vitamin B12 deficituri anemia

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

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klinikuri praqtikis erovnuli rekomendacia (gaidlaini) `vitamin
B12 deficituri anemia~ miRebulia klinikuri praqtikis erovnuli
rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo
standartebis (protokolebi) SemuSavebis, Sefasebis da danergvis
erovnuli sabWos 2008 wlis 5 noembris #1 sxdomaze da
damtkicebulia saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis ministris 2009 wlis 21 ianvris # 41/o
brZanebiT.

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1. daavadebis definicia
vitamin B12 deficituri anemia miekuTvneba megaloblastur anemiaTa jgufs,
romlebic gamowveulia eriTrokariocitebSi dnm-is sinTezis darRveviT. is
upiratesad ganpirobebulia vitamin B12 da/an foliumis mJavis deficitiT.
literaturaSi xSirad vxvdebiT gansazRvrebas vitamin B12 (foliumis) –
deficituri anemia. Tumca am ori vitaminis kombinirebuli deficiti iSviaTia.
perniciozuli anu avTvisebiani anemia pirvelad aRwera adisonma da birmerma
XIX saukunis meore naxevarSi. birmerma am daavadebas uwoda “progresirebadi
perniciozuli anemia”, perniciozuli avTvisebians niSnavs. XX saukunis
dasawyisSi perniciozuli anemia (adison birmeris daavadeba) erT-erT yvelaze
gavrcelebul da arakurabelur daavadebad iTvleboda. XX saukunis 20-ian 40-
ian wlebSi dadginda daavadebis paTogenezi, daavadebis gamomwvevi Sinagani
da garegani faqtorebi, ramac safuZveli daudo am daavadebis Tanamedrove
mkurnalobas da daavadeba gankurnebadi gaxada (1).

sinonimebi da terminologia
vitamin B12 deficituri anemia, perniciozuli anemia, adison-birmeris
daavadeba, makrocituli anemia, kobalaminis deficiti, aqilia,
adenozilkobalamini, meTilkobalamini, ciankobalamini, oqsikobalamini,
intrizing faqtori, aqlorhidria, gastreqtomia, tropikuli spru, enteriti,
koliti, mlivi nawlavis limfoma, megaloblasturi anemia, paresTezia, dnm-is
sinTezis darRveva, foliumis mJavas deficiti.

2. epidemiologia
vitamin B12 deficituri anemia sisxlis daavadebaTa Soris erT-erTi yvelaze
gavrcelebuli paTologiaa. umetesad avaddebian 60 welze meti asakis orive
sqesis warmomadgenlebi, upiratesad qalebi (2,3) [A]. axalgazrdaTa Soris
avadoba Seadgens 0,1%. moxucebSi 1%, 75 welze met asakSi ki gvxvdeba 4% (4)
[A]. saqarTveloSi sakmaod gavrcelebuli paTologiaa, magram bolo wlebSi
am paTologiis epidemiologiuri kvleva ar Catarebula da cifrobrivi
monacemebi ar moipoveba.

3. etiopaTogenezi
vitamin B12 deficituri anemiis paTogenezi dadginda XX saukunis dasawyisSi,
aRmoCenil iqna daavadebis gamomwvevi ZiriTadi mizezebi, garegani faqtori
vitamini B12 da Sinagani faqtori gastromukoproteini, romelsac misi
aRmomCenis sapativcemulod ewoda kaslis faqtori.
garegan faqtors vitamin B12 didi raodenobiT Seicavs cilovani produqtebi:
xorci, kvercxi, rZe, yveli, gansakuTrebiT bevria is RviZlsa da TirkmelSi
(5) [A]. sakvebSi vitamini B12 SekavSirebulia cilasTan. kulinaruli
damuSavebisas, agreTve kuWSi marilmJavasa da proteolizuri fermentebis
moqmedebis Sedegad is sakvebidan Tavisufldeba. kuWSi vitamini B12-s garegani
faqtori ukavSirdeba ”R” cilebs (Rapid-binders - romlebmac saxelwodeba miiRes
gastromukoproteinTan SedarebiT swrafi eleqtroforezuli moZraobis gamo).
es cilebi arsebobs kuWis wvenSi, sisxlis plazmaSi, nerwyvSi, qalis rZeSi,
fagocitebSi da gamomuSavdeba sanerwyve jirkvlebis, lorwovani garsebis
ujredebisa da fagocitebis mier.
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Semdeg etapze kompleqsi “vitamini B12 + cila R” gadaadgildeba Tormetgoja
nawlavSi. pankreasis proteolizuri fermentebis moqmedebiT, am kompleqsidan
wydeba cila “R” da vitamini B12 ukavSirdeba gastromukoproteins (kaslis
Sinagan faqtors), romelic gamomuSavdeba kuWis fundaluri nawilis
parietuli ujredebis mier. 1mg gastromukoproteins SeuZlia 25mg vitamin B12–
is SeboWva. Tormetgoja nawlavis tute are aZlierebs vitamin B12 da
gastromukoproteinis kavSirs, gastromukoproteini icavs vitamin B12-s
proteolizuri fermentebis zemoqmedebisagan.
amis Sedegad kompleqsi “vitamini B12 + gastromukoproteini” gadaadgildeba
wvrili nawlavis gaswvriv da xvdeba mliv nawlavSi. aq igi Ca2+ erTad
urTierTmoqmedebs specifiur receptorebTan, iSleba da gamonTavisuflebuli
vitamini B12 nawlavis lorwovanidan transportirdeba sisxlSi, sadac
uerTdeba satransporto cilebs - transkobalaminebs. cnobilia 3 tipis
transkobalamini _ I, II, III. maT Soris gansakuTrebuli mniSvneloba aqvs
transkobalamin II (igi sinTezirdeba hepatocitebis, enterocitebis,
monocitebis, fibroblastebis, Zvlis tvinis hemopoezis winamorbedi
ujredebis mier). vitamini B12-is mcire nawili ukavSirdeba transkobalamin II,
misi saSualebiT transportirdeba RviZlSi da Zvlis tvinSi. am organoebSi
vitamini B12 Tavisufldeba transkobalaminisagan lizosomuri hidrolizis
gziT. transkobalamin I Zalian hgavs kuWis wvenis “R” cilebs. transkobalamin
I sinTezirdeba leikocitebis mier. is boWavs sisxlis plazmis vitamin B12-is
udides nawils, SemdgomSi xdeba kompleqsis “vitamin B12 + transkobalamini”
eliminireba naRvlis saSualebiT. vitamini B12 transkobalamin I-is mier Zvlis
tvinSi ar miitaneba. transkobalamin I-is funqcia ar aris dazustebuli. aseve
ucnobia transkobalamin III funqciac (6).
amgvarad, sabolood vitamini B12 xvdeba Zvlis tvinSi da RviZlSi. Zvlis
tvinSi vitamini B12 gamoiyeneba sisxwarmoqmnisavis, RviZlSi deponirdeba da
saWiroebis SemTxvevaSi xvdeba sisxlSi. RviZlidan vitamin B12-is nawili
naRvlis saSualebiT isev xvdeba Tormetgoja nawlavSi da iwoveba zemoT
moyvanili meqanizmiT.
srulfasovani kvebis pirobebSi adamianis dRe-Ramis racioni Seicavs 30mkg
vitamin B12-s. adamianis organizmis moTxovnileba Seadgens 8,4mkg-s (7)
[A]. dRe-Ramis ganmavlobaSi Seiwoveba 6-9mkg. SardiTa da ganavliT ki
gamoiyofa 2-5 mkg.
janmrTeli adamianis organizmi Seicavs 2-5 mg vitamin B12-s. ZiriTad organos
sadac deponirdeba vitamini B12 warmoadgens RviZli. misi maragi RviZlSi
adamianis organizmisTvis sakmarisia 3-5 weli vitamini B12-is miRebis sruli
Sewyvetis pirobebSi (8).
vitamin B12 da Sesabamisad koferment meTilkobalaminis nakleboba arRvevs
Timidinis sinTezs, romelic Sedis dnm-Si, ris Sedegadac irRveva mitozuri
cikli da sinTezuri procesebi swrafad proliferirebad ujredebSi (Zvlis
tvini, kuW-nawlavis traqtis epiTeli); polipotenturi (Trombocitebis,
granulocitebis da eriTrocituli rigis winamorbedi) ujredebi kargaven
momwifebis unars _ ferxdeba eriTrokariocitebis momwifeba _
sisxlwarmoqmna aris megaloblasturi tipis. aseTi ujredebis sicocxlis
xangrZlivoba SedarebiT xanmoklea, irRveva granulocitopoezi da
Trombocitopoezic. warmoiqmneba giganturi formis Trombocitebi, maTi
raodenoba mcirdeba. granulocitebi hipersegmentirebulia. am mdgomareobas
axasiaTeben, rogorc araefeqtur eriTropoezs. izrdeba Zvlis tvinis

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makrofagebis mier neitrofilebis fagocitozi, rac xels uwyobs
neitropeniis ganviTarebas da neitrofilebis mimarT autoantisxeulebis
gamomuSavebas.
amgvarad vitamin B12 –is da misi kofermentis, meTikobalaminis deficiti
erTis mxriv iwvevs Zvlis tvinSi araefeqtur hemopoezs, megaloblasturi
anemiis, leikopeniis, Trombocitopeniis saxiT, meores mxriv kuW-nawlavis
traqtis epiTeluri ujredebis momwifebis darRvevis gamo _ lorwovanis
atrofias.
vitamin B12-is meore kofermentis dezoqsiadenozilkobalaminis deficiti
iwvevs cximovani mJavebis cvlis darRvevas. grovdeba nervuli sistemisTvis
toqsiuri meTilmaloninis da propanis mJava. zemoaRniSnuli darRvevbis gamo
xdeba zurgis tvinis ukana da gverdiTi svetebis dazianeba, mcirdeba nervuli
boWkoebis mielinis sinTezi.

etiologia
vitamin B12 deficitis gamomwvevi mizezebi (Harrison)
I. sakvebis arasakmarisi raodenobiT miReba: vegetarianelebi
II. Sewovis darRveva
a) kaslis Sinagani faqtoris deficiti
1. adison-birmeris daavadeba
2. gastreqtomia
3. Sinagani kaslis faqtoris Tandayolili ararseboba an
biologiurad araaqtiuri kaslis faqtoris sekrecia (iSviaTad)
b) mlivi nawlavis distaluri nawilis dazianeba
1. spru
2. celiakia
3. kronis daavadeba
4. nawlavis rezeqcia.
5. simsivneebi da granulomatozi (iSviaTad)
6. imerslund-gresbekis sindromi (iSviaTad)
g) vitamin B12 konkurentuli moxmareba
1. difilobotriozi
2. wvrili nawlavis mravlobiTi divertikuli.
d) samkurnalo saSualebebi amilosalicilis mJava, kolxicini,
neomicini.
III. sxva mizezebi:
a) azotis zeJangi
b) transkobalamin II nakleboba (iSviaTad)

I. sakvebis arasakmarisi raodenobiT miReba

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mizezi aris mkacri vegeterianeloba, rodesac avadmyofi ar iRebs cxoveluri
warmoSobis produqtebs (xorcs, Tevzs, RviZls, Tirkmels da sxva), aseve rZis
produqtebs da kvercxs (10,11). axalgazrdebSi Zalian iSviaTad viTardeba
mxolod xangrZlivi vegeterianelobis pirobebSi (12).

II. Sewovis darRveva

_ kaslis Sinagani faqtoris deficiti viTardeba adison-birmeris daavadebis
dros, romelic yvelaze xSiria vitamin B12 deficitur anemiaTa Soris.
gastromukoproteinis warmoqmnis darRvevis yvelaze xSiri mizezia
atrofiuli gastriti. es autoimunuri daavadebaa, mas axasiaTebs aqilia,
pepsinis ararseboba kuWis wvenSi da antisxeulebis produqcia parietuli
ujredebis mimarT, romelebic gamoimuSaveben gastromukoproteins.
vitamin B12 deficituri anemiis ganviTarebaSi imunuri faqtorebis
monawileoba dRemde msjelobis sagans warmoadgens. mas hyavs, rogorc
mowinaaRmdegeebi aseve momxreebi. imunuri Teoriis momxreebs moyavT Semdegi
mtkicebulebebi:
1) daavadeba ufro xSirad uviTardebaT im pirebs, romlebsac aqvT sxva
autoimunuri daavadebebic _ difuzuri toqsiuri Ciyvi, qronikuli
limfocituri Tireoditi (euTireoditi an hiperTireoditi), pirveladi
Tirkmelzeda ukmarisoba, vitiligo an hipoparaTireozi.
2) avadmyofTa 90%-s aqvs antisxeulebi kuWis lorwovanis ujredebisadmi, 60%-
s kaslis Sinagani faqtorisadmi.
3) avadmyofTa naTesavebsac aReniSnebaT antisxeulebi kaslis faqtoris
mimarT maSinac ki Tu maT ara aqvT anemia.
4) glukokortikoidebiT mkurnaloba remisias iwvevs.

• vitamin B12 deficituri anemiis xSiri mizezia gastreqtomia an kuWis

subtotaluri rezeqcia, rasac moyveba gastromukoproteinis ararseboba.
daavadeba ar viTardeba kuWis 2/3 rezeqciis SemTxvevaSi, subtotaluri
rezeqciis SemTxvevaSi ki daavadeba 3-5 weliwadSi yalibdeba, rodesac
amoiwureba vitamin B12 maragi RviZlSi (13, 14).
• Sinagani kaslis faqtoris Tandayolili ararseboba an biologiurad
araaqtiuri kaslis faqtoris sekrecia iSviaTi paTologiaa. daavadeba
autosomur recesiulia. klasikuri adison-birmeris daavadebisagan
gansxvavebiT pepsinisa da marilmJavas sekrecia normaluria da kuWis
lorwovanis atrofia ar aris.
• kuWis kibo vitamin B12 deficituri anemiis xSiri mizezia. aRiniSneba kuWis
lorwovanis atrofia da gastromukoproteinis warmoqmnis Semcireba.
• kuWis polipozi SeiZleba gaxdes gastromukoproteinis warmoqmnis
Semcirebis mizezi.

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_ wvril nawlavSi vitamin B12 Sewovis darRveva
• malabsorbciis sindromTan aris dakavSirebuli tropikuli spru,
celiakia, kronis daavadeba, qronikuli enteriti, wvrili nawlavis
rezeqcia, amiloidozi, limfoma, wvrili nawlavis kibo, tuberkulozi (15).
• qronikuli pankreatitis dros tripsinis warmoqmnis darveva iwvevs
Tormetgoja nawlavSi vitamin B12–is gadatanas R cilidan Sinagan kaslis
faqtoramde.
• zolinger-elisonis sindromis /hiperqlorhidria/ dros vitamin B12-is
Sewova ferxdeba wvril nawlavSi maRali mJavianobis gamo. mJave areSi
vitamini B12 ufro cudad ukavSirdeba Sinagan faqtors da vitamin B12 da
kaslis faqtori enterocitebs.
• immerslond-gresbekis sindromis dros mliv nawlavSi ar aris
receptorebi vitamin B12 + gastromukoproteinis kompleqsisadmi. aseve
iSviaTi paTologiaa (16, 17).

__ vitamin B12 konkurentuli moxmareba

• WiebiT invazia, romlebic moixmaren vitamin B12-is did raodenobas.
• wvril nawlavze anastomozebis dadebis Semdeg xSirad mravldeba
baqteriebi, igive procesi viTardeba divertikulozis dros. baqteriebi
sakuTari dnm-is sinTezisaTvis moixmaren didi raodenobiT vitamin B12-s,
rasac moyveba adamianis organizmisTvis vitamin B12-is miwodebis Semcireba.
• nawlavebis fsevdoobstruqcia (Saqriani diabeti, amiloidozi), rac aseve
xdeba baqteriebis gamravlebis mizezi.

__ samkurnalo preparatebi _ kolxicini, neomicini, aminosalicilis

preparatebi, biguanidebi SeiZleba iyos Sewovis Semaferxebeli faqtori,
magram es iSviaTi SemTxvevebia.

III. sxva mizezebi

_ vitamin B12 maragis Semcireba
• cirozi
• qronikuli hepatiti
_ transkobalamin II nakleboba _ uiSviaTesi daavadeba.

4. klinikuri simptomatika
damaxasiaTebelia darRvevebi sisxlwarmomqmneli, nervuli, saWmlis
momnelebeli da gul-sisxZarRvTa sistemis mxriv.
avadmyofebi uCivian saerTo sisustes, qoSins, tkivils gulis areSi, qveda
kidurebis SeSupebas, Tavbrusxvevas, WianWvelebis cocvis SegrZnebas xelebze
da qveda kidurebze, siarulis gaZnelebas, tkivils enis wveris areSi,
umadobas, faRaraTs (18).
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obieqturad _ kani da xiluli lorwovani fermkrTali, pergamentiseburi,
moyviTalo elferiT. avadmyofebi ufro xSirad Warbi wonis mqoneni arian,
saxe SebiJvinebulia, SeSupebulia qveda kidurebi. SeSupebas SeiZleba axldes
asciti.
saWmlis momnelebeli sistemis mxriv _ yuradRebas ipyrobs piris Rrusa da
enis anTebiTi atrofiuli cvlilebebi. B12 deficituri anemiisTvis
damaxasiaTebelia ”lakirebuli” ena, atrofiuli dvrilebiT, zogjer
wylulebiT (Hunter-is glositi). zogjer viTardeba aftozuri stomatiti.
zogjer umniSvnelod aris gadidebuli RviZli da elenTa. kuWis wvenis
analizisas rogorc wesi vlindeba histamin rezistentuli aqilia. faRaraTi
enteritis Sedegia (19).
gul-sisxlZarRvTa sistemis mxriv _ gulis yvela mosasmen wertilze Suili,
zogjer viTardeba stenokardia. xangrZlivad mimdinare daavadebebisas
viTardeba gulis cximovani gadagvareba.
nervuli sistemis dazianebas B12 deficituri anemiis dros ewodeba
funikularuli mielozi da xasiTdeba procesSi zurgis tvinis ukana da
gverdiTi svetebis CarTviT. viTardeba demielinizacia, Semdeg ki nervuli
boWkoebis degeneracia. avadmyofebs ucivdebaT kidurebi, aqvT kidurebze
WianWvelebis cocvis SegrZneba. siarulisas TiTqos bambas an raime sirbiles
abijeben. ukana svetebis dazianebisas viTardeba sensoruli ataqsia, siarulis
gaZneleba, qveda kidurebis kunTebis atrofia. SeiZleba ganviTardes Sardis
Seukavebloba, zurgis tvinis gverdiTi svetebis dazianebisas viTardeba qveda
kidurebis spastiuri paraparezi, Sardis da defekaciis Seukavebloba. ufro
iSviaTad viTardeba ynosvis da smenis darRvevebi, aseve fsiqiuri movlenebi
(bodvebi, halucinacia, fsiqozi, depresia) (20). iSviaTad aRiniSneba ufro Rrma
darRvevebi _ parezebi da periferiuli dambla, Rrma mgrZnobelobis
darRveva, vibraciuli da tkivilis SegrZnebis gaqroba, gemovnebisa da ynosvis
darRveva, kunTebis atrofia (21, 22, 23).

5. daavadebis diagnozi
mTavari klinikuri simptomebi
araspecifiuri Civilebi: saerTo sisuste, qoSini, Tavbrusxveva.
nervuli sistemis mxriv periferiuli polineiropaTiis suraTi: sicivis
mudmivi SegrZneba, WianWvelebis cocvis SegrZneba, mgrZobelobis darRveva. es
Civilebi, romlebsac funikularuli mielozi ewodeba, praqtikulad TiTqmis
yvela avadmyofs aReniSneba.
saWmlis momnelebeli sistemis mxriv _ enis wveris wva, aftozuri stomatiti,
lakirebuli ena, faRaraTi, yabzoba (24, 25).

mTavari instrumentuli laboratoriuli monacemebi:

1. hiperqromuli anemia (iSviaTad normoqromuli).
(Fi>1,05; MCV>96mkm3);
2. periferiuli sisxlis eriTrocitebis cvlilebebi makrocitozi
(diametris gadideba) _ 10-12mkm. anizocitozi _ sxvadasxva zomis
eriTrocitebi, poikilocitozi _ sxvadasxva formis eriTrocitebi,

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 megalocitozi, birTvis narCenebi (Jolis sxeulakebi, kebotis rgolebi),
specifiuri niSania eriTrocitebSi bazofiluri marcvlovnebis gaCena (37);
3. retikulocitopenia, retikulocitebis normaluri raodenoba an
hemolizuri komponentis arsebobis pirobebSi retikulocitozi;
4. periferiuli sisxlis leikocitebis cvlilebebi, leikocitebi normaSia an
Semcirebulia. neitropenia, neitrofilebis hipersegmentacia, eozinopenia,
SedarebiTi limfocitozi, periferiul sisxlSi Cndeba normoblastebi;
5. Trombocitopenia an Trombocitebi normaSia (20);
6. mielogramis cvlilebebs gadamwyveti mniSvneloba eniWeba daavadebis
diagnostikaSi. vitamin B12-is erTi ineqciac ki sakmarisia mielogramis
Sesacvlelad da Zvlis tvinidan megaloblastebis gasaqrobad. amitom
saWiroa Zvlis tvinis aspiracia mkurnalobis dawyebamde Catardes.
damaxasiaTebelia: sisxlwarmoqmnis eriTroiduli Stos gaRizianeba,
hiperplazia, leiko/eriTroblasturi indeqsi 1 : 2, 1 : 3; nacvlad 3 : 1; 4 : 1.
sisxlwarmoqmna megaloblasturi tipisaa. bazofiluri megaloblastebi
didi zomis ujredebia, lurji citoplazmiT da nazi, badisebri birTviT.
roca es ujredebi bevria _ nacxi iRebs specifiur lurj fers _ “lurji
Zvlis tvini”. mieloiduri rigis ujredebisTvis damaxasiaTebelia zomaSi
mateba, darRveulia megakariocitebis momwifeba, kerZod Trombocitebis
gadmosrola megakariocitebidan, tipiur SemTxvevaSi Zvlis tvinis suraTi
imdenad aSkaraa, rom Seucdomlad SeiZleba diagnozis dasma;
7. vitamin B12-is raodenobis Semcireba (radio imunologiuri meTodiT
gamokvlevisas < 150pg/ml-ze). N 150-200pg/ml-ze, Tumca kvlevebiT dadginda,
rom Tu vitamini B12 < 75pg/ml-ze yvela avadmyofs aqvs vitamini B12
deficituri anemiis gamovlineba.
B12 _ 150-200pg/ml-ze avadoba 5% aRiniSneba.
B12 > 220pg/ml-ze avadoba 0,2% aReniSneba. (27, 28).

sisxlis bioqimiuri gamokvlevisas:

• eriTrokariocitebis hemolizis gamo aRiniSneba arapirdapiri
hiperbilirubinemia _ zogierT SemTxvevaSi.
• Sratis rkinis raodenoba momatebulia. vitamin B12 mkurnalobis dawyebis
Semdeg 10-15 dReSi Sratis rkinis maCvenebeli qveiTdeba.

Sardis da ganavlis analizi intensiuri hemolizis dros:

• SardSi vlindeba urobilini;
• ganavalSi Cndeba sterkobilini.

ganavlis analizi helminTebze

Silingis testi _ xdeba vitamin B12-is Sewovis Sefaseba. ganasxvaveben am
testis 2 saxeobas:
I. avadmyofs aZleven Ca-iT niSandebul vit. B12–s per os, 1-6 sT-is Semdeg
kunTSi keTdeba vitamin B12–is e.w dartymiT dozas, RviZlis depos

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gajerebisaTvis. sabolood isazRvreba radioaqtiuri vitamin B12 sadReRamiso
SardSi. eqskreciis daqveiTeba miuTiTebs nawlavebSi vitamin B12–is Sewovis
darRvevaze.
II. tardeba I variantis msgavsad, gastromukoproteinis gamoyenebiT. vitamin B12
–is eqskreciis mateba miuTiTebs gastromukoproteinis deficitze. Tu
“Siling II”-iT radioaqtiuri vitamin B12–is mateba ar xdeba, SeiZleba
CaiTvalos, rom megaloblasturi anemiis mizezi aris ara
gastromukoproteinis deficiti, aramed vitamin B12–is Sewovis darRveva
nawlavebSi.

damatebiTi diagnostikuri kriteriumebi.

• ezofagoduodenoskopiiT vlindeba saWmlis momnelebeli traqtis
lorwivani garsis atrofiuli cvlilebebi _ atrofiuli gastriti da
ezofagoti;
• kuWis wvenis sekreciis gamokvleviT _ kuWis wvenis raodenobis Semcireba,
aqilia, pepsinis deficiti;
• ultrasonografiuli gamokvleva _ muclis Rrus organoebi RviZli da
elenTa umniSvnelod aris gadidebuli an normaSia;
• kuWis rentgenoskopiiT _ darRveulia kuWis evakuatoruli fuqcia,
gadasworebulia lorwovanis nakecebi.

diferencialuri diagnozis CamonaTvali:

aqlohidria;
alkoholuri hepatiti;
mwvave leikemia;
aplaziuri anemia;
spru;
cirozi;
foliumis mJavas deficiti;
kuWis kibo;
atrofiuli gastriti;
hemolizuri anemia;
hiperbilirubinemia;
hipoTireozi;
imunuri Trombocitopeniuri purpura;
malabsorbcia;
mieloproliferaciuli daavadeba;
WiebiT invazia;
Timoma.

sxva paTologiebi, romlebic unda iqnen gaTvaliswinebuli:

nevrologiuri daavadebebi;
alcheimeris daavadeba;
alkoholuri cirozi.

10
6. gamokvlevis sqema
1. sisxlis saerTo analizi: eriTrocitebis raodenoba da morfologia,
hemoglobini, feradobis maCvenebeli, retikuloctebis raodenoba,
leikocitebi, Trombocitebi, leikocituri formula, edsi;
2. Zvlis tvinis morfologia;
3. sisxlis bioqimiuri analizi: bilirubinis gansazRvra, cila da cilis
fraqciebi;
4. sisxlSi vitamin B12 da foliumis mJavas gansazRvra (Tu SesaZlebelia);
5. Sardis saerTo analizi.
yvela zemoT CamoTvlili gamokvleva pirvelive 24 saaTSi unda Catardes. ris
Semdegac unda Catardes:
• muclis Rrus organoebis: elenTis, kuWqveSa jirkvlis, naRvlis buStis,
Tirkmelebis eqoskopiuri gamokvleva;
• fibrogastroduodenoskopia;
• fibrokolonoskopia;
• ganavlis gamokvleva helminTebze.

7. mkurnalobis sqema
mkurnalobis dawyeba SeiZleba mxolod mielogramis safuZvelze diagnozis
verificirebis Semdeg, vinaidan vitamin B12-is erTma ineqciamac ki SeiZleba
Secvalos megaloblasturi sisxlwarmoqmna normoblasturiT da Zvlis
tvinis punqcia gaxados arainformatiuli (29).
B12 deficituri anemiis mkurnaloba swrafad LiZleva karg Sedegs. rogorc
wesi Terapias ar axlavs garTulebebi da swori mkurnalobis SemTxvevaSi
daavadeba ar iZleva recidivebs.
imis gamo, rom daavadeba ufro xSirad gamowveulia ASewovis procesebis
darRveviT, samkurnalod gamoiyeneba saineqcio vitamin B12-is 2 forma:
intramuskularulad keTdeba ciankobalamini an oqsikobalamini.
oqsikobalamini ukeTesad aiTviseba organizmis mier, vinaidan is ukeTesad
uerTdeba plazmis cilebs vidre ciankobalamini (30). organizmSi rCeba
Seyvanili:
• oqsikobalaminis _ 70-80%.
• ciankobalaminis _ 30%.
amitom oqsikobalamini iniSneba ufro mcire doziT. vitamin B12-is didi
dozebis 1000mkg da metis daniSvna araefeqturia, vinaidan didi
koncentraciisas is ar uerTdeba cilas da TiTqmis mTlianad gamoiyofa
organizmidan. amitom sasurvelia am preparatebis ufro mcire doziT Seyvana.

vitamin B12 deficituri anemiis tipiuri formis mkurnaloba:

_ ciankobalamini 400-500mkg kunTebSi yoveldRe 2 kviris ganmavlobaSi;

11
• Semdeg kviraSi 2 jer, sanam hemoglobini ar miaRwevs normas. Cveulebrivad
hemoglobinis maCvenebeli normalizdeba 1 an 2 TveSi;
• amis Semdeg _ vitamin B12-is ineqcia TveSi erTxel mTeli cxovrebis
ganmavlobaSi.

_ oqsikobalamini _ 200mkg kunTebSi yoveldRe 2 kviris ganmavlobaSi;

• Semdeg kviraSi 2-jer 200mkg, sanam hemoglobini ar miaRwevs normas.
Cveulebrivad hemoglobinis maCvenebeli normalizdeba 1 an 2 TveSi;
• amis Semdeg _ ineqcia TveSi erTxel mTeli cxovrebis ganmavlobaSi
(31,32,33).
• xelSemwyobi Terapia weliwadSi 2-jer 5 dRis ganmavlobaSi 200mkg (41).

mkurnaloba yvela SemTxvevaSi efeqturia, Tu diagnozi sworad aris dasmuli.

pirvelive ineqciis Semdeg avadmyofis mdgomareoba umjobesdeba. 5-6 dReSi
matulobs retikulocitebis raodenoba da aRwevs maqsimums me-7 dRes. sam
kviraSi matulobs eriTrocitebis raodenoba. wiTeli sisxlis maCveneblebi
normaSi modis 1-2 TveSi. SedarebiT nela umjobesdeba nevrologiuri statusi.
funikularuli mielozis movlenebi yvelaze gvian ixsneba. mkurnalobis
nevrologiuri movlenebi SeiZleba ar daeqvemdebaros mkurnalobas im
SemTxvevaSi, rodesac mkurnalobis dawyebamde nervuli sistemis cvlilebebi
ukve Seuqcevadi iyo.
mkurnalobis dawyebidan 1 kviraSi Tu ver miviReT retikulocituri krizi,
unda veZeboT daavadebis gamomwvevi sxva mizezi (infeqcia, Tanmxlebi
foliumis mJavas deficiti, hipoTireozi da a.S.).
vitamin B12 deficitTan erTad SeiZleba ganviTardes foliumis mJavas
deficitic. orive vitaminis deficiti erTad xSiria sprus da nawlavebis
sxvadasxva paTologiis dros. vitamin B12-is deficitis dros xSirad
viTardeba foliumis mJavas ujredSida deficiti. aseT SemTxvevaSi saWiroa
orive vitaminis daniSvna. foliumis mJava iniSneba yoveldRiurad 1mg (34, 35).
aqve xazgasmiT unda aRiniSnos, rom vitamin B12 deficituri anemiis dros
mxolod foliumis mJavas daniSvnam SeiZleba daamZimos avadmyofis
mdgomareoba.
rkinis preparatebi piriqiT xSirad iniSneba vitamin B12 deficituri anemiis
dros. daavadebis dasawyisSi rkinis cvlis maCveneblebi momatebulia, magram
vitamin B12-is mkurnalobam hemoglobinis sinTezis aqtivaciis xarjze SeiZleba
gamoiwvios rkinis deficiti. aseT SemTxvevaSi iniSneba rkinis peroraluri
preparatebi, Cveulebriv 200mg rkina dRe-RameSi, rkinis cvlis maCveneblebis
normalizaciamde.
vitamin B12 deficituri anemiis erT-erT mizezs miekuTvneba nawlavebSi
vitaminis konkurentuli moxmareba baqteriebis gamo. aseT SemTxvevebSi karg
Sedegs iZleva mkurnaloba baqteriociduli preparatebiT tetracikliniT,
ampiciliniT, rac xels uwyobs sisxlis maCveneblis normalizacias.
mkurnalobis procesSi SeiZleba ganviTardes hipokalemia da natriumis
Sekaveba.

12
vitamin B12-is deficiti iwvevs mielinuri boWkoebis dazianebas da demencias,
Tumca aRniSnulis meqanizmi bolomde ar aris garkveuli.
demenciis SemTxvevaSi vitamin B12 iniSneba 1000 mkg kunTebSi yoveldRe 1 kviris
ganmavlobaSi, Semdgom kviraSi erTxel erTi Tvis ganmavlobaSi. mkurnalobis
es sqema iwvevs vitamin B12 deficituri anemiis gankurnebas da demenciis
SeCerebas, Tumca demenciis sruli gankurneba SeuZlebelia (36, 37).
peroraluri preparatebiT mkurnaloba iniSneba mxolod im SemTxvevaSi, Tu
raime mizeziT ineqcia winaaRmdegnaCvenebia an avadmyofi uars acxadebs
ineqciebze. peroraluri preparatebi unda dainiSnos ufro didi doziT _
sadReRamiso doza 300-1000mkg. mkurnaloba ufro Zvirad Rirebulia da
saWiroebs mudmiv dakvirvebas recidivis Tavidan asacileblad.

mkurnalobis gverdiTi movlenebi

• faRarTi, tkivili ineqciis adgilas, temperaturuli reaqcia (es
garTulebebi Zalian iSviaTia);
• SeiZleba ganviTardes hipokalemia, natriumis Sekaveba.

eriT masis gadasxma unda Catardes sasicocxlo CvenebiT

• anemiuri koma, romlis dawyebis niSnebis dadgena Znelia, Zalian
swrafad viTardeba da Tu droulad ar iqna miRebuli zomebi, SeiZleba
letaluri gamosavliT damTavrdes;
• hemoglobinis maCveneblis dacema 40g/l-mde da naklebi;
• anemiuri encefalopaTia;
• gulis ukmarisoba, taqikardia, arteriuli wnevis vardna.

8. profilaqtika da meTvalyureoba
profilaqtikas saWiroeben:
• pirebi visac hqondaT vitamin B12 deficituri anemia an aqvT problemebi
saWmlis momnelebeli sistemis mxriv;
• moxucebi da vegeterianelebi (40).
• pirebi vinc qronikulad Rebuloben iseT preparatebs, romlebic iwveven
vitamin B12 Sewovis darRvevas;
• pirebi, romlebic sxvadasxva mizeziT xangrZlivad Rebuloben foliumis
mJavas;
• orsulebi, romlebic xangrZlivi drois ganmavlobaSi imyofebodnen
mkacr vegeterianul dietaze (41).

13
 konsultaciebi:
• vitamin B12 deficituri anemiiT daavadebulni ganwyobilni arian
polipozisadmi da 2-jer ufro xSirad avaddebian kuWis kiboTi, amitom
isini saWiroeben gastroenterologis mudmiv meTvalyureobas. kuW-
nawlavis traqtis profilaqtikur gamokvlevas weliwadSi erTxel;
• vitamin B12 deficituri anemiiT daavadebulni imyofebian hematologis
mudmivi meTvalyureobis qveS, 6 TveSi erTxel ukeTdebaT sisxlis
saerTo analizi. vitamin B12 ukeTdebaT mTeli cxovrebis ganmavlobaSi,
TveSi erTxel.

vitamin B12 –ze moTxovnileba umniSvnelod gansxvavdeba sqesisa da asakis

mixedviT. vitamin B12 –ze saSualo fiziologiuri moTxovnileba mocemulia
cxrilSi:

cxrili 1
vitamin B12 –ze dRe-Ramuri moTxovnileba sqesisa da asakis mixedviT

asaki - wlebi mamakacebi orsulebi meZuZurebi

qalebi mkg/dReSi Mmkg/dReSi Mmkg/dReSi U
14-18 2,4 2,6 2,8
19 da meti 2,4 2,6 2,8

9. gaidlainis gadasinjvisa da ganxilvis vada 2 weli.

10. gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia

• mocemuli gaidlainis Seqmnis procesSi samuSao jgufis mier moZiebul
da Sefasebul iqna ukve arsebuli praqtikuli rekomedaciebi. SemuSavda
arsebuli rekomendaciebis adaptirebuli varianti, romelic erTis
mxriv pasuxobs saerTaSoriso moTxovnebs, xolo meores mxriv
iTvaliswinebs saqarTvelos samedicino dawesebulebaTa, rogorc
adamianur, ise materialur-teqnikur resursebs.
• klinikuri rekomendaciebis diagnostikisa da mkurnalobis Tanamedrove
meTodebi, epidemiologiuri monacemebi moZiebul iqna eleqtronul
bibliografiul bazaSi (Medline), (EMBASE). agreTve Google, Yahoo, Ramblet,
Doctor Guide, Yandex saZiebo operatorebis meSveobiT da kohreinis
biblioTekis bazaSi (The Cohrane Library 2006).

14
 • mocemuli gaidlainis SemuSavebisas gamoyenebul iqna mxolod
mtkicebulebiTi medicinis monacemebi, mtkicebulebis donis
gaTvaliswinebiT.
• avtorTa jgufis mier moZiebul iqna 1000-mde statia, referati da
gaidlaini, romelTa analizis Sedegad gamoyofil iqna ZiriTadi 43
wyaro. aRniSnuli wyaroebi safuZvlad daedo klinikuri rekomendaciis
Seqmnas.

Mmtkicebulebis done da rekomendaciebis xarisxi

done mtkicebulebis siZlieris done xarisxi rekomendaciebis
(Muir Gray) xarisxi
(Cook et al)
Zlieri mtkicebuleba, eyrdnoba eyrdnoba I donis mtkice-
minimu erT mimoxilvas, romelic bulebas da Sesabamisad
A
efuZneba swori dizainis mqone mtkiced rekomendebulia
I. randomizebul kontrolirebad
kvlevas.
Zlieri mtkicebuleba, eyrdnoba eyrdnoba I donis mtkice-
minimu erTi swori dizainis bulebas da Sesabamisad
II B
mqone randomizebul rekomendebulia
kontrolirebad kvlevas.
klinikuri kvleva randomi- eyrdnoba III donis mtkice-
zaciis gareSe, kohortuli da bulebas SeiZelba
III C
SemTxveva-kontrolis kvlevebi. CaiTvalos Sesabamisad

11. alternatiuli gaidlaini ar arsebobs

12. gamoyenebuli literatura

1. James L H. Anemia Megaloblastic 2007;
2. Clarke R. Prevention of vitamin B12 deficiency in old age Am J. clin Nutr 2001; 73:151-2;
3. Clarke R. Refsum H. Birksj, et al. Screening for vitamin B12 and folate deficiency in older
persons. Am J. Clin Nutr, 2003; 77: 1241-1247;
4. Carmel R. Prevalence of undiagnosed Pernicious anemia in elderly. Arch Intern Med 1996;
156 (10): 1097-1100;
5. Health Canada. Nutrient value of some common foods 1999. Accessed July 10, 2006;
6. Scriver CR, Beaudet AL, SLy WS: The metabolic and Molecular Bases of inherited Disease
1995: 3129-49;
7. Health Canada. Dietary reference in takes reference values for vitamines. 2006. (screens).
8. Stover P. J. Physiology of folate and vitamin B12 in health and desease, Nutrition Reviews.
2004; 62 (6): S3-S12;
9. Carmel R, Green R, Rosenblatt DS, Watkins D, Update on cobalamin, folate. Am soc
Hematol Educ Program. 2003; 62-81;
10. Cravens DD, Nashelsky J. Now do we evalute a marginally low B12 level? The Journal of
Family Practice 2007 vol 56 No 1:62-63;
11. Hercberg S, Galan P. Nutritional anaemias. Bailieres Clin Haematol. Jan. 1992; 5 (1):1;

15
12. Rauma AL. Torronen R, Hanninen O, et al. Vitamin B12 status of long term adherents of
strick uncooked vegan diet (Living food diet) is compromised J. Nutr 1995; 125 (10). 2511-25;
13. Sumner AE, Chein MM, Abraham JL. Gerry GT, Allen RH, Stabler SP, Elevated
methylamonic acid and total homocysteine levels show high prevalence of vitamin B12
deficiency after gastric surgery. Ann intern Med 1996; 124:4 69-76;
14. Brolin RE, Gorman JH. Gorman RC, Petschenik AJ, Bradley LJ, Kenler HA, Co dy RP. Are
vitamin B12 and folate deficiency clinically import ant after roux-en-Y gastric bypass? I
gastrointets-Sarg 1988; 2:436-42;
15. Carmel R. Cobalamin, the stomach, and aging. AM J. Clin Nutr 1997; 66: 750-9;
16. Gangarossa S, Romano V, Schiliro G. Efficacy of oral administration of high-dose Imezslund-
Grasbeck syndrome (letter). Pediatr Hematol Oncol. Jul-Aug. 1996; 13 (4):38;
17. 1 Dugue B, Ismail E, sequeira F. Urinary excretion of intrinsic factor and the receptor for
Grasbech-Imerslund patients: the disease may have subsets. J. pediatr Gastroenterol (2):227-
30;
18. Sood AK, Handa R, Singh U. Clinical, hemato logical and electrophysiologic study of
megaloblastic anemias. Indian j. Med Sci. Aug 1994; 48 (8) : 175-80;
19. Chanarin J. Malkowska V, O’ Hea AM, Rinsler MG, Price AB. Megaloblastic anaemia in
community. Lancet. Nov. 23 1985; 2 (8465); 1168-72;
20. Hutto BR. Folate and Cobalamin in psychiatric illness. Comprehensive Psychiatry 1997;
38;305-14;
21. Healton EB, Savage DG, Brust IC. Neurologic aspects of cobalamin deficiency. Med.
(Baltimore), Jul. 1991; 70(4): 229-45;
22. Korenke GC, Hunneman DH, Eber S, Hanefeld F. Severe encephalopathy with epilep.
subclinical maternal pernicious anaemia: case report and revicw of the literature. Eur (5):
196-201;
23. Lindenbaum J, Healton EB, Savage DG. Neuropsychiatric disorders caused by cobalamin
absence of anemia or macrocytosis. NEngl J. Med. Jun 30. 1988:318(26):1720-8;
24. Andress E et al.Food-cobalamin malabsorbtion in eldarly patients:clinical manifestations and
treatment Am. J. Med 2005;118;1154-9;
25. .B12 deficiency – investigation Managment of vitamin B12 and Folac Deficiency
GPC:Guidelines and protocols advisory committe dec 2006;
26. Sarode R,Garewal G,Marwaha N.Pancytopenia in nutritional megaloblastic anaemi. Jndia.Trop
Geogr Med.Oct 1989; 41(4):331-6;
27. Allen RH,Stabler SP,Savage DG,Lindenbaum J.Diagnosis of cobalamin deficincy I:usefulness
of serum methylamonic acid and total homocysteine concentrations. Am,J.Hematol 1990;34-
90-98;
28. Lindenbaum J.Savarage DG,Stabler SP,Allen RH.Diagnosis of cobalamin deficiency.II Relatie
sentivities of serum cobalamin,methylmalonic acid,and total homocysteine concentrations,
Am.J.Hematol 1990;34(2):99-107;
29. UK official BNE guidelines B12-hydzoxocobalamin cyancobabala 2007 4:44pm;
30. Carmel R.Current Concepts of Cobalamin deficiency Anu Rev Med 2000:51. 357-375;
31. Sato I. Honda Y. Iwamoto J. et al.Effect of folate and metcobalamin on hip fracrtures in
patients with stoke: a randomized controlled trial. Jama 2005;293(9): 1082-1088;
32. Harvey S. Anemia B12 deficiency Adam Navigator 2007;
33. Aslinia F. Massa JM. and al.Megaloblastic Anemia and other Causes of Macrocytosis Clinial
Med and Research vol 4. N3 236. 241;
34. Latif T,Hsi ED,Rybicki LA.Adelstein DG.Is there a role for fotate determinations in current
clinical practic in the USA? Clin Lab Hacmat 2004;26:379-383;
35. .Robinson AR,Mladenovic J.Lack of clinic utility of folate levels in the evalution of
Macrocytosis or anemia Am J. Med 2001;110:88-90;
36. AL Essa M, Sakati, N. A. Dabbagh O.Inborn error of vitamin B12 metabolism: a treatabl
dementia paralysis. I Child Neurol.May 1998; 13(5):239-43;
37. Carmel R.Megaloblastic anemias Curr Opin Hematol 1994;1:107-12;

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 38. Kuzminski AM. Del Giacco EI Allen RH et al. Effective treatment of cobalamin deficiency
with oral cobalamin Blood 1998:92(4). 1191-98;
39. Altay C, Cetin M.Oral treatment in selective vitamin B12 malabsorption, I. Pediatr Hemat . yun
1997; 19(3):245-6;
40. Institute of Medicine. Food and Nutrition Board. Dietary Reference in takes:Thiamin,
riboflavin, niacin, vitamin B6 folate, vitamin B12, pan thotenic acid, biotin, and choline.
National Academy Press. Washington DC 1998;
41. Health Canada. Nutrition for a healthy pregnaney:national guide lines for the chieldbearning
years. Ottawa:Minister of Public Works and Goverment Sevices Canada 1999 Acceced
J.21.2006;
42. Tucker KL, Rich S, Rosenberg I. Jacquesp et al. Plesma vitamin B12 concentrations relate to in
take source in the Framingham off spring study. Am J. Clin Nutr 2000; 71:514-22;
43. Carmel R, Ellonbogen L, Herbert VD, Russell RM. Dietary Supplement Fact Sheet: Vitamin
B12 2004.

13. avtorTa jgufi

saqarTevlos hematologTa da transfuziologTa asocialcia

⇒ nino lolaSvili _ s.s hematologiisa da transfuziologiis
samecniero kvleviTi institutis wamyvani mecnier muSaki,
medicinis mecnierebaTa doqtori, sdasu sruli profesori;
⇒ genadi iosava _ s.s hematologiisa da transfuziologiis
samecniero kvleviTi institutes sameTvalyureo sabWos wevri,
transfuziologiuri samsaxuris xelmZRvaneli. saqarTvelos
transfuziologTa da hematologTa asociaciis prezidenti,
medicinis mecnierebaTa doqtori, Tssu sruli profesori;
⇒ marina abaSiZe _ s.s hematologiisa da transfuziologiis
samecniero kvleviTi institutes direqtori, Tssu asocirebuli
profeosori;
⇒ marina bogveliSvili _ s.s hematologiisa da transfuziologiis
samecniero kvleviTi institutes wamyvani mecnier muSaki,
medicinis mecnierebaTa doqtori, sruli profesori.

eqspertebi:
⇒ saojaxo medicinis profesionalTa kavSiri _ irina qarosaniZe;
⇒ saojaxo medicinis eqspertTa jgufi, romelic aerTianebs
Tbilissa da sxva regionebSi moqmedi saojaxo medicinis
saswavlo centris warmomadgenlebs m.S. praqtikos ojaxis
eqimebs.
⇒ saqarTvelos hematologTa da transfuziologTa asociaciis 2007
wlis 5 noembris sxdomis daskvna;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti.

17