sarCevi saredaqcio jgufi - DNT Union

siTxis balansis regulirebis intrarenuli meqanizmebicxrilSi #1 moyvanilia is intrarenuli faqtorebi, romlebic monawileobensiTxisa da marilis normaluri homeostazis SenarCunebaSi.nefronis nawiliproqsimaluri nefronisiTxis da marilis gamoyofaze moqmedi faqtorebigfs- peritubuluri starlingis Zalebi- milakisa da intersticiumis siTxis Semadgenloba- Tirkmlis nervuli sistema- angiotenzini, prostaglandinebi da sxva hormonebi- winagulovni natriurezuli peptidi, urodilatinidistaluri nefronicxr. 1. siTxis homeostazze moqmedi intrarenuli faqtorebiperitubuluri starlingis meqanizmi- aldosteroni- antidiurezuli hormoni- prostaglandinebi- winagulovani natriurezuli peptidi, urodilatiniproqsimalur milakSi filtratis ukuSewovis procesi starlingis meqanizmseyrdnoba: gfs-is SesanarCuneblad angiotenzin-II-is zegavleniT xdebaeferentuli arteriolis konstriqcia. Sesabamisad, postglomerulurkapilarSi ecema hidravlikuri da izrdeba onkozuri wneva, rac starlingisfenomenis Tanaxmad qmnis wnevaTa sxvaobas kapilarSida sivrcesa daperitubulur intersticiums Soris. yovelive amis Sedegad proqsimalurmilakSi Zlierdeba Na + -is da H 2O-s reabsorbcia. peritubulur intersticiursivrceSi siTxis gadasvla grZeldeba manam, sanam es wneva ar miaRwevs garkveulzRvrul sidides. amis Semdeg siTxe iwyebs ukudenas milakis sanaTurisken.eferentuli stimulaciasisxlis nakadis cvlilebaVas afferensVas efferensVas afferensVas efferensNa +H 2Operitubulurihidravlikuri wnevaperitubulurionkozuri wnevasur.3 peritubuluri starlingis meqanizmi5

edemis formirebis paTogeneziedema aris palpaciiT gamovlenili SeSupeba, romelic viTardebaintersticiumis (ujredgare sivrce) siTxiT eqspansiisas. edema klinikuradvlindeba maSin, rodesac am siTxis raodenoba aRwevs 2,5-3 litrs. aqve undaaRiniSnos, rom ujredSida sivrceSi siTxis Warbi dagroveba (antidiurezulihormonis araadekvaturi sekreciis sidnromis dros), ar iwvevs edemisganviTarebas. mozrdilebSi edema pirvel rigSi vlindeba qvemo kidurebzemaSin, rodesac bavSvebSi SeSupeba metad saxezea gamoxatuli.edemis ganviTarebas safuZvlad udevs ori ZiriTadi meqanizmi:‣ Tirkmlebis mier wylisa da marilis retencia;‣ hemodinamikuri darRvevebi kapilarebSi, ris Sedegadac xdeba siTxisgadanacvleba sisxlZrRvSida sivrcidan intersticiumSi (starlingismeqanizmi, ix. zemoT).edemis mizezebi‣kapilarSida wnevis anu hidravlikuri wnevis matebaa. TirkmlebiT natriumisa da wylis gaZlierebuli retencia• gulis ukmarisoba• Tirkmlis yvela is paTologia, romelic mimdinareobs natriumispirveladi retenciiT• RviZlis cirozis adreuli stadia• premenstrualuri sindromi da orsuloba• medikamenturi (monoqsidili, aass, estrogenebi)• Sardmden-asocirebuli SeSupebab. venuri obstruqcia• lokaluri venuri obstruqciag. arteriuli rezistentobis daqveiTeba• kalciumis antagonistebi• idiopaTiuri SeSupeba‣ hipoalbuminemia anu plazmis koloid-osmosuri wnevis daqveiTeba:a. albuminis danakargi• nefrozuli sindromi• cilis kargviT mimdinare enteropaTiebib. albuminis sinTezis daqveiTeba• RviZlis cirozi• malnutricia‣ kapilarebis permeabelobis mateba• damwvroba• travma• sefsisi• alergiuli reaqcia• interleikiniT mkurnaloba• Saqriani diabeti• malignizebadi asciti‣ intersticiumSi onkozuri wnevis mateba an limfuri obstruqcia• hipoTireozi• limfuri kvanZebis hipertrofia7

edema gulis ukmarisobis drosgulis ukmarisobis dros ganviTarebuli sisxlis efeqturi moculobisSemcireba iwvevs baroreceptorebis gaaqtivebas, rasac Tan sdevskateqolaminebis, angiotenzin II, argininvazopresinisa da endoTelinisgamonTavisufleba. amasTan qveiTdeba Tirkmlis perfuzia, izrdeba natriumisfraqciuli filtracia, rasac Tan sdevs proqsimalur milakebSi misigaZlierebuli reabsorbcia da Sesabamisad distalur milakamde miRweuliNaCl-is koncentraciis Semcireba. es ukanaskneli iwvevs iuqstaglomeruluriaparatis gaaqtivebas da angiotenzin II-is sinTezis gaZlierebas.ujredgare sivrce ↓kateqolaminebi ↑ angiotenzin II ↑ wnp ↑ endoTelin I ↑renuli sisxlis nakadi ↓gfsfiltraciis fraqcia ↑proqsimaluri reabsorbcia ↑natriumis distaluri miwodeba ↓baroreceptorebis gaaqtivebarenin - angiotenzin I - angiotenzin II ↑sur.4 edemis meqanizmi gulis ukmarisobis drosyovelive amis Sedegad Zlierdeba natriumisa da wylis retencia, izrdebakapilarSida wneva, filtracia aWarbebs ukuSewovas, rac xels uwyobs edemisformirebas.8edema RviZlis cirozis drosRviZlis cirozis dros edemis formirebas safuZvlad ori Teoria udevs:,,Seuvseblobis” (underfilling) Teoria – am Teoriis Tanaxmad, periferiulivazodilataciis, portuli hipertenziisa da hipoalbuminemiiT gamowveulionkozuri wnevis daqveiTebis gamo ecema sisxlis efeqturi moculoba. esaaqtivebs volumoreceptorebs da irTveba yvela is meqanizmi, rasac Tansdevs TirkmlebiT wylisa da marilis gaZlierebuli retencia. amas ematebavazopresinis sekreciis gaZliereba, rac iwvevs wylis eqskreciis Semcirebasda edemis kidev ufro gaRrmavebas.,,gadavsebis” (overfilling) Teoria _ garkveulii neirohumoruli meqanizmebiszegavleniT Zlierdeba proqsimalur milakebSi natriumis ukuSewova, racSesabamisad iwvevs wylis Sekavebas, sisxlis efeqturi moculobis gazrdasda edemis formirebas.

edema nefrozuli sindromis drosdidi xnis ganmavlobaSi nefrozuli sindromis dros edemis formirebamxolod kapilarSida onkozuri wnevis daqveiTebiT aixsneboda. am Teoriis(underfill) Tanaxmad, onkozuri wnevis daqveiTeba iwvevs sisxlis efeqturimoculobis vardnas, rasac Tan axlavs wylisa da natriumis retenciisgaZliereba da SeSupebis formireba. magram aRmoCnda, rom garkveuliglomerulopaTiebisas, magaliTad membranuli da membranulproliferaciuliglomerulonefritebis dros, adgili aqvs pirveladad palzmis moculobisgazrdas, rac natriumis retenciiT aixsneba (overfill Teoria). renin-angiotenzinaldosteronissistemis stimulacia am dros ar dafiqsirda. dRes ukve eWvsar badebs, rom nefrozuli sindromis dros edemis formirebas safuZvladorive meqanizmi udevs.miqsedemahipoTierozis dros SeiZleba adgili hqondes albuminisa da plazmis sxvaproteinebis intersticiumSi gadasvlis gaZlierebas da Tu am dros limfurisistemiT aRniSnuli ,,eqsudatis” drenireba arasakmarisi aRmoCndeba (miqsedemisdros limfuri nakadis siCqare ar matulobs ise, rogorc es xdeba sxvasaxis SeSupebebis dros), adgili eqneba intersticiumSi wnevis gazrdas daSesabamisad SeSupebis formirebas.neiropaTiuri genezis edemaviTardeba Saqriani diabetis dros simpaTikuri aqtivobis daqveiTebisa daperiferiuli neiropaTiis Sedegad ganviTarebuli e.w. avtonomiurineiropaTiuli darRvevebis farglebSi. avtonomiurad inervaciis moSla iwvevssisxlZarRvTa medialuri Sris gluvkunTovan dgeneracias da kalcinozs,rasac Tan sdevs kapilarebis permeabelobis gaZliereba. am saxis SeSupebaxSirad kargad pasuxobs simpaTikomimetur mkurnalobas.,,idiopaTiuri” edemaedema CaiTvleba ,,idiopaTiurad”, rodesac gamoiricxeba edemis ganviTarebisyvela sxva zemoT CamoTvlili mizezi. ,,idiopaTiuri” edema upiratesad gvxdebaaxalgazrda qalebSi, romlebic ZiriTadad uCivian sxeulis konkretulinawilebis SeSupebas – quTuToebi, TiTebi, fexebi. xSirad simptomebi ciklurixasiaTisaa da korelirebs menstrualur ciklTan. edemasTan erTad pacientebiuCivian Sardis raodenobis Semcirebasa da wonis matebas. amasTan, arcTuiSviaTia fsiqiuri darRvevebi (depresiebi, nevrozuli simptomebi).,,idiopaTiuri” edemis paTogenezs savaraudod safuZvlad udevs sami meqanizmi:1. kapilarebis permeabelobis mateba, romelic viTardeba garkveuli humorulifaqtorebis zegavleniT (hipoTalamusis hipofunqcia, prolaqtinis,maluTeinizebeli da sxv. hormonebis gamonTavisuflebis daqveiTeba);9

2. refeeding anu normaluri kvebis xagrZlivi droiT restriqciis an SimSilisSemdeg ganviTarebuli SeSupeba, rac aixsneba insulinis gaZlierebuligamonTavisuflebiTa da renin-angiotenzin-aldosteronis sistemis gaaqtivebiT;3. Sardmdenebis TviTneburi da arakontrolirebadi moxmareba, e.w. diuretikdamokidebuleba,romlis drosac adgili aqvs renin-angiotenzin-aldosteronissistemis gaaqtivebas.Sardmdenebi da maTi klinikuri gamoyenebaedemis samkurnalod mniSvnelovania paTofiziologiis gacnobiereba. asevesxvadasxva jgufis Sardmdenebis moqmedebis meqanizmis gaTvaliswineba.osmosuri Sardmdenebis garda yvela danarCenis moqmedebis meqanizmi efuZnebaurTierTqmedebas specifiur enzimebTan, satransporto proteinebTan, hormonisreceptorebTan, ionebis arxebTan anu yvela im komponentTan, romlebicgansazRvrul rols TamaSoben natriumis transepiTelur gadatanaSi. sworedam urTierTqmedebis mixedviT Sardmdenebi gaerTianebulni arian SemdegjgufebSi:‣ karboanhidrazas inhibitorebi, romlebic moqmedeben proqsimalurmilakze;‣ maryuJis Sardmdenebi, romelTa moqmedebis adgilia henles maryuJissqeli aswvrivi toti da Macula densa;‣ Tiazidebi, romlebic moqmedeben distalur milakze;‣ kaliumSemnaxveli diuretikebi, romelTa samoqmedo adgilia Semkrebimilaki.10karboanhidrazas inhibitorebiproqsimalur milakSi Na + -H + transepiTeluri gadaadgileba an e.w.kotranspoti uerTierTsapirispiroa. milakis sanaTurSi moxvedrili H +protoni ukavSiredeba HCO 3--s da warmoiqmneba H 2CO 3, romelic Tavis mxriviSleba CO 2da H 2O-d. CO 2Tavisuflad aRwevs ujredSi, sadac isev warmoqmnisH 2CO 3-s. am ukanasknelis disociaciis Sedegad warmoqmnili H + kvlav gadadismilakis sanaTurSi Na + -H + urTierTgacvlis principiT,xolo ujredSi darCeniliHCO 3¯monawileobs kotransportSi, romlis meSveobiT Na + bazaluri membranisgavliT xvdeba sisxlSi. H 2CO 3-is am gardaqmnebis katalizators rogorcepiTeluri ujredis membranaze, aseve ujredis SigniT, warmoadgenskarboanhidraza.karboanhidrazas inhibitorebi, rogoricaa acetazolamidi, zemoqmedeben HCO 3¯ukuSewovis samive safexurze: amcireben CO 2-is warmoqmnas sanaTurSi, ujredSiHCO 3¯-is regenerirebas da mis bazolateralur transports. yovelive amisSedegad mcirdeba H + gadasvla sanaTurSi da Na + gadasvla sisxlSi. viTardebabikarbonaturia da metaboluri acidozi. garda amisa, karboanhidrazas

arasruli inhibirebis da Na + ukuSewovis sxva gzebiT gaaqtivebis (pirvelyovlisa distaluri milakiT Na + Sewovis gaZliereba) gamo, am jgufisSardmdenebis diurezuli efeqti mcirea. amitom isini gamoiyeneba mxolodmetaboluri alkalozis farglebSi ganviTarebuli SeSupebis dros: hiperkapniafiltvismieri gulis da marcxena parkuWis disfunqciis dros; mTamsvlelebSimwvaved ganviTarebuli posthiperkapniuri alkalozi da siTxis retencia.acetazolamidi aseve iniSneba glaukomis samkurnalod.proqsimaluri milakisanaTurisisxliNa + atfNa +-HCO 3+ H + H + K +karboanhidrazaH 2CO 3CO 2-HCOH 32CO 3Na +karboanhidrazasinhibitoriNa + Cl - , H 2Okarboanhidrazas moqmedebis bloki↓bikarbonatis Sewovis blokiH + eqskreciis blokimetaboluri acidozisur.5 karboanhidrazas inhibitorebis moqmedebis meqanizmimaryuJis Sardmdenebihenles maryuJis sqeli aswvrivi nawili wyalgaumtaria. Na + -is ukuSewovaxorcieldeba milakis sanaTuris membranis Na + -2Cl¯-K + arxebis gaswvriv Na + -K + -atf-azas gamoyenebiT. ujredSi moxvedrili Cl¯ tovebs masbazolateralurad ganlagebuli Cl¯ arxebis meSveobiT, romlishiperpolarizebas ganapirobeben K + arxebi. am arxebis (e.w. ROM-K + arxebi)meSveobiT K + kvlav gadadis milakis sanaTurSi, radgan K + -is gareSe verganxorcieldeba zemoaRwerili Na + -2Cl¯-K + kotransporti.maryuJis Sardmdenebi (furosemidi, torasemidi, bumetanidi, piretanidi)ainhibireben Na + -2Cl¯-K + kotransports. Sesabamisad izrdeba distalurmilakamde miRweuli NaCl-is koncentracia. amasTan irRveva intersiciumiskoncentraciuli gradienti. Semkreb milakSi Zlierdeba Na + -is ukuSewova,rasac Tan sdevs K + -is eqskreciis gaZliereba da metaboluri alkalozisganviTareba. amasTan gasaTvaliswinebelia is faqtic, rom maryuJis SardmdenebiszemoqmedebiT mcirdeba Cl¯-is ujredSida Semcveloba. Macula densa-Siganlagebuli reninmaproducirebeli ujredebis membranuli potencialisgenerireba damokidebuli Cl¯ arxebze. amitom Cl¯ vardna iwvevs am ujredebisdepolarizacias, rac astimulirebs reninis gamonTavisuflebas.11

maryuJis sqeli aswvrivi nawilisanaTurisisxliNa + Na +2Cl - atfK + K +maryuJisSardmdeniClK + -+ -Na +Na + -2Cl - -K + kotransportis inhibirebaintersticiumSi koncentraciuligradientis daqveiTebakompensatorulad Semkreb milakSiNa + -is Sewovis gaZliereba↓K + -is eqskreciis kidev ufro gazrdametaboluri alkalozi da hipokalemiasur.6 maryuJis Sardmdenebis moqmedebis meqanizmiTiazidebidistalur milakSi Na + -is ukuSewova xorcieldeba Na + -Cl¯ kotransportisgziT Na + -K + -atf-azas meSveobiT. distaluri milaki wyalgaumtaria da amitomSardi am nawilSi ganzavebulia. Tiazidebi ainhibireben Na + -Cl¯ kotransports.Na + -is reabsorbciis inhibirebiT Tiazidebi iwveven membranishiperpolarizacias,Ca ++ -is arxebis gaxsnas da Ca ++ -is ukuSewovis gaZlierebas.distaluri milakisanaTuriNa +Cl -Tiazidiatfsisxli+Na +K +K +Cl -K +↓Na + -K + kotransportis blokiNa + -is ukuSewovis blokimembranis hiperpolarizebada Ca ++ -is arxebis gaxsnaCa ++ -is gamoyofis Semcireba12sur.7 Tiazidebis moqmedebis meqanizmi

kaliumis Semnaxveli SardmdenebiSemkreb milakSi Na + -is reabsorbcia xorcieldeba amilorid inhibirebadiNa + arxebis meSveobiT. am arxebs ewodebaT ,,epiTeluri natriumis arxebi” daaRiniSneba, rogorc ENaC. Na + da K + ionebis ujredis gaswvriv gadaadgilebaurTierTsapirispiroa, ris gamoc NNa + -is Sewovis inhibireba Sesabamisad iwvevsK + eqskreciis daTrgunvas. Na + -is ukuSewovaze arsebiT zegavlenas axdensaldosteroni.spironolaqtoni da eplerenoni ainhibireben aldosteronis receptorebs,ris Sedegadac aRar xdeba aldosteroniT inducirebuli proteinebis,rogoricaa Na + arxebi, Na + -K + -atf-aza, K + arxebi da mitoqondriuli enzimebi,warmoqmna. maTgan gansxvavebiT, amiloridi da triamtereni uSualodainhibireben ENaC arxebs, rasac Tan sdevs natriurezis gaZliereba da K + -iseqskreciis Semcireba.sanaTurisisxliNa + atfNa +amiloridiK + K +K +_+↓spironolaqtoni - aldosteronisreceptorebze zemoqmedebaproteinuri transkrifciis procesis(Na + arxebis, Na + -K + -atf-azas mitoqondriulienzimebis Seneba) blokinatriurezis gaZliereba da kaliumissekreciis daqveiTebaamiloridi, triamtereni - Na + -isarxebis inhibirebamembranis hiperpolarizacia -natriurezis↑ da K + -is sekreciis↓sur.8 kaliumis Semnaxveli Sardmdenebis moqmedebis meqanizmi13

14Sardmdenebis moqmedebis zogadi klinikuri aspeqtebiSardmdenebis moqmedeba mniSvnelovnad aris damokidebuli proqsimalurimilakis sekreciaze, gorglovan filtraciaze da wylis ukuSewovaze anuyvela im faqtorze, romlebic gansazRvraven Sardmdenis koncentracias milakissanaTuSi. SardSi Sardmdenebis raodenoba 20-100-jer unda aRematebodesplazmaSi koncentracias.Sardmdenebis moqmedeba Sesustebulia Semdegi faqtorebis zegavleniT:‣ sxva nivTierebasTan kombinireba (mag, β-laqtamuri antibiotikebi);‣ hipoalbuminemia;‣ dehidratacia, Tirkmlis hipoperfuzia, gfs-is daqveiTeba.gasaTvaliswinebelia isic, rom xanmokle moqmedebis Sardmdenebis daniSvnisasSeiZleba ver iqnas miRweuli natriumis cvlis uaryofiTi balansi. magaliTad,furosemidis miRebisas pirveli 6 saaTis ganmavlobaSi adgili aqvs natriumiseqskreciis gaZlierebas, xolo misi moqmedebis Sewyvetis Semdeg gaaqtivebasiwyeben natriumis retenciis mastimulirebeli meqanizmebi, ris SedegadacdRis ganmavlobaSi natriumis wonasworoba SeiZleba ucvleli darCes. maryuJisSardmdenebisgan gansxvavebiT, Tiazidebis moqmedeba SedarebiTgaxangrZlivebulia da natriumis uaryofiTi balansi SedarebiT didxansaris SenarCunebuli.natriumis uaryofiTi balansis misaRwevad rekomendebulia Semdegi:‣ natriumis miRebis SezRudva;‣ Sardmdenis dozis safexurebrivi mateba;‣ dRis ganmavlobaSi miRebis jeradobis gazrda;‣ maryuJis Sardmdenebisa da Tiazidebis kombinireba.mniSvnelovania Sardmdenebis antihipertenziul efeqtze SeCereba.Sardmdenebis antihipertenziuli moqmedeba damyarebulia plazmis moculobisada gulis dartymiTi moculobis Semcirebaze, Tumca paralelurad amisaadgili aqvs periferiuli rezistentobis matebas. aqve unda aRiniSnos isic,rom Sardmdenebis xangrZlivi miRebis sapasuxod viTardeba e.w. ,,reversautoregulacia”, rac niSnavs imas, rom plazmis moculobisa da gulis dartymiTimoculobis maCveneblebi ubrundebian sawyis sidides, sisxlZrRvTa periferiulirezistentoba ki mcirdeba. es fenomeni aixsneba SemdegiT:‣ ujredSida Na + da Ca ++ gazrdili koncentraciebis normalizeba;‣ angiotenzin II-is da noradrenalinis zemoqmedebis sapasuxovazokonstriqciis Sesusteba;‣ vazodilatatoruli efeqtis mqone prostaglandinebis sinTezisgaZliereba;‣ vazokonstriqtoruli Tvisebebis mqone endogenuri natriurezulihormonis sinTezis daqveiTeba;‣ rezistentuli arteriebis K + arxebis gaxsna.ar unda dagvaviwydes, rom SardmdenebiT inducirebuli wylisa da mariliskargvis gaZlierebis Sedegad aqtiurdeba renin-angiotenzin-aldosteronis

sistema (raas) da vazopresini, ris Sedegadac izrdeba Na + -is reabsorbcia dariTac aixsneba zemoxsenebuli periferiuli rezistentobis mateba. amis gamoSardmdenebis antihipertenziuli efeqti limitirebulia da maTi dozis matebaantihi pertenziuli efeqtis gasaZliereblad ar aris mizanSewonili. qvemoTmoyvanilia is minimaluri dozebi, romlebic sakmarisia antihipertenziuliefeqtis misaRebad: indapamidi 1,25 mg, hidroqlorTiazidi 12,5 mg, furosemidi20/40 mg, torasemidi 2,5/5 mg, spironolaqtoni 75 mg. renin-angiotenzinaldosteronissistemis gaaqtivebis sakompensaciod agf inhibitorebisa da/an ar blokerebis damateba aZlierebs Sardmdenebis antihipertenziul efeqts.Sardmdenebis xangrZlivi an arakontrolirebadi miRebisas mosalodneliaSemdegi gverdiTi movlenebis ganviTareba:‣ dehidratacia‣ azotemia‣ hiponatremia (mxolod Tiazidebi)‣ hipokalemia (TiTqmis yovelTvis metaboluri alkaloziT)‣ hiperkalemia (kaliumis Semnaxveli Sardmdenebi)‣ hiperurikemia‣ hipomagnemia‣ cximisa da naxSirwylebis cvlis moSlaSardmdenebi sxvadasxva genezis edemis drosgulis ukmarisobis dros efeqturia Tiazidebis agf-inhibitorebTankombinaciaSi miReba. gulis ukmarisobis simZimis zrdasTan erTaddehidrataciis gasaZliereblad aRniSnul kombinacias emateba maryuJisSardmdenebi. amasTan, kardialuri fibrozis saprofilaqtikod racionaluriaaldosteronis antagonstebis damateba.RviZlis cirozis dros gamoxatuli meoradi hiperaldosteronizmisgamo SeSupebis Sesamcireblad ukeTesia spironolaqtoni (25-400 mg dReSi).Tumca gasaTvaliswinebelia is faqti, rom spironolaqtonis miRebisas SeiZlebamatulobdes amoniumis sekrecia, rac RviZlis cirozis dros gansakuTrebiTsayuradReboa. maryuJis Sardmdenebi iniSneba sifrTxiliT hepatorenulisindromis Tavidan acilebis mizniT.refraqteruli edemebis dros rekomendebulia maryuJis Sardmdenebisada Tiazidebis kombinacia.Tirkmlebis funqciis daqveiTebis dros efeqturia Tiazidi metolazoni,romelic sxva Tiazidebisgan gamoirCeva epiTeluri ujredebis receptorebTanSekavSirebis gaZlierebuli unariT. amitom misi kombinacia maryuJisSardmdenebTan gansakuTrebiT efeqturiamZime nefrozuli sindromis dros diurezuli efeqti Zlierdeba, Tualbuminis xsnars daemateba maryuJis Sardmdenebi da ise moxdeba pacientisaTvisinfuzia. am dros ramdenadme matulobs proqsimalur milakamde miRweuliSardmdenis koncentracia.15

qvemoT moyvanil cxrilSi warmodgenilia SardmdenebiT mkurnalobisefeqturobis Semamcirebeli faqtorebi da maTi sawinaaRmdego RonisZiebebi.problemanatriumis Warbi miRebaproblemadaqveiTebuli bioSeRwevadoba(nawlavis SeSupeba)gaZlierebuli distalurireabsorbciahenles maryuJamde natriumisSemcirebuli miRwevaSardmdenis sekreciis daqveiTebagadaWris gza- SardSi natriumis gansazRvra- natriumisgadaWrismiRebisgzaSezRudva- intravenuri Seyvana- dozis gazrda- Tiazidis an kaliumis SemnaxveliSardmdenis damateba- acetazolamidis damateba- spironolaqtonis gamoyeneba- albumini + furosemidi- furosemidis uwyveti infuzia- hemofiltraciacxr. 2. problemebi SardmdenebiT mkurnalobisas da maTi gadaWris gzebiklinikur praqtikaSi Sardmdenebis saSualo da maqsimaluri dRiuri dozebiwarmodgenilia cxrilSi # 3:nivTierebatabletebimg-Sisawyisidoza (mg)saSualodRiuridoza (mg)maqsimalurimoqmedebisdRiurixangrZlivobadoza (mg)(sT)Tiazidebi:hidroqlorTiazidiqlortalidoniqsipamidi12.5/25/5012.5/25/5010/20/4012.512.51025-5025-5020-40100100806-126-128maryuJis Sardmdenebi:furosemiditorasemidibumetanidipiretanidi20/40/125/250/5002.5/5/10/20013/6/6020-1255-200.5-23-18damokidebuliagfs-ze1000200101206-86-84-63-5kaliumis Semnaxvelebi:spironolaqtoniamiloriditriamtereni25/50/1005502555050-1005-1050-100400203048-72247-9cxr. 3. Sardmdenebis dozireba16

imunoglobulin A nefropaTiaepidemiologiaimunoglobulin A nefropaTia anu mezangioproliferaciuliglomerulonefriti Tirkmlebis erT-erTi yvelaze ufro gavrcelebulidaavadebaa da biofsiis SemTxvevaTa 10-40%-Si aRiniSneba. igi gvxvdebayvela asakobriv jgufSi, Tumca ufro metad gavrcelebulia bavSvebsa daaxalgazrdebSi. IgA nefropaTia mamakacebSi 2-3-jer ufro xSirad gvxvdebaqalebTan SedarebiT. gansxvavebulia IgA nefropaTiis sixSire sxvadasxvaqveyanaSi, gansakuTrebiT xSirad is iaponiaSi gvxvdeba.etiologiaganasxvaveben pirvelad (idiopaTiur) da meorad IgA nefropaTias. pirveladIgA nefropaTias berJes daavadebas uwodeben. sainteresoa, rom henox-Sonlainis purpuras dros glomeruluri daavadeba praqtikulad argansxvavdeba IgA nefropaTiisagan. aqedan gamomdinare, berJes daavadebaSeiZleba henox-Sonlainis purpuris izolirebulad Tirkmlis dazianebiTmimdinare variantad iqnas ganxiluli.henox-Sonlainis purpurasTan kavSiris garda, aRwerilia meoradi IgAnefropaTiis ganviTarebis SemTxvevebi Semdegi daavadebebis dros:revmatoiduli arTriti, reiteris sindromi, alkoholuri cirozi, herpesulidermatiti, maankilozebeli spondiliti, fsoriazi, araspecifiuriwylulovani koliti, celiakia, sxvadasxva organos karcinoma da sokovaniinfeqciebi.paTogeneziIgA nefropaTiis etiologia da paTogenezi sabolood garkveuli araris, Tumca kargadaa cnobili, rom mniSvnelovani roli ekuTvnis IgAdepozitebis mezangiumSi Calagebas. aRsaniSnavia, rom IgA nefropaTiis drosplazmaSi momatebulia polimeruli IgA 1-sa da IgA matarebeli Blimfocitebis done, CD-4 ujredebis citoplazmaSi ki adgili aqvscitokinebis _ TGF-â da IL-4 mRNA, matebas. plazmaSi IgA donis matebaSesaZlebelia ganpirobebuli iyos IgA produqciis gazrdiT an RviZlSimisi katabolizmis daqveiTebiT. amasTan mniSnvelovania, rom mxolod IgAkoncentraciis mateba sakmarisi ar aris IgA nefropaTiis ganviTarebisaTvis;misi mateba aRiniSneba aiv-infeqciiTa da mielomiT daavadebul pacientebSi,magram IgA nefropaTia ar viTardeba.IgA nefropaTiiT daavadebuli pacientebis plazmaSi mocirkulire IgAmcire raodenobiT Seicavs galaqtozebs, rac amcirebs am kompleqsebiskatabolizms RviZlSi da zrdis maTi Calagebis unars mezangiumSi.sabolood adgili aqvs mezangiumis agalaqtozuri IgA imunuri kompleqsebiT17

dazianebas - eqspansiasa da gaZlierebul proliferacias. IgA imunurikompleqsebi xSir SemTxvevaSi Seicavs fibrineqtins, romelic aadvilebsimunuri kompleqsebis mezangiumis matriqsTan SekavSirebas, Tumca es araris specifiuri mxolod IgA nefropaTiisaTvis.sxvadasxva daavadebis fonze ganviTarebuli meoradi IgA nefropaTiispaTogenezi gansxvavebulia: RviZlis cirozis dros IgA nefropaTiaviTardeba RviZlSi imunuri kompleqsebis katabolizmis daqveiTebisSedegad; celiakiis, araspecifiuri wylulovani kolitisa da herpesulidermatitis dros paTogenezuri meqanizmia IgA gaZlierebuli produqcia;gaurkvevelia, Tu ra meqanizmiT viTardeba IgA nefropaTia kuW-nawlavistraqtisa da respiratoruli sistemis karcinomis dros.histologiaIgA nefropaTiis diagnozi Tirkmlis bioftatis morfologiuri kvlevissafuZvelze ismeba. sinaTlis mikroskopiiT IgA nefropaTiisaTvisdamaxasiaTebelia mezangiumis matriqsis proliferacia da monocituri dalimfocituri ujredebiT infiltracia, glomerulebSi aRiniSneba dazianebissxvadasxva morfologiuri suraTi: kafsuluri adhezia, segmenturi sklerozida eqstrakapilaruli proliferacia (eqstrakapiluri CanarTebi danaxevarmTvareebi).Tirkmlis morfologiuri suraTis variabeloba udevs safuZvlad jandacvismsoflio organizaciis mier mowodebul klasifikacias, romlis mixedviTacgamoyofen dazianebis 3 xarisxs: 1. msubuqi (G1) - morfologiuri cvlilebebiTirkmlis bioftatSi sustadaa gamoxatuli; 2. saSualo (G2) - aRiniSnebafokalur-segmenturi da difuzur-proliferaciuli cvlilebebi; 3. mZime (G3)- Tirkmelis bioftatSi gvxvdeba sklerozuli cvlilebebi. morfologiurisuraTis dazianebis xarisxs gansazRvravs naxevarmTvareebis raodenoba,tubuluri atrofiis arseboba/ararseboba, intesticiumis ujredovaniinfiltracia da fibrozi, glomerulosklerozi da mezangiumisproliferaciis xarisxi.Tirkmlis bioftatSi gamoxatuli sxvadasxva morfologiuri cvlilebebiserToblioba ganapirobebs IgA nefropaTiis Semdeg morfologiur suraTebs.sur.1 mezangiumis msubuqad gamoxatuli eqspansia da mezangiumis segmenturihiperujrperujredovnebaedovneba18

sur.2 mezangiumis saSualod gamoxatuli eqspansia da mezangiuri xe glomerulaSisur.3 mezangiumis kargad gamoxatuli eqspansia ganpirobebuli mezangiumishi perujredovnebiTaedovnebiTa da didi fuqsin-dadebiTi mezangiuri depozitebiTsur.4 mezangiumis mZime globaluri eqspansia, rac ganpirobebulia mezangiumisujredebis proliferaciiTa da mkvrivi depozitebis arsebobiTsur.5 segmenturi nekrozi, epiTeluri ujredebis proliferacia danaxevarmTvareebis arsebobasur.6 kafsulur adheziasTan SeuRlebuli segmenturi sklerozi19

sur. 7 kargad gamoxatuli mezangiuri proliferacia, mkvrivi depozitebisarseboba da kafsuluri adheziasur. 8 intesticiumis infiltracia mononukleuri ujredebiT, tubuluri atrofiada glomeruluri iSemiaimunohistoqimiiT aRiniSneba mezangiumSi IgA, gansakuTrebiT ki IgA 1subklasisCalageba. SemTxvevaTa daaxloebiT 70%-Si mezangiumSi gvxvdeba IgG-c, magramIgA–sTan SedarebiT naklebi intensivobiT. aseve aRiniSneba komlement C3-sada IgM mezangiumSi ganlageba.abgdsur. 9 imunofluorescenciuli depozitebi mezangio-proliferaciuliglomerulonefritis dros - IgA (a), IgG (b), IgM (g) da C3 (d) depozitebi.20

SemTxvevaTa 30-40%-Si gvxvdeba fibrin/fibrinogenis depozitebi. igi lagdebamezangiumsa da glomerulebis kapilarebis endoTelur ujredebSi.glomerulur kapilarebSi aRiniSneba fon vilenbrantis faqtorisa daTrombocitebis Calageba, romelic SemdgomSi iwvevs dazianebuli glomerulissklerozs. glomerulebSi fibrinogenis depozitebis gavrceleba mkacradkorelirebs glomerulur sklerozTan. aRniSnulis gaTvaliswinebiT SeiZlebavivaraudoT, rom koagulaciuri sistema mniSvnelovan rols TamaSobs IgAnefropaTiis paTogenezSi.eleqtronuli mikroskopiiT aRiniSneba eleqtronulad mkvrivi depozitebisCalageba mezangiumSi da paramezangiurad. eleqtronulad mkvrivi depozitebiszoma, forma, raodenoba da simkvrive gansxvavebulia. IgA nefropaTiiTdaavadebul pacientTa 40%-Si aRiniSneba mezangiolizi, romelic korelirebssklerozirebis procesTan. eleqtronulad mkvrivi depozitebi SesaZlebeliaganlagebuli iyos subendoTeluradac, xolo subepiTeluri daintramembranuli ganlageba praqtikulad ar gvxvdeba.klinikuri suraTiIgA nefropaTia klinikuri suraTis variabelobiT xasiaTdeba. SemTxvevaTa40-50%-Si daavadeba morecidive makrohematuriis epizodebiT vlindeba.makrohematuria Cveulebriv zeda sasunTqi gzebis infeqciis gadatanidan 1-3dRis Semdeg Cndeba da ramdenime dReSi gaivlis. ufro iSviaTiamakrohematuriis aRmoceneba mZime fizikuri samuSaos Sesrulebis an vaqcinaciisSemdeg. 40 wlis Semdeg amgvari epizodebi praqtikulad ar gvxvdeba.aRsaniSnavia, rom makrohematuriis epizodebis ararseboba da mis gareSemikrohematuriis perisistireba arasaxarbielo prognozul niSnad iTvleba.SemTxvevaTa 30-50%-Si berJes daavadeba asimptomuri hematuriiT(proteinuriiT an mis gareSe) vlindeba. proteinuria nefrozul rangs iSviaTad(SemTxvevaTa 5%-Si) aRwevs. nefrozuli sindromis ganviTarebas rig SemTxvevaSiIgA nefropaTiisa da minimaluri cvlilebebis glomerulonefritiserTdrouli aRmoceneba udevs safuZvlad.Tirkmlebis mwvave ukmarisoba berJes daavadebis dros iSviaTia. SesaZloamisi aRmoceneba makrohematuriis epizodis Semdeg, rac eriTrocitebis daSlisSedegad gamonTavisuflebuli rkinisa da hemoglobinis tubulotoqsiurobiTaixseba. kreatininis matebisas mxedvelobidan ar unda gamogvrCes swrafadprogresirebadi IgA nefropaTiis arsebobis SesaZlebloba, romelic gvxvdebaeqstrakapiluri proliferaciisa da naxevarmTvareebis arsebobis dros. amori garTulebis gasamijnad mniSvnelovania Tirkmlis biofsiis Catareba.pacientTa 10-20%-s diagnozi Tirkmlebis qronikuli ukmarisobis stadiaSiesmeba. amas Cveulebriv eqimTan dagvianebuli mimarTva ganapirobebs.IgA nefropaTiis SemTxvevaTa 50 %-Si plazmaSi imatebs IgA, gansakuTrebiTki IgA 1subklasi, SesaZlebelia moimatos antinuklearuli antisxeulebisa(ANA) da antistreptolizinis titrma, xolo komplement C3 da C4 ki normisfarglebSi rCeba.21

22mkurnalobadaavadebis klinikuri mimdinareobis simZimis mixedviT gamoyofen IgAnefropaTiiT daavadebul pacientTa Semdeg jgufebs:• pacientebi Tirkmlebis terminaluri ukmarisobis ganviTarebis dabaliriskiT:o maqsimaluri proteinuria < 1 g/24 saaTSi;o normaluri arteriuli wneva;o kreatininis klirensi normis farglebSi.• pacientebi Tirkmlebis terminaluri ukmarisobis ganviTarebis maRaliriskiT:o proteinuria > 1 g/24 saaTSi;o arteriuli hipertenzia;o kreatininis klirensi < 70 ml/wT.• atipiurad mimdinare IgA nefropaTia:o iSviaT SemTxvevaSi IgA nefropaTia mimdinareobs eqstrakapilaruliCanarTebisa da naxevarmTvareebis warmoqmniT da klinikurad swrafadprogresirebadi glomerulonefritiT vlindeba. aseT SemTxvevaSinaCvenebia agresiuli imunosupresiuli Terapia.o IgA nefropaTiisa da minimaluri cvlilebebis glomerulonefritiserTdrouli aRmocenebis SemTxvevaSi vlindeba nefrozuli sindromi,romelic kargad emorCileba steroidebiT mkurnalobas.rogorc wesi, dabali riskis pacientebi specifiur mkurnalobas ar saWiroeben,isini imyofebian nefrologis meTvalyureobis qveS da periodulad utardebaTgamokvlevebi: 24 saaTian SardSi cilis raodenobisa da kreatininis klirensisgansazRvra.arteriuli hipertenziis da/an mniSvnelovani proteinuriis (> 1 g/24 sT)arsebobis SemTxvevaSi pirvel rigSi agf-infibitorebi da/an angiotenzin 2receptoris blokerebi iniSneba. isini Semdegi TvisebebiT xasiaTdebian:• sistemuri arteriuli wnevis daqveiTeba;• antifibrozuli moqmedeba;• eferentuli sisxlZarRvis dilataciis gziT glomerulurifiltraciuli wnevis daqveiTeba da Sesabamisad proteinuriis xarisxiskleba.hiperqolesterinemiis SemTxvevaSi generalizirebuli aTerosklerozisada hiperlipidemiiT gamowveuli glomeruluri dazianebis Seferxebis mizniTaucilebelia Semdegi RonisZiebebis gatareba:• Tambaqos miRebisagan Tavis Sekaveba;• qolesteriniT Raribi dieta;• HMG-CoA reduqtazas inhibitorebis xangrZlivi gamoyeneba(rabdomiolizis riskis gamo - kreatikinazas kontroliT).

Tu agf inhibitoriT da/an ar blokeriT mkurnalobis miuxedavad proteinuria> 1g/24sT da/an aRiniSneba Tirkmlebis funqciis daqveiTeba, saWiroa damatebiTiRonisZiebebis gatareba. arsebobs monacemebi IgA nefropaTiis mkurnalobaSikortikosteroidebis, sxva imunosupresantebis, Tevzis qonis, antikoagulantebisada antiagreganetebis, tonzileqtomiis efeqturobis Sesaxeb.kortikosteroidebi mowodebulia simpotomuri Terapiis miuxedavadmniSvnelovani proteinuriis persistirebis SemTxvevaSi. gamoiyeneba e.w. Pozzissqema: 1 g meTilprednizoloni intravenurad I, III da V Tvis pirveli samidRis ganmavlobaSi, xolo Tvis sxva dReebSi 0,5 mg/kg prednizoloniperoralurad yovel meore dRes. mkurnalobis xangrZlivoba Seadgens 6Tves. Tirkmlebis daqveiTebuli funqciis (gfs < 70 ml/wT) SemTxvevaSisteroidebiT Terapia araefeqturia.Tevzis qoniT mkurnaloba (eikosapentanis mJava 1.8 g da dokosaheqsanismJava 1.2 g dReSi) IgA nefropaTiis samkurnalod mowodebulia proteinuriispersistirebisa da Tirkmlebis funqciis neli daqveiTebis SemTxvevaSi. Tevzisqonis efeqturobas yvela avtori ar aRiarebs, Tumca gverdiTi movlenebissimciridan gamomdinare misi gamoyeneba SeiZleba rekomendebulad CaiTvalos.antiokoagulantebiTa da antiagregantebiT mkurnalobas ZiriTadad aziaSiiyeneben. erT-erTma mcire kvlevam uCvena dipiridamoliT (75 mg samjer dReSi)da varfariniT (INR 1.3-1.5) mkurnalobis garkveuli efeqti.swrafad moprogresire glomerulonefritis ganviTarebis SemTxvevaSinaCvenebia agresiuli imunosupresiuli Terapia (ciklofosfamidi, azaTioprini,ciklosporini?). mkurnalobis Sesaxeb zusti rekomendaciebi ar arsebobs,imunosupresiis erT-erTi SesaZlo sqemaa:• prednizoloni 40 mg/dReSi, dozis etapobrivi klebiT;• ciklofosfamidi 1,5 mg/kg 3 Tvis ganmavlobaSi;• Semdeg azaTioprini 1,5 mg/kg 2-6 wlis ganmavlobaSi.bolo dros publikaciebSi gaCnda informacia IgA nefropaTiis samkurnalodmikofenolat-mofetilis gamoyenebis Sesaxeb. hong-kongSi Catarda mikofenolatmofetilis efeqturobis Semswavleli kvleva, romlis mixedviTac ori wlisganmavlobaSi proteinuriis xarisxi Semcirda 62%-iT, xolo sakontrolojgufSi ki gaizarda 120%-iT. 2004 wels aSS-Si Catarda meore kvleva, romlismixedviTac mikofenolat mofetili naklebad efeqturi aRmoCnda, racSesaZlebelia ganpirobebuli yofiliyo Semdeg faqtorebiT: sqesi, rasa daMMF dozis adekvaturoba. yovelive zemoTaRniSnulis gaTvaliswinebiT MMFefeqturoba IgA nefropaTiis samkurnalod sabolood damtkicebuli ar arisda aqtiuri Seswavlis fazaSia.sadavo sakiTxia rutinuli tonzileqtomiis Catarebis efeqturoba IgAnefropaTiiT daavadebul pacientebSi. cnobilia, rom tonzilebi monawileobasiReben IgA, gansakuTrebiT IgA 1subklasis produqciaSi, amasTan tonziliti dazeda sasunTqi sistemis anTebiTi daavadebebi xSirad win uZRvis IgA nefropaTiisklinikur gamovlenas (makrohematuria). miuxedavad amisa, mravali avtoriTvlis, rom rutinuli tonzileqtomia IgA nefropaTiiT daavadebul pacientebSinaCvenebi ar aris da mas mxolod morecidive tonzilitisa da mis Sedegadmakrohematuriis xSiri epizodebis SemTxvevaSi mimarTaven.23

IgA nefropaTiis mkurnalobis SesaZlo algoriTmiIgA nefropaTiaproteinuriiTagf inhibitorida/an ar blokeriproteinuria < 1 g/24 sTgfs - normaluriproteinuria > 1 g/24 sTdakvirvebadinamikaSisimptomuri mkurnalobisgagrZeleba+kreatininisklirensi > 70 ml/wTkreatininisklirensi < 70 ml/wTkreatininisprogresuli matebasteroid-TerapiaPozzi-s sqemiT (?)Tevzis qoni 2 wlismanZilze (?)gfs-is neli daqveiTeba(kreatininis mateba> 15% weliwadSi)kreatininis swrafimateba kvirebis anTveebis ganmavlobaSiimunosupresiuli Terapia:kortikosteroidi +3 Tve ciklofosfamidi,Semdeg - azaTioprini(2 weli da meti)TirkmlisganmeorebiTibiofsiamwvave tubulurinekrozieqstrakapilaruliproliferaciakonservatiuliTerapia; dializi (?)puls-Terapia steroidiT(?)ciklofosfamidi(?)plazmaferezi(?)24

IgA nefropaTiis recidivi Tirkmlis transplantatSiIgA nefropaTia transplantatSi recidivis sixSiris mixedviT meoreadgilzea fokalur-segmenturi glomerulosklerozis Semdeg. pacientTaumravlesobaSi sawyis stadiaze IgA morecidive depozitebis warmoqmnaklinikurad ar vlindeba. droTa ganmavlobaSi pacientTa mniSvnelovanprocents uviTardeba mezangioproliferaciuli glomerulonefriti datransplantatis moprogresire disfunqcia proteinuriiT. ZiriTadi daavadebisrecidivi ufro xSirad gvxvdeba cocxali donoridan Tirkmlistransplantaciis SemTxvevaSi gvamurTan SedarebiT. aRsaniSnavia, rom recidivisriski damokidebulia pacientis asakze - rac ufro axalgazrdaa pacienti,miT metia ZiriTadi daavadebis recidivis ganviTarebis riski gadanergilTirkmelSi.recidivis ganviTarebis maRali rikis miuxedavad IgA nefropaTiiTdaavadebul pacientebSi Tirkmlis transplantacia ukunaCvenebi ar aris daprognozic sakmaod kargia. savaraudod daavadebis recidivis mimdinareobazedadebiTi efeqti eqneba agf inhibitorebsa da/an ar blokerebs.25

Tirkmlebis autosomur-dominanturipolicisturi daavadebaTirkmlebis autosomur-dominanturi policisturi daavadeba (Tadpd)warmoadgens memkvidrul paTologias, romelic Cveulebriv mozrdil asakSivlindeba da xasiaTdeba TirkmlebSi mravlobiTi cistebis ganviTarebiT, rasacsabolood Tirkmlebis terminalur ukmarisobamde mivyavarT. dReisaTvisukve gansazRvrulia policisturi daavadebis ganviTarebaze pasuxismgebeligenebi – SemTxvevaTa 85%-Si is warmodgenilia PKD1 geniT, xolo danarCenSemTxvevaSi – PKD2 geniT. es genebi axdenen membranuli glikoproteinebis –Sesabamisad policistin-1-sa da policistin-2-is kodirebas. arsebobs hipoTezaPKD3 genis arsebobis Sesaxebac, Tumca am mosazrebas yveela avtori ariziarebs.epidemiologiaTirkmlebis autosomur-dominanturi policisturi daavadeba Tirkmlebismemkvidrul daavadebebs Soris yvelaze xSirad gvxvdeba. misi gavrcelebaSeadgens erTs yoveli 400-dan 1000-mde janmrTel adamianze. dasavleTisqveynebSi hemodializze myof pacientTa daaxloebiT 3-10%-s Tirkmlebisterminaluri ukmarisoba Tadpd-is Sedegad aqvs ganviTarebuli.26paTofiziologiaTirkmlebis autosomur-dominanturi policisturi daavadeba xasiaTdebasiTxiT savse cistebis ganviTarebiT Tirkmlis rogorc qerqovan, aseve tvinovanSreSi. cistebi warmoiqmneba nebismieri segmentidan, maT SorismniSvnelovanwilad Semkrebi milakebidan. TiToeuli cistis kedeli SedgebaepiTeluri ujredebis erTi Srisagan, romelic garSemortymulia bazalurimembraniT. cista formirdeba Tirkmlis milakis fokaluri hiperplaziissaxiT, romelic Semdgom zrdasTan erTad wydeba milaks. man SeiZleba sxvadasxvazomas miaRwios. progresulad sqeldeba bazaluri membranac. epiTeluriujredebis proliferaciis Sedegad warmoqmnil RruSi xdeba siTxis sekrecia,rac kidev ufro zrdis cistis zomas. mravlobiTi cistebis progresulizrda TandaTanobiT iwvevs mofunqcie parenqimis zomis Semcirebas, rasacumravles SemTxvevaSi Tirkmlebis terminaluri ukmarisobis ganviTarebamdemivyavarT.Tadpd-is paTogenezSi mniSvnelovania PKD1 da PKD2 genebis mier kodirebulimembranoproteinebi – Sesabamisad policistin-1 da policistin-2. aRniSnuligenebis defeqti am cilebis normaluri struqturis darRvevas iwvevs.fiziologiur pirobebSi policistin-1 Sedgeba grZeli eqstracelulurinawilis, 11 transmembranuli domeinis da citoplazmuri kudisagan. esukanaskneli ukavSirdeba ufro mcire zomis membranoproteinis, policistin-2-is, Sesabamis regions. es kompleqsi mniSvnelovan rols asrulebs nefronisnormaluri morfologiis formirebasa da SenarCunebaSi.

policistin-1policistin-2sur.1 policistin-1-s da policistin-2-s struqtura da urTierTkavSiriklinikuri mimdinareobaTirkmlebis autosomur-dominanturi policisturi daavadeba adreulstadiaze SeiZleba sruliad usimptomod mimdinareobdes. Sardis rutinulianaliziT daaxloebiT 25%-Si aRiniSneba hematuria da ufro naklebSi –proteinuria (Cveulebriv < 1g 24 saaTSi). daavadeba SeiZleba aRmoCeniliiqnas fizikuri gasinjviT an instrumentuli kvleviT (Cveulebrivultrasonografia) rogorc SemTxveviTi, aseve daavadebulTa ojaxis wevrebiskvlevis procesSi. Cveulebriv, Tirkmlebis policistozis diagnozis dasadgenadsakmarisia:• asaki < 30 w. – TirkmlebSi minimum ori cistis arseboba;• asaki 30-59 w. – minimum ori cistis arseboba TiToeul TirkmelSi;• asaki > 60w. – minimum oTxi cistis arseboba TiToeul TirkmelSi.klinikurad Tirkmlebis autosomur-dominanturi policisturi daavadebaSeiZleba gamovlindes renuli da eqstrarenuli garTulebebis saxiT. amdaavadebis tipiuri manifestaciebi da maTi sixSire mocemulia qvemoT moyvanilcxrilSi.27

gamovlenasixSirerenuliarteriuli hipertenzia60% - Tirkmlebis ukmarisobamde, 90% - Tqd Vst.tkivili (mwvave da qronikuli) 60%makrohematuria 50%saSarde gzebis infeqcia mamakacebi – 20%, qalebi – 70%kenWebi 20%Tirkmlebis ukmarisoba 70 wlis asakSi > 50%hepatobiliuriRviZlis asimptomuri cistebi 60 wlis asakSi – 80%RviZlis simptomuri policistozi Zalian iSviaTadRviZlis Tandayolili fibroziZalian iSviaTadkarolis daavadebaZalian iSviaTadkardiovaskulurimitraluri sarqvlis prolafsi 25%intrakraniuli anevrizma 8%intrakraniuli doliqoeqtazia 2%aRmavali aortis ganSrevebaZalian iSviaTadsxvapankresis cistebi 9%araqnoiduli cistebi 8%sazardulis Tiaqari 13%Wipis Tiaqari 7%cxr.1. Tadpd-is klinikuri manifestaciebi28renuli manifestirebatkivili welis an muclis areSiTadpd-iT daavadebul pacientTa daaxloebiT 60%-s sicocxlis ganmavlobaSierTxel mainc aReniSneba tkivili welis an muclis areSi, xolo SemTxvevaTa20-30%-Si is daavadebis pirveli gamovlenas warmoadgens. mwvave tkiviliSeiZleba ganpirobebuli iyos intracisturi hemoragiiT, saSarde gzebisobstruqciiT (koltiT an kenWiT) an infeqciiT (maRal temperaturasTan erTad).iSviaTad is SeiZleba gamowveuli iyos RviZlSi arsebuli cistebis infeqciiTan sisxldeniT.mizezi sixSire cxelebarenulisisxldena +++ normaluri T an msubuqi cxeleba(

qronikuli tkivili Tadpd-is dros xSirad abdominuri diskomfortiT dasisavsis SegrZnebiT vlindeba. tkivilis mizezad cistebis mier irgvlivmdebareqsovilebis kompresia da Tirkmlis kafsulis gadaWimva iTvleba. tkivilisintensivoba xSirad Tirkmlis zomasTan korelirebs.Tadpd-sTan dakavSirebuli tkivilebis mkurnaloba simptomuria.tkivilgamayuCebeli medikamentebi sifrTxiliT unda iqnas gamoyenebuli,yvelaze metad misaRebia acetaminofeni, ufro rTul SemTxvevebSi ki –tramadoli. unda moveridoT arasteroiduli anTebis sawinaaRmdegosaSualebebis gamoyenebas, aseve arasasurvelia narkotikulitkivilgamayuCeblebis xSiri miReba.konservatiuli Terapiisadmi rezistentuli tkivilebis SemTxvevaSiSesaZloa sxvadasxva qirurgiuli meTodis gamoyeneba, maT Soris: gansakuTrebiTmtkivneuli erTi an ramdenime cistis SigTavsis perkutanuli aspiracia(SesaZloa masklerozebeli nivTierebis instilaciiT siTxis reakumulaciisTavidan acilebis mizniT),Tirkmlis dekortikacia Ria wesiT an laparaskopiiT,Tirkmlis laparaskopiuli denervacia, nefreqtomia.welis an muclis areSi tkivilis SemTxvevaSi diferenciuli diagnoziunda gatardes RviZlis didi zomis cistebis arsebobasTan, aseve sxvadasxvamizeziT gamowveul nevralgiebTan.cisturi sisxldenahemoragia Tadpd-is tipiuri garTulebaa. sisxldenisadmi midrekilebaganpirobebulia cistis kedlis mravalricxovani sisxlZarRvovani wnulebiT,anevrizmebisa da neoformuli kapilarebis CaTvliT. intracistuli hemoragiaSeiZleba gamovlindes mwvave tkiviliT da/an makrohematuriiT. es ukanaskneliim SemTxvevaSi viTardeba, roca sisxlmdeni cista dakavSirebulia SemkrebsistemasTan.Tadpd-iT daavadebul pacientTa daaxloebiT 50%-s sicocxlis ganmavlobaSiaReniSneba makrohematuriis erTi epizodi mainc, xolo SemTxvevaTa 15-20%-Siis daavadebis pirvel gamovlenas warmoadgens. misi sixSire matulobsTirkmlis zomis matebasTan erTad. sisxldena SeiZleba ganviTardes mZimefizikur aqtivobas an mcire travmis Semdeg, Tumca xSiria spontanuriSemTxvevebic.intracistul hemoragias SeiZleba Tan axldes xanmokle msubuqi cxelebada leikocitozi infeqciis gareSec ki. aRwerilia perirenuli anintraperitoneuli hemoragiis ganviTarebis SemTxvevebi.cisturi hemoragiis SemTxvevaSi rekomendebulia fizikuri aqtivobis mkveTriSezRudva. makrohematuria Cveulebriv spontanurad wydeba da 7 dReze metxans iSviaTad grZeldeba. hemotransfuziis saWiroeba Cveulebriv ar aris.Zalze iSviaTad, persistuli da mZime sisxldenis SemTxvevaSi SeiZlebaaucilebeli gaxdes uninefreqtomia.29

makrohematuriis SemTxvevaSi diferenciuli diagnozi pirvel rigSi undagatardes saSarde gzebis infeqciasa da nefroliTiazTan. aseve ar undagamogvrCes hematuriis sxva mizezebis, magaliTad Sardis buStis kibos,arsebobis SesaZlebloba.infeqciaTadpd-iT daavadebuli qalebis daaxloebiT 70%-s da kacebis 20%-ssicocxlis ganmavlobaSi erTxel mainc uviTardeba qveda saSarde gzebisinfeqciisaTvis damaxasiaTebeli simptomebi, xolo Sesabamisad SemTxvevaTa40%-Si da 3%-Si is daavadebis pirvel gamovlenas warmoadgens. zeda saSardegzebis infeqcia SeiZleba ganviTardes daavadebis nebismier stadiaze.mikroorganizmebi TirkmelSi Cveulebriv aRmavali gziT xvdebian, ris gamocinfeqciis yvelaze xSir gamomwvevs enterobaqteriebi warmoadgenen. ufroiSviaTad gvxvdeba gramdadebiTi an anaerobuli daavadebiT gamowveuliinfeqciebi.Tadpd-iT daavadebuli pacientis gaurkveveli mizeziT gamowveuli cxelebisSemTxvevaSi yovelTvis unda gvaxsovdes cistis dainficirebis albaToba.mniSvnelovania, rom parenqimuli infeqciisagan gansxvavebiT Sardi xSiradsteriluria, ramdenadac inficirebuli cista SeiZleba dakavSirebuli ariyos Semkreb sistemasTan. diagnozis dasazusteblad xSirad informatiuliainstrumentuli kvlevebi, rogoricaa ultrasonografia da kompiuterulitomografia, riTac SeiZleba gamovlindes inficirebuli cistebisheterogenuli SigTavsi da araTanabrad gasqelebuli kedlebi.antibiotikebis efeqturoba Tadpd-is SemTxvevaSi yovelTvis erTnairi araris. zogjer infeqcia swrafad iTrguneba, xolo zog SemTxvevaSi cxelebaSesaZloa 5 dReze met xans persistirebdes adekvaturi antibiotikoTerapiismiuxedavad. cudi klinikuri pasuxi cistis infeqciaze an SardsawveTisobstruqciaze miuTiTebs. mkurnalobisadmi refraqterobis mTavari mizeziacistebis SigTavsSi antibiotikebis cudi SeRwevadoba. adekvaturiintracisturi koncetnraciis swrafi miRweva SesaZlebelia lipofiluriantibiotikebis (trimetoprimi, ftorqinolonebi da metronidazoli) gamoyenebiT.antibiotikis empiriuli SerCeva damokidebulia daavadebis klinikurgamovlenaze: septicemiiT garTulebuli mZime infeqciis SemTxvevaSirekomendebulia mkurnalobis dawyeba intravenuri ftorqinoloniT, SemdgomdReebSi peroralur formaze gadasvliT. ufro msubuq SemTxvevebSi SesaZloamkurnalobis Tavidanve peroraluri medikamentiT dawyeba. cistis infeqciisSemTxvevaSi antibiotikoTerapia sakmaod xangrZlivi (4-6 kvira) unda iyos.refraqteruli an morecidive infeqciis SemTxvevaSi SeiZleba saWiro gaxdesqirurgiuli Careva (cistis drenireba, nefreqtomia).Tadpd-iT daavadebuli pacientis cxelebis SemTxvevaSi diferenciulidiagnozi unda gatardes RviZlis cistebis infeqciasTan (iSviaTia),divertikulitTan (ZiriTadad Tirkmlis transplantaciis Semdgomimdgomareobisas) da cxelebis sxva SesaZlo mizezebTan.30

kenWebinefroliTiazi Tadpd-iT daavadebul pacientTa daaxloebiT 20%-SiviTardeba. kenWebis ganviTarebas xels uwyobs anatomiuri (Sardis stazicistiT kompresiis Sedegad) da metaboluri (SardiT citratisa da magniumisdaqveiTebuli eqskrecia) darRvevebis kombinacia. yvelaze xSirad gvxvdebakalciumis oqsalatisa da SardmJavas kenWebi.diferenciuli diagnozi unda gatardes kalciumis kenWsa da cistiskalcifikacias Soris. es ukanaskneli xSirad gvxvdeba Tadpd-is SorswasulSemTxvevebSi, savaraudod gadatanili intracisturi hemoragiebis Sedegad.sur.2 kalcificirebuli cistebi rentgenogramazeavTvisebiani simsivneiTvleba, rom Tirkmlis karcinomis sixSire Tadpd-is SemTxvevaSi zogadpopulaciasTan SedarebiT gazrdili ar aris, Tumca is garkveuliTaviseburebebiT xasiaTdeba: ufro xSirad gvxvdeba bilateraluri (12% da1-5%, Sesabamisad), multicentruli (28% da 6%) da sarkomatoiduri (33% da 1-5%) simsivneebi.Tirkmlis karcinomis diagnozi Tadpd-is SemTxvevaSi garTulebulia,ramdenadac iseTi simptomebi, rogoricaa hematuria, tkivili da cxelebaSeiZleba Tadpd-is banalur garTulebad CaiTvalos. rTulia instrumentulidiagnostikac, kompiuteruli da magnitur-rezonansuli tomografiis gamoyenebisSemTxvevaSic ki.zog SemTxvevaSi Tirkmlebis policistozi SeiZleba von hipel-lindausdaavadebis gamovlena iyos, romlis drosac maRalia Tirkmlis karcinomissixSire.31

arteriuli hipertenziahipertenzia Tadpd-is adreuli da xSiri gamovlenaa. is pacientTa 60%-sTirkmlis funqciis daqveiTebamde uviTardeba. savaraudo paTofiziologiurimeqanizmia cistebis mier sixlZarRvebis kompresiiT gamowveuli intrarenuliiSemia da renin-angiotenzinis sistemis gaaqtiveba. garkveul rols TamaSobsendoTeluri disfunqciac, ganpirobebuli rogorc Tirkmlis endoTelinissistemis gaaqtivebiT, aseve azotis oqsidiT gamowveuli vazorelaqsaciisprocesis darRveviT. arcTu iSviaTia hipertenziis gamomwvevi sxva daavadebebis,maT Soris Tirkmlis arteriis stenozis, pirveladi aldosteronizmisa dafeoqromocitomis, Tanaarseboba.aucilebelia arteriuli hipertenziis mkacri kontroli, ramdenadackadiovaskuluri daavadebebi am pacientebis sikvdilis wamyvan mizezswarmoadgenen. hipertenziis ganviTarebis genezSi renin-angiotenzinis sistemiswamyvani rolis gaTvaliswinebiT arCevis preparatebs warmoadgenen βblokerebi da agf inhibitorebi an angiotenzinis receptorebis blokerebi.sifrTxilea saWiro agf inhibitorebis daniSvnisas Tirkmlebis daqveiTebulifunqciis SemTxvevaSi.32Tirkmlebis ukmarisobaTirkmlebis autosomur-dominanturi policisturi daavadebas SemTxvevaTaumravlesobaSi (Tumca ara yovelTvis) Tirkmlebis terminalur ukmarisobamdemivyavarT. yvelaze xSirad es 40-60 wlis asakSi xdeba (68%), iSviaTad ufroadre (11%) an ufro gvian (21%).Cveulebriv, cistebis progresuli warmoqmnis da zrdis miuxedavadaTwleulebis manZilze SenarCunebulia glomeruli filtraciis normalurisiCqare. mas Semdeg ki, rac gfs 50 ml/wT-ze naklebi xdeba, misi daqveiTebisSemdgomi tempi Cveulebriv weliwadSi 5 ml/wT-s Seadgens. Tirkmlebisukmarisobis ganviTarebis arasasurvel prognozul faqtorebs miekuTvneba:• PKD-1 geni;• axalgazrda asakSi gamovlena;• mamrobiTi sqesi;• arteriuli hipertenzia da marcxena parkuWis hipertrofia;• makrohematuria;• saSarde gzebis infeqciebi mamakacebSi.Tirkmlebis terminaluri ukmarisobis ganviTarebis riski da asaki pirvelrigSi genetikur faqtorzea damokidebuli. am mxriv, PKD1 genis mutaciebiufro avTvisebianad mimdinarebos PKD2 genTan SedarebiT. amasTan, TiToeuligenisaTvis aRwerilia mravali sxvadasxva mutacia,romlis tipic mniSvnelovnadgansazRvravs daavadebis progress. prognozi damokidebulia sxva genebispolimorifizmzec.genetikuri faqtoris garda, Tirkmlebis ukmarisobis progresirebis tempidamokidebulia arteriul wnevaze, dietaze, Tambaqos wevaze da saSarde gzebismorecidive infeqciis arsebobaze.

Tirkmlebis terminaluri ukmarisobis ganviTarebis Semdeg CveulebrivSeiZleba rogorc Tirkmlis transplantacia, aseve hemo- an periotoneulidializiT mkurnaloba. Tirkmlis CanacvlebiTi Terapiis saxeobis SerCevasxvadasxva faqtorzea damokidebuli. sxva mizezebiT gamowveuli Tirkmlisterminaluri ukmarisobis msgavsad, arCevis Terapias SemTxvevaTaumravlesobaSi Tirkmlis transplantacia warmoadgens (garda im pacientebisa,romelTa sicocxlis mosalodneli xangrZlivoba naklebia 5 welze).pretransplantaciur kvlevebi unda moicavdes muclis Rrus kompiuterultomografias, eqokardiografias, stres-tests da aTerosklerozis niSnebisarsebobis SemTxvevaSi angiografias. pretransplantaciuri nefreqtomianaCvenebia saSarde gzebis morecidive infeqciebis, sisxldenebis, garTulebulinefroliTiazis an sxva garTulebebis SemTxvevaSi.peritoneuli dializis ukuCvenebebs warmoadgens giganturi zomis Tirkmlebi,muclis Tiaqari da nawlavebis divertikulozi.sicocxlis mosalodneli xangrZlivoba < 5 w.anqirurgiuli ukuCvenebaanukuCveneba imunosupresantebis mimarTki```pretransplantaciuri kvleva:eqokardiografia,miokardiumis stres-scintigrafia,saWiroebis SemTxvevaSi angiografianefreqtomia garTulebebis SemTxvevaSi:cistebis morecidive infeqciamorecidive sisxldenagarTulebuli liTiazitransplantacia ukunaCvenebiakiaraanaragiganturi Tirkmlebiandivertikulozianmuclis Tiaqarikitp pd hdsur.3 Tirkmlis CanacvelebiTi Terapiis modalobis SerCeva Tadpd-is SemTxvevaSiganviTarebuli Tirkmlebis terminaluri ukmarisobis dros33

Tirkmlebis ukmarisobis ganviTarebis Seferxebis Terapiuli perspeqtivebisamwuxarod, dResdReobiT ar arsebobs Tadpd-is dros Tirkmlebisukmarisobis progresirebis Semaferxebeli specifiuri Terapia. mosalodnelia,rom am daavadebis genetikuri da paTofiziologiuri safuZvlebis Sesaxebdagrovili codna uaxloes momavalSi SesaZlebels gaxdis am mxrivmniSvnelovani progresis miRwevas. aqtiurad mimdinareobs sxvadasxva tipismedikamentebis Seswavla Tadpd-is ujredul da cxovelur modelze.arsebobs monacemebi transplantaciaSi gamoyenebuli imunosupresantis –rapamicinis (sirolimusi) – SesaZlo dadebiT efeqtis Sesaxeb Tadpd-ismkurnalobaSi. rogorc cnobilia, es medikamenti warmoadgens proliferaciulisignalis inhibitors, kerZod moqmedebs e.w. rapamicinis samizneze (mTOR) damis inhibirebas iwvevs. amave kinazaze moqmedebs policistin-1-is citoplazmurinawili, xolo PKD1-is mutaciis Sedegad warmoqmnili araaqtiuri policistin-1-is arsebobis SemTxvevaSi epiTeluri ujredebis gaZlierebuli proliferaciamimdinareobs. Tagvis modelze Catarebul kvlevaSi rapamicinma cisturiepiTeluri ujredebis apoftozi, cistebis zomebis daqveiTeba, Tirkmlebiswonis mniSvnelovani Semcireba da funqciis gaumjobeseba gamoiwvia. arsebobsaseve saintereso dakvirveba, rom Tadpd-iTi daavadebul Tirkmelgadanergilim pacientebSi, romelTa imunosupresiuli mkurnaloba rapamicins Seicavda,natiuri policisturi Tirkmlebis zomis mniSvnelovani Semcireba aRiniSna.rogorc cnobilia, Tirkmlebis cistebis warmoqnis paTogenezSi gadamwyvetrols asrulebs epiTeluri ujredebis proliferacia da warmoqmnil RruebSisiTxis dagroveba. damtkicebulia, rom es procesebi cikluri amf-is kontrolisqveS mimdinareobs. cxovelebze Catarebulma cdebma aCvena, rom vazopresinisV 2receptorebis blokerebi cikluri amf-is produqciis inhibirebas axdenen,rac anelebs cistebis warmoqmnis process. am jgufis medikamentebi (e.w.„vaptanebi”) ukve gamoiyeneba antidiurezuli hormonis araadekvaturi sekreciissindromiT da sxva mizeziT (RviZlis cirozi, gulis ukmarisoba) gamowveuliwylis Sekavebis samkurnalod klinikur kvlevebSi. aRniSnuli kvlevebi ampreparatebis usafrTxoebaze metyvelebs, rac Tadpd-is mkurnalobaSi maTiefeqtis klinikuri SeswavlisaTvis karg safuZvels qmnis.cikluri amf-is produqciis inhbirebas efuZneba Tadpd-is mkurnalobaSisxva perspeqtiuli preparatis – somatostatinis gamoyenebac. arsebobspacientTa mcirericxvovan jgufze Catarebuli kvleva, romelSic 40 mggaxangrZlivebuli somatostatinis 28 dReSi erTxel intramuskulurmaineqciebma cistebisa da mTliani Tirkmlebis zomaSi zrdis Seneleba gamoiwvia.sxvadasxva eqsperimentuli kvlevebi adasturebs EGF (epidermuli zrdisfaqtori) – TGF-α (gardamqmneli zrdis faqtori) – EGFR (EGF receptori)RerZis mniSvnelobas tubuluri epiTeluri ujredebis proliferaciis dacistebis formirebis procesSi Tadpd-is dros. kerZod, gamoxatulia EGFR damasTan asocirebuli Tirozin kinazas receptoris – ErbB - gaZlierebulieqspresia, dislokalizacia da EGF-Tan SekavSirebis da ujredis proliferaciisgamomwvev signalTa kaskadis gaSvebis unari. eqsperimentul kvlevebSi EGFRTirozin kinazas receptorebis genetikuri da/an farmakologiuri inhibirebaaferxebs cistebis warmoqmnis process. saWiroa Semdgomi kvlevebimedikamentebis am klasis Terapiuli potencialis Sesafaseblad.34

eqstrarenuli manifestirebacistebi sxva organoebSicistebi RviZlSi Tadpd-is yvelaze xSir eqstrarenul gamovlenaswarmoadgens. maTi umravlesoba sanaRvle milakebis paTologiuri zrdisSedegad warmoiqmneba (e.w. biliuri mikrohamartomebi), meore tipis cistebiki peribiliuri jirkvlebis dilataciis gziT viTardeba. Cveulebriv, RviZliscistebi Tirkmlis cistebTan SedarebiT gvian Cndeba. 20 wlis asakmde isiniZalze iSviaTad gvxvdeba, 60 wlisTvis ki pacientTa 80%-Si gvxvdeba. RviZliscistebi ufro xSiria qalebSi mamakacebTan SedarebiT.SemTxvevaTa umravlesobaSi RviZlis cistebi asimptomuria da pacientsproblemas ar uqmnis. parenqima Senaxulia, ris gamoc RviZlis ukmarisoba arviTardeba. Zalze gadidebulma policisturma RviZlma SeiZleba mudmivi anSeteviTi tkivlebi an muclis daWimuloba gamoiwvios. sxvadasxva organosmeqanikuri kompresiis gamo SeiZleba gamovlindes iseTi simptomebi, rogoricaagulZmarva,kuWis sisavsis SegrZneba,sunTqvis gaZneleba,sazardulisa da WipisTiaqari,saSvilosnos prolafsi,asciti,portuli hipertenzia da sxv. pacientTadaaxloebiT naxevars aReniSneba sisxlSi gama-glutamiltransferaziskoncetnraciis 2-5-jer momateba; bilirubinisa da aminotransferazebis matebaiSviaTia.iSviaT SemTxvevebSi RviZlis cistebSi SeiZleba ganviTardes iseTigarTulebebi, rogoricaa infeqcia da hemoragia. cistis infeqcia vlindebacxelebiTa da lokaluri tkiviliT,Ceulebriv aminotransferazebis matebasTanerTad. rekomendebulia xangrZlivi (daaxloebiT 6 kvira) Terapiakombinirebuli antibiotikebiT (mag. ciprofloqsacini da amikacini).autosomur-recesiuli policisturi daavadebisagan gansxvavebiT, Tadpd-isdros RviZlis Tandayolili fibrozi Zalze iSviaTia. is SeiZlebaasocirebuli iyos segmenturi sanaRvle gzebis fokalur an difuzur cisturdilataciasTan (karolis sindromi).sxva organoebis cistebi Tadpd-is dros iSviaTad gvxvdeba. aRweriliaintrakraniuli, pankreasisa da saTesle buStukebis cistebi. isini Cveulebrivusimptomoa.intracerebruli anevrizmaTadpd-iT daavadebul pacientTa daaxloebiT 8%-s intracerebruli anevrizmaaReniSneba. iseve, rogorc zogad populaciaSi, anevrizmis mTavar,sicocxlisaTvis saSiS garTulebas misi gaskdoma warmoadgens. is vlindebauecari uZlieresi Tavis tkiviliT, rasac SeiZleba Tan axldes gulisreva,Rebineba,fotofobia,fokaluri nevrologiuri deficiti,krunCxvebi, leTargia,gonebis dakargva. diagnozi dasazustebelad kompiuteruli tomografiagamoiyeneba. prognozisaTvis gadamwyveti mniSvneloba aqvs droulneiroqirurgiul Carevas.35

anevrizmis gaskdomis mZime prognozis gamo sasurvelia maRali riskispacientebs CautardeT cerebruli anevrizmis skrininguli kvleva. am jgufspirvel rigSi miekuTvnebian Tadpd-iT daavadebuli is individebi, romelTacaReniSnebaT cerebruli anevrizmis gaskdomis ojaxuri SemTxvevebi.Tadpd-iT daavadebul pacientTa 2%-Si aRmoCenilia intrakraniuliarteriebis doliqoeqtazia (arteriuli segmentis dagrZeleba da dilatacia).Zalze iSviaTia muclis aortis anevrizmis SemTxvevebi.gulis sarqvlovani paTologiebiTadpd-is dros aRwerilia gulis sxvadasxva sarqvlovani paTologiebi.damtkicebulia mitraluri prolafsis gazrdili sixSire (25%). is Cveulebrivusimptomoa da raime saxis Carevas ar saWiroebs. endokarditis profilaqtikarekomendebulia mxolod im SemTxvevaSi, Tu mitralur prolafss Tan axlavsregurgitacia.nawlavis divertikuloziTadpd-is da nawlavis divertikulozs Soris zusti kavSiris arsebobadadgenili ar aris. Tirkmlis terminaluri ukmarisobis ganviTarebamde ampaTologiis sixSire zogad populaciasTan SedarebiT momatebuli ar aris.amave dros, dadgenilia divertikulitisa da nawlavis perforaciis gazrdilisixSire Tirkmlis transplantaciis Semdgom periodSi.36

nefrologiuri siaxleebis mokle anonsiaxali medikamentebi nefrologiaSimokled mimovixilavT im axal medikamentebs, romelTa danergva klinikurpraqtikaSi mosalodnelia uaxloesi ori wlis ganmavlobaSi.2007 wlis martSi FDA-s mier daSvebulia aliskirenis (Novartis) gamoyenebaarteriuli hipertenziis samkurnalod. es preparati agf inhibitorebisa daangiotenzinis blokerebis msgavsad, renin-angiotenzinis sistemaze moqmedebs,Tumca maTgan gansxvavebiT is axdens reninis inhibirebas, riTac ablokirebsangiotenzinogenisagan angiotenzin-1-is warmoqmnas.praqtikuli siaxlea eriTropoezis mastimulebeli agentebis jgufSi. welsfarmakologiur bazarze xelmisawvdomi gaxdeba e.w. eriTropoetinisreceptorebis mudmivi aqtivatori – CERA (Mircera®, Roche). am preparatisnaxevardaSlis periodi daaxloebiT 135 saaTs Seadgens, rac iZleva misigaiSviaTebuli intravenuri an subkutanuri dozirebis SesaZleblobas – 1-2-jer TveSi.2007 wlis meore naxevarSi mosalodnelia rkinis oqsidis agentis –ferumoqsitolis daSveba rkiniT CanacvlebiTi TerapiisaTvis TqdpacientebisaTvis. misi e.w. nanonawilakovani struqtura iZleva rkinis arsebulpreparatebTan SedarebiT intravenurad ufro maRali erTjeradi dozisSeyvanis saSualebas.2007-2008 wlebSi aseve mosalodnelia ukve arsebuli medikamentebis axaliformebis registrireba, magaliTad, amlodipinisa da valsarTaniskombinirebuli preparatis; aseve takrolimusis gaxangrZlivebuli formulis(dReSi erTjeradi dozirebiT) gamosvla.mniSvnelovani siaxlea klinikur praqtikaSi vazopresinis antagonistebis,e.w. vaptanebis danergva. vazopresinis receptorebis blokirebis gziT isinizrdian Tavisufali wylis eqskrecias (aqvarezi) da hiponatremiis koregirebaSeuZliaT. es medikamentebi optimalur Terapias warmoadgens antidiurezulihormonis araadekvaturi sekreciis sindromis (SIADH) dros. mimdinareobsmaTi efeqturobis Semswavleli kvlevebi RviZlis ciroziTa da gulisukmarisobiT gamowveuli wylis Sekavebis samkurnalod. arsebobs asevemosazreba am preparatebis Terapiuli perspeqtivebis Sesaxeb Tirkmlebisautosomur-dominanturi policisturi daavadebis mkurnalobaSi. ukveregistrirebulia V 1/V 2kombinirebuli antagonisti konivaptani parenteruligamoyenebisaTvis. uaxloes erT-or weliwadSi mosalodnelia peroraluriV 2seleqtiuri antagonistis tolvaptanis registrireba.transplantaciaSi perspeqtiuli preparatia belatasepti, romelic Tlimfocitebis gaaqtivebis e.w. II signalis blokirebas iwvevs. es strategiaarsebuli imunosupresiuli sqemebis gverdiTi movlenebis Semcirebis imedsiZleva.37

osiglotazoni hepatitis mqone hemodializze myof pacientebSiTiazolindinedionebis gamoyeneba glikemiis samkurnalod SeiZlebaqronikul hemodializze myof pacientebSi, maT Soris B da C hepatitis virusiTinficirebulebSi – aseT daskvnamde mividnen Chiang C-K et al 2007 wels CatarebulkvlevaSi. es preparatebi insulin-rezistentobis sawinaaRmdego moqmedebiTxasiaTdebian, romelic xSiria hemodializis pacientebSi.rosiglotazoni eZleoda hemodializis 78 pacients, romelTaganac 25 B anC hepatitis virusiT iyo inficirebuli. mkurnalobis saSualod 15.4 TvisganmavlobaSi rosiglotazonma (dReSi 8 mg-mde) gamoiwvia glikemiisgaumjobesebuli kontroli. mkurnalobas daemorCila (glikozirebulihemoglobini < 7%) pacientTa 86.1%. medikamentma aseve mniSvnelovnad SeamcirasisxlSi trigliceridebis done. arasasurveli movlena iyo wonis mateba.RviZlis aminotransferazebis maCveneblebi virusuli hepatitis mqonepacientebSi arainficirebulebTan SedarebiT ar Secvlila, ris gamoc kvlevisavtorebi askvnian, rom rosiglotazonis gamoyeneba usafrTxo hepatitis dros.aRsaniSnavia, rom Tiazolidinedionebi aqamde ar iyo rekomendebuli gulisan RviZlis ukmarisobis mqone pacientebSi siTxis Sekavebisaken midrekilebisada hepatotoqsiurobis gamo. aRniSnuli kvleva adasturebs, rom rosiglotazoniusafrTxod SeiZleba dainiSnos qronikul dializze myof, maT Sorisqronikuli virusuli hepatitis mqone, pacientebSi. Tumca Sesaswavli rCebamaTi xangrZlivi zegavlena kardiovaskulur rezervze.38.mikofenolat mofetili glomerulonefritebis mkurnalobaSiSegarra et al mier Catarebuli iqna kvleva, romelic miznad isaxavdarezistentuli pirveladi glomerulonefritebis mkurnalobaSi mikofenolatisefeqturobis Seswavlas. kvlevaSi monawileoba miiRo sxvadasxva tipispirveladi glomerulonefritis mqone 98 pacientma, romlebic rezistentuliiyvnen klasikuri mkurnalobisadmi (mag. steroidebi, ciklofosfamidi,ciklosporini). mikofenolat mofetili eZleoda 12 Tvis manZilze, dozaSerCeuli iyo pacientis Tirkmlebis funqciis mixedviT (2 g dReSi Tukreatininis klirensi > 60 ml/wT da 1.5 dReSi Tu kreatinis klirensi < 60ml/wT). proteinuriis sruli an nawilobrivi remisiis SemTxvevaSi xdebodadozis TandaTanobiTi Semcireba mkurnalobis Sewyvetamde an recidivisganviTarebamde. mkurnalobamde 6 TviT adre pacientebi aRar iRebdnen sxvaimunosupresantebs da arasteroidul anTebis sawinaaRmdego saSualebebs,imyofebodnen dabalmarilian dietaze da agf inhibitorsa an angiotenzinisreceptorebis blokerze.7 pacientTan (7%) miRweuli iqna proteinuriis sruli, xolo 46 pacientTan(47%) – nawilobrivi remisia. remisiis miRwevisaTvis saWiro xangrZlivobaiyo 141.5 + 61.1 dRe. cilis saSualo gamoyofa Semcirda 5.6+3.23 g–dan 2.55+1.06–mde dReSi dakvirvebis 12 Tvis Semdeg. glomeruluri filtraciis siCqarisan kreatininis maCveneblis cvlileba ar dafiqsirebula. proteinuriisgaumjobeseba yvelaze metad gamoxatuli iyo Tirkmlis kargi funqciis (gfs> 80 ml/wT/1.73m 2 ) da aranefrozuli rangis proteinuriis mqone pacientebSi.gverdiTi efeqtebidan yvelaze xSiri iyo gastrointestinuri simptomebi

izoosmolaruli sakontrasto nivTierebebi kontrast-nefropaTiisriskis Sesamcirebladsakontrasto nivTierebiT gamowveuli nefropaTia dResdReobiT Tirkmlismwvave dazianebis erT-erTi uxSiresi mizezia. kreatininis koncentraciisSedarebiT mcire da droebiTi matebac ki asocirebulia avadobisa dasikvdilobis gazrdasTan. siTxis intravenur transfuziasTan erTad, kontrastnefropaTiisprevenciis efeqturi midgomaa arainouri dabalosmolarulisakontrasto nivTierebis gamoyeneba.arsebobs mosazreba, rom Tirkmlis mwvave dazianebis riskis ufro metadSemcireba SesaZlebelia kidev ufro dabali osmolarobis mqone nivTierebis- izoosmolaruli preparatis gamoyenebiT. 2003 wels Catarebulma, ormagadbrma randomizebulma NEPHRIC kvlevam uCvena, rom izosomolurulisakontrasto nivTierebis – iodiqsanolis gamoyenebiT Saqriani diabetis daTirkmlis daqveiTebuli funqciis (gfs < 60 ml/wT) mqone 129 pacientSikontrast-nefropaTiis sixSire Semcirda 26%-idan (dabalosmolaruli agentis– ioheqsolis jgufSi) 3%-mde.gasaTvaliswinebelia iodiqsanolis maRali fasi, ris gamoc Znelia misirutinuli gamoyenebis rekomendeba yvela pacientSi. imis gasarkvevad, amcirebsTu ara izoosmolaruli sakontrasto nivTiereba nefropaTiis ganviTarebisrisks dabali riskis jgufis pacientebSi, saWiroa farTomasStabiani kvlevebi.spironolaqtonis CarTva diabeturi nefropaTiis mkurnalobaSicnobilia, rom renin-angiotenzinis sistemaze moqmedi medikamentebidiabeturi nefropaTiis SemTxvevaSi renoproteqtoruli moqmedebiTxasiaTdebian. Tirkmlis daavadebis progresirebaSi mniSvnelovani rolimiuZRvis aldosterons, ris safuZvelzec Meiracker et al. mier Catarebuli iqnakvleva, sadac diabeturi nefropaTiis standartul Terapias aldosteronisinhibitori - spironolaqtoni daemata.meore ti pis Saqriani diabetis da mikroalbuminuriis mqone pacientebi,romlebic erT weliwadze met xans imyofebodnen agf inhibitoriT anangiotenzinis receptorebis blokeriT Terapiaze, randomizebuli iyvnen orjgufad – erT jgufs (29 pacienti) daeniSna spironolaqtoni 25-50 mg dReSierTi wlis manZilze, xolo meore jgufs (30 pacienti) – placebo. kvlevasgamoeTiSa xuTi pacienti spironolaqtonis da erTi pacienti placebosjgufidan mkurnalobis dawyebis Semdeg ganviTarebuli hiperkalemiis gamo.erTi wlis Semdeg, protein/keratininis da albumin/kreatininis fardobamniSvnelovnad Semcirda spironolaqtonis jgufSi. aseve aRiniSna sistolurida diastoluri arteriuli wnevis daqveiTeba spironolaqtoniTmkurnalobisas. amave dros spironolaqtonis jgufSi, placebosagan gansxvavebiT,aRiniSna sisxlSi kaliumis donis mateba.kvlevis avtorebi askvnian, rom spironolaqtonis damateba agf inhibitorzean angiotenzinis receptoris blokerze amcirebs proteinurias mkurnalobisdawyebidan 1 wlis ganmavlobaSi. amasTan,hiperkalemiis riskis Sesamcirebladsawyisi doza ar unda aRematebodes 25 mg-s.39