rechazo agudo - Roche Trasplantes
Anuncio
RECHAZO AGUDO
RECHAZO AGUDO - ,QWURGXFFLyQ
RECHAZO AGUDO
,QWURGXFFLyQ
(OUHFKD]RDJXGRVLJXHUHSUHVHQWDQGRXQRGHORV
WHPDVPiVLPSRUWDQWHVHQHOWUDVSODQWHGHyUJDQRV/D
GLVPLQXFLyQHVSHFWDFXODUREVHUYDGDHQODLQFLGHQFLD
GHUHFKD]RDJXGRHQORV~OWLPRVDxRVKDVLGRXQRGH
ORVIDFWRUHVPiVLPSRUWDQWHVHQODPHMRUtDGHORVUH
VXOWDGRVGHOWUDVSODQWHGHyUJDQRV$ SHVDUGHHVWHGHV
FHQVRQRWDEOHHQODLQFLGHQFLDGHUHFKD]RDJXGRODVL
WXDFLyQHVGLVWLQWDVHJ~QVHWUDWHGHWUDVSODQWHUHQDO
FDUGtDFRRKHSiWLFR$VtODLQFLGHQFLDDFWXDOHQHOWUDV
SODQWHUHQDOVXHOHVHULQIHULRUDOHVWiHQWUHHO
HQHOWUDVSODQWHKHSiWLFR\DOUHGHGRUGHOHQ
WUDVSODQWHFDUGtDFR([LVWHQGLYHUVDVUD]RQHVTXHSR
GUtDQMXVWLILFDUHVWDLQFLGHQFLDWDQGLVWLQWDGHUHFKD]R
DJXGRVHJ~QORVGLYHUVRVyUJDQRVFRQVLGHUDGRVSHUR
XQIDFWRUGHFLVLYRSRGUtDVHUODSUiFWLFDGHELRSVLDVGH
SURWRFRORHQHOWUDVSODQWHFDUGtDFRORFXDOVLQGXGD
DXPHQWDODLQFLGHQFLD\GLDJQyVWLFRGHORVHSLVRGLRV
GHUHFKD]RDJXGR/DSUDFWLFDGHELRSVLDVGHSURWRFR
ORSRQHGHPDQLILHVWRODSUHVHQFLDHQHOyUJDQRHQ
FXHVWLyQGHLQILOWUDGRVFHOXODUHVFDUDFWHUtVWLFRVGHUH
FKD]RDJXGRDXQTXHFXUVDUiQVLQPDQLIHVWDFLRQHVFOt
QLFDVQLSUREDEOHPHQWHUHSHUFXVLRQHVIXQFLRQDOHV7DP
ELpQSUREDEOHPHQWHLQWHUYHQGUiQIDFWRUHVLQPXQROy
JLFRVGHOGRQDQWHV\UHFHSWRUTXHSRGUtDQFRQGLFLR
QDUXQDUHVSXHVWDDORJpQLFDGLVWLQWDDVtFRPRIDFWRUHV
SURSLRVGHOyUJDQRHQFXHVWLyQVLHQGRPiVRPHQRV
LQPXQRJpQLFR
2WURGHORVDVSHFWRVQRWRWDOPHQWHGLOXFLGDGRV
UHVSHFWRDOUHFKD]RDJXGRVRQODUHSHUFXVLyQGHOUH
FKD]RDJXGRVREUHORVUHVXOWDGRVGHVXSHUYLYHQFLDGHO
LQMHUWR\GHOSDFLHQWHDODUJRSOD]R$FWXDOPHQWHH[LV
WHDFXHUGRHQHOWUDVSODQWHUHQDOGHTXHORVHSLVRGLRV
GHUHFKD]RDJXGRQRVRQEHQHILFLRVRVSDUDODVXSHUYL
YHQFLDGHOLQMHUWR\HQTXHVHJ~QODVHYHULGDGGHORV
PLVPRVRHOJUDGRGHUHFXSHUDFLyQSRVWUDWDPLHQWRpV
WHWHQGUiPD\RURPHQRULPSDFWRQHJDWLYRVREUHODVX
SHUYLYHQFLDGHOLQMHUWRUHQDO'HWDOPRGRTXHORVHSL
VRGLRVGHUHFKD]RDJXGRJUDGR,GHODFODVLILFDFLyQGH
%DQIIFRPSOHWDPHQWHUHFXSHUDGRVSRVWUDWDPLHQWRHV
SUREDEOHTXHWHQJDQXQLPSDFWRPtQLPRVREUHODVX
SHUYLYHQFLDGHOLQMHUWR3RUFRQWUDHOUHFKD]RDJXGR
WLSR,,FRQUHFXSHUDFLyQSDUFLDOGHODIXQFLyQUHQDO
WHQGUiXQLPSDFWRTXHVHUiFRQWRGDVHJXULGDGQHJD
WLYR3RUHVWHPRWLYRH[LVWHHOREMHWLYRGHLQWHQWDUHYL
WDUHQORSRVLEOHORVHSLVRGLRVGHUHFKD]RDJXGRHQHO
WUDVSODQWHUHQDO(QHOWUDVSODQWHKHSiWLFRSDUHFHTXH
ODVFRVDVQRVRQWDQHYLGHQWHV\TXHYLHQHQEDVWDQWH
GHWHUPLQDGDVSRUODSUHVHQFLDRQRGHLQIHFFLyQSRUHO
YLUXVGHODKHSDWLWLV&'HWDOPRGRTXHORVHSLVRGLRV
GHUHFKD]RDJXGRWHQGUtDQXQLPSDFWRQHJDWLYR~QL
FDPHQWHHQUHODFLyQFRQODLQIHFFLyQSRU9+&\QR
GLUHFWDPHQWHUHODFLRQDGRFRQODHYROXFLyQGHOLQMHUWR
KHSiWLFR3RUORWDQWRVHUtDPX\LPSRUWDQWHHYLWDUORV
HSLVRGLRVGHUHFKD]RDJXGRHQHOWUDVSODQWHKHSiWLFR
9+&SRVLWLYRSHURQRDVtHQORVSDFLHQWHV9+&QH
JDWLYRVGRQGHORVHSLVRGLRVGHUHFKD]RSRGUtDQWHQHU
XQSDSHOSRVLWLYRHQODLQGXFFLyQGHWROHUDQFLD5HV
SHFWRDOWUDVSODQWHFDUGtDFRODVLWXDFLyQQRUHVXOWDWDQ
HYLGHQWH\SUREDEOHPHQWHVHFRPSRUWDUtDFRPRHO
WUDVSODQWHUHQDOHVGHFLUGHSHQGHUtDQGHODVHYHULGDG
GHOUHFKD]RDJXGRODVSRVLEOHVUHSHUFXVLRQHVQHJDWL
YDVVREUHODVXSHUYLYHQFLDGHOSDFLHQWH(OSUREOHPD
71
IXQGDPHQWDOHQWUDVSODQWHFDUGtDFRHVODSUiFWLFDKD
ELWXDOGHELRSVLDVGHSURWRFRORGHWDOPRGRTXHVH
GLDJQRVWLFDQFRQIUHFXHQFLDHSLVRGLRVGHUHFKD]RDJX
GRSRUODVLPSOHSUHVHQFLDGHLQILOWUDGRVFHOXODUHVSRU
OLQIRFLWRVVLQTXHH[LVWDQLQJXQDPDQLIHVWDFLyQFOtQL
FDQLUHSHUFXVLyQIXQFLRQDO(OVLJQLILFDGRGHHVWRVLQ
ILOWUDGRVHVGLVFXWLEOH\DOJXQRVDXWRUHVGHILHQGHQHO
SDSHOGHORVPLVPRVHQODLQGXFFLyQGHWROHUDQFLDGHO
LQMHUWR6HJXUDPHQWHVLVHOLPLWDUDODGHILQLFLyQGHUH
FKD]RDJXGRDODSUHVHQFLDGHXQDOHVLyQKLVWROyJLFD
VXJHVWLYDGHXQDDOWHUDFLyQFOtQLFD\RIXQFLRQDOODLQ
FLGHQFLDGHUHFKD]RDJXGRHQHOWUDVSODQWHFDUGtDFRVH
UtDPHQRU
MECANISMOS
INMUNOLÓGICOS DEL
RECHAZO AGUDO
(OUHFKD]RGHOLQMHUWRHVWiPHGLDGRIXQGDPHQWDO
PHQWHSRUODUHDFFLyQGHODVFpOXODV7 GHOUHFHSWRUIUHQ
WHDORVDQWtJHQRVDORJpQLFRVH[SUHVDGRVHQHOyUJDQR
WUDVSODQWDGR(OUHFRQRFLPLHQWRGHHVWRVDQWtJHQRVSR
QHHQPDUFKDODOLEHUDFLyQGHLQWHUOHXFLQD,/\
GHLQWHUOHXFLQD,/FRQODFRQVLJXLHQWHDFWLYDFLyQ
\SUROLIHUDFLyQGHFpOXODV&'\&'(QXQDFRP
SOHMDUHGGHLQWHUDFFLRQHVVHSURGXFHQXQDJUDQYDULH
GDGGHFLWRFLQDVTXHHVWLPXODQHOUHFOXWDPLHQWRGHOLQ
IRFLWRVKDFLDHOHVSDFLRSRUWD\PRGXODQODH[SUHVLyQ
GHPROpFXODVGHDGKHUHQFLD1RVHFRQRFHELHQODLQ
IOXHQFLDGHHVWDVFLWRFLQDVHQHOSURFHVRGHUHFKD]R
$OJXQDVGHHOODVFRPRHOIDFWRUGHQHFURVLVWXPRUDO
SRGUtDQUHODFLRQDUVHGHPRGRHVSHFLDOFRQODDSDULFLyQ
GHUHFKD]RDFX\RGLDJQyVWLFRSRGUtDFRQWULEXLU(Q
HOUHFKD]RKLSHUDJXGRH[WUHPDGDPHQWHLQIUHFXHQWH
KR\HQGtDLQWHUYLHQHQDQWLFXHUSRVFRPRPHGLDGRUHV
DWUDYpVGHVXDFFLyQIUHQWHDDQWtJHQRVGHORFDOL]DFLyQ
SUHIHUHQWHPHQWHHQGRWHOLDO
(QGLIHUHQWHJUDGRVHJ~QODIDVHHYROXWLYDHVSR
VLEOHLGHQWLILFDUOLQIRFLWRV7PD\RULWDULDPHQWH&'
HQHOLQILOWUDGRLQWHUVWLFLDO'XUDQWHORVIHQyPHQRVGH
UHFKD]RVHLQFUHPHQWDODH[SUHVLyQGHDQWtJHQRVGHFOD
VH,\,,HQWRGDVODVFpOXODVGHOyUJDQRWUDVSODQWDGR
VLHQGRHQPD\RULQWHQVLGDGHQFpOXODVHQGRWHOLDOHV\
HSLWHOLDOHV1RKD\HYLGHQFLDVFODUDVGHTXHHOJUDGR
GHFRPSDWLELOLGDG+/$ VHDGHWHUPLQDQWHHQODSUHYD
OHQFLDGHUHFKD]RFHOXODUHQWUDVSODQWHKHSiWLFR\FDU
GtDFRSHURVtHQHOUHQDO
ANATOMÍA PATOLÓGICA
/DELRSVLDGHOyUJDQRWUDVSODQWDGRVLJXHVLHQGRHO
JROGVWDQGDUG HQHOGLDJQyVWLFRGHORVHSLVRGLRVGHUH
FKD]RDJXGRGHOLQMHUWRVLHQGRHOPpWRGRPiVILDEOH
\REMHWLYRHQHOGLDJQyVWLFRGHOUHFKD]RDJXGR/DVOH
VLRQHVKLVWROyJLFDVGHOUHFKD]RVRQPX\SDUHFLGDVHQ
ORVWUHVWUDVSODQWHVFDUGtDFRUHQDO\KHSiWLFRGHVWD
FDQGRXQLQILOWUDGRLQWHUVWLFLDOSRUOLQIRFLWRVSUHGR
PLQDQWHPHQWH7SURYRFDQGRXQDOHVLyQGHOSDUpQTXL
PDFRUUHVSRQGLHQWH(QIDVHVLQLFLDOHVGHOUHFKD]RVH
SXHGHREVHUYDUODSUHVHQFLDGHSROLPRUIRQXFOHDUHV\
HRVLQyILORVHQHOLQILOWUDGRLQWHUVWLFLDOHQIDVHVPiV
HYROXFLRQDGDVFRQGHVWUXFFLyQFHOXODUVHREVHUYDXQ
LQILOWUDGRSRUPDFUyIDJRVPRQRFLWRV(QFDVRVJUDYHV
SXHGHQDVRFLDUVHOHVLRQHVGHHQGRWHOLWLV\RDUWHULWLV
TXHLUiQDFRPSDxDGDVGHPD\RUJUDGRGHOHVLyQSD
UHQTXLPDWRVD
(QWRGRVORVWUDVSODQWHVFDUGtDFRUHQDO\KHSiWL
FRH[LVWHXQDFODVLILFDFLyQDQWRPRSDWROyJLFDGHOD
VHYHULGDGGHOUHFKD]RTXHSHUPLWHVXJUDGDFLyQ\
WDPELpQSRGHUHVWDEOHFHUXQSURQyVWLFR\WUDWDPLHQ
WRGHORVHSLVRGLRVGHUHFKD]R/DVOHVLRQHVTXHDSD
UHFHQGXUDQWHXQUHFKD]RDJXGRVRQSRWHQFLDOPHQWH
UHYHUVLEOHVSHURHQRFDVLRQHVVHPDQWLHQHQ\GHWHU
PLQDQXQDIRUPDGHUHFKD]RTXHSXHGHHYROXFLRQDU
KDFLDODVIRUPDVGHUHFKD]RFUyQLFRFRQJUDQWUDV
FHQGHQFLDHQWUDVSODQWHUHQDO\FDUGtDFR/DUHYHUVL
ELOLGDGGHOUHFKD]RVHKDFHPHQRVSUREDEOHDPHGL
GDTXHGHVDSDUHFHHOFRPSRQHQWHFHOXODU\SUHGRPL
QDHOGHILEURVLVLQWHUVWLFLDO
DIAGNÓSTICO
/DPD\RUtDGHUHFKD]RVVHFRQFHQWUDQHQORVSUL
PHURVPHVHVSRVWUDVSODQWHHVSHFLDOPHQWHGXUDQWH
ODVSULPHUDVVHPDQDV\VREUHWRGRHQWUHORVGtDV
\SRVWUDVSODQWH(QODDFWXDOLGDGHVH[WUHPD
GDPHQWHLQIUHFXHQWHTXHXQHSLVRGLRGHUHFKD]RRFD
VLRQHIDOORGHOLQMHUWRWUDVSODQWDGR\DTXHORVWUDWD
PLHQWRVLQPXQRVXSUHVRUHVGLVSRQLEOHVSHUPLWHQUH
YHUWLUODPD\RUtDGHHSLVRGLRVGHUHFKD]R(QJHQH
UDOORVHSLVRGLRVGHUHFKD]RHQHOSRVWUDVSODQWHLQ
PHGLDWRVHDVRFLDQDDOWHUDFLRQHVIXQFLRQDOHVGHOyU
JDQRHQFXHVWLyQHQHOFDVRGHOWUDVSODQWHUHQDODO
DXPHQWRHQODVFLIUDVGHFUHDWLQLQDSODVPiWLFDHQHO
WUDVSODQWHKHSiWLFRDODHOHYDFLyQGHODVHQ]LPDVKH
72
RECHAZO AGUDO - 3RQHQFLDV
SiWLFDV\HQWUDVSODQWHFDUGtDFRDDOWHUDFLRQHVHQHO
(&*\RHFRFDUGLRJUDPD/DGXGDVXUJHFXDQGRVH
SUDFWLFDQELRSVLDVGHSURWRFRORHVSHFLDOPHQWHHQHO
WUDVSODQWHFDUGtDFR\VHLGHQWLILFDQOHVLRQHVDQDWR
PRSDWROyJLFDVVXJHVWLYDVGHUHFKD]RVLQQLQJXQDDO
WHUDFLyQIXQFLRQDO(QHVWRVFDVRVHVLPSUHVFLQGLEOH
ODXWLOL]DFLyQGHXQDFODVLILFDFLyQLQWHUQDFLRQDOTXH
QRVSHUPLWDODFODVLILFDFLyQ\JUDGXDFLyQGHODVELRS
VLDVSDUDSRGHUGHILQLUODSUHVHQFLDRQRGHXQUH
FKD]RDJXGR(QWRGRVORVWUDVSODQWHVODSUiFWLFDGH
XQDHFRJUDItDGHOyUJDQRWUDVSODQWDGRQRVSXHGHVHU
GHXWLOLGDGSDUDFRQILUPDUODSUHVHQFLDGHXQUHFKD
]RDJXGRGHILQLHQGRGLYHUVRVSDUiPHWURVHFRJUiIL
FRVVXJHVWLYRVGHUHFKD]RDJXGRDXQTXHHQWRGRV
ORVFDVRVSUHFLVDPRVXQDELRSVLDGHOyUJDQRWUDV
SODQWDGRSDUDSRGHUFRQILUPDUODH[LVWHQFLDGHXQUH
FKD]RDJXGR(QHOFDVRGHOWUDVSODQWHKHSiWLFRHQ
SDFLHQWHV9+&SRVLWLYRVVLHPSUHVHGHEHHVWDEOH
FHUHOGLDJQyVWLFRGLIHUHQFLDOFRQODUHDFWLYDFLyQ\R
UHLQIHFFLyQSRUHO9+&TXHSRGUtDGDUXQSDWUyQ
DQDWRPRSDWROyJLFRPX\VLPLODU(QWUDVSODQWHFDU
GtDFRVHKDQGHVDUUROODGRGLYHUVDVWpFQLFDVQRLQYD
VLYDVSDUDHYLWDUODELRSVLDHQGRPLRFiUGLFDQRH[HQ
WDGHULHVJRVHLQFRPRGLGDGHV$ SHVDUGHODPHMR
UtDGHHVWDVWpFQLFDVFRPRODGHWHUPLQDFLyQGHHQ
]LPDVFDUGLDFDVRSpSWLGRVFDUGtDFRVRODUHDOL]D
FLyQGHHVWXGLRVLVRWySLFRVTXHGHILQDQODSUHVHQFLD
GHXQDQHFURVLVPLRFiUGLFDODELRSVLDVLJXHVLHQGR
ODWpFQLFDGHHOHFFLyQHQHOGLDJQyVWLFRGHOUHFKD]R
DJXGRHQHOWUDVSODQWHFDUGtDFRSRUODSUHVHQFLDGH
IDOVRVSRVLWLYRV\QHJDWLYRVFRQODVWpFQLFDVQRLQ
YDVLYDV(VWDVWpFQLFDVQRLQYDVLYDVVHSXHGHQXWLOL
]DUSDUDODPRQLWRUL]DFLyQGHOWUDVSODQWDGRFDUGtDFR
UHVHUYDQGRODELRSVLDHQGRPLRFiUGLFDSDUDODFRQ
ILUPDFLyQGHORVHSLVRGLRVGHUHFKD]R
(OUHFKD]RGHDSDULFLyQWDUGtDHVHQJHQHUDOGH
SHRUSURQyVWLFRSUREDEOHPHQWHSRUTXHREHGHFHD
PHFDQLVPRVLQPXQROyJLFRVGLVWLQWRV\WDPELpQSRU
TXHVXGLDJQyVWLFR\WUDWDPLHQWRVXHOHUHWUDVDUVH6X
LGHQWLILFDFLyQKLVWROyJLFDSXHGHVHUGLItFLOSRUTXH
QRVLHPSUHHVWiQSUHVHQWHVORVVLJQRVFOiVLFRVGHLQ
ILOWUDGRLQWHUVWLFLDOFRQOHVLyQGHOSDUpQTXLPD$GH
PiVODUHVSXHVWDDOWUDWDPLHQWRQRHVWDQHOHYDGDFR
PRHQHOUHFKD]RGHODVSULPHUDVVHPDQDVSRVWUDV
SODQWHIUHQWHDO\ODHYROXFLyQDODFUR
QLFLGDGHVQHWDPHQWHVXSHULRUIUHQWHDO
HQWRGRVORVWUDVSODQWHV
TRATAMIENTO
(QORV~OWLPRVDxRVVHKDDPSOLDGRQRWDEOHPHQWH
ODHOHFFLyQGHIiUPDFRVLQPXQRVXSUHVRUHVSDUDSUH
YHQLUHOUHFKD]RFHOXODU/DLQPXQRVXSUHVLyQSXHGH
DFWXDOPHQWHDMXVWDUVHDODVFLUFXQVWDQFLDVGHFDGDSD
FLHQWHSURWHJLpQGROHGHOGHVDUUROORGHUHFKD]RDJXGR
VLQHOSHOLJURGHIDFLOLWDUXQDLQIHFFLyQJUDYH$ SHVDU
GHORVDYDQFHVHQODHVWUDWHJLDGHLQPXQRVXSUHVLyQXQ
SRUFHQWDMHGHSDFLHQWHVVLJXHQSUHVHQWDQGR\GHVDUUR
OODQGRXQHSLVRGLRGHUHFKD]RDJXGR(OWUDWDPLHQWR
PiVJHQHUDOL]DGRHQHOWUDWDPLHQWRGHOUHFKD]RDJXGR
VRQORVEROXVGHPHWLOSUHGQLVRORQDPJ[
GtDVGHSHQGLHQGRGHODVHYHULGDGGHOUHFKD]R\GH
ODVFDUDFWHUtVWLFDVGHOSDFLHQWH(QFDVRGHUHFKD]RDJX
GRVHYHUR\RUHVLVWHQWHDOWUDWDPLHQWRFRQEROXVGH
PHWLOSUHGQLVRORQDVHHVWiQXWLOL]DQGRDQWLFXHUSRVDQ
WLOLQIRFLWDULRV$7*X2.7GXUDQWHSHULRGRVFRU
WRVGHWLHPSR7DPELpQGHPDQHUDFDGDYH]PiVJH
QHUDOL]DGDVHHVWiQLQWURGXFLHQGRPRGLILFDFLRQHVHQ
ODVSDXWDVGHLQPXQRVXSUHVLyQGHEDVHTXHSRGUtDQ
UHVXOWDUHQDOJXQRVFDVRVVXILFLHQWHVSDUDFRQWURODUORV
HSLVRGLRVGHUHFKD]R&RPRHMHPSORVPiVXWLOL]DGRV
VHSXHGHQFLWDUODFRQYHUVLyQGHFLFORVSRULQDDWDFUR
OLPXVRODLQWURGXFFLyQGH00)HQSDFLHQWHVTXHSUH
VHQWDQXQHSLVRGLRGHUHFKD]RDJXGR(QIRUPDVOHYHV
GHUHFKD]RHVSRVLEOHTXHFRQVLPSOHVDXPHQWRVHQOD
LQPXQRVXSUHVLyQGHEDVHVHDVXILFLHQWHSDUDFRQWUR
ODUHVWRVHSLVRGLRVGHUHFKD]R'HKHFKRHQPXFKDV
XQLGDGHVGHWUDVSODQWHFDUGtDFRUHQDO\KHSiWLFRDO
SUHVHQWDUHOSDFLHQWHXQHSLVRGLRGHUHFKD]RDJXGR
DGHPiVGHLQVWDXUDUWUDWDPLHQWRFRQEROXV GHPHWLO
SUHGQLVRORQDVHLQWURGXFHQHVWRVFDPELRVHQHOWUDWD
PLHQWRLQPXQRVXSUHVRUGHEDVH
73
-0&DPSLVWRO
RECHAZO AGUDO - 3RQHQFLDV
5HFKD]RDJXGRFDUGtDFR
/XLV$OPHQDU%RQHW
+RVSLWDO8QLYHUVLWDULR/D)H9DOHQFLD
INTRODUCCIÓN
&XDQGRVHUHDOL]DHOWUDVSODQ
WHGHXQyUJDQRVXUJHQDXWpQWLFDV
OHJLRQHVGHFRPEDWHGLULJLGDVD
GHVWUXLUORVLVWHPDLQPXQLWDULR(OORRFXUULUtDVLQQLQ
JXQDGXGDDQRVHUSRUTXHVHERPEDUGHDHVHHMpUFLWR
SDUDGLVPLQXLUVXSRWHQFLDLQPXQRVXSUHVRUHV'HWDO
IRUPDTXHWUDVHOWUDVSODQWHGHEHH[LVWLUXQHTXLOLEULR
HQWUHODSRWHQFLDGHOHMpUFLWR\ODGHORVERPEDUGHRV
(QHOFDVRGHTXHSUHGRPLQHODFDQWLGDGGHERPEDVVH
SURGXFHXQDLQPXQRVXSUHVLyQH[FHVLYDIDYRUHFLHQGR
ODLQIHFFLyQ3RURWUDSDUWHHQHOFDVRGHHVFDVDDFWL
YLGDGGHORVERPEDUGHRVVHSURGXFHHOUHFKD]R'LD
SRVLWLYD
(OUHFKD]RHVLPSRUWDQWHSRUORWDQWRSRUTXH
(VIUHFXHQWH
7LHQHLPSOLFDFLRQHVHQODPRUELOLGDGLQIHFFLRVD
\QRLQIHFFLRVD\DTXHRFDVLRQDXQDXPHQWRGH
ODLQPXQXSUHVLyQ
7LHQHLPSOLFDFLRQHVHQODVXSHUYLYHQFLDGHIRUPD
GLUHFWDHLQGLUHFWD
$VtHQORV~OWLPRVGDWRVGHO5HJLVWUR(VSDxROGH
7UDVSODQWH&DUGtDFRVHSXHGHDSUHFLDUTXHHOUHFKD
]RRFDVLRQDHOH[LWXVHQHOGHORVSDFLHQWHWUDV
SODQWDGRV GHKHFKRHVXQDYDULDEOHFODUDPHQWH
DVRFLDGDDODPRUWDOLGDGFRQXQDRGGVUDWLR GH
'LDSRVLWLYD
7DPELpQHQORVGDWRVGHHVWHUHJLVWURVHSXHGHDSUH
FLDUTXHODLQFLGHQFLDGHLQIHFFLyQYDDXPHQWDQGRGH
IRUPDSURJUHVLYDDPHGLGDTXHHOQ~PHURGHUHFKD]RV
DXPHQWD'LDSRVLWLYD$GHPiVORVSDFLHQWHVTXH
GHVDUUROODQPHQRUQ~PHURGHUHFKD]RVVRQORVTXHPDQ
WLHQHQVXSHUYLYHQFLDVPiVDOWDVDORVDxRV
FRQ XQD FODUD GLIHUHQFLD VREUH ORV RWURV 'LDSRVLWLYD
MECANISMOS DEL RECHAZO
(OPXQGRGHODLQPXQRORJtDHVWiVXMHWRDJUDQGHV
FDPELRV'HKHFKRODVKLSyWHVLV\ORVDUWtFXORVGHKD
FHDxRVQRWLHQHQQDGDTXHYHUFRQODVWHRUtDVDF
WXDOHV\ORVKHFKRVGHPRVWUDGRVYLJHQWHVKR\HQGtD
$XQTXHSHUVLVWHQJUDQGHVODJXQDV\QXHVWURVFRQRFL
PLHQWRVDFWXDOHVHVWiQOHMRVGHVHUFRPSOHWRVKR\HQ
GtDH[LVWHQVXILFLHQWHVFRQRFLPLHQWRVIXQFLRQDOHV\HV
WUXFWXUDOHVVREUHORVFRPSRQHQWHVGHOVLVWHPDLQPX
QHTXHQRVSHUPLWHQDSUHFLDUPHMRUVXDOWRJUDGRGH
FRPSOHMLGDG\DGDSWDELOLGDG(QODDFWXDOLGDGODWHQ
GHQFLDVHRULHQWDDGHVDUUROODUVLVWHPDVGHDQiOLVLVTXH
QRVD\XGHQDHQWHQGHU\DSUHGHFLUHOVHJXLPLHQWRGH
FXDOTXLHUWLSRGHSURFHVRLQPXQROyJLFR\DVHDODFDX
VDRHOHIHFWR
/DGLIHUHQFLDPiVLPSRUWDQWHGHODDORLQPXQLGDG
DOFRPSDUDUODFRQODLQPXQLGDGIUHQWHDRWUDVSURWHt
QDVDQWLJpQLFDVHVHOUHFRQRFLPLHQWRGLUHFWRSRUSDU
WHGHFORQHVGHFpOXODV7 HVSHFtILFDVUHODFLRQDGDVFRQ
HStWRSHVDQWtJHQRVGHHVWUXFWXUDFRQRFLGDGHFpOXODV
7 SROLPyUILFDVVREUHPROpFXODVGHOVLVWHPD+/$([LV
WHQIXHUWHVHYLGHQFLDVGHTXHHVWHHVHOPHFDQLVPRSULQ
FLSDOTXHGDLQLFLRDXQDFDVFDGDTXHWHUPLQDHQHOUH
FKD]RDJXGRGHOLQMHUWR
7UDVODDFWLYDFLyQGHODVFpOXODV7 HVSHFtILFDVVHVH
JUHJDQXQDODUJDOLVWDGHPHGLDGRUHVFLWRFLQDVTXH
75
FRQVWLWX\HQP~OWLSOHVVLVWHPDVGHFRPXQLFDFLyQLQWHU
FHOXODUFRQVWLWXLGRVIXQGDPHQWDOPHQWHSRUSROLSpSWL
GRVGHEDMRSHVRPROHFXODUTXLPRFLQDV([LVWHXQD
TXLPRFLQDDLVODGDHQOD~OWLPDGpFDGDGHQRPLQDGD
5$17(6UHJXODWHGRQDFWLYDWLRQQRYHO7 H[SUHVVHG
DQGVHFUHWHGTXHSRVHHFDSDFLGDGTXLPRDWUDFWLYD\
RFDVLRQDHOSURFHVRGHDWUDFFLyQGHODVFpOXODVLQPX
QLWDULDVLQFOX\HQGRORVPRQRFLWRVORVOLQIRFLWRV7 \
ORVHRVLQyILORVHQORVVLWLRVGHODLQIODPDFLyQ3RURWUD
SDUWHWDPELpQSURORQJDODUHSXHVWDLQPXQH\DFWLYDDO
JXQRVWLSRVFHOXODUHV(VWDTXLPRFLQDHVSURGXFLGDSRU
ODVFpOXODV7 DSUR[LPDGDPHQWHDORVGtDVGHHPSH]DU
ODVHxDOGHDFWLYDFLyQ\HVHOSURWRWLSRGHOJUXSRGH
PROpFXODVTXLPRDWUDFWLYDVTXHVHHQFXHQWUDQHQORVLQ
ILOWUDGRVLQIODPDWRULRVGHVSXpVGHODDFWLYDFLyQGHODV
FpOXODV7/D5$17(6SXHVWLHQHXQLPSRUWDQWHSD
SHOHQHOSURFHVRGHOUHFKD]RGHOLQMHUWR
/DSUROLIHUDFLyQFORQDOGHFpOXODV7HQUHVSXHVWD
DODQWtJHQRGHSHQGHIXQGDPHQWDOPHQWHGHODOLEHUD
FLyQGHLQWHUOHXFLQDV&OiVLFDPHQWHODVLQWHUOHXFLQDV
\,/H,/KDQVLGRODVUHVSRQVDEOHVGHOIHQy
PHQRGHSUROLIHUDFLyQGHOLQIRFLWRV71RREVWDQWHDF
WXDOPHQWHVHFUHHTXHHVWDVLQWHUOHXFLQDVWLHQHQJUDQ
FDSDFLGDGLQYLWUR SHURQRLQYLYR(QHVWHPHGLRHV
WDVLQWHUOHXFLQDVQRVRQPX\DFWLYDV+R\HQGtDVHFUHH
TXHODVLQWHUOHXFLQDVTXHRFDVLRQDQXQFUHFLPLHQWR
PiVSRWHQWHGHFpOXODV7VRQOD,/H,/
$VtSXHVHQXQLQWHQWRGHUHVXPLUORVPHFDQLVPRV
GHOUHFKD]RHQHOWUDVSODQWHFDUGtDFRVHSXHGHGHFLU
TXHODUHVSXHVWDLQPXQLWDULDIUHQWHDODORDQWtJHQRFRQV
WDGHWUHVIDVHVVXFHVLYDV
5HFRQRFLPLHQWRGHODQWtJHQRHOOLQIRFLWR7D
WUDYpVGHVXVUHFHSWRUHV&'\&'UHFRQRFHHODQ
WtJHQRSURFHVDGRSRUHOPDFUyIDJR\HOVLVWHPD+/$
(VWLPXODFLyQ\SUROLIHUDFLyQGHOVLVWHPDLQPX
QHORVOLQIRFLWRV7 FRODERUDGRUHVDFWLYDGRVVHFUHWDQ
OLQIRFLQDVTXHHVWLPXODQODIRUPDFLyQGHOLQIRFLWRV
FLWRWy[LFRV
)DVHHIHFWRUDRGHGHVWUXFFLyQGHODQWtJHQRORV
OLQIRFLWRVVHWUDVIRUPDQHQFpOXODVFRQFDSDFLGDGFL
WROtWLFD
TIPOS DE RECHAZO
3DUDVLPSOLILFDUXQWHPDWDQFRPSOHMRFRPRHVWH\
GHVGHHOSXQWRGHYLVWDSUiFWLFRVHSXHGHFODVLILFDUHO
UHFKD]RHQWUHVWLSRV
5HFKD]RKLSHUDJXGRVHSURGXFHFXDQGRH[LVWHQ
DQWLFXHUSRVSUHIRUPDGRVFRQWUDGHWHUPLQDGRVDQWtJH
QRVGHO+/$ RGHO$%6HSRQHGHPDQLILHVWRHQORV
PLQXWRVVLJXLHQWHVDOGHVFODPSDMHDyUWLFR(OFXDGURFOt
QLFRHVFDWDVWUyILFRDSUHFLiQGRVHLQFOXVRHQHOPLVPR
DFWRTXLU~UJLFRXQDWXPHIDFFLyQSURJUHVLYDGHOyUJD
QRFRQLPSRVLELOLGDGWRWDOGHODIXQFLyQFRQWUiFWLO
5HFKD]RDJXGRHVHOKDELWXDOHQHOWUDVSODQWH
FDUGtDFR1RVXHOHVHUWDQVHYHURFRPRHODQWHULRU
&XDQGRVXFHGHORKDFHDSDUWLUGHORVSULPHURVGtDV
GHOWUDVSODQWH\DTXHVHQHFHVLWDQYDULRVGtDVFRQOD
LQPXQRVXSUHVLyQKDELWXDOSDUDTXHVHSURGX]FDODUHV
SXHVWDLQPXQLWDULDFRPSOHWDFRQWUDHOLQMHUWR6HJH
QHUDQHQHOPLRFDUGLRIRFRVGHQHFURVLVHLQILOWUDGRV
LQWHUVWLFLDOHV\SXHGHRFXUULUTXHHQYH]GHXQDDIHF
WDFLyQLQWHUVWLFLDOVHSURGX]FDXQDDIHFWDFLyQGHSUH
GRPLQLRYDVFXODU\FRQSRFRFRPSRQHQWHLQWHUVWLFLDO
+DHVWHWLSRGHUHFKD]RVHOHGHQRPLQDUHFKD]RDJXGR
YDVFXODURKXPRUDO
5HFKD]RFUyQLFRGHQRPLQDGRHQODDFWXDOLGDG
HQIHUPHGDGYDVFXODUGHOLQMHUWR1RVHFRQRFHELHQVX
HWLRSDWRJHQLDSHURVHSURGXFHXQDREOLWHUDFLyQGLIX
VDGHODVDUWHULDVFRURQDULDVGHVGHVXVSRUFLRQHVPiV
GLVWDOHVDODVPiVSUR[LPDOHV
MÉTODOS DIAGNÓSTICOS
/DVPDQLIHVWDFLRQHVFOtQLFDVGHOUHFKD]RDJXGRVRQ
PX\YDULDEOHV*HQHUDOPHQWHVHGLDJQRVWLFDHQXQD
ELRSVLDUXWLQDULDDQWHVGHODDSDULFLyQGHDOJ~QVtQWR
PDGHELGRDpOSRUWDQWRODPD\RUtDGHUHFKD]RVVRQ
DVLQWRPiWLFRV
Biopsia endomiocárdica
)XHHOSULPHUPpWRGRTXHVHXWLOL]ySDUDHOGLDJ
QyVWLFRGHOUHFKD]R\HVHOSDWUyQRURFRQHOTXHVH
FRPSDUDQWRGRVORVPpWRGRVGHVFULWRVSRVWHULRU
PHQWH&RQVLVWHHQREWHQHUPHGLDQWHXQDVSLQ]DV
ELySVLFDVIUDJPHQWRVGHOPLRFDUGLR\DTXHHO
UHFKD]RVXHOHVHPXOWLIRFDO\FXDQWRVPiVIUDJPHQWRV
VHREWHQJDQPiVSUREDEOHHVVXGLDJQyVWLFR\FRQ
HVWHQ~PHURGHIUDJPHQWRVHOPDUJHQGHHUURUHVPH
QRUDO6XHOHUHDOL]DUVHSRUYtD\XJXODUGHUH
FKD\ODPXHVWUDVHREWLHQHGHODSXQWDGHOYHQWUt
FXORGHUHFKRHQHOWDELTXHLQWHUYHQWULFXODU'LDSR
VLWLYD
76
RECHAZO AGUDO - 3RQHQFLDV
7UDVREWHQHUODVPXHVWUDVHOWHMLGRVHILMDHQIRU
PRODOVHLQFOX\HHQSDUDILQD\VHWLxHFRQKH
PDWR[LOLQDHRVLQD\FRQODFRORUDFLyQGH0DVVRQ6L
VHFUHHFRQYHQLHQWHXQRGHORVIUDJPHQWRVSXHGHFRQ
JHODUVHSDUDVXHVWXGLRLQPXQROyJLFR
3DUDODLQWHUSUHWDFLyQGHODVPXHVWUDVVHXWLOL]DODUH
JODPHQWDFLyQGHOD6RFLHGDG,QWHUQDFLRQDOGH7UDVSODQWH
&DUGtDFR\3XOPRQDU,6+/7TXHSRVHHJUDGRV
$%$%\HQIXQFLyQGHOLQILOWUDGROLQIR
FLWDULR\ODSUHVHQFLDGHQHFURVLV 'LDSRVLWLYD
/DELRSVLDHQGRPLRFiUGLFDHVHOPHMRUPpWRGRGH
TXHGLVSRQHPRVKR\HQGtDSDUDGLDJQRVWLFDUHOUH
FKD]RGHELGRDTXHHVHO~QLFRPpWRGRTXHSHUPLWH
XQGLDJQyVWLFRSUHFR]GHOUHFKD]RTXHSHUPLWHHYD
OXDUVXLQWHQVLGDGTXHD\XGDDSHUILODUODSDXWDLQPX
QRVXSUHVRUDTXHVLUYHSDUDHOGLDJQyVWLFRGHUHFKD]R
YDVFXODU\DGHPiVTXHSXHGHD\XGDUDGHWHFWDUODVLQ
IHFFLRQHVPLRFiUGLFDV'LDSRVLWLYD
$XQTXHDSDUHQWHPHQWHSXHGHSDUHFHUTXHWRGRVRQ
YHQWDMDVWLHQHSUREOHPDVLPSRUWDQWHVUHODFLRQDGRVFRQ
ODREWHQFLyQGHODVSLH]DVELySVLFDV\FRQVXLQWHUSUH
WDFLyQ/RVSUREOHPDVPDVLPSRUWDQWHVVRQ
3UREOHPDVFRQODREWHQFLyQ
(VDJUHVLYDSDUDHOSDFLHQWH
7LHQHPRUWDOLGDG
3RVHHPRUELOLGDGFDUGLRYDVFXODU
5HSUHVHQWDXQDSRUFLyQSHTXHxDGHOFRUD]yQ
0XFKDVYHFHVODPXHVWUDQRHVVXILFLHQWH
(OQ~PHURGHH[SORUDFLRQHVTXHVHSXHGHQUHD
OL]DUHVOLPLWDGR
([LVWHQIDOVRVQHJDWLYRV]RQDVQRUPDOHVRUH
FKD]RYDVFXODU
3UREOHPDVFRQODLQWHUSUHWDFLyQFUHDQGRFRQIX
VLyQFRQ
/HVLRQHVSRUSUHVHUYDFLyQ7&VHPDQD0LR
FLWyOLVLVFRQSRFDLQIODPDFLyQ
/HVLRQHVSRUFDWHFRODPLQDV,QILOWUDGRVLQIODPD
WRULRVHQFRUD]RQHVGHGRQDQWHVFRQUHFLELHURQ
JUDQGHVGRVLVGHFDWHFRODPLQDV
/HVLRQHVGHELRSVLDVSUHYLDVGHIHFWROLJHURLQ
ILOWUDGRLQIODPDWRULRFLFDWUL]ILEURVD
(VSRUHOORSRUORTXHVHKDQYDORUDGR\GHVDUUROODGR
PXFKRVRWURVPpWRGRVQRLQYDVRUHVSDUDKDFHUHOGLDJ
QyVWLFRGHUHFKD]R(VWRVPpWRGRVSXHGHQDJUXSDUVHHQ
3UHVHQFLDGHGHWHUPLQDGRVVtQWRPDVVLJQRVFOtQLFRV
'HWHFFLyQGHDOWHUDFLRQHVHQODVSURSLHGDGHVIL
VLROyJLFDVGHOFRUD]yQWUDVSODQWDGR
$QiOLVLVGHVXVWDQFLDVOLEHUDGDVSRUHOPLRFDUGLR
FXDQGRH[LVWHUHFKD]R
'HWHFFLyQGHODDFWLYDFLyQGHOVLVWHPDLQPXQH
Síntomas/signos clínicos de rechazo
([LVWHQDOJXQRVGDWRVTXHVHSXHGHQH[WUDHUGHOD
KLVWRULDFOtQLFD\GHODH[SORUDFLyQItVLFDGHOSDFLHQWH
TXHVXJLHUHQUHFKD]R'LFKRVGDWRVVRQ
/DILHEUHODOHXFRFLWRVLVODSpUGLGDGHSHVRHOFDQ
VDQFLRODVDUULWPLDVVXSUDYHQWULFXODUHVIXQGDPHQWDO
PHQWHILEULODFLyQ\IOXWWHU DXULFXODUODLQJXUJLWDFLyQ
\XJXODUORVHGHPDV\JDORSHYHQWULFXODU6RQVtQWR
PDVLQHVSHFtILFRVSHURXQDFOtQLFDGHLQVXILFLHQFLD
FDUGtDFDHQXQSDFLHQWHWUDVSODQWDGRTXHSUHYLDPHQ
WHQRSUHVHQWDEDHVWRVSUREOHPDVGHEHRULHQWDUKDFLD
HOGLDJQyVWLFRGHUHFKD]R
([LVWHQSRFRVHVWXGLRVELHQSURWRFROL]DGRVTXH
DQDOLFHQHOYDORUUHDOGHORVVtQWRPDVVLJQRVGHUHFKD
]R\VXXWLOLGDG1XHVWURJUXSRUHDOL]yXQHVWXGLRSURV
SHFWLYRGHGRVDxRVGHGXUDFLyQHQHOTXHHOPLVPR
PpGLFRDQRWDEDODSUHVHQFLDRODDXVHQFLDGHVtQWRPDV
FOtQLFRVHQODVKRUDVSUHYLDVDODELRSVLD/DFRPSDUD
FLyQSRVWHULRUHQWUHORVSDFLHQWHVFRQ\VLQUHFKD]RGH
PRVWUyTXH~QLFDPHQWHODSUHVHQFLDGHLQJXUJLWDFLyQ
\XJXODU\GHJDORSHYHQWULFXODUL]TXLHUGRVXJHUtDQUH
FKD]RFRQVXILFLHQWHILDELOLGDG
Electrocardiografía
(O(&*HVWiQGDUIXHHOSULPHUPpWRGRTXHVHXWL
OL]ySDUDKDFHUHOGLDJQyVWLFRQRLQYDVRUGHUHFKD]R
$QWHVGHODDGPLQLVWUDFLyQVLVWHPiWLFDGHODFLFORVSR
ULQDORVUHFKD]RVFXUVDEDQFRQXQJUDQFRPSRQHQWH
HGHPDWRVRLQWUDPLRFiUGLFRSRUORTXHVHSRGtDDSUH
FLDUXQDUHGXFFLyQVLJQLILFDWLYDGHOYROWDMHHQHO(&*
'LDSRVLWLYD'HWDOIRUPDTXHXQDUHGXFFLyQPD
\RUDOFRQUHVSHFWRDXQ(&*SUHYLRDOVXPDU
GHWHUPLQDGDVGHULYDFLRQHV',',,',,,99
SRVHtDXQDVHQVLELOLGDGSDUDHOGLDJQyVWLFRGHUHFKD
]RFHUFDQDDO
$FWXDOPHQWHQRVXHOHQH[LVWLUUHFKD]RVFRQXQJUDQ
FRPSRQHQWHHGHPDWRVRSRUORTXHORVFDPELRV(&*
VRQFDVLLQDSDUHQWHV(QODDFWXDOLGDGODVHQVLELOLGDG
FRQHOFULWHULRGHYROWDMHHVWiHQWRUQRDO
$GHPiVGHXQDGLVPLQXFLyQGHOYROWDMHHQHO(&*
FXDQGRH[LVWHUHFKD]RHQRFDVLRQHVH[LVWHQDOWHUDFLR
77
QHVGHOULWPRTXHVXJLHUHQIXHUWHPHQWHODSUHVHQFLDGH
UHFKD]R/DVPiVLPSRUWDQWHVVRQODILEULODFLyQ\HO
IOXWWHU DXULFXODUHV'HKHFKRDQWHXQSDFLHQWHTXHVH
QRVSUHVHQWDFRQXQOLJHURGHWHULRURGHOHVWDGRJHQH
UDO\FRQXQDDUULWPLDVXSUDYHQWULFXODUHVREOLJDGRVRV
SHFKDUXQUHFKD]RFRPRFDXVDGHVXVVtQWRPDV
$FWXDOPHQWHH[LVWHQRWURVPpWRGRVPiVVHQVLEOHV
SDUDHOGLDJQyVWLFRGHUHFKD]RTXHHOYROWDMHGHO(&*
SHURVRQODERULRVRVGHUHDOL]DU\WDPELpQSRVHHQIDO
VRVSRVLWLYRV\QHJDWLYRV/RVPiVHVWXGLDGRVVRQOD
SURPHGLDFLyQGHVHxDOODYDULDELOLGDGGHODIUHFXHQ
FLDFDUGtDFDODGLVSHUVLyQGHO47 \HOHOHFWURJUDPD
LQWUDPLRFiUGLFR(VWH~OWLPRVHSXHGHDQDOL]DUHQOD
IDVHSUHFR]GHOWUDVSODQWHFRQORVFDEOHVHSLFiUGLFRV
DXULFXODU\YHQWULFXODUTXHQRUPDOPHQWHVHGHMDQWUDV
ODFLUXJtDFDUGtDFDFRPRPHGLGDGHVHJXULGDGSRUVL
VHGHVDUUROODQEUDGLDUULWPLDVRHQIDVHVSRVWHULRUHV
WUDVODLPSODQWDFLyQGHXQPDUFDSDVRVHVSHFLDOGHDO
WDILGHOLGDGTXHSHUPLWHUHJLVWUDUGHIRUPDFRQWLQXD
HOYROWDMHPLRFiUGLFRLQWUDFDUGtDFRSDUDSRVWHULRU
PHQWHDQDOL]DUOR 'LDSRVLWLYD
1XHVWURJUXSRYDORUyODXWLOLGDGGHO(&*GHVX
SHUILFLHHQXQJUXSRGHSDFLHQWHVWUDWDGRVFRQFLFORV
SRULQDD]DWLRSULQDFRUWLFRLGHV6HHVWXGLDURQ
SDFLHQWHVFRQVHFXWLYRVFRQGLDJQyVWLFRDQDWRPRSDWR
OyJLFRGHUHFKD]R\TXHHQODELRSVLDSRVWHULRUDORV
GtDVGHOWUDWDPLHQWRFRQERORVGHPHWLOSUHGQLVR
ORQDQRSUHVHQWDEDQKDOOD]JRVFDUDFWHUtVWLFRVGHUH
FKD]R6HVXPyHOYROWDMHGHO(&*GHOGtDGHODELRS
VLDFRQUHFKD]R\FXiQGRpVWHKDEtDGHVDSDUHFLGR/DV
GLIHUHQFLDVIXHURQVLJQLILFDWLYDVSHURWDQVyORKXER
XQLQFUHPHQWRGHOFRQXQDJUDQGHVYLDFLyQHVWiQ
GDU'LDSRVLWLYD(VWRVUHVXOWDGRVKDFHQSUiFWLFD
PHQWHLQVHUYLEOHHQODSUDFWLFDFOtQLFDHOFULWHULRGH
YROWDMHHOHFWURFDUGLRJUiILFRSDUDHOGLDJQyVWLFRGHUH
FKD]R
Ecocardiografía-Doppler
/DHFRFDUGLRJUDItDKDVXSXHVWRXQDUHYROXFLyQGHQ
WURGHOPXQGRGHODFDUGLRORJtDGHELGRDODJUDQFDQ
WLGDGGHLQIRUPDFLyQTXHDSRUWDGHIRUPDUiSLGD\VLQ
VHUDJUHVLYDSDUDHOSDFLHQWH
/DVDOWHUDFLRQHVFDUGtDFDVTXHVHSURGXFHQFRQHO
UHFKD]RVHSXHGHQDQDOL]DUFRQODHFRFDUGLRJUDItD'H
HVWHPRGRORVGDWRVTXHVHXWLOL]DURQLQLFLDOPHQWHIXH
URQODYDORUDFLyQGHOWDPDxRGHODVFDYLGDGHV\HOJUR
VRUGHODVSDUHGHV\ODVDOWHUDFLRQHVGHODIXQFLyQVLV
WyOLFD\GLDVWyOLFDÔOWLPDPHQWHDPHGLGDTXHKDQLGR
VXUJLHQGRQXHYRVDYDQFHVHQHOFDPSRGHODLPDJHQ
pVWRVVHKDQLGRLQFRUSRUDQGRDODYDORUDFLyQGHOUH
FKD]RGHOFRUD]yQWUDVSODQWDGR$VtVHKDQHVWXGLDGR
ODGHQVLWRPHWUtDDF~VWLFDODFRORUFLQHVLVHO'RSSOHU
WLVXODU\ODGHWHFFLyQDXWRPiWLFDGHERUGHV
'DGRTXHVHUtDPX\H[WHQVRDQDOL]DUORVWRGRVHV
SUHIHULEOHSRUPHQRUL]DUORVPiVVHQFLOORVDOVHUHVWRV
ORVPiVXWLOL]DGRV
/RVUHFKD]RVPX\VHYHURVVXHOHQFXUVDUFRQDOWH
UDFLRQHVGHODIXQFLyQVLVWyOLFD1RREVWDQWHODPD
\RUtDGHORVUHFKD]RVVHGHEHQWUDWDUSHURQRSURGX
FHQGLVIXQFLyQGHOYHQWUtFXORL]TXLHUGR(ODQiOLVLVGH
ODIXQFLyQGLDVWyOLFDGHOYHQWUtFXORL]TXLHUGRSRUSD
UiPHWURVFRQYHQFLRQDOHVD\XGDPXFKRDKDFHUHOGLDJ
QyVWLFRDXQTXHH[LVWHQXQDVHULHGHYDULDFLRQHVTXH
VHGHEHQWHQHUHQFXHQWD
Conceptos generales
/DIXQFLyQGLDVWyOLFDSRGHPRVGHILQLUODFRPROD
FDSDFLGDGGHOFRUD]yQGHUHODMDUVH\GHDFHSWDUHOYR
OXPHQVDQJXtQHRGXUDQWHODGLiVWROH&XDQGRDFRQWH
FHHOUHFKD]RHOWHMLGRPLRFiUGLFRVHHGHPDWL]DDOWH
UiQGRVHVXFDSDFLGDGQRUPDOGHUHODMDFLyQ7DPELpQ
GXUDQWHHOUHFKD]RSXHGHSURGXFLUVHXQDOLEHUDFLyQGH
OLQIRFLQDVFRQODFRQVLJXLHQWHDOWHUDFLyQGHODIXQFLyQ
QRUPDOGHORVPLRFLWRV\DQRPDOtDVHQODIXQFLyQGLDV
WyOLFD(VWRVFDPELRVVHWUDGXFHQHQODUHODFLyQSUH
VLyQYROXPHQHQFDPELRVHQODYHORFLGDGGHOIOXMR
WUDQVYDOYXODUORVFXDOHVVHSXHGHQGHWHFWDUSRUHFR
FDUGLRJUDItD'RSSOHU
/RVSDUiPHWURVGHULYDGRVGHODVHxDO'RSSOHUTXH
VHKDQFRQVLGHUDGRHVSHFLDOPHQWH~WLOHVSDUDUHDOL]DU
XQDYDORUDFLyQGHODIXQFLyQGLDVWyOLFD\SRUWDQWR~WL
OHVSDUDYDORUDUHOUHFKD]RVRQHOWLHPSRGHUHODMDFLyQ
LVRYROXPpWULFD75,6HOWLHPSRGHGHFHOHUDFLyQGH
ODRQGD(7'(\YHORFLGDGPi[LPDGHODRQGD(
Particularidades en el examen Doppler del
corazón trasplantado
$XQTXHGHHQWUDGDHOH[DPHQGHXQFRUD]yQWUDV
SODQWDGRHVVLPLODUDOQRUPDOH[LVWHQDOJXQDVGLIH
UHQFLDVDWHQHUHQFXHQWDTXHQRVRQVXJHVWLYDVGH
QLQJXQDDQRUPDOLGDG
(OFRUD]yQWUDVSODQWDGRVXHOHDGRSWDUXQDRULHQ
WDFLyQGLVWLQWDDOQDWLYRGHQWURGHODFDYLGDGWR
78
RECHAZO AGUDO - 3RQHQFLDV
UiFLFDORFXDOVHKDUHODFLRQDGRFRQHOH[FHVL
YRHVSDFLRSHULFiUGLFRGHOQXHYRFRUD]yQFRQ
UHVSHFWRDODQWLJXR
(VIUHFXHQWHHQFRQWUDUVHFRQFDQWLGDGHVYDULDEOHV
GHOtTXLGRSHULFiUGLFRGHVSXpVGHODLQWHUYHQFLyQ
(VFRP~QFRPSUREDUXQHQJURVDPLHQWRGHOSHUL
FDUGLRSRVWHULRU
6HDSUHFLDQODVVXWXUDVDQLYHODXULFXODUFRPRHFRV
PX\UHIULQJHQWHVFRQDXUtFXODVJUDQGHVDHVWDViUHDV
GHDQDVWRPRVLVVHOHVGHEHSUHVWDUHVSHFLDODWHQFLyQ
GHELGRDTXHVRQIXHQWHVSRWHQFLDOHVGHIRUPDFLyQGH
WURPERV
Registro de velocidades
(OIOXMRPLWUDOVHGHEHREWHQHUHQXQSODQRDSLFDO
GHODVFiPDUDVFRQHOYROXPHQGHPXHVWUDGHO'RS
SOHUSXOVDGRVLWXDGRHQWUHORVYHORVGHODYiOYXODPL
WUDOHQODFDUDYHQWULFXODUGHODVYDOYDV(OVLWLRySWLPR
HVDTXHOHQTXHVHUHJLVWUDODPi[LPDYHORFLGDGDFRP
SDxDGDGHORVUXLGRVGHDSHUWXUD\FLHUUHYDOYXODU
/DLQWHUSUHWDFLyQGHORVFiOFXORVGHIOXMRGLDVWyOL
FRVHGHEHQUHDOL]DUDPPVHJGHYHORFLGDG\D
TXHGHHVWDIRUPDVXHOHVHUPiVIiFLO\FRQPHQRUHUURU
(O75,6VHSXHGHUHJLVWUDUWDPELpQHQHVWDORFDOL
]DFLyQFRQHO'RSSOHUSXOVDGRVLELHQGHELGRDODSR
VLFLyQGHYiOYXODDyUWLFDHQRFDVLRQHVQRHVSRVLEOH
GHELHQGRUHJLVWUDUVHFRQHO'RSSOHUFRQWLQXR
6HGHEHQH[FOXLUDOUHDOL]DUODVPHGLGDVORVIOXMRV
PLWUDOHVPDJQLILFDGRVSRUODFRQWUDFFLyQDXULFXODUGHO
UHFHSWRUHVGHFLUKD\TXHGHVFDUWDUDTXHOORVFLFORVHQ
GRQGHODRQGDSGHOUHFHSWRURFXUUDGXUDQWHODWHOHVtV
WROH\DTXHHVWRPDJQLILFDUtDHOUHJLVWURGHOIOXMRPL
WUDOVLJXLHQWH6RQySWLPRVORVFLFORVUHJLVWUDGRVFXDQ
GRODRQGDSGHOUHFHSWRUFDHHQDOJ~QOXJDUHQWUHOD
WHOHGLiVWROH\ODPHVRVtVWROH'LDSRVLWLYD
6HGHEHQUHJLVWUDUHQWUHIOXMRVGHOOHQDGRYHQ
WULFXODUHQORVTXHQRLQWHUYHQJDQODFRQWUDFFLyQDXUL
FXODU\SURPHGLDUORV
GHODRQGD(\DXPHQWRGHO75,6\GHO7'(HVWRV
FDPELRVUHIOHMDQODPHMRUtDHQHOOOHQDGRYHQWULFX
ODUVHFXQGDULDDXQDGLVPLQXFLyQGHODSUHVLyQGLDV
WyOLFDYHQWULFXODU(VLPSRUWDQWHWHQHUHQFXHQWD
TXHODIDOWDGHPHMRUtDGHHVWRVSDUiPHWURVHQHV
WHSHULRGRGHEHDOHUWDUVREUHODSRVLELOLGDGGHUH
FKD]R
$ SDUWLUGHODVHPDQDVHVXHOHQDOFDQ]DUORVYD
ORUHVPHVHWD
Cambios en los parámetros de función
diastólica con el rechazo
'HELGRDODJUDQGLIHUHQFLDHQORVYDORUHVEDVDOHV
GHFDGDSDFLHQWHVHGHEHQFRPSDUDUODVPHGLGDVRE
WHQLGDVFRQODSUHYLDVGHFDGDXQRHQSDUWLFXODU
6HFRQVLGHUDQFRPSDWLEOHVFRQUHFKD]RXQLQFUHPHQWR
PD\RUGHXQHQODYHORFLGDGGHODRQGD(RXQD
GLVPLQXFLyQPD\RUGHXQGHO75,6RGHO7'(VL
HVWRRFXUUH\ODIXQFLyQVLVWyOLFDHVWiFRQVHUYDGDVHGH
EHLQGLFDUXQDELRSVLD\HVSHUDUHOUHVXOWDGR
Cambios en los parámetros de función
diastólica no atribuibles a rechazo
VHPDQDSRV7&GHVSXpVGHO7&HO75,6\HO7'(
VRQDQRUPDOPHQWHFRUWRVPLHQWUDVTXHODYHORFLGDG
GHOOHQDGRYHQWULFXODUHVDQRUPDOPHQWHDOWDSURGX
FLGRSRULVTXHPLDHIHFWRGHODVFDWHFRODPLQDV
VHPDQDSRV7&ORVSDUiPHWURVYDQQRUPDOL
]iQGRVHFRQGLVPLQXFLyQJUDGXDOGHODYHORFLGDG
79
Problemas en la obtención de registros
adecuados
'LILFXOWDGHVWpFQLFDVH[LVWHXQSRUFHQWDMHGHSD
FLHQWHVHQORVTXHQRVHSXHGHQUHJLVWUDU
ORVIOXMRVGHELGRDTXHHVWiQFRQYHQWLODFLyQPH
FiQLFD\H[LVWHLPSRVLELOLGDGSDUDLQFOLQDUORVVR
EUHVXODGRL]TXLHUGRRSRUODSUHVHQFLDGHYHQ
GDVWRUiFLFDVRWXERVGHGUHQDMHSRVWRSHUDWRULRV
2EWHQFLyQVXEySWLPDGHUHJLVWURVDSUR[LPDGD
PHQWHHQXQGHORVSDFLHQWHVQRVHSXH
GHQUHJLVWUDUWRGRVORVSDUiPHWURVGHELGRDDUULW
PLDVDXULFXODUHVTXHDFRUWDQODGLiVWROHKDFLHQ
GRGLItFLOODPHGLGDGHODYHORFLGDGPi[LPDGHO
IOXMR\GHO7'('HWRGDVIRUPDVHQHVWRVFDVRV
VtVHSXHGHPHGLUHO75,6UHVXOWDQGRILDEOHVX
YDORU
)OXWWHUDXULFXODUGHOUHFHSWRUHQHVWRVFDVRVWRGRV
ORVUHJLVWURVWLHQHQDUWHIDFWRVKDFLHQGRLPSRVL
EOHODLQWHUSUHWDFLyQGHORVSDUiPHWURV
9DORUHVQRFRQFRUGDQWHVH[LVWHQXQGHSD
FLHQWHVHQORVTXHORVYDORUHVREWHQLGRVVRQFRQ
WUDGLFWRULRVHVGHFLUSXHGHRFXUULUTXHHO75,6
H[SUHVHXQHPSHRUDPLHQWRDFRUWDPLHQWR!
\VLQHPEDUJRHO7'(QRVHKD\DDOWHUDGRRKD
\DDXPHQWDGR(QHVWRVFDVRVORDFRQVHMDEOHHV
UHSHWLUODHFRFDUGLRJUDItDDOFDERGHGtDV\VL
DOJ~QSDUiPHWURRWRGRVVLJXHQDOWHUDGRVVHGH
EHDFRQVHMDUXQDELRSVLD
$OWHUDFLyQGHODIXQFLyQVLVWyOLFDQRDFRPSDxDGD
GHFDPELRVHQODIXQFLyQGLDVWyOLFDHQHVWRVFD
VRVVHGHEHUHDOL]DUXQDELRSVLDSUHFR]PHQWHVH
GHEHWUDWDULQPHGLDWDPHQWH\HVSHUDUHOUHVXOWDGR
,QFUHPHQWRV~ELWRGHOGHUUDPHSHULFiUGLFROD
PD\RUtDGHHVWRVSDFLHQWHVSUHVHQWDQGHUUDPHV
SHULFiUGLFRVOLJHURVTXHWDUGDQHQGHVDSDUHFHU
GHMDQGRXQHQJURVDPLHQWRSHULFiUGLFR(QHOFD
VRGHXQDXPHQWRV~ELWRHQODFDQWLGDGGHGHUUD
PHVHGHEHVRVSHFKDUUHFKD]R\UHDOL]DUXQDELRS
VLDVHGHEHWUDWDULQPHGLDWDPHQWH\HVSHUDUHO
UHVXOWDGR'LDSRVLWLYD
1XHVWURJUXSRKDHVWXGLDGRHOYDORUGHODHFRFDU
GLRJUDItDSDUDHOGLDJQyVWLFRGHOUHFKD]RXWLOL]DQGRXQ
QXHYRPpWRGRODIXQFLyQGLDVWyOLFDGHOYHQWUtFXORGH
UHFKRPHGLDQWHHOWLHPSRGHUHODMDFLyQLVRYROXPpWUL
FDGHHVWHYHQWUtFXOR'LDSRVLWLYD6HHQFXHQWUDQ
YDORUHVGHVLJQLILFDFLyQPXFKRPD\RUHVTXHFXDQGR
VHXWLOL]DQORVSDUiPHWURVGHIXQFLyQGLDVWyOLFDGHOYHQ
WUtFXORL]TXLHUGR$VtHQORVSDFLHQWHVVLQUHFKD]RHO
75,6GHOYHQWUtFXORGHUHFKRRVFLODEDHQWRUQRDORV
PVHJSHURFXDQGRDFRQWHFtDHOUHFKD]RORKDFtDHQ
WRUQRDORVPVHJ7DPELpQHVWXGLDPRVODGHQVL
WRPHWUtDDF~VWLFDSDUDGLDJQRVWLFDUHOUHFKD]RLQWHQ
WDGRFRUUHODFLRQDUVXVYDORUHVFRQGHWHUPLQDGDVDQR
PDOtDVDQDWRPRSDWROyJLFDVHQFRQWUDGDVHQODELRSVLD
QHFURVLVLQILOWUDGROLQIRFLWDULRHGHPDLQWHUVWLFLDOIL
EURVLV\WXPHIDFFLyQFHOXODUWDQVyORKDOODPRVXQDX
PHQWRGHGHQVLGDGGHOWDELTXHLQWHUYHQWULFXODUFXDQ
GRH[LVWtDWXPHIDFFLyQFHOXODU'LDSRVLWLYD(VWH
UHVXOWDGRDXQTXHFLHQWtILFDPHQWHLQWHUHVDQWHUHVXOWD
GHSRFDD\XGDDODKRUDGHGHFLGLUWUDWDURQRDXQSD
FLHQWHFRQUHFKD]R GHLQWHUpV8QDUHODFLyQGHFDSWDFLyQVXSHULRUDVX
JHULUtDODSUHVHQFLDGHUHFKD]R'LDSRVLWLYDV\
3DUDYDORUDUODXWLOLGDGGHHVWHPpWRGRVHUHDOL]yXQ
HVWXGLRSURVSHFWLYRGXUDQWHGRVDxRVH[SORUDFLR
QHV6HDGPLQLVWUyHODQWLFXHUSRSUHYLDPHQWHPDUFD
GRHOPLVPRGtDGHODELRSVLDFDOFXOiQGRVHODUHODFLyQ
GHFDSWDFLyQFRUD]yQSXOPyQ\ODILDELOLGDGGHORVUH
VXOWDGRVWRPDQGRODELRSVLDFRPRSDWUyQRUR3DUDGLV
FULPLQDUODSUHVHQFLDRQRGHUHFKD]RVHHQFRQWUyFRPR
PHMRUtQGLFHGHFDSWDFLyQ(VWHtQGLFHHVFDSD]GH
SUHGHFLUHOUHFKD]RFRQXQDILDELOLGDGGHO1RREV
WDQWHDXQTXHHVWHYDORUHVLPSRUWDQWHVHFRQVLGHUDTXH
XQHUURUGHOHVXQDYDORUH[FHVLYDPHQWHDOWRSRU
ORTXHDEDQGRQDPRVHVWDWpFQLFD
ÔOWLPDPHQWHVHKDGHVFULWRTXHXQQXHYRUDGLRL
VyWRSRODDQH[LQD9GLDJQRVWLFDUtDHOUHFKD]RFRQXQD
ILDELOLGDGPXFKRPD\RUTXHFRQORVDQWLFXHUSRVGLUL
JLGRVFRQWUDODPLRVLQD
Resonancia magnética nuclear y
tomografía de emisión de positrones
(VWDVWpFQLFDVWDPELpQVHKDQXWLOL]DGRHQODGH
WHFFLyQGHOUHFKD]R([LVWHQHVWXGLRVTXHDSXQWDQKD
FLDVXXWLOLGDG1RREVWDQWHSRUVXVFDUDFWHUtVWLFDV\
QRGLVSRQLELOLGDGHQWRGRVORVFHQWURVVyORVHKDQYD
ORUDGRHQHVWXGLRVFRQFUHWRV\QRSDUDXQGLDJQyVWLFR
VLVWHPiWLFRGHOUHFKD]R /DUHVRQDQFLDDQDOL]DODVGLPHQVLRQHVGHODVFDYL
GDGHVYHQWULFXODUHV\HOJURVRUGHODVSDUHGHVDODYH]
TXHODIXQFLyQYHQWULFXODU/DWRPRJUDItDDSRUWDLQ
IRUPDFLyQVREUHORVFDPELRVPHWDEyOLFRVTXHDFRQWH
FHQHQHOPLRFDUGLRFRQHOUHFKD]R
Troponina, péptido atrial natriurético y
péptido cerebral natriurético
Isótopos radioactivos
&RQHOUHFKD]RVHSURGXFHQIRFRVQHFUyWLFRVGLVHPL
QDGRVSRUHOPLRFDUGLR3RUHOORUHVXOWDDWUDFWLYDODLGHD
GHXWLOL]DUDQWLFXHUSRVSUHYLDPHQWHPDUFDGRVSDUDVXGH
WHFFLyQFRQLVyWRSRVUDGLDFWLYRVGLULJLGRVFRQWUDHVDV]R
QDVQHFUyWLFDV/RVPiVXWLOL]DGRVKDQVLGRORVDQWLFXHU
SRVGLULJLGRVFRQWUDODPLRVLQDSUHYLDPHQWHPDUFDGRV
VRQ,QGLR8QDYH]ILMDGRVHQHOPLRFDUGLRVHFDOFX
ODODUHODFLyQHQWUHODFDSWDFLyQPLRFiUGLFDFRPSDUiQ
GRODFRQODFDSWDFLyQSXOPRQDUHQGHWHUPLQDGDViUHDV
&XDQGRVHSURGXFHGHVWUXFFLyQGHFpOXODVFDUGtD
FDVVHOLEHUDQDODFLUFXODFLyQGHWHUPLQDGRVSURGXFWRV
LQWUDFHOXODUHVTXHSHUPLWHQPLGLHQGRVXFRQFHQWUD
FLyQHQVDQJUHKDFHUVHXQDLGHDGHODH[WHQVLyQGHO
GDxRPLRFiUGLFR3RUHOORGHWHUPLQDGRVHVWXGLRVKDQ
GHPRVWUDGRVTXHXQDHOHYDFLyQGHODVWURSRQLQDVFDU
GtDFDVVHFRUUHODFLRQDEDVWDQWHELHQFRQHOGDxRPLR
FiUGLFRDFRQWHFLGRHQHOUHFKD]R6HKDQHVWXGLDGRWDQ
WRODWURSRQLQD7 FRPROD,\GHHQWUDGDDPEDVSDUH
FHQLJXDOPHQWH~WLOHV
80
RECHAZO AGUDO - 3RQHQFLDV
&XDQGRH[LVWHQVLWXDFLRQHVGHHVWUpVPLRFiUGLFR
HOFRUD]yQLQFUHPHQWDHQJUDQPHGLGDODSURGXFFLyQ
GHGHWHUPLQDGDVVXVWDQFLDV$VtORVSpSWLGRVDXULFX
ODU\FHUHEUDOQDWULXUpWLFRVTXHQRUPDOPHQWHHVWiQHQ
VDQJUHHQSURSRUFLRQHVPX\EDMDVVHHOHYDQPXFKR
HQVXFRQFHQWUDFLyQSODVPiWLFDHQHOFDVRGHUHFKD]R
PLRFiUGLFR$PERVSpSWLGRVVHVHJUHJDQHQORVPLR
FLWRVDXULFXODU\YHQWULFXODUSHURDVtFRPRHOSpSWLGR
DXULFXODUORKDFHVREUHWRGRHQDPEDVDXUtFXODVHOFH
UHEUDOHVVLQWHWL]DGR\OLEHUDGRIXQGDPHQWDOPHQWHSRU
ODVFpOXODVPLRFiUGLFDVYHQWULFXODUHV'LDSRVLWLYD
6HUHDOL]yXQHVWXGLRFRQGHWHUPLQDFLRQHVGH
SDFLHQWHVWUDVSODQWDGRVDQDOL]DQGRHOSpSWLGRFHUHEUDOQD
WULXUpWLFR\GLVWULEX\pQGRORVHJ~QHOJUDGRGHUHFKD]RGH
ORVSDFLHQWHV6HHQFRQWUDURQJUDQGHVGLIHUHQFLDVHQWUH
WRGRVORVJUDGRVGHUHFKD]RFRQYDORUHVWDQHYLGHQWHVFR
PRSJHQHOFDVRGHELRSVLDVLQDOWHUDFLRQHV\PiV
GHSJHQORVFDVRVFRQUHFKD]RVHYHUR'LDSRVLWL
YD1RREVWDQWHHQORVJUDGRVLQWHUPHGLRVGHUHFKD
]RQRVHHQFRQWUyVLJQLILFDFLyQHVWDGtVWLFD\DOLQWHQWDU
HQFRQWUDUXQSXQWRGHFRUWHPHGLDQWHXQDFXUYD52&VH
KDOOyTXHHOiUHDEDMRODFXUYDHUDWDQVyORGH'HWR
GDVIRUPDVHVWHIXHXQHVWXGLRLQLFLDOVREUHHOTXHWRGD
YtDVHHVWiWUDEDMDQGR\HVGHHVSHUDUTXHVHDGHXWLOLGDG
SDUDDKRUUDUELRSVLDVDORVSDFLHQWHVWUDVSODQWDGRV
Monitorización inmunológica
([LVWHQJUDQFDQWLGDGGHHOHPHQWRVTXHFXDQGR
RFXUUHXQDDFWLYDFLyQGHOVLVWHPDLQPXQHHVWiQSUH
VHQWHVRHOHYDQVXQLYHOKDELWXDO6HKDQGHVFULWRPX
FKRVDOJXQRVVyORHQH[SHULPHQWDFLyQDQLPDO\RWURV
HQKXPDQRV
$EXQGDQODVSXEOLFDFLRQHVVREUHHOORVDWULEX\HQ
GRVXHOHYDFLyQDODH[LVWHQFLDGHUHFKD]R/RVPiV
LPSRUWDQWHVSRUODFDQWLGDGGHSXEOLFDFLRQHVHQFOt
QLFDKXPDQDVRQ
/DQHRSWHULQDODSURODFWLQHPLDOD`PLFURJOR
EXOLQDODVSROLDPLQDVXULQDULDV\HOIDFWRUGHQHFURVLV
WXPRUDO
3HVHDHOORKR\HQGtDVHFRQVLGHUDTXHORVPDUFD
GRUHVLQPXQROyJLFRVQRSRVHHQODSUHFLVLyQQLUHSUR
GXFLELOLGDGQHFHVDULDVQRREVWDQWHHQPXFKRVFDVRV
HVGHELGRDOWLSRGHDQiOLVLVHPSOHDGR\HVGHHVSHUDU
TXHPHMRUHQFRQHOWLHPSR
$ PRGRGHUHVXPHQGHORVPpWRGRVDFWXDOHVSD
UDGLDJQRVWLFDUUHFKD]RVHSXHGHGHFLUTXH
/DELRSVLDVLJXHVLHQGRHOSDWUyQRUR1RREV
WDQWHVLJXHWHQLHQGRVXVOLPLWDFLRQHVPXHVWUDVQRUH
SUHVHQWDWLYDVQRLQWHUSUHWDEOHVUHFKD]RVDWtSLFRVVLQ
LQILOWUDFLyQOLQIRFLWDULD(OORKDFHGLItFLOODYDORUDFLyQ
GHORVPpWRGRVQRLQYDVLYRV
/RVPpWRGRV(&*SDUHFHQWHQHUEXHQDVHQVLEL
OLGDGDXQTXHXQDHVSHFLILFLGDGEDMD
/DHFRFDUGLRJUDItD\ODUHVRQDQFLDVRQPX\~WL
OHVSRUTXHDGHPiVGHRULHQWDUKDFLDODSRVLELOLGDGGH
UHFKD]RYDORUDQODIXQFLyQFDUGtDFD(VSHFLDOPHQWH
~WLOHQHOFDVRGHLQIHFFLyQFRQUHFKD]R
/RVUDGLRQ~FOLGRVSURSRUFLRQDQHYLGHQFLDGL
UHFWDGHGDxRFDUGtDFR1RREVWDQWHQRSRVHHQODVX
ILFLHQWHILDELOLGDGFRPRSDUDFRQYHUWLUVHHQHOSDWUyQ
RUR\DGHPiVVHH[SRQHDOSDFLHQWHDXQDUDGLDFLyQ
UHSHWLGD
/RVPDUFDGRUHVLQPXQROyJLFRVQRSRVHHQDFWXDO
PHQWHODSUHFLVLyQQLUHSURGXFLELOLGDGQHFHVDULDV1R
REVWDQWHHQPXFKRVFDVRVHVGHELGRDOWLSRGHDQiOLVLV
HPSOHDGR\HVGHHVSHUDUTXHPHMRUHQFRQHOWLHPSR
TIPOS DE TRATAMIENTO
/RVIiUPDFRVTXHVHXWLOL]DQHQHOWUDWDPLHQWRGHO
UHFKD]RORVSRGHPRVDJUXSDUHQIiUPDFRVXWLOL]DGRV
HQODLQGXFFLyQDQWLFXHUSRVDQWLOLQIRFLWDULRVPRQR\
SROLFORQDOHVIiUPDFRVXWLOL]DGRVHQHOPDQWHQLPLHQWR
FRUWLFRVWHURLGHVFLFORVSRULQDWDFUROLPXVUDSDPLFL
QDD]DWLRSULQD\PLFRIHQRODWRPRIHWLO\IiUPDFRV
XWLOL]DGRVFXDQGRDFRQWHFHHOUHFKD]RFRUWLFRVWHURL
GHV+D\TXHWHQHUHQFXHQWDTXHHQHOFDVRGHUH
FKD]RVLIUDFDVDODWHUDSLDFRQYHQFLRQDOVHVXHOHQ
XWLOL]DUORVRWURVFRPRWHUDSLDGHUHVFDWHRPHGLGDV
DOWHUQDWLYDVLUUDGLDFLyQOLQIRLGHWRWDOIRWRIRUHVLV
PHWRWUH[DWR([FHSWRORVFRUWLFRLGHVORVLQPXQR
VXSUHVRUHVKDELWXDOHVQRVRQPX\HILFDFHVSDUDHOUH
FKD]RYDVFXODUDQWHODSUHVHQFLDGHpVWHVHXWLOL]DQ
RWUDVPHGLGDV\RWURVIiUPDFRVSODVPDIpUHVLVFL
FORIRVIDPLGD
Anticuerpos policlonales
6HSURGXFHQWUDVODLQPXQL]DFLyQGHDQLPDOHVFRQ
FpOXODVKXPDQDV/RVPiVIUHFXHQWHVVRQORVTXHVH
REWLHQHQGHFDEDOOR\GHFRQHMR(VWRVDQLPDOHVSUR
GXFHQGLIHUHQWHVDQWLFXHUSRVFRQWUDODVSURWHtQDVH[
WUDxDVTXHVHH[SUHVDQHQODVXSHUILFLHGHODFpOXODKX
81
PDQD'HWRGRVHVWRVDQWLFXHUSRVVyORXQDSHTXHxD
SRUFLyQEORTXHDODIXQFLyQGHORVOLQIRFLWRV7
Anticuerpos monoclonales
(VWRVDQWLFXHUSRVWLHQHQXQDPD\RUHVSHFLILFLGDG
3DUDVXIRUPDFLyQHVQHFHVDULDODDGPLQLVWUDFLyQGHO
DQWtJHQRTXHGHVHDPRVQHXWUDOL]DUDUDWRQHVORVFXD
OHVSURGXFHQXQDOtQHDGHOLQIRFLWRV%HVSHFtILFRVFRQ
WUDHVHDQWtJHQR/DSRVWHULRULQFXEDFLyQGHHVWDVFp
OXODVFRQFpOXODVGHPLHORPDIRUPDQXQKLEULGRPDTXH
XQDYH]FXOWLYDGRVLQYLWURQRVSHUPLWHQREWHQHUDQ
WLFXHUSRVLGpQWLFRV\HVSHFtILFRVSDUDHODQWtJHQRDG
PLQLVWUDGR
(ODQWLFXHUSRPRQRFORQDOPiVXWLOL]DGRHQFOtQLFD
HVHO2.7TXHHVWiGLULJLGRFRQWUDODSRUFLyQFRQV
WDQWH &' GHO OLQIRFLWR 7 TXH HV UHVSRQVDEOH GH
GHVHQFDGHQDUHOUHFKD]RGHOLQMHUWR
(OIXWXURHQHVWHFDPSRHVWiHQHOGHVDUUROORGHQXH
YRVDQWLFXHUSRVPRQRFORQDOHVKXPDQL]DGRVTXH\DHV
WiQDSXQWRSDUDVXDSOLFDFLyQFOtQLFDHQHO7&EDVLOL
[LPDEGDFOL]XPDE8QDGHODVYHQWDMDVGHVXXWLOL]D
FLyQVHUtDODPHQRULQFLGHQFLDGHHIHFWRVVHFXQGDULRV
FRPRHOVtQGURPHOLEHUDFLyQGHFLWRFLQDVSURGXFLGRSRU
HO2.7XQDPD\RUVHPLYLGD\XQDPHQRUUHVSXHVWD
GHSURGXFFLyQGHDQWLFXHUSRVFRQWUDHOPRQRFORQDO
Corticosteroides
,QKLEHQODVHFUHFLyQGH,/H,/SRUSDUWHGHORV
PRQRFLWRV\DVtVHSUHYLHQHODOLEHUDFLyQGH,/SRU
SDUWHGHORVOLQIRFLWRV7/RVFRUWLFRLGHVKDQVLGRVLHP
SUHXQLQPXQRVXSUHVRUEiVLFRHQFXDOTXLHUUpJLPHQ
LQPXQRVXSUHVRU1RREVWDQWHSRVHHQXQDPRUELOLGDG
LPSRUWDQWHFRQDEXQGDQWHVHIHFWRVVHFXQGDULRVKL
SHUOLSLGHPLDKLSHUJOXFHPLDRVWHRSRURVLVFDWDUDWDV
UHWUDVRGHOFUHFLPLHQWRHQORVQLxRV«
Ciclosporina
(VXQXQGHFDSpSWLGRI~QJLFRTXHLQKLEHODDFWLYD
FLyQGHORVOLQIRFLWRV7 PHGLDQWHHOEORTXHRGHODVtQ
WHVLV\OLEHUDFLyQGH,/1RSURGXFHDOWHUDFLyQGHOD
IXQFLyQIDJRFLWDULDQLGHODKHPDWRSR\HVLV
/DFLFORVSRULQDMXQWRDVXSRWHQWHHIHFWRLQPXQR
VXSUHVRUSUHVHQWDWDPELpQLPSRUWDQWHVHIHFWRVVHFXQ
GDULRVFRPRQHIURWR[LFLGDGKLSHUWHQVLyQDUWHULDOQHX
URWR[LFLGDGSDUHVWHVLDVWHPEORUHVVRPQROHQFLDHV
WXSRU\FRPDKLSHUWULFRVLVKLSHUSODVLDJLQJLYDOKL
SHUXULFHPLDKLSRPDJQHVHPLDHKLSHUSRWDVHPLD
/DQXHYDIyUPXODHQPLFURHPXOVLyQGHODFLFORV
SRULQD$ODIRUPDQHRUDOKDPHMRUDGRFRQVLGHUDEOH
PHQWHODDEVRUFLyQ(OORKDFRQWULEXLGRDXQDPHQRU
YDULDELOLGDGHQWUHGRVLVXQDPD\RUFRQFHQWUDFLyQPi
[LPDHQPHQRUWLHPSR\ILQDOPHQWHXQDPD\RUH[
SRVLFLyQDOIiUPDFRDODXPHQWDUHOiUHDEDMRODFXUYD
Tacrolimus
(VXQPDFUyOLGRREWHQLGRGHXQKRQJRGHOVXHOR
6XDFFLyQUDGLFDHQLQKLELUODVHFUHFLyQGH,/GHO
LQWHUIHUyQJDPPDGHOIDFWRUQHFURVLVWXPRUDO\HQOD
H[SUHVLyQGHORVUHFHSWRUHVGH,/(OWDFUROLPXVVH
PHWDEROL]DSRUHOFLWRFURPR3SRUORTXHSUHVHQ
WDPXFKDVLQWHUDFFLRQHVPHGLFDPHQWRVDV/RVHIHFWRV
VHFXQGDULRVPiVIUHFXHQWHVVRQODQHIURWR[LFLGDGOD
QHXURWR[LFLGDG\ODKLSHUJOXFHPLD5HVSHFWRDODFL
FORVSRULQDSURGXFHPHQRV+7$GLVOLSHPLDRKLSHU
SODVLDJLQJLYDO
Rapamicina
0DFUyOLGRVLPLODUDOWDFUROLPXV$ GLIHUHQFLDGHpV
WH\GHODFLFORVSRULQDQRUHGXFHODSURGXFFLyQGH,/
GHOUHFHSWRUVLQRTXHPiVELHQSDUHFHUHGXFLUODUHV
SXHVWDGHORVOLQIRFLWRVDODVFLWRFLQDVLQKLELHQGRLJXDO
PHQWHODSUROLIHUDFLyQ\ODGLIHUHQFLDFLyQGHORVOLQIR
FLWRV7([LVWHQHVWXGLRVSURPHWHGRUHVVREUHVXXVRHQ
WUDVSODQWHFDUGtDFRSHURWRGDYtDSUHVHQWDXQDLPSRU
WDQWHWR[LFLGDG
Azatioprina
(VXQDQiORJRGHODVSXULQDVHLQKLEHODVtQWHVLVGH
iFLGRVQXFOHLFRVHYLWDQGRODSUROLIHUDFLyQGHFORQHV
FHOXODUHV(VXQDJHQWHSRFRHVSHFtILFR\FRQSRWHQWHV
HIHFWRVPLHORGHSUHVRUHV
Micofenolato mofetil
(VXQQXHYRDJHQWHTXHKDPRVWUDGRFODURVEHQHIL
FLRVDQLYHOH[SHULPHQWDO\HQFOtQLFDKXPDQD(VWHIiU
PDFRHMHUFHVXHIHFWRLQPXQRVXSUHVRUDWUDYpVGHVX
SRUFLyQDFWLYDHOiFLGRPLFRIHQyOLFRTXHHVXQLQKLEL
82
RECHAZO AGUDO - 3RQHQFLDV
GRUSRWHQWH\HVSHFtILFRGHODYtDGH QRYR GHODVtQWHVLV
GHODVSXULQDVHYLWDQGRODSUROLIHUDFLyQGHORVOLQIRFL
WRV7 \%/RVSULPHURVHVWXGLRVHQWUDVSODQWHFDUGtDFR
PRVWUDURQODHILFDFLDGHHVWDVXVWDQFLDWDQWRSRUTXHHYL
WDODSURJUHVLyQGHOUHFKD]RDJXGRFRPRSRUVXXWLOLGDG
HQORVFDVRVGHUHFKD]RUHIUDFWDULRRSHUVLVWHQWH
TRATAMIENTO DEL RECHAZO
/DPHMRUtDGHODVXSHUYLYHQFLDHQHOWUDVSODQWHGHXQ
yUJDQRVyOLGRVHGHEHHQJUDQSDUWHDXQPHQRUWUDWD
PLHQWRGHORVHSLVRGLRVGHUHFKD]RJUDFLDVDORVQXH
YRVDJHQWHVTXHSUHVHQWDQXQDPD\RUHILFDFLD\PHQRV
HIHFWRVDGYHUVRV(VWHSXQWRHVPX\LPSRUWDQWHSRUTXH
WDUGHRWHPSUDQRVHGHEHSDJDUXQSUHFLRSRUODDGPL
QLVWUDFLyQGHIiUPDFRVDQWLUUHFKD]RDGHPiVGHOFRQVL
JXLHQWHDXPHQWRGHODFDUJDLQPXQRVXSUHVRUDWRWDO
5HFKD]ROLJHURJUDGRV$ \%VHWUDWDUtDDMXV
WDQGRODVGRVLVGHODWHUDSLDGHPDQWHQLPLHQWR
5HFKD]RPRGHUDGRIRFDOJUDGRVXWUDWDPLHQ
WRHVFRQWURYHUWLGRSHURVHVXHOHDFWXDUFRPRHQ
HOJUDGROLJHUR
5HFKD]RPRGHUDGR$HQODDFWXDOLGDGHOWUD
WDPLHQWRPiVKDELWXDOGXUDQWHORVSULPHURVPH
VHVSRVW7&GHORVHSLVRGLRVGHUHFKD]RVRQODV
GRVLVHOHYDGDVGHPHWLOSUHGQLVRORQDLY
PJGtDGXUDQWHGtDVTXHVRQHIHFWLYDVHQPiV
GHOGHORVUHFKD]RV3DVDGRVORVWUHVSULPH
URVPHVHVVHVXHOHQDGPLQLVWUDUFRUWLFRGHVSRUYtD
RUDOSUHGQLVRQDRGHIOD]DFRUWyPJNJGtD
GXUDQWHGtDVFRQGHVFHQVRSURJUHVLYRSRVWHULRU
(QFDVRVJUDYHVGHUHFKD]R$ FRQFRPSURPLVR
KHPRGLQiPLFR%\HOWUDWDPLHQWRVXHOHFRQVLVWLU
HQGRVLVHOHYDGDVGHHVWHURLGHVMXQWRDWHUDSLDFLWROtWL
FDFRQDQWLFXHUSRVPRQRFORQDOHVRSROLFORQDOHV
(OUHFKD]RKXPRUDOHVXQFXDGURFOtQLFRPX\JUDYH
TXHVXHOHDFRPSDxDUVHGHFRPSURPLVRKHPRGLQiPLFR\
GHGLVIXQFLyQGHOLQMHUWR6XWUDWDPLHQWRFRQVLVWHHQGR
VLVDOWDVGHHVWHURLGHVSODVPDIpUHVLV\RFLFORIRVIDPLGD
&XDQGRHOUHFKD]RHVFRUWLFRUUHVLVWHQWHVHKDGHUH
FXUULUDRWUDVWHUDSpXWLFDVOODPDGDVGHUHVFDWHTXHLQ
FOX\HQDQWLFXHUSRVDQWLOLQIRFLWDULRVFDPELRVUDGLFDOHV
GHORVLQPXQRVXSUHVRUHVKDELWXDOHVLUUDGLDFLyQOLQIRL
GHWRWDOIRWRIRUHVLVPHWRWUH[DWRHLQFOXVRHOUHWUDVSODQWH
BIBLIOGRAFÍA
$OPHQDU%RQHW/5HJLVWUR(VSDxROGH7UDVSODQWH&DUGtDFR;,Q
IRUPH2ILFLDO5HY(VS&DUGLRO
&DUSHQWHU&%0HFKDQLVPVRIUHMHFWLRQ&XUUHQW2SLQLRQLQ2U
JDQ7UDQVSODQWDWLRQ
.UHQVN\$07KHUROHRIWKH5$17(6FKHPRNLQHLQWUDQVSODQWUH
MHFWLRQ&XUUHQW2SLQLRQLQ2UJDQ7UDQVSODQWDWLRQ
.LP<6/L;&0DVOLQVNL:=KHQJ;;5R\&KDXGKXU\33D
YODNLV0HWDO7KHUROHRIQRYHO7FHOOJURZWKIDFWRUVLQUHMHF
WLRQ&XUUHQW2SLQLRQLQ2UJDQ7UDQVSODQWDWLRQ
%LOOLQJKDP0&DU\1+DPPRQG(.HPQLW]-0DUERH&0F&D
OOLVWHU+$ HWDO$ ZRUNLQJIRUPXODWLRQIRUWKHVWDQGDUL]DWLRQRI
QRPHQFODWXUHLQWKHGLDJQRVLVRIKHDUWDQGOXQJUHMHFWLRQKHDUW
UHMHFWLRQVWXG\JURXS-+HDUW7UDQVSODQW
&DUULHU01RQLQYDVLYHDVVHVVPHQWRIFDUGLDFWUDQVSODQWUH
MHFWLRQ$ FULWLFDOORRNDWWKHDSSURDFKWRDFXWHUHMHFWLRQ&DQ
-6XUJ
,EHUHU77+XWWHQ*6$QDO\VLVRIWKHYHQWULFXODUHYRNHGUHV
SRQVHIRUXVHLQFDUGLDFWUDQVSODQWPRQLWRULQJ3URJUHVVLQ%LR
PHGLFDO5HVHDUFK6SULQJ*HUPDQ\S
+VX'76SRWQLW]+0(FKRFDUGLRJUDSKLFGLDJQRVLVRIFDUGLDF
DOORJUDIWUHMHFWLRQ3URJ&DUGLRYDVF'LV
'RGG'$%UDG\/'&DUGHQ.$3DWWHUQRIHFKRFDUGLRJUDSKLF
DEQRUPDOLWLHVZLWKDFXWHFDUGLDFDOORJUDIWUHMHFWLRQLQDGXOWV
&RUUHODWLRQZLWKHQGRP\RFDUGLDOELRSV\-+HDUW/XQJ7UDQV
SODQW
&LOLEHUWR*50DVFDUHOOR0*URQGD($FXWHUHMHFWLRQDIWHU
KHDUWWUDQVSODQWDWLRQ1RQLQYDVLYHHFKRFDUGLRJUDSKLFHYD
OXDWLRQ-$P&ROO&DUGLRO
'tH]-/$OPHQDU/6DOYDGRU$0LUy9&KLULYHOOD0&HER
OOD5HWDO8WLOLGDGGHOWLHPSRGHUHODMDFLyQLVRYROXPpWULFDGH
DPERVYHQWUtFXORVHQODGHWHFFLyQGHUHFKD]RDJXGRGHOSDFLHQWH
WUDVSODQWDGRFDUGtDFR5HY(VS&DUGLRO
$OPHQDU/2VD$0LUy9$UQDX0$'LFHQWD)0DUWtQH]
'RO]/ HWDO8WLOLW\2I$FRXVWLF'HQVLWRPHWU\,Q*UDIW5HMHF
WLRQ'LDJQRVLV,Q+HDUW7UDQVSODQWDWLRQ7UDQVSODQWDWLRQSUR
FHHGLQJV
%HOOR$UTXHV3$OPHQDU%RQHW/0DUWt9LGDO-)3pUH]9HODV
FR5/ySH]$]QDU'0DWHR1DYDUUR$ HWDO9DORUDFLyQGHOD
83
FDSWDFLyQGHORVDQWLFXHUSRVPRQFORQDOHVDQWLPLRVLQD$0$
HQHOGLDJQyVWLFRGHUHFKD]RHQHOWUDVSODQWHFDUGtDFR5HY(VS
0HG1XFO
%ODQNHQEHUJ)*6WUDXVV+:1RQLQYDVLYHGLDJQRVLVRIDFX
WHKHDUWRUOXQJWUDQVSODQWUHMHFWLRQXVLQJUDGLRODEHOHGDQQH
[LQ93HGLDWU5DGLRO
0RXVVHDX[()DUJH'*XLOOHXUDLQ$VVHVVLQJKXUQDQFDU
GLDFDOORJUDIWUHMHFWLRQXVLQJ05,ZLWK*G'27$-&RPSXW
$VVLVW7RPRJU
+RII6-6WHZDUW-5)ULVW:+1RQLQYDVLYHGHWHFWLRQRIKHDUW
WUDQVSODQWUHMHFWLRQZLWKSRVLWURQHPLVVLRQVFLQWLJUDSK\$QQ
7KRUDF6XUJ
%XFNOH\0*<DFRXE0+6LQJHU'5,QYHVWLJDWLRQRIWKHSODV
PDFRQFHQWUDWLRQVDQGFLUFXODWLQJIRUPVRI%13 DQG$13 LQ
RUWKRWRSLFFDUGLDFWUDQVSODQWUHFLSLHQWV-+XP+\SHUWHQV
&DFD.6FKXEHO&.URPEDFK).HPNHV%0+DPPHU&
'1$ DQDO\VLVRIFLUFXODWLQJEORRGPRQRQXFOHDUFHOOVIRUGLDJ
QRVLVRIUHMHFWLRQLQKHDUWWUDQVSODQWSDWLHQWV7UDQVSODQW3URF
0RODMRQL(5&LQWL3%DFKHWRQL$6DOOXVWR)&DULFDWR0
0DQFLQL&HWDOOPPXQRORJLFDOGLDJQRVLVRIUHMHFWLRQLQKHDUW
WUDQVSODQWUHFLSLHQWV%LEO&DUGLRO
9DQ*HOGHU7.QRRS&-+HVVH&-9DHVVHQ/0%DON$+
<]HUPDQV-1HWDO3HULSKHUDOEORRGPRQLWRULQJGXULQJDQGDI
WHUUHMHFWLRQSURSK\OD[LVZLWKDPRQRFORQDODQWLLQWHUOHXNLQ
UHFHSWRUDQWLERG\LQNLGQH\DQGKHDUWWUDQVSODQWUHFLSLHQWV
7UDQVSODQW3URF
9DHVVHQ/0%DDQ&&'DDQH&5/RRQHQ(+%DON$+-XW
WH1+HWDO,PPXQRORJLFDOPRQLWRULQJLQSHULSKHUDOEORRGDI
WHUKHDUWWUDQVSODQWDWLRQIUHTXHQFLHVRI7KHOSHUFHOOVDQGSUH
FXUVRUVRIF\WRWR[LF7 FHOOVZLWKKLJKDYLGLW\IRUGRQRUDQWLJHQV
FRUUHODWHZLWKUHMHFWLRQ7UDQVSODQW3URF
+LVDQDJD0+XQGULHVHU-8WKRII.:DKOHUV73LFKOPD\U5
6FKOLWW+-*UDIWIXQFWLRQDQGUHMHFWLRQSDWWHUQVLQKHDUWWUDQV
SODQWHGSDWLHQWVZLWKDQGZLWKRXWV\VWHPLFPLFURFKLPHULVP
7UDQVSODQW3URF
.LPEDOO35DGRYDQFHYLF%,VRP7)UD]LHU%.HUPDQ5&\WR
NLQHSDQHOSUHGLFWVHDUO\UHMHFWLRQDQGWKHUDSHXWLFUHVSRQVHDI
WHUFDUGLDFWUDQVSODQWDWLRQ7UDQVSODQW3URF
84
RECHAZO AGUDO - 3UHVHQWDFLyQ
3UHVHQWDFLyQ
/XLV$OPHQDU%RQHW
'LDSRVLWLYD
'LDSRVLWLYD
6HDSUHFLDHOIRUPLGDEOHHMpUFLWRTXHDSDUHFHWUDVHOWUDV
SODQWHGLVSXHVWRDGHVWUXLUHOFRUD]yQVLVWHPDLQPXQL
WDULR\ODFRQWUDRIHQVLYDTXHQRVRWURVODQ]DPRVVREUH
HOORVSDUDDWHQXDUVXSRWHQFLDLQPXQRVXSUHVRUHV
'HEHH[LVWLUXQHTXLOLEULRHQWUHHOVLVWHPDLQPXQLWDULR\
ORVLQPXQRVXSUHVRUHVDGPLQLVWUDGRV(QFDVRGHH[FHVR
GHDFWLYLGDGGHHVWRVVHIDYRUHFHODLQIHFFLyQHQHOFDVR
FRQWUDULRHOUHFKD]RGHOLQMHUWR
85
'LDSRVLWLYD
'LDSRVLWLYD
5HJLVWUR(VSDxROGH7UDVSODQWH&DUGtDFR6HDSUHFLDOD
HOHYDGDLQFLGHQFLDGHUHFKD]RFRPRFDXVDGHPRUWDOLGDG
\ODVLJQLILFDWLYDDVRFLDFLyQDIDOOHFLPLHQWR
5HJLVWUR(VSDxROGH7UDVSODQWH&DUGtDFR2UGHQDGDVLQ
FLGHQFLDGHLQIHFFLyQDEFLVDVQ~PHURGHUHFKD]RV6H
DSUHFLDFRPRHOQ~PHURGHUHFKD]RVHVGLUHFWDPHQWHSUR
SRUFLRQDODODLQFLGHQFLDGHLQIHFFLRQHV3UiFWLFDPHQWH
VyORURPSHQODQRUPDORVUHFHSWRUHVFRQUHFKD]RV1R
REVWDQWHHOQ~PHURGHSDFLHQWHVFRQyUHFKD]RVHV
PX\EDMR\SDFLHQWHVUHVSHFWLYDPHQWH
'LDSRVLWLYD
'LDSRVLWLYD
5HJLVWUR(VSDxROGH7UDVSODQWH&DUGtDFR2UGHQDGDV
SUREDELOLGDGGHVXSHUYLYHQFLDDEFLVDVDxRVGHVGHHO
WUDVSODQWH6HDSUHFLDFRPRODVXSHUYLYHQFLDDFWXDULDO
WLHQGHDGLVPLQXLUDPHGLGDTXHHOQ~PHURGHUHFKD]RV
DXPHQWD
,]TXLHUGD/DELRSVLDVXHOHUHDOL]DUVHSRUYtD\XJXODUGH
UHFKD6HH[WUDHQIUDJPHQWRVGHPPGHOWDELTXH
LQWHUYHQWULFXODUHQHODSH[GHOYHQWUtFXORGHUHFKRVHHV
FRJHHVWD]RQDSRUTXHHVODTXHHPEULROyJLFDPHQWHPiV
VHSDUHFHDOYHQWUtFXORL]TXLHUGR'HUHFKD/RVIUDJ
PHQWRVVHILMDQ\WLxHQFRQKHPDWR[LOLQDHRVLQD\WULFUy
PLFRGH0DVVRQ&RQHVWH~OWLPRVHDSUHFLDHVSHFLDO
PHQWHELHQODH[LVWHQWFLDGHILEURVLVLQWHUVWLFLDO
86
RECHAZO AGUDO - 3UHVHQWDFLyQ
'LDSRVLWLYD
'LDSRVLWLYD
,]TXLHUGD*UDGRVGHUHFKD]RGHOD6RFLHGDG,QWHUQDFLR
QDOGH7UDVSODQWH&DUGtDFR\3XOPRQDU,6+/76$VLQ
DOWHUDFLRQHV'HUHFKD0XHVWUDVELySVLFDVFRQGLVWLQWRV
JUDGRVGHUHFKD]RL]TXLHUGDVLQDOWHUDFLRQHVOLJHURHGH
PDLQWHUVWLFLDOGHUHFKD$ YDULRVIRFRVGHQHFURVLVFRQ
LQILOWUDGRPXOWLIRFDOLQIODPDWRULR
,]TXLHUGD4XLVWHGHWR[RSODVPDWHxLGRFRQLQPXQRSHUR
[LGDVD&HQWUR,QFOXVLRQHVSRUFLWRPHJDORYLUXVHQORV
Q~FOHRVGHYDULRVPLRFLWRV'HUHFKD$ PD\RUDXPHQWR
VHREVHUYDXQD]RQDPiVRVFXUDGHOQ~FOHRFHOXODUGHEL
GDDODLQFOXVLyQGHOFLWRPHJDORYLUXV\GRV]RQDVPiVRV
FXUDVGHOFLWRSODVPDRFDVLRQDGDVSRULQFOXVLRQHVGHOYL
UXVDHVWHQLYHO
'LDSRVLWLYD
'LDSRVLWLYD
(&*GHXQSDFLHQWHFRQUHFKD]R6HDSUHFLDXQDUHGXF
FLyQGHOYROWDMHGHOFXDQGRDFRQWHFHHOUHFKD]R\
XQDUHFXSHUDFLyQGHOYROWDMHDORVGtDVGHOWUDWDPLHQ
WRFRQERORVGHPHWLOSUHGQLVRORQD
(OHFWURJUDPDLQWUDPLRFiUGLFRHQODGHWHFFLyQGHOUHFKD]R
1RWRGRVORVPRGHORVGHPDUFDSDVRVDFWXDOHVVRQFDSD
FHVGHUHJLVWUDUORVHOHFWURJUDPDV(OPRGHORGHODGLD
SRVLWLYDVtORKDFH1XHVWURJUXSRKDXWLOL]DGRHVWHVLVWH
PDHQGRVSDFLHQWHVXQRFRQHQIHUPHGDGGHOVHQR\RWUR
FRQEORTXHRDXUtFXORYHQWULFXODU
87
'LDSRVLWLYD
'LDSRVLWLYD
$XPHQWRGHOYROWDMHHOHFWURFDUGLRJUiILFRWUDVHOWUDWD
PLHQWRGHOUHFKD]R/DYDULDFLyQHVSHTXHxDSHURVLJQL
ILFDWLYDGHVGHHOSXQWRGHYLVWDHVWDGtVWLFR
(VWXGLRHFRFDUGLRJUiILFR'RSSOHUGHXQSDFLHQWHWUDV
SODQWDGRFDUGtDFR(OHVWXGLRGHOSDWUyQGHOOHQDGRPL
WUDOGHEHUHDOL]DUVHFXDQGRODRQGDSGHOUHFHSWRUHVWi
HQDOJ~QOXJDUHQWUHWHOHGLiVWROH\PHVRVtVWROH(QODGLD
SRVLWLYDVHDSUHFLDFRPRVHPRGLILFDODYHORFLGDGPi[L
PDGHODVRQGDV(\$ DOHVWDUODRQGDSGHOUHFHSWRUHQ
PHVRGLiVWROH\SURWRGLiVWROHDVWHULVFRV
'LDSRVLWLYD
'LDSRVLWLYD
(VWXGLRHFRFDUGLRJUiILFR'RSSOHUGHXQSDFLHQWHWUDV
SODQWDGRFDUGtDFR3ODQRSDUDHVWHUQDOORQJLWXGLQDO6H
SXHGHDSUHFLDUXQGHUUDPHSHULFiUGLFRTXHIXHGHDSD
ULFLyQV~ELWD\VHDVRFLyDXQUHFKD]RGHJUDGR$7DP
ELpQVHREVHUYDXQDDFHOHUDFLyQGHOIOXMRDQLYHOGHODV
VXWXUDVHQDXUtFXODL]TXLHUGD$,DXUtFXODL]TXLHUGD$2
UDt]DyUWLFD'3GHUUDPHSHULFiUGLFR9'YHQWUtFXOR
GHUHFKR9,YHQWUtFXORL]TXLHUGR
(VWXGLRHFRFDUGLRJUiILFR'RSSOHU&iOFXORGHOWLHPSRGH
UHODMDFLyQLVRYROXPpWULFDGHOYHQWUtFXORGHUHFKR6HPL
GHODGLVWDQFLDHQWUHHO456GHO(&*\HOILQDOGHODRQ
GDHVSHFWUDOGHOIOXMRSXOPRQDUHQXQSODQRSDUDHVWHU
QDOWUDQVYHUVDOGHJUDQGHVYDVRV$ FRQWLQXDFLyQVHRE
WLHQHODGLVWDQFLDHQWUHHO456\HOLQLFLRGHOIOXMRWULFXV
StGHRHQHOPLVPRSODQRSRVWHULRUPHQWHVHUHVWDQDP
EDVPHGLGDV(VWHPpWRGRSDUHFHPiVVHQVLEOHTXHVLVH
FDOFXODHQHOYHQWUtFXORL]TXLHUGR
88
RECHAZO AGUDO - 3UHVHQWDFLyQ
'LDSRVLWLYD
'LDSRVLWLYD
'HQVLWRPHWUtDDF~VWLFDHQODGHWHFFLyQGHOUHFKD]R,]
TXLHUGD=RQDGHLQWHUpVGHPRUIRORJtDFyQFDYDVLWXD
GDHQODSDUHGSRVWHULRUGHOYHQWUtFXORL]TXLHUGRHQXQ
SODQRSDUDHVWHUQDOWUDQVYHUVDO'HUHFKD5HJLVWURGHODV
YDULDFLRQHVGHLQWHQVLGDGGHODPXHVWUD
$QWLFXHUSRVDQWLPLRVLQDHQODGHWHFFLyQGHOUHFKD]R(O
FiOFXORGHODUHODFLyQGHFDSWDFLyQFRUD]yQSXOPyQIXH
GH(OORHVFRPSDWLEOHFRQUHFKD]R/DELRSVLDPRVWUy
XQUHFKD]RGHJUDGR$/D]RQDURMDGHPi[LPDFDSWD
FLyQFRUUHVSRQGHDOKtJDGR
'LDSRVLWLYD
'LDSRVLWLYD
$QWLFXHUSRVDQWLPLRVLQDHQODGHWHFFLyQGHOUHFKD]R&DX
VDGHIDOVRQHJDWLYR6HDSUHFLDXQEDMDUHODFLyQGHFDS
WDFLyQFRUD]yQSXOPyQGHELGRDXQLQFUHPHQWRHQODFDS
WDFLyQSXOPRQDURFDVLRQDGDSRUXQDLQIHFFLyQEURQFR
SXOPRQDU
$QWLFXHUSRVDQWLPLRVLQDHQODGHWHFFLyQGHOUHFKD]R(O
FiOFXORGHODUHODFLyQGHFDSWDFLyQFRUD]yQSXOPyQIXH
GH/DELRSVLDQRPRVWUyVLJQRVGHUHFKD]R6$VLQ
DOWHUDFLRQHV/DVGRViUHDVURMDVGHPi[LPDFDSWDFLyQ
FRUUHVSRQGHQDOKtJDGR\ED]R
89
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYDPRVWUDQGRODVHFUHFLyQGHORVSpSWLGRVQD
WULXUpWLFRVDXULFXODU\FHUHEUDO$13%13$PERVVH
VHJUHJDQHQORVPLRFLWRVDXULFXODUHV\YHQWULFXODUHV1R
REVWDQWHODVtQWHVLVGHO$13 HVPD\RUHQODVFpOXODVFDU
GtDFDVDXULFXODUHV\ODGHO%13 HQODVYHQWULFXODUHV
9DORUHVPHGLRVGHO%13 DJUXSDGRVVHJ~QHOJUDGRGH
UHFKD]R6HREVHUYDXQLQFUHPHQWRSURJUHVLYRGHOYDORU
DPHGLGDTXHHOJUDGRGHOUHFKD]RDXPHQWD1RREV
WDQWHURPSHODQRUPDHOJUDGR$(VWHKHFKROLPLWDHQ
JUDQPHGLGDHOYDORUGHO%13 \DTXHHVHOJUDGRGHUH
FKD]RTXHSUHVHQWDQFRQPiVIUHFXHQFLDORVSDFLHQWH
WUDVSODQWDGRV
90
RECHAZO AGUDO - 3RQHQFLDV
5HFKD]RDJXGRGHOLQMHUWRKHSiWLFR
0DQXHOGHOD0DWD
&RPSOHMR+RVSLWDODULR5HLQD6RItD&yUGRED
INTRODUCCIÓN
8QGHORVSDFLHQWHV
WUDVSODQWDGRVGHKtJDGRGHVDUUR
OODQXQHSLVRGLRGHUHFKD]RDJX
GRDORODUJRGHOSULPHUDxRTXHVLJXHDODLQWHUYHQ
FLyQ(VWDFRPSOLFDFLyQVHSURGXFHFRPRFRQVHFXHQ
FLDGHODUHVSXHVWDGHOVLVWHPDLQPXQHGHOUHFHSWRUKD
FLDHOLQMHUWR(QODPD\RUtDGHORVFDVRVHOUHFKD]R
DJXGRDSDUHFHGXUDQWHODVSULPHUDVVHLVVHPDQDVSRV
WUDVSODQWH6LQHPEDUJRVLELHQFRQSUREDELOLGDGGH
FUHFLHQWHHOSDFLHQWHWUDVSODQWDGRPDQWLHQHVLHPSUH
XQULHVJRFOtQLFDPHQWHVLJQLILFDWLYRGHTXHVHSURGX]
FDXQUHFKD]RDJXGRWDUGtR 'LDSRVLWLYDV\
(OUHFKD]RDJXGRSXHGHDGRSWDUGLIHUHQWHVJUDGRVGH
VHYHULGDGSHURSRUORJHQHUDOHVHVFDVDPHQWHVLQWRPiWL
FR\VyORHQORVFDVRVPX\JUDYHVFRQGXFHDODGLVIXQFLyQ
GHOLQMHUWRKHSiWLFR(OGLDJQyVWLFRGHUHFKD]RVHVRVSHFKD
SRUFDPELRVHQ]LPiWLFRVHOHYDFLyQGHWUDQVDPLQDVDVRGH
ODVHQ]LPDVGHFROHVWDVLVFRQRVLQDXPHQWRGHODELOLUUX
ELQD\GHEHFRQILUPDUVHPHGLDQWHELRSVLDKHSiWLFD
MECANISMOS
INMUNOLÓGICOS DEL
RECHAZO
(OUHFKD]RGHOLQMHUWRHVWiPHGLDGRIXQGDPHQWDO
PHQWHSRUODUHDFFLyQGHODVFpOXODV7 GHOUHFHSWRUIUHQ
WHDORVDQWtJHQRVDORJpQLFRVH[SUHVDGRVHQHOKtJDGR
WUDVSODQWDGR(OUHFRQRFLPLHQWRGHHVWRVDQWtJHQRVSR
QHHQPDUFKDODOLEHUDFLyQGHLQWHUOHXFLQD,/\
GHLQWHUOHXFLQD,/FRQODFRQVLJXLHQWHDFWLYDFLyQ
\SUROLIHUDFLyQGHFpOXODV&'\&'(QXQDFRP
SOHMDUHGGHLQWHUDFFLRQHVVHSURGXFHQXQDJUDQYDULH
GDGGHFLWRFLQDVTXHHVWLPXODQHOUHFOXWDPLHQWRGHOLQ
IRFLWRVKDFLDHOHVSDFLRSRUWD\PRGXODQODH[SUHVLyQ
GHPROpFXODVGHDGKHUHQFLD1RVHFRQRFHELHQODLQ
IOXHQFLDGHHVWDVFLWRFLQDVHQHOSURFHVRGHUHFKD]R
$OJXQDVGHHOODVFRPRHOIDFWRUGHQHFURVLVWXPRUDO
SRGUtDQUHODFLRQDUVHGHPRGRHVSHFLDOFRQODDSDULFLyQ
GHUHFKD]RDFX\RGLDJQyVWLFRSRGUtDQFRQWULEXLU (QHOUHFKD]RKLSHUDJXGRH[WUHPDGDPHQWHLQIUHFXHQWH
HQHOWUDVSODQWHGHKtJDGRLQWHUYLHQHQDQWLFXHUSRVFR
PRPHGLDGRUHVDWUDYpVGHVXDFFLyQIUHQWHDORVDQ
WtJHQRVGHORFDOL]DFLyQSUHIHUHQWHPHQWHHQGRWHOLDO
(QGLIHUHQWHJUDGRVHJ~QODIDVHHYROXWLYDHVSRVLEOH
LGHQWLILFDUOLQIRFLWRV7PD\RULWDULDPHQWH&'HQHOLQ
ILOWUDGRSRUWDOURGHDQGRDPHQXGRDORVFRQGXFWLOORVEL
OLDUHV(QORVKHSDWRFLWRVQRUPDOHVODH[SUHVLyQGHPROp
FXODVGH+/$ GHFODVH,HVHVFDVD\ODGHFODVH,,QXOD(Q
HOFRQGXFWLOORELOLDUVtVHH[SUHVDQPROpFXODVGHFODVH,
SHURQRGHFODVH,,'XUDQWHORVIHQyPHQRVGHUHFKD]RVH
LQFUHPHQWDODH[SUHVLyQGHDQWtJHQRVGHFODVH,\,,HQWR
GDVODVFpOXODVVLHQGRHQPD\RULQWHQVLGDGHQODVFpOXODV
HQGRWHOLDOHV\GHOHSLWHOLRELOLDU1RKD\HYLGHQFLDVFODUDV
GHTXHHOJUDGRGHFRPSDWLELOLGDG+/$ VHDGHWHUPLQDQ
WHHQODSUHYDOHQFLDGHUHFKD]RFHOXODU 'LDSRVLWLYD
ANATOMÍA PATOLÓGICA
/DELRSVLDKHSiWLFDHVHOPpWRGRPiVILDEOHSDUDHOGLDJ
QyVWLFRGHUHFKD]RDJXGR(QVXGHWHFFLyQVHKDSRGL
GRFRPSUREDUTXHODYDULDELOLGDGLQWHUREVHUYDGRUHVHVFD
VD/DVOHVLRQHVKLVWROyJLFDVGHOUHFKD]RVHFRQFHQWUDQ
91
TABLA I
GRADO DE SEVERIDAD DEL RECHAZO AGUDO
Grado I (leve):
• Infiltrado inflamatorio leve en algunos espacios porta
Grado II (moderado):
• Infiltrado inflamatorio en la mayoría o todos los espacios porta
Grado III (grave):
• Grado II, con extensión periportal, inflamación perivenular y necrosis central
HQORVHVSDFLRVSRUWDHQORVTXHVHGLVWLQJXHXQLQILOWUDGR
LQIODPDWRULRPL[WRFRQOLQIRFLWRVSROLPRUIRQXFOHDUHV\
HRVLQyILORVDOTXHVHDVRFLDHQGRWHOLWLV\DOWHUDFLRQHVGH
ORVFRQGXFWLOORVELOLDUHV(VWRVDSDUHFHQGHVHVWUXFWXUDGRV
HQJUDGRYDULDEOH\FRQLQILOWUDFLyQOLQIRFtWLFDHQHOHSLWH
OLR1RVXHOHQREVHUYDUVHDOWHUDFLRQHVHQHOOREXOLOORKH
SiWLFRVDOYRHQORVFDVRVJUDYHVHQORVTXHVHGHVDUUROODQ
FDPELRVLVTXpPLFRVHQOD]RQDFHQWUROREXODU 'LDSRVL
WLYDV\(QHVWRVFDVRVJUDYHVSXHGHQDVRFLDUVHOH
VLRQHVGHDUWHULWLVSHURHVGLItFLOLGHQWLILFDUODVHQODELRS
VLDKHSiWLFD\DTXHORVYDVRVPiVDIHFWDGRVVHVLW~DQHQOD
SUR[LPLGDGGHOKLOLRKHSiWLFR
6HKDHVWDEOHFLGRXQDFODVLILFDFLyQGHODJUDYHGDG
GHOUHFKD]RHQWUHVJUDGRVVHJ~QODLQWHQVLGDGGHODLQ
IODPDFLyQSRUWDO\GHODQHFURVLVFHQWUROREXOLOODU7D
EOD,'LDSRVLWLYD/DVOHVLRQHVTXHDSDUHFHQGX
UDQWHXQUHFKD]RDJXGRVRQSRWHQFLDOPHQWHUHYHUVLEOHV
SHURHQRFDVLRQHVVHPDQWLHQHQ\GHWHUPLQDQXQDIRU
PDGHUHFKD]RLQWHUPHGLDTXHSXHGHHYROXFLRQDUKDFLD
ODVIRUPDVFUyQLFDVGHUHFKD]R'LDSRVLWLYD(QORV
~OWLPRVDxRVVHKDQSXEOLFDGRGRFXPHQWRVGHFRQVHQ
VRSDUDKRPRJHQHL]DUODWHUPLQRORJtDODJUDYHGDG\ODV
GHVFULSFLRQHVGHODVGLVWLQWDVYDULHGDGHVGHUHFKD]R
'LDSRVLWLYD/DUHYHUVLELOLGDGGHOUHFKD]RVHKD
FHPHQRVSUREDEOHDPHGLGDTXHGHVDSDUHFHHOFRPSR
QHQWHFHOXODU\SUHGRPLQDHOGHILEURVLV\FROHVWDVLV
FACTORES DE RIESGO DE
RECHAZO
6HKDGHVFULWRXQDPD\RUSUREDELOLGDGGHUHFKD]R
DJXGRHQORVSDFLHQWHVMyYHQHVTXHOOHJDQDOWUDVSODQ
WHVLQLQVXILFLHQFLDUHQDO\HQDTXHOORVTXHUHFLEHQyU
JDQRVGHGRQDQWHVGHPiVGHDxRVRFRQWLHPSRVGH
LVTXHPLDSURORQJDGRV 'LDSRVLWLYD7DPELpQSD
UHFHGHWHUPLQDUODSUREDELOLGDGGHUHFKD]RODHQIHU
TABLA II
RIESGO DE RECHAZO SEGÚN LA ENFERMEDAD PRETRASPLANTE
Aumentan el riesgo:
• Hepatitis fulminante
• Hepatitis autoinmune
• Colangitis esclerosante primaria
Disminuyen el riesgo:
• Cirrosis alcohólica
• Cirrosis por virus B
92
RECHAZO AGUDO - 3RQHQFLDV
PHGDGSUHWUDVSODQWH7DEOD,,'LDSRVLWLYD/RV
SDFLHQWHVFRQFLUURVLVDOFRKyOLFDRFRQFLUURVLVSRUYL
UXV%WLHQHQXQDWDVDPHQRUGHHVWDFRPSOLFDFLyQ 3RUHOFRQWUDULRORVSDFLHQWHVFRQKHSDWLWLVIXOPLQDQ
WH\HQIHUPHGDGDXWRLQPXQHSUHWUDVSODQWH WLHQHQ
XQPD\RUULHVJRGHGHVDUUROODUHVWDFRPSOLFDFLyQ
MANIFESTACIONES
CLINICOANALÍTICAS
(OUHFKD]RVHSURGXFHHQODPD\RUtDGHORVFDVRVGX
UDQWHHOSULPHUPHVSRVWUDVSODQWH\GHPRGRPiVFRQ
FUHWRHQWUHORVGtDV\WUDVODLQWHUYHQFLyQ(QODDF
WXDOLGDGHVH[WUHPDGDPHQWHLQIUHFXHQWHTXHXQHSLVRGLR
GHUHFKD]RRFDVLRQHIDOORGHOLQMHUWRKHSiWLFR/RVSURWR
FRORVDFWXDOHVGHLQPXQRVXSUHVLyQKDQUHGXFLGRGUDVWL
FDPHQWHODJUDYHGDGGHHVWDFRPSOLFDFLyQTXHFXDQGR
DSDUHFHVHGHWHFWDSRUPRGLILFDFLRQHVHQHOSHUILOHQ]L
PiWLFR\HOHYDFLyQGHODELOLUUXELQD(QORVUDURVFDVRVHQ
ORVTXHHOUHFKD]RHVJUDYHVHSXHGHREVHUYDUILHEUHOHX
FRFLWRVLV\GHVFHQVRGHODDFWLYLGDGGHODSURWURPELQD3H
URHOULHVJRGHUHFKD]RDXQTXHDWHQXDGRDPHGLGDTXHSD
VDHOWLHPSRHVWiVLHPSUHSUHVHQWH\SXHGHDSDUHFHUPiV
DOOiGHOSULPHUDxRSRVWUDVSODQWHFRLQFLGLHQGRFRQQLYH
OHVVXEWHUDSpXWLFRVGHLQPXQRVXSUHVLyQ(VWDVLWXDFLyQ
SXHGHSURGXFLUVHGXUDQWHORVLQWHQWRVGHUHGXFLURVXSUL
PLUODPHGLFDFLyQSDUDSDOLDUVXVHIHFWRVVHFXQGDULRVD
ODUJRSOD]R (OUHFKD]RGHDSDULFLyQWDUGtDHVGHSHRU
SURQyVWLFR6XLGHQWLILFDFLyQKLVWROyJLFDSXHGHVHUGLItFLO
SRUTXHQRVLHPSUHHVWiQSUHVHQWHVORVVLJQRVFOiVLFRVHQ
HO HVSDFLR SRUWD \ DSDUHFHQ OHVLRQHV HQ HO OREXOLOOR
1HXEHUJHUGHVFULEHHVWHWLSRGHUHFKD]RWDUGtRDSDUWLUGH
ORVGtDVSRVWUDVSODQWHHQHOGHORVFDVRV/DUHV
SXHVWDDOWUDWDPLHQWRQRHVWDQHOHYDGDFRPRHQHOUHFKD
]RGHODVSULPHUDVVHPDQDVSRVWUDVSODQWHIUHQWHDO
\ODHYROXFLyQDODFURQLFLGDGHVQHWDPHQWHVXSH
ULRUIUHQWHDO 'LDSRVLWLYD
DIAGNÓSTICO DIFERENCIAL
6HGHEHHVWDEOHFHUFRQODOHVLyQGHSUHVHUYDFLyQ
$XQTXHORVFDPELRVDQDOtWLFRVVRQSDUHFLGRVDORVGHO
UHFKD]RHQHVWDOHVLyQVXHOHSUHGRPLQDUODFROHVWDVLV
TXHSXHGHVHUPX\LQWHQVD/DELRSVLDHQHVWRVFDVRV
GHPRVWUDUiXQDGHJHQHUDFLyQKLGUySLFDGHORVKHSDWR
FLWRVFHQWUROREXODUHVFROHVWDVLV\SUROLIHUDFLyQGXFWX
OLOODUFRQWURPERVELOLDUHV (QDOJXQRVSDFLHQWHVOD
OHVLyQGHSUHVHUYDFLyQ\HOUHFKD]RFHOXODUSXHGHQFRLQ
FLGLUHQHOWLHPSR/DUHFLGLYDYLUDO&SXHGHHQRFD
VLRQHVSODQWHDUGLILFXOWDGHVGLDJQyVWLFDV/DVOHVLRQHV
GHKHSDWLWLVWDPELpQVHFRQFHQWUDQHQHOHVSDFLRSRU
WDSHURHOLQILOWUDGRLQIODPDWRULRHVPRQRQXFOHDU3RU
RWUDSDUWHHQODOHVLyQGHKHSDWLWLVH[LVWHXQFRPSR
QHQWHOREXOLOODUFDUDFWHUtVWLFRTXHSHUPLWHHVWDEOHFHU
HOGLDJQyVWLFR$ SHVDUGHHOORDPEDVOHVLRQHVSXHGHQ
DVLPLVPRFRH[LVWLU 6HKDQGHVFULWRFDVRVGHVtQ
GURPHOLQIRSUROLIHUDWLYRTXHVLPXODQHSLVRGLRVGHUH
FKD]R 7DEOD,,,'LDSRVLWLYD
TRATAMIENTO
(QORV~OWLPRVDxRVVHKDDPSOLDGRQRWDEOHPHQWH
ODHOHFFLyQGHIiUPDFRVLQPXQRVXSUHVRUHVSDUDSUH
YHQLUHOUHFKD]RFHOXODU'LDSRVLWLYD/DLQPXQR
VXSUHVLyQSXHGHDMXVWDUVHHQODDFWXDOLGDGDODVFLU
FXQVWDQFLDV GH FDGD SDFLHQWH SURWHJLpQGROH GHO
TABLA III
DIAGNÓSTICO DIFERENCIAL DEL RECHAZO CELULAR
• Lesión de preservación
• Hepatitis C
• Hepatitis por CMV
• Colangitis aguda
• Hepatitis autoinmune de novo
• Síndrome linfoproliferativo
93
TABLA IV
RIESGO DE EVOLUCIÓN A LA CRONICIDAD
• Resistencia a esteroides
• Rechazo recidivante
• Isquemia centrolobulillar
• Rechazo tardío
GHVDUUROORGHUHFKD]RDJXGRJUDYHVLQHOSHOLJURGHID
FLOLWDUXQDLQIHFFLyQGHHYROXFLyQIDWDO$ SHVDUGHORV
DYDQFHVHQODHVWUDWHJLDGHLQPXQRVXSUHVLyQFDVLOD
PLWDGGHORVSDFLHQWHVWUDVSODQWDGRVVXIUHQHVWDFRP
SOLFDFLyQ(QHOGHORVFDVRVVHFRPSUXHED
TXHUHVSRQGHQDOWUDWDPLHQWRFRQHVWHURLGHVHQERORV
GHDJGHPHWLOSUHGQLVRORQD\HQQ~PHURGHXQR
DWUHV 'LDSRVLWLYD(VDFRQVHMDEOHTXHODUHV
SXHVWDVHFRQILUPHPHGLDQWHELRSVLDKHSiWLFD(QORV
SDFLHQWHVWUDVSODQWDGRVSRUFLUURVLVVHFXQGDULDDYLUXV
&ODGRVLV\HOQ~PHURGHERORVGHEHUHGXFLUVHDOPt
QLPRLPSUHVFLQGLEOHSDUDQRIDYRUHFHUODUHFLGLYDYL
UDO(QODVIRUPDVOHYHVGHUHFKD]RQRHVQHFHVDULR
DGPLQLVWUDUERORVGHHVWHURLGHV\VXHOHVHUVXILFLHQWH
DXPHQWDUORVQLYHOHVGHFLFORVSRULQDRWDFUROLPXV+DV
WDIHFKDVUHFLHQWHVORVSDFLHQWHVFRQUHFKD]RUHVLVWHQ
WHDHVWHURLGHVVHKDQWUDWDGRFRQDQWLFXHUSRVPRQR
FORQDOHV2.7FRQQRWDEOHHILFDFLDSHURFRQXQDSUR
SRUFLyQFRQVLGHUDEOHGHHIHFWRVVHFXQGDULRV(QOD
DFWXDOLGDGHOWUDWDPLHQWRGHOUHFKD]RDJXGRUHIUDFWD
ULRDHVWHURLGHVHVWiEDVDGRHQODFRQYHUVLyQGHOUpJL
PHQLQPXQRVXSUHVRUDWDFUROLPXV/DSRWHQFLDGH
HVWHDJHQWHHQODSUHYHQFLyQ\HOWUDWDPLHQWRGHOUH
FKD]RKDTXHGDGRGHPRVWUDGDHQDOJXQRVHVWXGLRVUH
FLHQWHV(QHVWRVORVSDFLHQWHVLQPXQRVXSULPLGRVED
VDOPHQWHFRQWDFUROLPXVWLHQHQXQDWDVDLQIHULRUGHUH
FKD]RDJXGRUHIUDFWDULR\GHUHFKD]RFUyQLFR 5H
FLHQWHPHQWHVHKDQDSRUWDGRGDWRVDIDYRUGHWUDWDUHO
UHFKD]RDJXGRFRQWDFUROLPXVFRPRWHUDSLDGHSULPH
UDOtQHDHQVXVWLWXFLyQGHORVERORVGHHVWHURLGHV $XQTXHHVPX\LQIUHFXHQWHDOJXQRVSDFLHQWHVLQPX
QRVXSULPLGRVFRQWDFUROLPXVSXHGHQWHQHUXQUHFKD]R
PRGHUDGRRJUDYHHQHOTXHQREDVWDFRQVXELUODGR
VLVGHHVWDPHGLFDFLyQ1RREVWDQWHORVGDWRVFRPX
QLFDGRVHQHOHVWXGLRFRPSDUDWLYRFRQFLFORVSRULQD
GHVWDFDQODEDMDWDVDGHUHFKD]RDJXGRWDUGtRGHUH
FKD]RUHVLVWHQWHDORVHVWHURLGHV\GHUHFKD]RFUyQLFR
GHHVWRVSDFLHQWHV
(QDOJXQRVFDVRVHOUHFKD]RQRDSDUHFHFRQORVUDV
JRVKLVWROyJLFRVWtSLFRVGHODIRUPDDJXGD(QODELRS
VLDGHHVWRVSDFLHQWHVVHREVHUYDQOHVLRQHVGHWLSRLV
TXpPLFR\GHORFDOL]DFLyQFHQWUROREXODU3RURWUDSDU
WHHQHVWRVHQIHUPRVXQDYH]GHVFDUWDGDVODVFRPSOL
FDFLRQHVYDVFXODUHVVHGHEHLQWURGXFLUVLQGHPRUDHO
WDFUROLPXV\DTXHODSUREDELOLGDGGHHYROXFLyQKDFLD
HOUHFKD]RFUyQLFRHVPX\HOHYDGDHQWRUQRDO
'LDSRVLWLYD2WUDFLUFXQVWDQFLDGHULHVJRHVHOUH
FKD]RDJXGRWDUGtR/DVDOWHUDFLRQHVKLVWROyJLFDVWDP
SRFRVRQDTXtODVFOiVLFDV\VXGLDJQyVWLFRSXHGHVHU
GLItFLO(QHOOREXOLOORSXHGHQLGHQWLILFDUVHFDPELRVVX
JHUHQWHVGHKHSDWLWLVTXHSXHGHQVHUHOSUHiPEXORGH
XQDHYROXFLyQKDFLDODFURQLFLGDG 'LDSRVLWLYD
(OWUDWDPLHQWRFRQHVWHURLGHVHVPHQRVHILFD]\VLHP
SUHVHGHEHFRQVLGHUDUHOXVRGHWDFUROLPXV(QORVFD
VRVUHIUDFWDULRVDHVWDWHUDSLDSXHGHUHFXUULUVHFRQp[L
WRDOiFLGRPLFRIHQyOLFR 7DEOD,9
IMPACTO DEL RECHAZO EN LA
SUPERVIVENCIA DEL
PACIENTE
1RVHKDGHPRVWUDGRTXHHOUHFKD]RDJXGRLQIOX
\DQHJDWLYDPHQWHVREUHODVXSHUYLYHQFLDGHOSDFLHQ
WH5HFLHQWHPHQWHVHKDFXHVWLRQDGRODQHFHVLGDG
GHWUDWDUWRGRVORVHSLVRGLRVGHUHFKD]RHQHVSHFLDO
ORVGHEDMRJUDGRDGXFLHQGRTXHVXDSDULFLyQSRGUtD
IDYRUHFHUORVIHQyPHQRVGHWROHUDQFLDLQPXQHTXHEH
QHILFLDQDODUJRSOD]RDXQJUXSRWRGDYtDQRELHQFR
94
RECHAZO AGUDO - 3RQHQFLDV
QRFLGRGHSDFLHQWHV 'HKHFKRHQXQHVWXGLRUH
FLHQWHVHKDGHVFULWRXQDVXSHUYLYHQFLDPD\RUSDUDORV
SDFLHQWHVTXHKDQGHVDUUROODGRXQHSLVRGLRGHUHFKD
]RDJXGR(VWRVKDOOD]JRVGHEHQWHQHUVHHQFXHQWD
DODKRUDGHGLVHxDUQXHYDVHVWUDWHJLDVGHLQPXQRVX
SUHVLyQODVFXDOHVQRGHEHQSHUVHJXLUH[FOXVLYDPHQ
WHXQDUHGXFFLyQGHODLQFLGHQFLDGHOUHFKD]RHQHO
SHULRGRSRVWUDVSODQWHLQPHGLDWR/DHILFDFLDGHODSUR
ILOD[LVGHOUHFKD]RWDPELpQGHEHLQFOXLUHOLPSDFWRHQ
ODIXQFLyQUHQDOLQIOX\HQGRVREUHODLQFLGHQFLDGHLQ
IHFFLRQHV$ ODUJRSOD]RWDPELpQHVHVHQFLDODQDOL]DU
HQTXpPHGLGDDXPHQWDHOULHVJRGHUHFLGLYDGHODHQ
IHUPHGDGEDVDORHOGHVDUUROORGHWXPRUHVGHQRYR
'LDSRVLWLYDV\
BIBLIOGRAFÍA
)LVKHU/5+HQOH\.6/XFH\05$FXWHFHOOXODUUHMHFWLRQDI
WHUOLYHUWUDQVSODQWDWLRQYDULDELOLW\PRUELGLW\DQGPRUWDOLW\
/LYHU7UDQVSO6XUJ
:LHVQHU5+'HPHWULV$-%HOOH6+HWDO$FXWHKHSDWLFDOOR
JUDIWUHMHFWLRQLQFLGHQFHULVNIDFWRUVDQGLPSDFWRQRXWFRPH
+HSDWRORJ\
$UJHOOR/3ULHWR0%HUHQJXHU-5HFKD]R+LSHUDJXGR\DJX
GR(Q7UDVSODQWHKHSiWLFR(GV-%HUHQJXHU\3 3DUULOOD0D
GULG(OEDS
:LOOLDPV-:)RVWHU3)6DQNDU\+15ROHRIOLYHUDOORJUDIWELRSV\
LQSDWLHQWPDQDJHPHQW6HPLQ/LYHU'LV
%DWKJDWH$-3UDYLFD93HUUH\&7KHUDSRQGRV*3OHYULV-1
+D\HV3&+XWFKLQVRQ,97KHHIIHFWRISRO\PRUSKLVPVLQWX
PRUQHFURVLVIDFWRUDOSKDLQWHUOHXNLQDQGWUDQVIRUPLQJ
JURZWKIDFWRUEHWDJHQHVLQDFXWHKHSDWLFDOORJUDIWUHMHFWLRQ
7UDQVSODQWDWLRQ
%DWKJDWH$-0F&ROO0*DUGHQ2-)RUV\WKH-/50DGKDYDQ
..+D\HV3&7KHHIIHFWRIDSRVLWLYH/\PSKRF\WRWR[LFFURVV
PDWFKRQKHSDWLFDOORJUDIWVXUYLYDODQGUHMHFWLRQ/LYHU7UDQVSO
6XUJ
'HPHWULV$-6KLTXDQJ4+RQJ6)XQJ--/LYHUDOORJUDIWUH
MHFWLRQDQRYHUYLHZRIPRUSKRORJLFILQGLQJV$P-6XUJ3D
WKRO
'HPHWULV$-%HOOH6++DUW-HWDO,QWUDREVHUYHUDQGLQWH
UREVHUYHUYDULDWLRQLQWKHKLVWRSDWKRORJLFDODVVHVVPHQWRIWKH
OLYHUDOORJUDIWUHMHFWLRQ+HSDWRORJ\
1DND]DZD<:DONHU1,.HUOLQ36WHDGPDQ&/\QFK696WURQJ
5:HWDO&OLQLFRSDWKRORJLFDODQDO\VLVRIOLYHUDOORJUDIWELRS
VLHVZLWKODWHFHQWULOREXODUQHFURVLVDFRPSDUDWLYHVWXG\LQ
SDWLHQWV7UDQVSODQWDWLRQ
'HPHWULV$-%DWWV.3'KLOORQ$3)HUUHOO/'/XGZLJ-0DU
NLQ56HWDO%DQIIVFKHPDIRUJUDGLQJOLYHUDOORJUDIWUHMHF
WLRQDQLQWHUQDWLRQDOFRQVHQVXVGRFXPHQW+HSDWRORJ\
,QWHUQDWLRQDO:RUNLQJ3DUW\7HUPLQRORJ\IRUKHSDWLFDOORJUDIW
UHMHFWLRQ+HSDWRORJ\
'HPHWULV$$GDPV'%HOODP\&EODNROPHU.FORXVWRQ$
'KLOORQ$3)XQJ-HWDO8SGDWHRIWKH,QWHUQDWLRQDO%DQII
6FKHPDIRU/LYHU$OORJUDIW5HMHFWLRQZRUNLQJUHFRPPHQGD
WLRQVIRUWKHKLVWRSDWKRORJLFVWDJLQJDQGUHSRUWLQJRIFKUR
QLFUHMHFWLRQ$Q,QWHUQDWLRQDO3DQHO+HSDWRORJ\
)DUJHV26DOLED))DUKDPDQW+HWDO,QFLGHQFHRIUHMHFWLRQ
DQGLQIHFWLRQDIWHUOLYHUWUDQVSODQWDWLRQDVDIXQFWLRQRIWKHSUL
PDU\GLVHDVH²SRVVLEOHLQIOXHQFHRIDOFRKRODQGSRO\FORQDOLP
PXQRJOREXOLQV+HSDWRORJ\
5HLFK'-)LHO,*XDUUHUD-9(PUH6*X\656FKZDUW]0(
HWDO/LYHUWUDQVSODQWDWLRQIRUDXWRLPPXQHKHSDWLWLV+HSDWR
ORJ\
0RU(*RQZD7$+XVEHUJ76HWDO/DWHRQVHWDFXWHUHMHF
WLRQLQRUWKRWRSLFOLYHUWUDQVSODQWDWLRQDVVRFLDWHGULVNIDFWRUV
DQGRXWFRPH7UDQVSODQWDWLRQ
6DQGERUQ:-+D\-(3RUD\NR0.HWDO&\FORVSRULQHZLWK
GUDZDOIRUQHSKURWR[LFLW\LQOLYHUWUDQVSODQWUHFLSLHQWVGRHV
QRWUHVXOWLQVXVWDLQHGLPSURYHPHQWLQNLGQH\IXQFWLRQDQG
FDXVHVFHOOXODUDQGGXFWRSHQLFUHMHFWLRQ+HSDWRORJ\
1HXEHUJHU-$GDPV'+:KDWLVWKHVLJQLILFDQFHRIDFXWHOL
YHUDOORJUDIWUHMHFWLRQ-+HSDWRO
:LOOLDPV-:9HU63HWHUV7*HWDO&KROHVWDWLFMDXQGLFHDI
WHUKHSDWLFWUDQVSODQWDWLRQDQRQLPPXQRORJLFDOO\PHGLDWHG
HYHQW$P-6XUJ
)HUUHO/':ULJWK7/5REHUWV-HWDO+HSDWLWLV&YLUDOLQIHF
WLRQLQOLYHUWUDQVSODQWUHFLSLHQWV+HSDWRORJ\
95
+RZDUG7..OLQWPDOP*%*6WRQH0-HWDO/\PSKRSUROLIH
UDWLYHGLVRUGHUPDVTXHUDGLQJDVUHMHFWLRQLQOLYHUWUDQVSODQW
UHFLSLHQWV$QHDUO\DJUHVVLYHWXPRUZLWKDW\SLFDOSUHVHQWDWLRQ
7UDQVSODQWDWLRQ
$GDPV'+1HXEHUJHU-07UHDWPHQWRIDFXWHUHMHFWLRQ6HPLQ
/LYHU'LV
:LHVVQHU5+3RUD\NR0.:DKOVWURP+(HWDO(DUO\FHOOX
ODUUHMHFWLRQWUHDWHGZLWKKLJKGRVHLQWUDYHQRXVFRUWLFRVWHURLG
WKHUDS\LVDVVRFLDWHGZLWKDGHFUHDVHLQWKHLQFLGHQFHRIVWH
URLGUHVLVWDQWUHMHFWLRQDQGJUDIWIDLOXUHIURPUHMHFWLRQ7UDQV
SODQW3URF
6KHLQHU3$6FKZDUW]0(0RU(6FKOXJHU/.7KHLVH1.LV
KLNDZD.HWDO6HYHUHRUPXOWLSOHUHMHFWLRQHSLVRGHVDUHDV
VRFLDWHGZLWKHDUO\UHFXUUHQFHRIKHSDWLWLV&DIWHURUWKRWRSLF
OLYHUWUDQVSODQWDWLRQ+HSDWRORJ\
&RORQQD-2*ROGVWHLQ/,%UHPV--HWDO$ SURVSHFWLYHVWXG\RQ
WKHXVHRIPRQRFORQDODQWL7FHOODQWLERG\2.7WRWUHDWVWHURLG
UHVLVWDQWOLYHUWUDQVSODQWUHMHFWLRQ$UFK6XUJ
0LOOLV-0:RRGOH(63LSHU-%%UXFH'61HZHOO.$6HD
PDQ'6HWDO7DFUROLPXVIRUSULPDU\WUHDWPHQWRIVWHURLGUH
VLVWDQW KHSDWLF DOORJUDIW UHMHFWLRQ 7UDQVSODQWDWLRQ .OHLQ$7DFUROLPXVUHVFXHLQOLYHUWUDQVSODQWSDWLHQWVZLWKUH
IUDFWRU\UHMHFWLRQRULQWROHUDQFHRUPDODEVRUSWLRQRIF\FORV
SRULQH7KH860XOWLFHQWHU)./LYHU6WXG\*URXS/LYHU
7UDQVSO6XUJ
:LHVQHU5+$ ORQJWHUPFRPSDULVRQRIWDFUROLPXV).
YHUVXVF\FORVSRULQHLQOLYHUWUDQVSODQWDWLRQ7UDQVSODQWDWLRQ
%RLOORW29LDOH-3*UDWDGRXU30HHXV36RXUDW\3/H'HUI
<HWDO5HYHUVDORIHDUO\DFXWHUHMHFWLRQZLWKLQFUHDVHGGRVHV
RIWDFUROLPXVLQOLYHUWUDQVSODQWDWLRQDSLORWVWXG\7UDQV
SODQWDWLRQ
4XDJOLD$)GHO9HFFKLR%ODQFR**UHDYHV5%XUURXJKV$.
'KLOORQ$3'HYHORSPHQWRIGXFWRSHQLFOLYHUDOORJUDIWUHMHF
WLRQLQFOXGHVD´KHSDWLWLFSKDVHµSULRUWRGXFWORVV-+HSDWRO
*DYOLN$*ROGEHUJ$7VDURXFKD0*HWDO0\FRSKHQRODWH
PRIHWLOUHVFXHWKHUDS\LQOLYHUWUDQVSODQWUHFLSLHQWV7UDQVSODQW
3URF
96
RECHAZO AGUDO - 3UHVHQWDFLyQ
3UHVHQWDFLyQ
0DQXHOGHOD0DWD
'LDSRVLWLYD
7tWXOR\VXEWtWXOR
'LDSRVLWLYD
*HQHUDOLGDGHVVREUHHOUHFKD]RFHOXODU
97
'LDSRVLWLYD
0HGLDGRUHVLQPXQROyJLFRVGHOUHFKD]RFHOXODU
'LDSRVLWLYD
5HODFLyQGHODVOHVLRQHVKLVWROyJLFDVHOHPHQWDOHV
'LDSRVLWLYD
'LDSRVLWLYD
)RWRJUDItDPLFURVFySLFDGHLQILOWUDGRSRUWDOPL[WRGHXQ
UHFKD]RDJXGR
'HWDOOHPLFURVFySLFRGHOHVLyQELOLDUHQHOUHFKD]RDJXGR
98
RECHAZO AGUDO - 3UHVHQWDFLyQ
'LDSRVLWLYD
'LDSRVLWLYD
&DPELRVLVTXpPLFRVFHQWUROREXOLOODUHVHQHOUHFKD]RFRQ
ULHVJRGHHYROXFLyQDODFURQLFLGDG
&ODVLILFDFLyQGHODJUDYHGDGKLVWROyJLFDGHOUHFKD]RDJX
GR%DQII
'LDSRVLWLYD
'LDSRVLWLYD
7HUPLQRORJtDGHOUHFKD]RGHOLQMHUWRKHSiWLFR
5HFKD]RDJXGRIDFWRUHVGHULHVJR
99
'LDSRVLWLYD
(QIHUPHGDGSUHWUDVSODQWH\ULHVJRGHUHFKD]R
'LDSRVLWLYD
'LIHUHQFLDVHQLQFLGHQFLD\UHVSXHVWDDOWUDWDPLHQWRHQ
WUHHOUHFKD]RDJXGRSUHFR]\WDUGtR
'LDSRVLWLYD
'LDJQyVWLFRGLIHUHQFLDOGHOUHFKD]RDJXGR
'LDSRVLWLYD
)iUPDFRVXWLOL]DGRVHQODSURILOD[LVGHOUHFKD]RDJXGR
100
RECHAZO AGUDO - 3UHVHQWDFLyQ
'LDSRVLWLYD
7UDWDPLHQWRGHOUHFKD]RDJXGR
'LDSRVLWLYD
'LDJQyVWLFRDQWLFLSDGRGHOUHFKD]RFUyQLFR
'LDSRVLWLYD
)DFWRUHVIDYRUHFHGRUHVGHHYROXFLyQDODFURQLFLGDG
'LDSRVLWLYD
)DFWRUHVGHGHFLVLyQHQODSODQLILFDFLyQGHODHVWUDWHJLD
LQPXQRVXSUHVRUD
101
'LDSRVLWLYD
)DFWRUHVGHLPSRUWDQFLDHQHODQiOLVLVGHHILFDFLDGHXQ
UpJLPHQLQPXQRVXSUHVRU
102
RECHAZO AGUDO - 3RQHQFLDV
7UDVSODQWHUHQDOPHGLFLQDEDVDGDHQOD
HYLGHQFLD,QPXQRVXSUHVLyQHQHOWUDVSODQWH
GHyUJDQRV5HFKD]RDJXGR
0DQXHO$ULDV
+RVSLWDO8QLYHUVLWDULR0DUTXpVGH9DOGHFLOOD6DQWDQGHU
INTRODUCCIÓN
PHQRVDPiVVHFRPSUXHEDTXHHQODPiVXVDGDOD
GH&RRNHO(&&HVHOHVWiQGDURURHVWDQGRORVUHJLV
WURVODVEDVHVGHGDWRV\GHVGHOXHJRODRSLQLyQGH
ORVH[SHUWRVHQODSDUWHPiVEDMDGHODHVFDOD
(QORVPLHPEURVGHOD)D
FXOWDGGH&LHQFLDVGHOD6DOXGGHOD
8QLYHUVLGDG0F0DVWHU+DPLOWRQ
(VFDODGH&RRNGHOD(YLGHQFLD&LHQWtILFD
2QWDULR&DQDGiSXEOLFDURQXQDVHULHGHWUDEDMRVDFHUFD
GHFyPRHYDOXDUFRUUHFWDPHQWHODOLWHUDWXUDPpGLFDHQOR
(VWXGLRVDOHDWRUL]DGRVFRQPXHVWUDJUDQGH\
TXHUHVSHFWDDOFXLGDGRGHOSDFLHQWHLQGLYLGXDO(OHQRUPH
ULHVJRGHHUURUWLSR,\,,SHTXHxRV *UDGR$
LQWHUpVGHOWHPDFUHyUiSLGDPHQWHXQDFRUULHQWHGHRSLQLyQ
(VWXGLRVDOHDWRUL]DGRVFRQPXHVWUDSHTXHxD\
TXHHQIXHEDXWL]DGDFRQHOQRPEUHGH0HGLFLQD%D
ULHVJRPHGLRDOWRGHHUURUWLSR,\,, *UDGR%
VDGDHQOD(YLGHQFLD0%((Q(VSDxDHOFRQFHSWRVHLQ
(VWXGLRVWLSRFRKRUWHVQRDOHDWRUL]DGRVFRQ
WURGXFHUHFLHQWHPHQWH\XQJUDQQ~PHURGHSURIHVLRQDOHV
FRQWUROHVFRQFXUUHQWHV*UDGR&
VHDGKLHUHQDpOFRQODIHGHOFRQYHUVR/D0%(SURSRQH
(VWXGLRVWLSRFRKRUWHVQRDOHDWRUL]DGRVFRQFRQ
XQFDPELRGHOSDUDGLJPDFOiVLFRXQDWUDQVIRUPDFLyQHQ
WUROHVKLVWyULFRVLQFOX\HQUHJLVWURVGHWUDVSODQWHV
ODSHUVSHFWLYDGHDQiOLVLVGHQXHVWUDDFWLWXGFOtQLFD
6HULHVGHFDVRV
(O3URIHVRU'DYLG6DFNHWWVXPiVVLJQLILFDGRSURPR
WRUODGHILQLyHQFRPR´ODXWLOL]DFLyQFRQVFLHQWHH[
,JXDOPHQWHHQOD(VFDODGH*RRGPDQ
SOtFLWD\MXLFLRVDGHODPHMRUHYLGHQFLDFLHQWtILFDGLVSRQLEOH
SDUDWRPDUGHFLVLRQHVVREUHHOFXLGDGRGHFDGDSDFLHQWHµ
&ODVLILFDFLyQGHOD(YLGHQFLD&LHQWtILFDVHJ~Q
/DKHUUDPLHQWDGHWUDEDMRIXQGDPHQWDOSDUDOD0%(
HVHOHQVD\RFOtQLFRFRQWURODGR(VWDKHUUDPLHQWDUHODWL HO5LJRU &LHQWtILFRWRPDGRGH*RRGPDQ&
YDPHQWHPRGHUQDKDSUROLIHUDGRGHIRUPDH[SRQHQFLDO
(QVD\RFRQWURODGR\DOHDWRUL]DGRFRQPXHVWUD
REOLJDQGRDHVWDEOHFHUPHFDQLVPRVGHUHJLVWUR\FRPSL
JUDQGH
ODFLyQGHODLQIRUPDFLyQREWHQLGDSDUDVXFRUUHFWDHYD
(QVD\RFRQWURODGR\DOHDWRUL]DGRFRQPXHVWUD
OXDFLyQQHFHVLGDGTXHKDGDGROXJDUDODFRODERUDFLyQGH
SHTXHxD
&RFKUDQHHOVDQWXDULRGHOD0%(
(QVD\R12DOHDWRUL]DGRFRQFRQWUROHVFRQFX
CRITERIOS DE EVIDENCIA
UUHQWHV
CIENTÍFICA
(QVD\R12DOHDWRUL]DGRFRQFRQWUROHVKLVWyUL
FRV
$VtFXDQGRVHDQDOL]DQORVFULWHULRVGHODHYLGHQ
(VWXGLRVGHFRKRUWHV
FLDFLHQWtILFDSODQWHDGRVFRPRXQDHVFDODGHYDORUGH
(VWXGLRVGHFDVRV\FRQWUROHV
103
(VWXGLRVWUDQVYHUVDOHV
9LJLODQFLDHSLGHPLROyJLFDEDVHVGHGDWRVRUH
JLVWURV
6HULHVFRQVHFXWLYDVGHFDVRV
1RWLILFDFLyQGHXQFDVRDLVODGRDQpFGRWD
&XDOTXLHUHVFDODGHPHGLGDVTXHVHXWLOLFHSDUDOD
YDORUDFLyQGHODFDOLGDGGHODHYLGHQFLDFLHQWtILFDHV
WDEOHFHXQDSULRULGDGDEVROXWDGHO(&&TXHGDQGRORV
GDWRVGHORVUHJLVWURVPX\DEDMRHQGLFKDHVFDOD7DP
ELpQHQOD&ODVLILFDFLyQPiVUHFLHQWHPHQWHSXEOLFDGD
ODVUHYLVLRQHVVLVWHPiWLFDV\ORV(&&VRQHOSLODUIXQ
GDPHQWDOGHODFDOLGDG
FUENTES DE DATOS
3HURWUDGLFLRQDOPHQWHHQOD0HGLFLQDGHO7UDVSODQ
WHODSULQFLSDOIXHQWHGHGDWRV\ODTXHKDJXLDGRODDF
WXDFLyQFOtQLFDKDVLGRSUHFLVDPHQWHODH[SHULHQFLD
REWHQLGDGHORVUHJLVWURVIXQGDPHQWDOPHQWHPXOWLFpQ
WULFRV\GHODVJUDQGHVEDVHVGHGDWRVTXHDFXPXODQ
PLOHVGHSDFLHQWHV\XWLOL]DQFDVLH[FOXVLYDPHQWHODFXU
YDGHVXSHUYLYHQFLDDFWXDULDO\ODUHJUHVLyQORJtVWLFD
SDUDUHDOL]DUFRPSDUDFLRQHVHQWUHGLYHUVDVYDULDEOHV
FOtQLFDVRHQWUHORVGLVWLQWRVSURWRFRORVWHUDSpXWLFRV
'HHVWDVJUDQGHVEDVHVGHGDWRVKDVXUJLGRUHFLHQ
WHPHQWHODGHPRVWUDFLyQHVWDGtVWLFDGHDOJXQDVFXHV
WLRQHVTXHOOHYDEDQPXFKRWLHPSRVLQUHVSXHVWDGHIL
QLWLYDSHMTXHHOWUDVSODQWHSURSRUFLRQDXQDPD\RU
VXSHUYLYHQFLDTXHODGLiOLVLV
7DPELpQVHXVDFRQIUHFXHQFLDODPHGLGDGHODVH
PLYLGDHOWLHPSRDOTXHOOHJDQIXQFLRQDQWHVHO
GHORVLQMHUWRV3UHFLVDPHQWHHOHVWDQFDPLHQWRHQOD
VHPLYLGDRVHDODQRPHMRUtDHQORVUHVXOWDGRVDODU
JRSOD]RHVXQDDVLJQDWXUDSHQGLHQWHHQHOWUDVSODQ
WHUHQDO
5HFLHQWHPHQWHHQXQDGHODVUHYLVWDVGHPD\RULP
SDFWRFLHQWtILFR1(-0VHSXEOLFDXQDUWtFXORHQHO
TXHVHSRQHGHPDQLILHVWRTXHHOWUDVSODQWHUHQDOKD
PHMRUDGRHQORV~OWLPRVDxRVWDQWRDFRUWRFRPRDODU
JRSOD]R/DVSULQFLSDOHVQRYHGDGHVVRQTXHHO55GH
SHUGHUXQLQMHUWRKDPHMRUDGRPXFKRVREUHWRGRHQ
ORVSDFLHQWHVTXHQRKDQVXIULGRUHFKD]R< DOJRIXQ
GDPHQWDOSDUDHOWHPDTXHHVWDPRVWUDWDQGRHVWDPH
MRUtDQRGHSHQGHGHORVQXHYRVLQPXQRVXSUHVRUHVSRU
TXHORVSDFLHQWHVGHHVWDVHULHQRORVWRPDEDQRWR
PDEDQPX\SRFRV
3RUWDQWRHQODSUiFWLFDFOtQLFDYDPRVDXWLOL]DUSUH
IHUHQWHPHQWHORVUHVXOWDGRVGHODVJUDQGHVEDVHVGHGD
WRV\UHJLVWURVPXOWLFpQWULFRV\TXpGXGDFDEHTXHOD
HYDOXDFLyQGHORVUHVXOWDGRVSURSLRVGHODVXQLGDGHV
GHWUDVSODQWHVTXHHQQXHVWURSDtVHQXQQ~PHUREDV
WDQWHHOHYDGRKDQSDVDGR\DGHODFLIUDVLJQLILFDWLYD
GHORVPLOWUDVSODQWHVUHDOL]DGRV
EVALUACIÓN DE LOS NUEVOS
INMUNOSUPRESORES
(QODHYDOXDFLyQGHORVQXHYRVLQPXQRVXSUHVRUHV
DOJXQRVGHORVFXDOHVOOHYDQ\DYDULRVDxRVHQHOPHU
FDGRVHKDXWLOL]DGRIXQGDPHQWDOPHQWHHOHQVD\RFOt
QLFRFRQWURODGRFRPRIDVHILQDOGHOHVWXGLRH[WUDRU
GLQDULDPHQWHSURORQJDGRTXHVXSRQHHOODQ]DPLHQWR
GHXQQXHYRSURGXFWRIDUPDFpXWLFRDOPHUFDGR
+D\TXHGHFLUGHHQWUDGDTXHHQHVWHWLSRGHHQ
VD\RVFOtQLFRVGHORV~OWLPRVFLQFRRGLH]DxRVVHKD
XWLOL]DGRVLHPSUHFRPR HQGSRLQW SULPDULRHOUHFKD]R
DJXGRSRUORJHQHUDOSUREDGRSRUELRSVLD
(QXQHVTXHPDOyJLFRGHDSDULFLyQHQHOWLHPSROD
SULPHUDSUHJXQWDTXHVHGHEHUtDGHSODQWHDUHQFXDQWR
DODHYLGHQFLDH[LVWHQWHHQODDFWXDOLGDGHQHOWUDWDPLHQ
WRLQPXQRVXSUHVRUGHOUHFKD]RDJXGRHVVLODDSDULFLyQ
GHOWDFUROLPXVR).SRVWHULRUPHQWHFRPHUFLDOL]DGR
FRQHOQRPEUHGH3URJUDIKDVXSXHVWRRQRXQDYHQWD
MDVREUHODXWLOL]DFLyQGHODFLFORVSRULQDSUHYLDPHQWHH[LV
WHQWHHQHOPHUFDGRGHVGHSULQFLSLRVGHORVDxRV\TXH
FDPELyGHIRUPDGUiVWLFDHOSDQRUDPDH[LVWHQWHHQHO
WUDVSODQWHGHyUJDQRVKDVWDHVHPRPHQWR
(QHOQ~PHURPRQRJUiILFRGHODUHYLVWD1HIURORJtD
TXHVHGHGLFyDODPHGLFLQDEDVDGDHQODHYLGHQFLDHO
WUDWDPLHQWRLQPXQRVXSUHVRUVHGLYLGLyHQGRVSDUWHV
UHFKD]RDJXGRTXHGHVDUUROOyHO'U-3DVFXDOGHO+RV
SLWDO5DPyQ\&DMDOGH0DGULG\HOGHOWUDWDPLHQWR
GHOUHFKD]RFUyQLFRTXHGHVDUUROODPRVHO'U-XDQ&DU
ORV5XL]\\RPLVPRHQFRODERUDFLyQFRQHO'U/3DXO
*2SHO]\&3RQWLFHOOL
RECHAZO AGUDO
(QFXDQWRDOUHFKD]RDJXGRHO'U-XOLR3DVFXDOHQ
GLFKRQ~PHURGHODUHYLVWD1HIURORJtDSODQWHyXQDVH
ULHGHSUHJXQWDVODSULPHUDGHODVFXDOHVFRQWHVWDGD
SUHYLDPHQWHHQORVWUDWDPLHQWRVGHLQGXFFLyQHVVLVRQ
QHFHVDULRVORVDQWLFXHUSRVDQWLOLQIRFLWDULRVFRPRWHUD
104
RECHAZO AGUDO - 3RQHQFLDV
SpXWLFDGHLQGXFFLyQ\RWUDHVVLGHEHXWLOL]DUVHFL
FORVSRULQDRWDFUROLPXV
$FWXDOL]DQGRODLQIRUPDFLyQH[LVWHQWHKDVWDHVWH
PRPHQWRVLDQDOL]DPRVHVSHFtILFDPHQWHORVUHVXOWD
GRVGHODLQFLGHQFLDGHUHFKD]RDJXGRHQORVHVWXGLRV
TXHVHKDQUHDOL]DGRHQWUH&V$ \).VHREVHUYDXQD
GLVPLQXFLyQGHODLQFLGHQFLDGHUHFKD]RDJXGRHQORV
SDFLHQWHVWUDWDGRVFRQ).HQFRPSDUDFLyQFRQORV
SDFLHQWHVWUDWDGRVFRQ&V$ \HVWRHVHVWDGtVWLFDPHQWH
VLJQLILFDWLYR(VWRVGDWRVKDQVLGRFRQILUPDGRVHQHO
(VWXGLR0XOWLFpQWULFR$PHULFDQR\HQHO(VWXGLR0XO
WLFpQWULFR(XURSHR
(QORVHVWXGLRVLQLFLDOHVWDFUROLPXVVHFRPSDUyFRQ
&V$ HQSUHVHQFLDGHWULSOHWHUDSLDRGREOHWHUDSLD\HV
WDQGRHQHOSULPHUFDVRDVRFLDGRVDD]DWLRSULQD&XDQ
GRVHKDUHDOL]DGRHOHVWXGLRHVWDGRXQLGHQVHGHFRP
SDUDFLyQGHWDFUROLPXVYHUVXV FLFORVSRULQDHQODDVR
FLDFLyQFRQPLFRIHQRODWRPRIHWLOVHREVHUYDTXHOD
GLVPLQXFLyQGHUHFKD]RDJXGRSUREDGRSRUELRSVLDHQ
DPEDVUDPDVHVPX\LPSRUWDQWH\VLQGLIHUHQFLDVHV
WDGtVWLFDPHQWHVLJQLILFDWLYDVHQWUH&V$ \WDFUROLPXV\
TXHODFRPSDUDFLyQGHXQDWHUFHUDUDPDGHWDFUROLPXV
\D]DWLRSULQDWDPSRFRWLHQHGLIHUHQFLDVLPSRUWDQWHV
FRQODVRWUDVGRV7DPSRFRKXERGLIHUHQFLDVVLJQLIL
FDWLYDVHQODQHFHVLGDGGHXWLOL]DFLyQGHDQWLFXHUSRV
DQWLOLQIRFLWDULRVSDUDHOWUDWDPLHQWRGHOUHFKD]R
&XDQGRVHDQDOL]DEDHQHOHVWXGLRPXOWLFpQWULFRUH
QDOGHORV((88DORVDxRVODSpUGLGDGHOLQMHUWR\
ODSpUGLGDGHOLQMHUWRSRUUHFKD]RQRVHKDQREVHUYDGR
GLIHUHQFLDVVLJQLILFDWLYDVHQODUDPDWUDWDGDFRQWDFUR
OLPXV\HQODUDPDWUDWDGDFRQ&V$ SDUDQLQJXQRGH
HVWRVGRVHYHQWRVREVHUYiQGRVHXQDWHQGHQFLDDXQD
PHQRUIUHFXHQFLDGHDSDULFLyQHQHOJUXSRGH).
SHURVLQVLJQLILFDFLyQHVWDGtVWLFD
&XDQGRVHDQDOL]DQODVJUDQGHVEDVHVGHGDWRVFR
PRODGHO&76&ROODERUDWLYH7UDQVSODQW6WXG\GH
*HUDUG2SHO]VHREVHUYDLJXDOPHQWHTXHDODUJRSOD
]RQRVHKDQREVHUYDGRGLIHUHQFLDVVLJQLILFDWLYDVHQOD
VXSHUYLYHQFLDGHOLQMHUWRHQWUH).\&V$,QFOXVRHQ
HVWDVJUDQGHVEDVHVGHGDWRVODDVRFLDFLyQ).\PL
FRIHQRODWRPRIHWLOWLHQHQXQDPD\RUSpUGLGDGHLQMHU
WRVSUREDEOHPHQWHHQUHODFLyQFRQXQH[FHVRGHLQ
PXQRVXSUHVLyQTXHKD\DSURYRFDGRHQDOJXQRVFDVRV
ODPXHUWHGHOSDFLHQWHFRQRVLQLQMHUWRIXQFLRQDQWH
(O'U.QROOGHODGLYLVLyQGH1HIURORJtDGHO+RV
SLWDOGH2WWDZDHQ2QWDULR&DQDGiKDSXEOLFDGRHQHO
%ULW0HG-XQHVWXGLRFRPSDUDWLYRGHWDFUROLPXVYHUVXV
&V$UHDOL]DQGRXQPHWDDQiOLVLVGHHQVD\RVFOtQLFRV
DOHDWRUL]DGRV
/DVFRQFOXVLRQHVPiVLPSRUWDQWHVGHHVWHH[KDXV
WLYRPHWDDQiOLVLVKHFKRFRQXQDPHWRGRORJtDTXHFXP
SOHWRGRVORVFULWHULRVGHOD0%(VRQTXHOD&V$ HUD
FXDQGRVHUHDOL]yHVWHHVWXGLRHODJHQWHPiVXVDGRHQ
HOWUDVSODQWHUHQDOTXHHOXVRGHWDFUROLPXVKDDXPHQ
WDGRHQORV~OWLPRVDxRVVLHQGRODFRQFOXVLyQIXQGD
PHQWDOTXHHOWUDWDPLHQWRFRQWDFUROLPXVGDFRPRUH
VXOWDGRXQDUHGXFFLyQVLJQLILFDWLYDGHORVHSLVRGLRVGH
UHFKD]RDJXGRFXDQGRVHFRPSDUDQFRQ&V$SHURTXH
VRQQHFHVDULRVPiVHVWXGLRVDODUJRSOD]RSDUDFRP
SUREDUVLHOWDFUROLPXVPHMRUDODVXSHUYLYHQFLDGHOWUDV
SODQWHUHQDODODUJRSOD]R/DVSULQFLSDOHVFUtWLFDV
UHDOL]DGDVLQLFLDOPHQWHDHVWRVHVWXGLRVFRPSDUDWLYRV
KDQVLGRTXHODVGRVLVGHWDFUROLPXVIXHURQVXSHULRUHV
DODVTXHVHXWLOL]DQDFWXDOPHQWH\TXHORVUDQJRVGHQL
YHOHVGH&V$ IXHURQFRPSDUDWLYDPHQWHLQIHULRUHVDORV
GHORWURIiUPDFR\HQJHQHUDOXQSRFRSRUGHEDMRGH
ODPHGLDXWLOL]DGDHQORVSULPHURVGtDVSRVWUDVSODQWH
$GHPiVWDPELpQVHKDEtDFULWLFDGRODDXVHQFLDGHFRP
SDUDFLyQFRQOD&V$ HQPLFURHPXOVLyQR&V$ 1HRUDO
VLHQGRXWLOL]DGR~QLFDPHQWH).YV &V$ FOiVLFD(VWX
GLRVUHFLHQWHVFRQILUPDQORVGDWRVGHGLVPLQXFLyQGHO
UHFKD]RDJXGRHQFRPSDUDFLyQFRQ&V$ 1HRUDO
/DVLJXLHQWH\SHUWLQHQWHSUHJXQWDVHUtD¢VHGHEH
XWLOL]DUPLFRIHQRODWRPRIHWLOHQODLQGXFFLyQLQLFLDOHQ
HOWUDVSODQWHUHQDO"
Estudio Tricontinental
/DHILFDFLDGHOPLFRIHQRODWRPRIHWLODVRFLDGRD&V$
\SODFHERRD]DWLRSULQDHQODSUHYHQFLyQGHOUHFKD]R
DJXGRKDVLGRH[KDXVWLYDPHQWHHVWXGLDGRHQHQVD\RV
FOtQLFRVDOHDWRUL]DGRV\FRQWURODGRVWDQWRHQHVWXGLRV
HXURSHRVFRPRDPHULFDQRVFRPRHOTXHVHOODPD(V
WXGLR7ULFRQWLQHQWDO
8QDVtQWHVLVYiOLGDGHHVWRVHQVD\RVVHH[SRQHGH
ODIRUPDTXHVLJXH$QDOL]DQGRODH[SHULHQFLDGH
SDFLHQWHVVHJXLGRVGXUDQWHXQDxR\GHSDFLHQWHV
GHODPLVPDVHULHVHJXLGRVGXUDQWHWUHVDxRVVHRE
VHUYyTXHODLQFLGHQFLDGHUHFKD]RDJXGRHQHOJUXSR
GHODD]DWLRSULQDRGHSODFHERHUDGHOHQFRP
SDUDFLyQFRQ00)JGtDFRQHOTXHIXHGHO\
HO00)JGtDHQTXHIXHGH(QFXDQWRDOD
VXSHUYLYHQFLDGHOLQMHUWRDXQDxRQRKXERGLIHUHQFLDV
QLWDPSRFRHQODVXSHUYLYHQFLDGHOLQMHUWRDDxRVSRU
105
WDQWRHQFRQFOXVLyQPX\UHVXPLGDGHHVWRVHVWXGLRV
SXHGHGHFLUVHTXHODDVRFLDFLyQGH00)D&V$ \D]D
WLRSULQDRSODFHERSURGXFHQXQDGLVPLQXFLyQJOREDOGH
XQGHODVFULVLVGHUHFKD]RDJXGRVLQTXHVHKD
\DGHPRVWUDGRXQDHILFDFLDGHILQLWLYDHQODVXSHUYL
YHQFLDGHOLQMHUWR5HFLHQWHPHQWHVHKDDQDOL]DGRLQ
GHSHQGLHQWHPHQWHODVXSHUYLYHQFLDGHORVLQMHUWRVD
DxRVSRU2MR\FROVXWLOL]DQGROD%DVHGH'DWRVGHOD
8126REVHUYiQGRVHXQDPHMRUtDHQHOJUXSRWUDWDGR
FRQ00)YV D]DWLRSULQDTXHSDUHFHLQGHSHQGLHQWHGHO
UHFKD]RDJXGRORTXHVHFRPHQWDUiSUREDEOHPHQWHHQ
ODVHFFLyQGHUHFKD]RFUyQLFR
8QDSUHJXQWDVLPLODUVHWHQGUtDTXHKDFHUSDUDOD
UDSDPLFLQDPHGLFDPHQWRGHPiVUHFLHQWHLQWURGXF
FLyQFRPHUFLDOL]DGR\DHQORV((88\SHQGLHQWHGH
VXFRPHUFLDOL]DFLyQWRGDYtDHQ(XURSD
/DUDSDPLFLQDKDVLGRXWLOL]DGDLQLFLDOPHQWHHQ
FRPSDUDFLyQFRQ&V$ FRPRLQPXQRVXSUHVLyQGHED
VHDVRFLDGDDODD]DWLRSULQD\DORVHVWHURLGHV\SRV
WHULRUPHQWHKDVLGRHYDOXDGDFRQ&V$ GHPRVWUiQGRVH
XQDLPSRUWDQWHVLQHUJLDRWUDVXQSHULRGRGHPHVHV
GHXWLOL]DFLyQFRQMXQWDGH&V$ \UDSDPLFLQD\OXHJR
UHWLUDQGRHODQWLFDOFLQHXUtQLFR/DUDSDPLFLQDGHPRV
WUyXQDHILFDFLDVLPLODUDODGHOD&V$ HQODSUHYHQFLyQ
GHOUHFKD]RDJXGRVLQGLIHUHQFLDVVLJQLILFDWLYDVHQWUH
DPEDV\WDPELpQPRVWUDQGRXQDLJXDOGDGHQODVX
SHUYLYHQFLDGHOLQMHUWR\GHOSDFLHQWHDXQDxRFXDQGR
VHFRPSDUDEDQVLUROLPXVRVLUROLPXVPiV&V$
(QORVHVWXGLRVHQIDVH,,,HQTXHVHKDDQDOL]DGR
OD&V$ HQGRVGRVLVDVRFLDGDD&V$ YV SODFHERRD]D
WLRSULQDVHKDGHPRVWUDGRXQDLPSRUWDQWtVLPDUHGXF
FLyQGHOUHFKD]RDJXGRXVDQGRWDQWRPJFRPRPJ
6LQHPEDUJRHQWRGRVORVHVWXGLRVUHDOL]DGRVODVX
SHUYLYHQFLDGHOLQMHUWR\GHOSDFLHQWHDODxRQRPRV
WUDURQQLQJXQDGLIHUHQFLD
3RUWDQWRFRPRVtQWHVLVGHORDQWHULRUPHQWHPHQ
FLRQDGRVHSXHGHGHFLUTXHHQWRGRVORVHQVD\RVFOtQL
FRVGHORVQXHYRVLQPXQRVXSUHVRUHVTXHKDQDFWXDOL]D
GRHOUHFKD]RDJXGRFRPRHQGSRLQW SULPDULRVHSXHGH
GHFLUTXHWDQWRHO00)FRPRHOWDFUROLPXVFRPRORVDQ
WLFXHUSRVDQWLUHFHSWRUGHOD,/\ODUDSDPLFLQDKDQ
PRVWUDGRXQDJUDQHILFDFLDHQODGLVPLQXFLyQGHODLQFL
GHQFLDGHOUHFKD]RDJXGRVLQEHQHILFLRVLJQLILFDWLYRHQ
ODVXSHUYLYHQFLDGHOLQMHUWRDFRUWRSOD]R¢$ TXpSXHGH
GHEHUVHTXHXQRVIiUPDFRVTXHWDQHILFD]PHQWHGLVPL
QX\HQHOUHFKD]RDJXGRQRPXHVWUHQXQDLPSRUWDQWHGL
IHUHQFLDHQODVXSHUYLYHQFLDGHOLQMHUWRDPiVODUJRSOD
]R"/RSULPHURTXHKD\TXHGHFLUHVTXHSDUHFHOyJLFR
TXHFXDQGRVHLQWHQWDYDORUDUXQIiUPDFRFX\RHIHFWR
IXQGDPHQWDOHVODLQPXQRVXSUHVLyQSURILOiFWLFDVHYD
ORUHHOUHFKD]RDJXGRSXHVWRTXHHVWiQGLULJLGRVDODLQ
KLELFLyQDGLYHUVRVQLYHOHVGHODFpOXOD7DVXVHxDOL
]DFLyQ\DVXSUROLIHUDFLyQFX\DPDQLIHVWDFLyQSULQFHSV
HVHOUHFKD]RDJXGR3HURKD\TXHGHFLUTXHHVWRQRVLHP
SUHKDVLGRDVt(QHOHQVD\RLQLFLDOKLVWyULFRGH0XUUD\
SXEOLFDGRHQ1HZ(QJODQGHQHODxRHQHOTXHVH
GHVFULEtDQFLQFRUHFHSWRUHVGHWUDVSODQWHUHQDOGHFDGi
YHUTXHUHFLELHURQD]DWLRSULQDVHPLGLyODVXSHUYLYHQ
FLDGHOSDFLHQWH\GHOLQMHUWRDXQDxR\FRQYLHQHUHFRU
GDUTXHVyORXQSDFLHQWHVREUHYLYLyORVGtDVFRQHO
LQMHUWRIXQFLRQDQWHVLHQGRHOSULPHUWUDVSODQWHUHQDOGH
FDGiYHUFRQp[LWR(VWRIXHVXILFLHQWHSDUDFRQWLQXDU
XVDQGRODD]DWLRSULQDFRPROD~QLFDSRVLELOLGDGGHSUH
YHQLUHOUHFKD]RDJXGR7DPELpQFRQYLHQHUHFRUGDUTXH
HQORVHVWXGLRVLQLFLDOHVGHOD&V$ HQORVDxRVVHXWL
OL]yFRPRHQGSRLQW ODVXSHUYLYHQFLDGHOLQMHUWR\TXH
WDQWRHQHOHVWXGLRPXOWLFpQWULFRHXURSHRGHFRPR
HQHOHVWXGLRPXOWLFpQWULFRFDQDGLHQVHVHGHPRVWUyXQ
DXPHQWRVLJQLILFDWLYRGHODVXSHUYLYHQFLDGHOLQMHUWRDO
SULPHUDxRGHXQDXQHQHOFDVRGH(XURSD\
GHXQDXQHQHOFDVRGH&DQDGiVLHQGRDPEDV
FLIUDVHVWDGtVWLFDPHQWHVLJQLILFDWLYDV
8QHQGSRLQW SDUDXQIiUPDFRHQJHQHUDO\SDUD
ORVLQPXQRVXSUHVRUHVHQSDUWLFXODUWLHQHTXHVHUKH
FKRVELHQGHILQLGRVRGDWRVTXHUHIOHMHQODVHJXULGDG
\ODHILFDFLDGHOIiUPDFR\DGHPiVHVWRVREMHWLYRV
WLHQHQTXHUHXQLUXQDVHULHGHFDUDFWHUtVWLFDVSDUDTXH
VHDQYiOLGRVWLHQHQTXHVHUFRPSUHQVLEOHVUHSURGX
FLEOHVYHULILFDEOHVFRQXQUD]RQDEOHQ~PHURGHSD
FLHQWHV\HQXQUHODWLYDPHQWHFRUWRSHULRGRGHWLHP
SR(QHVWDVFLUFXQVWDQFLDVHOUHFKD]RDJXGRHVXQ
HQGSRLQWDWUDFWLYRSRUTXHHVUHODWLYDPHQWHIUHFXHQWH
DSDUHFHSUHFR]PHQWHGHVSXpVGHOWUDVSODQWHHOQ~
PHURGHSDFLHQWHVQHFHVDULRVHVUD]RQDEOH\VHVXH
OHOLPLWDUHOVHJXLPLHQWRDORVVHLVPHVHVGHVSXpVGHO
WUDVSODQWHTXHHVFXDQGRFRQPD\RUIUHFXHQFLDVH
SURGXFHHVWDFRPSOLFDFLyQLQPXQROyJLFD3HURKH
PRVYLVWRTXHHVWHHQGSRLQW GHOUHFKD]RDJXGRQRVH
FRUUHODFLRQDELHQFRQODVXSHUYLYHQFLDGHOLQMHUWRQL
DFRUWRQLDODUJRSOD]R([LVWHQGLYHUVDVUD]RQHVSRU
ODVTXHODSUHYHQFLyQHIHFWLYDGHOUHFKD]RDJXGRSXH
GHQRPHMRUDUODVXSHUYLYHQFLDGHOLQMHUWR/DSULQ
FLSDOFDXVDTXHSRGUtDDGXFLUVHHVTXHHQHOFDVRGH
GLVSDULGDGLQPXQROyJLFDHQWUHHOGRQDQWH\HOUHFHS
106
RECHAZO AGUDO - 3RQHQFLDV
WRUORVPHFDQLVPRVTXHOOHYDQDOUHFKD]RDJXGRSXH
GHQSURGXFLUFRPRFRQVHFXHQFLDHOUHFKD]RFUyQL
FRRSRUHOFRQWUDULRODGLVSDULGDGLQPXQROyJLFDHQ
WUHGRQDQWH\UHFHSWRUSXHGHSURYRFDUUHFKD]RDJX
GRSRUXQDYtDLQPXQROyJLFDGHWHUPLQDGD\UHFKD]R
FUyQLFRSRURWUDLQGHSHQGLHQWHGHODDQWHULRU\XQ
IiUPDFRTXHFRQWUROHELHQHOUHFKD]RDJXGRSXHGHVHU
LQHILFD]HQHOFRQWUROGHOUHFKD]RFUyQLFR2WUDVUD
]RQHVPiVFOtQLFDVSRGUtDQVHUTXHQRWRGRVORVUH
FKD]RVDJXGRVSURYRFDQXQIUDFDVRGHOLQMHUWR\TXH
ORVTXHQRORSURYRFDQVRQORVPiVIiFLOPHQWHWUDWD
EOHV3RUWDQWRODUHVSXHVWDWDQIiFLOGHDOJXQRVIiU
PDFRVGHOUHFKD]RDJXGRQRWHQGUtDFRQVHFXHQFLDVR
EUHHOUHFKD]RFUyQLFRSRUTXHpVWHHVODFRQVHFXHQ
FLDGHORVFDVRVPiVVHYHURVTXHVRQORVTXHQRFRQ
WURODQQLVLTXLHUDORVIiUPDFRVPiVPRGHUQRV
/RVWUDWDPLHQWRVSDUDODSUHYHQFLyQGHOUHFKD]RDJX
GRSXHGHQSURYRFDUWR[LFLGDGDODUJRSOD]R\PXHUWHV
FRQLQMHUWRIXQFLRQDQWH$TXtODH[SOLFDFLyQGHULYDGH
TXHHOSURSLRIiUPDFRHVHOTXHLQGXFHODFRPSOLFDFLyQ
TXHOOHYDDODPXHUWH\SRUWDQWRDXQDPHQRUVXSHUYL
YHQFLDRLQFOXVRDXQDWR[LFLGDGGLUHFWDVREUHHOLQMHUWR
TXHDXQTXHSUHYHQJDHOUHFKD]RGLVPLQX\HODVXSHU
YLYHQFLDSRUGDxRVGLUHFWRVVREUHHOyUJDQRWUDVSODQWD
GR/DWHUFHUDKDVLGRFRPHQWDGD\DHWLRSDWROyJLFDPHQWH
\HVTXHODQHIURSDWtDFUyQLFDGHOLQMHUWRSXHGHQRPR
GLILFDUVHSRUODSUHYHQFLyQGHOUHFKD]RDJXGR<ILQDO
PHQWHWDPELpQORVWUDWDPLHQWRVSDUDODSUHYHQFLyQGHO
UHFKD]RDJXGRSXHGHQSURYRFDUGDxRUHQDO\IUDFDVRGHO
LQMHUWRDODUJRSOD]R
8QDVSHFWRSRFRDQDOL]DGRSHURPX\LPSRUWDQWH
WDPELpQGHODIUDJLOLGDGGHOUHFKD]RDJXGRFRPRHQG
SRLQW SULPDULRHQHOLQPHGLDWRIXWXURYDDVHUTXHDOLU
GLVPLQX\HQGRODSRVLELOLGDGGHHVWHHYHQWRVHKDFHFD
GDYH]PiVFRPSOLFDGRODHODERUDFLyQGHHQVD\RVFOt
QLFRVTXHVHIXQGDPHQWHQHQHOORDVtSRUHMHPSOR
FXDQGRQRVRWURVKDFtDPRVHQVD\RVFOtQLFRVHQTXHVH
HVSHUDEDXQDLQFLGHQFLDGHUHFKD]RDJXGRHQHOJUXSR
FRQWUROGHXQ\TXHHOJUXSRGHWUDWDPLHQWRIXH
UDDWHQHUXQDLQFLGHQFLDHVSHUDGDGHXQSRGUtD
PRVFDOFXODUTXHHOWDPDxRGHODPXHVWUDQHFHVDULRSD
UDGHPRVWUDUVLJQLILFDFLyQHVWDGtVWLFDLEDDVHUGHXQRV
SDFLHQWHV3HURVL\DGLVSRQHPRVGHIiUPDFRVFRQ
HOTXHHOJUXSRFRQWUROYDDWHQHUXQDLQFLGHQFLDGHUH
FKD]RDJXGRGHXQFRPRHVWiSDVDQGRFRQDOJX
QRVGHORVDFWXDOHVTXLHUHGHFLUTXHVLHQHOJUXSRGH
WUDWDPLHQWRODLQFLGHQFLDHVSHUDGDHVGHOHOQ~
PHURGHSDFLHQWHVQHFHVDULRVSDUDGHPRVWUDUVLJQLILFD
FLyQYDDVHUGH
$VtVHSXHGHUHVXPLUTXHODVXSHUYLYHQFLDGHOLQ
MHUWR\DQRVHYDDXWLOL]DUSRUTXHHOIDOORGHOLQMHUWRHV
PX\LQIUHFXHQWH4XHHOUHFKD]RDJXGRHVWiGLVPLQX
\HQGR\TXHQRWLHQHFRUUHODFLyQFRQODVXSHUYLYHQFLD
GHOLQMHUWR3DUDDQDOL]DUODYDOLGH]GHOGHVFHQVRGHOD
IXQFLyQUHQDOFRPR HQGSRLQW VHQHFHVLWDQPiVHVWX
GLRV\GHHQWUDGDHVPiVFRPSOLFDGRGHXWLOL]DUDXQ
TXHYDDVHULQHYLWDEOHKDFHUORFDGDYH]PiVGHELGRDO
GHVFHQVRGHOUHFKD]RDJXGR(OGDxRKLVWROyJLFRHVXQ
PDUFDGRUSURPHWHGRUGHIXWXURHQHQVD\RVFOtQLFRV8Q
WHPDGHXQDUWtFXORPX\UHFLHQWHGH7UDQVSODQWDWLRQ
GLFHTXHORTXHUHDOPHQWHVHQHFHVLWDDKRUDHQHOWUDV
SODQWHUHQDOHVXQDFRPSDUDFLyQDyDxRVGHODVX
SHUYLYHQFLDGHOLQMHUWR\GHOSDFLHQWHPLHQWUDVTXHODV
FRPSDxtDVIDUPDFpXWLFDVTXHHVSRQVRUL]DQODPD\RU
SDUWHGHORVHVWXGLRVSRQHQVXDWHQFLyQIXQGDPHQWDO
PHQWHHQORVUHVXOWDGRVDFRUWRSOD]RORVFXDOHVVHQH
FHVLWDQSDUDORVUHJLVWURVGHORVIiUPDFRV1RKD\TXH
ROYLGDUTXHODPD\RUtDGHORVQHIUyORJRVHVWiQLPSOL
FDGRVHQHQVD\RVFOtQLFRVGHKLSRWHQVRUHVFX\DGXUD
FLyQHVGHXQPtQLPRGHFLQFRDxRV
< SDUDWHUPLQDUVHUtDSRVLEOHKDFHUGHXQDIRU
PDFRPELQDGDODYDORUDFLyQFOtQLFD\HSLGHPLROy
JLFDDGHFXDGDV\D\XGDUDODVQHFHVLGDGHVGHODLQ
GXVWULDIDUPDFpXWLFDPHGLDQWHXQDQiOLVLVVHFXHQFLDO
GHXQHQGSRLQW SULPDULRTXHSRGUtDVHUHOUHFKD]R
DJXGRODIXQFLyQUHQDORHOGDxRKLVWROyJLFRDVHLV
PHVHVRDXQDxRSDUDGHPRVWUDUXQDSUHVXQFLyQGH
HYLGHQFLDSDUDODHILFDFLDDODUJRSOD]RORTXHSHU
PLWLUtDXQDOLFHQFLDLQLFLDOGHOIiUPDFR\DPiVODU
JRSOD]RDyDxRVORVIiUPDFRVSUREDEOHPHQ
WHGHEHUtDQVHUUHHYDOXDGRVPHGLDQWHHQGSRLQW VH
FXQGDULRVFRPRODVXSHUYLYHQFLDGHOSDFLHQWH\GHO
LQMHUWRODFDOLGDGGHYLGDHLQFOXVRORVFRVWHVORFXDO
VHGHEHUtDVXPDUDORVGDWRVGHORVJUDQGHVUHJLVWURV
PXOWLFpQWULFRV\XQLFpQWULFRV\GHORVKRVSLWDOHVFRQ
JUDQDFWLYLGDG
107
BIBLIOGRAFÍA
-RYHOO$-1DYDUUR5XELR0'(YDOXDFLyQGHODHYLGHQFLDFLHQ
WtILFD0HG&OLQ%DUF
6DFNHWW'/5LFKDUGVRQ:65RVHQEHUJ:+D\QHV(%(YL
GHQFHEDVHG0HGLFLQH+RZWRSUDFWLFHDQGWHDFK(0%/RQ
GUHV&KXUFKLOO/LYLQJVWRQH
6DFNHWW'/5RVHPEHUJ:*DU\-$+D\QHV5%5LFKDUGVRQ
:6(YLGHQFH%DVHG0HGLFLQH:KDWLVDQGZKDWLWLVQ·W"%0-
3LUVFK-'DQG6WXG\*URXS.LGQH\7UDQVSODQW7DFUROLPXVYHUVXV
&\FORVSRULQHLQ.LGQH\WUDQVSODQWDWLRQ)LYH\HDUVUHVXOWVRI
WKH860XOWLFHQWHU5DQGRPL]HG&RPSDUDWLYHVWXG\7UDQV
SODQWDWLRQ$EVWU$EVWUDFW6DUDQGRPL]HG
*RQZD7$-RKQVRQ&$KVDQ1+DOORUDQ36WHJDOO0+DUG\
00HW]JHU56KLHOG&5RFKHU/6FDQGOLQJ-6RUHQVHQ-
0XOOR\//LJKW-&RUZLQ&'DQRYLWFK*:DFKV09DQ
9HOGKXLVHQ36DOP.7RO]PDQ'6FRWHOODUR3DQG)LW]VLP
PRQV:7ZR\HDUIROORZXSRIDUDQGRPL]HGPXOWLFHQWHUNLG
QH\WUDQVSODQWVWXG\FRPSDULQJWDFUROLPXVSJD]DWKLR
SULQHD]DYV F\FORVSRULQHQHRUDOP\FRSKHQRODWHPR
IHWLOPPIYV WDFUROLPXVPPI7UDQVSODQWDWLRQ$EVWU
6
*UHJ$.QROO5REHUW&%HOO7DFUROLPXVYHUVXV &\FORVSRULQHIRU
,PPXQRVXSSUHVVLRQLQUHQDOWUDQVSODQWDWLRQPHWDDQDO\VLVRI
UDQGRPLVHGWULDOV%ULWLVK0HGLFDO-RXUQDO$SULO
7KHFRVWRI.QRZOHGJHLQ1HSKURORJ\DQGWKHLPSRUWDQFHRI&OL
QLFDO'DWDEDVHV-RXUQDORI1HSKURORJ\
3DVFXDO-7UDWDPLHQWRLQPXQRVXSUHVRULQLFLDOHQ7UDVSODQWH
5HQDO1HIURORJtDYRO6S
0XUUD\-(0HUULOO-3+DUULVRQ-+:LOVRQ5('DPPLQJ*-
3URORQJHGVXUYLYDORIKXPDQNLGQH\WUDQVSODQWDWLRQE\LP
PXQRVXSSUHVVLYH GUXJ WKHUDS\ 1HZ (QJO - 0HG *URWK&*%DFNPDQ/0RUDOHV-0&DOQH5.UHLV+/DQJ
37RXUDLQH-/&ODHVRQ.&DPSLVWRO-0'XUDQG':UDP
PHU/%UDWWVWURP&DQG&KDUSHQWLHU%IRUWKH6LUROLPXV(X
URSHDQ5HQDO6WXG\*URXS6LUROLPXVUDSDP\FLQEDVHGWKH
UDS\LQKXPDQUHQDOWUDQVSODQWDWLRQVLPLODUHIILFDF\DQGGLI
IHUHQWWR[LFLW\FRPSDUHGZLWKF\FORVSRULQH7UDQVSODQWDWLRQ
&DQDGLDQ0XOWLFHQWUH7UDQVSODQW6WXG\*URXS$ UDQGRPL]HG
FOLQLFDOWULDORIF\FORVSRULQHLQFDGDYHULFUHQOWUDQVSODQWDWLRQ
1HZ(QJO-0HG
&DOQH5:KLWH'-&(YDQV'%:ULJKW&7KUHH\HDUVH[SH
ULHQFHZLWKF\FORVSRULQHLQFOLQLFDOFDGDYHULFNLGQH\WUDQV
SODQWDWLRQ,Q:KLWH'-&(G3URFHHGLQJVRQD,QWHUQDWLR
QDO&RQIHUHQFHRQ&\FORVSRULQH$(OVHYLHU%LRPHGLFDO3UHVV
1XHYD<RUN
0\FRSKHQRODWH0RIHWLOLQUHQDOWUDQVSODQWDWLRQ\HDUVUH
VXOWVIURPWKHSODFHERFRQWUROOHGWULDO(XURSHDQ0\FRSKHQR
ODWH0RIHWLO6WXG\*URXS7UDQVSODQWDWLRQ
0\FRSKHQRODWH0RIHWLOLQFDGDYHULFUHQDOWUDQVSODQWDWLRQ86
5HQDO0\FRSKHQRODWH0RIHWLO6WXG\*URXS$PHULFDQ-RXUQDO
RI.LGQH\'LVHDVHV
6ROOLQJHU+:0\FRSKHQRODWHPRIHWLOIRUWKHSUHYHQWLRQRIDFX
WHUHMHFWLRQLQSULPDU\FDGDYHULFUHQDODOORJUDIWUHFLSLHQWV7KH
865HQDO7UDQVSODQW0\FRSKHQRODWH0RIHWLO6WXG\*URXS
7UDQVSODQWDWLRQ
7KH7ULFRQWLQHQWDO0\FRSKHQRODWH0RIHWLO5HQDO7UDQVSODQ
WDWLRQ6WXG\*URXS$ EOLQGHGUDQGRPL]HGFOLQLFDOWULDORIP\FR
SKHQRODWHPRIHWLOIRUWKHSUHYHQWLRQRIDFXWHUHMHFWLRQLQFD
GDYHULFUHQDOWUDQVSODQWDWLRQ7UDQVSODQWDWLRQ
(XURSHDQ0\FRSKHQRODWH0RIHWLO&RRSHUDWLYH6WXG\*URXS
3ODFHERFRQWUROOHGVWXG\RIP\FRSKHQRODWHPRIHWLOFRPELQHG
ZLWKF\FORVSRULQHDQGFRUWLFRVWHURLGVIRUSUHYHQWLRQRIDFXWH
UHMHFWLRQ/DQFHW
+DOORUDQ30DWKHZ77RPODQRYLWFK6*URWK&+RRIWPDQ/
%DUNHU&0\FRSKHQRODWHPRIHWLOLQUHQDODOORJUDIWUHFLSLHQWV
DSRROHGHIILFDF\DQDO\VLVRIWKUHHUDQGRPL]HGGRXEOHEOLQG
FOLQLFDOVWXGLHVLQSUHYHQWLRQRIUHMHFWLRQ7KH,QWHUQDWLRQDO
0\FRSKHQRODWH0RIHWLO5HQDO7UDQVSODQW6WXG\*URXSV7UDQ
SODQWDWLRQ
0DWKHZ7+$ EOLQGHGORQJWHUPUDQGRPL]HGPXOWLFHQWHUVWXG\
RIP\FRSKHQRODWHPRIHWLOLQFDGDYHULFUHQDOWUDQVSODQWDWLRQUH
VXOWVDWWKUHH\HDUV7ULFRQWLQHQWDO0\FRSKHQRODWH0RIHWLO5HQDO
7UDQVSODQWDWLRQ6WXG\*URXS7UDQVSODQWDWLRQ
(XURSHDQ0\FRSKHQRODWH0RIHWLO&RRSHUDWLYH6WXG\*URXS
0\FRSKHQRODWHPRIHWLOLQUHQDOWUDQVSODQWDWLRQ\HDUUHVXOWV
IURPWKHSODFHERFRQWUROOHGWULDO7UDQVSODQWDWLRQ
108
RECHAZO AGUDO - 3UHVHQWDFLyQ
3UHVHQWDFLyQ
0DQXHO$ULDV
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
109
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
110
RECHAZO AGUDO - 3UHVHQWDFLyQ
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
111
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
112
RECHAZO AGUDO - 3UHVHQWDFLyQ
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
113
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
'LDSRVLWLYD
114
RECHAZO AGUDO - &RQFOXVLRQHV
RECHAZO AGUDO
&RQFOXVLRQHV
/DLQFLGHQFLDGHUHFKD]RDJXGRHVYDULDEOHVHJ~Q
VHDXQWUDVSODQWHFDUGtDFRUHQDO\KHSiWLFRFLIUiQGR
VHHQXQRVSRUFHQWDMHVGHOGHO\GHO
UHVSHFWLYDPHQWH
(VWDVGLIHUHQFLDVHQODLQFLGHQFLDGHUHFKD]RDJX
GRYLHQHQFRQGLFLRQDGDVSRUGLIHUHQFLDVHQODUHDFWL
YLGDGDQWLJpQLFDGHORVyUJDQRVSHURWDPELpQSRUOD
SUiFWLFDGHELRSVLDVGHSURWRFRORHVSHFLDOPHQWHHQ
WUDVSODQWHFDUGtDFR
(QJHQHUDOVHFRQVLGHUDTXHHOUHFKD]RDJXGR
WLHQHXQLPSDFWRQHJDWLYRHQORVUHVXOWDGRVGHOWUDV
SODQWHDODUJRSOD]RDXQTXHGHSHQGHUiGHODLQWHQ
VLGDGGHOPLVPR\GHOWLHPSRGHGHVDUUROORSRV
WUDVSODQWH
/DELRSVLDVLJXHUHSUHVHQWDQGRHOJROGVWDQGDUG
HQHOGLDJQyVWLFRGHORVHSLVRGLRVGHUHFKD]RDJXGR
/RVEROXV GHPHWLOSUHGQLVRORQDVLJXHQVLHQGR
HOSULPHUWUDWDPLHQWRHQORVHSLVRGLRVGHUHFKD]R
DXQTXHFDGDYH]PiVVHDFRQVHMDQFDPELRVHQHOWUD
WDPLHQWRLQPXQRVXSUHVRUGHEDVHFRPRODLQWUR
GXFFLyQGHO00)\RODFRQYHUVLyQGHFLFORVSRULQD
DWDFUROLPXV
115
-0&DPSLVWRO
