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ПАЦИЕНТОВ, НАХОДЯЩИХСЯ НА ГЕМОДИАЛИЗЕИнфекция ВГС превалирует в гемодиализе населения и связан с повышенным риском для всех-причины и печеночно-связанной смертности. Сердечно-сосудистые заболевания по-прежнему, однако, основной причиной смерти у диализных пациентов независимо от статуса ВГС. Как и во всех настройках, кандидатуру диализных пациентов для противовирусной терапии требует специального рассмотрения сопутствующих заболеваний, поскольку болезнь печени может оказать незначительное влияние на прогнозируемые показатели заболеваемости и смертности этого пациента. ВГС-ассоциированного поражения печени может быть ускорен путем иммуносупрессии, и ИФН-α может привести к развитию почечной отторжение трансплантата. По этим причинам, противовирусная терапия должна быть рассмотрена для всех пациентов, находящихся на гемодиализе, которые будут кандидатами для трансплантации почки. Отражая опасения по поводу применения рибавирина в эту настройку, большинство опубликованных данных описывают использование ИФН-α монотерапии, в основном в небольших исследованиях с использованием обычных ИФН-α [154]. Пегилированный ИФН-α могут быть использованы и могут быть связаны с улучшением УВО [[155], [156]]. Пегилированный ИФН-α аккумулируется у пациентов с прогрессирующей почечной дисфункции, поэтому снижение дозы не требуется. Рекомендуемая доза Пег ИФН α 2а в этот параметр составляет 135 мкг/неделю. Обработка комбинации с Пегифн/РИБАВИРИН можно считать опытными врачами, и может повысить уровень УВО [157]. Индивидуализированное дозирование рибавирина по 200 мг/сут или 200 мг/через день или 200 мг трижды в неделю после гемодиализа, кроветворной и существенная поддержка необходима. Фармакокинетические исследования у пациентов с терминальной стадией почечной недостаточности выявляют существенного влияния почечной дисфункции на медикаментозное воздействие, предполагая, что оба ТВР и boc может быть использовано для лечения HCV-инфекции в этой обстановке [[158], [159]]. Нет опубликованных данных для описания эффективности и безопасности ПИ-включительно противовирусное лечение почечной недостаточности у пациентов с ВГС, так что клинические исследования в этой группе населения являются существенными. Недавно представила исследование, в котором участвовали 36 лечение-наивно Генотип 1 гемодиализных больных показал, что ТВР-содержащая тройная терапия имела более высокую эффективность, чем Пегифн/РИБАВИРИН-двойной терапии, но тройной терапии была связана с более анемия [160]. РЕКОМЕНДАЦИИ
НЕ ПЕЧЕНИ РЕЦИПИЕНТОВ ТРАНСПЛАНТАТОВ СОЛИДНЫХ ОРГАНОВ HCV-инфекции у реципиентов почечного трансплантата может ассоциироваться с повышением темпов прогрессирования фиброза печени. Большинство исследований по пересадке почки когорты показывают, что ВГС-позитивности связана с нарушением почечного трансплантата и выживаемость пациентов. Нарушениями зрения выживаемости трансплантата частично отражает увеличение смертности больных. Кроме того, ВГС специфических причин, связанных, таких как гломерулонефрит и повышенным риском диабета прививка повлияет на исход. ВГС-позитивности связана с повышенным от всех причин и печеночно-связанной смертности, хотя сердечно-сосудистые заболевания остаются основной причиной смерти пациента [161]. Как цирроз печени является важным предиктором плохого после трансплантации выживаемость после трансплантации почки, желательно сделать оценку стадии фиброза печени во всех ВГС-позитивных пересадки почки кандидатов [162]. Для пациентов с диагностированным циррозом печени, которым не удается (или непригодны к) гепатита противовирусное лечение, изолированной трансплантации почки может быть противопоказана и следует рассмотреть вопрос о комбинированной трансплантации печени и почек [163]. Лечение хронического гепатита С Пегифн/РИБАВИРИН у реципиентов почечного трансплантата связана с риском острого или хронического клеточного отторжения от 30% и более, в результате чего потери трансплантата и выживаемость пациентов снижена. Поэтому, Пегифн/РИБАВИРИН терапии имеет дополнительный риск в таких больных, и решение дать противовирусной терапии должны учитывать эти риски. Там, где это возможно, пациенты с показанием к трансплантации почки надо лечить от гепатита с. перед трансплантацией [164]. Данные об HCV-инфекции после трансплантации сердца немногочисленны и противоречивы исследования, показывающие без изменений или снизился уровень выживаемости у пациентов, инфицированных ВГС. Никаких исследований о рисках и преимуществах противовирусной терапии доступны для этих пациентов, а риск отторжения трансплантата на ИФН-α лечения остается неясной. В этом контексте лечения хронической HCV-инфекции в сердце реципиентов не может быть рекомендована и показания должны оцениваться на индивидуальной основе, если ВГС-инфекция представляет угрозу для жизни. Международные руководящие принципы список хронической HCV-инфекции как противопоказание к трансплантации легких [165]. Лечение легочного трансплантата до пересадки кандидатов был рекомендован некоторыми авторами, но существует ограниченный опыт с таким подходом. Нет данных о влиянии HCV-инфекции и ее лечение после трансплантации поджелудочной железы или тонкой кишки. РЕКОМЕНДАЦИИ
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