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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