??? (FHF)

1
?????????????? ??? ????????? ???????????????
???????? ??????
??????????? ??????????????? ?. ?????? ???
?????? ?????? ??. ?.?.
?????????????? ????????? ????? ??????????????
??????
2
(No Transcript)
3
????????? ? ?????????????? ??????

• ??????????? ??????????? ?????? ? ????????? ?????
  ????? 12 ???????
• ??????????? ??????????? ??????, ???????????
  ?????????? ???????? ????? ? ????????????????
• ??????????????? ??????????? ?????? ? ?????????
  ?????????????????? ????? ???????, ??? ? ??????
  ?????????????? ?????? ( 85 - ????? ?????
  ?????????????? ?????? ? ??????? 1 ????, 70 - ?
  ??????? 5 ???)

4
???????????????? ??? ?????????????? ??????

• ???????? ??? ????????
• ????????????? ??????????????? ???????????????
  ????????
• ?????????????????
• ????????????? ??????
• ??????? ???????????????????? ???????????
• ???????? ??????????

5
?????????? ???????????? ?????? ??????????? ??????

• ??????????????? ???????
• ???????????? ?????
• ?????????????
• ???????????? ?????? ???
• ???????????? ?? ???
• ??????????? ????????????
  
  (???????? ? ?????? ????????????????)
• ??????????????? ?????? ? ????????????
• ?????????? ????????????? ?????????

6
?????????????? ?????
7
?????? ?????????? ???????????????

• ??? (FHF)
• (??V - ???- ?????????????, ??V, HCV, HB?,
  HBD, HDV, ????????????????? ???,??????????
  ???????, ?????? ?????? ????????? ??????????,
  ?????? ? ??????????? ?????????

8
????????????????? ???????

• ???????????
• PNC-C
• PNC-B-Hbsag
• PNC-B-C
• PNC-B-D
• PNC-A
• PNC-D

• ???????????? (??????????????)
• PNC-???????????

9
??????????????? ???????????\???????

• PBC
• SBC
• SBS (??????? Caroli)
• SBS (????? ????????)

• PSC
• PSC ( ???)
• PSC (??????? Crohn)

10
????????? ???????

• ?????????????
• ??????? Alagille
• ??????????

11
?????????????? ???????????

• ?????-1-??????????? ???????
• ??????? ????????
• ????????????
• ???????????

• ??????????????
• ?????????? ??? II (GSD-II)
• GSD-I
• ??????????????-II

12
?????? ???????????

• ????????? ??????
• ??????? Budd-Chiari
• TPN/???????????????? - ?????????????? ???????
  ??????
• ???????????? ???????
• ?????????? ?????? ??????

• ???????? ????????
• ??????? Byler
• ?????? ??????
• GVHD
• ?????????? ??????
• ????????????????? ??????? ??????

13
??????????????? ???????????????

• ???
• ???
• ?????? - ???
• ??????????????
• ??????????????????? / ???????????????

• ???????????????? ???
• ??? ??????? ????????
• ???????????????? ???????
• ??????????????? ????????? ??????
• ??????

14
??????????? ? ?????????????? ??????

• 10 - 20 ?? 1 ???. ?????????

15
??????????? ?????? ? ????? ????????

• ?????? 1 - ??????????? ?????????
• ?????? 2? - ????????? ?????????? ???????????
  ?????????
• ?????? 2? - ?????? ?????????????? ? ????? ?
  ?????????????? ????????? ??????????? (CTPgt10)
• ?????? 3 - ?????????? ????????? (CTPgt7)
• ?????? 4 - ???????????? ??????????, ??????????? ?
  ????? ???????? ???????? ? ???????????

16
??? ???????????? ??????????? ?????????

• ???????? ? ????? ????????
• ?????????????? ?? ??? ? ??????????????????
  ???????????
• ???????? ?????????? ? ???? ????????
• ??? ?????? ?????? ???????? ? ?????? ???????
  ???????? ??????????? ??????? ???????
  ????????????????? ???????? ??????????? ?????? ???
  ????????? ??????????????

17
???????? ????? ???????? ?????? ? ???
UNOS 2001
?????????? ? ????? ???????? ?? 9,6 ?? 6,8
18
?????? ??????? ? ????? ????????
19
????????????? ??????? ?? ?????????
UNOS 2001
? 2002-2003 ?. ???? ????????? ? ??? ??? ???????
??? ???????? ?? 23.
20
????????????????? ????? ? ??????????? ??
?????????
UNOS 1998
21
?????????? ?? ?????????? ???? ??????

• ??? ????? ? ???? ?? ??????? ?????
  ??????????????? ???????????. 1 ???. ?????
  ???????? ??????? ? ?????????? ???
• ??? ?? 2,8 ?? 15 ??????? ? ??? ?? 100 ???.
  ??????? ????????????? ??? ??? ???????? ??????
  ?????????? 1,5 ? ???

22
????????? ? ??? ??? ???

• MELD (Model for END-Stage Liver Disease)
• PELD (Pediatric END-Stage Liver Disease)
• ????????? ????????

Freeman R. Impact of MELD on OLTx for HCC.
Program and abstracts from the ASTS 3rd Annual
Winter SymposiumJanuary 24-26, 2003 Miami,
Florida.
23

• MELD
• 0,95 x Log e (????????? ??/??) 0,378x Log e
  (????????? ??/??)1,120x Log e (???)0,643

• ????????? ????????
• ???? ???? ??? lt 5,0 ??.
• ?? ????? 3-? ????? ??? lt3,0 ??.

Mazzaferro V. et.al. Liver transplantation for
treatment of small hepatocellular Carcinomas in
patients with cirrhosis.// N.Eng.J.Med.-1996.-Vol.
334.-N11.-P.693-699
24

• ???????? ???????????????
  
  ???????????? (UCSF)
• ???? ???? lt6,5 ??.
• 3 ???? lt4,5 ??. ??? ????????? ??????? ??
  ????????? 8,0 ??.

• ???????????????? TNM ??????? ??????????????
  ????????????
• ?????? I, II, IIIA.

25
???????? ???????????? ?????????? ? ???? ????????
??? ??? ???

• I ?????? ??? 24 (20) ????? MELD ????????????
  ????????? ?????????
• II ?????? ??? 29 (24) ????? MELD
  ???????????? ????????? ?????????

???????? ??????? UNOS ? ??????? 2002 ?., ???
????????? ? ?????? ? 02.02 ?? 02.03 ?. ?????????
???? ????????? ? ???, ??????? ???? ????????? ???
?? 23!!!!, ??? ? 6 ??? ????????? ????
?????????? ? ???- MELD ???????. ????? ????????
??? ??? ???? ??????????? ?? 3 ???. ?? ???????
?????????? ? ???? ???????? ? ???? ??????? ?/?
??????????? ??? ??? ??? ??? ? 2003 ?. ????? MELD
???? ???????.( 9 ???????? ILTS ? 13 ????????
LI?AGE, ???? 18-21, ?????????, ???????)
26
??????????? ?????????????? ?????? (LRLT) ??? ???

• ?????????? ????????? ??????????? ????? ??????
  0,8 - 1 ?? ????? ???? ??????????. ? ???????????
  ??????????? ??????? ?????????? ????. ????
  ???????????? ?????? ??? ?????? ?????????? 0,2 -
  0,5.
• LRLT ????????? ????????? ????? ????????
  ?????????????? ? ???????? ?????????????? ???
  I,II??. ???.

Kaihara S.et.al. Living-donor liver
transplantation for hepatocellular
carcinoma.\\ Transplantation.-2003.-Vol.75-P.37-40
.
27
?????????? ????????? ? ??? ??? ??????? ???

• ???????? ?? ??????????????? ????????? ?????????
  ?? ?????? ??????? ??????????? ?? ????? ????????.
• LRLT ?????????? ??? ??????????? ?????????
  ????????? ? ??????????? ??????? ??? ???
  ????????????? ???????????????
• ???????? ????? ?????????? ?????????? ??? ??? ???
  ?? ???? ???????????? ?????? ?? ????????????
  ??????? ??????? (???????, NHBD,??????????????
  ?.?.?.)

Steinmuller T.et al.Living-donation liver
transplantation for hepatocellular
carcinoma time to drop the limitations?//
Transplant Proc.-2002-Vol.34.-P.2263-2264. Manza
rbeitia C. et.al. Long-term outcome of controlled
non heart beating donor liver. 9th ILTS
Meeting-June 18-21,2003, Barcelona,Spain.
Abstract 145.
28
??????????? ???????? ??? LRLT ??? ???

• ???? ???? ??? lt 7,0 ??.
• 3 ???? lt5 ??.
• 5 ????? lt 3 ??.

Llovet J.M., et all.Living donor liver
transplantation for hepatocellular carcinoma
with Expanded criteriaevaluation of
applicability in Europe. 9th. ILTS meeting.-June
18-21, Barcelona, Spain. Abstract 255.
29
??????? ????? ???????? ????? ???

• ??? ????????? ?????? ??????? ???????, ?????
  ?????, ?????- ? ???????????????? ????????
  ?????????? ???????, ??????????????, ???????
  ?-????????????.
• ??? ??? 10-?????? ???????????? ?????? ???????
  ?? ?????????? DNA (???????????? ?????????? 98
  ???
• ?????????? ???, 83-????????????,
  18-????????????.
• ????? ??????????????? ????????? ???????? ?????
  ????? ???????- ????????? ?????? ???????? 30 ??3.

Schumacher G. et.al.Hepatocellular
carcinomaclinical relevance of DNA-ploidy for
liver transplantation.//9th. ILTS meeting.-June
18-21,Barcelona, Spain. Abstract 125. Ravaioli
M.M., et.al. Liver transplantation for
hepatocellular carcinomaIs it justi- fied to
enlarge Milan criteria and should tumour features
be the only variables to select Patients? 9th.
ILTS meeting.-June 18-21,Barcelona, Spain.
Abstract 127.
30
?????????????? ??????? ????? ???

• ????????????????
• ?????????????? ???????
• ???????? ?????? ? ???? ??????? ????? ?????
  ??????????????? ? ???? ??????? ? ??? ?? ????
  ???????, ??? ??????? ?????? ????? ? ????????????
  ? ??????????? ?????????? ???

Cheng Y.F., at all. Significance of
transarterial embolization for hepatocellular
carcinoma In liver transplantation - Absract
46 Kosari K. et.al.Pretransplant radiofrequency
ablation (RFA) for hepatocellular carcinoma
(HCC)an analysis of specimen histopathology and
recipient outcome. Abstract 241 Resection
followed by liver transplantation for
hepatocellular carcinoma provides the
same Prognosis as primary transplantation.
Abstact 150 Program and abstracts of the 9th
Meeting of the International Liver
Transplantation Society (ILTS) and Intensive
care Group of Europe(LICAGE) June 18-21,
Barcelona, Spain.
31
????????????????? ????? ????? ??? ??? ???
(??????-?????)
94 HCV ? HBV. ?/? ??????????? 17, ???????
??? 8, ????????????????? ????? 4 ???? 75, 4
???? ??? ???????? 83. Mazzaferro V. et.al. NJM
- 1996.11.693.
32
???????? ?? ??? ??? ?????? ?????????
??????????????? ???????? ??????

• ????????????? ????????????????? ????? ? ???????
  1-?? ? 2-? ??? ????? ?????????????? ?????? ??
  ?????? ??????? ????????? ?????????? ?? ??????
  R.Pichlmayr 51 ? 40, ??? ???? ??????? ???????
  ???????? ? 36,4
• ??? ?????? ??????? ????????????????? ??? ????????
  ? ???????? ??????????? ???????????? ( 36,6 pts.
  ????? 1-9 ??? ????? ???, ?????? 99,3 ???
  ????????

Pichlmayr R. et al. Role of liver
transplantation in the treatment of
unresectable liver cancer. // World J.
Surg.- 1995.-Vol.19.-N6.-P.807-813. Rosen
C.(Mayo Clinic) Cholangiocarcinoma and liver
transplantation transplantation is
indicated. Program and abstracts from the ASTS
3rd Annual Winter Symposium January 24-26,2003
Miami, Florida
33
??????

1. ?????????????? ?????? ???????? ???????????
   ??????? ??????? ??? ????????? ????????????????
   ??? ? ????????? ? ???????? ??????
2. ??????????? ??? ??? ?????????????????? ????????
   ??????? ? ??????? ??????????? ??????????
3. ??????????? ?????????????? ??????, ? ?????
   ????????????? ??????? ?? ???????????? ???????
   ??????? ????????? ????????? ????? ???????? ???
   ????????? ? ???, ?????????? ???? ???????? ???
   ??????? ??????????? ?????? ???????????
   ??????????? ????? ???????? ???????

34

• ??? ?? ??. ?.?. ??????????????
• ?????????? ?????????
• ????? ?????????????? ??????
• 129010, ?. ??????, ?. ??????????? ??. ??? 3,
  ?????? 5
• ???. 7 [phone] ???? 7 [phone]
• E-mail ltc_at_sklif-ltc.ru www.sklif-ltc.ru