klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

kinadeficituri anemia
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
1

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`rkinadeficituri anemia~ miRebulia klinikuri praqtikis
erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis
saxelmwifo standartebis (protokolebi) SemuSavebis, Sefasebis
da danergvis erovnuli sabWos 2008 wlis 5 noembris #1 sxdomaze
da damtkicebulia saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis ministris 2009 wlis 21 ianvris # 38/o
brZanebiT.
2

kinadeficituri anemia
1. daaavdebis definicia, sinonimebi, klasifikacia da
terminologia
rkinadeficituri anemia (rda) _ ganpirobebulia organizmSi rkinis
raodenobis SemcirebiT, ris Sedegadac irRveva hemoglobinis sinTezi da
mcirdeba misi koncentracia TiToeul eriTrocitSi.
gamoyofen rkinis deficitis 2 formas:
1. rkinis faruli (latenturi) deficiti _ xasiaTdeba rkinis maragisa da
satransporto rkinis SemcirebiT, normaluri hemoglobinisa da
eriTrocitebis maCveneblebiT;
2. rkinadeficituri anemia _ xasiaTdeba yvela metaboluri fondis
SemcirebiT (maT Soris satransportoc), aseve eriTrocitebisa da
hemoglobinis raodenobis SemcirebiT.
rda sinonimebi da terminologia: hipoqromuli anemia, mikrocituli anemia,
posthemoragiuli anemia, rkinis deficiti, kuW-nawlavidan sisxldena, menometroragia,
cxviridan sisxldena, hematuria, melena, simsivnuri daavadebebi,
pagofagia, qlorozi, koilonixia, atrofiuli glositi, hemoglobinuria,
agastruli mdgomareoba, hipoaciduri gastriti, anaciduri gastriti,
Tormetgoja nawlavis rezeqcia, wvrili nawlavis rezeqcia, kronis daavadeba.
2. epidemiologia
rda-s pirveli adgili ukavia msoflioSi yvelaze gavrcelebul 38 daavadebas
Soris. pirveli adgili ukavia mas aseve kvebis darRvevebiT gamowveul
daavadebaTa Soris. janmos monacemebiT rda daavadebulTa ricxvi 1,8
miliards Seadgens, rkinadeficituri mdgomareoba ki orjer met adamians
aReniSneba. sxvadasxva genezis anemiaTa Soris rda-ze modis 70-80% (1,2,3,4). is
yvelaze xSirad gvxvdeba reproduqciuli asakis qalebSi, orsul da meZuZur
qalTa Soris, agreTve adreuli da pubertuli asakis bavSvebSi.
gansakuTrebiT maRalia avadobis sixSire susti socialur-ekonomiuri
ganviTarebis qveynebSi (arasrulfasovani kveba _ rkiniT, cilebiTa da
vitaminebiT Raribi sakvebi produqtebis miReba, samedicino momsaxurebis
miuwvdomloba). ganviTarebul evropis qveynebSi qalebisa da bavSvebis rda
avadoba Seadgens 7-14%. ganviTarebad qveynebSi es maCvenebeli 40%-ze metia.
aziis zogierT qveyanaSi es maCvenebeli 65-70% aRwevs. (5) msoflioSi orsuli
qalebis TiTqmis naxevari savaraudod anemiuria. (6) bolo wlebSi rda
avadobam moimata saqarTveloSic. sazogadoebrivi jandacvis departamentis
monacemebiT 2006 wels rda avadobam saqarTveloSi Seadgina orsul qalebSi
_ 66%, reproduqciuli asakis (17-45ww.) qalebSi _ 31%, mozrdilebSi (14-16ww.)
gogonebSi _ 24 %.
3

3. etiopaTogenezi
rkina adamianis organizmisTvis umniSvnelovanes mikroelements warmoadgens.
is monawileobs Jangbadis transportirebaSi, nivTierebaTa cvlis
regulaciaSi, ganapirobebs imunologiur rezistentobas. organizmSi rkina
aris 2 saxiT: heminuri da araheminuri. heminuri rkina Sedis hemoglobinis,
mioglobinis da sxva fermentebis SemadgenlobaSi, araheminuri saxiT ki
feritinis, hemosiderinis, transferinis da sxvadasxva fermentis
SemadgenlobaSi.
adamianis organizmi saSualod 4,5_5g rkinas Seicavs. (qalebi 3-4g, mamakacebis
3-5g). organizmSi rkinis ganawileba Semdegia: hemoglobini - 64%, depoorganoebi
– 30%, mioglobini – 4%, qsovilovani fermentebi – 1%, transferini
– 1%).
adamiani sakvebis saxiT yoveldRiurad Rebulobs 15-20mg rkinas. Tormetgoja
nawlavisa da wvrili nawlavis proqsimalur nawilSi iwoveba miRebuli
rkinis 10-20% – 1-1,5mg. gazrdili moTxovnilebisa da misi deficitisas ki
iwoveba 2-3mg dRe-RameSi.
sakvebi Seicavs rkinas 2 saxiT: heminuri Fe 2+ rkina, romelsac ZiriTadad
cxoveluri produqtebi Seicaven da araheminuri Fe 3+ , romelic mcenareuli
produqtebis SemadgenlobaSi Sedis. cxoveluri produqtebidan adamianis
organizmi Seiwovs rkinis 10-20%-s. mcenareulidan ki mxolod 1-5%-s. heminuri
Fe 2+ kargad ixsneba wvrili nawlavis tute areSi da advilad Seiwoveba.
araheminuri Fe 3+ ki ar ixsneba wvrili nawlavis tute areSi. wvril nawlavSi
is iwoveba mxolod marilmJavas moqmedebis Sedegad Fe 2+ gadasvlis Semdeg.
Sewovis intensioba sxvadasxvagvaria. rkinaze moTxovnilebis gazrdis
SemTxvevaSi Sewovis intensioba SeiZleba 5-6-jer gaizardos. moTxovnilebis
Semcirebis SemTxvevaSi Sewovis intesioba mcirdeba da amave dros izrdeba
misi depo organoebSi Calageba. Sewovaze aseve did gavlenas axdens
sxvadasxva sakvebi produqtebi da samkurnalo preparatebi. sakvebidan Sewovas
amcireben rkinis helatorebi: fosfatebi, oqsalatebi, karbonatebi, tanini,
antacidebi, tetraciklini. aZlierebs askorbinis mJava, fruqtoza da sxva (7).
rkinaze moTxovnileba da misaRebad rekomendirebuli odenobebi jamuradaa
mocemuli #1 cxrilSi, xolo maTze gavlenis mqone faqtorebi ganxilulia
Semdgom (8).
4

cxrili 1
rkinaze moTxovnileba da misaRebad rekomendirebuli raodenoba asakisa
da sqesis mixedviT
jgufebi asaki saSualo zrdisTvis
rkinis saSualo
(wlebi)
wona aucilebeli
danakargi
(kg) rkinis misaRebi
(mg/dReSi)
raodenoba
(mg/dReSi)
ZiriTadi menstrualuri
mamakacebi 11 _ 14 45.0
0.55
0.62
15 _ 17 64.4
0.60
0.90
18+ 75.0
1.05
qalebi 11 _14 b
menopauzis
Semdgomi
periodi
laqtaciis
periodi
11 _ 14
15 _ 17
18+
46.1
46.1
56.4
62.0
0.55
0.55
0.35
0.65
0.65
0.79
0.87
62.0 0.87
62.0 1.15
a) sruli saerTo moTxovnileba moicavs zrdis, ZiriTadi danakargebis da qalebSi
menstrualuri danakargebis Sesavsebad saWiro raodenobas;
b) romlebsac ar aqvT menstruacia.
(gagrZeleba) rkinaze moTxovnileba da mis misaRebad rekomendirebuli
raodenoba asakisa da sqesis mixedviT
saerTo
moTxovnileba a
0.72
0.46
0.50
0.71
1.17
1.50
(mg/dReSi)
0.48
0.48
0.48
rkinis miRebis rekomendaciebi mosaxleobis 97.5%-is
moTxovnilebaTa dasakmayofileblad, sxvadasxva
bioSeRwevadobis sakvebisaTvis (saSualo +2SD) (mg/dReSi)
sakvebis rkinis bioSeRwevadobis xarisxi %
maRali
15%
6.2
3.9
4.2
5.9
9.7
12.5
saSulo
12%
7.7
4.8
5.3
7.4
12.2
15.7
dabali
10%
9.3
5.8
6.3
8.9
14.6
18.8
Zalian dabali
5%
18.6
11.6
12.6
17.8
29.2
37.6
5

1.05
1.20
1.68
1.62
1.46
0.87
1.15
9.1
9.3
21.8
20.7
19.6
7.5
10.0
11.4
11.7
27.7
25.8
24.5
9.4
12.5
adaptirebulia: “adamianTa sakvebSi vitaminebis da mineralebis saWiroeba”, sakvebisa da
soflis meurneobis organizacia / janmrTelobis msoflio organizacia.
sisxlSi rkinis cirkulireba xdeba cila transferinis saSualebiT. nawlavis
lorwovanidan rkina transferinis saSualebiT midis specifiuri ujredebis
receptorebTan. transferinis receptorebi aris adamianis organizmis yvela
ujredis zedapirze, magram gansakuTrebiT bevria eriTrocitebisa da
kunTebis ujredebze. rkina Tavisufldeba transferinidan da gadadis am
ujredebSi, ZiriTadi nawili moixmareba hemis warmoqmnaze (9).
eriTropoezisTvis organizms dReRameSi esaWiroeba 25-30mg. rkina, rac
aRemateba nawlavebidan Sewovili rkinis raodenobas. hemopoezisTvis
gamoyenebuli rkinis ZiriTad nawils Seadgens rkina, romelic Tavisufldeba
elenTaSi eriTrocitebis daSlis Sedegad.
rkinis Senaxva deponireba xdeba feritinisa da hemosiderinis saxiT.
feritinis ZiriTadi nawili aris RviZlSi, elenTaSi, Zvlis tvinSi,
eriTrocitebSi, wvrili nawlavis lorwovansa da sisxlis SratSi.
hemosiderini _ feritinis naklebad xsnadi naerTia rkinis ufro maRali
koncentraciiT. fiziologiur pirobebSi adamianis organizmi kargavs 1mg
rkinas ganavlis, Sardis da kanis epiTelis desqvamaciis Sedegad (10).
qalebs damatebiT ekargebaT rkina Semdegi mdgomareobebis dros:
1. menstruacia 15-30 mg rkina;
2. orsuloba 600-800 mg rkina;
3. mSobiaroba 50-100 mg rkina;
4. laqtacia 400-700 mg rkina.
amgvarad mamakacebs dRe-RameSi saSualod esaWiroebaT 1,2 mg rkina, qalebs
fiziologiuri danakargebis gaTvaliswinebiT reproduqciul asakSi 2,0 mg.
rkinis deficiti viTardeba im SemTxvevaSi, rodesac irRveva balansi
miRebulsa da dakargul rkinas Soris.
rkinadeficituri mdgomareoba iwyeba rkinis maragis SemcirebiT depo
organoebSi _ RviZlSi, elenTasa da Zvlis tvinSi. aRniSnulTan erTad
13.7
14.0
32.7
31.0
29.4
11.3
15.0
27.4
28.0
65.4
62.0
58.8
22.6
30.0
6

mcirdeba feritinis raodenobac, romelic organizmSi rkinis saerTo maragis
maCvenebelia. organizmSi sarezervo rkinis raodenobis Semcireba iwvevs
Sratis rkinis koncentraciis daqveiTebas da Sratis mier rkinis SekavSirebis
unaris momatebas. irRveva hemoglobinis sinTezi, viTardeba anemia da
Semdgomi qsovilovani darRvevebi.
rkinis deficiti umetesad viTardeba nel-nela da Tanmimdevrulad gamoyofen
rkinis deficitis 3 etaps: I rkinis prelatenturi deficiti _ Semcirebulia
rkinis maragi depo organoebSi; II rkinis latenturi deficiti _ xasiaTdeba
rkinis maragisa da SesaZloa qsovilovani rkinis deficitiT; III
rkinadeficituri
SemcirebiT.
anemia _ xasiaTdeba rkinis yvela metaboluri fondis
rkinadeficituri mdgomareobis gamomwvevi ZiriTadi faqtorebia:
1. qronikuli sisxldenebi: ginekologiuri, onkologiuri paTologiebi, kuWis
wylulidan, Tormetgoja nawlavidan, hemoroiduli kvanZebidan,
salicilatebis miRebis Sedegad da sxva;
2. sakvebiT miRebuli rkinis arasakmarisi raodenoba;
3. rkinis gazrdili xarjva: zrdisa da momwifebis periodSi, orsulobisas,
sportiT da fizikuri SromiT didi datvirTvisas;
4. dabadebisas rkinis arasakmarisi maragi an laqtaciisas misi arasakmarisi
raodenobiT miReba;
5. rkinis rezorbciuli ukmarisoba _ postgastrorezeqciuli da agastruli,
anenteraluri da enterogenuli, kronis daavadeba;
6. rkinis transportis darRveva hipo da atransferinemia;
7. zemoT moyvanili faqtorebis kombinacia.
orsuloba da laqtacia _ orsulobis dros placentasa da nayofSi didi
raodenobiT rkina deponirdeba. amitom mTeli orsulobis ganmavlobaSi
gazrdilia rkinaze moTxovnileba da igi aRwevs daaxloebiT 700-800mg-s.
miuxedavad imisa, rom menstruaciis Sewyvetis gamo rkinis danakargi mcirdeba,
orsuli qali ver iRebs damatebiTi rkinis sakmaris raodenobas da imatebs
rkinis deficiti.
laqtacia iwvevs rkinis kargvas rZesTan erTad. amis Sedegad, zogierT
qalebSi orsulobis dros ganviTarebuli deficiti SeiZleba mudmivad
SenarCundes laqtaciis dros.
7

sqema #1
etiologiuri faqtorebi, romlebic xels uwyoben rkinadeficituri anemiis
ganviTarebas
rkinis arasakmarisi
miReba
rkiniT Raribi
sakvebis miReba
rkiniT mdidari
sakvebis miRebis
miuwvdomloba
tradiciebi-kvebis
Taviseburebebi
4. klinikuri simptomatika
rkinadeficituri anemia
gazrdili
moTxovnileba rkinaze
• menstruacia
• parazituli daavadebebi
• orsuloba
qalebi
• mcire intervalebi
orsulobebs Soris
bavSvebi
• dedis rkinis deficiti
yvela
• garemo pirobebi
• pirveladi samedicino
daxmarebis miuwvdomloba
Sewovis/utilizaciis
darRveva
Sewovis inhibitorebis
miReba
kvebis racionis
Taviseburebebi
a) rkinis deficiti SeiZleba gamovlindes 2 sindromiT: anemiuri da
sideropeniuli.
anemiuri sindromi _ ganpirobebulia hemoglobinisa da eriTrocitebis
SemcirebiT da warmodgenilia araspecifiuri simptomebiT: Tavbrusxveva,
yurebSi Suili, guliscemis gaxSireba, haeris ukmarisoba, Zilianoba,
gonebrivi da fizikuri Sromisunarianobis daqveiTeba. gamoxatuli anemiis
dros xSirdeba stenokardiuli Setevebi, viTardeba iSemiuri daavadebebis
gamwvaveba. sindromis gamovlena mniSvenlovnad aris damokidebuli daavadebis
ganviTarebis siCqareze. ufro xSirad daavadeba nela viTardeba. avadmyofi
egueba am mdgomareobas, gansakuTrebiT es exebaT qalebs da isini ukve Rrma
anemiis SemTxvevaSi mimarTaven eqims.
sideropeniuli sindromi _ hiposiderozi dakavSirebulia rkinis
qsovilovan deficitTan. gamoyofen organoebis 4 jgufs, romlebSic
hiposiderozi maqsimalurad aris gamoxatuli: kani da lorwovani garsebi
8

(simSrale, Tmis da frCxilebis dazianeba); kuW-nawlavis traqti (madis
daqveiTeba da gaukuRmareTeba, disfagia, Sekruloba an diarea), glositi, enis
wva, ezofagiti: morfologiurad piris Rrus lorwovanis atrofia,
hiperkeratozi, epiTeliumis vakuolizacia; kuWis lorwovani garsis
ujredebis distrofiuli cvlilebebi, sekretoruli ukmarisobis
ganviTarebiT; nervuli sistema _ advilad daRla, yurebSi Suili,
Tavbrusxveva, Tavis tkivili, inteleqtualuri SesaZleblobebis daqveiTeba;
sisxlZarRvovani sistema (taqikardia, diastoluri disfunqcia). qveiTdeba
aseve ujreduli da humoruli imunitetis maCveneblebi. avadmyofebi advilad
avaddebian infeqciuri da virusuli daavadebebiT.
sideropeniuri sindromisTvis damaxasiaTebelia gaukuRmarTebuli gemovneba _
pika qlorotika, survili Wamon carci, miwa, umi xorcis farSi da sxva
(paTofagia). uCveulo midrekileba garkveuli sunebis mimarT: acetoni, benzini
da sxva (paTosomia). damaxasiaTebelia lorwovanisa da kanis sifermkrTale,
zogjer momwvano elferiT _ qlorozi. kans aqvs moyviTalo cvilis feri
mxolod piris irgvliv (genode miusis “qlorozianebis yviTeli ulvaSebis
simptomi”). lurji sklerebis simptomi (osleris simptomi) xasiaTdeba
sklerebis silurjiT. am fenomenis mizezia Tvalis rqovanis distrofiuli
cvlilebebi. Sardis Seukavebloba sicilis, xvelis dros, zogjer Ramis
Sardis Seukavebloba, sideropeniuri subfebriliteti _ xangrZlivi
subfebriliteti.
b) daavadebis garTulebebi arasasurvel gavlenas axdens:
• Cvili, skolamdeli da skolis asakis bavSvebis SemecnebiT, qceviT da
fizikur ganviTarebaze;
• SemecnebiTi unari daqveiTebulia mozrdilebSic;
• imunur statussa da infeqciebiT avadobaze yvela asakobriv jgufSi;
• kunTebis mier energiis wyaros gamoyenebaze da amdenad, fizikur
SesaZleblobebsa da Sromisunarianobaze mozardebsa da nebismieri asakis
mozrdilebSi;
• amZimebs ZiriTadi daavadebis mimdinareobas.
rkinadeficituri anemia orsulobis dros: (12)
• zrdis perinatalur risks dedisa da axalSobilisaTvis. dedaTa
perinataluri sikvdilianobis 20-40% anemias ukavSirdeba;
• aseTi dedebis axalSobilebi Seicaven samarago rkinis naxevarze naklebs;
• zrdis bavSvTa saerTo sikvdilianobas;
• rkinis deficitis dros darRveulia kuW-nawlavis funqciebi;
• icvleba hormonebis produqcia da metabolizmi;
• neiromediatorebisa da Tireoiduli hormonebis cvla irRveva, rac iwvevs
nevrologiur, kunTovan da Termo-regulaciis cvlilebebs. adamians
umcirdeba siciveSi sxeulis temperaturis SenarCunebis unari da bolos
dnm-is replikacia da reparacia moiTxovs rkinis Semcvel fermentebs.
9

5. daavadebis diagnozi
a) diagnostikuri kriteriumebi
klinikuri simptomatika ganpirobebulia 2 sindromiT anemiuriT da
sideropeniuriT.
anemiuri sindromisTvis damaxasiaTebelia Civilebi: saerTo sisuste,
Tavbruxveva, Sromis unaris daqveiTeba, advilad daRla, Tavis tkivili,
gaRizianeba, qoSini, gulis wasvla, xmauri yurebSi. obieqturad: kanisa da
lorwovani garsebis sifermkrTale, taqikardia, hipertonia, gulis tonebis
moyrueba, sistoluri Suili.
sideropeniuli sindromisaTvis damaxasiaTebelia Civilebi: sisuste,
Tavbruxveva, gemovnebis, ynosvis, madis gaukuRmarTeba, kunTebis tkivili da
sisuste, disfagia, dispepsia, Sardis Seukavebloba xvelebis, sicilis dros,
Ramis Sardis Seukavebloba, diarea, yabzoba, Zilianoba; obieqturad: kanis
simSrale, stomatiti, piris kuTxeebTan naxeTqebis gaCena, Tmis simSrale,
mtvrevadoba, cvena, naadrevi gaTeTreba: frCxilebis mtvrevadoba, gaTxeleba,
ganSreveba; koilonixia; glositi (wiTeli feris, SeSupebuli, mtkivneuli ena),
dvrilebis atrofia, kbilebis kariesi, maTi gafxviereba, Tankbilvis darRveva,
emalis defeqtebi: atrofiuli ezofagiti, atrofiuli gastriti, kuW-nawlavis
disfunqcia; dismenorea; subfebriliteti, imunitetis daqveiTeba, xSiri
infeqciuri daavadebebi, kanisa da lorwovanis reparaciuli procesebis
Semcireba; lurji sklerebi.
laboratoriuli monacemebi: (13)
• hemoglobinis Secireba mamakacebisTvis 130g/l-ze naklebi, qalebisTvis 120
g/l-ze naklebi, orsulebisaTvis 110g/l-ze naklebi I-III tr, 105g/l-ze
naklebi II trimestrSi. eriTrocitebis raodenobis Semcireba
mamakacebisaTvis 4.0 X 10 12 /l-ze naklebi qalebisaTvis 3,9 X 10 12 /l-ze
naklebi. upiratesad aRiniSneba hemoglobinis Semcireba.
• hematokriti mamakacebisaTvis 39% naklebi, qalebisaTvis 36% naklebi.
orsulebisaTvis 33% naklebi;
• feradobis maCveneblis Semcireba

• feritinis raodenoba mamakacebisaTvis < 30 ng /ml, qalebisTvis < 25 ng /ml;
• transferinis receptorebis raodenoba momatebulia.
instrumentuli gamokvlevebi
hemoglobinisa da feritinis testi saukeTesoa rda diagnostikaSi [C] 14.15.
ekg _ miokardiodistrofiis suraTi: T kbilis amplitudis Semcireba, mZime
SemTxvevaSi uaryofiTi T kbili, SesaZlebelia eqstrasistolebis ganviTareba.
eqokardiografia _ SesaZlebelia marcxena parkuWis zomebis gadideba.
diferencialuri diagnozi
diferencialuri diagnozi unda gatardes sxva hipoqromul anemiebTan (16).
rkinis gadanawilebiTi anemia (rkinis reutilizaciis darRveviT gamowveuli
anemiebi) viTardeba qronikuli anTebiTi, Cirqovani, onkologiuri
daavadebebisa da sxva paTologiebis dros.
rkiniT gajerebiTi anemiebi (sideroaqrestuli) - Tandayolili da SeZenili.
hemis sinTezis darRveviT gamowveuli (Talasemia).
anemiis simZimis xarisxi hemoglobinis maCveneblebis mixedviT 5 welze meti
bavSvebisa da qalebisaTvis janmo/iunisefi 1997w
cxrili 2
anemiis simZimis xarisxi hemoglobinis done g/l
msubuqi 90-120
saSualo 70-90
mZime 70-ze naklebi
6. gamokvlevis sqema
gamokvlevis sqema moicavs ramodenime etaps:
I etapi _ unda dadgindes anemiis hipoqromuloba. feradobis maCvenebeli (0,85
naklebi). hematokriti qalebisTvis

− rkiniT gajerebiTi anemiebi (sideroaqrestiuli) Tandayolili da
SeZenili;
− hemis sinTezis darRveviT gamowveuli anemiebi (Talasemia);
hipoqromul anemiebTan diferencialuri diagnostikis kriteriumebi
mocemulia cxrilSi #3-Si.
III etapi _ rkinis deficitis mizezis dadgena. rkinadeficituri anemia aris
mxolod sindromi, romliTac rTuldeba sxvadasxva paTologia. maTgan didi
nawili gankurnebadia. amdenad rda mizezis dadgena umniSvnelovanesi
sakiTxia. reproduqciuli asakis qalebSi rda-s yvelaze xSiri mizezia
menoragiebi, orsuloba da laqtacia, mamakacebSi kuWnawlavidan sisxldena,
bavSvebSi alimenturi deficiti zrdis procesSi (17).
cxrili 3
hipoqromuli anemiis ZiriTadi diferencialur-diagnostikuri kriteriumebi
niSnebi rda sideroaqtresta Talasemia rkinis
gadanawilebiTi
retikulocitebi N N an N an N
mikrocitozisa (m)
da hipoqromiis (h)
urTierTdamokidebuleba
Sratis rkina
rkinis SekavSirebis
unari
transferinis gajereba
rkiniT
Sratis feritini
(N30-300 ng/ml )
arapirdapiri
bilirubini
rkinis preparatebiT
mkurnalobis Sedegi
m > h m > h
N
m > h
N
anemia
m > h
50% >50% >10%
400 >400 30-400
N NN
+ _ _
aucilebelia rda gamomwvevi mizezebis dadgena, romelTac miekuTvneba
sisxldena:
− sisxldena SeiZleba iyos saSvilosnodan; kuW-nawlavis traqtidan;
Tirkmelebidan (glomerulonefriti, pielonefriti, kenWovani daavadeba,
NN
-
12

Sardis buStis simsivne, Tirkmelebisa da saSarde gzebis tuberkulozi);
filtvebidan (filtvebis tuberkulozi, kibo, bronqoeqtaziebi); cxviridan
(hipertonuli daavadeba), randiu-osleris daavadeba; hemoragiuli
diaTezebi;
− rkinis Sewovis darRvevis mizezi _ gastreqtomia bilrot II wesiT, wvrili
nawlavis rezeqcia, hipo da anaciduri gastriti, enteritebi (18);
− rkinis Warbi moxmarebis an xarjvis mizezi _ orsuloba, laqtacia, didi
fizikuri da gonebrivi datvirTva;
− rkinis transportirebis darRveva gamowveulia _ transferinis raodenobis
SemcirebiT, romelic viTardeba hipoproteinemiebisas (nefrozuli
sindromi, RviZlis mier cilis sinTezis darRveva, alimenturi ukmarisoba,
Sewovis darRveva). iSviaTia genetikuri hipo da atransferinemia;
− alimenturi ukamrisoba _ viTardeba dabali socialur-ekonomiuri
pirobebis SemTxvevaSi; arasrulfasovani _ rkiniT, cilebiTa da
vitaminebiT Raribi sakvebis miRebisas; vegetarianelebSi, gansakuTrebiT
Tanmdevi kuWnawilavis paTologiisas; moxucebSi.
bolo wlebis gamokvlevebiT dadginda, rom kuW-nawlavis paTologiebiT
gamowveuli rda-s dros xSiria simsivnuri paTologiebi, ris gamoc
sasurvelia 50 wlis zemoT asakis avadmyofebSi Catardes kuW-nawlavis
endoskopiuri gamokvleva an reqtoskopia Civilebis mixedviT 19, 20 [B].
rekomendaciebi praqtikuli eqimebisaTvis mocemulia crilSi #4.
rda gamokvlevis da mkurnalobis sqema daavadebis gamomwvevi mizezis
gaTvaliswinebiT mocemulia sqema #2-Si (14) [A].
cxrili 4
rekomendaciebi praqtikuli eqimebisaTvis
evidensi bibliografia
65 welze meti asakis orive
kohortuli
sqesis adamianebi,
gamokvlevebiT 9%-Si
romlebsac CautardaT kuW-
aRmoCnda simsivne, rdanawlavis
skriningi
simsivneebze
B
19
s mqone pacientebs 3jer
ufro met
SemTxvevaSi
daudgindaT simsivnuri
daavadeba.
65 wlamde asakis orive
sqesis adamianebSi gastroenteraluri
traqtis
skriningi
B
19
kohortuli
gamokvlevebiT 6%-Si
aRmoCnda kuW-nawlavis
simsivne
13

da-s gamokvleva da mkurnaloba
rda gamowveuli sisxldeniT diax dazustdes sisxldenis
diagnostirebuli anamnezisa da mizezi
gamokvlevis Sedegad
ara
sqema 2
mamakacebi da qalebi, romlebsac diax 50w. meti asakis avadmyofebSi
ara aqvT menstruacia kuW-nawlavis endoskopiuri
ara
da kolonoskopiuri gamokvleva.
1 Tvis mkurnalobis Semdeg diax gagrZeldes mkurnaloba
(Hb moimata 10-20 g/l metad) 2- 3 Tve.
ara
diagnozis dazusteba.
Tu ara gvaqvs Sedegi vatarebT
gamokvlevebs
diagnozis dazustebis
mizniT.
A
A
randomizebuli gamokvlevebiT dadasturebulia kuW-nawlavis endoskopiuri
gamokvlevis aucilebloba rda daavadebul 50 welze meti asakis mamakacebsa
da qalebSi, romelTac ar aqvT menstrualuri cikli 47 [B].
dadgenilia HH. bacteri-is roli rda-s ganviTarebaSi (21).
Zalian xSirad rda-s gamomwvevi mizezi SeiZleba iyos ramdenime erTad:
magaliTad menoragia, hipoaciduri gastriti, alimenturi deficiti da a.S.
amitom aucilebelia daavadebis gamomwvevi yvela mizezis dazusteba.
gansakuTrebiT yuradReba unda mieqces kuW-nawlavis paTologias, rom ar
gamogvrCes kuW-nawlavidan sisxldena. sasurvelia gastroenterologis
konsultacia (22, 23).
Tu materialur-teqnikuri saSualebebi ar iZleva saSualebas, SeiZleba
gamokvlevis I etapidan III-ze gadasvla. III etapze gansakuTrebulad unda
gamaxvildes yuradReba kuW-nawlavis paTologiaze, rom ar gamogvrCes
mxedvelobidan faruli sisxldena. Semdegi etapia mkurnalobis dawyeba 120 mg
elementaruli rkiniT. Tu Hb-10g/l metad ar moimatebs hematokriti ki 3%-ze
14

metad, saWiroa avadmyofis gagzavna hematologTan. anemiis mZime formebi
Hb

da avadmyofTa mkurnalobis algoriTmi
Hb 120 g/l maRali
Ht 36% meti
ara
elementaruli rkina 100mg
2 jer dReSi
(dRiuri doza 200mg)
sisxlis saerTo analizi
hemoglobinis ganmeorebiTi analizi
erT TveSi
Hb momateba10 g/l da meti
Ht 3% da meti
gagrZeldes mkurnaloba
3-4 Tve
diax ara
sqema #3
diax ar saWiorebs mkurnalobas
hematologis konsultacia
anemiis sxva mizezebis dadgena
mZime formis SemTxvevaSi avadmyofi igzavneba hematologTan da utardeba
ufro Rrma gamokvlkevebi: sisxlis saerTo analizi, retikulocitebi, Sratis
rkina, transferini, Sratis feritini da a.S. iniSneba rkinis preparatebi 200mg
hemoglobinis, Sratis rkinis, feritinisa da sxva maCveneblebis
normalizaciamde.
eriTmasis gadasxma naCvenebia mxolod im SemTxvevaSi Tu avadmyofs aqvs
hipoqsiis gamoxatuli movlenebi.
gansakuTrebul yuradRebas moiTxovs orsulTa rda, radgan swor
mkurnalobaze damokidebulia orsulobisa da mSobiarobis normaluri
mimdinareoba da nayofis ganviTareba. orsulTa da namSobiareb qalTa rda-s
mkurnalobisa da profilaqtikis principebi mocemulia (26, 27, 28, 29, 30)
cxrilSi #5.
16

profilaqtika
orsulebSi
rda, romelic
dadasturebulia
laboratoriuli
kriteriumebiT
rda namSobiareb
qalebSi
rda profilaqtika da mkurnaloba
komentari daniSnuleba
CDC, amerikis pediatriis
akademia, amerikis
ginekologiis koleji, iZleva
rekomendacias _ pirveli
vizitis Semdeg
A
Tu rda-s diagnozi
dadasturebulia.
gamoricxulia foliumis
mJavis deficitiT gamowveuli
anemia, vit.B 12 deficituri
anemia, Talasemia da sxva
saxis anemiebi.
A
namSobiarebi anemiis riskis
mqone qalebis skriningi unda
moxdes 4-6 kviraSi.
A
cxrili 5
• vitaminebi da mineralebi
• 30mg rkina
yoveldRiurad
• rkinis absorbciis
gasaumjobeseblad
gamoyenebul iqnas,
rkinis danamatebi,
vitaminebi da mineralebi.
• wyliT
• danamatebi ar unda iyos
miRebuli rZiT,
kalciumis
preparatebTan, yavasa da
CaisTan erTad.
• 100-200mg rkina mTeli
orsulobis
ganmavlobaSi.
• gadamowmdes 4 kviraSi
Tu hemoglobinis
raodenobam ar moimata
10 g/l -ze metad
hematokritma ki 3%.
anemiis diagnozi unda
gadamowmdes sxva
testebiT.
• rodesac hemoglobinis
raodenoba gaxdeba
normaluri - hestadiamde
iniSneba 30mg rkina.
• Tu riski ar aris, rkinis
preparatebi unda
Sewydes.
• Tu anemia rCeba,
mkurnaloba unda
gagrZeldes, rogorc
araorsul qalebSi.
17

kinis
preparatebis
gamoyenebis
winaaRmdeg
Cveneba
hemoglobinis
maRali
maCvenebeli
gastrointestinaluri
simptomebi - gulisreva,
Rebineba, Seupovari
(aratranzitoruli) faRaraTi
an yabzoba aris winaaRmdeg
Cveneba.
A
hemoglobinis maRali
maCveneblebi
A
• SeecadeT minimumamde
daiyvanoT diskomforti.
• SewyviteT mkurnaloba
rkinis preparatebiT.
• Tu hemoglobini 150 g/l -ze
metia hematokriti 45%
metia.
• SesaZlebelia
hemoqromatozis
arseboba.
hematologis specialiastebis konsultacia saWiroa, rodesac:
• hemoglobini > 150,0 g /l an hematokriti > 45%. me-2 da me-3 trimestrSi;
• Tu hemoglobini naklebia 90 g /l an hematokriti

suspenzia _ 30 mg (6 mg elementuri rkina)
wveTebi _ 75 mg (15 mg elementuri rkina)
• rkinis glukonati _ tabletebi 300mg (35 mg elementuri rkina)
suspenzia _ 60 mg (7 mg elementuri rkina)
• rkinis fumarati 300 mg (90 mg elementuri rkina)
mkurnalobis gverdiTi movlenebi _ peroraluri preparatebis miRebis
Sedegad SeiZleba ganviTardes dispepsiuri darRvevebi (anoreqsia, gulisreva,
simZimis SegrZneba epigastriumis areSi), yabzoba, zogjer diarea
(gamonaklisia rkinis hidroqsid polimaltozuri kompleqsi). rkinis
preparatebi ainhibireben tetraciklinebis, sulfanilamidebisa da
trimetoprimebis Sewovas (gamonaklisia rkinis hidroqsid polimaltozuri
kompleqsi). aRsaniSnavia, rom rkinis hidroqsid polimaltozuri kompleqsi
praqtikulad ar urTierTqmedebs sxva medikamentebTan da sakveb produqtebTan
(48).
kvebasTan dakavSirebuli rCevebi. xazgasmiT unda aRiniSnos, rom mxolod
kvebiT, ukve arsebuli rkinis deficitis gamosworeba SeuZlebelia. sakvebis
saSualebiT adamianma SeiZleba miiRos mxolod adamianis
cxovelmyofelobisaTvis saWiro rkinis yoveldRiuri raodenoba. swori
sakvebis racionis SerCeva aucilebelia rda-s profilaqtikis mizniT. xorcis
produqtebidan Seiwoveba rkinis 10-20%, mcenareulidan mxolod 1-5%.
rkinis Sewova SeiZleba meryeobdes 1%-dan 40%-mde, rac damokidebulia
sakvebis racionze sakvebSi rkinis “xelSemwyobTa”, “xelSemSlelTa” da
inhibitorTa Tanaarsebobaze (32).
yoveldRiur sakvebSi rkinis adeqvaturoba, anu bioaTvisebadoba SeiZleba
gaumjobesdes kvebis stilis iseTi SecvliT, romelic iTvaliswinebs Sewovis
xelSewyobis upiratesobas, inhibitorebis Semcirebas an orives erTad.
rkinis Sewovis inhibitorebi: (33,34).
• fitatebi _ xorbleuli, burRuleuli, maRali eqstraqciis fqvili,
Txileuli da Teslebi;
• fenolis naerTebi _ taninebi, Cai, yava, kakao, mcenareuli nayinebi,
saneleblebi da zogierTi bostneuli;
• kalciumi _ rZe, rZis produqtebi.
rkinis Sewovis xelSemwyobebia:
• hemuri rkina romelic gvxvdeba xorcSi, Sinaur frinvelSi, TevzSi da
zRvis produqtebSi;
• askorbinis mJava, anu vitamini C, romelic aris xilSi, xilis wvenebSi,
kartofilSi da zogierT sxva gorglovan bostneulSi, agreTve
parkosnebSi, yvavilovan kombostoSi da kombostoSi;
• rkiniTa da vitaminebiT fortificirebuli produqtebi.
kvebis stilis martivi cvlilebebi, rac aumjobesebs rkinis Sewovas:
19

• Cais, yavis miReba sakvebis miRebidan 1-2 saaTis Semdeg, vinaidan sakvebi
aRar imyofeba kuWSi da es produqtebi ver Seaferxeben rkinis Sewovas;
• rZis, yvelis miReba kvebaTa Soris;
• inhibitorebis Semcveli produqtebi moixmareba umetesad rkiniT Raribi
sakvebis miRebis dros. mag. sauzmed rkinis dabali Semcvelobis
marcvleuli (puri an simindis produqtebi) moixmareba CaisTan an rZis
produqtebTan erTad. es ki uzrunvelyofs kalciumis adeqvatur miwodebas
rkinis Sewovis Seferxebis gareSe;
• sakvebTan erTad C vitaminiT mdidari produqtebis (xilis wveni,
forToxali) miReba;
• rkiniTa da vitaminebiT fortificirebuli produqtebis miReba.
8. profilaqtika
rda profilaqtika 3 nawilisagan Sedgeba. (35, 36, 37, 38, 39).
I profilaqtika _ daavadebis ganviTarebis faqtorebis mocileba, maT Soris
kvebis swori racionis SemuSaveba.
II profilaqtika _ daavadebis adreuli gamovlena da mkurnaloba. am mizniT
im pirebs, romlebic miekuTvnebian rda ganviTarebis risk-jgufebs (menometroragia,
kuWis rezeqcia bilrot II wesiT, wvrili nawlavis rezeqcia da
a.S.) weliwadSi erTxel unda Seumowmdes hemoglobinis maCvenebeli daavadebis
drouli gamovlenisa da mkurnalobis mizniT [B] 46.
III garTulebebis Semcireba _ am mizniT orsulebs saplimentaciis mizniT
normaluri hemoglobinis pirobebSi eniSnebaT rkinis profilaqtikuri doza
30mg mTeli orsulobisa da SemdgomSi laqtaciisas 3 Tvis ganmavlobaSi (40,
41, 42) [B].
riskis jgufebSi Semaval pirebs, romlebic sxvadasxva mizeziT Rebuloben
rkiniT Rarib sakvebs, eZlevaT rCeva moixmaron rkiniTa da vitaminebiT
fortificirebuli sakvebi [A] (43, 44).
sisxlis donorebma yoveldRiurad unda miiRon 20mg rkina 45 [C].
hemoglobinisa da Hhematokritis normaluri maCveneblebi
(WHO/UNICEF 1997)
sqesi hemoglobinis g/l hematokriti
mamakacebi 130-180 40-50%
qalebi 120-160 36-44%
cxrili 6
20

hemoglobinisa da hematokritis doneebi, romlis qvemoTac
populaciaSi anemia aReniSnebaT (WHO/UNICEF 1997)
cxrili 7
WHO Hb g/l CDC Hb g/l hematokriti Ht%
mamakacebi

9. gaidlainis gadasinjvisa da ganxilvis vada 2 weli
10. gaidlainis miRebis xerxi/wyaro
gaidlainis SemuSavebis meTodologia
• mocemuli gaidlainis Seqmnis procesSi samuSao jgufis mier moZiebul
da Sefasebul iqna ukve arsebuli praqtikuli rekomedaciebi. SemuSavda
arsebuli rekomendaciebis adaptirebuli varianti, romelic erTis
mxriv pasuxobs saerTaSoriso moTxovnebs, xolo meores mxriv
iTvaliswinebs saqarTvelos samedicino dawesebulebaTa, rogorc
adamianur, ise materialur-teqnikur resursebs.
• klinikuri rekomendaciebis diagnostikisa da mkurnalobis Tanamedrove
meTodebi, epidemiologiuri monacemebi moZiebul iqna eleqtronul
bibliografiul bazaSi (Medline), (EMBASE), agreTve Google, Yahoo, Ramblet,
Doctor Guide, Yandex saZiebo operatorebis meSveobiT da kohreinis
biblioTekis bazaSi (The Cohrane Library 2006).
• mocemuli gaidlainis SemuSavebisas gamoyenebul iqna mxolod
mtkicebulebiTi medicines monacemebi, mtkicebulebis donis
gaTvaliswinebiT.
• avtorTa jgufis mier moZiebul iqna 1000-mde statia, referati da
gaidlaini, romelTa analizis Sedegad gamoyofil iqna wyaro.
aRniSnuli wyaroebi safuZvlad daedo klinikuri rekomendaciis Seqmnas.
Mmtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis siZlieris done xarisxi rekomendaciebis xarisxi
I.
II
III
(Muir Gray)
Zlieri mtkicebuleba, eyrdnoba
minimum erT mimoxilvas,
romelic efuZneba swori
dizainis mqone randomizebul
kontrolirebad kvlevas
Zlieri mtkicebuleba, eyrdnoba
minimum erTi swori dizainis
mqone randomizebul
kontrolirebad kvlevas
klinikuri kvleva
randomizaciis gareSe,
kohortuli da SemTxvevakontrolis
kvlevebi
11. alternatiuli gaidlaini ar arsebobs
A
B
C
(Cook et al)
eyrdnoba I donis
mtkicebulebas da
Sesabamisad mtkiced
rekomendebulia
eyrdnoba I donis
mtkicebulebas da
Sesabamisad
rekomendebulia
eyrdnoba III donis
mtkicebulebas SeiZelba
CaiTvalos Sesabamisad
22

12. gamoyenebuli literatura
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2. Prevention and Control of Iron Deficiency Anemia in Women and Children. Report of the
UNICEF/WHO Regional Consultation 3-5 February 1999 Jeneva Switzerland;
3. Iron Deficiency Anemia Assessmentx Prevention and Control. A guide for programme manajers,
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4. Iron Deficiency Anemia assessment, prewention and control report of a joint WHO /VN;CEF/
UNV consultation Jeneva, WHO, 1998;
5. Berger J. Dillon J. Control of iron deficiency in developing countries Sante 2002, 12, 1, 23;
6. WHO. Iron Deficiency Anemia. Assessment, Preventia and control A Guide from Programme
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7. Sharma VR, Brannon MA, Carloss EA, Effect of omeprazole on oral iron replacement in patients
with iron deficiency anemia. South Med I. 2004; 97; 887-9;
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diagnosis of iron deficiency anemia in patients with liver cirrhosis. J. Intern Med 1998; 243: 233-
41;
16. Zuckerman K, Approach to the anemias-in; Cecil RL, Goldman L, Ausiello DA, Cecil Text boor
of Medicine. 22nd ed Philadelphia, Pa; Saunders 2004-969;
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March 2007 V. 75 No5;
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anemia. N Engl J. Med 2001 329: 1691-1695;
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Anemia. British Society of Gastroenterology Gut 2000; 46 suppl 3-4 : V1-V5;
20. Rockey DC. Simple Luideline entroduced for Diagnosing, Eveluating Iron Deficiency Anemia.
Am J. Med 2002; 113; 281-87;
21. Annibal B. Capurso G, Lahier E et al, Con cominant alternations in intragastric PH and Ascorbin
Acid concentration in ratient with H. Pilorv gastrites and associated iron deficiency anemia Gut,
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23. Ruhl CE, Everhart JE. Relationship of iron-deficiency anemia with esophagitis and hiatal hernia;
hospital fingings from a prospective, population based study. Am J. Gastroenterology 2001; 96:
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24. Cook JD. Newer aspects of the diagnosis and treatment of iron deficiency. American Society of
Hematology Educational Program Book, 2003: 40-61;
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2005; 18: 319-2;
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72 257S-264S;
23

27. Cuervo LG. Mahomed K. Treatments for iron deficiency anemia in pregnancy (Cochrane Revien).
In: the Cochrane Library, Jssue 2, 2003: Ox ford: Update Software;
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Among V.S. Children and Women of Childbearing Age. Institute of Medicine. National Academi
Press. Washington, D.C.-1993;
29. Mahomed K. Iron suplplementation in pregnancy (Cochrane Review). In: The Coclrane Library,
Issue 2 2003 Oxford: Update Software;
30. Stolhzfus RS. Dreyfuss ML. Guidelines for the use of Iron supplements tu Prevent and Treat Iron
Deficiency INACG 2005;
31. Crosby WH. The rational for treating Iron deficiency anemia. Arch Intern Med 1984; 144:471-2;
32. Hallberg L. IDA-WHO-EM/NUT 7-1996;
33. Disler Pb.\, Lynch SR, Chartion RW, Torrance JD, Bottwell Th, Walker RB et al. The effect of tea
on iron absbortion Gut 1975; 16:193-200;
34. Hallberg L, Rossander L, Skanberg AB. Phytates and the inhibitory effect of bran on Iron
absorbation in man Am. J. Clin Nutr 1987;45;988-96;
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Health Care. Ottawa: Minister of Sapply and services Canada 1994: 244-53;
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(No, RR-3) 1:29;
37. Goddord A.F. et al. Guidelines for the management of iron Deficiency Anemia. Gut 2000; 46
(suppl 4) iv1-iv5;
38. Goddard A.F., James M. W. , Melntyre A.S., Scott BB. Luidlines for the management of iron
deficiency. 2005;
39. US Departament of Health and Human Services, Centers for Disease Control. Recommendations
to prevent and control iron deficiency in the United states. MMWR 1998; 47 (RR3): 1-36;
40. U.S. Preventive Services Task Force. Rountine iron supplementation during pregnancy. JHMA
1993; 270: 2846-2854;
41. Allen L. Anemia and Iron Deficiency, Effects on Pregnancy Outcomes. Am J. Clin Nutr 2000; 71:
1280S -1284S;
42. Healthy eating during pregnancy and lactation. WHO Regional office for Europe, Copenhagen
1998;
43. Iron. In: DRI, dietary Refrence Inraes for Vitamin A, Vitamin K, Arsenic, Boren, Chromium,
Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc.
Washington, D.C. National Academy Press, 2001;
44. Stoltzfus R, Dreyfuss M, Guidelines for the Use of Iron Supplementation to Prevent and Treant
Iron Deficiency Anemia. INAGG /WHO/ UNICEF (1998);
45. Radtke H, Tegtmeir S, Rocker L, Salama A, Kiesewetter H. Daily doses of 20mg of elementar
iron compensate for iron loss in regular blood donors: a randomized, double-blind placebo –
controlled study. Transfussion 2004; 44: 1427-32;
46. Vardon F. Burnard B, Stubi CL, Bonard C G raff M, Michaud A et al, Iron supplementation for
anexplained fatigue in non-anemic women double bleeding randomized placebo controlled trail
BBj 2003:326:1124;
47. Ioannou J.N. Rockey D.C. Bryson C, L, Wess N,S. Iron deficiency and gastrointestinal
malignancy; a population – based cohort study. Am J. med 2002; 113: 276-80;
48. Geisser P. In vitro studies on interactions of iron salts and complexes with food-stuffs and
medicaments. Arzneimittelforschung 1990 Jul;40(7):754-60.
24

13. avtorTa jgufi
saqarTevlos hematologTa da transfuziologTa asocialcia
⇒ nino lolaSvili _ s.s hematologiisa da transfuziologiis
samecniero kvleviTi institutis wamyvani mecnier muSaki,
medicinis mecnierebaTa doqtori, sdasu sruli profesori;
⇒ genadi iosava _ s.s hematologiisa da transfuziologiis
samecniero kvleviTi institutes sameTvalyureo sabWos wevri,
transfuziologiuri samsaxuris xelmZRvaneli. saqarTvelos
transfuziologTa da hematologTa asociaciis prezidenti,
medicinis mecnierebaTa doqtori, Tssu sruli profesori;
⇒ marina abaSiZe _ s.s hematologiisa da transfuziologiis
⇒
samecniero kvleviTi institutes direqtori, Tssu asocirebuli
profeosori;
mamia zodelava _ saxelmwifo samedicino universitetis onkohematologiuri
departamentis direqtori, sruli profesori;
⇒ marina bogveliSvili _ s.s hematologiisa da transfuziologiis
samecniero kvleviTi institutes wamyvani mecnier muSaki,
medicinis mecnierebaTa doqtori, sruli profesori.
eqspertebi:
⇒ saojaxo medicinis profesionalTa kavSiri _ irina qarosaniZe;
⇒ saojaxo medicinis eqspertTa jgufi, romelic aerTianebs
Tbilissa da sxva regionebSi moqmedi saojaxo medicinis
saswavlo
eqimebs;
centris warmomadgenlebs m.S. praqtikos ojaxis
⇒ saqarTvelos hematologTa da transfuziologTa asociaciis 2007
wlis 5 noembris sxdomis daskvna;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti.
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