an Tirkmlis funqciis iseT daqveiTebas, romlis drosac Tirkmlis ...
an Tirkmlis funqciis iseT daqveiTebas, romlis drosac Tirkmlis ...
an Tirkmlis funqciis iseT daqveiTebas, romlis drosac Tirkmlis ...
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Tirkmlebis qronikuli daavadebis<br />
gaidlaini<br />
I. da av adebis de finicia<br />
Tqd ewodeba <strong>Tirkmlis</strong> funqciur <strong>an</strong> struqturul<br />
dazi<strong>an</strong>ebas ara nakleb 3 Tvis g<strong>an</strong>mavlobaSi, <strong>romlis</strong> <strong>drosac</strong><br />
glomeruluri filtraciis siCqare klebulobs <strong>an</strong> jer kidev<br />
normis farglebSia da romelic ma nifestirebulia <strong>an</strong><br />
paTomorfologiuri monacemebiT <strong>an</strong> <strong>Tirkmlis</strong> dazi<strong>an</strong>ebisaTvis<br />
damaxasiaTebeli cvlilebebiT sisxlsa da SardSi <strong>an</strong><br />
radiologiuri (g amosaxulebiTi) gamokvlevebiT; <strong>an</strong> <strong>Tirkmlis</strong><br />
<strong>funqciis</strong> <strong>iseT</strong> <strong>daqveiTebas</strong>, <strong>romlis</strong> <strong>drosac</strong> <strong>Tirkmlis</strong><br />
gamovlenili <strong>an</strong> gamouvleneli dazi<strong>an</strong>ebebis fonze<br />
glomeruluri filtraciis siCqare < 60ml/wT/1, 73 m2 ara<br />
nakleb 3 Tvis g<strong>an</strong>mavlobaSi.<br />
Tqd iyofa Semdeg stadiebad:<br />
stadi<br />
a<br />
aRweriloba gfs<br />
(m l/wT/1,<br />
73 m²)<br />
1 <strong>Tirkmlis</strong> dazi<strong>an</strong>eba<br />
nor-maluri <strong>an</strong><br />
gazrdili gfs-iT<br />
2 <strong>Tirkmlis</strong> dazi<strong>an</strong>eba<br />
normaluri <strong>an</strong> mcired<br />
daqveiTebuli gfs-iT<br />
3 <strong>Tirkmlis</strong> dazi<strong>an</strong>eba<br />
gfs-is sa Sualo<br />
klebiT<br />
≥ 90<br />
aw, lab, simp.<br />
aw norm/↑ lab+/-<br />
60-89 aw ↑/ lab+/-<br />
30-59 aw ↑/ lab+ /simp+/-<br />
4 gfs-is mkveTri vardna 15-29 aw ↑/ lab++ / simp<br />
+<br />
5 <strong>Tirkmlis</strong> ukmarisobis < 15 <strong>an</strong> aw↑/ lab+++ /simp<br />
terminaluri stadia dializi ++<br />
aw – arteriuli wneva<br />
lab _ laboratoriuli cvlilebebi<br />
simp _ klinikuri simptomebi<br />
II. ep idemi ologia<br />
1
saqarTveloSi Tirkmlebis qronikul daavadebiT Sepyrobil pacientTa<br />
raodenobis Sefaseba SesaZlebelia mxolod im pacientTa mixedviT,<br />
romlebic mimarTaven nefrologiur klinikebs. am monacemebze dayrdnobiT<br />
yovelwliurad Tqd Sepyrobil axalgamovlenil pacientTa raodenoba<br />
aRwevs 480-520, rac 1 mln mosaxleze Seadgens 120-160 pacients. amaTg<strong>an</strong><br />
<strong>Tirkmlis</strong> ukmarisobis terminalur stadiiT Sepyrobilni, romelnic<br />
gadaudeblad saWiroeben <strong>Tirkmlis</strong> C<strong>an</strong>acvlebiTi TerapiisaTvis momzadebas,<br />
ari<strong>an</strong> 160-200 <strong>an</strong>u 1 mln mosaxleze yovelwliurad modis 40-50 potenciurad<br />
sadializo pacienti. 2005 wlis monacemebiT <strong>Tirkmlis</strong> C<strong>an</strong>acvlebiT<br />
Terapiaze imyofeba (hd, pd, Tirkmelgad<strong>an</strong>ergilebi) 609 pacienti <strong>an</strong>u 200 1<br />
mln mosaxleze. epidemiologiuri kvlevis SedegebiT Tirkmlebis<br />
qronikuli daavadebiT Sepyrobil pacientTa raodenoba mniSvnelovnad<br />
gaizrdeba, rac aixsneba droulad gamouvleneli Saqri<strong>an</strong>i diabetis,<br />
hipertoniisa da proteinuriis arsebobiT; aseve mxedvelobaSia misaRebi<br />
<strong>Tirkmlis</strong> is qronikuli daavadebebi, romlebic viTardeba meoradad<br />
mravali sxva daavadebis fonze (kardiovaskuluri, revmatologiuri,<br />
hematologiuri da sxv.). Tirkmlebis qronikuli daavadebas SemTxvevaTa<br />
30%-Si safuZvlad udevs Saqri<strong>an</strong>i diabeti, 20%-Si – sxvadsxva tipis<br />
glomerulonefritebi, 15%-Si – sistemuri daavadebebi, 10% - sxvadsxva<br />
genezis tubulo-intersticiuri nefritebi, 3%-Si – Tirkmlebis cisturi<br />
daavadebebi, 1%-Si – T<strong>an</strong>dayolili daavadebebi, 21%-Si - hipertonia,<br />
aTerosklerozi da ucnobi genezis nefrosklerozi.<br />
III.<br />
et iopaTogenezi<br />
Tirkmlebis qronikuli daavadebas, romelic progresirebs da sabolood<br />
yalibdeba Tirkmlebis terminaluri ukmarisoba, safuZvlad udevs<br />
<strong>Tirkmlis</strong> mravalricxov<strong>an</strong>i daavadeba, rogorc pirveladi aseve meoradi;<br />
etiologiuri mniSvnelobis daavadebaTa mravalferovnebis gamo cxrilSi<br />
#1 moyv<strong>an</strong>ilia daavadebebi magaliTis saxiT, romlebmac SeiZleba<br />
gamoiwvion <strong>an</strong>TebiTi da ara<strong>an</strong>TebiTi tipis glomeruluri, sisxlZarRvov<strong>an</strong>i<br />
Tu tubulo-intersiciuri dazi<strong>an</strong>eba.<br />
cxrili #1. Tqd-s gamomwvevi daavadebebi<br />
paTologia etiologia<br />
(magaliTi)<br />
diabeturi glomerulosklerozi Saqri<strong>an</strong>i diabeti<br />
tipi I<br />
tipi II<br />
glomeruluri daavadebebi (p irve ladi da<br />
me oradi):<br />
1. pr oliferaciuli glomerulonefritebi<br />
mez<strong>an</strong>gioproliferaciuli glomerulonefriti<br />
membr<strong>an</strong>oproliferaciuli glomerulonefriti<br />
fokalur-proliferaciuli glomerulonefriti<br />
difuzur-proliferaciuli glomerulonefriti<br />
swrafadprogresirebadi glomerulonefriti<br />
sistemuri wiTeli mglura,<br />
baqteriuli endokarditi,<br />
vaskulitebi, hepatiti B, C,<br />
HIV infeqcia da sxv.<br />
2. ara<strong>an</strong>Tebadi glomeruluri daavadebebi<br />
minimaluri cvlilebebis glomerulonefriti<br />
fokaluri glomerulosklerozi<br />
membr<strong>an</strong>uli glomerulonefriti<br />
fibriluri glomerulonefriti<br />
hojkinis limfoma, HIV<br />
infeqcia, heroiniT<br />
intoqsikacia,<br />
medikamentozuri,<br />
amiloidozi, msubuqi jaWvebis<br />
2
daavadeba<br />
3. T<strong>an</strong>dayolili: alportis sindromi<br />
si sx lZarRvov<strong>an</strong>i d aavadebebi:<br />
1. msxvili yalibis sisxlZrRvov<strong>an</strong>i daavadebebi<br />
2. saSualo yalibis sisxlZrRvov<strong>an</strong>i daavadebebi<br />
nefrosklerozi<br />
3. mcire yalibis sisxlZrRvov<strong>an</strong>i daavadebebi<br />
mikro<strong>an</strong>giopaTiebi<br />
tubulo-intersticiuri daavadebebi:<br />
1. tubulo-intersi ciuri ne fritebi<br />
pielonefriti<br />
alergiuli intersticiuri nefriti<br />
<strong>an</strong>algetikebiT inducirebuli nefropaTia<br />
gr<strong>an</strong>ulomatozuri intersticiuri nefriti<br />
autoimunuri intersticiuri nefriti<br />
2. ara<strong>an</strong>Tebadi tubulointersticiuri<br />
daavadebebi<br />
refluqs-nefropaTia<br />
obstruqciuli nefropaTia<br />
mielomuri Tirkmeli<br />
cis turi daavadebebi<br />
Tirkmlebis policisturi daavadeba<br />
fon hipel lindaus daavadeba<br />
tuberozuli sklerozi<br />
meduluri cisturi daavadeba<br />
<strong>Tirkmlis</strong> tr<strong>an</strong>spl<strong>an</strong>tatis daavadebebi<br />
qronikuli mocilebis sindromi<br />
rekurentuli daavadeba<br />
tr<strong>an</strong>spl<strong>an</strong>tatis qronikuli nefropaTia<br />
medikamentozuri intoqsikacia<br />
<strong>Tirkmlis</strong> arteriis<br />
stenozi<br />
hipertonia<br />
hemolizur-uremiuli<br />
sindromi,<br />
namglisebrujredov<strong>an</strong>i <strong>an</strong>emia<br />
infeqciebi, Sard-kenWov<strong>an</strong>i,<br />
arasteroiduli <strong>an</strong>Tebis saw.<br />
preparatebi, sarkoidozi,<br />
uveiti<br />
vezikoureTeruli refluqsi,<br />
simsivne, SardkenWov<strong>an</strong>i<br />
daavadeba, mravlobiTi<br />
mieloma<br />
autosomur domin<strong>an</strong>turi <strong>an</strong><br />
recesiuli<br />
ciklosporini <strong>an</strong><br />
takrolimusi, glomeruluri<br />
daavadeba<br />
IV.<br />
klinikuri si mp tomatika<br />
klinikuri simptomatika damokidebulia im ZiriTad daavadebaze, romelmac<br />
gamoiwvia <strong>Tirkmlis</strong> qronikuli daavadeba: daavadebis mimdinareoba<br />
SeiZleba iyos usimptomo da vlindebodes SemTxveviT Sardis <strong>an</strong>alizis<br />
rutinuli gamokvlevisas; gorglov<strong>an</strong>i dazi<strong>an</strong>ebebi SeiZleba mimdinareobdes<br />
sxvadasxva xarisxis SeSupebiT, hipertoniiT, gorglov<strong>an</strong>i filtraciis<br />
siCqaris daqveiTebiT <strong>an</strong> daqveiTebis gareSe; tubulo-intersiciuri<br />
dazi<strong>an</strong>ebebi SeiZleba mimdinareobdes usimptomod <strong>an</strong> saSarde gzebis<br />
simptomatikiT, <strong>romlis</strong> qveS igulisxmeba dizuria, niqturia da sxv.<br />
<strong>Tirkmlis</strong> sxvadsxva daavadebis klinikur prezentacia moyv<strong>an</strong>ilia cxrilSi<br />
# 2:<br />
cxrili # 2 <strong>Tirkmlis</strong> daavadebaTa klinikuri prezentaciis magaliTebi.<br />
<strong>Tirkmlis</strong> daavadeba klinikuri gamovlena<br />
diabeturi ne fropaTia<br />
asimptomuri mikroalbuminuria,<br />
(tipi I, II,)<br />
nefrozuli sindromi<br />
glomeruluri daavadebebi<br />
proliferaciuli glomerulonefritebi<br />
ara<strong>an</strong>TebiTi glomerulopaTiebi<br />
si sx lZarRvov<strong>an</strong>i d aavadebebi<br />
msxvili yalibis<br />
nefrituli sindromi, asimptomuri<br />
mimdinareoba (izolirebuli hematuria<br />
da proteinuria)<br />
nefrozuli sindromi, asimtomuri<br />
mimdinareoba (proteinuria)<br />
hipertonia, asimptomuri mimdinareoba<br />
3
(radiologiuri cvlilebebi)<br />
saSualo yalibis<br />
mcire yalibis<br />
tubulo-intersticiuri daavadebebi<br />
tubulointersiciuri nefritebi<br />
ara<strong>an</strong>Tebadi daavadebebi<br />
cis turi daavadebebi<br />
<strong>Tirkmlis</strong> tr<strong>an</strong>spl<strong>an</strong>t<strong>an</strong>tis<br />
daavadebebi<br />
qronikuli mocilebis sindromi<br />
medikamentozuri intoqsikacia<br />
tr<strong>an</strong>spl<strong>an</strong>tis qronikuli nefropaTia<br />
rekurentuli daavadeba<br />
hipertonia, asimptomuri mimdinareoba<br />
(hematuria, proteinuria)<br />
hipertonia, asimptomuri mimdinareoba<br />
(hematuria, proteinuria)<br />
saSarde gzebis simptomatika,<br />
asimptomuri mimdinareoba (piuria da<br />
radiologiuri cvlilebebi), Sardis<br />
koncentrirebis darRveva<br />
asimptomuri mimdinareoba<br />
(proteinuria, piuria, tubuluri<br />
warmoSobis naleqi da radiologiuri<br />
cvlilebebi)<br />
saSarde gzebis simptomatika,<br />
asimptomuri mimdinareoba (cvlilebebi<br />
Sardis <strong>an</strong>alizSi, radiologiuri<br />
monacemebi)<br />
nefrituli sindromi, asimptomuri<br />
mimdinareoba (izolirebuli hematuria<br />
da proteinuria)<br />
nefrozuli sindromi, asimtomuri<br />
mimdinareoba (proteinuria)<br />
<strong>Tirkmlis</strong> daavadebebis mravalricxovnebis miuxedavad, klinikuri<br />
gamovlinebebi, <strong>romlis</strong> mixedviTac SeiZleba Sefasdes <strong>Tirkmlis</strong> qronikuli<br />
daavadebis stadia, arc Tu ise mravalferov<strong>an</strong>ia. es imas niSnavs, rom<br />
glomeruluri filtraciis siCqaris Sefasebis gareSe klinikurad<br />
SeiZleba saxeze iyos sxvadsxva org<strong>an</strong>oebis mxriv garTulebebi <strong>an</strong> pacienti<br />
iyos asimptomuri, ris gamoc is ar mimarTavs nefrologs. amis gamo<br />
gvi<strong>an</strong>deba Tqd-s drouli diagnostika da progresirebis Ses<strong>an</strong>elebeli<br />
RonisZiebebis gatareba. cxrilSi # 3 moyv<strong>an</strong>ilia Tqd-s stadiebis SesaZlo<br />
klinikuri prezentaciebi:<br />
cxrili #3. Tqd-s stadiebi: klinikuri prezentaciebi<br />
stadia aRweriloba gfs<br />
(ml/wT/1, 73m²)<br />
1 <strong>Tirkmlis</strong> dazi<strong>an</strong>eba normaluri<br />
<strong>an</strong> gazrdili<br />
≥ 90<br />
gfs-iT<br />
klinikuri<br />
prezentacia<br />
asimptomuri,<br />
hipertonia,<br />
nefrozuli sindromi,<br />
nefrituli sindromi,<br />
saSarde gzebis simptomatika<br />
2 <strong>Tirkmlis</strong> dazi<strong>an</strong>eba<br />
normaluri <strong>an</strong> mcired<br />
daqveiTebuli gfs-iT<br />
3 <strong>Tirkmlis</strong> dazi<strong>an</strong>eba gfsis<br />
saSualo klebiT<br />
60-89 garTulebebi<br />
iSviaTad vlindeba<br />
30-59 saSualo simZimis<br />
garTulebebi<br />
4 gfs-is mkveTri vardna 15-29 mZime garTulebebi<br />
4
5 <strong>Tirkmlis</strong> ukmarisobis<br />
terminaluri stadia<br />
< 15 <strong>an</strong><br />
dializi<br />
uremia,<br />
kardiovaskuluri<br />
daavadeba<br />
imis warmosadgenad, Tu ratom aris saxeze <strong>Tirkmlis</strong> qronikuli<br />
daavadebis dros cvlilebebi sxvadasxva org<strong>an</strong>os mxrid<strong>an</strong>, qvemoT<br />
mokled, sqematurad moyv<strong>an</strong>ilia im procesebis g<strong>an</strong>viTarebis meq<strong>an</strong>izmi,<br />
romlebic T<strong>an</strong> sdevs <strong>Tirkmlis</strong> gorglov<strong>an</strong>i siCqaris <strong>daqveiTebas</strong>:<br />
aRniSnuli garTulebebis klinikuri simptomatika, romelic yvelaze<br />
mZimed vlindeba Tqd-s 4 da 5 stadiebSi, SeiZleba iyos Semdegi: Zlieri<br />
saerTo sisuste, daRliloba, umadoba, gulisreva, dilis saaTebSi<br />
pirRebineba, Tavis tkivili, koncentrirebis unaris daqveiTeba, qavili<br />
(pruritis), dispnoe, krunCxvebi.<br />
amasT<strong>an</strong>, aRiniSneba cvlilebebi TiTqmis yvela org<strong>an</strong>osa da sistemis<br />
mxrid<strong>an</strong>:<br />
gul-sisxlZarRvTa sistema: marcxena parkuWis hipertrofia da<br />
diastoluri disfunqcia, aortisa da gulis sarqvelebis kalcifikacia,<br />
ventrikuluri ariTmiebi (hipo/hiperkalemiis fonze).<br />
wyal-ma rilov<strong>an</strong>i da mJava-tutov<strong>an</strong>i darRvevbi: hiperhidratacia,<br />
hiper/hiponatremia, hiperkalemia, metaboluri acidozi.<br />
renuli <strong>an</strong>emia: viTardeba eriTropoetinis deficitis gamo.<br />
renuli osteopaTia: hiperfosfatemia, hipokalcemia da meoradi<br />
hiperparaTireozis Sedegad viTardeba sxvadsxva saxis renuli<br />
osteopaTiebi: fibrozuli osteoiti, Zvlis adinamiuri daavadeba.<br />
he mostazi: sisxldenebi Trombocitebis agregaciis daqveiTebis gamo,<br />
ris gamoc xSiria gastriduodenuri sisxldena, hemoragiuli<br />
perikarditi da plevriti<br />
nervuli sistema: periferiuli neiropaTia, avtonomiuri neiropaTia,<br />
uremiuli encefalopaTia, mtevnis gvirabis sindromi, uremiuli<br />
miopaTia, mousvenari fexis sindromi.<br />
endokrinuli darRvevebi: hipoTireozi, sqesobrivi hormonebis<br />
disbal<strong>an</strong>si, maT Soris aRs<strong>an</strong>iSnavia hiperprolaqtinemia, bavSvebSi<br />
rezistentoba zrdis hormonis mimarT.<br />
metaboluri darRvevebi: dislipidemia IV tipis fredriqsonis<br />
(Fredricksion) mixedviT, hiperhomocisteinemia.<br />
dermatologiuri darRvevebi: qserozi, fsevdoporfiria, qavili.<br />
kuW-nawlavis traqti: gastriti, duodeniti, gastroparezi,<br />
p<strong>an</strong>kreatiti, kolondivertikulozi, hemoragiuli koliti.<br />
zemoT moyv<strong>an</strong>ili dazi<strong>an</strong>ebebis xarisxi damokidebulia Tqd-s 4 da 5<br />
stadiebSi uremiis xarisxze da individualuria. Sesabamisad, klinikuri<br />
simptomatika aris mravalferov<strong>an</strong>i da damokidebulia imaze, Tu<br />
CamoTvlili paTologiebid<strong>an</strong> romelia wina pl<strong>an</strong>ze.<br />
V. di ag nostika<br />
Tqd-s droulad gamovlenisaTvis aucilebelia pacientTa seleqcia,<br />
risTvisac rekomedebulia Semdegi gamokvlevebis warmoeba<br />
(sarwmunoebis done I, rekomendacia A) :<br />
5
Sardis <strong>an</strong>alizi proteinuriis, hematuriis, leikocituriis<br />
gamosavlenad pirveladi skriningis meTodiT testCxirebiT;<br />
proteinuriis SemTxvevaSi cilis raodenobrivi g<strong>an</strong>sazRvra 24<br />
saaTi<strong>an</strong> SardSi <strong>an</strong> dilis SardSi protein/kreatininis <strong>an</strong><br />
albumin/kreatininis fardobis mixedviT;<br />
arteriuli wnevis gazomva;<br />
glomeruluri filtraciis siCqaris gamoTvla.<br />
aRniSnuli gamokvlevebis safuZvelze SesaZlebelia risk<br />
faqtorebis matarebel pacientTa gamovlena da maTze mumivi<br />
monitoringis daweseba.<br />
risk faqtorebis matarebel pacientebSi rekomedebulia<br />
(sarwmunoebis done I, rekomendacia B) Semdegi gamokvlevebis<br />
Catareba:<br />
Tirkmelebisa da saSarde gzebis sonografiuli gamokvleva;<br />
sisxlis SratSi kreatininis, Sardov<strong>an</strong>as g<strong>an</strong>sazRvra;<br />
sisxlis SratSi eleqtrolitebis g<strong>an</strong>sazRvra (natriumi,<br />
kaliumi, qlori, bikarbonati, kalciumi, fosfatebi);<br />
Sardis xvedriTi wona <strong>an</strong> osmolaroba;<br />
Sardis pH<br />
g<strong>an</strong>sakuTrebuli mniSvneloba eniWeba <strong>Tirkmlis</strong> dazi<strong>an</strong>ebis markers –<br />
proteinurias, romelic SemTxvevaTa did nawilSi asimptomuri<br />
mimdinareobiT xasiaTdeba. asimptomuri proteinuriis mqone individTa<br />
j<strong>an</strong>mrTelebisg<strong>an</strong> seleqciisaTvis NKF PARADE-s mier mowodebulia<br />
gamokvlevaTa Semdegi T<strong>an</strong>mimdevroba:<br />
6
gamovlenili proteinuriisa da hematuriis SemTxvevaSi<br />
rekomendebulia (sarwmunoebis done II, rekomendacia B) gamokvlevaTa<br />
warmoeba Sesabamisi algoriTmebis mixedviT:<br />
7
<strong>Tirkmlis</strong> dazi<strong>an</strong>ebis markerebis gamovlenis SemTxvevaSi<br />
rekomendebulia radiologiuri kvlevebi imis mixedviT, Tu<br />
romeli paTologia udevs safuZvlad <strong>Tirkmlis</strong> qronikul<br />
daavadebas.<br />
gamokvlevis sworad SerCevisaTvis qvemoT moyv<strong>an</strong>ilia cxrili #4,<br />
romelSic warmodgenilia Tirkmlebis sxvadasxva dazi<strong>an</strong>ebis<br />
radiologiuri suraTis interpretaciebi:<br />
cxrili #4.<br />
radiologiuri kvlevis<br />
dasaxeleba<br />
ultrasonografia<br />
zogadi suraTi<br />
parenqimis eqogenobis mateba<br />
zomebis Semcireba<br />
gadidebuli zomebi<br />
dopleri<br />
Eeqskretoruli urografia<br />
kompiuteruli tomografia<br />
ma gnitur-rezon<strong>an</strong>suli<br />
kvleva<br />
izotopuri sk<strong>an</strong>ireba<br />
<strong>Tirkmlis</strong> daavadeba<br />
(magaliTi)<br />
nefrokalcinozi, SardkenWov<strong>an</strong>i,<br />
simsivne,<br />
hidronefrozi<br />
zogadad ,,<strong>Tirkmlis</strong> dazi<strong>an</strong>eba”<br />
<strong>Tirkmlis</strong> qronikuli daavadeba<br />
amiloidozi, diabeturi<br />
nefropaTia da sxv.<br />
venuri Trombozi,<br />
tr<strong>an</strong>spl<strong>an</strong>tatis mocilebis<br />
sindromi, arteriis stenozi<br />
Sard-kenWov<strong>an</strong>i daavadeba,<br />
simsivne, ostruqcia, funqcia<br />
osbtruqcia, simsivne, cistebi<br />
simsivne, cistebi, venuri<br />
Trombozi da sxv.<br />
<strong>funqciis</strong> Sefaseba TiToeul<br />
TirkmelSi cal-calke<br />
<strong>Tirkmlis</strong> gogrlov<strong>an</strong>i dazi<strong>an</strong>ebis SemTxvevaSi gamomwvevi daavadebis<br />
diagnostikis, prognozisa da swori mkurnalobis SesarCevad<br />
rekomendebulia (sarwmunoebis done I, rekomendacia A) <strong>Tirkmlis</strong> biofsia.<br />
<strong>Tirkmlis</strong> biofsiis Cvenebebi moyv<strong>an</strong>ilia cxrilSi #5.<br />
cxrili #5. <strong>Tirkmlis</strong> biofsiis Cvenebebi<br />
diagnozi<br />
<strong>Tirkmlis</strong> biofsiis Cveneba<br />
hematuria - izolirebuli hematuria 6 (12) Tveze meti<br />
- hematuria, romelsac T<strong>an</strong> axlavs arteriuli<br />
10
hipertenzia, proteinuria <strong>an</strong> <strong>Tirkmlis</strong> <strong>funqciis</strong><br />
daqveiTeba<br />
proteinuria - nefrozuli xarisxis proteinuria (>3,5g/24sT)<br />
- proteinuria, romelsac T<strong>an</strong> axlavs >2g/24sT<br />
arteriuli hipertenzia <strong>an</strong> <strong>Tirkmlis</strong> fuqciis<br />
daqveiTeba<br />
- proteinuria >2g/24sT, romelic persistirebs <strong>an</strong><br />
imatebs dinamikaSi<br />
Tirkmlebis<br />
mwvave<br />
ukmarisoba<br />
sistemuri<br />
daavadebebi<br />
- gaurkveveli genezi<br />
- 4 kviraze meti x<strong>an</strong>grZlivobis oliguria<br />
- maRali xarisxis proteinuria<br />
- swrafad progresirebadi glomerulonefriti<br />
- imunologiuri da par<strong>an</strong>eoplastiuri daavadebebi<br />
(vaskuliti, monoklonuri gamopaTia, amiloidozi,<br />
revmatoiduli poliarTriti, sklerodermia,<br />
sistemuri wiTeli mglura)<br />
Saqri<strong>an</strong>i diabeti - Saqri<strong>an</strong>i diabeti
Tqd III stadiaSi I, II stadiebSi moyv<strong>an</strong>ili RonisZiebebis garda<br />
renuli <strong>an</strong>emiisa da renuli osteopaTiis gamosavleni gamokvlevebis<br />
Catareba.<br />
Tqd-s IV da V stadiis dros rekomendebulia (sarwmunoebis done I,<br />
rekomendacia B):<br />
• arteriuli wnevis mkacri kontroli<br />
• wyal-marilov<strong>an</strong>i cvlis koreqcia (hiperkalemia,<br />
hipokalcemia, hiperfosfatemia)<br />
• mJava-tutov<strong>an</strong>i wonasworobis, kerZod, metaboluri<br />
acidozis koreqcia<br />
• renuli <strong>an</strong>emiis koreqcia<br />
• renuli osteopaTiis koreqcia<br />
• <strong>Tirkmlis</strong> C<strong>an</strong>acvlebiTi TerapiisaTvis (TCT) pacientis<br />
mzadeba: TCT-s saxeobis _ hemodializi (hd), peritoneuli<br />
dializi (pd) Tu preemftiuri tr<strong>an</strong>spl<strong>an</strong>tacia (<strong>Tirkmlis</strong><br />
gad<strong>an</strong>ergva dializiT mkurnalobis dawyebamde) _ winaswar<br />
g<strong>an</strong>sazRvra pacientis, misi axloblebis, samedicino<br />
Cvebebisa da pacientis socialuri mdgomareobis<br />
gaTvaliswinebiT (mag, hd centrid<strong>an</strong> siSore, aseve<br />
gasaTvaliswinebelia pacientis dasaqmeba); aseve<br />
hemodializis SemTxvevaSi sisxlZarRvov<strong>an</strong>i midgomis<br />
winaswar uzrunvelyofa da pd-s SemTxvevaSi peritoneuli<br />
dializis kaTeteris drouli impl<strong>an</strong>tacia.<br />
B-hepatitis sawinaaRmdego vaqcinacia.<br />
rodesac gfs < 15ml/wT/1,73m² pacientis mdgomareobis Sefaseba<br />
aucilebelia TveSi erTxel hipertoniis, hiperhidrataciis,<br />
bioqimiuri maCveneblebis, renuli <strong>an</strong>emiis, renuli osteopaTiisa<br />
da malnutriciis samarTavad.<br />
<br />
renuli <strong>an</strong>emia: koreqcia xdeba feritinis, tr<strong>an</strong>sferinis gajerebis<br />
indeqsisa da hipoqromuli retikulocitebis raodenobis mixedviT<br />
rkinis preparatebiTa da rekombin<strong>an</strong>tuli eriTropoetiniT. samizne<br />
hemoglobinia (sarwmunoebis done II, rekomendacia B) 11,0-12,0g/dl.<br />
<br />
renuli osteopaTiis koreqcia xdeba saerTo da<br />
ionizirebuli kalciumis, araorg<strong>an</strong>uli fosfatebis,<br />
intaqturi paraThormoninis, Zvlis tutefosfatazisa da<br />
aluminis koncentraciebis mixedviT fosforSemboWavi<br />
preparatebiTa da vit. D metabolitebiT.<br />
TCT-is dawyeba rekomendebulia, rodesac glomeruluri<br />
filtraciis siCqarea 8-10ml/wT/1,73m² (sarwmunoebis done I,<br />
rekomendacia A). am rekomendaciis gatareba g<strong>an</strong>sakuTrebiT<br />
mniSvnelov<strong>an</strong>ia maRali riskis mqone pacientebSi, magaliTad<br />
Saqri<strong>an</strong>i diabetiT daavadebulebsa da imaTSi, visT<strong>an</strong>ac<br />
uremiisaTvis damaxasiaTebeli klinikuri simptomatika mkveTrad<br />
aris gamovlenili <strong>an</strong> gaZnelebulia hidrataciisa da arteriuli<br />
12
wnevis kontroli <strong>an</strong> aReniSnebaT mkveTrad gauaresebuli<br />
nutriciuli statusi, raTa riskis qveS ar dadges pacientis<br />
sicocxle. yvela SemTxvevaSi, dializiT mkurnaloba dawyebul<br />
unda iqnas m<strong>an</strong>am, s<strong>an</strong>am gfs < 6ml/wT/1,73m².<br />
im pacientebSi, romlebic imyofebi<strong>an</strong> nefrologiuri zedamxedvelobis<br />
qveS da romlebT<strong>an</strong>ac dagegmilia hemodializi,<br />
sisxlZarRvov<strong>an</strong>i midgomis – arterio/venuri (a/v) fistulis -<br />
uzrunvelyofis sakiTxi unda dadges hemodializis dawyebamde 3-4<br />
TviT adre. dainficirebisa da Trombozis sixSiris mixedviT<br />
upiratesoba eniWeba natiur a/v fistulas. proTezireba naCvenebia<br />
natiuri a/v fistulis Seqmnis yvela SesaZleblobis amowurvis<br />
SemTxvevaSi. a/v fistulis, natiuri Tu proTezi, perm<strong>an</strong>entuli<br />
funqcionirebis uzrunvelsayofad aucilebeli pirobebia: piradi<br />
higiena, k<strong>an</strong>ulirebis win k<strong>an</strong>is aseptiuri damuSavebisa da punqciis<br />
teqnika. a/v fistulis ararsebobis SemTxvevaSi sisxlZarRvov<strong>an</strong>i<br />
midgomis uzrunvelsayofad gamoiyeneba centraluri venuri<br />
orarxi<strong>an</strong>i keTeteri: droebiTi (3/4kviraze gaTvlili) <strong>an</strong><br />
perm<strong>an</strong>entuli (erTwli<strong>an</strong>i). (sarwmunoebis done II, rekomendacia B).<br />
pacientis kardiovaskuluri statusi Sefasebul unda iqnas<br />
<strong>Tirkmlis</strong> C<strong>an</strong>acvlebiTi Terapiis dawyebis win da Semdeg 6 TveSi<br />
erTxel (sarwmunoebis done II, rekomendacia A). maRali riskis<br />
jgufSi Sedi<strong>an</strong>: mwevelebi, hiperglikemiis, dislipidemiisa da<br />
hipertoniis matarebeli pacientebi.<br />
eqimis taqtika Tqd-s stadiebis mixedviT sqematurad gamoiyureba<br />
Semdegnairad:<br />
13
hemodializis procesis monitoringi :<br />
hemodializis dozireba <strong>an</strong>u se<strong>an</strong>sebis raodenoba da<br />
x<strong>an</strong>grZlivoba g<strong>an</strong>isazRvreba dabali molekuluri wonis toqsinis,<br />
Sardov<strong>an</strong>as kinetikuri maCveneblebis mixedviT: hemodializis<br />
se<strong>an</strong>si iTvleba adekvaturad, rodesac Kt/V ≥ 1,2, xolo URR ≥ 65%.<br />
hemodializis st<strong>an</strong>dartul dozad iTvleba: hd-s 4 saaTi<strong>an</strong>i se<strong>an</strong>si<br />
kviraSi 3-jer. se<strong>an</strong>sis x<strong>an</strong>grZlivoba da/<strong>an</strong> sixSire izrdeba im<br />
pacientebSi, romelT<strong>an</strong> aReniSnebaT hemodinamikuri arastabiloba<br />
<strong>an</strong> kardiovaskuluri problemebi, rac metwilad vrceldeba<br />
x<strong>an</strong>dazmuli asakis pacientebze (sarwmunoebis done II,<br />
rekomendacia B).<br />
dializatorebis SerCeva unda xdebodes pacientis sxeulis<br />
farTobisa da adekvaturobis maCveneblebis mixedviT;<br />
dializatoris SerCevisas aseve mniSvnelov<strong>an</strong>ia masalis<br />
bioTavsebadobisa – modificirebuli celuloza/sinTezuri<br />
masalis dros ar AaRniSneba komplemenetisa da leikocitebis<br />
aqtivacia ise, rogorc es xdeba aramodificirebuli celulozis<br />
SemTxvevaSi – da hidravlikuri maxasiaTeblebis – dabali (low<br />
flux) da maRali (high flux) nakadis (naCvenebia saSualo molekuluri<br />
wonis toqsinebis mag, β2-mikroglobulini) klirensis<br />
gasaumjobeseblad _ gaTvaliswineba.<br />
hemodializisaTvis gamiznuli wyali unda iyos ultrasufTa,<br />
romelic miewodebaT sadializo m<strong>an</strong>q<strong>an</strong>ebs wyaldamamzadebeli<br />
14
sistemid<strong>an</strong>. wyaldamamzadebeli sistema, sadac xdeba wylis<br />
darbileba, deionizacia/demineralizacia, distilacia da<br />
filtracia (reverse osmosis). aucilebelia sadializo wylis<br />
qimiuri da baqteriologiuri sisufTavis rutinuli da<br />
regularuli monitoringi.<br />
hemodializis dros eqstrakorporuli Trombozis saprofilaqtikod<br />
aucilebelia <strong>an</strong>tikoagulaciuri RonisZiebebis<br />
arafraqcionirebuli <strong>an</strong> dabalmolekuluri hepariniT gatareba.<br />
hd asocirebuli infeqciebi: baqteriuli infeqciebi, kerZod ki<br />
Staphylococcus aureus –iT g<strong>an</strong>pirobebuli septicemiebi, warmoadgens<br />
hemodializis yvelaze xSir da sicocxlisaTvis saSiS infeqciur<br />
garTulebas. aqed<strong>an</strong> gamomdinare sisxlZarRvov<strong>an</strong>i midgomis,<br />
rogorc centraluri venuri kaTeterebis, aseve a/v fistulebis<br />
menejmenti unda mkacrad iyos daculi yvela hemodializis<br />
centrSi. aucilebelia aseve tuberkulozis diagnostika da<br />
prevencia imunosupresirebul da malnutriciis mqone<br />
pacientebSi. HBV, HCV da HIV virusebze skriningi<br />
rekomendirebulia 6 TveSi erTxel (sarwmunoebis done II,<br />
rekomendacia B).<br />
peritoneuli dializis monitoringi:<br />
im pacientebSi, romlebic imyofebi<strong>an</strong> nefrologiuri zedamxedvelobis<br />
qveS da romlebT<strong>an</strong>ac dagegmilia peritoneuli<br />
dializi, pd kaTeteris impl<strong>an</strong>tacia unda Catardes peritoneuli<br />
dializiT mkurnalobis dawyebamde 10-14 dRiT adre. sadializo<br />
siTxis mcire moculobebiT peritoneuli dializis dawyeba<br />
dasaSvebia postoperacilad maSinve, Tu arsebobs gadaudebeli<br />
samedicino Cveneba. pd kaTeteris impl<strong>an</strong>tacia xorcieldeba<br />
operaciuli <strong>an</strong> laparoskopiuli gziT.<br />
araavtomaturi <strong>an</strong>u mudmivi ambulatoriuli peritoneuli<br />
dializi (mapd) tardeba orparki<strong>an</strong>i (double-bag) sistemiT,<br />
romelic mniSvnelovnad amcirebs peritonitebis risks<br />
erTparki<strong>an</strong> sistemasT<strong>an</strong> SedarebiT. pd xsnarebi warmoadgens<br />
glukozis 3 tipis koncentaciis - dabali 1,36%-1,5%, saSualo<br />
2,27-2, 5% da maRali 3, 89%-4, 25% - st<strong>an</strong>dartul SemTxvevaSi 2,0<br />
litri<strong>an</strong> eleqtrolitur xsnarebs.<br />
mudmivi ambulatoriuli peritoneuli dializi iTvleba<br />
adekvaturad, rodesac kviris Kt/V ≥ 1,7, CrCl ≥45l/kviraSi/1,73m² (1<br />
kviris kreatininis klirensi) da peritoneumis<br />
ultrafiltraciis unari normalurad, rodesac<br />
maRalpocenti<strong>an</strong>i glukozis 2,0 litri<strong>an</strong>i xsnaris muclis RruSi<br />
4 saaTi<strong>an</strong>i dayovnebis Semdeg ultrafiltratis raodenoba ≥<br />
400ml.<br />
mapd-s dozireba unda warmoebdes pd adekvaturobis<br />
maCveneblebisa da pacientis peritoneumis mier<br />
dabalmolekuluri nivTierebebis e.w. tr<strong>an</strong>sportirebis<br />
15
maxasiaTbelebis mixedviT. peritoneumis tr<strong>an</strong>sportis tipi<br />
g<strong>an</strong>isazRvreba peritoneumis wonasworobis testiT (PET), romelic<br />
unda utardebodes pacientebs weliwadSi 2-jer (sarwmunoebis<br />
done II, rekomendacia B) <strong>an</strong> yoveli morigi peritonitid<strong>an</strong> 6 kviris<br />
gasvlis Semdeg da <strong>romlis</strong> mixedviT pacientebi iyofi<strong>an</strong> dabal<br />
(low tr<strong>an</strong>sporter), saSualod dabal (low average tr<strong>an</strong>sporter), saSualod<br />
maRal (high average tr<strong>an</strong>sporter) da maRal (high tr<strong>an</strong>sporter) tr<strong>an</strong>sportis<br />
peritoneumis mqoned.<br />
pd asocirebuli garTulebebi: infeqciur garTulebebs<br />
miekuTvneba peritoniti da kaTeteris gamosavali nawilis e.w. exit<br />
site infeqcia, romelTa mkurnaloba da profilaqtika warmoebs<br />
International Society for Peritoneal Dialysis (ISPD) mier mowodebuli<br />
gaidlainebis mixedviT. meq<strong>an</strong>ikur garTulebebs miekuTvneba<br />
Tiaqari, xsnaris Caqceva (leakage) da pd kaTeteris obstruqcia,<br />
romelTa menejmentic warmoebs ISPD -is rekomendaciebis mixedviT.<br />
peritoneumis ultrafiltraciis unaris kargva da maRali<br />
tr<strong>an</strong>spotis peritoneumi warmoadgens mapd-Ti mkurnalobis<br />
gagrZelebis prognozulad erTerT arakeTilsaimedo maCvenebels,<br />
<strong>romlis</strong> <strong>drosac</strong> naCvenebia mapd-Ti mkurnalobaSi maRalosmosuri<br />
xsnarebis, kerZod 7,5%-i<strong>an</strong>i Icodextrin -is xsnaris CarTva <strong>an</strong><br />
pacientis tr<strong>an</strong>sformacia avtomatur pd-ze <strong>an</strong> sabolood hd-ze<br />
(sarwmunoebis done I, rekomendacia A).<br />
pd kaTeteris eqspl<strong>an</strong>tacia naCvenebia mkurnalobarezistentuli<br />
peritonitis SemTxvevaSi <strong>an</strong>u Tu klinikuri gaumjobeseba ar<br />
aRiniSna mkurnalobis dawyebid<strong>an</strong> pirveli 72 saaTis<br />
g<strong>an</strong>mavlobaSi da pd xsnari mkurnalobis fonze rCeba amRvreuli<br />
4-5 dRis g<strong>an</strong>mavlobaSi; aseve kaTeteris dislokaciisas da<br />
obstruqciisas mxolod mas Semdeg, rodesac ISPD-gaidlainiT<br />
gaTvaliswinebuli yvela RonisZieba iqneba nacadi. <strong>Tirkmlis</strong><br />
tr<strong>an</strong>spl<strong>an</strong>taciis Semdeg SesaZloa saWiroebis SemTxvevaSi<br />
kaTeteris mucelSi 3-4 Tvis g<strong>an</strong>mavlobaSi Catoveba, Tumca<br />
rekomendirebulia (sarwmunoebis done II, rekomendacia B)<br />
SeZlebisdagvarad adreuli eqspl<strong>an</strong>tacia.<br />
dializze myof pacientTa nutriciuli statusi ZiriTadad<br />
g<strong>an</strong>isazRvreba proteinis katabolizmis siCqariT <strong>an</strong>u azotov<strong>an</strong>i<br />
produqtebis warmoqmnis siCqariT (nPNA- protein nitrogen appear<strong>an</strong>ce<br />
rate). hemodializis pacientebisaTvis nPNA ≥ 0,8g/kg/dR,<br />
peritoneuli dializis SemTxvevaSi nPNA ≥ 1,2 g/kg/dR<br />
(sarwmunoebis done I, rekomendacia B). aseve fasdeba sisxlSi<br />
prealbuminisa da albuminis koncentraciebi.<br />
<strong>Tirkmlis</strong> tr<strong>an</strong>spl<strong>an</strong>tacia<br />
sakiTxi preemftiuri (pre-emptive) <strong>Tirkmlis</strong> tr<strong>an</strong>spl<strong>an</strong>taciis<br />
(tr<strong>an</strong>spl<strong>an</strong>tacia dializamde) Sesaxeb unda dasmul iqnas yvela<br />
SesaZlo SemTxvevaSi, rodesac gfs < 20ml/wT/1,73m2 ara mxolod<br />
dializT<strong>an</strong> dakavSirebuli garTulebebis Tavid<strong>an</strong> asacileblad,<br />
aramed dializiT mkurnalobis xarjebis dasazogad. sakiTxis<br />
droulad dayeneba g<strong>an</strong>sakuTrebiT mniSvnelov<strong>an</strong>ia bavSvebisa da<br />
16
Saqri<strong>an</strong>i diabetiT daavadebul pacienTa SemTxvevaSi<br />
(sarwmunoebis done II, rekomendacia B).<br />
<strong>Tirkmlis</strong> tr<strong>an</strong>spl<strong>an</strong>taciis absoluturi ukuCvenebebis garda –<br />
arag<strong>an</strong>kurnebadi simsivne, HIV pozitiuroba, aqtiuri sistemuri<br />
infeqcia da/<strong>an</strong> mdgomareoba, rodesac sicocxlis x<strong>an</strong>grZlivoba <<br />
2 weliwadze – Tqd-iT daavadebuli yvela pacienti SeiZleba<br />
CaiTvalos <strong>Tirkmlis</strong> tr<strong>an</strong>spl<strong>an</strong>taciis k<strong>an</strong>didatad. donorisa da<br />
recipientis evolucia, romelSic gaerTi<strong>an</strong>ebulia rogorc<br />
samedicino aseve EeTikur-samarTlebrivi aspeqtebi, unda<br />
warmoebdes mkacrad Sesabamisi gaidlainebis mixedviT.<br />
Tirkmelgad<strong>an</strong>ergilTa postoperaciuli monitoringi<br />
iTvaliswinebs (sarwmunoebis done I, rekomendacia A).<br />
• yoveldRiur uwyvet mkacrad g<strong>an</strong>sazRvrul imunosupresiul<br />
Terapias pirveli 6 Tvis g<strong>an</strong>mavlobaSi mwvave mocilebis<br />
sindromis epizodebis Sesamcireblad, aseve<br />
tr<strong>an</strong>spl<strong>an</strong>t<strong>an</strong>tis adekvaturi funqcionirebis<br />
Ses<strong>an</strong>arCuneblad mokle- (1 weli), saSualo- (5 weli) da<br />
grZelvadi<strong>an</strong>i (>10weli) periodebis g<strong>an</strong>mavlobaSi.<br />
• imunosupresiuli mkurnalobis d<strong>an</strong>iSvnas preoperaciulad<br />
(cocxalis donoris SemTxvevaSi) <strong>an</strong> tr<strong>an</strong>spl<strong>an</strong>taciis dRes<br />
(gvamuri donaciis SemTxvevaSi) sisxlZarRvov<strong>an</strong>i<br />
<strong>an</strong>astomozis dadebamde da gagrZelebas yovldRiurad,<br />
magram pirveli 2 Tvis g<strong>an</strong>mavlobaSi gaZlierebulad, Semdeg<br />
dozebis adekvaturi klebiT infeqciebisa da de novo<br />
malignizaciis riskis Sesamcireblad.<br />
uk<strong>an</strong>askneli dekadis g<strong>an</strong>mavlobaSi Tirkmelgad<strong>an</strong>ergilTa<br />
imunosupresiuli mkurnaloba warmoebs<br />
Semdegi kombinaciiT: kalcinevrinis inhibitorebi<br />
(ciklosporin A, FK506), mikofenolat-mofetili <strong>an</strong><br />
azaTioprini da meTilprednizoloni/prednizoloni.<br />
regularuli intervalebiT rekomendebulia Cataredes<br />
(sarwmunoebis done II, rekomendacia B) Semdegi gamokvlevebi:<br />
mokle samedicino daxasiaTeba<br />
arteriuli wnevis, pulsis, sxeulis wonis monacemebi<br />
sruli obieqturi gamokvleva<br />
plazmaSi Na, K, Cl, bikarbonatis, kreatininis, Sardov<strong>an</strong>as<br />
g<strong>an</strong>sazRvra<br />
sisxlis suraTis g<strong>an</strong>sazRvra<br />
SardSi cilis, eriTrocitebis, leikocitebis, glukozis<br />
g<strong>an</strong>sazRvra<br />
sisxlSi ciklosporinis koncentraciis g<strong>an</strong>sazRvra<br />
<br />
damatebiT gamokvlevebSi Sedis:<br />
• RviZlis funqciuri testebi<br />
• plazmaSi Ca, P, iPTH<br />
• tr<strong>an</strong>spl<strong>an</strong>t<strong>an</strong>tis sono/doplerografiuli gamokvleva<br />
• 24 saaTi<strong>an</strong> SardSi cilis g<strong>an</strong>sazRvra<br />
17
• kreatininis klirensi<br />
• virusologiuri kvlevebi: CMV, EBV<br />
VII.<br />
gai dlainis ga da sinjva<br />
Cvens mier warmodgenili gaidlainis gadasinjva moxdeba yovel 2<br />
weliwadSi.<br />
VIII. gai dlainis mi Re bis we si<br />
aRniSnuli gaidlaini miRebulia literaturis Ziebis Sedegad SerCeuli<br />
sxvadasxva gaidlainebis Sejerebisa da adaptaciis gziT. amdenad<br />
alternatiuli gaidlaini ar aris warmodgenili.<br />
IX.<br />
gam oy enebuli leteratura:<br />
1. National Kidney Foundation K/DOQI: Clinical Practice Guidelines for Chronic Kidney<br />
Disease: evalution, classification <strong>an</strong>d stratification. Am J Kidney Dis 2002; vol 39 (Supp l).<br />
2. The Europe<strong>an</strong> Renal Association-Europe<strong>an</strong> Dialysis <strong>an</strong>d Tr<strong>an</strong>spl<strong>an</strong>t Association (ERA-<br />
EDTA) <strong>an</strong>d the Europe<strong>an</strong> Society for Org<strong>an</strong> Tr<strong>an</strong>spl<strong>an</strong>tation (ESOT): “Europe<strong>an</strong> Best Practice<br />
Guidelines for Renal Tr<strong>an</strong>spl<strong>an</strong>tation” (Part1). Neph Dial Tr<strong>an</strong>s 2000;<br />
vol.15,(Suppl 7)<br />
3. The Europe<strong>an</strong> Renal Association-Europe<strong>an</strong> Dialysis <strong>an</strong>d Tr<strong>an</strong>spl<strong>an</strong>t Association (ERA-<br />
EDTA) <strong>an</strong>d the Europe<strong>an</strong> Society for Org<strong>an</strong> Tr<strong>an</strong>spl<strong>an</strong>tation (ESOT): “Europe<strong>an</strong> Best Practice<br />
Guidelines for Renal Tr<strong>an</strong>spl<strong>an</strong>tation” (Part2). Neph Dial Tr<strong>an</strong>s 2002; vol.17,(Suppl 4).<br />
The Europe<strong>an</strong> Renal Association-Europe<strong>an</strong> Dialysis <strong>an</strong>d Tr<strong>an</strong>spl<strong>an</strong>t Association (ERA-<br />
EDTA). ): “Europe<strong>an</strong> Best Practice Guidelines for Haemodialysis” (Part1). Neph Dial Tr<strong>an</strong>s<br />
2002, vol 17,(Suppl 7).<br />
5. The Europe<strong>an</strong> Renal Association-Europe<strong>an</strong> Dialysis <strong>an</strong>d Tr<strong>an</strong>spl<strong>an</strong>t Association (ERA-<br />
EDTA). ): “Europe<strong>an</strong> Best Practice Guidelines for Peritoneal dialysis”. Neph Dial Tr<strong>an</strong>s<br />
2005, vol 20, (Suppl 9).<br />
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6. Alex M. Davison, J. Stewart Cameron, Je<strong>an</strong>-Pierre Grunfeld, Claudio Pontichelli, Eberhard<br />
Ritz, Cristopher G. Winearls,Charls v<strong>an</strong> Yeperele. Oxford Textbook of Clinical Nephrology,<br />
2005.<br />
7. B. Grabensee. Nephrologie, 2002.<br />
8. Ulrich Kuhlm<strong>an</strong>n, Dieter Walb, Friedrich C. Luft. Nephrologie.<br />
X. avtorTa jgufi:<br />
saqarTvelos dializis, nefrologiisa da <strong>Tirkmlis</strong> tr<strong>an</strong>spl<strong>an</strong>taciis<br />
kavSiris sainiciativo jgufi:<br />
1. irma WoxoneliZe - Tssu Sinag<strong>an</strong> sneulebaTa departamentis asistentprofesori<br />
nefrologiaSi, `saqarTvelos<br />
dializis, nefrologiisa da <strong>Tirkmlis</strong><br />
tr<strong>an</strong>spl<strong>an</strong>taciis kavSiris~ Tavmjdomare<br />
urologiis erovnuli centris nefrologiuri<br />
g<strong>an</strong>yofilebis gamge med. mecn. k<strong>an</strong>didati<br />
…<br />
2. elguja RonRaZe - s/s k.erisTavis sax. eqsperimentuli da klinikuri<br />
qirurgiis erovnuli centris _ tr<strong>an</strong>spl<strong>an</strong>taciis<br />
g<strong>an</strong>yofilebis gamge, med. mecn. doqtori<br />
3. merab suTiZe - Sps `ak. Nnikoloz yifSiZis saxelobis centraluri<br />
sauniversiteto klinikis~ _ <strong>Tirkmlis</strong> C<strong>an</strong>acvlebiTi<br />
Terapiis departamenti ufrosi<br />
abreviatura:<br />
DOKI – Dialysis Outcome Quality Initative<br />
NKF – National Kidney Foundation<br />
PARADE – Proteinuria, Albuminuria, Detection <strong>an</strong>d Elimination<br />
Tqd - Tirkmlebis qronikuli daavadeba<br />
aw - arteriuli wneva<br />
agf - <strong>an</strong>giotenzinis gardamqmneli fermenti<br />
ar - <strong>an</strong>giotenzinis receptori<br />
tr<strong>an</strong>sf. gaj. indeqsi - tr<strong>an</strong>sferinis gajerebis indeqsi<br />
i.v. - intravenurad<br />
hd - hemodializi<br />
pd - peritoneuli dializi<br />
TCT – <strong>Tirkmlis</strong> C<strong>an</strong>acvlebiTi Terapia<br />
mapd – mudmivi ambulatoriuli peritoneuli dializi<br />
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