Нефротический синдром как фактор риска тромботических и тромбоэмболических осложнений

В обзоре дано представление о многофакторном происхождении тромботических и тромбоэмболических осложнений при нефротическом синдроме (НС). В сумме первичный и вторичный НС в 8 раз повышает риск развития венозных и артериальных тромбоэмболических осложнений в сравнении с 10-летним общепопуляционным риском. Наиболее часто в клинической практике встречаются венозные тромбозы (глубоких вен нижних конечностей, почечной и/или нижней полой, воротной вены, мезентериальных и интракраниальных вен), в то время как артериальные тромбозы с поражением конечностей или головного мозга наблюдаются гораздо реже. В целом развитие тромбозов значительно чаще отмечается у взрослых больных с НС, частота развития тромбоэмболий составляет у них 25%, тогда как у детей - около 3%. Факторы риска развития ВТО (венозных тромботических осложнений) у больных НС можно разделить на традиционные (модифицируемые и немодифицируемые) и связанные с НС. К модифицируемым следует отнести госпитализацию, ранее перенесенные ВТО, длительную иммобилизацию (>3 суток), лечебно-диагностические манипуляции (центральные и периферические венозные катетеры), приобретенные тромбофилии (антифосфолипидный синдром, гипергомоцистеинемия), аутоиммунные гломерулопатии, злокачественные новообразования, ожирение, прием оральных контрацептивов. К немодифицируемым факторам относятся пожилой возраст и наследственные тромбофилии. НС может сочетаться с генетическими маркерами тромбофилии (мутации генов фактора V - Leiden, G1691A), фактора II (G20210A), ингибитора активатора плазминогена-1 (PAI, 4G/4G, 4G/5G), ферментов фолатного цикла - метилен тетрагидрофолатредуктаза, MTHFR), однако количество исследований ограничено, а результаты противоречивы. Это лежит в основе сохраняющейся дискуссии о необходимости скрининга данных маркеров у больных НС. К факторам риска ВТО, обусловленным НС, относится гипогидратация, острое почечное повреждение, использование диуретиков и глюкокортикостероидов. Подчеркивается, что подходы к профилактической терапии тромботических и тромбоэмболических осложнений НС достаточно трудны, в основе их лежит оценка баланса «польза-риск»: снижение риска тромботических событий при оценке риска геморрагических осложнений.

нефротический синдром, венозные тромботические осложнения, nephrotic syndrome, venous thrombotic complications

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