Автореферат и диссертация по медицине (14.00.29) на тему:Regularities of the development of iron-deficiency anemia and principles of prophylaxis in adult population of Georgia

TBILISI MEDICAL ACADEMY

Printed as manuscript

Nino 0.Lolashvili

REGULARITIES OP THE BSVBIOPMBHT OP IROK-DSPICIEIiCY AK3MIA AND PRINCIPLES OF PROPHYLAXIS IN ADULT POPULATION OP GEORGIA

14.28.00 - Hematology and Blood Transfusion

SYNOPSIS OP OHBSIS for the Degree oi Doctor oi Medicine

Tbilisi - 1994

The work is performed in G.Mukhadze Research. Institute of Hematology and Blood Transfusion of the Ministry of Public Health of the Republic of Georgia.

Scientific advisers:

Doctor of Medicine, Professor M.Sheklashvili Doctor of Medicine Ts.chinchaladze

Official opponents: Doctor of Medicine, Professor M.Zodelava Doctor of Medicine K.Piradashvili Doctor of Medicine T.8cvelidze

Defence of the thesis will take place on " & " tfûViffîvi/b 1994 at the Meeting of the Scientific-attestation commission №14.01 c №14-8 of Tbilisi Medical Academy.

One can look through the thesis at the library of Tbilisi Medical Acaderay. Address: Ave.I.Chavchavadze 29, Tbilisi, 380079.

Synopsis of the thesis is distributed on

»

Academic Secretary of the Specialized Council, professor

D.S.Metreveli

GEHERAL CHARACTERISTICS OP TH3 THESIS i

Actuality of the problem. Study of iron-deficiency anemia appears to be one of the actual problems of modern hematology. It is known that there are 700 million people suffering from anemia all over the world and of •them 80-95% belongs to ironT^efioiency anemia (IDA). IDA aggrevates the course of many diseasesreduces the capacity for work and correspondingly increases economical losses. The timely determination of IDA, its treatment and, what ia main, mass prophylaxis appear to be one of the important questions in the. =are of public health (M.M.Sherba et al., 1975; Yu.G.Miterev et al., [985; Burman, 1974; Rimber, Rudzuk, 1984).

The necessity of vfide epidemiological study is due to a high frequency of IDA diseases. On the 6asie of the investigations carried out io different countries of the world during the last years, the pecularitie3 of IDA distribution, ecological and social factors Df its provocation were established and the prophylaxis was laid Sown (ll.l.lioseva, H.P.Катета, 1984; V.n.Petrov et al., 1990; S.M. Jakhmarov et al., 1990; D.N.Suleimanova et al., 1990; lama et al., [984; Lyman et al., 1985; Decarli et al., 1986). It should be noted ;hat the ways of prophylaxis differ significantly.Sven under the ;onditions of the sane country they are elaborated with respect of regional, traditional-ethnic and ecological factors. At the same time the methods of prophylaxis applied in one country cannot be axpedient in another, especially in Georgia because of considerable iifference ia IDA evoking factors in its different regions.

Taking into account that Georgia is a country with specific ;eographical, social, economical or ethnic characteristics, it should эе noted that IDA evoking factors'are also characterized by definite pecularities.

During a long period of tiae Georgian hematologiats have been working on IDA problems (V.D.Kiknadze et al., 1983; 1985; E.G.Metre-veli, 1983; S.C-.Metreveli et al., 1985; ti.D.Makharadze, 1988; K.Z. Robakidze, 1992). Rather high frequency of IDA and pre-anemia stete in the population, of Tbilini in different age groups was revealed at their examination. Especially thoroughly, but only in Tbilisi, it was studied in children population (jf.D.Makharadze, 198and in pregnants (K.G.Metreveli et al., 1985). Epidemiological analysis of IDA distribution has not been studied at all throughout Georgia in different age and sex groups, taking into account geographical, traditional-ethnic and ecological factors. IDA underlying ecologica social, traditional-ethnic and professional causes are not establis ed. IDA evoking various causes were studied by a number of authors (H.R.Sedov, R.N.Butakova, 1984; yu.G.Miterev et al., 1985; Bentley, Jacobs, 1980; Balling et al., 3987; Capra et al., 1987). However, taking into consideration those reasons, IDA clinical, hematologics biochemical and immunological characteristic pecularities are not investigated. There are some papers dedicated only to immunological characteristics and even then, merely in cases of pregnancy and rneno-metrorrhagia (N.Milchev et al., 1988; A.A.Golovin et al., I98S K» Z.Robakidze, 1992).

All above mentioned has determined the actuality of the given

■work.

Aim of the work:

- epidemiological analysis of iron-deficience anftiin,

- estr.blisjment of risk-fr.ctors,

- identification of rink-groups,

- elaboration of scientifically proved principle: of proph.yla ic medical examination and mr.ar. propliyle.xia.

Objccts of the wcA:

1. IDA epidemiological analysis in adult population of Georgia

;ording to sex, age, nationality, residence- (town, village), two

rge regions of Georgia - 3ast and "est j 12 historico-geographical

* i

gions, administrative districts, big industrial. centres , II land-ape zones and 5 hydrogeological zones as well as according to I underlying causes.

2. Study of clinical, hematological, biochemical and inmunologic-pecularitiea in IDA, due to different factors.

3. Bstablis meat of IDA evoking social, traditional-ethnic, ^logical and professional risk-factors.

4. Prophylactic-hemstological- investigation of the population Georgia.

5. Identification of high risk-factor groups of IDA development.

6. Clinical, hematological and biochemical investigations in e risk-groups of IDA development.

7. Slaboration of scientifically proved principles of prophy-ctic medicine examination and prophylaxis in patients with IDA

d latent iron-deficiency.

. Scientific novelty. Epidemiological analysis of intensive dex Oil") of IDA disease according to age, sex, nationality, resi-nce (town, village), Eastern and Western Georgia, 12 historico-ographical regions, administrative districts, large industrial ntrea, II lrndacape, 5 hydrogeological Eonee and IDA underlying uaea was done in Georgia for the first time.

During pregnancy, ®eno-rr.strcrrhcgic, na3al nnd gastrointestinal act hemorrhage, bleeding hemorrhoids, agpstric state, hypo- end .acidic gastritis, allmi-ntary sncaia, IDA of unknown etiology,

6.

clinical> hematological, biochemical (iron metabolism, total proti indices of C, Bj2 vitamins and folio acid) and immunological (cell ar and humoral) pecularitiea during the course of the disease wer< studied in Georgia for the first time,

J.

Social, geographical, ecological and professional risk-factoi of IDA development were revealed in Georgia for the first tine.

Among the population of Georgia the risk-groups of IDA develc ment were revealed for the first time and the patients were aub;je! to clinical, hematological and biochemical investigations.

On the basis of all above-said, taking into account the pecu." rities of IDA distribution and its course in Georgia, scientifica^ proved principles of the treatment, prophylactic medicine eiamiaa' and prophylaxis of the patients with IDA and latent irom-deficien< were elaborated.

Practical importance. Study of IDA epidemiological, heaatolo al, clinical, biochemical and immunological pecularitiea promotes the individualization of treatment tactics in every individual oa The identification of IDA evoking risk-factors and groups wi high risks of the disease development allows us to reveal the ear stages of the disease and its latent forms, which, in its turn, a sista the timely beginning of the treatment and carrying out mass prophylaxis. On the basis of the mentioned, it is possible to restrict the distribution of the disease*

Introduction into practice and publications. The results of the given investigation are used in the work of Clinical and Disp sary-polyclinic Scientific Department of Hematology and Blood Trr fusion Research institute of Georgian Ministry of Public Health, as well as in the wotk of the chamber of Hematology and Blood Irs

ion of Advanced Training Instirute of Physicians of Georgian istry of Public Health.

II scientific papers have been published on the basis of thesis eriala.

<t

Aorobation of thq thesis. The basic tenets of the thesis were orted at: the 2nd Congress of Ukrainian hematologists and trans-iologists (Kiev, 1985) and the meeting of Scientific Council of atology and Blopi Transfusion Research Institute of Georgian istry of Public Health.

flhe volume and structure of, the thesis. The thesis Is presented 232 typed pages and consists of introduction, three chapters of per investigations, conclusions, practical recommendations and t of references consisting of 162 home and 113 foreign publicans. The thesis is illustrated by 72 tables and 25 figures.

The work is carried out in the Dispensary-polyclinic (head -tar of Medicine, professor M.Sheklashvili) and clinical depart-ts (head - Doctor of Medicine G.Khutsishvili) of G.Mukhadze earch institute of Hematology and Blood Transfusion of Georgian istry of Public Health ■(director - Doctor of Medicine, honoured entific worker of Georgia, professor I.Zedginidze).

MATBR.IAL AHD METHODS OP THS INVESTIGATION

The present atudy covers the results of the investigation of 4 IDA patiento, registered by the Clinical and Dispensary Depart-ts of the Georgian Hematology and Blood Transfusion Research Insti* e ao well as by the lienatologipal • centres in Sukhumi, Batumi, aisi, Tskhinvali and Hematological Polyclinic of Tbilisi from 2-to 1989, inclusive. The inspected patients aged from 16 to 88; IDA diseased 199 were hen and 4455 - women.

The follovfing documentation has been studied in order to co lect p. complete information on IDA patients.

1. The medical documentation of the patients (out-patient c and history) registered (since 1982-3989) by Clinical and Diapen Scientific Departments of the Georgian Hematology and Blood Iran fusion Research Institute.

2. The documentation of the patients registered by regional hematological centres all over the Republic as well as by Tbilis Hematological polyclinic.

The data on every single patient were included into a des: by ur IDA epidemiological map comprising the following parameter family name, given name, patronymic, date of birth, age when dii ed, sex, nationality, address, place of residence (town, village landscape zones, place of employnisnt, occupation, length of ser* contact with noxious sybstances, diagnosis; IDA underlying ceua pregnancy, meno-metrorrhagia, bleeding hemorrhoids, gastricinte nal tract hemorrhage, agastric aneraia, hypo- and anacidic gastr chlorosis, alimentary anemia, IDA of unknown etiology, nasal he rrhage, time of diagnosir. setting - year, month, date, duration the illness, origin of food, course of pregnancy, peripheral bl analysis, immunological data (humoral and cell immunity), iron, bolism data, ferritin, total protein, vitamins (Bjg, C, folic a the epidemiological map is enclosed.

The patientQ were divided into subgroups according to the ing parameters : sex, age, place of residence (town, village); i ing in the Eastern or ','Jestern Georgia, 32 historico-geographi« regions, administrative districts; II landscape zones; T: hydroj gical zones; residing in Tbilisi;. 5 nntionc?.lities and IDA c".usi

For the descriptive annlysia of IDA an annual averr.ge int.

lex (II) of IDA has been specified according to age, sex, residing Tbilisi, belonging to 5 nationalities (Georgian, Russian, Arrne-m, Azerbaijanian, Jew, a3 well as 26 scanty nationalities), place residence (tov/n, village), 2 large regions of Eastern and Vies tern >rgia, -12 historico-gepgraphical regions, asministr'ative districts,, •ge industrial cities (Tbilisi, Kutaisi, Rustavi, Batumi, Sulchumi, dvinvali), II landscape zones, 5 hydrogeological zones, IDA under-Lng causes: pregnancy, meno-metrorrhagia, gastrointestinal tract norrhagc, bleeding hemorrhoids, agastric anemia, hypo- and anacid-gastritis, chlorosis, alimentary anemia, IDA of unknown etiology, 3al hemorrhage. Epidemiological data were determined relative ta e and sex groups. The patients v/er^, divided into 5 age groups, or groups comprised patients from 16 to 55, each for every ten ars (16-25, 26-35, 36-45, 46-55) and one group involved 56 and er years old patients.

The calculation of the annual average intensive index was per-rmed after A.M.Merkov (1953) formula:

y. .1 ■ —«

NT

ere :"n' - number of registered cases,

N - average number of the population within the terras of

the observation,

m - qualitative index of a standard number of the population I - the annual time of observation

Certain demir.graphical findings obtained by Georgian Computing

sntre have been used at the deduction of IDA intensive index, lich mas determined for one million residents.

In order to identify the reliability of the results, an average .-ror of a selective study was counted up according to the following

10.

formula:

Pr n.

q»I0C.000-p

N - number of oboervations.

The intensive index reliability limits were calculated by means of the formula:.

Pgen^Sel±tnlP

where: p .. - intensive index s el

t - 95% criterion of reliability

mp - average error of the selective investigation.

The true value of the disease level mas figured out through a standard age index. With this view, at the first stage of the research an average index of the population number was examined, bringing the grounds for setting up the population standardized structure. At the second stage the standardized intensive index was calculated.

All the patients were exposed to generally accepted clinical and hematological tests. Hemoglobin, erythrocytes and leukocytes were measured and leukocytograram was performed as well.

According to the heaviness of the disease the patients were divided into three groups: I. easy, 2.moderate, 3.heavy, while according to the amount of leukocytes - into two groups: I. normal amount of leukocytes, 2. leukopenia.

Serum iron was determined in 695 cases: combining ability of serum - 595, saturation coefficient - 695, ferritin quantity - 463, total protein - 405, vitamin Bjo - 182, folic acid - 184, vitamin C 183, serum immunoglobulins - 59, T-lymphocytes amount, T average and 2 active - 14, B-lymphocytes - 17.

•Under the expeditionary conditions in 1985-1990 there were ;xamined 1549 practically healthy people. 3G3 oi then were men and [985 - women. The examined patients were divided into two groups. Che 1st group involved 428 practically healthy subjects (162 - men, 260 - women), who wer^ not determined according to' the IDA risk indices of the present epidemiological anp.ly3is.

The second group comprised II2I practically healthy people [195 - men, 926 - women), who were characterised by the signs typic-l1 of IDA risk groups.

The expeditionary investigation was started with the gathering if anamnesis, hemoglobin was determined, the amount of erythrocytes :nd leukocytes was measured, the leukocytoeramra was performed.

92 patients engaged in 3 noxious enterprises were exposed to a horough biochemical p.nalysis. Serua iron, serum combining ability .s well as saturation coefficient vfere closely inspected in 92 cases: erritin content - 21, total protein and protein fractions - 79, eruloplasmin - 74.

The results of all the biochemical analyses have been syste-atiaed and treated according to the method of variation statistics, he arithmetical mean "ll" was. calculated a3 well as the average qjxare "a" (A.E.Serenko, V.V.Srmakova, 1934).

The reliability index viaa determined by means of the Student's able. The difference ivas accurately evaluated with P 0.05.

Proper investigations. With the help of the resulta of the xeoutad epidemiological analysis it has been established that in ecrgia, 'il"of IDA equals to 15.9. TJoraen constitute the main part f IDA patients.

'Wof IDA is profoundly higher in the croups of age 16-25 20.(5) and 26-C5 (24^2) * than_in those of 53 and over years old,

where "il"is only 6.0.

II of the disease is the highest in 56 years old men and equals to 3.1 in older age group, which is explained by frequent pathologies of gastrointestinal tract in this age, and appears to be the n important cause of IDA among men.

Wof the disease is the highest in 16-25 years old womea -38.9 and 44.4 - in 25-35 years old group. Age standard indices for both these groups are the oanie and equal to 7.9.

The illness considerably differs according to the historico-geographical regions of Georgia. The highest rate of the disease i registered in Samachablo - 20.2, in £he Autonomic Republic of Adja ra - 14, while the lowest rate - in Meskheti-Javakheti - I.I, Sa-megrelo - 2.3 and Kakheti - 3.5.

High indices of fhe disease in the Autonomic Republic of Ad;Ja is explained by nursing children for a long period of time in mult delivery women. There are also noted frequent cases of helminthias Despite equal with other sort of meat content of iron, pork is sti missing in the nutrational ration, though it comprises a proper optimal amount of microelements to assist the organism in perfect iron absorbtion. In Meskheti-Javakheti and Kakheti protein producl containing iron, prevail in the nutrational ration which,in our opinion, stipulPtes a low rate of the disease in these regions.

There is a difference in various indices of IDA disease also observed in these regions, according to administrative districts. In Kartli the rate of the disease is the highest in Manreuli dist rict - 7.7, while it is low in Borjomi district - 1.9. A high rat of the disease in f,!orneuli is explained by the prevalence of Azer ¡jnnian population, among which there is a lot of multidelivery w men with long-lasting nursing, regular and frequent intake of tea

nd also by other peculaiities of their'nutrition: there is no pork nd fatty products prevail In their nutrational ration. The latter s well as tea appears to be an inhibitor of iron-absorbtion.

'W oS IDA disease La almost identically low in all administrat-ve districts of K&khet|L. m these districts protein products, con-aining herain iron in large amounts, prevail in nutrational ration. 1 of the same type are observed in the 3ast 'Caucasus and Meskheti-avakheti. In these .regions protein products also prevail in their utrational ration,

The highest"ll"of the disease in Imereti is registered in Kutai-i, Bagdadi and Ishsltubo districts, which should be explained by ■erf ect medicine care and also by a .high, pollution of the atmosphere Jid soil in Kutaisi.

m Samegrelo, Hacha, Svaneti and Gurin 'tl"of the disease i3 ¡omparatively low in all the regions.

On the basis of obtained by us results the disease of urban and •ural population Euro considerably different. "ll "of urban population lisease is 25.6, while those of rural population equals to 4.0, ■atio "if is 6.4. A higher "ll"of the disease in urban population may >e explained by the influence of ecological factors, pollution of :he atmosphere and relatively high level of diagnostics and registrants! in towns. At the same timel1II,,lovf rate attracts our attention In such industrial centres, as Rustavi'(10.7), which is much lower ;han in Tbilisi (41.0), Kutaisi (32,2.), Sukhumi l 20,9, Batumi (23',7.; md Tskhinvali (.38,£?. The mentioned fact may be explained by the existence of hematologics! dispensaries, except of Rustavi, in ill above-said to«a.s , where diagnostics and registration sire rather ligh. At the same time the air and the soil Eire pollutod with in-iustrial wastes above the'norm, >the content of microelements is

which sharply differs from each other. According to the findings c Georgia Republic's Hydrometeorological and Nature Control Office the amount of copper is 5-6 times aa high than normal in Rustavi and its suburbs , while the amount of lead remains within the norms The content of copper in the soil is several times lower in Tbilis than in Rustavi. In Kutaisi as compared to other tovms, the contc of lead is several times higher. All above-mentioned allows us to consider that to c. ceratin extent the content of microelements in the soil influences the rate of IDA disease. It is known, that cop per promotes iron abaorbtion. In Rustnvi, where there ia an iacree ed amount of copper, the rate of IDA disease is low, while in Tbil si, where the disease index i3 high, the content of copper i3 mucfc lesser thf.n in Rustavi. In Kutaisi, where the disease index is hig the soil as compared to other towns, contains lead in large amount which makes considerable difficulties in iroii absorbtion.

The analysis done in two large regions of Georgia has shown that the disease is higher (10.4) in Western Georgia, than in East (except of Tbilisi - 5.2), what can be explained by a considerabl« difference in nutrational ration of these regions, it should be nc that in Eastern Georgia protein products prevail in diet of the po lation.

According to data obtained in landscape zones "il" of the disease is high in the III zone (arid subtropical-fieldlike landscap 8.3, in the 1st zone (Kolkheti moist-subtropical lowland-plain las scape) - 7.9 and in the VIII zone (Eastern Transcaucausus type moderate moist mountainous-forest landscape) - 7.3, while it is low in the IXth zone (mountalnou3-field landscape) - 1.5. In these zon where high indices of the disease' arc observed, the scils ire distinguished to have a low content of copper and cobrlt ihich can be

of the underlying causes of IDA.

On the basis of the :analyoic dene in the bydrogeological zones,

s established that the disease is the highest in the IVth zone -

! and the lowest - in the Vth zone (1.2). These data are in ac' t

;ance-with the distribution of microelements in different hydro-ogical zones. It should be considered that the level of the ase does not depend on the amount of microelements in water.

It should be also noted that common "ll" of the disease cor-onds to "ll" exf the disease among women. "ll" of the disease in is low and does not significantly differ according to residence, .scape and hydrogeological zones, which again notes to the fact,

the level of IDA disease in wom^n as compared to men is much more ndent upon the influence of the environment. Therefore, irrational, ition as well as low content of microelements in water and food ars to be a stimulant of anemia more often in women than in men.

Among the multi-national population of Tbilisi the highest "ll" he disease is registered In Azerbaijanians (72,0) and Jews I), while the lowest - in Armenians (19.8). At the same time "ll" he disease is the highest in jew men, while among women they are . in Azerbaijanians. As all these nationalities live under the

oliaatic-geographical abd hydrogeological conditions, the dif-nce should be found in ethnic, religious and nutrational pecula-ea, as. well aa conditions of life. ' Among the Jewish population high "ll" ofthe disease is due to ational pecularitiea, Accodring to their religious restrictions e is no pork in the nuirational ration, containing in optimal arts microelements necessary for iron absorbtion, as well as inmuch fatty food, which appears to be an inhibitor for 'iron rbtion. Besides the mentioned, Azerbaijanians take much tea

which prevents iron absorbtion. Among Azarbaijanian women the causi of high indices of IDA disease together with nutrational peculiarities is multi pregnancy aad delivery, the nursing of children for a long period of time. All above-said notes that IDA disease is considerably due to ethnic, religious and nutrational pecularities. In raoslems one of the reasons of IDA disease are nutrational pecularities and religious restrictions.

Pregnancy (30.4$) and meno-metrorrhagia (28.9%) are the moat frequent causes of IDA in women, while in men such cause is gastrointestinal tract hemorrhage (28.1$). Both in men and women alimenta anemia is more rare - 0.5%.

Evoked by pregnancy IDA more often is developed in the age of 16-25 (51.1$) and by meno-metrorrhagia - in 26-35 (27.5%). Che frequency of IDA due to pregnancy in the age of 16-25 can be explained by the preliminary growth which, in its turn, induces expense of iron in large amounts, during this period the menstrual cycle ia formed which often evokes menorrhagias. In 26-35 age group the frequency of anemia evoked by meno-metrorrhagia mainly can be expla ed by gynecological pathologies.

Often IDA evoking causes are hypo- and anicidic gastritis (82,4/c) which accompanies meno-metrorrhagias, though there exists e contrary opinion that hypo- and anacidic gastritis are not stimular of IDA, but they appear to be only consequence.

As a result of our investigations rather high rates of IDA disease evoked by hypo-and ann.cidic gastritis were revealed - 10.0. Other evoking causes of IDA were not revealed. So, it should be su( gested that the both groups of authors are right, since in some cases hypo- and anacidic gastritis may be the causes cf IDA aid in other cases - its long-lp.stiiig result.

In Georgia the lowest IDA index is observed during alimentary - 3.5. We have registered only single cases of alimentary ane-mainly in those women, who in result of psychic shock and in r to keep to a diet, limited themselves in taking the food. Among men the highest IDA indices were noted at gastrointestinal t hemorrhages - 2.0, while in women the same indices were 3.6. We have analysed clinical and hematological course, taking account the evoking caus es.

According to the heaviness of the disease course the patients : divided into 3 groups. More often the course of IDA was mode! (55.755) and, in its turn, the cause of moderate cases was often pancy - 58.8%. The moderate course of the disease at IDA evoked iregnancy is due to timely diagnostics , as pregnant women are .stered at Prenatal dispensary, where they are regularly subject-;o blood peripheral investigations.

Heavy cases of IDA are more often observed during anemia evoked ileeding hemorrhoids (26.Cf), alimentary anemia (25%) and gastro-;stinp.l tract hemorrhage (24%).

Mild cases of IDA among women are observed during nasal hemo-ige (74,2%) and pregnancy (68%), among men - during agastric ane-(53.1%). The heavy course in women is more frequent during sding hemorrhoids (27.2%) and gastrointsstinal tract hemorrhage .I%)i among men - during hypo- and anacidic gastritis (31,4/?).

Unimportant decrease of erythrocytes :o 3. is chnrac-

istic of the majority of ID.l patients ( >3%). Unimportant decrease erythrocytes is more often observed in >regncnts (96.'1%) while nificant decrease (32.3$) i-; revealed daring gastrointestinal ct hemorrhage.

The amount of erythrocyte is more of en decreased in men

{•40.2$] then in women (15.9%)«.

ri>

The decrease to S.O'IC^"/! and moro of erythrocyte amount is often observed at gastrointestinal tract hemorrhage (44.6$), bleedi hemorrhoids (43.3$) and IDA of unknown etiology (44.2$).

In women considerable decrease ljelo-,7 of erythrocyte

amount is often found during nasal (35.5$) and gastrointestinal tract hemorrhages (28%). An insignificant decrease "of erythrocyte amount is characteristic of pregnancy (95.2$) and chlorosis (92.8%)

Normal amount of leukocytes was characteristic of the majority of patients (88 . 55Í). The amount of leukocytes above 4.0*

I09/l was

more often noted during pregnancy (95.0$) and nasal hemorrhage (91. Leukopenia more frequently v/as found during hypo- and onacidic gaat ritis (25.4$).

Leukopenia is found both in men (18.6?) and women (14.3%) with equal freguency. Normal amolint of leukocytes in men is more often characterized by bleeding hemorrhoids (90%) and .gastrointestinal tract hemorrhage (81.1$). Leukopenia is often met during hypo- and anacidic gastritis (31,4$).

More often IDA evoked by pregnancy (95.0$) and nasal hemorrhag (96.8$) is characterized ny normal leukocytes'in women.

So, much heavier course of IDA,reduction of erythrocytes to end over and leukopenia are far often observed ift men.

Analysis of the cpurse of IDA. evoked by pregnancy has shown th a severe course of the disease is more often met in 16-25 years old group, which can be explained by the fact that this age is preceded by growth and pubescence peiiod, that, in its turn, appears'to be the cause of abundant expence of iron. At the same time the final formation of menstrual cyclt takes plzcr-., often followed by menor-rhages, which also causes at undent iron -¡onsumptioa.

A moderate (60.8%) and a severe (20.i'%) courses of IDA evoked mcno-motrorrhagia are more often observed in group 35-45 of age.

The biochemical analysis of the results obtained showed that s ^erum iron index is most of all reduced in the patients with i. caused by hypo- and anacidic gastritis. Over 8 mcmol/l of serum jn was registered in 21-25^ of patients with this nosology.

A considerable decrease in serum iron amount, average 4.5-5.5 nol/l was revealed in cases of both severe and light forms of ane-i, with the difference that profound anemia vir„s mbre frequently and: In light forms of hypo- and anacidic gastritis there were % of sharply reduced serum iron, vrfiile more profound nneraia cons-tuted 90%.

In 30% of patients with hypo- and anr.cidic 'gastritis there was t observed any considerable reduction in serum iron, of them 24% mprised the patients v»ith hemoglobin level at S0-II8 gr/l.

Over 8 mcmol/l of serum iron was noted in 40% of patients with A due to meno-metrorrhagia, ivhose hemoglobin was more than

gr/l amd serum iron reached 4.9-4.4 mcr.;ol/l. The ability of trans— rrin saturation by iron was reduced in c.bout 5.5-5.4% of which % of patients were determined to have lc.ver then 90 gr/l hemoglo-n. Among the pregnant patients 53% had more than 8 mcmol/l serum on. At maximum reduction of the three prrameters its average 1b-ls made up 5.0-6.5 mcmol/l, iron-deficicncy was comparatively ss expressed in patients with IDA caused by pregnancy.

Cf all the underlying IDA causes the aost profound deficiency ' serum iron wrs observed at hypo- nnd anicidic gnstritis, while .glit cases were found at pregnancy, predc nination of light forms ' serum iron deficiency in pre/jvant IDA j »tients could be certain-■ explained by the fact thnt the patient, are constantly controlled

2C

by medioril personal and, thus, diagnosed in good time. AS regard

to hypo- and anicidic gastritis, this pathological process is de

veloped gradually, bringing about no complaints on the part of p

i

tients and the diagnosis, therefore, is not made until the level of serum iron ^ets too'low. A.11 the mentioned above makes it evi dent how important is a tinely diagnosis of IDA.

With this, it should be noticed that the level of serum ire does not always correlate vith the amount of hemoglobin. Very of with light forms of IDA, the amount of serum iron is considerabl reduced. This, particularly, concerns the gradually developing I forms, such as those caused by hypo- and anscidic gastritis.

All the cited above indicates that hemoglobin is not a mere rightful reason to judge on the degree of the disease.

Our investigations have demonstrated that 94.4% of patients have a considerably reduced amount of ferritin. The most signifi decrease of this parameter was identified at agaatric anemia r/it hemoglobin less than 90 gr/l. At the same time it should be not! that in 5.6$ of patients despite IDA, the level of ferritin was within the normal. Thus, it can be suggested.that' the ferritin t is 94.4$ reliable in determining IDA. Therefore, a complex exami tion of the patients is reasonable for the true diagnosis , which would comprise: serum iron amount, as well as ferritin and trans rin determination.

Total protein was reduced only in rare patients. The cases hypo- and anacidlc gastritis rapreaente d the exception, where were identified to have a profound reduction in tcdsal protoin.

Proceeded from the above data a conclusion can bo drawn the among the population of Geo.'gin the cacea of protein deficiency are far too rare in IDA pat Lents.

Vitamin study showed the slightest changes in Bjq, the decrease ihich was revealed only in 12.7%. Of them 10.9f~ should be noticed )e due to meno-metrorrhagia.

Par more often there were changes in folic acid and vitamin C.

At meno-metrohrhagia, as well as hypo- and anncidic gastritis, ic acid was reduced in 29-3Of- of cases, while the pregnant made 50%. Taking into account the fact that with the introduction of

the expense of folic acid noticeably increases, it is advisible state that this vitamin is not expediently to be prescribed in , of different etiology, especially in pregnant prtients. It uld be administered only in the cases, when there is a biochemical .dence of its deficiency.

Vitamin C deficiency was identified in more than a half of les at hypo- and anaoidio gastritis as v.ell as in the pregnants. meno-metrorrhagia -vitamin C deficiency wr.s expressed in rare jes.

The results of vitamin investigations have also demonstrated at in Georgia this parameter was as well different in IDA patients,'

compared to the residence of other regions (i.V.Gushin et al., 79; B.H.Khamzaliev et al., 1990). A sharp vitamin deficiency has en revealed in IDA patients over the Central Asian Republics. The iount of protein and vitamina waa determined to be so badly changed :at B.H.Khamzaliev and coauthors (I9?S,I990) found it urgent that )A should be renamed to polydeficiency anemia.

All the mentioned above indicates thnt the IDA pntients in ;orgia differ, in respect of protein metrbolism and vitamin level ?ora IDA diseased residents of other regiois, and these pecularities lould be taken into account at treatment.

Vitamin deficiency ie also unequal at IDA due to different causes, which should be accounted for in every single case of tj ment.

Particularly, the fact should be figured out that latent ii deficiency has been shown oy the biochemical analysis to revee the changes similar to tho^e in IDA of the same etiology. Thus, latent iron deficiency the disturbances in the metabolism cons t manifest themselves before peripheral blood anemia i3 revealed.

The study of humoral immunity in IDA due to different cause has shown that IgM. level i;: increased up to 1.3 gr/l in h&po- an anacidic gastritis and to 1.7 gr/l at chronic gastrointestinal t: hemorrhage as well as at bleeding hemorrhoids,

V?e consider it obligatory to take into account IDA underlyi; causes during the study of immunity disturbances, since we have failed to reveal any in IDA due to oeno-aotrorrhagia. It oea be i sumed that this variety of findings on immunity ¿isturbaaoes obsi in IDA is possibly brought about by the fact that moat investiga-l did not consider properly the underlying causes of IDA, fihich arc vitally important, as different causes induce either disturbance retention of different links .

Humoral immunity in IDA due to pragnancy is particularly to distinguished. According to the results obtained, there was no di turbanee of humoral immunity in IDA patients within the Jtrot tre ter of pregnency, while in the sedoc.fi. treracuter the reduction of to 10.9 gr/l and igA to 1.8 gr/l was obesrved,

f__. "I J_______. ,__A.1- — JJ____---t J.*- " — J--J- —--. _ - _ J A. .

KjVX r^i-JL1 J. CiU^'pOr'j -V J.U.V, I.¿¿W p^v-O—luo vU

the examination did not sho" any disturbances of humoral Inaunity in the first treses ter of p-.-DcasBcyrfS. .-pit.o oi the fact that the mtr. f, cavae o? ID., was ag^rcr ted by previous u*sao-ra&tr<

5ia. As regarded to the second tremester, the decrease in IgG ard laa found to have already been developed in the patients. IDA risk-groups among the population of Georgia have been iden-;d on the grounds of the results of epidemiological investiga-

To them belong: women of reproductive age (16-45), residents .rge industrial centers - Tbilisi and Kutaisi, population of rn Georgia and the Autonomic Republic of Adjara; national -,c group3 of Azerbaijanians and "Jews; persons contacting with us chemical substances, multi-delivery women, gynecological nts with meno-metrorrhagia and hypo- and anacidic gastritis; ith gastrointestinal pathology. In order to examine our results, itionary investigations were carried out in risk-groups. Practi-healthy people engaged in the enterprises of Tbilisi were as control.

1549 practically healthy people were investigated under expe-aary conditions from 16 to 78 years age, of them 373 men and ?romen.

Investigated people were divided into 2 groups: the 1st group ised 428 practically healthy people - 168 men and 260 women, ;d in various enterprises of Tbilisi ind not contacting with as chemical substances.

Phe 2nd group involved II2I practically healthy people, belonge 3 risk-groups (women - 926, men - 195). The majority of inves-:d people were at reproductive age - from 16 to 45. Residents :umi were investigated, v.here by means of preliminary epidemio-il investigations high activity of IDA was revealed, especially vfomen. Mr.rneuli and Gardnbani region?' with high density of :nl-ethnic group of Azerbrt ijnnirui popt lrvtion, were under study 1. By our preliminary in- -otigations high indices ■ i' IDA di-

sease were established in residents of '.Vestern Georgia, where indices of IDA were high as weUJ the people engaged in the enterprises of Tbilisi and Rustavi, contacting with noxious chemical av stances: lead, tin, nitrogen as well as ones who had high physical loading.

IDA disease index in the 1st group was: 1.5% in men and 2.3% in women. In the 2nd risk-group this index was considerably high ■ 20.4%f in men - 11,8% add 22.3% - in women. So, the expeditionary investigations have confirmed the necessity of a correct identification of risk-groups as a result of our epidemiological investigi tion. It .is exactly that group tfhere active prophylactic studies should be carried out in order to reveal IDA and perform further treatment.

Thorough biochemical investigations were carried out oa the workers of 3 enterprises, contacting with noxious chemical subsya: - lead, tin, nitrogen. Proceeding from the results of the biochem al investigations the fact attracts our attention that dysprotein was noticed in the majority of investigated people and in almost the ca3®s - reduction of ceruloplasmin index..

Prophylactic medical examination of IDA diseased persons was executed in 2 stages: the 1st stage - revelation of patients and their selection for prophylactic medical examination and the 2nd stage - dispensary observation. The treatment was mainly carried out using peroral iron preparation, and only in case or peroral 5 lerance, iron preparations V.';ro injected intravenously or intrami larly as well as at the lowest hemoglobin indices or in case wher a rapid augmentation of hemoglobin was necessary. Special ettentj requires the preacribtion of vitamins, which remains to be a disj able question up to present <lay, To our lind, vitamins should be

rescribed in an every specifio case taking into account IDA evoking auses and local conditions, ?h.e results of our investigations have tated that there is a deficiency of vitanin C end folic acid in he population of Georgia though the deficiency of vitamin Bj-jj is ore rare. Therefore we consider it neccseary to provide the treat-,ent by using mainly vitamin C and folic acid. Vitamin Bjg was pre-cribed in rare cases, only at proper- indications. It wa3 not pre-icribed during pregnancy, as it may cause more abundant expense of ,'olic acid. The prescribtiori of erythrocyte mss3 takes place in >ur investigations only in case of severe state of the patients.

All the patients, in accordance with IDA evoking causes, were iiwided into 2 groups:

The 1st group - patients to whom the cause of the disease was 3tated and then removed - 748 patients. They were subjected to active treatment. After the normalization of indices of iron metabolism they were controlled during 1-2 montha and then were removed from the registration.

The 2nd group comprised cases, when it was impossible to remove causes evoking IDA. There vters four subgroups in the 2nd group. The 1st subgroup - anemic patienys with gastrointestinal acidity and iron absorbtion disturbance in intestines - 759 patients, the 2nd subgroup - patients with posthemorrhage anemia - 1025. After the active treatment these patients remained to be registered in prophylactic medicine examination and they were subjected to favourable therapy.

The 3rd subgroup - 1414 pregnant women, who after the active therapy stayed under dispensary observation within one year and ffter that they moved into a risk-group.

The 4th subgroup - IIC p-tients with IDA of unknown etiology.

After the active therapy these patients remained to be registered

at prophylactic medicine examination.

Favourable therapy provides prolonged remissions without reft

lapse in 100% of patients. Handicap is sharply decreased from 60$ to 10$ by means of favourable therapy. Patients not subjected'to regular treatment, constituted 10$. ■

For the prophylaxis of IDA it Is necessary to carry out the treatment, especially in risk-groups, identified in the result of population investigations: adults, women in reproductive age, womi with gynecological pathology, pregnants.

It is necessary to perform peripheral blood counts in patieai with hypo- and anacidic gastritis.,

A special attention should be attracted to rational nutritioi especially among the population of Western Georgia and Adjara.

In order to reveal IDA» it is necessary to carry out extensi' investigations in large industrial centers, Western Georgia and ii the Autonomic Republic of Adjara.

prophylactic studies should be carried out in factories, whei workers contact with noxious chemival substances': lead, tin, nitri

gen. For the secondary prophylaxis it is necessary to remove IDA evoking cause.

conclusions

I. Iron-deficiency anemia is a widely distributed disease. T] average intensive index of irca-deficieney anemia disease is 15.9 (1.5 - ia men and 28.0 - in womea). The rate of the disease is hi, in the age of 16-25 (20.0) and 26-35 (24.2), in Samachablo (20.2) and ia the Autonomic Republic of Adjara (14.6); ia urban populate (25.6), in Tbilisi (41,0), and ia KUtaisi (32,2),. in VJestern Geor,

).4); 8.3, 7.9 and 7.3 In the Illrd, 1st and Vlllth landscape lea, correspondingly; in the Vth hydrological zone (15.9), among irbaijanian population (72.0) and among Jews (57.1), resided in Lliai.

2. Intensive index of IDA disease is low in men and does not isiderably differ according to the residence, landscape and hydro-(logical zones. In women iron-deficiency anemia is considerably

;h and is miich dependent on the effects of the environmental fac-

. Irational nutration, a low content of microelements in food >ear to be the cause of anemia more often in women, than in men.

3. Under the conditions of Georgia among the causes evoking «.-deficiency anemia more often appears to be in women pregnancy

I meno-netrorrhagia and gastrointestinal tract hemorrhage in men. ■e rare are alimentary anemia and chlorosis.

4. To the risk-factors of the development of iron-deficiency smia belong: undernourishment, contact with noxious chemical sub-iscea (lead, tin, nitrogen). In Ueorgian population high risk->ups of iron-deficiency anemia comprise: women in reproductive

> (16-45), residents of large industrial centres - Tbilisi and ;aiai; population of Western Georgia and the Autonomic Republic Adjara; national-ethnic group of Azerbaijanians and Jews; people, itacting with noxious chemical substances, multi-delivery women; ¡ecological patients with meno-metrorrhagia; men with gastroihtes-lal pathology.

5. The severe course of iron-deficiency anemia, reduction of ■throcytes and leukocytes are more often observed in men. The amount iron-metabolism is not due to the kind of iron-deficiency anemia arse. Sharp decrease of serum iron is the moat often observed phe-lenon in iron-deficiency anev.ia evoked by hypo- and anacidic gastri-

tis as well as agastric r.nemia and. is rare at pregnancy.

6. In Georgia the ccijrse of iron-deficiency anemia is charac

rized by the following pecularities: the decrease of the amount o i

total protein is not observed, vitamin Bjg deficiency is rare whi the deficiency of folic r.cid and vitamin C is more frequent. The content of vitamins is different depending on iron-deficiency ane evoked by different causes . The deficiency of vitamin Bjp content is more often observed at meno-metrorrhagia, vitamin "C - at pregn and hypo- and anacidic grstritis, folic acid - during pregnancy.

7. "Various links of humoral immunity are disturbed during ir deficiency anemia evoked by different causes-. Iron-deficiency ane due to meno-metrorr.hagia as well as humoral immunity in the first tremester of pregnancy are within the normal. T^e decrease of IgG and IgA is observed in the second tremsster of pregnancy.

8. Prophylactic medicine examination of patients with iron-deficiency anemia, the primary prophylaxis according to risk-grot and favourable therapy ensure the decrease of disease indices, tt course of disease without relapse, the decrease of capacity for work as well as the recovery of a considerable number .of patients

PRACTICAL RECOMMENDATIONS

1. Investigations in risk-group with developed iron-deficiei anemia are advisible to bs- executed in order to reveal and carry proper medical dispensary examination in the patients ehowing ]>r or evident iron-deficiency .¿iter the fictivc thorapy a part of th patients with stable ecus 23 evoking th~ disease* ahculd undergo : permanent favourable ther ipy in. order to prevent release.

2. m regions Tilth high lsvel o-f -jjjcn-deficiancy anemia in Vf est era Georgia, the Auto ionic Republic of Adjara it ia reasonab

carry out extensive prophylaxis, as well as in large industrial iters and in those enterprises, viherj workers have contacts with :ious chemical substances (lead, tin, nitrogen).

3. While latent iron-deficiency, the same changes in biochemic-parameters are noticed e.a during irjn-deficiency anemia of the

ie etiology. So, in case of hemoglobin lower norm, especielly at jgnancy and hypo- and anacidic gastritis, the investigation of зп-metabolism should be performed.

4. in the regions of high-risk iron-deficicncy anemia (Western orgia, the Autonomic Republic of Adj та) it is expedient to call

г attention to rational nutrition ani to diet rich in protein oducts, vitamins and microelements, as well as to reduce in food e content of such products, that prevent the process of iron ab-rbtion (tea, milk, fats). It is desirable to enrich of commodities th iron (bread, fruit jellies).

5. The treatment of iron-deficiency anemia, especially vitamino-.erapy should be prescribed individually, tr.king into account the .uses evoking the disease. We consider it advisible to prescribe .tamin С and folic acid, the deficiency of which was revealed in

le most part of patients. Vitemin Bjg being harmful for pregnants, i on the contrary, expedient to be proscribed in iron-deficiency lemia due to meno-metrorr'iagin, as in this case its deficiency i3 зге frequently observed.

30.

MST 05 НгаЫСАТ1Ст 0Я ТТГЕГ>1П MATEHIALS

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2. З.М.Робакадзе,Н.0.Лолас-ЕИли,Н.В.Китйя. Применение различных-доз эрит, массы к лечении анемических состояний/Дез.докл. '. Национального конгресса гематол. и трансфузиол. Болгария, С фия, 1986. ' '

3. З.Ы.Робакидзе.М.Г.Мухадзе,Г.С.Евания,Н.В.Кития,Н.О.Лолапшил] Влияние переливания разных доз эрятроцитарной массы на некоторые неспецяфяческяе факторы естественной-защиты при анемических состояниях//!! Респ. съезд гематол. и трансфузиол. Гр; зия. - Тбилиси, 1988. - С. 166-168.

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5. К.З.Робакидзе.Н.О.Лолашвили. Распространение и леченяе желе-зодефицитяой анемии беременных в Грузии//Йедико-соцвальные вопросы охраны материнства а детства. - Тбилиси, 1989. - С. 89.

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. Н.О.Лолапшили.К.З.Робакидзе,Р.К.Ыцивняшвили,М.И.Биняаишили. Распространенность желязоцефицитноГ анемия в Грузинской ССР// Ш Всес. съезд гематол. и трансфузиол. Тезвсы докладов. -М., 1991, П том. - С. 277-278. . о.обдрос/э ,о.Ьзоубозсп»®.росо^пЗзпсп,у .¿боО^,6.рчроЭдоро,р. об-

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