ΜΕΤΑΜΟΣΧΕΥΣΕΙΣ 2011

¶EPIEXOMENA

¶PO§O°O™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 EK¢OTE™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 ™Y°°PAºEI™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 I. ¶ø™ ¡∞ ∞À•∏™OÀª∂ ™∂ ∞ƒπ£ªO Δπ™ ¶Δøª∞Δπ∫∂™ ª∂Δ∞ªO™Ã∂À™∂π™ ™Δ∏ Ãøƒ∞ ª∞™ ™˘ÓÙ‹ÚËÛË ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ÛÙȘ ª∂£ Ã. π·ÛˆÓ›‰Ô˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 §‹„Ë Î·È Û˘ÓÙ‹ÚËÛË ÙˆÓ ÔÚÁ¿ÓˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ª. ª‹ÙÛ˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 ∞ÔÚÚ›ÙÔ˘Ì و̷ÙÈο ÓÂÊÚÈο ÌÔۯ‡̷ٷ ÁÈ· ÂÁ¯ÂÈÚËÙÈÎÔ‡˜ Ù¯ÓÈÎÔ‡˜ ÏfiÁÔ˘˜; π. ªfiÎÔ˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ¶ÚfiÛıÂÙ· ÔʤÏË ÙˆÓ mTOR ·Ó·ÛÙÔϤˆÓ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡: ΔÔ ·Ú¿‰ÂÈÁÌ· ÙÔ˘ everolimus. ∂. ¡ÙÔ˘ÓÔ‡ÛË . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

II. ¢π∫∞πO™À¡∏ ∫∞π øº∂§πªOΔ∏Δ∞ ∂¡∞¡Δπ Δ∏™ ∞¶OΔ∂§∂™ª∞Δπ∫OΔ∏Δ∞™ ™Δ∏¡ ∫∞Δ∞¡Oª∏ Δø¡ ¶Δøª∞Δπ∫ø¡ ¡∂ºƒπ∫ø¡ ªO™Ã∂Àª∞Δø¡ ∫·Ù·ÓÔÌ‹ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È Ë ¤ÓÓÔÈ· Ù˘ ‰ÈηÈÔÛ‡Ó˘. ¢. Δ·ÎÔ‡‰·˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 ¢fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·. ¢. °Ô‡ÌÂÓÔ˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 ¶ÚÔ‚Ï‹Ì·Ù· Ô˘ ÚÔÛÙ›ıÂÓÙ·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì á∞ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó·ÌÔÓ‹˜ ÁÈ· ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¢. OÈÎÔÓÔÌ›‰Ô˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 ∂È‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ Û Â·Ó·ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡ Ì ÌÔۯ‡̷ٷ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Ã. ™Î·ÏÈÒÙË . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

III. M∂Δ∞ªO™Ã∂À™∂π™ ¡∂ºƒOÀ: ™À¡À¶∞ƒ•∏ Oƒπ∞∫OÀ ªO™Ã∂Àª∞ΔO™ ª∂ Oƒπ∞∫O §∏¶Δ∏ ∞ÓÔÛÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂ȉÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË Û non HLA ·ÓÙÈÁfiÓÔ (MICA, ÂÓ‰ÔıËÏȷο, ·˘ÙÔ·ÓÙÈÁfiÓ·) ∞. πÓȈٿÎË . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 ΔÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·fiÚÚȄ˘ ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ £. ∞ÔÛÙfiÏÔ˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

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6 ∞Èٛ˜ ·ÒÏÂÈ·˜ ÙˆÓ و̷ÙÈÎÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. (OÍ›· ·fiÚÚÈ„Ë, ¯ÚfiÓÈ· ·fiÚÚÈ„Ë, ı¿Ó·ÙÔ˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì·) °. ª˘ÛÂÚÏ‹˜, μ. ¶··ÓÈÎÔÏ¿Ô˘, ¢. ¢È‚¿Ó˘, ÃÚ. ªÔ˘ÌԢڤη, º. ™ÔψӿÎË, ¢. Δ·ÎÔ‡‰·˜

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∏ ÔÚ›· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ¯ÚfiÓÔ ÈÛ¯·ÈÌ›·˜ ÌÂÁ·Ï‡ÙÂÚÔ ·fi 24 ÒÚ˜ Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ μ. ¢Ú·ÎfiÔ˘ÏÔ˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

IV. M∂Δ∞ªO™Ã∂À™∏ ¡∂ºƒOÀ ™Δ∞ ¶∞π¢π∞ ªÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÛÙ· ·È‰È¿. ∂ȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ-ȉȷÈÙÂÚfiÙËÙ˜ ∫. ∫ÔÏÈfi˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 ∞ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· ÛÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙ· ·È‰È¿ ™‡Á¯ÚÔÓ˜ Ù¿ÛÂȘ ¡. ¶Ú›ÓÙ˙· . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 ∂Á¯ÂÈÚËÙÈΤ˜ ȉȷÈÙÂÚfiÙËÙ˜ ÛÙ· ·È‰È¿ π. °ÂˆÚÁ¿Î˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

V. ¶∂ƒπ∂°Ã∂πƒ∏Δπ∫Oπ ∞¡∞π™£∏™πO§O°π∫O𠶃Oμ§∏ª∞Δπ™ªOπ ™Δ∏ ª∂Δ∞ªO™Ã∂À™∏ ∏¶∞ΔO™ ∫ÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·-πÛ¯·ÈÌÈ΋ ÓfiÛÔ˜-¶ÚÔÂÁ¯ÂÈÚËÙÈ΋ ·ÍÈÔÏfiÁËÛË Î·È ÂÈÏÔÁ‹ ¢. ∂ÎÎÏËÛ›·Ú¯Ô˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 ∞ÓÙÈÌÂÙÒÈÛË Ù˘ Ì·˙È΋˜ ·ÈÌÔÚÚ·Á›·˜ °. ªÔ‡ÙÛÈ·ÓÔ˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 ™Ô‚·Ú‹ ˘ÔÓ·ÙÚÈ·ÈÌ›· Î·È ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ· ÚÈÓ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ∞. ∫·Ú··Ó·ÁÈÒÙÔ˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

VI. M∂Δ∞ªO™Ã∂À™∏ ∏¶∞ΔO™ ™∂ πO°∂¡∂π™ ∏¶∞ΔπΔπ¢∂™ ∞ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ¯ÚfiÓÈ· Ë·Ù›Ùȉ· μ Î·È D ÚÈÓ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ £. μ·ÛÈÏÂÈ¿‰Ë˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 º˘ÛÈ΋ ÂͤÏÈÍË Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ Ë·Ù›Ùȉ·˜ C ÛÙÔ ÌfiÛ¯Â˘Ì· ¢. ™·ÌˆÓ¿Î˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

VII. H¶∞ΔO∫ÀΔΔ∞ƒπ∫O™ ∫∞ƒ∫π¡O™ ΔÚÔÔÔÈË̤ÓË ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Î·È Û˘ÌÏËڈ̷ÙÈ΋ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ÁÈ· Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ ¢. °È·ÎÔ˘ÛÙ›‰Ë˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Œ¯ÂÈ ı¤ÛË Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û ÌË Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡˜ ηÚΛÓÔ˘˜; π. ºÔ‡˙·˜, ¢. Δ·ÎÔ‡‰·˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

VIπI. Ã∂πƒπ™ªOπ ™∂ Oƒπ∞∫∂™ ∫ƒπ™πª∂™ ∫∞Δ∞™Δ∞™∂π™ ™Δ∏¡ ∏¶∞ΔO§O°π∞ º˘ÛÈÔ·ıÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› Ù˘ ÔÍ›·˜ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË: ∂Ӊ›ÍÂȘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ª. Deutsch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

7 ¢È·Ù·Ú·¯¤˜ Ù˘ ‹Íˆ˜ ÚÈÓ Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. º˘ÛÈÔ·ıÔÏÔÁ›· Î·È ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË °. ¶··˚ˆ¿ÓÓÔ˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 ∂ÈÏÔΤ˜ ·fi Ù· ¯ÔÏËÊfiÚ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË: ¶·ÚÂÌ‚·ÙÈ΋ ıÂÚ·›· π. ¶·¯È·‰¿Î˘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Artificial and bioartificial liver support F. Saliba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

IX. ¶O™O ª∞∫ƒπ∞ ª¶OƒOÀª∂ ¡∞ ¶∞ª∂ ª∂ ΔOÀ™ Oƒπ∞∫OÀ™ ¢OΔ∂™ ™Δπ™ ª∂Δ∞ªO™Ã∂À™∂π™ ∏¶∞ΔO™; ¶ˆ˜ ÔÚ›˙ÂÙ·È Ô ‰fiÙ˘ Ì ÂÎÙÂٷ̤ӷ ÎÚÈÙ‹ÚÈ· (‰ÈÂ˘Ú˘Ì¤Ó·); ¡. ∞ÓÙˆÓÈ¿‰Ë˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 ¶Ú¤ÂÈ ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜ Ó· ˘¿Ú¯ÂÈ Û˘Ì‚·ÙfiÙËÙ· ‰fiÙË Î·È Ï‹ÙË ¿ÏÏË ÂÎÙfi˜ Ù˘ ÔÌ¿‰·˜ ·›Ì·ÙÔ˜; ∂. ÃÔÏfiÁÎÈÙ·˜ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

8

¶PO§O°O™

∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› ÙË ÌfiÓË ıÂÚ·¢ÙÈ΋ ·ÁˆÁ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ Î·È Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ÔÈ ÂӉ›ÍÂȘ Î·È Î˘Ú›ˆ˜ Ë ·Ô‰Ô¯‹ Ù˘ ¤¯Ô˘Ó ·ÏÏ¿ÍÂÈ ÚÈ˙Èο ηٿ ÙËÓ ÔÚ›· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÙÚÈ¿ÓÙ· ¯ÚfiÓˆÓ. ™˘Ó¯›˙ÔÓÙ·˜ ÙËÓ ÂÈÙ˘¯‹ ÚÔÛ¿ıÂÈ· ÙˆÓ ÚÔËÁÔ‡ÌÂÓˆÓ ÂΉfiÛˆÓ, ¤¯Ô˘Ì ÂÈÎÂÓÙÚˆı› ÛÙȘ ÛÙÚ·ÙËÁÈΤ˜ Ô˘ ÛÎÔfi ¤¯Ô˘Ó Ó· ÂÚÈÔÚ›ÛÔ˘Ó ÙÔ ÎÂÓfi Ô˘ ˘¿Ú¯ÂÈ ·Ó¿ÌÂÛ· ÛÙȘ ·Ó¿ÁΘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÙËÓ ÚÔÛÊÔÚ¿ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ¶Ò˜ ı· ·˘Í‹ÛÔ˘Ì Û ·ÚÈıÌfi ÙȘ و̷ÙÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÛÙË ¯ÒÚ· Ì·˜, ·ÏÏ¿ Î·È Ò˜ ı· ·ÓÙÈ·Ú·ı¤ÛÔ˘Ì ÙȘ ¤ÓÓÔȘ ‰ÈηÈÔÛ‡ÓË Î·È ˆÊÂÏÈÌfiÙËÙ· Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·, ·ÊÔ‡ Û˘¯Ó¿ Û˘Ó˘¿Ú¯Ô˘Ó ÔÚȷο ÌÔۯ‡̷ٷ Ì ÔÚÈ·ÎÔ‡˜ Ï‹Ù˜; ¶Ò˜ ı· ¯ÂÈÚÈÛÙԇ̠ÔÚȷΤ˜ ÎÚ›ÛÈ̘ ηٷÛÙ¿ÛÂȘ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È fiÛÔ ÌÔÚԇ̠ӷ ÂÂÎÙ›ÓÔ˘Ì ٷ ÎÚÈÙ‹ÚÈ· ÁÈ· Ë·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙÔÓ Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ; OÈ ··ÓÙ‹ÛÂȘ ·ÔÙ˘ÒÓÔÓÙ·È ÛÙ· ΛÌÂÓ· Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó Î·È Î·Ù·ÁÚ¿ÊÔ˘Ó ÙȘ ÁÓÒÛÂȘ Î·È ÙȘ ÂÌÂÈڛ˜ ηٷÍÈˆÌ¤ÓˆÓ ÂȉÈÎÒÓ. °È· ÙËÓ Úfiı˘ÌË Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÛÙÔ ™˘ÌfiÛÈÔ Ô˘ Ú·ÁÌ·Ù‡ıËΠٷ ·Ú·¿Óˆ ı¤Ì·Ù·, ÙÔ˘˜ ¢¯·ÚÈÛÙԇ̠̠fiÏË Ì·˜ ÙËÓ Î·Ú‰È¿. ¢ËÌ‹ÙÚÈo˜ Δ·Îo‡‰·˜ ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ¢È¢ı˘ÓÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ∫ÏÈÓÈ΋˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£

9

EK¢OTE™

¢ËÌ‹ÙÚÈÔ˜ T·ÎÔ‡‰·˜ ÃÂÈÚÔ˘ÚÁfi˜, ∫·ıËÁËÙ‹˜ ∞¶£, ¢È¢ı˘ÓÙ‹˜ ÃÂÈÚo˘ÚÁÈ΋˜ ∫ÏÈÓÈ΋˜ ªÂÙ·Ìoۯ‡ÛÂˆÓ A¶£ °¡£ «πoÎÚ¿ÙÂÈo»

B·Û›ÏÂÈÔ˜ ¶··ÓÈÎÔÏ¿Ô˘ ÃÂÈÚÔ˘ÚÁfi˜, ∞Ó·ÏËÚˆÙ‹˜ ∫·ıËÁËÙ‹˜ ∞¶£, ÃÂÈÚo˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·Ìoۯ‡ÛÂˆÓ A¶£ °¡£ «πoÎÚ¿ÙÂÈo»

°ÂÒÚÁÈÔ˜ ÿÌ‚ÚÈÔ˜ ÃÂÈÚo˘ÚÁfi˜, ¢È¢ı˘ÓÙ‹˜ ÃÂÈÚo˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·Ìoۯ‡ÛÂˆÓ A¶£, °¡£ «πoÎÚ¿ÙÂÈo»

11

Oªπ§∏Δ∂™ – ¶ƒO∂¢ƒOπ – ™ÃO§π∞™Δ∂™ 1. Saliba Faouzi, Professeur, Faculté de Médecine Paris Sud, Réanimation-Centre Hépatobiliaire, Hôpital Paul Brousse, Villejuif-France 2. ∞ÓÙˆÓÈ¿‰Ë˜ ¡ÈÎfiÏ·Ô˜, §¤ÎÙÔÚ·˜ ÃÂÈÚÔ˘ÚÁÈ΋˜-ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛˆÓ, °¡£ «πÔÎÚ¿ÙÂÈÔ» 3 ∞ÔÛÙfiÏÔ˘ £ÂÔÊ¿Ó˘, ¢È¢ı˘ÓÙ‹˜-¡ÂÊÚÔÏfiÁÔ˜, ¡ÂÊÚÔÏÔÁÈÎfi ΔÌ‹Ì· Î·È ªªO, °¡∞ «O ∂˘·ÁÁÂÏÈÛÌfi˜» 4. μ·ÛÈÏÂÈ¿‰Ë˜ £ÂÌÈÛÙÔÎÏ‹˜, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜ ∞¶£, ∞’ ¶ÚÔ·È‰Â˘ÙÈ΋ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «∞Ã∂¶∞» 5. °ÂˆÚÁ¿Î˘ πˆ¿ÓÓ˘, ¶·È‰Ô¯ÂÈÚÔ˘ÚÁfi˜ 6. °È·ÎÔ˘ÛÙ›‰Ë˜ ¢ËÌ‹ÙÚÈÔ˜, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 7. °Ô˘Ï‹˜ πˆ¿ÓÓ˘, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜-°·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ ∞¶£, ¢’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ» 8. °Ô‡ÌÂÓÔ˜ ¢ËÌ‹ÙÚÈÔ˜, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜-¡ÂÊÚÔÏÔÁ›·˜, ¢È¢ı˘ÓÙ‹˜ ¡ÂÊÚÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜, ¶·ÓÂÈÛÙ‹ÌÈÔ˘ ¶·ÙÚÒÓ 9. ¢Ú·ÎfiÔ˘ÏÔ˜ μ·Û›ÏÂÈÔ˜, ÃÂÈÚÔ˘ÚÁfi˜, ∂ÈÎÔ˘ÚÈÎfi˜ π·ÙÚfi˜, ∞’ ÃÂÈÚÔ˘ÚÁÈÎÔ‡ ΔÌ‹Ì·ÙÔ˜ ªªO, °¡∞ «O ∂˘·ÁÁÂÏÈÛÌfi˜» 10. ∂ÎÎÏËÛ›·Ú¯Ô˜ ¢‹ÌÔ˜, ∂ÈÌÂÏËÙ‹˜ ∞’-∂ȉÈÎfi˜ ∫·Ú‰ÈÔÏfiÁÔ˜, μ’ ∫·Ú‰ÈÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ» 11. π·ÛˆÓ›‰Ô˘ ÃÚÈÛÙ›Ó·, ∂ÈÌÂÏ‹ÙÚÈ· ∞’-∞Ó·ÈÛıËÛÈÔÏfiÁÔ˜, ª∂£, °¡£ «°. ¶··ÓÈÎÔÏ¿Ô˘» 12. πÓȈٿÎË ∞Ï›ÎË, ¢È¢ı‡ÓÙÚÈ· ∞ÓÔÛÔÏÔÁÈÎÔ‡ ∂ÚÁ·ÛÙËÚ›Ô˘ Î·È ∂ıÓÈÎÔ‡ ∫¤ÓÙÚÔ˘ πÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜, °¡∞ «°. °ÂÓÓËÌ·Ù¿˜» 13. ∫·Ú··Ó·ÁÈÒÙÔ˘ ∞ÚÂÙ‹, ∂ÈÌÂÏ‹ÙÚÈ· ∞’-∞Ó·ÈÛıËÛÈÔÏfiÁÔ˜, ª∂£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 14. ∫ÔÏÈfi˜ ∫ˆÓÛÙ·ÓÙ›ÓÔ˜, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜-¶·È‰È·ÙÚÈ΋˜ ¡ÂÊÚÔÏÔÁ›·˜ 15. ª‹ÙÛ˘ ªÈ¯¿Ï˘, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜-ªÂÙ·ÌÔۯ‡ÛˆÓ, π·ÙÚÈ΋ ™¯ÔÏ‹, ¶·ÓÂÈÛÙ‹ÌÈÔ πˆ·ÓÓ›ÓˆÓ 16. ªÔ‡ÙÛÈ·ÓÔ˜ °ÂÒÚÁÈÔ˜, ∂ÈÌÂÏËÙ‹˜ ∞’-∞Ó·ÈÛıËÛÈÔÏfiÁÔ˜, ∞Ó·ÈÛıËÛÈÔÏÔÁÈÎfi ΔÌ‹Ì·, °¡£ «πÔÎÚ¿ÙÂÈÔ» 17. ªfiÎÔ˜ πˆ¿ÓÓ˘, ∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜-ÃÂÈÚÔ˘ÚÁfi˜, ªª¡, °¡∞ «§·˚Îfi» 18. ª˘ÛÂÚÏ‹˜ °ÚËÁfiÚÈÔ˜, ¡ÂÊÚÔÏfiÁÔ˜, ¢È¢ı˘ÓÙ‹˜, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 19. Deutsch ª¤Ï·ÓÈ-ª·Ú›·, ∂ÈÌÂÏ‹ÙÚÈ· ∞’- ¶·ıÔÏfiÁÔ˜, ∏·ÙÔÏfiÁÔ˜, °¡∞ «πÔÎÚ¿ÙÂÈÔ» 20. ¡ÙÔ˘ÓÔ‡ÛË ∂˘·ÁÁÂÏ›·, §¤ÎÙÔÚ·˜ ¡ÂÊÚÔÏÔÁ›·˜, ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô πˆ·ÓÓ›ÓˆÓ 21. OÈÎÔÓÔÌ›‰Ô˘ ¢ÔÌÈÓ›ÎË, ∂ÈÌÂÏ‹ÙÚÈ· ∞’ - ¡ÂÊÚÔÏfiÁÔ˜, ¡ÂÊÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ» 22. ¶··˚ˆ¿ÓÓÔ˘ °ÂˆÚÁ›·, ∞ÈÌ·ÙÔÏfiÁÔ˜, ¢È¢ı‡ÓÙÚÈ· ∫¤ÓÙÚÔ˘ ∞ÈÌÔ‰ÔÛ›·˜, °¡£ «πÔÎÚ¿ÙÂÈÔ» 23. ¶·¯È·‰¿Î˘ πˆ¿ÓÓ˘, °·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜, °·ÛÙÚÂÓÙÂÚÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, 424 °™¡∂ 24. ¶Ú›ÓÙ˙· ¡ÈÎÔϤÙÙ·, ∂ÈÌÂÏ‹ÙÚÈ·-¶·È‰ÔÓÂÊÚÔÏfiÁÔ˜, °¡£ «πÔÎÚ¿ÙÂÈÔ» 25. ™·ÌˆÓ¿Î˘ ¢ËÌ‹ÙÚÈÔ˜, ∂ÈÌÂÏËÙ‹˜ ∞’-°·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˜, °·ÛÙÚÂÓÙÂÚÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜, ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ ∏Ú·ÎÏ›Ԣ ∫Ú‹Ù˘ 26. ™Î·ÏÈÒÙË ÃÚ˘Û¿ÓıË, ¡ÂÊÚÔÏfiÁÔ˜, ¡ÂÊÚÔÏÔÁÈÎfi ΔÌ‹Ì· Î·È MÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ∫¤ÓÙÚÔ, °.N.A. «§·˚Îfi» 27. Δ·ÎÔ‡‰·˜ ¢ËÌ‹ÙÚÈÔ˜, ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜-ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, ¢È¢ı˘ÓÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ∫ÏÈÓÈ΋˜ ªÂÙ·ÌÔۯ‡ÛˆÓ, °¡£ «πÔÎÚ¿ÙÂÈÔ» 28. ºÔ‡˙·˜ πˆ¿ÓÓ˘, ∂›ÎÔ˘ÚÔ˜ ∫·ıËÁËÙ‹˜ ÃÂÈÚÔ˘ÚÁÈ΋˜ ∞¶£, ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ∞¶£, °¡£ «πÔÎÚ¿ÙÂÈÔ» 29. ÃÔÏfiÁÎÈÙ·˜ ∂˘¿ÁÁÂÏÔ˜, §¤ÎÙÔÚ·˜ ¶·ıÔÏÔÁ›·˜ ∞¶£, ¢’ ¶·ıÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, °¡£ «πÔÎÚ¿ÙÂÈÔ»

13

¶ø™ ¡∞ ∞Y•∏™OYª∂ ™∂ ∞ƒπ£ªO Δπ™ ¶Δøª∞Δπ∫∂™ ª∂Δ∞ªO™Ã∂Y™EI™ ™Δ∏ Ãøƒ∞ ª∞™

15

™˘ÓÙ‹ÚËÛË ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË ÛÙȘ M∂£ Ã. π·ÛˆÓ›‰Ô˘

ÏÂÈ· ÙˆÓ Û˘Ì·ıËÙÈÎÒÓ ÓˆÙÈ·›ˆÓ Ô‰ÒÓ Î·È ÂΉËÏÒÓÂÙ·È Ì ‚Ú·‰˘Î·Ú‰›· Î·È Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹ Ì ˘fiÙ·ÛË.

2) ∂Ó‰ÔÎÚÈÓÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∏ ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ¿ÍÔÓ· ˘Ôı¿Ï·ÌÔ˜- ˘fiÊ˘ÛË- ÂÈÓÂÊÚ›‰È· ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ Δ3 Î·È Δ4, ÙËÓ Ì›ˆÛË Ù˘ ADH ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ¿ÔÈÔ˘ ‰È·‚‹ÙË (ÔÏ˘Ô˘Ú›·, ˘ÔÔÁηÈÌ›·, ˘ÂÚˆÛ̈ÙÈÎfiÙËÙ· Ï¿ÛÌ·ÙÔ˜, ˘ÂÚ¡·-·ÈÌ›·) Û ÔÛÔÛÙfi 65%, ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ÎÔÚÙÈ˙fiÏ˘ ÌÂ Û˘Ó¤ÂÈ· ÙËÓ Ì›ˆÛË Ù˘ ·¿ÓÙËÛ˘ ÛÙÔ stress. Δ¤ÏÔ˜ Ë Ì›ˆÛË Ù˘ ¤ÎÎÚÈÛ˘ ÈÓÛÔ˘Ï›Ó˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÌÊ¿ÓÈÛË ˘ÂÚÁÏ˘Î·ÈÌ›·˜ Ì ·‡ÍËÛË Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜, ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË, ˆÛ̈ÙÈ΋ ‰ÈÔ‡ÚËÛË Î·È Î·Ú‰È·ÁÁÂȷ΋ ·ÛÙ¿ıÂÈ·.

3) ¢È·Ù·Ú·¯¤˜ ÙˆÓ Ó¢ÌfiÓˆÓ. ¡Â˘ÚÔÁÂÓ¤˜ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· Â›Ó·È Û‡ÓËı˜, ÂÓÒ Ë ·Ó·Ó¢ÛÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ÂÈÛÚfiÊËÛË, ıÏ¿ÛË Ó‡ÌÔÓ·, ·ÙÂÏÂÎÙ·Û›·, ˘ÂÚÊfiÚÙˆÛË Ì ˘ÁÚ¿.

4) ¢È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜. ∞ÈÌÔÛÙ·ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ¢∂¶ ÌÔÚ› Ó· ÂÊ·ÓÈÛÙÔ‡Ó ÏfiÁˆ ·ÂÏ¢ı¤ÚˆÛ˘ ÈÛÙÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ ·fi ÙÔÓ ÓÂÎڈ̤ÓÔ ÂÁΤʷÏÔ Î·È Ë Û˘¯ÓfiÙÍÙ· ÙÔ˘˜ ·˘Í¿ÓÂÙ·È Ì ÙËÓ ‰È¿ÚÎÂÈ· ÙÔ˘ ∂£.

5) ÀÔıÂÚÌ›·. ∏ ˘Ôı·Ï·ÌÈ΋ ·ÓÂ¿ÚÎÂÈ· ÚÔηÏ› ‰È·Ù·Ú·¯¤˜ Ù˘ ıÂÚÌÔÚÚ‡ıÌÈÛ˘ Ô˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ıÂÚÌfiÙËÙ·˜ (¯·ÌËÏfi˜ ÌÂÙ·‚ÔÏÈÎfi˜ Ú˘ıÌfi˜) Î·È ÙËÓ ·˘ÍË̤ÓË ·ÒÏÂÈ· ·˘Ù‹˜ (·ÁÁÂÈԉȷÛÙÔÏ‹) ¤¯Ô˘Ó ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ˘ÔıÂÚÌ›·˜.

6) ∞ÓÔÛÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜. ∂›Ó·È ϤÔÓ ÁÓˆÛÙfi fiÙÈ Ô ∂£ ·˘Í¿ÓÂÈ ÙËÓ ·ÓÔÛÔÁÔÓÈÎfiÙËÙ· ÙˆÓ ÔÚÁ¿ÓˆÓ Î·È Ë ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÛÙËÓ ‰È·‰Èηۛ· ·˘Ù‹.

∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ Â›Ó·È ¤Ó· ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ· ÂÈÙ‡ÁÌ·Ù· Ù˘ π·ÙÚÈ΋˜ ÛÙÔÓ 20Ô ·ÈÒÓ·. OÈ Û˘Ó¯Ҙ fï˜ ·˘Í·ÓfiÌÂÓ˜ ÂӉ›ÍÂȘ Î·È ÔÈ ·Ó¿ÁΘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯Ô˘Ó Ô‰ËÁ‹ÛÂÈ Û ÌÈ· ¯ÚfiÓÈ· ¤ÏÏÂÈ„Ë ÔÚÁ¿ÓˆÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ‰È‡ڢÓÛË ÙÔ˘ ¯¿ÛÌ·ÙÔ˜ ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ‰fiÙ˜ Î·È Ï‹Ù˜ ÔÚÁ¿ÓˆÓ. ∏ ÚfiÔ‰Ô˜ ·fi ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ÚÔ˜ ÙÔ ÛˆÌ·ÙÈÎfi ı¿Ó·ÙÔ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·ÒÏÂÈ· 10-20% ÙˆÓ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ. ŒÙÛÈ Ë ÊÚÔÓÙ›‰· ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË, Ë ÔÔ›· ÈÛÔ‰˘Ó·Ì› Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË ÊÚÔÓÙ›‰· ¤ˆ˜ Î·È 7 ÏËÙÒÓ, ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È ¤ÁηÈÚ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈο, ‚·ÛÈṲ̂ÓË ¿ÓÙ· ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ÚˆÙfiÎÔÏÏ·. ∏ Ú·ÎÙÈ΋ ·˘Ù‹, Ô˘ ¤¯ÂÈ ˆ˜ ÛÙfi¯Ô ÙËÓ ÛÙ·ıÂÚÔÔ›ËÛË Î·È ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÂÈ̤ÚÔ˘˜ ÔÚÁ¿ÓˆÓ, ÌÔÚ› Ó· ÂÈʤÚÂÈ ÙËÓ ·ÔηٿÛÙ·ÛË Î·È ÙËÓ ÚÔÛÊÔÚ¿ ÔÚÁ¿ÓˆÓ Ù· ÔÔ›· ·Ú¯Èο ›¯·Ó ¯·Ú·ÎÙËÚÈÛÙ› ˆ˜ ·Î·Ù¿ÏÏËÏ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ó· ÌÂÈÒÛÂÈ ÙËÓ ·ÒÏÂÈ· ‰ÔÙÒÓ Î·È Ó· ·˘Í‹ÛÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ì ÂÈÙ˘¯‹ ¤Î‚·ÛË.

¶·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÌÂÙ¿ ÙÔÓ ∂ÁÎÂÊ·ÏÈÎfi £¿Ó·ÙÔ ªÂÙ¿ ÙÔÓ ∂£ Û˘Ì‚·›ÓÔ˘Ó ÌÈ· ÛÂÈÚ¿ ·fi ·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ ÌÂÙ·‚ÔϤ˜ ÔÈ Ôԛ˜ ÌÔÚ› ÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ˘fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ (˘fiÙ·ÛË 80%, ¿ÔÈÔ˜ ‰È·‚‹Ù˘ 65%, ¢∂¶ 30%, ·ÚÚ˘ı̛˜ 30%, Ó¢ÚÔÁÂÓ¤˜ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ· 20%, ÔͤˆÛË 10%).

1) ∫·Ú‰È·ÁÁÂȷΤ˜ ÌÂÙ·‚ÔϤ˜. ¢È·ÎÚ›ÓÔ˘Ì ‰‡Ô Ê¿ÛÂȘ: ·) ˘ÂÚ‰˘Ó·ÌÈ΋ Ê¿ÛË: ¢ÂÓ ·Ú·ÙËÚÂ›Ù·È ¿ÓÙÔÙÂ, ÔÊ›ÏÂÙ·È Û ¤ÓÙÔÓË Û˘Ì·ıËÙÈ΋ ‰È¤ÁÂÚÛË Î·È ˘ÂÚ¤ÎÎÚÈÛË Î·Ù¯ÔÏ·ÌÈÓÒÓ. Œ¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÌÊ¿ÓÈÛË Ù·¯˘Î·Ú‰›·˜, ˘¤ÚÙ·Û˘, ·‡ÍËÛ˘ Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ Î·È ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛˆÓ. §fiÁˆ Ù˘ ‰È·Ù·Ú·¯‹˜ ÛÙËÓ ÈÛÔÚÚÔ›· ·ÚÔ¯‹/ηٷӿψÛË O2 ÛÙÔ Ì˘ÔοډÈÔ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ∏∫° ‰È·Ù·Ú·¯¤˜, ·ÚÚ˘ı̛˜, ·Ó·ÙÔÌÈ΋ ηډȷ΋ ‚Ï¿‚Ë. ‚) ˘Ô‰˘Ó·ÌÈ΋ Ê¿ÛË: OÊ›ÏÂÙ·È ÛÙËÓ ·Ò-

¢È·¯Â›ÚÈÛË ÙÔ˘ ‰˘ÓËÙÈÎÔ‡ ‰fiÙË 1) ∫·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· ∏ ‰È·Ù‹ÚËÛË ÙˆÓ ÔÚÁ¿ÓˆÓ ÙÔ˘ ‰fiÙË ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÈÌÔ‰˘Ó·ÌÈ΋ ÛÙ·ıÂÚfiÙËÙ· Î·È ÙËÓ Â-

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Í·ÛÊ¿ÏÈÛË Â·ÚÎÔ‡˜ ·ÈÌ¿ÙˆÛ˘ Û ·˘Ù¿. ÀfiÙ·ÛË ÂÌÊ·Ó›˙ÂÙ·È Û 80% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ∂£ Î·È Û 20% Â›Ó·È ·ÓıÂÎÙÈ΋. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋: 1) ˘ÔÔÁηÈÌ›· ·fiÏ˘ÙË ÏfiÁˆ ·ÒÏÂÈ·˜ ˘ÁÚÒÓ (¿ÔÈÔ˜ ‰È·‚‹Ù˘, Ì·ÓÓÈÙfiÏË, ˘ÂÚÁÏ˘Î·ÈÌ›·, ·ÓÂ·Ú΋˜ ·Ó·Ï‹ÚˆÛË), ‹ Û¯ÂÙÈ΋ ÏfiÁˆ ·ÁÁÂÈԉȷÛÙÔÏ‹˜, 2) ηډȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÏfiÁˆ ıÏ¿Û˘, ÈÛ¯·ÈÌ›·˜, ˘ÂÚ¤ÎÎÚÈÛ˘ ηÙ¯ÔÏ·ÌÈÓÒÓ, ËÏÂÎÙÚÔÏ˘ÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ˘ÂÚÊfiÚÙˆÛ˘ fiÁÎÔ˘, Î·È 3) ·ÁÁÂÈԉȷÛÙÔÏ‹. ∏ ÚÒÙË ÂÓ¤ÚÁÂÈ· ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Â›Ó·È Ë ·ÔηٿÛÙ·ÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ Ì ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ ‹ ÎÔÏÏÔÂȉ‹ ‰È·Ï‡Ì·Ù·. Δ· ‰Â‡ÙÂÚ· ÚÔÙÈÌÒÓÙ·È Û ‰˘ÓËÙÈÎfi ‰fiÙË Ó¢ÌfiÓˆÓ ÁÈ· ÙËÓ Ì›ˆÛË ·Ó¿Ù˘Í˘ Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜. ™Â ÂÚ›ÙˆÛË ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ó¢ÌfiÓˆÓ ÚÔÙÈÌ¿Ù·È ÙÔ ÂÏ¿¯ÈÛÙ· ıÂÙÈÎfi ÈÛÔ˙‡ÁÈÔ, ÂÓÒ ·ÓÙ›ıÂÙ· ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙˆÓ ÓÂÊÚÒÓ Â›Ó·È ÚÔÙÈÌfiÙÂÚË Ë ÂχıÂÚË ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ. ∞Ú¯ÈÎÔ› ·ÈÌÔ‰˘Ó·ÌÈÎÔ› ÛÙfi¯ÔÈ Â›Ó·È ª∞¶ 60-70 mmHg, CVP 6-10 mmHg, HR 60-120/min, ·ÚÔ¯‹ Ô‡ÚˆÓ 1-3 ml/Kg/h, Hb >10 mg/dl. ™Â ÂÚÈÙÒÛÂȘ ÌË ·ÓÙ·fiÎÚÈÛ˘ ÛÙ· ˘ÁÚ¿ ÚÔÛÙ›ıÂÓÙ·È Dopamine, Epinephrine, Dobutamine, Noradrenaline ·Ó·ÏfiÁˆ˜. ¶ÚÔÙÈÌ¿Ù·È Ô Û˘Ó‰˘·ÛÌfi˜ ·˘ÙÒÓ ÁÈ· ÙËÓ ·ÔÊ˘Á‹ ¤ÓÙÔÓ˘ ·ÁÁÂÈÔÛ‡Û·Û˘. ΔÔ monitoring ÂÚÈÏ·Ì‚¿ÓÂÈ ¤Ó· ·Ú¯ÈÎfi ˯ÔηډÈÔÁÚ¿ÊËÌ· (‰ÈÔÈÛÔÊ¿ÁÂÈÔ ‹ ‰È·ıˆÚ·ÎÈÎfi) ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ Î·Ú‰È·ÎÒÓ ‰ÔÌÒÓ Î·È ÙËÓ Î·ıÔ‰‹ÁËÛË Ù˘ ıÂÚ·›·˜. ™Â ¯·ÌËÏfi ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ <45% ‹ ÂÌ̤ÓÔ˘Û· ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· ÚÔÙ›ÓÂÙ·È Ë ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· Ó¢ÌÔÓÈ΋˜, Ô˘ ı· ‚ÔËı‹ÛÂÈ Î·È ÛÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ηډȷÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∞ÈÌÔ‰˘Ó·ÌÈÎÔ› ÛÙfi¯ÔÈ Â›Ó·È: PCWP 8-12 mmHg, CI >2,4 l/min/mÇ, SVR 800-900. ∞·Ú·›ÙËÙË Â›Ó·È Ë Â·ÓÂÎÙ›ÌËÛË Ì ECHO ÁÈ· ÙËÓ ‰È·›ÛÙˆÛË Èı·Ó‹˜ ·Ó·ÛÙÚ¤„ÈÌ˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ·ÚÈÛÙÂÚ¿˜. ™ÙÂÊ·ÓÈ·›· ·ÁÁÂÈÔÁÚ·Ê›· ÂӉ›ÎÓ˘Ù·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ. ™Â ÂÚÈÙÒÛÂȘ ·ÓıÂÎÙÈ΋˜ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜ Ë ¯ÔÚ‹ÁËÛË ÔÚÌÔÓÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ ¤¯ÂÈ ·Ó·‰Â›ÍÂÈ ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù·, ·Ó Î·È Ë ¯Ú‹ÛË ÙÔ˘˜ ·Ú·Ì¤ÓÂÈ ˘fi ·ÌÊÈÛ‚‹ÙËÛË.

2) ∞Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· O Ú˘ıÌfi˜ ·Ó¿Ó˄˘ ÙˆÓ Ó¢ÌfiÓˆÓ Â›Ó·È ·ÔÁÔËÙ¢ÙÈÎfi˜ Î·È ÌfiÓÔÓ 20% ‰È·Ù›ıÂÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ Ó¢ÌÔÓÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÌÂÙ¿ ÙÔÓ ∂£ ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È Û Ó¢ÌÔÓ›·, ÂÈÛÚfi-

ÊËÛË, ÙÚ·˘Ì·ÙÈÛÌfi ÙÔ˘ Ó‡ÌÔÓ·, ·ÙÂÏÂÎÙ·Û›·, Ó¢ÚÔÁÂÓ¤˜ Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·. π‰È·›ÙÂÚ· ÂÈÛËÌ·›ÓÂÙ·È Ë Û˘ÛÙËÌ·ÙÈ΋ ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ÛÙÔÓ ∂£ Î·È ÂËÚ¿˙ÂÈ È‰È·›ÙÂÚ· ÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Ó¢ÌfiÓˆÓ ÛÙÔÓ Ï‹ÙË. ™Ùfi¯ÔÈ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Â›Ó·È Ë ‰È·Ù‹ÚËÛË PaO 2 >80 mmHg, PaCO 2 35-40 mmHg, PH 7,35-7,45. ∏ Û˘Ó‹ı˘ ̤ıÔ‰Ô˜ ·ÂÚÈÛÌÔ‡ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ¯Ú‹ÛË ˘„ËÏÔ‡ ·Ó·ÓÂfiÌÂÓÔ˘ fiÁÎÔ˘ 10-15 ml/Kg Ì ¯·ÌËÏ‹ PEEP 5 cmH2O. ÕÏÏ· ΤÓÙÚ· ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÂÊ·ÚÌfi˙Ô˘Ó ÚÔÛٷ٢ÙÈÎfi ÁÈ· ÙÔÓ Ó‡ÌÔÓ· ·ÂÚÈÛÌfi Ì ¯·ÌËÏfi ·Ó·Ó. fiÁÎÔ 6-7 ml/Kg, Pplateau <30 Î·È PEEP 5-10. Δ¤ÏÔ˜ ¿ÏÏ· ΤÓÙÚ· ÚÔÙÈÌÔ‡Ó ÂӉȿÌÂÛ˜ ÛÙÚ·ÙËÁÈΤ˜ Ì ·Ó. fiÁÎÔ 8-10 ml/Kg, Ppeak <30 Î·È PEEP 5. π‰È·›ÙÂÚ· ÙÔÓ›˙ÂÙ·È fiÙÈ ÔÈ Ó‡ÌÔÓ˜ Ú¤ÂÈ Ó· ÚÔÛٷهÔÓÙ·È ·fi ÙÔ˘˜ ˘„ËÏÔ‡˜ fiÁÎÔ˘˜ ·ÂÚÈÛÌÔ‡, ÙȘ ˘„ËϤ˜ ȤÛÂȘ ηıÒ˜ Î·È ÙȘ ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ Ô͢ÁfiÓÔ˘. ∏ ÂÈϤÔÓ ÊÚÔÓÙ›‰· ÂÚÈÏ·Ì‚¿ÓÂÈ ‚ÚÔÁ¯Ô·Ó·ÚÚÔÊ‹ÛÂȘ, ‚ÚÔÁ¯ÔÛÎfiËÛË (‰È·ÁÓˆÛÙÈ΋ Î·È ıÂÚ·¢ÙÈ΋), ·ÔÊ˘Á‹ ˘ÂÚ‚ÔÏÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ˘ÁÚÒÓ, ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ·Ó¿ÏÔÁ· Ì ÙËÓ Gram ¯ÚÒÛË. Δ¤ÏÔ˜ ÔÚÈṲ̂ӷ ΤÓÙÚ· ÚÔÙ›ÓÔ˘Ó ÙË ¯ÔÚ‹ÁËÛË ÛÙÂÚÔÂȉÒÓ ÁÈ· ÙË Ì›ˆÛË Ù˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘.

3) OÚÌÔÓÈ΋ ıÂÚ·›· ¶ÚfiÛÊ·Ù˜ Ô‰ËÁ›Â˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ Û˘ÁÎÂÎÚÈ̤ÓË ¯ÔÚ‹ÁËÛË ÔÚÌÔÓÒÓ ÛÙÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ ‰fiÙ˜: ªÂı˘Ú‰ÓÈ˙ÔÏfiÓË 15 mg/Kg, Δ3 4 Ìg bolus Î·È ¤Á¯˘ÛË 3 Ìg/h, vasopressin 1U bolus Î·È 0,5- 4 U/h. πÓÛÔ˘Ï›ÓË ‰›ÓÂÙ·È ÁÈ· ‰È·Ù‹ÚËÛË ÁÏ˘Îfi˙˘ 120-180 mg/dl. Δ· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ¯ÔÚ‹ÁËÛË ÙÔ˘˜ ‚¤‚·È· Û˘Ó¯›˙Ô˘Ó Ó· Â›Ó·È ·ÓÙÈÎÚÔ˘fiÌÂÓ·. ∏ ÈÔ Û˘Ó‹ı˘ ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ· Û ∂£ Â›Ó·È Ô ¿ÔÈÔ˜ ‰È·‚‹Ù˘ ÛÙÔ 65%. ∏ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔÔÁηÈÌ›·˜ Î·È ˘ÂÚ¡·-·ÈÌ›·˜ Ô˘ ÚÔηÏ› Á›ÓÂÙ·È Ì ¯ÔÚ‹ÁËÛË ˘fiÙÔÓˆÓ ˘ÁÚÒÓ ·fi ÙÔÓ ÚÈÓÔÁ·ÛÙÚÈÎfi ۈϋӷ. ™Â ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ··ÈÙÂ›Ù·È Ë ¯ÔÚ‹ÁËÛË vasopressin, Ë ÔÔ›· ÂÎÙfi˜ Ù˘ ·ÓÙȉÈÔ˘ÚËÙÈ΋˜ ‰Ú¿Û˘ Ù˘ ÚÔηÏ› Î·È ·ÁÁÂÈÔÛ‡Û·ÛË. ∂Ó·ÏÏ·ÎÙÈο ÌÔÚ› Ó· ¯ÔÚËÁËı› DDAVP (‰ÂÛÌÔÚÂÛÛ›ÓË) 1-2 Ìg/4-6 h Ë ÔÔ›· ¤¯ÂÈ ÌfiÓÔÓ ·ÓÙȉÈÔ˘ÚËÙÈ΋ ‰Ú¿ÛË. π‰È·›ÙÂÚË ÚÔÛÔ¯‹ ‰›ÓÂÙ·È ÒÛÙ ÙÔ ¡· <155, ÁÈ·Ù› Û¯ÂÙ›˙ÂÙ·È Ì ·ÒÏÂÈ· ÌÔۯ‡̷ÙÔ˜ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜.

METAMO™XEY™Eπ™ 2011

4) ÀÔıÂÚÌ›· ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋: ·ÓÂ¿ÚÎÂÈ· ˘Ôı·Ï¿ÌÔ˘, ·ÒÏÂÈ· Ú›ÁÔ˘˜, ·ÁÁÂÈÔÛ‡Û·ÛË. OÈ ÂÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ηډȷ΋ ‰˘ÛÏÈÙÔ˘ÚÁ›·, ÔÏ˘Ô˘Ú›·, ·ÚÚ˘ı̛˜, ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜. ∞ÓÙÈÌÂÙˆ›˙ÂÙ·È Ì ı¤ÚÌ·ÓÛË Î·È ˘ÁÚÔÔ›ËÛË ÂÈÛÓÂfiÌÂÓˆÓ ·ÂÚ›ˆÓ, ı¤ÚÌ·ÓÛË ‰È·Ï˘Ì¿ÙˆÓ, ıÂÚÌÔÎÔ˘‚¤ÚÙ˜. ¶ÚÔÙÈÌfiÙÂÚË Ë ÚfiÏË„Ë ·Ú¿ Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘.

5) ¢È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜ OÈ ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜ Î·È Ë ¢∂¶ ÔÊ›ÏÔÓÙ·È ÛÂ Û˘Ó‰˘·ÛÌfi ·Ú·ÁfiÓÙˆÓ: ·ÂÏ¢ı¤ÚˆÛË ÈÛÙÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ ·fi ÙÔÓ ÓÂÎڈ̤ÓÔ ÂÁΤʷÏÔ, ˘ÔıÂÚÌ›·, ·Ú·›ˆÛË. ¢ÈfiÚıˆÛË ·˘ÙÒÓ Ì ÙË ¯ÔÚ‹ÁËÛË ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜ ÒÛÙÂ: Hb >10mg/dl, INR <2, PLT >80000.

™˘Ì¤Ú·ÛÌ· ªÂÙ¿ ÙËÓ ‰È·›ÛÙˆÛË ÙÔ˘ ∂£ Ô ∂ÓÙ·ÙÈÎÔÏfiÁÔ˜ ·fi ÙËÓ ÊÚÔÓÙ›‰· ÂÓfi˜ ÌfiÓÔÓ ·ÛıÂÓÔ‡˜ (‰fiÙË) ¤Ú¯ÂÙ·È ·ÓÙÈ̤وÔ˜ Ù·˘Ùfi¯ÚÔÓ· Ì ÙËÓ ÊÚÔÓÙ›‰· ÂÚÈÛÛfiÙÂÚˆÓ ·ÛıÂÓÒÓ (Ï‹Ù˜). ŒÙÛÈ Ë ÂÊ·ÚÌÔÁ‹ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÚˆÙÔÎfiÏÏˆÓ Ô˘ ı· ‚ÂÏÙÈÒÛÔ˘Ó ÙËÓ ·Ó·ÁÓÒÚÈÛË Î·È ‰È·¯Â›ÚÈÛË ÙÔ˘ ‰˘ÓËÙÈÎÔ‡

19

‰fiÙË Â›Ó·È ÂȂ‚ÏË̤ÓË. ∏ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ‰fiÙË ¤¯ÂÈ ˆ˜ ÛÙfi¯Ô˘˜ ÙËÓ ÂÍ·ÛÊ¿ÏÈÛË ÛÙ·ıÂÚ‹˜ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ÂÈÎfiÓ·˜, ȉ·ÓÈ΋˜ ·ÈÌ¿ÙˆÛ˘ ÙˆÓ ÔÚÁ¿ÓˆÓ, ‰È·Ù‹ÚËÛË Ù˘ Ô͢ÁfiÓˆÛ˘, ‰È·Ù‹ÚËÛË ‰ÈÔ‡ÚËÛ˘, ÓÔÚÌÔıÂÚÌ›·˜, ËÏÂÎÙÚÔÏ˘ÙÈ΋˜ ÈÛÔÚÚÔ›·˜, ‰ÈfiÚıˆÛ˘ ÌÂÙ·‚ÔÏÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ. ∏ ˘ÔÛÙ‹ÚÈÍË ·˘Ù‹ ı· Ú¤ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È ¤ÁηÈÚ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈο, ¤ÙÛÈ ÒÛÙÂ Ô ‰˘ÓËÙÈÎfi˜ ‰fiÙ˘ Ó· ÌÂÙ·ÙÚ¤ÂÙ·È Û Ú·ÁÌ·ÙÈÎfi Î·È ·ÔÙÂÏ› ÙËÓ ÌÔÓ·‰È΋ χÛË ÁÈ· ÙËÓ ÁÂʇڈÛË ÙÔ˘ ¯Ï·ÛÌ·ÙÔ˜ ÌÂٷ͇ ·ÚÔ¯‹˜ Î·È ˙‹ÙËÛ˘ ÔÚÁ¿ÓˆÓ.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Wood KE, et al. Care of the potential organ donor.

NEJM 2004; 351: 2730-9.

2. Keegan M, Wood K, et al. An update on ICU management of the potential organ donor. Yearbook of Intensive care and emergency medicine 2010, 547-559.

3. Frontera J, et al. How I manage the adult potential organ donor: Donation after Neurological death (part 1). Neurocritical care 2010; 12: 103-110.

4. DuBose J, et al. Aggressive organ donor management protocol. Journal of Intensive care med. 2008; 23: 6: 367-375.

5. Organ donor management in Canada: recommendations of the forum on medical management to optimize donor organ potential. CMAJ. 2006; 174(6): S13-S30.

§‹„Ë Î·È Û˘ÓÙ‹ÚËÛË ÔÚÁ¿ÓˆÓ ÁÈ· ÌÂÙ·ÌÔÛ¯Â˘ÛË ª. ª‹ÙÛ˘

∂ÈÛ·ÁˆÁ‹

ÎÚÈ¿ ·fi ¿ÏϘ ÂÚÈÛÛfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ ÁÈ· ÙË ‚ÂÏÙ›ˆÛË Ù˘ ˘¿Ú¯Ô˘Û·˜ ηٿÛÙ·Û˘. Δ¤ÙÔȘ, ÛÙÔ¯Â˘Ì¤Ó˜ Î·È Î·ı·Ú¿ ÂÈÛÙËÌÔÓÈÎÔ‡ ¯·Ú·ÎÙ‹Ú·, ·ÚÂÌ‚¿ÛÂȘ, Ô˘ ·ÊÔÚÔ‡Ó ÛÙË ‚ÂÏÙÈÛÙÔÔ›ËÛË: Ù˘ ·Ó·ÁÓÒÚÈÛ˘ Î·È ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ‰˘ÓËÙÈÎÒÓ ‰ÔÙÒÓ, Ù˘ ·‡ÍËÛ˘ ÙÔ˘ ÔÛÔÛÙÔ‡ Û˘Ó·›ÓÂÛ˘ ÚÔ˜ ‰ˆÚ¿, ·ÏÏ¿ Î·È Ù˘ ‰È·‰Èηۛ·˜ Ï‹„˘ Î·È Û˘ÓÙ‹ÚËÛ˘ ÔÚÁ¿ÓˆÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â›Ó·È Û ı¤ÛË Ó· ·˘Í‹ÛÔ˘Ó, ÙfiÛÔ ÙÔÓ ·ÚÈıÌfi, fiÛÔ Î·È ÙËÓ ÔÈfiÙËÙ· ÙˆÓ ÔÚÁ¿ÓˆÓ ·fi ·Ô‚ÈÒÛ·ÓÙ˜ ‰fiÙ˜ Î·È Ó· ‚ÂÏÙÈÒÛÔ˘Ó ÙË ÏÂÈÙÔ˘ÚÁ›· Î·È ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ.

OÈ Ù¯ÓÈΤ˜ Ï‹„˘ ÔÚÁ¿ÓˆÓ Î·È È‰È·›ÙÂÚ· ·fi ÔÏ˘ÔÚÁ·ÓÈÎÔ‡˜ ‰fiÙ˜, fiˆ˜ Î·È ·˘Ù¤˜ Ù˘ Û˘ÓÙ‹ÚËÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ÔÌÔÈÔÁÂÓ›˜ Î·È ÚÔÙÔÙ˘ÔÔÈË̤Ó˜. ŒÙÛÈ, Ôχ Û˘¯Ó¿ ‰È¿ÊÔÚ˜ ÌÔÓ¿‰Â˜ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ¯ÚËÛÈÌÔÔÈÔ‡Ó ‰È·ÊÔÚÂÙÈΤ˜ Ù¯ÓÈΤ˜, Ô˘ Èı·Ó¿ ·ÓÙ·Ó·ÎÏÔ‡Ó ÛÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ·. ∏ Ï‹Ú˘ Î·È ÏÂÙÔÌÂÚ‹˜ ÂÚÈÁÚ·Ê‹ ÙˆÓ ‰È·ÊfiÚˆÓ Ù¯ÓÈÎÒÓ Ï‹„˘ Î·È Û˘ÓÙ‹ÚËÛ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ì¿ÏÏÔÓ ÍÂʇÁÂÈ ·fi Ù· fiÚÈ· Î·È ÙȘ ‰˘Ó·ÙfiÙËÙ˜ Ù˘ ·ÚÔ‡Û·˜ ÂÈÛ‹ÁËÛ˘. ∞ÓÙ› ·˘ÙÔ‡, ı· ÂȯÂÈÚËı› ÌÈ· ·‰Ú‹ ÂÚÈÁÚ·Ê‹ ÙˆÓ Ù¯ÓÈÎÒÓ Ï‹„ˆ˜ Î·È Û˘ÓÙ‹ÚËÛ˘ ÔÚÁ¿ÓˆÓ ·fi Û˘Ì‚·ÙÈÎÔ‡˜ ‰fiÙ˜ Î·È ·fi ‰fiÙ˜ Ì ·‡ÛË Î·Ú‰È·Î‹˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ı· ı¤ÛÂÈ ÚÔ˜ Û¯ÔÏÈ·ÛÌfi Î·È Û˘˙‹ÙËÛË ÂÈ̤ÚÔ˘˜ ÂÚˆÙ‹Ì·Ù· Î·È Ú·ÎÙÈΤ˜.

Ÿˆ˜ ¯·Ú·ÎÙËÚÈÛÙÈο ¤¯ÂÈ ·Ó·ÊÂÚı›, «Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ¤¯ÂÈ ¤ÛÂÈ ı‡Ì· Ù˘ ›‰È·˜ Ù˘ ÂÈÙ˘¯›·˜ Ù˘»1. ∏ ηχÙÂÚË Î·Ù·ÓfiËÛË ÙˆÓ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ·ÓÔÛȷ΋˜ ·¿ÓÙËÛ˘ Î·È Ë ÎÏÈÓÈ΋ ¯Ú‹ÛË ÓÂfiÙÂÚˆÓ-·Ó›Û¯˘ÚˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, Ì·˙› Ì ÙȘ ÂÈ̤ÚÔ˘˜ ‚ÂÏÙÈÒÛÂȘ ÙˆÓ ÂÊ·ÚÌÔ˙fiÌÂÓˆÓ Ù¯ÓÈÎÒÓ, ¤¯Ô˘Ó Ô‰ËÁ‹ÛÂÈ Û ı·˘Ì·ÛÙ¿ ÎÏÈÓÈο ·ÔÙÂϤÛÌ·Ù· (ÚfiÁÓˆÛË ·ÛıÂÓÔ‡˜ Î·È ÌÔۯ‡̷ÙÔ˜, ‚ÂÏÙ›ˆÛË ÔÈfiÙËÙ·˜ ˙ˆ‹˜, ÎÏ). Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿, ·ÏÏ¿ Î·È Ë ‰È‡ڢÓÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ¤ÓÙ·Í˘ ·ÛıÂÓÒÓ ÛÙË Ï›ÛÙ·, Ô‰ËÁÔ‡Ó fiÏÔ Î·È ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ ÛÙËÓ ·Ó·˙‹ÙËÛË ÂÓfi˜ ÌÔۯ‡̷ÙÔ˜, ÒÛÙ ÙÔ ¯¿ÛÌ· ÌÂٷ͇ Ù˘ ÚÔÛÊÔÚ¿˜ Î·È Ù˘ ˙‹ÙËÛ˘ ÔÚÁ¿ÓˆÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó· ‰È¢ڇÓÂÙ·È Û˘Ó¯Ҙ. ¶·ÚfiÏË ÙËÓ ·Ú·ÙËÚÔ‡ÌÂÓË ·‡ÍËÛË ÚÔÛÊÔÚ¿˜ ÔÚÁ¿ÓˆÓ ·fi ˙ÒÓÙ˜ ‰fiÙ˜, Ù· ÚÔÁÚ¿ÌÌ·Ù· ÂÎ·›‰Â˘Û˘ ÙÔ˘ ÚÔÛˆÈÎÔ‡ ÙˆÓ ÌÔÓ¿‰ˆÓ ˘Á›·˜ Î·È ÙȘ ÂÎÛÙÚ·Ù›˜ ÂÓË̤ڈÛ˘ Î·È Â˘·ÈÛıËÙÔÔ›ËÛ˘ ÙÔ˘ ÏËı˘ÛÌÔ‡, Û fiÙÈ ·ÊÔÚ¿ ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ Î·È ÙË ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ, Ë Î·Ù¿ÛÙ·ÛË ‰ÈÂıÓÒ˜ Ôχ ·¤¯ÂÈ ·fi ÙÔ Ó· ÌÔÚ› Ó· ¯·Ú·ÎÙËÚÈÛı› ÈηÓÔÔÈËÙÈ΋. ∞ÎfiÌË Î·È ·Ó¿ÌÂÛ· ÛÙȘ ¯ÒÚ˜ Ù˘ ∂˘Úˆ·˚΋˜ ŒÓˆÛ˘ ·Ú·ÙËÚÂ›Ù·È ÛËÌ·ÓÙÈ΋ ÂÙÂÚÔÁ¤ÓÂÈ·, ÙfiÛÔ ÛÙÔ˘˜ ‰Â›ÎÙ˜ ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ, fiÛÔ Î·È ÛÙȘ ÂÙËÛ›ˆ˜ Ú·ÁÌ·ÙÔÔÈÔ‡ÌÂÓ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ. ∏ ÂÓۈ̿وÛË ÛÙËÓ ÂıÓÈ΋ ÓÔÌÔıÂÛ›· Ù˘ Ô‰ËÁ›·˜ 2010/45/∂∂ ÙÔ˘ ∂˘Úˆ·˚ÎÔ‡ ∫ÔÈÓÔ‚Ô˘Ï›Ô˘ Î·È ÙÔ˘ ∂˘Úˆ·˚ÎÔ‡ ™˘Ì‚Ô˘Ï›Ô˘ (7-72010), Û¯ÂÙÈο Ì ٷ ÚfiÙ˘· ÔÈfiÙËÙ·˜ Î·È ·ÛÊ¿ÏÂÈ·˜ ÙˆÓ ·ÓıÚÒÈÓˆÓ ÔÚÁ¿ÓˆÓ Ô˘ ÚÔÔÚ›˙ÔÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË2, ÙÔ ÂÍ ·˘Ù‹˜ ÚÔÛ¯¤‰ÈÔ ÓfiÌÔ˘3, ·ÏÏ¿ Î·È ‰È¿ÊÔÚ· ¿ÏÏ· ÓÔÌÔıÂÙÈÎÔ‡ ¯·Ú·ÎÙ‹Ú· ̤ÙÚ·, ÊÈÏÔ‰ÔÍÔ‡Ó Ó· ‰È·ÌÔÚÊÒÛÔ˘Ó ¤Ó· ÎÔÈÓfi Ï·›ÛÈÔ Ú·ÎÙÈÎÒÓ. ŸÌˆ˜, Ù¤ÙÔÈ· ̤ÙÚ·, ·ÚfiÙÈ ‰˘ÓËÙÈο ‰Â›¯ÓÔ˘Ó ¤Ó· ıÂÙÈÎfi (·ÏÏ¿ ¿ÓÙˆ˜ ÂÚÈÔÚÈṲ̂ÓÔ) ·ÔÙ¤ÏÂÛÌ·, ÎÈÓ‰˘ÓÂ‡Ô˘Ó Ó· ÂÎÙÚ¤„Ô˘Ó ÙË Û˘˙‹ÙËÛË Î·È ÙȘ ÚÔÛ¿ıÂȘ Ì·-

§‹„Ë ÔÚÁ¿ÓˆÓ ·fi ·Ô‚ÈÒÛ·ÓÙ˜ ‰fiÙ˜ ¶ÂÚÈÁڷʤ˜ Ù¯ÓÈÎÒÓ Ï‹„˘ ÔÚÁ¿ÓˆÓ ·fi ·Ô‚ÈÒÛ·ÓÙ˜ ‰fiÙ˜ (ηډȷÎfi˜ ı¿Ó·ÙÔ˜ - ¢¶∫§) ˘¿Ú¯Ô˘Ó ·fi ÙȘ ÚÒÙ˜ ‰ÂηÂٛ˜ Ù˘ ÎÏÈÓÈ΋˜ ÂÊ·ÚÌÔÁ‹˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ (Yu Yu Voronoy, O˘ÎÚ·Ó›· 1933 Î·È T. Starzl, ∏¶∞ 1963). ∏ ÂÈÛ·ÁˆÁ‹ Ù˘ ¤ÓÓÔÈ·˜ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ÂÈÛ‹¯ıÂÈ ÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔÓ Guy Alexandre to 1966 ÛÙË °·ÏÏ›·, Ô ÔÔ›Ô˜ ÂÚȤÁÚ·„ ÙË Ï‹„Ë ÔÚÁ¿ÓˆÓ ·fi ‰fiÙ˜ Ì ¿ÏÏÔ˘Û· ηډȿ. ∏ Û‡ÛÙ·ÛË ad hoc ÂÈÙÚÔ‹˜ ÛÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ ÙÔ˘ Harvard, ›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙË Û˘ÛÙËÌ·ÙÈ΋ Î·È ÏÂÙÔÌÂÚ‹ ÂÚÈÁÚ·Ê‹ ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ Â-

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METAMO™XEY™Eπ™ 2011

ÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ÙÔ 1968 Î·È ¤‰ˆÛ ·ÁÎÔÛÌ›ˆ˜ ÙÂÚ¿ÛÙÈ· ÒıËÛË ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ. ∏ ‰˘Ó·ÙfiÙËÙ· Û˘Ó‰˘·Ṳ̂Ó˘ Ï‹„˘ ıˆÚ·ÎÈÎÒÓ Î·È ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÔÚÁ¿ÓˆÓ ¤Ú¯ÂÙ·È ÛÙÔ ÚÔÛ΋ÓÈÔ ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 19804. ΔËÓ ›‰È· ÂÔ¯‹, ·fi ÔÏϤ˜ ÔÌ¿‰Â˜, ÂÚÈÁÚ¿ÊÔÓÙ·È ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ Ù¯ÓÈΤ˜ Ï‹„˘ ÁÈ· ÙËÓ Ù·˘Ùfi¯ÚÔÓË ·ÍÈÔÔ›ËÛË Ë·ÙÈÎÒÓ Î·È ·ÁÎÚ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ì ÙËÓ ÂÍ·›ÚÂÛË ‰ÔÙÒÓ Ô˘ ÂÌÊ¿ÓÈ˙·Ó ·Ó·ÙÔÌÈΤ˜ ·Ú·ÏÏ·Á¤˜ Ù˘ ¤ÎÊ˘Û˘ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜. ™‹ÌÂÚ·, Ì ÙËÓ ·Ú·‰Ô¯‹ fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ÏfiÁˆ ÙÔ˘ ÛˆÛÙÈÎÔ‡ Ù˘ ¯·Ú·ÎÙ‹Ú·) ·ÔÙÂÏ› ÚÔÙÂÚ·ÈfiÙËÙ· ¤Ó·ÓÙÈ ·˘Ù‹˜ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜, ·ÏÏ¿ Î·È Ì ÙËÓ ÂÚÈÁÚ·Ê‹ ÓÂfiÙÂÚˆÓ Ù¯ÓÈÎÒÓ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ‰È·ÊfiÚˆÓ ·Ó·ÙÔÌÈÎÒÓ ·Ú·ÏÏ·ÁÒÓ, Ë Û˘Ó‰˘·Ṳ̂ÓË Ï‹„Ë Ë·ÙÈÎÒÓ, ·ÁÎÚ·ÙÈÎÒÓ Î·È ÓÂÊÚÈÎÒÓ ÌÔۯ‡̷ÙÔ˜ ·ÔÙÂÏ› ÎÔÈÓ‹ Ú·ÎÙÈ΋.

π. Ï‹„Ë ÔÚÁ¿ÓˆÓ ·fi ÔÏ˘ÔÚÁ·ÓÈÎÔ‡˜ ‰fiÙ˜ Ì ¿ÏÏÔ˘Û· ηډȿ (ÂÁÎÂÊ·ÏÈÎfi˜ ı¿Ó·ÙÔ˜) ™˘¯Ó¿ ̤¯ÚÈ Î·È 4 ‰È·ÊÔÚÂÙÈΤ˜ ÔÌ¿‰Â˜ Ï‹„˘ ÌÔÚ› Ó· Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙËÓ fiÏË ‰È·‰Èηۛ· Î·È ·˘Ùfi ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ¯·ÔÙÈΤ˜ ηٷÛÙ¿ÛÂȘ ÂÓÙfi˜ ÙÔ˘ ¯ÒÚÔ˘ ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ, Â¿Ó ‰ÂÓ ¤¯ÂÈ Û˘˙ËÙËı› Î·È Û˘Ó·ÔÊ·ÛÈÛı› ¤Ó· Û˘ÁÎÂÎÚÈ̤ÓÔ Ï¿ÓÔ ÂÓÂÚÁÂÈÒÓ, ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÌÌÂÙ¤¯ÔÓÙ˜. ∏ ÔÏ˘ÏÔÎfiÙËÙ· Ù˘ fiÏ˘ ‰È·‰Èηۛ·˜ Ï‹„˘ ÔÚÁ¿ÓˆÓ ·fi ÔÏ˘ÔÚÁ·ÓÈÎÔ‡˜ ‰fiÙ˜, Ô ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ÂÌÏÂÎÔÌ¤ÓˆÓ Û ·˘Ù‹, ·ÏÏ¿ Î·È Î·ı·Ú¿ Ù¯ÓÈÎÔ› ÏfiÁÔÈ (fiˆ˜ Ô ··ÈÙÔ‡ÌÂÓÔ˜ ¯ÚfiÓÔ˜ ¯ÂÈÚÈÛÌÒÓ Ì ‡·ÚÍË ·ÈÌ·ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜) ¤¯Ô˘Ó Ô‰ËÁ‹ÛÂÈ ‰ÈÂıÓÒ˜ ÛÙËÓ ·Ó·ÁÓÒÚÈÛË Ù˘ ÔÌ¿‰·˜ Ï‹„˘ ‹·ÙÔ˜, ˆ˜ ÙËÓ ÚˆÙÔÛÙ·ÙÔ‡Û· ÔÌ¿‰·. ¶·Ú¿ ÙȘ ÂÈ̤ÚÔ˘˜ ÌÈÎÚ¤˜ Ù¯ÓÈΤ˜ ‰È·ÊÔÚ¤˜, Ô˘ ÌÔÚ› Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ·fi ÙȘ ‰È¿ÊÔÚ˜ ÔÌ¿‰Â˜ Ï‹„˘, Ë ÌfiÓË Ô˘ÛÈ·ÛÙÈ΋ ‰È·ÊÔÚÔÔ›ËÛË ·ÊÔÚ¿ ÛÙÔ ‚·ıÌfi Î·È ÛÙËÓ ¤ÎÙ·ÛË Ù˘ in vivo ·Ú·Û΢‹˜ ÙˆÓ ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÔÚÁ¿ÓˆÓ, Ô˘ ÚÔËÁÂ›Ù·È Ù˘ ˘ÔıÂÚÌÈ΋˜ ¤ÎÏ˘Û‹˜ ÙÔ˘˜. ™ÙÔ ¤Ó· ¿ÎÚÔ ÙÔ˘ Ê¿ÛÌ·ÙÔ˜ Â›Ó·È Ë Ï‹Ú˘ ·Ú·Û΢‹ ÙˆÓ ÚÔ˜ ·Ó¿ÎÙËÛË ÔÚÁ¿ÓˆÓ ÚÈÓ ÙËÓ ¤ÎÏ˘Û‹ ÙÔ˘˜ Ì „˘¯Úfi ‰È¿Ï˘Ì· (dissection in the warm), ÂÓÒ ÛÙÔ ¿ÏÏÔ ¿ÎÚÔ Ë ¤ÎÏ˘ÛË Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÛÙ· ÚÒÙ· ÛÙ¿‰È· Ù˘ Â¤Ì‚·Û˘ Î·È ·ÎÔÏÔ˘ı› Ë ·Ú·Û΢‹ ÙˆÓ ÔÚÁ¿ÓˆÓ (dissection in the cold). ™ÙËÓ ‰Â‡ÙÂÚË ·˘Ù‹ ÂÚ›ÙˆÛË Ë ·Ê·›ÚÂÛË ÙˆÓ ÔÚÁ¿ÓˆÓ ÌÔÚ› Ó· Á›ÓÂÈ Î·È en block Î·È Ë ·Ú·Û΢‹ Î·È Ô ‰È·¯ˆÚÈÛÌfi˜ ÙÔ˘˜ Ó· Ú·ÁÌ·ÙÔ-

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ÔÈËıÔ‡Ó ex vivo (rapid technique). Δ· ÂÚÈÛÛfiÙÂÚ· ¿ÓÙˆ˜ ΤÓÙÚ· ÚÔÙÈÌÔ‡Ó Ù¯ÓÈΤ˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È Î¿Ô˘ ÛÙÔ Ì¤ÛÔ ÙÔ˘ ·Ú·¿Óˆ Ê¿ÛÌ·ÙÔ˜. ∞ÓÂÍ¿ÚÙËÙ· ·fi Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· Î·È ÌÂÈÔÓÂÎÙ‹Ì·Ù· Ù˘ οı ÌÂıfi‰Ô˘, ηıÒ˜ Î·È ÙȘ ÚÔÛˆÈΤ˜ ÚÔÙÈÌ‹ÛÂȘ, Ë ÔÌ¿‰· Ï‹„˘ ı· Ú¤ÂÈ Ó· Â›Ó·È ÂÍÔÈÎÂȈ̤ÓË ÙfiÛÔ Ì ÙȘ ÂÈ̤ÚÔ˘˜ Ù¯ÓÈΤ˜ Ï‹„˘ ÔÚÁ¿ÓˆÓ, ¤ÙÛÈ ÒÛÙ ӷ Â›Ó·È ‰˘Ó·Ù‹ Ë ·Ó¿ÎÙËÛ‹ ÙÔ˘˜ Ù·¯‡Ù·Ù· Û ÂÚ›ÙˆÛË ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜ ‹ η٤ÚÂȄ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, fiÛÔ Î·È Ì Èı·Ó¤˜ ·Ó·ÙÔÌÈΤ˜ ·Ú·ÏÏ·Á¤˜ Ù˘ ·Ó·ÙÔÌ›·˜ Î·È Ù˘ ·ÁÁÂȷ΋˜ ·ÈÌ¿ÙˆÛ˘ ÙˆÓ ÔÚÁ¿ÓˆÓ. ∏ ÌË ·Ó·ÁÓÒÚÈÛË Ù¤ÙÔÈˆÓ ·Ú·ÏÏ·ÁÒÓ ÌÔÚ› Ó· Â›Ó·È Î·Ù·ÛÙÚÔÊÈ΋, ȉȷ›ÙÂÚ· ÁÈ· ÙÔ Ë·ÙÈÎfi ‹/Î·È ÙÔ ·ÁÎÚ·ÙÈÎfi ÌfiÛ¯Â˘Ì·. °È· ·Ú¿‰ÂÈÁÌ·, ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ·Ú·ÏÏ·Á¤˜ ÛÙËÓ ·ÚÙËÚȷ΋ ·ÈÌ¿ÙˆÛË ÙÔ˘ ‹·ÙÔ˜ Û ÔÛÔÛÙ¿ ¤ˆ˜ Î·È ¿Óˆ ÙÔ˘ 40% ÙˆÓ ÂÚÈÙÒÛˆÓ5,6. OÈ Û˘¯ÓfiÙÂÚ˜ ·fi ·˘Ù¤˜ ·ÊÔÚÔ‡Ó ÛÙËÓ ‡·ÚÍË: ‰ÂÍÈ¿˜ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ (ª15% - ¤ÎÊ˘ÛË ·fi ¿Óˆ ÌÂÛÂÓÙ¤ÚÈ· ·ÚÙËÚ›·, Ù‡Ô˜ 3 ηٿ Michels) Î·È ·ÚÈÛÙÂÚ‹˜ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ (ª12% - ¤ÎÊ˘ÛË ·fi ·ÚÈÛÙÂÚ‹ Á·ÛÙÚÈ΋, Ù‡Ô˜ 2 ηٿ Michels). ™˘¯Ó‹ Â›Û˘ Â›Ó·È Î·È Ë Û˘Ó‡·ÚÍ‹ ÙÔ˘˜ (ª7%), ÂÓÒ fi¯È Û¿ÓÈ· ·Ó¢ڛÛÎÔÓÙ·È Î·È ‰È¿ÊÔÚÔÈ ¿ÏÏÔÈ Û˘Ó‰˘·ÛÌÔ›. ∂›Û˘, ·Ó¿ÏÔÁ˜ ·Ú·ÏÏ·Á¤˜ ··ÓÙÒÓÙ·È Î·È ÛÙËÓ ·Ó·ÙÔÌÈ΋ Î·È ÙˆÓ ˘ÔÏÔ›ˆÓ ÔÚÁ¿ÓˆÓ, fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ‡·ÚÍË ÔÏÏ·ÏÒÓ ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ Û ÔÛÔÛÙfi ¤ˆ˜ Î·È 30%7. °ÂÓÈο, Ë Â¤Ì‚·ÛË ÍÂÎÈÓ¿ Ì ÙË ‰ËÌÈÔ˘ÚÁ›· ̤Û˘ ÙÔÌ‹˜, Ô˘ Û˘ÓËı¤ÛÙÂÚ· ÂÎÙ›ÓÂÙ·È ·fi ÙË ÛÊ·ÁÈÙȉÈ΋ ÂÓÙÔÌ‹, ¤ˆ˜ ÙËÓ Ë‚È΋ Û‡ÌÊ˘ÛË, Ì ‰È¿ÓÔÈÍË ÙÔ˘ ÛÙ¤ÚÓÔ˘ Î·È Ù˘ ÂÚÈÙÔÓ·˚΋˜ ÎÔÈÏfiÙËÙ·˜. ∞ÎÔÏÔ˘ı› ÂÈÛÎÔÈÎfi˜ Î·È „ËÏ·ÊËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÔÚÁ¿ÓˆÓ Î·È ¯ÒÚˆÓ, ÚÔ˜ ·ÔÎÏÂÈÛÌfi ‡·Ú͢ ÛËÙÈÎÒÓ ÂÛÙÈÒÓ ‹ ˘Ô‰ËψÙÈÎÒÓ ÛËÌ›ˆÓ ÓÂÔÏ·Û›·˜. ∏ ηډÈÔ/ıˆÚ·ÎÔ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· ‰È·ÓÔ›ÁÂÈ ÙÔ ÂÚÈοډÈÔ Î·È ÙȘ ˘Â˙ˆÎÔÙÈΤ˜ ÎÔÈÏfiÙËÙ˜, ÁÈ· ÚÔ˜ ¤ÏÂÁ¯Ô Ù˘ ηډȿ˜ Î·È ÙˆÓ Ó¢ÌfiÓˆÓ Î·È ÚÔ¯ˆÚ› Û ÂÚÈ‚ÚÔ¯ÈÛÌfi Ù˘ ¿Óˆ ÎÔ›Ï˘ ÊϤ‚·˜, Ù˘ ˘ÂÚË·ÙÈ΋˜ οو ÎÔ›Ï˘ ÊϤ‚·˜ Î·È Ù˘ ·ÔÚÙ‹˜. ™ÂÈÚ¿ ·›ÚÓÂÈ Ë ÔÌ¿‰· Ï‹„˘ ÙˆÓ ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÔÚÁ¿ÓˆÓ. ∏ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ¯ÂÈÚÈÛÌÔ‡ Cattel-Braasch, Ì ·Ú·Û΢‹ ÙÔ˘ ‰ÂÍÈÔ‡ ÎfiÏÔ˘, ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘ Î·È ÌÂÛÂÓÙÂÚ›Ô˘ ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘, ÂÈÙÚ¤ÂÈ ÙËÓ ÌÂٷΛÓËÛË ÙÔ˘ ·¯¤Ô˜ Î·È ÏÂ-

22

M. M∏Δ™∏™

∂ÈÎfiÓ· 1. ÃÂÈÚÈÛÌfi˜ Cattel-Braasch.

ÙÔ‡ ÂÓÙ¤ÚÔ˘ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿, ÒÛÙ ӷ Á›ÓÂÙ·È Â‡ÎÔÏ· ÔÚ·Ù‹ Ë Î¿Ùˆ ÎÔ›ÏË ÊϤ‚·, Ë ·ÔÚÙ‹ Î·È Ë Î¿Ùˆ ÌÂÛÂÓÙ¤ÚÈÔ˜ ÊϤ‚· (EÈÎ. 1). ∏ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿ Î·È ¿Óˆ ¿ÛÎËÛË Ù¿Û˘ ÛÙËÓ ÙÚ›ÙË ÌÔ›Ú· ÙÔ˘ 12/ÏÔ˘ ηıÈÛÙ¿ ¢¯ÂÚ‹ ÙËÓ ·Ó·ÁÓÒÚÈÛË Î·È ÙËÓ ·Ú·Û΢‹/ÂÚÈ‚ÚÔ¯ÈÛÌfi Ù˘ ¿Óˆ ÌÂÛÂÓÙÂÚ›Ô˘ ·ÚÙËÚ›·˜, Ë ÔÔ›· ÌÔÚ› Ó· ¯ÚÂÈ·Ûı› Ó· ·ÔÎÏÂÈÛı› ·ÚÁfiÙÂÚ· ηٿ ÙËÓ ‰È·‰Èηۛ· ¤ÎÏ˘Û˘ (ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ ÚÒÙÔ˘ Ï›ÙÚÔ˘ ÙÔ˘ ˘ÁÚÔ‡), ÁÈ· ·ÔÊ˘Á‹ ·ÁÎÚ·ÙÈ΋˜ ÈÛÙÈ΋˜ ‚Ï¿‚˘ (·fi ˘ÂÚ¤ÎÏ˘ÛË/overperfusion), Û ÂÚ›ÙˆÛË ‚‚·›ˆ˜ fiÔ˘ ÚfiÎÂÈÙ·È Ó· ·Ó·ÎÙËı› Î·È ·ÁÎÚ·ÙÈÎfi ÌfiÛ¯Â˘Ì·. ∏ ÎÔÈÏȷ΋ ·ÔÚÙ‹ ·Ú·Û΢¿˙ÂÙ·È Î·È ÂÚÈ‚ÚÔ¯›˙ÂÙ·È ¿ÓˆıÂÓ ÙÔ˘ ‰È¯·ÛÌÔ‡ Ù˘ (ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÙËÓ ¤ÎÏ˘ÛË), ·ÊÔ‡ ÂÏÂÁ¯ı› Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ÂÈÎÔ˘ÚÈÎÒÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ Ô˘ ÌÔÚ› Ó· ÂÎʇÔÓÙ·È ·fi ÙȘ ÎÔÈÓ¤˜ Ï·ÁfiÓȘ ·ÚÙËڛ˜. ™Â ÌÈ· Ù¤ÙÔÈ· ÂÚ›ÙˆÛË, ‹ ·Ó ÂÎÙÈÌ¿Ù·È fiÙÈ ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÈÛ·¯ı› ηıÂÙ‹Ú·˜ ¤ÎÏ˘Û˘ ·fi ÙËÓ ÂÚÈÊÂÚÈ΋ ÎÔÈÏȷ΋ ·ÔÚÙ‹, ·˘Ùfi ÌÔÚ› Ó· ÂÈÙ¢¯ı› ‰È·Ì¤ÛÔ˘ ÌÈ·˜ ÂÎ ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ÎÔÈÓÒÓ Ï·ÁÔÓ›ˆÓ ·ÚÙËÚÈÒÓ. ∞ÎÔÏÔ‡ıˆ˜, Ë Î¿Ùˆ ÌÂÛÂÓÙ¤ÚÈÔ˜ ·ÚÙËÚ›· ·ÔÏÈÓÔ‡Ù·È Î·È ‰È·Ù¤ÌÓÂÙ·È, ÂÓÒ Ë Î¿Ùˆ ÌÂÛÂÓÙ¤ÚÈÔ˜ ÊϤ‚· ÂÚÈ‚ÚÔ¯›˙ÂÙ·È (·Ó ÚfiÎÂÈÙ·È Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ ¤ÎÏ˘ÛË Î·È ‰È· ÙÔ˘ ˘Ï·›Ô˘ Û˘ÛÙ‹Ì·ÙÔ˜). O ·ÚÈÛÙÂÚfi˜ ÙÚ›ÁˆÓÔ˜ Û‡Ó‰ÂÛÌÔ˜ ÙÔ˘ ‹·ÙÔ˜ ‰È·Ù¤ÌÓÂÙ·È, Ô Ë·ÙÔÁ·ÛÙÚÈÎfi˜ Û‡Ó‰ÂÛÌÔ˜ ‰È·ÓÔ›ÁÂÙ·È Î·È ÂϤÁ¯ÂÙ·È ÏÂÙÔÌÂÚÒ˜ Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ·ÁÁÂÈ·ÎÒÓ ·Ú·ÏÏ·ÁÒÓ Ù˘ ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ‹·ÙÔ˜ (.¯. ·ÚÈÛÙÂÚ‹ Ë·ÙÈ΋ ·ÚÙËÚ›·). ∏ ‰È¿ÓÔÈÍË ÙÔ˘ ÈÓÔ΢ÙÙ·ÚÔÏÈÒ‰Ô˘˜ ÈÛÙÔ‡ ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ÔÈÛÔÊ·ÁÔÁ·ÛÙÚÈ΋˜ Û˘Ì‚ÔÏ‹˜, Ë ‰È·ÙÔÌ‹ ÙÔ˘ ÛΤÏÔ˘˜

ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Î·È Ë ÂÈ‚ÔËıÔ‡ÌÂÓË ÏfiÁˆ Ù˘ ‡·Ú͢ ÙÔ˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ۈϋӷ ·‰Ú‹ ·Ú·Û΢‹ ‰È· ÙÔ˘ ‰·ÎÙ‡ÏÔ˘ ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ÔÈÛÔÊ¿ÁÔ˘, ÂÈÙÚ¤ÂÈ ÙËÓ ÌÂٷΛÓËÛ‹ ÙÔ˘ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿, ÒÛÙ ӷ Á›ÓÂÈ ‰˘Ó·Ùfi˜ Ô ÂÚÈ‚ÚÔ¯ÈÛÌfi˜ (‹ Ë ·Ú·Û΢‹) ÙÔ˘ ·Ú¯ÈÎÔ‡ ÙÌ‹Ì·ÙÔ˜ Ù˘ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜, ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ‰È·ÊÚ·ÁÌ·ÙÈÎfi ÙÚ‹Ì·.

OÈ ·Ú·¿Óˆ ¯ÂÈÚÈÛÌÔ› ÌÔÚÔ‡Ó Ó· Á›ÓÔ˘Ó ÂÓÙfi˜ 15-20 ÏÂÙÒÓ ÂÚ›Ô˘ Î·È ÂÈÙÚ¤Ô˘Ó ÙËÓ ¿ÌÂÛË ¤Ó·ÚÍË ¤ÎÏ˘Û˘ (̤ۈ ÙÔ˘ ηıÂÙËÚÈ·ÛÌÔ‡ Ù˘ ÂÚÈÊÂÚÈ΋˜ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜ Î·È Ù˘ ·ÔϛӈÛ˘ ‹ ÙÔ˘ crossclamping Ù˘ ÎÂÓÙÚÈ΋˜ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜), Û ÂÚÈÙÒÛÂȘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜ ‹ ηډȷ΋˜ ·Ó·ÎÔ‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜/‰fiÙÔ˘. ™ÙËÓ ÂÚ›ÙˆÛË ·ÈÌÔ‰˘Ó·ÌÈο ÛÙ·ıÂÚÔ‡ ‰fiÙË, Ë ÚÔ Ù˘ ¤ÎÏ˘Û˘ ÂÚ·ÈÙ¤Úˆ ¤ÎÙ·ÛË ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ ·Ú·Û΢ÒÓ, ÂÍ·ÚÙ¿Ù·È ·fi ÙȘ ÚÔÙÈÌ‹ÛÂȘ ÙˆÓ ÂÈ̤ÚÔ˘˜ ÔÌ¿‰ˆÓ Ï‹„˘. ™Â Ï‹„Ë Î·È ·ÁÎÚ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ÔÚÈṲ̂ÓÔÈ ÚÔÙÈÌÔ‡Ó Ó· Ú·ÁÌ·ÙÔÔÈÔ‡Ó Û ·˘Ù‹ ÙË Ê¿ÛË ÔÏÈ΋ Á·ÛÙÚÂÎÙÔÌ‹, ÁÈ· ÏËÚ¤ÛÙÂÚË Î·È Â˘¯ÂÚ¤ÛÙÂÚË ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ·ÁÎÚ¤ÙÔ˜ (·ÊÔ‡ ÚÒÙ· ¤¯ÂÈ ÂÓÛÙ·Ï·¯ı›, ÛÙË ‰Â‡ÙÂÚË ÌÔ›Ú· ÙÔ˘ 12/ÏÔ˘ Î·È ‰È· ÙÔ˘ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ۈϋӷ, ·Ú·ÈˆÌ¤ÓÔ ‰È¿Ï˘Ì· betadine Î·È ·ÌÊÔÙÂÚÈΛÓË).

OÈ Ô˘ÚËÙ‹Ú˜ ·Ú·Û΢¿˙ÔÓÙ·È fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÊÂÚÈÎfiÙÂÚ· ÚÔ˜ ÙËÓ Ô˘ÚËÙËÚÔ΢ÛÙ΋ Û˘Ì‚ÔÏ‹. ∏ ÂÚÈÙÔÓ›· ÙÔ˘ Gerota ‰È·ÓÔ›ÁÂÙ·È Â˘Ú¤ˆ˜, ÒÛÙ ӷ ‰È¢ÎÔχÓÂÙ·È Ë Â·ÎfiÏÔ˘ıË „‡ÍË ÙˆÓ ÓÂÊÚÒÓ. OÚÈṲ̂ÓÔÈ ÚÔ¯ˆÚÔ‡Ó Û Ï‹ÚË ÎÈÓËÙÔÔ›ËÛË ÙˆÓ ‰‡Ô ÓÂÊÚÒÓ ·fi ÙÔÓ ÂÚÈÓÂÊÚÈÎfi ΢ÙÙ·ÚÔÏÈÒ‰Ë ÈÛÙfi, ·ÏÏ¿ Èı·Ó¿ ·˘Ùfi ηχÙÂÚ· Ó· ·ÔʇÁÂÙ·È Û ·˘Ù‹ ÙË Ê¿ÛË, ÒÛÙ ӷ ÌÂȈı› Ë Èı·ÓfiÙËÙ· οΈÛ˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ ‹/Î·È ‰È·ÙÔÌ‹˜ ÂÈÎÔ˘ÚÈÎÒÓ ·ÚÙËÚÈÒÓ. ∏ ˘Ï·›· ÙÚÈ¿‰· (¯ÔÏˉfi¯Ô˜ fiÚÔ˜ – Ë·ÙÈ΋ ·ÚÙËÚ›· – ˘Ï·›· ÊϤ‚·) ÂϤÁ¯ÂÙ·È ÏÂÙÔÌÂÚÒ˜ (ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi ‡·Ú͢ ‰ÂÍÈ¿˜ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜) Î·È Ë ÎÔÈÓ‹ Ë·ÙÈ΋ ·ÚÙËÚ›· ·Ú·Û΢¿˙ÂÙ·È Û ÛËÌ·ÓÙÈÎfi Ì‹ÎÔ˜, Ì ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÂÎʇÛÂˆÓ Ù˘ Á·ÛÙÚÔ12/‰·ÎÙ˘ÏÈ΋˜ Î·È ÛÏËÓÈ΋˜ ·ÚÙËÚ›·˜. O ¯ÔÏˉfi¯Ô˜ fiÚÔ˜ (‰ÂÍÈ¿ Î·È ÌÚÔÛÙ¿ ·fi ÙËÓ ˘Ï·›· ÊϤ‚·) ·Ú·Û΢¿˙ÂÙ·È ÌÂÚÈÎÒ˜ Î·È ·ÔÏÈÓÔ‡Ù·È/‰È·Ù¤ÌÓÂÙ·È ÛÙÔ ‡„Ô˜ ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ ¯Â›ÏÔ˘˜, ÒÛÙ ÙÔ ÎÂÓÙÚÈÎfi ÎÔÏfi‚ˆÌ¿ ÙÔ˘ Ó· ·Ú·Ì›ÓÂÈ ·ÓÔÈÎÙfi. ∏ ¯ÔÏˉfi¯Ô˜ ·ÛÙË ‰È·ÓÔ›ÁÂÙ·È Î·È ÙÔ ¯ÔÏËÊfiÚÔ Û‡ÛÙËÌ· ÂÎϤÓÂÙ·È ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi.

METAMO™XEY™Eπ™ 2011

∞ÎÔÏÔ˘ı› Û˘ÛÙËÌ·ÙÈÎfi˜ Ë·ÚÈÓÈÛÌfi˜ ÙÔ˘ ‰fiÙË (300 IU/Kg) Î·È ÌÂÙ¿ ¿ÚÔ‰Ô 3 ÏÂÙÒÓ Ë ÂÚÈÊÂÚÈ΋ ÎÔÈÏȷ΋ ·ÔÚÙ‹ ·ÔÏÈÓÔ‡Ù·È Î·È ÂÈÛ¿ÁÂÙ·È ÂÓÙfi˜ ·˘Ù‹˜ ηٿÏÏËÏÔ˜ ηıÂÙ‹Ú·˜ ÁÈ· ¤ÎÏ˘ÛË. ΔÔ ›‰ÈÔ Á›ÓÂÙ·È Î·È ÛÙËÓ Î¿Ùˆ ÌÂÛÂÓÙ¤ÚÈ· ÊϤ‚· (·Ó Ë ˘Ï·›· ¤ÎÏ˘ÛË Â›Ó·È ÂÈı˘ÌËÙ‹). ∏ ˘ԉȷÊÚ·ÁÌ·ÙÈ΋ ·ÔÚÙ‹ ·ÔÏÈÓÔ‡Ù·È ‹ ·ÔÎÏ›ÂÙ·È Ì Ϸ‚›‰· Î·È ·Ú¯›˙ÂÈ Ë ¤Á¯˘ÛË Î·Ù¿ÏÏËÏÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ¤ÎÏ˘Û˘/Û˘ÓÙ‹ÚËÛ˘. ¶·Ú¿ÏÏËÏ· Ë Î·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· ÍÂÎÈÓ¿ÂÈ ÙȘ ‰È·‰Èηۛ˜ ηډÈÔÏËÁ›·˜. ∏ ˘ÂډȷÊÚ·ÁÌ·ÙÈ΋ οو ÎÔ›ÏË ‰È·ÓÔ›ÁÂÙ·È ÛÙÔ Â›Â‰Ô Â΂ÔÏ‹˜ Ù˘ ÛÙÔÓ ‰ÂÍÈfi ÎfiÏÔ, ÁÈ· ·ÔÚÚÔ‹ ÙÔ˘ ÂÎχ̷ÙÔ˜ (‹ Ë Î·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ÔÌ¿‰· ‰È·Ù¤ÌÓÂÈ ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚· ·Ì¤Ûˆ˜ ¿ÓˆıÂÓ ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜. ™˘ÓÔÏÈο 5 lit ‰È·Ï‡Ì·ÙÔ˜ Â›Ó·È ·ÚÎÂÙ¿ ÁÈ· Ï‹ÚË ¤ÎÏ˘ÛË Î·È „‡ÍË ÙˆÓ ÔÚÁ¿ÓˆÓ, Ë ÔÔ›· ÂÈ‚ÔËıÂ›Ù·È Î·È ÌÂ Î¿Ï˘„Ë ·˘ÙÒÓ Ì ·ÔÛÙÂÈڈ̤ÓÔ ÙÚÈÌ̤ÓÔ ¿ÁÔ. ∏ Ï‹„Ë ÙÔ˘ ηډȷÎÔ‡ Î·È Ó¢ÌÔÓÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‹ Î·È Ë en bloc Ï‹„Ë ÙÔ˘˜ ÚÔËÁÂ›Ù·È Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙÔ ÂӉȷʤÚÔÓ ÛÙÚ¤ÊÂÙ·È Î·È ¿ÏÈ ÛÙË ÎÔÈÏÈ¿. ∏ ·Ú·Û΢‹ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ··ÈÙ› Ï‹ÚË ÎÈÓËÙÔÔ›ËÛ‹ ÙÔ˘, Ì ‰È·ÙÔÌ‹ ÙˆÓ Û˘Ó‰¤ÛÌˆÓ Î·È ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜. OÏÔÎÏËÚÒÓÂÙ·È Ë Ï‹Ú˘ ·Ú·Û΢‹ Ù˘ ÎÔÈÓ‹˜ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜, ¤ˆ˜ ÙÔÓ ÙÚ›Ô‰· ÙÔ˘ Haller, Ì ‰ËÌÈÔ˘ÚÁ›· ·ÔÚÙÈÎÔ‡ cuff, ·ÊÔ‡ ¤¯ÂÈ ÚÔËÁËı› Ë ‰È·ÙÔÌ‹ Ù˘ ·ÚÈÛÙÂÚ‹˜ Á·ÛÙÚÈ΋˜ Î·È ÛÏËÓÈ΋˜ ·ÚÙËÚ›·˜. ∫·Ïfi Â›Ó·È ÛÙÔ ÂÚÈÊÂÚÈÎfi ÎÔÏfi‚ˆÌ· Ù˘ ÛÏËÓÈ΋˜ ·ÚÙËÚ›·˜ Ó· ÙÔÔıÂÙÂ›Ù·È ¤Ó· Ú¿ÌÌ· ÒÛÙ ·˘Ù‹ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Â‡ÎÔÏ· ÎÔÓÙ¿ ÛÙÔ ¿ÁÎÚ·˜. ∏ Á·ÛÙÚÔ12/‰·ÎÙ˘ÏÈ΋ ·ÚÙËÚ›· ‰È·Ù¤ÌÓÂÙ·È, ·Ê‹ÓÔÓÙ·˜ ÙÔ ÎÂÓÙÚÈÎfi ¿ÎÚÔ Ù˘ ·ÓÔÈÎÙfi Î·È ‰È·ı¤ÛÈÌÔ ÁÈ· Èı·Ó¤˜ Ù¯ÓÈΤ˜ ·ÁÁÂȷ΋˜ ·Ó·Î·Ù·Û΢‹˜ ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∏ ‰È·ÙÔÌ‹ Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ ÔÏÔÎÏËÚÒÓÂÈ ÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜ ÛÙȘ Ë·ÙÈΤ˜ ‡Ï˜, ·Ê‹ÓÔÓÙ·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ 1,5 cm ·˘Ù‹˜ ÚÔ˜ ÙËÓ ÏÂ˘Ú¿ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜, ·Ó ۯ‰ȿ˙ÂÙ·È Ï‹„Ë ÙÔ˘ ÔÚÁ¿ÓÔ˘ ·˘ÙÔ‡. ∏ ˘ÊË·ÙÈ΋ οو ÎÔ›ÏË ÊϤ‚· ‰È·Ù¤ÌÓÂÙ·È ¿ÓˆıÂÓ Ù˘ Â΂ÔÏ‹˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ Î·È ÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· Â›Ó·È ¤ÙÔÈÌÔ ÁÈ· ·Ê·›ÚÂÛË. °È· ÙË Ï‹„Ë ÙÔ˘ ·ÁÎÚ·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‰È·Ù¤ÌÓÂÙ·È Ô Á·ÛÙÚÔÎÔÏÈÎfi˜ Û‡Ó‰ÂÛÌÔ˜ (·Ó ‰ÂÓ ¤¯ÂÈ ÚÔËÁËı› ÔÏÈ΋ Á·ÛÙÚÂÎÙÔÌ‹) Î·È ÔÈ Û‡Ó‰ÂÛÌÔÈ ÙÔ˘ ÛÏËÓfi˜, ÒÛÙ ·˘Ùfi˜ Ó· ÌÔÚ› Ó· ·Ó·Û·Ûı› Ì ¢ÎÔÏ›· ·fi ÙÔÓ ÔÈÛıÔÂÚÈÙÔÓ·˚Îfi

23

¯ÒÚÔ, Ú¿ÁÌ· Ô˘ ‰È¢ÎÔχÓÂÈ ÙËÓ ·ÔÎfiÏÏËÛË ÙÔ˘ ÛÒÌ·ÙÔ˜ Î·È Ù˘ Ô˘Ú¿˜ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜. ΔÔ 12/‰¿ÎÙ˘ÏÔ ‰È·Ù¤ÌÓÂÙ·È Ì ÙË ¯Ú‹ÛË ·˘ÙfiÌ·ÙÔ˘ Û˘ÚÚ·ÙÈÎÔ‡ Ì˯·Ó‹Ì·ÙÔ˜, ÙfiÛÔ ÎÂÓÙÚÈο (·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔÓ ˘ÏˆÚÈÎfi ÛÊÈÁÎÙ‹Ú·), fiÛÔ Î·È ÂÚÈÊÂÚÈο (·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ Û‡Ó‰ÂÛÌÔ ÙÔ˘ Treitz). ∞ÎÔÏÔ˘ı› Ë ‰È·ÙÔÌ‹ ÙÔ˘ ÂÁοÚÛÈÔ˘ ÌÂÛÔÎfiÏÔ˘, Ù˘ οو ÌÂÛÂÓÙ¤ÚÈ·˜ ÊϤ‚·˜ Î·È Ù˘ Ú›˙·˜ ÙÔ˘ ÌÂÛÂÓÙÂÚ›Ô˘ ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (Ô˘ ÂÚȤ¯ÂÈ ÙËÓ ¿Óˆ ÌÂÛÂÓÙ¤ÚÈ· ·ÚÙËÚ›· Î·È ÊϤ‚·), Â›Û˘ Ì ÙË ‚Ô‹ıÂÈ· ·˘ÙfiÌ·ÙÔ˘ Û˘ÚÚ·ÙÈÎÔ‡ Ì˯·Ó‹Ì·ÙÔ˜. ∏ ¿Óˆ ÌÂÛÂÓÙ¤ÚÈÔ˜ ·ÚÙËÚ›·, Ô˘ ›¯Â ÚÔËÁÔ˘Ì¤Óˆ˜ ÂÚÈ‚ÚÔ¯ÈÛÙ›, ·Ó¢ڛÛÎÂÙ·È Â‡ÎÔÏ· Î·È ‰È·Ù¤ÌÓÂÙ·È Ì·˙› Ì ÙÌ‹Ì· Ù˘ ·ÔÚÙ‹˜. ΔÔ ·ÁÎÚ·ÙÈÎfi ÌfiÛ¯Â˘Ì· ·Ê·ÈÚ›ٷÈ, Ì·˙› Ì ÙËÓ 12/‰·ÎÙ˘ÏÈ΋ ·Á·ÏË Î·È ÙÔ ÛÏ‹Ó·. ∞ÎÔÏÔ˘ı› Ë Ï‹„Ë ÙˆÓ ‰‡Ô ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ›Ù Í¯ˆÚÈÛÙ¿ ÙÔ ¤Ó· ÌÂÙ¿ ÙÔ ¿ÏÏÔ, ›Ù ٷ˘Ùfi¯ÚÔÓ· (en bloc). OÈ ‰‡Ô Ô˘ÚËÙ‹Ú˜ ·Ú·Û΢¿˙ÔÓÙ·È Î·È ‰È·Ù¤ÌÓÔÓÙ·È fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÊÂÚÈÎfiÙÂÚ·, ‰›ÓÔÓÙ·˜ ÚÔÛÔ¯‹ ÒÛÙ ӷ ÌËÓ ·ÔÁ˘ÌÓˆıÔ‡Ó (··ÁÁÂȈıÔ‡Ó) ÔÏÔÛ¯ÂÚÒ˜ ·fi ÙÔÓ ÂÚÈ-Ô˘ÚËÙËÚÈÎfi ÈÛÙfi. ∞Ê·ÈÚÂ›Ù·È Ô Î·ıÂÙ‹Ú·˜ ¤ÎÏ˘Û˘ ·fi ÙËÓ ÎÔÈÏȷ΋ ·ÔÚÙ‹ Î·È ‰È·Ù¤ÌÓÂÙ·È Ë Î¿Ùˆ ÎÔ›ÏË ÊϤ‚· (∫∫º) ¿Óˆ ·fi ÙÔ ‰È¯·ÛÌfi Ù˘ Î·È Ë ·ÚÈÛÙÂÚ‹ ÓÂÊÚÈ΋ ÊϤ‚· ·fi ÙËÓ ·˘Ù‹, ÒÛÙ ÙÔ Î‡ÚÈÔ Û٤ϯԘ Ù˘ ∫∫º Ó· ·Ú·Ì›ÓÂÈ Ì ÙË ‰ÂÍÈ¿ ÓÂÊÚÈ΋ ÁÈ· Èı·Ó‹ ·Ó·Î·Ù·Û΢‹. ∏ ÎÔÈÏȷ΋ ·ÔÚÙ‹ ‰È·ÓÔ›ÁÂÙ·È Î·Ù¿ ÙÔ ÚfiÛıÈÔ ÙÔ›¯ˆÌ¿ Ù˘ ̤ÓÔÓÙ·˜ ·ÎÚÈ‚Ò˜ ÛÙË ÌÂÛfiÙËÙ·. ∞ÎÔÏÔ˘ı› ÂÎ ÙˆÓ ¤Ûˆ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÛÙÔÌ›ˆÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ Î·È ÂϤÁ¯ÂÙ·È Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ÂÈÎÔ˘ÚÈÎÒÓ ·ÁÁ›ˆÓ, ÙfiÛÔ ·fi ÙËÓ ÎÔÈÏȷ΋ ·ÔÚÙ‹ fiÛÔ Î·È ·fi ÙȘ Ï·ÁfiÓȘ ·ÚÙËڛ˜. ™Â ÂÚ›ÙˆÛË ·ÌÊÈ‚ÔÏ›·˜, ‚Ô‹ıÂÈ· ÌÔÚ› Ó· ‰ÒÛÂÈ Ë ¯ÚËÛÈÌÔÔ›ËÛË ÏÂÙÔ‡ ηıÂÙ‹Ú· Fogarty, ÁÈ· ηıÂÙËÚÈ·ÛÌfi Î·È ÂȂ‚·›ˆÛË Ù˘ ÔÚ›·˜ ÙÔ˘ ·ÁÁ›Ԣ. ∏ ·ÔÚÙ‹ ‰È·Ù¤ÌÓÂÙ·È ·ÎÚÈ‚Ò˜ ¿Óˆ ·fi ÙÔ ‰È¯·ÛÌfi Ù˘ Î·È ‰È·ÓÔ›ÁÂÙ·È ÚÔÛÂÎÙÈο ÙÔ Ô›ÛıÈÔ ÙÔ›¯ˆÌ¿ Ù˘, ̤ÓÔÓÙ·˜ ·˘ÛÙËÚ¿ ÛÙË Ì¤ÛË ·˘ÙÔ‡, ÌÂٷ͇ ÙˆÓ ÛÙÔÌ›ˆÓ ÙˆÓ ÛÔÓ‰˘ÏÈÎÒÓ ·ÚÙËÚÈÒÓ, ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ÙÂÏÈο ·fi ¤Ó· ·ÔÚÙÈÎfi patch, ÁÈ· ÙË ‰ÂÍÈ¿ Î·È ÙËÓ ·ÚÈÛÙÂÚ‹ ÓÂÊÚÈ΋ ·ÚÙËÚ›·. ™Â ‡·ÚÍË ÂÚÈÛÛfiÙÂÚˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ, ·Ó ·˘Ù¤˜ ÂÎʇÔÓÙ·È Û¯ÂÙÈο ÎÔÓÙ¿ Ë Ì›· ·fi ÙËÓ ¿ÏÏË, Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· ÒÛÙ ٷ ÛÙfiÌÈ¿ ÙÔ˘˜ Ó· ÂͤگÔÓÙ·È ·fi ÎÔÈÓfi patch.

O οı ÓÂÊÚfi˜ ÎÈÓËÙÔÔÈÂ›Ù·È ·fi ÙÔ ·Ú·Î·È ÂÚÈ- ÓÂÊÚÈÎfi Ï›Ô˜ ·fi ÙÔÓ ÔÈÛıÔÂÚÈÙÔ-

24

M. M∏Δ™∏™

Ó·˚Îfi ¯ÒÚÔ Ì¤¯ÚÈ ·ÎÚÈ‚Ò˜ ¿Óˆ ·fi Ù· ÛÔÓ‰˘ÏÈο ÛÒÌ·Ù·, Ì·˙› Ì ÙÔ˘˜ Ô˘ÚËÙ‹Ú˜. ∫Ú·ÙÒÓÙ·˜ Î·È ·Ó·ÛËÎÒÓÔÓÙ·˜ ÙÔÓ Î¿ı ÓÂÊÚfi Ì ÙÔ ¯¤ÚÈ, ‰È·Ù¤ÌÓÔÓÙ·È ÔÈ Û˘ÌʇÛÂȘ ÙˆÓ ·ÚÙËÚÈ·ÎÒÓ patch Î·È Ù˘ ∫∫º ·fi ÙÔ˘˜ ÈÛÙÔ‡˜ Ô˘ ηχÙÔ˘Ó Ù· ÛÔÓ‰˘ÏÈο ÛÒÌ·Ù·. OÈ ÓÂÊÚÔ› ·Ê·ÈÚÔ‡ÓÙ·È Î·È ÙÔÔıÂÙÔ‡ÓÙ·È Û „˘¯Úfi ‰È¿Ï˘Ì· ¤ÎÏ˘Û˘. ™ÙËÓ ÂÚ›ÙˆÛË Ù˘ en bloc Ù¯ÓÈ΋˜, ÔÈ ÓÂÊÚÔ› ·Ú·Û΢¿˙ÔÓÙ·È ·fi ÙÔÓ ÔÈÛıÔÂÚÈÙÔÓ·˚Îfi ¯ÒÚÔ. ∞ÊÔ‡ ¤¯Ô˘Ó ‰È·Ù·Ì› ÔÈ ‰‡Ô Ô˘ÚËÙ‹Ú˜, Ë ·ÔÚÙ‹ Î·È ∫∫º (¿Óˆ ·fi ÙÔ ‰È¯·ÛÌfi ÙÔ˘˜), Ù· ÂÚÈÊÂÚÈο ¿ÎÚ· ÙˆÓ ‰‡Ô ·ÁÁ›ˆÓ Û˘ÏÏ·Ì‚¿ÓÔÓÙ·È ·fi ÎÔÈÓÔ‡ Ì ÏÂÙ‹ Ï·‚›‰· Î·È ·Ó·ÛËÎÒÓÔÓÙ·È ÚÔÛÂÎÙÈο, ÒÛÙ ӷ ‰È¢ÎÔÏ˘Óı› Ë ‰È·ÙÔÌ‹ ÙˆÓ Û˘Ó‰¤ÛÂÒÓ ÙÔ˘˜ Ì ÙÔ˘˜ ÈÛÙÔ‡˜ Î·È ÙÔ˘˜ ̇˜ Ô˘ ηχÙÔ˘Ó Ù· ÛÔÓ‰˘ÏÈο ÛÒÌ·Ù·, ̤¯ÚÈ ÙÔ ‡„Ô˜ Ù˘ ÚÔËÁËı›Û˘ ÎÂÓÙÚÈ΋˜ ‰È·ÙÔÌ‹˜ ÙˆÓ ‰‡Ô ·ÁÁ›ˆÓ. OÈ ‰‡Ô ÓÂÊÚÔ› ·Ê·ÈÚÔ‡ÓÙ·È en bloc Î·È ÙÔÔıÂÙÔ‡ÓÙ·È Û „˘¯Úfi ‰È¿Ï˘Ì· Û˘ÓÙ‹ÚËÛ˘, ÒÛÙ ӷ Â·ÎÔÏÔ˘ı‹ÛÂÈ Ô ex vivo ‰È·¯ˆÚÈÛÌfi˜ ÙÔ˘˜. ∞˘Ùfi˜ ı· Á›ÓÂÈ ÂÚ›Ô˘ fiˆ˜ Î·È ÛÙÔÓ in situ ‰È·¯ˆÚÈÛÌfi, Ì ·ÚÈ· ‰È·ÊÔÚ¿ fiÙÈ ÙÒÚ· ·Ú¯›˙ÂÈ Ì ÙË ‰È·ÙÔÌ‹ ÙÔ˘ ÔÈÛı›Ô˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜, ÁÈ· ¤ÏÂÁ¯Ô ÙˆÓ ÂÎÊ˘ÙÈÎÒÓ ÛÙÔÌ›ˆÓ ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÚÙËÚÈÒÓ. ∫·Ù¿ Ù· ÏÔÈ¿ ·ÎÔÏÔ˘ıÂ›Ù·È ÂÓ ÔÏÏÔ›˜ Ë ›‰È· ‰È·‰Èηۛ·, fiˆ˜ Î·È ÛÙËÓ ÚÔËÁÔ˘Ì¤Óˆ˜ ÂÚÈÁÚ·Ê›۷ Ù¯ÓÈ΋.

ππ. Ï‹„Ë ÔÚÁ¿ÓˆÓ ·fi ¢fiÙ˜ Ì ¶·‡ÛË ∫·Ú‰È·Î‹˜ §ÂÈÙÔ˘ÚÁ›·˜ (¢¶∫§ – ηډȷÎfi˜ ı¿Ó·ÙÔ˜) Ÿˆ˜ Â›Ó·È ÁÓˆÛÙfi, ηٿ ÙȘ ÚÒÙ˜ ‰ÂηÂٛ˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi ·Ô‚ÈÒÛ·ÓÙ˜ ‰fiÙ˜, Ë Ï‹„Ë ÙˆÓ ÔÚÁ¿ÓˆÓ Á›ÓÔÓÙ·Ó ·fi ¢¶∫§. ∏ ÂÈÛ·ÁˆÁ‹ Î·È ·Ô‰Ô¯‹ ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘ ¤‰ˆÛ Ӥ· ÒıËÛË, Ì ηχÙÂÚË ÔÈfiÙËÙ· ÙˆÓ ·Ó·ÎÙÔ‡ÌÂÓˆÓ ÔÚÁ¿ÓˆÓ, ÏfiÁˆ ÙÔ˘ ÂÚÈÔÚÈÛÌÔ‡ Ù˘ ÈÛÙÈ΋˜ ‚Ï¿‚˘ ·fi ÙË ıÂÚÌ‹ ÈÛ¯·ÈÌ›·. ŸÌˆ˜, ÙÔ Úfi‚ÏËÌ· Ù˘ ¤ÏÏÂȄ˘ ÔÚÁ¿ÓˆÓ Ô‰‹ÁËÛ ÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990 (Pittsburgh, Wisconsin) ÛÙËÓ ÂÎ Ó¤Ô˘ ¯ÚËÛÈÌÔÔ›ËÛË ·˘Ù‹˜ Ù˘ ηÙËÁÔÚ›·˜ ‰ÔÙÒÓ, ·ÊÔ‡ Ê¿ÓËΠfiÙÈ Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ì ٤ÙÔÈ· fiÚÁ·Ó· ‰ÂÓ ˘ÛÙÂÚÔ‡Ó Û ۯ¤ÛË Ì ·˘Ù¿ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ì fiÚÁ·Ó· ·fi Û˘Ì‚·ÙÈÎÔ‡˜ ‰fiÙ˜8-10. ∂Âȉ‹ Ë Î·Ú‰È·Î‹ ·Ó·ÎÔ‹ Î·È Ë ÂÍ’ ·˘Ù‹˜ ¤Ï¢ÛË ÙÔ˘ ı·Ó¿ÙÔ˘, ÌÔÚ› Ó· Û˘Ì‚Â› οو ·fi ‰È¿ÊÔÚ˜ Û˘Óı‹Î˜, Ë Î·ÙËÁÔÚÈÔÔ›ËÛË ÙˆÓ ¢¶∫§ ‹Ù·Ó ··Ú·›ÙËÙË. ŒÙÛÈ, ηٿ ÙË ‰È¿ÚÎÂÈ·

¶π¡∞∫∞™ 1. ∫·ÙËÁÔڛ˜ ¢¶∫§, ηٿ Maastricht. ∫·ÙËÁÔÚ›· π ππ πππ πV

¶ÂÚÈÁÚ·Ê‹ ÓÂÎÚÔ› ηٿ ÙËÓ ¿ÊÈÍË ·ÓÂÈÙ˘¯‹˜ ∫∫∞* ·Ó·Ì¤ÓÔÓÙ˜ ηډȷ΋ ·‡ÛË Î·Ú‰È·Î‹ ·‡ÛË, Û ‹‰Ë ÂÁηÙÂÛÙË̤ÓÔ ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ

§‹„Ë ªË ÂÏÂÁ¯fiÌÂÓË ªË ÂÏÂÁ¯fiÌÂÓË ∂ϯfiÌÂÓË ªË ÂÏÂÁ¯fiÌÂÓË

∫∫∞* = ∞ÓÂÈÙ˘¯‹˜ ∫·Ú‰ÈÔ·Ó·Ó¢ÛÙÈ΋ ∞Ó·˙ˆÔÁfiÓËÛË

ÙÔ˘ ÚÒÙÔ˘ ¢ÈÂıÓÔ‡˜ ™˘Ó‰ڛԢ ÁÈ· ÙÔ˘˜ ¢¶∫§, ÛÙÔ Maastricht Ù˘ OÏÏ·Ó‰›·˜, ηıÔÚ›ÛÙËÎ·Ó Ù¤ÛÛÂÚȘ ηÙËÁÔڛ˜ ‰ÔÙÒÓ11 (¶›Ó. 1). ∏ ÌË ÂÏÂÁ¯fiÌÂÓË Ï‹„Ë (ηÙËÁÔڛ˜ π, ππ Î·È IV) ·ÊÔÚ¿ ‰fiÙ˜ Ì ÌË ·Ó·ÌÂÓfiÌÂÓË Î·Ú‰ÈÔ·Ó·Ó¢ÛÙÈ΋ ·Ó·ÎÔ‹ ηÈ/‹ ·ÓÂÈÙ˘¯‹ ·Ó·˙ˆÔÁfiÓËÛË. ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ··ÈÙÂ›Ù·È Ë Ù·¯‡Ù·ÙË Ú·ÁÌ·ÙÔÔ›ËÛË ÓÔÌÈÎÒÓ, È·ÙÚÈÎÒÓ Î·È ‰È·¯ÂÈÚÈÛÙÈÎÒÓ ÂÓÂÚÁÂÈÒÓ, ÁÈ· ÙȘ Ôԛ˜ ı· Ú¤ÂÈ Ó· ˘¿Ú¯ÂÈ Î·Ù¿ÏÏËÏ· ÂÎ·È‰Â˘Ì¤ÓÔ ÚÔÛˆÈÎfi. ™ÙËÓ ÂÏÂÁ¯fiÌÂÓË Ï‹„Ë (ηÙËÁÔÚ›· III) ·˘Ù¤˜ ÔÈ ‰È¢ıÂÙ‹ÛÂȘ ÌÔÚÔ‡Ó Ó· Á›ÓÔ˘Ó ÚÔ Ù˘ ‰È·ÎÔ‹˜ ÙˆÓ ˘ÔÛÙËÚÈÎÙÈÎÒÓ Ì¤ÙÚˆÓ, Ô ¯ÚfiÓÔ˜ Ù˘ ÔÔ›·˜ (·ÛÊ·ÏÒ˜ ÂÓÙfi˜ οÔÈˆÓ ÔÚ›ˆÓ) ÌÔÚ› Ó· ÂÈÏÂÁ›. OÈ Ì¤ıÔ‰ÔÈ Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È, ÁÈ· ÙË Ì›ˆÛË Ù˘ ÈÛÙÈ΋˜ ‚Ï¿‚˘ ÏfiÁˆ Ù˘ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜, ‰È·Ê¤ÚÔ˘Ó ·fi ¯ÒÚ· Û ¯ÒÚ· Î·È ·fi ΤÓÙÚÔ Û ΤÓÙÚÔ. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¿ÓÙˆ˜ ÂÚÈÙÒÛÂȘ, Ù· ̤ÙÚ· ·˘Ù¿ Ï·Ì‚¿ÓÔÓÙ·È ·ÊÔ‡ ÚÒÙ· ÂÚ¿ÛÔ˘Ó 5 ÏÂÙ¿ (no touch period) ·fi ÙËÓ ÒÚ· ‰È·›ÛÙˆÛ˘ ÙÔ˘ ı·Ó¿ÙÔ˘. ™ÙȘ ηÙËÁÔڛ˜ ÌË ÂÏÂÁ¯fiÌÂÓ˘ Ï‹„˘ (π,ππ, IV), Ë Î·Ú‰ÈÔÓ·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË Û˘Ó¯›˙ÂÙ·È, Ì ¯ÔÚ‹ÁËÛË 100% O2 ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÙÚ·¯ÂÈÔۈϋӷ, ÂÓÒ ÔÈ Â͈ÙÂÚÈΤ˜ ηډȷΤ˜ Ì·Ï¿ÍÂȘ ÌÔÚ› Ó· ‰È¢ÎÔÏ˘ÓıÔ‡Ó Ì ÙË ¯Ú‹ÛË Û˘Û΢ÒÓ ·˘ÙfiÌ·Ù˘ ıˆÚ·ÎÈ΋˜ Û˘Ì›ÂÛ˘ (∂ÈÎ.

2), Ô˘ Ê·›ÓÂÙ·È Ó· ‚ÂÏÙÈÒÓÔ˘Ó ÂÚÈÛÛfiÙÂÚÔ ÙË ÛÏ·¯ÓÈ΋ ΢ÎÏÔÊÔÚ›·. °È· ÙȘ ηÙËÁÔڛ˜ π Î·È ππ, ÛÙ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë Ù¯ÓÈ΋ Ù˘ in situ „‡Í˘ ÙˆÓ ÔÚÁ¿ÓˆÓ, Ì ÙËÓ ÂÈÛ·ÁˆÁ‹ ‰È¿ Ù˘ ÌËÚÈ·›·˜ ·ÚÙËÚ›·˜ ÂÓfi˜ ηıÂÙ‹Ú· ‰ÈÏÔ‡-Ì·ÏÔÓÈÔ‡ ÙÚÈÏÔ‡-·˘ÏÔ‡ (Double-Ballon Triple-Lumen – DBTL), Ô˘ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ¿ÌÂÛ˘ ¤Ó·Ú͢ Ù˘ ¤ÎÏ˘Û˘ (Û˘Ó‹ıˆ˜ Ì 20 lit ‰È·Ï‡Ì·ÙÔ˜), ·ÊÔ‡ ¤¯ÂÈ ÚÔËÁËı› Ë·ÚÈÓÈÛÌfi˜ ÙÔ˘ ‰fiÙÔ˘. ∏ ÊÏ‚È΋ ·ÔÚÚÔ‹ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÂÈÛ·ÁˆÁ‹ ÂÓfi˜ ¢Ú›·˜ ‰È·Ì¤ÙÚÔ˘ ηıÂÙ‹Ú· Folley, ‰È¿ Ù˘ ÌËÚÈ·›·˜ ÊϤ‚·˜. ∏ ıÂÚÌÔÎÚ·Û›· ÙˆÓ ÓÂÊÚÒÓ Î·Ù¤Ú¯ÂÙ·È ÛÙÔ˘˜ 10 – 15 0C, Ô˘ ÂÈÙÚ¤ÂÈ ÙËÓ Ú·ÁÌ·ÙÔÔ›ËÛË Ù˘ ÓÂÊÚÂÎÙÔÌ‹˜ ·ÚÁfi-

METAMO™XEY™Eπ™ 2011

∂ÈÎfiÓ· 2. ªË¯·Ó‹ ·˘ÙfiÌ·Ù˘ ıˆÚ·ÎÈ΋˜ Û˘Ì›ÂÛ˘.

ÙÂÚ· (Î·È ¿ÓÙˆ˜ ÂÓÙfi˜ ‰‡Ô ˆÚÒÓ). ∂ÈÚfiÛıÂÙ· ̤ıÔ‰ÔÈ, fiˆ˜ Ë ÂÓ‰ÔÂÚÈÙÔÓ·˚΋ „‡ÍË, ̤ۈ ÂÈÛ·ÁˆÁ‹˜ „˘¯ÚÔ‡ ‰È·Ï‡Ì·ÙÔ˜ ·fi ÌÈÎÚ‹ ˘ÔÌÊ¿ÏÈ· ÙÔÌ‹, ¤¯Ô˘Ó ‰Â›ÍÂÈ Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· Û ÂÈÚ·Ì·ÙÈÎfi Â›‰Ô, ·ÏÏ¿ ·ÎfiÌË ‰ÂÓ ˘¿Ú¯Ô˘Ó ÎÏÈÓÈΤ˜ ·ԉ›ÍÂȘ. ™ÙȘ ›‰È˜ ηÙËÁÔڛ˜ (π Î·È ππ), ·ÏÏ¿ Û ϛÁ˜ ¯ÒÚ˜ (fiˆ˜ Ë πÛ·Ó›·) ÂÊ·ÚÌfi˙ÂÙ·È Î·È Ë Ù¯ÓÈ΋ Ù˘ Â͈ۈ̷ÙÈ΋˜ in-vivo ˘ÔıÂÚÌ›·˜ ‹ ÓÔÚÌÔıÂÚÌ›·˜, ÁÈ· ÙËÓ ÔÔ›· Â›Ó·È ··Ú·›ÙËÙË Ë ‡·ÚÍË Î˘ÎÏÒÌ·ÙÔ˜ ηډÈÔ-Ó¢ÌÔÓÈ΋˜ ·Ú¿Î·Ì„˘, Ú¿ÁÌ· Ô˘ ·ÔÙÂÏ› Î·È ÙÔ ‚·ÛÈÎfi ÌÂÈÔÓ¤ÎÙËÌ· Ù˘ ÌÂıfi‰Ô˘, ÏfiÁˆ ÙÔ˘ ÔÈÎÔÓÔÌÈÎÔ‡ ÎfiÛÙÔ˘˜, ·ÏÏ¿ Î·È Ù˘ ·Ó¿Á΢ ÂȉÈÎÂ˘Ì¤ÓÔ˘ ÚÔÛˆÈÎÔ‡ ÁÈ· ÙË ÏÂÈÙÔ˘ÚÁ›· Ù˘. ¶·ÚfiÏ· ·˘Ù¿ Ì ÙËÓ Ù¯ÓÈ΋ ·˘Ù‹, fiÙ·Ó ÌÔÚ› Ó· ÂÊ·ÚÌÔÛı›, Â›Ó·È ‰˘Ó·Ùfi Ó· ·Ú·Ù·ı› Ô ¯ÚfiÓÔ˜ Ù˘ Â͈ۈ̷ÙÈ΋˜ ΢ÎÏÔÊÔÚ›·˜, fiÛÔ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ ÂÓË̤ڈÛË, ÙË ÌÂÙ·ÊÔÚ¿ ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô Î·È ÙË Û˘ÁηٿıÂÛË ÙˆÓ Û˘ÁÁÂÓÒÓ ÙÔ˘ ˘Ô„ËÊ›Ô˘ ‰fiÙÔ˘. ∏ ÂÈÛ·ÁˆÁ‹ ÙˆÓ ÌÂÁ¿ÏÔ˘ ‡ÚÔ˘˜ ηıÂÙ‹ÚˆÓ Á›ÓÂÙ·È ‰È·Ì¤ÛÔ˘ ÙˆÓ ÎÔÈÓÒÓ ÌËÚÈ·›ˆÓ ·ÁÁ›ˆÓ Î·È Ë Ì›ˆÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÙÔ˘ ˘Ú‹Ó· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÂÈÙ˘Á¯¿ÓÂÙ·È ÁÚ‹ÁÔÚ· Î·È ‰È·ÙËÚÂ›Ù·È ÛÙÔ˘˜ 15 – 18 0C. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ¯ÂÈÚÔ˘ÚÁÔ›, Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó fiÚÁ·Ó· ·fi ¢¶∫§, ¯ÚËÛÈÌÔÔÈÔ‡Ó Î¿ÔÈ· ·Ú·ÏÏ·Á‹ Ù˘ Ù¯ÓÈ΋˜ super-rapid, Ô˘ ÂÚÈÁÚ¿ÊıËΠ·fi ÙËÓ ÔÌ¿‰· ÙÔ˘ Pittsburgh8. OÈ ÓÂÊÚÔ› ÌÔÚÔ‡Ó Ó· ·Ó·ÎÙËıÔ‡Ó, ›Ù Í¯ˆÚÈÛÙ¿, ›Ù en bloc, ·ÏÏ¿ Û οı ÂÚ›ÙˆÛË Ú¤ÂÈ Ó· ‰È·ÙÂı› ·ÚÎÂÙfi˜ ¯ÚfiÓÔ˜ ÁÈ· ex situ ¤ÏÂÁ¯Ô Ù˘ ·ÚÙÈfiÙËÙ·˜ Î·È Î·Ù·ÏÏËÏfiÙËÙ¿˜ ÙÔ˘˜, ÚÈÓ ·˘Ù¿ ·ÔÛÙ·ÏÔ‡Ó ÛÙ· ΤÓÙÚ· fiÔ˘ ı· ÂÌÊ˘Ù¢ıÔ‡Ó. ™Â

25

‰fiÙ˜ ηÙËÁÔÚ›·˜ πππ ηٿ Maastricht (ÂÏÂÁ¯fiÌÂÓË Ï‹„Ë), Ë Ù·¯Â›· Ï··ÚÔÙÔÌ›· Î·È ¤ÎÏ˘ÛË ‰È· Ù˘ ·ÔÚÙ‹˜, Ô‰ËÁ› Û ÌÔۯ‡̷ٷ ηχÙÂÚ˘ ÔÈfiÙËÙ·˜. Δ· ̤ÙÚ· ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ‰fiÙÔ˘ ÌÔÚÔ‡Ó Ó· ÛÙ·Ì·Ù‹ÛÔ˘Ó ÛÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ‹ ÛÙÔ ÎÚ‚¿ÙÈ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £ÂÚ·›·˜ ·ÚÔ˘Û›· ÙˆÓ Û˘ÁÁÂÓÒÓ. ∏ ·ÍÈÔÔ›ËÛË ÔÚÁ¿ÓˆÓ ·fi ¢¶∫§, ·ÚfiÙÈ ·Ï·È¿ ˆ˜ ȉ¤·, ‚Ú›ÛÎÂÈ ‰ÈÂıÓÒ˜ Ó¤· ‰˘Ó·ÌÈ΋ Û‹ÌÂÚ·. ∞ÓÙ›ıÂÙ· Ì ÙËÓ ·ÍÈÔÔ›ËÛË ÙÔ˘ ‹·ÙÔ˜ Î·È ·ÁÎÚ¤·ÙÔ˜ ·fi ¢¶∫§, Ô˘ Á›ÓÂÙ·È ·fi Û¯ÂÙÈο Ï›Á· ΤÓÙÚ· (Ì ÂÏȉÔÊfiÚ· fï˜ ˆ˜ ÙÒÚ· ·ÔÙÂϤÛÌ·Ù·), Ë ¯ÚËÛÈÌÔÔ›ËÛË ÓÂÊÚÒÓ ·fi ÙÔ˘˜ ›‰ÈÔ˘˜ ‰fiÙ˜ Ê·›ÓÂÙ·È Ó· Ù˘Á¯¿ÓÂÈ fiÏÔ Î·È Â˘Ú‡ÙÂÚ˘ ·Ô‰Ô¯‹˜, ÌÈ·˜ Î·È Ù· Ì·ÎÚÔ¯ÚfiÓÈ· ·ÔÙÂϤÛÌ·Ù¿ Ù˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ˘ÛÙÂÚÔ‡Ó Û ۯ¤ÛË Ì ·˘Ù¿ ·fi ÙÔ˘˜ Û˘Ì‚·ÙÈÎÔ‡˜ ‰fiÙ˜. ∏ ·Ó¿Ù˘ÍË ÌÂıfi‰ˆÓ ÚÔÂÁ¯ÂÈÚËÙÈ΋˜ ÂÎÙ›ÌËÛ˘ Ù˘ ηٷÏÏËÏfiÙËÙ·˜ Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ·ÏÏ¿ Î·È Ë Î·Ï‡ÙÂÚË Û˘ÓÙ‹ÚËÛ‹ ÙÔ˘˜, ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ‰Ú·ÛÙÈο ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Î˘Ú›ˆ˜ Ó· ÂÏ·¯ÈÛÙÔÔÈ‹ÛÂÈ ÙÔ ÔÛÔÛÙfi Ù˘ ÚˆÙÔ·ıÔ‡˜ ÌË-ÏÂÈÙÔ˘ÚÁ›·˜, Ô˘ ·ÔÙÂÏ› Î·È ÙËÓ ·¯›ÏÏÂÈÔ Ù¤ÚÓ· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·˘ÙÒÓ (΢ڛˆ˜ ÛÙȘ ηÙËÁÔڛ˜ ÌË ÂÏÂÁ¯fiÌÂÓ˘ Ï‹„˘). ∂›Û˘, Ù· ÛËÌ·ÓÙÈο ËıÈο Î·È ‰ÂÔÓÙÔÏÔÁÈο ˙ËÙ‹Ì·Ù· Ù˘ ·ÍÈÔÔ›ËÛ˘ ¢¶∫§, ı· Ú¤ÂÈ Ó· Ù‡¯Ô˘Ó ȉȷ›ÙÂÚ˘ ÌÂϤÙ˘ Î·È ÚÔÛÔ¯‹˜, ÒÛÙ ӷ ·ÔÊ¢¯ı› Û‡Á¯˘ÛË, Ô˘ ÌfiÓÔ Î·Î¤˜ ˘ËÚÂۛ˜ ÚÔÛʤÚÂÈ ÛÙÔÓ Â˘·›ÛıËÙÔ

∂ÈÎfiÓ· 3. Double-Ballon Triple-Lumen ηıÂÙ‹Ú·˜.

M. M∏Δ™∏™

26

NHBD PMP

NHBD as % of total deceased donors

6 40 5 30

4 3

20 2 10

1 0

. s a e n om ium pai anc stri Rep nd u h S Fr rla ingd elg A e c B e K th Cz Ne ited n U

ly

Ita

0

. ds om um ain nce tria ep lan ngd elgi Sp Fra Aus h R i c B e K t Cz Ne ited n U r he

ly

Ita

∂ÈÎfiÓ˜ 4, 5. ¢¶∫§ Û ‰È¿ÊÔÚ˜ ∂˘Úˆ·˚Τ˜ ¯ÒÚ˜, ηٿ ÙÔ 2008.

Heart-beating donors

200

Non heart-beating donors

-58.7% 150

100

50

0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

∂ÈÎfiÓ· 6. OÏÏ·Ó‰›·: ∏ Û¯¤ÛË ·Ó¿ÌÂÛ· Û ¢¶∫§ vs. Û˘Ì‚·ÙÈÎÔ‡˜ ‰fiÙ˜.

¯ÒÚÔ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ. ªÂ ÙȘ ·Ú·¿Óˆ ÚÔ¸Ôı¤ÛÂȘ, ÌÔÚ› ‚¿ÛÈÌ· Ó· ˘ÔÛÙËÚȯı›, fiÙÈ Û‡ÓÙÔÌ· ÙÔ ÎÏÈÓÈÎfi ·ÔÙ¤ÏÂÛÌ·, ·fi ÙËÓ ·ÍÈÔÔ›ËÛË ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ¢¶∫§, ‰ÂÓ ı· ‰È·Ê¤ÚÂÈ ·fi ·˘Ùfi Ô˘ ¤¯ÂÈ ‹‰Ë ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÔÚÁ¿ÓˆÓ ·fi ‰fiÙ˜ Ô˘ ÏËÚÔ‡Ó Ù· ÎÚÈÙ‹ÚÈ· ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘. ∏ ¯ÚËÛÈÌÔÔ›ËÛË ¢¶∫§ ÌÔÚ› Ó· ·Ô‰ÒÛÂÈ ·ÚÎÂÙ¿ ÌÂÁ¿ÏÔ ·ÚÈıÌfi ÔÚÁ¿ÓˆÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË (∂ÈÎ. 4 Î·È 5), ·ÏÏ¿ fiˆ˜ οı ÓfiÌÈÛÌ· ¤¯ÂÈ ‰‡Ô fi„ÂȘ12. ∏ ÌÂÁ¿ÏË ÚÔÛÊÔÚ¿ ÔÚÁ¿ÓˆÓ ·fi ¢¶∫§, ÌÔÚ› Ï·Óı·Ṳ̂ӷ Ó· Ô‰ËÁ‹ÛÂÈ ÛÙÔ Û˘Ì¤Ú·ÛÌ·, ˆ˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· χÛÂÈ ÙÔ Úfi-

‚ÏËÌ· Ù˘ ‰ˆÚ¿˜ ÔÚÁ¿ÓˆÓ Î·È ¤ÙÛÈ ÔÈ ÚÔÛ¿ıÂȘ ÁÈ· ·Ó¿ÎÙËÛË ÔÚÁ¿ÓˆÓ ·fi Û˘Ì‚·ÙÈÎÔ‡˜ ‰fiÙ˜ Ó· ÌÂȈıÔ‡Ó. ∞˘Ùfi Â›Ó·È ÂÌÊ·Ó¤˜ ÛÙËÓ ÂÚ›ÙˆÛË Ù˘ OÏÏ·Ó‰›·˜, fiÔ˘ ÌÂÙ¿ ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ¢¶∫§ ·Ú·ÙËÚ‹ıËΠ̛ˆÛË Î·Ù¿ 58,7% ÙˆÓ Û˘Ì‚·ÙÈÎÒÓ ‰ÔÙÒÓ Ì ηډȷ΋ ÏÂÈÙÔ˘ÚÁ›·12 (∂ÈÎ. 6).

™˘ÓÙ‹ÚËÛË ÔÚÁ¿ÓˆÓ ∏ ‰È·Ù‹ÚËÛË Ù˘ ÔÈfiÙËÙ·˜ ÙˆÓ ÔÚÁ¿ÓˆÓ, ÌÂÙ¿ ÙË Ï‹„Ë ÙÔ˘˜ Î·È Ì¤¯ÚÈ ÙËÓ ÂÌʇÙÂ˘Û‹ ÙÔ˘˜, Â›Ó·È ·fiÏ˘Ù· ÛËÌ·ÓÙÈ΋ ÁÈ· ÙË ‚¤ÏÙÈÛÙË ÏÂÈÙÔ˘ÚÁ›· Î·È ÂÈ‚›ˆÛ‹ ÙÔ˘˜. ª¤¯ÚÈ Û‹ÌÂÚ·, Ë „˘¯Ú‹ ÛÙ·ÙÈ-

METAMO™XEY™Eπ™ 2011

΋ Û˘ÓÙ‹ÚËÛ‹ ÙÔ˘˜ Û 4 0 C, Ì ¯Ú‹ÛË ¿ÁÔ˘ (static cold storage – CS), Â›Ó·È Ë ϤÔÓ Â˘Ú¤ˆ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓË Ì¤ıÔ‰Ô˜. ∏ ÌÂıfi‰Ô˜ ·ÔÛÎÔ› ÛÙË Ì›ˆÛË ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Î·È ÙˆÓ Î·Ù·‚ÔÏÈÎÒÓ ÂÓ˙‡ÌˆÓ, ̤ۈ Ù˘ ˘ÔıÂÚÌ›·˜. ∂›Ó·È ÁÓˆÛÙfi, ˆ˜ ÁÈ· οı Ì›ˆÛË Ù˘ ıÂÚÌÔÎÚ·Û›·˜ ÙÔ˘ ÔÚÁ¿ÓÔ˘ ηٿ 10 0C, ÂÈÙ˘Á¯¿ÓÂÙ·È ˘Ô‰ÈÏ·ÛÈ·ÛÌfi˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÎÔ‡ Ú˘ıÌÔ‡13. ™‹ÌÂÚ·, ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ ‰È·Ï‡Ì·Ù· Û˘ÓÙ‹ÚËÛ˘ (Euro-Collins, HTK, Marshall, UW) Ì ÂÓÙÂÏÒ˜ ‰È·ÊÔÚÂÙÈΤ˜ ¯ËÌÈΤ˜ Û˘Óı¤ÛÂȘ Î·È È‰ÈfiÙËÙ˜. ¶·ÚfiÙÈ, ÁÈ· fiÚÁ·Ó·, fiˆ˜ ÙÔ ‹·Ú Î·È ÙÔ ¿ÁÎÚ·˜, Ê·›ÓÂÙ·È fiÙÈ ÙÔ ‰È¿Ï˘Ì· UW (University of Wisconsin) ˘ÂÚÙÂÚ› ¤Ó·ÓÙÈ ÙˆÓ ˘ÔÏÔ›ˆÓ, ‰ÂÓ Û˘Ì‚·›ÓÂÈ ÙÔ ›‰ÈÔ ÁÈ· ÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ÓÂÊÚÒÓ, fiÔ˘ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÂÚ›Ô˘ Ù· ›‰È·, ÂÊfiÛÔÓ Ô ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ‰ÂÓ ˘ÂÚ‚·›ÓÂÈ ÙȘ 18 – 24 ÒÚ˜. °È· ÌÂÁ·Ï‡ÙÂÚ· ‰È·ÛÙ‹Ì·Ù· ÙÔ ‰È¿Ï˘Ì· UW ‰›ÓÂÈ Û·ÊÒ˜ ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù·. ŸÌˆ˜, Ì ÙËÓ ÔÏÔ¤Ó· Î·È Û˘¯ÓfiÙÂÚË ¯Ú‹ÛË ÔÚÁ¿ÓˆÓ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ/ÔÚÈ·ÎÔ› ‰fiÙ˜ (ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ ¿ÙÔÌ· - ‰fiÙ˜ ÌÂ Û˘ÓÔ‰¿ È·ÙÚÈο ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Î·È ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË – ¢¶∫§), Ê¿ÓËΠfiÙÈ Û˘¯Ó¿ Ù¤ÙÔÈ· fiÚÁ·Ó· ÂÌÊ·Ó›˙Ô˘Ó ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÂÈÏÔÎÒÓ (ÚˆÙÔ·ı‹˜ ÌË-ÏÂÈÙÔ˘ÚÁ›· – ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›·)14. ŒÙÛÈ, ÚԤ΢„Â Ë ·Ó¿ÁÎË ¯ÚËÛÈÌÔÔ›ËÛ˘ Î·È ¿ÏÏˆÓ ÂÓ·ÏÏ·ÎÙÈÎÒÓ invivo ‹ ex-vivo Ù¯ÓÈÎÒÓ Û˘ÓÙ‹ÚËÛ˘.

π. in-vivo Ù¯ÓÈΤ˜ Û˘ÓÙ‹ÚËÛ˘ ¶ÚfiÛÊ·Ù·, Ë ‚Ú·¯Â›·˜ ¯ÚÔÓÈ΋˜ ‰È¿ÚÎÂÈ·˜ ¯ÚËÛÈÌÔÔ›ËÛË Ù˘ Â͈ۈ̷ÙÈ΋˜ Ô͢ÁfiÓˆÛ˘ Ì ÌÂÌ‚Ú¿ÓË (extracorporeal membrane oxygenation - ECMO), Ì ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ ȉ›Ô˘ ÙÔ˘ ·›Ì·ÙÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ·Ú¯È΋ ÓÔÚÌÔıÂÚÌ›· (ÚÔ Ù˘ „˘¯Ú‹˜ ¤ÎÏ˘Û˘) ÙˆÓ ÔÚÁ¿ÓˆÓ, ¤‰ÂÈÍ ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·. ∞˘Ù‹ Ë ÌÈÎÚ‹ ÂÚ›Ô‰Ô˜ «·Ó¿Ó˄˘» ÙˆÓ ÔÚÁ¿ÓˆÓ, Ê·›ÓÂÙ·È fiÙÈ ÌÔÚ› Ó· ÙÔ˘˜ ‰ÒÛÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ηχÙÂÚ˘ ÏÂÈÙÔ˘ÚÁ›·˜.

ππ. ex-vivo Ù¯ÓÈΤ˜ Û˘ÓÙ‹ÚËÛ˘ ∫‡ÚÈ· ı¤ÛË Û ·˘Ù¤˜ η٤¯ÂÈ ÌÈ· Ù¯ÓÈ΋ fi¯È Î·È ÙfiÛÔ Ó¤·, ·ÏÏ¿ Ô˘ ÙÔ ÂӉȷʤÚÔÓ ÁÈ· ÙË ¯ÚËÛÈÌÔÔ›ËÛ‹ Ù˘ ·˘Í‹ıËÎÂ Î·È ¿ÏÈ Î·Ù·ÎfiÚ˘Ê· ηٿ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰‡Ô ‰ÂηÂٛ˜, ÏfiÁˆ Ù˘ ¯ÚËÛÈÌÔÔ›ËÛ˘ ÔÚÁ¿ÓˆÓ ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ Î·È ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ·fi ¢¶∫§. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙËÓ

27

∂ÈÎfiÓ· 7. ™˘Û΢‹ Ì˯·ÓÈ΋˜ ¤ÎÏ˘Û˘ ÓÂÊÚÒÓ (RM3 - Waters Instruments Inc. Medical Systems).

ex-vivo Ì˯·ÓÈ΋ ¤ÎÏ˘ÛË/Û˘ÓÙ‹ÚËÛË ÙˆÓ ÔÚÁ¿ÓˆÓ (Machine Perfuion – MP), Ì ÙË ¯Ú‹ÛË Î·Ù¿ÏÏËÏ˘ Ì˯·Ó‹˜ (∂ÈÎ. 7). ¶·ÚfiÙÈ, ÔÈ ÏfiÁÔÈ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ Ë Ì¤ıÔ‰Ô˜ ·˘Ù‹ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ Î¿ÔÈ· ÚÔÛٷ٢ÙÈ΋ Â›‰Ú·ÛË ÛÙÔ ÓÂÊÚfi ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ›, Â›Ó·È ÎÔÈÓ¿ ·Ô‰ÂÎÙfi fiÙÈ ÌÂÈÒÓÂÈ ÙȘ ·ÁÁÂȷΤ˜ ·ÓÙÈÛÙ¿ÛÂȘ ÙÔ˘ ÔÚÁ¿ÓÔ˘, ·ÔÌ·ÎÚ‡ÓÂÈ ÙÔ˘˜ ıÚfiÌ‚Ô˘˜ Î·È Ù· ÚÔ˚fiÓÙ· ÙÔ˘ ·Ó·ÂÚfi‚ÈÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ·fi ÙËÓ ÌÈÎÚÔ΢ÎÏÔÊÔÚ›· Î·È ‚ÂÏÙÈÒÓÂÈ ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ ÚÔ‹˜, ÎÏ. (¶›Ó·Î·˜ 2 - ÁÈ· Ï‹ÚË ·Ó¿Ï˘ÛË ÙˆÓ ÏÂÔÓÂÎÙËÌ¿ÙˆÓ Û˘ÓÈÛÙ¿Ù·È Ë ÌÂϤÙË ÂÓfi˜ ÂÍ·ÈÚÂÙÈÎÔ‡ state-of-the art ¿ÚıÚÔ˘ ·fi ÙÔÓ Taylor et al15). ∏ Ì˯·ÓÈ΋ ¤ÎÏ˘ÛË Â›¯Â ¯ÚËÛÈÌÔÔÈËı› ·fi Ôχ ·Ï·È¿, ·ÏÏ¿ Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ¤ÂÛ Û ‰˘Ṳ̂ÓÂÈ·, ΢ڛˆ˜ ÏfiÁˆ Ù˘ Û¯ÂÙÈ΋˜ Ô¶π¡∞∫∞™ 2. ¶ÏÂÔÓÂÎÙ‹Ì·Ù· ˘ÔıÂÚÌÈ΋˜ Ì˯·ÓÈ΋˜ ¤ÎÏ˘Û˘ ¶ƒO™¢O∫Oª∂¡∞/∞¡∞¢ÀOª∂¡∞ ¶§∂O¡∂∫Δ∏ª∞Δ∞ À¶O£∂ƒªπ∫∏™ ª∏Ã∞¡π∫∏™ ∂∫¶§À™∏™15 ‰È·Ù‹ÚËÛË ‚·ÙfiÙËÙ·˜ ·ÁÁÂÈ·ÎÔ‡ ‰ÈÎÙ‡Ô˘ «ıÚÂÙÈ΋» ˘ÔÛÙ‹ÚÈÍË Î·È Ô͢ÁfiÓˆÛË ·ÔÌ¿ÎÚ˘ÓÛË ÌÂÙ·‚ÔÏÈÎÒÓ ·Ú·ÁÒÁˆÓ Î·È ÙÔÍÈÓÒÓ ¯ÔÚ‹ÁËÛË Î˘ÙÙ·ÚÔÚÔÛٷ٢ÙÈÎÒÓ Î·È ·ÓÔÛÔÙÚÔÔÔÈËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ‰È¢ÎfiÏ˘ÓÛË ÂϤÁ¯ˆÓ ‚ȈÛÈÌfiÙËÙ·˜ Î·È Û˘Ì‚·ÙfiÙËÙ·˜ ‰˘Ó·ÙfiÙËÙ· ÂÎÏÂÎÙÈÎÔ‡ Î·È fi¯È Â›ÁÔÓÙÔ˜ ¯ÂÈÚÔ˘ÚÁ›Ԣ Ì›ˆÛË ÔÛÔÛÙÔ‡ PNF Î·È DGF ‚ÂÏÙ›ˆÛË ‹/Î·È ‰È¿ÛˆÛË ÔÚÁ¿ÓˆÓ ·fi ¢¶∫§ Ì›ˆÛË ÎfiÛÙÔ˘˜ PNF = ÚˆÙÔ·ı‹˜ ÌË-ÏÂÈÙÔ˘ÚÁ›·, DGF = ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ¢¶∫§ = ‰fiÙ˜ Ì ·‡ÛË Î·Ú‰È·Î‹˜ ÏÂÈÙÔ˘ÚÁ›·˜

28

M. M∏Δ™∏™

Ï˘ÏÔÎfiÙËÙ¿˜ Ù˘, Ù˘ ··›ÙËÛ˘ ÁÈ· ÂÎ·È‰Â˘Ì¤ÓÔ ÛÙË ¯Ú‹ÛË Ù˘ ÚÔÛˆÈÎfi Î·È Ù˘ Èı·Ó‹˜ ÂÈϤÔÓ ‚Ï¿‚˘ Ô˘ ıˆڋıËΠfiÙÈ ÂÈʤÚÂÈ ÛÙÔ˘˜ ÓÂÊÚÔ‡˜. ŸÌˆ˜ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ì ÙËÓ ·Ú·Û΢‹ ÂÚÈÛÛfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈÎÒÓ Î·È ÌË ‚Ï·ÙÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ Ì˯·ÓÈ΋˜ ¤ÎÏ˘Û˘ (Belzer UW) Î·È ·Ú¿ÏÏËÏ· Ì ÙÔ ÔÏÔ¤Ó· ·˘Í·ÓfiÌÂÓÔ ÂӉȷʤÚÔÓ ÁÈ· ÙËÓ ·ÍÈÔÔ›ËÛË ÔÚÈ·ÎÒÓ ‰ÔÙÒÓ Î·È È‰È·›ÙÂÚ· ¢¶∫§, Ë Ù¯ÓÈ΋ ·˘Ù‹ ¤¯ÂÈ Â·Ó¤ÏıÂÈ ÛÙÔ ÚÔÛ΋ÓÈÔ. ∏ ¯ÚËÛÈÌÔÔ›ËÛ‹ Ù˘ Ê·›ÓÂÙ·È Ó· ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ Â›ÙˆÛË Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ô˘ ·ÔÙÂÏ› ¤Ó· ·fi ÙÔ˘˜ ‚·ÛÈÎfiÙÂÚÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜ ÛÙË ¯Ú‹ÛË ÔÚÁ¿ÓˆÓ ·fi ¢¶∫§. ∞Ó Î·È ·fi ÔÏÏÔ‡˜ ˘ÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ë Ì›ˆÛË ‰ÂÓ Û˘ÓÂ¿ÁÂÙ·È ··Ú·›ÙËÙ· Î·È ‚ÂÏÙ›ˆÛË Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Â›Ó·È Û·Ê¤˜ fiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙÔ ÔÈÎÔÓÔÌÈÎfi ÎfiÛÙÔ˜. ∏ ¯Ú‹ÛË Ù˘ Ì˯·ÓÈ΋˜ ¤ÎÏ˘Û˘ ıˆÚÂ›Ù·È Â›Û˘, fiÙÈ ÌÔÚ› Ó· ÚÔÛʤÚÂÈ ÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜ Û ۯ¤ÛË Ì ÙË ‚ȈÛÈÌfiÙËÙ· Î·È Î·Ù·ÏÏËÏfiÙËÙ· ÙÔ˘ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ∏ ÂÎÙ›ÌËÛË ÙfiÛÔ ÙˆÓ Ì˯·ÓÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ (ÚÔ‹, ·ÓÙ›ÛÙ·ÛË, ›ÂÛË), fiÛÔ Î·È ‚ÈÔ¯ËÌÈÎÒÓ ‰ÂÈÎÙÒÓ (Á·Ï·ÎÙÈ΋ ‰Â¸‰ÚÔÁÔÓ¿ÛË, ÙÚ·ÓÛÊÂÚ¿ÛË S Ù˘ ÁÏÔ˘Ù·ıÂÈfiÓ˘, Î.Ï..) ÛÙÔ ˘ÁÚfi Ù˘ ¤ÎÏ˘Û˘, ÌÔÚ› Ó· Û˘Ì‚¿ÏÏÂÈ, ·Ó fi¯È ÛÙËÓ ÔÛÔÙÈÎÔÔ›ËÛË Ù˘ ÈÛ¯·ÈÌÈ΋˜ ‚Ï¿‚˘, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÛÙËÓ ·fiÚÚÈ„Ë ÔÚÁ¿ÓˆÓ Ì ÌÂÁ¿Ï˜ Èı·ÓfiÙËÙ˜ ÚˆÙÔ·ıÔ‡˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜. ÷ڷÎÙËÚÈÛÙÈο ·Ó·Ê¤ÚÂÙ·È, fiÙÈ Ë ¯ÚËÛÈÌÔÔ›ËÛË Ù˘ Ì˯·ÓÈ΋˜ ¤ÎÏ˘Û˘, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ‚ȈÛÈÌfiÙËÙ·˜ ÙÔ˘ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ̤ۈ Ù˘ ̤ÙÚËÛ˘ ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÙÚ·ÓÛÊÂÚ¿Û˘ S Ù˘ ÁÏÔ˘Ù·ıÂÈfiÓ˘ (GST), ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡ ·fi ¢¶∫§( 92,3% vs 45,5%)16. OÈ Û˘ÁÁÚ·Ê›˜ ÚÔÙ›ÓÔ˘Ó ˆ˜ ¯·ÌËÏfiÙÂÚÔ ·Ô‰ÂÎÙfi fiÚÈÔ ÚÔ‹˜ ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜ Ù· 50 ml/ÏÂÙfi/100g ÈÛÙÔ‡ Î·È ˆ˜ ˘„ËÏfiÙÂÚÔ fiÚÈÔ Û˘ÁΤÓÙÚˆÛ˘ Ù˘ GST ÂÓÙfi˜ ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ¤ÎÏ˘Û˘ ÙȘ 200 ÌÔÓ/lit/100g ÈÛÙÔ‡. ŸÌˆ˜, Ú·ÁÌ·ÙÈ΋ ·Ó·˙ˆÔÁfiÓËÛË, ¤ÏÂÁ¯Ô ‚ȈÛÈÌfiÙËÙ·˜ Î·È ÂÓÂÚÁfi ‚ÈÔÏÔÁÈ΋ ÙÚÔÔÔ›ËÛË ÂÓfi˜ ÔÚÁ¿ÓÔ˘ Ô˘ ¤¯ÂÈ ˘ÔÛÙ› ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë, Â›Ó·È Èı·ÓfiÓ Ó· ··ÈÙ› fi¯È ÌfiÓÔ ·ÚÔ¯‹ O2 Î·È ¿ÏÏˆÓ ÛÙÔȯ›ˆÓ, ·ÏÏ¿ Â›Û˘ Î·È Ê˘ÛÈÔÏÔÁÈ΋ ıÂÚÌÔÎÚ·Û›· (ÓÔÚÌÔıÂÚÌ›·) ÙÔ˘ ÔÚÁ¿ÓÔ˘. ¶ÔÏÏÔ› ÈÛÙ‡ԢÓ, fiÙÈ Ë ÓÔÚÌÔıÂÚÌÈ΋ Ì˯·ÓÈ΋ ¤ÎÏ˘ÛË ÌÔÚ› Ó· Â›Ó·È Ë Ì¤ıÔ‰Ô˜ ÂÎÏÔÁ‹˜ ÛÙÔ ¿-

ÌÂÛÔ Ì¤ÏÏÔÓ Î·È ÔÏϤ˜ Â˘Úˆ·˚Τ˜ ÔÌ¿‰Â˜ ÂÚ¢ÓÔ‡Ó ÂÓÂÚÁ¿ ÙËÓ Èı·ÓfiÙËÙ· ÓÔÚÌÔıÂÚÌÈ΋˜ Ì˯·ÓÈ΋˜ ¤ÎÏ˘Û˘, ÙfiÛÔ ÁÈ· Ù· ÓÂÊÚÈο, fiÛÔ Î·È ÁÈ· Ù· Ë·ÙÈο Î·È ·ÁÎÚ·ÙÈο ÌÔۯ‡̷ٷ. ∂›Û˘, ÓÂfiÙÂÚ˜ ÌÂϤÙ˜ Î·È ÚÔÛ¿ıÂȘ, ÙfiÛÔ ÛÙËÓ Î·Ù‡ı˘ÓÛË Ù˘ Ê·Ú̷΢ÙÈ΋˜ ·Ú¤Ì‚·Û˘ (Ì›ˆÛË ÔÍÂȉˆÙÈÎÔ‡ stress Î·È ‚Ï¿‚˘ ÈÛ¯·ÈÌ›·˜/Â·Ó·ÈÌ¿ÙˆÛ˘, Ì ÙÚÔÔÔ›ËÛË ÌÔÚ›ˆÓ ÊÏÂÁÌÔÓ‹˜, ·fiÙˆÛ˘, ÈÛ¯·ÈÌ›·˜, ıÚfiÌ‚ˆÛ˘, ÎÏ), fiÛÔ Î·È ·˘Ù‹Ó Ù˘ ÁÂÓÂÙÈ΋˜ ·Ú¤Ì‚·Û˘ (ex-vivo kidney gene transfer, Ì ÈÔ‡˜-ÊÔÚ›˜ ‹/Î·È Î˘ÙÙ·ÚÈÎÔ‡˜ ÊÔÚ›˜), ·Ó·Ì¤ÓÂÙ·È Ó· ‰ÒÛÔ˘Ó Ó¤· ÒıËÛË ÛÙÔ ‰›Ô Ù˘ Û˘ÓÙ‹ÚËÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ‚ÂÏÙ›ˆÛ˘ ÙˆÓ ÎÏÈÓÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ.

™ËÌ›· ¿ÍÈ· Û˘˙‹ÙËÛ˘ Ú¤ÂÈ Ó· ÚÔËÁÂ›Ù·È Ë Ï··ÚÔÙÔÌ›· Ù˘ ÛÙÂÚÓÔÙÔÌ‹˜; - ∂›Ó·È ··Ú·›ÙËÙË Ë ÛÙÂÚÓÔÙÔÌ‹, ·ÎfiÌË Î·È Û ÂÚÈÙÒÛÂȘ fiÔ˘ ‰ÂÓ Û¯Â‰È¿˙ÂÙ·È Ë Ï‹„Ë ÂÓ‰ÔıˆÚ·ÎÈÎÒÓ ÔÚÁ¿ÓˆÓ; ªÂ ÙȘ Û‡Á¯ÚÔÓ˜ ÚÔÛ¿ıÂȘ ·ÍÈÔÔ›ËÛ˘ fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔ ËÏÈÎÈˆÌ¤ÓˆÓ ‰ÔÙÒÓ (> 65 ÂÙÒÓ), Â›Ó·È ÏÔÁÈÎfi Ó· ·Ó·Ì¤ÓÂÙ·È ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ‡·Ú͢ οÔÈ·˜ ÂÓ‰ÔÎÔÈÏȷ΋˜ ηÎÔ‹ıÂÈ·˜. ŒÙÛÈ, ·ÚÎÂÙÔ› ÚÔÙ›ÓÔ˘Ó ÙËÓ Î·Ùã·Ú¯‹Ó Ú·ÁÌ·ÙÔÔ›ËÛË Ï··ÚÔÙÔÌ›·˜, Ô˘ ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ¤ÏÂÁ¯Ô ÙˆÓ ÂÓ‰ÔÎÔÈÏ·ÎÒÓ ÔÚÁ¿ÓˆÓ, ÒÛÙ ӷ ·ÔʇÁÂÙ·È ÌÈ· Èı·Ó¿ ¿ÛÎÔË ÛÙÂÚÓÔÙÔÌ‹. ∏ ·Ú·Û΢‹ Î·È ·Ê·›ÚÂÛË ÙˆÓ ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (‹·Ú-¿ÁÎÚ·˜-ÓÂÊÚÔ›) Â›Ó·È ‰˘Ó·Ù‹ ÌfiÓÔ Ì ÎÔÈÏȷ΋ ÚÔÛ¤Ï·ÛË. ŸÌˆ˜ ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÌʈÓÔ‡Ó, ˆ˜ ·ÎfiÌË Î·È fiÙ·Ó ‰ÂÓ Û¯Â‰È¿˙ÂÙ·È Ï‹„Ë ÂÓ‰ÔıˆÚ·ÎÈÎÒÓ ÔÚÁ¿ÓˆÓ, Ë Ú·ÁÌ·ÙÔÔ›ËÛË ÛÙÂÚÓÔÙÔÌ‹˜ Î·È ‰È¿ÓÔÈ͢ Ù˘ ıˆÚ·ÎÈ΋˜ ÎÔÈÏfiÙËÙ·˜ Â›Ó·È ÂÈı˘ÌËÙ‹, ÌÈ·˜ Î·È ÂÈÙÚ¤ÂÈ Î·Ï‡ÙÂÚË Î·È ϤÔÓ ¿ÌÂÛË ÚÔÛ¤Ï·ÛË ÙÔ˘ ‹·ÙÔ˜ Î·È Ù˘ ˘ÂÚË·ÙÈ΋˜ οو ÎÔ›Ï˘ ÊϤ‚·˜. ˘ÔÓÔ̇ÂÈ Ë ÔÏ˘ÔÚÁ·ÓÈ΋ Ï‹„Ë ÙËÓ ÔÈfiÙËÙ· ÙˆÓ ÂÈ̤ÚÔ˘˜ ÔÚÁ¿ÓˆÓ; ∞fi ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Û·Ó Û ÔÏϤ˜ ¯ÈÏÈ¿‰Â˜ ‰ÔÙÒÓ ¤¯ÂÈ ‰Âȯı› ˆ˜ ‰ÂÓ ˘¿Ú¯ÂÈ Î·ÌÈ¿ ¤Ó‰ÂÈÍË ˘ÔÓfiÌ¢Û˘ Ù˘ ÔÈfiÙËÙ·˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÓÂÊÚÔ‡, fiÙ·Ó ·˘Ù¿ ¤¯Ô˘Ó ·Ó·ÎÙËı› ·fi ÔÏ˘ÔÚÁ·ÓÈÎÔ‡˜ ‰fiÙ˜17,18. ÿ‰È· ·ÔÙÂϤÛÌ·Ù· ¤‰ÂÈÍ·Ó Î·È ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Û·Ó Ù· ·ÔÙÂϤÛÌ·Ù· Ë·ÙÈÎÒÓ Î·È ·ÁÎÚ·ÙÈÎÒÓ ÌÂÙ·ÌÔۯ‡-

METAMO™XEY™Eπ™ 2011

ÛˆÓ, fiÙ·Ó Ù· ‰‡Ô ·˘Ù¿ ÌÔۯ‡̷ٷ ›¯·Ó ·Ó·ÎÙËı› ·fi ÙÔÓ ›‰ÈÔ ‰fiÙË19. Û¯ÂÙ›˙ÂÙ·È Ë ÔÏ˘ÔÚÁ·ÓÈ΋ Ï‹„Ë, Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ‚Ï¿‚˘ ÙˆÓ ÔÚÁ¿ÓˆÓ; ΔÔ ÔÛÔÛÙfi ‚Ï¿‚˘ ÙˆÓ ÔÚÁ¿ÓˆÓ ηٿ ÙË Ï‹„Ë, Ê·›ÓÂÙ·È fiÙÈ ˘ÔÂÎÙÈÌ¿Ù·È. ªÂ ‚¿ÛË ÙȘ ·Ó·ÊÔÚ¤˜ ·fi ‰È¿ÊÔÚ· ΤÓÙÚ· ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙÔ ∏ӈ̤ÓÔ μ·Û›ÏÂÈÔ, Ë Ù·˘Ùfi¯ÚÔÓË ·Ó·ÊÔÚ¿ ÌÈ¿˜ ‚Ï¿‚˘ Î·È ·fi ÙÔ Î¤ÓÙÚÔ Ï‹„˘ Î·È ÙÔ Î¤ÓÙÚÔ ÂÌʇÙ¢Û˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó ÌfiÏȘ 3%. ΔËÓ ›‰È· ÛÙÈÁÌ‹, ‚¿ÛÂÈ ÙˆÓ ÛÙÔȯ›ˆÓ ÙÔ˘ UK National Transplant Database, Ê·›ÓÂÙ·È ˆ˜ ÙÔ ÔÛÔÛÙfi ‚Ï¿‚˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ·Ô‚ÈÒÛ·ÓÙ˜ ‰fiÙ˜ ‹Ù·Ó 19%. ΔÔ ÔÛÔÛÙfi ‹Ù·Ó ÌÈÎÚfiÙÂÚÔ fiÙ·Ó Ë Ï‹„Ë ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Â›¯Â Á›ÓÂÈ ÛÙ· Ï·›ÛÈ· ÔÏ˘ÔÚÁ·ÓÈ΋˜ Ï‹„˘ Î·È È‰È·›ÙÂÚ· ·fi ÔÌ¿‰Â˜ Ô˘ Ú·ÁÌ·ÙÔÔÈÔ‡Û·Ó ÂÚÈÛÛfiÙÂÚ˜ ·fi 50 ÔÏ˘ÔÚÁ·ÓÈΤ˜ Ï‹„ÂȘ ÂÙËÛ›ˆ˜, Û ۯ¤ÛË Ì ·˘Ùfi fiÙ·Ó Ë Ï‹„Ë ·ÊÔÚÔ‡Û ÌfiÓÔ ÓÂÊÚÔ‡˜20. Ú¤ÂÈ Ó· ÚÔÙÈÌ¿Ù·È Ë ·Ú·Û΢‹ Ì ‹ ¯ˆÚ›˜ ΢ÎÏÔÊÔÚ›· ÙÔ˘ ‰fiÙÔ˘; ¶·Ï·ÈfiÙÂÚ·, Ë Ï‹Ú˘ ·Ó·ÙÔÌÈ΋ ·Ú·Û΢‹ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ Ì›Û¯ˆÓ ÙˆÓ ‰È·ÊfiÚˆÓ ÔÚÁ¿ÓˆÓ Á›ÓÔÓÙ·Ó ·ÔÎÏÂÈÛÙÈο Ì ¿ÏÏÔ˘Û· ηډȿ, ÚÔ Ù˘ ÂÓ‰Ô·ÔÚÙÈ΋˜ ¤Á¯˘Û˘ ‰È·Ï‡Ì·ÙÔ˜ ¤ÎÏ˘Û˘. Δ· ÙÂÏÂ˘Ù·›· fï˜ ¯ÚfiÓÈ·, fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔÈ ÚÔÙÈÌÔ‡Ó Ó· Ú·ÁÌ·ÙÔÔÈÔ‡Ó ¤Ó· ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ Ù˘ ·Ú·Û΢‹˜ ÙˆÓ ÔÚÁ¿ÓˆÓ, ÌÂÙ¿ ÙËÓ in situ ¤ÎÏ˘ÛË Î·È ‰È·ÎÔ‹ Ù˘ ΢ÎÏÔÊÔÚ›·˜. ¶·ÚfiÙÈ, Ë ¯ÚËÛÈÌÔÔ›ËÛË Ù˘ ÌÈ·˜ ‹ ¿ÏÏ˘ Ù¯ÓÈ΋˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ·Ô‰›‰ÂÈ Î·Ï‡ÙÂÚ· ÓÂÊÚÈο ÌÔۯ‡̷ٷ, ÂÓ ÙÔ‡ÙÔȘ ·˘Ùfi ‰ÂÓ Â›Ó·È ·fiÏ˘Ù· ·ÏËı¤˜ ÛÙËÓ ÂÚ›ÙˆÛË Ï‹„˘ ÙˆÓ ¿ÏÏˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (‹·ÙÔ˜, ·ÁÎÚ¤·ÙÔ˜, ÎÏ). O ÏfiÁÔ˜ Â›Ó·È fiÙÈ Ë «ÂÓ ıÂÚÌÒ» ·Ú·Û΢‹ ÙˆÓ ·ÁÁ›ˆÓ Î·È ÔÈ ¯ÂÈÚÈÛÌÔ› Â› ÙˆÓ ÔÚÁ¿ÓˆÓ ÚÔηÏÔ‡Ó ·ÁÁÂÈfiÛ·ÛÌÔ Î·È Èı·Ó‹ ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë ·˘ÙÒÓ. ∂ÈϤÔÓ, ÔÈ ϤÔÓ ÁÚ‹ÁÔÚ˜ Ù¯ÓÈΤ˜ ¿ÌÂÛ˘ „‡Í˘ Î·È «ÂÓ „˘¯ÚÒ» ·Ú·Û΢‹˜ Ê·›ÓÂÙ·È, fiÙÈ Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·Ô‰ÂÎÙ¤˜ ·fi ÙÔ ÚÔÛˆÈÎfi ÙˆÓ ¯ÂÈÚÔ˘ÚÁ›ˆÓ Î·È ÙˆÓ Û˘ÓÂÚÁ·˙fiÌÂÓˆÓ ÔÌ¿‰ˆÓ Ï‹„˘. ÔÈ· Ë ‚¤ÏÙÈÛÙË Ù¯ÓÈ΋ ηıÂÙËÚÈ·ÛÌÔ‡ Î·È ¤ÎÏ˘Û˘; ∏ Â›‰Ú·ÛË Â› ÙˆÓ ÔÚÁ¿ÓˆÓ ÙˆÓ ‰‡Ô ÌÂıfi‰ˆÓ ¤ÎÏ˘Û˘, ‰ËÏ·‰‹ ·Ï‹ ¤ÎÏ˘ÛË ÌfiÓÔ ·fi ÙËÓ ÎÔÈÏȷ΋ ·ÔÚÙ‹, Î·È ‰ÈÏ‹ ¤ÎÏ˘ÛË ·fi ÙËÓ ·ÔÚÙ‹ Î·È ·fi ÙËÓ ˘Ï·›· ÊϤ‚· Ù·˘Ùfi¯ÚÔÓ·, ¤¯ÂÈ ÌÂÏÂÙËı› ·ÚÎÂÙ¿. OÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÌʈÓÔ‡Ó,

29

fiÙÈ Ë ·Ï‹ ¤ÎÏ˘ÛË, ̤ۈ ηıÂÙËÚÈ·ÛÌÔ‡ ÌfiÓÔ Ù˘ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜, ˘ÂÚÙÂÚ› ¤Ó·ÓÙÈ Ù˘ ‰ÈÏ‹˜ Ù·˘Ùfi¯ÚÔÓ˘ ¤ÎÏ˘Û˘. ∞˘Ùfi Â›Ó·È È‰È·›ÙÂÚ· ÂÌÊ·Ó¤˜ ÛÙËÓ ÂÚ›ÙˆÛË ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ21. ¢‡Ô ·ÎfiÌË ÛËÌ·ÓÙÈο ˙ËÙ‹Ì·Ù· Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙËÓ ¤ÎÏ˘ÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Â›Ó·È Ë ‚¤ÏÙÈÛË ›ÂÛË Î·È Ô ‚¤ÏÙÈÛÙÔ˜ Ú˘ıÌfi˜ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜ ¤ÎÏ˘Û˘. ∂›Ó·È Èı·Ófi, Ë ˘„ËÏ‹ ›ÂÛË ¤ÎÏ˘Û˘ (150 mmHg) Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÓÂ˘Ì·ÙÈÎÔ‡ ·ÛÎÔ‡, Ó· ·Ô‰›‰ÂÈ Î·Ï‡ÙÂÚ˘ ÔÈfiÙËÙ·˜ ÓÂÊÚÈο Î·È Ë·ÙÈο ÌÔۯ‡̷ٷ, Û ۇÁÎÚÈÛË Ì ÙË ¯·ÌËÏ‹ ›ÂÛË Ù˘ ‚·Ú‡ÙËÙ·˜ (80-100 cm H2O)22. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÎfiÌË Â·Ú΋ ÎÏÈÓÈο ‰Â‰Ô̤ӷ, Ô˘ Ó· ηıÔÚ›˙Ô˘Ó ÙÔÓ ‚¤ÏÙÈÛÙÔ Ú˘ıÌfi ¤Á¯˘Û˘ Î·È Û˘ÓÔÏÈÎÔ‡ fiÁÎÔ˘ ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜. ∂›Ó·È ··Ú·›ÙËÙË Ë in situ ÂÈÊ·ÓÂȷ΋ „‡ÍË ÙˆÓ ÔÚÁ¿ÓˆÓ Ì ¿ÁÔ; ¶·Ú¿ ÙËÓ ‚È‚ÏÈÔÁÚ·ÊÈ΋ ¤ÏÏÂÈ„Ë Â·ÚÎÒÓ ÛÙ·ÙÈÛÙÈÎÒÓ ‰Â‰Ô̤ӈÓ, Ë Ì¤ıÔ‰Ô˜ ·˘Ù‹ ·ÔÙÂÏ› ۯ‰fiÓ Î·ıÔÏÈο ·Ô‰ÂÎÙ‹ Ù·ÎÙÈ΋.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Kootstra G. The asystolic, or non-heart-beating, donor.

Transplantation 1997; 63(7): 917-921.

2. http://eur-lex.europa.eu/LexUriServ/LexUriServ. do?uri=OJ:L:2010:207:0014:0029:EN:PDF 3. http://www.yyka.gov.gr/article/news/320-prosxedionpmoy-laquo-dvrea-kai-metamosxeysh-organvn-kaialles-diatakseis-raquo.

4. Shaw BWJr, Rosenthal JT, Griffith BF, Haresty RL, Broznik B, Hakala T, et al. Techniques for combined procurement of hearts and kidneys with satisfactory early function of renal allografts. Surg Gynecol Obstet 1983; 157: 261–264.

5. Gruttadauria S, Scotti FC, Doria C, et al. The hepatic artery in liver transplantation and surgery: vascular anomalies in 701 cases. Clin Transplant 2001; 15: 359-363.

6. Michels NA. Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg 1962; 112: 337-347.

7. Roza AM, Perloff LJ, Naji A, et al. Living-related donors with bilateral multiple renal arteries: A twenty-year experience. Transplantation 1089; 47: 397–399.

8. Casavilla A, Ramirez C, Shapiro R, et al. Experience with liver and kidney allografts from non-heartbeating donors. Transplantation 1995;59:197–203.

9. D’Alessandro AM,Hoffmann RM,Knechtle SJ, et al. Successful extrarenal transplantation from non-heartbeating donors. Transplantation 1995;59:977–982.

10. ª‹ÙÛ˘ ª, ¶··Ïfi˘ μ. ªÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ‰fiÙ˜ Ì ·‡ÛË Î·Ú‰È·Î‹˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∂ÏÏËÓÈ΋ ÃÂÈ-

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ÚÔ˘ÚÁÈ΋; 76(2): 88-99, 2004.

11. Kootstra G, Daemen JH, Oomen AP. Categories of nonheart-beating donors. Transplant Proc 1995; 27(5): 2893-4.

12. Roels L, Rahmel A. The European Experience. Transplant Int 2011; 24: 350-367.

13. Southard JH, Belzer FO. Organ preservation. Ann Rev Med 1995; 46: 235.

14. Ernest van Heurn. Kidney preservation: from ‘do no further harm’ to ‘opportunity to recover’. Editorial. Current Opinion in Organ Transplantation 2011, 16:149–150.

15. Taylor MJ, Baicu SC. Current state of hypothermic machine perfusion preservation of organs: the clinical perspective. Cryobiology 2009; 60(Suppl 3): S20.

16. Balupuri S, Buckley P, Snowden C, et al. The trouble with kidneys derived from the non heart-beating donor: a single center 10-year experience. Transplantation 2000; 69(5): 842-846.

17. Peters TG, Vaughn WK. Organs for transplantation: analysis of 27,000 cadaveric donor organs. South Med J 1990; 83: 889-892.

18. Brockmann G, Vaidya A, Reddy S, Friend PJ. Retrieval

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of abdominal organs for transplantation. Review. Br J Surg 2006; 93: 133-146.

Schlumpf ∑, Morel P, Sutherland D, et al. Combined procurement of pancreas and liver grafts does not affect transplant outcome. Transplant Proc 1990; 22: 2074-2075.

Wigmore SJ, Seeney FM, Pleass HC, Praseedom RK, Forsythe JL. Kidney damage during organ retrieval: data from UK National Transplant Database. Kidney Advisory Group. Lancet 1999; 354: 1143–1146.

Conway MB, Saunders R, Munn SR, Perkins JD. Combined liver/pancreaticoduodenal procurement effect on allograft function. Transplant Proc 1990; 22: 429–430.

Iaria G, Tisone G, Pisani F, Buonomo O, Campione C, Pollicita S, et al. High-pressure perfusion versus gravity perfusion in liver harvesting: results from a prospective randomized study. Transplant Proc 2001; 33: 957–958.

Tisone G, Orlando G, Pisani F, Iaria G, Negrini S, Pollicita S, et al. Gravity perfusion versus high-pressure perfusion in kidney transplantation: results from a prospective randomized study. Transplant Proc 1999; 31: 3386–3387.

∞ÔÚÚ›ÙÔ˘Ì و̷ÙÈο ÓÂÊÚÈο ÌÔۯ‡̷ٷ ÁÈ· ÂÁ¯ÂÈÚËÙÈÎÔ‡˜ ÏfiÁÔ˘˜; π. ªfiÎÔ˜

Θ ÛÙË ÓÂÊÚÈ΋ ·ÚÙËÚ›·. ∂·Ó·ÈÌ¿ÙˆÛË ÚÔ‚ÏËÌ·ÙÈ΋, Ì ¤Î‚·ÛË ıÚfiÌ‚ˆÛË ÓÂÊÚÈ΋˜ ·ÚÙËÚ›·˜ ÙË 3Ë ÌÙ¯ Ë̤ڷ.

• §‹ÙÚÈ· (Δ∫) Á˘Ó·›Î· 48, و̷ÙÈÎfi˜ ÓÂÊÚfi˜ Ì ÌÂÁ¿ÏË ·ÔÁ‡ÌÓˆÛË Ô˘ÚËÙ‹ÚÔ˜. ¢È·Ê˘Á‹ Ô‡ÚˆÓ ÏfiÁˆ Ó¤ÎÚˆÛ˘ Ô˘ÚËÙ‹ÚÔ˜, ·ÔÙ˘¯‹˜ ÚÔÛ¿ıÂÈ· ‡ÂÏÔ-Ô˘ÚËÙËÚÈ΋˜ ·Ó·ÛÙfïÛ˘ Ì ۇÛÙÔÈ¯Ô Ê˘ÛÈÎfi Ô˘ÚËÙ‹Ú·, ·ÎÔÏÔ‡ıËÛ ·Ê·›ÚÂÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜.

• §‹Ù˘ (Ã∞) ¿Ó‰Ú·˜ 58, و̷ÙÈÎfi˜ ÓÂÊÚfi˜ Ì ԢÚËÙ‹Ú· ÎÔÌ̤ÓÔ ÛÙ· 3-4 ÂÎ, Î·È Ï›·Ó ¢ÌÂÁ¤ıË Î‡ÛÙË ¿Óˆ fiÏÔ˘ ‰È·Ì¤ÙÚÔ˘ 6-7 ÂÎ. ªÂÙ·ÌfiÛ¯Â˘ÛË, Ô˘ÚËÙËÚÈ΋ ·ÔηٿÛÙ·ÛË Ì ÙÂÏÈÎÔÙÂÏÈ΋ ·Ó·ÛÙfïÛË ÌÂ Ê˘ÛÈÎfi Ô˘ÚËÙ‹Ú· Î·È “double j” stent. ¢È·Ê˘Á‹ Ô‡ÚˆÓ 3Ë ÌÙ¯ Ë̤ڷ, Ë Â·ÓÂÁ¯Â›ÚËÛË ¤‰ÂÈÍ ¿ıÈÎÙË Ô˘ÚËÙËÚÈ΋ ·Ó·ÛÙfïÛË Î·È ‰È·Ê˘Á‹ ·fi ÂÈÎÔÈÓˆÓ›· ˘¤ÏԢ·ÛÙˆ˜. ¶ÚÔÛ¿ıÂÈ· ÁÈ· ·ÔηٿÛÙ·ÛË ·ÓÂÈÙ˘¯‹˜, ÂÎ Ó¤Ô˘ ‰È·Ê˘Á‹ Ô‡ÚˆÓ ·ÚÔ¯ÂÙ¢Ô̤ÓË Ô˘ ‰ÂÓ ÛÙ·Ì¿ÙËÛ ÙÔ ÂfiÌÂÓÔ ‰›ÌËÓÔ. ŒÁÈÓ ÓÂÊÚÂÎÙÔÌ‹ Ì ··›ÙËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜.

• §‹Ù˘ (§∞) ¿Ó‰Ú·˜ 34, و̷ÙÈÎfi˜ ÓÂÊÚfi˜ Ì 2 ·ÓÈÛÔÌÂÁ¤ıÂȘ ÓÂÊÚÈΤ˜ ÊϤ‚˜. ∏ ÌÂÁ·Ï‡ÙÂÚË ÂÍ ·˘ÙÒÓ ÎÔÌ̤ÓË Î·Ù¿ ÙË Ï‹„Ë. ∞Ó·ÛÙÔÌÒıËΠÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ë ·Ú·Ì¤ÓÔ˘Û· ÌÈÎÚfiÙÂÚË Î·È ÌÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ·ıÚfi· ·ÈÌÔÚÚ·Á›· ·fi ÙËÓ ÎÔÌ̤ÓË ÓÂÊÚÈ΋ ÊϤ‚·. ΔÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·Ê·ÈÚ¤ıËÎÂ. £· ÌÔÚÔ‡Û· Ó· Û˘Ó¯›Ûˆ Î·È Ó· ·Ó·Ê¤Úˆ ¿Ú· ÔÏÏ¿ ·ÚfiÌÔÈ· ÂÚÈÛÙ·ÙÈο ÌÂÚÈο ‰Â ·fi ·˘Ù¿ ÂÍ·ÈÚÂÙÈο ·Ú¿‰ÔÍ· Î·È Û¿ÓÈ·. ŸÌˆ˜ ÙÒÚ· ı· Â·Ó¤ÏıÔ˘ÌÂ Î·È ı· ··ÓÙ‹ÛÔ˘Ì ÛÙÔ ‚·ÛÈÎfi ÂÚÒÙËÌ·. ¡∞π Ú¤ÂÈ Ó· ·ÔÚÚ›ÙÔ˘Ì ÓÂÊÚÈο ÌÔۯ‡̷ٷ ÁÈ· ÂÁ¯ÂÈÚËÙÈÎÔ‡˜ ÏfiÁÔ˘˜. ∞˜ Û˘ÓÔ„›ÛÔ˘Ì ÏÔÈfiÓ ÙÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ·fiÚÚȄ˘ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ: 1. ∞ÚÙËÚȷο Â˘Ú‹Ì·Ù· ∞. ‚·Ú›· ·ıËڈ̿وÛË μ. ˘ÂÚ¿ÚÈı̘ ·ÚÙËڛ˜ ¯ˆÚ›˜ ‹ Û ‚·Ú¤ˆ˜ ·-

¶ÚÈÓ Ó· Á›ÓÂÈ ÌÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ˘¿Ú¯Ô˘Ó ‰È·ı¤ÛÈÌ· ÌÈ· ÛÂÈÚ¿ ·fi ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó ÙÔÓ ‰fiÙË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ªÂ ‚¿ÛË ·˘Ù¿ Ù· ‰Â‰Ô̤ӷ, ıˆÚËÙÈο, ı· Ú¤ÂÈ Ó· ÂÈÏÂÁÔ‡Ó ÔÈ ˘Ô„‹ÊÈÔÈ Ï‹Ù˜ Î·È ÌÂٷ͇ ·˘ÙÒÓ ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· Ó· ÙÔÔıÂÙËı› Û ·˘ÙfiÓ Ô˘ ı· ¤¯ÂÈ ·ÚÓËÙÈÎfi Cross match Î·È ÙËÓ Î·Ï‡ÙÂÚË ı¤ÛË ÛÙË Ï›ÛÙ· ÂÈÏÔÁ‹˜. O ˘‡ı˘ÓÔ˜ ¯ÂÈÚÔ˘ÚÁfi˜ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Â›Ó·È Ô ÙÂÏÈÎfi˜ ˘‡ı˘ÓÔ˜ Ô˘ Ì ‚¿ÛÂÈ fiÏ· Ù· ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó ÙÔÓ ‰fiÙË, ·ÏÏ¿ Î·È ÙÔÓ Ï‹ÙË ı· Ú¤ÂÈ Ó· ·ÔÊ·Û›ÛÂÈ ·Ó ı· ÚÔ¯ˆÚ‹ÛÂÈ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹ fi¯È. ∂ÈÚfiÛıÂÙ· ÛËÌ·ÓÙÈο ÛÙÔȯ›· Ô˘ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ÛÔ‚·Ú¿ ˘fi„Ë Â›Ó·È Ù· Â˘Ú‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· Î·È ÚÔ·ÙÔ˘Ó ·fi ÙÔ Ê‡ÏÏÔ ·Ê·ÈÚ¤Ûˆ˜ ÌÔۯ‡̷ÙÔ˜ Ô˘ Û˘Óԉ‡ÂÈ Î¿ı ÌfiÛ¯Â˘Ì· ·ÏÏ¿ ΢ڛˆ˜ ·fi ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú·Û΢‹ ÙÔ˘ ÚÈÓ ÙË ÙÔÔı¤ÙËÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙÔÓ ˘Ô„‹ÊÈÔ Ï‹ÙË. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ÏÔÈfiÓ ·Ú·Û΢‹ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ ¤¯ÂÈ ÌfiÓÔ ÛÎÔfi Ó· ÂÙÔÈÌ¿ÛÂÈ ÙÔ ÓÂÊÚfi ÁÈ· ÙË ÙÔÔı¤ÙËÛË ·ÏÏ¿ Ó· ·Ó·Î·Ï‡„ÂÈ Î·È Ó· ·Ó·‰Â›ÍÂÈ Ù˘¯fiÓ ·Ó·ÙÔÌÈΤ˜ ·ıÔÏÔÁÈΤ˜ ·Ú·ÏÏ·Á¤˜ Ù˘ ·ÈÌ¿ÙˆÛ˘, Ù˘ ÊÏ‚È΋˜ ·Ô¯¤Ù¢Û˘ Î·È Ù˘ Ô˘ÚËÙËÚÈ΋˜ ·ÔÚÚÔ‹˜. ΔÔ ÂfiÌÂÓÔ ‚‹Ì· Â›Ó·È Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ÙˆÓ ‚Ï·‚ÒÓ ‹ ÙˆÓ ·ıÔÏÔÁÈÎÒÓ Î·Ù·ÛÙ¿ÛˆÓ. ŸÙ·Ó Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÙÂÏÂÈÒÛÂÈ ÙfiÙ Ú¤ÂÈ Ó· ÏËÊı› Ë ÙÂÏÈ΋ ·fiÊ·ÛË ·Ó ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· Â›Ó·È ÌÂÙ·ÌÔۯ‡ÛÈÌÔ ‹ fi¯È. ∞ÔÚÚ›ÙÔ˘Ì ÏÔÈfiÓ ÓÂÊÚÈο ÌÔۯ‡̷ٷ ÁÈ· ÂÁ¯ÂÈÚËÙÈÎÔ‡˜ Ù¯ÓÈÎÔ‡˜ ÏfiÁÔ˘˜? ¶ÚÈÓ ··ÓÙ‹ÛÔ˘Ì ·˘Ùfi ÙÔ ÂÚÒÙËÌ· ·˜ ·Ó·ÙÚ¤ÍÔ˘Ì Û ÌÈ· ÛÂÈÚ¿ ·fi ·ÏËıÈÓ¿ ÂÚÈÛÙ·ÙÈο Ô˘ ÌÂÙ·ÌÔۯ‡ıËÎ·Ó ÛÙË ÎÏÈÓÈ΋ Ô˘ ˘ËÚÂÙÒ ÂÚÈÛÛfiÙÂÚ· ·fi 20 ¯ÚfiÓÈ·.

• §‹Ù˘ (∫∞) ¿Ó‰Ú·˜ 55, و̷ÙÈÎfi˜ (¢∂) ÓÂÊÚfi˜ Ì ‚·Ú›· ·ıËڈ̿وÛË, ·Ê·ÈÚ¤ıËΠÙÔ ·ÔÚÙÈÎfi ÂÌ‚¿ÏˆÌ·, ÔÏϤ˜ ·ıËڈ̷ÙÒ‰ÂȘ Ï¿-

31

32

π. M¶√∫√™

ıËڈ̷ÙÈÎfi ÂÌ‚¿ÏˆÌ· °. ÎÔÌ̤Ó˜ ·ÚÙËڛ˜ ¯ˆÚ›˜ ÈηÓÔÔÈËÙÈÎfi Ì‹ÎÔ˜ 2. ºÏ‚Èο Â˘Ú‹Ì·Ù· ∞. ÎÔÌ̤ÓË – ηÙÂÛÙÚ·Ì̤ÓË ÓÂÊÚÈ΋ ÊϤ‚· ¯ˆÚ›˜ ÈηÓÔÔÈËÙÈÎfi Ì‹ÎÔ˜ ( ·ÊÔÚ¿ ۯ‰fiÓ Î·Ù¿ ·ÔÎÏÂÈÛÙÈÎfiÙËÙ· ÙÔ ‰ÂÍÈfi ÓÂÊÚfi) 3. O˘ÚËÙËÚÈο Â˘Ú‹Ì·Ù· ∞. ÎÔÌ̤ÓÔ˜ – ÂÍ·ÈÚÂÙÈο ‚Ú·¯‡˜ Ô˘ÚËÙ‹Ú·˜ μ. ·ÔÁ˘Ìӈ̤ÓÔ˜ Ô˘ÚËÙ‹Ú·˜ °. οΈÛË – ‰È·ÙÔÌ‹ ÓÂÊÚÈ΋˜ ˘¤ÏÔ˘ ¢. Ï›·Ó ¢ÌÂÁ¤ı˘ ÓÂÊÚÈ΋ ·ÛÙË Ì Èı·Ó‹ ÂÈÎÔÈÓˆÓ›· Ì ‡ÂÏÔ 4. ∂˘Ú‹Ì·Ù· ·fi ÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì· ∞. OÁÎfiÌÔÚʘ ÂÂÍÂÚÁ·Û›Â˜ μ. ηÎÒÛÂȘ – ÙÚ·˘Ì·ÙÈΤ˜ Ú‹ÍÂȘ ·ÚÂÁ¯‡Ì·ÙÔ˜ °. ·ÔÎÔÏÏ‹ÛÂȘ ÓÂÊÚÈ΋˜ ο„·˜ Ì ˘ÂÏÈ΋ Û˘ÌÌÂÙÔ¯‹ ¢. ÂÌ‚·ÏˆÌ·ÙÈ΋ ÂÌÊ¿ÓÈÛË ·ÚÂÁ¯‡Ì·ÙÔ˜ ·fiÙÔÎË Î·Î‹˜ ¤ÎÏ˘Û˘. ŸÏÔÈ ÔÈ ·Ú·¿Óˆ ÏfiÁÔÈ ·fi ÌfiÓÔÈ ÙÔ˘˜ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi ‰‡Ô ‹ ÂÚÈÛÛÔÙ¤ÚˆÓ Â›Ó·È ÏfiÁÔÈ ·ÔÚÚ›„ˆ˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÁÈ· ¯ÂÈÚÔ˘ÚÁÈÎÔ‡˜ Ù¯ÓÈÎÔ‡˜ ÏfiÁÔ˘˜. ¶ÔÏϤ˜ ÊÔÚ¤˜ Ë ÚÔÛ¿ıÂÈ· ÁÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË Â›Ó·È ·‰‡Ó·ÙË ‹ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÌÂÙÂÁ¯ÂÈÚËÙÈΤ˜ ÂÈÏÔΤ˜ Ô˘ ·˘Í¿ÓÔ˘Ó ÙËÓ ÓÔÛËÚfiÙËÙ· Î·È ÙË ıÓËÙfiÙËÙ· Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘.

™ËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÂËÚ¿˙ÂÈ ÙË Ï‹„Ë ÔÔÈ·Û‰‹ÔÙ ·fiÊ·Û˘ Â›Ó·È Ë ËÏÈΛ· ÙÔ˘ ‰fiÙÔ˘, Ë Ê˘ÛÈÔÏÔÁÈ΋ ηٿÛÙ·ÛË ‰ËÏ·‰‹ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. °È· ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi Ó¤Ô Û¯ÂÙÈο ‰fiÙË Ì Ôχ ηϋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ú¤ÂÈ Ó· Á›ÓÂÈ Î¿ı ‰˘Ó·Ù‹ ÚÔÛ¿ıÂÈ· Ó· ·ÔηٷÛÙ·ıÔ‡Ó ÔÈ fiÔȘ ‚Ï¿‚˜ Î·È Ó· Á›ÓÂÈ ÌÂÙ·ÌÔۯ‡ÛÈÌÔ, ÂÓÒ ÁÈ· οÔÈÔ ¿ÏÏÔ ÌfiÛ¯Â˘Ì· Ì ÚÔ‚ÏËÌ·ÙÈ΋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ˘¿Ú¯ÂÈ ÌÂÁ¿ÏÔ˜ ÛÎÂÙÈÎÈÛÌfi˜ ÁÈ· ÙÔ Î·Ù¿ fiÛÔ ·˘Ùfi ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı›. ŒÓ·˜ ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÔÚ› Ó· Û˘ÌÌÂÙ¿Û¯ÂÈ ÛÙË Ï‹„Ë ÔÔÈ·Û‰‹ÔÙ ·fiÊ·Û˘ Â›Ó·È Ë Î·Ù¿ÛÙ·ÛË ÙÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË. °È· ¤Ó· Ó¤Ô Ï‹ÙË Û·Ó ·Ú¿‰ÂÈÁÌ· ¯ˆÚ›˜ ÚÔ‚Ï‹Ì·Ù· ·ÁÁÂȷ΋˜ ÚÔÛ¤Ï·Û˘ Ë ÚÔÛ¿ıÂÈ· Ó· ÌÂÙ·ÌÔÛ¯Â˘ı› Ì ¤Ó· ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ˘ÂÚ‹ÏÈη ‰fiÙË Ì 3 ÓÂÊÚÈΤ˜ ÔÈ ‰‡Ô ·fi ÙȘ Ôԛ˜ Â›Ó·È ÎÔÌ̤Ó˜ Î·È 3-4 ÓÂÊÚÈΤ˜ ·ÛÙÂȘ Â›Ó·È ·‰fiÎÈÌË, ÂÓÒ ÁÈ· ÙÔ ›‰ÈÔ ÌfiÛ¯Â˘Ì· ¤Ó·˜ ¿ÏÏÔ˜ Ï‹Ù˘ Ì ¿ÏÏ· ¯·Ú·ÎÙËÚÈÛÙÈο ·ÎÔ‡ÁÂÙ·È ÈÔ Ù·ÈÚÈ·ÛÙfi˜. ∫Ï›ÓÔÓÙ·˜ ı· Ú¤ÂÈ Ó· ÙÔÓÈÛı› ˆ˜ ÁÈ· ÌÈ· ¯ÒÚ· Û·Ó ÙË ‰È΋ Ì·˜ Ì ÙfiÛÔ Ï›Á· ÌÔۯ‡̷ٷ Î·È ÙfiÛ˜ ÔÏϤ˜ ·Ó¿ÁΘ Ë ·fiÚÚÈ„Ë Î¿ı ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÂÙ·È Ì ÔÏÏ‹ ÚÔÛÔ¯‹. ¢ÂÓ ı· Ú¤ÂÈ fï˜ Ó· ͯӿÌ ÔÙ¤ ÙËÓ πÔÎÚ¿ÙÂÈÔ Ú‹ÛË « ·ÛΤÂÈÓ ÂÚ› Ù· ÓÔ˘Û‹Ì·Ù·, ‰‡Ô, ˆÊÂϤÂÈÓ ‹ ÌË ‚Ï¿ÙÂÈÓ».

¶ÚfiÛıÂÙ· ÔʤÏË ÙˆÓ mTOR ·Ó·ÛÙÔϤˆÓ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡: ÙÔ ·Ú¿‰ÂÈÁÌ· ÙÔ˘ Everolimus ∂. ¡ÙÔ˘ÓÔ‡ÛË

ÌÔÔÈËÙÈο ·ÙÙ·Ú· Ê·›ÓÂÙ·È, ·fi Ù· ̤¯ÚÈ ÙÒÚ· ÂÈÚ·Ì·ÙÈο Î·È ÎÏÈÓÈο ‰Â‰Ô̤ӷ, fiÙÈ Â›Ó·È Ì¿ÏÏÔÓ Â˘ÂÚÁÂÙÈο. Δ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ‰Ú¿Û˘ ÙˆÓ PSIs ÂÈÁÚ·ÌÌ·ÙÈο Û˘Ó›ÛÙ·ÓÙ·È ÛÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÔÛÔηٷÛÙÔÏ‹ Ì ۇÁ¯ÚÔÓË ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜4, ÛÙËÓ ·Ó¿Ù˘ÍË ·ÓÔÛÔÏÔÁÈ΋˜ ·ÓÔ¯‹˜5, ÛÙËÓ ·ÓÙÈηÚÎÈÓÈ΋6, ·ÓÙÈ˚΋7 Î·È ·ÓÙÈ-ÈÓˆÙÈ΋ ‰Ú¿ÛË8, ηıÒ˜ Î·È ÛÙËÓ Èı·Ó‹ Ì›ˆÛË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ (∫∞) ÎÈÓ‰‡ÓÔ˘ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜9. ∏ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ÙÔ˘ everolimus ¤¯ÂÈ ‰Âȯı› Û ÚÔÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ÂÈÚ·Ì·ÙÈÎÒÓ ÌÔÓÙ¤ÏˆÓ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘10. ∏ ·ÛÊ¿ÏÂÈ· Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙÔ˘ everolimus ·Ó·ÊÔÚÈο Ì ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ ·ÛıÂÓ‹ ¤¯ÂÈ ÙÂÎÌËÚȈı› ·fi Ì›· ÛÂÈÚ¿ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ11. ™Â ·˘Ù¤˜ Ê¿ÓËΠfiÙÈ ÙÔ everolimus ‰ÂÓ ˘ÛÙÂÚ› ¤Ó·ÓÙÈ ¿ÏÏˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙ· ηıÔÚÈṲ̂ӷ ηٷÏËÎÙÈο ÛËÌ›· Ô˘ ‹Ù·Ó Ë ÔÍ›· ·fiÚÚÈ„Ë ‚‚·ÈˆÌ¤ÓË Ì ‚ÈÔ„›·, Ë ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ô ı¿Ó·ÙÔ˜ ÙÔ˘ ·ÛıÂÓ‹. ∞ÓÙÈı¤Ùˆ˜, ·fi ÙȘ ÚÒÈ̘ ·˘Ù¤˜ ÌÂϤÙ˜ ¿Ú¯ÈÛ ӷ ‰È·Ê·›ÓÂÙ·È Ì›· ‰È·ÊÔÚÂÙÈ΋ ÚÔÔÙÈ΋ ÙÔ˘ everolimus ÛÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÈ·˜ Î·È Ë ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ Â¤ÙÚ„ ÙË ‰˘Ó·ÙfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ ·ÛÊ·ÏÒÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Ì ÌÂȈ̤ÓË ‰fiÛË ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ (calcineurin inhibitors, CNIs) Ô˘ ›¯Â ˆ˜ Û˘Ó¤ÂÈ· ÙË Ì›ˆÛË Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ Î·È ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜11. ™ÙȘ Ë̤Ú˜ Ì·˜, Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂÚ·›· ÂÈÙ˘Á¯¿ÓÂÈ ˘„ËÏ¿ ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ ·ÛıÂÓ‹ ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÌÂ Û˘Ó¤ÂÈ· Ë ÚÔÛ¿ıÂÈ· Ó· ¤¯ÂÈ ÂÈÎÂÓÙÚˆı› ÛÙË ‚ÂÏÙ›ˆÛË Ù˘ Ì·ÎÚÔÚfiıÂÛÌ˘ ÂÈ‚›ˆÛ˘ ÙÔ˘˜. OÈ Holdaas Î·È Û˘ÓÂÚÁ¿Ù˜, ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ·ÓÙÈηٿÛÙ·ÛË Ù˘

∏ Ú··Ì˘Î›ÓË ·Ó·Î·Ï‡ÊıËΠÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ ’70 ·fi ‰Â›ÁÌ· ¯ÒÌ·ÙÔ˜ ÛÙË Ó‹ÛÔ ÙÔ˘ ¶¿Û¯· (Rapa Nui). §fiÁˆ Ù˘ ·ÓÙÈ-ÔÏÏ·Ï·ÛÈ·ÛÙÈ΋˜ ȉÈfiÙËÙ·˜ Ô˘ Ê¿ÓËΠӷ ‰È·ı¤ÙÂÈ ÙÔ ÌfiÚÈÔ Ù˘ Ú··Ì˘Î›Ó˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·Ú¯Èο ˆ˜ ·ÓÙÈÌÈÎÚÔ‚È·Îfi˜ ·Ú¿ÁÔÓÙ·˜ ηıÒ˜ Î·È Û ÌÂÁ¿Ï˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ˆ˜ ΢ÙÙ·ÚÔÙÔÍÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ¤Ó·ÓÙÈ ‰È·ÊfiÚˆÓ Î·ÎÔËıÂÈÒÓ1. ∏ ·ÚÈ· ¯Ú‹ÛË Ù˘ Ú··Ì˘Î›Ó˘ fï˜ ÚԤ΢„ ÛÙËÓ ÔÚ›· Ì ÙË Û˘Ó¯‹, Û ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ¯ÔÚ‹ÁËÛ‹ Ù˘ ˆ˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ. ¢È¿ÊÔÚ· Ê·ÚÌ·ÎÔÏÔÁÈο ·Ó¿ÏÔÁ· ¤¯Ô˘Ó ÚÔ·„ÂÈ ¤ÎÙÔÙÂ, Ù· ÔÔ›· Â›Ó·È ÁÓˆÛÙ¿ ˆ˜ ·Ó·ÛÙÔÏ›˜ Û‹Ì·ÙÔ˜ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ (proliferation signal inhibitors, PSIs) ‹ ·Ó·ÛÙÔÏ›˜ Ù˘ ÚˆÙ½Ó˘ mTOR (mammalian target of rapamycin inhibitors, mTORi). ªÂٷ͇ ·˘ÙÒÓ ÙˆÓ ·Ó·ÏfiÁˆÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È ÙÔ Everolimus (Certican*, Novartis Pharma AG, Basel, Switzerland) Ô˘ ÚԤ΢„ ·fi ÙËÓ ÚÔÛı‹ÎË Ì›·˜ 2-˘‰ÚÔ͢·Èı˘ÏÈ΋˜ ÔÌ¿‰·˜ ÛÙË ı¤ÛË C-40 ÙÔ˘ ÌÔÚ›Ô˘ Ù˘ Ú··Ì˘Î›Ó˘2. ™Â ÌÔÚÈ·Îfi Â›Â‰Ô ÙÔ everolimus Û˘Ó‰¤ÂÙ·È ÛÙËÓ Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ ÚˆÙ½ÓË FKB12, ÙÔ Û‡ÌÏÔÎÔ Ê¿ÚÌ·ÎÔ/ FKB12 ·ÏÏËÏÂȉڿ Ì ÙËÓ mTOR ÚˆÙ½ÓË, ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ÎÈÓ¿Û˘ p70 S6 Ì ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·Ó·ÛÙÔÏ‹ ÂÈÛfi‰Ô˘ ÙˆÓ Δ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·fi ÙË Ê¿ÛË G1 ÛÙË Ê¿ÛË S ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ·ÎÏÔ˘3. ∏ ·ÚÂÌ‚ÔÏ‹ ÙˆÓ PSIs ÛÙËÓ ÚÒÈÌË Ê¿ÛË ·ÓÙÈÁÚ·Ê‹˜ ÙÔ˘ DNA ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·ÓÙÈÔÏÏ·Ï·ÛÈ·ÛÙÈ΋ ÙÔ˘˜ ‰Ú¿ÛË. ∏ ·ÓÙÈ-ÔÏÏ·Ï·ÛÈ·ÛÙÈ΋ ‰Ú¿ÛË ÙˆÓ PSIs ·ÊÔÚ¿ ÙfiÛÔ Û ·ÙÙ·Ú· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, ÛÙ· Δ-ÏÂÌÊÔ·ÙÙ·Ú·, fiÛÔ Î·È Û ¿ÏϘ ηÙËÁÔڛ˜ ΢ÙÙ¿ÚˆÓ fiˆ˜ ÛÙ· Ï›· Ì˘˚ο ·ÙÙ·Ú·, ÛÙ· ÂÓ‰ÔıËÏȷο ·ÁÁÂȷο ·ÙÙ·Ú·, ÛÙÔ˘˜ ÈÓÔ‚Ï¿ÛÙ˜ Î·È ÛÙ· ηÚÎÈÓÈο ·ÙÙ·Ú·. Δ· ÏÂÈfiÙÚÔ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù‹˜ Ù˘ ‰Ú¿Û˘ ÛÙ· ÌË ·È-

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∂. ¡Δ√À¡√À™∏

΢ÎÏÔÛÔÚ›Ó˘ ·fi everolimus Û ·ÛıÂÓ›˜, Ô˘ ‰ÂÓ Â›¯·Ó ÚÔËÁÔ‡ÌÂÓÔ ÂÂÈÛfi‰ÈÔ ·fiÚÚȄ˘, ÂÍ·ÛÊ·Ï›˙ÂÈ Ì·ÎÚÔÚfiıÂÛÌ· ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜12. ∞ÎfiÌ· ÈÔ ÚfiÛÊ·Ù·, Ë ÌÂϤÙË ZEUS, ÙˆÓ Budde Î·È Û˘ÓÂÚÁ·ÙÒÓ, ¤‰ÂÈÍ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ‚·ÛÈṲ̂ÓÔ ÛÙÔ everolimus ÂÈÙÚ¤ÂÈ ÙËÓ ÚÒÈÌË ‰È·ÎÔ‹ ÙˆÓ CNIs, ‚ÂÏÙÈÒÓÂÈ ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¯ÚfiÓÔ˘, ÂÓÒ Ù·˘Ùfi¯ÚÔÓ· ÚÔÛʤÚÂÈ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Î·È ·ÛÊ¿ÏÂÈ·. Δ· Ó¤· ·˘Ù¿ ‰Â‰Ô̤ӷ ˘Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ÛÙÚ·ÙËÁÈ΋ ¯ÔÚ‹ÁËÛ˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ıÂÚ·›·˜ ÂχıÂÚ˘ ·fi CNIs ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË Ù˘ ‚ÂÏÙȈ̤Ó˘ Ì·ÎÚÔÚfiıÂÛÌ˘ ÂÈ‚›ˆÛ˘ Û ÂÈÏÂÁ̤Ó˜ ÔÌ¿‰Â˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ13. ŒÓ·˜ ·fi ÙÔ˘˜ ΢ڛ·Ú¯Ô˘˜ ÏfiÁÔ˘˜ Ô˘ ÙÔ everolimus ÂÈÙ˘Á¯¿ÓÂÈ ÌÂÛÔÚfiıÂÛÌ· ηχÙÂÚË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂÌϤÎÂÙ·È ÛÙË ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (áª), ¤Ó· ·fi Ù· ·ÚÈ· ·›ÙÈ· Ù˘ ÔÔ›·˜ Â›Ó·È Ë ÓÂÊÚÔÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ CNIs14. O Ì˯·ÓÈÛÌfi˜ ‰Ú¿Û˘ ÙÔ˘ everolimus ̤ۈ Ù˘ ·Ó·ÛÙÔÏ‹˜ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙˆÓ Ï›ˆÓ Ì˘˚ÎÒÓ ÈÓÒÓ Î·È Ù˘ ÚfiÏ˄˘ Ù˘ ·ÁÁÂȷ΋˜ ·Ó·‰È·ÌfiÚʈÛ˘ Ê·›ÓÂÙ·È Ó· ¢ı‡ÓÂÙ·È ˆ˜ ¤Ó· ‚·ıÌfi ÁÈ· ÙÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi4,15. ∂›Û˘, ¤Ó·˜ ¿ÏÏÔ˜ Ì˯·ÓÈÛÌfi˜ Ô ÔÔ›Ô˜ Èı·ÓfiÓ Ó· ‰È·‰Ú·Ì·Ù›˙ÂÈ Î¿ÔÈÔ ÚfiÏÔ Â›Ó·È Ë Ì›ˆÛË Ù˘ ›ÓˆÛ˘ ÛÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·16. ¶ÚfiÛÊ·Ù·, ¤¯ÂÈ Ê·Ó› ·fi ÂÈÚ·Ì·ÙÈο ‰Â‰Ô̤ӷ, fiÙÈ Ô TGF-‚ ¢ԉÒÓÂÈ ÙË ‰È¿ÌÂÛË ›ÓˆÛË Ì¤Ûˆ ÙÔ˘ ÛËÌ·ÙÔ‰ÔÙÈÎÔ‡ ÌÔÓÔ·ÙÈÔ‡ ÙÔ˘ AKT/mTORC1. O ·ÔÎÏÂÈÛÌfi˜ ÙÔ˘ mTORC1 ˘Ô‰Ô¯¤· Ê¿ÓËΠfiÙÈ ÌÂÈÒÓÂÈ ÙËÓ ›ÓˆÛË Û ÂÈÚ·Ì·ÙÈÎfi ÌÔÓÙ¤ÏÔ ·ÔÊÚ·ÎÙÈ΋˜ ÓÂÊÚÔ¿ıÂÈ·˜. Δ· ÎÏÈÓÈο ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ·ÓÙÈ-ÈÓˆÙÈ΋ ‰Ú¿ÛË Ù˘ Ú··Ì˘Î›Ó˘ ÛÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Â› ÙÔ˘ ·ÚfiÓÙÔ˜ ·ÓÙÈÎÚÔ˘fiÌÂÓ·. ∏ ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· ÙÔ˘ Pontrelli Î·È Û˘Ó. ‰È·›ÛÙˆÛ·Ó ˘ÔÛÙÚÔÊ‹ Ù˘ ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ Û ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ‰È·ÁÓˆÛı› Ì áª, ÂÓÒ Ë ÔÌ¿‰· ÙˆÓ Servais Î·È Û˘Ó. ‰ÂÓ ‚Ú‹Î·Ó ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ›ÓˆÛ˘ ¤Ó· ¯ÚfiÓÔ ÌÂÙ¿ ÙËÓ ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ CNIs Ì ڷ·Ì˘Î›ÓË16. ¢Â‰Ô̤ӷ ·fi ÌÂÁ¿Ï˜ ÛÂÈÚ¤˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ Ì ̷ÎÚÔÚfiıÂÛÌË ·Ú·ÎÔÏÔ‡ıËÛË ‰Â›¯ÓÔ˘Ó fiÙÈ Ô ı¿Ó·ÙÔ˜ ÙÔ˘ ·ÛıÂÓ‹ ·ÔÙÂÏ› ·›ÙÈÔ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ÔÛÔÛÙfi ¤ˆ˜ Î·È 40%. ¶ÚfiÛÊ·Ù· ÛÙÔȯ›· ·fi ÙÔ United Sta-

tes Renal Data System (USRDS) Ô˘ ·ÊÔÚÔ‡Ó ÛÙË ıÓËÙfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ì ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·, ÂÌÊ·Ó›˙Ô˘Ó ÙËÓ Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ (∫∞¡) ˆ˜ ÙËÓ Î‡ÚÈ· ·ÈÙ›· Ì ÔÛÔÛÙfi 30%, ÂÓÒ ·ÎÔÏÔ˘ıÔ‡Ó ÔÈ ÏÔÈÌÒÍÂȘ (18%) Î·È ÔÈ ÓÂÔϷۛ˜ (8.4%)17. ΔÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ∫∞¡ (ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜, ·ÁÁÂȷ΋ ÂÁÎÂÊ·ÏÈ΋ ÓfiÛÔ˜, ÂÚÈÊÂÚÈ΋ ·ÁÁÂȷ΋ ÓfiÛÔ˜, ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· Î·È ˘ÂÚÙÚÔÊ›· ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜) ·ÔÙÂÏ› ÙËÓ Î‡ÚÈ· ·ÈÙ›· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÛÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔÚ› Ó· ·Ô‰Ôı› ÂÓ Ì¤ÚÂÈ ÛÙÔ˘˜ ÎÏ·ÛÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘, ÛÙËÓ ÚÔ¸¿Ú¯Ô˘Û· ÓÂÊÚÈ΋ ÓfiÛÔ Î·È Û˘Ó˘¿Ú¯Ô˘Û· ÓÔÛËÚfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ, ÛÙË ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÛÙËÓ ›‰È· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™ÙÔȯ›· ·fi ÙÔ USRDS ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ fiϘ ÔÈ Î·ÙËÁÔڛ˜ ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ·ÔÙÂÏÔ‡Ó ·Ú¿ÁÔÓÙ· ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Î·È ‰ÚÔ˘Ó ·ıÚÔÈÛÙÈο Ì ÙÔ˘˜ ÎÏ·ÛÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ·˘Í¿ÓÔÓÙ·˜ ÙÔÓ Î›Ó‰˘ÓÔ17.

OÈ ·Ó·ÛÙÔÏ›˜ mTOR Î·È ÙÔ everolimus ¤¯Ô˘Ó ‰Â›ÍÂÈ ·fi ÂÈÚ·Ì·ÙÈΤ˜ Î·È ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ fiÙÈ ¤¯Ô˘Ó ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙÔÓ ¤ÏÂÁ¯Ô ·ÚÎÂÙÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ∫∞¡ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ÙÔ everolimus, fiˆ˜ ‹‰Ë Ϥ¯ıËÎÂ, ‚ÂÏÙÈÒÓÂÈ ÙÔ GFR Î·È ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ηٿ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÂ Û˘Ó¤ÂÈ· Èı·Ófi ÂÚÈÔÚÈÛÌfi ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ·ÊÔ‡ Ë ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ Û¯ÂÙ›˙ÂÙ·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο Ì ÙÔ Û¯ÂÙÈÎfi ΛӉ˘ÓÔ ÁÈ· ı¿Ó·ÙÔ ·fi ∫∞¡18. ∂ÈϤÔÓ, fiÛÔ ¯ÂÈÚfiÙÂÚË Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚË Ë Â›ÙˆÛË Î·È Ë ‚·Ú‡ÙËÙ· ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Ô˘ Û˘Ó‰¤ÔÓÙ·È Ì ÙË ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ, fiˆ˜ Ë ˘¤ÚÙ·ÛË, Ë ·Ó·ÈÌ›·, Ë ÊÏÂÁÌÔÓ‹ Î·È Ë ‰È·Ù·Ú·¯‹ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, Û¯ÂÙÈο Ì ÙË Ú‡ıÌÈÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (∞¶), ÔÈ CNIs ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› fiÙÈ ÚÔηÏÔ‡Ó ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, ÂÓÒ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· Ô˘ Ó· ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ ÔÈ mTORs ·Ó·ÛÙÔÏ›˜ ¤¯Ô˘Ó οÔÈ· ‰˘ÛÌÂÓ‹ Â›‰Ú·ÛË ÛÙË Ú‡ıÌÈÛË Ù˘ ∞¶19. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ PSIs ÂÈ‚·Ú‡ÓÔ˘Ó ÙÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ ·ÛıÂÓÒÓ20, ·fi ÂÈÚ·Ì·ÙÈÎfi ÌÔÓÙ¤ÏÔ ÔÓÙÈÎÒÓ ¤¯ÂÈ Ê·Ó› fiÙÈ ÙÔ everolimus ·Ú¿ ÙËÓ Û˘Ó˘¿Ú¯Ô˘Û· ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· Ì›ˆÛ ‰ÔÛÔÂÍ·ÚÙÒÌÂÓ· ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ·ıËÚÔ-

METAMO™XEY™Eπ™ 2011

ÛÎÏËÚˆÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ Û ÎÂÓÙÚÈΤ˜ ·ÚÙËڛ˜21. ª›· ‰˘ÓËÙÈο ˆÊ¤ÏÈÌË Â›‰Ú·ÛË ÙÔ˘ everolimus ÚÔ˜ ÙËÓ Î·Ù‡ı˘ÓÛË Ù˘ Ì›ˆÛ˘ Ù˘ ηډȷÁÁÂȷ΋˜ ÓÔÛËÚfiÙËÙ·˜ ÛÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Ë Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ÔÌÔ΢ÛÙÂ˚Ó˘ Ô˘ ·ÔÙÂÏ› ·ԉ‰ÂÈÁ̤ӷ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ∫∞¡22. ΔÔ everolimus Û ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ CNIs ÂÓÔ¯ÔÔÈÂ›Ù·È ÁÈ· ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi Â›ÙˆÛ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ÂÌÊ¿ÓÈÛË ÙÔ˘ ÔÔ›Ô˘ Û˘Ó‰¤ÂÙ·È Ì ÙÚÈÏ·ÛÈ·ÛÌfi ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ∫∞¡23. H ˘ÂÚÙÚÔÊ›· Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ Ù˘ ηډȿ˜ (À∞∫) Î·È Ë ·ÚÙËÚȷ΋ ÛÎÏËÚ›· ·ÔÙÂÏÔ‡Ó ·ÓÂÍ¿ÚÙËÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È ¤¯ÂÈ Ê·Ó› fiÙÈ ÔÈ PSIs ¤¯Ô˘Ó ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙÔÓ ¤ÏÂÁ¯Ô ·˘ÙÒÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ, Ì ÚÔÔÙÈ΋ Ì›ˆÛË Û ‰È¿ÛÙËÌ· ÂÓfi˜ ¤ÙÔ˘˜ ÙÔ˘ ‰Â›ÎÙË Ì¿˙·˜ Ù˘ ∞∫ Î·È ‰È·Ù‹ÚËÛË Ù˘ ˘¿Ú¯Ô˘Û·˜ ¢ÂÓ‰ÔÙfiÙËÙ·˜ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ ¯ˆÚ›˜ ÂÚ·ÈÙ¤Úˆ Âȉ›ӈÛË Û ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ CNIs24,25. Δ· ÓÂÔÏ¿ÛÌ·Ù· ·ÔÙÂÏÔ‡Ó Û˘¯Ó‹ ÂÈÏÔ΋ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∏ Â›ÙˆÛË ÙˆÓ ÓÂÔÏ·ÛÈÒÓ Â›Ó·È ·˘ÍË̤ÓË Î·Ù¿ 3-5 ÊÔÚ¤˜ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi Î·È ‚·›ÓÂÈ ·˘Í·ÓfiÌÂÓË Ì ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘. Ÿˆ˜ ÚԷӷʤÚıËÎÂ, ÔÈ ÓÂÔϷۛ˜ ·ÔÙÂÏÔ‡Ó ÙËÓ ÙÚ›ÙË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È Û‡Ìʈӷ Ì ÛÙÔȯ›· ·fi ÌÂϤÙË ÎÔÔÚÙ‹˜ ÙˆÓ Webster Î·È Û˘ÓÂÚÁ·ÙÒÓ, Ô Î·ÚΛÓÔ˜ ‹Ù·Ó ˘‡ı˘ÓÔ˜ ÁÈ· ÙÔ 25% ÙˆÓ ı·Ó¿ÙˆÓ ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ·fi 10ÂÙ‹ ·Ú·ÎÔÏÔ‡ıËÛË17,26. Δ· ·›ÙÈ· Ù˘ ·˘ÍË̤Ó˘ ÂÌÊ¿ÓÈÛ˘ ηÚΛÓÔ˘ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ ÌÔÚÔ‡Ó Ó· ·Ô‰ÔıÔ‡Ó ÌÂٷ͇ ÙˆÓ ¿ÏÏˆÓ ·ÈÙÈÒÓ ÛÙËÓ Î·Ù·ÛÙÔÏ‹ Ì˯·ÓÈÛÌÒÓ Â·ÁÚ‡ÓËÛ˘ ·fi Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η Î·È ÛÙËÓ ¿ÌÂÛË ÔÁÎÔÁfiÓÔ ‰Ú¿ÛË ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, Ë Èı·Ó‹ ηÚÎÈÓÔÁfiÓÔ˜ ‰Ú¿ÛË ÙÔ˘ οı ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÂÎÙÈÌËı› ͯˆÚÈÛÙ¿ ÌÈ·˜ Î·È ÔÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔÈ ·ÛıÂÓ›˜ Ï·Ì‚¿ÓÔ˘Ó Û˘Ó‰˘·ÛÌÔ‡˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ.

OÈ mTOR ·Ó·ÛÙÔÏ›˜, ·ÓÙ›ıÂÙ· Ì ÙÔ˘˜ CNIs, Ê·›ÓÂÙ·È ·fi ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ó· ‰È·ı¤ÙÔ˘Ó ·ÓÙÈÓÂÔÏ·ÛÌ·ÙÈΤ˜ ȉÈfiÙËÙ˜ Î·È ÔÈ ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó sirolimus ‹ everolimus ÂÌÊ·Ó›˙Ô˘Ó ¯·ÌËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÓÂÔÏ·ÛÈÒÓ Û˘ÁÎÚÈÙÈο Ì ·˘ÙÔ‡˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó

35

CNIs27,28. ∂ÈϤÔÓ, Ë ·ÏÏ·Á‹ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ Û sirolimus ‹ everolimus Î·È Ë ‰È·ÎÔ‹ ÙˆÓ CNIs Ô‰‹ÁËÛ Û ˘ÔÛÙÚÔÊ‹ ÙfiÛÔ ÙÔ˘ ‰ÂÚÌ·ÙÈÎÔ‡, fiÛÔ Î·È ÙÔ˘ ÛÏ·¯ÓÈÎÔ‡ Ù‡Ô˘ ÙÔ˘ Û·ÚÎÒÌ·ÙÔ˜ Kaposi29. ∏ ·ÓÙÈηÚÎÈÓÈ΋ ‰Ú¿ÛË ÙˆÓ PSIs ÔÊ›ÏÂÙ·È ÛÙÔ fiÙÈ Ô ¤ÏÂÁ¯Ô˜ Ù˘ mTOR ÚˆÙ½Ó˘ Âȉڿ ÛÙËÓ ·ÁÁÂÈÔÁ¤ÓÂÛË, ÛÙËÓ Î˘ÙÙ·ÚÈ΋ ·‡ÍËÛË, ÛÙËÓ ÚfiÛÏË„Ë Î·È ¯Ú‹ÛË ÙˆÓ ıÚÂÙÈÎÒÓ Ô˘ÛÈÒÓ Î·È ÛÙÔÓ ÌÂÙ·‚ÔÏÈÛÌfi ÙÔ˘ ΢ÙÙ¿ÚÔ˘30. ∞˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ fiˆ˜ Ô IGF (insulin growth factor), o EGF (epidermal growth factor), o PDGF (platelet-derived growth factor) Î·È Ô VEGF (vascular endothelial growth factor) Û˘Ó‰¤ÔÓÙ·È Î·È ÂÓÂÚÁÔÔÈÔ‡Ó ˘ԉԯ›˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ·˘ÙÔ› Ì ÙË ÛÂÈÚ¿ ÙÔ˘˜ ÂÓÂÚÁÔÔÈÔ‡Ó ÙȘ ÂÓ‰Ô΢ÙÙ¿ÚȘ ÛËÌ·ÙÔ‰ÔÙÈΤ˜ ·ÏÏËÏÔ˘¯›Â˜ Ù˘ ʈÛÊ·Ùȉ˘ÏÈÓÔÛÈÙfiÏ˘ 3 ÎÈÓ¿Û˘-ÛÂÚ›Ó˘-ıÚÂÔÓ›Ó˘-mTOR (PI3K-AKT-mTOR) Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚˆÙÂ˚ÓÈ΋ Û‡ÓıÂÛË. ¢È·Ù·Ú·¯¤˜ ÛÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘˜ Û˘Ó‰Â̤ÓÔ˘˜ Ì ÙËÓ mTOR ÚˆÙ½ÓË ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ηÚΛÓÔ˘ ‹ ¤¯Ô˘Ó ·Ó¢ÚÂı› Û ·ÚÎÂÙ¤˜ ÌÔÚʤ˜ ηÚΛÓÔ˘ ÛÙÔÓ ¿ÓıÚˆÔ30. ∏ ÛÙÔ¯Â˘Ì¤ÓË ıÂÚ·›· ·˘ÙÒÓ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ê·›ÓÂÙ·È fiÙÈ ·ÔÙÂÏ› ÂÈÙ˘¯Ë̤ÓË ·ÓÙÈηÚÎÈÓÈ΋ ÛÙÚ·ÙËÁÈ΋ fiˆ˜ ÛÙÔÓ Î·ÚΛÓÔ ÙÔ˘ ÓÂÊÚÔ‡ ÁÈ· ÙË ıÂÚ·›· ÙÔ˘ ÔÔ›Ô˘ ÙÔ everolimus ¤¯ÂÈ Ï¿‚ÂÈ Â›ÛËÌË ¤Ó‰ÂÈÍË (Affinitor*, Novartis Pharma AG, Basel, Switzerland)31.

OÈ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ Â›Ó·È Û˘¯Ó¤˜ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È ¤¯Ô˘Ó ηٷÛÙÚÔÊÈΤ˜ Û˘Ó¤ÂȘ ÙfiÛÔ ÛÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ·ÛıÂÓ‹, fiÛÔ Î·È ÛÙËÓ ¤Î‚·ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∂ÈϤÔÓ, οÔÈÔÈ ÂÚËÙÔ˚Ô› Ô˘ ÚÔÛ‚¿ÏÔ˘Ó ÙÔ˘˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÓÂÔÏ·ÛÈÒÓ. ΔÚÂȘ ÂÚËÙÔ˚Ô›, ÔÓÔÌ·ÛÙÈο, Ô Î˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜ (CMV ‹ HHV 5), Ô Epstein–Barr virus (EBV ‹ HHV 4) Î·È Ô ÂÚËÙÔ˚fi˜ 8 (HHV 8) Èı·ÓfiÓ Ó· ¤¯Ô˘Ó ÔÁÎÔÁÔÓÈ΋ ‰Ú¿ÛË32. ™˘ÁÎÂÎÚÈ̤ӷ, Ô Èfi˜ EBV ÂÌϤÎÂÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ÔÈ ÊÔÚ›˜ ÙÔ˘ HHV 8 Ô˘ ·Ó‹ÎÔ˘Ó ÛÂ Û˘ÁÎÂÎÚÈ̤Ó˜ ÂıÓfiÙËÙ˜ ÂÌÊ·Ó›˙Ô˘Ó Û ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· Û¿ÚΈ̷ Kaposi ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÂÓÒ Ë ÔÁÎÔÁÔÓÈ΋ ‰Ú¿ÛË ÙÔ˘ CMV Â›Ó·È ·ÌÊÈÏÂÁfiÌÂÓË. ∏ Â›ÙˆÛË Î·È Ë ‚·Ú‡ÙËÙ· ÙˆÓ ÈÔÁÂÓÒÓ ÏÔÈÌÒÍÂˆÓ Ê·›ÓÂÙ·È fiÙÈ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ Ù‡Ô Î·È ÙË ‰fiÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜. OÈ PSIs Ê·›ÓÂÙ·È ·fi Ù· ˘¿Ú¯ÔÓÙ· ÛÙÔȯ›· fiÙÈ ÌÔÚ› Ó· ÌÂÈÒÛÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÈÔÁÂÓÔ‡˜ Ïԛ̈͢ ̤ۈ ·Ó·ÛÙÔÏ‹˜ ÙÔ˘

36

∂. ¡Δ√À¡√À™∏

·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ‡ ÌÔÓÔ·ÙÈÔ‡ ÙˆÓ ÎÈÓ·ÛÒÓ (PI3K), ÙÔ ÔÔ›Ô ÂϤÁ¯ÂÈ ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi Î·È ÙËÓ ·ÓÙÈÁÚ·Ê‹ ÙˆÓ ÔÁÎÔÁfiÓˆÓ ÂÚËÙÔ˚ÒÓ32. ∞Ó·ÊÔÚÈο Ì ÙË Ïԛ̈ÍË ·fi CMV, ·˘Ù‹ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙË ¯ÔÚ‹ÁËÛË ATG Î·È OKT3 ˆ˜ ıÂÚ·›· ¤ÓÙ·Í˘, ηıÒ˜ Î·È Û ÌÂÚÈΤ˜ ÌÂϤÙ˜ Ì ÙË ¯ÔÚ‹ÁËÛË MMF ˆ˜ ıÂÚ·›· Û˘ÓÙ‹ÚËÛ˘33. ™Â Ì›· ÌÂÙ·-·Ó¿Ï˘ÛË ÙˆÓ Webster Î·È Û˘ÓÂÚÁ·ÙÒÓ, ‰È·ÈÛÙÒıËΠfiÙÈ fiÙ·Ó ÔÈ ·ÓÙÈÌÂÙ·‚Ôϛ٘ ·ÓÙÈηٷÛÙ¿ıËÎ·Ó ·fi ÙÔ˘˜ ·Ó·ÛÙÔÏ›˜ mTOR, ÌÂÈÒıËÎÂ Ô Î›Ó‰˘ÓÔ˜ ÁÈ· CMV Ïԛ̈ÍË Î·Ù¿ 51% 34. ªÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô Èfi˜ EBV ÂÌϤÎÂÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· ÙˆÓ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ. Œ¯ÂÈ Ê·Ó› ·fi ÌÂϤÙ˜ Ì ̷ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË, fiÙÈ ÔÈ ·ÛıÂÓ›˜ ÛÙË 10ÂÙ›· ÂÌÊ·Ó›˙Ô˘Ó 12 ÊÔÚ¤˜ ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ Ó· ÚÔÛ‚ÏËıÔ‡Ó ·fi ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈ΋ ‰È·Ù·Ú·¯‹ Û˘ÁÎÚÈÙÈο Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi35. In vitro ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ÔÈ PSIs Èı·ÓfiÓ Ó· η٤¯Ô˘Ó ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË ÂÓ·ÓÙ›ÔÓ ÙˆÓ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Ì¤Ûˆ ηٷÛÙÔÏ‹˜ Ù˘ ·‡ÍËÛ˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙˆÓ ÚÔÂÚ¯fiÌÂÓˆÓ ·fi ·˘Ù¤˜ ÙȘ ‰È·Ù·Ú·¯¤˜ Î·È Ì¤Ûˆ ·Ó·ÛÙÔÏ‹˜ ÙÔ˘ ÛËÌ·ÙÔ‰ÔÙÈÎÔ‡ ÌÔÓÔ·Ù›Ô˘ Ù˘ IL-1032. O Èfi˜ HHV 8 Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË Û·ÚÎÒÌ·ÙÔ˜ Kaposi. ∞ÍÈfiÈÛÙ· ‰Â‰Ô̤ӷ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ‡·ÚÍË ÂÓfi˜ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÁÔÓȉ›Ô˘, ÙÔ˘ vGPCR, ˆ˜ ··Ú·›ÙËÙÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ Û·ÚÎÒÌ·ÙÔ˜ Î·È Ê·›ÓÂÙ·È fiÙÈ ÙÔ ÛËÌ·ÙÔ‰ÔÙÈÎfi ÌÔÓÔ¿ÙÈ Ù˘ mTOR ÚˆÙ½Ó˘ ‰È·‰Ú·Ì·Ù›˙ÂÈ Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙË Û·ÚΈ̷ÙÔÁ¤ÓÂÛË ÙËÓ ÂÏÂÁ¯fiÌÂÓË ·fi ÙÔ ÚÔ·Ó·ÊÂÚı¤Ó ÁÔÓ›‰ÈÔ32. ∞fi ÎÏÈÓÈο ‰Â‰Ô̤ӷ ¤¯ÂÈ Ê·Ó› fiÙÈ Ë ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ CNIs ·fi sirolimus ‹ Everolimus Ô‰ËÁ› Û ‡ÊÂÛË ‹ Î·È ıÂÚ·›· ÙÔ˘ ‰ÂÚÌ·ÙÈ΋˜ Î·È ·ÎfiÌ· Î·È Ù˘ ÛÏ·¯ÓÈ΋˜ ÌÔÚÊ‹˜ ÙÔ˘ Û·ÚÎÒÌ·ÙÔ˜36. ŒÓ· ¿ÏÏÔ ÛËÌÂ›Ô ÎÏÂȉ› ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ ·ÔÙÂÏ› Ë ·Ó¿Ù˘ÍË ·ÓÔÛÔÏÔÁÈ΋˜ ·ÓÔ¯‹˜. Δ· Ú˘ıÌÈÛÙÈο Δ-ÏÂÌÊÔ·ÙÙ·Ú· Ê·›ÓÂÙ·È fiÙÈ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÚÔ˜ ·˘Ù‹ ÙËÓ Î·Ù‡ı˘ÓÛË Î·È ˘¿Ú¯Ô˘Ó ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ Û‡Ìʈӷ Ì ٷ ÔÔ›· Ë ·ÓÔÛÔηÛÙ·ÏÙÈ΋ ıÂÚ·›· Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ·Ó·ÛÙÔÏ›˜ mTOR ÌÔÚ› Ó· ÚÔ¿ÁÂÈ ÙË ÌÂÛÔÏ·‚Ô‡ÌÂÓË ·fi Ù· Ú˘ıÌÈÛÙÈο Δ-ÏÂÌÊÔ·ÙÙ·Ú· ·ÓÔÛÔÏÔÁÈ΋ ·ÓÔ¯‹37. ™˘ÓÔ„›˙ÔÓÙ·˜, Ù· fiÛ· ·Ó·Ê¤ÚıËÎ·Ó ÁÈ· ÙÔ˘˜ ·Ó·ÛÙÔÏ›˜ mTOR Î·È ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ ÁÈ· ÙÔ Everolimus, Ê·›ÓÂÙ·È fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· Ê¿Ú̷η Ì ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋, ·ÓÙÈ-ÔÏÏ·Ï·ÛÈ·ÛÙÈ΋

Î·È ·ÓÙÈηÚÎÈÓÈ΋ ‰Ú¿ÛË, Ë ÔÔ›· ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ Ù˘ Â›‰Ú·Û˘ Ù˘ Ú··Ì˘Î›Ó˘ Û ÏËıÒÚ· ΢ÙÙ¿ÚˆÓ Î·È Î˘ÙÙ·ÚÈÎÒÓ Ì˯·ÓÈÛÌÒÓ. ∏ ÔÏ˘ÏÔÎfiÙËÙ· Ù˘ ‰Ú¿Û˘ Ù˘ Ú··Ì˘Î›Ó˘ ·Ô‰ÂÈÎÓ‡ÂÙ·È ·fi ÙËÓ ÈηÓfiÙËÙ· ÙˆÓ ·Ú·ÁÒÁˆÓ Ù˘ Ó· ÂÌÊ·Ó›˙Ô˘Ó Û˘Á¯ÚÔÓÈṲ̂ÓË ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ Î·È ·ÓÙÈηÚÎÈÓÈ΋ ‰Ú¿ÛË ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ ÌÂ Û˘Ó˘¿Ú¯Ô˘Û· ÓÂÔÏ·Û›·. ∂›Û˘, ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· ¤Ó·ÓÙÈ ÙˆÓ ¿ÏÏˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ Ù˘ Èı·Ó‹˜ ¢ÂÚÁÂÙÈ΋˜ Â›‰Ú·Û˘ ÙˆÓ ·Ó·ÛÙÔϤˆÓ mTOR ÛÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi ΛӉ˘ÓÔ ÙˆÓ ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ΔÔ ÂÚÒÙËÌ· Ô˘ Ú¤ÂÈ Ó· ··ÓÙËı› Â›Ó·È Î·Ù¿ fiÛÔ Ù· ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ·ÓÙÈÛÙ·ıÌ›˙Ô˘Ó ÙȘ ·ÓÂÈı‡ÌËÙ˜ ‰Ú¿ÛÂȘ Ô˘ οÔȘ ÊÔÚ¤˜ Û˘ÓÔ‰Â‡Ô˘Ó ÙËÓ ıÂÚ·›· Ì ·˘Ù¿ Ù· Û΢¿ÛÌ·Ù·, fiˆ˜ Ë Âȉ›ӈÛË Ù˘ ÚˆÙÂ˚ÓÔ˘Ú›·˜. ªfiÓÔ Ó¤Â˜, ηϿ ۯ‰ȷṲ̂Ó˜ ÂÈÚ·Ì·ÙÈΤ˜ Î·È ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ÌÔÚÔ‡Ó ·Ó ‰ÒÛÔ˘Ó ·¿ÓÙËÛË ÛÙÔ ÂÚÒÙËÌ·.

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29. Campistol JM, Schena FP. Kaposi’s sarcoma in renal transplant recipients: the impact of proliferation signal inhibitors. Nephrol Dial Transplant 2007; 22 (Suppl1): 17-22.

30. Bertoni E, Salvadori M. Antineoplastic effect of proliferation signal inhibitors: from biology to clinical application. J Nephrol. 2009; 22(4): 457-62.

31. Motzer RJ, Escudier B, Oudard S, et al. RECORD-1 Study Group. Efficacy of everolimus in advanced renal cell carcinoma: a double-blind, randomised, placebo-controlled phase III trial. Lancet. 2008; 372(9637): 449-56.

32. Ponticelli C. Herpes viruses and tumours in kidney transplant recipients. The role of immunosuppression.

Nephrol Dial Transplant 2011; 0: 1–7.

33. Vitko S, Margreiter R, Wimar W, et al. for the RAD B201 Study Group. Three-year efficacy and safety results from a study of everolimus versus mycophenolate mofetil in de novo renal transplant patients. Am J Transplant 2005; 5: 2521-30.

34. Webster AC, Lee VWS, Chapman JR, et al. Target of rapamycin inhibitors (sirolimus and everolimus) for primary immunosupression of kidney transplant recipients: a systematic review and meta-analysis of randomized trials. Transplantation 2006; 81: 1234-48.

35. Opelz G, Dohler B. Lymphomas after solid organ transplantation: a collaborative transplant study report.

Am J Transplant 2003; 4: 222-30.

36. Campistol JM, Gutierrez-Dalmau A, Torregrosa JV. Conversion to sirolimus: a successful treatment for posttransplantation Kaposi’s sarcoma. Transplantation 2004; 77: 760–762.

37. Lange C, Tran T, Farnik H, et al. Increased frequency of regulatory T Cells and selection of highly potent CD62L+ cells during treatment of human lung transplant recipients with rapamycin. Transplant Int 2010; 23: 266–276.

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¤ÏÏÂÈ„Ë ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÔÈ ÎÔÈӈӛ˜ ηıÈ¤ÚˆÛ·Ó Î·ÓfiÓ˜ ÂÈÏÔÁ‹˜. ∏ ‰È·‰Èηۛ· Î·È ÔÈ Î·ÓfiÓ˜ ‰È·ÓÔÌ‹˜ ÙˆÓ و̷ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÂÓ Â›Ó·È Î·ÈÓÔ‡ÚÁÈÔÈ. ª¤¯ÚÈ ÙÒÚ· ÛÙËÚ›˙ÔÓÙ·È Û ‰‡Ô ·ÓÙÈÎÚÔ˘fiÌÂÓ˜ ÊÈÏÔÛÔÊÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ. ∏ ÚÒÙË Â›Ó·È fiÙÈ ·ÊÔ‡ Ù· ÌÔۯ‡̷ٷ Â›Ó·È Ï›Á· ı· Ú¤ÂÈ Ó· ‰È·Ó¤ÌÔÓÙ·È Î·Ù¿ ÚÔÙ›ÌËÛË Û ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÚÔÛ‰fiÎÈÌÔ Î·Ï‹˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ¿ÏÏË ÚÔÛ·ı› Ó· Û˘ÌÂÚÈÏ¿‚ÂÈ fiÛÔ ÙÔ ‰˘Ó·ÙfiÓ ÂÚÈÛÛfiÙÂÚÔ˘˜ ˘Ô„ËÊ›Ô˘˜ Î·È ¯ÚËÛÈÌÔÔÈ› ˆ˜ ÛËÌ·ÓÙÈÎfi ÎÚÈÙ‹ÚÈÔ ÙÔÓ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ‚·ÛÈ΋ ·Ú¯‹ Ô˘ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· «¶ÚÒÙÔ˜ ÂÁÁÚ¿ÊËη, ÚÒÙÔ˜ ı· Â͢ËÚÂÙËıÒ» ‰›ÓÂÈ ÌÈ· ·›ÛıËÛË ‰ÈηÈÔÛ‡Ó˘ ·ÏÏ¿ ıˆÚÂ›Ù·È Ôχ ·ÏÔ˘ÛÙ¢ÙÈ΋. ™Â ÙfiÛÔ ÔÏ˘¿ÚÈıÌÔ˘˜ ηٷÏfiÁÔ˘˜ ·Ó·ÌÔÓ‹˜ Ë ‰ÈÂΉ›ÎËÛË Â›Ó·È Û˘ÓÒÓ˘ÌË Ì ÙË ÓÔÛËÚfiÙËÙ· Î·È ÙË ıÓËÛÈÌfiÙËÙ·. ∞fi ÙË ÛÙÈÁÌ‹ Ù˘ ÂÁÁÚ·Ê‹˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ ÂÊ·ÚÌfi˙ÔÓÙ·È ÎÚÈÙ‹ÚÈ· ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘, ÔÏÏ¿ ·fi Ù· ÔÔ›· Â›Ó·È ÛÙ·ıÂÚ¿. ŒÓ· fï˜ Â›Ó·È ÌÂÙ·‚ÏËÙfi ·ÏÏ¿ ηıÔÚÈÛÙÈÎfi. ∂›Ó·È Ë ÎÏÈÓÈ΋ ηٿÛÙ·ÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÙË ÛÙÈÁÌ‹ Ù˘ ÂÁÁÚ·Ê‹˜ Î·È ÙË ÛÙÈÁÌ‹ Ù˘ ÂÈÏÔÁ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ΔÔ ÛËÌÂ›Ô ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ΤډԢ˜ ÁÈ· ÙÔÓ ·ÛıÂÓ‹ Ô˘ ÂÈϤÁÂÙ·È ÙÔÔıÂÙÂ›Ù·È Û¯ËÌ·ÙÈο ÛÙÔ ·ÓÒÙ·ÙÔ ÛËÌÂ›Ô ÌÈ·˜ ·Ú·‚ÔÏÈ΋˜ ηÌ‡Ï˘ Î·È Û¿ÓÈ· Û˘Ì›ÙÂÈ Ì ÙËÓ È‰·ÓÈÎfiÙÂÚË Ê˘ÛÈ΋ ÙÔ˘ ηٿÛÙ·ÛË.

OÈ ‰‡Ô ·˘Ù¤˜ ÚÔÛÂÁÁ›ÛÂȘ ʤÚÓÔ˘Ó ·ÓÙÈ̤و˜ ÙËÓ ˆÊÂÏÈÌfiÙËÙ· Ì ÙË ‰ÈηÈÔÛ‡ÓË Î·È ÈÛfiÙËÙ·. ∏ ÔÏÈÙÈ΋ Ù˘ ÈÛfiÙËÙ·˜ ÂÎÏËÚÒÓÂÙ·È ÂÊfiÛÔÓ fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÙËÓ ›‰È· ¢ÎÔÏ›· ÚfiÛ‚·Û˘ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ΔÔ ·ÔÙ¤ÏÂÛÌ· fï˜ ÙˆÓ Î·ÓfiÓˆÓ Ù˘ ‰È·ÓÔÌ‹˜ ÂÓfi˜ ÌÔۯ‡̷ÙÔ˜ Û ¤Ó·Ó ·ÛıÂÓ‹ ÂÍ·ÚÙ¿Ù·È Û‹ÌÂÚ· fi¯È ÌfiÓÔ ·fi ÙÔ ÁÂÁÔÓfi˜: ÂÈϤÁÂÙ·È ÁÈ· ıÂÚ·›· ‰›Î·È· ·ÏÏ¿ ıÂÚ·‡ÂÙ·È ÂÈÙ˘¯¤ÛÙÂÚ·.

∫¿ı ·ÛıÂÓ‹˜ Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙÔ ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È Ô ÔÔ›Ô˜ ÌÔÚ› Ó· ÂÈ‚ÈÒÛÂÈ ·fi ÙËÓ ÂÁ¯Â›ÚËÛË Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ıˆÚÂ›Ù·È fiÙÈ ÌÔÚ› Ó· ÂˆÊÂÏËı› ÌÈ·˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÁÈ· Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ ÙÔ˘ Î·È ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ Ô˘ ı· ·ÔÏ¿Ì‚·Ó ·Ó ·Ú¤ÌÂÓ ÛÙËÓ ·ÈÌÔοı·ÚÛË. ªÂÙ¿ ÙÔÓ 2Ô ¶·ÁÎfiÛÌÈÔ ¶fiÏÂÌÔ ÙÔ ‰Èη›ˆÌ· ÛÙËÓ ˘Á›· Â›Ó·È ıÂÌÂÏÈ҉˜ ·ÊÔ‡ ÚËÙ¿ ·Ó·Ê¤ÚÂÙ·È ÛÙȘ ‰ÈÂıÓ›˜ Û˘Óı‹Î˜ Î·È Û˘ÓÙ·ÁÌ·ÙÈΤ˜ ‰È·ÎËÚ‡ÍÂȘ. ∂›Ó·È ÌÈ· ÎÔÈÓˆÓÈ΋ ηٿÎÙËÛË. ŸÏÔÈ ¤¯Ô˘Ó ÙÔ ›‰ÈÔ ‰Èη›ˆÌ· ÚfiÛ‚·Û˘ Û fiÏ· Ù· ̤۷ ıÂÚ·›·˜ Ô˘ ·Ú¤¯ÔÓÙ·È ·fi ÙÔ Û‡ÛÙËÌ· ˘Á›·˜. øÛÙfiÛÔ ˘¿Ú¯Ô˘Ó fiÚÈ·: ¢‡Ô ·fi ·˘Ù¿ ÁÈ· ÙÔ ı¤Ì· Ô˘ Û˘˙ËÙ¿ÌÂ Â›Ó·È Ë ¤ÏÏÂÈ„Ë fiÚˆÓ ·ÏÏ¿ ΢ڛˆ˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∞˘Ù‹ Ô‰ËÁ› Û ‰È·Ì¿¯Â˜ Û ÔÏÏ¿ Â›‰·. ªÈ· ¤ÎÊÚ·ÛË ·˘Ù‹˜ Ù˘ ‰È·Ì¿¯Ë˜ Â›Ó·È ÔÈ Û˘Ó‰ÈηÏÈÛÙÈΤ˜ Î·È ‰ÈηÛÙÈΤ˜ ‰ÈÂΉÈ΋ÛÂȘ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ Û˘ÁÁÂÓÒÓ ÙÔ˘˜ ·fi ÙÔ Û‡ÛÙËÌ· ˘Á›·˜. ¶ÚÈÓ 50 ¯ÚfiÓÈ· ‰ÂÓ ÁÓˆÚ›˙·Ì ԇÙ ÙȘ Ù¯ÓÈΤ˜ Ù˘ ·ÈÌÔοı·ÚÛ˘ Ô‡ÙÂ Ê˘ÛÈο ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ. ΔfiÙ ÔÈ ¿ÓıÚˆÔÈ Ô˘ ÙȘ ›¯·Ó ·Ó¿ÁÎË ¤ı·ÈÓ·Ó ·‚Ô‹ıËÙÔÈ. OÈ ÂÈÙ˘¯›Â˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ù· ÙÂÏÂ˘Ù·›· 30 ¯ÚfiÓÈ· ›¯·Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ·, ÙfiÛÔ ÔÈ ÂӉ›ÍÂȘ ·ÏÏ¿ ΢ڛˆ˜ Ë ·Ô‰Ô¯‹ Ù˘, ÚÈ˙Èο Ó· ·ÏÏ¿ÍÔ˘Ó Î·È ·˘Ùfi Á›ÓÂÙ·È Ê·ÓÂÚfi ·fi ÙË ‰˘Û·Ó·ÏÔÁ›· Ô˘ ˘¿Ú¯ÂÈ ÛÙȘ ̤Ú˜ Ì·˜ ÌÂٷ͇ Ù˘ ÚÔÛÊÔÚ¿˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È Ù˘ Ú·ÁÌ·ÙÈ΋˜ ·Ó¿Á΢ ÁÈ· ·˘Ù¿. ŒÓ· ÌÂÁ¿ÏÔ ÌÂÚ›‰ÈÔ ·˘Ù‹˜ Ù˘ ˙‹ÙËÛ˘ ÁÈ· ÌÔۯ‡̷ٷ ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ ·Ó·ÌÔÓ‹˜ ÚÔÛÙ¤ıËÎ·Ó ·ÛıÂÓ›˜ ÌÂÁ¿ÏÔÈ Û ËÏÈΛ· Î·È ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ô˘ ̤¯ÚÈ ¯ı˜ ıˆÚÔ‡ÓÙ·Ó ·Î·Ù¿ÏÏËÏÔÈ. °È· Ó· ‰ÒÛÔ˘Ó Ï‡ÛË ÛÙÔ Úfi‚ÏËÌ· Ù˘ ÂÈÏÔÁ‹˜ Î·È Î˘Ú›ˆ˜ ¤ÌÊ·ÛË ÛÙÔ ‰Èη›ˆÌ· Ù˘ ÚfiÛ‚·Û˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, ¿ÓÙÔÙ Ì ‰Â‰Ô̤ÓÔ ÙËÓ

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ŒÓ·˜ ·ÚÈıÌfi˜ ·ÏÁÔÚ›ıÌˆÓ Â›Ó·È Û‹ÌÂÚ· ·Ô‰ÂÎÙfi˜. ∏ HLA Ù·˘ÙfiÙËÙ· ÌÂٷ͇ ‰fiÙË Î·È Ï‹ÙË Â›Ó·È ·‰È¿‚ÏËÙÔ ÛÙÔÈ¯Â›Ô ÂÈÏÔÁ‹˜ ÁÈ· ¤Ó· Ï‹ÙË و̷ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ fi¯È fï˜ ··Ú·›ÙËÙÔ ÁÈ· ÌÈ· ÂÈÙ˘¯Ë̤ÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ٷ Ó¤· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η. ΔÔ 25% ÌÂٷ͇ ·‰ÂÏÊÒÓ, ÔÈ Û‡˙˘ÁÔÈ, ÔÈ ·Ô‡‰Â˜ ‹ ÔÈ ı›ÔÈ Î·È Ù· Í·‰¤ÏÊÈ· Ô˘ ÙÔ ÓÔÌÔÛ¯¤‰ÈÔ ÂÈÙÚ¤ÂÈ Ó· Â›Ó·È ‰fiÙ˜ ‰ÂÓ Â›Ó·È Ô‡Ù ·ÏÔÙ·˘ÙfiÛËÌÔÈ Ì ÙÔ Ï‹ÙË. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿ ¤Ó·˜ ˘Ô„‹ÊÈÔ˜ Ï‹Ù˘ ÁÈ· Ó· ·ÓÙÈÛÙ·ıÌ›ÛÂÈ Ù· ÌfiÚÈ· Ô˘ ÙÔ˘ ·Ú¤¯ÔÓÙ·È ·fi ÙËÓ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ· ÙÚÈÒÓ HLA ·ÓÙÈÁfiÓˆÓ Ú¤ÂÈ Ó· ·Ú·Ì›ÓÂÈ ÂÁÁÂÁÚ·Ì̤ÓÔ˜ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ ÁÈ· 10 ¯ÚfiÓÈ· Ì fi,ÙÈ ·˘Ù‹ Ë ·Ú·ÌÔÓ‹ Û˘ÓÂ¿ÁÂÙ·È. ª¤¯ÚÈ ÚfiÙÈÓÔ˜ ÙÔ Û‡ÛÙËÌ· ‰È·ÓÔÌ‹˜ ¤‰ÈÓ ¤ÌÊ·ÛË ÛÙ· ·ÔÙÂϤÛÌ·Ù· ÂÓfi˜ ÎÏ·ÛÈÎÔ‡ ÚÔÙ‡Ô˘ ÌÂÙ·ÌÔۯ‡ÛˆÓ. ¡¤ÔÈ ·ÛıÂÓ›˜ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Ì ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì ÎÏ·ÛÈο (standard) ÎÚÈÙ‹ÚÈ·. O ÏËı˘ÛÌfi˜ ÙˆÓ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ ÛÙȘ ̤Ú˜ Ì·˜ ËÏÈÎȷο ¤¯ÂÈ ·ÏÏ¿ÍÂÈ. Œ¯Ô˘Ì ·ԉ¯ı› Î·È ‚Ú›ÛÎÔÓÙ·È ÂÁÁÂÁÚ·Ì̤ÓÔÈ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ ·ÛıÂÓ›˜ ÌÂÁ·Ï‡ÙÂÚÔÈ ·fi 60 ̤¯ÚÈ Î·È 70 ÂÙÒÓ. ΔÔ ÛÙÔÈ¯Â›Ô fï˜ Ô˘ ‰˘ÛÎÔχÂÈ ÂÚÈÛÛfiÙÂÚÔ ·’ fiÏ· ÙËÓ ·fiÊ·ÛË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È fiÙÈ Û‹ÌÂÚ· ·ԉ¯fiÌ·ÛÙ ÌÔۯ‡̷ٷ ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ÙˆÓ 60 ÂÙÒÓ (·ÔÙÂÏÔ‡Ó ÙËÓ ÏÂÈÔÓfiÙËÙ· ÙˆÓ و̷ÙÈÎÒÓ ‰ÔÙÒÓ) ‹ ·fi ‰fiÙ˜ 50-59 ÂÙÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Û˘Ó˘¿Ú¯Ô˘Ó 2 ·fi ÙÔ˘˜ 3 ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜: Ô ı¿Ó·ÙÔ˜ ÚÔ‹Ïı ·fi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ, ›¯·Ó ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘ Î·È ÎÚÂÙ·ÈÓ›ÓË ÌÂÁ·Ï‡ÙÂÚË ·fi 1,5 mg/dl ÙË ÛÙÈÁÌ‹ Ù˘ Ï‹„˘. ∞˘Ù¿ Ù· ÌÔۯ‡̷ٷ ¤¯Ô˘Ó Û¯ÂÙÈÎfi ΛӉ˘ÓÔ ·ÒÏÂÈ·˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜ ÌÂÁ·Ï‡ÙÂÚÔ ·fi 1,70, Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ 10-50 ÂÙÒÓ ¯ˆÚ›˜ ÙÔ˘˜ ÚÔËÁÔ‡ÌÂÓÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. Δ· ÓÂÊÚÈο ÌÔۯ‡̷ٷ Û‹ÌÂÚ· ·ÍÈÔÏÔÁÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚÔ ·fi ÙËÓ ÔÈfiÙËÙ¿ ÙÔ˘˜ Î·È ÙÔ Û˘ÓÔÏÈÎfi ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ·Ú¿ ·fi ÙÔ ‚·ıÌfi ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ¿˜ ÙÔ˘˜ Ì ÙÔ Ï‹ÙË. O ÌÂÁ¿ÏÔ˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ÂÓfi˜ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Î·ıÔÚÈÛÙÈÎfi˜ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÔÍ›·˜ ÛˆÏËÓ·Úȷ΋˜ Ó¤ÎÚˆÛ˘ Ë ÔÔ›· Ì ÙË ÛÂÈÚ¿ Ù˘ ÂËÚ¿˙ÂÈ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘. ¶ÚÔÊ·ÓÒ˜ ‰ÂÓ ı· ÚÔÛʤÚÔ˘Ì ¤Ó· ÌfiÛ¯Â˘Ì· 70 ÂÙÒÓ-ÌÔÏÔÓfiÙÈ Ô ˘ÔÏÔÁÈÛÙ‹˜ ÙÔ˘˜ Â¤ÏÂÍÂÛ ¤Ó· ·È‰› 5 ÂÙÒÓ ‹ Û ¤Ó· Ôχ Ó¤Ô ·ÛıÂÓ‹, ÔÈ

ÔÔ›ÔÈ ÛÙÔ ÚÔÛ‰fiÎÈÌÔ Ù˘ ÂÈ‚›ˆÛ˘ ÙÔ˘˜ ı· ¯ÚÂÈ·ÛÙÔ‡Ó ‰Â‡ÙÂÚË ›Ûˆ˜ Î·È ÙÚ›ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞ÓÙ›ıÂÙ· ·˘Ùfi ÙÔ ÌfiÛ¯Â˘Ì· ‹ ¤Ó· ¿ÏÏÔ ·fi Ó¤Ô ‰fiÙË 35 ÂÙÒÓ ¯Ú‹ÛÙË iv Ô˘ÛÈÒÓ ı· ÌÔÚÔ‡Û ӷ ÚÔÛÊÂÚı› ˘fi fiÚÔ˘˜ Û ¤Ó·Ó ·ÛıÂÓ‹ ÌÂÁ·Ï‡ÙÂÚÔ ·fi 60 ÂÙÒÓ, (ı· ÁÓˆÚ›˙ÂÈ ÙËÓ ÚԤϢÛË ÙÔ˘ Î·È Ô ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜ ı· Â›Ó·È ÌÈÎÚfi˜) Ô˘ ÚfiÛÊ·Ù· ÂÓÙ¿¯ıËΠÛÙËÓ ·ÈÌÔοı·ÚÛË Î·È Ô ÔÔ›Ô˜ ‰ÂÓ ÚfiÎÂÈÙ·È Ó· ÌÂÙ·ÌÔÛ¯Â˘ı› Ì ÙÔ˘˜ fiÚÔ˘˜ Ù˘ ÎÏ·ÛÈ΋˜ ÌÔÚÈÔ‰fiÙËÛ˘. ⁄ÛÙÂÚ· ·fi 30 ¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ ÛÙË ¯ÒÚ· Ì·˜ ÙÔ 25% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Â›Ó·È ÂÁÁÂÁÚ·Ì̤ÓÔÈ ÛÙÔ˘˜ ηٷÏfiÁÔ˘˜ Â›Ó·È ˘Ô„‹ÊÈÔÈ ÁÈ· Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™ÙÔ ·ÚÂÏıfiÓ ·Ó·ÎÔÈÓÒÛ·Ì ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ÙˆÓ Â·Ó·ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÛÙÔ ∫¤ÓÙÚÔ Ì·˜, ·ÊÔÚÔ‡Û·Ó fï˜ ÌÔۯ‡̷ٷ ÚÔÂÚ¯fiÌÂÓ· ·fi ‰fiÙË Ì ÛÙ¿ÓÙ·ÚÓÙ ÎÚÈÙ‹ÚÈ·2. ™Â ÚfiÛÊ·ÙË ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË 9641 ·ÛıÂÓ›˜ Ô˘ ¤¯·Û·Ó ÙÔ ÚÒÙÔ ÌfiÛ¯Â˘Ì¿ ÙÔ˘˜, Â·ÓÂÁÁÚ¿ÊËÎ·Ó ÁÈ· Ó¤· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· ÌÈ· ÂÚ›Ô‰Ô 10 ÂÙÒÓ. ∞fi ÙÔ˘˜ 2908 ·ÛıÂÓ›˜ Ô˘ Â·Ó·ÌÂÙ·ÌÔۯ‡ıËÎ·Ó ·˘ÙÔ› Ô˘ ¤Ï·‚·Ó ÌÔۯ‡̷ٷ ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ ‰ÂÓ Â›¯·Ó ηӤӷ fiÊÂÏÔ˜ Û ۇÁÎÚÈÛË Ì ·˘ÙÔ‡˜ Ô˘ ·Ú¤ÌÂÈÓ·Ó ÛÙËÓ ·ÈÌÔοı·ÚÛË. ∞ÓÙ›ıÂÙ· ÔÈ ·ÛıÂÓ›˜ ˆÊÂÏ‹ıËÎ·Ó fiÙ·Ó Â·Ó·ÌÂÙ·ÌÔۯ‡ıËÎ·Ó Ì ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì standard ÎÚÈÙ‹ÚÈ·3.

OÈ ·ÛıÂÓ›˜ ÛÙËÓ ·ÈÌÔοı·ÚÛË ¤¯Ô˘Ó ¿ÌÂÛË ÂÍ¿ÚÙËÛË ·fi ÙȘ ÌÔÓ¿‰Â˜ ·ÈÌÔοı·ÚÛ‹˜ ÙÔ˘˜ Î·È ÔÈ ÁÈ·ÙÚÔ› ÙÔ˘˜ ¤¯Ô˘Ó ·ÔÊ·ÛÈÛÙÈÎfi ÏfiÁÔ ÁÈ· οı ÂÈÏÔÁ‹ ‹ ·fiÊ·Û‹ ÙÔ˘˜. ŸÌˆ˜ Â›Ó·È ··Ú·›ÙËÙÔ ÂÚÈÛÛfiÙÂÚÔ ·fi ÔÙ¤ Û‹ÌÂÚ· Ô Î¿ı ˘Ô„‹ÊÈÔ˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó· ÂÓËÌÂÚÒÓÂÙ·È ÁÈ· ÙËÓ ÔÈfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ ÎÈÓ‰‡ÓÔ˘˜ Î·È Ù· ÔʤÏË Ô˘ ı· ·ÔÎÔÌ›ÛÂÈ ·fi ·˘Ùfi. £· ¯ÚÂÈ·ÛÙ› Û›ÁÔ˘Ú· ÂÚÈÛÛfiÙÂÚË ÂÓË̤ڈÛË Î·È ÂÎ·›‰Â˘ÛË ÛÙÔ ¯ÚfiÓÔ Ô˘ ı· ÌÂÛÔÏ·‚‹ÛÂÈ Ì¤¯ÚÈ ÙËÓ ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛ‹ ÙÔ˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË.

OÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÙËÓ ÂÔ›ıËÛË fiÙÈ ÙÔ Û‡ÛÙËÌ· ‰È·ÓÔÌ‹˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÙÔÓ ∂ıÓÈÎfi OÚÁ·ÓÈÛÌfi ªÂÙ·ÌÔۯ‡ÛÂˆÓ Â›Ó·È ‰›Î·ÈÔ Î·È ‰È·Ê·Ó¤˜ Î·È Ì’ ·˘Ù‹ ÙË ÛÈÁÔ˘ÚÈ¿ Ú¤ÂÈ Ó· ·Ú·Ì›ÓÔ˘Ó. O ∂ıÓÈÎfi˜ OÚÁ·ÓÈÛÌfi˜ ªÂÙ·ÌÔۯ‡ÛÂˆÓ fï˜ ı· Ú¤ÂÈ Ó· ηٷÚÙ›ÛÂÈ ¤Ó·Ó ÈÔ ‰ÈÂ˘Ú˘Ì¤ÓÔ Î·È Â˘¤ÏÈÎÙÔ Î·Ù¿ÏÔÁÔ ·Ó·ÌÔÓ‹˜ ˘Ô„ËÊ›ˆÓ Ô˘ ı· ÂÈı˘ÌÔ‡Û·Ó Ó· ‰Â¯ÙÔ‡Ó ¤Ó· ‰Â‰ÔÌ¤ÓˆÓ ¯·Ú·ÎÙ‹ÚˆÓ ÌfiÛ¯Â˘Ì·. ∏ ÔÏÈÙÈ΋ ·˘Ù‹

METAMO™XEY™Eπ™ 2011

ı· ·‡Í·Ó Èı·ÓfiÓ ÙËÓ ·ÍÈÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÏÈÁfiÙÂÚÔ È‰·ÓÈÎÔ‡˜ ‰fiÙ˜ ·ÏÏ¿ Ì ÂÏ¿¯ÈÛÙÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜. ∂ÈϤÔÓ, Ì ÌÂϤÙ˜ ı· Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÛÔ˘Ì ÙÔ˘˜ ˘Ô„ËÊ›Ô˘˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë ÚÔÛÊÔÚ¿ ÔÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰ÂÓ ÙÔ˘˜ ÚfiÛÊÂÚÂ Î·È ‰ÂÓ ı· ÙÔ˘˜ ÚÔÛʤÚÂÈ Î·Ó¤Ó· fiÊÂÏÔ˜. ∂›Ó·È fï˜ ··Ú·›ÙËÙÔ ÁÈ· fiÏÔ˘˜ ÂÌ¿˜ Ù˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋˜ ÎÔÈÓfiÙËÙ·˜ Ì Ôχ ÚÔÛÂÎÙÈο ‚‹Ì·Ù· Ó· ÚÔÙ›ÓÔ˘Ì οı ·ÏÏ·Á‹ fiÙ·Ó ÙËÓ ÎÚ›ÓÔ˘Ì ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÂÈÙ˘¯¤ÛÙÂÚË ·ÓÙÈÌÂÙÒÈÛË Î·ıÂÓfi˜ ͯˆÚÈÛÙ¿. ¢ÂÓ ı· ÌÈÏÔ‡Û·Ì ÁÈ· Ù· ÂÈÙ‡ÁÌ·Ù· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·Ó Ë È‰¤· Ù˘ ‰ˆÚ¿˜ ÙˆÓ ÔÚÁ¿ÓˆÓ ‰ÂÓ Â›¯Â Á›ÓÂÈ ·Ô‰ÂÎÙ‹ ·fi ÙÔ˘˜ Û˘Ó·ÓıÚÒÔ˘˜ Ì·˜ Î·È ·˘Ù‹ Ë È-

43

‰¤· Ú¤ÂÈ Ó· ÂÓÈÛ¯˘ı› ÂÚÈÛÛfiÙÂÚÔ.

BÈ‚ÏÈÔÁÚ·Ê›· 1. Wolfe RA, Ashley 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.

2. Δ·ÎÔ‡‰·˜ ¢, ∞ÓÙˆÓÈ¿‰Ë˜ ∞, ¶··ÁÈ¿ÓÓ˘ ∞, °¿Î˘ ¢, μ. ¶··ÓÈÎÔÏ¿Ô˘ μ, μ¤ÚÁÔ˘Ï·˜ °, πÌ‚ÚÈÔ˜ °, ∫˘ÚÈ·ÎfiÔ˘ÏÔ˜ °, ¶ÔÏ˘ÌÂÓ›‰Ë˜ ∑. ¶·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÛÙȘ ÓÂÊÚÈΤ˜ Â·Ó·ÌÂÙ·ÌÔۯ‡ÛÂȘ (¡∂ª). ªÂÙ·ÌfiÛ¯Â˘ÛË OÚÁ¿ÓˆÓ Î·È πÛÙÒÓ 1996; 1: 34-39.

3. Miles C.D, Schaubel D.E., Jia Ã, Ojo ∞O, Port FK, Rao PS. Mortality experience in recipients undergoing repeat transplantation with expanded criteria donor and non-ECD deceased-donor kidneys. Am J Transplantation 2007; 7: 1140-1147..

¢fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ¢. °Ô‡ÌÂÓÔ˜

°ÂÓÈο –OÚÈÛÌÔ›

ÛÙÔȯ·). ™ËÌ·ÓÙÈΤ˜ fï˜ ‰È·ÊÔÚ¤˜ ‰È·ÈÛÙÒıËÎ·Ó ÛÙ· ÔÛÔÛÙ¿ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·ÚÔ˘Û›·Û·Ó ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (63% vs. 32%) ‹ ÚˆÙÔ·ı‹ ÌË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (7.7% vs. 1.8%)2.

¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û ÚÔËÁ̤ӷ ÎÚ¿ÙË, fiˆ˜ ÔÈ ∏¶∞, ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ΢ڛˆ˜ ·fi ·Ô‚ÈÒÛ·ÓÙ˜ ‰fiÙ˜, ·˘Í¿ÓÔÓÙ·È Û ·ÚÈıÌfi, Ë Ï›ÛÙ· ÙˆÓ ·Ó·ÌÂÓfiÓÙˆÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓÒÓ Â›Û˘ ·˘Í¿ÓÂÙ·È. °È· ÙÔ ÏfiÁÔ ·˘Ùfi Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯Ô˘Ó ·Ú¯›ÛÂÈ Ó· ·ÍÈÔÔÈÔ‡ÓÙ·È ÔÈ ÏÂÁfiÌÂÓÔÈ ÔÚÈ·ÎÔ› ‰fiÙ˜ ‹ ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·. ™‡Ìʈӷ Ì ÙÔÓ ÔÚÈÛÌfi, ÛÙËÓ Î·ÙËÁÔÚ›· ·˘Ù‹ ˘¿ÁÔÓÙ·È ‰fiÙ˜ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 60 ÂÙÒÓ ‹ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 50 ÂÙÒÓ Ì ٷ˘Ùfi¯ÚÔÓË ·ÚÔ˘Û›· ‰‡Ô ÂÎ ÙˆÓ ·Ú·Î¿Ùˆ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ: ÈÛÙÔÚÈÎÔ‡ ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘, ÙÈÌ‹˜ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ >1.5 mg/dl ‹ ÈÛÙÔÚÈÎÔ‡ ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ˆ˜ ·ÈÙ›·˜ ı·Ó¿ÙÔ˘1. Δ· ÎÚÈÙ‹ÚÈ· ·˘Ù¿ ¤¯Ô˘Ó ıÂÛÈÛÙ› Ì ‚¿ÛË ÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û˘ÁÎÚÈÙÈο Ì ·˘ÙfiÓ Ô˘ ¤¯ÂÈ ·Ú·ÙËÚËı› Û ÂÚÈÙÒÛÂȘ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ȉÂÒ‰ÂȘ ‰fiÙ˜. ø˜ ȉÂÒ‰ÂȘ ‰fiÙ˜ ıˆÚÔ‡ÓÙ·È ¿ÙÔÌ· ËÏÈΛ·˜ 10 ¤ˆ˜ 39 ÂÙÒÓ, ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi ˘¤ÚÙ·Û˘, Ì ηϋ ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ <1.5 mg/dl) ηٿ ÙË Ê¿ÛË ·Ê·›ÚÂÛ˘ ÙˆÓ ÓÂÊÚÒÓ Î·È ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ˆ˜ ·ÈÙ›·˜ ı·Ó¿ÙÔ˘. ∏ ·ÍÈÔÔ›ËÛË ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·. ∂ÓÙÔ‡ÙÔȘ ÔÈ ‰fiÙ˜ ·˘ÙÔ› ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó ÌfiÏȘ ÙÔ 17% ÙˆÓ ‰ÔÙÒÓ Ì ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ Ô˘ ·ÍÈÔÔÈÔ‡ÓÙ·È ÛÙȘ ∏¶∞. ¶ÔÛÔÛÙfi ÂÚ›Ô˘ 40% ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·˘ÙÒÓ ‰ÂÓ ·ÍÈÔÔÈÂ›Ù·È ÏfiÁˆ ¿ÚÓËÛ˘ ÔÏÏÒÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎÒÓ Î¤ÓÙÚˆÓ Ó· Ù· ¯ÚËÛÈÌÔÔÈ‹ÛÔ˘Ó2. ¶·ÚfiÏ· ·˘Ù¿ Ê·›ÓÂÙ·È fiÙÈ Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ Ù· ÔÔ›· ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·fi οÔÈ· ΤÓÙÚ·, ·ÏÏ¿ ÌÂÙ¿ ·fi ¿ÚÓËÛË ‰‡Ô ÙÔ˘Ï¿¯ÈÛÙÔÓ ¿ÏÏˆÓ Î¤ÓÙÚˆÓ Ó· Ù· ·ÍÈÔÔÈ‹ÛÔ˘Ó, ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ·fi ÙËÓ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ¯ˆÚ›˜ ÚÔËÁÔ‡ÌÂÓË ¿ÚÓËÛË ·ÍÈÔÔ›ËÛ‹˜ ÙÔ˘˜ ·fi ¿ÏÏ· ΤÓÙÚ· (88.2% vs. 88.9% Î·È 70.4% vs. 76.7% ·ÓÙ›-

μÈÔ„›· ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÚÈÓ ·fi ÙËÓ ÂÌʇÙÂ˘Û‹ ÙÔ˘ ∏ ηٿÛÙ·ÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÚÈÓ ·fi ÙËÓ ÂÌʇÙÂ˘Û‹ ÙÔ˘ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ ÁÈ· ÙËÓ ÔÚ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ·˘Ùfi ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜. ¶·Ú¤¯ÂÈ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÎÙÈÌËıÔ‡Ó ÌfiÓÔ Ì ÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ÎÏÈÓÈÎÒÓ ‰Â‰ÔÌ¤ÓˆÓ Î·È ÙËÓ ÂÚÁ·ÛÙËÚȷ΋ ÂÎÙ›ÌËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜3. ∏ ‚·Ú‡ÙËÙ· Ù˘ ÔÍ›·˜ ÛˆÏËÓ·Úȷ΋˜ ‚Ï¿‚˘ ı· Ú¤ÂÈ Ó· ÂÎÙÈÌ¿Ù·È ‰ÈfiÙÈ ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ ÁÈ· ÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜. ™Â ÂÚÈÙÒÛÂȘ Ì ÛÔ‚·Ú‹ ÛˆÏËÓ·Úȷ΋ ‚Ï¿‚Ë ı· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ë ¯ÔÚ‹ÁËÛË ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ηٿ ÙÔ ·Ú¯ÈÎfi ‰È¿ÛÙËÌ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. OÚÈṲ̂ÓÔÈ ıˆÚÔ‡Ó fiÙÈ Ë ‚ÈÔ„›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÚÈÓ ·fi ÙËÓ ÂÌʇÙÂ˘Û‹ ÙÔ˘ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙË ‰ÈfiÙÈ Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË Û˘Û¯ÂÙ›˙ÂÙ·È Ôχ ηχÙÂÚ· ·fi Ù· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ì ÙËÓ ¤Î‚·ÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ™Â Û¯ÂÙÈο ÚfiÛÊ·ÙË fï˜ ÌÂϤÙË ‰È·ÈÛÙÒıËΠfiÙÈ ÙÔ 69% ÙˆÓ ‰ÔÙÒÓ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 55 ÂÙÒÓ Â›¯Â ÔÛÔÛÙfi ÛÎÏËÚ˘Ì¤ÓˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ÌÈÎÚfiÙÂÚÔ ·fi 10% Î·È Ù· ÌÔۯ‡̷ٷ ·fi ·˘ÙÔ‡˜ ÙÔ˘˜ ‰fiÙ˜ ›¯·Ó ÂÍ·ÈÚÂÙÈ΋ ÂÈ‚›ˆÛË ÌÂÙ¿ ·fi 4 ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘4. ∏ ‚ÈÔ„›· ÌÔÚ› Â›Û˘ Ó· Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ Â¿Ó Ô ¤Ó·˜ ·fi ÙÔ˘˜ ‰‡Ô ÓÂÊÚÔ‡˜ ÙÔ˘ ‰fiÙË Â›Ó·È ·ÚÎÂÙfi˜ ‹ Â¿Ó ı· Ú¤ÂÈ Ó· ÌÂÙ·ÌÔÛ¯Â˘ÙÔ‡Ó Î·È ÔÈ ‰‡Ô ÓÂÊÚÔ› ÛÙÔÓ ›‰ÈÔ Ï‹ÙË, Ì ÛÎÔfi ÙËÓ Î·Ï‡ÙÂÚË Ì·ÎÚÔ¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁ›·5. ∏ ·ÚÔ˘Û›· ÛÎÏËÚ˘ÓÙÈÎÒÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙ· ÛÂÈÚ¿Ì·Ù·, ¯ÚfiÓÈˆÓ ·ÏÏÔÈÒÛÂˆÓ ÛÙÔ ‰È·ÌÂÛÔÛˆÏËÓ·ÚÈ·Îfi ¯ÒÚÔ, ˘·Ï›ÓˆÛ˘ ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ

44

METAMO™XEY™Eπ™ 2011

Î·È ÈÓÒ‰Ô˘˜ ¿¯˘ÓÛ˘ ÙÔ˘ ¤Ûˆ ¯ÈÙÒÓ· ÙˆÓ ·ÚÙËÚÈÒÓ ·ÓÙÈÚÔÛˆ‡ÂÈ ÙȘ ΢ÚÈfiÙÂÚ˜ ÈÛÙÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ Ô˘ ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛÙ› Ì ‰˘ÛÌÂÓ‹ ÔÚ›· Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜3,6. ∏ ‚·Ú‡ÙËÙ· Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ÛÎÏ‹Ú˘ÓÛ˘ ıˆÚÂ›Ù·È ·fi ÔÏÏÔ‡˜ ˆ˜ Ô Î·Ï‡ÙÂÚÔ˜ ‰Â›ÎÙ˘ ÁÈ· ÙËÓ ÔÚ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∏ ·ÚÔ˘Û›· ÛÎÏ‹Ú˘ÓÛ˘ Û ÔÛÔÛÙfi >20% ÙˆÓ ÛÂÈÚ·Ì¿ÙˆÓ ·ÔÙÂÏ› ‰˘ÛÌÂÓ¤˜ ÚÔÁÓˆÛÙÈÎfi ÛÙÔÈ¯Â›Ô Î·È ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÓÂÊÚÔ› Ì ٤ÙÔÈ· ¯·Ú·ÎÙËÚÈÛÙÈο ηÏfi Â›Ó·È Ó· ÌËÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È3,4. °È· Ó· ÂÎÙÈÌËı› fï˜ ·ÍÈfiÈÛÙ· Ô ‚·ıÌfi˜ ÛÂÈÚ·Ì·ÙÈ΋˜ ÛÎÏ‹Ú˘ÓÛ˘ ı· Ú¤ÂÈ Ó· ˘¿Ú¯Ô˘Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ 15 ÛÂÈÚ¿Ì·Ù· ÛÙË ‚ÈÔ„›·. ∏ ·ÚÔ˘Û›· ·ÏÏÔÈÒÛÂˆÓ ÛÙÔ ‰È·ÌÂÛÔ-ÛˆÏËÓ·ÚÈ·Îfi ¯ÒÚÔ Î·È ·ÚÙËÚÈÔÏÔÛÎÏ‹Ú˘ÓÛ˘ ·ÎfiÌ· Î·È Û ÌÈÎÚÔ‡ ÌÂÁ¤ıÔ˘˜ ÙÂÌ¿¯ÈÔ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ ÌÔÚ› Ó· ‰ÒÛÂÈ ·ÍÈfiÈÛÙ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÈfiÙÈ ÔÈ ·ÏÏÔÈÒÛÂȘ ·˘Ù¤˜ ¤¯Ô˘Ó ‰È¿¯˘ÙË Î·Ù·ÓÔÌ‹ ÛÙÔ ÓÂÊÚÈÎfi ·Ú¤Á¯˘Ì·3,6. ªÈ· ¿ÏÏË ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ˜ Ù˘ ‚ÈÔ„›·˜ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ÙÚfiÔ Ô˘ ¤¯ÂÈ ÏËÊı› Ë ‚ÈÔ„›·. ∏ ‚ÈÔ„›· Ì ‚ÂÏfiÓ· ıˆÚÂ›Ù·È ÈÔ ·ÓÙÈÚÔÛˆ¢ÙÈ΋ ‰ÈfiÙÈ ‰›‰ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ï‹„˘ ÈÛÙÔ‡ ·fi ÙË ‚·ı‡ÙÂÚË ˙ÒÓË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÈÛÙÔ‡ ‰ËÏ·‰‹ ÙËÓ ·Ú·Ì˘ÂÏÈ΋ ÂÚÈÔ¯‹ fiÔ˘ ÂÓÙÔ›˙ÔÓÙ·È ÔÈ ÌÂÁ·Ï‡ÙÂÚ˜ ·ÚÙËڛ˜, ÔÈ Ôԛ˜ Â›Ó·È ÈÔ Èı·Ófi Ó· ÂÌÊ·Ó›˙Ô˘Ó ·ÚÙËÚÈÔÛÎÏËÚ˘ÓÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙÔ Á‹Ú·˜. ™ÙË ‚ÈÔ„›· Ì ÛÊËÓÔÂȉ‹ ÂÎÙÔÌ‹ Ô ÓÂÊÚÈÎfi˜ ÈÛÙfi˜ Ô˘ Ï·Ì‚¿ÓÂÙ·È ÚÔ¤Ú¯ÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÙËÓ Â͈ÙÂÚÈ΋ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ÊÏÔÈÔ‡ Î·È ÂȉÈÎfiÙÂÚ· ·fi ÙËÓ ÂÚÈÔ¯‹ οوıÂÓ Ù˘ ο„·˜, fiÔ˘ Û˘Ó‹ıˆ˜ ˘¿Ú¯ÂÈ ‰˘Û·Ó¿ÏÔÁ· ·˘ÍË̤ÓÔ˜ ·ÚÈıÌfi˜ ÛÎÏËÚ˘Ì¤ÓˆÓ ÛÂÈÚ·Ì¿ÙˆÓ. §fiÁˆ Ù˘ Èı·ÓfiÙËÙ·˜ ˘ÂÚÂÎÙ›ÌËÛ˘ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ÛÎÏ‹Ú˘ÓÛ˘ ··ÈÙÔ‡ÓÙ·È ÙÔ˘Ï¿¯ÈÛÙÔÓ 30 ÛÂÈÚ¿Ì·Ù· ÁÈ· Ó· Â›Ó·È ·ÓÙÈÚÔÛˆ¢ÙÈ΋ Ë ‚ÈÔ„›· Ô˘ Ï·Ì‚¿ÓÂÙ·È Ì ÛÊËÓÔÂȉ‹ ÂÎÙÔÌ‹3,6.

∂È‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ∏ ÂÈ‚›ˆÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi ·˘Ù‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ȉÂÒ‰ÂȘ ‰fiÙ˜. °È· ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·Ó¤Ú¯ÂÙ·È Û 83.6% Î·È 90.4% ·ÓÙ›ÛÙÔȯ·, Û ÂÚÈÙÒÛÂȘ fiÔ˘ ÙÔ ÎÚÈÙ‹-

45

ÚÈÔ ÁÈ· ÙËÓ Ù·ÍÈÓfiÌËÛË ÙÔ˘ ‰fiÙË ÛÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Â›Ó·È Ë ËÏÈΛ·. ∏ ÂÈ‚›ˆÛË fï˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌÔۯ‡̷ٷ ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ Â›Ó·È Î·Ï‡ÙÂÚË ·fi ·˘Ù‹ ·ÛıÂÓÒÓ Ô˘ ·Ú·Ì¤ÓÔ˘Ó Û Â͈ÓÂÊÚÈ΋ οı·ÚÛË ÁÈ· Ì·ÎÚ¿ ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô. Œ¯ÂÈ Ì¿ÏÈÛÙ· ·Ó·ÊÂÚı› fiÙÈ ÙÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Â›Ó·È ·˘ÍË̤ÓÔ Î·Ù¿ 5 ¯ÚfiÓÈ·7. §fiÁˆ fï˜ Ù˘ ·˘ÍË̤Ó˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ıÓËÙfiÙËÙ·˜, Ë Î·Ï‡ÙÂÚË ÂÈ‚›ˆÛË ÙˆÓ ÏËÙÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ ÍÂÂÚÓ¿ ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ·Ú·Ì¤ÓÔ˘Ó Û Â͈ÓÂÊÚÈ΋ οı·ÚÛË ÌÂÙ¿ ÙËÓ ¿ÚÔ‰Ô 3.5 ÂÙÒÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË8. ™Â ÔÚÈṲ̂Ó˜ ηÙËÁÔڛ˜ ·ÛıÂÓÒÓ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ‰fiÙË Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Â›‰Ú·ÛË ÛÙËÓ ÂÈ‚›ˆÛ‹ ÙÔ˘˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ·ÛıÂÓ›˜ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 40 ÂÙÒÓ, Ì ÈÛÙÔÚÈÎfi ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘ ‹ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ȉȷ›ÙÂÚ· Â¿Ó ·Ú·Ì¤ÓÔ˘Ó Û ÚfiÁÚ·ÌÌ· Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘ ÁÈ· ÂÚÈÛÛfiÙÂÚ· ·fi 4 ¯ÚfiÓÈ·. ∂ÓÙÔ‡ÙÔȘ ·Ú¿ Ù· ÏÂÔÓÂÎÙ‹Ì·Ù· ÁÈ· ÔÚÈṲ̂Ó˜ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ‰fiÙË Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ÌÔÚ› Ó· ¤¯ÂÈ ·ÚÓËÙÈο ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÏËÙÒÓ Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ˆ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÚfiÛÊ·Ù˘ ÌÂϤÙ˘, ·ÛıÂÓ›˜ ËÏÈΛ·˜ 60 ÂÙÒÓ Î·È ¿Óˆ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ıÓËÙfiÙËÙ·˜ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û˘ÁÎÚÈÙÈο Ì ·˘ÙÔ‡˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌÔۯ‡̷ٷ ·fi ȉÂÒ‰ÂȘ ‰fiÙ˜ (14.4% vs. 9.1%). ΔÔ Úfi‚ÏËÌ· ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Á›ÓÂÙ·È ·ÎfiÌ· ÌÂÁ·Ï‡ÙÂÚÔ fiÙ·Ó ÔÈ Ï‹Ù˜ ¿Óˆ ÙˆÓ 60 ÂÙÒÓ ¤¯Ô˘Ó Î·È ¿ÏÏ· Û˘Ó˘¿Ú¯ÔÓÙ· ÓÔÛ‹Ì·Ù·9. ™Â ·ÚÎÂÙ¿ ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÂÊ·ÚÌfi˙ÂÙ·È Ë ·Ú¯‹ ηٷÓÔÌ‹˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ‚¿ÛË ÙËÓ ËÏÈΛ·. ¢ËÏ·‰‹ ÁÈ· ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ÚÔ¯ˆÚË̤Ó˘ ËÏÈΛ·˜ ÚÔÙÈÌÔ‡ÓÙ·È ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜ Ï‹Ù˜ (old for old). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ÁÈ· Ó· ˘¿ÚÍÂÈ ˘„ËÏfi ÔÛÔÛÙfi ÂÈÙ˘¯›·˜ ı· Ú¤ÂÈ Ó· ˘¿Ú¯Ô˘Ó ‰‡Ô ‚·ÛÈΤ˜ ÚÔ¸Ôı¤ÛÂȘ: Ô ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Ó· Â›Ó·È ‚Ú·¯‡˜ Î·È Ô Ï‹Ù˘ Ó· ÌËÓ ¤¯ÂÈ ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È Ó· ÌËÓ Â›Ó·È Â˘·ÈÛıËÙÔÔÈË̤ÓÔ˜ (΢ÙÙ·ÚÔÙÔÍÈο ·ÓÙÈÛÒÌ·Ù· <5%). ªÂ ·˘Ù¤˜ ÙȘ ÚÔ¸Ôı¤ÛÂȘ Ë 3ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÂÚ›Ô˘ ›‰È·

46

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Ì ·˘Ù‹ ÙˆÓ ÏËÙÒÓ fiÔ˘ Ô ‰fiÙ˘ Â›Ó·È ÌÈÎÚfiÙÂÚ˘ ËÏÈΛ·˜ ¿ÙÔÌÔ (64% vs. 67% Î·È 70% vs. 71%, ·ÓÙ›ÛÙÔȯ·)10. ™Â ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤¯ÂÈ ‰ÈÂÚ¢ÓËı› Ë Â›‰Ú·ÛË Ù˘ ¯Ú‹Û˘ ·ÓÙÏ›·˜ ¿Ú‰Â˘Û˘ Ì ÛÎÔfi ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜. º·›ÓÂÙ·È fiÙÈ Ë ¯Ú‹ÛË Ù˘ ·ÓÙÏ›·˜ ÂÚÈÔÚ›˙ÂÈ ÙÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ·ÏÏ¿ ‰ÂÓ ÂËÚ¿˙ÂÈ ÙËÓ 2ÂÙ‹ ‹ 3ÂÙ‹ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ.

∫·Ù¿ÏÏËÏÔÈ Ï‹Ù˜ ÁÈ· ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· OÈ ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ÌÔÚÔ‡Ó Ó· Â›Ó·È ‰˘ÓËÙÈÎÔ› Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· Â›Ó·È ·˘ÙÔ› Ô˘ Â›Ó·È ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 40 ÂÙÒÓ Î·È Â›Ù ¤¯Ô˘Ó ÈÛÙÔÚÈÎfi ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Â›Ù ÚfiÎÂÈÙ·È Ó· Ì›ÓÔ˘Ó Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÂÚÈÛÛfiÙÂÚ· ·fi 4 ¯ÚfiÓÈ·. ∂Âȉ‹ fï˜ ÔÈ Î·ÙËÁÔڛ˜ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓË Î·Ú‰È·ÁÁÂȷ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· ¯Ú‹˙Ô˘Ó È‰È·›ÙÂÚ· ÂÈÌÂÏÔ‡˜ ηډÈÔÏÔÁÈ΋˜ ÂÎÙ›ÌËÛ˘ ÚÈÓ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË.

OÈ ·ÛıÂÓ›˜ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ı· Ú¤ÂÈ Ó· ÚÔÙÈÌ¿Ù·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ÌfiÛ¯Â˘Ì· ·fi ȉÂÒ‰Ë ‰fiÙË Â›Ó·È ¿ÙÔÌ· ËÏÈΛ·˜ οو ÙˆÓ 40 ÂÙÒÓ ‹ Î·È ¿ÙÔÌ· ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 40 ÂÙÒÓ, ·ÏÏ¿ ¯ˆÚ›˜ ÈÛÙÔÚÈÎfi ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È Ì ÚÔÔÙÈ΋ ·Ó·ÌÔÓ‹˜ Û ϛÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏÈÁfiÙÂÚ· ·fi 4 ¯ÚfiÓÈ·. OÈ ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ÚfiÎÂÈÙ·È Ó· ˘Ô‚ÏËıÔ‡Ó Û ‰Â‡ÙÂÚË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Â›Û˘ ÚÔÙÈÌfiÙÂÚÔ Ó· Ï·Ì‚¿ÓÔ˘Ó ÌÔۯ‡̷ٷ ·fi ȉÂÒ‰ÂȘ ‰fiÙ˜.

∂ÈÏÔΤ˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì ‰fiÙË Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ŒÓ· ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÔÈ Ï‹Ù˜ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· Â›Ó·È Ë Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÙÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ Ù˘ ÔÔ›·˜ ˘ÂÚ‚·›ÓÂÈ ·˘Ùfi Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·fi ȉÂÒ‰Ë ‰fiÙË. ∏ ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤¯ÂÈ ‰˘ÛÌÂÓ‹ Â›‰Ú·ÛË Î·È ÛÙË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛ‹ ÙÔ˘. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ıÓËÙfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ÚÔ¯ˆÚË̤Ó˘ ËÏÈΛ·˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÌÔۯ‡̷ÙÔ˜ ηٿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ

ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ‰ÈÏ¿ÛÈ· (16% vs.

8%) ·˘ÙÒÓ Ô˘ ‰ÂÓ ÂÌÊ·Ó›˙Ô˘Ó Î·ı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. OÈ ·ÛıÂÓ›˜ ÚÔ¯ˆÚË̤Ó˘ ËÏÈΛ·˜, ÔÈ ÔÔ›ÔÈ Û˘ÓËı¤ÛÙÂÚ· Ï·Ì‚¿ÓÔ˘Ó ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·, ÂÌÊ·Ó›˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ı·Ó¿ÙÔ˘ ·fi ÏÔÈÌÒÍÂȘ. ∞ÓÙ›ıÂÙ· ÂÌÊ·Ó›˙Ô˘Ó ÌÂȈ̤ÓË Èı·ÓfiÙËÙ· ÔÍ›·˜ ·fiÚÚȄ˘. ∞fi ÔÚÈṲ̂ӷ ΤÓÙÚ· ·Ó·Ê¤ÚÂÙ·È Â›Û˘ ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ÂÈÏÔÎÒÓ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Û ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·.

∞ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÛÙÔ˘˜ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ªÈ· ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ˜ Ô˘ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë Â›Ó·È Ë ÂÍ·ÙƠ̂΢ÛË Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜. ∂Âȉ‹ Ù· ÓÂÊÚÈο ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Û˘ÓËı¤ÛÙÂÚ· Û ¿ÙÔÌ· ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜, ÔÈ ÔÔ›ÔÈ ÂÌÊ·Ó›˙Ô˘Ó Î·È ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ı·Ó¿ÙÔ˘ ·fi ÏÔÈÌÒÍÂȘ, ı· Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È Ë ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·ÓÔÛÔηٷÛÙÔÏ‹. §fiÁˆ Ù˘ ·˘ÍË̤Ó˘ Èı·ÓfiÙËÙ·˜ ηı˘ÛÙÂÚË̤Ó˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÔÚÈ·Îfi ‰fiÙË, ηÏfi Â›Ó·È Ó· ·ÔʇÁÂÙ·È Ë ¯ÔÚ‹ÁËÛË ÙˆÓ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ ηٿ ÙËÓ ·Ú¯È΋ Ê¿ÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶ÚÔÙÈÌ¿Ù·È ‰ËÏ·‰‹ ·Ú¯Èο Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈÛÒÌ·ÙÔ˜ ηٿ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘-2 ‹ ·ÓÙÈı˘ÌÔ΢ÙÙ·ÚÈ΋˜ ÛÊ·ÈÚ›Ó˘ Ì·˙› Ì ÎÔÚÙÈÎÔÂȉ‹ Î·È mycophenolate mofetil (MMF). ™Â ÌÂϤÙË Ì ·Ú¯È΋ ¯ÔÚ‹ÁËÛË ·ÓÙÈı˘ÌÔ΢ÙÙ·ÚÈ΋˜ ÛÊ·ÈÚ›Ó˘ ‹ alemtuzumab Î·È ¤Ó·ÚÍË ÙÔ˘ tacrolimus ÌÂÙ¿ ÙËÓ ÙÒÛË Ù˘ ÙÈÌ‹˜ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ οو ·fi 4mg/dl, ·Ó·Ê¤ÚÔÓÙ·È ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ 93% Î·È 74% ·ÓÙ›ÛÙÔȯ·11. ∏ Ï‹Ú˘ ·ÔÊ˘Á‹ ÙˆÓ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ Û˘Óԉ‡ÂÙ·È ·fi ˘„ËÏfi ÔÛÔÛÙfi ·fiÚÚȄ˘ ÂÓÒ Ë ¯ÔÚ‹ÁËÛË sirolimus Î·È MMF ¯ˆÚ›˜ ·Ó·ÛÙÔϤ· ηÏÛÈÓ¢ڛÓ˘ ‰ÂÓ ¤¯ÂÈ Â·ÚÎÒ˜ ÌÂÏÂÙËı› Û ÂÚÈÙÒÛÂȘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·. º·›ÓÂÙ·È fiÙÈ Ë Î·Ï‡ÙÂÚË ÂÈÏÔÁ‹ Â›Ó·È Ë ¯ÔÚ‹ÁËÛË ·ÓÙ·ÁˆÓÈÛÙÔ‡ ÙÔ˘ ˘Ô‰Ô¯¤· Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘-2, MMF Î·È ÎÔÚÙÈÎÔÂȉÒÓ Ì ̤ÙÚÈ· ¤ÎıÂÛË Û tacrolimus12.

METAMO™XEY™Eπ™ 2011

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∏ ¯Ú‹ÛË ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· Ô‰ËÁ› Û ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ‰ÔÙÒÓ, Ì›ˆÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÂÚÈÔÚÈÛÌfi Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·Ú·ÌÔÓ‹ ÙˆÓ ·ÛıÂÓÒÓ Û ÚfiÁÚ·ÌÌ· ·ÈÌÔοı·ÚÛ˘. Δ· ÓÂÊÚÈο ÌÔۯ‡̷ٷ Ù˘ ηÙËÁÔÚ›·˜ ·˘Ù‹˜ ÂÌÊ·Ó›˙Ô˘Ó ÌÂȈ̤ÓË Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË Û ۯ¤ÛË Ì ٷ ÌÔۯ‡̷ٷ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ȉÂÒ‰ÂȘ ‰fiÙ˜ Î·È ÁÈ· ÙÔ ÏfiÁÔ ·˘Ùfi ηÏfi Â›Ó·È Ó· Á›ÓÂÙ·È ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ Î·È ·ÍÈÔÏfiÁËÛË ÙˆÓ ÈÛÙÔÏÔÁÈÎÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ÚÈÓ ÂÌÊ˘Ù¢ıÔ‡Ó ÛÙÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ Ï‹Ù˜. ªÂ ‚¿ÛË Ù· ˘¿Ú¯ÔÓÙ· ‰Â‰Ô̤ӷ, ·ÛıÂÓ›˜ ËÏÈΛ·˜ οو ÙˆÓ 40 ÂÙÒÓ ‰ÂÓ Â›Ó·È ÔÈ Î·Ù·ÏÏËÏfiÙÂÚÔÈ Ï‹Ù˜ ÁÈ· Ù· ÌÔۯ‡̷ٷ ·˘Ù¿. ∞ÓÙ›ıÂÙ· ·ÛıÂÓ›˜ ¿Óˆ ÙˆÓ 40 ÂÙÒÓ Ì ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ· ‹ ¯ˆÚ›˜ ‰È·‚‹ÙË Ô˘ ÚfiÎÂÈÙ·È Ó· ·Ú·Ì›ÓÔ˘Ó ÁÈ· Ì·ÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Û ·ÈÌÔοı·ÚÛË Â›Ó·È Î·Ù¿ÏÏËÏÔÈ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·, ‰ÈfiÙÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ï‡ÙÂÚË ÂÈ‚›ˆÛË ·fi ·˘Ù‹Ó Ô˘ ÂӉ¯Ô̤ӈ˜ ı· ›¯·Ó Â¿Ó ·Ú¤ÌÂÓ·Ó Û ·ÈÌÔοı·ÚÛË. ™Â ÂÚÈÙÒÛÂȘ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ÔÚÈṲ̂ӷ ̤ÙÚ· Ì ÛÎÔfi ÙËÓ ÚfiÏË„Ë ÚÔ‚ÏËÌ¿ÙˆÓ Ô˘ Â›Ó·È Èı·Ófi Ó· ÂÌÊ·ÓÈÛÙÔ‡Ó. O ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Ú¤ÂÈ Ó· Â›Ó·È ÌÈÎÚfi˜, Ë ÂÊ·ÚÌÔÁ‹ ·ÓÙÏ›·˜ ¿Ú‰Â˘Û˘ ¯Ú‹ÛÈÌË Î·È Ë ÂÍ·ÙƠ̂΢ÛË Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ·Ó·Áη›·. OÈ Î‡ÚÈÔÈ ÛÙfi¯ÔÈ Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Ú¤ÂÈ Ó· Â›Ó·È Ë Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ÛÔ‚·ÚÒÓ ÏÔÈÌÒÍÂˆÓ Î·È Ô ÂÚÈÔÚÈÛÌfi˜ Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ Ì ·Ú¯È΋ ÂÏ·¯ÈÛÙÔÔ›ËÛË Ù˘ ‰fiÛ˘ ÙˆÓ ·Ó·ÛÙÔϤˆÓ ηÏÛÈÓ¢ڛÓ˘ ‹ ηı˘ÛÙ¤ÚËÛË Ù˘ ¤Ó·Ú͢ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ ̤¯ÚȘ fiÙÔ˘ ·Ú¯›ÛÂÈ Ó· ÌÂÈÒÓÂÙ·È Ë ÙÈÌ‹ Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡.

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): S114-S125.

2. Pascual J, Zamora J, Pirsch JD. A systematic review of kidney transplantation from expanded criteria donors.

Am J Kidney Dis 2008; 52: 553-586.

3. D’Agati VD and Cohen DJ. Pre-implantation renal biopsy: Structure does predict function. Transplantation 2003; 75: 264-266.

4. Escofet X, Osman H, Griffiths DF, Woydag S, Jurewicz WA. The presence of glomerular sclerosis at time zero has significant impact on function after cadaveric renal transplantation. Transplantation 2003; 75: 344-346.

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: 343-352.

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-emplantation graft biopsy in the outcome of renal transplantation. Ren Fail 2010; 32: 434-439.

7. 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.

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

9. Kauffman HM, McBride MA, Cors CS. Rosa AM, Wynn JJ. Harley mortality rates in older kidney recipients with comorbid risk factors. Transplantation 2007; 83: 404-410.

10. Cohen B, Smits JM, Haase B, et al. Expanding the donor pool to increase renal transplantation. Nephrol Dial Transplant 2005; 20: 34-41.

11. Stratta RJ, Rohr MS, Sundberg AK, et al. Intermediateterm outcomes with expanded criteria deceased donors in kidney transplantation: A spectrum or specter of quality ? Ann Surg 2006; 243: 594-601.

12. Ekberg H, Tedesco-Silva H, Demirbas A, et al. Symphony comparing standard immunosuppression to low-dose cyclosporine, tacrolimus or sirolimus in combination with MMF, daclizumab and corticosteroids in renal transplantation. N Engl J Med 2007; 357: 2562-2575.

¶ÚÔ‚Ï‹Ì·Ù· Ô˘ ÚÔÛÙ›ıÂÓÙ·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÃN∞ ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó·ÌÔÓ‹˜ ÁÈ· ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¢. OÈÎÔÓÔÌ›‰Ô˘

οı·ÚÛ˘, ÙÔ Û‡ÛÙËÌ· ˘Á›·˜ Ù˘ ¯ÒÚ·˜ Î·È Ù· ‰ËÌÔÁÚ·ÊÈο ÛÙÔȯ›· ÙˆÓ ·ÛıÂÓÒÓ. ¶·ÚfiÏ· ·˘Ù¿ Ë Û˘¯ÓfiÙÂÚË ·ÈÙ›· ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ı¿Ó·ÙÔ˜ ÙÔ˘ Ï‹ÙË. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÈÛÙˆı› Ë Û˘¯ÓfiÙËÙ· ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙÔ˘˜ ·ÈÌÔηı·ÈÚfiÌÂÓÔ˘˜ Ô˘ Â›Ó·È Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜, ηٷÁÚ¿„·Ì ·Ó·‰ÚÔÌÈο ÙË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ· ·ÛıÂÓÒÓ Ô˘ ‹Ù·Ó ÛÙË Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ·ÊÔÚÔ‡Û·Ó ·ÛıÂÓ›˜ ÂÓfi˜ ΤÓÙÚÔ˘ ·ÈÌÔοı·ÚÛ˘. ªÂÏÂÙ‹ıËÎ·Ó 515 ÓÂÊÚÔ·ı›˜ Ì ̤ÛË ËÏÈΛ· 61,5±15,6 Ô˘ ÂÓÙ¿¯ıËÎ·Ó Û ÙÚÈÛ‚‰ÔÌ·‰È·›Ô ÚfiÁÚ·ÌÌ· ·ÈÌÔοı·ÚÛ˘ ·fi ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 1992 ¤ˆ˜ ÙÔÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 2010. ∞ÔÎÏ›ÛÙËÎ·Ó ·ÛıÂÓ›˜ Ì ·Ú·ÎÔÏÔ‡ıËÛË <12 Ì‹Ó˜. ∞fi ·˘ÙÔ‡˜ 151 ›¯·Ó ÙȘ ÚÔ¸Ôı¤ÛÂȘ (ËÏÈΛ· <65 ÂÙÒÓ, ¯ˆÚ›˜ ÓÂfiÏ·ÛÌ·, ÂÓÂÚÁfi Ïԛ̈ÍË Î·È ÛÔ‚·Ú¿ ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù·) ÁÈ· ¤ÓÙ·ÍË ÛÙË Ï›ÛÙ· ·Ó‡ÚÂÛ˘ Û˘Ì‚·ÙÔ‡ و̷ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ ̤ÛË ËÏÈΛ· ‹Ù·Ó 49,3±12,5 ¤ÙË. ∂›ÎÔÛÈ ·ÛıÂÓ›˜ (13,2%) Ì ̤ÛË ËÏÈΛ· 42,7±11,6 ÌÂÙ·ÌÔۯ‡ıËÎ·Ó ÌÂÙ¿ ·fi 72 (12-180) Ì‹Ó˜. OÈ ˘fiÏÔÈÔÈ 131 ›¯·Ó ̤ÛË ËÏÈΛ· 49,3±12,5 ¯ÚfiÓÈ· Î·È Ì¤ÛË ‰È¿ÚÎÂÈ· ·ÈÌÔοı·ÚÛ˘ ηٿ ÙËÓ Î·Ù·ÁÚ·Ê‹ 79±52 Ì‹Ó˜. ™Â ·˘Ùfi ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÂÈ‚›ˆÛ ÙÔ 52% ÙˆÓ ·ÛıÂÓÒÓ. ∏ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ·˘ÙÒÓ Ì ËÏÈΛ· >50 Î·È <50 ¤ÙË, ˘ÔÏÔÁÈ˙fiÌÂÓË Ì Kaplan-ªeier ‹Ù·Ó 75,4% Î·È 84% ·ÓÙ›ÛÙÔȯ· Î·È Ë ‰ÂηÂÙ‹˜ 30,9% Î·È 48%.

10% ÙˆÓ ·ÛıÂÓÒÓ Â›¯Â ηډȷÁÁÂȷο ÚÔ‚Ï‹Ì·Ù· (ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, ·ÚÚ˘ı̛˜, ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔ¿ıÂÈ·) ηٿ ÙËÓ ¤ÓÙ·ÍË Û ·ÈÌÔοı·ÚÛË. ΔÔ ÔÛÔÛÙfi ·˘Í‹ıËΠÛÙÔ Ù¤ÏÔ˜ Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ Û 49% Î·È 42% ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ >50 Î·È <50 ·ÓÙ›ÛÙÔȯ·. ∏ ÂÈ̤ÚÔ˘˜ ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙËÓ ·Ú¯‹ Î·È ÛÙÔ Ù¤ÏÔ˜ Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ Ê·›ÓÔÓÙ·È ÛÙÔ˘˜ ›Ó·Î˜ 1 Î·È 2. 26 ·ÛıÂÓ›˜ (16%) ÂÌÊ¿ÓÈÛ·Ó ÓÂfiÏ·ÛÌ· Î·È 43 ·-

¶·Ú¿ ÙËÓ ÚfiÔ‰Ô Ô˘ ¤ÁÈÓ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜ ÛÙË ÓÂÊÚÔÏÔÁ›·, Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÈÌÔηı·ÈÚfiÌÂÓˆÓ ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È ÂÏ·Ùو̤ÓË Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ ËÏÈ˘). ΔÔ 50% ÙˆÓ ·ÈÙ›ˆÓ ı·Ó¿ÙÔ˘ ·ÔÙÂÏÔ‡Ó Ù· ηډȷÁÁÂȷο ÓÔÛ‹Ì·Ù· Î·È ·ÎÔÏÔ˘ıÔ‡Ó ÔÈ ÏÔÈÌÒÍÂȘ Î·È Ù· ÓÂÔÏ¿ÛÌ·Ù·1. Δ· ·ÁÁÂȷο ÚÔ‚Ï‹Ì·Ù· ÙˆÓ ·ÛıÂÓÒÓ Û ·ÈÌÔοı·ÚÛË ÔÊ›ÏÔÓÙ·È ·) Û ÎÏ·ÛÈÎÔ‡˜ ·ıÔÁÂÓÂÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Â›Ó·È Ë ˘¤ÚÙ·ÛË, Î·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘, Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È Û ÌÂÁ¿ÏË Û˘¯ÓfiÙËÙ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Î·È ‚) Û ÂȉÈÎÔ‡˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÙȘ ÌÂıfi‰Ô˘˜ ·ÈÌÔοı·ÚÛ˘ Î·È Â›Ó·È ‰È·Ù·Ú·¯¤˜ ËÏÂÎÙÚÔÏ˘ÙÒÓ, ‚ÈÙ·ÌÈÓÒÓ, ÊÏÂÁÌÔÓ‹, η¯ÂÍ›·, ·Ó·ÈÌ›·, ‰È¤ÁÂÚÛË ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Î.¿. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó fiÙÈ ·ÎfiÌË Î·È Ë ‹È· ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Úԉȷı¤ÙÂÈ Û ÂΉ‹ÏˆÛË Î·È ÂͤÏÈÍË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ Î·È fiÙÈ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â›Ó·È ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÂΉ‹ÏˆÛË Ù˘2. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÂÏ·ÙÙÒÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Î·Ú‰È·ÁÁÂÈ·ÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜ Î·È Ô‰ËÁ› Û ÂÏ¿ÙÙˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ È‰È·›ÙÂÚ· ÌÂÙ¿ ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ3. OÈ ÎÏ·ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ·ıËÚÔÁ¤ÓÂÛ˘ ·Ú·Ì¤ÓÔ˘Ó ‹ ÌÔÚ› Ó· ÂȉÂÈÓÒÓÔÓÙ·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏfiÁˆ ·ÚÂÓÂÚÁÂÈÒÓ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ıÂÚ·›·˜. O ۷ί·Ú҉˘ ‰È·‚‹Ù˘, Ë ‰˘ÛÏÈȉ·ÈÌ›· Î·È Ë ˘¤ÚÙ·ÛË Û˘Ó‹ıˆ˜ ÂȉÂÈÓÒÓÔÓÙ·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂ÎÏ›Ô˘Ó fï˜ ÔÈ ÂȉÈÎÔ› Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ˘ÔηٿÛÙ·ÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÙËÓ ÂÏ¿ÙÙˆÛË Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘. ∏ ·ÔÌ¿ÎÚ˘ÓÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ·˘ÙÒÓ Ô‰ËÁ› Û ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÊÚÔ·ıÒÓ Î·È ·˘Ùfi ·Ô‰ÂÈÎÓ‡ÂÙ·È Û fiϘ ÙȘ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ Ô˘ ‰ËÌÔÛȇıËÎ·Ó ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË ¯ÒÚ· ‰ÈÂÓ¤ÚÁÂÈ·˜ Ù˘ ÌÂϤÙ˘, ÙÔÓ ÙÚfiÔ ·ÈÌÔ-

48

METAMO™XEY™Eπ™ 2011

49

¶π¡∞∫∞™ 1. ∞ÛıÂÓ›˜ ËÏÈΛ·˜ <50 ÂÙÒÓ Ô˘ ‹Ù·Ó Û ϛÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·ÌÌ¿ÙˆÓ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ·ÈÌÔοı·ÚÛ˘ Î·È ÛÙÔ Ù¤ÏÔ˜ Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘.

35 30,4

% ασθενών <50 ετών στη λίστα

30

29,6

25

22,2

20 16,7

15 10

9,3 5,6

5

3,7

1,9

0 Στεφ. νόσος - OΕΜ - Αρρυθμίες - Περιφ. αγγειοπ.

¶π¡∞∫∞™ 2. ∞ÛıÂÓ›˜ ËÏÈΛ·˜ >50 ÂÙÒÓ Ô˘ ‹Ù·Ó Û ϛÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÌÂÙ·‚ÔÏ‹ ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·ÌÌ¿ÙˆÓ ÛÙËÓ ¤Ó·ÚÍË Ù˘ ·ÈÌÔοı·ÚÛ˘ Î·È ÛÙÔ Ù¤ÏÔ˜ Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘.

50 44,3

% ασθενών >50 ετών στη λίστα

45

38

40 35

30,4

30

26,6

25 20 15 10 5

5,1

5,1 1,3

3,8

0 Στεφ. νόσος - OΕΜ - Αρρυθμίες - Περιφ. αγγειοπ.

ÛıÂÓ›˜ (26%) ÂÌÊ¿ÓÈÛ·Ó ÛÔ‚·Ú¤˜ ‚·ÎÙËÚȷΤ˜ (ÂÓ‰Ôηډ›Ùȉ·, ÔÛÙÂÔÌ˘ÂÏ›Ùȉ· ÊÏÂÁÌÔÓ¤˜ ·ÛÙÂˆÓ Î.·.) Î·È ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ (΢ڛˆ˜ ÔÚÔÌÂÙ·ÙÚÔ‹ HCV).

OÈ ·ÛıÂÓ›˜ Ô˘ ÂÓÙ¿ÛÛÔÓÙ·È Û ϛÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ÓÂfiÙÂÚÔÈ Î·È Â›Ó·È Û ηχÙÂÚË Î·Ù¿ÛÙ·ÛË ·fi ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÎÚ›ÓÔÓÙ·È ·Î·Ù¿ÏÏËÏÔÈ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶·ÚfiÏ· ·˘Ù¿ ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ì ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ ·ÎfiÌ· Û ·˘Ù‹ ÙËÓ ÔÌ¿‰· Â›Ó·È ˘„ËÏfi. ™˘-

Ó‹ıˆ˜ Ë ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì ‰ÔÎÈÌ·Û›· ÎfiˆÛ˘ Î·È Ì ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì˘Ôηډ›Ô˘. ™Â Ó¤Ô˘˜ ·ÈÌÔηı·ÈÚfiÌÂÓÔ˘˜ ÙÔ ÔÛÔÛÙfi Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘, ·ÁÁÂÈÔÁÚ·ÊÈο ÂȂ‚·ÈˆÌ¤ÓÔ Î˘Ì·›ÓÂÙ·È ·fi 25% Î·È ÊÙ¿ÓÂÈ ÛÙÔ 85% ÛÙÔ˘˜ ËÏÈÎȈ̤ÓÔ˘˜Î·È ‰È·‚ËÙÈÎÔ‡˜. ∏ ‰ËÌÈÔ˘ÚÁ›· Â·Û‚ÂÛÙÒÛÂˆÓ ÛÙÔÓ Ì¤ÛÔ ¯ÈÙÒÓ· ÙˆÓ ÌÈÎÚÒÓ Î·È ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ Â›Ó·È Ë ·ÈÙ›· Ù˘ ÂÏ·Ùو̤Ó˘ ¢ÂÓ‰ÔÙfiÙËÙ·˜ (compliance) ÙˆÓ ·ÁÁ›ˆÓ Î·È Ù˘ ηډȿ˜.

OÈ ·ÚÚ˘ı̛˜ ÂÌÊ·Ó›˙ÔÓÙ·È Û˘¯ÓfiÙÂÚ· Ì ÙËÓ ·-

50

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Ú·ÌÔÓ‹ ÛÙËÓ ·ÈÌÔοı·ÚÛË ÏfiÁˆ ÌÂÁ¿ÏˆÓ Î·È ÁÚ‹ÁÔÚˆÓ ÌÂÙ·‚ÔÏÒÓ ÛÙÔÓ ÂÓ‰·ÁÁÂÈ·Îfi ¯ÒÚÔ, ËÏÂÎÙÚÔÏ˘ÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ·ÏÏ¿ Î·È Ù˘ ›ÓˆÛ˘ ÙÔ˘ Ì˘Ôηډ›Ô˘. O ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜ Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙÔ˘˜ ÓÂÊÚÔ·ı›˜. ∂ÎÙfi˜ ·fi ÙÔ˘˜ ·Ú·‰ÔÛÈ·ÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Ô˘ ÈÛ¯‡Ô˘Ó ÁÈ· ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (ÈÛ¯·ÈÌÈ΋ ÓfiÛÔ˜), ‰È¿ÊÔÚÔÈ ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Î·È Î·Ù·ÛÙ¿ÛÂȘ ÂȉÈÎÔ› ÁÈ· ÙËÓ ·ÈÌÔοı·ÚÛË ÂÌϤÎÔÓÙ·È ÛÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÈÊÓȉ›Ô˘ ı·Ó¿ÙÔ˘. ∞˘ÙÔ› ÔÈ ·Ú¿ÁÔÓÙ˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‰È¤ÁÂÚÛË ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡, ˘ÂÚÙÚÔÊ›· Ù˘ ·ÚÈÛÙÂÚ¿˜ ÎÔÈÏ›·˜, ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ÌÂÙ·‚ÔϤ˜ Ù˘ ‰ÔÌ‹˜ ÙÔ˘ Ì˘Ôηډ›Ô˘, fiˆ˜ ÂÓ‰ÔıËÏȷ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Î·È ‰È¿ÌÂÛË ›ÓˆÛË. ∞fi ÙË ‰È΋ Ì·˜ ÌÂϤÙË ·ÏÏ¿ Î·È ·fi ¿ÏϘ ·ÚfiÌÔȘ ηٷÁڷʤ˜ Ê·›ÓÂÙ·È fiÙÈ ·˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ fiÛÔ ·Ú·Ì¤ÓÔ˘Ó Û ·ÈÌÔοı·ÚÛË ¤¯Ô˘Ó ·˘Í·ÓfiÌÂÓË ÓÔÛËÚfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. ∏ ÌÂϤÙË ÙˆÓ Kianda Î·È Û˘Ó. ·ÊÔÚÔ‡Û ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË ·ÛıÂÓÒÓ Ô˘ ‹Ù·Ó Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÙÔ˘˜ Û˘Ó¤ÎÚÈÓ Ì ÔÌ¿‰· ·ÛıÂÓÒÓ Ô˘ ÎÚ›ıËÎ·Ó ·Î·Ù¿ÏÏËÏÔÈ ÁÈ· Ó· ˘Ô‚ÏËıÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¢È·›ÛÙˆÛ·Ó fiÙÈ Î·È ÔÈ ‰‡Ô ÔÌ¿‰Â˜ ÂÌÊ¿ÓÈÛ·Ó ·ÚfiÌÔÈ· ˘„ËÏ‹ ıÓËÙfiÙËÙ· ÌÂÙ¿ ·fi ¤ÍË ¤ÙË Î·È Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ı·Ó¿ÙÔ˘ ‹Ù·Ó ÔÏÏ·Ï¿ÛÈÔ˜ ÁÈ· ·ÛıÂÓ›˜ ·¯‡Û·ÚÎÔ˘˜, Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ Î·È ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔ¿ıÂÈ·4. ∂Ô̤ӈ˜ Ë Î·Ù·ÏÏËÏfiÙËÙ· ÂÓfi˜ ÓÂÊÚÔ·ıÔ‡˜ Ô˘ ÂÓÙ¿ÛÛÂÙ·È ÛÙË Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Û¯ÂÙÈ΋ Î·È ·ÊÔÚ¿ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ï›ÁˆÓ ÂÙÒÓ. ∏ ·Ú·ÌÔÓ‹ ÛÙËÓ ·ÈÌÔοı·ÚÛË ÚÔÛ·˘Í¿ÓÂÈ Ì ٷ¯‡ Ú˘ıÌfi Ù· ÓÔÛ‹Ì·Ù· ÙˆÓ ·ÁÁ›ˆÓ Î·È Ù˘ ηډȿ˜. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ ÂÈÙÒÛÂˆÓ Ô˘ ¤¯ÂÈ Ë Ì·ÎÚÔ¯ÚfiÓÈ· ·ÈÌÔοı·ÚÛË ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙËÓ ÂÈ‚›ˆÛË ÙfiÛÔ ÙÔ˘ Ï‹ÙË fiÛÔ Î·È ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. O Cosio Î·È Û˘Ó. Û ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ¤‰ÂÈÍ·Ó fiÙÈ Ô ¯ÚfiÓÔ˜ ·ÈÌÔοı·ÚÛ˘ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ı·Ó¿ÙÔ˘ p=0,0003 Î·È ·ÒÏÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ p=0,00035.

H U.S. Renal Data System (USRDS) ÂÚ¢ÓÒÓÙ·˜ ÙË ÛËÌ·Û›· ·˘ÙÒÓ ÙˆÓ ·Ú·Ì¤ÙÚˆÓ ·Ó¤Ï˘Û·Ó ÙȘ ηٷÁڷʤ˜ Ô˘ ˘‹Ú¯·Ó Û 73.103 ÌÂÙ·ÌÔۯ‡ÛÂȘ. ∞fi Ù· ‰Â‰Ô̤ӷ Ô˘ ˘‹Ú¯·Ó ‰È·›ÛÙˆÛ·Ó fiÙÈ Ë ÚÔÏËÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÚÔÛʤÚÂÈ ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· ÂÈ‚›ˆÛ˘. O ¯ÚfiÓÔ˜ Û ·ÈÌÔοı·ÚÛË ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹Ù·Ó ‰ÔÛÔÂÍ·Ú-

ÙÒÌÂÓÔ˜ ·Ú¿ÁˆÓ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ı¿Ó·ÙÔ ÙÔ˘ Ï‹ÙË ÙfiÛÔ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi ˙ÒÓÙ· ‰fiÙË fiÛÔ Î·È ÛÙȘ و̷ÙÈΤ˜6. ∞fi ÙË ÌÂϤÙË ·˘Ù‹ Ê¿ÓËΠfiÙÈ ·ÎfiÌË 6 ¤ˆ˜ 12 Ì‹Ó˜ ·ÈÌÔοı·ÚÛ˘ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Ó‰¤ÂÙ·È Ì 37% ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ì·ÎÚÔ¯ÚfiÓÈ· ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Û ۇÁÎÚÈÛË Ì ·˘ÙÔ‡˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÚÔÏËÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ‰ÂÓ ÚÔËÁ‹ıËΠ·ÈÌÔοı·ÚÛË. ∂›Û˘ ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÏÂÔÓ¤ÎÙËÌ· Ù˘ ¤ÁηÈÚ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ›¯Â ÈÛ¯‡ ÁÈ· ‰È·ÊÔÚÂÙÈο ÚˆÙÔ·ı‹ ÓÔÛ‹Ì·Ù· (۷ί. ‰È·‚‹Ù˘, ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ· Î·È ˘¤ÚÙ·ÛË Î·È ·Ô‰›‰ÔÓÙ·Ó Î˘Ú›ˆ˜ ÛÙËÓ Î·Ï‡ÙÂÚË ÂÈ‚›ˆÛË ÙˆÓ ÏËÙÒÓ Î·È ÏÈÁfiÙÂÚÔ ÛÙËÓ Î·Ï‡ÙÂÚË ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ηٷÚÁ‹ÛÂÈ ÙÔ ÚfiÏÔ Ù˘ ÔÈfiÙËÙ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì›· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ‹ÏÂÁÍ ÙËÓ ÂÈ‚›ˆÛË Û ˙‡ÁË ÓÂÊÚÒÓ fiÔ˘ Ô ¤Ó·˜ ÌÂÙ·ÌÔۯ‡ıËΠ۠ϋÙË Ì ‚Ú·¯‡ ¯ÚfiÓÔ ·ÈÌÔοı·ÚÛ˘ <6 Ì‹Ó˜ Î·È Ô ¿ÏÏÔ˜ Û ϋÙË Ì ¯ÚfiÓÔ ·ÈÌÔοı·ÚÛ˘ ¿Óˆ ·fi 2 ¤ÙË. ∏ ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÙˆÓ ÏËÙÒÓ Ì ¯ÚfiÓÔ ·ÈÌÔοı·ÚÛ˘ <6 Ì‹Ó˜ ›¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο Ì·ÎÚ‡ÙÂÚË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi fiÙÈ ÔÈ Ï‹Ù˜ Ì ·ÈÌÔοı·ÚÛË >24 Ì‹Ó˜ (63% ¤Ó·ÓÙÈ 29% p=0,0001)7. ∂›Û˘ Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó ηχÙÂÚË. ΔÔ ÏÂÔÓ¤ÎÙËÌ· Ù˘ ηχÙÂÚ˘ ÂÈ‚›ˆÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÈÛ¯‡ÂÈ ·ÎfiÌ· Î·È ÁÈ· ·˘ÙÔ‡˜ Ô˘ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÌÂÙ¿ ·fi Ì·ÎÚ‡ ‰È¿ÛÙËÌ· ·ÈÌÔοı·ÚÛ˘. ŸÏ˜ ÔÈ ÌÂϤÙ˜ Ô˘ ·Û¯ÔÏ‹ıËÎ·Ó Ì ÙÔ ı¤Ì· ÂȂ‚·ÈÒÓÔ˘Ó ·˘Ù¿ Ù· Â˘Ú‹Ì·Ù· Î·È ‰›ÓÔ˘Ó ¤ÌÊ·ÛË ÛÙËÓ ÛÔ˘‰·ÈfiÙËÙ· Ù˘ ¤ÁηÈÚ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ™ÙÔ ÛËÌÂ›Ô ·˘Ùfi ı· Ú¤ÂÈ Ó· ·Ó·ÊÂÚı› ÔÏϤ˜ ÔÈ ÚÔ·Ó·ÊÂÚı›Û˜ ÌÂϤÙ˜ ¤ÁÈÓ·Ó ÛÙȘ ∏¶∞ fiÔ˘ Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ ·ÈÌÔοı·ÚÛË ÌÂÈÔÓÂÎÙ› ÛËÌ·ÓÙÈο Û ۇÁÎÚÈÛË Ì ·˘Ù‹ ÙˆÓ ·ÈÌÔηı·ÈÚfiÌÂÓˆÓ ÛÙËÓ ∂˘ÚÒË Î·È ÙËÓ π·ˆÓ›·. ∞ÔÙÂϤÛÌ·Ù· ÌÂϤÙ˘ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ ¤‰ÂÈÍ fiÙÈ ·È‰È¿ Ì ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÚÔÏËÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›¯·Ó ηχÙÂÚË ÂÈ‚›ˆÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È Û ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË ·ãfiÙÈ ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÚÔËÁ‹ıËΠ·ÈÌÔοı·ÚÛË Û Ù¯ÓËÙfi ÓÂÊÚfi ‹ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË. (8,9) Œ¯ÔÓÙ·˜ ˘fi„Ë fiÏ· ·˘Ù¿ Ù· ·ÔÙÂϤÛÌ·Ù· ‡ÎÔÏ· ηٷÓÔ› ηÓ›˜ ÙÔ ÏÂÔÓ¤ÎÙËÌ· Ù˘ ÚÔÏËÙÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ù· ÔÔ›· ÂÂÎÙ›ÓÔÓÙ·È ¤Ú·Ó ÙˆÓ ÔÚÁ·ÓÈÎÒÓ ÂӉ›ÍˆÓ

METAMO™XEY™Eπ™ 2011

ŒÁηÈÚË ÌÂÙ·ÌfiÛ¯Â˘ÛË ··ÏÏ¿ÛÛÂÈ ÙÔÓ ·ÛıÂÓ‹ ·fi ÙÔ „˘¯ÔÏÔÁÈÎfi ÛÙÚ˜ Ù˘ ·ÈÌÔοı·ÚÛ˘, ‰È·ÛÒ˙ÂÈ Ù· ·ÁÁ›· ·fi ÙË ‰ÈÂÓ¤ÚÁÂÈ· ·ÚÙËÚÈÔÊÏ‚È΋˜ ÂÈÎÔÈÓˆÓ›·˜ Î·È ÎÔÛÙ›˙ÂÈ Ôχ ÏÈÁfiÙÂÚÔ ÁÈ· Ù· Ù·Ì›· Î·È ÙÔ ÎÚ¿ÙÔ˜. (10) ™·ÊÒ˜ ı· Ú¤ÂÈ Ó· Â›Ó·È Ë ıÂÚ·›· ÂÈÏÔÁ‹˜ ÁÈ· Ù· Ó¤· ¿ÙÔÌ· Ô˘ ¤¯Ô˘Ó ‰fiÙË. ∏ ÚÔÂÙÔÈÌ·Û›· fiÙ·Ó ÊÙ¿ÓÔ˘Ó ÛÙÔ ÚÔÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ¤ÏÂÁ¯Ô ÁÈ· ηٿÏÏËÏÔ ‰fiÙË Î·È ÁÈ· ÚÔÏËÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¢˘ÛÙ˘¯Ò˜ Ë ¤ÏÏÂÈ„Ë ÌÔÛ¯Â˘Ì¿ÙˆÓ ÛÙËÓ ∂ÏÏ¿‰· ÛÙÂÚ› ·fi ·˘Ù‹ ÙË Ú·ÎÙÈ΋ ÙÔ˘˜ ÓÂÊÚÔ·ı›˜ Ô˘ ‰ÂÓ ‰È·ı¤ÙÔ˘Ó ‰fiÙË. ™ã·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ı· Ú¤ÂÈ Ë ÚÔÂÙÔÈÌ·Û›· ÁÈ· ¤ÓÙ·ÍË ÛÙËÓ و̷ÙÈ΋ Ï›ÛÙ· Ó· Â›Ó·È Ù·¯Â›·. ΔÔ Û‡ÛÙËÌ· ·ÍÈÔÏfiÁËÛ˘ ÁÈ· ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ ‰fiÙË ·˘Ù‹ ÙË ÛÙÈÁÌ‹ ÛÙË ¯ÒÚ· Ì·˜ ‰ÂÓ Â˘ÓÔ› ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÌÈÎÚfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÈÌÔοı·ÚÛ˘. ∏ ÌÔÚÈÔ‰fiÙËÛË ÙÔ˘ Ï‹ÙË Ì ٷ ÂÚÈÛÛfiÙÂÚ· ÎÔÈÓ¿ ·ÓÙÈÁfiÓ· Î·È ÙÔÓ ÌÂÁ·Ï‡ÙÂÚÔ ¯ÚfiÓÔ Û ¿ÏÏË Ì¤ıÔ‰Ô ˘ÔηٿÛÙ·Û˘ ·Ú·Ù›ÓÂÈ ÙËÓ ·Ó·ÌÔÓ‹ ÛÙË Ï›ÛÙ· ÁÈ· ·Ó‡ÚÂÛË ÌÔۯ‡̷ÙÔ˜ Ì ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ ÙfiÛÔ ÛÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ Ï‹ÙË fiÛÔ Î·È ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ¶Ú·ÎÙÈΤ˜ ÁÈ· ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ‰ÔÙÒÓ, ÌÂÁÈÛÙÔÔ›ËÛË Ù˘ ·ԉȉfiÌÂÓ˘ ·ÈÌÔοı·ÚÛ˘ Î·È ‰˘Ó·ÙfiÙËÙ· ¤ÓÙ·Í˘ ÓÂÊÚÔ·ıÒÓ ÛÙË Ï›ÛÙ· ÁÈ· ÚÔÏËÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË fiÙ·Ó Ë ÛÂÈÚ·Ì·ÙÈ΋ ‰È‹ıËÛË Â›Ó·È <15 ml/min ı· ‹Ù·Ó Ë ÚfiÙ·ÛË ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË ÂÚ›ı·Ï„Ë ÙˆÓ ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ.

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μÈ‚ÏÈÔÁÚ·Ê›· 1. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipiens of a first cadaveric transplant N Engl J Med 1999; 341: 1725-30 2. Ritz ∂., Bommer J. Cardiovascular problems on hemodialysis: Current deficits and potential improvement.

Clin J Am Soc Nephrol 2009; 4: S71–S78.

3. Mann JF, Gerstein HC, Dulau-Florea I, Lonn E. Cardiovascular risk in patients with mild renal insufficiency.

Kidney Int 2003; 84: S192–S196.

4. Kianda MN, Wissing KM, Broeders NE, et al. Ineligibility for renal transplantation: prevalence, causes and survival in a consecutive cohort of 445 patients. Clin Transplant 2010.

5. Cosio GF, Alamir A, Yim S, Pesavento ET, et al. Survival after renal transplantation: I. The impact of dialysis pre-transplant. Kidney Int. 1998; 53: 767–772.

6. Meier -Kriesche HU, Port KF, Akinlolu O, et al. Effect of waiting time on renal transplant outcome. Kidney Int. 2000; 58: 1311–1317.

7. Meier-Kriesche HU, Kaplan B. Waiting time on dialysis as the strogest modifiable risk factor for renal transplant outcomes- a paired donor kidney analysis. Transplantation 2002; 74: 1377-1381.

8. Mange CK, Weirc ªR. Preemptive renal transplantation: Why not? Am J Transplant 2003; 3: 1336–1340.

9. Kasiske BL, Snyder JJ, Matas AJ, Ellison MD, Gill JS, Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged.J Am Soc Nephrol 2002; 13: 1358–1364.

10. Laupacis A, Keown P, Pus N, Krueger H, Ferguson B, Wong C, Muirhead N: A study of the quality of life and cost-utility of renal transplantation. Kidney Int 1996; 50: 235–242.

∂È‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ Û Â·Ó·ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡ Ì ÌÔۯ‡̷ٷ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ X.N. ™Î·ÏÈÒÙË

∏ ·ÒÏÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ·fiÙÔÎÔ˜ ΢ڛˆ˜ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÈÛÙÚÔÊ‹ ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ Â͈ÓÂÊÚÈ΋ οı·ÚÛË Î·È ÙË Û˘¯Ó‹ ·ÍÈÔÏfiÁËÛ‹ ÙÔ˘˜ ÂÎ Ó¤Ô˘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™‡Ìʈӷ Ì ÙÔ Organ Procurement and Transplantation Network (OƒΔ¡), ÙÔÓ 04/2011, ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÙˆÓ ∏¶∞, ÔÛÔÛÙfi 15,5% ÙˆÓ ÂÁÁÂÁÚ·ÌÌ¤ÓˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Â›Ó·È ˘Ô„‹ÊÈÔÈ ÁÈ· Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË.1 ∏ ÏÂÈÔ„ËÊ›· ÙˆÓ Ó¤ˆÓ ÂÁÁÚ·ÊÒÓ ÚÔ˜ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·Ó‹ÎÂÈ ÛÙËÓ ËÏÈÎȷ΋ ÔÌ¿‰· 18-49 ÂÙÒÓ Î·È Ê˘ÛÈο ·˘ÙÔ› Â›Ó·È ÔÈ ·ÛıÂÓ›˜ Ô˘ Û˘¯ÓfiÙÂÚ· Â·Ó·ÌÂÙ·ÌÔۯ‡ÔÓÙ·È. ¶ÔÛÔÛÙfi 31,5% ÂÎÂ›ÓˆÓ Ô˘ Â›Ó·È Î·Ù¿ÏÏËÏÔÈ ÁÈ· Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ PRA ≥20% ηٿ ÙËÓ ¤ÓÙ·ÍË ÛÙË Ï›ÛÙ·. ∏ ·ÚÔ˘Û›· ÚÔÛ¯ËÌ·ÙÈÛÌ¤ÓˆÓ anti-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ ÁÈ· Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Û ÌÂÁ·Ï‡ÙÂÚË ·Ó·ÏÔÁ›· Û ۯ¤ÛË Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜, ‰˘Û¯ÂÚ·›ÓÂÈ ÙËÓ ·Ó‡ÚÂÛË Î·Ù¿ÏÏËÏÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ·Ú·Ù›ÓÂÈ ÙÔ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÙÔ˘˜.2 Δ· ÙÂÏÂ˘Ù·›· ¤ÙË Î·Ù·‚¿ÏÏÂÙ·È ÚÔÛ¿ıÂÈ· Ó· Î·Ï˘Êı› ÙÔ ÎÂÓfi ·Ó¿ÌÂÛ· ÛÙËÓ ÚÔÛÊÔÚ¿ Î·È ÙË ˙‹ÙËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÙË ¯Ú‹ÛË ÓÂÊÚÒÓ ·fi ·Ô‚ÈÒÛ·ÓÙ˜ ‰fiÙ˜ «‰ÈÂ˘Ú˘Ì¤ÓˆÓ» ÎÚÈÙËÚ›ˆÓ. ∞Ó Î·È ÔÈ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·˘Ù¤˜ Û¯ÂÙ›˙ÔÓÙ·È ÂÍ’ ÔÚÈÛÌÔ‡ Ì Ùˆ¯fiÙÂÚË ¤Î‚·ÛË, Ê·›ÓÂÙ·È fiÙÈ Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì «ÔÚÈ·ÎÔ‡˜» ÓÂÊÚÔ‡˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Û ۇÁÎÚÈÛË Ì ÂΛÓÔ˘˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û οı·ÚÛË Î·È/‹ ·Ú·Ì¤ÓÔ˘Ó ÛÙË Ï›ÛÙ·.3 §·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë fiÙÈ ÙÔ ÔÛÔÛÙfi Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·Ú·Ì¤ÓÂÈ Û¯Â‰fiÓ ÛÙ·ıÂÚfi ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· Ù›ıÂÙ·È Â‡ÏÔÁ· ÙÔ ÂÚÒÙËÌ·: ∏ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ‰fiÙ˜ «‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ» Û˘Óԉ‡ÂÙ·È ·fi ·Ó¿ÏÔÁÔ fiÊÂÏÔ˜ ÛÙËÓ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ; ∞ÚÎÂÙ¤˜ ·ÌÊÈ‚Ôϛ˜ ÂÎÊÚ¿˙ÔÓÙ·È ÚÔ˜ ·˘Ù‹Ó ÙËÓ Î·Ù‡ı˘ÓÛË.

OÈ Sellers Î·È Û˘Ó4 ·ÚÔ˘Û›·Û·Ó ÙËÓ ÂÌÂÈ-

Ú›· ÙÔ˘˜ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ, ·ÏÏ¿ Î·È ÙÔ ÔÛÔÛÙfi ·ÛıÂÓÒÓ Ô˘ ·Ô‚ÈÒÓÔ˘Ó Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· Û ̛· ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ô˘ η٤ÁÚ·„ ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡ ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË, ÌÂٷ͇ 1999 Î·È 2001, ÛÙÔ ¡ÔÛÔÎÔÌÂ›Ô ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ Ù˘ Pensylvania. ∞Ó¤Ï˘Û·Ó ·Ú¿ÏÏËÏ· ÙÔ Û˘ÓÔÏÈÎfi ÎfiÛÙÔ˜ ÓÔÛËÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ ÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™˘ÌÂÚȤϷ‚·Ó 202 ·ÛıÂÓ›˜, Ì ÔÛÔÛÙfi Â·Ó·ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙˆÓ ·fi ‰fiÙ˜ «‰ÈÂ˘Ú˘Ì¤ÓˆÓ» ÎÚÈÙËÚ›ˆÓ Î·È ·fi «standard» ‰fiÙ˜ 3,46% Î·È 16,33%·ÓÙ›ÛÙÔȯ·. ¶·Ú·Ù‹ÚËÛ·Ó fiÙÈ Û ·˘Ù‹ ÙËÓ ˘ÔÔÌ¿‰·, Ë ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ‹Ù·Ó Û·ÊÒ˜ ÌÂȈ̤ÓË ÛÙÔ˘˜ Ï‹Ù˜ «ÔÚÈ·ÎÒÓ» ÌÔÛ¯Â˘Ì¿ÙˆÓ Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ¤Ï·‚·Ó «ÌË ÔÚȷο» ÌÔۯ‡̷ٷ Î·È Ì¿ÏÈÛÙ· Û ‚·ıÌfi ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi. ∏ ̤ÛË ÙÈÌ‹ ÎÚ·ÙÈÓ›Ó˘ ‹Ù·Ó ˘„ËÏfiÙÂÚË ÛÙÔ˘˜ Â·Ó·ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ˜ ·fi «ÔÚÈ·Îfi» ‰fiÙË Î·È fiˆ˜ Â›Ó·È ·Ó·ÌÂÓfiÌÂÓÔ ÙÔ ÔÛÔÛÙfi ı·Ó¿ÙˆÓ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· ‹Ù·Ó ÂÏ·Ùو̤ÓÔ. Δ· Â˘Ú‹Ì·Ù· ·˘Ù¿ ‰Â Ê¿ÓËΠӷ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ÔÛÔÛÙfi ÙˆÓ Î˘ÙÙ·ÚÔÙÔÍÈÎÒÓ ·ÓÙÈۈ̿وÓ. ∂ӉȷʤÚÔÓ ¤¯ÂÈ Ë ‰È·›ÛÙˆÛË fiÙÈ ÙÔ ÎfiÛÙÔ˜ ÓÔÛËÏ›·˜ ÙˆÓ ÏËÙÒÓ Ô˘ Â·Ó·ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó ·fi «ÔÚÈ·ÎÔ‡˜» ‰fiÙ˜ ‹Ù·Ó ηٿ 50% ˘„ËÏfiÙÂÚÔ Û˘ÁÎÚÈÙÈο Ì ϋÙ˜ «ÌË ÔÚÈ·ÎÒÓ» ÌÔÛ¯Â˘Ì¿ÙˆÓ. ΔÔ 2007 ÔÈ Miles Î·È Û˘Ó5 ‰ËÌÔÛ›Â˘Û·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ÌÂϤÙ˘ ·Ú·Ù‹ÚËÛ˘ Ì ı¤Ì· ÙËÓ ÂÈ‚›ˆÛË 9641 ÂÓ‹ÏÈÎˆÓ ·ÛıÂÓÒÓ ÔÈ ÔÔ›ÔÈ ÂÓÙ¿¯ıËÎ·Ó ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ‰Â‡ÙÂÚË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, ÌÂÙ¿ ·fi ·ÒÏÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÛÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô 1995-2004, Û‡Ìʈӷ Ì ÛÙÔȯ›· ÙÔ˘ Scientific Registry of Transplant Recipients (SRTR) ÙˆÓ ∏¶∞.

OÈ ·ÛıÂÓ›˜ ηٷÓÂÌ‹ıËÎ·Ó Û ÙÚÂȘ ÔÌ¿‰Â˜: – ∞ÛıÂÓ›˜ Ô˘ Â·Ó·ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó Ì ÌÔۯ‡̷ٷ ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË «‰ÈÂ˘Ú˘Ì¤ÓˆÓ» ÎÚÈÙËÚ›ˆÓ.

– ∞ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ‰Â‡ÙÂÚË ÌÂ-

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Ù·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ·Ô‚ÈÒÛ·ÓÙ˜, ÌË «ÔÚÈ·ÎÔ‡˜», ‰fiÙ˜.

– ∞ÛıÂÓ›˜ Ô˘ ‰ÂÓ Â·Ó·ÌÂÙ·ÌÔۯ‡ÙËηÓ. ∞fi ÙË ÌÂϤÙË ·ÔÎÏ›ÛÙËÎ·Ó ÔÈ ·ÛıÂÓ›˜ ÂΛÓÔÈ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ˙ÒÓÙ· ‰fiÙË. ∫·Ù¿ ÙËÓ Â·Ó¤ÓÙ·ÍË ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ηٷÁÚ¿ÊËÎ·Ó Ë Ì¤ÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ Î¿ı ÔÌ¿‰·˜, Ë Ê˘Ï‹, Ë ·ÚÔ˘Û›· ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË ˆ˜ ÚˆÙÔ·ıÔ‡˜ ·ÈÙ›Ô˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘, Ô Ì¤ÛÔ˜ ¯ÚfiÓÔ˜ ·Ú·ÌÔÓ‹˜ Û Â͈ÓÂÊÚÈ΋ οı·ÚÛË ÚÈÓ ÙËÓ ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, Ë ·ÚÔ˘Û›· PRA >0%, ηıÒ˜ Î·È ÙÔ ÔÛÔÛÙfi ÙˆÓ ˘Ô„ËÊ›ˆÓ Ô˘ ›¯·Ó ·Ú¯Èο ÌÂÙ·ÌÔÛ¯Â˘ı› ·fi ˙ÒÓÙ˜ ‰fiÙ˜ Î·È ‰fiÙ˜ «‰ÈÂ˘Ú˘Ì¤ÓˆÓ» ÎÚÈÙËÚ›ˆÓ. ¶·Ú·ÙËÚ‹ıËΠfiÙÈ Ë Ì¤ÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ÚÒÙ˘ ÔÌ¿‰·˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË Û ۯ¤ÛË Ì ÙȘ ‰‡Ô ¿ÏϘ ÔÌ¿‰Â˜ (46,5 ¤Ó·ÓÙÈ 42 Î·È 44,5 ¤ÙË ·ÓÙ›ÛÙÔȯ·). ∂ÈϤÔÓ, ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ì ÈÛÙÔÚÈÎfi ÚÒÙ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·fi «ÔÚÈ·Îfi» ‰fiÙË ‹Ù·Ó ˘„ËÏfiÙÂÚÔ ÛÙËÓ ÚÒÙË ÔÌ¿‰· (16% ¤Ó·ÓÙÈ 12% Î·È 13% ·ÓÙ›ÛÙÔȯ·). ∂·Ó·ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó 2908 ·ÛıÂÓ›˜, ‰ËÏ·‰‹ ÔÛÔÛfi 30%. ªÂٷ͇ ·˘ÙÒÓ, 292 ·ÛıÂÓ›˜ (10%) ˘Ô‚Ï‹ıËÎ·Ó Û ‰Â‡ÙÂÚË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË «‰ÈÂ˘Ú˘Ì¤ÓˆÓ» ÎÚÈÙËÚ›ˆÓ. ∏ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi «standard» ‰fiÙ˜ Û¯ÂÙ›ÛÙËΠ̛̠ˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ ηٿ 56% Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ·Ú¤ÌÂÈÓ·Ó Û Â͈ÓÂÊÚÈ΋ οı·ÚÛË ÌÂÙ¿ ÙËÓ ·ÒÏÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, fiˆ˜ ·Ó·Ê¤ÚÂÙ·È Î·È Û ·Ï·ÈfiÙÂÚ˜ ÌÂϤÙ˜.3 ∞ÓÙ›ıÂÙ·, ‰ÂÓ ÙÂÎÌËÚÈÒıËΠ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ fiÙ·Ó Û˘ÁÎÚ›ıËÎ·Ó ÔÈ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ‰Â‡ÙÂÚÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi «ÔÚÈ·Îfi» ‰fiÙË Ì ÂΛÓÔ˘˜ Ô˘ ·Ú¤ÌÂÈÓ·Ó ÛÙË Ï›ÛÙ·, ÂÓ ·Ó·ÌÔÓ‹ Èı·Ó‹˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ «standard» ÎÚÈÙËÚ›ˆÓ. ∂ÈÚfiÛıÂÙ· ·Ú·ÙËÚ‹ıËΠfiÙÈ ÔÈ Ï‹Ù˜ «ÔÚÈ·ÎÒÓ» ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë ÚÒÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ›¯Â ‰È¿ÚÎÂÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ 4 ÂÙÒÓ, ·ÚÔ˘Û›·Û·Ó ÌÂȈ̤ÓË ıÓËÙfiÙËÙ· Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û Â͈ÓÂÊÚÈ΋ οı·ÚÛË. ∏ ÚÒÈÌË ·ÒÏÂÈ· ÙÔ˘ ÚÒÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÈÎÚfiÙÂÚÔ ÙˆÓ 4 ÂÙÒÓ ‰Â Û˘Û¯ÂÙ›ÛÙËΠ̠·Ó¿ÏÔÁÔ fiÊÂÏÔ˜. ΔÔ ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓ˘ ¯ÔÚ‹ÁËÛ˘ ÈÛ¯˘ÚfiÙÂÚ˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Û ·˘Ù‹ ÙËÓ Î·ÙËÁÔÚ›· ·ÛıÂÓÒÓ Èı·ÓÒ˜ ÂÍËÁ› ·˘Ùfi ÙÔ Â‡ÚËÌ·.

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∞ÓÙ›ıÂÙ·, Ë Â·Ó·ÌÂÙ·ÌÔۯ‡ÛË ·fi ÌË «ÔÚÈ·ÎÔ‡˜» ‰fiÙ˜ Û¯ÂÙ›˙ÂÙ·È Ì ÌÂȈ̤ÓË ıÓËÙfiÙËÙ· Û˘ÁÎÚÈÙÈο Ì ÙȘ ‰‡Ô ¿ÏϘ ÔÌ¿‰Â˜, ·ÓÂÍ¿ÚÙËÙ· ÙÔ˘ ¯ÚfiÓÔ˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÚÒÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ¶ÂÚÈÔÚÈÛÌfi˜ Î·È ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È Ô ÌÈÎÚfi˜ ·ÚÈıÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Â·Ó·ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó ·fi ‰fiÙ˜ «‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ», ÁÂÁÔÓfi˜ ÙÔ ÔÔ›Ô ›Ûˆ˜ ·ÓÙÈηÙÔÙÚ›˙ÂÈ ÙË ‰ÈÛÙ·ÎÙÈÎfiÙËÙ· ÙˆÓ ˘Ô„‹ÊÈˆÓ ÏËÙÒÓ (‹ Î·È ÙˆÓ ÁÈ·ÙÚÒÓ ÙÔ˘˜) Ó· ÚÔ¯ˆÚ‹ÛÔ˘Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ˘fi ·˘Ù¤˜ ÙȘ ÚÔ¸Ôı¤ÛÂȘ. ∂›Û˘, Èı·ÓfiÓ ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÈϤÁÔÓÙ·È ˆ˜ ηٷÏÏËÏfiÙÂÚÔÈ ÁÈ· ÌÈ· Ù¤ÙÔÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó· Â›Ó·È ÏÈÁfiÙÂÚÔ ˘ÁÈ›˜ Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ Â·Ó·ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ·fi «standard» ‰fiÙ˜ ÓÂÊÚÔ‡. ¡· ÛËÌÂȈı› fiÙÈ ÔÈ ·Ú¿ÁÔÓÙ˜ Û˘Ó-ÓÔÛËÚfiÙËÙ·˜ ÁÈ· ÙÔ˘˜ ÔÔ›Ô˘˜ ¤ÁÈÓ ÚÔÛ·ÚÌÔÁ‹ ηٿ ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi Ù˘ ÂÈ‚›ˆÛ˘ ‹Ù·Ó ÂΛÓÔÈ Ô˘ ηٷÁÚ¿ÊËÎ·Ó fiÙ·Ó ÔÈ ˘Ô„‹ÊÈÔÈ Ï‹Ù˜ ÂÓÙ¿¯ıËÎ·Ó ÛÙË Ï›ÛÙ·. ∞ÓÙ›ıÂÙ· Ì ٷ ·Ú·¿Óˆ Â˘Ú‹Ì·Ù·, ÛÙÔȯ›· ·fi ÙÔ OPTN, ˘Ô‰ËÏÒÓÔ˘Ó Û˘ÁÎÚ›ÛÈÌ· ·ÔÙÂϤÛÌ·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ¤Î‚·ÛË Ù˘ ÚÒÙ˘ Û˘ÁÎÚÈÙÈο Ì ÙËÓ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ‰fiÙ˜ «‰ÈÂ˘Ú˘Ì¤ÓˆÓ» ÎÚÈÙËÚ›ˆÓ. ™‡Ìʈӷ Ì ÙËÓ ¤ÎıÂÛË ÙÔ˘ 2007, Ë ÂÙ‹ÛÈ· ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó 85,4% Î·È 84,3% ·ÓÙ›ÛÙÔȯ·, Ì Ì›ˆÛË ÙˆÓ ÔÛÔÛÙÒÓ Û 57,8% Î·È 51,3% ÛÙ· ¤ÓÙ ¯ÚfiÓÈ· Î·È ·ÎÔÏÔ‡ıˆ˜ ‰ÂηÂÙ‹ ÂÈ‚›ˆÛË Ù˘ Ù¿Í˘ ÙÔ˘ 28,6% Î·È 27,8% ·ÓÙ›ÛÙÔȯ·. (ÌË ÚÔÛ·ÚÌÔṲ̂ÓË ·Ó¿Ï˘ÛË).6 ª¤¯ÚÈ ÛÙÈÁÌ‹˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÈÛ¯˘Ú¿ ‰Â‰Ô̤ӷ Ô˘ Ó· ÙÂÎÌËÚÈÒÓÔ˘Ó ÛËÌ·ÓÙÈÎfi fiÊÂÏÔ˜ ˆ˜ ÚÔ˜ ÙËÓ ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÂÙ¿ ·fi Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË «‰ÈÂ˘Ú˘Ì¤ÓˆÓ» ÎÚÈÙËÚ›ˆÓ. °ÓˆÚ›˙Ô˘Ì Ôχ ηϿ fiÙÈ ÔÈ ˘Ô„‹ÊÈÔÈ ÚÔ˜ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏÔ‡Ó È‰È·›ÙÂÚË ÔÌ¿‰· ·ÛıÂÓÒÓ Ì ·ÚÎÂÙÔ‡˜ ·Ú¿ÁÔÓÙ˜ Û˘Ó-ÓÔÛËÚfiÙËÙ·˜ (ηډȷÁÁÂȷ΋ ÓfiÛÔ˜, ÂÚÈÊÂÚÈ΋ ·ÁÁÂȷ΋ ÓfiÛÔ˜, ۷ί·Ú҉˘ ‰È·‚‹Ù˘ Î.·.) Ô˘ ÂȉÂÈÓÒÓÔÓÙ·È fiÛÔ ÂÚÈÛÛfiÙÂÚÔ Î·ÈÚfi ·Ú·Ì¤ÓÂÈ Ô ·ÛıÂÓ‹˜ Û ·ÈÌÔοı·ÚÛË ‹ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË. ∂Ô̤ӈ˜ Ë ·ÍÈÔÏfiÁËÛË ÙÔ˘˜ ÚÈÓ ÙËÓ ¤ÓÙ·ÍË ÛÙË Ï›ÛÙ· Ú¤ÂÈ Ó· Â›Ó·È È‰›·ÈÙÂÚ· ÚÔÛÂÎÙÈ΋ Î·È ·˘ÛÙËÚ‹, ÂÓÒ Â›Ó·È ÛËÌ·ÓÙÈ΋ Ë Ù·ÎÙÈ΋ Â·ÓÂÎÙ›ÌËÛË Î·È Ë ÚÔÛ¿ıÂÈ· ÁÈ· ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÌÔÓ‹˜ ÙˆÓ Î·Ù¿ÏÏËÏˆÓ ˘Ô„ËÊ›ˆÓ Û οı·ÚÛË. ∞fi ÙËÓ ¿ÏÏË ÌÂÚÈ¿, ‰ÂÓ Ú¤ÂÈ Ó· ͯӿÌ fi-

54

X. ™∫∞§πøΔ∏

ÙÈ ·˘Ùfi Ô˘ ΢ڛˆ˜ ÂӉȷʤÚÂÈ ÙÔ˘˜ ·ÛıÂÓ›˜ Â›Ó·È Ë ÔÈfiÙËÙ· ˙ˆ‹˜ Î·È Ë ·Ô‰¤ÛÌ¢ÛË ·fi ÙȘ ÌÂıfi‰Ô˘˜ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘. ∫·Ù¿ Û˘Ó¤ÂÈ·, Ì ٷ ˘¿Ú¯ÔÓÙ· ‰Â‰Ô̤ӷ, Ë ·fiÊ·ÛË ÁÈ· Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ·Ô‚ÈÒÛ·ÓÙ· ‰fiÙË «‰ÈÂ˘Ú˘Ì¤ÓˆÓ» ÎÚÈÙËÚ›ˆÓ Ú¤ÂÈ Ó· ÂÍ·ÙÔÌÈ·ÂÙ·È, ÛÙ·ıÌ›˙ÔÓÙ·˜ Ù· ÔʤÏË Î·È ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘˜ Î·È ÂÓËÌÂÚÒÓÔÓÙ·˜ ÁÈ· ·˘Ù¿ ÙÔÓ ·ÛıÂÓ‹.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Organ Procurement and Transplantation Network, April 29, 2011.

2. Magee JC, Barr ML, Basadonna GP, Johnson MR, Mahadevan S et al. Repeat organ transplantation in the United States, 1996-2005. Am J Transpl 2007; 7(2): 1424-33.

3. Hirata M, Terasaki PI. Renal retransplantation. Clin Transpl 1994; 419-433.

4. Sellers MT, Velidedeoglou E, Bloom RD, Grossman RA, Markmann JW et al. Expanded-criteria donor kidneys: Asingle-center clinical and short –term financial analysis-Cause for concern in retransplantation. Transpl 2004; 78: 1670-75.

5. Miles CD, Schaubel DE, Jia X, Ojo AO, Port FK et al.

Mortality experience in recipients undergoing repeat transplantation with expanded criteria donor and nonECD deceased-donor kidneys. Am J Transpl 2007; 7: 1140-47.

6. Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients 2009 Annual Report. Unadjusted Graft Survival, Deceased Donor ECD Kidney Transplants Survival at 3 Months, 1 Year, 5 Years, and 10 Years.

ª∂Δ∞ªO™Ã∂Y™∂π™ ¡∂ºƒOY: ™Y¡Y¶∞ƒ•∏ Oƒπ∞∫OY ªO™Ã∂Yª∞ΔO™ ª∂ Oƒπ∞∫O §∏¶Δ∏

55

∞ÓÔÛÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂ȉÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË Û non-HLA ·ÓÙÈÁfiÓ· (MICA, ÂÓ‰ÔıËÏȷο, ·˘ÙÔ·ÓÙÈÁfiÓ·) A. πÓȈٿÎË

∂›Ó·È ÁÓˆÛÙfi fiÙÈ ÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙÔ˜ ÔÚÁ¿ÓÔ˘ Â›Ó·È Ë ÚÒÙË ÁÚ·ÌÌ‹ ¿Ì˘Ó·˜ ·ÏÏ¿ Î·È Ô ÚÒÙÔ˜ ÛÙfi¯Ô˜ Ù˘ ¯˘ÌÈ΋˜ Î·È Î˘ÙÙ·ÚÈ΋˜ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ ÙÔ˘ Ï‹ÙË ÛÙ· ͤӷ ·ÓÙÈÁfiÓ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (¿ÏÏÔ-·¿ÓÙËÛË). ¶ÚÔÛ¯ËÌ·ÙÈṲ̂ӷ ·ÓÙÈÛÒÌ·Ù· ·ÏÏ¿ Î·È ·ÓÙÈÛÒÌ·Ù· Ô˘ ·Ú¿ÁÔÓÙ·È de novo ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔÚÔ‡Ó Ó· ηٷÛÙÚ¤„Ô˘Ó ÙÔ ÂÓ‰Ôı‹ÏÈÔ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ›Ù ¿ÌÂÛ· ÂÓÂÚÁÔÔÈÒÓÙ·˜ ÙÔ Û˘Ìϋڈ̷ ›Ù ¤ÌÌÂÛ· Ì ΢ÙÙ·ÚÔÙÔÍÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È ·fi Ù· ›‰È· Ù· ·ÓÙÈÛÒÌ·Ù· OÈ Î‡ÚÈÔÈ ÛÙfi¯ÔÈ Ù˘ ·ÏÏÔ·¿ÓÙËÛ˘ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ Â›Ó·È Ù· ÚÔÈfiÓÙ· ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (MHC) ‰ËÏ·‰‹ ÂÈÊ··ÓÂȷΤ˜ ÚˆÙ›Ó˜ ÁÓˆÛÙ¤˜ Û·Ó HLA-A,B,C,DR,DQ Î·È DP. ∂Âȉ‹ Ù· ·ÓÙÈÁfiÓ· ·˘Ù¿ ÂÎÊÚ¿˙ÔÓÙ·È Î·È ÛÙ· ÏÂÌÊÔ·ÙÙ·Ú·, ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ Í¤ÓˆÓ HLA ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ˘Ô„‹ÊÈÔ˘ ‰fiÙË ·ÓȯÓ‡ÔÓÙ·È Ì ÙËÓ ÎÏ·ÛÈ΋ ‰ÔÎÈÌ·Û›· ÈÛÙÈ΋˜ ‰È·ÛÙ·‡ÚˆÛ˘ (crossmatch) ÛÙËÓ ÔÔ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÔÚfi˜ ÙÔ˘ Ï‹ÙË Î·È ÏÂÌÊÔ·ÙÙ·Ú· ÙÔ˘ ‰fiÙË. ∂ÎÙfi˜ fï˜ ·fi Ù· HLA-ÌfiÚÈ·, Û‹ÌÂÚ· ÁÓˆÚ›˙Ô˘Ì fiÙÈ ÙÔ ÂÓ‰Ôı‹ÏÈÔ ÂÎÊÚ¿˙ÂÈ Î·È ¤Ó· ÌÂÁ¿ÏÔ ·ÚÈıÌfi ‰È·ÊÔÚÂÙÈÎÒÓ ·fi Ù· HLA ·ÓÙÈÁfiÓˆÓ Ù· ÔÔ›· ‰ÂÓ ÂÎÊÚ¿˙ÔÓÙ·È ÛÙ· ÏÂÌÊÔ·ÙÙ·Ú·. Δ· ·ÓÙÈÁfiÓ· ·˘Ù¿ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È Ì ÙÔ ÁÂÓÈÎfi fiÚÔ non-HLA ·ÓÙÈÁfiÓ· Î·È ·ÔÙÂÏÔ‡Ó Â›Û˘ ÛÙfi¯Ô Ù˘ ¯˘ÌÈ΋˜ Î·È Î˘ÙÙ·ÚÈ΋˜ ¿ÏÏÔ-·¿ÓÙËÛ˘ ÙÔ˘ Ï‹ÙË.

ÙˆÓ ‚ÈÔ„ÈÒÓ Ì C4d ıÂÙÈÎfiÙËÙ· ‰ÂÓ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ·ÓÙÈ- HLA ·ÓÙÈÛˆÌ¿ÙˆÓ Û˘ÓËÁÔÚ› ˘¤Ú Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ non -HLA ÛÙfi¯ˆÓ ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜. ∞ÓÙÈÛÒÌ·Ù· Û non- HLA ·ÓÙÈÁfiÓ· Ô˘ ·ÓÙȉÚÔ‡Ó Ì ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· Î·È ÌÔÓÔ‡ÚËÓ· (¤Ó· Û‡ÛÙËÌ· Ô˘ ÔÓÔÌ¿˙ÂÙ·È ∂ª) ‹ ÌfiÓÔ Ì ÂÓ‰Ôı‹ÏÈÔ, ¤¯Ô˘Ó ·Ó·ÎÔÈÓˆı› fiÙÈ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ηٷÛÙÚÔÊÈ΋ Â›‰Ú·ÛË ÛÙ· ÌÂÙ·ÌÔÛ¯Â˘ı¤ÓÙ· fiÚÁ·Ó·. ŒÓ·˜ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓÔ˜ ·ÚÈıÌfi˜ ‰ËÌÔÛȇÛÂˆÓ ˘ÔÛÙËÚ›˙ÂÈ fiÙÈ ·ÓÙÈÛÒÌ·Ù· Û non-HLA ·ÓÙÈÁfiÓ· Û˘Û¯ÂÙ›˙ÔÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ˘ÂÚÔÍ›·˜, ÂÈÙ·¯˘ÓfiÌÂÓ˘ Î·È ÔÍ›·˜ ·ÁÁÂȷ΋˜ ·fiÚÚȄ˘. ¶ÂÚÈÛÙ·ÙÈο ˘ÂÚÔÍ›·˜ ·fiÚÚȄ˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê‹ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi HLA Ù·˘ÙfiÛËÌ· ·‰¤ÏÊÈ·. ™ÙËÓ ÔÌ¿‰· ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ê·›ÓÂÙ·È fiÙÈ Ë ¯˘ÌÈ΋ ¿ÏÏÔ-·¿ÓÙËÛË Û nonHLA ·ÓÙÈÁfiÓ· ÌÔÚ› Ó· ¢ı‡ÓÂÙ·È ÁÈ· ÙȘ ¿Óˆ ·fi 80% ÌË ·ÓÙÈÛÙÚÂÙ¤˜ ·ÔÚÚ›„ÂȘ. ∂˘·ÈÛıËÙÔÔ›ËÛË Û non-HLA ·ÓÙÈÁfiÓ· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Û¯ÂÙ›ÛıËÎÂ Î·È Ì ¯ÚfiÓÈ· ·fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜ Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi HLA Û˘Ì‚·Ùfi ·‰ÂÏÊfi, ˘ÔÛÙËÚ›˙ÔÓÙ·˜ ÙÔ ÚfiÏÔ Ù˘ non-HLA ¿ÏÏÔ-·ÓÔÛ›·˜ ÛÙË ¯ÚfiÓÈ· ·fiÚÚÈ„Ë.

∂ȉÈÎfiÙËÙ· Ù˘ non-HLA ·ÏÏÔ·¿ÓÙËÛ˘ OÈ ÛÙfi¯ÔÈ Ù˘ non-HLA ¿ÏÏÔ-·ÓÔÛ›·˜ ÌÔÚ› Ó· Â›Ó·È ÔÏ˘ÌÔÚÊÈο ·ÓÙÈÁfiÓ· fiˆ˜ Ù· ÂÓ‰ÔıËÏȷο ·ÓÙÈÁfiÓ·, Ù· ÌË-ÎÏ·ÛÛÈο HLA-∂ ÌfiÚÈ·, Î·È Ù· Major histocompatibility complex (MHC) classIrelated chain A (MICA) Î·È MICB ·ÓÙÈÁfiÓ· ·ÏÏ¿ Î·È Ù· ÌË ÔÏ˘ÌÔÚÊÈο ÈÛÙÈο ·˘ÙÔ·ÓÙÈÁfiÓ·.

∏ ·Ó¿ÁÎË ·Ó›¯Ó¢Û˘ non-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙËÓ ÎÏÈÓÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ∂›Ó·È ÁÓˆÛÙfi fiÙÈ ·Ú¿ ÙȘ ·ÚÓËÙÈΤ˜ ÏÂÌÊÔ΢ÙÙ·ÚÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÈÛÙÈ΋˜ ‰È·ÛÙ·‡ÚˆÛ˘ Ô˘ ‚ÔËıÔ‡Ó ÛÙËÓ ·Ó›¯Ó¢ÛË ÂȉÈÎÒÓ ÛÙÔ ÌfiÛ¯Â˘Ì· HLA ·ÓÙÈۈ̿وÓ, ÂÚ›Ô˘ 10-15% ÙˆÓ ÓÂÊÚÒÓ ¯¿ÓÔÓÙ·È ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ·Ú·Ù‹ÚËÛË Â›Û˘ fiÙÈ ÂÚÈÛÛfiÙÂÚ˜ ·fi 10%

∂Ó‰ÔıËÏȷο ·ÓÙÈÁfiÓ· Î·È ·ÓÙÈ- ÂÓ‰ÔıËÏȷο ·ÓÙÈÛÒÌ·Ù· Δ· ÂÓ‰ÔıËÏȷο ·ÓÙÈÛÒÌ·Ù· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê‹ ÁÈ· ÚÒÙË ÊÔÚ¿ ÙÔ 1976 ·fi ÙËÓ ÔÌ¿‰· ÙÔ˘

57

58

∞. π¡πøΔ∞∫∏

Stastny Î·È ¯·Ú·ÎÙËÚ›ÛıËÎ·Ó ¤ÙÛÈ ÁÈ·Ù› ·ÚÔ˘Û›·˙·Ó ΢ÙÙ·ÚÔÙÔÍÈ΋ ·ÓÙ›‰Ú·ÛË Û ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÙÔ˘ ÔÌÊ·Ï›Ô˘ ÏÒÚÔ˘ ÂÓÒ ‰ÂÓ ¤‰ÈÓ·Ó Î·Ì›· ·ÓÙ›‰Ú·ÛË Ì ÏÂÌÊÔ·ÙÙ·Ú· ·fi ÙÔ ÔÌÊ·ÏÔÏ·ÎÔ˘ÓÙÈ·Îfi ·›Ì· ÙˆÓ ›‰ÈˆÓ ‰ÔÙÒÓ. ™‹ÌÂÚ·, Ù· ·ÓÙÈÛÒÌ·Ù· ·˘Ù¿ ·ÓȯÓ‡ÔÓÙ·È Ì ¢·›ÛıËÙ˜ Ù¯ÓÈΤ˜ ΢ÙÙ·ÚÔÌÂÙÚ›·˜ ÚÔ‹˜. ∞˘Ù¿ Ù· ·ÓÙÈÛÒÌ·Ù· ‰›ÓÔ˘Ó ıÂÙÈ΋ ·ÓÙ›‰Ú·ÛË Ì ÙÔ ÂÓ‰Ôı‹ÏÈÔ Î¿ÔÈˆÓ ‰ÔÙÒÓ Î·È ·ÚÓËÙÈ΋ Ì ÙÔ ÂÓ‰Ôı‹ÏÈÔ Î¿ÔÈˆÓ ¿ÏψÓ, ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ Ù· Ù˘Èο ÔÏ˘ÌÔÚÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ¿ÏÏÔ-·ÓÙÈۈ̿وÓ. Δ· ·ÓÙÈ-ÂÓ‰ÔıËÏȷο ·ÓÙÈÛÒÌ·Ù· ¤¯ÂÈ ‚ÚÂı› fiÙÈ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÔÍ›· Î·È ¯ÚfiÓÈ· ·fiÚÚÈ„Ë. Δ· ·ÓÙÈ – ÂÓ‰ÔıËÏȷο ·ÓÙÈÛÒÌ·Ù· Â¿ÁÔ˘Ó ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘, ·fiÙˆÛË Î·È Î˘ÙÙ·ÚÈ΋ ‚Ï¿‚Ë. Δ· ·ÓÙÈ-ÂÓ‰ÔıËÏȷο ·ÓÙÈÛÒÌ·Ù· ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó Ì›· ÂÙÂÚÔÁÂÓ‹ ÔÌ¿‰· ·fi IgM Î·È IgG Ù¿Í˘ ·ÓÙÈÛÒÌ·Ù· Ô˘ ηÙ¢ı‡ÓÔÓÙ·È Û ÔÈΛϷ ·ÓÙÈÁfiÓ· Ô˘ ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ. Δ· ·ÓÙÈÁfiÓ· ·˘Ù¿ ÌÔÚ› Ó· Â›Ó·È ÚˆÙ›Ó˜ Ô˘ ÂÎÊÚ¿˙ÔÓÙ·È ÌfiÓÔ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ Î·È ¤¯Ô˘Ó ªμ 97-110 kDa ‹ ÚˆÙ›Ó˜ Ô˘ ÂÎÊÚ¿˙ÔÓÙ·È Û ÂÓ‰Ôı‹ÏÈÔ Î·È ÌÔÓÔ‡ÚËÓ· Î·È ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ªμ 38-40 kDa, 54 kDa, 60 kDa,90-100 kDa ‹ 97-110 kDa. ∞Ó¿ÌÂÛ· ÛÙ· ÂÓ‰ÔıËÏȷο ·ÓÙÈÁfiÓ· Â›Ó·È Î·È Ë Tie-2 Ù˘ÚÔÛÈÓÈ΋ ÎÈÓ¿ÛË, ˘Ô‰Ô¯¤·˜ Ù˘ ·ÁÁÂÈÔÔÈËÙ›Ó˘.

Tie-2 ıÂÙÈο ·ÙÙ·Ú· ÙÔ˘ ‰fiÙË ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û‹ÌÂÚ· Û ‰ÔÎÈÌ·Û›· ÈÛÙÈ΋˜ ‰È·ÛÙ·‡ÚˆÛ˘ (XNONE crossmatch) ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÂÓ‰ÔıËÏÈ·ÎÒÓ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ‰fiÙË.

MICA ·ÓÙÈÁfiÓ· Î·È ·ÓÙÈ- MICA ·ÓÙÈÛÒÌ·Ù· Δ· MICA Έ‰ÈÎÔÔÈÔ‡ÓÙ·È ·fi ÁÔÓ›‰È· Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ MHC ÂÚÈÔ¯‹ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ 6. ∂›Ó·È ȉȷ›ÙÂÚ· ÔÏ˘ÌÔÚÊÈο ÌfiÚÈ· Ì ÂÚÈÛÛfiÙÂÚ· ·fi 68 ÁÓˆÛÙ¿ ·ÏÏËÏfiÌÔÚÊ·. £ÂˆÚÔ‡ÓÙ·È ÛÙfi¯ÔÈ Ù˘ ¿ÏÏÔ-·¿ÓÙËÛ˘ ÏfiÁˆ ÙÔ˘ ÔÏ˘ÌÔÚÊÈÛÌÔ‡ ÙÔ˘˜ Î·È ÙÔ˘ ÁÂÁÔÓfiÙÔ˜ fiÙÈ ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ ÌÂÙ¿ stress ÏfiÁˆ Ù˘ ‚Ï¿‚˘ ηٿ ÙËÓ ÈÛ¯·ÈÌ›· - Â·Ó·ÈÌ¿ÙˆÛË Î·È Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·fiÚÚȄ˘. MICA ·ÓÙÈÛÒÌ·Ù· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÔÍ›· Î·È ¯ÚfiÓÈ· ·fiÚÚÈ„Ë ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·Ú‰È¿, ÓÂÊÚÒÓ Î·È ·ÁÎÚ¤·ÙÔ˜. ∂ÈϤÔÓ, ÚÔ-¢·ÈÛıËÙÔÔ›ËÛË ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤Ó·ÓÙÈ MICA ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ‰fiÙË Û˘Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÌÔÚ› Ó· ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ·ÒÏÂÈ· ÌÔۯ‡̷ÙÔ˜ Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi HLA Û˘Ì‚·Ùfi ‰fiÙË.

πÛÙÈο ·˘ÙÔ·ÓÙÈÁfiÓ· Î·È ·˘Ùfi-·ÓÙÈÛÒÌ·Ù· ŸÙ·Ó ÂϤÁ¯Ô˘Ì ÔÚÔ‡˜ ÁÈ· ·ÓÙÈÛÒÌ·Ù· Û ¿ÓÂÏ ÊÚ¤ÛÎˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ ·Ú·ÙËÚԇ̠‰‡Ô Ù‡Ô˘˜ ·ÓÙȉڿÛˆÓ. ∏ Ì›· Â›Ó·È Ì›· ÔÏ˘ÌÔÚÊÈ΋ ·ÓÙ›‰Ú·ÛË fiÔ˘ οÔÈ· ·ÙÙ·Ú· Â›Ó·È ıÂÙÈο ÂÓÒ ¿ÏÏ· ‰ÂÓ ·ÓÙȉÚÔ‡Ó. ∞˘Ù¿ Ù· ·ÓÙÈÛÒÌ·Ù· Â›Ó·È ·ÓÙÈ- ÂÓ‰ÔıËÏȷο ·ÓÙÈÛÒÌ·Ù·. ∂ÈϤÔÓ fï˜ ˘¿Ú¯Ô˘Ó ÔÚÔ› Ô˘ ·ÓÙȉÚÔ‡Ó Ì fiÏ· Ù· ·ÙÙ·Ú· ÙÔ˘ ¿ÓÂÏ. OÈ ·ÓÙȉڿÛÂȘ ·˘Ù¤˜ Â›Ó·È Û˘¯Ó¿ Ôχ ¤ÓÙÔÓ˜ Î·È fiÏ· Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ·fi Ù˘¯·›Ô˘˜ ‰fiÙ˜ Â›Ó·È ıÂÙÈο. Œ¯ÂÈ ˘ÔÙÂı› fiÙÈ ·˘Ù¿ Ù· ·ÓÙÈÛÒÌ·Ù· ·Ó·ÁÓˆÚ›˙Ô˘Ó ·˘Ùfi-·ÓÙÈÁfiÓ·. ∏ ‚ÈÌÂÓÙ›ÓË Î·È Ô ˘Ô‰Ô¯¤·˜ Ù‡Ô˘ π Ù˘ ·ÁÁÂÈÔÙÂÓÛ›Ó˘ ππ (∞Δ1R) Â›Ó·È Ù· ηχÙÂÚ· ÌÂÏÂÙË̤ӷ ·˘Ùfi-·Ó·ÓÙÈÁfiÓ· ·¤Ó·ÓÙÈ ÛÙ· ÔÔ›· ·Ó·Ù‡ÛÛÂÙ·È ·˘ÙÔ¿ÓÔÛË ·¿ÓÙËÛË Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÔÍ›· Î·È ¯ÚfiÓÈ· ·fiÚÚÈ„Ë ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ‰ËÌÈÔ˘ÚÁ›· ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙË ‚ÈÌÂÓÙ›ÓË ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙË ‰ËÌÈÔ˘ÚÁ›· ÂȉÈÎÒÓ ÛÙË ‚ÈÌÂÓÙ›ÓË ·˘Ùfi-‰Ú·ÛÙÈÎÒÓ CD8+ T ΢ÙÙ¿ÚˆÓ. OÍ›· ·fiÚÚÈ„Ë Î·Ú‰È·ÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ·fi ÚÔÛ¯ËÌ·ÙÈṲ̂ӷ ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ηډȷ΋ Ì˘ÔÛ›ÓË. Ã˘ÌÈ΋ Î·È Î˘ÙÙ·ÚÈ΋ ·¿ÓÙËÛË ÛÙÔ ÎÔÏÏ·ÁfiÓÔ V Î·È ÙËÓ ∫·1 ÙÔ˘ÌÔ˘Ï›ÓË Û˘Û¯ÂÙ›˙ÂÙ·È Ì ۇӉÚÔÌÔ ¯ÚfiÓÈ·˜ ηٷÛÙÚÔÊ‹˜ ÙˆÓ ‚ÚÔÁ¯ÈÔÏ›ˆÓ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ó¢ÌfiÓˆÓ. Δ¤ÏÔ˜ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ÚfiÛÊ·Ù· Û ÂÈÚ·Ì·Ùfi˙ˆ· fiÙÈ IgM «Ê˘ÛÈο » ·ÓÙÈÛÒÌ·Ù· ·Ó·ÁÓˆÚ›˙Ô˘Ó «›‰È·» ·ÓÙÈÁfiÓ· Î·È Â˘ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ‚Ï¿‚˘ ·fi ÈÛ¯·ÈÌ›·- Â·Ó·ÈÌ¿ÙˆÛË. º·›ÓÂÙ·È fiÙÈ ÔÈ Û˘Óı‹Î˜ ˘ÔÍ›·˜ ηٿ ÙËÓ ÈÛ¯·ÈÌ›· ÚÔηÏÔ‡Ó ÙËÓ ¤ÎÊÚ·ÛË “Ó¤Ô-·ÓÙÈÁfiÓˆÓ” Ô˘ ÌÂÙ¿ ÙË Û‡Ó‰ÂÛË ÙÔ˘˜ ÌÂ Ê˘ÛÈο ·ÓÙÈÛÒÌ·Ù· ÚÔηÏÔ‡Ó Î˘ÙÙ·ÚÈ΋ ‰È‹ıËÛË ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ Û˘ÌÏËÚÒÌ·ÙÔ˜.

∞ÏÏËÏÂ›‰Ú·ÛË ÌÂٷ͇ ¿ÏÏÔ-¿ÓÔÛ˘ Î·È ·‡ÙÔ-¿ÓÔÛ˘ ·¿ÓÙËÛ˘ ÛÙËÓ ·fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜. ™˘Ó¯Ҙ ÂÓÈÛ¯‡ÂÙ·È Ë ¿Ô„Ë fiÙÈ ¿ÏÏÔ-¿ÓÔÛ˜ ··ÓÙ‹ÛÂȘ Î·È ÂȉÈΤ˜ Û ÈÛÙÔ‡˜ ·ÓÔÛÔÏÔÁÈΤ˜ ··ÓÙ‹ÛÂȘ (·˘Ùfi-¿ÓÔÛ˜ ··ÓÙ‹ÛÂȘ) ÏÂÈÙÔ˘ÚÁÔ‡Ó ÂÓÔÚ¯ÈÛÙڈ̤ӷ ÁÈ· Ó· ÂÓÈÛ¯‡ÛÔ˘Ó ÙËÓ ·fiÚÚÈ„Ë ÌÔۯ‡̷ÙÔ˜. OÈ ¿ÏÏÔ-¿ÓÔÛ˜ ··ÓÙ‹ÛÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÙ¿ ¿ÌÂÛË ‹ ¤ÌÌÂÛË ·Ó·ÁÓÒÚÈÛË ÙˆÓ Í¤ÓˆÓ ·ÓÙÈÁfiÓˆÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ™ÙËÓ ¿ÌÂÛË ·Ó·ÁÓÒÚÈÛË HLA Ù¿Í˘ π Î·È ππ ·ÓÙÈÁfiÓ· ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·-

METAMO™XEY™Eπ™ 2011

ÓÙÈÁfiÓ· Ô˘ ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ·fi Ù· Δ ÏÂÌÊÔ·ÙÙ·Ú· ÙÔ˘ Ï‹ÙË. ∞˘Ùfi˜ ÈÛÙ‡ÂÙ·È fiÙÈ Â›Ó·È Ô ÚÒÙÔ˜ Ì˯·ÓÈÛÌfi˜ Ô˘ Ô‰ËÁ› ÛÙË ‰ËÌÈÔ˘ÚÁ›· ΢ÙÙ·ÚÔÙÔÍÈÎÒÓ Δ Î˘ÙÙ¿ÚˆÓ Î·È ·ÓÙÈ- HLA ·ÓÙÈÛˆÌ¿ÙˆÓ Ù· ÔÔ›· ÚÔηÏÔ‡Ó ÙÚ·˘Ì·ÙÈÛÌfi ÛÙÔ ÌfiÛ¯Â˘Ì·. ∞fi ÙÔÓ ÙÚ·˘Ì·ÙÈÛÌfi ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È ·ÏÏÔ-·ÓÙÈÁfiÓ· Î·È “›‰È·” ·ÓÙÈÁfiÓ· Ô˘ ÛÙË Û˘Ó¤¯ÂÈ· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì¤Ûˆ Ù˘ ¤ÌÌÂÛ˘ Ô‰Ô‡ ÛÙ· Δ Î‡ÙÙ·Ú· ÙÔ˘ Ï‹ÙË Î·È ÚÔηÏÔ‡Ó ¿ÏÏÔ- Î·È ·˘Ùfi-‰Ú·ÛÙÈΤ˜ ΢ÙÙ·ÚÈΤ˜ Î·È ¯˘ÌÈΤ˜ ·ÔÚÚ›„ÂȘ. ∏ ¤ÌÌÂÛË Ô‰fi˜ ·ÚÔ˘Û›·Û˘ ÙˆÓ ·ÓÙÈÁfiÓˆÓ ÈÛÙ‡ÂÙ·È fiÙÈ Â›Ó·È Ô Î‡ÚÈÔ˜ ‰ÚfiÌÔ˜ Ô˘ Ô‰ËÁ› ÛÙË ¯ÚfiÓÈ· ·fiÚÚÈ„Ë. ŸÙ·Ó È Ë ¤ÌÌÂÛË ¿ÏÏÔ-·Ó·ÁÓÒÚÈÛË ÍÂÎÈÓ‹ÛÂÈ ÌÔÚ› Ó· ÂÍ·ψı› Û Ӥ· ͤӷ ·ÓÙÈÁfiÓ·, Ì›· ‰È·‰Èηۛ· Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È Û·Ó ÂÍ¿ψÛË Ù˘ ¿ÏÏÔ-·¿ÓÙËÛ˘ Û ӤԢ˜ ÂÈÙfiÔ˘˜. ™˘ÌÂÚ·ÛÌ·ÙÈο Ë ·˘ÙÔ¿ÓÔÛË ·¿ÓÙËÛË ÌÔÚ› Ó· ·ÎÔÏÔ˘ı› ÙËÓ ¿ÏÏÔ-‰Ú·ÛÙÈÎfiÙËÙ· Ô˘ ÚÔηÏÂ›Ù·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓÔ˘. ∂›Ó·È ÛËÌ·ÓÙÈÎfi Ó· ηıÔÚÈÛı› Ë Ê‡ÛË ÙˆÓ nonHLA ·ÓÙÈÁfiÓˆÓ Î·È ·˘Ùfi-·ÓÙÈÁfiÓˆÓ Ô˘ Â›Ó·È ÔÈ

59

ÛÙfi¯ÔÈ Ù˘ ¯˘ÌÈ΋˜ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓÔ˘, Ó· ‰È·Ï¢ηÓıÔ‡Ó ÔÈ Ì˯·ÓÈÛÌÔ› Î·È Ë ·ıÔÁ¤ÓÂÈ· ÙˆÓ non-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È Ó· ·Ó·Ù˘¯ıÔ‡Ó Ó¤Â˜ ̤ıÔ‰ÔÈ ıÂÚ·¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘.

μÈ‚ÏÈÔÁÚ·Ê›· Peter Stastny, Yizhou Zou,Yisun fan,Zhiqiang qin, Bhavna Lavingia. The emerging issue of MICA antibodies: antibodies to MICA and other antigens of endothelial cells. Contrib Nephrol,Basel, Karger, 2009, 162: 99-106.

Suchitra Sumitran-Holgersson. Relevance of MICA and other non-HLA antibodies in clinical transplantation.

Curr Opin Immunol, 2008; 20: 607-613.

Qiuheng Zhang and Elaine F Reed. Non-MHC antigenic targets of the humoral immune response in transplantation. Curr opin Immunol, 2010; 22: 682-688.

Zou Y, Stastny P. Role of MICA in the immune response to transplants. Tissue antigens 2010; 76: 171-176.

Qiquan Sun, Zhen Cheng, Dongrui Cheng et al. De novo development of circulating anti-endothelial cell antibodies rather than pre-existing antibodies is associated with post –transplant allograft rejection. Kidney International, 2011; 79: 655-662.

TÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ·fiÚÚȄ˘ ÛÙËÓ ÂÈ‚›ˆÛË ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ £. ∞ÔÛÙfiÏÔ˘

ÙËÙ·˜ ‚Ï¿‚˘ ηٿ ÙËÓ Û˘ÓÙ‹ÚËÛË, ÙËÓ ·¿ÓÙËÛË ÛÙ· Ê¿Ú̷η Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜, Ô˘ ÔÏϤ˜ ÊÔÚ¤˜ Â›Ó·È ÓÂÊÚÔÙÔÍÈο, ÂÓÒ Ê·›ÓÂÙ·È Ó· ·˘Í¿ÓÂÙ·È ÙÔ ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ˘¤ÚÙ·Û˘ ÛÂ Û˘ÁÎÂÎÚÈ̤ÓÔ˘˜ Ï‹Ù˜ Ù¤ÙÔÈˆÓ ÔÚÁ¿ÓˆÓ. ∂ÈÚfiÛıÂÙ·, Ë ‰È·Ù‹ÚËÛË Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ÈηÓÔ‡ ·ÚÈıÌÔ‡ Ù¤ÙÔÈˆÓ ÏËÙÒÓ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ ·˘ÍË̤ÓÔ ÎfiÛÙÔ˜ (·˘ÍË̤ÓË ÓÔÛËÏ›·, ·‡ÍËÛË ÏÔÈÌÒÍÂˆÓ ÎÏ). ∂ÎÙfi˜ ·˘ÙÒÓ, Ê·›ÓÂÙ·È fiÙÈ Ë ÂÈ‚›ˆÛË ·˘ÙÒÓ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ˘ÔÏ›ÂÙ·È ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ Ì ÛÙ·ıÂÚ¿ ηıÔÚÈṲ̂ӷ ÎÚÈÙ‹ÚÈ· (6-8 ¯ÚfiÓÈ· Û ·ÓÙ›ıÂÛË Ì 10-12 ¯ÚfiÓÈ· ·ÓÙ›ÛÙÔȯ·). ∏ ÔÏÈÙÈ΋ ·˘Ù‹ Ù˘ ·Ô‰Ô¯‹˜ Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ¤ÊÂÚ ·‡ÍËÛË ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÓÂÊÚÔ‡, Ì›ˆÛË Ù˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜, ÏfiÁˆ ·ÎÚÈ‚Ò˜ Ù˘ ÔÈfiÙËÙ·˜ ÙˆÓ ÔÚÁ¿ÓˆÓ, ·ÏÏ¿ Î·È ·‡ÍËÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. Δ· ÚÒÙ· ·ÔÙÂϤÛÌ·Ù· ‹Ù·Ó fï˜ ÂÓı·ÚÚ˘ÓÙÈο. ¢È·ÈÛÙÒıËΠfiÙÈ ÌÂÈÒıËÎÂ Ë ıÓËÙfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ ÛÙË Ï›ÛÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÂÓÒ ÙÔ fiÊÂÏÔ˜ ·fi ÌÂÙ·ÌÔۯ‡ÛÂȘ Ù¤ÙÔÈˆÓ ÔÚÁ¿ÓˆÓ Ê¿ÓËΠӷ ˘¿Ú¯ÂÈ Î˘Ú›ˆ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜ ÙˆÓ 40 ÂÙÒÓ, ÛÙÔ˘˜ ¤Á¯ÚˆÌÔ˘˜ Î·È ÛÙÔ˘˜ ∞ÛÈ¿Ù˜. ªÂÁ¿ÏÔ fiÊÂÏÔ˜ Ê¿ÓËΠӷ ˘¿Ú¯ÂÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ÌÂÁ¿ÏÔ˘˜ ¯ÚfiÓÔ˘˜ ·Ó·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ·ÓÙ›ıÂÛË Ì ·˘ÙÔ‡˜ Ô˘ ‹Ù·Ó Ó¤ÔÈ Î·È Â›¯·Ó Ôχ Ï›ÁÔ ¯ÚfiÓÔ ÛÙËÓ ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ÌÈ· ¿ÏÏË ·Ó¿Ï˘ÛË ‰Â‰ÔÌ¤ÓˆÓ fiÔ˘ ·Ó·Ï‡ıËÎ·Ó ÂÚ›Ô˘ 52000 ·ÛıÂÓ›˜ Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, (¤ÙË UNOS 1994-2000) fiÔ˘ ÂÍÂÙ¿ÛıËÎ·Ó ÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÒÏÂÈ· ÌÔۯ‡̷ÙÔ˜ Û ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÓÂÊÚÔ‡˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· Û ۇÁÎÚÈÛË Ì ·˘ÙÔ‡˜ Ì ٷ ηıÈÂڈ̤ӷ ÎÚÈÙ‹ÚÈ·, ¤‰ÂÈÍ fiÙÈ ÔÈ ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÌÈÎÚ‹ ËÏÈΛ· (<18 ¯ÚfiÓȈÓ), Ë ∞ÊÚÔ·ÌÂÚÈοÓÈÎË ÚԤϢÛË, Ô ÌÂÁ¿ÏÔ˜ ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜, Ë „˘¯Ú‹ ÈÛ¯·ÈÌ›· >24 ÒÚ˜, Ë ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË HLA ·Û˘Ì‚·ÙfiÙËÙ·˜, Î·È Ù· ΢ÙÙ·ÚÔÙÔÍÈο ·ÓÙÈÛÒÌ·Ù· ¤·È˙·Ó ÛËÌ·ÓÙÈÎfi

ªÈ· ·fi ÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ ÚÔÎÏ‹ÛÂȘ ÛÙÔ ¯ÒÚÔ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·ÔÙÂÏ› Ë ¤ÏÏÂÈ„Ë ÔÚÁ¿ÓˆÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÁÈ· Ó· ·˘ÍËı› Ë ‰ÂÍ·ÌÂÓ‹ ÙˆÓ Èı·ÓÒÓ ‰ÔÙÒÓ, ‰È·ÌÔÚÊÒıËÎ·Ó Ó¤· ÎÚÈÙ‹ÚÈ· ÁÈ· ‰ˆÚ¿ ÔÚÁ¿ÓˆÓ. ŒÙÛÈ ÚԤ΢„·Ó ÔÈ ÔÚÈ·ÎÔ› ‰fiÙ˜ ‹ ‰fiÙ˜ ÔÚÁ¿ÓˆÓ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ·. ∞˘ÙÔ› ‹Ù·Ó ‰fiÙ˜ ÔÚÁ¿ÓˆÓ Ô˘ ÏËÚÔ‡Û·Ó ÌÂÚÈο ‹ fiÏ· ·fi Ù· ÂÍ‹˜. ∂›¯·Ó ˘ÔÛÙ› ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ, ›¯·Ó ˘¤ÚÙ·ÛË, ·˘ÍË̤ÓË ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ (>1.5 mg%) Î·È ËÏÈΛ· > ·fi 50 ‹ 65 ¯ÚfiÓˆÓ. Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÌÂÙ¿ ÙÔ 2000 fiÏÔ Î·È ÂÚÈÛÛfiÙÂÚÔÈ ‰fiÙ˜ ·Ó‹ÎÔ˘Ó Û ·˘Ù‹ ÙËÓ Î·ÙËÁÔÚ›·. ŒÙÛÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ·ԂȈۿÓÙˆÓ ‰ÔÙÒÓ ÔÚÁ¿ÓˆÓ Ô˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔÈ Û ËÏÈΛ· ·fi 50 ¯ÚfiÓˆÓ ¤¯ÂÈ ÊÙ¿ÛÂÈ ÙÔ 30-35%.

OÈ Ï›ÛÙ˜ ˘Ô„ËÊ›ˆÓ ‰ÔÙÒÓ .¯. ÛÙȘ ∏¶∞, ¤¯Ô˘Ó ·˘ÍËı› ηٿ 260% ÂÓÒ Ô ·ÚÈıÌfi˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ¤¯ÂÈ ·˘ÍËı› ÌfiÓÔÓ Î·Ù¿ 16%. ™˘ÓÂÒ˜ ˘¿Ú¯ÂÈ ϤÔÓ ¤Ó· ÙÂÚ¿ÛÙÈÔ ¯¿ÛÌ· ÌÂٷ͇ ÚÔÛÊÔÚ¿˜ Î·È ˙‹ÙËÛ˘ ÔÚÁ¿ÓˆÓ. ΔÔ Úfi‚ÏËÌ· ÛÙÔÓ ∂ÏÏËÓÈÎfi ¯ÒÚÔ Â›Ó·È ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚÔ. ŒÙÛÈ Ë Ï›ÛÙ· ˘Ô„ËÊ›ˆÓ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ Á›ÓÂÈ Ï›ÛÙ· «ı·Ó¿ÙÔ˘’ ÌÈ· Î·È ÂÚ›Ô˘ 6% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÚÈ̤ÓÔ˘Ó ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Âı·›ÓÔ˘Ó Î¿ı ¯ÚfiÓÔ Â˘ÚÈÛÎfiÌÂÓÔÈ Û Â͈ÓÂÊÚÈ΋ οı·ÚÛË.. ΔÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ·‰È¤ÍÔ‰Ô ÛÙËÓ ÚÔÛÊÔÚ¿ ÔÚÁ¿ÓˆÓ ¤¯ÂÈ ÛÙÚ¤„ÂÈ ÙȘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈΤ˜ ÔÌ¿‰Â˜ Û ·Ó·ÛÎfiËÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ·Ô‰Ô¯‹˜ ÔÚÁ¿ÓˆÓ. ŒÁÈÓ ·Ô‰ÂÎÙfi fiÙÈ ˘¿Ú¯ÂÈ ·fiÏ˘ÙË ·Ó¿ÁÎË ÁÈ· ̤ÁÈÛÙË ‰˘Ó·Ù‹ ·ÍÈÔÔ›ËÛË ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ Èı·ÓfiÙËÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÔÚÁ¿ÓˆÓ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ·ÚÔ˘ÛÈ¿˙ÂÈ fï˜ Î·È ¤ÓÙÔÓÔ ÚÔ‚ÏËÌ·ÙÈÛÌfi ΢ڛˆ˜ ˆ˜ ÚÔ˜ ÙËÓ ÌÂȈ̤ÓË ÂÈ‚›ˆÛË Ù¤ÙÔÈˆÓ ÔÚÁ¿ÓˆÓ. Δ¤ÙÔÈÔ˘ ›‰Ô˘˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ, ·Ó ‰ÂÓ ·ÎÔÏÔ˘ıËı› ÌÈ· ÂÈÏÂÁ̤ÓË ÔÏÈÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ¤¯Ô˘Ó ÌÈ· ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÌË ¿ÌÂÛ˘ ÏÂÈÙÔ˘ÚÁ›·˜, ·fiÚÚȄ˘ Î·È ÌÂÁ·Ï‡ÙÂÚ˘ Èı·Ófi-

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METAMO™XEY™Eπ™ 2011

ÚfiÏÔ ÁÈ· ÙËÓ ·ÒÏÂÈ· ÌÔۯ‡̷ÙÔ˜, Î·È Ë ÚfiÁÓˆÛË ·˘Ù‹ ‹Ù·Ó ·ÎfiÌË ¯ÂÈÚfiÙÂÚË Û ·ÛıÂÓ›˜ Ô˘ ›¯·Ó Ï¿‚ÂÈ ÓÂÊÚÔ‡˜ ·fi ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜. ŒÙÛÈ ¤‚Á·Ï·Ó ÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë Ï‹„Ë Ù¤ÙÔÈˆÓ ÔÚÁ¿ÓˆÓ ı· Ú¤ÂÈ Ó· ‰›ÓÂÙ·È Û ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÒÏÂÈ· ÌÔۯ‡̷ÙÔ˜. ΔÔ Ì¤ÁÈÛÙÔ Î·È Î‡ÚÈÔ fiÊÂÏÔ˜ ·fi Ù¤ÙÔÈ· ÌÔۯ‡̷ٷ Â›Ó·È fiÙÈ ÌÂÈÒÓÔ˘Ó ÙÔÓ ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÛÙËÓ Ï›ÛÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ‰›ÓÔ˘Ó ÙËÓ ‰˘Ó·ÙfiÙËÙ· ‰È·ÎÔ‹˜ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ¯ÚfiÓÈ·˜ ˘ÔÛÙ‹ÚÈ͢ ˘fi Â͈ÓÂÊÚÈ΋ οı·ÚÛË. ΔÔ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘ ·˘Í¿ÓÂÈ Û ۯ¤ÛË Ì ÙÔ Ó· ‚Ú›ÛÎÂÙ·È Î·Ó›˜ Û Â͈ÓÂÊÚÈ΋ οı·ÚÛË Î·È Û ϛÛÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. °È· ÙÔ˘˜ ·Ú·¿Óˆ ÏfiÁÔ˘˜, Û ·ÚÎÂÙ¤˜ ¯ÒÚ˜ ˘¿Ú¯ÂÈ Ï›ÛÙ· ˘Ô„ËÊ›ˆÓ ÏËÙÒÓ ·Ô‰Ô¯‹˜ Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ¤ÙÛÈ ˘¿Ú¯ÂÈ Ë Èı·ÓfiÙËÙ· Ù˘ ÁÚËÁÔÚfiÙÂÚ˘ ÚÔÔÙÈ΋˜ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÈ· Î·È Ù¤ÙÔȘ Ï›ÛÙ˜ ‰ÂÓ ÂÚȤ¯Ô˘Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ. ŸÛÔÓ ·ÊÔÚ¿ ÙÔÓ Î›Ó‰˘ÓÔ ·fiÚÚȄ˘ Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ˘¿Ú¯Ô˘Ó ·ÓÙÈÊ·ÙÈο ·ÔÙÂϤÛÌ·Ù·. ™Â ÌË ÂÈÏÂÁ̤ÓÔ˘˜ Ï‹Ù˜ ÔÚÁ¿ÓˆÓ, Ê·›ÓÂÙ·È Û οÔȘ ÌÂϤÙ˜ ¤Ó·˜ ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ·fiÚÚȄ˘ ·ÎfiÌË Î·È Û ËÏÈÎȈ̤ÓÔ˘˜ (>65 ÂÙÒÓ). ™Â ·˘ÛÙËÚ¿ ÂÈÏÂÁ̤ÓÔ˘˜ Ï‹Ù˜ fï˜ ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ·ÓÔÛÔÏÔÁÈ΋ ·ÓÙ›‰Ú·ÛË Î·È Ô Î›Ó‰˘ÓÔ˜ ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ·fiÚÚÈ„Ë ‰ÂÓ Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfiÙÂÚÔ˜ Û ۯ¤ÛË Ì ÙÔ˘˜ Ï‹Ù˜ ÔÚÁ¿ÓˆÓ Ì ÛÙ·ıÂÚ¿ Î·È Î·ıÔÚÈṲ̂ӷ ÎÚÈÙ‹ÚÈ·. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÚÁ¿ÓˆÓ Ì ÔÚÈ·ÎÔ‡˜ ‰fiÙ˜ ¤¯ÂÈ ·ÔÎÙ‹ÛÂÈ ÌÈ· Ó¤· ‰˘Ó·ÌÈ΋ Î·È ÔÏÔ¤Ó· ·˘Í¿ÓÂÈ Û ÔÛÔÛÙ¿. ™›ÁÔ˘Ú·

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ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÙÔ˘˜ ÛÙÔÓ ¯ÚfiÓÔ.. ŸÌˆ˜, Ù·ÍÈÓÔÌÒÓÙ·˜ ÛˆÛÙ¿ Î·È ÌÂ Û˘ÛÙËÌ·ÙÈÎÔ‡˜ ·ÏÁfiÚÈıÌÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ÛÙË Ï›ÛÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ˘¿ÚÍÔ˘Ó Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÔÚÁ¿ÓˆÓ Î·È Ó· ÚÔÛÊÂÚı› ÌÈ· ηχÙÂÚË ÔÈfiÙËÙ· ˙ˆ‹˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô˘ ÂÚÈ̤ÓÔ˘Ó ¯ÚfiÓÈ· ÛÙË Ï›ÛÙ·, ÈηÓÔÔÈËÙÈ΋ ÂÈ‚›ˆÛË Î·È ·ÙÔÌÈ΋ ·˘ÙÔÓÔÌ›·.

BÈ‚ÏÈÔÁÚ·Ê›· 1. Lucarelli G, Bettocchi C, Battaglia M, et al. Extended criteria donor kidney transplantation: comparative outcome analysis between single versus double kidney transplantation at 5 years.Transplant Proc. 2010; 42: 1104-7.

2. Durrbach A, Pestana JM, Pearson et al. A phase III study of belatacept versus cyclosporine in kidney transplants from extended criteria donors (BENEFITEXT study). Am J Transplant. 2010; 10: 547-57.

3. Diet C, Audard V, Roudot-Thoraval F, Matignon M, Lang P, Grimbert P. Immunological risk in recipients of kidney transplants from extended criteria donors..

Nephrol Dial Transplant. 2010; 25: 2745-53.

4. Shaheen MF, Shaheen FA, Attar B, Elamin K, Al Hayyan H, Al Sayyari A. Impact of recipient and donor non immunologic factors on the outcome of deceased donor kidney transplantation.Transplant Proc. 2010; 42: 273-6.

5. Keitel E, Michelon T, dos Santos AF, et al. Renal transplants using expanded cadaver donor criteria. Ann Transplant. 2004; 9: 23-4.

6. Soló R, Guirado L, López Navidad A, et al. Renal transplantation with limit donors: to what should the good results obtained be attributed? Transplantation.

1998; 15; 66: 1159-63.

AÈٛ˜ ·ÒÏÂÈ·˜ ÙˆÓ و̷ÙÈÎÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ (ÔÍ›· ·fiÚÚÈ„Ë, ¯ÚfiÓÈ· ·fiÚÚÈ„Ë, ı¿Ó·ÙÔ˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì·) °Ú. ª˘ÛÂÚÏ‹˜, μ. ¶··ÓÈÎÔÏ¿Ô˘, ¢. ¢È‚¿Ó˘, ÃÚ. ªÔ˘ÌԢڤη, º. ™ÔψӿÎË, ¢. Δ·ÎÔ‡‰·˜

∂ÈÛ·ÁˆÁ‹

ÓÙÈÎfiÙÂÚÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· Î·È ·ÒÏÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ¶¿ÓÙˆ˜, fiÏ· Ù· ÂÂÈÛfi‰È· O∞ ‰ÂÓ Ô‰ËÁÔ‡Ó ˘Ô¯ÚˆÙÈο Û áª. ΔÔ Â›‰Ô˜, Ë ‚·Ú‡ÙËÙ·, Ë Û˘¯ÓfiÙËÙ·, Ô ¯ÚfiÓÔ˜ ÂÌÊ¿ÓÈÛ˘ Î·È Ë ·¿ÓÙËÛË ÛÙËÓ ·ÓÙÈ·ÔÚÚÈÙÈ΋ ·ÁˆÁ‹ ηıÔÚ›˙Ô˘Ó Î·È ÙËÓ ¤Î‚·ÛË ÚÔ˜ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∏ ÔÍ›· ·ÁÁÂȷ΋ ·fiÚÚÈ„Ë ·ÚÔ˘ÛÈ¿˙ÂÈ Ùˆ¯fiÙÂÚË ¤Î‚·ÛË Û˘ÁÎÚÈÓfiÌÂÓË Ì ÙËÓ ‰È·ÌÂÛÔÛˆÏËÓ·ÚÈ·ÎÔ‡ Ù‡Ô˘ O∞1,2. Δ· ÔÏÏ·Ï¿ ÂÂÈÛfi‰È· O∞ Û¯ÂÙ›ÛıËÎ·Ó Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ áª3,4. ∏ ᪠‚Ú¤ıËΠÈÔ Û˘¯Ó¿ Û ϋÙ˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ì ÂÚÈÛÛfiÙÂÚ· ·fi 1 ÂÂÈÛfi‰È· O∞ Û˘ÁÎÚÈÓfiÌÂÓË Ì ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ Ì 1 ÌfiÓÔ ÂÂÈÛfi‰ÈÔ O∞ (34.8% vs8.9%, ·ÓÙ›ÛÙÔȯ·). ∂›Û˘, ¤Ó· ÌfiÓÔ ·ÒÙÂÚÔ ÂÂÈÛfi‰ÈÔ O∞ (ÌÂÙ¿ ÙÔ˘˜ 3 ÚÒÙÔ˘˜ Ì‹Ó˜ ·fi ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË) ʤÚÂÈ Ôχ ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·ÓÂ¿ÚÎÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·’ fiÙÈ ¤Ó· ÚÒÈÌÔ ÂÂÈÛfi‰ÈÔ O∞ (<3 Ì‹Ó˜ ·fi ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË) (RR, ·ÓÂ¿ÚÎÂÈ·˜ ÙÔ˘ ¡ª 5.27 vs 3.07).

OÈ MeierKriescheÎ·È Û˘Ó 5 ¤‰ÂÈÍ·Ó fiÙÈ ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÂÈÛfi‰È· O∞ ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â·Ó‹Ïı ÛÙÔ ‚·ÛÈÎfi Â›Â‰Ô Û ÔÛÔÛÙfi % ÙÔ˘ 1Ô˘ ¤ÙÔ˘˜ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÂÌÊ·Ó›ÛıËΠηχÙÂÚË 6ÂÙ‹˜ ÂÈ‚›ˆÛË ÙÔ˘ ¡ª Û ۇÁÎÚÈÛË Ì ·˘ÙÔ‡˜ fiÔ˘ Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Â·Ó‹Ïı Û ÔÛÔÛÙfi ÏÈÁfiÙÂÚÔ ·fi 75% Ù˘ ‚·ÛÈ΋˜ ÙÈÌ‹˜ ÙÔ˘ 1Ô˘ ¤ÙÔ˘˜ (72.7% vs 38%, ·ÓÙ›ÛÙÔȯ·). OÈ MatasÎ·È Û˘Ó6 ÌÂϤÙËÛ·Ó ÙËÓ ËÌÈÂÚ›Ô‰Ô ˙ˆ‹˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ô˘ ÂÈ‚ÈÒÓÔ˘Ó ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ. ∏ ËÌÈÂÚ›Ô‰Ô˜ ˙ˆ‹˜ ÙˆÓ ¡ª ¯ˆÚȘ ÂÂÈÛfi‰ÈÔ O∞ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜ ·fi ÙË ¡ª ‚Ú¤ıËΠÌÂÁ·Ï‡ÙÂÚË ·fi ·˘ÙÔ‡˜ Ì 1 ÂÂÈÛfi‰ÈÔ O∞ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ. ΔÂÏÈο ·ÛıÂÓ›˜ Ì ÂÚÈÛÛfiÙÂÚ· ÙÔ˘ ÂÓfi˜ ÂÂÈÛfi‰È· O∞ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ-

OÈ Ì›˙ÔÓ˜ ·Èٛ˜ ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Ô ı¿Ó·ÙÔ˜ ·fi ·ÁÁÂȷο, ηÎÔ‹ıË Î·È ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù·, Î·È Ë ·ÒÏÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ë ÔÔ›· Û¯ÂÙ›˙ÂÙ·È Ì ·Ó¿Ù˘ÍË ›ÓˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË. ∏ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (áª) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ÈÛÙÔÏÔÁÈο ·fi ›ÓˆÛË, ÛÂÈÚ·Ì·ÙÈ΋ Î·È ·ÁÁÂȷ΋ ‚Ï¿‚Ë ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ ᪠¤¯ÂÈ ÔÏÏ·Ϥ˜ ·Èٛ˜: ‚Ï¿‚Ë ÈÛ¯·ÈÌ›·˜-Â·Ó·ÈÌ¿ÙˆÛ˘, ÔÍ›· ‹ ˘ÔÎÏÈÓÈ΋ ·fiÚÚÈ„Ë, ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ηıÒ˜ Â›Û˘ Î·È Âȉ›ӈÛË ÚÔ¸¿Ú¯Ô˘Û·˜ ÓfiÛÔ˘ ÙÔ˘ ‰fiÙË. ∂ÊfiÛÔÓ ÂÁηٷÛÙ·ıÔ‡Ó, ÙfiÛÔ Ë ‰È¿ÌÂÛË ›ÓˆÛË fiÛÔ Î·È Ë ˘·Ï›ÓˆÛË ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ, Ô‰ËÁÔ‡Ó ·Ó·fiÊ¢ÎÙ· Ù· ÂfiÌÂÓ· ¯ÚfiÓÈ· Û ÚÔԉ¢ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (¯ÚfiÓÈ· ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜). Œ¯Ô˘Ó ÚÔÙ·ı› ÔÏϤ˜ ÚÔÛÂÁÁ›ÛÂȘ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Î·È ÙËÓ Ì›ˆÛË Ù˘ Â›ÙˆÛ˘ Ù˘ ᪠ÔÈ Ôԛ˜ ΢ڛˆ˜ ÛÙÔ¯Â‡Ô˘Ó ÛÙËÓ Ì›ˆÛË ‹ ÙËÓ ·ÔÊ˘Á‹ ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Û ÂÈÏÂÁ̤Ó˜ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ. Δ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· Û˘Ó‰˘¿˙Ô˘Ó ÛÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ ·˙·ıÂÈÔÚ›ÓË ‹ mycophenolate mofetil (ªªF) / EC-MPS Ì mTOR ·Ó·ÛÙÔÏ›˜ (sirolimus ‹ everolimus) ‹ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·ÎfiÌË Î·È ¯·ÌËϤ˜ ‰fiÛÂȘ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘. ™ÙËÓ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ı· ·Ó·Ï˘ıÔ‡Ó Ë ÔÍ›· ·fiÚÚÈ„Ë, Ë ¯ÚfiÓÈ· ·fiÚÚÈ„Ë Î·È Ô ı¿Ó·ÙÔ˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· ˆ˜ ·ÚȘ ·Èٛ˜ ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜.

OÍ›· ·fiÚÚÈ„Ë ∏ ÔÍ›· ·fiÚÚÈ„Ë (O∞) ·ÔÙÂÏ› ÙÔÓ ÛËÌ·-

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METAMO™XEY™Eπ™ 2011

΋ Ì›ˆÛË Ù˘ 5ÂÙÔ‡˜ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ¶ÚÔÛ¿ıÂȘ ÁÈ· ÚfiÏË„Ë Î·È ‰Ú·ÛÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ Û˘ÓÈÛÙÔ‡Ó ÛËÌ·ÓÙÈ΋ ÎÏÈÓÈ΋ ·Ú¤Ì‚·ÛË ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡7. ∏ fi„ÈÌË ÔÍ›· ·fiÚÚÈ„Ë Û˘ÓÈÛÙ¿ ¤Ó·Ó ÈÛ¯˘Úfi ‰Â›ÎÙË ¯ÚfiÓÈ·˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Î·È fi„ÈÌ˘ ·ÒÏÂÈ·˜ ·˘ÙÔ‡8. ∂Ï¿¯ÈÛÙ˜ ÌfiÓÔ ÂÚÈÙÒÛÂȘ fi„ÈÌ˘ ÔÍ›·˜ ·fiÚÚȄ˘ ÔÊ›ÏÔÓÙ·È Û ·ÓÔÛÔÏÔÁÈο ·›ÙÈ·, fiˆ˜ ÂÂÈÛfi‰È· O∞ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÌÂÙ¿ ·fi ÌÂÙ·ÙÚÔ‹ ÙÔ˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜9. ∏ ΢ÚÈfiÙÂÚË ·ÈÙ›· O∞ ÛÙËÓ ·ÒÙÂÚË ÂÚ›Ô‰Ô Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Â›Ó·È Ë ÌË-Û˘ÌÌfiÚʈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜. ª›· ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË ¤‰ÂÈÍ fiÙÈ ÂÚ›Ô˘ ÙÔ ¤Ó· ٤ٷÚÙÔ ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘Û›·˙·Ó ÌËÛ˘ÌÌfiÚʈÛË ÛÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Î·È Â›¯·Ó ¤Ó·Ó ÂÙ·Ï¿ÛÈÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜10.

ÃÚfiÓÈ· ·fiÚÚÈ„Ë ∏ Ù·ÍÈÓfiÌËÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ ·fi ÙȘ ‚ÈÔ„›Â˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1990 Û ÌÈ· ÛÂÈÚ¿ meetings ÛÙÔ Banff ÙÔ˘ ∫·Ó·‰¿11,12-14. ŒÓ· ÂÓ·ÏÏ·ÎÙÈÎfi Û‡ÛÙËÌ· Ô˘ ÂÚȤÁÚ·Ê ٷ Â˘Ú‹Ì·Ù· Ù˘ ᪠‰ËÌÈÔ˘ÚÁ‹ıËΠÂ›Û˘ ÛÙÔ Helsinki (Chronic Allograft Damage Index – CADI)15.

O fiÚÔ˜ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ ·ÔÙÂÏ› ÈÛÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÚÔÛˆ‡ÂÈ ÙËÓ ÙÂÏÈ΋ ηٿÏËÍË Ù˘ ‚Ï¿‚˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜11. Δ· ÂȉÈο Â˘Ú‹Ì·Ù· Â›Ó·È Ë ‰È¿ÌÂÛË ›ÓˆÛË Î·È Ë ·ÙÚÔÊ›· ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ, fi¯È ÌfiÓÔÓ ÂÂȉ‹ Û˘ÓÈÛÙÔ‡Ó ÙȘ ÛÔ˘‰·ÈfiÙÂÚ˜ ·ÏÏÔÈÒÛÂȘ ÛÙȘ ÓÂÊÚÈΤ˜ ‚ÈÔ„›Â˜, ·ÏÏ¿ Î·È ÂÂȉ‹ Û˘Ó·ÓÙÒÓÙ·È Û˘¯Ó¿ Î·È Â˘Ú¤ˆ˜ ·ÎfiÌË Î·È ÂÓÙfi˜ ÌÈÎÚÒÓ ‰ÂÈÁÌ¿ÙˆÓ ‚ÈÔ„›·˜. ∏ Ù·ÍÈÓfiÌËÛË Ù˘ ᪠·fi π ¤ˆ˜ III ‚·Û›˙ÂÙ·È ÛÙËÓ ‚·Ú‡ÙËÙ· Ù˘ ¯ÚfiÓÈ·˜ ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ (ci0 – ci3) Î·È Ù˘ ·ÙÚÔÊ›·˜ ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ (ct0 – ct3).

OÈ ÛÔ˘‰·ÈfiÙÂÚ˜ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÛÂÈÚ¤˜ ‚ÈÔ„ÈÒÓ ÚˆÙÔÎfiÏÏÔ˘ Ì ÛÎÔfi Ù· ·›ÙÈ· Î·È ÙȘ ÂÈÙÒÛÂȘ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ó·Ê¤ÚÔÓÙ·È ·fi ÙËÓ ÔÌ¿‰· ÙÔ˘ Sydney1620. §‹Ù˜ ·ÁÎÚ¤·ÙÔ˜ Î·È ÓÂÊÚÔ‡ ˘Ô‚Ï‹ıËÎ·Ó Û ‚ÈÔ„›· ÓÂÊÚÔ‡ ·Ó¿ ¤ÙÔ˜ ÁÈ· ‰¤Î· ¯ÚfiÓÈ·, Ô‰ËÁÒÓÙ·˜ Û ÂÚ›Ô˘ 1000 ‚ÈÔ„›Â˜ ÁÈ· 120 ·ÛıÂÓ›˜. ∏ ÛÂÈÚ¿ ·fi ÙËÓ Mayo Clinic ÂÎÙ›ÌËÛ ¤Ó·Ó ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ÏËÙÒÓ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷-

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ÙÔ˜ ·fi ˙ÒÓÙ· ‰fiÙË ÛÙËÓ ‰È¿ÚÎÂÈ· ÙˆÓ ‰‡Ô ÚÒÙˆÓ ÂÙÒÓ ÌÂÙ¿ ÙËÓ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË21. ∏ ÂÚÈÛÛfiÙÂÚÔ, fï˜ ÙÂÎÌËÚȈ̤ÓË ÌÂϤÙË Û¯ÂÙÈο Ì ÙËÓ Â›ÙˆÛË Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ ÛÙ· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· ÚÔ¤Ú¯ÂÙ·È ·fi ¤Ó· US trial Ô˘ Û˘Ó¤ÎÚÈÓ ÙËÓ CsA Ì ÙÔ TAC Î·È ÛÙËÓ ÔÔ›· Ê¿ÓËΠfiÙÈ 72,3% Î·È 62% ÙˆÓ ‚ÈÔ„ÈÒÓ ·ÓÙ›ÛÙÔȯ· ÂÌÊ¿ÓÈ˙·Ó Â˘Ú‹Ì·Ù· ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÌÔۯ‡̷ÙÔ˜. ™ÙËÓ ÌÂϤÙË ·˘Ù‹ Ë ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ ÛÙ· ‰‡Ô ÚˆÙ· ¯ÚfiÓÈ· Û¯ÂÙ›ÛıËΠ̠ÙËÓ ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· ÙÔ˘ ‰fiÙË, Ù· ÚÒÈÌ· ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ Î·È ÙËÓ ÚÒÈÌË ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘. ™ÙËÓ ÌÂϤÙË Ù˘ ÔÌ¿‰·˜ ÙÔ˘ Sydney Ê¿ÓËΠfiÙÈ Ë ›ÓˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Û˘Ó¤‚·ÈÓ Û ‰‡Ô Ê¿ÛÂȘ18. Δ· ‰‡Ô ÙÚ›Ù· Ù˘ ›ÓˆÛ˘ Ô˘ ·ÚÔ˘ÛÈ¿ÛÙËΠÛÙ· ‰¤Î· ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›¯·Ó ‹‰Ë ÂΉËψı› ·fi ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Î·È ÛÙËÓ ‰È¿ÚÎÂÈ· ·˘ÙÔ‡ ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ Ë ‰È¿ÌÂÛË ›ÓˆÛË ˘ÂÚÎ¿Ï˘„ ÙËÓ ·ÙÚÔÊ›· ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ. ΔÔ ÁÂÁÔÓfi˜ ·˘Ùfi ‰Â›¯ÓÂÈ fiÙÈ Ë ÚÒÈÌË ¤Ó·ÚÍË Ù˘ ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ Û¯ÂÙ›˙ÂÙ·È Ì ·Ú¿ÁÔÓÙ˜ ‰È·ÊÔÚÂÙÈÎÔ‡˜ ·fi ·˘ÙÔ‡˜ Ô˘ ÚÔηÏÔ‡Ó ·ÙÚÔÊ›· ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ Ì ÚÔÂÍ¿Ú¯ÔÓÙ· ÙÔÓ ÚfiÏÔ ÙfiÛÔ Ù˘ ‚Ï¿‚˘ ÈÛ¯·ÈÌ›·˜ Â·Ó·ÈÌ¿ÙˆÛ˘ fiÛÔ Î·È Ù˘ ¿ÌÂÛ˘ Â›‰Ú·Û˘ ·ÓÔÛÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ. ∏ ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË Úԉȷı¤ÙÂÈ Û áª ÂÓÒ ÙÔ MMF ‰Ú· ÚÔÏËÙÈο16. ™Â ÌÈ· ÌÂϤÙË ·fi ÙÔ Hanover, Germany, 258 ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó Û ‚ÈÔ„›· ¡ª ÙËÓ 6Ë, 12Ë Î·È 26Ë Â‚‰ÔÌ¿‰· Î·È ÔÌ·‰ÔÔÈ‹ıËÎ·Ó ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÚÔ˘Û›· (n=70) ‹ ·Ô˘Û›· (n=120) Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ ÙËÓ 26Ë Â‚‰ÔÌ¿‰·22. OÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ã¡ª ÙËÓ 26Ë Â‚‰ÔÌ¿‰· ÂÚÈÂÏ¿Ì‚·Ó·Ó ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi و̷ÙÈÎfi ‰fiÙË, ·Ú·ÙÂٷ̤ÓÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Î·È ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘. ∏ ˘ÔÎÏÈÓÈ΋ ·fiÚÚÈ„Ë, fiˆ˜ ηÙËÁÔÚÈÔÔÈ‹ıËΠ̠ÙÔ Û¯‹Ì· Banff, Ô‰ËÁ› Â›Û˘ Û ·˘ÍË̤ÓË ‰È¿ÌÂÛË ›ÓˆÛË Î·È Ã¡ª ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ¤ÙÔ˘˜17. ¶·Ú·ÙËÚ‹ÛÂȘ Û Â·ÓÂÈÏËÌ̤Ó˜ ‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘ ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ, ¤‰ÂÈÍ·Ó fiÙÈ ·Ó Î·È ·ÊÔÚ¿ ÌfiÓÔ ÙÔ 6% ÙˆÓ ·ÛıÂÓÒÓ, Ë ˘ÔÎÏÈÓÈ΋ ·fiÚÚÈ„Ë Ô‰ËÁ› Û ÚÔԉ¢ÙÈ΋ ·‡ÍËÛË Ù˘ ›ÓˆÛ˘ Î·È Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜18. ΔÂÏÈο Ë ·ÚÔ˘Û›· ÊÏÂÁÌÔÓˆ-

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°. ªÀ™∂ƒ§∏™ ∫∞π ™À¡.

‰ÒÓ Î˘ÙÙ¿ÚˆÓ ÌÂÛ· Û ÂÚÈÔ¯¤˜ Ì ›ÓˆÛË Û¯ÂÙ›ÛıËΠÂ›Û˘ Ì ·‡ÍËÛË Ù˘ ÂÈÊ¿ÓÂÈ·˜ Ù˘ ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ Û Â·ÎfiÏÔ˘ı˜ ‚ÈÔ„›Â˜18. Δ· ‰Â‰Ô̤ӷ ·˘Ù¿ ‰Â›¯ÓÔ˘Ó fiÙÈ ÌË ıÂÚ·¢fiÌÂÓ˜ ÂÛٛ˜ ÊÏÂÁÌÔÓ‹˜ ÂÓÙfi˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô‰ËÁÔ‡Ó ·ıfiÚ˘‚· Û ηٷÛÙÚÔÊ‹ ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ Î·È ›ÓˆÛË ÙÔ˘ ‰È¿ÌÂÛÔ˘ ÈÛÙÔ‡ ¯ˆÚ›˜ ÛËÌ·ÓÙÈ΋ ‹ ·fiÙÔÌË ¿ÓÔ‰Ô Ù˘ ÎÚ·ÙÈÓ›Ó˘. ªÂٷ͇ ÙÔ˘ 1Ô˘ Î·È 10Ô˘ ¤ÙÔ˘˜ ÌÂÙ¿ ÙË ¡ª, Ë ·ÙÚÔÊ›· ÙˆÓ Ô˘ÚÔÊfiÚˆÓ ÛˆÏËÓ·Ú›ˆÓ Î·È Ë ‰È¿ÌÂÛË ›ÓˆÛË ÂÌÊ·Ó›˙Ô˘Ó ·Ú¿ÏÏËÏË ÚfiÔ‰Ô. ΔÂÏÈο Ë ‰È¿ÌÂÛË ›ÓˆÛË Î·È Ë ˘·Ï›ÓˆÛË ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ Ì ‹ ¯ˆÚ›˜ Â·Û‚ÂÛÙÒÛÂȘ ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ‚ÈÔ„ÈÒÓ ÛÙ· 10 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË ¡ª20. Ÿˆ˜ Î·È ÛÙÔ 2ÂÙ¤˜ ÔÏ˘ÎÂÓÙÚÈÎfi US trial ÌÂٷ͇ CsA Î·È Δ∞C23 ¤ÙÛÈ Î·È ÛÙÔ ÚˆÙfiÎÔÏÏÔ ÙÔ˘ Sydney ÙfiÛÔ Ô Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘ ᪠fiÛÔ Î·È Ë ‚·Ú‡ÙËÙ¿ Ù˘ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ Δ∞C Î·È CsA20. ∏ ˘·Ï›ÓˆÛË ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ Û˘Ì‚·›ÓÂÈ ÂÚÈÛÛfiÙÂÚÔ Û˘¯Ó¿ ÌÂٷ͇ 3Ô˘ Î·È 12Ô˘ Ì‹Ó· ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û˘Ó‰˘¿˙ÂÙ·È ‰Â Ì ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘, ÂȉÈο Ì¿ÏÈÛÙ· fiÙ·Ó Ù· Â›‰· CsA >200 ng/ml ÛÙÔ 3ÌËÓÔ, ηıÒ˜ Â›Û˘ Î·È Ì ÚÒÈÌ· ÂÂÈÛfi‰È· ÔÍ›·˜ ÎÏÈÓÈ΋˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜. ∏ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· Ù˘ CsA ÂÚÈÔÚ›˙ÂÙ·È Ì ÙË Ì›ˆÛË Ù˘ ‰ÔÛÔÏÔÁ›·˜ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘20. ∞ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ÂÏ¿Ì‚·Ó·Ó ΢ÎÏÔÛÔÚ›ÓË Û ‰fiÛË ¿Óˆ ·fi 5 mg/Kg μ™ ÙÔÓ 5Ô ¯ÚfiÓÔ ÌÂÙ¿ ÙË ¡ª ÂÌÊ¿ÓÈÛ·Ó Û ÔÛÔÛÙfi 75% ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ ÙÔ 10Ô ¯ÚfiÓÔ Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∏ ÎÏ·ÛÛÈ΋ ÌÔÚÊ‹ Ù˘ Ô˙Ò‰Ô˘˜ ˘·Ï›ÓˆÛ˘ Û˘Ó·ÓÙ¿Ù·È Û ϛÁÔ˘˜ ÌfiÓÔ ·ÛıÂÓ›˜. ¶ÂÚÈÛÛfiÙÂÚÔ Û˘¯Ó¿ ··ÓÙ¿Ù·È Ë ‰È¿¯˘ÙË ˘·Ï›ÓˆÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ Ì·˙› Ì Ì›ˆÛË ÙÔ˘ ‡ÚÔ˘˜ ÙÔ˘ ·˘ÏÔ‡ ÙÔ˘ ·ÁÁ›Ԣ Ô˘ Ô‰ËÁ› Û ÈÛ¯·ÈÌ›· ÛÂÈÚ¿Ì·ÙÔ˜. ∂›Û˘ Ë ˘·Ï›ÓˆÛË ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ ÚÔËÁÂ›Ù·È Ù˘ ˘¤ÚÙ·Û˘ ÛÙÔ˘˜ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È Û˘Ó·ÓÙ¿Ù·È Û ÔÛÔÛÙfi 60% ÛÙÔ˘˜ ÓÔÚÌÔÙ·ÛÈÎÔ‡˜ Î·È 68% ÛÙÔ˘˜ ˘ÂÚÙ·ÛÈÎÔ‡˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∏ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË ·ÓÙÈÚÔÛˆ‡ÂÈ ÙËÓ ÌË ·Ó·ÛÙÚ¤„ÈÌË ‚Ï¿‚Ë ÙˆÓ ÓÂÊÚÒÓˆÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Û˘Ó·ÓÙ¿Ù·È Û ‰‡Ô Ê¿ÛÂȘ ÛÙȘ ÛÂÈÚ¤˜ ‚ÈÔ„ÈÒÓ ÚˆÙÔÎfiÏÏÔ˘19. ™Â ÌÈ· ÚÒÈÌË Ê¿ÛË Ë ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë Û˘Ì‚·›ÓÂÈ ÌÂٷ͇ 2Ô˘ Î·È 5Ô˘ ¯ÚfiÓÔ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiÔ˘ ÌÈ· ÂÏ¿¯ÈÛÙË ·ÒÏÂÈ· ÛÂÈÚ·Ì·ÙÈ΋˜ Ì¿˙·˜ ÂÈÛ˘Ì‚·›ÓÂÈ ÚÈÓ

·fi ÙËÓ ÂÎÙÂٷ̤ÓË Î·È ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ‚Ï¿‚Ë ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜ Î·È ¿Ú· ÚÈÓ ÙËÓ ÂÁηٿÛÙ·ÛË ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜. ∏ ÚÒÈÌË ‚Ï¿‚Ë ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜ Û¯ÂÙ›ÛıËΠ̠˘ÔÎÏÈÓÈ΋ ·fiÚÚÈ„Ë ÂÓÒ ÂÏ¿¯ÈÛÙ· Û˘Ó‰˘¿ÛıËΠ̠·Ú·ÙÂٷ̤ÓÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜. ∏ ·ÒÙÂÚË Ê¿ÛË Ù˘ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ Ê·›ÓÂÙ·È fiÙÈ ·ÎÔÏÔ˘ı› ÙËÓ ÚÒÈÌË Ê¿ÛË Ù˘ ‰È¿ÌÂÛ˘ ›ÓˆÛ˘ Ô˘ Û˘Ì‚·›ÓÂÈ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ÌÂÙ¿ ÙË ¡ª. ∏ ‚·Ú‡ÙËÙ· Ù˘ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛ˘ ÛÙËÓ ·ÒÙÂÚË Ê¿ÛË Û¯ÂÙ›ÛıËΠ̠ÙË ‚·Ú‡ÙËÙ· Ù˘ ˘·Ï›ÓˆÛ˘ ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ.

ÃÚfiÓÈ· ¯˘ÌÈÎÔ‡ Ù‡Ô˘ ·fiÚÚÈ„Ë Î·È ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜ ∏ ·ÓÙÈۈ̷ÙÔÂÍ·ÚÒÌÂÓË ÔÍ›· ·fiÚÚÈ„Ë ·ÔÙÂÏ› ¤Ó· Ì˯·ÓÈÛÌfi O∞, Ë ÔÔ›· Û‹ÌÂÚ· Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ¤¯ÂÈ ÌÂȈı› ÏfiÁˆ Ù˘ ·Ó¿Ù˘Í˘ ÙÔ˘ HLA Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Ù˘ ¯Ú‹Û˘ Ó¤ˆÓ ÌÂıfi‰ˆÓ crossmach. Y¿Ú¯ÂÈ fï˜ ¤Ó· ·Ó·Óˆ̤ÓÔ ÂӉȷʤÚÔÓ ÁÈ· ÙË ¯˘ÌÈÎÔ‡ Ù‡Ô˘ ·fiÚÚÈ„Ë Î·ıÒ˜ Û ÔÏϤ˜ ‚ÈÔ„›Â˜ ÚˆÙÔÎfiÏÏÔ˘ Û˘Ó·ÙÒÓÙ·È ÛÙ· ÂÚÈÛˆÏËÓ·Úȷο ÙÚȯÔÂȉ‹ ÂÓ·Ôı¤ÛÂȘ C4d ÂȉÈο Ì¿ÏÈÛÙ· Û ϋÙ˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ì ΢ÎÏÔÊÔÚÔ‡ÓÙ· ·ÓÙÈ-HLA ·ÓÙÈÛÒÌ·Ù·24,25. O ÚfiÏÔ˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙË ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛı› Ï‹Úˆ˜ ·Ó Î·È Ë ·Ó›¯Ó¢ÛË ·ÓÙÈ-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ Úԉȷı¤ÙÂÈ Û Ùˆ¯‹ ¤Î‚·ÛË Î·È ·ÒÏÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ . ∏ ·ÚÔ˘Û›· C4d ÛÙ· ÂÚÈÛˆÏËÓ·Úȷο ÙÚȯÔÂȉ‹ ÚÔËÁÂ›Ù·È Ù˘ ¯ÚfiÓÈ·˜ ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜26-28. ªÈ· Èı·Ó‹ ÂÍ‹ÁËÛË ÙÔ˘ ·Ú·¿Óˆ Ê·ÈÓÔ̤ÓÔ˘ ·Ó·Ê¤ÚÂÈ fiÙÈ ÔÈ ˘„ËÏÔ› Ù›ÙÏÔÈ ·ÓÙÈ-HLA ·ÓÙÈÛˆÌ¿ÙˆÓ ÂÓÂÚÁÔÔÈÔ‡Ó Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÙˆÓ ·ÁÁ›ˆÓ ÒÛÙ ӷ ÚÔÎÏËı› ÔÏÏ·Ï·ÛÈ·ÛÌfi˜ ·˘ÙÒÓ Ô˘ ÂÓ Û˘Ó¯›· Ô‰ËÁ› Û ·ÁÁÂȷ΋ ÓfiÛÔ ÙÔ˘ ¡ª29. ∏ ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·Ó·‰Â›¯ıËΠÚÒÙ· ÙÔ 196330 Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ‰È‡ڢÓÛË ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜, ·‡ÍËÛË Ù˘ ÌÂÛ·ÁÁ›Ԣ Ô˘Û›·˜, ·ÏÏÔÈÒÛÂȘ ÙˆÓ ÌÂÛ·ÁÁÂÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ‰ÈÏ·ÛÈ·ÛÌfi Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ Î·È Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙˆÓ ÂÚÈÛˆÏËÓ·ÚÈ·ÎÒÓ ÙÚȯÔÂȉÒÓ. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ·Ó¤‰ÂÈÍ·Ó ÌÈ· Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ÂÌÊ¿ÓÈÛ˘ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ ‚·ÛÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ÙÔ˘ ÛÂÈÚ¿Ì·ÙÔ˜ Ù· ÔÔ›· ηÙ¢ı‡ÓÔÓÙ·È ¤Ó·ÓÙÈ ÌÈ·˜ ÚˆÙÂÔÁÏ˘Î¿Ó˘, Ù˘ ·ÁÎÚ›Ó˘31. ∂ÓÒ Ë ÛÂÈÚ·Ì·ÙÔ¿-

METAMO™XEY™Eπ™ 2011

ıÂÈ· Û˘ÓÈÛÙ¿ ÌÈ· ·ÛÙ·ı‹ ÈÛÙÔÏÔÁÈ΋ ‚Ï¿‚Ë, ·Ó·ÌÊ›‚ÔÏ· Ô‰ËÁ› Û ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ηıÒ˜ Â›Û˘ Î·È Û ·ÒÏÂÈ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜32-34. ∏ ÙÚ¤¯Ô˘Û· ÂfiÌÂÓˆ˜ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÂÓ Û˘ÓÙÔÌ›· ÛÙËÓ ÂÈÎfiÓ· 1. ™‡Ìʈӷ Ì ·˘Ù‹Ó Ô ÌÂÙ·ÌÔÛ¯Â˘ı›˜ ÓÂÊÚfi˜ ʤÚÂÈ Ì·˙› ÙÔ˘ ÙȘ ·ÏÏÔÈÒÛÂȘ ÙÔ˘ ‰fiÙË, ÂȉÈο ÙËÓ ÌÈÎÚÔ·ÁÁÂȷ΋ ÓfiÛÔ Î·È ÙËÓ ‰È¿ÌÂÛË ›ÓˆÛË. ∏ ÈÛ¯·ÈÌ›· ÛÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ë ÔÔ›· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÂÂÈÛfi‰È· O∞ Î·È ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘, Û˘ÓÂÈÛʤÚÔ˘Ó ÛÙË ‚Ï¿‚Ë ÙÔ˘ ‰È¿ÌÂÛÔ˘ ÈÛÙÔ‡ Î·È ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ. ∞ÙÂÏÒ˜ ıÂÚ·¢ı¤ÓÙ· ÂÂÈÛfi‰È· ¯˘ÌÈÎÔ‡ Ù‡Ô˘ ÔÍ›·˜ ·fiÚÚȄ˘ Ù· ÔÔ›· ÂÌϤÎÔ˘Ó Î·È ÙÔ ·ÁÁÂÈ·Îfi ÛÙÔÈ¯Â›Ô Â›Ó·È ÌÂÓ Û¿ÓÈ· ·ÏÏ¿ ÔÛ¿ÎȘ ÂÈÛ˘Ì‚·›ÓÔ˘Ó Û˘ÓÙÂÏÔ‡Ó ÛËÌ·ÓÙÈο ÛÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∞Ô ÙËÓ ¿ÏÏË ÌÂÚÈ¿ Ù· ÂÂÈÛfi‰È· ˘ÔÎÏÈÓÈ΋˜ ·fiÚÚȄ˘ Ô˘ ‰È·ÁÈÁÓÒÛÎÔÓÙ·È ÌfiÓÔ Ì ÙȘ ÛÂÈÚ¤˜ ‚ÈÔ„ÈÒÓ ÚˆÙÔÎfiÏÏÔ˘ Ô‰ËÁÔ‡Ó ·ıfiÚ˘‚· ÙÔ ÌfiÛ¯Â˘Ì· Û ÌË ·Ó·ÛÙÚ¤„ÈÌË ‚Ï¿‚Ë. ªÂÙ¿ ÙÔ˘˜ ÚÒÙÔ˘˜ Ì‹Ó˜ Ë ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Û˘ÓÈÛÙ¿ ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ‰È¿ÌÂÛ˘ ›ÓˆÛ˘

65

Î·È ˘·Ï›ÓˆÛ˘ ÙˆÓ ·ÚÙËÚÈÔÏ›ˆÓ Î·È Ô‰ËÁ› Û ÚÔԉ¢ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË. ŸÙ·Ó Ë ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ÂÓ·ÔÌÂÈÓ¿ÓÙˆÓ Î·È ˘ÂÚ‰ÈËıÔ‡ÓÙˆÓ ÓÂÊÚÒÓˆÓ ÂÍ·ÓÙÏËı›, Ô GFR ÌÂÈÒÓÂÙ·È, Î·È ÌfiÓÔÓ fiÙ·Ó ÏËÛÈ¿˙ÂÈ Ù· 30 ml/min/1,73 m2 ÂÌÊ·Ó›˙ÂÙ·È ÌÂÙ·‚ÔÏ‹ ÛÙËÓ ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡. ∏ ‚Ï¿‚Ë ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ fiÙ·Ó Ë ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡ Û˘Ó¯›˙ÂÈ Ó· ·˘Í¿ÓÂÈ Â›Ó·È Û˘¯Ó¿ ·Ó·fiÊ¢ÎÙË.

£¿Ó·ÙÔ˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· ˆ˜ ·ÈÙ›· ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ∏ ηډȷÁÁÂȷ΋ ÓfiÛÔ˜ (∫∞¡) ·ÔÙÂÏ› ÙÔÓ ÌÂÁ·Ï‡ÙÂÚÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ıÓËÙfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÈÌÔοı·ÚÛË35. ÀÔÏÔÁ›˙ÂÙ·È ÔÙÈ ¿Óˆ ·fi 50% ÙˆÓ ı·Ó¿ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙÔÓ Ù¯ÓËÙfi ÓÂÊÚfi ÔÊ›ÏÂÙ·È Û ηډȷÁÁÂȷο ·›ÙÈ·36. ∫·ÙãÂ¤ÎÙ·ÛË Ë Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ˜ ·Ú·Ì¤ÓÂÈ Ë Î‡ÚÈ· ·ÈÙ›· ıÓËÙfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË37. ∂ÈÚfiÛıÂÙ·, ÁÈ· ÙÔÓ Ï‹ÙË ÙÔ˘ ¡ª , ¤Ó·˜ ·ÚÈıÌfi˜ ÌË ÎÏ·ÛÛÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ∫∞¡, fiˆ˜ Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹, Ë ·Ó·ÈÌ›·, Ë ÏÂ˘ÎˆÌ·ÙÔ˘Ú›· Î·È ¿ÏÏÔÈ Û˘ÓÂÈÛʤÚÔ˘Ó ÛËÌ·ÓÙÈο ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ‡ÚÔ˘˜ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘38.

∂ÈÎfiÓ· 1. ∏ ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ÃÚfiÓÈ·˜ ¡ÂÊÚÔ¿ıÂÈ·˜ ªÔۯ‡̷ÙÔ˜ Î·È Ù˘ ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜

66

°. ªÀ™∂ƒ§∏™ ∫∞π ™À¡.

∏ Â›ÙˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÛÙËÓ ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ Î·È Ù˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ ‰Âȯı› Û ÔÏϤ˜ ÌÂϤÙ˜. ∏ ˘ÔΛÌÂÓË ÓÂÊÚÈ΋ ÓfiÛÔ˜, Ë ˘¤ÚÙ·ÛË, Ë ˘ÂÚÏÈȉ·ÈÌ›·, Ë ·¯˘Û·ÚΛ·, ÙÔ Î¿ÓÈÛÌ· Î·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ˆ˜ ÎÏ·ÛÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ∫∞¡ Î·È ıÓËÙfiÙËÙ·˜ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ Âȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙËÓ ÔÚ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ·˘Ù‹ Ë ›‰È· ·ÓÔÛÔηٷÛÙÔÏ‹ ÂÈÙ›ÓÔ˘Ó ÙÔÓ ·Ú·¿Óˆ ΛӉ˘ÓÔ. ∏ ·Ú¤Ì‚·ÛË ÂÔ̤ӈ˜ ÙÔ˘ ÎÏÈÓÈÎÔ‡ È·ÙÚÔ‡ ı· Ú¤ÂÈ Ó· ηÙ¢ı‡ÓÂÙ·È ÛÙÔ˘˜ ÙÚÔÔÔÈ‹ÛÈÌÔ˘˜ ·Ú¿ÁÔÓÙ˜ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÒÛÙ ӷ ·˘ÍËı› Ë Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ ÂÌÊ¿ÓÈÛË Î·ÎÔËıÂÈÒÓ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛı› ˆ˜ ÛËÌ·ÓÙÈÎfi˜ ÂÚÈÔÚÈÛÌfi˜ ÛÙËÓ ÂÈÙ˘¯›· Ù˘ ÓÂÊÚÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Î·È ·ÔÙÂÏ› ·Ó·ÌÊ›‚ÔÏ· ÙÔ ÎfiÛÙÔ˜ Ù˘ Ì·ÎÚÔ¯ÚfiÓÈ·˜ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜. ∏ Û˘¯ÓfiÙËÙ· Î·È Ô Î›Ó‰˘ÓÔ˜ ηÎÔ‹ıÂÈ·˜ Â›Ó·È ÔÏÏ·ÏÒ˜ ·˘ÍË̤ÓÔ˜ Û ϋÙ˜ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ ·’ fiÙÈ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ∏ ‰È¿ÚÎÂÈ· Ù˘ ¤ÎıÂÛ˘ ÛÙËÓ ·ÓÔÛÔηٷÛÙÔÏ‹ Î·È Ë ¤ÓÙ·Û‹ Ù˘ Û·ÊÒ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ÌÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ΛӉ˘ÓÔ ·Ó¿Ù˘Í˘ ηÎÔ‹ıÂÈ·˜. ∂ÊfiÛÔÓ ÂΉËψı› ηÎÔ‹ıÂÈ· ÙfiÙÂ, fiÛÔ ÈÔ ¤ÓÙÔÓË Â›Ó·È Ë ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÙfiÛÔ ÈÔ ÂÈıÂÙÈο ÂΉËÏÒÓÂÙ·È Î·È Ë Î·ÎÔ‹ıÂÈ· Ì ÌÂÙ·ÛÙ¿ÛÂȘ Î·È ÌÂȈ̤ÓË ÂÈ‚›ˆÛË ·ÛıÂÓÔ‡˜. Δ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο Ê¿Ú̷η ‰È¢ÎÔχÓÔ˘Ó ÙËÓ ‰Ú¿ÛË ÔÚÈÛÌ¤ÓˆÓ ÔÁÎÔÁfiÓˆÓ ÈÒÓ. À¿Ú¯Ô˘Ó fï˜ Î·È ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ì ·ÓÙÈ-ÔÁÎÔÁfiÓ˜ ‰Ú¿ÛÂȘ (sirolimus/ everolimus). ∞Ó·ÊÔÚ¤˜ ·fi ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙˆÓ Î·ÎÔËıÂÈÒÓ Û ϋÙ˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ˘fi ıÂÚ·›· Ì mTOR ·Ó·ÛÙÔÏ›˜ ·Ô‰ÂÈÎÓ‡Ô˘Ó Î·È ÙȘ ‰È·ÊÔÚÂÙÈΤ˜ Ô‰Ô‡˜ Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ·fi ÙËÓ ÔÁÎÔÁ¤ÓÂÛË. O ÚfiÏÔ˜ ÙˆÓ mTOR ·Ó·ÛÙÔϤˆÓ ¤¯ÂÈ Â·ÚÎÒ˜ ·Ô‰Âȯı› ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û·ÚÎÒÌ·ÙÔ˜ Kaposi ÌÂÙ¿ ÙË ¡ª. ŒÙÛÈ Ë ÚfiÏË„Ë Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ ıÓËÙfiÙËÙ·˜ ·fi ÙȘ ÌÂÙ¿ ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·ÎÔ‹ıÂȘ ı· Ú¤ÂÈ Ó· ·ÔÙÂϤÛÔ˘Ó Î‡ÚÈÔ Î·Ù·ÏËÎÙÈÎfi ÛËÌÂ›Ô ÛÙ· ÚÔÁÚ¿ÌÌ·Ù· ÌÂÙ·ÌfiÛ¯Â˘Û˘ Û˘Ì·ÁÒÓ ÔÚÁ¿ÓˆÓ ÂÓÒ Ë ÂÈÏÔÁ‹ Î·È Ë ‰È·¯Â›ÚÈÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÛÙËÓ ÔÚ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ.

∞fi Ù· ÏÔÈÌÒ‰Ë ·›ÙÈ· ı·Ó¿ÙÔ˘ Î·È ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· Ë CMVÏԛ̈ÍË Ô˘ ÂΉËÏÒÓÂÙ·È ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ÙÚÈÌ‹ÓÔ˘ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÔfiÙÂ Î·È Ë ·ÓÔÛÔηٷÛÙÔÏ‹ Â›Ó·È ÈÔ ¤ÓÙÔÓË-Û˘ÓÈÛÙ¿ ÙÔ Î˘ÚÈfiÙÂÚÔ ·›ÙÈÔ. ∏ CMVÏԛ̈ÍË ÂΉËÏÒÓÂÙ·È Ì ÔÈÎÈÏ›· Û˘Ìو̿وÓ, Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi ·Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË ¤ˆ˜ ÂȉÈ΋ ÁÈ· ÙÔ fiÚÁ·ÓÔ Ô˘ ÚÔÛ‚¿ÏÏÂÙ·È, ÛÔ‚·Ú‹ Î·È ÂÈΛӉ˘ÓË ÁÈ· ÙËÓ ˙ˆ‹ Ïԛ̈ÍË. ∂ÎÙfi˜ fï˜ ·fi ÙËÓ ¿ÌÂÛË Â›‰Ú·ÛË ÙÔ˘ ÈÔ‡, Ô CMV ¤ÌÌÂÛ· ¤¯ÂÈ Û¯ÂÙÈÛı› Ì ÔÍ›· Î·È ¯ÚfiÓÈ· ·fiÚÚÈ„Ë Î·ıÒ˜ Â›Û˘ Î·È ÌÂȈ̤ÓË ÂÈ‚›ˆÛË ·ÛıÂÓÒÓ Î·È ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∏ fi„ÈÌË CMVÏԛ̈ÍË, Ë ÔÔ›· ÂÈÛ˘Ì‚·›ÓÂÈ ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ, ÌÔÚ› Ó· ÂΉËψı› ¿Ù˘·, Ó· ¤¯ÂÈ ‰È·ÊÔÚÂÙÈ΋ ·ıÔÁ¤ÓÂÈ· Î·È ÌÔÚ› Ó· ÌËÓ Û¯ÂÙ›˙ÂÙ·È Ì ÚÒÈÌË CMVÏԛ̈ÍË. ∏ ¢Ú›· ¯Ú‹ÛË ÚˆÙÔÎfiÏÏˆÓ ÚfiÏ˄˘ Ù˘ CMV Ïԛ̈͢ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ Ì›ˆÛË Ù˘ ÓÔÛËÚfiÙËÙ·˜ Î·È Ù˘ ıÓËÙfiÙËÙ·˜ ·fi CMV ηٿ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ÚÒÈÌ˘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋˜ ÂÚÈfi‰Ô˘39.

÷ڷÎÙËÚÈÛÙÈο Î·È ÔÚ›· ·ÛıÂÓÒÓ Ì ϤÔÓ Ù˘ 10ÂÙ›·˜ ÏÂÈÙÔ˘ÚÁÔ‡Ó ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ™Â ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË Ë ÔÔ›· Ú·ÁÌ·ÙÔÔÈ‹ıËΠÛÙË ÃÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ πÔÎÚ¿ÙÂÈÔ˘ °¡ £ÂÛÛ·ÏÔӛ΢, ¤ÁÈÓ ·Ó·ÛÎfiËÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ·ÛıÂÓÒÓ Ì ϤÔÓ Ù˘ 10ÂÙ›·˜ ÏÂÈÙÔ˘ÚÁÔ‡Ó ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· Î·È Ì ÛÎÔfi ÙËÓ ‰ÈÂÚ‡ÓËÛË ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ Ï‹ÙË Î·È ·Ú·ÁfiÓÙˆÓ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ Ì·ÎÚÔ¯ÚfiÓÈ· ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ [ηı˘ÛÙÂÚË̤ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (∫§ª), ÔÍ›· ·fiÚÚÈ„Ë, ÚÒÈÌË ‹ fi„ÈÌË, ˘¤ÚÙ·ÛË ÙÔ˘ Ï‹ÙË Î·È ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (áª)]. ªÂÏÂÙ‹ıËÎ·Ó Û˘ÓÔÏÈο 90 ·ÛıÂÓ›˜ [51 ¿Ó‰Ú˜ (56.7%) Î·È 39 Á˘Ó·›Î˜ (43.3%)] ÔÈ ÔÔ›ÔÈ Â›¯·Ó Ï¿‚ÂÈ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ÌÂٷ͇ 1983-2000, Ì ̤ÛË ‰È¿ÚÎÂÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘(±SD, range) 200,25±40,35 Ì‹Ó˜ (r= 120-336 Ì‹Ó˜). ∞fi ·˘ÙÔ‡˜ 66 (73.3%) ¤Ï·‚·Ó ÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ˙ÒÓÙ· Û˘ÁÁÂÓ‹ ‰fiÙË ÂÓÒ 24 (26.7%) ·fi و̷ÙÈÎfi ‰fiÙË (p<0.0001). ∂›ÎÔÛÈ ÂÓÓ¤· (29) ·ÛıÂÓ›˜ (32.2%) ·ÚÔ˘Û›·Û·Ó ∫§ª ÂÓÒ 61 (67.8%) ›¯·Ó ¿ÌÂÛË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (p<0.001). ™ÙËÓ ÔÚ›· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ 25 ·ÛıÂÓ›˜ (27.8%) ·ÓÙÈÌÂÙˆ›-

METAMO™XEY™Eπ™ 2011

67

¶π¡∞∫∞™ 1. ∫Ú·ÙÈÓ›ÓË ÔÚÔ‡, χΈ̷ Ô‡ÚˆÓ 24ÒÚÔ˘ Î·È ∞¶ ÏËÙÒÓ ¡ª Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· ϤÔÓ Ù˘ 10ÂÙ›·˜ Screat Uprot24h SAP DAP

1,41 (±0,79) 92,31 ((±138,25) 140,44 (±21,81) 89,13 (±15,48)

1,54 (±0,69) 331,37 (±548,01) 137,88 (±20,86) 85,57 (±13,18)

ÛıËÎ·Ó ÁÈ· ÂÂÈÛfi‰ÈÔ ÔÍ›·˜ ·fiÚÚȄ˘ (O∞) [20 ·Ûı. (22.2%) Ì 1 ÂÂÈÛfi‰ÈÔ O∞ Î·È 5 ·Ûı. (5.6%) Ì 2 ÂÂÈÛfi‰È· O∞] ÂÓÒ 65 (72.2%) ·ÛıÂÓ›˜ ‰ÂÓ ÂÌÊ¿ÓÈÛ·Ó ÂÂÈÛfi‰ÈÔ O∞ (p<0.001) ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 30 ÂÂÈÛÔ‰›ˆÓ O∞ Ù· 25 (83.3%) ‹Ù·Ó ÚÒÈÌ· (<3 Ì‹Ó˜ ·fi ÙË ¡ª) ÂÓÒ Ù· 5 ‹Ù·Ó ÂÂÈÛfi‰È· O∞ Ù˘ ·ÒÙÂÚ˘ ÂÚÈfi‰Ô˘ (16.7%) (p<0.05). ∞ÛıÂÓ›˜ Ì ˘¤ÚÙ·ÛË ‹Ù·Ó 58 (64.4%), ÂÓÒ Ê˘ÛÈÔÏÔÁÈ΋ ∞¶ ·ÚÔ˘Û›·˙·Ó 32 (35.6%) ·ÛıÂÓ›˜ (p<0.05) H ÔÚ›· Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÔÚÔ‡ (Screat, mean±SD,mg/dl), ÙÔ˘ Ï¢ÎÒÌ·ÙÔ˜ Ô‡ÚˆÓ 24ÒÚÔ˘ (Uprot24h, mean±SD,mg/24h), Ù˘ Û˘ÛÙÔÏÈ΋˜ ∞¶ (SAP, mean±SD,mmHg) Î·È Ù˘ ‰È·ÛÙÔÏÈ΋˜ ∞¶ (DAP, mean±SD,mmHg) ÛÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÌÂÙ¿ ÙÔ 5Ô¤ÙÔ˜ ·fi ÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∏ Û‡ÁÎÚÈÛË ÌÂٷ͇ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ϤÔÓ Ù˘ 10ÂÙ›·˜ ÂÈ‚›ˆÛË (ÛËÌÂ›Ô ÂÎΛÓËÛ˘ Ù˘ ·Ó¿Ï˘Û˘ ÂÈ‚›ˆÛ˘ Ù· 10 ¤ÙË), ¤‰ÂÈÍ fiÙÈ ÌÔۯ‡̷ٷ Ô˘ ·ÚÔ˘Û›·Û·Ó ÂÂÈÛfi‰ÈÔ O∞ ÂÌÊ¿ÓÈ˙·Ó ηٿ Kaplan-Meier ˘ÔÏÔÁÈ˙fiÌÂÓË 10ÂÙ‹ Î·È 15ÂÙ‹ ÂÈ‚›ˆÛË 95.7% Î·È 71.7%, ÂÓÒ ÌÔۯ‡̷ٷ ¯ˆÚ›˜ ÂÂÈÛfi‰ÈÔ O∞ ›¯·Ó ÂÈ‚›ˆÛË 98.5% Î·È 73.2% Ù· ·ÓÙ›ÛÙÔȯ· ¯ÚÔÓÈο ‰È·ÛÙ‹Ì·Ù·. ∏ Û‡ÁÎÚÈÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÌÂٷ͇ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ̷ÎÚÔ¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·, ¤‰ÂÈÍ fiÙÈ ÌÔۯ‡̷ٷ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ∫§ª ›¯·Ó 10ÂÙ‹ Î·È 15ÂÙ‹ ÂÈ‚›ˆÛË 93.1% Î·È 65.5%, ÂÓÒ ÌÔۯ‡̷ٷ ¯ˆÚ›˜ ∫§ª ›¯·Ó ÂÈ‚›ˆÛË 98.4% Î·È 68.9% Ù· ·ÓÙ›ÛÙÔȯ· ÌÂÛԉȷÛÙ‹Ì·Ù·. ŸÛÔÓ ·ÊÔÚ¿ ÌÔۯ‡̷ٷ, Ì ÂÈ‚›ˆÛË ¤Ú·Ó Ù˘ 10ÂÙ›·˜, Ô˘ ÂΉ‹ÏˆÛ·Ó ᪠›¯·Ó 10ÂÙ‹ Î·È 15ÂÙ‹ ÂÈ‚›ˆÛË 97.4% Î·È 65.8% ¤Ó·ÓÙÈ 98% Î·È 68% ·ÓÙ›ÛÙÔȯ· ·˘ÙÒÓ ¯ˆÚ›˜ ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÌÔۯ‡̷ÙÔ˜. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë Ì¤ÛË ˘ÔÏÔÁÈ˙fiÌÂÓË ‰È¿ÚÎÂÈ· ÂÈ‚›ˆÛ˘ ηٿ Kaplan-Meier ÌÂٷ͇ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ÂÚÈÛÛfiÙÂÚÔ ·fi 10ÂÙ‹ ÂÈ‚›ˆÛË, ‚Ú¤ıËΠÁÈ· ÌÔۯ‡̷ٷ Ô˘ ·ÚÔ˘Û›·Û·Ó O∞ 193.28 Ì‹Ó˜ ÂÓÒ ÁÈ· Ù· ÌÔۯ‡̷ٷ ¯ˆÚ›˜ ÂÂÈÛfi‰ÈÔ O∞ 202.93 Ì‹Ó˜. ∂›Û˘ Û¯ÂÙÈο Ì ÙËÓ ˘¤ÚÙ·ÛË ÙÔ˘ Ï‹ÙË Ê¿ÓËΠfiÙÈ ·ÛıÂÓ›˜ Ì ˘¤ÚÙ·ÛË ·ÚÔ˘Û›·˙·Ó ÌÈÎÚfiÙÂÚË Î·Ù¿ Kaplan-

1,55 (±0,64) 438,27 (±711,91) 131,24 (±20,79) 84,1 (±12,37)

1,8 (±0,9) 1044,37 (±1097,14) 125,88 (±11,32) 78,11 (± 8,6)

Meier ˘ÔÏÔÁÈ˙fiÌÂÓË Ì¤ÛË ‰È¿ÚÎÂÈ· ÂÈ‚›ˆÛ˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ (Î·È ÂÔ̤ӈ˜ ÚÔÛ‰fiÎÈÌÔ ÂÈ‚›ˆÛ˘) Û ۇÁÎÚÈÛË Ì ÓÔÚÌÔÙ·ÛÈÎÔ‡˜ Ï‹Ù˜ (194.87 ¤Ó·ÓÙÈ 210 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ·). ™ÙË ‰È¿ÚÎÂÈ· ÌÂÙ¿ Ù· 10 ¤ÙË ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙÔ˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÁÈ· ÙÔÓ ÏËı˘ÛÌfi ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ·Ú·ÙËÚ‹ıËÎ·Ó 12 ·ÒÏÂȘ ÌÔÛ¯Â˘Ì¿ÙˆÓ (1 fi„ÈÌË O∞, 2 ı¿Ó·ÙÔÈ Ì ÏÂÈÙÔ˘ÚÁÔ‡Ó ÌfiÛ¯Â˘Ì· Î·È 9 ÏfiÁˆ ¯ÚfiÓÈ·˜ ÓÂÊÚÔ¿ıÂÈ·˜ ÌÔۯ‡̷ÙÔ˜). Δ· Â˘Ú‹Ì·Ù· Ù˘ ·ÓˆÙ¤Úˆ ÌÂϤÙ˘ ‰Â›¯ÓÔ˘Ó fiÙÈ ÌÔۯ‡̷ٷ Ì ¤Ú·Ó Ù˘ 10ÂÙ›·˜ ÂÈ‚›ˆÛË ÚÔ¤Ú¯ÔÓÙ·È Î˘Ú›ˆ˜ ·fi ˙ÒÓÙ· ‰fiÙË Î·ıÒ˜ Â›Û˘ Î·È fiÙÈ Ë Â›ÙˆÛË Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È Ù˘ ˘¤ÚÙ·Û˘ ÙÔ˘ Ï‹ÙË ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔÁÈ· ÙËÓ ÂÚ·ÈÙ¤Úˆ Ì·ÎÚÔ¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿ ÙÔ˘˜.

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H ÔÚ›· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ¯ÚfiÓÔ ÈÛ¯·ÈÌ›·˜ ÌÂÁ·Ï‡ÙÂÚÔ ·fi 24 ÒÚ˜ Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ B. ¢Ú·ÎfiÔ˘ÏÔ˜

∂ÈÛ·ÁˆÁ‹: ∏ ·Ú·ÙÂٷ̤ÓË „˘¯Ú‹ ÈÛ¯·ÈÌ›· ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Û‡Ìʈӷ Ì ÙËÓ ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, Ô‰ËÁ› Û ˘„ËÏfiÙÂÚË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ·˘ÙÒÓ, ˘„ËÏfiÙÂÚË ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÏËÙÒÓ Î·È ˘„ËÏfiÙÂÚÔ ÎfiÛÙÔ˜ ÓÔÛËÏ›·˜ Ù˘ ˘ÁÂÈÔÓÔÌÈ΋˜ ÂÚ›ı·Ï„˘. √ ̤ÛÔ˜ ¯ÚfiÓÔ˜ ·Ô‰ÂÎÙ‹˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ·Ú·Ì¤ÓÂÈ ‰ÈÂıÓÒ˜ ÂÚ›Ô˘ 21 ÒÚ˜. ∂Í·ÎÔÏÔ˘ı› Ó· ˘¿Ú¯ÂÈ ‰ËÏ·‰‹ ¤Ó· Úfi‚ÏËÌ· Ì ‰··ÓËÚ¤˜ Î·È ÛÔ‚·Ú¤˜ Û˘Ó¤ÂȘ Ô˘ ¯Ú‹˙ÂÈ ÂÈχÛˆ˜. ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ¤Ú¢ӷ˜ Â›Ó·È Ë ·ÍÈÔÏfiÁËÛË Ù˘ ÔÚ›·˜ Ù˘ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ì ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 24 ˆÚÒÓ Î·ıÒ˜ Î·È Ë ‰ÈÂÚ‡ÓËÛË ·Ú·ÁfiÓÙˆÓ Ô˘ ÂËÚ¿˙Ô˘Ó ·˘Ù‹. ∞ÔÙÂÏ› ÙÔ ÚÒÙÔ Ì¤ÚÔ˜ ÌÈ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÂÚ¢ÓËÙÈ΋˜ ·Ó·Ï‡Ûˆ˜ 500 ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÓÂÊÚÔ‡ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó ÛÙËÓ ªÔÓ¿‰· ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ °.¡.∞ Ô «∂˘·ÁÁÂÏÈÛÌfi˜». ª¤ıÔ‰Ô˜: ∫·Ù¿ ÙËÓ ÙÂÏÂ˘Ù·›· 20ÂÙ›· Ú·ÁÌ·ÙÔÔÈËı‹Î·Ó ÛÙËÓ ªÔÓ¿‰· Ì·˜ 500 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÔ‡. ™ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ 250 ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·Ú·ÙËÚ‹ıËÎ·Ó 14 ÓÂÊÚÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ Ì ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 24 ˆÚÒÓ. °È· ÙËÓ ÌÂϤÙË Ù˘ Â›‰Ú·Û˘ ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ÛÙÔ˘˜ Ï‹Ù˜ ‰È·ÈÚ¤ıËÎ·Ó Ù· ÌÔۯ‡̷ٷ Ì ¯ÚfiÓÔ ÈÛ¯·ÈÌ›·˜ ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 24 ˆÚÒÓ Û ‰‡Ô ÔÌ¿‰Â˜, ÔÌ¿‰· ∞ Î·È ÔÌ¿‰· μ. ™ÙËÓ ÔÌ¿‰· ∞ ·Ó‹ÎÔ˘Ó ÔÈ Ï‹Ù˜ ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ˘Á›·˜ (¡6) Î·È ÛÙËÓ ÔÌ¿‰· μ ·Ó‹ÎÔ˘Ó ÔÈ Ï‹Ù˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (¡.8). ∏ Û˘ÏÏÔÁ‹ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ Ì ÏÂÙÔÌÂÚ‹ ËÏÂÎÙÚÔÓÈ΋ ηٷÁÚ·Ê‹ ÙÔ˘ È·ÙÚÈÎÔ‡ ʷΤÏÔ˘ ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘ ‰Â›ÁÌ·ÙÔ˜ . ∞ÔÙÂϤÛÌ·Ù·: ∂Î ÙˆÓ ·ÛıÂÓÒÓ Ù˘ ∞ ÔÌ¿‰Ô˜ fiÏÔÈ ‹Ù·Ó ¿Ó‰Ú˜, ¤ÍÈ ·fi ÙÔ˘˜ ¤ÍÈ ·ÛıÂÓ›˜,

ÂÓÒ ÛÙËÓ ÔÌ¿‰· μ ‹Ù·Ó ¤ÓÙ ¿Ó‰Ú˜ ·fi ÙÔ˘˜ ÔÎÙÒ ·ÛıÂÓ›˜. ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó 52 ÂÙÒÓ, ÂÓÒ Ô Ì¤ÛÔ˜ ¯ÚfiÓÔ˜ ·Ó·ÌÔÓ‹˜ ÁÈ· ÌfiÛ¯Â˘Ì· 4,66 ¤ÙË (SD=3,14).

O ̤ÛÔ˜ ¯ÚfiÓÔ˜ ÓÔÛËÏ›·˜ ÛÙËÓ ÔÌ¿‰· ∞ ‹Ù·Ó 18,73 ̤Ú˜ ÂÓÒ ÛÙËÓ ÔÌ¿‰· μ ‹Ù·Ó 47,33 Ë̤Ú˜ . ™ÙËÓ ÔÌ¿‰· ∞ ¿ÌÂÛË Â›Ó·È Ë ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· fiÏˆÓ ÙˆÓ ·ÛıÂÓÒÓ ÔÛÔÛÙfi 100%. ™ÙËÓ ÔÌ¿‰· μ ¿ÌÂÛË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ›¯·Ó ¤ÍÈ (6) ·ÛıÂÓ›˜ ÔÛÔÛÙfi 75% ÂÓÒ ‰˘ÛÚ·Á›· ÌÔۯ‡̷ÙÔ˜ ·ÚÔ˘ÛÈ¿ÛıËΠ۠‰˘Ô (2) ·ÛıÂÓ›˜ ÔÛÔÛÙfi 25%. ŸÛÔ ·ÊÔÚ¿ ÙËÓ Ì·ÎÚÔ¯ÚfiÓÈ· (36 ÌËÓÒÓ) ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ ÛÙËÓ ∞ ÔÌ¿‰· ÔÈ ¤ÓÙ (5) ·ÛıÂÓ›˜ ÔÛÔÛÙfi 83,3% ¤¯Ô˘Ó ¿ÚÈÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÂÓÒ ¤Ó·˜ (1) ·ÛıÂÓ‹˜ ÔÛÔÛÙfi 16,6% ·‚›ˆÛ ÏfiÁˆ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘. ™ÙËÓ μ ÔÌ¿‰· ÛÙËÓ Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË ‰˘Ô (2) ·ÛıÂÓ›˜ ÔÛÔÛÙfi 25% ¤¯Ô˘Ó ¿ÚÈÛÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ‰˘Ô (2) ·ÛıÂÓ›˜ ÔÛÔÛÙfi 25% Â·ÓÂÓÙ¿¯ıËÎ·Ó Û ·ÈÌÔοı·ÚÛË ÂÓÒ Ù¤ÛÛÂÚȘ (4) ·ÛıÂÓ›˜ ·‚›ˆÛ·Ó ÏfiÁˆ ·) Ô͇ ÛÙÂÊ·ÓÈ·›Ô˘ Û˘Ó‰ÚfiÌÔ˘, ‚) Û‹„˘, Á) Ca ‹·ÙÔ˜, ‰) Ca ÂÁÎÂÊ¿ÏÔ˘, ÔÛÔÛÙfi 50% . ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Ì ¯ÚfiÓÔ ÈÛ¯·ÈÌ›·˜ ˘„ËÏfiÙÂÚÔ ·fi 24 ÒÚ˜ Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÙfiÛÔ ÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ fiÛÔ Î·È ÙÔ ÎfiÛÙÔ˜ ÓÔÛËÏ›·˜ Ù˘ ˘ÁÂÈÔÓÔÌÈ΋˜ ÂÚ›ı·Ï„˘ ÁÂÁÔÓfi˜. ¶·ÚÔ˘ÛÈ¿˙ÂÙ·È Â›Û˘ Î·È ˘„ËÏfiÙÂÚË ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÏËÙÒÓ ÛÙËÓ Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÎÔÏÔ‡ıËÛË. °È· ÙËÓ ÂÍ·ÁˆÁ‹ ·ÛʷϤÛÙÂÚˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ¯ÚÂÈ¿˙ÂÙ·È Ë Û˘Ó¤¯ÈÛË Ù˘ ¤Ú¢ӷ˜ ÛÂ Û˘ÛÙËÌ·ÙÈ΋ ‚¿ÛË Ì ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ.

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71

H ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÛÙ· ·È‰È¿: ÂȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ Î·È È‰È·ÈÙÂÚfiÙËÙ˜ ∫.¢. ∫ÔÏÏÈfi˜

ªÂ ÙËÓ ÚfiÔ‰Ô ÛÙȘ ¯ÂÈÚÔ˘ÚÁÈΤ˜ Ù¯ÓÈΤ˜ Î·È ÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂÚ·›·, Ë ıÓËÙfiÙËÙ· ÛÙ· ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ ¤¯ÂÈ ‰Ú·Ì·ÙÈο ÂÏ·ÙÙˆı› Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ∏ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÔÙÂÏ› ÙËÓ ıÂÚ·›· ÂÎÏÔÁ‹˜ Û ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ, ·ÊÔ‡ ÚÔÛʤÚÂÈ ‚ÂÏÙ›ˆÛË ÛÙËÓ ÂÈ‚›ˆÛË, ÙËÓ ·‡ÍËÛË, ÙËÓ ÁÓˆÛÙÈ΋ ·Ó¿Ù˘ÍË Î·È ÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜. ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ, ÔÈ ·È‰È·ÙÚÈΤ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ηχÙÔ˘Ó ÔÛÔÛÙfi 4% ¤ˆ˜ 5%. ∫·Ù¿ ÙËÓ ‰ÂηÂÙ›· ÙÔ˘ 1980 ·Ú·ÙËÚ‹ıËΠÌÈ· ÛÙ·ıÂÚ‹ ·‡ÍËÛË ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ, Ô˘ ÌÂÙ¿ ÙÔ 2000 ·ÎÔÏÔ‡ıËÛ ÌÈ· ÛÙ·ıÂÚÔÔ›ËÛË. ŒÙÛÈ, ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ, ÙÔ 2/3 ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÂÊ‹‚ˆÓ, Ô˘ Â›Ó·È Û ÚÔÁÚ¿ÌÌ·Ù· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ¤¯Ô˘Ó ¤Ó· ÌfiÛ¯Â˘Ì·.

Î·È Ë ∂ÏÏ¿‰·, ÚԤ΢„·Ó Ù· ‰Â‰Ô̤ӷ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÔȯ›ˆÓ ÙfiÛÔ ÙÔ˘ ¶›Ó·Î· 1, fiÛÔ Î·È ÙˆÓ Û˘ÓÔÏÈÎÒÓ ‰Â‰Ô̤ӈÓ, ÚÔ·ÙÂÈ fiÙÈ Ë Â›ÙˆÛË Î·È Ô ÂÈÔÏ·ÛÌfi˜ Ù˘ ıÂÚ·›·˜ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ ÛÙ· ·È‰È¿, Â›Ó·È ÂÚ›Ô˘ 20 ÊÔÚ¤˜ ÌÈÎÚfiÙÂÚË Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ.

π‰È·ÈÙÂÚfiÙËÙ˜ Δ· ·È‰È¿ ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó Ì›· ͯˆÚÈÛÙ‹ ÔÌ¿‰· ˘Ô„ËÊ›ˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ¶·Ú·Î¿Ùˆ ·Ó·Ù‡ÛÛÔÓÙ·È È‰È·ÈÙÂÚfiÙËÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙ· ·È‰È¿ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ.

·. ∏ ˘ÔΛÌÂÓË ·ÈÙÈÔÏÔÁ›· Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜

∂ȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ ·fi ÙËÓ ∞ÌÂÚÈ΋

™Â ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ, Ô˘ ÔÈ ‰˘Ô ·ÚȘ ·Èٛ˜ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ Â›Ó·È Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Î·È Ë ˘¤ÚÙ·ÛË, ÛÙ· ·È‰È¿ ÔÈ 3 ·ÚȘ ·Èٛ˜ Â›Ó·È Ë ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·, Ë ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›· Î·È Ë ∂ÛÙȷ΋ Î·È ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË Î·È Î·Ï‡ÙÔ˘Ó Ì·˙› ÔÛÔÛÙfi 40% Â› ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ·ÈÙÈÒÓ Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘. ŸÙ·Ó Ë ·ÈÙÈÔÏÔÁ›· Ù·ÍÈÓÔÌÂ›Ù·È ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ·Ú·ÙËÚÂ›Ù·È fiÙÈ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ 0-1 Î·È 2-5 ÂÙÒÓ ÔÈ Î˘ÚÈfiÙÂÚ˜ ·Èٛ˜ Â›Ó·È Ë ÓÂÊÚÈ΋ ‰˘ÛÏ·Û›· Î·È Ë ·ÔÊÚ·ÎÙÈ΋ Ô˘ÚÔ¿ıÂÈ·. ∞ÓÙ›ıÂÙ·, ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ ËÏÈΛ·˜ 6-18 ÂÙÒÓ Ë Î˘ÚÈfiÙÂÚË ·ÈÙ›· Â›Ó·È Ë ∂ÛÙȷ΋ Î·È ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·ÌÔÙÔÛÎÏ‹Ú˘ÓÛË (42,1%).

∏ NAPRTCS (North American Pediatric Renal Trials and Collaborative Studies) ·Ú¤¯ÂÈ ÂÙ‹ÛÈ· ÛÙÔȯ›· ·fi Ù· ‰Â‰Ô̤ӷ Û ۇÓÔÏÔ 150 ΤÓÙÚˆÓ ·fi ÙȘ ∏¶∞, ∫·Ó·‰¿, ªÂÍÈÎfi Î·È ∫fiÛÙ· ƒ›Î·, Ô˘ ·ÊÔÚÔ‡Ó ·È‰È¿ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·, Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ·ÈÌÔοı·ÚÛË, ÂÚÈÙÔÓ·˚΋ οı·ÚÛË ‹ Û ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË . ™‡Ìʈӷ Ì ÙËÓ ÂÙ‹ÛÈ· ¤ÎıÂÛË ÙÔ˘ 2010 Ù˘ NAPRTCS, ·fi ÙÔ 1987 ̤¯ÚÈ ÙÔÓ πÔ‡ÏÈÔ 2010 Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó 11.603 ÌÂÙ·ÌÔۯ‡ÛÂȘ ÓÂÊÚÒÓ Û ۇÓÔÏÔ 10.632 ·È‰ÈÒÓ.

∂ȉËÌÈÔÏÔÁÈο ‰Â‰Ô̤ӷ ·fi ÙËÓ ∂˘ÚÒË ¢Â‰Ô̤ӷ ÁÈ· ÙËÓ Â›ÙˆÛË Î·È ÙÔÓ ÂÈÔÏ·ÛÌfi Ù˘ ıÂÚ·›·˜ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ ÛÙËÓ ∂˘ÚÒË, ÛÙ· ÔÔ›· Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ‰Â‰Ô̤ӷ Ô˘ ·ÊÔÚÔ‡Ó Î·È ÙËÓ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ‰ËÌÔÛȇÙËÎ·Ó ÙÔ 2010 ·fi Ù˘ ESPN/ERA-EDTA Registry. ™Â Û‡ÓÔÏÔ 74.682.067 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ ·fi 28 ¯ÒÚ˜, ÌÂٷ͇ ÙˆÓ ÔÔ›ˆÓ ÂÚÈÏ·Ì‚¿ÓÂÙ·È

‚. ¶ÚÔÏËÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÚÈÓ ÙËÓ ¤ÓÙ·ÍË Û ¯ÚfiÓÈ· οı·ÚÛË (preemptive transplantation) À¿Ú¯ÂÈ Ù¿ÛË ·‡ÍËÛ˘ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÚÈÓ ÙËÓ ¤ÓÙ·ÍË Û ¯ÚfiÓÈ· οı·ÚÛË (preemptive transplantation) ÙfiÛÔ ÛÙËÓ ∂˘ÚÒË fiÛÔ Î·È ÛÙȘ

73

∫. ∫√§§π√™

74

¶π¡∞∫∞™ 1. ∂ȉËÌÈÔÏÔÁÈο ÛÙÔȯ›· ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì ÓÂÊÚÈ΋ ˘ÔηٿÛÙ·ÛË (·ÈÌÔοı·ÚÛË, ÂÚÈÙÔÓ·˚΋ Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË) Î·È ÂȉÈÎfiÙÂÚ· ÛÙ· ·È‰È¿ Ì ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙËÓ ∂˘ÚÒË Î·È ÙËÓ ∂ÏÏ¿‰· ÛÙȘ 31 ¢ÂÎÂÌ‚Ú›Ô˘ 2007 (™ÙÔȯ›· ESPN/ERA-EDTA Registry, van Stralen KJ, et al. 2010) ™‡ÓÔÏÔ 74.682.067 ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡, Û 28 ¯ÒÚ˜ Ù˘ ∂˘ÚÒ˘ ∂ÈÔÏ·ÛÌfi˜ ıÂÚ·›·˜ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ (ÂÎÊÚ·Ṳ̂ÓÔ˜ Û ·ÚÈıÌfi Î·È pmarp)

∂˘ÚÒË

∂ÏÏ¿‰·

n 2.512 (·fi ·˘Ù¿, ÔÈ 483 ‹Ù·Ó Ӥ˜ ÂÚÈÙÒÛÂȘ) 46 (·fi ·˘Ù¿, ÔÈ 13 ‹Ù·Ó Ӥ˜ ÂÚÈÙÒÛÂȘ)

∞ÚÈıÌfi˜ Î·È ÔÛÔÛÙfi ÙˆÓ ·È‰ÈÒÓ ÛÙȘ 3 ηÙËÁÔڛ˜ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ ∞ÈÌÔοı·ÚÛË n (%)

¶ÂÚÈÙÔÓ·˚΋ n (%)

ªÂÙ·ÌfiÛ¯Â˘ÛË n (%)

32.6 pmarp

373 (15%)

575 (22.8%)

1.564 (62.2%)

28.8 pmmarrp

9 (19.5%)

16 (34.8%)

21 (45.7%)

pmarp: per million age related population (·Ó¿ ÂηÙÔÌ̇ÚÈÔ ÏËı˘ÛÌÔ‡ Û¯ÂÙÈ˙fiÌÂÓÔ˘ Ì ÙËÓ ËÏÈΛ·)

∏¶∞, Ì ÙËÓ ¯Ú‹ÛË ˙ÒÓÙˆÓ Î·È و̷ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ™ÙËÓ ∂˘ÚÒË, Ë ™Ô˘Ë‰›·, Ë ¡ÔÚ‚ËÁ›· Î·È Ë OÏÏ·Ó‰›· ÂÌÊ·Ó›˙Ô˘Ó ÔÛÔÛÙ¿ preemptive ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ô˘ ˘ÂÚ‚·›ÓÔ˘Ó ÙÔ 30%.

Á. ∂È‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ™ÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ÚÈÓ ÙÔ 1983, Ë 10-ÂÙ‹˜ ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó ÌfiÓÔ 20%. ™Ù· ÂfiÌÂÓ· ¤ÙË, Ë ÂÈ‚›ˆÛË ·ÎÔÏÔ‡ıËÛÂ Û˘Ó¯‹ ·‡ÍËÛË (¶›Ó. 2), Ì 10-ÂÙ‹ ÂÈ‚›ˆÛË Û ¤Ó· ΤÓÙÚÔ Ô˘ ¤ÊÙ·Û ÙÔ 95% (Mehrabi A et al, 2004). ∏ ÂÈ‚›ˆÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ˙ÒÓÙ· ‰fiÙË Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Û ۇÁÎÚÈÛË Ì ÙËÓ ÂÈ‚›ˆÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi و̷ÙÈÎfi ‰fiÙË. ¶π¡∞∫∞™ 2. ∏ ÂÈ‚›ˆÛË ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ™Ù· 5 ¤ÙË ™Ù· 10 ¤ÙË ™Ù· 15 ¤ÙË ™Ù· 20 ¤ÙË

44%-95% 23%-95% 35% 21-36%

‰. ∏ ËÏÈΛ· ÙÔ˘ Ï‹ÙË ™‡Ìʈӷ Ì ÙËÓ ÂÙ‹ÛÈ· ¤ÎıÂÛË ÙÔ˘ 2010 Ù˘ NAPRTCS, ÙÔ ÌÂÁ·Ï‡ÙÂÚÔ ÔÛÔÛÙfi ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·ÊÔÚÔ‡Û ·È‰È¿ ËÏÈΛ·˜ 6-17 ÂÙÒÓ: 32, 8 % ËÏÈΛ·˜ 6-12 ÂÙÒÓ Î·È 39, 2% ËÏÈΛ·˜ 13-17 ÂÙÒÓ, Û‡ÓÔÏÔ 72%. ÓÙ›ıÂÙ·, ÌfiÓÔ 14,7% ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·ÊÔÚÔ‡Û ·È‰È¿ ËÏÈΛ·˜ 2-5 ÂÙÒÓ, Î·È 5,3% ‚Ú¤ÊË ËÏÈΛ·˜ 0-1 ¤ÙÔ˘˜, Û‡ÓÔÏÔ 20%. ™‡Ìʈӷ Ì ÙËÓ ¤ÎıÂÛË Ù˘ NAPRTCS ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 96 ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Ô˘ ¤ÁÈÓ·Ó Û ‚Ú¤ÊË < 1¤ÙÔ˘˜ ·fi ÙÔ 1987 ̤¯ÚÈ ÙÔ 2010, ÌfiÓÔ

10 ÌÂÙ·ÌÔۯ‡ÛÂȘ ¤¯Ô˘Ó Á›ÓÂÈ ·fi ÙÔ 2004 ̤¯ÚÈ ÙÔ 2010. ∞˘Ù‹ Ë ‰È·ÊÔÚ¿ ÛÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ËÏÈÎÈÒÓ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÚÔËÁÔ‡ÌÂÓ˜ ·Ó·ÊÔÚ¤˜ ÌÈÎÚfiÙÂÚ˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ϋÙ˜ ËÏÈΛ·˜ < 5 ÂÙÒÓ.

Â. ∏ ËÏÈΛ· ÙÔ˘ ‰fiÙË To ηÙÒÙÂÚÔ fiÚÈÔ ËÏÈΛ·˜ ÙÔ˘ ‰fiÙË ‰È·Ê¤ÚÂÈ ·fi ¯ÒÚ· Û ¯ÒÚ·. ™ÙËÓ °·ÏÏ›· Â›Ó·È Ù· 2 ¤ÙË, ÛÙËÓ πÛ·Ó›· Ù· 3 ¤ÙË Î·È ÛÙËÓ ªÂÁ¿ÏË μÚÂÙ·Ó›· Ù· 5 ¤ÙË. H ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ·ÓÂ¿ÚÎÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ‰fiÙ˜ ËÏÈΛ·˜ < 5 ÂÙÒÓ ·Ô‰›‰ÂÙ·È Â›Ù ÛÙËÓ ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÚˆÙÔ·ıÔ‡˜ ¤ÏÏÂȄ˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ›Ù ıÚfiÌ‚ˆÛ˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. μÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ¤¯ÂÈ ·Ú·ÙËÚËı› Ì en-bloc ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙˆÓ ÓÂÊÚÒÓ.

ÛÙ. ∞ÁÁÂȷ΋ ıÚfiÌ‚ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ O ·˘ÍË̤ÓÔ˜ ΛӉ˘ÓÔ˜ ıÚfiÌ‚ˆÛ˘ ÂÚÈÔÚ›˙ÂÈ ÙËÓ ¯Ú‹ÛË ‰ÔÙÒÓ < 2 ÂÙÒÓ Î·È ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ϋÙ˜ ËÏÈΛ·˜ < 12 ÌËÓÒÓ.

˙. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘ ∏ Û˘¯ÓfiÙËÙ· Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘ ÌÂÈÒıËΠ·fi 70% ÛÙ· ¤ÙË 1987-1990 ÛÙÔ 13% Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·.

Ë. ªË Û˘ÌÌfiÚʈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ H ÌË Û˘ÌÌfiÚʈÛË ÛÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ıÂÚ·›· ·Ú·ÙËÚÂ›Ù·È Û >30% ÙˆÓ ·È‰ÈÒÓ Î·È È‰È·›ÙÂÚ· ÙˆÓ ÂÊ‹‚ˆÓ Î·È ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋

METAMO™XEY™Eπ™ 2011

·ÈÙ›· ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜.

ı. ∞Èٛ˜ ·ÒÏÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ∏ ·ÚȘ ·Èٛ˜ ·ÒÏÂÈ·˜ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È Ë ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (32%), Ë ÔÍ›· ·fiÚÚÈ„Ë (21%), Ë ·ÁÁÂȷ΋ ıÚfiÌ‚ˆÛË (13%) Î·È Ë ÌË Û˘ÌÌfiÚʈÛË ÛÙËÓ ·ÁˆÁ‹ (ÛÙÔ˘˜ ÂÊ‹‚Ô˘˜ ·ÔÙÂÏ› ÙËÓ ·ÈÙ›· ÁÈ· ÙÔ 25 % ÙˆÓ ·ˆÏÂÈÒÓ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜). ¡fiÛÔÈ Ô˘ Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙Ô˘Ó ÛÙÔ ÌfiÛ¯Â˘Ì· Â›Ó·È Ë ∂ÛÙȷ΋ Î·È ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË, Ë ÌÂÌ‚Ú·ÓÔ¸ÂÚÏ·ÛÙÈ΋ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·, ηıÒ˜ Î·È Ë ÚˆÙÔ·ı‹˜ ˘ÂÚÔÍ·ÏÔ˘Ú›· ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ Á›ÓÂÈ Û˘Ó‰˘·Ṳ̂ÓË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Î·È ‹·ÙÔ˜.

È. ∏ ÂÈ‚›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜-·Èٛ˜ ı·Ó¿ÙÔ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜ ∏ ÂÈ‚›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Â›Ó·È Î·Ï‡ÙÂÚË ÛÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ Ï‹Ù˜ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·’fiÙÈ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ∞fi ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ·È‰ÈÒÓ ÛÙ· 10 ¯ÚfiÓÈ· ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÔÈ ÏÔÈÌÒÍÂȘ ¢ı‡ÓÔÓÙ·È Û ÔÛÔÛÙfi 34%, ÔÈ Î·Ú‰È·ÁÁÂȷΤ˜ ÓfiÛÔÈ ÁÈ· ÙÔ 15% Î·È ÔÈ ÓÂÔϷۛ˜ ÁÈ· ÙÔ 12%.

μÈ‚ÏÈÔÁÚ·Ê›· North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS), 2010 Annual Transplant Report. https://web.emmes.com/study/ped/annlrept/2010_Repo

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rt.pdf van Stralen KJ, Tizard EJ, Verrina E, Schaefer F, Jager KJ. European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) registry study group.

Demographics of paediatric renal replacement therapy in Europe: 2007 annual report of the ESPN/ERAEDTA registry. Pediatr Nephrol 2010;25(7): 1379-1382.

Stel VS, Kramer A, Zoccali C, Jager KJ. The 2007 ERAEDTA Registry Annual Report-a Précis. NDT Plus 2009; 2(6): 514-521.

Rees L. Long-term outcome after renal transplantation in childhood. Pediatr Nephrol 2009; 24(3): 475-484.

Stel VS, Kramer A, Zoccali C, Jager KJ. The 2007 ERAEDTA Registry Annual Report-a Précis. NDT Plus 2009; 2(6): 514-521.

Cochat P, Hebert D. Demographics of pediatric renal transplantation. In: Comprehensive Pediatric Nephrology, Geary DF, Schaefer F, editors. Mosby Elsevier 2008, 895- 904.

Mehrabi A, Kashfi A, Tönshoff B, Feneberg R, Mehls O, Schemmer P, Kraus T, Wiesel M, Büchler MW, Schmidt J. Long-term results of paediatric kidney transplantation at the University of Heidelberg: a 35 year singlecentre experience. Nephrol Dial Transplant 2004;19 Suppl 4: iv69-74.

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. ∏ ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÛÙ· ·È‰È¿, http:// pd3.gr/ pdf/6eteisFeb2011.pdf Pediatric kidney transplantation, http://emedicine.medscape.com/article/ 1012654-overview.

AÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· ÛÙË ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙ· ·È‰È¿. ™‡Á¯ÚÔÓ˜ Ù¿ÛÂȘ ¡. ¶Ú›ÓÙ˙·

1.À„ËÏfiÙÂÚË ·ÓÔÛÔηٷÛÙÔÏ‹ ÙÔ˘˜ ÙÚÂȘ ÚÒÙÔ˘˜ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÛÙ·‰È·Î‹ Ì›ˆÛË ÙˆÓ ‰fiÛÂˆÓ ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙË Û˘Ó¤¯ÂÈ· 2 ∞Ó·ÁÓÒÚÈÛË ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ˘„ËÏfi ΛӉ˘ÓÔ ÁÈ· ·fiÚÚÈ„Ë Ì ‚¿ÛË Ù· ·Ú·Î¿Ùˆ ¯·Ú·ÎÙËÚÈÛÙÈο: ·) ˘„ËÏ¿ ΢ÙÙ·ÚÔÙÔÍÈο ·ÓÙÈÛÒÌ·Ù· ‚) ÈÛÙÔÚÈÎfi ÚÔËÁÔ‡ÌÂÓ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Á) ÈÛÙÔÚÈÎfi ÔÍ›·˜ ·fiÚÚȄ˘ ‰) ÊÙˆ¯‹ HLA Û˘Ì‚·ÙfiÙËÙ· Î·È Â) ˘ÔÙÚÔ‹ Ù˘ ÚˆÙÔ·ıÔ‡˜ ÓfiÛÔ˘. ∏ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÈÛ·ÁˆÁÈ΋ ·ÓÔÛÔηٷÛÙÔÏ‹, ÙËÓ ·ÓÔÛÔηٷÛÙÔÏ‹ Û˘ÓÙ‹ÚËÛ˘ Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·fiÚÚȄ˘. ™ÙË Û˘Ó¤¯ÂÈ· ı· ·Ó·ÊÂÚıԇ̠·Ó·Ï˘ÙÈο ÛÙ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· ÛÙ· ·È‰È¿ Î·È ÛÙȘ Û‡Á¯ÚÔÓ˜ Ù¿ÛÂȘ ÛÙËÓ ·ÓÔÛÔηٷÛÙÔÏ‹.

™Ù· ·È‰È¿ Ì ÙÂÏÈÎfi ÛÙ¿‰ÈÔ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ (Δ™¡¡) Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ (ª¡) ·ÔÙÂÏ› ÙË ıÂÚ·›· ÂÎÏÔÁ‹˜ ηıÒ˜ ˘ÂÚ¤¯ÂÈ Û ۯ¤ÛË Ì ÙȘ ÌÂıfi‰Ô˘˜ Â͈ÓÂÊÚÈ΋˜ οı·ÚÛ˘, ÙfiÛÔ ÛÙ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘, fiÛÔ Î·È ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜.

O ¯ÚfiÓÔ˜ ·Ó·ÌÔÓ‹˜ ÁÈ· ÙËÓ Â‡ÚÂÛË ÙÔ˘ ηٿÏÏËÏÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ÙË Ï›ÛÙ· و̷ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÔÚ› Ó· Î˘Ì·›ÓÂÙ·È ·fi Ì‹Ó˜ ¤ˆ˜ ¯ÚfiÓÈ·. ªÂÙ¿ ÙË ª¡ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·‡ÍËÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·›˙ÂÈ Ë Î·Ù¿ÏÏËÏË ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹. πÛÙÔÚÈο, ·fi ÙÔ 1970 ¤ˆ˜ ÙÔ 1980 Ô Û˘Ó‰˘·ÛÌfi˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Ì ·˙·ıÂÈÔÚ›ÌË ·ÔÙÂÏÔ‡Û·Ó ÙÔ Î‡ÚÈÔ ·ÓÔÛÔηٷÛÙ·ÏÏÙÈÎfi Û¯‹Ì· ÛÙ· ·È‰È¿. ΔË ‰ÂηÂÙ›· ÙÔ˘ 1980 ¿Ú¯ÈÛÂ Ë ¯ÔÚ‹ÁËÛË Î˘ÎÏÔÛÔÚ›Ó˘ Î·È ·fi ÙÔ 1996-2000 Ë ¯ÔÚ‹ÁËÛË MycophenolateMofetil(MMF) Î·È tacrolimus. ∏ Ú·Á‰·›· ·Ó¿Ù˘ÍË Î·È ÂͤÏÈÍË ÙˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô‰‹ÁËÛ Û ·ÍÈÔÛËÌ›ˆÙË ‚ÂÏÙ›ˆÛË Ù˘ ‚Ú·¯‡¯ÚÔÓ˘ ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Ì ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ ·fiÚÚȄ˘ ÛÙÔ ÚÒÙÔ ¤ÙÔ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Ùfi¯Ô˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ Û‹ÌÂÚ· Â›Ó·È Ë ‚ÂÏÙ›ˆÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ÔÍ›·˜ Î·È ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ ·ÓÂÈı‡ÌËÙˆÓ ÂÓÂÚÁÂÈÒÓ, fiˆ˜ ÏÔÈÌÒÍÂȘ, ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·, ηÎÔ‹ıÂȘ, ÎÔÛÌËÙÈο ÚÔ‚Ï‹Ì·Ù· Î·È ÌÂȈ̤ÓË ·‡ÍËÛË, ÙˆÓ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓˆÓ Ê·Ú̿ΈÓ. ∏ ÂÌÂÈÚ›· ·fi Ù· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· ÙˆÓ ÂÓËÏ›ÎˆÓ ·ÔÙÂÏ› ÙÔÓ ‚·ÛÈÎfi ¿ÍÔÓ· Î·È ÁÈ· ÙÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜. ∂ÓÙÔ‡ÙÔȘ,Û˘Ó‹ıˆ˜ Ù· ·È‰È·ÙÚÈο ÚˆÙfiÎÔÏÏ· ÙÚÔÔÔÈÔ‡ÓÙ·È Ì ‚¿ÛË ÙfiÛÔ ÙÔ ‰È·ÊÔÚÂÙÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ·È‰ÈÒÓ fiÛÔ Î·È ÙËÓ È‰È·›ÙÂÚË Â›‰Ú·ÛË ÌÂÚÈÎÒÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ÛÙË ·‡ÍËÛË Î·È ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ. μ·ÛÈΤ˜ ·Ú¯¤˜ ÛÙËÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹ ÛÙË ª¡ ÛÙ· ·È‰È¿ ›ӷÈ:

∂·ÁˆÁ‹ Ì ∞ÓÙÈÛÒÌ·Ù· ™ÙËÓ ÂÈÛ·ÁˆÁÈ΋ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÌÔÚ› Ó· Á›ÓÂÈ Â·ÁˆÁ‹ Ì ÔÏ˘ÎψÓÈο ·ÓÙÈÛÒÌ·Ù· (Thymoglobulin) ‹ Û˘Ó‹ıˆ˜ Û‹ÌÂÚ· Ì ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ CD3 ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (OKT3), ¤Ó·ÓÙÈ ÙˆÓ CD52 (alemtuzumab) ‹ ¤Ó·ÓÙÈ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ÈÓÙÂÚÏ¢ΛÓ˘ 2 (basiliximab). ™Â ÌÂÁ¿ÏË ÔÏ˘ÎÂÓÙÚÈ΋ Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË Û ·È‰È¿ Ê¿ÓËΠfiÙÈ Ë ¯Ú‹ÛË O∫Δ3 ‰ÂÓ Ì›ˆÓ ÙÔ ÔÛÔÛÙfi ÔÍ›·˜ ·fiÚÚȄ˘ Ô‡Ù ‚ÂÏÙ›ˆÓ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Û˘Óԉ‡ÔÓÙ·Ó ·fi ÔÏϤ˜ ·Ó·Èı‡ÌËÙ˜ ‰Ú¿ÛÂȘ. ∂ÈϤÔÓ Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ‰‡Ô ÌÂÁ¿Ï˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ Û ·È‰È¿ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¯ÔÚ‹ÁËÛË basiliximab Û ·ÛıÂÓ›˜ Ì ¯·ÌËÏÔ‡ Î·È Ì¤ÙÚÈÔ˘ ÎÈÓ‰‡ÓÔ˘ ‰ÂÓ Ì›ˆÓ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο Ù· ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘. ∞ÓÙ›ıÂÙ· Û‡Ìʈӷ Ì ÙȘ ·Ú·ÙËÚ‹ÛÂȘ ·fi ÙËÓ Î·Ù·ÁÚ·Ê‹ ÛÙË μfiÚÂÈÔ ∞ÌÂÚÈ΋ (¡Ôrth American Pediaric Renal Trials and Calloborative Studies — NAPRTCS), Ù· ·È‰È¿ Ô˘ ¤Ï·‚·Ó ıÂÚ·›· Â·ÁˆÁ‹˜ Ì ·ÓÙÈÛÒÌ·Ù· ·ÚÔ˘-

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METAMO™XEY™Eπ™ 2011

Û›·˙·Ó ηχÙÂÚË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∂›Û˘ ÚfiÛÊ·ÙË ÌÂϤÙË ¤‰ÂÈÍ ÙÔ ıÂÙÈÎfi ÚfiÏÔ ÙˆÓ ÌÔÓÔÎψÓÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ÚˆÙÔÎfiÏÏˆÓ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ (TWIST study). ∂Ô̤ӈ˜ ·Ó Î·È ‰ÂÓ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· ·Ó·ÊÔÚÈο Ì ÙË ¯Ú‹ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙËÓ ÂÈÛ·ÁˆÁÈ΋ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ ÛÙ· ·È‰È¿ Ê·›ÓÂÙ·È fiÙÈ: 1) ‰ÂÓ ˆÊÂÏÔ‡ÓÙ·È ·ÛıÂÓ›˜ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÔÍ›· ·fiÚÚÈ„Ë Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÙÚÈÏ‹ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Ì ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, MMF ‹ MPA Î·È ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ 2) ˆÊÂÏÔ‡ÓÙ·È ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÔÍ›· ·fiÚÚÈ„Ë, fiˆ˜ ·È‰È¿ ¢·ÈÛıËÙÔÔÈË̤ӷ, ·ÊÚÔ-·ÌÂÚÈοÓÈ΢ Ê˘Ï‹˜ Î·È Ì ÌÂÁ¿ÏÔ ¯ÚfiÓÔ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Î·È Î·ı›ÛÙ·Ù·È ‰˘Ó·Ù‹ Ë ÂÊ·ÚÌÔÁ‹ ÚˆÙÔÎfiÏÏˆÓ Ì ÚÒÈÌË ‰È·ÎÔ‹ ‹ ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Î·È ¯·ÌËϤ˜ ‰fiÛÂȘ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘

∫ÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ ∏ ‚·ÛÈ΋ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ‰Ú¿ÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÔÊ›ÏÂÙ·È ÛÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘˜ Ó· ÂÌÔ‰›˙Ô˘Ó ÙËÓ ÂÓÂÚÁÔÔ›ËÛË Î·È ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ Δ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙË ÌÂÙ·ÁÚ·Ê‹ ΢ÙÙ·ÚÔÎÈÓÒÓ Î·ıÒ˜ Î·È ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ÌÔÓÔ΢ÙÙ¿ÚˆÓ Î·È ÙˆÓ ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÓ. Δ· ÂÚÈÛÛfiÙÂÚ· ÚˆÙfiÎÔÏÏ· ÚԂϤÔ˘Ó ÙË ÁÚ‹ÁÔÚË Ì›ˆÛË ·fi ÙËÓ ˘„ËÏ‹ ÂÈÛ·ÁˆÁÈ΋ ‰fiÛË ÛÙȘ ‰fiÛÂȘ Û˘ÓÙ‹ÚËÛ˘. ÃÔÚ‹ÁËÛË ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Û ̤ڷ ·Ú¿ Ë̤ڷ Û¯‹Ì· ÚÔÙ›ÓÂÙ·È ÌÂÙ¿ ÙÔ˘˜ 6 ¤ˆ˜ 12 Ì‹Ó˜ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÒÛÙ ӷ ‚ÂÏÙȈı› Ô Ú˘ıÌfi˜ ·‡ÍËÛ˘ ÙÔ˘ ·È‰ÈÔ‡.

OÈ ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉˆÓ fiˆ˜ ÎÔÓÙfi ·Ó¿ÛÙËÌ·, Û. Cushing, ˘¤ÚÙ·ÛË, ÏÔÈÌÒÍÂȘ, ηٷÚÚ¿ÎÙ˘, ˘ÂÚÁÏ˘Î·ÈÌ›· Î.· Ô‰‹ÁËÛ·Ó ÛÙËÓ ‰ËÌÈÔ˘ÚÁ›· ÚˆÙÔÎfiÏÏˆÓ ¯ˆÚ›˜ ‹ Ì ÂÏ¿¯ÈÛÙ˜ ‰fiÛÂȘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ. Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ˘‹ÚÍ·Ó ÌÂϤÙ˜, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ Ì ÌÈÎÚfi ·ÚÈıÌfi ·È‰ÈÒÓ, Ô˘ ¤‰ÂÈÍ·Ó fiÙÈ ÌÂÙ·ÌÔÛ¯Â˘Ì¤Ó· ·È‰È¿ Ì ¯·ÌËÏfi ·ÓÔÛÔÏÔÁÈÎfi ΛӉ˘ÓÔ ÁÈ· ·fiÚÚÈ„Ë, ·Ú¤ÌÂÈÓ·Ó Û ۯ‹Ì·Ù· ¯ˆÚ›˜ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹, ¯ˆÚ›˜ Ó· ·˘ÍËı› Ô Î›Ó‰˘ÓÔ˜ ·fiÚÚȄ˘. º·›ÓÂÙ·È fiÙÈ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ÒÛÙ ӷ ηıÔÚÈÛÙÔ‡Ó Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ (ÔÈÔÈ ·ÛıÂÓ›˜, fiÙÂ Î·È ˘fi ÔÈ· ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹) Ô˘ Ì ·ÛÊ¿ÏÂÈ· ı· ÙÂıÔ‡Ó Û ·ÓÔÛÔηٷÛÙ·ÏÙÈο Û¯‹Ì·Ù· ÂχıÂÚ· ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ.

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∞ÓÙÈÌÂÙ·‚ÔÏÈÎÔ› ·Ú¿ÁÔÓÙ˜ ∏ ·˙·ıÂÈÔÚ›ÌË ‹Ù·Ó Ô ‚·ÛÈÎfi˜ ·ÓÙÈÌÂÙ·‚ÔÏ›Ù˘ Ù˘ ÔÌ¿‰·˜ ÙˆÓ Ô˘ÚÈÓÒÓÔ˘ ÎÏ·ÛÛÈο ¯ÔÚËÁÔ‡ÓÙ·Ó ÛÙËÓ ª¡ ÛÙ· ·È‰È¿. ™‡Ìʈӷ Ì ٷ ÚfiÛÊ·Ù· ‰Â‰Ô̤ӷ ·fi ÙÔ NAPRTCS ÏÈÁfiÙÂÚÔ ·fi 5% ÙˆÓ ·È‰ÈÒÓ Ì ª¡ ÛÙËÓ μfiÚÂÈÔ ∞ÌÂÚÈ΋ Ï·Ì‚¿ÓÂÈ ·˙·ıÂÈÔÚ›ÌË. ΔÔ ªªF ‹ MPA Ô˘ Û‹ÌÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ¤¯Ô˘Ó ¯·ÌËÏfiÙÂÚË ÙÔÍÈÎfiÙËÙ· ·fi ÙËÓ ·˙·ıÂÈÔÚ›ÌË. ™Â ÌÂϤÙ˜ ÛÙ· ·È‰È¿ ¤¯ÂÈ Ê·Ó›, fiÙÈ Ë ¯ÔÚ‹ÁËÛË ªªF ‚ÂÏÙ›ˆÛ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ì›ˆÛ ٷ ÂÂÈÛfi‰È· ÔÍ›·˜ ·fiÚÚȄ˘ ÂÓÒ Î·È Û ÂÚÈÙÒÛÂȘ ¯ÚfiÓÈ·˜ ·fiÚÚȄ˘ Ë ·ÓÙÈηٿÛÙ·ÛË Ù˘ ·˙·ıÂÈÔÚ›Ì˘ Ì MMF ‚ÂÏÙ›ˆÛ ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·.

OÈ ÂÚÈÛÛfiÙÂÚ˜ ·ÓÂÈı‡ÌËÙ˜ ‰Ú¿ÛÂȘ ÙÔ˘ MMF Â›Ó·È ‰ÔÛÔ-ÂÍ·ÚÙÒÌÂÓ˜ Î·È ·ÊÔÚÔ‡Ó ‰È¿ÚÚÔÈ·, Â̤ÙÔ˘˜, Ï¢ÎÔÂÓ›· Î·È ÏÔÈÌÒÍÂȘ. Δ· ·È‰È¿ Î·È ÂȉÈÎfiÙÂÚ· ·˘Ù¿ οو ÙˆÓ 6 ÂÙÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘¯ÓfiÙÂÚ· ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ ·fi ÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ·ÔÙ¤ÏÂÛÌ· Û˘¯Ó¿ ÙËÓ ·Ó¿ÁÎË ÁÈ· ‰È·ÎÔ‹ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘. Δ· Û˘ÌÙÒÌ·Ù· ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi Â›Ó·È Û·ÓÈfiÙÂÚ· ÛÙË ÂÓÙÂÚÔ-‰È·Ï˘Ù‹ ÌÔÚÊ‹ (EC-MPS). ¢ÂÓ ˘¿Ú¯ÂÈ ÔÌÔʈӛ· ·Ó·ÊÔÚÈο Ì ÙËÓ ·Ó·ÁηÈfiÙËÙ· ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ mycophenolic acid ÛÙ· ·È‰È¿ Ì ª¡.

∞Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ OÈ ·Ó·ÛÙÔÏÂȘ Ù˘ ηÏÛÈÓ¢ڛÓ˘ (΢ÎÏÔÛÔÚ›ÓË Î·È tacrolimus) ·ÔÙÂÏÔ‡Ó ÙËÓ «Ú·¯ÔÎÔηÏÈ¿» Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ ÛÙ· ·È‰È¿ Ì ª¡. ∏ ¯Ú‹ÛË ÙÔ˘˜ ¤¯ÂÈ Û˘Ó‰Âı› Ì ÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∞Ó·ÊÔÚÈο Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË ¯ÔÚËÁÂ›Ù·È Û ˘„ËÏfiÙÂÚ˜ ‰fiÛÂȘ ÛÙ· ·È‰È¿ Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È ÂÈϤÔÓ Û ·È‰È¿ οو ÙˆÓ 6 ÂÙÒÓ ‰›ÓÂÙ·È ·Ó¿ 8ˆÚÔ ÏfiÁˆÙÔ˘ Ù·¯‡ÙÂÚÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ Ù˘. ªÂÙ¿ ÙÔ˘˜ ÚÒÙÔ˘˜ 3 ¤ˆ˜ 6 Ì‹Ó˜ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Á›ÓÂÙ·È ÛÙ·‰È·Î‹ Ì›ˆÛË Ù˘ ‰fiÛ˘, ÁÈ· ·ÔÊ˘Á‹ Ù˘ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜. ∏ ¯ÔÚ‹ÁËÛË Î˘ÎÏÔÛÔÚ›Ó˘ Ì sirolimus Î·È ÎÔÚÙÈÎÔÛÙÂÚÔÂȉ‹ Ê·›ÓÂÙ·È Ó· ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÏÂÌÊÔ¸ÂÚÏ·ÛÙÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘. ∞fi ÙȘ ÂÈÏÔΤ˜ Ù˘ ΢ÎÏÔÛÔÚ›Ó˘, Ù· ÎÔÛÌËÙÈο ÚÔ‚Ï‹Ì·Ù· (˘ÂÚÏ·Û›· ԇψÓ, ˘ÂÚÙÚ›¯ˆÛË) ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û η΋ Û˘ÌÌfiÚʈÛË Î˘Ú›ˆ˜ ÙÔ˘˜ ¤ÊË‚Ô˘˜ ·ÛıÂÓ›˜. ∞Ó·ÊÔÚÈο Ì ÙÔ Tacrolimus (FK506), ÈÛ¯‡Ô˘Ó ÔÈ ›‰ÈÔÈ ÂÚÈÔÚÈÛÌÔ› Ì ÙËÓ Î˘ÎÏÔÛÔÚ›ÓË, ÂÓÒ Ê·›ÓÂÙ·È Ó· ÏÂÔÓÂÎÙ›

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N. ¶ƒπ¡Δ∑∞

Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ ÛÙËÓ ÂÌÊ¿ÓÈÛË ÎÔÛÌËÙÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÛÙ· ·È‰È¿ Î·È ·ıÔÏÔÁÈÎÔ‡ ÏÈȉ·ÈÌÈÎÔ‡ ÚÔÊ›Ï ÛÙÔ˘˜ ÂÓ‹ÏÈΤ˜.

Y¿Ú¯Ô˘Ó ÂÏ¿¯ÈÛÙ· ‰Â‰Ô̤ӷ Ô˘ Ó· Û˘ÁÎÚ›ÓÔ˘Ó ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂٷ͇ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ ‚·ÛÈÛÌ¤ÓˆÓ ÛÙËÓ Î˘ÎÏÔÛÔÚ›ÓË ‹ ÛÙÔ tacrolimus. ∞Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ·fi ÙÔ NAPRTCS ¤‰ÂÈÍ fiÙÈ Ë ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹Ù·Ó ·ÚfiÌÔÈ· ÛÙËÓ ÔÌ¿‰· Ù˘ ΢ÎÏÔÛÔÚ›Ó˘ Î·È ÙÔ˘ tacrolimus. ¶ÚÔÔÙÈ΋ ÌÂϤÙË ¤‰ÂÈÍ ¯·ÌËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÔÍ›·˜ ·fiÚÚȄ˘ Î·È ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙ· 4 ¯ÚfiÓÈ· ÛÙË ÔÌ¿‰· ÙÔ˘ tacrolimus Û ۯ¤ÛË Ì ÙËÓ ÔÌ¿‰· Ù˘ ΢ÎÏÔÛÔÚ›Ó˘.

mTOR ·ÓÙ·ÁˆÓÈÛÙ¤˜ OÈ mTOR ·ÓÙ·ÁˆÓÈÛÙ¤˜ (Sirolimus, everolimus) ·Ó·ÛÙ¤ÏÏÔ˘Ó ÙË ‰È¤ÁÂÚÛË Î·È ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ Δ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ÙˆÓ μ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÙˆÓ ÈÓÔ‚Ï·ÛÙÒÓÎ·È ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∞Ó·ÊÔÚÈο Ì ÙÔ Sirolimus, Ê·›ÓÂÙ·È fiÙÈ ÛÙ· ·È‰È¿ ¤¯ÂÈ ‚Ú·¯‡ÙÂÚÔ ¯ÚfiÓÔ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ Î·È Èı·Ófiٷٷ ¯Ú‹˙ÂÈ ¯ÔÚ‹ÁËÛ˘ ·Ó¿ 12ˆÚÔ Î·È ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘. Δ· ‰Â‰Ô̤ӷ ÙÔ˘ 2007 ·fi ÙÔ NAPRTCS ¤‰ÂÈÍ·Ó ¯Ú‹ÛË Sirolimus ÌfiÏȘ ÛÙÔ 3% ÙˆÓ ·È‰ÈÒÓ Ì ª¡. ™Â Û˘Ó-¯ÔÚ‹ÁËÛË Ì ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Û˘ÛÙ‹ÓÔÓÙ·È ¯·ÌËÏfiÙÂÚ˜ ‰fiÛÂȘ ΢ÎÏÔÛÔÚ›Ó˘ Î·È tacrolimus ηıÒ˜ Ê·›ÓÂÙ·È Ó· ·˘Í¿ÓÂÈ ÙËÓ ÓÂÊÚÔÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘. ∂›Û˘ ηı˘ÛÙÂÚ› ÙËÓ ÂԇψÛË ÙˆÓ ÙÚ·˘Ì¿ÙˆÓ Î·È Ú¤ÂÈ Ó· ·ÔʇÁÂÙ·È ÛÙË ¿ÌÂÛË ÌÂÙ·-ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋ ÂÚ›Ô‰Ô.

∏ ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Ì SirolimusÛ ·È‰È¿ Ì ¯·ÌËÏfi ΛӉ˘ÓÔ ÁÈ· ·fiÚÚÈ„Ë Î·È Ì ÛÎÔfi ÙËÓ ·ÔÊ˘Á‹ Ù˘ ÓÂÊÚÔÙÔÍÈ΋˜ ‰Ú¿Û˘ ÙˆÓ ÚÒÙˆÓ ¤¯ÂÈ ÌÂÏÂÙËı› Û ÌÈÎÚfi ·ÚÈıÌfi ·È‰ÈÒÓ. Δ· ·ÔÙÂϤÛÌ·Ù· ¤‰ÂÈÍ·Ó fiÙÈ Ë ¯ÔÚ‹ÁËÛË Sirolimus ‰ÂÓ ‚ÂÏÙ›ˆÛ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Èı·Ófiٷٷ Û οÔȘ ÂÚÈÙÒÛÂȘ ÏfiÁˆ ÚÔ¯ˆÚË̤Ó˘ ÓÂÊÚÔ¿ıÂÈ·˜. ∞Ó·ÊÔÚÈο Ì ÙÔ Everolimus, ÌÂϤÙ˜ Ì ÓÂfiÙÂÚ· ·ÓÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· fiÔ˘ ¯ÔÚËÁ‹ıËΠEverolimusÛÂ Û˘Ó‰˘·ÛÌfi Ì ¯·ÌËϤ˜ ‰fiÛÂȘ ΢ÎÏÔÛÔÚ›Ó˘ Î·È ‰È·ÎÔ‹ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÌÂÙ¿ ÙÔ˘˜ 6 Ì‹Ó˜ ¤‰ÂÈÍ·Ó Î·Ï¿ ·ÔÙÂϤÛÌ·Ù· ÛÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙÔÓ ¤Ó· ¯ÚfiÓÔ. ∞·ÈÙÔ‡ÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ Î·È ÌÂÁ·Ï‡ÙÂÚ˜ ÌÂϤÙ˜ ÁÈ· ÙËÓ ·ÛÊ¿ÏÂÈ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ mTORÛÙË MNÛÙ· ·È‰È¿.

™˘ÌÂÚ¿ÛÌ·Ù· ∂·ÁˆÁ‹ Ì ·ÓÙÈÛÒÌ·Ù· ÛÙËÓ ÂÈÛ·ÁˆÁÈ΋ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ·ÁˆÁ‹ Û˘ÛÙ‹ÓÂÙ·È ÛÙȘ ÔÌ¿‰Â˜ ·È‰ÈÒÓ Ì ª¡ Ô˘ Â›Ó·È ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÔÍ›· ·fiÚÚÈ„Ë. Δ· ÂÚÈÛÛfiÙÂÚ· ·ÓÔÛÔÛÔηٷÛÙ·ÏÙÈο ÚˆÙfiÎÔÏÏ· Û ÛÙ·ıÂÚÔÔÈË̤ÓÔ˘˜ ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ª¡ ÚԂϤÔ˘Ó ÙË ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ, ÂÓfi˜ ·ÓÙÈÌÂÙ·‚ÔÏ›ÙË Î·È ÂÓfi˜ ·Ó·ÛÙÔϤ· Ù˘ ηÏÛÈÓ¢ڛÓ˘. ¶·Ú·Ì¤ÓÔ˘Ó ÛÔ‚·Ú¿ ÚÔ‚Ï‹Ì·Ù· ΢ڛˆ˜ ·fi ÙȘ Ì·ÎÚÔ¯ÚfiÓȘ ‰Ú¿ÛÂȘ ÙˆÓ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ Î·È ÙË ÓÂÊÚÔÙÔÍÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ηÏÛÈÓ¢ڛÓ˘ Î·È Ù· ÓÂfiÙÂÚ· ÚˆÙfiÎÔÏÏ· ÛÙÔ¯Â‡Ô˘Ó Û ¯·ÌËϤ˜ ‰fiÛÂȘ ‹ ·ÔÊ˘Á‹ ÙÔ˘˜.

MÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ Û ·È‰È¿. ∂Á¯ÂÈÚËÙÈΤ˜ ȉȷÈÙÂÚfiÙËÙ˜ π. °ÂˆÚÁ¿Î˘, π. ºÔ‡˙·˜

∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·ÔÙÂÏ› ÙËÓ ıÂÚ·›· ÂÎÏÔÁ‹˜ Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (á∞-Δ™). ∞ÔηıÈÛÙ¿ fi¯È ÌfiÓÔ Ù· Û˘ÌÙÒÌ·Ù· Ù˘ Ô˘Ú·ÈÌ›·˜, ·ÏÏ¿ Î·È ÙËÓ ÛˆÌ·ÙÈ΋, ÓÔËÙÈ΋ Î·È „˘¯ÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ. ∏ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ·È‰ÈÒÓ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·Ó¤Ú¯ÂÙ·È Û 95%, ÂÓÒ ÛÙ· ·È‰È¿ Ì á∞-Δ™ Û ·ÈÌÔοı·ÚÛË Êı¿ÓÂÈ ÛÙÔ 80%. ∂ÈϤÔÓ, Ë ÂÈÙ˘¯‹˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÚÔÛʤÚÂÈ Ôχ ηχÙÂÚË ÔÈfiÙËÙ· ˙ˆ‹˜ ·fi ÔÔÈ·‰‹ÔÙ ¿ÏÏË Ù¯ÓÈ΋ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘1.

Û‡Ó‰ÚÔÌÔ, ÔÏ˘Î˘ÛÙÈÎÔ› ÓÂÊÚÔ›, ÓfiÛÔ˜ ÙÔ˘ Berger, Û‡Ó‰ÚÔÌÔ Prune Belly, Û‡Ó‰ÚÔÌÔ Alport, Û‡Ó‰ÚÔÌÔ Nail Putela, ÎÔÎÎȈ̿وÛË Wegener, Û‡Ó‰ÚÔÌÔ Good pasture, ÔÚʇڷ Henoch Shoenlein, ·ÈÌÔÏ˘ÙÈÎfi Ô˘Ú·ÈÌÈÎfi Û‡Ó‰ÚÔÌÔ, ΢ÛÙ›ÓˆÛË, ‰È·‚ËÙÈ΋ ÓÂÊÚÔ¿ıÂÈ·, ˘¤ÚÙ·ÛË, ·ÁÁÂȷ΋ ÓfiÛÔ˜ Î.·.4. ¶ÂÚ›Ô˘ ¤Ó· ·fi Ù· Ù¤ÛÛÂÚ· ·È‰È¿ Ô˘ ηٷϋÁÔ˘Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ¿Û¯ÂÈ ·fi ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ηو٤ÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜5. ŒÓ· ÌÈÎÚfi ·ÏÏ¿ ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·È‰ÈÒÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Úfi‚ÏËÌ· ÛÙËÓ ÏÂÈÙÔ˘ÚÁ›· ·Ôı‹Î¢Û˘ ÙˆÓ Ô‡ÚˆÓ ÏfiÁˆ Ó¢ÚÔÁÂÓÔ‡˜ ·ÛÙ˘, ·fiÊڷ͢ ÙÔ˘ ηÙÒÙÂÚÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡,6 ·ÏÈÓ‰ÚfiÌËÛ˘7, ‹ Û˘ÁÁÂÓÔ‡˜ ·ÓˆÌ·Ï›·˜ Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ ‹ Ù˘ Ô˘Ú‹ıÚ·˜ (exstrophy, ‚·Ï‚›‰Â˜ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜). ∂ÈϤÔÓ, ÔÚÈṲ̂ӷ ·È‰È¿ ÌÔÚ› Ó· ¤¯Ô˘Ó ¯¿ÛÂÈ ÙËÓ Î‡ÛÙË ÙÔ˘˜ ˆ˜ Û˘Ó¤ÂÈ· οÔÈ·˜ ηÎÔ‹ıÂÈ·˜, ·ÎÙÈÓÔ‚ÔÏ›·˜, ‹ ‰ËÌÈÔ˘ÚÁ›· Ô˘ÏÒÓ ·fi ¯ÚfiÓÈ· Ïԛ̈ÍË. ¶·Ú¿ ÙËÓ ‡·ÚÍË ·˘ÙÒÓ ÙˆÓ ÚÔÎÏ‹ÛˆÓ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÌÔÚ› Ó· Â›Ó·È ÂÈÙ˘¯‹˜ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜. OÈ ıÂÚ·¢ÙÈΤ˜ ÂÈÏÔÁ¤˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÈÌÔοı·ÚÛË ‹ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË, ÙËÓ ‰ÈfiÚıˆÛË ÙˆÓ ·ÓˆÌ·ÏÈÒÓ Î·È ÙÂÏÈο ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡7. ∏ ıÂÚ·›· Ù˘ á∞-Δ™ ÛÙ· ·È‰È¿ ·ÚÔ˘ÛÈ¿˙ÂÈ ‰È·ÊÔÚ¤˜ ·fi ÙÔ˘˜ ÂÓ‹ÏÈΘ. ∏ ¤ÓÙ·ÍË ÙˆÓ ·È‰ÈÒÓ Ì á∞-Δ™, Û ÚfiÁÚ·ÌÌ· ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ Û˘Óԉ‡ÂÙ·È ·fi ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù·, fiˆ˜ Ë ·Ó·ÈÌ›·, Ë ˘ÔıÚ„›·, Ë Î·ı˘ÛÙ¤ÚËÛË ÛÙËÓ ·Ó¿Ù˘ÍË Î.¿. ∏ ·ÈÌÔοı·ÚÛË Â›Ó·È ‰˘Û¯ÂÚ‹˜ Û Ôχ ÌÈÎÚ¿ ·È‰È¿. ¶ÚÔÙÈÌ¿Ù·È Ë Û˘Ó¯‹˜ ÊÔÚËÙ‹ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË (™º¶∫) ˆ˜ ̤ıÔ‰Ô˜ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ ÁÈ· Ù· ÌÈÎÚ¿ ·È‰È¿ ·ÎfiÌË Î·È ËÏÈΛ·˜ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜. ∏ ™º¶∫ ÌÔÚ› Ó· ÌËÓ Â›Ó·È ÂÊÈÎÙ‹ ÏfiÁˆ Ù˘ ‡·Ú͢ ÂÚÈÙÔÓ·˚ÎÒÓ Ô˘ÏÒÓ. ∏ ηχÙÂÚË ÂÈÏÔÁ‹ Û ·˘Ù¿ Ù· ·È‰È¿ ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È Ë ÚÔÂÓÙ·Íȷ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË8.

∂Ӊ›ÍÂȘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ ÛÙ· ·È‰È¿ ∫¿ı ¯ÚfiÓÔ ÛÙȘ ∏ӈ̤Ó˜ ¶ÔÏÈÙ›˜ (Â›Ó·È Ë ¯ÒÚ· Ì ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ·Ó·ÊÔÚ¤˜ ) ÂÚ›Ô˘ 1200 ·È‰È¿ (ËÏÈΛ·˜ 0-18 ÂÙÒÓ) ı· ·Ó·Ù‡ÍÔ˘Ó Ã¡∞-Δ™. 2 . ∞˘Ùfi ·ÓÙÈÚÔÛˆ‡ÂÈ ÂÚ›Ô˘ 16 ÎÚÔ‡ÛÌ·Ù· ·Ó¿ 1 ÂηÙÔÌ̇ÚÈÔ ·È‰È¿. ∏ Û˘¯ÓfiÙËÙ· Ù˘ á∞-Δ™ ·˘Í¿ÓÂÈ Ì ÙËÓ ËÏÈΛ· Î·È ÛÙËÓ ÔÌ¿‰· ÙˆÓ 15-19 ÂÙÒÓ Êı¿ÓÂÈ ÛÙ· 28 ÎÚÔ‡ÛÌ·Ù· ·Ó¿ 1 ÂηÙÔÌ̇ÚÈÔ ·È‰È¿. O ·ÓÙ›ÛÙÔȯԘ ·ÚÈıÌfi˜ ÁÈ· ÙËÓ ∂ÏÏ¿‰· ‰ÂÓ Â›Ó·È Û·ÊÒ˜ ηıÔÚÈṲ̂ÓÔ˜ Î·È Ë ÌfiÓË ‚È‚ÏÈÔÁÚ·ÊÈ΋ ·Ó·ÊÔÚ¿ ÛÙÔ Pubmed ηٷÁÚ¿ÊÂÈ 8 ÎÚÔ‡ÛÌ·Ù· ·Ó¿ 1 ÂηÙÔÌ̇ÚÈÔ ·È‰È¿3. ™ÙËÓ ‚¿ÛË ‰Â‰ÔÌ¤ÓˆÓ Ù˘ À™∂ (ÀËÚÂÛ›· ™˘ÓÙÔÓÈÛÌÔ‡ Î·È ∂ϤÁ¯Ô˘ ·ÛıÂÓÒÓ Ì á∞-Δ™), ÛÙË ‰ÂηÂÙ›· 2000-2009, ¤¯Ô˘Ó ηٷÁÚ·Ê› 164 ·È‰È¿ Ì á∞-Δ™ (16.4/¤ÙÔ˜). ™ÙÔ˘˜ ÂÓ‹ÏÈΘ ÔÈ ÛËÌ·ÓÙÈÎfiÙÂÚ˜ ·Èٛ˜ Ù˘ á∞-Δ™ Â›Ó·È Î˘Ú›ˆ˜ Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Î·È Ë ˘¤ÚÙ·ÛË, ·ÏÏ¿ ÛÙ· ·È‰È¿ ÔÈ ÚˆÙ·Ú¯ÈΤ˜ ·Èٛ˜ Â›Ó·È ÔÈ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜, ÔÈ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ˜ Î·È Ë ÂÛÙȷ΋ ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË . ∂ȉÈÎfiÙÂÚ·, ·ı‹ÛÂȘ Ô˘ ıˆÚÔ‡ÓÙ·È ·Èٛ˜ á∞-Δ™ ÛÙ· ·È‰È¿ Î·È Ô‰ËÁÔ‡Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, Â›Ó·È Ë ·fiÊÚ·ÍË ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜, ‚·Ï‚›‰Â˜ Ô›ÛıÈ·˜ Ô˘Ú‹ıÚ·˜, ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·, Û˘ÁÁÂÓ¤˜ ÓÂÊÚˆÛÈÎfi

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80

I. °∂øƒ°∞∫∏™, π. º√À∑∞™

∏ ¤Ó·ÚÍË Ù˘ ıÂÚ·›·˜ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ Û ·È‰È¿ Ì á∞-Δ™ ı¤ÙÂÈ Î·È ÙËÓ ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡. ™˘Ó‹ıˆ˜ ÚÔËÁÂ›Ù·È ¤Ó· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ì ıÂÚ·›· ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘ ÁÈ· Ó· ÎÚ·ÙËı› ÛÙË ˙ˆ‹ Î·È Ó· ÌÂÁ·ÏÒÛÂÈ Ô ÌÈÎÚfi˜ ·ÛıÂÓ‹˜, ̤¯ÚÈ Ó· ‚ÚÂı› Ô Î·Ù¿ÏÏËÏÔ˜ ‰fiÙ˘. Δ· ÂÚÈÛÛfiÙÂÚ· ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ÚÔÙÈÌÔ‡Ó Ô Ï‹Ù˘ Ó· ¤¯ÂÈ ‚¿ÚÔ˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ 8-10 Kgr ÁÈ· Ó· ÂÏ·ÙÙˆı› Ô Î›Ó‰˘ÓÔ˜ ·ÁÁÂÈ·ÎÒÓ ıÚÔÌ‚ÒÛÂˆÓ Î·È Ó· Â›Ó·È ÂÊÈÎÙ‹ ÂÌʇÙ¢ÛË ÌÔۯ‡̷ÙÔ˜ ·fi ÂÓ‹ÏÈη ‰fiÙË. ™Â ‚Ú¤ÊË Ì á∞-Δ™ ÙÔ ‚¿ÚÔ˜ ÙˆÓ 8-10 Kgr Û˘Ó‹ıˆ˜ ‰ÂÓ ÂÈÙ˘Á¯¿ÓÂÙ·È ÚÈÓ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 12-24 ÌËÓÒÓ8. ∏ ÚÔÂÓÙ·Íȷ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÚÈÓ ·fi ÙËÓ ¤ÓÙ·ÍË Û ıÂÚ·›· ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘, ·ÔÙÂÏ› ÙÔ 25% fiÏˆÓ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ÓÂÊÚÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛˆÓ. §fiÁˆ ÙÔ˘ Ì·ÎÚÔ‡ ¯ÚfiÓÔ˘ ·Ó·ÌÔÓ‹˜ ÁÈ· و̷ÙÈÎfi ÌfiÛ¯Â˘Ì·, Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÚÔÂÓÙ·ÍÈ·ÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‰ÈÂÓÂÚÁÂ›Ù·È ·fi ˙ÒÓÙ˜ ‰fiÙ˜. O ·ÚÈÔ˜ ÏfiÁÔ˜ ÁÈ· ÚÔÂÓÙ·Íȷ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô˘ ·Ó·Ê¤ÚÂÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÂÓ›˜ Î·È ÙÔ˘˜ ·ÛıÂÓ›˜ Â›Ó·È Ë ÂÈı˘Ì›· ·ÔÊ˘Á‹˜ Ù˘ ıÂÚ·›·˜ ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘9. ∂ÈϤÔÓ, ˘¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ fiÙÈ Ë ˘ÔηٿÛÙ·ÛË Ì Ù¯ÓËÙfi ÓÂÊÚfi ÂÏ·ÙÙÒÓÂÈ ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ˙ÒÓÙ˜ ‰fiÙ˜26. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ÂÈ‚›ˆÛ˘ ÌÂÙ¿ ·fi ÚÔÂÓÙ·Íȷ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ˜ ‰fiÙ˜ ·Ô‰›‰ÂÙ·È ÛÙË ÌÈÎÚfiÙÂÚË ·Ú·ÌÔÓ‹ ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ Û ÙÂÏÈÎfi ÛÙ¿‰ÈÔ Ã¡∞ Î·È ÙË ÌÈÎÚfiÙÂÚË ÓÔÛËÚfiÙËÙ· ·fi ηډȷÁÁÂȷΤ˜ Î·È ÏÔÈÌÒ‰ÂȘ ÂÈÏÔΤ˜. ∞ÓÙ›ıÂÙ·, ‰ÂÓ ¤¯ÂÈ ·Ô‰Âȯı› ‰È·ÊÔÚ¿ ˆ˜ ÚÔ˜ ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ و̷ÙÈÎÒÓ ÓÂÊÚÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ ›¯·Ó ÚÔËÁÔ˘Ì¤Óˆ˜ ˘Ô‚ÏËı› Û ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Ì Ù¯ÓËÙfi ÓÂÊÚfi ‹ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË Î·È ÂÎÂ›ÓˆÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÚÔÂÓÙ·Íȷ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË10,11,26.

∞ÓÙÂӉ›ÍÂȘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ ÛÙ· ·È‰È¿ OÈ ·ÓÙÂӉ›ÍÂȘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ÛÙ· ·È‰È¿ ÌÂÈÒÓÔÓÙ·È Û˘Ó¯Ҙ, ∞fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·ÔÙÂÏ› Ë ÔÍ›· ‹ ¯ÚfiÓÈ· ÂÓÂÚÁfi˜ Ïԛ̈ÍË Î·È Ë Î·ÎÔ‹ıÂÈ·. Δ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· ıˆÚÔ‡Ó fiÙÈ ¤Ó· ·È‰› ÁÈ· Ó· ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡, Ú¤ÂÈ Ó· Â›Ó·È ÂχıÂÚÔ ÓfiÛÔ˘ ÁÈ· ‰‡Ô ¤ÙË ÌÂÙ¿ ÙË ıÂ-

Ú·›· Ù˘ ηÎÔ‹ıÂÈ·˜. ¶·ÚÔÌÔ›ˆ˜, ·È‰È¿ Ì ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· Ô˘ ηٷϋÁÔ˘Ó Û á∞Δ™ Â›Ó·È ˘Ô„‹ÊÈ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÂÙ¿ ·fi ÌÈ· ÂÚ›Ô‰Ô ·ÓÔÛȷ΋˜ ‡ÊÂÛ˘ Ù˘ ÚˆÙÔ·ıÔ‡˜ ÓfiÛÔ˘ ¯ˆÚ›˜ ‹ Ì ÂÏ¿¯ÈÛÙË ·ÓÔÛÔηٷÛÙÔÏ‹, Ë ÔÔ›· ‰È·ÚΛ ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ¯ÚfiÓÔ8. ∞fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ·ÔÙÂÏ› Ë ÚfiÛÊ·ÙË ıÂÙÈ΋ ‰ÔÎÈÌ·Û›· ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ (cross-match) Î·È Ë ‚·ÚÂÈ¿ ÔÏ˘ÔÚÁ·ÓÈ΋ ·ÓÂ¿ÚÎÂÈ·12. ∏ ·Û˘Ì‚·ÙfiÙËÙ· ÔÌ¿‰·˜ ·›Ì·ÙÔ˜ Î·È Ë ·Ï·ÈfiÙÂÚË ıÂÙÈ΋ ‰ÔÎÈÌ·Û›· ‰È·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ (9-12 Ì‹Ó˜) ıˆÚÔ‡ÓÙ·È, Û‹ÌÂÚ·, Û¯ÂÙÈΤ˜ ·ÓÙÂӉ›ÍÂȘ ÏfiÁˆ Ù˘ ÂÊ·ÚÌÔÁ‹˜ ÙˆÓ ÚˆÙÔÎfiÏÏˆÓ ·¢·ÈÛıËÙÔÔ›ËÛ˘ . ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Û˘ ·ÓÙÂӉ›ÎÓ˘Ù·È Û ¤Ó· ·È‰› Ì ÈÛÙÔÚÈÎfi ˘„ËÏÔ‡ ΛӉ˘ÓÔ˘ ÌË-Û˘ÌÌfiÚʈÛ˘ Ì ¤Ó· ‰ÔÛÔÏÔÁÈÎfi Û¯‹Ì· Ê·Ú̷΢ÙÈ΋˜ ·ÁˆÁ‹˜. Δ· ·È‰È¿ Ì ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· ·fi ÂÛÙȷ΋ ÙÌËÌ·ÙÈ΋ ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË, ÌÂÌ‚Ú·ÓÔ¸ÂÚÏ·ÛÙÈ΋ ÛÂÈÚ·Ì·ÙÔÓÂÊÚ›Ùȉ·, Û˘ÛÙËÌ·ÙÈÎfi ÂÚ˘ıËÌ·ÙÒ‰Ë Ï‡ÎÔ, ·ÈÌÔÏ˘ÙÈÎfi-Ô˘Ú·ÈÌÈÎfi Û‡Ó‰ÚÔÌÔ Î·È ÔÚʇڷ Henoch-Schönlein ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ˘ÔÙÚÔ‹˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞Ó Î·È ·˘Ù‹ Ë ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ‰ÂÓ ·ÔÙÂÏ› ·fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔÚ› Ó· ¤¯ÂÈ ÛËÌ·ÓÙÈΤ˜ ÂÈÙÒÛÂȘ ÛÙËÓ ÂÈ‚›ˆÛË Î·È ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ™¯ÂÙÈ΋ ·ÓÙ¤Ó‰ÂÈÍË Â›Ó·È Î·È Ë ÌÈÎÚ‹ ËÏÈΛ· Î·È ÙÔ ÛˆÌ·ÙÈÎfi ‚¿ÚÔ˜ ‰ÈfiÙÈ ÙÔ ÔÛÔÛÙfi ÂÈÙ˘¯›·˜ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÓÂÊÚÔ‡ Û Ôχ ÌÈÎÚ¿ ·È‰È¿, ȉȷ›ÙÂÚ· ÂΛӷ Ô˘ Â›Ó·È ÌÈÎÚfiÙÂÚ· ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜, Â›Ó·È ÛËÌ·ÓÙÈο ÌÈÎÚfiÙÂÚÔ ·fi ·˘Ùfi Û ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿13. ™¯ÂÙÈ΋ ·Ó٤Ӊ›ÍË ıˆÚÂ›Ù·È Î·È Ë „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ‹ „˘¯·Ûı¤ÓÂÈ· ÔÈ Ôԛ˜ ··ÈÙÔ‡Ó Û˘Ó¯‹ ÁÔÓÈ΋ ˘ÔÛÙ‹ÚÈÍË, fiˆ˜ Î·È Ë ¤ÏÏÂÈ„Ë ÔÈÎÔÁÂÓÂȷ΋˜ ˘ÔÛÙ‹ÚÈ͢ Û ηٿ ¿ÏÏ· Ê˘ÛÈÔÏÔÁÈο ·È‰È¿12.

¶ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË Î·È ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ∏ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË Î·È ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙˆÓ ·È‰ÈÒÓ Ì á∞-Δ™ Â›Ó·È ·ÚfiÌÔÈ· Ì ÂΛÓË ÙˆÓ ÂÓËÏ›ÎˆÓ ·ÏÏ¿ ÂÛÙÈ¿˙ÂÙ·È ÛÙ· ÚÔ‚Ï‹Ì·Ù· Ô˘ Â›Ó·È Û˘¯ÓfiÙÂÚ· ÛÙ· ·È‰È¿. ∂›Ó·È ȉȷ›ÙÂÚ· ÛËÌ·ÓÙÈÎfi Ó· ‰È·ÁÓˆÛı› Ë ·ÈÙ›· Ù˘ á∞, fiÙ·Ó ·˘Ùfi Â›Ó·È ‰˘Ó·Ùfi. ™˘¯Ó¿ ÚfiÎÂÈÙ·È ÁÈ· Ô˘ÚÔÏÔÁÈÎfi Úfi‚ÏËÌ· Ô˘ ··ÈÙ› ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞Ó ÚfiÎÂÈÙ·È ÁÈ· ÌÂÙ·‚ÔÏÈÎfi ÓfiÛËÌ· ‹ ÛÂÈÚ·Ì·ÙÔ¿ıÂÈ· Ú¤ÂÈ Â›Û˘ Ó· ‰È·-

METAMO™XEY™Eπ™ 2011

ÁÓˆÛı› Ë ·Ú¯È΋ ·ÈÙ›· ÁÈ·Ù› ÌÔÚ› Ó· ˘ÔÙÚÔÈ¿ÛÂÈ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™˘ÓÔÙÈο: ·. ΔÔ ÈÛÙÔÚÈÎfi ÙÔ˘ ÌÈÎÚÔ‡ ·ÛıÂÓÔ‡˜ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·ÈÙÈÔÏÔÁ›· Ù˘ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘, ÚÔËÁÔ‡ÌÂÓ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ (ÔÌ¿‰· ·›Ì·ÙÔ˜, HLAs, ΢ÙÙ·ÚÔÙÔÍÈο ·ÓÙÈÛÒÌ·Ù·, ›‰Ô˜ ÂÈÛ·ÁˆÁÈ΋˜ ıÂÚ·›·˜), ̤ıÔ‰Ô ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘, ÂÚÈÙÔÓ·˚΋ οı·ÚÛË ‹ ·ÈÌÔοı·ÚÛË (·ÁÁÂȷ΋ ÚfiÛ‚·ÛË, Û˘¯ÓfiÙËÙ·, ‰È¿ÚÎÂÈ·, Ê›ÏÙÚÔ), ˘ÔÏÂÈÌÌ·ÙÈÎfi ÔÛfi Ô‡ÚˆÓ, ÚÔËÁÔ‡ÌÂÓ˜ ÂÂÌ‚¿ÛÂȘ, ¿ÏϘ ÔÚÁ·ÓÈΤ˜ ·ı‹ÛÂȘ, ÈÛÙÔÚÈÎfi ÌÂÙ·ÁÁ›ÛˆÓ, Ï‹„Ë ÂÚ˘ıÚÔÔÈËÙ›Ó˘ Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÓÂÊÚÈÎÒÓ ·ı‹ÛˆÓ14. ΔÔ È·ÙÚÈÎfi ÈÛÙÔÚÈÎfi ı· Ú¤ÂÈ Ó· ·Ú¤¯ÂÈ ÌÈ· ‰ÈÂÍÔ‰È΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ·È‰ÈÔ‡. ŒÓ· ÈÛÙÔÚÈÎfi ÁÈ· ‡·ÚÍË Û˘ÁÁÂÓÔ‡˜ ·ÓˆÌ·Ï›·˜, ˘ÔÙÚÔÈ¿˙Ô˘Û˜ Ô˘ÚÔÏÔÈÌÒÍÂȘ, ·ÎÚ¿ÙÂÈ·, Ë ÂËÚ·Ṳ̂ÓË Û˘¯ÓfiÙËÙ· Ô‡ÚËÛ˘, ı· ·ÍÈÔÏÔÁ‹ÛÂÈ Ù· ·È‰È¿ Ô˘ ı· Ú¤ÂÈ Ó· ˘Ô‚ÏËıÔ‡Ó Û ÂÚ·ÈÙ¤Úˆ ·ÂÈÎfiÓÈÛË Î·È ·ÍÈÔÏfiÁËÛË Ì ΢ÛÙÂÔÔ˘ÚËıÚÔÁÚ·Ê›· Î·È Ô˘ÚÔ‰˘Ó·ÌÈ΋ ÌÂϤÙË. ‚. ∫ÏÈÓÈ΋ ÂͤٷÛË Î·Ù¿ Û˘ÛÙ‹Ì·Ù· Ë ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÂÈ Î·È ÙËÓ Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ‡„Ô˘˜, ‚¿ÚÔ˘˜, ÂÚÈ̤ÙÚÔ˘ ÙÔ˘ ÎÚ·Ó›Ô˘ Î·È ÂÛÙÈ¿˙ÂÙ·È ÛÙËÓ Î·Ù¿ÛÙ·ÛË ÙˆÓ Ï·ÁÔÓ›ˆÓ Î·È ÌËÚÈ·›ˆÓ ·ÁÁ›ˆÓ14. Á. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÔÌ¿‰· ·›Ì·ÙÔ˜, Rhesus, ÁÂÓÈ΋ ·›Ì·ÙÔ˜, ‚ÈÔ¯ËÌÈΤ˜ ÂÍÂÙ¿ÛÂȘ (Na+, K+, Cl-, Ô˘Ú›·, ÎÚ·ÙÈÓ›ÓË, Ca++, Mg++, P, ÁÏ˘Îfi˙Ë, ¯ÔÏËÛÙÂÚ›ÓË, ÙÚÈÁÏ˘ÎÂÚ›‰È·, ÔÏÈο Ï¢ÎÒÌ·Ù·, ÏÂ˘ÎˆÌ·Ù›ÓË, ¯ÔÏÂÚ˘ıÚ›ÓË, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ÁGT Î·È ÙÚ·ÓÛ·ÌÈÓ¿Û˜). ªÂϤÙË ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ (¯ÚfiÓÔ˜ ÚÔıÚÔÌ‚›Ó˘, ÂÓÂÚÁÔÔÈË̤Ó˘ ÌÂÚÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘, ηıÒ˜ Î·È ÙÔ ËÏ›ÎÔ INR (international normalized ratio), ÁÂÓÈ΋ Î·È Î·ÏÏȤÚÁÂÈ· Ô‡ÚˆÓ14. ‰. Δ›ÙÏÔÈ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÈÒÓ (΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜, [cytomegalovirus, CMV], Èfi˜ ÙÔ˘ ·ÏÔ‡ ¤ÚËÙ·, [herpes simplex virus, HSV], Èfi˜ ·ÓÂÌ¢ÏÔÁÈ¿˜-˙ˆÛÙ‹Ú·, [varicella-zoster virus, VZV], Èfi˜ Epstein-Barr virus [EBV], Èfi˜ Ë·Ù›Ùȉ·˜ B [hepatitis B virus, HBV], Èfi˜ Ù˘ Ë·Ù›Ùȉ·˜ C, [hepatitis C virus, HCV], Èfi˜ Â›ÎÙËÙ˘ ·ÓÔÛÔ·ÓÂ¿ÚÎÂÈ·˜ [human immunodeficiency virus, HIV])15,16. Δ· ·È‰È¿ Ô˘ ‰ÂÓ ¤¯Ô˘Ó ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ ÈÒÓ CMV, VZV, EBV ‰È·ÙÚ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· Ïԛ̈ÍË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÂȉÈο Â¿Ó Ï·Ì‚¿ÓÔ˘Ó ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ô˘ Â›Ó·È ÔÚÔıÂÙÈÎÔ› ÁÈ· ÙÔ˘˜ ÈÔ‡˜ ·˘ÙÔ‡˜. ∂›Û˘ ¯ÚÂÈ¿˙ÂÙ·È ·ÚÔ¯‹ ÚÔÏËÙÈ΋˜ ıÂÚ·›·˜. ŸÏ·

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Ù· ·È‰È¿ Ú¤ÂÈ Ó· ¤¯Ô˘Ó ÔÏÔÎÏËÚÒÛÂÈ ÙÔ ÚfiÁÚ·ÌÌ· ·È‰ÈÎÒÓ ÂÌ‚ÔÏÈ·ÛÌÒÓ (Hep B, Hep A, DTaP/Td, HIB, IPV, MMR, ÁÚ›Ë, VZV, Ó¢ÌÔÓÈfiÎÔÎÎÔ˜)12. Â. ∞ÓÔÛÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ [AÓÙÈÁfiÓ· ÙÔ˘ Ì›˙ÔÓÔ˜ Û˘ÌϤÁÌ·ÙÔ˜ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜ (Major Histocompatibillity Complex, MHC, ππ (Ù¿Í˘ π, ∞, μ, Î·È Ù¿Í˘ πI, DR), ΢ÙÙ·ÚÔÙÔÍÈο ·ÓÙÈÛÒÌ·Ù· (panel reactive antibodies, PRAs); ∞Ú¯È΋ Î·È ÙÂÏÈ΋ ‰ÔÎÈÌ·Û›· ‰·ÛÙ·˘ÚÔ‡ÌÂÓ˘ ·ÓÙ›‰Ú·Û˘ (cross-match, complement-dependent cytotoxicity / flow cytometry)12. Â. ∞ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂϤÙ˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ Î·È Doppler ‹ Î·È Ì·ÁÓËÙÈ΋ ·ÁÁÂÈÔÁÚ·Ê›· ·ÔÚÙ‹˜, οو ÎÔ›Ï˘ ÊϤ‚·˜ Î·È Ï·ÁÔÓ›ˆÓ ·ÚÙËÚÈÒÓ Î·È ÊÏ‚ÒÓ12. ∂ÈϤÔÓ, ‰ÈÂÓÂÚÁÂ›Ù·È Î·È ˘ÂÚ˯ÔοډÈÔÁÚ¿ÊËÌ·, ·Ó ÚÔ·ÙÔ˘Ó ÂӉ›ÍÂȘ ηډȷ΋˜ ÓfiÛÔ˘ ·fi ÙÔ ÈÛÙÔÚÈÎfi ÙËÓ ÎÏÈÓÈ΋ ÂͤٷÛË ‹ ÙÔ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ·. ÛÙ. O˘ÚÔ‰˘Ó·ÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ÙÔÓ ÔÔ›Ô ÌÂÙÚ¿Ù·È Ë ¯ˆÚËÙÈÎfiÙËÙ· Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ (Cystometric bladder capacity, CBC) Î·È Ë Û˘Û¯¤ÙÈÛË Ì ÙËÓ Î·Ù’ ÂÎÙ›ÌËÛË ¯ˆÚËÙÈÎfiÙËÙ· ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡ (Estimated bladder capacity, EBC),17,18 Ë ›ÂÛË ÙÔ˘ Â͈ÛÙ‹ÚÔ˜ Ì˘fi˜ (Detrusor pressure, PDet) Î·È ¿ÏϘ ·Ú¿ÌÂÙÚÔÈ Ô˘ ‚ÔËıÔ‡Ó ÛÙË ÏÂÈÙÔ˘ÚÁÈ΋ ·ÍÈÔÏfiÁËÛË Ù˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙ˘ Î·È ÛÙË ‰˘Ó·ÙfiÙËÙ· Ù˘ Ó· ·ԉ¯ı› Ù· Ô‡Ú· ÌÔۯ‡̷ÙÔ˜19. ∂¿Ó Ô Ô˘ÚÔ‰˘Ó·ÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‰Â›ÍÂÈ ÌÈÎÚ‹ ¯ˆÚËÙÈÎfiÙËÙ· Ù˘ ·ÛÙ˘ Î·È ÌÂȈ̤ÓË Â˘ÂÓ‰ÔÙfiÙËÙ· Ì ˘„ËÏ‹ ›ÂÛË ·Ôı‹Î¢Û˘ ‹ ·ÙÂÏ‹ ΤӈÛË, ‹ ˘„ËÏ‹ ›ÂÛË Ô‡ÚËÛ˘ ÙfiÙ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ Ó· ÂËÚ·Ûı› Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ÃÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÈ ÚÔÂÙÔÈÌ·Û›· ›Ù Ì ‰È·ÛÙÔϤ˜ ›Ù Ì ·‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ Ù˘ ·ÛÙ˘ Ì Ï·ÛÙÈ΋ (Ì ÌÂÁ·-Ô˘ÚËÙ‹Ú· ‹ ÙÌ‹Ì· ÙÔ˘ ÏÂÙÔ‡ ‹ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘) ‹ ÌfiÓÈÌË Â͈ÙÂÚÈ΋ ·ÚÔ¯¤Ù¢ÛË Ù˘ ·ÛÙ˘ ‹, ÛÙËÓ ¯ÂÈÚfiÙÂÚË ÂÚ›ÙˆÛË, ·Ó·ÛÙfïÛË ÙÔ˘ Ô˘ÚËÙ‹Ú· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ·ÔÌÔӈ̤ÓË ¤ÏÈη ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (ileal conduit)5,20. ∞Ó Ë ‰˘ÛÏÂÈÙÔ˘ÚÁ›· Ù˘ ·ÛÙ˘ ‰È·ÈÛÙˆı› ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÌÔÚ› Ó· ‰ÈÔÚıˆı› Ì Â¤Ì‚·ÛË, Ì ηϿ ·ÔÙÂϤÛÌ·Ù·. ∞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¿ÏÏ¢ÛË Ù˘ ÛΈÏËÎÔÂȉԇ˜ ·fiÊ˘Û˘ fiÔ˘ ÙÔ ¤Ó· ¿ÎÚÔ ÂÌÊ˘Ù‡ÂÙ·È ÛÙÔ ÙÔ›¯ˆÌ· Ù˘ ·˘ÍË-

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I. °∂øƒ°∞∫∏™, π. º√À∑∞™

̤Ó˘ Ô˘ÚÔ‰fi¯Ô˘ ·ÛÙˆ˜ Î·È ÙÔ ¿ÏÏÔ ¿ÎÚÔ Î·ıËÏÒÓÂÙ·È Û·Ó ÛÙÔÌ›·. ∏ ̤ıÔ‰Ô˜ ¯ÚËÛÈÌÔÔÈÂ›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. ¶·Ú¿ ·˘Ù‹Ó ÙËÓ ÌÂÁ¿ÏË ÂÌÂÈÚ›·, Ô Î·Ï‡ÙÂÚÔ˜ ¯ÚfiÓÔ˜ ÁÈ· ÙËÓ ·‡ÍËÛË Î‡ÛÙÂˆÓ Û ۯ¤ÛË Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (ÌÂÙ¿ ·fi ‹ ÚÈÓ), Â›Ó·È ·ÎfiÌ· ¤Ó· ı¤Ì· Û˘˙‹ÙËÛ˘20. ˙. ∂ÎÙÔÌ‹ ÙˆÓ Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ ‰ÈÂÓÂÚÁÂ›Ù·È ÛÙÔ 21.8% ÙˆÓ ·È‰ÈÒÓ Ô˘ ÚÔÂÙÔÈÌ¿˙ÔÓÙ·È ÁÈ· ÌÂÙ·ÌfiÛ¯ÂÛË ÓÂÊÚÔ‡, Û‡Ìʈӷ Ì ٷ ÛÙÔȯ›· Ù˘ NAPRTCS database (North American Pediatric Renal Trials Collaborative Studies)7. OÈ Û˘¯ÓfiÙÂÚ˜ ÂӉ›ÍÂȘ ÁÈ· ÓÂÊÚÂÎÙÔÌ‹ Â›Ó·È Ë ÔÏ˘Î˘ÛÙÈ΋ ÓfiÛÔ˜, ÙÔ ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ, Ë ÌË ÂÏÂÁ¯fiÌÂÓË ˘¤ÚÙ·ÛË Î·È Ë Ô˘ÚÔÏԛ̈ÍË. ™Â ·ÛıÂÓ›˜ Ì ΢ÛÙÂÔ-Ô˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, Ú¤ÂÈ ÚÒÙ· Ó· ·ÔÎÏ›ÂÙ·È Ë ·Ó¿ÁÎË ¯Ú‹Û˘ ÙÔ˘ ÌÂÁ·-Ô˘ÚËÙ‹Ú· ÁÈ· ·˘ÍËÙÈ΋ ΢ÛÙÂÔÏ·ÛÙÈ΋5.

¶ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô˜ ∏ Ù¯ÓÈ΋ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÓÂÊÚÔ‡ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙÔ˘ ÌÔۯ‡̷ÙÔ˜22,23. ∫·ıÔÚÈÛÙÈ΋ ÛËÌ·Û›· ¤¯ÂÈ Ë Û¯¤ÛË Ù˘ ‰È·Ì¤ÙÚÔ˘ ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ٷ ·ÁÁ›· ÙÔ˘ Ï‹ÙË, ηıÒ˜ Î·È Ë ÈηÓÔÔÈËÙÈ΋ ·ÚÔ¯‹ ·›Ì·ÙÔ˜. ™ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·È‰ÈÒÓ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÌÔۯ‡̷ٷ ·fi ÂÓ‹ÏÈΘ ˙ÒÓÙ˜ ‹ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ ‰ÈfiÙÈ Ù· ÌÔۯ‡̷ٷ ·fi ·È‰È¿ - ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜ ‰fiÙ˜ Â›Ó·È Ôχ Û¿ÓÈ·, ·ÏÏ¿ Î·È ‰ÈfiÙÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ˘„ËÏ¿ ÔÛÔÛÙ¿ ·ÁÁÂÈ·ÎÒÓ ıÚÔÌ‚ÒÛˆÓ, ÚˆÙÔ·ıÔ‡˜ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ·fiÚÚȄ˘. Δ· ·È‰È¿ Ì ۈ̷ÙÈÎfi ‚¿ÚÔ˜ ÌÂÁ·Ï‡ÙÂÚÔ ·fi 15-20 Kgr, ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Û·Ó ÌÈÎÚÔ› ÂÓ‹ÏÈΘ. ∏ ÂÌʇÙ¢ÛË Á›ÓÂÙ·È ÛÙÔÓ Ï·ÁfiÓÈÔ ‚fiıÚÔ, Â͈ÂÚÈÙÔÓ·˚ο. ∏ ÓÂÊÚÈ΋ ·ÚÙËÚ›· ·Ó·ÛÙÔÌÒÓÂÙ·È Â›Ù Ì ÙËÓ ¤Íˆ Ï·ÁfiÓÈ· ·ÚÙËÚ›·, ÙÂÏÈÎÔÏ¿ÁÈ·, Ì ڿÌÌ· polypropylene 6/0. ∏ ÓÂÊÚÈ΋ ÊϤ‚· ·Ó·ÛÙÔÌÒÓÂÙ·È ÛÙËÓ ¤Íˆ Ï·ÁfiÓÈÔ ÊϤ‚·22,23. ™Â ÌÈÎÚfiÙÂÚ· ·È‰È¿, Ì ‚¿ÚÔ˜ ÌÈÎÚfiÙÂÚÔ ·fi 1520 Kgr, ÙÔ ÌfiÛ¯Â˘Ì· ÙÔÔıÂÙÂ›Ù·È ÔÈÛıÔÂÚÈÙÔÓ·˚ο, Ì ̤ÛË Ï··ÚÔÙÔÌ›· Î·È ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ‰ÂÍÈÔ‡ ÎfiÏÔ˘ Î·È ÙÔ˘ ÙÂÏÈÎÔ‡ ÂÈÏÂÔ‡ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿ (∂ÈÎ. 1). ∏ ÓÂÊÚÈ΋ ·ÚÙËÚ›· ·Ó·ÛÙÔÌÒÓÂÙ·È Ì ÙËÓ ·ÔÚÙ‹ Î·È Ë ÓÂÊÚÈ΋ ÊϤ‚· ·Ó·ÛÙÔÌÒÓÂÙ·È Ì ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÊϤ‚·, ¿Óˆ ·fi ÙÔÓ ‰È¯·ÛÌfi ÙÔ˘˜ ÛÙȘ Ï·ÁfiÓȘ22. ªÔÚÔ‡Ó Â›Û˘ Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Ù· ÎÔÈÓ¿ Ï·ÁfiÓÈ· ·ÁÁ›·. ΔÔ Â›Â‰Ô ÙˆÓ ·-

Ó·ÛÙÔÌÒÛÂˆÓ Î·ıÔÚ›˙ÂÙ·È ·fi ÙËÓ ı¤ÛË Ô˘ ı· ηٷϿ‚ÂÈ Ô ÓÂÊÚfi˜.

OÈ Û˘¯ÓfiÙÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ Ù¯ÓÈΤ˜ ÁÈ· ÙËÓ ·Ó·ÛÙfïÛË ÙÔ˘ Ô˘ÚËÙ‹Ú· Ì ÙÔÓ ‚ÏÂÓÓÔÁfiÓÔ Ù˘ ·ÛÙ˘ Â›Ó·È Ë Leadbetter–Politano Î·È Lich-Gregoir, Ì ·ÔÚÚÔÊ‹ÛÈÌÔ Û˘ÓıÂÙÈÎfi Ú¿ÌÌ· polyglyconate 6/0. ∞Ó Î·È Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ·ÚfiÌÔÈ· Î·È ÁÈ· ÙȘ ‰‡Ô Ù¯ÓÈΤ˜, ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Û˘¯ÓfiÙÂÚ· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë ‰Â‡ÙÂÚË, Ë ÔÔ›· ÌÔÚ› Ó· ÌÂÙ·ÙÚ·› ÛÙËÓ ÚÒÙË Û ÂÚÈÙÒÛÂȘ Â·ÓÂ¤Ì‚·Û˘ ÁÈ· ‰È·Ê˘Á‹ Ô‡ÚˆÓ ·fi ÙËÓ ÂÍˆÎ˘ÛÙÈ΋ ÂÌʇÙ¢ÛË23. ™Â ÌÔۯ‡̷ٷ ·fi Ôχ ÌÈÎÚÔ‡˜ ‰fiÙ˜ (<5 Kgr) ‹ ·ÓÂÁΤʷϷ ÓÂÔÁÓ¿, ÂӉ›ÎÓ˘Ù·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÙˆÓ ‰‡Ô ÓÂÊÚÒÓ Û ¤Ó· Ï‹ÙË25. Δ· ·ÓÒÚÈÌ· ·˘Ù¿ ÌÔۯ‡̷ٷ, ·Ó ÌÂÙ·ÌÔÛ¯Â˘ıÔ‡Ó ÌÂÌÔӈ̤ӷ, ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÂÈÚ·Ì·ÙÔÛÎÏ‹Ú˘ÓÛË, ÚˆÙÂ˚ÓÔ˘Ú›· Î·È Ù·¯Â›· Ì›ˆÛË ÙÔ˘ GFR (glomerular filtration rate). ∂›Û˘ Ù· ·ÁÁ›· Â›Ó·È ÏÂÙ¿, ÂÈÚÚÂ‹ Û ‰È·ÙÔÌ‹, ÛÙÚÔÊ‹ Î·È ıÚfiÌ‚ˆÛË. °È· ·˘ÙfiÓ ÙÔÓ ÏfiÁÔ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È ÛÙÔ Û‡ÓÔÏfi ÙÔ˘˜ Ì·˙› Ì ÙËÓ ·ÔÚÙ‹ Î·È ÙËÓ Î¿Ùˆ ÎÔ›ÏË ÙÔ˘ ‰fiÙË. ¶Ú›Ó ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË , ÙÔ ÌfiÛ¯Â˘Ì· Ú¤ÂÈ Ó· ÂÈıˆÚËı› ÁÈ· Ù˘¯fiÓ ÙÚ·‡Ì· Ë ÛÙÚÔÊ‹. ∂›Û˘ Ú¤ÂÈ Ó· ˘¿ÚÍÂÈ ¤Ó· ÈηÓÔ-

∂ÈÎfiÓ· 1. ™Â ·È‰È¿ Î·È Û ÓÂÔÁÓ¿ Ì ‚¿ÚÔ˜ ÌÈÎÚfiÙÂÚÔ ·fi 10 Kgr ÙÔ ÌfiÛ¯Â˘Ì·, ·fi ÂÓ‹ÏÈη ‰fiÙË, ÙÔÔıÂÙÂ›Ù·È ÔÈÛıÔÂÚÈÙÔÓ·˚ο, Ì ̤ÛË Ï··ÚÔÙÔÌ›·, ÌÂÙ¿ ·fi ÂÎÙÔÌ‹ ÙˆÓ Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ Î·È ÎÈÓËÙÔÔ›ËÛË ÙÔ˘ ‰ÂÍÈÔ‡ ÎfiÏÔ˘ Î·È ÙÔ˘ ÙÂÏÈÎÔ‡ ÂÈÏÂÔ‡ ÚÔ˜ Ù· ·ÚÈÛÙÂÚ¿.

METAMO™XEY™Eπ™ 2011

∂ÈÎfiÓ· 2. ΔÔÔı¤ÙËÛË ‰ÈÏÔ‡ ÓÂÔÁÓÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ en-bloc ÛÙÔ ‰ÂÍÈfi Ï·ÁfiÓÈÔ ‚fiıÚÔ ·È‰ÈÔ‡ Î·È ·Ó·ÛÙfïÛË Ù˘ ·ÔÚÙ‹˜ Î·È Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ ÛÙ· ÎÔÈÓ¿ Ï·ÁfiÓÈ· ·ÁÁ›· ÙÔ˘ Ï‹ÙË.

ÔÈËÙÈÎfi Ì‹ÎÔ˜ (4-5 cm) Ù˘ οو ÎÔ›Ï˘ ÊϤ‚·˜ Î·È Ù˘ ·ÔÚÙ‹˜, ÁÈ· Ó· ÂÈÙÚ¤„ÂÈ ÙËÓ ¯ˆÚ›˜ Ù¿ÛË ·Ó·ÛÙfïÛË Ì ٷ Ï·ÁfiÓÈ· ·ÁÁ›· (∂ÈÎ. 2). ∞·ÈÙÔ‡ÓÙ·È 1-2 cm ¿Óˆ ·fi Ù· ÓÂÊÚÈο ·ÁÁ›· ÁÈ· ÙËÓ Û˘ÚÚ·Ê‹ Ì 6-0 prolene ÎÂÊ·ÏÈο ÙÔ˘ Ù¤ÏÔ˘˜ Ù˘ οو ÎÔ›Ï˘ Î·È Ù˘ ·ÔÚÙ‹˜ ÙÔ˘ ‰fiÙË. ∏ ÚÔÂÙÔÈÌ·Û›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·Ú¯›˙ÂÈ Ì ÙËÓ ·ÔϛӈÛË fiÏˆÓ ÙˆÓ ÔÛÊ˘ÈÎÒÓ ÎÏ¿‰ˆÓ ÙˆÓ ÌÂÁ¿ÏˆÓ ·ÁÁ›ˆÓ Ì 6-0 prolene. ∞ÎÔÏÔ˘ı› Ô ¤ÏÂÁ¯Ô˜ ÁÈ· Ù˘¯fiÓ ‰È·ÚÚÔ¤˜ Ì Ë·ÚÈÓÈṲ̂ÓÔ ÔÚfi. ΔÔ ÎÚ›ÛÈÌÔ ÛËÌÂ›Ô Â›Ó·È Ë ÙÔÔı¤ÙËÛË ÙˆÓ ÓÂÊÚÒÓ ¿Óˆ ÛÙÔÓ „Ô›ÙË Ì˘, οıÂÙ· ÛÙ· Ï·ÁfiÓÈ· ·ÁÁ›·. ∞˘Ù‹ Ë ı¤ÛË ·Ú¤¯ÂÈ ˘ÔÛÙ‹ÚÈÍË ÛÙÔ˘˜ ÓÂÊÚÔ‡˜ Î·È ÚÔÏ·Ì‚¿ÓÂÈ ÙËÓ ÙÒÛË ÙÔ˘˜ ÛÙËÓ ÏÂοÓË. ∏ οو ÎÔ›ÏË ÊϤ‚· ÙÔ˘ ‰fiÙË ·Ó·ÛÙÔÌÒÓÂÙ·È Ì ÙËÓ ¤Íˆ Ï·ÁfiÓÈÔ. OÌÔ›ˆ˜ Ë ·ÔÚÙ‹ ÙÔ˘ ‰fiÙË Ì ÙË ÎÔÈÓ‹ ‹ ¤Íˆ Ï·ÁfiÓÈÔ ·ÚÙËÚ›·. ∂Ó·ÏÏ·ÎÙÈο, Â¿Ó ÙÔ Ì¤ÁÂıÔ˜ Ù·ÈÚÈ¿˙ÂÈ Û ӤԢ˜ Ï‹Ù˜ Ë ·ÔÚÙ‹ ÙÔ˘ ‰fiÙË ·Ó·ÛÙÔÌÒÓÂÙ·È Ì ÙËÓ ÂÛˆ Ï·ÁfiÓÈÔ ·ÚÙËÚ›·, ÙÂÏÈÎÔÙÂÏÈο. °È· ÙËÓ ÂÌʇÙ¢ÛË ÙˆÓ Ô˘ÚËÙ‹ÚˆÓ, Ë ÚÔÙ›ÌËÛË Â›Ó·È Ó· ÂÎÙÂÏÔ‡ÓÙ·È ‰‡Ô ͯˆÚÈÛÙ¤˜ ·Ó·ÛÙÔÌÒÛÂȘ. Δ¤ÏÔ˜ ¯ÚÂÈ¿˙ÂÙ·È Ó· Á›ÓÂÈ Î·ı‹ÏˆÛË ÙˆÓ ÓÂÊÚÒÓ ÁÈ· Ó· ·ÔÙÚ·› Ë ÛÙÚÔÊ‹ Á‡Úˆ ·fi ÙÔÓ ¿ÍÔÓ· ÙˆÓ ÓÂÊÚÈÎÒÓ ·ÁÁ›ˆÓ Ì ÙÔÔı¤ÙËÛË ÛÙËÚÈÎÙÈÎÒÓ Ú·ÊÒÓ, ·fi ÙÔ˘˜ ¿Óˆ Î·È Î¿Ùˆ fiÏÔ˘˜ ÙˆÓ ÓÂÊÚÒÓ (ÂÚÈÓÂÊÚÈÎfi Ï›Ô˜) ÛÙÔÓ „Ô˚ÙË Ì˘.

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∏ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·Ó·ÈÛıËÛÈÔÏÔÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Ï‹ÙË ÛÙԯ‡ÂÈ ÛÙËÓ ÚfiÏË„Ë ÂÈÏÔÎÒÓ ·fi ÚÔ¸¿Ú¯Ô˘Û˜ Û˘ÛÙËÌ·ÙÈΤ˜ ·ı‹ÛÂȘ Î·È ÛÙËÓ ‰È·Ù‹ÚËÛË ÈηÓÔÔÈËÙÈ΋˜ ·ÚÔ¯‹˜ ·›Ì·ÙÔ˜ ÛÙÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì·. ΔÔ ÓÂÊÚÈÎfi ÌfiÛ¯Â˘Ì· ·fi ÂÓ‹ÏÈη ÌÔÚ› Ó· ·Áȉ‡ÛÂÈ Ì¤¯ÚÈ Î·È 250 ml ·›Ì·ÙÔ˜ Î·È ÛÙ· ÌÈÎÚ¿ ·È‰È¿ ۯ‰fiÓ ÙÔ 50% Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ ÌÔÚ› Ó· ÛÙÚ·Ê› ÁÈ· ÙËÓ ·ÈÌ¿ÙˆÛË ÙÔ˘ ™ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÂÓ‹ÏÈÎÔ˜ Û ·È‰› ηıÔÚÈÛÙÈ΋ ÛËÌ·Û›· ¤¯ÂÈ Ë ·‡ÍËÛË ÙÔ˘ ΢ÎÏÔÊÔÚÔ‡ÓÙÔ˜ fiÁÎÔ˘ ·›Ì·ÙÔ˜. ∞˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ ¯ÔÚ‹ÁËÛË ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‰È·Ï˘Ì¿ÙˆÓ ÚÈÓ ·fi ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ì ÛÙfi¯Ô ÙËÓ ‰È·Ù‹ÚËÛË Ù˘ ÎÂÓÙÚÈ΋˜ ÊÏ‚È΋˜ ›ÂÛ˘ ÛÙ· 10-12 cm H2O Î·È Ù˘ ̤Û˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÛÙ· 70 mm Hg. ∂¿Ó ¯ÚÂÈ¿˙ÂÙ·È ¯ÔÚËÁÂ›Ù·È ÓÙÔ·Ì›ÓË (̤¯ÚÈ 5 Ìg/kg/min), Ë ÔÔ›· ·ÔÙÂÏ› ÙËÓ Î·Ù¯ÔÏ·Ì›ÓË ÂÎÏÔÁ‹˜ ‰ÈfiÙÈ ÂÎÙfi˜ ·fi ÙËÓ Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈÔÛ‡Û·ÛË ÚÔηÏ› Î·È ÛÏ·¯ÓÈ΋ Î·È ÓÂÊÚÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹. ∫·Ù¿ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ·Ó·ÛÙfïÛ˘ ÙˆÓ ·ÁÁ›ˆÓ ¯ÔÚËÁ›ٷÈ, ÂÓ‰ÔÊϤ‚È·, Ì·ÓÓÈÙfiÏË 20% (1 g/kg) and ÊÔ˘ÚÔÛÂÌ›‰Ë (1 mg/kg). ∂ÈϤÔÓ, ··ÈÙÂ›Ù·È Û˘¯Ó‹ ̤ÙÚËÛË ÙˆÓ ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ ‰ÈfiÙÈ Ë ·Ú·ÙÂٷ̤ÓË Û‡ÁÎÏÂÈÛË Ù˘ ·ÔÚÙ‹˜ ‹ Ù˘ ÎÔÈÓ‹˜ Ï·ÁÔÓ›Ô˘ ·ÚÙËÚ›·˜ Ì ·ÁÁÂÈÔÏ·‚›‰· ÚÔηÏ› ·‡ÍËÛË ÙÔ˘ Á·Ï·ÎÙÈÎÔ‡ ÔͤԘ, ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË Î·È ·ÁÁÂÈÔÛ‡Û·ÛË 22. ªÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË ÙˆÓ ·Ó·ÛÙÔÌÒÛÂˆÓ ‰È·ÓÔ›ÁÂÙ·È ÚÒÙ· Ë ·ÁÁÂÈÔÏ·‚›‰· Ù˘ ÓÂÊÚÈ΋˜ ÊϤ‚·˜ Î·È ÌÂÙ¿ Ù˘ ·ÚÙËÚ›·˜, ˘fi Û˘Ó¯‹ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È ÙÔ˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜. ∏ Ù·¯Â›· ›ÛÔ‰Ô˜ ÙÔ˘ ˘ÁÚÔ‡ Û˘ÓÙ‹ÚËÛ˘ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ÌÔÚ› Ó· ÚÔηϤÛÂÈ ˘ÂÚηÏÈ·ÈÌ›· Î·È ‚Ú·‰˘Î·Ú‰›· Î·È Ó· ¯ÚÂÈ·Ûı› Ë ¯ÔÚ‹ÁËÛË ‰ÈÙÙ·Ó·ıÚ·ÎÈÎÔ‡ Ó·ÙÚ›Ô˘ ‹ Î·È ‰È·Ï‡Ì·ÙÔ˜ ÁÏ˘Îfi˙˘ Ì ÈÓÛÔ˘Ï›ÓË. ∂ÈϤÔÓ, Ë ‰È¿ÓÔÈÍË ÙˆÓ ·ÁÁÂÈÔÏ·‚›‰ˆÓ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÙÒÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÈÛ¯·ÈÌ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞Ó ¯ÚÂÈ·Ûı› Á›ÓÂÙ·È ÂÚÈÔ‰È΋ Û‡ÁÎÏÂÈÛË Î·È ‰È¿ÓÔÈÍË Ù˘ ·ÚÙËÚȷ΋˜ ·ÁÁÂÈÔÏ·‚›‰·˜ ̤¯ÚÈ Ó· ÛÙ·ıÂÚÔÔÈËı› Ë Î˘ÎÏÔÊÔÚ›·. ∞Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ, ¯ÔÚËÁÂ›Ù·È ‰È¿Ï˘Ì· ÏÂ˘ÎˆÌ·Ù›Ó˘ 20% (0.5 g/kg/‰fiÛË), ÊÔ˘ÚÔÛÂÌ›‰Ë (1 - 2 mg/kg/‰fiÛË), ‰ÈÙÙ·Ó·ıÚ·ÎÈÎfi Ó¿ÙÚÈÔ (1 mEq/kg) and Ì·ÓÓÈÙfiÏË 20% (0.3–0.5 g/kg/‰fiÛË) ‹ ‰È¿Ï˘Ì· ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ 0.9% (10-20 ml/kg/bolus), ÒÛÙ ӷ ‰È·ÙËÚËı› ÈηÓÔÔÈËÙÈ΋

I. °∂øƒ°∞∫∏™, π. º√À∑∞™

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·ÚÔ¯‹ ·›Ì·ÙÔ˜ ÚÔ˜ ÙÔ ÌfiÛ¯Â˘Ì·24. ™ÙȘ ÚÒÙ˜ 48 ÒÚ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ··ÈÙÂ›Ù·È ÚÔÛÔ¯‹ ÛÙËÓ ‰È·Ù‹ÚËÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ Î·È Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ ÙÔ˘ ·È‰ÈÔ‡. °›ÓÂÙ·È ˆÚÈ·›· ηٷ̤ÙÚËÛË ÙˆÓ Ô‡ÚˆÓ Î·È ·Ó·Ï‹ÚˆÛË Ì ›ÛÔ fiÁÎÔ ÎÚ˘ÛÙ·ÏÏÔÂȉÒÓ ‰È·Ï˘Ì¿ÙˆÓ, Û˘Ó‹ıˆ˜ ÌÂ Û˘Ó‰˘·ÛÌfi ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘, ÁÏ˘Îfi˙˘ Î·È ‰ÈÙÙ·ÓıÚ·ÎÈÎÒÓ. ∞Ó Ë ‰ÈÔ‡ÚËÛË ÌÂȈı› Û ÏÈÁfiÙÂÚÔ ·fi 1.5 mL/kg/ÒÚ· ¯ÔÚËÁÔ‡ÓÙ·È ÂÈϤÔÓ ÎÚ˘ÛÙ·ÏÏÔÂȉ‹, ÏÂ˘ÎˆÌ·Ù›ÓË Î·È ÊÔ˘ÚÔÛÂÌ›‰Ë. ∏ ‰È·Ù‹ÚËÛË ÙÔ˘ ÈÛÔ˙˘Á›Ô˘ ˘ÁÚÒÓ Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋ ‰ÈfiÙÈ Ë ˘ÂÚÊfiÚÙˆÛË ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ˘¤ÚÙ·ÛË Î·È Ó¢ÌÔÓÈÎfi Ô›‰ËÌ·. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ÂÓ‰·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ˘fiÙ·ÛË Î·È ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË22. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÏÈÁÔ˘Ú›· Â›Ó·È È‰È·›ÙÂÚ· ·ÓËÛ˘¯ËÙÈÎfi ÛËÌÂ›Ô Î·È Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ¿ÌÂÛ·. ªÔÚ› Ó· ÔÊ›ÏÂÙ·È Û ˘ÔÁηÈÌ›·, ·fiÊÚ·ÍË ÙÔ˘ ηıÂÙ‹Ú· Foley ·fi ‹ÁÌ·Ù·, ηı˘ÛÙÂÚË̤ÓË ¤Ó·ÚÍË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÔÍ›· ÛˆÏËÓ·Úȷ΋ Ó¤ÎÚˆÛË, ÚÒÈÌË ·fiÚÚÈ„Ë, ·ÁÁÂȷ΋ ıÚfiÌ‚ˆÛË ‹ ‰È·Ê˘Á‹ Ô‡ÚˆÓ ·fi ÙËÓ Î˘ÛÙÂÔÔ˘ÚËÙËÚÈ΋ ·Ó·ÛÙfïÛË. ∞Ó Ë ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ Î·È Ë ¤ÎÏ˘ÛË ÙÔ˘ ηıÂÙ‹Ú· Foley ‰ÂÓ ·Ô‰ÒÛÂÈ Ú¤ÂÈ Ó· ‰ÈÂÓÂÚÁÂ›Ù·È ÂÂÈÁfiÓÙˆ˜ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì triplex ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘, ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÓÂÊÚÔ‡, ‚ÈÔ„›· ‹ Î·È ÂÁ¯ÂÈÚËÙÈ΋ ‰ÈÂÚ‡ÓËÛË. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, Ë Î·ı˘ÛÙÂÚË̤ÓË ¤Ó·ÚÍË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ì ÔÏÈÁÔ˘Ú›· – ·ÓÔ˘Ú›·, ˘ÂÚÊfiÚÙˆÛË, ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ Î·È ÔÍÂÔ‚·ÛÈΤ˜ ‰È·Ù·Ú·¯¤˜ ··ÈÙ› ·ÓÙÈÌÂÙÒÈÛË Ì ·ÈÌÔοı·ÚÛË ‹ ÂÚÈÙÔÓ·˚΋ οı·ÚÛË22.

OÈ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÈÏÔΤ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ·. ¶ÚÒÈ̘ ÂÈÏÔΤ˜ Â›Ó·È Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·ÈÌÔÚÚ·Á›·, Ë ·ÙÂÏÂÎÙ·Û›·, Ë Ó¢ÌÔÓ›· , Ë ‰È·‡ËÛË ÙÔ˘ ÙÚ·‡Ì·ÙÔ˜, Ë ·Ó¿Ù˘ÍË ÂÚÈÓÂÊÚÈÎÒÓ Û˘ÏÏÔÁÒÓ (·È̿و̷, Ô˘Ú›ÓˆÌ·, ÏÂÌÊÔ΋ÏË, ·fiÛÙËÌ·), Ë ·fiÊÚ·ÍË ÙÔ˘ Ô˘ÚËÙ‹Ú· Î·È Ù˘ ˘ÂÏÔÔ˘ÚËÙËÚÈ΋˜ Û˘Ì‚ÔÏ‹˜. ™·Ó fi„È̘ ÂÈÏÔΤ˜ ·Ó·Ê¤ÚÔÓÙ·È Ë ¯ÚfiÓÈ· ÓÂÊÚÔ¿ıÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÔÈ ÏÔÈÌÒÍÂȘ, Ë ˘ÔÙÚÔ‹ Ù˘ ÚˆÙÔ·ıÔ‡˜ ÓfiÛÔ˘, Ë ÂÌÊ¿ÓÈÛË Î·ÎÔ‹ıÂÈ·˜, ÔÈ ÂÈ‚·Ú‡ÓÛÂȘ ·fi ÙËÓ ¯Ú‹ÛË ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ ·Ó¿Ù˘ÍË.

∂›ÏÔÁÔ˜ Δ· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯Ô˘Ó ‚ÂÏÙȈı› ÛËÌ·-

ÓÙÈο Ù· ÔÛÔÛÙ¿ ÂÈ‚›ˆÛ˘ ÙfiÛÔ ÙˆÓ ÌÈÎÚÒÓ ·ÛıÂÓÒÓ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËı› Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ fiÛÔ Î·È ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ™Â ·˘Ùfi Û˘Ó¤‚·ÏÂ Ë ¯Ú‹ÛË ÙˆÓ Ó¤ˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ, Ë ÊÚÔÓÙ›‰· ̤¯ÚÈ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË (ÂÚÈÙÔÓ·˚Τ˜ χÛÂȘ, ·ÈÌÔοı·ÚÛË) Î·È Î·ıÒ˜ ηٿÏÏËÏË ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ∏ ÚÔÂÓÙ·Íȷ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË, fiÙ·Ó Â›Ó·È ÂÊÈÎÙ‹, ·ÔÙÂÏ› ÙËÓ Î·Ï‡ÙÂÚË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ηı˘ÛÙ¤ÚËÛ˘ Ù˘ ·Ó¿Ù˘Í˘ Ô˘ Â›Ó·È ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ Úfi‚ÏËÌ· ÙˆÓ ÌÈÎÚÒÓ ·ÛıÂÓÒÓ ∏ ‰ÈÂÓ¤ÚÁÂÈ· ÓÂÊÚÂÎÙÔÌ‹˜ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘ÓÈÛÙ¿Ù·È È‰È·›ÙÂÚ· ÛÙ· ‚Ú¤ÊË ÛÙ· ÔÔ›· ˘¿Ú¯ÂÈ ÂÓÂÚÁfi˜ Ïԛ̈ÍË, ÌÂÁ¿ÏË ·ÚÙËÚȷ΋ ›ÂÛË Ô˘ ‰ÂÓ ÂϤÁ¯ÂÙ·È Î·È Û ‰È¿ÁÓˆÛË ÓÂÊÚˆÛÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘. ∂›Û˘ Ì·˙› Ì ÙȘ ·Ú·¿Óˆ ·Èٛ˜ ÔÈ ‰˘ÛÏ·ÛÙÈÎÔ›-ÔÏ˘Î˘ÛÙÈÎÔ› ÓÂÊÚÔ› Î·È Ë ÌÂÁ¿ÏÔ˘ ‚·ıÌÔ‡ ΢ÛÙÂÔ˘ÚËÙËÚÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Â›Ó·È ¤Ó‰ÂÈÍË ÁÈ· ·Ê·›ÚÂÛË ÙˆÓ Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, fiÔ˘ ÙÔ ÌfiÛ¯Â˘Ì· ÙÔÔıÂÙÂ›Ù·È ÔÈÛıÔÂÚÈÙÔÓ·Èο. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ Ë ÚÔÛ¤Ï·ÛË Á›ÓÂÙ·È ÂÓ‰ÔÎÔÈÏȷο, Ë ·Ê·›ÚÂÛË ÙˆÓ Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ ÌÔÚ› Ó· Á›ÓÂÈ Û ¤Ó· ¯ÚfiÓÔ Ì ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ŒÁÈÓ ·Ó·ÊÔÚ¿ ÛÙȘ ·ÓÙÂӉ›ÍÂȘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ ηÎÔ‹ıÂÈ· Î·È Ë ÂÓÂÚÁfi˜ Ïԛ̈ÍË ·ÔÙÂÏÔ‡Ó ·fiÏ˘ÙË ·ÓÙ¤Ó‰ÂÈÍË. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ËÏÈΛ· Î·È ÙÔ ‚¿ÚÔ˜ ÛÙ· ·È‰È¿ Ô˘ Â›Ó·È ÌÈÎÚfiÙÂÚ· ÙˆÓ 6 ÂÙÒÓ Î·È ÂÏ·ÊÚ‡ÙÂÚ· ÙˆÓ 6 ÎÈÏÒÓ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ¤¯ÂÈ ÊÙˆ¯¿ ·ÔÙÂϤÛÌ·Ù· ÌÂ Û˘¯Ó¤˜ ·ÁÁÂȷΤ˜ ÂÈÏÔΤ˜. ™Â ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ÓÂÊÚÔ‡ ·fi ÂÓ‹ÏÈη ‰fiÙË ÌÔÚ› Ó· Á›ÓÂÈ Â›Ù ÛÙÔ Ï·ÁfiÓÈÔ ‚fiıÚÔ, Ì Â͈ÂÚÈÙÔÓ·˚΋ ÚÔÛ¤Ï·ÛË, ›Ù Ì ̤ÛË Ï··ÚÔÙÔÌ›· Î·È ‰È·ÂÚÈÙÔÓ·˚΋ ÚÔÛ¤Ï·ÛË, Ì ‹ ¯ˆÚ›˜ ÂÎÙÔÌ‹ ÙˆÓ Èı·ÁÂÓÒÓ ÓÂÊÚÒÓ22. μ¿ÚÔ˜ ÌÂٷ͇ 15 Î·È 20 ÎÈÏÒÓ ÙˆÓ ÏËÙÒÓ ¤¯ÂÈ ·Ó·ÊÂÚı› ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ˆ˜ fiÚÈÔ ÁÈ· Ó· Ú·ÁÌ·ÙÔÔÈËı› ÌÈ· Â͈ÂÚÈÙÔÓ·˚΋ ÚÔÛ¤ÁÁÈÛË. ∏ ÓÂÊÚÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È Û‹ÌÂÚ· ıˆÚËÙÈο ‰È·ı¤ÛÈÌË ÁÈ· fiϘ ۯ‰fiÓ ÙȘ ËÏÈ˘ Ì ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ, ÏfiÁˆ Ù˘ ·Ó¿Ù˘Í˘ Ó¤ˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ Î·È Û‡Á¯ÚÔÓˆÓ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·Ú̿ΈÓ. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ·fi ˙ÒÓÙ˜ ‰fiÙ˜ Û˘Ó¯›˙ÂÈ Ó· Â›Ó·È Ô ¯Ú˘Ûfi˜ ηÓfiÓ·˜ ÁÈ· ÙËÓ ıÂÚ·›· ·È‰ÈÒÓ Ì á∞-Δ™ ÂȉÈο fiÙ·Ó Á›ÓÂÙ·È ÚÈÓ ·fi ÙËÓ ¤ÓÙ·ÛË Û ıÂÚ·›· ÓÂÊÚÈ΋˜ ˘ÔηٿÛÙ·Û˘. ∏ ÚÔÛ¤ÁÁÈÛË ·˘-

METAMO™XEY™Eπ™ 2011

Ù‹ ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È ÌÈ· ‰ÈÏ‹ ¢ı‡ÓË ÁÈ· ÙËÓ È·ÙÚÈ΋ ÔÌ¿‰· , ‰ÈfiÙÈ ¤Ó·˜ ÂÓ‹ÏÈη˜ Ô˘ ÂÈı˘Ì› Ó· ‰ˆÚ›ÛÂÈ ¤Ó· ÌfiÛ¯Â˘Ì· ÓÂÊÚÔ‡, Ú¤ÂÈ Ó· ‰È·ÙËÚ‹ÛÂÈ ÌÈ· Ê˘ÛÈÔÏÔÁÈ΋ ˙ˆ‹ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË Î·È Ô ·È‰È·ÙÚÈÎfi˜ ·ÛıÂÓ‹˜ Ó· ¤¯ÂÈ ÙËÓ ÌÂÁ¿ÏË Â˘Î·ÈÚ›· Ó· ÌÂÁ·ÏÒÛÂÈ Î·È Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ÔÈfiÙËÙ· Ù˘ ˙ˆ‹˜ ÙÔ˘.

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KÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·-ÈÛ¯·ÈÌÈ΋ ÓfiÛÔ˜ÚÔÂÁ¯ÂÈÚËÙÈ΋ ·ÍÈÔÏfiÁËÛË Î·È ÂÈÏÔ΋ ¢. ∂ÎÎÏËÛ›·Ú¯Ô˜

‚Ú¿Ó˘. Δ· ‰È¿ÊÔÚ· Û˘ÛÙ·ÙÈο Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘ ̤ۈ ÙÔ˘ ‰ÈÏÔ‡ ÛÙÚÒÌ·ÙÔ˜ ÏÈȉ›ˆÓ Â›Ó·È Û ‰˘Ó·ÌÈ΋ ÈÛÔÚÚÔ›·. ™ÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ë ·‡ÍËÛË ÙˆÓ ÂÈ¤‰ˆÓ ¯ÔÏËÛÙÂÚfiÏ˘ Î·È Ë Ì›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘ LCAT, ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ· ‰È·Ù·Ú·¯¤˜ ÛÙË ‰È·ÂÚ·ÙfiÙËÙ· Ù˘ ÌÂÌ‚Ú¿Ó˘. ™·Ó ·ÔÙ¤ÏÂÛÌ· ‰È·Ù·Ú¿ÛÛÂÙ·È Ë ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ‚ ˘Ô‰Ô¯¤ˆÓ Î·È ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙˆÓ ÚˆÙÂ˚ÓÒÓ-G, ÌÈ· Î·È ÂÍ·ÚÙÒÓÙ·È ÛÙÂÓ¿ ·fi ÙËÓ ·ÎÂÚ·ÈfiÙËÙ· Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘. ∞˘Ùfi ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· Ó· ·ÚÂÌÔ‰›˙ÂÙ·È Ë ‰Ú¿ÛË Ù˘ ·‰ÂÓ˘Ï- ΢ÎÏ¿Û˘ Î·È Ó· ·˘Í¿ÓÂÙ·È Ë ·Ô‰fiÌËÛË ÙÔ˘ cAMP. O ÚfiÏÔ˜ ÙÔ˘ ÌÔÓÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘ (¡O). ∏ ·˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÔÎÈÓÒÓ Î·È Ë ·˘ÍË̤ÓË ·ÔÚÚfiÊËÛË ‚·ÎÙËÚÈ·ÎÒÓ ÙÔÍÈÓÒÓ ·fi ÙÔ ÂÙÈÎfi, Èı·ÓÔÏÔÁÂ›Ù·È Û·Ó ÙÔ ·›ÙÈÔ ·˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ ÌÔÓÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘ ÛÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ∏ ·Ú·ÁˆÁ‹ ÙÔ˘ ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÚÈÊÂÚÈ΋ ·ÚÙËÚȷ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹ Î·È ˘ÂÚ‰˘Ó·ÌÈ΋ ΢ÎÏÔÊÔÚ›·. ∂ÈϤÔÓ ÙÔ ÌÔÓÔÍ›‰ÈÔ ÙÔ˘ ·˙ÒÙÔ˘ ̤ۈ ÔÍÂȉˆÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ Ô‰Ô‡, ·ÚÂÌ‚·›ÓÂÈ ÙfiÛÔ ÛÙËÓ ÌÂÙ¿‰ÔÛË ÙˆÓ ÂÚÂıÈÛÌ¿ÙˆÓ Ì¤Ûˆ ÙˆÓ ‚ ˘Ô‰Ô¯¤ˆÓ, fiÛÔ Ì¤Ûˆ Ù˘ ·‰ÂÓ˘Ï-ÎÈÎÏ¿Û˘ ·Ú·ÁˆÁ‹˜ cGMP ÛÙÔÓ ·ÔÎÏÂÈÛÌfi Ù˘ ΢ÎÏÔÊÔÚ›·˜ ÙÔ˘ ÂÍˆÎ˘ÙÙ¿ÚÈÔ˘ ·Û‚ÂÛÙ›Ô˘ ̤ۈ ÙˆÓ ‰È·‡ÏˆÓ L. OÈ ·Ú·¿Óˆ ÌÂÙ·‚ÔϤ˜ Ô‰ËÁÔ‡Ó ÛÙȘ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ ‰È·ÛÙÔÏÈ΋˜ Î·È Û˘ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ ÎÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·2,9,11. ªÂÙ·‚ÔϤ˜ ÙÔ˘ ·˘ÙÔÓfiÌÔ˘ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ∏ ÂÏ·Ùو̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ·Ú·Û˘Ì·ıËÙÈÎÔ‡, ıˆÚÂ›Ù·È ·ÓÙÈÚÚÔÈÛÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜. ∞˘ÍË̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· ÂÓ‰Ôηӷ‚ȉÔÂȉԇ˜ Û˘ÛÙ‹Ì·ÙÔ˜ ª¤Ûˆ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ CB1 ÚÔ¿ÁÂÈ ÙËÓ ÙfiÛÔ ·fiÙˆÛË ÙˆÓ Ë·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙˆÓ Ì˘ÔηډȷÎÒÓ Î˘ÙÙ¿ÚˆÓ, fiÛÔ ·˘Í¿ÓÂÈ Î·È ÙÔÓ ·ÁÁÂÈ·Îfi ÙfiÓÔ Ì ·ÔÙ¤ÏÂÛÌ· ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹ Î·È ÂÏ·Ùو̤ÓË Û˘ÛÙ·ÏÙÈÎfi-

∫ÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ∂›Ó·È ÙÔ Û‡Ó‰ÚÔÌÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¤Ó· Û‡ÓÔÏÔ ‰È·Ù·Ú·¯ÒÓ Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ÂÏ·ÙÙˆÌ¤ÓˆÓ ÂÚÈÊÂÚÈÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ Î·È ·˘ÍË̤Ó˘ ηډȷ΋˜ ·ÚÔ¯‹˜ ÛÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ·Ô˘Û›· ¿ÏÏ˘ ηډȷ΋˜ ÓfiÛÔ˘. ÷ڷÎÙËÚÈÛÙÈο ÙÔ˘ ›ӷÈ2,3,9: • º˘ÛÈÔÏÔÁÈ΋ Û˘ÛÙÔÏÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û ËÚÂÌ›· • ¶·ıÔÏÔÁÈ΋ ‰È·ÛÙÔÏÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∫·Ù¿ ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ ÚÔËÁÂ›Ù·È Ù˘ Û˘ÛÙÔÏÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜.

• ∞˘ÍË̤ÓË Î·Ú‰È·Î‹ ·ÚÔ¯‹ Û ËÚÂÌ›· ·ÏÏ¿ ¯ˆÚ›˜ ·ÓÙ·fiÎÚÈÛË Û ηٷÛÙ¿ÛÂȘ ÛÙÚ˜ • ∏ÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÔϤ˜ (ÎÔÏÈ΋ Ì·ÚÌ·Ú˘Á‹, ·Ú¿Ù·ÛË ÙÔ˘ ‰È·ÛÙ‹Ì·ÙÔ˜ QT) • ∂Ï·Ùو̤ÓË ·¿ÓÙËÛË ÛÙËÓ ÓÔÚÂÈÓÂÊÚ›ÓË, ·ÁÁÂÈÔÙÂÓÛ›ÓË ππ, ‰Ô‚Ô˘Ù·Ì›ÓË Î·È ‚·˙ÔÚÂÛÛ›ÓË

¶·ıÔÊ˘ÛÈÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ›2,9 ∞ÏÎÔfiÏ. O ÚfiÏÔ˜ ÙÔ˘ ·ÏÎÔfiÏ ÛÙËÓ ÎÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ¤¯ÂÈ ϤÔÓ ÛÔ‚·Ú¿ ·ÌÊÈÛ‚ËÙËı› ÌÈ· Î·È ÔÈ ÌÂÙ·‚ÔϤ˜ Ù˘ ÎÈÚÚˆÙÈ΋˜ Ì˘ÔηډÈÔ¿ıÂÈ·˜ ¤¯Ô˘Ó ·Ú·ÙËÚËı› Î·È ÛÙËÓ ÌË ·ÏÎÔÔÏÈ΋ ΛÚÚˆÛË. ¢È·Ù·Ú·¯¤˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ‚- ·‰ÚÂÓÂÚÁÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ. O ÚfiÏÔ˜ ÙˆÓ ‚ ·‰ÚÂÓÂÚÁÈÎÒÓ ˘Ô‰Ô¯¤ˆÓ ̤ۈ ÙˆÓ ˘ÔÙ‡ˆÓ ‚1 Î·È ‚2 ÛÙË Ú‡ıÌÈÛË Ù˘ ηډȷ΋˜ Û˘ÛÙÔÏ‹˜ Â›Ó·È ÁÓˆÛÙfi˜. ™ÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ¤¯ÂÈ ·Ú·ÙËÚËı› fiÙÈ Û˘Ì‚·›ÓÂÈ ·¢·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ‚ ˘Ô‰Ô¯¤ˆÓ ¯ˆÚ›˜ Ó· Â›Ó·È ÍÂοı·ÚÔ˜ Ô Ì˯·ÓÈÛÌfi˜. O ·˘ÍË̤ÓÔ˜ ÙfiÓÔ˜ ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Î·È Ù· ·˘ÍË̤ӷ Â›‰· ηÙ¯ÔÏ·ÌÈÓÒÓ ıˆÚÔ‡ÓÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ ÂÚ¢ÓËÙ¤˜ Û·Ó Ù· ΢ÚÈfiÙÂÚ· ·›ÙÈ· ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ‚ ˘Ô‰Ô¯¤ˆÓ. ªÂÙ·‚ÔϤ˜ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÚˆÙÂ˚ÓÒÓ G. Œ¯ÂÈ ÂÍÂÙ·Ûı› Î·È Ô ÚfiÏÔ˜ ÙˆÓ ÚˆÙÂ˚ÓÒÓ G, ·ÏÏ¿ Â›Ó·È ÁÓˆÛÙfi fiÙÈ ‰ÂÓ ·ÊÔÚÔ‡Ó ·ÔÎÏÂÈÛÙÈο ÙËÓ Î·Ú‰È¿ ·ÏÏ¿, fiÏÔ ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· ∞ÏÏ·Á¤˜ ÛÙȘ ȉÈfiÙËÙ˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ-

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¶∞£OºÀ™πO§O°π∫Oπ ª∏Ã∞¡π™ªOπ ∫πƒƒøΔπ∫∏™ ªÀO∫∞ƒ¢πO¶∞£∂π∞™ ·fi E.Zardi et al. Cirrhotic Cardomopathy. JACC 2010;56(7):539-49

ÙËÙ·. O ÚfiÏÔ˜ ÙˆÓ ·ÓÙ·ÁˆÓÈÛÙÒÓ ÙÔ˘ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ ·Ú·¿Óˆ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ‰ÂÓ ¤¯ÂÈ ÂÚ¢ÓËı› Â·ÚÎÒ˜. ∏·ÙÔ΢ÙÙ·ÚÈ΋ ·ÓÂ¿ÚÎÂÈ·. ™ÙÔ˘˜ ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÙÔÍÈο ÚÔ˚fiÓÙ· fiˆ˜ ÂÓ‰ÔÙÔ͛Ә Î·È Î˘ÙÔΛÓ˜ Â›Ó·È ·˘ÍË̤ӷ ÙfiÛÔ Û·Ó ·ÔÙ¤ÏÂÛÌ· ·˘ÍË̤Ó˘ ·ÔÚÚfiÊËÛ˘ ·fi ÙÔ ÂÙÈÎfi fiÛÔ Î·È ·˘ÍË̤ÓÔ˘ ÔÛÔÛÙÔ‡ ÏÔÈÌÒ͈Ó. OÈ ·Ú¿ÁÔÓÙ˜ ·˘ÙÔ› ÂÏ·ÙÙÒÓÔ˘Ó ÙËÓ Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ ηډȷÎÔ‡ Ì˘ Î·È ÚÔ¿ÁÔ˘Ó ÙËÓ ·Ô‰fiÌËÛË ÙˆÓ Î·Ú‰È·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ÕÏÏÔ˜ ÙÔÍÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Â›Ó·È Î·È Ù· ·˘ÍË̤ӷ Â›‰· ¯ÔÏÈÎÒÓ ÔͤˆÓ. ¶Ú¤ÂÈ ¿ÓÙˆ˜ Ó· ÛËÌÂȈı› fiÙÈ ·ÚfiÌÔȘ ÌÂÙ·‚ÔϤ˜ ‰ÂÓ Û˘Ì‚·›ÓÔ˘Ó Û ÎÏÈÓÈΤ˜ ηٷÛÙ¿ÛÂȘ Ì ÔÍ›· ·‡ÍËÛË ÙˆÓ ¯ÔÏÈÎÒÓ ÔͤˆÓ. ÀÂÚ‰˘Ó·ÌÈ΋ ΢ÎÏÔÊÔÚ›·. ∂›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ·Ú·ÙÂٷ̤ÓË ˘ÂÚÊfiÚÙˆÛË Ù˘ ηډȿ˜ Û·Ó ·ÔÙ¤ÏÂÛÌ· ·˘ÍË̤Ó˘ ηډȷ΋˜ ·ÚÔ¯‹˜ Î·È ·˘ÍË̤ÓÔ˘ ÂÓ‰Ô·ÁÁÂÈ·ÎÔ‡ fiÁÎÔ˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ‰È·Ù·Ú·¯¤˜ Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜

¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ OÈ ÌÈÎÚÔÛÎÔÈΤ˜ ÌÂÙ·‚ÔϤ˜ Â›Ó·È ÌË ÂȉÈΤ˜ Î·È ·Ú·ÙËÚÔ‡ÓÙ·È È‰È·›ÙÂÚ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ ÌÂ

·ÛΛÙË. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Ì˘Ôηډȷ΋ ˘ÂÚÙÚÔÊ›·, ‰È¿ÌÂÛÔ Î·È Î˘ÙÙ·ÚÈÎfi Ô›‰ËÌ· ηıÒ˜ Î·È ÛËÌ›· ΢ÙÙ·ÚÈ΋˜ ‚Ï¿‚˘. ∞˘Ùfi ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· Û˘¯Ó¤˜ ÌÂÙ·‚ÔϤ˜ ÛÙËÓ ÔÌÔÈfiÛÙ·ÛË ÙˆÓ ÈfiÓÙˆÓ Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘ Ô˘ ÂÍËÁÔ‡Ó ÙȘ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ú˘ıÌÔ‡ Ô˘ Â›Ó·È fi¯È Û¿ÓȘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË. ∏ ·ÚÈÛÙÂÚ‹ ÎÔÈÏ›· Â›Ó·È ˘ÂÚÙÚÔÊÈ΋ Î·È ÏÈÁfiÙÂÚÔ Â˘¤Ó‰ÔÙË2,9.

¶ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÎÙ›ÌËÛË ∏ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Â›Ó·È ·˘ÍË̤ÓË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÎÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·. ∞ӷʤÚÂÙ·È ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ı·Ó¿ÙÔ˘ ηٿ ÙËÓ ÙÔÔı¤ÙËÛË ˘Ï·ÈÔ – Û˘ÛÙËÌ·ÙÈ΋˜ ·Ú¿Î·Ì„˘ (TIPS) Î·È ·Ó¿Ù˘Í˘ Ë·ÙÔ-ÓÂÊÚÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÌÂÙ¿ ·fi ÂÂÈÛfi‰ÈÔ ‚·ÎÙËÚȷ΋˜ ÂÚÈÙÔÓ›Ùȉ·˜. ŸÌˆ˜ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·Ú·Ì¤ÓÂÈ Ë ÌÔÓ·‰È΋ ıÂÚ·›· ÁÈ· ÙÔ˘˜ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ ·ÛıÂÓ›˜. ∫·Ù¿ ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô Û˘Ì‚·›ÓÔ˘Ó ÛËÌ·ÓÙÈΤ˜ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ì ȉȷ›ÙÂÚË ÎÚ›ÛÈÌË ÙË Ê¿ÛË Â·Ó·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. OÈ ÌÂÙ·‚ÔϤ˜ ·˘Ù¤˜ Â›Ó·È ‰È·ÊÔÚÂÙÈΤ˜ ·fi ·˘Ù¤˜ Ù˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ÂÚÈfi‰Ô˘, ÛÙËÓ ÔÔ›· ¤¯ÂÈ ‰È·È-

METAMO™XEY™Eπ™ 2011

ÛÙˆı› ‚ÂÏÙ›ˆÛË Ù˘ Û˘ÛÙÔÏÈ΋˜ Î·È ‰È·ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û 6 Î·È 12 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ Â¤Ì‚·ÛË.

O ÂÓÙÔÈÛÌfi˜ ÏÔÈfiÓ ·˘ÙÒÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ Úԉȷı¤ÙÔ˘Ó ÛÙËÓ ÂΉ‹ÏˆÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜1,9. ∞fi ÙȘ ‰È·Ù·Ú·¯¤˜ Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙËÓ ÎÈÚÚˆÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ· ·˘Ù‹ Ô˘ Úԉȷı¤ÙÂÈ Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÂÈÏÔÎÒÓ Î·Ù¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Â›Ó·È Ë ·‰˘Ó·Ì›· ¯ÚÔÓfiÙÚÔ˘ ·¿ÓÙËÛ˘*. ∏ ·‰˘Ó·Ì›· Â›Ù¢Í˘ ÙÔ˘ 82 % Ù˘ ÚÔ‚ÏÂfiÌÂÓ˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ ηٿ ÙË ‰ÔÎÈÌ·Û›· ‰Ô‚Ô˘Ù·Ì›Ó˘ (DSE) Úԉȷı¤ÙÂÈ Û 22% ÂÚÈÛÛfiÙÂÚÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ·ÚÚ˘ıÌÈÒÓ Î·È ÂÌÊÚ¿ÁÌ·ÙÔ˜ Ì˘Ôηډ›Ô˘, ÙfiÛÔ Î·Ù¿ ÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô fiÛÔ Î·È ÁÈ· ‰È¿ÛÙËÌ· 4 ÌËÓÒÓ. ¶ÔÛÔÛÙfi ¿Óˆ ·fi 20% ÙˆÓ ÂÈÏÔÎÒÓ Û˘Ó¤‚ÂÈ Û ·ÛıÂÓ›˜ Ì ‚·ıÌÔÏÔÁ›· ÂÎÙ›ÌËÛ˘ ‚·Ú‡ÙËÙ·˜ Ë·ÙÈ΋˜ ÓfiÛÔ˘ (MELD score) ¿Óˆ ·fi 231,12. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÂÓÒ Ë ·‰˘Ó·Ì›· ·‡ÍËÛ˘ Ù˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜ Â›Ó·È ·ÓÂÍ¿ÚÙËÙÔ˜ ·Ú¿ÁÔÓÙ·˜ ı·Ó¿ÙÔ˘ Û ¿Ó‰Ú˜ Ì ÚÔ¯ˆÚË̤ÓË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ, ‰ÂÓ ˘¿Ú¯Ô˘Ó ‰Â‰Ô̤ӷ Ô˘ Ó· Û˘Ó‰¤ÔÓÙ·È Ì ·˘ÍË̤ÓË ıÓËÛÈÌfiÙËÙ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË. ¶·ÚfiÏ· ·˘Ù¿ Ë ÚÔ‚ÏÂÙÈ΋ ·Í›· Ù˘ DSE ‰ÂÓ ¤¯ÂÈ ÂÍÂÙ·ÛÙ›. ŒÙÛÈ Ë ‰ÔÎÈÌ·Û›· Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È fi¯È ÁÈ· ÙËÓ ·ÔÎ¿Ï˘„Ë Û˘ÛÙÔÏÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ·ÏÏ¿ ÌfiÓÔ ÛÂ Û˘Ó‡·ÚÍË ÛÔ‚·Ú‹˜ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ÁÈ· ÂÎÙ›ÌËÛË ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜2,8,9. ∏ ·‰˘Ó·Ì›· ·‡ÍËÛ˘ ÙÔ˘ fiÁÎÔ˘ ·ÏÌÔ‡ ÛÂ Û˘Óı‹Î˜ ÊfiÚÙÈÛ˘ ÌÔÚ› Ó· ÂÎÙÈÌËı› Î·È ·fi ÙËÓ ·ıÔÏÔÁÈ΋ Ï‹ÚˆÛË Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜, fiˆ˜ ηٷÁÚ¿ÊÂÙ·È ·fi ÙËÓ ·Ó¿Ï˘ÛË ‰È·ÌÈÙÚÔÂȉÈ΋˜ ÚÔ‹˜ Ì ÙÔ ·ÏÌÈÎfi Doppler. §fiÁÔ˜ ∂/∞ ÌÈÎÚfiÙÂÚÔ˜ ÙÔ˘ 1 Û¯ÂÙ›˙ÂÙ·È Ì ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓË-

91

Ù¤˜ Ì ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ıÓËÛÈÌfiÙËÙ·˜. ∞‡ÍËÛË Ù˘ ÚÔÂ͈ıËÙÈ΋˜ ÂÚÈfi‰Ô˘ ·ÔÙÂÏ› ÛËÌÂ›Ô ÂËÚ·ÛÌÔ‡ Î·È Ù˘ Û˘ÛÙÔÏÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜2,8. ∏ ÂÌÊ¿ÓÈÛË Î·Ú‰È·Î‹˜ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û˘Óԉ‡ÂÙ·È ·fi Ôχ ˘„ËÏ¿ ÔÛÔÛÙ¿ ıÓËÛÈÌfiÙËÙ·˜. ∞fi ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ Ê·›ÓÂÙ·È fiÙÈ 9% ÙˆÓ ·ÛıÂÓÒÓ ı· ·Ó·Ù‡ÍÔ˘Ó ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÔͤԘ Ó¢ÌÔÓÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÙÔ ÚÒÙÔ 24ˆÚÔ Î·È 3,4% ı· ÂÌÊ·Ó›ÛÔ˘Ó ÛÙÔ ÚÒÙÔ ÂÍ¿ÌËÓÔ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰È·Ù·ÙÈ΋ Ì˘ÔηډÈÔ¿ıÂÈ·. ∫·Ù¿ ÙÔ˘˜ ›‰ÈÔ˘˜ ÂÚ¢ÓËÙ¤˜ Ù· ·Ú·¿Óˆ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÎÈÚÚˆÙÈ΋˜ Ì˘ÔηډÈÔ¿ıÂÈ·˜ ¯ˆÚ›˜ ¤Î‰ËϘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ηٿ ÙËÓ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô2,3. ∏ ÛËÌ·Û›· Ù˘ ηٿÏÏËÏ˘ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ (monitoring) Â›Ó·È ·Ú·¿Óˆ ·fi ÚÔÊ·Ó‹˜. ¢›Ï· ÛÙÔ˘˜ ÓÂÒÙÂÚ˘ ÁÂÓÈ¿˜ ηıÂÙ‹Ú˜ ıÂÚÌÔ·Ú·›ˆÛ˘ ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ Ù˘ ‰ÈÔÈÛÔÊ·Á›Ԣ ˘ÂÚ˯ÔηډÈÔÁÚ·Ê›·˜. ∂›Ó·È Ë ÌfiÓË Ì¤ıÔ‰Ô˜ Ô˘ ÚÔÛʤÚÂÈ ‰˘Ó·ÌÈ΋ Î·È Û Ú·ÁÌ·ÙÈÎfi ¯ÚfiÓÔ ÂÎÙ›ÌËÛ˘ Ù˘ ηډȷ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ªÂÁ¿ÏÔ Â›Û˘ ÏÂÔÓ¤ÎÙËÌ· Ù˘ ÌÂıfi‰Ô˘ ·ÔÙÂÏ› Ë ¿ÌÂÛË ÂÎÙ›ÌËÛË Ù˘ ‰ÂÍÈ¿˜ ÎÔÈÏ›·˜ ÌÈ· Î·È Ë ·ÓÂ¿ÚÎÂÈ¿ Ù˘ ÌÔÚ› Ó· ‰È·ÁÓˆÛÙ› Î·È Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Ôχ ÚÈÓ ‰ÒÛÂÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÂӉ›ÍÂȘ1,10. ∞fi Ù· ·Ú·¿Óˆ Â›Ó·È ÚÔÊ·Ó¤˜, fiÙÈ Ë ·Ô˘Û›· ηıÔÚÈÛÙÈÎÒÓ ·ÓÙÈÎÂÈÌÂÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·ıÈÛÙ¿ ·Ó·Áη›· ÙËÓ ¿ÚÈÛÙË ÎÏÈÓÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ˘Ô„‹ÊÈˆÓ ·ÛıÂÓÒÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. OÈ ˘¿Ú¯Ô˘Û˜ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ ηıÔÚ›˙Ô˘Ó ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂÁηÙÂÛÙË̤ÓË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ Û ¯·ÌËÏÔ‡, ̤ÛÔ˘ Î·È ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ™ÙȘ ‰‡Ô ÚÒÙ˜ ÔÌ¿‰Â˜ ÛËÌ·ÓÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ Ù˘ DSE ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÂÎÙ›ÌËÛË ÙÔ˘ ·Ó·ıˆÚË̤ÓÔ˘ ‰Â›ÎÙË Î·Ú‰È·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (Lee index)**. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÙÂÏÂ˘Ù·›·˜ ÔÌ¿-

* ¢O∫πª∞™π∞ ¢OμOÀΔ∞ªπ¡∏™ ¶Ú·ÁÌ·ÙÔÔÈÂ›Ù·È ÂÎÙ›ÌËÛË ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ÙˆÓ 16 ÙÌËÌ¿ÙˆÓ Ì ٷ˘Ùfi¯ÚÔÓË ¯ÔÚ‹ÁËÛË ‰Ô‚Ô˘Ù·Ì›Ó˘ Û ·˘Í·ÓfiÌÂÓ˜ ‰fiÛÂȘ 10,20,30,40 Î·È 50 Ìg/kg/min Û ÌÂÛԉȷÛÙ‹Ì·Ù· 3 ÏÂÙÒÓ, Ì ÛÙfi¯Ô Â›Ù¢Í˘ Ù˘ ÚÔ‚ÏÂfiÌÂÓ˘ ηډȷ΋˜ Û˘¯ÓfiÙËÙ·˜. º˘ÛÈÔÏÔÁÈ΋ ·¿ÓÙËÛË ıˆÚÂ›Ù·È Ë ÚÔԉ¢ÙÈ΋ ˘ÂÚ‰˘Ó·ÌÈ΋ ·¿ÓÙËÛË. ∞ÓÙ›ıÂÙ· Âȉ›ӈÛË Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ‹ ‰ÈÊ·ÛÈ΋ ·¿ÓÙËÛË ( ‚ÂÏÙ›ˆÛË ÛÙȘ ¯·ÌËϤ˜ Ì Âȉ›ӈÛË ÛÙȘ ˘„ËϤ˜) ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙÔ˘˜ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ** LEE INDEX (IA).

• ∂¤Ì‚·ÛË ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ • πÛÙÔÚÈÎfi ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ • πÛÙÔÚÈÎfi Û˘ÌÊÔÚËÙÈ΋˜ ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ • πÛÙÔÚÈÎfi ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ • πÛÙÔÚÈÎfi ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË • πÛÙÔÚÈÎfi ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ (ÎÚ·ÙÈÓ›ÓË > 2mg% ¶ÔÛÔÛÙ¿ ÂÌÊ¿ÓÈÛ˘ (%) Ì›˙ÔÓˆÓ Î·Ú‰È·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ (·ÚÈıÌfi˜ ·Ú·ÁfiÓÙˆÓ) 0: 0.4 , 1: 0.9, 2: 7, >3: 11.

92

¢. ∂∫∫§∏™π∞ƒÃ√™

‰·˜ ÚÔ¤¯ÂÈ Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ Î·È Ë Â·Ó·ÍÈÔÏfiÁËÛ‹ ÙÔ˘˜1,4: • ·ÛÙ·ı‹ ÛÙÂÊ·ÓÈ·›· Û‡Ó‰ÚÔÌ· • ÌË ·ÓÙÈÚÔÔ‡ÌÂÓË Î·Ú‰È·Î‹ ·ÓÂ¿ÚÎÂÈ· • ÛÔ‚·Ú¤˜ ·ÚÚ˘ı̛˜ • ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ‚·Ï‚ȉÔ¿ıÂȘ • Û˘ÌÊÔÚËÙÈ΋ ηډȷ΋ ·ÓÂ¿ÚÎÂÈ· • ÈÛÙÔÚÈÎfi ·ÁÁÂÈ·ÎÔ‡ ÂÁηʷÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ • ÈÛÙÔÚÈÎfi ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË • ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· (ÎÚ·ÙÈÓ›ÓË > 2 mg%). ∏ ¯Ú‹ÛË ÙÔ˘ BNP (IIa/B) Î·È ¿ÏÏˆÓ ‚ÈÔ‰ÂÈÎÙÒÓ (III/C) Û‡Ìʈӷ Ì ÙȘ ˘¿Ú¯Ô˘Û˜ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ ÁÈ· Û·Ó ·ÓÂÍ¿ÚÙËÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ì›˙ÔÓˆÓ Î·Ú‰È·ÎÒÓ ÁÂÁÔÓfiÙˆÓ ÛÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ Î·È fi„ÈÌË ÂÚ›Ô‰Ô ‰Â Û˘ÓÈÛٿٷÈ4. øÛÙfiÛÔ Û ÔÚÈṲ̂Ó˜ ÌÂϤÙ˜, ÌÂÙÂÁ¯ÂÈÚËÙÈο Â›‰· μ¡ƒ >391 pg/ml Û˘Ó‰¤ÔÓÙ·È Ì ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿ ıÓËÛÈÌfiÙËÙ·˜ Î·È ÂÌÊ¿ÓÈÛ˘ ‰È·ÛÙÔÏÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜. ™ËÌ·ÓÙÈ΋ Â›Ó·È Â›Û˘ Ë Û¯¤ÛË ÙÔ˘ ‰Â›ÎÙË MELD Î·È ÙˆÓ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÒÓ ÙÈÌÒÓ ÙÔ˘ μ¡ƒ. OÈ ·ÛıÂÓ›˜ ÚÔÂÁ¯ÂÈÚËÙÈο ‰ÂÓ ·ÚÔ˘Û›·˙·Ó ÛËÌ›· ηډȷ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ¿ÌÂÛ· ÌÂÙÂÁ¯ÂÈÚËÙÈο ‰ÂÓ ÂÌÊ¿ÓÈÛ·Ó ÔÍ›· ·fiÚÚÈ„Ë ‹ Ì›˙ÔÓ· ηډȷο Û˘Ì‚¿ÓÙ·5-7. ∞fi ÛÙÂÊ·ÓÈÔÁÚ·ÊÈΤ˜ ÌÂϤÙ˜ Û ÔÛÔÛÙfi 5-26% ÙˆÓ ˘Ô„‹ÊÈˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛıÂÓÒÓ ˘¿Ú¯ÂÈ ÌÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÛËÌ·ÓÙÈ΋ ÛÙ¤ÓˆÛË ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ. ∞fi ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ 50% ı· Âı¿ÓÔ˘Ó ÛÙËÓ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô ÏfiÁˆ ÛÔ‚·ÚÒÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ, ·ÚÈıÌfi˜ ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi ÙÔ 10% ıÓËÛÈÌfiÙËÙ· ÙˆÓ ¿ÏÏˆÓ ÔÌ¿‰ˆÓ ·ÛıÂÓÒÓ. ∫·ıÔÚÈÛÙÈÎfi˜ Â›Ó·È Ô ÚfiÏÔ˜ ·ÚÓËÙÈ΋˜ DSE, ÌÈ· Î·È ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο Ë Èı·ÓfiÙËÙ· ‡·Ú͢ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘. ∂›Ó·È Â›Û˘ ÁÓˆÛÙfi fiÙÈ ÂÚÈÂÁ¯ÂÈÚËÙÈο ÌÔÚ› Ó· Û˘Ì‚Â› ¤ÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘ Î·È Û ·ÚÔ˘Û›· ÛÙ¤ÓˆÛ˘ 30%. ¢˘ÛÙ˘¯Ò˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÎfiÌË ·Ô‰ÂÎÙ¿ ÎÚÈÙ‹ÚÈ· ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ·ÛıÂÓÒÓ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÌÈ· Î·È ·ÚÈıÌfi˜ ÙˆÓ ÌÂÏÂÙÒÓ Ô˘ Û¯ÂÙ›˙Ô˘Ó ·ÚÂÌ‚¿ÛÂȘ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ Â›Ó·È Ôχ ÌÈÎÚfi˜*** 8.

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13. Thielmann M, et al. Risk prediction and outcomes in patients with liver cirrhosis undergoing open-heart surgery. European Journal of Cardio-thoracic Surgery.

2010; 38: 592-599.

*** ¶ÚfiÛÊ·ÙË ÌÂϤÙË Ë ÔÔ›· Û˘ÌÂÚȤϷ‚ 59 ·ÛıÂÓ›˜ ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1998-2008 ¤‰ÂÈÍ fiÙÈ ·ÛıÂÓ›˜ Ì MELD score >13.5 Ë ÂÈ‚›ˆÛË ÙÔÓ ÚÒÙÔ Î·È ¤ÌÙÔ ¯ÚfiÓÔ ‹Ù·Ó 23,8% Û˘ÁÎÚÈÓfiÌÂÓË Ì 74,6% Î·È 52,1% ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì score <13,5 (13).

“AÓÙÈÌÂÙÒÈÛË Ù˘ Ì·˙È΋˜ ·ÈÌÔÚÚ·Á›·˜ ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜” °. ªÔ‡ÙÛÈ·ÓÔ˜

Ó·È ÂÌÊ·Ó¤˜ ·Ó ÂÍÂÙ¿ÛÔ˘Ì ·Ó·‰ÚÔÌÈο ÙÔÓ fiÁÎÔ ·ÒÏÂÈ·˜ ·›Ì·ÙÔ˜ ÛÙ· ·Ú¯Èο ‚‹Ì·Ù· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ηٿ ÙË ‰ÂηÂÙ›· ÙÔ˘ ‘80 Ì ÙȘ ›ÎÔÛÈ (20), ηٿ ̤ÛÔ fiÚÔ, ÌÂÙ·ÁÁÈ˙fiÌÂÓ˜ ÌÔÓ¿‰Â˜ ·›Ì·ÙÔ˜ ˆ˜ ÙȘ ̤Ú˜ Ì·˜, fiÔ˘ Û ÔÏÏ¿ ÌÂÙ·ÌÔÛ¯Â˘ÙÈο ΤÓÙÚ· ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·ÛıÂÓÒÓ ‰ÂÓ ÌÂÙ·ÁÁ›˙ÂÙ·È Î·Ó7, ÂÓÒ ÂÓ‰ÂÈÎÙÈÎfi Ù˘ ÚÔfi‰Ô˘ Ô˘ ¤¯ÂÈ ÂÈÙÂÏÂÛÙ› ÛÙÔÓ ÙÔ̤· ·˘Ùfi Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ Ù˘ Ú·ÁÌ·ÙÔÔ›ËÛ˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ·ÎfiÌË Î·È Û ̿ÚÙ˘Ú˜ ÙÔ˘ π¯ˆ‚¿.10 ¶·ÚfiÏ· ·˘Ù¿, ÌÔÚ› ·ÎfiÌË Î·È Û‹ÌÂÚ· Ë ·ÈÌÔÚÚ·Á›· ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ·›Ì·ÙÔ˜ Ó· ÚÔÛÏ¿‚ÂÈ Ì·˙ÈÎfi ˆ˜ ηٷÎÏ˘ÛÌÈ·›Ô ¯·Ú·ÎÙ‹Ú·. ∏ ÔÏ˘ÏÔÎfiÙËÙ· Î·È Ô ˘„ËÏfi˜ ‚·ıÌfi˜ ··ÈÙ‹ÛÂˆÓ Î·È Ù¯ÓÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÙˆÓ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ, ÙÔ ÂÈ‚·Ú˘Ì¤ÓÔ Î·È ·ÛÙ·ı¤˜ ËÎÙÈÎfi ˘fiÛÙڈ̷ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÏfiÁˆ Ù˘ ÚÔ¸¿Ú¯Ô˘Û·˜ Ë·ÙÔ¿ıÂÈ·˜, ÙÔ ÂÈÛʷϤ˜ Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Ë ÏËıÒÚ· ÙˆÓ ÂÍÂÏÈÛÛfiÌÂÓˆÓ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ÌÂÙ·‚ÔÏÒÓ ÛÙÔ ÂËÚ·Ṳ̂ÓÔ ·fi ÙËÓ Ë·ÙÔ¿ıÂÈ· ˘fiÛÙڈ̷ ÙÔ˘ ·ÛıÂÓÔ‡˜ ηıÈÛÙÔ‡Ó ‰˘ÛÙ˘¯Ò˜ ‰˘Ó·Ù‹ ÙËÓ ÂͤÏÈÍË ·˘Ù‹. ∞Ó Î·È Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È ÌÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ Â¤Ì‚·ÛË Ì ÛËÌ·ÓÙÈΘ ȉȷÈÙÂÚfiÙËÙ˜, Ë ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ì·˙È΋˜ ·ÈÌÔÚÚ·Á›·˜ ηٷ ÙË ‰È¿ÚÎÂÈ· Ù˘, ÛÙËÚ›˙ÂÙ·È ÛÙȘ ‚·ÛÈΤ˜ ·Ú¯¤˜ Ô˘ ÈÛ¯‡Ô˘Ó ÁÂÓÈο, Ï·Ì‚¿ÓÔÓÙ·˜ ‚¤‚·È· ˘fi„Ë Î·È Ù· ȉȷ›ÙÂÚ· ÁÓˆÚÈÛÌ·Ù· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜. ∂Í¿ÏÏÔ˘, ÔÏϤ˜ ·fi ÙȘ ıÂÚ·¢ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ Ô˘ ÚÔÙ›ÓÔÓÙ·È Î·È ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ¤¯Ô˘Ó ÙÂÎÌËÚȈı› Î·È ¤¯Ô˘Ó ÚÔ¤ÏıÂÈ Î·È ·fi ¿ÏÏ· ¯ÂÈÚÔ˘ÚÁÈο ‰›· fiˆ˜ ·˘Ùfi Ù˘ ÙÚ·˘Ì·ÙÔÏÔÁ›·˜, Ù˘ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ΋˜ ‹ Ù˘ Ì·È¢ÙÈ΋˜ ·ÈÌÔÚÚ·Á›·˜.11 ∞fi ÙË ÛÙÈÁÌ‹, ÏÔÈfiÓ, Ô˘ Ë ·ÈÌÔÚÚ·Á›· ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÚÔÛÏ¿‚ÂÈ Ì·˙ÈÎfi ¯·Ú·ÎÙ‹Ú· Ë ·ÓÙÈÌÂÙÒÈÛË Û˘Ó›ÛÙ·Ù·È ÚÔÊ·ÓÒ˜ ÛÙËÓ ·Ó·Ï‹ÚˆÛË ÙˆÓ ·ˆÏÂÈÒÓ Ì ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ ÔÌfiÏÔÁÔ˘ ‹/Î·È ·˘ÙfiÏÔÁÔ˘, ÛÙËÓ ÂÚ›ÙˆÛË

∏ ·ÈÌÔÚÚ·Á›· ˘‹ÚÍ ¿ÓÙÔÙ ¤Ó· ·fi Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù· ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ÂÍ·ÎÔÏÔ˘ı› ·ÎfiÌË Ó· ·ÔÙÂÏ› ÌÈ· ·fi ÙȘ ‚·ÛÈÎfiÙÂÚ˜ ·Èٛ˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÌÂÙ¿ ·fi ·˘Ù‹,1 ·Ó Î·È Û¿ÓÈ·, ϤÔÓ, ‰ÈÂÁ¯ÂÈÚËÙÈÎÔ‡ ı·Ó¿ÙÔ˘. ∏ ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› ˆ˜ ‰Â›ÎÙ˘ ·ÚÓËÙÈ΋˜ ¤Î‚·Û˘ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, οÙÈ Ô˘ ¤¯ÂÈ ‚ÚÂı› Î·È ÁÈ· ¿ÏÏ· ›‰Ë ¯ÂÈÚÔ˘ÚÁÈ΋˜,2,3 ÂÓÒ ˆ˜ ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙȘ ·Ó¿ÁΘ Û ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ Â¯Ô‡Ó ÂÍÂÙ·Ûı› Î·È Î·Ù·‰Âȯı›, Ì ¿ÏÏÔÙ ¿ÏÏÔ ‚·ıÌfi ‚‚·ÈfiÙËÙ·˜, ÌÈ· ÏËıÒÚ· Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ Ï‹ÙË, ÙËÓ ÔÈfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ Î·È ÙË ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ˘ÔÛÙ‹ÚÈÍË – ·Ó·ÈÛıËÛ›·.4,5 °È· ÙÔ ÏfiÁÔ ·˘Ùfi ¤¯Ô˘Ó ηٷ‚ÏËı› ÛËÌ·ÓÙÈΤ˜ ÚÔÛ¿ıÂȘ ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·ÈÌÔÚÚ·Á›·˜ Î·È ÙËÓ ÂÏ¿ÙÙˆÛË ÙˆÓ ··ÈÙ‹ÛÂˆÓ Û ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ ÙfiÛÔ ·fi ÙËÓ ÏÂ˘Ú¿ Ù˘ ÂÁ¯ÂÈÚËÙÈ΋˜ Ù¯ÓÈ΋˜ (ÂÊ·ÚÌÔÁ‹ Ù¯ÓÈ΋˜ piggyback, ¯Ú‹ÛË ·ÈÌÔÛÙ·ÙÈÎÒÓ ˘ÏÈÎÒÓ, ¯Ú‹ÛË ‰È·ıÂÚÌ›·˜ argon)6 fiÛÔ Î·È ·fi ÙËÓ ÏÂ˘Ú¿ Ù˘ ÂÚÈÂÁ¯ÂÈÚËÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ô̤ÓÔ˘ ·ÛıÂÓÔ‡˜ (·ÔÊ˘Á‹ ÂÓıÔ˘ÛÈÒ‰Ô˘˜ ÌÂÙ¿ÁÁÈÛ˘ ˘ÁÚÒÓ Î·È ·Ú·ÁÒÁˆÓ ·›Ì·ÙÔ˜ Ì ÛÙfi¯Ô ‰È·Ù‹ÚËÛË Û¯ÂÙÈο ¯·ÌËÏˆÓ ÙÈÌÒÓ ÎÂÓÙÚÈ΋˜ ÊÏ‚È΋˜ ›ÂÛ˘, ȉȷ›ÙÂÚ· ηٿ ÙË Ê¿ÛË Ù˘ Ë·ÙÂÎÙÔÌ‹˜,7 ¯Ú‹ÛË ÛÏ·¯ÓÈÎÒÓ ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ fiˆ˜ Ë ·ÁÁÂÈÔÙÂÓÛ›ÓË, ˘ÈÔı¤ÙËÛË ¯·ÌËÏfiÙÂÚˆÓ ÙÈÌÒÓ ·ÈÌÔÛÊ·ÈÚ›Ó˘ ˆ˜ ‰Â›ÎÙ˜ ¤Ó·Ú͢ ÌÂÙ¿ÁÁÈÛ˘, ¯Ú‹ÛË ·ÓÙÈÈÓˆ‰ÔÏ˘ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ,8 ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÛˆÛÙ‹˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ Ë͈˜ Ì ÙËÓ ·ÔÊ˘Á‹ ‰˘ÛÌÂÓÒÓ ·Ú·ÁfiÓÙˆÓ fiˆ˜ Ë ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË, Ë ˘ÔıÂÚÌ›· Î·È Ë ˘·Û‚ÂÛÙÈ·ÈÌ›·, ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ‹Íˆ˜ Ì ‚¿ÛË ÎÏÈÓÈÎÔ‡˜ ηÈ/Ë ÂÚÈÛÛfiÙÂÚÔ ÛÊ·ÈÚÈÎÔ‡˜ ‰Â›ÎÙ˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘, fiˆ˜ Ë ıÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ·Ê›·9 Î·È fi¯È Ì ‚¿ÛË ÂÈ̤ÚÔ˘˜ ÂÚÁ·ÛÙËÚÈ·ÎÔ‡˜ ‰Â›ÎÙ˜). ΔÔ ·ÔÙ¤ÏÂÛÌ· ÙˆÓ ÚÔÛ·ıÂÈÒÓ ·˘ÙÒÓ Â›-

93

94

°. ª√ÀΔ™π∞¡√™

Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û˘Û΢‹ ·˘ÙÔÌÂÙ¿ÁÁÈÛ˘, ËÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ·ÈÌÔÂÙ·Ï›ˆÓ Ì ÛÙfi¯Ô Û˘ÁÎÂÎÚÈ̤Ó˜ ÙÈ̤˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘, ¯ÚfiÓˆÓ ËÎÙÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ‹ ıÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ·Ê›·˜, ÈÓˆ‰ÔÁfiÓÔ˘ Î·È ·ÈÌÔÂÙ·Ï›ˆÓ. OÈ ÙÈ̤˜ ÛÙfi¯ÔÈ Ô˘ ÁÂÓÈο ·Ó·Ê¤ÚÔÓÙ·È Â›Ó·È Hb >7 g/dl, ·ÈÌÔÂÙ¿ÏÈ· >50.000 /ml, aPTT <1.5 x ·ÓÒÙÂÚÔ fiÚÈÔ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ‡ÚÔ˘˜ ÙÈÌÒÓ Î·È ÈÓˆ‰ÔÁfiÓÔ >100 mg/ml.11 Δ·˘Ùfi¯ÚÔÓ· ÂȉÈÒÎÂÙ·È Ë ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÛˆÛÙ‹˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Ì ÙËÓ ·ÔÊ˘Á‹ Ù˘ ˘ÔıÂÚÌÈ·˜, Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ÔͤˆÛ˘ Î·È Ù˘ ˘·Û‚ÂÛÙÈ·ÈÌ›·˜. ∫·Ù·‚¿ÏÏÂÙ·È, Ê˘ÛÈο, ÚÔÛ¿ıÂÈ· ·ÔÎÏÂÈÛÌÔ‡ ÙÔ˘ ÂӉ¯Ô̤ÓÔ˘ Ì·ÎÚÔ·ÁÁÂȷ΋˜ ·ÈÌÔÚÚ·Á›·˜ Ì ÂÓ‰Âϯ‹ ¯ÂÈÚÔ˘ÚÁÈÎfi ¤ÏÂÁ¯Ô ÁÈ· οÔÈÔ ÂÌÊ·Ó¤˜ ÛËÌÂ›Ô ·ÈÌÔÚÚ·Á›·˜ ÛÙÔ ÂÎÙÂٷ̤ÓÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ‰›Ô. ™ÙÔȯ›· ·fi ÙË ıÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ·Ê›· ı· ηٷ‰Â›ÍÔ˘Ó ·ıÔÏÔÁÈο ÛÙÔȯ›· ÛÙË ‰È·‰Èηۛ· Ù˘ ‹Í˘ fiˆ˜ Ë ·ıÔÏÔÁÈ΋ ÈÓˆ‰fiÏ˘ÛË,12 Ô˘ ı· Û˘ÓËÁÔÚ‹ÛÂÈ ÁÈ· ÙË ¯Ú‹ÛË ·ÓÙÈÈÓˆ‰ÔÏ˘ÙÈÎÒÓ ·Ú·ÁÒÁˆÓ ‹ Ë Î˘ÎÏÔÊÔÚ›· Ë·ÚÈÓÔÂȉÒÓ Ô˘ ı· ··ÈÙ‹ÛÂÈ ÙË ¯Ú‹ÛË ÚˆÙ·Ì›Ó˘.13 °È· ÙËÓ ˘ÔÛÙ‹ÚÈÍË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÌÔÚ› Ó· ¯ÔÚËÁËı› ‰ÂÛÌÔÚÂÛÛ›ÓË ÂÓÒ Ë ¯Ú‹ÛË ÙÔ˘ ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˘ ·Ú¿ÁÔÓÙ· VII ·Ó Î·È fi¯È ·fiÏ˘Ù· ·ԉ‰ÂÈÁ̤Ó˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Î·Ï‡ÙÂÚÔ Ó· Á›ÓÂÙ·È ÓˆÚ›ÙÂÚ· ·Ú¿ ·ÚÁfiÙÂÚ· ÁÈ· Ó· ˘¿Ú¯Ô˘Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ÂÈÙ˘¯›·˜.14-16 π‰È·›ÙÂÚ· ÚÔ‚ÏËÌ·ÙÈÎfi ÛÙÔÈ¯Â›Ô ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ì·˙È΋˜ ·ÈÌÔÚÚ·Á›·˜ ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÔÙÂÏ› Ë ‰È·¯Â›ÚÈÛË ÙÔ˘ ÌÂÙ·ÁÁÈ˙fiÌÂÓÔ˘ fiÁÎÔ˘, ȉȷ›ÙÂÚ· ÙˆÓ ËÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, ηıÒ˜ Â›Ó·È Èı·Ófi Ó· ÚÔÎÏËı› Û¯ÂÙÈ΋ ‹ ·fiÏ˘ÙË Î˘ÎÏÔÊÔÚÈ΋ ˘ÂÚÊfiÚÙˆÛË, ȉȷÈÙÂÚ· ÛÙË ‰ÂÍÈ¿ ΢ÎÏÔÊÔÚ›·, Ì ‰˘ÛÌÂÓ‹ ·ÔÙÂϤÛÌ·Ù· ÛÙË ÊÏ‚È΋ ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È Û˘ÓÔ‰fi Ë·ÙÈ΋ ‰˘ÛÚ·Á›· Ô˘ ı· ÂÈÙ›ÓÂÈ ÙËÓ ·ÈÌÔÚÚ·Á›·. °È· ÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ·˘ÙÔ‡ ¯ÂÈ ÚÔÙ·ı› Ë ¯Ú‹ÛË Û˘ÌÏfiÎˆÓ ·Ú·ÁfiÓÙˆÓ ÚÔıÚÔÌ‚›Ó˘ (prothrombin complex concentrate) Ì fiÁÎÔ ¯ÔÚ‹ÁËÛ˘ ÌÈÎÚfiÙÂÚÔ ÙÔ˘ ÊÚ¤ÛÎÔ˘ ηÙ„˘Á̤ÓÔ˘ Ï¿ÛÌ·ÙÔ˜.17,18 ŒÓ· ¿ÏÏÔ ÚÔ˜ Èı·Ó‹ ÎÏÈÓÈ΋ ‰ÈÂÚ‡ÓÈÛË ÂӉ¯fiÌÂÓÔ Î·Ù¿ ÙËÓ ·ÈÌÔÚÚ·Á›· ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Â›Ó·È Ë ¯Ú‹ÛË Û˘Ì˘ÎÓÒÌ·ÙÔ˜ ÈÓˆ‰ÔÁfiÓÔ˘ (fibrinogen concentrate) ÁÈ· ÙËÓ Â›Ù¢ÍË ˘ÂÚÊ˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÈÓˆ‰ÔÁfiÓÔ˘ Ô˘ ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÂÈÒÓÔ˘Ó ÙËÓ ·ÈÌÔÚÚ·Á›· ÛÙËÓ Î·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋.19

∂Í›ÛÔ˘ ÛËÌ·ÓÙÈ΋ Ì ÙËÓ ·ÔÊ˘Á‹ Ù˘ ˘ÂÚÊfiÚÙˆÛ˘ Ì fiÁÎÔ Â›Ó·È Ê˘ÛÈο Î·È Ë ·ÔÊ˘Á‹ Ù˘ ˘ÔÔÁηÈÌ›·˜ Ì ÙËÓ È‰·›ÙÂÚ· ‰˘ÛÌÂÓ‹ Â›‰Ú·ÛË Ù˘ ÛÙËÓ Â˘¿ÏˆÙÙË, ÏfiÁˆ ÙˆÓ ÛÏ·¯ÓÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ Î·È ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ ÂȉڿÛÂˆÓ Ù˘ ΛÚÚˆÛ˘, ÓÂÊÚÈ΋ ¿Ú‰Â˘ÛË Î·È ÙË Û˘¯Ó¿ ÂÈ‚·Ú˘Ì¤ÓË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›·.20 Δ¤ÏÔ˜ ̤¯ÚÈ Ó· ÂÈÙ¢¯ı› ÓÔÚÌÔÔÁηÈÌ›· ‹ Ó· ·ÚÂÏıÔ˘Ó Ù˘¯fiÓ ‰˘ÛÌÂÓ›˜ ÂÈÙÒÛÂȘ Ù˘ ÈÛÙÈ΋˜ ˘ÔÍ›·˜ ÛÙÔ Ì˘ÔοډÈÔ ÌÔÚ› Ó· ··ÈÙËı› Ê·ÚÌ·ÎÔÏÔÁÈ΋ ˘ÔÛÙ‹ÚÈÍË, ÁÈ· οÔÈÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÌÂ Û˘Ó‰˘·ÛÌfi ÈÓÔÙÚfiˆÓ Î·È ·ÁÁÂÈÔÛ˘Û·ÛÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. º˘ÛÈο ‰ÂÓ Ú¤ÂÈ Ó· ͯӿ ηÓ›˜ fiÙÈ Î·È Ë ›‰È· Ë Ì·˙È΋ ÌÂÙ¿ÁÁÈÛË Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ì·˙È΋˜ ·ÈÌÔÚÚ·Á›·˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛËÌ·ÓÙÈο ÚÔ‚Ï‹Ì·Ù· Ù· ÔÔ›· ¯Ú‹˙Ô˘Ó ·ÓÙÈÌÂÙÒÈÛ˘. ∂ÈÁÚ·ÌÌ·ÙÈο ·Ó·Ê¤ÚÔ˘Ì ÙËÓ ˘·Û‚ÂÛÙÈ·ÈÌ›·, ÙËÓ ÙÔÍÈÎfiÙËÙ· ·fi ÎÈÙÚÈÎfi Î·È ÙËÓ ˘ÔÌ·ÁÓËÛÈ·Ì›·, ÙËÓ ˘ÂÚηÏÈ·ÈÌ›· ·Ú¯Èο Î·È ÙËÓ ˘ÔηÏÈ·ÈÌ›· ·ÚÁfiÙÂÚ·, ÙȘ ‰È·Ù·Ú·¯¤˜ Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜ - ΢ڛˆ˜ ÌÂÙ·‚ÔÏÈ΋ ·ÏοψÛË ÏÔÁˆ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ÎÈÙÚÈÎÔ‡ Û ‰ÈÙÙ·ÓıÚ·ÎÈÎfi, ÙËÓ ˘ÔıÂÚÌ›· ÌÂ Û˘ÓÔ‰Ô ÌÂÙ·‚ÔÏÈ΋ ÔͤˆÛË Î·È ÈÛÙÈ΋ ˘ÔÍ›· Î·È ÙËÓ ÌÈÎÚÔ·ÁÁÂȷ΋ ÈÛ¯·ÈÌ›· ÏfiÁˆ Ù˘ ‰È·Ù·Ú·Á̤Ó˘ Ï·ÛÙÈÎfiÙËÙ·˜ ÙˆÓ ÌÂÙ·ÁÁÈ˙fiÌÂÓˆÓ ÂÚ˘ıÚÒÓ. ∞ÒÙÂÚ˜ Î·È ÈÔ Â˘Ú›˜ ÂÈÏÔΤ˜ ·ÔÙÂÏÔ‡Ó Ë ·ÓÔÛÔηٷÛÙÔÏ‹, Ë ·ÓÔÛÔÙÚÔÔÔÈ‹ÛË, Ë Û‹„Ë Î·È ÔÈ ÂÈÏÔΤ˜ ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi fiˆ˜ ÙÔ Û‡Ó‰ÚÔÌÔ TRALI (Transfusion Related Lung Injury) ‹ ÙÔ ™‡Ó‰ÚÔÌÔ OÍ›·˜ ∞Ó·Ó¢ÛÙÈ΋˜ ¢˘Û¯¤ÚÂÈ·˜ (ARDS).21,22

μÈ‚ÏÈÔÁÚ·Ê›· 1. Lopez-Plaza I. Transfusion guidelines and liver transplantation: time for consensus. Liver Transpl 2007; 13: 1630-2.

2. de Boer MT, Molenaar IQ, Hendriks et al. Minimizing blood loss in liver transplantation: progress through research and techniques. Dig Surg 2005; 22: 265-75.

3. Massicotte L, Sassine MP, Lenis S et al. Survival rate changes with transfusion of blood products during liver transplantation.Can J Anaesth. 2005; 52(2): 148-55.

4. McCluskey SA, Karkouti K et al. Derivation of a risk index for the prediction of massive blood transfusion in liver transplantation. Liver Transpl. 2006; 12(11): 1584-93.

5. Steib A, Freys G, Lehmann C et al. Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict. Can J Anaesth. 2001; 48(11): 1075-9.

6. Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava.

METAMO™XEY™Eπ™ 2011

Ann Surg. 1989; 210(5): 649-52.

7. Massicotte L, Lenis S, Thibeault L et al. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl. 2006; 12(1): 117-23.

8. Xia VW, Steadman RH. Antifibrinolytics in orthotopic liver transplantation: current status and controversies.

Liver Transpl. 2005; 11(1): 10-8.

9. Kang Y. Thromboelastography in liver transplantation.

Semin Thromb Hemost. 1995; 21 Suppl 4: 34-44.

10. Jabbour N, Gagandeep S, Mateo R et al. Transfusion free surgery: single institution experience of 27 consecutive liver transplants in Jehovah’s Witnesses. J Am Coll Surg.

2005; 201(3): 412-7.

11. Shaz BH, Dente CJ, Harris RS et al. Transfusion management of trauma patients. Anesth Analg. 2009; 108(6): 1760-8.

12. Ozier Y, Steib A, Ickx B et al. Haemostatic disorders during liver transplantation.Eur J Anaesthesiol. 2001; 18(4): 208-18.

13. Bayly PJ, Thick M. Reversal of post-reperfusion coagulopathy by protamine sulphate in orthotopic liver transplantation. Br J Anaesth. 1994; 73(6): 840-2.

14. da Silva Viana J. Recombinant factor VIIa in major abdominal surgery and liver transplantation. Transplant Proc. 2006; 38(3): 818-9.

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15. Vincent JL, Rossaint R, Riou B et al. Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding – A European perspective. Crit Care 2006; R120.

16. Welsh A, McLintock C, Gatt S et al. Guidelines for the use of recombinant activated factor VII in massive obstetric haemorrhage. Aust N Z J Obstet Gynaecol.

2008; 48(1): 12-6.

17. Böhrer H. Prothrombin complex concentrate substitution during liver transplantation. Thromb Res. 999 15; 95(4 Suppl 1): S71-4.

18. Schöchl H, Nienaber U, Hofer G et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care. 2010; 14(2): R55.

19. Rahe-Meyer N, Pichlmaier M, Haverich A et al. Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study. Br. J. Anaesth. 2009; 102(6): 785-792.

20. Olteanu D, Lupu D. The kidney in cirrhosis with portal hypertension. J Med Life. 2010; 3(2): 175-7.

21. Collins JA. Problems associated with the massive transfusion of stored blood. Surgery. 1974; 75(2): 274-95.

22. Devi AS. Transfusion practice in orthotopic liver transplantation. Indian J Crit Care Med. 2009; 13(3): 120-8.

™Ô‚·Ú‹ ˘ÔÓ·ÙÚÈ·ÈÌ›· Î·È ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ· ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ∞. ∫·Ú··Ó·ÁÈÒÙÔ˘

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ÚˆÛ˘ Î·È ·Ó·Ê¤ÚÂÙ·È ·Ó·Ï˘ÙÈο ·Ú·Î¿Ùˆ. ™Â ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË7Ô˘ Û˘ÌÂÚȤϷ‚ 997 ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÛÔ‚·Ú‹ ˘ÔÓ·ÙÚÈ·ÈÌ›· (Na <130 mEq/l) ηٷÁÚ¿ÊËΠÛÙÔ ÙÔ 21,6%, ÛÙÔ 49,4% Ù· Â›‰· ÙÔ˘ NaÎ˘Ì·›ÓÔÓÙ·Ó ·fi 130135 mEq/l, ÛÙÔ 5,7% Na <125 mEq/l Î·È ÛÙÔ 1,2% Na <120 mEq/l. Δ· ¯·ÌËÏ¿ Â›‰· Na‚Ú¤ıËÎ·Ó ÛÙÔ 57% ÙˆÓ ÓÔÛËÏ¢ÔÌ¤ÓˆÓ ·ÏÏ¿ Î·È ÛÙÔ 40% ÙˆÓ Â͈ÓÔÛÔÎÔÌÂÈ·ÎÒÓ ·ÚÚÒÛÙˆÓ.

∏ ˘ÔÓ·ÙÚÈ·ÈÌ›· Â›Ó·È Û˘¯Ófi ‡ÚËÌ· ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Î·È ÔÊ›ÏÂÙ·È Û ‰È·Ù·Ú·¯‹ Ù˘ ÔÌÔÈÔÛÙ·Û›·˜ ÙˆÓ ˘ÁÚÒÓ1. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÙÔÓ›˙Ô˘Ó ÙÔÓ Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ Î·È ÙËÓ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ ˘ÔÓ·ÙÚ·ÈÌ›·˜ ÛÙËÓ ÚÔÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋2,3,4·ÏÏ¿ Î·È ÙËÓ ÌÂÙ·ÌÔÛ¯Â˘ÙÈ΋5ÂÚ›Ô‰Ô. ∏ ·ıÔÁ¤ÓÂÛ‹ Ù˘ Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙȘ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ΛÚÚˆÛ˘ Î·È ÙÔ˘˜ Ó¢ÚÔ¯˘ÌÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ ÚÔηÏÔ‡Ó ‰È·Ù·Ú·¯‹ Ù˘ ÈηÓfiÙËÙ·˜ ·Ô‚ÔÏ‹˜ ‡‰·ÙÔ˜ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡.

¶·ıÔÁ¤ÓÂÛË ∏ ·ıÔÁ¤ÓÂÛË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ 1,8 ÛÙËÓ Î›ÚÚˆÛË Â›Ó·È ÔχÏÔÎË Î·È ÂÌϤÎÔÓÙ·È ÓÂÊÚÈÎÔ› Î·È Â͈ÓÂÊÚÈÎÔ› ·Ú¿ÁÔÓÙ˜. ™’ ·˘ÙÔ‡˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ‰ÈËı‹Ì·ÙÔ˜ ÛÙÔ ¿ˆ ÂÛÂÈڷ̤ӷ ÛˆÏËÓ¿ÚÈ·, Ë ÂÏ·Ùو̤ÓË Û‡ÓıÂÛË ÙˆÓ ÚÔÛÙ·ÁÏ·Ó‰ÈÓÒÓ Î·È Î˘Ú›ˆ˜ Ë ÌË ˆÛ̈ÙÈ΋ ¤ÎÎÚÈÛË Ù˘ ·ÓÙȉÈÔ˘ÚÈÙÈ΋˜ ÔÚÌfiÓ˘ (ADH). OÈ ·ÈÌÔ‰˘Ó·ÌÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÛÙËÓ Î›ÚÚˆÛË ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ Î·È ÙÔ˘ ·ÛΛÙË º˘ÛÈÔÏÔÁÈο Ë ˆÛ̈ÙÈÎfiÙËÙ·ÙÔ˘ ÔÚÔ‡ Î˘Ì·›ÓÂÙ·È Û ÛÙÂÓ¿ fiÚÈ·, ÒÛÙ ӷ ‰È·ÙËÚÂ›Ù·È ÙÔ ÔÏÈÎfi ∏2O ÙÔ˘ ÛÒÌ·ÙÔ˜. ∏ Ú‡ıÌÈÛË Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ Ú·ÁÌ·ÙÔÔÈÂ›Ù·È Ì¤Ûˆ ÔÌÔÈÔÛÙ·ÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Ô ÔÔ›Ô˜ ÂÍ·ÚÙ¿Ù·È ·ÊãÂÓfi˜ ÌÂÓ ·fi ÙÔ˘˜ ˆÛ̈˘ԉԯ›˜ ÙÔ˘ ˘Ôı·Ï¿ÌÔ˘ Ô˘ ·ÓȯÓÂ‡Ô˘Ó ÙËÓ ‰È·Ù·Ú·¯‹ Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ ·Ê’ ÂÙ¤ÚÔ˘ ·fi ÙËÓ ÎÈÓËÙÔÔ›ËÛË ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ Ì˯·ÓÈÛÌÔ‡ ÛÙ· ·ıÚÔÈÛÙÈο ÛˆÏËÓ¿ÚÈ· ÙˆÓ ÓÂÊÚÒÓ Ô˘ ÂÈÙÚ¤Ô˘Ó ÙËÓ Â·Ó·ÚÚfiÊËÛË ÂχıÂÚÔ˘ ‡‰·ÙÔ˜. ™Â ·‡ÍËÛË Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ ·ÂÏ¢ıÂÚÒÓÂÙ·È Ë ·ÓÙȉÈÔ˘ÚËÙÈ΋ ÔÚÌfiÓË (ADH ‹ ‚·˙ÔÚÂÛÛ›ÓË) Ë ÔÔ›· Û˘Ó‰¤ÂÙ·È ÛÙÔ˘˜ ˘ԉԯ›˜ Ù‡Ô˘ 2 Ù˘ ‚·˙ÔÚÂÛÛ›Ó˘ (V) Ô˘ ‰ڿ˙ÔÓÙ·È ÛÙ· ·ıÚÔÈÛÙÈο ÛˆÏËÓ¿ÚÈ·, ÂÓÂÚÁÔÔÈ› ÙÔ˘˜ ‰È·‡ÏÔ˘˜ ‡‰·ÙÔ˜ (aquqporinchannels) Î·È Ô‰ËÁ› Û Â·Ó·ÚÚfiÊËÛË ÙÔ˘ ÓÂÚÔ‡. ∞ÓÙ›ıÂÙ· ÛÙËÓ ÙÒÛË Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ ÂÏ·ÙÙÒÓÂÙ·È Ë ·ÂÏ¢ı¤ÚˆÛË Ù˘ ADHÔÈ ‰›·˘ÏÔÈ ‡‰·ÙÔ˜ ÎÏ›ÓÔ˘Ó Ì ·ÔÙ¤ÏÂ-

OÚÈÛÌfi˜ ÀÔÓ·ÙÚÈ·ÈÌ›· ÛÙËÓ Î›ÚÚˆÛË ÔÚ›˙ÂÙ·È Ë ÂÏ¿ÙÙˆÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ Na ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ Û ÙÈ̤˜ ÌÈÎÚfiÙÂÚ˜ ·fi 130 mEq/l6. ™ÙËÓ ¯ÚfiÓÈ· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ¤¯Ô˘Ó ·Ó·ÊÂÚı› ‰‡Ô Ù‡ÔÈ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜1.

1) ∏ ˘Ô‚ÔÏ·ÈÌÈ΋ ˘ÔÓ·ÙÚÈ·ÈÌ›·: ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÏ·Ùو̤ÓÔ NaÔÚÔ‡ Î·È fiÁÎÔ Ï¿ÛÌ·ÙÔ˜, ·fi ·Ô˘Û›· Ôȉ‹Ì·ÙÔ˜ ‹ ·ÛΛÙË Î·È ˘¿Ú¯Ô˘Ó ÎÏÈÓÈο ÛËÌ›· ·Ê˘‰¿ÙˆÛ˘ Î·È ÚÔÓÂÊÚÈ΋˜ ·˙ˆı·ÈÌ›·˜. ∏ ˘Ô‚ÔÏ·ÈÌÈ΋ ˘ÔÓ·ÙÚÈ·ÈÌ›· ÔÊ›ÏÂÙ·È Û ÂÎÛÂÛËÌ·Ṳ̂ÓË ·ÒÏÂÈ· ÂÍˆÎ˘ÙÙ¿ÚÈˆÓ ˘ÁÚÒÓ Â›Ù ·fi ÙÔÓ Á·ÛÙÚÂÓÙÂÚÈÎfi ۈϋӷ ›Ù ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜ (·˘ÍË̤ÓË ¯ÔÚ‹ÁËÛË ‰ÈÔ˘ÚËÙÈÎÒÓ). Δ· Â›‰· ÙÔ˘ Na ·Ôηı›ÛÙ·ÓÙ·È Ì ÙÔÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ ‰ÈÔ˘ÚËÙÈÎÒÓ Î·È ÙËÓ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ.

2) ∏˘ÂÚ‚ÔÏ·ÈÌÈ΋ ‹ ˘ÔÓ·ÙÚÈ·ÈÌ›· ·fi ·Ú·›ˆÛË: ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÏ·Ùو̤ӷ Â›‰· NaÛÙÔÓ ÔÚfi, ·˘ÍË̤ÓÔ fiÁÎÔ ·›Ì·ÙÔ˜ (·Ó Î·È Ô ‰Ú·ÛÙÈÎfi˜ fiÁÎÔ˜ Ï¿ÛÌ·ÙÔ˜ Â›Ó·È ÂÏ·Ùو̤ÓÔ˜ ΢ڛˆ˜ ÏfiÁˆ Ù˘ ÛÏ·¯ÓÈ΋˜ ·ÁÁÂÈԉȷÛÙÔÏ‹˜). ∫ÏÈÓÈο ·Ó¢ڛÛÎÂÙ·È ·ÛΛÙ˘ Î·È Ô›‰ËÌ·, ¯ˆÚ›˜ ÛËÌ›· ·Ê˘‰¿ÙˆÛ˘ Î·È ÔÊ›ÏÂÙ·È Î˘Ú›ˆ˜ Û ‰È·Ù·Ú·¯‹ Ù˘ ·Ô‚ÔÏ‹˜ ‡‰·ÙÔ˜. ™ÙËÓ ÛÔ‚·Ú‹ ˘ÂÚ‚ÔÏ·ÈÌÈ΋ ˘ÔÓ·ÙÚÈ·ÈÌ›· Ù· Â›‰· Na<130 mEq/l. ∏ ‚·Ú‡ÙËÙ¿ Ù˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ ‚·ıÌfi Ù˘ ΛÚ-

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METAMO™XEY™Eπ™ 2011

ÛÌ· ÙËÓ ·Ô‚ÔÏ‹ ˘fiÙÔÓˆÓ Ô‡ÚˆÓ. ∏ ΛÚÚˆÛË9,10 Ì ÙËÓ ˘Ï·›· ˘¤ÚÙ·ÛË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÎÛÂÛËÌ·Ṳ̂ÓË ·ÁÁÂÈԉȷÛÙÔÏ‹ (΢ڛˆ˜ ÛÙËÓ ÛÏ·¯ÓÈ΋ ΢ÎÏÔÊÔÚ›·), ÛËÌ·ÓÙÈ΋ ÂÏ¿ÙÙˆÛË ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ·ÓÙÈÛÙ¿ÛÂˆÓ (SVR), Ù˘ ̤Û˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (MAP) Î·È ·‡ÍËÛË Ù˘ ηډȷ΋˜ ·ÚÔ¯‹˜ (CO). ∏ ˘fiÙ·ÛË Î·È Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ ‰Ú·ÛÙÈÎÔ‡ fiÁÎÔ˘ ·›Ì·ÙÔ˜ ̤ۈ ÙˆÓ Î·ÚˆÙȉÈÎÒÓ Î·È ÓÂÊÚÈÎÒÓ Ù·ÛÂÔ˘Ô‰Ô¯¤ˆÓ ÂÓÂÚÁÔÔÈÔ‡Ó Ó¢ÚÔ¯˘ÌÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ Ô˘ Ô‰ËÁÔ‡Ó ·Ú¯Èο ÛÙËÓ Î·Ù·ÎÚ¿ÙËÛË NaÎ·È ∏2O, ÛÙËÓ ÚÔÛ¿ıÂÈ· Ó· ·ÔηٷÛÙ·ı› Ë ›ÂÛË ‰È‹ıËÛ˘. OÈ Ì˯·ÓÈÛÌÔ› ·˘ÙÔ› ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ Û‡ÛÙËÌ· ÚÂÓ›Ó˘-·ÁÁÂÈÔÙÂÓÛ›Ó˘, ÙÔ Û˘Ì·ıËÙÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· Î·È ÙËÓ ADHÎ·È Ë ¤ÎÎÚÈÛ‹ ÙÔ˘˜ Â›Ó·È ·Ó¿ÏÔÁË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ΛÚÚˆÛ˘ Î·È Ù˘ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜. ∏ ¤ÎÎÚÈÛË Ù˘ ADH ÌÂÙ¿ ·fi ˘fiÙ·ÛË, ·Ú¿ ÙËÓ ˘Ô-ˆÛ̈ÙÈÎfiÙËÙ· ıˆÚÂ›Ù·È Ì˯·ÓÈÛÌfi˜ ÂÈ‚›ˆÛ˘: ·ÔʇÁÂÙ·È Ë Î·Ù¤ÚÚÂÈ„Ë ÙÔ˘ ΢ÎÏÔÊÔÚÈÎÔ‡ ·Ú·Î¿ÌÙÔÓÙ·˜ ÙÔÓ ÔÌÔÈÔÛÙ·ÙÈÎfi Ì˯·ÓÈÛÌfi Î·È Ô‰ËÁ› Û ηٷÎÚ¿ÙËÛË ÂχıÂÚÔ˘ ‡‰·ÙÔ˜. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Î·È ·ÛΛÙË ·Ú·ÙËÚÂ›Ù·È ÂÏ¿ÙÙˆÛË ÙÔ˘ ‰ÈËı‹Ì·ÙÔ˜10ÛÙ· ¿ˆ ÂÛÂÈڷ̤ӷ ÛˆÏËÓ¿ÚÈ· Î·È ÂÏ¿ÙÙˆÛË Ù˘ ·Ô‚ÔÏ‹˜ ÙÔ˘ ∏2O, ÏfiÁˆ ÂÏ¿ÙÙˆ-

97

Û˘ ÙÔ˘ Ú˘ıÌÔ‡ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR) ‹/Î·È Ù˘ ·˘ÍË̤Ó˘ Â·Ó·ÚÚfiÊËÛ˘ ‰È·Ï˘ÙÒÓ ÛÙ· ÂÁÁ‡˜ ÂÛÂÈڷ̤ӷ ÛˆÏËÓ¿ÚÈ·. ¶ÂÚ·ÈÙ¤Úˆ ‰È·Ù·Ú·¯‹ ÂÈʤÚÔ˘Ó Ù· ·˘ÍË̤ӷ Â›‰· Ù˘ ADHÔ˘ ·˘Í¿ÓÔ˘Ó ÙËÓ ‰È·ÂÚ·ÙfiÙËÙ· ÙÔ˘ ·ıÚÔÈÛÙÈÎÔ‡ ÛˆÏËÓ·Ú›Ô˘ ÛÙÔ ∏ 2O, ÂÓÂÚÁÔÔÈÒÓÙ·˜ ÙÔ˘˜ ‰È·‡ÏÔ˘˜ ∏2O (aquaporinchannels), ηٷϋÁÔÓÙ·˜ Û Â·Ó·ÚÚfiÊËÛË ÛËÌ·ÓÙÈÎÒÓ ÔÛÔÙ‹ÙˆÓ ∏2O Î·È ÂÏ¿ÙÙˆÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ Ô‡ÚˆÓ (EÈÎ. 1).

O ‚·ÛÈÎfi˜ ÚfiÏÔ˜ Ù˘ ADHÛÙËÓ ˘ÔÓ·ÙÚÈ·ÈÌ›· Ê·›ÓÂÙ·È ·fi Ù· ·Ú·Î¿Ùˆ11: a) Δ· Â›‰· Ù˘ ADH Â›Ó·È ·˘ÍË̤ӷ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Î·È ·ÛΛÙË Î·È Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ ‚·ıÌfi ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÂχıÂÚÔ˘ ‡‰·ÙÔ˜. b) ¶ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ÂȂ‚·ÈÒÓÔ˘Ó ÙËÓ Û¯¤ÛË ÙˆÓ ÂÈ¤‰ˆÓ Ù˘ ADHÎ·È ÙË ‰È·Î›ÓËÛË ÙÔ˘ ∏2O. ∏ ‰È·Ù·Ú·¯‹ ÛÙËÓ ·¤ÎÎÚÈÛË ÙÔ˘ ÂχıÂÚÔ˘ ∏2O ‰ÂÓ ·Ó·Ù‡ÛÛÂÙ·È Û ÔÓÙÈÎÔ‡˜ ÌÂ Û˘ÁÁÂÓ‹ ¤ÏÏÂÈ„Ë ADH (Brattlebororats). c) ™Â ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ÂȂ‚·ÈÒÓÂÙ·È Ë ‡·ÚÍË ‰È·‡ÏˆÓ ∏2O. d) ªÂ ÙËÓ ¯ÔÚ‹ÁËÛË ÙˆÓ ‚·Ù·ÓÒÓ 12 (vaptans), ÂȉÈÎÒÓ ·ÓÙ·ÁˆÓÈÛÙÒÓ ÙˆÓ V2˘Ô‰Ô¯¤ˆÓ Ù˘ ADH, ·Ôηı›ÛÙ·Ù·È ·Êã ÂÓfi˜ ÌÂÓ Ë ÈηÓfiÙËÙ· ÙˆÓ ÓÂÊÚÒÓ Ó· ·ÂÎÎÚ›ÓÔ˘Ó ∏2O ·Ê’ ÂÙ¤ÚÔ˘ ‰Â Ë Û˘ÁΤÓÙÚˆÛË NaÛ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi.

Advanced cirrhosis Portal hypertension

Decreased systemic vascular resistance ↓Effective arterial blood volume

Systemic circulation V2 receptors

Non-osmotic arginine-vasopressin hypersecretion

Kidney V2 receptors

Arterial vasoconstriction

Tubular water reabsorption

↑Arterial pressure

Solute-free water retention HYPONATREMIA

∂ÈÎ. 1. ™Â ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Ô Ì˯·ÓÈÛÌfi˜ ˘ÂÚ¤ÎÎÚÈÛ˘ Ù˘ ADH Î·È Ë Â›‰Ú·Û‹ Ù˘ ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜.

98

∞. ∫∞ƒ∞¶∞¡∞°πøΔ√À

¶ÚÔÛ·ÚÌÔÁ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÛÙËÓ ˘ÔÓ·ÙÚÈ·ÈÌ›· ΔÔ Î‡ÚÈÔ ÛÙÔÈ¯Â›Ô Ô˘ ηıÔÚ›˙ÂÈ ÙËÓ ˆÛ̈ÙÈÎfiÙËÙ· ÙÔ˘ ÂÍˆÎ˘ÙÙ¿ÚÈÔ˘ ¯ÒÚÔ˘ Â›Ó·È ÙÔ Na,ÔÈ ‰Â ·ıÔÊ˘ÛÈÔÏÔÁÈΤ˜ Û˘Ó¤ÂȘ ÙˆÓ ÌÂÙ·‚ÔÏÒÓ Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ ÙÔ˘ ÂÍˆÎ˘ÙÙ¿ÚÈÔ˘ ˘ÁÚÔ‡13Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ‰È·Î›ÓËÛË ÙÔ˘ ∏2O. ∏ ·‡ÍËÛË ÙÔ˘ Na ÙÔ˘ ÔÚÔ‡ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ÌÂٷΛÓËÛË ÙÔ˘ ∏2O ÚÔ˜ ÙÔÓ ÂÍˆÎ˘ÙÙ¿ÚÈÔ ¯ÒÚÔ Ì ÛÙfi¯Ô ÙËÓ ‰È·Ù‹ÚËÛË Ù˘ ˆÛ̈ÙÈ΋˜ ÈÛÔÚÚÔ›·˜ ÚÔηÏÒÓÙ·˜ ·Ê˘‰¿ÙˆÛË Î·È Û˘ÚÚ›ÎÓˆÛË ÙÔ˘ ΢ÙÙ¿ÚÔ˘. ∏ ˘ÔÓ·ÙÚÈ·ÈÌ›· ·ÓÙ›ıÂÙ· ÚÔηÏ› ÙËÓ ÌÂٷΛÓËÛË ∏2O ÛÙÔÓ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ ¯ÒÚÔ, Ì ·ÔÙ¤ÏÂÛÌ· ÂÓ‰Ô΢ÙÙ¿ÚÈÔ Ô›‰ËÌ·. ∏ ·‡ÍËÛË ÙÔ˘ fiÁÎÔ˘ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ·ÔÎÙ¿ ȉȷ›ÙÂÚË ÛËÌ·Û›· ÛÙÔÓ ÂÁΤʷÏÔ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ·ÚÂÌÔ‰›˙ÂÙ·È ·fi ÙÔ ÎÚ·Ó›Ô. ∏ ·Ó¿Ù˘ÍË ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÁÎÔÏ·ÛÌfi ÙÔ˘ ÛÙÂϤ¯Ô˘˜. °È’ ·˘Ùfi ÎÈÓËÙÔÔÈÔ‡ÓÙ·È ·Ì˘ÓÙÈÎÔ› Ì˯·ÓÈÛÌÔ› ÒÛÙ ӷ ÂÚÈÔÚÈÛÙ› ÙÔ Ô›‰ËÌ·. ∞̤ۈ˜ ÌÂÙ¿ ÙËÓ ·Ó¿Ù˘ÍË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜,14,15̤۷ ÛÙÔ ÚÒÙÔ 24ˆÚÔ, ·Ú·ÙËÚÂ›Ù·È Ù·¯Â›· ÌÂٷΛÓËÛË ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ, ΢ڛˆ˜ ÙÔ˘ ∫+, ÚÔηÏÒÓÙ·˜ ÌÈÎÚ‹ Ì›ˆÛË Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ ˆÛ̈ÙÈÎfiÙËÙ·˜. ∞ÎÔÏÔ˘ı› ÛÙ·‰È·Î‹ ·ÒÏÂÈ· ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ ÔÚÁ·ÓÈÎÒÓ Ô˘ÛÈÒÓ Ì ¯·ÌËÏfi ÌÔÚÈ·Îfi ‚¿ÚÔ˜, ÁÓˆÛÙÒÓ ˆ˜ ÔÚÁ·ÓÈÎÒÓ ˆÛ̈ϛˆÓ, Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙËÓ ÁÏÔ˘Ù·Ì›ÓË, ÙË ¯ÔÏ›ÓË, ÙËÓ Ù·˘Ú›ÓË Î· ÙËÓ Ì˘ÔÈÓ·ÛÈÙfiÏË Î·È ·ÔÙÂÏÔ‡Ó ÙÔ 1/3, ÂÚ›Ô˘, ÙˆÓ ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ ·ˆÏÂÈÒÓ ÛÙËÓ ¯ÚfiÓÈ· ˘ÔÓ·ÙÚÈ·ÈÌ›·. ∏ Û˘Ó‰˘·Ṳ̂ÓË ·˘Ù‹ ·ÒÏÂÈ· ËÏÂÎÙÚÔÏ˘ÙÒÓ-ˆÛ̈ϛˆÓ ·ÓÙÈÚÔÛˆ‡ÂÈ ¤Ó· ‰Ú·ÛÙÈÎfi Ì˯·ÓÈÛÌfi Ì·ÎÚÔÚfiıÂÛÌ˘ ÚÔÛ·ÚÌÔÁ‹˜ ÛÙȘ ÌÂÙ·‚ÔϤ˜ Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜. ∏ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘ ÛÙËÓ ÚfiÏË„Ë ÙÔ˘ ı·Ó·ÙËÊfiÚÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÂÍ·ÚÙ¿Ù·È ·fi ÔÏÏÔ‡˜ ·Ú¿ÁÔÓÙ˜ ΢ڛˆ˜ fï˜ ·fi ÙÔÓ Ú˘ıÌfi ÂÏ¿ÙÙˆÛ˘ Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ Na. ∏ ÚÔÛ·ÚÌÔÁ‹ Â›Ó·È ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙËÓ ¯ÚfiÓÈ· ·Ú¿ ÛÙËÓ ÔÍ›· ˘ÔÓ·ÙÚÈ·ÈÌ›·. ¶ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ·Ú¯Èο Î·È ÛÙËÓ Û˘Ó¤¯ÂÈ· ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ‰Â›¯ÓÔ˘Ó ÙËÓ ÂÏ·Ùو̤ÓË Û˘ÁΤÓÙÚˆÛË ˆÛ̈ϛˆÓ ÛÙËÓ Î›ÚÚˆÛË, ÁÂÁÔÓfi˜ Ô˘ Â›Ó·È Û Ï‹ÚË Û˘Ó¿ÊÂÈ· Ì ÙËÓ ‡·ÚÍË ÙÔ˘ ˆÛ̈-Ú˘ıÌÈÛÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. ∞Ó¿ÏÔÁ˘ ÛËÌ·Û›·˜ Â›Ó·È Î·È ÔÈ ÌÂÙ·‚ÔϤ˜ Ô˘ Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙËÓ ·Ó¿Ù·ÍË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜16. ¶·Ú¿ÏÏËÏ· Ì ÙËÓ ·ÔηٿÛÙ·ÛË ÛÙÔ

Ê˘ÛÈÔÏÔÁÈÎfi Ù˘ Û˘ÁΤÓÙÚˆÛ˘ ÙÔ˘ Na˘¿Ú¯ÂÈ Â·Ó¿ÎÙËÛË ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ Î·È ÙˆÓ ˆÛ̈ϛˆÓ ·fi Ù· ÂÁÎÂÊ·ÏÈο ·ÙÙ·Ú·. ∏ ‰ÈfiÚıˆÛË ÙˆÓ ËÏÂÎÙÚÔÏ˘ÙÒÓ Â›Ó·È Ù·¯Â›· ·ÏÏ¿ ÙˆÓ ˆÛ̈ϛˆÓ Á›ÓÂÙ·È Ì Ôχ ‚Ú·‰‡ÙÂÚÔ Ú˘ıÌfi, ȉȷ›ÙÂÚ· ·Ó Ë ‰È¿ÚÎÂÈ· Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ‹Ù·Ó ÌÂÁ¿ÏË. ™ÙËÓ Ù·¯Â›· ‰ÈfiÚıˆÛË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜, ‰ÂÓ ˘¿Ú¯ÂÈ ÚÔÛ·ÚÌÔÁ‹ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÛÙËÓ ˆÛ̈ÙÈÎfiÙËÙ· ÙˆÓ ÂÍˆÎ˘ÙÙ¿ÚÈˆÓ ˘ÁÚÒÓ Î·È ·˘Ùfi ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÛÔ‚·Ú‹ ‚Ï¿‚Ë ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÁÓˆÛÙ‹ ˆ˜ ÎÂÓÙÚÈ΋ ·ÔÌ˘ÂϛӈÛË Ù˘ Á¤Ê˘Ú·˜ ‹ ˆÛ̈ÙÈÎfi Û‡Ó‰ÚÔÌÔ ·ÔÌ˘ÂϛӈÛ˘. ÷ڷÎÙËÚ›˙ÂÙ·È ·fi Û˘ÚÚ›ÎÓˆÛË ÙˆÓ Î˘ÙÙ¿ÚˆÓ Î·È ·ÔÌ˘ÂϛӈÛË ÛÙÔ Î¤ÓÙÚÔ Ù˘ Á¤Ê˘Ú·˜ ·ÏÏ¿ ¤¯ÂÈ ÂÚÈÁÚ·Ê› Î·È Û ¿ÏÏ· ÛËÌ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, fiˆ˜ Ë ·ÚÂÁÎÂÊ·Ï›‰·, Ô ı¿Ï·ÌÔ˜ Î·È ÛÙȘ Û˘Ó‰ÂÙÈΤ˜ ÂÚÈÔ¯¤˜ ÌÂٷ͇ Ê·È¿˜ Î·È Ï¢΋˜ Ô˘Û›·˜. OÈ Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Î˘Ì·›ÓÔÓÙ·È ·fi „¢‰Ô·Ú¿Ï˘ÛË ÙˆÓ ÔÊı·ÏÌÈÎÒÓ, ‰È·Ù·Ú·¯¤˜ Ù˘ ÔÌÈÏ›·˜, Û·ÛÌÔ‡˜, ÙÂÙÚ·ÏËÁ›· ¤ˆ˜ Î·È ÎÒÌ·.

∫ÏÈÓÈΤ˜ ÂÈÙÒÛÂȘ Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ∏ ˘ÔÓ·ÙÚÈ·ÈÌ›· Û˘Ó˘¿Ú¯ÂÈ ÔÏϤ˜ ÊÔÚ¤˜ ÛÙËÓ ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Î·È Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ·Ó·ÁÓˆÚÈÛÙÔ‡Ó ÔÈ ·ÌÈÁ›˜ Û˘Ó¤ÂȤ˜ Ù˘. ∏ ÎÏÈÓÈ΋ ÛËÌ·Û›· Ù˘ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙȘ ·Ú·Î¿Ùˆ ηٷÛÙ¿ÛÂȘ.

∞) ∏ ˘ÔÓ·ÙÚÈ·ÈÌ›· Î·È Ó¢ÚÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ™Â ·ÛıÂÓ›˜ ¯ˆÚ›˜ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Ë ˘ÔÓ·ÙÚÈ·ÈÌ›·17Û˘Û¯ÂÙ›˙ÂÙ·È Ì ¤Ó· ¢ڇ Ê¿ÛÌ· Ó¢ÚÔÏÔÁÈÎÒÓ ÂΉËÏÒÛˆÓ, Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ‡·ÚÍË ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ fiˆ˜ ÎÂÊ·Ï·ÏÁ›·, ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÚÔÛ·Ó·ÙÔÏÈÛÌÔ‡, Û‡Á¯˘ÛË, ÂÛÙȷ΋ Ó¢ÚÔÏÔÁÈ΋ ÛËÌÂÈÔÏÔÁ›·, Û·ÛÌÔ› Î·È Û ‚·ÚȤ˜ ηٷÛÙ¿ÛÂȘ ı¿Ó·ÙÔ ·fi ÂÁÎÔÏ·ÛÌfi ÙÔ˘ ÛÙÂϤ¯Ô˘˜. O ΢ÚÈfiÙÂÚÔ˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ηıÔÚ›˙ÂÈ ÙËÓ ‚·Ú‡ÙËÙ· ÙˆÓ Ó¢ÚÔÏÔÁÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ Â›Ó·È Ô Ú˘ıÌfi˜ ÂÏ¿ÙÙˆÛ˘ ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ NaÙÔ˘ ÔÚÔ‡ (Na <120 mEq/l Û ÏÈÁfiÙÂÚÔ ·fi 48 h). ™ÙËÓ Î›ÚÚˆÛË Û·Ó›˙Ô˘Ó ÔÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ˘ÂÚ‚ÔÏ·ÈÌÈ΋˜ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜, fiˆ˜ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ·Ú·¿Óˆ Î·È ·˘Ùfi ·Ô‰›‰ÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÚfiÎÂÈÙ·È Û˘Ó‹ıˆ˜ ÁÈ· ¯ÚfiÓÈ· Î·È fi¯È ÁÈ· ÔÍ›·. ∏ Â›‰Ú·ÛË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ÂÍÂÙ¿˙ÂÙ·È ÛÙ· Ï·›ÛÈ· Ù˘ ÚfiÛÊ·Ù˘ ıˆڛ·˜ Ë ÔÔ›· ÚÔÙ›ÓÂÈ ¤Ó· ÚfiÏÔ ÁÈ· ÙÔ ÌÈÎÚÔ‡-‚·ıÌÔ‡ ÂÁÎÂÊ·ÏÈÎfi

METAMO™XEY™Eπ™ 2011

Ô›‰ËÌ·18,19 (lowgradecerebraledema) ÛÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜. ™‡Ìʈӷ Ì ÙËÓ ıˆڛ· ·˘Ù‹ Ë ˘ÂÚ-·Ì̈ÓÈ·ÈÌ›· ÚÔηÏ› ·‡ÍËÛË Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ ÁÏÔ˘Ù·Ì›Ó˘ ÛÙ· ·ÛÙÚÔ·ÙÙ·Ú· Ô˘ Â›Ó·È Ù· ÌÔÓ·‰Èο ·ÙÙ·Ú· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ô˘ ÂÚȤ¯Ô˘Ó ÁÏÔ˘Ù·ÌÈÓÈ΋ Û˘ÓıÂÙ¿ÛË ÁÈ· ÙËÓ ‰È¿Û·ÛË Ù˘ ¡∏3. ∏ ÁÏÔ˘Ù·Ì›ÓË ‰Ú· ˆÛ̈ÙÈο ¤ÏÎÔÓÙ·˜ ∏2O ÛÙÔÓ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ ¯ÒÚÔ ÚÔηÏÒÓÙ·˜ Ô›‰ËÌ· ÙˆÓ ·ÛÙÚÔ΢ÙÙ¿ÚˆÓ. ΔÔ ÚÔ·ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ· Â›Ó·È ÌÈÎÚÔ‡ ‚·ıÌÔ‡ ‰ÂÓ ÌÂÙ·‚¿ÏÂÈ ÙËÓ ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË ·ÏÏ¿ ÂÈʤÚÂÈ ÌÂÙ·‚ÔϤ˜ ÛÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜ fiˆ˜ ÛÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ Î·È ÙÔ ÔÍÂȉˆÙÈÎfi stress, ÂËÚ¿˙ÔÓÙ·˜ ÙËÓ ÂÈÎÔÈÓˆÓ›· ÌÂٷ͇ Ó¢ÚÔÁÏÔ›·˜ Î·È Ó¢ÚÒÓˆÓ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·. ∂Ӊ›ÍÂȘ ÌÈÎÚÔ‡-‚·ıÌÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ Ì·ÁÓËÙÈ΋ Ê·ÛÌ·ÙÔÛÎÔ›· 20 (1 HMRS). ∏ ˘ÔÓ·ÙÚÈ·ÈÌ›·21 ·ÓÙÈÚÔÛˆ‡ÂÈ ÙÔÓ ‰Â‡ÙÂÚÔ Î‡ÚÈÔ ·Ú¿ÁÔÓÙ· Ô˘ ÂȉÂÈÓÒÓÂÈ ÙÔ Ô›‰ËÌ· ÙˆÓ ·ÛÙÚÔ΢ÙÙ¿ÚˆÓ Ì ÙËÓ ÌÂٷΛÓËÛË ∏2O ÛÙÔÓ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ ¯ÒÚÔ ÏfiÁˆ Ù˘ ˘Ô-ˆÛ̈ÙÈÎfiÙËÙ·˜ fiˆ˜ ·Ó·Ù‡¯ıËΠ·Ú·¿Óˆ. ™ÙËÓ Î·Ù¿ÛÙ·ÛË ·˘Ù‹ ÔÔÈ·‰‹ÔÙ ÂÚ·ÈÙ¤Úˆ ‰È·Ù·Ú·¯‹ Ù˘ ˆÛ̈ÙÈÎfiÙËÙ·˜ ›Ù ÏfiÁˆ ·‡ÍËÛ˘ Ù˘ ¡∏3›Ù ÏfiÁˆ ÂÚ·ÈÙ¤Úˆ ÙÒÛ˘ ÙÔ˘ Na, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ÂÁÎÂÊ·ÏÔ¿ıÂÈ· (∂ÈÎ. 2).

99

™‡Ìʈӷ Ì ÙÔ˘˜ Angelietal7 ÔÈ ·ÛıÂÓ›˜ Ì NaÔÚÔ‡ <130 mEq/lÛ ‰È¿ÛÙËÌ· ÂÓfi˜ Ì‹Ó· ÂÌÊ¿ÓÈÛ·Ó ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ ÂÂÈÛfi‰ÈÔ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Û ÔÛÔÛÙfi 38%, Û ÙÈ̤˜ NaÌÂٷ͇ 130 Î·È 135 mEq/lÙÔ ÔÛÔÛÙfi ·Ó·Ê¤ÚÂÙ·È ÛÙÔ 24% ÂÓÒ ÛÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ ÛÙÔ 15%.

μ) ÀÔÓ·ÙÚÈ·ÈÌ›· Î·È ÂÈÏÔΤ˜ Ù˘ ΛÚÚˆÛ˘ ∂ÎÙfi˜ ·fi ÙËÓ Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜7,22Ì ÛÔ‚·ÚÔ‡ ‚·ıÌÔ‡ ·ÓıÈÛÙ¿ÌÂÓÔ ·ÛΛÙËÔ˘ ··ÈÙ› Û˘¯Ó¤˜ ·Ú·ÎÂÓÙ‹ÛÂȘ, ηٷÎÚ¿ÙËÛË ˘ÁÚÒÓ Î·È ·˘ÙfiÌ·ÙË ÌÈÎÚԂȷ΋ ÂÚÈÙÔÓ›Ùȉ·. OÈ ·ÛıÂÓ›˜ ·˘ÙÔ› ·Ó·Ù‡ÛÛÔ˘Ó Û ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ (Na ÔÚÔ‡ <130 mEq/l Û˘¯ÓfiÙËÙ· Ë·ÙÔÓÂÊÚÈÎÔ‡ 17%ÂÓÒ Û NaÔÚÔ‡ ÌÂٷ͇ 130 Î·È 135 mEq/lË Û˘¯ÓfiÙËÙ· ·Ó¤Ú¯ÂÙ·È Û 10%).

°) ÀÔÓ·ÙÚÈ·ÈÌ›· Î·È ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Ÿˆ˜ ‹‰Ë ·Ó·Ê¤ÚıËΠÔÈ ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË Î·È ˘ÔÓ·ÙÚÈ·ÈÌ›· ‰È·ÙÚ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·Ó¿Ù˘Í˘ ÎÂÓÙÚÈ΋˜ ·ÔÌ˘ÂϛӈÛ˘ Ù˘ Á¤Ê˘Ú·˜16,23 (‹ ˆÛ̈ÙÈÎfi Û‡Ó‰ÚÔÌÔ ·ÔÌ˘ÂϛӈÛ˘) ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. Œ¯ÂÈ Î·Ù·ÁÚ·Ê› Û ÔÛÔÛÙ¿ Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi 1,2-15%, Î·È Ë ıÓËÙfiÙËÙ· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 50% ÙȘ ÚÒÙ˜ ‰‡Ô

HYPERAMMONEMIA

HYPONATREMIA

Increased glutemia synthesis

Increased intracellular osmolality

Decreased extracellular osmolality

Astrocyte swelling

Water shift from extracellular space

Water shift from extracellular space Reduction of intracellular osmolytes Astrocyte dysfunction

Factors increasing ammonic synthesis Progressive hyponetremia

HEPATIC ENCEPHALOPATHY

∂ÈÎ. 2. ™¯ËÌ·ÙÈ΋ ·Ú¿ÛÙ·ÛË Ù˘ ·ÏÏËÏÂ›‰Ú·Û˘ Ù˘ ˘ÂÚ·Ì̈ÓÈ·ÈÌ›·˜ Î·È Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ Î·È Ë Èı·Ó‹ Û˘ÌÌÂÙÔ¯‹ ÙÔ˘˜ ÛÙËÓ Ë·ÙÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·.

100

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‚‰ÔÌ¿‰Â˜ Î·È ÛÙÔ 90% ÛÙÔ˘˜ ¤ÍÈ Ì‹Ó˜. ∫˘ÚÈfiÙÂÚË ·ÈÙ›· ·Ó¿Ù˘Í˘ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ıˆÚÂ›Ù·È Ë Ù·¯Â›· ‰ÈfiÚıˆÛË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜. ∞Ô‰ÂÎÙfi˜ Ú˘ıÌfi˜ ¯ÔÚ‹ÁËÛ˘24 NaÂ›Ó·È Ù· 0,5-1 mEq/l. ¶ÔÏϤ˜ ÌÂϤÙ˜ ÂÛÙÈ¿˙ÔÓÙ·È ÛÙËÓ Î·Î‹ ¤Î‚·ÛË ÙˆÓ ·ÚÚÒÛÙˆÓ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË fiÙ·Ó ÚÔ¸¿Ú¯ÂÈ ˘ÔÓ·ÙÚÈ·ÈÌ›·25-28. ºÙˆ¯‹ ¤Î‚·ÛË ¤¯ÂÈ Î·Ù·ÁÚ·Ê› Î·È Û ·ÛıÂÓ›˜ Ì ‰ÈÔÚıˆÌ¤ÓË ˘ÔÓ·ÙÚÈ·ÈÌ›· ·ÏÏ¿ Ì ÈÛÙÔÚÈÎfi ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ 6 Ì‹Ó˜ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË.

OÈ Boinetal26 η٤ÁÚ·„·Ó ÙËÓ ıÓËÙfiÙËÙ· ÛÙȘ 90 Ë̤Ú˜ ÛÙËÓ ÔÌ¿‰· Ù˘ ÛÔ‚·Ú‹˜ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ÛÙÔ 87,7% Û ·ÓÙ›ıÂÛË Ì ÙËÓ ÔÌ¿‰· ÙˆÓ ÓÔÚÌÔÓ·ÙÚÈ·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ Ô˘ ‹Ù·Ó 77,6%. ™‡Ìʈӷ Ì ÙÔ˘˜ Dawwasetal25 ÔÈ ·ÛıÂÓ›˜ Ì ˘ÔÓ·ÙÚÈ·ÈÌ›· ·ÏÏ¿ Î·È ÂΛÓÔÈ Ì ˘ÂÚÓ·ÙÚÈ·ÈÌ›· ÂÌÊ¿ÓÈÛ·Ó ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· ÛÙÔ ˘fi ÌÂϤÙË ‰È¿ÛÙËÌ· (90 Ë̤Ú˜ Î·È 3 ¯ÚfiÓÈ·) Û ۯ¤ÛË Ì ÂΛÓÔ˘˜ ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ Na. ™ÙÔ˘˜ ÂÈ‚ÈÒÛ·ÓÙ˜ ‰Â (ÛÙȘ 90 Ë̤Ú˜) ·Ó·Ê¤ÚÂÙ·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ÂÈÏÔÎÒÓ.

£ÂÚ·›· OÈ ÚÔÙÂÈÓfiÌÂÓ˜ ıÂÚ·¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó31,32: ·) ΔÔÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ ¯ÔÚËÁÔ‡ÌÂÓˆÓ ˘ÁÚÒÓ (1-1,5 l/day) ‚) ΔËÓ ¯ÔÚ‹ÁËÛË ‰È·Ï‡Ì·ÙÔ˜ ˘¤ÚÙÔÓÔ˘ Na Á) ΔËÓ ¯ÔÚ‹ÁËÛË ‰ÂÌÂÎÏÔ΢ÎÏ›Ó˘. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÂÙڷ΢ÎÏ›ÓË Ô˘ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ÛˆÏËÓ·Úȷ΋ ‰Ú¿ÛË Ù˘ ADH. ‰) ¶ÚfiÛÊ·Ù· ÚÔÙ¿ıËÎÂ Ë ¯ÔÚ‹ÁËÛË ‚·Ù·ÓÒÓ (Vaptans) Ô˘ ·ÓÙ·ÁˆÓ›˙ÔÓÙ·È ÙȘ ÂȉڿÛÂȘ Ù˘ ADHÛÙÔ˘˜ V-˘ԉԯ›˜ ÙˆÓ ÓÂÊÚÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ12. ŸÌˆ˜, Ë ˘ÂÚ‚ÔÏ·ÈÌÈ΋ ˘ÔÓ·ÙÚÈ·ÈÌ›· ·ÔÙÂÏ› ‚·ÛÈÎfi ‰Â›ÎÙË Ù˘ ˘ÔΛÌÂÓ˘ ΢ÎÏÔÊÔÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ fiˆ˜ Ê·›ÓÂÙ·È Î·È ·fi ÙËÓ ·ıÔÁ¤ÓÂÈ¿ Ù˘. ∏ ‰ÈfiÚıˆÛ‹ Ù˘ Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ‰ÂÓ ‚ÂÏÙ›ˆÛ ÙËÓ ÓÔÛËÚfiÙËÙ· Î·È ÙËÓ ıÓËÙfiÙËÙ·. ŸÙ·Ó ‰ÂÓ Û˘Óԉ‡ÂÙ·È ·fi ÂÌÊ·Ó›˜ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ‰ÂÓ ·Ó·Ù¿ÛÛÂÙ·È ·Ú¿ ÌfiÓÔ fiÙ·Ó Ë Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Na Â›Ó·È <120 mEq/l Î·È Ë ÔÔ›· ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi <1,2% ÛÙËÓ Î›ÚÚˆÛË7. ∂¿Ó ·ÔÊ·ÛÈÛı› Ë ıÂÚ·¢ÙÈ΋ ·Ú¤Ì‚·ÛË ··ÈÙÂ›Ù·È È‰È·›ÙÂÚË ÚÔÛÔ¯‹ ÛÙËÓ ‰ÈfiÚıˆÛË ÙÔ˘ Na. O Ú˘ıÌfi˜ ‰ÈfiÚıˆÛ˘24 ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ Ù· 10 mEq/l ÙȘ ÚÒÙ˜ 24 h Î·È Ù· 18 mEq/

l ÛÙȘ 48 h.

¶ÚfiÁÓˆÛË ™˘ÁΤÓÙÚˆÛË Na <130 mEq/l¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· (50%) Û ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 180 ËÌÂÚÒÓ Î·Ù¿ ÙËÓ ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË7. ∏ ˘ÔÓ·ÙÚÈ·ÈÌ›· ·ÔÙÂÏ› ·ÓÂÍ¿ÚÙËÙÔ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ıÓËÙfiÙËÙ·˜2ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ΛÚÚˆÛË Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ MELD score, Ë ÂÓۈ̿وÛË ‰Â Ù˘ ÙÈÌ‹˜ ÙÔ˘ NaÛÙÔ MELD score ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÚÔÁÓˆÛÙÈ΋ ÙÔ˘ ·Í›·29. ™Â ¯·ÌËÏ¿ MELD score ˘ÔÓ·ÙÚÈ·ÈÌ›· ·ÔÙÂÏ› ÈÔ ·ÍÈfiÈÛÙÔ ‰Â›ÎÙË ıÓËÙfiÙËÙ·˜28. ∏ Â›‰Ú·ÛË Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ÛÙËÓ ÚfiÁÓˆÛË ÂÎÙÈÌ‹ıËΠ·fi ÙÔ˘˜ Kimetal28 Û 6769 ˘Ô„ËÊ›Ô˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ‚Ú¤ıËΠfiÙÈ Ô ‰Â›ÎÙ˘ ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ (hazardratio) ‹Ù·Ó 1,05 ÁÈ· οı 1 mEq/l Ì›ˆÛ˘ ÙÔ˘ Na, ÁÈ· ÙÈ̤˜ 125-140 mEq/l. OÈ Jenqetal30 ÌÂϤÙËÛ·Ó ÙËÓ ÛËÌ·Û›· Ù˘ ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ÂÈÛ‹¯ıËÛ·Ó ÛÙËÓ ª∂£ NaÔÚÔ‡ <130 meq/l ηٷÁÚ¿ÊËΠÛÙÔ 29%. Δ· ¯·ÌËÏ¿ Â›‰· NaÛ˘Û¯ÂÙ›ÛıËÎ·Ó Ì ·ÛΛÙË, ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Û‹„Ë, ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Î·È ÌÂÁ·Ï‡ÙÂÚË ıÓËÙfiÙËÙ·. OÈ Û˘ÁÁÚ·Ê›˜ ÚÔÙ›ÓÔ˘Ó ÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· ÙˆÓ ·ÚÚÒÛÙˆÓ ·˘ÙÒÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ‡·ÚÍË ˘ÔÓ·ÙÚÈ·ÈÌ›·˜ ÚÈÓ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û˘Û¯ÂÙ›˙ÂÙ·È fi¯È ÌfiÓÔ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó¢ÚÔÏÔÁÈÎÒÓ ÂÈÏÔÎÒÓ ·ÏÏ¿ Î·È Ï‹ıÔ˜ ÂÈÏÔÎÒÓ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË5,25, fiˆ˜ Ë ÓÂÊÚÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ë ¯ÔÚ‹ÁËÛË ÌÂÁ·Ï‡ÙÂÚˆÓ ÔÛÔÙ‹ÙˆÓ ÚÔ˚fiÓÙˆÓ ·›Ì·ÙÔ˜, ÏÔÈÌÒÍÂȘ, ·Ú¿Ù·ÛË Ù˘ ÓÔÛËÏ›·˜ ÛÙËÓ ª∂£ Î·È ÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È Ù¤ÏÔ˜ ·˘ÍË̤ÓË ıÓËÙfiÙËÙ·.

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METAMO™XEY™Eπ™ 2011

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Î·È ÂÔ̤ӈ˜ Î·È ÙÔ˘ HDV ÌÂÙ¿ ª∏. Δ· Â›‰· ÙÔ˘ HDV RNA ‰ÂÓ ˘¿Ú¯ÂÈ ‰˘Ó·ÙfiÙËÙ· Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó ÛÙËÓ ∂ÏÏ¿‰·(ÂÏȉÔÊfiÚ˜ ÚÔÛ¿ıÂȘ Á›ÓÔÓÙ·È ÛÙÔ ÂÚ¢ÓËÙÈÎfi πÓÛÙÈÙÔ‡ÙÔ Ù˘ π·ÙÚÈ΋˜ Û¯ÔÏ‹˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ Ù˘ §¿ÚÈÛ·˜), ·ÏÏ¿ Â›Û˘ ‰ÂÓ ˘¿Ú¯ÂÈ ·ÎfiÌ· ‰ÈÂıÓÒ˜ ·Ô‰ÂÎÙ‹ ̤ıÔ‰Ô˜ ÔÛÔÙÈÎÔ‡ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ ÙÔ˘ HDV RNA. ŸÌˆ˜, Î·È ·Ó ·ÎfiÌ· ‹Ù·Ó ‰˘Ó·Ùfi Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó Ù· Â›‰· ÙÔ˘ HDV RNA ·˘Ùfi ‰ÂÓ ı· ‚ÔËıÔ‡ÛÂ,ÂÊfiÛÔÓ Ë ¯ÔÚ‹ÁËÛË IFN ‹ Peg IFN ·ÔÎÏ›ÂÙ·È Î·È Ù· NUCs ‰ÂÓ ¤¯Ô˘Ó ıÂÚ·¢ÙÈ΋ Â›‰Ú·ÛË ÛÙË HDV Ïԛ̈ÍË. ªÂÙ¿ ÙË ª∏ ÔÈ ·ÛıÂÓ›˜ Ì HBV+HDV ÂÈÏԛ̈ÍË ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È fiˆ˜ Î·È ÔÈ ·ÛıÂÓ›˜ Ì HBV Ïԛ̈ÍË, ·ÏÏ¿ ıˆÚÔ‡ÓÙ·È low risk ÁÈ· ˘ÔÙÚÔ‹,ÂÂȉ‹ fiˆ˜ ›·Ì ¤¯Ô˘Ó ηٿ ηÓfiÓ· ÌË ·ÓȯÓ‡ÛÈÌ· Â›‰· HBV DNA. ŒÙÛÈ, Ë ¯ÔÚ‹ÁËÛË HBIG(Hepatitis B Immunoglobulin) ÌÂÙ¿ ÙË ª∏ ÌÔÚ› Ó· Â›Ó·È ÈÔ ‚Ú·¯˘¯ÚfiÓÈ·(1-3 Ì‹Ó˜) Î·È Ó· Û˘Ó¯ÈÛÙ› Ë ¯ÔÚ‹ÁËÛË ÌfiÓÔ ·ÓÙÈÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (NUCs), ηٿ ÚÔÙ›ÌËÛË ETV ‹ TDF. H ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì HDV ÂÈÏԛ̈ÍË ÌÂÙ¿ ÙË ª∏ Â›Ó·È Î·Ï‡ÙÂÚË ·fi ÔÏϤ˜ ¿ÏϘ ·Èٛ˜ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜7 Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ª∏.ΔÔ HDV RNA ÂÍ·Ê·Ó›˙ÂÙ·È ÁÚ‹ÁÔÚ· ÌÂÙ¿ ÙË ª∏, ·Ú¿ÏÏËÏ· Ì ÙË Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙÔ˘ HBsAg8. MÂϤÙ˜ Û ÃÈÌ·Ù˙‹ ¤¯Ô˘Ó ·ÔÎÏ›ÛÂÈ ÙËÓ ·Ú·ÌÔÓ‹ HDV Ïԛ̈͢ ·Ô˘Û›· HBV9. ™‡Ìʈӷ Ì ÙȘ Û˘ÛÙ¿ÛÂȘ ÙÔ˘ AASLD (American Association for the Study of the Liver Disease)10 Î·È ÙÔ˘ ∂∞SL (European Association for the Study of the Liver)6, ÛÙËÓ HBV ª∏∞¡ΔI∫π, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔ HBeAg status (ıÂÙÈÎfi ‹ ·ÚÓËÙÈÎfi), ·Ó Ù· Â›‰· ÙÔ˘ HBV DNA Â›Ó·È ·ÓȯÓ‡ÛÈÌ·, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ·Ú¯›ÛÂÈ ıÂÚ·›· Ì Lamivudine (LAM) + Adefovir (ADV), ‹ Telbivudine (Ldt)+∞DV, ·ÏÏ¿ ÚÔÙÈÌÒÓÙ·È Ë ETV ‹ TDFÎ·È Ó· ·Ú·¤ÌÂÙ·È ÛÙÔ Î¤ÓÙÚÔ ª∏. ™ÙÔÓ ·ÛıÂÓ‹ Ì ÌË ·ÓȯÓ‡ÛÈÌ· Â›‰· HBV DNA Î·È ª∏∞¡Δπ∫π Û˘ÓÈÛÙ¿Ù·È ·ÏÒ˜ Ë

OÈ ·ÛıÂÓ›˜ Ô˘ ÂÓÙ¿ÛÛÔÓÙ·È ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ªÂÙ·ÌfiÛ¯Â˘ÛË ∏·ÙÔ˜ (ª∏), ÏfiÁˆ HBV ‹ HBV+HDV Ïԛ̈ÍË, Â›Ó·È ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË ∫›ÚÚˆÛË (ª∏∞¡Δπ∫π), ∏∫∫ Û ¤‰·ÊÔ˜ ·ÓÙÈÚÚÔÔ‡ÌÂÓ˘ (∞¡Δπ∫π) ‹ ª∏∞¡Δπ∫π Î·È ·ÛıÂÓ›˜ Ì OÍ›· ∏·ÙÈ΋ ∞ÓÂ¿ÚÎÂÈ· (O∏∞).

OÚÈṲ̂Ó˜ ÊÔÚ¤˜ Ë O∏∞ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ‰È·ÎÚÈı› ·fi ÙËÓ ÛÔ‚·Ú‹ Âȉ›ӈÛË ¯ÚfiÓÈ·˜ HBV Ïԛ̈͢, Ë ÔÔ›· Û˘Ì‚·›ÓÂÈ Â›Ù ·˘ÙfiÌ·Ù·, ›Ù ÌÂÙ¿ ¯ËÌÂÈÔıÂÚ·›·. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÌÂÙ¿ ¯ËÌÂÈÔıÂÚ·›· ÌÔÚ› Ó· ·Ó·˙ˆ˘Úˆı› Î·È Ó· ÂÍÂÏȯı› Û ÛÔ‚·Ú‹ ÔÍ›· Ë·Ù›Ùȉ· μ ‹ Î·È O∏∞ ·fi HBV, ·ÎfiÌ· Î·È Ï·Óı¿ÓÔ˘Û· HBV Ïԛ̈ÍË( fiÏÔÈ ÔÈ ‰Â›ÎÙ˜ HBV ÛÙÔÓ ÔÚfi ·ÚÓËÙÈÎÔ›, ·ÏÏ¿ HBV DNA ÛÙÔÓ ÔÚfi ‹ ÛÙÔÓ Ë·ÙÈÎfi ÈÛÙfi ıÂÙÈÎfi) ‹ Î·È ·ÚÂÏıÔ‡Û· Ïԛ̈ÍË ÌÂ Ê˘ÛÈ΋ ·ÓÔÛ›·( anti HBc+, anti HBs+).1-5 °ÂÓÈο ÌÈÏÒÓÙ·˜,ÔÈ ·ÛıÂÓ›˜ Ì ÂÈÏԛ̈ÍË HBV+HDV Î·È Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ‰ÂÓ ÌÔÚÔ‡Ó Ó· Ï¿‚Ô˘Ó IFN ‹ Peg-IFN, (ÙË ÌfiÓË ÂӉ‰ÂÈÁ̤ÓË ÁÈ· ÙË ıÂÚ·›· Ù˘ XÚfiÓÈ·˜ ∏·Ù›Ùȉ·˜ ¢¤ÏÙ· CHD),Ô‡Ù ÚÈÓ, Ô‡Ù ÌÂÙ¿ ÙË ª∏. ∏ IFNı· ÚÔηϤÛÂÈ ÂÚ·ÈÙ¤Úˆ Âȉ›ӈÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÛÙË ª∏∞¡Δπ∫π Î·È ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ÙË ª∏. ∂Ô̤ӈ˜ Ô ·ÛıÂÓ‹˜ Ì Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ·fi HBV+HDV, Ô˘ Â›Ó·È ÂÓÙ·Á̤ÓÔ˜ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ª∏, ı· Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ˆ˜ ¯ÚfiÓÈ· HBV Ïԛ̈ÍË. ŒÙÛÈ, ·Ó ÙÔ HBV DNA Â›Ó·È ·ÓȯÓ‡ÛÈÌÔ Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ÓÔ˘ÎÏÂÔÛ(Ù)ȉÈÎfi ·Ó¿ÏÔÁÔ (¡UC), ηٿ ÚÔÙ›ÌËÛË Entecavir (ETV) ‹ Tenofovir (TDF), ÂÓÒ ·Ó ÙÔ HBV DNA Â›Ó·È ÌË ·ÓȯÓ‡ÛÈÌÔ Ì ¢·›ÛıËÙË Ì¤ıÔ‰Ô ÚÔÛ‰ÈÔÚÈÛÌÔ‡ (Real time PCR)6, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Ó· ÚÔÛÙÂı› ·ÓÙÈÈ΋ ıÂÚ·›·. ∫·Ù¿ ηÓfiÓ· Ù· Â›‰· ÙÔ˘ HBV DNA, fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ÂÈÏԛ̈ÍË Ì HDV, Â›Ó·È ÌË ·ÓȯÓ‡ÛÈÌ· ‹ ·ÓȯÓ‡ÛÈÌ· Û ¯·ÌËÏÔ‡˜ Ù›ÙÏÔ˘˜ (<2000 IU/mL). ∞˘ÙÔ› ÔÈ ·ÛıÂÓ›˜ ıˆÚÔ‡ÓÙ·È ÌÈÎÚÔ‡ ÎÈÓ‰‡ÓÔ˘(low risk) ÁÈ· ˘ÔÙÚÔ‹ ÙÔ˘ HBV

105

106

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·Ú·ÔÌ‹ Û ΤÓÙÚÔ ª∏ Î·È Ë ¤ÓÙ·ÍË Û ϛÛÙ· ·Ó·ÌÔÓ‹˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞Ó¿ÏÔÁ· Ì ÙÔÓ Èı·Ófi ¯ÚfiÓÔ ·Ó·ÌÔÓ‹˜ ÛÙË Ï›ÛÙ·,ı· ÂÈÏÂÁ› Ô ¤ÏÂÁ¯Ô˜ ÙÔ˘ HBV DNA (·Ó¿ ÙÚ›ÌËÓÔ) Î·È Ë ¤Ó·ÚÍË ‹ fi¯È ·ÓÙÈÈ΋˜ ıÂÚ·›·˜. °ÂÓÈÎÒ˜, Ô ·ÛıÂÓ‹˜ Ì ª∏∞¡Δπ∫π ı· Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ˆ˜ Â›ÁˆÓ Úfi‚ÏËÌ·. ΔÔ ıÂÚ·¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Ù˘ TDF ‹ ETV ·Ó·Ì¤ÓÂÙ·È ÌÂÙ¿ ·fi 3-6 Ì‹Ó˜, ÂÓÒ Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜ Ë ÂͤÏÈÍË ‰ÂÓ ·Ó·ÎfiÙÂÙ·È Î·È ÔÈ ·ÛıÂÓ›˜ Ô‰ËÁÔ‡ÓÙ·È Û ª∏.

OÈ ıÂÚ·¢ÙÈÎÔ› ÛÙfi¯ÔÈ ÛÙËÓ HBV ª∏∞¡Δπ∫π ›ӷÈ: 1. ™Ù·ıÂÚÔÔ›ËÛË Ù˘ ÎÏÈÓÈ΋˜ ηٿÛÙ·Û˘ 2. ∏ ηı˘ÛÙ¤ÚËÛË ‹ ·Î‡ÚˆÛË Ù˘ ·Ó¿Á΢ ÁÈ· ª∏ 3. ∏ ÂÏ¿ÙÙˆÛË Ù˘ È·ÈÌ›·˜Û Â›‰· < 20200 IU/mL Î·È ‹ ‰˘Ó·ÙfiÓ Û Â›‰· ÌË ·ÓȯÓ‡ÛÈÌ· Ì ·Ó¿Ï˘ÛË real time PCR: <10-15 IU/mL, ¤ÙÛÈ ÒÛÙ ӷ ÌÂȈı› ÛÙÔ ÂÏ¿¯ÈÛÙÔ Ë Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ ÙÔ˘ HBV ÛÙÔ ÌfiÛ¯Â˘Ì·. ª¤¯ÚÈ ÙË ‰ËÌÔÛ›Â˘ÛË ÙˆÓ Î·Ù¢ı˘ÓÙËÚ›ˆÓ Ô‰ËÁÈÒÓ ÙÔ˘ EASL6 Î·È ÙÔ˘ AASLD10, ‰ÂÓ ‹Ù·Ó ‰ڷȈ̤ÓË ·fi ÌÂϤÙ˜ Ë ·ÛÊ¿ÏÂÈ· ÙˆÓ ÓÂÒÙÂÚˆÓ NUCs, ETV, TDF ÛÙË ª∏∞¡Δπ∫π. ªÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÌÂϤÙ˜11-14 ‰ڷ›ˆÛ·Ó ÙËÓ ·ÛÊ¿ÏÂÈ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ETV Î·È TDF (Ì ‹ ¯ˆÚ›˜ Emtricitabine-FTC). ∂Í·›ÚÂÛË ·ÔÙÂÏ› Ë ÌÂϤÙË ÙˆÓ Lange CM et al14 ÛÙËÓ ÔÔ›· ¯ÔÚËÁ‹ıËΠETV. ™Â Û‡ÓÔÏÔ 16 ·ÛıÂÓÒÓ Ì ª∏∞¡Δπ∫π, ÔÈ 5 Ì MELD score >22 ·ÚÔ˘Û›·Û·Ó Á·Ï·ÎÙÈ΋ ÔͤˆÛË. O ¤Ó·˜ ·fi ·˘ÙÔ‡˜ ·‚›ˆÛÂ, ¤Ó·˜ ¯ÚÂÈ¿ÛÙËΠӷ ˘Ô‚ÏËı› Û ª∏, ÂÓÒ ÛÙÔ˘˜ ˘fiÏÔÈÔ˘˜ 3 Ë Á·Ï·ÎÙÈ΋ ÔͤˆÛË ·ÔηٷÛÙ¿ıËΠÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ETV. ∂Ô̤ӈ˜ Û ·ÛıÂÓ›˜ ÛÔ‚·Ú‹ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· (MELD score >20-22) ¯ÚÂÈ¿˙ÂÙ·È ·˘ÍË̤ÓË ÂÁÚ‹ÁÔÚÛË ˆ˜ ÚÔ˜ ÙÔ ÂӉ¯fiÌÂÓÔ ·ÚÂÓÂÚÁÂÈÒÓ ·fi Ù· NUCs.

Ó·,Ì ÛÙfi¯Ô ÙË ‰È·Ù‹ÚËÛË ÂÈ¤‰ˆÓ anti HBs >100500 πU/mL,·Ó¿ÏÔÁ· Ì ÙËÓ ·ÓȯÓ¢ÛÈÌfiÙËÙ· ÙÔ˘ HBV DNA Ú›Ó ÙË ª∏ (μ′ ÂÚ›Ô‰Ô˜ 1991-1997). ∞fi ÙÔ 1997 (°′ ÂÚ›Ô‰Ô˜) ηıÈÂÚÒıËΠˆ˜ standard of care Ë Û˘Ó‰˘·Ṳ̂ÓË ıÂÚ·›· ÚfiÏ˄˘ ˘ÔÙÚÔ‹˜ LAM+HBIG (2000 U HBIG οı ̋ӷ,¤ÙÛÈ ÒÛÙ ӷ ‰ÈÙËÚÔ‡ÓÙ·ÈÂ›‰· anti HBs >100 IU/mL), ŒÙÛÈ,Ë 5ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂÙ¿ ª∏ ÁÈ· HBV ‚ÂÏÙÈÒıËΠÛËÌ·ÓÙÈο ·fi 53% (1987-1991), Û 69% (1992-1996) Î·È 76% (19972002)15. ∞˘Ùfi ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· ÁÈ· ÙËÓ ∂ÏÏ¿‰·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÙÔ 41% (110/268) ÙˆÓ ˘Ô‚ÏËı¤ÓÙˆÓ Û ª∏ ̤¯ÚÈ ÙÔ 2008 ÛÙË ÃÂÈÚÔ˘ÚÁÈ΋ ÎÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£-πÔÎÚ¿ÙÂÈÔ ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢,‹Ù·Ó ÁÈ· HBV ∫›ÚÚˆÛË. ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÔÛÔÛÙfi ÛÙËÓ ∂˘ÚÒË Â›Ó·È ~10% (ª. μÚÂÙ·Ó›· 5%). ∏ ˘„ËÏ‹ ‰ÔÛÔÏÔÁ›· HBIG (Ì ÙÂÚ¿ÛÙÈÔ ÎfiÛÙÔ˜, 1 U HBIG =1 Euro) ·ÓÙ·ÔÎÚ›ÓÔÓÙ·Ó ÛÙȘ ·Ó¿ÁΘ Ù˘ ÂÔ¯‹˜ ÛÙËÓ ÔÔ›· ·Ô˘Û›·˙·Ó Ù· NUCs ‹ ‰ÈÂÙ›ıÂÙÔ ·ÎfiÌ· ÌfiÓÔ Ë LAM (1997). ™‹ÌÂÚ· Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÚÔÛ¤Ú¯ÂÙ·È ÁÈ· ª∏ ¢ڛÛÎÂÙ·È Û Ï‹ÚË Î·Ù·ÛÙÔÏ‹ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙÔ˘ HBV, ›Ù ˘fi ıÂÚ·›· ÌÂ Û˘Ó‰˘·ÛÌfi LAM+ADV, ›Ù ETV ‹ TDF. E› ϤÔÓ, ÌÂÙ¿ ÙË ª∏ ı· Û˘Ó¯›ÛÔ˘Ó Ó· Ï·Ì‚¿ÓÔ˘Ó ÈÛ¯˘Ú‹ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÈ΋ıÂÚ·›· (LAM+ADV, ›Ù ETV ‹ TDF). ∞˘Ùfi ÙÔ ‰Â‰Ô̤ÓÔ ˘ÔÛÙËÚ›˙ÂÈ ÙËÓ ‰˘Ó·ÙfiÙËÙ· ·ÏÏ·Á‹˜ ÛÙÚ·ÙËÁÈ΋˜ ÚfiÏ˄˘, ÒÛÙ ӷ ÌË ¯ÚÂÈ¿˙ÔÓÙ·È Ô‡Ù ‰ÈÂÁ¯ÂÈÚËÙÈο,Ô‡ÙÂ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈο ÙfiÛÔ ˘„ËϤ˜ ‰fiÛÂȘ Î·È Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË HBIG. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ˘ÔÙÚÔ‹ ÙÔ˘ HBV ÛÙÔ ÌfiÛ¯Â˘Ì· ›ӷÈ: – ΢ڛˆ˜ Ù· Â›‰· ÙÔ˘ HBV DNA Ú›Ó ÙË ª∏, – Ë ·ÓÙ›ÛÙ·ÛË ÛÙ· ·ÓÙÈÈο (NUCs) Ú›Ó ÙË ª∏, – Ë ·Ô˘Û›· Û˘ÏÏԛ̈͢ ‹ ÂÈÏԛ̈͢ Ì HDV, – Ô ∏∫∫ Î·È – Èı·ÓfiÓ Ô ÁÔÓfiÙ˘Ô˜ ÙÔ˘ HBV AASLD Annual Meeting 2010

¶ÚfiÏË„Ë ˘ÔÙÚÔ‹˜ HBV ÛÙÔ ÌfiÛ¯Â˘Ì· ∏ 5ÂÙ‹˜ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì HBV Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û ª∏ ÚÈÓ ·fi ¯Ú‹ÛË Ù˘ HBIG ‹Ù·Ó ~50% (∞′ ÂÚ›Ô‰Ô˜ 1987-1991). ∞fi ÙÔ 1991 ¿Ú¯ÈÛ ӷ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë HBIG ‰ÈÂÁ¯ÂÈÚËÙÈο Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈο: 10 000 U ÂÓ‰ÔÊÏ‚›ˆ˜ ÛÙËÓ ·ÓË·ÙÈ΋ Ê¿ÛË Î·È 10 000 U/ËÌÂÚ. ÙËÓ 1Ë Â‚‰ÔÌ¿‰· ÌÂÙ¿ ÙË ª∏ (Hepatology 2000; 32(6): 1190), ÂÓÒ ÛÙË Û˘Ó¤¯ÂÈ· ¯ÔÚËÁÔ‡ÓÙ·Ó 5000-10000 U οı ̋-

¢ÈÂÚ‡ÓËÛË Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ ·ÏÏ·Á‹˜ ÛÙÚ·ÙËÁÈ΋˜ ÚfiÏ˄˘ ˘ÔÙÚÔ‹˜ ÙÔ˘ HBV ÛÙÔ ÌfiÛ¯Â˘Ì· ΔÔ ÎfiÛÙÔ˜ Ù˘ HBIG ·ÏÏ¿ Î·È Ë ÈÛ¯˘Ú‹ ·ÓÙÈÈ΋‰Ú¿ÛË, Ì ¯·ÌËÏfi ‹ ÌˉÂÓÈÎfi profile ·ÓÙ›ÛÙ·Û˘ Ù˘ ΔDF Î·È ∂ΔV, o‰‹ÁËÛ·Ó ÛÙË ‰ÈÂÚ‡ÓËÛË Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ ·ÏÏ·Á‹˜ ÛÙÚ·ÙËÁË΋˜ ÛÙËÓ ÚfiÏË„Ë ˘ÔÙÚÔ‹˜ ÛÙÔ ÌfiÛ¯Â˘Ì·.

METAMO™XEY™Eπ™ 2011 ¶π¡∞∫∞™ 1. ™‡Á¯ÚÔÓ˜ ÛÙÚ·ÙËÁËΤ˜ ÚfiÏ˄˘ ˘ÔÙÚÔ‹˜ HBV ÛÙÔ ÌfiÛ¯Â˘Ì· – ∞ÓÙÈÈ΋ ıÂÚ·›· ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜.™Ùfi¯Ô˜ HBV DNA: ÌË ·ÓȯÓ‡ÛÈÌÔ(real time PCR) – ÃÔÚ‹ÁËÛË HBIG+NUCs ÌÂÙ¿ ÙË ª∏ ( standard of care Û‹ÌÂÚ·) – ÃÔÚ‹ÁËÛË ÂÌ‚ÔÏ›Ô˘ Î·È NUCs* – ¢È·ÎÔ‹ HBIG, Û˘Ó¤¯ÈÛË Ì NUCs(Ë Ó¤· ÛÙÚ·ÙËÁÈ΋ ?)

– ∞ÓÙÈÌÂÙÒÈÛË ˘ÔÙÚÔ‹˜ Ì TDF‹ ETV Gut 2010; 59: 1430-1435 * OÈ ÚÔÛ¿ıÂȘ ÚfiÏ˄˘ Ì ÂÌ‚fiÏÈÔ ¤‰ˆÛ·Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. ªÈÎÚÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ˘ÔÙÚÔ‹ ıˆÚÔ‡ÓÙ·È ÔÈ ·ÛıÂÓ›˜ ÌÂ: I. HBV DNA < 10 000 IU/mL Î·È Wild type HBV* II. OÍ›· HBV ∏·ÙÈ΋ ∞ÓÂ¿ÚÎÂÈ· III. HBV+HDV Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Hepatology 2009;49 suppl 5:146-155 *T· Â›‰· ·˘Ù¿ ıˆÚÔ‡ÓÙ·È Û‹ÌÂÚ· Ôχ ˘„ËÏ¿, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ì ٷ ÓÂÒÙÂÚ· NUCs ˘¿Ú¯ÂÈ ‰˘Ó·ÙfiÙËÙ· Â›Ù¢Í˘ ÌË ·ÓȯÓ‡ÛÈÌÔ˘ HBV DNA (real time PCR <10-15 IU/mL )

¢È·ÎÔ‹ HBIG, Û˘Ó¤¯ÈÛË Ì NUCs, Ë Ó¤· ÛÙÚ·ÙËÁÈ΋? ™ÙË ÌÂϤÙË ÙˆÓ L. Teperman et al16 (EASL 2010) xÔÚËÁ‹ıËÎ·Ó ÌÂÙ¿ ÙË ª∏ ÁÈ· 12-24 ‚‰.

HBIG+TRUVADA (TDF+FTC ), ÒÛÙ ӷ ÛÙ·ıÂÚÔÔÈËı› HBsAg-ve, HBV DNA–ve Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÔÈ 40 ·ÛıÂÓ›˜ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û 2 ÔÌ¿‰Â˜. ∏ ÔÌ¿‰· ∞ ÁÈ· 72 ÂÈ ϤÔÓ Â‚‰ÔÌ¿‰Â˜ ‹Ú ÌfiÓÔ ΔRUVADA, ÂÓÒ Ë ÔÌ¿‰· μ Û˘Ó¤¯ÈÛ Ì ∏BIG+TRUVADA ÁÈ· 72 ‚‰. ™ÙÔ Ù¤ÏÔ˜ Ù˘ ıÂÚ·›·˜ Û ηӤӷ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Î·È ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ‰ÂÓ ÛËÌÂÈÒıËΠ·Ó›¯Ó¢ÛË HBsAg, Ô Û˘Ó‰˘·ÛÌfi˜ FTC (Emtricitabine)+TDF (Tenofovir) ‹Ù·Ó ηϿ ·ÓÂÎÙfi˜,ÂÓÒ ·ÎfiÌ· Î·È ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÌÂÙÚ›Ô˘ ‚·ıÌÔ‡ ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ·(GFR<50 ml/min)‰ÂÓ ÛËÌÂÈÒıËΠÂȉ›ӈÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ™Â ÌÂϤÙË ‰È΋ Ì·˜ (Vasiliadis et al AASLD 201017 ·fi ÙË ÃÂÈÚÔ˘ÚÁÈ΋ ÎÏÈÓÈ΋ ªÂÙ·ÌÔۯ‡ÛÂˆÓ ÙÔ˘ ∞¶£), ·ÍÈÔÏÔÁ‹ıËÎÂ Ë ·ÛÊ¿ÏÂÈ· Î·È Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ‰È·ÎÔ‹˜ ÙÔ˘ HBIG ÌÂÙ¿ 12ÌËÓË Û˘Á¯ÔÚ‹ÁËÛË HBIG 2000 U/ÌËÓÈ·›ˆ˜ Î·È NUCs. ™Â 38 ·ÛıÂÓ›˜ Ì HBsAg-ve, HBV DNA <6 πU/mL Î·È Â›‰· SCr <1.5 mg/dL ‰ÈÂÎfiË Ë ¯ÔÚ‹ÁËÛË HBIG Î·È ÔÈ 26 ·ÛıÂÓ›˜ Û˘Ó¤¯ÈÛ·Ó Ó· Ï·Ì‚¿ÓÔ˘Ó LAM (19 ÛÂ Û˘Ó‰˘·ÛÌfi Ì ADV, Î·È 3 ÛÂ Û˘Ó‰˘·ÛÌfi Ì TDF), ÔÈ 10 ·ÛıÂÓ›˜ ÂÏ¿Ì‚·Ó·Ó ÌfiÓÔ TDF Î·È ÔÈ 2 ÌfiÓÔ ETV. ªÂÙ¿ ‰È¿ÌÂÛÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 18 ÌËÓÒÓ( ‡ÚÔ˜ 10-36) Û ηӤӷ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ‰ÂÓ

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ÛËÌÂÈÒıËΠ˘ÔÙÚÔ‹ HBV Ïԛ̈͢(HBsAg-ve, HBV DNA –ve). ™ÙËÓ ÔÌ¿‰· ÙˆÓ ·ÛıÂÓÒÓ ADV‹ TDF ÛËÌÂÈÒıËΠ̛ˆÛË Ù˘ GFR(67±11 vs 91±16 mL/min/1.732), ·Ô̤ÓÂÈ fï˜ Ó· Û˘ÓÂÎÙÈÌËıÔ‡Ó ¿ÏÏÔÈ Û˘Ì·Ú¿ÁÔÓÙ˜ Èı·Ó‹˜ Û˘ÌÌÂÙÔ¯‹˜ ÛÙË Ì›ˆÛË Ù˘ GFR (™. ¢È·‚‹Ù˘, ∞ÚÙËÚȷ΋ À¤ÚÙ·ÛË, ÀÂÚÏÈȉ·ÈÌ›·, ËÏÈΛ·). ÕÏÏË ÌÂϤÙË, Ô˘ ˘ÔÛÙËÚ›˙ÂÈ ÙËÓ ·ÏÏ·Á‹ ÛÙÚ·ÙËÁÈ΋˜ ÚfiÏ˄˘ ˘ÔÙÚÔ‹˜ HBV, Â›Ó·È ÙˆÓ I.Lenci et al18 ÛÙËÓ ÔÔ›· ·ÛıÂÓ›˜, ‚ÔÈ ÔÔ›ÔÈ ÌÂÙ·ÌÔۯ‡ÙËÎ·Ó ÁÈ· ª∏∞¡Δπ∫π Î·È Ì HBsAg+, anti ∏μe+ Î·È HBV DNA (-), ÌÂÙ¿ 6 Ì‹Ó˜ ·fi ÙË ª∏ ˘Ô‚Ï‹ıËÎ·Ó Û ‚ÈÔ„›· ‹·ÙÔ˜ Î·È 30 ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÙÔ ÔÏÈÎfi HBV DNA Î·È ÙÔ ccc DNA ‹Ù·Ó ÌË ·ÓȯÓ‡ÛÈÌ· ÛÙÔÓ Ë·ÙÈÎfi ÈÛÙfi Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó ÛÙË ÌÂϤÙË. ¢ÈÂÎfiË Ë ¯ÔÚ‹ÁËÛË ÙÔ˘ HBIG Î·È ÔÈ ·ÛıÂÓ›˜ Û˘Ó¤¯ÈÛ·Ó Ó· Ï·Ì‚¿ÓÔ˘Ó LAM. ªÂÙ¿ 6 Ì‹Ó˜ ˘Ô‚Ï‹ıËÎ·Ó ÂÎ Ó¤Ô˘ Û ‚ÈÔ„›· ‹·ÙÔ˜, ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ Î·È ¿ÏÈ ÙÔ ÔÏÈÎfi HBV DNA Î·È ÙÔ cccDNA ÛÙÔÓ Ë·ÙÈÎfi ÈÛÙfi,Ô˘ ‚Ú¤ıËÎ·Ó ÌË ·ÓȯÓ‡ÛÈÌ· Î·È ‰ÈÂÎfiË Ë ¯ÔÚ‹ÁËÛË Î·È Ù˘ LAM. ªÂÙ¿ ‰È¿ÌÂÛÔ ¯ÚfiÓÔ 28,7 Ì‹Ó˜(‡ÚÔ˜ 22-42)Û 5 ·ÛıÂÓ›˜ ÛËÌÂÈÒıËΠ˘ÔÙÚÔ‹, ÛÙÔÓ ¤Ó· ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ ÙÔ˘ HBIG Î·È ÛÙÔ˘˜ ¿ÏÏÔ˘˜ 4 ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ LAM. ™ÙÔÓ 1Ô ·ÛıÂÓ‹ ÚÔÛÂÙ¤ıË ·Ì¤Ûˆ˜ HBIG, Î·È Û ¤Ó·Ó ‰Â‡ÙÂÚÔ ÚÔÛÂÙ¤ıË TDF. K·È ÛÙÔ˘˜ ‰‡Ô ·ÚÓËÙÈÎÔÔÈ‹ıËΠۇÓÙÔÌ· ÙÔ HBsAg, ÂÓÒ ÛÙÔ˘˜ ¿ÏÏÔ˘˜ 3 ‹Ù·Ó ÌfiÓÔ ·ÚÔ‰È΋ Ë ıÂÙÈÎÔÔ›ËÛË ÙÔ˘ HBsAg. To Û˘Ì¤Ú·ÛÌ· Ù˘ ÌÂϤÙ˘ Â›Ó·È fiÙÈ Ë ÌË ·ÓȯÓ¢ÛÈÌfiÙËÙ· ÙÔ˘ cccDNA ÛÙÔÓ Ë·ÙÈÎfi ÈÛÙfi ›Ûˆ˜ ·ÔÙÂÏ› ·ÛʷϤ˜ ÎÚÈÙ‹ÚÈÔ ·Ó·ÁÓÒÚÈÛ˘ ÙˆÓ low risk ·ÛıÂÓÒÓ ÁÈ· ˘ÔÙÚÔ‹ ÙÔ˘ HBV ÌÂÙ¿ ÙË ª∏. ™Â ÂÚ›ÙˆÛË ˘ÔÙÚÔ‹˜ ÙÔ˘ HBV ÛÙÔ ÌfiÛÂ˘Ì· Ë ¯Ú‹ÛË TDF ‹ ETV ÂÍ·ÛÊ·Ï›˙Ô˘Ó ÙËÓ ÎÏÈÓÈ΋ ÛÙ·ıÂÚfiÙËÙ·19.

OÈ ÌÂϤÙ˜ ·˘Ù¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÙË ‰˘Ó·ÙfiÙËÙ· ·ÏÏ·Á‹˜ ÛÙÚ·ÙËÁÈ΋˜ ÚfiÏ˄˘ ˘ÔÙÚÔ‹˜ ÙÔ˘ HBV ÛÙÔ ÌfiÛ¯Â˘Ì·, Ë ÔÔ›· ÌÔÚ› Ó· Û˘ÓÔ„ÈÛÙ› ÛÙȘ ·Ú·Î¿Ùˆ ÚÔÙ¿ÛÂȘ: • H ·ÓÙÈÈ΋ ıÂÚ·›· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Ì ÈÛ¯˘Ú¿ ·ÓÙÈÈο (TDF, ETV), Ì ÛÙfi¯Ô ÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË ‹ ηχÙÂÚ· ÙË ÌË ·ÓȯÓ¢ÛÈÌfiÙËÙ· ÙÔ˘ HBV DNA (<10-15 IU/mL), ·ÔÙÂÏ› ÙËÓ ÈÔ ÎÚ›ÛÈÌË ·Ú¿ÌÂÙÚÔ ÁÈ· ÙËÓ ÚfiÏË„Ë ˘ÔÙÚÔ‹˜ ÙÔ˘ ∏BV ÛÙÔ ÌfiÛ¯Â˘Ì·. °È· ·ÛıÂÓ›˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó LAM Î·È ‰È·ÙËÚÔ‡Ó ÌË ·ÓȯÓ‡ÛÈÌ·

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£. μ∞™π§∂π∞¢∏™

Â›‰· ∏μV DNA, Û˘Ó¤¯ÈÛË Ù˘ LAM. °È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó Û˘Ó‰˘·ÛÌfi LAM+ ADV, ·ÓÙÈηٿÛÙ·ÛË Ù˘ ADV Ì TDF. ™Â ÚˆÙÔıÂÚ·¢fiÌÂÓÔ˘˜ ·ÛıÂÓ›˜ ÛÙË Ï›ÛÙ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÂÈÏÔÁ‹ ÌÂٷ͇ ETV ‹ TDF. ¶ÚÔÛÔ¯‹ ÛÙËÓ ÚÔÛ·ÚÌÔÁ‹ Ù˘ ‰fiÛ˘ ÙˆÓ NUCs ÛÙËÓ GFR10 • ¢ÈÂÁ¯ÂÈÚËÙÈο ÛÙËÓ ·ÓË·ÙÈ΋ʿÛË: 5000 U HBIG IV • MÂÙÂÁ¯ÂÈÚËÙÈο ÙËÓ 1Ë Â‚‰ÔÌ¿‰·: 2000 U HBIG IV/ËÌÂÚËÛ›ˆ˜ Î·È Û˘Ó¤¯ÈÛË ·fi ÙËÓ 1Ë Ì¤Ú· ÙÔ˘ ·ÓÙÈÈÎÔ‡ Ô˘ ÂÏ¿Ì‚·Ó ÚÔÂÁ¯ÂÈÚËÙÈο.

• ΔÔ 1Ô ÙÚ›ÌËÓÔ: ¯ÔÚ‹ÁËÛË Î¿ı ̋ӷ 2000 U HBIG IM Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‰È·ÎÔ‹ ÙÔ˘ HBIG ÛÙÔ˘˜ low risk ·ÛıÂÓ›˜ (ÚÈÓ ÙË ª∏ ∏μeAg·ÚÓËÙÈÎfi, HBV DNA ÌË ·ÓȯÓ‡ÛÈÌÔ, HBV+HDV, ÔÍ›· Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ·fi HBV) Î·È ÂÊfiÛÔÓ ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 3 Ô˘ Ì‹Ó· HBsAg·ÚÓËÙÈÎfi, HBV DNA <10-15 IU/mL. ™˘Ó¤¯ÈÛË Ì ÙÔ ¡UC Ô˘ ÂÏ¿Ì‚·ÓÂ. ŒÏÂÁ¯Ô˜ ÙÔ˘ HBsAg, anti HBs οı ÙÚ›ÌËÓÔ Î·È ÙÔ˘ HBV DNA οı 6 Ì‹Ó˜.

• TÔ 2Ô ÙÚ›ÌËÓÔ .°È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ·ÓȯÓ‡ÛÈÌ· Â›‰· HBV DNA‹/Î·È HBeAg ıÂÙÈÎfi ÚÈÓ ÙË ª∏, ¯ÔÚ‹ÁËÛË Î¿ı ̋ӷ 2000 U HBIG IM. ™ÙÔ Ù¤ÏÔ˜ ÙÔ˘ 6Ô˘Ì‹Ó· Î·È ÂÊfiÛÔÓ ÙÔ HBsAg ·ÚÓËÙÈÎfi, HBV DNA <10-15 IU/mL, ‰È·ÎÔ‹ ÙÔ˘ HBIG Î·È Û˘Ó¤¯ÈÛË ÙÔ˘ Ì ÙÔ NUC Ô˘ ÂÏ¿Ì‚·ÓÂ, ¤ÏÂÁ¯Ô˜HBsAg, anti HBs οı 3 Ì‹Ó˜, HBV DNA οı 6 Ì‹Ó˜.

• ™ÙÔ˘˜ 6 Ì‹Ó˜ Î·È 18 Ì‹Ó˜ ÌÂÙ¿ ÙË ª∏, ‚ÈÔ„›· ‹·ÙÔ˜ Î·È ¤ÏÂÁ¯Ô˜ ÛÙÔÓ Ë·ÙÈÎfi ÈÛÙfi cccDNA ÁÈ· ÙËÓ ·ÛÊ·Ï‹ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ Èı·ÓfiÙËÙ·˜ ˘ÔÙÚÔ‹˜.

• ∂› ˘ÔÙÚÔ‹˜ ÙÔ˘ Ù˘ Ïԛ̈͢ (HBsAg+, HBV DNA ·ÓȯÓ‡ÛÈÌÔ) Â·ÓÂÈÛ·ÁˆÁ‹ ÙÔ˘ HBIG ‹/ Î·È ÙÚÔÔÔ›ËÛË Ù˘ ·ÓÙÈÈ΋˜ ·ÁˆÁ‹˜ Ì ‚¿ÛË ÙÔ profile ·ÓÙ›ÛÙ·Û˘ ÛÙ· NUCs

μÈ‚ÏÈÔÁÚ·Ê›· 1. Mukherjee S. A Review of Hepatitis B Management in Pre- and Post-Liver Transplant Recipients Δhe Open Immunology Journal 2010; 3: 27-35.

2. Loomba R, Rowley A, Wesley R, et al. Systematic review: the effect of preventive lamivudine on hepatitis B reactivation during chemotherapy. Ann Intern Med 2008; 148: 519-28.

3. Palmore TN, Shah NL, Loomba R, et al. Reactivation of hepatitis B with reappearance of hepatitis B surface antigen after chemotherapy and immune suppression.

Clin Gastroenterol Hepatol 2009; 7: 1130-7.

4. Pungapong S, Kim WR, Poterucha JJ. Natural history of

hepatitis B virus infection: an update for clinicians.

Mayo Clin Proc 2007; 82: 967-75.

5. Hoofnagle JH. Reactivation of hepatitis B. Hepatology 2009; 49 (5 Suppl): S156-65.

6. ∂∞SL Clinical Practice Guidelines: Management of Chronic Hepatits B. Journal of Hepatology 2009;50: 227-242.

7. Niro GA., Rosina F, Rizzetto M. Treatment of hepatitis D. J Viral Hepat 2005; 12, 2–9.

8. Mederacke I, et al. Early HDV-RNA kinetics after liver transplantation. Hepatology 2009; 50 (Suppl.), 507.

9. Smedile A, et al. Hepatitis D viremia following orthotopic liver transplantation involves a typical HDV virion with a hepatitis B surface antigen envelope. Hepatology 1998; 27: 1723–1729.

10. Lok AS, MacMachon BJ. Chronic Hepatitis B:Update 2009 AASLD Practice Guidelines Hepatology 2009; 50: 1-36.

11. Liau YF, Raptopoyloy-Gigi M, Cheinquer H, et al. Efficacy and Safety of Entecavir versus Adefovir in Chronic Hepatitis B Patients with Hepatic Decompensation: A Randomized Open-Label Study. Hepatology in Press.

12. Shim JH, Lee HC, Kim KM, Lim YS, Chung YH, Lee YS, et al. Efficacy of entecavir in treatment-naive patients with hepatitis B virus-related decompensated cirrhosis.

J Hepatol 2010; 52(2): 176-182.

13. Liaw YF, Sheen IS, Lee CM, Akarca US, Papatheodoridis VG, Wong F, et al. Tenofovir Disoproxil Fumarate (TDF), Emtricitabine/TDF and Entecavir in patients with decompensated chronic hepatitis B liver disease.

Hepatology 2011; 53(1): 62-72.

14. Lange CM, Bojunga J, Hofmann WP, Wunder K, Mihm U, Zeuzem S et al. Severe lactic acidosis during treatment of chronic hepatitis B with entecavir in patients with impaired liver function. Hepatology 2009; 50(6):2001-2006.

15. Ray Kim W, Poterucha LL, Kremers WK, Ishitani MB, Rolland E. Dickson Outcome of Liver Transplantation for Hepatitis B in the United States Liver Transplantation 2004; 10: 968-974.

16. Teperman L, Spivey J, Poordad F, Schiano T, Bzowej N, Pungpapong S, Martin P, Coombs D, Hirsch K, Anderson J, Rousseau F. Emtricitabine/Tenofovir DF Combination ± HBIG Post-Orthotopic Liver Transplantation to Prevent Hepatitis B Recurrence in Patients with Normal to Moderate Renal Impairment: Interim Results 45th Annual Meeting of the European Association for the Study of the Liver April 14-18, 2010 Vienna, Austria Oral Session # 28.

17. Vasiliadis Th, Antoniadis N, Akriviadis E, Fousas I, Goulis I, Imvrios G, Giouleme O, Giakoustidis D, Cholongitas E, Papanikolaou V, Takoudas D. Safety and Effectiveness of hepatitis B immunoglobulin (HBIG) with drawal and maintenance nucleos(t)ide analogues for prophylaxis against HBV recurrence: a single centre study AASLD 2010 Annual Meeting Abstract 1147.

18. Lenci I, Tisone G, Di Paolo D, Marcuccilli F, Tariciotti

METAMO™XEY™Eπ™ 2011

L, Ciotti M, Svicher V, Perno F, Angelico M. Safety of Complete and Sustained Prophylaxis Withdrawal in Patients Liver Transplanted for HBV-Related Cirrhosis at Low Risk of HBV Recurrence. Journal of Hepatology in press.

109

19. Papatheodoridis GV, Cholongitas E, Archimandritis AJ, Burroughs AK. Current Management of Hepatitis B Virus Infection before and after Liver Transplantation Liver International 2009; 29(9): 1294-1305.

º˘ÛÈ΋ ÂͤÏÈÍË Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ Ë·Ù›Ùȉ·˜ C ÛÙÔ ÌfiÛ¯Â˘Ì· ¢.¡. ™·ÌˆÓ¿Î˘

ÚÔÊÏÂÁÌÔÓÒ‰ÂȘ ΢ÙÙ·ÚÔΛÓ˜ ·ÏÏ¿ Î·È ¤ÎÊÚ·ÛË ÁÔÓȉ›ˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ›ÓˆÛË . º·›ÓÂÙ·È fiÙÈ Ù· ˘„ËÏfiÙÂÚ· ÊÔÚÙ›· Ô‰ËÁÔ‡Ó Û ÌÈ· ÂÓÈÛ¯˘Ì¤ÓË ÚÔ·ÔÙˆÙÈ΋, ÚÔ˚ÓˆÙÈ΋ ·ÓÙ›‰Ú·ÛË ÙÔ˘ ÍÂÓÈÛÙ‹ Ô˘ ηıÔÚ›˙ÂÈ ÙËÓ ÌÂÙ¤ÂÈÙ· ÔÚ›·. ∂ÈÚfiÛıÂÙ·, ‰È·‰Èηۛ˜ fiˆ˜ Ù˘ ÔÍ›·˜ ·fiÚÚȄ˘ ÌÔÚ› Ó· ÂÈÙ·¯‡ÓÔ˘Ó ÙȘ ˘¿Ú¯Ô˘Û˜ ‚Ï¿‚˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔÓ HCV. ΔÔ ÎÏÈÓÈÎfi Ê¿ÛÌ· Ù˘ ˘ÔÙÚÔ‹˜ Â›Ó·È ÔÈΛÏÔ. ™Â ÂÚ›Ô˘ 30% ÙˆÓ ·ÛıÂÓÒÓ ‰ÂÓ ˘¿Ú¯ÂÈ ÂÌÊ·Ó‹˜ ÂͤÏÈÍË Ù· ÚÒÙ· ¯ÚfiÓÈ·, ÂÓÒ Û ¤Ó· 70% - 90% ı· ·Ó·Ù˘¯ıÔ‡Ó ÛÙËÓ ÂÓÙ·ÂÙ›· ·ÏÏÔÈÒÛÂȘ ¯ÚfiÓÈ·˜ Ë·Ù›Ùȉ·˜, Ì ÔÈΛÏË ÂͤÏÈÍË Ù˘ ›ÓˆÛ˘ (™¯. 1).

O fiÚÔ˜ ¯ÔÏÔÛÙ·ÙÈ΋ (ÈÓˆÙÈ΋) Ë·Ù›Ùȉ· ÂÚÈÁÚ¿ÊÂÈ ÌÈ· ·Û˘Ó‹ıÈÛÙË ·ıÔÏÔÁÈ΋ ηٿÛÙ·ÛË Ô˘ Û˘Ì‚·›ÓÂÈ ÂÓ ·Ô˘Û›· ÛËÌ·ÓÙÈÎÒÓ ÛÙÂÓÒÛÂˆÓ ÛÙ· ¯ÔÏËÊfiÚ·, ·fiÊڷ͢ fiÚˆÓ, ÛÙ¤ÓˆÛ˘ ‹ ıÚfiÌ‚ˆÛ˘ Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜. ∏ ÔÓÙfiÙËÙ· ·˘Ù‹ ‰ÂÓ ˘¿Ú¯ÂÈ Û ÌË ·ÓÔÛÔηÙÂÛÙ·Ï̤ÓÔ˘˜ ·ÛıÂÓ›˜ Î·È Û˘Ó‹ıˆ˜ ·Ú·ÙËÚÂ›Ù·È ÌÂٷ͇ 1 Î·È 6 ÌËÓÒÓ ·fi ÙË ª∏. μÈÔ¯ËÌÈο ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ˘ÂÚ¯ÔÏÂÚ˘ıÚÈÓ·ÈÌ›· Ì ·‡ÍËÛË AlP & ÁGT > 5 x ULN Î·È ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ballooning ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ÎÂÓÙÚÈο ¯ˆÚ›˜ ȉȷ›ÙÂÚË Î˘ÙÙ·ÚÈ΋ ·ÒÏÂÈ·, Ì ÌÈÎÚ‹ ÊÏÂÁÌÔÓ‹ ÛÙ· ˘Ï·›· ‹ ÙÔ Ïfi‚ÈÔ. ™˘Û¯ÂÙ›˙ÂÙ·È Ì ÂÍ·ÈÚÂÙÈο ˘„ËÏfi HCV RNA ÛÙÔÓ ÔÚfi Î·È ÙÔ ‹·Ú, Û˘Ó‹ıˆ˜ Â› ȉȷ›ÙÂÚ· ÂÓÈÛ¯˘Ì¤Ó˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜. ™˘Ó˘¿Ú¯ÂÈ ‰È·Ù·Ú·Á̤ÓË ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË (·ÏÏ·Á‹ Δ∏1 Û Δ∏2 ·¿ÓÙËÛË ÂÓ‰ÔË·ÙÈÎÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ), ‰È·Ê˘Á‹ Î·È ¿ÌÂÛË Î˘ÙÙ·ÚÔ·ıËÙÈ΋ ‚Ï¿‚Ë ·fi ÙÔÓ HCV (Roche, 2010). ¶·Ú¿ ÙË Ì›ˆÛË Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Î·È ÙËÓ ·ÓÙÈÈ΋ ıÂÚ·›· ¤¯ÂÈ Î·Î‹ ÚfiÁÓˆÛË. ∏ ÂͤÏÈÍË Ù˘ Ë·Ù›Ùȉ·˜ C ÌÂÙ¿ ÙË ª∏ Â›Ó·È Ù·¯‡ÙÂÚË Û ۇÁÎÚÈÛË Ì ÙÔÓ ÌË ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ·ÓÙ›ÛÙÔÈ¯Ô ÏËı˘ÛÌfi (™¯. 2). ΔÔ 2030% ÂÚ›Ô˘ ÙˆÓ ·ÛıÂÓÒÓ ÛÙ· 5 ¯ÚfiÓÈ· ¤¯Ô˘Ó ΛÚÚˆÛË Î·È ÂÚÈÛÛfiÙÂÚÔ ·fi 40% ÛÙ· 10 ¯Úfi-

∏ Ë·ÙÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ (ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Ì ‹ ¯ˆÚ›˜ ∏∫∫) Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ Ë·Ù›Ùȉ· C ·ÔÙÂÏ› Û‹ÌÂÚ· ÙË Û˘¯ÓfiÙÂÚË ¤Ó‰ÂÈÍË ÛÙÔ ‰˘ÙÈÎfi ÎfiÛÌÔ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ª∏). ¢˘ÛÙ˘¯Ò˜ Ë Â·Ó·Ïԛ̈ÍË Ì ÙÔÓ Èfi Â›Ó·È ·Ó·fiÊ¢ÎÙË Û fiÛÔ˘˜ ·ÛıÂÓ›˜ ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯Ô˘Ó ıÂÙÈÎfi HCV-RNA. ¶ËÁ‹ Ù˘ Â·Ó·Ïԛ̈͢ ıˆÚÂ›Ù·È ÙÔ ›‰ÈÔ ÙÔ ·›Ì· Î·È ·˘Ùfi Û˘Ì‚·›ÓÂÈ Î·Ù¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÂÓÒ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ÚÔ¤Ú¯ÂÙ·È ·fi Â͈Ë·ÙÈΤ˜ ËÁ¤˜ ÙÔ˘ ÈÔ‡. ∞ÚÎÂÙÔ› ·ÛıÂÓ›˜ ÂÈÛÙÚ¤ÊÔ˘Ó Û Â›‰· È·ÈÌ›·˜ Û˘ÁÎÚ›ÛÈÌ· ‹ ÌÂÁ·Ï‡ÙÂÚ· (>1 log) ·’ fiÙÈ ÚÈÓ ÙË ª∏ ̤۷ Û ϛÁ˜ ÒÚ˜ ¤ˆ˜ 4 ‚‰ÔÌ¿‰Â˜ ·fi ÙËÓ Â¤Ì‚·ÛË (·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ¤Ï·‚·Ó ÛÙÂÚÔÂȉ‹ ηٿ ÙËÓ Â¤Ì‚·ÛË ·ÚÔ˘Û›·Û·Ó plateau, ¯ˆÚ›˜ ·˘Ù‹Ó ÙËÓ Ù·¯Â›· Â¿ÓÔ‰Ô ÛÙ· ÊÔÚÙ›· ÚÔ ª∏). ™ÙË ª∏ ·fi ˙ÒÓÙ· ‰fiÙË, Ë ÌfiÏ˘ÓÛË Î·Ù¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË Â›Ó·È Ù·¯‡ÙÂÚË Î·È ÁÚËÁÔÚfiÙÂÚ· ÚÔÛÂÁÁ›˙ÔÓÙ·È Ù· Â›‰· ÊÔÚÙ›Ô˘ ÚÔ Ù˘ ª∏. ø˜ ÚÔ˜ ÙË ‚Ï¿‚Ë ÈÛ¯·ÈÌ›·˜-Â·Ó·ÈÌ¿ÙˆÛ˘, Â›Ó·È Èı·Ófi Ó· Û˘ÓÂÈÛʤÚÂÈ ÛÙËÓ ÂͤÏÈÍË Ù˘ HCVÏԛ̈͢, fï˜ ˘¿Ú¯Ô˘Ó ·ÎfiÌË ·Û¿ÊÂȘ ˆ˜ ÚÔ˜ ÙÔ ‚·ıÌfi Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ Â·Ó·Ïԛ̈ÍË Î·È ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi.

OÍ›· Ë·Ù›Ùȉ· ·ÓȯÓ‡ÂÙ·È Û˘Ó‹ıˆ˜ ÌÂٷ͇ 1-4 ‚‰ÔÌ¿‰ˆÓ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ peak ÙÔ˘ ÈÈÎÔ‡ ÊÔÚÙ›Ô˘. ∞ÎÔÏÔ‡ıˆ˜ ÔÈ ÙÚ·ÓÛ·ÌÈÓ¿Û˜ Î·È ÙÔ HCV RNA ˘Ô¯ˆÚÔ‡Ó ÚÔԉ¢ÙÈο. πÛÙÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο Ë·Ù›Ùȉ·˜ (ÌÔÈ¿˙ÂÈ Ì ÙËÓ Ë·Ù›Ùȉ· ÚÔ ª∏) ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ÛÙÔ 75% ÙˆÓ ÏËÙÒÓ ÙÔ˘˜ ÚÒÙÔ˘˜ 6 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË . ª¤Û· ÛÙÔ ‹·Ú, Ë ¯ÚfiÓÈ· Ë·Ù›Ùȉ· (ÌÂÙ¿ ÙË ª∏) Û˘Û¯ÂÙ›˙ÂÙ·È Ì „ËÏ¿ Â›‰· ¤ÎÊÚ·Û˘ ÙˆÓ ÁÔÓȉ›ˆÓ TNF·, IFNÁ Î·È IL-2 Ì ٷ Â›‰· ¤ÎÊÚ·Û˘ ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ-Th1Ó· Â›Ó·È fiÌÔÈ· Û ·˘Ù¿ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙË ¯ÚfiÓÈ· HCV Ïԛ̈ÍË ÚÈÓ ÙË ª∏. ∂›Û˘ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÁÈ· ˘ÂÚ¤ÎÊÚ·ÛË ¿ÏÏˆÓ ÁÔÓȉ›ˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ Δ-·ÙÙ·Ú·, ÌfiÚÈ· ÙÔ˘ MHC,

110

METAMO™XEY™Eπ™ 2011

111

% Patients with severe fibrosis (bridging/cirrhosis)

50%

40%

Posttransplant

30%

Berenguer, 2002 Sanchez-Fueyo, 2002 Prieto, 1999 Gane, 1996 Yilmaz, 2007 Neumann, 2002

20%

10% Nontransplant Poynard,1997

0% 0

1

2

3

4

5

Years Posttransplant

™¯‹Ì· 1. ∂ͤÏÈÍË Ù˘ ÛÔ‚·Ú‹˜ ›ÓˆÛ˘ – ΛÚÚˆÛ˘ ·fi ˘ÔÙÚÔ‹ Ù˘ Ë·Ù›Ùȉ·˜ C ÂÓÙfi˜ 5 ÂÙÒÓ ·fi ÙË ª∏ Û ‰È¿ÊÔÚ· ΤÓÙÚ·. (Gane EJ, Liver Transplant 2008; 14: S36-S44).

NO HEPATITIS 20% - 30%

6 months

MINIMAL INJURY

Delayed injury

OLT

1-3 months

AUTE HEPATITIS 6 months 70%

CHRONIC HEPATITIS 50% - 80%

1-3 months

VIRAL RECURRENCE 95%

FIBROSING CHOLESTATIC HEPATITIS 2%- 8%

DEATH 50%

?

CIRRHOSIS 8% - 44% in 5-10 years

Re-OLT 10% DEATH

™¯‹Ì· 2. º˘ÛÈ΋ πÛÙÔÚ›· Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ Ë·Ù›Ùȉ·˜ C ÌÂÙ¿ ÙË ª∏. (McCaughan GW et al, J Hepatolo 2004; 40: 368-374).

ÓÈ·, Ì Â·ÎfiÏÔ˘ıÔ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ú‹Í˘ ·ÓÙÈÚÚfiËÛ˘ (>30% ÛÙÔ 1 ¤ÙÔ˜ Î·È >50% ÛÙ· 3 ¤ÙË). ∫·È Ë Î›ÚÚˆÛË ¤¯ÂÈ Û˘ÌÈÂṲ̂ÓË ÔÚ›· Û ۯ¤ÛË Ì ÙËÓ Î›ÚÚˆÛË C ÚÔ Ù˘ ª∏. ªÂÙ¿ ÙË Ú‹Í˘ Ù˘ ·ÓÙÈÚÚfiËÛ˘ ÂÎÙÈÌ¿Ù·È fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ı·Ó¿ÙÔ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ Û ۯ¤ÛË Ì ÚÔ Ù˘ ª∏ Ì 3ÂÙ‹ ÂÈ‚›ˆÛË < 10% ÌÂÙ¿ ÙËÓ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· Ô˘ ÔÊ›ÏÂÙ·È ÛÙÔÓ Èfi HCV, ¤Ó·ÓÙÈ >60% ÌÂÙ¿ ÙË Ú‹ÍË ·ÓÙÈÚÚfiËÛ˘ «Û ·ÓÔÛÔÂ·ÚΛ˜». ∂ÎÙÈÌ¿Ù·È fiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÔ 10% ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ı· ˘Ô‚ÏËıÔ‡Ó Û ª∏ ÁÈ· HCV ı· ¯ÚÂÈ·ÛÙÔ‡Ó Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÁÈ· Ë·ÙÔ¿ıÂÈ· ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔÓ Èfi, ·ÏÏ¿ Ù· ·ÔÙÂϤÛÌ·Ù· Â›Ó·È ÊÙˆ¯¿ Î·È Ë ıÓËÛÈÌfi-

ÙËÙ· ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ Ôχ ÌÂÁ¿ÏË. ¶ÔÏÏ¿ ÚÔÁÚ¿ÌÌ·Ù· ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ¤¯Ô˘Ó ·ÚÓËÙÈ΋ ÛÙ¿ÛË ÛÙËÓ Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ·ÛıÂÓÒÓ Ì ΛÚÚˆÛË ÛÙÔ ÌfiÛ¯Â˘Ì· ·fi ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘. ¶ÔÈÎÈÏ›· ·Ú·ÁfiÓÙˆÓ ÚÈÓ, ηٿ ÙË ‰È¿ÚÎÂÈ· Î·È ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯Ô˘Ó Û˘Û¯ÂÙÈÛı› Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ˘ÔÙÚÔ‹˜ . ∏ ·ÓÔÛÔηٷÛÙÔÏ‹ ÂÍ’ ÔÚÈÛÌÔ‡ ·ÔÛÎÔ› Û ÌÈ· ÏÂÙ‹ ÈÛÔÚÚÔ›·, ÌÂٷ͇ ηٷÛÙÔÏ‹˜ Ù˘ ·ÓÔÛÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ Î·È ‰È·Ù‹ÚËÛ˘ ·Ó·Áη›ˆÓ ·ÓÙȉڿÛÂˆÓ ÙÔ˘ ÍÂÓÈÛÙ‹ ÛÙÔÓ Èfi. Δ·˘Ùfi¯ÚÔÓ· fï˜, Ë ·ÓÔÛÔηٷÛÙÔÏ‹ ·ÔÙÂÏ› Ì›˙ÔÓ· ·Ú¿ÌÂÙÚÔ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ‰È·ÊÔÚÂÙÈ΋ Ê˘ÛÈ΋ ÈÛÙÔÚ›· ·ÏÏ¿ Î·È ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ÓfiÛÔ˘ ÌÂÙ¿ ÙË ÌÂÙ·Ìfi-

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Û¯Â˘ÛË. À¿Ú¯Ô˘Ó ·ÎfiÌ· ·Û¿ÊÂȘ ˆ˜ ÚÔ˜ ÙËÓ «Î·Ù·ÏÏËÏfiÙÂÚË» ·ÓÔÛÔηٷÛÙÔÏ‹ ÁÈ· ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÛÙËÓ Ë·Ù›Ùȉ· C, ÂÓÒ Ï›Ô˘Ó ‰Â‰Ô̤ӷ ·¢ı›·˜ Û‡ÁÎÚÈÛ˘ Ù˘ ‰˘Ó·ÌÈ΋˜ ÂοÛÙÔ˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÔ‡. ∂ÓÙÔ‡ÙÔȘ ÔÈ ÒÛÂȘ ÎÔÚÙÈÎÔÂȉÒÓ Î·È ÔÈ ·ÓÙÈÏÂÌÊÔ΢ÙÙ·ÚÈΤ˜ ıÂÚ·›˜ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÁÈ· ÙËÓ ÔÍ›· ΢ÙÙ·ÚÈ΋ ·fiÚÚÈ„Ë ¤¯ÂÈ ·Ô‰ÂȯÙ› fiÙÈ Û˘Ó‰¤ÔÓÙ·È Ì ÛÔ‚·ÚfiÙÂÚË ˘ÔÙÚÔ‹ ÌÂÙ¿ ÙË ª∏. OÈ ·Ó·ÛÙÔÏ›˜ ηÏÛÈÓ¢ڛÓ˘ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ÈÛÔ‰‡Ó·ÌÔÈ ˆ˜ ÚÔ˜ ÙË ‚·Ú‡ÙËÙ· Ù˘ ˘ÔÙÚÔ‹˜ ·ÏÏ¿ Èı·Ó¿ Ë ‚·ÛÈṲ̂ÓË Û ٷÎÚfiÏÈÌÔ˘˜ ·ÓÔÛÔηٷÛÙÔÏ‹ Û¯ÂÙ›˙ÂÙ·È Ì ηχÙÂÚË ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ Î·È ·ÛıÂÓÔ‡˜. À¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÁÈ· ÂӉ¯fiÌÂÓÔ fiÊÂÏÔ˜ ·fi ÙËÓ ·˙·ıÂÈÔÚ›ÓË ·ÏÏ¿ Î·È Ì ¯·ÌËÏ‹ ‰fiÛË Î·È Ôχ ·ÚÁ‹ Ì›ˆÛË ÙˆÓ ÎÔÚÙÈÎÔÂȉÒÓ Û˘ÓÙ‹ÚËÛ˘. ∏ ·Ó·Û‡ÓÙ·ÍË ÙÔ˘ ·ÓÔÛÔÏÔÁÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ (adaptive) ÌÂÙ¿ ÙË ª∏ Û˘Ó‰¤ÂÙ·È Ì ηχÙÂÚË ·¿ÓÙËÛË ÛÙ· ·ÓÙÈÈο Î·È Ì›ˆÛË Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢. ÀÔÛÙËÚ›˙ÂÙ·È fiÙÈ Ù·¯Â›Â˜ ·ÏÏ·Á¤˜ ‹ ÌÂÙ·‚ÔϤ˜ ÛÙË ‰˘Ó·ÌÈ΋ Ù˘ ·ÓÔÛÔηٷÛÙÔÏ‹˜ Â›Ó·È Èı·Ófi Ó· Â›Ó·È ·ÚÓËÙÈÎÔ› ÚÔÁÓˆÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙË ‚·Ú‡ÙËÙ· Ù˘ ˘ÔÙÚÔ‹˜. ΔÂÎÌËÚȈ̤ÓÔÈ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ (¶›Ó.

1) Â›Ó·È Â›Û˘ Ù· Ôχ „ËÏ¿ ÈÈο ÊÔÚÙ›· ÚÈÓ Î·È ÛÙÔ ÚÒÈÌÔ ‰È¿ÛÙËÌ· ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ë ÛÔ‚·Ú‹ ÈÛÙÔÏÔÁÈ΋ ˘ÔÙÚÔ‹ (ÛÙÔ˘˜ 4 & 12 Ì‹Ó˜ ÙÂÎÌËÚ›ˆÛË ·fi ‚ÈÔ„›·, HVPG, Fibrotest/Fibroscan), ·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ›Ù ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜, Û˘ÏÏԛ̈ÍË ·fi CMV Î·È HIV, ·ÏÏ¿ Î·È Û˘ÁÎÂÎÚÈ̤ÓÔÈ ÔÏ˘ÌÔÚÊÈÛÌÔ› Ù˘ IL-28b. ¶Ôχ ÛËÌ·ÓÙÈο ÛÙË Ê˘ÛÈ΋ ÔÚ›· Ù˘ Ïԛ̈͢ ÌÂÙ¿ ÙË ª∏ Â›Ó·È Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË Î·È Ë ÔÈfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Ì ‹·Ù· Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ‰fiÙ˜ ¿Óˆ ÙˆÓ 60 ÂÙÒÓ Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓË ıÓËÛÈÌfiÙËÙ· (ÚÒÈÌÔ ‰È¿ÛÙËÌ·) ÛÔ‚·ÚfiÙÂÚË ˘ÔÙÚÔ‹ ÙÔ˘ HCV, ÁÚËÁÔÚfiÙÂÚ· ·Ó¿Ù˘ÍË ÛÔ‚·Ú‹˜ ›ÓˆÛ˘ – ΛÚÚˆÛ˘ Î·È ÂÈÏÔÎÒÓ . ∏ ‰Ú¿ÛË ·˘Ù‹ ‰ÂÓ Â›Ó·È ÁÚ·ÌÌÈ΋ Ì ËÏÈ˘ ¿Óˆ ÙˆÓ 65 ÂÙÒÓ Ó· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ ¯ÂÈÚfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù·. ΔÔ ÂӉȷʤÚÔÓ ÛÙȘ Û˘ÁÎÂÎÚÈ̤Ó˜ ·Ú·Ì¤ÙÚÔ˘˜ Â›Ó·È fiÙÈ ·ÔÙÂÏÔ‡Ó ‰˘ÓËÙÈο

¶π¡∞∫∞™ 1. μ·ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÛÔ‚·Ú‹ ˘ÔÙÚÔ‹ Ù˘ ∏·Ù›Ùȉ·˜ C ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË μ·ıÌfi˜ ™˘Û¯¤ÙÈÛ˘ ¢fiÙË ÌÔۯ‡̷ÙÔ˜ ∏ÏÈΛ· ‰fiÙË ¢ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· °ÔÓfiÙ˘Ô˜ ILB §‹ÙË ÌÔۯ‡̷ÙÔ˜ ∏ÏÈΛ· Ï‹ÙË º˘Ï‹/º‡ÏÔ (Á˘Ó·›Î˜ ¯ÂÈÚfiÙÂÚ·) HIV Û˘ÏÏԛ̈ÍË °ÔÓfiÙ˘Ô˜ ILB HCV ÈÈÎfi ÊÔÚÙ›Ô ¶ÚÔ-ÌÂÙ·ÌfiÛ¯Â˘Û˘ ªÂÙ¿ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ∞ÓÔÛÔηٷÛÙÔÏ‹ OKT3 flÛÂȘ ÎÔÚÙÈÎÔÂȉÒÓ CMV

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ÙÚÔÔÔÈ‹ÛÈÌÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ÌÔÚÔ‡Ó Ó· ηıÔ‰ËÁ‹ÛÔ˘Ó ÙËÓ ÛˆÛÙ‹ ·fi‰ÔÛË ÙˆÓ ˘·Ú¯fiÓÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ. ∞ÓÙÈı¤Ùˆ˜ Ë ÂÎÚ›˙ˆÛË ÙÔ˘ ÈÔ‡ ÚÔÏ·Ì‚¿ÓÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘ Î·È ‚ÂÏÙÈÒÓÂÈ ÙËÓ ÂÈ‚›ˆÛË. ∏ ·ÓÙÈÈ΋ ıÂÚ·›· ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ı· ÌÔÚÔ‡Û ӷ ‚ÔËı‹ÛÂÈ ÛËÌ·ÓÙÈο ÛÙËÓ ¤Î‚·ÛË Î·ıÒ˜ ÔÈ ·ÛıÂÓ›˜ Ì „ËÏ¿ Â›‰· HCV RNA ÚÔ Ù˘ ª∏ ›¯·Ó ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ·ÒÏÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ ‹ ı·Ó¿ÙÔ˘. ∂ÓÙÔ‡ÙÔȘ Ë ıÂÚ·›· ·ÛıÂÓÒÓ Ì ÌË-·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË Î·È „ËÏfi MELD Â›Ó·È Ôχ ÊÙˆ¯¿ ·ÓÂÎÙ‹ Ì ÛÔ‚·Ú¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ (ÏÔÈÌÒÍÂȘ, Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·) Î·È ÊÙˆ¯‹ SVR. ∏ ıÂÚ·›· ÌÂÙ¿ ÙË ª∏ ·ÔÙÂÏ› ·ÎfiÌË ÔÌȯÏ҉˜ ÙÔ›Ô fi¯È ˆ˜ ÚÔ˜ ÙÔ fiÊÂÏÔ˜ (Ô˘ ÁÈ· fiÛÔ˘˜ ÂÌÊ·Ó›ÛÔ˘Ó SVR Â›Ó·È ‰Â‰Ô̤ÓÔ – SVR ÌÂٷ͇ 25-45%) ·ÏÏ¿ ÁÈ· ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ¤Ó·Ú͢ (Ê·›ÓÂÙ·È fiÙÈ Î·Ù¿ ÙËÓ ÚÒÈÌË ÂÚ›Ô‰Ô ÌÂÙ¿ ÙË ª∏ ηχÙÂÚ· Ó· ·ÔʇÁÂÙ·È ÏËÓ ÛÔ‚·Ú‹˜ ˘ÔÙÚÔ‹˜), ÙȘ ‰fiÛÂȘ ÙˆÓ Ê·ÚÌ¿ÎˆÓ (Û˘¯Ófiٷ٘ ÔÈ ÌÂÈÒÛÂȘ ‰fiÛÂˆÓ ·fi ·ÚÂÓ¤ÚÁÂȘ, ÙË Û˘Ó‡·ÚÍË ·ÓÙÈÈ΋˜ ıÂÚ·›·˜ Ì ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋ ‹ ¿ÏÏË ·ÁˆÁ‹), ÙË ‰‡ÛÎÔÏË ‰È·ÊÔÚԉȿÁÓˆÛË ÌÂٷ͇ ˘ÔÙÚÔ‹˜ ·fiÚÚȄ˘, ·ÏÏ¿ Î·È ÙÔ˘˜ ÎÈÓ‰‡ÓÔ˘ Â·ÁˆÁ‹˜ ·fiÚÚȄ˘ ‹ ·˘ÙÔ·ÓÔÛ›·˜ ·fi ÙË ¯ÔÚËÁÔ‡ÌÂÓË ıÂÚ·›·.

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ÙˆÓ Î·ÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ·ÚÂÌ‚·›ÓÔÓÙ·˜ ÛÙ· ÌÔÓÔ¿ÙÈ· ÙÔ˘ VEGF. ™Â ÂÈÚ·Ì·ÙÈÎfi ÌÔÓÙ¤ÏÔ RCC ÙÔ ÌÂÙ¤ÙÚ„ ·fi ‰ÈËıËÙÈÎfi Û ÌË-‰ÈËıËÙÈÎfi Î·È Ì›ˆÛË ÙËÓ ¤ÎÊÚ·ÛË ÌÔÚ›ˆÓ Û˘Ó‰Â‰ÂÌ¤ÓˆÓ Ì ηÚÎÈÓÈ΋ ·Ó¿Ù˘ÍË. ΔÔ Û‡ÌÏÔÎÔ Ù˘ ηÏÛÈÓ¢ڛÓ˘ ·ÔÙÂÏÂ›Ù·È ·fi ÙÚÂȘ ˘ÔÌÔÓ¿‰Â˜, ÙË Î·Ù·Ï˘ÙÈ΋ ∞, ÙË Ú˘ıÌÈÛÙÈ΋ μ Î·È ÙËÓ Î·ÏÌÔ‰Ô˘Ï›ÓË. ΔÔ Î˘ÙÙ·ÚÈÎfi ·Û‚¤ÛÙÈÔ ÂÓÂÚÁÔÔÈ› ÙË Î·Ù·Ï˘ÙÈ΋ ˘ÔÌÔÓ¿‰· Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ˘ÚËÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÌÂÙ·ÁÚ·ÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÙˆÓ Δ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. O ·Ó·ÛÙÔϤ·˜ Ù˘ ηÏÛÈÓ¢ڛÓ˘, ΢ÎÏÔÛÔÚ›ÓË, ÚÔÛÎÔÏÏ¿Ù·È ÛÙËÓ Î˘ÎÏÔÊÈÏÏ›ÓË Î·È ÙÔ Û‡ÌÏÂÁÌ· Ô˘ ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÂÓÒÓÂÙ·È Ì ÙË Ú˘ıÌÈÛÙÈ΋ μ ˘ÔÌÔÓ¿‰· Ù˘ ηÏÛÈÓ¢ڛÓ˘ Î·È ·ÔÙÚ¤ÂÈ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ˘ÚËÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÌÂÙ·ÁÚ·ÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÙˆÓ Δ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∂ÈϤÔÓ ÂÎÙfi˜ ·fi ÙËÓ ·Ó·ÛÙÔÏ‹ ˘ÚËÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÌÂÙ·ÁÚ·ÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÙˆÓ Δ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ÔÈ CNis Èı·ÓfiÓ Ó· Ú˘ıÌ›˙Ô˘Ó ÙË Â·ÁˆÁ‹ ÙÔ˘ Û‹Ì·ÙÔ˜ ¿ÏÏˆÓ ÌÔÚ›ˆÓ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ VEGF, ÙÔ˘ ÔÁÎÔÁÔÓȉ›Ô˘ Ras Î·È ¿ÏÏˆÓ ÔÁÎÔÁÔÓȉ›ˆÓ.

O ∏·ÙÔ΢ÙÙ·ÚÈÎfi˜ ηÚΛÓÔ˜ (∏∫∫) Â›Ó·È Ô ÈÔ Û˘¯Ófi˜ ηÚΛÓÔ˜ ÙÔ˘ ‹·ÙÔ˜. ™˘¯Ó¿ ÂÈϤÎÂÈ ÙËÓ ÂͤÏÈÍË Ù˘ ¯ÚfiÓÈ·˜ Ë·ÙÈ΋˜ ÓfiÛÔ˘ Î·È Ë ÂÌÊ¿ÓÈÛË Â›Ó·È ·˘Í·ÓfiÌÂÓË ÛÙË ¯ÒÚ˜ Ù˘ ¢‡Û˘. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (OLTx) Â›Ó·È Ë È‰·ÓÈ΋ ıÂÚ·›· ÙÔ˘ ∏∫∫ Û ΛÚÚˆÛË ÁÈ·Ù› ·ÓÙÈÌÂÙˆ›˙ÂÈ Î·È ÙËÓ ˘ÔΛÌÂÓË Î›ÚÚˆÛË. ¢˘ÛÙ˘¯Ò˜ Ô ∏∫∫ ÌÔÚ› Ó· ˘ÔÙÚÔÈ¿ÛÂÈ ÛÙÔ ÌfiÛ¯Â˘Ì· Î·È Ë Î‡ÚÈ· ·›ÙÈ· Â›Ó·È ·ıÔÏÔÁÔ·Ó·ÙÔÌÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ fiÁÎÔ˘ (Ì·ÎÚÔ-, ÌÈÎÚÔ- ‰È‹ıËÛË ·ÁÁ›ˆÓ). ∏ ˘ÈÔı¤ÙËÛË ÙˆÓ ÎÚÈÙËÚ›ˆÓ ÙÔ˘ ªÈÏ¿ÓÔ˘ ›¯·Ó ıÂÙÈÎfi ·ÓÙ›ÎÙ˘Ô ÛÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Î·È ÛÙË ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ ˘ÔÙÚÔÒÓ ∏∫∫ ÌÂÙ¿ ·fi OLTx. ΔÔ ÂfiÌÂÓÔ ‚‹Ì· Â›Ó·È Ë Î·Ù·ÓfiËÛË ÙˆÓ ‚ÈÔÏÔÁÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È È‰ÈÔÙ‹ÙˆÓ ÙÔ˘ ∏∫∫ ÁÈ· ÙËÓ Î·Ï‡ÙÂÚË ‰˘Ó·Ù‹ ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ. ∏ ˘ÔÙÚÔ‹ ÙÔ˘ ∏∫∫ ÌÂÙ¿ ·fi OLTx Û˘Ó‰¤ÂÙ·È Ì Ôχ ¿Û¯ËÌË ÚfiÁÓˆÛË Î·È Ë Ì¤ÛË ÂÈ‚›ˆÛË Â›Ó·È 13 Ì‹Ó˜.

∞ÓÔÛÔηٷÛÙÔÏ‹ Î·È Î·ÚΛÓÔ˜ O ÚfiÏÔ˜ ÙˆÓ CNi ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ∏∫∫ ∏ ÔÌ¿‰· ÙÔ˘ Suthanthiran ¤‰ÂÈÍ fiÙÈ fiÁÎÔÈ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ¯ÔÚËÁ‹ıËΠ΢ÎÏÔÛÔÚ›ÓË ÂͤÏÈÍ·Ó ¤Ó·Ó ‰ÈËıËÙÈÎfi Ê·ÈÓfiÙ˘Ô ‰È·Ì¤ÛÔ˘ ÂÓfi˜ ·˘ÙfiÓÔÌÔ˘ ΢ÙÙ·ÚÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Ô˘ ÚÔˆıÔ‡Û ÙË ÓÂÔÏ·ÛÌ·ÙÈ΋ ·‡ÍËÛË Û ‚·ÚÈ¿ ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ (SCID) ÔÓÙ›ÎÈ· Î·È ÔÈ ÂÈÚ·Ì·ÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ ÛÙÔ˘˜ Ó‡ÌÔÓ˜ ÚÔÂÏ‹ÊıËÛ·Ó Ì ÙÔÓ ·ÔÎÏÂÈÛÌfi ÙÔ˘ TGFb. ™Â ¿ÏÏÔ ÂÈÚ·Ì·ÙÈÎfi ÌÔÓÙ¤ÏÔ Î·ÚΛÓÔ˘ ÓÂÊÚÔ‡ (RCC) Ë ¯ÔÚ‹ÁËÛË Tacrolimus ›¯Â Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙˆÓ ÌÂÙ·ÛÙ¿ÛÂˆÓ Î·È ÛÙ· ·ÓÔÛÔÂÓÂÚÁ¿ Balb/c Î·È ÛÙ· ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ SCID ÔÓÙ›ÎÈ· Î·È Û˘Ó‰¤ıËÎ·Ó Ì ÙËÓ ¤ÎÊÚ·ÛË TGFb. OÈ mTOR ·Ó·ÛÙÔÏ›˜ ÌÂÈÒÓÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË Î·È ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi

™ËÌ·ÙÔ‰fiÙËÛË ÙÔ˘ ∏∫∫ OÈ Î‡ÚȘ Ô‰Ô› ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ Û‹Ì·ÙÔ˜ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙÔÓ Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ Â›Ó·È, Ë Ô‰fi˜ EGFR-RAS-MAPKK, Ë Ô‰fi˜ c-Met, Ë ÛËÌ·ÙÔ‰fiÙËÛË ÙÔ˘ IGF, Ë ÛËÌ·ÙÔ‰fiÙËÛË ÙÔ˘ PI3K/ Akt/mTor, ÔÈ Î·Ù·ÚÚ¿ÎÙ˜ ÛËÌ¿ÙˆÓ VEGF Î·È PDGFR, Ë Ô‰fi˜ Wnt/‚Catenin Î·È Ë Ô‰fi˜ Hedghog.

EGFR-RAS-MAPKK ∏ Ô‰fi˜ Û‹Ì·ÙÔ˜ ÙÔ˘ RAS-MAPKK ÂÓÂÚÁÔÔÈÂ›Ù·È ·fi ÙÔ˘˜ Û˘Ó‰¤ÛÌÔ˘˜ ÙˆÓ Epidermal Growth Factor(EGF), Hepatocyte Growth Factor

115

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∂ÈÎfiÓ· 1. ™¯ËÌ·ÙÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ∏∫∫ Î·È ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙË ‰ËÌÈÔ˘ÚÁ›·, ÙËÓ Â¤ÎÙ·ÛË Î·È ÙËÓ ‰È‹ıËÛË.

(HGF), Platelet Derived Growth Factor (PDGF) Î·È Vascular Endothelial Growth Factor (VEGF), Ù· ÔÔ›· Ì ÙË ÛÂÈÚ¿ ÙÔ˘˜ Â¿ÁÔ˘Ó ÙË ÌÂÙ·ÁÚ·Ê‹ ÁÔÓȉ›ˆÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÙÔ˘ Activating Protein1(AP-1) fiˆ˜ ÙˆÓ c-fos Î·È c-jun Ù· ÔÔ›· ·›˙Ô˘Ó ÚˆÙ·ÁˆÓÈÛÙÈÎfi ÚfiÏÔ ÛÙÔÓ Î˘ÙÙ·ÚÈÎfi ÔÏÏ·Ï·ÛÈ·ÛÌfi.

OÈ ÂÚÈÛÛfiÙÂÚÔÈ ·fi ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ˘fi ÌÂϤÙË ‰ÂÛÌÂ‡Ô˘Ó ˘ԉԯ›˜ Ù˘ Ù˘ÚÔÛÈÓÈ΋˜ ÎÈÓ¿Û˘(RTK). ∂ÈÙ˘¯‹˜ ·ÔÎÏÂÈÛÌfi˜ Ù˘ Ô‰Ô‡ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ Û‹Ì·ÙÔ˜ ÙÔ˘ EGFR ÌÔÚ› Ó· Á›ÓÂÈ Ì ÌÔÓÔÎψÓÈο ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ EGFR (cetuximab) ‹ ÙÔ˘ Erb2/Her2/neu (trastuzumab). ∂ÈϤÔÓ Ë ÂÓÂÚÁÔÔ›ËÛË Ù˘ Ô‰Ô‡ ÙÔ˘ EGFR ÌÔÚ› Ó· ·Ó·ÛÙ·Ï› ·fi ÌÈÎÚ¿ ÌfiÚÈ· fiˆ˜ Â›Ó·È Ù· erlotimib Î·È lapatinib Ù· ÔÔ›· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙÔÓ ÚÔ¯ˆÚË̤ÓÔ NSCLC Î·È ÛÙÔÓ Î·ÚΛÓÔ ÙÔ˘ Ì·ÛÙÔ‡ ·ÓÙ›ÛÙÔȯ·.

c-MET O Hepatocyte growth factor (HGF) Â›Ó·È ¤Ó· Ôχ ÛËÌ·ÓÙÈÎfi ÌfiÚÈÔ ÁÈ· ÙËÓ Ë·ÙÈ΋ ·Ó·Á¤ÓÓËÛË ÌÂÙ¿ ·fi ‚Ï¿‚Ë ÙÔ˘ ‹·ÙÔ˜. ¢ËÌÈÔ˘ÚÁÂ›Ù·È ·fi Ù· ·ÛÙÂÚÔÂȉ‹ ·ÙÙ·Ú· Î·È Û˘Ó‰¤ÂÙ·È Ì ÙÔÓ ˘Ô‰Ô¯¤· ÙÔ˘ c-MET (mesenchymal-epithelial transition

factor). ∏ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ c-MET Î·È HGF Â›Ó·È Û˘ÓËıÈṲ̂ÓË ÛÙÔÓ Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ, ·Ó Î·È Ô ·ÎÚÈ‚‹˜ ÚfiÏÔ˜ ÛÙËÓ ·ıÔÁ¤ÓÂÛ‹ ÙÔ˘ ‰ÂÓ Â›Ó·È ·ÎfiÌË ÍÂηı·ÚÈṲ̂ÓÔ˜.

IGF ∏ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ ·˘ÍËÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ insulid-like growth factor ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi, ‰È·ÊÔÚÔÔ›ËÛË, ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ΢ÙÙ¿ÚÔ˘, ÙËÓ ·fiÙˆÛË Î·È ¤¯ÂÈ ÂÓÔ¯ÔÔÈËı› Û ÔÏϤ˜ ηÎÔ‹ıÂȘ. O IGF-II ˘ÂÚÂÎÊÚ¿˙ÂÙ·È Û ÂÚ›Ô˘ 30% ÛÙÔÓ Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ Î·È Ù· IGFBP-1, IGFBP-3, IGFBP-4 ηٷÛÙ¤ÏÔÓÙ·È.∞ÎfiÌË ÈÔ ÛËÌ·ÓÙÈÎfi Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ ÔÁÎÔηٷÛÙ·ÏÙÈÎfi IGFR-II, Ô˘ Ë Î‡ÚÈ· ÙÔ˘ ‰Ú·ÛÙËÚÈfiÙËÙ· Â›Ó·È Ë Û‡Ó‰ÂÛË Î·È ·Ô‰ÔÌ‹ ÙÔ˘ IGF-II ˘ÔÂÎÊÚ¿˙ÂÙ·È Û ÌÈ· ˘Ô- ÔÌ¿‰· ·ÛıÂÓÒÓ Ì Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ ÏfiÁˆ ¯ÚˆÌÔÛˆÌÈÎÒÓ ‰È·ÁÚ·ÊÒÓ ‹ ÛËÌÂÈ·ÎÒÓ ÌÂÙ·ÏϿ͈Ó.

PI3K/Akt/mTOR ∏ Ô‰fi˜ ÙÔ˘ PI3/Akt/Mtor ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ Î·ÚÎÈÓÔÁ¤ÓÂÛË. ∏ Akt ÌÔÚ› Ó· ÂÓÂÚÁÔÔÈËı› ‰È·Ì¤ÛÔ˘ ÂÓfi˜ ˘Ô‰Ô¯¤· Ù˘ÚÔÛÈÓÈ΋˜ ÎÈÓ¿Û˘(EGF ‹ IGF) ‹ ‰È·Ì¤ÛÔ˘ Û˘ÓıÂÙÈ΋˜ Â-

METAMO™XEY™Eπ™ 2011

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∂ÈÎfiÓ· 2. O ÚfiÏÔ˜ ÙÔ˘ Wnt/‚-cadherin ÛÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ∏∫∫ Î·È Ë ‰ËÌÈÔ˘ÚÁ›· ÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÙÔ˘ ›‰ÈÔ˘ Î·È ÙˆÓ ˘Ô‰Ô¯¤ˆÓ ÙÔ˘ ·Ó·Ì¤ÓÂÙ·È Ó· ·›ÍÂÈ ÛÙÔ Ì¤ÏÏÔÓ Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ∏∫∫.

∂ÈÎfiÓ· 3. ™¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË ÙˆÓ ÌÔÚÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ, Ù˘ ÛËÌ·ÙÔ‰fiÙËÛ˘ Î·È ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÛÙÔ¯Â˘Ì¤ÓˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ·Ó·Ù‡ÛÛÔÓÙ·È ÁÈ· ÙÔÓ ∏∫∫.

118

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ÓÂÚÁÔÔ›ËÛ˘ ÙÔ˘ PI3K ‹ ·ÒÏÂÈ·˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ηٷÛÙ·ÏÙÈÎÔ‡ ÁÔÓȉ›Ô˘ PTEN. ∞Ó Î·È Ô ÚfiÏÔ˜ ÙÔ˘ pAkt ÛÙÔÓ Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ ··ÈÙ› ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ η٤‰ÂÈÍ·Ó Âȉ›ӈÛË Ù˘ ÚfiÁÓˆÛ˘ Û fiÁÎÔ˘˜ Ì ÂÓÂÚÁÔÔÈË̤ÓË ÙËÓ Akt. ŒÓ·˜ ÛËÌ·ÓÙÈÎfi˜ ÌÂÛÔÏ·‚ËÙ‹˜ Ù˘ PI3K/Akt Â›Ó·È Ô mTOR, Ô ÔÔ›Ô˜ ÏÂÈÙÔ˘ÚÁ› ˆ˜ ÎÂÓÙÚÈÎfi˜ Ú˘ıÌÈÛÙ‹˜ Ù˘ ΢ÙÙ·ÚÈ΋˜ ·‡ÍËÛ˘ ÙÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡. ∏ Ô‰fi˜ ÙÔ˘ mTOR ÂÓÂÚÁÔÔÈÂ›Ù·È Û οÔȘ ˘ÔÔÌ¿‰Â˜ ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ Î·È Ë ·Ó·ÛÙÔÏ‹ ÙÔ˘ Ì ÙË ¯Ú‹ÛË Ú··Ì˘Î›Ó˘ ‹ everolimus ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·Ó¿Ù˘ÍË Î˘ÙÙ·ÚÈÎÒÓ ÛÂÈÚÒÓ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ fiˆ˜ Î·È ÂÈÚ·Ì·ÙÈÎÒÓ ÌÔÓÙ¤ÏˆÓ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘.

VEGF/VEGFR ∏ in vivo ·Ó¿Ù˘ÍË ÙˆÓ fiÁÎˆÓ ··ÈÙ› ‰È¿ÊÔÚÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÙÔ˘ ˘Ô‰Ô¯¤· fiˆ˜ Î·È ·Ú¿ÁÔÓÙ˜ ÙÔ˘ fiÁÎÔ˘. ™˘ÁÎÂÎÚÈ̤ӷ Ë ÓÂÔ·ÁÁ›ˆÛË Â›Ó·È ¤Ó·˜ ·fi ÙÔ˘˜ ÈÔ ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Î·È Ô Ë·ÙÔ΢ÙÙ·ÚÈÎfi˜ ηÚΛÓÔ˜ Â›Ó·È ¤Ó·˜ ·fi ÙÔ˘˜ fiÁÎÔ˘˜ Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÌÂ Ù˘È΋ ÓÂÔ·ÁÁ›ˆÛË. O VEGF Â›Ó·È ¤Ó·˜ ·fi ÙÔ˘˜ ÈÔ ÈÛ¯˘ÚÔ‡˜ ·˘ÍËÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÙˆÓ ·ÁÁÂÈ·ÎÒÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ. ∏ ÔÈÎÔÁ¤ÓÂÈ· ÙÔ˘ VEGF ·ÔÙÂÏÂ›Ù·È ·fi ÙÔ˘˜ VEGF-A, VEGF-B, VEGF-C, VEGF-D, PIGF-1, PIGF-2, Î.·. ∏ ¤ÎÊÚ·ÛË ÙÔ˘ VEGF ‚Ú¤ıËΠӷ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÎÏÈÓÈÎÔ·ıÔÏÔÁÈο ÛÙÔȯ›· fiˆ˜ Ë ‰È‹ıËÛË Î·È Ô Î˘ÙÙ·ÚÈÎfi˜ ÔÏÏ·Ï·ÛÈ·ÛÌfi˜. ∏ ¤ÎÊÚ·ÛË ÙÔ˘ VEGF ¤¯ÂÈ Û˘Ó‰Âı› fi¯È ÌfiÓÔ Ì ‰È‹ıËÛË Î·È ÌÂÙ¿ÛÙ·ÛË ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ ·ÏÏ¿ Î·È Ì ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ˘ÔÙÚÔ‹. ∏ ˘ÔÍ›· ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· Ù˘ ·ÁÁÂÈÔÁ¤ÓÂÛ˘ Î·È ÂȉÈο ¤¯ÂÈ ‚ÚÂı› fiÙÈ Ô Hypoxia Inducible Factor (HIF) ÂÓÂÚÁÔÔÈ› ÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ VEGF. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÔÈ Ô‰Ô› ÙˆÓ VEGF Î·È VEGFR Â›Ó·È ÚÔ··ÈÙÔ‡ÌÂÓ· ÁÈ· ÙËÓ ·ıÔÁ¤ÓÂÈ· Î·È ·Ó¿Ù˘ÍË ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ Â›Ó·È Èı·ÓfiÓ Ë ·Ó·ÛÙÔÏ‹ Ù˘ ÛËÌ·ÙÔ‰fiÙËÛ˘ ÙÔ˘ VEGF Ó· ·ÔÙÂÏ› ÌÈ· ÛËÌ·ÓÙÈ΋ ·Ú¿ÌÂÙÚÔ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘.

Wtn/‚-catenin §›Á· Â›Ó·È ÁÓˆÛÙ¿ ÁÈ· ÙÔ ÚfiÏÔ Ô˘ ·›˙Ô˘Ó Ù· ÌfiÚÈ· Ô˘ ‰ÂÛ̇ÔÓÙ·È Î·È ÂÓÂÚÁÔÔÈÔ‡Ó ÙÔ ÌÔÓÔ¿ÙÈ Ù˘ (Wtn)‚-catenin. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ·˘Ùfi ÙËÓ Î·ıÈÛÙ¿ ¤Ó· ÚÔÓÔÌÈ·Îfi ‰›Ô ¤Ú¢ӷ˜.

ΔÔ ÌÔÓÔ¿ÙÈ Wnt/‚-catenin Â›Ó·È ÂÍ·ÈÚÂÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÏÂÈÙÔ˘ÚÁ›Â˜ fiˆ˜ Ë ÂÌ‚Ú˘ÔÁ¤ÓÂÛË Î·È Ë ÔÚÁ·ÓÔÁ¤ÓÂÛË, ÂÓÒ ·fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ Ë ·ÔÚ‡ıÌÈÛË ÙÔ˘ Û˘Ó‰¤ÂÙ·È Ì ‰˘ÛÏÂÈÙÔ˘ÚÁ›Â˜ fiˆ˜ Ô Î·ÚΛÓÔ˜. £· Ú¤ÂÈ Ó· ÙÔÓ›ÛÔ˘Ì fiÙÈ ÙÔ ÌÔÓÔ¿ÙÈ ·˘Ùfi ¤¯ÂÈ ·Ú·Ì›ÓÂÈ ·Ó·ÏÏÔ›ˆÙÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÍÂÏÈÎÙÈ΋˜ ‰È·‰Èηۛ·˜. ™˘ÁÎÂÎÚÈ̤ӷ Ë Û‡Ó‰ÂÛË ÌÈ·˜ ÂÍˆÎ˘ÙÙ·ÚÈο ÂÎÎÚÈÓfiÌÂÓ˘ ÁÏ˘ÎÔÚˆÙ½Ó˘ Wnt ÛÙÔÓ ˘Ô‰Ô¯¤· ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Fz Â¿ÁÂÈ ¤Ó·Ó ηٷÚÚ¿ÎÙË ÁÂÁÔÓfiÙˆÓ Ô˘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔ˘Ó ·ÏÏËÏÂȉڿÛÂȘ ÌÂٷ͇ ÚˆÙÂ˚ÓÒÓ Ô˘ Ô‰ËÁÔ‡Ó Û ·ÏÏ·Á¤˜ ÛÙË Û‡Ó‰ÂÛË, ÛÙË ÊˆÛÊÔÚ˘Ï›ˆÛË Î·È ÛÙËÓ ÙÔÔı¤ÙËÛË-ÚÔÛ·Ó·ÙÔÏÈÛÌfi ÙÔ˘˜. ™ÙËÓ ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ ¤¯Ô˘Ì ۇӉÂÛË Ù˘ Wnt ‹ Î·È fiÙ·Ó ¤¯Ô˘Ì ÂÚ›ÛÛÂÈ· Ù˘ ‚-catenin ÛÙÔ Î˘ÙÙ·ÚfiÏ·ÛÌ·, ÙfiÙÂ Ë ÙÂÏÂ˘Ù·›· ÛÙÔ¯ÔÔÈÂ›Ù·È Î·È ·ÂÓÂÚÁÔÔÈ›ٷÈ. ΔfiÙ ϤÌ fiÙÈ ÙÔ ÌÔÓÔ¿ÙÈ Â›Ó·È ÂÎÙfi˜ ÏÂÈÙÔ˘ÚÁ›·˜. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ‹·Ú ÙÔ ÌÔÓÔ¿ÙÈ Wnt/‚catenin fiˆ˜ ¤¯ÂÈ ÌÂÏÂÙËı› Û ÌÔÓ٤Ϸ ÔÓÙÈÎÒÓ Ê·›ÓÂÙ·È ˆ˜ ·›˙ÂÈ ÚfiÏÔ Î·Ù¿ ÙËÓ ÔÚÁ·ÓÔÁ¤ÓÂÛË Î·ıÒ˜ Û˘Ó‰¤ÂÙ·È Ì ÙÔÓ ¤ÏÂÁ¯Ô ÙÔ˘ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡ ÙˆÓ Î˘ÙÙ¿ÚˆÓ Î·È Û˘ÓÂ·ÎfiÏÔ˘ı· Ì ÙËÓ ·Ó·ÁÂÓÓËÙÈ΋ ÈηÓfiÙËÙ· ÙÔ˘ ‹·ÙÔ˜. ∏ ÌË Î·ÓÔÓÈ΋ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ÌÔÓÔ·ÙÈÔ‡ Wnt/‚-catenin ¤¯ÂÈ Û˘Ó‰Âı› Ì ‰È¿ÊÔÚÔ˘˜ ηÚΛÓÔ˘˜ ηıÒ˜ Î·È Ì ÙÔÓ Ë·ÙÔ΢ÙÙ·ÚÈÎfi. ∂Ó‰Âϯ›˜ ¤Ú¢Ó˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ·ÓÒÌ·ÏË ¤ÎÊÚ·ÛË Ù˘ ‚-catenin fiˆ˜ Î·È ÌÂÙ·ÏÏ¿ÍÂȘ ÛÙÔ Ctnb1 ÛÙÔ 25% fiÏˆÓ ÙˆÓ Ë·ÙÔ΢ÙÙ·ÚÈÎÒÓ Î·ÚÎ›ÓˆÓ Î·È Û ¿Óˆ ·fi 50% Û fiÏÔ˘˜ ÙÔ˘˜ Ë·ÙÈÎÔ‡˜ fiÁÎÔ˘˜ Û ‰È·ÁÂÓÂÙÈΤ˜ ÛÂÈÚ¤˜ fiˆ˜ Ë c-myc Î·È eH-ras.

Sonic Hedgehog ∏ ˘ÂÚ¤ÎÊÚ·ÛË ÙÔ˘ Hedgehog Â›Ó·È Û˘¯Ó‹ ÛÙÔÓ Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ Î·È ÛÙÔ Ë·ÙÔ‚Ï¿Ûو̷ Î·È Ë ·Ó·ÛÙÔÏ‹ ÙÔ˘ ·fi ÙÔÓ ·ÓÙ·ÁˆÓÈÛÙ‹ ÙÔ˘ Hedgehog ΢ÎÏÔ·Ì›ÓË ÌÂÈÒÓÂÈ ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ fiÁÎÔ˘, ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ ÁÔÓȉ›Ô˘ ÛÙfi¯Ô˘ ÙÔ˘ ∏edgehog ÂÓÒ ·fi ÙËÓ ¿ÏÏË ÚÔ¿ÁÂÈ ÙËÓ ·fiÙˆÛË. ΔÔ ÌÔÓÔ¿ÙÈ ÔÓÔÌ¿ÛÙËΠ·fi ÙȘ ÙÚÂȘ ÚˆÙ½Ó˜(sonic Hedgehog, shh-indian Hedgehog, ihh Î·È desert Hedhehog, dhh) ÔÈ Ôԛ˜ Û˘Ó‰¤ÔÓÙ·È Ì ÙÔÓ 7-‰È·ÌÂÌ‚Ú·ÓÈÎfi ˘Ô‰Ô¯¤· Patched. OÈ ÚˆÙ½Ó˜ ·˘Ù¤˜ ÂÎÊÚ¿˙ÔÓÙ·È ÛÙËÓ ·ÓÂÓÂÚÁ‹ ÌÔÚÊ‹ ÙˆÓ 45 kDa Î·È ÌÂÙ¿ ·˘ÙÔÚˆÙÂÔχÔÓÙ·È ÛÙËÓ ÂÓÂÚÁ‹ ÌÔÚÊ‹ ÙˆÓ 19 kDa. H Û‡Ó‰ÂÛË ÙˆÓ Hed-

METAMO™XEY™Eπ™ 2011

gehog ÚˆÙÂ˚ÓÒÓ ·Ó·ÛÙ¤ÏÏÂÈ ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ Patched Î·È ¤ÙÛÈ ÚÔ¿ÁÂÙ·È Ë ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ·Ú¿ÁÔÓÙ· ·ÓÙÈÁÚ·Ê‹˜ GIi3. ™Â ·Ô˘Û›· ÙˆÓ ÚˆÙÂ˚ÓÒÓ Hedgehog Ô ÚÔ·Ó·ÊÂÚfiÌÂÓÔ˜ ·Ú¿ÁÔÓÙ·˜ ÛÙÔ¯ÔÔÈÂ›Ù·È ÚÔ˜ ·Ô‰fiÌËÛË ·fi Ù· ÚˆÙÂÔÛÒÌ·Ù·. ŸÙ·Ó ÙÔ ÌÔÓÔ¿ÙÈ ÛËÌ·ÙÔ‰fiÙËÛ˘ Hedgehog Â›Ó·È ÂÓÂÚÁfi ÙfiÙ Á›ÓÂÙ·È ÌÂÙ¿ıÂÛË ÙˆÓ ÂÓÂÚÁÒÓ ÌÂÙ·ÁÚ·ÊÈÎÒÓ ÚˆÙÂ˚ÓÒÓ GIi ̤۷ ÛÙÔÓ ˘Ú‹Ó· Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ¤ÎÊÚ·ÛË ÁÔÓȉ›ˆÓ ÛÙfi¯ˆÓ fiˆ˜ Ù· GIi Î·È Ptc. ™˘ÌÂÚ·ÛÌ·ÙÈο ÌÔÚԇ̠ӷ ԇ̠ˆ˜ Ù· ÌÔÓÔ¿ÙÈ· Wnt/ ‚-catenin Î·È ∏edgehog fiÛÔÓ ·ÊÔÚ¿ ÙÔ ÚfiÏÔ ÙÔ˘˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ ·ÔÙÂÏÔ‡Ó ‰›· Ô˘ Âȉ¤¯ÔÓÙ·È ÂÚ·ÈÙ¤Úˆ ¤Ú¢ӷ˜.

Aurora A Î·È B ªÂϤÙ˜ ¤¯Ô˘Ó ·ԉ›ÍÂÈ ÙË Û¯¤ÛË Ù˘ Aurora A Ì ÙÔÓ Î·ÚΛÓÔ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Î·È fiÙÈ ÚÔ¿ÁÂÈ ÙË ‰Ú¿ÛË Ù˘ ÙÂÏÔÌÂÚ¿Û˘ ‰Ú·ÛÙËÚÈÔÔÈÒÓÙ·˜ ÙË C-Myc. ∏ ·˘ÍË̤ÓË ‰Ú¿ÛË Ù˘ ÙÂÏÔÌÂÚ¿Û˘ ··ÓÙ¿Ù·È Û˘¯Ó¿ Û ÔÏÏ¿ ηÚÎÈÓÈο ·ÙÙ·Ú· Î·È Ë ‰Ú¿ÛË Ù˘ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ÂÈÌ‹Î˘ÓÛË Ù˘ ˙ˆ‹˜ ÙÔ˘ ΢ÙÙ¿ÚÔ˘. ∫ÔÈÓ‹ ȉÈfiÙËÙ· Î·È Ù˘ Aurora A fiÛÔ Î·È Ù˘ Aurora B Â›Ó·È fiÙÈ ÚÔ¿ÁÔ˘Ó ÙËÓ ·Û‡ÌÌÂÙÚË ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘ (cellular mobility), Ë ÔÔ›· ÚÔ¿ÁÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÌÂÙ·ÛÙ¿ÛÂˆÓ ÙˆÓ Î·ÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ. ªÂÙ¿ ÙËÓ ·Ó·Î¿Ï˘„Ë Î·È ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ Aurora ÎÈÓ·ÛÒÓ ÂÊ·ÚÌfiÛÙËÎ·Ó ÈÔ Û˘Á¯ÚÔÓ¤˜ ÚÔÛÂÁÁ›ÛÂȘ ÛÙË Ú‡ıÌÈÛË ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ·ÎÏÔ˘. ∏ ÔÈÎÔÁ¤ÓÂÈ· ÙˆÓ Aurora ÎÈÓ·ÛÒÓ ‰Ú· ÛÙ· ÙÂÏÂ˘Ù·›· ÛÙ¿‰È· ÙÔ˘ ΢ÙÙ·ÚÈÎÔ‡ ·ÎÏÔ˘ ·fi ÙÔ ÛËÌÂ›Ô ÂϤÁ¯Ô˘ G2/M ̤¯ÚÈ ÙËÓ Î˘Ù·ÚÔΛÓËÛË. ¢È·ÊÔÚ¤˜ ÌÈÙˆÙÈΤ˜ ÎÈÓ¿Û˜, ÌÂٷ͇ ·˘ÙÒÓ Î·È ÔÈ Aurora ÎÈÓ¿Û˜ Ú˘ıÌ›˙Ô˘Ó ÙÔÓ Î˘ÙÙ·ÚÈÎfi ·ÎÏÔ ‰È· ̤ÛÔ˘ ÙÔ˘ ÂϤÁ¯Ô˘ Ù˘ ÌÈÙÒÛˆ˜. Œ¯ÂÈ ·Ô‰Âȯı› Û ÂÚÁ·Û›Â˜, fiÙÈ ÛÙÔ¯Â˘Ì¤Ó˜ ıÂÚ·›˜ Ù˘ Aurora A Ì ·Ú¤Ì‚·ÛË ÛÙÔ RNA ηٷÛÙ¤ÏÏÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ Î·ÚÎÈÓÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ì ÙÔÓ ›‰ÈÔ Ì˯·ÓÈÛÌfi Ô˘ ÚÔ¿ÁÂÙ·È Ë ·fiÙˆÛË, Î·È ÏfiÁˆ ·˘ÙÔ‡ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Ù· ηÚÎÈÓÈο ·ÙÙ·Ú· ηı›ÛÙ·ÓÙ ÈÔ Â˘·›ÛıËÙ· ÛÙË ¯ËÌÂÈÔıÂÚ·›· Î·È ÛÙËÓ ·ÎÙÈÓÔıÂÚ·›·.

™˘ÌÂÚ¿ÛÌ·Ù· O ÚfiÏÔ˜ Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ‰È·Ù‹ÚËÛ˘ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÁÈ· ∏∫∫ Ê·›ÓÂÙ·È Ó· ·›˙ÂÈ ÚfiÏÔ ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘ Ì ÙÔ˘˜ ·Ú·‰ÔÛÈ·ÎÔ‡˜ ·Ó·ÛÙÔÏ›˜ Ù˘ ηÏÛÈÓ¢-

119

Ú›Ó˘ Ó· ·ÔÙÂÏÔ‡Ó ÚÔ-ÔÁÎÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‰È·Ì¤ÛÔ˘ Ù˘ ·‡ÍËÛ˘ Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ TGFb Î·È ÙÔ˘ VEGF. ∞ÓÙ›ıÂÙ· ÔÈ ·Ó·ÛÙÔÏ›˜ ÙÔ˘ mTOR Èı·ÓfiÓ Ó· ·ÔÙÂϤÛÔ˘Ó ÙË ‚¿ÛË Ù˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈ΋˜ ·ÁˆÁ‹˜ ‰È·Ù‹ÚËÛ˘ ÛÙÔ Ì¤ÏÏÔÓ ÏfiÁˆ Ù˘ ηٷÛÙÔÏ‹˜ Ù˘ Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ TGFb Î·È ÙÔ˘ VEGF. ∏ ·ÔΈ‰ÈÎÔÔ›ËÛË Ù˘ ÛËÌ·ÙÔ‰fiÙËÛ˘ Î·È ÙˆÓ ÌÔÚÈ·ÎÒÓ ‰È·‰ÚÔÌÒÓ ÙÔ˘ ∏∫∫ Î·È ¯Ú‹ÛË ÛÙÔ¯Â˘Ì¤ÓˆÓ ·Ú·ÁfiÓÙˆÓ fiˆ˜ ÙÔ Sorafenib ·ÏÏ¿ Î·È ·˘ÙÒÓ Ô˘ ¤Ú¯ÔÓÙ·È ÛÙÔ ÚÔÛ¯¤˜ ̤ÏÏÔÓ ı· ‰ÒÛÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ‰È¢ڇÓÔ˘Ì ٷ ÛÙÂÓ¿ fiÚÈ· ¯Ú‹Û˘ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ∏∫∫.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Willett CG, Boucher Y, di Tomaso E, et al. Direct evidence that the VEGF-specific antibody bevacizumab has antivascular effects in human rectal cancer. Nat Med 2004; 10: 145-7.

2. Toyoda M, Hashimoto N, Tokita K, et al. Increased activity and expression of MAP kinase in HCC model rats induced by 3ã- methyl-4-dimethylamino – azobenzene.

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MÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Û ÌË Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡˜ ηÚΛÓÔ˘˜ π. ºÔ‡˙·˜, ¢. Δ·ÎÔ‡‰·˜

·ÒÏÂÈ· ‚¿ÚÔ˘˜ Î·È Ô ›ÎÙÂÚÔ˜. ™Ù· ÂÚÁ·ÛÙËÚȷο ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ÂÈÎfiÓ· ˘Ï·›·˜ ˘¤ÚÙ·Û˘, ÏfiÁˆ ‰È‹ıËÛ˘ ÙˆÓ ÎÔÏˆ‰ÒÓ ÙÚȯÔÂȉÒÓ ·fi Ù· ÓÂÔÏ·ÛÌ·ÙÈο ·ÙÙ·Ú· ‹ ›ÂÛË Ù˘ ˘Ï·›·˜ ÊϤ‚·˜ ·fi ÙÔÓ fiÁÎÔ, ÂÓÒ fiÏÔÈ Î·ÚÎÈÓÈÎÔ› ‰Â›ÎÙ˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎÔ›5. ™ÙȘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂϤÙ˜, Ì CT Î·È MRI, ÙÔ ∏∂∏∂ ÂÌÊ·Ó›˙ÂÙ·È Ì ‰‡Ô ÌÔÚʤ˜, ÙËÓ ÚÒÈÌË ÂÚÈÊÂÚÈ΋ Î·È ÛÙËÓ ·ÒÙÂÚË ‰È¿¯˘ÙË. ™ÙËÓ ÚÒÙË ·ÂÈÎÔÓ›˙ÔÓÙ·È Ô˙Ò‰ÂȘ Û¯ËÌ·ÙÈÛÌÔ› ÛÙËÓ ÂÚÈʤÚÂÈ· ÙÔ˘ ‹·ÙÔ˜ Ô˘ Û˘Ó‹ıˆ˜ ÂÓÙÔ›˙ÔÓÙ·È Î·È ÛÙÔ˘˜ ‰‡Ô ÏÔ‚Ô‡˜, ÂÓÒ ÛÙËÓ ‰È¿¯˘ÙË ÌÔÚÊ‹ ηٷϷ̂¿ÓÂÙ·È ÔÏfiÎÏËÚÔ ÙÔ ‹·Ú Î·È ÙÂÏÈο ‰ÈËıÔ‡ÓÙ·È Î·È Ù· ÌÂÁ¿Ï· ·ÁÁ›·. ™ÙÔ 20 % ÙˆÓ ÂÚÈÙÒÛÂˆÓ ˘¿Ú¯Ô˘Ó ÂÛÙȷΤ˜ Â·Û‚ÂÛÙÒÛÂȘ, ÂÓÒ ˘¿Ú¯ÂÈ Î·È Ú›ÎÓˆÛË Ù˘ ο„·˜ ÙÔ˘ Glisson, ÏfiÁˆ ‰È‹ıËÛ˘ Î·È ›ÓˆÛ˘. ΔÂÏÈο, Ë ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Ì ‚ÈÔ„›· ÛÙËÓ ÔÔ›· ·Ó·‰ÂÈÎÓ‡ÂÙ·È Ë ‰È‹ıËÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÏÔ‚›Ô˘ ·fi ÏÂÈÔÌÔÚÊÈο ÂÈıËÏÈÔÂȉ‹ ·ÙÙ·Ú· Ù· ÔÔ›· ÂÂÎÙ›ÓÔÓÙ·È Î·Ù¿ Ì‹ÎÔ˜ ÙˆÓ ÎÔÏˆ‰ÒÓ ÙÚȯÔÂȉÒÓ Î·È ‰ÈËıÔ‡Ó ÌÈÎÚÔ‡˜ ÎÏ¿‰Ô˘˜ Ù˘ ˘Ï·›·˜ Î·È ÙˆÓ Ë·ÙÈÎÒÓ ÊÏ‚ÒÓ ‹ ·ÎfiÌË Î·È ÙËÓ Î¿„· ÙÔ˘ Glisson. OÈ ˘Ï·›Â˜ ÙÚÈ¿‰Â˜ Î·È ÔÈ ÎÂÓÙÚÈΤ˜ ÊϤ‚˜ ‰È·ÙËÚÔ‡ÓÙ·È3,4. ™Â ·ÓÔÛÔ˚ÛÙÔ¯ËÌÈΤ˜ ¯ÚÒÛÂȘ, Ù· ÓÂÔÏ·ÛÌ·ÙÈο ·ÙÙ·Ú· ÙÔ˘ ∏∂∏∂ ÂÎÊÚ¿˙Ô˘Ó ÙÔ˘˜ ÂÓ‰ÔıËÏÈ·ÎÔ‡˜ ‰Â›ÎÙ˜ CD31, CD34 Î·È ·ÓÙÈÁfiÓÔ Û¯ÂÙÈ˙fiÌÂÓÔ Ì ÙÔÓ ·Ú¿ÁÔÓÙ· VIII. ™ÙËÓ ÛÙ·‰ÈÔÔ›ËÛË Î·È ÛÙÔÓ ·ÔÎÏÂÈÛÌfi ÁÂÓÈÎÂ˘Ì¤Ó˘ ÓfiÛÔ˘ Û˘Ì‚¿ÏÏÂÈ ÙfiÛÔ ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ÔÛÙÒÓ fiÛÔ Î·È ÙÔ FDG-PET5. OÈ Û˘¯ÓfiÙÂÚ˜ Â͈Ë·ÙÈΤ˜ ÂÓÙÔ›ÛÂȘ ηٿ ÙËÓ ÛÙÈÁÌ‹ Ù˘ ‰È¿ÁÓˆÛ˘ Â›Ó·È ÔÈ Ó‡ÌÔÓ˜, ÂÚÈÙfiÓ·ÈÔ, ÏÂÌÊ·‰¤Ó˜ Î·È ÔÛÙ¿3,4. ∏ ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ∏∂∏∂ ‰ÂÓ ¤¯ÂÈ ·ÔÛ·ÊËÓÈÛı›. ∏ ‚È‚ÏÈÔÁÚ·Ê›· ÂÚÈÔÚ›˙ÂÙ·È Û 13 ÌÈÎÚ¤˜ ÛÂÈÚ¤˜ ÂÚÈÛÙ·ÙÈÎÒÓ (Ì 5 ‹ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜), ÔÏϤ˜ ·Ó·ÎÔÈÓÒÛÂȘ ÂÚÈÙÒÛÂˆÓ Î·È ÙÚ›˜ ·Ó·ÛÎÔ‹ÛÂȘ, fiϘ ¯ˆÚ›˜ ÏÂÙÔÌÂÚ‹ ·Ó¿Ï˘ÛË, Ì·ÎÚfi¯ÚÔÓË ·Ú·ÎÔÏÔ‡ıËÛË Î·È Û‡ÁÎÚÈÛË ÌÂٷ͇ ÔÌ¿‰ˆÓ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Â›Ù ÛÂ Û˘ÓÙËÚËÙÈ΋ ›Ù Û ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ‹ ‰ÂÓ ¤Ï·‚·Ó η̛· ıÂÚ·›·5. ™Â Úfi-

O ÚfiÏÔ˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ (ª∏) ÛÙËÓ ıÂÚ·›· ÙˆÓ ÓÂÔÏ·ÛÌ¿ÙˆÓ ÙÔ˘ ‹·ÙÔ˜ ¤¯ÂÈ ·ÏÏ¿ÍÂÈ ÛËÌ·ÓÙÈο Ù· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ·. ¶·Ú¿ ÙËÓ ÂÚÈÔÚÈṲ̂ÓË ÂÈÙ˘¯›· ÙˆÓ ·Ú¯ÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Û ·ÛıÂÓ›˜ Ì ÚˆÙÔ·ı‹ ÓÂÔÏ¿ÛÌ·Ù· ÙÔ˘ ‹·ÙÔ˜,1 Ë Î·Ï‡ÙÂÚË ÂÈÏÔÁ‹ ÙˆÓ ÏËÙÒÓ Ô‰‹ÁËÛ ÛÙËÓ ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Î·È ÛÙËÓ ·Ô‰Ô¯‹ Ù˘ ª∏ ÛÙËÓ ıÂÚ·›· ÙÔ˘ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ηÚΛÓÔ˘ (∏∫∫). ™‹ÌÂÚ·, ÂÂÎÙ›ÓÔÓÙ·È ÔÈ ÂӉ›ÍÂȘ Ù˘ ª∏ Û ∏∫∫, ÂÓÒ ·Ú¯›˙ÂÈ Ó· ÂÊ·ÚÌfi˙ÂÙ·È Î·È Û ¿ÏÏÔ˘˜ Û·ÓÈfiÙÂÚÔ˘˜ Ù‡Ô˘˜ ÓÂÔÏ·ÛÌ¿ÙˆÓ, fiˆ˜ ÙÔ ÚˆÙÔ·ı¤˜ Ë·ÙÈÎfi ÂÈıËÏÈÔÂȉ¤˜ ·ÈÌ·ÁÁÂÈÔÂÓ‰ÔıËÏ›ˆÌ· (primary hepatic epithelioid hemangioendothelioma, HEHE), ÔÈ Ë·ÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ Ó¢ÚÔÂÓ‰ÔÎÚÈÓÈÎÒÓ fiÁÎˆÓ Î·È ÙÔ ÂÚÈ˘Ï·›Ô ¯ÔÏ·ÁÁÂÈÔηÚΛӈ̷. ∂ÈϤÔÓ, ˘¿Ú¯Ô˘Ó ·Ó·ÊÔÚ¤˜ ÂÚÈÛÙ·ÙÈÎÒÓ Î·È ÌÈÎÚ¤˜ ÛÂÈÚ¤˜ ª∏ Û Ë·ÙÔ‚Ï·ÛÙÒÌ·Ù·, ÈÓÔÂÙ·ÏÈÒ‰Ë Ë·ÙÔ΢ÙÙ·ÚÈο ηÚÎÈÓÒÌ·Ù·, ÚˆÙÔ·ı‹ Ë·ÙÈο Û·ÚÎÒÌ·Ù· Î·È Ë·ÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ ·fi ηÚΛÓÔ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘2.

¶ÚˆÙÔ·ı¤˜ Ë·ÙÈÎfi ÂÈıËÏÈÔÂȉ¤˜ ·ÈÌ·ÁÁÂÈÔÂÓ‰ÔıËÏ›ˆÌ· ΔÔ ÚˆÙÔ·ı¤˜ Ë·ÙÈÎfi ÂÈıËÏÈÔÂȉ¤˜ ·ÈÌ·ÁÁÂÈÔÂÓ‰ÔıËÏ›ˆÌ· (primary hepatic epithelioid hemangioendothelioma, HEHE), Â›Ó·È Û¿ÓÈÔ˜ ·ÁÁÂÈ·Îfi˜ fiÁÎÔ˜(<1/106 ÏËı˘ÛÌÔ‡). ∏ ‚ÈÔÏÔÁÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ∏∂∏∂ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ Ù˘ ‚Ú·‰Â›·˜ ۯ‰fiÓ Î·ÏÔ‹ıÔ˘˜ ÔÚ›·˜, Ù‡Ô˘ ·ÈÌ·ÁÁÂÈÒÌ·ÙÔ˜, Î·È Ù˘ Ôχ ÂÈıÂÙÈ΋˜ ηÎÔ‹ıÔ˘˜ Û˘ÌÂÚÈÊÔÚ¿˜, Ù‡Ô˘ Û·ÚÎÒÌ·ÙÔ˜3. ΔÔ Ë·ÙÈÎfi ∏∂∏∂ Â›Ó·È Û˘Ó‹ıˆ˜ ÚˆÙÔ·ı¤˜, ·ÏÏ¿ Ô fiÁÎÔ˜ ·Ó·Ù‡ÛÛÂÙ·È Î·È Û ¿ÏÏÔ˘˜ ÈÛÙÔ‡˜, fiˆ˜ Ù· ̷Ϸο ÌfiÚÈ·, Ô ÙÚ¿¯ËÏÔ˜, Ù· ÔÛÙ¿, ÔÈ Ó‡ÌÔÓ˜ Î·È ÔÈ ‚ÚfiÁ¯ÔÈ.4 OÈ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ ÙÔ˘ ∏∂∏∂ Â›Ó·È ÌË ÂȉÈΤ˜ Î·È ÂÎÙ›ÓÔÓÙ·È ·fi ÙËÓ ·Û˘Ìو̷ÙÈ΋ ηٿÛÙ·ÛË Ì¤¯ÚÈ ÙËÓ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ™Ù· Û˘ÌÙÒÌ·Ù· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔ ·›ÛıËÌ· ‚¿ÚÔ˘˜ ‹ ¿ÏÁÔ˜ ÛÙËÓ ¿Óˆ ÎÔÈÏ›·, ηٷ‚ÔÏ‹, ÂÓÒ Ù· Û˘¯ÓfiÙÂÚ· ÛËÌ›· Â›Ó·È Ë Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·, Ë

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π. º√À∑∞™, ¢. Δ∞∫√À¢∞™

ÛÊ·ÙË ·Ó·ÛÎfiËÛË ÙˆÓ Mehrabi Î·È Û˘Ó., 2006,6 ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÌÂٷ͇ 1984 Î·È 2006 ‰ËÌÔÛȇıËÎ·Ó 434 ÂÚÈÛÙ·ÙÈο Ì ∏∂∏∂, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Ì ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ (ª∏), 44.8%, ¯ˆÚ›˜ ıÂÚ·›·, 24.8%, ¯ËÌÂÈÔıÂÚ·›· Î·È ·ÎÙÈÓÔıÂÚ·›·, 21 % Î·È Ë·ÙÂÎÙÔÌ‹ 9.4%.

OÈ ·ÓÙ›ÛÙÔȯ˜ ÂÈ‚ÈÒÛÂȘ 1Ô˘ Î·È 5Ô˘ ¤ÙÔ˘˜ ‹Ù·Ó, ª∏ 96% Î·È 54.5%, ¯ˆÚ›˜ ıÂÚ·›· 39.3% Î·È 4.5%, ¯ËÌÂÈÔıÂÚ·›· Î·È ·ÎÙÈÓÔıÂÚ·›· 73.3 % Î·È 30% Î·È Ë·ÙÂÎÙÔÌ‹ 100 % Î·È 75%. ∏ Ë·ÙÂÎÙÔÌ‹ Ê·›ÓÂÙ·È Ó· ¤¯ÂÈ Ù· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù·, ·ÏÏ¿ ÌÔÚ› Ó· ÂÊ·ÚÌÔÛı› ÌfiÓÔ ÛÙÔ 10% ÙˆÓ ·ÛıÂÓÒÓ Ì ÂÚÈÔÚÈṲ̂ÓË ÓfiÛÔ, ÂÓÒ ÛÙÔ 90% Ë ÓfiÛÔ˜ Â›Ó·È ÔÏ˘ÂÛÙȷ΋6. ∞Ó¿ÏÔÁ· Â›Ó·È Ù· Â˘Ú‹Ì·Ù· Î·È ÌÈ·˜ ÓÂfiÙÂÚ˘ ÌÂϤÙ˘ ·fi ÙÔ˘˜ Grotz Î·È Û˘Ó. 2010,7 ÛÙËÓ ÔÔ›· Ë Ë·ÙÂÎÙÔÌ‹ ¤¯ÂÈ Î·Ï‡ÙÂÚ· ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ª∏, ·ÏÏ¿ Û ·ÛıÂÓ›˜ Ì ÌÈÎÚfiÙÂÚË ¤ÎÙ·ÛË Ù˘ ÓfiÛÔ˘. OÛÔÓ ·ÊÔÚ¿ ÙȘ ÌË ¯ÂÈÚÔ˘ÚÁÈΤ˜ ıÂÚ·›˜, fiˆ˜ ¯ËÌÂÈÔıÂÚ·›·, ·ÎÙÈÓÔ‚ÔÏ›·, ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi˜, ηٷÛÙÚÔÊ‹ Ì ڷ‰ÈÔÛ˘¯ÓfiÙËÙ˜ Î.·., Ù· ˘¿Ú¯ÔÓÙ· ÛÙÔȯ›· ‰ÂÓ Â·ÚÎÔ‡Ó ÁÈ· ÙËÓ ÂÍ·ÁˆÁ‹ ·ÛÊ·ÏÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ8. ∂¯Ô˘Ó ‰È·Ù˘ˆı› ÂÈÊ˘Ï¿ÍÂȘ ÁÈ· ÙËÓ ¤Ó‰ÂÈÍË Ù˘ ª∏ ÛÙË ıÂÚ·›· ÙÔ˘ ∏∂∏∂ ÏfiÁˆ Ù˘ Ì·ÎÚ¿˜ ÂÈ‚›ˆÛ˘ ÛËÌ·ÓÙÈÎÔ‡ ·ÚÈıÌÔ‡ ·ÛıÂÓÒÓ, ÙÔ ˘„ËÏfi ÔÛÔÛÙfi Â͈Ë·ÙÈ΋˜ ÓfiÛÔ˘ (̤¯ÚÈ 45%), ÙËÓ ¤ÏÏÂÈ„Ë ÚÔÁÓˆÛÙÈÎÒÓ ÎÏÈÓÈÎÒÓ Î·È ÈÛÙÔÏÔÁÈÎÒÓ ÎÚÈÙËÚ›ˆÓ Î·È ÙÔ ˘„ËÏfi ÔÛÔÛÙfi ˘ÔÙÚÔ‹˜ ÛÙÔ ÌfiÛ¯Â˘Ì· (̤¯ÚÈ 32%)4,9,10. ∏ ÔÌ¿‰· ÙÔ˘ Pittsburgh ‰ËÌÔÛ›Â˘Û ÙË ÚÒÙË ÛÂÈÚ¿ ª∏ Û ∏∂∏∂, Ì 16 ·ÛıÂÓ›˜, ÛÙËÓ ÔÔ›· Ë ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ‹Ù·Ó 71% Î·È Ë ÂχıÂÚË ÓfiÛÔ˘ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ‹Ù·Ó 60%11. ∂ÈϤÔÓ, Ë ÂÈÓ¤ÌËÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ÙˆÓ ˘ÏÒÓ ÙÔ˘ ‹·ÙÔ˜, ηıÒ˜ Î·È Ë ·ÁÁÂȷ΋ ‰È‹ıËÛË ‰ÂÓ ÂËÚ¤·Û ÙËÓ ÂÈ‚›ˆÛË. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ÂȂ‚·ÈÒıËÎ·Ó ·fi ‰‡Ô ÌÂÁ¿Ï˜ ÛÂÈÚ¤˜ ª∏ Û ∏∂∏∂ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙ· ·Ú¯Â›· ‰Â‰ÔÌ¤ÓˆÓ UNOS Î·È ELITA-ELTR.9,12. ∂ȉÈÎfiÙÂÚ·, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ELITA-ELTR ÚÔ¤Ú¯ÔÓÙ·È ·fi 59 ·ÛıÂÓ›˜ Ì ̤ÛË ·Ú·ÎÔÏÔ‡ıËÛË 79 ÌËÓÒÓ Î·È ¤‰ÂÈÍ·Ó Û˘ÓÔÏÈΤ˜ ÂÈ‚ÈÒÛÂȘ 5Ô˘ Î·È 10Ô˘ ¤ÙÔ˘˜ 83 % Î·È 74% Î·È ÂχıÂÚ˜ ÓfiÛÔ˘ ÂÈ‚ÈÒÛÂȘ 5Ô˘ Î·È 10Ô˘ ¤ÙÔ˘˜ 82% Î·È 64%, ·ÓÙ›ÛÙÔȯ·. Δ· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰ÂÓ ÂËÚ¿ÛıËÎ·Ó ·fi ÙËÓ ‡·ÚÍË ıÂÙÈÎÒÓ ˘Ï·›ˆÓ ÏÂÌÊ·‰¤ÓˆÓ (ÛÙÔ 30% ÙˆÓ ·ÛıÂÓÒÓ), «ÂÚÈÔÚÈṲ̂Ó˘» Â͈Ë·ÙÈ΋˜ ÓfiÛÔ˘ (17%) ‹ ·fi ÚÔËÁÔ‡ÌÂÓ˜ Û˘ÓÙËÚËÙÈΤ˜ Î·È ¯ÂÈÚÔ˘ÚÁÈΤ˜ ıÂÚ·›˜ (30%). ∞ÓÙ›-

ıÂÙ·, Ë Û˘Ó‡·ÚÍË ÌÈÎÚÔ Î·È Ì¿ÎÚÔ-·ÁÁÂȷ΋˜ ‰È‹ıËÛ˘ (49%) ÂËÚ¤·Û ÛËÌ·ÓÙÈο ÙËÓ ÂÈ‚›ˆÛË9. Δ· ·ÔÙÂϤÛÌ·Ù· ÙÔ˘ UNOS ÚÔ¤Ú¯ÔÓÙ·È ·fi 128 ª∏ Û ∏∂∏∂, ̤ÛË ·Ú·ÎÔÏÔ‡ıËÛË 24 ÌËÓÒÓ Î·È Î·È ¤‰ÂÈÍ·Ó Û˘ÓÔÏÈΤ˜ ÂÈ‚ÈÒÛÂȘ 1Ô˘ Î·È 5Ô˘ ¤ÙÔ˘˜ 80% Î·È 64%, ·ÓÙ›ÛÙÔȯ·12. ΔÔ ÚˆÙÔ·ı¤˜ Ë·ÙÈÎfi ÂÈıËÏÈÔÂȉ¤˜ ·ÈÌ·ÁÁÂÈÔÂÓ‰ÔıËÏ›ˆÌ· Â›Ó·È ÙÂÏÈο ı·Ó·ÙËÊfiÚÔ. ªÂ ‚¿ÛË Ù· ·ÓˆÙ¤Úˆ, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÂӉ›ÎÓ˘Ù·È Û ÂÈÏÂÁ̤ÓÔ˘˜ ·ÛıÂÓ›˜ Ì ∏∂∏∂ Î·È ÂÎÙÂٷ̤ÓË ÔÏ˘ÂÛÙȷ΋ ÓfiÛÔ, ÂÓÒ Û ·ÛıÂÓ›˜ Ì ÂÚÈÔÚÈṲ̂ÓË ÓfiÛÔ ÛÙÔ ‹ÌÈÛ˘ ÙÔ˘ ‹·ÙÔ˜, Ë Ë·ÙÂÎÙÔÌ‹ Ê·›ÓÂÙ·È Ó· ·Ú¤¯ÂÈ ÈÛÔ‰‡Ó·Ì· ·ÔÙÂϤÛÌ·Ù·. ∏ ª∏ Û ∏∂∏∂ ·Ú¤¯ÂÈ ·ÔÙÂϤÛÌ·Ù· ·Ó¿ÏÔÁ· Ì ÂΛӷ Ù˘ ª∏ ÁÈ· ΛÚÚˆÛË. ¢ÂÓ ¤¯Ô˘Ó ·ÔÛ·ÊËÓÈÛı› ÔÈ ÂӉ›ÍÂȘ Î·È Ë ÂÈÏÔÁ‹ Ù˘ ¯ÚfiÓÔ˘.

∏·ÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ Ó¢ÚÔÂÓ‰ÔÎÚÈÓÈÎÒÓ fiÁÎˆÓ OÈ Ó¢ÚÔÂÓ‰ÔÎÚÈÓÈÎÔ› fiÁÎÔÈ (¡∂O) Â›Ó·È Ì›· ¢Ú›· ÔÌ¿‰· ÓÂÔÏ·ÛÌ¿ÙˆÓ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi Ù· Ó¢ÚÔÂÓ‰ÔÎÚÈÓÈο ·ÙÙ·Ú· ÙÔ˘ Á·ÛÙÚÂÓÂÚÈÎÔ‡ ۈϋӷ Î·È ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜13. ™˘¯ÓfiÙÂÚÔÈ ¡∂O Â›Ó·È ÙÔ Î·ÚÎÈÓÔÂȉ¤˜, Ô˘ ÚÔ¤Ú¯ÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÙÔÓ ÙÂÏÈÎfi ÂÈÏÂfi Î·È ÂÎÎÚ›ÓÂÈ ÛÂÚÔÙÔÓ›ÓË, ηıÒ˜ ÓÂÔÏ¿ÛÌ·Ù· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ Ô˘ ÂÎÎÚ›ÓÔ˘Ó ÈÓÛÔ˘Ï›ÓË, ÁÏԢηÁfiÓÔ, Á·ÛÙÚ›ÓË Î·È ¿ÏÏ· Ó¢ÚÔÂÙ›‰È·.13 OÈ ¡∂O Û˘Ó‹ıˆ˜ Â›Ó·È ‚Ú·‰¤ˆ˜ ·Ó·Ù˘ÛÛfiÌÂÓ· ÓÂÔÏ¿ÛÌ·Ù· ÛÙ· ÔÔ›· Ë ‰È¿ÁÓˆÛË Á›ÓÂÙ·È ÛÙË ÌÂÙ·ÛÙ·ÙÈ΋ Ê¿ÛË (4080% ÙˆÓ ·ÛıÂÓÒÓ), Ì ÙÔ ‹·Ú Ó· Â›Ó·È Ë Î‡ÚÈ· ı¤ÛË ÌÂÙ·ÛÙ¿ÛÂˆÓ (40-93%), ÂÓÒ ·ÎÔÏÔ˘ıÔ‡Ó Ù· ÔÛÙ¿ (12-20%) Î·È ÔÈ Ó‡ÌÔÓ˜ (8-10%). ∏ ÂÈ‚¿Ú˘ÓÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ¡∂O Â¤Ú¯ÂÙ·È ÏfiÁˆ ηٿÏ˄˘ ÙÔ˘ ‹·ÙÔ˜ ·fi ÌÂÙ·ÛÙ¿ÛÂȘ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi Ë·ÙÔÌÂÁ·Ï›·, ‰˘ÛÊÔÚ›· Î·È Î·Î‹ ÔÈfiÙËÙ· ˙ˆ‹˜. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ÔÈ ÌÂÙ·ÛÙ¿ÛÂȘ ÙˆÓ ¡∂O ·Ú·Ì¤ÓÔ˘Ó ÂÚÈÔÚÈṲ̂Ó˜ ÛÙÔ ‹·Ú ÁÈ· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ì ÂÓÙ·ÂÙ‹ ÂÈ‚›ˆÛË Ô˘ ÏËÛÈ¿˙ÂÈ 30%, ·ÎfiÌË Î·È ¯ˆÚ›˜ ıÂÚ·›· 14. ¶ÔÏϤ˜ ıÂÚ·¢ÙÈΤ˜ ÚÔÛÂÁÁ›ÛÂȘ ¤¯Ô˘Ó ÚÔÙ·ı› ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ë·ÙÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ Ó¢ÚÔÂÓ‰ÔÎÚÈÓÈÎÒÓ fiÁÎˆÓ (∏ª-¡∂O), Ì ÛÎÔfi ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÓÂÔÏ·ÛÌ·ÙÈÎÔ‡ ÊÔÚÙ›Ô˘ Î·È Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, fiˆ˜ ·ÚÙËÚÈ·Îfi˜ ¯ËÌÂÈÔÂÌ‚ÔÏÈÛÌfi˜, ηٷÛÙÚÔÊ‹ Ì ڷ‰ÈÔÛ˘¯ÓfiÙËÙ˜ ‹ ÌÈÎÚÔ·̷ٷ Î·È Û˘ÓÙËÚËÙÈ΋ ·Áˆ-

METAMO™XEY™Eπ™ 2011

Á‹ Ì ·Ó¿ÏÔÁ· Ù˘ ۈ̷ÙÔÛÙ·Ù›Ó˘ ‹ ¯ËÌÂÈÔıÂÚ·›·15. ∏ Ë·ÙÂÎÙÔÌ‹ ÂıˆÚ›ÙÔ ·ÚËÁÔÚÈ΋ ıÂÚ·›· ÁÈ· ·ÛıÂÓ›˜ Ì ÌÂÁ¿ÏÔ ÓÂÔÏ·ÛÌ·ÙÈÎfi ÊÔÚÙ›Ô Î·È ÌË ÂÏÂÁ¯fiÌÂÓË Û˘Ìو̷ÙÔÏÔÁ›· ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÌÔÚÔ‡Û ӷ ·Ê·ÈÚÂı› ÙÔ 80-90 % ÙˆÓ ÌÂÙ·ÛÙ¿ÛˆÓ16,17. ¡ÂfiÙÂÚ˜ ÂÍÂÏ›ÍÂȘ ÛÙËÓ ÂÈÏÔÁ‹ Î·È ÛÙ·‰ÈÔÔ›ËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ∏ª¡∂O Â¤ÊÂÚ·Ó ÙÔÓ Â·Ó·ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ÚfiÏÔ˘ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ıÂÚ·›·˜. ∂ȉÈÎfiÙÂÚ·, Ë ª∏ ÚÔÙ›ÓÂÙ·È ÁÈ· ÙËÓ ıÂÚ·›· ·ÛıÂÓÒÓ Ì ÂÚÈÔÚÈṲ̂ÓÔ ÓÂÔÏ·ÛÌ·ÙÈÎfi ÊÔÚÙ›Ô Î·È ·Ó·ÌÂÓfiÌÂÓË Ì·ÎÚ¿ ÂÈ‚›ˆÛË, ›Ù ÏfiÁˆ Ó·ڿ˜ ËÏÈΛ·˜ ›Ù ÏfiÁˆ «Î·ÏÔ‹ıÔ˘˜» ‚ÈÔÏÔÁÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ÓÂÔÏ¿ÛÌ·ÙÔ˜14.

OÈ ÂÚÈÛÛfiÙÂÚ˜ ·Ó·ÊÔÚ¤˜ ÁÈ· ª∏ Û ∏ª¡∂O ÂÚÈÔÚ›˙ÔÓÙ·È Û ÌÈÎÚfi ·ÚÈıÌfi ·ÛıÂÓÒÓ. ∏ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË Â›Ó·È Û˘Ó‹ıˆ˜ ÌÂÁ·Ï‡ÙÂÚË ·fi 50 %, ·ÏÏ¿ Ë ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË Â›Ó·È Ôχ ÌÈÎÚfiÙÂÚË. ™Â Ì›· ÚfiÛÊ·ÙË °·ÏÏÈ΋ ÔÏ˘ÎÂÓÙÚÈ΋ ÌÂϤÙË, ÔÈ Le Treut Î·È Û˘Ó.,18 ·ÚÔ˘Û›·Û·Ó Ù· ·ÔÙÂϤÛÌ·Ù· ª∏ Û ∏ª-¡∂O Û 85 ·ÛıÂÓ›˜. ∏ ÂÓÙ·ÂÙ‹˜ Û˘ÓÔÏÈ΋ ÂÈ‚›ˆÛË ‹Ù·Ó 47% Î·È Ë Ë ÂχıÂÚË ÓfiÛÔ˘ ÂÈ‚›ˆÛË 20%. ™ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ‰È·ÈÛÙÒıËΠfiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ∏ª-¡∂O ·fi ÙÔÓ Á·ÛÙÚÂÓÙÂÚÈÎfi ۈϋӷ ‹ ·fi ¿ÁÓˆÛÙË ÚˆÙÔ·ı‹ ÂÛÙ›· ›¯·Ó ηχÙÂÚË ÂÈ‚›ˆÛË ·fi ÂΛÓÔ˘˜ Ì ÚˆÙÔ·ı‹ ÂÛÙ›· ÛÙÔ ¿ÁÎÚ·˜ ‹ ÛÙÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ. OÈ ·ÛıÂÓ›˜ Ì ÙÔÓ ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ ˘ÔÙÚÔ‹˜ ‹Ù·Ó ÂΛÓÔÈ Ô˘ ›¯·Ó Ë·ÙÔÌÂÁ·Ï›·, ›¯·Ó ˘Ô‚ÏËı› Û Â¤Ì‚·ÛË ÛÙËÓ ¿Óˆ ÎÔÈÏ›· Î·È Ë ÚˆÙÔ·ı‹˜ ÂÛÙ›· ‹Ù·Ó ÛÙÔ ¿ÁÎÚ·˜. ∞ÛıÂÓ›˜ Ì ‰‡Ô ·fi ÙÔ˘˜ ·ÓˆÙ¤Úˆ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ›¯·Ó ÂÓÙ·ÂÙ‹ ÂÈ‚›ˆÛË 20%, ÂÓÒ ÂΛÓÔÈ Ô˘ ›¯·Ó ¤Ó· ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ›¯·Ó ÂÓÙ·ÂÙ‹ ÂÈ‚›ˆÛË 75%18. ∞Ó¿ÏÔÁ˜ ÚÔÛ¿ıÂȘ Ù·ÍÈÓfiÌËÛ˘ Î·È ÛÙ·‰ÈÔÔ›ËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ∏ª-¡∂O ¤ÁÈÓ·Ó Î·È ·fi ¿ÏϘ ÔÌ¿‰Â˜, ¯ˆÚ›˜ ÚÔ˜ ÙÔ ·ÚfiÓ Ó· ¤¯ÂÈ ÚÔ·„ÂÈ ‚ÂÏÙ›ˆÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ14,15. ™˘ÓÔÙÈο, ÌÔÚ› Ó· ϯı› fiÙÈ Ë ª∏ ‚ÂÏÙÈÒÓÂÈ Ù· Û˘ÌÙÒÌ·Ù· ÙˆÓ ·ÛıÂÓÒÓ Ì ÏÂÈÙÔ˘ÚÁÈΤ˜ ÌÂÙ·ÛÙ¿ÛÂȘ Ó¢ÚÔÂÓ‰ÔÎÚÈÓÈÎÒÓ fiÁΈÓ, ·ÏÏ¿ Ë ˘ÔÙÚÔ‹ Â›Ó·È Û˘¯Ó‹. ¢ÂÓ ¤¯Ô˘Ó ·ÔÛ·ÊËÓÈÛı› ÔÈ ÂӉ›ÍÂȘ Î·È Ë ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ Ô˘ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ë ª∏.

¶ÂÚÈ˘Ï·›Ô ¯ÔÏ·ÁÁÂÈÔηÚΛӈ̷. Δ· ·Ú¯Èο ·ÔÙÂϤÛÌ·Ù· Ù˘ ª∏ ÁÈ· ÂÚÈ˘Ï·›Ô ¯ÔÏ·ÁÁÂÈÔηÚΛӈ̷ (¶Ã∫) ‹Ù·Ó ·Ô-

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ÁÔËÙ¢ÙÈο, Ì ·ÒÙÂÚË ÂÈ‚›ˆÛË ÌÈÎÚfiÙÂÚË ·fi 20%. ∞˘Ùfi ›Û¯˘Â ·ÎfiÌË Î·È fiÙ·Ó fiÁÎÔ˜ ‹Ù·Ó Ôχ ÌÈÎÚfi˜, ηıÒ˜ Î·È fiÙ·Ó ÂÚfiÎÂÈÙÔ ÁÈ· Ù˘¯·›Ô ‡ÚËÌ· Û ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·Ó Û ª∏ ÁÈ· ÚˆÙÔ·ı‹ ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›Ùȉ· 19 . Δ· ÛÙÔȯ›· ·˘Ù¿ ˘Ô‰ËÏÒÓÔ˘Ó fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ ·ÛıÂÓ‹˜ Ì ¶Ã∫ Ô˘ ÌÔÚ› Ó· ˘Ô‚ÏËı› Û ª∏ ·ÚÎÂÙ¿ ÓˆÚ›˜ ÒÛÙ ӷ ÌËÓ ¯ÚÂÈ¿˙ÂÙ·È Ó¤Ô-Û˘ÌÏËڈ̷ÙÈ΋ ıÂÚ·›· . ∏ ÚÒÙË ÚÔÔÙÈ΋ ÌÂϤÙË ª∏ Û ¶Ã∫, Ì ӤÔ-Û˘ÌÏËڈ̷ÙÈ΋ ıÂÚ·›·, ÔÚÁ·ÓÒıËΠÛÙË Mayo Clinic, ÙÔ 1993,20 Ì ·˘ÛÙËÚ¿ ÎÚÈÙ‹ÚÈ· ÛÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ: ·) ·ÓÂÁ¯Â›ÚËÙÔ, Ì Ë·ÙÂÎÙÔÌ‹, ¶Ã∫ Ì ‰È¿ÌÂÙÚÔ <3 cm, ·ÏÏ¿ ¯ˆÚ›˜ ÂÚÈÔÚÈÛÌfi ÛÙÔ Ì‹ÎÔ˜ Ù˘ ÛÙ¤ÓˆÛ˘ ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘, ‚) ÂÍ’ ÔÚÈÛÌÔ‡ ·ÛıÂÓ›˜ Ì ÚˆÙÔ·ı‹ ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›Ùȉ· Î·È ¶Ã∫ ‰ÂÓ Â›¯·Ó ¤Ó‰ÂÈÍË Ë·ÙÂÎÙÔÌ‹˜. ΔÔ ÚˆÙfiÎÔÏÏÔ ÂÚÈÂÏ¿Ì‚·Ó ·Ú¯Èο Â͈ÙÂÚÈ΋ ·ÎÙÈÓÔıÂÚ·›· Î·È ÛÙËÓ Û˘Ó¤¯ÂÈ· ÂÛˆÙÂÚÈ΋ ·ÎÙÈÓÔıÂÚ·›· Ì ÂÓ‰ÔÛÎÔÈ΋ ÙÔÔı¤ÙËÛË stent ·fi ÈÚ›‰ÈÔ 111. ∏ ıÂÚ·›· ·˘Ù‹ ÚÔηÏ› ÛËÌ·ÓÙÈ΋ Ó¤ÎÚˆÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ Î·È ÙˆÓ ¯ÔÏËÊfiÚˆÓ ÌÂ Û˘Ó¤ÂÈ· ›ÎÙÂÚÔ Î·È ¯ÔÏ·ÁÁÂÈ›Ùȉ˜ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È Â͈ÙÂÚÈ΋ ‰È·‰ÂÚÌÈ΋ ·ÚÔ¯¤Ù¢ÛË. ™ÙËÓ Û˘Ó¤¯ÂÈ· ÔÈ ·ÛıÂÓ›˜ Ï·Ì‚¿ÓÔ˘Ó ¯ËÌÂÈÔıÂÚ·›· Ì capecitabine, οı 2-3 ‚‰ÔÌ¿‰Â˜. ∞ÎÔÏÔ˘ı› Ï··ÚÔÛÎÔÈ΋ ÛÙ·‰ÈÔÔ›ËÛË ÁÈ· Ó· ·ÔÎÏÂÈÛı› Ë ÂÈÓ¤ÌËÛË ÙˆÓ ÂȯˆÚ›ˆÓ ÏÂÌÊ·‰¤ÓˆÓ, ÙÔ˘ ÂÚÈÙÔÓ·›Ô˘ Î·È Ù˘ ÂÈÊ·Ó›·˜ ÙÔ˘ ‹·ÙÔ˜. OÈ ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ·ÚÓËÙÈ΋ Ï··ÚÔÛÎfiËÛË ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∞fi ÙÔ 1994 ̤¯ÚÈ ÙÔ 2010, 193 ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó ÛÙÔ ·ÓˆÙ¤Úˆ ÚˆÙfiÎÔÏÏÔ Î·È 168 ¤Êı·Û·Ó ̤¯ÚÈ ÙË Ï··ÚÔÛÎÔÈ΋ ÛÙ·‰ÈÔÔ›ËÛË. ∏ ÙÂÏÂ˘Ù·›· ‹Ù·Ó ıÂÙÈ΋ ÛÙÔ 21% ÙˆÓ ·ÛıÂÓÒÓ, ÔÈ ÔÔ›ÔÈ ·ÔÎÏ›ÛıËηÓ. ΔÂÏÈο, ˘Ô‚Ï‹ıËÎ·Ó Û ª∏ 125 ·ÛıÂÓ›˜, 83 ·fi و̷ÙÈÎfi ‰fiÙË, 41 ·fi Û˘ÁÁÂÓ‹ ˙ÒÓÙ· ‰fiÙË Î·È 1 Û domino. ∏ ÂÓÙ·ÂÙ‹˜ ÂÈ‚›ˆÛË ‹Ù·Ó 73%. OÈ ·ÛıÂÓ›˜ Ì ÚˆÙÔ·ı‹ ÛÎÏËÚ˘ÓÙÈ΋ ¯ÔÏ·ÁÁÂÈ›Ùȉ· Î·È ¶Ã∫ ›¯·Ó ÂÏ·ÊÚ¿ ηχÙÂÚË ÂÈ‚›ˆÛË ·fi ÂΛÓÔ˘˜ Ì ÛÔÚ·‰ÈÎfi ¶Ã∫.21 OÈ ·ÛıÂÓ›˜ Ì ¶Ã∫ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ª∏ ›¯·Ó ÂÏ·ÊÚ¿ ηχÙÂÚË ÂÈ‚›ˆÛË ·fi ÂΛÓÔ˘˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ›¯·Ó ÂÍ·ÈÚ¤ÛÈÌÔ ¶Ã∫ Î·È ¤ÁÈÓ Ë·ÙÂÎÙÔÌ‹, ÛÙËÓ ›‰È· ÎÏÈÓÈ΋22. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ ·˘Ùfi, Û˘ÛÙ‹ÓÂÙ·È Ë Ë·ÙÂÎÙÔÌ‹ Û ·ÛıÂÓ›˜ Ì ÂÍ·ÈÚ¤ÛÈÌÔ ¶Ã∫, ÏfiÁˆ Ù˘ ¤ÏÏÂȄ˘ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ·ÏÏ¿ Î·È Ù˘ ÔÏ˘ÏÔÎfiÙËÙ·˜, ÙÔ˘ Îfi-

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π. º√À∑∞™, ¢. Δ∞∫√À¢∞™

ÛÙÔ˘˜ Î·È ÙˆÓ ‰˘Û¯ÂÚÂÈÒÓ Ô˘ ¤¯ÂÈ Ë Û˘ÌÏËڈ̷ÙÈ΋ ıÂÚ·›· ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ Ù˘ ª∏20.

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Third series, fascicle 31. ed. Armed Forces Institute of Pathology. Washington, USA, 1999: 282-307.

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6. Mehrabi A, Kashfi A, Fonouni H, Schemmer P, Schmied BM, Hallscheidt P, et al. Primary malignant hepatic epithelioid hemangioendothelioma: a comprehensive review of the literature with emphasis on the surgical therapy. Cancer 2006; 107: 2108-21.

7. Grotz TE, Nagorney D, Donohue J, et al. Hepatic epithelioid haemangioendothelioma: is transplantation the only treatment option? HPB (Oxford). 2010; 12(8): 546-53.

8. Liu YI, Brown SS, Elihu A, Bonham CA, Concepcion W, Longacre TA, Kamaya A. Hepatic epithelioid hemangioendothelioma. Dig Dis Sci. 2011; 56(2): 303-6.

9. Lerut JP, Orlando G, Adam R, et al. The place of liver transplantation in the treatment of hepatic epitheloid hemangioendothelioma: report of the European liver transplant registry. Ann Surg. 2007; 246: 949–57.

10. Demetris AJ, Minervini M, Raikow RB, Lee RG. Hepatic epithelioid haemangioendothelioma – biological questions based on pattern of recurrence in an allograft and tumor immunophenotype. Am J Surg Path. 1997; 21: 263–70.

11. Madariaga JR, Marino IR, Karavia DD, et al. Longterm results after liver transplantation for primary hepatic

epithelioid haemangioendothelioma. Ann Surg Oncol.

1995; 2: 483–7.

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14. Mazzaferro V, Pulvirenti A, Coppa J. Neuroendocrine tumors metastatic to the liver: how to select patients for liver transplantation? J Hepatol. 2007; 47(4): 460-6.

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Liver Transpl 2006; 12: 448-56.

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17. Yao KA, Talamonti MS, Nemcek A, Angelos P, Chrisman H, Skarda J, et al. Indications and results of liver resection and hepatic chemoembolization for metastatic gastrointestinal neuroendocrine tumors. Surgery 2001; 130: 677-82.

18. Le Treut YP, Gregoire E, Belghiti J, Boillot O, Soubrane O, Mantion G, et al. Predictors of long-term survival after liver transplantation for metastatic endocrine tumors: an 85-case French multicentric report. Am J Transplant 2008; 8: 1205-13.

19. Ghali P, Marotta PJ, Yoshida EM, Bain VG, Marleau D, Peltekian K, et al. Liver transplantation for incidental cholangiocarcinoma: analysis of the Canadian experience. Liver Transpl 2005; 11: 1412-6.

20. Gores GJ, Nagorney DM, Rosen CB. Cholangiocarcinoma: is transplantation an option? For whom? J Hepatol 2007; 47: 455-9.

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22. Rea DJ, Heimbach JK, Rosen CB, Haddock MG, Alberts SR, Kremers WK, et al. Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma. Ann Surg 2005; 242: 451-8.

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º˘ÛÈÔ·ıÔÏÔÁÈÎÔ› Ì˯·ÓÈÛÌÔ› Ù˘ ÔÍ›·˜ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Î·È ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË: ∂Ӊ›ÍÂȘ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ª. Deutsch

1. ∂ÈÛ·ÁˆÁ‹

Ú·¯‹ Ù˘ ΢ÙÙ·ÚÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ¯ˆÚ›˜ ·ÂÏ¢ı¤ÚˆÛË ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ Û˘ÛÙ·ÙÈÎÒÓ Î·È ¯ˆÚ›˜ ‰Â˘ÙÂÚÔÁÂÓ‹ ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË. ™Â ÌÔÚÈ·Îfi Â›Â‰Ô Ë ·fiÙˆÛË ÙÔ˘ ΢ÙÙ¿ÚÔ˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÂÓÂÚÁÔÔÈ‹Ûˆ˜ ÌÈ·˜ ÛÂÈÚ¿˜ ÚˆÙ·ÛÒÓ Ù˘ ΢ÛÙ›Ó˘-ηÛ¿Û˜. ŒÓ· Â͈ÙÂÚÈÎfi Û‹Ì· fiˆ˜ Ë Î·Û¿ÛË 8 Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÂÓÂÚÁÔÔ›ËÛ˘ ˘Ô‰Ô¯¤ˆÓ ı·Ó¿ÙÔ˘ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙËÓ ÌÂÌ‚Ú¿ÓË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ‹ ¤Ó· ÂÛˆÙÂÚÈÎfi Û‹Ì· fiˆ˜ Ë Î·Û¿ÛË 9 Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÔÍÂȉˆÙÈ΋˜ ÌÈÙÔ¯ÔÓ‰Úȷ΋˜ ‚Ï¿‚˘ ÌÔÚÔ‡Ó Ó· ˘ÚÔ‰ÔÙ‹ÛÔ˘Ó ÙËÓ ·fiÙˆÛË ÙÔ˘ ΢ÙÙ¿ÚÔ˘. ∏ Ó¤ÎÚˆÛË ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ÛËÌ·›ÓÂÈ ÌÂȈ̤ÓË ÂÓ¤ÚÁÂÈ· ( Ì›ˆÛË ATP) Ì ·ÔÙ¤ÏÂÛÌ· Ô›‰ËÌ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘, χÛË ÙÔ˘ ΢ÙÙ¿ÚÔ˘, ·ÂÏ¢ı¤ÚˆÛË ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ Ô˘ÛÈÒÓ Î·È ‰Â˘ÙÂÚÔÁÂÓ‹ ÊÏÂÁÌÔÓ‹. ™˘ÁÎÂÎÚÈ̤Ó˜ ·Èٛ˜ O∏∞ ÚÔηÏÔ‡Ó Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë Â›Ù Ì ÙÔÓ ¤Ó·Ó ›Ù Ì ÙÔÓ ¿ÏÏÔ Ì˯·ÓÈÛÌfi. °È· ·Ú¿‰ÂÈÁÌ· ÛÙËÓ O∏∞ ·fi ·Ú·ÎÂÙ·ÌfiÏË ˘ÂÚ¤¯ÂÈ Ë Ó¤ÎÚˆÛË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Î·È ÛÙËÓ O∏∞ ·fi ÈÛ¯·ÈÌ›· ‹ ÛÙË ÎÂÚ·˘ÓÔ‚fiÏÔ ÓfiÛÔ Wilson ˘ÂÚ¤¯ÂÈ Ô Ì˯·ÓÈÛÌfi˜ Ù˘ ·fiÙˆÛ˘. ¶ÔÏϤ˜ ÊÔÚ¤˜ fï˜ ·Ú·ÙËÚÂ›Ù·È Û˘Ó‰˘·ÛÌfi˜ ÙˆÓ ‰˘Ô Ì˯·ÓÈÛÌÒÓ ·˘ÙÒÓ: Û ¤Ó· ·ÔÙˆÙÈÎfi ·ÙÙ·ÚÔ ÌÔÚ› Ó· ‰ËÌÈÔ˘ÚÁËı› Î·È ÌÈÙÔ¯ÔӉȷ΋ ‚Ï¿‚Ë Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÍ·ÓÙÏËıÔ‡Ó ÔÈ ·Ôı‹Î˜ ATP Î·È Ó· Âı¿ÓÂÈ ÙÔ Î‡ÙÙ·ÚÔ Ì¤Ûˆ ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ù˘ Ó¤ÎÚˆÛ˘.

2.1.1. O ÚfiÏÔ˜ ÙÔÓ ˘Ô‰Ô¯¤ˆÓ ı·Ó¿ÙÔ˘ 1) TNF-R1 O ˘Ô‰Ô¯¤·˜ TNF-R1 ÂÎÊÚ¿˙ÂÙ·È Û ·ÊıÔÓ›· ÛÙËÓ ÌÂÌ‚Ú¿ÓË ÙÔ˘ Ë·ÙÔ΢ÙÙ¿ÚÔ˘. ŸÙ·Ó Û˘Ó‰¤ÂÙ·È Ì ÙÔÓ ‰ÈÂÁ¤ÚÙË ÙÔ˘ (TNF·) ÙÔ TNF-R1 ÂÓÂÚÁÔÔÈ› ̤ۈ ÂÓfi˜ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ ÚˆÙÂ˚ÓÈÎÔ‡ Û˘ÌϤÁÌ·ÙÔ˜ Ì ÙÔ fiÓÔÌ· TRADD (TNF-R associated protein with death domain) ÙÔÓ Î·Ù·ÚÚ¿ÎÙË ÙˆÓ Î·Û·ÛÒÓ ·ÏÏ¿ Î·È ·Ú¿ÁÔÓÙ˜ ÌÂÙ·ÁÚ·Ê‹˜ (˘ÚËÓÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Îμ –¡F-Îμ) Ô˘ ¤¯Ô˘Ó ÚÔÛٷ٢ÙÈÎfi- ·ÓÙÈ·Ô-

∏ 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 ÂΉËÏÒÛÂˆÓ , 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.

2.¶·ıÔÁ¤ÓÂÈ· O∏∞ 2.1. ªË¯·ÓÈÛÌÔ› Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ ‚Ï¿‚˘ ™ÙËÓ O∏∞ ηٷÛÙÚ¤ÊÂÙ·È ·ÈÊÓȉ›ˆ˜ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ Ë·ÙÔ΢ÙÙ¿ÚˆÓ ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ·ÚÎÂÙfi˜ ¯ÚfiÓÔ˜ ÁÈ· ÙËÓ ·ÓÙÈÚÚÔÈÛÙÈ΋ ·Ó·Á¤ÓÓËÛË ÙÔ˘˜. À¿Ú¯Ô˘Ó ‰˘Ô ÙÚfiÔÈ Ì ÙÔ˘˜ ÔÔ›Ô˘˜ ηٷÛÙÚ¤ÊÔÓÙ·È Ù· Ë·ÙÔ·ÙÙ·Ú·: Ë Ó¤ÎÚˆÛË Î·È ‹ ·fiÙˆÛË. ∏ ·fiÙˆÛË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘ÚËÓÈ΋ Î·È Î˘ÙÙ·ÚÔÏ·ÛÌ·ÙÈ΋ Û˘ÚÚ›ÎÓˆÛË ¯ˆÚ›˜ ‰È·Ù·-

127

128

M. DEUTSCH

¶I¡∞∫∞™ 1. ∞Èٛ˜ O∏∞ 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

FasL

TNF-a

Fas

TNF-R1

Caspase 8 Caspase 3,4,7

™¯‹Ì· 1. ªË¯·ÓÈÛÌÔ› Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ ‚Ï¿‚˘.

ÙˆÙÈÎfi ÚfiÏÔ. º˘ÛÈÔÏÔÁÈο Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ÈÛÔÚÚÔ›· ÌÂٷ͇ ÙˆÓ ·ÔÙˆÙÈÎÒÓ Î·È ·ÓÙÈ·ÔÙˆÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ¤ÙÛÈ ÒÛÙ ٷ ·ÙÙ·Ú· Û˘Ó‹ıˆ˜ Ó· Â›Ó·È ·ÓıÂÎÙÈο ÛÙËÓ Î·Ù·ÛÙÚÔÊÈ΋ ‰Ú¿ÛË ÙÔ˘ TNF-·.

O ÚÔÛٷ٢ÙÈÎfi˜ ÚfiÏÔ˜ ÙÔ˘ NF-kB Â›Ó·È Û‡ÓıÂÙÔ˜. ∫·Ù·ÛÙÔÏ‹ ÙÔ˘ NF-kB ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙfiÛÔ ÙËÓ ·fiÙˆÛË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ fiÛÔ Î·È ÙËÓ Ï‹ÚË Î·Ù·ÛÙÔÏ‹ ÙËÓ Ë·ÙÈ΋˜ ·Ó·Á¤ÓÓËÛ˘. ™Â ÂÈÚ¿Ì·Ù· Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ Û NFkB Î·È TNF-R1 knockout ÔÓÙ›ÎÈ· Ê¿ÓËΠfiÙÈ Ë ‰Ú¿ÛË ÙÔ˘ Û‡ÌÏÂÁÌ·ÙÔ˜ TNF-a/TNF-R1 ÛÙÔÓ

·Ú¿ÁÔÓÙ· ÌÂÙ·ÁÚ·Ê‹˜ NF-kB ¤¯ÂÈ ÚfiÏÔ ÚÔÛٷ٢ÙÈÎfi ·fi ÙËÓ ·fiÙˆÛË Î·È ÂÓÂÚÁÔÔÈ› Ô‰Ô‡˜ Ë·ÙÔ΢ÙÙ·ÚÈÎÔ‡ ÔÏÏ·Ï·ÛÈ·ÛÌÔ‡. ™ÙÔÓ ÂÚ›ÏÔÎÔ Ì˯·ÓÈÛÌfi ·˘ÙfiÓ ˘¿Ú¯Ô˘Ó Î·È ¿ÏϘ Ô˘Û›Â˜ Ì ÚfiÏÔ Â›Ù ÚÔ-·ÔÙˆÙÈÎfi (cJun-N-terminal kinase –JNK, activating protein-1AP1), ›Ù ÚÔÛٷ٢ÙÈÎfi (extracellular signal-regulated kinase, P38 mitogen –actived protein kinase) k.a. ∏·ÙÔ΢ÙÙ·ÚÈÎfi˜ ı¿Ó·ÙÔ˜ ̤ۈ TNF-a Â›Ó·È Ô ‚·ÛÈÎfi˜ ·ıÔÁÂÓÂÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ÛÙËÓ O∏∞ ·fi ÙÂÙÚ·¯ÏˆÚ¿Óıڷη Î·È ÛÙËÓ Ë·ÙÔ΢ÙÙ·ÚÈ΋

METAMO™XEY™Eπ™ 2011

‚Ï¿‚Ë ÌÂÙ¿ ·fi ÈÛ¯·ÈÌ›· ÛÙËÓ Ê¿ÛË ÙËÓ Â·Ó·ÈÌ¿ÙˆÛ˘ (ischemia-reperfusion injury). Δ· Â›‰· ÙÔ˘ TNF-a ÛÙÔÓ ÔÚfi Â›Ó·È ·˘ÍË̤ӷ ÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜. ∂›Û˘ ÔÓÙ›ÎÈ· ˘fi ıÂÚ·›· Ì ÂÓÙÔ͢ÊÈÏÏ›ÓË (·Ó·ÛÙÔϤ·˜ TNF) ·ÚÔ˘Û›·Û·Ó ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙËÓ ·fiÙˆÛË Î·È ÌÂÁ¿ÏË ÂÈ‚›ˆÛË ÌÂÙ¿ ·fi ÂÈÚ·Ì·ÙÈ΋ ÈÛ¯·ÈÌ›·. À¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÔÍÂȉˆÙÈÎÔ‡ ÛÙÚ˜ Î·È Ù˘ TNF ÂÍ·ÚÙÒÌÂÓ˘ ·fiÙˆÛ˘ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ O∏∞. £ÂÚ·›· Ì ¡-·ÎÂÙ˘ÏÔ΢ÛÙ›ÓË ÌÂÈÒÓÂÈ ÙËÓ TNF ÙÔÍÈÎfiÙËÙ· Û ÔÓÙ›ÎÈ· ÂÓÒ Ë Ì›ˆÛË Ù˘ Ê˘ÛÈ΋˜ ·ÓÙÈÔÍÂȉˆÙÈ΋˜ Ô˘Û›·˜ ÁÏÔ˘Ù·ıÈfiÓ˘ ÚÔηÏ› ·˘ÍË̤ÓË TNF ΢ÙÙ·ÚÔÙÔÍÈÎfiÙËÙ·.

OÈ ÌÂϤÙ˜ ·˘Ù¤˜ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ ÙÔ ÔÍÂȉˆÙÈÎfi ÛÙÚ˜ ‰Ú· ‚Ï·‚ÂÚ¿ ̤ۈ ‰˘Ô Ì˯·ÓÈÛÌÒÓ: 1) ¢·ÈÛıËÙÔÔÈÒÓÙ·˜ ÙÔ ‹·Ú ÛÙËÓ TNF ·fiÙˆÛË Î·È 2) ̤ۈ ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ó¤ÎÚˆÛ˘ ( ÌÂÈÒÓÔÓÙ·˜ ÙÔ ÌÈÙÔ¯ÔÓ‰ÚÈ·Îfi ATP). º·›ÓÂÙ·È ÏÔÈfiÓ Ó· ˘¿Ú¯ÂÈ ¤Ó·˜ Ê·‡ÏÔ˜ ·ÎÏÔ˜ Û˘Û¯¤ÙÈÛ˘ ·fiÙˆÛ˘-Ó¤ÎÚˆÛ˘ ̤ۈ ÌÈÙÔ¯ÔÓ‰Úȷ΋˜ ‚Ï¿‚˘. ªÈ· ·Ú¯È΋ ÌÈÙÔ¯ÔÓ‰Úȷ΋ ‚Ï¿‚Ë ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ ÛÙÚ˜ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÂÓ‰Ô΢ÙÙ¿ÚÈ· ¤Ó·ÚÍË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ·ÔÙˆÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡, ·ÏÏ¿, Û ‰Â‡ÙÂÚÔ ¯ÚfiÓÔ, ÌÂÙ¿ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ Î·Û·ÛÒÓ, ‰ËÌÈÔ˘ÚÁÂ›Ù·È ÌÈÙÔ¯ÔÓ‰Úȷ΋ ‚Ï¿‚Ë Ô˘ Û˘Ó¯›˙ÂÈ Î·È ‰È·ÙËÚ› ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ·ÔÙˆÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡. §fiÁˆ fï˜ ÌÂȈ̤Ó˘ ATP ÚÔηÏÂ›Ù·È ·Ú¿ÏÏËÏ· Î·È Ó¤ÎÚˆÛË ÙÔ˘ Ë·ÙÔ΢ÙÙ¿ÚÔ˘.

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∞ÓÙ›ıÂÙ· ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ O∏∞ ·fi ·ÎÂÙ·ÌÈÓÔÊ·›ÓË, ÂÓÂÚÁÔÔÈÂ›Ù·È Î˘Ú›ˆ˜ Ô ÔÍÂȉˆÙÈÎfi˜ Ì˯·ÓÈÛÌfi˜, Ë Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ Ó¤ÎÚˆÛ˘ Î·È fi¯È ·fiÙˆÛ˘. ™ËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ÂÓ‰Ô΢ÙÙ¿ÚÈÔ˘ ATP ÚÔηÏ› ηٷÛÙÔÏ‹ ÙˆÓ Î·Û·ÛÒÓ ÏfiÁˆ Ù˘ ˘ÂÚÔ¯‹˜ ÙÔ˘ ÔÍÂȉˆÙÈÎÔ‡ ÛÙÚ˜. ∏ ‰Ú¿ÛË TNF ÛÙ· Ë·ÙÔ·ÙÙ·Ú· ‰ÂÓ ÂÍ·ÚÙ¿Ù·È ÌfiÓÔ ·fi ÙÔÓ ‚·ıÌfi ÔÍÂȉˆÙÈÎÔ‡ ÛÙÚ˜ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ·ÏÏ¿ Î·È ·fi ÙȘ ΢ÙÙ·ÚÔΛÓ˜ Ô˘ ÂÚÈ‚¿ÏÏÔ˘Ó ÙÔ Î‡ÙÙ·ÚÔ Î·È ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È Û·Ó ·¿ÓÙËÛË Û ÙÔÍÈ΋ ‚Ï¿‚Ë. ∏ IFN-Á, ÈÓÙÂÚÏ¢ΛÓË 12 Î·È 18 ¢·ÈÛıËÙÔÔÈÔ‡Ó ÙÔ Ë·ÙÈÎfi ·ÙÙ·ÚÔ ÛÙË ‚Ï·ÙÈ΋ ‰Ú¿ÛË ÙÔ˘ TNF ÂÓÒ ÔÈ ÈÓÙÂÚÏ¢ΛÓ˜ 10, 1‚ Î·È ÙÔ ÓÈÙÚÈÎfi Ô͇ ( ¡O) ÚÔÛÙ·ÙÂ‡Ô˘Ó ÙÔ Î‡ÙÙ·ÚÔ.O 2) ™ÙËÓ O∏∞ Ô ˘Ô‰Ô¯¤·˜ FAS ÌÔÚ› Ó· ÂÎÊÚ¿˙ÂÙ·È Â›Û˘ ÛÙË ÌÂÌ‚Ú¿ÓË ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Î·È Â›Ó·È Ôχ ¢·›ÛıËÙÔ˜ ÛÙË ‰Ú¿ÛË ÙÔ˘ FASÚÔÛ‰¤ÙË ÂÓÂÚÁÔÔÈÒÓÙ·˜ ̤ÛÔ FADD (Fas-associated proteins with death domain) ÙÔÓ ·ÔÙˆÙÈÎfi ηٷÚÚ¿ÎÙË ÙˆÓ ÂÓ‰Ô΢ÙÙ¿ÚÈˆÓ Î·Û·ÛÒÓ. ¶·Ú¿ÏÏËÏ· ·Ú·ÙËÚÂ›Ù·È ÌÂȈ̤ÓË ¤ÎÊÚ·ÛË ÙÔ˘ ·ÓÙÈ-·ÔÙˆÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ ̤ۈ Bcl-2.

O Ì˯·ÓÈÛÌfi˜ Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ ·fiÙˆÛ˘ ̤ۈ Fas/Fas-ÚÔÛ‰¤ÙË Â›Ó·È Ô ‚·ÛÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ÎÂÚ·˘ÓÔ‚fiÏÔ˘ Ë·ÙÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ·fi ÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ μ. ∫‡ÙÙ·Ú· Ì ÂÓۈ̷و̤ÓÔ Èfi μ ηٷÛÙÚ¤ÊÔÓÙ·È ·fi Ù· ΢ÙÙ·ÚÔÙÔÍÈο Δ- ÏÂÌÊÔ·ÙÙ·Ú· ΢ڛˆ˜ ̤ۈ Ù˘ Fas ·fiÙˆÛ˘. ∫·È ÛÂ

HBV → μόλυνση ηπατοκυττάρων MHC –I + TCR

∆ιέγερση―ειδικών CTL

IFN-γ

∆ιέγερση μακροφάγων, Προθρομβινάση κυτ. Kuppfer, fgl2 λεμφοκυττάρων ουδετερόφιλων

Ενεργοποίηση καταρράκτη πήξης-απόφραξη αγγείων

Fas-FasL + caspases

Απόπτωση ηπατοκυττάρων

Φλεγμονώδεις κυτταροκίνες

Νέκρωση

HBV-OΗΑ

™¯‹Ì· 2. ¶·ıÔÁ¤ÓÂÛË Ù˘ OHA ·fi ÙÔ ÈÔ HBV ∞fi ÙÔ “Expert reviews in molecular medicine” http://www-ermm.cbcu.cam.ac.uk

130

M. DEUTSCH

·˘Ù‹Ó ÙËÓ ‰È·‰Èηۛ· fiˆ˜ Î·È ÛÙËÓ TNF ·fiÙˆÛË, ÚfiÏÔ ÎÏÂȉ› ·›˙Ô˘Ó Ë ‚Ï¿‚Ë ÙÔ˘ ÌÈÙÔ¯ÔÓ‰Ú›Ô˘ Î·È ÔÈ ·ÓÙȉڷÛÙÈÎÒ˜ ·Ú·ÁfiÌÂÓÔÈ ÔÍÂȉˆÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (reactive oxygen species ROS). ∞Ó¿ÏÔÁÔ˜, ̤ۈ Fas/Fas-ÚÔÛ‰¤ÙË, Â›Ó·È Î·È Ô Ì˯·ÓÈÛÌfi˜ ΢ÙÙ·ÚÈ΋˜ ηٷÛÙÚÔÊ‹˜ ÛÙËÓ ÎÂÚ·˘ÓÔ‚fiÏÔ ÓfiÛÔ Wilson.

2.1.2. O ÚfiÏÔ˜ ÙÔ˘ ¡O Î·È ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ΔÔ ÓÈÙÚÈÎfi Ô͇ (¡O) ·Ú¿ÁÂÙ·È ÛÙÔ ‹·Ú ÌÂÙ¿ ·fi ‰Ú¿ÛË Ù˘ ¡O Û˘ÓıÂÙ¿Û˘ ÙÔ˘ ÂÓ‰ÔıËÏ›Ô˘ ÛÙË L- ·ÚÁÈÓ›ÓË. ΔÔ ¡O ¤¯ÂÈ ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË ÛÙ· Ë·ÙÔ·ÙÙ·Ú· ‚ÂÏÙÈÒÓÔÓÙ·˜ ÙË ÌÈÎÚÔ΢ÎÏÔÊÔÚ›· ̤ۈ ·ÁÁÂȉȷÛÙÔÏ‹˜ Î·È ·ÓÙÈ-·ÈÌÔÂÙ·Ïȷ΋˜ ‰Ú¿Ûˆ˜. ΔÔ ¡O ÂÍÔ˘‰ÂÙÂÚÒÓÂÈ Â›Û˘ ÙËÓ ÔÍÂȉˆÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· Î·È Î·Ù·ÛÙ¤ÏÏÂÈ ÙËÓ ·fiÙˆÛË. ¶·Ú¿ÏÏËÏ· fï˜, ˘ÂÚ‚ÔÏÈ΋ ·Ú·ÁˆÁ‹ ¡O ̤ۈ Ù˘ Â·ÁfiÌÂÓ˘ NO Û˘ÓıÂÙ¿Û˘ (iNOS) Ë ÔÔ›· ÂÓÂÚÁÔÔÈÂ›Ù·È ·fi ÚÔ-ÊÏÂÁÌÔÓ҉˜ ΢ÙÙ·ÚÔΛÓ˜ (TNF-·) Î·È ÏÈÔÔÏ˘Û·Î¯·Ú›Ù˜ ÌÔÚ› Ó· ¤¯ÂÈ Ë·ÙÔÙÔÍÈ΋ ‰Ú¿ÛË. O Ì˯·ÓÈÛÌfi˜ ˘ÂÚ-ÂÓÂÚÁÔÔÈ‹Ûˆ˜ iNOSOÊ·›ÓÂÙ·È Ó· ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ O∏∞ ·fi ·ÎÂÙ·ÌÈÓÔÊ·›ÓË. ¶·Ú¿ÏÏËÏ· Ì ÙËÓ ¡O ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ·ÚÈıÌfi˜ ÚÔ-ÊÏÂÁÌÔÓˆ‰ÒÓ Î·È ·ÓÙÈ-ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ·›˙Ô˘Ó ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ O∏∞. ∏ πÓÙÂÚÊÂÚfiÓË-Á ¤¯ÂÈ ‚·ÛÈÎfi ÚfiÏÔ ÛÙËÓ O∏∞ ·fi ÙÔÓ Èfi HBV. ªÂÙ¿ ·fi ¤Ó· ·Ú¯ÈÎfi Ì˯·ÓÈÛÌfi ·fiÙˆÛ˘ ÙÔ˘ HBV ÌÔÏ˘Ṳ̂ÓÔ˘ Ë·ÙÔ΢ÙÙ¿ÚÔ˘ ̤ۈ Fas, ΢ÙÙ·ÚÔÙÔÍÈο Δ- ÏÂÌÊÔ·ÙÙ·Ú· ÛÙÚ¤ÊÔÓÙ·È ¤Ó·ÓÙÈ ÙÔ˘ ΢ÙÙ¿ÚÔ˘ ·˘ÙÔ‡ Î·È ÂÎÎÚ›ÓÔÓÙ·˜ IFN-Á ÂÓÂÚÁÔÔÈÔ‡Ó Ù· Ì·ÎÚÔÊ¿Á· ÚÔηÏÒÓÙ·˜ ÙËÓ ÂÈ‚Ú·‰˘ÓfiÌÂÓË ·ÓÙ›‰Ú·ÛË ˘ÂÚ¢·ÈÛıËÛ›·˜ Ô˘ ηٷÛÙÚ¤ÊÂÈ ÙÔ Ë·ÙÔ·ÙÙ·ÚÔ. ∏ IL-12 ÚÔηÏ› ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ Î·È ÙˆÓ ÂÓ‰ÔË·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ê˘ÛÈÎÒÓ ÊÔÓ¤ˆÓ ¢ԉÒÓÔÓÙ·˜ ÙËÓ Ë·ÙÔ΢ÙÙ·ÚÈ΋ Ó¤ÎÚˆÛË. ∏ IL-10 Â›Ó·È ÌÈ· ·ÓÙ›-ÊÏÂÁÌÔÓ҉˘ ΢ÙÙ·ÚÔΛÓË Ë ÔÔ›· ¤¯ÂÈ ÚÔÛٷ٢ÙÈ΋ ‰Ú¿ÛË, ÌÂÈÒÓÂÈ ÙËÓ Û‡ÓıÂÛË ÙˆÓ ÚÔ-ÊÏÂÁÌÔÓˆ‰ÒÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ Î·È ÙËÓ ‰Ú¿ÛË ÙˆÓ ¡O Î·È ROS. ™Â ÌÈ· ÌÂϤÙË 11 ·ÛıÂÓÒÓ Ì ÎÂÚ·˘ÓÔ‚fiÏÔ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ· ‚Ú¤ıËΠ˘ÂÚ‚ÔÏÈ΋ ¤ÎÊÚ·ÛË ÙˆÓ IFN-Á Î·È IL-12 ·Ú¿ÏÏËÏ· Ì ÌÂȈ̤ÓË ¤ÎÊÚ·ÛË IL-10.

2.2. ªË¯·ÓÈÛÌfi˜ Ù˘ ÔÏ˘ÔÚÁ·ÓÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÛÙËÓ O∏∞ ¶·Ú¿ÏÏËÏ· Ì ÙËÓ Î·Ù·ÛÙÚÔÊÈ΋ Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚Ë ÛÙËÓ O∏∞ ‰ËÌÈÔ˘ÚÁÂ›Ù·È Î·È ÔÏ˘ÔÚÁ·ÓÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, Ô˘ Â›Ó·È ÙÔ ·ÔÙ¤ÏÂ-

ÛÌ· Ù˘ Û˘ÛÛÒÚ¢Û˘ ÙÔÍÈÓÒÓ ( ·Ì̈ӛ· Î·È Á·Ï·ÎÙÈÎfi Ô͇) Ì·˙› Ì Ù˘ ‚Ï·ÙÈΤ˜ ‰Ú¿ÛÂȘ ΢ÙÙ·ÚÔÎÈÓÒÓ. ∫·Ù’ ·Ú¯‹Ó, ·˘ÍË̤ӷ Â›‰· IL-6 Î·È IL-8 ÚÔηÏÔ‡Ó ÛÏ·¯ÓÈ΋ Î·È Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹ Î·È ˘fiÙ·ÛË. ∞ÎÔÏÔ˘ı› Ë ÂÓÂÚÁÔÔ›ËÛË ‰‡Ô Ôχ ÛËÌ·ÓÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ 1) ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·ÓÙ›‰Ú·Û˘ (SIRS) Î·È 2) ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ Ù˘ ‰È¿¯˘Ù˘ ÂÓ‰·ÁÁÂȷ΋˜ ‹Í˘ (¢∂¶) (¶›Ó. 2). ¶π¡∞∫∞™ 2. OÚÈÛÌfi˜ SIRS SIRS=Û˘ÛÙËÌ·ÙÈ΋ ÊÏÂÁÌÔÓ҉˘ ·ÓÙ›‰Ú·ÛË Û ÔÈΛϘ ‚Ï¿‚˜ £ÂÚÌÔÎÚ·Û›· ÛÒÌ·ÙÔ˜ >38 ÔC ‹ < 36 ÔC ™Ê›ÍÂȘ > 90/ÏÂÙfi ∞Ó·ÓÔ¤˜ > 20/ÏÂÙfi ‹ pCO2 <32 torr §Â˘Î¿ > 12000/mm3 ‹ < 4000/mm3

A˘ÍË̤ÓË ÁÏ˘ÎfiÏ˘ÛË ( ·ÔÙ¤ÏÂÛÌ· ÙÔ˘ SIRS) Ì·˙› Ì ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ÌÈÎÚÔıÚÔÌ‚ÒÛˆÓ, ÙËÓ Î·Ù·Ó¿ÏˆÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È ÙËÓ ·˘ÍË̤ÓË ÚÔÛÎfiÏÏËÛË Ï¢ÎÒÓ ·ÈÌÔÛÊ·ÈÚ›ˆÓ ÛÙÔ ÂÓ‰Ôı‹ÏÈÔ (Ô˘ Â›Ó·È ·ÔÙÂϤÛÌ·Ù· Ù˘ ¢∂¶) ÚÔηÏÔ‡Ó ÙÂÏÈο ‚·ÚÈ¿ ÈÛÙÈ΋ ˘ÔÍ›·. ŸÏ· Ù· fiÚÁ·Ó· Â›Ó·È Â˘·›ÛıËÙ· ÛÙËÓ ÈÛÙÈ΋ ˘ÔÍ›· Ì ÚˆÙ·ÁˆÓÈÛÙ‹ ÙÔÓ ÂÁΤʷÏÔ. ∏ ·ÎÚÈ‚‹˜ ·ıÔÁ¤ÓÂÈ· Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÛÙËÓ O∏∞ ‰ÂÓ Â›Ó·È ·ÎfiÌ· Ï‹Úˆ˜ ÌÂÏÂÙË̤ÓË. º·›ÓÂÙ·È fiÙÈ Ë ·ÈÙ›· Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋. Δ· ÚÒÙ· Û˘Ì‚¿ÓÙ· Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ Ó¢ÚÔÙÔÍÈÎfiÙËÙ·˜ Ù˘ ·Ì̈ӛ·˜. ™ÙÔ Â›Â‰Ô ÙˆÓ ·ÛÙÚÔ΢ÙÙ¿ÚˆÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Ë ·Ì̈ӛ· ÌÂÙ·‚ÔÏ›˙ÂÙ·È Û ÁÏÔ˘Ù·Ì›ÓË Ë ÔÔ›· ÚÔηÏ› ·‡ÍËÛË Ù˘ ÂÓ‰Ô΢ÙÙ¿ÚÈ·˜ ÔÛ̈ÙÈÎfiÙËÙ·˜, Ô›‰ËÌ· ÙˆÓ ·ÛÙÚÔ΢ÙÙ¿ÚˆÓ Î·È ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ· Ì ·˘ÍË̤ÓË ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË. ∏ ÈÛÙÈ΋ ˘ÔÍ›· Î·È Ë ·˘ÍË̤ÓË ÁÏ˘ÎfiÏ˘ÛË Â˘ı‡ÓÔÓÙ·È ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ Á·Ï·ÎÙÈÎÔ‡ Ôͤˆ˜ ÛÙÔÓ ÂÁΤʷÏÔ ÙÔ ÔÔ›Ô ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ Âȉ›ӈÛË ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ Ôȉ‹Ì·ÙÔ˜ . À¿Ú¯ÂÈ ¿ÌÂÛË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ‚·ıÌÔ‡ ÙÔ˘ SIRS, ÙˆÓ ÂÈ¤‰ˆÓ Á·Ï·ÎÙÈÎÔ‡ Ôͤˆ˜ ÛÙÔÓ ÂÁΤʷÏÔ, Î·È Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ Ë·ÙÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÛÙËÓ O∏∞. ¶·Ú¿ÏÏËÏ· ηٷÚÁÂ›Ù·È Ë Ú‡ıÌÈÛË Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌ¿ÙˆÛ˘ Î·È ÚÔηÏÂ›Ù·È ÂÁÎÂÊ·ÏÈ΋ ˘ÂÚ·ÈÌ›· Ì ·ÔÙ¤ÏÂÛÌ· ÂÚ·ÈÙ¤Úˆ Âȉ›ӈÛË Ù˘ Ô͢ÁfiÓˆÛ˘ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ Î‡ÙÙ·ÚˆÓ. ΔÔ ÂÁÎÂÊ·ÏÈÎfi Ô›‰ËÌ· Î·È Ë ·˘ÍË̤ÓË ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË ÌÔÚÔ‡Ó Ó· ¤¯Ô˘Ó Û·Ó ·ÔÙ¤ÏÂÛÌ·

METAMO™XEY™Eπ™ 2011

ÙÔÓ ÂÁÎÂÊ·ÏÈÎfi ÂÁÎÔÏ·ÛÌfi ÙÔ ÔÔ›Ô ·ÔÙÂÏ› Û¯ÂÙÈο Û˘¯Ó‹ ·ÈÙ›· ı·Ó¿ÙÔ˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì O∏∞. ªÈ· Û˘Ó‹ı˘ ÂÈÏÔ΋ Ù˘ O∏∞ Â›Ó·È Ë Û‹„Ë. ∏ Û‹„Ë ÂȉÂÈÓÒÓÂÈ ÙËÓ Î·Ù¿ÛÙ·ÛË, ÚÔηÏ› Â›Û˘ SIRS Î·È ÂȉÂÈÓÒÓÂÈ ÙÔ ÔÍÂȉˆÙÈÎfi ÛÙÚ˜ ÛÙÔ Â›Â‰Ô ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Ì ·ÔÙ¤ÏÂÛÌ· ·‡ÍËÛË Ù˘ ηٷÛÙÚÔÊ‹˜ Î·È Ì›ˆÛË ÙËÓ ·Ó·ÁÂÓÓÂÙÈ΋˜ ÈηÓfiÙËÙ·˜ ÙÔ˘˜. ∏ Û‹„Ë ·˘Í¿ÓÂÈ Â›Û˘ ÙËÓ Î·Ù·Ó¿ÏˆÛË Û ÂÓ¤ÚÁÂÈ· ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ∂‰Ò ÚÔÛÙ›ıÂÙ·È Î·È Ë Î·Î‹ ıÚÂÙÈ΋ ηٿÛÙ·ÛË ÙˆÓ ·ÛıÂÓÒÓ ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ÌÈ·˜ Ï‹ÚÔ˘˜ ÌÂÙ·‚ÔÏÈ΋˜ «·ÔÚ‡ıÌÈÛ˘». ∞˘Í¿ÓÂÙ·È Ë ÁÏ˘ÎfiÏ˘ÛË, ηٷӷÏÒÓÔÓÙ·È ÔÈ ·Ôı‹Î˜ ÁÏ˘Î·ÁfiÓ˘, ÌÂÈÒÓÂÙ·È Ë ‰˘Ó·ÙfiÙËÙ· ÓÂÔÁÏ˘ÎÔÁ¤ÓÓÂÛ˘, ηٷӷÏÒÓÔÓÙ·È ˘ÂÚ‚ÔÏÈο Ù· Ï›Ë Î·È ÔÈ ÚˆÙ½Ó˜. OÈ ·ÛıÂÓ›˜ Û˘Ó‹ıˆ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‚·ÚÈ¿ ˘ÔÁÏ˘Î·ÈÌ›·. ∏ ÔÍ›· Ó¢ÌÔÓÈ΋ ‚Ï¿‚Ë Â›Ó·È Â›Û˘ ÌÈ· Û˘Ó‹ı˘ ÂÈÏÔ΋ Ù˘ O∏∞. ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈ΋ ÌÂϤÙË Ô˘ ‰ËÌÔÛȇÙËΠÚÔ 30-ÂÙ›·˜ Û ·ÛıÂÓ›˜ Ô˘ ·‚›ˆÛ·Ó ·fi O∏∞ ·¤‰ÂÈÍ fiÙÈ ˘¿Ú¯ÂÈ ‰È¿¯˘ÙË ‰È¿Ù·ÛË ÙˆÓ ·ÁÁ›ˆÓ ÙˆÓ Ó‡ÌÔÓ˜ ÌÂ Û˘ÌÌÂÙÔ¯‹ ÙfiÛÔ ÙˆÓ ·ÚÙËÚÈÒÓ fiÛÔ Î·È ÙˆÓ ÊÏ‚ÒÓ Î·È ÙÚȯÔÂȉÒÓ. Δ· Â˘Ú‹Ì·Ù· ·˘Ù¿ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Ë·ÙÔÓ¢ÌÔÓÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘ ÛÙË O∏∞ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ·˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ NO, ÂÓ‰ÔıËÏ›Ó˘ 1 Î·È TNF·. ∏ ÂÓ‰ÔÓ¢ÌÔÓÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹ Â›Ó·È ·ÈÙ›· ‰ÂÍÈ¿˜ ˘ÂÚÊfiÚÙˆÛ˘ Ì ‰È·Ù·Ú·¯¤˜ ·ÈÌ¿ÙˆÛ˘-·¤ÚˆÛ˘ , ÌÂȈ̤ÓË ·ÚÙËÚȷ΋ Ô͢ÁfiÓˆÛË Î·È ÙÂÏÈο ·Ó·Ó¢ÛÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ™Â ÌÂϤÙ˜ ·ÛıÂÓÒÓ Ì O∏∞ Ô˘ ÂÈ‚ÈÒÛ·Ó ÛÙË ª∂£ Ê¿ÓËΠÌÂÙ¿ ·fi ‚ÂÏÙ›ˆÛË Ù˘ Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ï‹Ú˘ ·ÔηٿÛÙ·ÛË Î·È ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ Ó¢ÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∏ ÔÍ›· ÓÂÊÚÈ΋ ·ÓÂ¿ÚÎÂÈ· Û˘ÓÈÛÙ¿ Û˘¯Ófi Úfi‚ÏËÌ· ηٿ ÙËÓ ÔÚ›· Ù˘ O∏∞ Î·È ·Ú·ÙËÚÂ›Ù·È Û 40-80% ÙˆÓ ·ÛıÂÓÒÓ. Δ· ·›ÙÈ· Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈο Î·È Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÈÙÈÔÏÔÁ›· ·ÏÏ¿ Î·È ·ÚÔ˘Û›· ÂÈÏÔÎÒÓ. ªÔÚ› Ó· ÚfiÎÂÈÙ·È ÁÈ· ÙÔ Ë·ÙÔÓÂÊÚÈÎfi Û‡Ó‰ÚÔÌÔ ·ÏÏ¿ ÌÔÚ› Ó· Â›Ó·È Î·È ·ÔÙ¤ÏÂÛÌ· ‰Ú¿Û˘ ÙÔÍÈÓÒÓ fiˆ˜ Ë ·Ú·ÎÂÙ·ÌfiÏË. ∏ ÂÌÊ¿ÓÈÛË ÔÍ›·˜ ÓÂÊÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ Û˘ÓÈÛÙ¿ ‰˘ÛÌÂÓ‹ ÚÔÁÓˆÛÙÈÎfi ‰Â›ÎÙË ÂÈ‚›ˆÛ˘.

3. ∞ÓÙÈÌÂÙÒÈÛË- £ÂÚ·›· ∏ Â›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÏÏ¿ η-

131

χÙÂÚ· 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·. ∂Ô̤ӈ˜, Ë 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‹ Ì ¤Ó· ªÂÙ·ÌÔÛ¯Â˘ÙÈÎfi ∫¤ÓÙÚÔ. ∏ ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‰ÂÓ Ú¤ÂÈ Ó· ·ÚÁ‹ÛÂÈ, ·ÏÏ¿ Ô‡Ù ӷ ÙÂı› Ôχ ÓˆÚ›˜. ∏ ·fiÊ·ÛË Ó· ·Ú·ÂÌÊı› ¤Ó·˜ ·ÛıÂÓ‹˜ Ì O∏∞ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È ÌÈ· ·fi Ù˘ ÈÔ ‰‡ÛÎÔϘ ÛÙË ‹·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· Û·ÛÙÈΤ˜ 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· ÙˆÓ ·ÛıÂÓ‹ ·ÏÏ¿ Î·È Ë ÂÈÙ¿¯˘ÓÛ‹ Ù˘ 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· ʤÚÔ˘Ó ÙÔÓ ı¿Ó·ÙÔ ÙÔ˘ ·ÛıÂÓ‹ Î·È ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË Û ÛËÌ·ÓÙÈ΋ ÔÛÔÛÙfi. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ÌÈ· Ï¿ıÔ˜ ıÂÙÈ΋ ·fiÊ·ÛË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ÙÔ ¯·Ìfi ÂÓfi˜ ÌÔۯ‡̷ÙÔ˜ Ô˘ ı· ‹Ù·Ó ¯Ú‹ÛÈÌÔ ÛÙËÓ ÂÚ›ÙˆÛË ¿ÏÏÔ˘ ·ÛıÂÓ‹, ·Û˘˙‹ÙËÙË ÙÔ Ì¤ÁÂıÔ˜ 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 Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë fiÙÈ Ë O∏∞ Â›Ó·È Ô˘ÛÈ·ÛÙÈο ÌÈ· Û¿ÓÈ· ÓfiÛÔ˜. ™ÙÔÓ ∂ÏÏËÓÈÎfi ¯ÒÚÔ, ÏfiÁˆ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÚÔÛÙ›ıÂÙ·È Î·È ÙÔ Úfi‚ÏËÌ· Ù˘ ·ÂÚÔÌÂÙ·ÊÔÚ¿˜ ÙÔ˘ ÛÔ‚·ÚÔ‡ ¿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 ÌÂÙ·ÊÔÚ¿˜ Ú¤ÂÈ Ó· Â›Ó·È ÓˆÚ›ÙÂÚ· Î·È ‰È·Ê¤ÚÂÈ Û·ÊÒ˜ ·fi ÙËÓ

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M. DEUTSCH

¤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· ÌÂÙ·ÊÂÚı› ‹ Ó· ÌÂÙ·ÌÔÛ¯Â˘Ù› Ô ·ÛıÂÓ‹˜, Ë ÛˆÛÙ‹ Î·È ¤ÁηÈÚË Û˘ÓÙËÚËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Â›Ó·È ˙ˆÙÈ΋˜ ÛËÌ·Û›·˜.

3.1 ¶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 Ù˘ ∏¶∞ ÌfiÓÔ 29% ÙˆÓ ·ÛıÂÓÒÓ Ì O∏∞ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Î·È 10% ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ ·‚›ˆÛ·Ó ÛÙË Ï›ÛÙ· ÂÚÈ̤ÓÔÓÙ·˜ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÓÂÍ¿ÚÙËÙ· ÔÙÈ Ë O∏∞ ıˆÚÂ›Ù·È Ë ÚÒÙË ÚÔÙÂÚ·ÈfiÙËÙ· ÁÈ· ˘ÂÚÂ›ÁÔ˘Û· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ™Â ¿ÏϘ ÛÂÈÚ¤˜ ·Ó·Ê¤ÚıËÎ·Ó ı¿Ó·ÙÔÈ ÛÙË Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì¤¯ÚÈ Î·È 40%. ªÂÙ¿ ·fi ÂÈÙ˘¯Â›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 63-82% ÛÙÔ 1 ¯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 ÛÙË Ï›ÛÙ·. OÈ ˘fiÏÔÈÔÈ ·ÛıÂÓ›˜ ‰ÂÓ ÎÚ›ıËÎ·Ó Î·Ù¿ÏÏËÏÔÈ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏfiÁˆ ËÏÈΛ·˜ Î·È ·Ú¿ÏÏËÏ· ‡·ÚÍË ¿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 III) Û ۯ¤ÛË Ì ÏÈÁfiÙÂÚ· ·fi 20 % ÛÙÔ˘˜ ·ÛıÂ-

Ó›˜ Ì ‚·ıÌfi ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ IV. ∞ÛıÂÓ›˜ ¿Óˆ ÙˆÓ 40 ÂÙÒÓ Î·È Î¿Ùˆ ÙˆÓ 10 ÂÙÒÓ ¤¯Ô˘Ó ÏÈÁfiÙÂÚË Èı·ÓfiÙËÙ· Ó· ‚ÂÏÙȈıÔ‡Ó Ì ÙËÓ Û˘ÓÙËÚËÙÈ΋ ·ÁˆÁ‹ Û ۯ¤ÛË Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·ÛıÂÓ›˜. ∂›Û˘ ·ÛıÂÓ›˜ Ì O∏∞ ÏfiÁˆ ·Ú·ÎÂÙ·ÌfiÏË , Ë·Ù›Ùȉ· ∞ Î·È μ ¤¯Ô˘Ó ηχÙÂÚË ÚfiÁÓˆÛË Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¿ÁÓˆÛÙË ·ÈÙ›· O∏∞, Ê·Ú̷΢ÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜, ‰ËÏËÙËÚ›·ÛË ·fi Amanita phalloides ‹ ÓfiÛÔ Wilson’s. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ÙÈÌ‹ Ù˘ ·-ÊÂÙÔÚˆÙ›Ó˘ (AFP) Ê·›ÓÂÙ·È fiÙÈ ·‡ÍËÛË Ù˘ AFP ÛÙÔ ÙÚÈÏ¿ÛÈÔ Ù˘ ÚÒÙ˜ 3 Ë̤Ú˜ ‹ ÙÈÌ‹ AFP >3.9 mcg/L ÚԂϤÂÈ 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· Ô˘ ηıÔÚ›˙Ô˘Ó ÙËÓ ¤Ó‰ÂÈÍË ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞ÚÎÂÙÔ› ÚÔÁÓˆÛÙÈÎÔ› ‰Â›ÎÙ˜ ¤¯Ô˘Ó ‰ËÌÈÔ˘ÚÁËı› 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 Î·È 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 Kingãs 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· Kingãs 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˘ ‚¿ÛË Ù˘ ÔÌ¿‰·˜ ÙÔ˘ King’s-College §ÔÓ‰›ÓÔ˘ ·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·-

METAMO™XEY™Eπ™ 2011

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‚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›˙ÂÈ 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, ˘Ô-

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ÁÚ·ÌÌ›˙ÔÓÙ·˜ ÙËÓ ÛËÌ·Û›· Ù˘ ·Ú¿ÏÏËÏ˘ ÓÂÊÚÈ΋˜ ‚Ï¿‚˘. ∏ ÚfiÛıÂÛË Ù˘ ÙÈÌ‹˜ ÙÔ˘ ʈÛÊfiÚÔ˘ ÛÙ· ÎÚÈÙ‹ÚÈ· King’s College Â›Û˘ ·‡ÍËÛ·Ó 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, ÔÈ Ì˯·ÓÈÛÌÔ› Ù˘ ÔÍ›·˜ Ë·ÙÔ΢ÙÙ·ÚÈ΢ ‚Ï¿‚˘ Â›Ó·È ÔÈΛÏÔÈ Î·È ÂÚ›ÏÔÎÔÈ. ΔÔ ·ÔÙ¤ÏÂÛÌ· Â›Ó·È ÌÈ· ‚·Ú‡Ù·ÙË ÔÏ˘ÔÚÁ·ÓÈ΋ Î·È ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ·¿ÓÙËÛË Ì Â›Û˘ Û‡ÓıÂÙË ·ıÔÁ¤ÓÂÈ· Ô˘ Ô‰ËÁ› ÛÙÔ ÔÏÔÎÏËڈ̤ÓÔ Î·È ·ÂÈÏËÙÈÎfi ÁÈ· ÙË ˙ˆ‹ Û‡Ó‰ÚÔÌÔ Ù˘ O∏∞. ¶ÔÏÏ¿ ÂÚˆÙ‹Ì·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙË ·ıÔÁ¤ÓÂÈ· Ù˘ O∏∞ ·Ú·Ì¤ÓÔ˘Ó ·ÎfiÌ· ¯ˆÚ›˜ ·¿ÓÙËÛË. ∏ O∏∞ ·ÔÙÂÏ› ÌÈ· ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ·Ú·ÔÌ‹˜ ·ÛıÂÓÔ‡˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÔÈ ·ÛıÂÓ›˜ ¤¯ÔÓÙ·˜ ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙ˘ Ï›ÛÙ˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘. ∏ ·fiÊ·ÛË ÁÈ· ÙËÓ ·Ú·ÔÌ‹ ‚·Û›˙ÂÙ·È ÛÙ· ‰È¿ÊÔÚ· ÚÔÁÓˆÛÙÈο ÎÚÈÙ‹ÚÈ· Ì ÚˆÙ‡ˆÓ 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˜.

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44. Miyake Y, Iwasaki Y, Terada R, Takaguchi K, Sakaguchi K, Shiratori Y. Systemic inflammatory response syndrome strongly affects the prognosis of patients with fulminant hepatitis B. J Gastroenterol. 2007; 42(6): 485-92.

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; 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; 27(3): 329-34.

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¢È·Ù·Ú·¯¤˜ Ù˘ ‹Íˆ˜ ÚÈÓ Î·È ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. º˘ÛÈÔ·ıÔÏÔÁ›· Î·È ıÂÚ·¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË 20′ °. ¶··˚ˆ¿ÓÓÔ˘

ΔÔ ‹·Ú ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfiÙ·ÙÔ ÚfiÏÔ ÛÙË ‰È·Ù‹ÚËÛË ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·ÈÌÔÛÙ·ÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ Î·È ÁÈ’ ·˘Ùfi ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·ÈÌfiÛÙ·Û˘ Â›Ó·È Ôχ Û˘¯Ó¤˜ ÛÙȘ Ë·ÙÈΤ˜ ÓfiÛÔ˘˜. ∏ Â›‰Ú·ÛË ÙˆÓ Ë·ÙÔ·ıÂÈÒÓ ÛÙËÓ ·ÈÌfiÛÙ·ÛË Â›Ó·È Û‡ÓıÂÙË, ·ÊÔ‡ ÙÔ ‹·Ú Â›Ó·È ˘‡ı˘ÓÔ ÁÈ· ÙË Û‡ÓıÂÛË, ÂÓÂÚÁÔÔ›ËÛË Î·È Î¿ı·ÚÛË ÙˆÓ ÂÚÈÛÛÔÙ¤ÚˆÓ ·Ú·ÁfiÓÙˆÓ Î·È ·Ó·ÛÙÔϤˆÓ Ô˘ ÂÌϤÎÔÓÙ·È ÙfiÛÔ ÛÙËÓ ‹ÍË fiÛÔ Î·È ÛÙËÓ ÈÓˆ‰fiÏ˘ÛË. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘¯Ó¿ ÔÏϤ˜ ·ÈÌÔÛÙ·ÙÈΤ˜ ÂÈÏÔΤ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ Ë·ÙÈ΋ ÓfiÛÔ ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘, Ì ÙËÓ ·ÈÌÔÚÚ·Á›· ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ Î·È ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÌÂÙ¿ ÙËÓ Ê¿ÛË Ù˘ ÈÛ¯·ÈÌ›·. ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·ÈÌÔÛÙ·ÙÈÎÒÓ ÂÈÏÔÎÒÓ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ··ÈÙ› Û ‚¿ıÔ˜ ηٷÓfiËÛË Ù˘ ·ıÔÊ˘ÛÈÔÏÔÁ›·˜ Ù˘ ‹Í˘ ÙÔ˘ ·›Ì·ÙÔ˜, ÎÏÈÓÈ΋ ÂÎÙ›ÌËÛË Ù˘ ‹Í˘, ηıÒ˜ Î·È ÂÈÏÔÁ‹ Ù˘ ÛˆÛÙ‹˜ ıÂÚ·›·˜.

Ù· Î·È ÙËÓ ·ÓÂ·Ú΋ ·ÏÏËÏÂ›‰Ú·ÛË ÌÂٷ͇ ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ ÂÓ‰ÔıËÏ›Ô˘ Î·È ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ. ∞˘Ùfi ÂÎÊÚ¿˙ÂÙ·È Ì ÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔ‹˜2.

2. ∏ ·ÈÌÔÂÙ·Ïȷ΋ Ê¿ÛË Â›Ó·È Â›Û˘ ÂËÚ·Ṳ̂ÓË ÛËÌ·ÓÙÈο ÛÙÔ˘˜ ÂÚÈÛÛfiÙÂÚÔ˘˜ ·ÛıÂÓ›˜. ¶·Ú·ÙËÚÂ›Ù·È ıÚÔÌ‚ÔÂÓ›· Û ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi ÙÔ 70% ÙˆÓ ·ÛıÂÓÒÓ3 –Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ÛÏËÓÔÌÂÁ·Ï›·– Ì›ˆÛË ÙÔ˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, ηٷӿψÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÛÙÔ ·Ó·ÁÂÓÓÒÌÂÓÔ ‹·Ú, ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÊÔÏÏÈÎÔ‡ ÔͤԘ ÛÙËÓ ·ÏÎÔÔÏÈ΋ Ë·ÙÔ¿ıÂÈ·, ηıÒ˜ Î·È ÙÔÍÈ΋ Â›‰Ú·ÛË ÙÔ˘ ·ÏÎÔfiÏ ÛÙ· ÌÂÁ·Î·Ú˘Ô·ÙÙ·Ú·. ¢˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Â›Ó·È ÂÌÊ·Ó‹˜ ·fi ÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔ‹˜ ·ÎfiÌË Î·È Ì ÙËÓ ·ÚÔ˘Û›· Â·ÚÎÔ‡˜ ·ÚÈıÌÔ‡ ·ÈÌÔÂÙ·Ï›ˆÓ, ηıÒ˜ Î·È ·fi ÙËÓ ÌÂȈ̤ÓË Û˘ÛÙÔÏ‹ ıÚfiÌ‚Ô˘4.

3. O ηٷÚÚ¿ÎÙ˘ Ù˘ ‹Í˘ ÂËÚ¿˙ÂÙ·È Û fiÏ· Ù· Â›‰·, ÂÂȉ‹ Ë ·Ú·ÁˆÁ‹ ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ÚˆÙÂ˚ÓÒÓ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ‹ÍË ‰È·Ù·Ú¿ÛÛÂÙ·È. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ˘˜ ËÎÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (II, V, VII, VIII, IX, X, XI, XII, XIII, ÚÂηÏÈÎÚ½ÓË, Ï·ÛÌÈÓÔÁfiÓÔ Î·È ˘„ËÏÔ‡ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ ÎÈÓÈÓÔÁfiÓÔ), Ù· Ê˘ÛÈο ·ÓÙÈËÎÙÈο (AT-III, ÚˆÙ½ÓË C, ÚˆÙ½ÓË S Î·È ·1-·ÓÙÈıÚ˘„›Ó˘) Î·È ÙȘ Ú˘ıÌÈÛÙÈΤ˜ ÚˆÙ½Ó˜ (C1 ·Ó·ÛÙÔϤ·˜ Î·È ·2-Ì·ÎÚÔÛÊ·ÈÚ›ÓË). Δ· Â›‰· ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘ Â›Ó·È ÁÂÓÈο Ê˘ÛÈÔÏÔÁÈο ‹ ·˘ÍË̤ӷ, ·ÏÏ¿ Ë ˘ÂÚ‚ÔÏÈ΋ ÂÚÈÂÎÙÈÎfiÙËÙ· Û ۷ÏÈ΢ÏÈÎfi Ô͇ ÛÙÔ ÌfiÚÈÔ ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘, Ô˘ ·ÚÂÌ‚·›ÓÂÈ ÛÙÔÓ ÔÏ˘ÌÂÚÈÛÌfi ÙÔ˘ ÈÓÒ‰Ô˘˜, Ô‰ËÁ› Û ‰˘ÛÈÓˆ‰ÔÁÔÓ·ÈÌ›· Ô˘ ‰È·ÈÛÙÒÓÂÙ·È Ì ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ıÚÔÌ‚›Ó˘ (ΔΔ)5,6. Δ· Â›‰· ÙÔ˘ ·Ú¿ÁÔÓÙ· VIII Â›Ó·È ·˘ÍË̤ӷ, Û˘¯Ó¿ Ì ·‡ÍËÛË ÙÔ˘ ·Ú¿ÁÔÓÙ· von Willebrand (vWF)7. Δ· ¯·ÌËÏ¿ Â›‰· ÙˆÓ Ê˘ÛÈÎÒÓ ·ÓÙÈËÎÙÈÎÒÓ (AT-III, ÚˆÙ½ÓË C, ÚˆÙ½ÓË S Î·È ·1-·ÓÙÈ-

• ¶·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ ‹Íˆ˜ Û ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋˜ ÓfiÛÔ˘ ∏ ·ÈÌfiÛÙ·ÛË, Â›Ó·È Ì›· ˙ˆÙÈ΋ ÔÌÔÈÔÛÙ·ÙÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ΔÔ ·ÁÁÂÈ·Îfi ÂÓ‰Ôı‹ÏÈÔ, Ù· ·ÈÌÔÂÙ¿ÏÈ·, Î·È ÔÈ ÚˆÙ½Ó˜ ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡, Û˘ÌÌÂÙ¤¯Ô˘Ó Ù·˘Ùfi¯ÚÔÓ· Î·È ·ÓÂÍ¿ÚÙËÙ·, Û 5 ÂÍ›ÛÔ˘ ÛËÌ·ÓÙÈΤ˜ Ê¿ÛÂȘ, ‰ËÏ·‰‹: 1. ÙËÓ ·ÁÁÂȷ΋ Ê¿ÛË, 2. ÙËÓ ·ÈÌÔÂÙ·Ïȷ΋ Ê¿ÛË, 3. ÙËÓ Ê¿ÛË ‰ËÌÈÔ˘Ú›·˜ ÙÔ˘ ÈÓÒ‰Ô˘˜, 4. ÙËÓ Ê¿ÛË ÙÔ˘ ÔÏ˘ÌÂÚÈÛÌÔ‡ ÙÔ˘ ÈÓÒ‰Ô˘˜ Î·È 5. ÙË Ê¿ÛË Ù˘ ÈÓˆ‰fiÏ˘Û˘. ∏ Ë·ÙÈ΋ ÓfiÛÔ˜ ÂËÚ¿˙ÂÈ fiϘ ÙȘ 5 Ê¿ÛÂȘ Ù˘ ·ÈÌfiÛÙ·Û˘1.

1. ∏ ·ÁÁÂȷ΋ Ê¿ÛË Ù˘ ‹Í˘ ÂËÚ¿˙ÂÙ·È ·ÚÓËÙÈο ·fi ÙËÓ ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈԉȷÛÙÔÏ‹, ·fi ÙËÓ ·Ó¿Ù˘ÍË ÔÏ˘¿ÚÈıÌˆÓ ·Ú¿ÏÂ˘ÚˆÓ ·ÁÁ›ˆÓ, ÙËÓ ÌÂȈ̤ÓË ·ÓÙ·fiÎÚÈÛË ÛÙËÓ ··ÈÙÔ‡ÌÂÓË ·ÁÁÂÈÔÛ‡Û·ÛË Î·È ÂÏ·ÛÙÈÎfiÙË-

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ıÚ˘„›ÓË) Î·È ÙˆÓ Ú˘ıÌÈÛÙÈÎÒÓ ÚˆÙÂ˚ÓÒÓ (C1 ·Ó·ÛÙÔϤ·˜ Î·È ·2-Ì·ÎÚÔÛÊ·ÈÚ›ÓË) ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ıÚfiÌ‚ˆÛË.

4. O ÔÏ˘ÌÂÚÈÛÌfi˜ ÙÔ˘ ÈÓÒ‰Ô˘˜ Â›Ó·È ÂËÚ·Ṳ̂ÓÔ˜ ·ÚÓËÙÈο ·fi Ù· ¯·ÌËÏ¿ Â›‰· ÙÔ˘ ·Ú¿ÁÔÓÙ· XIII Î·È ÙËÓ ‰˘ÛÈÓˆ‰ÔÁÔÓ·ÈÌ›·.

5. ΔÔ ÈÓˆ‰ÔÏ˘ÙÈÎfi Û‡ÛÙËÌ· Â›Ó·È Â›Û˘ ÂËÚ·Ṳ̂ÓÔ ·fi Ù· ÌÂȈ̤ӷ Â›‰· ÙˆÓ ÚÔÙÂ˚Ó·ÛÒÓ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ÈÓˆ‰fiÏ˘ÛË (Ï·ÛÌÈÓÔÁfiÓÔ˘ Î·È ·2-·ÓÙÈÏ·ÛÌ›Ó˘) ‹ ·fi Ù· ·˘ÍË̤ӷ Â›‰· ÙÔ˘ ÈÛÙÈÎÔ‡ ÂÓÂÚÁÔÔÈËÙ‹ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ (tPA) Ô˘ ÂÎχÔÓÙ·È ·fi ÙËÓ ÂÓ‰ÔıËÏȷ΋ ‚Ï¿‚Ë ÂÓÒ Ë Ë·ÙÈ΋ οı·ÚÛË ÙÔ˘ tPA Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË8. ™˘ÓÂÒ˜, ÌÔÚÔ‡Ó Ó· ·Ó·Ù˘¯ıÔ‡Ó fiÏˆÓ ÙˆÓ ÌÔÚÊÒÓ ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ‹Í˘ ·Ó¿ÏÔÁ· ÁÈ· ÙÔ ÈÛÔ˙‡ÁÈÔ ÌÂٷ͇ ÙˆÓ ÚÔËÎÙÈÎÒÓ ÚˆÙÂ˚ÓÒÓ Î·È ÙˆÓ ·Ó·ÛÙÔϤˆÓ, ηıÒ˜ Î·È ÙˆÓ ·Ó·ÛÙÔϤˆÓ ·˘ÙÒÓ69. ∏ ˘ÂÚËÎÙÈ΋ ηٿÛÙ·ÛË ÚÔηÏÂ›Ù·È ·fi ÙËÓ ‚Ï¿‚Ë ÛÙËÓ Ë·ÙÈ΋ Û‡ÓıÂÛË ÙˆÓ ÚÔËÎÙÈÎÒÓ Î·È ÙˆÓ ÔÛÔÙÈÎÒÓ Î·È ÔÈÔÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ. πÓˆ‰fiÏ˘ÛË ÂΉËÏÒÓÂÙ·È fiÙ·Ó ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ tPA ·Ú¿ÁÔÓÙ·È ·fi ÙË ‚Ï¿‚Ë ÙˆÓ ÂÓ‰ÔıËÏ›ˆÓ Î·È Ë ·Ú·ÁˆÁ‹ ÙˆÓ ·Ó·ÛÙÔϤˆÓ Ù˘ ÈÓˆ‰fiÏ˘Û˘ (·2-·ÓÙÈÏ·ÛÌ›Ó˘ Î·È ÈÛÙȉ›Ó˘) Â›Ó·È ·ÓÂ·Ú΋˜. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, Ë ÌÂȈ̤ÓË ‰Ú·ÛÙÈÎfiÙËÙ· ÙˆÓ ·Ó·ÛÙÔϤˆÓ ‹Í˘ ‹ Ù˘ ÈÓˆ‰fiÏ˘Û˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ıÚÔÌ‚ˆÙÈΤ˜ ηٷÛÙ¿ÛÂȘ. ∏ ˘ÂÚ‚ÔÏÈ΋ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ‹Í˘ ‹ Ë ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ‹·ÙÔ˜ ÁÈ· οı·ÚÛË ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Â›Û˘ Û ıÚfiÌ‚ˆÛË ‹ ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË.

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·Ú·Î·ÌÙ‹ÚÈˆÓ Î·ıÂÙ‹ÚˆÓ. ∫·È ÛÙÔ˘˜ 3 ·ÚÔ˘ÛÈ¿ÛÙËΠÔÏÏ·Ï‹ Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹. ™˘ÓÂÒ˜ ηٿÏËÍ·Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ˘ÂÚÈÓˆ‰fiÏ˘ÛË, ıÚÔÌ‚ÔÂÓ›· Î·È ¤ÏÏÂÈ„Ë ÙˆÓ ËÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ. ∏ ‚·Ú‡ÙËÙ· ÙˆÓ ·ÏÏ·ÁÒÓ ·˘ÙÒÓ Â›Ó·È ÚÔÁÓˆÛÙÈ΋, ·ÊÔ‡ Â›Ó·È ·Ó¿ÏÔÁË Ì ÙËÓ ¤ÎÙ·ÛË Ù˘ Ë·ÙÈ΋˜ ‚Ï¿‚˘. ∂›Û˘ Ë ·Ú¯È΋ ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË ‰ÂÓ Û˘Óԉ‡ÂÙ·È ··Ú·›ÙËÙ· ·fi ˘ÂÚËÎÙÈÎfiÙËÙ·, Â¿Ó ‰ÂÓ ¯ÔÚËÁËıÔ‡Ó ıÚÔÌ‚ÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜»9,10. OÈ ·Ú·ÙËÚ‹ÛÂȘ ·˘Ù¤˜ ¤¯Ô˘Ó ÂȂ‚·Èˆı› ·fi ÌÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜3,11,12 Î·È Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ›Ó·Î· 1. ¶›Ó·Î·˜ 1. ¢È·Ù·Ú·¯¤˜ ·ÈÌfiÛÙ·Û˘ ηٿ ÙË ÔÚıÔÙÔÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ º¿ÛË

¢È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜

1. ∏·ÙÈ΋˜ ÂÎÙÔÌ‹˜

¶ÚÔ¸¿Ú¯Ô˘Û· ‰È·Ù·Ú·¯‹ Ù˘ ‹Í˘ ∞ÈÌÔ·Ú·›ˆÛË πÓˆ‰fiÏ˘Û˘ (‹È·) À·Û‚ÂÛÙÈ·ÈÌ›·

2. ∞ÓË·ÙÈ΋

∏ ‰Ú¿ÛË Ù˘ Ë·Ú›Ó˘ (·fi ÊÏ‚ÔÊϤ‚ÈÎfi bypass) IÓˆ‰fiÏ˘Û˘ (̤ÙÚÈ·) ∂Ó‰·ÁÁÂȷ΋ ‹ÍË ÀÔıÂÚÌ›· À·Û‚ÂÛÙÈ·ÈÌ›·

3. ¶ÚfiˆÚË ªÂıË·ÙÈ΋

πÓˆ‰fiÏ˘Û˘ (ÛÔ‚·Ú‹) ∏ ‰Ú¿ÛË Ù˘ Ë·Ú›Ó˘ ∂Ó‰·ÁÁÂȷ΋ ‹ÍË ∞ÈÌÔ·Ú·›ˆÛ˘ ÀÔıÂÚÌ›· À·Û‚ÂÛÙÈ·ÈÌ›·

4. ∞ÒÙÂÚË ªÂıË·ÙÈ΋

™Ù·‰È·Î‹ ·Ó¿Î·Ì„Ë

• ∏ ·ÈÌfiÛÙ·ÛË Î·Ù¿ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜» ∏ Û‡ÓıÂÙË Ê‡ÛË Ù˘ ËÎÙÈÎfiÙËÙ·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜, ¿Ú¯ÈÛ ӷ ÂÚÈÁÚ¿ÊÂÙ·È ·fi ÙȘ ·Ú¯¤˜ Ù˘ ‰ÂηÂÙ›·˜ ÙÔ˘ 1960, Ì ÙȘ ÚÒÙ˜ ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜: «À‹ÚÍ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·ÈÌÔÚÚ·ÁÈ΋ ‰È¿ıÂÛË Î·È ÙËÓ ›‰È· ÛÙÈÁÌ‹ ·Ó·Ù‡¯ÙËΠÈÓˆ‰fiÏ˘Û˘ Î·È ˘ÔÈÓˆ‰ÔÁÔÓ·ÈÌ›·. ™Â 4 ·fi ÙȘ ÂÚÈÙÒÛÂȘ, Ë ·ÈÌÔÚÚ·Á›· ÂϤÁ¯ıËΠÌÂÙ¿ ÙËÓ ¯ÔÚ‹ÁËÛË ÙÔ˘ e-·ÌÈÓÔηÚÔÓÈÎÔ‡ ÔͤԘ (EACA), ÈÓˆ‰ÔÁfiÓÔ˘ Î·È ÊÚ¤ÛÎÔ˘ ÔÏÈÎÔ‡ ·›Ì·ÙÔ˜. ™ÙË Û˘Ó¤¯ÂÈ·, 3 ·fi ÙÔ˘˜ 4 ÂÈ˙ÒÓÙ˜ Û¯ËÌ¿ÙÈÛ·Ó ıÚfiÌ‚Ô˘˜ ÎÔÓÙ¿ ÛÙ· ÛËÌ›· ÙˆÓ ÌËÚÈ·›ˆÓ ÊÏ‚ÔÎÂÓÙ‹ÛÂˆÓ Ô˘ ›¯·Ó ¯ÚËÛÈÌÔÔÈËı› ÁÈ· ÙËÓ ·ÚÂÌ‚ÔÏ‹ Â͈ÙÂÚÈÎÒÓ

1. º¿ÛË ∏·ÙÈ΋˜ ÂÎÙÔÌ‹˜ ∫·Ù¿ ÙË Ê¿ÛË Ù˘ Ë·ÙÂÎÙÔÌ‹˜, ÔÈ ÚÔ¸¿Ú¯Ô˘Û˜ ‰È·Ù·Ú·¯¤˜ ËÎÙÈÎfiÙËÙ·˜ ÂȉÂÈÓÒÓÔÓÙ·È ·fi ÙËÓ Ì›ˆÛË ÙˆÓ ËÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÏfiÁˆ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ê·›ÚÂÛ˘ ÙÔ˘ ‹·ÙÔ˜ Î·È Ù˘ ηٷӿψÛ˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ. OÈ ·ÈÌÔÚÚ·ÁÈΤ˜ ÂÈÏÔΤ˜ Â›Ó·È ÈÔ Û˘¯Ó¤˜ Î·È ÛÔ‚·Ú¤˜ Û ·ÛıÂÓ›˜ Ì Ë·ÙÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ, ˘Ï·›· ˘¤ÚÙ·ÛË, ÚÔËÁËı›Û˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ ¿Óˆ ÎÔÈÏ›·˜ Î·È Û ·˘ÙÔ‡˜ Û ¯ÚÔÓ›· ıÂÚ·›· Ì ÛÙÂÚÔÂȉ›.

OÈ ·ÁÁÂȷΤ˜ ‚Ï¿‚˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÌÂȈ̤ÓË Î¿ı·ÚÛË ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ ÌÂȈ̤ÓË

138

°. ¶∞¶∞´ø∞¡¡√À

Ë·ÙÈ΋ ÚÔ‹, ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ˘ÂÚ‚ÔÏÈ΋ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ‹Í˘. ∫·Ù¿ Û˘Ó¤ÂÈ·, Ë ÁÂÓÈÎÂ˘Ì¤ÓË ‰È·Ù·Ú·¯‹ Ù˘ ‹Í˘ ÂÓ‰¤¯ÂÙ·È Ó· ·Ú·ÙËÚËı›, ·ÎfiÌË Î·È ·ÚÔ˘Û›· Û˘Ó¯ԇ˜ ¤Á¯˘Û˘ ·›Ì·ÙÔ˜, Ï¿ÛÌ·ÙÔ˜ Î·È ·Ú·ÁfiÓÙˆÓ ·˘ÙÔ‡. ∏ ·ÎÔ‡ÛÈ· ˘ÔıÂÚÌ›· Î·È Ë ˘·Û‚ÂÛÙÈ·ÈÌ›· ÌÔÚÔ‡Ó Â›Û˘ Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ‹ÍË. ∏ πÓˆ‰fiÏ˘ÛË ÌÔÚ› Ó· ·Ú¯›ÛÂÈ Ó· ·Ó·Ù‡ÛÛÂÙ·È Û ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ Ë·ÙÔ΢ÙÙ·ÚÈ΋ ÓfiÛÔ ··ÈÙÒÓÙ·˜ Ì·˙È΋ ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜.

2. ∞ÓË·ÙÈ΋ º¿ÛË ¶ÈÔ ÛËÌ·ÓÙÈΤ˜ ·ÏÏ·Á¤˜ Û˘Ì‚·›ÓÔ˘Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓË·ÙÈ΋˜ Ê¿Û˘. ∏ ‰Ú¿ÛË Ù˘ Ë·Ú›Ó˘ ·Ú·ÙËÚÂ›Ù·È ·fi ÙÔ ‰È¿Ï˘Ì· Ë·Ú›ÓË (2000 ¤ˆ˜ 5000 ÌÔÓ¿‰Â˜ Ë·Ú›Ó˘) Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙÔ ÊÏ‚ÔÊÏ‚ÈÎfi Û‡ÛÙËÌ· ·Ú¿Î·Ì„˘ Î·È ÌÔÚ› Ó· ‰È·ÚΤÛÂÈ ·fi 30 ¤ˆ˜ 60 ÏÂÙ¿. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÈÌÔÚÚ·Á›· Î·È Ë ·Ô˘Û›· Ù˘ Ë·ÙÈ΋˜ Û˘ÓıÂÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È Î¿ı·ÚÛ˘, ÂÈ‚·Ú‡ÓÔ˘Ó ÂÚÈÛÛfiÙÂÚÔ ÙËÓ Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È ÙËÓ ·Ó¿ÏˆÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘. ∏ ·ÂÏ¢ı¤ÚˆÛË Ù˘ ÈÛÙÈ΋˜ ıÚÔÌ‚ÔÏ·ÛÙ›Ó˘ Î·È Ë ·Ô˘Û›· Ù˘ Ë·ÙÈ΋˜ οı·ÚÛ˘ ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ˘ÂÚ‚ÔÏÈ΋ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ‹Í˘, Ô˘ ·Ô‰ÂÈÎÓ‡ÂÙ·È Ì ÙË ÛÙ·‰È·Î‹ ·‡ÍËÛË ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ ıÚÔÌ‚›Ó˘-·ÓÙÈıÚÔÌ‚›Ó˘ (Δ∞Δ) Î·È ÙˆÓ ÚÔ˚fiÓÙˆÓ ·Ô‰fiÌËÛ˘ ÈÓÈ΋˜13. øÛÙfiÛÔ, ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋ ‰È¿¯˘ÙË ÂÓ‰·ÁÁÂȷ΋ ‹ÍË ‹ ıÚfiÌ‚ˆÛË Â›Ó·È ·Û˘Ó‹ıÈÛÙ· Û˘Ì‚¿ÓÙ· ηٿ ÙË ‰È¿ÚÎÂÈ· ·˘Ù‹˜ Ù˘ Ê¿Û˘. ∏ ÈÓˆ‰fiÏ˘ÛË, Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ Î˘ÎÏÔÊÔÚ›· ÙÔ˘ tPA Î·È ÙËÓ ·Ô˘Û›· Ë·ÙÈ΋˜ οı·ÚÛ˘, ·Ú·ÙËÚÂ›Ù·È ÂÚ›Ô˘ ÛÙÔ 20% ÙˆÓ ·ÛıÂÓÒÓ.

3. ¶ÚfiˆÚË ªÂıË·ÙÈ΋ º¿ÛË ™Â ·˘Ù‹ ÙËÓ Ê¿ÛË ·Ú·ÙËÚÂ›Ù·È ÛÔ‚·Ú‹ ‰È·Ù·Ú·¯‹ Ù˘ ‹Í˘, ¤Ó· Û˘ÛÙ·ÙÈÎfi ÛÙÔÈ¯Â›Ô ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ··Ó·ÈÌ¿ÙˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∂ÚÁ·ÛÙËÚȷο ·Ú·ÙËÚÔ‡ÓÙ·È ·Ú·Ù¿ÛÂȘ ÙÔ˘ (PT), ÙÔ˘ aPTT, ÙÔ˘ ¯ÚfiÓÔ˘ reptilase (RT) Î·È ¯ÚfiÓÔ˘ ıÚÔÌ‚›Ó˘ (TT), ıÚÔÌ‚ÔÂÓ›· Î·È Ì›ˆÛË ÙˆÓ ÂÈ¤‰ˆÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ ππ, V, VII Î·È VIII, ·fiÙÔÌË ·‡ÍËÛË ÙÔ˘ tPA, Î·È Ì¤ÙÚÈ· ·‡ÍËÛË ÙˆÓ FDP Î·È TAT13-15. ∏ ·ÈÙ›· Ù˘ ‰È·Ù·Ú·¯‹˜ Ù˘ ‹Í˘ ÛÙËÓ Ê¿ÛË Ù˘ Â·Ó·ÈÌ¿ÙˆÛ˘ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋. ∏ ·ÂÏ¢ı¤ÚˆÛË ÂÓ‰ÔÁÂÓÔ‡˜ Ë·Ú›Ó˘ ·fi

ÙÔ ÌfiÛ¯Â˘Ì·, ÌÔÚ› Ó· ‰È·ÚΤÛÂÈ ·fi 60 ¤ˆ˜ 120 ÏÂÙ¿. º·›ÓÂÙ·È fï˜ fiÙÈ Î·È ¿ÏÏÔÈ ·Ó·ÛÙÔÏ›˜ Ù˘ ‹Í˘ ‹ Ë·ÚÈÓÔÂȉ‹ ·›˙Ô˘Ó ÚfiÏÔ16. ∏ ÈÓˆ‰fiÏ˘ÛË ÂÌÊ·Ó›˙ÂÙ·È ÂÚ›Ô˘ ÛÙÔ 80% ÙˆÓ ·ÛıÂÓÒÓ, ·ÏÏ¿ ÎÏÈÓÈο ÛËÌ·ÓÙÈ΋ ÈÓˆ‰fiÏ˘ÛË Î·È ·ÈÌÔÚÚ·Á›· ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi ÂÚ›Ô˘ 40% ÙˆÓ ·ÛıÂÓÒÓ14. ¶ÚÔηÏÂ›Ù·È ·fi ÙË Ì·˙È΋ ·ÂÏ¢ı¤ÚˆÛË ÙÔ˘ tPA ·fi ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ‹·Ú, ·fi Ù· Û˘ÌÊÔÚË̤ӷ ÛÏ·¯ÓÈο ·ÁÁ›· Î·È ·fi Ù· ·ÁÁ›· ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙË ÌÂȈ̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ·Ó·ÛÙÔϤ· ÙÔ˘ ÂÓÂÚÁÔÔÈËÙ‹ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘17-18. ™Â ·˘Ù‹ ÙËÓ Ê¿ÛË ¤¯Ô˘Ì ÚˆÙÔ·ı‹ ÈÓˆ‰fiÏ˘ÛË, ·ÊÔ‡ Û˘Óԉ‡ÂÙ·È ·fi ˘„ËÏ¿ Â›‰· tPA, ‰ÂÓ ‰È·Ù·Ú¿ÛÛÔÓÙ·È Ù· Â›‰· ·ÓÙÈıÚÔÌ‚›Ó˘ πππ, ·Ú·ÙËÚÂ›Ù·È ÌÈÎÚ‹ ·‡ÍËÛË ÙˆÓ FDP Î·È ÙˆÓ ¢-¢ÈÌÂÚÒÓ14, ÌÈÎÚ‹ Ì›ˆÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ππ, V Î·È VIII, Î·È ·ÓÙ·ÔÎÚ›ÓÂÙ·È ¯ˆÚ›˜ ÌÈÎÚÔÂÌ‚ÔÏÈÛÌÔ‡˜ ÛÙÔ EACA. ∏ ÈÓˆ‰fiÏ˘ÛË ÂÚÈÔÚ›˙ÂÙ·È ÛÙ·‰È·Î¿ ̤۷ ÛÙȘ ÂfiÌÂÓ˜ 2 ÒÚ˜, Â¿Ó ÙÔ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ ‹·Ú ·Ú¯›ÛÂÈ Ó· ÏÂÈÙÔ˘ÚÁ›.

4. ∞ÒÙÂÚË ªÂıË·ÙÈ΋ Ê¿ÛË ™Â ·˘Ù‹ ÙËÓ Ê¿ÛË ·Ú·ÙËÚÂ›Ù·È ˘ÂÚ‚ÔÏÈ΋ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ‰Â˘ÙÂÚÔÁÂÓ‹ ˘ÂÚÈÓˆ‰fiÏ˘ÛË, Ì ˘„ËÏ¿ Â›‰· ÙÔ˘ Û˘ÌϤÁÌ·ÙÔ˜ Δ∞Δ, FDP Î·È ¢-¢ÈÌÂÚÒÓ, Ì ¯·ÌËÏ¿ Â›‰· AT-III Î·È ÙÔ˘ ·Ó·ÛÙÔϤ· ÙÔ˘ ÂÓÂÚÁÔÔÈËÙ‹ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ (ƒ∞π 1). ΔÔ Ê·ÈÓfiÌÂÓÔ ·˘Ùfi Ê·›ÓÂÙ·È Ó· ÚÔηÏÂ›Ù·È ·fi ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ·fi ÙÔ tPA20, ‹ ÙËÓ ·ÂÏ¢ı¤ÚˆÛË ÙˆÓ Ï˘ÛÔÛˆÌÈ·ÎÒÓ ÚˆÙÂ˚Ó·ÛÒÓ ÙˆÓ Ì·ÎÚÔÊ¿ÁˆÓ (ηı„›ÓË μ) Î·È ÙˆÓ ÎÔÎÎÈÔ΢ÙÙ¿ÚˆÓ (∂Ï·ÛÙ¿ÛË) 21. ∫ÏÈÓÈο ÌÔÚ› Ó· ÚÔηϤÛÂÈ ˘ÂÚËÎÙÈÎfiÙËÙ· ·Ô Î·Ù·Ó¿ÏˆÛË, ÊÏ‚È΋ ıÚfiÌ‚ˆÛË ‹ Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹22. ∫ÏÈÓÈ΋ ÌÂϤÙË, Ì ÙËÓ ¯Ú‹ÛË ‰ÈÔÈÛÔÊ¿ÁÂÈÔ˘ ˘ÂÚ˯ÔηډÈÔÁÚ·Ê‹Ì·ÙÔ˜, ·ÔÎ¿Ï˘„ ÌÈ· ÛËÌ·ÓÙÈ΋ Ó¢ÌÔÓÈ΋ ıÚÔÌ‚ÔÂÌ‚ÔÏ‹ (>0,5 ÂηÙÔÛÙ¿ ‰È¿ÌÂÙÚÔ˜ ıÚfiÌ‚Ô˘) ̤۷ Û 60 ‰Â˘ÙÂÚfiÏÂÙ· ·fi ÙËÓ Â·Ó·ÈÌ¿ÙˆÛ˘ ÛÙÔ 59% ÙˆÓ ·ÛıÂÓÒÓ ¯ˆÚ›˜ ÊÏ‚ÔÊÏ‚È΋ ·Ú¿Î·Ì„Ë Î·È ÛÙÔ 11% ÙˆÓ ·ÛıÂÓÒÓ Ì ÊÏ‚ÔÊÏ‚È΋ ·Ú¿Î·Ì„Ë23. ΔÔ ›‰ÈÔ ·Ó·Ê¤ÚÂÙ·È Î·È Û ¿ÏϘ ÌÂϤÙ˜. ∂˘Ù˘¯Ò˜, ı·Ó·ÙËÊfiÚ˜ Ó¢ÌÔÓÈΤ˜ ÂÌ‚ÔϤ˜ Û˘Ì‚·›ÓÔ˘Ó Û¿ÓÈ·, Èı·ÓÒ˜ ÏfiÁˆ Ù˘ Ù·˘Ùfi¯ÚÔÓ˘ ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ ÈÓˆ‰fiÏ˘Û˘. ∏ ˘ÂÚÈÓˆ‰ÔÏ˘ÙÈ΋ Ê¿ÛË Ú·ÎÙÈο ·Ú¯›˙ÂÈ Ì ÙËÓ Ë·ÙÂÎÙÔÌ‹, ‚Ú›ÛÎÂÙ·È ÛÙÔ ˙ÂÓ›ı ÙËÓ 1Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ̤-

METAMO™XEY™Eπ™ 2011

Ú· Î·È ÂÈÛÙÚ¤ÊÂÈ ÛÙ· Ê˘ÛÈÔÏÔÁÈο Â›‰· ÌÂÙ¿ ·fi 3-7 Ë̤Ú˜68. OÈ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÌÔÚÔ‡Ó Ó· ·›ÍÔ˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Û ÔÏÏÔ‡˜ ·ÛıÂÓ›˜. ∏ ‰ÈË·ÙÈ΋ Û˘ÛÛÒÚ¢ÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ·ÊÔÚ¿ ÙÔ 55% ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È ÌÔÚ› Ó· ÚÔÎÏËı› ·fi ÂÍ·ÁÁ›ˆÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÛÙ· ‰È·ÛÙ‹Ì·Ù· ÙÔ˘ Disse Î·È ÛÙËÓ Ê·ÁÔ΢ÙÙ¿ÚˆÛË ·fi Ù· ·ÙÙ·Ú· ÙÔ˘ Kupffer25. ∏ ÂËÚ·Ṳ̂ÓË ·ÚÓËÙÈο ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ· ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÌÔÚ› Ó· ·Ô‰Ôı› ÛÙËÓ ·ÒÏÂÈ· Ù˘ ÎÔÎÎÔÔ›ËÛ˘ Î·È ÙËÓ ‰È·Ù·Ú·¯‹ Ù˘ Û˘ÛÛÒÚ¢Û˘ ·˘ÙÒÓ. ∂ÈϤÔÓ Ë ˘ÔıÂÚÌ›· Â·Ó·ÈÌ¿ÙˆÛ˘ (·fi 1 ¤ˆ˜ 21ÔC), Ë ·ÈÌÔ·Ú·ÈÒÛË, ¿ÁÓˆÛÙÔÈ Î˘ÎÏÔÊÔÚÔ‡ÓÙ˜ ·Ó·ÛÙÔÏ›˜ Ù˘ ‹Í˘ ÚÔÂÚ¯fiÌÂÓÔÈ ·fi ÙÔ ÌfiÛ¯Â˘Ì· Î·È Ë ˘·Û‚ÂÛÙÈ·ÈÌ›· ÌÔÚÔ‡Ó Â›Û˘ Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ‹Í˘ ÙÔ˘ ·›Ì·ÙÔ˜. ∏ ‰È·Ù·Ú·¯‹ Ù˘ ‹Í˘ ‚ÂÏÙÈÒÓÂÙ·È ÛÙ·‰È·Î¿ ηıÒ˜ ÙÔ ÌfiÛ¯Â˘Ì· ·Ú¯›˙ÂÈ ÁÈ· Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÂÈ. ∏ ÈÓˆ‰fiÏ˘ÛË Î·È Ë ‰Ú¿ÛË Ù˘ Ë·Ú›Ó˘ ˘Ô¯ˆÚÔ‡Ó ÛÙ·‰È·Î¿, Î·È Ù· Â›‰· ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ Î·È ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ·˘Í¿ÓÔÓÙ·È ÚÔ˜ Ù· ·Ú¯Èο Â›‰· ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ¯ÂÈÚÔ˘ÚÁ›Ԣ3. øÛÙfiÛÔ, Ë ·ÈÌÔÚÚ·Á›· ÌÔÚ› Ó· ÂÈÌ›ÓÂÈ Û ÔÚÈṲ̂ÓÔ˘˜ ·ÛıÂÓ›˜. ∞ÈÌÔÚÚ·Á›· Ì Â›ÌÔÓË ‰È·Ù·Ú·¯‹ Ù˘ ‹Í˘ ÂÓ‰¤¯ÂÙ·È Ó· ÔÊ›ÏÂÙ·È Â›Ù Û ·ÓÂ·Ú΋ ıÂÚ·¢ÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ‹ Û ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜22,26. ∞ÈÌÔÚÚ·Á›· Ì Â›ÌÔÓ· ¯·ÌËÏ¿ Â›‰· ÙˆÓ ·Ú·ÁfiÓÙˆÓ πI, V Î·È VIII Â›Ó·È ÌÈ· ÂÈÏÔ΋ Ù˘ ÈÓˆ‰fiÏ˘Û˘, ηıÒ˜ ÙÔ Ï·ÛÌÈÓÔÁfiÓÔ Î·È Ë Ï·ÛÌ›ÓË, ÂÈÏÂÎÙÈο ηٷÛÙÚ¤ÊÔ˘Ó ·˘ÙÔ‡˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜12. ∫·ı˘ÛÙÂÚË̤ÓË ·ÈÌÔÚÚ·Á›·, 1-2 ÒÚ˜ ÌÂÙ¿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË, ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÒÏÂÈ· ÙˆÓ ÂÏ·Ùو̷ÙÈÎÒÓ ıÚfiÌ‚ˆÓ Ô˘ Û¯ËÌ·Ù›˙ÔÓÙ·È ·fi ÌË ÈηÓÔÔÈËÙÈÎfi ËÎÙÈÎfi Ì˯·ÓÈÛÌfi, ÏfiÁˆ ·ÈÌÔ·Ú·ÈÒÛˆ˜. ¢ÂÓ ˘¿Ú¯ÂÈ ÂȉÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ıÂÚ·›· Î·È Ë ·ÈÌÔÚÚ·ÁÈ΋ ÂÈÏÔ΋ ÂÚÈÔÚ›˙ÂÙ·È Ì¤Û· Û 60 ¤ˆ˜ 90 ÏÂÙ¿ ÌÂÙ¿ ÙÔÓ Û¯ËÌ·ÙÈÛÌfi Ó¤ˆÓ ıÚfiÌ‚ˆÓ ÂÓÙfi˜ ÙˆÓ ·ÁÁ›ˆÓ Ô˘ ¤¯Ô˘Ó ÙÚˆı›.

• ∞ÍÈÔÏfiÁËÛË Î·È ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ‹Í˘ ÙÔ˘ ·›Ì·ÙÔ˜ ∞Ó Î·È ÌÈ· ÔÈÎÈÏ›· ·fi Û˘Ì‚·ÙÈΤ˜ ÂÚÁ·ÛÙËÚȷΤ˜ ‰ÔÎÈ̤˜ Ô˘ ‰ÈÂÓÂÚÁ‹ıËÎ·Ó ÁÈ· Ó· ÚÔÛ‰ÈÔÚ›ÛÔ˘Ó ÙÔ Â›‰Ô˜ Î·È ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ‰È·Ù·Ú·¯‹˜ Ù˘ ‹Í˘, ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ‰ÔÎÈ̤˜ ¤¯Ô˘Ó ÂÚÈÔÚÈṲ̂ÓË ÂÊ·ÚÌÔÁ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜. £ÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ·Ê›· (Δ∂G) Î·È Ù· Û‡Á¯ÚÔ-

139

Ó· ·Ú¿ÁˆÁ· ·˘Ù‹˜: ∞Ó·Ù‡¯ıËΠÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1950, ÂÈÛ‹¯ıË ÛÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹Ë·ÙÔ˜ ·fi ÂÈÎÔÛ·ÂÙ›·˜3. ªÂÙÚ¿ Û˘Ó¯Ҙ ÙËÓ ÂÏ·ÛÙÈÎfiÙËÙ· ÙˆÓ ıÚfiÌ‚ˆÓ, Ô˘ Û¯ËÌ·Ù›˙ÔÓÙ·È Û ÊÚ¤ÛÎÔ Ï‹Ú˜ ·›Ì· Î·È ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ‹Í˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜3, ÙȘ ηډÈÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ Î·È ¿ÏϘ ÌÂÁ¿Ï˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ31,32,33.

• ¶ÂÚÈÂÁ¯ÂÈÚËÙÈ΋ ıÂÚ·›· Ù˘ ‹Í˘ ¶ÚÔÂÁ¯ÂÈÚËÙÈ΋ ¢È·¯Â›ÚÈÛ˘. ∏ ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‚ÂÏÙÈÛÙÔÔ›ËÛË Ù˘ ‹Í˘, ηıÔÚ›˙ÂÙ·È ·fi ÙÔ È‰È·›ÙÂÚÔ ËÍÈÔÏÔÁÈÎfi ÚÔÊ›Ï ÙÔ˘ οı ·ÛıÂÓÔ‡˜ Î·È Û˘¯Ó¿ Â›Ó·È ·ÓÂÈÙ˘¯‹˜ ÏfiÁˆ Ù˘ ·ÓÂ·ÚÎÔ‡˜ Ë·ÙÈ΋˜ Û‡ÓıÂÛ˘ ÙˆÓ ËÎÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È Ù˘ ÂÓ ÂÍÂÏ›ÍÂÈ ˘ÂÚ‚ÔÏÈ΋˜ ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ ‹Í˘. ™˘ÓÂÒ˜ Ë ÚÔÂÁ¯ÂÈÚËÙÈ΋ ‰È·¯Â›ÚÈÛË, ı· Ú¤ÂÈ Ó· Â›Ó·È ÚÔÛ·ÚÌÔṲ̂ÓË ÛÙȘ ÂȉÈΤ˜ ÎÏÈÓÈΤ˜ ·Ó¿ÁΘ Ì ‚¿ÛË ÙÔÓ Ù‡Ô Î·È ÙË ÛÔ‚·ÚfiÙËÙ· ÙˆÓ ËÎÙÈÎÒÓ ‰È·Ù·Ú·¯ÒÓ, ÙÔ Â›‰Ô˜ Ù˘ ÂÂÌ‚·ÙÈ΋ ‰È·‰Èηۛ·, ηıÒ˜ Î·È ÙË Ê‡ÛË Î·È ÙË ı¤ÛË Ù˘ ·ÈÌÔÚÚ·Á›·˜. ∏ ‚ÈÙ·Ì›ÓË ∫, ·ÔÚÚÔÊ¿Ù·È ¿ÌÂÛ· ·fi ÙË Á·ÛÙÚÂÓÙÂÚÈ΋ Ô‰fi, (Ì ÙË ‚Ô‹ıÂÈ· ¯ÔÏÈÎÒÓ ·Ï¿ÙˆÓ Ô˘ ·Ú¿ÁÔÓÙ·È ·fi ÙËÓ ÂÓÙÂÚÈ΋ ¯ÏˆÚ›‰·) Î·È Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ Ë·ÙÈ΋ Û‡ÓıÂÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ II, VII, πÃ, Î·È X. °È· ÙËÓ ‹È· ·ÓÂ¿ÚÎÂÈ· ‚ÈÙ·Ì›Ó˘ ∫, Ë ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛË ‚ÈÙ·Ì›Ó˘ ∫ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ¯ÔÚ‹ÁËÛË ¯ÔÏÈÎÒÓ ·Ï¿ÙˆÓ, ‹ ÂÓ¤ÛÈÌË ‚ÈÙ·Ì›ÓË ∫ (IM ‹ IV, 5mg/d) Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË ‰ÈfiÚıˆÛË ÙÔ˘ PT ̤۷ Û 24 ÒÚ˜. ∂·Ó·Ï·Ì‚·ÓfiÌÂÓË ¯ÔÚ‹ÁËÛË Ù˘ ‚ÈÙ·Ì›Ó˘ ∫ Î·È ·Ú·ÁfiÓÙˆÓ ‹Í˘ ÌÔÚ› Ó· Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰ÈfiÚıˆÛË Ù˘ ·ÈÌÔÚÚ·ÁÈ΋˜ ‰È¿ıÂÛ˘. ºÚ¤ÛÎÔ Î·Ù„˘Á̤ÓÔ Ï¿ÛÌ· (FFP). ∂› ·ÔÙ˘¯›·˜ Ù˘ ‚ÈÙ·Ì›ÓË ∫, Û ·ÛıÂÓ›˜ Ì ÛÔ‚·Ú‹ Ë·ÙÔ΢ÙÙ·ÚÈ΋ ‚Ï¿‚˘39 ÌÔÚ› Ó· ¯ÔÚËÁËı› FFP, Ô˘ ÂÚȤ¯ÂÈ ¤ÙÔÈÌ· Ù· ÂÚÈÛÛfiÙÂÚ· ÛÙÔȯ›· Ù˘ ‹Í˘ Î·È ÙˆÓ ·Ó·ÛÙÔϤˆÓ ÙÔ˘˜. ∂›Ó·È ÁÂÓÈο ·Ô‰ÂÎÙfi fiÙÈ ÙÔ FFP ¯ÔÚËÁÂ›Ù·È Û ·ÛıÂÓ›˜ Ì ·Ú·ÙÂٷ̤ÓÔ PT (>1,5 INR) ÚÈÓ ·fi ÙËÓ ‰È· ‚ÂÏfiÓ˘ ‚ÈÔ„›· ‹·ÙÔ˜. ∏ ‚ÂÏÙ›ˆÛË Ù˘ ‹Í˘, ˆÛÙfiÛÔ, Â›Ó·È ÌfiÓÔ ·ÚÔ‰È΋ Î·È Ô ÌÂÁ¿ÏÔ˜ fiÁÎÔ˜ ÙˆÓ FFP Ô˘ ··ÈÙÔ‡ÓÙ·È ÁÈ· ÙË ıÂÚ·›·, ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÁÁÂȷ΋ ˘ÂÚÊfiÚÙˆÛË ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡. ∏ ÌÂÙ¿ÁÁÈÛË ·ÈÌÔÂÙ·Ï›ˆÓ ¯ÚËÛÈÌÔÔÈ›ٷÈ

140

°. ¶∞¶∞´ø∞¡¡√À

ÁÈ· ÙË ıÂÚ·›· Ù˘ ÛÔ‚·Ú‹˜ ıÚÔÌ‚ÔÂÓ›·˜. ∏ ıÂÚ·¢ÙÈ΋ ‰Ú¿ÛË Ù˘ Â›Ó·È ‚Ú·¯‡‚È·, ·ÊÔ‡ Ù· ·ÈÌÔÂÙ¿ÏÈ· Û˘ÏÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔÓ ÛÏ‹Ó· Î·È ·ÔÌ·ÎÚ‡ÓÔÓÙ·È ·fi ÙËÓ Î˘ÎÏÔÊÔÚ›·. ∫ÏÈÓÈ΋ ·ÈÌÔÚÚ·Á›· Â›Ó·È Û¿ÓÈ· Ì ·ÈÌÔÂÙ¿ÏÈ· ÂÚÈÛÛfiÙÂÚ· ·fi 75.000/mm3, ·Ó Î·È ÈηÓÔÔÈËÙÈ΋ ·ÈÌfiÛÙ·ÛË ÌÔÚ› Ó· ÂÈÙ¢¯ı› Î·È Ì ÏÈÁfiÙÂÚ· ·ÈÌÔÂÙ¿ÏÈ· (>40.000/mm3). ΔÔ ÎÚ˘Ô˝˙ËÌ·, Ô˘ ÂÚȤ¯ÂÈ ÈÓˆ‰ÔÁfiÓÔ Î·È ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ VIII Î·È XIII, ÂӉ›ÎÓ˘Ù·È fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ˘Ô˚Óˆ‰ÔÁÔÓ·ÈÌ›· ‹ ÈÓˆ‰fiÏ˘ÛË. ª›· ÌÔÓ¿‰· ÎÚ˘Ô˚˙‹Ì·ÙÔ˜ ÂÚȤ¯ÂÈ 300mg ÈÓˆ‰ÔÁfiÓÔ˘ Î·È fiÙ·Ó ÌÂÙ·ÁÁÈÛÙ›, 1 ÌÔÓ¿‰· ÎÚ˘Ô˚˙‹Ì·ÙÔ˜ ·˘Í¿ÓÂÈ Ù· Â›‰· ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘ ÂÚ›Ô˘ 10 mg/dL Û ¤Ó· ·ÛıÂÓ‹ Ô˘ ˙˘Á›˙ÂÈ 60 kg. O ¯ÚfiÓÔ˜ ËÌ›ÛÂÈ·˜ ˙ˆ‹˜ ÙÔ˘ ÈÓˆ‰ÔÁfiÓÔ˘ Â›Ó·È ÂÚ›Ô˘ 3 ¤ˆ˜ 4 Ë̤Ú˜. ∞ÓÙÈËÎÙÈ΋ ıÂÚ·›· ¯ÔÚËÁԇ̠Û·Ó›ˆ˜ ÛÙËÓ Ë·ÙÈ΋ ÓfiÛÔ, ·Ó Î·È ÌÈ· ˘Ô‰fiÚÈ· ‰fiÛË Ë·Ú›Ó˘ (<5000 ÌÔÓ¿‰Â˜) Ê·›ÓÂÙ·È Ó· Â›Ó·È ·Ô‰ÂÎÙ‹ Û ·ÛıÂÓ›˜ Ì ıÚÔÌ‚ˆÙÈ΋ Ù¿ÛË. ∏ ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ·ÓÙÈËÎÙÈ΋ ·ÁˆÁ‹ ··ÈÙ› ÛÙÂÓ‹ ·Ú·ÎÔÏÔ‡ıËÛË, ÏfiÁˆ ·Úfi‚ÏÂÙˆÓ ·ÓÙȉڿÛˆÓ.

OÈ ·ÓÙÈÈÓˆ‰ÔÏ˘ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÌÔÚÔ‡Ó Ó· ÌÂÈÒÛÔ˘Ó ÙËÓ ·ÈÌÔÚÚ·Á›· ·ÎfiÌË Î·È ¯ˆÚ›˜ ÛËÌ›· ÈÓˆ‰fiÏ˘Û˘, ÛÙ·ıÂÚÔÔÈÒÓÙ·˜ ÙÔ˘˜ ‡ıÚ·˘ÛÙÔ˘˜ ·ÈÌÔÛÙ·ÙÈÎÔ‡˜ ıÚfiÌ‚Ô˘˜ Ô˘ Û¯ËÌ·Ù›˙ÔÓÙ·È ÛÙ· ¤ÏÎË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ‹ ÙˆÓ ÎÈÚÛÒÓ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘. øÛÙfiÛÔ, Ë EACA ‰ÂÓ ¤¯ÂÈ ‰Â›ÍÂÈ Ó· ‚ÂÏÙÈÒÓÂÈ ÙËÓ ‹ÍË Û ·ÛıÂÓ›˜ Ì Ë·ÙÈ΋ ÓfiÛÔ40. ¶Ï·ÛÌ·Ê·›ÚÂÛË (30 ¤ˆ˜ 40 ml/kg), ÛÂ Û˘Ó‰˘·ÛÌfi Ì ıÂÚ·›· ˘ÔηٿÛÙ·Û˘, ÌÔÚ› Ó· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ‹ÍË ÙÔ˘ ·›Ì·ÙÔ˜, ·›ÚÔÓÙ·˜ ÂӉ¯Ô̤ӈ˜ ‰ÈËıËÙÔ‡˜ ·Ó·ÛÙÔÏ›˜ Ù˘ ‹Í˘, ȉȷ›ÙÂÚ· Û ·ÛıÂÓ›˜ Ì ÎÂÚ·˘ÓÔ‚fiÏÔ Ë·ÙÈ΋ ·ÓÂ¿ÚÎÂÈ·. ∏ Ï·ÛÌ·Ê·›ÚÂÛË Ê·›ÓÂÙ·È Ó· ÌÂÈÒÓÂÈ ÙÔ PT ·fi 28,3′′ Û 17,7′′ Î·È ÙÔ aPTT ·fi 64,8′′ Û 43,3′′ Û ·ÛıÂÓ›˜ ˘Ô„‹ÊÈÔ˘˜ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜39. ∞Ó·Û˘Ó‰È·Ṳ̂ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ VIIa (rFVIIa). Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ ‚ÂÏÙÈÒÓÂÈ ÙËÓ ‹Í˘ Û ·ÛıÂÓ›˜ Ì ·ÓÂ¿ÚÎÂÈ· ÙÔ˘ ·Ú¿ÁÔÓÙ· VII, ¤ÏÏÂÈ„Ë ÙÔ˘ ·Ú¿ÁÔÓÙ· Ã, ÙÔ˘ ·Ú¿ÁÔÓÙ· Ãπ, Ì ÓfiÛÔ˜ von Willebrand ·fi ·Ó·ÛÙÔÏ›˜ ÛÙÔÓ vWF, Û ·ÛıÂÓ›˜ Ì ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È ıÚÔÌ‚ÔÂÓ›·. O rFVIIa ı· ·ÔÙÂÏÔ‡Û ÂÏȉÔÊfiÚ· ıÂÚ·¢ÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÎÈÚÚˆÙÈÎÒÓ ·ÛıÂÓÒÓ Ì ÛÔ‚·Ú¤˜ ‰È·Ù·Ú·¯¤˜ ‹Í˘. ∞Ú¯Èο, ‰Â›¯ıËΠfiÙÈ Ì›·

ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË rFVIIa Û ‰fiÛË 5, 20, ‹ 80 Ìg/Kg Â›Ó·È ·ÛÊ·Ï‹˜ Î·È Û¯ÂÙ›˙ÂÙ·È Ì ÔÌ·ÏÔÔ›ËÛË ÙÔ˘ ·Ú·ÙÂٷ̤ÓÔ˘ ¯ÚfiÓÔ˘ ÚÔıÚÔÌ‚›Ó˘ Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ÁÈ· 2, 6 ‹ 12 ÒÚ˜ ·ÓÙ›ÛÙÔȯ·66. ¶·Ú¿ÏÏËÏ·, Ê¿ÓËΠfiÙÈ Ë ˘„ËÏ‹ ‰fiÛË ÙÔ˘ rFVIIa ›¯Â ¢ÓÔ˚΋ Â›‰Ú·ÛË Î·È ÛÙË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ in vitro Î·È ÙËÓ ·ÈÌfiÛÙ·ÛË ıÚÔÌ‚ÔÂÓÈÎÒÓ ·ÛıÂÓÒÓ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÚÔ˘Û›· ÈÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Èı·ÓfiÓ Ì¤Ûˆ ÂÓ›Û¯˘Û˘ Ù˘ ‰Ú¿Û˘ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ηٿ ÙË ‰Â˘ÙÂÚÔÁÂÓ‹ ·Ú·ÁˆÁ‹ ıÚÔÌ‚›Ó˘67. ∏ Ôχ ¢ÓÔ˚΋ Â›‰Ú·ÛË ÙÔ˘ rFVIIa ÛÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ù˘ ·ÈÌfiÛÙ·Û˘, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ ÌÈÎÚfi fiÁÎÔ ÙÔ˘ Ê·ÚÌ¿ÎÔ˘ Î·È ÙËÓ ·Ô˘Û›· Û·ÊÒÓ ·ÚÂÓÂÚÁÂÈÒÓ, ›¯·Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÔÏÔ¤Ó· Î·È Û˘¯ÓfiÙÂÚË ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘ Û ·ÛıÂÓ›˜ Ì ‰È·Ù·Ú·¯¤˜ ·ÈÌfiÛÙ·Û˘ ÏfiÁˆ ΛÚÚˆÛ˘ ‹ ÔÍ›·˜ Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜, ·Ú¿ ÙËÓ ¤ÏÏÂÈ„Ë Â·ÚÎÒÓ ÛÙÔȯ›ˆÓ ÁÈ· ÙËÓ ÙÂÏÈ΋ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ ÙÔ˘ Î·È Î˘Ú›ˆ˜ ÁÈ· ÙÔ ÚÔÛÊÂÚfiÌÂÓÔ fiÊÂÏÔ˜ Û ۯ¤ÛË Ì ÙÔ Ôχ ˘„ËÏfi ÎfiÛÙÔ˜ ÙÔ˘16. O rFVIIa ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› Û ·ÛıÂÓ›˜ Ì Ë·ÙÈ΋ ÓfiÛÔ Î·È ÛËÌ·ÓÙÈ΋ ‰È·Ù·Ú·¯‹ ‹Í˘ ›Ù ÚÔÏËÙÈο, ÚÈÓ ·fi οÔÈ· ·ÈÌ·ÙËÚ‹ ‰È·ÁÓˆÛÙÈ΋ ‹ ıÂÚ·¢ÙÈ΋ ·Ú¤Ì‚·ÛË, ›Ù ıÂÚ·¢ÙÈο, Û ÂÚ›ÙˆÛË ÛÔ‚·Ú‹˜ ·ÈÌÔÚÚ·Á›·˜. ¢ÈÂÁ¯ÂÈÚËÙÈ΋ ¢È·¯Â›ÚÈÛ˘: O ÛÙfi¯Ô˜ Ù˘ ·ÔηٿÛÙ·Û˘ ÙÔ˘ ·ÈÌÔÛÙ·ÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Â›Ó·È Ó· ‰È·ÙËÚËı› ÎÔÓÙ¿ ÛÙÔ Ê˘ÛÈÔÏÔÁÈÎfi Ë ËÎÙÈÎfiÙËÙ· ÙÔ˘ ·›Ì·ÙÔ˜ ÌÂ Û˘¯Ó‹ ·Ú·ÎÔÏÔ‡ıËÛË, ÂȉÈΤ˜ ıÂÚ·›˜ ˘ÔηٿÛÙ·Û˘ ηÈ/‹ Ê·ÚÌ·ÎÔÏÔÁÈ΋ ıÂÚ·›· ·ÔʇÁÔÓÙ·˜ fï˜ ÙËÓ ıÚfiÌ‚ˆÛË. ∞ÔÙÂÏÂ›Ù·È ·fi: 1) ΔËÓ ‰ÈfiÚıˆÛË ÙˆÓ ·ıÔÏÔÁÈÎÒÓ ‚ÈÔÏÔÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ, 2) ΔËÓ ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ Î·È 3) ΔËÓ ¯ÔÚ‹ÁËÛË ÂȉÈÎÒÓ Ê·Ú̿ΈÓ.

1) ¢ÈfiÚıˆÛË ÙˆÓ ·ıÔÏÔÁÈÎÒÓ ‚ÈÔÏÔÁÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ. ÀÔıÂÚÌ›· ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ‹ÍË ·ÚÂÌ‚·›ÓÔÓÙ·˜ ÛÙËÓ ‰Ú·ÛÙÈÎfiÙËÙ· ÙˆÓ ÚˆÙ·ÛÒÓ Ô˘ ÂÌϤÎÔÓÙ·È ÛÙËÓ ‹ÍË Î·È ·˘Ùfi ·Ô‰ÂÈÎÓ‡ÂÙ·È Ì ÙËÓ ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ ·ÓÙ›‰Ú·Û˘ Î·È Ì›ˆÛË ÙÔ˘ Û˘ÓÙÂÏÂÛÙ‹ Û¯ËÌ·ÙÈÛÌÔ‡ ıÚfiÌ‚Ô˘ ÛÙÔ £ÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ¿ÊËÌ· (TEG). ªÈ· ·ÚfiÌÔÈ· ηı˘ÛÙ¤ÚËÛË ·Ú·ÙËÚÂ›Ù·È Û ·ÛıÂÓ›˜ Ì ˘·Û‚ÂÛÙÈ·ÈÌ›·, ÂÂȉ‹ ÙÔ ÈÔÓÈṲ̂ÓÔ ·Û‚¤ÛÙÈÔ Â›Ó·È ¤Ó·˜ Û˘Ì·Ú¿ÁÔÓÙ·˜ Ù˘ ‹Í˘. ∏ ÔͤˆÛË Î·È Ë ‰È·Ù·Ú·Á̤ÓË ËÏÂÎÙÚÔÏ˘ÙÈ΋ ÈÛÔÚÚÔ›· ÌÔÚÔ‡Ó Â›Û˘ Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ‹ÍË41.

METAMO™XEY™Eπ™ 2011

ø˜ ÂÎ ÙÔ‡ÙÔ˘, Ë ıÂÚÌÔÎÚ·Û›· ÙÔ˘ ÛÒÌ·ÙÔ˜, Ë ·ÈÌ¿ÙˆÛË ÙˆÓ ÈÛÙÒÓ, Ë ·ÓÙ·ÏÏ·Á‹ ·ÂÚ›ˆÓ, Ë ÔÍÂÔ‚·ÛÈ΋ ÈÛÔÚÚÔ›· Î·È Ë ËÏÂÎÙÚÔÏ˘ÙÈ΋ ·ÔηٿÛÙ·ÛË ı· Ú¤ÂÈ Ó· ‚ÂÏÙÈÛÙÔÔÈËıÔ‡Ó ÒÛÙ ӷ ‰È·ÙËÚ‹ÛÔ˘Ó Ê˘ÛÈÔÏÔÁÈ΋ ÙËÓ ËÎÙÈÎfiÙËÙ· ÙÔ˘ ·›Ì·ÙÔ˜.

2) £ÂÚ·›· ÀÔηٿÛÙ·Û˘. ∏ ıÂÚ·›· ˘ÔηٿÛÙ·Û˘ ηıÔ‰ËÁÂ›Ù·È ·fi ÙÔ ËÍÈÔÏÔÁÈÎfi ÚÔÊ›Ï ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹ ÙȘ ıÚÔÌ‚ÔÂÏ·ÛÙÔÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜. OÈ Î·Ù¢ı˘ÓÙ‹ÚȘ ÁÚ·Ì̤˜ ˘ÔηٿÛÙ·Û˘ ÔÈΛÏÏÔ˘Ó Â˘Ú¤ˆ˜ ÌÂٷ͇ ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÂÈÛÙËÌÔÓÈÎÒÓ ÔÌ¿‰ˆÓ, Î·È Î˘Ì·›ÓÔÓÙ·È ·fi ÂȉÈΤ˜ ηÙ¢ı˘ÓÙ‹ÚȘ ÁÚ·Ì̤˜ fiˆ˜: PT (π¡R) <1,5, ·ÈÌ·ÙÔÎÚ›Ù˘ >30%, ·ÚÈıÌfi˜ ·ÈÌÔÂÙ·Ï›ˆÓ >30.000/mm3, AT-III >70%42 ¤ˆ˜ ÁÂÓÈΤ˜ ηÙ¢ı˘ÓÙ‹ÚȘ ÁÚ·Ì̤˜ ·ÈÌÔÛÊ·ÈÚ›ÓË >9 g, FFP Ó· ‰ÈÔÚıÒÛÂÈ ‰È·Ù·Ú·¯‹ Ù˘ ‹Í˘, Ô ·ÚÈıÌfi˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ >100.000/mm3 43 Δ· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· ÌÂÙ·ÌfiÛ¯Â˘Û˘ ¯ÔÚËÁÔ‡Ó ∂Ú˘ıÚ¿ ·ÈÌÔÛÊ·›ÚÈ· / FFP = 1:1, ÒÛÙ ӷ ‰È·ÙËÚÔ‡Ó ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹Í˘ ¿Óˆ ·fi ÙÔ 30% ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ PT (π¡R) <1,5-2,0. ΔÔ ÎÚ›ÛÈÌÔ Â›Â‰Ô ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È Ù˘ Ù¿Í˘ ÙˆÓ 40.000 ¤ˆ˜ 50.000/mm3. °È· ·Ú¿‰ÂÈÁÌ·, ÛÙÔ Thomas Jefferson University Hospital, Ô ¯ÂÈÚÈÛÌfi˜ Ù˘ ‹Í˘ ηıÔ‰ËÁÂ›Ù·È ·fi ÙȘ ÌÂÙ·‚ÏËÙ¤˜ ÙÔ˘ TEG Î·È ÙÔÓ ·ÚÈıÌfi ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ. ™Â ÁÂÓÈΤ˜ ÁÚ·Ì̤˜, Ë Û˘Ó¯‹˜ ·ÓÙÈηٿÛÙ·ÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· Ó· ·ÓÙÈÛÙ·ıÌ›ÛÂÈ ÙȘ ÂÈÏÔΤ˜ ·fi ÙËÓ ·ÈÌÔ·Ú·›ˆÛË, ÙËÓ ˘ÂÚËÎÙÈÎfiÙËÙ· Î·È ÙËÓ ÈÓˆ‰fiÏ˘ÛË. ∞˘Ùfi ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÂÓfi˜ Ì›ÁÌ·ÙÔ˜ ·fi RBC: FFP: ÎÚ˘ÛÙ·ÏÏÔÂȉ‹ = 300:200:250 mL Ô˘ ÂÚȤ¯Ô˘Ó 30% ¤ˆ˜ 50% ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÈ¤‰ˆÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘. ¶ÚfiÛıÂÙ· ÚÔ˚fiÓÙ· ·›Ì·ÙÔ˜ ÌÔÚ› Ó· ¯ÔÚËÁËıÔ‡Ó Ì ‚¿ÛË ÙȘ TEG ÌÂÙ·‚ÏËÙ¤˜ Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ. ∫Ú˘Ô˝˙ËÌ· ¯ÔÚËÁÂ›Ù·È È‰È·›ÙÂÚ· Û ·ÛıÂÓ›˜ Ì ÈÓˆ‰fiÏ˘ÛË Ô˘ ÚÔηÏ› ˘ÔÈÓˆ‰ÔÁÔÓ·ÈÌ›·44. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓË·ÙÈ΋˜ Ê¿Û˘, Ë ¯ÔÚ‹ÁËÛË ·ÈÌÔÂÙ·Ï›ˆÓ Î·È ÎÚ˘Ô˝˙ËÌ·ÙÔ˜ ·Ôı·ÚÚ‡ÓÂÙ·È, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÙÚ·Ô‡Ó Èı·Ó¤˜ ıÚÔÌ‚ÔÂÌ‚ÔÏÈΤ˜ ÂÈÏÔΤ˜. ªÈ· ÂÈıÂÙÈ΋ ıÂÚ·›· ˘ÔηٿÛÙ·Û˘

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ÌÔÚ› Ó· ¯ÚÂÈ·ÛÙ› ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÓÂÔË·ÙÈ΋˜ Ê¿Û˘, fiÙ·Ó Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÈÌÔÚÚ·Á›· ÂÈ̤ÓÂÈ, ‹ Ë ÈÓˆ‰fiÏ˘ÛË ‹ Ë Â›‰Ú·ÛË Ù˘ Ë·Ú›Ó˘ ‰ÂÓ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È. ∏ ÂÌ̤ÓÔ˘Û· ÈÓˆ‰fiÏ˘ÛË ÌÔÚ› Ó· ··ÈÙ‹ÛÂÈ ÌÈ· ÌÂÁ¿ÏË ÔÛfiÙËÙ· ÙˆÓ ·Ú·ÁfiÓÙˆÓ πI, V Î·È VIII, Î·È ‚ÂÏÙÈÒÓÂÙ·È ¯ÔÚËÁÒÓÙ·˜ FFP Î·È ÎÚ˘Ô˚˙‹Ì·Ù·. ¶ÚfiÛıÂÙË ÌÂÙ¿ÁÁÈÛË ·ÈÌÔÂÙ·Ï›ˆÓ ÂÓ‰¤¯ÂÙ·È Ó· ··ÈÙËı› Û ·ÛıÂÓ›˜ Ì η΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ∂ÈϤÔÓ, Ë ·ÏÏÔ·ÓÔÛÔÔ›ËÛË ÛÂ Û˘ÁÎÂÎÚÈ̤ӷ ·ÓÙÈÁfiÓ· Ù¿Í˘-1 ·ÓıÚÒÈÓˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Û ·ÛıÂÓ›˜ Ì ȉȷ›ÙÂÚË Â˘·ÈÛıËÛ›· ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÓıÂÎÙÈÎfiÙËÙ· ÛÙË ÌÂÙ¿ÁÁÈÛË ·ÈÌÔÂÙ·Ï›ˆÓ Î·È ÙÔ Úfi‚ÏËÌ· ÌÔÚ› Ó· Ï˘ı› ÌfiÓÔÓ Ì ÌÂÙ¿ÁÁÈÛË ÂȉÈο Ù˘ÔÔÈËÌ¤ÓˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ·fi ¤Ó·Ó ‰fiÙË45. ∏ ¯ÔÚ‹ÁËÛË AT-III, ÚÔÙ¿ıËΠÒÛÙ ӷ ÂÏ·¯ÈÛÙÔÔÈËı› Ë ˘ÂÚ‚ÔÏÈ΋ ÂÓÂÚÁÔÔ›ËÛË Ù˘ ‹Í˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓË·ÙÈ΋˜ Î·È ÛÙȘ ·Ú¯¤˜ Ù˘ ÓÂÔË·ÙÈ΋˜ Ê¿Û˘. øÛÙfiÛÔ, Ù· Â›‰¿ Ù˘ ·Ú·Ì¤ÓÔ˘Ó ÛÙÔ 30% ¤ˆ˜ 50% ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÈ¤‰ˆÓ ÌfiÓÔÓ Ì ÙËÓ ¯ÔÚ‹ÁËÛË FFP19 Î·È ÚfiÛıÂÙË ¯ÔÚ‹ÁËÛË AT-III ‰ÂÓ ‚ÂÏÙÈÒÓÂÈ ÙÔ ÚÔÊ›Ï Ù˘ ‹Í˘ Ô‡Ù ÙËÓ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ Î·È ÙËÓ ÈÓˆ‰fiÏ˘ÛË46. ø˜ ÂÎ ÙÔ‡ÙÔ˘, Ë AT-III ÂÚÈÔÚ›˙ÂÙ·È ·ÔÎÏÂÈÛÙÈο ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ÂÍ·ÈÚÂÙÈο ¯·ÌËÏ¿ Â›‰· AT-III. 3) ÃÔÚ‹ÁËÛË ÂȉÈÎÒÓ Ê·ÚÌ¿ÎˆÓ ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Î·Ì›· Ê·Ú̷΢ÙÈ΋ ·Ú¤Ì‚·ÛË ‰ÂÓ ÌÔÚ› Ó· ÚÔ¿ÁÂÈ ÙËÓ Â·Ú΋ ·ÈÌfiÛÙ·ÛË Î·È Ó· ÌÂÈÒÛÂÈ ÙȘ ·Ó¿ÁΘ Û ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜, ÙÔ fiÔÈÔ ·Ó·ÌÂÓfiÌÂÓÔ fiÊÂÏÔ˜ Û ÌÂÙ·ÁÁ›ÛÂȘ ı· Ú¤ÂÈ Ó· ÛÙ·ıÌÈÛÙ› Û ۯ¤ÛË Ì ÙËÓ ÂΉ‹ÏˆÛË ıÚÔÌ‚ˆÙÈÎÒÓ ÂÈÏÔÎÒÓ. ∞ÓÙÈÈÓˆ‰ÔÏ˘ÙÈ΋ ıÂÚ·›·. ¶ÚfiÎÂÈÙ·È ÁÈ· Ê·Ú̷΢ÙÈΤ˜ Ô˘Û›Â˜ ·Ó¿ÏÔÁ˜ Ù˘ Ï˘Û›Ó˘, EACA Î·È ÙÚ·ÓÂÍ·ÌÈÎfi Ô͇. ∂ÈÙ·¯‡ÓÔ˘Ó ÙË ÌÂÙ·ÙÚÔ‹ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘ Û Ï·ÛÌ›ÓË, Â¿ÁÔÓÙ·˜ ·ÏÏ·Á¤˜ ÛÙÔ ÌfiÚÈÔ ÙÔ˘ Ï·ÛÌÈÓÔÁfiÓÔ˘. ∞Ó·ÛÙ¤ÏÏÔ˘Ó ÙËÓ ÈÓˆ‰fiÏ˘ÛË, ‰ÂÛ̇ÔÓÙ·˜ ÙÔÓ Â›ÙÔÔ Ù˘ Ï˘Û›Ó˘ Â› Ù˘ Ï·ÛÌ›Ó˘. ΔÔ EACA ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 ÁÈ· ÙË ıÂÚ·›· Ù˘ ÁÂÓÈÎÂ˘Ì¤Ó˘ ·ÈÌÔÚ·Á›·˜ ·fi ÈÓˆ‰fiÏ˘ÛË, ·ÏÏ¿ fiÏÔÈ ÔÈ 3 ·ÛıÂÓ›˜ ·Ó¤Ù˘Í·Ó ı·Ó·ÙËÊfiÚ· ·ÈÌÔÚÚ·Á›· ‹ Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹9. ∞Ó Î·È ·˘Ù‹ Ë ·Ù˘¯‹˜ ÂÌÂÈÚ›· ·Ôı¿ÚÚ˘Ó ·Ú¯Èο ÙË ¯Ú‹ÛË ÙˆÓ ·ÓÙÈÈÓˆ‰ÔÏ˘ÙÈÎÒÓ ıÂÚ·ÂÈÒÓ, ÌÂÙ·ÁÂÓ¤ÛÙÂÚ˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ıÂÙÈο ·ÔÙÂϤÛÌ·Ù·. ™Â ÌÈ· ÌÂϤÙË Ì 79 ·ÛıÂÓ›˜, ¯ÔÚËÁ‹ıËÎÂ

142

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EACA (1g) Û 20 ·ÛıÂÓ›˜ Ô˘ ·Ó¤Ù˘Í·Ó ÛÔ‚·Ú‹ ÈÓˆ‰fiÏ˘ÛË. ∏ ÈÓˆ‰fiÏ˘ÛË ‰ÈÔÚıÒıËΠ¯ˆÚ›˜ ıÚÔÌ‚ˆÙÈΤ˜, ·ÈÌÔÚÚ·ÁÈΤ˜ ‹ ÓÂÊÚÈΤ˜ ÂÈÏÔΤ˜14. ∏ ¯ÔÚ‹ÁËÛË ÌÈÎÚfiÙÂÚˆÓ ‰fiÛÂˆÓ EACA, ‹Ù·Ó ¤Ó· ·fi Ù· ÛËÌ·ÓÙÈÎfiÙÂÚ· Â˘Ú‹Ì·Ù· ·˘Ù‹˜ Ù˘ ÌÂϤÙ˘ Û ۇÁÎÚÈÛË Ì ÙËÓ ·Ú¯È΋ ıÂÚ·›· ÙˆÓ 4 ¤ˆ˜ 5g47. º·›ÓÂÙ·È fiÙÈ ÌÈ· ÂÓÈ·›·, ÌÈÎÚ‹ ‰fiÛË EACA Â›Ó·È Â·Ú΋˜ ÁÈ· ÙË ıÂÚ·›· Ù˘ ÛÔ‚·Ú‹˜, ·ÏÏ¿ ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ ÈÓˆ‰fiÏ˘Û˘. ŸÌˆ˜ Ë ÌÈÎÚ‹ ËÌËÂÚ›Ô‰Ô˜ ˙ˆ‹˜ ÙÔ˘ EACA, ÂÈ‚¿ÏÏÂÈ ÙËÓ ¯ÔÚ‹ÁËÛË 2˘ ‰fiÛ˘ Û ·ÛıÂÓ›˜ Ì Ôχ ˘„ËÏ¿ tPA Î·È Ì·˙ÈΤ˜ ÌÂÙ·ÁÁ›ÛÂȘ. ÕÏϘ ÌÂϤÙ˜ ·Ô‰ÂÈÎÓ‡Ô˘Ó fiÙÈ ·ÎfiÌË Î·È ÌÈ· ÌÈÎÚfiÙÂÚË ‰fiÛË ÙÔ˘ EACA (250 ¤ˆ˜ 500mg) Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙË ıÂÚ·›· ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ Ù‡ˆÓ ÈÓˆ‰fiÏ˘Û˘48,49. ∏ ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ıÂÚ·›· Ù˘ ÈÓˆ‰fiÏ˘Û˘ Ê·›ÓÂÙ·È Ó· Â›Ó·È ÂˆÊÂÏ‹˜, ÁÈ·Ù› ÌÂÈÒÓÂÈ ÙËÓ ·ÈÌÔÚÚ·Á›· Î·È ÙËÓ ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜, Û˘ÓÙËÚ› Ù· Â›‰· ÙˆÓ ·Ú·ÁfiÓÙˆÓ Iπ, V Î·È VIII, ·Ó·ÛÙ¤ÏÏÔÓÙ·˜ ÙËÓ Ï·ÛÌ›ÓË Î·È ÂÏ·¯ÈÛÙÔÔÈÒÓÙ·˜ ÙËÓ Î·Ù·ÛÙÚÔÊÈ΋ ÈÛ¯·ÈÌ›· Î·È ÙË Ì›ˆÛË ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÈÎÔ‡ ¯ÚfiÓÔ˘. ∏ ÈÓˆ‰fiÏ˘ÛË ÌÔÚ› Ó· ‰È·ÁÓˆÛÙ› Î·È Ó· ·ÓÙÈÌÂÙˆÈÛÙ› Û ·Ú¯ÈÎfi ÛÙ¿‰ÈÔ, ·Ú·ÙËÚÒÓÙ·˜ ÙȘ TEG ÌÂÙ·‚ÏËÙ¤˜ (¯ÚfiÓÔ˜ ·ÓÙ›‰Ú·Û˘ Î·È Ú˘ıÌfi˜ Û¯ËÌ·ÙÈÛÌÔ‡ ıÚfiÌ‚Ô˘). ∏ ÚÔÊ˘Ï·ÎÙÈ΋ ¯Ú‹ÛË ÙÔ˘ EACA ‰ÂÓ Û˘ÓÈÛٿٷÈ, ÂÂȉ‹ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ıÚÔÌ‚ˆÙÈ΋ ÂÈÏÔÏ‹24,50. OÈ Carlier et al50 ·Ó¤ÊÂÚ·Ó fiÙÈ Ë ¯Ú‹ÛË ÙÔ˘ ÙÚ·ÓÂÍ·ÌÈÎÔ‡ Ôͤˆ˜ Â›Ó·È ·ÛÊ·Ï‹˜ Û ·È‰È·ÙÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Î·È ·ÚfiÌÔÈ· ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· ·Ó·Ê¤ÚıËÎ·Ó Î·È Û ¿ÏϘ ÚÔÔÙÈΤ˜, Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ Ì ÙÚ·ÓÂÍ·ÌÈÎfi acid51,52. ∞ÚÔÙÈÓ›ÓË. ∂›Ó·È ÌË ÂȉÈÎfi˜ ·Ó·ÛÙÔϤ·˜ ÙˆÓ ÛÂÚÈÓÈÎÒÓ ÚˆÙ·ÛÒÓ Î·È ·‰Ú·ÓÔÔÈ› ¤Ó·Ó ÌÂÁ¿ÏÔ ·ÚÈıÌfi ÛÂÚÈÓÈÎÒÓ ÚˆÙ·ÛÒÓ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Ù˘ ıÚ˘„›Ó˘, ¯˘ÌÔıÚ˘„›Ó˘, Ï·ÛÌ›Ó˘, ηÏÏÈÎÚ½Ó˘, ·Ú¿ÁÔÓÙ· Hageman Î·È ÙˆÓ ÂÚÈÛÛÔÙ¤ÚˆÓ ·Ú·ÁfiÓÙˆÓ ‹Í˘. ∂›Û˘, ÂÌÔ‰›˙ÂÈ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ηډÈÔÓ¢ÌÔÓÈ΋˜ ·Ú¿Î·Ì„˘ Î·È ¤¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÚÔÊ˘Ï¿ÛÛÂÈ ÙÔ˘˜ ˘ԉԯ›˜ GPIb ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ. Δ· ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù· Ù˘ ·ÚÔÙÈÓ›Ó˘ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÌÂȈ̤ÓË ·Ú·ÁˆÁ‹ ÙÔ˘ tPA Î·È Ù˘ Ï·ÛÌ›Ó˘ ̤ۈ Ù˘ ·Ó·ÛÙÔÏ‹˜ Ù˘ ÈÓˆ‰fiÏ˘Û˘53. ∏ ·ÚÔÙÈÓ›ÓË ·Ó·ÛÙ¤ÏÏÂÈ Â›Û˘ ÙÔÓ Î·Ù·ÚÚ¿ÎÙË Ù˘ ‹Í˘ Î·È ·˘Ùfi ¤¯ÂÈ Î·Ù·‰Â›¯ıËΠÛÙËÓ TEG

ÙÔ˘ ·›Ì·ÙÔ˜ ·ÛıÂÓÒÓ Ô˘ ¤Ï·‚·Ó ıÂÚ·›· Ì ·ÚÔÙÈÓ›ÓË37. ø˜ ÂÎ ÙÔ‡ÙÔ˘, ÙÔ ÎÏÈÓÈÎfi fiÊÂÏÔ˜ Ù˘ ·ÚÔÙÈÓ›Ó˘ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·Ó·ÛÙÔÏ‹ Ù˘ ˘ÂÚ‚ÔÏÈ΋˜ ÂÓÂÚÁÔÔ›ËÛ˘ Ù˘ ‹Í˘ Î·È Ù˘ ÈÓˆ‰fiÏ˘Û˘. ∏ ‰ÔÛÔÏÔÁ›· Ù˘ Î˘Ì·›ÓÂÙ·È ·fi ÌÈ· ˘„ËÏ‹ ‰fiÛË (2 ÂηÙ. KIU ·ÎÔÏÔ˘ıÔ‡ÌÂÓË ·fi 0,5 ÂηÙ. U/h) ÛÂ Û˘Ó¯‹ ÛÙ¿Á‰ËÓ ¤Á¯˘ÛË (0,2 – 0,4 U/h). OÈ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ·ÚÔÙÈÓ›ÓË ÌÂÈÒÓÂÈ ÙËÓ ·ÒÏÂÈ· ·›Ì·ÙÔ˜, ÙÔÓ ¯ÂÈÚÔ˘ÚÁÈÎfi ¯ÚfiÓÔ Î·È ÙË ‰È¿ÚÎÂÈ· ·Ú·ÌÔÓ‹˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÛÙË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂÚ·›·˜53,55,56. ∞ӷʤÚÔÓÙ·È ·ÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ, ÓÂÊÚÈ΋ ‚Ï¿‚Ë, ı·Ó·ÙËÊfiÚ˜ Ó¢ÌÔÓÈΤ˜ ÂÌ‚ÔϤ˜60 Î·È Ë ¯Ú‹ÛË Ù˘ ¤¯ÂÈ ÌÂȈı› Û ÔÏÏ¿ ΤÓÙÚ· 57-59 . ¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÂȂ‚·ÈÒÓÔ˘Ó fiÙÈ Ë ·ÚÔÙÈÓ›ÓË ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙËÓ ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ·Ó¿ÁÎË Û ÚÔ˚fiÓÙ· ·›Ì·ÙÔ˜ ÛÙËÓ Oª∏ Î·È ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂΉ‹ÏˆÛË ·ÈÌÔÚÚ·Á›·˜ ·fi ÙÔ ¯ÂÈÚÔ˘ÚÁÈÎfi ‰›Ô, Ì ıÚÔÌ‚ˆÙÈο ÂÂÈÛfi‰È· Î·È ÙËÓ ıÓËÛÈÌfiÙËÙ·76,77. ÕÏ·˜ ıÂÈÈ΋˜ ¶ÚÔÙ·Ì›Ó˘. (25 ¤ˆ˜ 50mg) ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· Ó· ·Ó·ÛÙÚ¤„ÂÈ ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ Ë·Ú›Ó˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓË·ÙÈ΋˜ Î·È ÓÂÔË·ÙÈ΋˜ Ê¿Û˘. ™Â ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜, Ë ¯ÔÚ‹ÁËÛË Ù˘ ıÂÈÈ΋˜ ÚˆÙ·Ì›Ó˘ ¤‰ÂÈÍ ӷ Û˘ÓÙÔÌ¢ı› ÙÔ ¯ÚfiÓÔ ·ÓÙ›‰Ú·Û˘ ÙÔ˘ TEG Î·È ÙÔÓ aPTT. ¢ÂÛÌÔÚÂÛÛ›ÓË (DDAVP, 1-deamino 8-D-·ÚÁÈÓ›ÓË ‚·˙ÔÚÂÛÛ›Ó˘) Â›Ó·È ¤Ó· Û˘ÓıÂÙÈÎfi ·Ó¿ÏÔÁÔ Ù˘ ÔÚÌfiÓ˘ Ô˘ ÂÎÎÚ›ÓÂÙ·È ·fi ÙÔÓ Ô›ÛıÈÔ ÏÔ‚fi Ù˘ ˘fiÊ˘Û˘, ÙË ‚·˙ÔÚÂÛÛ›ÓË ‹ ·ÓÙȉÈÔ˘ÚËÙÈ΋ ÔÚÌfiÓË. ¢ÈÂÁ›ÚÂÈ Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÒÛÙ ӷ ·ÂÏ¢ıÂÚÒÛÔ˘Ó ÙÔÓ ·Ú¿ÁÔÓÙ· vWF Û ‰È¿ÛÙËÌ· 1 ÒÚ·˜ ·fi ÙËÓ ¤Á¯˘ÛË. ∏ ¢ÂÛÌÔÚÂÛÛ›ÓË ‚ÂÏÙÈÒÓÂÈ ÙËÓ ·ÈÌfiÛÙ·ÛË Û ·ÛıÂÓ›˜ Ì ·ÈÌÔÚÚÔÊÈÏ›· ∞ Î·È ÓfiÛÔ von Willebrand61 Î·È ÌÂÈÒÓÂÈ ÙÔÓ ¯ÚfiÓÔ ÚÔ‹˜ Û ·ÛıÂÓ›˜ Ì ԢڷÈÌ›·62, ÌÂ Û˘ÁÁÂÓ›˜ ıÚÔÌ‚·Ûı¤ÓÂȘ, Ì ÙÂÏÈÎÔ‡ ÛÙ·‰›Ô˘ Ë·ÙÈ΋ ÓfiÛÔ63, Î·È Û ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ηډÈÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ64. ∏ Û˘ÓÈÛÙÒÌÂÓË ‰ÔÛÔÏÔÁ›· Ù˘ ‰ÂÛÌÔÚÂÛÛ›Ó˘ Â›Ó·È 0,3 mg/kg ÂÓ‰ÔÊÏ‚›ˆ˜ ‹ 300 mg (150 mg Û ·È‰È¿) ÂÓ‰ÔÚÚÈÓÈο Ì Â·Ó¿ÏË„Ë 12 ¤ˆ˜ 24 ÒÚ˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ‰fiÛË. ∏ DDAVP ‚ÂÏÙÈÒÓÂÈ ÙËÓ ËÎÙÈÎfiÙËÙ· ÙÔ˘ ·›Ì·ÙÔ˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û Ë·ÙÈ΋ ÌÂÙ·ÌfiÛ¯Â˘ÛË in vitro, ÂӉ¯Ô̤ӈ˜ Ì ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ·Ú·ÁfiÓÙˆÓ ‹Í˘ Î·È ·ÈÌÔÂÙ·Ï›ˆÓ38. øÛÙfiÛÔ, ÙÔ ÎÏÈÓÈÎfi fiÊÂÏÔ˜ ÛÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ‰ÂÓ ¤¯ÂÈ ÙÂÎÌËÚȈı›.

METAMO™XEY™Eπ™ 2011

∞Ó·Û˘Ó‰˘·Ṳ̂ÓÔ˜ ·Ú¿ÁÔÓÙ·˜ VIIa (rVIIa). ∂›Ó·È Ô ÈÔ ÚfiÛÊ·Ù· ÂÈÛËÁ̤ÓÔ˜ Ê·Ú̷΢ÙÈÎfi˜ ·Ú¿ÁˆÓ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. O ÂÓÂÚÁÔÔÈË̤ÓÔ˜ ·Ú¿ÁÔÓÙ· VII, Û ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ, 80 mg/Kg, Û ̛· ÂÊ ¿·Í ‰fiÛË, 10ã ÚÈÓ ÙËÓ ¤Ó·ÚÍË Ù˘ Â¤Ì‚·Û˘, ÚÔÛÎÔÏÏ¿Ù·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ÂÓÂÚÁÔÔÈËÌ¤ÓˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ Î·È ¿ÌÂÛ· ÂÓÂÚÁÔÔÈ› ÙÔÓ ·Ú¿ÁÔÓÙ· Ã, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ‰ËÌÈÔ˘ÚÁ›· ıÚÔÌ‚›Ó˘ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ, ¯ˆÚ›˜ ÚÔ··ÈÙÔ‡ÌÂÓÔ ÙËÓ ‡·ÚÍË ÙˆÓ ·Ú·ÁfiÓÙˆÓ VIIIa Î·È IXa 65. Œ¯ÂÈ ·Ô‰Âȯı› fiÙÈ ÌÂÈÒÓÂÈ ÙÔ PT Û ·ÛıÂÓ›˜ Ì Ë·ÙÈ΋ ÓfiÛÔ Î·È ÙËÓ ·ÒÏÂÈ· ·›Ì·ÙÔ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ Ë·ÙÈ΋˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. øÛÙfiÛÔ, ··ÈÙÔ‡ÓÙ·È ÂÚ·ÈÙ¤Úˆ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜, ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÓÙÔÈÛÙÔ‡Ó Ù· ÔʤÏË Î·È ÔÈ Èı·Ó¤˜ ÂÈÏÔΤ˜. ∏ Û˘Ó¯Ҙ ÔÚıfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‰È·Ù·Ú·¯ÒÓ Ù˘ ·ÈÌfiÛÙ·Û˘, ¤¯ÂÈ ÛËÌ·Û›·, fi¯È ÌfiÓÔÓ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ηٿ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ Â¤Ì‚·Û˘, ·ÏÏ¿ Î·È ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi Ù˘ ÌÂÙ¿ÁÁÈÛ˘ ÂÚ˘ıÚÒÓ Î·È ·ÈÌÔÂÙ·Ï›ˆÓ. ∏ ÌÂÙ¿ÁÁÈÛË ÂÚÈÛÛÔÙ¤ÚˆÓ ·fi 6 ÌÔÓ¿‰ˆÓ ÂÚ˘ıÚÒÓ, Û˘Óԉ‡ÂÙ·È ·fi ÂÚÈÔÚÈṲ̂ÓË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ∞ÎfiÌË Î·È Û‹ÌÂÚ·, ΤÓÙÚ· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó 2-3 ÌÔÓ¿‰Â˜ ÂÚ˘ıÚÒÓ Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜, ·Ó·Ê¤ÚÔ˘Ó ÌÈ· ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ‰ÈÂÁ¯ÂÈÚËÙÈ΋˜ ÌÂÙ¿ÁÁÈÛ˘ ·›Ì·ÙÔ˜ Î·È ÌÂÙÂÁ¯ÂÈÚËÙÈÎÒÓ ÏÔÈÌÒÍÂȘ Î·È ÓÔÛËÚfiÙËÙ·˜. ÃÚËÛÈÌÔÔÈÒÓÙ·˜ ÔÏ˘·Ú·ÁÔÓÙÈΤ˜ ÛÙ·ÙÈÛÙÈΤ˜ ·Ó·Ï‡ÛÂȘ, ÔÈ ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó ÌÂÙ·ÁÁ›ÛÂȘ ·ÈÌÔÂÙ·Ï›ˆÓ, ÂÌÊ¿ÓÈÛ·Ó 5 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË ıÓËÛÈÌfiÙËÙ· ·fi ·˘ÙÔ‡˜ ÔÈ ÔÔ›ÔÈ ‰ÂÓ ¤Ï·‚·Ó ÌÂÙ·ÁÁ›ÛÂȘ71. ™Â ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜, ÔÏϤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ù· ·ÈÌÔÂÙ¿ÏÈ· ÂÌϤÎÔÓÙ·È ÛÙËÓ ·ıÔÁ¤ÓÂÈ· Ù˘ ‚Ï¿‚˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ηٿ ÙËÓ Â·Ó·ÈÌ¿ÙˆÛË, ÚÔηÏÒÓÙ·˜ ·fiÙˆÛË ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ72,73. ∞˘Ùfi ÙÔ ÁÂÁÔÓfi˜ Â›Ó·È ·ÓÂÍ¿ÚÙËÙÔ ·fi ÙËÓ ‚Ï¿‚Ë ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÈÛ¯·ÈÌ›· Î·È ‰ÂÓ ÌÔÚ› Ó· ·Ô‰Ôı› ÛÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘ ËÎÙÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Î·È ÙËÓ Û˘ÛÛÒÚ¢ÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ÛÙ· ÛËÌ›· ÙˆÓ ÂÓ‰ÔıËÏÈ·ÎÒÓ ‚Ï·‚ÒÓ72-75. º·›ÓÂÙ·È fiÙÈ Ô ÚfiÏÔ˜ ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ ‰ÂÓ ÂÚÈÔÚ›˙ÂÙ·È ÌfiÓÔÓ ÛÙËÓ ·ÈÌfiÛÙ·ÛË. Δ· ·ÈÌÔÂÙ¿ÏÈ· ÂÚȤ¯Ô˘Ó ΢ÙÙ·ÚÔΛÓ˜ Î·È ·ÁÁÂÈÔ‰Ú·ÛÙÈÎÔ‡˜ Î·È ÊÏÂÁÌÔÓÒ‰ÂȘ ‰È·ÌÂ-

143

ÛÔÏ·‚ËÙ¤˜, ÔÈ ÔÔ›ÔÈ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È ÌÂÙ¿ ÙËÓ ÂÓÂÚÁÔÔ›ËÛË ÙÔ˘˜, Ô˘ ÚÔηÏÂ›Ù·È Â›Ù ηٿ ÙËÓ ‰È·‰Èηۛ· ·Ú·Û΢‹˜ ÙÔ˘˜, ›Ù ·fi ‰È¿ÊÔÚ· ÂÚÂı›ÛÌ·Ù· ηٿ ÙËÓ Ê¿ÛË Ù˘ Â·Ó·ÈÌ¿ÙˆÛ˘. Δ· ·ÈÌÔÂÙ¿ÏÈ· Û˘Ó‰¤ÔÓÙ·È Ì ٷ ÏÂ˘Î¿ ·ÈÌÔÛÊ·›ÚÈ·, ÂÓÂÚÁÔÔÈÔ‡ÓÙ·È Î·È ÂÎÊÚ¿˙Ô˘Ó ‰È¿ÊÔÚ· ÌfiÚÈ· ÚÔÛÎfiÏÏËÛ˘ 71. Δ· Â›‰· ÙˆÓ Î˘ÙÙ·ÚÔÎÈÓÒÓ ÌÔÚ› Ó· ·˘ÍËıÔ‡Ó Î·È 1000 ÊÔÚ¤˜, ÌÂÙ·ÙÚ¤ÔÓÙ·˜ ÙËÓ ÌÂÙ¿ÁÁÈÛË ·ÈÌÔÂÙ·Ï›ˆÓ Û ÌÈ· ÚÔÊÏÂÁÌÔÓÒ‰Ë Î·Ù¿ÛÙ·ÛË. ∞˘Ù¤˜ ÔÈ Ô˘Û›Â˜ ‰˘ÓËÙÈο Û˘ÌÌÂÙ¤¯Ô˘Ó ÛÙȘ ÌÂÙ·ÌÔÛ¯Â˘ÙÈΤ˜ ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÓÙȉڿÛÂȘ, ·ÏÏ¿ ‰ÂÓ ¤¯Ô˘Ó ÂÚ¢ÓËı› ÂȉÈο. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÂȂ‚·ÈÒÓÂÙ·È70 Ë ·ÚÓËÙÈ΋ Â›‰Ú·ÛË Ù˘ ÌÂÙ¿ÁÁÈÛ˘ ÂÚ˘ıÚÒÓ ÛÙË ¤Î‚·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∂› ϤÔÓ Ë ‰ÈÂÁ¯ÂÈÚËÙÈ΋ ÌÂÙ¿ÁÁÈÛË ·ÈÌÔÂÙ·Ï›ˆÓ Â›Ó·È ¤Ó·˜ ÈÛ¯˘Úfi˜ ·ÓÂÍ¿ÚÙËÙÔ˜ ‰Â›ÎÙ˘ ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÂÙ¿ ·fi Oª∏. ∏ ·ÚÓËÙÈ΋ Â›‰Ú·ÛË Ù˘ ÌÂÙ¿ÁÁÈÛ˘ ·ÈÌÔÂÙ·Ï›ˆÓ Â›Ó·È ·ÓÂÍ¿ÚÙËÙË ·fi ¿ÏÏÔ˘˜ ÁÓˆÛÙÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Î·È Â›Ó·È ÛÂ Û˘Ìʈӛ· Ì ٷ Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó Û ·ÛıÂÓ›˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û ηډÈÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ Î·È Ù· ÂÈÚ·Ì·ÙÈο ÌÔÓ٤Ϸ Oª∏. ∞˘Ù¿ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ¤¯Ô˘Ó ÎÏÈÓÈÎfi ÂӉȷʤÚÔÓ ÛÙÔ ı¤Ì· Ù˘ ¯Ú‹Û˘ ÚÔ˚fiÓÙˆÓ ·›Ì·ÙÔ˜ ÛÙËÓ Oª∏ Î·È ÙËÓ ¤Î‚·ÛË ·˘Ù‹˜. ¶ÚfiÛÊ·Ù·, ∞ÌÂÚÈηÓÔ› ÂÚ¢ÓËÙ¤˜ ·Ó·ÎÔ›ÓˆÛ·Ó fiÙÈ Û ¤ÓÙ ¯ÚfiÓÈ· ı· ÌÔÚÔ‡Ó Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó ÙÔ ÚÒÙÔ ‹·Ú ÂÚÁ·ÛÙËÚ›Ô˘ ·fi ‚Ï·ÛÙÔ·ÙÙ·Ú·. OÈ ÂÈÛÙ‹ÌÔÓ˜ «·ÔÁ˘ÌÓÒÓÔ˘Ó» ¯ËÌÈο ÙÔ ·ÏÈfi Û˘ÎÒÙÈ ·Ê‹ÓÔÓÙ·˜ ÌfiÓÔ ÙÔ ‚·ÛÈÎfi «ÂÎÌ·Á›Ի ÈÛÙÔ‡ Î·È ·ÈÌÔÊfiÚˆÓ ·ÁÁ›ˆÓ. ™ÙË Û˘Ó¤¯ÂÈ· Â¿Óˆ ÛÙÔ «Ûηڛ» ·˘Ùfi ·Ó·Ù‡ÛÛÂÙ·È ÙÔ Ó¤Ô fiÚÁ·ÓÔ Ì ÙË ¯Ú‹ÛË ‚Ï·ÛÙÔ΢ÙÙ¿ÚˆÓ ·fi ÙÔÓ ·ÛıÂÓ‹ ‹ ·fi ¤Ì‚Ú˘·. ΔÔ Û˘ÎÒÙÈ ÌÔÚ› Ó· ÌÂÁ·ÏÒÛÂÈ Ì ÙË Û˘Ó‰ÚÔÌ‹ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ›‰ÈÔ˘ ÙÔ˘ ·ÛıÂÓÔ‡˜, ÂÓÒ Î·Ù·ÚÁ› ÙËÓ ·Ó¿ÁÎË Ï‹„˘ ·ÓÔÛÔηٷÛÙ·ÏÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ Ô˘ ¯ÔÚËÁÔ‡ÓÙ·È ÁÈ· Ó· ÌËÓ ·ÔÚÚ›„ÂÈ Ô ÔÚÁ·ÓÈÛÌfi˜ ÙÔ ÌfiÛ¯Â˘Ì·. ∞Ó ÙÔ Ó¤Ô ‹·Ú ı· ÌÔÚ¤ÛÂÈ ¿ÌÂÛ· Ó· ·ÓÙÈÌÂÙˆ›˙ÂÈ ÙȘ ËÍÈÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ Ô˘ Û˘ÓÂ¿ÁÔÓÙ·È ·˘ÍË̤Ó˜ ·Ó¿ÁΘ Û ÌÂÙ¿ÁÁÈÛË ·›Ì·ÙÔ˜ Î·È ·Ú·ÁÒÁˆÓ, ·˘Ùfi ̤ÓÂÈ Ó· ‰ÈÂÚ¢ÓËı›.

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EÈÏÔΤ˜ ·fi Ù· ¯ÔÏËÊfiÚ· ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ O ÚfiÏÔ˜ Ù˘ ÂÓ‰ÔÛÎÔÈ΋˜ ·Ú¤Ì‚·Û˘ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘˜ π. ¶·¯È·‰¿Î˘

1. ‰È·Ê˘Á‹ ¯ÔÏ‹˜ ·fi ÙÔ ¯ÔÏËÊfiÚÔ ‰¤Ó‰ÚÔ-¯fiψ̷ 2. ÛÙÂÓÒÛÂȘ [·Ó·ÛÙÔ̈ÙÈΤ˜ (∞™) – Â› Ù˘ ·Ó·ÛÙfïÛ˘, Î·È ÌË ·Ó·ÛÙÔ̈ÙÈΤ˜ (ª∞™) – Û˘Ó‹ıˆ˜ ÛÙÔÓ fiÚÔ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÎÂÓÙÚÈÎfiÙÂÚ· Ù˘ ·Ó·ÛÙfïÛ˘) 3. Û˘ÁÎڛ̷ٷ (Ï›ıÔÈ, ¯ÔÏÈ΋ Ï¿ÛË, ·ÏÈÓ‰ÚÔÈ-ÂÎÌ·Á›· ¯ÔÏËÊfiÚˆÓ) 4. ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÛÊÈÁÎÙ‹Ú· ÙÔ˘ Oddi (Sphincter of Oddi Dysfunction-SOD)

OÈ ÂÈÏÔΤ˜ ·fi Ù· ¯ÔÏËÊfiÚ· Â›Ó·È Û˘Ó˘Ê·Ṳ̂Ó˜ Ì ÙËÓ ¤ÓÓÔÈ· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ (Orthotopic Liver Transplantation – OLT). Δ· ÔÛÔÛÙ¿ ÔÈΛÏÏÔ˘Ó ·Ó¿ÌÂÛ· ÛÙȘ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ ·fi 5%-35% (10%-20% Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÏÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜). ¶·Ú¿ÁÔÓÙ˜ fiˆ˜ Ô Ù‡Ô˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (Deceased Donor Liver Transplantation – DDLT vs Living Donor Liver Transplantation – LDLT vs Ï‹„Ë ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ÙÔÓ «Î·Ú‰È·Îfi ı¿Ó·ÙÔ» ÙÔ˘ ‰fiÙË ‹ split-liver vs ÔÏÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ vs ÌÔۯ‡̷ÙÔ˜ ÌÂȈ̤ÓÔ˘ ÌÂÁ¤ıÔ˘˜), Ë ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ Ù˘ ·Ó·ÛÙfïÛ˘ ÛÙ· ¯ÔÏËÊfiÚ· (ÙÂÏÈÎÔ-ÙÂÏÈ΋ vs Ï·ÁÈÔ-Ï¿ÁÈ· ¯ÔÏˉfi¯Ô-¯ÔÏˉfi¯Ô ·Ó·ÛÙfïÛË vs Roux-en-Y ¯ÔÏˉfi¯Ô-¤ÓÙÂÚÔ ·Ó·ÛÙfïÛË) Î·È Ë ÙÔÔı¤ÙËÛË ‹ fi¯È ۈϋӷ Kehr, ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ‰È·ÌfiÚʈÛË ÙˆÓ ‰È·Î˘Ì¿ÓÛÂˆÓ ÛÙ· ÔÛÔÛÙ¿ ÙˆÓ ÂÈÏÔÎÒÓ. ∂ÓÒ ·Ï·ÈfiÙÂÚ· Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈÏÔÎÒÓ ·fi Ù· ¯ÔÏËÊfiÚ· ÌÂÙ¿ OLT ‹Ù·Ó ηٿ ·ÚÈÔ ÏfiÁÔ ¯ÂÈÚÔ˘ÚÁÈ΋, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Ì ÙËÓ ÂͤÏÈÍË ÙÔ˘ ¤¯ÂÈ ÁÓˆÚ›ÛÂÈ Ë ÌË ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ú¤Ì‚·ÛË ÛÙ· ¯ÔÏËÊfiÚ· ̤ۈ ΢ڛˆ˜ Ù˘ ERCP ·ÏÏ¿ Î·È Ù˘ ·ÎÙÈÓÔÏÔÁÈ΋˜-‰È·‰ÂÚÌÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ (Percutaneous Transhepatic Cholangiography – PTC ‹ Percutaneous Transhepatic Drainage – PTD +/– stenting), ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ·˘ÙÒÓ ÙˆÓ ÂÈÏÔÎÒÓ ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ϤÔÓ ÌË-¯ÂÈÚÔ˘ÚÁÈο ÚÔ˜ ÌÂÁ¿ÏÔ fiÊÂÏÔ˜ ÙÔ˘ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓÔ˘ fiÛÔÓ ·ÊÔÚ¿ ÙË ÓÔÛËÚfiÙËÙ· Î·È ÙËÓ ıÓËÛÈÌfiÙËÙ·. ¶ÚÈÓ fï˜ ·Ó·ÊÂÚıԇ̠ÛÙȘ ‰˘Ó·ÙfiÙËÙ˜ ÂÓ‰ÔÛÎÔÈ΋˜ ·Ú¤Ì‚·Û˘ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ηÙËÁÔÚÈÔÔÈ‹ÛÔ˘Ì ÙȘ ÂÈÏÔΤ˜ ÙˆÓ ¯ÔÏËÊfiÚˆÓ ÌÂÙ¿ OLT ÙfiÛÔ Î·Ù¿ ·ÈÙÈÔÏÔÁÈÎfi ·Ú¿ÁÔÓÙ· fiÛÔ Î·È ÙÔÔÁÚ·ÊÈο Û ۯ¤ÛË Ì ÙËÓ ı¤ÛË Ù˘ ·Ó·ÛÙfïÛ˘ ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘. ∏ Ù·ÍÈÓfiÌËÛË Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ ÂÓ‰ÔÛÎÔÈ΋˜ ·Ú¤Ì‚·Û˘ Î·È Ù˘ ÚfiÁÓˆÛ˘, ΢ڛˆ˜ ÏfiÁˆ ·ıÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ‰È·ÊÔÚÒÓ.

OÈ Û˘ÓËı¤ÛÙÂÚ˜ ÂÈÏÔΤ˜ ·fi Ù· ¯ÔÏËÊfiÚ· ÌÂÙ¿ OLT ›ӷÈ:

∞˘Ù¤˜ Ù·ÍÈÓÔÌÔ‡ÓÙ·È ·ÈÙÈÔÏÔÁÈο ˆ˜ ÂÍ‹˜: ™¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ Ù¯ÓÈ΋ 1. ÙÂÏÈÎÔ-ÙÂÏÈ΋ vs Ï·ÁÈÔ-Ï¿ÁÈ· ¯ÔÏˉfi¯Ô-¯ÔÏˉfi¯Ô ·Ó·ÛÙfïÛË vs Roux-en-Y ¯ÔÏˉfi¯Ô¤ÓÙÂÚÔ ·Ó·ÛÙfïÛË 2. ¯ÚËÛÈÌÔÔ›ËÛË ‹ fi¯È ۈϋӷ Kehr 3. LDLT vs DDLT ™¯ÂÙÈ˙fiÌÂÓ˜ Ì ·ÁÁÂȷΤ˜ ‚Ï¿‚˜ – ÈÛ¯·ÈÌ›· ÙˆÓ ¯ÔÏËÊfiÚˆÓ 1. ıÚfiÌ‚ˆÛË Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ (3%-10% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ) – ۯ‰fiÓ ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Ì ª∞™ («Ì·ÎÚÔ·ÁÁÂÈÔ·ıÈ΋» ÈÛ¯·ÈÌ›·) 2. ¯ÚfiÓÔ˜ «„˘¯Ú‹˜» Î·È «ıÂÚÌ‹˜» ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ̤ۈ «ÙÚ·˘Ì·ÙÈÛÌÔ‡» ÈÛ¯·ÈÌ›·˜Â·Ó·ÈÌ¿ÙˆÛ˘ (reperfusion injury)(«ÌÈÎÚÔ·ÁÁÂÈÔ·ıÈ΋» ÈÛ¯·ÈÌ›·) 3. «··ÁÁ›ˆÛË» ÙÔ˘ ÂÚȯÔÏÈÎÔ‡ ϤÁÌ·ÙÔ˜ ηٿ ÙËÓ ·Ú·Û΢‹ Î·È Ï‹„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ («ÌÈÎÚÔ·ÁÁÂÈÔ·ıÈ΋» ÈÛ¯·ÈÌ›·) 4. §‹„Ë ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ·fi «Î·Ú‰È·Îfi ı¿Ó·ÙÔ» ÙÔ˘ ‰fiÙË (non-heart beating donors) («ÌÈÎÚÔ·ÁÁÂÈÔ·ıÈ΋» ÈÛ¯·ÈÌ›·) 5. ·ÈÌÔ‰˘Ó·ÌÈ΋ ·ÛÙ¿ıÂÈ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ™¯ÂÙÈ˙fiÌÂÓ˜ Ì ÙÔ ‰È¿Ï˘Ì· Î·È ÙËÓ Ù¯ÓÈ΋ Û˘ÓÙ‹ÚËÛ˘ ÌÔۯ‡̷ÙÔ˜ 1. University of Wisconsin solution(˘„ËÏÔ‡ ÈÍÒ‰Ô˘˜) vs Histidine-tryptophan-ketoglutarate solution (¯·ÌËÏÔ‡ ÈÍÒ‰Ô˘˜) vs Collins solution (¯·ÌËÏÔ‡ ÈÍÒ‰Ô˘˜) 2. ÌË ÂÊ·ÚÌÔÁ‹ arterial back-table pressure perfusion

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™¯ÂÙÈ˙fiÌÂÓ˜ Ì ·ÓÔÛÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ 1. ∞Û˘Ì‚·ÙfiÙËÙ· ABO 2. ÃÚfiÓÈ· ·fiÚÚÈ„Ë (ductopenic) 3. PSC ™¯ÂÙÈ˙fiÌÂÓ˜ Ì ÏÔÈÌÒÍÂȘ 1. ªÈÎÚԂȷΤ˜ 2. πÔÁÂÓ›˜ (.¯ CMV) 3. ª˘ÎËÙÈ·ÛÈΤ˜ ™¯ÂÙÈ˙fiÌÂÓ˜ Ì ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÛÊÈÁÎÙ‹Ú· ÙÔ˘ Oddi (SOD) 1. ¢˘ÛÎÈÓËÛ›· (ÏÂÈÙÔ˘ÚÁÈ΋ ‰È·Ù·Ú·¯‹) 2. Ô˘Ï҉˘ ÛÙ¤ÓˆÛË. ÃÚÔÓÈο ÔÈ ‰È·Ê˘Á¤˜ ·fi Ù· ¯ÔÏËÊfiÚ· ÂÌÊ·Ó›˙ÔÓÙ·È ÚÒÈÌ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Û˘Ó‹ıˆ˜ ÂÓÙfi˜ ÙˆÓ ÚÒÙÔ˘ 2Ì‹ÓÔ˘ (1-28 ‚‰ÔÌ¿‰Â˜, ̤ÛÔ˜ fiÚÔ˜ 12 ‚‰ÔÌ¿‰Â˜) ÂÓÒ ÔÈ ·ÔÊÚ·ÎÙÈÎÔ‡ Ù‡Ô˘ ÂÈÏÔΤ˜ (ÛÙÂÓÒÛÂȘ, ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Oddi - SOD, ÏÈı›·ÛË, ¯ÔÏÈ΋ Ï¿ÛË, ÂÎÌ·Á›· ¯ÔÏËÊfiÚˆÓ) Ù›ÓÔ˘Ó Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÙ·ÁÂÓ¤ÛÙÂÚ· (2-109 ‚‰ÔÌ¿‰Â˜, Ì.Ô 15 ‚‰ÔÌ¿‰Â˜) Ì ÛËÌ·ÓÙÈ΋ ¯ÚÔÓÈ΋ ÂÈÎ¿Ï˘„Ë fiˆ˜ Ê·›ÓÂÙ·È Î·È ÛÙÔ ·ÎfiÏÔ˘ıÔ Û¯Â‰È¿ÁÚ·ÌÌ·. ∞‰Ú¿ Ë ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙˆÓ ÂÈÏÔÎÒÓ ·fi Ù· ¯ÔÏËÊfiÚ· ÌÂÙ¿ OLT, Û˘ÓÔ„›˙ÂÙ·È ÛÙÔÓ ·Ú·Î¿Ùˆ ·ÏÁfiÚÈıÌÔ:

1. ¢È·Ê˘Á‹ ·fi Ù· ¯ÔÏËÊfiÚ· Î·È ¯fiψ̷ OÈ ‰È·Ê˘Á¤˜ ·fi Ù· ¯ÔÏËÊfiÚ· ÂÌÊ·Ó›˙ÔÓÙ·È Û 2-25% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ. ªÔÚÔ‡Ó Ó· ¯ˆÚÈÛÙÔ‡Ó Û ÚÒÈ̘ (ÂÓÙfi˜ ÙˆÓ ÚÒÙˆÓ 4 ‚‰ÔÌ¿‰ˆÓ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË) Î·È fi„È̘. OÈ ÚÒÈ̘ ‰È·Ê˘Á¤˜ ÔÊ›ÏÔÓÙ·È Î·Ù¿ ·ÚÈÔ ÏfiÁˆ Û Ù¯ÓÈΤ˜ ·ÛÙÔ¯›Â˜ ÛÙȘ ·Ó·ÛÙÔÌÒÛÂȘ ÙˆÓ ¯ÔÏËÊfiÚˆÓ Î·È Û ÈÛ¯·ÈÌÈο ·›ÙÈ·. OÈ ÂÚÈÛÛfiÙÂÚ˜ ‰È·Ê˘Á¤˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙËÓ ·Ó·ÛÙfïÛË, ÙÔ ÎÔÏfi‚ˆÌ· ÙÔ˘ ΢ÛÙÈÎÔ‡ fiÚÔ˘ ‹ ÛÙÔ ÛËÌÂ›Ô ÂÈÛfi‰Ô˘ ÙÔ˘ Kehr, ηٿ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ (·ÙÂÏÒ˜ Û¯ËÌ·ÙÈṲ̂ÓÔ Û˘Ú›ÁÁÈÔ ÛÙËÓ ÔÚ›· ÙÔ˘ Kehr). ªÂÁ¿Ï· ÂÏÏ›ÌÌ·Ù· ÛÙ· ¯ÔÏËÊfiÚ· Ì ¢¯ÂÚ‹ ‰È·Ê˘Á‹ Ù˘ ¯ÔÏ‹˜ Û MRCP ‹ ÛÎÈ·ÁÚ·ÊÈÎÔ‡ ÛÙËÓ ERCP ηٿ ·ÚÈÔ ÏfiÁˆ ÔÊ›ÏÔÓÙ·È Û ÈÛ¯·ÈÌ›· ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘ (.¯ ıÚfiÌ‚ˆÛË Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜) Î·È Â›Ó·È ‰‡ÛÎÔÏ· ·ÓÙÈÌÂÙˆ›ÛÈÌ· ÂÓ‰ÔÛÎÔÈο. OÈ ÂÚÈÛÛfiÙÂÚ˜ (84%) ‰È·Ê˘Á¤˜ ·fi Ù· ¯ÔÏËÊfiÚ· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È ÂÓ‰ÔÛÎÔÈο Ì ÛÊÈÁÎÙËÚÔÙÔÌ‹ Î·È ÙÔÔı¤ÙËÛË Ï·ÛÙÈÎÒÓ stent. ™˘Ó‹ıˆ˜ ÙÔÔı¤ÙËÛË ÂÓfi˜ Ï·ÛÙÈÎÔ‡ stent 10Fr ‹ Î·È ÌÈÎÚfiÙÂÚ˘ ‰È·Ì¤ÙÚÔ˘ ›ӷÈ

·ÚÎÂÙfi. TÔ stent ·Ê·ÈÚÂ›Ù·È ÂÓ‰ÔÛÎÔÈο ÌÂÙ¿ 612 ‚‰ÔÌ¿‰Â˜ Î·È Ë ¯ÔÏ·ÁÁÂÈÔÁÚ·Ê›· ηٿ ÙËÓ ERCP Û˘Ó‹ıˆ˜ ‰ÂÓ ·Ó·‰ÂÈÎÓ‡ÂÈ ‰È·Ê˘Á‹. ™·ÓÈfiÙÂÚ· 2-3 Û˘Ó‰ڛ˜ ·ÏÏ·Á‹˜ Ï·ÛÙÈÎÒÓ stent Â›Ó·È ··Ú·›ÙËÙ˜ ÁÈ· ÙËÓ ·ÔηٿÛÙ·ÛË Ù˘ ‚Ï¿‚˘. ∫·ıÒ˜ ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ‰È·Ê˘Á‹˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ÔÊ›ÏÔÓÙ·È ÛÙÔ Kehr Î·È ÂÓÒ Ù·˘Ùfi¯ÚÔÓ· ÙÂÏÂ˘Ù·›Â˜ ÌÂϤÙ˜ ‰ÂÓ ‰Â›¯ÓÔ˘Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÏÂÔÓÂÎÙ‹Ì·Ù· ·fi ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘, Ë Ù¿ÛË Ó· ·ÔʇÁÂÙ·È Ë Î·ıÔÏÈ΋ ¯ÚËÛÈÌÔÔ›ËÛË ÛˆÏ‹Ó· Kehr ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‚Ú›ÛÎÂÈ ÔÏÔ¤Ó· Î·È ÂÚÈÛÛfiÙÂÚÔ˘˜ ıÈ·ÛÒÙ˜. ™Â ÂÚ›ÙˆÛË ‰È·Ê˘Á‹˜ Û ·ÛıÂÓ‹ Ô˘ ¤¯ÂÈ ˘Ô‚ÏËı› Û Roux-en-Y ·Ó·ÛÙfïÛË Ë ÚÔÛ¤Ï·ÛË ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘ Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ ‰È·‰ÂÚÌÈο (PTC-PTD). ¶ÂÚÈÛÛfiÙÂÚÔ ÔχÏÔΘ ·Ó·ÛÙÔÌÒÛÂȘ ¯ÔÏËÊfiÚˆÓ fiˆ˜ ·˘Ù¤˜ Ô˘ ··ÓÙÒÓÙ·È Û LDLT ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚ˜ Èı·ÓfiÙËÙ˜ ‰È·Ê˘Á‹˜. ™˘Ó‹ıˆ˜ ¯ÔÏ‹ ‰È·Ê‡ÁÂÈ ·fi ÙËÓ ‰È·ÙÌËı›۷ ÂÈÊ¿ÓÂÈ· ÙÔ˘ ‹·ÙÔ˜ ·ÏÏ¿ Î·È ·fi ‰È¿Û·ÛË Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ó·ÛÙfïÛ˘ ‹ Î·È ÈÛ¯·ÈÌÈΤ˜ ‚Ï¿‚˜ ÙˆÓ ¯ÔÏËÊfiÚˆÓ ÏfiÁˆ ıÚfiÌ‚ˆÛ˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜ ÂÓÒ Ù¤ÏÔ˜ Û˘¯Ó‹ Â›Ó·È Î·È Ë ‰È·Ê˘Á‹ ÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË ÙÔ˘ Kehr. ™ÙȘ ÂÚÈÙÒÛÂȘ ‰È·Ê˘Á‹˜ ·fi Ù· ¯ÔÏËÊfiÚ· Û LDLT Ë ıÂÚ·¢ÙÈ΋ ÂÓ‰ÔÛÎÔÈ΋ ·Ú¤Ì‚·ÛË ‰ÂÓ ¤¯ÂÈ ‰ÒÛÂÈ È‰È·›ÙÂÚ· ÈηÓÔÔÈËÙÈο ·ÔÙÂϤÛÌ·Ù·. ƒ‹ÍË ¯ÔÏËÊfiÚˆÓ Î·È «ÂÍ·ÁÁ›ˆÛË» ¯ÔÏ‹˜, ›Ù ÂÓÙfi˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜ ›Ù Â͈Ë·ÙÈο, ÌÔÚ› Ó· ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ‰ËÌÈÔ˘ÚÁ›· Û˘ÏÏÔÁ‹˜ – ¯ÔÏÒÌ·ÙÔ˜. ÃÔÏÒÌ·Ù· Û ÂÈÎÔÈÓˆÓ›· Ì ÙÔ ¯ÔÏËÊfiÚÔ ‰¤Ó‰ÚÔ ¯Ú‹˙Ô˘Ó ‰ÈÂÓ¤ÚÁÂÈ·˜ ÂÓ‰ÔÛÎÔÈ΋˜ ÛÊÈÁÎÙËÚÔÙÔÌ‹˜ Î·È Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ (ÌÂÁ¿ÏË ‰È·Ê˘Á‹ ¯ÔÏ‹˜) Û‡Á¯ÚÔÓ˘ ÙÔÔı¤ÙËÛ˘ Ï·ÛÙÈÎÔ‡ stent (7Fr-10Fr) ÛÙÔÓ ÎÔÈÓfi ¯ÔÏˉfi¯Ô fiÚÔ. OÈ Û˘ÏÏÔÁ¤˜ ηı’ ·˘Ù¤˜ ·Ó ‰ÂÓ ˘Ô¯ˆÚ‹ÛÔ˘Ó ÌÂÙ¿ ÙËÓ ÂÓ‰ÔÛÎÔÈ΋ ·Ú¤Ì‚·ÛË ı· Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ‰È·‰ÂÚÌÈ΋ ·ÚÔ¯¤Ù¢ÛË. ªË ÂÈÎÔÈÓˆÓ›· Ì ÙÔ ¯ÔÏËÊfiÚÔ ‰¤Ó‰ÚÔ Î·ıÈÛÙ¿ ·Ó·Áη›· ÙËÓ ‰È·‰ÂÚÌÈ΋ ‹ ·ÎfiÌ· Î·È ÙËÓ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÚÔ¯¤Ù¢ÛË ÙÔ˘ ¯ÔÏÒÌ·ÙÔ˜.

2. ™ÙÂÓÒÛÂȘ ¯ÔÏËÊfiÚˆÓ OÈ ÛÙÂÓÒÛÂȘ ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘ Â›Ó·È È‰È·›ÙÂÚ· Û˘¯Ó¤˜ ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. ∞Ó¿ÏÔÁ· Ì ÙËÓ ÌÂϤÙË ÙÔ ÔÛÔÛÙfi ÔÈΛÏÏÂÈ ·fi 4% ¤ˆ˜ 16% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ Û ÂÚ›ÙˆÛË

METAMO™XEY™Eπ™ 2011

ÔÏÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi و̷ÙÈÎfi ‰fiÙË, ÂÓÒ ÙÔ ÔÛÔÛÙfi ·Ó‚·›ÓÂÈ ÛÙÔ 28%-32% Û ÂÚ›ÙˆÛË LDLT, ÚÔÊ·ÓÒ˜ ÏfiÁˆ ÂÚÈÛÛfiÙÂÚˆÓ Î·È Ù¯ÓÈο ÈÔ ‰‡ÛÎÔÏˆÓ ·Ó·ÛÙÔÌÒÛÂˆÓ ÛÙ· ¯ÔÏËÊfiÚ·.

OÈ ÛÙÂÓÒÛÂȘ ·˘Ù¤˜ ηÙËÁÔÚÈÔÔÈÔ‡ÓÙ·È Û ·Ó·ÛÙÔ̈ÙÈΤ˜ (∞™) Î·È ÌË ·Ó·ÛÙÔ̈ÙÈΤ˜ (ª∞™). OÈ ∞™ Û˘Ó‹ıˆ˜ Â›Ó·È Ô˘ÏÒ‰ÂȘ Î·È ÂÌÊ·Ó›˙ÔÓÙ·È fi„ÈÌ· ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË (∼1 ¤ÙÔ˜), ÂÓÒ ÔÈ ª∞™ ÂÌÊ·Ó›˙Ô˘Ó ÙËÓ Ù¿ÛË Ó· Â›Ó·È ÔÏÏ·Ϥ˜, ÌÂÁ·Ï‡ÙÂÚ˜ Û ̋ÎÔ˜, ÌÔÚ› Ó· ·ÊÔÚÔ‡Ó ÙÔ ÙÌ‹Ì· ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘ Ô˘ ·Ó‹ÎÂÈ ÛÙÔ ÌfiÛ¯Â˘Ì· (ÎÂÓÙÚÈÎfiÙÂÚ· Ù˘ ·Ó·ÛÙfïÛ˘) Î·È / ‹ Ù· ÂÓ‰ÔË·ÙÈο ¯ÔÏËÊfiÚ·, ÔÊ›ÏÔÓÙ·È Û ÈÛ¯·ÈÌ›· ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘ Î·È Ù›ÓÔ˘Ó Ó· ÂÌÊ·Ó›˙ÔÓÙ·È ÓˆÚ›ÙÂÚ· (ÙÔ˘˜ ÚÒÙÔ˘˜ 3-6 Ì‹Ó˜ ÌÂÙ¿ OLT).

OÈ ∞™ ÔÈ Ôԛ˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÂÓÙfi˜ 6Ì‹ÓÔ˘ ·fi ÙËÓ OLT Â›Ó·È Â˘ÎÔÏfiÙÂÚ· ·ÓÙÈÌÂÙˆ›ÛÈ̘ Ì ‰È·ÛÙÔÏ‹ Ì Ì·ÏfiÓÈ Î·È ‚Ú·¯˘ÚfiıÂÛÌË (ÁÈ· 3-6 Ì‹Ó˜). ÙÔÔı¤ÙËÛË Ï·ÛÙÈÎÒÓ stent. OÈ ÈÔ fi„È̘ ∞™ ¯Ú‹˙Ô˘Ó Â·Ó·Ï·Ì‚·ÓfiÌÂÓˆÓ (Û˘Ó‹ıˆ˜ ·Ó¿ ÙÚ›ÌËÓÔ ÁÈ· 12-24 Ì‹Ó˜) Û˘Ó‰ÚÈÒÓ ‰È·ÛÙÔÏ‹˜ Ì Ì·ÏfiÓÈ (Û˘Ó‹ıˆ˜ ̤¯ÚÈ ‰È·Ì¤ÙÚÔ˘ 6mm – 8mm) Î·È ÙÔÔı¤ÙËÛ˘ ·˘Í·ÓfiÌÂÓ˘ ‰È·Ì¤ÙÚÔ˘ Î·È ·ÚÈıÌÔ‡ Ï·ÛÙÈÎÒÓ stents ÂÓÒ ·ÎfiÌË Î·È ÌÂÙ¿ ÙËÓ ·ÔηٿÛÙ·ÛË ÈηÓÔÔÈËÙÈ΋˜ ‰È·Ì¤ÙÚÔ˘ ÙÔ˘ ·˘ÏÔ‡ ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘ Ô ·ÛıÂÓ‹˜ ı· Ú¤ÂÈ Ó· ·Ú·ÎÔÏÔ˘ıÂ›Ù·È ·ÂÈÎÔÓÈÛÙÈο (USS, MRCP) Û ٷÎÙ¿ ‰È·ÛÙ‹Ì·Ù· ÏfiÁˆ Ù˘ ·˘ÍË̤Ó˘ Èı·ÓfiÙËÙ·˜ ˘ÔÙÚÔÒÓ ·˘ÙÒÓ ÙˆÓ ÛÙÂÓÒÛˆÓ. ΔÔ ÔÛÔÛÙfi ÂÈÙ˘¯›·˜ Ù˘ ÂÓ‰ÔÛÎÔÈ΋˜ ıÂÚ·›·˜ Û ∞™ ÌÔÚ› Ó· ÊÙ¿ÛÂÈ ·ÎfiÌ· Î·È ÙÔ 90% ÂÓÒ ÔÈ ·ÔÙ˘¯›Â˜ Ô‰ËÁÔ‡ÓÙ·È Û Â·ÓÂÁ¯Â›ÚËÛË (Roux-en-Y Û ·ÛıÂÓ›˜ Ì ¯ÔÏˉfi¯Ô-¯ÔÏˉfi¯Ô ·Ó·ÛÙfïÛË ‹ hepaticojejunostomy).

OÈ ª∞™ ÔÊ›ÏÔÓÙ·È Û ÈÛ¯·ÈÌ›·, ·ÊÔÚÔ‡Ó ÙÔ ¯ÔÏËÊfiÚÔ ‰¤Ó‰ÚÔ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (ÎÂÓÙÚÈÎfiÙÂÚ· Ù˘ ·Ó·ÛÙfïÛ˘) Î·È Â›Ó·È ÈÔ ‰‡ÛÎÔÏ¿ ·ÓÙÈÌÂÙˆ›ÛÈ̘ ÂÓ‰ÔÛÎÔÈο ÏfiÁˆ ı¤Û˘ (ÛÙËÓ ‡ÏË ÙÔ˘ ‹·ÙÔ˜ ‹ Î·È ÂÓ‰ÔË·ÙÈΤ˜ ÛÙÂÓÒÛÂȘ), ÔÏÏ·ÏÒÓ ÂÓÙÔ›ÛˆÓ, ÌÂÁ¿ÏÔ˘ Ì‹ÎÔ˘˜ ÛÙÂÓÒÛÂˆÓ Î·È Û˘¯Ó¿ Ù˘ ÈÛ¯·ÈÌÈ΋˜ ÙÔ˘˜ ·ÈÙÈÔÏÔÁ›·˜. ø˜ ÂÎ ÙÔ‡ÙÔ˘ ΢ÔÊÔÚÔ‡Ó ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· ·Ó¿Á΢ ÁÈ· Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË ÏfiÁˆ Û˘Ó¯È˙fiÌÂÓ˘ ·fiÊڷ͢ ÙˆÓ ¯ÔÏËÊfiÚˆÓ Î·È ÙÂÏÈο ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (graft survival). ∏ ÂÓ‰ÔÛÎÔÈ΋ ·Ú¤Ì‚·ÛË Î·È Û ·˘ÙÔ‡ ÙÔ˘ ›‰Ô˘˜ ÙȘ ÛÙÂÓÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÂÈ fiˆ˜ Î·È ÛÙȘ ∞™ ‰È·ÛÙÔÏ‹ Ì Ì·ÏfiÓÈ (Û˘Ó‹ıˆ˜ 4mm-6mm, ÏfiÁˆ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ڋ͢ ÙÔ˘ ÈÛ¯·ÈÌÈÎÔ‡

149

ÙÔȯÒÌ·ÙÔ˜) Î·È Â·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ Û˘Ó‰ڛ˜ ·ÏÏ·Á‹˜ ·˘Í·ÓfiÌÂÓ˘ ‰È·Ì¤ÙÚÔ˘ Î·È ·ÚÈıÌÔ‡ Ï·ÛÙÈÎÒÓ stents. ™ÙȘ ª∞™ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÂÓ‰ÔÛÎÔÈ΋˜ ıÂÚ·›·˜ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Ô ·ÚÈıÌfi˜ ÙˆÓ Û˘Ó‰ÚÈÒÓ Ô˘ ··ÈÙÔ‡ÓÙ·È Â›Ó·È ·˘ÍË̤ӷ Û ۯ¤ÛË Ì ÙȘ ∞™, ÂÓÒ ÙÔ ÔÛÔÛÙfi ÂÈÙ˘¯Ô‡˜ ¤Î‚·Û˘ Â›Ó·È Û·ÊÒ˜ ¯·ÌËÏfiÙÂÚÔ (50%75%). ∏ ÏÂÈÔ„ËÊ›· (68%) ÙˆÓ ·ÛıÂÓÒÓ Ì ª∞™ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÎÙÈÓÔÏÔÁÈ΋ Âȉ›ӈÛË Ù˘ ÂÈÎfiÓ·˜ ÙˆÓ ¯ÔÏËÊfiÚˆÓ Ì ÙÔ ¯ÚfiÓÔ, ÂÓÒ ∼28% ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ̤ÛÔ fiÚÔ Û 3.7 ¤ÙË ı· ·Ó·Ù‡ÍÂÈ ÛÔ‚·Ú‹ ÁÂÊ˘ÚÔÔÈfi ›ÓˆÛË Î·È ¯ÔÏÈ΋ ΛÚÚˆÛË, ȉȷ›ÙÂÚ· ÔÈ ·ÛıÂÓ›˜ Ì ÔÏÏ·Ϥ˜ ÂÓ‰ÔË·ÙÈΤ˜ ‚Ï¿‚˜, ÂÓÒ ÙÔ˘Ï¿¯ÈÛÙÔÓ 16% ÙˆÓ ·ÛıÂÓÒÓ (¿ÏϘ ÌÂϤÙ˜ ·Ó‚¿˙Ô˘Ó ÙÔ ÔÛÔÛÙfi ̤¯ÚÈ ÙÔ 50%) ı· ¯ÚÂÈ·ÛÙÔ‡Ó Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË.

3. ∂ÏÏ›ÌÌ·Ù· Ï‹ÚˆÛ˘ ÂÓÙfi˜ ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘ ÌÂÙ¿ OLT ∂ÏÏ›ÌÌ·Ù· Ï‹ÚˆÛ˘ ÛÙ· ¯ÔÏËÊfiÚ· ÌÂÙ¿ OLT ··ÓÙÒÓÙ·È ÛÙÔ 2%-18% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ. Δ· Û˘ÓËı¤ÛÙÂÚ· Â›Ó·È Ï›ıÔÈ ‹ ¯ÔÏÈ΋ Ï¿ÛË ‹ Ù¤ÏÔ˜ ÌÈ· ¿ÏÏË Î·ÙËÁÔÚ›· «ÂÚȯÔ̤ÓÔ˘» ÙfiÛÔ ÛÙÔ ¤Íˆ- fiÛÔ Î·È ÛÙÔ ¤Ó‰Ô-Ë·ÙÈÎfi ¯ÔÏËÊfiÚÔ ‰¤Ó‰ÚÔ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÈÛ¯·ÈÌ›· ÙˆÓ ¯ÔÏËÊfiÚˆÓ (.¯. Û ıÚfiÌ‚ˆÛË Ù˘ Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜) Î·È ·›ÚÓÂÈ ÙËÓ ÌÔÚÊ‹ «ÂÎÌ·Á›Ԣ» ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘, ÙÔ ÁÓˆÛÙfi ·fi ÙË ‚È‚ÏÈÔÁÚ·Ê›· BCS-biliary cast syndrome. ™ÙËÓ ÂÚ›ÙˆÛË ‰È¿Û·ÚÙˆÓ Û fiÏÔ ÙÔ ¯ÔÏËÊfiÚÔ ‰¤Ó‰ÚÔ «ÂÎÌ·Á›ˆÓ» (BCS) Ë Û‡ÛÙ·ÛË ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ÂÚÈÏ·Ì‚¿ÓÂÈ ÎÚ˘ÛÙ¿ÏÏÔ˘˜ ¯ÔÏÂÚ˘ıÚ›Ó˘, ›Ó˜ ÎÔÏÏ·ÁfiÓÔ˘, ‚ϤÓÓË Î·È ÓÂÎÚˆÙÈÎfi ÂÈı‹ÏÈÔ ¯ÔÏËÊfiÚˆÓ ÂÓÒ Ô ·ıÔÊ˘ÛÈÔÏÔÁÈÎfi˜ Ì˯·ÓÈÛÌfi˜ ‚·Û›˙ÂÙ·È ÛÙËÓ ÈÛ¯·ÈÌ›· ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘ ›Ù ÏfiÁˆ ÂÏ·Ùو̤Ó˘ ·ÚÙËÚȷ΋˜ ·ÚÔ¯‹˜ (.¯. ıÚfiÌ‚ˆÛË Ë·ÙÈ΋˜ ·ÚÙËÚ›·˜, ¯ÂÈÚ/ÎË «··ÁÁ›ˆÛË» ÙˆÓ ¯ÔÏËÊfiÚˆÓ), ›Ù ÏfiÁˆ Ì·ÎÚÔ‡ ‰È·ÛÙ‹Ì·ÙÔ˜ «„˘¯Ú‹˜» (>12 ÒÚ˜) ‹ «ıÂÚÌ‹˜» (>48 ÏÂÙ¿) ÈÛ¯·ÈÌ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ›Ù ٤ÏÔ˜ ÏfiÁˆ ·ÈÌÔ‰˘Ó·ÌÈ΋˜ ·ÛÙ¿ıÂÈ·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜. ™ÙËÓ ÂÚ›ÙˆÛË ÌÂÌÔÓˆÌ¤ÓˆÓ «ÂÎÌ·Á›ˆÓ» ¯ÔÏËÊfiÚˆÓ, fiˆ˜ Î·È ÛÙËÓ ÂÚ›ÙˆÛË ·ÏÒÓ Ï›ıˆÓ ‹ ¯ÔÏÈ΋˜ Ï¿Û˘ ÛÙÔÓ ÎÔÈÓfi ¯ÔÏˉfi¯Ô fiÚÔ, Ë Û‡ÓıÂÛ‹ ÙÔ˘˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ¯ÔÏÂÚ˘ıÚ›ÓË, ¯ÔÏËÛÙÂÚfiÏË Î·È ÚˆÙÂ˚Ó˜ ¯ˆÚ›˜ ÓÂÎÚˆÙÈÎfi ÂÈı‹ÏÈÔ ‹ ÎÔÏÏ·ÁfiÓÔ Î·È Ë ·ıÔÊ˘ÛÈÔÏÔÁ›· ÙÔ˘˜ Û¯ÂÙ›˙ÂÙ·È Ì ÛÙÂÓÒÛÂȘ ÛÙ· ¯ÔÏËÊfiÚ· Ô˘ ÚÔηÏÔ‡Ó ‚Ú·‰Â›· ÚÔ‹ Ù˘ ¯ÔÏ‹˜ Î·È ÏÔÈÌÒÍÂȘ ‹ Î·È ‰È·Ù·Ú·¯‹ Û ÌÔÚÈ·Îfi Â›-

150

I. ¶∞Ãπ∞¢∞∫∏™

Â‰Ô Ù˘ ÂÓÂÚÁÔ‡ ÌÂÙ·‚›‚·Û˘ ÏÈȉ›ˆÓ-¯ÔÏÈÎÒÓ ·Ï¿ÙˆÓ ÛÙËÓ ÌÂÌ‚Ú¿ÓË ÙÔ˘ Ë·ÙÔ΢ÙÙ¿ÚÔ˘ Ô˘ ¤Ú¯ÂÙ·È Û Â·Ê‹ Ì ٷ ÂÓ‰ÔË·ÙÈο ÌÈÎÚÔÛÎÔÈο ¯ÔÏËÊfiÚ· (MDR3 gene, BSEP bile salt export pump) ηٿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∞Ê·›ÚÂÛË-ÏÈıÔÙÚÔ„›· ÌÂÌÔÓˆÌ¤ÓˆÓ Ï›ıˆÓ Î·È ¯ÔÏÈ΋˜ Ï¿Û˘ Ì ERCP Î·È ÛÊÈÁÎÙËÚÔÙÔÌ‹ ¤¯ÂÈ ı·̷ÙÈο ·ÔÙÂϤÛÌ·Ù· (∼90% ·ÎÙÈÓÔÏÔÁÈ΋, ‚ÈÔ¯ËÌÈ΋ Î·È ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË), fï˜ ¤Ó· 17%-24% ÙˆÓ ·ÛıÂÓÒÓ ı· ˘ÔÙÚÔÈ¿ÛÔ˘Ó Î·È ı· ¯ÚÂÈ·ÛÙÔ‡Ó ‰Â‡ÙÂÚË ‹ Î·È ÙÚ›ÙË Û˘Ó‰ڛ· ERCP. ™ÙËÓ ÂÚ›ÙˆÛË BCS (2,5% ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ) Ë ÂÓ‰ÔÛÎÔÈ΋ ·ÓÙÈÌÂÙÒÈÛË Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÂÚ›ÏÔÎË – ÔÏÏ·Ϥ˜ Û˘Ó‰ڛ˜ ERCP Ì ÛÊÈÁÎÙËÚÔÙÔÌ‹, ·Ê·›ÚÂÛË Ï›ıˆÓ Ì Ì·ÏfiÓÈ Î·È basket ¯ÔÏËÊfiÚˆÓ, ÂÎχÛÂȘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘ – ¯ÚÔÓÔ‚fiÚ· Î·È Û·ÊÒ˜ Ôχ ÏÈÁfiÙÂÚÔ ·ÔÙÂÏÂÛÌ·ÙÈ΋ (ÛÙËÓ Î·Ï‡ÙÂÚË ÂÚ›ÙˆÛË 60% ÂÈÙ˘¯‹˜ ·ÔÛ˘ÌÊfiÚËÛË ÙÔ˘ ¯ÔÏËÊfiÚÔ˘ ‰¤Ó‰ÚÔ˘ Ô˘ ·ÎÔÏÔ˘ı‹ıËΠ·fi ·ÎÙÈÓÔÏÔÁÈ΋, ‚ÈÔ¯ËÌÈ΋ Î·È ÎÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË Ì ÌÂȈ̤ÓË Èı·ÓfiÙËÙ· ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÂÏ·Ùو̤ÓË ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÌÂÙ·ÌÔÛ¯Â˘Ì¤ÓˆÓ).

4. ¢˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÛÊÈÁÎÙ‹Ú· ÙÔ˘ Oddi (SOD – Sphincter of Oddi Dysfunction) ªÂÙ¿ OLT 2%-7% ÙˆÓ ·ÛıÂÓÒÓ ı· ÂÌÊ·Ó›ÛÔ˘Ó SOD, ›Ù ÏfiÁˆ ‰˘ÛÎÈÓËÛ›·˜ ÙÔ˘ ÛÊÈÁÎÙ‹Ú· (? «·ÔÓ‡ڈÛË», ? ÔÚÌÔÓÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ ÙÔ˘ ÛÊÈÁÎÙ‹Ú· ηٿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË), ›Ù ÏfiÁˆ Ô˘ÏÒ‰Ô˘˜ ÛÙÂÓÒÛˆ˜ ·˘ÙÔ‡ (¯ÂÈÚ/ÎÔÈ ¯ÂÈÚÈÛÌÔ›, ‰È¤Ï¢ÛË ¯ÔÏfiÏÈıÔ˘, ·‰ÂÓÔÌ˘ˆÌ¿ÙˆÛË). OÈ ·ÛıÂÓ›˜ ÂÌÊ·Ó›˙Ô˘Ó ·ÂÈÎÔÓÈÛÙÈο ÔÌÔÈfiÌÔÚÊË ‰È¿Ù·ÛË ÙÔ˘ ¯ÔÏˉfi¯Ô˘ fiÚÔ˘, ¯ˆÚ›˜ ÂÏÏ›ÌÌ·Ù· Ï‹ÚˆÛ˘ ÂÓÙfi˜ ·˘ÙÔ‡, ‰È·Ù·Ú·¯‹ Ù˘ Ë·ÙÈ΋˜ ‚ÈÔ¯ËÌ›·˜ ¯ˆÚ›˜ ÛÙÔȯ›· (ÈÛÙÔÏÔÁÈο) ·fiÚÚȄ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, Î·È ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ô˘ ÔÈΛÏÏÂÈ ·fi ·Û˘Ìو̷ÙÈ΋ ÔÚ›· ̤¯ÚÈ ÎÔÏÈÎfi ¯ÔÏËÊfiÚˆÓ Î·È ¯ÔÏ·ÁÁ›Ùȉ·. ∏ ıÂÚ·›· Û˘ÓÔ„›˙ÂÙ·È Û ÂÓ‰ÔÛÎÔÈ΋ ÛÊÈÁÎÙËÚÔÙÔÌ‹ Î·È ÙÔÔı¤ÙËÛË Ï·ÛÙÈÎÔ‡ stent (ηٿ ÚÔÙ›ÌËÛË ¯ˆÚ›˜ Ì·ÓÔÌÂÙÚ›· Ë ÔÔ›· ·˘Í¿ÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ Èı·ÓfiÙËÙ· ÂÈÏÔÎÒÓ). ™˘ÓÔÙÈο ÏÔÈfiÓ ·Ó·Ê¤ÚıËÎ·Ó ÔÈ Û˘¯ÓfiÙÂÚ˜ ÂÈÏÔΤ˜ ·fi Ù· ¯ÔÏËÊfiÚ· ÌÂÙ¿ ·fi ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ÔÈ Ôԛ˜ Û¯ÂÙ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜. ñ μ·ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Â›Ó·È Ë ÈÛ¯·ÈÌ›· ÙˆÓ ¯ÔÏËÊfiÚˆÓ ÏfiÁˆ ·ÁÁÂÈ·ÎÒÓ ÂÈÏÔÎÒÓ Î·È Ô «ÙÚ·˘Ì·ÙÈÛÌfi˜» ÈÛ¯·ÈÌ›·˜-Â·Ó·ÈÌ¿ÙˆÛ˘.

ñ ∞ÓÔÛÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ê·›ÓÂÙ·È Â›Û˘ fiÙÈ ·›˙Ô˘Ó ·ıÔÁÂÓÂÙÈÎfi ÚfiÏÔ. ñ ∏ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÚÈÛÛÔÙ¤ÚˆÓ ·fi ·˘Ù¤˜ ÙȘ ÂÈÏÔΤ˜ ÌÔÚ› Ó· Á›ÓÂÈ ÌË-¯ÂÈÚÔ˘ÚÁÈο Ì ÂÓ‰ÔÛÎÔÈ΋ (ERCP) ‹ ‰È·‰ÂÚÌÈ΋ (PTCPTD) ·Ú¤Ì‚·ÛË. ñ ∏ ıÂÚ·¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙˆÓ ÂÈÏÔÎÒÓ ·˘ÙÒÓ ··ÈÙ› ηϋ Û˘ÓÂÚÁ·Û›· Á·ÛÙÚÂÓÙÂÚÔÏfiÁˆÓ, ÌÂÙ·ÌÔÛ¯Â˘ÙÒÓ ¯ÂÈÚÔ˘ÚÁÒÓ, ·ÎÙÈÓÔÏfiÁˆÓ Î·È ·ıÔÏÔÁÔ·Ó·ÙfïÓ. ñ ¶·Ú¿ ÙȘ fiÔȘ ÚÔÛ¿ıÂȘ ÂÚ›Ô˘ ÙÔ 50% ÙˆÓ ·ÛıÂÓÒÓ Ì ÌË-·Ó·ÛÙÔ̈ÙÈΤ˜ ÛÙÂÓÒÛÂȘ ÙÂÏÈο ı· ¯ÚÂÈ·ÛÙÔ‡Ó Â·Ó·ÌÂÙ·ÌfiÛ¯Â˘ÛË.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Ayoub WS, Esquivel CO, Martin P. Dig Dis Sci. 2010; 55(6): 1540-6.

2. Pfau PR, Kochman ML, Lewis JD, Long WB, Lucey MR, Olthoff K, Shaked A, Ginsberg GG. Gastrointest Endosc. 2000; 52(1): 55.

3. Sotiropoulos GC, Sgourakis G, Radtke A, Molmenti EP, Goumas K, Mylona S, Fouzas I, Karaliotas C, Lang H. Transplantation. 2009; 87(11): 1672.

4. Fung JJ, Eghtesad B, Patel-Tom K. Liver Transpl. 2007; 13(12): 1633.

5. Gor NV, Levy RM, Ahn J, Kogan D, Dodson SF, Cohen SM. Liver Transpl. 2008; 14(10): 1466.

6. Cillo U, Burra P, Norberto L, D’Amico D. Liver Transpl.

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8. Pascher A, Neuhaus P. J Hepatobiliary Pancreat Surg.

2006; 13(6): 487.

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10. Verdonk RC, Buis CI, van der Jagt EJ, Gouw AS, Limburg AJ, Slooff MJ, Kleibeuker JH, Porte RJ, Haagsma EB. Liver Transpl. 2007; 13(5): 725-32.

11. Gor NV, Levy RM, Ahn J, Kogan D, Dodson SF, Cohen SM. Liver Transpl. 2008; 14(10): 1466-72.

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13. Linhares MM, Gonzalez AM, Goldman SM, Coelho RD, Sato NY, Moura RM, Silva MH, Lanzoni VP, Salzedas A, Serra CB, Succi T, D’Ippolito G, Szejnfeld J, Triviño T. Transplant Proc. 2004; 36(4): 947.

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Artificial and Bioartificial Liver Support F. Saliba

Despite a great improvement in the field of transplantation, the mortality in patients developing hepatic failure remains very high and many patients are dying awaiting liver transplantation mainly due to scarcity of organ donors.

Since the late fifty’s, a major interest has been the replacement of the liver by extracorporeal systems that may provide or allow time for a spontaneous recovery of the liver and more recently, since the development of liver transplantation, for a bridge to transplantation until an appropriate donor is available.

out the use of multiple devices. However, despite the great development of the devices in the recent years, the concept of bioartificial livers have still major limitations: – the synthetic capacity is very poor and clinically not sufficient, – the systems have more than one hollow fiber membrane therefore the mass exchange between the patients blood and the extracorporeal liver cells is limited, – the blood flow rate of 150 to 300 ml/mn is very low in comparison to the anatomic liver blood flow, – the liver mass cells incorporated in the devices (2 to 3% of the liver mass) not sufficient in contrast with lessons learned from living donor transplantation, – the viability of the cells is limited in time.

Despite the fact that major advances were made to avoid the risk of transmission of porcine endogenous retroviruses (PERV) from pig hepatocyes and the risk of cancer cell lines to transmit some portions of DNA or RNA that could promote cancer growth in the patient, many questions about biochemical, immunological and metabolical incompatibilities and the risk of xenozoonosis remained uncertain. There are currently few BAL devices in clinical trials.

Bioartificial Liver Support Delives(BAL) BALs are essentially bioreactors, with embedded hepatocytes (liver cells) that perform the functions of a normal liver. Bioreactors can provide a favorable growth and metabolic environment, mass exchange and immunological isolation as a platform. Several types of BALs are being developed, including hollow fiber systems, flat membrane sheet systems and spheroid bioreactors. Several cell types have been used mainly primary hepatocytes, immortalized cell lines and stem cells. Human line of normal hepatocytes is not available for various reasons: the regenerative capacity of human hepatocytes is limited in vitro, hepatocytes dedifferenciate in culture system and loose their normal function, hepatocytes loose their gap junction when cultured and therefore decrease their function. For these reasons, only human tumor hepatocyte line or porcine hepatocytes are available. Primary porcine hepatocytes are the most commonly used in devices but cells isolated from rabbit, canine and rodent species were also experimented.

The advantages of using a BAL, over other dialysis-type devices is that metabolic functions (such as lipid and plasma lipoprotein synthesis, regulation of carbohydrate homeostasis, production of serum albumin and clotting factors…), in addition to detoxification, can be replicated with-

The Extracorporeal Liver Assist Device (ELAD®) The ELAD® (Vital Therapies Inc., San Diego, CA) uses hepatocytes derived from human liver (immortalized C3A cell line) which is derived from hepatoblastoma cell line hepG 2. The C3A cells have demonstrated experimentally capacity of synthesis of albumin, factor V, transferrin, antithrombin III, C3 complement, alpha-1 antitrypsin and alpha foetoprotein as well as the ability to metabolize galactose and lidocaine. An early report of its use in patients with fulminant liver fail-

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ure in a randomized trial has shown mixing results with some improvement in neurological condition of the patients but no clear improvement in survival. Phase II/III clinical trials in patients with fulminant hepatic failure and decompensated chronic liver diseases are currently undergoing.

The HepatAssist 2000 System (Arbios Systems Inc., formerly Circe Biomedical, Watham, MA) and HepaMate (HepaLife Technologies, Boston, MA) The HepatAssist system uses a hollow fiber bioreactor embedded with 7 billion porcine hepatocytes, a combined oxygenator and blood warmer and a charcoal column. A phase I clinical trial performed in ten patients with fulminant liver failure showed neurogical improvement and safety of the device. A prospective randomized phase III clinical trial that included 171 patients (147 with acute liver failure and 24 with primary non graft function of the liver) didn’t show significant difference in 1 month survival in the whole population (62% in the control arm versus 71% in the treated arm).

However, there was a significant 30-day survival benefit in acetaminophen induced hepatitis, viral and drug induced hepatitis, and fulminant liver failure (delay between jaundice and development of encephalopathy <2 weeks) compared to subacute liver failure. The hepatAssist second generation more recently called HepaMate (HepaLife Technologies, Boston, MA) is a new generation of the HepatAssist system that provides 15 billion cryopreserved porcine liver cells; a phase III clinical trial is pending.

Other bioartificial devices – The Modular extracorporeal Liver Support (MELS, Charité Virchow Clinic, Berlin, Germany) consists of a CellModule bioreactor composed of four independently functionning hollow fiber capillary compartments which contains primary porcine hepatocytes, a DetoxModule enabling albumin dialysis and a conventional dialysis module. In a phase 1 trial, eight patients who had continuous liver support for a period of 8 to 46 hours improved and were successfully transplanted.

– The Amsterdam Medical Centre Bioartificial liver (AMC-BAL, Amsterdam, Netherlands)

uses porcine hepatocytes bound to a spiralshaped polyester fabric with integrated hollow fibers. The system was evaluated for safety in a phase 1 trial in 12 patients with acute liver failure awaiting liver transplantation. 11 was succesfully bridged to transplantation.

– The Bioartificial Liver Support System (BLSS®, Excorp Medical Inc., Mineapolis, USA) uses hollow fiber cartridge embedded with 100g of primary porcine hepatocytes. The system has demonstrated its safety in a phase 1 trial treating 4 patients.

– Several other bioreactors as well as in vivo systems for human hepatocyte expansion are under development for future bioartificial liver support.

Artificila Liver Support Devices Since the late fifty’s, many non-biologic liver support therapies based on detoxification of the patient’s blood were developed and tested in patients with acute liver failure and cirrhotics with hepatic encephalopathy. These included charcoal perfusion, hemadsorption with non-biologic adsorbents, plasma or blood exchange, plasmapheresis, continuous veno-venous hemofiltration or hemodiafiltration, onlinehemodialysis and high-flux hemodialysis. Most of these devices aimed to decrease abnormal middle molecular weight substances suspected of playing an etiological role in the pathogenesis of cerebral oedema and showed in some cases, a transient neurological improvement but no improvement in survival. The causes of failures of these treatments was probably multifactorial: a) they were not able to favor regeneration and replace the synthetic functions of the liver; b) liver regeneration is probably not a constant event after fulminant hepatitis and when it occurs, may be insufficient as it is observed in patients with subacute hepatitis who developed poorly efficient nodules of regeneration.

The Liver Dialysis Unit (formerly BioLogicDT, HemoCleanse, Lafayette, Indiana) The system uses a cation exchange resin in addition to charcoal. A randomized controlled trial, conducted in several centers with Biologic-DT sorbent-suspension dialyser, enrolled 56 patients with acute hepatic encephalopathy (grade II-IV).

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These patients had either acute liver failure or an acute on chronic liver disease. The duration of each course was 6 hours. Liver dialysis significantly improved the incidence of positive outcome (recovery of hepatic function or improvement for liver transplantation) of patients with acute on chronic liver disease versus controls (71.5% vs.

35.7 %, p=0.03). But in the group of fulminant hepatitis, there was not significant improvement of the outcome versus the control group. The overall survival was 51.6%. The FDA approved Liver Dialysis Unit for the treatment of hepatic encephalopathy in 1997. It’s not currently marketed in the USA as it is being redesigned.

The Concept of albumin dialysis Human serum albumin is an important antioxidant, drug carrier and transporter for endogenous and physiological anions like bilirubin, bile salts, long chain fatty acids, nitric oxide and a variety of other substances. The transport function for liver toxins makes albumin an interesting target for liver detoxification research. Introduced in 1993 by Mitzner and Stange, albumin dialysis aimed to specifically clear albumin-bound toxins from the blood of patients with liver failure. They showed a clear link between the removal of albumin-bound toxins and clinical improvement in different forms of acute and chronic liver disease. To date, the most widely developed and used system has been the Molecular Adsorbents Recirculating System MARS ® (Gambro AB, Lund, Sweden) that use albumin dialysis to mainly replace the excretory and detoxification function of the liver.

The Molecular Adsorbent Recirculating System (MARS®) The system is based on the dialysis of blood with a membrane separation system coated albumin which enables the exchange of water soluble and protein bound toxins by an albumin-coated membrane and recycled protein containing dialysate. The system has three different fluid compartments: a blood circuit, a 600ml of 20% human serum albumin circuit with a charcoal and an anion exchange resin columns and a dialysate circuit. MARS® requires a standard dialysis machine to control the blood and dialysate circuits.

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Clinical applications of MARS® The MARS® has been widely used in the ICU in most clinical situations of hepatic failure. The main indications of treatment with MARS® are now better established but that they still need further validation; they are summarized in table 1.

Table 1: Common situations and indication groups for use of MARS® therapy in the reported literature.

1. Acute Liver Failure 2. Acute Decompensation of a Chronic liver Disease Complicated by progressive jaundice Complicated by hepatic encephalopathy Complicated by renal dysfunction 3. Intractable pruritus in cholestasis 4. Acute intoxication or overdose with substances potentially bound to albumin 5. Other indications • After liver transplantation – Primary non function or primary dysfunction of the graft – Acute decompensation of the graft (disease recurrence, chronic rejection…)

• Acute hepatic failure after major hepatectomy • Secondary liver failure or multi-organ failure

1. MARS® in Acute Liver Failure (ALF) Several authors reported about treatment with MARS of patients with ALF (table 1). MARS has been shown to improve both biochemical and clinical manifestations of ALF by removing both water-soluble and protein-bound toxins. Few authors assessed the effectiveness of MARS to treat the cardio-circulatory associated syndrome, induced by the severity of liver disease, by monitoring hemodynamics and evaluating nitrous oxide (NO), TNF-· and cytokines removal.

Impact of MARS on systemic and cerebral haemodynamics in patients with ALF Schmidt and colleagues randomized 13 patients with ALF due to acetaminophen (n=10), Hepatitis B (HBV, n=2) and disulfram (n=1): eight received MARS therapy and 5 received standard medical treatment (SMT) with cooling to match hypothermia induced by MARS. They assessed the effects of a single 6-hour MARS treatment on hemodynamics, oxygen consumption and biochemical profile. Cardiac index decreased by 20% in the MARS group and by 7% in the control group (p=0.0007). SVRI increased by 46% in the MARS group during the 6-hour treatment versus a 6% increase in the controls (p< 0.0001). Mean arterial pressure (MAP) also increased in the MARS

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group from 69±5 mmHg to 83±11 mmHg (p< 0.0001), while MAP was unchanged in controls.

Oxygen consumption decreased by 22% (p<0.05) in the MARS group while there was no significant change in the control group. Compared to baseline, there were significant reductions in bilirubin, creatinine, and urea (p< 0.05) but not in ammonia in the MARS group. Survival was 60%, not different between the MARS and control patients.

Tsai and colleagues reported, in a case series of 10 consecutive patients with ALF due to HBV, significant improvement in hepatic encephalopathy grading (p<0.001), mean arterial pressure (p<0.001), plasma rennin activity (p=0.02), ammonia (p=0.001), bilirubin and creatinine levels (p<0.001). Three patients were alive and one patient received a liver transplant.

Lai and colleagues reported 10 consecutive patients admitted with ALF and Grade III/IV hepatic encephalopathy (paracetamol 8, NANB 1, isoniazid 1) who were treated with MARS for 8 hours on two consecutive days. During the first MARS treatment there was a significant increase in systemic vascular resistance index (SVRI) from 1114±196 to 1432±245 dyn/cm5/m2, p=0.02) with a reduction in cardiac index from 5.5±0.6 to 4.2±0.4 l/min/m2, p=0.01). The changes were maintained between the start of the first and second sessions but not to the end of second. No significant changes in MAP or intracranial pressure, as measured by reverse jugular bulb saturation, were noted. Three patients (30%) survived without liver transplantation; two died after liver transplantation.

Pugliese et al reported hemodynamics after each session treatment of 83 patients with ALF from which 39 were affected by fulminant hepatic failure (14 hyperacute, 11 subacute, 14 acute); 16 by primary nonfunction of the graft; 21 by delayed function of the graft; and 7 after hepatic resection.

They found significant improvement, when compared respectively prior and at the end of treatment session with MARS, of MAP (56±9.7 and 82±6.2 mmHg), SVRI (745±29.6 and 1330±41 dyn/cm5 /m 2 ) and Pulmonary vascular resistance index (PVRI = 260±40 and 82±11.1 dyn/cm5/m2). The same authors reported on three patients with ALF (due to HBV in two cases and acetaminophen in the other one) with a Glasgow Coma Score (GCS) <8 and under mechanical ventilation who had an

invasive monitoring of intracranial pressure. The patients received MARS treatments every day after their admission to liver transplantation. After MARS therapy the ICP decreased on average from 21 to 7 mm Hg. Significant hemodynamic modifications were not observed and their neurological conditions improved.

Impact of MARS on survival in patients with ALF Since the early period of clinical development of MARS in 1999, several authors reported on patients with acute fulminant hepatic failure treated with MARS. Different etiologies of ALF have been treated with MARS. Beyond the improvements described previously in this chapter, in encephalopathy, hemodynamics, cerebral perfusion pressure, intracranial pressure, liver and renal biological parameters, we reviewed most available studies including patients with ALF regarding outcome and survival with and without transplantation.

Felldin and colleagues treated 10 patients with ALF with MARS. 7/10 patients (70%) were alive (2 patients without liver transplantation and 5 patients after transplantation).

Doria et al reported on seven adult patients affected by fulminant hepatic failure underwent seven courses (one to five sessions each, 6 hr in duration) of MARS. Six of the seven patients (85.7%) survived. Four patients (57%) were successfully bridged (two patients in 1 day and two other patients in 4 days) to liver transplantation, while two (5%) recovered fully without transplantation.

Lee et al have reported similar outcomes with MARS in a serie of 13 patients with drug-induced ALF treated with 40 sessions; they observed a statistically significant reduction in total and conjugated bilirubin after a single MARS treatment (p< 0.006). All patients satisfied the criteria for urgent liver transplantation. Only one patient received a liver transplantation from a live donor (right lobe). Overall mortality was 85%. Median time-to-death from the start of MARS was 8 days.

Camus and colleagues observed in 22 patients who had acute liver failure with the criteria of liver transplantation a 32% recovery after MARS® therapy avoiding the need of transplantation. The twenty-two patients received 56 MARS treatments

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(median: 2 sessions; mean duration 7.6±2.6h).

They were either listed for LT (n=14), delayed (n=1), or not listed (contra-indication, n=7). Following MARS dialysis, the authors observed an improvement in the grade of hepatic encephalopathy (p=0.02) and the Glasgow coma score (p= 0.02), a decrease in conjugated bilirubin (p=0.05) and INR (p=0.006), and an increase in prothrombin index (p=0.005). Overall, liver function improved in seven patients (32%): four listed patients in whom transplantation could be avoided and three patients among those not listed due to contra-indications. Transplant-free recovery was more frequent than expected.

Sein Anand et al treated 14 patients with ALF due to an acute intoxication with Amanita phalloides with 26 MARS sessions. Ten patients (71%) recovered, one was transplanted and three patients at the age from 68 to 79 (average 72.6) years died because of acute liver failure (21.4% cases).

Koivusalo et al reported on 56 patients with ALF (29 toxic ie. paracetamol, mushroom poisoning; 22 unknown and 5 others). Mean number of treatment was 3 sessions per patient with a targeted duration of 22 hours/session. The 6-months and 1year survival rate were respectively 88% and 84%. Transplant free survival rate was 79% at 1year and liver transplantation was performed in 17 patients, with a 1-year survival rate of 94%.

From the same group, Kantola and colleagues reported later their series of 113 patients with ALF, treated with MARS between 2001 and 2007, and compared them to an historical control group of 46 ALF patients treated without MARS between 1995 and 2001. Overall survival of transplanted patients was 94% in the MARS group and 77% in the control group (p=0.06). Without transplantation, survival was 66% and 40% (p=0.03), respectively. However, the etiological distribution of ALF differed significantly between the groups.

In ALF patients with unknown etiology, groups were comparable at baseline; 91% and 69% of transplanted patients survived the MARS and control groups and the native liver recovered in 20% and 8% of the patients, respectively. Of the originally non-encephalopathic patients of unknown etiology, 36% underwent liver transplantation in the MARS group compared to 100% in the control group. This emphasized the need to treat at an

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earlier stage these patients.

Pugliese, Novelli and colleagues reported on 43 patients with fulminant hepatitis with a mean age 29.5 (range 3-56) who underwent a continuous MARS treatment. Thirty one of the 43 patients (72%) survived: 17 went to the transplant while 14 have continued extracorporeal method for a maximum period of 17 days indicating a positive resolution of the clinical condition. When an improvement of GCS (from 7-8 to 10-11), lactates levels<3mmol/L, serum sodium (135-142 mg/dl), SIRS and a change in hemodynamic instability from hyperkinetic to normal kinetic condition between 24 and 36 hours with the treatment MARS was obtained, the authors decided to continue extracorporeal treatment. Twelve patients have died, including 3 before and nine after transplantation.

We underwent a randomized controlled multicenter, open-label, parallel-assignment, efficacy study trial in France comparing albumin dialysis with MARS, initiated within 12 hours of randomization, with conventional medical treatment in patients with fulminant (FHF) or subfulminant acute hepatic failure. Patients had to fulfill the definition of fulminant or subfulminant hepatic failure and must have the Clichy or King’s College criteria in order to be included and randomized in the study. Patients were stratified according to paracetamol (P) etiology (63 P, 39 non-paracetamol [NP]), Importantly, 75% of the study patients underwent transplantation within 24 hours and 90% within 48 hours due to the effective transplantation system in France. Hence, although 110 patients were randomized, 7 patients in the MARS group received a liver transplantation before any MARS therapy was given, and another 7 after only limited MARS (less than 4 hours treatment). A trend towards MARS benefit was seen in 6-month survival, the primary endpoint, although this difference lacked significance (84.9% MARS vs 75.5% conventional treatment group; p= 0.28).

When analysed according to cohort, P patients with FHF showed a more pronounced trend than NP patients with FHF. Overall transplant-free survival did not differ between groups, although the P group showed a trend towards MARS benefit. However, univariate analysis according to the number of MARS sessions showed a highly significant benefit in patients who received 3 or more treatments

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(p<0.0001). Patients in the MARS groups also had significantly improved renal and hepatic function. In a multivariate analysis, treatment with 3 or more MARS sessions was associated with a significantly increased relative risk of 6-month transplant-free survival (RR 6.3, p<0.01). MARS treatment also significantly reduced platelet counts, but this was not associated with significantly increased bleeding adverse events. Rates of adverse events and serious adverse events were similar for the MARS and conventional treatment groups.

2. MARS® in patients with an acute decompensation of a chronic liver disease The MARS® has already been the object of three prospective randomized studies to evaluate the short-term benefits. Mitzner S and colleagues randomized 13 patients with hepato-renal syndrome, 8 in the MARS group and 5 in a control group. The mortality was 100% in the control group and 75 % in the MARS treated group (p < 0.01), effectiveness was also demonstrated by the increase in arterial pressure, the urinary volume, and the decrease in creatininemia and bilirubinemia. In a second clinical trial, Heemann U. and colleagues randomized 24 patients with severe cholestasis (bilirubin > 20 mg/dl) not improving after 3 to 5 days of standard medical therapy (SMT) in two groups SMT versus SMT+MARS. The determining factors for acute decompensation were infection, drug intoxication, and hemorrhage or alcohol abuse. The results showed a significant difference (p < 0.05) in the 30-days survival rate in favor of the MARS group: 6 deaths in the SMT group (survival = 50 %) and only one death in the MARS group (survival = 91 %). The effectiveness was also shown on hepatic-encephalopathy, bilirubinemia, biliary acids, arterial pressure and the creatininemia. More recently, the results of a prospective randomized multicenter study including 70 patients with grade 3 and 4 hepatic encephalopathy have been reported with a primary objective of decreasing by two stages the degree of encephalopathy after five days of therapy. The study showed a significant improvement in the degree of encephalopathy respectively in 64% of the patients treated with MARS and 38% of the control group (p= 0.04). Particularly, MARS has significantly reduced ammonia levels.

Other uncontrolled studies have shown a bene-

ficial effect of the MARS in severe cholestatic liver disease, acute alcoholic hepatitis, hypoxic liver, and graft dysfunction after liver transplantation. Parés et al reported the spectacular effect of MARS on refractory pruritus in patients with primary biliary cirrhosis. Finally, a european multicenter randomized study has been performed in patients with an acute decompensation of chronic liver disease comparing MARS therapy to control has just been ended. The results are expected to give more insight about therapeutical strategies in this field.

Fractionated Plasma Separation and Adsorption (FPSA, Prometheus®) The Prometheus system (Fresenius Medical Care AG, Hamburg, Germany) is based on the concept of fractionated plasma separation and adsorption (FPSA). Albumin-bound substances are directly removed from the blood by special adsorber (albumin permeable polysulfon filter). The AlbuFlow membrane allows the passage of a plasma fraction containing patients’ albumin. Molecules up to 68 kD (size of albumin) pass from the blood side into a secondary circuit. This fraction is passed over two sorbent columns (a neutral resin and an anion exchanger) to achieve removal of albumin-bound toxins from the albumin. The fraction is then passed back to the blood. The whole blood is then dialyzed while passed through a high flux-dialyzer and returned to the patient. Rifai and colleagues described 11 cirrhotic patients with acute liver failure being treated with Prometheus.

Baseline bilirubin was 446±286 Ìmol/L. Average treatment time was 5±1 hours. There was an insignificant trend towards a decrease in total bilirubin (reduction rate (RR) 21%), a significant decrease in creatinine, urea, ammonia, bile acids, conjugated bilirubin, while unconjugated bilirubin and cholinesterase increased significantly. No significant clinical changes were reported for hepatic encephalopathy, Child and Glasgow coma scores. Coagulation problems/clotting were reported in 36% of cases (4/11). The thirty day-survival rate was 36% (4/11) and the hospital-survival rate was 27% (3/11). Evenepoel and colleagues treated nine patients with acute on chronic liver failure with Prometheus® for three consecutive days. A significant decrease of urea, creatinine, total bili-

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rubin, bile acids was observed and particularly a decrease in serum albumin concentration (30.2± 1.6 – 27.4± .7 g/L, p=0.055). A large multicenter randomized trial has been performed in Europe in patients with acute decompensation of a chronic liver disease. The results have not been yet communicated or published.

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were found among SPAD, MARS, and CVVHDF with respect to other water-soluble substances.

SPAD induced a significantly greater reduction in bilirubin levels than MARS. Reductions in bile acid levels were similar for SPAD and MARS. In another in vitro comparison between single pass albumin dialysis vs. recirculation (MARS), MARS was the more effective kind of albumin dialysis for bile acids. In addition, with SPAD, an improvement of efficacy can be reached only by dramatic increase of the costs.

The Single-Pass Albumin Dialysis (SPAD) is another method of albumin dialysis that uses standard renal replacement therapy system without an additional perfusion pump system. The patient’s blood flows through a circuit containing a highflux hollow fiber hemodiafilter. The other side of this membrane is cleansed by an albumin dialysate flowing in the counter-direction; this solution is discarded after passing the filter. This solution is prepared by bicarbonate buffered 4.5 liters’bag, 1 liter is replaced by 1 liter of 20 % human albumin solution resulting in a 44 g/ albumin concentration with a slow dialysate flow rate (1-2 Liters/hour).

This technique is similar to continuous veno-venous hemofiltration; the difference is the dialysate composition and the time of treatment. Only few single cases of SPAD use have previously been reported. The technique has been applied to a young patient with fulminant Wilson disease. After the first six treatments, the authors observed improvement of the clinical condition, the renal function and regression of hemolysis. In total, 35 treatments were performed in this patient before liver transplantation. Moreover, three cirrhotic patients were treated long-term, resulting in two successful transplantations and one patient dying from sepsis after 140 days. Significant removal of bilirubin and copper was observed.

In recent years, there has been a considerable interest in the use of newer forms of liver support that may provide a bridge until a spontaneous recovery of the liver or until an appropriate donor is available for transplantation.

Few bioartifical systems are being investigated clinically but main problems including cell availability, maintenance of cell viability and functionality throughout treatment, hepatocyte culture, cryopreservation, safety and ethical issues are still challenging.

To date, three artificial liver support devices are available: the liver dialysis unit, The MARS and the Prometheus. The most widely studied and used system is the MARS® that use albumin dialysis to replace the detoxification function of the liver.

The MARS has demonstrated interesting results in controlled and uncontrolled trials in improving clinical, biological parameters and shortterm survival. However, technical improvements, randomized controlled trials evaluating indications and timing of treatment, cost-effectiveness studies, are still justified and needed to evaluate the impact of liver support therapies in medical practice.

Albumin dialysis comparison studies

References

Sauer et al compared in vitro MARS, SPAD and continuous veno-venous hemodiafiltration (CVVHDF). Plasma was obtained from patients undergoing plasmapheresis treatment, spiked with bilirubin, urea, creatinine, ammonium chloride, deoxycholic acid, cholic acid, chenodeoxycholic, lithocholic acid to achieve concentration equivalent to 3 times of normal. SPAD and CVVHDF induced a significantly greater reduction of ammonia levels than MARS. No significant differences

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‚Ï‹Ì·Ù· ÙÔ˘ οı ϋÙË. Œ¯Ô˘Ó ·Ó·ÁÓˆÚÈÛÙ› οÔÈÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÛÙÔÓ ˘Ô„‹ÊÈÔ و̷ÙÈÎfi ‰fiÙË Ô˘ ÂËÚ¿˙Ô˘Ó ·Ó·ÛÙ·ÏÙÈο ÙËÓ ÂÈÏÔÁ‹ ÁÈ· ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ Î·È ·ÔÙÂÏÔ‡Ó ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜ ‰fiÙË: ËÏÈΛ· >65 ¯ÚÔÓÒÓ, ·Ú·ÌÔÓ‹ ÛÙË ª.∂.£. ˘fi Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi >7 Ë̤Ú˜ (‹ >4 Ë̤Ú˜ Û οÔȘ ÌÂϤÙ˜), ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ >30, ‚ÈÔ„›· Ì ÏÈÒ‰Ë ‰È‹ıËÛË ‹·ÙÔ˜ >40%, ¡¿ÙÚÈÔ ·›Ì·ÙÔ˜ >165 mmol/l, ÙÈ̤˜ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ SGOT (AST) Î·È SGPT (ALT) >ÙÚÈÏ¿ÛȘ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ, ÔÏÈ΋ ¯ÔÏÂÚ˘ıÚ›ÓË >3 mg/dl, ıÂÙÈÎÔ› ÔÚÔÏÔÁÈÎÔ› ‰Â›ÎÙ˜ Ë·Ù›Ùȉ·˜ HbsAg, antiHBc Î·È anti-HCV, Û‹„Ë Ì ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜, ÌËÓÈÁÁ›Ùȉ·, ÈÛÙÔÚÈÎfi Â͈Ë·ÙÈ΋˜ ηÎÔ‹ıÂÈ·˜, ¯Ú‹ÛË ÂÓ‰ÔÊϤ‚ÈˆÓ Ó·ÚΈÙÈÎÒÓ Ô˘ÛÈÒÓ.4 ∞˘ÙÔ› ÔÈ ·Ú¿ÁÔÓÙ˜ Ê¿ÓËÎ·Ó Ó· ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÌÔۯ‡̷ÙÔ˜ Î·È Ô Û˘Ó‰˘·ÛÌfi˜ ·˘ÙÒÓ ‰Ú· ·ıÚÔÈÛÙÈο ÛÙË ‚Ï¿‚Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.5-7 ªÂ ÛÎÔfi Ó· ÚÔÛ‰ÈÔÚÈÛÙÔ‡Ó ÔÈ ·Ú¿ÁÔÓÙ˜ ÛÙÔÓ ‰fiÙË Ô˘ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ ÂÈÏÔÎÒÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, ÚÔÙ¿ıËÎÂ Ë ‚·ıÌÔÏfiÁËÛË ·˘ÙÒÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ (donor risk score) ‚·ÛÈṲ̂ÓË Û ¤Ó· ÌÂÁ¿ÏÔ ·ÚÈıÌfi ‰ÔÙÒÓ Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜ ÂÓËÏ›ÎˆÓ ÛÙȘ ∏.¶.∞ (¶›Ó. 1).8 ∏ ‚·ıÌÔÏfiÁËÛË ·˘Ù‹ ‰ÂÓ Ï·Ì‚¿ÓÂÈ ˘fi„Ë ÛËÌ·ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ fiˆ˜ Â›Ó·È Ë ÛÙ¿وÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Î·È ÁÂÓÈο ‰ÂÓ Â›Ó·È ÂÊ·ÚÌfiÛÈÌË ÛÙËÓ ∂˘ÚÒË Î·È ÛÙËÓ ∞Û›· ŸÌˆ˜ ‰ÈÂıÓÒ˜ ·fi Ù· ΢ÚÈfiÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ‰fiÙË Ô˘ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÂÚÈÛÛfiÙÂÚÔ ÙËÓ ÂÌÊ¿ÓÈÛË ÚÒÈÌ˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ‹ ·ÓÂ¿ÚÎÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·ÔÙÂÏÔ‡Ó Ë ÌÂÁ¿ÏË ËÏÈΛ·, Ë ·Ú·ÙÂٷ̤ÓË „˘¯Ú‹ ÈÛ¯·ÈÌ›·, Ë ·Ó¿ÁÎË ÁÈ· ˘ÔÛÙ‹ÚÈÍË Ì ÈÓfiÙÚÔ·, Ë ÏÈ҉˘ ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜ Î·È ·Ó ÚfiÎÂÈÙ·È ÁÈ· و̷ÙÈÎfi ‰fiÙË Ì ηډȷ΋ ·Û˘ÛÙÔÏ›· (non heart beating donor).8-12 ∂›Û˘, ηıÔÚÈÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ Ì·ÎÚÔÚfiıÂÛÌË ÂÈ‚›ˆÛË ÙÔ˘ Ï‹ÙË ·ÔÙÂÏÔ‡Ó ÙÔ ÈÛÙÔÚÈÎfi ηÎÔ‹ıÂÈ·˜ ‹ ÈÔÁÂÓÔ‡˜ Ë·Ù›Ùȉ·˜ ÙÔ˘ ‰fiÙË.

∏ ÂͤÏÈÍË Ô˘ ÛËÌÂÈÒÓÂÙ·È ÛÙÔÓ ÙÔ̤· Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜ Ô‰‹ÁËÛ ÛÙÔ Ó· ·ÔÙÂÏ› ıÂÚ·¢ÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ¤Ó· ‰ÈÂ˘Ú˘Ì¤ÓÔ ·ÚÈıÌfi ·ı‹ÛÂˆÓ Ì ·˘Í·ÓfiÌÂÓÔ ÔÛÔÛÙfi ÂÈÙ˘¯›·˜.1-3 ™˘Á¯ÚfiÓˆ˜ fï˜ Ù· ‰È·ı¤ÛÈÌ· و̷ÙÈο ÌÔۯ‡̷ٷ ‰ÂÓ Â·ÚÎÔ‡Ó ÁÈ· Ó· ηχ„Ô˘Ó ÙȘ ·˘ÍË̤Ó˜ ·Ó¿ÁΘ Û ÌÔۯ‡̷ٷ, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ˘Ô„ËÊ›ˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜. °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ·˘ÙÔ‡ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, Ì ÛÎÔfi ÙËÓ ‰È‡ڢÓÛË Ù˘ ‰ÂÍ·ÌÂÓ‹˜ ÙˆÓ ‰È·ı¤ÛÈÌˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÔÈ ¯ÂÈÚÔ˘ÚÁÔ› ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ÂÊ·ÚÌfi˙Ô˘Ó ‰È¿ÊÔÚ˜ Ù·ÎÙÈΤ˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÙÌËÌ·ÙÈÎÒÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ¯ÚËÛÈÌÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ Ô˘ ·Ï·ÈfiÙÂÚ· ÎÚ›ÓÔÓÙ·Ó ·Î·Ù¿ÏÏËÏÔÈ (‰fiÙ˜ Ì ‰ÈÂ˘Ú˘Ì¤Ó· ÎÚÈÙ‹ÚÈ· ÂÈÏÔÁ‹˜), ·fi ˙ÒÓÙ˜ ‰fiÙ˜ Î·È ·fi ·Û˘ÛÙÔÏÈÎÔ‡˜ ‰fiÙ˜ (non-heart beating). ªÂ ·˘ÙÔ‡˜ ÙÔ˘˜ ÙÚfiÔ˘˜, Û οÔÈÔ ‚·ıÌfi, ‚ÂÏÙÈÒıËÎÂ Ë Î·Ù¿ÛÙ·ÛË Ù˘ ¤ÏÏÂȄ˘ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÚԤ΢„·Ó fï˜ ˙ËÙ‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÛÙÔÓ Î·ıÔÚÈÛÌfi ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ οÓÔ˘Ó Ù· ÌÔۯ‡̷ٷ ηٿÏÏËÏ· ‹ ·Î·Ù¿ÏÏËÏ· ÁÈ· Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó, ÙËÓ ÂÈÏÔÁ‹ ÙˆÓ ÏËÙÒÓ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Ù· «‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ» ÌÔۯ‡̷ٷ Î·È ÙËÓ ·Ó··Ú·ÁˆÁÈÌfiÙËÙ· ÙˆÓ Î·ÏÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ·fi ΤÓÙÚÔ Û ΤÓÙÚÔ. ∏ Ù¿ÛË Ù˘ ¯ÚËÛÈÌÔÔ›ËÛ˘ ÔÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‰È·Ê¤ÚÂÈ ·fi ΤÓÙÚÔ Û ΤÓÙÚÔ. ŒÓ· ÌfiÛ¯Â˘Ì· Ô˘, ‚¿ÛÂÈ Î¿ÔÈˆÓ ÎÚÈÙËÚ›ˆÓ, ·ÔÚÚ›ÙÂÙ·È ·fi ¤Ó· ΤÓÙÚÔ ÌÔÚ› Ó· ¯ÚËÛÈÌÔÔÈËı› ˆ˜ ÔÚÈ·Îfi ÌfiÛ¯Â˘Ì· ·fi οÔÈÔ ¿ÏÏÔ Î¤ÓÙÚÔ. ¢ÂÓ ˘¿Ú¯ÂÈ ÎÔÈÓ‹ ·Ô‰Ô¯‹ ÁÈ· ÙÔ ÔÈÔ› ·Ú¿ÁÔÓÙ˜ ÚÔÛ‰ÈÔÚ›˙Ô˘Ó ÙÔ ÌfiÛ¯Â˘Ì· ˆ˜ ÔÚÈ·Îfi ‹ ÔÈÔ› ·fi ·˘ÙÔ‡˜ ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‹ Û˘Ó‰˘·ÛÌfi˜ ·˘ÙÒÓ Ó· ·ÔÙÂÏÔ‡Ó ÎÚÈÙ‹ÚÈ· ÁÈ· Ó· ·ÔÎÏÂÈÛı› Ë ¯ÚËÛÈÌÔÔ›ËÛË ÂÓfi˜ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÏfiÁˆ ÙÔ˘ ·ÓÂ›ÙÚÂÙ· ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙÔÓ Ï‹ÙË. ∏ ·fiÊ·ÛË Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÎÚ›ÛË ÙÔ˘ ¯ÂÈÚÔ˘ÚÁÔ‡ Ï·Ì‚¿ÓÔÓÙ·˜ ˘’ fi„ÈÓ Ù· ȉȷ›ÙÂÚ· ÚÔ-

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¶π¡∞∫∞™ 1: ¶·Ú¿ÁÔÓÙ˜ ‰fiÙË Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ·ÓÂ¿ÚÎÂÈ· Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜, ·fi ÙË ÌÂϤÙË ÙˆÓ Feng et al8 ¶·Ú¿ÁÔÓÙ·˜ ‰fiÙË ∏ÏÈΛ· <40 40-49 50-59 60-69 >70 ª·‡ÚË Ê˘Ï‹ ⁄„Ô˜ ‰fiÙË (ÌÈÎÚfiÙÂÚÔ Î·Ù¿ 10 cm) ∞ÈÙ›· ı·Ó¿ÙÔ˘: ·ÁÁÂÈ·Îfi ÂÁÎÂÊ·ÏÈÎfi ÂÂÈÛfi‰ÈÔ ÕÏÏË ·ÈÙ›· ı·Ó¿ÙÔ˘ ÂÎÙfi˜ ÙÚ·‡Ì·ÙÔ˜, ÈÛ¯·ÈÌÈÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡, ‹ ·ÓÔÍ›·˜ ¢fiÙ˜ Ì ηډȷ΋ ·Û˘ÛÙÔÏ›· ΔÌËÌ·ÙÈÎfi ÌfiÛ¯Â˘Ì·

∞Ó·ÏÔÁ›· ÎÈÓ‰‡ÓÔ˘ 1,00 1,17 1,32 1,53 1,65 1,19 1,07 1,16 1,51 1,52

μÈÔ„›· Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÚÈÓ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ™Â ·ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ‚¿ÛÂÈ Ù˘ ‚ÈÔ„›·˜ ‹·ÙÔ˜ ÎÚ›ÓÂÙ·È Ë Î·Ù·ÏÏËÏfiÙËÙ· ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. ªÂ ÙËÓ Ù·¯Â›· ‚ÈÔ„›· Û ÙÔ̤˜ ÎÚ˘ÔÛÙ¿ÙÔ˘ ÌÔÚ› Û ۇÓÙÔÌÔ ¯ÚfiÓÔ Ó· ÂÎÙÈÌËıÔ‡Ó Ë ·Ú¯ÈÙÂÎÙÔÓÈ΋ ÙÔ˘ ‹·ÙÔ˜ ÁÈ· ÙËÓ ‡·ÚÍË ›ÓˆÛ˘, ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘, ÊÏÂÁÌÔÓ‹˜ Î·È Ë ¤ÎÙ·ÛË Ù˘ Ë·ÙÔ΢ÙÙ·ÚÈ΋˜ Ó¤ÎÚˆÛ˘. ∏ ‚ÈÔ„›· ·ÔÙÂÏ› ÙËÓ ÌfiÓË ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô ÂÎÙ›ÌËÛ˘ Ù˘ Ì·ÎÚÔÊ˘ÛÛ·ÏÈ‰Ò‰Ô˘˜ ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ ·ÏÏ¿ Î·È ÙËÓ Èı·Ó‹ ‡·ÚÍË ÚfiÛıÂÙˆÓ ‚Ï·‚ÒÓ, fiˆ˜ ›ÓˆÛË Î·È ÊÏÂÁÌÔÓÒ‰ÂȘ ‰ÈËı‹ÛÂȘ, Ô˘ ÌÔÚÔ‡Ó ·fi ÌfiÓ˜ ÙÔ˘˜ ·ÏÏ¿ ΢ڛˆ˜ ÛÂ Û˘Ó‰˘·ÛÌfi Ó· ·ÔÙÂÏÔ‡Ó ·ÓÙÂӉ›ÍÂȘ ÁÈ· ÙË ¯ÚËÛÈÌÔÔ›ËÛË Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜.13 ∂ÎÙfi˜ ·fi ÙȘ ÏËÚÔÊÔڛ˜ ÁÈ· ÏÈÒ‰Ë ‰È‹ıËÛË ‹ ›ÓˆÛË, Ë ‚ÈÔ„›· ‰ÂÓ ÌÔÚ› Ó· ‰ÒÛÂÈ Û˘ÁÎÂÎÚÈ̤Ó˜ ÏËÚÔÊÔڛ˜ ÛÙËÓ ÂÎÙ›ÌËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ ˘ÂÚ‹ÏÈΘ ‹ ·ÈÌÔ‰˘Ó·ÌÈο ·ÛÙ·ı›˜ ‹ ·Û˘ÛÙÔÏÈÎÔ‡˜ ‰fiÙ˜. ∂›Û˘, Ë Ù·¯Â›· ‚ÈÔ„›· ‰ÂÓ ÌÔÚ› Ó· ÚÔÛʤÚÂÈ Î·È ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÓÒ ÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· Ì·ÎÚÔÛÎÔÈο Ê·›ÓÂÙ·È Î·Ïfi ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ηٿ¯ÚËÛ˘ ·ÏÎÔfiÏ ÛÙÔÓ ‰fiÙË. ΔÔ ·ÚÓËÙÈÎfi Ù˘ ÌÂıfi‰Ô˘ Â›Ó·È Ë ·Ú¿Ù·ÛË ÙÔ˘ ¯ÚfiÓÔ˘ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Ô˘ ÌÔÚ› Ó· ÂÈʤÚÂÈ Ë ·Ó·ÌÔÓ‹ ÙÔ˘ ÔÚ›ÛÌ·ÙÔ˜ Ù˘ Ù·¯Â›·˜ ‚ÈÔ„›· Î·È Û˘ÁÎÂÎÚÈ̤ӷ fiÙ·Ó Ë ÂÈÏÔÁ‹ ÙÔ˘ Ï‹ÙË Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÔÈfiÙËÙ· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ (·Ú·Î¿Ùˆ Á›ÓÂÙ·È ·Ó·ÊÔÚ¿ ÁÈ· ÙÔÓ Û˘Ó‰˘·ÛÌfi ÌÔۯ‡̷ÙÔ˜ – Ï‹ÙË).

∏ÏÈΛ· ÙÔ˘ ‰fiÙË ¶·Ï·ÈfiÙÂÚ·, Ë ¯ÚËÛÈÌÔÔ›ËÛË Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·fi ÚÔ¯ˆÚË̤Ó˘ ËÏÈΛ·˜ ‰fiÙ˜ (>50

¯ÚÔÓÒÓ) ıˆÚÔ‡ÓÙ·Ó ·ÓÙ¤Ó‰ÂÈÍË ‰ÈfiÙÈ ˘‹Ú¯Â Êfi‚Ô˜ fiÙÈ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÏÂÈÙÔ˘ÚÁÈ΋˜ ·ÓÂ¿ÚÎÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.14 ™ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· fï˜, Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ‰fiÙ˜ ÚÔ¯ˆÚË̤Ó˘ ËÏÈΛ·˜, Ô˘ ‰ÂÓ ¤¯Ô˘Ó ¿ÏÏÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜, Ê¿ÓËÎ·Ó Ó· Â›Ó·È ›‰È· Ì ٷ ·ÔÙÂϤÛÌ·Ù· fiÙ·Ó ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Û¯ÂÙÈο Ó·ÚfiÙÂÚ˘ ËÏÈΛ·˜ ‰fiÙ˜.15,16 ™‡Ìʈӷ Ì ٷ ‰Â‰Ô̤ӷ ÙÔ˘ UNOS, ÙÔ ·ÓÒÙÂÚÔ fiÚÈÔ ÙˆÓ و̷ÙÈÎÒÓ ‰ÔÙÒÓ ‹·ÙÔ˜ ·˘Í‹ıËΠٷ ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ΔÔ 1996, ÙÔ 25% ÙˆÓ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi و̷ÙÈÎÔ‡˜ ‰fiÙ˜ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 50 ¯ÚfiÓˆÓ, ÂÓÒ ÙÔ 2006 ÙÔ 34% ÙˆÓ و̷ÙÈÎÒÓ ‰ÔÙÒÓ ‹Ù·Ó ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 50 ¯ÚfiÓˆÓ. ¶·ÚfiÌÔÈ· Ù¿ÛË ·Ú·ÙËÚÂ›Ù·È Î·È ÁÈ· ÙÔ˘˜ و̷ÙÈÎÔ‡˜ ‰fiÙ˜ ËÏÈΛ·˜ ÌÂÁ·Ï‡ÙÂÚ˘ ÙˆÓ 65 ¯ÚfiÓˆÓ: 6% ÙÔ 1996 ¤Ó·ÓÙÈ 10% ÙÔ 2006.17 ∞Ó Î·È, ·fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙÔ˘ European Liver Transplant Registry, Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË ÌÂÁ·Ï‡ÙÂÚË ·fi 60 ¯ÚÔÓÒÓ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· ÙÔ˘˜ ÚÒÙÔ˘˜ 3 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ ËÏÈΛ·˜ ¿Óˆ ·fi 60 ¯ÚÔÓÒÓ ·˘Í‹ıËΠÛËÌ·ÓÙÈο (·fi 2% ÙÔ 1991 ÛÙÔ 20% ÙÔ 2001).18,19 ∞˘Ù‹ Ë Î·ÙËÁÔÚ›· ‰ÔÙÒÓ ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛÙ› ˆ˜ Ô ÛËÌ·ÓÙÈÎfiÙÂÚÔ ·Ú¿ÁÔÓÙ·˜ ÁÈ· ÙËÓ ·‡ÍËÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ و̷ÙÈÎÒÓ Ë·ÙÈÎÒÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ Î·È fiÙ·Ó ·Ô˘ÛÈ¿˙Ô˘Ó ¿ÏÏÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô Î›Ó‰˘ÓÔ˜ ·˘ÍË̤Ó˘ ıÓËÙfiÙËÙ·˜ ÂÏ·ÙÙÒÓÂÙ·È Û ÚÔÛÂÎÙÈο ÂÈÏÂÁ̤ÓÔ˘˜ Ï‹Ù˜.20 Δ· Û¯ÂÙÈο ηϿ ·ÔÙÂϤÛÌ·Ù· ·fi ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÌÂÁ¿Ï˘ ËÏÈΛ·˜ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Èı·ÓÒ˜ Ó· ÔÊ›ÏÔÓÙ·È ÛÙȘ Â·ÚΛ˜ ÏÂÈÙÔ˘ÚÁÈΤ˜ Âʉڛ˜, ÛÙËÓ ·Ó·ÁÂÓÓËÙÈ΋ ÈηÓfiÙËÙ· Î·È ÛÙË ‰ÈÏ‹ ·ÈÌ¿ÙˆÛË ÙÔ˘ ‹·ÙÔ˜ Ù· ÔÔ›· ˘ÂÚηχÙÔ˘Ó ÙȘ ÌÂÙ·‚ÔÏÈΤ˜ ·Ó¿ÁΘ ÙÔ˘.21,22 ŸÌˆ˜ ÁÂÓÈο, ÔÈ ÌÂÁ¿Ï˘ ËÏÈΛ·˜ ‰fiÙ˜ ¤¯Ô˘Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ÂÌÊ¿ÓÈÛ˘ ‚·ÚÂÈ¿˜ ·ıËÚÔÛÎÏ‹ÚˆÛ˘ Î·È ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ ‹·ÙÔ˜. ¶Ú¤ÂÈ Ó· ‰›ÓÂÙ·È ÚÔÛÔ¯‹ ÛÙËÓ Èı·Ó‹ ‡·ÚÍË ·ıËÚÔÛÎÏËÚˆÙÈÎÒÓ ‚Ï·‚ÒÓ ÛÙ· ·ÁÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‰ÈfiÙÈ ÌÔÚ› Ó· Á›ÓÔ˘Ó ·ÈÙ›· ÛËÌ·ÓÙÈÎÒÓ ÌÂÙÂÁ¯ÂÈÚËÙÈÎÒÓ ÂÈÏÔÎÒÓ.16 ∂›Û˘, Ô Û˘Ó‰˘·ÛÌfi˜ ÌÂÁ¿Ï˘ ËÏÈΛ·˜ ‰fiÙË Î·È Ì¤ÙÚÈ·˜ ÚÔ˜ ‚·ÚÂÈ¿˜ ÛÙ¿وÛ˘ ÂËÚ¿˙ÂÈ ‰˘ÛÌÂÓÒ˜ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÛÙËÓ ·Ú¯È΋ ÂÚ›Ô‰Ô.23 ∞ÎfiÌË ¤Ó· ı¤Ì· Ô˘ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ Â›Ó·È fiÙÈ ÔÈ ÌÂÁ¿Ï˘ ËÏÈΛ·˜ ‰fiÙ˜ ¤¯Ô˘Ó ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· Ó· ¤¯Ô˘Ó οÔÈ· ·‰È¿ÁÓˆÛÙË Î·ÎÔ‹ıÂÈ· Ô˘ ÌÔÚ› Ó· ÙË ÌÂÙ·‰ÒÛÔ˘Ó ÛÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô Ï‹ÙË.

METAMO™XEY™Eπ™ 2011

™ÙÔ˘˜ Ï‹Ù˜ Ì Ë·Ù›Ùȉ· C (HCV +), Ë ÌÂÁ¿ÏË ËÏÈΛ· ÙÔ˘ ‰fiÙË Û¯ÂÙ›˙ÂÙ·È Ì ‚·ÚÂÈ¿˜ ÌÔÚÊ‹˜ ˘ÔÙÚÔ‹ Ù˘ ÓfiÛÔ˘, ÓˆÚ›˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. Œ¯ÂÈ Ê·Ó› fiÙÈ fiÙ·Ó Ô ‰fiÙ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi 60 ¯ÚÔÓÒÓ, Ô Ï‹Ù˘ Ù›ıÂÙ·È Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÛËÌ·ÓÙÈ΋˜ ÈÛÙÔÏÔÁÈ΋˜ ‚Ï¿‚˘ Î·È ·ÓÂ¿ÚÎÂÈ·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ÏfiÁˆ Ù˘ ÁÚ‹ÁÔÚ· ÂÍÂÏÈÛÛfiÌÂÓ˘ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢ ÛÙÔ ÌfiÛ¯Â˘Ì·.24,25 ŒÙÛÈ ÚÔÙ›ÓÂÙ·È, Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË Ó· ·ÔÙÂÏ› ·Ú¿ÁÔÓÙ· Ô˘ Ï·Ì‚¿ÓÂÙ·È ˘’ fi„Ë ÛÙËÓ ÂÈÏÔÁ‹ Î·È ÛÙËÓ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ÎÏÈÓÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î¿ÔÈÔ˘ HCV+ Ï‹ÙË.

¶·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜ ∏ ÈÛ¯·ÈÌÈ΋ ‚Ï¿‚Ë ·ÔÙÂÏ› ·fi ÙȘ ΢ÚÈfiÙÂÚ˜ ·Èٛ˜ ÚÒÈÌ˘ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜. O ·Ú·ÙÂٷ̤ÓÔ˜ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ Â›Ó·È ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ‰ËÌÈÔ˘ÚÁ›·˜ ‚Ï¿‚˘ Û˘ÓÙ‹ÚËÛ˘, ÛËÌ·ÓÙÈÎfiÙÂÚÔ˜ ·fi fiÙÈ Â›Ó·È Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË.26 ÃÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ ÌÔۯ‡̷ÙÔ˜ ÂÚÈÛÛfiÙÂÚÔ˜ ·fi 14 ÒÚ˜ Û¯ÂÙ›˙ÂÙ·È Ì ‰ÈÏ¿ÛÈ· ·‡ÍËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ‚Ï¿‚˘ Û˘ÓÙ‹ÚËÛ˘, ¤¯ÔÓÙ·˜ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÂÈÏÂÁ̤ÓË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÂÚ›Ô‰Ô, ÙÔÓ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚÒÈÌ˘ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ÙËÓ ÂÌÊ¿ÓÈÛË ÛÙÂÓÒÛÂˆÓ ÛÙ· ¯ÔÏËÊfiÚ· Î·È ÙË ÌÂȈ̤ÓË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.26-29 ∏ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ELTR ÚÔÛ‰ÈfiÚÈÛ fiÙÈ ¯ÚfiÓÔ˜ „˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ >13 ÒÚ˜ Û¯ÂÙ›˙ÂÙ·È Ì ·˘ÍË̤ÓË ıÓËÙfiÙËÙ· ÛÙÔ˘˜ 3 Î·È 12 Ì‹Ó˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË.18 ¶ÚÔÙ›ÓÂÙ·È Ô ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜ Ó· ·Ú·Ì¤ÓÂÈ Î¿Ùˆ ·fi 12 ÒÚ˜, ·Ó Î·È ·˘Ùfi ÙÔ ¯ÚÔÓÈÎfi fiÚÈÔ ‰ÂÓ Â›Ó·È ·fiÏ˘ÙÔ ·ÊÔ‡ ÁÈ· οı ÌfiÛ¯Â˘Ì· Ë Â˘¿ıÂÈ· ÛÙÔ ¯ÚfiÓÔ ÈÛ¯·ÈÌ›·˜ ÂÍ·ÚÙ¿Ù·È Î·È ·fi ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜.18 ™Ù· ÔÚȷο ÌÔۯ‡̷ٷ, Ì ÂÈÚfiÛıÂÙÔ˘˜ ÂÈ‚·Ú˘ÓÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ fiˆ˜ ÏÈ҉˘ ‰È‹ıËÛË, ËÏÈΛ· ÙÔ˘ ‰fiÙË ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 50 ¯ÚfiÓˆÓ Î·È ÌÈÎÚfi ̤ÁÂıÔ˜ ÌÔۯ‡̷ÙÔ˜, Ô ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜ Ú¤ÂÈ Ó· ·Ú·Ì¤ÓÂÈ Î¿Ùˆ ·fi 12 ÒÚ˜. ∂ÓÒ, ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ¯ˆÚ›˜ Î·Ó¤Ó·Ó ¿ÏÏÔ ÂÈ‚·Ú˘ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÌÔÚÔ‡Ó Ó· ·Ó¯ÙÔ‡Ó, ‰›¯ˆ˜ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÌÂÙÂÁ¯ÂÈÚËÙÈο ÏÂÈÙÔ˘ÚÁÈο ÚÔ‚Ï‹Ì·Ù·, ·Ú·ÙÂٷ̤ÓÔ ¯ÚfiÓÔ ÈÛ¯·ÈÌ›·˜ >12 ÒÚ˜ (¤ˆ˜ Î·È 16 ÒÚ˜).

¶·Ú·ÌÔÓ‹ ÛÙË ª∂£ Î·È ˘ÔÛÙ‹ÚÈÍË Ì ÈÓfiÙÚÔ· OÈ ‰fiÙ˜ Ì ·Ú·ÙÂٷ̤ÓË ·Ú·ÌÔÓ‹ ÛÙË

163

ª∂£ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÏÔÈÌÒÍÂȘ. Œ¯ÂÈ Ê·Ó› fiÙÈ Ë ·Ú·ÌÔÓ‹ ÛÙË ª∂£ ≥3 Ë̤Ú˜ ·ÔÙÂÏ› ÙÔ ÌfiÓÔ ·fi Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ‰fiÙË Ô˘ ·˘Í¿ÓÔ˘Ó ÛËÌ·ÓÙÈο ÙËÓ Èı·ÓfiÙËÙ· Ïԛ̈͢ ÙÔ˘ ˘Ô„‹ÊÈÔ˘ ‰fiÙË.30 ∞fi ÌÂÁ¿Ï˜ ÛÂÈÚ¤˜ Ô˘ ÌÂϤÙËÛ·Ó ÙÔ˘˜ ‰fiÙ˜ Ì ÌÈÎÚÔ‚È·ÈÌ›· Û˘ÌÂÚ·›ÓÂÙ·È fiÙÈ ÌÔۯ‡̷ٷ ·fi Ù¤ÙÔÈÔ˘˜ ‰fiÙ˜ ÏÂÈÙÔ˘ÚÁÔ‡Ó ÈηÓÔÔÈËÙÈο, ¯ˆÚ›˜ Ó· ÚÔÛı¤ÙÂÙ·È ÛËÌ·ÓÙÈÎfi˜ ÂÈ‚·Ú˘ÓÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ÛÙÔÓ Ï‹ÙË, Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ÛÙÔÓ Ï‹ÙË ı· ¯ÔÚËÁËı› Ë Î·Ù¿ÏÏËÏË ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ ÁÈ· ÙÔ ÌÈÎÚfi‚ÈÔ Ô˘ ·ÔÌÔÓÒıËΠÛÙÔÓ ‰fiÙË.31-34 ∏ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ UNOS ¤‰ÂÈÍ fiÙÈ Ù· ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ Ô˘ Ì ·Ú·ÙÂٷ̤ÓË ˘fiÙ·ÛË ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÚÒÈÌ˘ ·ÓÂ¿ÚÎÂÈ·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∏ Èı·ÓfiÙËÙ· ·ÓÂ¿ÚÎÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ ·˘Í¿ÓÂÙ·È fiÙ·Ó ÛÙÔ˘˜ ‰fiÙ˜ Â›Ó·È ·Ó·Áη›· Ë ¯ÔÚ‹ÁËÛË ÓÔÚ·‰ÚÂÓ·Ï›Ó˘.35 ™Â ¿ÏϘ ÌÂϤÙ˜, Ë ¯ÔÚ‹ÁËÛË ‰fiÛÂˆÓ ÓÙÔ·Ì›Ó˘ ≥10 Ìg/kg/min ‹ ≥6 Ìg/kg/min ›¯Â ÛËÌ·ÓÙÈ΋ ·ÚÓËÙÈ΋ Â›ÙˆÛË ÛÙËÓ ·Ú¯È΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ŸÌˆ˜, Ë ‡·ÚÍË Ë fi¯È ÚfiÛıÂÙˆÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ (¯. ËÏÈΛ·, ÏÈ҉˘ ‰È‹ıËÛË) ηıÔÚ›˙ÂÈ ÙÂÏÈο ÙÔÓ ‚·ıÌfi Ù˘ Â›ÙˆÛ˘ Ù˘ ·Ú·ÙÂٷ̤Ó˘ ˘fiÙ·Û˘ ÛÙË ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜.36

§È҉˘ ‰È‹ıËÛË (ÛÙ¿وÛË) ΔÔ 13% - 26% ÙˆÓ ‰ÔÙÒÓ ¤¯Ô˘Ó ÏÈÒ‰Ë ‰È‹ıËÛË ÙÔ˘ ‹·ÙÔ˜.37 OÈ Û˘Ó‹ıÂȘ ·Èٛ˜ Ù˘ ·ÔÙÂÏÔ‡Ó Ë ·¯˘Û·ÚΛ·, Ë ÚÔ¯ˆÚË̤ÓË ËÏÈΛ·, Ô ·ÏÎÔÔÏÈÛÌfi˜, Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Î·È ÔÈ ÂÈÙÒÛÂȘ ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ı·Ó¿ÙÔ˘. ¢‡Ô ÈÛÙÔÏÔÁÈÎÔ› Ù‡ÔÈ ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ ÂÚÈÁÚ¿ÊÔÓÙ·È: Ë ÌÈÎÚÔÊ˘Û·Ïȉ҉˘, Î·È Ë ÌÂÁ·ÏÔÊ˘Û·Ïȉ҉˘. ∏ ÔÛÔÙÈ΋ ·ÍÈÔÏfiÁËÛË ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ ‚·Û›˙ÂÙ·È ÛÙÔ ÔÛÔÛÙfi ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÓ‰Ô΢ÙÙ·ÚÔÏ·ÛÌ·ÙÈΤ˜ Ê˘Û·Ï›‰Â˜ Ï›Ô˘˜. ∏ ‡·ÚÍË ÌÈÎÚÔÊ˘Û·ÏÈ‰Ò‰Ô˘˜ ÏÈÒ‰Ô˘˜ ‰È‹ıËÛ˘ Ê·›ÓÂÙ·È Ó· ÌËÓ ÂËÚ¿˙ÂÈ ÙËÓ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË.38,39 ∂›Û˘, Ù· ÌÔۯ‡̷ٷ Ì ‹È· ÌÂÁ·ÏÔÊ˘Û·ÏÈ‰Ò‰Ë ÏÈÒ‰Ë ‰È‹ıËÛË (< 30% ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ) ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó Ì ·ÛÊ¿ÏÂÈ·, ·ÊÔ‡ Ù· ·ÔÙÂϤÛÌ·Ù· fiÛÔ ·Ó·ÊÔÚ¿ ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Â›Ó·È ›‰È· Ì ٷ ÌÔۯ‡̷ٷ ¯ˆÚ›˜ ÏÈÒ‰Ë ‰È‹ıËÛË.40 Δ· ‹·Ù· Ì ¤ÓÙÔÓË ÏÈÒ‰Ë ‰È‹ıËÛË (>60% ÙˆÓ Ë·ÙÔ΢ÙÙ¿ÚˆÓ) ¤¯Ô˘Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘-

164

¡. ∞¡Δø¡π∞¢∏™, ¢. Δ∞∫OÀ¢∞™

ÛÈ¿ÛÔ˘Ó ·ÓÂ¿ÚÎÂÈ· ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·˜ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ‰ÂÓ Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÌÔۯ‡̷ٷ.41 ∏ ¯ÚËÛÈÌÔÔ›ËÛË Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ì ̤ÙÚÈÔ˘ ‚·ıÌÔ‡ ÏÈÒ‰Ë ‰È‹ıËÛË (30% 60%) Â›Ó·È Û¯ÂÙÈ΋ Î·È ·ÌÊÈÏÂÁfiÌÂÓË. ¶ÂÚÈÁÚ¿ÊÔÓÙ·È ·ÔÙÂϤÛÌ·Ù· ÏÂÈÙÔ˘ÚÁ›·˜ Ù¤ÙÔÈˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·ÚfiÌÔÈ· Ì ·˘Ù¿ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ·ÏÏ¿ ÂÚÈÁÚ¿ÊÔÓÙ·È Î·È ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ÚÒÈÌ˘ ·ÓÂ¿ÚÎÂÈ·˜ (13% ¤Ó·ÓÙÈ ÙÔ˘ 3% ÁÈ· Ù· Ê˘ÛÈÔÏÔÁÈο ÌÔۯ‡̷ٷ).40 ∂›Ó·È ·Ô‰ÂÎÙfi fiÙÈ Ù· ÌÔۯ‡̷ٷ Ì ̤ÙÚÈÔ˘ ‚·ıÌÔ‡ ÏÈÒ‰Ë ‰È‹ıËÛË Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È fiÙ·Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó ¿ÏÏÔÈ ÂÈÚfiÛıÂÙÔÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÛÙÔÓ ‰fiÙË ·ÏÏ¿ Î·È ÛÙÔÓ Ï‹ÙË.

∏·Ù›Ùȉ· μ Î·È C ™ÙÔ ·ÚÂÏıfiÓ ‰ÂÓ ‹Ù·Ó ·Ô‰ÂÎÙ‹ Ë ÂÈÏÔÁ‹ ‰ÔÙÒÓ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ Ô˘ ‹Ù·Ó ÔÚÔıÂÙÈÎÔ› ÁÈ· ÙÔ˘˜ ÈÔ‡˜ Ù˘ Ë·Ù›Ùȉ· μ Î·È C. O ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ˘ ÛÙÔÓ Ï‹ÙË ÙÔ˘ ÈÔ‡ Ù˘ Ë·Ù›Ùȉ·˜ μ (HBV) Ì ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ Â›Ó·È ˘„ËÏfi˜, ¯ˆÚ›˜ Ó· ÌÂÈÒÓÂÙ·È ·˘Ùfi˜ Ô Î›Ó‰˘ÓÔ˜ Â¿Ó Ô ‰fiÙ˘ Â›Ó·È ·ÚÓËÙÈÎfi˜ Û ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÈÊ·Ó›·˜ ÙÔ˘ ÈÔ‡ Ë·Ù›Ùȉ·˜ μ (HbsAb).42 ¶ÂÚÈÁÚ¿ÊÂÙ·È fiÙÈ Ë·ÙÈο ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ·ÚÓËÙÈÎÔ‡˜ ÛÙÔ ·ÓÙÈÁfiÓÔ ÂÈÊ·Ó›·˜ (HbsAg -) ·ÏÏ¿ ıÂÙÈÎÔ‡˜ Û ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ˘Ú‹Ó· (anti-Hbc +) ÙÔ˘ ÈÔ‡ Ë·Ù›Ùȉ·˜ μ ¤¯Ô˘Ó ÌÂÙ·‰ÒÛÂÈ HBV Ïԛ̈ÍË Û ϋÙ˜ Ô˘ ‹Ù·Ó HbsAg (-) Û ÔÛÔÛÙfi 33% - 78%.43 O ΛӉ˘ÓÔ˜ ·˘Ùfi˜ ÌÂÈÒÓÂÙ·È ÛËÌ·ÓÙÈο (13%) ÛÙÔ˘˜ Ï‹Ù˜ Ô˘ ÚÔ¸¿Ú¯Ô˘Ó ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÂÈÊ·Ó›·˜ (anti-HBs) ‹ ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ˘Ú‹Ó· (anti-Hbc +).44 OÈ Ï‹Ù˜ Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ anti-Hbc(+) ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ HBV Ïԛ̈͢, ÂÓÒ ÔÈ Ï‹Ù˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ anti-HBs(+) ¤¯Ô˘Ó ÂÏ¿¯ÈÛÙÔ Î›Ó‰˘ÓÔ Ó· ·ÔÎÙ‹ÛÔ˘Ó HBV Ïԛ̈ÍË. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·fi ‰fiÙ˜ anti-HBc ‰ÂÓ ÂËÚ¿˙ÂÈ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹ ÙÔ˘ Ï‹ÙË, ·ÏÏ¿ ·˘Í¿ÓÂÙ·È Ë Èı·ÓfiÙËÙ· ηٿ 2,5 ÊÔÚ¤˜ Ó· ˘ÔÙÚÔÈ¿ÛÂÈ Ë HBV Ïԛ̈ÍË ÙÔ˘ Ï‹ÙË, ·Ó Î·È ˘ÔÙÚÔ‹ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔ˘˜ Ï‹Ù˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÚÔÊ˘Ï·ÎÙÈ΋ ıÂÚ·›· Ì ·ÓÔÛÔÛÊ·ÈÚ›ÓË Ë·Ù›Ùȉ·˜ μ (HBIG) Î·È lamivudine.45 ªÔۯ‡̷ٷ ·fi ‰fiÙ˜ HBc(+) Ú¤ÂÈ ÂÈÏÂÎÙÈο Ó· ‰›ÓÔÓÙ·È Û HbsAg(+) Ï‹Ù˜, ·ÊÔ‡ Ô‡Ùˆ˜ ‹ ¿Ïψ˜ ÙÔ˘˜ ¯ÔÚËÁÂ›Ù·È ‰È· ‚›Ô˘ HBIG. ø˜ ‰Â‡ÙÂÚË ÂÈÏÔÁ‹, ·˘Ù¿ Ù· ÌÔۯ‡̷ٷ Ú¤ÂÈ Ó· ‰›ÓÔÓÙ·È

Û anti-HBs(+) Ï‹Ù˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Û˘Ó‹ıˆ˜ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Ó· ¯ÔÚËÁÂ›Ù·È HBIG. ªÔۯ‡̷ٷ ·fi HBc(+) ‰fiÙ˜ ‰ÂÓ Ú¤ÂÈ Ó· ‰›ÓÔÓÙ·È Û HBV ÔÚÔ·ÚÓËÙÈÎÔ‡˜ Ï‹Ù˜, ·Ú¿ ÌfiÓÔ Â¿Ó ‚Ú›ÛÎÔÓÙ·È Û ÎÚ›ÛÈÌË Î·Ù¿ÛÙ·ÛË ¤¯ÔÓÙ·˜ ¿ÌÂÛË ·Ó¿ÁÎË ÁÈ· ÌfiÛ¯Â˘Ì·. ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·fi ‰fiÙË ıÂÙÈÎfi Û ·ÓÙÈÛÒÌ·Ù· Ë·Ù›Ùȉ·˜ C (HCV+) ÌÂÙ·‰›‰ÂÈ ¿ÓÙÔÙ de novo Ïԛ̈ÍË Û ϋÙË Ô˘ ‰ÂÓ ¤¯ÂÈ ÂÎÙÂı› ÚÔËÁÔ˘Ì¤Óˆ˜ ÛÙÔÓ Èfi Ù˘ Ë·Ù›Ùȉ·˜ C (HCV-).46 ŸÌˆ˜, Ë ÌÂÙ·ÌfiÛ¯Â˘ÛË ·˘ÙÒÓ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ Û HCV(+) Ï‹Ù˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÙËÓ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ‹ ÙÔ˘ Ï‹ÙË. ∞ÚÎÂÙ¤˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÌÔۯ‡̷ٷ ·fi HCV(+) ‰fiÙ˜ Â›Ó·È ›‰È·, Î·È Î¿ÔȘ ÊÔÚ¤˜ ηχÙÂÚË, ·fi ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÌÔۯ‡̷ٷ ·fi HCV(-) ‰fiÙ˜.47-52 ¶Ú¤ÂÈ fï˜ Ó· ÛËÌÂȈı› fiÙÈ HCV(+) ÌÔۯ‡̷ٷ ·fi Û¯ÂÙÈο ÌÂÁ¿Ï˘ ËÏÈΛ·˜ ‰fiÙ˜ (≥50 ¯ÚÔÓÒÓ) ›¯·Ó ·˘ÍË̤ӷ ÔÛÔÛÙ¿ ·ÓÂ¿ÚÎÂÈ·˜ ÌÔۯ‡̷ÙÔ˜ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ï‹Ù˜ HCV(-) ÌÔÛ¯Â˘Ì¿ÙˆÓ Ù˘ ›‰È·˜ ËÏÈÎȷ΋˜ ÔÌ¿‰·˜. μ¿ÛÂÈ ÙˆÓ ·Ú·¿Óˆ, Ù· ÂÚÈÛÛfiÙÂÚ· ΤÓÙÚ· ıˆÚÔ‡Ó ‰Â‰Ô̤ÓË ÙË ¯ÚËÛÈÌÔÔ›ËÛË Ë·ÙÈÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi HCV(+) ‰fiÙ˜ Û ∏CV(+) Ï‹Ù˜, Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ Ë ‚ÈÔ„›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÚÔËÁÂ›Ù·È ·ÔÎÏ›ÂÈ ÙËÓ ‡·ÚÍË ‚Ï¿‚˘ Ë·Ù›Ùȉ·˜.

∫·ÎÔ‹ıÂÈ· ∏ ‡·ÚÍË ÂÓÂÚÁÔ‡˜ ηÎÔ‹ıÂÈ·˜ Ì ٿÛË Ó· ÌÂı›ÛÙ·Ù·È ·ÔÙÂÏ› ·ÓÙ¤Ó‰ÂÈÍË ÂÈÏÔÁ‹˜ ‰fiÙË. ŸÌˆ˜, Ô ¯·ÌËÏ‹˜ ηÎÔ‹ıÂÈ·˜ ηÚΛÓÔ˜ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, fiˆ˜ ÙÔ ‚·ÛÈÎÔ΢ÙÙ·ÚÈÎfi ηÚΛӈ̷ Î·È Ù· ηÚÎÈÓÒÌ·Ù· ·fi Ï·ÎÒ‰Ë Î‡ÙÙ·Ú·, Ô in situ ηÚΛÓÔ˜ (Ù˘ Ì‹ÙÚ·˜ Î·È ÙÔ˘ ÙÚ·¯‹ÏÔ˘) Î·È ÔÈ ÚˆÙÔ·ı›˜ ηÚΛÓÔÈ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ¯ˆÚ›˜ Â͈ÎÚ¿ÓȘ ÌÂÙ·ÛÙ¿ÛÂȘ ‰ÂÓ ·ÔÎÏÂ›Ô˘Ó ÙËÓ ÂÈÏÔÁ‹ οÔÈÔ˘ ‰fiÙË.53,54 ŸÛÔÓ ·ÊÔÚ¿ ÛÙÔ˘˜ ÂÁÎÂÊ·ÏÈÎÔ‡˜ fiÁÎÔ˘˜, οÔÈÔÈ ÈÛÙÔÏÔÁÈÎÔ› Ù‡ÔÈ, fiˆ˜ ÙÔ ÔχÌÔÚÊÔ ÁÏÔÈÔ‚Ï¿Ûو̷ Î·È ÙÔ Ì˘ÂÏÔ‚Ï¿Ûو̷, Î·È ÙÔ ÈÛÙÔÚÈÎfi ÎÚ·ÓÈÔÙÔÌ‹˜, ‰ÈÂÓ¤ÚÁÂÈ·˜ ·Ô¯ÂÙ¢ÙÈ΋˜ ·Ú¿Î·Ì„˘ ÙˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ ÎÔÈÏÈÒÓ Î·È ıÂÚ·¢ÙÈ΋˜ ·ÎÙÈÓÔ‚ÔÏ›·˜ ·˘Í¿ÓÔ˘Ó ÙÔÓ Î›Ó‰˘ÓÔ Èı·Ó‹˜ ÌÂÙ¿‰ÔÛ˘ ηÎÔ‹ıÂÈ·˜ ÛÙÔÓ Ï‹ÙË. ŸÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ‰fiÙË Ì ÚÔËÁÔ‡ÌÂÓÔ ÈÛÙÔÚÈÎfi ÓÂÔÏ·Û›·˜ Û˘Ì·ÁÔ‡˜ ÔÚÁ¿ÓÔ˘, Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’ fi„ÈÓ Ë ‚ÈÔÏÔÁÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ Ù‡Ô˘ Ù˘ ÓÂÔÏ·Û›·˜, Ù· ÈÛÙÔ-

METAMO™XEY™Eπ™ 2011

ÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È ÙÔ ÛÙ¿‰ÈÔ Î·Ù¿ ÙÔÓ ¯ÚfiÓÔ Ù˘ ‰È¿ÁÓˆÛ˘, Î·È ÙÔ ÂχıÂÚÔ ÓfiÛÔ˘ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ô˘ ÌÂÛÔÏ¿‚ËÛÂ. ∞ÛıÂÓ›˜ Ì ηÎÔ‹ıÂÈ· Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠÛÙÔ ·ÚÂÏıfiÓ ıˆÚÔ‡ÓÙ·È ıÂÚ·Â˘Ì¤ÓÔÈ ÌÂÙ¿ ·fi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· 5 ¯ÚfiÓˆÓ ÂχıÂÚÔ ÓfiÛÔ˘.55 ΔÔ ÌÂϿӈ̷, ÙÔ ¯ÔÚÈÔηÚΛӈ̷, Ô Î·ÚΛÓÔ˜ ÙÔ˘ Ó‡ÌÔÓ· Î·È ÙÔ˘ Ì·ÛÙÔ‡ ·ÔÙÂÏÔ‡Ó ·fiÏ˘Ù˜ ·ÓÙÂӉ›ÍÂȘ ÂÈÏÔÁ‹˜ ‰fiÙË ÂÂȉ‹ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÌÂÙ¿‰ÔÛ˘ ηÎÔ‹ıÂÈ·˜ ÛÙÔÓ Ï‹ÙË.56 °ÂÓÈο, ·fi ÙËÓ ·Ó¿Ï˘ÛË ‰Â‰ÔÌ¤ÓˆÓ ÙÔ˘ UNOS Ê·›ÓÂÙ·È fiÙÈ ÙÔ ÔÛÔÛÙfi Èı·Ó‹˜ ÌÂÙ¿‰ÔÛ˘ ηÎÔ‹ıÂÈ·˜ ·fi ÙÔÓ ‰fiÙË ÛÙÔÓ Ï‹ÙË Â›Ó·È Ôχ ¯·ÌËÏfi (0,02%).56

∞Û˘ÛÙÔÏÈÎÔ› ‰fiÙ˜ ∏ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ·fi ‰fiÙ˜ Ì ηډȷ΋ ·Û˘ÛÙÔÏ›·, Ô˘ ϤÔÓ ÔÓÔÌ¿˙ÔÓÙ·È ‰fiÙ˜ ÌÂÙ¿ ·fi ηډȷÎfi ı¿Ó·ÙÔ [donation after cardiac death (DCD)], Â›Ó·È ¤Ó·˜ ˘ÔÛ¯fiÌÂÓÔ˜ ÙÚfiÔ˜ Ó· ·˘ÍËı› Ë ÚÔÛÊÔÚ¿ ÌÔÛ¯Â˘Ì¿ÙˆÓ.57 ™ÙȘ ÂÏÂÁ¯fiÌÂÓ˜ ηٷÛÙ¿ÛÂȘ, Ù· fiÚÁ·Ó· Ï·Ì‚¿ÓÔÓÙ·È ÌÂÙ¿ ·fi ÂÚ›Ô‰Ô ·Ó·ÌÔÓ‹˜ 2 Ì 5 ÏÂÙÒÓ ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ÈÛÙÔÔÈËı› Ô ı¿Ó·ÙÔ˜. ™Â οÔȘ ¯ÒÚ˜, ÏfiÁˆ ËıÈÎÒÓ ‰ÂÛ̇ÛÂˆÓ Â›Ó·È ·Ô‰ÂÎÙ‹ Ë ‰ˆÚ¿ ÌÂÙ¿ ·fi ÌË ÂÏÂÁ¯fiÌÂÓ˜ ηٷÛÙ¿ÛÂȘ ηډȷÎÔ‡ ı·Ó¿ÙÔ˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Î·Ù·ÛÙ¿ÛÂȘ fiÔ˘ Ô ·ÛıÂÓ‹˜ ÚÔÛ¤Ú¯ÂÙ·È ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ‹‰Ë ÓÂÎÚfi˜ ‹ ÂÚÈÙÒÛÂȘ ÌÂÙ¿ ·fi ·ÓÂÈÙ˘¯Â›˜ ÚÔÛ¿ıÂȘ ·Ó¿Ó˄˘. ∫·È ÛÙȘ ‰‡Ô ÂÚÈÙÒÛÂȘ, ÂÏÂÁ¯fiÌÂÓ˘ ‹ ÌË ÂÏÂÁ¯fiÌÂÓ˘ ηٿÛÙ·Û˘ ηډȷÎÔ‡ ı·Ó¿ÙÔ˘ ÙÔ˘ ‰fiÙË, Ù· fiÚÁ·Ó· ˘fiÎÂÈÓÙ·È Û οÔÈ· ÂÚ›Ô‰Ô ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜ Ë ÔÔ›· Â›Ó·È ˘‡ı˘ÓË ÁÈ· ÙËÓ ·˘Í·ÓfiÌÂÓË Èı·ÓfiÙËÙ· Ù· ÌÔۯ‡̷ٷ Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÚÒÈÌË ÌË ÏÂÈÙÔ˘ÚÁ›· ‹ ‰˘ÛÏÂÈÙÔ˘ÚÁ›·, ηı˘ÛÙÂÚË̤ÓË ¤Ó·ÚÍË ÏÂÈÙÔ˘ÚÁ›·˜, ‹ ÌË ·Ó·ÛÙÚ¤„ÈÌË ÈÛ¯·ÈÌÈÎÔ‡ Ù‡Ô˘ ‰È¿¯˘ÙË ¯ÔÏ·ÁÁÂÈÔ¿ıÂÈ·.58 ¶·›ÚÓÔÓÙ·˜ οÔÈ· ̤ÙÚ· ÌfiÚÂÛ·Ó Ó· ÂÈÙ‡¯Ô˘Ó ηϿ ·ÔÙÂϤÛÌ·Ù· Ì ÔÛÔÛÙfi ÂÌÊ¿ÓÈÛ˘ ÚÒÈÌ˘ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ ÌÈÎÚfiÙÂÚÔ ÙÔ˘ 15% Î·È ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ ÂÌÊ¿ÓÈÛ˘ ÂÈÏÔÎÒÓ ·fi Ù· ¯ÔÏËÊfiÚ·.59,60 ∞˘Ù¿ Ù· ̤ÙÚ· ·ÊÔÚÔ‡Ó ÙËÓ ÚÔÛÂÎÙÈ΋ ÂÈÏÔÁ‹ ÙÔ˘ ‰fiÙË, ¤ÙÛÈ ÒÛÙ ӷ Â›Ó·È Î¿Ùˆ ·fi 40 ¯ÚÔÓÒÓ Î·È Ó· ÌËÓ ¤¯ÂÈ ÛÙ¿وÛË, ÙËÓ ÂÊ·ÚÌÔÁ‹ Û˘ÁÎÂÎÚÈ̤Ó˘ Ù¯ÓÈ΋˜ ·Ó¿Ó˄˘ Ô˘ Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË Ë·Ú›Ó˘ ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ÙˆÓ ÔÚÁ¿ÓˆÓ, ÛÙË ¯ÔÚ‹ÁËÛË Ô͢ÁfiÓÔ˘, ÛÙË ‰È·Ù‹ÚËÛË Û‡ÓÙÔÌÔ˘ ¯ÚfiÓÔ˘ ıÂÚÌ‹˜ ÈÛ¯·ÈÌ›·˜ (< 15 ÏÂÙ¿) Î·È Û‡ÓÙÔÌÔ˘ ¯ÚfiÓÔ˘

165

„˘¯Ú‹˜ ÈÛ¯·ÈÌ›·˜ (< 10 ÒÚ˜).61,62 ∞Ó Î·È ÂÚÈÔÚÈṲ̂ÓÔ˜ ·ÚÈıÌfi˜ ΤÓÙÚˆÓ ¯ÚËÛÈÌÔÔÈÔ‡Ó ‰fiÙ˜ Ì ηډȷÎfi ı¿Ó·ÙÔ, ÂÊ·ÚÌfi˙ÔÓÙ·˜ Û˘ÁÎÂÎÚÈ̤ӷ ÚˆÙfiÎÔÏÏ·, Ë ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘˜ ÌÔÚ› Ó· ·‡ÍËÛË ÙËÓ ‰ÂÍ·ÌÂÓ‹ ÙˆÓ ‰ÔÙÒÓ Î·Ù¿ 10% Ì 20%.57,60 ¶ÚfiÛÊ·ÙË ·Ó·ÊÔÚ¿ ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÔÙ¤ÏÂÛÌ· ÂÈ‚›ˆÛ˘ ÛÙÔÓ 1Ô, 3Ô Î·È 5Ô ¯ÚfiÓÔ Î·È Â›Ó·È 89,9% , 85,6% Î·È 83,6% ·ÓÙ›ÛÙÔȯ·. °È· ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ë ÂÈ‚›ˆÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‹Ù·Ó 85,8%, 80,8% Î·È 76,6% ·ÓÙ›ÛÙÔȯ·. ™˘ÓÔÏÈο, Ë ÂÈ‚›ˆÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ Î·È ÏËÙÒÓ Â›Ó·È ·ÚfiÌÔÈ· Ì ·˘Ù‹ ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ·fi ‰fiÙ˜ Ì ÂÁÎÂÊ·ÏÈÎfi ı¿Ó·ÙÔ. OÈ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜ Â›Ó·È ÛÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÚÒÈÌ˘ ÌË ÏÂÈÙÔ˘ÚÁ›·˜ ÌÔۯ‡̷ÙÔ˜ Ô˘ ‹Ù·Ó ÂÚ›Ô˘ 4% (1% ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ·fi ‰fiÙ˜ ÂÁÎÂÊ·ÏÈο ÓÂÎÚÔ‡˜) Î·È ÛÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÈÛ¯·ÈÌÈ΋˜ ¯ÔÏ·ÁÁÂÈÔ¿ıÂÈ·˜ Ô˘ ‹Ù·Ó 2,1%.

™˘Ó‰˘·ÛÌfi˜ ‰ÔÙÒÓ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Ì ϋÙ˜ Δ· ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ‰ÂÓ ‰›ÓÔÓÙ·È Ù˘¯·›· Û ϋÙ˜. ¶Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ÁÂÓÈο Ë ÛÙÚ·ÙËÁÈ΋ ‰È·ÓÔÌ‹˜ ÌÔÛ¯Â˘Ì¿ÙˆÓ Ú¤ÂÈ Ó· ‚·Û›˙ÂÙ·È ÛÙËÓ ÚÔÙÂÚ·ÈfiÙËÙ· ÙÔ˘ ·ÛıÂÓ‹ Ô˘ ÙÔ ¯ÚÂÈ¿˙ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ, ÛÙËÓ ÈÛfiÙËÙ·, ÛÙËÓ ÚÔÛ¿ıÂÈ· ÁÈ· Ì›ˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ ÙˆÓ ·ÛıÂÓÒÓ ÛÙË Ï›ÛÙ· ·Ó·ÌÔÓ‹˜ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È ÛÙÔ fiÊÂÏÔ˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ÛÙËÓ ÌÂÙ¤ÂÈÙ· ÂÈ‚›ˆÛË ÙÔ˘ Ï‹ÙË. ¶·Ú·ÙËÚÂ›Ù·È ÌÂÙ·‚ÔÏ‹ ÛÙËÓ ·ÓÙ›ÏË„Ë fiÙÈ ÔÈ ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ú¤ÂÈ Ó· ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Ì ηϋ˜ ÔÈfiÙËÙ·˜ ÌÔۯ‡̷ٷ, ÚÔ˜ ÌÈ· ‰È·ÊÔÚÂÙÈ΋ ·ÓÙ›ÏË„Ë Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· ÔÈ ‚·Ú‡ÙÂÚ· ·ÛıÂÓ›˜ ÌÔÚÔ‡Ó Ó· ˆÊÂÏËıÔ‡Ó ·fi ÔÔÈÔ‰‹ÔÙ ÌfiÛ¯Â˘Ì·. ∞˘Ùfi ÛÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·Ú·Ù‹ÚËÛË fiÙÈ Ô ‰Â›ÎÙ˘ ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ ¯ÚËÛÈÌÔÔ›ËÛ˘ ÌÔۯ‡̷ÙÔ˜ ·fi οÔÈÔÓ ‰fiÙË (donor risk index ‹ DRI), Ô˘ ‚Á·›ÓÂÈ ·fi ÙËÓ ‚·ıÌÔÏÔÁ›· ÙˆÓ ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÙÔ˘ ‰fiÙË, ‰ÂÓ ÂËÚ¿˙ÂÙ·È ·fi ÙË ‚·Ú‡ÙËÙ· (‚¿ÛÂÈ MELD) ÙÔ˘ Ï‹ÙË.63 ∞ÔÙÂϤÛÌ·Ù· ·fi ÌÂÁ¿ÏÔ ·ÚÈıÌfi ·ÛıÂÓÒÓ ÛÙȘ ∏.¶.∞. ÂȂ‚·›ˆÛ·Ó fiÙÈ ÙÔ fiÊÂÏÔ˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘ (‰ËÏ. Ì·ÎÚ‡ÙÂÚË ÂÈ‚›ˆÛË ·’ fiÙÈ ¯ˆÚ›˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË) Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ fiÙ·Ó ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ ÌÂÙ·ÌÔۯ‡ÔÓÙ·È Û ϋÙ˜ Ì ÛÎÔÚ MELD >20.64 ŒÙÛÈ, Ë ¯ÚËÛÈÌÔÔ›ËÛË ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ

166

¡. ∞¡Δø¡π∞¢∏™, ¢. Δ∞∫OÀ¢∞™

ÚÔÛı¤ÙÂÈ ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚÔ Î›Ó‰˘ÓÔ ÛÙÔ˘˜ ÛÙ·ıÂÚÔ‡˜ ·ÛıÂÓ›˜, Û ۯ¤ÛË Ì ·˘ÙfiÓ Ô˘ ‹‰Ë ¤¯Ô˘Ó, ·ÏÏ¿ ÁÈ· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· Âı¿ÓÔ˘Ó - fiˆ˜ Â›Ó·È ·˘ÙÔ› Ì MELD >20 ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· Ì·ÎÚfi¯ÚÔÓ˘ ÂÈ‚›ˆÛ˘. °È· ÙÔ˘˜ ·ÛıÂÓ›˜ Ì Ë·ÙÔ΢ÙÙ·ÚÈÎfi ηÚΛÓÔ, ÂÎÙfi˜ ÙÔ˘ MELD, Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë Î·È Ô Î›Ó‰˘ÓÔ˜ Ù˘ ÂͤÏÈ͢ ÙÔ˘ ηÚΛÓÔ˘ ÛÙËÓ ·Ó·ÌÔÓ‹ ÚÔ˜ ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¢ÂÓ ˘¿Ú¯Ô˘Ó ·ÏÁfiÚÈıÌÔÈ ÁÈ· ÙËÓ ‰È·ÓÔÌ‹ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ Û ·ÛıÂÓ›˜ ·˘ÍË̤ÓÔ˘ ‹ ¯·ÌËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ÔÈ ÁÂÓÈΤ˜ Ù¿ÛÂȘ Î·È ÔÈ ·Ó¿ÁΘ Î·È Ë ÂÌÂÈÚ›· ÙÔ˘ οı ΤÓÙÚÔ˘ Ô‰ËÁÔ‡Ó ÙȘ ÂÈÏÔÁ¤˜ ÙˆÓ ÏËÙÒÓ. ΔÔ ı¤Ì· ‰ÂÓ Â›Ó·È ·Ó Ú¤ÂÈ ‹ fi¯È Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙȘ ÌÂÙ·ÌÔۯ‡ÛÂȘ ‹·ÙÔ˜ ÌÔۯ‡̷ٷ ·fi ‰fiÙ˜ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ. ∞˘ÙÔ› ÔÈ ‰fiÙ˜ ¯ÚÂÈ¿˙ÔÓÙ·È ¤ÛÙˆ ÎÈ ·Ó Ë ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘˜ ·˘Í¿ÓÂÈ Ù· ÔÛÔÛÙ¿ ıÓËÛÈÌfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÛÙÔ˘˜ Ï‹Ù˜. ∏ Û‡Á¯ÚÔÓË ·ÓÙ›ÏË„Ë Â›Ó·È fiÙÈ ÔÈ ‰fiÙ˜ ‰ÂÓ Â›Ó·È «Î·ÏÔ› ‹ ηÎÔ›», fiÛÔ ·Ó·ÊÔÚ¿ ÙȘ ÂÈÙÒÛÂȘ ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ô˘ ÌÔÚ› Ó· ¤¯ÂÈ Ë ¯ÚËÛÈÌÔÔ›ËÛ‹ ÙÔ˘˜, ·ÏÏ¿ Ë ÔÈfiÙËÙ¿ ÙÔ˘˜ ·ÓÙÈÚÔÛˆ‡ÂÈ ¤Ó· ¿ıÚÔÈÛÌ· ÂÈ‚·Ú˘ÓÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘. ΔÔ Î‡ÚÈÔ ÂӉȷʤÚÔÓ Â›Ó·È ˆ˜ Ó· ‰È¢ڢÓı› Ë ‰ÂÍ·ÌÂÓ‹ ÙˆÓ ‰ÔÙÒÓ Û ۯ¤ÛË ÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ οı ‰fiÙË Î·È ˆ˜ Ó· ‰È·Ó¤ÌÔÓÙ·È Î·Ï‡ÙÂÚ· Ù· ÌÔۯ‡̷ٷ ‰ÈÂ˘Ú˘Ì¤ÓˆÓ ÎÚÈÙËÚ›ˆÓ.

μÈ‚ÏÈÔÁÚ·Ê›· 1. Cameron A, Busuttil R. AASLD/ILTS transplant course: is there an extended donor suitable for everyone? Liver Transpl 2005; 11(11 Suppl 1): S2-5.

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·ÚÎÂÙ¿ ·ÎÚÈ‚¤˜ ÁÈ· ÙËÓ ÚfiÁÓˆÛË Ù˘ ıÓËÙfiÙËÙ·˜ ηٿ ÙËÓ ·Ó·ÌÔÓ‹ ÛÙË Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË, ·ÏÏ¿ fi¯È ÁÈ· ÙÔ Û˘ÓÔÏÈÎfi fiÊÂÏÔ˜, fiˆ˜ ηıÔÚ›˙ÂÙ·È ·fi ÙËÓ ‰È·ÊÔÚ¿ Ù˘ ÚÔ‚ÏÂfiÌÂÓ˘ ÂÈ‚›ˆÛ˘ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË Ì›ÔÓ ÙËÓ ÚÔ‚ÏÂfiÌÂÓË ÂÈ‚›ˆÛË ÚÈÓ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË5.

O Û˘Ó˘ÔÏÔÁÈÛÌfi˜ ÌÂÙ·‚ÏËÙÒÓ ÙÔ˘ ‰fiÙË ·ÔÙÂÏ› ‚·ÛÈ΋ ÚÔ¸fiıÂÛË ÁÈ· ÙËÓ Â›Ù¢ÍË ÙÔ˘ ‚¤ÏÙÈÛÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÔʤÏÔ˘˜ ÂÈ‚›ˆÛ˘ ·fi ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ∂›ÛËÌ·, Ì ÂÍ·›ÚÂÛË ÙËÓ ÔÌ¿‰· ·›Ì·ÙÔ˜ ÙÔ˘ ‰fiÙË, Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ‚·Û›˙ÂÙ·È ·ÔÎÏÂÈÛÙÈο Û ÌÂÙ·‚ÏËÙ¤˜ ÙÔ˘ Ï‹ÙË (.¯. Child-Pugh score, MELD score). ™ÙËÓ Ú¿ÍË, Ì ‚¿ÛË ÙËÓ ÂÌÂÈÚ›· ·ÏÏ¿ Î·È ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ, Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ ÙÔ˘ ‰fiÙË Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë ÚÔۂϤÔÓÙ·˜ ÛÙÔ Î·Ï‡ÙÂÚÔ «Ù·›ÚÈ·ÛÌ·» ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ‰fiÙË/Ï‹ÙË. ªÈ· Ù¤ÙÔÈ· ‚·ÛÈ΋ ·Ú¿ÌÂÙÚÔ˜ Â›Ó·È ÔÈ ‰È·ÛÙ¿ÛÂȘ ÙÔ˘ ÛÒÌ·ÙÔ˜ ‰fiÙË Î·È Ï‹ÙË, ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÊı¯ıÔ‡Ó 2 ÎÏÈÓÈΤ˜ ηٷÛÙ¿ÛÂȘ ·fi ÙË Ï‹„Ë6: ·) ÌÈÎÚÔ‡ ÌÔۯ‡̷ÙÔ˜, Ô˘ ‰ÂÓ ÌÔÚ› Ó· ηχ„ÂÈ ÙȘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ·Ó¿ÁΘ ÙÔ˘ Ï‹ÙË Ì ·ÔÙ¤ÏÂÛÌ· ÙË ‚Ï¿‚Ë ÙÔ˘ ‹·ÙÔ˜ Ì ÙËÓ ÂÁηٿÛÙ·ÛË ¯ÔÏfiÛÙ·Û˘ Î·È ‰˘ÛÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Ô˘ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ ˆ˜ ÙÔ ı¿Ó·ÙÔ, Î·È ‚) ÌÂÁ¿ÏÔ˘ ÌÔۯ‡̷ÙÔ˜ (Û‡ÓËı˜ Úfi‚ÏËÌ· Û ÌÂÙ·ÌÔۯ‡ÛÂȘ ·È‰ÈÒÓ), Ì ΛӉ˘ÓÔ ÙË ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÙËÓ ıÚfiÌ‚ˆÛË ÙˆÓ ·ÁÁ›ˆÓ Î·È ÙË Ó¤ÎÚˆÛË. °È· ÙËÓ ·ÔÊ˘Á‹ ·˘ÙÒÓ ÙˆÓ Î·Ù·ÛÙ¿ÛˆÓ, ‰È¿ÊÔÚ˜ ‰Â›ÎÙ˜ ¤¯Ô˘Ó ·Ó·Ù˘¯ı› (.¯. BSA, GWRBW), Ô˘ ‚·Û›˙ÔÓÙ·È ÛÙËÓ ÂÈÊ¿ÓÂÈ· Î·È ÙÔ ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ ‰fiÙË Î·È Ï‹ÙË7,8. ¶ÚfiÛÊ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ¤¯Ô˘Ó ÚÔÛ·ı‹ÛÂÈ Ó· Ù˘ÔÔÈ‹ÛÔ˘Ó Î·Ï‡ÙÂÚ· ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÂΛÓÔ˘˜ ÙÔ˘ ‰fiÙË Ô˘ ¤¯Ô˘Ó ÚÔÁÓˆÛÙÈ΋ ·Í›· ÁÈ· ÙËÓ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË. ◊‰Ë ·fi ÙÔ 2006 ›¯Â ÚÔÙ·ı› Ë ·Ó¿ÁÎË Î·ıȤڈÛ˘ ÙÔ˘ MELDD score (ÙÔ ‰Â‡ÙÂÚÔ D ÁÈ· Donor characteristics)9 Î·È ÂÎÊÚ¿ÛÙËΠ̠ÙËÓ ÚfiÙ·ÛË ÂÓfi˜ ÚÔÁÓˆÛÙÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘, ÛÙËÚÈ˙fi-

™·Ú¿ÓÙ· Î·È ϤÔÓ ¤ÙË ÌÂÙ¿ ·fi ÙËÓ ÚÒÙË ÂÈÙ˘¯‹ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Ë ÙÂÏÂ˘Ù·›· ·ÔÙÂÏ› ÙËÓ ‚¤ÏÙÈÛÙË ÂÈÏÔÁ‹ Û ·ÛıÂÓ›˜ Ì ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î›ÚÚˆÛË1. ª¿ÏÈÛÙ·, ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›· ¤¯ÂÈ ÛËÌÂȈı› ÛËÌ·ÓÙÈ΋ ÚfiÔ‰Ô˜ ÛÙËÓ Î·Ï‡ÙÂÚË Î·È ÈÔ ·ÓÙÈÎÂÈÌÂÓÈ΋ ·ÍÈÔÏfiÁËÛË ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Â›Ó·È ˘Ô„‹ÊÈÔÈ Ï‹Ù˜ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ‹·ÙÔ˜. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, Ë Î·ıȤڈÛË ÙÔ˘ MELD score ¿ÓÔÈÍ ÙÔ ‰ÚfiÌÔ Ù˘ ηıȤڈÛ˘ ÙÔ˘ «evidence based medicine” Î·È ÛÙÔÓ ÙÔ̤· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‹·ÙÔ˜, ηıÒ˜ Ë ÚÔÙÂÚ·ÈfiÙËÙ· ÛÙË Ï‹„Ë Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ÛÙËÚ›˙ÂÙ·È Î˘Ú›ˆ˜ Û 3 ÂÚÁ·ÛÙËÚȷΤ˜ ÌÂÙ·‚ÏËÙ¤˜ (¯ÔÏÂÚ˘ıÚ›ÓË, INR Î·È ÎÚ·ÙÈÓ›ÓË), Ô˘ ıˆÚÔ‡ÓÙ·È ·Ϥ˜, ·ÓÙÈÎÂÈÌÂÓÈΤ˜ Î·È Â˘Ú¤ˆ˜ ‰È·ı¤ÛÈ̘1,2. ¶·Ú¿ ÙȘ ÛËÌ·ÓÙÈΤ˜ ÚÔfi‰Ô˘˜ ÛÙÔÓ ÙÔ̤· ÙˆÓ ÌÂÙ·ÌÔۯ‡ÛÂˆÓ ‹·ÙÔ˜, ˘¿Ú¯ÂÈ ¤ÓÙÔÓÔ˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ Û 2 ΢ڛˆ˜ ÙÔÌ›˜: ·) ÙË ÛËÌ·ÓÙÈ΋ ¤ÏÏÂÈ„Ë ‰ÔÙÒÓ Û ۯ¤ÛË Ì ÙÔ˘˜ ˘Ô„‹ÊÈÔ˘˜ Ï‹Ù˜, οÙÈ Ô˘ ¤¯ÂÈ Ô‰ËÁ‹ÛÂÈ Û ÌÈ· ÚÔÛ¿ıÂÈ· ¯ÚËÛÈÌÔÔ›ËÛ˘ ÔÚÈ·ÎÒÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, Î·È ‚) ÙËÓ ·Ó¿ÁÎË ‚¤ÏÙÈÛÙ˘ ¯ÚËÛÈÌÔÔ›ËÛ˘ ÙˆÓ ˘·Ú¯fiÓÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ, ÚÔÎÂÈ̤ÓÔ˘ Ó· ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ÛÙÔÓ ÈÔ Î·Ù¿ÏÏËÏÔ Ï‹ÙË. ªÂ ÙÔ ‚¤ÏÙÈÛÙÔ «Ù·›ÚÈ·ÛÌ·» ‰fiÙË/Ï‹ÙË ÂȉÈÒÎÂÙ·È ÙÔ Ì¤ÁÈÛÙÔ fiÊÂÏÔ˜ ·fi ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, fiˆ˜ ÂÎÊÚ¿˙ÂÙ·È ·fi ÙËÓ Î·Ï‡ÙÂÚË ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Î·È ÙÔ˘ ·ÛıÂÓÔ‡˜ ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË. Àfi ·˘Ùfi ÙÔ Ú›ÛÌ·, ÙÔ MELD score, ‰ÂÓ ÌÔÚ› Ó· ÈηÓÔÔÈ‹ÛÂÈ ÙËÓ Â›Ù¢ÍË ÙÔ˘ ‚¤ÏÙÈÛÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜, ηıÒ˜ ‰ÂÓ ÌÔÚ› Ó· ÚԂϤ„ÂÈ ÙËÓ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË 3. ª¿ÏÈÛÙ·, ·Ó Î·È ÙÔ MELD score ≥15 ›¯Â ÙÂı› ˆ˜ ÙÔ ÂÏ¿¯ÈÛÙÔ ÛÎÔÚ ˘Ô‚ÔÏ‹˜ Û ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜, Û‡Ìʈӷ Ì ÚfiÛÊ·Ù˜ ÌÂϤÙ˜, ˘¿Ú¯Ô˘Ó ·ÛıÂÓ›˜ Ô˘ ı· ›¯·Ó fiÊÂÏÔ˜ ·Ó ÌÂÙ·ÌÔۯ‡ÔÓÙ·Ó Ì ¯·ÌËÏfiÙÂÚÔ MELD score Î·È ÙÔ ·ÓÙ›ÛÙÚÔÊÔ4. ŒÙÛÈ, ¤¯ÂÈ ÍÂÎÈÓ‹ÛÂÈ ¤Ó·˜ ¤ÓÙÔÓÔ˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ Á‡Úˆ ·fi ‚¤ÏÙÈÛÙÔ Û‡ÛÙËÌ· Ù·ÍÈÓfiÌËÛ˘, ηıÒ˜ ÙÔ MELD score ·Ô‰ÂÈÎÓ‡ÂÙ·È

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ÌÂÓÔ Û ¿Óˆ ·fi 34664 ·ÛıÂÓ›˜ ·fi 23 Â˘Úˆ·˚ο ΤÓÙÚ· ÌÂÙ·ÌfiÛ¯Â˘Û˘, fiÔ˘ ÌÂÙ·‚ÏËÙ¤˜ fiˆ˜ Ë ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜, ÙÔ ·›ÙÈÔ Ù˘ Ë·ÙÔ¿ıÂÈ·˜ Î·È ÙÔ Â›‰Ô˜ Ù˘ ÌÂÙ·ÌfiÛ¯Â˘Û˘, ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂÈ‚›ˆÛË ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË10. ΔÔ DRI score Â›Ó·È ¤Ó·˜ Ó¤Ô˜ ‰Â›ÎÙ˘ Ô˘ ÛÙËÚ›˙ÂÙ·È Û ·ÚÎÂÙ¤˜ ÌÂÙ·‚ÏËÙ¤˜ ÙÔ˘ ‰fiÙË (ËÏÈΛ·, ‡„Ô˜, Ê˘Ï‹, ·ÈÙ›· ı·Ó¿ÙÔ˘ Î·È ¯ÚfiÓÔ˜ ÈÛ¯·ÈÌ›·˜)11. ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· Û˘Ó¯¤˜ ÛÎÔÚ Ô˘ ˘ÔÏÔÁ›˙ÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂÈ‚›ˆÛ˘ ÙÔ˘ ÌÔۯ‡̷ÙÔ˜. ™Â ÙÈ̤˜ ÙÔ˘ ÛÎÔÚ <1.0, Ë 3ÂÙ‹˜ ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ ˘ÔÏÔÁ›˙ÂÙ·È Û 80% ÂÚ›Ô˘, ÂÓÒ fiÙ·Ó ÙÔ ÛÎÔÚ Â›Ó·È >2.0, Ë ÂÈ‚›ˆÛË ÙÔ˘ ÌÔۯ‡̷ÙÔ˜ Â›Ó·È ÌfiÏȘ 60% ÛÙ· 3 ¤ÙË. ∞Ó Î·È ÙÔ DRI Â›Ó·È ·ÚÎÂÙ¿ ÔχÏÔÎÔ ·Ó·‰ÂÈÎÓ‡ÂÈ ÙË ¯ÚËÛÈÌfiÙËÙ· Ù¤ÙÔÈˆÓ ÛÎÔÚ ÚÔÎÂÈ̤ÓÔ˘ Ó· ηÙ¢ı‡ÓÔÓÙ·È Û˘ÁÎÂÎÚÈ̤ӷ ÌÔۯ‡̷ٷ ÛÂ Û˘ÁÎÂÎÚÈ̤ÓÔ˘˜ Ï‹Ù˜11. ŒÓ· Ôχ ·ÏÔ‡ÛÙÂÚÔ ÛÎÔÚ ·ÔÙÂÏ› ÙÔ DMELD ÛÎÔÚ, fiÔ˘ D Â›Ó·È Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË12. ŒÙÛÈ, ÙÈ̤˜ DMELD >400 Û¯ÂÙ›˙ÔÓÙ·È Ì ÂÙ‹ÛÈ· ÂÈ‚›ˆÛË ÌÔۯ‡̷ÙÔ˜ ÌÂÁ·Ï‡ÙÂÚË ·fi 91% ÌÂÙ¿ ÙËÓ ÌÂÙ·ÌfiÛ¯Â˘ÛË, ÂÓÒ ÌÂÈÒÓÂÙ·È Û ÌfiÏȘ 74% fiÙ·Ó ÙÔ DMELD ÛÎÔÚ Â›Ó·È >200012. H ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÛÎÔÚ ·˘ÙÔ‡ ÂÓ¤¯ÂÈ ÙÔÓ Î›Ó‰˘ÓÔ Î·Ù‡ı˘ÓÛË ÙˆÓ ÌÔÛ¯Â˘Ì¿ÙˆÓ ·fi ËÏÈÎȈ̤ÓÔ˘˜ ‰fiÙ˜ Û ·ÛıÂÓ›˜ Ì ¯·ÌËÏfi MELD ÛÎÔÚ, ÂÓÒ Ë ·Ó·ÌÔÓ‹ ÁÈ· ηχÙÂÚÔ ÌfiÛ¯Â˘Ì· (Ì ‚¿ÛË ÙÔ DMELD) Û ·ÛıÂÓ›˜ Ì ˘„ËÏfi MELD ›Ûˆ˜ Â›Ó·È ‰‡ÛÎÔÏÔ ÛÙËÓ Ú¿ÍË Î·È ÂӉ¯Ô̤ӈ˜ Ó· Ô‰ËÁ‹ÛÂÈ Û ·‡ÍËÛË Ù˘ ıÓËÙfiÙËÙ·˜ ηٿ ÙËÓ ·Ó·ÌÔÓ‹ ÛÙËÓ Ï›ÛÙ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË. ¶¤Ú· ·fi ÙȘ ‚·ÛÈΤ˜ ·Ú¯¤˜ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ÛÙËÓ ÂÈÏÔÁ‹ ÙÔ˘ ηٿÏÏËÏÔ˘ Ë·ÙÈÎÔ‡ ÌÔۯ‡̷ÙÔ˜ ·ÏÏ¿ Î·È ÙȘ ÚÔÙ¿ÛÂȘ Ô˘ ˘¿Ú¯Ô˘Ó Î·È Èı·ÓfiÓ Ó· ˘ÈÔıÂÙËıÔ‡Ó ÛÙÔ Ì¤ÏÏÔÓ, ˘¿Ú¯Ô˘Ó ÔÚÈṲ̂ÓÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë (Û ÌÈÎÚfiÙÂÚÔ ‹ ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi) ·Ó¿ÏÔÁ· Ì ÙÔ ·›ÙÈÔ Ù˘ ˘ÔΛÌÂÓ˘ Ë·ÙÔ¿ıÂÈ·˜ ÙÔ˘ ˘Ô„‹ÊÈÔ˘ Ï‹ÙË. ªÈ· Ù¤ÙÔÈ· ÛËÌ·ÓÙÈ΋ ηÙËÁÔÚ›· ·Ú·ÁfiÓÙˆÓ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜ Ù˘ ∞·ıÔ‡˜ ÓfiÛÔ˘ ÛÙÔ ÌfiÛ¯Â˘Ì·. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, ÌÔۯ‡̷ٷ ·fi anti-HBcore ıÂÙÈÎÔ‡˜ ‰fiÙ˜ ı· Ú¤ÂÈ Ó· ‰›ÓÔÓÙ·È Î·Ù¿ ÚÔÙ›ÌËÛË Û HBsAg (+) ·ÛıÂÓ›˜ (‰ËÏ HBV Ë·ÙÔ¿ıÂÈ·), ηıÒ˜ ÔÈ ÙÂÏÂ˘Ù·›ÔÈ ı· Ï¿‚Ô˘Ó Ô‡Ùˆ˜ ‹ ¿Ïψ˜ ·ÓÙÈÈ΋ ÚÔʇϷÍË ÁÈ· ÙËÓ ·ÔÊ˘Á‹ Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ HBV Ïԛ̈͢ ÛÙÔ ÌfiÛ¯Â˘Ì·13. ∂›Û˘ Ù¤ÙÔÈ· ÌÔۯ‡̷ٷ ÌÔÚÔ‡Ó Ó· ‰ÔıÔ‡Ó Û antiHBcore/antiHBs ıÂÙÈÎÔ‡˜ ‰fi-

Ù˜, ÔÈ ÔÔ›ÔÈ ‰Â ¯ÚÂÈ¿˙ÂÙ·È Ó· Ï¿‚Ô˘Ó ·ÓÙÈÈ΋ ÚÔʇϷÍË13. ŸÛÔÓ ·ÊÔÚ¿ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì HCV ΛÚÚˆÛË, ˘¿Ú¯Ô˘Ó ÛÂÈÚ¿ ·Ú·ÁfiÓÙˆÓ ÙÔ˘ ‰fiÙË Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ٷ¯‡ÙÂÚË ÂͤÏÈÍË Ù˘ ˘ÔÙÚÔ‹˜ Ù˘ HCV Ïԛ̈͢ ÌÂÙ¿ ÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË, Ô Î˘ÚÈfiÙÂÚÔ˜ ÙˆÓ ÔÔ›ˆÓ Â›Ó·È Ë ËÏÈΛ· ÙÔ˘ ‰fiÙË14. ¶Èı·Ó‹ Âȉ›ˆÍË Ï‹„˘ ÌÔۯ‡̷ÙÔ˜ ·fi ÓÂfiÙÂÚÔ ‰fiÙË ı· ›¯Â Èı·ÓfiÓ ıÂÙÈ΋ Â›‰Ú·ÛË ÛÙËÓ ‚Ú·‰‡ÙÂÚË ÂͤÏÈÍË Ù˘ HCV Ë·ÙÔ¿ıÂÈ·˜ ÛÙÔ ÌfiÛ¯Â˘Ì·. Δ¤ÏÔ˜, fiÛÔÓ ·ÊÔÚ¿ ÙÔ «Ù·›ÚÈ·ÛÌ·» ÙˆÓ HLA ‰fiÙË Î·È ‰¤ÎÙË, ·Ó Î·È ÁÂÓÈο ÛÙË ÌÂÙ·ÌfiÛ¯Â˘ÛË ‹·ÙÔ˜ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ‰È·‰Ú·Ì·Ù›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·fiÚÚÈ„Ë ÙÔ˘ ÌÔۯ‡̷ÙÔ˜, ›Ûˆ˜ ¤¯ÂÈ ÛËÌ·Û›· ÛÙËÓ Û˘¯ÓfiÙÂÚË ˘ÔÙÚÔ‹ Ù˘ PSC ÛÙÔ Ë·ÙÈÎfi ÌfiÛ¯Â˘Ì· ‹ ·ÎfiÌ· ÛÙËÓ ˘ÔÙÚÔ‹ Ù˘ ·˘ÙÔ¿ÓÔÛ˘ Ë·Ù›Ùȉ·˜ Û ÂÚ›ÙˆÛË fiÔ˘ Ô ‰fiÙ˘ Â›Ó·È Â›Û˘ HLA DR3 ıÂÙÈÎfi˜ ‹ fiÙ·Ó Ù· HLA ÌÂٷ͇ ‰fiÙË Î·È ‰¤ÎÙË ‰ÂÓ Ù·ÈÚÈ¿˙Ô˘Ó15.

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