nefrologiis aqtualuri - DNT Uniondntunion.ge/sites/default/files/2008_1.pdf · policisturi...
Transcript of nefrologiis aqtualuri - DNT Uniondntunion.ge/sites/default/files/2008_1.pdf · policisturi...
nefrologiis
aqtualuri
sakiTxebi
2008-----11111Jurnali gamodis sam TveSi erTxel
Tbilisis saxelmwifo samedicino universiteti
saqarTvelos dializis, nefrologiisa da Tirkmlistransplantaciis kavSiri
saredaqcio jgufi:
irma WoxoneliZe - saqarTvelos dializis, nefrologiisa daTirkmlis transplantaciis kavSiris Tavmjdomare
avTandil TaTaraZe
nino maRlakeliZe
redaqtori - prof. daviT WavWaniZe
teqnikuri redaqtori - zaza beriSvili
gamocema xorcieldeba Tssu reqtoris,
profesor giorgi menabdis mxardaWeriT
2
cxr.1. ADQI-s mier SemuSavvebuli RIFLE kriteriumebi
gfs kriteriumi diurezis kriteriumi
riski kreatininis mateba X 1.5 < 0.5 ml/kg/sT X 6sT
an gfs daqveiTeba > 25%
dazianeba kreatininis mateba X 2 < 0.5 ml/kg/sT X 12sT
an gfs daqveiTeba > 50%
ukmarisoba kreatininis mateba X 3 < 0.3 ml/kg/sT X 24sT
an gfs daqveiTeba > 75% an anuria X 12 sT
funqciis kargva Tirkmlis funqciis kargva > 4 kvira
terminaluri ukmarisoba Tirkmlis terminaluri ukmarisoba > 3 Tve
Tirkmlis mwvave ukmarisoba
Tirkmlis mwvave ukmarisoba (Tmu) war-
moadgens Tirkmlis funqciis (gorglovani
filtraciis siCqaris) swraf daqveiTebas,
rac organizmSi azotis cvlis produqteb-
is Sekavebas da ujredgare siTxisa da ele-
qtrolitebis balansis darRvevas iwvevs.
es erTi SexedviT martivi da naTeli
gansazRvreba sakmaod dauzustebeli iyo.
kerZod, miTiTebuli ar iyo, Tu gfs-is ra
simZimis daqveiTeba SeiZleba CaTvliliyo
Tirkmlis mwvave ukmarisobad da Tu ra kri-
teriumebiT unda momxdariyo Tavad gfs-
is Sefaseba. es dauzustebloba problemebs
gansakuTrebiT epidemiologiuri da klin-
ikuri kvlevebis TvalsazrisiT qmnida, ram-
denadac SeiZleba sxvadasxva SemTxvevaSi
„Tirkmlis mwvave ukmarisobis~ diagnozis
sxvadasxva kriteriumebi yofiliyo gamoy-
enebuli. standartuli gansazRvrebis
ararseboba aZneldebda sxvadasxva jgufeb-
Si prognozis Sedarebas da ama Tu im pre-
venciuli Tu samkurnalo RonisZiebis efeq-
turobis Sefasebas.
intensiuri Terapiisa da nefrologiis
eqspertTa jgufma, Acute Dialysis Quality Ini-
tiative (ADQI), romlis mizansac warmoadgen-
da Tirkmlis mwvave ukmarisobis mkurnalo-
bisa da prevenciis konsensusisa da mtki-
cebulebebze damyarebuli gaidlainebis
SemuSaveba, aRniSnul sferoSi termi-
nologiis dasazusteblad miiRo e.w. RIFLE
kriteriumebi (cxr.1).
aRniSnuli klasifikacia moicavs dazia-
nebis sam dones (riski, dazianeba da ukmari-
soba), rac ganisazRvreba sisxlSi kreatini-
nis koncentraciis matebis an Sardis rao-
denobis Semcirebis xarisxiT, da gamosav-
lis or formas (Tirkmlis funqciis kargva
da terminaluri ukmarisoba);
garkveuli drois Semdeg eqspertTa axa-
li jgufis, Acute Kidney Injury Network (AKIN)
mier moxda RIFLE kriteriumebis modifi-
cireba (cxr.2). kerZod, klasifikaciidan
amoRebuli iqna gamosavlis formebi - Tirk-
mlis funqciis kargva da terminaluri uk-
marisoba, xolo pirveli sami formis - ris-
ki, dazianeba da ukmarisoba dasaxasiaTeb-
lad miRebuli iqna saerTo termini - Tirk-
mlis mwvave dazianeba (Tmd). gamoiyo Tmd
sami stadia, romlebic Seesabameba RIFLE
kriteriumebis pirvel sam safexurs (mcire
cvlilebebiT).
terminologia
3
klasifikacia
paTogenezi
Tirkmlis mwvave dazianebis mravalfer-
ovani etiologiuri speqtridan gamom-
dinare, misi ganviTarebis meqanizmic sxva-
dasxvaa. Cven aq ganvixilavT mxolod Tirk-
diagnozisa da marTvis TvalsazrisiT,
Tirkmlis mwvave ukmarisoba tradiciulad
sam kategoriad iyofa:
- prerenuli - gamowveuli Tirkmlis hipo-
perfuziiT, Tirkmlis parenqima intaq-
turia;
- intrarenuli - gamowveuli Tirkmlis
parenqimis dazianebiT, maT Soris:
- Tirkmlis didi sisxlZarRvebis da-
zianeba;
- Tirkmlis mcire sisxlZarRvebis da glo-
merulebis dazianeba (mwvave an swrafad
progresirebadi glomerulonefriti);
- mwvave tubulur-intersticiuli ne-
friti;
- Tirkmlis milakebis mwvave dazianeba iSe-
miis an toqsinebis zemoqmedebiT (mwvave
tubuluri nekrozi);
- postrenuli - gamowveuli saSarde
sistemis mwvave obstruqciiT.
es klasifikacia garkveulwilad pirobi-
Tia. magaliTad, Tirkmlis gaxangrZlive-
bulma hipoperfuziam (prerenuli ukmari-
soba) SeiZleba mwvave tubuluri nekrozis
(intrarenuli ukmarisoba) ganviTareba gam-
oiwvios. AKIN klasifikaciaSi SeiZleba Tmd
adreuli (I-II) stadia prerenul, xolo
Semdgomi (III) stadia - intrarenul ukmari-
sobas Seesabamebodes.
miuxedavad aRniSnuli pirobiTobisa,
prerenul, intrarenul da postrenul
formebad dayofa naTlad asaxavs Tmd etio-
logia-paTogenezs da Tanamedrove lite-
raturaSic aqtiurad gamoiyeneba.
aRsaniSnavia, rom am Tanamedrove klasi-
fikaciasac mniSvnelovani naklovanebebi
aqvs. kerZod gasaTvaliswinebelia, rom kre-
atininis koncentraciis mateba Tirkmlis
mwvave dazianebis gviani gamovlenaa da mxo-
lod mniSvnelovani dazianebis Semdgom
xdeba. amasTan, mis koncentraciaze gavle-
nas axdens iseTi faqtorebi, rogoricaa misi
generacia, ganawilebis moculoba da eqs-
traglomeruluri gamoyofa.
mosalodnelia, rom momavalSi Tmd diag-
nozi daefuZneba SardSi epiTeluri ujre-
debis e.w. biomarkerebis (tubuluri enzi-
muria) aRmoCenas. es SesaZlebels gaxdis mi-
lakebis adreuli dazianebis aRmoCenas da
im pacientTa identifikacias, romlebic,
SesaZloa, droul Carevas saWiroebdnen.
dResdReobiT mimdinareobs ramdenime ase-
Ti biomarkeris Seswavla, Tumca isini jer-
jerobiT klinikurad ar gamoiyeneba.
cxr. 2. Tirkmlis mwvave dazianebis stadiebi AKIN klasifikaciiT
stadia gfs kriteriumi diurezis kriteriumi
1 kreatininis mateba > 0.3mg/dl < 0.5 ml/kg/sT X 6sTan 150-200%-iT
gfs daqveiTeba > 25%
2 kreatininis mateba 200-300%-iT < 0.5 ml/kg/sT X 12sT
3 kreatininis mateba > 300%-iT < 0.3 ml/kg/sT X 24sTan kreatinini > 4.0 mg/dl da an anuria X 12 sT
momatebuli > 0.5 mg/dl-iT
4
mlis mwvave dazianebis yvelaze tipiuri
formis, mwvave milakovani nekrozis, paTo-
morfologiasa da paTogenezs. Tmd gamom-
wvevi sxva mizezebi, magaliTad obstruqci-
uli uropaTia, glomerulonefriti, mwvave
tubulur-intersticiuli nefriti da sxv.
dawvrilebiT urologiisa da nefrologiis
Sesabamis TavebSi ganixileba.
cialuri wneva 10-20 mm vwy. sv. farglebSia.
gamomdinare iqidan, rom natriumis reab-
sorbciis procesisasTvis milakovan ujre-
debs sakmaod didi raodenobiT atf es-
aWireobaT, isini mudmivad hipoqsiis zR-
varze imyofebian (sur.1).
aRwerili fiziologiuri Tavisebure-
bidan gamomdinare, TirkmelSi sisxlis na-
kadis daqveiTeba pirvel rigSi tubuluri
ujredebis iSemiur dazianebas iwvevs. is
aseve xsnis, Tu ratom iwvevs sxvadasxva to-
qsiuri zemoqmedeba milakebis struqtur-
is darRvevas, gansakuTrebiT sxva
Tanaarsebuli faqtorebiT gamowveuli
Tirkmlis daqveiTebuli sisxlmomaragebis
pirobebSi.
fiziologiurad Tirkmlis tvinovani
nawilis sisxlis momaragebis SenarCunebas
sxvadasxva e.w. avtomaregulebeli faqtori
uzrunvelyofs. maTgan erT-erTi umniS-
vnelovanesia prostaglandini E2, romelic
medulur vazodilatacias iwvevs da amave
dros amcirebs tubuluri ujredebis moTx-
ovnilebas Jangbadze. arasteroiduli an-
Tebis sawinaaRmdego saSualebebi prostag-
landinebis sinTezis inhibirebis gziT am
procesebis Seferxebas iwveven. swored
amiT aixsneba maTi nefrotoqsiuroba.
mniSvnelovan avtomaregulebel faq-
torebs miekuTvneba henles maryuJis medu-
lur nawilSi warmoqmnili azotis oqsidi
(NO) da distalur milakebSi warmoqmnili
urodilatini (winagulovani natriurezu-
li peptidis homologi), romlebic vazodi-
latatoruli moqmedebiT xasiaTdebian.
mwvave milakovani nekrozis kardinalu-
ri gamovlenaa gorglovani filtraciis
siCqaris mkveTri daqveiTeba, miuxedavad
imisa, rom Tavad gorglebi Cveulebriv in-
taqturia. cnobilia sul mcire sami
meqanizmi, romliTac es movlena SeiZleba
aixsnas. pirveli meqanizmia glomerulis
aferentuli arteriolebis vazokon-
striqcia, rac ganpirobebulia rogorc en-
doTeluri ujredebis dazianebiT, aseve
sur.1
mwvave tubuluri nekrozi, rogorc sax-
elwodeba miuTiTebs, Tirkmlis milakebis
dazianebiT xasiaTdeba. Tirkmelze ama Tu
im damazianebeli faqtoris zemomqedebis
Sedegad pirvel rigSi milakebis dazianeba
am organos sisxliT momaragebis Tavisebu-
rebiT aixsneba. rogorc cnobilia, gulis
wuTmoculobis daaxloebiT 25% Tirkm-
lebSi gaivlis, anu Tirkmeli organos ma-
saze gadaangariSebiT organizmis yvelaze
uxvad sisxlmomaragebuli organoa, rac
uzrunvelyofs gorglovani filtraciis
sakmarisi donis SenarCunebas. Tirkmlis
saerTo sisxlmomaragebasTan SedarebiT,
meduluri (tvinovani) nawilis sisxlmoma-
rageba mniSvnelovnad mcirea, rac saWiroa
Tirkmlis qerqovan da tvinovan Sres Soris
osmosuri gradientis da Sesabamisad reab-
sorbiciis procesis SesanarCuneblad.
Tirkmlis tvinovan SreSi Jangbadis par-
5
e.w. tubulur-glomeruluri ukukavSiriT:
dazianebul proqsimalur milakebSi NaCl
reabsorbciis daqveiTebis Sedegad izrde-
ba macula densa-mde miRweuli NaCl koncen-
tracia, rac iwvevs Cl arxebisa da adenozi-
nis gaaqtivebas da sabolood dehidrat-
aciisagan damcavi preglomeruluri va-
zokonstriqtoruli signalis warmoqmnas.
meore meqanizmia milakebSi gorglovani
filtratis ukudena da e.w. efeqturi gfs-
is daqveiTeba milakis - darRveuli stru-
qturis gavliT filtrati xvdeba Tirkm-
lis intersticiumSi, saidanac reabsorbi-
rebs sisxlis mimoqcevis sistemaSi. mesame
meqanizmia milakis obstruqcia epiTeluri
ujredebisgan formirebuli cilindrebis
mier.
gfs-is daqveiTebis garda, mwvave milak-
ovani nekrozis dros Tirkmeli kargavs Sar-
dis koncentrirebis unars, rac nawilobriv
ganpirobebulia nefronis sxvadasxva naw-
ilSi (maT Soris Semkreb milakSi) aqvapori-
nis arxebis eqspresiis funqciis moSliT.
mwvave milakovani nekrozis mimdinare-
obaSi ganarCeven oTx fazas:
- sawyisi faza: irRveva Tirkmlis perfu-
zia da vaskuluri reaqtiuloba, viTar-
deba prerenuli azotemia;
- gaRrmavebis faza: aRniSnuli procesis
Sedegad xdeba dendrituli ujredeb-
is, makrofagebis, endoTeluri ujre-
debis da Tirklmis epiTeluri ujre-
debis aqtivacia, rac proanTebiT sta-
tuss qmnis. peritubuluri kapilarebis
gaaqtivebul endoTeliumze xdeba anTe-
biTi ujredebis adhezia, rasac medulu-
ri Segubeba da proqsimaluri milakis
hipoqsiuri dazianebis gaRrmaveba mos-
devs;
- SemanarCunebeli faza: iwyeba tubuluri
ujredebis aRdgena Semdegi meqanizmebiT:
- Tavad tubuluri ujredebis redifer-
enciacia da proliferacia,
- Tirkmlis Rerovani ujredebis difer-
encireba tubulur ujredebad,
- hematopoeturi ujredebis CarTva da-
zianebis ubnebSi da maTi diferencire-
ba tubulur ujredebad;
- aRdgenis faza: Tirkmlis funqciis
aRdgena.
diagnostika
diferenciuli diagnozi
Tmd da Tqd Soris
gorglovani filtraciis daqveiTebis
nebismier SemTxvevaSi pirvel rigSi unda
moxdes diferencireba Tirkmlis qroni-
kul da mwvave ukmarisobas Soris (axali te-
rminologiiT Sesabamisad Tirkmlis qroni-
kuli daavadeba da Tirkmlis mwvave da-
zianeba). amasTan, yovelTvis unda gvaxsov-
des, rom sakmaod xSirad adgili aqvs sxva-
dasxva faqtoris zemoqmedebiT e.w. Tirkm-
lis qronikuli ukmarisobis gamwvavebas (ax-
ali terminologiiT - Tmd Tqd-is fonze).
Tirkmlis qronikuli daavadebisagan
gansxvavebiT, Tirkmlis mwvave dazianeba
kreatininis koncentraciis swrafi matebiT
(saaTebis an dReebis ganmavlobaSi) xasiaT-
deba. aqedan gamomdinare, mwvave da qroni-
kuli formebis diferencirebisTvis yve-
laze zustia dinamikaSi arsebuli analize-
bis Sedareba.
vTqvaT, pacients aReniSneba sisxlSi
kreatininis koncentracia 4.0 mg/dl. Tu
cnobilia, rom erTi Tvis win is Seadgenda
1.0 mg/dl-s, saxezea mwvave (an swrafad pro-
gresirebadi) procesi, xolo ori wlis win
kreatininis 3.0 mg/dl maCveneblis SemTxve-
vaSi unda vivaraudoT Tirkmlis qroniku-
li daavadebis progresireba. Tmd-is diag-
nozi ueWvelia hospitalizebul pacienteb-
Si, romelTac kreatininis koncentraciis
yoveldRiuri mateba aReniSnebaT.
6
im SemTxvevaSi, Tu ucnobia Tirkmlis
funqciis statusi dinamikaSi, Tqd da Tmd
diferencirebisaTvis Semdeg faqtorebs
SeiZleba daveyrdnoT:
- klinikuri konteqsti: Tmd-is diagnozi
savaraudoa, Tu cnobilia misi SesaZlo
etiologiuri faqtoris arseboba. Tmd-
ze miuTiTebs aseve Tirkmlis daqveiTe-
buli funqciis simptomebis (SeSupeba,
arteriuli hipertenzia, Sardis feris
Secvla, sisuste, umadoba, gulisreva,
mentaluri cvilelebi, krunCxva da sxv.)
swrafi ganviTareba bolo dReebis gan-
mavlobaSi;
- Sardis raodenoba: anuria an uecrad gan-
viTarebuli mkveTri oliguria Tmd-is
sasargeblod metyvelebs, Tumca ar
unda dagvaviwydes Tmd-is araoliguri-
uli formis arseboba, rac arcTu iSvi-
aTad gvxvdeba;
- radiologiuri kvleva: Tirkmlebis eqo-
skopia warmoadgens Tmd da Tqd sa-
diferenciacio klevis yvelaze mniS-
vnelovan meTods. eqogenurad mcire zo-
mis Tirkmlebis arseboba Tqd-ze miu-
TiTebs.
amasTan, unda gvaxsovdes Tqd-is fonze
Tmd-is ganviTarebis SesaZlebloba da
aseve isic, normaluri zomis Tirkmlebi
ar gamoricxavs Tqd-is arsebobas (diabe-
turi nefropaTia, Tirkmlis amiloidozi
da sxv.).
- anemia: marTalia, anemia aReniSneba Tqd-
is mqone pacientebis umravlesobas, ma-
gram es simptomi Tqd-is da Tmd-is
sadiferenciaciod arcTu ise Rirebu-
lia - anemia SeiZleba Segvxvdes Tmd-
sTan asocirebuli sxvadasxva darRveve-
bis (hemolizi, sisxldena) farglebSi,
xolo Tqd mqone zogierT pacients (mag.
policisturi daavadeba) SeiZleba is ar
aReniSnebodes.
Tmd
diferenciuli
diagnozi
Tirkmlis mwvave dazianebis swori mar-
TvisaTvis aucilebelia misi etiologiis
garkveva. Tmd tipiuri forma - mwvave mila-
kovani nekrozi - romelic zogjer araswo-
rad Tirkmlis mwvave ukmarisobis sinoni-
mad ganixileba, praqtikulad warmoadgens
gamoricxvis diagnozs da unda daisvas Tmd
prerenuli da postrenuli formebis, sisx-
lZarRvovani movlenebis, glomerulo-
paTiebis da tubulur-intersticiuli ne-
fritis gamoricxvis Semdeg. diferenciu-
li diagnozi unda Catardes Semdeg faq-
torebze dayrdnobiT:
- anamnezi: anamnezs Tmd etiologiis gasa-
rkvevad uaRresad didi mniSvneloba
aqvs. mwvave tubuluri nekrozi xSirad
asocirebulia sxvadasxva nefrotoqsi-
uri medikamentis (aminoglikozidebi,
antivirusuli nivTierebebi, amfoteri-
cini, asass, qimiopreparatebi da sxv.) an
Sxamis zemoqmedebasTan. radiokon-
trastuli nivTierebis gamoyenebasTan
asocirebuli Tmd-is SemTxvevaSi mniS-
vnelovania misi aRmocenebis dro -
mwvave milakovani nekrozi angiografi-
idan 1-3 dRis, xolo Tirkmlis aTeroem-
boluri daavadeba - 1-4 kviris Semdeg vi-
Tardeba. SeiZleba adgili qondes anam-
nezSi sxvadasxva specifiuri daavadeb-
isaTvis damaxasiaTebeli movlenis arse-
bobas (mag. gadatanili streptokokuli
infeqcia - mwvave postinfeqciuri glom-
erulonefriti, sisxliani diarea - hemo-
lizur-uremiuli sindromi, kraS-sin-
dromi - mioglobulinuria da a.S.). Zalze
mniSvnelovania yvela im faqtoris moZi-
eba, romelsac SeeZlo Tirkmlis perfu-
ziis darRveva da prerenuli (an garTu-
lebuli intrarenuliT) Tmd gamowveva
(gulis funqciis daqveiTeba, arteriu-
li hipotenzia, dehidratacia, sefsisi,
agf inhibitoris gamoyeneba da a.S.).
7
- simptomebi: yuradReba unda mieqces ise-
Ti simptomebis arsebobas, romlebic SeiZ-
leba Tmd specifiur etiologiaze miu-
TiTebdnen (dehidrataciis simptomebi -
prerenuli Tmd, tkivili welis areSi -
postrenuli Tmd, sistemuri daavadebis
SesaZlo eqstrarenuli gamovlenebi -
swrafad progresirebadi glomerulone-
friti, alergiuli simptomebi - mwvave
intersticiuli nefriti da a.S.).
- Sardis analizi uaRresad mniSvnelovania
Tmd-is etiologiis gasarkvevad. sxva-
dasxva tipiuri monacemebis arseboba
Sardis analizSi SeiZleba Tmd-is ama Tu
im formaze miuTiTebdes (cxr.3).
- sisxlis analizi: klinikuri konteqs-
tidan gamomdinare, pacients unda Cau-
tardes specifiuri laboratiuli kv-
levebi sxvadasxva daavadebisaTvis dam-
axasiaTebeli cvlilebebis aRmosaCenad
(imunologiuri kvlevebi glomerulone-
fritis diagnozisaTvis, laqtatde-
hidrogenaza da haptoglobini – husis
gamosaricxad, msubuqi jaWvebi – mrav-
lobiT mielomaze eWvis mitanis SemTx-
vevaSi da a.S.).
- natriumis fraqciuli gamoyofa Ziri-
Tadad Rirebulia Tmd prerenuli da in-
trarenuli formebis sadiferencia-
ciod. hipovolemiisa da Tirkmlis jer
kidev SenarCunebuli funqciis SemTx-
vevaSi (prerenuli Tmd) SardSi natriu-
mis koncentracia Cveulebriv Zalian
dabalia (<20mmol/l), ramdenadac de-
hidrataciis sapasuxod Tirkmlis mi-
lakebSi misi maqsimaluri reabsorbcia
xdeba. mwvave tubuluri nekrozis SemTx-
vevaSi ki milakebs daqveiTebuli aqvT
natriumis reabsorbciis unari da Sesa-
bamisad SardSi misi koncentracia ufro
maRalia (>40mmol/l).
natriumis fraqciuli gamoyofa Semde-
gi formuliT gamoiTvleba:
FENa (%) = UNa / PNa X PCr / Ucr X 100
sadac: FENa - natriumis fraqciuli
gamoyofa, UNa, PNa, UCr da Pcr -
Sesabamisad natriumisa da kreatininis
koncentraciebi Sardsa da sisxlSi
im SemTxvevaSi, roca FENa < 1%, savarau-
doa prerenuli Tmd, xolo roca FENa > 2% -
intrarenuli Tmd. maCvenebeli 1% da 2% So-
ris aradiagnostikuria. aRsaniSnavia, rom
FENa gansazRvra prerenuli da intrarenu-
li Tmd-is sadiferenciaciod bolomde
specifiuri ar aris - dabali FENa SeiZleba
aseve Segvxvdes mwvave glomerulonefri-
tis, vaskulitis, postrenuli Tmd-is, nat-
riumis qronikuli retenciis pirobebSi (mag.
cxr.3. Sardis analizis tipiuri monacemebi
sxvadasxva etiologiis Tmd-is dros
Sardis analizis monacemebi Tirkmlis daavadeba
hematuria, eriTrocituli cilindrebi, glomeruluri daavadeba anproteinuria, lipiduria vaskuliti
mravali marcvlovani da epiTeluri mwvave tubuluri nekrozicilindri Tavisufali epiTeluriujredebiT
piuria Cveulebriv infeqcia; steriluri piuriaSeiZleba saSarde sistemis tuberkulozze
an tubulur-intersticiul daavadebaze miuiTebdes
8
RviZlis cirozi) ganviTarebuli mwvave tu-
buluri nekrozis dros.
- radiologiuri kvleva: Tmd-is dros um-
ravles SemTxvevaSi kvlevis arCevis me-
Todia ultrasonografia, gamomdinare
simartividan, arainvaziurobidan, siia-
fidan da maRali diagnostikuri Rire-
bulebidan. misi Catarebis ZiriTadi mi-
zania obstruqciuli faqtoris (pos-
trenuli Tmd) iseve, rogorc nefrosk-
lerozis (Tqd) gamoricxva.
- Tirkmlis biofsia: Tirkmlis biofsiis
Cvenebebs Tmd-is dros miekuTvneba:
- glomerulonefritis (garda mwvave
postinfeqciuri glomerulonefritis)
damaxasiaTebeli niSnebis arseboba;
- gaurkveveli etiologiis Tmd;
- Tirkmlis funqciis aRdgenis niSnebis
ararseboba 4 kviraze meti xnis ganmav-
lobaSi.
mwvave tubuluri nekrozisaTvis histo-
logiurad damaxasiaTebelia pirvel rigSi
proqsimaluri milakis swori nawilis (pars
recta) da henles maryuJis aRmavali totis
dazianeba. dazianebis kerebi SeiZleba aseve
Segvxvdes Tirkmlis qerqovan SreSic, ne-
fronis rogorc proqsimalur, aseve dista-
lur nawilSi. morfologiurad damaxasiaTe-
belia milakebis ujredovani dazianeba da
disfunqcia, maT Soris apoftozi, milako-
vani arqiteqturis Semqmneli ujredebis
kargva, mkvdari ujredebis dagroveba mi-
lakebis sanaTurSi (sur. 2).
sur.2
sinaTlis mikroskopia - mwvave tubuluri nek-
rozi. aRiniSneba milakebis epiTeluri ujre-
debis fokaluri kargva (isrebi) da milakebis
sanaTuris nawilobrivi daxSoba ujrdebiT (D).
prevencia da mkurnaloba
Tirkmlis mwvave dazianebis mkurnalo-
ba SeiZleba daiyos Semdeg jugfebad: eti-
ologiuri mkurnaloba, organizmis norma-
luri cxvelqmedebis uzrunvelsayofi zo-
gadi RonisZiebebi, mwvave tubuluri nek-
rozis sawinaaRmdego specifiuri strate-
giebi da Tirkmlis CanacvlebiTi Terapia.
etiologiuri mkurnaloba
Tmd-is etiologiuri mkurnaloba mima-
rTulia misi aRmocenebis ganmapirobebeli
ZiriTadi daavadebis sawinaaRmdegod - ma-
galiTad, mwvave da swrafad progresireba-
di glomerulonefritis, hemolizur-ure-
miuli sindromis, mwvave tubulur-inter-
sticiuli nefritis, obstruqciuli ne-
fropaTiis da a.S. mkurnaloba.
is nefrologiisa da urologiis Sesabam-
is TavebSi ganixileba.
zogadi RonisZiebebi
zogad RonisZiebebs uaRresad didi mniS-
vneloba aqvs rogorc Tmd saprevenciod,
aseve misi ganviTarebis SemTxvevaSi pacien-
tis prognozis gaumjobesebis Tvalsazri-
siT.
Tirkmlis mwvave dazianebis saprevencio
yvelaze efeqtur RonisZiebas dRemde or-
ganizmis adekvaturi hidrataciis uzrun-
velyofa warmoadgens. intrevanurad opti-
9
maluri raodenobiT fiziologiuri xsnar-
is gadasxmiT (amasTan unda gvaxsovdes hi-
pervolemiis riskis Sesaxeb) SesaZloa Tavi-
dan aviciloT Tmd-is ganviTareba, aseve
misi prerenulidan renul formaSi gadasv-
la. adekvatur hidrataciasTan erTad,
Tirkmlis normaluri perfuziis Sesanar-
Cuneblad mniSvnelovania optimaluri gu-
lis funqciisa da sistemuri hemodinamikis
miRweva.
Tmd ganviTarebis SemTxvevaSi prog-
nozisaTvis uaRresad mniSvnelovania ise-
Ti zogadi RonisZiebebi, roogricaa anemi-
is da anTebis sawinaaRmdego mkurnaloba,
adekvaturi nutricia, normaluri hemodi-
namikis uzrunvelyofa da a.S.
specifiuri strategiebi
specifiur strategiebSi igulisxmeba
sxvadasxva farmacevtuli saSualebis gamo-
yenebiT Tirkmlis milakebis dazianebis
riskis Semcireba an maTi aRdgenis proce-
sis xelSewyoba. aq ar ganvixilavT konkre-
tuli klinikuri situaciebisaTvis reko-
mendebul RonisZiebebs (mag. Sardis gatu-
tovneba kraS-sindromis dros, kontrast-
inducirebuli nefropaTiis saprevencio
sxvadasxva meTodebi da sxv.).
miuxedavad imisa, rom Teoriulad Tu
cxovelebze Catarebul eqsperimentebSi
naCvenebia sxvadasxva medikamentis mwvave
tubuluri nekrozis sawinaaRmdego efeq-
ti, klinikuri kvlevebiT is arc erTi maT-
ganisaTvis ar aris dadasturebuli da Se-
sabamisad dResdReobiT rekomendebulad
ver CaiTvleba.
Sardmdenebi
Sardmdenebis (furosemidi, manitoli)
SesaZlo gamoyeneba Tmd-is prevenciisaTvis
efuZneba im mosazrebas, rom diurezis ga-
ZlierebiT moxdeba Tirkmlis milakebis ob-
struqciis gamomwvevi ujredebis da cilin-
drebis ̀ gamorecxva~. garda amisa, furose-
midis mier henles maryuJis aRmaval totSi
NaCl-is transportis inhibirebiT SeiZleba
Semcirdes ujredebis moTxovnileba ener-
giaze da Sesabamisad mgrnobeloba iSemi-
isadmi. manitolma osmosuri zemoqmedebiT
SeiZleba moaxdinos ujredebis postiSemi-
uri SeSupebis inhibireba.
furosemidisa da manitolis am Teoriu-
li renoproteqtoruli Tvisebebis miuxe-
davad, dResdReobiT arsebuli mtkice-
bulebebis safuZvelze maTi gamoyeneba
Tmd saprevenciod rekomendebuli ar aris.
metic, erT-erTma kvlevam aCvena furose-
midis gamoyenebiT Tmd-is sixSiris gazrda.
calke sakiTxia maRali doziT maryuJis
Sardmdenebis (furosemidi intravenurad
500-2000 mg-de dReSi) gamoyeneba Tmd-is
dros diurezis stimulaciis mizniT. amiT
SesaZlebelia miRweuli iqnas Tmd-is olig-
uriulidan araoliguriul formaSi gaday-
vana da siTxis balansis marTvis gaumjobe-
seba. miuxedavad amisa, dResdReobiT arse-
buli mtkicebulebebis safuZvelze Sard-
mdenis gaxangrZlivebuli gamoyeneba ar
SeiZleba rekomendebulad CaiTvalos, ram-
denadac is ar aumjobesebs pacientis an
Tirkmlis gadarCenis maCvenebels. furose-
midis gamoyenebis xarjze ar unda moxdes
dializis dawyebis gadavadeba am ukanaskne-
lis Cvenebis arsebobis SemTxvevaSi.
dopamini
dopamini didi xnis ganmavlobaSi iTvle-
boda Tirkmlis mwvave ukmarisobis efeq-
tur saprevencio saSualebad. gamoiyenebo-
da misi e.w. renuli doza (0,5-3 mkg/kg wT-
Si), romelic iwvevs wilTaSua arteriebis
da rogorc aferentuli, aseve eferentu-
li arteriolebis dilatacias da Sesabam-
isad aumjobesebs Tirkmlis sisxlis mimo-
qcevas. Tumca mravali kvlevis mixedviT ar
damtkicda dopaminis renoproteqtoruli
efeqti Tmd-is riskis Semcirebis Tvalsaz-
risiT, xolo misma gverdiTma movlenebma
(taqikardia, aritmia, miokardiumis da naw-
lavis iSemia) SeiZleba avadobis da sikvdi-
10
lobis zrda gamoiwvios.
bolo xanebSi dopaminis nacvlad Tmd-is
saprevenciod mowodebuli iqna fenoldo-
pami, romelic moqmedebs seleqtiurad do-
paminis A1 receptorebze da ar xasiaTdeba
alfa- an beta-adrenerguli efeqtiT. zo-
gierTma kvlevam aCvena misi efeqturoba,
xolo zogierTis mixedviT fenoldopamis
gamoyenebas ar Seumcireba Tmd-is ganviTa-
rebis sixSire. saWiroa am mimarTulebiT
multicentruli randomizebuli kontro-
lirebuli kvlevis Catareba.
winagulovani
natriurezuli peptidi
rogorc cnobilia, winagulovani natri-
urezuli (wnp) peptidi, sxva moqmedebebT-
an erTad, iwvevs Tirkmlis sisxlis nakadis,
natriumis eqskreciis da gfs-is gazrdas.
aqedan gamomdinare, is SeiZleba amcirebdes
tubuluri nekrozis da milakebSi cilin-
drebis formirebis risks. wnp analogiuri
preparatebi (anaritidi, nesiritidi) gam-
oiyeneba gulis ukmarisobis samkurnalod.
wnp renoproteqtoruli efeqtis Sesaxeb
sxvadasxva kvlevis mixedviT gansxvavebu-
li monacemebi arsebobs da jer-jerobiT
dadasturebulad ver CaiTvleba.
vazodilatatorebi
aRwerilia mwvave tubuluri nekrozis
ganviTarebis paTogenezSi endoTelin-1-is
- mZlavri vazokonstriqtoris - roli. te-
zasartanma - endoTelin-1-is receptoreb-
is antagonistma – eqsperimentSi Seamcira
Tirkmlis mwvave dazianeba iSemiis mod-
elze.
anTebis sawinaaRmdego
preparatebi
bolo xanebSi yuradReba maxvildeba
mwvave tubuluri nekrozis paTogenezSi
anTebiTi komponentis arsebobaze. dadas-
turebulia anTebiTi ujredebis, maT Soris
polimorfulbirTviani ujredebis, monoc-
itebis, makrofagebis da T limfocitebis
roli Tmd ganviTarebaSi. amis safuZvelze
SemuSavda ramdenime axali preparati, rom-
lebic eqsperimentSi leikocitebze mo-
qmedebis gziT amcireben milakebis iSemi-
ur dazianebas. magaliTad, minociklini war-
moadgens preparats, romelic erTdrou-
lad xasiaTdeba antiapoftozuri da anti-
anTebiTi moqmedebiT, amcirebs TirkmelSi
anTebiT processa da mikrovaskulur gam-
avlobas. SesaZloa am jgufis preparatebi
momavalSi dainergos klinikur praqtikaSi.
aRsaniSnavia, rom Tagvebze Catarebul
eqsperimentSi sefsisis modelze Tmd-s
ganviTarebaze dadebiTi efeqti moaxdina
simvastatinma. misi gamoyenebiT miRweuli
iqna sistemuri anTebis sawinaaRmdego efeq-
ti, milakebis hipoqsiis Semcireba, in-
trarenuli mikrocirkulaciis SenarCune-
ba, sisxlSi kreatininis donis daqveiTeba.
zrdis faqtorebi
mwvave tubuluri nerozis ganviTarebis
Semdeg milakebis aRdgena asocirebulia
zrdaze pasugismgebeli genebis gaaqtive-
basTan da zrdis faqtorebis (maT Soris in-
sulinis msgavsi zrdis faqtori - IGF-I, epi-
dermuli zrdis faqtori - EGF, hepatocite-
bis zrdis faqtori - HGF) gamoTavisufle-
basTan. isini astimuleben milakebis ujre-
debis regeneracias, rasac maTi mofunqcie
ujredebad diferenciacia moyveba. eqs-
perimentSi, zrdis faqtorebis egzogenuri
Seyvana aCqarebs milakebis regeneraciisa
da Tirkmlis funqciis aRdgenis process.
adamianebze Catarebul erT mcire kv-
levaSi IGF-I-s gamoyenebam ver Seamcira
Tqd-is sixSire. SesaZloa, es ganpirobe-
buli yofiliyo maTi dagvianebuli gamoy-
enebiT. savaraudod, maTi gamoyeneba uf-
ro efeqturi iqneba milakebis dazianebis
sawyis stadiaze.
zemoT aRwerili medikamentebis garda,
literaturaSi gvxvdeba monacemebi cxo-
velebze Catarebul eqsperimentebSi Tmd
11
saprevenciod Tu samkurnalod gamoyeneb-
uli sxvadasxva preparatebis efeqturobis
Sesaxeb, maT Soris: deferoqsamini, biliru-
bini, eriTropoetini, Tiroiduli hormoni,
Rerovani ujredebi da sxv.
Tirkmlis CanacvlebiTi Terapia
ar arsebobs gaidlainebi Tirkmlis Cana-
cvlebiTi Terapiis dawyebis Cvenebis Sesax-
eb. yvela calkeul SemTxvevaSi saWiroa pa-
cientis mdgomareobis individualuri Se-
faseba da klinikuri moqmedebis gegmis Se-
dgena.
amasTan, unda gvaxsovdes Tmd-is iseTi
garTulebebi, romlebic safrTxes uqmnian
pacientis sicocxles da Sesabamisad SeiZ-
leba dializis dawyebis ̀ absolutur~ Cve-
nebebad CaiTvalos (cxr.4).
aRsaniSnavia, rom bolo dros aRiniSneba
dializis SedarebiT adreuli dawyebis ten-
dencia. zogierTi retrospeqtiuli kvleva
miuTiTebs, rom winmswrebi dializi mZime
uremiis niSnebis ganviTarebamde SeiZleba
sikvdilobis SemcirebasTan iyos asocirebu-
li. Tirkmlis CanacvelebiTi Terapiis daw-
yebis optimaluri, mtkicebulebebze
dafuZnebuli, dros gansasazRvrad farTo
prospeqtuli kvlevebis Catarebaa saWiro.
arsebobs Tmd SemTxvevaSi Tirkmlis Ca-
nacvlebiTi Terapiis sxvadasxva formebi,
romlebic Semdeg jgufebad SeiZleba gaer-
Tiandes:
1. peritoneuli dializi;
2. xangamoSvebiTi hemodializi;
3. sisxlis eqstrakorporaluri wmendis
uwyveti meTodebi.
peritoneuli dializi
peritoneuli dializi Tmd SemTxvevaSi
iSviaTad gamoiyeneba da is ZiriTadad Tirk-
mlis terminaluri ukmarisobis samkurna-
lo meTodad ganixileba.
miuxedavad amisa, pd SeiZleba Tmd mqone
pacientTa zogierTi jgufisTvis opti-
malur Tirkmlis CanacvlebiT Terapias
warmoadgendes da garkveuli upiratesobe-
biTac xasiaTdeba:
- hemodinamikuri stabiloba: pd-is dros
siTxe organizmidan nela gamoidevneba,
rac amcirebs hemodinamikuri garTule-
bebis risks;
- metaboluri darRvevebis neli koreq-
cia: mwvave pd-iT uremiuli toqsinebis
neli mocileba amcirebs diseqvilibri-
umis risks;
cxr. 4. Tirkmlis CanacvlebiTi Terapiis Cvenebebi Tmd-is dros
anuria an oliguria < 200 ml/12 sT
hiperkalemia > 6.5 mmol/l
mZime acidemia (pH > 7.1)
mZime azotemia (Sardovana > 30 mmol/l)
organoTa (pirvel rigSi filtvis) refraqteruli SeSupeba
uremiuli encefalopaTia
uremiuli perikarditi
uremiuli neiropaTia / miopaTia
mZime disnatremia (>160 an < 115 mmol/l)
hiperTermia
dializiT mocilebadi toqsiniT mowamvla
12
- ar saWiroebs sistemur antikoagula-
cias;
- hiperalimentacia: pd siTxeSi glukozis
Semcveloba damatebiTi kaloriebis
wyaroa malnutriciis sawinaaRmdegod;
- ar saWiroebs specialur aparaturas da
aqedan gamomdinare, SeiZleba Catardes
nebismier saavadmyofoSi;
- hemodializTan SedarebiT ufro mosax-
erxebeli, martivi da usafrTxoa bavS-
vebSi.
peritoneuli dializis absolutur
Cvenebas Tmd-is dros warmoadgens Tirkm-
lis CanacvelebiTi Terapiis saWiroeba,
roca sxva meTodis gamoyeneba SeuZlebelia.
SedarebiT Cvenebebs miekuTvneba:
- hemodinamikuri arastabiloba,
- sisxlmdeni diaTezi an hemoragiuli mdgo-
mareobebi,
- sisxlZarRvovani midgomis sirTule,
- mZime hiper- an hipoTermia,
- bavSvTa asaki.
mwvave peritoneuli dializis Se-
darebiTi ukuCvenebebia:
- axlo warsulSi gadatanili operacia mu-
clis an gulmkerdis Rruze,
- sunTqviTi ukmarisoba
- mZime gastroezofaguli refluqi
- sicocxlisaTvis saSiSi hiperkalemia
- sicocxlisaTvis saSiSi hipervolemia
- hiperkataboluri Tmd
- orsuloba
xangamoSvebiTi
hemodializi
xangamoSvebiTi dializi Tmd-is dros
praqtikulad ar gansxvavdeba qronikuli
hemodializisagan. dResdReobiT ar arse-
bobs mtkicebulebebze dafuZnebuli reko-
mendaciebi Tmd-is dros hemodializis op-
timaluri reJimis Sesaxeb.
aSS-Si xangamoSvebiTi hemodializi Cveu-
lebriv dRegamoSvebiT an kviraSi samjer
tardeba. rac Seexeba hemodializis dozas,
ADQI-s mier mowodebulia rekomendacia,
romlis mixedviTac is ar unda iyos qroni-
kuli hemodializisTvis gansazRvrul min-
imalur adekvatur dozaze (anu Kt/V 1.2) na-
klebi kviraSi samjeradi dializis SemTx-
vevaSi.
yoveldRiuri (an kviraSi eqvsjer) hemo-
dializis SemTxvevaSi SeiZleba sakmarisi
iyos Kt/V > 1.0.
uwyveti meTodebi
Tirkmlis CanacvlebiTi Terapiis uwyve-
ti meTodebi uzrunvelyofen Tmd-is dros
organizmis uwvyvet eqstrakorporul wmen-
das. maT miekuTvneba:
- uwyveti veno-venuri hemodializi (Con-
tinuous venovenous hemodialysis – CVVHD).
hemodializis dros xdeba sivrceTa (sis-
xli da dializati) Soris nivTierebaTa
difuzia membranis gavliT koncentraci-
uli gradientis sawinaaRmdegod, magal-
iTad Sardovana, kreatinini, kaliumi
gadadis sisxlidan dializatSi, xolo
kalciumi, bikarbonati - sapirispiro mi-
marTulebiT.
- uwyveti veno-venuri hemofiltracia
(Continuous venovenous hemofiltration - CVVH).
hemofiltraciis dros hidrostatikuri
wnevis gamoyenebiT xdeba plazmis wylis
filtracia membranis gavliT. wyalTan
erTad konveqciiT organizmidan gam-
oidevneba masSi gaxsnili mcire da saSu-
alo molekuluri masis mqone nivTier-
ebebi. erTdroulad organizmSi xdeba Ca-
manacvlebeli siTxis, e.w. substituatis
reinfuzia.
- uwyveti veno-venuri hemodiafiltra-
cia (Continuous venovenous hemodiafiltration
- CVVHDF) warmoadgens zemoT aRwerili
ori meTodis (CVVHD da CVVH) kombina-
cias.
Tirkmlis CanacvlebiTi Terapiis uwyve-
ti meTodebis upiratesobas xangamoSvebiT
hemodializTan SedarebiT miekuTvneba:
- kardiovaskuluri stabilobis gazrda,
rac gansakuTrebiT mniSvnelovania hemod-
13
mZime hiperkatabolizmis SemTxvevaSic ki;
- anTebiTi mediatorebis gaumjobesebu-
li klirensi, rasac SeiZleba dadebiTi efe-
qti hqondes sefsisis dros;
- RviZlis fulminanturi ukmarisobis
SemTxvevaSi Tirkmlis CanacvlebiTi Tera-
piis uwyvetma meTodebma SeiZleba cereb-
ruli perfuziis SenarCunebas Seuwyos xeli.
aRniSnulis miuxedavad, dResdReobiT
uwyveti meTodebis upiratesoba xangamoS-
vebiT dializTan SedarebiT mtkicebule-
bebiT dadasturebuli ar aris. amasTan,
gasaTvaliswinebelia, rom uwyveti meTode-
bi moiTxovs gazrdil xarjs, ZviradRire-
bul aparaturas, samedicino personalis
gaZlierebul datvirTvas da a.S.
bolo wlebSi zogierTi centri iyenebs
Tirkmlis CanacvlebiTi Terapiis iseTi
formebs, romlebic marTalia, ar aris ̀ uw-
yveti~, magram imave miznebs isaxavs, rasac
uwyveti meTodebi. igulisxmeba sisxlis
eqstrakorporuli wmendis yoveldRiuri,
gaxangrZlivebuli da naklebad intensiuri
meTodebi.
literaturaSi maT xSirad moixseneben,
rogorc hibridul Terapias. gvxvdeba aseve
terminebi `sustained low efficiency (daily) dialy-
sis~ (SLEDD), ̀ sustained low efficiency (daily) diafil-
tration~ (SLEDD-f), ̀ extended daily dialysis~ (EDD),
`slow continuous dialysis~ (SCD), ̀ go slow dialysis~.
inamikuri darRvevebis mqone pacientebSi;
- ultrafiltraciisadmi tolerantobis
gazrda, rac aumjobesebs pacientis vole-
miuri statusis kontrols;
- azotemiis dabal doneze SenarCuneba
gamoyenebuli literatura:
1. Alex M. Davison et al. Oxford Textbook of Clinical Nephrology, 2005
2. Ulrich Kuhlman et at. Nephrologie, 1998
3. Barry M. Brenner. Brenner & Rector’s The Kidney, 2008
4. Rasheed A Balogun, Mark D Okusa. Possible prevention and therapy of postischemic
acute tubular necrosis, UpToDate.
5. Paul M Palevsky. Renal replacement therapy (dialysis) in acute renal failure: Indications,
timing, and dialysis dose. UpToDate
6. Thomas A Golper. Dialysis in acute renal failure: Metabolic and hemodynamic considerations,
UpToDate
7. Theodore W Post, Burton D Rose. Diagnostic approach to the patient with acute or chronic kidney
disease, UpToDate.
8. Mark R Marshall, Thomas A Golper. Sustained low efficiency or extended daily dialysis, UpToDate.
14
tubulur-intersticiuli nefriti
tubulur-intersticiuli nefritis (tin) mTavari ganmsazRvreli niSani interstici-
umSi mimdinare anTebiTi procesia. ganarCeven mwvaved da qronikulad mimdinare tin-s.
intersticiuli sivrcis dazianeba SeiZleba iyos rogorc pirveladi, aseve meoradi glom-
eruluri da vaskuluri daavadebaTa farglebSi. sxvadasxva literaturuli monacemebis
mixedviT, Tirkmlis mwvave ukmarisobis SemTxvevaTa 15%-mde, xolo Tirkmlis qroniku-
li daavadebis 25%-s Seadgens pirveladi tubulur-intersticiuli nefriti. qvemoT ganx-
iluli iqneba pirveladi tin-is mwvave da qronikuli SemTxvevebi.
mwvave tubulur-intersticiuli nefriti
definicia:
Tirkmlis funqciis swrafi gauareseba,
romlis histopaTologiuri niSnebia inter-
sticiumis anTeba da SeSupeba, aseve Tirkm-
lis tubuluri aparatis dazianeba. yvela
is tubulur-intersticiuli dazianeba,
romelic ar aris gamowveuli mwvave
pielonefritiT, mwvave tubuluri nek-
roziTa da mwvave mocilebis sindromiT,
iyofa sam kategoriad: medikamenturi, in-
feqciaasocirebuli da idiopaTiuri.
medikamenturi
sul ufro da ufro izrdeba im medika-
mentebis ricxvi, romlebmac SeiZleba mwva-
ve tubulur-intersticiuli dazianeba gam-
oiwvion. xSiria ara mxolod β-laqtam anti-
biotikebTan asocirebuli SemTxvevebi,
aramed sxva antibiotikebiT (sulfonamide-
bi, rifampicini, vankomicini, ciproflo-
qsacini, klaritromicini da sxv.) gamowveu-
lic. savaraudod ori faqtori unda gana-
pirobebdes antibiotikebis nefrotoqsi-
urobas imaze ufro xSirad, vidre es Cveu-
lebriv aris mosalodneli. pirveli, bevri
maTgani iniSneba sxva medikamentebTan ko-
mbinaciaSi, rac aZlierebs maT toqsiurobas
(magaliTad, arasteroidul anTebis sawi-
naaRmdego saSualebebi); meore, antimik-
robul saSualebaTa didi nawili organizmi-
dan gamoiyofa TirkmliT, ris gamoc Tirkm-
lis funqciis daqveiTebis pirobebSi –
iqneba es sakuTriv mocemuli Tu sxva
medikamentiT an raime sxva mizeziT ganpi-
robebuli - maTi koncentracia sisxlis Sra-
tSi matulobs da toqsiurobis albaTobac
izrdeba. iTvleba, rom β-laqtamebis mier
tin-is inducireba gamowveulia maTi hap-
tenizaciiT: β-laqtam rgolis gaxsnis Semdeg
molekula iZens damatebiT karboqsilireb-
is unars da SeuZlia kovalenturi bmebiT
SeuerTdes Sratis cilebis terminalur ami-
nomJavur boloebs. hapten-bmuli peptide-
bis mimarT ki, iseve rogorc sxva antigeneb-
is mimarT, mosalodnelia sxvadasxva xasia-
Tis imunuri pasuxis ganviTareba.
aseve maRalia arasteroiduli anTebis
sawinaaRmdego saSualebebiT (aass) gamo-
wveuli mwvave tin-is sixSire. gansakuTre-
biT xSiria revmatuli daavadebebis mqone
pacientebSi dehidrataciis, gulis dart-
ymiTi moculobis Semcirebisa da Tirkmlis
perfuziis daqveiTebis sxva mizezebis
dros. aass mkurnalobis fonze mwvave tu-
bulur-intersticiul dazianebasTan er-
Tad SeiZleba adgili hqondes podociteb-
is pedikulebis gasadavebas – minimaluri
cvlilebebis glomerulopaTias, rac klin-
ikurad saSualo an masiuri proteinuriiT
vlindeba. daavadeba SeiZleba gamovlindes
aass mimarT eqspoziciidan 2 kviradan 18
Tvemde periodSi.
aass Tirkmelze toqsiuri efeqti Sei-
Zleba gamowveuli iyos:
1. araqidonis mJavis metabolizmis gan-
mapirobebeli mTvari enzimis ciklooqsi-
genazas inhibirebisas TirkmelSi alterna-
15
tiuli lipooqsigenizaciis gaaqtivebiT,
ris Sedegadac gamomuSavdeba proanTebiTi
leikotrienebi da hidroqsieikozoanoide-
bi;
2. alergiuli reaqciiT, razec miuTi-
Tebs intersticiumSi eozinofilebis arse-
boba an manifestirebuli Ig-E hipersensibi-
loba.
infeqcia
mwvave tubulur-intersticiuri nefri-
ti SeiZleba asocirebuli iyos mwvave baq-
teriul pielonefritTan, Tirkmlis tu-
berkulozTan da sokovan infeqciasTan.
mwvave tin-is ganviTarebas aseve SeiZleba
iwvevdes virusebi (hantavirusi, citomeg-
alovirusi, ebStein baris virusi, herpes
simpleqsi, C hepatiti da sxva), protozoe-
bi (toqsoplazma, leiSmaniozi), baqterie-
bi (difteria, streptokoki, brucelozi,
leptospirozi da sxva), riketsia, qlamid-
ia, mikoplazma. sistemuri xasiaTis infeq-
cia SeiZleba Tavad iwvevdes Tirkmlis tu-
bulur-intersticiuli sivrcis dazianebas
an adgili hqondes Tirkmlis im medikamen-
tebiT dazianebas, romlebic gamoiyeneba
gamomwvevis samkurnalod.
idiopaTiuri
tubulur-intersticiuli sivrce Sei-
Zleba Tavad gaxdes anTebiTi procesis daw-
yebis mizezi. am procesSi mTavar rols Tama-
Soben e.w. nefritogenuri antigenebi:
1. megalini, romelic warmoadgens trans-
membranul proteins da ganlagebulia
mocimcime epiTeliumSi;
2. Tam-horsfalis glikoproteini (Thp),
romelic garkveul pirobebSi antigenur
Tvisebebs iZens. es dadasturebul iqna Thp
Semcveli imunuri depozitebisa da anti-
Thp antisxeulebis aRmoCeniT henles
maryuJis sqeli aswvrivi totis ujred-
Soris sivrceSi;
3. tin-antigeni, romelic identificir-
ebul iqna tubuluri bazaluri membranis
(tbm) mimarT gamomuSavebuli anti-tbm-an-
tisxeulebiT gamowveuli intersticiuri
nefritis dros da romelic lokalizebu-
li iyo ZiriTadad proqsimaluri milakebis
bazalur membranaSi, mcire raodenobiT
distalur milakebsa da boumenis kafsula-
Si. dadgenil iqna tin-antigenis msgavseba
tip-IV kolagenTan da lamininTan da misi
roli milakebis bazaluri membranis inte-
grirebaSi. tin-antigenis defeqtis Sedegia
Tandayolili tubulur-intersticiuli
darRvevis - iuveniluri nefronoftizis
ganviTareba.
anti-tbm-nefriti SeiZleba asocirebu-
li iyos membranul nefropaTiasTan. is up-
iratesad viTardeba mamakacebSi. SiZleba
daiwyos bavSvobis asakSi da vlindebodes
mikrohematuriiTa da nefrozuli xarisxis
proteinuriiT. aseT pacientebs aReniS-
nebaT tubuluri disfunqcia (sruli an
arasruli fankonis sindromi), sisxlSi
mocirkulire anti-tbm antisxeulebi, rom-
lebic xasiaTdebian eqskluziuri urT-
ierTqmedebiT mxolod proqsimaluri mi-
lakis bazalur membranasTan da Tirkmlis
funqciis progresuli daqveiTeba.
idiopaTiuri tubulur-interstici-
uli nefriti da wina bilateraluri uvei-
ti e.w. tinu (TINU) sindromi, pirvelad aRwe-
ra 1975 w Dobrin, romelic gvxvdeba mozrdil
asakSi da upiratesad qalebSi (3:1). sindro-
mis imunur genezs adasturebs TirkmelSi
T limfocitebis proliferacia. Senelebu-
li tipis hipersensibilobaze miuTiTebs
agreTve am dros TirkmelSi CD4/CD8 limfo-
citebis 2:1 Tanafardobis arseboba.
klinikuri manifestacia da
diagnozi
mwvave tin klinikuri suraTi Sedgeba
lokaluri da sistemuri manifestaciis
niSnebidan. Tirkmlis dazianeba vlindeba
Tirkmlis mwvave ukmarisobis niSnebiT,
rogoric aris oliguria, sisuste, anoreq-
sia, gulisreva da Rebineba. klinikuri niS-
nebi meryeobs did diapazonSi – kreatini-
nis usimptomo matebidan generalizebuli
hipersensibilobis sindromamde - cxeleba,
16
kanze makulur-papulozuri egzanTema,
eozinofilia da oliguria. klasikuri tri-
ada, rogoricaa subfebriluri xasiaTis
temperaturuli reaqcia, kanze gamonayari
da arTalgia, pirvelad aRwerili iyo meTi-
cilin-inducirebuli mwvave tin-is dros,
Zalian iSviaTia. arteriuli wneva Cveu-
lebriv ar aris maRali, Tu ar ganviTarda
Tirkmlis mwvave ukmarisoba.
Tirkmlis mwvave ukmarisobis garda,
mwvave tin SeiZleba vlindebodes tubulo-
paTiiT: tubuluri acidozi, tubuluri
proteinuria, fankonis sindromi, hip-
erkalemia, hipernatremia da Sardis koncen-
trirebis unaris daqveiTeba. am dros xSiria
eozinofiluria, gansakuTrebiT β -laqtame-
bis SemTxvevaSi, magram is ar aris specifi-
uri mxolod intersticiuli nefritisTvis;
eozinofiluria SeiZleba aRiniSnebodes
swrafad progresirebadi glomerulone-
fritis, mwvave prostatitis, cistitis,
Sardis buStis karcinomis, saSarde gzebis
qronikuli infeqciisa da Tirkmlis ar-
teriis emboliis drosac. aass inducirebu-
li mwvave tin-is SemTxvevaSi xSiria pro-
teinuria (ix. zemoT).
tin savaraudoa yvela im pacientTan,
romelTanac adgili aqvs sisxlSi kreatini-
nis matebas glomeruluri an vaskuluri
dazianebis, prerenuli faqtorebisa da
sonografiulad saSarde sistemis dilat-
aciis gamoricxvisas. gansakuTrebiT rTu-
lia diagnostika im SemTxvevebSi, rodesac
erTmaneTs droSi emTxveva nefritoge-
nuri/nefrotoqsiuri medikamentebis miRe-
ba da mZime operacia, sistemuri xasiaTis
infeqcia an iseTi daavadeba, romelic Ta-
vad SeiZleba iwvevdes tubulur nekrozs.
tin-is dros Tirkmelebi sonografiu-
lad SeiZleba iyos normaluri an gadide-
buli, kortikaluri Sris eqogenoba momate-
buli an Seucvleli, Tumca es monacemebi
ar iZleva mwvave tin-is Tikmlis mwvave uk-
marisobis sxva mizezebisgan diferencire-
bis saSualebas.
tin-is diagnostikis ̀ oqros standarti~
Tirkmlis biofsiaa. is naCvenebia im SemTx-
vevaSi, Tu savaraudo gamomwvevi mizezis
moxsnis pirobebSi Tirkmlis dazianebis
xarisxi darCeba Seucvleli da/an steroi-
debiT mkurnalobis sakiTxis gadawyveti-
saTvis.
prognozi da mkurnaloba
mwvave tubulur-inersticiuli nefri-
tis gamovlenidan 2 kviris manZilze daa-
vadebis gamomwvevi medikamentis SeCereb-
is SemTxvevaSi ufro metia Tirkmlis nor-
maluri funqciis aRdgenis albaToba. ga-
momwvevi agentis miRebis gaxangrZliveba 3
da met kviremde mniSvnelovnad auaresebs
gamosavals. pacientebis umravlesobas
medikamentis SeCerebis Semdeg aReniS-
nebaT Tirkmlis funqciis spontanuri,
yovelgvari damatebiTi saSualebebis
CarTvis gareSe, gaumjobeseba; Tumca
garkveul nawils SeiZleba esaWiroebodes
simptomuri mkurnaloba wyal-marilovani
balansis dasaregulireblad, aseve cx-
elebisa da sistemuri xasiaTis sxva sim-
ptomebis samkurnalod. dializiT mkur-
naloba naCvenebia Tirkmlis mwvave ukmari-
sobis SemTxvevaSi. steroidebiT mkurnalo-
bis Sesaxeb monacemebi araerTmniSvnelova-
nia. amitom gadawyvetileba steroidebis
gamoyenebaze metwilad daavadebis klini-
kuri suraTidan gamomdinare unda iqnas
miRebuli. magaliTad tinu sidnromis
SemTxvevaSi steroidebiT mkurnalobis
Sedegad swrafad xdeba Tvalisa da Tirkm-
lis mxriv ganviTarebuli darRvevebis
ukuqceva. am dros prednizoloni gamoiy-
eneba 1,0 mg/kg/d 2-3 kvira dozis Semdgomi
swrafi klebiT 3-4 kviris ganmavlobaSi.
biofsiiT imunuri kompleqsebis akumu-
laciis SemTxvevaSi SeiZleba dRis wesrig-
Si dayenebul iqnas ciklofosfamidiT an
ciklosporiniT mkurnalobis sakiTxic.
sisxlSi mocirkulire anti-tbm-antisxeu-
lebis SemTxvevaSi SesaZloa dadges plazma-
fereziT mkurnalobis saWiroebac ki.
17
qronikuli tubulur-intersticiuli nefriti
qronikuli tubulur-intersticiuli
nefritis gamomwvevi mizezebi Sejamebulia
cxril 5-Si.
qronikuli tin-isTvis Semdegi mor-
fologiuri cvlilebebia damaxasiTebeli:
milakovani (tubuluri) ujredebis atro-
fia da brtyeli epiTeluri ujredebiT
Canacvleba, milakebis dilatacia, inters-
ticiumis fibrozi, aseve mononukleuri
ujredebiT infiltrirebuli ubnebis arse-
boba intersticiumsa da milakTa Soris siv-
rceSi; tubuluri bazaluri membranis gas-
qeleba; intersticiumis infiltracia lim-
focitebiT, makrofagebiTa, ufro iSviaT-
ad neitrofilebiT, plazmuri ujredebiTa
da eozinofilebiT. Tavidan glomerulebi
Seucvlelia, magram intersticiuli ne-
fritis progresirebasTan erTad matu-
lobs cvlilebebi glomerulebis mxridan-
ac: periglomeruluri fibrozi, segmentu-
ri sklerozi da bolos globaluri sklero-
zi; mcire arteriebsa da arteriolebSi
aRiniSneba intimis sxvadasxva xarisxis fi-
brozuli gasqeleba, magram ara vaskuliti-
savis damaxasiaTebeli niSnebi.
Tu gadavxedavT tubulur-interstici-
uli nefritis gamomwvev mizezebs, mivx-
vdebiT, rom SeuZlebelia TiToeuli maT-
ganis am nawilSi ganxilva. amitom gadavw-
yviteT SevCerdeT mxolod zogierT maT-
ganze.
analgetikuri nefropaTia
analgetikuri nefropaTia Tirkmlis
nela moprogresire daavadebaa, rom-
lisTvisac damaxasiaTebelia Tirkmlis
dvrilovani (papiluri) nekrozi da qroni-
kuli intersticiuli nefriti. aRniSnuli
daavadebis mizezi sxvadasxva analgetikuri
saSualebebis (antipiretikebi, anilidebi
da salicilatebi kofeinTan an kodeinTan
kombinaciaSi) Warbi da sistematuri mox-
marebaa. evropaSi Tirkmlis terminaluri
ukmarisobas 3-5%-Si analgetikuri nefro-
paTia ganapirobebs maSin, roca amerikaSi
es maCvenebeli mxolod 0,8 % Seadgens.
cxr. 5. qronikuli intersticiuli
nefritis mizezebi
pirveladi
medikamentebi analgetikebi,5-aminosalicilis mJava,arasteroiduli anTebis
sawinaaRmdego preparatebi,Cinuri mcenareebi,
liTiumi.
toqsinebi tyvia,kadmiumi,
balkanuri nefropaTia.
metaboluri SardmJavaddarRvevebi paTologiuri
metabolizmi,hipokalemia,
hiperkalcemia,hiperoqsaluria.
imunuri sarkoidozi,Sogrenis sindromi.
infeqcia bacterial pielonefriti,hanta virusi,
leptospirozi.
hematologiuri namglisebrujre-darRvevebi dovani anemia,
msubuqi jaWvebisnefropaTia,amiloidozi.
meoradi
meoradi qronikuli tubulur-inter-sticiuli nefriti gulisxmobs daa-
vadebebs, rodesac pirveladi pa-Tologiuri procesi iwyeba sisxlZarR-
vovan, glomerulur an milakovansistemaSi da Semdeg erTveba tubulur-
intersticiuli sivrce.
18
paTogenezi:
meqanizmi, romelic safuZvlad udevs
Tirkmlis dazianebas, ar aris bolomde
gasagebi. fenacetinis metabolizmis Sede-
gad warmoiqmneba acetaminofeni da reaqti-
uli Sualeduri produqtebi, romlebsac
SeuZliaT ujredis dazianeba lipiduri pe-
roqsidaciis gaaqtivebis gziT. aRniSnuli
metabolitebis Calageba xdeba tvinovan
SreSi koncentraciuli gradientis Semqmne-
li sistemis gaswvriv, ris gamoc dvrilis
mwvervalSi metabolitebis did raodenoba
iyris Tavs - aq maTi koncentracia maqsi-
maluria.
swored amitom sisxlZarRvovani da-
zianeba swored Tirkmlis dvrilovani naw-
ilidan iwyeba.
Tirkmlis dazianeba aspiriniT acetami-
nofenTan kombinaciaSi Semdegi ori meqa-
nizmiT aris ganpirobebuli:
1. prostaglandin-H saSualebiT acetami-
nofeni ganicdis metabolizms, ris Sedega-
dac adgili aqvs N-acetil-p-benzoqvinon-
eiminebis kumulacias da glutaTionTan
koniugirebas. aRniSnuli iwvevs glutaTio-
nis, romelic icavs ujreds reaqtiuli me-
tabolitebis zemoqmedebisgan, Semcvelo-
bis Semcirebas. izolirebulad acetami-
nofenis gamoyenebisas glutaTioni im rao-
denobiT warmoiqmneba, romelic sakmari-
sia reaqtiuli metabolitebis deto-
qsikaciisaTvis. aspirinTan kombinaciisas ki
damatebiT warmoiqmneba salicilatebi,
romlebic Tavis mxriv kidev ufro amcir-
eben glutaTionis Semcvelobas, rasac
moyveba acetaminofenis metabolitebis
mier lipiduri peroqsidaciisa da qsovilo-
vani cilebis arilizaciis procesebis gaaq-
tiveba da sabolood dvrilovani nekrozis
ganviTareba;
2. aspirini ciklooqsigenazas inhibireb-
is gziT iwvevs prostaglandinebis sin-
Tezis supresias. Tirkmlis perfuzia mniS-
vnelovnad aris damokidebulis `vazodi-
latator~ prostaglandinebis rogorc
sistemur aseve lokalur produqciaze. am-
itom aspirinis daniSvnisas adgili aqvs
Tirkmlis hemodinamikis gauaresebas.
dvrilovani nekrozis adreul stadiaze
Tirkmeli makroskopulad normaluri
zomisaa. fenacetinis xangrZlivi gamoy-
enebisas Tirkmlis piramidebi moyviTalo-
moyavisfro ferisaa; Cveulebriv Tirkmlis
tvinovani Sris gareTa nawilsa da qerqovan
SreSi cvlilebebi ar aRiniSneba. Tirkmlis
ganiv WrilSi fiqsirdeba dvrilebis maku-
luri transformacia, romelic koncentr-
irebulia Semkrebi milakebis irgvliv. in-
testiciumis matriqsi gasqelebulia;
gamoxatulia peritubuluri kapilarebis
sklerozi an bazaluri membranisAgasqele-
ba. henles maryuJis aswvrivi nawilis epiTe-
liumsa da peritubuluri sisxlZarRvebis
endoTeliumSi aRiniSneba degeneraciuli
cvlilebebi an sruli nekrozi. ujredebis
danekrozebas SeiZleba adgili hqondes in-
testiciumSic. agreTve xSiria kalciumis
marilebis precipitaciac (sur.3).
19
sur.3.
intersticiuli nefriti da dvrilovani
nekrozi analgetikuri nefropaTiis dros:
mwvave kortikaluri atrofia da kortiko-
meduluri ujredovani infiltracia (a),
Tirkmlis dvrilovani nekrozi da kalci-
fikacia (b).
klinika:
analgetikuri nefropaTia SeiZleba
wlebis ganmavlobaSi usimptomod mimdinar-
eobdes. Tirkmlis milakebis disfunqcia
adreul stadiaSi vlindeba Sardis koncen-
trirebis unaris daqveiTebiTa da tubu-
luri acidoziT. aseve xSiria steriluri
leikocituria da tubuluri proteinuria.
xolo Tu proteinuriis xarisxi > 3,0 g/24
sT, safiqrebelia intesticiul nefritTan
erTad glomerulopaTiis Tanaarseboba.
arteriuli hipertenzia gvxvdeba anal-
getikuri nefritis 50%-Si da xasiaTdeba
avi mimdinareobiT, rac Tirkmlis qroniku-
li daavadebis swraf progress gana-
pirobebs.
hematuria dvrilovani nekrozis an
saSarde gzebis garTulebuli infeqciis
dros aRiniSneba. dvrilovani nekrozi iw-
yeba tkiviliT welis areSi, morecidive di-
zuriiT, romelic xSir SemTxvevaSi saSarde
gzebis infeqciiT rTuldeba; CamoTvlilT-
an erTad saxezea steriluri leikoci-
turia, tubuluri proteinuria da gorglo-
vani filtraciis progresirebadi daqveiTe-
ba. iq, sadac maRalia fenacetinis metabo-
litebis koncentracia, kerZod, Tirkmlis
tvinovani Sre, menji, SardsawveTi da Sar-
dis buSti, xSiria am nawilebSi uroepiTe-
luri simsivneebis ganviTareba, rac fenace-
tinis metabolitebis maalkilirebeli mo-
qmedebiT aisxsneba.
eqstrarenuli manifestaciebidan aR-
saniSnavia gul-sisxlZarRvovani daavade-
bebis, kerZod ki generalizebuli aTerosk-
lerozis, arteriuli hipertenziisa da
Tirkmlis arteriis stenozis ganviTareb-
is riskis gazrda; acetilsalicilis mJavis
mier eroziuli gastritisa da peptiuri wy-
lulis provocireba; fenacetinis deri-
vatebis mier splenomegaliis, hemolizis da
sisxlSi met-/sulfohemoglobinis da-
grovebis gamowveva; renuli osteodistro-
fia gacilebiT xSiria analgetikuri nefro-
paTiisas, vidre sxva etiologiis Tqd-is
dros. amis mizezia plazmaSi vitamin D3 da
1,25(OH)2-D
3 ufro adreuli daqveiTeba,
metad gamoxatuli acidozi da eTdroulad
safaRaraTe saSualebebis moxmarebis
SemTxvevaSi malabsorbcia. sxvadasxva
fsiqopaTologiuri cvlilebebidan aRsani-
Snavia qronikuli tkivilis sindromi, ris
gamoc pacientebi Tavis, welis, mxar-kisris
midamos da a.S. `tkivilis~ gamo mudmivad
iReben sxvadasxva tkivilgamayuCeblebs.
analgetikuri nefropaTiaze eWvi unda
iqnas mitanili:
- Tirkmlis qronikuli daavadebisa da gas-
trointestinuri simptomebis Tanaarse-
bobisas
- sonografiulad SeWmuxnuli Tirkmelebi,
milakovani acidozi da hiperkalemia no-
rmaluri gfs-is fonze
- Tirkmlis Wvali kenWis ararsebobis (dvri-
lovani nekrozi) dros
- Tirkmlis qronikul daavadebis stadiisa
da anemiis simZimis Seusabamoba
- radiologiuri da sonografiuli gamokv-
leviT Tirkmlis tvinovani Sris kalci-
fikacia da/an dvrilovani nekrozi
20
analgetikuri nefropaTiis diagnozis
dasmaSi didi mniSvneloba aqvs anamnezur
monacemebs, Tumca isic unda aRiniSnos, rom
xSir SemTxvevaSi pacientebi uaryofen an-
algetikebis miRebas.
analgetikuri nefropaTiis dros ganvi-
Tarebuli dvrilovani nekrozis vizual-
izacia SesaZlebelia pielografiiT.
analgetikuri nefropaTiis
radiologiuri niSnebi:
1.Seucvleli fiala; 2.dvrili SeSupebuli, sakontrasto nivTiere-
bis CarTva daqveiTebuli; 3.parcialuri dvrilovani nekrozi cen-
traluri RariTa da fistulis CamoyalibebiT; 4.sruli dvrilovani
nekrozi beWdiseburi Crdili; 5.dvrilovani nekrozi in situ; 6.dvri-
lis sekvestracia SardsawveTis okluziiT; 7.Tirkmlis `talRovani~
gareTa konturi - homogenurad gaTxelebuli qerqovani Sre nekro-
zuli dvrilis Tavze Cazneqilia da amozneqilia hipertrofuli Ber-
tini’s svetebis gaswvriv; 8. uroepiTeluri karcinoma
sonografiulad Tirkmlis gareTa konturi
uswormasworoa, piramidebi kalcificirebuli,
xolo parenqimis eqogenoba momatebuli.
aqve moyvanilia Sesabamisi kompiuter-
ul-tomografiuli gamosaxuleba.
analgetikuri nefropaTiis mkurnaloba
pirvel rigSi medikamentebis miRebisagan
Tavis Sekavebas gulisxmobs.
gasaTvaliswinebelia, rom dehidratacia
dvrilovani nekrozis ganviTarebis xelSem-
wyobi faqtoria; amitom analgetikuri nef-
ropaTiis dros sasurvelia pacientis ade-
kvaturi hidrataciuri statusis dacva,
Tumca Tqd-s dros sifrTxilea saWiro or-
ganizmSi siTxis mosalodneli retenciis
gamo. mniSvnelovania aseve antihiperten-
ziuli da saSarde gzebis infeqciis mku-
rnaloba, acidozisa da eleqtrolituri
disbalansis koreqcia.
21
arasteroiduli anTebis
sawinaaRmdego saSualebebi (aass)
am preparatebis gamoyenebisas ufro
xSirad zemoT aRwerili mwvave tin-ia dam-
axasiaTebeli, vidre qronikuli. Tirkmlis
dazianebis xelSemwyobi faqtorebia xan-
dazmuli asaki, hipertonia, aspiriniTan da
diuretikebTan kombinacia, dehidratacia,
dros TirkmelSi ganviTarebuli morfo-
logiuri cvlilebebi.
mkurnaloba mdgomareobs medikamentis
moxsnaSi, Tumca raoden paradoqsuladac
ar unda gveCvenos, zogierTi avtoris
azriT prednizolonis mokle kursi xels
uwyobs daavadebis swraf ukuqcevas.
5-aminosalicilis
mJava
bolo xanebSi nawlavis qronikuli anTe-
biT daavadebul pacientebSi gaxSirda aso-
ciacia 5-aminosalicilis mJavis preparate-
bis miRebasa da qronikul tin-s Soris.
amasTan, zogierT avtors aRwerili aqvs
SemTxvevebi, rodesac medikamentis Se-
Cerebis miuxedavad garkveuli wlebis gan-
mavlobaSi mainc ar aRiniSna Tirkmlis fun-
qciis sruli aRdgena.
5-aminosalicilis mJava struqturulad
gavs salicilis mJavas, fenacetinsa da ami-
nofens, amitom Tirkmels savaraudod igive
meqanizmiT unda azianebdes. gamoyofen 5-
aminosalicilis mJaviT ganpirobebul tin-
is gansakuTrebul formasac, romelic gam-
oirCeva intersticiumis gamoxatuli in-
filtraciiT makrofagebiT, T da B ujre-
debiT. es ki imis safuZvels iZleva, rom
aRniSnuli dazianebis mizezad medikamen-
turi autoantigenis sapasuxo imunuri
reaqcia CaiTvalos.
klinikurad, analgeziuri nefropaTiis-
gan gansxvavdebiT, daavadeba vlindeba 5-
aminosalicilis mJaviT mkurnalobi dawye-
bis pirveli wlis ganmavlobaSi. ufro xSir-
ia mamkacebSi, vidre qalebSi 15 : 2, aRwer-
ili SemTxvevebi meryeobs 14-45 wlis asakis
farglebSi. medikamentis kumulaciuri
doza ar aris intersticiuli dazianebis
prediqtori.
liTiumi
liTiumis preparatebi maniakalur-de-
presiuli sindromis samkurnalod gamoiye-
neba. am medikamentebis xangrZlivi miReba
Saqriani diabeti. qronikuli daavadeba ux-
Siresad mwvave tubulur-intersticiuli
nefritis gadatanis Semdeg yalibdeba.
aq moyvanil suraTebze (sur. 4, sur. 5)
mocemulia mwvave da qronikuli tin-is
sur. 4arasteroidiuli anTebis sawinaaRmdego sa-
SualebebiT gamowveuli mwvave intersticiulinefriti. aRiniSneba intersticiumis infiltra-cia mononukleuri ujredebiTa da eozino-
filebiT, romlebic iWrebian da azianeben mi-lakebs.
sur. 5intersticiuli nefritis gviani stadia. aRin-
iSneba fibrozi tubuluri atrofiiT, arterieb-is intimuri gasqeleba da mcire raodenobiT mo-nonukleuri ujrdebi.
22
iwvevs nefrogenul uSaqro diabets, qroni-
kul tubulur-intesticiul nefritsa da
fokalur-segmentur glomerulosklerozs.
liTiumi gamoiyofa Tirkmlis saSu-
alebiT: is gadis gorglovan filtrs da Sem-
deg xdeba misi proqsimaluri milakebiT
reabsorbcia ise, rom misi klirensi kreat-
ininis klirensis 1/3 Seadgens. Semkreb mi-
lakebSi liTiumis akumulacia iwvevs ade-
nilataciklazas da cikluri-AMP warmoqm-
nis inhibirebas, ris Sedegadac mcirdeba
aqvaporin-2 da antidiurezuli hormonis
(adh) receptorTa warmoqmna da rac adh-is
mimarT rezistentobis ganviTarebis mize-
zia. liTiumi aseve ainhibirebs ujredSida
glikogenis daSlis process da iwvevs mis
ujredSi dagrovebas. Tavis mxriv glikoge-
nis dagroveba aris distaluri milakebis
disfunqciis mizezi. Semkreb milakebSi
H+ATPase tumboze zemoqmedebis gamo li-
TiumiT mkurnalobisas irRveva Sardis
acidifikaciis procesic.
liTiumis preparatebis miReba gana-
pirobebs im zRurblis gazrdas, romelzec
plazmis kalciumi ainhibirebs paraThormo-
nis gamomuSavebas, rac meoradad hiper-
paraTireozis ganviTarebas iwvevs. liTiu-
mis preparatebiT mkurnalobisas ganvi-
Tarebuli hiperparaTireozisaTvis damax-
asiaTebelia paraThormonis donis mateba,
hiperkalcemia da pirveladi hiperparaT-
ireozisgan gansxvavebiT (romelic xasiaT-
deba hipofosfatemiiTa da hiperkalciuri-
iT), plazmaSi fosfatebis normaluri kon-
centraciiTa da hipokalciuriiT.
Tirkmlis liTiumiT dazianebisas biof-
siur masalaSi vlindeba fokaluri tubu-
luri cistebis arseboba distalursa da
Semkreb milakebSi; aseve mZime interstici-
uli nefriti da tubuluri atrofia (sur.6).
liTiumis preparatebiT inducirebuli
milakovani dazianebis – nefrogenuri uS-
aqro diabetis mkurnaloba liTiumis
preparatebis miRebis Sewyvetas gulisx-
mobs. Tu pacientis fsiqiuri mdgomareobis
gamo liTiumis preparatebis Sewyveta ver
xerxdeba, maSin iniSneba amiloridi an aras-
teroiduli anTebis sawinaaRmdego saSu-
alebebi. qronikuli intersticiuli nefri-
tis dros daavadebis prognozs gan-
sazRvravs Tirkmlis ukmarisobis xarisxi:
Tu kreatinini > 2,5 mg/dl, xSir SemTxveva-
Si liTiumis preparatis miRebis Sewyvetis
miuxedavad mainc viTareba Tirkmlis qron-
ikuli daavadeba, xolo Tu kreatinini < 2,1
mg/dl, prognozi metwilad keTilsaimedoa.
radiaciuli nefropaTia
sxvadasxva simsivnuri daavadebebis sa-
mkurnalod retroperitoneuli sivrcisa
da mTeli sxeulis dasxiveba an radioizo-
topuri nivTierebis gamoyeneba arcTu iS-
viaTad radiaciuli nefropaTiis ganvi-
Tarebas iwvevs. arsebobs radiaciuli ne-
fropaTiis paTogenezis ori Teoria: vasku-
luri da parenqimuli. vaskuluri Teoriis
Tanaxmad, radiaciuli nefropaTiis dros
pirvel rigSi ziandeba endoTeli, rac sisx-
lZarRvis Sida da Sua Sris gasqelebas iw-
vevs da viTardeba glomeruluri sisxl-
ZarRvebis Trombozi. parenqimuli Teori-
is Tanaxmad ki, radiaciuli nefropaTiis
sur. 6
23
dros Tavdapirvelad ziandeba epiTeluri
ujredi, rasac mosdevs intersticiuli
fibrozi da tubulebis nekrozi.
radiaciuli nefropaTiis dros aRiniS-
neba glomerulebis, tubulebis, sisx-
lZarRvebisa da intersticiumis daziane-
ba. rogorc zemoT avRniSneT, pirvel rig-
Si ziandeba endoTeliumi, rac iwvevs mis
SeSupebasa da leikocitebiT infiltra-
cias. mezangiolizi xels uwyobs mik-
roanevrizmebis Camoyalibebas. podociti
radiaciuli nefropaTiis dros ar ziande-
ba, xolo glomerulur sisxlZarRvebSi
gvxvdeba fibrinuli depozitebi. am dros
ganviTarebuli tubulolizi iwvevs baza-
luri membranidan nekrozuli epiTeluri
ujredebis Camofcqvnas; intersticiumi
sxvadasxva anTebiTi ujredebiTaa infil-
trirebuli (sur.6).
radiaciuli nefriti viTardeba dasxive-
bidan 6-12 Tvis Semdeg da xasiaTdeba arte-
riuli hipertenziiT, proteinuriiTa da
Tirkmlis funqciis daqveiTebiT. anemia
mkveTrad aris gamoxatuli, romelic ar
Seesabameba Tirkmlis ukmarisobis xarisxs.
arteriuli hipertenzia xasiaTdeba avi mim-
dinareobiT da rTulad emorCileba mkur-
nalobas. Tirkmlis ukmarisoba yalibdeba
swrafad da SesaZlebelia pacienti ukve
erT weliwadSi Tirkmlis CanacvlebiT Ter-
apiaze gaxdes gadasayvani.
radiaciuli nefropaTiis mkurnaloba
antifibrozuli-antihipertenziuli
preparatebiT _ agf-infibitorebi da/an ar-
blokerebiT mkurnalobas gulisxmobs.
mkveTrad gamoxatuli anemiis dros gamoiy-
eneba erTiTropoetini. Catarebuli mkur-
nalobis miuxedavad xSir SemTxvevaSi Tqd
progresirebs da dgeba Tirkmlis Canacv-
lebiTi Terapiis aucilebloba. dialize
myof pacientTa prognozi ar aris kargi,
rasac umetesad pacientis ZiriTadi daa-
vadeba (limfoproliferaciuli daavadeba,
simsivnuri procesi, sxvadasxva infeqcie-
bisadmi momatebuli mgrZnobeloba) gana-
pirobebs. Tirkmlis transplantaciis
SemTxvevaSi prognozi gacilebiT ukeTesia,
gansakuTrebiT maSin, Tu Zvlis tvinisa da
Tirkmlis donori erTi da igive piria. aseT
SemTxvevaSi imunosupresiul Terapias pa-
cientebi ar saWiroeben; gvamuri trans-
plantaciis SemTxvevaSi imunosupresante-
bis doza 50%-iT mcirdeba.
balkanuri nefropaTia
balkanuri nefropaTia gvxvdeba rumi-
neTSi, bulgareTsa da serbeTSi. igi viTa-
rdeba 30-40 wels gadacilebul mosaxle-
obaSi. qalebi da mamakacebi avaddebian Ta-
nabrad. balkanuri nefropaTiis etiolo-
giuri faqtori sabolood dadgenili ar
aris, SesaZloa igi ganpirobebuli iyos gene-
tikuri, infeqciuri, garemo faqtorebiT an
zogierTi mikroelementis deficitiT. ar-
sebobs garkveuli korelacia balkanur ne-
fropaTiis ganviTarebis sixSiresa da 3q25
qromosomis mutacias Soris, magram serbeb-
Si es korelacia ar dadasturda. is faqti,
rom balkanuri nefropaTia igive sixSiriT
gvxvdeba emigrantebs Sorisac, daavadebis
paTogenezze garemo faqtorebis rolis
mniSvnelobaze miuTiTebs. eleqtronuli
mikroskopiiT Tirkmlis morfologiur su-
raTSi virusis nawilakebi iqna nanaxi, magram
konkretulad romeli virusi iwvevs balka-
nur nefropaTias, daudgenelia.
sur. 7isari - mezangiolizi da subendoTeluri glo-
meruluri kapilarebis mikroanevrizmebi, fifqi- bazaluri membranis gasqeleba.
24
sur. 8(a) - balkanuri nefropaTiis adreuli stadia,
normaluri glomerula, romelic garSemoc aRin-iSneba intersticiuli SeSupeba da tubulurisklerozi. (b) - peritubuluri kapilaruli baza-luri membranis gasqeleba. (c) - kortiko-medu-luri diferenciaciis Semcireba, tubuluri atro-fia da glomerulebis kolafsi. (d) - hipocelu-luri intersticiuli fibrozi, romlis garSemoatrofiuli epiTeluri ujredebi aRiniSneba.
baSi usimptomod mimdinareobdes. klini-
kuri niSnebi mxolod Tirkmlis funqciis
mniSvnelovani xarisxiT daqveiTebis dros
aRiniSneba. anemia gvxvdeba 80%-Si, romel-
ic normocituli da hipoqromulia. arte-
riuli hipertenzia aRiniSneba 40%-Si,
romelic kargad emorCileba antihiperten-
ziul Terapias. saSarde gzebis infeqcia
aRiniSneba 14%-Si. aseve aRiniSneba nefrit-
uli xarisxis proteinuria, romelic Ziri-
Tadad β2 –mikroglobulinisa da cistatin
C-sgan Sedgeba. uroepiTeluri da Sard-
sawveTis simsivneebi CveulebrivTan Sedar-
ebiT 100-jer ufro xSirad gvxvdeba balka-
nuri nefropaTiis dros.
sinaTlis mikroskopiiT aRiniSneba di-
fuzuri, subkafsuluri intersticiuli
fibrozi. glomerulebis umetesi nawili
sklerozul cvlilebebs ganicdis da mor-
fologiurad Trombotuli mikroangio-
paTiis msgavs morfologiur cvlilbebs
gvaZlevs. wilakTaSoris sisxlZarRvebSi
aRiniSneba hialinuri cvlilebebi. imuno-
histoqimiiT cvlilebebi araspecifiuria;
adgili aqvs bazaluri membranis gaswvriv
granuluri IgM da C3 komplementis Calage-
bas (sur.8).
balkanuri nefropaTiis mkurnaloba sim-
ptomuria. arteriuli hipertenziis SemTx-
vevaSi iniSneba anitihipertenziuli mkur-
naloba agf-infibitorebiTa da/an ar blok-
erebiT. anemiis dros antianemiuri Terapia
erTiTropoetiniT. Tirkmlis terminaluri
ukmarisobis ganviTarebsas pacienti gada-
dis Tirkmlis CanacvlebiT Terapiaze:
hemo- an peritoneuli dializi da Tirkmlis
transplantacia.
a b
c d
balkanuri nefropaTia qronikuli, nela
progresirebadi daavadebaa, romelic sab-
olood Tirkmlis terminalur ukmarisobas
iwvevs. igi SesaZlebelia wlebis ganmavlo-
gamoyenebuli literatura:
1. Alex M. Davison et al. Oxford Textbook of Clinical Nephrology, 2005
2. Barry M. Brenner. Brenner & Rector’s The Kidney, 2008
25
18 wlis mamakaci moTavsda klinikaSi Sar-
dis analizSi aRmoCenili cvlilebebis sa-
diagnostikod. klinikaSi moTavsebamde
sami TviT adre aReniSneboda saxsrebis tki-
vili, xangamoSvebiTi cxeleba da gamonayari
saxeze. hospitalizaciisas obieqturad:
gamonayari saxeze, arteriuli wneva 130/80
mm vwy.sv., temperatura 37.50C; laboratori-
ulad: leikocitebi 4100/mm3, hematokriti
30%, Trombocitebi 105000/mm3, kreatinini
0.8 mg/dl, kreatininis klirensi 115 ml/wT,
saerTo cila sisxlSi 6.8 g/dl, albumini 3.8
g/dl, C3 da C34 komplementi daqveiTebu-
li, anti-DNA dadebiTi, mgluras antikoag-
ulanti dadebiTi; Sardis analiziT: pro-
teinuria 600 mg/24 sT, eriTrociti 15,
leikociti 5 mxedvelobis areSi, aRmoCnda
marcvlovani da ujredovani cilindrebi.
kiTxva 1.
rogoria Tirkmlis biofsiiT fokalur
an difuzur proliferaciuli lupus ne-
fritis (III an IV klasi) arsebobis albaToba
pacientSi, romelsac aReniSneba dar-
Rvevebi Sardis analizSi nefrozuli sin-
dromisa da Tirkmlis ukmarisobis gareSe?
1. 0%
2. 20-35%
3. 60-80%
4. 100%
Catarda Tirkmlis biofsia (sur.1). dais-
va difuzur-proliferaciuli glomeru-
lonefritis (IV klasi) diagnozi; aqtivobis
indeqsi 8, qronikulobis indeqsi 0.
suraTi 1.
dawyebul iqna mkurnaloba meTilpred-
nizolonis pulsiT (1 g dReSi sami dRis gan-
mavlobaSi, Semdgom prednizoni 0.5 mg/kg
dReSi) da peroraluri ciklofosfamidiT
(1 mg/kg dReSi). sami Tvis Semdeg miRweuli
iqna sruli klinikuri da laboratoriuli
remisia: kreatinini 0.6 mg/dl, proteinur-
ia 0.1 g/24 sT, Sardis naleqi paTologiis
gareSe.
kiTxva 2.
rogor imoqmedebdiT difuzur-pro-
liferaciuli lupus-nefritis sruli
remisiis miRwevis Semdeg?
1. mkurnalobis gagrZeleba
2. mkurnalobis Sewyveta
3. mkurnalobis neli Semcireba
4. mkurnalobis swrafi Semcireba
SemTxvevis ganxilva: lupus-nefriti
Dr G. Moroni
IRCCS Ospedale Maggiore, Policlinico, Milan, Italy
sruli remisiis miRwevidan erTi Tvis
Semdeg pacientma TviTneburad Sewyvita
mkurnaloba. eqvsi Tvis Semdeg gamoixata
cxeleba, saxsrebis tkivili, saxeze gamona-
26
yari, perikarditi, krunCxvebi. hospital-
izaciisas: arteriuli wneva 160/110 mm
vwy.sv., kreatinini 2.9 mg/dl, hematokriti
24%, leikocitebi 4100/mm3, Trombocitebi
102000/mm3, saerTo cila sisxlSi 5.3 g/dl,
albumini 2.8 g/dl, C3 da C34 komplementi
daqveiTebuli, proteinuria 5.6 g/24 sT;
Sardis naleqSi: eriTrocitebi 100, leikoc-
itebi 20 mxedvelobis areSi, aRiniSna
marcvlovani da eriTrocituli cilin-
drebis arseboba.
Catarda Tirkmlis ganmeorebiTi biof-
sia (sur.2). daisva difuzur-proliferaci-
uli lupus-glomerulonefritis (IV klasi)
diagnozi glomerulebis daaxloebiT 50%-
Si eqstrakapilaruli proliferaciiT,
10%-Si fibrinoiduli nekroziT da mZime
intersticiuli infiltraciiT; aqtivobis
indeqsi 15, qronikulobis indeqsi 2.
remisiis miRwevidan erTi wlis Semdeg
pacientma TviTneburad Sewyvita predni-
zonis miReba da eqimTan kontroli.
eqvsi wlis Semdeg pacientma kvlav mima-
rTa klinikas gamokvlevis mizniT. ar aRin-
iSneboda sistemuri wiTeli mgluras
eqstrarenuli niSnebi, arteriuli wneva
160/90 mm vwy.sv.; laboratoriulad: kreat-
inini 1.6 mg/dl, hematokriti 36%, leikoc-
itebi, Trombocitebi, C3 da C34 komplemen-
ti normaSi, saerTo cila sisxlSi 6.1 mg/dl,
albumini 3.4 g/dl, anti-DNA dadebiTi; 24
saaTiani proteinuria 2.8 g, eriTrocitebi
5 mxedvelobis areSi, marcvlovani cilin-
drebi.
aRniSnuli monacemebis mixedviT Sesa-
Zloa saqme gvqonoda sistemuri wiTeli
mgluras Tirkmlismier gamwvavebasTan an
qronikul araaqtiur cvlilebebTan.
kiTxva 3.
qvemoT CamoTvlili analizebidan
romelia saukeTeso sistemuri wiTeli
mgluras Tirkmlismieri gamwvavebis da-
dasturebis mizniT?
1. C reaqtiuli cila
2. antinukleuri antisxeulebi
3. anti-C1q antisxeulebi
4. edsi
5. anti-SM antisxeulebi
suraTi 2.
ganmeorebiT dainiSna mkurnaloba me-
Tilprednizolonis pulsiT (1 g dReSi sami
dRis ganmavlobaSi, Semdeg prednizoni 1 mg/
kg dReSi klebadi doziT) da peroraluri
ciklofosfamidiT (2 mg/kg dReSi pirveli
sami Tvis ganmavlobaSi da 1 mg/kg Semdegi
sami Tve).
10 Tvis Semdeg pacienti kvlav imyofe-
boda srul klinikur remisiaSi - kreati-
nini 1.1 mg/dl, proteinuria 0.12 g/24 sT,
Sardis araaqtiuri naleqi. daeniSna Sema-
narCunebeli Terapia - prednizoni 15 mg
dReSi.
dawyebul iqna mkurnaloba agf inhibi-
toriT (enalaprili 40 mg dReSi). sami Tvis
Semdeg 24 saaTiani proteinuria gaizarda
21 g-de, xolo kreatinini 2.1 mg/dl-mde.
Catarda Tirkmlis mesame biofsia, romel-
mac aCvena transformacia membranul lu-
pus-nefritad segmenturi proliferaciis
fonze (III+V klasi); glomerulebis 30%-is
danawibureba; aqtivobis indeqsi 3, qroni-
kulobis indeqsi 5.
27
kiTxva 4.
rogoria IV klasis lupus-nefritis
membranul glomerulonefritad (V kla-
si) transformaciis sixSire?
1. 0-10%
2. 10-20%
3. 20-30%
4. 30-40%
pacientma uari ganacxada steroidiT
puls-Terapiaze da daeniSna intravenuri
ciklofosfamidi (0.75 g/m2 TveSi 6 Tvis gan-
mavlobaSi, Semdeg sam TveSi erTxel) per-
oralur prednizonTan erTad. momdevno
sami wlis ganmavlobaSi Tirkmlis funqcia
iyo stabiluri (kreatinini 2-2.5 mg/dl),
Tumca rCeboda nefrozuli sindromi (24
saaTiani proteinuria daaxloebiT 10 g).
sami wlis Semdeg pacients ganuviTarda
hemianofsia cerebruli Trombozis Sede-
gad.
laboratoriulad: kreatinini 2.5 mg/dl,
saerTo cila sisxlSi 5.7 mg/dl, albumini
3.2 g/dl, proteinuria 12 g/24 sTi, C3 da C34
komplementi daqveiTebuli, anti-DNA
dadebiTi, mgluras antikoagulanti dadeb-
iTi, aCL IgG antisxeulebis maRali titri.
kiTxva 5.
ra saxis Terapias dauniSnavdiT lu-
pus nefritisa da antifosfolipiduri
antisxeulebis maRali titris mqone pa-
cients seriozuli Trombotuli
garTulebis Semdeg?
1. meTilprednizolonis pulsi
2. ciklofosfamidis pulsi
3. varfarini, samizne INR 2-3
4. varfarini, samizne INR 3-4
pacientis Tirkmlis funqcia progresu-
lad qveiTdeboda da daaxloebiT 3 wlis
Semdeg dawyebuli iqna hemodializiT mkur-
naloba. ori wlis Semdeg pacienti mokvda
miokardiumis infarqtis Sedegad.
ganxilul pacients aReniSneboda mrava-
li cudi prognozuli faqtori:
- mamrobiTi sqesi;
- difuzuri eqstrakapilaruli prolif-
eracia da nekrozi ganmeorebiTi biofsiisas;
- qronikulobis maRali indeqsi mesame
biofsiisas;
- morecidive Tirkmlismieri gamwva-
vevebi;
- antifosfolipiduri antisxeulebi.
amasTan, yvelaze mniSvnelovani faqtori, romelmac cud gamosavals Seuwyo xeli, iyo
pacientis daumorCilebloba SeTavazebuli Terapiis mimarT.
klinikur praqtikaSi daumorCilebloba xSirad Zneli dasamtkicebelia da misi alba-
Toba yovelTvis unda gvaxsovdes, gansakuTrebiT sistemuri wiTeli mgluras cudi gamo-
savlis SemTxvevaSi.
pasuxebi:
1. - 2
2. - 3
3. - 3
4. - 2
5. - 3
28
SemTxvevis ganxilva: sunTqvisa da Tirkmlis
kombinirebuli ukmarisoba
Dr Vincent M. Brandenburg, Prof Jürgen Floege Dr G. Moroni
Department of Nephrology, University Hospital Aachen, Germany
http://www.ndt-educational.org/brandenburgcase3.asp
42 wlis mamakaci Semovida klinikaSi xve-
liT, mzardi qoSiniTa da cxelebiT. sun-
TqviTi statusis swrafi gauaresebis gamo
saWiro gaxda filtvebis xelovnuri venti-
laciis dawyeba. 100%-iani JangbadiT moma-
ragebis, ventilaciuri parametrebis opti-
mizaciisa da pacientis poziciis SerCevis
miuxedavad ramdenime dRis ganmavlobaSi
arteriul sisxlSi Janbadis parcialuri
wneva progresulad ecemoda da sabolood
saturaciam 75%-ze naklebi Seadgina. paci-
enti gagzavnili iqna mwvave respiratoru-
li distresis centrSi.
gulmkerdis seriuli rentgenogramebiT
gamovlinda bilateruli moprogresire in-
filtratebis arseboba (sur.1). dawyebuli
iqna eqstrakorporuli oqsigenacia.
sunTqvis ukmarisobis pararelurad gan-
viTarda Tirkmlis mwvave oliguriuli uk-
marisoba. mdgomareoba Sefasda, rogorc
pulmo-renuli sindromi. dawyebuli iqna
mkurnaloba uwyveti veno-venuri hemofil-
traciiT.
laboratoriuli analizebiT gamovlin-
da anTebis suraTi (leikocitozi, C reaq-
tiuli cilisa da prokalcitoninis maRali
titri) da msubuqi anemia. RviZlis fermen-
tebi da koagulaciuri testebi iyo normis
farglebSi.
diferenciuli diagnostikisas ganix-
ileboda Semdegi variantebi:
- Tirkmlis mwvave ukmarisobis ganvi-
Tareba pirveladi sunTqvis ukmarisobis
mqone pacientSi iseTi araspecifiuri faq-
torebis moqmedebis Sedegad, rogoricaa
sefsisi, Soki;
- Tirkmlisa da sunTqvis kombinirebuli
ukmarisoba specifiuri infeqciebis Sede-
gad;
- imunologiuri daavadebebi, romlebic
gaerTianebulia `pulmo-renuli sindro-
mis~ saxeliT (gudpasCeris sindromi, vege-
neris granulomatozi da sxv.);
- medikamentebis an toqsiuri nivTier-
ebebis zemoqmedebiT ganviTarebuli sin-
dromi.
sur. 1
infeqciis gamosaricxad ramdenjerme
daiTesa sisxli, Sardi, bronqoalveoluri
kultura da dawyebuli iqna empiriuli an-
tibiotikoTerapia imipenemiTa da ciprof-
loqsaciniT. Tumca yvela naTesi aRmoCnda
steriluri, aseve uaryofiTi iyo testebi
antigenebsa da antisxeulebze.
29
amave dros gairkva, rom anamnezSi paci-
ents aReniSneboda arTralgiebi (asimetri-
uli oligoarTriti) da sisxliani gamonad-
eni cxviridan.
mikroskopSi gaisinja Sardis naleqi. aR-
moCnda mravali dismorfuli ertiTroci-
ti da eriTrocituli cilindrebi (sur. 2).
Catarda Tirkmlis biofsia. aRmoCnda
mcire imunuri (pauci-immune) fokalur-seg-
menturi glomerulonefriti naxevarmTva-
reebiT (sur.3).
Catarebuli imunologiuri kvleviT gam-
ovlinda ANCA-s maRali titri (1:320); PR3-
ANCA - 19 (norma <5); ANA da glomerulis
bazaluri membranis sawinaaRmdego antisx-
eulebi - uaryofiTi.
kiTxva 2
qvemoT CamoTvlilia sxvadasxva daa-vadebisaTvis damaxasiaTebeli simptom-ebi. romeli maTgani Seesabameba sinamd-viles?
1. leptospirozi - orfaziani daa-vadeba, kunTebis mtkivneuloba, mRrR-nelebTan kontaqti anamnezSi, koniuq-tiviti, siyviTle.
2. vegeneris granulomatozi - ar-Tralgiebi, riniti, otiti, sisxlianigamonadeni cxviridan.
3. sistemuri wiTeli mglura - po-liseroziti, arTralgiebi, Tromboci-topenia, saxis eriTemia, komplementisdaqveiTebuli done.
4. hanta virusi - muclisa da welistkivili, hipotenzia, kontaqti mRrRne-lebTan.
5. legionelozi - maRali cxeleba,diarea da sxva gastrointestinuri sim-ptomebi, Zilianoba, hiponatremia.
6. krioglobulinemia - purpura,periferiuli dambla, hepatitis niSne-bi
7. yvela maTgani
kiTxva 1
qvemoT CamoTvlil daavadebaTaganromelia yvelaze naklebad savaraudoaRniSnul situaciaSi?
1. gudpasCeris sindromi; 2. vegen-eris granulomatozi; 3. legion-elozi; 4. hantavirusuli infeqcia; 5.sistemuri wiTeli mglura; 6. liste-riozi
kiTxva 3
qvemoT CamoTvlilia sadiagnostikoRonisZiebebi sxvadasxva daavadebi-saTvis. romeli maTgani Seesabameba si-namdviles?
1. vegeneris granulomatozi - ANCA;cxviris lorwovanis, filtvis an Tirkm-lis biofsia
2. legionelozi - antigenis aRmoCe-na SardSi an naxvelSi; antisxeulebi sisx-lSi;
3. leptospirozi - Sardis mikrosk-opia; sisxlis, Sardis an Tav-zurg tvi-nis siTxis daTesva, sisxlis ELISA.
4. hantavirusi - Sardis PCR, antisx-eulebi sisxlSi.
5. sistemuri wiTeli mglura - ANA
da komplementi; Tirkmlis biofsia.6. Sonlain-henoxis purpura - kanis
biofsia, Tirkmlis biofsia.7. yvela CamoTvlili
sur. 2
sur. 3
30
kiTxva 4
qvemoT moyvanil cxrilSi mocemulia pulmo-renuli sindromis gamomwvevi sxvadasx-
va daavadebisaTvis damaxasiaTebeli imunologiuri da histologiuri monacemebi. rome-
li maTganisaTvis ar aris moyvanili monacemebi WeSmariti?
vg mpa Css gs swm kv Shp
PR3-ANCA +++ (+) + (+)
MPO-ANCA (+) ++ ++ +
Anti-GBM +++
ANA +++ +
krioglobulinebi (+) +++
komplementi ↓↓↓↓↓ ↓↓↓↓↓
histologia mid - - xid mid mid mid
vg - vegeneris granulomatozi, mpa - mikroskopuli poliaangiiti, Css - Carg-Strausis sindromi,
gs - gudpasCeris sindromi, kv - krioglobulinemiuri vaskuliti, Shp - Sonlain-henoxis purpura
mid - marcvlovani imunuri depozitebi, xid - xazovani imunuri depozitebi.
1. vegeneris granulomatozi
2. mikroskopuli poliangiiti
3. Carg-Strausis sindromi
4. gudpasCeris sindromi
5. krioglobulinemuri vaskuliti
6. Sonlain-henoxis purpura
daisva diagnozi: vegeneris granulomatozi. dawyebuli iqna imunosupresiuli Tera-
pia ciklofosfamidiT (3 mg/kg dReSi peroralurad) da prednizoloniT (500 mg intrave-
nurad sami dRe, Semdeg 1 mg/kg dReSi). klinikuri suraTi swrafad gaumjobesda: Semosvl-
idan meSvide dRes Sewyda filtvebis xelovnuri ventilacia, hemodializis bolo seansi
Catarda merve dRes. 4 kviris Semdeg pacienti gaewera saavadmyofodan sruli klinikur
remisiaSi. kreatinini am dros meryeobda 3.5-4.5 mg/dl farglebSi.
pasuxebi:
1. - 1
2. - 7
3. - 7
4. - 1 (vegeneris granulomatozisaTvis damaxasiaTebeli ar aris imunuri depozitebis arseboba)
31
siaxleebiK
K vitaminis roli sisxlZarRvTa kalcifikaciaSi Tqd-is dros
ANCA asocirebuli vaskulitis recidivis riski Tirkmlis
transplantaciis Semdeg
monacemebi ANCA asocirebuli vaskuli-
tis recidivis Sesaxeb Tirkmlis trans-
plantaciis Semdeg araerTgvarovania.
gaurkvevelia Tanamedrove imunosupresi-
uli sqemebis roli recidivis riskis Sem-
cirebaSi. aseve dauzustebelia transplan-
taciis rekomendebuli optimaluri dro.
Tirkmlis tranplnataciis Semdeg ANCA
asocirebuli vaskulitis recidivis six-
Siris Sefasebis mizniT Gera et al. mier gaana-
faqtors da SesaZloa, samkurnalo saSu-
alebasac ki warmoadgendes.
mtkicebulebebi uremiuli kalci-
fikaciis procesSi K vitaminis SesaZlo dam-
cav rolze mwiria. niderlandSi aRwerili
iqna kavSiri sakvebiT K vitaminis gaZliere-
bul miRebasa da kardiovaskuluri
garTulebebis riskis Semcirebas Soris. gar-
da amisa, winaswarma kvlevebma aCvena aso-
ciacia mocirkule imunoreaqtiuli os-
teokalcinis fraqciebis (K vitaminis sta-
tusis biomarkerebi) suboptimalur done-
sa da aortis kalcifikacias Soris post-
menopauzur qalebSi.
dializze myofi pacientebis tipiuri
dieta Seicavs dReSi 80 mkg an nakleb K vi-
tamins, rac naklebia janmrTeli populaci-
isaTvis rekomendebul doneze. erT-erTi
kvlevis mixedviT, hemodializze myofi pa-
cientebis daaxloebiT 30%-Si K vitaminis
subklinikuri deficiti aRiniSneba.
mniSvnelovani sakiTxia varfarinis - K
vitaminis antagonistis - farTo gamoyene-
ba hemodializis pacientebSi. monacemebi
varfarinis gamoyenebasa da sisxlZarRvo-
van kalcifikacias Soris kavSiris Sesaxeb
jerjerobiT Zalze mwiria, Tumca misi mo-
qmedebis meqanizmidan gamomdinare, mos-
alodnelia varfarini zrdides kalci-
fikaciis risks. es sakiTxi kvlevebiT das-
abuTebas moiTxovs.
Tirkmlis qronikuli daavadebis Sors-
wasuli stadiis mqone pacientTa sikvdilo-
bis ZiriTadi mizezi gul-sisxlZarRvTa
daavadebebia. dializze myof pacientebSi
mniSvnelovania rogorc aTerosklerozis
klasikuri riskis faqtorebi (arteriuli
hipertenzia, dislipidemia da sxv.), aseve
uremia-specifiuri faqtorebi, romlebic
xels uwyoben sisxlZarRvovan kalcifika-
cias da amZimeben gul-sisxlZarRvTa daa-
vadebebs.
sisxlZarRvTa kalcifikaciis riskis
faqtorebs miekuTvneba hiperfosfatemia,
meoradi hiperparaTireozi, D vitaminis
preparatebiTa da kalciumis Semcveli
fosfor-SemboWvelebiT Terapia. bolo
wlebSi gamoCnda monacemebi K vitaminis
damcavi rolis Sesaxeb kalcifikaciis pro-
cesSi dializze myof pacientebSi.
sisxlZarRvTa kalcifikaciis dros
gluvkunTovani ujredebi gardaiqmneba
osteoblastis msgavs ujredebad, rom-
lebic gamoimuSaveben mineralizaciis ma-
regulebel cilebs. erT-erTi maTgani -
e.w. Matrix Gla Protein (MGP) - arteriis ked-
lis mineralizaciis mainhibirebeli faq-
toria. vitamini K kofaqtoris rols asru-
lebs MGP-is aqtiur formad gardaqmnis
procesSi. arsebobs varaudi, rom vitami-
ni K dializis pacientebSi sisxlZarRvTa
kalcifikaciis modificirebad riskis
32
lizebuli iqna 1996-2005 wlebSi gadaner-
gili 35 pacientis samedicino istoria. Zir-
iTadi saboloo wertili iyo vaskulitis
recidivi, romelic ganisazRvreboda, ro-
gorc: kreatininis mateba nefrituli Sar-
dis fonze (nefropaTiis sxva mizezebis
gamoricxvis Semdeg); Tirkmlis biofsiiT
dadasturebuli mwvave nekrozi, mcired
imunuri an naxevarmTvareebiT mimdinare
glomerulonefriti; biofsiiT dadastu-
rebuli aqtiuri vaskuliti respiratorul
an gastrointestinur traqtSi; biofsiiT
dadasturebuli manekrozebeli vaskuliti
nebismier sxva organoSi; iriti an uveiti
sxva etiologiuri faqtorebis ararsebobi-
sas; hemoptizi, pulmonuri hemoragia an ax-
ali kvanZebis gaCena infeqciis niSnebis
ararsebobisas; mravlobiTi mononevritis
pirveli diagnozi.
aRniSnuli 35 pacientidan 20-is diagnozi
iyo mikroskopuli poliangiiti, xolo 15-
is - vegeneris granulomatozi. transplan-
tacia Catarda vaskulitis aqtivobis uka-
nasnkneli gamovlenidan saSualod 25 (4-
120) Tvis Semdeg, yvela pacienti gadanerv-
is dros imyofeboda klinikur remisiaSi.
pacientebis umravlesoba (74%) gadanerg-
vamde imyofeboda SemanarCunebel imuno-
supresiaze. yvela pacients perioperaci-
ulad daniSnuli qonda intravenuri meTil-
prednizoloni; 28 maTgans Cautarda indu-
qciuri Terapia (yvelaze xSirad antiTi-
mocituri globuliniT).
imunosupresiul sqemebSi yvelaze xSir-
ad (83%-Si) gamoiyeneboda mikofenolatis
mofetili takrolimusTan an ciklosporin-
Tan kombinaciaSi.
dakvirvebis saSualod 4.4 wlis periodis
ganmavlobaSi, 8 pacients (23%) ganuviTar-
da biofsiiT dadasturebuli mwvave moc-
ileba. sam (9%) pacients (ors vegeneris
granulomatoziT da erTs mikroskopuli
poliangiitiT) aReniSna vaskulitis reci-
divi. samive SemTxvevaSi recidivi iyo eqs-
trarenuli. mkurnaloba Catarda predni-
zolonis dozis gazrdiT da takrolimusis
damatebiT an meTilprednizoloniTa da
rituqsimabiT.
samive pacientTan miRweuli iqna klini-
kuri da bioqimiuri remisia.
avtorebi askvnian, rom ANCA asocire-
buli vaskulitis recidivis riski Tirkm-
lis transplantaciis Semdeg dabalia da
is pacientTa am jgufSi Tirkmlis Canacv-
lebiTi Terapiis optimalur meTods war-
moadgens.