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MINISTRY OF HEALTH OF REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF INTERNAL DESEASES
LECTURE THEME:
The differential diagnosis of a urinary sediments changes and General
Practitioner tactics.
(For the students of medico-pedagogical faculty)
ТASHKENT – 2016
MINISTRY OF HEALTH OF REPUBLIC OF UZBEKISTAN
TASHKENT MEDICALACADEMY
DEPARTMENT OF № 3 INTERNAL DESEASES
«APPROVED»
Dean of medical-pedagogical faculty,
professor ___________________
____ _____________ 2016 й
The differential diagnosis of a urinary sediments changes and general
Practitioner tactics.
(For the students of medico-pedagogical faculty)
Professor Gadayev G.A.
Tashkent – 2016
Changes in urinary sediments and their diagnostic significance
'Any benign proteinuria as a pathological character, in all cases, a careful inspection of the
patient and to identify the main causes of action should be
M.S.Vovsi
"Urinary Syndrome" is determined using biochemical and microscopic examination
includes a number of changes. This syndrome only in the kidney and urinary tract, but also in
other diseases is one of the many observable characteristics, all the doctors in the field, including
GP activity occurs on a regular basis. Variety syndrome, and it is not specific to identify the
causes which lead to additional challenges. Kidney and urinary tract diseases ekstrarenal
asymptomatic (edema, hypertension), only changes in the urinary sediments with urinary
syndrome diagnostic importance of further increases. Basic types of pathological urinary
syndrome, proteinuria, hematuria, leykotsituriya tsilindruriya, bacteriuria, sometimes
gemoglobinuriya and mioglobinuriyadan each individual case, or are susceptible to various
forms together. To identify them in a timely manner UAVdan in-depth knowledge about the
disease, as well as a special analysis of the results of laboratory and equipment inspections are
required. Laboratory analysis be conducted primarily at the level of urine, and the observance of
the rules of conduct. Healthy human urine sac sterile, urethane and urethane industry microflora
with pollution. Therefore, the external sexual organs and wash with warm water in the morning
after the removal of the middle portion of the urine should be a special meeting of the sterile
container. If the urine immediately (within half an hour) or planting is not possible to check the
refrigerator for 24 hours (temperature of 4 ° C).
Lecture coverage prior to the formation of the structure of the kidney and urinary Let's
dwell on the process.
Kidney beans in the form of two members, and weigh about 120 g. He is the functional
unit - consisting of nefronlardan. Healthy person of a kidney has about 1.3 million nephron. Each
nephron (50-55 mm in length) balls and tubes. Nefronlarning (80-85%) (all elements of the balls,
the people of the proximal and distal kanalchalar and genes) bark portion of the kidney. In
addition, its bark and the west part of the border between the second yukstamedulyar nefronlar
(15-20%) to differ. Their balls at the proximal and distal kanaltsevvoy bark, much longer than
people going into the top of the kidney powerhouse of genes and provides an effective reabsorption of sodium.
Koptokchalar capillaries, which is a complex arteriolalardan (VAS afferent). Balls, which
lead to the diameter of the capillaries in the nation arteriolalardan small efferent (VAS efferent)
extend arteriolalarga (Figure 1). Arteriolalar yukstaglomerulyar hardware (yuga). Efferent
arteriolalar kanalchalar divided over the capillary network is formed. Their blood will be
venulalarga. Yukstamedulyar balls, which lead to the same diameter and standing arteriolalar.
Efferent arteriola people nephron and collecting duct (arteriola recto) around the hole, which is
added to the capillaries.
Balls are divided into two yukstamezangial and peripheral areas. Balls peripheral part of
the three floors and basement membrane (BM) and covered with podotsitlar floor, and it is a
relief from the inside. Second - yukstamezangial industry with the capillary endothelium with its
mezangiyasiga in the United BM clear. Podotsitlar BMning all wrapped in a sector. 30% of the
endothelial surface is covered with a special diaphragm holes 40 nm in size. Capillary
endothelium and the UN is set to a relatively large molecular weight proteins.
Kidney kapilyarlarini a specific thing, he has three endothelin, BM and epithelial stroma.
On a normal capillaries between arteriolalar then added venulalarga balls from the capillaries
arterioladan, which is added to the efferent arteriolaga and ends with them. Capillaries in the
tissues there is a two-way kidney capillaries only in a way that moves in the direction of the
urinary space.
95% of the renal parenchyma kanalchalar. He said the proximal segment, the segment of
the distal nephron people and the collector pipe. The last part of the kidney quarters into the
open, and then his jomchalariga.
The result of the work of the kidneys in all nefronlar implications. Koptokchalar capillary
blood serum ultrafiltratsiyalanadi. Caudan ultrafiltratdan a part of water, electrolytes, glucose,
amino acids and other substances absorbed. Every minute a liter of blood through the kidneys
(600-800 ml of plasma), the circulating blood volume 1 / 5-1 / 4. Each day, the kidneys 170-180
l glomerulyar liquid is formed and it is approximately equal to the relative density of 1.002-1.028
1.5 l secondary to the surface of the body into the urine.
The following are the major changes we observed in urine sediments Let each one.
Proteinuria
"Proteinuria" means the norm in the urine (30-50 mg a day or more) than is the amount of
protein.
Doctor-threatening symptoms of proteinuria in the eyes of different diagnostic
importance of protein in the urine is the beginning of a diagnostic study. Went up because the
causes of proteinuria and urinary protein content in different areas. The study of the amount of
protein in the urine, and play an important role in determining the underlying disease. Is a very
complex process of blood proteins in the urine, kidney balls, kanaltsevvoy related activities, and
blood circulation.
70 kg of weight a person with normal kidney blood flow rate equal to 1.1 l per minute. A
healthy kidney of a liter of 60-80 g of protein per day, which is 180 l of blood plasma filtration.
Intact handball wall during the day, it may take 30-50 mg of protein. This indicates kidney
filtirlash barrier to working effectively. Filtrate oncotic pressure is generated using the effect of
hydrostatic pressure. In addition to the protein filtration depends on the relative mechanical
system of electric power. But, according to some authors a day from 50-80 mg of protein in the
urine indicates the presence of kidney pathological process. The wall of the protein in the urine
via the kidneys balls are filtered through the channels of the proximal part of the flat epithelial
reabsorbtsiya (nonabsorbable) can not be certain faction. Modern control methods (starch and
polyacrylamide Geld elektrofarez immune), protein in the urine of healthy people over 20
fractions can be identified, they prealbuminlar, protein, postalbuminlar siderofilin tseruloplazmin
gaptoglobulin, immunoglobulin A, G, and others. In addition, a protein in the urine during the
day proved to be a rough divorce: its maximum excretion of the day, the minimum hours of the
night.
While analyzing the proteinuria syndrome in front of the UAV is to solve the following
problems: to determine the boundaries of normal and pathological proteinuria; Does any
evidence of proteinuria renal injury to answer that question. But in some cases, qualified experts
struggled to answer this question. Because the amount of proteinuria and sometimes kidney
damage, such as human physical zo'riqqanda Xue, spine lordozida, the structure of the protein,
plus consumer products, they will grow. In recent years, a special rapid analysis methods with
the help of a very low amount of protein in the urine - an opportunity to determine
mikroalbuminlarni.
The following proteinuriyaning practice is widely used in classification.
1. Disease relates to:
- Functional;
- Pathological.
2. Source:
- Prerenal (saturated);
- Renal (koptokchali kanalchali and balls - kanalchali);
- Postrenal (kidneys, the false appearance).
3. Contents:
- Selective;
- Non-selective.
4. Amount:
- Mikroalbuminuriya (up to 300 mg a day);
- Light (traces of protein a day to 1 g);
- Average (1-3 g per day);
- High nephrotic (more than 3 g per day).
Functional (physiological, harmless), proteinuria pathogenesis of kidney occurs in
healthy people and not yet fully understood. Nefronlardagi the organic phase is associated with
pathological proteinuriyadan Unlike its physiological round of the amount of protein excreted in
the urine a day, often exceeding 2 g factor was removed, incurable, and in rare cases,
eritrotsituriya leykotsituriya, accompanied with tsilindruriya. Functional proteinuriyaning a few
types differ.
While some healthy people take a cold bath, hand and wrist after being dipped in cold
water for 2-3 minutes standing proteinuria. It's a violation of their renal blood flow reflex is
explained as a result. Occurring in the skin under the influence of strong insolation albuminuria
Solaris also develop as a result of the above mechanism is supposed to be.
Passing proteinuria may occur in the following cases:
• proof of proteinuria, when the consumption of protein-rich food dishes;
• Central (tsentrogen) proteinuria after epileptic seizures and brain concussion, after a
strong emotional excitement;
• palpation proteinuria and kidney as a result of the deep palpation of the abdomen for a
long time;
• tension (Marshall) - Working kanalchalar proteinuria less than 1-2 g per day, and as a
result of severe physical tension, and urine to be the first out of the normal daily physical load is
lost. In most cases, such proteinuria depends on 2 factors: the kidneys, blood circulation is poor
and koptokchalar basal membrane hypoxemia. Part of this article, as well as the basal membrane
of the main gialuron lead acid depolyarizatsiyasiga hyaluronidase sekretsiyasining lead to an
increase in the basal membrane permeability approved.
• fever proteinuria was associated with koptokchali mechanism (1-2 g per day) than in the
case of young children and the elderly, the body temperature rises, and after having lost. He
handball walls of capillaries in the secondary toxic-infectious injury occurred as a result, there is
no change in the other parts of the nefronlarning. If you keep the body temperature after receipt
of proteinuria, an outbreak of acute or chronic inflammation process to determine that additional
research should be carried out.
• sometimes 13-20 years of age, body composition, a young asthenic, disappearing in a
horizontal drop (lordotik postdural) koptokchali (not higher than 1 g per day), proteinuria is of
particular importance. Usually in the morning urine analysis, there is no significant proteinuria.
He orthostatic test vacant or after 1-2 hours of walking. In a vertical position in the field of waist
Lardos renal vein (usually on the left) hinder the passage of blood may be the cause of this type
of functional proteinuria.
Heart diseases common stasis proteinuria is not always functional characteristic. Because
for a long time, slowing blood flow in the kidney as a result of hypoxia koptokchalar basal
membrane and kanalchalar epithelial damage. This in turn increases the protein balls filtration,
Caudan will lead to a reduction in the vessel. Often exceed one liter of urine 1-3 g of protein.
Determining the transient proteinuria should be careful with the approach, because in some
cases, detailed inspections (including morphological) renal parenchymal can determine the
existence of a secret ongoing inflammatory process. So here, in a well-known Russian therapist
M.S.Vovsining 60 years of the last century: how safe proteinuria as a pathological character, in
all cases, a careful inspection of the patient and to try to identify the main causes of the opinion
that it should be appropriate to mention the We have found that.
Pathological proteinuria, renal (some of the kidney) damage is accompanied by diseases,
and as noted above its saturated prerenal, renal (koptokchali kanalchali, mixed) and postrenal
(kidneys, false) types differ.
Prerenal proteinuria in practice, rarely in a separate group. He is "excessive" or also
referred to as the saturation of proteinuria limfoplazmotsitar system in the plasma of patients
with various diseases has accumulated a large amount of blood circulating in the small molecular
weight (200.000-400.000A) of the proteins in the kidney balls damaged wall filtration due to the
excess of the amount required to Caudan fully absorbed or reabsorbtsiya result due to the lack of
the enzyme completely absorbed. This proteinuria the structure of immunoglobulin light chains
(Bens-Jones protein) mioglobin, hemoglobin, mezotsimlardan. Typically, the amount of urinary
protein losses through 0,1- 20 g per day, and may be more. But he nephrotic syndrome does not,
because it is not specific to gipoalbuminemiya and other characters.
Saturated proteinuria myelin disease, Valderstrem makroglobulinemiyasi, intravascular
hemolysis, rhabdomyolysis, monotsitar is one of the signs of leukemia and some other diseases.
Miele disease (plazmatsitoma) kanalchalar causing obstruction will be a series of
pathological production of immunoglobulins. This disease proteinuria stable character, amount
to 20 g per day (the majority of its Bens-Jones proteins), as well as other clinical signs (pain in
bones, destructive changes as a result of their sudden failure, hepatitis and splenomegaliya
parasteziya). In addition to the above, a strong M-gradient disproteinemiya high level of
pathological blood immunoglobulins and sternal punktatda plasmatic cells were detected. This
disease kanaltsevvoy K and L chains of immunoglobulins and antibody against them, Tammy
Xorsfall protein, partially filled with a cylinder composed of albumin and fibrinogen observed.
This marks only the myelin disease observable kidney damage, but in some cases, lead to the
emergence of acute renal failure. Typically, the amount of protein in the urine increases with
increased risk of acute renal failure. In most cases, the development of this disease, renal failure
developing myelin tubular obstruction, or amyloidosis shows the confluence. Kidney was
characterized by functional changes based on urine Bens-Jones protein or light chains of proteins
lies in the tubular epithelial toxic effects. In addition, other factors in this process
giperkaltsiemiya, hyperuricemia, plays an important role in the increase in the viscosity of the
blood serum. During the same time, in many cases, the start of the myelin disease in patients
with high proteinuria and causes an increase in Echt, later changes in the concentration join the
doctors should be borne in mind.
Valdenstrem makroglobulinemiyasida, pathological LgM produced large amounts of
protein accumulates in the blood of the patient. This disease, renal disorders are less common
(15-20% of cases is low to non-proteinuria), often splenomegaliya, hemorrhagic syndrome, Echt
increased sharply, in some cases, osteoporosis, the bones will be changes in the myelin disease
like many osteolitik.
Intravascular hemolysis in erythrocytes of various factors (incompatible blood
transfusion group, hemolytic properties of the toxic substances, toxins, drugs, and direct immune
effects, and the cells traumatic injury) as a result of the impact of damage caused. Hemolysis
caused by free hemoglobin in the blood plasma combined with gaptaglobin. Gaptoglobin then
filtered through koptokchalar hemoglobin saturation. They are formed as a result of grain into
the cylinder block kanalchalar crack may develop acute renal failure. Such analyzes of patients
with urinary protein and red blood cells, white blood cells, and in some cases free hemoglobin
determined. As well as acute renal failure specific clinical signs (oligoanuriya AG, edema,
anemia, bilirubinemiya).
Rhabdomyolysis (traumatic crushing syndrome, ischemic, toxic, genetic), proteinuria,
and will mioglobulinuriya. Blood aminotransferase, kreatinfosfokinazalar increases and
Hyperpotassemia, hyperuricemia determined. Clinic with symptoms of acute renal failure,
swelling, pain in damaged muscles, oliguria.
Monotsitar leukemia, chronic lizotsimni a lot of production as a result of his blood and
urine levels (normal 4-7 mg / ml) increased dozens of times, and with the emergence of the
blood and bone marrow monotsitoz will appear. In some cases, as a result of the production of
lysozyme many chronic monotsitar leukemia, proteinuria may occur.
UAV activities renal proteinuria associated with diseases often occur. As noted above, its
koptokchali kanalchali and mixed types differ.
Handball proteinuria, blood plasma proteins is caused by damage the basal membrane
filtration. At the same time, the amount of proteinuria 0.1 g to 20 g per day, albumin, transferrin,
a2 -mikroglobulin and consists of g-globulin. This type of proteinuria various diseases, often
acute and chronic glomerular amyloidosis, diabetic glomerulosklerozda and renal vein
thrombosis.
Occupies a special place among glomerular kidney balls initial damage, and then the
process kanalchalar and tissue distribution, and the CRF is characterized by the development.
Acute glomerulonephritis (Og) - acute kidney balls immune inflammatory disease, then
this process kidney tissue distribution and renal and (or) the kidneys also accompanied with
symptoms. Often occurs in children and young people. He streptococcal (angina, pharyngitis,
chronic tonsillitis fixed skarlatina, erysipelas, and others), in some cases, staphylococci,
pneumonia, or viral infections that patients develops in 10-12 days later. The development of this
disease vaccine, serum, to be caused by certain drugs and chemicals in the UAV must be kept in
mind. The disease is more common in young people is the basis of changes in the development
of the immune system. Og bladder syndrome, along with various levels of proteinuria, micro and
makrogematuriya (urine color, redness, or "meat flood similar to" character), and sometimes a
small amount of leykotsituriya cylinder (gialinli grained, erythrocytes), and there is a separation
of the epithelial cells. In addition Og swelling (edema syndrome presented), AG and nephrotic
syndrome (NFS) (Report) and in some cases of acute renal failure (oliguria or anuria,
koptokchalar filtration rate decline, azotemia) marks can be. In addition to the above-mentioned
changes in the patient's waist bilateral pain, increase in body temperature, a decrease in the
volume of urine (oliguria), AG night with head pain, symptoms of acute left ventricular failure
(cardiac asthma, pulmonary edema), brain (encephalopathy, eclamp- ) and the bottom
(arteriolalarni narrows the intersection phenomenon, the swelling of the nerve sponge, small
hemorrhage) changes may occur. Along with the diagnosis of urine UQT (anemia, increase in
Echt), biochemical (creatinine and urea, and uric acid increased, gipoproteinemiya
gipoalbumeniya, hypercholesterolemia, and others), immunology (against Streptococcus IT,
ASL-O, antistreptokinaza increase in titer), ultrasound ( nephrotic syndrome, swelling of the
pyramid), X-ray (to deny urological diseases), and morphological (kidney biopsy) inspections.
UAV Og, specializing in all patients with suspected immediately to the hospital () should
always bear in mind the need to put. The procedure in a hospital bed, table salt (1-2 g per day),
water (the number of days allocated urine + 200-400 ml) and protein (0.5 g of 1 kg of body
weight per day) restricted diet (edema and AG evening), streptococcal infection suspected cases
of penicillin (ampicillin, fenoksimetilpenitsillin and others).
The main pathogenetic treatment as GKS (prednisolone per day, 1 mg / kg 1.5-2 months),
tsitostatiklar (strictly the instructions of the azathioprine and merkaptopurin 2-3 mg / kg, an
average of 150-200 mg 1-3 months), anticoagulants (heparin 5.000-10.000 unit T / o every 4-6
hours, 6-8 weeks, antiplatelet agents (Chime of 225-400 mg per day for 6-8 weeks),
aminoxinolin compounds (Delage 0,5-0,75 g 3 -6 weeks, for a few months and then 0.25 g) is
recommended.
To eliminate the bottle diuretic drugs (furatsemid uregit and others), a network of the CA
(nifedipine, amlodipine, and others).
After the collapse of the symptoms of the disease after 6 months later tonziloektomiya is
recommended. It is timely measures 90 and sometimes resulted in 100% of cases, the patient 1.52 months in recovery reported earlier. If some of the symptoms of the disease 6 months when
stored for a long time is extended type. After their testimony to be at least 2 years of regular
control of the UAV and every two-three months, the total urine analysis should be carried out.
Occurs in the patient respiratory tests every 2 weeks for its intended purpose.
At the same time, Og chronic excited periods. Og never infection symptoms related to the
disease does not appear in the first days, in contrast to chronic glomerular (SGN) recurrence
rates can be monitored. Og cyclic withdrawal, chronic in the majority of cases it is not possible
to differentiate. All of the disease in patients with Og the first xaftasidayoq complement and
increase the amount of ASL-O. Concentration of kidney function impairment in late-stage
SGNni Og tumor starts again. In most cases, a secret ongoing SGNni sharp distinction difficult
for her kidney biopsy should be carried out.
A related disease ekstrarenal the urine of patients with asymptomatic infection (swelling,
AG) changes in urine sediments need to focus on the detection of infectious toxic kidney. It is
evident in the changes of the disease observed in a period of 1-2 weeks in the disappearance.
Often leading to the outbreak (subacute or bad quality) as glomerulonephritis -O'GN
short time (the beginning of the disease 2 years), nephrosclerosis and CRF development leads to
death. He is the primary (idiopathic) and secondary (TQV Gudpascher syndrome, mixed
krioglobulinemiya, infectious endocarditis, hemorrhagic vasculitis, Knots periarteriit Wegener
granulematozi). Denied, leading to glomerulonephritis Og, as in most cases of streptococcal
infection after back pain and makrogematuriya sharp. Within a short period of time, which is
evident in NFS, poor quality AG, retinopathy (eye retina detachment, blind), leading to the
outbreak of kidney failure. BTTKda quickly, leading to the outbreak of GN be the first sign of
the disease, or other criteria may be available. If urgent measures are carried out 6-18 months of
treatment in patients with renal failure and died.
Used books:
1.Мерта Дж. Справочник врача общей практики. М., Практикум, 1998г.
2.Диагностика внутренних болезней в 10 -ти томах Окороков А. Н. М.: Мед.
лит.,2000-2007гг
3.Textbook of Internal Medicine Editor-in-Chief William N. Kelley1997
4. Internal Medicine Edward D. Frohlich 1996
5.www.nedug.ru/…/мочевой осадок
6.www.spruce.ru/diagnostics/urine/
7.www.medkarta.com/?...Россия
8.www. biosensoran.ru/Bios…/osadok_m