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THAI TRANSPLANT CARE (TTC) LIVER. . . . . . . . . . . . . . . . . . . . . . . . . . 1

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫THAI TRANSPLANT CARE (TTC)

LIVER

¡“§¡ª≈Ÿ°∂à“¬Õ«—¬«–·Ààßª√–‡∑»‰∑¬Thai Transplantation Society

‡¡…“¬π Úıı¯

April 2015

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .2

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫THAI TRANSPLANT CARE (TTC) LIVER

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‚∑√ “√ 02-716-6183www.transplantthai.org

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“√∫—≠

Õ¿‘∏“π»—æ∑å ............................................................................................ 9 “‡Àμÿ¢Õß‚√§μ—∫∑’Ëπ”‰ª Ÿà°“√ª≈Ÿ°∂à“¬μ—∫„πºŸâ„À≠à ............................. 10¢âÕ∫àß™’È (indication) ·≈–‡°≥±å (criteria)

¢Õß°“√ª≈Ÿ°∂à“¬μ—∫„πºŸâ„À≠à ............................................................. 11¢âÕÀâ“¡ (contraindication) „π°“√ª≈Ÿ°∂à“¬μ—∫„πºŸâ„À≠à ....................... 13 “‡Àμÿ¢Õß‚√§μ—∫∑’Ëπ”‰ª Ÿà°“√ª≈Ÿ°∂à“¬μ—∫„π‡¥Á° ................................. 14¢âÕ∫àß™’È (indication) ·≈–‡°≥±å (criteria) ¢Õß°“√ª≈Ÿ°∂à“¬μ—∫„π‡¥Á° .. 15¢âÕÀâ“¡ (contraindication) „π°“√ª≈Ÿ°∂à“¬μ—∫„π‡¥Á° ........................... 16‡Õ° “√Õâ“ßÕ‘ß ......................................................................................... 16Õ‘¡¡Ÿπ«‘∑¬“¢Õß°“√ª≈Ÿ°∂à“¬Õ«—¬«– ....................................................... 17‡Õ° “√Õâ“ßÕ‘ß ......................................................................................... 20ª√–‡¿∑¬“°¥¿Ÿ¡‘§ÿâ¡°—π∑’Ë„™â„π°“√ª≈Ÿ°∂à“¬μ—∫...................................... 21‡Õ° “√Õâ“ßÕ‘ß ................................................................................ 26, 30°“√¥Ÿ·≈√—°…“ acute rejection „π°“√ª≈Ÿ°∂à“¬μ—∫ ................................ 34°“√¥Ÿ·≈√—°…“ chronic rejection „π°“√ª≈Ÿ°∂à“¬μ—∫ ............................ 40‡Õ° “√Õâ“ßÕ‘ß ......................................................................................... 41


Õ¿‘∏“π»—æ∑å (Glossary)

ACR Acute cellular rejection

ALT Alanine aminotransferase

AST Aspartate aminotransferase

APC Antigen presenting cell

ALP Alkaline phosphatase

ATG Antithymocyte globulin

CMV Cytomegalovirus

CNI Calcineurin inhibitors

CR Chronic rejection

CKD Chronic kidney disease

GFR Glomerular filtration rate

EBV Ebstein-Barr

INR International ratio

IL2 Interleukin 2 (IL-2)

MMF Mycophenolatemofetil

MPA Mycophenolic acid

mTOR Mammalian Target of Rapamycin

PTLD Post-transplant lymphoproliferative disorders

RAI Rejection activity index

TCR T cell receptors

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .10

“‡Àμÿ¢Õß‚√§μ—∫∑’Ëπ”‰ª Ÿà°“√ª≈Ÿ°∂à“¬μ—∫„πºŸâ„À≠à ¡’¥—ßπ’È

1. μ—∫Õ—°‡ ∫‡√◊ÈÕ√—ß®“°‰«√— μ—∫Õ—°‡ ∫∫’‰«√— μ—∫Õ—°‡ ∫´’ autoimmune

hepatitis μ—∫Õ—°‡ ∫®“°¬“ ¡ÿπ‰æ√·≈– ÿ√“

2. ‚√§∑àÕπÈ”¥’Õÿ¥μ—π‡√◊ÈÕ√—ß ‡™àπ primary biliary cirrhosis, sclerosing cholan-

gitis, biliary atresia

3. ‚√§ metabolic liver disorders ‡™àπ hemochromatosis, Wilsonûs disease,

tyrosinemia, glycogen storage disease

4. μ—∫«“¬‡©’¬∫æ≈—π (fulminant hepatic failure) ®“° “‡Àμÿμà“ßÊ ‡™àπ ¬“

¡ÿπ‰æ√ ‰«√— μ—∫Õ—°‡ ∫

5. ¡–‡√Áß‡´≈≈åμ—∫ (hepatocellular carcinoma)

6. ¿“«–Õ◊ËπÊ ∑’Ë‰¡àæ∫∫àÕ¬ ‡™àπ hepatoblastoma, hepatic hemangioendot-

helioma, polycystic liver disease, Budd-Chiari syndrome ‡ªìπμâπ

“‡Àμÿ¢Õß‚√§μ—∫∑’Ëπ”‰ª Ÿà°“√ª≈Ÿ°∂à“¬μ—∫„πºŸâ„À≠à


¢âÕ∫àß™’È (indication) ·≈–‡°≥±å (criteria) °“√ª≈Ÿ°∂à“¬μ—∫„πºŸâ„À≠à·∫àßμ“¡ª√–‡¿∑¢Õß‚√§μ—∫

● μ—∫·¢Áß√–¬– ÿ¥∑â“¬ (decompensated cirrhosis)

ºŸâªÉ«¬§«√‰¥â√—∫°“√ª≈Ÿ°∂à“¬μ—∫‡¡◊ËÕ¡’‚Õ°“ √Õ¥™’«‘μ„π 1 ªïπâÕ¬°«à“

√âÕ¬≈– 90 À√◊Õ¡’μ—∫·¢ÁßÕ¬Ÿà„π√–¬– Child-Pugh B (Child-Pugh score >7) À√◊Õ Child-

Pugh C (Child-Pugh score >9) À√◊Õ¡’Õ“°“√·≈–Õ“°“√· ¥ß∂÷ß¿“«–·∑√°´âÕπ

¢Õßμ—∫·¢Áß ‰¥â·°à ¡’πÈ”„π∑âÕß (ascites), ‡¬◊ËÕ∫ÿ™àÕß∑âÕßÕ—°‡ ∫ (spontaneous bacte-

rial peritonitis), Õ“°“√∑“ß ¡Õß®“°‚√§μ—∫ (hepatic encephalopathy), À≈Õ¥

‡≈◊Õ¥¢Õ¥¢ÕßÀ≈Õ¥Õ“À“√·μ° (variceal hemorrhage), hepatorenal syndrome ‡ªìπμâπ

ºŸâªÉ«¬μ—∫·¢Áß√–¬– ÿ¥∑â“¬∑’Ë®–‰¥â√—∫°“√ª≈Ÿ°∂à“¬μ—∫ §«√¡’§à“ MELD score# ¡“°

°«à“ 15 ·≈–μâÕßÀ¬ÿ¥ ÿ√“μ‘¥μàÕ°—π‰¡àπâÕ¬°«à“ 6 ‡¥◊Õπ

#MELD score = (0.957loge (Cr.-mg/dl) + 0.378loge (Bili-mg/dl) + 1.12loge (INR) +

0.643)*10

● ¡–‡√Áß‡´≈≈åμ—∫ (hepatocellular carcinoma)

‡æ◊ËÕ„Àâ‰¥âÕ—μ√“√Õ¥™’«‘μ¿“¬À≈—ßª≈Ÿ°∂à“¬μ—∫∑’Ë 5 ªï Ÿß°«à“√âÕ¬≈– 70 °“√

ª≈Ÿ°∂à“¬μ—∫‡π◊ËÕß®“°‚√§¡–‡√Áß‡´≈≈åμ—∫§«√¡’¢âÕ∫àß™’È¥—ßπ’È ¢π“¥‡ âπºà“»Ÿπ¬å°≈“ß

¢Õß°âÕππâÕ¬°«à“ 5 ¡.„π°√≥’∑’Ë¡’‡æ’¬ß 1 °âÕπ À√◊Õ∂â“¡’¡“°°«à“ 1 °âÕπ·μà‰¡à‡°‘π

3 °âÕπ ¢π“¥¢Õß‡ âπºà“»Ÿπ¬å°≈“ß¢Õß°âÕπ∑’Ë„À≠à∑’Ë ÿ¥μâÕß‰¡à‡°‘π 3 ¡.(À√◊Õ‡√’¬°«à“

Milan criteria) ‚¥¬‰¡à¡’°“√°√–®“¬¢Õß¡–‡√ÁßÕÕ°πÕ°μ—∫À√◊Õ‰¡à°√–®“¬‡¢â“

À≈Õ¥‡≈◊Õ¥¥”æÕ√å∑—≈(portal vein)

°“√ª≈Ÿ°∂à“¬μ—∫ºŸâ∑’Ë¡’√–¬–¢Õß¡–‡√Áßμ—∫‡°‘π Milan criteria §«√Õ¬Ÿà„π¥ÿ≈¬

æ‘π‘®¢Õß§≥–·æ∑¬å∑’Ë¥Ÿ·≈ª≈Ÿ°∂à“¬μ—∫¢Õß ∂“∫—ππ—ÈπÊ

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .12

● μ—∫«“¬‡©’¬∫æ≈—π (fulminant hepatic failure)

„™â‡°≥±åμ“¡ Kingûs College criteria ¥—ß· ¥ß„π μ“√“ß∑’Ë 1

μ“√“ß∑’Ë 1 ¢âÕ∫àß™’È°“√ª≈Ÿ°∂à“¬μ—∫μ“¡ Kingûs College criteria

Acetaminophen overdose Non-acetaminophen causes

Arterial pH < 7.3 Prothrombin time > 100 «‘π“∑’ (INR > 6.5)

À√◊Õ ¡’ 3 ¢âÕμàÕ‰ªπ’È À√◊Õ ¡’ 3 „π 5 ¢âÕμàÕ‰ªπ’È

1. Prothrombin time > 100 «‘π“∑’ 1. Õ“¬ÿ < 10 À√◊Õ > 40 ªï

(À√◊Õ INR > 7.7) 2. “‡Àμÿ¢Õßμ—∫«“¬: non-A, non-B À√◊Õ

2. Creatinine > 3.4 ¡°./¥≈. μ—∫Õ—°‡ ∫®“°¬“

3. Grade III À√◊Õ IV hepatic 3. Jaundice > 7 «—π°àÕπ encephalopathy

encephalopathy 4. Prothrombin time > 50 «‘π“∑’ (INR > 3.5)

5. Bilirubin > 17.5 ¡°./¥≈.

● ¢âÕ∫àß™’È®”‡æ“–¢Õß‚√§∫“ß‚√§∑’Ë‰¡à “¡“√∂√—°…“¥â«¬«‘∏’Õ◊Ëπ ‡™àπ ¡’

§ÿ≥¿“æ™’«‘μ≈¥≈ß®“°Õ“°“√§—π¡“°∑’Ë‰¡àμÕ∫ πÕßμàÕ°“√√—°…“„π¿“«– chronic

cholestasis, hepatopulmonary syndrome œ≈œ


¢âÕÀâ“¡ (contraindication) „π°“√ª≈Ÿ°∂à“¬μ—∫„πºŸâ„À≠à

1. ¬—ß¥◊Ë¡ ÿ√“‡ªìπª√–®”

2. μ‘¥‡™◊ÈÕ∑—Ë«√à“ß°“¬√ÿπ·√ß (uncontrolled sepsis)

3. μ‘¥‡™◊ÈÕ human immunodeficiency virus (HIV)

4. ¡’‚√§√à«¡∑’Ë¡’º≈μàÕ√à“ß°“¬§àÕπ¢â“ß¡“° ‰¥â·°à ‚√§À—«„® ªÕ¥ À√◊Õ

√–∫∫ª√– “∑œ≈œ

5. ¡’¡–‡√Áß¢ÕßÕ«—¬«–Õ◊ËππÕ°‡Àπ◊Õ®“°¡–‡√Áß‡´≈≈åμ—∫∑’Ë¬—ß‰¡àÀ“¬¢“¥

6. §«“¡º‘¥ª°μ‘¢Õß®‘μÀ√◊Õ‚√§®‘μ∑’Ë‰¡à “¡“√∂§«∫§ÿ¡‰¥â

7. ‰¡à “¡“√∂„Àâ§«“¡√à«¡¡◊Õ°—∫°“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫∑—Èß°àÕπ·≈–¿“¬

À≈—ßºà“μ—¥

8. ‰¡à¡’§√Õ∫§√—« ≠“μ‘À√◊Õ‡æ◊ËÕπ™à«¬‡À≈◊Õ¥Ÿ·≈‰¥âÕ¬à“ß‡À¡“– ¡

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .14

¢âÕ∫àß™’È (indication) ·≈–‡°≥±å (criteria) „π°“√ª≈Ÿ°∂à“¬μ—∫„π‡¥Á°

“‡Àμÿ¢Õß‚√§μ—∫∑’Ëπ”‰ª Ÿà°“√ª≈Ÿ°∂à“¬μ—∫„π‡¥Á° ¡’¥—ßπ’È

1. ‚√§∑’Ë¡’°“√Õÿ¥μ—πÀ√◊Õ§«“¡º‘¥ª°μ‘¢Õß∑àÕπÈ”¥’ ‡™àπ biliary atresia, scle-

rosing cholangitis

2. ‚√§∑“ßæ—π∏ÿ°√√¡∑’Ë¡’πÈ”¥’§—ËßÀ√◊Õ§«“¡º‘¥ª°μ‘¢Õß∑àÕπÈ”¥’ ‡™àπ progres-

sive familial intrahepatic cholestasis, Alagilleûs syndrome ‡ªìπμâπ

3. Metabolic liver disorders ‡™àπ Wilsonûs disease, tyrosinemia, Crigler-

Najjar syndrome, disorder of urea cycle, inborn error of bile acid me-

tabolism ‡ªìπμâπ

4. μ—∫«“¬‡©’¬∫æ≈—π (fulminant hepatic failure) ®“° “‡Àμÿμà“ßÊ

5. “‡ÀμÿÕ◊ËπÊ ‡™àπ primary liver tumor, cystic fibrosis, total parenteral

nutrition-induced cholestasis

“‡Àμÿ¢Õß‚√§μ—∫∑’Ëπ”‰ª Ÿà°“√ª≈Ÿ°∂à“¬μ—∫„π‡¥Á°


¢âÕ∫àß™’È (indication) ·≈–‡°≥±å (criteria) „π°“√ª≈Ÿ°∂à“¬μ—∫„π‡¥Á°

1. ‚√§μ—∫·¢Áß (cirrhosis) §«√∑”°“√ª≈Ÿ°∂à“¬μ—∫‡¡◊ËÕ¡’¢âÕ„¥¢âÕÀπ÷ËßμàÕ

‰ªπ’È

1.1 ‚√§μ—∫·¢Áß¥”‡π‘π‰ª Ÿà√–¬–∑â“¬‚¥¬¡’º≈°“√μ√«®¥—ßπ’È

- Total bilirubin „π´’√—Ë¡ > 9 ¡°./¥≈.

- Prothrombin time ¬“«π“π°«à“§à“ª°μ‘‡°‘π 5 «‘π“∑’ À√◊Õ INR

> 1.4

- Serum albumin< 3.5 °√—¡/¥≈.

1.2 ¡’¿“«–·∑√°´âÕπ®“°‚√§μ—∫·¢Áß‡™àπ

- Hepatic encephalopathy

- Refractory ascites

- Spontaneous bacterial peritonitis

- Recurrent variceal bleeding

- Intractable pruritus

- Hepatopulmonary syndrome

- Growth failure (∑—Èß∑’Ë‰¥â„Àâ nutritional support ‡μÁ¡∑’Ë)

2. Acute liver failure (fulminant hepatic failure) „™â‡°≥±åμ“¡

Kingûs College criteria ‡™àπ‡¥’¬«°—∫ºŸâ„À≠à (μ“√“ß∑’Ë 1) πÕ°®“°π’È§«√æ‘®“√≥“

ª≈Ÿ°∂à“¬μ—∫„π°√≥’æ¬“°√≥å‚√§‰¡à¥’ ‰¥â·°à grade III - IV hepatic encephalopathy

¢π“¥μ—∫≈¥≈ßÕ¬à“ß√«¥‡√Á«√à«¡°—∫ AST ·≈– ALT ≈¥≈ßÕ¬à“ß√«¥‡√Á«·≈–¬—ß¡’

coagulogram º‘¥ª°μ‘Õ¬à“ß√ÿπ·√ß

3. Metabolic liver disorders ∑’Ë‰¡àμÕ∫ πÕßμàÕ°“√√—°…“μ“¡¡“μ√∞“π

‡™àπ tyrosinemia, Crigler-Najjar type I, organic acidemia, primary oxalosis, Wilsonûs

disease ‡ªìπμâπ

4. ‡π◊ÈÕßÕ°ª∞¡¿Ÿ¡‘¢Õßμ—∫∑’Ë‰¡à “¡“√∂ºà“μ—¥‰¥â‚¥¬¬—ß‰¡à¡’°“√°√–®“¬

ÕÕ°πÕ°μ—∫ ”À√—∫¡–‡√Áß‡´≈≈åμ—∫„™â Milan criteria ‡™àπ‡¥’¬«°—∫ºŸâ„À≠à

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .16

¢âÕÀâ“¡ (contraindication) „π°“√ª≈Ÿ°∂à“¬μ—∫„π‡¥Á°

1. μ‘¥‡™◊ÈÕ HIV

2. μ‘¥‡™◊ÈÕ∑—Ë«√à“ß°“¬√ÿπ·√ß (uncontrolled sepsis)

3. ¡’‚√§¢ÕßÕ«—¬«–Õ◊ËπÊ ∑’Ë√ÿπ·√ß´÷Ëß‰¡à “¡“√∂°≈—∫§◊π‰¥â¿“¬À≈—ßª≈Ÿ°

∂à“¬μ—∫

4. ‚√§ªÕ¥À√◊Õ‚√§À—«„®√ÿπ·√ß∑’Ë¡’§«“¡‡ ’Ë¬ß Ÿß„π°“√¥¡¬“ ≈∫·≈–

°“√ºà“μ—¥

5. ¡’§«“¡æ‘°“√∑“ß ¡ÕßÀ√◊Õªí≠≠“ÕàÕπ

6. ‰¡à¡’§√Õ∫§√—«À√◊Õ≠“μ‘™à«¬‡À≈◊Õ¥Ÿ·≈‰¥âÕ¬à“ß‡À¡“– ¡

‡Õ° “√Õâ“ßÕ‘ß

1. Murray KF, Carithers RL Jr, AASLD. AASLD practice guidelines: Evaluation of

the patient for liver transplantation. Hepatology 2005;41:1407-32.

2. Martin P, DiMartini A, Feng S, Brown R Jr, Fallon M. Evaluation for liver

transplantation in adults: 2013 practice guideline by the American Association

for the Study of Liver Diseases and the American Society of Transplantation.

Hepatology 2014;59:1144-65.

3. Kelly D, Mayer D. Liver transplantation. In: Kelly D, editor. Diseases of Liver

and Biliary System in Children. 3rd ed. West Sussex: Blackwell publishing;

2008. p. 503-530.


Õ‘¡¡Ÿπ«‘∑¬“¢Õß°“√ª≈Ÿ°∂à“¬Õ«—¬«–Immunological pathway of organ transplantation

§«“¡ ”‡√Á®¢Õß°“√ª≈Ÿ°∂à“¬μ—∫‡°‘¥¢÷Èπ§√—Èß·√°‡¡◊ËÕªï æ.». 2506 À√◊Õ

ª√–¡“≥§√÷Ëß»μ«√√…∑’Ëºà“π¡“ §«“¡ ”‡√Á®π’È§«∫§Ÿà‰ª°—∫°“√æ—≤π“¢Õß¬“°¥

¿Ÿ¡‘§ÿâ¡°—π™π‘¥μà“ßÊ À≈—°°“√ ”§—≠¢Õß°“√ª≈Ÿ°∂à“¬Õ«—¬«–§◊Õ°“√À“∑“ß≈¥¿Ÿ¡‘

μâ“π∑“π¢Õß√à“ß°“¬∑’Ë‰ª∑”≈“¬Õ«—¬«– À√◊Õ alloantigen ∑’Ë√à“ß°“¬‰¥â√—∫‡¢â“‰ª

„π¬ÿ§·√°Ê ¢Õß°“√„™â¬“°¥¿Ÿ¡‘π—Èπ‡√‘Ë¡¥â«¬°“√„™â steroid √à«¡°—∫¬“ azathioprine

®“°π—Èπ∑ÿ°Ê √–¬–ª√–¡“≥Àπ÷Ëß∑»«√√… ®–¡’°“√æ—≤π“¬“°≈ÿà¡„À¡àÊ ÕÕ°¡“

∑”„ÀâÕ—μ√“°“√√Õ¥™’«‘μÀ≈—ß°“√ª≈Ÿ°∂à“¬μ—∫ Ÿß¢÷Èπ‡ªìπ≈”¥—∫ ®π√–¬–À≈—ß¢Õß

°“√æ—≤π“¬“°¥¿Ÿ¡‘§ÿâ¡°—π ¡’·π«‚πâ¡¢Õß°“√æ—≤π“™π‘¥¢Õß¬“À√◊Õ«‘∏’°“√„™â¬“

‡æ◊ËÕ≈¥°“√‡°‘¥¿“«–·∑√° âÕπμà“ßÊ ‡™àπ ≈¥°“√‡°‘¥¿“«–·∑√° âÕπ¢Õß‰μ ‡ªìπμâπ

√«¡∂÷ß°“√À“™π‘¥¢Õß¬“ À√◊Õ °“√μ√«®À“≈—°…≥–∑“ßæ—π∏ÿ°√√¡¢Õß recipient ·≈–

donor ∑’Ë®–™à«¬À√◊Õ∑”π“¬°“√‡°‘¥¿“«–¢Õß immune tolerance ®π “¡“√∂À¬ÿ¥

¬“°¥¿Ÿ¡‘§ÿâ¡°—π‰ª„π∑’Ë ÿ¥

Recipient ‡¡◊ËÕ‰¥â√—∫μ—∫®“°donor À√◊Õ alloantigen ‡¢â“ Ÿà√à“ß°“¬ ®–¡’°“√

‡°‘¥ªØ‘°‘√‘¬“¢Õß¿Ÿ¡‘§ÿâ¡°—π∑—Èß·∫∫‰¡à‡©æ“–‡®“–®ß·≈–·∫∫‡©æ“–‡®“–®ß (innate

and adaptive immune response) °“√‡°‘¥ªØ‘°‘√‘¬“‡∫◊ÈÕßμâππ—Èπ antigen presenting

cell (APC) °√–μÿâπ‡´≈≈å‡¡Á¥‡≈◊Õ¥¢“«™π‘¥ T helper cell (TH) ®“°π—Èπ®–¡’°“√À≈—Ëß

interleukin 2 (IL-2) ´÷Ëß‡ªìπ‰´‚μ‰§πå∑’Ë ”§—≠∑’Ë‡ªìπ®ÿ¥‡√‘Ë¡μâπ¢Õß°√–∫«π°“√

Õ—°‡ ∫μà“ßÊμ“¡¡“ IL-2 ∑’ËÀ≈—ËßÕÕ°®“°‡´≈≈å®–‰ª∑”ªØ‘°‘√‘¬“°—∫ IL-2 receptor

∫π‡´≈≈å‡¡Á¥‡≈◊Õ¥¢“«∑”„Àâ‡°‘¥°“√·∫àßμ—«·≈–°“√‡æ‘Ë¡®”π«π¢Õß specific T cell

(¿“æ∑’Ë 1)

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .18

¿“æ∑’Ë 1 °“√‡°‘¥ allograft rejection ‡¡◊ËÕ antigen presenting cells (APC) π” al-

loantigen ´÷Ëß express ∫π MHC class II ‚¡‡≈°ÿ≈∑”ªØ‘°‘√‘¬“°—∫ T cell

receptor (TCR) ∑”„Àâ¡’°“√°√–μÿâπ°“√‡æ‘Ë¡®”π«π¢Õß specific T cell

°≈‰° ”§—≠¢Õß°“√°√–μÿâπ TH π—ÈπæÕ®– √ÿª‰¥â¥—ßπ’È (¿“æ∑’Ë 2) „πμ—∫¡’

‡´≈≈åÀ≈—°∑’Ë∑”Àπâ“∑’Ë APC ´÷Ëß‰¥â·°à ‡´≈≈å¢Õß bile duct ·≈– vascular endothelium

‡ÀÁπ‰¥â®“°º≈∑“ßæ¬“∏‘«‘∑¬“¢Õßμ—∫‡«≈“‡°‘¥¿“«– acute rejection ≈—°…≥–°“√

Õ—°‡ ∫∑’Ë‡©æ“–„π¿“«–π’È§◊Õ endotheliitis ·≈– bile duct ¡’°“√Õ—°‡ ∫ ∫«¡·≈–

∂Ÿ°∑”≈“¬ ·≈–æ∫°“√Õ—°‡ ∫∫√‘‡«≥æÕ√å∑—≈ APC ‡À≈à“π’È∑”Àπâ“∑’Ë¬àÕ¬‚¡‡≈°ÿ≈¢Õß

antigen ®π¡’¢π“¥‡≈Á° ·≈–∂Ÿ° àßμàÕ‰ª∫πº‘«‡´≈≈å‚¥¬ —¡æ—π∏å°—∫ MHC class II

molecule ®“°π—Èπ TH ®–∑”Àπâ“∑’Ë√—∫√Ÿâ·≈–μÕ∫ πÕßμàÕ antigen π’È‚¥¬ºà“π∑“ßμ—«√—∫

§◊Õ T cell receptors (TCR) ´÷Ëß¡’≈—°…≥–‡ªìπ complex ‚¡‡≈°ÿ≈ √à«¡°—∫ co-receptor

∑’Ë¡’Õß§åª√–°Õ∫¢Õß CD3 ‚¡‡≈°ÿ≈ πÕ°®“°π’È TCR ¬—ß¡’ co-stimulatory receptor:

CD28 [´÷Ëß∑”ªØ‘°‘√‘¬“°—∫ APC ºà“π‚¡‡≈°ÿ≈¢Õß B7 (CD80, CD86)], TCR ‡¡◊ËÕ√—∫√Ÿâ

antigen ®“° MHC class II ®–‡°‘¥ªØ‘°‘√‘¬“ àßºà“π®“°º‘«‡´≈≈å‡¢â“ Ÿà¿“¬„π‡´≈≈å


·≈– àßμàÕ¢âÕ¡Ÿ≈ºà“π°√–∫«π°“√¿“¬„π‡´≈≈åÀ≈“¬¢—ÈπμÕπ ∑’Ë ”§—≠§◊Õ calcineurin

∂â“∂Ÿ°°√–μÿâπ ®–‡°‘¥ªØ‘°‘√‘¬“ àßμàÕ‰ª∑”„Àâ nuclear factor of activated T cell (NF-

AT) ‡§≈◊ËÕπμ—«‡¢â“‰ªπ‘«‡§≈’¬ ∑”Àπâ“∑’Ë‡ªìπ transcription factor °√–μÿâπ

‚ª√‚¡‡μÕ√å¢Õß¬’π IL-2 ∑”„Àâ¡’°“√ √â“ß IL-2 ‡æ‘Ë¡¡“°¢÷Èπ ®÷ß‡°‘¥«ß®√°“√ √â“ß

·≈–°√–μÿâπ‡´≈≈å„Àâº≈‘μ IL-2 ·≈–‰´‚μ‰§πåÀ√◊Õ “√μà“ßÊ ∑’Ë‡°’Ë¬«‡π◊ËÕß°—∫°“√

Õ—°‡ ∫¡“°¢÷Èπ

πÕ°®“°°≈‰°¢â“ßμâπ·≈â« „π‡´≈≈åÀ≈—ß®“°∂Ÿ°°√–μÿâπºà“π IL-2/IL-2 receptor

¿“¬„π‡´≈≈å¬—ß¡’°≈‰°À≈—°∑’Ëºà“π‚¡‡≈°ÿ≈∑’Ë ”§—≠§◊Õ molecular target of rapamycin

À√◊Õ∑’Ë‡√’¬°«à“ mTOR ‚¡‡≈°ÿ≈π’È¬—ß¡’§«“¡‡°’Ë¬«‡π◊ËÕß°—∫ TCR co-receptor: CD28

¿“æ∑’Ë 2 °≈‰°°“√°√–μÿâπ°“√ √â“ß IL-2 ·≈– signaling molecules ∑’Ë ”§—≠¿“¬„π

‡´≈≈å ‡¡◊ËÕ‡°‘¥¿“«– allograft rejection √«¡∂÷ß°≈ÿà¡·≈–™π‘¥¢Õß¬“°¥

¿Ÿ¡‘§ÿâ¡°—π∑’ËÕÕ°ƒ∑∏‘Ï„π·μà≈–μ”·Àπàß¢Õß‡´≈≈å

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .20

(‡°’Ë¬«‡π◊ËÕß°—∫¿“«– anergy), NF-KB ´÷Ëß‡ªìπ transcription factor ∑’Ë ”§—≠„π°“√

°√–μÿâπ¬’π∑’Ë‡°’Ë¬«‡π◊ËÕß°—∫¿“«–°“√Õ—°‡ ∫ ·≈– cyclin dependent kinase (CDK)

´÷Ëß‡°’Ë¬«‡π◊ËÕß°—∫°“√·∫àßμ—«¢Õß‡´≈≈å√–¬–μà“ßÊ πÕ°®“°π’È„ππ‘«‡§≈’¬ ‡Õß°“√∑’Ë

‡´≈≈å¢Õß‡¡Á¥‡≈◊Õ¥¢“«®–·∫àßμ—«‡æ‘Ë¡®”π«π¬àÕ¡μâÕß¡’°“√ √â“ß nucleic acid ∑—Èß

°≈ÿà¡ purine ·≈– pyrimidine ‡æ◊ËÕ„™â„π°“√ √â“ß “¬ DNA

∑’Ë°≈à“«¡“‚¥¬¬àÕ¢â“ßμâπ‡æ◊ËÕ„Àâ ‡ÀÁπ¿“æ¢Õß«ß®√μâπ°”‡π‘¥¢Õß

°√–∫«π°“√‡°‘¥¿“«– acute rejection ∑’Ë‡√‘Ë¡‡°‘¥¢÷Èπ„π∑—π∑’À≈—ß∑’Ë√à“ß°“¬‰¥â√—∫

·Õπμ‘‡®π·ª≈°ª≈Õ¡‡¢â“‰ª ∑”„Àâ¡’°“√ √â“ß IL-2 ·≈–¡’°“√‡æ‘Ë¡®”π«π¢Õß spe-

cific T cell ·≈–‡°‘¥¡’¿“«–°“√Õ—°‡ ∫μ“¡¡“ ¬“°¥¿Ÿ¡‘§ÿâ¡°—π™π‘¥μà“ßÊ ∑’Ë∂Ÿ°§âπ

æ∫μà“ß°Á¡’°≈‰°„π°“√¬—∫¬—Èß°“√°√–μÿâπ√–∫∫¿Ÿ¡‘§ÿâ¡°—π„πμ”·Àπàßμà“ßÊ ¢Õß‡´≈≈å

(¿“æ∑’Ë 2)

‡Õ° “√Õâ“ßÕ‘ß

1. Starzl TE, Klintmalm GB, Porter KA, Iwatsuki S, Schroter GP. Liver transplanta-

tion with use of cyclosporina and prednisone. N Engl J Med 1981;305:266-9.

2. John Devlin, Peter Donaldson, Roger Williams. Type of rejection and immuno-

suppression. In: Williams R, Portmann B, Tan K-C, eds. The Practice of Liver

Transplantation. London: Churchill Livingstone, 1995. p. 183-89.


ª√–‡¿∑¢Õß¬“°¥¿Ÿ¡‘§ÿâ¡°—π∑’Ë„™â„π°“√ª≈Ÿ°∂à“¬μ—∫

Corticosteroids

¬“°≈ÿà¡π’ÈÕÕ°ƒ∑∏‘Ï°«â“ß¢«“ß„π°“√°¥¿Ÿ¡‘§ÿâ¡°—π‰¥â·°à ¬—∫¬—Èß T-cell ·≈–

antigen-derived cytokine expression ‡™àπ IL-1, IL-2, IL-3 ·≈– IL-6 ¢π“¥∑’Ë„Àâ

√–À«à“ßºà“μ—¥‰¥â·°à 500-1000 ¡°. ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”®“°π—Èπ®÷ßª√—∫≈¥¢π“¥¬“

≈ßμ“¡≈”¥—∫ à«π„À≠à¡—°À¬ÿ¥¬“ corticosteroids ¿“¬À≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫

3-6 ‡¥◊Õπ

Calcineurin inhibitors (CNI) ‰¥â·°à ¬“ cyclosporine ·≈– tacrolimus

Cyclosporine ·≈– tacrolimus —ß‡§√“–Àå®“°‡™◊ÈÕ√“ ÕÕ°ƒ∑∏‘Ï‚¥¬

cyclosporine ®—∫°—∫‚ª√μ’π™◊ËÕ cyclophilin ·≈– tacrolimus ®—∫°—∫‚ª√μ’π FK-binding

protein ‡¡◊ËÕ¬“®—∫°—∫‚ª√μ’π·≈â«®–¬—∫¬—Èß calcineurin ≈¥°“√°√–μÿâπ transcription

activation ¢Õß cytokine genes ¢Õß IL-2, TNF-alpha, IL-3, IL-4, œ≈œ π”‰ª Ÿà°“√

≈¥≈ß¢Õß T cell activation ·≈– proliferation

Tacrolimus ¡’°“√‡ª≈’Ë¬π·ª≈ß‚¥¬ºà“π CYP3A4 ·≈– CYP3A5 √âÕ¬≈– 90

¢Õß¬“ tacrolimus ∂Ÿ°°”®—¥ºà“ππÈ”¥’ ¢π“¥¢Õß¬“ª√—∫μ“¡√–¥—∫¬“ tacrolimus

°àÕπ√—∫ª√–∑“π (trough level) „π™à«ß·√°À≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫ª√–¡“≥ 5-15

π“‚π°√—¡/¡≈.À≈—ß 4-6 ‡¥◊Õπ ‡ªìπμâπ‰ª ∂â“Õ“°“√ª°μ‘ √–¥—∫¬“ trough level

Õ“®≈¥≈ß‡ªìπ 5-7 π“‚π°√—¡/¡≈. „πºŸâªÉ«¬‡¥Á°„Àâ¢π“¥¬“√—∫ª√–∑“π‡√‘Ë¡μâπ 0.05-

0.1 ¡°./°°./«—π ·∫àß„Àâ 2 ‡«≈“À√◊Õ„π°√≥’∑’Ë‰¡à “¡“√∂√—∫ª√–∑“π¬“∑“ßª“°‰¥â

„Àâ™π‘¥©’¥„π¢π“¥ 0.03-0.05 ¡°./°°./«—π À¬¥μàÕ‡π◊ËÕß∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ·≈â«

ª√—∫μ“¡√–¥—∫¬“¥—ß°≈à“«¢â“ßμâπÀ√◊ÕμË”°«à“À“°‰¥â√—∫¬“°¥¿Ÿ¡‘§ÿâ¡°—πÕ◊Ëπ√à«¡

”À√—∫ cyclosporine À≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫™à«ß·√° §«√„Àâ√–¥—∫¬“ trough

level Õ¬Ÿàª√–¡“≥ 250-350 π“‚π°√—¡/¡≈. ∑’Ë 1 ‡¥◊ÕπÀ≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫Õ“®

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .22

≈¥√–¥—∫¬“ trough level ‡ªìπ 150-250 π“‚π°√—¡/¡≈. ·≈– 6 ‡¥◊ÕπÀ≈—ßºà“μ—¥

Õ“®≈¥≈ß‡ªìπ 100-200 π“‚π°√—¡/¡≈. „πºŸâªÉ«¬‡¥Á°„Àâ¢π“¥¬“√—∫ª√–∑“π‡√‘Ë¡μâπ

5 ¡°./°°./«—π ·∫àß„Àâ 2 ‡«≈“ ·≈â«ª√—∫μ“¡√–¥—∫¬“¥—ß°≈à“«¢â“ßμâππÕ°®“°

μ‘¥μ“¡¥â«¬√–¥—∫ trough level ¬—ß “¡“√∂μ‘¥μ“¡√–¥—∫ cyclosporine ∑’Ë 2 ™—Ë«‚¡ß

À≈—ß√—∫ª√–∑“π¬“‡√’¬°«à“ C2 (‡æ◊ËÕμ‘¥μ“¡√–¥—∫¬“‰¡à„Àâ Ÿß®π¡’º≈μàÕ°“√∑”ß“π

¢Õß‰μ) §à“√–¥—∫ C2 À≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫™à«ß·√°§«√Õ¬Ÿà∑’Ë√–¥—∫ 850-1400

π“‚π°√—¡/¡≈. ·≈–≈¥≈ß‰¥âμ“¡≈”¥—∫∂â“º≈‡≈◊Õ¥¥’¢÷Èπ ª√–‚¬™πå¢Õß°“√„™â¬“

cyclosporine ‚¥¬μ‘¥μ“¡¥â«¬√–¥—∫ C2 Õ“®‰¡àμà“ß®“°°“√„™â tacrolimus Õ¬à“ß‰√

°Áμ“¡ „π¢≥–π’È¬—ß‰¡à¡’À≈—°∞“π¬◊π¬—π«à“°“√μ‘¥μ“¡ cyclosporine ¥â«¬√–¥—∫ C2

¥’°«à“°“√„™â troughlevel

Antiproliferativedrug ‰¥â·°à mycophenolatemofetil (MMF),mycophenolic acid (MPA) ·≈– azathioprine

∑—Èß¬“ MMF ·≈– MPA ÕÕ°ƒ∑∏‘Ï¢—¥¢«“ß°√–∫«π°“√ √â“ß purine nucle-

otides ¢—¥¢«“ß°“√·∫àßμ—«¢Õß T ·≈– B lymphocytes ¬“ MMF ÕÕ°ƒ∑∏‘Ï‡ªìπ·∫∫

immediate release à«π MPA ÕÕ°ƒ∑∏‘Ï‡ªìπ·∫∫ delayedrelease ¢π“¥¢Õß¬“ MMF

∑’Ë„™â∑—Ë«‰ªª√–¡“≥ 2-3 °√—¡/«—π „πºŸâªÉ«¬‡¥Á°„Àâ¢π“¥¬“√—∫ª√–∑“π 30-40 ¡°./

°°./«—π À√◊Õ 600 ¡°./æ◊Èπ∑’Ëº‘«°“¬ (μ√.¡.)/«—π ¢π“¥ Ÿß ÿ¥‰¡à‡°‘π 2-3 °√—¡/«—π à«π

MPA „Àâ¢π“¥720-1440 ¡°./«—π ·∫àß√—∫ª√–∑“π«—π≈–2 §√—Èß „π‡¥Á°¬—ß‰¡à¡’°“√

»÷°…“¢π“¥¬“ MPA

¬“ azathioprine ‡ªìπ¬“∑’Ë¬—∫¬—Èß°“√·∫àßμ—«¢Õß‡´≈≈åºà“π purine synthesis

inhibition ¢π“¥¬“ azathioprine ∑’Ë„™â‰¥â·°à 1-3 ¡°./°°./«—π

mTOR Inhibitor

¬“°≈ÿà¡π’È®–‰ª®—∫°—∫ FK506-binding protein ‡°‘¥°“√¬—∫¬—Èß mammalian

targets of rapamycin ∑”„Àâ‡°‘¥°“√¬—∫¬—Èß T-cell proliferation ¢π“¥¢Õß¬“ sirolimus


∑’Ë√—∫ª√–∑“π‡∑à“°—∫ 0.1 ¡°./°°. À√◊Õ 5 ¡°.„π§√—Èß·√° ®“°π—Èπ√—∫ª√–∑“π 2 ¡°./

«—π μ‘¥μ“¡√–¥—∫¬“°àÕπ√—∫ª√–∑“π¬“ (trough level) ‡æ◊ËÕ„Àâ‰¥â√–¥—∫¬“ª√–¡“≥

5-10 π“‚π°√—¡/¡≈. à«π¢π“¥¬“√—∫ª√–∑“π‡√‘Ë¡μâπ¢Õß¬“ everolimus ‰¥â·°à 1

¡°.«—π≈– Õß§√—Èß ª√—∫¢π“¥¬“„Àâ‰¥â√–¥—∫¬“ trough level 3-8 π“‚π°√—¡/¡≈.¬“

∑—Èß Õß™π‘¥¡—°„™â√à«¡°—∫¬“°≈ÿà¡ CNI„π°√≥’∑’ËμâÕß°“√≈¥¢π“¥¢Õß¬“ CNI

”À√—∫¬“ sirolimus ¡’§”‡μ◊Õπ®“°Õß§å°“√Õ“À“√·≈–¬“¢Õßª√–‡∑» À√—∞Õ‡¡√‘°“

«à“°“√„™â√à«¡°—∫ tacrolimus À√◊Õ cyclosporine „πºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫Õ“®∑”„Àâ¡’ graft

survival ≈¥≈ß ‡æ‘Ë¡Õ—μ√“μ“¬¢ÕßºŸâªÉ«¬ ·≈–¡’ hepatic artery thrombosis ‡æ‘Ë¡¢÷Èπ

Antibody therapy ·∫àß‡ªìπ 2 ª√–‡¿∑§◊Õ

Lymphocyte depleting antibody ‰¥â·°à antithymocyte globulin (ATG)

‡ªìπ polyclonal antilymphocyte antibody ÕÕ°ƒ∑∏‘Ï∑”≈“¬ T cell ºà“π°√–∫«π°“√

apoptosis ·≈– antibody-mediated cytolysis ¢π“¥¬“∑’Ë„™â 1.5-5 ¡°./°°. „Àâ„π 4-6

™¡. ‡ªìπ‡«≈“ 3-5 «—π Õ“®¡’º≈¢â“ß‡§’¬ß®“°¬“©’¥‰¥â

Non-lymphocyte depleting antibody ‰¥â·°à IL-2 receptor antibody

∑’Ë¡’„™â„π¢≥–π’È§◊Õ basiliximab ¬“®—∫°—∫ IL-2 α-chain ‡°‘¥ competitive antagonism

¢Õß IL2-induced T cell proliferation ¢π“¥¬“∑’Ë„Àâ‰¥â·°à 20 ¡°. ∑“ßÀ≈Õ¥‡≈◊Õ¥

¥”„π«—πºà“μ—¥ ·≈–Õ’° 20 ¡°. ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”«—π∑’Ë 4 À≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫

„π‡¥Á°∑’ËπÈ”Àπ—°μ—«πâÕ¬°«à“ 35 °°. „Àâ≈¥¢π“¥¬“‡À≈◊Õ 10 ¡°./§√—Èß

À¡“¬‡Àμÿ °“√‡≈◊Õ°„™â¬“°¥¿Ÿ¡‘§ÿâ¡°—π·μà≈–™π‘¥¢÷Èπ°—∫ªí®®—¬μà“ßÊ ∑’Ë

‡°’Ë¬«¢âÕß¢ÕßºŸâªÉ«¬ ‡™àπ Õ“¬ÿ ‚√§ª√–®”μ—«À√◊Õ‚√§√à«¡ ¢âÕ∫àß™’È¢Õß°“√ª≈Ÿ°∂à“¬

μ—∫ ¿“«–·∑√°´âÕπ ‡ªìπμâπ

¿“«–·∑√°´âÕπ¢Õß¬“°¥¿Ÿ¡‘§ÿâ¡°—π · ¥ß„πμ“√“ß∑’Ë 2

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .24

μ“√“ß∑’Ë 2 º≈¢â“ß‡§’¬ß®“°¬“°¥¿Ÿ¡‘§ÿâ¡°—π

™π‘¥¢Õß¬“ º≈¢â“ß‡§’¬ß

Tacrolimus Hypertension, headache, infection, hyperglycemia, insu-lin dependence, tremor, chronic renal failure, PTLD

Cyclosporine Hypertension, infection, hyperglycemia, chronic renal fail-ure, hirsutism, gingival hyperplasia, PTLD

Sirolimus Hypercholesterolemia, infection, edema, proteinuria,PTLD,delayed wound healing, may be associated withhepatic artery thrombosis when use early post liver trans-plantation

Corticosteroid Hypertension, increased appetite, Cushing syndrome, acne,gastritis, hyperglycemia, delayed wound healing, osteoporo-sis, delayed linear growth

Mycophenolate- Intestinal hypermotility, cramping, diarrhea, leukopenia,mofetil (MMF) anemia, thrombocytopenia, PTLDAntithymocyte globulin Fever, chills, rash, anemia, thrombocytopenia, serum sick-

ness, nephritis, CMV infection and PTLDIL-2 receptor antibody Rare infusion reaction, less opportunistic infection and

PTLD

¿“¬À≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫ “¡“√∂·∫àß√–¬–¢Õß°“√„™â¬“°¥¿Ÿ¡‘§ÿâ¡°—π

‰¥â‡ªìπ 2 √–¬– ‰¥â·°à √–¬–induction ·≈–√–¬– maintenance

1. Induction immunosuppression: „πªí®®ÿ∫—π à«π„À≠à„™â¬“ 3

ª√–‡¿∑√à«¡°—π ‰¥â·°à corticosteroid, CNI √à«¡°—∫ antimetabolite ¬°‡«âπ„π°√≥’

æ‘‡»…∫“ß°√≥’ ‡™àπ °“√∑”ß“π¢Õß‰μ≈¥≈ß À√◊Õ‰¡àμâÕß°“√„™â corticosteroid

·π–π”„Àâ„™â IL-2 receptor antibody À√◊Õ antithymocyte globulin (ATG)


● Steroid induction „™â methylprednisolone „π¢π“¥ 500 ¡°. ∂÷ß 1 °√—¡

● Antibody induction Õ“®„™â IL-2R antibody À√◊Õ lymphocytedepleting

antibody

‡π◊ËÕß®“°μ—∫‡ªìπÕ«—¬«–∑’Ë§àÕπ¢â“ß∑πμàÕ°“√‡°‘¥ rejection ·≈–°“√‡°‘¥

acute cellular rejection Õ“®‰¡à¡’º≈‡ ’¬„π√–¬–¬“«∑—ÈßμàÕμ—«ºŸâªÉ«¬·≈–μàÕÕ«—¬«–

¥—ßπ—Èπ°“√„™â antibody induction ®÷ß¡’ºŸâ„™â‰¡à¡“°π—° ®“° ∂‘μ‘¢Õß UNOS æ∫°“√„™â

antibody induction ª√–¡“≥√âÕ¬≈– 25 ·μà¡’·π«‚πâ¡∑’Ë‡æ‘Ë¡¢÷Èπ™â“Ê ∑ÿ°ªï

°“√»÷°…“∑’Ëºà“π¡“ à«π¡“°æ∫«à“°“√„™â antibody induction ™à«¬≈¥°“√

‡°‘¥ rejection ‰¥â°Á®√‘ß·μà‰¡à¡“°π—° ·≈–¬—ßæ∫«à“Õ—μ√“°“√√Õ¥¢ÕßºŸâªÉ«¬·≈–

Õ«—¬«–∑’Ë 1 ªï ‰¡à‰¥â‡æ‘Ë¡¢÷Èπ‡¡◊ËÕ‡∑’¬∫°—∫°≈ÿà¡∑’Ë‰¡à‰¥â„™â antibody induction

πÕ°®“°π’È¬—ßæ∫«à“ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫¡’‚Õ°“ ‡°‘¥‰μ«“¬À≈—ß

ºà“μ—¥‰¥â Ÿß °“√»÷°…“„π√–¬–À≈—ß¡—°„™â antibody induction ‡æ◊ËÕ®ÿ¥ª√– ß§å∑’Ë®–

≈¥ renal toxicity ¢Õß CNI¥â«¬°“√„Àâ antibody induction √à«¡°—∫°“√„™â CNI

¢π“¥μË”°«à“ª°μ‘ ·≈–/À√◊Õ ‡√‘Ë¡°“√„™â CNI À≈—ßºà“μ—¥√–¬–Àπ÷Ëß (delayed introduc-

tion of CNI)

‡π◊ËÕß®“° IL-2 receptor antibody ¡’√“§“ Ÿß¡“° ·≈–º≈μàÕ°“√Õ¬Ÿà√Õ¥

¢ÕßÕ«—¬«–·≈–¢ÕßºŸâªÉ«¬„π√–¬–¬“«‰¡à‰¥â¥’°«à“°≈ÿà¡∑’Ë‰¡à‰¥â„™â¡“°π—° ®÷ß§«√

‡≈◊Õ°„™â antibody induction „πºŸâªÉ«¬∫“ß√“¬ ¥—ß¡’¢âÕ∫àß„™â¥—ßπ’È

¢âÕ∫àß„™â

1. ºŸâªÉ«¬∑’Ë¡’¿“«– hepatorenal syndrome

2. ºŸâªÉ«¬∑’Ë¡’¿“«–‰μ«“¬‡©’¬∫æ≈—π°àÕπºà“μ—¥

3. ºŸâªÉ«¬ CKD stage 3 ¢÷Èπ‰ª À√◊ÕºŸâªÉ«¬ CKD stage 2 with acute kidney

injury

4. μ—∫∑’Ë‰¥â√—∫∫√‘®“§®“° extended criteria donor

5. ¿“«–Õ◊ËπÊ ∑’Ë¡’§«“¡‡ ’Ë¬ßμàÕ°“√‡°‘¥ rejection À√◊Õ post-operative renal

impairment Ÿß°«à“ª°μ‘

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .26

¬“∑’Ë„™â

Antibody ∑’Ë¡’„™â„πªí®®ÿ∫—π¡’ IL-2R receptorantibody (´÷Ëßªí®®ÿ∫—π‡À≈◊Õ‡æ’¬ß

μ—«‡¥’¬«§◊Õ basiliximab) ·≈– lymphocyte depleting antibody ‰¥â·°à thymoglobulin

·≈– anti-thymocyteglobulin

Basiliximab

„Àâ¢π“¥ 20 ¡°. ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”¡—°‡√‘Ë¡„Àâ¬“„πÀâÕßºà“μ—¥À≈—ß®“°À¬ÿ¥

‡≈◊Õ¥‰¥â·≈â« (μà“ß®“°°“√ª≈Ÿ°∂à“¬‰μ∑’Ëπ‘¬¡„Àâ°àÕπ°“√ºà“μ—¥ ‡π◊ËÕß®“°°“√ºà“μ—°

ª≈Ÿ°∂à“¬μ—∫¡’°“√‡ ’¬‡≈◊Õ¥¡“° ∂â“„Àâ°àÕπºà“μ—¥Õ“®¡’°“√ Ÿ≠‡ ’¬‰ª°—∫°“√‡ ’¬

‡≈◊Õ¥‰¥â) ·≈–„Àâ§√—Èß∑’Ë Õß „π«—π∑’Ë 4 À≈—ßºà“μ—¥

Thymoglobulin ·≈– anti-thymocyte globulin

„Àâ„π¢π“¥ 1.5 ¡°./°°./§√—Èß«—π≈–§√—Èß‡ªìπ‡«≈“ 5-7 «—π (°“√∫√‘À“√¬“√«¡

∑—Èß°“√„Àâ pre-medication √“¬≈–‡Õ’¬¥„πÀ—«¢âÕ°“√√—°…“ rejection)

‡Õ° “√Õâ“ßÕ‘ß1. Tchervenkov J, Flemming C, Guttmann RD, des Gachons G. Use of

thymoglobulin induction therapy in the prevention of acute graft rejection epi-sodes following liver transplantation. Transplant Proc 1997;29:13S-5S.

2. Emre S, Gondolesi G, Polat K, Ben-Haim M, Artis T, Fishbein TM, et al. Use ofdaclizumab as initial immunosuppression in liver transplant recipients withimpaired renal function. Liver Transpl 2001;7:220-5.

3. Neuhaus P, Clavien PA, Kittur D, Salizzoni M, Rimola A, Abeywickrama K, etal. Improved treatment response with basiliximabimmunoprophylaxis after livertransplantation: results from a double-blind randomized placebo-controlled trial.Liver Transpl 2002;8:132-42.

4. Ojo AO, Held PJ, Port FK, Wolfe RA, Leichtman AB, Young EW, et al. Chronicrenal failure after transplantation of a nonrenal organ. N Engl J Med 2003;349:931-40.


5. Yoshida EM, Marotta PJ, Greig PD, Kneteman NM, Marleau D, Cantarovich M,et al. Evaluation of renal function in liver transplant recipients receiving daclizumab(Zenapax), mycophenolatemofetil, and a delayed, low-dose tacrolimus regimenvs. a standard-dose tacrolimus and mycophenolatemofetil regimen: a multicenterrandomized clinical trial. Liver Transpl 2005;11:1064-72.

6. Soliman T, Hetz H, Burghuber C, Gyori G, Silberhumer G, Steininger R, et al.Short-term induction therapy with anti-thymocyte globulin and delayed use ofcalcineurin inhibitors in orthotopic liver transplantation. Liver Transpl 2007;13:1039-44.

7. Bajjoka I, Hsaiky L, Brown K, Abouljoud M. Preserving renal function in livertransplant recipients with rabbit anti-thymocyte globulin and delayed initiationof calcineurin inhibitors. Liver Transpl 2008;14:66-72.

8. Neuberger JM, Mamelok RD, Neuhaus P, Pirenne J, Samuel D, Isoniemi H, etal. Delayed introduction of reduced-dose tacrolimus, and renal function in livertransplantation: the ùReSpECTû study. Am J Transplant 2009;9:327-36.

9. Boillot O, Seket B, Dumortier J, Pittau G, Boucaud C, Bouffard Y, et al.Thymoglobulin induction in liver transplant recipients with a tacrolimus,mycophenolatemofetil, and steroid immunosuppressive regimen: a five-yearrandomized prospective study. Liver Transpl 2009;15:1426-34.

10. Wang XF, Li JD, Peng Y, Dai Y, Shi G, Xu W. Interleukin-2 receptor antago-nists in liver transplantation: a meta-analysis of randomized trials. TransplantProc 2010;42:4567-72.

11. Benitez CE, Puig-Pey I, Lopez M, Martinez-Llordella M, Lozano JJ, Bohne F, etal. ATG-Fresenius treatment and low-dose tacrolimus: results of a randomizedcontrolled trial in liver transplantation. Am J Transplant 2010;10:2296-304.

12. http://www.fda.gov/safety/medwatch/safetyinformation/ucm187076.htm

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .28

2. Maintenance immunosuppression: À≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫ à«π

„À≠à¡’°“√„™â corticosteroid ¢π“¥ Ÿß„π™à«ß·√° μàÕ¡“®÷ß§àÕ¬Ê≈¥¢π“¥¬“≈ß

μ“¡≈”¥—∫ ®πÀ¬ÿ¥¬“ corticosteroid ¿“¬„π 3-6 ‡¥◊Õπ (¬°‡«âπ°“√ºà“μ—¥ª≈Ÿ°

∂à“¬μ—∫®“°¿“«– autoimmune hepatitis) Õ“®„™â¬“‡æ’¬ß™π‘¥‡¥’¬« (monotherapy)

À√◊Õ 2 ™π‘¥ (double therapy) ‚¥¬¡’ CNI ‡ªìπ¬“À≈—°·≈–„™â√à«¡°—∫¬“°≈ÿà¡ anti-

proliferative drug À√◊Õ mTOR-inhibitor

°“√„™â¬“°¥¿Ÿ¡‘§ÿâ¡°—π ”À√—∫°“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫‚¥¬∑—Ë«‰ª

®“°°“√»÷°…“ meta-analysis „πºŸâ„À≠àæ∫«à“ tacrolimus ™à«¬≈¥Õ—μ√“μ“¬

°“√ Ÿ≠‡ ’¬μ—∫·≈–°“√‡°‘¥ acute rejection ¡“°°«à“ cyclosporine Õ¬à“ß‰√°Áμ“¡∑—Èß

tacrolimus ·≈– cyclosporine ‡ªìπ∑’Ëπ‘¬¡„™â‡ªìπ¬“°¥¿Ÿ¡‘§ÿâ¡°—π¿“¬À≈—ßºà“μ—¥ª≈Ÿ°

∂à“¬μ—∫ ‚¥¬„™â‡æ’¬ßμ—«‡¥’¬« (monotherapy) À√◊Õ„™â√à«¡°—∫¬“Õ◊Ëπ ‡™àπ „™â√à«¡°—∫

¬“°≈ÿà¡ anti-proliferative À√◊Õ¬“°≈ÿà¡ mTOR-inhibitor ‡æ◊ËÕÀ≈’°‡≈’Ë¬ßº≈¢â“ß‡§’¬ß

®“°¬“ CNI „π¢π“¥ ŸßÕ“®æ‘®“√≥“„™â cyclosporine „π°√≥’∑’Ë¡’§«“¡‡ ’Ë¬ßμàÕ

°“√‡°‘¥ PTLD ‰¥â·°à °“√ª≈Ÿ°∂à“¬μ—∫∑’Ë‰¥âμ—∫®“°ºŸâ∫√‘®“§∑’Ë¡’ EBV IgG (+) ·≈–

ºŸâ√—∫∫√‘®“§¡’ EBV IgG (-) À√◊Õ°√≥’∑’Ë¡’º≈¢â“ß‡§’¬ßÀ√◊Õªí≠À“®“°°“√„™â¬“

tacrolimus

°“√„™â¬“°¥¿Ÿ¡‘§ÿâ¡°—π‡¡◊ËÕºà“μ—¥ª≈Ÿ°∂à“¬μ—∫„π°√≥’‡©æ“–

● ¿“«–‰μ«“¬À√◊Õ°“√∑”ß“π¢Õß‰μ≈¥≈ß (À√◊Õ¡’§«“¡‡ ’Ë¬ßμàÕ°“√

∑”ß“π¢Õß‰μ≈¥≈ß)

“‡Àμÿ∑’Ë∑”„Àâ°“√∑”ß“π¢Õß‰μ≈¥≈ß°àÕπ·≈–À≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫ ‰¥â·°à

●● ¡’ªí®®—¬‡ ’Ë¬ß°àÕπºà“μ—¥ª≈Ÿ°∂à“¬μ—∫ ‡™àπ ‡∫“À«“π §«“¡¥—π‚≈À‘μ

Ÿß œ≈œ

●● ‡°‘¥¿“«–‡∫“À«“πÀ≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫

●● ‡°‘¥§«“¡¥—π‚≈À‘μ ŸßÀ≈—ßºà“μ—¥ª≈Ÿ°∂à“¬μ—∫


●● ‰¥â√—∫¬“∑’Ë¡’º≈‡ ’¬μàÕ‰μ

●● ‡ªìπº≈¢â“ß‡§’¬ß¢Õß¬“ CNI

·π«∑“ß‡≈◊Õ°ªØ‘∫—μ‘‡¡◊ËÕ¡’¿“«–°“√∑”ß“π¢Õß‰μ≈¥≈ß

1. „™â¬“ CNI ¢π“¥πâÕ¬μ—Èß·μà·√° (early minimization) À√◊ÕÀ¬ÿ¥„™â¬“ CNI

·μà‡π‘ËπÊ (early withdrawal CNI)

■ °“√„™â¬“ CNI ¢π“¥μË”Ê (‰¥â·°à target level ¢Õß¬“ CNI ª√–¡“≥

√âÕ¬≈– 50-70 ¢Õß√–¥—∫ª°μ‘) √à«¡°—∫ MMF æ∫«à“¡’Õÿ∫—μ‘°“√≥å

¢Õß¿“«– rejection πâÕ¬°«à“„™â¬“ CNI ¢π“¥ª°μ‘

■ °“√»÷°…“™◊ËÕ PROTECT study ‡√‘Ë¡„Àâ¬“ CNI ¢π“¥μË”Ê √à«¡°—∫¬“

everolimus æ∫«à“™à«¬‡æ‘Ë¡ glomerular filtration rate (GFR) ‡¡◊ËÕ

‡∑’¬∫°—∫¬“ CNI „π¢π“¥ª°μ‘

2. ‡ª≈’Ë¬π CNI ‰ª„™â¬“ CNI ¢π“¥μË”√à«¡°—∫¬“μ—«Õ◊Ëπ (CNI switching) ‡™àπ

■ CNI ¢π“¥μË”Ê √à«¡°—∫ MMF æ∫«à“™à«¬‡æ‘Ë¡°“√∑”ß“π¢Õß‰μ

■ ¿“¬À≈—ßºà“μ—¥ª≈Ÿ°μ—∫π“π°«à“ 6 ‡¥◊Õπ „π°√≥’∑’Ë¡’°“√∑”ß“π¢Õß

‰μ≈¥≈ß¡“° ¡’§«“¡‡ªìπ‰ª‰¥â∑’Ë®–„™â¬“ antiproliferative drug

‡æ’¬ß™π‘¥‡¥’¬«„π°“√°¥¿Ÿ¡‘§ÿâ¡°—π ·μà®”‡ªìπμâÕß‡ΩÑ“√–«—ßÕ¬à“ß

„°≈â™‘¥‡æ√“–¡’§«“¡‡ ’Ë¬ß¢Õß°“√‡°‘¥ rejection §àÕπ¢â“ß Ÿß‚¥¬

‡©æ“–Õ¬à“ß¬‘Ëß¿“¬„π 5 ªï·√°

3. ‰¡à„™â CNI „π Ÿμ√¬“°¥¿Ÿ¡‘§ÿâ¡°—π (CNI-free regimen) À≈—ßºà“μ—¥ª≈Ÿ°

∂à“¬μ—∫™à«ß·√°Ê ‡π◊ËÕß®“°¡’§«“¡‡ ’Ë¬ß Ÿß¢Õß°“√‡°‘¥ rejection

¢≥–π’È¬—ß‰¡à¡’¢âÕ¡Ÿ≈ π—∫ πÿπ‡æ’¬ßæÕ¢Õß°“√‰¡à„™â¬“ CNI ‡ªìπ¬“°¥

¿Ÿ¡‘§ÿâ¡°—π

● °“√μ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫ ´’

●● ¡’√“¬ß“π∑’Ëæ∫«à“¬“ cyclosporine ¡’ƒ∑∏‘ÏμàÕμâ“π‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫

´’ ®÷ß¡’ºŸâ‡™◊ËÕ«à“¬“ cyclosporine πà“®–‡ªìπ¬“°¥¿Ÿ¡‘§ÿâ¡°—π∑’Ë§«√

„™â„π¿“«–ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫∑’Ëμ‘¥‡™◊ÈÕ‰«√— μ—∫Õ—°‡ ∫´’ ·μà®π∂÷ß

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .30

ªí®®ÿ∫—π‰¡à¡’¢âÕ¡Ÿ≈¬◊π¬—π‰¥â·πàπÕπ«à“°“√„™â¬“ cyclosporine ¥’°«à“

tacrolimus „π°√≥’π’È

● ¡–‡√Áß‡´≈≈åμ—∫ (hepatocellular carcinoma)

·π–π”„Àâ„™â¬“ sirolimus À√◊Õ everolimus ‡ªìπ¬“°¥¿Ÿ¡‘§ÿâ¡°—π√à«¡

„π°“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫®“°¡–‡√Áß‡´≈≈åμ—∫ ‡π◊ËÕß®“° sirolimus ·≈–

everolimus ∑”Àπâ“∑’Ë¬—∫¬—Èß mammalian target of rapamycin (m-TOR)

pathway ÷Ëß¡’§«“¡‡°’Ë¬«¢âÕß°—∫°“√‡°‘¥¡–‡√Áß‡´≈≈åμ—∫ ®“°°“√»÷°…“

meta-analysis 2 √“¬ß“π æ∫«à“ sirolimus ™à«¬≈¥°“√°≈—∫‡ªìπ

„À¡à¢Õß¡–‡√Áß‡´≈≈åμ—∫·≈–™à«¬≈¥Õ—μ√“‡ ’¬™’«‘μÕ¬à“ß‰√°Áμ“¡ ¡’

§”‡μ◊Õπ‡°’Ë¬«°—∫°“√„™â sirolimus „πºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫¥—ß°≈à“«

¢â“ßμâπ

● °“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫·≈–‰μ (combined liver kidney trans-

plantation - CLKT)

·π«∑“ß°“√„™â¬“°¥¿Ÿ¡‘§ÿâ¡°—π§≈â“¬°—∫°“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫

Õ¬à“ß‡¥’¬« ·μà¡’¢âÕæ÷ß√–«—ß‰¥â·°à GFR ¿“¬À≈—ß CLKT ®–μË”°«à“

ª°μ‘À√◊Õ¡’§à“ª√–¡“≥√âÕ¬≈– 50 ¢Õßª°μ‘ °“√‡≈◊Õ°„™â¬“ CNI

¢π“¥μË”Ê √à«¡°—∫¬“°≈ÿà¡ antiproliferative ‡ªìπ¬“°¥¿Ÿ¡‘§ÿâ¡°—π®÷ß¡’

§«“¡‡À¡“– ¡°—∫°√≥’π’È

‡Õ° “√Õâ“ßÕ‘ß1. Zarrinpar A, Busuttil RW. Immunomodulating options for liver transplant pa-

tients. Expert Rev Clin Immunol 2012;8:565-78.2. Post DJ, Douglas DD, Mulligan DC. Immunosuppression in liver transplanta-

tion. Liver Transpl 2005;11:1307-14.3. Shenoy S, Hardinger KL, Crippin J, Korenblat K, Lisker-Melman M, Lowell JA,

et al. A randomized, prospective, pharmacoeconomic trial of neoral 2-hourpostdose concentration monitoring versus tacrolimus trough concentration


monitoring in de novo liver transplant recipients. Liver Transpl 2008;14:173-80.4. Levitsky J. Next level of immunosuppression: drug/immune monitoring. Liver

Transpl 2011;17Suppl 3:S60-5.5. Wiesner RH, Fung JJ. Present state of immunosuppressive therapy in liver

transplant recipients. Liver Transpl 2011;17Suppl 3:S1-9.6. McAlister VC, Haddad E, Renouf E, Malthaner RA, Kjaer MS, Gluud LL.

Cyclosporin versus tacrolimus as primary immunosuppressant after liver trans-plantation: a meta-analysis. Am J Transplant 2006;6:1578-85.

7. OûGrady JG, Burroughs A, Hardy P, Elbourne D, Truesdale A, Uk, et al. Tacrolimusversus microemulsifiedciclosporin in liver transplantation: the TMC randomisedcontrolled trial. Lancet 2002;360:1119-25.

8. A comparison of tacrolimus (FK 506) and cyclosporine for immunosuppressionin liver transplantation. The U.S. Multicenter FK506 Liver Study Group. N EnglJ Med 1994;331:1110-5.

9. Boudjema K, Camus C, Saliba F, Calmus Y, Salame E, Pageaux G, et al.Reduced-dose tacrolimus with mycophenolatemofetil vs. standard-dosetacrolimus in liver transplantation: a randomized study. Am J Transplant2011;11:965-76.

10. Pageaux GP, Rostaing L, Calmus Y, Duvoux C, Vanlemmens C, HardgwissenJ, et al. Mycophenolatemofetil in combination with reduction of calcineurininhibitors for chronic renal dysfunction after liver transplantation. Liver Transpl2006;12:1755-60.

11. Schmeding M, Kiessling A, Neuhaus R, Heidenhain C, Bahra M, Neuhaus P, etal. Mycophenolatemofetilmonotherapy in liver transplantation: 5-year follow-upof a prospective randomized trial. Transplantation 2011;92:923-9.

12. Fischer L, Klempnauer J, Beckebaum S, Metselaar HJ, Neuhaus P, SchemmerP, et al. A randomized, controlled study to assess the conversion from calcineurin-inhibitors to everolimus after liver transplantation-PROTECT. Am J Transplant2012;12:1855-65.

13. Abdelmalek MF, Humar A, Stickel F, Andreone P, Pascher A, Barroso E, et al.

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .32

Sirolimus conversion regimen versus continued calcineurin inhibitors in liverallograft recipients: a randomized trial. Am J Transplant 2012;12:694-705.

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·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .34

°“√¥Ÿ·≈√—°…“ acute rejection „π°“√ª≈Ÿ°∂à“¬μ—∫

ºŸâªÉ«¬À≈—ß°“√ª≈Ÿ°∂à“¬μ—∫Õ“®¡’¿“«–·∑√°´âÕπÀ≈“¬ª√–°“√ ‡™àπ º≈¢â“ß

‡§’¬ß¢Õß¬“°¥¿Ÿ¡‘§ÿâ¡°—π °“√°≈—∫‡ªìπ´È”¢Õß‚√§μ—∫‡¥‘¡ ¡–‡√Áß‡´≈≈åμ—∫ μ—∫

Õ—°‡ ∫‡√◊ÈÕ√—ß∑’Ë‰¡à∑√“∫ “‡Àμÿ allograft rejection ·≈– graft fibrosis ‚¥¬∑—Ë«‰ª liver

allograft rejection ¡—°‰¡à∑”„Àâ‡°‘¥ late graft deterioration ·≈– graft failure ‡À¡◊Õπ

solid organ allograft Õ◊ËπÊ ‡π◊ËÕß®“° liver allograft ¡’ tolerogenic properties

Acute cellular rejection (ACR)

ACR ¡—°‡°‘¥„π™à«ß‡¥◊Õπ·√°Ê À≈—ß°“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫ ‚¥¬·∫àß‡ªìπ

(1) early ACR (‡°‘¥¿“¬„π 90 «—πÀ≈—ß°“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫) ´÷Ëß¡—°‰¡à¡’º≈°√–∑∫

μàÕÕ—μ√“√Õ¥¢Õßμ—∫·≈–ºŸâªÉ«¬„π√–¬–¬“«¬°‡«âπ„πºŸâªÉ«¬‰«√— μ—∫Õ—°‡ ∫ ’‡√◊ÈÕ√—ß

·≈– (2) late ACR (‡°‘¥¿“¬À≈—ß 90 «—πÀ≈—ß°“√ºà“μ—¥ª≈Ÿ°∂à“¬μ—∫) ´÷ËßÕ“®¡’§«“¡

—¡æ—π∏å°—∫°“√‡°‘¥ chronic rejection ¿“¬À≈—ß ·≈–Õ“® àßº≈„ÀâÕ—μ√“√Õ¥¢Õß

μ—∫·≈–Õ—μ√“√Õ¥¢ÕßºŸâªÉ«¬≈¥≈ß

®“°°“√»÷°…“ SPLIT study μ‘¥μ“¡‡¥Á° 461 §π‰ªÕ¬à“ßπâÕ¬ 5 ªïÀ≈—ß

°“√ª≈Ÿ°∂à“¬μ—∫ æ∫«à“ª√–¡“≥√âÕ¬≈– 50 ¡’ ACR „πªï·√° √âÕ¬≈– 60 ¡’ ACR

¿“¬„π 5 ªï ·≈–ª√–¡“≥√âÕ¬≈– 20 ∑’Ë‰¡à¡’ early ACR ‡°‘¥ late-onset ACR „π™à«ß

1-5 ªï°“√‡°‘¥ ACR ¡“°°«à“ 1 §√—Èß¡’§«“¡ —¡æ—π∏å°—∫°“√‡æ‘Ë¡§«“¡‡ ’Ë¬ßμàÕ°“√

‡°‘¥ late graft loss ª√–¡“≥ 2 ‡∑à“

Õ“°“√/Õ“°“√· ¥ß ·≈–°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√

●● ºŸâªÉ«¬ à«π„À≠à‰¡à¡’Õ“°“√ „π√“¬∑’Ë¡’ ACR √ÿπ·√ßÕ“®¡’Õ“°“√ÕàÕπ‡æ≈’¬

§≈◊Ëπ‰ âÕ“‡®’¬π ‡∫◊ËÕÕ“À“√ ª«¥∑âÕß ‰¢âμË”Ê ·≈–μ“μ—«‡À≈◊Õß „π

ºŸâªÉ«¬‡¥Á°Õ“®¡’Õ“°“√‰¢â √âÕß°«π ·≈–°√–«π°√–«“¬ (irritability)


●● °“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√ æ∫√–¥—∫AST, ALT, ALP, GGT, ·≈– biliru-

bin Ÿß¢÷Èπ

°“√«‘π‘®©—¬ ACR

μâÕßμ√«®«‘π‘®©—¬·¬°®“°‚√§Õ◊ËπÊ ‡™àπ °“√μ‘¥‡™◊ÈÕ (‡™àπ CMV, herpes sim-

plex virus, hepatitis E), recurrent hepatitis B ·≈– C, steatohepatitis, drug-induced

liver injury, biliary complications ·≈– hepatic artery thrombosis ‚¥¬„™âÕ“°“√/

Õ“°“√· ¥ß∑“ß§≈‘π‘° °“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√ °“√μ√«®∑“ß√—ß ’«‘∑¬“ ·≈–/

À√◊Õ °“√μ√«®™‘Èπ‡π◊ÈÕμ—∫

●● °“√μ√«®™‘Èπ‡π◊ÈÕμ—∫‡æ◊ËÕ«‘π‘®©—¬ ACR ¡’≈—°…≥–∑“ßæ¬“∏‘«‘∑¬“∑’Ë ”§—≠

§◊Õ (1) mixed, but predominantly mononuclear inflammatory cells infil-

trate in the portal triad; (2) bile duct inflammation/damage; ·≈– (3)

endotheliitis ·≈–§«√ª√–‡¡‘π§«“¡√ÿπ·√ß¢Õß ACR ¥â«¬√–∫∫ rejection

activity index (RAI) ¢Õß International Banff Schema 1997 ¥—ßμ“√“ß∑’Ë 3

‚¥¬¡’‡°≥±å°“√ª√–‡¡‘π (0-9 §–·ππ) ¥—ßπ’È

■ 0-2 §–·ππ = no rejection

■ 3 §–·ππ = borderline

■ 4-5 §–·ππ = mild rejection

■ 6-7 §–·ππ = moderate rejection

■ 8-9 §–·ππ = severe rejection

Õ¬à“ß‰√°Áμ“¡ °“√«‘π‘®©—¬ ACR §«√ Õ∫∂“¡ª√–«—μ‘§«“¡§√∫∂â«π¢Õß°“√

√—∫ª√–∑“π¬“ (drug compliance) ·≈–μ√«®«—¥√–¥—∫¬“°¥¿Ÿ¡‘§ÿâ¡°—π (immunosup-

pression) „π‡≈◊Õ¥¥â«¬‡ ¡Õ

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .36

μ“√“ß∑’Ë 3 Rejection activity index (RAI): Banff Schema for Grading Liver Allograft

Rejection: An International Consensus (Hepatology 1997;25:658-63)

Category Criteria Score

Mostly lymphocytic inflammation involving, but notnoticeably expanding, a minority of the triadsExpansion of most or all of the triads, by a mixed infil-trate containing lymphocytes with occasional blasts, neu-trophils and eosinophilsMarked expansion of most or all of the triads by a mixedinfiltrate containing numerous blasts and eosinophils withinflammatory spillover into the periportal parenchyma

A minority of the ducts are cuffed and infiltrated byinflammatory cells and show only mild reactive changessuch as increased nuclear: cytoplamic ratio of theepithelial cellsMost or all of the ducts infiltrated by inflammatory cells.More than an occasional duct shows degenerative changessuch as nuclear pleomorphism, disordered polarity andcytoplasmic vacuolization of the epitheliumAs above for 2, with most or all of the ducts showingdegenerative changes or focal lumenal disruption

Subendothelial lymphocytic infiltration involving some, butnot a majority of the portal and/or hepatic venulesSubendothelial infiltration involving most or all of theportal and/or hepatic venulesAs above for 2, with moderate or severe perivenularinflammation that extends into the perivenular parenchymaand is associated with perivenular hepatocyte necrosis

Portalinflammation

Bile ductinflammation/damage

Venous endo-thelial inflam-mation

1

2

3

1

2

3

1

2

3

NOTE: Total Score = Sum of Components. Criteria that can be used to score liver allograft biopsieswith acute rejection, as defined by the World Gastroenterology Consensus Document.


·π«∑“ß°“√√—°…“ ACR (¿“æ∑’Ë 3)

¿“æ∑’Ë 3 ·π«∑“ß¥Ÿ·≈√—°…“ acute cellular rejection (ACR)

●● °√≥’ μ√«®™‘Èπ‡π◊ÈÕμ—∫¡’ RAI 4-5 ·π–π”„Àâ‡æ‘Ë¡√–¥—∫¬“ baseline immu-

nosuppression À√◊Õ‡æ‘Ë¡¬“°¥¿Ÿ¡‘§ÿâ¡°—π°≈ÿà¡Õ◊Ëπ ‡™àπ corticosteroid

(∂â“‡¥‘¡‰¡à‰¥â À√◊ÕÀ¬ÿ¥·≈â«), MMF À√◊Õ mTOR inhibitor

●● °√≥’ μ√«®™‘Èπ‡π◊ÈÕμ—∫¡’ RAI ≥ 6 À√◊Õ > 4 √à«¡°—∫Õ“°“√∑“ß§≈‘π‘° À√◊Õ

§«“¡º‘¥ª°μ‘∑“ßÀâÕßªØ‘∫—μ‘°“√ §«√„Àâ methylprednisolone 250-1000

¡°./«—π(„π‡¥Á°„Àâ methylprednisolone 10 ¡°./°°./«—π¢π“¥ Ÿß ÿ¥ 1 °√—¡)

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .38

∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ‡ªìπ‡«≈“ 1-3 «—π ·≈–ª√—∫≈¥¢π“¥¬“≈ß¿“¬„π

5-10 «—π

●● °√≥’‰¡à “¡“√∂∑”°“√μ√«®™‘Èπ‡π◊ÈÕμ—∫ ‚¥¬¡’Õ“°“√∑“ß§≈‘π‘° ·≈–

§«“¡º‘¥ª°μ‘∑“ßÀâÕßªØ‘∫—μ‘°“√ ‡¢â“‰¥â°—∫ ACR ·π–π”„Àâ methylpred-

nisolone 250-1000 ¡°./«—π (À√◊Õ 10 ¡°./°°./«—π) ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

‡ªìπ‡«≈“ 1-3 «—π·≈–ª√—∫≈¥¢π“¥¬“≈ß¿“¬„π 5-10 «—π

●● ºŸâªÉ«¬ ACR ∑’ËμÕ∫ πÕßμàÕ corticosteroid ¡—°¡’Õ“°“√ ·≈–√–¥—∫§à“

‡Õπ‰´¡åμ—∫¥’¢÷Èπ¿“¬„π 2-5 «—π À≈—ß‰¥â¬“

●● °√≥’ ACR ‰¡àμÕ∫ πÕßμàÕ methylprednisolone ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”§√—Èß

·√° („π°√≥’∑’Ë‰¡à‰¥â∑”°“√μ√«®™‘Èπ‡π◊ÈÕ„π§√—Èß·√° §«√∑”°“√μ√«®

™‘Èπ‡π◊ÈÕμ—∫‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬) Õ“®æ‘®“√≥“„Àâ°“√√—°…“¥â«¬ meth-

ylprednisolone ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ´È”Õ’°§√—Èß „π¢π“¥ 250-1000 ¡°./

«—π(À√◊Õ 10 ¡°./°°./«—π) μ‘¥μàÕ°—π‡ªìπ‡«≈“ 3-7 «—π À√◊Õæ‘®“√≥“

„Àâ°“√√—°…“¥â«¬ ATG „π¢π“¥ 1.5 ¡°./°°./§√—Èß«—π≈–§√—Èß∑“ßÀ≈Õ¥

‡≈◊Õ¥„π‡«≈“¡“°°«à“ 4-6 ™—Ë«‚¡ßμ‘¥μàÕ°—π 4-7 «—π (maximum cumula-

tive dose 21 ¡°./°°./course)

■ °√≥’„Àâ ATG §«√„Àâ pre-medication ¥â«¬ acetaminophen 500-1000

¡°. (À√◊Õ 10 ¡°./°°.„π‡¥Á°) ∑“ßª“°, diphenhydramine 25-100 ¡°.

(À√◊Õ1 ¡°./°°.„π‡¥Á°) ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”·≈– methylprednisolone

50-100 ¡°. (À√◊Õ 2 ¡°./°°.„π‡¥Á°) ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” §«√‡ΩÑ“

√–«—ß°“√‡°‘¥ infusion-related reaction, °“√μ‘¥‡™◊ÈÕ, ¿“«–‡¡Á¥

‡≈◊Õ¥¢“«·≈–‡°≈Á¥‡≈◊Õ¥μË”·≈–μ‘¥μ“¡°“√μÕ∫ πÕßμàÕ ATG

‚¥¬¥ŸÕ“°“√∑“ß§≈‘π‘° ·≈–√–¥—∫§à“‡Õπ‰´¡åμ—∫

■ °√≥’ª√—∫‡æ‘Ë¡√–¥—∫ baseline immunosuppression, „Àâ methylpred-

nisolone ·≈–/À√◊Õ ATG ·π–π”„Àâ cotrimoxazole ·≈–/À√◊Õ antifun-

gal ‡æ◊ËÕªÑÕß°—π°“√μ‘¥‡™◊ÈÕ


■ ‡π◊ËÕß®“°ºŸâªÉ«¬∑’Ë‰¥â√—∫ methylprednisolone À√◊Õ ATG ∑“ßÀ≈Õ¥‡≈◊Õ¥

¥”¡’§«“¡‡ ’Ë¬ßμàÕ°“√‡°‘¥ CMV reactivation/infection ®÷ß§«√

„Àâ°“√ªÑÕß°—π´÷Ëß¡’ 2 ∑“ß‡≈◊Õ° ‰¥â·°à (1) °“√„Àâ ganciclovir prophy-

laxis; À√◊Õ (2) μ‘¥μ“¡°“√‡ª≈’Ë¬π·ª≈ß¢Õß CMV viral load Õ¬à“ß

„°≈â™‘¥ ‡ªìπ‡«≈“ 3-6 ‡¥◊Õπ

●● √–À«à“ß√—°…“ ACR §«√ª√—∫ tacrolimus „ÀâÕ¬Ÿà√–¥—∫ 8-15 π“‚π°√—¡/

¡≈. ·≈–/À√◊Õ‡æ‘Ë¡¬“°¥¿Ÿ¡‘§ÿâ¡°—π °≈ÿà¡Õ◊Ëπ ‡™àπ corticosteroid (∂â“‡¥‘¡

‰¡à‰¥â À√◊ÕÀ¬ÿ¥·≈â«), MMF À√◊Õ mTOR inhibitor

●● „π°√≥’∑’Ë‡ªìπ refractory rejection À√◊Õ recurrent rejection Õ“®‡æ‘Ë¡¬“

°¥¿Ÿ¡‘§ÿâ¡°—πÕ’°Àπ÷Ëß™π‘¥ ‡™àπ MMF 1-2 °√—¡/«—π („π‡¥Á° ‡√‘Ë¡¢π“¥ 5

¡°./°°. √—∫ª√–∑“π«—π≈– 2 §√—Èß °àÕπÕ“À“√ ·≈â«‡æ‘Ë¡‡ªìπ 10-20 ¡°./

°°. ∂â“‰¡à¡’∑âÕß‡ ’¬·≈–√–¥—∫‡¡Á¥‡≈◊Õ¥¢“«‰¡àμË”¢π“¥¬“ Ÿß ÿ¥ 1 °√—¡)

À√◊Õ mTOR inhibitor

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .40

°“√¥Ÿ·≈√—°…“ chronic rejection „π°“√ª≈Ÿ°∂à“¬μ—∫

Chronic rejection æ∫‰¥â‰¡à∫àÕ¬„πªí®®ÿ∫—π ·μà¡’§«“¡ ”§—≠ ‡π◊ËÕß®“°Õ“®

π”‰ª Ÿà graft dysfunction ·≈– graft loss „π√–¬–¬“«‚¥¬¡’ 2 ≈—°…≥–À≈—°Ê ‰¥â·°à

ductopenic rejection ·≈– late-onset cellular rejection „π‡¥Á°æ∫πâÕ¬°«à“√âÕ¬≈– 10

‚¥¬∑—Ë«‰ªæ∫πâÕ¬≈ß¡“°μ—Èß·μà¡’°“√„™â tacrolimus ¿“«–∑’Ë∑”„Àâ¡’°“√¥Ÿ¥´÷¡¬“°¥

¿Ÿ¡‘§ÿâ¡°—π∫°æ√àÕß ‡™àπ ∑âÕß‡ ’¬À√◊Õ medication non-compliance Õ“®‡ªìπ “‡Àμÿ

¢Õß CR Õ¬à“ß‰√°Áμ“¡ ¿“«– CR Õ“®‰¡à‰¥â‡°‘¥®“°°“√¡’ acute rejection ´È”Ê

„π‡¥Á°∑’Ë√—∫°“√ª≈Ÿ°∂à“¬μ—∫‰ª·≈â«π“π°«à“ 12 ‡¥◊Õπ¡—°æ∫ rejection πâÕ¬

Õ¬à“ß‰√°Áμ“¡‡¡◊ËÕ‡¢â“ Ÿà«—¬√ÿàπ Õ“®¡’ non-compliance ∑”„Àâ√–¥—∫¬“°¥¿Ÿ¡‘§ÿâ¡°—π

‰¡à‡æ’¬ßæÕ àßº≈„Àâ‡°‘¥ late rejection ¿“«– CR Õ“®∑”„Àâ‡°‘¥ graft dysfunction

·≈– fibrosis „π√–¬–¬“«

Õ“°“√/Õ“°“√· ¥ß ·≈–°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√

●● ºŸâªÉ«¬ à«π„À≠à‰¡à¡’Õ“°“√ „π√“¬∑’Ë¡’ CR √ÿπ·√ßÕ“®¡’Õ“°“√/Õ“°“√

· ¥ß ¢Õß graft failure

°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√ æ∫√–¥—∫ ALP, GGT, AST, ALT, ·≈– bilirubin

Ÿß¢÷Èπ

°“√«‘π‘®©—¬ CR

●● μâÕß¡’°“√μ√«®™‘Èπ‡π◊ÈÕμ—∫ (Õâ“ßÕ‘ßμ“¡√–∫∫ International Banff Schema

2000) √à«¡°—∫«‘π‘®©—¬·¬°®“°‚√§Õ◊ËπÊ ‡™àπ °“√μ‘¥‡™◊ÈÕ, biliary complications,

recurrent primary sclerosing cholangitis/primary biliary cirrhosis ·≈– drug-induced

liver injury ‚¥¬„™âÕ“°“√/Õ“°“√· ¥ß∑“ß§≈‘π‘° °“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√

À√◊Õ°“√μ√«®∑“ß√—ß ’«‘∑¬“


●● §«√ Õ∫∂“¡ª√–«—μ‘§«“¡§√∫∂â«π¢Õß°“√√—∫ª√–∑“π¬“·≈–μ√«®

«—¥√–¥—∫¬“°¥¿Ÿ¡‘§ÿâ¡°—π„π‡≈◊Õ¥

°“√√—°…“ CR

●● §«√ª√—∫‡æ‘Ë¡√–¥—∫¬“ baseline immunosuppression, ‡æ‘Ë¡¬“°¥¿Ÿ¡‘§ÿâ¡°—π

™π‘¥Õ◊Ëπ (‡™àπ MMF ·≈–/À√◊Õ mTOR inhibitors), °√≥’∑’Ë„™â cyclosporine-based im-

munosuppression ·π–π”„Àâ‡ª≈’Ë¬π‡ªìπ tacrolimus-based

●● °√≥’‡°‘¥ graft failure Õ“®æ‘®“√≥“°“√ª≈Ÿ°∂à“¬μ—∫„À¡à

‡Õ° “√Õâ“ßÕ‘ß1. Importance of liver biopsy findings in immunosuppression management:

biopsy monitoring and working criteria for patients with operational tolerance.Liver Transpl 2012;18:1154-70.

2. McDiarmid SV, Anand R, Lindblad AS. Development of a pediatric end-stageliver disease score to predict poor outcome in children awaiting liver transplan-tation. Transplantation 2002;74:173-81.

3. Lucey MR, Terrault N, Ojo L, Hay JE, Neuberger J, Blumberg E, TepermanLW. Long-term management of the successful adult liver transplant: 2012practice guideline by the American Association for the Study of Liver Diseasesand the American Society of Transplantation. Liver Transpl 2013;19:3-26.

4. Wiesner RH, Fung JJ. Present state of immunosuppressive therapy in livertransplant recipients. Liver Transpl 2011;17 Suppl 3:S1-9.

5. Kelly DA, Bucuvalas JC, Alonso EM, Karpen SJ, Allen U, Green M, Farmer D,et al. Long-term medical management of the pediatric patient after liver trans-plantation: 2013 practice guideline by the American Association for the Studyof Liver Diseases and the American Society of Transplantation. Liver Transpl2013;19:798-825.

6. Banff schema for grading liver allograft rejection: an international consensus

·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ª≈Ÿ°∂à“¬μ—∫. . . . . . . . . . . . . . . . . . . . . . . .42

document. Hepatology 1997;25:658-63.7. Volpin R, Angeli P, Galioto A, Fasolato S, Neri D, Barbazza F, Merenda R, et al.

Comparison between two high-dose methylprednisolone schedules in the treat-ment of acute hepatic cellular rejection in liver transplant recipients: a con-trolled clinical trial. Liver Transpl 2002;8:527-34.

8. Thangarajah D, OûMeara M, Dhawan A. Management of Acute Rejection inPaediatric Liver Transplantation. Paediatr Drugs 2013;15:459-71.

9. Matteoni CA, Younossi ZM, Gramlich T, Boparai N, Liu YC, McCullough AJ.Nonalcoholic fatty liver disease: a spectrum of clinical and pathologicalseverity. Gastroenterology 1999;116:1413-9.

10. Schmitt TM, Phillips M, Sawyer RG, Northup P, Hagspiel KD, Pruett TL, BonattiHJ. Anti-thymocyte globulin for the treatment of acute cellular rejectionfollowing liver transplantation. Dig Dis Sci 2010;55:3224-34.

11. Murphy MS, Harrison R, Davies P, Buckels JA, Mayer AD, Hubscher S, KellyDA. Risk factors for liver rejection: evidence to suggest enhanced allografttolerance in infancy. Arch Dis Child 1996;75:502-6.

12. Demetris A, Adams D, Bellamy C, Blakolmer K, Clouston A, Dhillon AP, et al.Update of the International Banff Schema for Liver Allograft Rejection: work-ing recommendations for the histopathologic staging and reporting of chronicrejection. An International Panel. Hepatology 2000;31:792-9.

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