer WA, Rovin BH, Hebert CJ, Rao SV, Kumor K, Hebert LA. Management of glomerular proteinuria: a commentary. J Am Soc Nephrol 2003: 14: 3217.

79. Keane WF. Proteinuria: its clinical importance and role in progressive renal disease. Am J Kidney Dis 2000: 4(Suppl 1): S97.

80. Amer H, Fidler ME, Myslak M et al. Proteinuria after kidney transplantation, relationship to allograft histology and survival. Am J Transplant 2007: 7: 2748.

KA£Y™ΔEƒ∏MENH §EπΔOYƒ°πA NEºƒπ∫OY MO™ÃEYMATO™

¶·ıÔÁ¤ÓÂÈ· Î·È ÂͤÏÈÍË ¢ËÌ‹ÙÚÈÔ˜ ™. °Ô‡ÌÂÓÔ˜

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‰fiÙ˜ ËÏÈΛ·˜ 15-20 ÂÙÒÓ Î·È ÛÙÔ 40-50% ÙˆÓ ÏËÙÒÓ ·fi ‰fiÙ˜ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ2,3.

O ·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ·ÔÙÂÏ› ÚԉȷıÂÛÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·ı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞ӷʤÚÂÙ·È fiÙÈ ÁÈ· οı 6 ÒÚ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, Ë Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ‹˜ Ù˘ ·˘Í¿ÓÂÈ Î·Ù¿ 23%. ∏ ÔÍ›· ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë Â›Ó·È ÈÔ Û˘¯Ó‹ Û ÂÚÈÙÒÛÂȘ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË, Ú¿ÁÌ· Ô˘ ÔÊ›ÏÂÙ·È Û ·ÂÏ¢ı¤ÚˆÛË Î˘ÙÙ·ÚÔÎÈÓÒÓ Î·È ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Ô‰ËÁÔ‡Ó Û ÊÏÂÁÌÔÓ‹, ÈÛ¯·ÈÌ›· Î·È ‚Ï¿‚Ë. ™Â ÂÚÈÙÒÛÂȘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ Û˘Ó‹ıˆ˜ ˘¿Ú¯ÂÈ ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· Ô˘ Ô‰ËÁ› Û ˘Ô-ÔÁηÈÌ›· Î·È ·Ó¿ÁÎË ÁÈ· ¯Ú‹ÛË ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ Ô˘ ·˘Í¿ÓÔ˘Ó ÙËÓ ÈÛ¯·ÈÌ›·. ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë Û˘Ì‚ÔÏ‹ Ù˘ ‚ÈÔ„›·˜ ÂÌʇÙ¢Û˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ȉȷ›ÙÂÚ· Û ÂÚÈÙÒÛÂȘ ÔÚÈ·ÎÒÓ ‰ÔÙÒÓ4,5. ∏ ‚ÈÔ„›· ÂÌʇÙ¢Û˘, ·Ú¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ·ÏÏ¿ Î·È ÁÈ· ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛ‹ ÙÔ˘. ∂› ϤÔÓ ÌÔÚ› Ó· ¯ÚËÛÈ̇ÛÂÈ ÁÈ· Û‡ÁÎÚÈÛË Ì ÌÂÏÏÔÓÙÈΤ˜ ‚ÈÔ„›Â˜ Ô˘ ÌÔÚ› Ó· Á›ÓÔ˘Ó ÁÈ· ÙË ‰È¿ÁÓˆÛË ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹ ÙÔÍÈÎfiÙËÙ·˜ ·fi ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ ‹ ÛÙ· Ï·›ÛÈ· ‚ÈÔ„ÈÒÓ ÚˆÙÔÎfiÏÏÔ˘4,5. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË Ì·˜ ‰È·ÈÛÙÒÛ·ÌÂ, ·Ó·Ï‡ÔÓÙ·˜ ÌÂÁ¿ÏÔ ·ÚÈıÌfi ‚ÈÔ„ÈÒÓ ÂÌʇÙ¢Û˘, fiÙÈ Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË Î·È Ô ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Û¯ÂÙ›˙ÔÓÙ·Ó ·ÚÓËÙÈο Ì ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∂› ϤÔÓ, Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË, Ë ‚·Ú‡ÙËÙ· Ù˘ ÛˆÏËÓ·Úȷ΋˜ ‚Ï¿‚˘ Î·È Ë ·ÚÔ˘Û›· ·ÚÙËÚÈÔÛÎÏ‹Ú˘ÓÛ˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜6.

OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ Ï‹ÙË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ÚÔÓÂÊÚÈÎÔ›, ÓÂÊÚÈÎÔ› Î·È ÌÂÙ·ÓÂÊÚÈÎÔ›. ∏ ˘Ô-ÔÁηÈÌ›· ÙÔ˘ Ï‹ÙË Â›Ó·È Ë ÈÔ Û˘¯Ó‹ ÚÔÓÂÊÚÈ΋ ·ÈÙ›· ÂÓÒ Ë ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯ÔÚ‹ÁËÛË ÏÂ˘ÎˆÌ·Ù›Ó˘ ÌÔÚ› Ó· ¤¯ÂÈ ıÂÙÈ΋ Â›‰Ú·ÛË ÛÙËÓ ¿ÌÂÛË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘

∏ ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¿ÌÂÛ· ÌÂÙÂÁ¯ÂÈÚËÙÈο, ·ÔÙÂÏ› Û˘¯Ó‹ ηٿÛÙ·ÛË Î˘Ú›ˆ˜ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ¶·Ú·ÙËÚÂ›Ù·È ÏÈÁfiÙÂÚÔ Û˘¯Ó¿ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi ˙ÒÓÙ· ‰fiÙË. ∏ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ‹˜ Ù˘ ÔÈΛÏÂÈ ·fi 8 ¤ˆ˜ 50% Î·È ÔÈ ÌÂÁ¿Ï˜ ·˘Ù¤˜ ‰È·ÊÔÚ¤˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ ‰È·ÊÔÚÂÙÈο ÎÚÈÙ‹ÚÈ· ·Ô‰Ô¯‹˜ ‰ÔÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi Ù· ‰È¿ÊÔÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· (.¯. ÔÚÈ·ÎÔ› ‰fiÙ˜, ‰fiÙ˜ ¯ˆÚ›˜ ¿ÏÏÔ˘Û· ηډȿ Î.Ï.). ¶ÂÚ›Ô˘ 50% ÙˆÓ ·ÛıÂÓÒÓ Ì ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ·ÔηıÈÛÙÔ‡Ó ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û ‰È¿ÛÙËÌ· 10 ËÌÂÚÒÓ, 33% Û ‰È¿ÛÙËÌ· 10-20 ËÌÂÚÒÓ Î·È 10-15% ÛÙË Û˘Ó¤¯ÂÈ·. ΔÔ ÔÛÔÛÙfi ÌË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ó¤Ú¯ÂÙ·È Û 2-15% 1,2. ¶·ÚfiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· ÁÈ· ÙÔ ÔÚÈÛÌfi Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ·Ô‰¤¯ÔÓÙ·È ÙÔÓ ÔÚÈÛÌfi Ô˘ ‚·Û›˙ÂÙ·È ÛÙËÓ ·Ó¿ÁÎË ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ·ÈÌÔοı·ÚÛË Î·Ù¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÈ· Û˘Ó‰ڛ· ηٿ ÙȘ ÚÒÙ˜ 7 Ë̤Ú˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË).

∞›ÙÈ· Î·È ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ∏ ÈÔ Û˘¯Ó‹ ·ÈÙ›· ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Ë ÔÍ›· ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë, Ë ÔÔ›· ÔÊ›ÏÂÙ·È Û ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ‰fiÙË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, Ì ÙÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Î·È Ì ÙÔ Ï‹ÙË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÌÂÁ¿ÏË ¤ÏÏÂÈ„Ë ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ·ÍÈÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ ‹ ·ÎfiÌ· Î·È ·fi ‰fiÙ˜ Ì ÌË ¿ÏÏÔ˘Û· ηډȿ. ∏ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ Â›Ó·È ‰ÈÏ¿ÛÈ· fiÙ·Ó Ô ‰fiÙ˘ Â›Ó·È ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 55 ÂÙÒÓ. ∏ ·Ó¿ÁÎË ÁÈ· ·ÈÌÔοı·ÚÛË Î·Ù¿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ 17% ÙˆÓ ÏËÙÒÓ ·fi

91

92

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ÌÔۯ‡̷ÙÔ˜. ∏ Â›ÙˆÛË Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÌÈÎÚfiÙÂÚË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÚÈÙÔÓ·˚΋ οı·ÚÛË Û˘ÁÎÚÈÙÈο Ì ·˘ÙÔ‡˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÈÌÔοı·ÚÛË. ∏ ¯ÔÚ‹ÁËÛË ˘„ËÏÒÓ ‰fiÛÂˆÓ Î˘ÎÏÔÛÔÚ›Ó˘ ‹ tacrolimus, ηıÈÛÙ¿ ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ÓÂÊÚfi ÈÔ Â˘·›ÛıËÙÔ Û ۈÏËÓ·Úȷ΋ ‚Ï¿‚Ë, ȉȷ›ÙÂÚ· fiÙ·Ó Ù· Ê¿Ú̷η ·˘Ù¿ Û˘Ó‰˘¿˙ÔÓÙ·È Ì ·ÌÈÓÔÁÏ˘ÎˆÛ›‰Â˜, ÌË ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë, ‹ ·ÌÊÔÙÂÚÈΛÓË μ2,3. ÕÏÏ· ·›ÙÈ· ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÂÎÙfi˜ Ù˘ ÔÍ›·˜ ÛˆÏËÓ·Úȷ΋˜ ‚Ï¿‚˘, Â›Ó·È Ë ˘ÂÚÔÍ›· Î·È ÔÍ›· ·fiÚÚÈ„Ë Ì ·ÚÔ˘Û›· ·ÓÙÈۈ̿وÓ, Ë ·ÚÔ˘Û›· ÂÌ‚fiÏˆÓ ‹ ıÚfiÌ‚ˆÓ Ù˘ ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ ‹ ÊϤ‚·˜ Î·È Ë ·fiÊÚ·ÍË Ù˘ ·Ô¯ÂÙ¢ÙÈ΋˜ ÌÔ›Ú·˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. ∞ÁÁÂȷ΋ ıÚfiÌ‚ˆÛË ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› Û ηٷÛÙ¿ÛÂȘ ˘ÂÚËÎÙÈÎfiÙËÙ·˜ fiˆ˜ Û ÂÚÈÙÒÛÂȘ ·ÚÔ˘Û›·˜ ·ÓÙÈʈÛÊÔÏÈȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹ ¤ÏÏÂȄ˘ Ù˘ ·ÓÙÈıÚÔÌ‚›Ó˘ πππ. ÕÏÏÔÈ ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ Â›Ó·È Ë ‰˘Û·Ó·ÏÔÁ›· ÙÔ˘ ‡ÚÔ˘˜ ÙˆÓ ·Ó·ÛÙÔÌÔ‡ÌÂÓˆÓ ·ÁÁ›ˆÓ, Ë ·ıËڈ̿وÛË ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ‰fiÙË Î·È ÙÔ˘ Ï‹ÙË, Ë ·ÚÔ˘Û›· ÔÏÏÒÓ ·ÚÙËÚÈÒÓ ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È Ë Î·ÎÔÔ›ËÛË Ù˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜ ηٿ ÙË Ï‹„Ë. ∞fiÊÚ·ÍË ÙÔ˘ Ô˘ÚËÙ‹Ú· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÏfiÁˆ ·ÚÔ˘Û›·˜ ‹ÁÌ·ÙÔ˜ ‹ Ôȉ‹Ì·ÙÔ˜ ÛÙËÓ Ô˘ÚËÙËÚÔ΢ÛÙÈ΋ ·Ó·ÛÙfïÛË, ·ÏÏ¿ Î·È ÏfiÁˆ ·ÚÔ˘Û›·˜ ÏÂÌÊÔ΋Ï˘, ·ÈÌ·ÙÒÌ·ÙÔ˜ ‹ Ô˘ÚÈÓÒÌ·ÙÔ˜ Ô˘ Ô‰ËÁ› Û Â͈ÙÂÚÈ΋ ›ÂÛË ÙÔ˘ Ô˘ÚËÙ‹Ú·. °È· ÙÔ˘˜ ÏfiÁÔ˘˜ ·˘ÙÔ‡˜ Á›ÓÂÙ·È Û˘ÛÙËÌ·ÙÈ΋ ÂͤٷÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, Doppler Î·È ÛÈÓıËÚÔÁÚ¿ÊËÌ·. ∏ ‚ÈÔ„›· Â›Ó·È ·Ó·Áη›· ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘1,2.

¶·ıÔÁ¤ÓÂÈ· ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ‰Â›¯ÓÔ˘Ó fiÙÈ ÛËÌ·ÓÙÈΤ˜ ÌÂÙ·‚ÔϤ˜ Û˘Ì‚·›ÓÔ˘Ó ÛÙ· ÂÈıËÏȷο ÛˆÏËÓ·Úȷο ·ÙÙ·Ú· ηٿ ÙË Ê¿ÛË ÈÛ¯·ÈÌ›·˜ Î·È Â·Ó·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÓÂÊÚÔ‡. ∏ ÈÛ¯·ÈÌ›· ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙË ‰È·ÎÔ‹ ÙÔ˘ ÔÍÂȉˆÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Î·È ÙËÓ ¤ÏÏÂÈ„Ë ∞Δƒ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó·ÛÙÔÏ‹ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÓÙÏ›·˜ ¡·/∫ ∞Δƒ¿Û˘. ∏ ·Ó·ÂÚfi‚È· ÁÏ˘ÎfiÏ˘ÛË Ô‰ËÁ› ÛÂ Û˘ÛÛÒÚ¢ÛË Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ Ô˘ ÌÂÈÒÓÂÈ ÙÔ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ pH Î·È ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ÂÓÂÚÁÔÔ›ËÛË

Ï˘ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ. ∏ Û‡Ó‰ÂÛË ÙÔ˘ Ûȉ‹ÚÔ˘ Ì ÚˆÙ½Ó˜ ÌÂÈÒÓÂÙ·È ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ Ûȉ‹ÚÔ˘ Ô˘ Ô‰ËÁ› Û ·ÂÏ¢ı¤ÚˆÛË ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ ÔÈ Ôԛ˜ ÚÔηÏÔ‡Ó Ú‹ÍË ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÛÎÂÏÂÙÔ‡ Î·È ·ÔÎfiÏÏËÛË ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙˆÓ ÂÁÁ‡˜ ÂÛÂÈÚ·Ì¤ÓˆÓ ÛˆÏËÓ·Ú›ˆÓ ·fi ÙË ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË2,3. ∫·Ù¿ ÙË Ê¿ÛË Â·Ó·ÈÌ¿ÙˆÛ˘ ÚÔηÏÂ›Ù·È ÂÓÂÚÁÔÔ›ËÛË ·Ú·ÁfiÓÙˆÓ Ô˘ Û˘ÓÙËÚÔ‡Ó ÙË ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë Î·È ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÌÊ¿ÓÈÛË Î·ı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Â·Ó·ÈÌ¿ÙˆÛË ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ Ô͢ÁfiÓˆÛË Î·È ÙËÓ ·Ú·ÁˆÁ‹ ∞Δƒ, Ë Û˘ÁΤÓÙÚˆÛË ÙˆÓ ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ Ô˘ ¢ڛÛÎÔÓÙ·È ÛÙÔ˘˜ ÈÛÙÔ‡˜ ·Ú·Ì¤ÓÂÈ ·˘ÍË̤ÓË Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Û˘Ó¤¯ÈÛË Ù˘ ‰È·‰Èηۛ·˜ ·fiÙˆÛ˘ ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ¶·Ú¿ÏÏËÏ· ηٿ ÙË Ê¿ÛË ‰ËÌÈÔ˘ÚÁ›·˜ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È Î˘ÙÙ·ÚÔΛÓ˜ Î·È ¯˘ÌÔΛÓ˜ (ÈÓÙÂÚÏ¢ΛÓ˜ ÈÓÙÂÚÊÂÚfiÓË-Á, monocyte chemoattractant protein-1) ÂÓÒ ·Ú·ÙËÚÂ›Ù·È ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘ [intracellular adhesion molecule (ICAM-1) Î·È vascular cell adhesion molecule 1 (VCAM 1)] ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚÔÛ¤Ï΢ÛË Ô˘‰ÂÙÂÚfiÊÈÏˆÓ Î·È ÌÔÓÔ΢ÙÙ¿ÚˆÓ Ù· ÔÔ›· ·Ú¿ÁÔ˘Ó ÂÚ·ÈÙ¤Úˆ Ú›˙˜ Ô͢ÁfiÓÔ˘ Î·È ÂȉÂÈÓÒÓÔ˘Ó ÙË ÓÂÊÚÈ΋ ‚Ï¿‚Ë. ∂› ϤÔÓ, ¤¯ÂÈ ‰È·ÈÛÙˆı› Ë ·˘ÍË̤ÓË ¤ÎÊÚ·ÛË ÌÂÙ·ÁÚ·ÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (Erg-1, c-fos) Î·È ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (Hepatocyte growth factor, Transforming growth factor-beta) Ô˘ ÂÓ¤¯ÔÓÙ·È ÛÙË ‰È·‰Èηۛ· ΢ÙÙ·ÚÈ΋˜ ‚Ï¿‚˘1,2,7. ΔÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· Ù˘ ·ÏÏËÏÂ›‰Ú·Û˘ ÙˆÓ ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘, ¯˘ÌÔÎÈÓÒÓ Î·È Î˘ÙÙ·ÚÔÎÈÓÒÓ, ÛÙÔȯ›ˆÓ ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜, ÌÔÚ›ˆÓ ÚÔÛÎfiÏÏËÛ˘ Î·È Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Â›Ó·È ÌÈ· ÊÏÂÁÌÔÓ҉˘ ‰È·‰Èηۛ· Ô˘ ÙÂÏÈο Ô‰ËÁ› ÛÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÂÈıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÂÁÁ‡˜ ÂÛÂÈڷ̤ÓÔ˘ ÛˆÏËÓ·Ú›Ô˘. ™ÙËÓ fiÏË ‰È·‰Èηۛ· Û˘ÌÌÂÙ¤¯ÂÈ Î·È ÙÔ ÂÓ‰Ôı‹ÏÈÔ, ÙÔ ÔÔ›Ô ÂÓÂÚÁÔÔÈÂ›Ù·È Î·Ù¿ ÙË Ê¿ÛË ÈÛ¯·ÈÌ›·˜ Ì ·ÔÙ¤ÏÂÛÌ· Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· Ó· ¯¿ÓÔ˘Ó ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ȉÈfiÙËÙ¤˜ ÙÔ˘˜ Î·È Ó· ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓË ‰È·‚·ÙfiÙËÙ· Î·È ·˘ÍË̤ÓË Ù¿ÛË ÚÔÛÎfiÏÏËÛ˘ Î·È ËÎÙÈÎfiÙËÙ·˜. ªÂÙ¿ ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ Ë ‰È·‚·ÙfiÙËÙ· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ·˘Í¿ÓÂÙ·È ÂÚ·ÈÙ¤Úˆ ÂÓÒ Ï¢ÎÔ·ÙÙ·Ú· ÂÈÛ¤Ú¯ÔÓÙ·È ÛÙÔÓ ˘ÂÓ-

METAMO™XEY™Eπ™ 2010

93

‰ÔıËÏÈ·Îfi ¯ÒÚÔ Î·È ÚÔ¿ÁÔ˘Ó ÙËÓ ·ÂÏ¢ı¤ÚˆÛË Î˘ÙÙ·ÚÔÎÈÓÒÓ Î·È ÂÓÂÚÁÒÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘.

¶ÚfiÏË„Ë Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜

∂ͤÏÈÍË Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜

∏ ÚfiÏË„Ë Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔÓ Î·Ù¿ÏÏËÏÔ ¯ÂÈÚÈÛÌfi ÙÔ˘ ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË, ÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ÙËÓ ÛˆÛÙ‹ ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ Î·È ÙËÓ Î·Ù¿ÏÏËÏË ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ Ï‹ÙË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ Û˘ÓÙ‹ÚËÛË ÙÔ˘ ‰fiÙË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·ÔÊ˘Á‹ Ù˘ ˘Ô-ÔÁηÈÌ›·˜ Î·È ÙË ‰È·Ù‹ÚËÛË ÈηӋ˜ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÁÈ· ηϋ ¿Ú‰Â˘ÛË ÙˆÓ ÈÛÙÒÓ Ì ÙË ¯Ú‹ÛË Ù˘ ÏÈÁfiÙÂÚ˘ ‰˘Ó·Ù‹˜ ÔÛfiÙËÙ·˜ ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÒÓ Ê·Ú̿ΈÓ. O ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ı· Ú¤ÂÈ Ó· Â›Ó·È fiÛÔ Á›ÓÂÙ·È ÌÈÎÚfiÙÂÚÔ˜ ‰ÈfiÙÈ Û ÂÚÈÙÒÛÂȘ Ì ¯ÚfiÓÔ ÈÛ¯·ÈÌ›·˜ ¿Óˆ ÙˆÓ 24 ˆÚÒÓ Ë Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÔÙÂÏ› Û˘Ó‹ıË Î·Ù¿ÛÙ·ÛË. ∏ ¯ÔÚ‹ÁËÛË ·Ó·ÛÙÔϤˆÓ ÙˆÓ ÂχıÂÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘ Î·È ÙˆÓ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ·Ú·Ì¤ÓÂÈ ÛËÌ·ÓÙÈÎfi˜ ÛÙfi¯Ô˜ Ù˘ ÚfiÏ˄˘ Ù˘ ‚Ï¿‚˘ ·fi ÈÛ¯·ÈÌ›· Î·È Â·Ó·ÈÌ¿ÙˆÛË, Ô ÔÔ›Ô˜ fï˜ ‰ÂÓ Â›Ó·È ·ÎfiÌ· ÂÊÈÎÙfi˜ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË. O ¯ÂÈÚÈÛÌfi˜ ÙÔ˘ Ï‹ÙË Â›Û˘ ··ÈÙ› ȉȷ›ÙÂÚË ÚÔÛÔ¯‹. £· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ë ·Ê˘‰¿ÙˆÛË ÙÔ˘ Ï‹ÙË Î·Ù¿ ÙË Û˘Ó‰ڛ· ·ÈÌÔοı·ÚÛ˘ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÓÒ Ë ¯ÔÚ‹ÁËÛË Ï¿ÛÌ·ÙÔ˜ ‰ÈÂÁ¯ÂÈÚËÙÈο Û˘Ì‚¿ÏÏÂÈ ÛÙË ‰È·Ù‹ÚËÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘. ∏ ¤Á¯˘ÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Ù˘ ·Á·Ï˘ Ì·˙› Ì ÓÙÔ·Ì›ÓË Û ÓÂÊÚÈ΋ ‰fiÛË (1-3Ìg/kg/min) Û˘Ì‚¿ÏÂÈ ÛÙË ‰È·Ù‹ÚËÛË ‰ÈÔ‡ÚËÛ˘. Δ¤ÏÔ˜ Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ Û ϋÙ˜ Ì ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÁÈ· ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηÏfi Â›Ó·È Ó· ·ÔʇÁÂÙ·È Ì¤¯ÚȘ fiÙÔ˘ Ë ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ÛÙ·ıÂÚÔÔÈËı› ÛÙ· Â›‰· ÙÔ˘ 2.0 Ì 2.5 mg/dl.

∏ ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Û˘Ó‹ıˆ˜ ·Ôηı›ÛٷٷÈ. ΔÔ ÂÈı‹ÏÈÔ ÙˆÓ ÛˆÏËÓ·ÚÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Â›Û˘ ·Ôηı›ÛÙ·Ù·È fiˆ˜ Û˘Ì‚·›ÓÂÈ ÛÙËÓ ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∫‡ÙÙ·Ú· ÙÔ˘ ÛˆÏËÓ·ÚÈԉȿÌÂÛÔ˘ ¯ÒÚÔ˘ ÔÏÏ·Ï·ÛÈ¿˙ÔÓÙ·È Î·È ‰È·ÊÔÚÔÔÈÔ‡ÓÙ·È Û ÂÈıËÏȷο ÛˆÏËÓ·Úȷο ·ÙÙ·Ú· ηٿ ÙË Ê¿ÛË ·Ó·Á¤ÓÓËÛ˘ ÂÓÒ ·Ú¯¤ÁÔÓ· ·ÙÙ·Ú· ÙÔ˘ Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ ÌÂÙ·Ó·ÛÙÂ‡Ô˘Ó ÛÙË ı¤ÛË Ù˘ ‚Ï¿‚˘ Î·È ˘ÊÈÛÙ¿ÌÂÓ· ‰È·ÊÔÚÔÔ›ËÛË Û˘Ì‚¿ÏÔ˘Ó ÛÙË ‰ÔÌÈ΋ Î·È ÏÂÈÙÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÌÂÙ¿ ·fi ÈÛ¯·ÈÌÈ΋ ÓÂÊÚÈ΋ ‚Ï¿‚Ë ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÔÍ›·˜ ·fiÚÚȄ˘ ÏfiÁˆ ·˘ÍË̤Ó˘ ¤ÎÊÚ·Û˘ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ Ù¿Í˘ π Î·È ππ ÛÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ™ÙËÓ ÂÚ›ÙˆÛË ·˘Ù‹ Ë ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Â›Ó·È ÂÊÈÎÙ‹ ÌfiÓÔ Ì ‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘8,9. ∏ ÂÌÊ¿ÓÈÛË Î·ı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·Ó¿ÁÎË ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ·ÈÌÔοı·ÚÛË, ÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÓÔÛËÏ›·˜ Î·È ÙËÓ ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÏÔÈÌÒ͈Ó. ªÂϤÙ˜ Û ÂÈÚ·Ì·Ùfi˙ˆ· ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ‚Ï¿‚Ë ·fi ÈÛ¯·ÈÌ›·-Â·Ó·ÈÌ¿ÙˆÛË ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ›ÓˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÂÓÒ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È ·ÚÓËÙÈο Ì ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ™Â ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË ÙˆÓ ÌÂÏÂÙÒÓ Û˘Û¯¤ÙÈÛ˘ Ù˘ ·ÚÔ˘Û›·˜ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Î·È Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰È·ÈÛÙÒıËΠfiÙÈ ·ÛıÂÓ›˜ Ì ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ›¯·Ó 38% ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È 41% ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ 3 ÂÙÒÓ10. Δ· Â›‰· Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ ÌÂÙ¿ ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÔÙÂÏÔ‡Ó ÙÔÓ Î·Ï‡ÙÂÚÔ ‰Â›ÎÙË ÁÈ· ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∞ÛıÂÓ›˜ Ì ÌÂÚÈ΋ ·Ó¿ÎÙËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÁÈ· ‰˘ÛÌÂÓ‹ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Ojo AO, Wolfe RA, Held P, Port FK, Schmouder RL. Delayed graft function: risk factors and implications for renal allograft survival. Transplantation 1997; 63: 968-974.

2. Perico N, Cattaneo D, Saegh MH, Remuzzi G. Delayed graft function in kidney transplantation. Lancet 2004; 364: 1814-1827.

3. 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.

4. D’Agati VD and Cohen DJ. Pre-implantation renal biopsy: Structure does predict function. Transplantation 2003; 75: 264.

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5. Remuzzi G, Cravedi P, Perna A, et al for Dual Kidney Transplant Group. Long-term outcome of renal transplantation from older donors. N Engl J Med 2006; 354: 343.

6. Goumenos DS, Kalliakmani P, Tsamandas AC, Maroulis I, Savidaki E, Fokaefs E, Papachristou E, Karavias D, Vlachojannis JG. The prognostic value of rapidly processed pre-implantation graft biopsy in the outcome of renal transplantation. Ren Fail in press.

7. Goumenos DS, Tsakas S, Karavias D, Savidaki E, Karatzas T, Vlachojannis JG. Urinary Transforming Growth Factor - beta excretion in renal allograft

recipients during the early post-transplantation period.

Ren Fail 2003; 25: 561-568.

8. Chapman JR, O’Connell PJ, Nankivell BJ. Chronic renal allograft dysfunction. J Am Soc Nephrol 2005; 16: 3015-3026.

9. Nankivell BJ and Chapman JR. Chronic allograft nephropathy: Current concepts and future directions.

Transplantation 2006; 81: 643-654.

10. Yarlagadda SG, Coca SG, Formica RN, Poggio ED, Parikh CR. Association between delayed graft function and allograft and patient survival: a systematic review and metaanalysis. Nephrol Dial Transplant 2009; 34: 1039-1047.

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«O ÎÈÚÚˆÙÈÎfi˜ ·ÛıÂÓ‹˜ ÛÙÔ ¯ÂÈÚÔ˘ÚÁ›Ի °ÂÒÚÁÈÔ˜ ªÔ‡ÙÛÈ·ÓÔ˜ ıÚÔÌ‚ÔÂÓ›· ÂÓÒ Ô Ì·˙ÈÎfi˜ ·ÛΛÙ˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ¿ÓÔ‰Ô Ù˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ ›ÂÛ˘ Ì ÂÈÙÒÛÂȘ ÛÙËÓ ·Ó·Ó¢ÛÙÈ΋ Î·È ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∏ Á·ÛÙÚÈ΋ ΤӈÛË ÂÈ‚Ú·‰‡ÓÂÙ·È ·˘Í¿ÓÔÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ ÂÈÛÚfiÊËÛ˘ fiÍÈÓÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ηıÈÛÙÒÓÙ·˜ ··Ú·›ÙËÙË ÙË ¯ÔÚ‹ÁËÛË ∏2 ·ÓÙ·ÁˆÓÈÛÙÒÓ ÚÈÓ Î·È ÙËÓ ÂÊ·ÚÌÔÁ‹ ÎÚÈÎÔÂȉÈ΋˜ ›ÂÛ˘ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙËÓ ·Ó·ÈÛıËÛ›·. °È· ÙË Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈÎÒÓ ÎÈÚÛÒÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ·Ú¯Èο ‚·ÔÎÏÂÈÛÙ¤˜ fiˆ˜ Ë ÚÔÚ·ÓÔÏfiÏË. ∂› ·ÈÌÔÚÚ·Á›·˜ ÌÔÚ› Ó· ¯ÔÚËÁËı› ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÔÎÙÚÂÔÙ›‰Ë ‹ ‚·˙ÔÚÂÛÛ›ÓË. O ·ÛΛÙ˘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÂÚÈÔÚÈÛÌfi ÚfiÛÏ˄˘ ‡‰·ÙÔ˜ Î·È ¿Ï·ÙÔ˜, ÌÔÚ› ˆÛÙfiÛÔ Ó· ··ÈÙËı› ÂÚÈÙÔÓ·˚΋ ·Ú·Î¤ÓÙËÛË ÁÈ· ·ÚÔ¯¤Ù¢ÛË ÙÔ˘. ™Â ÂÚ›ÙˆÛË ·ÚÔ¯¤Ù¢Û˘ ÌÂÁ¿ÏÔ˘ fiÁÎÔ˘ ·ÛΛÙË, Ù·¯Â›· ÂÏ¿ÙÙˆÛË Ù˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ ›ÂÛ˘ ÚÔηÏ› ÌÂÁ¿ÏË ÂÏ¿ÙÙˆÛË Ù˘ ∫º¶ Î·È Ù˘ PCWP Ì ÙÒÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ Î·È Èı·Ó‹ ηډȷÁÁÂȷ΋ η٤ÚÚÈ„Ë ∞Ó ··ÈÙÂ›Ù·È ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ·ÛΛÙË, ·˘Ù‹ ‰ÂÓ Ú¤ÂÈ Ó· ÍÂÂÚÓ¿ Ù· 5 lt, ÂÓÒ Û˘ÓÈÛÙ¿Ù·È Ù·˘Ùfi¯ÚÔÓË ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË ÎÔÏÏÔÂȉÒÓ ‹ ·Ï‚Ô˘Ì›Ó˘.

OÈ ·ÛıÂÓ›˜ Ì Ë·ÙÈ΋ ÓfiÛÔ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÌÂÙ¿ ·fi ·Ó·ÈÛıËÛ›· Î·È ÂÁ¯Â›ÚËÛË. ∫¿ı ›‰Ô˘˜ Â¤Ì‚·ÛË Â›Ó·È ‰˘Ó·Ùfi Ó· ÂȉÂÈÓÒÛÂÈ ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ÙËÓ Ë·ÙÈ΋ ÙÔ˘˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È Ó· ÚÔηϤÛÂÈ ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∏ Û˘¯ÓfiÙËÙ· Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ (ȉȷ›ÙÂÚ· ·ÏÎÔÔÏÈ΋˜ Ë·Ù›Ùȉ·˜ Î·È Ë·Ù›Ùȉ·˜ C)·˘Í¿ÓÂÈ ‰È·ÚÎÒ˜ ÛÙÔÓ ·ÓÂÙ˘Á̤ÓÔ ÎfiÛÌÔ Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ È‰È·›ÙÂÚ˜ ÚÔÎÏ‹ÛÂȘ ÁÈ· ÙÔÓ ·Ó·ÈÛıËÛÈÔÏfiÁÔ Ô˘ ı· ÎÏËı› Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ ¤Ó· Ù¤ÙÔÈÔ ÂÚÈÛÙ·ÙÈÎfi ÛÙÔ ¯ÂÈÚÔ˘ÚÁ›Ô. ∏ ‚·Ú‡ÙËÙ· Ù˘ ηٿÛÙ·Û˘ Â›Ó·È Ù¤ÙÔÈ· Î·È Âȉڿ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi Û ÙfiÛË ¤ÎÙ·ÛË ÒÛÙÂ Ë Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ú¤ÂÈ Ó· ·ÔÙÂÏ› Û¯ÂÙÈ΋ ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ÂÎÙfi˜ ·ÂÈÏËÙÈÎÒÓ ÁÈ· ÙË ˙ˆ‹ ÂÂÈÁfiÓÙˆÓ. ™˘¯ÓfiÙÂÚ˜ ·Èٛ˜ ¯ÚfiÓÈ·˜ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ·ÔÙÂÏÔ‡Ó ÔÈ ÈÔÁÂÓ›˜ Ë·Ù›Ùȉ˜ (Ë·Ù›Ùȉ· μ Î·È C), ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ·, ·˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ·, ÛÙ·ÙÔË·Ù›Ùȉ· ÂÓÒ Û˘¯Ó‹ Â›Ó·È Î·È Ë Ë·Ù›Ùȉ· ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜ (ÎÚ˘ÙÔÁÂÓ‹˜). ÕÏϘ ·Èٛ˜ ·ÔÙÂÏÔ‡Ó ¯ÔÏÔÛÙ·ÙÈΤ˜ ηٷÛÙ¿ÛÂȘ, (ÚˆÙÔ·ı‹˜ ¯ÔÏÈ΋ ΛÚÚˆÛË, ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›Ùȉ·), Ê¿Ú̷η, ÙÔ͛Ә, ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· (ÓfiÛÔ˜ Wilson, ·ÈÌԯڈ̿وÛË, ¤ÏÏÂÈ„Ë ·1-·ÓÙÈıÚ˘„›Ó˘). §fiÁˆ ÙÔ˘ ‰ÂÛfi˙ÔÓÙÔ˜ ÌÂÙ·‚ÔÏÈÎÔ‡ ÚfiÏÔ˘ ÙÔ˘ ‹·ÙÔ˜, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÔÏ˘Û˘ÛÙËÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ:

∫˘ÎÏÔÊÔÚÈÎfi Û‡ÛÙËÌ· ∏ ΢ÎÏÔÊÔÚ›· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÚÔ¯ˆÚË̤ÓË Ë·ÙÈ΋ ÓfiÛÔ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈο ˘ÂÚ‰˘Ó·ÌÈ΋ Ì ˘„ËÏ‹ ηډȷ΋ ·ÚÔ¯‹ Î·È ¯·ÌËϘ ÂÚÈÊÂÚÈΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ Î·È Ì ‰È·Ù·Ú·Á̤ÓË ·¿ÓÙËÛË ÛÙÔ Û˘Ì·ıËÙÈÎfi. ™ÙËÓ ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ· Î·È ÙËÓ ·ÈÌÔÛȉ‹ÚˆÛË ÌÔÚ› Ó· Û˘Ó˘¿Ú¯ÂÈ Ì˘ÔηډÈÔ¿ıÂÈ·. ∂Í¿ÏÏÔ˘, Î·È ÔÈ Ë·ÙÔ·ı›˜ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ¤¯Ô˘Ó ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ fiˆ˜ οÓÈÛÌ· Î·È ˘ÂÚÏÈȉ·ÈÌ›·. ΔÔ ÂÏ·Ùو̤ÓÔ Ì˘ÔηډȷÎfi ¤ÚÁÔ ÏfiÁˆ Ù˘ ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈԉȷÛÙÔÏ‹˜ ÌÔÚ› Ó· ·ÔÎÚ‡ÙÂÈ ÙË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ Î·È ÙË Ì˘ÔηډÈÔ¿ıÂÈ·, ·˘Ù¤˜ fï˜ ÌÔÚ› Ó· Á›ÓÔ˘Ó ÎÏÈÓÈο ÂÌÊ·Ó›˜ ηٿ ÙËÓ ·Ó·ÈÛıËÛ›· Î·È ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË.

°·ÛÙÚÂÓÙÂÚÈÎfi Û‡ÛÙËÌ· μ·ÛÈ΋ ÂΉ‹ÏˆÛË ·ÔÙÂÏ› Ë ˘Ï·›· ˘¤ÚÙ·ÛË (>10 mm Hg). ∞ÔÙ¤ÏÂÛÌ· Ù˘ ·ÔÙÂÏ› Ë ÂÌÊ¿ÓÈÛË ·Ú¿Ï¢Ú˘ ÊÏ‚È΋˜ ΢ÎÏÔÊÔÚ›·˜ (ÎÈÚÛÒÓ), ·ÛΛÙË Î·È ÛÏËÓÔÌÂÁ·Ï›·˜. ∏ ·ÚÔ˘Û›· ÎÈÚÛÒÓ ÔÈÛÔÊ¿ÁÔ˘-ÛÙÔÌ¿¯Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ηٷÛÙÚÔÊÈ΋ ·ÈÌÔÚÚ·Á›· Ì ÚfiÎÏËÛË ‹ Âȉ›ӈÛË Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÏfiÁˆ Ù˘ ·ÔÚÚfiÊËÛ˘ Ù˘ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi ۈϋӷ. ∏ ÛÏËÓÔÌÂÁ·Ï›· ÚÔηÏ› ·˘ÍË̤ÓË Î·Ù·ÛÙÚÔÊ‹ ·ÈÌÔÂÙ·Ï›ˆÓ ηÈ

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∂ÎÙfi˜ ·fi ÙȘ ·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ ·˘Ù¤˜ ·ÏÏ·Á¤˜, Ë Ë·ÙÈ΋ ÓfiÛÔ˜ ÙÂÏÈÎÔ‡ ÓfiÛÔ˘ ÂÈʤÚÂÈ ÌÂÙ·‚ÔϤ˜ Î·È ÛÙËÓ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ÛÙȘ ‰È¿ÊÔÚ˜ Ê·Ú̷΢ÙÈΤ˜ Ô˘Û›Â˜.

∞Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· ¢È·ÊÚ·ÁÌ·ÙÈ΋ ηı‹ÏˆÛË ÏfiÁˆ ÙÔ˘ ·ÛΛÙË ‹/Î·È ·ÚÔ˘Û›· Ï¢ÚÈÙÈÎÒÓ Û˘ÏÏÔÁÒÓ ÂÚÈÔÚ›˙Ô˘Ó ÙÔÓ Î˘„ÂÏȉÈÎfi ·ÂÚÈÛÌfi, ÂÏ·ÙÙÒÓÔ˘Ó ÙË §ÀÃ Î·È Úԉȷı¤ÙÔ˘Ó Û ·ÙÂÏÂÎÙ·Û›· Î·È ˘ÔÍ›·. ¶Èı·Ó‹ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ÔÍ›· ̤ıË Î·È Ì·˙ÈÎfi˜ ·ÛΛÙ˘ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÂÈÛÚfiÊËÛ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯfiÌÂÓÔ˘. ™Â Ë·ÙÔ·ı›˜ ·ÛıÂÓ›˜ ÌÔÚ› Â›Û˘ Ó· ÂÌÊ·ÓÈÛÙ› ÂÓ‰ÔÓ¢ÌÔÓÈÎfi ·ÚÙËÚÈÔÊÏ‚ÈÎfi shunt ÚÔηÏÒÓÙ·˜ ‰‡ÛÓÔÈ· Î·È ˘ÔÍ›· ΢ڛˆ˜ Û ·Ó·ÎÂÎÏÈ̤ÓË ı¤ÛË Ì ¯·Ú·ÎÙËÚÈÛÙÈ΋ ‚ÂÏÙ›ˆÛË Û ηٿÎÏÈÛË (ÔÚıÔ‰ÂÔÍ›·). ∏ ÎÏÈÓÈ΋ ·˘Ù‹ ÔÓÙfiÙËÙ· ÔÓÔÌ¿˙·ÙÈ Ë·ÙÔÓ¢ÌÔÓÈÎfi Û˘Ó‰ÚÔÌÔ Î·È Â›Ó·È ‰˘ÓËÙÈο ·Ó·ÛÙÚ¤„ÈÌÔ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ™ÙÔ ·ÓÙ›ıÂÙÔ ¿ÎÚÔ, Û ÌÈÎÚfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ì ˘Ï·›· ˘¤ÚÙ·ÛË ÌÔÚ› Ó· ·ÚÔ˘ÛÈ·ÛÙ› Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË, Ô˘ ‰ÂÓ ÌÔÚ› Ó· ·Ô‰Ôı› Û ¿ÏÏË ·ÈÙ›·, Ì ·‡ÍËÛË ÙˆÓ Ó¢ÌÔÓÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ Î·È Ê˘ÛÈÔÏÔÁÈ΋ ›ÂÛË ÂÓÛÊ‹ÓˆÛ˘. OÓÔÌ¿˙ÂÙ·È ˘Ï·ÈÔÓ¢ÌÓÈ΋ ˘¤ÚÙ·ÛË.

∞ÈÌÔÔÈËÙÈÎfi Û‡ÛÙËÌ· ªÔÚ› Ó· ÂÓ˘¿Ú¯ÂÈ ·Ó·ÈÌ›· ÏfiÁˆ ¯ÚfiÓÈ·˜ ·ÒÏÂÈ·˜ ·fi ÙÔ °∂™, ·ÈÌfiÏ˘Û˘ ·fi ˘ÂÚÛÏËÓÈÛÌfi, ¯ÚÔÓ›·˜ ÓfiÛÔ˘ Î·È ˘ÔÛÈÙÈÛÌÔ‡. ∏ ÂÏ·Ùو̤ÓË Û˘ÓıÂÙÈ΋ ÈηÓfiÙËÙ· ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜ Ô‰ËÁ› Û ‰È·Ù·Ú·Á̤ÓË ËÎÙÈÎfiÙËÙ·, ÂȉÈο Û ۯ¤ÛË Ì ·Ú¿ÁÔÓÙ˜ Û¯ÂÙÈ˙fiÌÂÓÔ˘˜ Ì ÙË ‚ÈÙ·Ì›ÓË ∫: ππ, VII, IX Î·È Ã ÌÂ Û˘Ó˘¿Ú¯Ô˘Û· ·‡ÍËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘ Î·È ÙÔ˘ ¯ÚfiÓÔ˘ ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘. ™˘¯Ó‹ Â›Ó·È Ë ıÚÔÌ‚ÔÂÓ›· Î·È Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ. ªÔÚ› Â›Û˘ Ó· ÂÓ˘¿Ú¯Ô˘Ó ‰˘ÛÈÓˆ‰ÔÁÔÓ·ÈÌ›· Î·È ÈÓˆ‰fiÏ˘ÛË.

¡ÂÊÚÔ› Î·È ªÂÙ·‚ÔÏÈÛÌfi˜ ¢Â˘ÙÂÚÔ·ı‹˜ ˘ÂڷωÔÛÙÂÚÔÓÈÛÌfi˜ ÚÔηÏ› ηٷÎÚ¿ÙËÛË ‡‰·ÙÔ˜ Î·È ˘ÔÓ·ÙÚÈ·ÈÌ›· Ì ·ÔÙ¤ÏÂÛÌ· Û¯ËÌ·ÙÈÛÌfi ·ÛΛÙË Î·È ÂÚÈÊÂÚÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜. ¢ÈÔ˘ÚËÙÈο Ù˘ ·Á·Ï˘ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·Û΋ÙË Î·È ÙÔ˘ Ôȉ‹Ì·ÙÔ˜ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó Û¯ÂÙÈ΋

˘ÔÔÁηÈÌ›· Î·È ˘ÔηÏÈ·Ì›·. ∞ÓÙ›ÛÙÚÔÊ· Ô ·ÓÙ·ÁˆÓÈÛÙ‹˜ Ù˘ ·Ï‰ÔÛÙÂÚfiÓ˘, ÛÈÚÔÓÔÏ·ÎÙfiÓË, ÌÔÚ› Ó· ÚÔηϤÛÂÈ ˘ÂÚηÏÈ·ÈÌ›·. ∏ ·ÁÁÂÈԉȷÛÙÔÏ‹ Ô˘ ÚÔηÏ› Ë ÁÂÓÈ΋ ·Ó·ÈÛıËÛ›· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ˘Ô¿Ú‰Â˘ÛË ÙˆÓ ÓÂÊÚÒÓ Î·È Ó· ÂÈʤÚÂÈ ÚÔÓÂÊÚÈÎÔ‡ Ù‡Ô˘ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∫¿ı ÔÍ›· Âȉ›ӈÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙÔ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ ÏfiÁˆ ÓÂÊÚÈ΋˜ ˘Ô¿Ú‰Â˘Û˘, ˘Ï·›·˜ ˘¤ÚÙ·Û˘, ÂÓ‰ÔÎÔÈÏȷ΋˜ ˘¤ÚÙ·Û˘, ÓÂÊÚÔÙÔÍÈÓÒÓ ‹ Û˘Ó‰˘·ÛÌÔ‡ ·˘ÙÒÓ. ∏ ÂÌÊ¿ÓÈÛË Ë·ÙÔÓÂÊÚÈÎÔ˘ Û˘Ó‰ÚfiÌÔ˘ ı· ··ÈÙ‹ÛÂÈ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÓÂÊÚÈ΋ ·ÈÌÔοı·ÚÛË Î·È ˘Ô‰ËÏÒÓÂÈ ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË. ∂Í¿ÓÙÏËÛË ÙˆÓ Ë·ÙÈÎÒÓ Î·È Ì˘ÈÎÒÓ ·ÔıËÎÒÓ ÁÏ˘ÎÔÁfiÓÔ˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÚÈÂÁ¯ÂÈÚËÙÈ΋ ˘ÔÁÏ˘Î·ÈÌ›·. ∂›Û˘ Â›Ó·È Û˘¯Ó‹ Ë ·ÒÏÂÈ· Ì˘È΋˜ Ì¿˙·˜ ÏfiÁˆ ÂÏ·Ùو̷ÙÈ΋˜ Û‡ÓıÂÛ˘ ÚˆÙÂ˚ÓÒÓ Î·È ˘ÔÛÈÙÈÛÌÔ‡.

∫¡™ ∞ÛıÂÓ›˜ Ì ·ÏÎÔÔÏÈ΋ Ë·Ù›Ùȉ· Î·È ÂÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ μ1 (ıÂÈ·Ì›ÓË) ÎÈÓ‰˘ÓÂ‡Ô˘Ó ·fi ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Wernicke. ∏ ·Ó¿Ù˘ÍË Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (¶›Ó·Î·˜ 1) Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ ÌÔÚ› Ó· ÚÔÎÏËı› ·fi Ïԛ̈ÍË, ·ÈÌÔÚÚ·Á›· ÂÙÈÎÔ‡, ÔÍÂÔ‚·ÛÈΤ˜ ‰¯ ‹ ‰¯ ËÏÂÎÙÚÔÏ˘ÙÒÓ, ηٷÛÙ·ÏÙÈο Ê¿Ú̷η, ˘ÔÁÏ˘Î·ÈÌ›·, ˘ÔÍ›·, ˘fiÙ·ÛË ‹ ˘ÂÚ‚ÔÏÈ΋ Ï‹„Ë ÚˆÙÂ˚ÓÒÓ Ì¤Ûˆ ÙÚÔÊ‹˜. ∂Ó·ÏÏ·ÎÙÈο ÌÔÚ› ·Ï¿ Ó· Â›Ó·È ¤Ó· ÛËÌÂ›Ô Âȉ¤ÈÓˆÛ˘ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘. ¶›Ó·Î·˜ 1. μ·ıÌÔ› Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ μ·ıÌfi˜

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¡Â˘ÚÔÏÔÁÈο Û˘ÌÙÒÌ·Ù· ∫·Ó¤Ó· ΔÚfiÌÔ˜, ·Ú·Í›·, ·Û˘Ó¤ÚÁÂÈ· ∞ÛÙËÚÈÍ›·, ‰˘Û·ÚıÚ›·, ·Ù·Í›· ∞ÛÙËÚÈÍ›·, Ì˘È΋ ‰˘Ûη̄›·, ÛËÌÂ›Ô Babinski, ˘ÂÚÙÔÓ›· ∞ÂÁÎÂÊ·Ï›ÛÌfi˜

∂ÎÙfi˜ ·fi ÙȘ ·Ú·¿Óˆ ·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÂȉڿÛÂȘ, Ë Ë·ÙÈ΋ ÓfiÛÔ˜ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÌÂÙ·‚ÔϤ˜ ÛÙËÓ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ÛÙȘ ‰È¿ÊÔÚ˜ Ê·Ú̷΢ÙÈΤ˜ Ô˘Û›Â˜, fiˆ˜ ÛÙ· ·Ó·ÈÛıËÛÈÔÏÔÁÈο Ê¿Ú̷η.

METAMO™XEY™Eπ™ 2010

∂Ó‰ÔÊϤ‚È· ·Ó·ÈÛıËÙÈο ∏ ‰fiÛË Ù˘ ıÂÈÔÂÓÙ¿Ï˘ Ú¤ÂÈ Ó· ÂÏ·ÙÙÒÓÂÙ·È ÏfiÁˆ ·‡ÍËÛ˘ ÙÔ˘ Ê·ÚÌ·ÎÔÎÈÓËÙÈο ÂÓÂÚÁÔ‡, ÌË ‰ÂÛÌÂ˘Ì¤ÓÔ˘ ÛÙȘ ÏÂ˘ÎˆÌ·Ù›Ó˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ÂÍ·ÈÙ›·˜ Ù˘ ˘ÔÚˆÙÂ˚Ó·ÈÌ›·˜, ÎÏ·ÛÌ·ÙÔ˜ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. ∏ ‰È¿ÚÎÂÈ· ‰Ú¿Û˘ Â›Ó·È Â›Û˘ ·Ú·ÙÂٷ̤ÓË. ∏ ¢·ÈÛıËÛ›· ÛÙËÓ Î·Ù·ÛÙ·ÏÙÈ΋ ‰Ú¿ÛË (∫¡™, ηډȷÁÁÂÈ·Îfi, ·Ó·Ó¢ÛÙÈÎfi) Ù˘ ÚÔÔÊfiÏ˘ ·˘Í¿ÓÂÙ·È Â›Û˘ Ì ·ÔÙ¤ÏÂÛÌ· Ó· ··ÈÙÂ›Ù·È ÂÏ¿ÙÙˆÛË Ù˘ ‰fiÛ˘. ∏ ÂÙÔÌȉ¿ÙË ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ¯ˆÚ›˜ ÚÔ‚Ï‹Ì·Ù·. O ·ÏÎÔÔÏÈÛÌfi˜ Ô˘ ·ÔÙÂÏ› Û˘¯Ó‹ ·ÈÙ›· Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÌÔÚ› Ó· ·˘Í‹ÛÂÈ ÙȘ ··ÈÙ‹ÛÂȘ Û ·Ó·ÈÛıËÛ›· ·ÏÏ¿ ·ÚfiÏ· ·˘Ù¿ fiÏÔÈ ÔÈ ÂÓ‰ÔÊϤ‚ÈÔÈ ·Ó·ÈÛıËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Ì ÔÏÏ‹ ÚÔÛÔ¯‹.

¡Â˘ÚÔÌ˘ÈÎÔ› ·ÔÎÏÂÈÛÙ¤˜ O ÌÂÙ·‚ÔÏÈÛÌfi˜ Ù˘ ÛÔ˘ÎÎÈÓ˘ÏÔ¯ÔÏ›Ó˘ ÂÈ‚Ú·‰‡ÓÂÙ·È ÏfiÁˆ ÌÂȈ̤Ó˘ Û‡ÓıÂÛ˘ „¢‰Ô¯ÔÏÈÓÂÛÙÂÚ¿Û˘ ¯ˆÚ›˜ fï˜ ·˘Ùfi Ó· ·ÔÙÂÏ› ÎÏÈÓÈο Úfi‚ÏËÌ·. ¶·Ú·ÙËÚÂ›Ù·È ÎÏÈÓÈο ÌÈ· ·ÓÙ›ÛÙ·ÛË ÛÙÔ˘˜ ÌË ·ÔÔψÙÈÎÔ‡˜ Ó¢ÚÔÌ˘ÈÎÔ‡˜ ·ÔÎÏÂÈÛÙ¤˜ Ë ÔÔ›· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙË Û¯ÂÙÈ΋ ·˘ÍËÛË ÙÔ˘ fiÁÎÔ˘ ηٷÓÔÌ‹˜ ÙÔ˘˜ ÏfiÁˆ ÌÂÙ·‚ÔÏÒÓ ÛÙË Û‡Ó‰ÂÛË Ì ÙȘ ÚˆÙ½Ó˜ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ™Â ‚·ÚÈ¿ Ë·ÙÈ΋ ÓfiÛÔ ˘¿Ú¯ÂÈ ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ËÌÈ˙ˆ‹˜ ÙˆÓ ·ÌÈÓÔÛÙÂÚÔÂȉÒÓ Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ fiˆ˜ ÙÔ ‚ÂÎÔ˘ÚfiÓÈÔ Î·È ÙÔ ÚÔÎÔ˘ÚfiÓÈÔ Û ·ÓÙÈıÂÛË Ì ÙÔ ·ÙÚ·ÎÔ‡ÚÈÔ Î·È ÙÔ cis-·ÙÚ·ÎÔ‡ÚÈÔ Ô˘ ıˆÚÔ‡ÓÙ·È Î·Ù¿ÏÏËÏ· ÁÈ· ¯Ú‹ÛË ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ηıÒ˜ Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ ÙÔ˘˜ ‰ÂÓ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ ‹·Ú. ™Â οı ÂÚ›ÙˆÛË Û˘ÓÈÛÙ¿Ù·È monitoring ÙÔ˘ Ó¢ÚÔÌ˘ÈÎÔ‡ ·ÔÎÏÂÈÛÌÔ‡.

OÈÔÂȉ‹ O ÌÂÙ·‚ÔÏÈÛÌfi˜ Ù˘ ÌÔÚÊ›Ó˘ Â›Ó·È ÂÏ·Ùو̤ÓÔ˜ ÛÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÏfiÁˆ ÌÂȈ̤Ó˘ Ë·ÙÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ Î·È ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘ ÛÙÔ ‹·Ú. ™Â ·ÛıÂÓ›˜ ÌÂ Û˘Ó˘¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÌÔÚ› Ó· ·Ú·ÙËÚËı› ¿ıÚÔÈÛË ÙÔ˘ ÂÓÂÚÁÔ‡ Ù˘ ÌÂÙ·‚ÔÏ›ÙË ÌÔÚÊ›Ó˘-6-ÁÏ˘ÎÔÚÔ˘Óȉ›Ô˘. ™Â ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ηÏfi Â›Ó·È Ë ÌÔÚÊ›ÓË Ó· ·ÔʇÁÂÙ·È Î·ıÒ˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. ΔÔ fentanyl Û ÌÈÎÚ¤˜ ‰fiÛÂȘ Â›Ó·È Î·Ù¿ÏËÏÔ ÁÈ· ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯Ú‹ÛË Î·ıÒ˜ ÛÙÂÚÂ›Ù·È ÂÓÂÚÁÒÓ ÌÂÙ·‚ÔÏÈÙÒÓ Î·È ÂÎÎÚ›ÓÂÙ·È ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜. øÛÙfiÛÔ, Û Â·Ó·Ï·Ì‚·ÓfiÌÂ-

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Ó˜ ‹ ÌÂÁ¿Ï˜ ‰fiÛÂȘ, Î·È ·˘Ùfi ·ıÚÔ›˙ÂÙ·È. ΔÔ remifentanil ıˆÚÂ›Ù·È È‰Â҉˜ ÁÈ· ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ¯Ú‹ÛË Î·ıÒ˜ ÌÂÙ·‚ÔÏ›˙ÂÙ·È ·fi ÂÛÙÂÚ¿Û˜, ÈÛÙÈΤ˜ Î·È ÂÚ˘ıÚÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ, ÔÈ Ôԛ˜ ‰ÂÓ ÂËÚ¿˙ÔÓÙ·È ·fi ÙË ‚·Ú‡ÙËÙ· Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘.

¶ÙËÙÈο ·Ó·ÈÛıËÙÈο ŸÏ· Ù· ÙËÙÈο ·Ó·ÈÛıËÙÈο ÂÏ·ÙÙÒÓÔ˘Ó ÙËÓ Î·Ú‰È·Î‹ ·ÚÔ¯‹ Î·È ÙË Ì¤ÛË ·ÚÙËÚȷ΋ ›ÂÛË, ÂÏ·ÙÙÒÓÔÓÙ·˜ ¤ÙÛÈ ÙËÓ Ë·ÙÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹. πÛÔÊÏÔ˘Ú¿ÓÈÔ, Û‚ÔÊÏÔ˘¿ÓÈÔ Î·È ‰ÂÛÊÏÔ˘Ú¿ÓÈÔ ÌÂÙ·‚ÔÏ›˙ÔÓÙ·È ÂÏ¿¯ÈÛÙ· Ë·ÙÈο Î·È ıˆÚÔ‡Ó·ÙÈ ·ÛÊ·Ï‹. ΔÔ ‰ÂÛÊÏÔ˘Ú¿ÓÈÔ Â›Ó·È Ì¿ÏÏÔÓ Ô È‰Â҉˘ ÙËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜, ηıÒ˜ ÌÂÙ·‚ÔÏ›˙ÂÙ·È ÏÈÁfiÙÂÚÔ ·fi fiÏ· Î·È ÚÔÛʤÚÂÈ ÙËÓ ÁÚËÁÔÚfiÙÂÚË ·Ó¿ÓË„Ë ·fi ÙËÓ ·Ó·ÈÛıËÛ›·. ∂ÈÛ˘, ‰È·ÙËÚ› Û¯ÂÙÈο ÂÚÈÛÛfiÙÂÚÔ ÙËÓ Ë·ÙÈ΋ ¿Ú‰Â˘ÛË Î·È ÙËÓ Î·Ú‰È·Î‹ ·ÚÔ¯‹.

¶ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË Î·È ÚÔÂÙÔÈÌ·Û›· ∏ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì Ë·ÙÈ΋ ÓfiÛÔ Ú¤ÂÈ Ó· ÂÛÙÈ¿˙ÂÈ ÛÙËÓ ÂÍ·ÎÚ›‚ˆÛË ÙÔ˘ ‚·ıÌÔ‡ Ù˘ Ë·ÙÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÙˆÓ ÂȉڿÛÂˆÓ Ù˘ ÛÙ· ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù·. ¢ÂÓ Ú¤ÂÈ Ó· ·Ú·‚ϤÂÙ·È fiÙÈ ÔÈ ÈÔÁÂÓÂÓ›˜ Ë·Ù›Ùȉ˜ ·ÔÙÂÏÔ‡Ó È‰È·›ÙÂÚÔ Î›Ó‰˘ÓÔ ÁÈ· ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ. ∞ÛıÂÓ›˜ Ì Ë·Ù›Ùȉ· ·ÁÓÒÛÙÔ˘ ·ÈÙÈÔÏÔÁ›·˜ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ˆ˜ ÌÔÏ˘ÛÌ·ÙÈÎÔ›. ∞ÛıÂÓ›˜ Ì ·ÓÙÈÚÚÔÔ‡ÌÂÓË Ë·ÙÈ΋ ÓfiÛÔ ÌÔÚ› Ó· ›ӷ ·Û˘Ìو̷ÙÈÎÔ› ‹ Ó· ¤¯Ô˘Ó ÌfiÓÔ ‹È· ÂÓԯϋ̷ٷ fiˆ˜ ηÎÔ˘¯›·, ·ÒÏÂÈ· ‚¿ÚÔ˘˜ ‹ ‰˘Û„›·. Δ· Ê˘ÛÈο ÛËÌ›· Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· ·Ô˘ÛÈ¿˙Ô˘Ó ‹ Ó· Â›Ó·È ÌË ÂȉÈο. ∞·ÈÙÂ›Ù·È Ï‹Ú˘ Ê˘ÛÈ΋ ÂͤٷÛË Ì ȉȷ›ÙÂÚË ¤ÌÊ·ÛË ÛÙËÓ ·Ó‡ÚÂÛË ·ÒÏÂÈ·˜ Ì˘È΋˜ Ì¿˙·˜, ·ÛÙÂÚÔÂȉÒÓ ÎËÏ›‰ˆÓ, Ï¢ÚÈÙÈÎÒÓ Û˘ÏÏÔÁÒÓ, ·ÛΛÙË, ÛÏËÓÔÌÂÁ·Ï›·˜ Î·È ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (fiÏ· Ù· ·Ú·¿Óˆ ·ÔÙÂÏÔ‡Ó ÛËÌ›· ÚÔ¯ˆÚË̤Ó˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘). ™Â fiÙÈ ·ÊÔÚ¿ ÛÙȘ ·Ú·ÎÏÈÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ, ÛÙË ÁÂÓÈ΋ ·›Ì·ÙÔ˜ ·ÓȯÓ‡ÂÙ·È ·Ó·ÈÌ›·, ıÚÔÌ‚ÔÂÓ›·, ‹ Ï¢ÎÔ΢ÙÙ¿ÚˆÛË ·Ó Û˘Ó˘¿Ú¯ÂÈ Ïԛ̈ÍË. O ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ (PT) ·ÔÙÂÏ› ¯Ú‹ÛÈÌÔ ‰Â›ÎÙË Ù˘ Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ¯ÚËÛÈÌÔÔÈÂ›Ù·È ˆ˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÌÂÙ¿ ·fi ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ. øÛÙfiÛÔ o PT ÌÔÚ› Ó· ·˘ÍËı› ·ÓÂÍ·Úًو˜ Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ÛÂ

100

°. ª√ÀΔ™π∞¡√™

·ÛıÂÓ›˜ Ì ¤ÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ ∫, ‰È¿¯˘Ù˘ ÂÓ‰·ÁÁÂȷ΋˜ ‹Í˘ ‹ ıÂÚ·›·˜ Ì ‚·ÚÊ·Ú›ÓË. ŸÔ˘ Â›Ó·È ‰˘Ó·Ùfi, ÚÈÓ ÙËÓ Â¤Ì‚·ÛË, Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ÁÈ· ·ÚÎÂÙ¤˜ Ë̤Ú˜ ‚ÈÙ·Ì›ÓË ∫. ¶Ú¤ÂÈ Ó· ˘¿Ú¯Ô˘Ó ÚÔÂÁ¯ÂÈÚËÙÈΤ˜ ÙÈ̤˜ ·Ó·ÊÔÚ¿˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁÈ·˜. Δ˘¯fiÓ ÛÔ‚·Ú‹ ˘ÔÓ·ÙÚÈ·ÈÌ›· Î·È ‰È·Ù·Ú·¯¤˜ Î·Ï›Ô˘ Ó· ‰ÈÔÚıÒÓÔÓÙ·È ÚÈÓ ÙËÓ Â¤Ì‚·ÛË. μ·ÚÈ¿ ˘ÔÓ·ÙÚÈ·ÈÌ›· Û¯ÂÙÈ˙fiÌÂÓË Ì ÛÔ‚·Ú‹ Ë·ÙÈ΋ ÓfiÛÔ ÌÔÚ› Ó· ÚÔηÏ› ‰¯ ÙÔ˘ ÂÈ¤‰Ô˘ Û˘ÓÂȉ‹Ûˆ˜. ¶Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ù·¯Â›· ‰ÈfiÚıˆÛË Ù˘ ˘ÔÓ·ÙÚÈ·Ì›·˜ ÏfiÁˆ ÛËÌ·ÓÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚfiÎÏËÛ˘, ‰˘ÓËÙÈο ÌÔÈÚ·›·˜, ÎÂÓÙÚÈ΋˜ ÁÂÊ˘ÚÈ΋˜ Ì˘ÂÏÈÓfiÏ˘Û˘. °È’ ·˘Ùfi Û˘ÛÙ‹ÓÂÙ·È ‰ÈfiÚıˆÛË Ù˘ ˘ÔÓ·ÙÚÈ·Ì›·˜ Ì ڢıÌfi <10 mmol/l ·Ó¿ 24h. ∏ Û˘ÓıÂÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ ‹·ÙÔ˜, fiˆ˜ ·Ó·Ê¤ÚıËÎÂ, ÂÎÙÈÌ¿Ù·È Î·Ï‡ÙÂÚ· Ì ÙÔÓ ƒΔ, Â›Ó·È fï˜ ¯Ú‹ÛÈÌ· Î·È Ù· Â›‰· ÏÂ˘ÎˆÌ·Ù›Ó˘ ÙÔ˘ Ï¿ÛÌ·ÙÔ˜. ÕÏϘ ‰¯ Â›Ó·È ·˘ÍË̤ӷ Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ÂÓÒ ÔÈ ÙÈ̤˜ ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÔÈΛÏÔ˘Ó ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜.

O ÚÔÂÁ¯ÂÈÚËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ∏∫° Î·È Â›Û˘ ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ· ·Ó Û˘Ó˘¿Ú¯Ô˘Ó ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÚÈÛÙÂÚ‹ ηډȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ì˘ÔηډÈÔ¿ıÂÈ·, ‚·Ï‚ȉÈΤ˜ ‚Ï¿‚˜ ‹ ·ıÔÏÔÁÈ΋ Ó¢ÌÔÓÈ΋ ΢ÎÏÔÊÔÚ›·. ∞Ó ˘¿Ú¯ÂÈ ˘Ô„›· ÛÔ‚·Ú‹˜ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ÂÈı˘ÌËÙfi˜ Â›Ó·È ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô˜ Ì ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘ Î·È ‰˘Ó·ÌÈÎfi ¤ÏÂÁ¯Ô Ù˘ ·ÚÈÛÙÂÚ‹˜ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ™¯ÂÙÈο Ì ÙÔ ·Ó·Ó¢ÛÙÈÎfi, Ë ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ Î·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ı· ηٷ‰Â›ÍÔ˘Ó Ï¢ÚÈÙÈΤ˜ Û˘ÏÏÔÁ¤˜ Ô˘ ı· ··ÈÙ‹ÛÔ˘Ó ·ÚÔ¯¤Ù¢ÛË ÚÔÂÁ¯ÂÈÚËÙÈο. OÈ ·Ó·Ó¢ÛÙÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Â› ˘Ô„›·˜ ·ÔÊÚ·ÎÙÈ΋˜ ‹ ÂÚÈÔÚÈÛÙÈ΋˜ Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘ ÁÈ· ÙË ‰È·ÊÔÚԉȿÁÓˆÛË ÙÔ˘˜. ŒÓ· Ôχ ÛËÌ·ÓÙÈÎfi ÛÙÔÈ¯Â›Ô ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Â›Ó·È Ë ÂÊ·ÚÌÔÁ‹ ηٿÏÏËÏˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ıÓËÙfiÙËÙ·˜ ÙÔ˘˜. O ÈÔ ÁÓˆÛÙfi˜ Â›Ó·È Ô ‰Â›ÎÙ˘ Child fiˆ˜ ÙÚÔÔÔÈ‹ıËΠηٿ Pugh (¶›Ó·Î·˜ 2).

¶›Ó·Î·˜ 2. ∫ϛ̷η Child (ÙÚÔÔÔÈË̤ÓË Î·Ù¿ Pugh) ∫ÏÈÓÈ΋ ‹ ‚ÈÔ¯ËÌÈ΋ ·Ú¿ÌÂÙÚÔ˜

1

μ·ıÌÔ› (ηٿ ·‡ÍÔ˘Û· ‚·Ú‡ÙËÙ·) 2 3

∂ÁÎÂÊ·ÏÔ¿ıÂÈ· (‚·ıÌfi˜)

0

∂Ï¿¯ÈÛÙË (1 Î·È 2)

∞ÛΛÙ˘

Èڛ˜ ·ÛΛÙË

∂‡ÎÔÏ· ¢‡ÛÎÔÏ· ÂÏÂÁ¯fiÌÂÓÔ˜ ÂÏÂÁ¯fiÌÂÓÔ˜

ÃÔÏÂÚ˘ıÚ›ÓË ÔÚÔ‡ (mg/ dl)

<2.0

2.0–3.0

>3.0

§Â˘ÎˆÌ·Ù›ÓË ÔÚÔ‡ (g/ dl)

>3.5

2.8–3.5

<2.8

4–6

>6

ÃÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ 1–4 (s > control)

¶ÚÔ¯ˆÚË̤ÓË (3 Î·È 4)

OÈ ‚·ıÌÔ› ÁÈ· οı ·Ú¿ÌÂÙÚÔ ÚÔÛÙ›ıÂÓÙ·È ÁÈ· Ó· ‰ÒÛÔ˘Ó ÙË Û˘ÓÔÏÈ΋ ‚·ıÌÔÏÔÁ›·. ™˘ÓÔÏÈ΋ ‚·ıÌÔÏÔÁ›· 5-6 ıˆÚÂ›Ù·È Î·ÙËÁÔÚ›· ∞ (Class A) ηٿ Child Î·È Û¯ÂÙ›˙ÂÙ·È Ì ¯·ÌËÏ‹ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· (<5%), ‚·ıÌÔÏÔÁ›· 7-9 (ηÙËÁÔÚ›· μ - class B) Û˘ÓÂ¿ÁÂÙ·È Ì¤ÙÚÈÔ Î›Ó‰˘ÓÔ (25%) Î·È ‚·ıÌÔÏÔÁ›· 10-15 (ηÙËÁÔÚ›· C - class C)Û˘ÓÂ¿ÁÂÙ·È ˘„ËÏfi ΛӉ˘ÓÔ (>50%). ∞Ó Î·È Ë Ù·ÍÈÓfiÌËÛË ·˘Ù‹ ‰ËÌÈÔ˘ÚÁ‹ıËΠ·Ú¯Èο ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Û ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û ˘Ï·ÈÔÛ˘ÛÙËÌ·ÙÈΤ˜ ÂÈÎÔÈӈӛ˜, ˆÛÙfiÛÔ Ê¿ÓËΠfiÙÈ Â›Ó·È ÚÔÁÓˆÛÙÈ΋ Ù˘ ¤Î‚·Û˘ ÙˆÓ ·ÛıÂÓÒÓ Ì Ë·ÙÈ΋ ÓfiÛÔ ÁÈ· οı ›‰Ô˜ ÂÓ‰ÔÎÔÈÏȷ΋˜ Â¤Ì‚·Û˘. ∂ÎÙfi˜ ·fi ÙËÓ Îϛ̷η Child-Pugh, ÓÂfiÙÂÚË Îϛ̷η ·ÔÙÂÏ› Ë Îϛ̷η ª∂LD (Model for End Stage Liver Disease) Ô˘ ‰›ÓÂÙ·È ·fi ÙÔÓ Ù‡Ô: MELD score = {(9.6 × loge[ÎÚ·ÙÈÓ›ÓË mg/dl]) + (3.8 × loge[¯ÔÏÂÚ˘ıÚ›ÓË mg/dl]) + (11.2 × loge[INR]) + 6.4}

∞˘Ù‹, fiˆ˜ Î·È Ë ÚÔËÁÔ‡ÌÂÓË, ·Ó Î·È ÂÈÓÔ‹ıËΠÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ıÓËÙfiÙËÙ·˜ Û ÎÈÚÚˆÙÈÎÔ‡˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ‰È·ÛÊ·ÁÈÙȉÈ΋ ÂÓ‰ÔË·ÙÈ΋ ˘Ï·ÈÔÛ˘ÛÙËÌ·ÙÈ΋ ÂÈÎÔÈÓˆÓ›· (TIPS) Î·È ÂÊ·ÚÌfi˙ÂÙ·È ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ıÓËÛÈÌfiÙËÙ·˜ Û ·ÛıÂÓ›˜ Û ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Ê·›ÓÂÙ·È fiÙÈ ·Ú¿ÏÏËÏ·, ·ÔÙÂÏ› Î·È ¤Ó·Ó ·ÚÎÂÙ¿ ηÏfi ‰Â›ÎÙË ÂÎÙ›ÌËÛ˘ Ù˘ ÁÂÓÈÎfiÙÂÚ˘ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· Ì ηϋ ·ÓÙÈÛÙÔ›¯ËÛË Ì ÙËÓ Îϛ̷η Child-Pugh (ªELD < 10 – Child A, ª∂LD >10 Î·È <14 – Child B, ª∂LD >14 – Child C). ÕÏÏÔÈ ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Â›Ó·È Ô ˘ÔÛÈÙÈÛÌfi˜, Ë Â›ÁÔ˘Û· ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, Ë Û‹„Ë Î·È Ë ·ÒÏÂÈ· ·›Ì·ÙÔ˜.

METAMO™XEY™Eπ™ 2010

∞Ó·ÈÛıËÛ›· ¶ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË Ú¤ÂÈ Ó· Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÌfiÓÔ Û ·ÛıÂÓ›˜ Ì ηϿ ·ÓÙÈÚÚÔÔ‡ÌÂÓË ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ. °È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È Â›ÁÔ˘Û· ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË Ú¤ÂÈ Ó· ÚÔËÁÂ›Ù·È Ù·¯Â›· ‚ÂÏÙÈÛÙÔÔ›ËÛË Ì ȉȷ›ÙÂÚË ÛÙfi¯Â˘ÛË ÛÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi fiÁÎÔ, ÛÙËÓ ËÎÙÈÎfiÙËÙ· ηıÒ˜ Î·È ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ Ó¢ÚÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ Î·È ÙËÓ ·Ó›¯Ó¢ÛË Ïԛ̈͢. ∞Ó¿ÏÔÁ· Ì ٷ Â˘Ú‹Ì·Ù· ÙÔ˘ ÂϤÁ¯Ô˘ ËÎÙÈÎfiÙËÙ·˜ Î·È Ù˘ ıÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ·Ê›·˜ ÌÔÚ› Ó· ··ÈÙËı› ¯ÔÚ‹ÁËÛË ÚÔ˚fiÓÙˆÓ ·›Ì·ÙÔ˜. ºÚ¤ÛÎÔ Î·Ù„˘Á̤ÓÔ Ï¿ÛÌ· ÌÔÚ› Ó· ··ÈÙËı› ·Ó Ô ƒΔ Â›Ó·È >1,5 × ÙÈÌ‹ Ì¿ÚÙ˘Ú· ÂÓÒ ·ÈÌÔÂÙ¿ÏÈ· ¯ÔÚËÁÔ‡ÓÙ·È ·Ó Ô ·ÚÈıÌfi˜ ÙÔ˘˜ Â›Ó·È <50.000/ml. ∫Ú˘Ô˝˙ËÌ· Û˘Ó‹ıˆ˜ ÂӉ›ÎÓ˘Ù·È ÌfiÓÔ ·Ó ÙÔ ÈÓˆ‰ÔÁfiÓÔ <1g/l. A˘Í¿ÓÂÈ Â›Û˘ Ë ¯Ú‹ÛË ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ ·Ú¿ÁÔÓÙ· VIIa ÙfiÛÔ ÁÈ· ÚÔʇϷÍË fiÛÔ Î·È ·ÓÙÈÌÂÙÒÈÛË ÂÚÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜. ÕÏϘ Ê·Ú̷΢ÙÈΤ˜ ÂΉԯ¤˜ Â›Ó·È ÙÔ ÙÚ·ÓÂÍ·ÌÈÎfi Ô͇ Î·È Ë ‰ÂÛÌÔÚÂÛÛ›ÓË. ∏ ÚÔÓ¿ÚΈÛË Ì ηٷÛÙ·ÏÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Î·ıÒ˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂΉ‹ÏˆÛË ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜. ∞ÓÙ›ıÂÙ· Û˘ÓÈÛÙ¿Ù·È ¯ÔÚ‹ÁËÛË Î¿ÔÈÔ˘ ∏2·ÓÙ·ÁˆÓÈÛÙ‹, fiˆ˜ Ë Ú·ÓÈÙȉ›ÓË. OÈ Î‡ÚÈÔÈ ÛÙfi¯ÔÈ Ù˘ ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÓÙÈÌÂÙÒÈÛ˘ Ú¤ÂÈ Ó· Â›Ó·È Ë ‰È·Ù‹ÚËÛË Â·ÚÎÔ‡˜ Ë·ÙÈ΋˜ ·ÈÌ·ÙÈ΋ ÚÔ‹˜ Î·È ·ÚÔ¯‹˜ Ô͢ÁfiÓÔ˘. ™¯ÂÙÈ΋ ˘Ô¿Ú‰Â˘ÛË ‹ ˘ÔÍ·ÈÌ›· ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ÂÚ·ÈÙ¤Úˆ Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë Î·È Ó· Â¤ÏıÂÈ ·ÒÏÂÈ· Ù˘ ·ÓÙÈÚÚfiËÛ˘ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘. ∂› ˘Ï·›·˜ ˘ÂÚÙ¿Ûˆ˜, Ë Ë·ÙÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ÚÔ‹ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜. ŸÏ· Ù· ›‰Ë ·Ó·ÈÛıËÛ›·˜ ÌÔÚ› Ó· ÂÏ·ÙÙÒÛÔ˘Ó ÙË Ì¤ÛË ·ÚÙËÚȷ΋ ›ÂÛË Î·È Û˘ÓÂÒ˜ Ó· ÂÏ·ÙÙÒÛÔ˘Ó ÙËÓ Ë·ÙÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹. ÕÏÏÔÈ ‰ÈÂÁ¯ÂÈÚËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ÂÏ·ÙÙÒÛÔ˘Ó ÙËÓ Ë·ÙÈ΋ ·ÈÌ·ÙÈ΋ ÚÔ‹ Â›Ó·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ¤ÏÍË ÙÔ˘ ‹·ÙÔ˜, Ô ·ÂÚÈÛÌfi˜ Ì ıÂÙÈΤ˜ ȤÛÂȘ, Ë ˘ÔηÓ›·, ÔÈ ¿ÏÊ·-·‰ÚÂÓÂÚÁÈÎÔ› ·ÔÎÏÂÈÛÙ¤˜ Î·È Ë Ï··ÚÔÛÎÔÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋. °È· ÌÂÁ¿Ï˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, ÂÎÙfi˜ ·fi ÙÔ Û˘ÓËıÈṲ̂ÓÔ monitoring, ··ÈÙÂ›Ù·È ÂÂÌ‚·ÙÈ΋ ̤ÙÚËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Ù˘ ÎÂÓÙÚÈ΋˜ ÊÏ‚È΋˜ ›ÂÛ˘. ΔÔ ‰ÈÔÈÛÔÊ¿ÁÂÈÔ Doppler Î·È Ë ‰ÈÔÈÛÔÊ¿ÁÂÈÔ˜ ˘ÂÚ˯ÔÁÚ·Ê›· ÌÔÚ› Ó· ‚ÔËı‹ÛÔ˘Ó Û οÔÈÔ˘˜ ·ÛıÂÓ›˜ ·Ó Î·È Ë ‡·ÚÍË ÎÈÚÛÒÓ ÔÈÛÔÊ¿ÁÔ˘ ηıÈÛÙ¿ ··Ú·›ÙËÙË

101

ÙËÓ È‰È·›ÙÂÚ· ÚÔÛÂÎÙÈ΋ ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜ Î·È ÁÈ· οÔÈÔ˘˜ ·ÔÙÂÏ› Û¯ÂÙÈ΋ ·ÓÙ¤Ó‰ÂÈÍË. ∂Ó·ÏÏ·ÎÙÈο ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ηıÂÙ‹Ú·˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜. ∂Í¿ÏÏÔ˘ ̤ۈ Ù˘ ·ÚÙËÚȷ΋˜ ÁÚ·ÌÌ‹˜ Á›ÓÂÙ·È Ù·ÎÙÈ΋ ̤ÙÚËÛË ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜, Á·Ï·ÎÙÈÎÔ‡, ÁÏ˘Îfi˙˘, ËÏÂÎÙÚÔÏ˘ÙÒÓ Î·È ËÎÙÈÎfiÙËÙ·˜. ∂›Û˘ Û˘ÓÈÛÙ¿Ù·È Ë Ì¤ÙÚËÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ (˘Ú‹Ó·), Ù˘ Ì˘Ô¯¿Ï·Û˘ Î·È Ù˘ ‰ÈÔ‡ÚËÛ˘. ∏ ÂÈÏÔÁ‹ ÙˆÓ ·Ó·ÈÛıËÛÈÔÏÔÁÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÁÈ· ÙËÓ ÂÈÛ·ÁˆÁ‹ Î·È ÙË ‰È·Ù‹ÚËÛË Â›Ó·È ÏÈÁfiÙÂÚÔ ÛËÌ·ÓÙÈ΋ ·fi ÙËÓ ÚÔÛÔ¯‹ Ì ÙËÓ ÔÔ›· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È. ŒÓ·˜ ÚÔÙÂÈÓfiÌÂÓÔ˜ Û˘Ó‰˘·ÛÌfi˜ Â›Ó·È ÂÓ‰ÔÊϤ‚È· ÂÈÛ·ÁˆÁ‹ Ì ÚÔÔÊÔÏË Î·È ÚÂÌÈÊÂÓÙ·Ó›Ï, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÚÔÔÔÈË̤ÓË Ù·¯Â›· ÂÈÛ·ÁˆÁ‹ Ì ÎÚÈÎÔÂȉÈ΋ ›ÂÛË Î·È ÚÔÎÔ˘ÚfiÓÈÔ 1mg/kg, ÂÓÒ ÁÈ· ÙË ‰È·Ù‹ÚËÛË ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ì›ÁÌ· Ô͢ÁfiÓÔ˘/·¤Ú·/‰ÂÛÊÏÔ˘Ú·Ó›Ô˘ Î·È ÛÙ¿Á‰ËÓ ÂÊ ¤Á¯˘ÛË ÚÂÌÈÊÂÓÙ·Ó‡Ï. ™Ù¿Á‰ËÓ ÚÔÔÊfiÏË ÁÈ· ‰È·Ù‹ÚËÛË ÌÔÚ› ÂÓ·ÏÏ·ÎÙÈο Ó· ¯ÚËÛÈÌÔÔÈËı› ·ÓÙ› ÙËÙÈÎÔ‡ Û ÂÓ‰ÔÛÎÔÈΤ˜ Î·È ÂÂÌ‚·ÙÈΤ˜ ·ÎÙÈÓÔÏÔÁÈΤ˜ Ù¯ÓÈΤ˜ ηıÒ˜ Ë ·¤ÎÎÚÈÛË Ù˘ ÚÔÔÊfiÏ˘ ‰ÂÓ ÂËÚ¿˙ÂÙ·È ÛËÌ·ÓÙÈο ·fi ÙËÓ Ë·ÙÈ΋ ÓfiÛÔ. ∞fi Ù· Ì˘Ô¯·Ï·ÚˆÙÈο, ÂÚÈÛÛfiÙÂÚÔ ÂӉ‰ÂÈÁ̤ÓÔ ÁÈ· ÙË ‰È·Ù‹ÚËÛË ÙÔ˘ Ó¢ÚÔÌ˘ÈÎÔ‡ ·ÔÎÏÂÈÛÌÔ‡ Â›Ó·È ÙÔ ·ÙÚ·ÎÔ‡ÚÈÔ. ™Â fiÙÈ ·ÊÔÚ¿ ÙÔÓ ·ÂÚÈÛÌfi ÛÙfi¯Ô˜ Â›Ó·È Ë ÓÔÚÌÔηÓ›·. ∞·ÈÙÂ›Ù·È Â›Û˘ ¿ÓÙ· ÚÔÂÁ¯ÂÈÚËÙÈ΋ ¯ËÌÂÈÔÚÔʇϷÍË Ì ·ÓÙÈ‚ÈÔÙÈο. ∏ ‡·ÚÍË ÂÓ‰ÔÊϤ‚È·˜ ÚfiÛ‚·Û˘ ÌÂÁ¿Ï˘ ‰È·Ì¤ÙÚÔ˘ Â›Ó·È ··Ú·›ÙËÙË. ŸÏ· Ù· ÂÓ‰ÔÊϤ‚È· ˘ÁÚ¿ Ú¤ÂÈ Ó· ıÂÚÌ·›ÓÔÓÙ·È Ì ηٿÏÏËϘ ıÂÚÌ·ÓÙÈΤ˜ Û˘Û΢¤˜ ÂÓÒ Ú¤ÂÈ ·Ó ˘¿Ú¯ÂÈ Î·È Ë ‰˘Ó·ÙfiÙËÙ· Ù·¯Â›·˜ ¤Á¯˘Û˘ ÂȉÈο ÛÙȘ ÌÂÁ¿Ï˜ ÂÂÌ‚¿ÛÂȘ. ∏ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Ú¤ÂÈ Ó· ηıÔ‰ËÁÂ›Ù·È ·fi ÙȘ ηډȷÁÁÂȷΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, ÙËÓ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Î·È ÙË ‰ÈÔ‡ÚËÛË. ÃÔÚ‹ÁËÛË ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ fiˆ˜ ÓÔÚ·‰ÚÂÓ·Ï›ÓË ‹ Ê·ÈÓ˘ÏÂÊÚ›ÓË ÁÈ· ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ˘fiÙ·Û˘, ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ÙË ‚ÂÏÙÈÛÙÔÔ›ËÛË ÙˆÓ Î·Ú‰È·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ ›ÂÛ˘. ∏ ‰È·Ù‹ÚËÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ Î·È Ë Î·Ù¿ÏÏËÏË ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ Â›Ó·È ··Ú·›ÙËÙ˜ ÁÈ· ÙËÓ Â›Ù¢ÍË Â·ÚÎÔ‡˜ ‰ÈÔ‡ÚËÛ˘, ˆÛÙfiÛÔ ÂÓ›ÔÙ ··ÈÙÂ›Ù·È Ë ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ Ù˘ ·Á·Ï˘ ‹ Ì·ÓÈÙfiÏ˘ Ë ÔÔ›· ¤¯ÂÈ Î·È ÙËÓ È‰ÈfiÙËÙ· ÙÔ˘ ·ÓÙ·ÁˆÓÈÛÙ‹ ÙˆÓ ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ Ô͢ÁfiÓÔ˘. ™Â fiÙÈ ·ÊÔÚ¿ ÙÔ Â›‰Ô˜ ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ˘ÁÚÒÓ, Ù· ÎÚ˘ÛÙ·ÏÏÔÂȉ‹, Â› ·ÚÔ˘Û›·˜ ·ÛΛÙË, ¤¯Ô˘Ó ÏÈÁfiÙÂÚË ¤Ó‰ÂÈÍË ·fi Ù· ÎÔÏÏÔÂȉ‹,

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°. ª√ÀΔ™π∞¡√™

ÌÔÚ› fï˜ Ó· ¯ÚÂÈ·ÛÙ› ÛÙ¿Á‰ËÓ ¯ÔÚ‹ÁËÛË ‰ÂÍÙÚfi˙˘ 5-10% Ì 50-100 ml/h ÁÈ· ·ÔÊ˘Á‹ Èı·Ó‹˜ ˘ÔÁÏ˘Î·ÈÌ›·˜ Î·È ˘ÂÚÓ·ÙÚÈ·ÈÌ›·˜.

ªÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ó·ÏÁËÛ›· ªÈ· ηϋ Ù¯ÓÈ΋ ·ÔÙÂÏ› Ë ÂÓ‰ÔÊϤ‚È· PCA Û˘Ó‹ıˆ˜ Ì fentanyl Î·È Û·ÓÈfiÙÂÚ· Ì ÌÔÚÊ›ÓË. ΔÔ Û¯‹Ì· Ì fentanyl ÂÚÈÏ·Ì‚¿ÓÂÈ bolus 10 Ìg Î·È ÌÂÛԉȿÛÙËÌ· 10 min.OÈ ÂÚÈÔ¯ÈΤ˜ Ù¯ÓÈΤ˜ Û˘Ì‚¿ÏÏÔ˘Ó Ôχ ÛÙËÓ ÔÈfiÙËÙ· Ù˘ ·Ó·ÏÁËÛ›·˜ Î·È ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒ˜ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ·Ó·ÏÁËÙÈÎÒÓ, ¯ÚÂÈ¿˙ÂÙ·È fï˜ ÚÔÛÔ¯‹ ÛÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. ™˘ÓÈÛٿٷÈ, Û οı ÂÚ›ÙˆÛË, Ë ‰È‹ıËÛË ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ÙÚ·‡Ì·ÙÔ˜ Ì ÙÔÈÎfi ·Ó·ÈÛıËÙÈÎfi ÂÓÒ Ë ÂÈÛÎÏËÚ›‰ÈÔ˜ Ú¤ÂÈ Ó· Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì ÌÂÁ¿ÏË ÚÔÛÔ¯‹ Î·È ÌfiÓÔ fiÙ·Ó ÙÔ π¡R<1,5 Î·È Ù· ·ÈÌÔÂÙ¿ÏÈ· >100000/ml. ∂Ó‰ÔÌ˘ÈΤ˜ ‹ ˘Ô‰fiÚȘ ÂÓ¤ÛÂȘ ÌÔÚ› ·Ó ÚÔηϤÛÔ˘Ó ·È̿و̷. Δ· ª™∞º ·ÓÙÂӉ›ÎÓ˘ÓÙ·È ÏfiÁˆ ÙˆÓ ·ÚÂÓÂÚÁÂÈÒÓ Ù˘ ·ÈÌÔÚÚ·Á›·˜ ÙÔ˘ ÂÙÈÎÔ‡, Ù˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜. ∏ ·Ú·Î·Ù·ÌfiÏË ‰ÂÓ ·ÓÙÂӉ›ÎÓ˘Ù·È, Ú¤ÂÈ fï˜ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ì ÚÔÛÔ¯‹ Î·È Ê˘ÛÈο Ì ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜.

ªÂÙÂÁ¯ÂÈÚËÙÈ΋ ÊÚÔÓÙ›‰· ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÈÛ·ÁˆÁ‹ Û ª∂£ Û˘ÓÈÛÙ¿Ù·È ÁÈ· ·ÛıÂÓ›˜ Ì ÚÔ¯ˆÚË̤ÓË Ë·ÙÈ΋ ÓfiÛÔ.

™Â οÔȘ ÂÚÈÙÒÛÂȘ ··ÈÙÂ›Ù·È ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ fï˜ ··ÈÙÂ›Ù·È Ù·¯Â›· ‰È·ÎÔ‹ Ù˘ ηٷÛÙÔÏ‹˜ Î·È ·Ê‡ÓÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË. ∏ ÂȉÂÈÓÔ‡ÌÂÓË ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ô ›ÎÙÂÚÔ˜ Î·È Ô ·ÛΛÙ˘ ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎÔ‡˜ ‰Â›ÎÙ˜ ·ÒÏÂÈ·˜ ·ÓÙÈÚÚfiËÛ˘ Ù˘ Ë·ÙÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜. ªÂÙÂÁ¯ÂÈÚËÙÈο, Û˘Ó¯›˙ÂÙ·È ÙÔ ÂÂÌ‚·ÙÈÎfi ·ÈÌÔ‰˘Ó·ÌÈÎfi monitoring Î·È Ë ÚÔÛÂÎÙÈ΋ ‰È·¯Â›ÚÈÛË ÙˆÓ ˘ÁÚÒÓ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ∂›Û˘ ··ÈÙÂ›Ù·È ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ËÎÙÈÎfiÙËÙ·˜ Î·È Â·ÁÚ‡ÓËÛË ÁÈ· ÂÌÊ¿ÓÈÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜. OÈ ÂÓ‰·ÁÁÂÈ·ÎÔ› ηıÂÙ‹Ú˜ Ú¤ÂÈ Ó· ·ÔÌ·ÎÚ‡ÓÔÓÙ·È ÌfiÏȘ ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ··Ú·›ÙËÙÔÈ, ηıÒ˜ ˘¿Ú¯ÂÈ ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ Ïԛ̈͢.

μÈ‚ÏÈÔÁÚ·Ê›· Ziser A, Plevak DJ, Wiesner RH, Rakela J, Offord KP, Brown DL. Morbidity and mortality in cirrhotic patients undergoing anesthesia andsurgery. Anesthesiology 1999; 90:42-53.

Maze M, Bass NM. Anaesthesia and the hepatobiliary system. In: Miller RD, ed. Anesthesia, 5th Edn. Philadelphia: Churchill Livingstone, 2000; 1960-72.

Strunin L, Eagle CJ. Hepatic diseases. In: Benumof JL, ed.

Anesthesia & Uncommon Diseases, 4th Edn. Philadelphia: WB Saunders Company, 1998; 147-74.

Wiklund RA. Preoperative preparation of patients with advanced liver disease. Crit Care Med 2004; 32: S106–15.

¢ÈÂÁ¯ÂÈÚËÙÈ΋ ·ÈÌÔÚÚ·Á›· Û Ë·ÙÂÎÙÔÌ‹.

TÈ ÌÔÚ› Ó· οÓÂÈ Ô ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ ∞ÈηÙÂÚ›ÓË §·Ì·‰·Ú›Ô˘

∂ÈÛ·ÁˆÁ‹

ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Ì ÂȉÈΤ˜ Û˘Û΢¤˜ (CUSA, Argon laser) Î·È Ë ÙÔÈ΋ ¯Ú‹ÛË ‚ÈÔÏÔÁÈÎÒÓ ‹ Û˘ÓıÂÙÈÎÒÓ ·ÈÌÔÛÙ·ÙÈÎÒÓ ˘ÏÈÎÒÓ, Â›Ó·È ÚfiÛıÂÙ· ̤۷ Ô˘ Û˘ÓÙÂÏÔ‡Ó ÛËÌ·ÓÙÈο ÛÙËÓ ÚfiÏË„Ë Î·È Ì›ˆÛË Ù˘ ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜.

¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÙÂÏÂ˘Ù·›· 25 ¯ÚfiÓÈ· ¤¯Ô˘Ó Á›ÓÂÈ ÌÂÁ¿Ï˜ ÚfiÔ‰ÔÈ ÛÙËÓ Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋, Ô˘ ÂÈÙÚ¤Ô˘Ó ÙËÓ ·ÛÊ·Ï‹ ÂÎÙÔÌ‹ ·ÎfiÌË Î·È ÙˆÓ ÈÔ ‰‡ÛÎÔÏ· ÚÔÛÂÏ¿ÛÈÌˆÓ Ë·ÙÈÎÒÓ ÙÌËÌ¿ÙˆÓ, Ë ÌÂÁ¿ÏË ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·ÈÌÔÚÚ·Á›· ·Ú·Ì¤ÓÂÈ ¤Ó·˜ ÛÔ‚·Úfi˜ ˘·ÚÎÙfi˜ ΛӉ˘ÓÔ˜, Ô˘ ÂÈ‚·Ú‡ÓÂÈ ÙËÓ ÙÂÏÈ΋ ¤Î‚·ÛË ÙÔ˘ ·ÚÚÒÛÙÔ˘.

μ. O ÚfiÏÔ˜ ÙÔ˘ ·Ó·ÈÛıËÛÈÔÏfiÁÔ˘ O ÚfiÏÔ˜ ÙÔ˘ ·Ó·ÈÛıËÛÈÔÏfiÁÔ˘ ÂÈÎÂÓÙÚÒÓÂÙ·È ·ÊÂÓfi˜ ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ‚·ÛÈÎÒÓ Ú·ÎÙÈÎÒÓ ÚfiÏ˄˘ – ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ÌÂÁ¿Ï˘ ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ Â͇ÚÂÛË Ù˘ «¯Ú˘Û‹˜ ÙÔÌ‹˜» ÙˆÓ ÂȉÈÎÒÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Î·È ·Ó·ÈÛıËÛÈÔÏÔÁÈÎÒÓ Ú·ÎÙÈÎÒÓ (Ë ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÔÔ›ˆÓ ÌÂÈÒÓÂÈ ÙËÓ ·ÈÌÔÚÚ·Á›·) Î·È Ù˘ ÌÈÎÚfiÙÂÚ˘ ‰˘ÛÌÂÓÔ‡˜ Â›‰Ú·Û˘ ·˘ÙÒÓ, ÛÙ· ˙ˆÙÈο Û˘ÛÙ‹Ì·Ù· ÙÔ˘ ·ÚÚÒÛÙÔ˘.9,10

¶ÚfiÏË„Ë – ·ÓÙÈÌÂÙÒÈÛË ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Û Ë·ÙÂÎÙÔÌ‹ A. ÃÂÈÚÔ˘ÚÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ŸÏ˜ ÔÈ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ÈÛ¯˘Ú‹ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ·ÒÏÂÈ·˜ Î·È Î·Ù’ Â¤ÎÙ·ÛË Ù˘ ÌÂÙ¿ÁÁÈÛ˘ ·›Ì·ÙÔ˜ Î·È Ù˘ ·‡ÍËÛ˘ Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜.1-3 °È· ·˘Ùfi, ÔÈ ÚÔÛ¿ıÂȘ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÔÌ¿‰·˜ ÂÈÎÂÓÙÚÒÓÔÓÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ÚfiÏË„Ë ÌÂÁ¿Ï˘ ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜.4-8 O ۯ‰ȷÛÌfi˜ Ù˘ ÂÁ¯Â›ÚËÛ˘ Ì ‚¿ÛË ÙËÓ ¿ÚÈÛÙË ÁÓÒÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈ΋˜ ·Ó·ÙÔÌ›·˜ ÙÔ˘ ‹·ÙÔ˜ Î·È ÙÔÓ ÚÔÂÁ¯ÂÈÚËÙÈÎfi ·ÂÈÎÔÓÈÛÙÈÎfi ¤ÏÂÁ¯Ô, Ô˘ Ì ·ÎÚ›‚ÂÈ· ı· ηıÔÚ›ÛÂÈ ÙËÓ ÚÔÛ¤Ï·ÛË Î·È ·ÁÁ›ˆÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ ‹ ÙˆÓ ÙÌËÌ¿ÙˆÓ Ô˘ Ú¤ÂÈ Ó· ·Ê·ÈÚÂıÔ‡Ó, Â›Ó·È ÙÔ ÚÒÙÔ Ô˘ÛÈ·ÛÙÈÎfi ‚‹Ì· ÁÈ· ÌÈ· ·Ó·›Ì·ÎÙË Ë·ÙÂÎÙÔÌ‹.

OÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ Ù¯ÓÈΤ˜ Ô˘ ÂÊ·ÚÌfi˙ÔÓÙ·È ÁÈ· ÙË Ì›ˆÛË Ù˘ ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜, Â›Ó·È Ô ¯ÂÈÚÈÛÌfi˜ Pringle (·ÔÎÏÂÈÛÌfi˜ Ù˘ ˘Ï·›·˜ ÊϤ‚·˜, Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ Î·È ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘ ÛÙȘ ‡Ï˜ ÙÔ˘ ‹·ÙÔ˜) Î·È Ô ÔÏÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜ ÙˆÓ Ë·ÙÈÎÒÓ ·ÁÁ›ˆÓ (¯ÂÈÚÈÛÌfi˜ Pringle Û˘Ó‰˘·˙fiÌÂÓÔ˜ Ì ÌÂÚÈÎfi ‹ Ï‹ÚË ·ÔÎÏÂÈÛÌfi Ù˘ ˘ÂÚ- Î·È ˘ÊË·ÙÈ΋˜ οو ÎÔ›Ï˘ ÊϤ‚·˜). ∂Ó·ÏÏ·ÎÙÈ΋ Ù¯ÓÈ΋ ·ÔÙÂÏ› Ô ÂÎÏÂÎÙÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜ ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ –·Ó¿ÏÔÁ· Ì ÙË ı¤ÛË ÙÔ˘ fiÁÎÔ˘ Î·È ÙË ÊÏ‚È΋ ·Ô¯¤Ù¢ÛË ÙÔ˘ ÙÌ‹Ì·ÙÔ˜ Ô˘ Ú¤ÂÈ Ó· ·Ê·ÈÚÂı›– Ô˘ ÌÔÚ› Ó· Û˘Ó‰˘·ÛÙ› Î·È Ì ¯ÂÈÚÈÛÌfi Pringle. ΔÔ ‰ÈÂÁ¯ÂÈÚËÙÈÎfi ˘ÂÚ˯ÔÁÚ¿ÊËÌ·, Ë ‰È·ÙÔÌ‹

1. ∏ ‚·ÛÈ΋ Ú·ÎÙÈ΋ Ô˘ ÔÊ›ÏÂÈ Ó· ÂÊ·ÚÌfi˙ÂÈ Ô ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ ÛÙÔ˘˜ ·ÚÚÒÛÙÔ˘˜ – Ì ‹ ¯ˆÚ›˜ ˘ÔΛÌÂÓË Ë·ÙÈ΋ ÓfiÛÔ – Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û Ë·ÙÂÎÙÔÌ‹, ·ÊÔÚ¿ ÛÙËÓ: ÔÏÔÎÏËڈ̤ÓË ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË Ù˘ ËÎÙÈÎfiÙËÙ·˜, Ô˘ ÂÎÙfi˜ ·fi ÙÔ Û˘Ó‹ıË ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô (PT, aPTT, INR, ¤ÏÂÁ¯Ô ·ÈÌÔÂÙ·Ï›ˆÓ) Â›Ó·È Î·Ïfi Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ıÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ¿ÊËÌ·. O ·Ó·ÈÛıËÛÈÔÏfiÁÔ˜ ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙÔ ¯ÂÈÚÔ˘ÚÁfi, Ú¤ÂÈ Ó· ÊÚÔÓÙ›ÛÔ˘Ó ÙËÓ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‰ÈfiÚıˆÛË Ù˘ ËÎÙÈÎfiÙËÙ·˜ ηıÒ˜ Î·È ÙËÓ ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓË ÂÊ·ÚÌÔÁ‹ ÌÂıfi‰ˆÓ Ì›ˆÛ˘ ÙˆÓ ·Ó·ÁÎÒÓ ÌÂÙ¿ÁÁÈÛ˘ (¯ÔÚ‹ÁËÛË ÂÚ˘ıÚÔÔÈËÙ›Ó˘, ‰ˆÚ¿ ·˘ÙfiÏÔÁÔ˘ ·›Ì·ÙÔ˜, ÈÛÔÔÁηÈÌÈ΋ ·Ú·›ˆÛË, ¯Ú‹ÛË Cell Saver)4,9 ‰È·Ú΋ ÂÁÚ‹ÁÔÚÛË Î·È ÛÙÔÓ ˘„ËÏfi ‚·ıÌfi ÂÙÔÈÌfiÙËÙ·˜ (ÊÏ‚ÈÎÔ› ηıÂÙ‹Ú˜ ÌÂÁ¿Ï˘ ‰È·Ì¤ÙÚÔ˘, ÁÚ‹ÁÔÚË ÚfiÛ‚·ÛË ÛÂ Û˘Û΢¤˜ Ù·¯Â›·˜ ¤Á¯˘Û˘ – ı¤ÚÌ·ÓÛ˘ ˘ÁÚÒÓ, ηٿÏÏËÏÔ monitoring), ÁÈ·Ù› Ë ÌÂÁ¿ÏË ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ÌÔÚ› Ó· Â›Ó·È ·Ó·ÌÂÓfiÌÂÓË ·ÏÏ¿ ÌÔÚ› Ó· Û˘Ì‚Â› ·Úfi‚ÏÂÙ· Î·È Í·ÊÓÈο

103

104

∞. §∞ª¶∞¢∞ƒπ√À

Û˘Ó¯‹ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ‚ÂÏÙ›ˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ‹Í˘, ȉȷ›ÙÂÚ· ÛÙÔ˘˜ Ë·ÙÔ·ı›˜ ·ÚÚÒÛÙÔ˘˜, ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ ÙÔ˘˜ (ÂÏ·Ùو̤ÓË ·Ú·ÁˆÁ‹ Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·Ú·ÁfiÓÙˆÓ ‹Í˘, ‰˘ÛÈÓˆ‰ÔÁÔÓ·ÈÌ›·, ıÚÔÌ‚ÔÂÓ›·) ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ÂÍ·ÛÊ¿ÏÈÛË ÓÔÚÌÔıÂÚÌ›·˜, ÓÔÚÌÔηÓ›·˜, ËÏÂÎÙÚÔÏ˘ÙÈ΋˜ Î·È ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ ·ÔÊ˘Á‹ ˘ÔÍ·ÈÌ›·˜ Î·È ÛÔ‚·Ú‹˜ ˘fiÙ·Û˘ (ÈÛ¯·ÈÌ›· Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ‹·ÙÔ˜) ·ÔÊ˘Á‹ ˘ÂÚÊfiÚÙˆÛ˘ ÙÔ˘ ·ÚÚÒÛÙÔ˘ Ì ˘ÁÚ¿ (dilutional coagulopathy, ·‡ÍËÛË ·ÒÏÂÈ·˜ ·›Ì·ÙÔ˜ ·fi ÙȘ Ë·ÙÈΤ˜ ÊϤ‚˜, Ô›‰ËÌ· ÙÚ·˘Ì·ÙÈṲ̂ÓÔ˘ Ë·ÙÈÎÔ‡ ÈÛÙÔ‡).

2. OÈ ÂȉÈΤ˜ Ú·ÎÙÈΤ˜ ·ÊÔÚÔ‡Ó ÛÙËÓ ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ˙ˆÙÈÎÒÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ·ÚÚÒÛÙÔ˘ ηٿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ Î·ıÒ˜ Î·È Û ·Ó·ÈÛıËÛÈÔÏÔÁÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜ Î·È ·ÚÂÌ‚¿ÛÂȘ, Ô˘ ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÚÒÙˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·ÛÊ·ÏÈÛÙ› ·Ó·›Ì·ÎÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ‰›Ô. ∞Ó·Ï˘ÙÈο: ÃÂÈÚÈÛÌfi˜ Pringle: ·ÔÙÂÏ› ϤÔÓ, ÎÔÈÓ‹ Ù·ÎÙÈ΋ ÛÙËÓ Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÂÊ·ÚÌÔÁ‹ ÙÔ˘ Û˘Óԉ‡ÂÙ·È ·fi ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ (Ì›ˆÛË ÙÔ˘ ÚÔÊÔÚÙ›Ô˘ Î·È Ù˘ ›ÂÛ˘ Ù˘ Ó¢ÌÔÓÈ΋ ·ÚÙËÚ›·˜, ·ÓÙ·Ó·ÎÏ·ÛÙÈ΋ ·‡ÍËÛË ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ Î·È ·‡ÍËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘), ·˘Ù¤˜ Â›Ó·È ÁÂÓÈο ‹Ș Î·È Î·Ï¿ ·ÓÂÎÙ¤˜ ·fi ÙÔÓ ¿ÚÚˆÛÙÔ, ÁÈ· ·˘Ùfi ‰ÂÓ ··ÈÙÂ›Ù·È Î¿ÔÈ· ȉȷ›ÙÂÚË ·Ó·ÈÛıËÛÈÔÏÔÁÈ΋ ·Ú¤Ì‚·ÛË ÂÎÙfi˜ ·fi ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÙËÓ Î·Ù·ÁÚ·Ê‹ Ù˘ ‰È¿ÚÎÂÈ·˜ ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘.11 O Û˘Ó¯‹˜ ·ÔÎÏÂÈÛÌfi˜ Ù˘ Ë·ÙÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi ‹·Ú Î·È ÛÂ Û˘Óı‹Î˜ ÓÔÚÌÔıÂÚÌ›·˜ Â›Ó·È ·ÛÊ·Ï‹˜ ÁÈ· ÂÚ›Ô˘ 60 min ÂÓÒ ÛÙÔ ÎÈÚÚˆÙÈÎfi ‹·Ú ÁÈ· 30 min. ÷ÌËÏ‹ ÎÂÓÙÚÈ΋ ÊÏ‚È΋ ›ÂÛË (¯∫º¶): ÁÈ· Ó· ÂÏ·¯ÈÛÙÔÔÈËı› Ë ·ÈÌÔÚÚ·Á›· ηٿ ÙË ‰È¿ÚÎÂÈ· ÂÎÙÔÌ‹˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, Ô˘ fiÙ·Ó ˘¿Ú¯ÂÈ ·ÔÎÏÂÈÛÌfi˜ ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÏÈÓ‰ÚfiÌËÛË ·›Ì·ÙÔ˜ ·fi ‰È¿Ù·ÛË ÛÙȘ Ë·ÙÈΤ˜ ÊϤ‚˜ Î·È ÛÙÔ˘˜ ÊÏ‚҉ÂȘ ÎfiÏÔ˘˜, Ú¤ÂÈ Ó· ‰È·ÙËÚÂ›Ù·È Ë ∫º¶ Û ÙÈ̤˜ <5 mm Hg. OÈ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ˆ˜ ÔÈ ¿ÚÚˆÛÙÔÈ Ô˘

˘Ô‚¿ÏÏÔÓÙ·È Û Ë·ÙÂÎÙÔÌ‹ Ì ÙÈ̤˜ ∫º¶ > 6 mm Hg, ÂÌÊ·Ó›˙Ô˘Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ ·ÒÏÂÈ·˜ ·›Ì·ÙÔ˜, Ù˘ ·Ó¿Á΢ ÁÈ· ÌÂÙ¿ÁÁÈÛË, Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ ıÓËÙfiÙËÙ·˜.12,13 ∏ Ì›ˆÛË Ù˘ ∫º¶ ÂÈÙ˘Á¯¿ÓÂÙ·È Î˘Ú›ˆ˜ Ì ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ¯ÔÚ‹ÁËÛ˘ ˘ÁÚÒÓ (1 ml/kg/h) ̤¯ÚÈ Î·È ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ÂÎÙÔÌ‹˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ˘fi ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ‰ÈÔ‡ÚËÛ˘ (0.5-1 ml/kg/h).9,10,12 ∞Ó ·Ú¿ Ù·‡Ù·, ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÈηÓÔÔÈËÙÈο ¯∫º¶, ¯ÔÚËÁÂ›Ù·È ÓÈÙÚÔÁÏ˘ÎÂÚ›ÓË (ÊÏ‚ԉȷÛÙÔÏ‹ Î·È Ì›ˆÛË ÙÔ˘ ÚÔÊÔÚÙ›Ô˘) ÛÙË Ê¿ÛË ÂÎÙÔÌ‹˜ Î·È ÂÊfiÛÔÓ ˘¿Ú¯ÂÈ ÔÚ·Ù‹ ‰ÈfiÁΈÛË ÙÔ˘ ‹·ÙÔ˜ Î·È ‰È¿¯˘ÙË ÌÈÎÚÔ·ÈÌÔÚÚ·Á›·. ∂›Û˘, ‚ÔËı¿ Î·È Ô ÂÈÛÎÏËÚ›‰ÈÔ˜ ·ÔÎÏÂÈÛÌfi˜ (Ô˘ ÂÍ·ÛÊ·Ï›˙ÂÈ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·Ó·ÏÁËÛ›·) ÂÓÈÛ¯‡ÔÓÙ·˜ ÙË ÊÏ‚ԉȷÛÙÔÏ‹.14 ∏ ¯∫º¶ ÂÓ¤¯ÂÈ ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Ù˘ ˘Ô¿Ú‰Â˘Û˘ ÙˆÓ ÔÚÁ¿ÓˆÓ, ÙˆÓ ·ÓÂ·ÚÎÒÓ ÂʉÚÂÈÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÌÈ·˜ Í·ÊÓÈ΋˜ ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Î·È Ù˘ ÂÌ‚ÔÏ‹˜ ·¤Ú·. °ÂÓÈο, ÙÔ 3% ÙˆÓ ·ÚÚÒÛÙˆÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û Ì›˙ÔÓ· Ë·ÙÂÎÙÔÌ‹ ˘Ê›ÛÙ·Ù·È ÌfiÓÈÌË ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ÙÔ 10% ·ÚÔ‰È΋ Î·È Ù· ÔÛÔÛÙ¿ ·˘Ù¿ ‰ÂÓ ÌÂÙ·‚¿ÏÏÔÓÙ·È fiÙ·Ó Ë ÂÎÙÔÌ‹ ÂÎÙÂÏÂ›Ù·È ˘fi Û˘Óı‹Î˜ ¯∫º¶.12 °È· Ó· ÂÏ·¯ÈÛÙÔÔÈËı› Ô Î›Ó‰˘ÓÔ˜ ÂÌ‚ÔÏ‹˜ ·¤Ú· ·fi ÙË ¯∫º¶, Ú¤ÂÈ Ô ¿ÚÚˆÛÙÔ˜ Ó· ÙÔÔıÂÙÂ›Ù·È Û ı¤ÛË Trendelenburg Ì ÎÏ›ÛË 15Ô. ªÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ Ë·ÙÂÎÙÔÌ‹˜ Î·È ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ·ÈÌfiÛÙ·Û˘, ·Ôηı›ÛÙ·Ù·È Ô ÂÓ‰·ÁÁÂÈ·Îfi˜ fiÁÎÔ˜ Ì ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ ‹ ·›Ì·ÙÔ˜ ‹ ·Ú·ÁÒÁˆÓ ·Ó¿ÏÔÁ· Ì ÙȘ ·ÒÏÂȘ, ·ÏÏ¿ Ë ÙÈÌ‹ Ù˘ ∫º¶ Ú¤ÂÈ Ó· ‰È·ÙËÚÂ›Ù·È <10 mm Hg ÁÈ·Ù› ÙÔ ÙÚ·˘Ì·ÙÈṲ̂ÓÔ Ë·ÙÈÎfi ·Ú¤Á¯˘Ì· ·Ó·Ù‡ÛÛÂÈ Â‡ÎÔÏ· Ô›‰ËÌ·, Ô˘ ÚÔηÏ› ‹ ÂȉÂÈÓÒÓÂÈ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. ∂ÎÏÂÎÙÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ ‹ ÔÏÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜ Ë·ÙÈ΋˜ ·ÁÁ›ˆÛ˘: ·Ó Ô ¯ÂÈÚÈÛÌfi˜ Pringle Î·È Ë ¯∫º¶, ‰ÂÓ ÂϤÁ¯Ô˘Ó ÈηÓÔÔÈËÙÈο ÙËÓ ·ÈÌÔÚÚ·Á›·, ÙfiÙ ÂÊ·ÚÌfi˙ÂÙ·È Î·Ù¿ ÂÚ›ÙˆÛË ÂÎÏÂÎÙÈÎfi˜ ·ÔÎÏÂÈÛÌfi˜ ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ ‹ ÌÂÚÈÎfi˜ ‹/Î·È Ï‹Ú˘ ·ÔÎÏÂÈÛÌfi˜ Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ (∫∫º).

OÈ ¯ÂÈÚÈÛÌÔ› ·˘ÙÔ› ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ Û Ì›˙ÔÓ˜ Ë·ÙÂÎÙÔ̤˜ Î·È ÂÎÙÔ̤˜ fiÁÎˆÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Ôχ ÎÔÓÙ¿ ‹ ‰ÈËıÔ‡Ó ÙËÓ ∫∫º. ∏ ‰È·ÎÔ‹ Ù˘ ÚÔ‹˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙËÓ ∫∫º, Û˘Óԉ‡ÂÙ·È ·fi ÔÚÌÔÓÈΤ˜ Î·È ·ÈÌÔ‰˘Ó·ÌÈΤ˜

METAMO™XEY™Eπ™ 2010

105

‰È·Ù·Ú·¯¤˜ (Ì›ˆÛË ÙÔ˘ ÚÔÊÔÚÙ›Ô˘ Î·È Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ ∼50%, Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, ÙˆÓ ȤÛÂˆÓ Ï‹ÚˆÛ˘ ÙˆÓ Î·Ú‰È·ÎÒÓ ÎÔÈÏÔًوÓ, ·‡ÍËÛË ÙˆÓ Û˘ÛÙËÌ·ÙÈÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ Î·È ·ÓÙÈÚÚÔÈÛÙÈ΋ Ù·¯˘Î·Ú‰›·), Ô˘ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ¯ÔÚ‹ÁËÛË fiÁÎÔ˘ (ÂÚ›Ô˘ 500 ml ÎÔÏÏÔÂȉÒÓ ‹ FFP, ·Ó¿ÏÔÁ· Ì ÙȘ ÂӉ›ÍÂȘ) Î·È ·Ó ·˘Ùfi ‰Â Â·ÚΛ Ì ¯ÔÚ‹ÁËÛË ÈÓfiÙÚÔˆÓ Ê·ÚÌ¿ÎˆÓ (ÓÔÚ·‰ÚÂÓ·Ï›ÓË ‹/Î·È ·‰ÚÂÓ·Ï›ÓË).15 ∞ÓÙÈ˚Óˆ‰ÔÏ˘ÙÈο Ê¿Ú̷η: ·fi ÙȘ ÙÚÂȘ ÌÂÁ¿Ï˜ ηÙËÁÔڛ˜ Ê·ÚÌ¿ÎˆÓ – ‰ÂÛÌÔÚÂÛÛ›ÓË Î·È ·Ó¿ÏÔÁ· ·˘Ù‹˜, ·ÓÙÈ˚Óˆ‰ÔÏ˘ÙÈο, ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔÈ ·Ú¿ÁÔÓÙ˜ ‹Í˘ (΢ڛˆ˜ ÔVIIa) – Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ËÎÙÈÎfiÙËÙ·˜, Ë ÚÔÏËÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ˚Óˆ‰ÔÏ˘ÙÈÎÒÓ (΢ڛˆ˜ ¤¯ÂÈ ÌÂÏÂÙËı› Ë ·ÚÔÙÈÓ›ÓË) Û ÂÁ¯ÂÈÚ‹ÛÂȘ Ô˘ ·Ó·Ì¤ÓÂÙ·È ÛÔ‚·Ú‹ ·ÈÌÔÚÚ·Á›·, ¤¯ÂÈ ‰Â›ÍÂÈ fiÙÈ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙȘ ‰ÈÂÁ¯ÂÈÚËÙÈΤ˜ ·ÒÏÂȘ ·›Ì·ÙÔ˜. ∞Ó Î·È ÛÂ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË ·Ó·Ê¤ÚÂÙ·È fiÙÈ Ë ÚÔÏËÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÚÔÙÈÓ›Ó˘ Ì›ˆÛ ÙȘ ·ÒÏÂȘ ·›Ì·ÙÔ˜ ηٿ 25% Î·È Î·Ù¿ ÙÔ ‹ÌÈÛ˘ ÙȘ ·Ó¿ÁΘ ÁÈ· ÌÂÙ¿ÁÁÈÛË, ¯ˆÚ›˜ ÂÌÊ¿ÓÈÛË ıÚÔÌ‚ˆÙÈÎÒÓ ‹ ıÚÔÌ‚ÔÂÌ‚ÔÏÈÎÒÓ ÂÈÏÔÎÒÓ, Ë ÚÔÏËÙÈ΋ ¯ÔÚ‹ÁËÛË ‰ÂÓ ÚÔÙ›ÓÂÙ·È ˆ˜ Û˘Ó‹ı˘ Ú·ÎÙÈ΋. ∞ÎfiÌË Î·È ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Ë ÚÔÏËÙÈ΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈ˚Óˆ‰ÔÏ˘ÙÈÎÒÓ ÂÚÈÔÚ›˙ÂÙ·È Û ·ÚÚÒÛÙÔ˘˜ Ì ÛÔ‚·Ú¤˜ ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜, ‚·ÚÈ¿ ˘Ï·›· ˘¤ÚÙ·ÛË Î·È ÈÛÙÔÚÈÎfi ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÂÁ¯ÂÈÚ‹ÛˆÓ.16,17

ÛÌ·ÙÔ˜ (FFP) ÒÛÙ ӷ ‰È·ÙËÚÂ›Ù·È ÙÔ π¡R < 1.5, ·ÈÌÔÂÙ·Ï›ˆÓ (PLT) ÒÛÙ ӷ ‰È·ÙËÚÂ›Ù·È Ô ·ÚÈıÌfi˜ ÙÔ˘˜ >50.000/mm3 Î·È ÎÚ˘ÔηıÈ˙‹Ì·ÙÔ˜ ÒÛÙ ӷ ‰È·ÙËÚÂ›Ù·È Ë ÙÈÌ‹ ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘ >100 mg/dl.

OÈ ÂÈÏÔΤ˜ Ô˘ ÂÈʤÚÂÈ ÌÈ· ÌÂÁ¿ÏË ·ÈÌÔÚÚ·Á›·, ÂÏ·¯ÈÛÙÔÔÈÔ‡ÓÙ·È ·Ó ˘¿Ú¯ÂÈ Ë ‰˘Ó·ÙfiÙËÙ· Ù·¯Â›·˜ Î·È Î·Ù¿ÏÏËÏ˘ ·ÔηٿÛÙ·Û˘ ÙˆÓ ·ˆÏÂÈÒÓ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ·Ú·ÙÂٷ̤Ó˘ ˘fiÙ·Û˘ Î·È ˘ÔıÂÚÌ›·˜, ‰ÈfiÚıˆÛ˘ Ù˘ ËÎÙÈÎfiÙËÙ·˜ Î·È Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÈ΋˜ ÈÛÔÚÚÔ›·˜.18

3. ∞ÓÙÈÌÂÙÒÈÛË ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Û Ë·ÙÂÎÙÔÌ‹: ÔÈ Ì›˙ÔÓ˜ Ë·ÙÂÎÙÔ̤˜, Ô‰ËÁÔ‡Ó Û ÌÂÁ¿Ï˜ ·ÒÏÂȘ ·›Ì·ÙÔ˜ ÛÙÔ 20-30% ÙˆÓ ·ÚÚÒÛÙˆÓ. ∂ÍÂȉÈÎÂ˘Ì¤Ó· ΤÓÙÚ· ·Ó·Ê¤ÚÔ˘Ó ·ÒÏÂȘ ·›Ì·ÙÔ˜ Û ‰ÂÍȤ˜ Ë·ÙÂÎÙÔ̤˜ Û ˘ÁÈ›˜ ‰fiÙ˜ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ 600-900 ml ηٿ ̤ÛÔ fiÚÔ Î·È Û ·ÚÈÛÙÂÚ¤˜ 300-500 ml.

9. Lentschener C, Ozier Y: Anaesthesia for elective liver resection: some points should be revisited. Review. Eur J Anaesth 2002; 19: 780-788.

∏ ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ¯ÔÚ‹ÁËÛË ÎÔÏÏÔÂȉÒÓ Î·È ÂÏ¿¯ÈÛÙˆÓ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ Î·È ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ fiÙ·Ó Ô ·ÈÌ·ÙÔÎÚ›Ù˘ Â›Ó·È <25%, ÂÎÙfi˜ ·Ó Û˘Ó˘¿Ú¯ÂÈ ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ ‹ ·ÁÁÂÈÔ¿ıÂÈ·. ∏ ‰ÈfiÚıˆÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ËÎÙÈÎfiÙËÙ·˜, Â›Ó·È Î·Ï‡ÙÂÚ· Ó· ‚·Û›˙ÂÙ·È ÛÙȘ ÂӉ›ÍÂȘ ÙÔ˘ ıÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ·Ê‹Ì·ÙÔ˜. °ÂÓÈο, ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ·Ó¿ÏÔÁË ¯ÔÚ‹ÁËÛË ÊÚ¤ÛÎÔ˘ ηÙ„˘Á̤ÓÔ˘ Ï¿-

μÈ‚ÏÈÔÁÚ·Ê›· 1. Stephenson KR et al. Perioperative blood transfusions are associated with decreased time to recurrence and decreased survival after resection of colorectal liver metastases. Ann Surg 1988; 208: 679-687.

2. Savage AP, Malt RA. Elective and emergency hepatic resection. Ann Surg 1991; 214: 689-695.

3. Melendez JA, et al. Extended hepatic resection: A -6 year retrospective study od risk factors for perioperative mortality. J Am Coll Surg 2001; 192 (1): 47-53.

4. Bui LL, Smith AJ, et al. Minimising blood loss and transfusion requirements in hepatic resection. HPB 2002; Vol 4 (1): 5-10.

5. Clavien P-A, et al. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med 2007; 356: 1545-1559.

6. Guest Reviwers: Amy R Evenson, Josef E Fischer.

Hepatic Surgery: Current Techniques and Outcomes.

Cur Surg 62 (4) Jul-Aug 2005.

7. Liver surgery has become simpler. Editorial. Eur J An 2002; 19: 777-779.

8. M Rees, et al. One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery. BJA 1996, 83: 1526-1529.

10. Imre Redai, et al. Anesthetic considerations during liver surgery. Surg Clin N Am 84(2004): 401-411.

11. Delva E, et al. Hemodynamic effects of portal triad clamping in humans. Anaesth Analg 1987; 66 (9): 846-848.

12. Melendez JA, et al. Perioperative outcomes of major hepatic liver resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 1998 Dec; 187 (6): 620-625.

13. Smyrniotis V, Kostopanagiotou G, et al. The role of central venous pressure and the type of vascular control in blood loss during major liver resection. Am J Coll Surg 2004; 187: 398-402.

14. Matot J, et al. Epidural anesthesia analgesia in liver resection. Anaesth Analg 2002; 95 (5): 1179-1181.

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15. Eyraud D, et al. Hemodynamic and hormonal responses to the sudden ial flow: Insights from a prospective study of hepatic vascular exclusion during major liver resections. Anaesth Analg 2002; 95 (5): 1173-1178.

16. Porte RJ, Leebeek FW. Pharmacological strategies to decrease transfusion requirements in patients undergoing surgery. Drugs 2002; 62 (15): 2193-2211.

17. Lentschener C, et al. Aprotinin reduces blood loss in patients undergoing elective liver resection. Anaesth Analg 1997; 84 (4): 875-81.

18. Helling TS, et al. Perioperative factors and outcome associated with massive blood loss during major liver resections. HPB 2004; Vol 6 (3): 181-185.

AÓ·ÈÛıËÛ›· Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ Ì ‹·Ú ·ÛıÂÓ‹ Δ·ÙÈ·Ó‹ ™È‰ËÚÔÔ‡ÏÔ˘ ∫¿ı ¯ÚfiÓÔ Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È Û fiÏÔÓ ÙÔÓ ÎfiÛÌÔ ·˘Í¿ÓÂÙ·È. ªfiÓÔ ÛÙȘ ∏¶∞, ÂÚÈÛÛfiÙÂÚÔÈ ·fi 6.000 ·ÛıÂÓ›˜ ¤Ï·‚·Ó ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÙÔ 2009. ∫·ıÒ˜ Ë ÂÙ‹ÛÈ· ÂÈ‚›ˆÛË Î·È Ë ÔÈfiÙËÙ· ˙ˆ‹˜ ‰È·ÚÎÒ˜ ‚ÂÏÙÈÒÓÂÙ·È, fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔÈ Ï‹Ù˜ ÌÔۯ‡̷ÙÔ˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Â›Ù ÁÈ· Â›ÁÔ˘Û· ›Ù ÁÈ· ÚÔÁÚ·ÌÌ·ÙÈṲ̂ÓË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, Î·È Ì¿ÏÈÛÙ· Û ÓÔÛÔÎÔÌ›· ÛÙ· ÔÔ›· ‰ÂÓ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È ÌÂÙ·ÌÔۯ‡ÛÂȘ1-4.

OÈ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ··ÈÙÔ‡Ó Û˘Ó‹ıˆ˜ ˘„ËÏÔ‡ ÂÈ¤‰Ô˘, ÔÏ˘‰˘Ó·ÌÈ΋ Î·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ ˘ÔÛÙ‹ÚÈÍË. Δ· ÁÂÓÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ ÙÔ˘˜ ·ÊÔÚÔ‡Ó Û¯ÂÙ›˙ÔÓÙ·È Î˘Ú›ˆ˜ Ì ÙȘ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜, ÙȘ Èı·Ó¤˜ ·ÏÏËÏÂȉڿÛÂȘ Ì ·Ó·ÈÛıËÙÈο Ê¿Ú̷η, ı¤Ì·Ù· Û¯ÂÙÈο Ì ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ÔÚÁ¿ÓÔ˘ Î·È ÙˆÓ ¿ÏÏˆÓ Û˘ÛÙËÌ¿ÙˆÓ Î·È Ê˘ÛÈÔÏÔÁÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ, Ì ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÊÚÔÓÙ›‰· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ·ÛıÂÓ‹ Ô˘ ˘Ô‚¿ÏÏÂÙ·È Û ¿ÏÏË ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË. À¿Ú¯Ô˘Ó Î·È Î¿ÔÈ· ÂÈ̤ÚÔ˘˜ ·ıÔÊ˘ÛÈÔÏÔÁÈο ı¤Ì·Ù· ÂȉÈο ÁÈ· ÙÔ˘˜ Ï‹Ù˜ ‹·ÙÔ˜ ‹ ÁÈ· ÙÔ Â›‰Ô˜ Ù˘ Â¤Ì‚·Û˘ ÛÙËÓ ÔÔ›· ı· ˘Ô‚ÏËıÔ‡Ó.

ηÏ› ÌÈ· ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË Ì›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ Î·È ÙÔ˘ Ú˘ıÌÔ‡ ÛÂÈÚ·Ì·ÙԉȋıËÛ˘ Ô˘ ÔÊ›ÏÂÙ·È Û ÓÂÊÚÈ΋ ·ÁÁÂÈÔÛ‡Û·ÛË. º¿Ú̷η Ô˘ ÚÔηÏÔ‡Ó ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·Ó ¯ÔÚËÁËıÔ‡Ó Ì·˙› Ì tacrolimus Î·È Î˘ÎÏÔÛÔÚ›ÓË ∞ Â›Ó·È Ë ·ÌÊÔÙÂÚÈΛÓË, Ù· ª™∞º, Ë Ú·ÓÈÙȉ›ÓË, Ë ÛÈÌÂÙȉ›ÓË, Ë ÎÔÙÚÈÌÔÍ·˙fiÏË, ÁÎÂÓÙ·Ì˘Î›ÓË Î·È ‚·ÓÎÔÌ˘Î›ÓË. ∏ ΢ÎÏÔÛÔÚ›ÓË ÂËÚ¿˙ÂÈ Â›Û˘ ÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ¿ÏÏˆÓ Ê·Ú̷΢ÙÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ fiˆ˜ ‰ÈÁÔÍ›ÓË, ÏÔ‚·ÛÙ·Ù›ÓË, Ú‰ÓÈÛÔÏfiÓË5. ∏ ΢ÚÈfiÙÂÚË ·ÓÂÈı‡ÌËÙË ‰Ú¿ÛË Ù˘ ·˙·ıÂÈÔÚ›Ó˘ Â›Ó·È Ë Î·Ù·ÛÙÔÏ‹ ÙÔ˘ Ì˘ÂÏÔ‡. ∞Ó ÂÌÊ·ÓÈÛÙ› Ï¢ÎÔÂÓ›· ‹ ıÚÔÌ‚Ô΢ÙÙ·ÚÔÂÓ›· ı· Ú¤ÂÈ Ó· ÌÂȈı› Ë ‰ÔÛÔÏÔÁ›· Ù˘. º¿Ú̷η Ô˘ ·˘Í¿ÓÔ˘Ó ÙËÓ Ì˘ÂÏÔÙÔÍÈÎfiÙËÙ· Ù˘ ·˙·ıÂÈÔÚ›Ó˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÏÏÔÔ˘ÚÈÓfiÏË, ·-ª∂∞, ÛÔ˘ÏÊ·Û·Ï·˙›ÓË Î·È ÙÔ 5-·ÌÈÓÔÛ·ÏÈ΢ÏÈÎfi Ô͇10-14. ™ÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÎÙfi˜ ·fi ÙȘ ·ÚÂÓ¤ÚÁÂȘ ÙÔ˘ ›Ó·Î· 2 Î·È ¯·Ú·ÎÙËÚÈÛÙÈο Cushing, ·ıÔÏÔÁÈο ηٿÁÌ·Ù· ‹ ηı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË 15,16. ∏ ÂÌÊ¿ÓÈÛË ˘ÂÚÙÚÔÊÈ΋˜ ·ÔÊÚ·ÎÙÈ΋˜ ηډÈÔÌ˘Ô¿ıÂÈ·˜ Â›Ó·È ÌÈ· Û¿ÓÈ· ÂÈÏÔ΋ ·È‰È·ÙÚÈÎÒÓ ·ÛıÂÓÒÓ Ù˘ ¯Ú‹Û˘ ÙÔ˘ tacrolimus17,18. ∏ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ú¤ÂÈ Ó· Û˘Ó¯ÈÛÙ› ηٿ ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô. ∞˘Ù‹ Ë ÂÚ›Ô‰Ô˜ ˘„ËÏÔ‡ ÛÙÚ˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÔÍ›· Ïԛ̈ÍË, Û ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹ Î·È ÛÙ· ‰‡Ô. °È· Ó· ‰È·ÙËÚËıÔ‡Ó Ù· ıÂÚ·¢ÙÈο Â›‰· ÙÔ˘ tacrolimus Î·È Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ∞ ı· Ú¤ÂÈ Ó· ¯ÔÚËÁËıÔ‡Ó ·fi ÙÔ ÛÙfiÌ· 4 Ì 7 ÒÚ˜ ÚÔ ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ ηıfiÙÈ Ë ¯ÔÚ‹ÁËÛË <4 ÚÔÂÁ¯ÂÈÚËÙÈο ¤¯ÂÈ Û˘Ó‰˘·ÛÙ› Ì ˘ÔıÂÚ·¢ÙÈο Â›‰·19. ∏ ‰ÔÛÔÏÔÁ›· ÙˆÓ ˘ÔÏÔ›ˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ÌÂÙ·‚ÏËı› ÂÎÙfi˜ Â¿Ó Ë ¯ÔÚËÁÔ‡ÌÂÓË Ô‰fi˜ ·ÏÏ¿ÍÂÈ Û ÂÓ‰ÔÊϤ‚È·. ∏ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ‰fiÛË Ù˘ Ú‰ÓÈÛÔÏfiÓ˘ Â›Ó·È ›ÛË Ì ÙËÓ ÂÓ‰ÔÊϤ‚È· ‰fiÛË Ù˘ ÌÂı‡ÏÚ‰ÓÈÛÔÏfiÓ˘. ∏ ·˙·ıÂÈÔÚ›ÓË ¯ÔÚËÁÂ›Ù·È ÛÙËÓ ›‰È· ‰fiÛË ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ Î·È ÂÓ‰ÔÊϤ‚È·.

∏ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Î·È Èı·Ó¤˜ ·ÏÏËÏÂȉڿÛÂȘ Ì ·Ó·ÈÛıËÙÈο Ê¿Ú̷η ŸÏÔÈ ÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÛıÂÓ›˜ Ï·Ì‚¿ÓÔ˘Ó ÂÊ’fiÚÔ˘ ˙ˆ‹˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Ô˘ ÔÈΛÏÔ˘Ó ·Ó¿ÏÔÁ· Ì ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ fiÚÁ·ÓÔ, ÙÔÓ ¯ÚfiÓÔ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¢ÛË Î·È ÙËÓ ·Ô‰Ô¯‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÙÔÓ ÔÚÁ·ÓÈÛÌfi. ∏ ÙÔÍÈÎfiÙËÙ· ÙˆÓ ‰È·ÊfiÚˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ¤¯ÂÈ ÌÂÏÂÙËı› ÂÎÙÂÓÒ˜3,5 Î·È ÔÈ Û˘¯ÓfiÙÂÚ˜ ·ÚÂÓ¤ÚÁÂȘ Ô˘ ÌÔÚ› Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ·Ó·ÈÛıËÛÈÔÏÔÁÈ΋ Ù¯ÓÈ΋ Î·È ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ›Ó·Î· 1. ∏ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙÔ˘ tacrolimus Î·È Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ∞ ÔÊ›ÏÂÙ·È ÛÙËÓ ·Ú·ÁˆÁ‹ ıÚÔÌ‚ÔÍ¿Ó˘ ∞ Ô˘ ÚÔηÏ› ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ ÓÂÊÚÈ΋˜ ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·˜6-9. ™Â ıÂÚ·¢ÙÈΤ˜ ‰fiÛÂȘ Ë Î˘ÎÏÔÛÔÚ›ÓË ‹ ÙÔ tacrolimus ÚÔ-

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ΔÔÍÈÎfiÙËÙ· Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ §ÔÈÌÒÍÂȘ ÕÏÏ· ∞Ó·Ê˘Ï·ÎÙÈΤ˜ ·ÓÙȉڿÛÂȘ* CRS** ∫·Ù·Ú¿¯Ù˘ ∏ÏÂÎÙÚÔÏ˘Ù. ‰È·Ó·Ú·¯¤˜

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ALG = ·ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ÛÊ·ÈÚ›ÓË, ATG = ·ÓÙÈı˘ÌÔ΢ÙÙ·ÚÈ΋ ÛÊ·ÈÚ›ÓË, Aza = ·˙·ıÂÈÔÚ›ÓË, CyA = ΢ÎÏÔÛÔÚ›ÓË ∞, MMF = Ì˘ÎÔÊ·ÈÓÔÏÈÎfi˜ ÂÛÙ¤Ú·˜, OKT3 = ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ηٿ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ CD-3 Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ste = ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, Tac = tacrolimus, IL2RA = ·ÓÙ·ÁˆÓÈÛÙ¤˜ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ IL-2 (Basiliximab ‹ Daclizumab), C1H = alemtuzumab (Campath-1H). * = ˘ÚÂÙfi˜, Ú›ÁÔ˜, ˘fiÙ·ÛË, ‚ÚÔÁ¯fiÛ·ÛÌÔ. $= ÌfiÓÔ Ì ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË **=CRS (cytokine release syndrome) ÂÚÈÏ·Ì‚¿ÓÂÈ Î·Ú‰È·ÁÁÂÈ·Îfi ÛÔÎ, Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·, Û·ÛÌÔ‡˜ Î·È ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·.

¶›Ó·Î·˜ 2. ¶ÂÚÈÙÒÛÂȘ Ô˘ Û˘Ó‹ıˆ˜ Ô Ï‹Ù˘ ÌÔۯ‡̷ÙÔ˜ ··ÈÙ› ·Ó·ÈÛıËÛ›· ‹ ηٷÛÙÔÏ‹. ∞. ∫·Ù¿ ÙËÓ ¿ÌÂÛË ÂÚ›Ô‰Ô ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË – ∂·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË, ¤ÏÂÁ¯Ô ·ÈÌÔÚÚ·Á›·˜, ıÚfiÌ‚ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ – ∞ÔηٿÛÙ·ÛË ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÂÈÏÔ΋˜ – ∞ÓÙÈÌÂÙÒÈÛË ÂÓ‰ÔÎÔÈÏȷ΋˜ ‹ ÂÓ‰ÔıˆÚ·ÎÈ΋˜ ÛËÙÈ΋˜ ÂÛÙ›·˜, ÂÎΤӈÛË ·ÔÛÙ‹Ì·ÙÔ˜. μ. ¢È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ ‹ ‚ÈÔ„›Â˜ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·fiÚÚȄ˘ – μÚÔÁ¯ÔÛÎfiËÛË, Á·ÛÙÚÔÛÎfiËÛË, ÎÔÏÔÓÔÛÎfiËÛË – ∞ÍÔÓÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· – μÈÔ„›· ˘fi ˘ÂÚ˯ÔÁÚ·ÊÈÎfi ¤ÏÂÁ¯Ô °. ÃÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Ô˘ ‰ÂÓ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË (ÙÚ·‡Ì·, ·Ê·›ÚÂÛË fiÁÎÔ˘, ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË, ·ÁÁÂÈÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, Ì·È¢ÙÈο ·›ÙÈ· ÎÏ) ¢. ∂Ê·ÚÌÔÁ‹ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ÛÙËÓ ª∂£ (Ïԛ̈ÍË ·Ó·Ó¢ÛÙÈÎÔ‡, ARDS, ·fiÚÚÈ„Ë ‹ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÌÔۯ‡̷ÙÔ˜ ÎÏ)

METAMO™XEY™Eπ™ 2010

™Â Û¯¤ÛË Ì ٷ ·Ó·ÈÛıËÙÈο Ê¿Ú̷η ÌfiÓÔ Ë ·ÏÏËÏÂ›‰Ú·ÛË Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ∞ ¤¯ÂÈ ÌÂÏÂÙËı› Â·ÚÎÒ˜. OÈ ÏËÚÔÊÔڛ˜ Û¯ÂÙÈο Ì ٷ ÓÂfiÙÂÚ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜. ∏ ΢ÎÏÔÛÔÚ›ÓË ÌÔÚ› Ó· ÂÈÙ›ÓÂÈ ÙËÓ Â›‰Ú·ÛË ÙˆÓ Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ, ÙÔ˘ ÈÛÔÊÏÔ˘Ú·Ó›Ô˘ Î·È ÙˆÓ ‚·Ú‚ÈÙÔ˘ÚÈÎÒÓ20-26. OÈ ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó Î˘ÎÏÔÛÔÚ›ÓË ÌÔÚ› Ó· ÂÌÊ·Ó›ÛÔ˘Ó ·Ú¿Ù·ÛË ÙÔ˘ Ó¢ÚÔÌ˘˚ÎÔ‡ ·ÔÎÏÂÈÛÌÔ‡ Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ··ÈÙÔ‡Ó ÌÈÎÚfiÙÂÚ˜ ‰fiÛÂȘ Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ. ∏ Û˘Ó¯‹˜ ¤Á¯˘ÛË ÚÔÔÊfiÏ˘ ‰ÂÓ ÂËÚ¿˙ÂÈ Ù· Â›‰· ΢ÎÏÔÛÔÚ›Ó˘ ÛÙÔ ·›Ì·27. ™Â ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, Ë ·Ú¯È΋ ‰fiÛË ÙˆÓ Ì˘Ô¯·Ï·ÚˆÙÈÎÒÓ Ú¤ÂÈ Ó· ·˘ÍËı› ·Ó ÛÙÔÓ ·ÛıÂÓ‹ ¯ÔÚËÁÂ›Ù·È ·˙·ıÂÈÔÚ›ÓË (37% ÙÔ ·ÙÚ·ÎÔ‡ÚÈÔ, 20% ‚ÂÎÔ˘ÚfiÓÈÔ Î·È 45% ·ÓÎÔ˘ÚfiÓÈÔ)28. ΔÔ tacrolimus, Ë Ú··Ì˘Î›ÓË Î·È Ë Î˘ÎÏÔÛÔÚ›ÓË ∞ ·›˙Ô˘Ó Î¿ÔÈÔ ÚfiÏÔ ÛÙËÓ Ó¢ÚÈ΋ ·Ó·‰ÈÔÚÁ¿ÓˆÛË Î·È ÙËÓ Ó¢ÚÔÚÔÛÙ·Û›·29. OÈ ‰Â›ÎÙ˜ Ù˘ ‹Íˆ˜ Î·È Ù˘ ÈÓˆ‰ÔÁÔÓfiÏ˘Û˘ ·˘Í¿ÓÔÓÙ·È Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË ∞ Î·È ÙÔ OKT3 (ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ηٿ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ CD-3 Ù˘ ÂÈÊ¿ÓÂÈ·˜ ÙˆÓ Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ) ÂÚÈÂÁ¯ÂÈÚËÙÈο ÂÓÒ ÙÔ OKT3 ÚÔοÏÂÛ ·‡ÍËÛË Î·È ÙÔ˘ ÂÓ‰ÔıËÏÈÎÔ‡ TPA30. ∏ ·fiÙÔÌË ‰È·ÎÔ‹ Ù˘ ·˙·ıÂÈÔÚ›Ó˘ ÂÚÈÂÁ¯ÂÈÚËÙÈο Û ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ‚·ÚÊ·Ú›ÓË ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÈÌÔÚÚ·Á›·31.

¶ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô˜ O Ï‹Ù˘ ÌÔۯ‡̷ÙÔ˜ ÌÔÚ› Ó· ··ÈÙ‹ÛÂÈ ·Ó·ÈÛıËÛ›· ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ›Ó·Î· 2. ™˘Ó‹ıˆ˜ ¿ÌÂÛ˜ ÂÈÏÔΤ˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ï·Ì‚¿ÓÔ˘Ó ¯ÒÚ· ÛÙÔ Î¤ÓÙÚÔ fiÔ˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎÂ Î·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË.

¶ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË ∏ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ·ÛıÂÓÔ‡˜ ÛÙԯ‡ÂÈ Ó· ·ÔÎÏ›ÛÂÈ Î·Ù·ÛÙ¿ÛÂȘ Ô˘ ÌÔÚ› Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ‹·ÙÔ˜ Î·È Û˘ÓÂÒ˜ Ó· ÂϤÁÍÂÈ ÙËÓ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘. ∂›Û˘ ÛÙԯ‡ÂÈ Ó· ·ÍÈÔÏÔÁ‹ÛÂÈ ÙËÓ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ÏÔÈÒÓ ÔÚÁ¿ÓˆÓ Î·È Û˘ÛÙËÌ¿ÙˆÓ. ∞Èٛ˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ Ú¤ÂÈ Û οı ÂÚ›ÙˆÛË Ó· ·ÔÎÏÂÈÛıÔ‡Ó Â›Ó·È ÔÈ ÏÔÈÌÒÍÂȘ, Ë ·fiÚÚÈ„Ë, Ë ÓfiÛÔ˜ ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ˘ ÍÂÓÈÛÙ‹ ‹ graftversus-host disease (GVHD) Î·È Ë post transplant lympho-proliferative disease (PLTD).

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OÈ ÏÔÈÌÒÍÂȘ ÛÙÔÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ·ÛıÂÓ‹ Â›Ó·È Ë Î‡ÚÈ· ·ÈÙ›· ıÓËÙfiÙËÙ·˜ Î·È ÌÔÚÔ‡Ó Ó· Â›Ó·È ‚·ÎÙËÚȷΤ˜, Ì˘ÎËÙÈ·ÛÈΤ˜, ÈÔÁÂÓ›˜ ‹ ÚˆÙÔ˙ˆ˚Τ˜32. ¶ÚԉȷıÂÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ïԛ̈͢ Â›Ó·È Ë ÚÔÂÁ¯ÂÈÚËÙÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ (·ÚÔ˘Û›· ·ÓÂ¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰ÈÔ‡ ¯ Ô˘Ú·ÈÌ›·, ΛÚÚˆÛË, ηډÈÔÌ˘Ô¿ıÂÈ·, η΋ ıÚ¤„Ë, ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÛÏ‹Ó·). ¡ÔÛÔÎÔÌÂÈ·ÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÚÔηÏÔ‡Ó ÌÂÙ·ÎÈÓ‹ÛÂȘ Ù˘ ÌÈÎÚԂȷ΋˜ ·Ó›‰·˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ¯ÂÈÚÔ˘ÚÁÈΤ˜ ‹/Î·È ÂÂÌ‚·ÙÈΤ˜ ÌÂıfi‰Ô˘˜, ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Î·È Ù˘ ÌÔÓ¿‰·˜ ÂÓÙ·ÙÈ΋˜ ıÂÚ·›·˜, ·ÚÔ˘Û›· ÔÏ˘·ÓıÂÎÙÈÎÒÓ ÓÔÛÔÎÔÌÂÈ·ÎÒÓ ÔÚÁ·ÓÈÛÌÒÓ, ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Î·È Ë ‰ÔÛÔÏÔÁ›· ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ33. ∏ ·fiÚÚÈ„Ë Â›Ó·È Ë ÛÔ‚·ÚfiÙÂÚË ÂÈÏÔ΋ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, Ô˘ Ô‰ËÁ› Û ¤ÎÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ·ÔÙÂÏ› ÙËÓ Î˘ÚÈfiÙÂÚË ·ÈÙ›· ·ÒÙÂÚ˘ ıÓËÙfiÙËÙ·˜ ÁÈ· ÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜34. ∂Âȉ‹ ÔÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡ÓÙ·È Û ʿÛË ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û˘Ó‰¤ÔÓÙ·È Ì ·˘ÍË̤ÓË ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·, Ë ·ÚÔ˘Û›· Ù˘ Ú¤ÂÈ Ó· ‰ÈÂÚÂ˘Ó¿Ù·È ÚÔÂÁ¯ÂÈÚËÙÈο35. ∏ ·fiÚÚÈ„Ë ÌÔÚ› Ó· Â›Ó·È ˘ÂÚÔÍ›·, ÔÍ›· ‹ ¯ÚfiÓÈ·. ÀÂÚÔÍ›· ·fiÚÚÈ„Ë Â›Ó·È ÈÔ Û˘¯Ó‹ ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÒÓ, Î·È ÔÊ›ÏÂÙ·È Û ·Û˘Ì‚·ÙfiÙËÙ· ÔÌ¿‰·˜ ∞μO. ∏ ÔÍ›· ·fiÚÚÈ„Ë ÍÂÎÈÓ¿ Ì›· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ë Û˘¯ÓfiÙËÙ· Ù˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ÙÔ˘˜ ÚÒÙÔ˘˜ 3 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÊ›ÏÂÙ·È Û ·Û˘Ì‚·ÙfiÙËÙ· HLA Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ·ÓÙ›‰Ú·ÛË ÙˆÓ Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ŸÛÔ ÈÔ ·ÁÁÂÈÔ‚ÚËı¤˜ Â›Ó·È ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ fiÚÁ·ÓÔ ÙfiÛÔ ÈÔ ÁÚ‹ÁÔÚ· Î·È Û˘¯Ó¿ ÂΉËÏÒÓÔ˘Ó ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘. ∏ ‰È¿ÁÓˆÛË Ù˘ ·fiÚÚȄ˘ Â›Ó·È Û˘Ó‹ıˆ˜ ÈÛÙÔ·ıÔÏÔÁÈ΋ fiÔ˘ ·Ó·˙ËÙÔ‡ÓÙ·È Ù· ·Ú·Î¿Ùˆ 3 ¯·Ú·ÎÙËÚÈÛÙÈο: ·ÚÔ˘Û›· Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ‚Ï¿‚Ë Ù˘ ÈÛÙÈ΋˜ ‰ÔÌ‹˜ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ÔÚÁ¿ÓÔ˘ Î·È ‚Ï¿‚Ë ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ Î·È ÙˆÓ ·ÁÁ›ˆÓ. ¶ÔÏÏ¿ ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ ·Ó ‰ÂÓ Ô‰ËÁ‹ÛÔ˘Ó Û ӤÎÚˆÛË ÙÔ˘ ÔÚÁ¿ÓÔ˘ Ô‰ËÁÔ‡Ó Û ¯ÚfiÓÈ· ·fiÚÚÈ„Ë. ∞Ú¯Èο ·˘Ùfi˜ Ô fiÚÔ˜ ¯ÚËÛÈÌÔÔÈÔ‡Ù·Ó ÁÈ· Ó· ÂÚÈÁÚ¿„ÂÈ ÙËÓ Ì·ÎÚÔ¯ÚfiÓÈ· ¤ÎÙˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÔÚÁ¿ÓÔ˘ Ô˘ Û˘Ó‰ÂfiÙ·Ó Ì ›ÓˆÛË ÙˆÓ ·ÁÁ›ˆÓ. ™‹ÌÂÚ· ·˘Ùfi ÔÓÔÌ¿˙ÂÙ·È ¯ÚfiÓÈ· ·ÁÁÂÈÔ¿ıÂÈ· ÙÔ˘ ·ÏÏÔÌÔۯ‡̷ÙÔ˜.

O fiÚÔ˜ ¯ÚfiÓÈ· ·fiÚÚÈ„Ë ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û Â-

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T. ™π¢∏ƒ√¶√À§√À

ÚÈÛÙ·ÙÈο fiÔ˘ Ë ·fiÚÚÈ„Ë ÔÊ›ÏÂÙ·È Û ¯ÚfiÓÈ· ÊÏÂÁÌÔÓÒ‰Ë Î·È ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ηٿ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜34,36. ∏ ÓfiÛÔ˜ ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔ˘ ÍÂÓÈÛÙ‹ (graft-versus-host disease, GVHD) Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì˘ÂÏÔ‡ ÙˆÓ ÔÛÙÒÓ. ∞fi ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Û˘Ì·ÁÔ‡˜ ÔÚÁ¿ÓÔ˘ ÌfiÓÔ ·fi ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ۈϋӷ ÌÔÚ› Ó· ÂÎÏ˘ı› ÏfiÁˆ Ù˘ ¤ÓÙÔÓ˘ ·ÚÔ˘Û›·˜ ÏÂÌÊÈÎÔ‡ ÈÛÙÔ‡ Û ·˘Ùfi ÙÔ fiÚÁ·ÓÔ. Δ· fiÚÁ·Ó· Ô˘ Û˘¯ÓfiÙÂÚ· ÂÌϤÎÔÓÙ·È Â›Ó·È ÙÔ ‹·Ú, ÙÔ ‰¤ÚÌ·, ÔÈ ‚ÏÂÓÓÔÁfiÓÔÈ Î·È Ô Á·ÛÙÚÂÓÙÂÚÈÎfi˜ ۈϋӷ˜ Î·È ÂΉËÏÒÓÂÙ·È Ì ÂÚ‡ıËÌ·, ÊχÎÙ·ÈÓ˜, ¤ÏÎÔ˜ ÛÙËÓ ‚ÏÂÓÓÔÁfiÓÔ ÙÔ˘ ÛÙfiÌ·ÙÔ˜, ‰È¿ÚÚÔÈ·, ·Ó΢ÙÙ·ÚÔÂÓ›·, Ó¢ÌÔÓ›·, Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ‹ Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·37. ∏ posttransplant lymphoproliferative disease (PTLD) Â›Ó·È ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ EBV(+) ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Ô˘ ÌÔÚ› Ó· ÂÍÂÏȯı› ·fi ÏÂÌÊÔÂȉ‹˜ ˘ÂÚÏ·Û›· Û ηÎÔ‹ı˜ ϤÌʈ̷38,39. AÔÙÂÏ› ÌÈ· ÛÔ‚·Ú‹ ÂÈÏÔ΋ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜. ∏ Û˘¯ÓfiÙÂÚË ÂÚ›Ô‰Ô˜ ÂÌÊ¿ÓÈÛ˘ Â›Ó·È 2 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ÚÒÙË ÁÚ·ÌÌ‹ ·ÓÙÈÌÂÙÒÈÛ˘ Â›Ó·È Ë Ì›ˆÛË Ù˘ ·ÓÔÛÔηٷÛÙ·lÙÈ΋˜ ·ÁˆÁ‹˜ Î·È Ë ¯ÔÚ‹ÁËÛË rituximab Ô˘ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Û οÔȘ ÌÔÚʤ˜ PTLD40,41.

O ÚÔÂÁ¯ÂÈÚËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÎÙfi˜ ·fi ÙȘ Û˘Ó‹ıÂȘ ÂÚÁ·ÛÙËÚȷΤ˜ Î·È ÏÔÈ¤˜ ‰È·ÁÓˆÛÙÈΤ˜ ÂÍÂÙ¿ÛÂȘ Î·È ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÂÍÂÙ¿ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ ÔÚÁ¿ÓÔ˘.

∞Ó·ÈÛıËÛ›· – ¶ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ºÚÔÓÙ›‰· ∏ ÌÂÙ·‚ÔÏÈ΋ Î·È ·ÔÙÔÍÈÓˆÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ ‹·ÙÔ˜ ·Ôηı›ÛÙ·Ù·È ·Ì¤Ûˆ˜ ÌÂÙ¿ ·fi ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË 42,43. ŒÓ· ÏÂÈÙÔ˘ÚÁÈÎfi ÌfiÛ¯Â˘Ì· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ·Ú·ÁˆÁ‹ ηʤ ¯ÔÏÒ‰Ô˘˜ ˘ÁÚÔ‡, ‰ÈfiÚıˆÛË Ù˘ ‰È·Ù·Ú·¯‹˜ Ù˘ ËÎÙÈÎfiÙËÙ·˜ Î·È ‚ÂÏÙ›ˆÛË ÙˆÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ¶ÂÚÈÛÙ·Ûȷο ÌÔÚ› Ó· ·Ú·ÙËÚËı› ÌÈ· ·Ú¯È΋ ‰˘ÛÚ·Á›· ÙÔ˘ ÔÚÁ¿ÓÔ˘ (initial poor function) Û ÌÔۯ‡̷ٷ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜ ‹ Ô˘ ¤¯Ô˘Ó ÂÎÙÂı› Û ÂÚ›Ô‰Ô ·Ú·ÙÂٷ̤Ó˘ ÈÛ¯·ÈÌ›·˜. OÈ ‰È·Ù·Ú·¯¤˜ ÂΛӘ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ù˘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (·ÛΛÙ˘ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ, Ë·ÙÔÓ¢ÌÔÓÈÎfi Û‡Ó‰ÚÔÌÔ, ˘ÂÚ‰˘Ó·ÌÈ΋ ·ÈÌÔ‰˘Ó·ÌÈ΋ ηٿÛÙ·ÛË, ·ÓÂ·Ú΋˜ ·ÁÁÂÈÔ-

ÎÈÓËÙÈÎfi˜ ÙfiÓÔ˜ Î·È Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·) ·Ôηı›ÛÙ·ÓÙ·È ÛÙ·‰È·Î¿ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ‰ÈfiÚıˆÛË Ù˘ Ô͢ÁfiÓˆÛ˘ ÌÔÚ› Ó· ‰È·ÚΤÛÂÈ Ì‹Ó˜ ÂÓÒ ·Ó Û˘Ó˘¿Ú¯ÂÈ Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ÔÙ¤ Ï‹Ú˘ ·ÔηٿÛÙ·ÛË44. ∞ÛıÂÓ›˜ Ì Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙÔ‡Ó ·ÈÌÔ‰È¿Ï˘ÛË ÁÈ· ·ÚÎÂÙÔ‡˜ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÈ Ê˘ÛÈÔÏÔÁÈÎÔ› ·ÓÙÈÚÚÔÈÛÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ô˘ ÚÔÛÙ·ÙÂ‡Ô˘Ó ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ ÙÔ˘ ‹·ÙÔ˜ ·Ô˘ÛÈ¿˙Ô˘Ó ÛÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ‹·Ú, ÙÔ ÔÔ›Ô Â›Ó·È È‰È·›ÙÂÚ· ¢·›ÛıËÙÔ ÛÙË ÌÂȈ̤ÓË ÚÔ‹ ·›Ì·ÙÔ˜ Î·È ÙËÓ ˘ÔÍ·ÈÌ›·. ΔÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ‹·Ú ‰ÂÓ ·ÔÙÂÏ› ËÁ‹ ÂʉÚÈÎÔ‡ fiÁÎÔ˘ ·›Ì·ÙÔ˜ Û ηٷÛÙ¿ÛÂȘ ηٷÏËÍ›·˜, ‰ÈfiÙÈ Î·Ù¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰È·Ù·Ú¿ÛÛÂÙ·È Ô ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜, Ô˘ ÂÓÂÚÁÔÔÈÂ›Ù·È ÛÙÔ Ê˘ÛÈÎfi ‹·Ú45.

O ·ÛıÂÓ‹˜ ı· Ú¤ÂÈ Ó· ‰ÈÂÚ¢ÓËı› ÁÈ· ·ÚÔ˘Û›· ›ÎÙÂÚÔ˘, ˘ÚÂÙÔ‡, ·˘ÍËÌ¤ÓˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ¯ÔÏfiÛÙ·Û˘ Î·È ‰È·Ù·Ú·¯ÒÓ ËÎÙÈÎfiÙËÙ·˜ ·Ó Î·È Ë ‚ÈÔ„›· ÙÔ˘ ‹·ÙÔ˜ Â›Ó·È Ë ÌfiÓË ÂͤٷÛË Ô˘ ı¤ÙÂÈ ÙËÓ ‰È¿ÁÓˆÛË. ∏ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Ô‰ËÁ› Û ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›· Î·È Ë ‰ÈfiÚıˆÛË Ù˘ ÌÂÙ¿ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔÚ› Ó· ‰È·ÚΤÛÂÈ Ì‹Ó˜. ¶ÔÏÏ¿ ·Ó·ÈÛıËÙÈο Ê¿Ú̷η (ÔÔÈÂȉ‹, ‚·Ú‚ÈÙÔ˘ÚÈο) Û˘Ó‰¤ÔÓÙ·È ÛÙËÓ ÏÂ˘ÎˆÌ·Ù›ÓË Î·È Û˘ÓÂÒ˜ ¯·ÌËÏ¿ Â›‰· ÌÔÚ› Ó· ·˘Í‹ÛÔ˘Ó ÙÔ ÂχıÂÚÔ ÎÏ¿ÛÌ· ÙˆÓ Ê·ÚÌ¿ÎˆÓ Î·È Û˘ÓÂÒ˜ ÙËÓ ÎÏÈÓÈ΋ ÙÔ˘˜ ‰Ú¿ÛË. ∏ ÚÔÓ¿ÚΈÛË ÌÔÚ› Ó· ¯ÔÚËÁËı› ηٿ ÙËÓ Û˘Ó‹ıË Ù·ÎÙÈ΋. Δ· ÂÚÈÛÛfiÙÂÚ· Ê¿Ú̷η ÂÈÛ·ÁˆÁ‹˜ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó. ∏ ÚÔÔÊfiÏË Â›Ó·È ÌÈ· ·ÛÊ·Ï‹˜ ÂÈÏÔÁ‹46-48, ·ÏÏ¿ Ë ÂÙÔÌȉ¿ÙË ÂӉ›ÎÓ˘Ù·È ÂÚÈÛÛfiÙÂÚÔ Û ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı‹˜ ·ÛıÂÓ›˜. ¶·ÚÔ˘Û›· ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (.¯. Û ‰¤ÎÙ˜ ‹·ÙÔ˜ Ô˘ ··ÈÙÔ‡Ó ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË ÛÙËÓ ÚÒÈÌË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô) ı· Ú¤ÂÈ Ó· ·ÔÊ¢¯ıÔ‡Ó ‚ÂÓ˙ԉȷ˙Â›Ó˜, Î·È Ó· ÂÚÈÔÚÈÛÙ› Ë ¯Ú‹ÛË ÙˆÓ ÔÈÔÂȉÒÓ. Δ· ÔÔÈÂȉ‹ ÊÂÓÙ·Ó‡ÏË Î·È ÌÔÚÊ›ÓË ÂӉ›ÎÓ˘ÓÙ·È ÁÈ· ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ·Ó·ÏÁËÛ›·. ∞Ó Ô ·ÛıÂÓ‹˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ÔÈ ÂÓÂÚÁÔ› ÌÂÙ·‚Ôϛ٘ Ù˘ ÌÂÂÚȉ›Ó˘ Î·È Ù˘ ÌÔÚÊ›Ó˘ (ÓÔÚÌÂÂÚȉ›ÓË Î·È ÌÔÚÊ›ÓË-6- Î·È -3-ÁÏÔ˘ÎÔ˘ÚÔÓ›‰ÈÔ, ·ÓÙ›ÛÙÔȯ·) ÌÔÚ› Ó· Û˘ÛÛˆÚ¢ıÔ‡Ó Î·È Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ·Ú·ÙÂٷ̤ÓË Î·Ù·ÛÙÔÏ‹49. OÔÈÂȉ‹ ‚Ú·¯Â›·˜ ‰Ú¿Û˘ fiˆ˜ Ë ÚÂÌÈÊÂÓÙ·Ó‡ÏË ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ·Ó·ÏÁËÛ›· 50 . ∏ ¯ÔÚ‹ÁËÛË ÂÈÛÓÂfiÌÂÓˆÓ ·Ó·ÈÛıËÙÈÎÒÓ ÌÔÚ› Ó· ÚÔηϤ-

METAMO™XEY™Eπ™ 2010

ÛÂÈ Ì›ˆÛË Ù˘ Ë·ÙÈ΋˜ ÚÔ‹˜ ·ÏÏ¿ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û ٷÎÙÈ΋ ‚¿ÛË ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜. ΔÔ ÈÛÔÊÏÔ˘Ú¿ÓÈÔ, Û‚ÔÊÏÔ˘Ú¿ÓÈÔ Î·È ‰ÂÛÊÏÔ˘Ú¿ÓÈÔ Â›Ó·È Î·Ù¿ÏÏËÏ· ÙËÙÈο ·Ó·ÈÛıËÙÈο48,51-54. ∂¿Ó ˘¿Ú¯ÂÈ ÓÂÊÚÈ΋ ‹ Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÚÔÙÈÌÔ‡ÓÙ·È Ì˘Ô¯·Ï·ÚˆÙÈο Ô˘ ‰ÂÓ ˘fiÎÂÈÓÙ·È Û Ë·ÙÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi ‹ ÓÂÊÚÈ΋ ·¤ÎÎÚÈÛË ·ÙÚ·ÎÔ‡ÚÈÔ Î·È cis-·ÙÚ·ÎÔ‡ÚÈÔ3,55. º˘ÛÈÔÏÔÁÈο ÙÔ ‹·Ú ÂÓÂÚÁ› Û·Ó ·Ôı‹ÎË ·›Ì·ÙÔ˜, ÙÔ ÔÔ›Ô ÂϤÁ¯ÂÙ·È ·fi ÙÔ Û˘Ì·ıËÙÈÎfi Û‡ÛÙËÌ· Î·È ·ÓÙÈÛÙ·ıÌ›˙ÂÈ Ù˘¯fiÓ ÔÍ›˜ ·ÒÏÂȘ ·›Ì·ÙÔ˜. ∏ ÌÂȈ̤ÓË ·ÓÙ·fiÎÚÈÛË Ù˘ Ë·ÙÈ΋˜ ÌÈÎÚÔ΢ÎÏÔÊÔÚ›·˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ú¿ÏÏËÏ· Ì ÙËÓ ¿Ì‚Ï˘ÓÛË Ù˘ Û˘Ì·ıËÙÈ΋˜ ·¿ÓÙËÛË ÏfiÁˆ Ù˘ ·Ó·ÈÛıËÛ›·˜ ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ·˘Ùfi ÙÔÓ ·ÓÙÈÚÚÔÈÛÙÈÎfi Ì˯·ÓÈÛÌfi. º¿Ú̷η fiˆ˜ Ë ÛÈÌÂÙȉ›ÓË ‹ Ë ÚÔÚ·ÓÔÏfiÏË Ô˘ ÂÏ·ÙÙÒÓÔ˘Ó ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ ÙÔ˘ ‹·ÙÔ˜ ·ÓÙ‰›ÎÓ˘ÓÙ·È. ¶ÚÔÛÔ¯‹ ı· Ú¤ÂÈ Ó· ‰›ÓÂÙ·È Û ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó Ë·Ú›ÓË ¯·ÌËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˜, ‰ÂÍÙÚ¿Ó˜ ‹ ·ÓÙÈ·ÈÌÔÂÙ·Ïȷο Ê¿Ú̷η ÁÈ· ıÚÔÌ‚ÔÚÔʇϷÍË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙËÓ ÚÒÈÌË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô56. ∞Ó ı· Ú·ÁÌ·ÙÔÔÈËı› ÂÚÈÔ¯È΋ ·Ó·ÈÛıËÛ›· ÔÈ ¯ÚfiÓÔÈ ËÎÙÈÎfiÙËÙ·˜ Î·È Ô ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ Ú¤ÂÈ Ó· Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎÔ›. ∏ ¯ÔÚ‹ÁËÛË ÌÔ˘È‚·Î·˝Ó˘ ‹ ÚÔÈ‚·Î·˝Ó˘ ıˆÚÂ›Ù·È ·ÛÊ·Ï‹˜ ÛÙȘ Û˘ÓËıÈṲ̂Ó˜ ÎÏÈÓÈΤ˜ ‰fiÛÂȘ57-59. ∏ ‰È·¯Â›ÚËÛË ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ ÂӉ¯fiÌÂÓÔ ‚Ú·‰Â›·˜ ΤӈÛ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÔfiÙ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› Ù·¯Â›· ÂÈÛ·ÁˆÁ‹ Ì ›ÂÛË ÛÙÔÓ ÎÚÈÎÔÂȉ‹60. ∏ PTLD ÌÔÚ› Ó· ÚÔηϤÛÂÈ Î·È ÛÔ‚·Ú‹ ·fiÊÚ·ÍË ÙÔ˘ ·ÂÚ·ÁˆÁÔ‡6,55,61. £· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ô Ì˯·ÓÈÎfi˜ ˘ÂÚ·ÂÚÈÛÌfi˜ ηıfiÙÈ Ô Ô˘‰fi˜ ÁÈ· ÂÈÏËÙÈΤ˜ ÎÚ›ÛÂȘ Â›Ó·È ‹‰Ë ¯·ÌËÏfi˜ Û ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó tacrolimus ‹ ΢ÎÏÔÛÔÚ›ÓË. ∏ ·ÚÔ˘Û›· ·ÛΛÙË ‹ Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ·ÏÏ¿ Î·È Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ËÌȉ·ÊÚ¿ÁÌ·ÙÔ˜ ÌÔÚ› Ó· ÂËÚÚ¿ÛÔ˘Ó ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÛÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô. ∏ ·˘ÙfiÌ·ÙË ·Ó·ÓÔ‹ Î·È Ë ¿ÌÂÛË ·ԉȷۈϋӈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È Î·ÏÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜62,63. ∫·Ù¿ ÙËÓ Ú·ÁÌ·ÙÔÔ›ËÛË ÂÂÌ‚·ÙÈÎÒÓ Ú¿ÍÂˆÓ ··ÈÙÂ›Ù·È Ë ÂÊ·ÚÌÔÁ‹ ¿ÚÈÛÙ˘ ·ÓÙÈÛË„›·˜.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Zitelli BJZ, Miller JW, Gartner JJ, et al. Changes in life style after liver transplantation. Pediatrics 1988; 82: 173– 80.

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2. Barone GW, Sailors DM, Hudec WA, Ketel BL. Trauma management in solid organ transplant recipients. J Emerg Med 1997; 15:169-76.

3. Kostopanagiotou G, Smyrniotis V, Arkadopoulos N Theodoraki K, Papadimitriou L, Papadimitriou J. Anesthetic and perioperative management of adult transplant recipients in nontransplant surgery. Anesth Analg 1999; 89:613-22.

4. Organ Procurement and Transplantation Network information database, available at: http://www.optn.org (Last accessed May 30th, 2007).

5. Cohen SM. Current immunossuppression in liver transplantation. Am J Ther 2002; 9:119-25.

6. Tzakis AG, Kato T, Levi DM, Defaria W, Selvaggi G, Weppler D, Nishida S, Moon J, Madariaga JR, David AI, Gaynor JJ, Thompson J, Hernandez E, Martinez E, Cantwell GP, Augenstein JS, Gyamfi A, Pretto EA, Dowdy L, Tryphonopoulos P, Ruiz P. 100 multivisceral transplants at a single center. Ann Surg 2005; 242:480-93.

7. Kopp JB, Klotman PE. Cellular and molecular mechanisms of cyclosporine nephrotoxicity. J Am Soc Nephrol 1990; 1:162-79.

8. McCauley J, Fung J, Jain A, Todo S, Starzl TE. The effects of FK506 on renal function after liver transplantation. Transplant Proc 1990; 22:17-20.

9. Khanna A. Tacrolimus and cyclosporine in vitro and in vivo induce osteopontin mRNA and protein expression in renal tissues. Nephron Exp Nephrol 2005; 101:119-26.

10. Tzakis AG, Tryphonopoulos P, Kato T, Nishida S, Levi DM, Nery JR, Madariaga J, De Faria W, Mittal N, Thompson JF, Ruiz P. Intestinal transplantation: advances in immunosuppression and surgical techniques.

Transplant Proc 2003; 35:1925-26.

11. Tzakis AG, Kato T, Nishida S, Levi DM, Tryphonopoulos P, Madariaga JR, De Faria W, Nery JR, Regev A, Vianna R, Miller J, Esquenazi V, Weppler D, Ruiz P. Alemtuzumab (Campath-1H) combined with tacrolimus in intestinal and multivisceral transplantation.

Transplantation 2003; 75:1512-17.

12. Grant D, Abu-Elmagd K, Reyes J, Tzakis A, Langnas A, Fishbein T, Goulet O, Farmer D; on behalf of the Intestine Transplant Registry. 2003 Report of the Intestine Transplant Registry: a new era has dawned.

Ann Surg 2005; 241:607-13.

13. Berden JH, Hoitsma AJ, Merx JL, Keyser A. Severe central nervous system toxicity associated with cyclosporine. Lancet 1985; 1:219-20.

14. Killenberg PG, Cotton PK. Drug interactions with commonly used immunosuppressive agents. In: Killenberg PG, Clavien P-A, eds. Medical care of the liver transplant patient. Malden, MA: Blackwell Science, 1997; 341-58.

15. Ellis EN, Floyd-Gimon DM, Berry PL, Wells TG, Seibert J, Belsha C. Risk factors for bone mineral density loss in pediatric renal transplant patients. Pediatr Transplant 2000; 4:146-50

112

T. ™π¢∏ƒO¶OÀ§OÀ

16. Paolillo JA, Boyle GJ, Law YM, Miller SA, Lawrence K, Wagner K, Pigula FA, Griffith BP, Webber SA. Posttransplant diabetes mellitus in pediatric thoracic organ recipients receiving tacrolimus-based immunosuppression. Transplantation 2001; 71:252-6

30. Deira J, Alberca I, Lerma JL, Martin B, Tabernero JM. Changes in coagulation and fibrinolysis in the postoperative period immediately after kidney transplantation in patients receiving OKT3 or cyclosporine A as induction therapy. Am J Kidney Dis 1998; 32: 575-81.

17. Pappas PA, Weppler D, Pinna AD, Rusconi P, Thompson JF, Jaffe JS, Tzakis AG. Sirolimus in pediatric gastrointestinal transplantation: the use of sirolimus for pediatric transplant patients with tacrolimus-related cardiomyopathy. Pediatr Transplant 2000; 4:45-9.

31. Singleton JD, Conyers L. Warfarin and azathioprine: an important drug interaction [letter]. Am J Med 1992; 2:217.

18. Kostopanagiotou G, Smyrniotis V, Arkadopoulos N, Contis J, Briassoulis G, Kostopanagiotou E. Anaesthetic and perioperative management of paediatric organ recipients in nontransplant surgery. Paediatr Anaesth 2003; 13:754-63.

19. Brown MR, Brajtboard D, Johnson DW, Ramsay MA, Paulsen AW. Efficacy of oral cyclosporine given prior to liver transplantation. Anesth Analg 1989; 69:773-5.

20. Hoffman A, Habib G, Gilhar D, Zohar H. Cyclosporine increases the CNS sensitivity to the hypnotic effect of phenobarbitone but not ethanol in rats. J Pharm Pharmacol 1994; 46:760-4.

21. Cirella VN, Pantuk CB, Lee YJ, Pantuk EL. Effects of cyclosporine on anesthetic action. Anesth Analg 1987; 66:703-6.

22. Hoffman A, Levy G. Kinetics of drug action in disease states. Effect of cyclosporine on the pharmacodynamics and pharmacokinetics of a barbiturate (heptabarbital) in rats. J Pharm Sci 1990; 79:19-22.

23. Niemann CU, Stabernak C, Serkova N, Jacobsen W, Christians U, Eger II EI. Cyclosporine can increase isoflurane MAC. Anesth Analg 2002; 95: 930-4.

24. Gelb AW, Freeman D, Robertson KM, Zhang C. Isoflurane alters the kinetics of oral cyclosporine. Anesth Analg 1991; 72:801-4.

25. Sidi A, Kaplan RF, Davis RF. Prolonged neuromuscular blockade and ventilatory failure after renal transplantation and cyclosporine. Can J Anaesth 1990; 37:543-8.

26. Ilkiw JE, Forsyth SF, Hill T, Gregory CR. Atracurium administration as an infusion to induce neuromuscular blockade in clinically normal and temporarily immunesuppressed cats. J Am Vet Med Assoc 1990; 197:1153-6.

27. Pertek JP, Chaoui K, Junke E, Artis M, Coissard A, Frisoni A, Meistelman C. Effects of propofol on blood concentration of cyclosporine. Ann Fr Anesth Reanim 1996; 15:589-594.

28. Gramstad L. Atracurium, vecuronium and pancuronium in endstage renal failure. Dose-response properties and interactions with azathioprine. Br J Anaesth 1987; 59: 995-1003.

29. Gold BG, Villafranca JE. Neuroimmunophilin ligands: The development of novel neuroregenerative / neuroprotective compounds. Curr Top Med Chem 2003; 3: 1368-75.

32. Dunn DL. Problems related to immunosuppression, infection and malignancy occurring after solid organ transplantation. Crit Care Clin 1990; 6:955-77.

33. Fishman JA, Rubon RH. Infection in organ transplant recipiens. NEJM 1998; 338:1741-51.

34. McCarthy PM. Immediate postoperative care after thoracic organ transplantation. In: Shumway SJ, Shumway NE (eds) Thoracic transplantation. Blackwell Science. Oxford 1995; 205-18.

35. Black AE. Anesthesia for pediatric patients who have had a transplant. Int Anesthesiol Clin 1995; 33:107-23.

36. Howard TK. Postoperative intensive care management of the adult. In: Busuttil RW, Klintmalm GB, eds. Transplantation of the liver. Philadelphia: WB Saunders, 1996:551-63.

37. Mazariegos GV, Abu-elmagd K, Jaffe R, Bond G, Sindhi R, Martin L, Macedo C, Peters J, Girnita A, Reyes J. Graft versus Host disease in intestinal transplantation Am J Transplant 2004; 4: 1459-65.

38. Abu-Elmagd KM, Zak M, Stamos JM, Bond GJ, Jain A, Youk AO, Ezzelarab M, Costa G, Wu T, Nalesnik MA, Mazariegos GV, Sindhi RK, Marcos A, Demetris AJ, Fung JJ, Reyes JD. De novo malignancies after intestinal and multivisceral transplantation. Transplantation 2004; 77: 1719-25.

39. Ruiz P, Soares MF, Garcia M, Nicolas M, Kato T, Mittal N, Nishida S, Levi D, Selvaggi G, Madariaga J, Tzakis A. Lymphoplasmacytic hyperplasia (possibly pre-PTLD) has varied expression and appearance in intestinal transplant recipients receiving Campath1H immunosuppression. Transplant Proc 2004; 36:386-7.

40. Serinet MO, Jacquemin E, Habes D, Debray D, Fabre M, Bernard O. Anti-CD20 monoclonal antibody (Rituximab) treatment for Epstein-Barr virus-associated, B-cell lymphoproliferative disease in pediatric liver transplant recipients. J Pediatr Gastroenterol Nutr. 2002; 34:389-93.

41. Nishida S, Kato T, Burney T, Levi D, Nery J, Madariaga J, Mittal N, Weppler D, Ruiz P, Tzakis A. Rituximab treatment for posttransplantation lymphoproliferative disorder after small bowel transplantation. Transplant Proc 2002; 34:957.

42. Gelb AW, Sharpe MD. Organ transplantation: anesthetic considerations for the previously transplanted patient. Anesthesiol Clin North Am 1994: 827-43.

43. Shelly MP, Dixon JS, Park GR. The pharmacokinetics of midazolam following orthotopic liver transplantation.

Br J Clin Pharmacol 1989; 27: 629-33.

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44. Eriksson LS, Soderman C, Ericzon BG, Eleborg L, Wahren J, Hedestierna G. Normalization of ventilation/perfusion relationships after liver transplantation in patients with decompensated cirrhosis: evidence for a hepapulmonary syndrome. Hepatology 1990; 12:1350-7.

45. Henderson JM, Mackay GJ, Lumsden AB, Atta HM, Breouillard R, Kutner MH. The effect of liver denervation on hemodynamics during hypovolemic shock in swine. Hepatology 1992; 15:130-3.

46. Dash A. Anesthesia for patients with a previous heart transplant. Int Anesthesiol Clin 1995; 33:1-9.

47. Mandell MS, Durham J, Kumpe D, Trotter JF, Everson GT, Niemann CU. The effects of desflurane and propofol on portosystemic pressure in patients with portal hypertension. Anesth Analg 2003; 97:1573-7.

48. Goldman LJ, Lopez Santamaria M, Gamez M. Anaesthetic management of a patient with microvillus inclusion disease for intestinal transplantation. Paediatr Anaesth 2002; 12:278-83.

49. Hanna MH, D’Costa F, Peat SJ, Fung C, Venkat N, Zilkha TR, Davies S. Morphine-6-glucuronide disposition in renal impairement. Br J Anaesth 1993; 70:511-4.

50. Park GR, Evans TN, Hutchins J, Borissov B, Gunning KE, Klinck JR. Reducing the demand for admission to intensive care after major abdominal surgery by a chang in anaesthetic practice and the use of remifentanil. Eur J Anaesthesiol 2000; 17:111-9.

51. Bito H, Ikeuchi Y, Ikeda K. Effects of low-flow sevoflurane anesthesia on renal function: comparison with high-flow sevoflurane anesthesia and low-flow isoflurane anesthesia. Anesthesiology 1997; 86:1231-7.

52. Gelb AW, Sharpe MD. Organ transplantation: anesthetic considerations for the previously transplanted patient. Anesthesiol Clin North Am 1994: 827-43.

53. Van Obbergh LJ, Verbeeck RK, Michel I, Lim S, Veyckemans F. Extrahepatic metabolism of sevoflurane in children undergoing orthotopic liver transplantation.

Anesthesiology 2000; 92:683-6.

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54. Smith CE, Hunter JM. Anesthesia for renal transplantation: relaxants and volatiles. Int Anesthesiol Clin 1995: 33: 69-92.

55. Toivonen HJ. Anaesthesia for patients with a transplanted organ. Acta Anaesthesiol Scand 2000; 44: 812-33.

56. Troppmann C, Grrussner AC, Dunn DL, Sutherland DE, Grussner RW. Surgical complications requiring early relaparotomy after pancreas transplantation: a multivariate risk factor and economic impact analysis of the cyclosporine era. Ann Surg 1998; 227:255-68.

57. Bodenham A, Park GR. Plasma concentrations of bupivacaine after intercostals nerve block in patients after orthotopic liver transplantation. Br J Anaesth 1990; 64:436-41.

58. Hammouda GE, Yahya R, Atallah MM. Plasma bupivacaine concentrations following epidural administration in kidney transplant recipients. Reg Anesth 1996; 21:308-11.

59. Dauri M, Costa F, Servetti S, Sidiropoulou T, Fabbi E, Sabato AF. Combined general and epidural anesthesia with ropivacaine for renal transplantation. Minerva Anestesiol 2003; 69:873-84.

60. Mousa H, Bueno J, Griffiths J, Kocoshis S, Todo S, Reyes J, Di Lorenzo C. Intestinal motility after small bowel transplantation. Transplant Proc 1998; 30:2535-6.

61. Hammer GB, Cao S, Boltz MG, Messner A. Posttransplant lymphoprolipherative disease may present with severe airway obstruction. Anesthesiology 1998; 89:263-5.

62. Mandell MS, Lesotte D, Kam I, Zamudio S. Reduced use of intensive care after liver transplantation: influence of early extubation. Liver Transpl 2002; 8:676-81.

63. Cammu G, Decruyenaere J, Troisi R, de Hemptinne B, Colardyn F, Mortier E. Criteria for immediate postoperative extubation in adult recipients following living-related liver transplantation with total intravenous anesthesia. J Clin Anesth 2003; 15:515-9.

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Ì·Ù· ·Ó·Ù‡ÛÛÔ˘Ó Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ÌÂÙ¿ 1012 ¤ÙË16. ∏ ÙÚÈÂÙ‹˜ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ˘ÂÚ‚·›ÓÂÈ ÙÔ 90%. ∂ÓÒ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÛÙÔ ÌfiÛ¯Â˘Ì· ÙÔ ÁÂÁÔÓfi˜ ·˘Ùfi ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÙËÓ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË. øÛÙfiÛÔ Ë ·Ó¿Ù˘ÍË ¯ÔÏ·ÁÁÂÈÔηÚÎÈÓÒÌ·ÙÔ˜ ÌÂÈÒÓÂÈ ÙËÓ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË17,18.

μ. ÃÚfiÓÔ˜ ·Ú·ÔÌ‹˜ ∂¿Ó ÏËÚÔ‡ÓÙ·È Ù· ··Ú·›ÙËÙ· ÎÚÈÙ‹ÚÈ· Û˘ÛÙ‹ÓÂÙ·È ¿ÌÂÛË ·Ú·ÔÌ‹ Û ΤÓÙÚÔ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÒÛÙ ӷ ˘¿Ú¯ÂÈ ·ÚÎÂÙfi˜ ¯ÚfiÓÔ˜ ÁÈ· ÙËÓ ÂÓË̤ڈÛË Î·È ÂÍÔÈΛˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙˆÓ Û˘ÁÁÂÓÒÓ. ∂›Û˘ ÂÓÙÔ›˙ÔÓÙ·È Èı·Ó¿ ÚÔ‚Ï‹Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Ô ·ÛıÂÓ‹˜ ÚÔÂÙÔÈÌ¿˙ÂÙ·È ·fi ¤ÌÂÈÚË ÔÌ¿‰·, Ë ÔÔ›· Û˘Ó‹ıˆ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ Ë·ÙÔÏfiÁÔ, ¯ÂÈÚÔ˘ÚÁfi, „˘¯›·ÙÚÔ, ηډÈÔÏfiÁÔ, Ó¢ÌÔÓÔÏfiÁÔ Î·È ÂÍÂȉÈÎÂ˘Ì¤ÓÔ ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi. Δ· ÚÔÁÓˆÛÙÈο ÌÔÓ٤Ϸ ÛÙËÓ Î›ÚÚˆÛË ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙË Ï‹„Ë ·ÔÊ¿ÛÂˆÓ Û¯ÂÙÈο Ì ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ, ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÂÈ‚›ˆÛ˘ Î·È ÙËÓ ¤ÓÙ·ÍË ÛÙË Ï›ÛÙ· ÌÂÙ·ÌÔۯ‡ÛˆÓ. ¢‡Ô ÌÔÓ٤Ϸ Û˘Ó‹ıˆ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È, ÙÔ ChildTurcotte-Pugh (CTP) score Î·È ÚfiÛÊ·Ù· ÙÔ Model for End-stage Liver Disease (MELD)19,20. ¶ÔÏÏ¿ ΤÓÙÚ· ·Ó·ÊÔÚ¿˜ ıˆÚÔ‡Ó ÙÔ Child Pugh score 7 ˆ˜ ÙÔ ÂÏ¿¯ÈÛÙÔ ÎÚÈÙ‹ÚÈÔ ·Ú·ÔÌ‹˜ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ηıÒ˜ ·ÓÙÈÛÙÔȯ› Û ÂÙ‹ÛÈ· ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÚ›Ô˘ 90%. °È· ÙÔÓ ›‰ÈÔ ÏfiÁÔ ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÙÔ Meld score 10 ‹ ÔÔÈ·‰‹ÔÙ ÂÈÏÔ΋ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ ˆ˜ ‰Â›ÎÙ˜ ÁÈ· ÙËÓ ·Ó¿ÁÎË ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋˜ ÂÎÙ›ÌËÛ˘ Î·È ¤ÓÙ·Í˘ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜. ·) Child-Turcotte-Pugh (CTP). ∞Ó·Ù‡¯ıËΠ·Ú¯Èο ·fi ÙÔ˘˜ Child and Turcotte ÙÔ 1964 ÁÈ· ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ı· ¤Î·Ó·Ó ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ÛÙ· Ï·›ÛÈ· ·ÔÛ˘ÌÊfiÚËÛ˘ Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘21. O ·Ú¯ÈÎfi˜ ÙÚfiÔ˜ ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜ Child-Turcotte ÙÚÔÔÔÈ‹ıËΠ·fi ÙÔÓ Pugh ÙÔ 1973 22 Î·È ·Ó·Ê¤ÚÂÙ·È ˆ˜ ChildTurcotte-Pugh (CTP) score. ™ÙËÚ›˙ÂÙ·È Û ¤ÓÙ ·Ú·Ì¤ÙÚÔ˘˜: ¯ÔÏÂÚ˘ıÚ›ÓË, ·Ï‚Ô˘Ì›ÓË, ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘, ·ÛΛÙ˘ Î·È ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. ΔÔ CTP ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ÚfiÁÓˆÛË ·ÛıÂÓÂÒÓ Ì ˘Ï·›· ˘¤ÚÙ·ÛË23. ¶Èı·Ó¿ ÚÔ‚Ï‹Ì·Ù· ÛÙÔÓ ˘ÔÏÔÁÈÛÌfi ÙÔ˘ ·ÔÙÂÏÔ‡Ó: ·) Ë ·ÎÚÈ‚‹˜ ÂÎÙ›ÌËÛË ÙÔ˘ ·ÛΛÙË Î·È Ù˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜,

‚) ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÚfiÙÈ Ì›· ·Ú¿ÌÂÙÚÔ˜ fiˆ˜ Ë ¯ÔÏÂÚ˘ıÚ›ÓË, Ô˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ‰Â›ÎÙË ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘, ÌÔÚ› Ó· ·˘ÍËı› ¿Óˆ ·fi ¤Ó· fiÚÈÔ (.¯ 4 mg/dL Î·È 30 mg/dL) ÙÔ CTP score ‰ÂÓ ·˘Í¿ÓÂÙ·È. ¶·ÚÔÌÔ›ˆ˜ ‰‡Ô ·ÛıÂÓ›˜ Ì Â›‰· ·Ï‚Ô˘Ì›Ó˘ ÛËÌ·ÓÙÈο ‰È·ÊÔÚÂÙÈο (.¯ 2.7 g/dL Î·È 1.4 g/dL) Â›Û˘ ı· ¤¯Ô˘Ó ÙÔ ›‰ÈÔ CTP score Î·È Á) ‰È·ÊÔÚÂÙÈΤ˜ ̤ıÔ‰ÔÈ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘ Î·È Ù˘ ·Ï‚Ô˘Ì›Ó˘ Û ‰È·ÊÔÚÂÙÈο ÂÚÁ·ÛÙ‹ÚÈ·20. ¶·ÚfiÙÈ ˘¿Ú¯Ô˘Ó ÂÚÈÔÚÈÛÌÔ› ÛÙË ¯Ú‹ÛË ÙÔ˘, ÙÔ CTP score ¤¯ÂÈ ˘ÈÔıÂÙËı› ¢ڤˆ˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÚÔ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‰ÈfiÙÈ Â›Ó·È ·Ïfi Î·È Â‡¯ÚËÛÙÔ24. ¶ÂÚÈÛÛfiÙÂÚÔ ·fi ÙÔ 1/3 ÙˆÓ ·ÛıÂÓÒÓ Ì CTP score ≥ 10 (class C) Ô˘ ÂÚÈ̤ÓÔ˘Ó ÌÂÙ·ÌfiÛ¯Â˘ÛË ·Ó·Ì¤ÓÂÙ·È Ó· ·Ô‚ÈÒÛÔ˘Ó ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ25. ∞ÛıÂÓ›˜ Ì CTP score ·fi 7 ˆ˜ 9 (class B) ¤¯Ô˘Ó 80% 5ÂÙ‹ ÂÈ‚›ˆÛË, ÂÓÒ ÂΛÓÔÈ Ì CTP score 5 Î·È 6 ¤¯Ô˘Ó 5ÂÙ‹ ÂÈ‚›ˆÛË 90%26. ‚) MELD. ΔÔ MELD·Ú¯Èο ¯ÚËÛÈÌÔÔÈ‹ıËΠ۠·ÛıÂÓ›˜ Ì ΛÚÚˆÛË ÙÔ˘ ‹·ÙÔ˜ ÔÈ ÔÔ›ÔÈ ˘Ô‚Ï‹ıËÎ·Ó Û TIPS (transjugular intrahepatic portosystemic shunt)27. O ·Ú¯ÈÎfi˜ ÙÚfiÔ˜ ˘ÔÏÔÁÈÛÌÔ‡ ¤¯ÂÈ ÙÚÔÔÔÈËı›, ηıÒ˜ Ë ·ÈÙ›· Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ ‰ÂÓ ˘ÔÏÔÁ›˙ÂÙ·È ϤÔÓ ÛÙÔ ÌÔÓÙ¤ÏÔ28. ΔÔ MELD score ¯ÚËÛÈÌÔÔÈ› ÂÚÁ·ÛÙËÚȷΤ˜ ÙÈ̤˜ Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘, Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ Î·È ÙÔ˘ INR Û ÌÈ· ÏÔÁ·ÚÈıÌÈ΋ Â͛ۈÛË Ì ÙËÓ ÔÔ›· ÂÎÙÈÌ¿Ù·È Ë Èı·ÓfiÙËÙ· ÙÚ›ÌËÓ˘ ÂÈ‚›ˆÛ˘. À„ËÏfiÙÂÚ· MELD scores Û˘Ó‰¤ÔÓÙ·È Ì ÌÂȈ̤ӷ ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘29. ªÂ ÙË ¯Ú‹ÛË ÙÔ˘ MELD ÔÈ·ÛıÂÓ›˜ ηٷٿÛÛÔÓÙ·È Û Îϛ̷η ·fi ÙÔ 6 ˆ˜ ÙÔ 40 Ô˘ ·ÓÙÈÛÙÔȯ› Û ÂÎÙÈÌÔ‡ÌÂÓÔ 3ÌËÓÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ·fi 90% ˆ˜ 7% ·ÓÙ›ÛÙÔȯ·27. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì MELD score 40 ˘ÔÏÔÁ›˙ÂÙ·È 3ÌËÓË ÂÈ‚›ˆÛË ÌÈÎÚfiÙÂÚË ÙÔ˘ 20%. ∂›Û˘ ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ÂȂ‚·›ˆÛ·Ó ÙË ÛËÌ·Û›· ÙÔ˘ ÛÙËÓ ÚfiÁÓˆÛË ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ20. ΔÔ ÙÚÔÔÔÈË̤ÓÔ ÌÔÓÙ¤ÏÔ28,30 ¯ÚËÛÈÌÔÔÈÂ›Ù·È (United Network for Organ Sharing (UNOS)) ÛÙËÓ ¤ÓÙ·ÍË ÙˆÓ ·ÛıÂÓÒÓ ÛÙË Ï›ÛÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ (www.unos.org/resources/MeldPeldCalculator. asp?index=98) MELD calculation formula: (MELD = 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4) (Ln: natural logarithm). ∂›Û˘ ηıÒ˜ Ë ˘ÔÓ·ÙÚÈ·ÈÌ›· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË31 Ë ÚÔÛı‹ÎË ÙÔ˘ Ó·ÙÚ›Ô˘ ÛÙÔ ÌÔ-

METAMO™XEY™Eπ™ 2010

ÓÙ¤ÏÔ (MELDNa) ¤¯ÂÈ Â›Û˘ ÌÂÏÂÙËı› ·ÏÏ¿ ··ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ· ‰Â‰Ô̤ӷ ÁÈ· Ó· ÂÎÙÈÌËı› Ë ¯ÚËÛÈÌfiÙËÙ· ÙÔ˘ ÛÙËÓ ¤ÓÙ·ÍË ·ÛıÂÓÂÒÓ ÛÙË Ï›ÛÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› ˆ˜ ÙÔ MELD score ÂÍ·ÚÙ¿Ù·È ·fi ‰È·ÊÔÚ¤˜ ÛÙȘ ÂÚÁ·ÛÙËÚȷΤ˜ ÌÂÙÚ‹ÛÂȘ Û ‰È·ÊÔÚÂÙÈο ÂÚÁ·ÛÙ‹ÚÈ·32-34, ηıÒ˜ Î·È ·fi ÙËÓ Ì¤ıÔ‰Ô Ô˘ ÌÂÙÚ¿Ù·È Ë ÎÚ·ÙÈÓ›ÓË È‰È·›ÙÂÚ· fiÙ·Ó Ë ÙÈÌ‹ Ù˘ ÔÏÈ΋˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi 25 mg/dL35,36. ™¯ÂÙÈο Ì ÙËÓ ¶Ã∫ ÙÔ ÚÔÁÓˆÛÙÈÎfi ÌÔÓÙ¤ÏÔ Ù˘ Mayo Clinic ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÚfiÁÓˆÛ˘37,38 ÂÓÒ ·ÓÙ›ÛÙÔȯ· ÌÔÓ٤Ϸ ¤¯Ô˘Ó ·Ó·Ù˘¯ı› Î·È ÁÈ· ÙËÓ ¶™Ã39, Ù· ÔÔ›· fï˜ Â›Ó·È ¯Ú‹ÛÈÌ· ÌfiÓÔ ÁÈ· ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÓfiÛÔ Î·È ‰ÂÓ Â›Ó·È ÍÂοı·ÚÔ ÙÔ ·Ó ÚÔÛʤÚÔ˘Ó ÂÈϤÔÓ ÛÙÔȯ›· ÁÈ· ÙËÓ ÚfiÁÓˆÛË Û ۯ¤ÛË Ì ٷ ÎÏ·ÛÛÈο ÚÔÁÓˆÛÙÈο ÌÔÓ٤Ϸ fiˆ˜ Â›Ó·È Ë Ù·ÍÈÓfiÌËÛË Child-Turcotte-Pugh40,41.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Fattovich G, Giustina G, Degos F, Tremolada F, Diodati G, Almasio P, et al. Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients. Gastroenterology 1997 Feb; 112(2):463-72.

2. Gines P, Quintero E, Arroyo V, Teres J, Bruguera M, Rimola A, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987 Jan; 7(1):122-8.

3. Andreu M, Sola R, Sitges-Serra A, Alia C, Gallen M, Vila MC, et al. Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites. Gastroenterology 1993 Apr;104(4):1133-8.

4. Gines A, Escorsell A, Gines P, Salo J, Jimenez W, Inglada L, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology 1993 Jul; 105(1):229-36.

5. Cross TJ, Antoniades CG, Muiesan P, Al-Chalabi T, Aluvihare V, Agarwal K, et al. Liver transplantation in patients over 60 and 65 years: an evaluation of longterm outcomes and survival. Liver Transpl 2007 Oct; 13(10):1382-8.

6. Seeff LB. Natural history of chronic hepatitis C. Hepatology 2002 Nov; 36(5 Suppl 1):S35-S46.

7. Gane EJ, Portmann BC, Naoumov NV, Smith HM, Underhill JA, Donaldson PT, et al. Long-term outcome of hepatitis C infection after liver transplantation. N Engl J Med 1996 Mar 28; 334(13):815-20.

8. Everson GT. Treatment of patients with hepatitis C virus on the waiting list. Liver Transpl 2003 Nov; 9(11):S90-S94.

9. Lok AS, McMahon BJ. Chronic hepatitis B. Hepatology 2001 Dec; 34(6):1225-41.

119

10. O’Grady JG, Smith HM, Davies SE, Daniels HM, Donaldson PT, Tan KC, et al. Hepatitis B virus reinfection after orthotopic liver transplantation. Serological and clinical implications. J Hepatol 1992 Jan; 14(1):104-11.

11. Lok AS. Prevention of recurrent hepatitis B post-liver transplantation. Liver Transpl 2002 Oct; 8(10 Suppl 1):S67-S73.

12. Czaja AJ, Freese DK. Diagnosis and treatment of autoimmune hepatitis. Hepatology 2002 Aug; 36(2):479-97.

13. Neuberger J. Transplantation for autoimmune hepatitis.

Semin Liver Dis 2002 Nov; 22(4):379-86.

14. Liermann Garcia RF, Evangelista GC, McMaster P, Neuberger J. Transplantation for primary biliary cirrhosis: retrospective analysis of 400 patients in a single center.

Hepatology 2001 Jan; 33(1):22-7.

15. Heathcote EJ. Management of primary biliary cirrhosis.

The American Association for the Study of Liver Diseases practice guidelines. Hepatology 2000 Apr; 31(4):1005-13.

16. Harnois DM, Lindor KD. Primary sclerosing cholangitis: evolving concepts in diagnosis and treatment. Dig Dis 1997 Jan; 15(1-2):23-41.

17. Goss JA, Shackleton CR, Farmer DG, Arnaout WS, Seu P, Markowitz JS, et al. Orthotopic liver transplantation for primary sclerosing cholangitis. A 12-year single center experience. Ann Surg 1997 May; 225(5):472-81.

18. Graziadei IW, Wiesner RH, Marotta PJ, Porayko MK, Hay JE, Charlton MR, et al. Long-term results of patients undergoing liver transplantation for primary sclerosing cholangitis. Hepatology 1999 Nov; 30(5):1121-7.

19. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006 Jan; 44(1):217-31.

20. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al. A model to predict survival in patients with end-stage liver disease.

Hepatology 2001 Feb; 33(2):464-70.

21. Child III C, Turcotte J. Surgery and portal hypertension. In: Child III CG, editor. Liver and Portal Hypertension.Philadelphia: Saunders; 1964.

22. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973 Aug; 60(8):646-9.

23. Christensen E, Schlichting P, Fauerholdt L, Gluud C, Andersen PK, Juhl E, et al. Prognostic value of ChildTurcotte criteria in medically treated cirrhosis. Hepatology 1984 May; 4(3):430-5.

24. Conn HO. A peek at the Child-Turcotte classification.

Hepatology 1981 Nov; 1(6):673-6.

25. Oellerich M, Burdelski M, Lautz HU, Binder L, Pichlmayr R. Predictors of one-year pretransplant survival in patients with cirrhosis. Hepatology 1991 Dec; 14(6):1029-34.

26. Lucey MR, Brown KA, Everson GT, Fung JJ, Gish R, Keeffe EB, et al. Minimal criteria for placement of adults on the liver transplant waiting list: a report of a

120

Ã. Δƒπ∞¡ΔO™, ¡. ∫OÀ∫π∞™

national conference organized by the American Society of Transplant Physicians and the American Association for the Study of Liver Diseases. Liver Transpl Surg 1997 Nov; 3(6):628-37.

27. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000 Apr; 31(4):864-71.

28. Wiesner RH, McDiarmid SV, Kamath PS, Edwards EB, Malinchoc M, Kremers WK, et al. MELD and PELD: application of survival models to liver allocation. Liver Transpl 2001 Jul; 7(7):567-80.

29. Freeman RB, Jr., Wiesner RH, Harper A, McDiarmid SV, Lake J, Edwards E, et al. The new liver allocation system: moving toward evidence-based transplantation policy. Liver Transpl 2002 Sep; 8(9):851-8.

30. Freeman RB, Wiesner RH, Edwards E, Harper A, Merion R, Wolfe R. Results of the first year of the new liver allocation plan. Liver Transpl 2004 Jan;10(1):7-15.

31. Londono MC, Guevara M, Rimola A, Navasa M, Taura P, Mas A, et al. Hyponatremia impairs early posttransplantation outcome in patients with cirrhosis undergoing liver transplantation. Gastroenterology 2006 Apr; 130(4):1135-43.

(32) Trotter JF, Brimhall B, Arjal R, Phillips C. Specific laboratory methodologies achieve higher model for endstage liver disease (MELD) scores for patients listed for liver transplantation. Liver Transpl 2004 Aug;10(8):995-1000.

33. Tripodi A, Chantarangkul V, Primignani M, Fabris F, Dell’Era A, Sei C, et al. The international normalized ratio calibrated for cirrhosis (INR(liver)) normalizes

34.

35.

36.

37.

38.

39.

40.

41.

prothrombin time results for model for end-stage liver disease calculation. Hepatology 2007 Aug; 46(2):520-7.

Bellest L, Eschwege V, Poupon R, Chazouilleres O, Robert A. A modified international normalized ratio as an effective way of prothrombin time standardization in hepatology. Hepatology 2007 Aug; 46(2):528-34.

Cholongitas E, Marelli L, Kerry A, Senzolo M, Goodier DW, Nair D, et al. Different methods of creatinine measurement significantly affect MELD scores. Liver Transpl 2007 Apr; 13(4):523-9.

Miller WG, Myers GL, Ashwood ER, Killeen AA, Wang E, Thienpont LM, et al. Creatinine measurement: state of the art in accuracy and interlaboratory harmonization.

Arch Pathol Lab Med 2005 Mar; 129(3):297-304.

Dickson ER, Grambsch PM, Fleming TR, Fisher LD, Langworthy A. Prognosis in primary biliary cirrhosis: model for decision making. Hepatology 1989 Jul; 10(1):1-7.

Murtaugh PA, Dickson ER, Van Dam GM, Malinchoc M, Grambsch PM, Langworthy AL, et al. Primary biliary cirrhosis: prediction of short-term survival based on repeated patient visits. Hepatology 1994 Jul; 20(1 Pt 1):126-34.

Dickson ER, Murtaugh PA, Wiesner RH, Grambsch PM, Fleming TR, Ludwig J, et al. Primary sclerosing cholangitis: refinement and validation of survival models. Gastroenterology 1992 Dec; 103(6):1893-901.

Murray KF, Carithers RL, Jr. AASLD practice guidelines: Evaluation of the patient for liver transplantation.

Hepatology 2005 Jun; 41(6):1407-32.

Shetty K, Rybicki L, Carey WD. The Child-Pugh classification as a prognostic indicator for survival in primary sclerosing cholangitis. Hepatology 1997 May; 25(5):1049-53.

OÍ›· H·ÙÈ΋ AÓÂ¿ÚÎÂÈ· Deutsch Melanie ¶›Ó·Î·˜ 1. ∞Èٛ˜ O∏∞

∂ÈÛ·ÁˆÁ‹

OÍ›· ÈÔÁÂÓ‹˜ Ë·Ù›Ùȉ· HAV, HBV, HDV, HCV, HEV HSV 1-2, HSV-6, πfi˜ ·ÓÂÌ¢ÏÔÁÈ¿˜, ∫˘ÙÙ·ÚÔÌÂÁ·ÏÔÈfi˜, πfi˜ Epstein-Barr ¶·Ú‚ÔÈfi˜ B-19, ∞‰ÂÓÔ-ÈÔ›, πÔ› ·ÈÌÔÚÚ·ÁÈÎÔ‡ ˘ÚÂÙÔ‡, πfi˜ Coxsackie B OÍ›· ‰ËÏËÙËÚ›·ÛË ¶·Ú·ÎÂÙ·ÌfiÏË, OÍ›· Ê·Ú̷΢ÙÈ΋ Ë·Ù›Ùȉ· ª·ÓÈÙ¿ÚÈ· Amanita phalloides, μfiÙ·Ó·, ΔÔÍÈΤ˜ Ô˘Û›Â˜ (ecstasy) ÕÏϘ ·Èٛ˜ ÀÔÍ·ÈÌÈ΋ Ë·ÙÔ΢ÙÙ·ÚÈ΋ Ó¤ÎÚˆÛË (ÈÛ¯·ÈÌ›·, ‚·ÚÈ¿ ˘Ô͢ÁÔÓ·ÈÌ›·) £ÂÚÌÔÏËÍ›· ∞˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ· °ÈÁ·ÓÙÔ΢ÙÙ·ÚÈ΋ Ë·Ù›Ùȉ· ¡fiÛÔ˜ Wilson ªÈÎÚÔÊ˘ÛÛ·Ïȉ҉˘ ÛÙ¿وÛË (Ê¿Ú̷η, Û‡Ó‰ÚÔÌÔ Reye, ÔÍ›· Ï›ˆÛË ÙÔ˘ ‹·ÙÔ˜ ηٿ ÙËÓ Î‡ËÛË) ∞fiÊÚ·ÍË Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ (Û‡Ó‰ÚÔÌÔ Budd- Chiari, ·ÁÁÂÈÔ·ÔÊÚ·ÎÙÈ΋ ÓfiÛÔ˜ ÙÔ˘ ‹·ÙÔ˜) ¡ÂÔÏ·ÛÌ·ÙÈ΋ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜ ∂ÈÏÔΤ˜ Ë·ÙÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ªÂÚÈ΋ Ë·ÙÂÎÙÔÌ‹ ¢ÚÂ·ÓÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ˜ ∞ÈÌԯڈ̿وÛË

∏ ÔÍ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· (O∏∞) Â›Ó·È ¤Ó· Û¿ÓÈÔ Û‡Ó‰ÚÔÌÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÔÍ›·, ÛÔ‚·Ú‹ ¤ÎÙˆÛË fiÏˆÓ ÙˆÓ ˙ˆÙÈÎÒÓ ÏÂÈÙÔ˘ÚÁÈÒÓ ÙÔ˘ ‹·ÙÔ˜. ¶·ÚfiÏË ÙËÓ ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô Ù˘ ˘ÔÛÙËÚÈÎÙÈ΋˜ È·ÙÚÈ΋˜ ÊÚÔÓÙ›‰·˜, ÌfiÓÔ 5-60 % ÙˆÓ ·ÛıÂÓÒÓ ÂÈ‚ÈÒÓÔ˘Ó ¯ˆÚ›˜ Â›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. §fiÁˆ Ù˘ ÌÂÁ¿Ï˘ ÂÙÂÚÔÁ¤ÓÂÈ·˜ ÙˆÓ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛˆÓ, Ô ·ÎÚÈ‚‹˜ ÔÚÈÛÌfi˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ Â›Ó·È ‰‡ÛÎÔÏÔ˜. O fiÚÔ˜ ÎÂÚ·˘ÓÔ‚fiÏÔ˜ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ·Ó·Ê¤ÚÂÙ·È Û ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜ (INR>1.5) Î·È ÛËÌ›· Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÙȘ ÚÒÙ˜ 2-8 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ·fi ÙËÓ ¤Ó·ÚÍË ÔÍ›·˜ Ë·Ù›Ùȉ·˜, ÂÓÒ Ô fiÚÔ˜ ˘Ô- ÎÂÚ·˘ÓÔ‚fiÏÔ˜ (sub-fulminant) Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· (ηı˘ÛÙÂÚË̤Ó˘ ¤Ó·Ú͢ = late onset) ·Ó·Ê¤ÚÂÙ·È Û ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ·ÚfiÌÔÈ· ÛËÌ›· ÌÂÙ¿ ÙȘ ÚÒÙ˜ 8 ‚‰ÔÌ¿‰Â˜ ̤¯ÚÈ Î·È 6 Ì‹Ó˜. ∏ Û˘¯ÓfiÙËÙ· Î·È Ù· ·›ÙÈ· Ù˘ O∏∞ ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ÛÙ· ‰È¿ÊÔÚ· ̤ÚË ÙÔ˘ ÎfiÛÌÔ˘ Î·È Ê·›ÓÂÙ·È Ó· ·ÏÏ¿˙ÂÈ ‰È·¯ÚÔÓÈο Ì ÚÒÙË ·ÈÙ›· ÙËÓ ÈÔÁÂÓ‹ Ë·Ù›Ùȉ· Î·È ÙËÓ Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë ·fi Ê¿Ú̷η. OÈ Û˘ÓËı¤ÛÙÂÚ˜ ·Èٛ˜ Ù˘ O∏∞ Ê·›ÓÔÓÙ·È ÛÙÔ ›Ó·Î· 1.

Ì ¤Ó· ªÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ∫¤ÓÙÚÔ. ∏ ·fiÊ·ÛË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ Ú¤ÂÈ Ó· ·ÚÁ‹ÛÂÈ, ·ÏÏ¿ Ô‡ÙÂ Î·È Ó· ÙÂı› Ôχ ÓˆÚ›˜ ηٷϋÁÔÓÙ·˜ ¤ÙÛÈ Ó· Â›Ó·È Ì›· ·fi ÙȘ ‰˘ÛÎÔÏfiÙÂÚ˜ ·ÔÊ¿ÛÂȘ ÛÙËÓ ∏·ÙÔÏÔÁ›·. ¶ÔÏϤ˜ ÊÔÚ¤˜ ÔÈ ÎÏÈÓÈΤ˜ ÏËÚÔÊÔڛ˜ Â›Ó·È ÂÏÏÈ›˜ Î·È Ë Ù·¯Â›· Âȉ›ӈÛË Ù˘ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÔÚ› Ó· ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ‚‚ȷṲ̂Ó˜ ÎÈÓ‹ÛÂȘ Î·È Ï¿ıÔ˜ ·ÔÊ¿ÛÂȘ ÂΠ̤ÚÔ˘˜ ÙˆÓ ıÂÚ·fiÓÙˆÓ È·ÙÚÒÓ. ∏ ηı˘ÛÙ¤ÚËÛË Ù˘ ·fiÊ·Û˘ ÌÔÚ› Ó· Â›Ó·È ÌÔÈÚ·›· ÁÈ· ÙÔÓ ·ÛıÂÓ‹ fï˜ ·fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ Î·È Ë ÚÒÈÌË ·fiÊ·ÛË ÌÔÚ› Ó· ¤¯ÂÈ ÛËÌ·ÓÙÈο ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù·. OÈ ÂÈÏÔΤ˜ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ Î·È Ù˘ ÌÂÙ·ÁÂÓ¤ÛÙÂÚ˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ÌÔÚÔ‡Ó Ó· ÚÔηϤÛÔ˘Ó ÙÔÓ ı¿Ó·ÙÔ ÙÔ˘ ·ÛıÂÓ‹ Î·È ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÛËÌ·ÓÙÈ΋

∞ÓÙÈÌÂÙÒÈÛË – £ÂÚ·›· ∏ Â›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È Î·Ù¿ ÚÔÙ›ÌËÛË Ë ‰È¿ÛˆÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ‹·ÙÔ˜ Ì ÙË Û˘ÓÙËÚËÙÈ΋ ˘ÔÛÙËÚÈÎÙÈ΋ ·ÁˆÁ‹ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ·ÚÈÔ˘˜ ¿ÍÔÓ˜ Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ·ÛıÂÓÒÓ Ì O∏∞. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ÔÈfiÙËÙ·˜ Ù˘ Û˘ÓÙËÚËÙÈ΋˜ ·ÁˆÁ‹˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Î·È Ë ·ÏÏ·Á‹ Ù˘ ÂȉËÌÈÔÏÔÁ›·˜ Ù˘ O∏∞ ÌÂ Û˘¯ÓfiÙÂÚË ·ÈÙ›· ÛÙÔÓ ‰˘ÙÈÎfi ÎfiÛÌÔ ÙËÓ ·Ú·ÎÂÙ·ÌfiÏË Â›¯·Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÙfiÌ·ÙË ‚ÂÏÙ›ˆÛË Û 40% Û ۯ¤ÛË Ì 15% ·Ï·ÈfiÙÂÚ·. ∏ ıÂÚ·›· Ù˘ O∏∞ ‚·Û›˙ÂÙ·È ÛÙËÓ ÂÓÙ·ÙÈ΋ ÊÚÔÓÙ›‰· ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ÂÍÂȉÈÎÂ˘Ì¤ÓË ÌÔÓ¿‰· (ª∂£) Ô˘ Ú¤ÂÈ Ó· ‚Ú›ÛÎÂÙ·È Û ¿ÌÂÛË Â·Ê‹

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ÔÛÔÛÙfi. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ÌÈ· Ï¿ıÔ˜ ıÂÙÈ΋ ·fiÊ·ÛË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÒÏÂÈ· ÂÓfi˜ ÌÔۯ‡̷ÙÔ˜ Ô˘ ı· ‹Ù·Ó ¯Ú‹ÛÈÌÔ ÛÙËÓ ÂÚ›ÙˆÛË ¿ÏÏÔ˘ ·ÛıÂÓ‹, ¯ˆÚ›˜ Ó· ˘ÔÏÔÁ›˙ÂÙ·È ÙÔ ÎfiÛÙÔ˜ Ù˘ ‰È·‰Èηۛ·˜.

O ·ÎÚÈ‚‹˜ ¯ÚfiÓÔ˜ ·Ú·ÔÌ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ¤Ó· ˙‹ÙËÌ· Ô˘ Û˘Ó‹ıˆ˜ ηıÔÚ›˙ÂÙ·È ·fi Ù· ˘¿Ú¯ÔÓÙ· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·, Ù· ÔÔ›· fï˜ ‰ÂÓ Â›Ó·È ¿ÓÙ· ÍÂοı·Ú· ÏfiÁˆ fiÙÈ ¤¯Ô˘Ó ‚·ÛÈÛÙ› Û ÌÂϤÙ˜ Ì ۯÂÙÈο ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ, ηْ ·Ó¿ÁÎË ·ÊÔ‡ Ë O∏∞ Â›Ó·È Ô˘ÛÈ·ÛÙÈο ÌÈ· Û¿ÓÈ· ÓfiÛÔ˜. ™ÙÔÓ ∂ÏÏËÓÈÎfi ¯ÒÚÔ, ÛÙÔ Úfi‚ÏËÌ· Ù˘ ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÚÔÛÙ›ıÂÙ·È Î·È ÙÔ Úfi‚ÏËÌ· Ù˘ ·ÂÚԉȷÎÔÌȉ‹˜ ÙÔ˘ ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙÔ˜ ·ÛıÂÓÔ‡˜ Ì O∏∞ ·fi ÎÔÈÓfi ı¿Ï·ÌÔ ‹ ÁÂÓÈ΋ ª∂£ Û ªÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ∫¤ÓÙÚÔ Û˘Ó‹ıˆ˜ ÙÔ˘ ∂͈ÙÂÚÈÎÔ‡. ∏ ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ ÁÈ· ÙËÓ ¤Ó‰ÂÈÍË ‰È·ÎÔÌȉ‹˜ Ú¤ÂÈ Ó· Â›Ó·È ÓˆÚ›ÙÂÚ· Î·È ‰È·Ê¤ÚÂÈ Û·ÊÒ˜ ·fi ÙËÓ ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô˘ ηıÔÚ›˙ÂÙ·È ·fi Ù· Û˘ÓËıÈṲ̂ӷ ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·. ∞fi ÙËÓ ÛÙÈÁÌ‹ Ù˘ ‰È¿ÁÓˆÛ˘ Î·È Ì¤¯ÚÈ Ó· ‰È·ÎÔÌÈÛÙ› ‹ Ó· ÌÂÙ·ÌÔÛ¯Â˘Ù› Ô ·ÛıÂÓ‹˜, Ë ÛˆÛÙ‹ Î·È ¤ÁηÈÚË Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜.

¶ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· ÛÙË O∏∞ Î·È ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ OÈ ·ÛıÂÓ›˜ Ì O∏∞ οı ·ÈÙÈÔÏÔÁ›·˜ η٤¯Ô˘Ó ·ÚÈ· ı¤ÛË ÌÂٷ͇ ÙˆÓ ÂӉ›ÍÂˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ΔÔ 11% ÂÚ›Ô˘ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‹·ÙÔ˜ ÛÙËÓ ∂˘ÚÒË Á›ÓÂÙ·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ O∏∞, Ì ÂÈ‚›ˆÛË ÌÂÙ¿ ¤Ó· ¯ÚfiÓÔ Ô˘ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 50-75%. ™ÙȘ ∏¶∞ Ô Ì¤ÛÔ˜ ¯ÚfiÓÔ˜ ·Ó·ÌÔÓ‹˜ ÁÈ· ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È 3.3-5.3 Ë̤Ú˜, 11% ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ·Ú¯Èο Ì ABO ÌË Û˘Ì‚·Ùfi ÌfiÛ¯Â˘Ì·. ¶·ÚÔÏ’ ·˘Ù¿ ‚¿ÛË Ù˘ ÌÂÁ·Ï‡ÙÂÚ˘ ÌÂϤÙ˘ ·fi ÙȘ ∏¶∞ ÌfiÓÔ ÙÔ 29% ÙˆÓ ·ÛıÂÓÒÓ Ì O∏∞ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ÂÓÒ 10% ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ ·‚›ˆÛ·Ó ÂÚÈ̤ÓÔÓÙ·˜ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë O∏∞ ıˆÚÂ›Ù·È ˆ˜ ÚÒÙË ÚÔÙÂÚ·ÈfiÙËÙ· ÁÈ· ˘ÂÚÂ›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ¿ÏϘ ÛÂÈÚ¤˜ ·Ó·Ê¤ÚıËÎ·Ó ı¿Ó·ÙÔÈ Î·Ù¿ ÙËÓ ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì¤¯ÚÈ Î·È 40%. ªÂÙ¿ ·fi ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 63-82% ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ. ∞fi ÙËÓ ‰ÈÎÈ¿ Ì·˜ ÛÂÈÚ¿ 40 ·ÛıÂÓÒÓ Ì O∏∞, ÙÔ 15% ·ÚÔ˘Û›·Û·Ó ·˘ÙfiÌ·ÙË ›·ÛË ÌÂ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹, 45%

ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó Û ∫¤ÓÙÚÔ Ù˘ ∂˘ÚÒ˘ Î·È ÙÔ 17.5% ·‚›ˆÛ·Ó ÂÓ ·Ó·ÌÔÓ‹ ÌÂÙ·ÌfiÛ¯Â˘Û˘. OÈ ˘fiÏÔÈÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ÎÚ›ıËÎ·Ó Î·Ù¿ÏÏËÏÔÈ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏfiÁˆ ËÏÈΛ·˜ Î·È ·Ú¿ÏÏËÏ· ÏfiÁˆ Û˘Ó‡·Ú͢ Î·È ¿ÏÏˆÓ ÓÔÛËÌ¿ÙˆÓ. ∏ Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ‹Ù·Ó ÛÙÔ 57.5%. ∏ ·fiÊ·ÛË ÁÈ· ÙË Ú·ÁÌ·ÙÔÔ›ËÛË ‹ ÌË ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O∏∞ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÚfiÁÓˆÛË Î·È ‚·ÛÈο ·fi ÙËÓ Èı·ÓfiÙËÙ· ·˘ÙfiÌ·Ù˘ ‚ÂÏÙ›ˆÛ˘. ∏ ‚·Ú‡ÙËÙ· Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Î·È Ù˘ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ¤¯Ô˘Ó Û·Ê‹ ÚÔÁÓˆÛÙÈ΋ ·Í›·. ∏ ËÏÈΛ·, ÙÔ BMI >29, Ë ÎÚ·ÙÈÓ›ÓË >2 mg/dL, Ô ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÙÈÌ‹ ¯ÔÏÂÚ˘ıÚ›Ó˘ Î·È ÙÔ pH ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ ·›Ì·ÙÔ˜ ·ÔÙÂÏÔ‡Ó ÛËÌ·ÓÙÈÎfi ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË. ŒÙÛÈ ÁÈ· ·Ú¿‰ÂÈÁÌ· ·˘ÙfiÌ·ÙË ›·ÛË ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÈÔ Û˘¯Ó¿ (65-70 %) ÔÈ ·ÛıÂÓ›˜ Ì ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (ÛÙ¿‰ÈÔ I-II) Û ۯ¤ÛË Ì οو ·fi 20 % ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‚·ıÌfi ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ IV. ∞ÛıÂÓ›˜ ¿Óˆ ÙˆÓ 40 ÂÙÒÓ Î·È Î¿Ùˆ ÙˆÓ 10 ÂÙÒÓ ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚË Èı·ÓfiÙËÙ· ‚ÂÏÙ›ˆÛ˘ Ì ÙËÓ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ Û ۯ¤ÛË Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·ÛıÂÓ›˜. ∂›Û˘ ·ÛıÂÓ›˜ Ì O∏∞ ÏfiÁˆ Ï‹„˘ ·Ú·ÎÂÙ·ÌfiÏ˘, Ë·Ù›Ùȉ·˜ ∞ Î·È μ ¤¯Ô˘Ó ηχÙÂÚË ÚfiÁÓˆÛË Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¿ÁÓˆÛÙË ·ÈÙ›· O∏∞, ¿ÏÏ˘ Ê·Ú̷΢ÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜, ‰ËÏËÙËÚ›·ÛË ·fi Amanita phalloides ‹ ÓfiÛÔ Wilson’s. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÙÈÌ‹ Ù˘ ·-ÊÂÙÔÚˆÙ½Ó˘ (AFP) Ê·›ÓÂÙ·È fiÙÈ ·‡ÍËÛË Ù˘ AFP ÛÙÔ ÙÚÈÏ¿ÛÈÔ ÙȘ ÙÚ›˜ ÚÒÙ˜ Ë̤Ú˜ ‹ ÙÈÌ‹ AFP >3.9 mcg/L ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¤Ó‰ÂÈÍË ÁÈ· ÂÈ‚›ˆÛË ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. °È· ÙËÓ ÛˆÛÙ‹ Î·È ¤ÁηÈÚË ·fiÊ·ÛË ÁÈ· ÙËÓ ·Ú·ÔÌ‹ ·ÛıÂÓÔ‡˜ ÁÈ· Â›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ‚¿ÛË ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ‰ÂÈÎÙÒÓ ¤¯Ô˘Ó ÔÚÈÛÙ› ‰È¿ÊÔÚ· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ·. ∞ÚÎÂÙÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ¤¯Ô˘Ó ıÂÛÈÛı› ÁÈ· Ó· ‚ÔËı‹ÛÔ˘Ó ÛÙËÓ Ï‹„Ë Ù˘ ·fiÊ·Û˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹ fi¯È. OÈ È‰·ÓÈÎÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ı· ¤ÚÂ ӷ ·Ó·ÁÓˆÚ›˙Ô˘Ó ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ı· ¤¯Ô˘Ó ı·Ó·ÙËÊfiÚ· ηٿÏËÍË, ·ÏÏ¿ Ô˘ ¢ڛÛÎÔÓÙ·È ·ÎfiÌ· ÛÙÔ ÛÙ¿‰ÈÔ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ π ‹ ππ (ıÂÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, Positive Predictive Value: PPV) Î·È ·ÚÔÌÔ›ˆ˜ Ó· ÌÔÚÔ‡Ó Ó· ·Ó·ÁÓˆÚ›˙Ô˘Ó ÂΛÓÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÙÂÏÈÎÒ˜ ı· ÂÈ˙‹ÛÔ˘Ó ·Ú¿ ÙËÓ ‡·ÚÍË ÚÔ¯ˆÚË̤Ó˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (ÛÙ¿‰ÈÔ ∏∂ πππ ηÈ

METAMO™XEY™Eπ™ 2010

πV) Ì ˘ÔÛÙËÚÈÎÙÈο ̤ÙÚ· ÌfiÓÔÓ Î·È ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (·ÚÓËÙÈ΋ ÚÔÁÓˆÛÙÈ΋ ·Í›·, ¡egative Predictive Value: NPV). ΔÔ ÚÔÁÓˆÛÙÈÎfi ÌÔÓÙ¤ÏÔ ·fi ÙÔ King’s College Hospital ÙÔ˘ §ÔÓ‰›ÓÔ˘ Â›Ó·È ÙÔ ÂÚÈÛÛfiÙÂÚÔ ‰ËÌÔÊÈϤ˜. ∞Ó·Ù‡¯ÙËΠÌÂÙ¿ ·fi ÙËÓ ÌÂϤÙË ÌÈ·˜ ÛÂÈÚ¿˜ ·fi 588 ·ÛıÂÓ›˜ Ì O∏∞ ÌÂٷ͇ 1973 Î·È 1985 Ô˘ ‰ÂÓ Â›¯·Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. Δ· ÎÚÈÙ‹ÚÈ· King’s College Â›Ó·È ‰È·ÊÔÚÂÙÈο ÛÙËÓ O∏∞ ·fi ·Ú·ÎÂÙ·ÌfiÏË Î·È ÌË ·Ú·ÎÂÙ·ÌfiÏË. ™ÙËÓ ÌË-·Ú·ÎÂÙ·ÌfiÏË O∏∞ Ù· ÎÚÈÙ‹ÚÈ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·ÔÙÂÏÔ‡Ó Ô ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ >100 ‰Â˘ÙÂÚfiÏÂÙ· ‹ ÙÚ›· ·fi Ù· ·Ú·Î¿Ùˆ ¤ÓÙ ÎÚÈÙ‹ÚÈ· 1) Ê·Ú̷΢ÙÈ΋ Ë·Ù›Ùȉ· ‹ Ë·Ù›Ùȉ· ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜ 2) ËÏÈΛ· <10 ‹ >40 ÂÙÒÓ, 3) ¤Ó·ÚÍË ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ <7 Ë̤Ú˜, 4) ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ >50 ‰Â˘ÙÂÚfiÏÂÙ· (INR >3.5) Î·È 5) ¯ÔÏÂÚ˘ıÚ›ÓË >17,5 mg/dl. °È· ÙËÓ ÂÚ›ÙˆÛË O∏∞ ·fi ·Ú·ÎÂÙ·ÌfiÏË ˘¿Ú¯Ô˘Ó ‰È·ÊÔÚÂÙÈο ÎÚÈÙ‹ÚÈ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: pH<7,3 ‹ Ù·˘Ùfi¯ÚÔÓ· ¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘ >100 ‰Â˘ÙÂÚfiÏÂÙ·, ÎÚ·ÙÈÓ›ÓË >3,4 mg/dl Î·È Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÛÙ·‰›Ô˘ 4. ªÈ· ÛÂÈÚ¿ ·fi ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë PPV ÙˆÓ ÎÚÈÙËÚ›ˆÓ King’s College Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 70-100% ·ÏÏ¿ Ë NPV Â›Ó·È Û¯ÂÙÈο ¯·ÌËÏfiÙÂÚË (24-94%). Δ· ÎÚÈÙ‹ÚÈ· Clichy ‚·Û›˙ÔÓÙ·È ÛÙ· Â›‰· ÙÔ˘ ·Ú¿ÁÔÓÙ· ‹Í˘ V. OÚ›ÛÙËÎ·Ó ‚·ÛÈ˙fiÌÂÓ· Û 115 ·ÛıÂÓ›˜ Ì O∏∞ ·fi ÙÔÓ Èfi HBV ÛÙË ÂÚ›Ô‰Ô 1972-1981 Ô˘ ‰ÂÓ Â›¯·Ó ÌÂÙ·ÌÔÛ¯Â˘Ù›. μ¿ÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ·˘ÙÒÓ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂӉ›ÎÓ˘Ù·È fiÙ·Ó Ô ·ÛıÂÓ‹˜ Â›Ó·È Û ϋı·ÚÁÔ ‹ ÎÒÌ· Ì Â›Â‰Ô ·Ú¿ÁÔÓÙ· V<20% ÁÈ· ·ÛıÂÓ›˜ ËÏÈΛ·˜ <20 ÂÙÒÓ Î·È <30% ÁÈ· ·ÛıÂÓ›˜ ËÏÈΛ·˜ >30 ÂÙÒÓ. Δ· ÎÚÈÙ‹ÚÈ· Clichy Ê·›ÓÂÙ·È Ó· ÚԂϤÔ˘Ó ÙÔÓ ı¿Ó·ÙÔ ·ÛıÂÓÔ‡˜ Ì ÈÔÁÂÓ›˜ ·ÈÙÈÔÏÔÁ›·˜ O∏∞ Ì PPV 82% Î·È NPV 98%, ·ÏÏ¿ ‰ÂÓ ¤¯Ô˘Ó ηχÙÂÚË ÚÔÁÓˆÛÙÈ΋ ·Í›· ·fi Ù· ÎÚÈÙ‹ÚÈ· Kings College Û ÌË ÈÔÁÂÓ›˜ ·ÈÙÈÔÏÔÁ›·˜ O∏∞. ªÈ· ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË Û‡ÁÎÚÈÓ ٷ ‰È¿ÊÔÚ· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Û ·ÛıÂÓ›˜ Ì O∏∞ ·fi ·Ú·ÎÂÙ·ÌfiÏË Û˘ÌÂÚÈÏ·Ì‚·ÓfiÌÂÓ· Ù· King’s College ÎÚÈÙ‹ÚÈ·, Û˘Ó‰˘·ÛÌÔ‡˜ ÎÚ·ÙÈÓ›Ó˘ Î·È ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘, ÙËÓ Ì›ˆÛË ÙÔ˘ ·Ú¿ÁÔÓÙ· V, ÙÔ APACHE ππ (Acute physiology and Chronic health evaluation) ÛÎÔÚ Î·È ÙËÓ Gc-ÛÊ·ÈÚ›ÓË (ÚˆÙ½ÓË Ô˘ ÚÔÛ‰¤ÓÂÈ ÙËÓ ‚ÈÙ·Ì›ÓË ¢). μÚ¤ıËΠfiÙÈ Ù· King’s College ÎÚÈÙ‹ÚÈ· Ì·˙› Ì pH<7.30 ‹Ù·Ó Ù· ÈÔ ÈÛ¯˘Ú¿ ÎÚÈÙ‹ÚÈ· ÁÈ· ÙËÓ Úfi-

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‚ÏÂ„Ë Î·Î‹˜ ÚfiÁÓˆÛ˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜. ¶ÚfiÛÊ·Ù· ¤¯ÂÈ ÚÔÙ·ı› Ë ¯Ú‹ÛË ÙÔ˘ ÚÔÁÓˆÛÙÈÎÔ‡ ÛÎÔÚ MELD Î·È ÛÙË ÂÚ›ÙˆÛË Ù˘ O∏∞ Ì ÙÈ̤˜ ‰Â›ÎÙË MELD >32 ˘Ô‰ËÏÒÓÔÓÙ·˜ Ôχ η΋ ÚfiÁÓˆÛË ·ÏÏ¿ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Ó· ˘ÔÛÙËÚ›ÍÔ˘Ó ÙÔ ÚfiÏÔ ÙÔ˘ ‰Â›ÎÙË ·˘ÙÔ‡ ÛÙË O∏∞. ¢˘Ô ÛËÌ·ÓÙÈΤ˜ ÂÍÂÏ›ÍÂȘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÚfiÛÊ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÚfiÁÓˆÛË ·ÛıÂÓÒÓ Ì O∏∞ ·fi ·Ú·ÎÂÙ·ÌfiÏË. Δ· Â›‰· Á·Ï·ÎÙÈÎÔ‡ Ôͤˆ˜ Ô˘ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ÙËÓ ‚·Ú‡ÙËÙ· Ù˘ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È Ù˘ Ë·ÙÈ΋˜ ‚Ï¿‚˘ ÚÔÛÙ¤ıËÎ·Ó ÛÙ· ÎÚÈÙ‹ÚÈ· King’s College Ì ·ÔÙ¤ÏÂÛÌ· ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ¢·ÈÛıËÛ›·˜ ÙÔ˘ ‰Â›ÎÙË. ∞Ó¿ÏÔÁ· Ë ˘ÂÚʈÛÊ·Ù·ÈÌ›· Ê·›ÓÂÙ·È Ó· ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ˆ˜ ·ÚÓËÙÈÎfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ‰Â›ÎÙ˘ ÛÙË O∏∞ ·fi ·Ú·ÎÂÙ·ÌfiÏË, ˘ÔÁÚ·ÌÌ›˙ÔÓÙ·˜ ÙËÓ ÛËÌ·Û›· Ù˘ ·Ú¿ÏÏËÏ˘ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘. ∏ ÚÔÛı‹ÎË Ù˘ ÙÈÌ‹˜ ÙÔ˘ ʈÛÊfiÚÔ˘ ÛÙ· ÎÚÈÙ‹ÚÈ· King’s College Â›Û˘ ·‡ÍËÛ ÙËÓ Â˘·ÈÛıËÛ›· ÙÔ˘˜. ∞ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙË O∏∞ ·ÔÙÂÏÔ‡Ó Ë Â͈Ë·ÙÈ΋ ηÎÔ‹ıÂÈ·, Ë ÌË ÂÏÂÁ¯fiÌÂÓË Û‹„Ë Î·È Ë ÌË ·Ó·ÛÙÚ¤„ÈÌË ÂÁÎÂÊ·ÏÈ΋ ‚Ï¿‚Ë Ì ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË ÛÙ·ıÂÚ¿ >50 mmHg. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë O∏∞ ·ÔÙÂÏ› ÌÈ· ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ·Ú·ÔÌ‹˜ ·ÛıÂÓÔ‡˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ÔÈ ·ÛıÂÓ›˜ ¤¯ÔÓÙ·˜ ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙȘ Ï›ÛÙ˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∏ ·fiÊ·ÛË ÁÈ· ÙËÓ ·Ú·ÔÌ‹ ‚·Û›˙ÂÙ·È ÛÙ· ‰È¿ÊÔÚ· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ì ÚˆÙ‡ÔÓÙ· Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ King’s College. ™ËÌ·ÓÙÈÎfi˜ ÛÙfi¯Ô˜ Â›Ó·È Ë Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÛÎÔfi ÙËÓ ·˘ÙfiÌ·ÙË ‚ÂÏÙ›ˆÛË ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Trey C, Davidson CS. The management of fulminant hepatic failure. In: Popper H, Schaffner S, eds. Progress in liver diseases. Vol III. New York. Grune and Stratton 1970; 282-98.

2. Bernuau J, Rueff B, Benhamou JP. Fulminant and subfulminant liver failure: Definition and causes.

Semin Liver Dis 1986; 6:97-106.

3. O’Grady G, Schalm SW, Williams R. Acute liver failure: Redefining the syndromes. Lancet 1993; 342:373-375.

4. Hoofnagle JH, Carithers RL Jr. Shapiro C, Ascher N. Fulminant hepatic failure: summary of a workshop.

Hepatology 1995; 21:240-252.

5. Williams R. Classification and clinical syndromes of acute liver failure. In: Lee WM, Williams R, eds. Acute

124

DEUTSCH MELANIE

6. Gill RQ, Sterling RK. Acute liver failure. J Clin Gastroenterol 2001; 33:191-198.

25. Kao JH, Hsu HM, Shau WY, Chang MH, Chen DS. Universal hepatitis B vaccination and the decreased mortality from fulminant hepatic failure in infants in Taiwan. J Pediatr 2001; 139:349-352.

7. Main AJ, Williams R. Acetaminophen-induced acute liver failure. In: Lee WM, Williams R, eds. Acute liver failure.

Cambridge, Cambridge University Press 1997; 32-42.

26. Schiodt FV, Davern TJ, Shakil AO, McGuire B, Samuel G, Lee WM. Viral hepatitis –related acute liver failure.

Am J Gastroenterol 2003; 98:448-453.

8. Lee WM. Drug-induced hepatotoxicity. N Eng J Med 1995; 333:1.118-1.127.

27. Papaevangelou G, Tassopoulos N, RoumeliotouKarayannis A, Richardson C. Etiology of fulminant viral hepatitis in Greece. Hepatology 1984; 4:369-372.

liver failure. Cambridge, Cambridge University Press 1997; 1-9.

9. Larsen S Biel AT. Pathophysiology of cerebral edema in fulminant hepatic failure. J Hepatol 1999; 31:771-776.

10. Lee WM. Acute liver failure. ¡ Eng J Med 1993; 329:1.862-1.872.

11. Pereira SP, Langley PG, Williams R. The management of abnormalities of hemostasis in acute liver failure.

Semin Liver Dis 1996; 16:403-412.

12. Rolando N, Philpott-Howard J, Williams R. Bacterial and fungal infection in acute liver failure. Sem Liv Dis 1996; 16:389-402.

13. O’Grady JG, Portmann B, Williams R. Fulminant hepatic failure. In: Schiff L, Schiff R, eds. Diseases of the liver. JB Lippincott, Philadelphia 1993: 1.077-1.090.

14. Ellis A, Wendon J. Circulatory, respiratory, cerebral and renal derangements in acute liver failure.

15. Riordan SM, Williams R. Fulminant hepatic failure.

Clinics Liver Dis 2000; 4:25-45.

16. Caraceni P, van Thiel DH. Acute liver failure. Lancet 1995; 345:163-169.

17. Ferenci P, Herneth A, Steindl P. Newer approaches to treatment of hepatic encephalopathy. Semin Liv Dis 1996; 16:329-338.

18. Munoz SJ. Difficult management problems in fulminant hepatic failure. Semin Liv Dis 1993; 13:395-413.

19. Carithers RL. Liver transplantation. AASLD practice quidelines. Liver Transplantation 2000; 6:122-135.

20. O’Grady JG, Alexander GJM, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology 1989; 97:439-445.

28. Carman WF, Fagan EA, Hadziyannis S, et al. Association of a precore genomic variant of hepatitis B virus with fulminant hepatitis. Hepatology 1991; 14:219-222.

29. Farci P, Alter HJ, Shimoda A, Govindarajan S, et al.

Hepatitis C virus associated fulminant hepatic failure N Engl J Med 1996; 335:631-634.

30. Yanagi M, Kaneko S, Unoura M, et al. Hepatitis C virus in fulminant hepatic failure. N Engl J Med 1991; 324:1895-6.

31. Papatheodoridis GV, Delladetsima JK, Kavallierou L, Kapranos N, Tassopoulos NC. Fulminant hepatitis due to Epstein-Barr virus infection. J Hepatol 1995; 23:348-50.

32. Larson AM, Ostapowitcz G, Fontana RJ, et al. Outcome of acetaminophen induced acute liver failure in the USA in suicidal vs accidental overdose: preliminary study of a prospective multicenter trial. Hepatology 2000; 32:A396.

33. Jackson N, Ellis A, Rhodes A, et al. Non-paracetamol drug induced acute liver failure in a specialist liver intensive care unit: a seven year experience. Hepatology 1998; 28:496.

34. Kaplowitz N. Mechanisms of liver cell injury. J Hepatol 2000; 32(Suppl 1): 39-47.

35. Riordan SM, Williams R. Mechanisms of hepatocyte injury, multiorgan failure, and prognostic criteria in Acute Liver failure. Semin Liver Dis. 2003; 23:203-215.

36. Leitfeld L, Cheng S, Ramakers J, et al. Imbalanced intrahepatic expression of interleukin 12, interferon gamma, and interleukin 10 in fulminant hepatitis B. Hepatology 2002; 36:1001-1008.

21. Acharya SK, Dasarathy S, Kumer TL, Sushma S, Prassanna KS, Tandon A, et al. Fulminant hepatitis in a tropical population: clinical course, cause, and early predictors of outcome. Hepatology 1996; 23:1.448-1.455.

37. Alexopoulou A, Koskinas J, Deutsch M, Delladetsima J, Kountouras D, Dourakis SP. Acute liver failure as the initial manifestation of hepatic infiltration by a solid tumor: report of 5 cases and review of the literature.

Tumori 2006; 92:354-357.

22. Ostapowicz G, Fontana RJ, Schiodt FV, Larson A, Davern TJ, Han SHB, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Int Med 2002; 137:947-954.

38. Deutsch M, Koskinas J, Kountouras D, Archimandritis AJ. Amanita phalloides poisoning: Reassessment of prognostic factors and indications for emergency liver transplantation.J Hepatol. 2007 Aug 21; 728-729.

23. Shakil AO, Kramer D, Mazariegos GV et al. Acute liver failure: clinical features, outcome analysis, and applicability of prognostic criteria. Liver Transplantation 2000; 6:163-169.

39. Koskinas J, Deutsch M, Kountouras D, Kostopanagiotou G, Arkadopoulos N, Smyrniotis V, Rapti I, Manesis E, Archimandritis A. Aetiology and outcome of acute hepatic failure in Greece: experience of two academic hospital centres. Liver Int. 2008 Jul; 28(6):821-827.

24. Schiodt FV, Atillasoy E, Shakil O, Schiff ER, Caldwell C, Kowdley KV, Stribling R, et al. Etiology and outcome for 295 patients with acute liver failure in the United States. Liver Transpl Surg 1999; 5:29-34.

40. Perkins JD. Another formula to determine the prognosis of patients with acute liver failure. Liver Transpl. 2009 Aug; 15(8):986-91.

METAMO™XEY™Eπ™ 2010

41. Leithead JA, Ferguson JW, Bates CM, Davidson JS, Lee A, Bathgate AJ, Hayes PC, Simpson KJ. The systemic inflammatory response syndrome is predictive of renal dysfunction in patients with non-paracetamol-induced acute liver failure. Gut. 2009 Mar; 58(3):443-9. Epub 2008 Nov 10.

42. Rajekar H, Wai CT, Majeed TA, Lee KH, Wong SY, Leong SO, Singh R, Tay KH, Soosaynathan C, Tan KC. Prognostic factors in patients with acute liver failure undergoing live donor liver transplantation. Transplant Proc. 2008 Oct; 40(8):2492-3.

43. Hadem J, Stiefel P, Bahr MJ, Tillmann HL, Rifai K, Klempnauer J, Wedemeyer H, Manns MP, Schneider AS. Prognostic implications of lactate, bilirubin, and etiology in German patients with acute liver failure. Clin Gastroenterol Hepatol. 2008 Mar; 6(3):339-45.

44. Miyake Y, Iwasaki Y, Terada R, Takaguchi K, Sakaguchi K, Shiratori Y. Systemic inflammatory response

125

syndrome strongly affects the prognosis of patients with fulminant hepatitis B. J Gastroenterol. 2007 Jun; 42(6):485-92. Epub 2007 Jun 29.

45. Miyake Y, Iwasaki Y, Makino Y, Kobashi H, Takaguchi K, Ando M, Sakaguchi K, Shiratori Y. Prognostic factors for fatal outcomes prior to receiving liver transplantation in patients with non-acetaminophen-related fulminant hepatic failure. Gastroenterol Hepatol. 2007 Jun; 22(6):855-61.

46. Katoonizadeh A, Decaestecker J, Wilmer A, Aerts R, Verslype C, Vansteenbergen W, Yap P, Fevery J, Roskams T, Pirenne J, Nevens F. MELD score to predict outcome in adult patients with non-acetaminophen-induced acute liver failure. Liver Int. 2007 Apr; 27(3):329-34.

47. Bailey B, Amre DK, Gaudreault P. Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation.

Crit Care Med. 2003 Jan; 31(1):299-305.

H·ÙÔ΢ÙÙ·ÚÈÎfi˜ ηÚΛÓÔ˜ ¢.¡. ™·ÌˆÓ¿Î˘ ¶›Ó·Î·˜: ∫Ï·ÛÈΤ˜ ‰ËÌÔÛȇÛÂȘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÁÈ· ∏∫∫ – ·ÔÙÂϤÛÌ·Ù· Û ۯ¤ÛË Ì ٷ ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜

πÛÙÔÚ›· & ¶Ú·ÁÌ·ÙÈÎfiÙËÙ· ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ [ª∏] ·ÔÙÂÏ› ÙËÓ Î·Ï‡ÙÂÚË ‰˘ÓËÙÈο ıÂÚ·¢ÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ·ÛıÂÓ›˜ Ì Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛӈ̷ [∏∫∫] Î·È ÚÔ¯ˆÚË̤ÓË Î›ÚÚˆÛË ÙÔ˘ ‹·ÙÔ˜, ηıÒ˜ ·ÔÌ·ÎÚ‡ÓÂÈ ÙÔÓ fiÁÎÔ Ù·˘Ùfi¯ÚÔÓ· Ì ÙËÓ ˘ÔΛÌÂÓË ÚÔηÚÎÈÓÈ΋ «Î·Ù¿ÛÙ·ÛË» Ô˘ Â›Ó·È Ë Î›ÚÚˆÛË. ΔÔ ıÂÌÂÏÈ҉˜ fï˜ ˙‹ÙËÌ· Â›Ó·È ÔÈÔÈ ·ÛıÂÓ›˜ Ì ∏∫∫ ı· ˆÊÂÏËıÔ‡Ó ·fi ª∏ ηıÒ˜ Î·È ÔÈÔ Â›Ó·È ÙÔ Î·Ù¿ÏÏËÏÔ ¯ÚÔÓÈÎfi ÛËÌÂ›Ô Ó· ÚÔÙ·ı› Ë ıÂÚ·›· ·˘Ù‹. ΔÔ ·Ú¯ÈÎfi ‰È¿ÛÙËÌ· ηıȤڈÛ˘ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ˆ˜ ıÂÚ·¢ÙÈ΋˜ È· ÂÈÏÔÁ‹˜ (Î·È fi¯È ˆ˜ ÂÈÚ·Ì·ÙÈ΋˜ ÌÂıfi‰Ô˘), Ù· ·ÔÙÂϤÛÌ·Ù· ÁÈ· ÙÔÓ ∏∫∫ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·Ó ·fi ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ˘ÔÙÚÔ‹˜ Î·È ·ÔÁÔËÙ¢ÙÈ΋ ÂÈ‚›ˆÛË, ηıÒ˜ Ë ª∏ ÚÔÛʤÚÔÓÙ·Ó Û ·ÛıÂÓ›˜ Ì ÚÔ¯ˆÚË̤ÓÔ ÌË ¯ÂÈÚÔ˘ÚÁ‹ÛÈÌÔ ∏∫∫. ∞Ó·ÁÓˆÚ›ÛÙËΠfiÙÈ Ë ˘ÔÙÚÔ‹ Î·È Ô ı¿Ó·ÙÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ∏∫∫ ‹Ù·Ó Ô Î·ÓfiÓ·˜ fiÙ·Ó ˘‹Ú¯Â Ì·ÎÚÔÛÎÔÈ΋ ·ÁÁÂȷ΋ ‰È‹ıËÛË Î·È Â͈Ë·ÙÈ΋ Â¤ÎÙ·ÛË (ÏÂÌÊ·‰¤Ó˜, ÌÂÙ·ÛÙ¿ÛÂȘ). ∂ÈÚfiÛıÂÙ· ‰È·ÈÛÙÒıËΠfiÙÈ ·ÛıÂÓ›˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·Ó ÁÈ· ΛÚÚˆÛË ‹·ÙÔ˜ Î·È ÛÙÔ˘˜ ÔÔ›Ô˘˜ ·Ó¢ڛÛÎÔÓÙ·Ó ÌÈÎÚ¿ ∏∫∫ (incidental) ›¯·Ó fiÌÔÈ· ÂÈ‚›ˆÛË Ì ÎÈÚÚˆÙÈÎÔ‡˜ ¯ˆÚ›˜ ∏∫∫ Î·È ‰ÂÓ ˘‹Ú¯Â ˘ÔÙÚÔ‹.

™˘ÁÁڷʤ·˜

Mazzaferro

∞ÚÈıÌfi˜ ∫ÚÈÙ‹ÚÈ· ·ÛıÂÓÒÓ ÂÈÏÔÁ‹˜ 48

N Engl J Med 1996

Bismuth

ÀÔÙÚÔ‹

5ÂÙ‹˜ ÂÈ‚›ˆÛË

8%

74% [4yr]

11%

74%

1 fi˙Ô˜ <5cm ‹ 3<3cm

45

Semin Liver Dis

1 fi˙Ô˜ <3cm ‹ 3<3cm

1999

Llovet

79

1 fi˙Ô˜ < 5cm

4%

75%

120

1 fi˙Ô˜ <5cm

16%

71%

11%

73%

Hepatology 1999

Jonas Hepatology 2001

Yao Hepatology 2001

‹ 3 fi˙ÔÈ <3cm 64

1 fi˙Ô˜ <6.5cm, 3 fi˙ÔÈ <4.5cm

ŒÎÙÔÙ ·ÎÔÏÔ‡ıËÛ Ôχ Û˘˙‹ÙËÛË ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ¿Óˆ ÛÙËÓ Â¤ÎÙ·ÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ηıÒ˜ fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔÈ ·ÛıÂÓ›˜ Ì ∏∫∫ ·Ú·¤ÌÔÓÙ·Ó ÁÈ· ª∏. ∂ÈÚfiÛıÂÙ·, Û ÔÏÏ¿ ÚÔÁÚ¿ÌÌ·Ù· ÂÓÒ Ô ·ÛıÂÓ‹˜ ÏËÚÔ‡Û ٷ ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ ÛÙËÓ ¤ÓÙ·ÍË, ηٿ ÙËÓ ·Ó·ÌÔÓ‹ Û˘¯Ó¿ Ù· ˘ÂÚ¤‚·ÈÓ ηıÈÛÙÒÓÙ·˜ ·Ó·Áη›· ÙËÓ ·Ó‡ÚÂÛË ıÂÚ·¢ÙÈÎÒÓ ÂÈÏÔÁÒÓ ÒÛÙ ӷ ÎÚ·ÙËı› Ô ·ÛıÂÓ‹˜ ÂÓÙfi˜ ·˘ÙÒÓ ·ÏÏ¿ Î·È ÙËÓ Èı·ÓfiÙËÙ· Â¤ÎÙ·Û˘ ·fi Ù· ·˘ÛÙËÚ¿ ıÂÛÈṲ̂ӷ fiÚÈ·. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ ·ÎfiÌË Î·È ·ÛıÂÓ›˜ Ì fiÁÎÔ˘˜ ÂÓÙfi˜ ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ ªÈÏ¿ÓÔ˘ 8-15% ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ª∏. ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ÈÔ ÂÎÙÂٷ̤ӷ ÎÚÈÙ‹ÚÈ· –‚·ÛÈṲ̂ӷ Û ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ fiÁÎÔ˘ ÛÙÔ ·Ê·ÈÚÂı¤Ó ‹·Ú– Ë ÔÌ¿‰· ÙÔ˘ ™·Ó ºÚ·ÓÛ›ÛÎÔ ˘fi ÙÔÓ Yao Î·È Û˘ÓÂÚÁ¿Ù˜ ·Ó·ÎÔ›ÓˆÛ ÂÈ‚›ˆÛË 1 ¤ÙÔ˘˜ 90% Î·È 5ÂÙ‹ 75.2% ÂÈϤÁÔÓÙ·˜ ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ›Ù 1 fiÁÎÔ ÌÈÎÚfiÙÂÚÔ ÙˆÓ 6.5 cm ›Ù ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi 3 –Ô ÌÂÁ·Ï‡ÙÂÚÔ˜ 4.5 cm– ÌÂ Û˘ÓÔÏÈ΋ ‰È¿ÌÂÙÚÔ fiÏˆÓ ÙˆÓ fi˙ˆÓ ÏÈÁfiÙÂÚÔ ·fi 8cm (Yao, Hepatology 2001). Δ· ÎÚÈÙ‹ÚÈ· ·˘Ù¿ ÂȂ‚·ÈÒıËÎ·Ó ÚfiÛÊ·Ù· Û ¯ˆÚÈÛÙ‹ ÔÌ¿‰· ÛÙÔ ·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ ™·Ó ºÚ·ÓÛ›ÛÎÔ ‚¿ÛÂÈ ·ÂÈÎÔÓÈÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ·˘Ù‹ ÙË ÊÔÚ¿ (Yao,

Δ· ÎÚÈÙ‹ÚÈ· ∏ Â·Ó¿ÛÙ·ÛË ÛÙË ª∏ Ì ¤Ó‰ÂÈÍË ∏∫∫ ‹Úı ÙË ‰ÂηÂÙ›· ÙÔ˘ ’90 Ì ÙȘ ÚˆÙÔfiÚ˜ ÂÚÁ·Û›Â˜ ÙˆÓ Bismuth (Ann Surg, 1993) & Mazzaferro (N Engl J Med 1996) ı¤ÙÔÓÙ·˜ ÂÚÈÔÚÈÛÙÈο ÎÚÈÙ‹ÚÈ· (›Ó·Î·˜) ÛÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ, Ì Â·ÎfiÏÔ˘ıÔ ·ÓÙ›ÎÙ˘Ô ÛÙËÓ ˘ÔÙÚÔ‹ ÙÔ˘ fiÁÎÔ˘ Î·È ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ. ™Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ Ô˘ ¤¯Ô˘Ó Â·ÏËı¢ı› ·fi ÔÏϤ˜ ÔÌ¿‰Â˜ Î·È ¤¯Ô˘Ó ηıÈÂÚˆı›, Ë ÂÈÏÔÁ‹ ÂÓfi˜ ÓÂÔÏ·ÛÌ·ÙÈÎÔ‡ fi˙Ô˘ ÌÂÁ›ÛÙ˘ ‰È·Ì¤ÙÚÔ˘ 5cm ‹ ÙÚÈÒÓ fi˙ˆÓ ‰È·Ì¤ÙÚÔ˘ <3cm ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÂÈ‚›ˆÛË ∼75% ÛÙ· 4 ¯ÚfiÓÈ· Ì ˘ÔÙÚÔ‹ <10%.

126

METAMO™XEY™Eπ™ 2010

Am J Transplant 2007). ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ ÙÈ̤˜ ·FP>1000 ng/ml ‚Ú¤ıËÎ·Ó ÈÛ¯˘Úfi˜ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ˘ÔÙÚÔ‹ ÌÂÙ¿ ÙË ª∏.

∏ ·Ú·ÔÌ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ∏∫∫ ÁÈ· ªÂÙ·ÌfiÛ¯Â˘ÛË ◊·ÙÔ˜ ™‡Ìʈӷ Ì ÙÔ AASLD (Practice guideline Hepatology 2005) Ë ª∏ Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È ıÂÚ·›· ÂÎÏÔÁ‹˜ Û ÂÈÏÂÁ̤ÓÔ˘˜ ·ÛıÂÓ›˜ Ì ∏∫∫ Ô˘ ‰ÂÓ Â›Ó·È ˘Ô„‹ÊÈÔÈ ÁÈ· Ë·ÙÂÎÙÔÌ‹ Î·È ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë Î·ÎÔ‹ıÂÈ· ÂÓÙÔ›˙ÂÙ·È ÛÙÔ ‹·Ú. °È· ȉÂÒ‰Ë ·ÔÙÂϤÛÌ·Ù· ÔÈ ·ÛıÂÓ›˜ Ô˘ ÏËÚÔ‡Ó Ù· ηıÈÂڈ̤ӷ ÎÚÈÙ‹ÚÈ· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔ˘Ó ÙÔ ÌfiÛ¯Â˘Ì· ÂÓÙfi˜ 6 ÌËÓÒÓ. ∏ ·Ú·ÔÌ‹ ÂÓfi˜ ÎÈÚÚˆÙÈÎÔ‡ ·ÛıÂÓÔ‡˜ Ì ∏∫∫ ÁÈ· Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÎÏÈÓÈΤ˜ Ù·ÍÈÓÔÌ‹ÛÂȘ, Û˘¯ÓfiÙÂÚ· ηٿ ChildPugh B/ C Î·È Î·Ù¿ BCLC-0 Ì ˘Ï·›· ˘¤ÚÙ·ÛË ‹ BCLC-A, ·Ô˘Û›· ÛÔ‚·ÚÒÓ Û˘Ó˘·Ú¯fiÓÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ (Llovet, J Natl Cancer Inst 2008). ΔÔ UNOS (United Network for Organ Sharing) [http://www.optn.org/PoliciesandBylaws2/ policies/pdfs/policy_8pdf] ··ÈÙ› Û˘ÁÎÂÎÚÈ̤ӷ ÛÙÔȯ›·: ÂÎÙ›ÌËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ & ·ÚÈıÌÔ‡ ÙˆÓ fiÁÎˆÓ Î·ıÒ˜ Î·È ÙËÓ Â͈Ë·ÙÈ΋ Â¤ÎÙ·ÛË Ì CT ‹ MRI. ¢ÂÓ ÚÔ¸ÔÙ›ıÂÙ·È ‚ÈÔ„›· ‹·ÙÔ˜ ·ÏÏ¿ ÔÈ ·ÛıÂÓ›˜ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ›Ù ıÂÙÈ΋ ÈÛÙÔÏÔÁÈ΋, ‹ ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÚfiÛÏË„Ë ÛÙËÓ ·ÚÙËÚȷ΋ Ê¿ÛË Û ‰˘Ó·ÌÈ΋ ·ÂÈÎfiÓÈÛË, ·FP>200 ng/ml, ·ÚÙËÚÈÔÁÚ·Ê›· ÂȂ‚·ÈÒÓÔÓÙ·˜ fiÁÎÔ, ÈÛÙÔÚÈÎfi ‰È·‰ÂÚÌÈ΋˜ Â¤Ì‚·Û˘ (TACE, RFA, PEI), ÈÛÙÔÚÈÎfi ΛÚÚˆÛ˘ Î·È ·˘Í·ÓfiÌÂÓË ·FP>500 ng/ml ·Ú¿ ÙËÓ ·Ô˘Û›· ‰È·ÎÚÈÙÔ‡ fiÁÎÔ˘ ÛÙËÓ ·ÂÈÎfiÓÈÛË, Ó· ÌËÓ Â›Ó·È ˘Ô„‹ÊÈÔ˜ ÁÈ· ÂÎÙÔÌ‹ Î·È Ó· ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÛÙÂÓ¿ Ì ‰˘Ó·ÌÈΤ˜ ·ÂÈÎÔÓ›ÛÂȘ.

∏ ¤ÏÏÂÈ„Ë ‰ÔÙÒÓ Î·È ÙÔ ÌÂÙ¤ˆÚÔ ‚‹Ì· ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ∏ Â¤ÎÙ·ÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ Â›Ó·È Ë ÌÈ· fi„Ë ÙÔ˘ ÓÔÌ›ÛÌ·ÙÔ˜ ηıÒ˜ Ë ¿ÏÏË ·ÊÔÚ¿ ÛÙËÓ ¤ÏÏÂÈ„Ë Â·ÚÎÔ‡˜ ·ÚÈıÌÔ‡ ‰ÔÙÒÓ. ΔÔ‡ÙÔ ÍÂοı·Ú· ‰ÈηÈÔÏÔÁ› ÙË ı¤ÛÈÛË ÂÚÈÔÚÈÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ ÒÛÙ ӷ ÂÈϤÁÔÓÙ·È ÔÈ Î·Ù·ÏÏËÏfiÙÂÚÔÈ ˘Ô„‹ÊÈÔÈ Ô˘ ı· ÂÙ‡¯Ô˘Ó Ù· ηχÙÂÚ· Ì·ÎÚÔÚfiıÂÛÌ· ·ÔÙÂϤÛÌ·Ù·. ∫·Ù¿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ Ô fiÁÎÔ˜ ÌÔÚ› Ó· ÂÂÎÙ·ı›, ¤¯ÂÈ ‰Â ‰Âȯı› fiÙÈ ÌÔÚ› Ó· ·ÔÎÏ›ÛÂÈ ˆ˜ Î·È 25% ÙˆÓ ·ÛıÂÓÒÓ ·fi ÙË ª∏ ÂÓÙfi˜ 12 ÌËÓÒÓ (Yao, Liver Transplant 2002). ∂ÈϤÔÓ ÔÈ ·ÛıÂ-

127

Ó›˜ ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÂÈÏÔΤ˜ ÌË Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙÔÓ fiÁÎÔ (Ï.¯. ˘ÔÙÚÔ‹ ÛÙÔ ·ÏÎÔfiÏ, ηډȷÁÁÂȷο) ‹ ÚfiÔ‰Ô Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ (ÔÍ›· Â› ¯ÚÔÓ›·˜, Ë·ÙÔÓÂÊÚÈÎfi Î.Ï.). ∏ ÛÙ·ıÂÚÔÔ›ËÛË Î·È Ë «˘Ô-ÛÙ·‰ÈÔÔ›ËÛË» ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ∏∫∫ ηٿ ÙËÓ ·Ú·ÌÔÓ‹ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ Â›Ó·È Î·˘Ùfi ÛËÌÂ›Ô ÛÙËÓ ‚È‚ÏÈÔÁÚ·Ê›·. °È· ÙÔ ÛÎÔfi ·˘Ùfi ¤¯Ô˘Ó ÚÔÙ·ı› ‰È¿ÊÔÚ˜ ÚÔÛÂÁÁ›ÛÂȘ, ΢ڛˆ˜ Ô ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi˜, Ô Î·˘ÙËÚÈ·ÛÌfi˜ Ì ڷ‰ÈÔÛ˘¯ÓfiÙËÙ˜, Ë ‰È·‰ÂÚÌÈ΋ ¤Á¯˘ÛË ·Èı·ÓfiÏ˘, ÂÓÒ ·ıÚÔ›˙ÂÙ·È ÂÌÂÈÚ›· ÛÙË ¯Ú‹ÛË sorafenib. ∏ ÂÈÏÔÁ‹ Ù˘ ·Ï‹˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ‰ÂÓ Â˘ÓÔÂ›Ù·È ·fi Ù· ‰Â‰Ô̤ӷ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜. À¿Ú¯Ô˘Ó ıÂÙÈΤ˜ ‰ËÌÔÛȇÛÂȘ –¤ÛÙˆ Î·È Ì ÌË Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜– fiÙÈ Ô ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi˜ Î·È Ë Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ fiÁÎÔ˘ Ì ڷ‰ÈÔÛ˘¯ÓfiÙËÙ˜ ÚÔÛʤÚÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ÂͤÏÈ͢ ÙÔ˘ ∏∫∫ Î·È ÙË Ì›ˆÛË Ù˘ ÂÍfi‰Ô˘ ·fi ÙË Ï›ÛÙ· ¯ˆÚ›˜ Ó· Û˘Ó‰¤ÔÓÙ·È Ì ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ (Majno, Liver Transplant 2007). ∂ÈÚfiÛıÂÙ· ÌÔÚ› Ó· ÂÈÙÚ¤„Ô˘Ó ÙËÓ ˘¤Ú‚·ÛË ÙˆÓ Î·ıÈÂÚˆÌ¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Û ·ÛıÂÓ›˜ Ì ηϋ ·ÓÙ·fiÎÚÈÛË ÛÙȘ ÌÂıfi‰Ô˘˜ ˘ÔÛÙ·‰ÈÔÔ›ËÛ˘ (Koschny, Clin Transplant 2009), ÚÔÙ›ÓÂÙ·È ‰Â Ë ÂÎÙ›ÌËÛË 1 Ì‹Ó· ÌÂÙ¿ ÙÔ ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi ˆ˜ ·ÍÈfiÈÛÙÔ ÎÚÈÙ‹ÚÈÔ ÂÈÏÔÁ‹˜ (Bargellini, Radiology 2010). ™Â ÌÂϤÙË Â› 177 ·ÛıÂÓÒÓ Ì ∏∫∫ Ô˘ Û˘Ó¤ÎÚÈÓ ·˘ÙÔ‡˜ Ô˘ ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ Î·È ·˘ÙÔ‡˜ Ì ۯÂÙÈο ÈÔ ÂÎÙÂٷ̤ÓÔ˘˜ fiÁÎÔ˘˜ Ô˘ ˘‚ϋıËÛ·Ó Û ˘ÔÛÙ·‰ÈÔÔ›ËÛË ‰ÂÓ ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ (Ravaioli, Am J Transplant 2008). ∂ӉȷʤÚÔÓ ¤¯ÂÈ Î·È Ô ÚfiÏÔ˜ Ù˘ Ë·ÙÂÎÙÔÌ‹˜ Ô˘ Â›Ó·È ‰˘Ó·Ùfi Ó· ÚÔËÁËı› Ù˘ ª∏ Û ÂÈÏÂÁ̤ÓÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ηٷگ‹Ó ‰ÂÓ ÏËÚÔ‡Ó ·˘ÛÙËÚ¿ Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ ÂÓÒ ¤¯ÂÈ ÚÔÙ·ı› ª∏ Î·È Â› ˘ÔÙÚÔ‹˜ ÌÂÙ¿ ·Ú¯È΋ Ë·ÙÂÎÙÔÌ‹ (Ikegami, Transplantation 2008). ¶Ôχ ÚfiÛÊ·Ù· ‰ËÌÔÛȇÙËΠÌÂϤÙË Ô˘ ıˆÚ› ÙË ¯ÔÚ‹ÁËÛË sorafenib cost-effective Û ۇÁÎÚÈÛË Ì ÙËÓ ·Ï‹ ·Ú·ÎÔÏÔ‡ıËÛË Û Δ2-∏∫∫ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ª∏, ΢ڛˆ˜ ÁÈ· ‰È¿ÌÂÛÔ˘˜ ¯ÚfiÓÔ˘˜ ˆ˜ ÙË ª∏ ÏÈÁfiÙÂÚÔ ·fi 6 Ì‹Ó˜ (Vitale, Hepatology 2010).

∏ ªÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·fi ˙ÒÓÙ· ‰fiÙË ∏ ª∏ ·fi ˙ÒÓÙ· ‰fiÙË (LDLT) fiˆ˜ Î·È Ë ¯Ú‹ÛË «ÔÚÈ·ÎÒÓ – marginal» ‰ÔÙÒÓ ÌÔÚ› Ó· Û˘ÓÂÈÛʤÚÂÈ ÛÙËÓ ·‡ÍËÛË ÙˆÓ ‰ÔÙÒÓ Î·È Ó· ‰ÒÛÂÈ ÚÔÔÙÈ΋ Û ·ÛıÂÓ›˜ Ì ∏∫∫ Ô˘ ˘ÂÚ‚·›ÓÔ˘Ó

128

¢. ™∞ªø¡∞∫∏™

Ù· ηıÈÂڈ̤ӷ ÎÚÈÙ‹ÚÈ· (Broelsch, J Hepatol 2005). H LDLT ÍÂÂÚÓ¿ ÙÔ ÌÂÁ¿ÏÔ Úfi‚ÏËÌ· Ù˘ ·Ó·ÌÔÓ‹˜ ÚÔÛʤÚÔÓÙ·˜ Ù·˘Ùfi¯ÚÔÓ· Ù¯ÓÈο ÏÂÔÓÂÎÙ‹Ì·Ù· („˘¯Ú‹ ÈÛ¯·ÈÌ›·, ÛÙ¿وÛË, ËÏÈΛ· Î·È ÁÂÓÈ΋ ηٿÛÙ·ÛË ‰fiÙË) ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ªÔÚ› Ó· ‰ÒÛÂÈ Ï‡ÛÂȘ Ì ·ÔÙÂϤÛÌ·Ù· Ô˘ ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ·fi ÙË ª∏ ·fi و̷ÙÈÎfi ‰fiÙË. ∫ÂÓÙÚÈ΋˜ ÛËÌ·Û›·˜ Û fiÏ· Ù· ·Ó¿ÏÔÁ· ÚÔÁÚ¿ÌÌ·Ù· ·ÔÙÂÏ› Ë ·ÛÊ¿ÏÂÈ· ÙÔ˘ ‰fiÙË ÂÓÒ Ù· ÎÚÈÙ‹ÚÈ· ÌÔÚ› Ó· Â›Ó·È ÏÈÁfiÙÂÚÔ ÂÚÈÔÚÈÛÙÈο. ∂ӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ π·ˆÓÈ΋ ÌÂϤÙË 125 ·ÛıÂÓÒÓ Ì ∏∫∫, 70 ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ Î·È 55 fi¯È. ™ÙË ÛÂÈÚ¿ ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ∏∫∫ Ô˘ ˘‚ϋıËÛ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ· ‰fiÙË ‰È·ÈÛÙÒıËΠfiÙÈ Ë ÂÈÏÔÁ‹ ·ÛıÂÓÒÓ ÌÔÚ› Ì ·ÛÊ¿ÏÂÈ· Ó· ÂÂÎÙ·ı› Û ÏÈÁfiÙÂÚÔ˘˜ ·fi 10 fiÁÎÔ˘˜, fiÏÔÈ ≤5cm Û ‰È¿ÌÂÙÚÔ Î·È ‰Â˜-Á·ÌÌ·-ηڂÔ͢ ÚÔıÚÔÌ‚›ÓË (PIVKA-II)≤400 mAU/ml (Ito, Liver Transplant 2007).

O ÚfiÏÔ˜ ÙÔ˘ MELD ∏ ˘ÈÔı¤ÙËÛË ÙÔ˘ Model for End-stage Liver Disease ÙÔ 2002 Î·È ·ÎÔÏÔ‡ıˆ˜ Ë Èı·ÓfiÙËÙ· «ÚÈÌÔ‰fiÙËÛ˘» Ì „ËÏfiÙÂÚ˜ ÙÈ̤˜ MELD ÙˆÓ ·ÛıÂÓÒÓ Ì ∏∫∫ (.¯. ·ÛıÂÓ‹˜ Ì ‚Ï¿‚Ë ÛÙ·‰›Ô˘ 1 –ÌÔÓ‹ÚË fiÁÎÔ ≤2cm– ı· ÂÏ¿Ì‚·Ó MELD 24, ÂÓÒ Ì ÛÙ·‰›Ô˘ 2 –ÌÔÓ‹Ú˘ 2-5 cm ‹ ¤ˆ˜ ÙÚÂȘ fiÁÎÔ˘˜ ηı¤Ó·˜ ≤3 cm ı· ÌÔÚÔ‡Û ӷ ·˘Í‹ÛÂÈ ÙÔ MELD Û 29) Ô‰‹ÁËÛ Û ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡ ηٿ ÙËÓ ·Ú·ÌÔÓ‹ ÙÔ˘˜ ÛÙË Ï›ÛÙ·. ™˘ÓÂ·ÎfiÏÔ˘ı·, ÂÓÒ ÛÙËÓ ÚÔ MELD ÂÔ¯‹ ÙÔ ÂÙ‹ÛÈÔ ÔÛÔÛÙfi Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ و̷ÙÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ô˘ ÂÏ¿Ì‚·Ó·Ó ÔÈ ·ÛıÂÓ›˜ Ì ∏∫∫ ‹Ù·Ó 7% ÂÓÒ ÛÙË ÌÂÙ¿ MELD ·˘Í‹ıËΠ۠22% (Sharma, Liver Transplant 2004). ¶ÚÔÊ·ÓÒ˜ ÛËÌ·ÓÙÈ΋ ‹Ù·Ó Ë Ì›ˆÛË ÛÙÔ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ (·fi 2.3 Û 0.7 ¤ÙË) Î·È ÛÙÔ Ú˘ıÌfi ÂÍfi‰Ô˘ ·fi ÙË Ï›ÛÙ·. ∫·ıÒ˜ Ê¿ÓËΠfiÙÈ Ì ÙÔ Ó¤Ô ·˘Ùfi Û‡ÛÙËÌ· ˘‹Ú¯Â ÚÔÒıËÛË ·ÛıÂÓÒÓ Ì ∏∫∫ Û ۯ¤ÛË Ì ¿ÏÏÔ˘˜ (ÌË ∏∫∫) ·ÛıÂÓ›˜ Ì ÙÔ ›‰ÈÔ MELD Î·È ˘‹ÚÍ ‰È˜ ÙÚÔÔÔ›ËÛË Î·È ·fi ÙÔÓ ª¿ÚÙÈÔ ÙÔ˘ 2005 ‰›ÓÔÓÙ·È 22 ‚·ıÌÔ› ÁÈ· fiÁÎÔ˘˜ ÛÙ·‰›Ô˘ 2, Ì Â·ÎfiÏÔ˘ıË Û¯ÂÙÈ΋ Ì›ˆÛË Ù˘ ª∏ ÁÈ· ∏∫∫. ∂ÓÙÔ‡ÙÔȘ, Û ÌÂÁ¿ÏË ÌÂϤÙË ∼140,000 ·ÛıÂÓÒÓ Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ª∏, Ë ¤ÓÙ·ÍË ÏfiÁˆ ∏∫∫ ›¯Â ·˘Í·ÓfiÌÂÓË Â›ÙˆÛË ÂÓÒ ÁÈ· ÙȘ ÈÔÁÂÓ›˜ Ë·Ù›Ùȉ˜ ÌÂÈÔ‡ÌÂÓË (Ray Kim, Gastroenterology

2009). ¶Ôχ ÚfiÛÊ·Ù· ·Ó·ÎÔÈÓÒıËÎ·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ·ÓÂıÓÈ΋ Û‡ÛÎÂ„Ë ÛÙȘ ∏¶∞ ÁÈ· ÙËÓ ÚÔÛÊÔÚ¿ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û ·ÛıÂÓ›˜ Ì ∏∫∫. À‹ÚÍÂ Û˘Ìʈӛ· ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ˘ÔÏÔÁÈ˙fiÌÂÓÔ˘ ÛÎÔÚ ÚÔÙÂÚ·ÈfiÙËÙ·˜ ÁÈ· ∏∫∫ Ô˘ ı· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ ˘ÔÏÔÁÈ˙fiÌÂÓÔ MELD, ÙËÓ ·FP, ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ fiÁÎÔ˘ Î·È ÙÔ Ú˘ıÌfi ·Ó¿Ù˘Í˘ ÙÔ˘ (Pomfret, Liver Transplant 2010).

μÈÔ„›· ÚÈÓ ÙË ªÂÙ·ÌfiÛ¯Â˘ÛË ◊·ÙÔ˜ ∏ ηıȤڈÛË ·ÂÈÎÔÓÈÛÙÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Î·È Ô ÂÓ·ÁηÏÈÛÌfi˜ ÙÔ˘˜ ·fi ‰ÈÂıÓ›˜ ÂÈÛÙËÌÔÓÈÎÔ‡˜ ÊÔÚ›˜ (EASL, AASLD) ¤‰ˆÛ·Ó ÛËÌ·ÓÙÈΤ˜ χÛÂȘ ÛÙË ‰È¿ÁÓˆÛË ÙÔ˘ ∏∫∫ ÛÙ· Ï·›ÛÈ· Ù˘ ΛÚÚˆÛ˘ ÌÂÈÒÓÔÓÙ·˜ ‰Ú·ÛÙÈο ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÈÛÙÔÏÔÁÈ΋˜ ÙÂÎÌËÚ›ˆÛ˘. Δ· ·ÔÙÂϤÛÌ·Ù· fï˜ ÁÈ· ÌÈÎÚÔ‡˜ fi˙Ô˘˜ (<1 cm) ‰ÂÓ Â›Ó·È Ù· ÂÈı˘ÌËÙ¿, Ì ·ÔÙ¤ÏÂÛÌ· ·ÛıÂÓ›˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó ÁÈ· Δ1 ∏∫∫ –Â› ÙË ‚¿ÛÂÈ ÌfiÓÔ ·ÎÙÈÓÔÏÔÁÈÎÒÓ ÎÚÈÙËÚ›ˆÓ– Ó· ÌËÓ ¤¯Ô˘Ó ÓÂfiÏ·ÛÌ· ÛÙÔ ·Ê·ÈÚÂı¤Ó ‹·Ú. ∏ ‰È·‰ÂÚÌÈ΋ ‚ÈÔ„›· (gold standard) ¤¯ÂÈ ÙÂÎÌËÚȈ̤ÓÔ Î›Ó‰˘ÓÔ ‰È·ÛÔÚ¿˜ Ô˘ fï˜ Â›Ó·È <2% ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÛÂÈÚ¤˜ ÂÓÒ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÍÂοı·Ú· ÛÙÔȯ›· ÁÈ· ÙÔÓ Î›Ó‰˘ÓÔ ÌÂÙ¿ ÙË ª∏ (Durand, Liver Transplant 2007). O ΛӉ˘ÓÔ˜ ‰È·ÛÔÚ¿˜ ÂÎÙÈÌ¿Ù·È ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ‰È·ÁÓˆÛÙÈ΋ ‚ÈÔ„›· Û˘ÁÎÚÈÓfiÌÂÓÔ˜ Ì ·˘Ù‹Ó ÌÂÙ¿ ·fi ‰È·‰ÂÚÌÈΤ˜ Ù¯ÓÈΤ˜ (Stigliano, Cancer Treat Rev 2007). ŸÌˆ˜, Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ fiÔ˘ Ë ‚ÈÔ„›· ‡ÔÙÔ˘ fi˙Ô˘ Û ÎÈÚÚˆÙÈÎfi ‹·Ú ı· ·ÏÏ¿ÍÂÈ ÛËÌ·ÓÙÈο ÙËÓ ·fiÊ·ÛË ÁÈ· ª∏ Â›Ó·È ÌÈÎÚfi˜. ÕÏϘ ÛÙÚ·ÙËÁÈΤ˜ fiˆ˜ ÂȉÈΤ˜ ·ÎÙÈÓÔÏÔÁÈΤ˜ Ù¯ÓÈΤ˜ ‹ ·Ó·ÌÔÓ‹ ÁÈ· Û˘ÁÎÂÎÚÈ̤ÓÔ ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Î·È Â·Ó¿ÏË„Ë ·ÂÈÎfiÓÈÛ˘ ÌÔÚ› Â›Û˘ Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈο (Stigliano, J Hepatol 2005). ∂ӉȷʤÚÔ˘Û· ÌÂϤÙË ·fi ÙÔ˘˜ Pawlik Î·È Û˘ÓÂÚÁ¿Ù˜ (Ann Surgery 2007) ·fi 120 ·ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ‚ÈÔ„›· ‰È¿ ‚ÂÏfiÓ˘ (Û˘ÓÔÏÈ΋ ÔÌ¿‰· 178 ·ÛıÂÓÒÓ Ô˘ ˘¤ÛÙËÛ·Ó Ë·ÙÂÎÙÔÌ‹ ‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜) ·Ó·ÎÔ›ÓˆÛ ·ÓÂ·Ú΋ Û˘Ìʈӛ· ÌÂٷ͇ ‚ÈÔ„›·˜ Î·È ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ıÔÏÔÁ›·˜. OÈ Û˘ÁÁÚ·Ê›˜ Û˘ÌÂÚ·›ÓÔ˘Ó fiÙÈ ÙÔ grade Ô˘ ·Ú¤¯ÂÈ Ë ‚ÈÔ„›· Ì ‚ÂÏfiÓË ÙÔ˘ fiÁÎÔ˘ Û˘¯Ó¿ ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ·˘Ùfi Ù˘ ÙÂÏÈ΋˜ ·ıÔÏÔÁÔ·Ó·ÙÔÌ›·˜ Ô‡Ù ÙËÓ ·ÚÔ˘Û›· ÌÈÎÚÔ·ÁÁÂȷ΋˜ ‰È‹ıËÛ˘.

METAMO™XEY™Eπ™ 2010

™ËÌ·ÓÙÈΤ˜ ÚfiÛıÂÙ˜ ÚÔÁÓˆÛÙÈΤ˜ ·Ú¿ÌÂÙÚÔÈ ∏ ÌÈÎÚÔ·ÁÁÂȷ΋ ‰È‹ıËÛË ÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ÙÔ˘ ‹·ÙÔ˜ Û˘Ó‰¤ÂÙ·È Ì ÊÙˆ¯‹ ÂÈ‚›ˆÛË (Bhattacharjya, Dig Surg 2004), ÙÔ ÔÔ›Ô ÂȂ‚·ÈÒıËΠ̷˙› Ì ÙË ÊÙˆ¯‹ ‰È·ÊÔÚÔÔ›ËÛË ÈÛÙÔÏÔÁÈο (grading) fiÙÈ Û¯ÂÙ›˙ÔÓÙ·È Ì η΋ ¤Î‚·ÛË ÌÂÙ¿ ÙË ª∏ Î·È Û ¿ÏÏË ¤Ú¢ӷ ·ÓÂÍ·Úًو˜ ÙÔ˘ ÛÙ·‰›Ô˘ ÙÔ˘ ∏∫∫ (Befeler, Gastroenterology 2005). ∏ ‰È¿ÌÂÙÚÔ˜ ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ fi˙Ô˘ ÚÔÙ¿ıËΠfiÙÈ ÚԂϤÂÈ Î·Ï‡ÙÂÚ· ÙËÓ ˘ÔÙÚÔ‹ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ ·ÚÈıÌfi ÙˆÓ fi˙ˆÓ (Grasso, Transplantation 2006) ÌÂϤÙË Ô˘ ÂȂ‚·ÈÒıËΠ·fi ÙËÓ ›‰È· ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· Û ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ (Marelli, Ann Surg Oncol 2008). ™Â Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÚÈÓ Î·È ÌÂÙ¿ ÙË ı¤ÛÈÛË ÙÔ˘ MELD Ì ÛÙÔȯ›· ·fi ÙË UNOS, ·ÛıÂÓ›˜ Ì ÌÂÁ·Ï‡ÙÂÚÔ˘˜ fiÁÎÔ˘˜, Ì aFP>455 ng/ml, ‹ MELD≥20 ›¯·Ó ÊÙˆ¯‹ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ª∏ (Ioannou, Gastroenterology 2008). ¶ÚfiÛÊ·ÙË ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË 1556 ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔۯ‡ıËÎ·Ó ÁÈ· ∏∫∫ ÂÚȤϷ‚ 1112 ·ÛıÂÓ›˜ Ô˘ ˘ÂÚ¤‚·ÈÓ·Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ Î·È Ë ÂÈ‚›ˆÛË Û˘Û¯ÂÙ›ÛıËΠ·Ó·‰ÚÔÌÈο Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ fi˙ˆÓ, ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ fi˙Ô˘ Î·È ÙËÓ ·ÚÔ˘Û›· ‹ fi¯È ÌÈÎÚÔ·ÁÁÂȷ΋˜ ‰È‹ıËÛ˘ (Mazzaferro, Lancet Oncol 2009). ∏ ·ÚÔ˘Û›· Ù˘ ÙÂÏÂ˘Ù·›·˜ ‰ÈÏ·Û›·˙ ÙÔÓ Î›Ó‰˘ÓÔ ˘ÔÙÚÔ‹˜ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜, ÂÓÒ Ë Â›‰Ú·ÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ‹ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ fi˙ˆÓ Ê·›ÓÔÓÙ·Ó ‰È¿ Ù˘ ˘ÔÙÚÔ‹˜.

OÈ Û˘ÁÁÚ·Ê›˜ ÂÚȤÁÚ·„·Ó ÔÌ¿‰· ·ÛıÂÓÒÓ fiÔ˘ ı· ÌÔÚÔ‡Û ӷ Á›ÓÂÈ ·ÎÚÈ‚¤ÛÙÂÚ· ÂÎÙ›ÌËÛË Ù˘ ÂÈ‚›ˆÛ˘ ‚¿ÛÂÈ ÂÍ·ÙÔÌÈÎÂ˘Ì¤ÓˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ ÓÂÔÏ¿ÛÌ·Ùfi˜ ÙÔ˘˜. H ·ÁÁÂȷ΋ ‰È‹ıËÛË ·fi ÙÔ ∏∫∫, Ô ‚·ıÌfi˜ ‰È·ÊÔÚÔÔ›ËÛ˘ & Ë ÔÏÏ·Ï·ÛÈ·ÛÙÈ΋ Ù¿ÛË ·˘ÙÔ‡, Û˘Ó‰¤ıËÎ·Ó ÂÈϤÔÓ Û ÚfiÛÊ·ÙË ÌÂϤÙË Ì ÙÔÓ Î›Ó‰˘ÓÔ ˘ÔÙÚÔ‹˜ ·ÓÂÍ·Úًو˜ ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ fiÁÎÔ˘ (Marshall, Liver Transplant 2010). ∂›Ó·È ¿ÓÙˆ˜

129

ÁÂÁÔÓfi˜ fiÙÈ ·ÊÂÓfi˜ ÔÈ ÌÔÚÊÔÏÔÁÈÎÔ› ‰Â›ÎÙ˜ ·¤¯Ô˘Ó ·ÎfiÌË ·fi ÙÔ Ó· Â›Ó·È ·Ôχو˜ ÈηÓÔÔÈËÙÈÎÔ› Î·È ·ÊÂÙ¤ÚÔ˘ ÔÚÔÏÔÁÈÎÔ›, ÌÔÚÈ·ÎÔ› ‹ ÈÛÙÔÏÔÁÈÎÔ› ‰Â›ÎÙ˜ ‰ÂÓ ¤¯Ô˘Ó Â·ÏËı¢ı› ÒÛÙ ӷ ·ÔÙÂϤÛÔ˘Ó ‚¿ÛË ÁÈ· Ï‹„Ë ·ÔÊ¿ÛÂˆÓ (Neuberger, Liver Transplant 2010).

μÈ‚ÏÈÔÁÚ·Ê›· 1. Bismuth H et al. Ann Surg 1993; 218(2): 145-51.

2. Mazzaferro V et al. N Engl J Med 1996; 334(11): 693-9.

3. Yao FY, et al. Hepatology 2001; 33 (6):1394-403.

4. Yao FY, et al. Am J Transplant 2007; 7(11): 2587-96.

5. Bruix J, et al. Hepatology 2005; 42(5): 1208-36.

6. Llovet JM, et al. J Natl Cancer Inst 2008; 100(10): 698-711.

7. http://www.optn.org/PoliciesandBylaws2/policies/pdfs/ policy_8pdf 8. Yao FY, et al. Liver Transplant 2002; 8(10): 873-83.

9. Majno P, et al. Liver Transplant 2007; 13: S27-35.

10. Koschny R. Clin Transplant 2009; 23: Suppl 21: 49-60.

11. Bargellini I, et al. Radiology 2010; 255(1): 289-300.

12. Ravaioli M, et al. Am J Transplant 2008; 8(12): 2547-57.

13. Ikegami T, et al. Transplantation 2008; 86(5): 64-6.

14. Vitale A, et al. Hepatology 2010; 51(1): 12-5.

15. Broelsch CE, et al. J Hepatol 2005; 43(4): 569-73.

16. Ito T, et al. Liver Transplant 2007; 13(12): 1637-44.

17. Sharma P, et al. Liver Transplant 2004; 10(1): 36-41.

18. Kim WR, et al. Gastroenterology 2009; 137(5): 1680-6.

19. Pomfret EA, et al. Liver Transplant 2010; 16(3): 262-78.

20. Durand F, et al. Liver Transplant 2007; Suppl 2: S17-23.

21. Stigliano R, et al. Cancer Treat Rev 2007; 38(5): 437-47.

22. Stigliano R, et al. J Hepatol 2005; 43(4): 563-8.

23. Pawlik TM, et al. Ann Surg 2007; 245(3): 435-42.

24. Battacharjya S, et al. Dig Surg 2004; 21(2): 152-9.

25. Befeler AJ, et al. Gastroenterology 2005; 128(6): 1752-64.

26. Grasso A, et al. Transplantation 2006; 81(11): 1532-41.

27. Marelli L, et al. Ann Surg Oncol 2008; 15(12): 3503-11.

28. Ioannou GN, et al. Gastroenterology 2008; 134(5): 1342-51.

29. Mazzaferro V, et al. Lancet Oncol 2009; 10(1): 35-43.

30. Marshall AE, et al. Liver Transplant 2010; 16(3): 279-88.

31. Neuberger J. Liver Transplant 2010; 16(3): 249-51.

METAMO™ÃEY™∏ ∏¶ATO™ ™Δ∏¡ E§§A¢A: ¶ƒOB§∏ªATπ™ªOπ & ¶ƒOO¶Δπ∫E™

H ·ÁˆÓ›· ÙÔ˘ Ë·ÙÔÏfiÁÔ˘ πˆ¿ÓÓ˘ ∫ÔÛΛӷ˜

∂ÈÛ·ÁˆÁ‹

ÔχÏ¢Ú˘ Î·È ÔÏ˘Â›‰˘ ·ÁˆÓ›·˜ Î·È ›ÂÛ˘ ÙÔ˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ¶ÚÔ‚Ï‹Ì·Ù· Ï‹Ó Ù˘ ·Ó‡ÚÂÛ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Ë ÓÔÛËÏ›· ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ª∂£ Î·È Ë ÎÈÓËÙÔÔ›ËÛË ÔÏÏÒÓ; ÁÚ·ÊÂÈÔÎÚ·ÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Ô˘ ÛÙËÓ ÃÒÚ· Ì·˜ ηı›ÛÙ·ÓÙ·È ÔÏÏ¿ÎȘ Ï›·Ó ÚÔ‚ÏËÌ·ÙÈÎÔ› Î·È ¯ÚÔÓÔ‚fiÚÔÈ.

∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ·fi و̷ÙÈÎfi ΢ڛˆ˜ Î·È ÔÏÈÁÒÙÂÚÔ Û˘¯Ó¿ ·fi ˙ÒÓÙ· ‰fiÙË, ·ÔÙÂÏ› ÙË ıÂÚ·¢ÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ÙËÓ ÔÍ›· Î·È ¯ÚÔÓ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∂ÈϤÔÓ ·ÔÙÂÏ› ÙËÓ È‰·ÓÈ΋ χÛË ÁÈ· Û˘ÛÙËÌ·ÙÈο ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù· Ô˘ ÙÔ ‹·Ú ÌÂÓ ‰ÂÓ ¿Û¯ÂÈ ·ÏÏ¿ ¢ı‡ÓÂÙ·È ÁÈ· ÙË ÌÂÙ·‚ÔÏÈ΋ ‰È·Ù·Ú·¯‹ ∏ ÔÍ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ¢ı‡ÓÂÙ·È ÁÈ· ÙÔ 5% ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ù· ‰Â ·›ÙÈ· Ù˘ ÔÈΛÏÔ˘Ó ·fi ¯ÒÚ· Û ¯ÒÚ· Î·È Â›Ó·È Ù· Ê¿Ú̷η Î·È È‰È·›ÙÂÚ· Ë ‰ËÏËÙËÚ›·ÛË ·fi ·Ú·ÎÂÙ·ÌfiÏË ÛÙȘ ¢˘ÙÈΤ˜ ÃÒÚ˜ ÂÓÒ ÛÙËÓ ∂ÏÏ¿‰· ΢Úȷگ› Ë ÔÍ›· HBV Ïԛ̈ÍË (55%) Î·È ‰Â˘ÙÂÚ¢fiÓÙˆ˜ Ù· Ê¿Ú̷η (15%). ™Â ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ‰ÂÓ ·Ó¢ڛÛÎÂÙ·È ÙÔ ·›ÙÈÔ (15-40%). Δ· ·›ÙÈ· Ù˘ ¯ÚÔÓ›·˜ Ë·ÙÈ΋˜ ÓfiÛÔ˘ ηٿ ÛÂÈÚ¿ Û˘¯ÓfiÙËÙ·˜ ·ÔÙÂÏÔ‡Ó ÔÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (HBV, HCV), Ë ·ÏÎÔÔÏÈ΋ Ë·ÙÔ¿ıÂÈ·, Ù· ·˘ÙÔ¿ÓÔÛ· ¯ÔÏÔÛÙ·ÙÈο ÓÔÛ‹Ì·Ù· ÙÔ˘ ‹·ÙÔ˜ (ÚˆÙÔÁÂÓ‹˜ ¯ÔÏÈ΋ ΛÚÚˆÛË Î·È ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›Ùȉ·), Ë ÎÚ˘„ÈÁÂÓ‹˜ ΛÚÚˆÛË, ÙÔ ÚˆÙÔ·ı¤˜ ÓÂfiÏ·ÛÌ· ÙÔ˘ ‹·ÙÔ˜ Û ¤‰·ÊÔ˜ ˘ÔΛÌÂÓ˘ Ë·ÙÔ¿ıÂÈ·˜, ÙÔ Û‡Ó‰ÚÔÌÔ Budd-Chiari Î·È Ù· ÌÂÙ·‚ÔÏÈο ÓÔÛ‹Ì·Ù·.

ππ) ÃÚÔÓ›· Ë·ÙÈ΋ ÓfiÛÔ˜ Δ· ÂÏ¿¯ÈÛÙ· ÎÚÈÙ‹ÚÈ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ‚·ıÌfi Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, Ô˘ ·ÍÈÔÏÔÁÂ›Ù·È Ì ‰È¿ÊÔÚ· Û˘ÛÙ‹Ì·Ù· (Child-Pugh, MELD), Î·È ÙË ·ÚÔ˘Û›· ÂÈÏÔÎÒÓ Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ fiˆ˜ Ù· ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· ÎÈÚÛÔÚÚ·Á›·˜, Ô ·ÓıÂÎÙÈÎfi˜ ·ÛΛÙ˘, Ë Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Î·È Ë ·˘ÙfiÌ·ÙË ‚·ÎÙËÚȷ΋ ÂÚÈÙÔÓ›Ùȉ·. ∏ ÂÌÊ¿ÓÈÛË ÂÓfi˜ ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ ÂÈÏÔÎÒÓ ÛËÌ·ÙÔ‰ÔÙ› ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô‡ fï˜ ÛÙËÓ ¯ÒÚ· Ì·˜ ÏfiÁˆ Ù˘ ·ÓÂ¿ÚÎÂÈ·˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·ı˘ÛÙÂÚ› ÂÙÛÈ ÒÛÙÂ Ô ·ÛıÂÓ‹˜ Ó· ÂȉÂÈÓÒÓÂÙ·È Î·È Ó· ÂÓÙ¿ÛÛÂÙ·È ÛÙË Ï›ÛÙ· Ë Ó· ˘Ô‚¿ÏÏÂÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË fiÙ·Ó Â›Ó·È ‚·ÚÈ¿. ∞‡ÍËÛË Î·Ù¿ 1 ‚·ıÌfi ÛÙËÓ Îϛ̷η Child ÚÔηÏ› ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ı·Ó¿ÙÔ˘ ηٿ 37%. π‰È·›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Ô˘ ı· ·Ó·Î‡„Ô˘Ó Â›Ó·È Ë Î·Î‹ ıÚ¤„Ë Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ .OÛÔÓ ·ÊÔÚ¿ ÙË ıÚ¤„Ë 20% ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ Î·È ÙÔ 65-80% ÌÂ ÙˆÓ ·ÛıÂÓÒÓ Ì ÛÔ‚·Ú‹ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ¤¯Ô˘Ó η΋ ıÚ¤„Ë Ô˘ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. ∏ 5ÂÙ‹˜ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÂÈÒÓÂÙ·È Î·È Ô Î›Ó‰˘ÓÔ˜ ÏÔÈÌÒÍÂˆÓ ·˘Í¿ÓÂÙ·È ÛËÌ·ÓÙÈο. ª¤¯ÚÈ 64% ÙˆÓ ı·Ó¿ÙˆÓ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÊ›ÏÂÙ·È Û ÏÔÈÌÒÍÂȘ Ì 30% ıÓËÙfiÙËÙ· ÛÙË ª∂£. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ˘ÔÓ·ÙÚÈ·ÈÌ›·, Ì›ˆÛË Î·Ù¿ 1 mEq/l ÙÔ˘ ¡· ÚÔηÏ› ·‡ÍËÛË Î·Ù¿ 5-7% Ù˘ ıÓËÙfiÙËÙ·˜. ™˘ÌÂÚ·ÛÌ·ÙÈο Ë ‚·ÚÈ¿ ˘ÔıÚ„›·, Ô ·ÓıÂÎÙÈÎfi˜ ·ÛΛÙ˘-Î·È Ë ·Ó¿ÁÎË ÁÈ· Û˘Ó‰ڛ˜ ÂÎÎÂÓˆÙÈÎÒÓ ·Ú·ÎÂÓÙ‹ÛˆÓ, Ù· ÂÂÈÛfi‰È· ·˘ÙfiÌ·Ù˘ ‚·ÎÙËÚȷ΋˜ ÂÚÈÙÔÓ›Ùȉ·˜, Ë ˘ÔÓ·ÙÚÈ·ÈÌ›· ÙÔ

∫ÚÈÙ‹ÚÈ· Î·È ·fiÊ·ÛË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË π) OÍ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ∫¿ı ·ÛıÂÓ‹˜ Ì ÎÂÚ·˘ÓÔ‚fiÏÔ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·, ‰ËÏ·‰‹ Ì ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜ (INR>1,5) Î·È ‰È·Ù·Ú·¯¤˜ ÂÈ¤‰Ô˘ Û˘Ó›‰ËÛ˘ 2-8 ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÔÍ›·˜ Ë·ÙÈ΋˜ ÓfiÛÔ˘, Ú¤ÂÈ ¿ÌÂÛ· Ó· ·ÍÈÔÏÔÁÂ›Ù·È Û ÂȉÈÎfi ªÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ∫¤ÓÙÚÔ ÁÈ· ÙËÓ Èı·ÓfiÙËÙ· Â›ÁÔ˘Û·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∏ ·ÌÂÛfiÙËÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Î·Ù¿ ÙÔ Ï›ÛÙÔÓ Ù·¯Â›· ·Ó¿Ù˘ÍË ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ Î·È ÂÁÎÂÊ·ÏÈ΋˜ ÈÛ¯·ÈÌ›·˜ ‹ ÂÁÎÔÏ·ÛÌÔ‡. OÈ ·ÛıÂÓ›˜ Ì O∏∞ Â›Ó·È Û˘Ó‹ıˆ˜ Ó·ڋ˜ ËÏÈΛ·˜ Î·È Â‡ÏÔÁÔ Â›Ó·È ÂÈÚÔÛı¤Ùˆ˜ Ù˘ ¿ÌÂÛ˘ ·Ó¿Á΢ Á·È ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ë ‰È·¯Â›ÚËÛË Ù˘

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π. ∫O™∫π¡∞™

Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ Ù‡Ô˘ ππ, Ë ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· ÛÙË ÓÔÛËÏ›· ÙˆÓ ·ÛıÂÓÒÓ ÏfiÁˆ Ïԛ̈͢ ‹ ÚÔÓÂÊÚÈ΋˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ·ÔÙÂÏÔ‡Ó ÛÔ‚·Ú¤˜ ÂÍÂÏ›ÍÂȘ Ù˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ Ì ·Î·ıfiÚÈÛÙÔ ÙÔÓ ¯ÚfiÓÔ ÂÌÊ¿ÓÈÛ˘ Î·È ¿ÌÂÛÔ ÙÔÓ Î›Ó‰˘ÓÔ ı·Ó¿ÙÔ˘ ‹ ÙËÓ ÂÌÊ¿ÓÈÛË ÛÔ‚·ÚÒÓ ÂÈÏÔÎÒÓ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. À¿Ú¯Ô˘Ó fï˜ Î·È È‰È·›ÙÂÚ· ÎÚÈÙ‹ÚÈ·, Û˘Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙË ÓfiÛÔ. ™ÙËÓ ÚˆÙÔ·ı‹ ¯ÔÏÈ΋ ΛÚÚˆÛË Ë ‚·Ú‡ÓÔ˘Û· ·fiÏ˘ÙË ¤Ó‰ÂÈÍË Â›Ó·È Ë ·‡ÍËÛË Ù˘ ¯ÔÏÂÚ˘ıÚ›Ó˘ >10 mg/dl. O ΛӉ˘ÓÔ˜ ı·Ó¿ÙÔ˘ ·ÛıÂÓÒÓ ÛÙË Ï›ÛÙ· Â›Ó·È <15% Î·È Ë Ì¤ÛË ÂÈ‚›ˆÛË Ì ÙÈÌ‹ ¯ÔÏÂÚ˘ıÚ›Ó˘ >6mg/dl Î·È >9mg/dl Â›Ó·È 24 Î·È 17 Ì‹Ó˜, ·ÓÙ›ÛÙÔȯ·. ∏ ¯ÔÚ‹ÁËÛË ·ÚÎÙÔ-‰ÂÔ͢¯ÔÏÈÎÔ‡ ÔͤԘ (ursofalk) ÙÚÔÔÔÈ› Ù· Â›‰· ¯ÔÏÂÚ˘ıÚ›Ó˘ ¤ÙÛÈ ÒÛÙ ÔÈ ÂӉ›ÍÂȘ Û‹ÌÂÚ· ‚·Û›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ÛÙȘ ÂÈÏÔΤ˜ Ù˘ ˘Ï·›·˜ ˘¤ÚÙ·Û˘ Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜.

™Â ·ÛıÂÓ›˜ Ì ÚˆÙÔ·ı‹ ÛÎÏ˘ÚËÓÙÈ΋ ¯ÔÏ·ÁÁ›Ùȉ· Ë ÛËÌ·ÓÙÈ΋ ¤ÎÙˆÛË Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ Î·È Ù· ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· ÌÈÎÚԂȷ΋˜ ¯ÔÏ·ÁÁÂÈ›Ùȉ·˜ (10-20% ÌË È·ÙÚÔÁÂÓÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜) ÚÔÛı¤ÙÔ˘Ó ÂÈÚfiÛıÂÙË 8% Èı·ÓfiÙËÙ· ı·Ó¿ÙÔ˘ Û 3 Ì‹Ó˜. °È· ÙÔÓ ÚˆÙÔ·ı‹ ηÚΛÓÔ ÙÔ˘ ‹·ÙÔ˜ Ë ·ÚÔ˘Û›· 1 ÂÛÙ›·˜ ≤5cm ‹ ≤3 ÂÛÙÈÒÓ, ≤3cm ÂοÛÙË Ì ٷ˘Ùfi¯ÚÔÓË ·Ô˘Û›· ·ÁÁÂȷ΋˜ ÚÔÛ‚ÔÏ‹˜ Î·È Â͈Ë·ÙÈ΋˜ ÓfiÛÔ˘ ·ÔÙÂÏÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ ÁÈ· ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ·Ó·ÌÔÓ‹ ÛÙË Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓÒÓ Ì ∏∫∫ Â›Ó·È ·fi ÙȘ ϤÔÓ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ Î·È ·˘Í¿ÓÂÈ Î·Ù· Ôχ ÙËÓ ·ÁˆÓ›· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÁÈ·Ù› ÛÙÔ 25% ÙˆÓ ·ÛıÂÓÒÓ Ì ∏∫∫ ˘¿Ú¯ÂÈ ·ÏÏ·Á‹ ÙÔ˘ ÛÙ·‰›Ô˘ Î·È ÂÔ̤ӈ˜ ·Ú¿ ÙËÓ ˘ÔÛÙ·‰ÈÔÔ›ËÛË Ì ÂÌ‚ÔÏÈÛÌfi Ë ıÂÚÌÔη˘ÙËÚ›·ÛË Ë Èı·ÓfiÙËÙ· ÂÍfi‰Ô˘ ·fi ÙË Ï›ÛÙ· ·˘Í¿ÓÂÙ·È.

H ·ÁˆÓ›· ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÔ‡ °ÂÒÚÁÈÔ˜ ÿÌ‚ÚÈÔ˜ ÙËÙ·˜. ™ÙËÓ ÂÚ›ÙˆÛË ÂÓfi˜ ·ÛıÂÓÔ‡˜ Ô˘ Â›Ó·È Û ‚·Ú›· ÁÂÓÈ΋ ηٿÛÙ·ÛË ‹ ·ÚÔ˘ÛÈ¿˙ÂÈ Î¿ÔÈ· ÂÈÏÔ΋ Ô˘ ηıÈÛÙ¿ ÙËÓ Â¤Ì‚·ÛË ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ÁÂÓÓÈÔ‡ÓÙ·È ˆÚÈṲ̂ӷ ÂÚˆÙ‹Ì·Ù· Î·È ‰ËÌÈÔ˘ÚÁÔ‡ÓÙ·È ‰ÈÏ‹ÌÌ·Ù·, Ô˘ ı¤ÙÔ˘Ó Û ‰ÔÎÈÌ·Û›· ÙËÓ ÎÚ›ÛË ÁÈ· ¤ÁÎÚÈÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û ¤Ó·Ó Ù¤ÙÔÈÔ ·ÛıÂÓ‹: ¡ÔÌÈÌÔÔÈÂ›Ù·È Ô ÃÂÈÚÔ˘ÚÁfi˜ Ó· ·ÔÎÏ›ÛÂÈ ¤Ó·Ó ·ÛıÂÓ‹ Û ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ·Ô ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË; ΔÈ Â›ÙˆÛË ¤¯ÂÈ Ì›· ·fiÊ·ÛË Ó· ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤Ó·˜ ·ÛıÂÓ‹˜ Ì ÂÏ¿¯ÈÛÙ˜ Èı·ÓfiÙËÙ˜ Ó· ÂÈ‚ÈÒÛÂÈ Ù˘ ÂÁ¯ÂÈÚ‹Û˘, ÛÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ·Ó·Ì¤ÓÔ˘Ó Ó· ˘Ô‚ÏËıÔ‡Ó Û ª∏; ¶ÔÈ¿ Â›Ó·È Ë ·ÓÙ›‰Ú·ÛË Ù˘ ˘fiÏÔÈ˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋˜ ÔÌ¿‰Ô˜ (∏·ÙÔÏfiÁÔÈ, ∞Ó·ÈÛıËÛÈÔÏfiÁÔÈ, ∂ÓÙ·ÙÈÎÔÏfiÁÔÈ) Û ̛· ·fiÊ·ÛË ÂÈÏÔÁ‹˜ ˘„ËÏÔ‡ Ú›ÛÎÔ˘ ·ÛıÂÓÔ‡˜ ·Ô ÙÔÓ ÃÂÈÚÔ˘ÚÁfi; ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÎÙÈÌËı› ηχÙÂÚ· Ë ‰È·‰Èηۛ· Ì›·˜ Èı·Ó‹˜ ·fiÚÚȄ˘ ‹ ÂÁÎÚÈÛ˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÓfi˜ ‚·ÚÈ¿ ÛıÂÓÔ‡˜, ÚˆÙ· ·fiÏ· Ú¤ÂÈ Ó· ·Ó·ÙÚ¤ÍÔ˘Ì ÛÙ· ‚·ÛÈο ÎÚÈÙ‹ÚÈ·, ·fiÏ˘Ù· ‹ Û¯ÂÙÈο, ηıÒ˜ Î·È ÙȘ ηٷÛÙ¿ÛÂȘ Ô˘ ÂÈϤÎÔ˘Ó Ì›· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (¶›Ó·Î·˜ 1 Î·È 2).

O ÙÂÏÈÎfi˜ ·Ô‰¤ÎÙ˘ Ù˘ ÂÈÏÔÁ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â›Ó·È Ë ÔÌ¿‰· Ô˘ ı· ÎÏËı› Ó· ÂˆÌÈÛı› ÙËÓ ‚·Ú‡ÙËÙ· Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È Ó· ‰È·¯ÂÈÚÈÛı› Ì ÂÈÙ˘¯›·, fi¯È ÌÔÓÔ Ù· ‰ÈÂÁ¯ÂÈÚËÙÈο ÚÔ‚Ï‹Ì·Ù·, ·ÏÏ¿ Î·È ÙȘ ÂÈÏÔΤ˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·ıÒ˜ Î·È ÙËÓ Ú‡ıÌÈÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜. ∂Ô̤ӈ˜, Ë ·ÍÈÔÏfiÁËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ˘Ô„ËÊ›Ô˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â›Ó·È Ë ÚÔÙÂÚ·ÈfiÙËÙ· Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÔÌ¿‰·˜, Ë ÂÎÙ›ÌËÛË ÙˆÓ ·Ó·ÌÂÓfiÌÂÓˆÓ ÂÁ¯ÂÈÚËÙÈÎÒÓ ‰˘ÛÎÔÏÈÒÓ Î·È ÏÂÙÔÌÂÚ‹˜ ۯ‰ȷÛÌfi˜ Ù˘ ÂÁ¯ÂÈÚËÙÈ΋˜ ÛÙÚ·ÙËÁÈ΋˜, ˆÛÙ¤ Ó· ÌËÓ ·ÈÊÓȉȷÛÙ› ·fi οÔÈ· ·Úfi‚ÏÂÙË ÂÈÏÔ΋.

OÈ ·ÛıÂÓ›˜ Ì ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË,¯ˆÚ›˜ ˘ÔΛÌÂÓ˜ ÓfiÛÔ˘˜ ¤Ú·Ó Ù˘ ΛÚÚˆÛ˘(fiˆ˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘,ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ Î.Ï.), Ì ·Ô‰ÂÎÙfi MELD (<25) ‹ ¤ÏÏÂÈ„Ë ÚÔ‚ÏÂfiÌÂÓˆÓ ÂÁ¯ÂÈÚËÙÈÎÒÓ ‰˘ÛÎÔÏÈÒÓ, fiˆ˜ ·˘ÙÔ› Ô˘ ‰ÂÓ ˘Ô‚Ï‹ıËÎ·Ó Û οÔÈ· ÂÁ¯Â›ÚËÛË ÛÙËÓ ¿Óˆ ÎÔÈÏ›· ‹ Ì ıÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜, ‰ÂÓ ÚÔ‚ÏËÌ·Ù›˙Ô˘Ó ÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰·.

O ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ÁÈ· ÙÔÓ ¯ÂÈÚÔ˘ÚÁfi ·ÊÔÚ¿ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ‚·Ú›· ÁÂÓÈ΋ ηٿÛÙ·ÛË, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› Ô˘ÛÈ·ÛÙÈο Â¤Ì‚·ÛË ˘„ËÏfiÙ·ÙÔ˘ ÎÈÓ‰‡ÓÔ˘, Ì ȉȷ›ÙÂÚ· ÌÂÁ¿Ï· ÔÛÔÛÙ¿ ıÓËÙfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜. ∂‰Ò Ô ¯ÂÈÚÔ˘ÚÁfi˜ ηÏÂ›Ù·È Ó· ·ÔÊ·Û›ÛÂÈ ÔÈÔ˘˜ ·ÛıÂÓ›˜ ·fi ·˘Ù‹ ÙËÓ ÔÌ¿‰· ı· ·ÔÎÏ›ÛÂÈ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ¤ÏÏÂÈ„Ë ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙË ¯ÒÚ· Ì·˜ ·ÔÙÂÏ› ÛËÌÂ›Ô ¤ÁÂÚÛ˘ ËıÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ, ÁÈ· ÙË ‰È¿ıÂÛ‹ ÙÔ˘˜, Û ¿ÙÔÌ· Ì ÂÏ¿¯ÈÛÙ˜ Èı·ÓfiÙËÙ˜ ÂÈ‚›ˆÛ˘ Û ۇÁÎÚÈÛË Ì ˘Ô„‹ÊÈÔ˘˜ Ì Ì›˙ÔÓ· Èı·ÓfiÙËÙ· ÂÈ‚›ˆÛ˘.

O ·ÔÎÏÂÈÛÌfi˜ ·Ô ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÓfi˜ ˘Ô„ËÊ›Ô˘ Ï‹ÙË Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Û˘Ó‰È·ÛÌÔ‡ ÂÈ̤ÚÔ˘˜ ·Ú·ÁfiÓÙˆÓ, Ô˘ ηıÈÛÙÔ‡Ó ÙËÓ ÂÁ¯Â›ÚËÛË ˘„ËÏÔ‡ Ú›ÛÎÔ˘, Ì ·ÔÁÔËÙ¢ÙÈÎfi ÔÛÔÛÙfi ÂÚÈÂÁ¯ÂÈÚËÙÈ΋˜ ıÓËÙfi-

¶›Ó·Î·˜ 1. ∞ÓÙÂӉ›ÍÂȘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ∞fiÏ˘Ù˜ ¶ÚˆÙÔ·ı‹˜ Â͈Ë·ÙÈ΋ ÓÂÔÏ·Û›· ªÂÙ·ÛÙ·ÙÈ΋ ÓfiÛÔ˜ ‹·ÙÔ˜ ¶Úԉ¢ÙÈ΋ ‹ ·Ó›·ÙÔ˜ ÌË Ë·ÙÈ΋ ÓfiÛÔ˜ (∏πV) ∂ÓÂÚÁfi˜ Û‹„Ë ÂÎÙfi˜ ¯ÔÏËÊfiÚˆÓ μ·ÚÈ¿ ηډÈÔ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ™¯ÂÙÈΤ˜ ¶ÚÔËÁËı›۷ ˘Ï·ÈÔÎÔÈÏÈ΋ ·Ó·ÛÙfïÛË £ÚfiÌ‚ˆÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ A‰˘Ó·Ì›· Û˘ÌÌÔÚÊÒÛˆ˜-ηٷÓÔ‹Ûˆ˜ Ù˘ ÔÈÎÔÁÂÓ›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜.

TˆÓ ··ÈÙ‹ÛÂˆÓ ıÂÚ·›·˜/·Ú·ÎÔÏÔ˘ı‹Ûˆ˜ Ù˘ LTx ∫·Ú‰ÈÔ·Ó·Ó¢ÛÙÈ΋ ÓfiÛÔ˜ ¶ÚÔ¯ˆÚË̤ÓË ¯ÚÔÓ›· ÓÂÊÚÈ΋ ÓfiÛÔ˜

135

136

°. πªμƒπO™

¶›Ó·Î·˜ 2. ∫·Ù·ÛÙ¿ÛÂȘ Ô˘ ÂÈϤÎÔ˘Ó ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ªÂÁ¿ÏË ËÏÈΛ· ¶ÚÔ¯ˆÚË̤ÓÔ ÛÙ¿‰ÈÔ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ (πππ-πV) ¡ÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (ÂÎÙfi˜ ·Ó ª¡ Û˘Á¯ÚfiÓˆ˜) ÀÔÍ·ÈÌ›· ·fi Ó¢ÌÔÓÈÎfi Shunt £ÚfiÌ‚ˆÛË ˘Ï·›Ô˘ Û˘ÛÙ‹Ì·ÙÔ˜ ¶ÚÔËÁËı›۷ ˘Ï·ÈÔ-ÎÔÈÏÈ΋ ·Ó·ÛÙfïÛË ¶ÚÔËÁËı›۷ Â¤Ì‚·ÛË ÛÙ· ¯ÔÏËÊfiÚ· ∫·Î‹ ıÚ¤„Ë ∞ÛΛÙ˘ ∞ıËÚÔÛÎÏËÚ˘ÓÙÈΤ˜ ‚Ï¿‚˜ ·ÔÚÙ‹˜ Î·È ÎÔÈÏȷ΋˜ ·ÚÙËÚ›·˜

OÈ ·ÓÙÂÓ‰›ÍÂȘ ·ÏÏ¿ Î·È ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÈ‚·Ú‡ÓÙÔÓ ÙËÓ Î·Ï‹ ¤Î‚·ÛË ÌÈ¿ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ·ÔÙÂÏÔ‡Ó ÙÔÓ Î·ÓfiÓ· ÂÎÙ›ÌËÛ˘ Ù˘ ÂȂȈÛËÌfiÙËÙ·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÂ Û˘Ó‰È·ÛÌfi Ì ÙËÓ Î·Ù¿Ù·ÍË Î·Ù¿ Child-Pugh Î·È ÙËÓ ‚·ıÌÔÏfiÁËÛË MELD. øÛÙfiÛÔ, ÂÎÙfi˜ ·Ô Ù· ·Ú·¿Óˆ, ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ‰È·‰Ú·Ì·Ù›˙ÂÈ Ë ÂÌÂÈÚ›· Ô˘ ·ÂÎfiÌÈÛÂ Ë ÃÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· ÙÔ˘ ªÂÙ·ÌÔÛ¯Â˘ÙÈÎÔ‡ ∫¤ÓÙÚÔ˘ ·Ô ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ ˘„ËÏÔ‡ Ú›ÛÎÔ˘. OÈ ÂÈ̤ÚÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ ÂÎÙ›ÌËÛË ÂÁ¯ÂÈÚËÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ›Ó·Î· 3. ¶›Ó·Î·˜ 3. ∂È̤ÚÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ °ÂÓÈ΋ ηٿÛÙ·ÛË ˘Ô„‹ÊÈÔ˘ ÁÈ· ª∏ ∂È̤ÚÔ˘˜ ÂÁ¯ÂÈÚËÙÈο ÚÔ‚Ï‹Ì·Ù· μ·ÙfiÙËÙ· ·ÁÁ›ˆÓ ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜

∏ ÁÂÓÈ΋ ηٿÛÙ·ÛË Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, ÙfiÛÔ ·Ó ·Ó·ÊÂÚfiÌ·ÛÙ Û η¯ÂÍ›· fiÛÔ Î·È Û ·¯˘Û·ÚΛ·. ΔÔ ÚÒÙÔ ÁÈ·Ù› Â›Ó·È ‰ËψÙÈÎfi ÁÂÓÈ΋˜ Ê˘ÛÈ΋˜ Î·È ·ÓÔÛÔÏÔÁÈ΋˜ ·‰˘Ó·Ì›·˜ Ó· ·ÓÙ·ÂͤÏıÂÈ ÛÙÔ Ô͇ٷÙÔ ÂÁ¯ÂÈÚËÙÈÎfi Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈÎfi stress Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ÙÔ ‰Â‡ÙÂÚÔ ÁÈ·Ù› ‰ËÌÈÔ˘ÚÁ› ‰ÈÂÁ¯ÂÈÚËÙÈο Ù¯ÓÈο ÚÔ‚Ï‹Ì·Ù· ηıÒ˜ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈο ÚÔ‚Ï‹Ì·Ù· ·ÔÁ·Ï·ÎÙÈÛÌÔ‡ ·Ô ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÛÙË ª∂£. ∞Ô Ù· ÂÈ̤ÚÔ˘˜ ÂÁ¯ÂÈÚËÙÈο ÚÔ‚Ï‹Ì·Ù·, ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ¤¯Ô˘Ó ÔÈ ÂÁ¯ÂÈÚ‹ÛÂȘ Ô˘ ¤¯ÂÈ ˘Ô‚ÏËı› ÛÙÔ ·ÚÂÏıfiÓ Ô ·ÛıÂÓ‹˜ (¶›Ó·Î·˜ 4), Ô˘ ηıÈÛÙÔ‡Ó ÙÔ˘˜ ÂÁ¯ÂÈÚËÙÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜ ȉȷ›ÙÂÚ· ·ÈÌÔÚÚ·ÁÈÎÔ‡˜, ‰Â‰Ô̤Ó˘ Î·È Ù˘ ˘„ËÏ‹˜

˘Ï·›·˜ ˘¤ÚÙ·Û˘ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜. ¶Ú¤ÂÈ Â›Û˘ Ó· ÂÛÙÈ·ÛÙ› Ô ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÔ‡ ÛÙÔ ‚·ıÌfi ˘Ï·›·˜ ˘¤ÚÙ·Û˘ ÙÔ˘ ·ÛıÂÓÔ‡˜. ∞˘Ù‹ Û˘ÓÂÎÙÈÌ¿Ù·È ·Ô Ù· Â˘Ú‹Ì·Ù· Ù˘ ÔÈÛÔÊ·ÁÔÛÎfiËÛ˘ –Á·ÛÙÚÔÛÎfiËÛ˘ Î·È ·Ô Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ù˘ MRI ÛÏËÓÔ˘Î·ÈÔÁÚ·Ê›·˜, fiÔ˘ ηٷÁÚ¿ÊÔÓÙ·È ÔÈ ÎÈÚÛÈÎÔ› Û¯ËÌ·ÙÈÛÌÔ› ÂÚÈ˘Ï·›·, ÛÙȘ ‡Ï˜ ÙÔ˘ ‹·ÙÔ˜, ÂÚÈÛÏËÓÈο ·ÏÏ¿ Î·È ÔÈÛıÔÂÚÈÙÔÓ·˚ο. ΔÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ‰›ÎÙ˘Ô˘ ÙˆÓ ÎÈÚÛÒÓ, ÚÔ˚‰Â¿˙ÂÈ ÁÈ· ÙËÓ ·ÈÌÔÚÚ·ÁÈÎfiÙËÙ· ÙˆÓ ÂÁ¯ÂÈÚËÙÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ. ¶›Ó·Î·˜ 4. ¶ÚÔËÁËı›Û˜ ¯ÂÈÚÔ˘ÚÈΤ˜ ÂÂÌ‚¿ÛÂȘ Ô˘ ÂÈ‚·Ú‡ÓÔ˘Ó ÙËÓ ÂͤÏÈÍË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ °ÂÓÈ΋˜ ÃÂÈÚÔ˘ÚÁÈ΋˜: ∂Á¯ÂÈÚ‹ÛÂȘ ¿Óˆ ÎÔÏ›·˜ (°·ÛÙÚÂÎÙÔÌ‹ / ™ÏËÓÂÎÙÔÌ‹ / ∂ÈÏÂÁ̤ÓË ÂÁ¯Â›ÚËÛË ¯ÔÏËÊfiÚˆÓ) ™˘ÌÊ˘ÛÈfiÏ˘ÛË (∂ÈÏÂfi˜) ∂ÓÙÂÚÂÎÙÔÌ‹ ∞ÁÁÂÈÔ¯ÂÈÚÔ˘ÚÁÈ΋˜: ∞ÓÔȯً ÂÁ¯Â›ÚËÛË ∞ÔÚÙÈÎÔ‡ ∞Ó¢ڇÛÌ·ÙÔ˜ £ÚfiÌ‚ˆÛ˘ ∞ ÌÂÛÂÓÙÂÚ›Ô˘ ∂Á¯ÂÈÚ‹ÛÂȘ ÁÈ· ˘Ï·›· ˘¤ÚÙ·ÛË ¶ÚÔËÁËı›۷ ª ∏

∏ ‚·ÙfiÙËÙ· ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ˘Ô„ËÊ›Ô˘ Ï‹ÙË ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ·fiÚÚÈ„Ë ‹ Û˘ÌÂÚ›ÏË„‹ ÙÔ˘ ÛÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ÚfiÁÚ·ÌÌ·. ∏ ÌÂÚÈ΋ ·fiÁÚ·ÍË Ù˘ ˘Ï·›·˜ ·Ô ÌfiÓË Ù˘ ‰ÂÓ ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË. øÛÙfiÛÔ Â¿Ó Ë ·fiÊÚ·ÍË Â›Ó·È Ï‹Ú˘ Î·È ÛÎÈ·ÁÚ·ÊÂ›Ù·È Ô ˘fiÏÔÈÔ˜ ¿ÍÔÓ·˜ (ÛÏËÓÈ΋ Î·È · ÌÂÛÂÓÙ¤ÚÈÔ˜ ÊϤ‚·), Ù· ÂÁ¯ÂÈÚËÙÈο Ù¯ÓÈο ÚÔ‚Ï‹Ì·Ù· Â›Ó·È ·Ó˘¤Ú‚ÏËÙ· Î·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ ¤¯ÂÈ ¤Ó‰ÂÈÍË. ™Â Ì›· Ù¤ÙÔÈ· ηٿÛÙ·ÛË Ô ¯ÂÈÚÔ˘ÚÁfi˜ ηٷʤ˘ÁÂÈ ÛÙËÓ ·Ó·ÛÙfïÛË Ù˘ ˘Ï·›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì οÔÈÔ ÎÈÚÛfi, ÁÂÁÔÓfi˜ Ô˘ ÛÙÔ Ì¤ÁÈÛÙÔ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ·ÚΛ ÁÈ· ÙËÓ ÙÚÔÊÔ‰ÔÛ›· Ù˘ ˘Ï·›·˜ Î·È Â›Ù ıÚÔÌ‚ÒÓÂÙ·È Â›Ù ÈÛ¯·ÈÌ› ˘Ï·›·. ∏ Ë·ÙÈ΋ ·ÚÙËÚ›· ÌÔÚ› Ó· Ì‹Ó ÛÎÈ·ÁÚ·ÊÂ›Ù·È ¯ˆÚ›˜ ·˘Ùfi Ó· ·ÔÙÂÏ› Ì›˙ÔÓ Úfi‚ÏËÌ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ì¤Ûˆ Â͈·Ó·ÙÔÌÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (Jump graft) ÌÔÚ› Ó· ÏËÊı› ‰Ôı› ·›Ì· ÛÙËÓ Ë·ÙÈ΋ ·ÚÙËÚ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ô ÙËÓ ·ÔÚÙ‹ ÙÔ˘ Ï‹ÙË. ¶ÚÔ‚Ï‹Ì·Ù· ·Ó·Ì¤ÓÂÙ·È Ó· ‰ËÌÈÔ˘ÚÁËıÔ‡Ó Û ÂÎÙÂٷ̤ÓË ·ıËڈ̿وÛË Ù˘ ·ÔÚÙ‹˜ ÔfiÙÂ Â›Ó·È Ôχ ·˘ÍË̤Ó˜ Ë Èı·ÓfiÙËÙ· ‰ËÌÈ-

METAMO™XEY™Eπ™ 2010

Ô˘ÚÁ›·˜ „¢‰·Ó¢ڇÛÌ·ÙÔ˜ ‹ η΋˜ Ù¯ÓÈο ·Ó·ÛÙfïÛ˘ ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÛÙËÓ ·ÔÚÙ‹, ÌÂ Û˘Ó¤ÂÈ· ›Ù ڋÍË ÙÔ˘ „¢‰Ô·Ó¢ڇÛÌ·ÙÔ˜ ›Ù η΋ ÏÂÈÙÔ˘ÚÁ›· ‹ ·fiÊÚ·ÍË Ù˘ ·Ó·ÛÙfïÛ˘. ∏ ıÚfiÌ‚ˆÛË ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ ‰ÂÓ ·ÔÙÂÏÔ‡Ó Ì›˙ÔÓ· ·ÓÙ¤Ó‰ÂÈÍË, ÂÎÙfi˜ ·Ó Û˘Ó‰È¿˙ÔÓÙ·È Ì ıÚfiÌ‚ˆÛË Ù˘ οو ÎÔ›Ï˘. ™Â Û¿ÓÈ· ÂÚÈÛÙÂÙÈο Ô ıÚfiÌ‚Ô˜ ÌÔÚ› Ó· ÂÎÙ›ÓÂÙ·È ¤ˆ˜ ÙÔÓ ÎfiÏÔ (atrium) ηٿÛÙ·ÛË Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ÙËÓ Û˘Ì‚ÔÏ‹ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÔÌ¿‰·˜ Î·È ÙÔÓ ·ÛıÂÓ‹ Ó· Ú¤ÂÈ Ó· ˘Ô‚ÏËı› Û Â͈ۈ̷ÙÈ΋ ΢ÎÏÔÊÔÚ›·. ∂›Û˘ Ú¤ÂÈ Ó· Û˘ÓÂÎÙÈÌËıÔ‡Ó ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔÓ ›Ó·Î· 5. ¶›Ó·Î·˜ 5. ™˘ÓÂÎÙÈÌÒÌÂÓÔÈ ¶·ıÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∞ÈÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù· ªË ÂÏÂÁ¯fiÌÂÓÔ˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ ΔÈÌ‹ ¯ÔÏÂÚ˘ıÚ›Ó˘ (>20mg/dL) μ·ıÌfi˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ™Ù¿‰ÈÔ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ∫·Ú‰ÈÔÓ¢ÌÔÓÈÎfi status

∞Ô Ù· ·Ú·¿Óˆ Á›ÓÂÙ·È Ê·ÓÂÚfi fiÙÈ ¤Ó·˜ ‚·ÚÈ¿ ·ÛıÂÓ‹˜ Â›Ó·È ‰ËψÙÈÎfi˜ ˘„ËÏ‹˜ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋˜ ıÓËÙfiÙËÙ·˜, fiÙ·Ó Û˘Ó‰È¿˙ÂÈ 4 ÙÔ˘Ï¿¯ÈÛÙÔÓ ·Ô ÙÔ˘˜ ÚÔ·Ó·ÊÂÚı¤Ó˜ ·Ú¿ÁÔÓÙ˜, ·Ô ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ 2 Ú¤ÂÈ Ó· Â›Ó·È Ì›˙ÔÓ˜ ¯ÂÈÚÔ˘ÚÁÈÎÔ› (.¯. ·fiÊÚ·ÍË ˘Ï·›·˜ Î·È ÚÔËÁÂÈı›۷ Ì›˙ÔÓ· ÂÁ¯Â›ÚËÛË ¿Óˆ ÎÔÈÏ›·˜). ™Ù· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ÚÔ‚Ï‹Ì·Ù· ηٷ ηÈÚÔ‡˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ¤¯Ô˘Ó ·Ó·ÊÂÚı› χÛÂȘ Ô˘ fï˜ ÙÂÏÈο Â›Ó·È ÚÔÓfiÌÈÔ ÔÏ›ÁˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ ·ÁÎÔÛÌ›ˆ˜, Ô˘ ¿ÓÙÏËÛ·Ó ÙËÓ ÂÌÂÈÚ›· ÙÔ˘˜ ·Ô ÙÔ Ï‹ıÔ˜ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Ô˘ ‰È·ÎÈÓÔ‡Ó Î·È ‰ÂÓ ·ÔÙÂÏÔ‡Ó Û˘Ó‹ıË ¯ÂÈÚÔ˘ÚÁÈ΋ ‰˘Ó·ÙfiÙËÙ· Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È ÛÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ. ∏ ·fiÊ·ÛË Ó· ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤Ó·˜ ‚·ÚÈ¿ ·ÛıÂÓ‹˜ Ô˘ ÙÂÏÈο ηٷϋÁÂÈ Â›Ù ‰ÈÂÁ¯ÂÈÚËÙÈο ›Ù ÙȘ Ù˜ ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ Ë̤Ú˜, ¤¯ÂÈ ˆÚÈṲ̂Ó˜ ÂÈÙÒÛÂȘ ÛÙËÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÔÌ¿‰·: ·Ô ÙȘ ÚÒÙ˜ ÂÓÙ˘ÒÛÂȘ Ô˘ Ï·ÓÒÓÙ·È Â›Ó·È Ë ÎÚÈÙÈ΋ fiÙÈ ˘¿Ú¯ÂÈ ¤ÏÏÂÈÌ· Ë ÂÁ¯ÂÈÚËÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÚfiÌÔÈˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ·Ô ÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· Î·È ÂÔ̤ӈ˜ ÔÈ ·ÛıÂÓ›˜ ·˘ÙÔ› Ú¤ÂÈ Ó· ÚÔˆıÔ‡ÓÙ·È Û ΤÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡. 줂·È·, Ë ÂÌÂÈÚ›· ·Ô Ù· ÂÚÈÛÙ·ÙÈο ·˘Ù¿ ‰Â›¯ÓÂÈ fiÙÈ

137

ÂÏ¿¯ÈÛÙ· ΤÓÙÚ· ÛÙÔ Â͈ÙÂÚÈÎfi ·Ó·Ï·Ì‚¿ÓÔ˘Ó ÂÓ Ù¤ÏÂÈ Ó· Ù· ·ÓÙÈÌÂÙˆ›ÛÔ˘ÓË Î·È, ‚¤‚·È·, Ì ÂÓȯڿ ·ÔÙÂϤÛÌ·Ù·. ∏ η΋ ÂͤÏÈÍË Ì›·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ Û ¤Ó·Ó ‚·ÚÈ¿ ·ÛıÂÓ‹, ‰ËÌÈÔ˘ÚÁ› ·›ÛıËÌ· ·ÔÁÔ‹Ù¢Û˘ ÛÙÔ˘˜ ÂÌÏÂÎfiÌÂÓÔ˘˜ È·ÙÚÔ‡˜ ÁÈ· ÙËÓ ·ÓÂÈÙ˘¯‹ ÂͤÏÈÍË Ì›·˜ Ôχ ÌÂÁ¿Ï˘ ÚÔÛ¿ıÂÈ·˜. ΔÔ ‹‰Ë ÂÈ‚·Ú˘Ì¤ÓÔ Îϛ̷ ÂÈÙ›ÓÂÈ ÙÔ ËıÈÎÔ‡‰ÂÔÓÙÔÏÔÁÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ‰›ÏËÌÌ· fiÙÈ, Ë ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Èı·ÓfiÓ Ó· ÛÙÔȯ›ÛÂÈ ÙËÓ ˙ˆ‹ Î·È Û ÂÓ· ¿ÏÏÔ ˘Ô„‹ÊÈÔ Ï‹ÙË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ı· ÌÔÚÔ‡Û ӷ ¯ÚËÛÈÌÔÔÈËı› Ì ÂÈÙ˘¯›· Û ·ÛıÂÓ‹ ¯ˆÚ›˜ Ù· ÚÔ‚Ï‹Ì·Ù· Ô˘ ηıÈÛÙÔ‡Û·Ó ·Î·Ù¿ÏÏËÏÔ ÙÔ ‚·ÚÈ¿ ·ÛıÂÓ‹ Ô˘ ÂÈϤÁËΠӷ ÌÂÙ·ÌÔÛ¯Â˘ı›. ∂›Û˘ Ì›· Ù¤ÙÔÈ· ·ÔÙ˘¯›· Û˘ÓÙÂÏ› ÛÙË ‰ËÌÈÔ˘ÚÁ›· ‰˘ÛÌÂÓÔ‡˜ Îϛ̷ÙÔ˜ ÁÈ· ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ Î·È Á›ÓÂÙ·È ·ÈÙ›· ÛÔ‚·Ú‹˜ ÔÈÎÔÓÔÓÈ΋˜ ·ÒÏÂÈ·˜ Ì ÂÌÊ·Ó‹ Â›ÙˆÛË ÛÙÔ ∫ÔÈÓˆÓÈÎfi Û‡ÓÔÏÔ. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÔÙÂÏ› ·Ó·ÌÊÈÛ‚‹ÙËÙ· ÛˆÙ‹ÚÈ· Â¤Ì‚·ÛË ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÔÔ‡ÌÂÓË Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘. ∏ ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ó·È ÌÂÓ ·ÔÙÂÏ› ÌÈ· ηıãfiÏ· ‰ÂÔÓÙÔÏÔÁÈο ·„ÂÁ¿‰È·ÛÙË Ú¿ÍË, ÔÛÙÒÛÔ ÛÙȘ ÂÚÈÙÒÛÂȘ ‚·Ú›·˜ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙˆÓ ·ÛıÂÓÒÓ, ÌÔÚ› Ó· ÎÈÓÂ›Ù·È ÛÙÔ Â›Â‰Ô ÙÔ˘ ÂÈı˘ÌËÙÔ‡ Î·È fi¯È ÙÔ˘ ÂÊÈÎÙÔ‡.∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· ·ÔÙÂÏ› ÙÔÓ ÙÂÏÈÎfi ËıÌfi, fiÔ˘ Ì ·ÓÙÈÎÂÈÌÂÓÈο Î·È ·Ì¿¯ËÙ· ÎÚÈÙ‹ÚÈ·, ı· ÚÂ¤È Ó· ·ÔÊ·Û›˙ÂÙ·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË. Δ· ÎÚÈÙ‹ÚÈ· ·˘Ù¿ ÔÊ›ÏÔ˘Ó Ó· ÌËÓ ·Ê›ÛÙ·ÓÙ·È Î·È Ù˘ ËıÈ΋˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÌÈ· ·ÔÙ˘¯Ë̤ÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiˆ˜ ·˘Ù‹ Ô˘ ı· ·Ú¤‚ÏÂ ÙȘ ·ÓÙ‰›ÍÂȘ, ÛÙÂÚ›,fi¯È ÙËÓ Èı·ÓfiÙËÙ·, ·ÏÏ¿ ÙËÓ ‚‚·ÈfiÙËÙ· Ó· ÂÈ‚ÈÒÛÂÈ ¤Ó·˜ ¿ÏÏÔ˜ ·ÛıÂÓ‹˜. ΔÔ Úfi‚ÏËÌ· ÙˆÓ ·ÛıÂÓÒÓ Ì ‚·Ú›· ÁÂÓÈ΋ ηٿÛÙ·ÛË, ı· ÌÔÚÔ‡Û ӷ ·ÓÙÈÌÂÙˆÈÛÙ› ÂÊfiÛÔÓ ˘‹Ú¯Â ·ÚfiÛÎÔÙË Î·È Î·ıËÌÂÚÈÓ‹ ÚÔ‹ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÒÛÙ ӷ ÌËÓ ·‰ÈÎÂ›Ù·È Î·Ó›˜ ·fi ·˘ÙÔ‡˜ Ô˘ ÂÚÈ̤ÓÔ˘Ó ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ÛËÌÂÚÈÓ‹ fï˜ ηٿÛÙ·ÛË ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ ÛÙËÓ ∂ÏÏ¿‰·, ‰ÂÓ ÂÈÙÚ¤ÂÈ ·ÚfiÌÔȘ ÛΤ„ÂȘ. øÛÙfiÛÔ, Î·È ÛÙËÓ ˘ÔıÂÙÈ΋ ÂÚ›ÙˆÛË Ô˘ ˘‹Ú¯Â ·ÊıÔÓ›· ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÂÁ›ÚÔÓÙ·È ¿ÏÏ· ÂÚˆÙ‹Ì·Ù· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ÙfiÛÔ Ì ÙÔ ÓÂ˘Ì·ÙÈÎfi Î·È ÛˆÌ·ÙÈÎfi ÎfiÛÙÔ˜ ÌÈ·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙˆÓ ·ÓıÚÒˆÓ Ô˘ ÂÌϤÎÔÓÙ·È Û ·˘Ù‹ fiÛÔ Î·È Ì ÙÔ ÔÈÎÔÓÔÌÈÎfi ÎfiÛÙÔ˜ Ô˘ Â›Ó·È È‰È·›ÙÂÚ· ˘„ËÏfi.

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°. πªμƒπO™

™Â ¯ÒÚ˜ Ì ̷ÎÚ¿ ÂÌÂÈÚ›· ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜, fiÔ˘ ÂÍ ·ÓÙÈÎÂÈ̤ÓÔ˘ ‰ÂÓ Ù›ıÂÙ·È ı¤Ì· ÂÌÂÈÚ›·˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·ÛıÂÓÒÓ Ôχ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ÔÈ ÂÈÏÔÁ¤˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÎÔÏÔ˘ıÔ‡Ó ÙËÓ ÚÔÔÙÈ΋ Ô˘ ı· ¤¯ÂÈ ¤Ó·˜ ‚·ÚÈ¿ ·ÛıÂÓ‹˜ Ó· ÂÈ‚ÈÒÛÂÈ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Jagganath S, kaloo AN. Biliary complications after liver transplantation. Curr Treat Opin Gastoenterol 5: 101112, 2002.

2. Cavallari A, Vivarelli M, Bellusci R, et al. Treatment of vascular complications following liver transplantation: Multidisciplinary approach. Heepatogastroenterology 48: 179-183, 2001.

3. Holt CD, Winston DJ. Infections after liver transplantation. In: Transplantation of the liver.Busuttil RW, Klintmaim GK (eds), Philadelphia, Elsevier Saunders, pp 963-994, 2005.

4. Klintmalm GB, Nery JR, HusbergbBS, et al: Rejection in liver transplantation. Hepatology 10: 978-985, 1989.

5. Lipshutz GS, Ascher NL, Roberts JP. Rejection after transplantation. In: Transplantation of the liver.

Busuttil RW, Klintmaim GK, (eds), Philadelphia, Elsevier Saunders, pp 1167-1182, 2005.

6. Adam R, McMaster P, O’Grady JG, et al: Evolution of liver Transplantation in Europe: Reporet of the European Liver Transplantation Registry. Liver Transpl 9: 1231-1243, 2003.

¶AƒA°O¡ΔE™ ¶OY E¶∏ƒEAZOYN THN E¶πμπø™∏ META A¶O TEXNIKA E¶πΔYXHMENH METAMO™ÃEY™∏ ∏¶ATO™

AÓÙÈÌÂÙÒÈÛË ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ π. °Ô˘Ï‹˜ ¢ÈÂÁ¯ÂÈÚËÙÈ΋ ·ÈÌÔÚÚ·Á›· Î·È fiÁÎÔ˜ ÌÂÙ·ÁÁÈ˙fiÌÂÓˆÓ ·Ú·ÁfiÓÙˆÓ ·›Ì·ÙÔ˜ ∫Ï·ÛÛÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ vs Ù¯ÓÈ΋ piggyback ÕÏÏÔÈ ÎÏ·ÛÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘

∏ ÔÍ›· Î·È ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ‚Ï¿‚Ë ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ·˘ÍË̤ÓË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. ∏ ·‡ÍËÛË Ù˘ ÂÈ‚›ˆÛ˘ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ ÙËÓ ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÛÙËÓ ÎÔÚ˘Ê‹ ÙˆÓ ÂÈÏÔÎÒÓ ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì ÙË Ì·ÎÚfiÙÂÚË ÂÈ‚›ˆÛË. ™ÙËÓ ·ÚÔ‡Û· ÂÈÛ‹ÁËÛË Î·Ù·ÁÚ¿ÊÔÓÙ·È ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. °›ÓÂÙ·È Â›Û˘ ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÚ·ÙËÁÈÎÒÓ Ô˘ ¤¯Ô˘Ó ÛÙfi¯Ô ÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· de novo ÂÌÊ¿ÓÈÛË ÓÂÊÚÈ΋˜ ‚Ï¿‚˘ ‹ ÁÈ· ηı˘ÛÙ¤ÚËÛË ÂͤÏÈ͢ ÚÔ¸¿Ú¯Ô˘Û·˜ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜, ÒÛÙ ӷ ‚ÂÏÙȈıÔ‡Ó Ù· Ì·ÎÚÔ¯ÚfiÓÈ· ·ÔÙÂϤÛÌ·Ù· Ù˘ Ë·ÙÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘. °È· ÙËÓ Î·Ï˘ÙÂÚË Î·Ù·ÓfiËÛË ÙÔ˘ ı¤Ì·ÙÔ˜ ÂÈϤ¯ıËΠӷ ·ÚÔ˘ÛÈ·ÛıÔ‡Ó Ù· ‰Â‰Ô̤ӷ ÁÈ· ‰‡Ô ‰È·ÊÔÚÂÙÈΤ˜ ¯ÚÔÓÈο ÂÚÈfi‰Ô˘˜: ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ Î·È ÙËÓ ÂÚ›Ô‰Ô Ì·ÎÚ¿˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜.

3. ªÂÙÂÁ¯ÂÈÚËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜: OÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË ‰Â˘ÙÂÚÔ·ı‹˜ Û ÈÛ¯·ÈÌÈο ‹ ÙÔÍÈο ·›ÙÈ· ∫·ı˘ÛÙÂÚË̤ÓË Ë·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÌÔۯ‡̷ÙÔ˜ ‹ ÚˆÙÔÁÂÓ‹˜ ÌË ÏÂÈÙÔ˘ÚÁ›· ™‡Ó‰ÚÔÌÔ ÌÂÙ¿ Â·Ó·ÈÌ¿ÙˆÛË ¡ÂÊÚÔ¿ıÂÈ· ·fi ÛÎÈ·ÛÙÈÎfi º·Ú̷΢ÙÈ΋ ‰È¿ÌÂÛË ÓÂÊÚ›Ùȉ· ¶·Ú·ÙÂٷ̤ÓË ¯ÔÚ‹ÁËÛË ÓÙÔ·Ì›Ó˘ ‹ ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÒÓ ªÈÎÚԂȷ΋ Ïԛ̈ÍË ∞ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂÚ·›· Ì ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ (calcineurin inhibitors-CNI)

™ÙÚ·ÙËÁÈΤ˜ ÁÈ· ÙË Ì›ˆÛË ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË

¶·Ú·ÁfiÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÛÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô

™˘ÓÙÔÓÈṲ̂Ó˜ ÚÔÛ¿ıÂȘ Ú¤ÂÈ Ó· ηٷ‚¿ÏÏÔÓÙ·È ÁÈ· ÙËÓ ÚfiÏË„Ë ‹ ÙËÓ Ì›ˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ ·Ó¿Ù˘Í˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ‹ Ë·ÙÔÓÂÊÚÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. Δ· Èı·Ó¿ ÏÂÔÓÂÎÙ‹Ì·Ù· ·fi ÙË ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ, Ï·ÎÙÔ˘Ïfi˙˘, ÓÂÊÚÔÙÔÍÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ª™∞º Î·È ·Ó·ÛÙÔϤˆÓ COX-2, ‹ ¤ÎıÂÛË Û ÛÎÈ·ÛÙÈΤ˜ Ô˘Û›Â˜ Ú¤ÂÈ Ó· ˙˘Á›˙ÔÓÙ·È ¤Ó·ÓÙÈ ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÚfiÎÏËÛ˘ Ë·ÙÔÓÂÊÚÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘. ∂›Û˘ ı· Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Ì·˙ÈΤ˜ ÂÎÎÂÓˆÙÈΤ˜ ·Ú·ÎÂÓÙ‹ÛÂȘ ȉȷ›ÙÂÚ· Û ·ÛıÂÓ›˜ Ì ˘Ô·Ï‚Ô˘ÌÈÓ·ÈÌ›· ‹ ·ÛΛÙË ¯ˆÚ›˜ ÂÚÈÊÂÚÈο Ôȉ‹Ì·Ù·. °È· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ΢ÎÏÔÊÔÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ·Ú·Î¤ÓÙËÛË (paracenteses-induced circulatory dysfunction) Û˘ÓÈÛÙ¿Ù·È Ë ¯ÔÚ‹ÁËÛË ·Ï‚Ô˘Ì›Ó˘ (Û˘Ó‹ıˆ˜ 8 g/l), ȉȷ›ÙÂÚ· Û ÂÚÈÙÒÛÂȘ ÂÎÎÂÓˆÙÈ΋˜ ·Ú·Î¤ÓÙËÛ˘ ¿Óˆ ÙˆÓ 5 lt ·ÛÎÈÙÈÎÔ‡ ˘ÁÚÔ‡2. ∞ÎfiÌË Û ·ÛıÂÓ›˜ Ì ·˘ÙfiÌ·ÙË ‚·ÎÙËÚȷ΋ ÂÚÈÙÔÓ›Ùȉ· Ë

™Ô‚·ÚÔ‡ ‚·ıÌÔ‡ ÔÍ›· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ô˘ ··ÈÙ› ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ ÂÚÈÁÚ¿ÊÂÙ·È Û ÔÛÔÛÙfi 5%-35% ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜1. OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÔÍ›·˜ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÌÔÚÔ‡Ó Ó· ‰È·¯ˆÚÈÛıÔ‡Ó Û ·Ú¿ÁÔÓÙ˜ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ‰ÈÂÁ¯ÂÈÚËÙÈÎÔ‡˜ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ˆ˜ ÂÍ‹˜: 1. ¶·Ú¿ÁÔÓÙ˜ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË:

¡ÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ∏·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ À„ËϤ˜ ÙÈ̤˜ ¯ÔÏÂÚ˘ıÚ›Ó˘ ÀÔÚˆÙÂ˚Ó·ÈÌ›·, ˘Ô·Ï‚ÈÌÔ˘Ó·ÈÌ›· ÀÔÓ·ÙÚÈ·ÈÌ›·

2. ¢ÈÂÁ¯ÂÈÚËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∞ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· ηٿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ·Ó·ÈÛıËÛ›·˜ Î·È ÙËÓ ·ÓË·ÙÈ΋ Ê¿ÛË

141

142

π. °√À§∏™

¯ÔÚ‹ÁËÛË ·Ï‚Ô˘Ì›Ó˘ (1.5g/kg ™μ ηٿ ÙË ‰È¿ÁÓˆÛË Î·È 1g/kg ™μ ÙËÓ Ë̤ڷ 3) ÌÂÈÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ÙË ıÓËÙfiÙËÙ· ΢ڛˆ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· ηٿ ÙË ‰È¿ÁÓˆÛË3. ¶ÚfiÛÊ·Ù˜ ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÔÈ ÏÔÈÌÒÍÂȘ ÙˆÓ ¯ÔÏËÊfiÚˆÓ Î·È ÙÔ˘ Á·ÛÙÙÚÂÓÙÂÚÈÎÔ‡ ηıÒ˜ Î·È Ë ·˘ÙfiÌ·ÙË ‚·ÎÙËÚȷ΋ ÂÚÈÙÔÓ›Ùȉ· Î·È ÔÈ Ô˘ÚÔÏÔÈÌÒÍÂȘ Â›Ó·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ˘‡ı˘Ó˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÔÍ›·˜ Âȉ›ӈÛ˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË Î·È ·ÛΛÙË4.

™ÙÚ·ÙËÁÈΤ˜ ÁÈ· ÙË Ì›ˆÛË ÙˆÓ ‰ÈÂÁ¯ÂÈÚËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ∫·ıÔÚÈÛÙÈο ‚‹Ì·Ù· ÁÈ· ÙË Ì›ˆÛË ·˘ÙÒÓ ÙˆÓ ÎÈÓ‰‡ÓˆÓ Â›Ó·È Ô ¤ÏÂÁ¯Ô˜ Ù˘ ·ÈÌÔÚÚ·Á›·˜, Ë ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚÔÔ›ËÛË, Ë Ú‡ıÌÈÛË ÙˆÓ ˘ÁÚÒÓ, Î·È Ë ‚ÂÏÙÈÛÙÔÔ›ËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜. ∏ ÂÊ·ÚÌÔÁ‹ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ÂÌÊ¿ÓÛÈÛ˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ‰ÂÓ ·ÔÙÂÏ› ·ÓÙÈΛÌÂÓÔ ·˘Ù‹˜ Ù˘ ÂÈÛ‹ÁËÛ˘.

™ÙÚ·ÙËÁÈΤ˜ ÁÈ· ÙË Ì›ˆÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÛÙËÓ ÚÒÈÌË ÂÚ›Ô‰Ô ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ∂ÂÈÛfi‰È· ·ÈÌÔÚÚ·Á›·˜ ηıÒ˜ Î·È ÏÔÈÌÒÍÂȘ ÛÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô Ú¤ÂÈ Ó· ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ¿ÌÂÛ· Î·È Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÂÈıÂÙÈο. ∏ ¯Ú‹ÛË ÛÎÈ·ÛÙÈÎÒÓ Ô˘ÛÈÒÓ ‹ ÓÂÊÚÔÙÔÍÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ı· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È fiÛÔ ·˘Ùfi Â›Ó·È ÂÊÈÎÙfi. ŸÏ˜ ÔÈ ıÂÚ·¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Û ·ÛıÂÓ›˜ Ì ÚÔ¸¿Ú¯ÔÓ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ ‹ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ı· Ú¤ÂÈ Ó· ÙÚÔÔÔÈÔ‡ÓÙ·È Î·Ù¿ÏÏËÏ·. Δ· ÚˆÙfiÎÔÏÏ· ·ÔÊ˘Á‹˜ ¯ÔÚ‹ÁËÛ˘ ·Ó·ÛÙÔÏÂÒÓ Î·ÏÛÈÓ¢ڛÓ˘ ÁÈ· ÙËÓ ÚfiÏË„Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ÔÍ›·˜ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÈÎÙ¿ ·ÔÙÂϤÛÌ·Ù·. ™ÙË Û˘Ó¤¯ÂÈ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ‰Â‰Ô̤ӷ ·ÛÊ¿ÏÂÈ·˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ ·˘ÙÒÓ: ∫·ı˘ÛÙÂÚË̤ÓË ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘: Û¯‹Ì·Ù· Â·ÁˆÁ‹˜ Ì ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ™¯‹Ì·Ù· Â·ÁˆÁ‹˜ Ì ·ÓÙÈÛÒÌ·Ù· ÂÍ¿ÏÂȄ˘ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (fiˆ˜ Ë ı˘ÌÔÁÏÔ‚Ô˘Ï›ÓË) ‹ ÌË ÂÍ¿ÏÂȄ˘ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (fiˆ˜ ÔÈ ·Ó·ÛÙÔÏ›˜

˘Ô‰Ô¯¤ˆÓ IL-2) Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ë Î·ı˘ÛÙÂÚË̤ÓË (ηٿ 3-7 Ë̤Ú˜) ÂÈÛ·ÁˆÁ‹ ·Ó·ÛÙÔÏÂÒÓ Î·ÏÛÈÓ¢ڛÓ˘ Èı·ÓÒ˜ Ó· ÚÔÛÙ·ÙÂ‡Ô˘Ó ‹ Ó· ‚ÂÏÙÈÒÓÔ˘Ó ÙË ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Û ·ÛıÂÓ›˜ Ì ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Ì ÚÔ¸¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÔ˘ÚÁ›· ¯ˆÚ›˜ Ó· ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·fiÚÚȄ˘ ‹ Ó· ı¤ÙÔ˘Ó Û ΛӉ˘ÓÔ ÙËÓ ÂÈ‚›ˆÛË ·ÛıÂÓÔ‡˜ Î·È ÌÔۯ‡̷ÙÔ˜. øÛÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚ˜ ηı˘ÛÙÂÚ‹ÛÂȘ ÛÙËÓ ÂÈÛ·ÁˆÁ‹ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ ÌÔÚ› Ó· ·˘Í‹ÛÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÔÍ›·˜ ·fiÚÚȄ˘5,6. ∂›Û˘ ÔÈ Ì·ÎÚÔ¯ÚfiÓȘ Û˘Ó¤ÂȘ Ù˘ Â·ÁˆÁ‹˜ Ì ·ÓÙÈÛÒÌ·Ù· ÛÙË Ê˘ÛÈ΋ ÈÛÙÔÚ›· Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢ ÛÙÔ ÌfiÛ¯Â˘Ì· ‰ÂÓ ¤¯Ô˘Ó ·ÎfiÌË ÍÂηı·Ú›ÛÂÈ.

ÃÔÚ‹ÁËÛË ·ÓÔÛÔηٷÛÙÔÏ‹˜ ‚·ÛÈṲ̂ÓË Û de novo ¯ÔÚ‹ÁËÛË sirolimus Û ÚˆÙfiÎÔÏÏ· ¯ˆÚ›˜ ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ÛÙÚ·ÙËÁÈ΋ de novo ¯ÔÚ‹ÁËÛË sirolimus Û ÚˆÙfiÎÔÏÏ· ¯ˆÚ›˜ ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ Â›Ó·È Î·Ï¿ ·ÓÂÎÙ‹ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ Û ϋÙ˜ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÚÔ¸¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·. ™Â ÌÈ· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË 181 ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ ÔÈ Zagha Î·È Û˘Ó ¤‰ÂÈÍ·Ó ·ÚfiÌÔÈ· ÂÙ‹ÛÈ· ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÂٷ͇ ·ÛıÂÓÒÓ Û ÌÔÓÔıÂÚ·›· Ì sirolimus (n=28), Û ıÂÚ·›· Û˘Ó‰˘·ÛÌÔ‡ Ì sirolimus Î·È CNI (n=56) ‹ Û ÌÔÓÔıÂÚ·›· Ì CNI (n=101)7. H Û˘ÓÔÏÈ΋ Â›ÙˆÛË ÔÍ›·˜ ΢ÙÙ·ÚÈ΋˜ ·fiÚÚȄ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· 12 ÌËÓÒÓ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÁÈ· Ù· ÙÚ›· ·ÓˆÙ¤Úˆ Û¯‹Ì·Ù· ‹Ù·Ó 20%, 35% Î·È 31% ·ÓÙ›ÛÙÔȯ· (p=0.42). ªÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì ÚÔ¸¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ë Ì¤ÁÈÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ‰È·ÈÛÙÒıËΠ۠·ÛıÂÓ›˜ Ô˘ ¤Ï‚·Ó sirolimus ¯ˆÚ›˜ CNI. øÛÙfiÛÔ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ¿ÓÙ· ˘ãfi„ÈÓ Ë ¯ÔÚ‹ÁËÛË sirolimus Èı·ÓÒ˜ ηı˘ÛÙÂÚ› ÙËÓ ÂԇψÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜ Î·È ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÔ‚·Ú‹ ıÚÔÌ‚ÔÂÓ›· ÛÙËÓ ¿ÌÂÛË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô.

¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÂÌÊ¿ÓÈÛË ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÔÙÔ˘ÚÁ›·˜ Û ·ÛıÂÓ›˜ Ì ̷ÎÚ¿ ÂÈ‚›ˆÛË ÌÂÙ¿ ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ™ÙÔ˘˜ Û˘¯ÓfiÙÂÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Úԉ¢ÙÈ΋˜ á∞ ‹ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Û ·ÛıÂÓ›˜ Ì ̷ÎÚ¿

METAMO™XEY™Eπ™ 2010

ÂÈ‚›ˆÛË ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ CNI, ÙÔ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ÚÔ¸¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ë ‰È¿ÚÎÂÈ· Ù˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÛÙËÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÂÚ›Ô‰Ô, Ë ÂÌÊ¿ÓÈÛË ˘¤ÚÙ·Û˘, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË (ÛÙËÓ ÚÔ- ‹ ÌÂÙ·- ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÂÚ›Ô‰Ô) Î·È Ë ¯ÔÚ‹ÁËÛË ÓÂÊÚÔÙÔÍÈÎÒÓ Ê·Ú̿ΈÓ. ∞ÎfiÌË Ë ÔÍ›· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ·Ó¿ÁÎË ·ÈÌÔοı·ÚÛ˘ ÛÙËÓ ÚÔ ‹ ÌÂÙ·-ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÂÚ›Ô‰Ô, Ë ¯ÚfiÓÈ· Ë·Ù›Ùȉ· C, Î·È Ë ·˘ÍË̤ÓË ËÏÈΛ· ¤¯Ô˘Ó Â›Û˘ ÂÓÔ¯ÔÔÈËı› ÁÈ· ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ 8,9. ∫ÂÓÙÚÈÎfi ÚfiÏÔ ÌÂٷ͇ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ η٤¯ÂÈ Ë ¯ÔÚ‹ÁËÛË ÙˆÓ CNI, ηıÒ˜ Ë ¤ÏÂ˘Û‹ ÙÔ˘˜ Û˘Óԉ‡ÙËΠ·fi ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÏÏ¿ Ë ·ÛÊ·Ï‹˜ Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛ‹ ÙÔ˘˜ ·ÚÂÌÔ‰›˙ÂÙ·È ·fi ÙËÓ ·Ó¿Ù˘ÍË ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ Ì ÙËÓ ·Ó¿ÏÔÁË Û˘ÓÔ‰fi ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·.

∞ÓÙÈÌÂÙÒÈÛË ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Û ·ÛıÂÓ›˜ Ì ̷ÎÚ¿ ÂÈ‚›ˆÛË ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ∞ÓÙÈÌÂÙÒÈÛË Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ Ô˘ ÔÊ›ÏÂÙ·È Û ·ÓÔÛÔηٷÛÙÔÏ‹ ∏ ÂÊ·ÚÌÔÁ‹ ÚˆÙÔÎfiÏÏˆÓ ÂÏ·¯ÈÛÙÔÔ›ËÛ˘ Ù˘ ‰ÔÛÔÏÔÁ›·˜ ‹ ·fiÛ˘ÚÛ˘ ÙˆÓ CNI ¤¯ÂÈ ‰ÒÛÂÈ ·Ó¿ÌÈÎÙ· ·ÔÙÂϤÛÌ·Ù·10-15. OÈ ÛÙÚ·ÙËÁÈΤ˜ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Û Û ·ÛıÂÓ›˜ Ì ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ·fi CNI ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË Ì›ˆÛË Ù˘ ‰fiÛ˘ ‹ ÙËÓ ·fiÛ˘ÚÛË ÙˆÓ CNI ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¯ÔÚ‹ÁËÛË mycophenolate mofetil (MMF) ‹ ıÂÚ·›·˜ ‚·ÛÈṲ̂Ó˘ Û sirolimus. ªÈÎÚ¤˜, Úfi‰ÚÔ̘ ÌË ÂÏÂÁ¯fiÌÂÓ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÂÈÙ˘¯‹ ·ÔÙÂϤÛÌ·Ù·. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·fi ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÂÎÙÈÌ‹ıËΠ̠ÙËÓ ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ ‹ ÂÍÈÛÒÛÂȘ ‚·ÛÈṲ̂Ó˜ ÛÙËÓ ÎÚ·ÙÈÓ›ÓË, ‰Â›ÎÙ˜ Ô˘ Â›Ó·È Î·Ï¿ ÁÓˆÛÙfi fiÙÈ ·ÔÙÂÏÔ‡Ó ·Ó·ÎÚȂ›˜ ·Ú·Ì¤ÙÚÔ˘˜ ÂÎÙ›ÌËÛ˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û Ë·ÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ™ˆÛÙfiÙÂÚÔ˜ ı· ‹Ù·Ó Ô Ú·‰ÈÔÛÔÙÔÈÎfi˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ Ú˘ıÌÔ‡ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR) Ì 125π, ‹ 51Cr-EDTA. ™Â ÌÈ· ÚfiÛÊ·ÙË ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË 57 ·ÛıÂÓÒÓ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÔÊÂÈÏfiÌÂÓË Û CNI, ÔÈ DuBay ηÈ

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Û˘Ó ¤‰ÂÈÍ·Ó fiÙÈ Ë ·fiÛ˘ÚÛË ÙˆÓ CNI Î·È Ë ÌÂÙ·ÙÚÔ‹ Û sirolimus ‰ÂÓ ˘ÂÚ›¯Â ˆ˜ ÚÔ˜ ÙËÓ ‰È·Ù‹ÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û ۯ¤ÛË Ì ÙË Ì›ˆÛË Ù˘ ‰ÔÛÔÏÔÁ›·˜ ÙˆÓ CNI ÌfiÓÔ16. ¢ÂÓ ‰È·ÈÛÙÒıËÎ·Ó ‰È·ÊÔÚ¤˜ ÛÙËÓ Î¿ı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ ‹ Ù· ÂÂÈÛfi‰È· ·fiÚÚȄ˘ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÛÙÚ·ÙËÁÈÎÒÓ ·ÏÏ¿ ÔÈ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙË ¯ÔÚ‹ÁËÛË sirolimus ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ˜ Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘, ȉȿÈÙÂÚ· ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì ÛÔ‚·Ú‹ ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· (CrCl < 30 ml/min). ∞fi ÙËÓ ¿ÏÏË ‰È·ÈÛÙÒıËΠÌÈ· Ù¿ÛË ˘¤Ú Ù˘ ¯ÔÚ‹ÁËÛ˘ sirolimus Û ·ÛıÂÓ›˜ Ì ˘„ËÏfiÙÂÚË ·Ú¯È΋ ÙÈÌ‹ οı·ÚÛ˘ ÎÚ·ÙÈÓ›Ó˘ (CrCl 45-60 ml/min). ŸÌˆ˜ ηχÙÂÚ· ‹Ù·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ÚÔÔÙÈ΋˜ ÌÂϤÙ˘ ·ÓÙÈηٿÛÙ·Û˘ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ Ì everolimus ·fi ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΤÓÙÚÔ Ù˘ πÛ·Ó›·˜ Ô˘ ‰ËÌÔÛȇıËΠÔχ ÚfiÛÊ·Ù·17. ™ÙË ÌÂϤÙË ÂÚÈÏ‹ÊıËÎ·Ó 21 ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÌÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ > 1.5 mg/dL). ∏ ‰ÔÛÔÏÔÁ›· ÙÔ˘ everolimus ‹Ù·Ó 0.75mg ‰È˜ ËÌÂÚËÛ›ˆ˜ Ì ÛÙfi¯Ô ÙË ‰È·Ù‹ÚËÛË ÙˆÓ ÂÈ¤‰ˆÓ ÌÂٷ͇ 3 Î·È 8 ng/mL. ∏ ·fiÛ˘ÚÛË ÙˆÓ CNIs ¤ÁÈÓ ÂÈÙ˘¯Ò˜ Û 20/21 ·ÛıÂÓ›˜ (95.2%). ∏ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ¿ÓÈÛ ÌÈ· ÌÈÎÚ‹ ·Ú¯È΋ ‚ÂÏÙ›ˆÛË ·ÏÏ¿ ·˘Ù‹ ‰ÂÓ ‹Ù·Ó ÛÙ·ıÂÚ‹ ηıÒ˜ ÂÌÊ·Ó›ÛıËÎÂ Î·È Âȉ›ӈÛË ÛÙË Û˘Ó¤¯ÂÈ· Û ÔÚÈṲ̂ÓÔ˘˜ ·fi ·˘ÙÔ‡˜. ™ËÌ·ÓÙÈÎfi ¿ÓÙˆ˜ ‹Ù·Ó ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ ÂÌÊ·Ó›ÛıËΠ·fiÚÚÈ„Ë Û ηӤӷ ·ÛıÂÓ‹. Δ· ÚˆÙfiÎÔÏÏ· ‰È·ÎÔ‹˜ ¯ÔÚ‹ÁËÛ˘ CNI ‰Â›¯ÓÔ˘Ó Ó· ¤¯Ô˘Ó ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Û ·ÛıÂÓ›˜ ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓÔ ÂÂÈÛfi‰ÈÔ ·fiÚÚȄ˘ Î·È Û ·˘ÙÔ‡˜ Ì ÂÏ¿¯ÈÛÙ˜ ·Ó¿ÁΘ Û CNI ÚÈÓ ÙËÓ ·fiÛ˘ÚÛ‹ ÙÔ˘˜, fiˆ˜ Ê·›ÓÂÙ·È Î·È ·fi ÌÈ· ÚfiÛÊ·ÙË ÌÂϤÙË ·ÓÙÈηٿÛÙ·Û˘ ÙˆÓ CNIs Ì sirolimus18. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ Û‡Ìʈӷ Ì ÙË Û‡Á¯ÚÔÓË ‚È‚ÏÈÔÁÚ·Ê›· Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· Ì ¯ÔÚ‹ÁËÛË MMF Î·È ÔÏÈ΋ ·fiÛ˘ÚÛË ÙˆÓ CNI ÛÙËÓ ÚÒÈÌË ÂÚ›Ô‰Ô ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ·fiÚÚȄ˘. ∂ÈÚfiÛıÂÙ· Ë ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ‰ÔÛÔÏÔÁ›·˜ fiÛÔ Î·È Ë ·fiÛ˘ÚÛË ÙˆÓ CNI ÌÔÈ¿˙ÂÈ ·ÓÒÊÂÏË ÛÙËÓ ‡ÛÙÂÚË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÚ›Ô‰Ô fiÙ·Ó ¤¯ÂÈ ÂÁηٷÛÙ·ı› ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∏ ηٿÏÏËÏË ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ ÁÈ· ÙË ÌÂÙ·ÙÚÔ‹ Ù˘ ·ÓÔÛηٷÛÙÔÏ‹˜ ‰ÂÓ ¤¯ÂÈ Â› ÙÔ˘ ·ÚfiÓÙÔ˜ Â·ÚÎÒ˜ ηıÔÚÈÛı›.

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™ÙÚ·ÙËÁÈΤ˜ ÚÔʇϷ͢ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ô˘ ‰ÂÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂÚ·›·

delayed, low dose tacrolimus regomen vs. Standarddose tacrolimus and mycophenolate mofetil regimen: a multicenter randomized clinical trial. Liver Transpl 2005; 11;1064-1072.

OÈ ·ÓÙ·ÁˆÓÈÛÙ¤˜ ‰È·‡ÏÔ˘ ·Û‚ÂÛÙ›Ô˘ fiˆ˜ Ë ‰ÈÏÙÈ·˙¤ÌË Î·È Ë ‚ÂÚ··Ì›ÏË, ηıÒ˜ Î·È ÔÈ ·Ó·ÛÙÔÏ›˜ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ (ACEIs) Î·È ÔÈ ·ÓÙ·ÓÙ·ÁˆÓÈÛÙ¤˜ ˘Ô‰Ô¯¤ˆÓ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ (∞ƒμs) ÌÔÚÔ‡Ó ıˆÚËÙÈο Ó· ·Ú¿Û¯Ô˘Ó ÚÔÛÙ·Û›· ÙfiÛÔ ·fi ÙÔ Ô͇ ·ÈÌÔ‰˘Ó·ÌÈÎfi˜ ÛÙÔÈ¯Â›Ô fiÛÔ Î·È ·fi ÙË ¯ÚfiÓÈ· ‚Ï¿‚Ë19. ∂¯ÂÈ Â›Û˘ ‰È·Ù˘ˆı› Ë ¿Ô„Ë fiÙÈ ÙfiÛÔ ÔÈ ÔÈ ·Ó·ÛÙÔÏ›˜ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ (ACEIs) Î·È ÔÈ ·ÓÙ·ÓÙ·ÁˆÓÈÛÙ¤˜ ˘Ô‰Ô¯¤ˆÓ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ (∞ƒμs) ηı˘ÛÙÂÚÔ‡Ó ÙËÓ ÂͤÏÈÍË Ù˘ ‰È¿ÌÂÛ˘ ›ÓˆÛ˘. O ÚfiÏÔ˜ ÙÔ˘˜ ˆÛÙfiÛÔ ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ¤¯ÂÈ Û·ÊÒ˜ ηıÔÚÈÛı›.

Oˆ˜ Î·È ÛÙÔ˘˜ ÌË ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Û ϋÙË Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ¤ÏÂÁ¯Ô Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘, Î·È Î·Ï‹ Ú‡ıÌÈÛË ÙÔ˘ ۷ί¿ÚÔ˘. Δ¤ÏÔ˜ Û ·ÛıÂÓ›˜ Ì ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏÂÔÓÂÎÙ› ¤Ó·ÓÙÈ Ù˘ ·ÈÌÔοı·ÚÛ˘ fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÂÈ‚›ˆÛË.

7. Zaghla H, Selby RR, Chan LS et al. A comparison of sirolimus vs.calcineurin inhibitor-based immunosuppressive therapies in liver transplantation. Aliment Pharmacol Ther 2006; 23:51-520.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Contreras G, Garces G, Quartin AA, et al. An epidemiology study of early renal replacement therapy after orthotopic liver transplantation. J Am Soc Nephrol 2002; 13:228-233.

2. Ruiz del Arbol L, Monescillo A, Jimenez W, et al. Paracentesis-induced circulatory dysfunction: mechanism and effect on hepatic hemodynamics in cirrhosis.

Gastroenterology 1997; 113:579-588.

3. Ghassemi S, Garcia-Tsao G. Prevention and treatment of infections in patients with cirrhosis. Best Pract Res Clin Gastroenterol 2007; 21:77-93.

4. Fasolato S, Angeli P, Dallagnese L. Renal failure and bacterial infections in patients with cirrhosis: epidemiology and clinical features. Hepatology 2007; 45:223-229.

5. Bajjoka I, Hsaiky L, Brown K, et al. Preserving renal function in liver transplant recipients with rabbitantithyhmocyte globulin and delayed initiation of calcineurin inhibitors. Liver Transpl 2008; 14:66-72.

6. Yoshida EM, Marotta PJ, Greig PD, et al. Evaluation of renal function in liver transplant recipients receiving daclizumab (Zenapax), mycophenolate mofetil, and a

8. Gonwa TA, Mai M, Melton MB et al. End-stage renal disease (ESRD) after orthotopic liver transplantation (OLTX) using calcineurin-based immunotherapy.

Transplantation 2001; 72:1934-1939.

9. Ojo AO, Held PJ, Port FK, et al. Chronic renal failure afer transplantation of a nonrenal organ. N Engl J Med 2003; 349:931-940.

10. Pham PTT, Pham PCT, Wilkinson AH. Management of renal dysfunction in the liver transplant recipient. Curr Opin Organ Transpl 2009; 14:231-239.

11. Cantarovich M, Tzimas GN< Barkun J, et al. Efficay of mycophenolate mofetil combined with very low dose cyclosporine microemulsion in long-term liver transplant patients with renal dysfunction. Transplantation 2003; 15:98-102.

12. Reich Dj, Clavien PA, Hodge EE et al. Mycophenolate mofetil for renal dysfunction in liver transplant recipientson cyclosporine or tacrolimus: randomized, prospective, multicenter, pilot study results.

Transplantation 2005; 80:18-25.

13. Neau-Cransac M, Morel D, Bernard P-H et al. Renal failure after liver transplantation: outcome after calcineurin inhibitor withdrawal. Clin Transplant 2002; 16:368-373.

14. Watson CJE, Gimson AES, Alexander GJ, et al. A ramdomized controlled trial of late conversion from calcineurin inhibitor (CNI)-based to sirolimus-based immunosuppression in liver transplant recipients with impaired renal function. Liver Transpl 2007; 13:16941702.

15. Yang YJ, Chen LX, Li LX, et al. Sirolimus-based immunosuppressive therapy in liver transplant recipient with tacrolimus-related chronic renal insufficiency. Transpl Proc 2008; 40:1541-1544.

16. Dubay D, Smith RJ, Oiu KG, et al. Sirolimus in liver transplant recipients with renal dysfunction: a combination with reduction of calcineurin inhibitor regimens. Liver Transpl 2008; 14:651-659.

17. Castroagudin JF, Molina E, Romero R, et al. Improvement.

18. Stratta P, Canavese C, Quoaglia M, et al. Posttransplantation chronic renal damage in nonrenal transplant recipients. Kidney Int 2005; 68:143-146.

YÔÙÚÔ‹ Ù˘ ÚˆÙÔ·ıÔ‡˜ ÓfiÛÔ˘ ∂˘¿ÁÁÂÏÔ˜ ÃÔÏfiÁÎÈÙ·˜

ÓfiÛÔ˘8. OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ‰ÂÓ ¤¯Ô˘Ó Ï‹Úˆ˜ ·ÔÛ·ÊËÓÈÛÙ›, fï˜ ıˆÚÂ›Ù·È fiÙÈ Ë ·˘ÍË̤ÓË ËÏÈΛ· ÙÔ˘ ‰fiÙË ›Ûˆ˜ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË Î˘ÎÏÔÛÔÚ›Ó˘ ˆ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ÓÔ Î›Ó‰˘ÓÔ ˘ÔÙÚÔ‹˜ 7,9,10,11 , ·Ó Î·È Ë ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË ‰ÂÓ ÌfiÚÂÛ ӷ ÂȂ‚·ÈÒÛÂÈ ÙÔ ÙÂÏÂ˘Ù·›Ô ‡ÚËÌ·3. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ˘ÔÙÚÔ‹ Ù˘ PSC, Ê·›ÓÂÙ·È ˆ˜ ·Ó Î·È Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ‰ÂÓ ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο12,13, ÔÈ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ Ô‰ËÁÔ‡ÓÙ·È ÈÔ Û˘¯Ó¿ ÛÙËÓ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÏfiÁˆ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜14. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ Â›Ó·È Ë ¯Ú‹ÛË O∫Δ3, Ù· ÂÂÈÛfi‰È· ·fiÚÚȄ˘ ·ÓıÂÎÙÈο ÛÙËÓ ·ÁˆÁ‹ Ì ÎÔÚÙÈÎÔÂȉ‹ Î·È Ë Ïԛ̈ÍË ·fi CMV15-19, ·Ó Î·È ÔÈ ÌÂϤÙ˜ ·˘Ù¤˜ ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈ‹ÛÂÈ ‰È·ÊÔÚÂÙÈο ÎÚÈÙ‹ÚÈ· ‰È¿ÁÓˆÛ˘ ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘3. ∂ÓÙÔ‡ÙÔȘ, ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ·ÚÔ˘Û›· ÛÔ‚·Ú‹˜ ‹ de novo ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û¯ÂÙ›˙ÂÙ·È Ì ˘ÔÙÚÔ‹ Ù˘ PSC13, ·ÔÙÂÏÒÓÙ·˜ ¤Ó· ·ÎfiÌ· ÛÙÔÈ¯Â›Ô ˘¤Ú Ù˘ ÂÌÏÔ΋˜ ÎÔÈÓÒÓ ·ıÔÁÂÓÂÓÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÌÂٷ͇ PSC Î·È ÂÏÎÒ‰Ô˘˜ ÎÔÏ›Ùȉ·˜20. Δ¤ÏÔ˜, Ë ˘ÔÙÚÔ‹ Ù˘ AIH Ê·›ÓÂÙ·È fiÙÈ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ÓË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ·Ó Î·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ˘¿Ú¯ÂÈ Î·Ï‹ ·ÓÙ·fiÎÚÈÛË ÛÙÔ˘˜ ıÂÚ·¢ÙÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜21. ŒÙÛÈ, ÔÏÏ¿ ΤÓÙÚ· ÚÔÙ›ÓÔ˘Ó ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË Ú‰ÓÈ˙ÔÏfiÓ˘ Û ¯·ÌËÏ‹ ‰fiÛË (5-10mg) ÁÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ¤ÙÔ˜14,22, ·Ó Î·È ÌÈ· ÚfiÛÊ·ÙË ÌÂϤÙË Î·Ù¤ÏËÍ ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Î¿ÙÈ Ù¤ÙÔÈÔ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙÔ23. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ‰ÂÓ ¤¯Ô˘Ó ·ÔÛ·ÊËÓÈÛÙ› (¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› Û˘ÁÎÂÎÚÈ̤ӷ HLA)24, ÂÓÒ ÙÔ Â›‰Ô˜ Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ‰Â Ê·›ÓÂÙ·È Ó· ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ21,25.

ÀÔÙÚÔ‹ ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ∏ Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ ÙˆÓ ·˘ÙÔ¿ÓÔÛˆÓ ÓÔÛËÌ¿ÙˆÓ [·˘ÙÔ¿ÓÔÛ˘ Ë·Ù›Ùȉ·˜ (∞π∏), ÚˆÙÔ·ıÔ‡˜ ¯ÔÏÈ΋˜ ΛÚÚˆÛ˘ (PBC), ÚˆÙÔ·ıÔ‡˜ ÛÎÏËÚ˘ÓÙÈ΋˜ ¯ÔÏ·ÁÁÂÈ˝Ùȉ·˜ (PSC)] ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÔÈΛÏÂÈ ÛÙȘ ‰È¿ÊÔÚ˜ ÛÂÈÚ¤˜ ·ÛıÂÓÒÓ, οÙÈ Ô˘ ÂÓ Ì¤ÚÂÈ ÌÔÚ› Ó· ÂÚÌËÓ¢Ù› Î·È ·fi Ù· ‰È·ÊÔÚÂÙÈο ÎÚÈÙ‹ÚÈ· Î·È ÌÂıfi‰Ô˘˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÁÈ· ÙËÓ ‰È¿ÁÓˆÛË Ù˘ ˘ÔÙÚÔ‹˜, ·fi ÙÔÓ ‰È·ÊÔÚÂÙÈÎfi ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÏÏ¿ Î·È ·fi ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Â›Ó·È Ë ‰ÈÂÓ¤ÚÁÂÈ· ‚ÈÔ„ÈÒÓ ‹·ÙÔ˜ ·Ó¿ Ù·ÎÙ¿ ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù· ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ‡·ÚÍË ‰È·Ù·Ú·¯ÒÓ Ë·ÙÈ΋˜ ‚ÈÔ¯ËÌ›·˜ (protocol liver biopsy). ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ·˘ÙÔ¿ÓÔÛË Ë·Ù›Ùȉ· (∞π∏), ·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜ ·Ó¤ÊÂÚ·Ó ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ˆ˜ Î·È 42%1,2, ÂÓÒ Û ̛· ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË ·Ó·Ê¤ÚÂÙ·È Ì¤ÛË Û˘¯ÓfiÙËÙ· 23% ÌÂÙ¿ ·fi 26.4 Ì‹Ó˜ ·Ú·ÎÔÏÔ‡ıËÛ˘3. ÀÔÙÚÔ‹ Ù˘ PSC ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙ¿ Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi 9% ˆ˜ 47%4, ÂÓÒ ÛÙËÓ ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË3 ˘ÔÏÔÁ›ÛÙËΠfiÙÈ 17% ·fi ÙÔ˘˜ 940 ·ÛıÂÓ›˜ ›¯·Ó ˘ÔÙÚÔ‹ Ù˘ PSC. Δ¤ÏÔ˜, ˘ÔÙÚÔ‹ Ù˘ PBC ·Ó·Ê¤ÚÂÙ·È Û ÔÛÔÛÙ¿ Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi 10% ˆ˜ Î·È 35% ÛÙ· 5 ¤ÙË5, Î·È ÛÙËÓ ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË3, Ë Â›ÙˆÛË ˘ÔÏÔÁ›ÛÙËΠÛÙÔ 16% ÌÂÙ¿ ·fi 69 Ì‹Ó˜ ‰È¿ÌÂÛÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.

ŒÎ‚·ÛË Î·È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ˘ÔÙÚÔ‹˜ ∏ ˘ÔÙÚÔ‹ Ù˘ PBC ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ Û˘Ó¤ÂȘ ÛÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ηıÒ˜ Ê·›ÓÂÙ·È fiÙÈ ÂÍÂÏ›ÛÛÂÙ·È ·ÚÁ¿6, ·ÎfiÌ· Î·È fiÙ·Ó Ô ¯ÚfiÓÔ˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ¤ÊÙ·Ó ٷ 20 ¤ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË7, ·ÚfiÏÔ Ô˘ ÔÈ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ PBC ¤¯Ô˘Ó ‚·Ú‡ÙÂÚ˜ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ Î·È ›ÓˆÛË Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ Â›¯·Ó ˘ÔÙÚÔ‹ Ù˘

145

146

∂. ÃO§O°∫πΔ∞™

¢È¿ÁÓˆÛË ˘ÔÙÚÔ‹˜ Ù˘ ÓfiÛÔ˘ ∏ ‰È¿ÁÓˆÛË Ù˘ ˘ÔÙÚÔ‹˜ ÙÔ˘ ·˘ÙÔ¿ÓÔÛÔ˘ ÓÔÛ‹Ì·ÙÔ˜ ÛÙËÚ›˙ÂÙ·È ÛÙÔ Û˘Ó‰˘·ÛÌfi ‚ÈÔ¯ËÌÈÎÒÓ, ÔÚÔÏÔÁÈÎÒÓ Î·È ÈÛÙÔÏÔÁÈÎÒÓ (‹ ·ÎÙÈÓÔÏÔÁÈÎÒÓ) ¢ÚËÌ¿ÙˆÓ Û ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó ÁÈ· ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ·˘ÙÔ¿ÓÔÛÔ ÓfiÛËÌ·. ¡· ÛËÌÂȈı› fiÙÈ ÔÈ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ÌÔÚ› Ó· ÚÔËÁÔ‡ÓÙ·È ÙˆÓ ˘fiÏÔÈˆÓ ‰È·Ù·Ú·¯ÒÓ26-28. °È· ·Ú¿‰ÂÈÁÌ·, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÌfiÓÔ 50% Ì ˘ÔÙÚÔ‹ Ù˘ PBC ¤¯Ô˘Ó ‰È·Ù·Ú·¯¤˜ Ù˘ Ë·ÙÈ΋˜ ‚ÈÔ¯ËÌ›·˜ Î·È ÌÔÚ› Ó· ·Ú·Ì›ÓÔ˘Ó ÁÈ· ¤ÙË ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ ·Ú¿ ÙËÓ ‡·ÚÍË ÈÛÙÔÏÔÁÈÎÒÓ ‚Ï·‚ÒÓ8. ∂ÈϤÔÓ, Ë ·Ó›¯Ó¢ÛË ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÔÈ ˘„ËϤ˜ IgG ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ÙÂÎÌËÚÈÒÛÔ˘Ó ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘2,29, Î·È ·˘Ùfi ÈÛ¯‡ÂÈ ÙfiÛÔ ÁÈ· ÙËÓ PBC fiÛÔ Î·È ÁÈ· ÙËÓ AIH28,30-32.

H ˘Ô„›· Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ PBC ÌÔÚ› Ó· ÙÂı› ÛÙȘ ÂÚÈÙÒÛÂȘ ‰È·Ù·Ú·¯ÒÓ Ù˘ Ë·ÙÈ΋˜ ‚ÈÔ¯ËÌ›·˜ Ì ˘ÂÚÔ¯‹ ÙˆÓ ¯ÔÏÔÛÙ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, fï˜ Ë ‚ÈÔ„›· ‹·ÙÔ˜ Ì ÙȘ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ·ÔÙÂÏ› ÙËÓ ÂͤٷÛË ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË ÂÊfiÛÔÓ ·ÔÎÏÂÈÛÙÔ‡Ó ¿ÏÏ· ·›ÙÈ· (.¯. ÔÍ›· Î·È ¯ÚfiÓÈ· ·fiÚÚÈ„Ë)33. ∏ ‰È¿ÁÓˆÛË Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ PSC ‚·Û›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ Â‡ÚÂÛË ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÛÙË ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›·, fï˜ ı· Ú¤ÂÈ Ó· ·ÔÎÏÂÈÛÙÔ‡Ó ¿ÏÏ· ·›ÙÈ· Ô˘ ÚÔηÏÔ‡Ó ·ÚfiÌÔȘ ‚Ï¿‚˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiˆ˜ ÏÔÈÌÒÍÂȘ ¯ÔÏËÊfiÚˆÓ, ıÚfiÌ‚ˆÛË ‹ ÛÙ¤ÓˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ Î·È ¯ÚfiÓÈ· ·fiÚÚÈ„Ë34-36. O˘ÛÈ·ÛÙÈο, Ë ‰È¿ÁÓˆÛË Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ PSC Â›Ó·È ‰È¿ÁÓˆÛË ÂÍ ·ÔÎÏÂÈÛÌÔ‡ Î·È ·˘ÛÙËÚ¿ ¯ÔÏ·ÁÁÂÈÔÁÚ·ÊÈο ηÈ/‹ ÈÛÙÔÏÔÁÈο ÎÚÈÙ‹ÚÈ· ¤¯Ô˘Ó ÚÔÙ·ı›37. Δ¤ÏÔ˜, ·Ó Î·È Ë ˘Ô„›· ˘ÔÙÚÔ‹˜ Ù˘ AIH ÌÔÚ› Ó· ÙÂı› ·fi ÙÔÓ ·˘ÍË̤ÓÔ Ù›ÙÏÔ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È IgG, Ë ‚ÈÔ„›· ‹·ÙÔ˜ ·ÔÙÂÏ› Î·È Â‰Ò ÙË ‚·ÛÈ΋ ÂͤٷÛË Ô˘ ÌÔÚ› Ó· ı¤ÛÂÈ ÙËÓ ‰È¿ÁÓˆÛË Ì ÙËÓ Â‡ÚÂÛË ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÈÛÙÔÏÔÁÈÎÒÓ ‚Ï·‚ÒÓ, ·ÊÔ‡ ·ÔÎÏÂÈÛÙÔ‡Ó ¿ÏÏ· ·›ÙÈ·, fiˆ˜ ÈÔÁÂÓ›˜ Ë·Ù›Ùȉ˜ Î·È ÂÂÈÛfi‰È· ·fiÚÚȄ˘21,38.

£ÂÚ·›· ∞Ó Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ·fiÏ˘ÙË ÙÂÎÌËÚ›ˆÛË, Ù· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Û˘ÓÈÛÙÔ‡Ó ¤Ó·ÚÍË UDCA 10–15 mg/kg/day ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ PBC. ŒÙÛÈ, ·Ú·ÙËÚÂ›Ù·È ‚ÂÏÙ›ˆÛË Ù˘ Ë·ÙÈ΋˜ ‚ÈÔ¯ËÌ›·˜, fï˜ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ηχÙÂÚ· ۯ‰ȷṲ̂Ó˜ ÌÂϤÙ˜ ÁÈ·

ÙËÓ ÂÍ·ÁˆÁ‹ ÙÂÏÈÎÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ fiÛÔÓ ·ÊÔÚ¿ ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ ÈÛÙÔÏÔÁÈÎÒÓ ‚Ï·‚ÒÓ Î·È Ù˘ ÂÈ‚›ˆÛ˘39, ·ÏÏ¿ Î·È ÙÔÓ Èı·Ófi ÚÔÛٷ٢ÙÈÎfi ÚfiÏÔ ÙÔ˘ UDCA ÛÙËÓ ÚfiÏË„Ë ·Ó¿Ù˘Í˘ ÂÓÙÂÚÈ΋˜ ηÎÔ‹ıÂÈ·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂›Û˘, ·Ó·Ê¤ÚÂÙ·È fiÙÈ Èı·ÓfiÓ Ë ·ÏÏ·Á‹ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ·fi tacrolimus Û ΢ÎÏÔÛÔÚ›ÓË Èı·ÓfiÓ Ó· ˆÊÂÏ› ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ PBC ÏfiÁˆ ‚Ú·‰‡ÙÂÚ˘ ÂͤÏÈ͢ Ù˘ ÓfiÛÔ˘. ΔÔ UDCA Èı·ÓfiÓ Ó· ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› Î·È Û ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ PSC (›Ûˆ˜ ȉȷ›ÙÂÚ· Û ·ÛıÂÓ›˜ Ì PSC Î·È ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·), fï˜ Ë ¯ÚËÛÈÌfiÙËÙ· ÌÈ·˜ Ù¤ÙÔÈ·˜ ·Ú¤Ì‚·Û˘ ¤¯ÂÈ ÙÂı› Û ¤ÓÙÔÓË ·ÌÊÈÛ‚‹ÙËÛË Ì ‚¿ÛË Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ ·fi ·ÛıÂÓ›˜ Ì PSC ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. Δ¤ÏÔ˜, Û ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ ∞π∏, ÚÔÙ›ÓÂÙ·È Ë ·‡ÍËÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ (20 mg/day Ì ‹ ¯ˆÚ›˜ ·˙·ıÂÈÔÚ›ÓË) Î·È ÛÙÔ˘˜ ÌË ·ÓÙ·ÔÎÚÈÓfiÌÂÓÔ˘˜ ·ÏÏ·Á‹ ·fi ΢ÎÏÔÛÔÚ›ÓË Û tacrolimus40. ∏ ÚÔÛı‹ÎË mycophenolate 2 g/Ë̤ڷ Èı·ÓfiÓ Ó· ˆÊÂÏ‹ÛÂÈ Î¿ÔÈÔ˘˜ ·ÛıÂÓ›˜. ∏ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÌÔÚ› Á›ÓÂÈ Ì ‚¿ÛË ÙËÓ Ë·ÙÈ΋ ‚ÈÔ¯ËÌ›·, Ù· Â›‰· ÙˆÓ IgG ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ Î·È ÙȘ ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜. ¶·Ú¿ Ù· ̤ÙÚ· ·˘Ù¿ οÔÈÔÈ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙÔ‡Ó ÙÂÏÈο Ó· ˘Ô‚ÏËıÔ‡Ó Í·Ó¿ Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜.

ÀÔÙÚÔ‹ ÈÔÁÂÓÔ‡˜ Ë·Ù›Ùȉ·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÀÔÙÚÔ‹ Ë·Ù›Ùȉ·˜ C ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÂÚ›Ô˘ 180 ÂηÙÔÌ̇ÚÈ· ¿ÙÔÌ· ·ÁÎÔÛÌ›ˆ˜ ¿Û¯Ô˘Ó ·fi ¯ÚfiÓÈ· Ë·Ù›Ùȉ· C (Ã∏C)41,42. ∏ Ã∏C Â›Ó·È ¤Ó· ·fi Ù· ΢ÚÈfiÙÂÚ· ·›ÙÈ· ¯ÚfiÓÈ·˜ Ë·ÙÔ¿ıÂÈ·˜, ȉȷ›ÙÂÚ· ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜, fiÔ˘ ·ÔÙÂÏ› ÙËÓ Û˘¯ÓfiÙÂÚË ¤Ó‰ÂÈÍË ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜43. ¢˘ÛÙ˘¯Ò˜, Ë Ïԛ̈ÍË ·fi ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ C ηٿ ηÓfiÓ· ˘ÔÙÚÔÈ¿˙ÂÈ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ηıÒ˜ Û ·ÓÙ›ıÂÛË Ì ÙËÓ HBV ΛÚÚˆÛË, ‰ÂÓ ¤¯ÂÈ ‚ÚÂı› ·ÎfiÌ· ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ÙÚfiÔ˜ ÚfiÏ˄˘ Ù˘ Â·Ó·ÌfiÏ˘ÓÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÙÔÓ HCV. ∂ÈϤÔÓ, ÏfiÁˆ Ù˘ ÂÊ·ÚÌÔÁ‹˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ÂͤÏÈÍË Ù˘ HCV Ïԛ̈͢ Â›Ó·È Ù·¯Â›·, Ì ·ÔÙ¤ÏÂÛÌ· Ôχ Û‡ÓÙÔÌ· Ó· ÂÁηı›ÛÙ·Ù·È ÛÔ‚·Ú‹ ›ÓˆÛË Î·È Î›ÚÚˆÛË ÛÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì·. ŒÙÛÈ, ˘ÔÏÔÁ›˙ÂÙ·È ˆ˜ 20-30% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÌÂÙ·ÌÔ-

METAMO™XEY™Eπ™ 2010

ۯ‡ÔÓÙ·È ÏfiÁˆ XHC, ·Ó·Ù‡ÛÛÔ˘Ó Î›ÚÚˆÛË ÏfiÁˆ ˘ÔÙÚÔ‹˜ Ù˘ Ïԛ̈͢ Û 5 ¤ÙË ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË44, ÂÓÒ ¿Óˆ ·fi 40% ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ÂÌÊ·Ó›˙ÂÈ ¿ÚÛË Ù˘ ·ÓÙÈÚÚfiËÛ˘ Û 1 ¤ÙÔ˜45. ª¿ÏÈÛÙ·, ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ô Ú˘ıÌfi˜ ÂͤÏÈ͢ Ù˘ ›ÓˆÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 0.3-0.6/¤ÙÔ˜, Û ۯ¤ÛË Ì 0.1-0.2/¤ÙÔ˜ Û ·ÓÔÛÔÂ·ÚΛ˜ XHC ·ÛıÂÓ›˜. ø˜ ·ÔÙ¤ÏÂÛÌ·, ÔÈ ·ÛıÂÓ›˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÏfiÁˆ HCV-ΛÚÚˆÛ˘ ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚË ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ۯ¤ÛË Ì ·ÛıÂÓ›˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÁÈ· ¿ÏÏ· ·›ÙÈ· ¯ÚfiÓÈ·˜ Ë·ÙÔ¿ıÂÈ·˜46.

OÈ ·ÎÚȂ›˜ ·ıÔÁÂÓÂÙÈÎÔ› Ì˯·ÓÈÛÌÔ› Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ Ù·¯‡ÙÂÚË ÂͤÏÈÍË Ù˘ XHC ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÚÔ˜ ΛÚÚˆÛË ‰ÂÓ ¤¯Ô˘Ó Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ›, fï˜ ÔÏÏÔ› ·Ú¿ÁÔÓÙ˜ (ÚÈÓ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË) ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı›. ∞fi ÙÔ˘˜ È˚ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, ÙÔ ˘„ËÏfi È˚Îfi ÊÔÚÙ›Ô Î·Ù¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÏÏ¿ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ıˆÚÂ›Ù·È Ô ÈÔ ÛËÌ·ÓÙÈÎfi˜ Î·È ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ٷ¯‡ÙÂÚË ÂͤÏÈÍË Ù˘ ›ÓˆÛ˘45. °È’ ·˘Ùfi Î·È Ë ÂÊ·ÚÌÔÁ‹ ·ÓÙÈÈ΋˜ ·ÁˆÁ‹˜ [ÂÁ΢ÏȈ̤Ó˘ ÈÓÙÂÚÊÂÚfiÓ˘ (Peg-IFN) Î·È ÚÈÌ·‚ÈÚ›Ó˘] ·ÔÙÂÏ› ¤Ó· ÛËÌ·ÓÙÈÎfi ̤ÛÔ Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÌfiÏ˘ÓÛ˘ ‹ ÙËÓ ÂÎÚ›˙ˆÛË ÙÔ˘ ÈÔ‡ ·fi ÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì·. ∏ ¯ÔÚ‹ÁËÛË ·ÓÙÈÈ΋˜ ·ÁˆÁ‹˜ ÌÔÚ› Ó· Á›ÓÂÈ Û ‰‡Ô ΢ڛˆ˜ ¯ÚÔÓÈο ÛËÌ›·: ›Ù ÚÈÓ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ›Ù ÌÂÙ¿ ·fi ÙËÓ ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜47. ™ÙËÓ ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË, Ë ·ÓÙÈÈ΋ ·ÁˆÁ‹ ÌÔÚ› Ó· ¯ÔÚËÁËı› ›Ù ۯÂÙÈο Û‡ÓÙÔÌ· (ÚÈÓ ÙËÓ ÂÁηٿÛÙ·ÛË Ë·ÙÈ΋˜ ‚Ï¿‚˘ ·fi ÙËÓ ˘ÔÙÚÔ‹ Ù˘ HCV Ïԛ̈͢), ›Ù ÌÂÙ¿ ·fi ÔÚÈṲ̂ÓÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, fiÔ˘ Ë ˘ÔÙÚÔ‹ Ù˘ HCV Ïԛ̈͢ ¤¯ÂÈ ·Ú¯›ÛÂÈ Ó· ÚÔηÏ› ÈÛÙÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ÛÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì·. º·›ÓÂÙ·È Ì¿ÏÈÛÙ· fiÙÈ Ë Â›Ù¢ÍË ÌfiÓÈÌ˘ ÈÔÏÔÁÈ΋˜ ·ÓÙ·fiÎÚÈÛ˘ Û˘ÓÂ¿ÁÂÙ·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘, Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ Î·Ù¿ÊÂÚ·Ó Ó· ÂÎÚÈ˙ÒÛÔ˘Ó ÙÔÓ Èfi ÌÂÙ¿ ·fi ÙËÓ ·ÓÙÈÈ΋ ıÂÚ·›·48,49. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ÁÔÓÔÙ‡Ô˘ ÛÙË ÂͤÏÈÍË Ù˘ XHC ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ˘¿Ú¯Ô˘Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·, Èı·ÓfiÓ fï˜ Ô ÁÔÓfiÙ˘Ô˜ 1b Î·È 4 Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ¯‡ÙÂÚË ÂÁηٿÛÙ·ÛË Î›ÚÚˆÛ˘45. ∞fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ‰fiÙË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ë ÌÂÁ¿ÏË ËÏÈΛ· ÙÔ˘ ‰fiÙË ¤¯ÂÈ ‚ÚÂı› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÛÔ‚·Ú‹ ˘ÔÙÚÔ‹ Ù˘ HCV Ïԛ̈͢50. ∞fi Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Ï‹-

147

ÙË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÙÔ Ù·›ÚÈ·ÛÌ· ÙˆÓ HLA ‰fiÙË/‰¤ÎÙË, ÙÔ Á˘Ó·ÈÎÂ›Ô Ê‡ÏÔ, Ë ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË Î·È Ë ‡·ÚÍË HCV ÎÚ˘ÔÛÊ·ÈÚÈÓ·ÈÌ›·˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ÁÈ· Ù·¯‡ÙÂÚË ÂÁηٿÛÙ·ÛË Î›ÚÚˆÛ˘, fï˜ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ¯ÚÂÈ¿˙ÔÓÙ·È ÁÈ· ÙËÓ ÂȂ‚·›ˆÛË ÙˆÓ ·Ú·¿Óˆ ¢ÚËÌ¿ÙˆÓ45. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ Â›‰Ô˜ Ù˘ ·ÓÔÛÔηٷÏÛÙ·ÙÈ΋˜ ·ÁˆÁ‹˜, Ê·›ÓÂÙ·È ˆ˜ Ë Ë ÚÒÈÌË ‰È·ÎÔ‹ ¯·ÌËÏÒÓ ‰fiÛÂˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Î·È Ù˘ ·˙·ıÂÈÔÚ›Ó˘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛı› Ì ٷ¯‡ÙÂÚË ÂͤÏÈÍË Ù˘ ›ÓˆÛ˘51, ÂÓÒ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ Â›‰Ú·ÛË ·Ó¿ÏÔÁ· Ì ÙË ¯Ú‹ÛË tacrolimus ‹ ΢ÎÏÔÛÔÚ›Ó˘45. ∏ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙˆÓ ·ÛıÂÓÒÓ ÏfiÁˆ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ ıˆÚÂ›Ù·È Â‡ÎÔÏË ÂÈÏÔÁ‹ ÂÍ·ÈÙ›·˜ Ù˘ η΋˜ ÚfiÁÓˆÛ˘ ·ÏÏ¿ Î·È Ù˘ ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ™˘ÓÂÒ˜, Ë ÚÔÛ¿ıÂÈ· ı· Ú¤ÂÈ Ó· ÂÈÎÂÓÙÚÒÓÂÙ·È ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÂΛÓÔ˘˜ Ô˘ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› fiÙÈ Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ¯‡ÙÂÚË ˘ÔÙÚÔ‹ Î·È ÂͤÏÈÍË Ù˘ ›ÓˆÛ˘. Ÿˆ˜ ¤¯ÂÈ ‹‰Ë ·Ó·ÊÂÚı›, ȉȷ›ÙÂÚË ‚·Ú‡ÙËÙ· ¤¯ÂÈ ‰Ôı› ÛÙËÓ ¯ÔÚ‹ÁËÛË ·ÓÙÈÈ΋˜ ·ÁˆÁ‹˜ ÚÈÓ ‹ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜ ·Ó·Ì¤ÓÂÙ·È Ó· ·ÔÛ·ÊËÓ›ÛÔ˘Ó Î·Ï‡ÙÂÚ· ÙÔ ‚¤ÏÙÈÛÙÔ ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Ù˘ ·ÓÙÈÈ΋˜ ıÂÚ·›·˜ Î·È ÙÔÓ Î·Ï‡ÙÂÚÔ ¯ÂÈÚÈÛÌfi ÙˆÓ Èı·ÓÒÓ ·ÚÂÓÂÚÁÂÈÒÓ. OÈ ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÛËÌ·ÓÙÈο, ηıÒ˜ Ë ÚÈÌ·‚ÈÚ›ÓË ·ÔÙÂÏ› ̤¯ÚÈ ÛÙÈÁÌ‹˜ ‚·ÛÈÎfi Û˘ÛÙ·ÙÈÎfi Ù˘ ·ÓÙÈÈ΋˜ ıÂÚ·›·˜. ¡¤Â˜ ‰˘Ó·ÙfiÙËÙ˜ ÌÔÚ› Ó· ÚÔʤÚÂÈ Ë ¯Ú‹ÛË Ù˘ eltrombopag (·˘ÍËÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ) ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ıÚÔÌ‚ÔÂÓ›·˜ ·fi ÙËÓ ¯ÔÚ‹ÁËÛË IFN52, ÂÓÒ Ë ¯Ú‹ÛË ÙˆÓ Ó¤ˆÓ ·ÓÙÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ·Ó·Ì¤ÓÂÙ·È Ì ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ.

ÀÔÙÚÔ‹ Ë·Ù›Ùȉ·˜ μ ∏ ¯ÚfiÓÈ· Ë·Ù›Ùȉ· μ (Ã∏μ) ·ÔÙÂÏ› ÌÈ· Û˘¯Ó‹ ¤Ó‰ÂÈÍË ÌÂÙ·ÌfiÛ¯Â˘Û˘, ÂȉÈο ÛÙȘ ¯ÒÚ˜ Ù˘ Õˆ ∞Ó·ÙÔÏ‹˜ Î·È Ù˘ ªÂÛÔÁ›Ԣ. ∏ ˘ÔÙÚÔ‹ Ù˘ HBV Ïԛ̈͢ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏÔ‡Û ÙÔÓ Î·ÓfiÓ· ÚÈÓ ·fi ÙËÓ ÂÊ·ÚÌÔÁ‹ ÚÔÊ˘Ï·ÎÙÈ΋˜ ·ÁˆÁ‹˜ Ì HBIG Î·È ÓÔ˘ÎÏÂÔÛ(Ù)ȉÈο ·Ó¿ÏÔÁ·53-55, ÁÈ ·˘Ùfi Î·È ÛÙ· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· Ë HBV ΛÚÚˆÛË ·ÔÙÂÏÔ‡Û ·ÓÙ¤Ó‰ÂÈÍË ˘Ô‚ÔÏ‹˜ Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. Δ· ‰Â‰Ô̤ӷ ¿ÏÏ·Í·Ó Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË Ù˘ ∏μIG ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 90, fiÔ˘ ÌÂÈÒıËΠÛËÌ·ÓÙÈο Ë Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Ù˘ HBV

148

∂. ÃO§O°∫πΔ∞™

Ïԛ̈͢ Î·È ‚ÂÏÙÈÒıËΠÛËÌ·ÓÙÈο Ë ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË56. ∫·Ù¿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, ÛÙË ÚÔÊ˘Ï·ÎÙÈ΋ Ê·Ú¤ÙÚ· ÚÔÛÙ¤ıËÎ·Ó Ù· ÓÔ˘ÎÏÂÔÛ(Ù)ȉÈο ·Ó¿ÏÔÁ·, Ù· ÔÔ›· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Â›Ù ˆ˜ ÌÔÓÔ-ÚÔʇϷÍË Â›ÙÂ Û˘ÓËı¤ÛÙÂÚ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ HBIG, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ Â›Ù¢ÍË ·ÎfiÌ· ηχÙÂÚˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. ∏ ¯Ú‹ÛË ÙˆÓ ÓÔ˘ÎÏÂÔÛ(Ù)ȉÈÎÒÓ ·Ó·ÏfiÁˆÓ ˘‹ÚÍ ηıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜, ηıÒ˜ ‰›ÓÔ˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì HBV ΛÚÚˆÛË Ó· ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Ì ·ÚÓËÙÈÎfi ÈÈÎfi ÊÔÚÙ›Ô, Ó· ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο ÙÔ ÎfiÛÙÔ˜ ̤ۈ Ù˘ Ì›ˆÛ˘ ÙˆÓ ·Ó·ÁÎÒÓ ¯ÔÚ‹ÁËÛ˘ Ù˘ HBIG, Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ·ÔÙÂÏÂÛÌ·ÙÈο Ë Ù˘¯fiÓ ˘ÔÙÚÔ‹ Ù˘ HBV Ïԛ̈͢ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÏÏ¿ Î·È Ó· ÌÂÈÒÓÂÙ·È Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ de novo HBV Ïԛ̈͢57. ªÂ ÙÔÓ ÙÚfiÔ ·˘Ùfi Ê·›ÓÂÙ·È fiÙÈ ÌÔÚÔ‡Ó Ó· ÌÂÈÒÛÔ˘Ó ÙË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Î·È ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ (∏∫∫) ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·ÛıÂÓ›˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó ÏfiÁˆ ∏∫∫ Û ¤‰·ÊÔ˜ HBV ΛÚÚˆÛ˘58.

O Û˘Ó‰˘·ÛÌfi˜ Ù˘ HBIG Ì ÙË Ï·ÌÈ‚Ô˘‰›ÓË ¤¯ÂÈ Ê·Ó› fiÙÈ ˘ÂÚ¤¯ÂÈ ¤Ó·ÓÙÈ Ù˘ ¯ÔÚ‹ÁËÛ˘ ÂÓfi˜ ÂÎ ÙˆÓ ‰‡Ô ˆ˜ ÚÔʇϷÍË59. ª¿ÏÈÛÙ· Û ÌÈ· ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË, Ê¿ÓËΠfiÙÈ Ô Û˘Ó‰˘·ÛÌfi˜, Û ۯ¤ÛË Ì ÙË ¯ÔÚ‹ÁËÛË ÌfiÓÔ HBIG, Û¯ÂÙ›˙ÂÙ·È Ì Ì›ˆÛË Î·Ù¿ 12 ÊÔÚ¤˜ Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ HBV ˘ÔÙÚÔ‹˜ Î·È Î·Ù¿ 5 ÊÔÚ¤˜ Ù˘ ıÓËÙfiÙËÙ·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË60. ™Â ÌÈ· ÚfiÛÊ·ÙË ·Ó·ÛÎfiËÛË Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜, ‚Ú¤ıËΠfiÙÈ Ì ÙÔ Û˘Ó‰˘·ÛÌfi HBIG Î·È Ï·ÌÈ‚Ô˘‰›Ó˘ ·Ú·ÙËÚÂ›Ù·È ˘ÔÙÚÔ‹ Ù˘ HBV Ïԛ̈͢ ÌfiÓÔ ÛÙÔ 6.3% ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 6-96 ÌËÓÒÓ ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û ·ÚÎÂÙÔ‡˜ ·fi ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ›¯Â ·Ó·Ù˘¯ı› YMDD ÌÂÙ·ÏÏ·Á‹ Î·È ˘„ËÏfi ÈÈÎfi ÊÔÚÙ›Ô ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÂÓÒ Î¿ÔÈÔÈ ¿ÏÏÔÈ ·ÛıÂÓ›˜ ›¯·Ó ‰È·Îfi„ÂÈ ÙËÓ HBIG ηÈ/‹ ÙË Ï·ÌÈ‚Ô˘‰›ÓË fiÙ·Ó ÂÌÊ¿ÓÈÛ·Ó ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘. ¡· ÛËÌÂȈı› fiÙÈ Û ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤¯ÂÈ Á›ÓÂÈ ÚÔÛ¿ıÂÈ· ¯ÔÚ‹ÁËÛ˘ HBIG Û ¯·ÌËÏ‹ ‰ÔÛÔÏÔÁ›· ‹ ÂÓ‰ÔÌ˘Èο Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù·61-64. ¡¤Â˜ ÌÂϤÙ˜ ·Ó·Ì¤ÓÔÓÙ·È Ó· ·ÔÛ·ÊËÓ›ÛÔ˘Ó ÙÔ ÚfiÏÔ ÙˆÓ Ó¤ˆÓ ÓÔ˘ÎÏÂÔÛ(Ù)ȉÈÎÒÓ ·Ó·ÏfiÁˆÓ (ÂÓٷη‚›ÚË, ÙÂÓÔÊÔ‚›ÚË), Ô˘ ·Ó·Ì¤ÓÂÙ·È Ó· ·ÓÙÈηٷÛÙ‹ÛÔ˘Ó ‹ Ó· ‰›ÓÔÓÙ·È ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË Ï·ÌÈ‚Ô˘‰›ÓË, ÂȉÈο Û ·ÛıÂÓ›˜ Ì ˘„ËÏfi ÈÈÎfi ÊÔÚÙ›Ô ‹ Ì ·Ó¿Ù˘ÍË ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ô‰ËÁÒÓÙ·˜ Èı·Ófiٷٷ

Û Ì›ˆÛË ‹ ‰˘Ó·ÙfiÙËÙ· ‰È·ÎÔ‹˜ Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ HBIG. ™Â ÂÚ›ÙˆÛË ˘ÔÙÚÔ‹˜ Ù˘ HBV Ïԛ̈͢, Ô ÛÙfi¯Ô˜ ı· Ú¤ÂÈ Ó· Â›Ó·È Ë Ì›ˆÛË ÙÔ˘ ÈÈÎÔ‡ ÊÔÚÙ›Ô˘ Î·È Ë ÛÙ·ıÂÚÔÔ›ËÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ Ï·ÌÈ‚Ô˘‰›ÓË Â›Ó·È Ë ıÂÚ·¢ÙÈ΋ ·Ú¤Ì‚·ÛË Ô˘ ·Ó·Ê¤ÚÂÙ·È Û˘¯ÓfiÙÂÚ· ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Û ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ Ì HBV ˘ÔÙÚÔ‹, fï˜ Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ Ù˘ Â›Ó·È ·ÓÂ·Ú΋˜ Û ÂÚÈÙÒÛÂȘ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ. °ÂÓÈο ıˆÚÂ›Ù·È fiÙÈ Ë Ï·ÌÈ‚Ô˘‰›ÓË ‰ÂÓ ·ÔÙÂÏ› ¿ÚÈÛÙË ÂÈÏÔÁ‹, ηıÒ˜ Û˘Ó‰˘¿˙ÂÙ·È Ì ·Ó¿Ù˘ÍË ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ Ô˘ ÍÂÂÚÓ¿ ÙÔ 50% Û 3 ¤ÙË Û ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜65-69, οÙÈ Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Ù·¯¤ˆ˜ ÛÙËÓ ·Ó¿Ù˘ÍË ÛËÌ·ÓÙÈÎÒÓ ÈÛÙÔÏÔÁÈÎÒÓ ‚Ï·‚ÒÓ, Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ˆ˜ Î·È ı¿Ó·ÙÔ Û ÌÂÚÈÎÔ‡˜ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ˜ ·˜ıÂÓ›˜68,70,71. ∏ ÚÔÛı‹ÎË ·‰ÂÊÔ‚›Ú˘ ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ÈÈÎÔ‡ ÊÔÚÙ›Ô˘ Û ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ HBV Ïԛ̈͢ ·fi ·ÓıÂÎÙÈο ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË ÛÙÂϤ¯Ë72. ∏ ÙÂÓÔÊÔ‚›ÚË ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ› Ì ȉȷ›ÙÂÚË ÂÈÙ˘¯›· Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ73,74, Î·È ›Ûˆ˜ ·ÔÙÂÏ› ηχÙÂÚË ÂÈÏÔÁ‹ ·fi ÙËÓ ·‰ÂÊÔ‚›ÚË, ÂÓÒ Ë ÂÓÙÂη‚›ÚË ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ¯Ú‹ÛÈÌÔ ÂÚÁ·Ï›Ô, ÂȉÈο Û ˘ÔÙÚÔ‹ Ù˘ HBV Ïԛ̈͢ ·fi ÛÙÂϤ¯Ë ¢·›ÛıËÙ· ÛÙË Ï·ÌÈ‚Ô˘‰›ÓË75 ‹ fiÙ·Ó ˘¿Ú¯ÂÈ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ¶ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˜ ·Ó·Ì¤ÓÂÙ·È Ó· ÍÂηı·Ú›ÛÔ˘Ó Î·Ï‡ÙÂÚ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È Î˘Ú›ˆ˜ ÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ ÙÂÓÔÊÔ‚›Ú˘ Î·È ÂÓÙÂη‚›Ú˘ Û ·ÛıÂÓ›˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.

ÀÔÙÚÔ‹ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ∏ ˘ÔÙÚÔ‹ ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ (HKK) ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘ÓÂ¿ÁÂÙ·È ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘. Δ· ÎÚÈÙ‹ÚÈ· ÙÔ˘ ªÈÏ¿ÓÔ˘ (¤Ó·˜ fi˙Ô˜ ÌÈÎÚfiÙÂÚÔ˜ ·fi 5cm ‹ ̤¯ÚÈ 3 fi˙ÔÈ ÌÈÎÚfiÙÂÚÔÈ ·fi cm) ·ÔÙÂÏÔ‡Ó ·ÓÂÍ¿ÚÙËÙÔ ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ˘ÔÙÚÔ‹˜ ÙÔ˘ HKK ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜76. ∏ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ ªÈÏ¿ÓÔ˘ ¤¯ÂÈ ÂȂ‚·Èˆı› Û ÔÏϤ˜ ÌÂϤÙ˜ Î·È ÁÈ’ ·˘Ùfi Ù· ÎÚÈÙ‹ÚÈ· ·˘Ù¿ ¤¯Ô˘Ó ˘ÈÔıÂÙËı› ·fi Ù· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ·, ÂÍ·ÛÊ·Ï›˙ÔÓÙ·˜ Ôχ ÌÈÎÚ¿ ÔÛÔÛÙ¿ ˘ÔÙÚÔ‹˜ (<8% ÛÙ· 4 ¤ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË)76. ∂Ï·ÛÙÈÎfiÙÂÚ· ÎÚÈÙ‹ÚÈ· ¤¯Ô˘Ó ÚÔÙ·ı› (.¯. ÙÔ˘ ™·Ó ºÚ·ÓÛ›ÛÎÔ) Ì ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·

METAMO™XEY™Eπ™ 2010

ˆ˜ ÚÔ˜ ÙËÓ ˘ÔÙÚÔ‹ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û˘Ó‹ıˆ˜ fï˜ ¯ÂÈÚfiÙÂÚ· Û ۯ¤ÛË Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ ªÈÏ¿ÓÔ˘. À¿Ú¯Ô˘Ó ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó ·Ó·‰Â›ÍÂÈ Î·È ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ˘ÔÙÚÔ‹ ÙÔ˘ HKK, fiˆ˜ Â›Ó·È Ô ‚·ıÌfi˜ ‰È·ÊÔÚÔÔ›ËÛ˘ Î·È ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘ fiÁÎÔ˘77, fï˜ Ù· Â˘Ú‹Ì·Ù· ·˘Ù¿ ‰ÂÓ ¤¯Ô˘Ó ÂȂ‚·Èˆı› Û fiϘ ÙȘ ÌÂϤÙ˜, ÂÓÒ ˘¿Ú¯ÂÈ Î·È Ô Î›Ó‰˘ÓÔ˜ ‰È·ÛÔÚ¿˜ ÙˆÓ Î·ÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·Ù¿ ÙË ‰ÈÂÓ¤ÚÁÂÈ· Ï‹„˘ ÈÛÙÔÏÔÁÈÎÔ‡ ˘ÏÈÎÔ‡ ·fi ÙÔÓ fiÁÎÔ78. π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ Ô˘ Û˘Ó‰˘¿˙Ô˘Ó ÙË ¯ÔÚ‹ÁËÛË sirolimus Ì ÌÂȈ̤ÓË Û˘¯ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Î·È ·˘ÍË̤ÓË ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·ÛıÂÓ›˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó ÏfiÁˆ HKK79.

ÀÔÙÚÔ‹ NASH ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜

149

5. Guy JE, Qian P, Lowell JA, Peters MG. Recurrent primary biliary cirrhosis: peritransplant factors and ursodeoxycholic acid treatment post-liver transplant.

Liver Transpl 2005 Oct; 11(10):1252-7.

6. Jacob DA, Neumann UP, Bahra M, Klupp J, Puhl G, Neuhaus R, et al. Long-term follow-up after recurrence of primary biliary cirrhosis after liver transplantation in 100 patients. Clin Transplant 2006 Mar; 20(2):211-20.

7. Neuberger J, Gunson B, Hubscher S, Nightingale P. Immunosuppression affects the rate of recurrent primary biliary cirrhosis after liver transplantation.

Liver Transpl 2004 Apr; 10(4):488-91.

8. Sylvestre PB, Batts KP, Burgart LJ, Poterucha JJ, Wiesner RH. Recurrence of primary biliary cirrhosis after liver transplantation: Histologic estimate of incidence and natural history. Liver Transpl 2003 Oct; 9(10):1086-93.

9. Liermann Garcia RF, Evangelista GC, McMaster P, Neuberger J. Transplantation for primary biliary cirrhosis: retrospective analysis of 400 patients in a single center. Hepatology 2001 Jan; 33(1):22-7.

H ΛÚÚˆÛË ÏfiÁˆ ÌË ·ÏÎÔÔÏÈ΋˜ ÛÙ·ÙÔË·Ù›Ùȉ·˜ (NASH) ·ÔÙÂÏ› Û˘¯Ófi ·›ÙÈÔ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜80. π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ôχ Û˘¯Ó¿ Ë NASH ˘ÔÙÚÔÈ¿˙ÂÈ ÛÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· (ˆ˜ Î·È 25% 18 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË)80. OÈ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ NASH ‰Â Ê·›ÓÂÙ·È Ó· ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜80. OÈ ·ÎÚȂ›˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ˘ÔÙÚÔ‹˜ ‰ÂÓ ¤¯Ô˘Ó ‰È¢ÎÚÈÓÈÛÙ›, Ê·›ÓÂÙ·È fï˜ fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ˘ÔÙÚÔ‹ Ù˘ NASH ¤¯Ô˘Ó Û˘¯ÓfiÙÂÚ· ™.¢., ·¯˘Û·ÚΛ· Î·È ‰˘ÛÏÈȉ·ÈÌ›·. ∞Ó Î·È Ë ÂÈ‚›ˆÛË ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ ‰ÂÓ ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο81, Ë Û˘¯ÓfiÙÂÚË ‡·ÚÍË ÌÂÙ·‚ÔÏÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ›Ûˆ˜ ÂËÚ¿˙ÂÈ ÛËÌ·ÓÙÈο ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ.

10. Levitsky J, Hart J, Cohen SM, Te HS. The effect of immunosuppressive regimens on the recurrence of primary biliary cirrhosis after liver transplantation.

Liver Transpl 2003 Jul; 9(7):733-6.

μÈ‚ÏÈÔÁÚ·Ê›·

15. Brandsaeter B, Schrumpf E, Bentdal O, Brabrand K, Smith HJ, Abildgaard A, et al. Recurrent primary sclerosing cholangitis after liver transplantation: a magnetic resonance cholangiography study with analyses of predictive factors. Liver Transpl 2005 Nov; 11(11):1361-9.

1. Gonzalez-Koch A, Czaja AJ, Carpenter HA, Roberts SK, Charlton MR, Porayko MK, et al. Recurrent autoimmune hepatitis after orthotopic liver transplantation. Liver Transpl 2001 Apr; 7(4):302-10.

2. Vogel A, Heinrich E, Bahr MJ, Rifai K, Flemming P, Melter M, et al. Long-term outcome of liver transplantation for autoimmune hepatitis. Clin Transplant 2004 Feb; 18(1):62-9.

3. Gautam M, Cheruvattath R, Balan V. Recurrence of autoimmune liver disease after liver transplantation: a systematic review. Liver Transpl 2006 Dec; 12(12):1813-24.

4. Kotlyar DS, Campbell MS, Reddy KR. Recurrence of diseases following orthotopic liver transplantation. Am J Gastroenterol 2006 Jun; 101(6):1370-8.

11. Sanchez EQ, Levy MF, Goldstein RM, Fasola CG, Tillery GW, Netto GJ, et al. The changing clinical presentation of recurrent primary biliary cirrhosis after liver transplantation. Transplantation 2003 Dec 15; 76(11):1583-8.

12. Graziadei IW. Recurrence of primary sclerosing cholangitis after liver transplantation. Liver Transpl 2002 Jul; 8(7):575-81.

13. Cholongitas E, Shusang V, Papatheodoridis GV, Marelli L, Manousou P, Rolando N, et al. Risk factors for recurrence of primary sclerosing cholangitis after liver transplantation. Liver Transpl 2008 Feb; 14(2):138-43.

14. Rowe IA, Webb K, Gunson BK, Mehta N, Haque S, Neuberger J. The impact of disease recurrence on graft survival following liver transplantation: a single centre experience. Transpl Int 2008 May; 21(5):459-65.

16. Khettry U, Keaveny A, Goldar-Najafi A, Lewis WD, Pomfret EA, Pomposelli JJ, et al. Liver transplantation for primary sclerosing cholangitis: a long-term clinicopathologic study. Hum Pathol 2003 Nov; 34(11):1127-36.

17. Kugelmas M, Spiegelman P, Osgood MJ, Young DA, Trotter JF, Steinberg T, et al. Different immunosuppressive regimens and recurrence of primary sclerosing cholangitis after liver transplantation. Liver Transpl 2003 Jul; 9(7):727-32.

150

∂. ÃO§O°∫πΔ∞™

18. Vera A, Moledina S, Gunson B, Hubscher S, Mirza D, Olliff S, et al. Risk factors for recurrence of primary sclerosing cholangitis of liver allograft. Lancet 2002 Dec 14; 360(9349):1943-4.

19. Jeyarajah DR, Netto GJ, Lee SP, Testa G, Abbasoglu O, Husberg BS, et al. Recurrent primary sclerosing cholangitis after orthotopic liver transplantation: is chronic rejection part of the disease process? Transplantation 1998 Nov 27; 66(10):1300-6.

20. Cholongitas E, Shusang V, Patch D, Burroughs AK. Pathogenesis of primary sclerosing cholangitis. J Hepatol 2008 Nov; 49(5):863-4.

21. Molmenti EP, Netto GJ, Murray NG, Smith DM, Molmenti H, Crippin JS, et al. Incidence and recurrence of autoimmune/alloimmune hepatitis in liver transplant recipients. Liver Transpl 2002 Jun; 8(6):519-26.

32.

33.

34.

35.

22. Neuberger J, Jothimani D. Long-term immunosuppression for prevention of nonviral disease recurrence.

Transplant Proc 2005 May; 37(4):1671-4.

36.

23. Campsen J, Zimmerman MA, Trotter JF, Wachs M, Bak T, Steinberg T, et al. Liver transplantation for autoimmune hepatitis and the success of aggressive corticosteroid withdrawal. Liver Transpl 2008 Sep; 14(9):1281-6.

37.

24. Wright HL, Bou-Abboud CF, Hassanein T, Block GD, Demetris AJ, Starzl TE, et al. Disease recurrence and rejection following liver transplantation for autoimmune chronic active liver disease. Transplantation 1992 Jan; 53(1):136-9.

38.

25. Heffron TG, Smallwood GA, Oakley B, Pillen T, Welch D, Martinez E, et al. Autoimmune hepatitis following liver transplantation: relationship to recurrent disease and steroid weaning. Transplant Proc 2002 Dec; 34(8):3311-2.

39.

40.

26. Ahmed M, Mutimer D, Hathaway M, Hubscher S, McMaster P, Elias E. Liver transplantation for autoimmune hepatitis: a 12-year experience. Transplant Proc 1997 Feb; 29(1-2):496.

27. Gotz G, Neuhaus R, Bechstein WO, Lobeck H, Berg T, Hopf U, et al. Recurrence of autoimmune hepatitis after liver transplantation. Transplant Proc 1999 Feb; 31(1-2):430-1.

28. Duclos-Vallee JC, Sebagh M, Rifai K, Johanet C, Ballot E, Guettier C, et al. A 10 year follow up study of patients transplanted for autoimmune hepatitis: histological recurrence precedes clinical and biochemical recurrence. Gut 2003 Jun; 52(6):893-7.

29. Haydon GH, Neuberger J. PBC: an infectious disease?

Gut 2000 Oct; 47(4):586-8.

30. Lohse AW, Obermayer-Straub P, Gerken G, Brunner S, Altes U, Dienes HP, et al. Development of cytochrome P450 2D6-specific LKM-autoantibodies following liver transplantation for Wilson’s disease — possible association with a steroid-resistant transplant rejection episode. J Hepatol 1999 Jul; 31(1):149-55.

31. Jones DE, James OF, Portmann B, Burt AD, Williams R, Hudson M. Development of autoimmune hepatitis fol-

41.

42.

43.

44.

45.

lowing liver transplantation for primary biliary cirrhosis. Hepatology 1999 Jul; 30(1):53-7.

Kerkar N, Hadzic N, Davies ET, Portmann B, Donaldson PT, Rela M, et al. De-novo autoimmune hepatitis after liver transplantation. Lancet 1998 Feb 7; 351(9100): 409-13.

Hubscher SG, Elias E, Buckels JA, Mayer AD, McMaster P, Neuberger JM. Primary biliary cirrhosis. Histological evidence of disease recurrence after liver transplantation. J Hepatol 1993 Jun; 18(2):173-84.

Faust TW. Recurrent primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis after transplantation. Liver Transpl 2001 Nov; 7(11 Suppl 1): S99-108.

LaRusso NF, Shneider BL, Black D, Gores GJ, James SP, Doo E, et al. Primary sclerosing cholangitis: summary of a workshop. Hepatology 2006 Sep; 44(3):746-64.

Gordon F. Recurrent primary sclerosing cholangitis: Clinical diagnosis and long-term management issues.

Liver Transpl 2006 Nov; 12 Suppl 2:S73-S75.

Graziadei IW, Wiesner RH, Batts KP, Marotta PJ, LaRusso NF, Porayko MK, et al. Recurrence of primary sclerosing cholangitis following liver transplantation. Hepatology 1999 Apr; 29(4):1050-6.

Manns MP, Bahr MJ. Recurrent autoimmune hepatitis after liver transplantation-when non-self becomes self.

Hepatology 2000 Oct; 32(4 Pt 1):868-70.

Charatcharoenwitthaya P, Pimentel S, Talwalkar JA, Enders FT, Lindor KD, Krom RA, et al. Long-term survival and impact of ursodeoxycholic acid treatment for recurrent primary biliary cirrhosis after liver transplantation. Liver Transpl 2007 Sep; 13(9):1236-45.

Hurtova M, Duclos-Vallee JC, Johanet C, Emile JF, Roque-Afonso AM, Feray C, et al. Successful tacrolimus therapy for a severe recurrence of type 1 autoimmune hepatitis in a liver graft recipient. Liver Transpl 2001 Jun; 7(6):556-8.

Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology 2009 Apr; 49(4):1335-74.

Davis GL, Albright JE, Cook SF, Rosenberg DM. Projecting future complications of chronic hepatitis C in the United States. Liver Transpl 2003 Apr; 9(4):331-8.

Dominguez-Gil B, Morales JM. Transplantation in the patient with hepatitis C. Transpl Int 2009 Dec; 22(12): 1117-31.

Watt K, Veldt B, Charlton M. A practical guide to the management of HCV infection following liver transplantation. Am J Transplant 2009 Aug; 9(8):1707-13.

Gane EJ. The natural history of recurrent hepatitis C and what influences this. Liver Transpl 2008 Oct; 14 Suppl 2: S36-S44.

46. Thuluvath PJ, Krok KL, Segev DL, Yoo HY. Trends in post-liver transplant survival in patients with hepatitis C between 1991 and 2001 in the United States. Liver Transpl 2007 May; 13(5):719-24.

METAMO™XEY™Eπ™ 2010

47. McCashland TM. Management of liver transplant recipients with recurrent hepatitis C. Curr Opin Organ Transplant 2009 Jun; 14(3):221-4.

48. Selzner N, Renner EL, Selzner M, Adeyi O, Kashfi A, Therapondos G, et al. Antiviral treatment of recurrent hepatitis C after liver transplantation: predictors of response and long-term outcome. Transplantation 2009 Nov 27; 88(10):1214-21.

49. Kornberg A, Kupper B, Tannapfel A, Thrum K, Barthel E, Habrecht O, et al. Sustained clearance of serum hepatitis C virus-RNA independently predicts longterm survival in liver transplant patients with recurrent hepatitis C. Transplantation 2008 Aug 15; 86(3):469-73.

50. Gallegos-Orozco JF, Yosephy A, Noble B, Aqel BA, Byrne TJ, Carey EJ, et al. Natural history of post-liver transplantation hepatitis C: A review of factors that may influence its course. Liver Transpl 2009 Dec; 15(12):1872-81.

51. Manousou P, Samonakis D, Cholongitas E, Patch D, O’Beirne J, Dhillon AP, et al. Outcome of recurrent hepatitis C virus after liver transplantation in a randomized trial of tacrolimus monotherapy versus triple therapy. Liver Transpl 2009 Dec; 15(12):1783-91.

52. McHutchison JG, Dusheiko G, Shiffman ML, RodriguezTorres M, Sigal S, Bourliere M, et al. Eltrombopag for thrombocytopenia in patients with cirrhosis associated with hepatitis C. N Engl J Med 2007 Nov 29; 357(22): 2227-36.

53. Todo S, Demetris AJ, Van Thiel D, Teperman L, Fung JJ, Starzl TE. Orthotopic liver transplantation for patients with hepatitis B virus-related liver disease. Hepatology 1991 Apr; 13(4):619-26.

54. O’Grady JG, Smith HM, Davies SE, Daniels HM, Donaldson PT, Tan KC, et al. Hepatitis B virus reinfection after orthotopic liver transplantation. Serological and clinical implications. J Hepatol 1992 Jan; 14(1):104-11.

55. Davies SE, Portmann BC, O’Grady JG, Aldis PM, Chaggar K, Alexander GJ, et al. Hepatic histological findings after transplantation for chronic hepatitis B virus infection, including a unique pattern of fibrosing cholestatic hepatitis. Hepatology 1991 Jan; 13(1):150-7.

56. 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 Dec 16; 329(25):1842-7.

57. Cholongitas E, Papatheodoridis GV, Burroughs AK. Liver grafts from anti-hepatitis B core positive donors: a systematic review. J Hepatol 2010 Feb; 52(2):272-9.

58. Wu JC, Huang YH, Chau GY, Su CW, Lai CR, Lee PC, et al. Risk factors for early and late recurrence in hepatitis B-related hepatocellular carcinoma. J Hepatol 2009 Nov; 51(5):890-7.

59. Papatheodoridis GV, Cholongitas E, Archimandritis AJ, Burroughs AK. Current management of hepatitis B virus infection before and after liver transplantation.

Liver Int 2009 Oct; 29(9):1294-305.

151

60. Loomba R, Rowley AK, Wesley R, Smith KG, Liang TJ, Pucino F, et al. Hepatitis B immunoglobulin and Lamivudine improve hepatitis B-related outcomes after liver transplantation: meta-analysis. Clin Gastroenterol Hepatol 2008 Jun; 6(6):696-700.

61. Chu C-J, Fontana RJ, Moore C, Wai C-T, Punch J, Su G, et al. Efficacy of HBIG weaning in the long-term prophylaxis of HBV reinfection following liver transplantation.

Hepatology 36, 221A. 2002. Ref Type: Abstract.

62. Kim DD, Heffernan DJ, Bass NM, Roberts JP, Ascher NL, Terrault NA. Comparison of 6 versus 12 months hepatitis B immune globulin in combination with lamivudine as prophylaxis in liver transplant recipients with hepatitis B. Hepatology 36, 221A. 2002. Ref Type: Abstract.

63. Neff GW, Kemmer N, Kaiser TE, Zacharias VC, Alonzo M, Thomas M, et al. Combination therapy in liver transplant recipients with hepatitis B virus without hepatitis B immune globulin. Dig Dis Sci 2007 Oct; 52(10):2497-500.

64. Nath DS, Kalis A, Nelson S, Payne WD, Lake JR, Humar A. Hepatitis B prophylaxis post-liver transplant without maintenance hepatitis B immunoglobulin therapy. Clin Transplant 2006 Mar; 20(2):206-10.

65. Perrillo R, Rakela J, Dienstag J, Levy G, Martin P, Wright T, et al. Multicenter study of lamivudine therapy for hepatitis B after liver transplantation. Lamivudine Transplant Group. Hepatology 1999 May; 29(5):1581-6.

66. Seehofer D, Rayes N, Bechstein WO, Naumann U, Neuhaus R, Berg T, et al. Therapy of recurrent hepatitis B infection after liver transplantation. A retrospective analysis of 200 liver transplantations based on hepatitis B associated liver diseases. Z Gastroenterol 2000 Sep; 38(9):773-83.

67. Fontana RJ, Hann HW, Wright T, Everson G, Baker A, Schiff ER, et al. A multicenter study of lamivudine treatment in 33 patients with hepatitis B after liver transplantation. Liver Transpl 2001 Jun; 7(6):504-10.

68. Ben-Ari Z, Mor E, Shapira Z, Tur-Kaspa R. Long-term experience with lamivudine therapy for hepatitis B virus infection after liver transplantation. Liver Transpl 2001 Feb; 7(2):113-7.

69. Rayes N, Seehofer D, Hopf U, Neuhaus R, Naumann U, Bechstein WO, et al. Comparison of famciclovir and lamivudine in the long-term treatment of hepatitis B infection after liver transplantation. Transplantation 2001 Jan 15; 71(1):96-101.

70. Ben-Ari Z, Pappo O, Zemel R, Mor E, Tur-Kaspa R. Association of lamivudine resistance in recurrent hepatitis B after liver transplantation with advanced hepatic fibrosis. Transplantation 1999 Jul 27; 68(2):232-6.

71. Peters MG, Singer G, Howard T, Jacobsmeyer S, Xiong X, Gibbs CS, et al. Fulminant hepatic failure resulting from lamivudine-resistant hepatitis B virus in a renal transplant recipient: durable response after orthotopic liver transplantation on adefovir dipivoxil and hepatitis B immune globulin. Transplantation 1999 Dec 27; 68(12):1912-4.

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72. Schiff E, Lai CL, Hadziyannis S, Neuhaus P, Terrault N, Colombo M, et al. Adefovir dipivoxil for wait-listed and post-liver transplantation patients with lamivudine-resistant hepatitis B: final long-term results. Liver Transpl 2007 Mar; 13(3):349-60.

73. Neff GW, O’brien CB, Nery J, Shire N, Montalbano M, Ruiz P, et al. Outcomes in liver transplant recipients with hepatitis B virus: resistance and recurrence patterns from a large transplant center over the last decade. Liver Transpl 2004 Nov; 10(11):1372-8.

74. Lilly L, Therapondos G, Mason AL, Burak KW. Tenofovir is effective in suppressing HBV replication in liver transplant recipients with nucleos(t)ide resistant recurrent disease.

Hepatology 48 (Suppl.), 574A. 2008. Ref Type: Abstract.

75. Tenney D, Pokorowski KA, Rose RE, Baldick CJ, Eggers BJ, Fang J, et al. Entecavir at five years shows long-term maintenance of high genetic barrier to hepatitis B virus resistance. APASL Abstr. PL02. 2008. Ref Type: Abstract.

76. Tanwar S, Khan SA, Grover VP, Gwilt C, Smith B, Brown A. Liver transplantation for hepatocellular carcinoma.

World J Gastroenterol 2009 Nov 28; 15(44):5511-6.

77. Marshall AE, Rushbrook SM, Vowler SL, Palmer CR, Davies RJ, Gibbs P, et al. Tumor recurrence following liver transplantation for hepatocellular carcinoma: role of tumor proliferation status. Liver Transpl 2010 Mar; 16(3):279-88.

78. Marelli L, Grasso A, Pleguezuelo M, Martines H, Stigliano R, Dhillon AP, et al. Tumour size and differentiation in predicting recurrence of hepatocellular carcinoma after liver transplantation: external validation of a new prognostic score. Ann Surg Oncol 2008 Dec; 15(12):3503-11.

79. Toso C, Merani S, Bigam DL, Shapiro AM, Kneteman NM. Sirolimus-based immunosuppression is associated with increased survival after liver transplantation for hepatocellular carcinoma. Hepatology 2010 Apr; 51(4):1237-43.

80. Malik SM, Devera ME, Fontes P, Shaikh O, Sasatomi E, Ahmad J. Recurrent disease following liver transplantation for nonalcoholic steatohepatitis cirrhosis. Liver Transpl 2009 Dec; 15(12):1843-51.

81. Bhagat V, Mindikoglu AL, Nudo CG, Schiff ER, Tzakis A, Regev A. Outcomes of liver transplantation in patients with cirrhosis due to nonalcoholic steatohepatitis versus patients with cirrhosis due to alcoholic liver disease.

Liver Transpl 2009 Dec; 15(12):1814-20.

Pediatric liver transplantation. A 2010 perspective Raymond Reding, MD PhD

Pediatric liver transplantation (LT) has become a validated modality for the therapy of chronic and acute liver insufficiency, as well as of selected metabolic diseases in children. In experienced centers, the overall results of LT in children nowadays reach patient survival rates beyond 90% at one year for most indications.

When compared to adult cases, pediatric LT is characterized by several specificities, including the mandatory use of left liver lobes from adult donors, the technical difficulties of vascular anastomoses in small recipients, and the peculiar approach towards immunosuppression in small infants. The aims of this talk is to review our recent observations regarding the management of portal hypoplasia in children with biliary atresia, as well as the impact of recipient age and donor type on long-term graft acceptance and tolerance following pediatric LT.

Figure 1. Measure of hepatic artery resistivity index (ARI) >1, in a child with biliary atresia. The diastolic arterial flow is hepatofugal.

1. Impact of Pre-Transplant Liver Hemodynamics and Portal Reconstruction Technique on Post-Transplant Portal Vein Complications

(latero-lateral anastomosis of donor inferior mesenteric vein graft and recipient PV: Figure 2) (n=21, 11%).

Portal vein (PV) complications are the most frequent vascular complications in LT and may result in graft loss and mortality. We hypothesized that pre-LT liver hemodynamic parameters and PV reconstruction technique could predict the risk of PV complications post-LT.

Patients and methods Between 07/1993 and 01/2008, 373 children (<18 yr) had a primary LT (minimal follow-up: 6 mo). A detailed ultrasound study of the pre-LT hemodynamics, including PV diameter/flow direction and hepatic arterial resistance index (ARI: Figure 1), was available in 198 cases.

The details of the PV reconstruction technique were available for 193 of these patients: end-toend anastomosis (n=153, 79%), interposition vein graft technique (n=19, 10%) or portoplasty

Figure 2. Portoplasty technique for portal vein reconstruction in pediatric liver transplantation in case of portal hypoplasia.

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Results Overall 5- and 10-yr patient survival rates were 90% and 89%, respectively, the corresponding graft survival rates being 84% and 82%. Among the 198 patients with liver hemodynamic data, 79 (40%) had PV hypoplasia (diameter ≤ 4mm), 64 (32%) had a pathological portal flow (nonhepatopetal flow) and 47 (24%) had an ARI ≥ 1.

Abnormal liver hemodynamics were mostly observed in biliary atresia (BA): 73 of the 79 with PV hypoplasia (92%), 55 of the 64 with a pathological portal flow (86%) and 46 of the 47 with an abnormal ARI (98%). Among these 3 parameters pre-LT, only ARI ≥ 1 was significantly correlated with a higher rate of PV complications post-LT (p=0.042). Among the 193 children with technical details available, the PV complication free survival at 5 and 10 yr were respectively 91% and 87% for end-to-end anastomosis, 91 % for portoplasty and 49% for interposition vein graft (p<0.001). At multivariate analysis, the use of an interposition vein graft was the only factor to be significantly associated with a higher rate of PV complications post-LT (p=0.015).

Conclusions (1) PV hypoplasia with liver hemodynamic disturbances was mainly observed in BA; (2) hepatic ARI ≥ 1 seemed to constitute a good predictor of PV complications post-LT; (3) PV reconstruction using latero-lateral portoplasty seemed to provide the best results when end-toend anastomosis is not feasible.

2. Does Liver Transplantation during Infancy Provide Better Allograft Acceptance and Enhanced Long-Term Tolerance?

In our recent LT experience, as much as 38% of patients were transplanted during infancy (<1yr).

We hypothesized that immunological immaturity observed in infants might result in lower rejection rates and enhanced allograft tolerance.

Patients and Methods 196 pediatric recipients (biliary atresia: n=98; other diagnoses: n=98) of a primary LT, transplanted between 04/1999 and 06/2007 under tacrolimus-based immunosuppression, were

reviewed. A subpopulation of 168 children became long-term survivors (>1 yr post-LT), with a documented median follow-up of 6.0 yrs. In these, prope tolerance was defined as tacrolimus monotherapy, with mean trough blood levels 4ng/ml during the preceding year, combined with normal liver tests; operational tolerance was defined as stable immunosuppression withdrawal (>1yr).

Results Among the 75 children transplanted as infants, the 1- and 5-yr patient survival rates were 97% and 93%, versus 93% and 92% for children transplanted beyond 1 year of age, respectively (NS); the corresponding graft survival rates were 95% and 90%, versus 88% and 84% (NS). At 5 yrs, no significant difference was observed in term of hepatic artery thrombosis rate (<1yr: 7%; >1yr: 4%, NS) or biliary complication rate (<1yr: 16%; >1yr: 22%, NS). Only the 5-yr rate of portal vein complication was significantly higher in infants (<1yr: 12%; >1yr: 4%, p=0.01). Regarding the immunological issues, the 5 yr rate of acute rejection was comparable in both groups (<1yr: 66%; >1yr: 61%, NS); similarly, no difference was found for chronic rejection (<1yr: 1%; >1yr: 4%, NS). Among the 168 long-term survivors post-LT, 38/68 recipients transplanted as infants became prope/operationally tolerant (56%), compared to 41/100 children transplanted beyond 1 yr of age (41%) (p=0.058). Moreover, steroid avoidance and living related LT were both significantly associated with later occurrence of a prope/operational tolerance (p=0.011 and p=0.01, respectively).

Conclusions (1) No significant impact of recipient age on overall patient/graft outcome could be evidenced; (2) transplanted infants seemed to have increased rate of portal complications, possibly related to portal vein hypoplasia; (3) despite similar rejection rates, infants showed a trend toward enhanced allograft tolerance in the long-term.

Overall, these two recent works performed at our center illustrate how the conjunction of efforts to improve early and late outcome might both contribute to further improvements of results in pediatric liver transplantation.

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΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Â›‰Ô˜ Ù˘ ÔÍ›·˜ Ë·Ù›Ùȉ·˜. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ ÈÔÁÂÓÔ‡˜ Ë·Ù›Ùȉ·˜ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ˘ÂÚ‚·›ÓÂÈ ÙÔ 10%2, ÂÓÒ ÛÙËÓ ÔÍ›· ·Èı·ÓÔÏÈ΋ Ë·Ù›Ùȉ· Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 50%3, Èı·ÓfiÓ ÏfiÁˆ Ù˘ Û˘¯Ó‹˜ Û˘Ó‡·Ú͢ Ì ΛÚÚˆÛË. ∂ÈϤÔÓ, fiÙ·Ó ‰È·ÈÛÙÒÓÂÙ·È ÎÂÚ·˘ÓÔ‚fiÏÔ˜ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·, ÙfiÙÂ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ÁÈ· ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ ÊÙ¿ÓÂÈ ÛÙÔ 90%4. ∂˘Ù˘¯Ò˜, Ë Û˘Ó‡·ÚÍË ÔÍ›·˜ Ë·Ù›Ùȉ·˜ Î·È ÌË Ë·ÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÓfiÛÔ˘ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· Î·È ‰ÂÓ ·ÔÙÂÏ› Ú·ÁÌ·ÙÈÎfi Úfi‚ÏËÌ· Ù˘ ηıËÌÂÚÈÓ‹˜ ÎÏÈÓÈ΋˜ Ú¿Í˘. ŸÛÔÓ ·ÊÔÚ¿ ÛÙË ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ ¯ˆÚ›˜ ΛÚÚˆÛË, Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ÁÈ· Û˘Ó˘¿Ú¯Ô˘Û· ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ ‰ÂÓ Â›Ó·È ·˘ÍË̤ÓË5, ÔfiÙÂ, ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË, ‰ÂÓ ˘Ê›ÛÙ·Ù·È ÎÏÈÓÈÎfi Úfi‚ÏËÌ·. ∞ÏÒ˜ ¯ÚÂÈ¿˙ÂÙ·È ÚÔÛÔ¯‹ ÛÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· Ô˘ ÌÔÚ› Ó· ÚÔ·„ÂÈ ·fi Ù· Û˘ÓÔ‰¿ È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ Ë Î·Ú‰ÈÔÌ˘Ô¿ıÂÈ· Î·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ÛÙËÓ ·ÈÌԯڈ̿وÛË, ÔÈ Ó¢ÚÔ„˘¯È·ÙÚÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙË ÓfiÛÔ ÙÔ˘ Wilson Î·È Ë Ê·Ú̷΢ÙÈ΋ ÂÈÓÂÊÚȉÈ΋ ηٷÛÙÔÏ‹ ÛÙȘ ·˘ÙÔ¿ÓÔÛ˜ Ë·ÙÔ¿ıÂȘ6,7. ΔÔ Ú·ÁÌ·ÙÈÎfi Î·È ·ÚÎÂÙ¿ Û˘¯Ófi ÎÏÈÓÈÎfi Úfi‚ÏËÌ· ‚Ú›ÛÎÂÙ·È ÛÙË Û˘Ó‡·ÚÍË Î›ÚÚˆÛ˘ Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ. ΔÔ 10% ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ ÂÓÙÂÙ·ÁÌ¤ÓˆÓ ‹ ÌË ÛÙË Ï›ÛÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ı· ˘Ô‚ÏËıÔ‡Ó Û οÔÈÔ Â›‰Ô˜ ÌË Ë·ÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ ηٿ Ù· ‰‡Ô ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜8. ΔÚÂȘ Â›Ó·È ÔÈ Î·ÙËÁÔڛ˜ ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÂÌ‚¿ÛÂˆÓ ÛÙȘ Ôԛ˜ ˘Ô‚¿ÏÏÔÓÙ·È ÔÈ ÎÈÚÚˆÙÈÎÔ›9: 1) OÈ Â›ÁÔ˘Û˜ (.¯. Ë ÂÚÈÛÊÈÁ̤ÓË Î‹ÏË). 2) OÈ ··Ú·›ÙËÙ˜ ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÛÙË Ï›ÛÙ· Ù˘ ª∏, ÔÈ Ôԛ˜ ˘ԉȷÈÚÔ‡ÓÙ·È Û ÂÂÌ‚¿ÛÂȘ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ-

∏ Û˘Ó‡·ÚÍË Ë·ÙÔ¿ıÂÈ·˜ Î·È ÌË Ë·ÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÓfiÛÔ˘ Â›Ó·È ¤Ó· ÈÔ ‰‡ÛÎÔÏ· ÚÔ‚Ï‹Ì·Ù· Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ Ô Û‡Á¯ÚÔÓÔ˜ Ë·ÙÔÏfiÁÔ˜. ¶·Ú·‰Â›ÁÌ·ÙÔ˜ ¯¿ÚÈÓ, ·˜ ˘Ôı¤ÛÔ˘Ì fiÙÈ ·Ú·ÎÔÏÔ˘ıԇ̛̠· Á˘Ó·›Î· 38 ÂÙÒÓ Ì ÚˆÙÔ·ı‹ ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁ›Ùȉ· Î·È ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ·, ‰È·ÈÛو̤ÓË Â‰Ò Î·È 15 ¯ÚfiÓÈ·. ∏ ‚·ıÌÔÏÔÁ›· MELD Ù˘ ·ÛıÂÓÔ‡˜ Ì·˜ Â›Ó·È 16 Î·È ÂÈϤÔÓ ‰È·ÈÛÙÒÓÔÓÙ·È fiÏÔ Î·È Û˘¯ÓfiÙÂÚ· ÂÂÈÛfi‰È· ¯ÔÏ·ÁÁÂÈ›Ùȉ·˜. ∏ Ó·ڋ Á˘Ó·›Î· ÂÓÙ¿ÛÛÂÙ·È ÛÙË Ï›ÛÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ª∏). øÛÙfiÛÔ, ηٿ ÙËÓ ÎÔÏÔÓÔÛÎfiËÛË Ô˘ ˘Ê›ÛÙ·Ù·È Ë ·ÛıÂÓ‹˜ ÛÙ· Ï·›ÛÈ· Ù˘ ÚÔÂÁ¯ÂÈÚËÙÈ΋˜ ÂÎÙ›ÌËÛ˘, ‰È·ÈÛÙÒÓÂÙ·È ˘„ËÏÔ‡ ‚·ıÌÔ‡ ‰˘ÛÏ·Û›· Û ¤Ó·Ó Â›Â‰Ô ÔχÔ‰· ÙÔ˘ ·ÓÈfiÓÙÔ˜ ÎfiÏÔ˘. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÛÙÔ 30% ÙˆÓ ‰˘ÛÏ·ÛÈÒÓ ˘„ËÏÔ‡ ‚·ıÌÔ‡ Û˘Ó˘¿Ú¯ÂÈ Î·ÚΛÓÔ˜1 Î·È Ì ‚¿ÛË ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Ó·ڋ Á˘Ó·›Î· Â›Ó·È ÎÈÚÚˆÙÈ΋, ÔÈfi ı· Ú¤ÂÈ Ó· Â›Ó·È ÙÔ ÂfiÌÂÓÔ ‚‹Ì·; Ó· Ú·ÁÌ·ÙÔÔÈËı› ÎÔÏÂÎÙÔÌ‹ Î·È ÌÂÙ¿ ª∏; Ó· Ú·ÁÌ·ÙÔÔÈËı› ª∏ Î·È ÌÂÙ¿ ÎÔÏÂÎÙÔÌ‹; Ó· ‰È·ÁÚ·Ê› Ë ·ÛıÂÓ‹˜ ·fi ÙË Ï›ÛÙ·; °È· Ó· ··ÓÙ‹ÛÔ˘Ì ÛÙÔ ÎÏÈÓÈÎfi ·˘Ùfi Úfi‚ÏËÌ·, ı· Û˘ÛÙËÌ·ÙÔÔÈ‹ÛÔ˘Ì ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ÏËÚÔÊÔڛ˜ Î·È ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ì ¤Ó· Û¯ÂÙÈÎfi ·ÏÁfiÚÈıÌÔ ·ÓÙÈÌÂÙÒÈÛ˘, Ô ÔÔ›Ô˜ ‚·Û›˙ÂÙ·È ÛÙËÓ ÂÌÂÈÚ›· ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÔ‡ ΤÓÙÚÔ˘ ÙÔ˘ ·ÓÂÈÛÙËÌ›Ô˘ McGill.

∫·ÙËÁÔÚÈÔÔ›ËÛË Ë·ÙÈÎÒÓ ·ı‹ÛÂˆÓ Î·È ÂÂÌ‚¿ÛÂˆÓ ΔÚÂȘ Â›Ó·È ÔÈ ‚·ÛÈΤ˜ ηÙËÁÔڛ˜ Ë·ÙÔ·ıÂÈÒÓ Ô˘ ÌÔÚ› Ó· Û˘Ó˘¿Ú¯Ô˘Ó Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ: 1) ∏ ÔÍ›· Ë·Ù›Ùȉ·. 2) ∏ ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ˜ ¯ˆÚ›˜ ΛÚÚˆÛË. 3) ∏ ¯ÚfiÓÈ· Ë·ÙÈ΋ ÓfiÛÔ˜ Ì ΛÚÚˆÛË. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÔÍ›· Ë·Ù›Ùȉ·, Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ÁÈ· Û˘Ó˘¿Ú¯Ô˘Û· ÌË Ë·ÙÈ-

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΋˜ (.¯. ÙÔ bypass) Î·È Û ÂÂÌ‚¿ÛÂȘ ÔÁÎÔÏÔÁ›·˜ (.¯. Ë ÎÔÏÂÎÙÔÌ‹). 3) OÈ Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ (.¯. Ë ÔÏÈ΋ ·ÚıÔÏ·ÛÙÈ΋ ÁfiÓ·ÙÔ˜). ∂ÈϤÔÓ, ·Ó¿ÏÔÁ· Ì ÙË ‚·Ú‡ÙËÙ¿ ÙÔ˘˜9,10, ÔÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ÁÈ· ÌË Ë·ÙÈ΋ ÓfiÛÔ Û ÎÈÚÚˆÙÈÎÔ‡˜ ‰È·ÎÚ›ÓÔÓÙ·È Û ÌÈÎÚ‹˜ ‚·Ú‡ÙËÙ·˜ (.¯. ÎÔÈÏÈ·ÎÔ‡ ÙÔȯÒÌ·ÙÔ˜, ‰¤ÚÌ·ÙÔ˜, Î.¿.) Î·È Û ÌÂÁ¿Ï˘ ‚·Ú‡ÙËÙ·˜ (.¯. ÚÔÛı›Ô˘ ÂÓÙ¤ÚÔ˘, ̤ÛÔ˘ Î·È ÔÈÛı›Ô˘ ÂÓÙ¤ÚÔ˘, ηډȿ˜ Î·È Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜). ™Â ÁÂÓÈΤ˜ ÁÚ·Ì̤˜, ÔÈ ÂÂÌ‚¿ÛÂȘ Ô˘ ÌÔÚÔ‡Ó Ó· Ú·ÁÌ·ÙÔÔÈËıÔ‡Ó Ì ÙÔÈ΋ ·Ó·ÈÛıËÛ›· (΋ÏË, Ì·ÛÙÂÎÙÔÌ‹) Â›Ó·È ÌÈÎÚ‹˜ ‚·Ú‡ÙËÙ·˜, ÂÓÒ ÂΛӘ Ô˘ ‰ÈÂÓÂÚÁÔ‡ÓÙ·È ÌfiÓÔ Î¿Ùˆ ·fi ÁÂÓÈ΋ ·Ó·ÈÛıËÛ›· (Á·ÛÙÚÂÎÙÔÌ‹, ÎÔÏÂÎÙÔÌ‹, bypass, ·ÚıÚÔÏ·ÛÙÈ΋) Â›Ó·È ÌÂÁ¿Ï˘ ‚·Ú‡ÙËÙ·˜. ΔÔ ÎÏÈÓÈÎfi ‰›ÏËÌÌ· Û˘Ó‹ıˆ˜ ÚÔ·ÙÂÈ fiÙ·Ó Ú¤ÂÈ Ó· ·ÔÊ·ÛÈÛÙ› Ë ‰ÈÂÓ¤ÚÁÂÈ· ÌÈ·˜ ÌÂÁ¿Ï˘ ‚·Ú‡ÙËÙ·˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘, ··Ú·›ÙËÙ˘ ÁÈ· ÙËÓ ¤ÓÙ·ÍË ÛÙË Ï›ÛÙ· ÚÔ˜ ª∏. ∞˘Ùfi ÁÈ·Ù› ÔÈ ÂÂÌ‚¿ÛÂȘ ÌÈÎÚ‹˜ ‚·Ú‡ÙËÙ·˜ ÂÓ¤¯Ô˘Ó ÌÈÎÚfi ΛӉ˘ÓÔ ÁÈ· ÙÔÓ ÎÈÚÚˆÙÈÎfi ·ÛıÂÓ‹9, ÔÈ Â›ÁÔ˘Û˜ ÂÂÌ‚¿ÛÂȘ ı· Ú·ÁÌ·ÙÔÔÈËıÔ‡Ó Ô‡Ùˆ˜ ‹ ¿Ïψ˜, ÂÓÒ ÔÈ Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÌÔÚÔ‡Ó Â˘ÎÔÏfiٷٷ Ó· ·Ó·‚ÏËıÔ‡Ó.

ÀÔÏÔÁÈÛÌfi˜ Ë·ÙÈ΋˜ Â¿ÚÎÂÈ·˜ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ À¿Ú¯ÂÈ ¤Ó· ‚·ÛÈÎfi ÂÚÒÙËÌ· Ô˘ Ú¤ÂÈ Ó· ··ÓÙËı› ÚÔÙÔ‡ Ô ıÂÚ¿ˆÓ È·ÙÚfi˜ ·ÔÊ·Û›ÛÂÈ Ó· ÚÔÙ›ÓÂÈ Ì›· ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË ÛÙÔÓ ÎÈÚÚˆÙÈÎfi ·ÛıÂÓ‹ Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ. ΔÔ ÂÚÒÙËÌ· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ fiÛÔ ¯ÂÈÚÔ˘ÚÁÈÎfi stress ÌÔÚ› Ó· ·ÓÙ¤ÍÂÈ Ô ÎÈÚÚˆÙÈÎfi˜ ·ÛıÂÓ‹˜ Ì ηϋ ·ÓÙÈÚÚfiËÛË Î·È Ì ÔÈfi ÚÔÛ‰ÔÎfiÌÂÓÔ fiÊÂÏÔ˜. ◊, ·ÏÏÈÒ˜, “fiÛÔ ·fiıÂÌ· Ë·ÙÈ΋˜ Â¿ÚÎÂÈ·˜ ÌÔÚ› Ó· ηٷӷψı› ¯ˆÚ›˜ Ó· ÂËÚÚ¿ÛÂÈ ·ÚÓËÙÈο ÙËÓ ÚÔ‚ÏÂfiÌÂÓË ÂÈ‚›ˆÛË ÙÔ˘ ÎÈÚÚˆÙÈÎÔ‡ ·ÛıÂÓÔ‡˜;”. °È· Ó· ‰Ôı› ·¿ÓÙËÛË ÛÙÔ ÂÚÒÙËÌ· ·˘Ùfi, Ú¤ÂÈ ÚÒÙ· Ó· ˘ÔÏÔÁ›ÛÔ˘Ì ÙËÓ Ë·ÙÈ΋ Â¿ÚÎÂÈ· ÙÔ˘ ÂοÛÙÔÙ ÎÈÚÚˆÙÈÎÔ‡. Δ· ‰‡Ô ˘ÔÏÔÁÈÛÙÈο ÂÚÁ·Ï›· ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ Ë·ÙÈ΋˜ Â¿ÚÎÂÈ·˜ Â›Ó·È Ë ‚·ıÌÔÏÔÁ›· Child-Turcotte-Pugh (CTP)11 Î·È Ë ‚·ıÌÔÏÔÁ›· Model for End-stage Liver Disease (MELD)12. ªÂ ÙË ‚·ıÌÔÏÔÁ›· CTP Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ë ·Ó·ÌÂÓfiÌÂÓË ıÓËÙfiÙËÙ· (Ê˘ÛÈ΋ ÈÛÙÔÚ›·) ÙÔ˘ ÎÈÚÚˆÙÈÎÔ‡ Ô˘ ‰ÂÓ ¤¯ÂÈ ˘Ô‚ÏËı› Û ª∏. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, Ë ÂÙ‹ÛÈ· ÚÔ‚ÏÂfiÌÂ-

ÓË ıÓËÙfiÙËÙËÙ· ÁÈ· ‚·ıÌÔÏÔÁ›· CTP 5-6 (Child’s A), 7-9 (Child’s B) Î·È 10-15 (Child’s C) Â›Ó·È 0%, 19% Î·È 55% ·ÓÙ›ÛÙÔȯ·. ∂ÈϤÔÓ, Ë ‰ÈÂÙ‹˜ ÚÔ‚ÏÂfiÌÂÓË ıÓËÙfiÙËÙËÙ· ÁÈ· ‚·ıÌÔÏÔÁ›· ÁÈ· Ù· ÛÙ¿‰È· Child’s A, B Î·È C Â›Ó·È 15%, 43% Î·È 65% ·ÓÙ›ÛÙÔȯ·13. ◊‰Ë ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ ’80, ÔÏÏÔ› Û˘ÁÁÚ·Ê›˜14-16 ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÙËÓ ÚÔÁÓˆÛÙÈ΋ ÈηÓfiÙËÙ· Ù˘ ‚·ıÌÔÏÔÁ›·˜ CTP ÁÈ· Ó· ÚÔÛ‰ÈÔÚ›ÛÔ˘Ó ÙËÓ Èı·ÓfiÙËÙ· ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡ ı·Ó¿ÙÔ˘ ÛÙÔÓ ÎÈÚÚˆÙÈÎfi Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ (¶›Ó·Î·˜ 1). ∞fi ÙȘ ÌÂϤÙ˜ ·˘Ù¤˜ ÚÔ·ÙÔ˘Ó ‰‡Ô ÛËÌ›·. ∏ ‚·ıÌÔÏÔÁ›· CTP ‚·Û›˙ÂÙ·È Î·È Û ˘ÔÎÂÈÌÂÓÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, ÁÂÁÔÓfi˜ Ô˘ ÙËÓ Î·ıÈÛÙ¿ ÏÈÁfiÙÂÚÔ ·ÍÈfiÈÛÙË. ∂ÈϤÔÓ, Ë ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ· Ù˘ ‚·ıÌÔÏÔÁ›·˜ CTP Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ‰È·ÎÚ›ÓÂÈ ÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ Û ÙÚÂȘ, ÌfiÓÔ, ÔÌ¿‰Â˜ ‚·Ú‡ÙËÙ·˜ ÓfiÛÔ˘. π‰È·›ÙÂÚ· ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, ηٿ ÙËÓ ÔÔ›· ÔÈ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ·Ó·ÈÛıËÛÈÔÏÔÁ›· Î·È ÙËÓ ÂÓÙ·ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ¤¯Ô˘Ó ‚ÂÏÙÈÒÛÂÈ ÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÚ›· ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ, Ë ÌÈÎÚ‹ ‰È·ÎÚÈÙÈ΋ ÈηÓfiÙËÙ· Ù˘ ‚·ıÌÔÏÔÁ›·˜ CTP ·ÔÙÂÏ› ·ÎfiÌ· ÌÂÁ·Ï‡ÙÂÚÔ Úfi‚ÏËÌ·. ¶·Ú·‰Â›ÁÌ·ÙÔ˜ ¯¿ÚÈÓ, Û ۯÂÙÈο ÚfiÛÊ·ÙË ÌÂϤÙË, Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ÁÈ· ÌË Ë·ÙÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÓfiÛÔ˘˜ ‹Ù·Ó 17%, 18% Î·È 100% ÁÈ· ÎÈÚÚˆÙÈÎÔ‡˜ ηÙËÁÔÚ›·˜ Child’s A, B Î·È C ·ÓÙ›ÛÙÔȯ·14. ¶›Ó·Î·˜ 1: ∏ ÂͤÏÈÍË, ·Ó¿ ‰ÂηÂÙ›·, Ù˘ ‚·ıÌÔÏÔÁ›·˜ CTP ÛÙÔÓ ˘ÔÏÔÁÈÛÌfi Ù˘ Èı·ÓfiÙËÙ·˜ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÔ‡ ı·Ó¿ÙÔ˘ ÁÈ· ÙÔÓ ÎÈÚÚˆÙÈÎfi ·ÛıÂÓ‹ Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ. ªÂÙÂÁ¯ÂÈÚËÙÈ΋ ¶ÔÚ›· £ÓËÙfiÙËÙ· 90 ∏ÌÂÚÒÓ (%) CTP (Child’s) Garrison, et al Ann Surg 1984; 199: 648 5-6 (A) 7-9 (B) 10-15 (C)

10 31 76

Mansour, et al Surgery 1997; 122: 730

Farnsworth, et al Am J Surg 2004; 188: 580

10 30 82

17 18 100

∏ ‚·ıÌÔÏÔÁ›· MELD ‰ÂÓ ¤¯ÂÈ ÙȘ ‰‡Ô ÚÔ·Ó·ÊÂÚfiÌÂÓ˜ ·‰˘Ó·Ì›Â˜ Ù˘ ‚·ıÌÔÏÔÁ›·˜ CTP. ∞ÊÂÓfi˜ ÛÙËÚ›˙ÂÙ·È ÌfiÓÔ Û ·ÓÙÈÎÂÈÌÂÓÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, ·ÊÂÙ¤ÚÔ˘ ηÙËÁÔÚÈÔÔÈ› ÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ Ì ‚¿ÛË Ì›· Û˘Ó¯‹ Îϛ̷η Ô˘ Ï·Ì‚¿ÓÂÈ fiϘ ÙȘ ·Î¤Ú·È˜ ÙÈ̤˜ ·fi ÙÔ 6 ¤ˆ˜ ÙÔ 40 (ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈÎÔ˘˜). ªÂ ÙË ‚·ıÌÔÏÔÁ›· MELD Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› Ì ·ÎÚ›‚ÂÈ· Ë ·Ó·ÌÂ-

METAMO™XEY™Eπ™ 2010

ÓfiÌÂÓË ıÓËÙfiÙËÙ· (Ê˘ÛÈ΋ ÈÛÙÔÚ›·) ÙÔ˘ ÎÈÚÚˆÙÈÎÔ‡ Ô˘ ‰ÂÓ ¤¯ÂÈ ˘Ô‚ÏËı› Û ª∏. ∂Ó‰ÂÈÎÙÈο, Ë ÚÔ‚ÏÂfiÌÂÓË ıÓËÙfiÙËÙ· ÙÚÈÌ‹ÓÔ˘ ÛÙË Ï›ÛÙ· ÚÔ˜ ª∏ Â›Ó·È 85%, 75% Î·È 50% ÁÈ· ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ‚·ıÌÔÏÔÁ›· MELD 20, 25 Î·È 30 ·ÓÙ›ÛÙÔȯ·17. ∏ ‚·ıÌÔÏÔÁ›· MELD ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ÂÎÙÂÙ·Ì̤ӷ ·fi ÙȘ ·Ú¯¤˜ Ù˘ ÙÚ¤¯Ô˘Û·˜ ‰ÂηÂÙ›·˜ ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÛÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ. ŒÙÛÈ, ÔÈ ÎÈÚÚˆÙÈÎÔ› Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ¯ÔÏÔ΢ÛÙÂÎÙÔÌ‹ ¤¯Ô˘Ó ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜ 10%, ·Ó Ë ‚·ıÌÔÏÔÁ›· MELD Â›Ó·È ÌÈÎÚfiÙÂÚË ‹ ›ÛË ÙÔ˘ 8 Î·È 44%, ·Ó Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË ·fi 818. ™Â ¿ÏÏË ÌÂϤÙË ·Ó·‰Â›¯ıËΠfiÙÈ ‚·ıÌÔÏÔÁ›· MELD ›ÛË Ì 14 ÈÛÔ‰˘Ó·Ì› Ì ηÙËÁÔÚ›· Child’s C Î·È Û˘ÓÂ¿ÁÂÙ·È ıÓËÙfiÙËÙ· 17% ÛÙÔÓ ÎÈÚÚˆÙÈÎfi Ô˘ ı· ˘Ô‚ÏËı› Û ¯ÔÏÔ΢ÛÙÂÎÙÔÌ‹19. ∂ÈϤÔÓ, Û ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË 140 ·ÛıÂÓÒÓ Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ, ·fi ÙÔ˘˜ ÔÔ›Ô˘˜ ÔÈ ÌÈÛÔ› ÂÚ›Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û Ϸ·ÚÔÙÔÌ›·, ˘ÔÏÔÁ›ÛÙËΠfiÙÈ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ÙˆÓ ÚÒÙˆÓ 30 ËÌÂÚÒÓ ‹Ù·Ó 1% ÁÈ· οı ÌÔÓ¿‰· MELD ¤ˆ˜ Î·È ÙÔ 20 Î·È 2% ÁÈ· οı ÌÔÓ¿‰· MELD ¿Óˆ ·fi ÙÔ 2020. ª¿ÏÈÛÙ·, ·˘Ùfi˜ Â›Ó·È Ô ÌÓËÌÔÓÈÎfi˜ ηÓfiÓ·˜ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó Û‹ÌÂÚ· ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ıÂÚ¿ÔÓÙ˜ fiÙ·Ó Ï·Ì‚¿ÓÔ˘Ó ·ÔÊ¿ÛÂȘ ÁÈ· ÙÔÓ ÎÈÚÚˆÙÈÎfi ·ÛıÂÓ‹ Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ. øÛÙfiÛÔ, Ë ÌÂÁ·Ï‡ÙÂÚË (·fi ÏÂ˘Ú¿˜ ·ÚÈıÌÔ‡ ·ÛıÂÓÒÓ) Î·È Û˘¯ÓfiÙÂÚ· ·Ó·ÊÂÚfiÌÂÓË ÌÂϤÙË ÚÔ¤Ú¯ÂÙ·È ·fi ÙË Mayo Clinic Î·È Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÈ 772 ÎÈÚÚˆÙÈÎÔ‡˜ ÔÈ ÔÔ›ÔÈ ˘Ô‚Ï‹ıËÎ·Ó Û ÂÂÌ‚¿ÛÂȘ ηډȿ˜ (8%), Û ÂÂÌ‚¿ÛÂȘ ÙÔ˘ ÚfiÛıÈÔ˘ ÂÓÙ¤ÚÔ˘ (49%), Û ÂÂÌ‚¿ÛÂȘ ÙÔ˘ ̤ÛÔ˘ Î·È Ô›ÛıÈÔ˘ ÂÓÙ¤ÚÔ˘ (29%), ηıÒ˜ Î·È Û ÂÂÌ‚¿ÛÂȘ ÙÔ˘ Ì˘ÔÛÎÂÏÂÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (14%). ™ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ÌÂÙÚ‹ıËÎÂ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ÙˆÓ 7, 30 Î·È 90 ËÌÂÚÒÓ (¶›Ó·Î·˜ 2), ηıÒ˜ Î·È Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÌÂÙ¿ ·fi ¤Ó· Î·È ¤ÓÙ ¤ÙË Î·È Û˘Û¯ÂÙ›ÛÙËΠ̠ÙË ‚·ıÌÔÏÔÁ›· MELD9. ¢‡Ô ·ÚÈ· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙË ÌÂϤÙË ·˘Ù‹ Â›Ó·È Ù· ·ÎfiÏÔ˘ı·: 1) ∏ ıÓËÙfiÙËÙ· ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ÁÈ· ÌË Ë·ÙÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÓfiÛÔ˘˜ ÂÎÙ›ÓÂÙ·È ¤ˆ˜ Î·È ÙËÓ 90Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ. ¶Ú¿ÁÌ·ÙÈ, Ë ıÓËÙfiÙËÙ· ÌÂÙ¿ ·fi Á·ÛÙÚÂÎÙÔÌ‹ ÂÓfi˜ ·ÛıÂÓÔ‡˜ Ì ‚·ıÌÔÏÔÁ›· MELD ›ÛË Ì 6 ·Ó¤Ú¯ÂÙ·È Û ÂÚ›Ô˘ 2%, 6% Î·È 10% ÙËÓ 7Ë, 30Ë Î·È 90Ë ÌÂÙÂÁ-

159

¶›Ó·Î·˜ 2: ªÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· 772 ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ ‡ÛÙÂÚ· ·fi Â¤Ì‚·ÛË ÁÈ· ÌË Ë·ÙÈ΋ ÓfiÛÔ, ·Ó¿ÏÔÁ· Ì ÙË ‚·ıÌÔÏÔÁ›· MELD. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙËÓ ÂÌÂÈÚ›· Ù˘ Mayo Clinic. μ·ıÌÔÏÔÁ›· MELD

ªÂÙÂÁ¯ÂÈÚËÙÈ΋ £ÓËÙfiÙËÙ· (%) 7Ë ∏̤ڷ 30Ë ∏̤ڷ 90Ë ∏̤ڷ

0-7

1.9

5.7

9.7

8-11

3.3

10.3

17.7

12-15

7.7

25.4

32.2

16-20

14.6

44.0

55.8

21-25

23.0

53.8

66.7

≥ 26

30.0

90.0

90.0

¯ÂÈÚËÙÈ΋ Ë̤ڷ ·ÓÙ›ÛÙÔȯ·. 2) ∏ ıÓËÙfiÙËÙ· ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ÁÈ· ÌË Ë·ÙÈΤ˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÓfiÛÔ˘˜ ·˘Í¿ÓÂÙ·È Î·Ù·ÎfiÚ˘Ê· Û ·ÛıÂÓ›˜ Ì ‚·ıÌÔÏÔÁ›· MELD ÌÂÁ·Ï‡ÙÂÚË ·fi 15. ¶Ú¿ÁÌ·ÙÈ, Ë ıÓËÙfiÙËÙ· ÙËÓ 90Ë Ë̤ڷ ÌÂÙ¿ ·fi Á·ÛÙÚÂÎÙÔÌ‹ ÂÓfi˜ ÎÈÚÚˆÙÈÎÔ‡ Â›Ó·È ÂÚ›Ô˘ 30% fiÙ·Ó Ë ‚·ıÌÔÏÔÁ›· MELD Î˘Ì·›ÓÂÙ·È ·fi 12 ¤ˆ˜ 15 Î·È 60% fiÙ·Ó Ë ‚·ıÌÔÏÔÁ›· MELD Î˘Ì·›ÓÂÙ·È ·fi 16 ¤ˆ˜ 20. ∂ÈϤÔÓ, ÛÙË ÌÂϤÙË ·˘Ù‹ ·Ó·‰Â›¯ıËÎÂ Î·È Ô ÚfiÏÔ˜ Ù˘ ËÏÈΛ·˜ ÙÔ˘ ÎÈÚÚˆÙÈÎÔ‡ ÛÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ·fi ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ. ™˘ÁÎÂÎÚÈ̤ӷ, ËÏÈΛ· ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 70 ÂÙÒÓ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ·, ÈÛÔ‰‡Ó·ÌÔ Ì ·‡ÍËÛË ÙÔ˘ MELD ηٿ 3 ÌÔÓ¿‰Â˜. ¢Â‰Ô̤ÓÔ˘, ˆÛÙfiÛÔ, fiÙÈ ÔÈ ÎÈÚÚˆÙÈÎÔ› Û¿ÓÈ· ÍÂÂÚÓÔ‡Ó ÙÔ 70Ô ¤ÙÔ˜, Ë ·Ú¿ÌÂÙÚÔ˜ Ù˘ ·˘Ù‹ ¤¯ÂÈ ÌÈÎÚ‹ ÎÏÈÓÈ΋ ÛËÌ·Û›·. ∂›Û˘, Ë ÌÂϤÙË ·Ó¤‰ÂÈÍÂ Î·È ÙÔ ÚfiÏÔ Ù˘ ηÙËÁÔÚ›·˜ American Society of Anesthesiology (ASA) ÙÔ˘ ÎÈÚÚˆÙÈÎÔ‡ ÛÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ·fi ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ. ∂Í’ ÔÚÈÛÌÔ‡, Ô ÎÈÚÚˆÙÈÎfi˜ ·Ó‹ÎÂÈ ÛÙËÓ Î·ÙËÁÔÚ›· ASA III. ªÂÙ¿ÙˆÛË ÛÙËÓ Î·ÙËÁÔÚ›· IV ÈÛÔ‰˘Ó·Ì› Ì ·‡ÍËÛË ÙÔ˘ MELD ηٿ 5,5 ÌÔÓ¿‰Â˜. ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi Ú¤ÂÈ Ó· ÛËÌÂȈı› ˆ˜ Ë Î·ÙËÁÔÚÈÔÔ›ËÛË Î·Ù¿ ASA ‚·Û›˙ÂÙ·È Û ˘ÔÎÂÈÌÂÓÈ΋ ·ÍÈÔÏfiÁËÛË. ªÂ ‚¿ÛË ÙȘ ‰È·ÈÛÙÒÛÂȘ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜, ·Ó·Ù‡¯ıËΠ·fi ÙË Mayo Clinic ÂÚÁ·ÏÂ›Ô ˘ÔÏÔÁÈÛÌÔ‡ Ù˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ıÓËÙfiÙËÙ·˜ ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ, ÙÔ ÔÔ›Ô ‰È·Ù›ıÂÙ·È ‰ˆÚÂ¿Ó ÛÙËÓ È·ÙÚÈ΋ ÎÔÈÓfiÙËÙ· ·fi ÙËÓ ÈÛÙÔÛÂÏ›‰·: http://www.mayoclinic.org/meld/mayomodel9.html ∂ÎÙfi˜ ·fi ÙȘ ‚·ıÌÔÏÔÁ›Â˜ CTP Î·È MELD, ¤¯ÂÈ ÌÂÏÂÙËı› Ë ÈηÓfiÙËÙ· Úfi‚Ï„˘ Ù˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ıÓËÙfiÙËÙ·˜ ÙÔ˘ ÎÈÚÚˆÙÈÎÔ‡ Ì ÌË Ë·ÙÈ΋ ÓfiÛÔ Î·È Û ۯ¤ÛË Ì ¿ÏϘ ·Ú·Ì¤ÙÚÔ˘˜,

160

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fiˆ˜ Ô ·ÛΛÙ˘, Ô ›ÎÙÂÚÔ˜, Ë ˘ÔËÎÙÈÎfiÙËÙ·, Ë ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Ë ˘ÔÓ·ÙÚÈ·ÈÌ›·, Ë ˘ÔÏÂ˘ÎˆÌ·ÙÈÓ·ÈÌ›· Î·È ÙÔ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ. ¢Â‰Ô̤ÓÔ˘, ˆÛÙfiÛÔ, fiÙÈ Ë ÚÔÁÓˆÛÙÈ΋ ‰‡Ó·ÌË Ù˘ ‚·ıÌÔÏÔÁ›·˜ MELD ˘ÂÚÙÂÚ› ¤Ó·ÓÙÈ fiψÓ, ÔÈ ·Ú¿ÌÂÙÚÔÈ ·˘Ù¤˜ ‰Â ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û˘¯Ó¿ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË21.

¶ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ∞Ó Ô ÎÈÚÚˆÙÈÎfi˜ ·ÛıÂÓ‹˜ Ì ÙË ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ ‰ÂÓ Â›Ó·È ÂÓÙÂÙ·Á̤ÓÔ˜ ÛÙË Ï›ÛÙ· ÚÔ˜ ª∏ (Ôχ ÌÈÎÚfi MELD, ÌÂÁ¿ÏË ËÏÈΛ·, Û˘Ó¯È˙fiÌÂÓË ¯Ú‹ÛË Ô˘ÛÈÒÓ, Î.¿.), ÙfiÙÂ Ë ·fiÊ·ÛË ÁÈ· ÙË ‰ÈÂÓ¤ÚÁÂÈ· Ë ÌË Ì›·˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ Â›Ó·È Û¯ÂÙÈο ·Ï‹. O ıÂÚ¿ˆÓ È·ÙÚfi˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ·ÛıÂÓ‹ Î·È ÙÔ Û˘ÁÁÂÓÈÎfi ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓ “˙˘Á›˙Ô˘Ó” ÙÔÓ Î›Ó‰˘ÓÔ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ıÓËÙfiÙËÙ·˜ ηÈ, ·Ó¿ÏÔÁ· Ì ÙÔ ÚÔÛ‰ÔÎfiÌÂÓÔ fiÊÂÏÔ˜, ·ÔÊ·Û›˙Ô˘Ó ˘¤Ú ‹ ηٿ ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ. ™ÙËÓ ÂÚ›ÙˆÛË ‰ÈÂÓ¤ÚÁÂÈ·˜ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘ Ï·Ì‚¿ÓÔÓÙ·È fiÏ· Ù· ̤ÙÚ· ‰È·Ê‡Ï·Í˘ Ù˘ Ë·ÙÈ΋˜ Â¿ÚÎÂÈ·˜ ÙÔ˘ ÎÈÚÚˆÙÈÎÔ‡, fiˆ˜ Ë ·ÔÊ˘Á‹ ÙˆÓ ‚ÂÓ˙ԉȷ˙ÂÈÓÒÓ, Ë ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ÔÈÔÂȉÒÓ, Ë ‰È·Ù‹ÚËÛË Ù˘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ¢ÛÙ¿ıÂÈ·˜, Ë ·ÔÊ˘Á‹ ¯ÂÈÚÈÛÌÔ‡ Pringle Î·È Ë ¯Ú‹ÛË ÎÔÏÏÔÂȉÒÓ Î·Ù¿ ÙËÓ ·Ó¿ÓË„Ë22. Δ· ‰ÈÏ‹ÌÌ·Ù· ÚÔ·ÙÔ˘Ó ·fi ÙË ÛÙÈÁÌ‹ Ô˘ Ô ÂÓÙÂÙ·Á̤ÓÔ˜ ÛÙË Ï›ÛÙ· ÚÔ˜ MH ÎÈÚÚˆÙÈÎfi˜ ¿Û¯ÂÈ ·fi Ì›· ¿ÏÏË ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ. ΔÔ ÎÏÈÓÈÎfi ÂÚÒÙËÌ· ¤¯ÂÈ Û˘Ó‹ıˆ˜ ˆ˜ ÂÍ‹˜: “¶Ú¤ÂÈ Ë ıÂÚ·›· Ù˘ ÌË Ë·ÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÓfiÛÔ˘ Ó· ÚÔËÁËı› ‹ Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ÙË ª∏;”. ™Â ÁÂÓÈΤ˜ ÁÚ·Ì̤˜, ‰È·ÈÛÙÒÓÔÓÙ·È ÙÚ›˜ ÔÌ¿‰Â˜ ÌË Ë·ÙÈÎÒÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÓfiÛˆÓ: 1) OÈ Â͈Ë·ÙÈΤ˜ ηÎÔ‹ıÂȘ. 2) OÈ ÌË Î·ÎÔ‹ıÂȘ Â͈Ë·ÙÈΤ˜ ÓfiÛÔÈ Ô˘ ‰ÂÓ ·ÏÏ¿˙Ô˘Ó ¿ÌÂÛ· ÙËÓ ¤Î‚·ÛË Ù˘ ª∏. 3) OÈ ÌË Î·ÎÔ‹ıÂȘ Â͈Ë·ÙÈΤ˜ ÓfiÛÔÈ Ô˘ ·ÏÏ¿˙Ô˘Ó ¿ÌÂÛ· ÙËÓ ¤Î‚·ÛË Ù˘ ª∏. ™ÙËÓ ÚÒÙË Î·ÙËÁÔÚ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Â›Ù ÚÔηÚÎÈÓÈΤ˜ ηٷÛÙ¿ÛÂȘ (.¯. ‰˘ÛÏ·ÛÙÈÎÔ› Ôχԉ˜) ›Ù ηÎÔ‹ıÂȘ ÙˆÓ ÔÔ›ˆÓ Ë ÂÎÙÔÌ‹ ÈÛÔ‰˘Ó·Ì› Ì ›·ÛË (.¯. ÚÒÈÌÔÈ Î·ÚΛÓÔÈ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜, ÙÔ˘ ÓÂÊÚÔ‡ Î·È ÙÔ˘ Ì·ÛÙÔ‡). ™ÙË ‰Â‡ÙÂÚË Î·ÙËÁÔÚ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ Î·ÏÔ‹ıÂȘ ÓfiÛÔÈ ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ÔÈ Ì˘ÔÛÎÂÏÂÙÈΤ˜ ·ı‹ÛÂȘ. ™ÙËÓ ÙÚ›ÙË Î·ÙËÁÔÚ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î˘Ú›ˆ˜ ÔÈ Î·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ ·ı‹ÛÂȘ. °È· ÙȘ ‰‡Ô ÚÒÙ˜ ÔÌ¿‰Â˜, ÚÔËÁÂ›Ù·È Ë Â͈Ë·ÙÈ΋ Â¤Ì‚·ÛË Î·È ·ÎÔÏÔ˘-

ı› Ë ª∏, ÂÊfiÛÔÓ Ë ÚÔ‚ÏÂfiÌÂÓË (Ì ‚¿ÛË ÙÔ MELD) ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ‰ÂÓ Â›Ó·È ··ÁÔÚ¢ÙÈ΋. ∞Ó Ë Û˘ÁÎÂÎÚÈ̤ÓË ÚÔ‚ÏÂfiÌÂÓË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· Â›Ó·È Ôχ ÌÂÁ¿ÏË, ÙfiÙ ÚÔËÁÂ›Ù·È Ë ª∏. °È· ÙËÓ ÙÚ›ÙË ÔÌ¿‰· ‰ÈÂÓÂÚÁÂ›Ù·È Ù·˘Ùfi¯ÚÔÓË Â͈Ë·ÙÈ΋ Â¤Ì‚·ÛË Î·È ª∏23.

£ÂÚ·¢ÙÈÎÔ› ·ÏÁfiÚÈıÌÔÈ ª¤¯ÚÈ ÙÒÚ· ›‰·Ì fiÙÈ Ë ·fiÊ·ÛË ÁÈ· ıÂÚ·›· Ù˘ ÌË Ë·ÙÈ΋˜ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ÓfiÛÔ˘ ÛÙÔÓ ÎÈÚÚˆÙÈÎfi ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ Ë·ÙÈ΋ ÙÔ˘ Â¿ÚÎÂÈ·, fiˆ˜ ·˘Ù‹ ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ·fi ÙË ‚·ıÌÔÏÔÁ›· MELD. ∂ÈϤÔÓ, Ë Ë·ÙÈ΋ Â¿ÚÎÂÈ· ηıÔÚ›˙ÂÈ Î·È ÙÔ ¯ÚÔÓÈÛÌfi ‰ÈÂÓ¤ÚÁÂÈ·˜ ª∏ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÂΛÓÔ˘˜ Ô˘ Â›Ó·È ÂÓÙÂÙ·Á̤ÓÔÈ ÛÙË Ï›ÛÙ·. ªÂ ‚¿ÛË Ù· ·Ú·¿Óˆ, Ô A.J. Hanje Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ ÚÔÙ›ÓÔ˘Ó ·ÏÁfiÚÈıÌÔ, Û‡Ìʈӷ Ì ÙÔÓ ÔÔ›Ô ÔÈ ÎÈÚÚˆÙÈÎÔ› Ì MELD ÌÈÎÚfiÙÂÚÔ ÙÔ˘ 10 Î·È Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ Ó· Ô‰ËÁÔ‡ÓÙ·È ÌfiÓÔ ÛÙËÓ Â͈Ë·ÙÈ΋ Â¤Ì‚·ÛË, ÔÈ ÎÈÚÚˆÙÈÎÔ› Ì MELD ·fi 10 ¤ˆ˜ Î·È 15 Ó· ˘Ô‚¿ÏÏÔÓÙ·È ÚÒÙ· ÛÙËÓ Â͈Ë·ÙÈ΋ Â¤Ì‚·ÛË Î·È Î·ÙfiÈÓ ÛÙË ª∏, ÂÓÒ ÔÈ ÎÈÚÚˆÙÈÎÔ› Ì MELD ÌÂÁ·Ï‡ÙÂÚÔ ·fi 15 Ó· Ô‰ËÁÔ‡ÓÙ·È ÚÒÙ· ÛÙË ª∏ Î·È Î·ÙfiÈÓ ÛÙËÓ Â͈Ë·ÙÈ΋ Â¤Ì‚·ÛË24. ∏ Û˘ÁÎÂÎÚÈ̤ÓË ÙÔÔı¤ÙËÛË Â›Ó·È ÏÔÁÈ΋, ·ÏÏ¿ ıˆÚ› ‰Â‰Ô̤ÓË ÙËÓ Â¿ÚÎÂÈ· Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∞Ó Ù· ÌÔۯ‡̷ٷ ‰ÂÓ Â·ÚÎÔ‡Ó, ÔÈÔ˜ ı· Ú¤ÂÈ Ó· Â›Ó·È Ô ÂÍ·ÚÙÒÌÂÓÔ˜ ·fi ÙË ‚·ıÌÔÏÔÁ›· MELD ·ÏÁfiÚÈıÌÔ˜ ¯ÚÔÓÈÛÌÔ‡ Ù˘ Â͈Ë·ÙÈ΋˜ Â¤Ì‚·Û˘ Û ۯ¤ÛË Ì ÙË ª∏; ™ÙÔ ·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ McGill Î·È Ì ‰Â‰Ô̤ÓË ÙËÓ ¤ÏÏÂÈ„Ë Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (18 DPMP) ¤¯ÂÈ Î·ıÈÂÚˆı› ¢¤ÏÈÎÙÔ˜ ·ÏÁfiÚÈıÌÔ˜ ‰ÈÂÓ¤ÚÁÂÈ·˜ Â͈Ë·ÙÈÎÒÓ ÂÂÌ‚¿ÛÂˆÓ ÛÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ (∂ÈÎfiÓ· 1). ™‡Ìʈӷ Ì ÙÔÓ ·ÏÁfiÚÈıÌÔ ·˘Ùfi, Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ ÙÔ ÙÚ¤¯ÔÓ MELD ÁÈ· ÙÔ ÔÔ›Ô ‰ÈÂÓÂÚÁÂ›Ù·È ª∏ ÁÈ· Û˘ÁÎÂÎÚÈ̤ÓË ÔÌ¿‰· ·›Ì·ÙÔ˜. O ÎÈÚÚˆÙÈÎfi˜ Ì ÌË Ë·ÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ÓfiÛÔ Ï·Ì‚¿ÓÂÈ ÚÒÙ· ÌfiÛ¯Â˘Ì· Î·È ÌÂÙ¿ ˘Ô‚¿ÏÏÂÙ·È ÛÙËÓ Â͈Ë·ÙÈ΋ Â¤Ì‚·ÛË, ÌfiÓÔÓ ÂÊfiÛÔÓ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· Ù˘ Â͈Ë·ÙÈ΋˜ Â¤Ì‚·Û˘ ÍÂÂÚÓ¿ ÙË ÌÂÙ·ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ıÓËÙfiÙËÙ· ÙÔ˘ ÙÚ¤¯ÔÓÙÔ˜ MELD ÁÈ· Û˘ÁÎÂÎÚÈ̤ÓË ÔÌ¿‰· ·›Ì·ÙÔ˜. ∏ ¯Ú‹ÛË ÙÔ˘ ¢¤ÏÈÎÙÔ˘ ·ÏÁfiÚÈıÌÔ˘ ı· Á›ÓÂÈ Â‡ÎÔÏ· ηٷÓÔËÙ‹ ÛÙËÓ ÂfiÌÂÓË ·Ú¿ÁÚ·ÊÔ, fiÔ˘ ·Ó·Ï‡ÂÙ·È ÙÔ ÛÎÂÙÈÎfi Ù˘ ÚÔÙÂÈÓfiÌÂÓ˘ ıÂÚ·›·˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ 38¯ÚÔÓ˘ ·ÛıÂÓÔ‡˜ Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËΠÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘.

METAMO™XEY™Eπ™ 2010

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Ασθενής με κίρρωση και Χειρουργική νόσο Υπολογισμός MELD

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Χειρουργείο Πρώτα Μεταμόσχευση Μετά

Μεταμόσχευση Πρώτα Χειρουργείο Μετά

∂ÈÎfiÓ· 1. O ¢¤ÏÈÎÙÔ˜ ·ÏÁfiÚÈıÌÔ˜ ‰ÈÂÓ¤ÚÁÂÈ·˜ Â͈Ë·ÙÈÎÒÓ ÂÂÌ‚¿ÛÂˆÓ Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È ÛÙÔ ·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ McGill. x: ∏ ‚·ıÌÔÏÔÁ›· MELD ÌÂÙ¿ ·fi ÙËÓ ÔÔ›· ·Ú·ÙËÚÂ›Ù·È ·‡ÍËÛË ÙÔ˘ ÚÔÛ‰fiÎÈÌÔ˘ ÂÈ‚›ˆÛ˘ ‡ÛÙÂÚ· ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û ۯ¤ÛË Ì ÙËÓ ·Ï‹ ·Ú·ÌÔÓ‹ ÛÙË Ï›ÛÙ·, ÛÙÔ ÂοÛÙÔÙ ΤÓÙÚÔ. y: ∏ ‚·ıÌÔÏÔÁ›· MELD ÌÂÙ¿ ·fi ÙËÓ ÔÔ›· Ë ˘ÔÏÔÁÈ˙fiÌÂÓË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ÁÈ· Â͈Ë·ÙÈ΋ ÓfiÛÔ (Mayo Model) ˘ÂÚ‚·›ÓÂÈ ÙËÓ ÙÚ¤¯Ô˘Û· ÌÂÙ·ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ıÓËÙfiÙËÙ· ÙÔ˘ ÂοÛÙÔÙ ΤÓÙÚÔ˘, ÁÈ· Û˘ÁÎÂÎÚÈ̤ÓË ÔÌ¿‰· ·›Ì·ÙÔ˜.

∞ÓÙ› ÂÈÏfiÁÔ˘ ∏ 38¯ÚÔÓË ÎÈÚÚˆÙÈ΋ Ì ÚˆÙÔ·ı‹ ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁ›Ùȉ· Î·È ÂÏÎÒ‰Ë ÎÔÏ›Ùȉ· ‰È·ÈÛو̤ÓË ·fi 15 ÂÙ›·˜, ÛÙËÓ ÔÔ›· ·ÓȯÓ‡ıËΠ˘„ËÏÔ‡ ‚·ıÌÔ‡ ‰˘ÛÏ·Û›· Û ¤Ó·Ó Â›Â‰Ô ÔχÔ‰· ÙÔ˘ ·ÓÈfiÓÙÔ˜ ÎfiÏÔ˘, ·Ó‹ÎÂÈ ÛÙËÓ ÔÌ¿‰· ·›Ì·ÙÔ˜ 0. Œ¯ÂÈ ‚·ıÌÔÏÔÁ›· MELD ›ÛË Ì 16. ™ÙÔ ·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ McGill, ÙÔ MELD ‡ÛÙÂÚ· ·fi ÙÔ ÔÔ›Ô Ë ª∏ Ô‰ËÁ› Û ·‡ÍËÛË Ù˘ ÂÈ‚›ˆÛ˘ Û ۯ¤ÛË Ì ÙËÓ ·Ï‹ ·Ú·ÌÔÓ‹ ÛÙË Ï›ÛÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÈÛÔ‡Ù·È Ì 12. ∂Ô̤ӈ˜, Ë ·ÛıÂÓ‹˜ ¤¯ÂÈ ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ÙÔ ÙÚ¤¯ÔÓ MELD ÁÈ· ÙÔ ÔÔ›Ô ‰ÈÂÓÂÚÁÂ›Ù·È ª∏ ÛÙËÓ ÔÌ¿‰· ·›Ì·ÙÔ˜ 0 ÈÛÔ‡Ù·È Ì 27 Î·È ·ÓÙÈÛÙÔȯ› Û ÌÂÙ·ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ıÓËÙfiÙËÙ· 20% 25 . ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ÙÔ ˘ÔÏÔÁÈÛÙÈÎfi ÂÚÁ·ÏÂ›Ô Ù˘ Mayo Clinic ‰È·ÈÛÙÒÓÔ˘Ì fiÙÈ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· ÌÂÙ¿ ·fi ÎÔÏÂÎÙÔÌ‹ Û ·ÛıÂÓ‹ Ì ‚·ıÌÔÏÔÁ›· MELD ›ÛË Ì 16 Â›Ó·È 6,9%. ∂Ô̤ӈ˜, Ë Û˘ÁÎÂÎÚÈ̤ÓË ·ÛıÂÓ‹˜, ı· ˘Ô‚ÏËı› ÚÒÙ· Û ÎÔÏÂÎÙÔÌ‹ Î·È Î·ÙfiÈÓ Û ª∏, ÂÊfiÛÔÓ ÙÔ MELD Ù˘ ÂȉÂÈÓˆı› ÂÚÂÙ·›Úˆ. °È· Ó· Ï¿‚ÂÈ ÚÒÙ· Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· ÛÙÔ ·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ McGill, Ë 38¯ÚÔÓË ı· ¤ÚÂ ӷ ›¯Â ‚·ıÌÔÏÔÁ›· MELD ›ÛË ‹ ÌÂÁ·Ï‡ÙÂÚË ·fi 24, ÁÈ·Ù› ÙfiÙÂ Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· Ù˘ Â͈Ë·ÙÈ΋˜ Â¤Ì‚·Û˘ (ÌÂÁ·Ï‡ÙÂÚË ·fi 20%) ı· ÍÂÂÚÓÔ‡Û ÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ıÓËÙfiÙËÙ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘.

1. Corman M. Ulcerative Colitis. In: Corman M, Allison S, Huehne J, eds. Handbook of Colon and Rectal Surgery. Philadelphia: LWW, 2002: 725.

2. Powell-Jackson P, Greenway B, Williams R. Adverse effects of exploratory laparotomy in patients with unsuspected liver disease. Br J Surg 1982; 69:449-451.

3. Mikkelsen WP, Turrill FL, Kern WH. Acute hyaline necrosis of the liver. A surgical trap. Am J Surg 1968; 116:266-272.

4. Jepsen P, Sorensen HT, Vilstrup H, Ott P. [Surgical risk for patients with liver disease]. Ugeskr Laeger 2006; 168:4299-4302.

5. Runyon BA. Surgical procedures are well tolerated by patients with asymptomatic chronic hepatitis. J Clin Gastroenterol 1986; 8:542-544.

6. Farrell FJ, Nguyen M, Woodley S, Imperial JC, GarciaKennedy R, Man K, Esquivel CO, et al. Outcome of liver transplantation in patients with hemochromatosis.

Hepatology 1994; 20:404-410.

7. Yarze JC, Martin P, Munoz SJ, Friedman LS. Wilson’s disease: current status. Am J Med 1992; 92:643-654.

8. Propst A, Propst T, Zangerl G, Ofner D, Judmaier G, Vogel W. Prognosis and life expectancy in chronic liver disease. Dig Dis Sci 1995; 40:1805-1815.

9. Teh SH, Nagorney DM, Stevens SR, Offord KP, Therneau TM, Plevak DJ, Talwalkar JA, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007; 132:1261-1269.

10. Ziser A, Plevak DJ, Wiesner RH, Rakela J, Offord KP, Brown DL. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery. Anesthesiology 1999; 90:42-53.

11. Christensen E, Schlichting P, Fauerholdt L, Gluud C, Andersen PK, Juhl E, Poulsen H, et al. Prognostic value of Child-Turcotte criteria in medically treated cirrhosis. Hepatology 1984; 4:430-435.

12. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D’Amico G, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33:464-470.

13. O’Leary JG, Yachimski PS, Friedman LS. Surgery in the patient with liver disease. Clin Liver Dis 2009; 13:211-231.

14. Farnsworth N, Fagan SP, Berger DH, Awad SS. ChildTurcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients. Am J Surg 2004; 188:580-583.

15. Garrison RN, Cryer HM, Howard DA, Polk HC, Jr. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984; 199:648-655.

16. Mansour A, Watson W, Shayani V, Pickleman J. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 1997; 122:730-735; discussion 735-736.

17. http://www.unos.org.

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18. Perkins L, Jeffries M, Patel T. Utility of preoperative scores for predicting morbidity after cholecystectomy in patients with cirrhosis. Clin Gastroenterol Hepatol 2004; 2:1123-1128.

19. Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Bisceglie AM. The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg 2005; 140:650-654; discussion 655.

20. Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL. Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 2005; 242:244-251.

21. Frye JW, Perri RE. Perioperative risk assessment for patients with cirrhosis and liver disease. Expert Rev Gastroenterol Hepatol 2009; 3:65-75.

22. Picker O, Beck C, Pannen B. Liver protection in the perioperative setting. Best Pract Res Clin Anaesthesiol 2008; 22:209-224.

23. Axelrod D, Koffron A, Dewolf A, Baker A, Fryer J, Baker T, Frederiksen J, et al. Safety and efficacy of combined orthotopic liver transplantation and coronary artery bypass grafting. Liver Transpl 2004; 10:1386-1390.

24. Hanje AJ, Patel T. Preoperative evaluation of patients with liver disease. Nat Clin Pract Gastroenterol Hepatol 2007; 4:266-276.

25. Vrochides D, Hassanain M, Barkun J, Tchervenkov J, Paraskevas S, Chaudhury P, et al. Association of preoperative parameters with postoperative mortality and long term survival after liver transplantation. Can J Surg 2010; ahead of print.