Cov Ntsiab Lus Qhia Txog KDIGO 2022 Cov Lus Qhia Txog Kev Kho Mob Rau Kev Tiv Thaiv, Kev Ntsuas, Kev Ntsuam Xyuas, Thiab Kev Kho Mob Kab Mob Siab C hauv Kab Mob Raum Ntev
Sep 19, 2023
Kev kis tus kab mob siab C (HCV) muajlub siab tsis zoo, lub raum, thiab mob plawv rau cov neeg mob nrogmob raum mob (CKD), suav nrog cov nyob raudialysis khosau nrog ahloov raum. Txij li thaum luam tawm ntawm lubKab mob raum: Txhim Kho Ntiaj Teb Cov Tau Txais (KDIGO) HCV Cov Lus Qhia hauv 2018, nce qib hauv kev tswj hwm HCV, tshwj xeeb tshaj yog nyob rau hauv kev kho tshuaj tiv thaiv kab mob thiab kev kho mob.HCV-txo cov kab mob glomerular, nrog rau kev siv ntau ntxiv ntawm HCV-zoo rau lub raum grafts, tau ua kom rov kuaj xyuas dua ntawm 2018 cov lus qhia. Yog li ntawd, Pawg Neeg Ua Haujlwm tau ua tiav kev tshuaj xyuas thiab hloov kho cov lus qhia 2018. Cov Lus Qhia Txog Kev Ua Haujlwm no qhia txog cov ntsiab lus tseem ceeb ntawm cov lus qhia hloov kho tshiab rau 3 tshooj: Tshooj 2: Kev Kho HCV kab mob hauv cov neeg mob CKD; Tshooj 4: Kev tswj cov neeg mob HCV ua ntej thiab tom qabhloov raum; thiab Tshooj 5: Kev kuaj mob thiab kev tswj xyuas ntawmkab mob raumcuam tshuam nrog tus kab mob HCV.
Kab mob siab C (HCV) kab mob nyob rau hauv lubmob raum mob(CKD) cov pej xeem tau nthuav tawm qee qhov kev sib tw tshwj xeeb. Cov no suav nrog nws qhov muaj feem ntau ntawm cov neeg mob lim ntshav, kis mus rau hauv chav lim ntshav thiab los ntawm cov kab mob grafts, thiab qhov ua rau muaj kev pheej hmoo siab ntawm cov kab mob siab hauv cov neeg mob mob uas tseem nyob hauv kev lim ntshav, nrog rau hauvhloov raumcov neeg txais. Cov kev sib tw ntxiv hauv cov neeg no yav dhau los suav nrog kev txo qis kev ua siab ntev ntawm kev kho tshuaj tiv thaiv kab mob thiab kev xaiv cov txheej txheem tsim nyog. Hauv xyoo 2008, Kab Mob Raum: Txhim Kho Ntiaj Teb Cov Txheej Txheem (KDIGO) tau tshaj tawm cov lus qhia 1 hais txog kev tswj hwm HCV hauv CKD, thiab hauv 2018, kev hloov kho tshiab ntawm cov lus qhia tau tsim tawm uas suav nrog cov kev nce qib loj hauv HCV kev tswj hwm uas tau tshwm sim nyob rau xyoo dhau los,2 xws li cov txheej txheem noninvasive rau kev soj ntsuam daim siab-kab mob hnyav thiab muaj cov kev kho qhov ncauj ncaj qha-tshuaj tiv thaiv kab mob (DAA) . Txij li xyoo 2018 cov lus qhia tau tshaj tawm, cov kev tswj hwm DAA ntxiv tau siv rau hauv cov pej xeem CKD thiabcov neeg tau txais kev hloov lub raum. Tsis tas li ntawd, kev paub ntau ntxiv nrog kev siv cov khoom nruab nrog cev los ntawm cov neeg pub dawb HCV tau nthuav dav kev nkag mus rau hauv kev hloov pauv raum. Lub luag haujlwm ntawm kev kho tshuaj tiv thaiv kab mob hauv kev kho mob glomerulonephritis vim kev kis kab mob HCV kuj tau hais meej meej dua. Raws li qhov tshwm sim ntawm cov kev nce qib no, peb tau ua qhov hloov tshiab ntawm feem ntawm 2018 cov lus qhia tsom mus rau cov chaw hloov pauv no hauv Tshooj 2, 4, thiab 5. Tshooj 1 thiab 3, hais txog kev tshawb nrhiav thiab kev ntsuam xyuas ntawm HCV hauv CKD, thiab kev tiv thaiv nws. Kev xa mus rau hauv hemodialysis units, raws li, nyob twj ywm tam sim no thiab tsis tau lees paub qhov hloov kho tseem ceeb; yog li, lawv tseem tsis hloov pauv ntawm 2018 cov lus qhia. Cov Lus Qhia Txog Kev Ua Haujlwm no nthuav tawm cov lus pom zoo kho dua tshiab thiab hais txog qhov laj thawj rau kev hloov kho rau Tshooj 2, 4, thiab 5.3 Cov lus pom zoo no hloov pauv tag nrho cov lus pom zoo los ntawm tshooj sib npaug hauv 2018 cov lus qhia.
Tshooj 2: Kev kho tus kab mob HCV hauv cov neeg mob nrog CKD DAA txoj kev kho tau zoo thiab ua tau zoo (nrog cov xwm txheej tsis tshua muaj tshwm sim) hauv cov neeg mob thoob plaws txhua theem ntawm CKD, suav nrog cov neeg mob uas tau lim ntshav thiab tom qab hloov lub raum. Kev tiv thaiv kab mob virologic cov lus teb 12 lub lis piam tom qab kev kho mob (SVR12) muaj li ntawm 92% -100% hauv txhua theem ntawm CKD thiab thoob plaws ntau yam kev tswj hwm DAA. Cov xwm txheej tsis zoo tshwm sim los ntawm DAA feem ntau tau tshaj tawm tsawg dua 1% ntawm cov neeg mob kho. Yog li ntawd, kev kho mob raws li interferon tsis siv hauv HCV. Nrog rau kev qhia txog ntau yam DAA cov kev tswj hwm tawm tsam txhua HCV genotypes (pan-genotypic), kev paub txog HCV genotype tsis tshua muaj kev txhawj xeeb hauv kev kho tshuaj tiv thaiv kab mob. Txawm li cas los xij, hauv qee lub tebchaws, genotype-specific DAA cov kev tswj hwm tau yooj yim dua, thiab kev siv cov kev tswj hwm no yog li yuav tsum tau ua kom paub tseeb ntawm HCV genotype ua ntej kho.
Ntau yam pangenotypic thiab genotype-specific DAA cov kev tswj hwm tau raug tshawb xyuas hauv CKD G4-G5ND (ND, tsis yog lim ntshav), G5D (D, lim ntshav), thiab hauv cov neeg tau txais kev hloov lub raum, thiab lawv tau ua haujlwm zoo thiab zam tau zoo. Txij li thaum tshaj tawm ntawm KDIGO 2018 HCV cov lus qhia, cov pov thawj tau hais tias sofosbuvir, ib feem tseem ceeb ntawm ntau txoj kev tswj hwm, muaj kev nyab xeeb rau txhua theem ntawm CKD, suav nrog rau cov tib neeg uas tsis tshua muaj glomerular filtration rate (GFR) lossis kev lim ntshav. Txoj kev loj hlob no tseem ceeb heev vim tias nyob hauv ntau lub tebchaws, tsuas yog muaj cov kev tswj hwm DAA nkaus xwb yog cov uas yog sofosbuvir-based. Tsis tas li ntawd, protease inhibitors ("-previrs" xws li simeprevir, paritaprevir, thiab grazoprevir) yog contraindicated nyob rau hauv cov neeg mob nrog Child-Pugh B thiab C cirrhosis.
Hauv cov neeg mob uas muaj lub raum ua haujlwm, DAA txoj kev kho mob ntes cov kab mob siab thiab txo nws cov teeb meem, thaum txhim kho cov neeg mob muaj sia nyob nrog kev txaus siab toxicity. Tsis tas li ntawd, muaj pov thawj muaj rau kev txhim kho cov kab mob plawv tom qab kev kho HCV hauv cov pej xeem. Cov txiaj ntsig ntawm DAA txoj kev kho no muaj peev xwm txhais tau rau cov neeg mob CKD thiab. KDIGO HCV Ua Haujlwm Pab Pawg pom zoo nrog lwm cov kev qhia tshwj xeeb, suav nrog American Association rau Kev Tshawb Fawb Txog Kab Mob Siab / Kab Mob Sib Kis ntawm Lub Koom Haum Asmeskas Cov Lus Qhia [AASLD/IDSA]), tias kev kho HCV yuav tsum raug txwv rau cov neeg mob uas muaj kev cia siab heev.
CKD G1–G5ND. Raws li pom nyob rau hauv daim duab 1, ib tug xov tooj ntawm pan-genotypic regimens yuav siv tau, tsis hais txog GFR. Yog tias qhov kev kho mob uas tsis yog pangenotypic tau xav txog, kev txheeb xyuas ntawm ib qho genotype yog tsim nyog los txiav txim siab nws cov txiaj ntsig. Kev hloov koob tshuaj ntawm DAA tsis tas yuav tsum muaj hauv CKD G1-G5ND. Lub sijhawm kho mob txawv raws li kev tswj hwm (tab sis tam sim no feem ntau yog 12 lub lis piam), muaj mob cirrhosis, thiab kev kho DAA ua ntej. Cov lus pom zoo tsis ntev los no yuav tsum tau lees paub los ntawm kev sab laj AASLD / IDSA cov lus qhia tshiab (https://www.hcvguidelines.org) lossis European Association rau Kev Tshawb Fawb Txog Kev Mob Siab (EASL) cov lus qhia
NATURAL ORGANIC CISTANCHE EXTRACT nrog 25% ECHINACOSIDE thiab 9%
CKDG5D. Zoo ib yam li CKD G1–G5ND, ntau lub lauj kaub-genotypic nrog rau cov txheej txheem genotype tshwj xeeb muaj rau cov neeg mob CKD G5D (Daim duab 1), nrog rau kev kho lub sijhawm sib txawv raws li DAA txoj cai nrog rau qhov muaj lossis tsis muaj mob cirrhosis thiab / lossis Kev kho HCV ua ntej. Kev hloov kho koob tshuaj DAA kuj tsis tas yuav tsum muaj rau cov neeg mob CKD G5D. Cov lus pom zoo tsis ntev los no yuav tsum tau lees paub los ntawm kev sab laj AASLD / IDSA lossis EASL cov lus qhia tshiab ntawm HCV kho. Feem ntau ntawm cov ntaub ntawv ntawm DAA txoj kev kho hauv CKD G5D muab tau los ntawm cov neeg mob uas tau txais hemodialysis nrog cov ntaub ntawv txwv tsis pub muaj kev nyab xeeb thiab kev ua tau zoo ntawm DAA hauv cov neeg mob uas tau kuaj ntshav peritoneal.
Cov neeg tau txais kev hloov pauv raum. Pangenotypic regimens, nrog rau cov txheej txheem genotype tshwj xeeb, muaj kev nyab xeeb thiab siv tau zoo rau cov neeg tau txais kev hloov pauv raum. Feem ntau ntawm cov ntaub ntawv rau DAA siv rau hauv lub raum hloov pauv tau muab los ntawm cov tib neeg uas muaj GFR $ 30 ml / min ib 1.73 m2 (CKD G1T–G3T; Daim duab 1). Cov ntaub ntawv txwv tsis pub muaj kev ua tau zoo thiab kev nyab xeeb ntawm DAA tuaj yeem nthuav tawm los ntawm DAA siv nyob rau hauv cov neeg xaiv ntau ntawm HCV-tsis muaj kab mob cov neeg tau txais lub raum los ntawm cov neeg pub dawb HCV uas tsawg kawg yog pib muaj GFR tsawg. Qhov kev txhawj xeeb loj txog kev siv DAA hauv kev hloov lub raum yog qhov muaj peev xwm rau kev siv tshuaj yeeb-tshuaj uas tuaj yeem tshwm sim nrog kev siv cov tshuaj tiv thaiv kab mob xws li calcineurin thiab mTOR inhibitors. Cov lus pom zoo tsis ntev los no yuav tsum tau lees paub los ntawm kev sab laj AASLD/IDSA lossis EASL cov lus qhia tshiab ntawm HCV txoj kev kho nrog rau University of Liverpool Hepatitis Drug Interactions lub vev xaib (http://www.hep-druginteractions.org).
Reactivation of hepatitis B virus infection with DAA therapy. Nrog kev tawm tsam ntawm HCV replication, reactivation ntawm HBV replication yuav tshwm sim nyob rau hauv cov neeg mob uas muaj tus kab mob HBV tam sim no los yog ua ntej. Kev ntsuam xyuas cov cim ntawm tus kab mob HBV suav nrog kab mob siab B nto antigen (HBsAg), tag nrho cov core antibody (anti-HBc antibody), thiab tshuaj tiv thaiv kab mob siab B nto antigen (anti-HBs antibody) yog qhia ua ntej DAA txoj kev kho. HBV tshuaj tiv thaiv kab mob yuav tsum tau ua ua ntej kev kho DAA yog tias cov txheej txheem rau kev kho HBV raws li AASLD lossis EASL tau ntsib.4,5 Yog tias tsis muaj HBsAg tab sis cov cim ntawm tus kab mob HBV ua ntej (HBcAb-zoo nrog lossis tsis muaj HBsAb) raug kuaj pom, HBV antiviral therapy tsis tas yuav tsum tau ua ua ntej DAA txoj kev kho, tab sis cov qib aminotransferase yuav tsum tau kuaj xyuas tsis tu ncua thiab kuaj HBV DNA yuav tsum tau ua yog tias qib ntawm daim siab ua haujlwm siab nce thaum kho DAA. Yog tias muaj HBV viremia tam sim no, lees paub qhov rov ua haujlwm dua vim li cas rau qhov nce hauv aminotransferases, kev kho rau HBV yuav tsum pib.
QHOV 2: Kev kho mob ntawm HCV kab mob hauv cov neeg mob nrog CKD
2.1: Peb pom zoo kom txhua tus neeg mob nrog CKD (G1-G5), ntawm kev lim ntshav (G5D), thiab cov neeg tau txais kev hloov raum (G1T G5T) nrog HCV raug soj ntsuam rau kev kho mob ncaj qha los tiv thaiv kab mob (DAA) raws li tau hais tseg. hauv daim duab 1 (1A).
2.1.1: Peb pom zoo kom xaiv cov kev kho mob tshwj xeeb raws li keeb kwm kev kho mob ua ntej, kev sib cuam tshuam ntawm cov tshuaj yeeb tshuaj, glomerular filtration rate (GFR), theem ntawm hepatic fibrosis, lub raum thiab lub siab hloov pauv, thiab comorbidities (1A). Yog tias tsis muaj pangenotypic regimens, HCV genotype (thiab subtype) yuav tsum coj cov kev xaiv ntawm kev kho mob (Daim duab 1).
Figure 1 | Direct-acting antiviral (DAA) regimens with evidence of effectiveness for various chronic kidney disease (CKD) populations. a The table includes only regimens that were evaluated by at least 2 studies in the specific CKD population and for which summary sustained virologic response at 12 weeks [wks] (SVR12) was >92%. Sofosbuvir monotherapy raug cais tawm txij li tam sim no DAA kev tswj hwm suav nrog tsawg kawg 2 tus neeg sawv cev. Lwm cov kev tswj hwm yuav tsim nyog rau cov neeg saum toj no. Cov neeg nyeem tau raug txhawb kom sab laj nrog Lub Koom Haum rau Kev Tshawb Fawb Txog Kab Mob Siab (AASLD) lossis European Association rau Kev Tshawb Fawb Txog Lub Siab (EASL) cov lus qhia rau cov ntaub ntawv tshiab ntawm ntau yam kev tswj hwm. Lub sijhawm qhia txog kev kho mob yog cov feem ntau ua haujlwm los ntawm cov kev tshawb fawb cuam tshuam. Cov kev tshawb fawb feem ntau txuas ntxiv kev kho mob rau cov neeg mob cirrhosis, ua ntej DAA tsis ua haujlwm, lossis rau qee yam genotypes. Cov neeg nyeem yuav tsum sab laj nrog AASLD lossis EASL cov lus qhia, raws li xav tau, txhawm rau txiav txim siab lub sijhawm kho kom zoo. b Qhov kev txiav txim ntawm tus kab mob siab C (HCV) cov txheej txheem tsis qhia txog qhov qeb duas lossis qhov kev xaiv zoo tshaj plaws. Cov txheej txheem tau nthuav tawm nyob rau hauv qhov kev txiav txim ntawm cov pov thawj zoo, tom qab ntawd los ntawm HCV genotype, thiab tom qab ntawd sau ntawv. Qhov sib txawv ntawm qhov ua tau zoo ntawm cov pov thawj feem ntau cuam tshuam nrog cov neeg mob soj ntsuam thiab qhov sib txawv me me hauv cov txheej txheem zoo ntawm cov kev tshawb fawb hauv qab (saib Cov Lus Qhia Ntxiv Ntxiv S5–S7). c Kwv yees glomerular filtration rate (eGFR) $30 ml/min ib 1.73 m2 . d eGFR<30 ml/min per 1.73 m2 , not dialysis-dependent. e Regimens in kidney transplant recipients (KTRs) should be selected to avoid drug–drug interactions, particularly with calcineurin inhibitors. f Strength of evidence for CKD G4T-G5T is very low for all regimens. g Evidence primarily for patients on hemodialysis. Very few patients were on peritoneal dialysis. G, refers to the GFR category with suffix D denoting patients on dialysis and ND denoting patients not on dialysis; PrO D, ritonavir-boosted paritaprevir and ombitasvir with or without dasabuvir.
2.1.2: Kho lub raum hloov cov neeg sib tw hauv kev koom tes nrog lub chaw hloov pauv kom zoo rau lub sijhawm ntawm kev kho mob (Tsis Qib).
2.1.3: Peb pom zoo rau kev ntsuam xyuas ua ntej rau kev siv tshuaj yeeb-tshuaj sib cuam tshuam ntawm DAA-raws li kev tswj hwm thiab lwm yam tshuaj noj nrog rau cov tshuaj tiv thaiv kab mob hauv lub raum hloov pauv (1A).
2.1.4: Peb pom zoo kom saib xyuas cov qib calcineurin inhibitor thaum lub sijhawm thiab tom qab kev kho DAA hauv cov neeg tau txais kev hloov raum (1B).
2.2: Txhua tus neeg mob uas muaj CKD (G1-G5), ntawm kev lim ntshav (G5D), thiab cov neeg tau txais kev hloov lub raum (G1T-G5T) nrog HCV yuav tsum tau kuaj tus kab mob siab B (HBV) ua ntej kev kho DAA (Tsis yog Qib). 2.2.1: Yog tias muaj kab mob siab B nto antigen [HBsAg], tus neeg mob yuav tsum tau txais kev ntsuam xyuas rau HBV kho (Tsis Qib).
2.2.2: Yog tias tsis muaj HBsAg tab sis cov cim ntawm tus kab mob HBV ua ntej (HBcAb-zoo nrog lossis tsis muaj HBsAb) raug kuaj pom, tsis suav nrog HBV rov ua haujlwm nrog HBV DNA kuaj yog tias qib ntawm daim siab ua haujlwm hauv siab nce thaum kho DAA (Tsis Qib).
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