6 курс / Гастроэнтерология / Аутоиммунные_заболевания_печени_в_практике_клинициста_Ивашкин_В
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h 1. ! !- % +
" - - "! % + G (HGV, GBV-C), ' ! + ) -
) "!= HGV #<9 ! 9–15% )-> h. + %-
- ) - " " ;- ( , HGV &+ ; , ,* $ + % !
! !-> ) %" ,* $ "+ " = + ' .
" %% "$ " "! ; ( +" $ $ $.' !, ; ! " "! "% ) ,-$ ! +" ! ( "$ ( , ' γ-"-
; " , "- ! & +" , HLA I !( "!-& +" , HLA II % + ( >; + +" &
+" )" , = ;! ( " % +"- "!,* ( ?9). ) + ,, ; ! ; ( ,-
' , $ + ( ; ' '- %! "- !- >-
-. ! % ' % "! - +" !( "!, ) , >-
- + % "! !" ) ' , ( ' -
-; (- %! + " " -! &+ + .
` "! !" > "! -> ( = , "! -
->) ! &+ + + ) +" +" ) , "$
+-> ! ( ! "-> !- +-> . " ! % ( "- ( + "= ! "- -; (--> + "- - $ " . ; (- % , !* &+ +-, +- " " " % "!,* “ "- -” ! &+ + , - -
& +" , - ! "!,* > ! (CD2, CD28, LFA-1),
' % +" > ($ ! "-> -> +-
" . ! !' "-, ! "- ; (-
(" . 1) != != , $ ! + )- " %- " ! &+ + + "> “ +" ; ->” ?9 (% + (-, ) " % &+$).
-'- + " " " % "!,* &+ +- = %! +" "-! " , + "!% ! > !. % ! "- -; (- %! )- "--, -> + "-, “ ” "-> != , $, -
h 1
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h 1. ! !- % +
) >$ $ $ " + ( " ( ! % , ) + )- " +
“ "- -” &+ +-. & - %! $ - "!%
&+ +- + " " " % "!,* % % , +" "!$ % +- " " - &+ +- ! "- -> + " ( " ( ,' $ > ( . ? " % ; " " !$" ) " )$ ! &+ +, -> + "-, - $
$ $ " , "!, -; (- (" .2).
; ( " + + 33 -> ,
>$* ' , %- - &+ + (-
>" P450 2D6 (CYP2D6). 0- + + " " $ ' % ! &+ + , " ! ) "--; (-, + " = ,* % + (- +" h-2. ` "! !" & % + + > "! !" ) IEP-175 "! +" - % % "+ + 1 (HSV-1). $ & " + !> '- $(-> ) ( , ,* > - % + + HLA A1B8DR3. h-2 " $ ! >
# . 1. ! ($ -> + " + " " " % "!,* % |
(+$ $ ). |
13 |
h 1. ! !- % + |
h 1 |
# . 2. ! ($ -" ) ! + " " " % "!,* |
% (+$ $ ). |
+ + " % "+ ' ; ( , +" ' " !+ $ >"$ $ - " HSV-1 [Manns M.P., 1996]. ? !'- = - % % '-> + -$> $" % +" HCV CYP2A6.
<$ ,' , ' , " "! , ;! ( , ( "
! + % ' > +" ( %! -+$ "!% ;-
"- "!= ,* "-, ' "- )- - " -> +" + " . ) "!,* " ; "-- I II ;-, . . ; "- CYP b0\-% , !"- " ; "-, $ $, $ $ ! !-> " ( , !- ( "!-> " , "! (" .3) [Manns M.P., Obermayer-Strauss P., 1997, 2000]. ?" $ $ "$ -, ' " '- %- %! +! ! !- +" ( -, - +"- +" = !$" .
. 9 !- -
-, +" h -$ $, $ " )"- ! , + " "-> + = ! )* +"$ ; ( , % " - $, :
14
h 1. ! !- % +
# . 3. ` ( #450 b0\-% , !" " ; " " % +" )$> + ' .
1 (-1), > " " !,* $ ( " !$( !- "-> (ANA) ! ! 70–80% )-> / %-
-'-> ! (SMA) – ! 50–70% " ' " ;- ( + ' "-+ (p-ANCA);
2 (-2) " + ' + '
I + (-LKM-1), +"$ - ! 100% )->, % - ' -LKM-3 + ' '-( ! % ! (-LC-1);
3 (-3) " " ! + ' ' ! % ! (-SLA) + ' '-+ " ' ! % ! (--LP). ? + - $ $ " ; % " " $ + + h-1, !'- $ - ' ' ' ( 74%) -$ !,* > - " % ' > " " (ANA SMA).
? % ' $ " ! +" h $ $ .
15
h 1. ! !- % +
, ANA +" h-1 > " " !, $ " % " % ,;
" % "!, ( + ' ' !( + ' ' 0<9, " ) !-
+" , " + " #<9, % , ( "!- % + $" . _ $ ; ! !+" - " + ! ) )-> ANA SMA ' , , & !- = +" % ' " " , = > >- ".
" % +" ! " ( + "! (ASGP-R) – % +" ! + ' )"- % + ( – "" "!, h-1. -ASGP-R %! -$ $ $ +" ? d, - "! % + "!% > )$> + ' , !*
" = > " >. 9" % , ! |
) ($ |
-; ( & ! % !. $ & +" |
$ ASGP-R - |
) -" = + " + " , % )-' ) , , $
!+ '- "-, " = ,* )$.
" "-ANCA +"$ $ - ' > -$ -$ +" h-1 (65–96%), ' !* +"- !, +" "!% > )$> + ' [Zauli D. et al., 1997]. , $ & > ! != + G - )$ %"!++ -
% -> >" -> ) HMG1 HMG2.
CY#2D6 – -LKM-1 – != - % - ' " " h-2 [Obermayer-Strauss P. et al., 1998]. 9
!' ASGP-R, -$ ) ($ -; ( ! &-
+ + CYP2D6. % , + )- ) "- - ; (- ) "!=- +-> ; " > + ' )--> h-2. 85% & > ; ( ! ; + CD4+CD8- +"- !( "!, γ-"; " ( \<-γ) "-4 ( f-4), ' -! ) > +" = !)+ +!$( -> + " 1-% + . ! !+" $ " +$ = , -' %- ! &+ + CYP2D6. ? - ) ( -, " -LKM-1 + " = % + ( = ,' $ ( + NK-; ( + > ! ' ( ' .
-LKM-3 ) ' -$ $, $ +" >" ' % +-D, ) "!= , $ ! 10% )-> h-2. ,$ > != !' b0\-% , !" " ; "--1.
h 1
16
h 1. ! !- % +
? ' '- " - (-L ) "!-
, $ +" h " > ?`-1 +" " % + , --+" % " .
-LC-1 -$ $, $ ! 50% )-> h-2 +"$ $, - ( , = , " + ! ' , ;
! !+" |
, ' = !- > " + % . |
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-SLA, ) "!=- ! 30% )->, +"- +" |
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) . |
50 0 |
;! ( . 3/ !' |
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4 |
" |
-SLA +" ! !, ANA SMA, ' - |
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" |
" - |
" % ' " + + |
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h-1. |
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-LP, -" )- - ; ( "- ) |
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. |
52 48 0 , "$, " + , '- - |
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SLA - ! &+ +-. |
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+ %- ) "!=- β- !)X ( - % % " %- ( 0h), ' ,* $ + " + ! &+ +! -> +" % ) + ' [Ma Y. et al.,
1997, 2000].
)" , '- ) % = " % ' > " " > h $* % " '-> -+ ! " > " + " = + ' . -- ! , -$ $ - +" )$> + ' , > -
%-- +"- ) . 1.
-. < %$ = -
+ , "$ ! "= , ' ,'$ " + % h +" = ; ! ! " %!$( , +"$ $,* ! $ + " " ) - % . ? -" " ,* > ; " & , “ +" *-->” ; ( , ) "-> ! % + ' -,* > + " = ,* % + (-.
`" + "!$ ! " %!$( , + " -!* $,* > "! ( , + ' , ) "- $ - +" $ $ "!,* ' -' (-' . + ! & % !, +" ) - +-> ; " > -> + " 1-% + +" !( "!->
17
h 1. ! !- % +
1. $ - $ "
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% |
Y ) |
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ANA |
h" %- |
h; " = – ? d, ?`_, "! - |
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- %+, " - |
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%+ |
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LKM-1 |
CYP 2D6 |
h-2; " = – %+ ` |
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LKM-2 |
CYP 2C9 |
" ;- %+ |
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LKM-3 |
b0\-% , !" " - |
h+ D, h-2 |
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; " |
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LM |
CYP 1A2 |
0 % "- %+, |
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%+ +" ?`-1 |
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SMA |
F- |
h; " = – %+ ` |
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-SLA |
d "-? |
h-3 |
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-LP |
? |
h-3 |
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-LC-1 |
? |
h-2 |
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-LC-2 |
? |
h-2 |
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-ASGP-R |
ASGP-R |
h |
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M |
( " ; "-, +"- |
? d |
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!* c2-?0h |
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ANCA |
? |
h, ?`_ |
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( , = ) ($ -; ( !- % , " ; ( "- ' $ !- . ?" >" ' HBVHCV-; ( )- ($ -; ( % + ' !* ) . #$ & + "-> =-> h, " "-> - ) " +" " + !' )"$ $ - C57BI/6, +$, ) , -" =- -'- , +" !,* " , % % ' > +" % + .$ " , )! +" ! !- +" " , -'$ " +"$ $ [Lohse A.W. et al., 1993, 1995]. ; ($ -'-> &+ + – -$ ( ' > !-> " ( – + !* -" " +" $ + % h. -! +-> , +"$ !' !,* >+ " = + ' +" h, +" " . 4.
h 1
18
h 1. ! !- % +
1.3. $" ( /
` = * !=' " ) > -$ 8:1. ' ! +- + "- +- +$ $, $ " 10 30 ; " + ) +" > $ + + ! !. < ) ' ) " $ + +- , +"$ $$ ), + ( ; ' + : =-" ) + ) , " " %$, = ! , = ". b 1/4 ' )-> ), ) + " ! - " % "! % % + : "$ ) , " $, ,-" =$ = !> , % > " . + - !' )- "- % " $ + + +! ;! % % + " + ' ' ' . " ' , $ "- "!,* + ' '- +"$ $, +" ,* + " ' , " % " " ,
# . 4. ! + " = + ' .
19
h 1. ! !- % +
-> ! . . < (, ! "-> )-> )-' $ , % ! , !'-" = % + " =$ + ' , ! 10–20% – ( "" .
# " !$ $ h > " " ! $ ' - " , = !> , > " , " " %$, %$, $= ,+" + " ) " , " , " )"- =- - --
+$. - =- ! > " " $ ! $ % +" + = ' + " " % " h/? d. ?" )X -$ $, $ “ ! - ' ”, $"-" % ( " = )- " >, % "" % ' !%"- =- - -+$, ! %-+ " " +" = " ( = +"$ % , "- ), % + %$, + %$. 10–40% !' +"$-$ + + "$ ) +" + " ) " . < ( "" +" $, $ +" + " % + " +- ' ' & ( ; + .
. h - % )"-- +"$ $, ) ' - "-> )-, "-
" % ( 36% )->) ( "!+->, -
> ! >. " " % )-' , " "- > " " " = , )$, ! "-> )-> " $ + " " &"$ ! -> + "> '-
+$ " " % ; " . %! ) ,-
$ = + , ; +$, +$, ; )" "!- ,* , + " , + " " , " , " _ -(10–13%), % "! ;" ( ' ,* ' "- ,- + % ), !)! " (- ;" , " ^ %" , $ -- , > "- ) , % ' $ $, +- ' $ " ) ( +$, % + "& ;- " ". 9" " )"- =- + " =$: " - + - , "% ' +$" , ! - $ - ' , %- "" % ' ! , + " , + ; % , !$ &" , ! +"!" % . 9 !- -, h = )- +-?`-1, +"$ $,* % $ " " ! ; " =- -
h 1
20
h 1. ! !- % +
- , + " = & "-> (>80%), &- "-> = (>80%) ' (30%).
1.4. 1 # (($, /
-$ $, $ +- ` e, ' ' , ! "--" =- +$ " ) ( +$. $ )-'$ – % ' $ + " " +"$, ' +- "= $ " ! +"$ +" )- 9! ) $ ) = . "!) +- 2–10 " +" !*' +"$ ;" ( . " = +--$ 5–10 " ) , &;; ( # ( ` : f ) 1. b" * ' ; ;- +- - ' ! " . < ; - )-$ * ( "" ' = +$ +-+ ' ' ' : % + )! , % "" %- ' % " , =$ +" " ) % ( - !,* % ! ' , +" " ) % " ). _" " % + "% % )!$ +"- "- 2 " ) , )-' +$ +" !* - +- IgG. < " +"$, $ + ( ; ' + =- " !-- " '-> ! " % ' > " ( , ' -- $ ) "$ (E. oli, Treponema, Bacteroides, Salmonella) "! ( " , " !> , ( % "! !). < ) ,-$ +- α-; +" , "" "!,* ) > ' -, )$. < ( "" ' - " = , $ + ' ;! ( + ' .
1.5. (
= ! " %"!++ + !' , h +" = )-$ % % )$ ( ) ., +" -$ = ). = ! h-1 h-2, + " % ' >, ,-