СОВРЕМЕННЫЕ ПРОБЛЕМЫ ВТОРИЧНЫХ ИММУНОДЕФИЦИТОВ (ОБЗОР ЛИТЕРАТУРЫ)

В обзоре дано определение вторичного иммунодефицита (ВИД), обосновывается его присутствие в структуре мультиморбидности, охарактеризованы последствия течения мультиморбидности с включением ВИД. Представлены немногочисленные эпидемиологические данные о распространенности ВИД, анализируется наиболее часто встречающиеся факторы риска (причины) иммунодефицита, подчеркивается растущее число этих факторов, связанных с получением новых знаний о патогенезе болезней и появлением новых классов лекарственных средств, способных негативно влиять на клетки и медиаторы иммунной системы, а также с увеличением продолжительности жизни и распространенностью хронических заболеваний. Описан структурированный подход к диагностике и терапии ВИД. Первым этапом является выявление выявление факторов риска и ранних клинических проявлений ВИД, связанных с особенностями течения тяжелых и часто рецидивирующих инфекций как маркеров ВИД, что позволяет заподозрить иммунодефицит на доклиническом этапе. Далее, диагноз ВИД выставляется с учетом как клинических, так и лабораторных данных. Подробно изложен алгоритм обследования больного с подозрением на ВИД, включающий тщательный анамнестический и клинический анализ, позволяющий обосновать объем лабораторных, в том числе иммунологического, этапов обследования, а также определить показания к динамическому наблюдению и консультации иммунолога. Подчеркивается, что отсутствие измененных показателей иммунного статуса при наличии тяжелого или рецидивируещего инфекционного синдрома не исключает ВИД. Описаны дифференцированные подходы к противоинфекционной профилактике в различных группах риска развития инфекций, освещены основные методы лечения вторичных иммунодефицитов с применением вакцин и иммуноглобулинов, с учетом индивидуального профиля риска пациента. Отмечается недостаток доказательных данных об эффективности и безопасности терапии вторичных иммунодефицитов вакцинами и иммуноглобулинами. Представленные рекомендации основаны на нескольких консенсусах экспертов (клиницистов и иммунологов), работающих по проблеме ВИД. Сделан вывод о том, что оптимальное ведение пациентов с вторичными иммунодефицитами должно осуществляться мультидисциплинарной командой клиницистов с обязательным участием иммунолога, что особенно важно в условиях нарастающей мультиморбидности и полипрагмазии.

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