Benign Hematological Disorders

‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÕ¥ÿµ—π„π‡¥Á°·≈–«¬—√πÿà Stroke in Children and Adolescents 229

computed tomography (CT) brain ‡∫È◊Õßµâπ ‚æ√ßÀ≈Õ¥‡≈◊Õ¥¥”„π ¡ÕßÕ¥ÿµπ—
‡æÕË◊ ¥«Ÿ“à ¡¿’“«–‡≈Õ◊ ¥ÕÕ°„π ¡ÕßÀ√Õ◊ ‰¡à ®–™«à ¬„π √–∫“¥«‘∑¬“
°“√«“ß·ºπ°“√√°—…“  «à π°“√ ßà µ√«®‡æÕË◊ À“§«“¡
º¥‘ª°µ¢‘ÕßÀ≈Õ¥‡≈Õ◊ ¥ ‡™πà magnetic resonance Õÿ∫—µ‘°“√≥å¢Õß‚æ√ßÀ≈Õ¥‡≈◊Õ¥¥”„π ¡Õß
angiography (MRA), CT angiography (CTA) Õÿ¥µ—π æ∫‰¥âπâÕ¬°«à“À≈Õ¥‡≈◊Õ¥·¥ß„π ¡ÕßÕÿ¥
‡æ◊ËÕÀ“ dissection, stenosis ·≈–≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π µπ— ®“°°“√»°÷…“‚¥¬ The Canadian Pediatric
¢ÕßÀ≈Õ¥‡≈Õ◊ ¥ „π°√≥∑’¡’˧’«“¡º¥‘ª°µ¢‘ÕßÀ≈Õ¥ Ischemic Stroke Registry æ∫ª√–¡“≥ 0.67
‡≈Õ◊ ¥¢π“¥‡≈°ÁÀ√Õ◊  ß ¬—arterial dissection µÕà ª√–™“°√ 100,000 √“¬µÕà ª8ï æ∫Õ∫ÿµ—°‘“√≥ å ߟ
¢÷Èπ„π‡¥Á°ºâŸ™“¬ µ”·Àπàß∑Ë’æ∫∫àÕ¬ §◊Õ superior
°“√µ√«®∑“ßÀÕâߪؑ∫—µ‘°“√ sagittal sinus (√âÕ¬≈– 55) lateral sinuse
·π«∑“ß„π°“√ ßà µ√«®∑“ßÀÕâ ߪÆ∫‘µ—°‘“√„π (√âÕ¬≈– 51) ·≈– straight sinus (√âÕ¬≈– 24)
ª√–¡“≥§√÷ËßÀπË÷ߢÕߺŸâªÉ«¬®–¡’√Õ¬‚√§¡“°°«à“
ªí®®ÿ∫—π¬—߉¡à¡’™—¥‡®π °“√´—°ª√–«—µ‘‡æË◊ÕÀ“ªí®®—¬ Àπß÷Ë·Àßà
‡ ’ˬß∑’Ë®”‡æ“–„πºŸâªÉ«¬·µà≈–∫ÿ§§≈®–¡’ à«π™à«¬„π  “‡Àµÿ·≈–ªí®®—¬‡ Ë’¬ß
°“√‡≈◊Õ° àßµ√«®∑“ßÀâÕߪؑ∫—µ‘°“√ °“√ àßµ√«®
§«√§√Õ∫§≈ÿ¡ªí®®—¬‡ ’ˬß∑’Ëæ∫∫àÕ¬ ‡™à𠧫“¡º‘¥ ª®í ®¬—∑æË’∫∫Õà ¬ §Õ◊ ¿“«–∑¡Ë’°’“√·¢ßÁµ«—¢Õß
ª°µ¢‘ÕßÀ«—„® ·π–π”µ√«® echocardiography „π ‡≈Õ◊ ¥º¥‘ª°µ‘(prothrombotic disorder) πÕ°®“°
ºâŸªÉ«¬ AIS ∑ÿ°√“¬ √«¡∂÷ß àßµ√«® intravenous π’Ȭ—߇°‘¥‰¥â®“° ¿“«– Ÿ≠‡ ’¬πÈ” (dehydration)
saline injection ‡æÕË◊ ‡æ¡‘Ë‚Õ°“ „π°“√«π‘®‘©¬—‚√§ °“√µ‘¥‡™◊ÈÕ∫√‘‡«≥ à«π»’√…–·≈–≈”§Õ √«¡∂÷ß
patent foramen ovale (PFO) ∑¡’Ë¢’𓥇≈°Á¥«â ¬ °“√‰¥â√—∫¬“∑Ë’‡ªìπ procoagulant drug ‡™àπ L-
πÕ°®“°π§’È«√µ√«®À“§«“¡º¥‘ª°µ¢‘Õß√–∫∫‡≈◊Õ¥ asparaginase À√Õ◊ ¬“§¡ÿ°”‡π¥‘ ‡ªπì µπâ
‚¥¬‡©æ“–¿“«–∑’Ë¡’·π«‚πâ¡„π°“√·¢Áßµ—«¢Õ߇≈◊Õ¥
ß“à ¬º¥‘ª°µ‘

√Ÿª∑Ë’15.2 T1-weighted MRI · ¥ß clot „π superior sagittal sinus ·≈– straight sinus ¢Õß
ºªŸâ «É ¬ cerebral venous thrombosis (≈°Ÿ»√™)’È(‰¥√â ∫—§«“¡‡ÕÕ◊ȇøÕóô √ªŸ®“° æ.≠.¿√‘¥’ «ÿ√√≥¿°—¥)’

230 ¿√‘¥’ ÿ«√√≥¿°—¥’

Õ“°“√·≈–Õ“°“√· ¥ß ª®í ®¬—ÕπË◊ Ê ∑®’Ë–∑”„À‚â √§·¬≈à ß ‡™πà °“√µ¥‘‡™Õ◊È ™°—
‡π◊ËÕß®“°‚æ√ßÀ≈Õ¥‡≈◊Õ¥¥”„π ¡ÕßÕÿ¥µ—𠧫“¡¥π—‚≈Àµ‘µË” ‡ªπì µπâ  «à π„π‚√§ CSVT ππ—È
®– àߺ≈√∫°«πµàÕ venous drainage ∑”„À⇰‘¥ ®”‡ªπì ∑µ’ËÕâ ß„À â “√πÈ”∑‡’Ë欒ßæÕ‡æÕ◊˪ÕÑ ß°π—‰¡„à À‡â °¥‘
¿“«–§«“¡¥π—„π ¡Õߠߟ  ¡Õß∫«¡ ®π∂ß÷¡‡’≈Õ◊ ¥ ≈¡Ë‘‡≈Õ◊ ¥Õ¥ÿµπ— ¢πÈ÷Õ°’
ÕÕ°„π ¡ÕßÀ√◊Õ ¡Õߢ“¥‡≈◊Õ¥‰¥â ¥—ßπ—Èπ Õ“°“√ ¢. °“√√°—…“¥«â¬¬“ ª√–°Õ∫¥«â ¬
·≈–Õ“°“√· ¥ß¢ÕߺªŸâ «É ¬ «à π„À≠®à –¡“¥«â ¬Õ“°“√ 1. °≈¡ÿà‚æ√ßÀ≈Õ¥‡≈Õ◊¥¥”„π ¡ÕßÕ¥ÿµπ—
ª«¥»’√…–√ÿπ·√ß °“√≈¥≈ߢÕß√–¥—∫§«“¡√Ÿâ ÷°µ—« „πªí®®ÿ∫—π°“√√—°…“ CSVT „π‡¥Á°π‘¬¡
™°— ·≈–Õ¡—惰…¢å Õß·¢π¢“ ‡ªπì µπâ ‡√¡Ë‘°“√√°—…“¥«â ¬ unfractionated heparin (UFH)
À√Õ◊ low molecular weight heparin (LMWH)
°“√ àßµ√«®∑“ßÀÕâߪØ∫‘—µ‘°“√ „π°√≥’ºâŸªÉ«¬∑’ˉ¡à¡’‡≈◊Õ¥ÕÕ°„π ¡Õß‚¥¬°“√√—°…“
°“√µ√«®¿“æ∂“à ¬√ß— ∑’ ’Ë”§≠— §Õ◊ °“√µ√«® ª√–¡“≥ 3 ‡¥Õ◊ π9 À≈ß—®“°ππ—Ȫ√–‡¡π‘¥«â ¬ CTV
§≈◊Ëπ·¡à‡À≈Á°‰øøÑ“ (MRI brain) (√Ÿª∑Ë’15.2) À√◊Õ MRV ∂â“æ∫«à“‰¡à¡’≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—πÀ≈߇À≈◊Õ
·≈– magnetic resonance venography (MRV) „Àâæ‘®“√≥“À¬ÿ¥¬“ ·µà∂⓬—ß¡’≈‘Ë¡‡≈◊Õ¥À≈߇À≈◊Õ
∂Õ◊ ‡ªπì gold standard ·µÀà “°‰¡ à “¡“√∂µ√«®‰¥â Õ¬àŸ®÷ßæ‘®“√≥“„ÀâµàÕ‡π◊ËÕ߉ªÕ’° 3 ‡¥◊Õπ ®÷ß∑”°“√
°“√µ√«®‡Õ°Á´‡√¬§å Õ¡æ«‘‡µÕ√ å ¡Õß (CT brain) ª√–‡¡π‘´È”Õ°’§√ß—ÈÀπßË÷ ”À√∫—„π°√≥∑’¡Ë’‡’≈Õ◊ ¥ÕÕ°„π
·≈– CT venography (CTV) ° Á“¡“√∂„À¢â Õâ ¡≈Ÿ  ¡Õß殑“√≥“‰¡‡à √¡Ë‘¬“ anticoagulant ·µæà ®‘“√≥“
‡æ¬’ßæÕ„π°“√«π‘®‘©¬— ∑ßÈ—π°È’“√µ√«®æ∫ sinoveous µ¥‘µ“¡º≈¢Õß°Õâ π‡≈Õ◊ ¥„π√–¬–‡«≈“ª√–¡“≥ 7-10
thrombosis ππÈ— ¢π÷ÈÕ¬°àŸ∫—≈°—…≥–¢Õߪ√–™“°√·≈– «π— ∂“â æ∫«“à ‡≈Õ◊ ¥ÕÕ°„π ¡Õß≈¥≈ß√«à ¡°∫—°“√¡≈’¡Ë‘
«‘∏’°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√„π·µà≈–‚√ß欓∫“≈ ‡≈Õ◊ ¥Õ¥ÿµπ—‡æ¡Ë‘¢πÈ÷Õ“®®–殑“√≥“„Àâ anticoagulant
¥â«¬ ¡’°“√»÷°…“®“°ª√–‡∑»‡¬Õ√¡—πæ∫«à“ºâŸªÉ«¬∑’Ë ‰¥â ∑ßÈ—πµÈ’Õâ ß殑“√≥“‡ªπì √“¬Ê ‰ª µ“¡„π√“¬≈–‡Õ¬’¥
¡’§«“¡º‘¥ª°µ‘¢Õß thrombophilia ¡“°°«à“ „π·ºπ¿¡Ÿ∑‘Ë’15.2
À√◊Õ‡∑à“°—∫ 2 ™π‘¥ ®–¡’‚Õ°“ ‡°‘¥≈‘Ë¡‡≈◊Õ¥Õ¥ÿµπ— °√≥’ºŸâªÉ«¬∑Ë’¡’‚√§ª√–®”µ—«‡™àπ nephrotic
‡√«Á¢π÷ÈÀ√Õ◊ ¡‚’Õ°“ ∑√’ËÕ¬‚√§®–°≈∫—¡“‡ªπì „À¡‰à ¥âÕ’° syndrome, SLE ´ßË÷‚√§¬ß—‰¡ à ß∫ (active) Õ¬ÀŸà √Õ◊
 ”À√—∫°“√µ√«®§—¥°√Õß thrombophilia ∑’Ë¡≈’¡‘Ë ‰¥√â ∫—¬“ L-asparaginase „πºªâŸ«É ¬¡–‡√ßÁ‡¡¥Á‡≈Õ◊ ¥
‡≈Õ◊ ¥Õ¥ÿµπ—„π ¡Õß„π‡¥°Áπ¬‘¡®–µ√«®À≈ß—®“°‡°‘¥ ¢“« Õ“®®–æ‘®“√≥“„À⬓ prophylactic antico-
≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—Õ¬“à ßπÕâ ¬À≈ß—®“°‡√¡Ë‘°“√√°—…“ 3-6 agulant ‡™àπ LMWH «—π≈–§√—Èß  ”À√—∫°“√
‡¥Õ◊ π À√Õ◊ À≈ß—À¬¥ÿ oral anticoagulant ·≈«â 殑“√≥“∑”°“√º“à µ¥— (surgical decompression)10
À√◊Õ„À⬓„π°≈ÿà¡ thrombolytic agent ®–
·π«∑“ß°“√√—°…“·≈–ªÕÑß°π—‚√§ æ‘®“√≥“„π°√≥’∑Ë’‰¡àµÕ∫ πÕßµàÕ°“√√—°…“¥â«¬
‡πÕË◊ ß®“°°“√√°—…“‚√§À≈Õ¥‡≈Õ◊ ¥·¥ß„π ¡Õß UFH À√Õ◊ LMWH ‡∑“à ππÈ—
Õÿ¥µπ— ·≈–‚æ√ßÀ≈Õ¥‡≈Õ◊ ¥¥”„π ¡ÕßÕ¥ÿµπ—¡·’π« 2. °≈¡ÿà≈¡‘ˇ≈Õ◊¥Õ¥ÿµπ—„πÀ≈Õ¥‡≈Õ◊¥·¥ß
∑“ß°“√√°—…“„°≈‡â §¬’ß°π— º‡Ÿâ ¢¬’π®ß÷¢Õ°≈“à «√«¡‰«â  ”À√—∫°“√√—°…“ AIS ·π–π”„Àâ‡√Ë‘¡√—°…“
¥«â ¬°π— ¥ß—πÈ’ ¥â«¬ UFH À√◊Õ LMWH ‡ªìπ‡«≈“ 7 «—π ·≈â«
°. °“√√°—…“ª√–§∫—ª√–§Õß ‚¥¬°“√√°—…“ µ“¡¥â«¬ aspirin (1-5 ¡°./°°./«—π) À√◊Õ

‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÿ¥µπ—„π‡¥°Á·≈–«—¬√ÿàπ Stroke in Children and Adolescents 231

·ºπ¿¡Ÿ∑‘’Ë15.2 ·π«∑“ß°“√√°—…“ CSVT „π‡¥°Á

CSVT = cerebral sinovenous thrombosis, UFH = unfractionated heparin,
LMWH = low molecular weight heparin, CT = computed tomography,
MRI = magnetic resonance imaging, MRV = magnetic resonance venography

232 ¿‘√¥’ ÿ«√√≥¿°—¥’

LMWH11 ¢πÈ÷Õ¬°Ÿà ∫— ¿“«–¢ÕߺªŸâ «É ¬¥ß—µÕà ‰ªπ’È °“√欓°√≥å‚√§
2.1 °≈¡ÿà∑æ’Ë®‘“√≥“„Àâaspirin °“√欓°√≥‚å √§¢ÕߺªŸâ «É ¬ AIS ·≈– CSVT
2.1.1 °≈¡ÿà idiopathic (‰¡∑à √“∫ “‡Àµ)ÿ πÈ—π ¢È÷π°—∫ “‡Àµÿ«‘∏’°“√√—°…“ ·≈–√–¬–‡«≈“„π
2.1.2 °≈àÿ¡ cerebral arteriopathy ‡™àπ °“√µ¥‘µ“¡ æ∫«“à ºªâŸ«É ¬ AIS √Õâ ¬≈– 35 ®–À“¬
post-varicella, Moyamoya, vasculitis ‡ªπì µπâ ‡ªìπª°µ‘‚¥¬∑Ë’√âÕ¬≈– 55 ®–¡’ªí≠À“°“√‡√’¬π√Ÿâ
2.1.3 °≈¡àÿ congenital heart disease ‡™πà ·≈–°“√‡§≈Ë◊Õπ‰À« ·≈–¡’ºâŸªÉ«¬√âÕ¬≈– 10 ∑’ˇ ’¬
PFO ™’«‘µ13 ªí®®—¬∑’Ë∫Õ°°“√欓°√≥å‚√§∑’ˉ¡à¥’‰¥â·°à
2.1.4 °≈¡ÿà sickle cell disease Õ“°“√‚§¡“à ™°— À√Õ◊ ¡‚’√§ÕπË◊ √«à ¡‡™πà Moyamoya,
2.1.5 °≈¡àÿ∑¡Ë’’complete occlusion ¢Õß arterial dissection ‡ªπì µπâ ‚¥¬æ∫«“à ºªâŸ«É ¬ AIS ¡’
cerebral artery ‚Õ°“ ‡°‘¥´”ȉ¥â√âÕ¬≈– 6-30 À“°¡’À≈“¬ªí®®—¬
2.2 °≈¡àÿ∑æË’®‘“√≥“„ÀâLMWH/coumadin ‡ ¬’Ëß®–¬ßË‘¡‚’Õ°“ ‡°¥‘´È”¡“°¢πÈ÷14
2.2.1 °≈¡ÿà ºªŸâ «É ¬∑¡’˧’«“¡º¥‘ª°µ¢‘Õß√–∫∫  «à πºªâŸ«É ¬ CSVT æ∫«“à √Õâ ¬≈– 51 ®–À“¬
anticoagulant system ‡™πà protein C, protein S ‡ªπì ª°µ‘‚¥¬√Õâ ¬≈– 39 ®–¡ª’≠í À“∑“ß√–∫∫ª√– “∑
‡ªπì µπâ ·≈–ºŸâªÉ«¬ª√–¡“≥√âÕ¬≈– 10 ®–‡ ’¬™’«‘µ ºŸâªÉ«¬
2.2.2 °≈¡ÿà ºªâŸ«É ¬∑¡Ë’§’«“¡º¥‘ª°µ¢‘Õßarte- CSVT ¡‚’Õ°“ ‡°¥‘´È”‰¥ªâ √–¡“≥√Õâ ¬≈– 1713 ·≈–
rial dissection À“°¡’Õ“°“√™—°®–‡ªìπªí®®—¬∑’Ë∫Õ°∂÷ß°“√欓°√≥å
2.2.3 °≈¡àÿºªŸâ «É ¬∑‰Ë’¥¬â “ aspirin °Õà πÀπ“â πÈ’ ‚√§∑‰Ë’¡¥à ’
2.2.4 °≈àÿ¡ congenital heart disease ∑’Ë
‡ÀÁπ≈‘Ë¡‡≈◊Õ¥™—¥‡®π „πÀâÕßÀ—«„® (intracardiac ∫∑ √ÿª
thrombus) ‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÿ¥µ—π„π‡¥Á°‡ªìπ‚√§∑’Ë
2.2.5 °≈¡ÿà ∑¡Ë’’non-occlusion ¢Õß cere- æ∫‰¥‰â ¡∫à Õà ¬ ·µ‡à ªπì  “‡Àµ∑ÿ Ë’”§≠—¢Õß°“√‡ ¬’™«’µ‘
bral artery ‚¥¬æ®‘“√≥“®“° angiogram ·≈–∑æÿæ≈¿“æ °“√„À°â “√«π‘®‘©¬—∑·’Ë¡πà ¬”·≈–√«¥‡√«Á
‚¥¬„π°≈¡àÿ∑Ë’2.2 ®–殑“√≥“„Àâ LMWH À√Õ◊ ®–™à«¬‡À≈◊ÕºŸâªÉ«¬‰¥â °“√»÷°…“‡æË‘¡‡µ‘¡‡°Ë’¬«°—∫
coumadin Õ¬à“ßπâÕ¬ 3-6 ‡¥◊Õπ ·≈⫇ª≈Ë’¬π‡ªìπ ª®í ®¬—‡ ¬’Ëß ·π«∑“ß°“√µ√«®∑“ßÀÕâ ߪØ∫‘µ—°‘“√ «∏‘’
aspirin  ”À√∫—„π°≈¡ÿà ∑Ë’2.1 ®–殑“√≥“„Àâ aspirin °“√√—°…“ µ≈Õ¥®π°“√µ‘¥µ“¡ºâŸªÉ«¬∑Ë’‡ªìπ√–∫∫
(1-5 ¡°./°°./«—π) ‡ªìπ√–¬–‡«≈“ 2 ªï ‚¥¬ ·≈–¡’ª√– ‘∑∏‘¿“æ ¬—߇ªìπ Ë‘ß∑’Ë®”‡ªìπµâÕßµ‘¥µ“¡
√–À«à“ß∑Ë’ºâŸªÉ«¬‰¥â√—∫ aspirin ‡ªìπ‡«≈“ 2 ªï ·≈– µÕà ‰ª„πÕ𓧵
æ∫«“à ¡Õ’“°“√¢Õß‚√§°≈∫—¡“‡ªπì „À¡à (recurrence)
g®–reæl®‘1“2√≥À“√„Õ◊ Àæ¬â ®‘““µ√“â≥𓇰„À≈â¥ÁL‡≈MÕ◊ ¥W™Hπ¥‘ÀÕπ√◊ËÕ◊ ‡™πàcoculompaiddoin-
‚¥¬æ‘®“√≥“‡ªìπ√“¬Ê ‰ª µ“¡„π√“¬≈–‡Õ’¬¥„π
·ºπ¿¡Ÿ∑‘’Ë15.3

‚√§À≈Õ¥‡≈Õ◊¥ ¡ÕßÕÿ¥µ—π„π‡¥°Á·≈–«—¬√àÿπ Stroke in Children and Adolescents 233

·ºπ¿¡Ÿ∑‘Ë’15.3 ·π«∑“ß°“√√°—…“ AIS „π‡¥°Á

AIS = arterial ischemic stroke, UFH = unfractionated heparin, LMWH = low molecular weight
heparin, CT = computed tomography, MRI = magnetic resonance imaging, MRA = magnetic
resonance arteriography

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345(6):417-23. children. Curr Neurol Neurosci Rep. 2004;4(2):
9. Kenet G, Kirkham F, Niederstadt T, Heinecke 129-38.
A, Saunders D, Stoll M, et al.; European Throm- 14. Lanthier S, Carmant L, David M, Larbrisseau
boses Study Group. Risk factors for recurrent A, de Veber G. Stroke in children: the coexistence
venous thromboembolism in the European of multiple risk factors predicts poor outcome.
collaborative paediatric database on cerebral Neurology. 2000, 54(2):371-378.

∫∑∑’Ë
°“√„À‡â≈◊Õ¥·≈–¿“«–·∑√°´âÕπ
Blood Transfusion and Its

16 Complications

Õ¿‘™“µ‘‚æ∏‘Õ–

°“√„Àâ‡≈◊Õ¥·≈– à«πª√–°Õ∫¢Õ߇≈◊Õ¥π—∫ ‡≈Õ◊ ¥∑¡’˧’«“¡‡¢“â°π—‰¥¡â “°∑ ’Ë¥ÿ ¥ß—ππÈ—®ß÷®–µÕâß¡’
‰¥â«à“‡ªìπ°“√√—°…“«‘∏’ÀπË÷ß ´÷Ëß¡’§«“¡ ”§—≠·≈– àß °“√µ√«®§«“¡‡¢“â°π—‰¥â(compatibility testing)
º≈°√–∑∫‚¥¬µ√ßµàÕÕ—µ√“°“√√Õ¥™’«‘µ¢Õߺ⟪ɫ¬ °Õàπ°“√„À‡â≈Õ◊ ¥ ‡æÕ◊˪ÕÑß°π—‰¡„àÀ‡â¡¥Á‡≈Õ◊ ¥·¥ß¢Õß
„π°“√µ—¥ ‘π„®„Àâ‡≈◊Õ¥∑ÿ°§√È—ß ·æ∑¬å®–µâÕß ºâŸ∫√‘®“§∑Ë’¡’À¡àŸ‡≈◊Õ¥µ√ß°—π°—∫·Õπµ‘∫Õ¥’(anti-
æ‘®“√≥“Õ¬à“ß√Õ∫§Õ∫·≈–æ÷ß√–≈÷°‡ ¡Õ«à“ºâŸªÉ«¬¡’ body) „πæ≈“ ¡“¢ÕߺŸâªÉ«¬ ‚¥¬°“√µ√«®§«“¡
§«“¡‡ Ë’¬ß∑’Ë®–‡°‘¥¿“«–·∑√°´âÕπ®“°°“√µ‘¥‡™◊ÈÕ ‡¢“â°π—‰¥â´ß÷Ë®–ª√–°Õ∫‰ª¥«â¬ 4 ¢πÈ—µÕπ ¥ß—µÕà‰ªπ’È
‚√§µ“àßÊ ®“°°“√√∫—‡≈Õ◊ ¥ √«¡∂ß÷Õ“®‡°¥‘ªØ°‘√‘¬‘“ 1. °“√µ√«®À¡‡àŸ≈Õ◊¥ ABO (ABO group-
‰¡æà ß÷ª√– ß§´å ßË÷Õ“®√πÿ·√ß∂ß÷·°™à«’µ‘‰¥âµÕâߧ”πß÷ ing)
∂÷ߪ√–‚¬™πå∑Ë’‰¥â®“°°“√„Àâ‡≈◊Õ¥ ´÷Ëß®–µâÕß„Àⵓ¡ °“√µ√«®À¡àŸ‡≈◊Õ¥ ABO ´Ë÷ß∂Ⓣ¡à‡¢â“°—π
§«“¡‡À¡“– ¡ ∂Ÿ°µâÕß ¥—ßπÈ—π·æ∑¬åºâŸ Ë—ß°“√„Àâ Õ“®‡°¥‘ªØ°‘√‘¬‘“∑√’Ëπÿ·√߉¥â‡πÕ◊Ëß®“° anti-A ·≈–
‡≈Õ◊ ¥·≈– «àπª√–°Õ∫¢Õ߇≈Õ◊ ¥®–µÕâß¡§’«“¡‡¢“â„® anti-B ‡ªπì antibody ™π¥‘ IgM ´ßË÷∑”ªØ°‘√‘¬‘“
∂÷ßÀ≈—°°“√·≈–°“√¥Ÿ·≈√—°…“À“°‡°‘¥º≈¢â“߇§’¬ß ‰¥â¥’∑Ë’Õÿ≥À¿Ÿ¡‘37 Õß»“‡´≈‡´’¬  ‚¥¬°“√°√–µÿâπ
®÷ßµâÕߪ√–‡¡‘πÕ“°“√∑“ߧ≈‘π‘°‡ªì𠔧—≠ ‰¡à„™à º“àπ°√–∫«π°“√ complement ∑”„À‡â°¥‘°“√·µ°
µ—¥ ‘π®“°º≈°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‡æ’¬ß ¢Õ߇¡Á¥‡≈◊Õ¥·¥ß„πÀ≈Õ¥‡≈◊Õ¥ (intravascular
Õ¬“à߇¥¬’« hemolysis) ∑”„À⇰‘¥ acute hemolytic trans-
fusion reaction ∑√Ë’πÿ·√ß·≈–∂ß÷·°™à«’µ‘‰¥â
°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‡æ◊ËÕ‡µ√’¬¡„Àâ ‚¥¬°“√µ√«®ππ—È ®–¡°’“√µ√«®À¡‡Ÿà≈Õ◊ ¥ ABO
‡≈◊Õ¥1-4 ∑ßÈ— antigen ∫πº«‘‡¡¥Á‡≈Õ◊ ¥·¥ß ·≈– antibody „π

‡¡◊ËÕ·æ∑¬åºâŸ∑”°“√√—°…“‰¥âµ—¥ ‘π„®„Àâ‡≈◊Õ¥ æ≈“ ¡“
·≈– à«πª√–°Õ∫¢Õ߇≈◊Õ¥°—∫ºŸâªÉ«¬ °àÕπ°“√„Àâ 2. °“√µ√«®À¡‡àŸ≈Õ◊¥ Rh (Rh D typing)
‡≈◊Õ¥∑ÿ°§√—Èß®–µâÕß¡’°“√µ√«®‡æË◊ÕÀ≈’°‡≈’ˬ߰“√ ‡ªπì°“√µ√«®À¡‡àŸ≈Õ◊ ¥ Rh ‚¥¬‡ππâ D antigen
‡°¥‘ªØ°‘√‘¬‘“∑√Ë’πÿ·√ßÀ≈ß—°“√„À‡â≈Õ◊ ¥ ‚¥¬®–µÕâß„Àâ ∫πº«‘¢Õ߇¡¥Á‡≈Õ◊ ¥·¥ß ´ß÷ˇªπì antibody ™π¥‘ IgG

236 Õ¿‘™“µ‘‚æ∏‘Õ–

∂Ⓣ¡à‡¢â“°—π “¡“√∂°√–µâÿπ„À⇰‘¥°“√·µ°¢Õ߇¡Á¥ æ≈“ ¡“
‡≈Õ◊ ¥·¥ßπÕ°À≈Õ¥‡≈Õ◊ ¥ (extravascular hemoly-  “¡“√∂µ√«® ABO grouping °Á‡æ’¬ßæÕ
sis) ‚¥¬®–¡°’“√∑”≈“¬‡¡¥Á‡≈Õ◊ ¥·¥ßº“àπ°√–∫«π°“√ ‡πÕ◊Ëß®“° „πæ≈“ ¡“¢Õߺ∫Ÿâ √®‘“§®–¡’antibody Õ¬àŸ
opsonization ·µà‰¡à¡’Rh antigen ´÷Ëß®–Õ¬Ÿà∫πº‘«‡¡Á¥‡≈◊Õ¥·¥ß
°“√µ√«®®–‡πâπµ√«®‡©æ“– Rh D ∫πº‘« ‡∑“àππÈ— ®ß÷‰¡®à”‡ªπì µÕâßµ√«® Rh D typing ·≈–
¢Õ߇¡¥Á‡≈Õ◊ ¥·¥ß crossmatching
3. °“√µ√«®‡æÕË◊§¥—°√ÕßÀ“ antibody
‡ªπì °“√µ√«®‡æÕË◊ §¥—°√ÕßÀ“ antibody µÕà ‡°≈¥Á‡≈Õ◊¥
À¡‡àŸ≈Õ◊ ¥ÕπË◊ Ê πÕ°®“° ABO „πæ≈“ ¡“¢Õߺ√âŸ∫— ·π–π”„Àµâ√«® ∑ß—ÈABO grouping ·≈– Rh
‡≈Õ◊ ¥ ‰¥·â°°à“√µ√«®À¡‡àŸ≈Õ◊ ¥ Rh (C, c, D, E, e), typing ‡πË◊Õß®“°„πº≈‘µ¿—≥±å‡°≈Á¥‡≈◊Õ¥ ®–¡’‡¡Á¥
Kidd (Jka, Jkb), Duffy (Fya, Fyb), MNS (M, ‡≈◊Õ¥·¥ßªπ‡ªôóÕπ¡“ ·¡â‡æ’¬ßª√‘¡“≥‡≈Á°πâÕ¬°Á
N·≈,–SD, ise,goM(iaD)i,a,LDewibi)s (Lea, Leb), P (P1PK) Õ“®°√–µÿâπ„ÀâºâŸªÉ«¬ √â“ß antibody ¢÷Èπ¡“‰¥â„π
‚¥¬„™°â“√∑¥ Õ∫ direct º≈µ‘¿≥— ±‡å°≈¥Á‡≈Õ◊ ¥™π¥‘‡°≈¥Á‡≈Õ◊ ¥‡¢¡â¢πâ (platelet
antiglobulin test (DAT) ·≈– indirect anti- concentrate) ´ßË÷æ∫«“à¡°’“√ªπ‡ªÕóôπ‡¡¥Á‡≈Õ◊ ¥·¥ß
globulin test (IAT) ´÷Ëß∂⓵√«®æ∫ antibody 0.5 ¡≈.µÕà∂ßÿ ·µ„àπ°“√√∫—∫√®‘“§‚¥¬«∏‘’apheresis
„πæ≈“ ¡“¢ÕߺŸâªÉ«¬°Á®–µâÕßµ√«® antibody ®–‰¥âº≈‘µ¿—≥±å‡°≈Á¥‡≈◊Õ¥™π‘¥ single donor
identification test ‡æÕË◊ √–∫∂ÿß÷ antibody ∑®’Ë”‡æ“– platelet ´Ë÷ß®–¡’ª√‘¡“≥‡¡Á¥‡≈◊Õ¥·¥ßªπ‡ªóôÕπ
‡æË◊Õπ”¡“„™âcrossmatching °—∫‡≈◊Õ¥ºŸâ∫√‘®“§„π πÕ⬡“°
¢π—ȵÕπµÕà‰ª
4. Crossmatching °“√„™‡â≈Õ◊ ¥·≈– à«πª√–°Õ∫¢Õ߇≈Õ◊ ¥
‡ªπì °“√µ√«®À“ antibody „π plasma ¢Õß Packed red cell (PRC)2, 5
ºŸâ√—∫µàÕ antigen ∫πº‘«¢Õ߇¡Á¥‡≈◊Õ¥·¥ß¢Õߺ⟄Àâ  ”À√∫— PRC ‡µ√¬’¡®“°°“√·¬°‡Õ“æ≈“ ¡“
‚¥¬„™â°“√∑¥ Õ∫ DAT ·≈– IAT ‚¥¬®–µâÕß ®”π«π 200-250 ¡≈. ÕÕ°®“° whole blood ‚¥¬
‡≈Õ◊ °‡≈Õ◊ ¥∑¡’Ë’ABO ·≈– Rh µ√ß°∫—æ≈“ ¡“¢Õß °“√ªπíò·¬°‡≈Õ◊ ¥∑‰’Ë¥√â∫—∫√®‘“§¡“„À¡¥à«â¬ refriger-
ºªâŸ«É¬¡“∑”°“√∑¥ Õ∫ ated centrifuge ∑ÕË’≥ÿ À¿¡Ÿ‘4 Õß»“‡´≈‡´¬’  ∑ß—ÈπÈ’
PRC∑„Ë’™§â«√®–¡§’“৫“¡‡¢¡â¢πâ‡≈Õ◊ ¥(hematocrit)
°“√µ√«®§«“¡‡¢“â°π—‰¥„âπ‡≈Õ◊ ¥·≈– «àπª√–°Õ∫ ª√–¡“≥√âÕ¬≈– 70-80 µ“¡¡“µ√∞“π¢Õß ¡“§¡
¢Õ߇≈Õ◊ ¥ c∏iπa“ti§o“n√‡≈oÕ◊ f¥B·ÀloßàoÕd‡¡B√°‘a“nkÀ√(Õ◊ AAABmBer)i1c,a6n Asso-
‡¡¥Á‡≈Õ◊¥·¥ß °”Àπ¥
‡ªìπ°“√µ√«®§«“¡‡¢â“°—π‰¥â‚¥¬°“√µ√«® «à“ PRC ∑Ë’‰¥â¡“µ√∞“π®–µâÕß¡’ª√‘¡“≥‡¡Á¥‡≈◊Õ¥
∑—Èß ABO grouping, Rh D typing, antibody ¢“«πÕ⬰«“à 1.0 x 1011 ‡´≈≈/å∂ßÿ  ”À√∫—°“√„Àâ
screening, crossmatching PRC §«√„Àâ∑’Ë¡’À¡àŸ‡≈◊Õ¥ ABO ·≈– Rh ∑’˵√ß
°—π ·µà„π°√≥’∑’ˉ¡à¡’À¡Ÿà∑Ë’‡¢â“°—π‰¥âÕ“® “¡“√∂„Àâ
À¡Ÿà‡≈◊Õ¥Õ◊Ëπ‰¥â ¥—ß· ¥ß„πµ“√“ß∑Ë’16.1 ¬°‡«âπ

°“√„À‡â≈◊Õ¥·≈–¿“«–·∑√°´Õâπ Blood Transfusion and Its Complications 237

ºŸâªÉ«¬À¡Ÿà‡≈◊Õ¥ O ®”‡ªìπµâÕ߉¥â√—∫‡≈◊Õ¥®“°ºâŸ ¡“µ√∞“π¥â«¬Õÿ≥À¿Ÿ¡‘37 Õß»“‡´≈‡´’¬  ‡æ◊ËÕ
∫√‘®“§À¡àŸ‡≈◊Õ¥ O ‡∑à“πÈ—π ·≈–‡¡Ë◊Õ‰¥â√—∫‡≈◊Õ¥µà“ß ªÑÕß°—π‡¡Á¥‡≈◊Õ¥·¥ß·µ° ‡æ√“–‡≈◊Õ¥∑’ËÕàÿπ·≈â«·µà
À¡àŸ·≈â« °àÕπ®–¡’°“√„Àâ‡≈◊Õ¥§√—Èß∂—¥‰ª®–µâÕß¡’ ‰¡à‰¥â„À⺟âªÉ«¬ ®–µâÕß∑‘È߇≈◊Õ¥∂ÿßπ—Èπ ·≈–Àâ“¡§◊π
°“√µ√«®«“à¬ß—µ√«® æ∫ anti-A ·≈–/À√Õ◊ anti- ∏𓧓√‡≈◊Õ¥‚¥¬‰¡à·®âß«à“ºà“π°“√Õÿàπ·≈â« ‡æ√“–
B Õ¬ÀŸà √Õ◊ ‰¡àÀ“°‰¡æà ∫®ß÷®– “¡“√∂°≈∫—‰ª„ÀÀâ ¡Ÿà Õ“®‡æË‘¡§«“¡‡ Ë’¬ßµàÕ°“√µ‘¥‡™◊ÈÕ∑Ë’Õ“®ªπ‡ªóôÕπ„π
‡≈Õ◊ ¥‡¥¡‘∑º’Ë≈ crossmatching ‡¢“â°π—‰¥â ∂ßÿ‡≈Õ◊ ¥ππ—ȉ¥â
 à«πºŸâªÉ«¬À¡àŸ‡≈◊Õ¥ Rh negative ®–µâÕß
‰¥√â∫—‡≈Õ◊ ¥®“°º∫Ÿâ√®‘“§À¡‡àŸ≈Õ◊ ¥ Rh negative ‡ ¡Õ Leukocyte-depleted packed red cell
¬°‡«âπ„π°√≥’‡√àߥà«π∑Ë’Õ—πµ√“¬∂÷ß™’«‘µ ·≈–ºâŸªÉ«¬ (LDPRC)2

®–µÕâ߬ߗ‰¡¡à°’“√ √“âß anti-D ®ß÷®– “¡“√∂„À‡â≈Õ◊ ¥  ”À√∫— LDPRC  “¡“√∂‡µ√¬’¡®“°°“√≈¥
À¡Ÿà‡≈◊Õ¥ Rh positive ‰¥âπÕ°®“°π—Èπ‡≈◊Õ¥∑ÿ° ª√¡‘“≥‡¡¥Á‡≈Õ◊ ¥¢“«ÕÕ°‰ª¥«â¬«∏‘°’“√°√Õß (leuko-
∂ÿß®–µâÕߺà“π°“√∑” antibody screening ·≈– cyte filtration) µ“¡¡“µ√∞“π¢Õß ¡“§¡∏𓧓√
crossmatching ®π§√∫∑ÿ°§√—Èß πÕ°‡ ’¬®“°¡’ ‡≈◊Õ¥·ÀàßÕ‡¡√‘°“1 °”Àπ¥„Àâ¡’ª√‘¡“≥¢Õ߇¡Á¥
§«“¡®”‡ªìπ∑Ë’µâÕ߉¥â√—∫‡≈◊Õ¥Õ¬à“߇√àߥà«πÀ√◊Õ ‡≈Õ◊ ¥¢“«πÕ⬰«“à 5.0 x 106 ‡´≈≈/å∂ßÿ À√Õ◊ πÕâ¬
©°ÿ‡©π‘  “¡“√∂¢Õ‡≈Õ◊ ¥¡“„À°âÕàπµ“¡§«“¡‡√ß५àπ °«“à 1.0 x 106 ‡´≈≈/å∂ßÿ µ“¡¡“µ√∞“π¢Õ߬‚ÿ√ª2
¥ß—· ¥ß„πµ“√“ß∑’Ë16.2 ·µÕଓà߉√°µÁ“¡ ∏𓧓√ ∑ßÈ—π®È’– “¡“√∂≈¥°“√‡°¥‘ febrile non-hemolytic
‡≈Õ◊ ¥®–¥”‡ππ‘°“√µ√«® antibody screening ·≈– transfusion reaction (FNHTR) „πºŸâªÉ«¬∑’ˇ§¬
crossmatching ®π®∫°√–∫«π°“√∑°ÿ§√ßÈ— „π°√≥’ ¡Õ’“°“√Àπ“« π—Ë®“°°“√√∫—‡≈Õ◊ ¥‰¥â√«¡∂ß÷≈¥§«“¡
∑’Ëæ∫§«“¡º‘¥ª°µ‘∏𓧓√‡≈◊Õ¥®–·®âß·æ∑¬åºŸâ∑” ‡ ¬Ë’ßµÕà°“√µ¥‘‡™ÕÈ◊ cytomegalovirus (CMV) ‰¥â
°“√√°—…“∑π—∑’ ¥«â¬7 ·µÕଓà߉√°µÁ“¡ °“√∑” leukocyte filtra-
∑ß—Èπ’È°Õàππ”‡≈Õ◊ ¥‰ª„Àºâ ªŸâ «É¬À“â¡∑”°“√Õπÿà tion ‰¡™à«à¬ªÕÑß°π—¿“«– transfusion-associated
‡≈Õ◊ ¥‡æÕ◊Ë„Àæâ √Õâ¡„™‚⥬‰¡®à”‡ªπì ¬°‡«πâ „π°√≥„’Àâ graft-versus-host disease (TA-GvHD) ´÷Ëß
‡≈Õ◊ ¥ª√¡‘“≥¡“° (massive transfusion) §Õ◊ °“√ °“√®–ªÑÕß°—π°“√‡°‘¥π—Èπ®–µâÕß∑”°“√¬—∫¬È—ß°“√
„À‡â≈Õ◊ ¥¡“°°«“à 50 ¡≈./π“∑’„πº„âŸÀ≠àÀ√Õ◊ ¡“° ·∫àßµ—«¢Õ߇¡Á¥‡≈◊Õ¥¢“«™π‘¥ lymphocyte ¥â«¬
°«“à 15 ¡≈./°°./™¡. „π‡¥°Á ®ß÷®– “¡“√∂殑“√≥“ °“√©“¬√ß— ·’°¡¡“∑’Ë25-30 ‡°√¬å(Gy)8
Õÿàπ‡≈◊Õ¥„Àâæ√âÕ¡„™â¥â«¬ blood warmer ∑Ë’‰¥â

µ“√“ß∑Ë’16.1 °“√‡≈Õ◊ °„™ºâ ≈µ‘¿≥— ±®å“°‡≈Õ◊ ¥·¥ß„πºªâŸ«É¬À¡‡Ÿà≈Õ◊ ¥µ“àßÊ

§«√‡≈Õ◊ °„™∑â ¡Ë’’ABO ·≈– Rh µ√ß°∫—º√âŸ∫—‡ªπì Õπ—¥∫—·√° ‚¥¬¡‡’°≥±æå ®‘“√≥“¥ß—πÈ’

º√Ÿâ∫—À¡‡àŸ≈Õ◊ ¥ O  “¡“√∂√∫—‡≈Õ◊ ¥®“°º∫âŸ√®‘“§À¡‡Ÿà≈Õ◊ ¥ O ‡∑“àππÈ—
º√Ÿâ∫—À¡‡àŸ≈Õ◊ ¥ A  “¡“√∂√∫—‡≈Õ◊ ¥®“°º∫âŸ√®‘“§À¡‡àŸ≈Õ◊ ¥ A ·≈– O µ“¡≈”¥∫—
º√âŸ∫—À¡‡Ÿà≈Õ◊ ¥ B  “¡“√∂√∫—‡≈Õ◊ ¥®“°º∫Ÿâ √®‘“§À¡‡Ÿà≈Õ◊ ¥ B ·≈– O µ“¡≈”¥∫—
º√âŸ∫—À¡‡àŸ≈Õ◊ ¥ AB  “¡“√∂√∫—‡≈Õ◊ ¥®“°º∫Ÿâ √®‘“§À¡‡àŸ≈Õ◊ ¥ AB, A, B ·≈– O

238 Õ¿™‘“µ‘‚æ∏Õ‘–

µ“√“ß∑’Ë16.2 °“√¢Õ„™‚â≈Àµ‘„𧫓¡‡√ß५àπµ“àßÊ

°√≥©’°ÿ‡©‘π (emergency)
¢Õâ∫ßà™:’ȵÕâß°“√„™‡â≈Õ◊ ¥∑π—∑’
√–¬–‡«≈“„π°“√√ÕâߢÕ: ¡‡’≈Õ◊ ¥ standby Õ¬∑àŸÀË’Õâß©°ÿ‡©π‘
§” ßË—¢Õ: uncrossmatched, group O packed red cell without antibody screening
º≈µ‘¿≥— ±‡å≈Õ◊ ¥∑·’Ëπ–π”„À„â™:â packed red cell group O, Rh negative (Õ“®„™âRh positive „π°√≥’
∑‰Ë’¡¡à ‡’≈Õ◊ ¥ Rh negative „πª√–™“°√‰∑¬)

°√≥’¥à«π¡“° (urgency)
¢Õâ∫ßà™:’ȵÕâß°“√„™‡â≈Õ◊ ¥·µ‰à¡ à“¡“√∂√Õº≈ antibody screening ·≈– crossmatching ‰¥â
√–¬–‡«≈“„π°“√√ÕâߢÕ: 5-10 π“∑’
§” ßË—¢Õ: uncrossmatched, group specific packed red cell without antibody screening
º≈µ‘¿≥— ±‡å≈Õ◊ ¥∑·Ë’π–π”„À„â™:â packed red cell ∑¡Ë’À’¡‡àŸ≈Õ◊ ¥ ABO, Rh µ√ß°∫—ºªŸâ «É¬

°√≥¥’«àπ (immediate)
¢Õâ∫ßà™:È’µÕâß°“√„™‡â≈Õ◊ ¥ ·µ‰à¡ à“¡“√∂√Õº≈ antibody screening ‰¥â
√–¬–‡«≈“„π°“√√ÕâߢÕ: 15-30 π“∑’
§” ßË—¢Õ: crossmatched, group specific packed red cell without antibody screening
º≈µ‘¿≥— ±‡å≈Õ◊ ¥∑·Ë’π–π”„À„â™:â packed red cell ∑¡Ë’À’¡‡àŸ≈Õ◊ ¥ ABO, Rh µ√ß°∫—ºªâŸ«É¬·≈–‡¢“â°π—‰¥â

°√≥’ª°µ‘(routine)
¢Õâ∫ßà™:È’µÕâß°“√„™‡â≈Õ◊ ¥µ“¡·ºπ°“√√°—…“
√–¬–‡«≈“„π°“√√ÕâߢÕ: 60 π“∑’
§” ß—Ë¢Õ: crossmatched, group specific packed red cell with antibody screening
º≈µ‘¿≥— ±‡å≈Õ◊ ¥∑·’Ëπ–π”„À„â™:â packed red cell ∑¡’ËÀ’¡‡àŸ≈Õ◊ ¥µ√ß°∫—ºªâŸ«É¬·≈–‡¢“â°π—‰¥âµ“¡∑√Ë’ÕâߢÕ

°√≥‡’µ√¬’¡‡≈Õ◊ ¥‰«â(type and screen)
¢Õâ∫ßà™:È’«“ß·ºπ„™‡â≈Õ◊ ¥„πÕ𓧵 ‡™πà °“√‡µ√¬’¡°Õàπ°“√º“൥—
√–¬–‡«≈“„π°“√√Õâß¢Õ : 60 π“∑’
§” ßË—¢Õ: µ√«® antibody screening „π‡≈Õ◊ ¥ºªâŸ«É¬
º≈µ‘¿≥— ±‡å≈Õ◊ ¥∑·’Ëπ–π”„À„â™:â∏𓧓√‡≈Õ◊ ¥‡µ√¬’¡æ√Õâ¡ „π°√≥∑’µ’ËÕâß°“√„™‡â≈Õ◊ ¥√–À«“àߺ“൥—„À∑â ” ABO

grouping, Rh typing ·≈– crossmatching µÕà
À¡“¬‡Àµÿ:„π∑°ÿ°√≥’∏𓧓√‡≈Õ◊ ¥®–∑” complete compatibility testing µÕà®π®∫ „π°√≥∑’æ’Ë∫§«“¡‡¢“â

°π—‰¡‰à¥âÀ√Õ◊ æ∫§«“¡º¥‘ª°µ‘®–√∫’·®ßâ·æ∑¬ºå √⟰—…“∑√“∫∑π—∑’
À¡“¬‡Àµÿ: ºªâŸ«É¬∑ÀË’¡‡àŸ≈Õ◊ ¥ Rh negative §«√‰¥√â∫—‡≈Õ◊ ¥ Rh negative ‡∑“àππÈ— ·µ„àπ°√≥©’°ÿ‡©π‘∂“â®–„À‡â≈Õ◊ ¥

Rh positive ®–µÕâßµ√«®‰¡æà ∫ anti-D „πµ«—Õ¬“à߇≈Õ◊ ¥¢ÕߺªŸâ «É¬

°“√„À‡â≈◊Õ¥·≈–¿“«–·∑√°´Õâπ Blood Transfusion and Its Complications 239

Leukocyte-poor packed red cell (LPRC)2 ‡°≈¥Á‡≈Õ◊ ¥ Rh positive ®–µÕâß„ÀâRhIG ·°ºà ªâŸ«É¬
 ”À√—∫ LPRC  “¡“√∂‡µ√’¬¡®“°°“√¢®—¥ ¿“¬„π‡«≈“ 72 ™«Ë—‚¡ß‡æÕË◊ ªÕÑß°π—°“√ √“âß anti D
‡¡¥Á‡≈Õ◊ ¥¢“«ÕÕ°‰ª¥«â¬«∏‘°’“√ªπòí ·¬° (leukocyte ‚¥¬„À„âπ¢π“¥ 300 ¡§°. ´ßË÷‡æ¬’ßæÕ ”À√∫—°“√„Àâ
removed by centrifugation) ‚¥¬®–‡À≈◊Õ random platelet (Rh positive) ®”π«π 30 ∂ßÿ
ª√¡‘“≥¢Õ߇¡¥Á‡≈Õ◊ ¥¢“«πÕ⬰«“à 1.2 x 109 ‡´≈≈/å À√Õ◊ SDP (Rh positive) 3 ∂ßÿ ‚¥¬Õµ—√“¢Õß°“√
∂ÿß µ“¡¡“µ√∞“π¢Õß ¡“§¡∏𓧓√‡≈◊Õ¥·Ààß „Àªâ √–¡“≥ 4-10 ¡≈./π“∑’À√Õ◊ „À‡â√«Á‡∑“à∑ºË’ªâŸ«É¬
Õ‡¡√‘°“1 ´Ë÷ß “¡“√∂≈¥°“√‡°‘¥ febrile non- ®–√—∫‰¥â‚¥¬®–„™â‡«≈“ª√–¡“≥ 30-60 π“∑’·µà
hemolytic transfusion reaction (FNHTR) „π ∫“ß°√≥Õ’“®„À™â“â°«“àπÈ’ª√–¡“≥ 2 ¡≈./π“∑’„π
ºŸâªÉ«¬∑Ë’‡§¬¡’Õ“°“√Àπ“« —Ëπ®“°°“√√—∫‡≈◊Õ¥·≈– °√≥¡’ª’≠í À“ volume overload
 à«πª√–°Õ∫¢Õ߇≈◊Õ¥‰¥â ·µà‰¡à™à«¬≈¥§«“¡‡ ’ˬß
°“√µ¥‘‡™Õ◊È CMV ·≈–‰¡™à«à¬≈¥ TA-GvHD ¢Õâ∫ßà™¢’ÈÕß°“√„À‡â°≈¥Á‡≈Õ◊ ¥9 ª√–°Õ∫¥«â¬
1. ¡¿’“«–‡≈Õ◊ ¥ÕÕ°‡πÕË◊ ß®“°¡‡’°≈¥Á‡≈Õ◊ ¥µ”Ë
Platelet concentrate (PC)9, 10 §«√殑“√≥“„Àºâ ªŸâ «É¬∑¡’˪’√¡‘“≥‡°≈¥Á‡≈Õ◊ ¥¡“°°«“à
„πªí®®ÿ∫—π PC ¡’À≈“¬™π‘¥‰¥â·°àrandom 50,000 ‡´≈≈å/≈∫.¡¡. À√◊Õ¡’‡≈◊Õ¥ÕÕ°„π√–∫∫
platelet, pool random platelet, single donor ª√– “∑ à«π°≈“ß ·≈–À“°µâÕß∑”À—µ∂°“√∑“ß
platelet (SDP) ‚¥¬∑Ë’1 ∂ÿߢÕß single donor ®—°…ÿ°√√¡ µâÕß„À⺟âªÉ«¬¡’‡°≈Á¥‡≈◊Õ¥ 100,000
platelet ‡∑“à°∫— 6-8 ∂ßÿ¢Õß random platelet ·≈– ‡´≈≈/å≈∫.¡¡.
1 ∂ßÿ¢Õß pool random platelet ‡∑“à°∫— 4 ∂ßÿ¢Õß 2. ¡’¿“«–‡≈◊Õ¥ÕÕ°‡πË◊Õß®“°¡’ªí≠À“°“√
random platelet ®”π«π‡°≈Á¥‡≈◊Õ¥∑’Ë„À⺟âªÉ«¬ ∑”ß“π¢Õ߇°≈Á¥‡≈◊Õ¥ ‰¡à«à“®–¡’®”π«π‡°≈Á¥‡≈◊Õ¥
 ”À√∫—„πºªŸâ«É¬∑“√°·√°‡°¥‘·≈–ºªâŸ«É¬‡¥°Á·π–π”„Àâ ‡∑à“„¥ ‚¥¬‡©æ“–Õ¬à“߬‘ËßÀ≈—ß„™â‡§√Ë◊Õß cardio-
random platelet 10 ¡≈./°°.  à«π„πºâŸ„À≠à pulmonary bypass (CPB) À√◊Õ‡§√◊ËÕß extra-
·π–π”„Àârandom platelet 1 ∂ßÿ µÕàπ”ÈÀπ°—ºªŸâ «É¬ corporeal membrane oxygenation (ECMO)
10 °°. À√Õ◊ „ÀâSDP §√ß—È≈– 1 ∂ßÿ 3. °Õàπ∑”°“√º“൥—ºªŸâ«É¬§«√®–µÕâß¡ª’√¡‘“≥
°“√„À‡â°≈¥Á‡≈Õ◊ ¥·°ºàªŸâ«É¬ §«√„Àµâ“¡À¡‡Ÿà≈Õ◊ ¥ ‡°≈Á¥‡≈◊Õ¥¡“°°«à“ 50,000 ‡´≈≈å/≈∫.¡¡. ·≈–
ABO ·≈– Rh D ¢Õߺ⟪ɫ¬‚¥¬‡©æ“–Õ¬à“߬‘Ëß ¡“°°«à“ 100,000 ‡´≈≈å/≈∫.¡¡.  ”À√—∫°“√
∂ⓇªìπºŸâªÉ«¬‡¥Á° °√≥’‰¡à¡’‡°≈Á¥‡≈◊Õ¥µ√ß°—∫À¡àŸ º“൥—∑“ß√–∫∫ª√– “∑
‡≈Õ◊ ¥ ABO ¢ÕߺªŸâ «É¬ ∂“â®”‡ªπì °ÕÁ“®„À‡â°≈¥Á‡≈Õ◊ ¥ 4. °“√„À⇰≈Á¥‡≈◊Õ¥„πºâŸªÉ«¬∑’Ë¡’ª√‘¡“≥
À¡àŸÕË◊π·°àºâŸªÉ«¬‰¥â11 ·µàÕ“®¡’º≈µàÕ°“√‡æË‘¡¢÷Èπ ‡°≈Á¥‡≈◊Õ¥µ”Ë¡“° ®π¡’§«“¡‡ Ë’¬ßµàÕ°“√‡°‘¥¿“«–
¢Õ߇°≈¥Á‡≈Õ◊ ¥ ‡™πà „ÀâPC À¡‡àŸ≈Õ◊ ¥ AB (compat- ‡≈◊Õ¥ÕÕ°‰¥â‡Õß ‡™àπ „πºŸâªÉ«¬∑’Ë¡’√–¥—∫‡°≈Á¥‡≈◊Õ¥
ible plasma) À√◊ÕÀ¡àŸ‡≈◊Õ¥ O (incompatible πÕ⬰«“à 5,000-10,000 ‡´≈≈/å≈∫.¡¡.
plasma)12 ·°ºà ªŸâ «É¬À¡‡Ÿà≈Õ◊ ¥ A À√Õ◊ B, „Àâ PC
À¡‡Ÿà≈Õ◊ ¥ A À√Õ◊ B ·°ºà ªâŸ«É¬ À¡‡Ÿà≈Õ◊ ¥ AB √«¡ Fresh frozen plasma (FFP)4
∑ß—È„ÀâPC À¡‡Ÿà≈Õ◊ ¥ÕπË◊ ·°ºà ªŸâ «É¬À¡‡àŸ≈Õ◊ ¥ O ‚¥¬ª°µ‘®–„Àâ‡æË◊Õ∑¥·∑πªí®®—¬°“√·¢Áßµ—«
 ”À√—∫°√≥’ºâŸªÉ«¬ Rh negative ·µà‰¥â√—∫ ¢Õ߇≈◊Õ¥ ‚¥¬‡©æ“–‡¡Ë◊Õ¡’°“√≈¥≈ߢÕßªí®®—¬°“√

240 Õ¿‘™“µ‘‚æ∏‘Õ–

·¢Áßµ—«¢Õ߇≈◊Õ¥À≈“¬µ—«À√◊Õ‡¡Ë◊Õ¡’¿“«–‡≈◊Õ¥ÕÕ° Cryoprecipitate4
·≈–‰¥â√—∫°“√„Àâ‡≈◊Õ¥·∫∫ massive transfusion „π cryoprecipitate ¡’ à«πª√–°Õ∫¢Õß
¿“«– disseminated intravascular coagulation ·ø§‡µÕ√åVIII, von Willebrand factor (vWF)
(DIC) ·≈–‚√§µ∫—‡√Õ◊È√ß— ´ßË÷∑”„Àºâ ªŸâ «É¬‰¡ à“¡“√∂ ·ø§‡µÕ√åXIII ·≈– fibrinogen ¥—ßπ—Èπ®÷ß¡—°π”
 √“âߪ®í®¬—°“√·¢ßÁµ«—¢Õ߇≈Õ◊ ¥‰¥â¿“«–¢“¥«µ‘“¡π‘ ¡“„™â‡æË◊Õ∑¥·∑π·ø§‡µÕ√å VIII „πºŸâªÉ«¬‚√§
‡§ ·≈–°“√‰¥√â∫—¬“ warfarin ¡“°‡°π‘¢π“¥ ‡ªπìµπâ Œ‚’¡ø‡ï≈¬’ ‡Õ ·≈–„À‡âæÕË◊ ∑¥·∑π vWF „πºªŸâ«É¬ von
‚¥¬·π–π”„Àâ„π¢π“¥ 10-15 ¡≈./°°. ´÷Ëß®– Willebrand disease ·≈–ºŸâªÉ«¬∑Ë’¡’¿“«–‡≈◊Õ¥
 “¡“√∂‡æË‘¡ªí®®—¬°“√·¢Áßµ—«¢Õ߇≈◊Õ¥‰¥âª√–¡“≥ ÕÕ°‡πÕ◊Ëß®“°°“√∑”ß“π¢Õ߇°≈¥Á‡≈Õ◊ ¥º¥‘ª°µ‘‡™πà
√Õâ¬≈– 10-20 ∑ß—Èπ¢’Èπ÷ÈÕ¬°Ÿà∫—™π¥‘¢Õߪ®í®¬—°“√·¢ßÁ ºâŸªÉ«¬‚√§‰µ∑’Ë¡’¿“«– uremia πÕ°®“°πÈ—π¬—ß„Àâ
µ«—¢Õ߇≈Õ◊ ¥‚¥¬·π–π”„ÀÀâ ¡‡Ÿà≈Õ◊ ¥µ√ßµ“¡À¡‡Ÿà≈Õ◊ ¥ ‡æË◊Õ∑¥·∑π fibrinogen „πºŸâªÉ«¬∑’Ë¡’¿“«–
ABO ¢ÕߺŸâªÉ«¬‚¥¬‰¡àµâÕß„Àⵓ¡À¡àŸ‡≈◊Õ¥ Rh ‡≈Õ◊ ¥ÕÕ°‡æ√“–¡’fibrinogen µ”Ë°«“à 100 ¡°./¥≈.
„π°√≥’‰¡à¡’FFP µ√ßÀ¡àŸ‡≈◊Õ¥ ABO ¢Õߺ⟪ɫ¬ ‚¥¬‡©æ“–Õ¬à“߬ˑ߄πºâŸªÉ«¬∑“ß»—≈¬°√√¡∑Ë’¡’¿“«–
 “¡“√∂„ÀâÀ¡Ÿà‡≈◊Õ¥ AB ·°àºŸâªÉ«¬∑ÿ°À¡Ÿà‡≈◊Õ¥‰¥â ‡≈◊Õ¥ÕÕ°®“° “‡Àµÿµà“ßÊ ‡™à𠧫“¡¥—π‡≈◊Õ¥µË”
‡æ√“– FFP ¢ÕßÀ¡‡Ÿà≈Õ◊ ¥ AB ‰¡¡à ’anti-A ·≈– µ‘¥‡™È◊Õ„π°√–· ‡≈◊Õ¥ À√◊ÕµâÕß°“√„Àâ‡≈◊Õ¥®”π«π
anti-B ·≈–„πºªâŸ«É¬À¡‡àŸ≈Õ◊ ¥ O ®–‰¡¡à∑’ß—È·Õ𵇑®π ¡“° ‡ªπì µπâ
(antigen) A ·≈– B ®÷ß “¡“√∂√—∫ FFP ®“° „πºâŸªÉ«¬∑Ë’µâÕß°“√‡æ‘Ë¡ fibrinogen §«√„Àâ
º∫Ÿâ √®‘“§∑°ÿÀ¡‡Ÿà≈Õ◊ ¥‰¥â¥ß—· ¥ß„πµ“√“ß∑Ë’16.3 cryoprecipitate ª√‘¡“≥ 1 ¬Ÿπ‘µ µàÕπÈ”Àπ—°µ—«
 ”À√∫—°“√„ÀâFFP ‰¡§à«√„À‡â√«Á‡°π‘‰ª ‚¥¬ 5 °°. ®– “¡“√∂‡æ¡‘˪√¡‘“≥ fibrinogen ‰¥ªâ√–¡“≥
·π–π”„À⧫“¡‡√Á«ª√–¡“≥ 4-10 ¡≈./π“∑’À√◊Õ 60-100 ¡°./¥≈. °“√„Àâcryoprecipitate ‰¡à¡’
‡∑“à∑ºË’ªŸâ«É¬ “¡“√∂√∫—‰¥â¿“¬„π‡«≈“ª√–¡“≥ 30-60 §«“¡®”‡ªìπµâÕß„Àⵓ¡À¡Ÿà‡≈◊Õ¥ ABO ¢ÕߺŸâªÉ«¬
π“∑’‚¥¬Àâ“¡„Àâπ“π‡°‘π 4 ™—Ë«‚¡ß ∑—Èßπ’ȧ«“¡∂Ë’ ‡æ√“–„π·µ≈à–∂ßÿ¡®’”π«πæ≈“ ¡“πÕ⬡“° (5-10
¢Õß°“√„Àâ FFP ´”È·°àºâŸªÉ«¬§«√æ‘®“√≥“¥Ÿ®“° ¡≈.) Õ¬“à߉√°µÁ“¡‡πÕË◊ ß®“°À¡‡Ÿà≈Õ◊ ¥ O ¡ª’√¡‘“≥
half-life ¢Õßªí®®—¬°“√·¢Áßµ—«¢Õ߇≈◊Õ¥·µà≈–µ—« ·ø§‡µÕ√åVIII ·≈– vWF µË”°«“àÀ¡‡àŸ≈Õ◊ ¥ÕπË◊ ¥ß—ππ—È
µ“¡∑µË’Õâß°“√ °“√„Àâcryoprecipitate ·°àºŸâªÉ«¬À¡Ÿà‡≈◊Õ¥ O ®÷ß

µ“√“ß∑Ë’16.3 °“√‡≈Õ◊ °„™æâ ≈“ ¡“„πºªŸâ «É¬À¡‡àŸ≈Õ◊ ¥µ“àßÊ

§«√‡≈Õ◊ °„™∑â ¡’ËÀ’¡‡Ÿà≈Õ◊ ¥µ√ß°∫—º√Ÿâ∫—‡ªπì Õπ—¥∫—·√°

À“°‰¡¡à À’¡‡àŸ≈Õ◊ ¥∑µË’√ß°π— ·π–π”„Àæâ ®‘“√≥“§«“¡‡¢“â°π—‰¥¢âÕßÀ¡‡Ÿà≈Õ◊ ¥¥ß—π’È
æ≈“ ¡“ O (¡’anti-A, anti-B)  “¡“√∂„Àºâ √Ÿâ∫—À¡‡Ÿà≈Õ◊ ¥ O ‡∑“àππ—È
æ≈“ ¡“ A (¡’anti-B)  “¡“√∂„Àºâ √âŸ∫—À¡‡Ÿà≈Õ◊ ¥ O ·≈– A
æ≈“ ¡“ B (¡’anti-A)  “¡“√∂„Àºâ √Ÿâ∫—À¡‡Ÿà≈Õ◊ ¥ O ·≈– B
æ≈“ ¡“ AB (‰¡¡à ’anti-A/anti-B)  “¡“√∂„Àºâ √âŸ∫—À¡‡àŸ≈Õ◊ ¥ AB, A, B ·≈– O

°“√„À‡â≈Õ◊ ¥·≈–¿“«–·∑√°´Õâπ Blood Transfusion and Its Complications 241

§«√„À⺠¡À¡àŸ‡≈◊Õ¥ ‰¡à§«√„À⇩擖À¡àŸ‡≈◊Õ¥ O ‡æ¬’ßæÕ·≈«â¬ß—‰¡¡àª’√¡‘“≥ª í “«–∑Õ’ËÕ°‡°π‘ 0.5-1
‡∑à“π—Èπ ‡πË◊Õß®“° half-life ¢Õßªí®®—¬°“√·¢Áßµ—« ¡≈./°°./™¡. „π 2-3 ™«—Ë‚¡ß Õ“®‡°¥‘¿“«– acute
¢Õ߇≈Õ◊ ¥·µ≈à–µ«—¡‡’«≈“‰¡‡à∑“à°π— tubular necrosis ´ßË÷°“√„À¬â“¢∫—ª í “«–·≈– “√
π”ȵÕà‰ªÕ°’Õ“®®–‡ªπì Õπ—µ√“¬ ®ß÷§«√ª√°÷…“·æ∑¬å
¿“«–·∑√°´Õâπ∑’‡Ë°‘¥®“°°“√„Àâ‡≈Õ◊ ¥ ºâŸ‡™Ë’¬«™“≠‡æ◊ËÕª√—∫¬“¢—∫ªí  “«–·≈– “√π”È„Àâ
Immune-mediated hemolysis13 ‡À¡“– ¡
‡ªπì Õ“°“√∑§’ËÕàπ¢“âß√πÿ·√ß ‡°¥‘®“° antigen ªí≠À“ DIC ·≈–‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘Õ“®
∫πº‘«‡¡Á¥‡≈◊Õ¥·¥ß¢ÕߺŸâ∫√‘®“§∑”ªØ‘°‘√‘¬“°—∫ ‡ÀπÁ‡¥πà ™¥—„π hemolytic transfusion reaction ´ß÷Ë
antibody „πæ≈“ ¡“¢Õߺ√Ÿâ∫—‡≈Õ◊ ¥ ∑æË’∫‰¥‰â¡∫à ÕଠºªŸâ «É¬∫“ß√“¬ ®”‡ªπì µÕâß„Àâplatelet concentrate
§Õ◊ ªØ°‘√‘¬‘“∑‡Ë’°¥‘®“°°“√„Àæâ ≈“ ¡“ ∑¡’Ë’antibody FFP À√◊Õ cryoprecipitate Õ“®µâÕßæ‘®“√≥“°“√
‰ª∑”ªØ°‘√‘¬‘“°∫— antigen ∫πº«‘‡¡¥Á‡≈Õ◊ ¥·¥ß¢Õß „Àâheparin ‡ªπì √“¬Ê ‰ª ‚¥¬‰¡®à”‡ªπì µÕâß„À∑â °ÿ
ºªŸâ «É¬ ∑”„À¡â °’“√·µ° ≈“¬¢Õ߇¡¥Á‡≈Õ◊ ¥·¥ß ·≈– √“¬ °“√∑”°“√‡ª≈’ˬπ‡≈◊Õ¥ (blood exchange)
¬—ß∑”„À⇰‘¥°“√µÕ∫ πÕß∑“ß neuroendocrine Õ“®®”‡ªπì „π√“¬∑¡’ËÕ’“°“√√πÿ·√ß ‚¥¬‡©æ“–„π√“¬∑’Ë
·≈–°“√°√–µπâÿ¢Õß complement ´ßË÷ ßàº≈°√–∑∫ ¡’antibody titer ∑‡’˪πì “‡Àµ„ÿπ√–¥∫—∑ Ë’ߟ¡“°‡°π‘
µÕà¢∫«π°“√·¢ßÁµ«—¢Õ߇≈Õ◊ ¥·≈– cytokine µ“àßÊ °“√ªÕÑ ß°π— §«“¡ ”§≠— Õ¬∑àŸµË’Õâß √“âß√–∫∫
 “‡Àµ ÿ«àπ„À≠¡à°—‡°¥‘®“°°“√∑º’˪⟫ɬ‰¥√â∫— ABO- °“√µ√«® Õ∫‡æ◊ËÕµ√«®À“§«“¡º‘¥æ≈“¥„π¢∫«π
incompatible red blood cell Õ“®®–¡’Õ“°“√ °“√µÈ—ß·µà‡®“–µ—«Õ¬à“߇≈◊Õ¥∑—ÈߺŸâªÉ«¬·≈–ºâŸ∫√‘®“§
‡°¥‘‰¥·â¡Àâ ≈ß—‰¥√â∫—‡≈Õ◊ ¥¥ß—°≈“ૉª‡æ¬’ß 10-15 ¡≈. ‡≈Õ◊ ¥ °“√‡≈Õ◊ °«∏‘∑’“ßÀÕâߪØ∫‘µ—°‘“√∑‰’Ë¥¡â “µ√∞“π
À√Õ◊ „πºªâŸ«É¬∑°’Ë”≈ß—‰¥√â∫—°“√¥¡¬“ ≈∫´ß÷ˉ¡ à“¡“√∂ ¡’√–∫∫°“√µ√«® Õ∫´”ȇæ◊ËÕªÑÕß°—π°“√·ª≈º≈º‘¥
∫Õ°Õ“°“√‰¥â‡™πà ¡‡’≈Õ◊ ¥´¡÷ÕÕ°¡“®“°·º≈º“൥— °“√∫—π∑÷°º≈º‘¥ √«¡∑—Èß°“√®à“¬‡≈◊Õ¥º‘¥ ·≈–°“√
¡“°º‘¥ª°µ‘√à«¡°—∫§«“¡¥—π‡≈◊Õ¥µË”À√◊Õ¡’¿“«– „À‡â≈Õ◊ ¥∑‰Ë’¡µà√ß°∫—ºªâŸ«É¬ πÕ°®“°π∂È’“âæ∫§«“¡º¥‘
hemoglobinuria ·≈–®“°°“√∑’Ë¡’À≈Õ¥‡≈◊Õ¥À¥ ª°µ∑‘‡Ë’°¥‘¢πÈ÷°∫—ºªâŸ«É¬¢≥–√∫—‡≈Õ◊ ¥®–µÕâßÀ¬¥ÿ°“√
µ«—·≈–°“√‡°¥‘≈¡‘ˇ≈Õ◊ ¥¢π“¥‡≈°Á„πÀ≈Õ¥‡≈Õ◊ ¥ ∑” „À‡â≈Õ◊ ¥∑π—∑’·≈–∑”°“√µ√«® Õ∫„À¡„àÀ∂â°ŸµÕâß
„À‡âπÕÈ◊ ‰µ «àπ cortex ¢“¥‡≈Õ◊ ¥‰ª‡≈¬’Èß ´ßË÷Õ“®‡ªπì
¡“°∂ß÷¢πÈ—‡°¥‘ acute tubular necrosis ·≈– acute Alloimmunization to red cell antigen14
kidney injury µ“¡¡“„π∑ Ë’¥ÿ ‡¡◊Ëպ⟪ɫ¬‡§¬‰¥â√—∫‡≈◊Õ¥´÷Ëß¡’ antigen ∑Ë’
°“√√°—…“ ¢πÈ÷Õ¬°Ÿà∫—ª√¡‘“≥‡≈Õ◊ ¥∑‡’Ë¢“â°π—‰¡à ·µ°µà“ß®“°ºŸâªÉ«¬ ºâŸªÉ«¬®– √â“ß primary allo-
‰¥â∑Ë’‰¥â√—∫‡¢â“‰ª ™π‘¥¢Õß antibody ·≈–Õ“°“√ immunization µàÕ red cell antigen πÈ—π ´÷Ëß
∑“ߧ≈‘π‘°¢ÕߺŸâªÉ«¬ ‚¥¬®–µâÕß欓¬“¡·°â‰¢ Õ“®„™â√–¬–‡«≈“‡ªìπ —ª¥“Àå À√◊Õ‡ªìπ‡¥◊Õπ ·≈–
¿“«–§«“¡¥—π‡≈◊Õ¥µ”Ë ·≈–‡æË‘¡ª√‘¡“≥‡≈◊Õ¥∑’ˉª  «àπ„À≠àantibody Õ“® √“âߢπ÷ÈÀ≈ß—®“°∑’Ëdonor
‡≈’Ȭ߉µ ∂â“·°â‰¢‰¥â∑—π®–‰¡à‡°‘¥¿“«–‰µ«“¬ °“√ red cell À¡¥‰ª®“°°√–· ‡≈Õ◊ ¥¢ÕߺªâŸ«É¬·≈«â ´ß÷Ë
√—°…“‚¥¬°“√„À⬓¢—∫ªí  “«– ‡™àπ furosemide antibody ∑Ë’‡°‘¥¢÷Èπ‡ªìπ§√—Èß·√°πÈ’¡—°®–Õ¬Ÿà„π√–¥—∫
πÕ°®“°®–¡’ƒ∑∏‘ϙ૬¢—∫ªí  “«–¬—ß∑”„Àâ‡≈◊Õ¥‰ª µË”Ê ´Kß÷ËiÕd“d®µ‰¥√«·â®°‰à¡anæàt∫i-‚J¥k¬a‡©·æ≈–“–anatnit-iJbkobdy·≈¢–∂Õß“â
¬ß—‰µ‰¥¥â ¢’πÈ÷ ·µ∂à “â„À∑â ßÈ—¬“¢∫—ª í “«– ·≈– “√πÈ” √–∫∫

242 Õ¿™‘“µ‘‚æ∏Õ‘–

ºªâŸ«É¬‰¥√â∫—‡≈Õ◊ ¥∑¡Ë’’antigen ´È”‡¢“≪հ’§√ßÈ—®–‡°¥‘ ‡ª√’¬∫‡∑’¬∫√–À«à“ߺ≈®“°µ—«Õ¬à“߇≈◊Õ¥°àÕπ·≈–
anamnestic response antibody Õ¬à“ß√«¥‡√Á« À≈—ß®“°‰¥â√—∫‡≈◊Õ¥ ∂â“„Àâº≈∫«°‡©æ“–„πµ—«Õ¬à“ß
¿“¬„π‰¡°à™Ë’«Ë—‚¡ßÀ√Õ◊ ‰¡°à«Ë’π— ´ß÷ˇªπì IgG antibody ‡≈◊Õ¥¿“¬À≈—ß®“°∑’˺⟪ɫ¬‰¥â√—∫‡≈◊Õ¥ ¡—°∫àß™’È«à“
∑’ˉª∑”ªØ‘°‘√‘¬“°—∫ red cell ∑’ˇæ‘Ëß„À⇢Ⓣª ∂â“ ¡¿’“«– DHTR
antibody ‰ª‡°“–µ¥‘º«‘¢Õß donor red cell ‡√“ °“√√°—…“ ∂“⇪πì ™π¥‘∑ÕË’“°“√‰¡√àπÿ·√ß Õ“®
Õ“®µ√«®æ∫ DAT „Àºâ ≈∫«° „π¢≥–∑Ë’antibody ‰¡µàÕâß„À°â“√√°—…“ ·µ§à«√®¥∫π—∑°÷ª√¡‘“≥ª í “«–
„πæ≈“ ¡“ºŸâªÉ«¬Õ“®¬—߉¡à¡“°æÕ„Àâµ√«®æ∫‰¥â ·≈–ª√–‡¡π‘°“√∑”ß“π¢Õ߉µ ∂“⡧’«“¡®”‡ªπì µÕâß
®÷ß∑”„ÀâIAT ‰¥âº≈≈∫ „π°√≥’‡™àππÈ’·π–π”„Àâ∑” „Àâ‡≈◊Õ¥ „Àâ‡≈◊Õ°¬Ÿπ‘µ∑’ˉ¡à¡’ antigen ∑Ë’µ√ß°—∫
adsorption, elution ·≈–µ√«®™π¥‘¢Õß antibody antibody ∑ºË’ªŸâ «É¬ √“âߢπ÷È
ππÈ— ·µ∂à“âµ√«®æ∫ antibody „πæ≈“ ¡“ºªŸâ«É¬‡¡ÕË◊ °“√ªÑÕß°—𠧫√¡’∫—π∑÷°∑Ë’·øÑ¡ª√–«—µ‘°“√
∑” crossmatch ´È”°—∫¬Ÿπ‘µ∑Ë’„À≪·≈â«¡’ªØ‘°‘√‘¬“ √—°…“·≈–∑’Ë∏𓧓√‡≈◊Õ¥ √«¡∑—Èß„À⇪ìπ¢âÕ¡Ÿ≈∑’˵‘¥
®–æ∫«à“„Àâº≈∫«° ∑È—ßÊ ∑’ˇ§¬„Àâº≈≈∫¡“°àÕπ µ—«ºâŸªÉ«¬‡æË◊ՙ૬„Àâ°“√√—∫‡≈◊Õ¥§√È—ßµàÕ‰ªª≈Õ¥¿—¬
§«√√“¬ß“π„À·âæ∑¬∑å √“∫ ·≈–°“√„À‡â≈Õ◊ ¥§√ߗȵÕà‰ª ‡æ√“–‡≈Õ◊ ¥∑®’Ë–„ÀµâÕà‰ªµÕâ߇≈Õ◊ °¬πŸµ‘∑‰’Ë¡¡à’antigen
·π–π”„Àâ∑” red cell antigen typing ·≈–µâÕß ¥ß—°≈“à« ·¡«â“à„π¢≥–ππ—È antibody ™π¥‘ππ—È®–≈¥
‡≈◊Õ°‡≈◊Õ¥∑’ˉ¡à¡’antigen µ—«∑Ë’µ√«®æ∫πÈ—π¡“∑” ≈ß®πµ√«®‰¡æà ∫·≈«â°µÁ“¡
crossmatch „À·â°ºà ªâŸ«É¬µÕà‰ª
Delayed hemolytic transfusion reaction Platelet refractoriness10, 11
(DHTR) «àπ„À≠®à–∑”„À‡â°¥‘‡æ¬’ß°“√‡ª≈¬Ë’π·ª≈ß °“√∑’˪√‘¡“≥‡°≈Á¥‡≈◊Õ¥‰¡à¢÷ÈπÀ√◊Õ¢÷ÈππâÕ¬
´ßË÷µ√«®‰¥∑â “ßÀÕâߪØ∫‘µ—°‘“√ §Õ◊ ®–µ√«®æ∫ DAT À≈ß—®“°„À‡â°≈¥Á‡≈Õ◊ ¥„πª√¡‘“≥∑‡’ËÀ¡“– ¡·≈«â ‡°¥‘
„Àâº≈∫«°À≈—ß°“√‰¥â√—∫‡≈◊Õ¥∑—ÈßÊ ∑Ë’‡§¬„Àâº≈≈∫ ¢÷Èπ‰¥â®“° “‡Àµÿ®“°¿Ÿ¡‘§ÿâ¡°—π (immune) ·≈–
¡“°àÕπ √«¡∑È—ß°“√∑” crossmatch ®–„Àâº≈∫«° ‰¡„à™ à“‡Àµ®ÿ“°¿¡Ÿ§‘¡âÿ°π—(nonimmune)∂“⇪πì°√≥’
°—∫∫“߬Ÿπ‘µ∑Ë’‡§¬∑”·≈â«„Àâº≈≈∫¡“°àÕπ ¡’‡æ’¬ß immune ‡ªπ쉥∑âß—Èalloimmune À√Õ◊ autoimmune
√Õâ¬≈– 20-3515, 16 ‡∑“àππ—È∑æ’Ë∫«“à¡’hemolysis reactivity ´ß÷Ë®–∂°Ÿ°√–µπÿ≥®â“°°“√‰¥√â∫—‡≈Õ◊ ¥À√Õ◊
‡πË◊Õß®“°√–¥—∫¢Õß antibody ®–¢÷Èπ Ÿß„π¢≥–∑Ë’¡’ ®“°°“√µß—ȧ√√¿∑å ”„À‡â°¥‘ antibody µÕà‡°≈¥Á‡≈Õ◊ ¥
red cell ¢Õߺ∫Ÿâ √®‘“§¬πŸµ‘∑¡Ë’’antigen µ√ß°π—‰ª ™π‘¥À¡àŸ‡≈◊Õ¥ ABO À√◊Õ human leukocyte
°√–µâÿπ„À⇰‘¥ anamnestic response °√–µâÿπ„Àâ antigen class I (HLA class I)
√“âß antibody ¢π÷È¡“¡“°Õ¬“àß√«¥‡√«Á„πºªâŸ«É¬  «à𠓇Àµ‡ÿ°¬’Ë«°∫— autoimmune µÕà‡°≈¥Á
Õ“°“√· ¥ß∑Ë’ ”§—≠¢Õß DHTR §◊Õ ¡’‰¢â ‡≈Õ◊ ¥Õ“®æ∫‰¥„âπ‚√§ immune thrombocytopenia
¿“«–‡≈◊Õ¥®“ß≈ß ·≈–µ—«‡À≈◊Õß ∫“ß√“¬Õ“®æ∫ (ITP) À√◊Õ„π∑“√°∑Ë’§≈Õ¥®“°¡“√¥“∑’Ë¡’‚√§
‡æ’¬ßª√‘¡“≥Œ’‚¡‚°≈∫‘π‰¡à¢÷Èπµ“¡∑’˧«√À≈—߉¥â√—∫ autoimmune ‰¥‡â™πà ‡¥¬’«°π—
‡≈◊Õ¥ Õ“®æ∫ hemoglobinuria ‰¥â„π∫“ß√“¬·µà °“√√°—…“ „π°“√·°ªâ ≠í À“ immune-medi-
æ∫‰¥â‰¡à∫àÕ¬  à«π¿“«–‰µ«“¬‡©’¬∫æ≈—ππÈ—πæ∫‰¥â ated platelet refractoriness ππ—È “¡“√∂„™‡â°≈¥Á
πâÕ¬¡“° „π°√≥’∑Ë’ ß —¬ DHTR „À⇮“–µ—«Õ¬à“ß ‡≈◊Õ¥®“° HLA matched donor À√◊ÕÕ“®„™â
‡≈◊Õ¥¢Õߺ⟪ɫ¬‡æ◊ËÕµ√«® IAT ·≈– DAT ‡æË◊Õ crossmatch-compatible platelet ‚¥¬‰¡àµâÕß

°“√„Àâ‡≈Õ◊ ¥·≈–¿“«–·∑√°´âÕπ Blood Transfusion and Its Complications 243

§”π÷ß∂÷ß HLA matching À√◊ÕÕ“®∑”‰¥â‚¥¬°“√ ‡ªì𠓇Àµÿ°Á‰¡à§«√„™â‡≈◊Õ¥¢ÕߺŸâ∫√‘®“§πÈ—π¡“∑”
identify ™π¥‘¢Õß antibody ·≈«â§¥—‡≈Õ◊ °º∫Ÿâ √®‘“§ plasma containing component Õ’°µàÕ‰ª „π
∑‰Ë’¡¡à ’antigen ∑µË’√ß°∫— antibody ¢ÕߺªâŸ«É¬¡“∑” ª®í®∫ÿπ— ¿“°“™“¥‰∑¬¡·’π«‚π¡â ∑®Ë’–‰¡„à™æâ ≈“ ¡“
platelet apheresis ‡æÕ◊Ë„À‰â¥âSDP °∫—ºªŸâ «É¬ ®“°ºŸâ∫√‘®“§∑Ë’‡ªìπºâŸÀ≠‘ß∑’ˇ§¬µ—Èߧ√√¿å¡“°àÕπ‡æË◊Õ
≈¥§«“¡‡ ¬’Ëß°“√‡°¥‘ TRALI
Transfusion-related acute lung injury
(TRALI)17, 18 Febrile non-hemolytic transfusion reaction
§«√§‘¥∂÷ß¿“«–πÈ’‡¡◊Ëպ⟪ɫ¬∑Ë’‰¥â√—∫‡≈◊Õ¥À√◊Õ (FNHTR)21-23
 à«πª√–°Õ∫¢Õ߇≈◊Õ¥·≈⫇°‘¥¿“«–À“¬„®µ‘¥¢—¥ æ∫‰¥„âπºªâŸ«É¬∑‰’Ë¥√â∫— «àπª√–°Õ∫‡≈Õ◊ ¥·≈«â
À√Õ◊ π”È∑«à¡ªÕ¥ (pulmonary edema) ‚¥¬‰¡¡à ’ ¡’Õ“°“√‰¢â¢È÷π ≥1 Õß»“‡´≈‡´’¬  ‚¥¬‰¡à “¡“√∂
¿“«–À«—„®«“¬ Õ“°“√· ¥ß¢Õß TRALI Õ“®µ√«® Õ∏‘∫“¬‰¥â¥â«¬ “‡ÀµÿÕË◊π ®“°°“√»÷°…“„πª√–‡∑»
æ∫ ‰¢âÀπ“« —Ëπ ‡¢¬’« ·≈–§«“¡¥π—‚≈Àµ‘µË”≈ß19  À√∞—Õ‡¡√°‘“æ∫«“à FNHTR æ∫‰¥ªâ √–¡“≥√Õâ¬≈–
´÷Ëß TRALI ‡°‘¥‰¥â®“°À≈“¬ “‡Àµÿ‡™àπ °“√„Àâ 0.5-124 ¢Õß°“√‰¥â√—∫‡≈◊Õ¥ ´÷Ëß¡—°‡°‘¥√à«¡°—∫
 à«πª√–°Õ∫‡≈◊Õ¥®“°ºŸâ∫√‘®“§∑’ËÕ“®¡’antibody Õ“°“√Àπ“« Ë—π·≈–¡—°¡’Õ“°“√‰¡à√ÿπ·√ß Õ“°“√‰¢â
µàÕ HLA À√◊Õ antigen µàÕ‡¡Á¥‡≈◊Õ¥¢“«™π‘¥ ¡—°‡°‘¥À≈—߉¥â√—∫‡≈◊Õ¥∑—π∑’À√◊ÕÕ“®‡°‘¥™â“À≈“¬
neutrophil ´÷Ëß®–‰ª∑”ªØ‘°‘√‘¬“°—∫‡¡Á¥‡≈◊Õ¥¢“« ™—Ë«‚¡ß°Á‰¥âºâŸ∑Ë’‡§¬∂Ÿ° immunized ¡“°àÕ𠇙àπ
¢ÕߺâŸ√—∫ ∑”„À⇰‘¥Õ“°“√¥—ß°≈à“« Õ’° “‡Àµÿ∑’Ëæ∫ ‡§¬‰¥â√—∫‡≈◊Õ¥ À√◊Õ‡§¬µÈ—ߧ√√¿å¡’·π«‚πâ¡∑’Ë®–‡°‘¥
‰¥πâ Õ⬰«“à §Õ◊ ºªâŸ«É¬¡’antibody ¥ß—°≈“à«Õ¬‡àŸ¥¡‘ FNHTR ¡“°¢π÷È
·≈«â‰ª∑”ªØ°‘√‘¬‘“°∫—‡¡¥Á‡≈Õ◊ ¥¢“«∑Ւˬ„àŸπ «àπª√–°Õ∫ °“√‡°‘¥ FNHTR πÈ—π¡’ “‡Àµÿ®“°ªØ‘°‘√‘¬“
‡≈Õ◊ ¥¢Õߺ∫âŸ√®‘“§20 √–À«“àß antibody „πæ≈“ ¡“¢ÕߺªŸâ«É¬°∫— antigen
„π∫“ß√“¬∑Ë’‡°‘¥ TRALI Õ“®µ√«®‰¡àæ∫ ∑Ւˬ∫àŸπ‡¡¥Á‡≈Õ◊ ¥¢“«™π¥‘ lymphocyte, granulo-
antibody ¥ß—°≈“à« ®ß÷ √ªÿ«“àÕ“®‡°¥‘®“°°≈‰°ÕπË◊ Ê cyte À√Õ◊ ‡°≈¥Á‡≈Õ◊ ¥∑„Ë’À‡â¢“≪ À√Õ◊ Õ“®‡°¥‘®“°°“√
‡™πà complement activation direct aggregation „À‡â≈Õ◊ ¥∑¡Ë’’cytokine À√Õ◊ ‡°¥‘¡’cytokine release
¢Õ߇¡¥Á‡≈Õ◊ ¥¢“«‚¥¬Õ“®∑”„À‡â°¥‘≈¡‘ˇ≈Õ◊ ¥¢π“¥‡≈°Á Õ¬“à߉√°µÁ“¡·¡«â“à‰¢Õâ“®‡ªπìÕ“°“√·√°¢ÕßFNHTR
(leukothrombi) ‰ªÕ¥ÿµπ—À≈Õ¥‡≈Õ◊ ¥„πªÕ¥ À√Õ◊ ·µàµâÕߧ‘¥∂÷ß°“√µ‘¥‡™È◊Õ®“° «àπª√–°Õ∫‡≈Õ◊ ¥∑„Ë’Àâ
„À‡â≈Õ◊ ¥∑¡’Ë°’“√ – ¡¢Õß cytokine ‡¡Õ◊ˇ°¥‘Õ“°“√ ‡¢“≪ ´ß÷ËÕπ—µ√“¬·≈–Õ“°“√√πÿ·√ß°«“à24,25 ¥ß—ππÈ—
acute pulmonary reaction ®“° “‡Àµÿ„¥°Áµ“¡ ‡¡◊ËÕºŸâªÉ«¬‡°‘¥Õ“°“√‰¢â Àπ“« Ë—π3 ®÷ßµâÕßµ√«®¥Ÿ
®–µâÕßÀ¬ÿ¥°“√„Àâ‡≈◊Õ¥·≈–‰¡à§«√„ÀâµàÕ‰ªÕ’°·¡â ¿“«–‡À≈“àπ¥È’«â¬
Õ“°“√®–¥¢’π÷ÈÀ√Õ◊ À“¬‰ª·≈«â°µÁ“¡ ®“°°“√»°÷…“¢Õß Traivaree ·≈–§≥–26 ´ß÷Ë
°“√√°—…“ °“√√°—…“ª√–§∫—ª√–§Õߥ«â¬°“√ ‡ªπì°“√»°÷…“·∫∫ RCT ‰¥√⓬ߓπºªâŸ«É¬∏“≈ —´‡’¡¬’
„ÀâÕÕ°´‘‡®π·≈–°“√™à«¬°“√À“¬„® ·≈–¡—°µâÕß„Àâ ®”π«π 147 √“¬ ∑‰Ë’¥√â∫— chlorpheniramine ·≈–
¬“°¥¿¡Ÿ‘‡™πà corticosteroid  «àπ„À≠®à–°≈∫—¡“ paracetamol ‡∑¬’∫°∫—¬“À≈Õ°°Õàπ°“√„À‡â≈Õ◊ ¥ 30
¥¿’“¬„π 12-24 ™«Ë—‚¡ß π“∑’∂÷ß 1 ™Ë—«‚¡ß æ∫«à“Õÿ∫—µ‘°“√≥å¢Õß°“√‡°‘¥
°“√ªÕÑ ß°π— ∂“â antibody „π‡≈Õ◊ ¥º∫âŸ√®‘“§ FNHTR „π°≈àÿ¡∑Ë’‰¥âparacetamol √âÕ¬≈– 6.9

244 Õ¿™‘“µ‘‚æ∏Õ‘–

·ºπ¿Ÿ¡‘∑Ë’16.1 ·π«∑“ß°“√¥·Ÿ≈‡¡ÕË◊ ‡°¥‘¿“«–·∑√°´Õâπ∑¡Ë’‰’¢√â–À«“àß°“√„À‡â≈Õ◊ ¥ (¥¥—·ª≈ß®“°‡Õ° “√Õ“âßÕß‘
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°“√„À‡â≈Õ◊ ¥·≈–¿“«–·∑√°´âÕπ Blood Transfusion and Its Complications 245

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√âÕ¬≈– 9.5 ‚¥¬‰¡à¡’§«“¡·µ°µà“ß°—πÕ¬à“ß¡’π—¬ ‡πÕ◊Ëß®“° FNHTR ‰¡‡à°¬Ë’«°∫—°“√À≈ßË—¢Õß hista-
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‡Õ° “√Õ“âßÕß‘ 5. Cable RG, Birch RJ, Spencer BR, Wright DJ,
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and Intravenous Chlorpheniramine Maleate



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∑Ë’º‘¥ª°µ‘(body disposition) ‚Õ°“ ‡°‘¥
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¿“«–µ«—‡µ¬È’·≈–°“√‡®√≠‘‡µ∫‘‚µ™“â ∂Õ◊‡ªπì ¿“«– ture ‰¥∫â Õà ¬‚¥¬‰¡¡à Õ’“°“√
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¢“¥∏“µ ÿß—°– ’(zinc) ¿“«–¢“¥ “√Õ“À“√√«à ¡°∫—
§«“¡º¥‘ª°µ¢‘ÕߌÕ√‚å ¡π µ“à ßÊ ‰¥·â °à ¢“¥ŒÕ√‚å ¡π 2. ¿“«–‡ªπì Àπÿ¡à  “«™“â (hypogonadism)
°“√‡®√‘≠‡µ‘∫‚µ ‰∑√Õ¬¥åŒÕ√‚å ¡π·≈–ŒÕ√‚å ¡π‡æ» ¿“«–πÈ’∂◊Õ‡ªìπ¿“«–·∑√°´âÕπ∑“ßµàÕ¡‰√â∑àÕ
√«¡∂ß÷¿“«–‡§√¬’¥¥“â 𮵑„® ∑æË’∫‰¥∫â Õà ¬∑ Ë’¥ÿ„πºªâŸ«É ¬‚√§∏“≈ —´‡’¡¬’3, 12
πÕ°®“°πÈ’¬ß—æ∫«“à ¿“«– ¥— «à π√“à ß°“¬º¥‘  “‡Àµ ÿ«à π„À≠¢à Õß¿“«–‡ªπì Àπ¡ÿà  “«™“â ‡°¥‘
ª°µ‘(body disproportion) „πºªŸâ «É ¬‚√§∏“≈ —´‡’¡¬’ ®“°°“√¡‡’À≈°Á‰ª – ¡Õ¬„Ÿà π‡´≈≈å gonadotrope ∑Ë’
‰¥â∂÷ß√âÕ¬≈– 15-72 ´Ë÷߇°‘¥®“°§«“¡º‘¥ª°µ‘¢Õß µÕà ¡„µ â ¡Õß (pituitary gland) ∑”„À¡â °’“√À≈ß—ËLH
°√–¥°Ÿ π—À≈ß—∑”„À¡â ≈’”µ«— π—È≈ß (decrease upper ·≈– FHS ≈¥≈ß (hypogonadotropic hypogo-
to lower segment ratio) ·≈–®–√ÿπ·√ß¡“°¢÷Èπ nadism) ¡’‡æ’¬ß à«ππâÕ¬∑Ë’¡’¿“«–‡À≈Á° – ¡„π
À≈ß—Õ“¬ÿ10 ª¢ï πÈ÷‰ª ´ßË÷‡™ÕË◊«“à ‡ªπì º≈®“°¿“«–‡¢“â µÕà ¡‡æ» §Õ◊ √ß—‰¢Àà √Õ◊Õ≥—±– ®π∑”„À‰â ¡ à “¡“√∂
‚ ¥àŸ«¬—¬‡©Àæπ“àÿ¡– d“e«f™eâ“ro√à«x¡am°—∫inºe≈(¢Dâ“ßF‡O§’¬)ß1®8“°¬“¢—∫‡À≈Á°  √“â ߌÕ√‚å ¡π‡æ»‰¥â (hypergonadotropic hypogo-
nadism) ®–„Àâ°“√«‘π‘®©—¬¿“«–‡ªìπÀπàÿ¡ “«™â“
‡¡Ë◊Õ‡¥Á°À≠‘ßÕ“¬ÿ13 ªï·≈⫬—߉¡à‡√‘Ë¡¡’‡µâ“π¡ À√◊Õ
§”·π–π”„π°“√¥·Ÿ≈ºŸªâ «É ¬1,19-21 ‡¥°Á™“¬Õ“¬¡ÿ“°°«“à 14 ªï ¬ß—¡¢’π“¥Õ≥—±–πÕâ ¬°«“à

1. ª√–‡¡π‘§«“¡ ßŸ·≈–π”ÈÀπ°—∑°ÿ3-6 ‡¥Õ◊π 4 ¡≈. „π∫“ß√“¬æ∫«“à  “¡“√∂‡¢“â  «Ÿà ¬—Àπ¡ÿà  “«‰¥â
2. ª√–‡¡‘πÕ—µ√“°“√‡æË‘¡§«“¡ ŸßµàÕªï∑ÿ°ªï ‡Õß·µ‰à ¡ à “¡“√∂¡°’“√ æ≤—π“°“√∑“߇滉¥ â ¡∫√Ÿ≥å

¿“«–·∑√°´Õâ π∑“ßµÕà ¡‰√∑â Õà „πºªŸâ «É ¬‡¥°Á‚√§∏“≈ —´‡’¡¬’ Endocrinopathy Complications in Thalassemia Disease 251

‡™àπ ‰¡à¡’°“√æ—≤π“¢Õß≈—°…≥–°“√‡ªìπÀπàÿ¡ “« one enanthate ¢π“¥ 50 ¡°. ‡¢â“°≈â“¡‡πÈ◊Õ∑ÿ°
‡æË‘¡¢È÷π„π‡«≈“ 1 ªï ‰¡à¡’ª√–®”‡¥◊Õπ (primary  ª—¥“Àå ‡ªπì √–¬–‡«≈“ 6 ‡¥Õ◊π ®“°ππ—È≈ÕßÀ¬¥ÿ¬“
amenorrhea) À√Õ◊ª√–®”‡¥Õ◊π¢“¥À“¬‰ªÀ≈ß—®“° À“°ºŸâªÉ«¬‰¡à¡’æ—≤π“°“√∑“߇滇æË‘¡‡µ‘¡·≈–‰¡à
∑‡’˧¬¡ª’√–®”‡¥Õ◊π·≈«â (secondary amenorrhea)  “¡“√∂‡¢“â  «àŸ¬—Àπ¡ÿà ‰¥‡â Õß¿“¬„π 6 ‡¥Õ◊π ∂Õ◊«“à ¢“¥
ŒÕ√å‚¡π‡æ»®√‘ß æ‘®“√≥“„Àâ depot testosterone
§”·π–π”„π°“√¥Ÿ·≈ºªâŸÉ«¬ enanthate ¢π“¥‡¥‘¡µàÕ·≈–§àÕ¬Ê ‡æË‘¡¢π“¥¢È÷π

1. ª√–‡¡‘π°“√‡¢â“ Ÿà«—¬Àπàÿ¡ “«‚¥¬µ√«® ®π∂ß÷250 ¡°.
≈°—…≥–∑“߇æ»∑µÿ¬‘¿¡Ÿ‘(secondary sex charac-
teristics) µ“¡ Tanner staging ∑ÿ°Ê 6 ‡¥◊Õπ 3. ¿“«–æ√àÕ߉∑√Õ¬¥åŒÕ√å‚¡π (hypothy-
‡√¡‘˵ߗȷµÕà “¬ÿ12 ªï roidism)

2. „π°√≥∑’º’ËªâŸ«É ¬‡æ»À≠ß‘Õ“¬¡ÿ“°°«“à 13 ªï æ∫§«“¡™ÿ°¢Õß¿“«–æ√àÕ߉∑√Õ¬¥åŒÕ√å‚¡π
·≈–‡æ»™“¬Õ“¬¡ÿ“°°«“à 14 ªï ·µ¬à ß—‰¡¡à °’“√æ≤— π“ „πºªŸâ «É ¬‚√§∏“≈ —´‡’¡¬’ ª√–¡“≥√Õâ ¬≈– 8-1022, 23
∑“߇æ»∑µÿ¬‘¿¡Ÿ‘·π–π”„Àâ  “‡ÀµÿÀ≈—°‡°‘¥®“°°“√¡’¿“«–‡À≈Á°‡°‘π‡ªìπ
-  ßà µ√«®√–¥∫— LH, FSH ·≈– estradiol ‡«≈“π“π  à«π¡“°¡—°‰¡à¡’Õ“°“√‡¥àπ™—¥ §«“¡º‘¥
„π‡æ»À≠ß‘À√Õ◊ testosterone „π‡æ»™“¬ ∂“â √–¥∫— ª°µ‘∑Ë’æ∫ à«π„À≠à¡—°‡°‘¥®“°§«“¡º‘¥ª°µ‘¢Õß
FSH ·≈– LH µ”Ë„À°â “√«π‘®‘©¬—¿“«– hypogona- µÕà ¡‰∑√Õ¬¥å (primary hypothyroidism)2
dotropic hypogonadism ·π–π”„Àâµ√«®§≈Ë◊π
·¡à‡À≈Á°‰øøÑ“ ¡Õß∫√‘‡«≥µàÕ¡„µâ ¡Õ߇æ‘Ë¡‡µ‘¡ §”·π–π”„π°“√¥Ÿ·≈ºªâŸ«É ¬1, 2
∂â“√–¥—∫ FSH ·≈– LH  Ÿß „Àâ°“√«‘π‘®©—¬¿“«– µ√«®√–¥—∫ free thyroxine (FT4) and
hypergonadotropic hypogonadism thyroid stimulating hormone (TSH) ∑ÿ°ªï
- µ√«®Õ≈—µ√“´“«π¡å ¥≈°Ÿ·≈–√ß—‰¢à µÈ—ß·µàÕ“¬ÿ9 ªï ¬°‡«âπ„π°√≥’∑’Ë¡’Õ“°“√¢Õß¿“«–
¿“«–æ√Õà ߉∑√Õ¬¥Œå Õ√‚å ¡π‡°¥‘¢π÷È°Õà π
°“√√—°…“
„π‡æ»À≠ß‘„Àâ conjugated estrogen ¢π“¥ °“√√—°…“3
0.3 ¡°. À√Õ◊ ethinyl estradiol (EE) ¢π“¥ 2.5-5 °“√‰¥â√—∫¬“¢—∫‡À≈Á°Õ¬à“ß ¡Ë”‡ ¡Õ®–™à«¬
¡§°. √∫—ª√–∑“π«π—≈–§√ß—È ‡ªπì √–¬–‡«≈“ 6 ‡¥Õ◊π ªÕÑ ß°π—·≈–∑”„À¿â “«–æ√Õà ߉∑√Õ¬¥Œå Õ√‚å ¡π¥¢’π÷ȉ¥â
®“°π—Èπ≈ÕßÀ¬ÿ¥¬“ À“°ºâŸªÉ«¬‰¡à¡’æ—≤π“°“√∑“ß „π°√≥’subclinical hypothyroidism ∑√Ë’–¥∫— TSH
‡æ»‡æ¡‘ˇµ¡‘·≈–‰¡ à “¡“√∂‡¢“â  «Ÿà ¬— “«‰¥‡â Õß¿“¬„π 5-7 ¬πŸµ‘/¡≈. Õ“®„™«â ∏‘µ’¥‘µ“¡·≈–„À¬â “¢∫—‡À≈°Á
6 ‡¥Õ◊π ∂Õ◊«“à ¢“¥ŒÕ√‚å ¡π‡æ»®√ß‘ ®–„Àâ ethinyl „À‡â À¡“– ¡¡“°¢πÈ÷24 „π°√≥’overt hypothyroidism
estradiol Õ°’§√ß—È·≈–§Õà ¬Ê ‡æ¡‘Ë√–¥∫—¬“∑°ÿ 6 ‡¥Õ◊π „À°â “√√°—…“¥«â ¬ L-thyroxine
®π∂ß÷¢π“¥ 20 ¡§°. ¿“¬„π‡«≈“ 1-2 ªï ®“°ππÈ—
„ÀâŒÕ√å ‚¡π progesterone √à«¡¥â«¬ ‡æ◊ËÕ„Àâ¡’ 4. ¿“«–æ√àÕßæ“√“‰∑√Õ¬¥åŒÕ√å‚¡π (hypo-
ª√–®”‡¥Õ◊π parathyroidism)

„π‡æ»™“¬ √°—…“‚¥¬°“√©¥’ depot testoster- ‡°‘¥®“°¿“«–‡À≈Á°‡°‘π‰ª – ¡∑’˵àÕ¡æ“

252 «√≈°—…≥å ¿∑—√°‘®π‘√π—¥√å

√“‰∑√Õ¬¥å  à«ππâÕ¬Õ“®‡°‘¥®“°°“√¬—∫¬È—ß°“√À≈—Ëß deformity «à πºªŸâ «É ¬∑‰Ë’¥√â ∫—‡≈Õ◊¥‡æ¬’ßæÕ®–¡’bone
æ“√“‰∑√Õ¬¥åŒÕ√å‚¡π®“°°“√ ≈“¬°√–¥Ÿ°∑Ë’¡“° resorption ‡æ‘Ë¡¢È÷π ∑”„Àâ¡’¡«≈°√–¥Ÿ°πâÕ¬°«à“
¢È÷πÕ—π‡ªìπº≈®“°¿“«–‡≈◊Õ¥®“߇√È◊Õ√—ß25 ∂◊Õ‡ªìπ ª°µ‘20 ·≈–ºŸâªÉ«¬¡’‚Õ°“ ‡°‘¥¿“«–πÈ’‰¥â¡“°¢È÷π
¿“«–·∑√°´Õâ π∑æË’∫‰¥πâ Õâ ¬ (√Õâ ¬≈– 2-19)19, 23 ‡¡ÕË◊Õ“¬‡ÿæ¡‘Ë¢π÷È®“° √Õâ ¬≈– 8.7 „πºªŸâ «É ¬Õ“¬πÿÕâ ¬°«“à
·≈–¡°—æ∫„πºªŸâ «É ¬∑ÕË’“¬¡ÿ“°°«“à 16 ªï  «à π„À≠à 10 ªï ‡æ¡Ë‘¢π÷ȇªπì √Õâ ¬≈– 44 „πºªâŸ«É ¬Õ“¬ÿ11-19 ªï
¡“¥«â ¬Õ“°“√¢Õß·§≈‡´¬’¡„π‡≈Õ◊¥µ”Ë·∫∫‰¡√à πÿ·√ß ·≈–√Õâ ¬≈– 61 „πºªŸâ «É ¬Õ“¬¡ÿ“°°«“à 20 ªï  “‡Àµÿ
‡™πà ™“ ¡ ’«à ππÕâ ¬∑®Ë’–¡Õ’“°“√√πÿ·√ß ‡™πà ¡Õ◊®∫’ ™°— ¢Õß¿“«–°√–¥°Ÿ∫“ß·≈–°√–¥°Ÿæ√πÿ¬ß—‰¡∑à √“∫·π™à ¥—
À√Õ◊À«—„®≈¡â ‡À≈« πÕ°®“°¿“«–æ√Õà ßæ“√“‰∑√Õ¬¥å ·µà‡™Ë◊Õ«à“‡°‘¥®“°°“√ ≈“¬°√–¥Ÿ°¡“°¢÷Èπ√à«¡°—∫
ŒÕ√å‚¡π ¬—ßæ∫«à“ºâŸªÉ«¬‚√§∏“≈— ´’‡¡’¬¡’‚Õ°“  °“√ √â“ß°√–¥Ÿ°≈¥≈ß®“°À≈“¬Ê ªí®®—¬ ‰¥â·°à
‡°‘¥¿“«– hypercalciuria ‰¥â∂÷ß√âÕ¬≈– 50 ·≈– ¿“«–‡≈◊Õ¥®“ß ¡’°“√¢¬“¬µ—«¢Õ߉¢°√–¥Ÿ° ¿“«–
nephrolithiasis √Õâ ¬≈– 10 ‚¥¬¬ß—‰¡∑à √“∫ “‡Àµÿ ‡À≈Á° – ¡„π√à“ß°“¬ ¢“¥«‘µ“¡‘π¥’≈¥°“√¡’
∑·’Ëπ™à ¥— ·µÕà “®‡ªπì º≈¡“®“°°“√„™¬â “¢∫—‡À≈°Á ·≈– °®‘°√√¡∑“ß°“¬ ·≈–§«“¡º¥‘ª°µÕ‘πË◊¢Õß µÕà ¡‰√∑â Õà
¡—°æ∫¿“«–π’ȉ¥â „π°√≥’∑’˺ŸâªÉ«¬¡’√–¥—∫«‘µ“¡‘π¥’ ‰¥·â °à ¿“«–¢“¥ŒÕ√‚å ¡π‰∑√Õ¬¥å ŒÕ√‚å ¡π°“√‡®√≠‘
(25-hydroxyvitamin D, 25-OHD) „π‡≈◊Õ¥ ‡µ‘∫‚µ·≈–ŒÕ√å‚¡π‡æ»17, 27-31 µ”·Àπàß∑’˧«“¡
¡“°°«“à 30 π°./¡≈.26 Àπ“·ππà °√–¥°Ÿµ”Ë ¥ÿ¡°—‡ªπì ∫√‡‘«≥ °√–¥°Ÿ π—À≈ß—
‡πÕ◊Ëß®“°‡ªπì trabecular bone ‡ªπì  «à π„À≠à
§”·π–π”„π°“√¥Ÿ·≈ºŸªâ «É ¬1, 2, 19

µß—È·µÕà “¬ÿ9-16 ªï §«√µ√«®√–¥∫— serum °“√«π‘®‘©¬—
calcium, phosphate, magnesium, alkaline ‚¥¬°“√µ√«®§«“¡Àπ“·ππà °√–¥°Ÿ¥«â ¬‡§√Õ◊Ëß
phosphatase (ALP), 25-OHD, parathyroid dual-energy x-ray absorptiometry (DXA) À“°
hormone (PTH) ·≈– urine calcium ª≈ï –§√ßÈ— §«“¡Àπ“·ππà ¢Õß°√–¥°Ÿ (Z-score) πÕâ ¬°«“à §à“
ª°µ‡‘°π‘ 2 ‡∑“à ‡¡Õ◊ˇ∑¬’∫°∫—§«“¡Àπ“·ππà °√–¥°Ÿ
°“√√—°…“ ¢Õ߇¥°Á‡æ»‡¥¬’«°π— ‡™Õ◊È™“µ‡‘¥¬’«°π—∑¡Ë’Õ’“¬‡ÿ∑“à °π—

„Àâ calcium ·≈– active vitamin D ∑¥·∑π ∂Õ◊«“à §«“¡Àπ“·ππà ¢Õß°√–¥°ŸπÕâ ¬°«“à ª°µ‘(low
bone density for chronological age) ·µà®–
5. °√–¥Ÿ°∫“ß (osteopenia) À√◊Õ°√–¥Ÿ°æ√ÿ𠉥√â ∫—°“√«π‘®‘©¬—«“à ¿“«–°√–¥°Ÿ∫“ß (osteopenia)
(osteoporosis) ·≈–°√–¥Ÿ°æ√ÿπ (osteoporosis) µàÕ‡¡◊ËÕ¡’¿“«–

¿“«–°√–¥°Ÿ∫“ß (osteopenia) ·≈–°√–¥°Ÿ °√–¥Ÿ°À—°√à«¡°—∫¡’§«“¡Àπ“·πàπ¢Õß°√–¥Ÿ°πâÕ¬
æ√ÿπ (osteoporosis) ‡ªìπ¿“«–·∑√°´âÕπ∑Ë’æ∫ °«“à ª°µ‘
‰¥∫â Õà ¬„πºªŸâ «É ¬‚√§∏“≈ —´‡’¡¬’ ·¡ºâ ªŸâ «É ¬∏“≈ —´‡’¡¬’
∑’ˉ¥â√—∫°“√√—°…“Õ¬à“ߥ’°Á¬—ßæ∫¿“«–πÈ’ ∂÷ß√âÕ¬≈– §”·π–π”„π°“√¥·Ÿ≈ºªŸâ É«¬1, 2, 19, 20
40-5027 ‡πÕ◊Ëß®“°„π√“¬∑‰Ë’¥√â ∫—‡≈Õ◊¥‰¡‡à 欒ßæÕ ®– ·π–π”„Àâ∑”°“√µ√«®§«“¡Àπ“·πàπ°√–¥Ÿ°
¡’erythropoiesis ¡“°  ßà º≈„À¡â ’bone marrow ¥â«¬‡§√Ë◊Õß DXA √à«¡°—∫µ√«® “√·≈–ŒÕ√å‚¡π„π
cavity °«“â ß ·≈–¡°’√–¥°Ÿcortex ∫“ß√«à ¡°∫—¡’bone ‡≈◊Õ¥∑Ë’¡’º≈µàÕ§«“¡Àπ“·πàπ¢Õß°√–¥Ÿ° ‰¥â·°à

¿“«–·∑√°´Õâ π∑“ßµÕà ¡‰√∑â Õà „πºªâŸ«É ¬‡¥°Á‚√§∏“≈ —´‡’¡¬’ Endocrinopathy Complications in Thalassemia Disease 253

√–¥—∫ serum calcium, phosphate, ALP, 25- IFG ·≈– impair glucose tolerance, IGT)
OHD, parathyroid hormone (PTH), ·≈–‡æË‘¡‚Õ°“ ‡ ’ˬߵàÕ°“√‡ªìπ‚√§‡∫“À«“π34, 35
osteocalcin ·≈– urine calcium ‡ªπì ª√–®”∑ÿ°ªï “‡Àµÿ‡°‘¥®“°°“√∑Ë’¡’‡À≈Á°‡°‘π – ¡„πµ—∫·≈–
‚¥¬‡√¡Ë‘µ√«®µß—È·µàÕ“¬ÿ9-10 ªï °≈â“¡‡π◊ÈÕ ∑”„À≡ࠓ¡“√∂π”°≈Ÿ‚§ ‡¢â“ Ÿà‡´≈≈å
‰¥â ‡°¥‘¿“«–¥Õ◊ȵÕà Õπ‘´≈Ÿπ‘ ∑”„Àâµ—∫ÕàÕπµâÕß √â“ß
°“√√°—…“ Õ‘π´Ÿ≈‘πÕÕ°¡“¡“°¢È÷π‡æË◊Õ§«∫§ÿ¡„Àâ√–¥—∫πÈ”µ“≈

‰¥â√—∫·§≈‡´’¬¡ «‘µ“¡‘π¥’·≈– —ß°– ’Õ¬à“ß „π‡≈Õ◊¥ª°µ‘‡¡Õ◊ˇ«≈“º“à π‰ª°“√∑”ß“π¢Õßµ∫—ÕÕà π
‡æ¬’ßæÕ Õ“®„À·â §≈‡´¬’¡‡ √¡‘„πª√¡‘“≥‹500-1,000 ≈¥≈ß ∑”„À°â ≈“¬‡ªπì ‡∫“À«“π„π∑ ’Ë¥ÿ36
¡°./«—π √à«¡°—∫«‘µ“¡‘π¥’400-800 ¬Ÿπ‘µµàÕ«—π
·π–π”„À⺟âªÉ«¬ÕÕ°°”≈—ß°“¬√–¥—∫ª“π°≈“ßÕ¬à“ß °“√«π‘‘®©¬—
¡Ë”‡ ¡Õ „π°√≥’∑Ë’¡’¿“«– osteoporosis Õ“®„Àâ ºªâŸ«É ¬∑‡’˪πì ‡∫“À«“π·≈«â (overt diabetes)
°“√√°—…“¥«â ¬ bisphosphonates ¡°—®–¡ª’√–«µ—π‘È”Àπ°—≈¥ ¥¡Ë◊πÈ”∫Õà ¬ ª í  “«–∫Õà ¬
·µà„π√“¬∑Ë’∑Ë’‡√‘Ë¡‡ªìπ‡∫“À«“π IFG À√◊Õ IGT)
6. ¿“«–µÕà ¡À¡«°‰µ∑”ß“π∫°æ√Õà ß(adrenal ¡—°‰¡à¡’Õ“°“√º‘¥ª°µ‘·µà‡¡Ë◊Õµ√«®√–¥—∫πÈ”µ“≈„π
insufficiency) ‡≈◊Õ¥®–¡’§à“ Ÿß°«à“ª°µ‘ À“°µ√«®√–¥—∫π”ȵ“≈

§«“¡™°ÿ¢Õß¿“«–µÕà ¡À¡«°‰µ∑”ß“π∫°æ√Õà ß À≈—ßߥՓÀ“√ ≥ 100-125 ¡°./¥≈. ‡√’¬°«à“
„πºŸâªÉ«¬‚√§∏“≈— ´’‡¡’¬∑’ˉ¥â√—∫°“√«‘π‘®©—¬‚¥¬°“√ IFG À“°√–¥∫—π”ȵ“≈ ≥ 126 ¡°./¥≈. ∂Õ◊«“à ‡ªπì
µ√«®√–¥∫—ŒÕ√‚å ¡πæ∫‰¥√â Õâ ¬≈– 0-45.32, 33 Õ¬“à ߉√ ‡∫“À«“π °“√µ√«® oral glucose tolerance test
°Áµ“¡ ºŸâªÉ«¬ à«π„À≠à¡—°‰¡à¡’Õ“°“√¢Õß°“√¢“¥ (OGTT) ®–µ√«®æ∫§«“¡º¥‘ª°µ‰‘¥‡â √«Á°«“à ‚¥¬
ŒÕ√‚å ¡π®“°µÕà ¡À¡«°‰µ ‚¥¬‡©æ“–„π ¿“«–ª°µ‘ „Àâ√—∫ª√–∑“ππÈ”µ“≈°≈Ÿ‚§ ¢π“¥ 1.75 °.µàÕ°°.
·µÀà “°Õ¬„Ÿà π¿“«–‡§√¬’¥√πÿ·√ß ‡™πà °“√µ¥‘‡™Õ◊È ‰¥â (¢π“¥ ßŸ ¥ÿ 75 °.) ∂“â √–¥∫—πÈ”µ“≈∑’Ë2 ™«—Ë‚¡ß ≥
√∫—°“√º“à µ¥—À√Õ◊Õ∫ÿµ—‡‘ÀµÿÕ“®®–¡¿’“«–™ÕÁ°‰¥â 140-199 ¡°./¥≈. ‡√¬’°«“à IGT ∂“â √–¥∫—π”ȵ“≈ ≥
200 ¡°./¥≈. · ¥ß«“à ‡ªπì ‡∫“À«“π
§”·π–π”„π°“√¥Ÿ·≈ºªŸâ É«¬

ºªâŸ«É ¬∑¡’ˇ’À≈°Á – ¡‡°π‘¡“° §«√ ßà ª√°÷…“ §”·π–π”„π°“√¥Ÿ·≈ºªâŸ«É ¬
°¡ÿ“√·æ∑¬µå Õà ¡‰√∑â Õà ∑°ÿ1-2 ªï ‡æÕ◊Ë∑¥ Õ∫ŒÕ√‚å ¡π §«√µ√«® OGTT ¢≥–Õ“¬ÿ10, 12, 14
cortisol ·≈– 16 ªï À≈ß—®“°ππ—È ·π–π”„Àµâ √«®´”È∑°ÿªï

7. ‚√§‡∫“À«“π (diabetes mellitus) √ÿª§”·π–π”„π°“√ª√–‡¡‘π¿“«–·∑√°´âÕπ
∂Õ◊‡ªπì ¿“«–·∑√°´Õâ π∑æË’∫‰¥∫â Õà ¬„πº„Ÿâ À≠à ∑“ßµÕà ¡‰√∑â Õà „πºªâŸ«É ¬‚√§∏“≈ —´‡’¡¬’1, 2, 19, 20
ë µß—È ·µ‡à √¡Ë‘ √°—…“
∑‡Ë’ªπì ‚√§‡≈Õ◊¥®“ß∏“≈ —´‡’¡¬’ ·µ à “¡“√∂æ∫„π‡¥°Á
·≈–«¬—√πÿà ‰¥‡â ™πà °π— ‚¥¬‡©æ“–Õ“¬ÿ10 ª¢ï πÈ÷‰ª ‚¥¬ 1. ª√–‡¡π‘§«“¡ ßŸ·≈–πÈ”Àπ°—∑°ÿ3-6 ‡¥Õ◊π
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πÈ”µ“≈„π‡≈Õ◊¥º¥‘ª°µ‘(impair fasting glucose, ®π°√–∑ߗˇªπì º„Ÿâ À≠à

254 «√≈°—…≥å ¿∑—√°®‘π√‘—π¥√å

3. «¥—§«“¡¬“«™«à ß≈”µ«—°∫—™«à ߢ“ (upper ºªâŸ«É ¬À≠ß‘Õ“¬¡ÿ“°°«“à 13 ªï ·≈–™“¬Õ“¬¡ÿ“°°«“à
to lower segment ratio) ∑ÿ° 6 ‡¥◊Õπ ‡æ◊ËÕ 14 ªï ·µ¬à ß—‰¡¡à °’“√æ≤—π“∑“߇æ»∑µÿ¬‘¿¡Ÿ‘(secondary
ª√–‡¡π‘¿“«– ¥— «à π√“à ß°“¬º¥‘ª°µ‘ sex characteristics)
4. µ√«®√–¥∫— zinc ‡ªπì √–¬– ·≈–„Àâ zinc 7. ‡Õ°´‡√¬åÕ“¬ÿ°√–¥Ÿ° (bone age) ∑ÿ°
∑¥·∑¥„π°√≥∑’¡’Ë¿’“«–¢“¥∏“µ ÿß—°– ’ 1-2 ªï
8. ‡Õ°´‡√¬å°√–¥Ÿ° —πÀ≈—ß (lateral spine
ë ‡√Ë¡‘ª√–‡¡π‘∑Õ’Ë“¬ÿ9-10 ª¢ï ’Èπ‰ª radiography) ∑°ÿ 1 ªï

1. ª√–‡¡‘π°“√‡¢â“ àŸ«—¬Àπÿà¡ “«‚¥¬µ√«® 9. µ√«®§«“¡Àπ“·πàπ°√–¥Ÿ°¥â«¬‡§√◊ËÕß
≈—°…≥–∑“߇æ»∑ÿµ‘¬¿Ÿ¡‘µ“¡ Tanner staging DXA ∑°ÿ 1 ªï
∑°ÿÊ 6 ‡¥Õ◊π ‡√¡Ë‘µßÈ—·µÕà “¬ÿ12 ªï
2. Serum TSH and F T4 ∑°ÿ 1 ªï ∫∑ √ÿª

3. Serum calcium, phosphate, magne- ¿“«–·∑√°´âÕπ∑“ßµàÕ¡‰√â∑àÕ„πºŸâªÉ«¬‡¥Á°
sium, 25-OHD, ALP ·≈– urine calcium ·≈–«—¬√ÿàπ‚√§∏“≈— ´’‡¡’¬¡’À≈“¬¿“«–·≈–æ∫‰¥â
À“°¡§’«“¡º¥‘ª°µ„‘Àµâ √«® PTH ‡æ¡Ë‘ ∑°ÿ 1 ªï ∫àÕ¬ ·µà∂Ÿ°¡Õߢⓡ‰ª‡π◊ËÕß®“°‰¡à‰¥â¡’Õ“°“√·≈–
4. Fasting glucose, fasting insulin ·≈– Õ“°“√· ¥ß∑’Ë√ÿπ·√ß Õ¬à“߉√°Áµ“¡·æ∑¬åºâŸ¥Ÿ·≈
oral glucose tolerance testing (OGTT) „𠧫√µ√–Àπ—°∂÷ߪí≠À“¥—ß°≈à“«·≈– “¡“√∂„Àâ°“√
°√≥’∑Ë’‡ªìπ impaired fasting glucose (IFG) ªÑÕß°—π‚¥¬°“√„Àâ‡≈◊Õ¥Õ¬à“ß ¡Ë”‡ ¡Õ√à«¡°—∫¬“
∑°ÿ 2 ªï ¢—∫‡À≈Á° ‡æ◊ËÕ‰¡à„À⇰‘¥¿“«–‡≈◊Õ¥®“߇√◊ÈÕ√—ß·≈–
5. Serum cortisol ∑ÿ° 1-2 ªï ∂â“√–¥—∫ ‡À≈°Á‡°π‘„π√“à ß°“¬ √«¡∑ß—È¡°’“√µ√«®ª√–‡¡π‘µ“¡
cortisol µË” æ‘®“√≥“∑” ACTH À√◊Õ insulin ‡°≥±å ‡æÕ◊Ë®– “¡“√∂«π‘®‘©¬—¿“«–·∑√°´Õâ π∑‡Ë’°¥‘
stimulation test ¢È÷π‰¥âÕ¬à“߇√Á« √—°…“‰¥â∑—π∑à«ß∑’·≈–¡ÿàßÀ«—ß„Àâ
6. LH, FSH ·≈– sex steroids „π°√≥∑’’Ë ºªŸâ «É ¬¡§’≥ÿ¿“晫’µ‘∑¥’Ë„’π√–¬–¬“«

‡Õ° “√Õ“â ßÕß‘ and endocrine disorders in thalassemia: The
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¿“«–·∑√°´Õâ π∑“ßµÕà ¡‰√∑â Õà „πºªâŸ«É ¬‡¥°Á‚√§∏“≈ —´‡’¡¬’ Endocrinopathy Complications in Thalassemia Disease 255

AM, Musallam KM, Taher AT. Serum ferritin 1998;139(2):143-4.
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·≈–¬π’∫”∫¥—

18 Hematopoietic Stem Cell
Transplantation and Gene Therapy

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marrow failure syndrome) ·≈– ‚√§‚≈À‘µ®“ß ®”π«π‰¥â‡Õß (self-renewal) ·≈–§ÿ≥ ¡∫—µ‘∑Ë’
∏“≈— ´’‡¡’¬ ‡ªìπµâπ ∑È—ßπ’È°“√æ‘®“√≥“‡≈◊Õ°∑”°“√ ‡´≈≈ å “¡“√∂æ≤— 𓉪‡ªπì ‡´≈≈Õå π◊ËÊ ‰¥â πÕ°®“°πÈ’
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µÕ∫ πÕßµÕà °“√√°—…“¡“µ√∞“π πÕ°®“°π„È’πª®í ®∫ÿπ— „ÀâÀ√◊Õª≈Ÿ°∂à“¬„Àâ°—∫§πÕ’°§πÀπË÷߉¥â (trans-
‰¥â¡’°“√»÷°…“‡°Ë’¬«°—∫°“√√—°…“¥â«¬¬’π∫”∫—¥ „π plantibility)·≈–‡¡Õ◊Ëπ”‡´≈≈‰å ª„À·â ≈«â ‡´≈≈ å “¡“√∂
‚√§∑“ß‚≈À‘µ«‘∑¬“À≈“¬™π‘¥ ‰¥â·°à ‚√§‚≈À‘µ®“ß ‡¥π‘∑“ß°≈∫—‰ª¬—߉¢°√–¥°Ÿ‰¥‡â Õß (homing) ·≈–
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258 ªî¬– √®ÿ°‘®¬“ππ∑å

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2. º∑Ÿâ „’ËÀâ À√Õ◊ º∫Ÿâ √®‘“§‡´≈≈µå πâ °”‡π¥‘‡¡¥Á °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥¢Õßµ«—ºªŸâ «É ¬‡Õß°≈∫—¡“„À‡â ´≈≈µå πâ
‡≈Õ◊ ¥ (donor) ‚¥¬º∑Ÿâ „Ë’À‡â ´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥‡À≈“à π®’È–°≈∫—‡¢“â ‰ª„π‰¢°√–¥°Ÿ¢Õß
Õ“®®–‡ªπì µ«—ºªŸâ «É ¬‡ÕßÀ√Õ◊ ∫§ÿ§≈ÕπË◊ °‰Á¥â ºâŸªÉ«¬·≈–‡®√‘≠‡µ‘∫‚µ‰ª‡ªìπ‡´≈≈å∑Ë’∑”ß“π‰¥â‡ªìπ
3. «‘∏’°“√∑’Ë·æ∑¬å„™â‡µ√’¬¡ºâŸ∑’Ë®–‰¥â√—∫‡´≈≈å ª°µ‘(stem cell rescue) ∑ß—Èπ°’È“√ª≈°Ÿ∂“à ¬‡´≈≈å
µπâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥‡æÕ◊Ë„À â ¿“æ√“à ß°“¬¡§’«“¡æ√Õâ ¡ µâ𰔇𑥇¡Á¥‡≈◊Õ¥‚¥¬„™â‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥
∑Ë’®–√—∫‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥®“°ºŸâ∑’Ë„À⇴≈≈åµâπ ¢Õßµ—«‡Õß à«π„À≠à®–‰¡à∑”„À⇰‘¥ªØ‘°‘√‘¬“À√◊Õº≈
°”‡π‘¥‡¡Á¥‡≈◊Õ¥ (conditioning regimen À√◊Õ ·∑√°´Õâ π®“°°“√‰¥√â ∫—‡´≈≈¢å Õßµπ‡Õß
preparative regimen) ‚¥¬«‘∏’°“√∑Ë’·æ∑¬å„™âÕ“® 2. °“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥
®–‡ªìπ°“√„À⬓‡§¡’∫”∫—¥„π¢π“¥ Ÿß·≈–/À√◊Õ√à«¡ ‚¥¬„™‡â ´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥¢Õߺ՟â π◊Ë(allogeneic
°∫—°“√©“¬√ß— ’ hematopoietic stem cell transplantation) ‡ªπì °“√
ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥∑Ë’ºâŸ∑’ˉ¥â√—∫‡´≈≈å
ª√–‡¿∑¢Õß°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥ µâ𰔇𑥇¡Á¥‡≈◊Õ¥ ·≈–ºŸâ∑’Ë„À⇴≈≈åµâ𰔇𑥇¡Á¥
‡≈◊Õ¥ ‡≈◊Õ¥‡ªìπ§π≈–§π°—π °“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇π‘¥
‚¥¬∑—Ë«‰ª·≈â«°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥠‡¡Á¥‡≈◊Õ¥¥â«¬«‘∏’°“√π’È¡’¢âÕ∫àߙȒ„πºâŸªÉ«¬∑Ë’¡’‚√§À√◊Õ
‡¡¥Á‡≈Õ◊ ¥ “¡“√∂·∫ßà ÕÕ°‰¥‡â ªπì 2 ª√–‡¿∑ ‰¥·â °à §«“¡º¥‘ª°µ„‘π‰¢°√–¥°Ÿ ∑”„À‰â ¡ à “¡“√∂„™‡â ´≈≈å
1. °“√ª≈°Ÿ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥‚¥¬ µâ𰔇𑥇¡Á¥‡≈◊Õ¥¢Õßµπ‡Õß„π°“√ª≈Ÿ°∂à“¬‡´≈≈å
„™‡â ´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥¢Õßµ«—‡Õß (autologous µâ𰔇𑥇¡Á¥‡≈◊Õ¥‰¥â À≈—°°“√ª≈Ÿ°∂à“¬‡´≈≈åµâπ
hematopoietic stem cell transplantation) ‡ªπì °“√ °”‡π‘¥‡¡Á¥‡≈◊Õ¥‚¥¬«‘∏’πÈ’®÷߇ªìπ°“√°”®—¥‡´≈≈凡Á¥
ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥∑’˺âŸ∑’ˉ¥â√—∫‡´≈≈å ‡≈◊Õ¥·≈–‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥„π‰¢°√–¥Ÿ°∑’Ë¡’
µâ𰔇𑥇¡Á¥‡≈◊Õ¥ ·≈–ºâŸ∑Ë’„À⇴≈≈åµâ𰔇𑥇¡Á¥ §«“¡º‘¥ª°µ‘¢ÕߺŸâªÉ«¬∑‘È߉ª ·≈–π”‡Õ“‡´≈≈åµâπ
‡≈Õ◊ ¥‡ªπì §πÊ ‡¥¬’«°π— (host = donor)  “‡Àµÿ °”‡π‘¥‡¡Á¥‡≈◊Õ¥®“°ºâŸ∫√‘®“§∑Ë’ª°µ‘¡“ª≈Ÿ°∂à“¬
„π°“√ª≈°Ÿ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥¥«â ¬«∏‘°’“√πÈ’ ·∑π∑Ë’ Õ¬à“߉√°Áµ“¡∑—ÈߺâŸ∫√‘®“§‡´≈≈åµâ𰔇π‘¥
‡æË◊Õ∑Ë’®–„À⬓‡§¡’∫”∫—¥„π¢π“¥∑’Ë Ÿß¡“°°«à“¢π“¥ ‡¡Á¥‡≈◊Õ¥·≈–ºâŸªÉ«¬®–µâÕß¡’human leukocyte
¡“µ√∞“π∑Ë’„Àâ„πºŸâªÉ«¬∑’Ë¡’‚√§¡–‡√Áß°≈—∫¡“À√◊Õ‚√§ antigen (HLA) ∑‡Ë’¢“â °π—‰¥â ∑ß—Èπ®’Ȗ殑“√≥“∑Ë’HLA
¡–‡√ÁߥÈ◊ÕµàÕ¬“„π¢π“¥¡“µ√∞“π ‚¥¬·æ∑¬å®–‡°Á∫ locus A, B ·≈– DRB1 („πª®í ®∫ÿπ—¡°—®–殑“√≥“
‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥®“°µ—«ºŸâªÉ«¬‰«â°àÕπ ‚¥¬ HLA locus C ·≈– DQ √à«¡¥â«¬) ‚¥¬®–§—¥
‡°∫Á®“°‰¢°√–¥°Ÿ (bone marrow collection) À√Õ◊ ‡≈◊Õ°®“°æË’πâÕß√à«¡∫‘¥“¡“√¥“‡¥’¬«°—π (related
®“°°√–· ‡≈Õ◊ ¥ (peripheral blood collection) donor) ‡ªπì ≈”¥∫—·√° ‡πÕ◊Ëß®“°¡‚’Õ°“ ∑®’Ë–¡’HLA

°“√ª≈°Ÿ∂“ଇ´≈≈µåπâ°”‡π¥‘‡¡¥Á‡≈Õ◊¥·≈–¬π’∫”∫¥—Hematopoietic Stem Cell Transplantation and Gene Therapy 259

µ√ß°π—‰¥∂â ß÷ 1 „π 4 À√Õ◊ √Õâ ¬≈– 25 „π°√≥∑’º’ËªâŸ«É ¬ °√–¥Ÿ° √â“߇´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥¡“°¢È÷π ∑”
‰¡¡à æ’π’ËÕâ ßÀ√Õ◊ ¡æ’πË’Õâ ß·µà HLA ‰¡µà √ß°π— ·æ∑¬å „À⇴≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥ÕÕ°®“°‰¢°√–¥Ÿ°‡¢â“
®–∑”°“√§πâ À“®“°º∫Ÿâ √®‘“§Õπ◊Ë (alternative donor) ¡“Õ¬àŸ„π°√–· ‡≈◊Õ¥ ·≈â«®÷ß∑”°“√‡°Á∫·¬°‡¡Á¥
‚¥¬Õ“®®–‡ªπì º∫âŸ√®‘“§∑≈Ë’ß∑–‡∫¬’π· ¥ß§«“¡®”πß§å ‡≈Õ◊ ¥¢“«ÕÕ°¡“®“°‡≈Õ◊ ¥¢Õߺ∫âŸ√®‘“§‚¥¬„™‡â §√ÕË◊ ß
∑Ë’®–∫√‘®“§‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥ (unrelated ªòíπ·¬°‡¡Á¥‡≈◊Õ¥Õ—µ‚π¡—µ‘(leukapheresis) ‚¥¬
donor)À√Õ◊ Õ“®®–‡ªπì ‡≈Õ◊ ¥®“° “¬ –¥Õ◊ √°∑∫’Ë√®‘“§ ®”π«π‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥∑’ˇ撬ßæÕ°—∫§«“¡
‰«‡â æÕ◊Ë°“√√°—…“ºªŸâ «É ¬ (cord blood donor)3 µâÕß°“√ ª√–¡“≥ 2-3 ≈â“π‡´≈≈åµâ𰔇𑥇¡Á¥
‡≈Õ◊ ¥µÕà πÈ”Àπ°—µ«—∑‡’˪πì °‚‘≈°√¡—¢ÕߺªŸâ «É ¬
·À≈ßà∑’Ë¡“¢Õ߇´≈≈µåâ𰔇𑥇¡Á¥‡≈Õ◊¥ blood)35. ‡≈Õ◊ ¥®“° “¬ –¥Õ◊ √° (umbilical cord
‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥ “¡“√∂‡°∫Á‰¥®â “°3
‡≈◊Õ¥„𠓬 –¥◊Õ√°®–¡’‡´≈≈åµâ𰔇π‘¥
·À≈ßà ¥«â ¬°π—4 §Õ◊ ‡¡Á¥‡≈◊Õ¥‡ªìπ à«πª√–°Õ∫„π —¥ à«π∑’˧àÕπ¢â“ß Ÿß
1. ‰¢°√–¥°Ÿ (bone marrow) °“√‡°Á∫‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥¥â«¬«‘∏’πÈ’®–∑”„π
‰¢°√–¥Ÿ°‡ªìπ∑Ë’Õ¬Ÿà¢Õ߇´≈≈åµâ𰔇𑥇¡Á¥ ÀÕâ ߧ≈Õ¥¥«â ¬§«“¡√–¡¥—√–«ß—°“√µ¥‘‡™ÕÈ◊ „À¡â “°∑ Ë’¥ÿ
‚¥¬À≈ß—®“°·æ∑¬µå ¥— “¬ –¥Õ◊ ÕÕ°®“°µ«—∑“√°‡¡ÕË◊
‡≈Õ◊ ¥·≈–‡ªπì Õ«¬—«–À≈°—∑¡Ë’À’π“â ∑„Ë’π°“√ √“â ߇´≈≈å ∑“√°‡°¥‘ ·æ∑¬®å –‡°∫Á‡≈Õ◊ ¥®“° “¬ –¥Õ◊ ¥“â π∑µ’Ë¥‘
‡¡Á¥‡≈◊Õ¥µà“ßÊ ‰¥â·°à ‡´≈≈凡Á¥‡≈◊Õ¥·¥ß ‡´≈≈å °∫—√°‚¥¬°“√·∑߇¢¡ÁÀ√Õ◊  Õ¥ “¬ «π (catheter)
‡¡Á¥‡≈◊Õ¥¢“« ·≈– ‡°≈Á¥‡≈◊Õ¥ °“√‡°Á∫‡´≈≈åµâπ ‡¢“â ‰ª„πÀ≈Õ¥‡≈Õ◊ ¥ “¬ –¥Õ◊ √° (umbilical vein)
°”‡π‘¥‡¡Á¥‡≈◊Õ¥®“°‰¢°√–¥Ÿ° (bone marrow ·≈–ª≈Õà ¬„À‡â ≈Õ◊ ¥®“° “¬ –¥Õ◊ ‰À≈≈ß„π∂ßÿ‡°∫Á‡≈Õ◊ ¥
harvest)  “¡“√∂∑”‰¥â‚¥¬°“√‡®“–‰¢°√–¥Ÿ°®“° ‚¥¬µ√ß‚¥¬Õ“»—¬·√ß‚πâ¡∂à«ß (gravity) ‚¥¬
º∫âŸ√®‘“§ „πÀÕâ ߺ“à µ¥—À≈ß—®“°¥¡¬“ ≈∫ ∑µË’”·Àπßà ∑—Ë«‰ª°“√‡°Á∫¥â«¬«‘∏’πÈ’®– “¡“√∂‡°Á∫‡≈◊Õ¥®“° “¬
posterior superior iliac crest ∑ß—È Õߢ“â ß ·≈–„™â  –¥Õ◊ ‰¥ªâ √–¡“≥ 50-150 ¡≈. ‡¡ÕË◊ π∫—®”π«π‡´≈≈å
heparin ‡ªπì  “√°π—‡≈Õ◊ ¥·¢ßÁµ«— ‚¥¬∑«Ë—‰ªª√¡‘“≥ µâ𰔇𑥇¡Á¥‡≈◊Õ¥¡—°®–¡’®”π«π¡“°æÕ  ”À√∫—
‰¢°√–¥°Ÿ∑‡Ë’®“–ÕÕ°¡“‰¡§à «√‡°π‘ 20 ¡≈./°°. ¢Õß °“√√°—…“‚¥¬‡©æ“–„π‡¥°Á‡πÕË◊ ß®“°¡π’”ÈÀπ°—µ—«πâÕ¬
ºâŸ∫√‘®“§À√◊Õ‡¡Ë◊Õπ—∫‰¥â®”π«π‡´≈≈åµâ𰔇𑥇¡Á¥ °«“à º„âŸÀ≠à ‚¥¬‡≈Õ◊ ¥®“° “¬ –¥Õ◊ ∑‡’Ë°∫Á‰¥®â –∂°Ÿ·™à
‡≈Õ◊ ¥∑‡’Ë欒ßæÕ°∫—§«“¡µÕâ ß°“√ ª√–¡“≥ 2-3 ≈“â π ·¢ßÁ‰«®â π°«“à ®–¡°’“√π”¡“„™â
‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥µàÕπ”ÈÀπ—°µ—«∑’ˇªìπ
°‚‘≈°√¡—¢ÕߺªâŸ«É ¬ ¿“«–·∑√°´âÕπÀ√◊Õº≈¢â“߇§’¬ß∑’˵“¡¡“À≈—ß
°“√ª≈Ÿ°∂“ଇ´≈≈åµâ𰔇𥑇¡¥Á ‡≈◊Õ¥
2. °√–· ‡≈Õ◊ ¥ (peripheral blood)
°“√‡°Á∫‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥®“°°√–·  ¿“«–·∑√°´Õâ π∑ Ë’“¡“√∂æ∫‰¥®â “°°“√ª≈°Ÿ
‡≈◊Õ¥ à«π„À≠à®–‡°Á∫®“°ºâŸ∫√‘®“§∑Ë’‡ªìπ‡¥Á°‚µÀ√◊Õ ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥ ‰¥·â °à
ºŸâ„À≠à ‚¥¬∑Ë—«‰ª‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥®–æ∫‰¥â
πâÕ¬¡“°„π°√–· ‡≈◊Õ¥ ¥â«¬‡ÀµÿπÈ’°“√‡°Á∫‡´≈≈å 1. °“√µ¥‘‡™Õ◊È√πÿ·√ß6 ‡ªπì ¿“«–·∑√°´Õâ π∑’Ë
µπâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥¥«â ¬«∏‘π’ ’È“¡“√∂∑”‰¥‚â ¥¬°“√©¥’ ¡’§«“¡ ”§—≠·≈–æ∫‰¥â∫àÕ¬‡πË◊Õß®“°ºŸâªÉ«¬∑Ë’‰¥â√—∫
G-CSF „À°â ∫—º∑Ÿâ ®Ë’–∫√®‘“§ 4-5 «π— °àÕπ«—π‡°Á∫ °“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥¡’¿Ÿ¡‘§âÿ¡°—π∑Ë’
‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥ ‡æ◊ËÕ∑’Ë®–°√–µÿâπ„À≢

260 ª¬î– √®ÿ°®‘¬“ππ∑å

µ”Ë®“°°“√‰¥â√—∫¬“‡§¡’∫”∫—¥¢π“¥ Ÿß À√◊Õ ¬“‡§¡’ ¢÷ÈπÕ¬àŸ°—∫™π‘¥¢Õ߬“‡§¡’∫”∫—¥∑Ë’ºâŸªÉ«¬‰¥â√—∫ ¥â«¬
∫”∫—¥¢π“¥ Ÿß√à«¡°—∫°“√©“¬√—ß ’·≈–®“°°“√‰¥â ‡Àµÿπ’ȺŸâªÉ«¬‡°◊Õ∫∑ÿ°√“¬®–‰¥â√—∫¬“ªÑÕß°—πÕ“°“√
√—∫¬“°¥¿Ÿ¡‘§ÿâ¡°—πÀ≈—ß®“°°“√ª≈Ÿ°∂à“¬‡´≈≈åµâπ §≈Ë◊π‰ â Õ“‡®’¬π ‰¥â√—∫ “√π”ÈÕ¬à“߇À¡“– ¡ √«¡
°”‡π¥‘‡¡¥Á‡≈Õ◊ ¥‡æÕ◊˪ÕÑ ß°π—¿“«– graft-versus-host ∂÷߉¥â√—∫°“√‡ΩÑ“√–«—ߺ≈¢â“߇§’¬ß∑Ë’®–‡°‘¥¢È÷πÕ¬à“ß
disease (GvHD) ¥â«¬‡Àµÿπ’È®÷ß∑”„À⧫“¡‡ ’Ë¬ß „°≈♑¥ „π°√≥’∑Ë’ºŸâªÉ«¬‰¥â√—∫°“√©“¬√—ß ’ ºŸâªÉ«¬
µÕà °“√µ¥‘‡™ÕÈ◊  ßŸ¢πÈ÷ ∑ß—È®“°‡™Õ◊È·∫§∑‡’√¬’ ‰«√ — ·≈– Õ“®®–¡’Õ“°“√§≈◊Ëπ‰ â Õ“‡®’¬π ·≈–ª«¥»’√…–À≈—ß
‡™◊ÈÕ√“ ºâŸªÉ«¬∑Ë’‰¥â√—∫°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥠°“√©“¬√—ß ’‰¥â ¥â«¬‡ÀµÿπÈ’ºŸâªÉ«¬§«√®–‰¥â√—∫¬“
‡¡¥Á‡≈Õ◊ ¥¡§’«“¡‡ ¬Ë’ß∑‡’Ëæ¡‘Ë¢π÷È®“°°“√µ¥‘‡™ÕÈ◊ ·∫§∑‡’√¬’ ªÑÕß°—πÕ“°“√§≈Ë◊π‰ âÕ“‡®’¬π°àÕπ·≈–√–À«à“߉¥â√—∫
∑È—ß®“°‡™È◊Õ·∫§∑’‡√’¬™π‘¥·°√¡≈∫ ®“°°“√∑Ë’ºâŸªÉ«¬ °“√©“¬√ß— ¥’«â ¬‡™πà °π—
‡À≈“à π¡È’°—¡·’º≈„π™Õà ߪ“°·≈–∑“߇¥π‘Õ“À“√ ·≈– 4. ‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥∑„’ËÀºâ ªâŸ«É ¬‰¡µà ¥‘
®“°‡™◊ÈÕ·∫§∑’‡√¬’™π‘¥·°√¡∫«° ®“°°“√∑ºË’Ÿªâ É«¬¡’ (graft rejection)  “¡“√∂‡°¥‘¢πÈ÷‰¥®â “°°“√∑º’ËªâŸ«É ¬
 “¬ «πÀ≈Õ¥‡≈◊Õ¥¥” πÕ°®“°π’È¿“«–‡¡Á¥‡≈◊Õ¥ ‰¥â√—∫¬“°¥¿Ÿ¡‘§ÿâ¡°—π∑Ë’‰¡à‡æ’¬ßæÕ„π™à«ß∑’ˉ¥â√—∫
¢“«µË”¬—߇æË‘¡§«“¡‡ Ë’¬ßµàÕ °“√µ‘¥‡™È◊Õ√“ ‚¥¬‡™È◊Õ conditioning regimen À√Õ◊ °“√∑º’ËªâŸ«É ¬¡·’Õπµ∫‘Õ¥’
√“∑æË’∫«“à ‡ªπì  “‡Àµÿ‰¥·â °à ‡™Õ◊È√“„π°≈¡ÿà Candida ∑ Ë’“¡“√∂‰ª∑”≈“¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥¢Õߺ„Ÿâ Àâ
species ·≈– Aspergillus species  ”À√—∫ ‰¥â ‚¥¬°√≥’π’È®–æ∫¡“°„πºŸâªÉ«¬∏“≈— ´’‡¡’¬∑Ë’¡’
°“√µ‘¥‡™◊ÈÕ‰«√— ∑’Ëæ∫‰¥â∫àÕ¬ ‰¥â·°à°“√µ‘¥‡™È◊Õ ª√–«—µ‘‰¥â√—∫‡≈◊Õ¥¡“π“πÀ≈“¬§√—Èß°àÕπ∑’Ë®–∑”°“√
cytomegalovirus (CMV) infection ª≈°Ÿ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥ πÕ°®“°π’È¿“«–
2. ¿“«–´’¥·≈–‡°≈Á¥‡≈◊Õ¥µË” À≈—ß®“°∑Ë’ graft rejection ¬—ß “¡“√∂‡°‘¥®“°ª√‘¡“≥‡´≈≈å
ºâŸªÉ«¬‰¥â√—∫¬“‡§¡’∫”∫—¥¢π“¥ Ÿß À√◊Õ ¬“‡§¡’ µπâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥∑„Ë’À·â °ºà ªâŸ«É ¬¡®’”π«π‰¡‡à 欒ßæÕ
∫”∫—¥¢π“¥ Ÿß√à«¡°—∫°“√©“¬√—ß ’(conditioning ∑—Èßπ’È “¡“√∂√—°…“‰¥â‚¥¬°“√À¬ÿ¥¬“°¥¿Ÿ¡‘§ÿâ¡°—π
regimen) ·≈–√Õ‰¢°√–¥Ÿ°øóôπµ—«°≈—∫¢÷Èπ¡“ °“√„Àâ donor lymphocyte infusion (DLI) À√Õ◊
(engraftment) ºâŸªÉ«¬ à«π„À≠à®–‰¥â√—∫‡≈◊Õ¥ Õ“®®–µâÕß„Àâ conditioning regimen µ“¡¥â«¬
·≈–‡°≈¥Á‡≈Õ◊ ¥‡ªπì √–¬–Ê ‚¥¬∑«Ë—‰ª®–„À‡â ≈Õ◊ ¥™π¥‘ °“√„À‡â ´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥„À¡Õà °’§√ß—È
leukocyte poor packed red cell À√Õ◊ leukocyte 5. ‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥®“°ºâŸ„À⇰‘¥
depleted packed red cell ∂â“√–¥—∫Œ’‚¡‚°≈∫‘π ªØ°‘√‘¬‘“µÕà µ“â πºªâŸ«É ¬ (graft-versus-host disease
πÕâ ¬°«“à 8 °./¥≈. ·≈–„À‡â °≈¥Á‡≈Õ◊ ¥™π¥‘ single À√◊Õ GvHD) ¿“«–πÈ’‡°‘¥®“°°“√∑’ˇ´≈≈凡Á¥‡≈◊Õ¥
donor platelet ‡¡Ë◊Õ®”π«π‡°≈Á¥‡≈◊Õ¥πâÕ¬°«à“ ¢“«™π¥‘ T lymphocyte ¢Õߺ„âŸÀ‡â ´≈≈µå πâ °”‡π¥‘
20,000 ‡´≈≈/å ¡≈. ‡¡Á¥‡≈◊Õ¥‡ÀÁπ«à“√à“ß°“¬ºŸâªÉ«¬‡ªìπ Ë‘ß·ª≈°ª≈Õ¡
3. º≈¢â“߇§’¬ß®“°¬“‡§¡’∫”∫—¥¢π“¥ Ÿß ‚¥¬ªØ‘°√‘‘¬“µàÕµâ“πµ—«ºâªŸÉ«¬πÈ’Õ“®®–√ÿπ·√ß¡“°®π
À√◊Õ¬“‡§¡’∫”∫—¥¢π“¥ Ÿß√à«¡°—∫°“√©“¬√—ß ’ ∑”„Àºâ ªâŸ«É ¬‡ ¬’™«’µ‘‰¥â ¿“«– GvHD  “¡“√∂·∫ßà
(conditioning regimen) „π√–À«“à ß∑ºË’ªâŸ«É ¬‰¥√â ∫— ÕÕ°‰¥‡â ªπì 2 ª√–‡¿∑ ‰¥·â °à ·∫∫‡©¬’∫æ≈π— (acute
conditioning regimen ºªŸâ «É ¬Õ“®®–¡Õ’“°“√ª«¥ GvHD) ·≈–·∫∫‡√ÕÈ◊ √ß— (chronic GvHD) ¿“«–
‡¡Ë◊Õ¬µ“¡√à“ß°“¬ ª«¥∑âÕß §≈◊Ëπ‰ â Õ“‡®’¬π ‡∫Ë◊Õ GvHD ·∫∫‡©’¬∫æ≈—π à«π„À≠à¡—°®–‡°‘¥¿“¬„π
Õ“À“√ ¡·’º≈ „π™Õà ߪ“° º¡√«à ß ‚¥¬Õ“°“√¥ß—°≈“à « √–¬–‡«≈“ 100 «—π·√°¢Õß°“√ª≈Ÿ°∂à“¬‡´≈≈åµâπ

°“√ª≈°Ÿ∂“ଇ´≈≈µåπâ°”‡π¥‘‡¡¥Á‡≈Õ◊¥·≈–¬π’∫”∫¥—Hematopoietic Stem Cell Transplantation and Gene Therapy 261

°”‡π‘¥‡¡Á¥‡≈◊Õ¥ ‚¥¬Õ«—¬«– ”§—≠∑’ˇ°‘¥ªØ‘°‘√‘¬“ ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥°Á‡ªìπÕ’°∑“ß
µÕà µ“â π‰¥·â °à º«‘Àπß— √–∫∫∑“߇¥π‘Õ“À“√ ·≈–µ∫— ‡≈Õ◊ °Àπß÷Ë∑ Ë’“¡“√∂∑”„Àºâ ªâŸ«É ¬À“¬¢“¥®“°‚√§‰¥â
ºªŸâ «É ¬®–¡Õ’“°“√ºπ◊˺«‘Àπß—Õ°—‡ ∫·¥ß∑Õâ ߇ ¬’√πÿ·√ß °“√ª≈°Ÿ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥„πºªâŸ«É ¬
·≈–µ«—‡À≈Õ◊ ß  ”À√∫—¿“«– GvHD ·∫∫‡√ÕÈ◊ √ß—¡°— ∏“≈ —´‡’¡¬’‡√¡Ë‘¡°’“√∑”§√ß—È·√°„πªï æ.». 2523 ‚¥¬
®–‡°¥‘À≈ß—®“°°“√ª≈°Ÿ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥ 𓬷æ∑¬å Lucarelli ª√–‡∑»Õ‘µ“≈’8  ”À√—∫
ª√–¡“≥ 100 «π— ·µ„à π∫“ß√“¬Õ“®®–‡°¥‘‡√«Á‡æ¬’ß ª√–‡∑»‰∑¬π—Èπ ‰¥â¡’°“√∑”°“√ª≈Ÿ°∂à“¬‡´≈≈åµâπ
40-50 «π—À≈ß—®“°°“√ª≈°Ÿ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á °”‡π‘¥‡¡Á¥‡≈◊Õ¥„πºâŸªÉ«¬∏“≈— ´’‡¡’¬§√—Èß·√°∑’Ë‚√ß
‡≈◊Õ¥°Á‰¥â ºŸâªÉ«¬®–¡’Õ“°“√∑“ߺ‘«Àπ—ß (sclero- 欓∫“≈»√‘√‘“™ ‚¥¬π“¬·æ∑¬«å 𑬗  «ÿµ—∂’·≈–π“¬
derma) ¢âÕµ‘¥ µ—∫Õ—°‡ ∫‡√È◊Õ√—ß ‡∫◊ËÕÕ“À“√ ·æ∑¬ å √ÿæ≈ Õ ‘√‰°√»≈’ ‚¥¬„™‡â ´≈≈µå πâ °”‡π¥‘‡¡¥Á
π”ÈÀπ°—≈¥ª“°·Àßâ ‡πÕË◊ ß®“°¡°’“√ √“â ßπÈ”≈“¬≈¥≈ß ‡≈Õ◊ ¥®“° “¬ –¥Õ◊ √° (cord blood stem cell) ∑Ë’
À√Õ◊ µ“·Àßâ √«à ¡¥«â ¬ °“√√°—…“¿“«– GvHD  “¡“√∂ ‰¥â®“°πâÕߺ⟪ɫ¬∑Ë’¡’HLA ‡¢â“°—π¡“ª≈Ÿ°∂à“¬„Àâ
∑”‰¥‚â ¥¬°“√„™¬â “„π°≈¡ÿà corticosteroid (methyl- °∫—ºªŸâ «É ¬
prednisolone À√◊Õ prednisolone) À√◊Õ ¬“
°¥¿Ÿ¡‘§ÿâ¡°—π™π‘¥ÕË◊πÊ ‰¥â·°à antithymocyte ¢âÕ∫àߙȒ„π°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥
globulin, infliximab ·≈– etanercept ‡ªπì µπâ 7 ‡≈◊Õ¥„πºªŸâ«É¬∏“≈— ´‡’¡’¬
‰¥â·°à ºâŸªÉ«¬‚√§∏“≈— ´’‡¡’¬∑’Ë¡’Õ“°“√√ÿπ·√ß
°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥„π‚√§ ‡™àπ¡’Õ“°“√´’¥µÈ—ß·µàÕ“¬ÿ1-2 ªï ·≈–µâÕ߉¥â√—∫
‚≈Àµ‘®“ß∏“≈ —´‡’¡¬’(hematopoietic stem cell ‡≈Õ◊ ¥‡ªπì ª√–®”∑°ÿ‡¥Õ◊ π
transplantation in thalassemia disease)

‚√§‚≈Àµ‘®“ß∏“≈ —´‡’¡¬’‡ªπì ‚√§∑“ßæπ—∏°ÿ√√¡ ªí®®—¬∑Ë’¡’º≈µàÕ°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇π‘¥
∑‡Ë’°¥‘®“°§«“¡º¥‘ª°µ¢‘Õ߬π’∑§Ë’«∫§¡ÿ°“√ √“â ß “¬ ‡¡Á¥‡≈◊Õ¥„πºŸªâ«É¬∏“≈ —´‡’¡’¬
‚°≈∫‘π´Ë÷߇ªìπ à«πª√–°Õ∫ ”§—≠¢Õߌ’‚¡‚°≈∫‘π °“√»÷°…“®“°ª√–‡∑»Õ‘µ“≈’‰¥â√“¬ß“π∂÷ß
„π‡¡Á¥‡≈◊Õ¥·¥ß ∑—Èßπ’ȺâŸ∑’Ë¡’§«“¡º‘¥ª°µ‘¢Õ߬’π¡’ ªí®®—¬∑’Ë¡’º≈µàÕ°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥
∑ßÈ—º∑⟇˒ªπì ‚√§·≈–º∑⟉’Ë¡‡à ªπì ‚√§ º∑Ÿâ ‡Ë’ªπì ‚√§  “¡“√∂ ‡≈Õ◊ ¥„πºªŸâ «É ¬∏“≈ —´‡’¡¬’ ‚¥¬æ∫«“à ¡’3 ª®í ®¬—À≈°—
¡Õ’“°“√µß—È·µ´à ¥’‡≈°ÁπÕâ ¬ ´¥’¡“° ‰ª®π∂ß÷¡Õ’“°“√ ‰¥·â °à
√πÿ·√ß¡“° ‡™πà ∫«¡ µ∫—‚µ ¡“â ¡‚µ ‚¥¬§«“¡√πÿ·√ß 1. µ∫—∑‚’˵¡“°°«“à 2 ´¡. ®“°™“¬‚§√ß
¢Õß‚√§¢È÷πÕ¬Ÿà°—∫™π‘¥¢Õ߬’π∑’˺‘¥ª°µ‘´Ë÷߉¥â√—∫ 2. µ∫—¡æ’ß—º¥◊ (liver or portal fibrosis)
∂“à ¬∑Õ¥¡“®“°æÕà ·≈–·¡à  «à πº∑Ÿâ ‰’Ë¡‡à ªπì ‚√§ À√Õ◊ ®“°°“√µ√«®™πÈ‘‡πÕÈ◊ ∑“ß欓∏‘
ºŸâ∑’ˇªìπæ“À–¢Õß‚√§®–¡’ ÿ¢¿“æ√à“ß°“¬·¢Áß·√ß 3. °“√‰¥√â ∫—¬“¢∫—‡À≈°ÁÕ¬“à ß ¡”ˇ ¡Õ
‡™àπ‡¥’¬«°—∫§πª°µ‘·µà¡’¬’π∏“≈— ´’‡¡’¬·ΩßÕ¬Ÿà„π ®“°∑—Èß 3 ªí®®—¬À≈—°¢â“ßµâπ ∑”„Àâ “¡“√∂
√à“ß°“¬ °“√√—°…“ºŸâªÉ«¬‚√§‚≈À‘µ®“ß∏“≈— ´’‡¡’¬ ·¬°ª√–‡¿∑¢Õߺ≈°“√√—°…“µàÕ°“√ª≈Ÿ°∂à“¬‡´≈≈å
‰¥â·°à °“√„Àâ‡≈◊Õ¥„π°√≥’ºâŸªÉ«¬¡’¿“«–´’¥ ·≈–„Àâ µπâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥„πºªŸâ «É ¬∏“≈ —´‡’¡¬’ ÕÕ°‰¥‡â ªπì
¬“¢∫—‡À≈°Á„πºªâŸ«É ¬∑µ’ËÕâ ߉¥√â ∫—‡≈Õ◊ ¥Õ¬“à ß ¡”ˇ ¡Õ 3 ª√–‡¿∑ (Pesaro classification)9,10 ¥ß—πÈ’
·≈–¡’¿“«–‡À≈Á°‡°‘π πÕ°®“°π’È°“√√—°…“‚¥¬°“√ 1. ª√–‡¿∑∑’Ë1 º≈°“√√°—…“¥¡’“° „π°√≥’

262 ª¬î– √ÿ®°®‘¬“ππ∑å

∑’˺ŸâªÉ«¬‰¡à¡’¿“«–µ—∫‚µ ‰¡àæ∫«à“µ—∫¡’æ—ߺ◊¥ ·≈– √°—…“¥«â ¬°“√ª≈°Ÿ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥  ß‘Ë
‰¥√â ∫—¬“¢∫—‡À≈°ÁÕ¬“à ß ¡Ë”‡ ¡Õ ∑’˵âÕß∑”‡ªìπ≈”¥—∫µàÕ¡“§◊Õ °“√§—¥‡≈◊Õ°ºâŸ„À⇴≈≈å
2. ª√–‡¿∑∑Ë’2 º≈°“√√—°…“ª“π°≈“ß „π µπâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥ (donor) ∑‡’ËÀ¡“– ¡ ∑ßÈ—πº’È„Ÿâ Àâ
°√≥∑’ºË’ªŸâ «É ¬µ√«®æ∫«“à ¡’2 „π 3 Õ¬“à ß ‰¥·â °à ¡’ ‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥∑’Ë¥’∑’Ë ÿ¥§◊ÕæË’À√◊ÕπâÕß√à«¡
¿“«–µ∫—‚µ æ∫«“à µ∫—¡æ’ß—º¥◊ À√Õ◊ ‰¥√â ∫—¬“¢∫—‡À≈°Á ∫¥‘“¡“√¥“°∫—ºªâŸ«É ¬∑¡Ë’ ’¢ÿ¿“æ·¢ßÁ·√ß·≈–¡’HLA
‰¡ à ¡Ë”‡ ¡Õ ‡¢“â °π—‰¥°â ∫—ºªâŸ«É ¬ (HLA-matched sibling donor)
3. ª√–‡¿∑∑’Ë3 º≈°“√√°—…“‰¡¥à ’„π°√≥∑’Ë’ ¥ß—∑°Ë’≈“à «‰ª·≈â«¢“â ßµπâ ‚Õ°“ ∑’˺⟪ɫ¬®–¡’HLA
ºâŸªÉ«¬¡’¿“«–µ—∫‚µ æ∫«à“µ—∫¡’æ—ߺ◊¥ ·≈–‰¥â√—∫¬“ µ√ß°∫—æÀË’√Õ◊ πÕâ ߇∑“à °∫—√Õâ ¬≈– 25 À√Õ◊ 1 „π 4 §π
¢∫—‡À≈°Á‰¡ à ¡Ë”‡ ¡Õ „π°√≥’∑Ë’ºŸâªÉ«¬‰¡à¡’æË’πâÕßÀ√◊Õ¡’æË’πâÕß·µà HLA
‰¡àµ√ß°—π ·æ∑¬å®–∑”°“√§âπÀ“®“°ºâŸ∫√‘®“§∑Ë’≈ß
°“√‡µ√’¬¡ºŸâªÉ«¬∏“≈— ´’‡¡’¬ ”À√—∫ª≈Ÿ°∂à“¬ ∑–‡∫¬’π· ¥ß§«“¡®”πߧ∑å ®Ë’–∫√®‘“§‡´≈≈µå πâ °”‡π¥‘
‡´≈≈åµπâ °”‡π‘¥‡¡Á¥‡≈◊Õ¥ ‡¡Á¥‡≈◊Õ¥°—∫ ¿“°“™“¥‰∑¬∑’Ë¡’HLA ‡À¡◊Õπ°—π

ºâŸªÉ«¬∏“≈— ´’‡¡’¬∑Ë’‰¥â√—∫°“√«“ß·ºπ∑Ë’®–‰¥â °—∫ºŸâªÉ«¬ (HLA-matched unrelated donor)
√—∫°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥ ‚¥¬∑Ë—«‰ª ∑ß—Èπ‚’ÈÕ°“ ∑Ë’HLA ¢ÕߺªâŸ«É ¬®–µ√ß°π—°∫—º∫âŸ√®‘“§
·æ∑¬ºå √⟰—…“®–π¥—ºªâŸ«É ¬¡“„À‡â ≈Õ◊ ¥∂¢’ËπÈ÷·≈– ¡”ˇ ¡Õ ®–πÕâ ¬≈ß ª√–¡“≥ 1 „π 10,000 §π
‡æÕ◊Ë∑®’Ë–„À‡â ≈Õ◊ ¥¢ÕߺªâŸ«É ¬¡§’«“¡‡¢¡â ¢πâ  ßŸ(hyper
transfusion) ‚¥¬®–√—°…“√–¥—∫Œ’‚¡‚°≈∫‘πÕ¬àŸ∑’Ë º≈°“√√—°…“¥â«¬°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇π‘¥
ª√–¡“≥ 10 °./¥≈ ·≈–ºâŸªÉ«¬®–‰¥â√—∫§”·π–π” ‡¡Á¥‡≈◊Õ¥„πºâŸª«É¬∏“≈— ´’‡¡¬’
„À√â ∫—ª√–∑“π¬“¢∫—‡À≈°ÁÕ¬“à ß ¡”ˇ ¡Õ  ”À√∫—¢π“¥ §«“¡ ”‡√Á®¢Õß°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇π‘¥
¢Õß¡“â ¡ºªŸâ «É ¬ §«√®–µÕâ ߉¡‚à µ¡“° À“°¢π“¥¢Õß ‡¡¥Á‡≈Õ◊ ¥„πºªŸâ «É ¬∏“≈ —´‡’¡¬’¢π÷ÈÕ¬°Ÿà ∫— ¿“æ√“à ß°“¬
¡“â ¡‚µ¡“°Õ“®®–殑“√≥“µ¥—¡“â ¡‰¥âπÕ°®“°π’ȇ≈Õ◊ ¥ ¢Õߺªâÿ«É ¬ √–¥∫—∏“µ‡ÿÀ≈°Á„π√“à ß°“¬ °“√‰¥√â ∫—‡≈Õ◊ ¥
∑„Ë’À°â ∫—ºªŸâ «É ¬§«√‡ªπì ‡≈Õ◊ ¥∑º’Ë“à π°“√°√Õ߇¡¥Á‡≈Õ◊ ¥ Õ¬“à ß ¡Ë”‡ ¡Õ °“√∑¡’˵’∫—·≈–¡“â ¡∑‰’Ë¡‚à µ °Õà π°“√
¢“« ‰¥â·°à leukocyte poor packed red cell ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥ ∑—Èßπ’È®“°°“√
(LPRC) À√Õ◊ leukocyte depleted packed red »÷°…“·≈–µ‘¥µ“¡ºŸâªÉ«¬∏“≈— ´’‡¡’¬∑’ˉ¥â√—∫°“√ª≈Ÿ°
cell (LDPRC) À√Õ◊ °“√„™™â ¥ÿ°√Õ߇¡¥Á‡≈Õ◊ ¥¢“« ∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥„πª√–‡∑»‰∑¬®”π«π
(leukocyte filter set) ∑“â ¬∑ ’Ë¥ÿ ·æ∑¬ºå √Ÿâ °—…“®– 200 √“¬ æ∫«à“∂Ⓡªìπ°“√√—°…“‚¥¬ºâŸ„À⇴≈≈åµâπ
∑”°“√ ßà µ√«®‡æ¡‘ˇµ¡‘‡æÕ◊Ë„À·â π„à ®«“à ºªâŸ«É ¬¡ ’¢ÿ¿“楒 °”‡π‘¥‡¡Á¥‡≈◊Õ¥‡ªìπæ’ËπâÕß∑âÕ߇¥’¬«°—π (HLA-
√“à ß°“¬·¢ßÁ·√ß‚¥¬°“√ ßà µ√«®°“√∑”ß“π¢ÕßÕ«¬—«– matched sibling donor) ®–¡’‚Õ°“ ª√– ∫
µà“ßÊ ‰¥â·°à À—«„® (echocardiography) ªÕ¥ §«“¡ ”‡√Á® √âÕ¬≈– 80-85 „π°√≥’∑Ë’ºâŸ„À⇴≈≈åµâπ
(pulmonary function test) µ∫— (liver function °”‡π‘¥‡¡Á¥‡≈◊Õ¥∑Ë’‰¡à„™à≠“µ‘ (HLA-matched
test) ‰µ (BUN ·≈– creatinine) ·≈–°“√µ√«® unrelated donor) ®–¡’‚Õ°“ ª√– ∫§«“¡ ”‡√Á®
§¥—°√Õß°“√µ¥‘‡™Õ◊ȵ“à ßÊ ‰¥·â °à Hepatitis A, B, √âÕ¬≈– 70-75 ∂÷ß·¡â«à“°“√„™â‡´≈≈åµâ𰔇𑥇¡Á¥
C, HIV, CMV ·≈– EBV ‡≈Õ◊ ¥®“°æÕà À√Õ◊ ·¡ºà ªŸâ «É ¬ (haploidentical stem
‡¡◊ËÕºŸâªÉ«¬‚√§∏“≈— ´’‡¡’¬¡’¢âÕ∫àß™’È„π°“√ cell) ®–¡§’«“¡‡ ¬Ë’ߧÕà π¢“â ߠߟ ‡πÕË◊ ß®“°¡’HLA

°“√ª≈°Ÿ∂“ଇ´≈≈µåπâ°”‡π¥‘‡¡¥Á‡≈Õ◊¥·≈–¬π’∫”∫¥—Hematopoietic Stem Cell Transplantation and Gene Therapy 263

‡¢â“°—π‰¥â°—∫ºâŸªÉ«¬‡æ’¬ß§√÷Ë߇¥’¬«‡∑à“π—Èπ „πªí®®ÿ∫—π ∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥ ·≈–°“√„À⬓°¥
¡’°“√æ—≤π“ Ÿµ√·≈–«‘∏’°“√„À⬓‡§¡’∫”∫—¥‡æ◊ËÕ ¿Ÿ¡‘§âÿ¡°—π  ”À√—∫°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥
∑Ë’®–≈¥§«“¡‡ ’ˬߥ—ß°≈à“« ∑—ÈßπÈ’®“°°“√»÷°…“„π ‡≈Õ◊ ¥®–殑“√≥“∑”„π°√≥∑’º’Ë„âŸÀ‡â ´≈≈µå πâ °”‡π¥‘‡¡¥Á
ª√–‡∑»‰∑¬≈à“ ÿ¥æ∫«à“ Õ—µ√“°“√√Õ¥™’«‘µ∑Ë’2 ªï ‡≈◊Õ¥‡ªìπæ’ËπâÕß∑Ë’¡’HLA ‡¢â“°—π‰¥â°—∫ºâŸªÉ«¬‡ªìπ
„πºÿâªÉ«¬∏“≈— ´’‡¡’¬∑’ˉ¥â√—∫°“√ª≈Ÿ°∂à“¬‡´≈≈åµâπ ≈”¥—∫·√° À“°‰¡à¡’æ’ËπâÕß∑’Ë¡’HLA ‡¢â“°—π‰¥â°—∫
°”‡π‘¥‡¡Á¥‡≈◊Õ¥®“°æàÕ À√◊Õ·¡à (haploidentical ºªŸâ «É ¬®–殑“√≥“„À¬â “°¥¿¡Ÿ§‘¡âÿ°π— ‰¥·â °à °“√„À¬â “
hematopoietic stem cell transplantation) Õ¬Ÿà antithymocyte globulin (ATG) √à«¡°—∫¬“
∑√Ë’Õâ ¬≈– 9511,12 cyclosporine°√≥∑’ºË’ªŸâ «É ¬‰¡µà Õ∫ πÕßµÕà °“√„À¬â “
ATG √«à ¡°∫—¬“ cyclosporine Õ“®æ®‘“√≥“„À¬â “
°“√ª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥‡≈◊Õ¥„π‚√§ ATG √«à ¡°∫—¬“ cyclosporine ´È”Õ°’ 1 §√ßÈ— ¿“¬
‰¢°√–¥°ŸΩÕÉ (hematopoietic stem cell trans- À≈ß—¬“™¥ÿ·√° 3-4 ‡¥Õ◊ π À“°‰¡‰à ¥ºâ ≈Õ“®æ®‘“√≥“
plantation in aplastic anemia) √°—…“¥«â ¬°“√ª≈°Ÿ∂“à ¬‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥ ‚¥¬

‚√§‰¢°√–¥°ŸΩÕÉ ‡°¥‘®“°°“√∑‰’Ë¢°√–¥°Ÿ √“â ß „™ºâ ∫Ÿâ √®‘“§∑‡Ë’ªπì matched unrelated donor ∑≈’Ëß
‡¡¥Á‡≈Õ◊ ¥‰¥πâ Õâ ¬ ‡πÕË◊ ß¡“®“°°“√∑¡Ë’‡’´≈≈µå πâ °”‡π¥‘ ∑–‡∫’¬π‰«â°—∫»Ÿπ¬å∫√‘°“√‚≈À‘µ  ¿“°“™“¥‰∑¬
‡¡¥Á‡≈Õ◊ ¥≈¥≈ß ∑”„Àºâ ªâŸ«É ¬¡®’”π«π‡¡¥Á™π¥‘µ“à ßÊ ‚Õ°“ ª√– ∫§«“¡ ”‡√®Á„π°“√√°—…“¥«â ¬°“√ª≈°Ÿ∂“à ¬
„π‡≈Õ◊ ¥ ‰¥·â °à ‡¡¥Á‡≈Õ◊ ¥·¥ß ‡¡¥Á‡≈Õ◊ ¥¢“« ·≈– ‡°≈¥Á ‡´≈≈µå πâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥ª√–¡“≥√Õâ ¬≈– 85-90 „π
‡≈◊Õ¥≈¥≈ß (pancytopenia) „πª√–‡∑»‰∑¬¡’ ºŸâªÉ«¬∑’ˉ¡à‰¥â√—∫‡≈◊Õ¥À√◊Õ à«πª√–°Õ∫¢Õ߇≈◊Õ¥
Õÿ∫—µ‘°“√≥å¢Õß‚√§‰¢°√–¥Ÿ°ΩÉÕª√–¡“≥ 3.9-5.0 ·≈–√âÕ¬≈– 50-70 „πºâŸªÉ«¬∑’ˉ¥â√—∫‡≈◊Õ¥À√◊Õ à«π
§π µàÕª√–™“°√≈â“π§πµàÕªï ‚¥¬æ∫∑Ë’¿“§µ–«—π ª√–°Õ∫¢Õ߇≈◊Õ¥À≈“¬§√È—ß ªí≠À“ ”§—≠¢Õß
ÕÕ°‡©¬’߇ÀπÕ◊  ßŸ∑ Ë’¥ÿ13 ºŸâªÉ«¬∑’ˉ¥â√—∫‡≈◊Õ¥À≈“¬§√—È߉¥â·°à ‡´≈≈åµâ𰔇π‘¥
欓∏‘°”‡π‘¥¢Õß‚√§π’ȇ°Ë’¬«¢âÕß°—∫√–∫∫ ‡¡Á¥‡≈◊Õ¥∑’Ë„À⺟âªÉ«¬‰¡àµ‘¥ (graft rejection) ®“°
¿Ÿ¡‘§ÿâ¡°—π∑’˺‘¥ª°µ‘ àߺ≈„À⇰‘¥°“√∑”≈“¬‡´≈≈å °“√∑’˺⟪ɫ¬¡’·Õπµ‘∫Õ¥’∑’Ë “¡“√∂‰ª∑”≈“¬‡´≈≈å
µâ𰔇𑥇¡Á¥‡≈◊Õ¥„π‰¢°√–¥Ÿ°  “‡Àµÿ¢Õß‚√§π’È µπâ °”‡π¥‘‡¡¥Á‡≈Õ◊ ¥¢Õߺ„âŸÀâ ∑ßÈ—π°È’“√„À¬â “‡§¡∫’”∫¥—
 à«π„À≠à‰¡à∑√“∫·πà™—¥ ºŸâªÉ«¬∫“ß√“¬Õ“®‡°‘¥®“° ‡æË◊Õ‡µ√’¬¡ºâŸªÉ«¬°àÕπª≈Ÿ°∂à“¬‡´≈≈åµâ𰔇𑥇¡Á¥
°“√ —¡º—  “√‡§¡’·≈–°“√„™â¬“∫“ß™π‘¥ ‡™àπ  “√ ‡≈◊Õ¥ (conditioning regimen) ®÷ßπ‘¬¡„™â¬“
√–‡À¬ ‡∫π´π‘ ¬“¶“à ·¡≈ß ¬“ chloramphenicol cyclophosphamide ·≈– ATG ‡æÕË◊ °¥¿¡Ÿ§‘¡âÿ°π—
¬“´—≈ø“ ¡’°“√µ‘¥‡™◊ÈÕ‰«√— ∫“ß™π‘¥‡™àπ EBV, ¢ÕߺªŸâ «É ¬
HBV À√Õ◊ °“√‰¥√â ∫—√ß— „’π¢π“¥ ßŸ14,15
°“√√°—…“‚√§‰¢°√–¥°ŸΩÕÉ ª√–°Õ∫¥«â ¬ °“√ ¬π’∫”∫¥— (gene therapy)
√—°…“ª√–§—∫ª√–§Õß ‰¥â·°à °“√„Àâ‡≈◊Õ¥·≈–‡°≈Á¥ °“√√°—…“¥«â ¬ ¬π’∫”∫¥— À√Õ◊ gene therapy
‡≈Õ◊ ¥ °“√„À¬â “ªØ™‘«’π– ¬“µ“â π‡™Õ◊È√“ ·≈– ¬“µ“â π §Õ◊ °“√√°—…“‚√§ À√Õ◊ §«“¡º¥‘ª°µ∑‘“ßæπ—∏°ÿ√√¡
‰«√—  √«¡‰ª∂÷ß°“√√—°…“¿“«–µ‘¥‡™◊ÈÕ  ”À√—∫°“√ ‚¥¬°“√𔬒π∑’Ë¡’§ÿ≥ ¡∫—µ‘∑Ë’µâÕß°“√‡¢â“ àŸ‡´≈≈å
√—°…“®”‡æ“–„π°√≥’∑’Ë‚√§√ÿπ·√ß (severe) ·≈– ‡æË◊Õ„À⇰‘¥º≈∑“ß°“√√—°…“„π√à“ß°“¬ ∑È—ßπ’Ȭ’π‡ªìπ
√πÿ·√ß¡“° (very severe) ª√–°Õ∫¥«â ¬ °“√ª≈°Ÿ Àπ૬æÈ◊π∞“π∑“ßæ—π∏ÿ°√√¡ °“√· ¥ßÕÕ°¢Õ߬’π

264 ªî¬– √ÿ®°®‘¬“ππ∑å

µ“à ßÊ ∑”„À‡â °¥‘≈°—…≥–Õπ—À≈“°À≈“¬¢Õß ßË‘¡™’«’µ‘ ¿“¬À≈ß—‡™πà ¡–‡√ßÁ∫“ß™π¥‘ √«¡∂ß÷°“√µ¥‘‡™ÕÈ◊ ‰«√ —
¿“«–∑Ë’º‘¥ª°µ‘À√◊Õ‚√§À≈“¬™π‘¥„π¡πÿ…¬å ‡°‘¥ ·µà«‘∏’°“√√—°…“π’Ȭ—ߧߡ’§«“¡‡ ’ˬ߷≈–Õ¬àŸ„π
®“°°“√∑”Àπâ“∑’Ë¢Õ߬’π∑’˺‘¥ª°µ‘À√◊Õ∫°æ√àÕ߉ª ¢—Èπ§âπ§«â“«‘®—¬‡æ◊ËÕ„Àâ·πà„®∂÷ߧ«“¡ª≈Õ¥¿—¬·≈–
¥«â ¬‡Àµπÿ’È®ß÷¡§’«“¡§¥‘∑æË’≤— π“°“√√°—…“∑ ’Ë“¡“√∂ ª√– ‘∑∏‘¿“æ„π°“√√—°…“ ¥â«¬‡ÀµÿπÈ’„πªí®®ÿ∫—π°“√
®–𔬒π∑’˪°µ‘®“°¿“¬πÕ°‡¢â“ Ÿà‡´≈≈å¢Õß√à“ß°“¬ √°—…“¥«â ¬¬π’∫”∫¥— ®ß÷¡ßÿà ‡ππâ ∑®Ë’–√°—…“„π‚√§∑‰Ë’¡¡à ’
‡æ◊ËÕ„Àâ∑”ß“π∑¥·∑πÀ√◊Õ·°â‰¢¬’π∑Ë’º‘¥ª°µ‘∑È—ßπÈ’ ∑“ß√°—…“„ÀÀâ “¬¢“¥‰¥‚â ¥¬«∏‘°’“√ÕπË◊
„πÕ𓧵°“√√—°…“¥â«¬«‘∏’°“√π’ÈÕ“®®–∂Ÿ°π”¡“„™â
·∑π∑°’Ë“√„™¬â “À√Õ◊ °“√º“à µ¥—16,17 «∏‘°’“√√°—…“·≈–¢π—È µÕπ°“√√°—…“¥«â¬¬π’∫”∫¥—

°“√√°—…“¥«â ¬¬π’∫”∫¥—‰¥‡â √¡Ë‘∑¥≈Õß„π¡π…ÿ¬å °“√√°—…“¥«â ¬¬π’∫”∫¥— ‰¥·â °à °“√„ ¬à π’À√Õ◊
‡ªπì º≈ ”‡√®Á‡¡Õ◊˪ï 1990 ·≈–‰¥·â  ¥ß„À‡â ÀπÁ«“à ‡ªπì Àπ૬∑“ßæ—π∏ÿ°√√¡ª°µ‘À√◊Õ∑’Ë¡’§ÿ≥ ¡∫—µ‘∑’˵âÕß
«∏‘∑’¡’Ë»’°—¬¿“æ ßŸ„π°“√√°—…“‚√§À≈“¬™π¥‘ ª®í ®∫ÿπ— °“√‡¢â“‰ª„π‡´≈≈å ‡æË◊Õ¡ÿàßÀ«—ß∑’Ë®–·∑π∑Ë’¬’π∑’˺‘¥
¡’ß“π«‘®—¬¡“°¡“¬∑Ë’»÷°…“‡°Ë’¬«°—∫°“√√—°…“¥â«¬¬’π ª°µ‘À√Õ◊ ‡æË◊Õ¡àßÿÀ«ß—„À⬒π∑„Ë’ ‡à ¢â“‰ª √“â ß‚ª√µπ’∑Ë’
∫”∫—¥µà“ßÊ ‰¥â·°à °“√·∑π∑’ˬ’π°≈“¬æ—π∏ÿå∑Ë’°àÕ ¡ª’√–‚¬™πÀå √Õ◊ ‚ª√µπ’∑µ’ËÕâ ß°“√¢π÷È¡“ À“°¬π’°≈“¬
‚√§¥â«¬¬’πª°µ‘ °“√¬—∫¬—È߬’π°≈“¬æ—π∏ÿå∑’Ë∑”ß“π æπ—∏‰åÿ¡ à “¡“√∂ √“â ß‚ª√µπ’À√Õ◊  √“â ß‚ª√µπ’∑º’Ë¥‘ª°µ‘
º‘¥ª°µ‘·≈–°“√„ à¬’π„À¡à‡¢â“‰ª„π√à“ß°“¬ ‚¥¬ °“√√—°…“¥â«¬¬’π∫”∫—¥‚¥¬°“√„ à¬’πª°µ‘‡¢â“‰ª°Á
¡àÿßÀ«—߇æ◊ËÕ„™â√—°…“‚√§ ∂÷ß·¡â®–¡’§«“¡‡ªìπ‰ª‰¥â ®– “¡“√∂∑”„À₪√µ’π¥—ß°≈à“«∂Ÿ° √â“ߢ÷Èπ·≈–
«à“„πÕπ“§µÕ—π„°≈â °“√√—°…“¥â«¬¬’π∫”∫—¥®– √“à ß°“¬π”‰ª„™‰â ¥â
 “¡“√∂π”¡“„™„â π°“√√°—…“‚√§µ“à ßÊ ¡“°¡“¬ ‰¥·â °à °“√„ à¬’π∑’Ë¡’§ÿ≥ ¡∫—µ‘∑’˵âÕß°“√‡¢â“‰ª„π
‚√§∑“ßæ—π∏ÿ°√√¡∑’ˇªìπ¡“·µà°”‡π‘¥À√◊Õ‚√§∑Ë’‡ªìπ ‡´≈≈å‚¥¬µ√ß „π∑“ߪؑ∫—µ‘·≈⫉¡à “¡“√∂∑”„À⬒π

√ªŸ∑Ë’18.1 °“√∑”¬π’∫”∫¥—·∫∫ in vivo gene therapy (√ªŸÕÕ°·∫∫‚¥¬ π“¬‡Õ°æß»å ¥«â ßÕπ‘∑√)å

°“√ª≈°Ÿ∂“ଇ´≈≈µåπâ°”‡π¥‘‡¡¥Á‡≈Õ◊¥·≈–¬π’∫”∫¥—Hematopoietic Stem Cell Transplantation and Gene Therapy 265

¥ß—°≈“à «∑”ß“π‰¥â ¥«â ¬‡Àµπÿ®È’ß÷µÕâ ßÕ“»¬—µ«—π” À√Õ◊ 擬π’∑¡’˧’≥ÿ  ¡∫µ—∑‘µË’Õâ ß°“√º“à π‡¢“â ‰ª„π‡´≈≈¢å Õß
vector ‡æË◊Õπ”擬’π¥—ß°≈à“«‡¢â“‰ª„π‡´≈≈å·≈– ºŸâªÉ«¬ ·æ∑¬å°Á®–∑”°“√©’¥‡´≈≈套߰≈à“«´÷Ëß¿“¬„π
Àπ«à ¬æπ—∏°ÿ√√¡¢ÕߺªŸâ «É ¬ µ«—π”∑¡Ë’°’“√»÷°…“«®‘¬— ¡µ’«—π”·≈–¬π’∑µË’Õâ ß°“√°≈∫—‡¢“â ‰ª„π√“à ß°“¬ºªâŸ«É ¬
·≈–æ∫«à“¡’ª√– ‘∑∏‘¿“楒„π°“√π”擬’π∑’Ë¡’ Õ°’§√ßÈ— (√ªŸ∑’Ë18.2) À“°°“√√°—…“¥ß—°≈“à «¢“â ßµπâ
§ÿ≥ ¡∫—µ‘∑Ë’µâÕß°“√‡¢â“‰ª„π‡´≈≈å·≈–Ωí߇¢â“‰ª„π ª√– ∫§«“¡ ”‡√Á® ¬’π„À¡à∑’Ë∂Ÿ°π”‡¢â“ àŸ‡´≈≈å·≈–
Àπ૬æ—π∏ÿ°√√¡¢ÕߺŸâªÉ«¬ ‰¥â·°à ‡™È◊Õ‰«√—  ∑—ÈßπÈ’ Àπ૬æ—π∏ÿ°√√¡¢Õߺ⟪ɫ¬‚¥¬µ—«π”°Á®–‡√Ë‘¡∑”ß“π
‡™È◊Õ‰«√— ®–‰¥â√—∫°“√ª√—∫‡ª≈’ˬπ‚§√ß √â“߇æË◊Õ„Àâ‰¡à ·≈– √â“ß‚ª√µ’π∑Ë’µâÕß°“√ÕÕ°¡“‰¥â Õ¬à“߉√°Áµ“¡
 “¡“√∂°àÕ‚√§„πºâŸªÉ«¬‰¥â ‡™È◊Õ‰«√— ∑Ë’∂Ÿ°„™â„π°“√ °“√√—°…“¥â«¬¬’π∫”∫—¥¬—ßÕ¬àŸ„π¢—ÈπµÕπ°“√»÷°…“
»°÷…“∑¥≈Õß∑“ߥ“â π¬π’∫”∫¥— ‰¥·â °à ‡™ÕÈ◊ retrovirus, «‘®—¬·≈–µâÕß°“√°“√æ—≤π“‡æË‘¡‡µ‘¡„πÀ≈“¬Ê ¥â“π
adenovirus ·≈– lentivirus ‡ªπì µπâ 18 ‰¥·â °à «∏‘°’“√∑®Ë’–π”¬π’∑¡Ë’§’≥ÿ  ¡∫µ—∑‘µ’ËÕâ ß°“√‡¢“â  Ÿà
¢π—ȵÕπ°“√√°—…“¥«â ¬¬π’∫”∫¥— “¡“√∂∑”‰¥â ‡´≈≈‡å ©æ“–‡®“–®ß∑µË’Õâ ß°“√·≈–¬π’∑„’Ë ‡à ¢“â ‰ª„À¡®à –
‚¥¬°“√©’¥‡™È◊Õ‰«√— ∑Ë’∂Ÿ°¥—¥·ª≈ß∑“ßæ—π∏ÿ°√√¡„Àâ µÕâ ß “¡“√∂∂°Ÿ§«∫§¡ÿ‚¥¬√“à ß°“¬ºªâŸ«É ¬‰¥âπÕ°®“°π’È
‡ªìπµ—«π”·≈–‰¥â√—∫°“√µ—¥µàÕ¬’π∑’Ë¡’§ÿ≥ ¡∫—µ‘∑Ë’ ¬—ß¡’Õÿª √√§Õ’°À≈“¬ª√–°“√∑Ë’µâÕ߉¥â√—∫°“√·°â‰¢
µâÕß°“√‡¢â“‰ª„π®’‚π¡ ‚¥¬©’¥ºà“π∑“ßÀ≈Õ¥‡≈◊Õ¥ ‰¥â·°à ªí≠À“¢Õß°“√· ¥ßÕÕ°¢Õ߬’π∑’Ë„ à‡¢â“‰ª
‡¢â“‰ª„π∫√‘‡«≥‡π◊ÈÕ‡¬È◊ÕÀ√◊ÕÕ«—¬«–∑Ë’µâÕß°“√ ∑È—ßπÈ’ ·≈–ªí≠À“¥â“𧫓¡ª≈Õ¥¿—¬¢Õߺ⟪ɫ¬ ‡ªìπµâπ
‡™◊ÈÕ‰«√— ®– “¡“√∂ºà“π‡¢â“‰ª„π‡´≈≈å„π∫√‘‡«≥ ´÷ËßÕÿª √√§‡À≈à“π’È°”≈—߉¥â√—∫°“√«‘®—¬·≈–·°â‰¢‡æË◊Õ
¥ß—°≈“à «‰¥â (√ªŸ∑Ë’18.1) °“√∑”¬π’∫”∫¥—Õ°’«∏‘’‰¥·â °à ∑’Ë®–∑”„Àâ°“√√—°…“¥â«¬¬’π∫”∫—¥  “¡“√∂𔉪„™â
°“√π”‡´≈≈å¢Õߺ⟪ɫ¬ÕÕ°¡“‡æ“–‡≈’Ȭß√«¡°—∫ ‰¥Õâ ¬“à ß·æ√Àà ≈“¬·≈–ª≈Õ¥¿¬—¡“°¢π÷È„πÕ𓧵
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¡√’“¬ß“π„πªï æ.». 2554 ‚¥¬°“√©¥’µ«—π” ‰¥·â °à (autologous hematopoietic stem cell transplan-
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VIII deficiency)20,21 °“√√—°…“ºâŸªÉ«¬‚√§∑“ß‚≈À‘µ«‘∑¬“ Õ¬à“߉√°Áµ“¡
 ”À√∫—°“√√°—…“‚√§‚≈Àµ‘®“ß∏“≈ —´‡’¡¬’¥«â ¬ °“√√—°…“¥â«¬¬’π∫”∫—¥¬—ßÕ¬Ÿà„π¢—ÈπµÕπ°“√»÷°…“
¬π’∫”∫¥— ¢≥–πÕÈ’¬„Ÿà π¢πÈ— 1-2 (phase 1-2 study) «‘®—¬·≈–µâÕß°“√°“√æ—≤π“‡æË‘¡‡µ‘¡„πÀ≈“¬Ê ¥â“π
¢Õß°“√«®‘¬—∑“ߧ≈π‘°‘ ‚¥¬°“√π”‡Õ“‡´≈≈µå πâ °”‡π¥‘ ∑ß—È„π·ßªà √– ∑‘∏¿‘“æ°“√√°—…“ ·≈–‚¥¬‡©æ“–Õ¬“à ߬ßË‘
‡¡¥Á‡≈Õ◊ ¥ (hematopoietic stem cell) ¢ÕߺªŸâ «É ¬ §«“¡ª≈Õ¥¿¬—¢Õßµ«—ºªâŸ«É ¬
‚√§∏“≈— ´’‡¡’¬™π‘¥‡∫µâ“ (beta thalassemia) ∑Ë’

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1479-1493.



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19 Psychological Aspects in Children
with Benign Hematology

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nalized) ‡¥°Á®–· ¥ß惵°‘√√¡‚«¬«“¬ Õ“≈–«“¥ ‡¥°Á∑ß—ÈÀ¡¥‡¡ÕË◊ ÕÕ°®“°‚√ß欓∫“≈·≈«â µÕâ ߇º™≠‘
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2. º≈°√–∑∫µÕà µ«—§√Õ∫§√«—4-10 πÕ°®“°ππÈ—º‡âŸ≈¬’Èߥ՟“®µÕâ ß¡§’π„¥§πÀπßË÷ÕÕ°®“°
ë ‡¡ÕË◊ ‰¥√â ∫—°“√«π‘®‘©¬—À√Õ◊ ‡¡Õ◊˺ªâŸ«É ¬¡Õ’“°“√ ß“π‡æÕ◊Ë¡“¥·Ÿ≈ºªâŸ«É ¬ ∑”„À√â “¬‰¥§â √Õ∫§√«—≈¥≈ß
‡≈«≈ß §√Õ∫§√«—µÕâ ߇º™≠‘ °∫—°“√ª√∫—µ«— ‡¡ÕË◊ º“à π ë Õ“®‡°¥‘ª≠í À“§«“¡ ¡—æπ—∏„å π§√Õ∫§√«—
√–¬–¢Õß°“√ª√—∫µ—«‡æ◊ËÕ‡¢â“ Ÿà°“√¬Õ¡√—∫„π Ë‘ß∑Ë’ ¡‚’Õ°“ À¬“à √“â ߠߟ¢πÈ÷

°“√¥·Ÿ≈ ¿“段‘„®„πºªâŸÉ«¬‡¥Á°∑“ß‚≈À‘µ«‘∑¬“ Psychological Aspects in Children with Benign Hematology 271

ë æπË’Õâ ߢÕ߇¥°Á∑ª’Ë«É ¬Õ“®∂°Ÿª≈Õà ¬ª≈–≈–‡≈¬ §√Õ∫§√«— ·≈– ß—§¡
‰¥â√—∫§«“¡ π„®≈¥≈ß À√◊ÕÕ“®‰¥â√—∫Àπâ“∑Ë’§«“¡
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°≈«—°“√‡®∫Áª«É ¬∑‡Ë’°¥‘¢πÈ÷°∫—æπ’ËÕâ ß ´ß÷ËÕ“® ßà º≈„Àâ ¡°’“√‡®∫Á ª«É¬ (µ“√“ß∑Ë’19.1)
æË’πâÕߺ⟪ɫ¬‡¥Á°‚√§‡√È◊Õ√—ßÕ“®¡’ªí≠À“惵‘°√√¡ 1. ªí®®—¬¥â“π≈—°…≥–¢Õß‚√§·≈–§«“¡
À√Õ◊ Õ“√¡≥µå “¡¡“12 ‡®∫Áª«É ¬
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°≈à“«¢â“ßµâπ ∫“ߧ√Õ∫§√—« “¡“√∂ª√—∫µ—«‰¥â ·µà Õ“°“√¢Õß‚√§¡“µ—Èß·µà‡¥Á°‡≈Á°Õ“®¡’°“√ª√—∫µ—«‰¥â
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∑“ߥâ“𮑵„®µ“¡¡“ ‡™àπ «‘µ°°—ß«≈ ´÷¡‡»√â“ ‡¥°Á‡≈°ÁÕ“®¡º’≈µÕà °“√‡®√≠‘ ‡µ∫‘‚µÀ√Õ◊ æ≤— π“°“√‰¥â
‡°¥‘¿“«– –‡∑Õ◊ π¢«≠— À≈ß—‡Àµ°ÿ“√≥√å πÿ·√ß (post- °“√‡°¥‘‚√§„π™«à ß«¬—√πàÿÕ“® ßà º≈µÕà æ≤— π“°“√¢Õß
traumatic stress disorder) ‡ªπì µπâ «¬—√πàÿ ‡™πà §«“¡µÕâ ß°“√Õ ‘√– °“√¬Õ¡√∫—®“°°≈¡ÿà
‡æÕ◊Ëπ
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µ—«ºŸâªÉ«¬‡¥Á°·≈–§√Õ∫§√—« ´÷Ëß·µà≈–§π®–¡’«‘∏’°“√ ‚Õ°“ ¡“‡¢â“√—°…“„π‚√ß欓∫“≈·∫∫©ÿ°‡©‘π∫àÕ¬Ê
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1. °“√ª√∫—µ«—°∫—°“√√°—…“欓∫“≈ ·≈–°“√ µ—«∑”‰¥â¬“° ‡™à𠇥Á°‚√§∏“≈— ´’‡¡’¬∑Ë’¡’π—¥¡“√—∫
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2. °“√∑”„ÀÕâ “°“√¢Õß‚√§‡√ÕÈ◊ √ß—¥¢’πÈ÷ ‰¥âßà“¬°«à“‡¥Á°‚√§∏“≈— ´’‡¡’¬∑Ë’¡’‡¡Á¥‡≈◊Õ¥·¥ß·µ°
3. °“√ “¡“√∂„™™â «’µ‘‰¥µâ “¡ª°µ‘¡§’≥ÿ ¿“æ ‡©¬’∫æ≈π—·≈–µÕâ ß¡“√∫—‡≈Õ◊ ¥©°ÿ‡©π‘∫Õà ¬Ê
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4. °“√¡ ’¢ÿ¿“段‘∑¥’Ë’‡ÀπÁ§≥ÿ §“à „πµπ‡Õß æ¬“∫“≈∫àÕ¬Ê À√◊ÕµâÕß∂Ÿ°®”°—¥°‘®°√√¡ Õ“®¡’
´Ë÷ß°“√ª√—∫µ—«π—Èπ¡’À≈“¬¥â“π·≈–·µà≈–¥â“π º≈µÕà æ≤— π“°“√¢Õ߇¥°Á∑ßÈ—°“√‡√¬’π√·âŸ≈– ß—§¡
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 ÿ¢¿“楒¢È÷π ∑”„Àâ¡’ ÿ¢¿“殑µ¥’¢È÷π  “¡“√∂°≈—∫ ‡©æ“–‚√§∑Ë’¡’º≈µàÕ ¡Õß®–¡’ªí≠À“°“√ª√—∫µ—«
‰ª„™â™’«‘µ‰¥âµ“¡ª°µ‘·µà„π∑“ß°≈—∫°—π ∂⓺ŸâªÉ«¬ ¡“°°«“à
´÷¡‡»√â“ °Á®–‰¡à√à«¡¡◊Õ„π°“√√—°…“·≈–¥Ÿ·≈µπ‡Õß - ‚√§∑°’ËÕà „À‡â °¥‘§«“¡º¥‘√ªŸÀ√Õ◊ ¡≈’°—…≥–
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‡ªìπµâπ ´÷Ëß°“√ª√—∫µ—«π—Èπ‡ªìπ°√–∫«π°“√∑’ˇª≈’Ë¬π §«“¡‰¡¡à π—Ë„®„𵫗‡Õß °“√‚¥π≈Õâ ∑”„À¡â °’“√ª√∫—
·ª≈߉¥µâ ≈Õ¥‡«≈“ µ“¡ª®í ®¬—∑¡Ë’º’≈°√–∑∫µÕà °“√ µ—«‰¥â¬“°¢È÷𠇙àπ °“√‡ª≈’ˬπ·ª≈ߢÕßÀπ⓵“„π
ª√∫—µ«—¢ÕߺªâŸ«É ¬ ‰¥·â °à ª®í ®¬—®“°µ«—‡¥°Á‡Õß µ«—‚√§ ‚√§∏“≈ —´‡’¡¬’ ‡ªπì µπâ

272 ‡¢¡‘°“ ‡¢¡–°π°  ÿ¥π“«“

- §«“¡√ÿπ·√ߢÕß‚√§ ´÷Ëß¡’º≈µàÕ°“√¡“ §«“¡‡¢â“„®√—∫√⟇√◊ËÕß°“√‡®Á∫ªÉ«¬ ·≈–°“√·°âªí≠À“
‚√ß欓∫“≈ À√Õ◊ °“√®”°¥—°®‘°√√¡µ“à ßÊ ¢Õ߇¥°Á µ“¡√–¥∫— µª‘≠í ≠“¢Õßµπ‡Õß ‡¥°Á∑ ’Ë“¡“√∂  ÕË◊  “√
2. ª®í ®¬—¥“â 𵫗‡¥°Á ∫Õ°§«“¡µâÕß°“√ Õ“√¡≥姫“¡√Ÿâ ÷°¢Õßµπ‡Õ߉¥â
ë ‡æ» ‡æ»À≠ß‘¡·’π«‚π¡â ∑®’Ë–¡ª’≠í À“¥â“π ®–™«à ¬∑”„À‡â ¥°Áª√∫—µ«— ·≈–¡ ’¢ÿ¿“段‘∑¥’Ë’
Õ“√¡≥¡å “°°«“à ‡æ»™“¬ ë æÈ◊πÕ“√¡≥å (temperament)14 §◊Õ
ë Õ“¬ÿ‡¥°Á®–¡§’«“¡‡¢“â „®√∫—√‡Ÿâ √ÕË◊ ß‚√§·≈– ≈—°…≥–∑“ßÕ“√¡≥å·≈–惵‘°√√¡∑’ˇ¥Á°·µà≈–§π¡’
°“√‡®∫Áª«É ¬µ“¡√–¥∫—æ≤— π“°“√∑“ß µª‘≠í ≠“∑‡Ë’æ¡Ë‘ ·µ°µà“ß°—πµ—Èß·µà°”‡π‘¥ ·≈–¡—°‡µ‘∫‚µ¢È÷π‚¥¬¡’
¡“°¢πÈ÷µ“¡Õ“¬ÿ(µ“√“ß∑’Ë19.2) ·π«‚π¡â ∑®Ë’–¡≈’°—…≥–·∫∫‡¥¡‘ ‚¥¬·∫ßà ‡ªπì 3 °≈¡ÿà
ë √–¥—∫ µ‘ªí≠≠“·≈–°“√ Ë◊Õ “√ ‡¥Á°®–¡’ ‰¥·â °à

µ“√“ß∑’Ë19.1 ªí®®—¬∑Ë’¡’º≈µàÕæ—≤π“°“√·≈–惵‘°√√¡¢Õߺ⟪ɫ¬‡¥Á°‚√§‡√◊ÈÕ√—ß (¥—¥·ª≈ß®“°‡Õ° “√
Õ“â ßÕß‘À¡“¬‡≈¢ 1)

ª®í ®¬—¥“â π √“¬≈–‡Õ¬’¥
µ“à ßÊ

ª®í ®¬—¥“â π - Õ“¬∑ÿ‡’Ë√¡Ë‘‡ªπì ‚√§ ·≈–√–¬–‡«≈“
≈°—…≥–¢Õß‚√§ - ≈°—…≥–¢Õß‚√§: §«“¡√πÿ·√ߢÕß‚√§ °“√¥”‡ππ‘‚√§ (§ß∑Ë’À√Õ◊ ¡Õ’“°“√¡“°¢π÷È)
·≈–§«“¡‡®∫Áª«É ¬ §«“¡·πàπÕπ¢Õß‚√§ (§“¥°“√≥å≈à«ßÀπⓉ¥â À√◊Õ‰¡à·πàπÕπ) 欓°√≥å¢Õß‚√§
- º≈¢Õß‚√§∑¡’˵’Õà  µª‘≠í ≠“°“√ ÕË◊  “√°“√‡§≈ÕË◊ π‰À«À√Õ◊ °®‘°√√¡∑‡Ë’À¡“– ¡°∫—«¬—
- §«“¡‡®∫Áª«¥
ª®í ®¬—¥“â 𵫗‡¥°Á - ‡æ»
- Õ“¬ÿ
- √–¥∫— µª‘≠í ≠“·≈–°“√ ÕË◊  “√
- æπ◊ÈÕ“√¡≥å (temperament)
- ∑°—…–·≈–«∏‘°’“√·°ªâ ≠í À“
ª®í ®¬—¥“â π - §«“¡ ¡—æπ—∏·å ≈–∫∑∫“∑Àπ“â ∑„Ë’π§√Õ∫§√«—
§√Õ∫§√«— -  ¢ÿ¿“段‘¢Õߺ‡âŸ≈¬È’ߥŸ
- ‚§√ß √“â ߢÕߧ√Õ∫§√«— (®”π«π¢Õß ¡“™°‘º„Ÿâ À≠·à ≈–‡¥°Á)
- √–¥∫—‡»√…∞“π–
- ∑»—𧵇‘°¬’Ë«°∫—‚√§·≈–°“√√°—…“
ª®í ®¬—¥“â π ß—§¡ - ∑»—π§µ¢‘Õß ß—§¡
- °“√‡¢“â ∂ß÷∫√°‘“√∑“ß ¢ÿ¿“æ ·≈–∑√æ—¬“°√°“√™«à ¬‡À≈Õ◊ „π™¡ÿ™π
- √–∫∫‚√߇√¬’π

°“√¥Ÿ·≈ ¿“段‘„®„πºŸªâ«É¬‡¥Á°∑“ß‚≈À‘µ«∑‘¬“ Psychological Aspects in Children with Benign Hematology 273

µ“√“ß∑Ë’19.2 æ—≤π“°“√¢Õ߇¥Á°‡°Ë’¬«°—∫§«“¡‡¢â“„®¿“«–§«“¡‡®Á∫ªÉ«¬ (¥—¥·ª≈ß®“°‡Õ° “√Õâ“ßÕ‘ß
À¡“¬‡≈¢ 14, 16, 17)

Õ“¬ÿ æ≤— π“°“√∑“ß µª‘≠í ≠“¢Õ߇¥°Á §«“¡‡¢“â „®‡°¬Ë’«°∫—‚√§¢Õ߇¥°Á µ«—Õ¬“à ß
(ª)ï (Piagetûs Cognitive

Development)

2-7 √–¬–°“√§¥‘Õ¬“à ß„™‡â Àµºÿ≈∑¬Ë’ß— - Õ“®‰¡‡à ¢“â „®‡√Õ◊Ëß‚√§À√Õ◊ §«“¡ - „ ‡à  ÕÈ◊  ·’¥ß·≈«â À°≈¡â ‡≈Õ◊ ¥ÕÕ°
‰¡ à ¡∫√Ÿ≥å (pre-operational ‡®∫Áª«É ¬¡“°π°— ·µ√à ∫—√∂Ÿâ ß÷°“√ ‰¡Àà ¬¥ÿ → ‡¥°Á§¥‘«“à ‡≈Õ◊ ¥ÕÕ°‰¡à
period) ‡ª≈¬Ë’π·ª≈ß∑‡Ë’°¥‘¢πÈ÷ ‡™πà ‚¥π À¬¥ÿ ‡æ√“–„ ‡à  Õ◊È ·’¥ß → ‡¥°Á®ß÷
- ‡¥°Á√∫—√·âŸ≈–µ§’«“¡µ“¡ª√– “∑ ‡®“–‡≈Õ◊ ¥ µÕâ ßπÕπ‚√ß欓∫“≈ ‰¡¬à Õ¡„ ‡à  ÕÈ◊  ·’¥ßÕ°’
 ¡—º —∑µË’π‡Õ߉¥√â ∫— - §¥‘«“à  “‡Àµ¢ÿÕß‚√§‡°¥‘®“°
- §¥‘‰¡‡à ªπì ‡Àµ‡ÿªπì º≈ ‡™ÕË◊ ¡‚¬ß ª®í ®¬—¿“¬πÕ°√“à ß°“¬
ª√“°Ø°“√≥å 2 Õ¬“à ß∑‡’Ë°¥‘¢πÈ÷æ√Õâ ¡ - Õ“®§¥‘«“à ‚√§À√Õ◊ §«“¡‡®∫Áª«É ¬
°π—¡“‡ªπì ‡Àµºÿ≈´ß÷Ë°π—·≈–°π— ‡°¥‘®“°°“√∂°Ÿ≈ß‚∑… ∑‡Ë’ªπì ‡¥°Á
‰¡¥à ’À√Õ◊ ‰¡‡à ™Õ◊Ëøßí æÕà ·¡à

7-12 √–¬–°“√§¥‘Õ¬“à ß„™‡â Àµºÿ≈‡™ß‘ - ‡¢“â „®‡Àµºÿ≈∑‡Ë’ªπì √ªŸ∏√√¡¿“¬ - ‡≈Õ◊ ¥ÕÕ°‰¡Àà ¬¥ÿ ‡æ√“–À°≈¡â
√ªŸ∏√√¡ (concrete operation) πÕ°∑‡Ë’°¬Ë’«¢Õâ ß°∫—°“√‡®∫Áª«É ¬
- ®¥—√–‡∫¬’∫§«“¡§¥‘‰¥µâ “¡ - ¡§’«“¡®”‡°¬’Ë«°∫—‚√§∑‰Ë’¥¡â “®“°
√ªŸ∏√√¡ ®“°°“√ ß—‡°µ ‡ÀπÁ§«“¡ º„Ÿâ À≠à
µÕà ‡πÕË◊ ߢÕ߇Àµ·ÿ≈–º≈‡™Õ◊Ë¡‚¬ß
‡ªπì ¿“æ√«¡‰¥¥â ’

>12 √–¬–°“√§¥‘Õ¬“à ß„™‡â Àµºÿ≈∑¡Ë’·’∫∫ - √«âŸ“à ‚√§·≈–°“√‡®∫Áª«É ¬‡°¥‘®“° - ∑≈Ë’¡â ·≈«â ‡≈Õ◊ ¥ÕÕ°‰¡Àà ¬¥ÿ ‡°¥‘
·ºπ‡™ß‘π“¡∏√√¡ (formal opera-  “‡Àµ¿ÿ“¬„π√“à ß°“¬º¥‘ª°µ‘ ®“°°“√∑¡Ë’§’«“¡º¥‘ª°µ‡‘°¬’Ë«°∫—°“√
tion) - ¡§’«“¡§¥‘√«∫¬Õ¥ Õ“® “¡“√∂ ·¢ßÁµ«—¢Õ߇≈Õ◊ ¥
- §¥‘„™‡â Àµºÿ≈µ“¡À≈°—°“√¡“ Õ∏∫‘“¬ “‡Àµ¿ÿ“¬„π√“à ß°“¬∑∑’Ë”
Õ∏∫‘“¬‡Àµ°ÿ“√≥∑å ‡’Ë°¥‘¢π÷ȉ¥â „À‡â °¥‘Õ“°“√º¥‘ª°µµ‘“à ßÊ ‰¥â

- ‡¥°Á°≈¡àÿ‡≈¬È’ßß“à ¬ (easy child) ª√∫—µ«— √ Ÿâ °÷¡πË—„®·≈–∑”°®‘°√√¡µ“à ßÊ ‰¥â æ∫√Õâ ¬≈– 15
ß“à ¬ Õ“√¡≥¥å ’°π‘πÕπ‡ªπì ‡«≈“ æ∫√Õâ ¬≈– 40 - ‡¥°Á°≈¡àÿæπ◊ÈÕ“√¡≥·å ∫∫º ¡æ∫√Õâ ¬≈–35
- ‡¥°Á°≈¡àÿ‡≈¬’È߬“° (difficult child) ª√∫— ‡ªπì ∑π’Ë“à  ß—‡°µ«“à „π°≈¡ÿà ºªŸâ «É ¬‡¥°Á∑‡Ë’ªπì ‚√§
µ«—¬“° ÀߥÿÀߥ‘ß“à ¬ §“¥°“√‰¥¬â “° æ∫√Õâ ¬≈– 10 ‡√Õ◊È√ß— º‡Ÿâ ≈¬’Èߥ¡Ÿ°—√“¬ß“πæ∫≈°—…≥–¢ÕßæπÈ◊ Õ“√¡≥å
- ‡¥Á°°≈ÿà¡∑’˵âÕß°“√‡«≈“„π°“√ª√—∫µ—« ·∫∫‡≈¬È’߬“°¡“°°«“à ·∫∫ÕπË◊ ´ß÷ËÕ“®‡ªπì ®“°¿“«–
(slow to warm up child) ‡¥°Á®–¡§’«“¡«µ‘°°ß—«≈ ¢Õß°“√ª√∫—µÕà ¢Õ߇¥°ÁµÕà °“√‡®∫Áª«É ¬15-17
µâÕß„™â‡«≈“„π°“√ª√—∫µ—«„À⇢⓰—∫§πÀ√◊Õ ∂“π∑’Ë ‚¥¬∑«Ë—‰ª‡¥°Á°≈¡àÿ‡≈¬’Èßß“à ¬¡°—®–¡°’“√ª√∫—µ«—
„À¡Êà ·µ‡à ¡ÕË◊ „À‡â «≈“·≈–√ Ÿâ °÷ª≈Õ¥¿¬—‡¥°Á®–§Õà ¬Ê ‰¥¥â µ’Õà °“√‡®∫Áª«É ¬µ“à ßÊ Õ¬“à ߉√°µÁ“¡‡¥°Á∑°ÿ°≈¡àÿ

274 ‡¢¡‘°“ ‡¢¡–°π°  ÿ¥π“«“

¡®’¥ÿ·¢ßÁ·≈–®¥ÿÕÕà π∑·Ë’µ°µ“à ß°π— ‡¥°ÁµÕâ ß°“√§«“¡ ‡√ÕÈ◊ √ß—
‡¢“â „®„πæπÈ◊ Õ“√¡≥¢å Õ߇¥°Á‡æÕ◊Ë∑º’Ë„Ÿâ À≠®à –‰¥ªâ √∫—µ«—
„À‡â À¡“– ¡°∫—æπÈ◊ Õ“√¡≥¢å Õ߇¥°Á·µ≈à –§π °“√¥·Ÿ≈ ¿“段‘„®„πºªâŸ«É¬‡¥°Á ‚√§‡√ÕÈ◊√ß—∑“ß
ë ∑—°…–·≈–«‘∏’°“√·°âªí≠À“ ®–¢È÷πÕ¬àŸ°—∫ ‚≈À‘µ«∑‘¬“1,18-21
Õ“¬ÿ·≈–√–¥—∫ µ‘ªí≠≠“¢Õ߇¥Á° ‚¥¬‡¥Á°·µà≈–§π ºŸâªÉ«¬·≈–§√Õ∫§√—«‚¥¬∑Ë—«‰ª®– “¡“√∂
®–¡’∑—°…–·≈–«‘∏’°“√·°âªí≠À“∑’ˇªìπ·∫∫≈—°…≥– ª√∫—µ«—°∫—°“√‡®∫Áª«É ¬‰¥â ·µÕà “®¡§’«“¡¬“°≈”∫“°
‡©æ“–µ—« ´Ë÷ß∫ÿ§§≈“°√∑“ß°“√·æ∑¬å§«√µâÕß ·≈–µâÕß„™â‡«≈“„π°“√ª√—∫µ—« À√◊Õ∫“ߧπÕ“®ª√—∫
 —߇°µ‡æ◊ËÕ„Àâ°“√™à«¬‡À≈◊Õ∑Ë’‡À¡“– ¡µàÕ‰ª ‚¥¬ µ—«‰¡à‰¥â °Õà „À‡â °¥‘‚√§∑“ߥ“â 𮵑„®µ“¡¡“ ·æ∑¬å
≈°—…≥–°“√‡º™≠‘ ª≠í À“ (coping) ∑¥’˧’Õ◊ «∏‘°’“√ ∑‡’Ë°¬Ë’«¢Õâ ß “¡“√∂„À§â «“¡™«à ¬‡À≈Õ◊ ºªŸâ «É ¬„À¡â °’“√
¡ÿàß·°âªí≠À“ (approach-oriented or active ª√∫—µ«—∑¥Ë’·’≈–‡√«Á¢πÈ÷‰¥â ¥ß—πÈ’
coping strategies) ‚¥¬¡ßàÿ‡ππâ ∑°’Ë“√À“∑“ß·°ªâ ≠í À“ 1. °“√√°—…“‡°¬’Ë«°∫—‚√§
À“¢âÕ¡Ÿ≈ ¢Õ§«“¡™à«¬‡À≈◊Õ®“°ºâŸÕË◊π ´Ë÷ß·µ°µà“ß ∑ßÈ—„π·ß°à “√√°—…“ °“√øπôó øŸ·≈–°“√ªÕÑ ß°π—
°—∫≈—°…≥–°“√‡º™‘≠ªí≠À“·∫∫À≈’°Àπ’ªí≠À“ ‡æÕË◊ „Àºâ ªâŸ«É ¬¡§’≥ÿ ¿“晫’µ‘∑„Ë’°≈‡â §¬’ߪ°µ¡‘“°∑ Ë’¥ÿ
(avoidance-oriented coping strategies) À≈∫ ≈¥°“√¡“‚√ß欓∫“≈¥â«¬¿“«–©ÿ°‡©‘π´÷Ëß®– àߺ≈
‡≈’ˬߪí≠À“ ‰¡à π„® ´Ë÷ß«‘∏’°“√πÈ’Õ“®∑”„Àâ¡’ªí≠À“ µàÕ°“√ª√—∫µ—«¢Õߺ⟪ɫ¬ ºŸâªÉ«¬§«√¡’·æ∑¬åª√–®”
µ“à ßÊ µ“¡¡“ ‡™πà ‚√§´¡÷‡»√“â µ—«∑’˺ŸâªÉ«¬§ÿâπ‡§¬  ∫“¬„® ·≈–¡’§«“¡‰«â«“ß„®
3. ª®í ®¬—¥“â π§√Õ∫§√«— §Õ¬¥Ÿ·≈ ÿ¢¿“溟âªÉ«¬Õ¬à“ßÕߧå√«¡·≈–∑”Àπâ“∑’Ë
ë §√Õ∫§√—«∑”Àπâ“∑’ËÀ≈—°„π°“√¥Ÿ·≈·≈– „π°“√ª√– “π√–À«à“ß·æ∑¬å·≈–‡®â“Àπâ“∑Ë’‡©æ“–
ª√–§—∫ª√–§Õß π—∫ πÿπ∑“ߥâ“𮑵„®¢Õߺ⟪ɫ¬ ∑“ßµ“à ßÊ
§√Õ∫§√«—®ß÷‰¥√â ∫—º≈°√–∑∫Õ¬“à ß¡“°®“°°“√¡‡’¥°Á 2. ª√–‡¡‘𧫓¡æ√âÕ¡¢Õߧ√Õ∫§√—«·≈–
‡ªìπ‚√§‡√È◊Õ√—ß„π∫â“π §√Õ∫§√—«∑’Ë ¡“™‘°„π∫â“π¡’ „À°â “√™«à ¬‡À≈Õ◊
§«“¡ ¡—æπ—∏Õå π—¥’§Õ¬™«à ¬‡À≈Õ◊ ·≈–„À°â ”≈ß—„®·°°à π— ·æ∑¬å ·≈–§√Õ∫§√—« µâÕ߇ªìπ∑’¡‡¥’¬«°—π
¡ ’¢ÿ¿“æ°“¬∑·Ë’¢ßÁ·√ß·≈– ¢ÿ¿“段‘∑¥Ë’’¡√’“¬‰¥∑â Ë’ „π°“√™à«¬‡À≈◊պ⟪ɫ¬ ®÷ߧ«√¡’°“√查§ÿ¬°—πÕ¬à“ß
‡æ’¬ßæÕ¡—Ëπ§ß ·≈–¡’∑—»π§µ‘‡°Ë’¬«°—∫‚√§∑Ë’∂Ÿ°µâÕß  ¡”ˇ ¡Õ‡æ◊ËÕ √â“ߧ«“¡ —¡æ—π∏åÕ—π¥’ ‚¥¬æŸ¥§ÿ¬
®– ßà º≈„Àºâ ªâŸ«É ¬‡¥°Á·≈–§√Õ∫§√«—¡°’“√ª√∫—µ«—∑¥’Ë’ ∂÷ß®ÿ¥·¢ÁßÀ√◊Õªí≠À“∑Ë’§√Õ∫§√—«¡’ ·≈–„Àâ°“√
4. ª®í ®¬—¥“â π ß—§¡  π—∫ πÿ𧫓¡™à«¬‡À≈◊Õ¥â“πµà“ßÊ ‡™à𠇧√◊Õ¢à“¬
ë  —ߧ¡‡ªìπªí®®—¬ ”§—≠∑’Ë¡’Õ‘∑∏‘æ≈Õ¬à“ß ºªâŸ°§√Õß∑¡Ë’‚’√§‡¥¬’«°π— °“√‡¢“â ∂ß÷∫√°‘“√∑“ß°“√
¡“°µàÕ§√Õ∫§√—«·≈–µ—«‡¥Á° °“√‡¢â“∂÷ß∫√‘°“√∑“ß ·æ∑¬å ·≈–√–∫∫°“√»°÷…“ ‡ªπì µπâ
 “∏“√≥ ÿ¢∑ß’Ë“à ¬·≈– –¥«° °“√‰¥√â ∫—‡ßπ‘ π∫— ππÿ 3. °“√ª√–‡¡‘π·≈–™à«¬‡À≈◊Õ‡¥Á°·≈–
§“à „™®â “à ¬„π°“√√—°…“·≈–¥Ÿ·≈ºâŸªÉ«¬ °“√‰¥â√—∫°“√ §√Õ∫§√«—∑“ߥ“â πª≠í À“¥“â πÕ“√¡≥·å ≈–惵°‘√√¡
™à«¬‡À≈◊Õ¥â“πÕË◊πÊ „π —ߧ¡‡æ◊ËÕ‡Õ◊ÈÕÕ”π«¬§«“¡ ∑µË’“¡¡“
 –¥«°·≈–‚Õ°“ „Àâ°—∫ºŸâªÉ«¬ √«¡∂÷ß√–∫∫°“√ ë ·æ∑¬å§«√„À⧫“¡ ”§—≠·≈–„ à„®„π°“√
»÷°…“∑Ë’‡ÕÈ◊ÕÕ”π«¬„ÀâºâŸªÉ«¬‰¥â‡√’¬π ®–™à«¬∑”„Àâ ª√–‡¡π‘¥“â πÕ“√¡≥å æ≤— π“°“√ ·≈–惵°‘√√¡¢Õß
‡°‘¥°“√ª√—∫µ—«∑’Ë¥’¢Õߧ√Õ∫§√—«·≈–ºâŸªÉ«¬‡¥Á°‚√§ ºªŸâ «É ¬·≈–§√Õ∫§√«—‡ªπì √–¬–Õ¬“à ß ¡”ˇ ¡Õ

°“√¥Ÿ·≈ ¿“段‘„®„πºŸâª«É¬‡¥Á°∑“ß‚≈Àµ‘«∑‘¬“ Psychological Aspects in Children with Benign Hematology 275

ë ·æ∑¬åµâÕ߇¢â“„®·≈–¬Õ¡√—∫Õ“°“√À√◊Õ ‡À¡“– ¡°∫—√–¥∫—æ≤— π“°“√∑“ß µª‘≠í ≠“¢Õ߇¥°Á
惵‘°√√¡∑Ë’‡°‘¥¢È÷π¢ÕߺŸâªÉ«¬·≈–§√Õ∫§√—««à“‡ªìπ Õ“®¡’ ◊ËÕª√–°Õ∫‡æË◊Õ∑”„À⇥Á°‡¢â“„®ßà“¬¢÷È𠇙àπ
°√–∫«π°“√®“°°“√ª√—∫µ—« · ¥ß§«“¡‡¢â“„® „Àâ π∑‘“𠇪πì µπâ Õ“®„À§â «“¡√°Ÿâ ∫—ºªŸâ «É ¬·≈–§√Õ∫§√«—
‡«≈“√∫—øßí „À°â ”≈ß—„®·≈–ª√–§∫—ª√–§Õß∑“ßÕ“√¡≥å ·∫∫‡¥¬’Ë« À√Õ◊ ®¥—‡ªπì °®‘°√√¡°≈¡àÿ√«à ¡°∫—ºªâŸ«É ¬À√Õ◊
· ¥ß§«“¡Àà«ß„¬ ·≈–„À⧫“¡¡Ë—π„®„π°“√¥Ÿ·≈ §√Õ∫§√—«Õ◊ËπÊ ‡æ◊ËÕ„Àâ√ૡ查§ÿ¬·≈–·≈°‡ª≈’ˬπ
√°—…“Õ¬“à ߥ’ ª√– ∫°“√≥å°—π ·≈–Õ“®„™â«‘∏’°“√‡æ‘Ë¡ª√– ‘∑∏‘-
ë °“√„À¢â Õâ ¡≈Ÿ‡æ¡Ë‘‡µ¡‘‡°¬Ë’«°∫—‚√§ °“√√°—…“ ¿“æ°“√ ÕË◊  “√22 (µ“√“ß∑Ë’19.3)
·≈–°“√ªØ∫‘µ—µ‘«— ‚¥¬æ¬“¬“¡„Àºâ ªŸâ «É ¬·≈–§√Õ∫§√«— ë °“√„Àºâ ªâŸ«É ¬‰¥æâ ¥Ÿ§¬ÿ∂ß÷§«“¡‰¡ à ∫“¬„®
√∫—√§âŸ«“¡®√ß‘¡“°∑ ’Ë¥ÿ‡∑“à ∑®Ë’–‰¡‡à ªπì º≈‡ ¬’ „À‡â «≈“ ·≈–¢Õ§«“¡™à«¬‡À≈◊Õ∑“ß®‘µ„®®“°ºŸâÕ◊Ëπ ‚¥¬§«√
„π°“√µÕ∫§”∂“¡·≈–¢Õâ  ß ¬— ®–™«à ¬≈¥§«“¡°≈«—  π—∫ πÿπ„À⺟âªÉ«¬·≈–§√Õ∫§√—«‰¥â· ¥ßÕÕ°·≈–
·≈–«‘µ°°—ß«≈∑’ˇ°‘¥®“°§«“¡‡¢â“„®º‘¥ ·≈–„Àâ ¬Õ¡√—∫§«“¡√⟠÷°∂÷ßÕ“√¡≥åµà“ßÊ ∑’ˇ°‘¥¢÷È𠧫“¡
‚Õ°“ ºâŸªÉ«¬‡¥Á°·≈–§√Õ∫§√—«¡’ à«π√à«¡„π°“√ √ Ÿâ °÷∑‰Ë’¡¥à ’‡™πà ‚°√∏ °≈«— ‡ ¬’„® ‡ªπì  ßË‘∑‡’Ë°¥‘¢πÈ÷‰¥â
µ—¥ ‘π„® ´÷Ëß®– à߇ √‘¡„À⺟âªÉ«¬·≈–§√Õ∫§√—«‡°‘¥ ‡ªìπª°µ‘„À⺟âªÉ«¬‰¥â查§ÿ¬ª√÷°…“°—∫∫ÿ§≈“°√∑“ß
æ≈—ß·≈–§«“¡‡¢â¡·¢Áß (empowerment) ´÷Ë߇ªìπ °“√·æ∑¬å§π„°≈♑¥ À√◊Õ°≈ÿࡺ⟪ɫ¬‚√§‡¥’¬«°—π
 à«π∑’Ë ”§—≠¡“°„π°“√¥Ÿ·≈ ÿ¢¿“æ·≈–®‘µ„®„π ‡æÕ◊Ë„Àºâ ªâŸ«É ¬‰¥√â –∫“¬§«“¡∑°ÿ¢„å ® ‰¥√â ∫—°”≈ß—„®À√Õ◊
√–¬–¬“« ·π«∑“ß„π°“√ª√∫—µ«—¡“°¢πÈ÷
°“√查 Ë◊Õ “√°—∫‡¥Á°§«√„™â°“√Õ∏‘∫“¬∑Ë’ ë °“√„ÀâºâŸªÉ«¬Õ¬Ÿà°—∫ªí®®ÿ∫—π·≈–°“√µ—Èß

µ“√“ß∑Ë’19.3 «∏‘°’“√‡æ¡Ë‘ª√– ∑‘∏¿‘“æ°“√ ÕË◊  “√°∫—ºªâŸ«É ¬‡¥°Á·≈–§√Õ∫§√«— (TEACHER) (¥¥—·ª≈ß
®“°‡Õ° “√Õ“â ßÕß‘À¡“¬‡≈¢ 22)

À≈°—°“√ «∏‘°’“√

Trust (°“√ √“â ߧ«“¡‰««â “ß„®)  √“â ß ¡—æπ—∏¿“æ „À§â «“¡‡ªπì °π—‡Õß „À‡â ¥°Á‡°¥‘§«“¡‰««â “ß„®

Elicit (§«“¡°√–®“à ߢÕߢÕâ ¡≈Ÿ) ´—°∂“¡§«“¡‡¢â“„®¢ÕߺŸâªÉ«¬‡°Ë’¬«°—∫‚√§ ·≈–§«“¡‰¡à ∫“¬„® ‚¥¬„™â
§”∂“¡ª≈“¬‡ª¥î „À‡â «≈“„π°“√√∫—øßí ºªŸâ «É ¬

Agenda (°“√∫π—∑°÷¢Õâ ¡≈Ÿ) ∫π—∑°÷¢Õâ ¡≈Ÿ ‡æÕË◊ °“√µ¥‘µ“¡Õ¬“à ßµÕà ‡πÕË◊ ß

Control (ºªŸâ «É ¬√ âŸ°÷§«∫§¡ÿ „Àºâ ªâŸ«É ¬‰¥√â ∂âŸß÷ ß‘Ë∑®Ë’–‡°¥‘¢πÈ÷µÕà ‰ª ‡ª¥î ‚Õ°“ „À√â «à ¡„π°“√µ¥— π‘„®·≈–
 ∂“π°“√≥‰å ¥)â ´°—∂“¡
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