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1
danarTi 2
anemiis marTva pirvelad
jandacvaSi
klinikuri mdgomareobis marTvis saxelmwifo standarti
(protokoli)
damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris 2010 wlis 24 seqtembris
# 305/o brZanebiT
miRebulia “klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo
standartebis (protokolebi) SemuSavebis, Sefasebisa da danergvis erovnuli sabWos"
2009 wlis 30 dekembris #2 sxdomis gadawyvetilebis Sesabamisad
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anemiis marTva pirvelad jandacvaSi
gamoyenebuli Semoklebebi
rda – rkinadeficituri anemia
janmo – jandacvis msoflio organizacia
MCV – eriTrocitebis saSualo moculoba
MCHC – hemoglobinis saSualo koncentracia
TIBC – rkinis totaluri (saerTo) SekavSirebis unari
Ret – retikulocitebi
RI – retikulocituri indeqsi
Hct – hematokriti
RDW – eriTrocitebis gadanawilebis farTi
Rouleaux formation
– “monetebis svetis” magvari formacia
LDH – laqtatdehidrogenaza
HELLP – hemolitiko-uremiuli sindromi
sTfR – xsnadi transferin receptori
hsCRP – maRalsensitiuri c-reaqtiuli cila
Anti-TTG – antisxeulebi qsovilovani transglutaminazas
mimarT
CDC – aSS-is daavadebaTa kontrolis centri
Sf – Sinagani faqtori
mmm – meTilmalonis mJava
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rkinadeficituri anemia
(protokoli)
1. daavadebis / problemis ganmarteba
definicia (janmo-s mixedviT):
mamakacebi hemoglobinis koncentracia sisxlSi < 130 g/l (< 13 g/l) an hematokriti < 39 % (< 0.39)
qalebi hemoglobinis koncentracia sisxlSi < 120 g/l (< 12 g/l) an hematokriti < 36 % (< 0.36)
orsuli qalebi hemoglobinis koncentracia sisxlSi < 110 g/l (< 11 g/l) an hematokriti < 33 % (< 0.33)
sinonimebi: sideropeniuri anemia
2. sadiagnozo kriteriumebi
damadasturebeli kriteriumebi
hemoglobinis Semcireba: mamakaci < 130g/l; qali < 120g/l; orsulebi < 110g/l (rkinis deficitis gviani manifestacia; xasiaTdeba dabali specifikurobiT);
hematokriti: mamakaci < 39%; qali < 36%; orsuli < 33%;
feradobis maCvenebeli < 0.85;
MCV – eriTrocitebis saSualo moculoba (hematokriti % X 10/eriTrocitebis raodenoba (X 10^6/microL) < 80fL;
MCH – eriTrocitebSi hemoglobinis saSualo Semcveloba (hemoglobini g/dl X 10/eriTrocitebis raodenoba (X 10^6/microL) <
27.5 pg/Er;
MCHC – eriTrocitebSi hemoglobinis saSualo koncentracia (hemoglobini g/dl X 100/hematokriti%) < 29.5 g/dl;
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RDW - eriTrocitebis moculobis variaciis koeficienti > 14.6%; RDW-s mateba aris rda-is ufro adreuli niSani, vidre MCV-s Semcireba. Talasemiisgan rda-s difdiagnostikis TvalsazrisiT misi sensitiuroba Seadgens 90-100%, magram specifikuroba Seadgens mxolod 50-70%-s;
periferiuli sisxlis nacxSi: mikrocitozi – mcire diametris eriTrocitebis raodenobis mateba; anizocitozi-sxvadasxva zomis eriTrocitebi; poikilocitozi – sxvadasxva formis eriTrocitebi;
retikulocitebi – normaluri an momatebulia sisxldenis an rkinis preparatebiT mkurnalobis dros;
retikulocituri indeqsi < 2; SeiZleba momatebuli iyos sisxldenis dros;
leikocitebi – norma; SeiZleba iyos leikopenia, gansakuTrebiT xangrZlivi mimdinareobis dros;
Trombocitebi – tendencia momatebisadmi;
edsi – SesaZlebelia mateba mZime anemiis dros;
Sratis rkina – Semcirebulia;
rkinis saerTo SeboWvis unari (TIBC) – momatebulia;
transferinis saturacia (Sratis rkina X 100/TIBC) < 16%;
feritini: mamakaci < 30 ng/ml; qali < 25 ng/ml;
transferinis receptorebis raodenoba – momatebulia.
simptomebi da niSnebi
Civilebi:
sisuste;
haeris ukmarisoba;
gulis friali;
Tavis tkivili;
Sromis unaris daqveiTeba, Zilianoba;
tinitusi;
gemovnebis gaukuRmarTeba (pika): survili Wamon carci, miwa;
Civilebis gamovlena mniSvnelovnad aris damokidebuli daavadebis ganviTarebis siswrafeze. Daavadebis neli ganviTarebis SemTxvevaSi SesaZlebelia Civilebi ar iyos warmodgenili gamoxatuli anemiis pirobebSic.
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fizikuri gamokvlevis Sedegebi:
kanis da lorwovanis sifermkrTale;
atrofiuli glositi da anguluri qeiliti;
trofikuli darRvevebi (Tmebi, kani, frCxilebi);
taqikardia, sistoluri Suili gulze, gulis ukmarisoba (mZime da xangrZlivi mimdinareobis dros);
kogniciuri da qceviTi deficiti bavSvebSi, gansakuTrebiT yuradRebis deficiti;
mousvenari fexebis sindromi.
3. instrumentul-laboratoriuli gamokvlevebi da
specialistTa konsultaciebi
instrumental-laboratoriuli gamokvlevebi anemiis dros etapobrivad tardeba.
sadiagnozo ZiebisaTvis mniSvneloba aqvs retikulocitebis raodenobas, romlis gansazRvra pirvel etapzeve xdeba (ix. sqema 1) da eriTrocitebis morfologias (ix. sqema 2).
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anemia
koregirebuli retikulocituri indeqsi (CRI)
CRI<2 CRI>2
MCV(fL)
< 80 80-100 >100
- rda; - qda; - Talasemia; - sideroblasturi anemia;
- tyviiT mowamvla.
- Zvlis tvinis aplazia; - Tqu; - izolirebuli eriTroculi aplazia;
- mielofibrozi; - mieloftizi; - mielodisplazia (uxSiresad); - qda (uxSiresad); - rda (msubuqi forma); - mikrocituli da makrocituli anemiis Sereuli forma.
- B12-deficituri anemia; - foliumdeficiutri anemia; - mielodisplazia (iSviaTad); - hipoTireozi; - RviZlis paTologia; - medikamentebi, romlebic Trgunaven dnm-is sinTezs.
hemolizi
- arapirdapiri bilirubini;
- ldh;
sisxldena
- anamnezi; - rkina SratSi; - feritini.
SeZenili Tandayolili/memkvidruli
eriTrocitebis
membranopaTia
- sferocotozi; - eliptocitozi; - piropoikilocitozi; - stomatocitozi.
eriTrocitebis
fermentopaTia
- G6-PD deficiti;
- piruvatkinazas deficiti; - sxva iSviaTi formebi.
hemoglobinopaTia
- Talasemia; - hemoglobin S,C,D,E daavadeba; - arastabiluri hemoglobini; - sxva iSviaTi daavadeba.
imunuri hemolizi
- autoimunuri - medikamenturi - aloimunuri
travmuli .
- mikro da makroangio paTiuri;
- Trombuli Trombo-citopeniuri purpura
- eklamfsia; - dik-sindromi; - vaskuliti; - avTvisebiani hipertenzia;
- sarqvlis proTezi da arteriuli Sunti
hipersplenizmi
membranopaTia
- akantocitebi - eqinocitebi - Ramis paroqsizmuli hemoglobinuria
- damwvroba
infeqcia
- malaria - babeziozi - barTonelozi - klostridiumis toqsini
osmosuri dazianeba
sqema #1
anemiis sadiagnozo zogadi
algoriTmi
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sqema #2 mikrocitozi
CRI<2
gansazRvre: feritini, Fe
Fe↓
dadebiTi
Sardis skriningi tyviis Semcvelobaze
sTFR/log ferritin >2
Hb-eleqtroforezi da eriTroc. morfologia
Fe, feritini-N an ↑
gansazRvre
sTfR
feritini >100;
TIBC↓ feritini 30-100
feritini <30;
TIBC↑
paTologia
sTFR/log ferritin <1
norma
norma
Zvlis tvinis biofsia
qda
rda
Talasemia
sideroblastebi momatebulia
qda
Sereuli
(rda da qda)
tyviiT
mowamvla
sideroblas-
turi anemia
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pacientis gamokvleva dadasturebuli rkinadeficituri anemiis SemTxvevaSi:
rkinadeficituri mdgomareoba dadasturebuli unda iyos feritinis dabali doniT, mikrocitoziT, hipoqromiiT qronikuli daavadebis anemiis (qda) da sxvadasxva saxis hemogloninopaTiis ararsebobis pirobebSi (A);
rkinadeficituri anemiis nebismieri done saWiroebs gamokvlevas (B);
yvela mamakacs unda Cautardes kuW-nawlavis kvleva (zemo da qveda nawilebi), garda im SemTxevevisa rodesac ASkaraa gamoxatuli sisxlkargva arakuWnawlavidan (A);
kuW-nawlavis kvleva (zemo da qveda nawilebi) unda Cautardes yvela qals postmenopauzur periodSi, 50 wlis zeviT da koloreqtaluri simsivnis ojaxuri anamnezis arsebobisas (B);
yvela pacients unda Cautardes skriningi celiakiaze. uaryofiTi serologiis pirobebSi wvrili nawlavis biofsia tardeba mxolod celiakiis maRali klinikuri albaTobis SemTxvevaSi (B). (anamnezSi-dermatitis herpetiformis, morecidive afTozuri stomatiti, RviZlis funqciuri sinjebis auxsneli darRveva, daunis sindromi, autoimunuri Tiroiditi, Saqriani diabeti-I tipis, adisonis daavadeba, budobrivi alopecia);
Tu ezofagogastroduodenoskopia Catarda rogorc sawyisi kvleva, mxolod kuWis kibo an celiakia gamoricxavs damatebiT msxvili nawlavis kvlevas. erozia, ezofagiti an peptiuri wyluli ar gamoricxavs msxvili nawlavis damatebiT kvlevas;
msxvili nawlavis kvlevisas upiratesoba eniWeba kolonoskopias; Tumca misaRebia agreTve bariumiT kvleva (kontrastireba per/rectum),gansakuTrebiT ormagi kontrastirebis pirobebSi (B);
ganavlis analizi farul sisxldenaze xasiaTdeba dabali sensitiurobiT da specifikurobiT da ar gamoiyeneba (B);
wvrili nawlavis dabatebiTi vizualizacia (video-kapsulirebuli enteroskopia) saWiroa mxolod im SemTxvevebSi rodesac anemia aris transfuziebze damokidebuli (B).
mniSvnelovania instrumental-laboratoriuli gamokvlevebis dagegmva rkinis deficitis mizezis (etiologiis) dasadgenad, rac anamnezuri monacemebs unda Seesabamebodes (ix. cxrili 1.).
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cxrili #1
gamokvlevebi rkinis deficitis etiologiis dasadgenad
anamnezi gamokvleva
wylulovani daavadeba an dispefsia, melena, asas-ebis gamoyeneba gastroskopia
reqtaluri sisxldena, qr. yabzoba an diarea, warsulSi aRmoCenili simsivnuri warmonaqmnebi, wvrili nawlavis rezeqcia
kolonoskopia
eozinofilia, atopia ganavlis analizi
parazitebze
hematuria
ultrasonografia,
cistoskopia,
rentgenokontrastuli
kvleva
metroragia an raime ginekologiuri problema
mcire menjis organoebis
ultrasonografia
Dermatitis herpetiformis, morecidive afTozuri wylulebi, gaRizianebuli nawlavis sindromi, RviZlis funqciuri sinjebis auxsneli darRveva, osteoporozi, daunis sindromi, autoimunuri Tiroiditi, Saqriani diabeti-I tipi, ucnobi warmoSobis ataqsia, adisonis daavadeba, budobrivi alopecia – anti tTG (dadebiTi testis SemTxvevaSi)
wvrili nawlavis
biofsia
(celiakiis gamosaricxad)
anamnezSi sayuradRebo niSnebis ararsebobis SemTxvevaSi tardeba
yvela zemoTCamoTvlili kvleva!
4. mkurnaloba
zogadi principebi
rkinadeficituri anemiis mkurnalobis principebi Semdegia:
erTi mxriv, rkinadeficituri mdgomarebis diagnostirebis Semdeg aucilebelia etiologiuri faqtoris identifikacia da koreqcia (Tu SesaZlebelia), meore mxriv, CanacvlebiTi Terapia ar unda gadaidos diagnostikuri kvlevebis dasrulebamde;
medikamenturi Terapia moicavs Semdegs: (a) anemiis koreqcia; (b) rkiniT gajerebis Terapia – organizmSi rkinis depos Seqmna;
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upiratesoba eniWeba rkinis peroralur formebs;
parenteraluri Terapia iniSneba mxolod Semdeg SemTxvevebSi: (a) peroraluri formebis autanlobis SemTxvevaSi; (b) peroraluri Terapiis araefeqturobisas; (g) malabsorbciisas da (d) mkveTrad gamoxatuli anemiis dros, rodesac saWiroa anemiis swrafi koreqcia (SemdgomSi peroralur formaze gadasvliT);
vitamini B-12 da foliumis mJava iniSneba mxolod kombinirebuli paTologiis dros; an im SemTxvevaSi roca Terapia iniSneba empiriulad;
mxolod rkiniT mdidari sakvebis miRebiT SeuZlebelia arsebuli deficitis koreqcia;
mkurnalobis efeqturobis kriteriumebi: retikulocituri krizi mkurnalobis me-10-12 dRes, hemoglobinis mateba erTi Tvis Semdeg 20g/l-iT (2g/dl-iT);
hemoglobinis normalizaciis Semdeg mkurnaloba grZeldeba damatebiT 3-4 Tve (rkinis depos Seqmna).
mkurnaloba rkinis preparatebiT aucilebelia yvela
SemTxvevaSi, maT Soris daudgeneli etiologiis anemiis dros!
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oraluri CanacvlebiTi Terapia:
elementaruli rkina 2-3 mg/kg/dReSi (saSualod 200 mg), gayofili 2-3 miRebaze;
rkinis (III) hidroqsidis polimaltozuri kompleqsi: abebi (100mg elementaruli rkina); saReWi abebi (100mg elementaruli rkina); sirofi (50mg/5ml)
rkinis (II) sulfati: abebi (100mg elementaruli rkina);
rkinis (II) glukonati: wveTebi (1ml-5mg elementaruli rkina); ampulebi (per/os misaRebad) (1amp-50mg elementaruli rkina);
rkinis (II) fumarati: kafsula (152mg elementaruli rkina); abebi (90mg elementaruli rkina);
arahemuri rkina (mcenareuli da rZis produqtebi) SewovisTvis saWiroebs mJavas. rkinis Sewovis xelSemwyobebia askorbinis mWava, xorci da zRvis produqtebi; xolo inhibitorebi – kalciumi, Cai, yava, Rvino, mcenareuli boWko;
pacientTa daaxloebiT 10%-s aReniSneba autanloba (gulis reva/Rebineba, Sekruloba/diarea), risi Semcireba SesaZlebelia preparatis dozis SecvliT, preparatis miRebiT sakvebTan erTad.
parenteraluri Terapia:
rkinis (III) hidroqsidis polimaltozuri kompleqsi: erTi ampula -100 mg elementaruli rkina (i/m);
rkinis deqstranis formebi: elementaruli rkinis sxvadasxva SemcvelobiT; gamoiyeneba i/v-ad; daaxloebiT pacientTa 1%-Si aRiniSneba anafilaqtiuri reaqcia, ris gamoc aucilebelia preparatis Seyvana test-reJimiT;
rkinis natrium glukonatis kompleqsi: 125 mg i/v-ad; 1-jer kviraSi (8-kvira);
rkinis sukrozis forma: 200 mg i/v-ad; sul 5-ineqcia 2-kviriani intervaliT.
transfuziuri Terapia:
ar arsebobs mkacri kriteriumi rodis unda Catardes eriTrocituli masis gadasxma; aseT kriteriumad SeiZleba CaiTvalos hemodinamikuri arastabiluroba, Tanmxlebi kardiovaskuluri daavadebebi (mag,koronaruli arteriebis daavadeba);
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transfuziis Semdeg unda Catardes CanacvlebiTi Terapia rkinis preparatiT Cveuli sqemiT, radganac eriTrocituli masis erTi erTeulis gadasxma awvdis pacients mxolod 250 mg rkinas rac sakmarisia hemoglobinis mxolod 1g-iT zrdisTvis;
pacientma unda daicvas woliTi reJimi Tu is simptomuria da saWiroebs transfuzias (aseTi pacientebis mkurnaloba tardeba stacionarSi hematolobis meTvalyureobiT).
gasaTvaliswinebelia hemotrasfuziasTan dakavSirebuli Semdegi SesaZlo garTulebebi: infeqciuri daavadebebis transmisia, mwvave da Seyovnebuli tipis transfuziuri reaqcia, posttransfuziuri purpura, distres-sindromi.
5. referalis Cveneba
mZime anemia gansakuTrebiT hemodinamiuri arastabilurobis pirobebSi (stacionaruli mkurnaloba);
mkurnalobis araefeqturoba;
rkinis preparatis autanloba;
anemiis ganmeorebiTi ganviTareba sawyisi efeqturi mkurnalobis Semdeg.
6. reabilitacia / meTvalyureoba
sakontrolo kvleva:
ganmeorebiTi sisxlis analizi tardeba mkurnalobis dawyebidan erT TveSi (2-4 kvira); mkurnalobis efeqturobis kriteriumia hemoglobinis donis mateba 20g/l-iT (2g/dl-iT);
mkurnalobis araefeqturobis SemTxvevaSi pacienti igzavneba hematologTan;
hemoglobinis normalizaciamde sakontrolo sisxlis analizi tardeba TveSi erTxe;
hemoglobinis normalizaciis Semdeg sisxlis analizi tardeba 3-TveSi erTxel, pirveli wlis manZilze; erTi wlis Semdeg ki – weliwadSi erTxel.
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skriningi:
aSS-s prevenciuli samsaxuri (USPSTF) rekonendacias iZleva Catardes rkinadeficituri anemiis skriningi mxolod orsulebSi (A);
aSS-is daavadebaTa kontrolis centri (CDC) rekomendacias iZleva Catardes skriningi skolamdeli bavSvebis, orsulebis da premenopauzuri qalebis maRali riskis populaciaSi.
prevencia:
aSS-s prevenciuli samsaxuri (USPSTF) rekonendacias iZleva Catardes rkiniT rutinuli saplementacia maRali riskis asimptomur Cvil bavSvebSi (asaki: 6-12 Tve): bavSvebi Raribi ojaxidan, afrikuli rasis warmomadgenlebi, emigrantebi ganviTarebadi qveynebidan, dRenakluli an dabali woniT dabadebuli bavSvebi, xelovnur kvebaze (arafortificirebuli Zroxis rZe) myofi bavSvebi (A);
aSS-is daavadebaTa kontrolis centri (CDC) rekomendacias iZleva Catardes universaluri saplementacia 30-mg/dReSi rkiniT mTeli orsulobis periodSi. igive rekomendacias iZleva amerikis pediatriis akademia, amerikis ginekologTa koleji (A);
janmo rekomendacias iZleva Catardes universaluri prevencia rkinis miwodebiT orsulebSi, meZuZur qalebSi da dabali woniT dabadebul bavSvebSi (A).
7. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli
- `anemiis marTva pirvelad jandacvaSi~.
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B12-deficituri anemia
(protokoli)
1. daavadebis / problemis ganmarteba
B12–deficituri anemia xasiaTdeba megaloblasturi tipis sisxlwarmoqmniT da manifestirdeba nevrologiuri, fsiqiatriuli da hematologiuri sindromebiT.
sinonimebi: adison-birmeris daavadeba, perniciozuli anemia, avTvisebiani anemia.
terminologia: megaloblastebi, megalocitebi, makrocitebi, eriTrocitebis hiperqromia, retikulocitozi, Sinagani faqtori, kaslis faqtori, antisxeulebi Sinagani faqtoris mimarT, malabsorbcia, araefeqturi eriTropoezi, aqilia, funikuluri mielozi, meTilmalonis mJava, homocisteini, mielodisplazia, mieloproliferacia.
2. sadiagnozo kriteriumebi
damadasturebeli kriteriumebi
1. hemoglobinis Semcireba: mamakaci < 130g/l; qali < 120g/l; orsulebi < 110g/l;
2. hematokriti: mamakaci < 39%; qali < 36%; orsuli < 33%;
3. feradobis maCvenebeli > 1.05;
4. MCV - eriTrocitebis saSualo moculoba (hematokriti % X 10/eriTrocitebis raodenoba (X 106/microL) > 100flL;
5. periferiuli sisxlis nacxSi: makrocitozi – momatebuli diametris eriTrocitebis raodenobis mateba; megalocitebi- didi zomis eriTrocitebi; nefitrofilebis hipersegmentacia; anizocitozi; eriTrocitebis bazofiluri punqtuacia; eriTrocitebSi narCenebi (Jolis sxeulakebi, kebotis rgolebi);
6. retikulocitebi – normaluri an momatebulia hemolizis dros;
7. retikulocituri indeqsi < 2; SeiZleba momatebuli iyos hemolizuri komponentis dros;
8. leikocitebi – leokopenia;
9. Trombocitebi – Trombocitopenia;
10. edsi – SesaZlebelia mateba mZime anemiis dros;
11. vitamini B12 < 148 pmol/l (< 200 pg/ml);
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12. meTilmalonis mJavis raodenoba – momatebulia;
13. homocisteinis raodenoba – momatebulia;
14. antisxeulebi Sinagani faqtoris mimarT: roca B12-is deficiti dadasturebulia es testi gamoiyeneba mizezis dasadgenad (perniciozuli anemia); 50%-iani sensitiuroba, magram maRali specifikuroba;
15. antisxeulebi kuWis parietaluri ujredebis mimarT: roca B12-is deficiti dadasturebulia es testi gamoiyeneba mizezis dasadgenad (perniciozuli anemia); 85%-iani sensitiuroba, magram dabali specifikuroba; momatebulia agreTve atrofiuli gastritis dros;
16. Silingis testi: roca B12-is deficiti dadasturebulia es testi gamoiyeneba mizezis dasadgenad (Sewovis Sefaseba); pacints aZleven niSandebul vitamin B12-s peroralurad. ramodenime saaTis Semdeg keTdeba 1000mkg vitamini B12 i/m depos gajerebisaTvis. 24-sT SardSi radioaqtiuri vitamin B12 eqskreciis daqveiTeba miuTiTebs nawlavebSi Sewovis darRvevaze;
17. holotranskobalamini: axali testi, romelic jerjerobiT farTod ar gamoiyeneba; dabali done vitamin B12-s SratSi dabal/normalur koncentraciasTan erTad adasturebs malabsorbcias;
18. arapirdapiri hiperbilirubinemia: hemolizuri komponentis arsebobis dros;
19. Sardis saerTo analizi: momatebuli urobilini hemolizuri komponentis arsebobis dros;
20. Zvlis tvinis punqcia: gamoiyeneba iSviaTad dif.diagnostikuri sirTuleebis dros mkurnalobis dawyebamde; axasiaTebs eriTroiduli Stos gaRizianeba, megaloblasturi tipis sisxlwarmoqmna, nacxi iRebs tipiur fers - “lurji Zvlis tvini”;
21. ganavlis analizi helminTebze.
3. simptomebi da niSnebi
Civilebi da fizikuri kvleva:
Civilebi: sisuste, Sromis unaris daqveiTeba, gulis friali, Tavis tkivili/Tavbruxveva, tinitusi, depresiuli simptomatika, paresTezia, sisuste qvemo kidurebSi, enis wva;
fizikuri gamokvlevis Sedegebi:
fizikuri gamokvlevis Sedegad gamovlenili niSnebi ganpirobebulia hemoliziT, saWmlis momnelebeli sistemis lorwovani garsis
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atrofiul-wylulovani cvlilebebiT, fsiqiatriuli da nevrologiuri sindromebiT;
hemolozi:
o kanis moyviTalo elferi;
o splenomegalia (iSviaTad).
saWmlis momnelebeli sistemis lorwovanis atrofiul-wylulovani cvlilebebi:
o atrofiuli glositi, wiTeli, “laqiseburi ena”;
o anguluri qeiliti;
o profaringealuri wylulebi;
o atrofiuli gastroenterokoliti.
fsiqiatriuli sindromi:
o gaRizianeba;
o depresia;
o fsiqozi;
o demencia.
nevrologiuri sindromi (zurgis tvinis dazianeba)
o paresTezia;
o ataqsia;
o mxedvelobis darRveva;
o sisuste qvemo kidurebSi;
o kunTebis atrofia.
4. instrumentul-laboratoriuli gamokvlevebi da
specialistTa konsultaciebi
instrumentul-laboratoriuli gamokvlevebi aucileblad unda moicavdes detalur hematologiur kvlevas, romelic moicavs Semdegs: hemoglobini, hematokriti, feradobis maCvenebeli, eriTrocitebis saSualo moculoba, eriTrocitebis morfologia (didi mniSvneloba aqvs makricitebis arsebobis dadgenas), leikocitebi, Trombocitebi, eds-i.
aRniSnulTan erTad, saWiroebisas tardeba Semdegi instrumentul-laboratoriuli kvlevebi:
bilirubini: arapirdapiri hiperbilirubinemia hemolizis komponentis arsebobis dros;
17
Sardis saerTo analizi: momatebuli urobilini hemolizuri komponentis arsebobis dros;
ezofagogastroduodenoskopia: atrofiuli gastroduodeniti, ezofagiti;
muclis Rrus organoebis ultrasonografiuli kvleva: SesaZlebelia dafiqsirdes msubuqi hepato/splenomegalia;
ekg – ST segmentisa da T kbilis araspecifiuri cvlilebebi.
momdevno gverdze sqemis saxiT (sqema 1) naCvenebia makricituli anemiis gamokvlevis algoriTmi.
B-12 anemiis kvlevis algoriTmi mocemulia sqemaze 2.
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sqema #1 makrocitozi
CRI<2 CRI>2
megaloblastebi periferiaze (neitrofilebis hipersegmentacia)
aris ar aris
cru makrocitozi?
ganmeorebiTi kvleva
gansazRvre B12 da folis mJava SratSi
B12 ↓
B12-N, foli-umis
mJava ↓
B12-N, foli-umis
mJava-N
B12-defic
anemia
Silingis testi (etiologiis dasadgenad)
folis
mJava
defic. anemia
gansazRvre meTilmalonis mJava SratSi da/an SratSi
gamoricxe medikamentis efeqti
norma momatebulia
Zvlis tvinis biofsia (mielodisplaziis
gamosaricxad) B12-deficituri
anemia
RviZlis funqciuri sinjebi (RviZlis
paTologiis gamosaricxad)
farisebri jirkvlis
hormonebi (f/j-is paTologiis
gamosaricxad)
daunis sindromi
19
B12-deficituri anemia
pacienti iRebs medikamentebs: aminosalicilis mJava, kalciumis arxis
antagonistebi, askorbinis mJava (megadozebi), kolxicini, metformini.
gastroskopia antisxeulebis gansazRvra Sinagani faqtoris mimarT
dadebiTi uaryofiTi
perniciozuli
anemia
referali gastroenterologTan
atrofiuli
gastritis
(aqlorhidria)
sqema #2
ki Tu SesaZlebelia, wamali unda moixsnas an moxdes koreqcia
vitamin B12-iT
ara
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5. mkurnaloba
mkurnalobis principebi:
yvela pacients (simptomuri Tu asiptomuri) dadasturebuli B12-deficituri anemiis SemTxvevaSi utardeba mkurnaloba;
mkurnaloba tardeba rogorc wesi oqsikobalaminiT, romelic ukeT aiTviseba organizmis mier vidre ciankobalamini;
mkurnaloba oraluri preparatiT tardeba mxolod im SemTxvevaSi Tu anemia gamowveulia dieturi faqtoriT (arasakmarisi kveba, mkacri vegetarianuli dieta); yvela sxva SemTxvevaSi mkurnaloba tardeba saineqcio formebiT;
mkurnalobis sqema nevrologiuri simptomatikis arsebobisas: oqsikobalamini 1mg (1000 mkg) i/m yovel meore dRes nevrologiuri gaumjobesebis dadebiTi dinamikis Sewyvetamde; Semdeg igive doza TveSi erTxel mTeli cxovrebis manZilze;
mkurnalobis sqema nevrologiuri simptomatikis gareSe: oqsikobalamini 1mg (1000 mkg) i/m, yovel meore dRes 2-kviris manZilze; SemanarCunebeli Terapia tardeba igive doziT 3-TveSi erTxel mTeli cxovrebis manZilze;
SemanarCunebeli Terapia SeiZleba Sewydes rodesac anemia dakavSirebulia B12-s sakvebiT arasakmaris miRebasTan (anemiis koreqciis da kvebis reJimis mowesrigebis Semdeg);
vegetarianelebSi SemanarCunebeli Terapia tardeba mTeli cxovrebis manZilze; SesaZlebelia B12-s oraluri formis gamoyeneba;
mkurnalobis garTulebebi Zalze iSviaTia: adgilobrivi reaqcia, alergiuli reaqcia, faRaraTi, hipernatriemia;
eriTrocituli masis gadasxma xdeba mkacri CvenebiT: mkveTrad gamoxatuli anemia hemodinamiuri arastabilurobiT; anemiuri encefalopaTia (stacionarSi);
monitoringi: pirveli sakontrolo sisxlis analizi – 10 dReSi (retikulocituri krizis dadastureba); Semdeg 2 TveSi (sisxlis suraTis normalizacia).
21
6. referali:
referali hematologTan saWiroa Semdeg SemTxvevebSi:
pacients aReniSneba nevrologiuri simptomatika;
pacienti orsulia;
mZime mimdinareoba (hemodinamiuri arastabiluroba);
mkurnalobis araefeqturoba;
miuxedavad Catarebuli kvlevebisa etiologia ucnobia (saWiroa Zvlis tvinis punqcia/biofsia).
7. meTvalyureoba, reabilitacia,da prevencia
sisxlis analizis Catarebis sqema:
o 0, 1-kvira, 2-kvira, 2-Tve;
o sisxlis maCveneblebis normalizaciis Semdeg weliwadSi 1-
xel;
anemiis prevencia:
o dRe-Ramuri moTxovnileba B12-ze Seadgens 2mkg-s;
o ZiriTad wyaros warmoadgens xorci da rZis produqtebi;
o profilaqtikuri mkurnaloba (B12-is damateba, polivitaminuri preparatebi) tardeba risk-jgufSi: (1) moxucebi; (2) pirebi, romlebic xangrZlivad iReben B12-s Sewovaze da metabolizmze moqmed preparatebs; (3) vegetarianelebi;( 4) pirebi qronikuli gastrointestinuri paTologiiT (malabsorbciis sindromi);
kuWis kibos prevencia:
o perniciozuli anemiis dros 2-3-jer ar momatebuli kuWis
kibos ganviTarebis riski; aseTi pacientebi saWiroeben
endoskopiur kontrols.
8. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli
- `anemiis marTva pirvelad jandacvaSi~.
22
foliumis mJavas deficitiT gamowveuli anemia
(protokoli)
1. daavadebis / problemis ganmarteba
foliumis mJavas deficitiT gamowveuli anemia xasiaTdeba megaloblasturi tipis sisxlwarmoqmniT da manifestirdeba ZiriTadad anemiuri sindromebiT.
sinonimebi: folat-deficituri anemia.
terminologia: megaloblastebi, megalocitebi, makrocitebi, eriTrocitebis hiperqromia, retikulocitozi, malabsorbcia, araefeqturi eriTropoezi, aqilia, meTilmalonis mJava, homocisteini, mielodisplazia, mieloproliferacia, neitrofilebis hipersegmentacia.
2. sadiagnozo kriteriumebi
damadasturebeli kriteriumebi
1. hemoglobinis Semcireba: mamakaci < 130g/l; qali < 120g/l; orsulebi < 110g/l;
2. hematokriti: mamakaci < 39%; qali < 36%; orsuli < 33%;
3. feradobis maCvenebeli > 1.05;
4. MCV - eriTrocitebis saSualo moculoba (hematokriti % X
10/eriTrocitebis raodenoba (X 10^6/microL) > 100fl;L
5. periferiuli sisxlis nacxSi: makrocitozi - momatebuli diametris eriTrocitebis raodenobis mateba; megalocitebi - didi zomis eriTrocitebi; nefitrofilebis hipersegmentacia; anizocitozi; eriTrocitebis bazofiluri punqtuacia; eriTrocitebSi narCenebi (Jolis sxeulakebi, kebotis rgolebi);
6. retikulocitebi – normaluri an momatebulia hemolizis dros;
7. retikulocituri indeqsi < 2; SeiZleba momatebuli iyos hemolizuri komponentis dros;
8. leikocitebi – leokopenia;
9. Trombocitebi – Trombocitopenia;
10. edsi – SesaZlebelia mateba mZime anemiis dros;
11. vitamini B12 SratSi – norma;
12. folis mJavas koncentracia eriTrocitebSi – dabali;
23
13. meTilmalonis mJavis raodenoba – normaluri;
14. homocisteinis raodenoba – momatebulia;
15. arapirdapiri hiperbilirubinemia – hemolizuri komponentis arsebobis dros;
16. Sardis saerTo analizi – momatebuli urobilini hemolizuri komponentis arsebobis dros;
17. Zvlis tvinis punqcia – gamoiyeneba iSviaTad difdiagnostikuri sirTuleebis dros mkurnalobis dawyebamde; axasiaTebs eriTroiduli Stos gaRizianeba, megaloblasturi tipis sisxlwarmoqmna.
3. simptomebi da niSnebi
damadasturebeli
Civilebi:
sisuste;
Sromis unaris daqveiTeba;
gulis friali;
Tavis tkivili/Tavbruxveva;
tinitusi.
fizikuri kvleva:
kanis da lorwovanis sifermkrTale moyviaTalo elferiT;
anguluri qeiliti;
trofikuli darRvevebi (Tmebi, kani, frCxilebi);
taqikardia, sistoluri Suili gulze, gulis ukmarisoba (mZime da xangrZlivi mimdinareobis dros).
24
4. instrumentul-laboratoriuli gamokvlevebi da
specialistTa konsultaciebi
instrumentul-laboratoriuli gamokvlevebi aucileblad unda moicavdes detalur hematologiur kvlevas, romelic moicavs Semdegs: hemoglobini, hematokriti, feradobis maCvenebeli, eriTrocitebis saSualo moculoba, eriTrocitebis morfologia (didi mniSvneloba aqvs makricitebis arsebobis dadgenas), leikocitebi, Trombocitebi, eds-i.
momdevno gverdze sqemis saxiT (sqema 1) naCvenebia makricituli anemiis gamokvlevis algoriTmi.
kvlevis algoriTmi foliumis mJavis deficitis arsebobisas mocemulia sqemaze 2.
25
sqema #1 makrocitozi
CRI<2 CRI>2
megaloblastebi periferiaze (neitrofilebis hipersegmentacia)
aris ar aris
cru makrocitozi?
ganmeorebiTi kvleva
gansazRvre B12 da folis mJava SratSi
B12 ↓
B12-N, foli-umis
mJava ↓
B12-N, foli-umis
mJava-N
B12-defic
anemia
Silingis testi (etiologiis dasadgenad)
folis
mJava
defic. anemia
gansazRvre meTilmalonis mJava SratSi da/an SratSi
gamoricxe medikamentis efeqti
norma momatebulia
Zvlis tvinis biofsia (mielodisplaziis
gamosaricxad) B12-deficituri
anemia
RviZlis funqciuri sinjebi (RviZlis
paTologiis gamosaricxad)
farisebri jirkvlis
hormonebi (f/j-is paTologiis
gamosaricxad)
daunis sindromi
26
foliumis mJavas deficiti
pacienti iRebs medikamentebs: fenitoini, barbituratebi
(Sewovis darRveva), metotreqsati, pentamidini, trimetoprimi, triamtereni
(vitaminis metabolizmis darRveva).
anti-tTG
dadebiTi uaryofiTi, magram maRali klinikuri albaToba
celiakia
sqema #2
ki
Tu SesaZlebelia, wamali unda moixsnas an moxdes koreqcia foliumis mJavas
preparatiT
ara
malnutricia
alkoholizmi
uaryofiTi
referali gastroenterologTan da wvrili nawlavis biofsia
mkurnaloba foliumis
mJavas preparatiT
27
5. mkurnaloba
mkurnalobis principebi:
mkurnalobis dawyebamde unda gamoiricxos Tamxmlebi B12-deficituri anemia! B12-deficituri anemiis pirobebSi foliumis mJavas daniSvna auaresebs pacientis mdgomareobas (B12-s deficitis gaRrmaveba); Tu dif.diagnostika SeuZlebelia (pirobebis ararseboba) unda Catardes kombinirebuli Terapia (foliumis mJava da B12);
pacients eniSneba 5mg foliumis mJava 4 Tvis ganmavlobaSi;
SemanarCunebeli Terapia, rogorc wesi, ar aris saWiro; tardeba mxolod im SemTxvevaSi Tu etiologiuri faqtoris koregireba SeuZlebelia;
sakontrolo sisxlis analizi: 2-kviraSi (retikulocituli krizi) da 2 TveSi (suraTis normalizacia);
eriTrocituli masis gadasxma tardeba mxolod sasicocxlo CvenebiT.
6. referali
referali hematologTan saWiroa Semdeg SemTxvevebSi:
1. orsuli pacienti;
2. mZime mimdinareoba (hemodinamiuri arastabiluroba);
3. mkurnalobis araefeqturoba;
4. miuxedavad Catarebuli kvlevebisa etiologia ucnobia (saWiroa Zvlis tvinis punqcia/biofsia)
7. reabilitacia / meTvalyureoba
profilaqtikuri mkurnaloba (foliumis mJavas damateba, polivitaminuri preparati) tardeba risk-jgufSi: (1) moxucebi; (2) pirebi, romlebic xangrZlivad iReben foliumis mJavas Sewovaze da metabolizmze moqmed preparatebs; (3) pirebi arasrulfasovani kvebiT; 4) pirebi qronikuli gastrointestinuri paTologiiT (malabsorbciis sindromi); (5) orsulebi da meZuZurebi.
nayofis nervuli sistemis Tandayolili paTologiis prevenciis TvalsazrisiT rekomendebulia orsulobisas folis mJavas miReba; optimaluri doza gaurkvevelia.
28
qalebma, romlebmac wina orsulobidan gaaCines bavSvi nervuli sistemis paTologiiT, unda miiRon foliumis mJava 4mg/dReSi orsulobamde minimum 1 TviT adre da mTeli pirveli trimestris ganmavlobaSi.
qalebma, romlebic iReben karbamazepins an valproats, da qalebma pregestaciuri diabetiT unda miiRon foliumis mJava 4mg/dReSi orsulobamde minimum 1 TviT adre da mTeli pirveli trimestris ganmavlobaSi.
reproduqciuli asakis qalebma unda miiRon folis mJava 0.4-0.8 mg/dReSi.
9. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli
- `anemiis marTva pirvelad jandacvaSi~.
