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#1
12.02.2011, 22:52
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Я имел в виду, что процесс тромбообразования с нарушением микрогемореологии в клубочках имеет место быть наряду с отложением фибрина.
Но спасибо за разъяснения! Тогда что остаётся автору темы для диф. д-за - ФК-микроскопия и экскреторная урограмма? 
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#2
13.02.2011, 00:47
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Цитата:
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#3
25.02.2011, 17:57
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Цитата:
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#4
26.02.2011, 00:15
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Цитата:
Brenner: Brenner and Rector's The Kidney, 8th ed. Copyright © 2007 Saunders, An Imprint of Elsevier CHAPTER 23 – Laboratory Assessment of Kidney Disease: Clearance, Urinalysis, and Kidney Biopsy[*] The differential diagnosis of hematuria is broad but for practical purposes can be categorized as originating in the upper or lower urinary tract. Hematuria that is accompanied by red blood cell casts, marked proteinuria, or both is most likely to be glomerular in origin. In the absence of these important findings, distinguishing glomerular from postglomerular bleeding can be difficult. Red blood cells originating in glomeruli have been reported to have a distinctive dysmorphic appearance that is most readily appreciated using phase-contrast microscopy. [283] [284] [285] Automated blood cell analysis has also been used to determine the number of dysmorphic red cells in urine. [286] [287] In vitro studies suggest that pH and osmolality changes found in the distal tubule could explain the higher number of dysmorphic red blood cells in patients with glomerular disease.[288] The clinical utility of tests to distinguish dysmorphic red cells in the urine has been examined in numerous studies. [287] [289] [290] [291] [292] [293] Most investigators concluded that detecting dysmorphic red cells reliably identified patients with glomerular disease; however, one investigator-blinded, controlled trial found unacceptable interobserver variability.[290] A number of investigators have attempted to develop automated methods to detect glomerular hematuria. [294] [295] [296] These techniques employ cell counters or more sophisticated flow cytometry methods. However, the use of automated cell size determinations in individuals with low-grade hematuria may be particularly unreliable owing to interference from cell debris.[295] A meta-analysis of 21 published studies using predetermined criteria for evaluation of dysmorphic urine red cells was carried out.[297] All studies originated in referral centers. The weighted average sensitivity and specificity for dysmorphic red cell test detection of glomerular disease were (with 95% confidence intervals): 0.88 (0.86–0.91) and 0.95 (0.93–0.97), respectively. The sensitivity and specificity for the use of abnormal (automated) red blood cell volumes to detect glomerular disease were 1.00 (0.98–1.00) and 0.87 (0.80–0.91). The investigators in this meta-analysis concluded that the negative predictive value of these tests was probably not sufficient to rule out important urologic lesions, especially in a referral setting in which the prevalence of urologic disease may be relatively high. Ссылки: 283. Fairley KF, Birch DF: Hematuria: A simple method for identifying glomerular bleeding. Kidney Int 1982; 21:105-108. 284. Fassett RG, Horgan BA, Mathew TH: Detection of glomerular bleeding by phase-contrast microscopy. Lancet 1982; 1:1432-1434. 285. Van Iseghem PH, Hauglastaine D, Bollens W, Michielsen P: Urinary erythrocyte morphology in acute glomerulonephritis. BMJ 1983; 287:1183. 286. Shichiri M, Nishio Y, Suenaga M, et al: Red-cell volume distribution curves in diagnosis of glomerular and non-glomerular haematuria. Lancet 1988; 1:908-911. 287. Goldwasser P, Antignani A, Mittman N, et al: Urinary red cell size: Diagnostic value and determinants. Am J Nephrol 1990; 10:148-156. 288. Schramek P, Moritsch A, Haschkowitz H, et al: In vitro generation of dysmorphic erythrocytes. Kidney Int 1989; 36:72-77. 289. Thal SM, DeBellis CC, Iverson SA, Schumann GB: Comparison of dysmorphic erythrocytes with other urinary sediment parameters of renal bleeding. Am J Clin Pathol 1986; 86:784-787. 290. Raman GV, Pead L, Lee HA, Maskell R: A blind controlled trial of phase-contrast microscopy by two observers for evaluating the source of hematuria. Nephron 1986; 44:304-308. 291. Sayer J, McCarthy MP, Schmidt JD: Identification and significance of dysmorphic versus isomorphic hematuria. J Urol 1990; 143:545-548. 292. Marcussen N, Schumann JL, Schumann GB, et al: Analysis of cytodiagnostic urinalysis findings in 77 patients with concurrent renal biopsies. Am J Kidney Dis 1992; 20:618-628. 293. Dinda AK, Saxena S, Guleria S, et al: Diagnosis of glomerular haematuria: Role of dysmorphic red cell, G1 cell and bright-field microscopy. Scand J Clin Lab Invest 1997; 57:203-208. 294. Lettgen B, Hestermann C, Rascher W: Differentiation of glomerular and non-glomerular hematuria in children by measurement of mean corpuscular volume of urinary red cells using a semi-automated cell counter. Acta Paediatr 1994; 83:946-949. 295. Apeland T: Flow cytometry of urinary erythrocytes for evaluating the source of haematuria. Scand J Urol Nephrol 1995; 29:33-37. 296. Hyodo T, Kumano K, Haga M, et al: Analysis of urinary red blood cells of healthy individuals by an automated urinary flow cytometer. Nephron 1997; 75:451-457. Editors: Davison, Alex M.; Cameron, J. Stewart; Grunfeld, Jean-Pierre; Ponticelli, Claudio; Ritz, Eberhard; Winearls, Christopher G.; Ypersele, Charles van Title: Oxford Textbook of Clinical Nephrology, 3rd EditionCopyright В©2005 Oxford University Press 1.2 Urinalysis and microscopy Giovanni B. Fogazzi Erythrocytes Erythrocytes may be found in the urine due to bleeding occurring at any point of the urinary tract or a contamination of the urine, as frequently happens in women during menstruation. When true haematuria occurs, the examination of erythrocyte morphology can be used to differentiate the source of the bleeding. If the erythrocytes come from the excretory system they have a regular shape (Fig. 1a), while if they come from the glomeruli, they have irregular shapes and contours (Fig. 1b) (Fairley and Birch 1982). According to some investigators (Fasset et al. 1982a) haematuria is defined as вЂ?non-glomerular’ when at least 80 per cent of the erythrocytes show a regular (or вЂ?isomorphic’) appearance and вЂ?glomerular’ when a similar proportion of erythrocytes are changed (or вЂ?dysmorphic’). The haematuria is вЂ?mixed’ when the two types of cells are approximately in the same proportion. Instead, other investigators define, haematuria as glomerular when more than two (Koene 1999) or three (Crompton et al. 1993) different forms of erythrocytes are found. Still others have demonstrated that haematuria is glomerular when at least 5 per cent of erythrocytes are acanthocytes of G1 cells (KГ¶hler et al. 1991; Kitamoto et al. 1993; Lettgen and Wohlmuth 1995; Dinda et al. 1997). Compared to generically defined dysmorphic erythrocytes, acantocythes/G1 cells have the advantage of being easily identifiable due to their shape, which is characterized by one or more blebs of different shapes and sizes protruding from a ring-shaped cell body (Fig. 1c). For this reason they are worth looking for. However, they are P.30 not always found in patients with haematuria caused by a glomerular disorder, their sensitivity varying in different studies from 52 to 100 per cent (specificity 98–100 per cent) (KГ¶hler et al. 1991; Kitamoto et al. 1993; Lettgen and Wohlmuth 1995; Dinda et al. 1997). The evaluation of erythrocyte morphology is an important tool in the management of patients with isolated microscopic haematuria of unknown origin. In fact, it allows an early orientation of the diagnostic work-up towards a nephrological or a urological disorder, which avoids unnecessary and often invasive investigation (Schrameck et al. 1989a). When I have a patient with isolated microscopic haematuria of unknown origin, I do examine red cell morphology. I do this by evaluating 100 erythrocytes/sample, and first I look for acanthocytes or G1 cells. If they are not found or are less than 5 per cent of total erythrocytes, P.31 I look for other dysmorphic erythrocytes and use the cut-off of 80 per cent to discriminate between a glomerular and a non-glomerular bleeding. When I come across a mixed haematuria, I consider this, similarly to others (Rizzoni et al. 1983; Rath et al. 1990), as the expression of glomerular bleeding. In addition, since in occasional cases, I found a change in the type of haematuria in the same patient over time, I examine at least three consecutive samples for each patient before establishing the origin of haematuria. Using these criteria, I found, at renal biopsy, a clear-cut glomerular disease in 10 of 12 patients (83 per cent) whose isolated microscopic haematuria, I had classified as glomerular on the basis of red-cell morphology (data unpublished). The cause of red-cell dysmorphism is not entirely clear. However, clinical observations and experimental findings suggest that dysmorphism is the result of a dual injury—passage through gaps in the glomerular basement membrane and exposure within the tubular lumen to different osmolalities, pH, and haemolytic substances (Schramek et al. 1989b; Briner and Reinhart 1990; Rath et al. 1992). It is worth remembering that the appearance of erythrocytes in the urine may also reflect the appearance they have in the blood. Thus, patients with haematuria caused by sickle-cell disease may have sickled erythrocytes in their urine (Fogazzi et al. 1996), and patients with peripheral anisopoikilocytosis may have poikilocytes in the urine (personal observation). 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