Тактика ведения тяжелого АНЦА-ассоциированного гломерулонефрита: сравнение международных рекомендаций и обзор литературы

Тяжелое поражение почек при АНЦА-ассоциированном васкулите остается серьезной проблемой для практикующего врача ввиду сложности определения самого термина и ограниченной доказательной базы, что связано с исключением пациентов с наиболее тяжелым поражением почек из большинства протоколов клинических исследований. Обсуждаемые в данном обзоре рекомендации ACR/VF, EULAR и KDIGO призваны ответить на вопросы, возникающие при ведении этой категории пациентов, однако ряд рекомендательных позиций, касающихся как индукционной, так и поддерживающей терапии, отличаются между документами, что с одной стороны повышает возможность выбора схем лечения, а с другой – увеличивает неопределенность их ожидаемого эффекта. Важную роль в идентификации пациентов с благоприятным и неблагоприятным почечным прогнозом играет биопсия почки, своевременное выполнение которой необходимо не только для подтверждения диагноза, но для решения вопроса об интенсификации терапии в случае выявления активных изменений и, наоборот, ее прекращении при выявлении преобладания хронических изменений и потребности в постоянной заместительной почечной терапии в отсутствии экстраренальных проявлений. В настоящее время разработано несколько шкал для оценки поражения почек при АНЦА-ассоциированных васкулитах, включающих целый рад гистологических параметров. Сохраняются противоречия в отношении дозировок глюкокортикоидов и выбора циклофосфамида или ритуксимаба для индукционной терапии и в отношении совместного применения этих препаратов. Наиболее противоречивым до настоящего времени остается вопрос о показаниях к применению плазмообменов, роль которых все еще не определена. Новые возможности лечения АНЦА-ассоциированных нефритов, связанные с применением комплемент-блокирующей терапии, вероятно смогут обеспечить улучшение прогноза при тяжелом поражении почек, принимая во внимание максимальный восстановительный эффект в отношении почечной функции именно для этой категории пациентов.

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