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danarTi 1

anemiis marTva pirvelad

jandacvaSi

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

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

gaidlainSi gamoyenebuli Semoklebebi

janmo – jandacvis msoflios organizacia

rda – rkinadeficituri anemia

qda – qronikul daavadebasTan asocirebuli anemia

ldh – laqtatdehidrogenaza

asas – arasteroiduli anTebis sawinaaRmdego saSualebebi

mmm – meTilmalonis mJava

Hb – hemoglobini

Hct – hematokriti

MCV – eriTrocitebis saSualo moculoba

MCHC – hemoglobinis saSualo koncentracia

TIBC – rkinis totaluri (saerTo) SekavSirebis unari

Ret – retikulocitebi

RI – retikulocituri indeqsi

RDW – eriTrocitebis gadanawilebis farTi

HELLP – hemolitiko-uremiuli sindromi

sTfR – xsnadi transferin receptori

hsCRP – maRalsensitiuri c-reaqtiuli cila

Anti-TTG – antisxeulebi qsovilovani transglutaminazas

mimarT

1. daavadebis ganmarteba, sinonimebi, klasifikacia da

terminologia

ganmarteba

anemia ganimarteba rogorc eriTrocitebis arasakmirisi raodenoba periferiuli qsovilebis JangbadiT uzruvelyofisaTvis.

praqtikuli miznebisTvis anemiis gansazRvra xdeba Semdegi sami parametridan nebismieris daqveiTebis safuZvelze:

a) hemoglobini (Hb);

b) hematokriti (Hct), romelsac daleqili eriTrocitebis moculobasac uwodeben (PCV an vPRC);

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g) eriTrocitebis raodenoba.

jandacvis msoflio organizaciis (janmo) mixedviT anemia ganimarteba hemoglobinis da hematokritis safuZvelze Semdegi kriteriumebis gamoyenebiT:

kaci: Hb<130g/L (<13 g/dL); Hct<39% (<0.39)

qali: Hb<120g/L (<12 g/dL); Hct<37% (<0.37)

orsuli: Hb<110g/L (<11 g/dL); Hct<35% (<0.35)

klasifikacia

anemiis klasifikacia SesaZlebelia ganviTarebis meqanizmis (daqveiTebuli warmoqmna, gaZlierebuli daSla-dakargva; ix. Tavi etiopaTogenezi) an eriTrocitebis moculobis mixedviT – mikrocituli, makrocituli, normocituli (cxrili. #1).

cxrili #1

anemiebis klasifikacia

anemiebis klasifikacia eriTrocitebis moculobis safuZvelze

mikrocituli: o rkinis deficiti; o Talasemia; o qronikuli daavadebebis dros ganviTarebuli anemia;

makrocituli: o megaloblasturi:

B12 vitaminis deficiti; foliumis deficiti;

o aramegaloblasturi; o mielodisplacia, qimioTerapia; o RviZlis daavadeba; o gazrdili retikulocitozi; o miqsedema;

normocituli o mravali mizezi.

2. epidemiologia

anemia yvelaze gavrcelebuli problemaa eqimis, maT Soris, ojaxis eqimis praqtikaSi. anemiis yvelaze xSiri formaa rkinadeficituri anemia.

rkinadeficituri anemia:

rkinadeficituri anemia erT-erTi yvelaze farTod gavrcelebuli paTologiaa mTel msoflioSi;

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inglisSi mamakacTa 3%-s da qalTa 8%-s aReniSneba rkinadeficituri anemia;

aSS daavadebaTa kontrolis centris monacemebis mixedviT mamakcTa (> 20weli) da qalTa (> 50 weli) 2%-s aReniSneba rkinadeficituri anemia;

rkinadeficituri anemia ufro xSiria premenopauzur qalebSi;

aSS daavadebaTa kontrolis centris monacemebis mixedviT araorsul qalTa 11%-s (16-49 wlamde) aReniSneba rkinis deficiti; aqedan 3-5%-s rkinadeficituri anemia;

Raribi ojaxidan orsul qalebSi (aSS) rkinadeficituri anemiis sixSire pirvel, meore da mesame trimestrSi Seadgens 9%, 14% da 37%-s Sesabamisad;

xelovnur kvebaze (arafortificirebuli formula, Zroxis rZe) myof Cvil bavSvebSi rkinadeficituri anemiis ganviTarebis riski Seadgens 20%-40%-s;

sazogadoebrivi jandacvis departamentis monacemebiT 2006 wels rkinadeficituri anemiiT avadobam saqarTveloSi Seadgina orsul qalebSi-66%, reproduqciuli asakis (17-45ww) qalebSi-31%, mozrdil (14-16ww) gogonebSi – 24%.

B12-deficituri anemia:

fremingemis kvlevis mixedviT B12-deficituri anemiis ganviTarebis riskis qveS imyofeba aSS-is zrdasruli mosaxleobis 39% (kriteriumi: Sratis B12 < 258 pmol/l; < 350 pg/ml);

daavadebis gavrcelebis sixSire asakovnebSi Seadgens 5-15%-s;

daavadeba ufro xSiria ganviTarebad qveynebSi da vegetarianelebSi.

foliumdeficituri anemia:

daavadebis gavrcelebis sixSire 65-74 asakovan jgufSi Seadgens daaxloebiT 5%-s (28);

amave kvlebis mixedviT, B12-deficituri anemiis arsebobisas Tanmxlebi foliumis mJavas deficiti Seadgens 10%;

daavadeba ufro xSiria vegetarianelebSi, indo-CineTis mosaxleobaSi (xorcis sakvebad naklebad moxmareba da bostneulis zedmetad Termuli gadamuSaveba);

daavadebis risk-jgufs miekuTvneba:

o moxucebi; o pirebi, romlebic xangrZlivad iReben foliumis mJavas Sewovaze

da metabolizmze moqmed preparatebs; 3) vegetarianelebi; o pirebi qronikuli gastrointestinuri paTologiiT

(malabsorbciis sindromi); o orsulebi; o qalebi laqtaciis periodSi.

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prognozi

prognozi damokidebulia anemiis gamomwvev daavadebaze.

rkinadeficituri anemiis adekvaturi mkurnalobisas prognozi keTilsaimedoa. mwvave posthemoragiuli anemiis dros prognozi damokidebulia dakarguli sisxlis raodenobasa da siswrafeze (ra drois ganmavlobaSi moxda sisxlis dakargva). Tu rikinis deficiti meoreulia (simsivne, qronikuli daavadeba) prognozs ganapirobebs ZiriTadi daavadeba.

B12-deficituri anemiis drouli diagnostikisa da adekvaturi mkurnalobis SemTxvevaSi prognozi keTilsaimedoa. spinaluri degeneraciis gamovlinebis SemTxvevaSi klinikuri suraTis sruli alageba iSviaTad xdeba. demencia, periferiuli neiropaTia, depresia da sxva neirofsiqiatriuli simptomatika umjobesdeba adekvaturi mkurnalobis fonze, Tumca sruli gajansaReba, rogorc wesi, SeuZlebelia.

foliumdeficituri anemiis adekvaturi mkurnalobisas prognozi keTilsaimedoa. Tu foliumdeficituri anemia meoreulia prognozi, aseve ZiriTad daavadebazea damokidebuli (malabsorbcia, qronikuli daavadeba).

3. etiopaTogenezi

anemiis ganviTarebas iwvevs disbalansi eriTrocitebis warmoqmnasa da mis daSlas an dakargvas Soris. roca iSleba/ikargeba ufro meti eriTrociti, vidre warmoiqmneba viTardeba anemia. aRniSnulis mizezi SeiZleba iyos gaZlierebuli daSla-dakargva, daqveiTebuli warmoqmna da orive erTad.

anemiebis ganviTarebis paTofiziologiuri meqanizmebi Sejamebulia cxrilSi #2.

cxrili #2

anemiebis ganviTareba

anemiebis ganviTarebis paTofiziologiuri meqanizmebi

daqveiTebuli warmoqna:

o hemoglobinis sinTezis darRveva: rkinis deficiti, Talasemia, anemia qronikuli daavadebebi;

o dnm-s sinTezis darRveva: megaloblasturi anemia – B12 vitaminis deficiti an foliumis mJavas deficiti;

o Rerovani ujredebis dazianeba: aplaziuri anemia, mieloproliferaciuli leikemia;

o Zvlis tvinis infiltracia: karcinoma, limfoma;

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o erTirocitebis aplazia;

gaZlierebuli daSla-dakargva:

o sisxldena;

o hemolizi (Sinagani);

membranis dazianeba: memkvidreobiTi sferocitozi, elifsocitozi;

hemoglobinis dazianeba: namglisebrujredovani anemia, arastabiluri hemoglobini;

glikolizi: piruvatkinazas deficiti da sxv.;

oqsidaciis darRveva: gulokozo-6-fosfatdehidrogenazas deficiti;

o hemolizi (garegani);

imunuri: sicxis antisxeulebi, sicivis antisxeulebi;

mikoangiopaTiuri: Trombozuli Trombocitopeniuli purpura, hemolizur-uremiuli sindromi, gulis meqanikuri sarqvlebi, paravalvuluri Jonva;

infeqcia: klostridia;

hipersplenizmi;

zemoaRniSnulTagan yvelaze xSirad anemiis ganviTarebis meqanizmia rkinis deficiti, B12 vitaminis deficiti an foliumis mJavas deficiti.

rkinadeficituri anemiis paTogenezi:

rkinis deficitis ganviTarebis mizezebi mravalgvaria, romelTa CamonaTvali mocemulia cxrilSi #3.

cxrili #3

rkinadeficituri anemiis mizezebi

rkinis nakleboba sakvebSi;

daqveiTebuli Sewova: celiakia, gastreqtomia, nawlavis rezeqcia da sxva;

gaZlierebuli moxmareba:

o orsuloba;

o laqtacia;

sisxlis kargva:

o kuW-nawlavis traqtidan;

o menstrualuri;

o sisxlis donorobasTan dakavSirebuli;

hemoglobinuria;

rkinis sekvestracia:

o filtvebis hemosiderozi.

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cxrilSi #4 mocemulia rkinadeficituri anemiis sxvadasxva mizezebis sixSire.

cxrili #4

rkinadeficituri anemiis ZiriTadi mizezebis sixSire

rkinadeficituri anemiis mizezebi sixSire

sisxlis kargva

o asas-bis gamoyenebis Sedegad 10-15 %

o nawlavis karcinoma 5-10 %

o kuWis karcinoma 5 %

o wylulovani daavadeba 5 %

o angiodisplazia 5 %

o ezofagiti 2-4 %

o ezofaguri karcinoma 1-2 %

o kuWis vaskuluri eqtazia 1-2 %

o wvrili nawlavis simsivne 1-2 %

o Ancylostoma duodenale < 1 %

o menstruacia 20-30 %

o sisxlis donori 5 %

o hematuria 1 %

o epistaqsisi < 1 %

malabsorbciis sindromi

o celiakia; 4-6 %

o gastreqtomia; < 5 %

o kolonizacia Helicobacter pylori-iT; < 5 %

o nawlavebis rezeqcia; < 1 %

o disbaqteriozi. < 1 %

rkinadeficituri anemiis ganviTarebis risk-faqtorebi:

orsuloba: dRiuri kargva Seadgens 2.5 mg-s elementur rkinas dReSi; jamSi 9-Tvis manZilze es cifri Seadgens 680 mg-s;

vegetarianelebi: mkacr vegetarianelebSi rkinis deficitis sixSire (asaki 19-50) Seadgens 40%-s;

menoragia;

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glisturi invazia;

hemodializi: sisxlis kargva proceduris Catarebis dros da rkinis darRveuli absorbcia;

celiakia: subklinikuri mimdinareobisas rkinadeficituri anemiis ganviTarebis sixSire Seadgens 46%-s; xSirad rkinadeficituri anemia aris celiakiis erTaderTi gamovlineba;

gastreqtomia /aqlorhidria;

medikamenturi: mag., asas-is gamoyeneba;

dabali socialur-ekonomikuri statusi postpartul periodSi;

Warbi wona da simsuqne bavSvobaSi da mozrdilobaSi;

Helicobacter pylori-iT infeqcia: rkinadeficituri anemiis ganviTarebis sixSire imatebs 40%-iT;

afrikuli rasis qalebi: rkinadeficituri anemiis ganviTarebis sixSire TeTri rasis qalebSi Seadgens daaxloebiT 7%-s, maSin rodesac es maCvenebeli afrikuli rasis qalebSi Seadgens 25%-s;

B12-deficituri anemiis paTogenezi:

qvemoT mocemulia organizmis mier B12 vitaminis Sewovisa da aTvisebis etapebi. am rgolebidan nebismieris moSla iwvevs B12-deficitur anemias.

B12 vitaminis gamonTavisufleba sakvebidan (xorci, Sinauri frinvelis xorci, rZis nawarmi) xdeba kuWis SigTavsSi arsebuli mJavas meSveobiT;

Tavisufali vitamini B12 uerTdeba Sinagan faqtors, romelic sekretirdeba kuWis fundaluri nawilis pariesuli ujredebis mier;

kompleqsi B12-Sinagani faqtori TeZos nawlavis terminalur nawilSi endocitozis meSveobiT uerTdeba transkobalamins;

axladwarmoqmnili kopleqsi transkobalamini-B12 (holotrans-kobalamini) Seiwoveba sisxlSi Semdgomi moxmarebisTvis;

organizmSi vitamini B12-is maragi normaSi Seadgens 2-3 mg-s. es raodenoba sakmarisia moxmarebisTvis 2-4 wlis manZilze. Sesabamisad, anemia viTardeba etiologiri faqtorebis xangrZlivi arsebobis SemTxvevaSi.

foliumdeficituri anemiis paTogenezi:

foliumis mJavas organizmi iRebs ZiriTadad sakvebidan (RviZli, soko, mwvane salaTi, axali xili, safuari);

foliumis mJava Termolabiluri vitaminia; Termuli damuSavebisas folatebis 50-70% iSleba;

foliumis mJavaze dRe-Ramuri moTxovnileba Seadgens daaxloebiT 200mkg-s (metia orsulobisas, laqtaciisas);

vitaminis maragi organizms hyofnis mxolod 4 Tvis manZilze;

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vitaminis Sewova xdeba wvrili nawlavis proqsimalur nawilSi;

sakvebSi arsebuli folatebi iSleba monoglutamatebad nerwyvis da wvrili newlavis fermentebis meSveobiT; Semdeg ferment dehidrofolatreduqtazas zemoqmedebiT warmoiqmneba 5-meTiltetrahidrofolati, romelic Seiwoveba sisxlSi, sadac is ukavSirdeba cilebs da transportirdeba RviZlSi da Zvlis tvinSi;

foliumis mJavas deficitis pirobebSi irRveva nukleinis mJavas sinTezi sisxlmbad ujredebSi da viTardeba megaloblasturi anemia.

4. klinikuri simptomatika

simptomebi da niSnebi

anemiis klinikuri suraTi moicavs sxvadasxva etiopaTogeneziT ganpirobebuli anemiebisaTvis damaxasiaTebel saerTo klinikur suraTs – anemiur sindroms da ama Tu im formis anemiisaTvis specifikur simptomebsa da niSnebs, rac anemiis gamomwvevi daavadebiT aris ganpirobebuli.

anemiuri sindromi

Civilebi (simptomebi):

o sisuste;

o haeris ukmarisoba, qoSini;

o gulis friali;

o Tavis tkivili da Tavbruxveva;

o tinitusi;

o gemovnebis gaukuRmarTeba.

niSnebi (fizikuri kvlevis Sedegebi):

o kanis da lorwovani garsebis sifermkrTale;

o atrofiuli glositi da anguluri qeiliti;

o trofikuli darRvevebi (Tmebi, kani, frCxilebi);

o taqikardia, sistoluri Suili gulze, gulis ukmarisoba (mZime da xangrZlivi mimdinareobis dros);

o splenomegalia.

anemiis formebi

anemiebis mravali formidan (romlebic anemiis mizezes Seesabameba) winamdebare gaidlainSi ZiriTadad ganxilulia yvelaze xSiri formebi:

rkinis deficitiT gamowveuli anemia – rkinadeficituri anemia;

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B12 vitaminis deficitiT gamowveuli anemia – B12-deficituri anemia;

foliumis mJavas deficitiT gamowveuli anemia –foliumdeficituri anemia;

5. daavadebis diagnozi

sadiagnozo kriteriumebi

anemiis arsebobaze miuTiTebs damaxasiaTebeli Civilebi da niSnebi, romelic gamokiTxviTa da fizikuri gasinjviT dgindeba (ix. Tavi klinikuri simptomatika).

anemiis sadiagnozo laboratoriuli kriteriumebia:

kaci: Hb<130g/L (<13 g/dL); Hct<39% (<0.39)

qali: Hb<120g/L (<12 g/dL); Hct<37% (<0.37)

orsuli: Hb<110g/L (<11 g/dL); Hct<35% (<0.35)

diferenciuli diagnozi

anamnezi

anamnezuri monacemebis Segrovebas garkveuli mniSvneloba aqvs anemiis etiologiis dadgenisa da Semdgomi diagnostikuri ZiebisaTvis (cxrili #5).

cxrili #5

anamnezi da anemiis SesaZlo etiologia

anamnezi anemiis SesaZlo etiologia

normaluri sisxlis saerTo analizi warsulSi

naklebad savaraudoa Tandayolili paTologia

anemia cnobilia bavSvobis asakidan

hemoglobinopaTia, Tandayolili/SeZenili hemolizuri anemia, Zvlis tvinis hipoplazia

spleneqtomia,

naRvlkenWovani daavadeba, siyviTle

qronikuli hemolizuri anemia,

RviZlis paTologia

spleneqtomia,

naRvlkenWovani daavadeba, siyviTle - (ojaxuri anamnezi)

Tandayolili hemolizuri anemia, hemoglobinopaTia

kvebiTi deficiti, alkoholizmi Zvlis tvinis hipoplazia,

B12/folis mJavas deficiti

wylulovani daavadeba, arasteroidebis gamoyeneba, reqtaluri sisxldena, menometroragia, mravlobiTi orsuloba, gastreqtomia, wvrili nawlavis rezeqcia, malabsorbciis sindromi

rkinis deficiti,

B12/folis mJavas deficiti

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anamnezi anemiis SesaZlo etiologia

sistemuri paTologia (revmatologia, imunologia, infeqcia, neoplazia)

qronikuli daavadebis anemia, autoimunuri hemolizuri anemia

Semcirebuli Sardva anemia Tqu-s dros

muqi Sardi intravaskuluri hemolizi

kontaqti toqsinebTan (benzini, tyvia, radiacia)

Zvlis tvinis aplazia/hipoplazia, leikozi, mielodisplazia, tyviiT mowamvla

parkosnebi, dapsoni, naftalini hemolizi (G-6-PD-deficiti)

penicilini, cefalosporini, prokainamidi, qinidini, sulfonamidi

medikamentiT inducirebuli hemolizuri anemia

qimioTerapia (axlo warsulSi) Zvlis tvinis aplazia/hipoplazia, megaloblasturi anemia

qimioTerapia (Soreul warsulSi) Zvlis tvinis hipoplazia, mielodisplazia, mwvave leikemia

qloramfenikoli, oqros preparatebi, sulfonamidebi, anTebis sawinaaRmdego preparatebi

Zvlis tvinis aplazia/hipoplazia

eTanoli, qloramfenikoli

Zvlis tvinis mwvave gardamavali dazianeba

diferenciuli diagnozi laboratoriuli monacemebis safuZvelze

animiis diferenciuli diagnozisaTvis mniSvnelovania Semdegi parametrebis gansazRvra:

retikulocitebis raodenoba;

eriTrocitebis morfologia;

koregirebuli retikulocituri indeqsi (CRI);

eriTrocitebis zoma.

anemiebis diferenciuli diagnozis sqema retikulocitebis raodenobisa da koregirebuli retikulocituri indeqsis (CRI) gamoyenebiT mocemulia sqemaze #1.

eriTrocitebis morfologiis mniSvneloba anemiebis mizezebis diferenciul-sadiagnozo ZiebisaTvis asaxulia cxrilSi #6

anemiebis diferenciuli diagnozis sqema eriTrocitebis zomis safuZvelze mocemulia sqemebze #2 da #3.

diagnostikuri Ziebis rekomendaciebi anemiis calkeuli formisaTvis mocemulia TavSi `anemiis marTva~, romelSic diagnozTan dakavSirebuli rekomendaciebis garda asaxulia mkurnalobis da meTvalyureobis rekomendaciebic.

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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

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cxrili #6

eriTrocitebis morfologia da anemiis mizezebi

eriTrocitebis

morfologia anemiis SesaZlo mizezi

mikrocitebi rda, qronikuli daavadebis anemia, Talasemia, sideroblasturi anemia, tyviiT mowamvla

makrocitebi

B-12/foliumis mJavis deficiti, mielodisplazia (iSviaTad), hipoTireozi, RviZlis paTologia, preparatebis gamoyeneba, romlebic Trgunaven dnm-is sinTezs (qimioTerapiuli preparatebi, imunodepresantebi -azaTioprini, metotreqsati, sulfa preparatebi, zidovudini, hidroqsikarbamidi)

bazofilebis punqtuacia

hemolizi, tyviiT mowamvla, Talasemia

samiznis formis eriTrocitebi

hemoglobonopaTia (Talasemia; hemoglobin-C, D, E, S daavadeba), RviZlis daavadeba, abetalipoproteinemia

mikrosferocitebi autoimunuri hemolizuri anemia, aloimunuri hemolizi, Tandayolili sferocitozi

Sistocitebi da fragmentirebuli eriTrocitebi

Trombuli Trombocitopeniuri purpura, dik-sindromi, vaskuliti, avTvisebiani hipertenzia, eklamfsia, travmuli hemolizi (xelovnuri sarqveli), damwvroba, spleneqtomiis Semdgomi periodi

cremlis formis eriTrocitebi

mielofibrozi, mieloftizi (Zvlis tvinis infiltracia neoplaziuri ujredebiT)

namglis formis eriTrocitebi

β-Talasemia, namglisebrujredovani anemia

akantocitebi RviZlis mZime paTologia, malabsorbciis sindromi

eqinocitebi Tqu, hemolizi (hipomagnemia, hipofosfatemia), piruvatkinazas defifiti, in vitro artefaqti

stomatocitebi alkoholizmi, Tandayolili stomatocitozi

“bite” eriTrocitebi hemolizi (G-6-PD deficiti, arastabiluri hemoglobinis daavadeba)

Jolis sxeulakebi spleneqtomiis Semdgomi periodi, hiposplenizmi

intraeriTrocituli infeqciuri CanarTebi

malaria (paraziti), babeziozi (paraziti), bartonelozi (gramuaryofiTi kokobaqteria)

aglutinirebuli eriTrocitebi

sicivis aglutininis daavadeba, in vitro artefaqti

Rouleaux formation (monetis svetis formis grovebi)

mielomuri daavadeba

14

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

15

sqema #3 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

16

6. anemiebis marTva

winamdebare TavSi asaxulia anemiis sami yvelaze gavrcelebuli formis – rkinadeficituri, B-12-deficituri, foliumdeficituri anemiebis marTvis rekomendaciebi, romelic moicavs:

zust diagnozs – etiologiis dadgenas;

mkurnalobas;

meTvalyureobas.

rkinadeficituri anemiis marTva

etapi I: etiologiis dadgena

anamnezSi:

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 zemoT CamoTvlili kvleva!

17

etapi II: mkurnaloba

o upiratesoba eniWeba samvalentiani rkinis preparatebs; o elementaruli rkinis sadReRamiso doza aris 200 mg, gayofili 2-3

miRebaze; o parenterulad rkinis preparati iniSneba mxolod p/os

autanlobis SemTxvevaSi, malabsorbciisas an mkveTrad

gamoxatuli anemiis dros, rodesac aucilebelia anemiis swrafi

koreqcia (SemdgomSi peroralur formaze gadasvliT);

o B-12 da folis mJava iniSneba mxolod kombinirebuli paTologiis

dros;

mkurnaloba rkinis preparatebiT aucilebelia yvela

SemTxvevaSi, maT Soris daudgeneli etiologiis anemiis dros!

parenteraluri mkurnaloba rkiniT

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);

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).

18

gasaTvaliswinebelia hemotrasfuziasTan dakavSirebuli Semdegi SesaZlo garTulebebi: infeqciuri daavadebebis transmisia, mwvave da Seyovnebuli tipis transfuziuri reaqcia, posttransfuziuri purpura, distres-sindromi.

etapi III: meTvalyureoba

o ganmeorebiTi sisxlis analizi tardeba 2-4 kviraSi; o sakontrolo sisxlis analizi (hemoglobinis normalizaciis

Semdeg) keTdeba 3-TveSi erTxel – pirveli wlis manZilze, SemdgomSi - weliwadSi erTxel;

o mkurnalobis efeqturobis kriteriumebia: retikulocituri krizi, hemoglobinis mateba (0.1-0.2 g/dL dReSi);

o hemoglobinis normalizaciis periodidan mkurnaloba grZeldeba kidev 3-Tve (rkinis depos Seqmnis mizniT).

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).

19

B12-deficituri anemiis marTva

etapi I: etiologiis dadgena

etapi II: zusti diagnozi

arasakmarisi miReba malabsorbcia

malabsorbcia

mkacri

vegetarian-

nuli kveba

kuWis doneze:

perniciozuli anemia; atrofiuli gastriti (aqlorhidria); totaluri gastreqtomia; antisekretoruli preparatebi.

nawlavis doneze:

celiakia; regionuli enteriti; wvrili nawlavis rezeqcia.

konkurentuli STanTqma:

Diphyllobothrium latum; disbaqteriozi.

medikamentebi:

aminosalicilis mJava; kalciumis arxebis antagonistebi; kolxicini; metformini; askorbinis mJava (megadozebi).

B12-deficituri anemia

B12-deficituri anemia

medikamentebis efeqtis gamoricxva

gastroskopia antisxeulebis gansazRvra Sinagani faqtoris mimarT

dadebiTi uaryofiTi

perniciozuli

anemia

referali gastroenterologTan

atrofiuli

gastriti

20

etapi III: mkurnaloba da Semdgomi meTvalyureoba

sawyisi Terapia:

o hidroqsikobalamini 1mg kunTebSi yoveli 2-4 dRes (sul 6 ineqcia) -

nevrologiuri garTulebebis gareSe mimdinare anemiis dros;

o nevrologiuri garTulebebis SemTxvevaSi iniSneba 1mg kunTebSi

yoveli meore dRes (nevrologiuri klinikis gaumjobesebamde);

o peroraluri mkurnaloba SesaZlebelia mxolod im SemTxvevaSi,

rodesac anemia ganpirobebulia miRebis deficitiT (malnutricia).

SemanarCunebeli Terapia:

aramodificirebadi mizezis SemTxvevaSi, mag. perniciozuli anemia, totaluri gastreqtomia, wvrili nawlavis rezeqcia:

o hidroqsikobalamini 1mg kunTebSi yovel 3-TveSi erTxel (mTeli

cxovrebis manZilze);

o mkurnalobis dasawyisSi nevrologiuri klinikis arsebobis

SemTxvevaSi -- hidroqsikobalamini 1mg kunTebSi yovel 2-TveSi

erTxel (mTeli cxovrebis manZilze)

modificirebadi mizezis SemTxvevaSi SemanarCunebeli Terapia ar iniSneba. sisxlis analizis Catarebis sqema:

o 0, 1-kvira, 2-kvira, 2-Tve.

o sisxlis maCveneblebis normalizaciis Semdeg weliwadSi 1-xel

mkurnalobis efeqturobis kriteriumebi:

klinikuri gaumjobeseba 2-3 dReSi

retikulocituri krizi 5-8 dRes

eriTrocitebis raodenoba imatebs 1-kviraSi, normalizacia 4-8

kviraSi

MCV imatebs 3-4 dReSi, normalizacia 25-80 dReSi

hemoglobinis done imatebs 2-3 g/dL-iT yovel 2 kviraSi

leikocitebisa da Trombocitebis raodenoba normalizdeba 7-10

dReSi

M

21

foliumdeficituri anemiis marTva

etapi I: etiologiis dadgena

etapi II: diagnozi

arasakmarsi miReba malabsorbcia darRveuli

metabolizmi

gazrdili

moTxovnileba

malnutricia

dieta xilis da bostneulis dabali SemcvelobiT

B 12-deficituri anemia

medikamentebi:

fenitoini fenobarbitali

celiakia

medikamentebi:

metotreqsati triamtereni pentamidini trimetoprimi

alkoholizmi

laqtacia

orsuloba

folis mJavas deficiti

medikamentis miReba

malnutricia alkoholizmi

ara ki

anti-tTG

celiakia

referali gastroenterologTan da wvrili nawlavis biofsia

moixsnas medikamenti (Tu SesaZlebelia) an koreqcia folis mJavas preparatiT

dadebiTi

22

etapi III: mkurnaloba da Semdgomi meTvalyureoba

o mkurnalobis dawyebamde unda gamoiricxos Tanmxlebi B12-

deficituri anemia;

o pacients eniSneba 5 mg folis mJava 4-TviT (depos Seqmna);

o SemanarCunebeli Terapia rogorc wesi ar aris saWiro, Tu

koregirebulia celiakia da kvebiTi disbalansi;

o sakontrolo sisxlis analizi - 2 kviraSi, 2 TveSi, 4 TveSi da

Semdeg weliwadSi erTxel.

7. eTikur-samarTlebrivi sakiTxebi

miesadageba zogadi eTikuri samarTlebrivi principebi, romelic eqimis praqtikuli saqmianobisa da pacientTan misi urTierTobisTvis aris mniSvnelovani.

8. gaidlainis miRebis xerxi/wyaro

gaidlaini warmoadgens sxvadasxva gaidlainebis (ix. literatura) Sejerebis da adaptaciis Sedegs.

mtkicebulebis done da rekomendaciebis xarisxi

done mtkicebulebis done xaris-

xi rekomendaciis xarisxi

I

Zlieri mtkicebuleba, eyrdnoba minimum erT sistemur mimoxilvas, romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas

A

eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia

II

Zlieri mtkicebuleba, eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas

B

eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia

III klinikuri kvleva randomizaciis gareSe, kohortuli da SemTxveva-kontrolis kvlevebi

C

eyrdnoba III donis mtkicebulebas, SeiZleba CaiTvalos Sesabamisad

23

IV araeqsperimentuli multicentruli kvlevebi

D

eyrdnoba IV da V donis mtkicebulebas, saWiroebs konsesuss

Vა avtoritetul profesionalTa mosazreba

Vბ klinikuri gamocdileba, aRwerilobiTi kvlevebi an eqspertTa angariSi

9. alternatiuli gaidlaini

klinikuri praqtikis erovnuli gaidlainebi:

foliumis mJavas deficitiT gamowveuli anemia;

vitamin B12 deficituri anemia;

rkinadeficituri anemia;

aplaziuri anemia.

10. gamoyenebuli literatura

1. WHO, UNICEF, UNU: Iron-deficiency anemia: assessment, prevention and control;

WHO/IVMD/01.3. Geneva, Switzerland

2. Anemia of chronic disease; NEJM 2005, 352

3. Hoffman: Hematology - Basic Principles and Practice; 2008; 5th edition

4. Harrison’s Principles of Internal Medicine ; 2008; 17th edition

5. BMJ Evidence Center / Best Practice: Anaemia,2009

6. Killip et al; Iron-deficiency anemia; American Family Physician; 2007, 75

7. British Society of Gastroenterology : Guidelines for the management of iron deficiency anaemia;

2005

8. Wintrobe’s Clinical Hematology; Iron deficiency and related disorders; 1999; 979-1010

9. Waldman et al. German vegan study; Ann Nutr Metabol. 2005; 49

10. Halfdanarson et al. Hematologic manifestations of celiac disease; Blood. 2007; 109

11. Bodnar et al. Low income postpartum women are at risk of iron deficiency; J Nutr. 2002; 132

12. Nead et al. Overweight children and adolescent: a risk group for iron deficiency; Pediatrics 2004,

114

13. DuBois et al. Iron-deficiency anemia and Helicobacter pylori infection: a review of the evidence;

Am J Gastroenterol. 2005; 100

14. Cardens et al. Iron deficiency and Helicobacter pylori infection in the United States; Am J

Epidemiol. 2006; 163

15. AHRQ (2006) Recommendation statement: Screening for iron deficiency anemia – including iron

supplementation for children and pregnant women

16. Frewin et al. ABC of clinical haematology: iron deficiency anaemia; BMJ 314; 1997

24

17. McCann et al; An overview of evidence for a causal relation between iron deficiency during

development and deficits in cognitive and behavioral function. Am J Clin Nutr. 2007, 85

18. Gamaldo et al. Restless legs syndrome: a clinical update. Chest. 2006, 130

19. Kaferle et al. Evaluation of macrocytosis , American Family Physician; 2009, February 1, 203-208

20. Recommendations to prevent and control iron deficiency anemia; CDC. 1998

21. CKS: Anaemia,2009

22. rkinadeficituri anemia, klinikuri praqtikis erovnuli rekomendacia (gaidlaini) 2009

23. Refferal advice: a guide to appropriate refferal from general to specialist care; NICE, 2001

24. USPSTF Recommendations, 2008

25. vitamin B12 deficituri anemia, klinikuri praqtikis erovnuli rekomendacia (gaidlaini) 2009

26. Foliumis mJavas deficitiT gamowveuli anemia, klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

2009

27. Dietary Reference Intakes (DRI). Institute of Medicine. Food and Nutrition Board; 1999

28. Clarke et al; Vitamin B12 and folate deficiency in later life, 2004

29. UpToDate: Causes of folate deficiency; 2009

30. Wilson et al; The use of folic acid for the prevention of neural tube defects and other congenital

anomalies. J Obstet Gynaecol Can; 2003

31. Folic acid for the prevention of neural tube defects. American Academy of Pediatrics. Committee

on Genetics. Pediatrics 1999

32. CDC: Use of folic acid for prevention of spina bifida and other neural tube defects: 1983-1991

33. Prevention of neural tube defects: MRC Vitamin Study Research Group. Lancet 1991

11. avtorTa jgufi

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier

avtorebi:

guram kiknaZe (ojaxis eqimi), zaza makariZe (ojaxis eqimi), givi javaSvili (redaqtori).

eqspertebi:

saqarTvelos saojaxo medicinis profesionalTa kavSiri;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti.