Tirkmlebis qronikuli daavadeba

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

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klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`Tirkmlebis qronikuli daavadeba~ miRebulia klinikuri
praqtikis erovnuli rekomendaciebis (gaidlainebi) da
daavadebaTa marTvis saxelmwifo standartebis (protokolebi)
SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2006
wlis 21 noembris #2 sxdomaze da damtkicebulia saqarTvelos
Sromis, janmrTelobisa da socialuri dacvis ministris 2007
wlis 21 dekembris # 364/o brZanebiT.

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 Tirkmlebis qronikuli daavadeba

gamoyenebuli Semoklebebi
DOKI – Dialysis Outcome Quality Initative
NKF – National Kidney Foundation
PARADE – Proteinuria, Albuminuria, Detection and Elimination
Tqd _ Tirkmlebis qronikuli daavadeba
aw _ arteriuli wneva
agf _ angiotenzinis gardamqmneli fermenti
ar _ angiotenzinis receptori
transf. gaj. indeqsi _ transferinis gajerebis indeqsi
i.v. _ intravenurad
hd _ hemodializi
pd _ peritoneuli dializi
TCT – Tirkmlis CanacvlebiTi Terapia
mapd – mudmivi ambulatoriuli peritoneuli dializi
lab _ laboratoriuli cvlilebebi
simp _ klinikuri simptomebi

1. daavadebis definicia

Tqd ewodeba Tirkmlis funqciur an struqturul dazianebas aranakleb 3

Tvis ganmavlobaSi, romlis drosac gorglovani filtraciis siCqare
klebulobs an jer kidev normis farglebSia da romelic
manifestirebulia an paTomorfologiuri monacemebiT an Tirkmlis
dazianebisaTvis damaxasiaTebeli cvlilebebiT sisxlsa da SardSi an
radiologiuri (gamosaxulebiTi) gamokvlevebiT; an Tirkmlis funqciis
iseT daqveiTebas, romlis drosac Tirkmlis gamovlenili an
gamouvleneli dazianebebis fonze gorglovani filtraciis siCqare <
60ml/wT/1,73m2 ara nakleb 3 Tvis ganmavlobaSi.

Tqd iyofa Semdeg stadiebad:

stadia aRweriloba gfs aw, lab, simp.
(ml/wT/1, 73m²)
1 Tirkmlis dazianeba nor- ≥ 90 aw norm / ↑ lab+/-
maluri an gazrdili
gfs-iT
2 Tirkmlis dazianeba 60-89 aw ↑/ lab+/-
normaluri an mcired
daqveiTebuli gfs-iT
3 Tirkmlis dazianeba gfs- 30-59 aw ↑/ lab+ /simp+/-
is saSualo klebiT
4 gfs-is mkveTri vardna 15-29 aw ↑/ lab++ / simp +

5 Tirkmlis ukmarisobis < 15 an aw↑/ lab+++ /simp

terminaluri stadia dializi ++

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2. epidemiologia

saqarTveloSi Tirkmlebis qronikul daavadebiT Sepyrobil pacientTa

raodenobis Sefaseba SesaZlebelia mxolod im pacientTa mixedviT,
romlebic mimarTaven nefrologiur klinikebs. am monacemebze
dayrdnobiT yovelwliurad Tqd Sepyrobil axalgamovlenil pacientTa
raodenoba aRwevs 480-520, rac 1 mln mosaxleze Seadgens 120-160 pacients.
amaTgan Tirkmlebis ukmarisobis terminalur stadiiT Sepyrobilni,
romelnic gadaudeblad saWiroeben Tirkmlis CanacvlebiT Terapias,
Seadgenen 160-200 anu 1 mln mosaxleze yovelwliurad modis 40-50
potenciurad sadializo pacienti. 2005 wlis monacemebiT Tirkmlis
CanacvlebiT Terapiaze imyofeba (hd, pd, Tirkmelgadanergilebi) 609
pacienti anu 200 1 mln mosaxleze. epidemiologiuri kvlevis SedegebiT
Tirkmlebis qronikuli daavadebiT Sepyrobil pacientTa raodenoba
mniSvnelovnad gaizrdeba, rac aixsneba droulad gamouvleneli Saqriani
diabetis, hipertoniisa da proteinuriis arsebobiT; aseve mxedvelobaSia
misaRebi Tirkmlis is qronikuli daavadebebi, romlebic viTardeba
meoradad mravali sxva daavadebis fonze (kardiovaskuluri,
revmatologiuri, hematologiuri da sxv.). Tirkmlebis qronikuli
daavadebas SemTxvevaTa 30%-Si safuZvlad udevs Saqriani diabeti, 20%-Si
– sxvadsxva tipis glomerulonefritebi, 15%-Si – sistemuri daavadebebi,
10% - sxvadsxva genezis tubulo-intersticiuli nefritebi, 3%-Si –
Tirkmlebis cisturi daavadebebi, 1%-Si – Tandayolili daavadebebi, 21%-
Si - hipertonia, aTerosklerozi da ucnobi genezis nefrosklerozi.

3. etiopaTogenezi

Tirkmlebis qronikul daavadebas, romelic progresirebs da sabolood

yalibdeba Tirkmlebis terminaluri ukmarisoba, safuZvlad udevs
Tirkmlebis mravalricxovani daavadeba, rogorc pirveladi aseve
meoradi; etiologiuri mniSvnelobis daavadebaTa mravalferovnebis gamo
cxrilSi #1 moyvanilia daavadebebi magaliTis saxiT, romlebmac
SeiZleba gamoiwvion anTebiTi da araanTebiTi tipis gorglovani
(glomeruluri), sisxlZarRvovani Tu tubulo-intersiciuli dazianeba.

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 Tqd-s gamomwvevi daavadebebi cxrili #1.

paTologia etiologia
(magaliTi)
diabeturi glomerulosklerozi Saqriani diabeti
tipi I
tipi II
gorglovani daavadebebi (pirveladi da meoradi):
1. proliferaciuli glomerulonefritebi
mezangioproliferaciuli glomerulonefriti
membranoproliferaciuli glomerulonefriti sistemuri wiTeli mglura,
fokalur-proliferaciuli glomerulonefriti baqteriuli endokarditi,
difuzur-proliferaciuli glomerulonefriti vaskulitebi, hepatiti B, C,
swrafad progresirebadi glomerulonefriti HIV infeqcia da sxv.

2. araanTebadi gorglovani daavadebebi

minimaluri cvlilebebis glomerulonefriti hojkinis limfoma, HIV
fokaluri glomerulosklerozi infeqcia, heroiniT
membranuli glomerulonefriti intoqsikacia, medikamenturi,
fibriluri glomerulonefriti amiloidozi, msubuqi
jaWvebis daavadeba

3. Tandayolili: alportis sindromi

sisxlZarRvovani daavadebebi:
1. msxvili yalibis sisxlZarRvovani daavadebebi Tirkmlis arteriis stenozi

2. saSualo yalibis sisxlZarRvovani daavadebebi hipertonia

nefrosklerozi

3. mcire yalibis sisxlZarRvovani daavadebebi hemolizur-uremiuli

mikroangiopaTiebi sindromi,
namglisebrujredovani anemia

tubulo-intersticiuli daavadebebi:
1. tubulo-intersiciuli nefritebi
pielonefriti infeqciebi, Sard-kenWovani,
alergiuli intersticiuli nefriti arasteroiduli anTebis saw.
analgetikebiT inducirebuli nefropaTia preparatebi, sarkoidozi,
granulomatozuri intersticiuli nefriti uveiti
autoimunuri intersticiuli nefriti
2. araanTebadi tubulointersticiuli daavadebebi vezikoureTeruli refluqsi,
refluqs-nefropaTia simsivne, Sard-kenWovani
obstruqciuli nefropaTia daavadeba, mravlobiTi
mielomuri Tirkmeli mieloma
cisturi daavadebebi
Tirkmlebis policisturi (Tp) daavadeba autosomur dominanturi an
fon hipel lindaus daavadeba recesiuli
tuberozuli sklerozi
meduluri cisturi daavadeba
Tirkmlis transplantatis daavadebebi
qronikuli mocilebis sindromi ciklosporini an
rekurentuli daavadeba takrolimusi, gorglovani
transplantatis qronikuli nefropaTia daavadebebi
medikamenturi intoqsikacia

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4. klinikuri simptomatika

klinikuri simptomatika damokidebulia im ZiriTad daavadebaze,

romelmac gamoiwvia Tirkmlebis qronikuli daavadeba: daavadebis
mimdinareoba SeiZleba iyos usimptomo da vlindebodes SemTxveviT
Sardis analizis rutinuli gamokvlevisas; gorglovani dazianebebi
SeiZleba mimdinareobdes sxvadasxva xarisxis SeSupebiT, hipertoniiT,
gorglovani filtraciis siCqaris daqveiTebiT an daqveiTebis gareSe;
tubulo-intersiciuli dazianebebi SeiZleba mimdinareobdes usimptomod
an saSarde gzebis daavadebebisaTvis damaxasiaTebeli simptomatikiT,
romlis qveS igulisxmeba dizuria, niqturia da sxv. Tirkmlebis
sxvadasxva daavadebis klinikuri prezentacia moyvanilia cxrilSi #2.

Tirkmlis daavadebaTa klinikuri prezentaciis magaliTebi cxrili # 2

Tirkmlis daavadeba klinikuri gamovlena
diabeturi nefropaTia asimptomuri mikroalbuminuria,
(tipi I, II,) nefrozuli sindromi
gorglovani daavadebebi
proliferaciuli glomerulonefritebi nefrituli sindromi, asimptomuri
mimdinareoba (izolirebuli
hematuria da proteinuria)
nefrozuli sindromi, asimtomuri
araanTebiTi glomerulopaTiebi mimdinareoba (proteinuria)
sisxlZarRvovani daavadebebi
msxvili yalibis hipertonia, asimptomuri mimdinareoba
(radiologiuri cvlilebebi)

saSualo yalibis hipertonia, asimptomuri mimdinareoba

(hematuria, proteinuria)

mcire yalibis hipertonia, asimptomuri mimdinareoba

(hematuria, proteinuria)
tubulo-intersticiuli daavadebebi
tubulointersticiuli nefritebi saSarde gzebis simptomatika,
asimptomuri mimdinareoba (piuria da
radiologiuri cvlilebebi), Sardis
koncentrirebis darRveva

araanTebadi daavadebebi asimptomuri mimdinareoba

(proteinuria, piuria, tubuluri
warmoSobis naleqi da radiologiuri
cvlilebebi)
cisturi daavadebebi saSarde gzebis simptomatika,
asimptomuri mimdinareoba
(cvlilebebi Sardis analizSi,
radiologiuri monacemebi)
Tirkmlis transplantantis daavadebebi

qronikuli mocilebis sindromi nefrituli sindromi, asimptomuri

medikamenturi intoqsikacia mimdinareoba (izolirebuli
transplantis qronikuli nefropaTia hematuria da proteinuria)
rekurentuli daavadeba nefrozuli sindromi, asimtomuri
mimdinareoba (proteinuria)

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Tirkmlebis daavadebebis mravalricxovnebis miuxedavad, klinikuri
suraTi, riTic SeiZleba gamovlindes Tirkmlebis qronikuli daavadeba,
arcTu ise mravalferovania. es imas niSnavs, rom klinikurad pacienti
SeiZleba iyos asimptomuri an saxeze iyos eqstrarenuli garTulebebi,
ris gamoc is droulad ar mimarTavs nefrologs. amis gamo gviandeba
Tqd-s drouli diagnostika da daavadebis swrafi progresirebis
sawinaaRmdego RonisZiebebis gatareba. cxrilSi #3 moyvanilia Tqd-s
stadiebis SesaZlo klinikuri prezentaciebi.

Tqd-s stadiebi: klinikuri prezentaciebi cxrili#3

stadia aRweriloba gfs klinikuri

(ml/wT/1, 73m²) prezentacia
1 Tirkmlebis dazianeba, ≥ 90 asimptomuri,
gfs normaluri an hipertonia,
gazrdili nefrozuli sindromi,
nefrituli sindromi,
saSarde gzebis
anTebiTi
daavadebisaTvis
damaxasiaTebeli
simptomatika
2 Tirkmlebis dazianeba, 60-89 eqstrarenuli
gfs normaluri an darRvevebis
mcired daqveiTebuli klinikuri gamovlena
iSviaTia
3 Tirkmlebis dazianeba, 30-59 saSualo simZimis
gfs saSualod eqstrarenuli
daqveiTebuli darRvevebi
4 Tirkmlebis dazianeba, 15-29 mZime eqstrarenuli
gfs mkveTrad darRvevebi
daqveiTebuli
5 Tirkmlebis ukmarisobis < 15 an uremia, mZime
terminaluri stadia dializi kardiovaskuluri
darRvevebi

imis warmosadgenad, Tu ratom aris saxeze Tirkmlebis qronikuli

daavadebis dros cvlilebebi sxvadasxva organos mxridan, qvemoT
mokled, sqematurad moyvanilia im procesebis ganviTarebis meqanizmi,
romlebic Tan sdevs Tirkmlis gorglovani siCqaris daqveiTebas.

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 wyal-
Na da H2O
marilovani SeSupeba
Sekaveba TirkmlebiT
cvlis darRveva
eqskretoruli
“fluid lung”
funqciis
darRveva
hipertonia

hiperurikemia meoradi podagra

distalur
milakSi K+-is
sekreciis
darRveva
hiperkalemia

amoniumis
Zvelebis
sinTezis acidozi
demineralizacia
darRveva
hiperventilacia
uremiuli
gastrointestinuri
toqsinebis
darRvevebi
retencia
glomerulopaTiebi
neiropaTia

Tirkmlebis encefalopaTia
Tandayolili
daavadebebi perikarditi

hemolizi
tubulo-
intersticiuri
daavadeba Trombocitebis
funqciis darRveva

obstruqciuli
uropaTiebi
hiperfosfatemia CaXP↑ kalcifilaqsisi

qavili

qsovilebis
metastazuri
kalcifikacia

1.25(OH)2O3 meoradi
deficiti hiperparaTireozi

eriTropoetinis
eriTropoezis
sinTezis renuli anemia
daqveTieba
deficiti

reninis hipertoniis
gazrda
endokrinuli produqcia erT-erT mizezi
funqciis
darRveva
distalur da
Semkreb poliuria
milakebSi
adh-is mimarT
renuli uSaqro
mgrZnobelobis
diabeti
daqveiTeba

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aRniSnuli garTulebebis klinikuri simptomatika, romelic yvelaze
mZimed vlindeba Tqd-s 4 da 5 stadiebSi, SeiZleba iyos Semdegi: Zlieri
saerTo sisuste, daRliloba, umadoba, gulisreva, dilis saaTebSi
pirRebineba, Tavis tkivili, koncentrirebis unaris daqveiTeba, qavili
(pruritis), dispnoe, krunCxvebi.
amasTan, aRiniSneba cvlilebebi TiTqmis yvela organosa da sistemis
mxridan:
gul-sisxlZarRvTa sistema: marcxena parkuWis hipertrofia da
diastoluri disfunqcia, aortisa da gulis sarqvelebis
kalcifikacia, ventrikuluri ariTmiebi (hipo/hiperkalemiis fonze).
wyal-marilovani da mJava-tutovani darRvevbi: hiperhidratacia,
hiper/hiponatremia, hiperkalemia, metaboluri acidozi.
renuli anemia: viTardeba eriTropoetinis deficitis gamo.
renuli osteopaTia: hiperfosfatemia, hipokalcemia da meoradi
hiperparaTireozis Sedegad viTardeba sxvadasxva saxis renuli
osteopaTiebi: fibrozuli osteoiti, Zvlis adinamiuri daavadeba.
hemostazi: sisxldenebi Trombocitebis agregaciis daqveiTebis gamo,
ris gamoc xSiria gastroduodenuli sisxldena, hemoragiuli
perikarditi da plevriti.
nervuli sistema: periferiuli neiropaTia, avtonomiuri neiropaTia,
uremiuli encefalopaTia, mtevnis gvirabis sindromi, uremiuli
miopaTia, mousvenari fexis sindromi.
endokrinuli darRvevebi: hipoTireozi, sqesobrivi hormonebis
disbalansi, maT Soris aRsaniSnavia hiperprolaqtinemia, bavSvebSi
rezistentoba zrdis hormonis mimarT.
metaboluri darRvevebi: dislipidemia IV tipis fredriqsonis
(Fredricksion) mixedviT, hiperhomocisteinemia.
dermatologiuri darRvevebi: qserozi, fsevdoporfiria, qavili.
kuW-nawlavis traqti: gastriti, duodeniti, gastroparezi,
pankreatiti, kolondivertikulozi, hemoragiuli koliti.

zemoT moyvanili dazianebebis xarisxi damokidebulia Tqd-s 4 da 5

stadiebSi uremiis xarisxze da individualuria. Sesabamisad, klinikuri
simptomatika aris mravalferovani da damokidebulia imaze, Tu
CamoTvlili paTologiebidan romelia wina planze.

5. diagnostika

Tqd-s droulad gamovlenisaTvis aucilebelia pacientTa seleqcia,

risTvisac rekomedebulia Semdegi gamokvlevebis warmoeba (sarwmunoebis
done I, rekomendacia A):
¾ Sardis analizi proteinuriis, hematuriis, leikocituriis
gamosavlenad pirveladi skriningis meTodiT testCxirebiT;

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 ¾ proteinuriis SemTxvevaSi cilis raodenobrivi gansazRvra 24
saaTian SardSi an dilis SardSi protein/kreatininis an
albumin/kreatininis fardobis mixedviT;
¾ arteriuli wnevis gazomva;
¾ gorglovani (glomeruluri) filtraciis siCqaris gamoTvla.
aRniSnuli gamokvlevebis safuZvelze SesaZlebelia risk faqtorebis
matarebel pacientTa gamovlena da maTze mumivi monitoringis daweseba.
risk faqtorebis matarebel pacientebSi rekomedebulia (sarwmunoebis
done II, rekomendacia B) Semdegi gamokvlevebis Catareba:
¾ Tirkmelebisa da saSarde gzebis sonografiuli gamokvleva;
¾ sisxlis SratSi kreatininis, Sardovanas gansazRvra;
¾ sisxlis SratSi eleqtrolitebis gansazRvra (natriumi, kaliumi,
qlori, bikarbonati, kalciumi, fosfatebi);
¾ Sardis xvedriTi wona an osmolaroba;
¾ Sardis pH.

gansakuTrebuli mniSvneloba eniWeba Tirkmlis dazianebis markers –

proteinurias, romelic SemTxvevaTa did nawilSi asimptomuri
mimdinareobiT xasiaTdeba. asimptomuri proteinuriis mqone individTa
janmrTelebisgan seleqciisaTvis NKF PARADE-s mier mowodebulia
gamokvlevaTa Semdegi Tanmimdevroba:

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gamovlenili proteinuriisa da hematuriis SemTxvevaSi rekomendebulia
(sarwmunoebis done II, rekomendacia B) gamokvlevaTa warmoeba Sesabamisi
algoriTmebis mixedviT:

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12
Tirkmlebis dazianebis markerebis gamovlenis SemTxvevaSi
rekomendebulia radiologiuri kvlevebi imis mixedviT, Tu romeli
paTologia udevs safuZvlad Tirkmlebis qronikul daavadebas.
gamokvlevis sworad SerCevisaTvis qvemoT moyvanilia cxrili #4,
romelSic warmodgenilia Tirkmlebis sxvadasxva dazianebis
radiologiuri suraTis interpretaciebi.

radiologiuri kvlevebi Tirkmlebis daavadebebis dros cxrili #4

radiologiuri kvlevis Tirkmlis daavadeba

dasaxeleba (magaliTi)
ultrasonografia
zogadi suraTi nefrokalcinozi, Sard-kenWovani
daavadeba, simsivne, hidronefrozi

parenqimis eqogenobis mateba zogadad ,,Tirkmlis dazianeba”

zomebis Semcireba Tirkmlis qronikuli daavadeba

gadidebuli zomebi amiloidozi, diabeturi nefropaTia da

sxv.

dopleri venuri Trombozi, transplantatis

mocilebis sindromi, arteriis stenozi

eqskretoruli urografia Sard-kenWovani daavadeba, simsivne,

obstruqcia
kompiuteruli tomografia obstruqcia, simsivne, cistebi
magnitur-rezonansuli kvleva simsivne, cistebi, venuri Trombozi da
sxv.
izotopuri skanireba funqciis Sefaseba TiToeul TirkmelSi
cal-calke

Tirkmlebis gogrlovani dazianebis SemTxvevaSi gamomwvevi daavadebis

diagnostikis, prognozisa da swori mkurnalobis SesarCevad
rekomendebulia (sarwmunoebis done I, rekomendacia A) Tirkmlis biofsia.
Tirkmlis biofsiis Cvenebebi moyvanilia cxrilSi #5.

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 Tirkmlis biofsiis Cvenebebi cxrili #5

diagnozi Tirkmlis biofsiis Cveneba

hematuria - izolirebuli hematuria 6 (12) Tveze meti

- hematuria, romelsac Tan axlavs arteriuli
hipertenzia, proteinuria an Tirkmlis funqciis
daqveiTeba

proteinuria - nefrozuli xarisxis proteinuria (>3,5g/24sT)

- proteinuria, romelsac Tan axlavs >2g/24sT
arteriuli hipertenzia an Tirkmlis fuqciis
daqveiTeba
- proteinuria >2g/24sT, romelic persistirebs an
imatebs dinamikaSi

Tirkmlebis - gaurkveveli genezi

mwvave - 4 kviraze meti xangrZlivobis oliguria
ukmarisoba - maRali xarisxis proteinuria
- swrafad progresirebadi glomerulonefriti

sistemuri - imunologiuri da paraneoplastiuri daavadebebi

daavadebebi (vaskuliti, monoklonuri gamopaTia, amiloidozi,
revmatoiduli poliarTriti, sklerodermia,
sistemuri wiTeli mglura)

Saqriani - Saqriani diabeti <10 welze

diabeti - proteinuria retinopaTiis gareSe

orsuloba - mZime nefrozuli sindromi

- gaurkveveli genezis Tmu
- aqtiuri sistemuri wiTeli mglura

transplantati - 10 dReze meti xangZlivobis Tirkmlis funqciuri

ukmarisoba
- Tirkmlis mogvianebiTi funqciuri ukmarisoba
- nefrozuli xarisxis proteinuria
- sakontrolo biofsia

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6. mkurnaloba

Tirkmlebis ZiriTadi daavadebis drouli diagnostikisa da mkurnalobis

Sedegad SesaZloa Tirkmlebis qronikuli daavadebis Tavidan acileba.

¾ Tqd-s I, II stadiis dros Tqd-s progresis Sesaneleblad

rekomendebulia (sarwmunoebis done I, rekomendacia A):
• agf-inhibitorebis/ar-blokerebis daniSvna;
• arteriuli wnevis maCveneblebis mkacri kontroli (Saqrian
diabetianebsa da maRali xarisxis proteinuriisas < 125/80mmHg,
danarCen SemTxvevebSi dasaSvebia <130/80mmHg);
• glikemiis mkacri kontroli Saqriani diabetis SemTxvevaSi.
¾ Tqd III stadiis dros I, II stadiebSi moyvanili RonisZiebebis garda
renuli anemiisa da renuli osteopaTiis gamosavleni gamokvlevebis
Catareba.
¾ Tqd-s IV da V stadiis dros rekomendebulia (sarwmunoebis done I,
rekomendacia A):
• arteriuli wnevis mkacri kontroli;
• wyal-marilovani cvlis koreqcia (hiperkalemia, hipokalcemia,
hiperfosfatemia);
• mJava-tutovani wonasworobis, kerZod, metaboluri acidozis
koreqcia;
• renuli anemiis koreqcia;
• renuli osteopaTiis koreqcia;
• pacientis Tirkmlis CanacvlebiTi TerapiisaTvis (TCT) momzadeba,
rac gulisxmobs: TCT-s saxeobis _ hemodializi (hd),
peritoneuli dializi (pd) Tu preemftiuri transplantacia
(Tirkmlis gadanergva dializiT mkurnalobis dawyebamde) _
winaswar gansazRvras pacientis, misi axloblebis, samedicino
Cvebebisa da pacientis socialuri mdgomareobis gaTvaliswinebiT
(mag, hd centridan siSore, aseve gasaTvaliswinebelia pacientis
dasaqmeba); aseve hemodializis SemTxvevaSi sisxlZarRvovani
midgomis winaswar uzrunvelyofa da pd-s SemTxvevaSi
peritoneuli dializis kaTeteris drouli implantacia.
pacientTan zemoaRniSnuli mosamzadebeli RonisZiebebis
gatarebis Semdeg, dializiT (hd/pd) mkurnalobis dawyeba an
preeftiuri transplantacia.
¾ B-hepatitis sawinaaRmdego vaqcinacia.
¾ rodesac gfs < 15ml/wT/1,73m² pacientis mdgomareobis Sefaseba
aucilebelia TveSi erTxel hipertoniis, hiperhidrataciis, bioqimiuri
maCveneblebis, renuli anemiis, renuli osteopaTiisa da malnutriciis
samarTavad.

15
 ƒ renuli anemia: koreqcia xdeba feritinis, transferinis
gajerebis indeqsisa da hipoqromuli retikulocitebis
raodenobis mixedviT rkinis preparatebiTa da rekombinantuli
eriTropoetiniT. samizne hemoglobinia (sarwmunoebis done II,
rekomendacia B) 11,5-12,0g/dl.
ƒ renuli osteopaTiis koreqcia xdeba saerTo da ionizirebuli
kalciumis, araorganuli fosfatebis, intaqturi paraThormonis,
Zvlis tutefosfatazisa da aluminis koncentraciebis mixedviT
fosforSemboWavi preparatebiTa da vit. D metabolitebiT.
¾ TCT-is dawyeba rekomendebulia, rodesac glomeruluri filtraciis
siCqarea 8-10ml/wT/1,73m² (sarwmunoebis done I, rekomendacia A). am
rekomendaciis gatareba gansakuTrebiT mniSvnelovania maRali riskis
mqone pacientebSi, magaliTad Saqriani diabetiT daavadebulebsa da
imaTSi, visTanac uremiisaTvis damaxasiaTebeli klinikuri simptoma-
tika mkveTrad aris gamovlenili an gaZnelebulia hidrataciisa da
arteriuli wnevis kontroli an aReniSnebaT mkveTrad gauaresebuli
nutriciuli statusi imisaTvis, rom pacientis sicocxle ar davayenoT
riskis qveS. yvela SemTxvevaSi, dializiT mkurnaloba dawyebul unda
iqnas manam, sanam gfs < 6ml/wT/1,73m².
¾ im pacientebSi, romlebic imyofebian nefrologiuri zedamxedvelobis
qveS da romlebTanac dagegmilia hemodializi, sisxlZarRvovani
midgomis – arterio/venuri (a/v) fistulis - uzrunvelyofis sakiTxi
unda dadges hemodializis dawyebamde 3-4 TviT adre. dainficirebisa
da Trombozis sixSiris mixedviT upiratesoba eniWeba natiur a/v
fistulas. proTezireba naCvenebia natiuri a/v fistulis Seqmnis yvela
SesaZleblobis amowurvis SemTxvevaSi. a/v fistulis, natiuri Tu
proTezi, permanentuli funqcionirebis uzrunvelsayofad aucilebeli
pirobebia: piradi higiena, kanulirebis win kanis aseptiuri
damuSavebisa da punqciis teqnika. a/v fistulis ararsebobis
SemTxvevaSi sisxlZarRvovani midgomis uzrunvelsayofad gamoiyeneba
centraluri venuri orarxiani keTeteri: droebiTi (3/6kviraze
gaTvlili) an permanentuli (erTwliani). (sarwmunoebis done I,
rekomendacia A).
¾ pacientis kardiovaskuluri statusi Sefasebul unda iqnas Tirkmlis
CanacvlebiTi Terapiis dawyebis win da Semdeg 6 TveSi erTxel
(sarwmunoebis done II, rekomendacia B). maRali riskis jgufSi Sedian:
mwevelebi, hiperglikemiis, dislipidemiisa da hipertoniis matarebeli
pacientebi.

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 eqimis taqtika Tqd-s stadiebis mixedviT

hemodializis procesis monitoringi

¾ hemodializis dozireba anu seansebis raodenoba da xangrZlivoba
ganisazRvreba dabali molekuluri wonis toqsinis, Sardovanas
kinetikuri maCveneblebis mixedviT: hemodializis seansi iTvleba
adekvaturad, rodesac Kt/V ≥ 1,2, xolo URR ≥ 65%. hemodializis
standartul dozad iTvleba: hd-s 4 saaTiani seansi kviraSi 3-jer.
seansis xangrZlivoba da/an sixSire izrdeba im pacientebSi, romelTan
aReniSnebaT hemodinamikuri arastabiloba an kardiovaskuluri
problemebi, rac metwilad vrceldeba xandazmuli asakis pacientebze
(sarwmunoebis done I, rekomendacia A).
¾ dializatorebis SerCeva unda xdebodes pacientis sxeulis farTobisa
da adekvaturobis maCveneblebis mixedviT; dializatoris SerCevisas
aseve mniSvnelovania masalis bioTavsebadobisa – modificirebuli
celuloza/sinTezuri masalis dros ar AaRiniSneba komplemenetisa da
leikocitebis aqtivacia ise, rogorc es xdeba aramodificirebuli
celulozis SemTxvevaSi – da hidravlikuri maxasiaTeblebis – dabali
(low flux) da maRali (high flux) nakadis (naCvenebia saSualo molekuluri
wonis toqsinebis mag, β2-mikroglobulini) klirensis gasaumjobe-
seblad _ gaTvaliswineba.
¾ hemodializisaTvis gamiznuli wyali unda iyos ultrasufTa, romelic
miewodebaT sadializo manqanebs wyaldamamzadebeli sistemidan.
wyaldamamzadebeli sistema, sadac xdeba wylis darbileba,
deionizacia/demineralizacia, distilacia da filtracia (reverse

17
 osmosis). aucilebelia sadializo wylis qimiuri da baqteriologiuri
sisufTavis rutinuli da regularuli monitoringi.
¾ hemodializis dros eqstrakorporuli Trombozis saprofilaqtikod
aucilebelia antikoagulaciuri RonisZiebebis arafraqcionirebuli an
dabalmolekuluri hepariniT gatareba.
¾ hd asocirebuli infeqciebi: baqteriuli infeqciebi, kerZod ki
Staphylococcus aureus–iT ganpirobebuli septicemiebi, warmoadgens
hemodializis yvelaze xSir da sicocxlisaTvis saSiS infeqciur
garTulebas. aqedan gamomdinare sisxlZarRvovani midgomis, rogorc
centraluri venuri kaTeterebis, aseve a/v fistulebis menejmenti unda
mkacrad iyos daculi yvela hemodializis centrSi. aucilebelia aseve
tuberkulozis diagnostika da prevencia imunosupresirebul da
malnutriciis mqone pacientebSi. HBV, HCV da HIV virusebze skriningi
rekomendirebulia 6 TveSi erTxel (sarwmunoebis done II, rekomendacia
B).

peritoneuli dializis monitoringi

¾ im pacientebSi, romlebic imyofebian nefrologiuri zedamxedvelobis
qveS da romlebTanac dagegmilia peritoneuli dializi, pd kaTeteris
implantacia unda Catardes peritoneuli dializiT mkurnalobis
dawyebamde 10-14 dRiT adre. sadializo siTxis mcire moculobebiT
peritoneuli dializis dawyeba dasaSvebia postoperacilad maSinve,
Tu arsebobs gadaudebeli samedicino Cveneba. pd kaTeteris
implantacia xorcieldeba operaciuli an laparoskopiuli gziT.
¾ araavtomaturi anu mudmivi ambulatoriuli peritoneuli dializi
(mapd) tardeba orparkiani (double-bag) sistemiT, romelic mniSvnelovnad
amcirebs peritonitebis risks erTparkian sistemasTan SedarebiT. pd
xsnarebi warmoadgens glukozis 3 tipis koncentaciis - dabali 1,36%-
1,5%, saSualo 2,27-2, 5% da maRali 3, 89%-4, 25% - standartul
SemTxvevaSi 2,0 litrian eleqtrolitur xsnarebs.
¾ mudmivi ambulatoriuli peritoneuli dializi iTvleba adekvaturad,
rodesac kviris Kt/V ≥ 1,7, CrCl ≥45l/kviraSi/1,73m² (1 kviris kreatininis
klirensi) da peritoneumis ultrafiltraciis unari normalurad,
rodesac maRalprocentiani glukozis 2,0 litriani xsnaris muclis
RruSi 4 saaTiani dayovnebis Semdeg ultrafiltratis raodenoba ≥
400ml.
¾ mapd-s dozireba unda warmoebdes pd adekvaturobis maCveneblebisa da
pacientis peritoneumis mier dabalmolekuluri nivTierebebis e.w.
transportirebis maxasiaTeblebis mixedviT. peritoneumis transportis
tipi ganisazRvreba peritoneumis wonasworobis testiT (PET), romelic
unda utardebodes pacientebs weliwadSi 2-jer (sarwmunoebis done II,
rekomendacia B) an yoveli morigi peritonitidan 6 kviris gasvlis
Semdeg da romlis mixedviT pacientebi iyofian dabal (low transporter),
saSualod dabal (low average transporter), saSualod maRal (high average
transporter) da maRal (high transporter) transportis peritoneumis mqoned.
¾ pd asocirebuli garTulebebi: infeqciur garTulebebs miekuTvneba
peritoniti da kaTeteris gamosavali nawilis e.w. exit site infeqcia,
18
 romelTa mkurnaloba da profilaqtika warmoebs International Society for
Peritoneal Dialysis (ISPD) mier mowodebuli gaidlainebis mixedviT.
meqanikur garTulebebs miekuTvneba Tiaqari, xsnaris Caqceva (leakage) da
pd kaTeteris obstruqcia, romelTa menejmentic warmoebs ISPD-is
rekomendaciebis mixedviT. peritoneumis ultrafiltraciis unaris
kargva da maRali transportis peritoneumi warmoadgens mapd-Ti
mkurnalobis gagrZelebis prognozulad erT-erT arakeTilsaimedo
maCvenebels, romlis drosac naCvenebia mapd-Ti mkurnalobaSi
maRalosmosuri xsnarebis, kerZod 7,5%-iani Icodextrin-is xsnaris CarTva
an pacientis transformacia avtomatur pd-ze an sabolood hd-ze
(sarwmunoebis done I, rekomendacia A).
¾ pd kaTeteris eqsplantacia naCvenebia mkurnalobarezistentuli
peritonitis SemTxvevaSi anu Tu klinikuri gaumjobeseba ar aRiniSna
mkurnalobis dawyebidan pirveli 72 saaTis ganmavlobaSi da pd xsnari
mkurnalobis fonze rCeba amRvreuli 4-5 dRis ganmavlobaSi; aseve
kaTeteris dislokaciisas da obstruqciisas mxolod mas Semdeg,
rodesac ISPD-gaidlainiT gaTvaliswinebuli yvela RonisZieba iqneba
nacadi. Tirkmlis transplantaciis Semdeg SesaZloa saWiroebis
SemTxvevaSi kaTeteris mucelSi 3-4 Tvis ganmavlobaSi Catoveba, Tumca
rekomendirebulia (sarwmunoebis done II, rekomendacia B)
SeZlebisdagvarad adreuli eqsplantacia.
¾ dializze myof pacientTa nutriciuli statusi ZiriTadad
ganisazRvreba proteinis katabolizmis siCqariT anu azotovani
produqtebis warmoqmnis siCqariT (nPNA- protein nitrogen appearance rate).
hemodializis pacientebisaTvis nPNA ≥ 0,8g/kg/dR, peritoneuli
dializis SemTxvevaSi nPNA ≥ 1,2 g/kg/dR (sarwmunoebis done II,
rekomendacia B) aseve fasdeba sisxlSi prealbuminisa da albuminis
koncentraciebi.

Tirkmlis transplantacia
¾ sakiTxi preemftiuri (pre-emptive) Tirkmlis transplantaciis
(transplantacia dializamde) Sesaxeb unda dasmul iqnas yvela
SesaZlo SemTxvevaSi, rodesac gfs < 20ml/wT/1,73m2 ara mxolod
dializTan dakavSirebuli garTulebebis Tavidan asacileblad, aramed
dializiT mkurnalobis xarjebis dasazogad. sakiTxis droulad
dayeneba gansakuTrebiT mniSvnelovania bavSvebisa da Saqriani
diabetiT daavadebul pacienTa SemTxvevaSi (sarwmunoebis done II,
rekomendacia B).
¾ Tirkmlis transplantaciis absoluturi ukuCvenebebis garda –
aragankurnebadi simsivne, HIV pozitiuroba, aqtiuri sistemuri
infeqcia da/an mdgomareoba, rodesac sicocxlis xangrZlivoba < 2
weliwadze – Tqd-iT daavadebuli yvela pacienti SeiZleba CaiTvalos
Tirkmlis transplantaciis kandidatad. donorisa da recipientis
evolucia, romelSic gaerTianebulia rogorc samedicino aseve
eTikur-samarTlebrivi aspeqtebi, unda warmoebdes mkacrad Sesabamisi
gaidlainebis mixedviT.

19
¾ TirkmelgadanergilTa postoperaciuli monitoringi iTvaliswinebs
(sarwmunoebis done I, rekomendacia A):
• yoveldRiur uwyvet mkacrad gansazRvrul imunosupresiul
Terapias rogorc pirveli 6 Tvis, aseve mokle- (1 weli),
saSualo- (5 weli) da grZelvadiani (>10weli) periodebis
ganmavlobaSi transplantantis adekvaturi funqcionirebis
SesanarCuneblad.
• imunosupresiuli mkurnalobis daniSvnas preoperaciulad
(cocxali donoris SemTxvevaSi) an transplantaciis dRes
(gvamuri donaciis SemTxvevaSi) sisxlZarRvovani anastomozis
dadebamde da gagrZelebas yovldRiurad, magram pirveli 2 Tvis
ganmavlobaSi gaZlierebulad, Semdeg dozebis adekvaturi
klebiT infeqciebisa da de novo malignizaciis riskis
Sesamcireblad.
– ukanaskneli dekadis ganmavlobaSi Tirkmel-gadanergilTa
imunosupresiuli mkurnaloba warmoebs Semdegi kombinaciiT:
kalcinevrinis inhibitorebi (ciklosporin A, FK506),
mikofenolat-mofetili an azaTioprini da meTilprednizo-
loni/prednizoloni.
¾ regularuli intervalebiT rekomendebulia Cataredes (sarwmunoebis
done II, rekomendacia B) Semdegi gamokvlevebi:
• mokle samedicino daxasiaTeba
• arteriuli wnevis, pulsis, sxeulis wonis monacemebi
• sruli obieqturi gamokvleva
• plazmaSi Na, K, Cl, bikarbonatis, kreatininis, Sardovanas
gansazRvra
• sisxlis suraTis gansazRvra
• SardSi cilis, eriTrocitebis, leikocitebis, glukozis
gansazRvra
• sisxlSi ciklosporinis koncentraciis gansazRvra

damatebiT gamokvlevebSi Sedis:

• RviZlis funqciuri testebi
• plazmaSi Ca, P, iPTH
• transplantantis sono/doplerografiuli gamokvleva
• 24 saaTian SardSi cilis gansazRvra
• kreatininis klirensi
• virusologiuri kvlevebi: CMV, EBV

7. gaidlainis gadaxedvisa da gadasinjvis vada _ 2 weli

8. gaidlainis miRebis wesi

aRniSnuli gaidlaini miRebulia literaturis Ziebis Sedegad SerCeuli

sxvadasxva gaidlainebis Sejerebisa da adaptaciis gziT.

20
9. alternatiuli gaidlaini ar arsebobs

10. gamoyenebuli leteratura

1. National Kidney Foundation K/DOQI: Clinical Practice Guidelines for Chronic Kidney
Disease: evalution, classification and stratification. Am J Kidney Dis 2002; vol 39 (Supp l).
2. The European Renal Association-European Dialysis and Transplant Association (ERA-
EDTA) and the European Society for Organ Transplantation (ESOT): “European Best
Practice Guidelines for Renal Transplantation” (Part1). Neph Dial Trans 2000; vol.15,(Suppl
7)
3. The European Renal Association-European Dialysis and Transplant Association (ERA-
EDTA) and the European Society for Organ Transplantation (ESOT): “European Best
Practice Guidelines for Renal Transplantation” (Part2). Neph Dial Trans 2002; vol.17,(Suppl
4).
4. The European Renal Association-European Dialysis and Transplant Association (ERA-
EDTA). ): “European Best Practice Guidelines for Haemodialysis” (Part1). Neph Dial Trans
2002, vol 17,(Suppl 7).
5. The European Renal Association-European Dialysis and Transplant Association (ERA-
EDTA). ): “European Best Practice Guidelines for Peritoneal dialysis”. Neph Dial Trans
2005, vol 20, (Suppl 9).
6. Alex M. Davison, J. Stewart Cameron, Jean-Pierre Grunfeld, Claudio Pontichelli, Eberhard
Ritz, Cristopher G. Winearls,Charls van Yeperele. Oxford Textbook of Clinical
Nephrology, 2005.
7. B. Grabensee. Nephrologie, 2002.
8. Ulrich Kuhlmann, Dieter Walb, Friedrich C. Luft. Nephrologie.

11. avtorTa jgufi:

saqarTvelos dializis, nefrologiisa da Tirkmlis transplantaciis

kavSiri:
⇒ irma WoxoneliZe - Tssu Sinagan sneulebaTa departamentis
asistent profesori nefrologiaSi, `saqarTvelos dializis,
nefrologiisa da Tirkmlis transplantaciis kavSiris~
Tavmjdomare urologiis erovnuli centris nefrologiuri
ganyofilebis gamge med. mecn. kandidati;
⇒ elguja RonRaZe - s/s k.erisTavis sax. eqsperimentuli da
klinikuri qirurgiis erovnuli centris _ transplantaciis
ganyofilebis gamge, med. mecn. doqtori;
⇒ merab suTiZe - Sps `ak. n. yifSiZis saxelobis centraluri
sauniversiteto klinikis~ _ Tirkmlis CanacvlebiTi Terapiis
departamenti ufrosi.

21
eqspertebi:
⇒ g. boWoriSvili _ ss al. wulukiZis sax. urologiis urovnuli
centris direqtori saswavlo dargSi, med. mec. doq. profesori;
⇒ g. Citaia _ saxelmwifo sauniversiteto pediatriuli klinikis
nefrologiuri ganyofilebis gamge, med. mec. doq. profesori;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti.

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