1
ivane javaxiSvilis saxelobis Tbilisis saxelmwifo
universiteti
medicinis fakulteti
giorgi lobJaniZe
gulis da Tirkmelebis urTierTqmedebis garkveuli
maxasiaTeblebi kardio-renuli sindromis pirveli da meore
tipis dros
disertacia
medicinis doqtoris akademiuri xarisxis
mosapoveblad
samecniero xelmZRvanelebi: zurab faRava
nino SaraSiZe
Tbilisi
2016
ავტორის სტილი დაცულია
2
sarCevi
gamoyenebuli Semoklebebi.................................................................................................................................................4
winasityvaoba..................................................................................................................................................................................8
Sesavali..............................................................................................................................................................................................9
sadisertacio naSromis struqtura, moculoba da programuli uzrunvelyofa.......14
publikaciebi................................................................................................................................................................................14
1. literaturis mimoxilva.............................................................................................................................................16
1.1. kardio-renuli sindromi....................................................................................................................................16
1.1.1. I tipis kardio-renuli sindromi........................................................................................................20
1.1.2. II tipis kardio-renuli sindromi......................................................................................................21
1.1.3. III tipis kardio-renuli sindromi.....................................................................................................23
1.1.4. IV tipis kardio-renuli sindromi....................................................................................................24
1.1.5. V tipis kardio-renuli sindromi......................................................................................................25
1.1.6. mkurnaloba..............................................................................................................................................................26
1.2. gulis ukmarisoba.....................................................................................................................................................29
1.3. Tirkmelebis dazianebis meqanizmi.............................................................................................................36
1.4. marjvena parkuWis roli.....................................................................................................................................40
1.5. Tirkmelebis dazianeba da gorglovani filtraciis siCqare.........................................42
1.6. daskvna.................................................................................................................................................................................46
2. eTikuri sakiTxebis gadawyveta.............................................................................................................................47
2.1. mimoxilva..........................................................................................................................................................................47
2.2. pacientebis piradi informaciis konfidencialuroba...........................................................48
2.3. daskvna.................................................................................................................................................................................55
3. kvlevis miznebi, meTodologia da protokoli....................................................................................57
3.1. kvlevis miznebi............................................................................................................................................................57
3.2. dizaini................................................................................................................................................................................57
3.3. sakvlevi populacia, CarTvis da gamoricxvis kriteriumebi...........................................58
3.5. statistikuri damuSavebis gegma.................................................................................................................58
3.6. monacemTa mopoveba...................................................................................................................................................59
4. Sedegebi......................................................................................................................................................................................62
5. daskvna.........................................................................................................................................................................................66
ავტორის სტილი დაცულია
3
5. English summary........................................................................................................................................................................68
ACKNOWLEDGEMENTS..........................................................................................................................................................68
OBJECTIVES..................................................................................................................................................................................69
BACKGROUND.............................................................................................................................................................................69
MechanismofRenalImpairment...................................................................................................................................71
TheroleofrightventricleandCVP...............................................................................................................................73
METHODS......................................................................................................................................................................................74
Participants‐StudyPopulation......................................................................................................................................74
SamplesizeandstatisticalPlan......................................................................................................................................75
Ethicalconsiderations.........................................................................................................................................................75
RESULTS.........................................................................................................................................................................................76
CONCLUSIONS.............................................................................................................................................................................79
PUBLICATIONS.................................................................................................................................................................................80
6. bibliografia........................................................................................................................................................................81
danarTi 1. pacientis registraciis forma..................................................................................................113
danarTi 2. Patientregistrationform............................................................................................................................114
ავტორის სტილი დაცულია
4
gamoyenebuli Semoklebebi
ACCF/AHA amerikis kardiologTa kolejis fondi da amerikis gulis
asociacia(AmericanCollegeofCardiologyFoundation/AmericanHeart
Association)
ACE
Inhibitors
angiotenzinis gardamqmneli fermentis (agf) inhibitorebi
(Angiotensin‐ConvertingEnzymeInhibitors)
ACS mwvave koronaruli sindromi (AcuteCoronarySyndrome)
ADCHF mwvave, dekompensirebuli SegubebiTi gulis ukmarisoba
(AcuteDecompensatedCongestiveHeartFailure)
ADHF mwvave dekompensirebuli gulis ukmarisoba (Acute
DecompensatedHeartFailure)
AHF gulis mwvave ukmarisoba (AcuteHeartFailure)
AKI Tirkmelebis mwvave dazianeba (AcuteKidneyInjury)
AVP arginin vazopresini (ArginineVasopressin)
ARBs angiotenzinis receptorebis blokerebi (AngiotensinIIReceptor
Blockers)
BNP B-tipis natriurezuli peptidi (B‐typeNatriureticPeptide)
BIVA bioimpedansuri veqtoruli analizi (BIoimpedanceVector
Analysis)
BUN sisxlis Sardovana azoti (BloodUreaNitrogen)
CHD gulis Tandayolili daavdeba (CongenitalHeartDisease)
CHF gulis SegubebiTi ukmarisoba (CongestiveHeartFailure)
ავტორის სტილი დაცულია
5
CKD Tirkmelebis qronikuli daavadeba (ChronicKidneyDisease)
CKD‐EPI Tirkmelebis qronikuli daavadebis epidemiologTa
kolaboraciisformula(ChronicKidneyDiseaseEpidemiology
Collaborationformula)
CO gulis wuTmoculoba (CardiacOutput)
COPD filtvebis qronikuli obstruqciuli daavadeba (Chronic
ObstructivePulmonaryDisease)
CRS kardio-renuli sindromi (Cardio‐RenalSyndrome)
CRCS kardio-renuli kaxeqsiis sindromi (Cardio‐RenalCachexia
Syndrome)
CVP centraluri venuri wneva (CentralVenousPressure)
EF gandevnis fraqcia (EjectionFraction)
eGFR gorglovani filtraciis SefasebiTi maCvenebeli (Estimated
GlomerularFiltrationRate)
EPO eriTropoetini (Erythropoietin)
ESC evropis kardiologTa sazogadoeba (EuropeanSocietyof
Cardiology)
ESKD Tirkmelebis daavadebis terminaluri stadia (EndStageKidney
Disease)
GFR gorglovani filtraciis siCqare (GlomerularFiltrationRate)
HF gulis ukmarisoba (HeartFailure)
HFREF gulis ukmarisoba daqveiTebuli gandevnis fraqciiT (Heart
FailurewithReducedEjectionFraction)
HFPEF gulis ukmarisoba SenarCunebuli gandevnis fraqciiT (Heart
ავტორის სტილი დაცულია
6
FailurewithPreservedEjectionFraction)
IAP intra-abdominuri wneva (Intra‐AbdominalPressure)
IRVF marjvena parkuWis izolirebuli ukmarisoba (IsolatedRight
VentricularFailure)
JNC erToblivi erovnuli komiteti (JointNationalCommittee)
KIM-1 Tirkmlis dazianebis molekula 1 (KidneyInjuryMolecule‐1)
LV marcxena parkuWi (LeftVentricle)
LVEF marcxena parkuWis gandevnis fraqcia (LeftVentricleEjection
Fraction)
MDRD Tirkmelebis daavadebebis dros modificirebuli dietis
formula (ModificationofDietinRenalDiseaseformula)
NGAL neitrofilur JelatinazasTan asocirebuli lipokalini
(Neutrophilgelatinase‐associatedlipocalin)
NICVP arainvaziuri centraluri venuri wneva (NoninvasiveCentral
VenousPressure)
NKF Tirkmelebis erovnuli fondi (NationalKidneyFoundation)
NSAID arasteroiduli anTebis sawinaaRmdego preparatebi(Non‐
SteroidalAnti‐InflammatoryDrugs)
NYHA niu-iorkis gulis asociacia (NewYorkHeartAssociation)
PH filtvismieri hipertenzia (PulmonaryHypertension)
RAAS renin-angiotenzin-aldosteronis sistema (Renin‐Angiotensin‐
AldosteroneSystem)
RAP marjvena winagulis wneva (RightAtrialPressure)
ავტორის სტილი დაცულია
7
RBF renuli sisxlmomarageba (RenalBloodFlow)
RVP Tirkmelebis venuri wneva (RenalVenousPressure)
RSHF marjvenamxrivi gulis ukmarisoba (Right‐SidedHeartFailure)
RV marjvena parkuWi (SystolicBloodPressure)
RVEDD marjvena parkuWis saboloo diastoluri diametri (Right
VentricularEnd‐DiastolicDiameter)
SBP sistoluri arteriuli wneva (SystolicBloodPressure)
SCUF Senelebuli uwyveti ultrafiltracia (SlowContinuous
Ultrafiltration)
SD standartuli gadaxრa (StandardDeviation)
SNS simpaTikuri nervuli sistema (SympatheticNervousSystem)
TAPSE samkarediani sarqvlis rgolisebri zedapiris sistoluri
eqskursia (TricuspidAnnularPlaneSystolicExcursion)
WRF Tirkmelebis funqciis mzardi gauareseba (WorseningRenal
Function)
ავტორის სტილი დაცულია
8
winasityvaoba
msurs madliereba gamovxato norvegiis arqtikuli universitetis (tromsos
universitetis) profesoris biorn straumes mimarT, kvlevis procesSi
gaweuli xelmZRvanelobisTvis da epidemiologiasa da biostatistikSi
codnis gaRrmavebis xelSewyobisTvis.
madlobas vuxdi profesor turalf hasvolds, misi gansakuTrebuli
wvlilisTvis Tbilisis saxelmwifo universitetsa da tromsos
universitets Soris TanamSromlobis gaRrmavebisTvis, romelic
ganxorcielda proeqt “sadoqtoro programa sazogadoebriv jandacvaSi:
norvegiis ganaTlebis mesame safexuris gamocdileba saqarTvelosTvis”
farglebSi.
swavlis periodSi gaweuli mxrdaWerisTvis, xelmZRvanelobisTvis da
sasargeblo rCevebisTvis gansakuTrebul madlobas vuxdi profsor zurab
faRavas, Tsu medicinis fakultetis dekans aleqsandre ciskariZes,
profesor dimitri korZaias, asocirebul profesor nino CixlaZes da
asocirebul profesor nino SaraSiZes.
da bolos, madlobas vuxdi Cems mSoblebs da Cems meuRles, guliTadi
mxardaWerisTvis da sasargeblo rCevebisTvis.
ავტორის სტილი დაცულია
9
Sesavali
warmodgenili kvleva ganxorcielda Tbilisis saxelmwifo universitetis
medicinis fakultetis doqtoranturis programis farglebSi da misi
mizani iyo kardio-renuli sindromis I da II tipiT daavadebul pacientebSi
marcxena parkuWis gandevnis fraqciis (LVEF), marjvena parkuWis
ukmarisobis (RSHF), centraluri venuri wnevis (CVP) da Tirkmelebis
funqciis darRvevis (gamoxatuli, rogorc Semcirebuli gorglovani
filtraciis siCqare - GFR<90) urTierTkavSiris dadgena.
kvlevis Tematikis SerCeva ganapiroba sakiTxis aqtualobam – kardio-
renuli sindromis definiciis da klasifikaciis Sesaxeb informacia
pirvelad 2008 wels gamoCnda samecniero literaturaSi da imTaviTve
miipyro samedicino sazogadoebis yuradReba. Tumca, gulis da Tirkmelebis
disfunqciis Tanxvedra klinikur praqtikaSi didi xania eqimebis interesis
sagans warmoadgens 59. statistikuri monacemebiT, Tirkmelebis zomieri-mZime
dazianeba gulis ukmarisobis mqone pacientebis daaxloebiT 30 - 60
procentSi aRiniSneba 2. gulsa da Tirkmelebs Soris urTierTkavSiri
kompleqsuri procesia da moicavs ramodenime ZiriTad faqtors:
miokardiumis sistoluri da diastoluri funqciis darRvevas SeuZlia
gamoiwvios hemodinamikuri darRvevebi, rogorebicaa Semcirebuli
dartymiTi moculoba da wuTmoculoba, arasruli arteriuli avseba,
gazrdili winagulovani wneva da venuri Segubeba 24.
miuxedavad sakiTxis mimarT arsebuli didi interesisa, gul-sisxlZarRvTa
daavadebebis dros Tirkmelebis funqciis gauaresebis paTfiziologia
jerac ar aris srulyofilad Seswavlili. bolo drois gamokvlevebi
aCvenebs, rom gulis pirveladi da Tirkmelebis meoradi disfunqciis mqone
pacientebis marTva mxolod “Semcirebuli nakadis” Teoriaze dayrdnobiT,
ar iZleva sasurvel Sedegebs 34 35. aseve dadgnilia, rom intra-abdominuri
wnevis (IAP) da centraluri venuri wnevis mateba, romelic Tavis mxriv
zrdis renul venur wnevas (RVP), GFR-is Semcirebas ganapirobebs 60.
ავტორის სტილი დაცულია
10
aRniSnuli garemoebebis gaTvaliswinebiT interess iwvevs marjvena parkuWis
(RV) roli kardio-renuli sindromis paTogenezSi. Tumca, marjvena
parkuWis funqciuri mdgomareobis Sefaseba problemas warmoadgens - ar
arsebobs erTi, sazogadod miRebuli da praqtikaSi gamoyenebadi RVindeqsi 54. marjvena parkuWis rTuli anatomiis gamo, mxolod ramodenime
eqoskopiuri parametria miCneuli sarwmunod, romelTa Sorisac
upiratesoba TAPSE-s, anu samkarediani sarqvlis rgolisebri zedapiris
sistoluri eqskursias eniWeba 55. frank dinim (FrankL.Dini) da Tanaavtorebma
Seiswavles RV disfunqciis da Tirkmelebis qronikuli daavadebis (CKD)
urTierTkavSiri gulis qronikuli ukmarisobis mqone pacientebSi da
daadgines, rom TAPSE-s da GFR-s Soris arsebobs mniSnvnelovani korelacia
53.
centraluri venuri wneva, romelic marjvena winagulovani wnevis (RAP)
miaxloebiTi maCveneblia, aseve SesaZloa gamoyenebul iqnes marjvena
parkuWis funqciuri mdgomareobis SefasebisTvis, Tumca, yovelTvis
gasaTvaliswinebelia sxva gul-sisxlZarRvovani parametrebi, magaliTad,
rogoricaa marcxena parkuWis gandevnis fraqcia (LVEF), radgan
marjvenamxrivi wneva SesaZloa iribad asaxavdes marcxenamxriv wnevas da
marcxenamxrivi avsebis wneva SesaZloa iyos marcxena gulis funqciuri
mdgomareobis niSani 56. kevin damanis (KevinDamman) da Tanaavtorebis mier
Catarebulma kvlevam aCvena, rom CVP asocirebulia Tirkmelebis funqciis
gauaresebasTan da damoukideblad ukavSirdeba yvela mizeziT gamowveul
sikvdilobas gul-sisxlZarRvTa daavadebebis mqone pacientebis farTo
speqtrSi 41. heiko uToftis (Heiko Uthofft) da Tanaavtorebis mier Catarebulma
kvlevam ufro ganamtkica mosazreba, rom CVP aris mniSvnelovani
hemodinamikuri faqtori Tirkmelebis funqciis gauaresebisTvis,
gansakuTrebiT maSin, rodesac is ukavSirdeba daqveiTebul wuTmoculobas 42. aRniSnuli kvlevebi sxva relevantur wyaroebTan erTad detalurad
ganxilulia warmodgenili naSromis literaturis mimoxilvis nawilSi.
ავტორის სტილი დაცულია
11
kardio-renuli sindromis mqone pacientebis marTva ar aris martivi
sakiTxi, radgan erT organoTa sistemaze mimarTul mkurnalobas SesaZloa
hqondes sasargeblo, an piriqiT, saziano Sedegi meore organoTa sistemis
funqciur mdgomareobaze. swored amitom, gansakuTrebuli mniSvneloba
eniWeba gulsa da Tirkmelebs Soris arsebuli urTierTkavSiris meqanizmis
srulyofilad Seswavlas da gaazrebas.
aRniSnul sakiTxSi meti sicxadis Setanis mizniT daigegma da
ganxorcielda warmodgenili kvleva, romelic efuZneba hipoTezas, rom CVP,
marcxena parkuWis gandevnis fraqciaze metad aris korelaciaSi
Tirkmelebis funqciis darRvevasTan im pacientebSi, romlebsac aReniSnebaT
kardio-renuli sindromis I da II tipi.
kvlevis dizaini ganisazRvra, rogorc retrospeqtiuli kros-seqciuli da
saerTaSoriso gamocdilebis gaTvaliswinebiT SemuSavda ganxorcielebis
gegma, romelic moicavda Semdeg etapebs 61 62 63:
sakvlevi sakiTxis garSemo arsebuli samecniero literaturis
mimoxilva da analizi;
kvlevis mimdinareobisas mosalodneli eTikuri sakiTxebis analizi
da gadaWris gzebis gansazRvra;
kvlevis protokolis SemuSaveba (CarTvis da gamoricxvis
kriteriumebi, SerCevis moculoba da sxv.);
protokolis registracia saerTaSoriso reestrSi;
samedicino dawesebulebebis SerCeva da eTikis komisiebis Tanxmobis
mopoveba kvlevis ganxorcielebaze;
monacmebis amoReba samedicino Canawerebidan, monacemTa bazis Seqmna;
monacemebis statistikuri analizi;
publikaciebis momzadeba da gamoqveyneba samecniero JurnalebSi,
universitetis doqtoranturis debulebis Sesabamisad.
ავტორის სტილი დაცულია
12
rogorc ukve aRiniSna, kvleva moicavda pacientebs kardio-renuli
sindromis I da II tipiT. Sesabamisad, CarTvis kriteriumebi iyoHF da eGFR
<90. gamoricxvis kriteriumebi gansazRvruli iyo Semdegnairad:
1. Tirkmelebis funqciis darRvevis damoukidebeli risk-faqtorebis
arseboba (magaliTad, sefsisi, diabeti);
2. pirveladi nefropaTia an meoradi nefropaTia gamowveuli gulis
ukmarisobis garda nebismieri sxva mizeziT.
retrospeqtiulad Seswavlil iqna im pacientebis samedicino Canawerebi,
romlebic drois gansazRvrul monakveTSi hospitalizirebulebi iyvnen
winaswar SerCeuli samedicino dawesebulebis * intensiuri Terapiis da
zogad-Terapiul ganyofilebebSi gulis ukmarisobis diagnoziT (ICD10:I50.0
–I50.9).kvlevis Sedegebma aCvena, romkardio-renuli sindromis meore tipis
dros marcxena parkuWis gandevnis fraqciis Semcireba ar ukavSirdeba
Tirkmelebis funqciis gauaresebas (aRiniSna statistikurad mniSvnelovani
urayofiTi korelacia LVEF-s da eGFR-s Soris (n=44,r=‐0.336,p=0.026)). amave
kategoriaSi, gamovlinda kavSiri NYHA-s klasifikaciiT gulis ukmarisobis
funqciuri klasis matebas da eGFR-is Semcirebas Soris (n=44, r=‐0.349,
p=0.02). pirsonis korelaciis testma ki aCvena saSualo daswvrivi
(uaryofiTi) kavSiri CVP‐s da eGFR-s Soris (r=‐0.48,p=0.13) kardio-renuli
sindromis pirveli tipis dros, rac gansazRvravs SerCevis sasurvel
moculobas statistikuri analizisaTvis amgvari, magram ufro
farTomasStabiani kvlevebisTvis.
zemoTaRniSnuli Sedegebi gvaZlevs safuZvels vifiqroT, rom marcxena
parkuWis gandevnis fraqciis Semcireba ar ukavSirdeba Tirkmelebis
funqciis gauaresebas kardio-renuli sindromis II tipis dros. diastoluri
*hospitaluri qseli “medalfas” 4 samedicino centri, mediqlabjorjia, sisxlZarRvTa da gulis daavadebaTa centri
ავტორის სტილი დაცულია
13
disfunqcia, marjvenaparkuWovani ukmarisoba, venuri Segubeba da
neirohormonaluri aqtivacia aris savaraudod is ZiriTadi faqtorebi,
romlebic iwvevs GFR-is Semcirebas gulis qronikuli ukmarisobis mqone
pacientebSi. kardio-renuli sindromis I tipis drosSesaZloa centraluri
venuri wneva LVEF‐ze metad iyos korelaciaSi Tirkmelebis funqciis
gauaresebasTan, Tumca, miRebuli Sedegebis verificireba saWiroa ufro
farTomasStabiani kvleviT, romelsac SesaZloa hqondes mniSvnelovani
gavlena kardio-renuli sindromis srulyofilad gaazrebis da marTvis
TvalsazrisiT (ix.: daskvna, gv.66).
ავტორის სტილი დაცულია
14
sadisertacio naSromis struqtura, moculoba da programuli
uzrunvelyofa
sadoqtoro naSromi warmodgenilia qarTul enaze, Semajamebeli daskvniT
inglisur enaze. jamSi moicavs 114 nabeWd A4 gverds, aqedan, 2 suraTs, 10
cxrils, 1 grafiks da or danarTs (inglisurenovan daskvnaSi
warmodgenilia 1 suraTi, 3 cxrili da 1 grafiki).
sadoqtoro naSromis, iseve rogorc publikaciebis momzadebisas
gamoyenebulia ThomsonReuters‐is bibliografis marTvis programa EndNote X7.
citirebulia 287 literaturuli wyaro.
monacemTa statistikuri damuSavebisTvis gamoyenebulia programa IBM SPSS
Statistics22.
publikaciebi
sadoqtoro kvlevaze muSaobis dasawyisSi ganisazRvra publikaciebis
momzadebis gegma 3 ZiriTadi mimarTulebiT: kvlevis ganxorcielebisas
mosalodneli eTikuri sakiTxebis mimoxilva, sakvlevi Tematikis
srulyofili literaturuli analizi da kvlevis Sedegebis gamoqveyneba.
aRniSniSnuli gegma ganxorcielda warmatebiT. warmodgenili naSromi
efuZneba Semdeg publikaciebs:
1. George Lobzhanidze (First Author). Ethical considerations in non‐experimental
studies‐GeorgianandNorwegianexperience.PUBLICHEALTH,ELSEVIER†,2016.
2. George Lobzhanidze (Sole Author). The role of right‐sided heart failure in patients
with Cardio‐Renal Syndrome. TRANSLATIONAL AND CLINICAL MEDICINE ‐
GEORGIANMEDICALJOURNAL,2016.
†5‐YearImpactFactor:1.746©JournalCitationReports2016,publishedbyThomsonReuters
ავტორის სტილი დაცულია
15
3. GeorgeLobzhanidze(SoleAuthor).Cardio‐RenalSyndrometype1:theroleofCentral
Venous Pressure and Left Ventricle Ejection Fraction. International Journal of
Sciences:BasicandAppliedResearch,2016.
4. George Lobzhanidze (Sole Author). The Association among Left Ventricle Ejection
FractionandeGFRinpatientswithCardio‐RenalSyndromeType2.(articleinreview).
ავტორის სტილი დაცულია
16
1. literaturis mimoxilva
1.1. kardio-renuli sindromi
gulis da Tirkmelebis funqciis darRveva xSirad Tanxvdeba klinikur
praqtikaSi - erT-erTi maTganis pirveladi dazianeba iwvevs meores meorad
disfunqcias 64. es urTierTkavSiri qmnis paTfiziologiur safuZvels
klinikuri mdgomareobisa, romelic cnobilia, rogorc kardio-renuli
sindromi. am terminis qveS ZiriTadad igulisxmeba Tirkmelebis
ukmarisobis ganviTareba/progresireba arsebuli gulis ukmarisobis fonze,
Tumca, xSirad aseve gulisxmoben mdgomareobas, rodesac Tirkmelebis
daqveiTebuli funqcia meoradad iwvevs gul-sisxlZarRvTa sistemis
funqciis darRvevas (aRniSnul mdgomareobas aseve uwodeben reno-kardiul
sindroms) 14 21.
Tirkmelebis zomieri-mZime dazianebis (ganisazRvreba, rogorc GFR < 60
ml/wT 1,73 m2-ze) gavrceleba (prevalensi) gulis ukmarisobis mqone
pacientebSi aris daaxloebiT 30-dan 60 procentamde 2-5. NYHA-s me-4
funqciuri klasis gulis ukmarisobis mqone pacientebis 39%-s da me-3
funqciuri klasis 31%-s aReniSnebaT Tirkmelebis mZime xarisxis dazianeba
65. aseve, arsebobs monacemebi, rom Tirkmelebis daavadebis terminaluri
stadiiT (ESKD) diagnostirebuli pacientebis sikvdilobis 44%
ganpirobebulia gul-sisxlZarRvTa daavadebebiT 66.
gulis da Tirkmelebis daavadebebis urTierTkavSiri gamoixateba Semdegi
faqtebiT 6:
sikvdiloba gazrdilia gulis ukmarisobis mqone im pacientebSi,
romelTac aReniSnebaT Semcirebuli GFR 7;
Tirkmelebis qronikuli daavadebis mqone pacientebs aqvT gul-
sisxlZarRvTa aTerosklerozuli daavadebis da gulis ukmarisobis
gazrdili riski; gul-sisxlZarRvTa daavadebebi ki warmoadgens
ავტორის სტილი დაცულია
17
Tirkmelebis ukmarisobis mqone pacientebis sikvdilobis daaxl. 50
procents 8;
mwvave an qronikul sistemur daavadebebs SeuZliaT gamoiwvion rogorc
gulis, aseve Tirkmelebis disfunqcia 9.
profesor klaudio ronkos ‡ da Tanaavtorebis mier 2008 wels ganisazRvra
kardio-renuლi sindromis xuTi tipi, romlebic erTmaneTisgan ganirCeva
klinikuri mimdinareobis, paTfiziologiis, diagnostirebis da marTvis
taqtikis mixedviT 10. aRniSnuli klasifikacia 2010 wlis konferenciaze
mowonebul iqna organizacia “mwvave dializis xarisxis iniciativis” (ADQI)§
mier.
kardio-renuli sindromi moicavs rogorc mwvave, aseve qronikuli
mimdinareobis mdgomareobebs, romlebic xasiaTdebian rogorc gulis
pirveladi, aseve Tirkmelebis pirveladi dazianebiT:
I tipi: mwvave, dekompensirebuli gulis ukmarisoba (ADHF) iwvevs
Tirkmelebis mwvave dazianebas. sxvadasxva mosaxleobaSi, ADHF-is gamo
hospitalizirebuli pacientebis 27% - 40%-s aReniSneba Tirkmelebis
mwvave dazianeba (AKI) **. Sesabamisad, I tipis CRS xSirad gvxvdeba
kardiologiuri intensiuri Terapiis ganyofilebebSi 11-14;
II tipi: gulis qronikuli daavadeba iwvevs Tirkmelebis qronikul
daavadebas; “gulis qronikuli daavadeba” SesaZloa moicavdes iseT
mdgomareobebs, rogorebicaa gulis qronikuli ukmarisoba,
Tandayolili manki, winagulebis cimcimi, konstriqciuli perikarditi
da koronaruli arteriebis daavadeba 15;
III tipi: Tirkmelebis mwvave dazianeba iwvevs gulis disfunqcias -
ariTmiis an gulis ukmarisobis saxiT 16. me-3 tipi gvxvdeba ufro
‡ClaudioRonco,MD.nefrologiis departamenti, wm. borTolos hospitali, viCenza, italia.§ Acute Dialysis Quality Initiative (ADQI) ‐ saerTaSoriso, interdisciplinuri organizacia, romelic aerTianebs msoflios 150 wamyvani universitetis warmomadgenels. daarsda 2000 wels. **adre gamoiyeneboda termini –Tirkmelebis mwvave ukmarisoba(AcuteRenalFailure(ARF))
ავტორის სტილი დაცულია
18
iSviaTad, vidre I tipi, Tumca, es SesaZloa ganpirobebuli iyos imiT,
rom es tipi ufro naklebad aris Seswavlili 10;
• IV tipi: Trkmelebis pirveladi daavadeba iwvevs darRvevebs gulis
mxriv, rogorebicaa parkuWebis hipertrofia, marcxena parkuWis
diastoluri disfunqcia da gul-sisxlZarRvTa garTulebebis gazrdili
riski 17-19;
• V tipi: gulis da Trkmelebis kombinirebuli ukmarisoba gamowveuli
sistemuri daavadebiT. CRS-is es tipi SesaZloa moicavdes mraval mwvave
da qronikul mgdomareobas, rodesac aRiniSneba gulis da Tirkmlebis
erToblivi disfunqcia (magaliTad, Saqriani diabeti, sefsisi, sistemuri
wiTeli mglura da sxv.) 20. CRS-is aRniSnul tips aseve uwodeben meorad
kardio-renul sindroms 20 22.
termini kardio-renuli kaxeqsiis sindromi gamoiyeneba im SemTxvevaSi,
rodesac aRiniSneba CRS-s fonze kaxeqsiis ganviTareba an kaxeqsiis fonze
CRS‐s ganviTareba 23.
aqve unda aRiniSnos, rom CRS-is am klasifikacias hyavs skeptikosebic,
kerZod, branko braami (BrankoBraam) da Tanaavtorebi miiCneven, rom CRS-is
tipebis gansazRvra organoTa dazianebis rigiTobaze (pirveladi, meoradi)
da ganviTarebis mimdinareobaze (mwvave, qronikuli) dayrdnobiT, metad
martivi da xelovnuria 67 68. isini kardio-renul sindroms aRiqvamen
rogorc erT mTlian, integrirebul process, sadac gulis da Tirkmelebis
kombinirebuli ukmarisoba auaresebs erTmaneTis funqcias identuri
paTfiziologiuri meqanizmebiT. Sesabamisad, ar aqvs mniSvneloba Tu
romeli organos disfunqcia ganviTardeba pirvelad, radgan adgili aqvs
erTi da igive neirohormonaluri sistemebis aqtivacias orive SemTxvevaSi,
rac iwvevs gul-sisxlZarRvTa daavadebis progresirebas an orive organos
funqciis gauaresebas. es neirohormonaluri sistemebi iyofa or ZiriTad
kategoriad: “hemodinamikuri faqtorebi” da “ara-hemodinamikuri faqtrebi”,
anu “kardio-renuli koneqtorebi” 64.
ავტორის სტილი დაცულია
19
kardio-renuli sindromis SemTxvevebis matebasTan asocirebulia Semdegi
risk-faqtorebis arseboba 69:
moxucebulTa asaki
Tanmxlebi daavadebebi (Saqriani diabeti, arakontrolirebadi
arteriuli hipertenzia, anemia)
medikamentebis moxmareba (arasteroiduli anTebis sawinaaRmdego
preparatebi (NSAID), Sardmdenebi, angiotenzinis gardamqmneli
fermentis inhibitorebi (ACE Inhibitors), angiotenzinis receptorebis
blokerebi (ARBs))
gulis ukmarisobis an marcxena parkuWis daqveiTebuli gandevnis
fraqciis anamnezi
gadatanili miokardiumis mwvave infarqti
HF funqciuri klasi NYHA-s mixedviT
momatebuli kardiuli troponinebi
Tirkmelebis qronikuli daavadeba (Semcirebuli eGFR, momatebuli
sisxlis Sardovana azoti (BUN), kreatinini an cistatini)
gulis ukmarisobis mqone pacientebSi, romlebsac aqvT Semcirebuli GFR,
mniSvnelovania ganvasxvavoT Tirkmelebis pirveladi daavadeba da kardio-
renuli sindromiT gamowveuli Tirkmelebis daqveiTebuli funqcia 70. es
gansxvaveba SesaZloa iyos Zalzed rTuli, radgan pacientebis garkveul
nawils aReniSneba rogorc Tirkmlebis qronikuli daavadeba, aseve kardio-
renuli sindromi (igulisxmeba I da II tipi) 71. is, rac gvafiqrebinebs
Tirkmelebis pirvelad daavadebaze, aris mniSvnelovani proteinuria
(Cveulebriv, 1000 mg/dR-ze meti), hematuria piuriiT da cilindruriiT an
mis gareSe, da/an radiologiuri kvlevebiT gamovlenili Tirkmelebis
Semcirebuli zoma 72. Tumca, normaluri Sardis saerTo analizi, romelic,
rogorc wesi, xSiria kardio-renuli sindromis dros, aseve SeiZleba
aRiniSnebodes zogierTi kategoriis Tirkmelebis daavadebebis drosac, maT
Soris nefrosklerozis da obstruqciuli nefropaTiis dros 73 74.
ავტორის სტილი დაცულია
20
1.1.1. I tipis kardio-renuli sindromi
I tipis, anu mwvave kardio-renuli sindromi, xasiaTdeba gulis funqciis
swrafi gauaresebiT, rasac mivyavarT Tirkmelebis mwvave dazianebamde.
gulis mwvave ukmarisoba SesaZloa mimdinareobdes 75:
hipertenziis fonze ganviTarebuli filtvebis SeSupebiT, rodesac
Senaxulia marcxena parkuWis sistoluri funqcia;
mwvave, dekompensirebuli SegubebiTi gulis ukmarisobiT (ADCHF);
kardiogenuli SokiT.
meqanizmi, romliTac gulis mwvave ukmarisoba iwvevs Tirkmelebis mwvave
dazianebas, metad rTuli da mravalmxrivia 76. Tirkmelebis funqciis
gauareseba aris ara mxolod daavadebis simZimis maCvenebeli, aramed
ganapirobebs gul-sisxlZarRvTa sistemis disfunqciis gauaresebis
aqseleracias, savarudod anTebiTi gzebis aqtivaciis wyalobiT 77. dabali
wuTmoculoba da/an maRali venuri wneva, rac iwvevs renul Segubebas, meti
albaTobiT warmoadgens Tirkmelebis mwvave dazianebis ganviTarebis
ZiriTad mizezs 78.
aseT situaciaSi, reaqcia diuretikebze SesaZloa darRveuli iyos da
gamovlindes SegubebiTi mdgomareoba (periferiuli edema, sxeulis Warbi
wona, maRali centraluri venuri wneva) mniSvnelovan hiponatremiasTan
erTad 79. gamovlenili moculobiTi gadatvirTvis dros Sardmdenebi unda
dainiSnos diurezis etapobrivi zrdis miRweviT, met-naklebad optimaluri
hidrataciuli statusis miRwevamde, eleqtrolituri darRvevebis
koregirebis paralelurad 80 81. biomarkerebi, rogoricaa B-tipis
natriurezuli peptidi (BNP), teqnologiur saSualebebTan erTad,
rogoricaa bioimpedansuri veqtoruli analizi (BIVA), SesaZloa
dagvexmaros Warbi hidrataciis xarisxis SefasebaSi, rac Tavis mxriv
gvexmareba diuretikebiT da ultrafiltraciiT (SCUF) mkurnalobis
ავტორის სტილი დაცულია
21
taqtikis gansazRvraSi adekvaturi hidrataciuli statusis miRwevis mizniT
11-14.
gulis ukmarisobis da misi mkurnalobis procesis erT-erTi yvelaze xSiri
garTuleba aris hiponatremiis ganviTareba 82 83. hiponatremia viTardeba
arginin vazopresinis (AVP) araosmosuri gamoyofis, renin-angiotenzin-
aldosteronis sistemis neirohormonaluri aqtivaciis da simpaTikuri
nervuli sistemis aqtivaciis gamo 84. gulis ukmarisobis mqone pacientebSi
ganviTarebuli hiponatremia dakavSirebulia arakeTilsaimedo prognozTan
da diuretikebis gamoyenebis SezRudvasTan 85.
AVP antagonistebi, romlebsac „vaptanebi“ ewodebaT, aumjobeseben plazmis
natriumis koncentracias, Sardis gamoyofas, sxeulis wonas da cnobierebis
statuss, Tumca ar aCveneben xangrZliv sargebels sikvdilobis Semcirebis
TvalsazrisiT gulis ukmarisobis mqone pacientebSi 86 87.
hiperkalemiiT, an mis gareSe mimdinare Tirkmelebis mwvave dazianebam
SesaZloa gavlena iqonios saboloo gamosavalze, radgan am dros saWiro
xdeba angiotenzinis gardamqmneli fermentis inhibitorebis da
aldosteronis blokerebis daniSvnis SezRudva 88 89. am tipis preparatebis
sargebloba ki gulis ukmarisobis da miokardiumis infarqtis dros
mravali randomizebuli kontrolirebuli kvleviT aris dadasturebuli 90
91 92.
1.1.2. II tipis kardio-renuli sindromi
II tipis, anu qronikuli kardio-renuli sindromi xasiaTdeba gulis
funqciis qronikuli darRveviT (magaliTad, gulis qronikuli SegubebiTi
ukmarisoba) gamowveuli progresirebadi Tirkmelebis qronikuli
daavadebiT. gulis ukmarisobis fonze mimdinare Tirkmelebis funqciis
mzardi gauareseba (WRF) dakavSirebulia garTulebebis sixSiris
matebasTan da hospitalizaciis saWiroebis xangrZlivobis zrdasTan 15.
ავტორის სტილი დაცულია
22
gulis ukmarisobis dros Tirkmelebis funqciis darRveva daaxloebiT 25
%-Si aRiniSneba 93. miCneulia, rom gorglovani filtraciis siCqaris
mcirediT Semcirebac ki iwvevs sikvdilobis riskis mniSvnelovan zrdas 94.
zogierTi mkvlevaris azriT, Tirkmelebis funqciis mzardi gauareseba
SesaZloa miCneul iqnes gul-sisxlZarRvTa generalizebuli daavadebis
simZimis amsaxvel markerad 95.
gulis qronikuli ukmarisoba xasiaTdeba Tirkmelebis perfuziis
xangrZlivi SemcirebiT, rasac xSirad win uswrebs is mikro da
makroangiopaTiebi, romlebic aseve asocirebulia gul-sisxlZarRvTa
daavadebebis ganviTarebis riskTan 96 97. neirohormonuli darRvevebi
gamoixateba vazokonstiqtorebis (epinefrini, angiotenzini, endoTelini)
Warbi gamomuSavebiT da endogenuri vazodilatatorebis (natriurezuli
peptidebi, azotis oqsidi (NO)) mimarT darRveuli mgrZnobelobiT 98. bolo
dros gamoikveTa samecniero interesi eriTropoetinis (EPO) SedarebiTi an
sruli deficitis paTogenuri rolis mimarT, romelic ganapirobebs
gamoxatuli anemiis ganviTarebas da gulis da Tirkmelebis negatiuri
urTierTqmedebis mankieri wris Seqmnas 99 100.
EPO-s daniSvna gulis qronikuli ukmarisobiT, Tirkmelebis qronikuli
daavadebiT da anemiiT daavadebul pacientebSi, aumjobesebs gulis
funqcias, iwvevs marcxena parkuWis zomis daBNP-s donis Semcirebas 101 102.
rkinis preparatebis intravenurma infuziam aseve SesaZlebelia xeli
Seuwyos eriTropoezis procesis daregulirebas 103 104 105.
kardio-renuli sindromis am tipis dros, gulis ukmarisobis
biomarkerebis, GFR-is da pacientis “fluid statusis” (Fluid status)
gansazRvra warmoadgens adekvaturi marTvis qvakuTxeds 106 107 108 109. ufro
specifiuri biomarkerebis gamoyeneba, rogorebicaa neitrofilur
JelatinazasTan asocirebuli lipokalini (NGAL), Tirkmelebis dazianebis
molekula 1 (KIM‐1) da kopeptini (CT‐proAVP) SesaZloa sasargeblo iyos
ავტორის სტილი დაცულია
23
organoTa qsovilebis mwvave iSemiuri an toqsiuri dazianebis gamovlenis
TvalsazrisiT 110 111. meore mxriv, fibrozis biomarkerebis gansazRvra
(activematrixmetalloproteinase2,activematrixmetalloproteinase9,totaltissueinhibitorof
metalloproteinase 1) SesaZloa dagvexmaros organoTa qronikuli dazianebis
progresirebis SefasebaSi 112 113.
1.1.3. III tipis kardio-renuli sindromi
III tipis kardio-renuli sindromi, anu mwvave reno-kardiuli sindromi,
xasiaTdeba Tirkmelebis funqciis pirveladi mwvave gauaresebiT
(magaliTad, Tirkmelebis mwvave dazianeba, iSemia, glomerulonefriti), rac
Tavis mxriv iwvevs, an xels uwyobs gulis mwvave dazianebas da/an
disfunqcias (magaliTad, gulis ukmarisoba, ariTmia, iSemia) 114.
Tirkmelebis mwvave dazianeba gul-sisxlZarRvTa sistemaze gavlenas axdens
sxvadasxva gziT. kerZod, oligurias SeuZlia gamoiwvios moculobiTi
gadatvirTva, rac Tavis mxriv xels uwyobs filtvebis SeSupebis da
miokardiuli disfunqciis ganviTarebas 115. aseT situaciaSi, optimaluri
hidrataciuli statusis miRwevis mizniT SesaZloa saWiro gaxdes
Tirkmelebis CanacvlebiTi Terapia 116 117. dializis Sedegad ganviTarebuli
siTxis da eleqtrolitebis donis mkveTri cvlileba SesaZloa gaxdes
kardiovaskuluri arastabilurobis mizezi, rac gamoixateba hipotenziis,
ariTmiebis da miokardiumis iSemiis ganviTarebiT 118 119. Tirkmelebis
CanacvlebiTi Terapiis uwveti meTodebi (dializi an filtracia‐Continuous
renal replacement therapies (CRRTs)), romlebsac minimumade dahyavs aseTi
kardiovaskuluri garTulebebi, miCneulia ufro usafrTxod da
logikurad aseT situaciaSi 120 121 122.
ავტორის სტილი დაცულია
24
1.1.4. IV tipis kardio-renuli sindromi
IV tipis kardio-renuli sindromi, anu qronikuli reno-kardiuli sindromi,
xasiaTdeba Tirkmelebis pirveladi qronikuli daavadebiT (magaliTad,
qronikuli glomeruluropaTia), rac xels uwyobs gulis funqciis
gauaresebas, parkuWebis hipertrofiis da diastoluri disfunqciis
ganviTarebas, da/an kardiovaskuluri garTulebebis riskis zrdas 123. aseT
situaciaSi, xSirad aRiniSneba mudmivi moculobiTi gadatvirTva da
diuretikebis gamoyenebis xangrZlivi anamnezi 124. BNP-is mateba xSirad
mudmiv xasiaTs atarebs da amitom, gansxvaveba „svel“ da mSral“
komponetebs Soris gadamwyvet rols TamaSobs gulis ukmarisobis
diagnostirebis da klasificirebis TvalsazrisiT 14 21.
Tirkmelebis erovnuli fondi (NKF) gansazRvravs Tirkmelebis qronikuli
daavadebis 5 stadias, rac efuZneba Trkmelebis dazianebis simZimis da
gorglovani filtraciis siCqaris kombinacias. Tirkmelebis qronikuli
daavadeba ganisazRvreba, rogorc Tirkmelebis mudmivi dazianeba
(dadasturebuli biofsiiT an Tirkmelebis dazianebis biomarkerebiT) da/an
gorglovani filtraciis siCqaris SemcirebiT < 60ml/wT 1,72m2 3 Tveze meti
xniT 125. miCneulia, rom Tirkmelebis funqciis gauareseba am donemde an
kidev ufro dabla, asaxavs Tirkmelebis normaluri funqciis daqveiTebas
1/2-iT an metad, rac SesaZloa ukavSirdebodes garTulebebis ganviTarebas,
rogorebicaa gul-sisxlZarRvTa daavadebebi da sxv. 126.
Tirkmelebis qronikuli daavadeba aris gul-sisxlZarRvTa daavadebebis
ganviTarebis mniSvnelovani risk-faqtori: Tirkmelebis qronikuli
daavadebiT Sepyrobil pirebs aqvT kardiuli sikvdilobis 10 da 20-jer
meti riski, asakiT da sqesiT Sesabamis sakontrolo jgufebTan SedarebiT
Tirkmelebis qronikuli daavadebis gareSe 127.
ავტორის სტილი დაცულია
25
1.1.5. V tipis kardio-renuli sindromi
V tipis kardio-renuli sindromi, anu meoradi kardio-renuli sindromi,
xasiaTdeba Tirkmelebis da gulis kombinirebuli disfunqciiT, gamowveuli
mwvave an qronikuli daavadebebiT 128 129. mTel rig mwvave da qronikul
daavadebebs SeuZliaT gamoiwvion orive organoTa sistemis erTdrouli
dazianeba, sadac erTis dazianeba gavlenas axdens meoreze da piriqiT 130.
mwvave daavadebaTagan, orive organoTa sistemis disfunqciis ganviTarebis
yvelaze xSiri da sayuradRebo mizezi aris mZime sefsisi. qronikul
daavadebaTagan ki, Saqriani diabeti warmoadgens gulis da Tirkmelebis
kombinirebuli disfunqciis yvelaze xSir mizezs 20 22.
kardio-renuli sindromis yvela zemoTCamoTvlili tipis dros, kardiuli
da renuli biomarkerebis gansazRvra saSualebas aZlevs klinicist eqimebs
dasvan kardio-renuli sindromis diagnozi da daiwyon adreuli da
garkveulwilad, ufro efeqturi mkurnaloba 131. kreatininis da diurezis
monacemebze dayrdnobiT Tirkmelebis mwvave dazianebis (AKI) diagnostireba
da misi simZimis Sefaseba klinikur praqtikaSi dReisaTvis sirTules ar
warmoadgens 132. Tirkmelebis qronikuli daavadebis (CKD) an Tirkmelebis
funqciis darRvevis Sefaseba xdeba glomeruli filtraciis siCqaris (GFR)
da Sratis kreatininis donis mixedviT. orive SemTxvevaSi, organoTa
dazianebis adreuli diagnostireba da progresirebis zedmiwevniTi
Sefaseba gaadvilebulia specifiuri biomarkerebis gansazRvriT, Tu
uzrunvelyofilia maTi xelmisawvdomoba 133. es biomarkerebi gviCvenebs
Tirkmelebis dazianebas manam, sanam is gamovlindeba gorglovani
filtraciis siCqaris SemcirebiT. BNP aris gulis ukmarisobis yvelaze
Rirebuli da amave dros xelmisawvdomi biomarkeri, xolo NGAL-is
gansazRvra ki informatiulia Tirkmelebis mwvave dazianebis dros 134 135.
gulis ukmarisobis SemTxvevaSi, Camoyalibebulia kriteriumebi da
algoriTmebi gulis ukmarisobis diagnostirebisaTvis, rac efuZneba
ავტორის სტილი დაცულია
26
rogorc anamnezis da fizikuri gasinjvis monacemebs, aseve instrumentuli
da laboratoriuli kvlevebis Sedegebs 136. am SemTxvevaSic xelmisawvdomia
biomarkerebis gansazRvra, gulis kunTis iSemiis gamovlenis da gulis
ukmarisobis xarisxis Sefasebis mizniT 137.
1.1.6. mkurnaloba
Tirkmelebis disfunqciiT da moculobiTi gadatvirTviT damZimebuli da
Sardmdenebis mimarT refraqtoruli gulis ukmarisobis mqone pacientebis
marTva metad rTuli procesia. efeqturi, mtkicebulebebze dafuZnebuli
Terapiuli midgomebi ar arsebobs. potenciur sargebels da zians Soris
kompromisis mosaZebnad eqimebi xSirad iReben gadawyvetilebebs, romlebic
SesaZloa urTierTgamoricxavadac ki mogveCvenos. aseT situaciaSi
mkurnalobis procesi xSirad rTuldeba standartuli mkurnalobis
(Sardmdenebi da inotropebi) mimarT rezistentobis ganviTarebiT, rac
arakeTilsaimedo prognozs ganapirobebs 138 139 140.
im mraval darRvevaTa Soris, romlebic kardio-renuli sindromis dros
aRiniSneba, siTxiT gadatvirTva warmoadgens mTavar klinikur problemas,
romelic saWiroebs zust Sefasebas da mkurnalobas 141 142. Warbi
hidratacia, hormonaluri darRvevebiT gamowveul eleqtrolitur
disbalansTan (magaliTad, hiponatremia) erTad, warmoadgens
umniSvnelovanes klinikur mdgomareobas, romelic saWiroebs droul
diagnostirebas da koreqcias 143 144. vazopresinis Warbi, ara-osmosuri
gamoyofa aris hiponatremiis ganviTarebis mTavari etiologiuri faqtori
gulis ukmarisobis dros 145 146 147. I tipis kardio-renul sindromze
saubrisas naxsenebi iyo vazopresinis V2 receptorebis antagonistebi, e.w.
vaptanebi, romlebic aumjobeseben plazmis natriumis koncentracias da
zrdian Sardis gamoyofas, Tumca, isini ar aCveneben sargebels
hospitalizaciis da sikvdilobis Semcirebis TvalsazrisiT gulis
ukmarisobis mqone pacientebSi 148 149.
ავტორის სტილი დაცულია
27
SegubebiTi movlenebis arsebobisas mkurnalobis procesSi wamyvani roli
maryuJovan Sardmdenebs eniWebaT. diurezis gaZlierebiT SesaZlebelia ara
mxolod moculobiTi gadatvirTvis, aramed gulis parkuWebis dilataciis
Semcireba da miokardiumis funqciis gaumjobeseba miokardiumis kedlebze
stresis, endo-miokardiuli iSemiis da funqciuri mitraluri
regurgitaciis Semcirebis xarjze. aseve, maryuJovani Sardmdenebis
gamoyenebisas mosalodnelia Tirkmelebis funqciis TandaTanobiTi
gaumjobeseba neirohormonalur aqtivaciaze gavlenis Sedegad 150.
mkurnalobas xSirad amateben Tiazidur diuretikebsac, magaliTad
metolazons, Tumca am dros matulobs azotemiis da eleqtrolituri
darRvevebis ganviTarebis riski 151.
inotropebis gamoyeneba SezRudulia iseTi potenciuri gverdiTi efeqtebis
ganviTarebis gamo, rogorebicaa hemodinamikuri darRevebi da ariTmiebi 152.
agreTve, randomizebuli da retrospeqtiuli kvlevebiT gamovlenilia
mkafio asociacia inotropebis gamoyenebasa da avadobis da sikvdilobis
gazrdil maCveneblebTan 153 154 155. Sardmdenebis adeqvaturi dozebiT
mkurnalobisas arasakmarisi efeqtis miRebisas SasaZloa inotropuli
agentebis (dopamini, dobutamini, fosfodiesterazas inhibitorebi da
levosimendani) mcire dozebiT damateba diurezis gaumjobesebis mizniT,
mxolod xanmokle efeqtis misaRebad. rogorc ukve aRiniSna, mTeli rigi
kvlevebi adasturebs, rom kardio-renuli sindromis dros gulis
wuTmoculobis gazrda ar ukavSirdeba Tirkmelebis funqciis
gaumjobesebas 156. dopaminis mcire, anu “Tirkmlis doziT” (2–4 mkg/kg/wT)
gamoyeneba miRebulia Tirkmelebis mwvave dazianebis prevenciis an
mkurnalobis mizniT. am dozebiT infuziisas dopamini aaqtiurebs A1
receptorebs, rac iwvevs renuli arteriebis dilatacias da Tirkmelebis
sisxlmomaragebis gazrdas. ufro maRali dozebiT infuziisas dopamini
aaqtiurebs β1 da β2 adrenergul receptorebs, rac iwvevs gulis
wuTmoculobis gazrdas. Sesabamisad, dopaminiT mkurnalobisas gadamwyveti
mniSvneloba mis zust dozirebas eniWeba, rac xSirad ar aris advili
ავტორის სტილი დაცულია
28
amocana – rTulia im optimaluri dozis gansazRvra, rac iwvevs
Tirkmelebis sisxlmomaragebis maqsimalurad gazrdas 157 158.
mwvave dekompensirebuli gulis ukmrisobiT hospitalizirebul pacientebSi
xSirad niSnaven vazodilatatorebs (nitroglicerini, natriumis
nitroprusidi, neziritidi) Tirkmelebis sisxlmomaragebis gazrdis mizniT.
Tumca, miuxedavad gulis wuTmculobis zrdisa, maT Zalzed mcire efeqti
aqvT RBF-s matebaze 159 160 161.
miCneulia, rom adenozini aris WRF-isdiuretikebis mimarT rezistentobis
mniSvnelovani intra-renuli mediatori. adenozin-trifosfatis hidrolizis
Sedegad eqstracelularul sivrceSi gamoiyofa Tavisufali adenozini,
romelic moqmedebs A1 receptorebze da iwvevs aferentuli arteriolebis
konstriqcias, rac Tavis mxriv iwvevs RBF-sdaGFR-is Semcirebas da reninis
gamoyofis stimulirebas. amasTan erTad, A1 receptorebis aqtivacia
aZlierebs natriumis reabsorbcias proqsimalur da distalur milakebSi,
rac iwvevs natriumis da siTxis Sekavebas 162.
adenozinis A1 receptorebis antagonist rolofilinze (Rolofylline)
Catarebulma mcre kvlevam aCvena, rom gulis ukmarisobis mqone pacientebSi
misi gamoyeneba ukavSirdeboda diurezis da GFR-is zrdas 163 164. Tumca,
ufro didma, 2033 pacientze Catarebulma kvlevam ar daadastura misi
upiratesoba placebosTan SedarebiT 165.
ultrafiltracia aris mkurnalobis meTodi, romelic gamoiyeneba
moculobiTi gadatvirTvis dros organizmidan Warbi siTxis mocilebis
mizniT. yvelaze praqtikulad miiCneva veno-venozuri ultrafiltracia,
rodesac venuri sisxli gaivlis eqstrakorporaluri filtraciis
aparatSi. ultrafiltracias SeuZlia sisxlidan siTxis mocileba im
siCqariT, ra siCqariTac siTxe qsovilebidan sisxlSi gadadis. Tumca,
zedmetad agresiulma ultrafiltraciam SesaZloa gamoiwvios
heodinamikuri arastabiluroba da Tirkmelebis funqciis gauareseba 166 167.
ავტორის სტილი დაცულია
29
diuretikebis gamoyenebasTan SedarebiT ultrafiltraciis
upiratesobebia 168:
siTxis swrafad mocileba da simptomebis swrafi gaumjobeseba;
igive moculobis siTxis mocilebasTan erTad meti natriumis
gamoyofa;
eleqtrolituri disbalansis ganviTarebis naklebi riski (magaliTad,
hipokalemia);
neirohormonaluri aqtivaciis ararseboba;
diuretikebis mimarT mgrZnobelobis potenciuri aRdgena;
hospitalizaciis xangrZlivobis da re-hospitalizaciis SemTxvevebis
Semcireba;
Tirkmelebis funqciis mzardi gauaresebis Tavidan acileba.
1.2. gulis ukmarisoba
gulis ukmarisoba (HF) aris kompleqsuri klinikuri sindromi, romelsac
iwvevs sisxlis parkuWovani Sevsebis an gandevnis rogorc struqturuli,
aseve funqciuri darRveva. gulis ukmarisobis ZiriTadi gamovlineba aris
qoSini da daRlilobis SegrZneba, rac ukavSirdeba datvirTvis mimarT
tolerantobis Semcirebas da siTxis Sekavebas, ramac Tavis mxriv SesaZloa
migviyvanos SegubebiT movlenebamde filtvebSi da/an muclis RruSi da/an
periferiul SeSupebamde 169 170.
zogierT pacients aReniSneba datvirTvis mimarT tolerantobis darRveva
gamoxatuli SegubebiTi movlenebis gareSe, maSin rodesac sxva pacientebs
aReniSnebaT Segubebis, qoSinis da daRlilobis mkveTrad gamoxatuli
simptomatika 171. im SemTxvevebSi, rodesac moculobiTi gadatvirTvis
niSnebi gamoxatuli ar aris, umjobesia gamoyenebul iqnes termini gulis
ukmarisoba, nacvlad gulis SegubebiTi ukmarisobisa (CHF) 172. ar arsebobs
gulis ukmarisobis erTi diagnostikuri testi, radgan metwilad HF aris
ავტორის სტილი დაცულია
30
klinikuri diagnozi, romelic efuZneba anamnezis da fizikuri gasinjvis
Sedegebs 173.
gulis ukmarisobis klinikuri sindromi SesaZloa ganviTardes
perikardiumis, miokardiumis, endokardiumis, gulis sarqvelebis,
magistraluri sisxlZarRvebis dazianebis da metaboluri darRvevebis
Sedegad, Tumca, HF-s mqone pacientebis umetesobas aReniSneba marcxena
parkuWis miokardiuli disfunqcia 174. aqve unda aRiniSnos, rom HFar aris
kardiomiopaTiis an marcxena parkuWis disfunqciis sinonimi. es
ukanasknelni asaxavan im struqturul Tu funqciur darRvevebs, romlebic
SesaZloa gulis ukmarisobis ganviTarebis mizezi gaxdes 175 176.
amerikis kardiologTa kolejis fondis da amerikis gulis asociaciis
(ACCF/AHA) 2013 wlis gulis ukmarisobis marTvis gaidlaini gansazRvravs
gulis ukmarisobas SenarCunebuli gandevnis fraqciiT (HFPEF) da gulis
ukmarisobas daqveiTebuli gandevnis fraqciiT (HFREF)177:
klasifikacia
EF (%)
ganmarteba
I. gulis ukmarisoba daqveiTebuli gandevnis fraqciiT (HFREF)
≤40 aseve uwodeben sistolur gulisukmarisobas. randomizirebulikontrolirebuli kvlevebi ZiriTadadmoicavs pacientebs (HFREF)-iT daefeqturi Terapia dReisTvis metwiladxelmisawvdomia am kategoriisTvis
II. gulis ukmarisoba SenarCunebuli gandevnis fraqciiT (HFPEF)
≥50 aseve uwodeben diastolur gulisukmarisobas 178. HFPEF-s gasazRvrisTvis SemuSavebulia ramodenime sxvadsxva kriteriumi. diagnostireba ar aris martivi, radgan saWiroebs im arakardiuli mizezebis gamoricxvas, romlebic aseve SesaZloa iwvevdnengulis ukmarisobis msgavs simptomebs. am droisTvis, efeqturi mkurnaloba ar aris gansazRvruli
a. HFPEF, mosazRvre 41-dan es pacientebi Tavsdebian mosazRvre,
ავტორის სტილი დაცულია
31
49-mde anu gardamaval kategoriaSi. maTi daavadebis mimdinareoba, mkurnalobis sqemebi da gamosavali msgavsia pacientebisa HFPEF-iT.
b. HFPEF,gaumjobesebuli
>40 am kategoriis pacientebs warsulSi hqondaT HFREF. klinikuri mimdinareoba SesaZloa gansxvavdebodes rogorcHFREF-s, aseve HFPEF-s persistirebadiformebisgan. damatebiTi kvlevebia saWiro am kategoriis pacientebis ukeTesad klasificirebis mizniT
cxrili 1. HFREFda HFPEFdefiniciaACCF/AHAmixedviT
rogorc amerikis kardiologTa kolejis fondis da amerikis gulis
asociaciis (ACCF/AHA) gulis ukmarisobis stadiebi, aseve niu-iorkis gulis
asociaciis (NYHA)funqciuri klasebi, moicaven mravalmxriv da sasargeblo
informacias gulis ukmarisobis arsebobis da misi simZimis Sesaxeb.
ACCF/AHA-s HFstadiebi ufro fokusirebulia daavadebis ganviTarebasa da
progresirebaze da SesaZloa gamoyenebul iqnes pirovnebebis da
populaciis daxasiaTebisaTvis, maSin, rodesac NYHA-s funqciuri klasebi
fokusirebulia fizikuri aqtivobis SesaZleblobasa da daavadebis
simptomur statusze 179:
ACCF/AHA-s mier gansazRvruli
gulis ukmarisobis stadiebi 180
NYHA-s mier gansazRvruli
funqciuri klasebi 181
A gulis ukmarisobis ganviTarebis maRali riski. gulis struqturuli daavadeba anHF simptomebi ar aRiniSneba
arcerTi
B gulis struqturuli daavadeba, I fizikuri aqtivobis
ავტორის სტილი დაცულია
32
HF-is niSnebi an simptomebi ar aRiniSneba
SezRudva ar aRiniSneba. Cveulebrivi fizikuri datvirTva ar iwvevs HF simptomebis aRmocenebas
C gulis struqturuli daavadeba, aRiniSneboda an aRiniSneba HF- simptomebi
I fizikuri aqtivobis SezRudva ar aRiniSneba. Cveulebrivi fizikuri datvirTva ar iwvevs HF simptomebis aRmocenebas
II aRiniSneba fizikuri aqtivobis mcirediT SezRudva. komfortulad grZnobs Tavs mosvenebis mdgomareobaSi, Tumca, Cveulebrivi fizikuri datvirTva iwvevs HF simptomebis aRmocenebas
III aRiniSneba fizikuri aqtivobis gamoxatuli SezRudva. komfortulad grZnobs Tavs mosvenebis mdgomareobaSi, Tumca, Cveulebrivze naklebi fizikuri datvirTvac ki iwvevs HF simptomebis aRmocenebas
IV nebismieri fizikuri aqtivoba iwvevs HF simptomebis aRmocenebas an HF simptomebi aRiniSneba mosvenebis mdgomareobaSi
D refraqtoruli HF,romelic saWiroebs specializirebul intervenciebs
IV nebismieri fizikuri aqtivoba iwvevs HF simptomebis aRmocenebas an HF simptomebi aRiniSneba mosvenebis mdgomareobaSi
cxrili 2. ACCF/AHAstadiebis da NYHA-s mier gansazRvruli funqciuri
klasebis Sedareba 182
ავტორის სტილი დაცულია
33
Terapiuli intervenciebi TiToeul stadiaze mimarTulia cxovrebis wesis
modificirebaze (stadia A), gulis struqturuli daavadebebis
mkurnalobaze (stadia B), morbidobisa da sikvdilobis Semcirebaze (stadia
C da D) 183. NYHA-s funqciuri klasifikacia warmoadgens sikvdilobis
damoukidebel prediqtors. es klasifikacia farTod gamoiyeneba klinikur
praqtikaSi da samecniero kvlevebSi, iseve, rogorc pacientebis sxvadasxva
mkurnalobis sqemebSi CarTvis gansazRvris mizniT 184 185.
klinikur praqtikaSi aseve gamoiyeneba gulis SegubebiTi ukmarisobis (CHF)
framingamis kriteriumebi (Framingham Criteria) 186. CHF-s diagnozi ismeva im
SemTxvevaSi, Tu saxezea ori ZiriTadi kriteriumi an 1 ZiriTadi da 2 mcire
kriteriumi:
ZiriTadi kriteriumebi
paroqsizmuli Ramis qoSini
kisris venebis daWimuloba
sveli xixini
kardiomegalia (radiologiurad dadasturebuli)
filtvebis mwvave SeSupeba
gazrdili CVP (>16smH2Omarjvena winagulSi)
S3galopi
hepato-iugularuli refluqsi
wonaSi kleba >4.5kg 5 dReSi mkurnalobis fonze
mcire kriteriumebi
bilateraluri SeSupeba koWebis areSi
Ramis xvela
qoSini Cveulebriv fizikur datvirTvaze
hepatomegalia
siTxis dagroveba plevris RruSi
ავტორის სტილი დაცულია
34
sasicocxlo tevadobis Semcireba bolos dafiqsirebuli maqsimumis
mesamedze metad
taqikardia >120 dartyma/wT
mcire kriteriumebis gamoyeneba nebadarTulia mxolod maSin, Tu isini ar
aris gamowveuli sxva samedicino mdgomareobiT (magaliTad, filtvismieri
hipertenziiT, filtvebis qronikuli obstruqciuli daavadebiT, ciroziT,
ascitiT, an nefrozuli sindromiT) 187.
framingamis gulis kvlevis (The Framingham Heart Study criteria) kriteriumebi
xasiaTdeba gulis SegubebiTi ukmarisobis diagnostirebis 100%-iani
mgrZnobelobiT da 78%-iani specifiurobiT 188 189.
gulis ukmarisobis definicia evropis kardiologTa sazogadoebis mier
(ESC) Semdegnairad aris warmodgenili (I da II kriteriumis dakmayofileba
aucilebelia) 190 191:
I. gulis ukmarisobis simptomebi (datvirTvis an mosvenebis dros)
da
II. gulis kunTis disfunqciis (sistoluri an diastoluri) obieqturi
dadastureba (umjobesia eqokardiografiiT) mosvenebaSi da
datvirTvis fonze, rodesac diagnozi saeWvoa
da
III. adeqvaturi pasuxi gulis ukmarisobis winaaRmdeg mimarTul
mkurnalobaze
gulis ukmarisobis mkurnalobis miznebi evropis kardiologTa
sazogadoebis mier Semdegnairad aris gansazRvruli 152:
I. prevencia
a) prevencia da kontroli im daavadebebisa, romelTac mivyavarT
gulis kunTis disfunqciamde da gulis ukmarisobis
ganviTarebamde;
ავტორის სტილი დაცულია
35
b) gulis kunTis disfunqciis SemTxvevaSi daavadebis
progresirebis prevencia;
II. avadobis Semcireba da cxovrebis xarisxis gaumjobeseba;
III. sikvdilianobis Semcireba, sicocxlis gaxangrZliveba.
saqarTveloSi gulis ukmarisobis simZimis SefasebisaTvis ZiriTadad
gamoiyeneba NYHA-s klasifikacia, xolo diagnostirebisTvis gamoiyeneba
evropis kardiologTa sazogadoebis kriteriumebi. aRniSnulis mizezi
metwilad albaT aris is, rom saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis ministris brZanebiT damtkicebuli klinikuri praqtikis
erovnuli rekomendacia (gaidlaini) `gulis qronkuli ukmarisobis
diagnostika da marTva” efuZneba rogorc NYHA-s, aseve ESC gaidlainebs 192.
warmodgenil kvlevaSic gamoyenebulia NYHA-s klasifikacia (ix.: danarTi 1).
rogorc ukve aRiniSna, gulis ukmarisobis dros adgili aqvs simpaTikuri
nervuli sistemis aqtivacias da vazokostriqtorebis da natriumis
Semakavebeli neorohormonebis (angiotenzini II, norepinefrini, endoTelini-1
da arginin vazopresini) Warbad gamoyofas 193. es neirohormonaluri
sistemebi TamaSoben centralur rols rogorc gulis ukmarisobis
paTfiziologiaSi, aseve Tirkmelebis funqciis mravali aspeqtis
regulirebaSi. amgvarad, gulis ukmarisobis dros Warbi neirohormonaluri
aqtivacia iTvleba kardio-renuli sindromis erT-erT mTavar mediatorad,
Tumca, es kavSiri mkafiod gnsazRvruli jerjerobiT ar aris 194.
mediatori
renuli efeqti
wyaro
angiotenzini II aferentuli da eferentuli arteriolebis
konstriqcia;
195
endoTelini-1 aferentuli da eferentuli arteriolebis 196 197
ავტორის სტილი დაცულია
36
konstriqcia, rac ganapirobebs renuli
sisxlmomaragebis da gorglovani filtraciis
siCqaris Semcirebas;
adenozini aferentuli arteriolebis konstriqcia;
eferentuli arteriolebis dilatacia;
renuli sisxlmomaragebis da gorglovani
filtraciis siCqaris Semcireba;
reninis sekreciis daTrgunva;
tubulo-glomeruluri ukukavSiris aqtivacia;
198
simpaTikuri
nervuli
sistema
eferentuli arteriolebis konstriqcia;
renuli sisxlmomaragebis Semcireba;
reninis gamoyofis gazrda iuqstra-
glomerulur aparatSi arsebuli β-
receptorebis meSveobiT;
199
natriurezuli
peptidebi
aferentuli arteriolebis dilataciis
stimulacia da eferentuli arteriolebis
konstriqcia, rac iwvevs gorglovani
filtraciis zrdas;
reninis sekreciis daTrgunva;
200 201
cxrili 3. neirohormonaluri sistemebis aqtivaciis zegavlena Tirkmelebis
hemodinamikaze gulis ukmarisobis dros 202.
1.3. Tirkmelebis dazianebis meqanizmi
GFR–is Semcirebis paTfiziologia HF‐is dros kompleqsuria da moicavs
ramodenime ZiriTad faqtors: miokardiumis sistoluri da diastoluri
ავტორის სტილი დაცულია
37
funqciis darRvevas SeuZlia gamoiwvios hemodinamikuri darRvevebi,
rogorebicaa Semcirebuli dartymiTi moculoba da wuTmoculoba,
arasruli arteriuli avseba, gazrdili winagulovani wneva da venuri
Segubeba 24. es hemodinamikuri darRvevebi biZgs aZlevs mTel rig
kompensatorul neirohormonalur adaptaciebs, rogorebicaa simpaTikuri
nervuli sistemis (SNS) da renin-angiotenzin-aldosteronis sistemis (RAAS)
aqtivacia, sxvadasxva ujreduli procesebi (oqsidaciuri dazianeba da
endoTeluri disfunqcia), rasac sabolood mivyavarT apoftozamde da
renul fibrozamde 1 5 25-29. renin-angiotenzin-aldosteronis sistemis da
sxva neirohormonaluri sistemebis efeqti vrceldeba ara mxolod
sistemur funqciebze, aramed im intra-renul komponentebzec, romlebic
ganapirobebs Tirkmelebis funqciis modulirebas.
bolo wlebis ganmavlobaSi SemuSavda gulis da Tirkmelebis dazianebis
axali biomarkerebi, rogorebicaa: cistatini C, NGAL, KIM-1 (Tirkmlis
dazianebis molekula 1), NAG (N-acetil‐β‐(D) glukozaminidaza), IL‐1 8
(interleikini-18), L‐FABP (RviZlis cximovani mJavebis SemakavSirebeli cila),
CI (katalizuri rkina) 30 203. mosalodnelia, rom am biomarkerebis gamoyeneba
gaaadvilebs CRS-s adreul diagnostirebas da misi tipebis gansazRvras 31.
samwuxarod, aRniSnuli biomarkerebis gamoyeneba jerjerobiT ar aris
farTod xelmisawvdomi 204.
ავტორის სტილი დაცულია
HF-s
Tumc
marc
sind
mult
ukmar
da T
“Semc
Sede
gamok
venur
mtkic
mniSv
suraTi 1.
dros CKD
ca, ar ari
cxena par
romis me
tifaqtor
risobas 3
Tirkmeleb
cirebuli
gebs 34
kvlevebi
ri wnevis
cebuleba
vnelovan
K Tirkme
DxSiria
is naTeli
kuWis ga
eqanizmis
uli daav
33. bolo
bis meora
nakadis”
35. rogo
aCvenebs,
s (CVP) ma
imisa,
rols T
elebis da
si
da ukavSi
i CKD-s ga
andevnis
Camoyali
vadebebis
drois ga
adi disf
Teoriaz
orc cxo
rom int
ateba iwve
rom Ti
TamaSoben
a gulis u
indromis
irdeba ga
avlena si
fraqciaz
ibeba agr
gamo, ro
amokvleve
funqciis
ze dayr
ovelebze,
tra-abdomi
evs GFR-is
irkmelebi
n Tirkmel
urTierTka
dros
azrdil s
ikvdiloba
ze (LVEF).
reTve gar
omlebic x
ebi aCveneb
mqone pac
rdnobiT,
, aseve
inuri wne
s Semcire
is venur
lebis di
avSiri ka
sikvdilob
aze damok
I tipis
rTulebul
xSirad T
bs, rom g
cientebis
ar iZ
adamiane
evis (IAP)
ebas 36-40.
ri wneva
isfunqcis
rdio-renu
bis maCven
kidebulia
s kardio
lia mTel
an axlavs
gulis pi
marTva
Zleva s
bze Cat
da cent
arsebobs
(RVP)
s progres
38
uli
nebels32.
a Tu ara
o-renuli
li rigi
s gulis
rveladi
mxolod
asurvel
arebuli
traluri
mzardi
da IAP
sirebaSi
ავტორის სტილი დაცულია
39
gulis ukmarisobis mqone pacientebSi 39 41 42. kevin damanis (KevinDamman) da
Tanaavtorebis mier Catarebulma kvlevam aCvena, rom CVP asocirebulia
Tirkmelebis funqciis gauaresebasTan da damoukideblad ukavSirdeba
yvela mizeziT gamowveul sikvdilobas gul-sisxlZarRvTa daavadebebis
mqone pacientebis farTo speqtrSi 41. kvlevis mixedviT, renuli
sisxlmomarageba (RBF) aris mTavari faqtori, romelic gansazRvravs GFR-s
gulis disfunqciis mqone pacientebSi. Tumca, venuri Segubeba, romelic
xasiaTdeba gazrdili marjvena winagulis wneviT (RAP), aseve ukavSirdeba
GFR-s. mkurnaloba mimarTuli unda iyos ara mxolod Tirkmelebis
perfuziis gazrdisken, aramed venuri Segubebis Semcirebisken. kvleva
gansakuTrebiT imiT aris saintereso, rom is moicavda pacientebs
filtvismieri hipertenziiT, romelTac aReniSnebodaT metwilad
marjvenaparkuWovani ukmarisoba 41.
heiko uToftis (Heiko Uthofft) da Tanaavtorebis mier Catarebulma kvlevam
ufro ganamtkica mosazreba, rom CVP aris mniSvnelovani hemodinamikuri
faqtori Tirkmelebis funqciis gauaresebisTvis, gansakuTrebiT maSin,
rodesac is ukavSirdeba daqveiTebul wuTmoculobas 42. aRniSnuli kvlevis
mixdviT, gulis mwvave ukmarisobis dros, dabali sistoluri arteriuli
wneva (SBP) da maRali CVPganapirobebs eGFR-is Semcirebas. Tumca, dabali
CVP-c SesaZloa ukavSirdebodes Tirkmelebis funqciis gauaresebas mcire
xniT. aRsaniSnavia, rom kvlevisas gamoyenebuli iyo CVP-s gazomvis ara
tradiciuli, aramed axali, ara-invaziuri meTodi NICVP, romelic iyenebs
periferiul venas centraluris nacvlad da efuZneba kompresiuli
sonografiis meqanizms 205. aseve arsebobs NICVP-is sxva meTodic, romelic
efuZneba impedansuli pleTizmografiis meqanizms 206 207. arcerTi
aRniSnuli meTodis validurobis Sesaxeb jerjerobiT ar arsebobs
sakmarisi informacia 208.
ali ahmedis (Ali Ahmed) da Tanaavtorebis mier ganxorcielebulma kvlevam
aCvena, rom CKD-sTan dakavSirebuli sikvdiloba ufro maRali iyo im
pacientebSi, romlebsac aReniSnebodaT diastoluri disfunqcia sistolur
ავტორის სტილი დაცულია
40
HF-sTan SedarebiT 43. diastoluriHF, anu gulis ukmarisoba SenarCunebuli
gandevnis fraqciiT (HFPEF) zogadad gulis ukmarisobis yvelaze xSiri
formaa 44-46 (arsebobs monacemebi, rom HFPEF-is insidensi aris mTlianad
gulis ukmarisobis SemTxvevebis 50% 47). Tirkmelebis dazianebis Tanxvedra
HFPEF-Tan sakmaod xSiria (gansakuTrebiT asakovan qalebSi hipertenziiT
da/an diabetiT), aseve, mravali SemTxveva SesaZloa ar iyos
diagnostirebuli 48. Tirkmelebis da gulis urTierTkavSiri, rac
potenciurad aRrmavebs HFPEF-s, kompleqsuria da moicavs moculobiT
gadatvirTvas, renul hipertenzias, oqsidaciur stress da anTebiT
procesebs 49 50.
zemoTaRniSnulma faqtebma, romlebic erTgvarad aknineben daqveiTebuli
marcxena parkuWis gandevnis fraqciis rols Tirkmelebis funqciis
gauaresebis procesSi, mkvlevarebi aiZula yuradReba miepyroT marjvena
parkuWisTvis, rogorc SesaZlo faqtorisTvis CRS-is ganviTarebaSi.
1.4. marjvena parkuWis roli
marjvena parkuWis Seswavlis sakiTxi da mis Sesaxeb arsebuli codna
tradiciulad mniSvnelovnad CamorCeba marcxena parkuWisas 51. miuxedavad
imisa, rom marjvenamxrivi gulis ukmarisoba (RSHF) xSirad viTardeba
marcxenamxrivi gulis ukmarisobis Sedegad, is damoukidebladac SeiZleba
ganviTardes iseT klinikur situaciebSi, rogorebicaa: filtvismieri
hipertenzia (PH), filtvebis qronikuli obstruqciuli daavadeba (COPD),
gulis Tandayolili daavdeba (CHD), SemaerTebelqsovilovani daavadeba,
koronaruli arteriebis daavadeba da gulis sarqvelebis dazianeba 209 210.
rodesac marjvena parkuWis funqcia darRveulia, xolo marcxena parkuWis
normaluria, saubroben izolirebul marjvenamxriv gulis ukmarisobaze
(IRVF) 52. monacemebi Tirkmlis funqciis darRvevis Sesaxeb aseT pacientebSi
mwiria da savaraudod xSirad arc aris diagnostirebuli 211 212.
ავტორის სტილი დაცულია
41
marjvena parkuWis disfunqcia SesaZloa TamaSobdes mniSvnelovan da
adreul rols Tirkmelebis funqciis darRvevis paTfiziologiaSi 53, Tumca,
misi funqciuri mdgomareobis Sefaseba problemas warmoadgens. am
droisTvis ar arsebobs erTi, sazogadod miRebuli da praqtikaSi
gamoyenebadi RV indeqsi 54. marjvena parkuWis rTuli anatomiis gamo,
mxolod ramodenime eqoskopiuri parametria miCneuli sarwmunod. TAPSE, anu
samkarediani sarqvlis rgolisebri zedapiris sistoluri eqskursia aris
validuri parametri RV funqciis SefasebisTvis 55. Tumca, klinikur
praqtikaSi misi gansazRvra iSviaTad xdeba. marjvena parkuWis funqciur
mdgomareobasa da moculobiT gadatvirTvaze aseve warmodgenas gviqmnis
marjvena parkuWis saboloo diastoluri diametri (RVEDD).
CVP, romelic marjvena winagulovani wnevis (RAP) miaxloebiTi maCveneblia,
aseve SesaZloa gamoyenebul iqnes RSHF-s diagnostirebisTvis, Tumca,
yovelTvis gasaTvaliswinebelia sxva gul-sisxlZarRvovani parametrebi,
magaliTad, rogoricaa LVEF, radgan marjvenamxrivi wneva SesaZloa iribad
asaxavdes marcxenamxriv wnevas da marcxenamxrivi avsebis wneva SesaZloa
iyos marcxena gulis funqciuri mdgomareobis niSani 56.
frank dinim (FrankL. Dini) da Tanaavtorebma Seiswavles RV disfunqciis da
CKD urTierTkavSiri gulis qronikuli ukmarisobis mqone ambulatoriul
pacientebSi. mkvlevarebma aRmoaCines, rom aRiniSneboda mniSvnelovani
korelacia TAPSE-s da GFR-s Soris 53. kvlevis Sedegebi aZlierebs
mosazrebas, rom gulis ukmarisobis dros Tirkmelebis funqciis
gauaresebis paTfiziologiaSi “ukana” (Backward) ukmarisobiT gamowveuli
venuri Segubeba SesaZloa iseve mniSvnelovani iyos, rogorc “wina”
(Forward) ukmarisoba. RSHF-is gamo gazrdil Tirkmelebis venur wnevas
SeuZlia GFR-is Semcireba TirkmelebSi intersticiuri da milakovani
hidrostatikuri wnevis gazrdis, Tirkmelebis perfuziuli wnevis da
sisxlis midinebis Semcirebis xarjze. hipoqsia, iseve rogorc gazrdili
venuri wneviT gamowveuliHlokaluri da sistemuri neirohormonaluri
aqtivacia kidev ufro amZimebs Tirkmelebis funqciur mdgomareobas am
ავტორის სტილი დაცულია
42
pacientebSi 57 58. Tumca, miuxedavad zemoTaRniSnuli mtkicebulebebisa,
marjvena parkuWis rolis Sefaseba gaZnelebulia, radgan: 1) is xSirad
Tanxvdeba marcxenaparkuWovan ukmarisobasTan SenarCunebuli an
Semcirebuli gandevnis fraqciiT, da 2) Tirkmelebis funqciis darRvevas
aseve SeuZlia gazardos marjvena winagulis wneva (RAP) da gamoiwvios
siTxis Sekaveba, miuxedavad Tanmxlebi gulis ukmarisobis arsebobisa 41.
1.5. Tirkmelebis dazianeba da gorglovani filtraciis siCqare
miCneulia, rom gorglovani filtraciis siCqare yvelaze kargad asaxavs
Tirkmelebis funqciur mdgomareobas 213. rogorc cnobilia, gorglovani
filtraciis siCqare aris siTxis garkveuli moculoba, romelic
ifiltreba Tirkmelebis gorglovan (glomerulur) barierSi drois
garkveul monakveTSi (ml/wT). is ganisazRvreba starlingis formuliT
(Starling equation): GFR = Kf[(Pc‐Pb)‐(Πc)] (ix.: suraTi 2) 214. GFR-is mTavari
fiziologiuri modulatorebi arian aferentuli da eferentuli
arteriolebis rezistentoba: aferentuli arteriolebis rezistentobis
gazrda iwvevs wnevis Semcirebas gorglovan aparatSi da Sesabamisad, GFR-
is Semcirebas 215. eferentul arteriolebsa da GFR-s Soris kavSiri ufro
kompleqsuria: eferentuli rezistentobis gazrda Tavidan iwvevs
glomerulebSi wnevis gazrdas da GFR-ismomatebas, xolo Semdeg, rodesac
eferentuli rezistentoba matulobs, sisxlis nakadi glomerulebSi
mcirdeba da GFR iklebs 216.
ავტორის სტილი დაცულია
gorg
gamoy
klir
konc
gamoi
kreat
kreat
Tirk
Ra= artereziRe= arterezi
glovani
yofil
rensi, xo
centracia
iyeneba go
tininis
tininis m
kmelebis q
aferentuli eriolebis istentoba eferentuli eriolebis istentoba
suraTi 2
filtrac
SardSi
olo ve
217. Tu
orglovan
koncentr
mateba iwv
qronikul
2. gorglo
ciis dasa
ganisazR
nidan u
umca, kl
ni filtra
raciasa
vevs GFR-i
li daavade
GFR=
ovani fil
adgenad
Rvros en
uzmoze a
linikur
aciis Sef
da GFR-s
is Semcir
ebis (CKD)
Kf [(Pc‐Pb)‐
ltraciis
saWiroa
ndogenur
aRebul
praqtikaS
fasebiTi m
s Sori
rebas. GFR
) 5 stadia
‐(Πc)]
meqanizmi
24 saaT
i kreat
sisxlSi
Si dRes
maCvenebel
is arseb
R-ze dayr
a 219:
i
Tis ganma
tininis s
- kre
ufro
li (eGFR) 2
bobs uku
rdnobiT g
Kf= Pgorglokapilarebis ganvladoba Pc= gorglovkapilarebis hidrostatikwneva Pb= boumanis kafsulis hidrostatikwneva Πc= gorglovkapilarebis onkozuri wn
43
vlobaSi
saSualo
eatininis
xSirad
218.
ukavSiri:
ganirCeva
ovani
vani
uri
uri
vani
neva
ავტორის სტილი დაცულია
44
stadia
GFR
aRweriloba
1 >90 Tirkmelebis funqcia normis
farglebSia, Tumca, Sardis monacemebi
da/an struqturuli cvlilebebi
mianiSnebs Tirkmelebis dazianebis
arsebobaze
2 60‐89 Tirkmelebis funqcia mcirediT
daqveiTebulia. sxva mxriv, igive
mdgomareobaa, rogorc pirveli xarisxis
dros
3 30‐59 Tirkmelebis funqcia zomierad aris
daqveiTebuli (saSualo xarisxis
disfunqcia)
4 15‐29 Tirkmelebis funqcia Zlier aris
daqveiTebuli (mZime xarisxis
disfunqcia)
5 <15an dializi Tirkmelebis daavadebis terminaluri
stadia (umZimesi xarisxis disfunqcia)
cxrili 4. CKD 5 stadiaGFR-is mixedviT
Trikmelebis mwvave dazianebis (AKI) SemTxvevaSi GFR-ze dafuZnebuli
klasifikacia am etapisTvis miRebuli ar aris 220 221. Tirkmelebis mwvave
dazianebis qselis (AKIN) †† mier mowodebuli diagnostikuri kriteriumebi
efuZneba Sratis kreatininis matebas ≥ 0.3 mg/dl (≥ 26.4 mkmol/l), mis
procentul matebas ≥50% (sawyisi monacemidan 1.5-jer mateba), an diurezis
†† Acute Kidney Injury Network – saerTaSoriso organizacia, romlis misiac aris internacionaluri da interdisciplinuri kvleviTi aqtivobebis ganxorcieleba Tirkmelebis mwvave dazianebis diagnostirebis, prevenciis da mkurnalobis sferoSi
ავტორის სტილი დაცულია
45
Semcirebas (dokumentirebuli oliguria < 0.5 ml/kg saaTSi 6 sT-ze met
xans) 222.
kardio-renuli sindromis dros arsebuli Tirkmelebis funqciis darRvevis
aRsaniSnavad xSirad gamoiyeneba termini - Tirkmelebis funqciis mzardi
gauareseba (WRF)223224. aRniSnuli terminis qveS metwilad moiazreba gulis
mwvave dekompensirebuli ukmarisobis (ADHF) da mwvave koronaruli
sindromis (ACS) fonze arsebuli Tirkmelebis funqciis mwvave an qvemwvave
gauareseba, rac gamoixateba Sratis kreatininis matebiT. kreatininis
zRvari, ris Semdegac xdeba WRF-is diagnostireba, aris ≥0.3 mg/dl (26.5
mmol/l) 225 226 227, Tumca, rig kvlevebSi es zRvari gansazRvrulia, rogorc
≥0.5 mg/dl 228 229.
ADHF-is diagnoziT hospitalizirebuli pacientebis 14-34%-s aReniSneba WRF
230. aseTi farTo diapazoni metwilad ganpirobebulia imiT, rom sxvadasxvaa
Tirkmelebis funqciis gauaresebis diagnostirebis zRurbli da aseve
gansxvavdeba dakvirvebis dro da hospitalizirebuli pacientebis
Tirkmelebis funqciis sawyisi mdgomareoba 231 232. garda kreatininisa,
Tirkmelebis funqciis Sesafaseblad aseve gamoiyeneba sisxlis Sardovana
azoti (BUN)233234.arsebobs mosazreba, rom is ufro Zlieri markeria vidre
kreatinini, savaraudod imitom, rom im neirohormonaluri aqtivaciis
paralelurad, rasac adgili aqvs gulis ukmarisobis fonze ganviTarebuli
WRF-s dros, BUN ufro kargad asaxavs gulis ukmarisobis
paTfiziologiur meqnizms 235 236. aqve unda aRiniSnos, rom ADHF-s gamo
hospitalizaciis pirvel 48 saaTSi cistatin C‐s mateba 0.3 mg/l-ze metad
miiCneva sikvdilobis damoukidebel prediqtorad 237.
miuxedavad zemoTaRniSnuli mosazrebebisa, Tirkmelebis qronikuli
daavadebis msgavsad, AKI-s simZimis Sefasebisas bolo dros aqtiurad
gamoiyeneba eGFR, kerZod misi MDRD formula 238.
ავტორის სტილი დაცულია
46
1.6. daskvna
mwvave an qronikuli gulis ukmarisobis mqone pacientebSi Tirkmelebis
gauaresebuli funqcia Tanamedrove medicinis mniSvnelovan klinikur
problemas warmoadgens. gul-sisxlZarRvTa daavadebebis dros Tirkmelebis
dazianebis paTfiziologia kompleqsuri procesia da bolomde Seswavlili
ar aris. bolo drois kvlevebi aCvenebs, rom IAP‐is da CVP-s matebas, rac
aseve iwvevs RVP-s matebas, mivyavarTGFR-is Semcirebamde.LVEF‐is da RSHF–is
mniSvneloba CRS‐is dros ar aris srulyofilad Sefasebuli.
gulsa da Tirkmelebs Soris arsebuli ormimarTulebiani kavSiris
srulofilad gaazreba mniSvnelovania, rom gansazRvros optimaluri
mkurnalobis strategiebi CRS–is TiToeuli tipisTvis, radgan erT
organoTa sistemaze mimarTul mkurnalobas SesaZloa hqondes dadebiTi, an
piriqiT, uaryofiTi Sedegi meore organoTa sistemis funqciur
mdgomareobaze.
RSHF-is Sefaseba garTulebulia, Tumca TAPSE da CVP,romelic savaraudo
RAP-s asaxavs, SesaZloa gamoyenebul iqnes RSHF-s diagnostirebisTvis. aqve
unda aRiniSnos, rom maTi gamoyeneba aucilebelia sxva kardio-vaskularul
parametrebTan erTobliobaSi. miuxedavad bolo drois monacemebisa, RSHF-
is rolis Sefaseba CRS-is ganviTarebaSi sakmaod rTulia, radgan RSHF
xSirad aris dakavSirebuli marcxenaparkuWovan ukmarisobasTan da
Tirkmelebis funqciis daRvevasac SeuZlia Tavis mxriv RAP-is mateba
siTxis Sekavebis xarjze, miuxedavad Tanmxlebi gulis ukmarisobis
arsebobisa. meti kvlevebi aris saWiro marjvnaparkuWovan ukmarisobas, CVP-
s da Tirkmlis funqciis gauaresebas Soris korelaciis dadgenis mizniT.
ავტორის სტილი დაცულია
47
2. eTikuri sakiTxebis gadawyveta
nebismieri biosamedicino kvleva saWiroebs eTikuri sakiTxebis
gaTvaliswinebas kvlevis protokolis SemuSavebis fazaSi. Tavidanve unda
ganisazRvros, Tu ra eTikuri sakiTxebi SeiZleba warmoiSvas kvlevis
mimdinareobisas da rogor unda moxdes maTi gadawyveta 239. piradi
informacis konfidencialurobis dacva aris is mTavari eTikuri sakiTxi,
rasac xSirad adgili aqvs ara-eqsperimentul kvlevebSi 240 241. ZiriTadad is
ukavSirdeba pirovnebebis identifikaciis da piradi informaciis
(pirovnebis maidentificirebeli piradi monacemebis) gamJRavnebis safrTxes.
prospeqtuli kvlevebis SemTxvevaSi, pacientebisgan SesaZlebelia
informirebuli Tanxmobis miReba piradi informaciis gamJRavnebis
nebarTvaze, Tumca, retrospeqtiuli kvlevis dizainis gamoyenebisas,
romelic tardeba ukve arsebul monacemebze, es Zalian rTulia da xSirad
SeuZlebelic 242 243. monacemTa anonimizacia SesaZlebelia iyos gamosavali
aseT situaciaSi, sxva im RonisZiebebTan erTad, romlebic gawerilia
saqarTvelos erovnul kanonmdeblobasa da saerTaSoriso gaidlainebSi.
saqarTveloSi samedicino momsaxurebis sferoSi samedicino eTikisa da
bioeTikis mTavar sakonsultacio organos warmoadgens saqarTvelos
Sromis, janmrTelobisa da socialuri dacvis saministrosTan arsebuli
bioeTikis erovnuli sabWo, romlis mizanic aris mosaxleobis samedicino
momsaxurebasTan, samedicino-biologiur kvlevasTan dakavSirebuli eTikuri
aspeqtebis warmoCena da saTanado rekomendaciebis momzadeba.
2.1. mimoxilva
biosamedicino kvlevebSi eTikuri sakiTxebis gaTvaliswineba gansakuTrebiT
aqtualuri gaxda bolo 60-70 wlis manZilze. 1942 wels amerikelma
sociologma robert mertonma (Robert Merton) SeimuSava akronimi CUDOS –
samecniero saqmianobis gunduroba, sazogado Rirebulebebi, uangaroba da
organizebuli skepticizmi (Communism, Universalism, Disinterestedness, and
Organized Skepticism), rac iqca samecniero eTikuri normebis qvakuTxedad 244.
ავტორის სტილი დაცულია
48
mas Semdeg msoflioSi Seiqmna mTeli rigi maregulirebeli dokumentebisa
imisaTvis, rom uzrunvelyofiliyo dadebiT gamosavalze orientirebuli
praqtikuli rekomendaciebis kompleqsi biosamedicino kvelvebis
erTianobis SenarCunebis mizniT 245.
saganmanaTleblo sferoSi saerTaSoriso TanamSromlobis norvegiuli
centris (SIU ‐ Norwegian Centre for International Cooperation in Education) 246 mier
dafinansebulma proeqtma “sadoqtoro programa sazogadoebriv jandacvaSi:
norvegiis ganaTlebis mesame safexuris gamocdileba saqarTvelosTvis”
(Doctoral Programme in Public Health: Norway Experience of Third Cycle Studies for
Georgia), saSualeba misca Tbilisis saxelmwifo universitetis da
saqarTvelos universitetis ramodenime doqtorants CarTuliyvnen
norvegiis tromsos universitetis (UiT:UniversityofTromsø–TheArcticUniversity
of Norway) sadoqtoro swavlebis programaSi. aRniSnulma programam
doqtorantebs, maT Soris warmodgenili sadoqtoro naSromis avtors,
saSualeba misca detalurad gascnobodnen biosamedicino eTikis
regulaciebs norvegiaSi da saerTSoriso gamocdilebas aRniSnul sferoSi.
warmodgenili sadoqtoro kvelvis magaliTze qvemoT ganxiluli iqneba im
eTikuri sakiTxebis gadaWris gzebi, romlebsac zogadad adgili aqvs ara-
eqsperimentul kvlevebSi.
2.2. pacientebis piradi informaciis konfidencialuroba
eqsperimentuli kvlevebisgan gansxvavebiT, ara-eqsperimentul
(obzervaciul-analitikur) kvlevebs zogadad naklebad axasiaTebs
eTikasTan dakavSirebuli sirTuleebi, Tumca, mainc aris sakiTxebi rac
saWiroebs kvalificiur gadawyvetas 247. piradi informacis
konfidencialurobis dacva aris is mTavari eTikuri sakiTxi, rasac xSirad
adgili aqvs ara-eqsperimentul kvlevebSi. ZiriTadad is ukavSirdeba
pirovnebebis identifikaciis da piradi informaciis (pirovnebis
maidentificirebeli piradi monacemebis) gamJRavnebis safrTxes 248. es
ავტორის სტილი დაცულია
49
informacia ZiriTadad Tavmoyrilia samedicino baraTebSi da moicavs
pacientis sqess, asaks, sxeulis masis indeqss da sxva specifiur
informacias, rogorebicaa anamnezi, fizikuri gasinjvis monacemebi da
kvlevebis Sedegebi. aRniSnuli Canawerebi samedicino dawesebulebebSi
inaxeba xangrZlivi droiT (stacionarul dawesebulebebSi 15 wliT,
rogorc gansazRvrulia saqarTvelos kanonmdeblobiT) 249, rac
SesaZleblobas iZleva biosamedicino kvlevebi ganxorcieldes
retrospeqtiulad. prospeqtuli dizainis mqone kvlevebis
ganxorcielebisas informirebuli Tanxmobis miReba pacientebisgan
sirTules ar warmoadgens, Tumca retrospqtiuli kvlevebis SemTxvevaSi es
Zalzed rTuli, an SeuZlebelia 250.
Tu kvleva saWiroebs warsulSi namkurnalevi pacientebis samedicino
Canawerebis retrospeqtiul Seswavlas, maTTan dakavSireba da
informirebuli Tanxmobis mopovoba mniSvnelovnad gaarTulebs kvlevis
mimdinareobas 251. ufro metic, pacientebTan dakavSireba da Tanxmobis
mopoveba unda moxdes mkurnali eqimebis, da ara mkvlevarebis mier, radgan
maT ar aqvT (ar unda hqondeT) wvdoma pacientebis pirad informaciasTan.
rodesac mkurnalobis dros pacientebma eqimebs miawodes garkveuli piradi
informacia, maT CaTvales, rom es informacia gamoyenebuli iqneboda
mxolod mkurnalobisaTvis da ara kvlevebisTvis 252. maSin maTTvis aravis
uTqvams, rom odesme, SesaZloa maTi gardacvalebis Semdegac ki, samdicino
Canawerebi gamoyenebuli iqneboda biosamedicino kvelvebisTvis. ra SeiZleba
iyos gamosavali aseT situaciaSi? pasuxi ar aris calsaxa, Tumca,
SeiZlebelia vipovoT im erovnul da saerTaSoriso normatiul aqtebSi,
romlebic aregulirebs eTikis sakiTxebs medicinaSi, maT Soris
biosamedicino kvlevebis dros. saqarTveloSi es normatiuli aqtebia:
saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris
brZaneba # 276/n - bioeTikis erovnuli sabWos debulebis damtkicebis
Sesaxeb 253
ავტორის სტილი დაცულია
50
saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris
brZaneba #N128/n - samedicino eTikis komisiis debulebis damtkicebis
Sesaxeb 254
saqarTvelos kanoni janmrTelobis dacvis Sesaxeb 255
saqarTvelos kanoni pacientis uflebebis Sesaxeb 256
saqarTvelos kanoni sazogadoebrivi janmrTelobis Sesaxeb 257
saqarTvelos kanoni saeqimo saqmianobis Sesaxeb 258
saqarTvelos eqimis eTikis kodeqsi 259
saerTaSoriso aqtebi, romlebic ratificirebuli aqvs saqarTvelos,
rogorc evrosabWos wevr qveyanas:
biologiasa da medicinaSi adamianis uflebebis da keTildReobis dacvis
konvencia: konvencia adamianis uflebebis da biomedicinis Sesaxeb
(oviedos konvencia) (Convention for the Protection ofHumanRights andDignity of
theHumanBeingwithregardtotheApplicationofBiologyandMedicine:Conventionon
HumanRightsandBiomedicine,(OviedoConvension)) 260
adaminis uflebebis da biomedicinis damatebiTi protokoli
biosamedicino kvlevebis Sesaxeb(AdditionalProtocoltotheConventiononHuman
RightsandBiomedicine,concerningBiomedicalResearch) 261
evropuli konvencia xerxemliani cxovelebis dacvis Sesaxeb
eqsperimentebSi da sxva samecniero mizniT gamoyenebis dros (European
Convention for the Protection of Vertebrate Animals used for Experimental and Other
ScientificPurposes)262
sxva mniSvnelovani saerTaSoriso dokumentebi, romlebic saerToa
saqarTvelosa da norvegiisaTvis:
msoflio samedicino asociaciis helsinkis deklaracia - adamianze
Catarebuli samedicino kvlevis eTikuri principebi (World Medical
Association Declaration of Helsinki ‐ Ethical Principles for Medical Research Involving
HumanSubjects)263264
ავტორის სტილი დაცულია
51
msoflio samedicino asociaciis samedicino eTikis saerTaSoriso
kodeqsi (WorldMedicalAssociation‐InternationalCodeofMedicalEthics) 265
vankuveris sazogadoebrivi kolejis eTikis kodeqsi (Vancouver Community
CollegeCodeofEthics)266
bioeTikis erovnuli sabWos struqtura da funqciebi gansazRvrulia
saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris
brZanebiT 267. sabWos SesaZloa mimarTos mkvlevarma individualurad, an im
samedicino dawesebulebis eTikis komisiam, sadac kvleva unda Catardes.
eTikis komisiebis arseboba samedicino dawesebulebebSi savaldebuloa da
gansazRvrulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis
ministris brZanebiT268.eTikis komisiebi Sedgeba departamentis minimum erTi
eqimisgan, eqTnis da administraciis TanamSromlisgan. iuristis, eTikis
specialistis da sasuliero piris CarTvac SesaZlebelia, Tumca
savaldebulo ar aris. erovnuli kanonmdeblobiT, samedicino
dawesebulebebis eTikis komisiebs aqvT valdebuleba daamtkicon
nebismieri warmodgenili kvleva, miuxedavad dizainisa (prospeqtuli,
retrospeqtiuli) da monacemTa miRebis gzisa. eTikis komisiebs SeuZliaT
saWiroebis SemTxvevaSi konsultaciis mizniT mimarTon bioeTikis erovnul
sabWos, Tumca amis valdebuleba ar aqvT. rogorc ukve aRiniSna,
individualur mkvevarebsac SeuZliaT mimarTon bioeTikis erovnul sabWos,
iqneba es samecniero Tu studenturi kvleviTi proeqti. universitetebSi,
samecniero sabWoebi axdenen warmodgenili samecniero kvelvebis
samecniero da eTikuri aspeqtebis zogad Sefasebas da saWiroebis
SemTxvevaSi mimarTaven bioeTikis erovnul sabWos. amis Semdgom, eTikuri
sakiTxebis Sefaseba da kanonmdeblobasTan Sesabamisobis uzrunvelyofa
ukve im samedicino dawesebulebebis eTikuri komisiebis pasuxismgeblobaa,
sadac kvleva unda Catardes.
norvegiaSi, yvela proeqti romelic janmrTelobis kvlevis aqtiT (Health
Research Act) aris gansazRvruli, dawyebamde damtkicebuli unda iqnes
ავტორის სტილი დაცულია
52
medicinis da janmrTelobis kvlevis eTikis regionuli komitetis (REK) ‡‡–is
mier. REK–is saqmianoba gansazRvrulia norvegiis kanoniT samedicino
kvlevis da eTikis Sesaxeb 269. komitetebs, romlebic Sedgeba gansxvavebuli
profesiuli kompetenciis pirebisgan, niSnavs ganaTlebis da kvlevis
saministro 4 wlis vadiT. REK-s aqvs Tavisi portali ganacxadis
ganTavsebisaTvis, romelic moicavs informacias erovnuli
administraciuli procedurebis da gaidlainebis Sesaxeb, rom
uzrunvelyofili iyos kvlevis ganxorcielebis usafrTxoeba da
Sesabamisoba kanonmdeblobasTan 270. universitetebs akisriaT
pasuxismgebloba, rom uzrunvelyon maTi kvleviTi proeqtebis Sesabamisoba
norvegiis janmrTelobis kvlevis aqtTan da norvegiis monacemTa dacvis
aqtTan 271. aseve, maT unda uzrunvelyon resursebis mobilizeba xarisxis
SenarCunebis da gaumjobesebis mimarTulebiT. doqtoranturis studentebs
da samecniero proeqtis monawileebs utardebadaT srulyofili
treiningebi im samecniro proeqtebTan dakavaSirebiT, romlebSic isini
erTvebian da Semdgomac, proeqtis mimdinareobisas, uwyvetad iReben
miTiTebebs da rekomendaciebs. rogorc wesi, piradi informaciis gamoyeneba
kvlevis dros mxolod aucileblobis SemTxvevaSi unda moxdes. piradi
informacia ganmartebulia norvegiis monacemTa dacvis aqtis meore muxliT
272. universitetebma kvlevebSi piradi informacia unda gamoiyenon mxolod
kvlevis eTikis principebis dacviT 273.
imisaTvis, rom efeqturad imarTos konfidencialurobis sakiTxi ara-
eqsperimentul kvlevebSi, aucilebelia zemoTaRniSnuli eTikuri
sakiTxebis maregulirebeli normatiuli aqtebis mimoxilva. rogorc
saqarTvelos kanoni saeqimo saqmianobis Sesaxeb da saqarTvelos kanoni
pacientis uflebebis Sesaxeb gansazRvravs, mkurnali eqimebi, romlebic
TavianTi pcientebis samedicino dokumentaciidan kvlevisTvis saWiro
informacias iReben, ar arRveven pacientis konfidencialurobas, Tu
daculia piroba, rom Sedegebi gamoqveyndeba imgvarad, rom SeuZlebeli
iqneba pacientis identificireba. eqimebis piradi pasuxismgeblobaa
‡‡RegionalCommitteesforMedicalandHealthResearchEthics
ავტორის სტილი დაცულია
53
pacientebis samedicino informaciis konfidencialurobis dacva.
miuxedavad amisa, maT unda warudginon TavianTi kvlevebi samedicino
dawesebulebebis eTikis komisiebs gansaxilvelad, rogorc amas
kanonmdebloba moiTxovs.
konfidencialuri samedicino informaciis gamJRavneba uSualod pacientis
da misi mkurnali eqimis (eqimebis) garda sxva pirebze dasaSvebia moxdes
Semdeg situaciebSi:
1. rodsac pacienti iZleva Tanxmobas;
2. rodesac amas moiTxovs kanoni (arsebobs sasamarTlos
gadawyvetileba);
3. rodesac aris gansakuTrebuli sazogadoebrivi interesi.
rogor unda moviqceT im SemTxvevaSi, rodesac kvlevis interesebidan
gamomdinare mkvlevarebi saWiroeben wvdomas samedicino CanawerebTan?
eTikuri principebi daculi iqneba, Tu:
1. pacientebs micemuli aqvT Tanxmoba maTi samedicino Canawerebis
kvlevisTvis gamoyenebaze;
2. samedicino Canawerebi aris anonimuri;
3. daculia specialuri sakomunikacio procedura ara-anonimuri
informaciis kvlevisTvis gamoyenebaze.
rogorc ukve aRiniSna, retrospeqtiuli kohortuli an kros-seqciuli
kvlevebis dros gamoiyeneba ukve arsebuli samedicino Canawerebi da am
dros Zalian rTulia pacientebisgan informirebuli Tanxmobis mopoveba 274
275. SesaZlebelic rom iyos, pacientebisgan informirebuli Tanxmobis
moTxovnis ufleba mxolod mkurnal eqimebs aqvT, da ar mkvlevarebs 276.
SesaZlebelia Tu ara, monacemTa anonimizacia iyos gamosavali aseT
situaciaSi? Teoriulad, SesaZlebelia, da informirebuli Tanxmobis
miRebis procedurac Tavidan iqneba acilebuli. es xdeba Semdegnairad:
rodesac samedicino Canawerebis anonimizacia xorcieldeba samedicino
dawesebulebebSi, TiToeul pacients eniWeba unikaluri kodi. kodi da
masze mibmuli samedicino monacemebi xelmisawvdomia mkvlevarebisTvis,
ავტორის სტილი დაცულია
54
xolo piradi informacia, rac dgas kodis ukan da iZleva pirovnebis
identifikaciis SesaZleblobas (magaliTad, identifikatorebi – saxeli,
gvari, dabadebis TariRi, piradi nomeri, dazRvevis nomeri, misamarTi, tel.
nomeri, el.fosta, fotosuraTi, da sxv.), mkacrad aris daculi samedicino
centris personalis mier 277. amgvari anonimizacia SesaZlebelia, rodesac
yvela samedicino Canaweri Senaxulia eleqtronulad, rac samwuxarod ar
aris xSiri praqtika qarTul samedicino dawesebulebebSi. garkveul doneze
anonimizacia miiRweva, Tumca, samedicino Canawerebis nawili, rogorebicaa
magaliTad, laboratoriuli kvlevis Sedegebi an eqimi-specialitebis
dRiuri Canawerebi (kursusebi), mxolod qaRaldzea Senaxuli. Sesabamisad,
rodesac vinmes survili aqvs am Canawerebis naxvis, xdeba SemTxveviTi
wvdoma pacientis pirad informaciasTan (identifikatorebTan).
gamosavali am SemTxvevaSi SesaZloa iyos specialuri sakomunikacio
proceduris dacva samedicino kvlevisTvis ara-anonimuri informaciis
gamoyenebze. samedicino dawesebulebebma unda SeimuSavon iseTi procedura,
romelic uzrunvelyofs pacientebis piradi informaciis daculobas
mkvlevarebisgan. es SesaZlebelia ganxorcieldes mkurnali eqimebis
CarTviT kvleviT proeqtebSi, sadac isini Seasruleben “mekavSiris” rols
mkvlevarebsa da samedicino Canawerebs Soris. samedicino daweseblebebma
aseve unda gamonaxon resursebi im eqimebis mxardasaWerad, romlebic
gamoTqvamen survils daexmaron mkvlevarebs da CaerTon kvleviT
proeqtebSi. Tavisi mxidan, mkvlevarebma unda aiRon valdebuleba, rom ara-
anonimuri monacemebi Senaxuli iqneba mkacrad konfidencialurad.
identifikatorebis mocileba samedicino failebze unda moxdes rac
SeiZleba adreul etapze da kvleviTi samuSao unda Catardes anonimur
monacemTa bazaze. es aris is sakiTxi, raze meTvalyureobazec Tavis Tavze
unda aiRon samedicino dawesebulebebis eTikis komisiebma.
aseve, metad mniSvnelovania, rom kvlevis protokolebi, romlebic
gansaxilvelad wardgenili iqneba eTikis komisiebisTvis, moicavdes
potenciuri eTikuri sirTuleebis gadaWris gzebs da asabuTebdes
gansaxorcielebeli kvlevis klinikur mniSvnelobas. pacientebis
ავტორის სტილი დაცულია
55
konfidencialurobis darRvevis safrTxe zedmiwevniT unda iqnes
Sefasebuli da maTi Tavidan acilebis gzebic unda iyos warmodgenili.
mxolod aRniSnuli pirobebis dakmayofilebis Semdgom unda moiwonon
eTikis komisiebma kvlevebis protokolebi da uzrunvelyon wvdoma
samedicino Canawerebze.
2.3. daskvna
pacientebis paradi informaciis konfidencialuroba SesaZloa iyos
mniSvnelovani gamowveva ara-eqsperimentuli kvlevebis ganxorcielebisas.
imisaTvis, rom eTikuri sakiTxebis gadawyveta SesabamisobaSi iyos
maregulirebel normatiul aqtebTan, samedicino dawesebulebebi da
mkvlevarebi valdebulni arian:
rodesac SesaZlebelia, miawodon informacia pacientebs (an maT
kanonier warmomadgenlebs) samedicino Canawerebis kvlevisTvis
gamoyenebis SesaZleblobis Sesaxeb. prospeqtul reJimSi
informirebuli Tanxmoba mopovebul inda iqnes mkurnali eqimebis mier,
Semdegi niuansis gaTvaliswinebiT: “eqimi gansakuTrebuli sifrTxiliT
unda miudges pacientis mxridan Tanxmobis miRebis sakiTxs, radgan
SesaZlebelia is Tavs Tvlides masze (eqimze) damokidebulad da es
gaakeTos garkveuli iZulebiT. aseT situaciaSi umjobesia Tanxmoba
mopovebul iqnes sxva pirisgan, romelic Tavisufali iqneba aRniSnuli
damokidebulebisgan (msoflio samedicino asociacia (WMA), helsinkis
deklaracia, paragrafi 26, 2008).
kvlevis mimdinareobisas minimumamde unda iqnes dayvanili pirad
informaciasTan wvdoma, im SemTxvevebSi, rodesac SeuZlebelia
informirebuli Tanxmobis miReba da/an monacemTa sruli anonimizacia.
samedicino failebidan piradi identifikatorebis mocileba unda
moxdes rac SeiZleba adreul etapze da kvleviTi samuSao unda
Catardes anonimur monacemTa bazaze. kvlevis Sedegebi unda
ავტორის სტილი დაცულია
56
gamoqveyndes imgvarad, rom SeuZlebeli iyos pacientebis
identificireba.
warmodgenilma sadoqtoro kvlevam gaiara zemoTaRniSnuli yvela
procedura, kerZod, Tbilisis saxelmwifo univesitetis sadsertacio
sabWos mier kvlevis damtkicebis Semdeg, kvlevis protokoli ganxilul da
mowonebul iqna im samedicino dawesebulebebis eTikis komisiebis mier,
sadac kvleva ganxorcielda. magaliTisTvis mogvyavs amonaridi
hospitaluri qseli “medalfas” kaspis samedicino centris eTikis komisiis
daskvnidan: “kvlevis Catarebis mimarT eTikuri winaaRmdegoba ar arsebobs.
kvleva aris retrospeqtiuli, rac gamoricxavs pacientebis informirebuli
Tanxmobis mopovebis SesaZleblobas. Sesabamisad, saWiro monacemebis
amoReba samedicino baraTebidan unda moxdes mkurnali eqimebis mier, raTa
daculi iqnes pacientebis konfidencialuroba. TiToeul pacients mieniWeba
individualuri kodi, romelic Seinaxeba samedicino dawesebulebaSi.
kvlevis oqmi, romelic gadaecema kvlevis samecniero xelmZRvanels, iqneba
anonimuri, rac SeuZlebels gaxdis pirovnebis identificirebas”.
kvlevis Sesaxeb informacia aseve miewoda bioeTikis erovnul sabWos.
ავტორის სტილი დაცულია
57
3. kvlevis miznebi, meTodologia da protokoli
rogorc ukve aRiniSna, warmodgenili kvelva warmoadgens ara-
eqsperimentul kvlevas. miuxedavad amisa, saerTaSoriso rekomendaciebis
Tanaxmad is registrirebulia klinikuri kvlvebis saerTaSoriso reestrSi
veb gverdze: https://clinicaltrials.gov.registraciis nomeria:NCT02792387.
3.1. kvlevis miznebi
kvleva efuZneba hipoTezas, rom marcena parkuWis gandevnis fraqciis
Semcireba ar ukavSirdeba GFR-is Semcirebas, xolo CVP, marcxena parkuWis
gandevnis fraqciaze metad aris korelaciaSi Tirkmelebis funqciis
darRvevasTan (gamoxatuli, rogorc Semcirebuli GFR<90) im pacientebSi,
romlebsac aReniSnebaT kardio-renuli sindromis I da II tipi. hipoTezis
dadastureba gavlenas iqoniebs riskebis adreul Sefasebasa da CRS‐s
adreul diagnostirebaze, aseve, daavadebis mimdinareobasa da gamosavalze.
3.2. dizaini
kvlevis dizaini iyo kros-seqciuli tipis §§ da ganxorcielda Semdegi
samedicino dawesebulebebis bazaze: hospitaluri qseli “medalfas” 4
samedicino centri, mediqlabjorjia, sisxlZarRvTa da gulis daavadebaTa
centri (n. boxuas saxelobis). kvleva moicavda stacionaruli pacientebis
klinikur SemTxvevebs, 2015 wlis seqtembridan 2016 wlis maisis CaTvliT.
pacientebis retrospeqtiuli CarTva ganxorcielda winaswar gansazRvruli
kriteriumebis mixedviT (ix.: 3.3.). monacemebis amoReba ganxorcielda
stacionaruli samedicino baraTebidan, romlebic rig SemTxvevebSi
§§kros-seqciuli kvleva, anu analizi, aris obzervaciuli kvlevebis nairsaxeoba romelic gulisxmobs drois garkveul monakveTSi populaciidan an warmomadgenlobiTi (reprezentatiuli) jgufidan mopovebuli informaciis analizs. kros-seqciuli kvlevebi aris deskrifciuli xasiaTis (ar aris xangrZlivi (longitudinal), arc eqsperimentuli)
ავტორის სტილი დაცულია
58
xelmisawvdomi iyo eleqtronulad (sisxlZarRvTa da gulis daavadebaTa
centri). eGFRganisazRvra Tirkmelebis daavadebebis dros modificirebuli
dietis formuliT (MDRD). CVP-s monacemebi mocemuli iyo vercxliswylis
svetis sidideSi (Canawerebis mixedviT, yvela SemTxvevaSi CVPgansazRvruli
iyo eleqtronuli gadamwodiT laviwqveSa an Sida sauRle venis midgomiT).
3.3. sakvlevi populacia, CarTvis da gamoricxvis kriteriumebi
kvleva moicavda pacientebs gulis ukmarisobis sxvadasxva funqciuri
klasiT (NYHA klasi I – IV, SenarCunebuli an daqveiTebuli gandevnis
fraqciiT - ICD10: I50.0 – I50.9; I13.0 – I13.9) da Semcirebuli eGFR-iT (kardio-
renuli sindromi I da II tipi). Sesabamisad, CarTvis kriteriumebi iyoHFI‐IV
daeGFR<90.
gamoricxvis kriteriumebi gansazRvruli iyo Semdeg saxiT:
1. Tirkmelebis funqciis darRvevis damoukidebeli risk-faqtorebis
arseboba (magaliTad, sefsisi, diabeti);
2. pirveladi nefropaTia an meoradi nefropaTia gamowveuli gulis
ukmarisobis garda nebismieri sxva mizeziT.
3.5. statistikuri damuSavebis gegma
aRweriTi da analitikuri statistikis, damokidebul cvladze
statistikuri testirebis mizniT gamoyenebuli iyo programa IBM SPSS
Statisticsversion22.
eGFR (MDRD formula) gansazRvruli iyo rogorc damokidebuli cvladi
(OutcomeVariable), xolo sqesi, asaki, LVEF%,HF(NYHAklasi I ‐ IV),CVP, RVEDD
da arteriuli hipertenzia (JNCVIII klasifikaciiT), rogorc damoukidebeli
cvladebi (Predictor Variable), LVEF, rogorc potenciuri gavlenis faqtori
(ConfoundingFactor)CVP-s daeGFR-s Soris korelaciis arsebobis SemTxvevaSi.
ავტორის სტილი დაცულია
59
3.6. monacemTa mopoveba
warmodgenili kvlevis SemTxvevaSi, iseve rogorc zogadad retrospetiuli
kvlevebis dros, saWiro monacemebis amoReba xdeboda ukve arsebuli
klnikuri SemTxvevebis samedicino Canawerebidan. am konkretul SemTxvevaSi
problemas warmoadgenda is garemoeba, rom zogadad ar arsebobs kardio-
renuli sindromis diagnozis ICD10*** kodi (klasifikatori), romelic dRes
farTod gamoiyeneba saqarTveloSi da msoflios mniSvnelovan nawilSi 278.
Sesabamisad, monacemTa bazebSi kardio-renuli sindromis diagnozi ar
yofila (da dResac ar aris) dafiqsirebuli. samedicino dawesebulebebSi
mkurnali eqimebis mier saWiro iyo gulis ukmarisobiT (ICD10: I50.0 – I50.9)
diagnostirebuli yvela pacientis samedicino baraTis naxva da
Tirkmelebis funqciuri mdgomareobis Sefaseba iq arsebuli Canawerebis da
kvlevis Sedegebis mixedviT. aqve unda aRiniSnos, rom kardio-renul
sindromTan erTi SexedviT axlos aris ICD10kodi I13, romelic gulisxmobs
“gulisa da Tirkmlis hipertenziul avadmyofobas” †††, Tumca, misi
gamoyenebis aucilebeli pirobaa arteriuli hipertenziis arseboba, rac
yovelTvis ar gvxvdeba CRS-is dros.
rogorc pacientis kvlevaSi registraciis formiT da protokoliT iyo
gansazRvruli, mkurnali eqimebis mier saWiro iyo Semdegi monacemebis
amoReba pacientebis samedicino baraTebidan:
1. sqesi
2. asaki
3. LVEF%
4. gulis ukmarisobis klasi (I-IV NYHA)
5. CVPmmHg
6. kreatinini
7. RVEDD*** ICD‐10 aris jandacvis msoflio organizaciis (WHO) daavadebebis da janmrTelobasTan dakavSirebuli problemebis saerTaSoriso statistikuri klasifikaciis me-10 gadaxedva †††Hypertensiveheartandrenaldisease
ავტორის სტილი დაცულია
60
8. arteriuli hipertenzia (JNCVIII)
garda aRweriTi (deskrifciuli) statistikis miRebisa, 1-li, me-2, da me-6
monacemebi auclebeli iyo kvlevis damokidebuli cvladis (dependent
variable, outcome variable) ‐ eGFR‐is gamosaTvlelad (gamoTvlisas aseve
gamoiyeneba pacientis rasobrivi kuTvnilebis monacemi). eGFR, anu
gorglovani filtraciis SefasebiTi maCvenebeli (Estimated Glomerular
Filtration Rate) aris GFR-is miaxloebiTi, maTematikuri formuliT miRebuli
sidide 279.
zrdasrul pacientebSi rekomendebulia eGFR-is ori formulis gamoyeneba.
esenia: Tirkmelebis daavadebebis dros modificirebuli dietis formula
(Modification of Diet in Renal Disease (MDRD) formula)da Tirkmelebis qronikuli
daavadebis epidemiologTa kolaboraciis formula (Chronic Kidney Disease
EpidemiologyCollaboration(CKD‐EPI)formula)280.
MDRDformula:
eGFR = 186 Sratis kreatinini ‐1.154 asaki ‐0.203 (1.210Tu Savkaniania)
(0.742Tu qalia)
CKD‐EPIformula:
eGFR=141min(SCr/k,l)max(Scr/k,l)‐1.2090.993asaki (1.018Tu qalia) (1.159
Tu Savkaniania)
eGFR-is gamoTvla aseve SesaZlebelia onlain kalkulatorebis saSualebiT,
magaliTad, Tirkmelebis erovnuli fondis (NationalKidneyFoundation) ‡‡‡ veb-
gverdze ganTavsebuli onlain kalkulatoris meSveobiT:
https://www.kidney.org/professionals/kdoqi/gfr_calculator.
warmodgenil kvlevaSi gamoyenebulia MDRD formula, radgan arsebobs
monacemebi, rom CKD‐EPI-sgan gansxvavebiT is Tanabrad zustia mwvave da
qronikuli SemTxvevebis dros 281 282.
‡‡‡ aSS-Si registrirebuli msxvili arasamTavrobo organizacia, romlis Stab-binac mdebareobs niu-iorkSi
ავტორის სტილი დაცულია
61
pacientebis samedicino CanawerebSi arsebuli Sratis kreatininis
monacemebi ZiriTadad gansazRvruli iyo mg/dl (mg/dL) sidideSi. mkmol/l
(µmol/L) sidideSi gansazRvruli monacemebis gadayvana mg/dl-ze xdeboda
88.4-ze gayofiT 283.
rac Seexeba CVP-s, kvlevaSi gamoyenebuli yvela monacemi mocemuli iyo
vercxliswylis svetis sidideSi (Canawerebis mixedviT, yvela SemTxvevaSi
CVP gansazRvruli iyo eleqtronuli gadamwodiT laviwqveSa an Sida
sauRle venis midgomiT).
kvlevis mimdinareobisas gamoikveTa, rom asobiT pacientis klinikuri
SemTxvevidan mxolod Zalzed mcire nawili akmayofilebda kvlevaSi
CarTvis kriteriumebs. umetes SemTxvevebSi ar iyo gansazRvruli CVP,an ar
iyo miTiTebuli gazomvis meTodologia. bunebrivia, CVP gansazRvruli iyo
mxolod im klinikur SemTxvevebSi, rodesac pacientebs aReniSnebodaT
gulis mwvave ukmarisoba (AHF) da mkurnaloba utardebodaT intensiuri
Terapiis ganyofilebaSi (kardio-renuli sindromis pirveli tipi). aseve,
xSirad ar iyo sakmarisi informacia anamnezis Sesaxeb, rac ar iZleoda
saSualebas diferencireba momxdariyo Tirkmelebis pirvelad Tu meorad
dazianebas Soris. gadawyda Seqmniliyo 2 jgufi (monacemTa baza), erTi CVP-
s monacemebiT (CVP group), romelic moicavda kardio-renuli sindromis
pirveli tipis klinikur SemTxvevebs, xolo meore CVP‐s gareSe (Non‐CVP
group), romelic moicavda kardio-renuli sindromis meore tipis klinikur
SemTxvevebs. CVP group‐Si Catarda piloturi kvleva didi kvlevisTvis
statistikuri parametrebis gansazRvris da instrumentebis testirebis
mizniT 284 285.
ავტორის სტილი დაცულია
62
4. Sedegebi
Non‐CVP jgufSi (CRS II tipi) monawileTa saerTo raodenoba iyo 44,
saSualo asaki - 67.8 (SD 13.1), da 64% iyo mamakaci. saSualo eGFR iyo 60.8
ml/min/1.73m2(SD19), saSualo LVEF–42.7(SD14)da saSualoRVEDD–34.5(SD
6.2).
cxrili 5. Non‐CVP jgufis aRweriTi statistika
LVEF‐s da eGFR-s Soris asociaciis dadgenis mizniT gamoyenebul iqna
pirsonis korelaciis testi (Pearson correlation analysis) 286 287, romelic iyo
statistikurad mniSvnelovani, Tumca uaryofiTi:‐0.336(Sig.0.026).
Correlations
LVEF eGFR
LVEF Pearson Correlation 1 -.336*
Sig. (2-tailed) .026
N 44 44
eGFR Pearson Correlation -.336* 1
Sig. (2-tailed) .026
N 44 44
*. Correlation is significant at the 0.05 level (2-tailed).
cxrili 6. korelacia eGFR-sdaLVEF-sSoris
Descriptive Statistics
N Range Minimum Maximum Sum Mean Std.
Deviation
Variance
eGFR 44 85.00 5.00 90.00 2673.00 60.7500 19.02401 361.913
LVEF 44 44.00 16.00 60.00 1880.00 42.7273 14.03544 196.994
HF 44 3.00 1.00 4.00 120.00 2.7273 .62370 .389
RVEDd 44 28.00 21.00 49.00 1516.00 34.4545 6.23738 38.905
Age 44 67.00 23.00 90.00 2981.00 67.7500 13.14344 172.750
Valid N
(listwise)
44
ავტორის სტილი დაცულია
gr
rac
pirso
uary
gamov
dias
rafiki 1.
Seexeba k
onis kor
ofiTi, sa
vlinda
tolur d
eGFR-sda
korelacia
relaciis
aSualo s
eGF
R
HF
*. C
cxril
korelac
diametrsa
LVEF-s S
as gulis
testiT
iZlieris
F Pearson
Sig. (2-ta
N
Pearson
Sig. (2-ta
N
Correlation is sig
li 7. kor
ciis ar
(RVEDD)
oris kor
diagram
ukmariso
gamovlin
korelac
Correlation
n Correlation
ailed)
n Correlation
ailed)
gnificant at the
elacia eG
rarseboba
da eGFR-s
relaciis
ma
obis NYHA
nda stat
cia: ‐0.349
ns
eGFR
1
44
-.349*
.020
44
0.05 level (2-t
GFR-sdaH
marjve
Soris(n
amsaxveli
A‐s klass
tistikura
(Sig.0.020)
HF
-.349*
.020
44
1
44
tailed).
HF-sSoris
ena park
=44,r=‐0.0
i wertil
daeGFR-s
d mniSvn
).
s
kuWis s
093,p=0.54
63
ovani
s Soris,
elovani,
saboloo
48).
ავტორის სტილი დაცულია
64
Correlations
eGFR RVEDd
eGFR Pearson Correlation 1 -.093
Sig. (2-tailed) .548
N 44 44
RVED
d
Pearson Correlation -.093 1
Sig. (2-tailed) .548
N 44 44
cxrili 8. korelacia eGFR-sdaRVEDD-sSoris
Non‐CVP jgufis (CRS II tipi) Seqmnisas gamovlinda, rom sakvlev drois
monakveTSi gulis ukmarisobiT hospitalizirebuli pacientebis 31.7%-s
aReniSneboda Tirkmelebis funqciis meoradi gauareseba (kardio-renuli
sindromis meore tipi). aqedan, Tirkmelebis qronikuli daavadebis (CKD)
klasifikaciiT, 59%-s aReniSneboda Tirkmelebis funqciis mciredi (GFR=60-
89), 25%-s zomieri (GFR=30-59), 13.7%-s mZime (GFR=15-29) da 2.3%-s terminaluri
(GFR<15) daqveiTeba. CKDdiagnostirebuli iyo SemTxvevaTa 11.4 %-Si.
CVP jgufSi (CRS I tipi) monawileTa saerTo raodenoba iyo 11, saSualo
asaki - 65 (SD 12.5), da 63.6% iyo mamakaci. saSualo eGFRiyo43ml/min/1.73m2
(SD10), saSualo LVEF‐46(SD6)da saSualoCVP–10.4mmHg(SD1.1).
Descriptive Statistics
N Minimum Maximu
m
Mean Std.
Deviation
Age 11 45.00 86.00 64.9091 12.49363
LVEF 11 37.00 55.00 45.9091 6.00757
Cr 11 1.35 1.90 1.6045 .17096
eGFR 11 27.30 57.30 42.9455 10.04205
CVP 11 8.00 12.10 10.3545 1.13258
Valid N (listwise) 11
cxrili 9. CVP jgufis aRweriTi statistika
ავტორის სტილი დაცულია
65
aRniSnul jgufSi CVP‐s da eGFR-s Soris asociaciis dadgenis mizniT
gamoyenebul iqna pirsonis korelaciis testi, romlis mixedviTac
korelacia iyo saSualo siZlieris, Tumca, monawileTa mcire raodenobis
gamo, statistikurad ara-mniSvnelovani: ‐0.48 (Sig. 0.14). LVEF‐s da eGFR-s
Soris gamovlinda ufro susti, Tumca statistikurad aseve ara-
mniSvnelovani korelacia: 0.12 (sig. 0.72). ganisazRvra CarTvis moculoba
farTomasStabiani kvlevebisTvis: α (two‐tailed) = 0.050, β = 0.200, r = ‐0.480,N =
[(Zα+Zβ)/C]2+3=32.
Correlations
eGFR CVP
eGF
R
Pearson Correlation 1 -.475
Sig. (2-tailed) .139
N 11 11
CVP Pearson Correlation -.475 1
Sig. (2-tailed) .139
N 11 11
cxrili 10. korelacia eGFR-sdaCVP-sSoris
pacientebis samedicino Canawerebze muSaobisas gamoikveTa sayuradRebo
tendencia, rom rogorc mwvave, aseve qronikuli gulis ukmarisobis dros
Tirkmelebis funqciis Sefasebisas eqimebi eyrdnobodnen ara eGFR‐is, aramed
Sratis kreatininis monacemebs, rac naklebad iZleva CKD-is adreuli da
srulyofili Sefasebis SesaZleblobas.
ავტორის სტილი დაცულია
66
5. daskvna
1. dadasturda kvlevis hipoTeza im nawilSi, rom kardio-renuli
sindromis meore tipiT daavadebul pacientebSi marcxena parkuWis
gandevnis fraqciis Semcireba ar ukavSirdeba Tirkmelebis funqciis
gauaresebas (gamoxatuli, rogorc eGFR<90). kvlevis Sedegebma aCvena
statistikurad mniSvnelovani uaryofiTi korelacia LVEF-s da eGFR-s
Soris (n=44,r=‐0.336,p=0.026).
2. marcxena parkuWis gandevnis fraqciisgan gansxvavebiT, kardio-renuli
sindromis meore tipiT daavadebul pacientebSi gamovlinda kavSiri
NYHA-s klasifikaciiT gulis ukmarisobis funqciuri klasis matebas
da eGFR-is Semcirebas Soris (n=44, r=‐0.349, p=0.02). aRniSnuli Sedegi
kidev erTxel xazs usvams NYHA-s klasifikaciis sargeblobas gulis
ukmarisobis simZimis Sefasebis mxriv da aseve, Tirkmelebis funqciis
gauaresebis riskis gansazRvris mizniT.
3. pirsonis korelaciis testma aCvena saSualo daswvrivi (uaryofiTi)
kavSiri CVP‐s da eGFR-s Soris (r=‐0.48, p=0.13) kardio-renuli
sindromis pirveli tipis dros, rac gansazRvravs SerCevis sasurvel
moculobas statistikuri analizisaTvis amgvari, magram ufro
farTomasStabiani kvlevebisTvis: α(two‐tailed)=0.050,β=0.200,r=‐0.480,
N=[(Zα+Zβ)/C]2+3=32.
4. kvlevam gamoavlina korelaciis ararseboba marjvena parkuWis
saboloo diastolur diametrsa (RVEDD) da eGFR-s Soris (n=44, r = ‐
0.093, p=0.548) kardio-renuli sindromis meore tipiT daavadebul
pacientebSi.
5. sakvlev drois monakveTSi gulis qronikuli ukmarisobiT
hospitalizirebuli pacientebis 31.7%-s aReniSneboda Tirkmelebis
funqciis meoradi gauareseba (kardio-renuli sindromis meore tipi).
aqedan, Tirkmelebis qronikuli daavadebis (CKD) klasifikaciiT, 59%-s
aReniSneboda Tirkmelebis funqciis mciredi (GFR=60-89), 25%-s
ავტორის სტილი დაცულია
67
zomieri (GFR=30-59), 13.7%-s mZime (GFR=15-29) da 2.3%-s terminaluri
(GFR<15) daqveiTeba. CKDdiagnostirebuli iyo SemTxvevaTa 11.4 %-Si.
6. kardio-renuli sindromis adreuli diagnostirebisTvis
mizanSewonilia Tirkmelebis funqciuri mdgomareobis Sefaseba eGFR
MDRD formulis gamoyenebiT. eGFR-is gansazRvra SesaZleblobas
iZleva adreul stadiaze gamovlindes Tirkmelebis disfunqcia da
saWiroebis SemTxvevaSi moxdes arsebul mkurnalobaSi koreqtivebis
Setana (ACEInhibitors,ARBs, NSAIDda sxv.).
ავტორის სტილი დაცულია
68
5. English summary
SomecharacteristicsofinteractionbetweenheartandkidneysinCardio‐
RenalSyndromeType1andType2
ADissertationThesisSummary
Author:GeorgeLobzhanidze
TbilisiStateUniversity,FacultyofMedicine
ACKNOWLEDGEMENTS
IwouldliketoexpressmydeepestgratitudetomyscientificadvisorattheTheUniversityof
Tromsø ‐TheArcticUniversityofNorway (UiT),ProfessorBjørnStraume, forhis excellent
guidance,andforhelpingmetodevelopmybackgroundinepidemiologyandbiostatistics.
I would like to thank Professor Toralf Hasvold, for his exceptional contribution in the
cooperation betweenTSU andUiTwithin the framework ofDoctoral Programme in Public
Health:NorwayExperienceofThirdCycleStudiesforGeorgia.
Special thanks go to Professor Zurab Pagava, TSU Medical Faculty Dean Alexandre
Tsiskaridze,ProfessorDimitriKordzaia,AssociateProfessorNinoChikhladzeandAssociate
ProfessorNinoSharashidze,fortheirsupport,guidanceandvaluableadvicesduringthePhD
educationprocess.
Lastbutnot the least, Iwould liketothankmyparentsandmywife forsupportingmeand
encouragingmewiththeirbestwishes.
ავტორის სტილი დაცულია
69
OBJECTIVES
TheprimaryaimofthisPhDstudyhasbeentoexploretheassociationbetweenLeftVentricle
Ejection Fraction (LVEF), right heart failure, increased central venous pressure (CVP), and
renal dysfunction manifested as reduced Estimated Glomerular Filtration Rate (eGFR) in
patients with Cardio‐Renal Syndromes types 1 and 2. The hypothesis suggests that CVP,
ratherthanLVEFcorrelatesdirectlywithreducedeGFR.
BACKGROUND
Deteriorated renal function in patients with acute or chronic heart failure represents an
importantclinicalchallengeofmodernmedicine.Theprevalenceofmoderatetosevererenal
impairment (defined as a Glomerular Filtration Rate less than 60mL/min per 1.73m2) is
approximately30to60percentinpatientswithHeartFailure(HF)2.Clinicalimportanceof
interactions between heart disease and kidney disease is illustrated by the following
observations:
MortalityisincreasedinpatientswithHFwhohavereducedGFR
Patientswith chronic kidney disease have an increased risk of both atherosclerotic
cardiovasculardiseaseandheartfailure,andcardiovasculardiseaseisresponsiblefor
upto50percentofdeathsinpatientswithrenalfailure
Acuteorchronicsystemicdisorderscancausebothcardiacandrenaldysfunctions.
The term Cardio‐Renal syndrome has been brought into use in the last decade. Professor
Claudio Ronco §§§ et al, has defined five subtypes of Cardio‐Renal Syndrome, which are
distinguishable from each other by the clinical course, pathophysiology, diagnostic
approaches and management tactics 7. CRS involves both ‐ the acute and the chronic
conditionswhicharecharacterizedbytheheart'sprimary,andprimaryrenalinjury:
• Type 1: Worsening renal function complicates Acute Decompensated Heart Failure
(ADHF)andAcuteCoronarySyndrome(ACS).Dependingonthepopulation,27%‐40%
§§§Claudio Ronco, MD. Department of Nephrology, St. Bortolo Hospital, Vicenza, ITALY.
ავტორის სტილი დაცულია
70
of patients hospitalized for ADHF develop Acute Kidney Injury (AKI). Consequently,
CRStype1isoftenseeninthecoronarycareandintensivecareunits1112;
• Type 2: Chronic abnormalities in myocardial function leading to Chronic Kidney
Disease (CKD). The “chronic abnormalities” may include many different heart
conditions, such as chronic heart failure, congenital heart disease, atrial fibrillation,
constrictivepericarditisandchroniccoronaryheartdisease15;
• Type 3: Acute renal failure leading to cardiac dysfunction, such as cardiac ischemic
syndromes,congestiveheartfailure,orarrhythmia16.Type3emergeslessfrequently
thanCRStype1,butthismaybeduetothefactthatithasbeenlessthoroughlystudied
thentype110;
• Type 4: Primary renal disease leading to cardiac dysfunction, such as ventricular
hypertrophy,diastolicdysfunction,increasedriskofadversecardiovascularevents17‐
19;
• Type 5: Systemic illness leading to simultaneous heart and renal failure. This CRS
subtypemay covermany acute or chronic conditions inwhich combined heart and
kidneydysfunctionisobserved(e.g.diabetesmellitus,sepsis,lupus,etc.)20.
When reno‐parenchymal disease leads to cardiovascular complications, it’s been
recommendedtonamethelatterconditionasReno‐CardiacSyndrome(CRStype3andtype
4)1421.CRStype5isalsocalledasecondaryCRS2022.
The term ‐ Cardio‐Renal Cachexia Syndrome (CRCS) has been suggested when there are
complexinterrelationsthatinvolvetransitionfromCRStocachexiaandfromcachexiatoCRS
23.
ავტორის სტილი დაცულია
CVP=CSympathLVH=L
Mecha
Patho
major
numb
arteri
deran
activa
and a
dysfu
Novel
sever
Central Venous hetic Nervous S
Left Ventricular H
anismofRe
ophysiology
r factors: ab
berofhemo
ialunderfill
ngements t
ationofsym
a range of
nction)lead
l biomarke
al years.Th
Fig.1. Bi
Pressure; NYHASystem; CVP=CHypertrophy.
nalImpairm
y of reducti
bnormalitie
dynamicde
ling,elevate
rigger a v
mpatheticne
f adverse c
dingtoapop
rs of acute
hese includ
idirectional p
A=New York HCentral Venous
ment
on in GFR
es in systoli
erangement
edatrialpre
ariety of c
ervoussyste
cellular pro
ptosisandr
e cardiac an
eCystatinC
pathways of
Heart AssociatioPressure; IAP=
in patients
ic anddiast
ts,including
essuresand
compensato
em,theRen
ocesses (in
renalfibrosi
nd renal in
C,NGAL (N
f Cardio-Ren
on; RAAS= Re= Intra-Abdomin
s with HF is
tolicmyoca
greducedst
dvenouscon
ory neuroh
nin‐Angioten
ncluding ox
is1525‐29.
njury have
NeutrophilG
nal Syndrom
enin-Angiotensinnal Pressure; RV
s complex
rdialperfor
trokevolum
ngestion24.
ormonal a
nsin‐Aldoste
xidative inj
become ac
Gelatinase‐A
me
n-Aldosterone SVP= Renal Ven
and include
rmance can
meandcardi
Thesehem
daptations
eroneSyste
ury and e
ccessible fo
AssociatedL
71
System; SNS= nous Pressure;
es several
n lead toa
iacoutput,
modynamic
including
em(RAAS)
ndothelial
or the last
Lipocalin),
ავტორის სტილი დაცულია
72
KIM‐1 (Kidney Injury Molecule 1), NAG (N‐Acetyl‐β‐(D) Glucosaminidase), IL‐1 8
(Interleukin‐18), L‐FABP (Liver‐Fatty Acid Binding Protein), CI (Cataitic Iron) 30. It is
expected,thatthesebiomarkerswillfacilitatemakinganearlierdiagnosisofCRS,aswellas
identifythespecifictypeofCRS31.Unfortunately,thesetestsarenotwidelyavailableyet.
CKD is commonand is associatedwith increasedmortality inHF 32. Though, it isnot clear
whether the effect ofCKDonmortality variesbyLeftVentricularEjectionFraction (LVEF).
Themechanismofacutecardio‐renalsyndrome(type1)isdifficulttoclarifyalsobecauseof
thecomplexandmultifactorialcomorbiditiesassociatedwithacuteheartfailuresyndrome33.
Recent investigations suggest that management of patients with primary cardiac and
secondary renal dysfunction based only on the low‐flow theorydoes not lead to improved
outcomes3435.BothanimalandhumanstudieshaveshownthatIntra‐AbdominalandCentral
Venous Pressure (CVP) elevation, which also increases the renal venous pressure, lead to
reduction of GFR 36‐40. There is a growing evidence to support the roles for elevated renal
venous pressure and Intra‐Abdominal Pressure (IAP) in development of progressive renal
dysfunctioninpatientswithHF394142.ThestudybyKevinDammanetal.hasshownthatCVP
isassociatedwithimpairedrenalfunctionandindependentlyrelatedtoall‐causemortalityin
abroadspectrumofpatientswithcardiovasculardisease41.ThestudybyHeikoUthofftetal.
further supported theconcept thatCVP is an importanthaemodynamic factor for impaired
renalfunction,especiallyincombinationwithdecreasedcardiacoutput42.
ThestudybyAliAhmedetal.hasshownthatCKD‐associatedmortalitywashigher inthose
with diastolic than systolic HF 43. Diastolic HF or Heart Failure with Preserved Ejection
Fraction(HFPEF)isthemostfrequentformofHF44‐46(theincidenceofHFPEFisreportedto
include about 50% of the general heart failure population 47). Coexistence of renal
impairment in heart failure with preserved EF is reasonably common (especially in older
femaleswith hypertension and/or diabetes), butmay be under‐diagnosed 48. The Cardio‐
Renal interactions potentially contributing to HFPEF are complex and include volume
overload,due to inadequate renalhandlingof saltor fluid, renalhypertension,oroxidative
stressandinflammatoryprocesses4950.
Theabove‐mentionedevidencedissuadingtheroleofreducedLVEFastheprimarydriverof
renal impairment has prompted researchers to have a closer look into the role of right
ventricle(RV)inthepathogenesisofCRS.
ავტორის სტილი დაცულია
73
TheroleofrightventricleandCVP
Awareness about the role of right ventricle in health and disease traditionally has been
lagging behind that of the left ventricle 51. Even though, right‐sided (or right ventricular)
heart failure (RSHF) usually occurs as a result of left‐sided failure, RV function may be
impaired in pulmonary hypertension (PH), chronic obstructive pulmonary disease (COPD),
congenital heart disease (CHD), connective tissue diseases, coronary artery disease and in
patients with valvular heart disease. When left ventricular function is normal, the term ‐
Isolated Right Ventricular Failure is used (IRVF) 52. Data about prevalence of kidney
impairmentinthosepatientsisuncertain,asitstillremainslargelyunder‐diagnosed.
Right ventricular dysfunction may play an important and possibly earlier role in the
pathophysiologyofimpairedrenalfunction53,butassessingRVfunctionremainsachallenge.
At this time, there is no single commonly accepted and generally applicable index of RV
function 54. Due to the complex anatomy of right ventricular anatomy, only a few
echocardiographic parameters are reliable. Tricuspid Annular Plane Systolic Excursion
(TAPSE) is a validated parameter of global right ventricular function 55. Right Ventricular
End‐Diastolic Diameter (RVEDD) is another parameter that can be used for assasement of
RightHeart and volume overload, althoughnot yet validated. CVP,which is an estimate of
Right Atrial Pressure (RAP), can also help to diagnose RSHF, but it should always be
consideredinconjunctionwithothercardiovascularparameters,e.g.LVEF,astherightheart
sided pressures should indirectly reflect left sided pressures, and the left sided filling
pressuremaybeanindicatorofleftventricularfunction56.
FrankL.Dinietal.studiedrelationshipbetweenRVdysfunctionandCKDinoutpatientswith
chronic systolic HF. The authors found that TAPSE and estimated GFR were significantly
correlated 53. The findings of the study support the concept that venous congestion from
backwardcardiacfailuremightbeasimportantasforwardfailureinthepathophysiologyof
renal impairment inHF.Elevated renal venouspressuredue toRSHF candecreaseGFRby
increasinginterstitialandtubularhydrostaticpressureswithinthekidneysandbydecreasing
renal perfusion pressure and renal blood flow. Hypoxia, as well as local and systemic
neurohormonal activation from elevated venous pressuremay further compromise kidney
functioninthesepatients5758.
ავტორის სტილი დაცულია
74
However,despitetheabove‐mentionedreports,theroleofrightsidedheartfailureinCRSis
difficulttoascertain,because:(I)itisfrequentlycombinedwithleftsidedheartfailurewith
orwithoutreducedejectionfraction;and(II)renaldysfunctioncanalsoraiseRAPbycausing
fluidretention,regardlessofconcomitantcardiacdysfunction41.
ProperunderstandingofCRSmechanismiscrucial,astherapiesdirectedtowardsoneorgan
system may have beneficial or unfavorable effects on the other.Additional high‐quality
studiesareneededforappropriateevaluationoftheroleofRVandCVPinCRS.
METHODS
TheresearchhasbeenbasedonthehypothesisthatCVPratherthanLVEFcorrelatesdirectly
with the level of renal impairment manifested as reduced eGFR in patients with CRS.
ConfirmingthehypothesiswouldprovidesufficientriskpredictionorearlydiagnosisofCRS,
leadingtoimprovementofitscourseandsubsequently,influencingthelong‐termoutcome.
The study was designed in a cross‐sectional manner, involving inpatients with HF and
reduced eGFR, who had undergone treatment at several hospitals in Georgia, between
September 2015 and May 2016. The participants were selected according to the
predetermined selection criteria, and necessary data had been extracted from themedical
charts. Estimated Glomerular FiltrationRatewas assessedwith theModification of Diet in
Renal Disease (MDRD) formula, and CVP measurements had been performed with an
electronic pressure transducer in spontaneously breathing non‐ventilated patients. Central
veinaccesswasestablishedtroughthesubclavianor internal jugularveins. MeanCVPwas
recordedforeachpatient,measuredinmmHg.
Participants‐StudyPopulation
ThestudyincludedpatientswithvariousdegreesofclinicalmanifestationsofHF(NYHAclass
I–IV,withpreservedandreducedEF)andreducedGFR.Listofcriteriathatwouldexcludea
subjectfromthestudyincludedthefollowing:
• Independentriskfactorsforrenalimpairment(e.g.diabetes,sepsis).
ავტორის სტილი დაცულია
75
• PrimarynephropathyorsecondarynephropathyduetodiseasesotherthanHF.
Presenceofhypertensionandotherriskfactors,co‐morbidities,andthecurrentand/orpast
conservative or surgical treatments have also been taken into account.
eGFR(MDRDformula)hasbeendefinedasanOutcomeVariable,whilesex,age,LVEF%,HF
level (NYHA class 1 ‐ 4), RVEDD, CVP and Arterial hypertension (According to JNC VIII
classification) comprised the Predictor Variables. LVEF had been treated as a potential
confoundingfactorforCVPandeGFR.
SamplesizeandstatisticalPlan
In theprocessofdatacollection, thedoctorshadto lookatmedical recordsofhundredsof
patientswithheartfailure.Manyofthemdidnotmeetthecriteriaforinclusionduetolackof
necessaryinformationinthecharts.AsCVPhasbeenrecordedonlyinacutecases(CRStype
I),decisionwasmadetosetuptwodifferentgroups(datasets)‐CVP(CRSType1)andnon‐
CVP (CRSType 2).Non‐CVP group included44participants,while the CVP group included
only11,whichwasonlysufficienttoperformapilotstudy.
IBM SPSS Statistics version 22 has been used to obtain the standard descriptive statistics,
summarystatisticsandstatisticaltestsforoutcomevariable.
Ethicalconsiderations
The study is of observational‐analytical (non‐experimental) type and is based on a
retrospective chart review. Confidentiality of patients’ personal information has been an
ethical issue to address. The study was approved by the ethics comitees at the Medical
Centers and the data extraction had been performed by the treating physicians only. The
patients’personalidentifierswereconcealedandananonymizeddatasetsused(uniquecode
hadbeengiven to eachpatient,whichwaskept secureunder the control ofhospital staff).
Resultspublishedinawaythatnopatients’identificationispossible.
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76
RESULTS
Innon‐CVP(CRSType2)group,totalnumberofparticipantswas44,meanagewas67.8(SD
13.1),and64%weremen.MeaneGFRwas60.8ml/min/1.73m2(SD19),MeanLVEF–42.7
(SD14)andMeanRVEDD–34.5(SD6.2).
Fig.1.Descriptivestatisticsfornon‐CVPgroup
PearsonCorrelationanalysiswasusedtocharacterizeassociationbetweenLVEFandeGFR,
whichwasfoundtobenegativeandstatisticallysignificant:‐0.336(Sig.0.026).
Correlations
LVEF eGFR
LVEF Pearson Correlation 1 -.336*
Sig. (2-tailed) .026
N 44 44
eGFR Pearson Correlation -.336* 1
Sig. (2-tailed) .026
N 44 44
*. Correlation is significant at the 0.05 level (2-tailed).
Fig.2.CorrelationanalysisbetweenLVEFandeGFR
Descriptive Statistics
N Range Minimum Maximum Sum Mean Std.
Deviation
Variance
eGFR 44 85.00 5.00 90.00 2673.00 60.7500 19.02401 361.913
LVEF 44 44.00 16.00 60.00 1880.00 42.7273 14.03544 196.994
HF 44 3.00 1.00 4.00 120.00 2.7273 .62370 .389
RVEDd 44 28.00 21.00 49.00 1516.00 34.4545 6.23738 38.905
Age 44 67.00 23.00 90.00 2981.00 67.7500 13.14344 172.750
Valid N
(listwise)
44
ავტორის სტილი დაცულია
Statis
reduc
tically sign
ctionofeGF
Fig.3
ificant corr
R:‐0.336(S
eGF
R
HF
*. C
Fig.4.Corre
.Correlatio
relation wa
Sig.0.026).
F Pearson
Sig. (2-ta
N
Pearson
Sig. (2-ta
N
Correlation is sig
elationanaly
nscatterpl
s found bet
Correlation
n Correlation
ailed)
n Correlation
ailed)
gnificant at the
ysisbetwee
lotofLVEFa
tween incre
ns
eGFR
1
44
-.349*
.020
44
0.05 level (2-t
enNYHAHF
andeGFR
ease of the
HF
-.349*
.020
44
1
44
tailed).
Fclassande
e NYHA HF
eGFR
77
class and
ავტორის სტილი დაცულია
78
TherewasnosignificantcorrelationbetweenRVEDDandeGFR:n=44,r=‐0.093,p=0.548.
Whencreating thenon‐CVP (CRSType2)dataset,weobserved thatpercentageofpatients
hospitalizedwithdiagnosisofHFanddeterioratedrenal function(CRSTypeII)was31.7%.
AccordingtotheRenalAssociationCKDclassificationofstages,59%ofthemhadmildly(GFR
= 60‐89), 25%moderately (GFR = 30‐59), 13.7% severely (GFR = 15‐29 ) and 2.3% very
severely(GFR<15)reducedkidneyfunction.CKDhadbeendiagnosedin11.4%ofCRScases.
We also observed that doctorsmainly used serum creatinine level for evaluation of renal
functionbothinacuteandchroniccasesofHF,whichhasapparentlylessvaluecomparedto
eGFRMDRDformulaintermsofearlyandpreciseassessmentofdeterioratedrenalfunction.
In the CVP group (CRS Type 1), Pearson correlation test showed a descending (negative)
correlation between CVP and eGFR, although not statistically significant due to the small
numberofparticipants(n=11,r= ‐0.48,p=0.13).Therewasaweakcorrelationbetween
LVEFand eGFR, althoughnot statistically significant:n=11, r =0.12,p=0.72. Basedon
theseresults,samplesizecalculationwasmadeforalargerstudy:α(two‐tailed)=0.050,β=
0.200,r=‐0.480,N=[(Zα+Zβ)/C]2+3=32.
Correlations
eGFR CVP
eGF
R
Pearson Correlation 1 -.475
Sig. (2-tailed) .139
N 11 11
CVP Pearson Correlation -.475 1
Sig. (2-tailed) .139
N 11 11
Fig.5.CorrelationanalysisbetweenCVPandeGFR
ავტორის სტილი დაცულია
79
CONCLUSIONS
The study confirmed the hypothesis to the extent that reduction of LVEF is not correlated
withdeteriorationofkidneyfunction(manifestedaseGFR<90)inpatientswithCRSType2.
TheresultsshowedastatisticallysignificantnegativecorrelationbetweenLVEFandeGFR(n
=44,r=‐0,336,p=0.026).
NYHA classification functional class, by contrast, was found to be correlatedwith reduced
eGFR (n =44, r = ‐0,349, p=0.02) inpatientswithCRSType2.The results underline the
usefulnessofNYHA classification for assessment ofHF severity andCKD riskprediction in
patientswithCRS.
Pearsoncorrelationtestshowedadescending(negative)correlationbetweenCVPandeGFR
inpatientswithCRSType1,althoughnotstatisticallysignificantduetothesmallnumberof
participants (n = 11, r = ‐0.48, p = 0.13). The results can be used for the sample size
calculationforalargerstudy:α(two‐tailed)=0.050,β=0.200,r=‐0.480,N=[(Zα+Zβ)/C]2+
3=32.
ThestudyrevealednostatisticallysignificantcorrelationbetweenRVEDDandeGFR(n=44,r
=‐0,093,p=0.548)inpatientswithCRSType2.
In the time period of the study, deteriorated renal function (CRS type II)was observed in
31.7% of patients hospitalized with diagnosis of chronic HF. According to the Renal
Association CKD classification of stages, 59% of them had mildly (GFR = 60‐89), 25%
moderately(GFR=30‐59),13.7%severely(GFR=15‐29)and2.3%veryseverely(GFR<15)
reducedkidneyfunction.CKDhadbeendiagnosedin11.4%ofCRSType2cases.
ForanearlydiagnosisofCRS,eGFRMDRDformulaseemstobeausefultool forestimating
kidney function. eGFR determination allows detection of reduced renal function in early
stagestherebyprovidinganopportunityforcorrectionofexistingtreatments(ACEInhibitors,
ARBs,NSAID,etc.).
ავტორის სტილი დაცულია
80
PUBLICATIONS
Theworkisbasedonfollowingpublications:
1. George Lobzhanidze (First Author). Ethical considerations in non‐experimental
studies‐GeorgianandNorwegianexperience.PUBLICHEALTH,ELSEVIER****,2016.
2. George Lobzhanidze (Sole Author). The role of right‐sided heart failure in patients
with Cardio‐Renal Syndrome. TRANSLATIONAL AND CLINICAL MEDICINE ‐
GEORGIANMEDICALJOURNAL,2016.
3. GeorgeLobzhanidze(SoleAuthor).Cardio‐RenalSyndrometype1:theroleofCentral
Venous Pressure and Left Ventricle Ejection Fraction. International Journal of
Sciences:BasicandAppliedResearch,2016.
4. George Lobzhanidze (Sole Author). The Association among Left Ventricle Ejection
FractionandeGFRinpatientswithCardio‐RenalSyndromeType2.(articleinreview).
****5‐YearImpactFactor:1.746©JournalCitationReports2016,publishedbyThomsonReuters
ავტორის სტილი დაცულია
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