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Том 22 №4 2020 год - Нефрология и диализ

Иммуносупрессивная терапия при стероид-зависимом нефротическом синдроме у детей. Обзор литературы

Агаронян А.Г. Вашурина Т.В. Комаров О.В. Зробок О.А. Ананьин П.В. Тимофеева А.Г. Фисенко А.П. Цыгин А.Н.

DOI: 10.28996/2618-9801-2020-4-474-489

Аннотация: Нефротический синдром является серьезным заболеванием почек, приводящим к жизнеугрожающим осложнениям и часто требующим повторных госпитализаций и длительного лечения. Терапия нефротического синдрома в дебюте направлена на индукцию ремиссии и включает прием преднизолона. Большинство пациентов чувствительны к начальной стероидной терапии, однако более половины имеют в последующем рецидивы, приобретая часто-рецидивирующий или стероид-зависимый характер болезни, что требует назначения кортикостероид-сберегающих агентов. Несмотря на многочисленные исследования эффективности иммуносупрессивных препаратов, до настоящего времени отсутствует консенсус по оптимальной стратегии выбора первой линии. Потенциальный риск канцерогенности и инфертильности привели к значительному сокращению показаний к применению алкилирующих агентов. Из-за недостаточной эффективности и малой доступности крайне редко используется неспецифический иммуностимулятор левамизол. Ингибиторы кальцинейрина показали хорошую эффективность в виде поддержания стойкой ремиссии болезни у большинства больных. Вместе с тем, актуальными проблемами стали формирование циклоспориновой зависимости, развитие нефротоксичности, присоединение артериальной гипертензии и формирование косметических побочных эффектов. В последние годы все чаще применяется микофенолата мофетил, эффективность которого продемонстрирована во многих многоцентровых исследованиях. Как правило, препарат назначается при доказанном недостаточном эффекте или токсичности циклоспорина А, тогда как его роль как иммуносупрессивного препарата первой линии недостаточно изучена. Отсутствие стероид-сберегающего действия перечисленных препаратов и критическая степень хронической стероидной интоксикации диктует необходимость использования курса биологической терапии ритуксимабом после тщательного исключения противопоказаний. Внедрение глюкокортикоидной терапии в свое время сыграло колоссальную роль в повышении выживаемости детей с нефротическим синдромом. После того, как достижение ремиссии у большинства больных перестало быть проблемой, новым вызовом явилось формирование стероидной зависимости, необходимость повторных курсов и/или длительной поддерживающей терапии преднизолоном. Для преодоления этой зависимости на протяжении полувека применяются и изучаются различные иммуносупрессивные препараты, которым посвящен данный обзор.

Для цитирования: Агаронян А.Г., Вашурина Т.В., Комаров О.В., Зробок О.А., Ананьин П.В., Тимофеева А.Г., Фисенко А.П., Цыгин А.Н. Иммуносупрессивная терапия при стероид-зависимом нефротическом синдроме у детей. Обзор литературы. Нефрология и диализ. 2020. 22(4):474-489. doi: 10.28996/2618-9801-2020-4-474-489

Весь текст

Ключевые слова: стероидзависимый нефротический синдром, глюкокортикостероиды, иммуносупрессивная терапия, микофенолата мофетил, циклоспорин А, левомизол, циклофосфамид, ритуксимаб, steroid-dependent nephrotic syndrome, glucocorticosteroids, immunosuppressive therapy, mycophenolate mofetil, cyclosporine A, levamisole, cyclophosphamide, rituximab

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