6 курс / Гастроэнтерология / Аутоиммунные_заболевания_печени_в_практике_клинициста_Ивашкин_В
.pdf91
h 5. "= " +
5."= " +
" " + % +
$ $, "-, !* !% !) +" -
$ > > !-> " ( , "!% – + +- " $ - ' + " " ) ""-
( = % ! % . ? !* ) = +" ) ! ! !-> ) +" ) +"-
$ "=$ " + "-> "% , -
"$ ' + " !' !$ %" $ !* $-
$ +" “ % ”, " – +" “'!= % ”. & %= ; " " " , $ + =$ !' > "=$ " + , +" & - -( " + ( , + ' , = "- ' & + "- + >- "" ( " ( "=$.
5.1. $(( 6 % /, 66 %$2 , &
"= " + +" $ ) ! --> +" ' " >" ' % ' . <- ' " + – ' = , ) , ,-
h 5
92
h 5. "= " +
* $ + " + ' " + ( + ' . # '- +" '- ;! ( = %"!++ " + "!,* " > $. ! % ' % > , >- -) > ' +"$ $, $ " ; ( % " )! $ ) + $ + ' . # '- ; "- "=-$, ,* %-> " +" ' '-" + , +" - = .
. 2 $ $ #- 2 # (& % ' ; "- " + =- + "$ !)- $ > ' -)
1–5 , ($ ( $%
•" ) + ' ' " " .
•? " = /" + ";! .
•` "> " "= .
5–30 , ($ ( $%
•" "= .
•< $ ) " % .
•f " - % + ( +" ).
•? " = /" + ";! .
>30 ,
•" "= .
•_" ' "= .
•d % "! - % + .
•"- " !"-.
•# ( % + `.
•# ( ? d ?`_.
•0"!% "! - % +-
) )* "= = > " " - ! - " ( + " + . ` ! - , ' + " "=$ "> " , " >"- ' + " !, ' " "-> + " " >,!* > > >, = * > > + % .
93
h 5. "= " +
0) b c, " ,* $ 1–5- , + " + ( + ' ) , $ ' " , $ % "$, +" , " )! $ ' +" " -
) ( " + !.
; " " "> " % "=$ " + ' – + 0. ) "!=- +-
' '-> + > IgM, IgG +- + C1q `3 !-, "!,*!, " + % %! "-> !-> " ( . -" ) ) % ' )! -; ( , + + " = &$ "--> ! , ' +-, +" ( >
, %" % ( ; "-> & +" !-
. 9 " = + % , ) + + ' -$ $, "- )- > "$> + ' ' " " . ` "> " -
"= ) !' " ! !+"" )! & " " " + ( .
' c )-' " $ = ! 5- 30- + " + ( + ' (+ +" > $ 10- ) -- !+ +" ' ' " +
& + " . p "$ & % =$ $ 50
70%. + % " % "=$ %$ " +"- = -' ! ! ! ! + ,' " )"--> &;; "-> > , "- + " ) )! ! " - "- = . - $ ( ' > !-> " ( != &+$ = '-> +" &$
" -> ! .
> ' % – +- "=$ "q\ – +" !, +$, ' + .
d " % ) + $ + ' , +-$,*$ -$ !, ; " ( , ! " + "-> + ! " + " >- ; " "-" (" .17). _" "$ % % ' $ " " % "=$ ,' + "- + " + "- % + , %- > % ! , +" & + ) "!=- , ! ' ' )->. ?" +" , $ + +-
h 5
95
h 5. "= " +
= . 0 % ) "! $ ' =-> +"
' 50% + "-> " , ' ' |
+" =- |
$ ! + ! * " -> |
! )- |
" + -> . 0$ + > & + > " " - )-' " . b ! !- +" " + = ! &;; !; !' +" %" - "!,* % '$ ;! ($ " + )-' , )" !>! $.
5.2. ! &
5 -. < & + "->
$> + !'- !)- ,' "
- ! % +" ( |
>, !* > "= , |
" + . , "- - - |
" =- ! - |
' =- "% , '!= "- . b " -> =--> ! % ' $ " " + ! ; " "! $ ) ( & () "!,* "--; ( ) - ) !' (& "!,* "- -) + !,* " + ( % %
( , $ % + & . " +- ( % ! = -; ( "- % = % = . # !- & > +- - " ( , " "!% > ! +-> " ($> - "=$, , ' $ + ! "-$ "!,* % '$ -; ( .
) " ($> "=$ +" = CD4+- - ; ( (-> + " ). & "- ) !'-- - CD4+-; ( + ) --- " "= " + . )- "-> CD8+-; ( (-( ' >) - % ' % " ! , ) ' ) % ' -> + " ( "! )- " " " ( - "=$.
h 5
96
h 5. "= " +
- # # . 9 -
, -'- " ( + " ( 9#), & +" "-
-; ( >, + ) " + %- + +-
+ ! % % + % -
( <`). b' !- <`, )>- $ -'- % " +$, ! $ " !> α-( + , = ! "- * + * $ %- + + . b-$ $ = !- <` $ + -
> $ % !)-> > "! !"- & * ,
, $ -' % " +$ +" ( + ' , ; " " +" "$ * , +"$,- * , + +- %! )- ; "- )!-
! " "- + , 9#.
; % ' > ! $> * ! <` $ - + +-
, )" !,* $ +" ( "! ( -
. 9$ ($ -; ( , !* $ $ '-= , ) + ' -!, ( " !, - " , +" " * ,*!, -' " + ) -
-> % + ) - ! <`.
< "! & ( " , ! !-> )-( . % ! “ ! !- % + ”). c = ! - "$ $ ; (- % ( +" ", "! ), "- - '- + +- * , $ '!= "-, +" )"% +" "!,* . -; (- " + , '!-
= "- + +- + ) - !
<`.
? " % ' ' +" "- , " ! ( . 0"!%$ ; " " +" "$ % * ! <` " + )! , " - + = + + , & +" "-> ' + ">- , ' ,* $ % ! " . %- " '$ %! ! !%!)$ $ ' "!% > -> ; " "-> '-> + ! " + , +"$ -> --- - ( "-) ! % .& % " + $ $ '
97
h 5. "= " +
) % ' % , " +-> -; (-" .
)* +"$ - $ 2 " '->, ,' ,- * > +! -' % " +$ % " + [Womer K.L. et al., 2000]. # d + ( > " " ! $ " +--; ( " ( + " )"-> + + - + ! <` + "> " > "--> ?9. ?" !* # + -; (- " (-
+ " + , - " ! +" ( % %-
"- %- % + ) -
- ! <` + "> ?9 " ( + (" . 18). 9 + $, +"$ +! = %" !, " + % >" ' % - "=$.
6 . ($ -; ( , + " -!* $,* > " "= " + , +"$= +" ! ( ; " " - (TCGF), $* > $ -
h 5
# . 18. `> +"$% +"$% +! " +$ " +-; ( (+$ $ ). ?9 – % +" "!,*$ ; <` – %- + % ; T9# – -'- " ( + ".
98
h 5. "= " +
! ( + ( ' ,. 9 + " !, ' " $ $ "--2, -4, -7, -9 –15,
"- ! "!, +" ; " ( ,, " !, & + , "-> -; ( . , $
, ' TCGF %! = +" !' !- ( + " ; " ' " " + + "
! "$ +" ( + + ( " %!$"-> -
! +-> [Li X.C. et al, 2000].
% ' - ;! ( !* " ( " - + ( % ! -+$ \<-γ, "- !(- "! & +" , ! <` I II & ( > + " >-> > ( ' , % + ( >), "! ( '- -; (-, " ; % “+" ; -” ?9. ?- $ & +" $ <` > " + - " ! , ! % " ( + " + . < "$! TNF-β ( ; ) \<-γ !
& +" , > &$ ) " % &+$ ! % (ICAM), )>-> $ !* $ %" ( - ( " !' !,* >-; ( ?9 [Hutchinson I., 1998].
0$ +" $ $ " " ; " "!,* % ; " " (TGFβ): "-, $ $$ %- ; )" %-
( , , + , ! "! " (-
; )" " +" >" ' "= , "!% – !( "! + + -; ( , + ) !$ ; " " , " " + !.
5.3. 1 " -/
< " "$ "=$ ' $ +" - ' % % % ) " ! " " ( + , ' )--" " ( +" ", ! % %-> ) ( ). +"-+ " "=$ ! $ +" + ) " - " + % <`, " "-> $ " +"-
99
h 5. "= " +
= <` II , + )- + " " - > + "- " ( + . +" +" " +-
( "$ "% , ' + ' , %" ' , $ + "-
+ 0, +"$ ; ( " >
"% +- "$ +" =$ " + +" ! " % " ( .
7$ # . e %
+$, +" ! ( , ( "- " ; %--; ( = , & +" , ! <` " + "-> $>. ) ' ! % ' -> &;; \<-γ, " "-> -.
* – ) %" ) % +" > =$, $-
* $ %"!++ " , +$ +" ! ( , f-2 -> + "-
+ 1 & +" , " ( + " f-2 ( ' >-; ( >, +" " *$ - > ( ,. - + (FK-506) ! % ' ( + " !, ) )-
- ,.
& ; " " "! $ in vivo 6-" +- +!" !, !, "$ +$ -0<9 ' ,'$ ' = % $, % ) "!$ +" ; " ( , )- " $* > $ , '
; ( .
, – "- +" + " , "! ,* ;- & + + ( ; ' % +! +!-
"-> ! , !* $,* % $ +" +" ; " ( ; ( %- ! .
9 ) " + " ' -> +" + " = " " '- $ -$ ! +-> , +$$ ) &;; +-$ !- " + , +" & "-! '$ ' -" = + ) '-> &;; .$ & , ' +" " + ( + ' , ' -) " + +"$, 2 ! !+" " (+"- / +" + ( + " / " ! ), +- -> " !' ), " % "=$. < '-
h 5
100
h 5. "= " +
$ &;; ! $ ) ! !+" != + + ,' , +" + " " " – +"; ; .
#$ $ # . ) ( !- "- " +"$ - ' +" & + "-
- - ! !+" |
. |
|
; ( "$ |
-" + + |
! !- |
+" ! , |
+"$ - =-> $> - |
- ) !' ;-> "% " = &;-
; +" ; ( *-. $ & -
$* "$ $ +" + ' ) ! ! !$ ( " ! "!,* > -; ( – `D3. ,-CD3 +" +" "-, " % "=$ " + " + ' ! 75% )->, >
! " ! !+" [Lake
J.R., Gournay J., 1998]. ?-, &;; -CD3 c+- ) ! > +" " )- ;- "- , +" " " * ! !-
+" ! +" [Hubbard W.J. et al., 2000].
` 90-> % " > & + " " + %
T , & , ( ((
|
% |
|
|
|
|
h " % ' $ |
; ( "$ |
; (- |
-" /- |
||
|
-" |
-; (- |
( "- % )! |
|
|
|
|
|
- |
-CD3 |
Y"- -; (- |
|
-CD4 |
->+"- |
|
-CD25 (" (+" f-2) |
"- |
|
|
-; (- |
K X,%- - -CD5 + |
"- (CD5+) |
|
|
-(+, " ( |
-; (- |
K X,%- (- |
f-2 + |
"- (CD25+) |
|
; "- |
-; (- |
% )"- |
DAF/MCP/CD59, "- |
K+ ( ($ |
+ |
" + |
+ ' ! |
|
|
" ! +! ) |
|
|
|