У пациентов с неалкогольной жировой болезнью печени (НАЖБП), не реагирующих на изменение образа жизни и фармакотерапию, рекомендовано хирургическое лечение
Бариатрическая (метаболическая) хирургия
У пациентов, не реагирующих на изменение образа жизни и медикаментозное лечение, бариатрическая хирургия позволяет снизить массу тела и частоту метаболических осложнений со стабильными результатами в долгосрочной перспективе [142]. Суррогатные маркеры показывают, что бариатрическая хирургия эффективна в лечении поражений печени при НАЖБП; новые данные подтверждают ее эффективность в лечении некровоспалительного процесса и фиброза [143]. По данным нового когортного исследования с 1-летним периодом наблюдения, снижение массы тела на фоне бариатрической хирургии способствовало устранению НАСГ у 85% пациентов и уменьшило выраженность фиброза у 34% [144], хотя этот эффект следует сбалансировать с учетом периоперационных и послеоперационных осложнений. Достоверные данные по сравнению влияния различных бариатрических процедур на содержание жира в печени отсутствуют.
Рекомендации
- За счет контроля ожирения и сахарного диабета бариатрическая (метаболическая) хирургия снижает содержание жира в печени и уменьшает прогрессирование НАСГ; проспективные данные показали улучшение гистологической картины при НАСГ, в том числе фиброза (B1)
Трансплантация печени
Цирроз печени на фоне НАЖБП входит в число первых трех показаний к трансплантации печени. 3- и 5-летняя выживаемость при наличии и отсутствии НАЖБП не различаются; НАЖБП обуславливает более высокий риск смерти от сердечно-сосудистых осложнений и сепсиса, риск отторжения трансплантата ниже [145,146]. Общая смертность связана с ИМТ и сахарным диабетом, 50% пациентов с ИМТ >35 кг/м2 умирают в течение 1-го года после трансплантации [147]. Отторжение трансплантата (10 и 45% после 10 и 20 лет соответственно [148]) у пациентов с ожирением редко ассоциируется с рецидивирующим циррозом при НАСГ (≈2%) [146]. Рекомендации
Трансплантация печени – общепринятый метод лечения НАСГ у пациентов с терминальной стадией болезни печени; общая выживаемость сопоставима с другими показаниями, несмотря на более высокую сердечно-сосудистую смертность. Пациентов с НАСГ в сочетании с печеночной недостаточностью и/или ГЦК нужно рассматривать как кандидатов на трансплантацию печени (A1)
Источник: EASL–EASD–EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease, Journal of Hepatology 2016 vol. 64 j 1388–1402
Дополнительные данные
Дополнительные данные к этой статье доступны онлайн по адресу: http://dx.doi.org/10.1016/j.jhep.2015.11.004.
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