giorgi lobjanize gulis da tirkmelebis urtiertqmedebis...

1

ivane javaxiSvilis saxelobis Tbilisis saxelmwifo

universiteti

medicinis fakulteti

giorgi lobJaniZe

gulis da Tirkmelebis urTierTqmedebis garkveuli

maxasiaTeblebi kardio-renuli sindromis pirveli da meore

tipis dros

disertacia

medicinis doqtoris akademiuri xarisxis

mosapoveblad

samecniero xelmZRvanelebi: zurab faRava

nino SaraSiZe

Tbilisi

2016

ავტორის სტილი დაცულია

2

sarCevi

gamoyenebuli Semoklebebi.................................................................................................................................................4

winasityvaoba..................................................................................................................................................................................8

Sesavali..............................................................................................................................................................................................9

sadisertacio naSromis struqtura, moculoba da programuli uzrunvelyofa.......14

publikaciebi................................................................................................................................................................................14

1. literaturis mimoxilva.............................................................................................................................................16

1.1. kardio-renuli sindromi....................................................................................................................................16

1.1.1. I tipis kardio-renuli sindromi........................................................................................................20

1.1.2. II tipis kardio-renuli sindromi......................................................................................................21

1.1.3. III tipis kardio-renuli sindromi.....................................................................................................23

1.1.4. IV tipis kardio-renuli sindromi....................................................................................................24

1.1.5. V tipis kardio-renuli sindromi......................................................................................................25

1.1.6. mkurnaloba..............................................................................................................................................................26

1.2. gulis ukmarisoba.....................................................................................................................................................29

1.3. Tirkmelebis dazianebis meqanizmi.............................................................................................................36

1.4. marjvena parkuWis roli.....................................................................................................................................40

1.5. Tirkmelebis dazianeba da gorglovani filtraciis siCqare.........................................42

1.6. daskvna.................................................................................................................................................................................46

2. eTikuri sakiTxebis gadawyveta.............................................................................................................................47

2.1. mimoxilva..........................................................................................................................................................................47

2.2. pacientebis piradi informaciis konfidencialuroba...........................................................48

2.3. daskvna.................................................................................................................................................................................55

3. kvlevis miznebi, meTodologia da protokoli....................................................................................57

3.1. kvlevis miznebi............................................................................................................................................................57

3.2. dizaini................................................................................................................................................................................57

3.3. sakvlevi populacia, CarTvis da gamoricxvis kriteriumebi...........................................58

3.5. statistikuri damuSavebis gegma.................................................................................................................58

3.6. monacemTa mopoveba...................................................................................................................................................59

4. Sedegebi......................................................................................................................................................................................62

5. daskvna.........................................................................................................................................................................................66


3

5. English summary........................................................................................................................................................................68

ACKNOWLEDGEMENTS..........................................................................................................................................................68

OBJECTIVES..................................................................................................................................................................................69

BACKGROUND.............................................................................................................................................................................69

MechanismofRenalImpairment...................................................................................................................................71

TheroleofrightventricleandCVP...............................................................................................................................73

METHODS......................................................................................................................................................................................74

Participants‐StudyPopulation......................................................................................................................................74

SamplesizeandstatisticalPlan......................................................................................................................................75

Ethicalconsiderations.........................................................................................................................................................75

RESULTS.........................................................................................................................................................................................76

CONCLUSIONS.............................................................................................................................................................................79

PUBLICATIONS.................................................................................................................................................................................80

6. bibliografia........................................................................................................................................................................81

danarTi 1. pacientis registraciis forma..................................................................................................113

danarTi 2. Patientregistrationform............................................................................................................................114


4

gamoyenebuli Semoklebebi

ACCF/AHA amerikis kardiologTa kolejis fondi da amerikis gulis

asociacia(AmericanCollegeofCardiologyFoundation/AmericanHeart

Association)

ACE

Inhibitors

angiotenzinis gardamqmneli fermentis (agf) inhibitorebi

(Angiotensin‐ConvertingEnzymeInhibitors)

ACS mwvave koronaruli sindromi (AcuteCoronarySyndrome)

ADCHF mwvave, dekompensirebuli SegubebiTi gulis ukmarisoba

(AcuteDecompensatedCongestiveHeartFailure)

ADHF mwvave dekompensirebuli gulis ukmarisoba (Acute

DecompensatedHeartFailure)

AHF gulis mwvave ukmarisoba (AcuteHeartFailure)

AKI Tirkmelebis mwvave dazianeba (AcuteKidneyInjury)

AVP arginin vazopresini (ArginineVasopressin)

ARBs angiotenzinis receptorebis blokerebi (AngiotensinIIReceptor

Blockers)

BNP B-tipis natriurezuli peptidi (B‐typeNatriureticPeptide)

BIVA bioimpedansuri veqtoruli analizi (BIoimpedanceVector

Analysis)

BUN sisxlis Sardovana azoti (BloodUreaNitrogen)

CHD gulis Tandayolili daavdeba (CongenitalHeartDisease)

CHF gulis SegubebiTi ukmarisoba (CongestiveHeartFailure)


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CKD Tirkmelebis qronikuli daavadeba (ChronicKidneyDisease)

CKD‐EPI Tirkmelebis qronikuli daavadebis epidemiologTa

kolaboraciisformula(ChronicKidneyDiseaseEpidemiology

Collaborationformula)

CO gulis wuTmoculoba (CardiacOutput)

COPD filtvebis qronikuli obstruqciuli daavadeba (Chronic

ObstructivePulmonaryDisease)

CRS kardio-renuli sindromi (Cardio‐RenalSyndrome)

CRCS kardio-renuli kaxeqsiis sindromi (Cardio‐RenalCachexia

Syndrome)

CVP centraluri venuri wneva (CentralVenousPressure)

EF gandevnis fraqcia (EjectionFraction)

eGFR gorglovani filtraciis SefasebiTi maCvenebeli (Estimated

GlomerularFiltrationRate)

EPO eriTropoetini (Erythropoietin)

ESC evropis kardiologTa sazogadoeba (EuropeanSocietyof

Cardiology)

ESKD Tirkmelebis daavadebis terminaluri stadia (EndStageKidney

Disease)

GFR gorglovani filtraciis siCqare (GlomerularFiltrationRate)

HF gulis ukmarisoba (HeartFailure)

HFREF gulis ukmarisoba daqveiTebuli gandevnis fraqciiT (Heart

FailurewithReducedEjectionFraction)

HFPEF gulis ukmarisoba SenarCunebuli gandevnis fraqciiT (Heart


6

FailurewithPreservedEjectionFraction)

IAP intra-abdominuri wneva (Intra‐AbdominalPressure)

IRVF marjvena parkuWis izolirebuli ukmarisoba (IsolatedRight

VentricularFailure)

JNC erToblivi erovnuli komiteti (JointNationalCommittee)

KIM-1 Tirkmlis dazianebis molekula 1 (KidneyInjuryMolecule‐1)

LV marcxena parkuWi (LeftVentricle)

LVEF marcxena parkuWis gandevnis fraqcia (LeftVentricleEjection

Fraction)

MDRD Tirkmelebis daavadebebis dros modificirebuli dietis

formula (ModificationofDietinRenalDiseaseformula)

NGAL neitrofilur JelatinazasTan asocirebuli lipokalini

(Neutrophilgelatinase‐associatedlipocalin)

NICVP arainvaziuri centraluri venuri wneva (NoninvasiveCentral

VenousPressure)

NKF Tirkmelebis erovnuli fondi (NationalKidneyFoundation)

NSAID arasteroiduli anTebis sawinaaRmdego preparatebi(Non‐

SteroidalAnti‐InflammatoryDrugs)

NYHA niu-iorkis gulis asociacia (NewYorkHeartAssociation)

PH filtvismieri hipertenzia (PulmonaryHypertension)

RAAS renin-angiotenzin-aldosteronis sistema (Renin‐Angiotensin‐

AldosteroneSystem)

RAP marjvena winagulis wneva (RightAtrialPressure)


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RBF renuli sisxlmomarageba (RenalBloodFlow)

RVP Tirkmelebis venuri wneva (RenalVenousPressure)

RSHF marjvenamxrivi gulis ukmarisoba (Right‐SidedHeartFailure)

RV marjvena parkuWi (SystolicBloodPressure)

RVEDD marjvena parkuWis saboloo diastoluri diametri (Right

VentricularEnd‐DiastolicDiameter)

SBP sistoluri arteriuli wneva (SystolicBloodPressure)

SCUF Senelebuli uwyveti ultrafiltracia (SlowContinuous

Ultrafiltration)

SD standartuli gadaxრa (StandardDeviation)

SNS simpaTikuri nervuli sistema (SympatheticNervousSystem)

TAPSE samkarediani sarqvlis rgolisebri zedapiris sistoluri

eqskursia (TricuspidAnnularPlaneSystolicExcursion)

WRF Tirkmelebis funqciis mzardi gauareseba (WorseningRenal

Function)


8

winasityvaoba

msurs madliereba gamovxato norvegiis arqtikuli universitetis (tromsos

universitetis) profesoris biorn straumes mimarT, kvlevis procesSi

gaweuli xelmZRvanelobisTvis da epidemiologiasa da biostatistikSi

codnis gaRrmavebis xelSewyobisTvis.

madlobas vuxdi profesor turalf hasvolds, misi gansakuTrebuli

wvlilisTvis Tbilisis saxelmwifo universitetsa da tromsos

universitets Soris TanamSromlobis gaRrmavebisTvis, romelic

ganxorcielda proeqt “sadoqtoro programa sazogadoebriv jandacvaSi:

norvegiis ganaTlebis mesame safexuris gamocdileba saqarTvelosTvis”

farglebSi.

swavlis periodSi gaweuli mxrdaWerisTvis, xelmZRvanelobisTvis da

sasargeblo rCevebisTvis gansakuTrebul madlobas vuxdi profsor zurab

faRavas, Tsu medicinis fakultetis dekans aleqsandre ciskariZes,

profesor dimitri korZaias, asocirebul profesor nino CixlaZes da

asocirebul profesor nino SaraSiZes.

da bolos, madlobas vuxdi Cems mSoblebs da Cems meuRles, guliTadi

mxardaWerisTvis da sasargeblo rCevebisTvis.


9

Sesavali

warmodgenili kvleva ganxorcielda Tbilisis saxelmwifo universitetis

medicinis fakultetis doqtoranturis programis farglebSi da misi

mizani iyo kardio-renuli sindromis I da II tipiT daavadebul pacientebSi

marcxena parkuWis gandevnis fraqciis (LVEF), marjvena parkuWis

ukmarisobis (RSHF), centraluri venuri wnevis (CVP) da Tirkmelebis

funqciis darRvevis (gamoxatuli, rogorc Semcirebuli gorglovani

filtraciis siCqare - GFR<90) urTierTkavSiris dadgena.

kvlevis Tematikis SerCeva ganapiroba sakiTxis aqtualobam – kardio-

renuli sindromis definiciis da klasifikaciis Sesaxeb informacia

pirvelad 2008 wels gamoCnda samecniero literaturaSi da imTaviTve

miipyro samedicino sazogadoebis yuradReba. Tumca, gulis da Tirkmelebis

disfunqciis Tanxvedra klinikur praqtikaSi didi xania eqimebis interesis

sagans warmoadgens 59. statistikuri monacemebiT, Tirkmelebis zomieri-mZime

dazianeba gulis ukmarisobis mqone pacientebis daaxloebiT 30 - 60

procentSi aRiniSneba 2. gulsa da Tirkmelebs Soris urTierTkavSiri

kompleqsuri procesia da moicavs ramodenime ZiriTad faqtors:

miokardiumis sistoluri da diastoluri funqciis darRvevas SeuZlia

gamoiwvios hemodinamikuri darRvevebi, rogorebicaa Semcirebuli

dartymiTi moculoba da wuTmoculoba, arasruli arteriuli avseba,

gazrdili winagulovani wneva da venuri Segubeba 24.

miuxedavad sakiTxis mimarT arsebuli didi interesisa, gul-sisxlZarRvTa

daavadebebis dros Tirkmelebis funqciis gauaresebis paTfiziologia

jerac ar aris srulyofilad Seswavlili. bolo drois gamokvlevebi

aCvenebs, rom gulis pirveladi da Tirkmelebis meoradi disfunqciis mqone

pacientebis marTva mxolod “Semcirebuli nakadis” Teoriaze dayrdnobiT,

ar iZleva sasurvel Sedegebs 34 35. aseve dadgnilia, rom intra-abdominuri

wnevis (IAP) da centraluri venuri wnevis mateba, romelic Tavis mxriv

zrdis renul venur wnevas (RVP), GFR-is Semcirebas ganapirobebs 60.


10

aRniSnuli garemoebebis gaTvaliswinebiT interess iwvevs marjvena parkuWis

(RV) roli kardio-renuli sindromis paTogenezSi. Tumca, marjvena

parkuWis funqciuri mdgomareobis Sefaseba problemas warmoadgens - ar

arsebobs erTi, sazogadod miRebuli da praqtikaSi gamoyenebadi RVindeqsi 54. marjvena parkuWis rTuli anatomiis gamo, mxolod ramodenime

eqoskopiuri parametria miCneuli sarwmunod, romelTa Sorisac

upiratesoba TAPSE-s, anu samkarediani sarqvlis rgolisebri zedapiris

sistoluri eqskursias eniWeba 55. frank dinim (FrankL.Dini) da Tanaavtorebma

Seiswavles RV disfunqciis da Tirkmelebis qronikuli daavadebis (CKD)

urTierTkavSiri gulis qronikuli ukmarisobis mqone pacientebSi da

daadgines, rom TAPSE-s da GFR-s Soris arsebobs mniSnvnelovani korelacia

53.

centraluri venuri wneva, romelic marjvena winagulovani wnevis (RAP)

miaxloebiTi maCveneblia, aseve SesaZloa gamoyenebul iqnes marjvena

parkuWis funqciuri mdgomareobis SefasebisTvis, Tumca, yovelTvis

gasaTvaliswinebelia sxva gul-sisxlZarRvovani parametrebi, magaliTad,

rogoricaa marcxena parkuWis gandevnis fraqcia (LVEF), radgan

marjvenamxrivi wneva SesaZloa iribad asaxavdes marcxenamxriv wnevas da

marcxenamxrivi avsebis wneva SesaZloa iyos marcxena gulis funqciuri

mdgomareobis niSani 56. kevin damanis (KevinDamman) da Tanaavtorebis mier

Catarebulma kvlevam aCvena, rom CVP asocirebulia Tirkmelebis funqciis

gauaresebasTan da damoukideblad ukavSirdeba yvela mizeziT gamowveul

sikvdilobas gul-sisxlZarRvTa daavadebebis mqone pacientebis farTo

speqtrSi 41. heiko uToftis (Heiko Uthofft) da Tanaavtorebis mier Catarebulma

kvlevam ufro ganamtkica mosazreba, rom CVP aris mniSvnelovani

hemodinamikuri faqtori Tirkmelebis funqciis gauaresebisTvis,

gansakuTrebiT maSin, rodesac is ukavSirdeba daqveiTebul wuTmoculobas 42. aRniSnuli kvlevebi sxva relevantur wyaroebTan erTad detalurad

ganxilulia warmodgenili naSromis literaturis mimoxilvis nawilSi.


11

kardio-renuli sindromis mqone pacientebis marTva ar aris martivi

sakiTxi, radgan erT organoTa sistemaze mimarTul mkurnalobas SesaZloa

hqondes sasargeblo, an piriqiT, saziano Sedegi meore organoTa sistemis

funqciur mdgomareobaze. swored amitom, gansakuTrebuli mniSvneloba

eniWeba gulsa da Tirkmelebs Soris arsebuli urTierTkavSiris meqanizmis

srulyofilad Seswavlas da gaazrebas.

aRniSnul sakiTxSi meti sicxadis Setanis mizniT daigegma da

ganxorcielda warmodgenili kvleva, romelic efuZneba hipoTezas, rom CVP,

marcxena parkuWis gandevnis fraqciaze metad aris korelaciaSi

Tirkmelebis funqciis darRvevasTan im pacientebSi, romlebsac aReniSnebaT

kardio-renuli sindromis I da II tipi.

kvlevis dizaini ganisazRvra, rogorc retrospeqtiuli kros-seqciuli da

saerTaSoriso gamocdilebis gaTvaliswinebiT SemuSavda ganxorcielebis

gegma, romelic moicavda Semdeg etapebs 61 62 63:

sakvlevi sakiTxis garSemo arsebuli samecniero literaturis

mimoxilva da analizi;

kvlevis mimdinareobisas mosalodneli eTikuri sakiTxebis analizi

da gadaWris gzebis gansazRvra;

kvlevis protokolis SemuSaveba (CarTvis da gamoricxvis

kriteriumebi, SerCevis moculoba da sxv.);

protokolis registracia saerTaSoriso reestrSi;

samedicino dawesebulebebis SerCeva da eTikis komisiebis Tanxmobis

mopoveba kvlevis ganxorcielebaze;

monacmebis amoReba samedicino Canawerebidan, monacemTa bazis Seqmna;

monacemebis statistikuri analizi;

publikaciebis momzadeba da gamoqveyneba samecniero JurnalebSi,

universitetis doqtoranturis debulebis Sesabamisad.


12

rogorc ukve aRiniSna, kvleva moicavda pacientebs kardio-renuli

sindromis I da II tipiT. Sesabamisad, CarTvis kriteriumebi iyoHF da eGFR

<90. gamoricxvis kriteriumebi gansazRvruli iyo Semdegnairad:

1. Tirkmelebis funqciis darRvevis damoukidebeli risk-faqtorebis

arseboba (magaliTad, sefsisi, diabeti);

2. pirveladi nefropaTia an meoradi nefropaTia gamowveuli gulis

ukmarisobis garda nebismieri sxva mizeziT.

retrospeqtiulad Seswavlil iqna im pacientebis samedicino Canawerebi,

romlebic drois gansazRvrul monakveTSi hospitalizirebulebi iyvnen

winaswar SerCeuli samedicino dawesebulebis * intensiuri Terapiis da

zogad-Terapiul ganyofilebebSi gulis ukmarisobis diagnoziT (ICD10:I50.0

–I50.9).kvlevis Sedegebma aCvena, romkardio-renuli sindromis meore tipis

dros marcxena parkuWis gandevnis fraqciis Semcireba ar ukavSirdeba

Tirkmelebis funqciis gauaresebas (aRiniSna statistikurad mniSvnelovani

urayofiTi korelacia LVEF-s da eGFR-s Soris (n=44,r=‐0.336,p=0.026)). amave

kategoriaSi, gamovlinda kavSiri NYHA-s klasifikaciiT gulis ukmarisobis

funqciuri klasis matebas da eGFR-is Semcirebas Soris (n=44, r=‐0.349,

p=0.02). pirsonis korelaciis testma ki aCvena saSualo daswvrivi

(uaryofiTi) kavSiri CVP‐s da eGFR-s Soris (r=‐0.48,p=0.13) kardio-renuli

sindromis pirveli tipis dros, rac gansazRvravs SerCevis sasurvel

moculobas statistikuri analizisaTvis amgvari, magram ufro

farTomasStabiani kvlevebisTvis.

zemoTaRniSnuli Sedegebi gvaZlevs safuZvels vifiqroT, rom marcxena

parkuWis gandevnis fraqciis Semcireba ar ukavSirdeba Tirkmelebis

funqciis gauaresebas kardio-renuli sindromis II tipis dros. diastoluri

*hospitaluri qseli “medalfas” 4 samedicino centri, mediqlabjorjia, sisxlZarRvTa da gulis daavadebaTa centri


13

disfunqcia, marjvenaparkuWovani ukmarisoba, venuri Segubeba da

neirohormonaluri aqtivacia aris savaraudod is ZiriTadi faqtorebi,

romlebic iwvevs GFR-is Semcirebas gulis qronikuli ukmarisobis mqone

pacientebSi. kardio-renuli sindromis I tipis drosSesaZloa centraluri

venuri wneva LVEF‐ze metad iyos korelaciaSi Tirkmelebis funqciis

gauaresebasTan, Tumca, miRebuli Sedegebis verificireba saWiroa ufro

farTomasStabiani kvleviT, romelsac SesaZloa hqondes mniSvnelovani

gavlena kardio-renuli sindromis srulyofilad gaazrebis da marTvis

TvalsazrisiT (ix.: daskvna, gv.66).


14

sadisertacio naSromis struqtura, moculoba da programuli

uzrunvelyofa

sadoqtoro naSromi warmodgenilia qarTul enaze, Semajamebeli daskvniT

inglisur enaze. jamSi moicavs 114 nabeWd A4 gverds, aqedan, 2 suraTs, 10

cxrils, 1 grafiks da or danarTs (inglisurenovan daskvnaSi

warmodgenilia 1 suraTi, 3 cxrili da 1 grafiki).

sadoqtoro naSromis, iseve rogorc publikaciebis momzadebisas

gamoyenebulia ThomsonReuters‐is bibliografis marTvis programa EndNote X7.

citirebulia 287 literaturuli wyaro.

monacemTa statistikuri damuSavebisTvis gamoyenebulia programa IBM SPSS

Statistics22.

publikaciebi

sadoqtoro kvlevaze muSaobis dasawyisSi ganisazRvra publikaciebis

momzadebis gegma 3 ZiriTadi mimarTulebiT: kvlevis ganxorcielebisas

mosalodneli eTikuri sakiTxebis mimoxilva, sakvlevi Tematikis

srulyofili literaturuli analizi da kvlevis Sedegebis gamoqveyneba.

aRniSniSnuli gegma ganxorcielda warmatebiT. warmodgenili naSromi

efuZneba Semdeg publikaciebs:

1. George Lobzhanidze (First Author). Ethical considerations in non‐experimental

studies‐GeorgianandNorwegianexperience.PUBLICHEALTH,ELSEVIER†,2016.

2. George Lobzhanidze (Sole Author). The role of right‐sided heart failure in patients

with Cardio‐Renal Syndrome. TRANSLATIONAL AND CLINICAL MEDICINE ‐

GEORGIANMEDICALJOURNAL,2016.

†5‐YearImpactFactor:1.746©JournalCitationReports2016,publishedbyThomsonReuters


15

3. GeorgeLobzhanidze(SoleAuthor).Cardio‐RenalSyndrometype1:theroleofCentral

Venous Pressure and Left Ventricle Ejection Fraction. International Journal of

Sciences:BasicandAppliedResearch,2016.

4. George Lobzhanidze (Sole Author). The Association among Left Ventricle Ejection

FractionandeGFRinpatientswithCardio‐RenalSyndromeType2.(articleinreview).


16

1. literaturis mimoxilva

1.1. kardio-renuli sindromi

gulis da Tirkmelebis funqciis darRveva xSirad Tanxvdeba klinikur

praqtikaSi - erT-erTi maTganis pirveladi dazianeba iwvevs meores meorad

disfunqcias 64. es urTierTkavSiri qmnis paTfiziologiur safuZvels

klinikuri mdgomareobisa, romelic cnobilia, rogorc kardio-renuli

sindromi. am terminis qveS ZiriTadad igulisxmeba Tirkmelebis

ukmarisobis ganviTareba/progresireba arsebuli gulis ukmarisobis fonze,

Tumca, xSirad aseve gulisxmoben mdgomareobas, rodesac Tirkmelebis

daqveiTebuli funqcia meoradad iwvevs gul-sisxlZarRvTa sistemis

funqciis darRvevas (aRniSnul mdgomareobas aseve uwodeben reno-kardiul

sindroms) 14 21.

Tirkmelebis zomieri-mZime dazianebis (ganisazRvreba, rogorc GFR < 60

ml/wT 1,73 m2-ze) gavrceleba (prevalensi) gulis ukmarisobis mqone

pacientebSi aris daaxloebiT 30-dan 60 procentamde 2-5. NYHA-s me-4

funqciuri klasis gulis ukmarisobis mqone pacientebis 39%-s da me-3

funqciuri klasis 31%-s aReniSnebaT Tirkmelebis mZime xarisxis dazianeba

65. aseve, arsebobs monacemebi, rom Tirkmelebis daavadebis terminaluri

stadiiT (ESKD) diagnostirebuli pacientebis sikvdilobis 44%

ganpirobebulia gul-sisxlZarRvTa daavadebebiT 66.

gulis da Tirkmelebis daavadebebis urTierTkavSiri gamoixateba Semdegi

faqtebiT 6:

sikvdiloba gazrdilia gulis ukmarisobis mqone im pacientebSi,

romelTac aReniSnebaT Semcirebuli GFR 7;

Tirkmelebis qronikuli daavadebis mqone pacientebs aqvT gul-

sisxlZarRvTa aTerosklerozuli daavadebis da gulis ukmarisobis

gazrdili riski; gul-sisxlZarRvTa daavadebebi ki warmoadgens


17

Tirkmelebis ukmarisobis mqone pacientebis sikvdilobis daaxl. 50

procents 8;

mwvave an qronikul sistemur daavadebebs SeuZliaT gamoiwvion rogorc

gulis, aseve Tirkmelebis disfunqcia 9.

profesor klaudio ronkos ‡ da Tanaavtorebis mier 2008 wels ganisazRvra

kardio-renuლi sindromis xuTi tipi, romlebic erTmaneTisgan ganirCeva

klinikuri mimdinareobis, paTfiziologiis, diagnostirebis da marTvis

taqtikis mixedviT 10. aRniSnuli klasifikacia 2010 wlis konferenciaze

mowonebul iqna organizacia “mwvave dializis xarisxis iniciativis” (ADQI)§

mier.

kardio-renuli sindromi moicavs rogorc mwvave, aseve qronikuli

mimdinareobis mdgomareobebs, romlebic xasiaTdebian rogorc gulis

pirveladi, aseve Tirkmelebis pirveladi dazianebiT:

I tipi: mwvave, dekompensirebuli gulis ukmarisoba (ADHF) iwvevs

Tirkmelebis mwvave dazianebas. sxvadasxva mosaxleobaSi, ADHF-is gamo

hospitalizirebuli pacientebis 27% - 40%-s aReniSneba Tirkmelebis

mwvave dazianeba (AKI) **. Sesabamisad, I tipis CRS xSirad gvxvdeba

kardiologiuri intensiuri Terapiis ganyofilebebSi 11-14;

II tipi: gulis qronikuli daavadeba iwvevs Tirkmelebis qronikul

daavadebas; “gulis qronikuli daavadeba” SesaZloa moicavdes iseT

mdgomareobebs, rogorebicaa gulis qronikuli ukmarisoba,

Tandayolili manki, winagulebis cimcimi, konstriqciuli perikarditi

da koronaruli arteriebis daavadeba 15;

III tipi: Tirkmelebis mwvave dazianeba iwvevs gulis disfunqcias -

ariTmiis an gulis ukmarisobis saxiT 16. me-3 tipi gvxvdeba ufro

‡ClaudioRonco,MD.nefrologiis departamenti, wm. borTolos hospitali, viCenza, italia.§ Acute Dialysis Quality Initiative (ADQI) ‐ saerTaSoriso, interdisciplinuri organizacia, romelic aerTianebs msoflios 150 wamyvani universitetis warmomadgenels. daarsda 2000 wels. **adre gamoiyeneboda termini –Tirkmelebis mwvave ukmarisoba(AcuteRenalFailure(ARF))


18

iSviaTad, vidre I tipi, Tumca, es SesaZloa ganpirobebuli iyos imiT,

rom es tipi ufro naklebad aris Seswavlili 10;

• IV tipi: Trkmelebis pirveladi daavadeba iwvevs darRvevebs gulis

mxriv, rogorebicaa parkuWebis hipertrofia, marcxena parkuWis

diastoluri disfunqcia da gul-sisxlZarRvTa garTulebebis gazrdili

riski 17-19;

• V tipi: gulis da Trkmelebis kombinirebuli ukmarisoba gamowveuli

sistemuri daavadebiT. CRS-is es tipi SesaZloa moicavdes mraval mwvave

da qronikul mgdomareobas, rodesac aRiniSneba gulis da Tirkmlebis

erToblivi disfunqcia (magaliTad, Saqriani diabeti, sefsisi, sistemuri

wiTeli mglura da sxv.) 20. CRS-is aRniSnul tips aseve uwodeben meorad

kardio-renul sindroms 20 22.

termini kardio-renuli kaxeqsiis sindromi gamoiyeneba im SemTxvevaSi,

rodesac aRiniSneba CRS-s fonze kaxeqsiis ganviTareba an kaxeqsiis fonze

CRS‐s ganviTareba 23.

aqve unda aRiniSnos, rom CRS-is am klasifikacias hyavs skeptikosebic,

kerZod, branko braami (BrankoBraam) da Tanaavtorebi miiCneven, rom CRS-is

tipebis gansazRvra organoTa dazianebis rigiTobaze (pirveladi, meoradi)

da ganviTarebis mimdinareobaze (mwvave, qronikuli) dayrdnobiT, metad

martivi da xelovnuria 67 68. isini kardio-renul sindroms aRiqvamen

rogorc erT mTlian, integrirebul process, sadac gulis da Tirkmelebis

kombinirebuli ukmarisoba auaresebs erTmaneTis funqcias identuri

paTfiziologiuri meqanizmebiT. Sesabamisad, ar aqvs mniSvneloba Tu

romeli organos disfunqcia ganviTardeba pirvelad, radgan adgili aqvs

erTi da igive neirohormonaluri sistemebis aqtivacias orive SemTxvevaSi,

rac iwvevs gul-sisxlZarRvTa daavadebis progresirebas an orive organos

funqciis gauaresebas. es neirohormonaluri sistemebi iyofa or ZiriTad

kategoriad: “hemodinamikuri faqtorebi” da “ara-hemodinamikuri faqtrebi”,

anu “kardio-renuli koneqtorebi” 64.


19

kardio-renuli sindromis SemTxvevebis matebasTan asocirebulia Semdegi

risk-faqtorebis arseboba 69:

moxucebulTa asaki

Tanmxlebi daavadebebi (Saqriani diabeti, arakontrolirebadi

arteriuli hipertenzia, anemia)

medikamentebis moxmareba (arasteroiduli anTebis sawinaaRmdego

preparatebi (NSAID), Sardmdenebi, angiotenzinis gardamqmneli

fermentis inhibitorebi (ACE Inhibitors), angiotenzinis receptorebis

blokerebi (ARBs))

gulis ukmarisobis an marcxena parkuWis daqveiTebuli gandevnis

fraqciis anamnezi

gadatanili miokardiumis mwvave infarqti

HF funqciuri klasi NYHA-s mixedviT

momatebuli kardiuli troponinebi

Tirkmelebis qronikuli daavadeba (Semcirebuli eGFR, momatebuli

sisxlis Sardovana azoti (BUN), kreatinini an cistatini)

gulis ukmarisobis mqone pacientebSi, romlebsac aqvT Semcirebuli GFR,

mniSvnelovania ganvasxvavoT Tirkmelebis pirveladi daavadeba da kardio-

renuli sindromiT gamowveuli Tirkmelebis daqveiTebuli funqcia 70. es

gansxvaveba SesaZloa iyos Zalzed rTuli, radgan pacientebis garkveul

nawils aReniSneba rogorc Tirkmlebis qronikuli daavadeba, aseve kardio-

renuli sindromi (igulisxmeba I da II tipi) 71. is, rac gvafiqrebinebs

Tirkmelebis pirvelad daavadebaze, aris mniSvnelovani proteinuria

(Cveulebriv, 1000 mg/dR-ze meti), hematuria piuriiT da cilindruriiT an

mis gareSe, da/an radiologiuri kvlevebiT gamovlenili Tirkmelebis

Semcirebuli zoma 72. Tumca, normaluri Sardis saerTo analizi, romelic,

rogorc wesi, xSiria kardio-renuli sindromis dros, aseve SeiZleba

aRiniSnebodes zogierTi kategoriis Tirkmelebis daavadebebis drosac, maT

Soris nefrosklerozis da obstruqciuli nefropaTiis dros 73 74.


20

1.1.1. I tipis kardio-renuli sindromi

I tipis, anu mwvave kardio-renuli sindromi, xasiaTdeba gulis funqciis

swrafi gauaresebiT, rasac mivyavarT Tirkmelebis mwvave dazianebamde.

gulis mwvave ukmarisoba SesaZloa mimdinareobdes 75:

hipertenziis fonze ganviTarebuli filtvebis SeSupebiT, rodesac

Senaxulia marcxena parkuWis sistoluri funqcia;

mwvave, dekompensirebuli SegubebiTi gulis ukmarisobiT (ADCHF);

kardiogenuli SokiT.

meqanizmi, romliTac gulis mwvave ukmarisoba iwvevs Tirkmelebis mwvave

dazianebas, metad rTuli da mravalmxrivia 76. Tirkmelebis funqciis

gauareseba aris ara mxolod daavadebis simZimis maCvenebeli, aramed

ganapirobebs gul-sisxlZarRvTa sistemis disfunqciis gauaresebis

aqseleracias, savarudod anTebiTi gzebis aqtivaciis wyalobiT 77. dabali

wuTmoculoba da/an maRali venuri wneva, rac iwvevs renul Segubebas, meti

albaTobiT warmoadgens Tirkmelebis mwvave dazianebis ganviTarebis

ZiriTad mizezs 78.

aseT situaciaSi, reaqcia diuretikebze SesaZloa darRveuli iyos da

gamovlindes SegubebiTi mdgomareoba (periferiuli edema, sxeulis Warbi

wona, maRali centraluri venuri wneva) mniSvnelovan hiponatremiasTan

erTad 79. gamovlenili moculobiTi gadatvirTvis dros Sardmdenebi unda

dainiSnos diurezis etapobrivi zrdis miRweviT, met-naklebad optimaluri

hidrataciuli statusis miRwevamde, eleqtrolituri darRvevebis

koregirebis paralelurad 80 81. biomarkerebi, rogoricaa B-tipis

natriurezuli peptidi (BNP), teqnologiur saSualebebTan erTad,

rogoricaa bioimpedansuri veqtoruli analizi (BIVA), SesaZloa

dagvexmaros Warbi hidrataciis xarisxis SefasebaSi, rac Tavis mxriv

gvexmareba diuretikebiT da ultrafiltraciiT (SCUF) mkurnalobis


21

taqtikis gansazRvraSi adekvaturi hidrataciuli statusis miRwevis mizniT

11-14.

gulis ukmarisobis da misi mkurnalobis procesis erT-erTi yvelaze xSiri

garTuleba aris hiponatremiis ganviTareba 82 83. hiponatremia viTardeba

arginin vazopresinis (AVP) araosmosuri gamoyofis, renin-angiotenzin-

aldosteronis sistemis neirohormonaluri aqtivaciis da simpaTikuri

nervuli sistemis aqtivaciis gamo 84. gulis ukmarisobis mqone pacientebSi

ganviTarebuli hiponatremia dakavSirebulia arakeTilsaimedo prognozTan

da diuretikebis gamoyenebis SezRudvasTan 85.

AVP antagonistebi, romlebsac „vaptanebi“ ewodebaT, aumjobeseben plazmis

natriumis koncentracias, Sardis gamoyofas, sxeulis wonas da cnobierebis

statuss, Tumca ar aCveneben xangrZliv sargebels sikvdilobis Semcirebis

TvalsazrisiT gulis ukmarisobis mqone pacientebSi 86 87.

hiperkalemiiT, an mis gareSe mimdinare Tirkmelebis mwvave dazianebam

SesaZloa gavlena iqonios saboloo gamosavalze, radgan am dros saWiro

xdeba angiotenzinis gardamqmneli fermentis inhibitorebis da

aldosteronis blokerebis daniSvnis SezRudva 88 89. am tipis preparatebis

sargebloba ki gulis ukmarisobis da miokardiumis infarqtis dros

mravali randomizebuli kontrolirebuli kvleviT aris dadasturebuli 90

91 92.

1.1.2. II tipis kardio-renuli sindromi

II tipis, anu qronikuli kardio-renuli sindromi xasiaTdeba gulis

funqciis qronikuli darRveviT (magaliTad, gulis qronikuli SegubebiTi

ukmarisoba) gamowveuli progresirebadi Tirkmelebis qronikuli

daavadebiT. gulis ukmarisobis fonze mimdinare Tirkmelebis funqciis

mzardi gauareseba (WRF) dakavSirebulia garTulebebis sixSiris

matebasTan da hospitalizaciis saWiroebis xangrZlivobis zrdasTan 15.


22

gulis ukmarisobis dros Tirkmelebis funqciis darRveva daaxloebiT 25

%-Si aRiniSneba 93. miCneulia, rom gorglovani filtraciis siCqaris

mcirediT Semcirebac ki iwvevs sikvdilobis riskis mniSvnelovan zrdas 94.

zogierTi mkvlevaris azriT, Tirkmelebis funqciis mzardi gauareseba

SesaZloa miCneul iqnes gul-sisxlZarRvTa generalizebuli daavadebis

simZimis amsaxvel markerad 95.

gulis qronikuli ukmarisoba xasiaTdeba Tirkmelebis perfuziis

xangrZlivi SemcirebiT, rasac xSirad win uswrebs is mikro da

makroangiopaTiebi, romlebic aseve asocirebulia gul-sisxlZarRvTa

daavadebebis ganviTarebis riskTan 96 97. neirohormonuli darRvevebi

gamoixateba vazokonstiqtorebis (epinefrini, angiotenzini, endoTelini)

Warbi gamomuSavebiT da endogenuri vazodilatatorebis (natriurezuli

peptidebi, azotis oqsidi (NO)) mimarT darRveuli mgrZnobelobiT 98. bolo

dros gamoikveTa samecniero interesi eriTropoetinis (EPO) SedarebiTi an

sruli deficitis paTogenuri rolis mimarT, romelic ganapirobebs

gamoxatuli anemiis ganviTarebas da gulis da Tirkmelebis negatiuri

urTierTqmedebis mankieri wris Seqmnas 99 100.

EPO-s daniSvna gulis qronikuli ukmarisobiT, Tirkmelebis qronikuli

daavadebiT da anemiiT daavadebul pacientebSi, aumjobesebs gulis

funqcias, iwvevs marcxena parkuWis zomis daBNP-s donis Semcirebas 101 102.

rkinis preparatebis intravenurma infuziam aseve SesaZlebelia xeli

Seuwyos eriTropoezis procesis daregulirebas 103 104 105.

kardio-renuli sindromis am tipis dros, gulis ukmarisobis

biomarkerebis, GFR-is da pacientis “fluid statusis” (Fluid status)

gansazRvra warmoadgens adekvaturi marTvis qvakuTxeds 106 107 108 109. ufro

specifiuri biomarkerebis gamoyeneba, rogorebicaa neitrofilur

JelatinazasTan asocirebuli lipokalini (NGAL), Tirkmelebis dazianebis

molekula 1 (KIM‐1) da kopeptini (CT‐proAVP) SesaZloa sasargeblo iyos


23

organoTa qsovilebis mwvave iSemiuri an toqsiuri dazianebis gamovlenis

TvalsazrisiT 110 111. meore mxriv, fibrozis biomarkerebis gansazRvra

(activematrixmetalloproteinase2,activematrixmetalloproteinase9,totaltissueinhibitorof

metalloproteinase 1) SesaZloa dagvexmaros organoTa qronikuli dazianebis

progresirebis SefasebaSi 112 113.

1.1.3. III tipis kardio-renuli sindromi

III tipis kardio-renuli sindromi, anu mwvave reno-kardiuli sindromi,

xasiaTdeba Tirkmelebis funqciis pirveladi mwvave gauaresebiT

(magaliTad, Tirkmelebis mwvave dazianeba, iSemia, glomerulonefriti), rac

Tavis mxriv iwvevs, an xels uwyobs gulis mwvave dazianebas da/an

disfunqcias (magaliTad, gulis ukmarisoba, ariTmia, iSemia) 114.

Tirkmelebis mwvave dazianeba gul-sisxlZarRvTa sistemaze gavlenas axdens

sxvadasxva gziT. kerZod, oligurias SeuZlia gamoiwvios moculobiTi

gadatvirTva, rac Tavis mxriv xels uwyobs filtvebis SeSupebis da

miokardiuli disfunqciis ganviTarebas 115. aseT situaciaSi, optimaluri

hidrataciuli statusis miRwevis mizniT SesaZloa saWiro gaxdes

Tirkmelebis CanacvlebiTi Terapia 116 117. dializis Sedegad ganviTarebuli

siTxis da eleqtrolitebis donis mkveTri cvlileba SesaZloa gaxdes

kardiovaskuluri arastabilurobis mizezi, rac gamoixateba hipotenziis,

ariTmiebis da miokardiumis iSemiis ganviTarebiT 118 119. Tirkmelebis

CanacvlebiTi Terapiis uwveti meTodebi (dializi an filtracia‐Continuous

renal replacement therapies (CRRTs)), romlebsac minimumade dahyavs aseTi

kardiovaskuluri garTulebebi, miCneulia ufro usafrTxod da

logikurad aseT situaciaSi 120 121 122.


24

1.1.4. IV tipis kardio-renuli sindromi

IV tipis kardio-renuli sindromi, anu qronikuli reno-kardiuli sindromi,

xasiaTdeba Tirkmelebis pirveladi qronikuli daavadebiT (magaliTad,

qronikuli glomeruluropaTia), rac xels uwyobs gulis funqciis

gauaresebas, parkuWebis hipertrofiis da diastoluri disfunqciis

ganviTarebas, da/an kardiovaskuluri garTulebebis riskis zrdas 123. aseT

situaciaSi, xSirad aRiniSneba mudmivi moculobiTi gadatvirTva da

diuretikebis gamoyenebis xangrZlivi anamnezi 124. BNP-is mateba xSirad

mudmiv xasiaTs atarebs da amitom, gansxvaveba „svel“ da mSral“

komponetebs Soris gadamwyvet rols TamaSobs gulis ukmarisobis

diagnostirebis da klasificirebis TvalsazrisiT 14 21.

Tirkmelebis erovnuli fondi (NKF) gansazRvravs Tirkmelebis qronikuli

daavadebis 5 stadias, rac efuZneba Trkmelebis dazianebis simZimis da

gorglovani filtraciis siCqaris kombinacias. Tirkmelebis qronikuli

daavadeba ganisazRvreba, rogorc Tirkmelebis mudmivi dazianeba

(dadasturebuli biofsiiT an Tirkmelebis dazianebis biomarkerebiT) da/an

gorglovani filtraciis siCqaris SemcirebiT < 60ml/wT 1,72m2 3 Tveze meti

xniT 125. miCneulia, rom Tirkmelebis funqciis gauareseba am donemde an

kidev ufro dabla, asaxavs Tirkmelebis normaluri funqciis daqveiTebas

1/2-iT an metad, rac SesaZloa ukavSirdebodes garTulebebis ganviTarebas,

rogorebicaa gul-sisxlZarRvTa daavadebebi da sxv. 126.

Tirkmelebis qronikuli daavadeba aris gul-sisxlZarRvTa daavadebebis

ganviTarebis mniSvnelovani risk-faqtori: Tirkmelebis qronikuli

daavadebiT Sepyrobil pirebs aqvT kardiuli sikvdilobis 10 da 20-jer

meti riski, asakiT da sqesiT Sesabamis sakontrolo jgufebTan SedarebiT

Tirkmelebis qronikuli daavadebis gareSe 127.


25

1.1.5. V tipis kardio-renuli sindromi

V tipis kardio-renuli sindromi, anu meoradi kardio-renuli sindromi,

xasiaTdeba Tirkmelebis da gulis kombinirebuli disfunqciiT, gamowveuli

mwvave an qronikuli daavadebebiT 128 129. mTel rig mwvave da qronikul

daavadebebs SeuZliaT gamoiwvion orive organoTa sistemis erTdrouli

dazianeba, sadac erTis dazianeba gavlenas axdens meoreze da piriqiT 130.

mwvave daavadebaTagan, orive organoTa sistemis disfunqciis ganviTarebis

yvelaze xSiri da sayuradRebo mizezi aris mZime sefsisi. qronikul

daavadebaTagan ki, Saqriani diabeti warmoadgens gulis da Tirkmelebis

kombinirebuli disfunqciis yvelaze xSir mizezs 20 22.

kardio-renuli sindromis yvela zemoTCamoTvlili tipis dros, kardiuli

da renuli biomarkerebis gansazRvra saSualebas aZlevs klinicist eqimebs

dasvan kardio-renuli sindromis diagnozi da daiwyon adreuli da

garkveulwilad, ufro efeqturi mkurnaloba 131. kreatininis da diurezis

monacemebze dayrdnobiT Tirkmelebis mwvave dazianebis (AKI) diagnostireba

da misi simZimis Sefaseba klinikur praqtikaSi dReisaTvis sirTules ar

warmoadgens 132. Tirkmelebis qronikuli daavadebis (CKD) an Tirkmelebis

funqciis darRvevis Sefaseba xdeba glomeruli filtraciis siCqaris (GFR)

da Sratis kreatininis donis mixedviT. orive SemTxvevaSi, organoTa

dazianebis adreuli diagnostireba da progresirebis zedmiwevniTi

Sefaseba gaadvilebulia specifiuri biomarkerebis gansazRvriT, Tu

uzrunvelyofilia maTi xelmisawvdomoba 133. es biomarkerebi gviCvenebs

Tirkmelebis dazianebas manam, sanam is gamovlindeba gorglovani

filtraciis siCqaris SemcirebiT. BNP aris gulis ukmarisobis yvelaze

Rirebuli da amave dros xelmisawvdomi biomarkeri, xolo NGAL-is

gansazRvra ki informatiulia Tirkmelebis mwvave dazianebis dros 134 135.

gulis ukmarisobis SemTxvevaSi, Camoyalibebulia kriteriumebi da

algoriTmebi gulis ukmarisobis diagnostirebisaTvis, rac efuZneba


26

rogorc anamnezis da fizikuri gasinjvis monacemebs, aseve instrumentuli

da laboratoriuli kvlevebis Sedegebs 136. am SemTxvevaSic xelmisawvdomia

biomarkerebis gansazRvra, gulis kunTis iSemiis gamovlenis da gulis

ukmarisobis xarisxis Sefasebis mizniT 137.

1.1.6. mkurnaloba

Tirkmelebis disfunqciiT da moculobiTi gadatvirTviT damZimebuli da

Sardmdenebis mimarT refraqtoruli gulis ukmarisobis mqone pacientebis

marTva metad rTuli procesia. efeqturi, mtkicebulebebze dafuZnebuli

Terapiuli midgomebi ar arsebobs. potenciur sargebels da zians Soris

kompromisis mosaZebnad eqimebi xSirad iReben gadawyvetilebebs, romlebic

SesaZloa urTierTgamoricxavadac ki mogveCvenos. aseT situaciaSi

mkurnalobis procesi xSirad rTuldeba standartuli mkurnalobis

(Sardmdenebi da inotropebi) mimarT rezistentobis ganviTarebiT, rac

arakeTilsaimedo prognozs ganapirobebs 138 139 140.

im mraval darRvevaTa Soris, romlebic kardio-renuli sindromis dros

aRiniSneba, siTxiT gadatvirTva warmoadgens mTavar klinikur problemas,

romelic saWiroebs zust Sefasebas da mkurnalobas 141 142. Warbi

hidratacia, hormonaluri darRvevebiT gamowveul eleqtrolitur

disbalansTan (magaliTad, hiponatremia) erTad, warmoadgens

umniSvnelovanes klinikur mdgomareobas, romelic saWiroebs droul

diagnostirebas da koreqcias 143 144. vazopresinis Warbi, ara-osmosuri

gamoyofa aris hiponatremiis ganviTarebis mTavari etiologiuri faqtori

gulis ukmarisobis dros 145 146 147. I tipis kardio-renul sindromze

saubrisas naxsenebi iyo vazopresinis V2 receptorebis antagonistebi, e.w.

vaptanebi, romlebic aumjobeseben plazmis natriumis koncentracias da

zrdian Sardis gamoyofas, Tumca, isini ar aCveneben sargebels

hospitalizaciis da sikvdilobis Semcirebis TvalsazrisiT gulis

ukmarisobis mqone pacientebSi 148 149.


27

SegubebiTi movlenebis arsebobisas mkurnalobis procesSi wamyvani roli

maryuJovan Sardmdenebs eniWebaT. diurezis gaZlierebiT SesaZlebelia ara

mxolod moculobiTi gadatvirTvis, aramed gulis parkuWebis dilataciis

Semcireba da miokardiumis funqciis gaumjobeseba miokardiumis kedlebze

stresis, endo-miokardiuli iSemiis da funqciuri mitraluri

regurgitaciis Semcirebis xarjze. aseve, maryuJovani Sardmdenebis

gamoyenebisas mosalodnelia Tirkmelebis funqciis TandaTanobiTi

gaumjobeseba neirohormonalur aqtivaciaze gavlenis Sedegad 150.

mkurnalobas xSirad amateben Tiazidur diuretikebsac, magaliTad

metolazons, Tumca am dros matulobs azotemiis da eleqtrolituri

darRvevebis ganviTarebis riski 151.

inotropebis gamoyeneba SezRudulia iseTi potenciuri gverdiTi efeqtebis

ganviTarebis gamo, rogorebicaa hemodinamikuri darRevebi da ariTmiebi 152.

agreTve, randomizebuli da retrospeqtiuli kvlevebiT gamovlenilia

mkafio asociacia inotropebis gamoyenebasa da avadobis da sikvdilobis

gazrdil maCveneblebTan 153 154 155. Sardmdenebis adeqvaturi dozebiT

mkurnalobisas arasakmarisi efeqtis miRebisas SasaZloa inotropuli

agentebis (dopamini, dobutamini, fosfodiesterazas inhibitorebi da

levosimendani) mcire dozebiT damateba diurezis gaumjobesebis mizniT,

mxolod xanmokle efeqtis misaRebad. rogorc ukve aRiniSna, mTeli rigi

kvlevebi adasturebs, rom kardio-renuli sindromis dros gulis

wuTmoculobis gazrda ar ukavSirdeba Tirkmelebis funqciis

gaumjobesebas 156. dopaminis mcire, anu “Tirkmlis doziT” (2–4 mkg/kg/wT)

gamoyeneba miRebulia Tirkmelebis mwvave dazianebis prevenciis an

mkurnalobis mizniT. am dozebiT infuziisas dopamini aaqtiurebs A1

receptorebs, rac iwvevs renuli arteriebis dilatacias da Tirkmelebis

sisxlmomaragebis gazrdas. ufro maRali dozebiT infuziisas dopamini

aaqtiurebs β1 da β2 adrenergul receptorebs, rac iwvevs gulis

wuTmoculobis gazrdas. Sesabamisad, dopaminiT mkurnalobisas gadamwyveti

mniSvneloba mis zust dozirebas eniWeba, rac xSirad ar aris advili


28

amocana – rTulia im optimaluri dozis gansazRvra, rac iwvevs

Tirkmelebis sisxlmomaragebis maqsimalurad gazrdas 157 158.

mwvave dekompensirebuli gulis ukmrisobiT hospitalizirebul pacientebSi

xSirad niSnaven vazodilatatorebs (nitroglicerini, natriumis

nitroprusidi, neziritidi) Tirkmelebis sisxlmomaragebis gazrdis mizniT.

Tumca, miuxedavad gulis wuTmculobis zrdisa, maT Zalzed mcire efeqti

aqvT RBF-s matebaze 159 160 161.

miCneulia, rom adenozini aris WRF-isdiuretikebis mimarT rezistentobis

mniSvnelovani intra-renuli mediatori. adenozin-trifosfatis hidrolizis

Sedegad eqstracelularul sivrceSi gamoiyofa Tavisufali adenozini,

romelic moqmedebs A1 receptorebze da iwvevs aferentuli arteriolebis

konstriqcias, rac Tavis mxriv iwvevs RBF-sdaGFR-is Semcirebas da reninis

gamoyofis stimulirebas. amasTan erTad, A1 receptorebis aqtivacia

aZlierebs natriumis reabsorbcias proqsimalur da distalur milakebSi,

rac iwvevs natriumis da siTxis Sekavebas 162.

adenozinis A1 receptorebis antagonist rolofilinze (Rolofylline)

Catarebulma mcre kvlevam aCvena, rom gulis ukmarisobis mqone pacientebSi

misi gamoyeneba ukavSirdeboda diurezis da GFR-is zrdas 163 164. Tumca,

ufro didma, 2033 pacientze Catarebulma kvlevam ar daadastura misi

upiratesoba placebosTan SedarebiT 165.

ultrafiltracia aris mkurnalobis meTodi, romelic gamoiyeneba

moculobiTi gadatvirTvis dros organizmidan Warbi siTxis mocilebis

mizniT. yvelaze praqtikulad miiCneva veno-venozuri ultrafiltracia,

rodesac venuri sisxli gaivlis eqstrakorporaluri filtraciis

aparatSi. ultrafiltracias SeuZlia sisxlidan siTxis mocileba im

siCqariT, ra siCqariTac siTxe qsovilebidan sisxlSi gadadis. Tumca,

zedmetad agresiulma ultrafiltraciam SesaZloa gamoiwvios

heodinamikuri arastabiluroba da Tirkmelebis funqciis gauareseba 166 167.


29

diuretikebis gamoyenebasTan SedarebiT ultrafiltraciis

upiratesobebia 168:

siTxis swrafad mocileba da simptomebis swrafi gaumjobeseba;

igive moculobis siTxis mocilebasTan erTad meti natriumis

gamoyofa;

eleqtrolituri disbalansis ganviTarebis naklebi riski (magaliTad,

hipokalemia);

neirohormonaluri aqtivaciis ararseboba;

diuretikebis mimarT mgrZnobelobis potenciuri aRdgena;

hospitalizaciis xangrZlivobis da re-hospitalizaciis SemTxvevebis

Semcireba;

Tirkmelebis funqciis mzardi gauaresebis Tavidan acileba.

1.2. gulis ukmarisoba

gulis ukmarisoba (HF) aris kompleqsuri klinikuri sindromi, romelsac

iwvevs sisxlis parkuWovani Sevsebis an gandevnis rogorc struqturuli,

aseve funqciuri darRveva. gulis ukmarisobis ZiriTadi gamovlineba aris

qoSini da daRlilobis SegrZneba, rac ukavSirdeba datvirTvis mimarT

tolerantobis Semcirebas da siTxis Sekavebas, ramac Tavis mxriv SesaZloa

migviyvanos SegubebiT movlenebamde filtvebSi da/an muclis RruSi da/an

periferiul SeSupebamde 169 170.

zogierT pacients aReniSneba datvirTvis mimarT tolerantobis darRveva

gamoxatuli SegubebiTi movlenebis gareSe, maSin rodesac sxva pacientebs

aReniSnebaT Segubebis, qoSinis da daRlilobis mkveTrad gamoxatuli

simptomatika 171. im SemTxvevebSi, rodesac moculobiTi gadatvirTvis

niSnebi gamoxatuli ar aris, umjobesia gamoyenebul iqnes termini gulis

ukmarisoba, nacvlad gulis SegubebiTi ukmarisobisa (CHF) 172. ar arsebobs

gulis ukmarisobis erTi diagnostikuri testi, radgan metwilad HF aris


30

klinikuri diagnozi, romelic efuZneba anamnezis da fizikuri gasinjvis

Sedegebs 173.

gulis ukmarisobis klinikuri sindromi SesaZloa ganviTardes

perikardiumis, miokardiumis, endokardiumis, gulis sarqvelebis,

magistraluri sisxlZarRvebis dazianebis da metaboluri darRvevebis

Sedegad, Tumca, HF-s mqone pacientebis umetesobas aReniSneba marcxena

parkuWis miokardiuli disfunqcia 174. aqve unda aRiniSnos, rom HFar aris

kardiomiopaTiis an marcxena parkuWis disfunqciis sinonimi. es

ukanasknelni asaxavan im struqturul Tu funqciur darRvevebs, romlebic

SesaZloa gulis ukmarisobis ganviTarebis mizezi gaxdes 175 176.

amerikis kardiologTa kolejis fondis da amerikis gulis asociaciis

(ACCF/AHA) 2013 wlis gulis ukmarisobis marTvis gaidlaini gansazRvravs

gulis ukmarisobas SenarCunebuli gandevnis fraqciiT (HFPEF) da gulis

ukmarisobas daqveiTebuli gandevnis fraqciiT (HFREF)177:

klasifikacia

EF (%)

ganmarteba

I. gulis ukmarisoba daqveiTebuli gandevnis fraqciiT (HFREF)

≤40 aseve uwodeben sistolur gulisukmarisobas. randomizirebulikontrolirebuli kvlevebi ZiriTadadmoicavs pacientebs (HFREF)-iT daefeqturi Terapia dReisTvis metwiladxelmisawvdomia am kategoriisTvis

II. gulis ukmarisoba SenarCunebuli gandevnis fraqciiT (HFPEF)

≥50 aseve uwodeben diastolur gulisukmarisobas 178. HFPEF-s gasazRvrisTvis SemuSavebulia ramodenime sxvadsxva kriteriumi. diagnostireba ar aris martivi, radgan saWiroebs im arakardiuli mizezebis gamoricxvas, romlebic aseve SesaZloa iwvevdnengulis ukmarisobis msgavs simptomebs. am droisTvis, efeqturi mkurnaloba ar aris gansazRvruli

a. HFPEF, mosazRvre 41-dan es pacientebi Tavsdebian mosazRvre,


31

49-mde anu gardamaval kategoriaSi. maTi daavadebis mimdinareoba, mkurnalobis sqemebi da gamosavali msgavsia pacientebisa HFPEF-iT.

b. HFPEF,gaumjobesebuli

>40 am kategoriis pacientebs warsulSi hqondaT HFREF. klinikuri mimdinareoba SesaZloa gansxvavdebodes rogorcHFREF-s, aseve HFPEF-s persistirebadiformebisgan. damatebiTi kvlevebia saWiro am kategoriis pacientebis ukeTesad klasificirebis mizniT

cxrili 1. HFREFda HFPEFdefiniciaACCF/AHAmixedviT

rogorc amerikis kardiologTa kolejis fondis da amerikis gulis

asociaciis (ACCF/AHA) gulis ukmarisobis stadiebi, aseve niu-iorkis gulis

asociaciis (NYHA)funqciuri klasebi, moicaven mravalmxriv da sasargeblo

informacias gulis ukmarisobis arsebobis da misi simZimis Sesaxeb.

ACCF/AHA-s HFstadiebi ufro fokusirebulia daavadebis ganviTarebasa da

progresirebaze da SesaZloa gamoyenebul iqnes pirovnebebis da

populaciis daxasiaTebisaTvis, maSin, rodesac NYHA-s funqciuri klasebi

fokusirebulia fizikuri aqtivobis SesaZleblobasa da daavadebis

simptomur statusze 179:

ACCF/AHA-s mier gansazRvruli

gulis ukmarisobis stadiebi 180

NYHA-s mier gansazRvruli

funqciuri klasebi 181

A gulis ukmarisobis ganviTarebis maRali riski. gulis struqturuli daavadeba anHF simptomebi ar aRiniSneba

arcerTi

B gulis struqturuli daavadeba, I fizikuri aqtivobis


32

HF-is niSnebi an simptomebi ar aRiniSneba

SezRudva ar aRiniSneba. Cveulebrivi fizikuri datvirTva ar iwvevs HF simptomebis aRmocenebas

C gulis struqturuli daavadeba, aRiniSneboda an aRiniSneba HF- simptomebi

I fizikuri aqtivobis SezRudva ar aRiniSneba. Cveulebrivi fizikuri datvirTva ar iwvevs HF simptomebis aRmocenebas

II aRiniSneba fizikuri aqtivobis mcirediT SezRudva. komfortulad grZnobs Tavs mosvenebis mdgomareobaSi, Tumca, Cveulebrivi fizikuri datvirTva iwvevs HF simptomebis aRmocenebas

III aRiniSneba fizikuri aqtivobis gamoxatuli SezRudva. komfortulad grZnobs Tavs mosvenebis mdgomareobaSi, Tumca, Cveulebrivze naklebi fizikuri datvirTvac ki iwvevs HF simptomebis aRmocenebas

IV nebismieri fizikuri aqtivoba iwvevs HF simptomebis aRmocenebas an HF simptomebi aRiniSneba mosvenebis mdgomareobaSi

D refraqtoruli HF,romelic saWiroebs specializirebul intervenciebs

IV nebismieri fizikuri aqtivoba iwvevs HF simptomebis aRmocenebas an HF simptomebi aRiniSneba mosvenebis mdgomareobaSi

cxrili 2. ACCF/AHAstadiebis da NYHA-s mier gansazRvruli funqciuri

klasebis Sedareba 182


33

Terapiuli intervenciebi TiToeul stadiaze mimarTulia cxovrebis wesis

modificirebaze (stadia A), gulis struqturuli daavadebebis

mkurnalobaze (stadia B), morbidobisa da sikvdilobis Semcirebaze (stadia

C da D) 183. NYHA-s funqciuri klasifikacia warmoadgens sikvdilobis

damoukidebel prediqtors. es klasifikacia farTod gamoiyeneba klinikur

praqtikaSi da samecniero kvlevebSi, iseve, rogorc pacientebis sxvadasxva

mkurnalobis sqemebSi CarTvis gansazRvris mizniT 184 185.

klinikur praqtikaSi aseve gamoiyeneba gulis SegubebiTi ukmarisobis (CHF)

framingamis kriteriumebi (Framingham Criteria) 186. CHF-s diagnozi ismeva im

SemTxvevaSi, Tu saxezea ori ZiriTadi kriteriumi an 1 ZiriTadi da 2 mcire

kriteriumi:

ZiriTadi kriteriumebi

paroqsizmuli Ramis qoSini

kisris venebis daWimuloba

sveli xixini

kardiomegalia (radiologiurad dadasturebuli)

filtvebis mwvave SeSupeba

gazrdili CVP (>16smH2Omarjvena winagulSi)

S3galopi

hepato-iugularuli refluqsi

wonaSi kleba >4.5kg 5 dReSi mkurnalobis fonze

mcire kriteriumebi

bilateraluri SeSupeba koWebis areSi

Ramis xvela

qoSini Cveulebriv fizikur datvirTvaze

hepatomegalia

siTxis dagroveba plevris RruSi


34

sasicocxlo tevadobis Semcireba bolos dafiqsirebuli maqsimumis

mesamedze metad

taqikardia >120 dartyma/wT

mcire kriteriumebis gamoyeneba nebadarTulia mxolod maSin, Tu isini ar

aris gamowveuli sxva samedicino mdgomareobiT (magaliTad, filtvismieri

hipertenziiT, filtvebis qronikuli obstruqciuli daavadebiT, ciroziT,

ascitiT, an nefrozuli sindromiT) 187.

framingamis gulis kvlevis (The Framingham Heart Study criteria) kriteriumebi

xasiaTdeba gulis SegubebiTi ukmarisobis diagnostirebis 100%-iani

mgrZnobelobiT da 78%-iani specifiurobiT 188 189.

gulis ukmarisobis definicia evropis kardiologTa sazogadoebis mier

(ESC) Semdegnairad aris warmodgenili (I da II kriteriumis dakmayofileba

aucilebelia) 190 191:

I. gulis ukmarisobis simptomebi (datvirTvis an mosvenebis dros)

da

II. gulis kunTis disfunqciis (sistoluri an diastoluri) obieqturi

dadastureba (umjobesia eqokardiografiiT) mosvenebaSi da

datvirTvis fonze, rodesac diagnozi saeWvoa

da

III. adeqvaturi pasuxi gulis ukmarisobis winaaRmdeg mimarTul

mkurnalobaze

gulis ukmarisobis mkurnalobis miznebi evropis kardiologTa

sazogadoebis mier Semdegnairad aris gansazRvruli 152:

I. prevencia

a) prevencia da kontroli im daavadebebisa, romelTac mivyavarT

gulis kunTis disfunqciamde da gulis ukmarisobis

ganviTarebamde;


35

b) gulis kunTis disfunqciis SemTxvevaSi daavadebis

progresirebis prevencia;

II. avadobis Semcireba da cxovrebis xarisxis gaumjobeseba;

III. sikvdilianobis Semcireba, sicocxlis gaxangrZliveba.

saqarTveloSi gulis ukmarisobis simZimis SefasebisaTvis ZiriTadad

gamoiyeneba NYHA-s klasifikacia, xolo diagnostirebisTvis gamoiyeneba

evropis kardiologTa sazogadoebis kriteriumebi. aRniSnulis mizezi

metwilad albaT aris is, rom saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis ministris brZanebiT damtkicebuli klinikuri praqtikis

erovnuli rekomendacia (gaidlaini) `gulis qronkuli ukmarisobis

diagnostika da marTva” efuZneba rogorc NYHA-s, aseve ESC gaidlainebs 192.

warmodgenil kvlevaSic gamoyenebulia NYHA-s klasifikacia (ix.: danarTi 1).

rogorc ukve aRiniSna, gulis ukmarisobis dros adgili aqvs simpaTikuri

nervuli sistemis aqtivacias da vazokostriqtorebis da natriumis

Semakavebeli neorohormonebis (angiotenzini II, norepinefrini, endoTelini-1

da arginin vazopresini) Warbad gamoyofas 193. es neirohormonaluri

sistemebi TamaSoben centralur rols rogorc gulis ukmarisobis

paTfiziologiaSi, aseve Tirkmelebis funqciis mravali aspeqtis

regulirebaSi. amgvarad, gulis ukmarisobis dros Warbi neirohormonaluri

aqtivacia iTvleba kardio-renuli sindromis erT-erT mTavar mediatorad,

Tumca, es kavSiri mkafiod gnsazRvruli jerjerobiT ar aris 194.

mediatori

renuli efeqti

wyaro

angiotenzini II aferentuli da eferentuli arteriolebis

konstriqcia;

195

endoTelini-1 aferentuli da eferentuli arteriolebis 196 197


36

konstriqcia, rac ganapirobebs renuli

sisxlmomaragebis da gorglovani filtraciis

siCqaris Semcirebas;

adenozini aferentuli arteriolebis konstriqcia;

eferentuli arteriolebis dilatacia;

renuli sisxlmomaragebis da gorglovani

filtraciis siCqaris Semcireba;

reninis sekreciis daTrgunva;

tubulo-glomeruluri ukukavSiris aqtivacia;

198

simpaTikuri

nervuli

sistema

eferentuli arteriolebis konstriqcia;

renuli sisxlmomaragebis Semcireba;

reninis gamoyofis gazrda iuqstra-

glomerulur aparatSi arsebuli β-

receptorebis meSveobiT;

199

natriurezuli

peptidebi

aferentuli arteriolebis dilataciis

stimulacia da eferentuli arteriolebis

konstriqcia, rac iwvevs gorglovani

filtraciis zrdas;

reninis sekreciis daTrgunva;

200 201

cxrili 3. neirohormonaluri sistemebis aqtivaciis zegavlena Tirkmelebis

hemodinamikaze gulis ukmarisobis dros 202.

1.3. Tirkmelebis dazianebis meqanizmi

GFR–is Semcirebis paTfiziologia HF‐is dros kompleqsuria da moicavs

ramodenime ZiriTad faqtors: miokardiumis sistoluri da diastoluri


37

funqciis darRvevas SeuZlia gamoiwvios hemodinamikuri darRvevebi,

rogorebicaa Semcirebuli dartymiTi moculoba da wuTmoculoba,

arasruli arteriuli avseba, gazrdili winagulovani wneva da venuri

Segubeba 24. es hemodinamikuri darRvevebi biZgs aZlevs mTel rig

kompensatorul neirohormonalur adaptaciebs, rogorebicaa simpaTikuri

nervuli sistemis (SNS) da renin-angiotenzin-aldosteronis sistemis (RAAS)

aqtivacia, sxvadasxva ujreduli procesebi (oqsidaciuri dazianeba da

endoTeluri disfunqcia), rasac sabolood mivyavarT apoftozamde da

renul fibrozamde 1 5 25-29. renin-angiotenzin-aldosteronis sistemis da

sxva neirohormonaluri sistemebis efeqti vrceldeba ara mxolod

sistemur funqciebze, aramed im intra-renul komponentebzec, romlebic

ganapirobebs Tirkmelebis funqciis modulirebas.

bolo wlebis ganmavlobaSi SemuSavda gulis da Tirkmelebis dazianebis

axali biomarkerebi, rogorebicaa: cistatini C, NGAL, KIM-1 (Tirkmlis

dazianebis molekula 1), NAG (N-acetil‐β‐(D) glukozaminidaza), IL‐1 8

(interleikini-18), L‐FABP (RviZlis cximovani mJavebis SemakavSirebeli cila),

CI (katalizuri rkina) 30 203. mosalodnelia, rom am biomarkerebis gamoyeneba

gaaadvilebs CRS-s adreul diagnostirebas da misi tipebis gansazRvras 31.

samwuxarod, aRniSnuli biomarkerebis gamoyeneba jerjerobiT ar aris

farTod xelmisawvdomi 204.


HF-s

Tumc

marc

sind

mult

ukmar

da T

“Semc

Sede

gamok

venur

mtkic

mniSv

suraTi 1.

dros CKD

ca, ar ari

cxena par

romis me

tifaqtor

risobas 3

Tirkmeleb

cirebuli

gebs 34

kvlevebi

ri wnevis

cebuleba

vnelovan

K Tirkme

DxSiria

is naTeli

kuWis ga

eqanizmis

uli daav

33. bolo

bis meora

nakadis”

35. rogo

aCvenebs,

s (CVP) ma

imisa,

rols T

elebis da

si

da ukavSi

i CKD-s ga

andevnis

Camoyali

vadebebis

drois ga

adi disf

Teoriaz

orc cxo

rom int

ateba iwve

rom Ti

TamaSoben

a gulis u

indromis

irdeba ga

avlena si

fraqciaz

ibeba agr

gamo, ro

amokvleve

funqciis

ze dayr

ovelebze,

tra-abdomi

evs GFR-is

irkmelebi

n Tirkmel

urTierTka

dros

azrdil s

ikvdiloba

ze (LVEF).

reTve gar

omlebic x

ebi aCveneb

mqone pac

rdnobiT,

, aseve

inuri wne

s Semcire

is venur

lebis di

avSiri ka

sikvdilob

aze damok

I tipis

rTulebul

xSirad T

bs, rom g

cientebis

ar iZ

adamiane

evis (IAP)

ebas 36-40.

ri wneva

isfunqcis

rdio-renu

bis maCven

kidebulia

s kardio

lia mTel

an axlavs

gulis pi

marTva

Zleva s

bze Cat

da cent

arsebobs

(RVP)

s progres

38

uli

nebels32.

a Tu ara

o-renuli

li rigi

s gulis

rveladi

mxolod

asurvel

arebuli

traluri

mzardi

da IAP

sirebaSi


39

gulis ukmarisobis mqone pacientebSi 39 41 42. kevin damanis (KevinDamman) da

Tanaavtorebis mier Catarebulma kvlevam aCvena, rom CVP asocirebulia

Tirkmelebis funqciis gauaresebasTan da damoukideblad ukavSirdeba

yvela mizeziT gamowveul sikvdilobas gul-sisxlZarRvTa daavadebebis

mqone pacientebis farTo speqtrSi 41. kvlevis mixedviT, renuli

sisxlmomarageba (RBF) aris mTavari faqtori, romelic gansazRvravs GFR-s

gulis disfunqciis mqone pacientebSi. Tumca, venuri Segubeba, romelic

xasiaTdeba gazrdili marjvena winagulis wneviT (RAP), aseve ukavSirdeba

GFR-s. mkurnaloba mimarTuli unda iyos ara mxolod Tirkmelebis

perfuziis gazrdisken, aramed venuri Segubebis Semcirebisken. kvleva

gansakuTrebiT imiT aris saintereso, rom is moicavda pacientebs

filtvismieri hipertenziiT, romelTac aReniSnebodaT metwilad

marjvenaparkuWovani ukmarisoba 41.

heiko uToftis (Heiko Uthofft) da Tanaavtorebis mier Catarebulma kvlevam

ufro ganamtkica mosazreba, rom CVP aris mniSvnelovani hemodinamikuri

faqtori Tirkmelebis funqciis gauaresebisTvis, gansakuTrebiT maSin,

rodesac is ukavSirdeba daqveiTebul wuTmoculobas 42. aRniSnuli kvlevis

mixdviT, gulis mwvave ukmarisobis dros, dabali sistoluri arteriuli

wneva (SBP) da maRali CVPganapirobebs eGFR-is Semcirebas. Tumca, dabali

CVP-c SesaZloa ukavSirdebodes Tirkmelebis funqciis gauaresebas mcire

xniT. aRsaniSnavia, rom kvlevisas gamoyenebuli iyo CVP-s gazomvis ara

tradiciuli, aramed axali, ara-invaziuri meTodi NICVP, romelic iyenebs

periferiul venas centraluris nacvlad da efuZneba kompresiuli

sonografiis meqanizms 205. aseve arsebobs NICVP-is sxva meTodic, romelic

efuZneba impedansuli pleTizmografiis meqanizms 206 207. arcerTi

aRniSnuli meTodis validurobis Sesaxeb jerjerobiT ar arsebobs

sakmarisi informacia 208.

ali ahmedis (Ali Ahmed) da Tanaavtorebis mier ganxorcielebulma kvlevam

aCvena, rom CKD-sTan dakavSirebuli sikvdiloba ufro maRali iyo im

pacientebSi, romlebsac aReniSnebodaT diastoluri disfunqcia sistolur


40

HF-sTan SedarebiT 43. diastoluriHF, anu gulis ukmarisoba SenarCunebuli

gandevnis fraqciiT (HFPEF) zogadad gulis ukmarisobis yvelaze xSiri

formaa 44-46 (arsebobs monacemebi, rom HFPEF-is insidensi aris mTlianad

gulis ukmarisobis SemTxvevebis 50% 47). Tirkmelebis dazianebis Tanxvedra

HFPEF-Tan sakmaod xSiria (gansakuTrebiT asakovan qalebSi hipertenziiT

da/an diabetiT), aseve, mravali SemTxveva SesaZloa ar iyos

diagnostirebuli 48. Tirkmelebis da gulis urTierTkavSiri, rac

potenciurad aRrmavebs HFPEF-s, kompleqsuria da moicavs moculobiT

gadatvirTvas, renul hipertenzias, oqsidaciur stress da anTebiT

procesebs 49 50.

zemoTaRniSnulma faqtebma, romlebic erTgvarad aknineben daqveiTebuli

marcxena parkuWis gandevnis fraqciis rols Tirkmelebis funqciis

gauaresebis procesSi, mkvlevarebi aiZula yuradReba miepyroT marjvena

parkuWisTvis, rogorc SesaZlo faqtorisTvis CRS-is ganviTarebaSi.

1.4. marjvena parkuWis roli

marjvena parkuWis Seswavlis sakiTxi da mis Sesaxeb arsebuli codna

tradiciulad mniSvnelovnad CamorCeba marcxena parkuWisas 51. miuxedavad

imisa, rom marjvenamxrivi gulis ukmarisoba (RSHF) xSirad viTardeba

marcxenamxrivi gulis ukmarisobis Sedegad, is damoukidebladac SeiZleba

ganviTardes iseT klinikur situaciebSi, rogorebicaa: filtvismieri

hipertenzia (PH), filtvebis qronikuli obstruqciuli daavadeba (COPD),

gulis Tandayolili daavdeba (CHD), SemaerTebelqsovilovani daavadeba,

koronaruli arteriebis daavadeba da gulis sarqvelebis dazianeba 209 210.

rodesac marjvena parkuWis funqcia darRveulia, xolo marcxena parkuWis

normaluria, saubroben izolirebul marjvenamxriv gulis ukmarisobaze

(IRVF) 52. monacemebi Tirkmlis funqciis darRvevis Sesaxeb aseT pacientebSi

mwiria da savaraudod xSirad arc aris diagnostirebuli 211 212.


41

marjvena parkuWis disfunqcia SesaZloa TamaSobdes mniSvnelovan da

adreul rols Tirkmelebis funqciis darRvevis paTfiziologiaSi 53, Tumca,

misi funqciuri mdgomareobis Sefaseba problemas warmoadgens. am

droisTvis ar arsebobs erTi, sazogadod miRebuli da praqtikaSi

gamoyenebadi RV indeqsi 54. marjvena parkuWis rTuli anatomiis gamo,

mxolod ramodenime eqoskopiuri parametria miCneuli sarwmunod. TAPSE, anu

samkarediani sarqvlis rgolisebri zedapiris sistoluri eqskursia aris

validuri parametri RV funqciis SefasebisTvis 55. Tumca, klinikur

praqtikaSi misi gansazRvra iSviaTad xdeba. marjvena parkuWis funqciur

mdgomareobasa da moculobiT gadatvirTvaze aseve warmodgenas gviqmnis

marjvena parkuWis saboloo diastoluri diametri (RVEDD).

CVP, romelic marjvena winagulovani wnevis (RAP) miaxloebiTi maCveneblia,

aseve SesaZloa gamoyenebul iqnes RSHF-s diagnostirebisTvis, Tumca,

yovelTvis gasaTvaliswinebelia sxva gul-sisxlZarRvovani parametrebi,

magaliTad, rogoricaa LVEF, radgan marjvenamxrivi wneva SesaZloa iribad

asaxavdes marcxenamxriv wnevas da marcxenamxrivi avsebis wneva SesaZloa

iyos marcxena gulis funqciuri mdgomareobis niSani 56.

frank dinim (FrankL. Dini) da Tanaavtorebma Seiswavles RV disfunqciis da

CKD urTierTkavSiri gulis qronikuli ukmarisobis mqone ambulatoriul

pacientebSi. mkvlevarebma aRmoaCines, rom aRiniSneboda mniSvnelovani

korelacia TAPSE-s da GFR-s Soris 53. kvlevis Sedegebi aZlierebs

mosazrebas, rom gulis ukmarisobis dros Tirkmelebis funqciis

gauaresebis paTfiziologiaSi “ukana” (Backward) ukmarisobiT gamowveuli

venuri Segubeba SesaZloa iseve mniSvnelovani iyos, rogorc “wina”

(Forward) ukmarisoba. RSHF-is gamo gazrdil Tirkmelebis venur wnevas

SeuZlia GFR-is Semcireba TirkmelebSi intersticiuri da milakovani

hidrostatikuri wnevis gazrdis, Tirkmelebis perfuziuli wnevis da

sisxlis midinebis Semcirebis xarjze. hipoqsia, iseve rogorc gazrdili

venuri wneviT gamowveuliHlokaluri da sistemuri neirohormonaluri

aqtivacia kidev ufro amZimebs Tirkmelebis funqciur mdgomareobas am


42

pacientebSi 57 58. Tumca, miuxedavad zemoTaRniSnuli mtkicebulebebisa,

marjvena parkuWis rolis Sefaseba gaZnelebulia, radgan: 1) is xSirad

Tanxvdeba marcxenaparkuWovan ukmarisobasTan SenarCunebuli an

Semcirebuli gandevnis fraqciiT, da 2) Tirkmelebis funqciis darRvevas

aseve SeuZlia gazardos marjvena winagulis wneva (RAP) da gamoiwvios

siTxis Sekaveba, miuxedavad Tanmxlebi gulis ukmarisobis arsebobisa 41.

1.5. Tirkmelebis dazianeba da gorglovani filtraciis siCqare

miCneulia, rom gorglovani filtraciis siCqare yvelaze kargad asaxavs

Tirkmelebis funqciur mdgomareobas 213. rogorc cnobilia, gorglovani

filtraciis siCqare aris siTxis garkveuli moculoba, romelic

ifiltreba Tirkmelebis gorglovan (glomerulur) barierSi drois

garkveul monakveTSi (ml/wT). is ganisazRvreba starlingis formuliT

(Starling equation): GFR = Kf[(Pc‐Pb)‐(Πc)] (ix.: suraTi 2) 214. GFR-is mTavari

fiziologiuri modulatorebi arian aferentuli da eferentuli

arteriolebis rezistentoba: aferentuli arteriolebis rezistentobis

gazrda iwvevs wnevis Semcirebas gorglovan aparatSi da Sesabamisad, GFR-

is Semcirebas 215. eferentul arteriolebsa da GFR-s Soris kavSiri ufro

kompleqsuria: eferentuli rezistentobis gazrda Tavidan iwvevs

glomerulebSi wnevis gazrdas da GFR-ismomatebas, xolo Semdeg, rodesac

eferentuli rezistentoba matulobs, sisxlis nakadi glomerulebSi

mcirdeba da GFR iklebs 216.


gorg

gamoy

klir

konc

gamoi

kreat

kreat

Tirk

Ra= artereziRe= arterezi

glovani

yofil

rensi, xo

centracia

iyeneba go

tininis

tininis m

kmelebis q

aferentuli eriolebis istentoba eferentuli eriolebis istentoba

suraTi 2

filtrac

SardSi

olo ve

217. Tu

orglovan

koncentr

mateba iwv

qronikul

2. gorglo

ciis dasa

ganisazR

nidan u

umca, kl

ni filtra

raciasa

vevs GFR-i

li daavade

GFR=

ovani fil

adgenad

Rvros en

uzmoze a

linikur

aciis Sef

da GFR-s

is Semcir

ebis (CKD)

Kf [(Pc‐Pb)‐

ltraciis

saWiroa

ndogenur

aRebul

praqtikaS

fasebiTi m

s Sori

rebas. GFR

) 5 stadia

‐(Πc)]

meqanizmi

24 saaT

i kreat

sisxlSi

Si dRes

maCvenebel

is arseb

R-ze dayr

a 219:

i

Tis ganma

tininis s

- kre

ufro

li (eGFR) 2

bobs uku

rdnobiT g

Kf= Pgorglokapilarebis ganvladoba Pc= gorglovkapilarebis hidrostatikwneva Pb= boumanis kafsulis hidrostatikwneva Πc= gorglovkapilarebis onkozuri wn

43

vlobaSi

saSualo

eatininis

xSirad

218.

ukavSiri:

ganirCeva

ovani

vani

uri

uri

vani

neva


44

stadia

GFR

aRweriloba

1 >90 Tirkmelebis funqcia normis

farglebSia, Tumca, Sardis monacemebi

da/an struqturuli cvlilebebi

mianiSnebs Tirkmelebis dazianebis

arsebobaze

2 60‐89 Tirkmelebis funqcia mcirediT

daqveiTebulia. sxva mxriv, igive

mdgomareobaa, rogorc pirveli xarisxis

dros

3 30‐59 Tirkmelebis funqcia zomierad aris

daqveiTebuli (saSualo xarisxis

disfunqcia)

4 15‐29 Tirkmelebis funqcia Zlier aris

daqveiTebuli (mZime xarisxis

disfunqcia)

5 <15an dializi Tirkmelebis daavadebis terminaluri

stadia (umZimesi xarisxis disfunqcia)

cxrili 4. CKD 5 stadiaGFR-is mixedviT

Trikmelebis mwvave dazianebis (AKI) SemTxvevaSi GFR-ze dafuZnebuli

klasifikacia am etapisTvis miRebuli ar aris 220 221. Tirkmelebis mwvave

dazianebis qselis (AKIN) †† mier mowodebuli diagnostikuri kriteriumebi

efuZneba Sratis kreatininis matebas ≥ 0.3 mg/dl (≥ 26.4 mkmol/l), mis

procentul matebas ≥50% (sawyisi monacemidan 1.5-jer mateba), an diurezis

†† Acute Kidney Injury Network – saerTaSoriso organizacia, romlis misiac aris internacionaluri da interdisciplinuri kvleviTi aqtivobebis ganxorcieleba Tirkmelebis mwvave dazianebis diagnostirebis, prevenciis da mkurnalobis sferoSi


45

Semcirebas (dokumentirebuli oliguria < 0.5 ml/kg saaTSi 6 sT-ze met

xans) 222.

kardio-renuli sindromis dros arsebuli Tirkmelebis funqciis darRvevis

aRsaniSnavad xSirad gamoiyeneba termini - Tirkmelebis funqciis mzardi

gauareseba (WRF)223224. aRniSnuli terminis qveS metwilad moiazreba gulis

mwvave dekompensirebuli ukmarisobis (ADHF) da mwvave koronaruli

sindromis (ACS) fonze arsebuli Tirkmelebis funqciis mwvave an qvemwvave

gauareseba, rac gamoixateba Sratis kreatininis matebiT. kreatininis

zRvari, ris Semdegac xdeba WRF-is diagnostireba, aris ≥0.3 mg/dl (26.5

mmol/l) 225 226 227, Tumca, rig kvlevebSi es zRvari gansazRvrulia, rogorc

≥0.5 mg/dl 228 229.

ADHF-is diagnoziT hospitalizirebuli pacientebis 14-34%-s aReniSneba WRF

230. aseTi farTo diapazoni metwilad ganpirobebulia imiT, rom sxvadasxvaa

Tirkmelebis funqciis gauaresebis diagnostirebis zRurbli da aseve

gansxvavdeba dakvirvebis dro da hospitalizirebuli pacientebis

Tirkmelebis funqciis sawyisi mdgomareoba 231 232. garda kreatininisa,

Tirkmelebis funqciis Sesafaseblad aseve gamoiyeneba sisxlis Sardovana

azoti (BUN)233234.arsebobs mosazreba, rom is ufro Zlieri markeria vidre

kreatinini, savaraudod imitom, rom im neirohormonaluri aqtivaciis

paralelurad, rasac adgili aqvs gulis ukmarisobis fonze ganviTarebuli

WRF-s dros, BUN ufro kargad asaxavs gulis ukmarisobis

paTfiziologiur meqnizms 235 236. aqve unda aRiniSnos, rom ADHF-s gamo

hospitalizaciis pirvel 48 saaTSi cistatin C‐s mateba 0.3 mg/l-ze metad

miiCneva sikvdilobis damoukidebel prediqtorad 237.

miuxedavad zemoTaRniSnuli mosazrebebisa, Tirkmelebis qronikuli

daavadebis msgavsad, AKI-s simZimis Sefasebisas bolo dros aqtiurad

gamoiyeneba eGFR, kerZod misi MDRD formula 238.


46

1.6. daskvna

mwvave an qronikuli gulis ukmarisobis mqone pacientebSi Tirkmelebis

gauaresebuli funqcia Tanamedrove medicinis mniSvnelovan klinikur

problemas warmoadgens. gul-sisxlZarRvTa daavadebebis dros Tirkmelebis

dazianebis paTfiziologia kompleqsuri procesia da bolomde Seswavlili

ar aris. bolo drois kvlevebi aCvenebs, rom IAP‐is da CVP-s matebas, rac

aseve iwvevs RVP-s matebas, mivyavarTGFR-is Semcirebamde.LVEF‐is da RSHF–is

mniSvneloba CRS‐is dros ar aris srulyofilad Sefasebuli.

gulsa da Tirkmelebs Soris arsebuli ormimarTulebiani kavSiris

srulofilad gaazreba mniSvnelovania, rom gansazRvros optimaluri

mkurnalobis strategiebi CRS–is TiToeuli tipisTvis, radgan erT

organoTa sistemaze mimarTul mkurnalobas SesaZloa hqondes dadebiTi, an

piriqiT, uaryofiTi Sedegi meore organoTa sistemis funqciur

mdgomareobaze.

RSHF-is Sefaseba garTulebulia, Tumca TAPSE da CVP,romelic savaraudo

RAP-s asaxavs, SesaZloa gamoyenebul iqnes RSHF-s diagnostirebisTvis. aqve

unda aRiniSnos, rom maTi gamoyeneba aucilebelia sxva kardio-vaskularul

parametrebTan erTobliobaSi. miuxedavad bolo drois monacemebisa, RSHF-

is rolis Sefaseba CRS-is ganviTarebaSi sakmaod rTulia, radgan RSHF

xSirad aris dakavSirebuli marcxenaparkuWovan ukmarisobasTan da

Tirkmelebis funqciis daRvevasac SeuZlia Tavis mxriv RAP-is mateba

siTxis Sekavebis xarjze, miuxedavad Tanmxlebi gulis ukmarisobis

arsebobisa. meti kvlevebi aris saWiro marjvnaparkuWovan ukmarisobas, CVP-

s da Tirkmlis funqciis gauaresebas Soris korelaciis dadgenis mizniT.


47

2. eTikuri sakiTxebis gadawyveta

nebismieri biosamedicino kvleva saWiroebs eTikuri sakiTxebis

gaTvaliswinebas kvlevis protokolis SemuSavebis fazaSi. Tavidanve unda

ganisazRvros, Tu ra eTikuri sakiTxebi SeiZleba warmoiSvas kvlevis

mimdinareobisas da rogor unda moxdes maTi gadawyveta 239. piradi

informacis konfidencialurobis dacva aris is mTavari eTikuri sakiTxi,

rasac xSirad adgili aqvs ara-eqsperimentul kvlevebSi 240 241. ZiriTadad is

ukavSirdeba pirovnebebis identifikaciis da piradi informaciis

(pirovnebis maidentificirebeli piradi monacemebis) gamJRavnebis safrTxes.

prospeqtuli kvlevebis SemTxvevaSi, pacientebisgan SesaZlebelia

informirebuli Tanxmobis miReba piradi informaciis gamJRavnebis

nebarTvaze, Tumca, retrospeqtiuli kvlevis dizainis gamoyenebisas,

romelic tardeba ukve arsebul monacemebze, es Zalian rTulia da xSirad

SeuZlebelic 242 243. monacemTa anonimizacia SesaZlebelia iyos gamosavali

aseT situaciaSi, sxva im RonisZiebebTan erTad, romlebic gawerilia

saqarTvelos erovnul kanonmdeblobasa da saerTaSoriso gaidlainebSi.

saqarTveloSi samedicino momsaxurebis sferoSi samedicino eTikisa da

bioeTikis mTavar sakonsultacio organos warmoadgens saqarTvelos

Sromis, janmrTelobisa da socialuri dacvis saministrosTan arsebuli

bioeTikis erovnuli sabWo, romlis mizanic aris mosaxleobis samedicino

momsaxurebasTan, samedicino-biologiur kvlevasTan dakavSirebuli eTikuri

aspeqtebis warmoCena da saTanado rekomendaciebis momzadeba.

2.1. mimoxilva

biosamedicino kvlevebSi eTikuri sakiTxebis gaTvaliswineba gansakuTrebiT

aqtualuri gaxda bolo 60-70 wlis manZilze. 1942 wels amerikelma

sociologma robert mertonma (Robert Merton) SeimuSava akronimi CUDOS –

samecniero saqmianobis gunduroba, sazogado Rirebulebebi, uangaroba da

organizebuli skepticizmi (Communism, Universalism, Disinterestedness, and

Organized Skepticism), rac iqca samecniero eTikuri normebis qvakuTxedad 244.


48

mas Semdeg msoflioSi Seiqmna mTeli rigi maregulirebeli dokumentebisa

imisaTvis, rom uzrunvelyofiliyo dadebiT gamosavalze orientirebuli

praqtikuli rekomendaciebis kompleqsi biosamedicino kvelvebis

erTianobis SenarCunebis mizniT 245.

saganmanaTleblo sferoSi saerTaSoriso TanamSromlobis norvegiuli

centris (SIU ‐ Norwegian Centre for International Cooperation in Education) 246 mier

dafinansebulma proeqtma “sadoqtoro programa sazogadoebriv jandacvaSi:

norvegiis ganaTlebis mesame safexuris gamocdileba saqarTvelosTvis”

(Doctoral Programme in Public Health: Norway Experience of Third Cycle Studies for

Georgia), saSualeba misca Tbilisis saxelmwifo universitetis da

saqarTvelos universitetis ramodenime doqtorants CarTuliyvnen

norvegiis tromsos universitetis (UiT:UniversityofTromsø–TheArcticUniversity

of Norway) sadoqtoro swavlebis programaSi. aRniSnulma programam

doqtorantebs, maT Soris warmodgenili sadoqtoro naSromis avtors,

saSualeba misca detalurad gascnobodnen biosamedicino eTikis

regulaciebs norvegiaSi da saerTSoriso gamocdilebas aRniSnul sferoSi.

warmodgenili sadoqtoro kvelvis magaliTze qvemoT ganxiluli iqneba im

eTikuri sakiTxebis gadaWris gzebi, romlebsac zogadad adgili aqvs ara-

eqsperimentul kvlevebSi.

2.2. pacientebis piradi informaciis konfidencialuroba

eqsperimentuli kvlevebisgan gansxvavebiT, ara-eqsperimentul

(obzervaciul-analitikur) kvlevebs zogadad naklebad axasiaTebs

eTikasTan dakavSirebuli sirTuleebi, Tumca, mainc aris sakiTxebi rac

saWiroebs kvalificiur gadawyvetas 247. piradi informacis

konfidencialurobis dacva aris is mTavari eTikuri sakiTxi, rasac xSirad

adgili aqvs ara-eqsperimentul kvlevebSi. ZiriTadad is ukavSirdeba

pirovnebebis identifikaciis da piradi informaciis (pirovnebis

maidentificirebeli piradi monacemebis) gamJRavnebis safrTxes 248. es


49

informacia ZiriTadad Tavmoyrilia samedicino baraTebSi da moicavs

pacientis sqess, asaks, sxeulis masis indeqss da sxva specifiur

informacias, rogorebicaa anamnezi, fizikuri gasinjvis monacemebi da

kvlevebis Sedegebi. aRniSnuli Canawerebi samedicino dawesebulebebSi

inaxeba xangrZlivi droiT (stacionarul dawesebulebebSi 15 wliT,

rogorc gansazRvrulia saqarTvelos kanonmdeblobiT) 249, rac

SesaZleblobas iZleva biosamedicino kvlevebi ganxorcieldes

retrospeqtiulad. prospeqtuli dizainis mqone kvlevebis

ganxorcielebisas informirebuli Tanxmobis miReba pacientebisgan

sirTules ar warmoadgens, Tumca retrospqtiuli kvlevebis SemTxvevaSi es

Zalzed rTuli, an SeuZlebelia 250.

Tu kvleva saWiroebs warsulSi namkurnalevi pacientebis samedicino

Canawerebis retrospeqtiul Seswavlas, maTTan dakavSireba da

informirebuli Tanxmobis mopovoba mniSvnelovnad gaarTulebs kvlevis

mimdinareobas 251. ufro metic, pacientebTan dakavSireba da Tanxmobis

mopoveba unda moxdes mkurnali eqimebis, da ara mkvlevarebis mier, radgan

maT ar aqvT (ar unda hqondeT) wvdoma pacientebis pirad informaciasTan.

rodesac mkurnalobis dros pacientebma eqimebs miawodes garkveuli piradi

informacia, maT CaTvales, rom es informacia gamoyenebuli iqneboda

mxolod mkurnalobisaTvis da ara kvlevebisTvis 252. maSin maTTvis aravis

uTqvams, rom odesme, SesaZloa maTi gardacvalebis Semdegac ki, samdicino

Canawerebi gamoyenebuli iqneboda biosamedicino kvelvebisTvis. ra SeiZleba

iyos gamosavali aseT situaciaSi? pasuxi ar aris calsaxa, Tumca,

SeiZlebelia vipovoT im erovnul da saerTaSoriso normatiul aqtebSi,

romlebic aregulirebs eTikis sakiTxebs medicinaSi, maT Soris

biosamedicino kvlevebis dros. saqarTveloSi es normatiuli aqtebia:

saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris

brZaneba # 276/n - bioeTikis erovnuli sabWos debulebis damtkicebis

Sesaxeb 253


50


brZaneba #N128/n - samedicino eTikis komisiis debulebis damtkicebis

Sesaxeb 254

saqarTvelos kanoni janmrTelobis dacvis Sesaxeb 255

saqarTvelos kanoni pacientis uflebebis Sesaxeb 256

saqarTvelos kanoni sazogadoebrivi janmrTelobis Sesaxeb 257

saqarTvelos kanoni saeqimo saqmianobis Sesaxeb 258

saqarTvelos eqimis eTikis kodeqsi 259

saerTaSoriso aqtebi, romlebic ratificirebuli aqvs saqarTvelos,

rogorc evrosabWos wevr qveyanas:

biologiasa da medicinaSi adamianis uflebebis da keTildReobis dacvis

konvencia: konvencia adamianis uflebebis da biomedicinis Sesaxeb

(oviedos konvencia) (Convention for the Protection ofHumanRights andDignity of

theHumanBeingwithregardtotheApplicationofBiologyandMedicine:Conventionon

HumanRightsandBiomedicine,(OviedoConvension)) 260

adaminis uflebebis da biomedicinis damatebiTi protokoli

biosamedicino kvlevebis Sesaxeb(AdditionalProtocoltotheConventiononHuman

RightsandBiomedicine,concerningBiomedicalResearch) 261

evropuli konvencia xerxemliani cxovelebis dacvis Sesaxeb

eqsperimentebSi da sxva samecniero mizniT gamoyenebis dros (European

Convention for the Protection of Vertebrate Animals used for Experimental and Other

ScientificPurposes)262

sxva mniSvnelovani saerTaSoriso dokumentebi, romlebic saerToa

saqarTvelosa da norvegiisaTvis:

msoflio samedicino asociaciis helsinkis deklaracia - adamianze

Catarebuli samedicino kvlevis eTikuri principebi (World Medical

Association Declaration of Helsinki ‐ Ethical Principles for Medical Research Involving

HumanSubjects)263264


51

msoflio samedicino asociaciis samedicino eTikis saerTaSoriso

kodeqsi (WorldMedicalAssociation‐InternationalCodeofMedicalEthics) 265

vankuveris sazogadoebrivi kolejis eTikis kodeqsi (Vancouver Community

CollegeCodeofEthics)266

bioeTikis erovnuli sabWos struqtura da funqciebi gansazRvrulia


brZanebiT 267. sabWos SesaZloa mimarTos mkvlevarma individualurad, an im

samedicino dawesebulebis eTikis komisiam, sadac kvleva unda Catardes.

eTikis komisiebis arseboba samedicino dawesebulebebSi savaldebuloa da

gansazRvrulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis

ministris brZanebiT268.eTikis komisiebi Sedgeba departamentis minimum erTi

eqimisgan, eqTnis da administraciis TanamSromlisgan. iuristis, eTikis

specialistis da sasuliero piris CarTvac SesaZlebelia, Tumca

savaldebulo ar aris. erovnuli kanonmdeblobiT, samedicino

dawesebulebebis eTikis komisiebs aqvT valdebuleba daamtkicon

nebismieri warmodgenili kvleva, miuxedavad dizainisa (prospeqtuli,

retrospeqtiuli) da monacemTa miRebis gzisa. eTikis komisiebs SeuZliaT

saWiroebis SemTxvevaSi konsultaciis mizniT mimarTon bioeTikis erovnul

sabWos, Tumca amis valdebuleba ar aqvT. rogorc ukve aRiniSna,

individualur mkvevarebsac SeuZliaT mimarTon bioeTikis erovnul sabWos,

iqneba es samecniero Tu studenturi kvleviTi proeqti. universitetebSi,

samecniero sabWoebi axdenen warmodgenili samecniero kvelvebis

samecniero da eTikuri aspeqtebis zogad Sefasebas da saWiroebis

SemTxvevaSi mimarTaven bioeTikis erovnul sabWos. amis Semdgom, eTikuri

sakiTxebis Sefaseba da kanonmdeblobasTan Sesabamisobis uzrunvelyofa

ukve im samedicino dawesebulebebis eTikuri komisiebis pasuxismgeblobaa,

sadac kvleva unda Catardes.

norvegiaSi, yvela proeqti romelic janmrTelobis kvlevis aqtiT (Health

Research Act) aris gansazRvruli, dawyebamde damtkicebuli unda iqnes


52

medicinis da janmrTelobis kvlevis eTikis regionuli komitetis (REK) ‡‡–is

mier. REK–is saqmianoba gansazRvrulia norvegiis kanoniT samedicino

kvlevis da eTikis Sesaxeb 269. komitetebs, romlebic Sedgeba gansxvavebuli

profesiuli kompetenciis pirebisgan, niSnavs ganaTlebis da kvlevis

saministro 4 wlis vadiT. REK-s aqvs Tavisi portali ganacxadis

ganTavsebisaTvis, romelic moicavs informacias erovnuli

administraciuli procedurebis da gaidlainebis Sesaxeb, rom

uzrunvelyofili iyos kvlevis ganxorcielebis usafrTxoeba da

Sesabamisoba kanonmdeblobasTan 270. universitetebs akisriaT

pasuxismgebloba, rom uzrunvelyon maTi kvleviTi proeqtebis Sesabamisoba

norvegiis janmrTelobis kvlevis aqtTan da norvegiis monacemTa dacvis

aqtTan 271. aseve, maT unda uzrunvelyon resursebis mobilizeba xarisxis

SenarCunebis da gaumjobesebis mimarTulebiT. doqtoranturis studentebs

da samecniero proeqtis monawileebs utardebadaT srulyofili

treiningebi im samecniro proeqtebTan dakavaSirebiT, romlebSic isini

erTvebian da Semdgomac, proeqtis mimdinareobisas, uwyvetad iReben

miTiTebebs da rekomendaciebs. rogorc wesi, piradi informaciis gamoyeneba

kvlevis dros mxolod aucileblobis SemTxvevaSi unda moxdes. piradi

informacia ganmartebulia norvegiis monacemTa dacvis aqtis meore muxliT

272. universitetebma kvlevebSi piradi informacia unda gamoiyenon mxolod

kvlevis eTikis principebis dacviT 273.

imisaTvis, rom efeqturad imarTos konfidencialurobis sakiTxi ara-

eqsperimentul kvlevebSi, aucilebelia zemoTaRniSnuli eTikuri

sakiTxebis maregulirebeli normatiuli aqtebis mimoxilva. rogorc

saqarTvelos kanoni saeqimo saqmianobis Sesaxeb da saqarTvelos kanoni

pacientis uflebebis Sesaxeb gansazRvravs, mkurnali eqimebi, romlebic

TavianTi pcientebis samedicino dokumentaciidan kvlevisTvis saWiro

informacias iReben, ar arRveven pacientis konfidencialurobas, Tu

daculia piroba, rom Sedegebi gamoqveyndeba imgvarad, rom SeuZlebeli

iqneba pacientis identificireba. eqimebis piradi pasuxismgeblobaa

‡‡RegionalCommitteesforMedicalandHealthResearchEthics


53

pacientebis samedicino informaciis konfidencialurobis dacva.

miuxedavad amisa, maT unda warudginon TavianTi kvlevebi samedicino

dawesebulebebis eTikis komisiebs gansaxilvelad, rogorc amas

kanonmdebloba moiTxovs.

konfidencialuri samedicino informaciis gamJRavneba uSualod pacientis

da misi mkurnali eqimis (eqimebis) garda sxva pirebze dasaSvebia moxdes

Semdeg situaciebSi:

1. rodsac pacienti iZleva Tanxmobas;

2. rodesac amas moiTxovs kanoni (arsebobs sasamarTlos

gadawyvetileba);

3. rodesac aris gansakuTrebuli sazogadoebrivi interesi.

rogor unda moviqceT im SemTxvevaSi, rodesac kvlevis interesebidan

gamomdinare mkvlevarebi saWiroeben wvdomas samedicino CanawerebTan?

eTikuri principebi daculi iqneba, Tu:

1. pacientebs micemuli aqvT Tanxmoba maTi samedicino Canawerebis

kvlevisTvis gamoyenebaze;

2. samedicino Canawerebi aris anonimuri;

3. daculia specialuri sakomunikacio procedura ara-anonimuri

informaciis kvlevisTvis gamoyenebaze.

rogorc ukve aRiniSna, retrospeqtiuli kohortuli an kros-seqciuli

kvlevebis dros gamoiyeneba ukve arsebuli samedicino Canawerebi da am

dros Zalian rTulia pacientebisgan informirebuli Tanxmobis mopoveba 274

275. SesaZlebelic rom iyos, pacientebisgan informirebuli Tanxmobis

moTxovnis ufleba mxolod mkurnal eqimebs aqvT, da ar mkvlevarebs 276.

SesaZlebelia Tu ara, monacemTa anonimizacia iyos gamosavali aseT

situaciaSi? Teoriulad, SesaZlebelia, da informirebuli Tanxmobis

miRebis procedurac Tavidan iqneba acilebuli. es xdeba Semdegnairad:

rodesac samedicino Canawerebis anonimizacia xorcieldeba samedicino

dawesebulebebSi, TiToeul pacients eniWeba unikaluri kodi. kodi da

masze mibmuli samedicino monacemebi xelmisawvdomia mkvlevarebisTvis,


54

xolo piradi informacia, rac dgas kodis ukan da iZleva pirovnebis

identifikaciis SesaZleblobas (magaliTad, identifikatorebi – saxeli,

gvari, dabadebis TariRi, piradi nomeri, dazRvevis nomeri, misamarTi, tel.

nomeri, el.fosta, fotosuraTi, da sxv.), mkacrad aris daculi samedicino

centris personalis mier 277. amgvari anonimizacia SesaZlebelia, rodesac

yvela samedicino Canaweri Senaxulia eleqtronulad, rac samwuxarod ar

aris xSiri praqtika qarTul samedicino dawesebulebebSi. garkveul doneze

anonimizacia miiRweva, Tumca, samedicino Canawerebis nawili, rogorebicaa

magaliTad, laboratoriuli kvlevis Sedegebi an eqimi-specialitebis

dRiuri Canawerebi (kursusebi), mxolod qaRaldzea Senaxuli. Sesabamisad,

rodesac vinmes survili aqvs am Canawerebis naxvis, xdeba SemTxveviTi

wvdoma pacientis pirad informaciasTan (identifikatorebTan).

gamosavali am SemTxvevaSi SesaZloa iyos specialuri sakomunikacio

proceduris dacva samedicino kvlevisTvis ara-anonimuri informaciis

gamoyenebze. samedicino dawesebulebebma unda SeimuSavon iseTi procedura,

romelic uzrunvelyofs pacientebis piradi informaciis daculobas

mkvlevarebisgan. es SesaZlebelia ganxorcieldes mkurnali eqimebis

CarTviT kvleviT proeqtebSi, sadac isini Seasruleben “mekavSiris” rols

mkvlevarebsa da samedicino Canawerebs Soris. samedicino daweseblebebma

aseve unda gamonaxon resursebi im eqimebis mxardasaWerad, romlebic

gamoTqvamen survils daexmaron mkvlevarebs da CaerTon kvleviT

proeqtebSi. Tavisi mxidan, mkvlevarebma unda aiRon valdebuleba, rom ara-

anonimuri monacemebi Senaxuli iqneba mkacrad konfidencialurad.

identifikatorebis mocileba samedicino failebze unda moxdes rac

SeiZleba adreul etapze da kvleviTi samuSao unda Catardes anonimur

monacemTa bazaze. es aris is sakiTxi, raze meTvalyureobazec Tavis Tavze

unda aiRon samedicino dawesebulebebis eTikis komisiebma.

aseve, metad mniSvnelovania, rom kvlevis protokolebi, romlebic

gansaxilvelad wardgenili iqneba eTikis komisiebisTvis, moicavdes

potenciuri eTikuri sirTuleebis gadaWris gzebs da asabuTebdes

gansaxorcielebeli kvlevis klinikur mniSvnelobas. pacientebis


55

konfidencialurobis darRvevis safrTxe zedmiwevniT unda iqnes

Sefasebuli da maTi Tavidan acilebis gzebic unda iyos warmodgenili.

mxolod aRniSnuli pirobebis dakmayofilebis Semdgom unda moiwonon

eTikis komisiebma kvlevebis protokolebi da uzrunvelyon wvdoma

samedicino Canawerebze.

2.3. daskvna

pacientebis paradi informaciis konfidencialuroba SesaZloa iyos

mniSvnelovani gamowveva ara-eqsperimentuli kvlevebis ganxorcielebisas.

imisaTvis, rom eTikuri sakiTxebis gadawyveta SesabamisobaSi iyos

maregulirebel normatiul aqtebTan, samedicino dawesebulebebi da

mkvlevarebi valdebulni arian:

rodesac SesaZlebelia, miawodon informacia pacientebs (an maT

kanonier warmomadgenlebs) samedicino Canawerebis kvlevisTvis

gamoyenebis SesaZleblobis Sesaxeb. prospeqtul reJimSi

informirebuli Tanxmoba mopovebul inda iqnes mkurnali eqimebis mier,

Semdegi niuansis gaTvaliswinebiT: “eqimi gansakuTrebuli sifrTxiliT

unda miudges pacientis mxridan Tanxmobis miRebis sakiTxs, radgan

SesaZlebelia is Tavs Tvlides masze (eqimze) damokidebulad da es

gaakeTos garkveuli iZulebiT. aseT situaciaSi umjobesia Tanxmoba

mopovebul iqnes sxva pirisgan, romelic Tavisufali iqneba aRniSnuli

damokidebulebisgan (msoflio samedicino asociacia (WMA), helsinkis

deklaracia, paragrafi 26, 2008).

kvlevis mimdinareobisas minimumamde unda iqnes dayvanili pirad

informaciasTan wvdoma, im SemTxvevebSi, rodesac SeuZlebelia

informirebuli Tanxmobis miReba da/an monacemTa sruli anonimizacia.

samedicino failebidan piradi identifikatorebis mocileba unda

moxdes rac SeiZleba adreul etapze da kvleviTi samuSao unda

Catardes anonimur monacemTa bazaze. kvlevis Sedegebi unda


56

gamoqveyndes imgvarad, rom SeuZlebeli iyos pacientebis

identificireba.

warmodgenilma sadoqtoro kvlevam gaiara zemoTaRniSnuli yvela

procedura, kerZod, Tbilisis saxelmwifo univesitetis sadsertacio

sabWos mier kvlevis damtkicebis Semdeg, kvlevis protokoli ganxilul da

mowonebul iqna im samedicino dawesebulebebis eTikis komisiebis mier,

sadac kvleva ganxorcielda. magaliTisTvis mogvyavs amonaridi

hospitaluri qseli “medalfas” kaspis samedicino centris eTikis komisiis

daskvnidan: “kvlevis Catarebis mimarT eTikuri winaaRmdegoba ar arsebobs.

kvleva aris retrospeqtiuli, rac gamoricxavs pacientebis informirebuli

Tanxmobis mopovebis SesaZleblobas. Sesabamisad, saWiro monacemebis

amoReba samedicino baraTebidan unda moxdes mkurnali eqimebis mier, raTa

daculi iqnes pacientebis konfidencialuroba. TiToeul pacients mieniWeba

individualuri kodi, romelic Seinaxeba samedicino dawesebulebaSi.

kvlevis oqmi, romelic gadaecema kvlevis samecniero xelmZRvanels, iqneba

anonimuri, rac SeuZlebels gaxdis pirovnebis identificirebas”.

kvlevis Sesaxeb informacia aseve miewoda bioeTikis erovnul sabWos.


57

3. kvlevis miznebi, meTodologia da protokoli

rogorc ukve aRiniSna, warmodgenili kvelva warmoadgens ara-

eqsperimentul kvlevas. miuxedavad amisa, saerTaSoriso rekomendaciebis

Tanaxmad is registrirebulia klinikuri kvlvebis saerTaSoriso reestrSi

veb gverdze: https://clinicaltrials.gov.registraciis nomeria:NCT02792387.

3.1. kvlevis miznebi

kvleva efuZneba hipoTezas, rom marcena parkuWis gandevnis fraqciis

Semcireba ar ukavSirdeba GFR-is Semcirebas, xolo CVP, marcxena parkuWis

gandevnis fraqciaze metad aris korelaciaSi Tirkmelebis funqciis

darRvevasTan (gamoxatuli, rogorc Semcirebuli GFR<90) im pacientebSi,

romlebsac aReniSnebaT kardio-renuli sindromis I da II tipi. hipoTezis

dadastureba gavlenas iqoniebs riskebis adreul Sefasebasa da CRS‐s

adreul diagnostirebaze, aseve, daavadebis mimdinareobasa da gamosavalze.

3.2. dizaini

kvlevis dizaini iyo kros-seqciuli tipis §§ da ganxorcielda Semdegi

samedicino dawesebulebebis bazaze: hospitaluri qseli “medalfas” 4

samedicino centri, mediqlabjorjia, sisxlZarRvTa da gulis daavadebaTa

centri (n. boxuas saxelobis). kvleva moicavda stacionaruli pacientebis

klinikur SemTxvevebs, 2015 wlis seqtembridan 2016 wlis maisis CaTvliT.

pacientebis retrospeqtiuli CarTva ganxorcielda winaswar gansazRvruli

kriteriumebis mixedviT (ix.: 3.3.). monacemebis amoReba ganxorcielda

stacionaruli samedicino baraTebidan, romlebic rig SemTxvevebSi

§§kros-seqciuli kvleva, anu analizi, aris obzervaciuli kvlevebis nairsaxeoba romelic gulisxmobs drois garkveul monakveTSi populaciidan an warmomadgenlobiTi (reprezentatiuli) jgufidan mopovebuli informaciis analizs. kros-seqciuli kvlevebi aris deskrifciuli xasiaTis (ar aris xangrZlivi (longitudinal), arc eqsperimentuli)


58

xelmisawvdomi iyo eleqtronulad (sisxlZarRvTa da gulis daavadebaTa

centri). eGFRganisazRvra Tirkmelebis daavadebebis dros modificirebuli

dietis formuliT (MDRD). CVP-s monacemebi mocemuli iyo vercxliswylis

svetis sidideSi (Canawerebis mixedviT, yvela SemTxvevaSi CVPgansazRvruli

iyo eleqtronuli gadamwodiT laviwqveSa an Sida sauRle venis midgomiT).

3.3. sakvlevi populacia, CarTvis da gamoricxvis kriteriumebi

kvleva moicavda pacientebs gulis ukmarisobis sxvadasxva funqciuri

klasiT (NYHA klasi I – IV, SenarCunebuli an daqveiTebuli gandevnis

fraqciiT - ICD10: I50.0 – I50.9; I13.0 – I13.9) da Semcirebuli eGFR-iT (kardio-

renuli sindromi I da II tipi). Sesabamisad, CarTvis kriteriumebi iyoHFI‐IV

daeGFR<90.

gamoricxvis kriteriumebi gansazRvruli iyo Semdeg saxiT:

1. Tirkmelebis funqciis darRvevis damoukidebeli risk-faqtorebis

arseboba (magaliTad, sefsisi, diabeti);

2. pirveladi nefropaTia an meoradi nefropaTia gamowveuli gulis

ukmarisobis garda nebismieri sxva mizeziT.

3.5. statistikuri damuSavebis gegma

aRweriTi da analitikuri statistikis, damokidebul cvladze

statistikuri testirebis mizniT gamoyenebuli iyo programa IBM SPSS

Statisticsversion22.

eGFR (MDRD formula) gansazRvruli iyo rogorc damokidebuli cvladi

(OutcomeVariable), xolo sqesi, asaki, LVEF%,HF(NYHAklasi I ‐ IV),CVP, RVEDD

da arteriuli hipertenzia (JNCVIII klasifikaciiT), rogorc damoukidebeli

cvladebi (Predictor Variable), LVEF, rogorc potenciuri gavlenis faqtori

(ConfoundingFactor)CVP-s daeGFR-s Soris korelaciis arsebobis SemTxvevaSi.


59

3.6. monacemTa mopoveba

warmodgenili kvlevis SemTxvevaSi, iseve rogorc zogadad retrospetiuli

kvlevebis dros, saWiro monacemebis amoReba xdeboda ukve arsebuli

klnikuri SemTxvevebis samedicino Canawerebidan. am konkretul SemTxvevaSi

problemas warmoadgenda is garemoeba, rom zogadad ar arsebobs kardio-

renuli sindromis diagnozis ICD10*** kodi (klasifikatori), romelic dRes

farTod gamoiyeneba saqarTveloSi da msoflios mniSvnelovan nawilSi 278.

Sesabamisad, monacemTa bazebSi kardio-renuli sindromis diagnozi ar

yofila (da dResac ar aris) dafiqsirebuli. samedicino dawesebulebebSi

mkurnali eqimebis mier saWiro iyo gulis ukmarisobiT (ICD10: I50.0 – I50.9)

diagnostirebuli yvela pacientis samedicino baraTis naxva da

Tirkmelebis funqciuri mdgomareobis Sefaseba iq arsebuli Canawerebis da

kvlevis Sedegebis mixedviT. aqve unda aRiniSnos, rom kardio-renul

sindromTan erTi SexedviT axlos aris ICD10kodi I13, romelic gulisxmobs

“gulisa da Tirkmlis hipertenziul avadmyofobas” †††, Tumca, misi

gamoyenebis aucilebeli pirobaa arteriuli hipertenziis arseboba, rac

yovelTvis ar gvxvdeba CRS-is dros.

rogorc pacientis kvlevaSi registraciis formiT da protokoliT iyo

gansazRvruli, mkurnali eqimebis mier saWiro iyo Semdegi monacemebis

amoReba pacientebis samedicino baraTebidan:

1. sqesi

2. asaki

3. LVEF%

4. gulis ukmarisobis klasi (I-IV NYHA)

5. CVPmmHg

6. kreatinini

7. RVEDD*** ICD‐10 aris jandacvis msoflio organizaciis (WHO) daavadebebis da janmrTelobasTan dakavSirebuli problemebis saerTaSoriso statistikuri klasifikaciis me-10 gadaxedva †††Hypertensiveheartandrenaldisease


60

8. arteriuli hipertenzia (JNCVIII)

garda aRweriTi (deskrifciuli) statistikis miRebisa, 1-li, me-2, da me-6

monacemebi auclebeli iyo kvlevis damokidebuli cvladis (dependent

variable, outcome variable) ‐ eGFR‐is gamosaTvlelad (gamoTvlisas aseve

gamoiyeneba pacientis rasobrivi kuTvnilebis monacemi). eGFR, anu

gorglovani filtraciis SefasebiTi maCvenebeli (Estimated Glomerular

Filtration Rate) aris GFR-is miaxloebiTi, maTematikuri formuliT miRebuli

sidide 279.

zrdasrul pacientebSi rekomendebulia eGFR-is ori formulis gamoyeneba.

esenia: Tirkmelebis daavadebebis dros modificirebuli dietis formula

(Modification of Diet in Renal Disease (MDRD) formula)da Tirkmelebis qronikuli

daavadebis epidemiologTa kolaboraciis formula (Chronic Kidney Disease

EpidemiologyCollaboration(CKD‐EPI)formula)280.

MDRDformula:

eGFR = 186 Sratis kreatinini ‐1.154 asaki ‐0.203 (1.210Tu Savkaniania)

(0.742Tu qalia)

CKD‐EPIformula:

eGFR=141min(SCr/k,l)max(Scr/k,l)‐1.2090.993asaki (1.018Tu qalia) (1.159

Tu Savkaniania)

eGFR-is gamoTvla aseve SesaZlebelia onlain kalkulatorebis saSualebiT,

magaliTad, Tirkmelebis erovnuli fondis (NationalKidneyFoundation) ‡‡‡ veb-

gverdze ganTavsebuli onlain kalkulatoris meSveobiT:

https://www.kidney.org/professionals/kdoqi/gfr_calculator.

warmodgenil kvlevaSi gamoyenebulia MDRD formula, radgan arsebobs

monacemebi, rom CKD‐EPI-sgan gansxvavebiT is Tanabrad zustia mwvave da

qronikuli SemTxvevebis dros 281 282.

‡‡‡ aSS-Si registrirebuli msxvili arasamTavrobo organizacia, romlis Stab-binac mdebareobs niu-iorkSi


61

pacientebis samedicino CanawerebSi arsebuli Sratis kreatininis

monacemebi ZiriTadad gansazRvruli iyo mg/dl (mg/dL) sidideSi. mkmol/l

(µmol/L) sidideSi gansazRvruli monacemebis gadayvana mg/dl-ze xdeboda

88.4-ze gayofiT 283.

rac Seexeba CVP-s, kvlevaSi gamoyenebuli yvela monacemi mocemuli iyo

vercxliswylis svetis sidideSi (Canawerebis mixedviT, yvela SemTxvevaSi

CVP gansazRvruli iyo eleqtronuli gadamwodiT laviwqveSa an Sida

sauRle venis midgomiT).

kvlevis mimdinareobisas gamoikveTa, rom asobiT pacientis klinikuri

SemTxvevidan mxolod Zalzed mcire nawili akmayofilebda kvlevaSi

CarTvis kriteriumebs. umetes SemTxvevebSi ar iyo gansazRvruli CVP,an ar

iyo miTiTebuli gazomvis meTodologia. bunebrivia, CVP gansazRvruli iyo

mxolod im klinikur SemTxvevebSi, rodesac pacientebs aReniSnebodaT

gulis mwvave ukmarisoba (AHF) da mkurnaloba utardebodaT intensiuri

Terapiis ganyofilebaSi (kardio-renuli sindromis pirveli tipi). aseve,

xSirad ar iyo sakmarisi informacia anamnezis Sesaxeb, rac ar iZleoda

saSualebas diferencireba momxdariyo Tirkmelebis pirvelad Tu meorad

dazianebas Soris. gadawyda Seqmniliyo 2 jgufi (monacemTa baza), erTi CVP-

s monacemebiT (CVP group), romelic moicavda kardio-renuli sindromis

pirveli tipis klinikur SemTxvevebs, xolo meore CVP‐s gareSe (Non‐CVP

group), romelic moicavda kardio-renuli sindromis meore tipis klinikur

SemTxvevebs. CVP group‐Si Catarda piloturi kvleva didi kvlevisTvis

statistikuri parametrebis gansazRvris da instrumentebis testirebis

mizniT 284 285.


62

4. Sedegebi

Non‐CVP jgufSi (CRS II tipi) monawileTa saerTo raodenoba iyo 44,

saSualo asaki - 67.8 (SD 13.1), da 64% iyo mamakaci. saSualo eGFR iyo 60.8

ml/min/1.73m2(SD19), saSualo LVEF–42.7(SD14)da saSualoRVEDD–34.5(SD

6.2).

cxrili 5. Non‐CVP jgufis aRweriTi statistika

LVEF‐s da eGFR-s Soris asociaciis dadgenis mizniT gamoyenebul iqna

pirsonis korelaciis testi (Pearson correlation analysis) 286 287, romelic iyo

statistikurad mniSvnelovani, Tumca uaryofiTi:‐0.336(Sig.0.026).

Correlations

LVEF eGFR

LVEF Pearson Correlation 1 -.336*

Sig. (2-tailed) .026

N 44 44

eGFR Pearson Correlation -.336* 1


N 44 44

*. Correlation is significant at the 0.05 level (2-tailed).

cxrili 6. korelacia eGFR-sdaLVEF-sSoris

Descriptive Statistics

N Range Minimum Maximum Sum Mean Std.

Deviation

Variance

eGFR 44 85.00 5.00 90.00 2673.00 60.7500 19.02401 361.913

LVEF 44 44.00 16.00 60.00 1880.00 42.7273 14.03544 196.994

HF 44 3.00 1.00 4.00 120.00 2.7273 .62370 .389

RVEDd 44 28.00 21.00 49.00 1516.00 34.4545 6.23738 38.905

Age 44 67.00 23.00 90.00 2981.00 67.7500 13.14344 172.750

Valid N

(listwise)

44


gr

rac

pirso

uary

gamov

dias

rafiki 1.

Seexeba k

onis kor

ofiTi, sa

vlinda

tolur d

eGFR-sda

korelacia

relaciis

aSualo s

eGF

R

HF

*. C

cxril

korelac

diametrsa

LVEF-s S

as gulis

testiT

iZlieris

F Pearson

Sig. (2-ta

N

Pearson

Sig. (2-ta

N

Correlation is sig

li 7. kor

ciis ar

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oris kor

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ukmariso

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Correlation

n Correlation

ailed)

n Correlation

ailed)

gnificant at the

elacia eG

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relaciis

ma

obis NYHA

nda stat

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ns

eGFR

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44

-.349*

.020

44

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marjve

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amsaxveli

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44

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tailed).

HF-sSoris

ena park

=44,r=‐0.0

i wertil

daeGFR-s

d mniSvn

).

s

kuWis s

093,p=0.54

63

ovani

s Soris,

elovani,

saboloo

48).


64

Correlations

eGFR RVEDd

eGFR Pearson Correlation 1 -.093


N 44 44

RVED

d

Pearson Correlation -.093 1


N 44 44

cxrili 8. korelacia eGFR-sdaRVEDD-sSoris

Non‐CVP jgufis (CRS II tipi) Seqmnisas gamovlinda, rom sakvlev drois

monakveTSi gulis ukmarisobiT hospitalizirebuli pacientebis 31.7%-s

aReniSneboda Tirkmelebis funqciis meoradi gauareseba (kardio-renuli

sindromis meore tipi). aqedan, Tirkmelebis qronikuli daavadebis (CKD)

klasifikaciiT, 59%-s aReniSneboda Tirkmelebis funqciis mciredi (GFR=60-

89), 25%-s zomieri (GFR=30-59), 13.7%-s mZime (GFR=15-29) da 2.3%-s terminaluri

(GFR<15) daqveiTeba. CKDdiagnostirebuli iyo SemTxvevaTa 11.4 %-Si.

CVP jgufSi (CRS I tipi) monawileTa saerTo raodenoba iyo 11, saSualo

asaki - 65 (SD 12.5), da 63.6% iyo mamakaci. saSualo eGFRiyo43ml/min/1.73m2

(SD10), saSualo LVEF‐46(SD6)da saSualoCVP–10.4mmHg(SD1.1).


N Minimum Maximu

m

Mean Std.

Deviation

Age 11 45.00 86.00 64.9091 12.49363

LVEF 11 37.00 55.00 45.9091 6.00757

Cr 11 1.35 1.90 1.6045 .17096

eGFR 11 27.30 57.30 42.9455 10.04205

CVP 11 8.00 12.10 10.3545 1.13258

Valid N (listwise) 11

cxrili 9. CVP jgufis aRweriTi statistika


65

aRniSnul jgufSi CVP‐s da eGFR-s Soris asociaciis dadgenis mizniT

gamoyenebul iqna pirsonis korelaciis testi, romlis mixedviTac

korelacia iyo saSualo siZlieris, Tumca, monawileTa mcire raodenobis

gamo, statistikurad ara-mniSvnelovani: ‐0.48 (Sig. 0.14). LVEF‐s da eGFR-s

Soris gamovlinda ufro susti, Tumca statistikurad aseve ara-

mniSvnelovani korelacia: 0.12 (sig. 0.72). ganisazRvra CarTvis moculoba

farTomasStabiani kvlevebisTvis: α (two‐tailed) = 0.050, β = 0.200, r = ‐0.480,N =

[(Zα+Zβ)/C]2+3=32.

Correlations

eGFR CVP

eGF

R

Pearson Correlation 1 -.475


N 11 11

CVP Pearson Correlation -.475 1


N 11 11

cxrili 10. korelacia eGFR-sdaCVP-sSoris

pacientebis samedicino Canawerebze muSaobisas gamoikveTa sayuradRebo

tendencia, rom rogorc mwvave, aseve qronikuli gulis ukmarisobis dros

Tirkmelebis funqciis Sefasebisas eqimebi eyrdnobodnen ara eGFR‐is, aramed

Sratis kreatininis monacemebs, rac naklebad iZleva CKD-is adreuli da

srulyofili Sefasebis SesaZleblobas.


66

5. daskvna

1. dadasturda kvlevis hipoTeza im nawilSi, rom kardio-renuli

sindromis meore tipiT daavadebul pacientebSi marcxena parkuWis

gandevnis fraqciis Semcireba ar ukavSirdeba Tirkmelebis funqciis

gauaresebas (gamoxatuli, rogorc eGFR<90). kvlevis Sedegebma aCvena

statistikurad mniSvnelovani uaryofiTi korelacia LVEF-s da eGFR-s

Soris (n=44,r=‐0.336,p=0.026).

2. marcxena parkuWis gandevnis fraqciisgan gansxvavebiT, kardio-renuli

sindromis meore tipiT daavadebul pacientebSi gamovlinda kavSiri

NYHA-s klasifikaciiT gulis ukmarisobis funqciuri klasis matebas

da eGFR-is Semcirebas Soris (n=44, r=‐0.349, p=0.02). aRniSnuli Sedegi

kidev erTxel xazs usvams NYHA-s klasifikaciis sargeblobas gulis

ukmarisobis simZimis Sefasebis mxriv da aseve, Tirkmelebis funqciis

gauaresebis riskis gansazRvris mizniT.

3. pirsonis korelaciis testma aCvena saSualo daswvrivi (uaryofiTi)

kavSiri CVP‐s da eGFR-s Soris (r=‐0.48, p=0.13) kardio-renuli

sindromis pirveli tipis dros, rac gansazRvravs SerCevis sasurvel

moculobas statistikuri analizisaTvis amgvari, magram ufro

farTomasStabiani kvlevebisTvis: α(two‐tailed)=0.050,β=0.200,r=‐0.480,

N=[(Zα+Zβ)/C]2+3=32.

4. kvlevam gamoavlina korelaciis ararseboba marjvena parkuWis

saboloo diastolur diametrsa (RVEDD) da eGFR-s Soris (n=44, r = ‐

0.093, p=0.548) kardio-renuli sindromis meore tipiT daavadebul

pacientebSi.

5. sakvlev drois monakveTSi gulis qronikuli ukmarisobiT

hospitalizirebuli pacientebis 31.7%-s aReniSneboda Tirkmelebis

funqciis meoradi gauareseba (kardio-renuli sindromis meore tipi).

aqedan, Tirkmelebis qronikuli daavadebis (CKD) klasifikaciiT, 59%-s

aReniSneboda Tirkmelebis funqciis mciredi (GFR=60-89), 25%-s


67

zomieri (GFR=30-59), 13.7%-s mZime (GFR=15-29) da 2.3%-s terminaluri

(GFR<15) daqveiTeba. CKDdiagnostirebuli iyo SemTxvevaTa 11.4 %-Si.

6. kardio-renuli sindromis adreuli diagnostirebisTvis

mizanSewonilia Tirkmelebis funqciuri mdgomareobis Sefaseba eGFR

MDRD formulis gamoyenebiT. eGFR-is gansazRvra SesaZleblobas

iZleva adreul stadiaze gamovlindes Tirkmelebis disfunqcia da

saWiroebis SemTxvevaSi moxdes arsebul mkurnalobaSi koreqtivebis

Setana (ACEInhibitors,ARBs, NSAIDda sxv.).


68

5. English summary

SomecharacteristicsofinteractionbetweenheartandkidneysinCardio‐

RenalSyndromeType1andType2

ADissertationThesisSummary

Author:GeorgeLobzhanidze

TbilisiStateUniversity,FacultyofMedicine

ACKNOWLEDGEMENTS

IwouldliketoexpressmydeepestgratitudetomyscientificadvisorattheTheUniversityof

Tromsø ‐TheArcticUniversityofNorway (UiT),ProfessorBjørnStraume, forhis excellent

guidance,andforhelpingmetodevelopmybackgroundinepidemiologyandbiostatistics.

I would like to thank Professor Toralf Hasvold, for his exceptional contribution in the

cooperation betweenTSU andUiTwithin the framework ofDoctoral Programme in Public

Health:NorwayExperienceofThirdCycleStudiesforGeorgia.

Special thanks go to Professor Zurab Pagava, TSU Medical Faculty Dean Alexandre

Tsiskaridze,ProfessorDimitriKordzaia,AssociateProfessorNinoChikhladzeandAssociate

ProfessorNinoSharashidze,fortheirsupport,guidanceandvaluableadvicesduringthePhD

educationprocess.

Lastbutnot the least, Iwould liketothankmyparentsandmywife forsupportingmeand

encouragingmewiththeirbestwishes.


69

OBJECTIVES

TheprimaryaimofthisPhDstudyhasbeentoexploretheassociationbetweenLeftVentricle

Ejection Fraction (LVEF), right heart failure, increased central venous pressure (CVP), and

renal dysfunction manifested as reduced Estimated Glomerular Filtration Rate (eGFR) in

patients with Cardio‐Renal Syndromes types 1 and 2. The hypothesis suggests that CVP,

ratherthanLVEFcorrelatesdirectlywithreducedeGFR.

BACKGROUND

Deteriorated renal function in patients with acute or chronic heart failure represents an

importantclinicalchallengeofmodernmedicine.Theprevalenceofmoderatetosevererenal

impairment (defined as a Glomerular Filtration Rate less than 60mL/min per 1.73m2) is

approximately30to60percentinpatientswithHeartFailure(HF)2.Clinicalimportanceof

interactions between heart disease and kidney disease is illustrated by the following

observations:

MortalityisincreasedinpatientswithHFwhohavereducedGFR

Patientswith chronic kidney disease have an increased risk of both atherosclerotic

cardiovasculardiseaseandheartfailure,andcardiovasculardiseaseisresponsiblefor

upto50percentofdeathsinpatientswithrenalfailure

Acuteorchronicsystemicdisorderscancausebothcardiacandrenaldysfunctions.

The term Cardio‐Renal syndrome has been brought into use in the last decade. Professor

Claudio Ronco §§§ et al, has defined five subtypes of Cardio‐Renal Syndrome, which are

distinguishable from each other by the clinical course, pathophysiology, diagnostic

approaches and management tactics 7. CRS involves both ‐ the acute and the chronic

conditionswhicharecharacterizedbytheheart'sprimary,andprimaryrenalinjury:

• Type 1: Worsening renal function complicates Acute Decompensated Heart Failure

(ADHF)andAcuteCoronarySyndrome(ACS).Dependingonthepopulation,27%‐40%

§§§Claudio Ronco, MD. Department of Nephrology, St. Bortolo Hospital, Vicenza, ITALY.


70

of patients hospitalized for ADHF develop Acute Kidney Injury (AKI). Consequently,

CRStype1isoftenseeninthecoronarycareandintensivecareunits1112;

• Type 2: Chronic abnormalities in myocardial function leading to Chronic Kidney

Disease (CKD). The “chronic abnormalities” may include many different heart

conditions, such as chronic heart failure, congenital heart disease, atrial fibrillation,

constrictivepericarditisandchroniccoronaryheartdisease15;

• Type 3: Acute renal failure leading to cardiac dysfunction, such as cardiac ischemic

syndromes,congestiveheartfailure,orarrhythmia16.Type3emergeslessfrequently

thanCRStype1,butthismaybeduetothefactthatithasbeenlessthoroughlystudied

thentype110;

• Type 4: Primary renal disease leading to cardiac dysfunction, such as ventricular

hypertrophy,diastolicdysfunction,increasedriskofadversecardiovascularevents17‐

19;

• Type 5: Systemic illness leading to simultaneous heart and renal failure. This CRS

subtypemay covermany acute or chronic conditions inwhich combined heart and

kidneydysfunctionisobserved(e.g.diabetesmellitus,sepsis,lupus,etc.)20.

When reno‐parenchymal disease leads to cardiovascular complications, it’s been

recommendedtonamethelatterconditionasReno‐CardiacSyndrome(CRStype3andtype

4)1421.CRStype5isalsocalledasecondaryCRS2022.

The term ‐ Cardio‐Renal Cachexia Syndrome (CRCS) has been suggested when there are

complexinterrelationsthatinvolvetransitionfromCRStocachexiaandfromcachexiatoCRS

23.


CVP=CSympathLVH=L

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numb

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Left Ventricular H

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Fig.1. Bi

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erangement

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pathways of

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ormonal a

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71

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ndothelial

or the last

Lipocalin),


72

KIM‐1 (Kidney Injury Molecule 1), NAG (N‐Acetyl‐β‐(D) Glucosaminidase), IL‐1 8

(Interleukin‐18), L‐FABP (Liver‐Fatty Acid Binding Protein), CI (Cataitic Iron) 30. It is

expected,thatthesebiomarkerswillfacilitatemakinganearlierdiagnosisofCRS,aswellas

identifythespecifictypeofCRS31.Unfortunately,thesetestsarenotwidelyavailableyet.

CKD is commonand is associatedwith increasedmortality inHF 32. Though, it isnot clear

whether the effect ofCKDonmortality variesbyLeftVentricularEjectionFraction (LVEF).

Themechanismofacutecardio‐renalsyndrome(type1)isdifficulttoclarifyalsobecauseof

thecomplexandmultifactorialcomorbiditiesassociatedwithacuteheartfailuresyndrome33.

Recent investigations suggest that management of patients with primary cardiac and

secondary renal dysfunction based only on the low‐flow theorydoes not lead to improved

outcomes3435.BothanimalandhumanstudieshaveshownthatIntra‐AbdominalandCentral

Venous Pressure (CVP) elevation, which also increases the renal venous pressure, lead to

reduction of GFR 36‐40. There is a growing evidence to support the roles for elevated renal

venous pressure and Intra‐Abdominal Pressure (IAP) in development of progressive renal

dysfunctioninpatientswithHF394142.ThestudybyKevinDammanetal.hasshownthatCVP

isassociatedwithimpairedrenalfunctionandindependentlyrelatedtoall‐causemortalityin

abroadspectrumofpatientswithcardiovasculardisease41.ThestudybyHeikoUthofftetal.

further supported theconcept thatCVP is an importanthaemodynamic factor for impaired

renalfunction,especiallyincombinationwithdecreasedcardiacoutput42.

ThestudybyAliAhmedetal.hasshownthatCKD‐associatedmortalitywashigher inthose

with diastolic than systolic HF 43. Diastolic HF or Heart Failure with Preserved Ejection

Fraction(HFPEF)isthemostfrequentformofHF44‐46(theincidenceofHFPEFisreportedto

include about 50% of the general heart failure population 47). Coexistence of renal

impairment in heart failure with preserved EF is reasonably common (especially in older

femaleswith hypertension and/or diabetes), butmay be under‐diagnosed 48. The Cardio‐

Renal interactions potentially contributing to HFPEF are complex and include volume

overload,due to inadequate renalhandlingof saltor fluid, renalhypertension,oroxidative

stressandinflammatoryprocesses4950.

Theabove‐mentionedevidencedissuadingtheroleofreducedLVEFastheprimarydriverof

renal impairment has prompted researchers to have a closer look into the role of right

ventricle(RV)inthepathogenesisofCRS.


73

TheroleofrightventricleandCVP

Awareness about the role of right ventricle in health and disease traditionally has been

lagging behind that of the left ventricle 51. Even though, right‐sided (or right ventricular)

heart failure (RSHF) usually occurs as a result of left‐sided failure, RV function may be

impaired in pulmonary hypertension (PH), chronic obstructive pulmonary disease (COPD),

congenital heart disease (CHD), connective tissue diseases, coronary artery disease and in

patients with valvular heart disease. When left ventricular function is normal, the term ‐

Isolated Right Ventricular Failure is used (IRVF) 52. Data about prevalence of kidney

impairmentinthosepatientsisuncertain,asitstillremainslargelyunder‐diagnosed.

Right ventricular dysfunction may play an important and possibly earlier role in the

pathophysiologyofimpairedrenalfunction53,butassessingRVfunctionremainsachallenge.

At this time, there is no single commonly accepted and generally applicable index of RV

function 54. Due to the complex anatomy of right ventricular anatomy, only a few

echocardiographic parameters are reliable. Tricuspid Annular Plane Systolic Excursion

(TAPSE) is a validated parameter of global right ventricular function 55. Right Ventricular

End‐Diastolic Diameter (RVEDD) is another parameter that can be used for assasement of

RightHeart and volume overload, althoughnot yet validated. CVP,which is an estimate of

Right Atrial Pressure (RAP), can also help to diagnose RSHF, but it should always be

consideredinconjunctionwithothercardiovascularparameters,e.g.LVEF,astherightheart

sided pressures should indirectly reflect left sided pressures, and the left sided filling

pressuremaybeanindicatorofleftventricularfunction56.

FrankL.Dinietal.studiedrelationshipbetweenRVdysfunctionandCKDinoutpatientswith

chronic systolic HF. The authors found that TAPSE and estimated GFR were significantly

correlated 53. The findings of the study support the concept that venous congestion from

backwardcardiacfailuremightbeasimportantasforwardfailureinthepathophysiologyof

renal impairment inHF.Elevated renal venouspressuredue toRSHF candecreaseGFRby

increasinginterstitialandtubularhydrostaticpressureswithinthekidneysandbydecreasing

renal perfusion pressure and renal blood flow. Hypoxia, as well as local and systemic

neurohormonal activation from elevated venous pressuremay further compromise kidney

functioninthesepatients5758.


74

However,despitetheabove‐mentionedreports,theroleofrightsidedheartfailureinCRSis

difficulttoascertain,because:(I)itisfrequentlycombinedwithleftsidedheartfailurewith

orwithoutreducedejectionfraction;and(II)renaldysfunctioncanalsoraiseRAPbycausing

fluidretention,regardlessofconcomitantcardiacdysfunction41.

ProperunderstandingofCRSmechanismiscrucial,astherapiesdirectedtowardsoneorgan

system may have beneficial or unfavorable effects on the other.Additional high‐quality

studiesareneededforappropriateevaluationoftheroleofRVandCVPinCRS.

METHODS

TheresearchhasbeenbasedonthehypothesisthatCVPratherthanLVEFcorrelatesdirectly

with the level of renal impairment manifested as reduced eGFR in patients with CRS.

ConfirmingthehypothesiswouldprovidesufficientriskpredictionorearlydiagnosisofCRS,

leadingtoimprovementofitscourseandsubsequently,influencingthelong‐termoutcome.

The study was designed in a cross‐sectional manner, involving inpatients with HF and

reduced eGFR, who had undergone treatment at several hospitals in Georgia, between

September 2015 and May 2016. The participants were selected according to the

predetermined selection criteria, and necessary data had been extracted from themedical

charts. Estimated Glomerular FiltrationRatewas assessedwith theModification of Diet in

Renal Disease (MDRD) formula, and CVP measurements had been performed with an

electronic pressure transducer in spontaneously breathing non‐ventilated patients. Central

veinaccesswasestablishedtroughthesubclavianor internal jugularveins. MeanCVPwas

recordedforeachpatient,measuredinmmHg.

Participants‐StudyPopulation

ThestudyincludedpatientswithvariousdegreesofclinicalmanifestationsofHF(NYHAclass

I–IV,withpreservedandreducedEF)andreducedGFR.Listofcriteriathatwouldexcludea

subjectfromthestudyincludedthefollowing:

• Independentriskfactorsforrenalimpairment(e.g.diabetes,sepsis).


75

• PrimarynephropathyorsecondarynephropathyduetodiseasesotherthanHF.

Presenceofhypertensionandotherriskfactors,co‐morbidities,andthecurrentand/orpast

conservative or surgical treatments have also been taken into account.

eGFR(MDRDformula)hasbeendefinedasanOutcomeVariable,whilesex,age,LVEF%,HF

level (NYHA class 1 ‐ 4), RVEDD, CVP and Arterial hypertension (According to JNC VIII

classification) comprised the Predictor Variables. LVEF had been treated as a potential

confoundingfactorforCVPandeGFR.

SamplesizeandstatisticalPlan

In theprocessofdatacollection, thedoctorshadto lookatmedical recordsofhundredsof

patientswithheartfailure.Manyofthemdidnotmeetthecriteriaforinclusionduetolackof

necessaryinformationinthecharts.AsCVPhasbeenrecordedonlyinacutecases(CRStype

I),decisionwasmadetosetuptwodifferentgroups(datasets)‐CVP(CRSType1)andnon‐

CVP (CRSType 2).Non‐CVP group included44participants,while the CVP group included

only11,whichwasonlysufficienttoperformapilotstudy.

IBM SPSS Statistics version 22 has been used to obtain the standard descriptive statistics,

summarystatisticsandstatisticaltestsforoutcomevariable.

Ethicalconsiderations

The study is of observational‐analytical (non‐experimental) type and is based on a

retrospective chart review. Confidentiality of patients’ personal information has been an

ethical issue to address. The study was approved by the ethics comitees at the Medical

Centers and the data extraction had been performed by the treating physicians only. The

patients’personalidentifierswereconcealedandananonymizeddatasetsused(uniquecode

hadbeengiven to eachpatient,whichwaskept secureunder the control ofhospital staff).

Resultspublishedinawaythatnopatients’identificationispossible.


76

RESULTS

Innon‐CVP(CRSType2)group,totalnumberofparticipantswas44,meanagewas67.8(SD

13.1),and64%weremen.MeaneGFRwas60.8ml/min/1.73m2(SD19),MeanLVEF–42.7

(SD14)andMeanRVEDD–34.5(SD6.2).

Fig.1.Descriptivestatisticsfornon‐CVPgroup

PearsonCorrelationanalysiswasusedtocharacterizeassociationbetweenLVEFandeGFR,

whichwasfoundtobenegativeandstatisticallysignificant:‐0.336(Sig.0.026).

Correlations

LVEF eGFR

LVEF Pearson Correlation 1 -.336*


N 44 44

eGFR Pearson Correlation -.336* 1


N 44 44

*. Correlation is significant at the 0.05 level (2-tailed).

Fig.2.CorrelationanalysisbetweenLVEFandeGFR


N Range Minimum Maximum Sum Mean Std.

Deviation

Variance

eGFR 44 85.00 5.00 90.00 2673.00 60.7500 19.02401 361.913

LVEF 44 44.00 16.00 60.00 1880.00 42.7273 14.03544 196.994

HF 44 3.00 1.00 4.00 120.00 2.7273 .62370 .389

RVEDd 44 28.00 21.00 49.00 1516.00 34.4545 6.23738 38.905

Age 44 67.00 23.00 90.00 2981.00 67.7500 13.14344 172.750

Valid N

(listwise)

44


Statis

reduc

tically sign

ctionofeGF

Fig.3

ificant corr

R:‐0.336(S

eGF

R

HF

*. C

Fig.4.Corre

.Correlatio

relation wa

Sig.0.026).

F Pearson

Sig. (2-ta

N

Pearson

Sig. (2-ta

N

Correlation is sig

elationanaly

nscatterpl

s found bet

Correlation

n Correlation

ailed)

n Correlation

ailed)

gnificant at the

ysisbetwee

lotofLVEFa

tween incre

ns

eGFR

1

44

-.349*

.020

44

0.05 level (2-t

enNYHAHF

andeGFR

ease of the

HF

-.349*

.020

44

1

44

tailed).

Fclassande

e NYHA HF

eGFR

77

class and


78

TherewasnosignificantcorrelationbetweenRVEDDandeGFR:n=44,r=‐0.093,p=0.548.

Whencreating thenon‐CVP (CRSType2)dataset,weobserved thatpercentageofpatients

hospitalizedwithdiagnosisofHFanddeterioratedrenal function(CRSTypeII)was31.7%.

AccordingtotheRenalAssociationCKDclassificationofstages,59%ofthemhadmildly(GFR

= 60‐89), 25%moderately (GFR = 30‐59), 13.7% severely (GFR = 15‐29 ) and 2.3% very

severely(GFR<15)reducedkidneyfunction.CKDhadbeendiagnosedin11.4%ofCRScases.

We also observed that doctorsmainly used serum creatinine level for evaluation of renal

functionbothinacuteandchroniccasesofHF,whichhasapparentlylessvaluecomparedto

eGFRMDRDformulaintermsofearlyandpreciseassessmentofdeterioratedrenalfunction.

In the CVP group (CRS Type 1), Pearson correlation test showed a descending (negative)

correlation between CVP and eGFR, although not statistically significant due to the small

numberofparticipants(n=11,r= ‐0.48,p=0.13).Therewasaweakcorrelationbetween

LVEFand eGFR, althoughnot statistically significant:n=11, r =0.12,p=0.72. Basedon

theseresults,samplesizecalculationwasmadeforalargerstudy:α(two‐tailed)=0.050,β=

0.200,r=‐0.480,N=[(Zα+Zβ)/C]2+3=32.

Correlations

eGFR CVP

eGF

R

Pearson Correlation 1 -.475


N 11 11

CVP Pearson Correlation -.475 1


N 11 11

Fig.5.CorrelationanalysisbetweenCVPandeGFR


79

CONCLUSIONS

The study confirmed the hypothesis to the extent that reduction of LVEF is not correlated

withdeteriorationofkidneyfunction(manifestedaseGFR<90)inpatientswithCRSType2.

TheresultsshowedastatisticallysignificantnegativecorrelationbetweenLVEFandeGFR(n

=44,r=‐0,336,p=0.026).

NYHA classification functional class, by contrast, was found to be correlatedwith reduced

eGFR (n =44, r = ‐0,349, p=0.02) inpatientswithCRSType2.The results underline the

usefulnessofNYHA classification for assessment ofHF severity andCKD riskprediction in

patientswithCRS.

Pearsoncorrelationtestshowedadescending(negative)correlationbetweenCVPandeGFR

inpatientswithCRSType1,althoughnotstatisticallysignificantduetothesmallnumberof

participants (n = 11, r = ‐0.48, p = 0.13). The results can be used for the sample size

calculationforalargerstudy:α(two‐tailed)=0.050,β=0.200,r=‐0.480,N=[(Zα+Zβ)/C]2+

3=32.

ThestudyrevealednostatisticallysignificantcorrelationbetweenRVEDDandeGFR(n=44,r

=‐0,093,p=0.548)inpatientswithCRSType2.

In the time period of the study, deteriorated renal function (CRS type II)was observed in

31.7% of patients hospitalized with diagnosis of chronic HF. According to the Renal

Association CKD classification of stages, 59% of them had mildly (GFR = 60‐89), 25%

moderately(GFR=30‐59),13.7%severely(GFR=15‐29)and2.3%veryseverely(GFR<15)

reducedkidneyfunction.CKDhadbeendiagnosedin11.4%ofCRSType2cases.

ForanearlydiagnosisofCRS,eGFRMDRDformulaseemstobeausefultool forestimating

kidney function. eGFR determination allows detection of reduced renal function in early

stagestherebyprovidinganopportunityforcorrectionofexistingtreatments(ACEInhibitors,

ARBs,NSAID,etc.).


80

PUBLICATIONS

Theworkisbasedonfollowingpublications:

1. George Lobzhanidze (First Author). Ethical considerations in non‐experimental

studies‐GeorgianandNorwegianexperience.PUBLICHEALTH,ELSEVIER****,2016.

2. George Lobzhanidze (Sole Author). The role of right‐sided heart failure in patients

with Cardio‐Renal Syndrome. TRANSLATIONAL AND CLINICAL MEDICINE ‐

GEORGIANMEDICALJOURNAL,2016.

3. GeorgeLobzhanidze(SoleAuthor).Cardio‐RenalSyndrometype1:theroleofCentral

Venous Pressure and Left Ventricle Ejection Fraction. International Journal of

Sciences:BasicandAppliedResearch,2016.

4. George Lobzhanidze (Sole Author). The Association among Left Ventricle Ejection

FractionandeGFRinpatientswithCardio‐RenalSyndromeType2.(articleinreview).

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