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ACTUALITI N DIAGNOSTICUL I
TRATAMENTUL AFECIUNILOR
HEPATICE EREDITARE
Confereniar universitar
Dr. Tofan-Scutaru Liudmila
TESTAREA N BOAL DE FICAT SAU HEPATIT DE ETIOLOGIE NECUNOSCUT
INDICATII PENTRU TESTARE
Boala hepatic de etiologie necunoscut (serologia: toi marcheri virali - negativi,
valori crescute ale transaminazelor)
ANA i/sau F-actin/ASMA + LKM-1 + AMA-M2 + i ANA +/- Decizie: ANCA, IgG; ASLA, IgG
HAI-1 sau CSP Sugestiv HAI-2 Sugestiv CBP Unul dintre teste pozitiv Negativ
Sex - M: F, egal.
Boala Wilson poate prezenta simptomatica la orice vrst, dei majoritatea prezint
vrstele de 5 i 35.
Cel mai tnr dintre pacienii raportai cu ciroza din cauza bolii Wilson a fost de 3
ani [9].
circulant liber
bazali)
COMPLICAIILE BW
Mutation analysis
On both chromosomes detected 4
On 1 chromosome detected 1
No mutations detected 0
Total Score and Evaluation
4 diagnosis established
3 diagnosis possible; more tests needed
2 diagnosis very unlikely
*Or typical abnormalities at brain magnetic resonance imaging
**If no quantitative liver copper available
SCORUL DIAGNOSTIC PENTRU BW
Scoring system developed at the 8th International Meeting on Wilsons disease, Leipzig 2001
Inducerea metallothioneinei
mg.
imunosupresoare.
Monitorizarea eficienei tratamentului cu D-penicilamina
Tratamentul poate fi monitorizat prin msurarea excreiei urinare de cupru n 24/h n
timpul tratamentului.
Cu urinar imediat dup nceperea tratamentului adecvat poate depi 16 mol/g/24 h (1000
g/24 h)
eficient.
Valorile excreiei urinare de cupru > 1,6 mol/24 ore, dup dou zile de suspendare de D-
penicilamina poate indica non-aderenta la tratament (la acei pacieni cuprul liber este
La copii, doza pe baz de greutate nu este stabilit, dar doza utilizat n general
este de 20 mg / kg / zi rotunjit cu o precizie de 250 mg, administrat n 2-3 prize.
150 mg/zi
150 mg
Zinc 150 mg/zi
25 mg/zi
Piridoxina per os 25 mg
Bibliografie BW
Guidelines
European Association for Study of Liver. EASL Clinical Practice Guidelines: Wilson's disease. J Hepatol. 2012; 56(3): 671-85.
PubMed
Roberts EA, Schilsky ML, American Association for Study of Liver Diseases (AASLD). Diagnosis and treatment of Wilson
disease: an update. Hepatology. 2008; 47(6): 2089-111. PubMed
General References
Ala A, Walker AP, Ashkan K, Dooley JS, Schilsky ML. Wilson's disease. Lancet. 2007; 369(9559): 397-408. PubMed
Bennett J, Hahn SH. Clinical molecular diagnosis of Wilson disease. Semin Liver Dis. 2011; 31(3): 233-8. PubMed
Gouider-Khouja N. Wilson's disease. Parkinsonism Relat Disord. 2009; 15 Suppl 3: S126-9. PubMed
Huster D. Wilson disease. Best Pract Res Clin Gastroenterol. 2010; 24(5): 531-9. PubMed
Kanwar P, Kowdley KV. Metal storage disorders: Wilson disease and hemochromatosis. Med Clin North Am. 2014; 98(1): 87-
102. PubMed
Lorincz MT. Neurologic Wilson's disease. Ann N Y Acad Sci. 2010; 1184: 173-87. PubMed
Mak CM, Lam C. Diagnosis of Wilson's disease: a comprehensive review. Crit Rev Clin Lab Sci. 2008; 45(3): 263-90. PubMed
McMillin GA, Travis JJ, Hunt JW. Direct measurement of free copper in serum or plasma ultrafiltrate. Am J Clin Pathol. 2009;
131(2): 160-5. PubMed
Walshe JM. Monitoring copper in Wilson's disease. Adv Clin Chem. 2010; 50: 151-63. PubMed
Zarrilli F, Elce A, Scorza M, Giordano S, Amato F, Castaldo G. An update on laboratory diagnosis of liver inherited
diseases. Biomed Res Int. 2013; 2013: 697940. PubMed
References from the ARUP Institute for Clinical and Experimental Pathology
McMillin GA, Travis JJ, Hunt JW. Direct measurement of free copper in serum or plasma ultrafiltrate. Am J Clin Pathol. 2009;
131(2): 160-5. PubMed
Medical Reviewers
Best, Hunter, PhD, Medical Director, Molecular Genetics; Director, High Complexity Platforms-NGS at ARUP Laboratories;
Assistant Professor of Clinical Pathology, University of Utah
Strathmann, Frederick G., PhD, MS, Medical Director, Toxicology; Director of High-Complexity Platforms, Mass
Spectrometry; Interim Scientific Director, Biocomputing; Assistant Director, ARUP Institute for Clinical and Experimental
Pathology; Assistant Professor of Clinical Pathology and Associate Member of the Interdepartmental Program in
Neuroscience, University of Utah
HEMOCROMATOZA EREDITARA
Definiie
Considerat mult timp drept o boala unitar monogenic HE este de fapt o afeciune
poligenic cu faete multiple5.
ciroza hepatic,
diabetul zaharat,
artrita,
cardiomiopatia
hipogonadismul hipogonadotropic.
HEMOCROMATOZA EREDITARA
Expresia clinic a bolii este de 5-10 ori mai
frecvent la barbati.
Expresia fenotipic este influenat de:
consumul de alcool,
aportul alimentar de fier,
pierderile menstruale,
sarcina, alaptare,
donrile de snge.
Clasificarea hemocromatozei ereditare
Baza de date OMIM (Online Mendelian Inheritance in Man) listeaz 4 tipuri de HE
caracterizate prin mutaii genetice diferite. Genele afectate codific proteine care
sunt implicate n cile metabolice relevante pentru sinteza hepatic de hepcidin.
Homozigoia C282Y
Hemocromatoza non-HFE:
diabet zaharat, cardiomiopatie, etc) este redus, ceea ce indic faptul c ali
cu fier.
Statusul homozigot pentru mutaia H63D, n absena altor factori modificatori, este
fier crescute.
Aproximativ 1-2% din persoanele cu acest genotip vor dezvolta semne clinice ale
suprancrcrii cu fier. Dei indivizii cu acest genotip pot prezenta anomalii ale
consum excesiv de etanol. Alela mutant H63D se ntlnete la cca. 22% din europeni.
HE, tip 2
HE de tip 2 include cazurile de hemocromatoz juvenil i prezint dou
forme:
Astenie
la femei amenoree.
Diabet zaharat
Glicemia