Лечение хронического гепатита С у больных с избыточной
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ЛЕКЦИЯ Лечение хронического гепатита С у больных с избыточной массой тела П.П.Огурцов Кафедра факультетской терапии Российского университета дружбы народов, Национальный научный центр наркологии Росздрава Российской Федерации ωˈËÌÒÍËÏ ÔÓ·ÎÂχÏ, Ò‚flÁ‡ÌÌ˚Ï Ò ÓÊËÂÌËÂÏ, ÓÚÌÓÒflÚ ÔÓ‚˚¯ÂÌÌ˚È ËÒÍ Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ı Á‡·Ó΂‡ÌËÈ, Ò‡ı‡ÌÓ„Ó ‰Ë‡·ÂÚ‡ 2 ÚËÔ‡, ÌÂÍÓÚÓ˚ı ‚ˉӂ ÓÔÛıÓÎÂÈ, ÒË̉Óχ ‡ÔÌÓ˝ ‚Ó ÒÌÂ, ÔÓ‰‡„˚, ÔÒËı˘ÂÒÍÓÈ Ô‡ÚÓÎÓ„ËË [1,2]. Ç ÔÓÒΉÌË „Ó‰˚ ‰‡ÌÌ˚È Ô˜Â̸ ‡Ò¯ËËÎÒfl Á‡ Ò˜ÂÚ ‡ÍÚË‚ÌÓ ËÁÛ˜‡ÂÏÓÈ Ì‡ÎÍÓ„ÓθÌÓÈ ÊËÓ‚ÓÈ ·ÓÎÂÁÌË Ô˜ÂÌË (çÄÜÅè) Ë Â ÍÎËÌ˘ÂÒÍËı ‚‡Ë‡ÌÚÓ‚ (ÒÚ‡‰ËÈ): ÒÚ‡ÚÓÁ‡, ÒÚ‡ÚÓ„ÂÔ‡ÚËÚ‡, ÙË·ÓÁ‡ Ë ˆËÓÁ‡ Ô˜ÂÌË. è‚˘̇fl ÙÓχ çÄÜÅè ‡ÒÒχÚË‚‡ÂÚÒfl Í‡Í Ó‰ÌÓ ËÁ Ó„‡ÌÌ˚ı ÔÓfl‚ÎÂÌËÈ ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒË̉Óχ, ÍÓÚÓ˚È ‰Ë‡„ÌÓÒÚËÛ˛Ú ÔË Ì‡Î˘ËË ≥3 ÍËÚÂË‚ ËÁ 4: ËÁ·˚ÚӘ̇fl χÒÒ‡ Ú· (Ë̉ÂÍÒ Ï‡ÒÒ˚ Ú· (àåí) ≥25 Í„/Ï2), ‰ËÒÎËÔˉÂÏËfl, ̇ۯÂÌË ÚÓ·ÌÚÌÓÒÚË Í „βÍÓÁ ËÎË Ò‡ı‡Ì˚È ‰Ë‡·ÂÚ, ‡Ú¡θ̇fl „ËÔÂÚÂÌÁËfl. é·ÒÛʉ‡˛ÚÒfl Ë ‰Û„Ë Ô˘ËÌ˚ çÄÜÅè (‚ÚÓ˘̇fl ÙÓχ) – ÎÂ͇ÒÚ‚ÂÌÌ˚ ÔÂÔ‡‡Ú˚, Ô‡ÂÌÚ‡θÌÓ ÔËÚ‡ÌËÂ, ıËۄ˘ÂÒÍË ‚ϯ‡ÚÂθÒÚ‚‡ ̇ ÚÓÌÍÓÈ Í˯ÍÂ, ÒË̉ÓÏ ËÁ·˚ÚÓ˜ÌÓ„Ó ·‡ÍÚ¡θÌÓ„Ó ÓÒÚ‡ ‚ ÚÓÌÍÓÈ Í˯ÍÂ Ë ‰. èÓ Ï ̇ÍÓÔÎÂÌËfl ‰‡ÌÌ˚ı Ó Ù‡ÍÚÓ‡ı ËÒ͇, ÓÒÓ·ÂÌÌÓÒÚflı Ú˜ÂÌËfl, „ËÒÚÓÎӄ˘ÂÒÍËı ı‡‡ÍÚÂËÒÚË͇ı Ë ÔÓ„ÌÓÁ çÄÜÅè, ÒÚ‡ÎÓ ‚ÓÁÏÓÊÌ˚Ï ÓˆÂÌË‚‡Ú¸ ‚Í·‰ ˝ÚÓ„Ó Á‡·Ó΂‡ÌËfl ‚ ‡Á‚ËÚË ÒÓ˜ÂÚ‡ÌÌ˚ı ÙÓÏ ÔÓ‡ÊÂÌËfl Ô˜ÂÌË, ‚ ÚÓÏ ˜ËÒΠÔË ıÓÌ˘ÂÒÍÓÏ „ÂÔ‡ÚËÚ ë (ïÉë). ùÚÓ Ì‡Ô‡‚ÎÂÌË ‚ „ÂÔ‡ÚÓÎÓ„ËË Ô‰ÒÚ‡‚ÎflÂÚÒfl ÔÂÒÔÂÍÚË‚Ì˚Ï ÔÓ fl‰Û Ô˘ËÌ. ÇÓ-Ô‚˚ı, ÓÊËÂÌËÂ Ë Ò‚flÁ‡ÌÌ˚È Ò ÌËÏ ÏÂÚ‡·Ó΢ÂÒÍËÈ ÒË̉ÓÏ, ÔËÓ·ÂÚ‡˛˘ËÈ ‚ ‡Á‚ËÚ˚ı Òڇ̇ı ı‡‡ÍÚ ԇ̉ÂÏËË, ‚ÌÓÒflÚ ÒÛ˘ÂÒÚ‚ÂÌÌ˚È ‚Í·‰ ‚ Ó·˘Û˛ ÒÏÂÚÌÓÒÚ¸. ïÓÌ˘ÂÒ͇fl HCV-ËÌÙÂ͈Ëfl, ·Û‰Û˜Ë Ú‡ÍÊ ¯ËÓÍÓ ‡ÒÔÓÒÚ‡ÌÂÌÌÓÈ, Á‡ÌËχÂÚ ÎˉËÛ˛˘Ë ÔÓÁˈËË ÒÂ‰Ë Ô˘ËÌ ÒÏÂÚË ÓÚ Á‡·Ó΂‡ÌËÈ Ô˜ÂÌË. í‡ÍËÏ Ó·‡ÁÓÏ, Ó·‡ Á‡·Ó΂‡ÌËfl fl‚Îfl˛ÚÒfl ÒӈˇθÌÓ Á̇˜ËÏ˚ÏË. ÇÓ-‚ÚÓ˚ı, ÔÓ„ÌÓÁ ËÒıÓ‰Ó‚ ÔË Ì‡Î˘ËË ÒÓ˜ÂÚ‡ÌËfl çÄÜÅè Ë ïÉë ËÁÛ˜ÂÌ Ì‰ÓÒÚ‡ÚÓ˜ÌÓ, Ë, ÒΉӂ‡ÚÂθÌÓ, Ì ‡Á‡·Óڇ̇ Ú‡ÍÚË͇ ‚‰ÂÌËfl Ú‡ÍËı ·ÓθÌ˚ı. çÄÜÅè fl‚ÎflÂÚÒfl χÎÓÒËÏÔÚÓÏÌÓÈ ·ÓÎÂÁ̸˛, Ì Ó͇Á˚‚‡˛˘ÂÈ ÒÛ˘ÂÒÚ‚ÂÌÌÓ„Ó ‚ÎËflÌËfl ̇ ͇˜ÂÒÚ‚Ó ÊËÁÌË ‚ÔÎÓÚ¸ ‰Ó ‡Á‚ËÚËfl ÚÂÏË̇θÌ˚ı ÙÓÏ ÔÓ‡ÊÂÌËfl Ô˜ÂÌË. Ç ÚÓ Ê ‚ÂÏfl ÓÒÌÓ‚Ì˚ Ô˘ËÌ˚ ÒÏÂÚË ·ÓθÌ˚ı çÄÜÅè Ò‚flÁ‡Ì˚ Ò Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ÏË Á‡·Ó΂‡ÌËflÏË. í‡Í, ‚ ‰Ó΄ӂÂÏÂÌÌÓÏ ËÒÒΉӂ‡ÌËË, Ôӂ‰ÂÌÌÓÏ ‚ ò‚ˆËË, К ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 3 ÔÓ͇Á‡ÌÓ, ˜ÚÓ Á‡ 15 ÎÂÚ Ì‡·Î˛‰ÂÌËfl ËÁ 129 ·ÓθÌ˚ı Ò ÏÓÙÓÎӄ˘ÂÒÍË ‰Ó͇Á‡ÌÌÓÈ çÄÜÅè, ÒÓÔÓ‚Óʉ‡‚¯ÂÈÒfl ÔÓÒÚÓflÌÌ˚Ï ÔÓ‰˙ÂÏÓÏ ÛÓ‚Ìfl Ò˚‚ÓÓÚÓ˜Ì˚ı ‡ÏËÌÓÚ‡ÌÒÙ‡Á, 12,7% ·ÓθÌ˚ı ÛÏÂÎË ÓÚ Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ı ÓÒÎÓÌÂÌËÈ Ë ÚÓθÍÓ 1,6% ÓÚ ÔÓ‡ÊÂÌËfl Ô˜ÂÌË [3]. Ä̇Îӄ˘Ì˚ ÂÁÛθڇÚ˚ ÔÓÎÛ˜ÂÌ˚ Ë ‚ ‰Û„Ëı ËÒÒΉӂ‡ÌËflı [4]. è˜ÂÌÓ˜ÌÓ-‡ÒÒÓˆËËÓ‚‡Ì̇fl ÒÏÂÚÌÓÒÚ¸ ÒÓÒÚ‡‚ÎflÂÚ Ì ·ÓΠ20% ÔË ÒÚ‡ÚÓ„ÂÔ‡ÚËÚÂ Ë ÓÍÓÎÓ 3% ÔË ÒÚ‡ÚÓÁ Ô˜ÂÌË [5]. àÒıÓ‰fl ËÁ Ú˜ÂÌËfl Ë ÔÓ„ÌÓÁ‡ çÄÜÅè, ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ÔÓÙË·ÍÚ˘ÂÒÍËı ÒÚ‡Ú„ËÈ ÒΉÛÂÚ ÓˆÂÌË‚‡Ú¸, ‚ ÔÂ‚Û˛ Ә‰¸, ÔÓ „·‚ÌÓÏÛ ÍËÚÂ˲ ‰Ó͇Á‡ÚÂθÌÓÈ Ï‰ˈËÌ˚ – Ó·˘ÂÈ ‚˚ÊË‚‡ÂÏÓÒÚË. èÓ˝ÚÓÏÛ ÔËÁ̇‚‡Âχfl Ò„ӉÌfl ‚ ͇˜ÂÒÚ‚Â ÓÔÚËχθÌÓ„Ó Òڇ̉‡Ú‡ ÓˆÂÌÍË ÔÓ„ÌÓÁ‡ ÒÍÓÓÒÚ¸ ÔÓ„ÂÒÒËÓ‚‡ÌËfl ÙË·ÓÁ‡ Ô˜ÂÌË ·Û‰ÂÚ fl‚ÎflÚ¸Òfl ÚÓθÍÓ ÒÛÓ„‡ÚÌ˚Ï ÍËÚÂËÂÏ ˝ÙÙÂÍÚË‚ÌÓÒÚË Î˛·ÓÈ Ú‡ÔËË. Ç-ÚÂÚ¸Ëı, ̇΢ˠ‚ËÛÒÌÓ„Ó ÔÓ‡ÊÂÌËfl Ô˜ÂÌË ÏÓÊÂÚ ÒÛ˘ÂÒÚ‚ÂÌÌÓ ÎËÏËÚËÓ‚‡Ú¸ Ú‡Ô˲ ÔÓ ÒÌËÊÂÌ˲ ËÒ͇ ͇‰ËÓ-‚‡ÒÍÛÎflÌ˚ı ÓÒÎÓÊÌÂÌËÈ Û ·ÓθÌ˚ı c ÏÂÚ‡·Ó΢ÂÒÍËÏ ÒË̉ÓÏÓÏ. é· ˝ÚÓÏ Ò‚Ë‰ÂÚÂθÒÚ‚ÛÂÚ ÍÎËÌ˘ÂÒÍËÈ ÓÔ˚Ú ÔËÏÂÌÂÌËfl Ô‚˚ı ÔÂÔ‡‡ÚÓ‚ ËÁ „ÛÔÔ˚ Ò‰ÒÚ‚, ÔÓ‚˚¯‡˛˘Ëı ˜Û‚ÒÚ‚ËÚÂθÌÓÒÚ¸ ÔÂËÙ¢ÂÒÍËı Ú͇ÌÂÈ Í ËÌÒÛÎËÌÛ – ·Ë„Û‡Ìˉӂ (ÒËÌÚÓÎËÌ) Ë „ÎËÚ‡ÁÓÌÓ‚ (ÚÓ„ÎËÚ‡ÁÓÌ), ËÒÔÓθÁÓ‚‡ÌË ÍÓÚÓ˚ı ‚ ÍÎËÌ˘ÂÒÍÓÈ Ô‡ÍÚËÍ ·˚ÎÓ Á‡Ô¢ÂÌÓ ‚ Ò‚flÁË Ò ˜‡ÒÚ˚Ï ‡Á‚ËÚËÂÏ ÎÂ͇ÒÚ‚ÂÌÌÓ„Ó ÔÓ‡ÊÂÌËfl Ô˜ÂÌË [6]. é˜Â‚ˉÌÓ, ˜ÚÓ ÔË ÒÓ˜ÂÚ‡ÌËË çÄÜÅè Ò HCV-ËÌÙÂ͈ËÂÈ ÔÓ„ÌÓÁ Ô‰ÒÚ‡‚ÎflÂÚÒfl ·ÓΠҸÂÁÌ˚Ï. ÄÍÚۇθÌÓÈ ÔÓ·ÎÂÏÓÈ fl‚ÎflÂÚÒfl ı‡‡ÍÚ ‚ÎËflÌËfl ÓÊËÂÌËfl ̇ ÂÒÚÂÒÚ‚ÂÌÌÓ Ú˜ÂÌË ıÓÌ˘ÂÒÍÓÈ HCV-ËÌÙÂ͈ËË. ë‡Ï‡ ÔÓ Ò· HCV-ËÌÙÂ͈Ëfl ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ÙÓÏËÓ‚‡Ì˲ ÒÚ‡ÚÓÁ‡ Ô˜ÂÌË, ÓÒÓ·ÂÌÌÓ ÔË 3 „ÂÌÓÚËÔ HCV [7,8]. é‰Ì‡ÍÓ ÒÛÏÏËÛ˛˘Â Ì„‡ÚË‚ÌÓ ‚ÎËflÌË ˝ÚËı ‰‚Ûı Ô‡ÚÓ„ÂÌÂÚ˘ÂÒÍËı ÔÛÚÂÈ Ì‡ÍÓÔÎÂÌËfl Êˇ ‚ Ô˜ÂÌË ÓÍÓ̘‡ÚÂθÌÓ Ì ‰Ó͇Á‡ÌÓ. éÚ‰ÂθÌÓ„Ó ‡ÒÒÏÓÚÂÌËfl Á‡ÒÎÛÊË‚‡˛Ú ˝ÙÙÂÍÚ˚, Ó͇Á˚‚‡ÂÏ˚ ̇ ÔÓÚË‚Ó‚ËÛÒÌÛ˛ Ú‡Ô˲ (èÇí) Í‡Í Ò‡ÏËÏ ÓÊËÂÌËÂÏ, Ú‡Í Ë Ò‚flÁ‡ÌÌÓÈ Ò ÌËÏ çÄÜÅè Ë àê. äÓÏ ÚÓ„Ó, Û‚Â΢ÂÌ̇fl χÒÒ‡ Ú· Ú·ÛÂÚ ÍÓÂ͈ËË ‰ÓÁ˚ Í‡Í ËÌÚÂÙÂÓ̇-α (àîçα), ‚Íβ˜‡fl Ô„ËÎËÓ‚‡ÌÌ˚Â Â„Ó ÙÓÏ˚ (è„-àîçα), Ú‡Í Ë Ë·‡‚ËË̇, ˜ÚÓ ÏÓÊÂÚ ‚ÎËflÚ¸ ̇ ˜‡ÒÚÓÚÛ Ë ÒÔÂÍÚ ÌÂÊ·ÚÂθÌ˚ı fl‚ÎÂÌËÈ èÇí. 21 ЛЕКЦИЯ Влияние массы тела на результаты противовирусной терапии хронического гепатита С àÁÛ˜ÂÌË ‚ÎËflÌËfl χÒÒ˚ Ú· ̇ ÂÁÛθڇÚ˚ èÇí ̇˜‡ÎÓÒ¸ Ô‡ÍÚ˘ÂÒÍË Ò‡ÁÛ ÔÓÒΠÒÓÓ·˘ÂÌËÈ Ó· ÛÒÔ¯ÌÓÏ ÔËÏÂÌÂÌËË àîç-α ÔË ïÉë [9-12]. í‡Í, B.L.Bressler Ë ÒÓ‡‚Ú. (2003), ÔӇ̇ÎËÁËÓ‚‡‚ 253 ·ÓθÌ˚ı ïÉë, ÔÓÎÛ˜‡‚¯Ëı Ú‡Ô˲ àîç-α Ë Ë·‡‚ËËÌÓÏ, ÛÒÚ‡ÌÓ‚ËÎË, ˜ÚÓ ÔË Ì‡Î˘ËË ÓÊËÂÌËfl (àåí>30 Í„/Ï2) ˜‡ÒÚÓÚ‡ ÒÚÓÈÍÓ„Ó ‚ËÛÒÓÎӄ˘ÂÒÍÓ„Ó ÓÚ‚ÂÚ‡ (ëÇé) ·˚· ÌËÊ (ÓÚÌÓ¯ÂÌË ¯‡ÌÒÓ‚ 0,23), ˜ÂÏ ÔË ÔÓ‚˚¯ÂÌÌÓÈ (àåí – 25-30 Í„/Ï2) ËÎË ÌÓχθÌÓÈ (àåí<25 Í„/Ï2) χÒÒ Ú· [9]. Ñ‚‡ ÒÓ‚ÂÏÂÌÌ˚ı ÔÂÔ‡‡Ú‡ è„-àîç-α ËÏÂ˛Ú ‡Á΢ÌÛ˛ ÏÓÎÂÍÛÎflÌÛ˛ χÒÒÛ, ÔÓ˝ÚÓÏÛ Ëı هχÍÓÍËÌÂÚË͇ Ë Ù‡Ï‡ÍÓ‰Ë̇ÏË͇ ÒÛ˘ÂÒÚ‚ÂÌÌÓ ‡Á΢‡˛ÚÒfl. è„-àîç-α2‡ (脇ÒËÒ), Ëϲ˘ËÈ ·Óθ¯Û˛ ÏÓÎÂÍÛÎflÌÛ˛ χÒÒÛ (40Íч), ËÏÂÂÚ Ó„‡Ì˘ÂÌÌ˚È Ó·˙ÂÏ ‡ÒÔ‰ÂÎÂÌËfl Ë Ì‡Á̇˜‡ÂÚÒfl ‚ Òڇ̉‡ÚÌÓÈ ‰ÓÁ 180 ÏÍ„/̉ ÌÂÁ‡‚ËÒËÏÓ ÓÚ Ï‡ÒÒ˚ Ú·. ÑÂÈÒÚ‚ËÚÂθÌÓ, ÔÓ ÂÁÛÎ¸Ú‡Ú‡Ï Ì‰‡‚ÌÓ Á‡ÍÓ̘ÂÌÌÓ„Ó ËÒÒΉӂ‡ÌËfl HERACLES, ‚Íβ˜Ë‚¯Â„Ó 475 ·ÓθÌ˚ı ïÉë, ËÌÙˈËÓ‚‡ÌÌ˚ı HCV 1 „ÂÌÓÚËÔ‡ Ë ÔÓÎÛ˜‡‚¯Ëı èÇí è„-àîç-α2‡ Ë Ë·‡‚ËËÌÓÏ, ·Î‡„ÓÔËflÚÌ˚ÏË Ù‡ÍÚÓ‡ÏË ‰ÓÒÚËÊÂÌËfl ëÇé fl‚ËÎËÒ¸ ÚÓθÍÓ ÌËÁ͇fl ‚ËÛÒ̇fl ̇„ÛÁ͇ Ë ÌÓχÎËÁ‡ˆËfl ÛÓ‚Ìfl ‡ÏËÌÓÚ‡ÌÒÙ‡Á ˜ÂÂÁ 12 ̉Âθ ΘÂÌËfl [13]. é‰Ì‡ÍÓ ˝ÚË ‰‡ÌÌ˚ ÔÓ‰Ú‚Âʉ‡˛ÚÒfl Ì ‚Ó ‚ÒÂı ËÒÒΉӂ‡ÌËflı. Ç ËÒÒΉӂ‡ÌËË å.W.Fried Ë ÒÓ‡‚Ú. (2002 „.), ‚Íβ˜‡‚¯ÂÏ 453 ·ÓθÌ˚ı ïÉë, ÔÓÎÛ˜‡‚¯Ëı è„-àîç-α2‡ 180 ÏÍ„/̉ Ë Ë·‡‚ËËÌ 1000-1200 Ï„/ÒÛÚ, χÒÒ‡ Ú· >75 Í„ ·˚· ÌÂÁ‡‚ËÒËÏ˚Ï ÓÚˈ‡ÚÂθÌ˚Ï Ù‡ÍÚÓÓÏ ‰ÓÒÚËÊÂÌËfl ëÇé (ÓÚÌÓ¯ÂÌË ¯‡ÌÒÓ‚ 1,91; =0,002), ̇fl‰Û Ò „ÂÌÓÚËÔÓÏ HCV Ë ‚ÓÁ‡ÒÚÓÏ ·ÓθÌ˚ı [11]. Ç ‰Û„ÓÏ ËÒÒΉӂ‡ÌËË ÔÓ͇Á‡ÌÓ, ˜ÚÓ ˜‡ÒÚÓÚ‡ ëÇé Û ·ÓθÌ˚ı, ÔÓÎÛ˜‡‚¯Ëı è„-àîç-α2‡ 180 ÏÍ„/̉, ÒÓÒÚ‡‚Ë· 49% ÔË Ï‡ÒÒ Ú· ·ÓθÌ˚ı >85 Í„ ‚ Ò‡‚ÌÂÌ˲ Ò 60% ÔË ÏÂ̸¯ÂÈ Ï‡ÒÒ Ú· [14]. è„-àîç-α2b (è„àÌÚÓÌ) ËÏÂÂÚ ÏÂ̸¯Û˛ ÏÓÎÂÍÛÎflÌÛ˛ χÒÒÛ (12 Íч), ·Î‡„Ó‰‡fl ˜ÂÏÛ ËÏÂÂÚ ·Óθ¯ËÈ Ó·˙ÂÏ ‡ÒÔ‰ÂÎÂÌËfl. èË ˝ÚÓÏ Ï‡ÒÒ‡ Ú· Ó͇Á˚‚‡ÂÚ ÛÏÂÂÌÌÓ ‚˚‡ÊÂÌÌÓ ÔflÏÓ ‚ÓÁ‰ÂÈÒÚ‚Ë ̇ Â„Ó ÍÎËÂÌÒ, ÔÓ˝ÚÓÏÛ è„-àîç-α2b ÔËÌflÚÓ ‰ÓÁËÓ‚‡Ú¸ ÔÓ Ï‡ÒÒ Ú· – 1,5 ÏÍ„/Í„/̉ [15]. èË Ú‡ÍÓÏ ÔÓ‰ıӉ ‚ÎËflÌË χÒÒ˚ Ú· ·ÓθÌÓ„Ó Ì‡ ÂÁÛÎ¸Ú‡Ú èÇí ÚÂÓÂÚ˘ÂÒÍË ‰ÓÎÊÌÓ ÌË‚ÂÎËÓ‚‡Ú¸Òfl. ùÚÓ ÔÓ‰Ú‚Âʉ‡ÂÚÒfl fl‰ÓÏ ËÒÒΉӂ‡ÌËÈ ÒÂ‰Ë ÍÓÚÓ˚ı ·˚ÎË Í‡Í Î˜ÂÌÌ˚ ‚Ô‚˚Â, Ú‡Í Ë Ì ÓÚ‚ÂÚË‚¯Ë ̇ Ô‰˚‰Û˘ËÈ ÍÛÒ Ú‡ÔËË ·ÓθÌ˚ ïÉë [16-18]. é‰Ì‡ÍÓ ÒÛ˘ÂÒÚ‚Û˛Ú ËÒÒΉӂ‡ÌËfl, ÔÓ͇Á˚‚‡˛˘Ë ÒÌËÊÂÌË ˜‡ÒÚÓÚ˚ ÙÓÏËÓ‚‡ÌËfl ëÇé Û ·ÓθÌ˚ı Ò ‚˚ÒÓÍÓÈ Ï‡ÒÒÓÈ Ú·. í‡Í, ÒÓÓ·˘‡ÂÚÒfl, ˜ÚÓ ˜‡ÒÚÓÚ‡ ëÇé Û ·ÓθÌ˚ı Ò Ï‡ÒÒÓÈ Ú· >85 Í„ ÒÓÒÚ‡‚Ë· 49% ÔÓÚË‚ 58% ÔË ·ÓΠÌËÁÍÓÈ Ï‡ÒÒ [14]. Ç ‰Û„ÓÏ ËÒÒΉӂ‡ÌËË ÔË ‡Ì‡ÎËÁ ˜‡ÒÚÓÚ˚ ëÇé ‚ Á‡‚ËÒËÏÓÒÚË ÓÚ Ï‡ÒÒ˚ Ú· ·ÓθÌ˚ı, ÔÓÎÛ˜‡‚¯Ëı Í‡Í ÏÓÌÓÚ‡Ô˲ è„-àîç-α2b, Ú‡Í Ë ‚ ÒÓ˜ÂÚ‡ÌËË Ò Ë·‡‚ËËÌÓÏ 1000-1200 Ï„/ÒÛÚ ‚˚fl‚ÎÂ̇ ÒÛ˘ÂÒÚ‚ÂÌ̇fl ‡ÁÌˈ‡ ‚ ˜‡ÒÚÓÚ ‰ÓÒÚËÊÂÌËfl ëÇé Û ·ÓθÌ˚ı Ò ‚˚ÒÓÍÓÈ Ë ÌËÁÍÓÈ Ï‡ÒÒÓÈ Ú·. í‡Í, ·ÓθÌ˚Â Ò Ï‡ÒÒÓÈ Ú· >98 Í„ ËÏÂÎË ëÇé ÔËÏÂÌÓ ‚ 1,5 ‡Á‡ ÂÊ ÓÒ22 ڇθÌ˚ı ·ÓθÌ˚ı [10]. Ç ÔÓÒΉÌ ‚ÂÏfl ‚ÓÁÓ·ÌÓ‚ËÎÒfl ËÌÚÂÂÒ Í Ù‡Ï‡ÍÓÍËÌÂÚËÍ è„-àîç-α ‚ Ò‚flÁË Ò ÔÓfl‚ÎÂÌËÂÏ ÌÓ‚˚ı ÔÓÚË‚Ó˜˂˚ı ‰‡ÌÌ˚ı. ê‡Ò˜ÂÚ ÔÎÓ˘‡‰Ë ÔÓ‰ ÍË‚ÓÈ, ÍÓÚÓ‡fl fl‚ÎflÂÚÒfl ÔËÌflÚÓÈ ‚ ÍÎËÌ˘ÂÒÍÓÈ Ù‡Ï‡ÍÓÎÓ„ËË ı‡‡ÍÚÂËÒÚËÍÓÈ, Óڇʇ˛˘ÂÈ ËÌÚ„ËÓ‚‡ÌÌÛ˛ ÍÓ̈ÂÌÚ‡ˆËÓÌÌÛ˛ ÍË‚Û˛ (ÔÓ ÒÛÚË – ÔÓËÁ‚‰ÂÌË ÍÓ̈ÂÌÚ‡ˆËË Ì‡ ‰ÎËÚÂθÌÓÒÚ¸  ۉÂʇÌËfl), ÔÓ͇Á˚‚‡ÂÚ, ˜ÚÓ ÌÂÚ ˜ÂÚÍÓÈ ÍÓÂÎflˆËË ÏÂÊ‰Û Ï‡ÒÒÓÈ Ú· Ë ÔÓ͇Á‡ÚÂÎflÏË ÔÎÓ˘‡‰Ë ÔÓ‰ ÍË‚ÓÈ ÌË ‰Îfl è„-àîç-α2‡, ÌË ‰Îfl è„-àîç-α2b, Ì ÒÏÓÚfl ̇ ‰ÓÁËÓ‚‡ÌË ÔÓÒΉÌÂ„Ó ÔÓ Ï‡ÒÒ Ú· [21]. LJˇ·ÂθÌÓÒÚ¸ ÒÓÒÚ‡‚ÎflÂÚ ÓÍÓÎÓ 40% (50-80% ÔÓ ‰Û„ËÏ ‰‡ÌÌ˚Ï). ëΉӂ‡ÚÂθÌÓ, ÒÌËÊÂÌË ˜‡ÒÚÓÚ˚ ëÇé Û ·ÓθÌ˚ı ïÉë Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú· Ó·ÛÒÎÓ‚ÎÂÌÓ, ÒÍÓ ‚Ò„Ó, Ì ÚÓθÍÓ, Ë Ì ÒÚÓθÍÓ ÏÂ̸¯ÂÈ ÍÓ̈ÂÌÚ‡ˆËÂÈ ÔÂÔ‡‡Ú‡ ‚ ÍÓ‚Ë, ‡ ËÌ˚ÏË Ù‡ÍÚÓ‡ÏË, ÚÂ·Û˛˘ËÏË ‰‡Î¸ÌÂÈ¯Â„Ó ËÁÛ˜ÂÌËfl. Ожирение, стеатоз печени и эффективность противовирусной терапии хронического гепатита С ÇÓÁÏÓÊÌÓ, Ì χÒÒ‡ Ú·, ‡ ÓÊËÂÌËÂ Ë Ò‚flÁ‡ÌÌ˚Â Ò ÌËÏ Ô‡ÚÓÎӄ˘ÂÒÍË ÒÓÒÚÓflÌËfl ËÏÂ˛Ú Á̇˜ÂÌË ‚ ÒÌËÊÂÌËË ˜‡ÒÚÓÚ˚ ÙÓÏËÓ‚‡ÌËfl ëÇé. ä ÒÓʇÎÂÌ˲, àåí Ì ‡ÒÒ˜ËÚ˚‚‡ÎÒfl ‚Ó ÏÌÓ„Ëı ÍÛÔÌ˚ı ËÒÒΉӂ‡ÌËflı ÔÓ ÓˆÂÌÍ ˝ÙÙÂÍÚË‚ÌÓÒÚË ‡Á΢Ì˚ı ÒıÂÏ èÇí ïÉë ËÎË ËÒÍβ˜‡ÎÒfl ÔË Ôӂ‰ÂÌËË ÏÌÓ„ÓÙ‡ÍÚÓÌÓ„Ó ‡Ì‡ÎËÁ‡. Ç ËÒÒΉӂ‡ÌËË HERACLES ÌË Ï‡ÒÒ‡ Ú·, ÌË àåí Ì ‚ÎËflÎË Ì‡ ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ èÇí [13]. C ‰Û„ÓÈ ÒÚÓÓÌ˚, ‚ ËÒÒΉӂ‡ÌËË B.L.Bressler Ë ÒÓ‡‚Ú. (2003) ÔÓ ÓˆÂÌÍ ˝ÙÙÂÍÚË‚ÌÓÒÚË èÇí àîç-α Ë Ë·‡‚ËËÌÓÏ ·˚· ÛÒÚ‡ÌÓ‚ÎÂ̇ Ó·‡Ú̇fl Á‡‚ËÒËÏÓÒÚ¸ ˜‡ÒÚÓÚ˚ ëÇé ÓÚ àåí [9]. í‡ÍËÏ Ó·‡ÁÓÏ, ÓÒÚ‡ÂÚÒfl ÌÂflÒÌ˚Ï, ˜ÚÓ ËÏÂÌÌÓ – χÒÒ‡ Ú· ËÎË àåí – ‚ ·Óθ¯ÂÈ ÒÚÂÔÂÌË ÓÔ‰ÂÎflÂÚ ÔÓ„ÌÓÁ èÇí. ç‡Î˘Ë ÓÊËÂÌËfl Û ·ÓθÌ˚ı ïÉë Ó·ÛÒÎÓ‚ÎË‚‡ÂÚ Ì ÚÓθÍÓ ËÁÏÂÌÂÌËfl هχÍÓÍËÌÂÚËÍË àîç-α Ë è„-àîç-α, ÌÓ Ë ‡Á‚ËÚË çÄÜÅè. éÚϘÂ̇ Ôflχfl ÍÓÂÎflˆËfl ˜‡ÒÚÓÚ˚ ‚˚fl‚ÎÂÌËfl ÒÚ‡ÚÓÁ‡ Ò ‚Â΢ËÌÓÈ àåí [22]. ÇÎËflÌË ÒÚ‡ÚÓÁ‡ Ô˜ÂÌË Ì‡ ˜‡ÒÚÓÚÛ ëÇé ÔÓ͇Á‡ÌÓ ‚ ËÒÒΉӂ‡ÌËË T.Poynard Ë ÒÓ‡‚Ú., (2003), „‰Â ÔË ËÁÛ˜ÂÌËË ÏÓÙÓÎӄ˘ÂÒÍÓ„Ó Ï‡Ú¡· Ú͇ÌË Ô˜ÂÌË Û 574 ·ÓθÌ˚ı ïÉë (1,4,5,6 „ÂÌÓÚËÔ˚ ) ÓÚϘÂ̇ Á̇˜ËÚÂθ̇fl ‡ÁÌˈ‡ ‚ ˜‡ÒÚÓÚ ëÇé Û ·ÓθÌ˚ı Ò Ì‡Î˘ËÂÏ Ë ÓÚÒÛÚÒÚ‚ËÂÏ ÒÚ‡ÚÓÁ‡ Ô˜ÂÌË (35% Ë 57% ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ, <0,001) [7]. äÓÏ ÚÓ„Ó, ˝Ú‡ ‡ÒÒӈˇˆËfl ÒÓı‡Ìfl·Ҹ ÔË Òڇ̉‡ÚËÁ‡ˆËË ·ÓθÌ˚ı ÔÓ ‚ÓÁ‡ÒÚÛ, ÔÓÎÛ, àåí, ‚ËÛÒÌÓÈ Ì‡„ÛÁÍÂ, ÛÓ‚Ì˛ „βÍÓÁ˚ Ë ÒÚÂÔÂÌË ÙË·ÓÁ‡. ÅÓθÌ˚Â, ËÌÙˈËÓ‚‡ÌÌ˚ HCV 2 „ÂÌÓÚËÔ‡, ı‡‡ÍÚÂËÁÛ˛˘ËÂÒfl Ó·˚˜ÌÓ ‚˚ÒÓÍËÏË ÔÓ͇Á‡ÚÂÎflÏË ëÇé, Ú‡ÍÊ ‰ÂÏÓÌÒÚËÓ‚‡ÎË ‡Á΢Ëfl ‚ ˜‡ÒÚÓÚ ëÇé ‚ Á‡‚ËÒËÏÓÒÚË ÓÚ Ì‡Î˘Ëfl ËÎË ÓÚÒÛÚÒÚ‚Ëfl ÒÚ‡ÚÓÁ‡ (86% Ë 96% ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ, =0,04), ‚ ÚÓ ‚ÂÏfl Í‡Í Û ·ÓθÌ˚ı, ËÌÙˈËÓ‚‡ÌÌ˚ı HCV 3 „ÂÌÓÚËÔ‡, Ì ÓÚϘÂÌÓ ÍÓÂÎflˆËË ÏÂÊ‰Û ÒÚ‡ÚÓÁÓÏ Ë ˜‡ÒÚÓÚÓÈ ëÇé (85% ÔË Ì‡Î˘ËË ÒÚ‡ÚÓÁ‡ Ë 76% ‚ Â„Ó ÓÚÒÛÚÒÚ‚ËÂ, =0,34). Ç ‰Û„ÓÏ ËÒÒΉӂ‡ÌËË Û ·ÓθÌ˚ı ïÉë Ò 1 „ÂÌÓÚËÔÓÏ HCV ÏÂ̸¯‡fl ÒÚÂÔÂ̸ ÒÚ‡ÚÓÁ‡ Ô‰ ̇˜‡ÎÓÏ Ú‡ÔËË ‡ÒГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 3 ЛЕКЦИЯ ÒÓˆËËÓ‚‡Î‡Ò¸ Ò ·Óθ¯ÂÈ ˜‡ÒÚÓÚÓÈ ëÇé. í‡Í, ëÇé ÔË 1 „ÂÌÓÚËÔ HCV ˜‡˘Â ̇·Î˛‰‡ÎÒfl ÔË ÌÛ΂ÓÈ ÒÚÂÔÂÌË ÒÚ‡ÚÓÁ‡ (0-2% „ÂÔ‡ÚÓˆËÚÓ‚, ÒÓ‰Âʇ˘Ëı ÊË) – 71% ÔÓÚË‚ 42% ÔË Ì‡Î˘ËË ÒÚ‡ÚÓÁ‡ ‡Á΢ÌÓÈ ‚˚‡ÊÂÌÌÓÒÚË (=0,003). ëÚ‡ÚÓÁ Ô‰ÒÚ‡‚ÎflÂÚÒfl ‚‡ÊÌ˚Ï ÍÓÙ‡ÍÚÓÓÏ ÔÓ„ÂÒÒËÓ‚‡ÌËfl ïÉë, ‡ÒÒÓˆËËÓ‚‡ÌÌ˚Ï Ò ÙË·ÓÁÓÏ Ë ÒÌËʇ˛˘ËÏ ‚ÂÓflÚÌÓÒÚ¸ ÙÓÏËÓ‚‡ÌËfl ëÇé ÔË èÇí Û ·ÓθÌ˚ı Ò HCV-ËÌÙÂ͈ËÂÈ [23]. ç ÚÓθÍÓ Ì‡Î˘Ë ÒÚ‡ÚÓÁ‡, ÌÓ Ë ÒÚÂÔÂ̸ Â„Ó ‚˚‡ÊÂÌÌÓÒÚË fl‚ÎflÂÚÒfl ÌÂÁ‡‚ËÒËÏ˚Ï ÔÓ„ÌÓÒÚ˘ÂÒÍËÏ Ù‡ÍÚÓÓÏ ‰ÓÒÚËÊÂÌËfl ëÇé, ‚ ÚÓÏ ˜ËÒΠÔÓÒΠÒڇ̉‡ÚËÁ‡ˆËË ÔÓ ‚ÓÁ‡ÒÚÛ, ÔÓÎÛ Ë àåí [7,22,24]. í‡ÍËÏ Ó·‡ÁÓÏ, ÔÓ ÂÁÛÎ¸Ú‡Ú‡Ï ÏÌÓ„Ó˜ËÒÎÂÌÌ˚ı ËÒÒΉӂ‡ÌËÈ ÒÚ‡ÚÓÁ, ̇fl‰Û Ò ÙË·ÓÁÓÏ Ô˜ÂÌË, ÛıÛ‰¯‡ÂÚ ÂÁÛθڇÚ˚ èÇí ·ÓθÌ˚ı ïÉë. à ıÓÚfl ÒÚ‡ÚÓÁ fl‚ÎflÂÚÒfl Ù‡ÍÚÓÓÏ ÔÓ„ÂÒÒËÓ‚‡ÌËfl ÙË·ÓÁ‡, ÔÓ͇Á‡ÌÓ, ˜ÚÓ ÒÚ‡ÚÓÁ Ò‡Ï ÔÓ Ò·Â, ÌÂÁ‡‚ËÒËÏÓ ÓÚ ÙË·ÓÁ‡, ÒÔÓÒÓ·ÂÌ Ì„‡ÚË‚ÌÓ ‚ÎËflÚ¸ ̇ ‚ÂÓflÚÌÓÒÚ¸ ‰ÓÒÚËÊÂÌËfl ëÇé. Инсулинорезистентность и противовирусная терапия ÉËÔ„ÎËÍÂÏËfl fl‚ÎflÂÚÒfl Ù‡ÍÚÓÓÏ ËÒ͇ ‡Á‚ËÚËfl Ì ÚÓθÍÓ Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ı Á‡·Ó΂‡ÌËÈ, ÌÓ Ë çÄÜÅè, ‡ ÔË ÒÓ˜ÂÚ‡ÌËË Ò HCV-ËÌÙÂ͈ËÂÈ Â ÓÚˈ‡ÚÂθ̇fl Óθ ÏÓÊÂÚ ‚ÓÁ‡ÒÚ‡Ú¸. ìÒÚ‡ÌÓ‚ÎÂ̇ ˜ÂÚ͇fl Ò‚flÁ¸ ËÒ͇ Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ı Á‡·Ó΂‡ÌËÈ Ì ÚÓθÍÓ Ò „ËÔ„ÎËÍÂÏËÂÈ, ÌÓ Ë àê. àê ËÁÏÂflÂÚÒfl ÏÂÚÓ‰ÓÏ “„ÓÏÂÓÒÚ‡Ú˘ÂÒÍÓÈ” ÏÓ‰ÂÎË (Homeostasis Model Assessment ËÎË HOMAË̉ÂÍÒ), ÍÓÚÓ˚È ‡ÒÒ˜ËÚ˚‚‡ÂÚÒfl ̇ ÓÒÌÓ‚‡ÌËË ÔÓ͇Á‡ÚÂÎÂÈ ËÌÒÛÎË̇ Ë „βÍÓÁ˚ ‚ Ò˚‚ÓÓÚÍ ÍÓ‚Ë: çéåÄ-Ë̉ÂÍÒ = ÛÓ‚Â̸ ËÌÒÛÎË̇ ̇ÚÓ˘‡Í (åÖ/ÏÎ) ı „βÍÓÁ‡ ̇ÚÓ˘‡Í (ÏÓθ/Î) / 22,5. Ç ÌÓÏÂ Û Á‰ÓÓ‚˚ı β‰ÂÈ HOMA-Ë̉ÂÍÒ ‰ÓÎÊÂÌ ·˚Ú¸ <2,77. àÁÛ˜‡ÂÚÒfl Á̇˜ËÏÓÒÚ¸ Ë ÔÓ„ÌÓÒÚ˘ÂÒ͇fl ˆÂÌÌÓÒÚ¸ çéåÄ-Ë̉ÂÍÒ‡ ‚ ÔÂ‚Û˛ Ә‰¸ ÔË ÙÓχı (ÒÚ‡‰Ëflı) çÄÜÅè – ÒÚ‡ÚÓÁÂ Ë ÒÚ‡ÚÓ„ÂÔ‡ÚËÚÂ. ëÓÓ·˘‡ÂÚÒfl, ˜ÚÓ Û ·ÓθÌ˚ı ̇ÎÍÓ„ÓθÌ˚Ï ÒÚ‡ÚÓ„ÂÔ‡ÚËÚÓÏ çéåÄ-Ë̉ÂÍÒ ‚ 8% ÒÎÛ˜‡Â‚ Ô‚˚¯‡ÂÚ ÔÓ͇Á‡ÚÂθ 3 [25]. àϲÚÒfl ‰‡ÌÌ˚Â Ó Á̇˜ËÏÓÒÚË ÔÓ‚˚¯ÂÌËfl çéåÄ-Ë̉ÂÍÒ‡ Ë ÔË ‚ËÛÒÌ˚ı Á‡·Ó΂‡ÌËflı Ô˜ÂÌË. èË Ó·ÒΉӂ‡ÌËË 291 ·ÓθÌÓ„Ó ïÉë (1 „ÂÌÓÚËÔ) ·ÂÁ „ËÔ„ÎËÍÂÏËË ·˚ÎÓ ÔÓ͇Á‡ÌÓ, ˜ÚÓ ÛÏÂÂÌÌ˚È Ë ‚˚‡ÊÂÌÌ˚È ÒÚ‡ÚÓÁ ·˚Î ‡ÒÒÓˆËËÓ‚‡Ì Ò ÊÂÌÒÍËÏ ÔÓÎÓÏ, ‚˚ÒÓÍËÏ ÛÓ‚ÌÂÏ γ-„βڇÏËÎÚ‡ÌÒÔÂÔÚˉ‡Á˚ Ë ÔÓ‚˚¯ÂÌÌ˚Ï çéåÄ-Ë̉ÂÍÒÓÏ. ç‡Í‡ÔÎË‚‡ÂÚÒfl ‚Ò ·Óθ¯Â ‰‡ÌÌ˚ı Ó ÚÓÏ, ˜ÚÓ Ì ÒÚÓθÍÓ ÓÊËÂÌË ËÎË ÒÚ‡ÚÓÁ Ô˜ÂÌË, ÌÓ Ë àê fl‚ÎflÂÚÒfl Ó‰ÌËÏ ËÁ „·‚Ì˚ı ÔÓ„ÌÓÒÚ˘ÂÒÍËı Ù‡ÍÚÓÓ‚ ÙÓÏËÓ‚‡ÌËfl ëÇé [26]. LJÊÌÓÒÚ¸ àê ‰Îfl ‰ÓÒÚËÊÂÌËfl ëÇé ÔÓ͇Á‡Ì‡ ‚ ËÒÒΉӂ‡ÌËË, ÔÓ ‰‡ÌÌ˚Ï ÍÓÚÓÓ„Ó ˜‡ÒÚÓÚ‡ ëÇé ÔË ËÌÙˈËÓ‚‡ÌËË HCV 1 „ÂÌÓÚËÔ‡ ·˚· ÎËÌÂÈÌÓ Ò‚flÁ‡Ì‡ Ò ÔÓ͇Á‡ÚÂÎflÏË çéåÄ-Ë̉ÂÍÒ‡ Ë ÒÓÒÚ‡‚Îfl· 61%, 40% Ë 20% ‚ ÒÓÓÚ‚ÂÚÒÚ‚ËË ÒÓ Á̇˜ÂÌËflÏË çéåÄ-Ë̉ÂÍÒ‡ <2, 2-4 Ë >4 [27]. èË ÏÌÓ„ÓÙ‡ÍÚÓÌÓÏ ‡Ì‡ÎËÁ àê (çéåÄ-Ë̉ÂÍÒ >2), ÙË·ÓÁ Ë „ÂÌÓÚËÔ HCV ·˚ÎË ÌÂÁ‡‚ËÒËÏ˚ÏË Ù‡ÍÚÓ‡ÏË ‰ÓÒÚËÊÂÌËfl ëÇé, ÔË ˝ÚÓÏ àåí ·˚Î Ù‡ÍÚÓÓÏ ‡Á‚ËÚËfl àê (ÓÚÌÓ¯ÂГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 3 ÌË ¯‡ÌÒÓ‚ 2,49). èË ÏÌÓ„ÓÙ‡ÍÚÓÌÓÏ ‡Ì‡ÎËÁÂ, ‚Íβ˜‡‚¯ÂÏ àåí, ÒÚÂÔÂ̸ ÒÚ‡ÚÓÁ‡ Ô˜ÂÌË Ë ‰Û„Ë ÔÂÂÏÂÌÌ˚Â, àê Ú‡ÍÊ ‚˚ÒÚÛԇ· ‚ ͇˜ÂÒÚ‚Â ÔÓ„ÌÓÒÚ˘ÂÒÍÓ„Ó Ù‡ÍÚÓ‡ ‰ÓÒÚËÊÂÌËfl ëÇé. í‡ÍËÏ Ó·‡ÁÓÏ, ‚ÂÓflÚÌÓ, àê ËÏÂÂÚ ·Óθ¯Â ‚ÎËflÌË ̇ ÂÁÛÎ¸Ú‡Ú èÇí, ˜ÂÏ àåí. ÇÓÁÏÓÊÌÓ, Ò‚flÁ¸ ÏÂÊ‰Û „ËÔ„ÎËÍÂÏËÂÈ, àê Ë HCV-ËÌÙÂ͈ËÂÈ Á‡Íβ˜‡ÂÚÒfl Ì ÚÓθÍÓ ‚Ó ‚ÎËflÌËË Ì‡Û¯ÂÌËÈ Û„Î‚ӉÌÓ„Ó Ó·ÏÂ̇ ˜ÂÂÁ ‡Á‚ËÚË ÒÚ‡ÚÓÁ‡ Ë ÒÚ‡ÚÓ„ÂÔ‡ÚËÚ‡ ̇ ÒÍÓÓÒÚ¸ ÔÓ„ÂÒÒËÓ‚‡ÌËfl ïÉë Ë ‚ÂÓflÚÌÓÒÚ¸ ‰ÓÒÚËÊÂÌËfl ëÇé. Ç Ì‡ÒÚÓfl˘Â ‚ÂÏfl Ó·ÒÛʉ‡ÂÚÒfl Ë Ó·‡ÚÌÓ ‚ÎËflÌË HCV-ËÌÙÂ͈ËË Ì‡ ‡Á‚ËÚË ̇ۯÂÌËÈ Û„Î‚ӉÌÓ„Ó Ó·ÏÂ̇. ùÚÓ Ô‰ÔÓÎÓÊÂÌË ÓÒÌÓ‚˚‚‡ÂÚÒfl ̇ ÚÓÏ, ˜ÚÓ Û ·ÓθÌ˚ı Ò‡ı‡Ì˚Ï ‰Ë‡·ÂÚÓÏ 2 ÚËÔ‡ ËÌÙˈËÓ‚‡ÌË HCV ‚˚fl‚ÎflÂÚÒfl ˜‡˘Â, ˜ÂÏ ‚ Ó·˘ÂÈ ÔÓÔÛÎflˆËË [28-30]. èÓ͇Á‡Ì‡ Ò‚flÁ¸ ÏÂÊ‰Û ‡Á‚ËÚËÂÏ Ò‡ı‡ÌÓ„Ó ‰Ë‡·ÂÚ‡ Ë „ÂÌÓÚËÔÓÏ 2‡ HCV [29]. ÅÓΠÚÓ„Ó, ˝‡‰Ë͇ˆËfl HCV ÒÌËʇÂÚ Ì ÚÓθÍÓ àê, ÌÓ Ë ËÒÍ ‡Á‚ËÚËfl Ò‡ı‡ÌÓ„Ó ‰Ë‡·ÂÚ‡ [31]. í‡ÍËÏ Ó·‡ÁÓÏ, HCV-ËÌÙÂ͈Ëfl Ë Ì‡Û¯ÂÌËfl ۄ΂ӉÌÓ„Ó Ó·ÏÂ̇ ÒÔÓÒÓ·Ì˚ ‚Á‡ËÏÌÓ ÔÓÚÂ̈ËÓ‚‡Ú¸ ‰Û„ ‰Û„‡, Á‡Ï˚͇fl Ò‚ÓÂÓ·‡ÁÌ˚È “ÔÓÓ˜Ì˚È ÍÛ„”. Гиперхолестеринемия и ее коррекция, “нелипидные” эффекты статинов ÉËÔÂıÓÎÂÒÚÂËÌÂÏËfl, fl‚ÎflflÒ¸ Ó‰ÌËÏ ËÁ ÍÓÏÔÓÌÂÌÚÓ‚ ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒË̉Óχ, ̇·Î˛‰‡ÂÚÒfl Û 2080% ·ÓθÌ˚ı çÄÜÅè [32]. Ç ÚÓ Ê ‚ÂÏfl Û fl‰‡ ·ÓθÌ˚ı ÛÓ‚Â̸ ÎËÔˉӂ ÓÒÚ‡ÂÚÒfl ‚ ԉ·ı ÌÓÏ˚. ëÛ˘ÂÒÚ‚Û˛Ú Â‰ËÌ˘Ì˚ ËÒÒΉӂ‡ÌËfl ‚ÎËflÌËfl ıÓÎÂÒÚÂËÌÒÌËʇ˛˘Ëı ÔÂÔ‡‡ÚÓ‚ ̇ Ú˜ÂÌË çÄÜÅè, ÒÂ‰Ë ÍÓÚÓ˚ı ÒÚ‡ÚËÌ˚ fl‚Îfl˛ÚÒfl ·ÂÁÛÒÎÓ‚Ì˚ÏË Îˉ‡ÏË Ë Ëı ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ÔÓ ÛÏÂ̸¯ÂÌ˲ ËÒ͇ ‚ÒÂı Ì„‡ÚË‚Ì˚ı Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ı ÒÓ·˚ÚËÈ ‰Ó͇Á‡Ì‡ ÏÌÓ„Ó˜ËÒÎÂÌÌ˚ÏË ÍÎËÌ˘ÂÒÍËÏË ËÒÒΉӂ‡ÌËflÏË (4S, HPS, ASCOT-LLA, MIRACL Ë ‰.). é‰Ì‡ÍÓ ‚ Ô˜̠ÎÂ͇ÒÚ‚ÂÌÌ˚ı ÔÂÔ‡‡ÚÓ‚, ‚˚Á˚‚‡˛˘Ëı ÎÂ͇ÒÚ‚ÂÌÌÓ ÔÓ‡ÊÂÌË Ô˜ÂÌË, ÒÚ‡ÚËÌ˚ ̇Á˚‚‡˛ÚÒfl ‚ Ô‚ÓÏ ‰ÂÒflÚÍÂ, ‡ ‚ fl‰Â ‡·ÓÚ Ë ˜‡˘Â ÒÂ‰Ë „ÂÔ‡ÚÓÚÓÍÒ˘ÂÒÍËı ÔÂÔ‡‡ÚÓ‚ [33]. à ıÓÚfl ËÒÒΉӂ‡ÌË HPS (Heart Protection Study), ÔÓ‚Ó‰ËÏÓÂ Ò ‚Íβ˜ÂÌËÂÏ ·ÓΠ20 Ú˚Òfl˜ ˜ÂÎÓ‚ÂÍ, ‰ÎËÚÂθÌÓ (ÓÍÓÎÓ 5 ÎÂÚ) ÔÓÎÛ˜‡‚¯Ëı ÒËÏ‚‡ÒÚ‡ÚËÌ, ÔÓ͇Á‡ÎÓ ÓÚÌÓÒËÚÂθÌÛ˛ ·ÂÁÓÔ‡ÒÌÓÒÚ¸ Â„Ó ÔËÂχ – ÍÎËÌ˘ÂÒÍË Á̇˜ËÏÓ ÔÓ‚˚¯ÂÌË ÛÓ‚Ìfl ‡ÏËÌÓÚ‡ÌÒÙ‡Á ÓÚϘ‡ÎÓÒ¸ Û 0,8% ·ÓθÌ˚ı ÔÓÚË‚ 0,6% ÒÎÛ˜‡Â‚ ‚ „ÛÔÔ Ô·ˆÂ·Ó – ̇Á̇˜ÂÌË ÒÚ‡ÚËÌÓ‚ Ô‰ÔËÒ˚‚‡ÂÚ Ó·flÁ‡ÚÂθÌ˚È ÍÓÌÚÓθ Ô˜ÂÌÓ˜Ì˚ı ÙÂÏÂÌÚÓ‚ ͇ʉ˚ 3 ÏÂÒflˆ‡ ‚ Ô‚˚ 3 „Ó‰‡ ÔËÂχ. êfl‰ ËÒÒΉӂ‡ÌËÈ ‰Ó͇Á˚‚‡ÂÚ ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ Ë ·ÂÁÓÔ‡ÒÌÓÒÚ¸ ÔËÂχ ÒÚ‡ÚËÌÓ‚ ÔË çÄÜÅè. èÓ ‰‡ÌÌ˚Ï M.Ökstedt Ë ÒÓ‡‚Ú. (2006), Û 15 ·ÓθÌ˚ı çÄÜÅè, ÔÓÎÛ˜‡‚¯Ëı ÒÚ‡ÚËÌ˚ ·ÓΠ6 ÎÂÚ, Á‡Â„ËÒÚËÓ‚‡Ì „ÂÒÒ ÒÚ‡ÚÓÁ‡, ‚ ÚÓ ‚ÂÏfl Í‡Í ‚ „ÛÔÔ 53 ·ÓθÌ˚ı, ÒÓÔÓÒÚ‡‚ËÏ˚ı ÔÓ ÔÓÎÛ, ‚ÓÁ‡ÒÚÛ, ÎËÔˉÌÓÏÛ ÔÓÙËβ Ë „ËÒÚÓÎӄ˘ÂÒÍËÏ ı‡‡ÍÚÂËÒÚËÍ‡Ï ‚ ÓÚÒÛÚÒÚ‚Ë Ú‡ÔËË ‰‡ÌÌ˚ÏË ÔÂÔ‡‡Ú‡ÏË ÓÚϘ‡ÎÒfl ÔÂÊÌËÈ ÛÓ‚Â̸ ÒÚ‡ÚÓÁ‡ Ë Á‡Â„ËÒÚËÓ‚‡ÌÓ ÔÓ„ÂÒÒËÓ‚‡ÌË ÙË·ÓÁ‡ [34]. 23 ЛЕКЦИЯ ÇÎËflÌË „ËÔÂıÓÎÂÒÚÂËÌÂÏËË Ì‡ Ú˜ÂÌË ıÓÌ˘ÂÒÍÓÈ HCV-ËÌÙÂ͈ËË Ë ÂÁÛθڇÚ˚ èÇí Ô‡ÍÚ˘ÂÒÍË Ì ËÁÛ˜ÂÌÓ. Ç ËÒÒΉӂ‡ÌËË M.Ikeda (2006) ÔÓ͇Á‡ÌÓ ËÌ„Ë·ËÛ˛˘Â ‚ÎËflÌË ÒÚ‡ÚËÌÓ‚ ̇ ÂÔÎË͇ˆË˛ HCV Í‡Í ‚ ÂÊËÏ ÏÓÌÓÚ‡ÔËË, Ú‡Í Ë ‚ ÒÓ˜ÂÚ‡ÌËË Ò àîç-α. àÌÚÂÂÒÌÓ, ˜ÚÓ ÔÓÚË‚Ó‚ËÛÒÌ˚È ˝ÙÙÂÍÚ ÒÚ‡ÚËÌÓ‚ Ì Á‡‚ËÒÂÎ ÓÚ ıÓÎÂÒÚÂËÌÒÌËʇ˛˘Â„Ó ‰ÂÈÒÚ‚Ëfl Ë ·˚Î ÔËÒÛ˘ ‚ÒÂÏ ÔÂÔ‡‡Ú‡Ï ‰‡ÌÌÓÈ Ù‡Ï‡ÍÓÎӄ˘ÂÒÍÓÈ „ÛÔÔ˚, ÌÓ ‚ ·Óθ¯ÂÈ ÒÚÂÔÂÌË ·˚Î Ô‰ÒÚ‡‚ÎÂÌ Û Ô‡‚‡ÒÚ‡ÚË̇ [35]. åÂı‡ÌËÁÏ ÔÓÚË‚Ó‚ËÛÒÌÓ„Ó ‰ÂÈÒÚ‚Ëfl ÒÚ‡ÚËÌÓ‚ Ú·ÛÂÚ ËÁÛ˜ÂÌËfl. ÇÓÁÏÓÊÌÓ, ˝ÚÓ Ó·ÛÒÎÓ‚ÎÂÌÓ “ÌÂÎËÔˉÌ˚ÏË” ˝ÙÙÂÍÚ‡ÏË ÒÚ‡ÚËÌÓ‚, Í ÍÓÚÓ˚Ï ÓÚÌÓÒflÚ Ëı ÔÓÚË‚Ó‚ÓÒÔ‡ÚËÚÂθÌÓ ‰ÂÈÒÚ‚ËÂ, Ó·˙flÒÌflÂÏÓ ÒÚËÏÛÎflˆËÂÈ ÂˆÂÔÚÓÓ‚, ‡ÍÚË‚ËÛÂÏ˚ı ÔÓÎËÙ‡ÚÓÓÏ ÔÂÓÍÒËÒÓÏ (êêÄRγ). Ç ÍÛÔÌ˚ı ÍÎËÌ˘ÂÒÍËı ËÒÒΉӂ‡ÌËflı ÔÓ ÓˆÂÌÍ ˝ÙÙÂÍÚË‚ÌÓÒÚË ÒÚ‡ÚËÌÓ‚ (CARE, AFCAPS) ÔÓ͇Á‡ÌÓ, ˜ÚÓ ÓÌË ˝ÙÙÂÍÚË‚Ì˚ Û ·ÓθÌ˚ı Ò ÔÓ‚˚¯ÂÌÌ˚ÏË ÛÓ‚ÌflÏË Ï‡Í‡ ‚ÓÒÔ‡ÎÂÌËfl – ë-‡ÍÚË‚ÌÓ„Ó ·ÂÎ͇. ëӄ·ÒÌÓ ‰‡ÌÌ˚Ï ËÒÒΉӂ‡ÌËfl AFCAPS ˝ÚÓ ÓÚÌÓÒËÚÒfl Ë Í Î˛‰flÏ Ò Ô‡ÍÚ˘ÂÒÍË ÌÓχθÌ˚Ï ÛÓ‚ÌÂÏ ıÓÎÂÒÚÂË̇ ÎËÔÓÔÓÚÂËÌÓ‚ ÌËÁÍÓÈ ÔÎÓÚÌÓÒÚË (ïë-ãèçè). í‡ÍËÏ Ó·‡ÁÓÏ, ‚ÓÁÏÓÊÌÓ, ÒÚ‡ÚËÌ˚ ̇ȉÛÚ Ò‚Ó ÏÂÒÚÓ ‚ ΘÂÌËË çÄÜÅè, ‡ÒÒÓˆËËÓ‚‡ÌÌÓÈ Ò ïÉë. 臇‰ÓÍ҇θÌ˚ ÂÁÛθڇÚ˚ ·˚ÎË ÔÓÎÛ˜ÂÌ˚ ‚ ‡·ÓÚ ËÁ‡ËθÒÍËı Û˜ÂÌ˚ı: ‡Ì‡ÎËÁ, Ôӂ‰ÂÌÌ˚È Û 99 ·ÓθÌ˚ı ïÉë, ÔÓÎۘ˂¯Ëı èÇí, ÔÓ͇Á‡Î, ˜ÚÓ ÛÓ‚Â̸ ËÒıÓ‰ÌÓ„Ó Ó·˘Â„Ó ıÓÎÂÒÚÂË̇ Ë ïë ãèçè ·˚Î ‚˚¯Â ‚ ÒÎÛ˜‡Â ÙÓÏËÓ‚‡ÌËfl ëÇé [36]. êÂÁÛθڇÚ˚ ·˚ÎË ‰ÓÒÚÓ‚ÂÌ˚ÏË ÔÓÒΠÔӂ‰ÂÌËfl ÏÌÓ„ÓÙ‡ÍÚÓÌÓ„Ó ‡Ì‡ÎËÁ‡ Ò Û˜ÂÚÓÏ ÔÓ·, ‚ÓÁ‡ÒÚ‡, ÒÚ‡‰ËË ÙË·ÓÁ‡, ‚ËÛÒÌÓÈ Ì‡„ÛÁÍË, „ÂÌÓÚËÔ‡ HCV. ëÇé ·˚Î ÔÓÎÛ˜ÂÌ Û 33% ·ÓθÌ˚ı Ò ÛÓ‚ÌÂÏ ıÓÎÂÒÚÂË̇ <150 Ï„/‰Î Ë Û 64% ·ÓθÌ˚ı Ò ÛÓ‚ÌÂÏ ıÓÎÂÒÚÂË̇ >200 Ï„/‰Î, Ô˘ÂÏ ‚ ÓÒÓ·ÓÈ ÒÚÂÔÂÌË ‡ÁÌˈ‡ ‚ ÂÁÛθڇڇı èÇí ·˚· Ô‰ÒÚ‡‚ÎÂ̇ ÔË ËÌÙˈËÓ‚‡ÌËË HCV 1 Ë 2 „ÂÌÓÚËÔÓ‚. Ç ‰‡ÌÌÓÏ ËÒÒΉӂ‡ÌËË Ó‰ÌÓ‚ÂÏÂÌÌÓ Ò ÛÓ‚ÌÂÏ Ó·˘Â„Ó ıÓÎÂÒÚÂË̇ ÓˆÂÌË‚‡ÎÒfl ÛÓ‚Â̸ ïë-ãèçè, Á̇˜ÂÌË ÍÓÚÓÓ„Ó >100 Ï„/‰Î ‚ ̇ÒÚÓfl˘Â ‚ÂÏfl Ò‚flÁ˚‚‡˛Ú Ò ‚˚ÒÓÍËÏ ËÒÍÓÏ Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ı Á‡·Ó΂‡ÌËÈ. Ç˚fl‚ÎÂ̇ ÔÓÎÓÊËÚÂθ̇fl ÍÓÂÎflˆËfl ÏÂÊ‰Û ÛÓ‚ÌÂÏ ïë-ãèçè Ë ˜‡ÒÚÓÚÓÈ ëÇé: ÔË ÔÓ͇Á‡ÌËflı ïë-ãèçè <88 Ï„/‰Î, 88-119 Ï„/‰Î Ë >119 Ï„/‰Î ëÇé Á‡Â„ËÒÚËÓ‚‡Ì ‚ 37%, 43% Ë 58% ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ. èË Ó·˙flÒÌÂÌËË ÔÓÎÛ˜ÂÌÌ˚ı ‰‡ÌÌ˚ı ‡‚ÚÓ˚ ÒÒ˚·˛ÚÒfl ̇ ˝ÍÒÔÂËÏÂÌڇθÌ˚ ‡·ÓÚ˚, ‚ ÍÓÚÓ˚ı ·˚ÎÓ ÔÓ͇Á‡ÌÓ ÒÓ‰ÒÚ‚Ó HCV Í ÍÎÂÚÓ˜Ì˚Ï ÂˆÂÔÚÓ‡Ï ãèçè, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ Ó·ÒÛʉ‡Ú¸ ÍÓÌÍÛÂÌÚÌ˚È ÏÂı‡ÌËÁÏ Ò‚flÁ˚‚‡ÌËfl ãèçè Ë HCV Ò ‰‡ÌÌ˚ÏË ÂˆÂÔÚÓ‡ÏË. å‡ÎÓ ˜ËÒÎÓ ÍÎËÌ˘ÂÒÍËı ̇·Î˛‰ÂÌËÈ Ì ÔÓÁ‚ÓÎflÂÚ Ò‰Â·ڸ Ó‰ÌÓÁ̇˜Ì˚ı ‚˚‚Ó‰Ó‚, ÚÂÏ ·ÓΠ˜ÚÓ ÓÍÓÎÓ ÔÓÎÓ‚ËÌ˚ Ó·ÒΉӂ‡ÌÌ˚ı ·ÓθÌ˚ı ËÏÂÎË Ô‰ ̇˜‡ÎÓÏ èÇí ‚˚ÒÓÍÛ˛ ÒÚÂÔÂ̸ ÙË·ÓÁ‡ (F3 ËÎË F4), ˜ÚÓ ÏÓÊÂÚ ÓڇʇڸÒfl ̇ ÎËÔˉÌÓÏ ÔÓÙËÎÂ. èÓÎÛ˜ÂÌÌ˚ ÂÁÛθڇÚ˚ Ô‰ÒÚ‡‚Îfl˛ÚÒfl ËÌÚÂÂÒÌ˚ÏË Ë ÌÛʉ‡˛ÚÒfl ‚ Ò¸ÂÁÌÓÈ ÔÓ‚ÂÍÂ, ÔÓÒÍÓθÍÛ ÓÌË ÒÓÁ‰‡˛Ú ÚÂÓÂÚ˘ÂÒÍÓ ӷÓÒÌÓ‚‡Ìˠ̈ÂÎÂÒÓÓ·‡ÁÌÓÒÚË ıÓÎÂÒÚÂËÌÒÌËʇ˛˘ÂÈ Ú‡ÔËË Ô‰ èÇí Û ·ÓθÌ˚ı ïÉë Ò „ËÔÂıÓÎÂÒÚÂËÌÂÏËÂÈ. 24 Возможные механизмы снижения эффективности противовирусной терапии при ожирении é·ÒÛʉ‡˛ÚÒfl ÌÂÒÍÓθÍÓ Ì‡Ë·ÓΠ‚ÂÓflÚÌ˚ı Ô˘ËÌ ÒÌËÊÂÌËfl ˜‡ÒÚÓÚ˚ ëÇé ÔË ÓÊËÂÌËË, ‚Íβ˜‡fl ÒÌËÊÂÌË ·ËÓ‰ÓÒÚÛÔÌÓÒÚË àîç-α Ë Â„Ó ÒÔÓÒÓ·ÌÓÒÚË ‚ÓÁ‰ÂÈÒÚ‚Ó‚‡Ú¸ ̇ ÏÂÏ·‡ÌÛ „ÂÔ‡ÚÓˆËÚÓ‚ ÔË Ì‡Î˘ËË ÒÚ‡ÚÓÁ‡, ËÏÏÛÌÌÛ˛ ‰ËÒ„ÛÎflˆË˛, Ó·ÛÒÎÓ‚ÎÂÌÌÛ˛ ÂÁËÒÚÂÌÚÌÓÒÚ¸˛ Í ÎÂÔÚËÌÛ, ‚˚ÒÓÍÛ˛ ÒÚÂÔÂ̸ ÙË·ÓÁ‡ Ë ÒÚ‡ÚÓÁ‡ [37]. çÓ‚ÓÈ „ËÔÓÚÂÁÓÈ fl‚ÎflÂÚÒfl Ô‰ÔÓÎÓÊÂÌËÂ Ó ÒÛÔÂÒÒËË ˆËÚÓÍËÌÓ‚ ÔË ÓÊËÂÌËË. ì ·ÓθÌ˚ı ïÉë, ËÌÙˈËÓ‚‡ÌÌ˚ı HCV 1 „ÂÌÓÚËÔ‡ Ë Ëϲ˘Ëı ÓÊËÂÌËÂ, ‚˚fl‚ÎÂÌ ÔÓ‚˚¯ÂÌÌ˚È ÛÓ‚Â̸ ˝ÍÒÔÂÒÒËË ‚ Ô˜ÂÌË ·ÂÎ͇ SOCS-3 – ÒÛÔÂÒÒÓ‡ ˆËÚÓÍËÌÓ‚˚ı Ò˄̇ÎÓ‚. ùÍÒÔÂÒÒËfl SOCS3 ‚˚¯Â Û ·ÓθÌ˚ı, Ì Óڂ˜‡˛˘Ëı ̇ èÇí. ìÒÚ‡ÌÓ‚ÎÂ̇ ÍÓÂÎflˆËfl ˝ÍÒÔÂÒÒËË SOCS-3 Ò ÛÓ‚ÌÂÏ Ù‡ÍÚÓ‡ ÌÂÍÓÁ‡ ÓÔÛıÓÎÂÈ-α, Û˜‡ÒÚ‚Û˛˘Â„Ó ‚ Ô‡ÚÓ„ÂÌÂÁ ÙÓÏËÓ‚‡ÌËfl àê Ë ÒÚ‡ÚÓÁ‡ [38,39]. Терапевтические подходы в лечении хронического гепатита С при избыточной массе тела èËÌËχfl ‚Ó ‚ÌËχÌËÂ, ˜ÚÓ ÒÚ‡ÚÓÁ ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ÔÓ„ÂÒÒËÓ‚‡Ì˲ ÙË·ÓÁ‡ ÔË ïÉë, ˆÂÎÂÒÓÓ·‡ÁÌÓ ‚˚Òڇ˂‡Ú¸ ÒÚ‡Ú„˲ ΘÂÌËfl Ú‡ÍËı ·ÓθÌ˚ı, ̇ԇ‚ÎÂÌÌÛ˛ ̇ ÒÌËÊÂÌËÂ Â„Ó ÒÚÂÔÂÌË. ùÚÓ ÏÓÊÂÚ ·˚Ú¸ ‰ÓÒÚË„ÌÛÚÓ Í‡Í Á‡ Ò˜ÂÚ ÒÌËÊÂÌËfl χÒÒ˚ Ú·, Ú‡Í Ë Ì‡Á̇˜ÂÌËÂÏ ÎÂ͇ÒÚ‚ÂÌÌ˚ı ÔÂÔ‡‡ÚÓ‚, ÍÓË„ËÛ˛˘Ëı ‡ÁÌ˚ ÍÓÏÔÓÌÂÌÚ˚ ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒË̉Óχ: ÒÌËʇ˛˘Ëı „ËÔ„ÎËÍÂÏ˲, ÔÓ‚˚¯‡˛˘Ëı ˜Û‚ÒÚ‚ËÚÂθÌÓÒÚ¸ Í ËÌÒÛÎËÌÛ, ÌÓχÎËÁÛ˛˘Ëı ÎËÔˉÌ˚È ÒÔÂÍÚ. ᇉÂÊÍÛ Ì‡˜‡Î‡ èÇí ÓÚ ÌÂÒÍÓθÍËı ̉Âθ ‰Ó ÌÂÒÍÓθÍËı ÏÂÒflˆÂ‚ ‚ Ú‡ÍËı ÒÎÛ˜‡flı ÒΉÛÂÚ ÔËÁ̇ڸ ÓÔ‡‚‰‡ÌÌ˚Ï. ëÌËÊÂÌË χÒÒ˚ Ú· – ÏÛθÚˉËÒˆËÔÎË̇̇fl Á‡‰‡˜‡. Ç ÓÒÌÓ‚Â Ô‰‡ÌËfl, Ú‡Í ÊÂ Í‡Í Ë ÁÎÓÛÔÓÚ·ÎÂÌËfl ÔÒËıÓ‡ÍÚË‚Ì˚ÏË ‚¢ÂÒÚ‚‡ÏË (Ú‡·‡ÍÓÏ, ‡ÎÍÓ„ÓÎÂÏ, ̇ÍÓÚË͇ÏË) ÎÂÊ‡Ú Ó·˘Ë ԇÚÓ„ÂÌÂÚ˘ÂÒÍË ÏÂı‡ÌËÁÏ˚ ÙÓÏËÓ‚‡ÌËfl ıËÏ˘ÂÒÍÓÈ Á‡‚ËÒËÏÓÒÚË [40]. á̇˜ËÚÂθÌÛ˛ ˜‡ÒÚ¸ ·ÓθÌ˚ı ïÉë Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú· ÒÓÒÚ‡‚Îfl˛Ú ·ÓθÌ˚ ‡ÎÍÓ„ÓÎËÁÏÓÏ Ë Ì‡ÍÓχÌËÂÈ ‚ ÒÓÒÚÓflÌËË ÂÏËÒÒËË Ò ‡Á‚ËÚËÂÏ Á‡ÏÂÒÚËÚÂθÌÓÈ ·ÛÎËÏËË [41]. É·‚̇fl Ú‡Ô‚Ú˘ÂÒ͇fl ˆÂθ – ËÁÏÂÌÂÌË ÌÂÔ‡‚ËθÌÓ„Ó ÔË˘Â‚Ó„Ó Ôӂ‰ÂÌËfl – ‰ÓÒÚË„‡ÂÚÒfl Ò ÔÓÏÓ˘¸˛ ‡ˆËÓ̇θÌÓÈ ÔÒËıÓÚ‡ÔËË, ÒÏÂÌ˚ Ó·‡Á‡ ÊËÁÌË, Û‚Â΢ÂÌËfl ÙËÁ˘ÂÒÍÓÈ ‡ÍÚË‚ÌÓÒÚË, هχÍÓÎӄ˘ÂÒÍËı ÏÂÚÓ‰Ó‚, ıËۄ˘ÂÒÍËı ÔÓÒÓ·ËÈ, ÔËÏÂÌflÂÏ˚ı ‚ ÍÓÏÔÎÂÍÒ ËÎË ÔÓ ÓÚ‰ÂθÌÓÒÚË [42-44]. Ç Í‡˜ÂÒÚ‚Â ÔËχ ÏÓÊÌÓ ÔË‚ÂÒÚË ËÒÒΉӂ‡ÌËÂ, ‚ ÍÓÚÓÓÏ ËÁÛ˜‡ÎÓÒ¸ ‚ÎËflÌË ÒÌËÊÂÌËfl χÒÒ˚ Ú· Á‡ Ò˜ÂÚ „ËÔÓ͇ÎÓËÈÌÓÈ ‰ËÂÚ˚ Ë ÔÓ‚˚¯ÂÌËfl ÙËÁ˘ÂÒÍÓÈ ‡ÍÚË‚ÌÓÒÚË Ì‡ ÔÓÚflÊÂÌËË 3 ÏÂÒflˆÂ‚ ̇ „ËÒÚÓÎӄ˘ÂÒÍÛ˛ ͇ÚËÌÛ ‚ Ô˜ÂÌË Û ·ÓθÌ˚ı ïÉë Ò ÓÊËÂÌËÂÏ [45]. èÓ͇Á‡ÌÓ, ˜ÚÓ Ô‡‡ÎÎÂθÌÓ ÛÏÂ̸¯ÂÌ˲ χÒÒ˚ Ú· (‚ Ò‰ÌÂÏ Ì‡ 5,9±3,2 Í„) ÒÌËʇÎÒfl ÛÓ‚Â̸ Äãí (ËÒ. 1). óÂÂÁ 3 ÏÂÒflˆ‡ ‚˚fl‚ÎÂÌÓ ‰ÓÒÚÓ‚ÂÌÓ ÛÏÂ̸¯ÂÌË ÛÓ‚Ìfl ËÌÒÛÎË̇ ̇ÚÓ˘‡Í Ò 16±7 ‰Ó 11±4 ÏÏÓθ/Î (p<0,002) Ë HOMA-Ë̉ÂÍÒ‡ Ò 4,2±3,3 ‰Ó 2,5±1,1 (p=0,03). Ç 9 ËÁ 10 Ô‡Ì˚ı ·ËÓÔÒËÈ ÓÚϘÂÌ Â„ÂÒÒ ÒÚ‡ÚÓÁ‡ ÌÂÁ‡‚ËÒËÏÓ ÓÚ „ÂÌÓÚËÔ‡ HCV, ‚ ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 3 5 ·ËÓÔÒËflı – ÒÌËÊÂÌË ‡ÍÚË‚‡ˆËË Á‚ÂÁ‰˜‡Ú˚ı ÍÎÂÚÓÍ Ë ÔÓ͇Á‡ÚÂÎfl ÙË·ÓÁ‡ ÔÓ K.Ischak Ò 3 ‰Ó 1, =0,04 (ËÒ. 2). í‡ÍËÏ Ó·‡ÁÓÏ, ÒÌËÊÂÌË ‚ÂÒ‡ Û ·ÓθÌ˚ı ïÉë ÒÓÔÓ‚Óʉ‡ÂÚÒfl ÛÎÛ˜¯ÂÌËÂÏ ˜Û‚ÒÚ‚ËÚÂθÌÓÒÚË Í ËÌÒÛÎËÌÛ, ÒÌËÊÂÌËÂÏ ÛÓ‚Ìfl Äãí, „ÂÒÒÓÏ ÒÚ‡ÚÓÁ‡ Ë ÙË·ÓÁ‡ Ô˜ÂÌË Ì ÒÏÓÚfl ̇ ÔÂÒËÒÚËÓ‚‡ÌË HCV, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ Ô‰·„‡Ú¸ ‚ ͇˜ÂÒÚ‚Â ‚‡ÊÌÓ„Ó ‰ÓÔÓÎÌËÚÂθÌÓ„Ó Î˜ÂÌËfl Û ·ÓθÌ˚ı ïÉë Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú· ÍÓÏÔÎÂÍÒ ÏÂÓÔËflÚËÈ, ̇ԇ‚ÎÂÌÌ˚ı ̇ ÛÏÂ̸¯ÂÌË χÒÒ˚ Ú·. ùÙÙÂÍÚË‚ÌÓÒÚ¸ ÏÂÚÓ‰Ó‚ هχÍÓÎӄ˘ÂÒÍÓÈ Ë ıËۄ˘ÂÒÍÓÈ ÍÓÂ͈ËË Ï‡ÒÒ˚ Ú· Û ·ÓθÌ˚ı ïÉë Ò ÓÊËÂÌËÂÏ ‚ ̇ÒÚÓfl˘Â ‚ÂÏfl Ì ӈÂÌÂ̇, Ӊ̇ÍÓ ‰‡ÌÌ˚ ÔÓ‰ıÓ‰˚, ‚ÂÓflÚÌÓ, ÓÔ‡‚‰‡Ì˚ Ë Û ˝ÚÓÈ Í‡Ú„ÓËË ·ÓθÌ˚ı. ëӄ·ÒÌÓ ÂÍÓÏẨ‡ˆËflÏ ç‡ˆËÓ̇θÌÓ„Ó ËÌÒÚËÚÛÚ‡ Á‰ÓÓ‚¸fl (ëòÄ) هχÍÓÎӄ˘ÂÒ͇fl ÍÓÂ͈Ëfl ÓÊËÂÌËfl ÔÓ͇Á‡Ì‡ ÔË àåí ≥30 Í„/Ï2 ËÎË ≥27 Í„/Ï2 ÔË Ì‡Î˘ËË ÓÒÎÓÊÌÂÌËÈ, ‚˚Á‚‡ÌÌ˚ı ÓÊËÂÌËÂÏ. ÑÎfl ‰ÎËÚÂθÌÓÈ Ù‡Ï‡ÍÓÚ‡ÔËË ËÒÔÓθÁÛ˛ÚÒfl ÒË·ÛÚ‡ÏËÌ (ËÌ„Ë·ËÚÓ Á‡ı‚‡Ú‡ ÒÂÓÚÓÌË̇ Ë ÌÓ˝ÔËÌÂÙË̇, ÔÓ‰‡‚Îfl˛˘ËÈ ˜Û‚ÒÚ‚Ó „ÓÎÓ‰‡ Ë ÒÔÓÒÓ·ÒÚ‚Û˛˘ËÈ ·˚ÒÚÓÏÛ Ì‡ÒÚÛÔÎÂÌ˲ Ò˚ÚÓÒÚË ‚Ó ‚ÂÏfl ÔËÂχ ÔˢË) Ë ÓÎËÒÚ‡Ú (ËÌ„Ë·ËÚÓ Í˯˜ÌÓÈ ÎËÔ‡Á˚, ÒÌËʇ˛˘ËÈ ‚Ò‡Ò˚‚‡ÌË ÊËÓ‚). ç‰ÓÒÚ‡Ú͇ÏË Ù‡Ï‡ÍÓÚ‡ÔËË fl‚ÎflÂÚÒfl Ó·‡ÚÌ˚È ·˚ÒÚ˚È ÓÒÚ Ï‡ÒÒ˚ Ú· ÔË ÓÚÏÂÌ ÔÂÔ‡‡ÚÓ‚ Ë Ì‡Î˘Ë ÔÓÚË‚ÓÔÓ͇Á‡ÌËÈ Í Ì‡Á̇˜ÂÌ˲ ÒË·ÛÚ‡ÏË̇ ·ÓθÌ˚Ï Ò Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ÏË Á‡·Ó΂‡ÌËflÏË (‚ ÔÂ‚Û˛ Ә‰¸, ‡Ú¡θÌÓÈ „ËÔÂÚÂÌÁËÂÈ), ÍÓÚÓ˚ ˜‡ÒÚÓ ‚˚fl‚Îfl˛ÚÒfl Û ·ÓθÌ˚ı ÓÊËÂÌËÂÏ [44]. ÑÎfl Îˈ Ò ÏӷˉÌ˚Ï ÓÊËÂÌËÂÏ ËÎË ÔË ÓÚÒÛÚÒÚ‚ËË ˝ÙÙÂÍÚ‡ ÓÚ Ù‡Ï‡ÍÓÚ‡ÔËË ‚ ͇˜ÂÒÚ‚Â ‡Î¸ÚÂ̇ÚË‚˚ ‚˚ÒÚÛÔ‡ÂÚ ·‡Ë‡Ú˘ÂÒÍÓ ıËۄ˘ÂÒÍӠΘÂÌËÂ. éÌÓ ÔÓ͇Á‡ÌÓ ÔË àåí ≥40 Í„/Ï2 ËÎË ≥35 Í„/Ï2 ÔË Ì‡Î˘ËË ÓÒÎÓÊÌÂÌËÈ ÓÊËÂÌËfl [46]. àÁ ıËۄ˘ÂÒÍËı ÏÂÚÓ‰ËÍ Î˜ÂÌËfl ÓÊËÂÌËfl ËÒÔÓθÁÛ˛ÚÒfl ÓÔ‡ˆËË „‡ÒÚÓ-Â˛Ì‡Î¸ÌÓ„Ó Ë „‡ÒÚÓËÌÚÂÒÚË̇θÌÓ„Ó ¯ÛÌÚËÓ‚‡ÌËfl Ò ‚˚Íβ˜ÂÌËÂÏ ‰‚Â̇‰ˆ‡ÚËÔÂÒÚÌÓÈ Í˯ÍË, ÓÒÎÓÊÌÂÌËÂÏ ÍÓÚÓ˚ı ÏÓ„ÛÚ ·˚Ú¸ ÒË̉ÓÏ Ì‡Û¯ÂÌÌÓ„Ó ‚Ò‡Ò˚‚‡ÌËfl, ‡‚ËÚ‡- Масса тела АЛТ АЛТ, Ед/л Масса тела, кг Время, нед Рис. 1. Динамика массы тела и уровня АЛТ у больных хроническим гепатитом С при изменении образа жизни (гипокалорийная диета, дозированные физические нагрузки) ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 3 Стадия фиброза по K.Ischak ЛЕКЦИЯ До снижения массы тела После снижения массы тела Рис. 2. Динамика показателя фиброза печени по K.Ischak при снижении массы тела у больных хроническим гепатитом С с ожирением ÏËÌÓÁ˚. é‰ÌËÏ ËÁ ‚‡Ë‡ÌÚÓ‚ fl‚ÎflÂÚÒfl ̇ÎÓÊÂÌË ·‡Ì‰‡Ê‡ ̇ ÊÂÎÛ‰ÓÍ, ˜ÚÓ Ó‰Ì‡ÍÓ Ì ËÒÍβ˜‡ÂÚ ÔÓÒÎÂ‰Û˛˘ÂÈ ‰ËÎflÚ‡ˆËË ÊÂÎۉ͇ ËÎË ÒÓÒ͇θÁ˚‚‡ÌËfl ·‡Ì‰‡Ê‡. ÇÂÚË͇θ̇fl „‡ÒÚÓÔ·ÒÚË͇ – ÙÓÏËÓ‚‡ÌË χÎÓ„Ó (‰Ó 15 ÏÎ) Ó·˙Âχ ÊÂÎۉ͇ ÔÛÚÂÏ Ôӯ˂‡ÌËfl Â„Ó Ï‡ÎÓÈ ÍË‚ËÁÌ˚, ı‡‡ÍÚÂËÁÛÂÚÒfl Ò‡Ï˚Ï ·˚ÒÚ˚Ï ÒÌËÊÂÌËÂÏ Ï‡ÒÒ˚ Ú·, Ӊ̇ÍÓ ÔË ÒËÒÚÂχÚ˘ÂÒÍÓÏ Ô‚˚¯ÂÌËË Ó·˙Âχ ÊÂÎۉ͇ Ó·˙ÂÏÓÏ ÔËÌËχÂÏÓÈ ÔË˘Ë Ú‡ÍÊ ‚ÓÁÏÓÊ̇ Â„Ó ‰ËÎflÚ‡ˆËfl Ë ÒÌËÊÂÌË ˝ÙÙÂÍÚ‡ ÓÚ ÓÔ‡ˆËË [46]. Ç Ì‡ÒÚÓfl˘Â ‚ÂÏfl ̇ÎÓÊÂÌË ËÎÂÓ-Â˛Ì‡Î¸ÌÓ„Ó ‡Ì‡ÒÚÓÏÓÁ‡ Ì ËÒÔÓθÁÛÂÚÒfl ‚ Ò‚flÁË Ò ‚ÓÁÏÓÊÌÓÒÚ¸˛ ÔÓ„ÂÒÒËÓ‚‡Ì˲ ÒÚ‡ÚÓÁ‡ Ë ‚ÓÒÔ‡ÎËÚÂθÌÓ-ÙË·ÓÚ˘ÂÒÍËı ËÁÏÂÌÂÌËÈ ‚ Ô˜ÂÌË, Ì ÒÏÓÚfl ̇ ÒÌËÊÂÌË χÒÒ˚ Ú·. ëÓÓÚ‚ÂÚÒÚ‚Û˛˘‡fl ÔÒËıÓÎӄ˘ÂÒ͇fl ÔÓ‰„ÓÚӂ͇ ·ÓθÌÓ„Ó – ËÁÏÂÌÂÌË ӷ‡Á‡ ÊËÁÌË, ‰ËÂÚ˚, ‡ Ú‡ÍÊ ‚ fl‰Â ÒÎÛ˜‡Â‚ هχÍÓÎӄ˘ÂÒ͇fl ÍÓÂ͈Ëfl ÒÚ‡ÚÓÁ‡ Ë ÒÚ‡ÚÓ„ÂÔ‡ÚËÚ‡ – ÏÓÊÂÚ ·˚Ú¸ ÔÓÎÂÁÌÓÈ Û ·ÓθÌ˚ı ïÉë Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú· Ô‰ ̇˜‡ÎÓÏ èÇí. ëÂ‰Ë ÔÂÔ‡‡ÚÓ‚ ÓÒÓ·ÂÌÌÓ Ì‡Ë·ÓΠÏÌÓ„Óӷ¢‡˛˘ËÏË fl‚Îfl˛ÚÒfl ÎÂ͇ÒÚ‚‡, Û‚Â΢˂‡˛˘Ë ˜Û‚ÒÚ‚ËÚÂθÌÓÒÚ¸ ÔÂËÙ¢ÂÒÍËı Ú͇ÌÂÈ Í ËÌÒÛÎËÌÛ – ÏÂÚÙÓÏËÌ (‰ËÏÂÚËη˄ۇÌˉ) Ë ÓÁË„ÎËÚ‡ÁÓÌ Ë ÔËÓ„ÎËÚ‡ÁÓÌ (ÚˇÁÓÎˉË̉ËÓÌ˚ ‚ÚÓÓ„Ó ÔÓÍÓÎÂÌËfl) [47]. Заключение ç‡ ÓÒÌÓ‚‡ÌËË ‡Ì‡ÎËÁ‡ ‰‡ÌÌ˚ı ÎËÚ‡ÚÛ˚ ÏÓÊÌÓ ‚˚‰ÂÎËÚ¸ ÌÂÒÍÓθÍÓ ÔÓ‰ıÓ‰Ó‚ Í ÓˆÂÌÍ ÓÎË ÓÊËÂÌËfl ‚ ˝ÙÙÂÍÚË‚ÌÓÒÚË èÇí ïÉë: 1) çÄÜÅè Ë HCV-ËÌÙÂ͈Ëfl ‚‰ÛÚ Í ÔÓ„ÂÒÒËÓ‚‡Ì˲ ÙË·ÓÁ‡ Ò ÔÓÒÎÂ‰Û˛˘ËÏ ËÒıÓ‰ÓÏ ‚ ˆËÓÁ Ô˜ÂÌË, ÔË ˝ÚÓÏ ÒÚ‡ÚÓÁ Ô˜ÂÌË fl‚ÎflÂÚÒfl ÌÂÁ‡‚ËÒËÏ˚Ï Ù‡ÍÚÓÓÏ ÔÓ„ÂÒÒËÓ‚‡ÌËfl Ì ÚÓθÍÓ çÄÜÅè, ÌÓ Ë ïÉë (1 „ÂÌÓÚËÔ HCV); 2) ëÛ˘ÂÒÚ‚Û˛Ú ‰ËÂÚ˘ÂÒÍËÂ, ωË͇ÏÂÌÚÓÁÌ˚Â Ë ıËۄ˘ÂÒÍË ÔÓ‰ıÓ‰˚ Í Î˜ÂÌ˲ ÓÊËÂÌËfl Ë ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒË̉Óχ, ̇fl‰Û ÒÓ ÒÌËÊÂÌËÂÏ ËÒ͇ 25 ЛЕКЦИЯ Ò‰˜ÌÓ-ÒÓÒÛ‰ËÒÚ˚ı ÓÒÎÓÊÌÂÌËÈ ÛÏÂ̸¯‡˛˘Ëı ËÒÍ ÔÓ„ÂÒÒËÓ‚‡ÌËfl çÄÜÅè; 3) ëÚ‡ÚÓÁ Ô˜ÂÌË ÛıÛ‰¯‡ÂÚ ÂÁÛθڇÚ˚ èÇí ïÉë; 4) ìÒÔ¯̇fl èÇí ÔË‚Ó‰ËÚ Í ÒÚ‡·ËÎËÁ‡ˆËË Ë Â„ÂÒÒÛ ÙË·ÓÁ‡ Ô˜ÂÌË Ë ÛÏÂ̸¯ÂÌ˲ ÒÚÂÔÂÌË ÒÚ‡ÚÓÁ‡ Ô˜ÂÌË; 5) àÁ·˚ÚӘ̇fl χÒÒ‡ Ú· Û ·ÓθÌ˚ı ïÉë ÔË‚Ó‰ËÚ Í Û‚Â΢ÂÌ˲ Á‡Ú‡Ú ̇ Ôӂ‰ÂÌË èÇí. êfl‰ ÔÓÁˈËÈ ÏÓÊÌÓ Ò˜ËÚ‡Ú¸ ‰Ó͇Á‡ÌÌ˚ÏË ÛÒÎÓ‚ÌÓ: 1) èÇí Û ·ÓθÌ˚ı ïÉë Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú· ÒÓÔÓ‚Óʉ‡ÂÚÒfl ÔÓ‚˚¯ÂÌËÂÏ ËÒ͇ ‡Á‚ËÚËfl ÌÂÊ·ÚÂθÌ˚ı fl‚ÎÂÌËÈ (‰ÓÁÓÁ‡‚ËÒËÏ˚ ˝ÙÙÂÍÚ˚ ÔÓÚË‚Ó‚ËÛÒÌ˚ı ÔÂÔ‡‡ÚÓ‚); 2) àÁ·˚ÚӘ̇fl χÒÒ‡ Ú· Ë àê ÛıÛ‰¯‡˛Ú ÂÁÛθڇÚ˚ èÇí Û ·ÓθÌ˚ı ïÉë. çÂÍÓÚÓ˚ ‚ÓÔÓÒ˚ ÚÂ·Û˛Ú ‰‡Î¸ÌÂÈ¯Â„Ó ËÁÛ˜ÂÌËfl: 1) ä‡ÍÓ‚Ó Á̇˜ÂÌË „ËÔÂıÓÎÂÒÚÂËÌÂÏËË ÔË ïÉë? ÖÒÚ¸ ÎË ÏÂÒÚÓ ÒÚ‡ÚËÌ‡Ï ‚ ΘÂÌËË ·ÓθÌ˚ı ïÉë Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú·? 2) ëΉÛÂÚ ÎË Ô‰‚‡ËÚÂθÌÓ „ÓÚÓ‚ËÚ¸ Í èÇí ·ÓθÌ˚ı ïÉë Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú·? ä‡ÍÓ‚˚ ÔÓ‰ıÓ‰˚ ‚ ΘÂÌËË çÄÜÅè Û ·ÓθÌ˚ı ïÉë? 3) ÇÓÁÏÓÊÌÓ ÎË Ó‰ÌÓ‚ÂÏÂÌÌÓ ̇Á̇˜ÂÌË èÇí ÔÓ ÔÓ‚Ó‰Û ïÉë Ë Î˜ÂÌË çÄÜÅè ÔË ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒ Ú·? é˜Â‚ˉÌÓ, ˜ÚÓ ‰Ó ÔÓÎÛ˜ÂÌËfl ÂÁÛθڇÚÓ‚ ÍÛÔÌ˚ı ÔÓÒÔÂÍÚË‚Ì˚ı ‡Ì‰ÓÏËÁËÓ‚‡ÌÌ˚ı ÍÓÌÚÓÎËÛÂÏ˚ı ÍÎËÌ˘ÂÒÍËı ËÒÒΉӂ‡ÌËÈ ÒΉÛÂÚ Â¯‡Ú¸ ˝ÚË ‚ÓÔÓÒ˚ Ë̉˂ˉۇθÌÓ ‰Îfl Í‡Ê‰Ó„Ó ·ÓθÌÓ„Ó, ‚Á‚¯˂‡fl ‚Í·‰ Í‡Ê‰Ó„Ó ÍÓÏÔÓÌÂÌÚ‡ ‚ ÔÓ„ÂÒÒËÓ‚‡ÌË Á‡·Ó΂‡ÌËfl Ô˜ÂÌË Ë ÓˆÂÌË‚‡fl ÒÓÒÚÓflÌË ‚ÒÂı “Ó„‡ÌÓ‚-Ï˯ÂÌÂÈ” ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒË̉Óχ. 1. Jones E.D., Ivanov L.L., Wallace D.C., Voncannon L. Examining the metabolic syndrome in Russia. Int. J. Nurs. Pract., 2006, 12, 260-266. 2. Loas G., Guilbaud O., Perez-Diaz F. et al. Dependency and suicidality in addictive disorders. Psychiatry Res., 2005, 137, 103-111. 3. Ekstedt M., Franzen L.E., Mathiesen U.L. et al. 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Meta-analysis: surgical treatment of obesity. Ann. Intern. Med., 2005, 142, 547-559. 47. ÅÛÌ‚˘ ù.á., ô‡Ìˈ˚̇ ë.Ö. ëÓ‚ÂÏÂÌÌ˚ ÔÓ‰ıÓ‰˚ Í Î˜ÂÌ˲ ̇ÎÍÓ„ÓθÌÓÈ ÊËÓ‚ÓÈ ·ÓÎÂÁÌË Ô˜ÂÌË. ÉÂÔ‡ÚÓÎӄ˘ÂÒÍËÈ ÙÓÛÏ, 2006, 3, 15-20. Комментарий главного редактора Ç Ì‡ÒÚÓfl˘Â ‚ÂÏfl ̇ÎÍÓ„Óθ̇fl ÊËÓ‚‡fl ·ÓÎÂÁ̸ Ô˜ÂÌË (çÄÜÅè) ÔËÁ̇̇ Ò‡Ï˚Ï ‡ÒÔÓÒÚ‡ÌÂÌÌ˚Ï ‚ ÔÓÔÛÎflˆËË Á‡·Ó΂‡ÌËÂÏ Ô˜ÂÌË, Ó·˚˜ÌÓ ÔӇʇ˛˘ËÏ ·ÓθÌ˚ı Ò‰ÌËı ÎÂÚ Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú· Ë ÒÚ‡‰‡˛˘Ëı Ò‡ı‡Ì˚Ï ‰Ë‡·ÂÚÓÏ Ë/ËÎË „ËÔÂÎËÔˉÂÏËÂÈ Ë Ó·‡˘‡˛˘ËıÒfl Á‡ ωˈËÌÒÍÓÈ ÔÓÏÓ˘¸˛ Ò Ê‡ÎÓ·‡ÏË, Ì ҂flÁ‡ÌÌ˚ÏË Ò Á‡·Ó΂‡ÌËÂÏ Ô˜ÂÌË, Ë ÔÓ˜ÚË ‚Ò„‰‡ Ëϲ˘Ëı ·ÂÒÒËÏÔÚÓÏÌÛ˛ „ÂÔ‡ÚÓÏ„‡Î˲. ÅËÓÔÒËfl Ô˜ÂÌËfl fl‚ÎflÂÚÒfl ̇˷ÓΠÒÔˆËÙ˘Ì˚Ï Ë ˜Û‚ÒÚ‚ËÚÂθÌ˚Ï ‰Ë‡„ÌÓÒÚ˘ÂÒÍËÏ ÏÂÚÓ‰ÓÏ ‚˚fl‚ÎÂÌËfl Á‡·Ó΂‡ÌËfl, ÔÓÁ‚ÓÎfl˛˘ËÏ Ó‰ÌÓ‚ÂÏÂÌÌÓ ÓˆÂÌËÚ¸ Ë ÔÓ„ÌÓÁ ·ÓÎÂÁÌË. àÌÒÛÎËÌÓÂÁËÒÚÂÌÚÌÓÒÚ¸ – ̇˷ÓΠÒÛ˘ÂÒÚ‚ÂÌÌ˚È Ù‡ÍÚÓ Ô‡ÚÓ„ÂÌÂÁ‡ çÄÜÅè, ‚Â‰Û˘ËÈ Í Ì‡ÍÓÔÎÂÌ˲ Êˇ ‚ „ÂÔ‡ÚÓˆËÚ‡ı. LJÊÌ˚Ï Á‚ÂÌÓÏ ÏÂı‡ÌËÁχ ‡Á‚ËÚËfl ÒÚ‡ÚÓÁ‡ fl‚ÎflÂÚÒfl Ú‡Íʠ̉ÓÒÚ‡ÚÓ˜ÌÓÒÚ¸ ÙÂÏÂÌÚÓ‚ ÔÂÓÍÒËÒÓχθÌÓ„Ó β-ÓÍËÒÎÂÌËfl. Ç ÂÁÛθڇÚ ӷÓËı ÔÓˆÂÒÒÓ‚ ÛÓ‚Â̸ ÊËÌ˚ı ÍËÒÎÓÚ ‚ „ÂÔ‡ÚÓˆËÚ‡ı Ó͇Á˚‚‡ÂÚÒfl ÒÎ˯ÍÓÏ ‚˚ÒÓÍËÏ, ˜ÚÓ Ô‰ÒÚ‡‚ÎflÂÚ ÒÓ·ÓÈ ËÒÚÓ˜ÌËÍ ÓÍËÒÎËÚÂθÌÓ„Ó ГЕПАТОЛОГИЧЕСКИЙ ФОРУМ, 2006, 3 ÒÚÂÒÒ‡, ÍÓÚÓ˚È ÏÓÊÂÚ ‚ Á̇˜ËÚÂθÌÓÈ ÒÚÂÔÂÌË ÒÔÓÒÓ·ÒÚ‚Ó‚‡Ú¸ ÔÓ„ÂÒÒËÓ‚‡Ì˲ ÒÚ‡ÚÓÁ‡ ‚ ÒÚ‡ÚÓ„ÂÔ‡ÚËÚ, Ë Á‡ÚÂÏ ‚ ÙË·ÓÁ Ë ˆËÓÁ Ô˜ÂÌË. åËÚÓıÓ̉ËË – „·‚Ì˚È ÍÎÂÚÓ˜Ì˚È ËÒÚÓ˜ÌËÍ ‡ÍÚË‚Ì˚ı ÙÓÏ ÍËÒÎÓÓ‰‡, ÍÓÚÓ˚ ÏÓ„ÛÚ fl‚ÎflÚ¸Òfl ÚË„„‡ÏË ÒÚ‡ÚÓ„ÂÔ‡ÚËÚ‡ Ë ÙË·ÓÁ‡ Á‡ Ò˜ÂÚ ÔÂÂÍËÒÌÓ„Ó ÓÍËÒÎÂÌËfl ÎËÔˉӂ, Ë̉Û͈ËË ˆËÚÓÍËÌÓ‚ Ë ‡ÔÓÔÚÓÁ‡. èÓÒÍÓθÍÛ ËÌÒÛÎËÌÓÂÁËÒÚÂÌÚÌÓÒÚ¸ Ë ÓÍËÒÎËÚÂθÌ˚È ÒÚÂÒÒ Ë„‡˛Ú Íβ˜Â‚Û˛ Óθ ‚  ԇÚÓ„ÂÌÂÁÂ, ÚÓ çÄÜÅè Ô‰ÒÚ‡‚ÎflÂÚ ÒÓ·ÓÈ Ò‚ÓÂÓ·‡ÁÌÛ˛ ÏÓ‰Âθ ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒË̉Óχ, ÍÓÚÓÛ˛ ÛÒÎÓ‚ÌÓ ÏÓÊÌÓ Ì‡Á‚‡Ú¸ “Ô˜ÂÌÓ˜ÌÓÈ ÏÓ‰Âθ˛” ‰‡ÌÌÓ„Ó ÒË̉Óχ. àÏÂÌÌÓ ÔÓ˝ÚÓÏÛ ÔÓ‰ıÓ‰˚ Í Î˜ÂÌ˲ çÄÜÅè, ËÁÎÓÊÂÌÌ˚ ‚ Òڇڸ ù.á.ÅÛÌ‚˘‡ Ë ë.Ö.ô‡ÌˈËÌÓÈ, ÓÒÌÓ‚‡Ì˚ ̇ ÒÓ‚ÂÏÂÌÌÓÈ ÍÓ̈ÂÔˆËË Î˜ÂÌËfl ËÏÂÌÌÓ ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒË̉Óχ. ÅÂÁÛÒÎÓ‚ÌÓ, ·‡ÁËÒÓÏ ‚ ΘÂÌËË çÄÜÅè fl‚ÎflÂÚÒfl ÌÓχÎËÁ‡ˆËfl χÒÒ˚ Ú·, ÚӘ̠ÍÓÂ͈Ëfl ÔÛÚÂÏ ËÁÏÂÌÂÌËfl Ó·‡Á‡ ÊËÁÌË, ‚ ÚÓ ‚ÂÏfl Í‡Í Ù‡Ï‡ÍÓÎӄ˘ÂÒÍË ÔÓ‰ıÓ‰˚ ‚Ó ÏÌÓ„ÓÏ ÓÒÚ‡˛ÚÒfl ÔÓ͇ ¢ Ì ‡Á‡·ÓÚ‡ÌÌ˚ÏË. ÄÍÚË‚ÌÓ ÏÌÓ„ÓÒÚÓÓÌÌ ËÁÛ˜ÂÌË HCV-ËÌÙÂ͈ËË ÔÓÁ‚ÓÎËÎÓ Ó·ÒÛʉ‡Ú¸ ˝ÚÛ ÔÓ·ÎÂÏÛ ‚ ÚÓÏ ˜ËÒÎÂ Ë ‚ ‡ÒÔÂÍÚ ÔÓÚË‚Ó‚ËÛÒÌÓÈ Ú‡ÔËË. ÑÎËÚÂθÌ˚È ˝Ú‡Ô ËÁÛ˜ÂÌËfl ÓÒÓ·ÂÌÌÓÒÚÂÈ ÂÒÚÂÒÚ‚ÂÌÌÓ„Ó Ú˜ÂÌËfl ıÓÌ˘ÂÒÍÓ„Ó „ÂÔ‡ÚËÚ‡ ë (ïÉë), ‚ ÚÓÏ ˜ËÒÎÂ Ë Ò ÏÓÙÓÎӄ˘ÂÒÍËı ÔÓÁˈËÈ, ÔÓ͇Á‡Î, ˜ÚÓ ÒÚ‡ÚÓÁ Ô˜ÂÌË fl‚ÎflÂÚÒfl ı‡‡ÍÚÂÌ˚Ï Ë ˜‡ÒÚ˚Ï „ËÒÚÓÎӄ˘ÂÒÍËÏ ÔËÁ̇ÍÓÏ ıÓÌ˘ÂÒÍÓÈ HCV-ËÌÙÂ͈ËË. ê‡Ò¯ËÙӂ͇ ÏÂı‡ÌËÁÏÓ‚ ÒÚ‡ÚÓÁ‡ Ô˜ÂÌË ÔË ïÉë ÔÓÁ‚ÓÎË· ÛÒÚ‡ÌÓ‚ËÚ¸ ‚ÎËflÌË ‰‚Ûı „·‚Ì˚ı Ù‡ÍÚÓÓ‚ Â„Ó ‡Á‚ËÚËfl – ËÌÒÛÎËÌÓÂÁËÒÚÂÌÚÌÓÒÚË (‡, ÔÓ ÒÛ˘ÂÒÚ‚Û, ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒË̉Óχ), ˜ÚÓ ÔÓÎÛ˜ËÎÓ Ì‡Á‚‡ÌË ÏÂÚ‡·Ó΢ÂÒÍÓ„Ó ÒÚ‡ÚÓÁ‡, Ë ÁÎÓÛÔÓÚ·ÂÎÂÌËfl ‡ÎÍÓ„ÓÎÂÏ (‡ÎÍÓ„ÓθÌ˚È ÒÚ‡ÚÓÁ Ô˜ÂÌË) Ò Ó‰ÌÓÈ ÒÚÓÓÌ˚, Ë ÌÂÔÓÒ‰ÒÚ‚ÂÌÌÓ Ù‡ÍÚÓÓ‚ ‚ËÛÒ‡ (ÔÂʉ ‚Ò„Ó, „ÂÌÓÚËÔ‡ 3 HCV (‚ËÛÒÌ˚È ÒÚ‡ÚÓÁ Ô˜ÂÌË), Ò ‰Û„ÓÈ ÒÚÓÓÌ˚. éÒÓ·˚È ËÌÚÂÂÒ Í ÒÚ‡ÚÓÁÛ Ô˜ÂÌË ÔË HCV-ËÌÙÂ͈ËË ‚ÓÁÌËÍ ÔË ÔÓfl‚ÎÂÌËË Û͇Á‡ÌËÈ Ì‡ ‚ÓÁÏÓÊÌÓÒÚ¸ ·ÓΠ·˚ÒÚÓ„Ó ÔÓ„ÂÒÒËÓ‚‡ÌËfl ïÉë ÔË Ì‡Î˘ËË ÒÚ‡ÚÓÁ‡, Ë, ˜ÚÓ ÓÒÓ·ÂÌÌÓ ‚‡ÊÌÓ, ·ÓΠÌËÁÍËÏË ÂÁÛθڇڇÏË ÒÓ‚ÂÏÂÌÌÓÈ èÇí. éÒÓ·ÂÌÌÓÒÚË ÔÓÚË‚Ó‚ËÛÒÌÓÈ Ú‡ÔËË ïÉë Û ·ÓθÌ˚ı Ò ËÁ·˚ÚÓ˜ÌÓÈ Ï‡ÒÒÓÈ Ú· Ó·ÒÛʉ‡˛ÚÒfl ‚ Òڇڸ è.è.é„ÛˆÓ‚‡. Ç Ô‡ÍÚ˘ÂÒÍÓÈ ‰ÂflÚÂθÌÓÒÚË ÌÂÓ·ıÓ‰ËÏÓ ÔÓÏÌËÚ¸ Ó ÚÓÏ, ˜ÚÓ ‡Á‚ËÚË ÒÚ‡ÚÓÁ‡ Ô˜ÂÌË (‡ ËÏÂÌÌÓ çÄÜÅè) ÏÓÊÂÚ Ô‰¯ÂÒÚ‚Ó‚‡Ú¸ ‚ËÛÒÌÓÈ ËÌÙÂ͈ËË (HCV-ËÌÙÂ͈ËË ‚ ˜‡ÒÚÌÓÒÚË), ÔÓ˝ÚÓÏÛ ÒΉÛÂÚ Ó·‡˘‡Ú¸ ‚ÌËχÌË ̇ ̇΢ËÂ Û ·ÓθÌÓ„Ó ïÉë ÏÂÚ‡·Ó΢ÂÒÍËı Ù‡ÍÚÓÓ‚ ËÒ͇ (ËÁ·˚ÚӘ̇fl χÒÒ‡ Ú·, ̇ۯÂÌË ÚÓ·ÌÚÌÓÒÚË Í „βÍÓÁ ËÎË Ò‡ı‡Ì˚È ‰Ë‡·ÂÚ 2 ÚËÔ‡, „ËÔÂÚË„ÎˈÂˉÂÏËfl). éÒÓ·Û˛ ÔÓ·ÎÂÏÛ Ô‰ÒÚ‡‚ÎflÂÚ ÁÎÓÛÔÓÚ·ÎÂÌË ‡ÎÍÓ„ÓÎÂÏ ·ÓθÌ˚ÏË ïÉë, ˜ÚÓ Ó·ÛÒÎÓ‚ÎË‚‡ÂÚ ·˚ÒÚÓ ÔÓ„ÂÒÒËÓ‚‡ÌË HCV-ËÌÙÂ͈ËË. ç‡ÍÓ̈, ÒÚ‡ÚÓÁ Ô˜ÂÌË ÔË ïÉë ÏÓÊÂÚ ·˚Ú¸ ‚ËÛÒ-Ë̉ۈËÓ‚‡ÌÌ˚Ï, ÓÒÓ·ÂÌÌÓ ÔË ËÌÙˈËÓ‚‡ÌËË HCV 3 „ÂÌÓÚËÔ‡. èÓ‰ıÓ‰˚ Í ÍÓÂ͈ËË ÒÚ‡ÚÓÁ‡ Ë ÒÚ‡ÚÓ„ÂÔ‡ÚËÚ‡ ËÒıÓ‰fl ËÁ Ëı Ô‡ÚÓ„ÂÌÂÚ˘ÂÒÍËı ‚‡Ë‡ÌÚÓ‚ ‚ ÓÔ‰ÂÎÂÌÌÓÈ ÒÚÂÔÂÌË ÓÚ΢‡˛ÚÒfl, Ë ˝Ú‡ ÍÓÂ͈Ëfl Ó˜Â̸ ‚‡Ê̇ ‰Îfl ÛÎÛ˜¯ÂÌËfl ÂÁÛθڇÚÓ‚ èÇí ïÉë. 27
