Тромбогеморрагические осложнения при лечении больных острым лимфобластным лейкозом L-аспарагиназой

Г.М. Галстян, О.А. Полеводова, А.В. Баженов, В.В. Троицкая, О.А. Гаврилина, Д.Г. Гительзон, А.Э. Васильев, Е.Н. Паровичникова

ФГБУ «НМИЦ гематологии» Минздрава России, Новый Зыковский пр-д, д. 4, Москва, Российская Федерация, 125167

Для переписки: Геннадий Мартинович Галстян, д-р мед. наук, Новый Зыковский пр-д, д. 4, Москва, Российская Федерация, 125167; тел.: +7(916)488-50-73; e-mail: gengalst@gmail.com

Для цитирования: Галстян Г.М., Полеводова О.А., Баженов А.В. и др. Тромбогеморрагические осложнения при лечении больных острым лимфобластным лейкозом L-аспарагиназой. Клиническая онкогематология. 2018;11(1):89-99.

DOI: 10.21320/2500-2139-2018-11-1-89-99


РЕФЕРАТ

Настоящая статья представляет собой обзор литературы, посвященный применению L-аспарагиназы (АСП) при остром лимфобластном лейкозе (ОЛЛ), с описанием 2 собственных клинических наблюдений. Лечение АСП при проведении индукции ремиссии осложнилось у пациентов венозными тромбозами и кровоизлиянием в ЦНС. В обоих случаях эти осложнения возникли на фоне сниженной плазменной активности антитромбина III (АТ), гипофибриногенемии и тромбоцитопении. Обсуждаются факторы риска возникновения тромбогеморрагических осложнений у больных ОЛЛ во время лечения АСП, роль в их развитии сочетанной терапии АСП с антрациклинами, пероральными контрацептивами, глюкокортикостероидами, наличия тромбофилии и центрального венозного катетера. Описаны возможные механизмы развития тромбозов, определены наиболее вероятные сроки их возникновения, локализация. В статье приводятся различные варианты профилактики и лечения тромбогеморрагических осложнений у больных ОЛЛ во время лечения АСП. Рекомендуется у всех больных ОЛЛ, получающих АСП, исследовать в плазме концентрацию фибриногена и активность АТ до начала лечения, на 3-й день после введения препарата и далее каждые 5–7 дней на протяжении 3 нед. после введения. Новые пероральные антикоагулянты не зависят от активности АТ в крови и могут использоваться для профилактики и лечения тромботических осложнений, связанных с АСП. Приводятся рекомендации по коррекции содержания АТ и гипофибриногенемии.

Ключевые слова: L-аспарагиназа, осложнения, тромбоз, тромбоэластография, антитромбин III, гипофибриногенемия, тромбоцитопения, новые пероральные антикоагулянты.

Получено: 16 августа 2017 г.

Принято в печать: 27 октября 2017 г.

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Особенности диагностики и лечения тромботической тромбоцитопенической пурпуры, развившейся во время беременности: обзор литературы и собственное наблюдение

В.В. Войцеховский1, Л.Б. Филатов2, А.В. Пивник3, П.В. Авдонин4, Т.В. Есенина5, А.Г. Судаков5

1 Амурская государственная медицинская академия, ул. Горького, д. 95, Благовещенск, Амурская обл., Российская Федерация, 675000

2 Екатеринбургский консультативно-диагностический центр, Суворовский пер., д. 5, Екатеринбург, Свердловская обл., Российская Федерация, 620039

3 Московский клинический научно-практический центр им. Д.Д. Плетнева Департамента здравоохранения, ш. Энтузиастов, д. 86, Москва, Российская Федерация, 111123

4 Институт биологии развития им. Н.К. Кольцова, ул. Вавилова, д. 26, Москва, Российская Федерация, 119334

5 ГАУЗ АО «Амурская областная клиническая больница», ул. Воронкова, д. 26, Благовещенск, Амурская обл., Российская Федерация, 675028

Для переписки: В.В. Войцеховский, д-р мед наук, доцент, ул. Горького, д. 95, Благовещенск, Амурская обл., Российская Федерация, 675000; тел.: +7(4162)42-94-97; e-mail: voitsehovsckij@yandex.ru

Для цитирования: Войцеховский В.В., Филатов Л.Б., Пивник А.В., Авдонин П.В., Есенина Т.В., Судаков А.Г. Особенности диагностики и лечения тромботической тромбоцитопенической пурпуры, развившейся во время беременности: обзор литературы и собственное наблюдение. Клин. онкогематол. 2014; 7(4): 587–598.


РЕФЕРАТ

В работе отражены современные представления об этиологии, патогенезе, клинических особенностях и диагностике тромботической тромбоцитопенической пурпуры (ТТП или болезнь Мошковица). Обобщены сведения о редкой патологии — наследственной ТТП (синдром Апшо—Шульмана), ее манифестации в период беременности. Освещены различные аспекты дифференциальной диагностики микроангиопатических гемолитических анемий, сложности дифференциальной диагностики тромботических микроангиопатий (ТТП, гемолитико-уремический синдром, HELLP-синдром) во время беременности. Рассмотрены особенности клинического течения и дифференциальной диагностики приобретенной и наследственной ТТП у беременных. Подробно изложены вопросы лечения ТТП во время беременности.


Ключевые слова: тромботическая тромбоцитопеническая пурпура, наследственная тромботическая тромбоцитопеническая пурпура, синдром Апшо—Шульмана, тромботическая микроангиопатия, микроангиопатическая гемолитическая анемия, шистоциты, тромбоцитопения, ADAMTS-13, HELLP-синдром, беременность.

Принято в печать: 3 октября 2014 г.

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