Differential estimation method for checking inflammatory process activity in chronic glomerulonephritis cases

FIELD: medicine.

SUBSTANCE: method involves determining coagulating blood viscosity values like reaction period r, thrombin constant K, maximum amplitude MA, time T for forming fibrin-thrombocytic blood clot, spontaneous blood platelets aggregation intensity Ar, retraction and spontaneous clot lysis total FA. The r being within 5-7 min, Ar from -2 to -6 relative units, K being within 4-6 min, MA within 500-700 relative units, T within 40-60 min and FA equal to 10-20%, low inflammatory process activity is considered to be the case. The r being less than 5 min, Ar equal to -8 to -12 relative units, T less than 40 min and FA less than 10% with no changes in K and MA being observed, inflammatory process activity in chronic glomerulonephritis case is considered to be of high severity degree.

EFFECT: high accuracy of diagnosis; enhanced effectiveness of treatment method selection.

1 dwg

 

The invention relates to medicine, namely to Nephrology, and relates to methods of differentiated assessment of inflammatory activity in chronic glomerulonephritis (CS).

Known methods of assessment of inflammatory activity when pumps are mainly based on the clinical picture of the disease, the data in the urine (proteinuria, erythrocyturia), data of immunological indexes and dynamics of indicators of the functional status of the kidneys, as well as the results of morphological study nepaliputi[1, 2, 3].

However, they are complex, long and traumatic for the patient.

Closest to the present invention is a method of differentiated assessment of the inflammatory process in CS, which consists in carrying out thromboelastography (TAG) by the graphics Desk and subsequent measurement the viscosity of collapsing the blood [4, 5].

However, the method of thromboelastography nizkochastotnik that it is not possible to identify subtle changes in the blood clotting process. This method is applicable for oriented definition of gross abnormalities of coagulation parameters. Due to certain design flaws of the device, this method of diagnosis is too vague, difficult to reproduce it. Blood and fibrin in the research process-rayed the tsya mechanical stress from moving parts of the measuring cell of thromboelastography, which leads to the destruction of blood corpuscles and long strands of fibrin, resulting in incorrect results. The TAG does not reflect the intensity of spontaneous platelet aggregation, and it is rarely possible to determine the time of fibrinolysis.

Thromboelastography evaluates the clotting process in a stationary blood, few standardized. For the study of hemostasis in this way requires a lot of time, about 120-150 minutes.

There are no numerical criteria that determine the activity of the inflammatory process in patients with CS.

New technical problem - increasing accuracy, repeatability, informative and reducing research time.

The set task is solved by a new method of assessing the activity of the inflammatory process in CS, which consists in determining the viscosity of collapsing the blood of the period of reaction r, the constant of thrombin To the maximum amplitude MA, the time of formation of the clot T, and additionally determine the intensity of the spontaneous aggregation of platelets Ar, the total retraction and spontaneous lysis of the clot FA and the indices r within 5-7 minutes, Ar from -2 to -6 relative units, within 4-6 minutes, MA in the range of 500-700 relative units, T within 40-60 minutes, FA equal to 10-20%, determine the low activity of populationincrease, and when r is less than 5 minutes, Ar, equal to -8 to -12 relative units, T less than 40 minutes, the F below 10%, but not less than 5%, in the absence of changes To, and MA determined by high activity of inflammatory process in CS.

The method is as follows. After the tourniquet is applied the dotted line a large vein dry silikonizirovannoj needle, tourniquet is removed immediately after receiving the first drop of blood. The first drops of blood allowed to drain, then fill removable cuvette two ml of blood and placed in a chamber of emotionography ARP-01 "mednord (patent RF №2063037, BI No. 18 of 27.06.1996) [6, 7].

Registration processes gemokoagulyatsii, retraction and spontaneous lysis of the blood clot is carried out for 90 minutes. The resulting graph measuring the state of aggregation of blood shown in the drawing, and when indicators of r within 5-7 minutes, Ar from -2 to -6 relative units, within 4-6 minutes, MA in the range of 500-700 relative units, T within 40-60 minutes, FA equal to 10-20%, determine the low degree of inflammatory activity; and when r is less than 5 minutes, Ar, equal to -8 to -12 relative units, T less than 40 minutes, the F below 10%, but not less than 5% if no changes are made To define and MA a high degree of inflammatory activity in chronic glomerulonephritis. For different morphological forms of pumps, including complete remissions C is dependent on the degree of reversibility of the microcirculation.

CS is considered as a systemic disease, which is based on immune inflammatory process with mandatory activation of the hemostatic system, especially during exacerbation of the inflammatory process[1, 2, 3, 4, 8, 9, 10, 11].

In connection with the foregoing, it was necessary to refer to the evaluation criteria that characterize this process.

We examined 40 patients aged 15 to 40 years with a diagnosis of CS, mezangioproliferativnom. In 18 patients pumps we did not observe significant deviations from the norm in the study of rheological properties of blood on the proposed method. This is also confirmed by the study of blood coagulation with the determination of clotting time, prothrombinase index, APTT, duration of bleeding, fibrinolytic activity of plasma, ethanol and orthophenanthroline tests. Morphological index of activity in these patients was low - 2,4±0.35 points.

However, in 22 patients from this group in the study of the rheological characteristics of the proposed method was revealed hypercoagulable state, characterized by the fact that r was less than 5 minutes (on average 4,22±0,12 min), Ar=-9,04±0,13 relative units (fluctuations from -8 to -12 relative units), acceleration T less than 40 minutes (average 36,44±1,91), decreased FA below 10% (average of 8.34 per±1,2). In this category of patients pumps we found increased aggregation activity of blood cells and procoagulant hemostasis, a slight inhibition of fibrinolysis. 18 persons identified with the syndrome of hypercoagulability in the following examination of the results of histological examination of probiotical revealed a high index of morphological activity of the inflammatory process in the kidneys (8,5±0.43 points). There was a high degree of correlation between morphological activity index and r, Ar and T (respectively r=-0,583; 0,688; -0,455; p<0,05).

Example.

As an example of the use of the proposed method of differentiated assessment of inflammatory activity in CS can serve as the medical history of the patient K., aged 30, was treated at the Nephrology Department of the Regional clinical hospital with 17.08.01, 20.09.01, When receiving complained of headaches in the temporal areas, a feeling of heaviness in the lumbar region, periodic swelling of the legs and face.

From the anamnesis revealed that first appeared swelling on the face and legs in 1993 after suffering a sore throat. However, the swelling wore transistor in nature, the urine does not give to the doctors until 2001 did not apply because felt good.

However, at 24 years of age during pregnancy is yli revealed changes in the urine (proteinuria, hematuria), increased numbers of the a/D. These changes were interpreted in the framework of nephropathy pregnant, it is recommended to examine the condition of the kidneys in the postpartum period. Compassionate patient care is not addressed, despite the fact that began to reappear swelling and headaches. Diuretics brought relief.

It should be noted frequent colds, allergies to certain medicines.

In July 2001 after supercooling condition has deteriorated: swelling in the legs, feet and area periorbital tissue, headaches, increase the numbers of a/D up to 170/100 mm Hg. He was treated initially in outpatients, and later enrolled in a specialized Department for examination. When receiving a satisfactory condition. The position of an active, clear consciousness. Weight 66 kg, height - 171 cm normal Skin color and moisture. The subcutaneous layer is moderately developed. The thyroid gland is not enlarged. Pastos legs and paraorbital, a/D 160/100 mm Hg, the pulse 66 beats per minute. The respiratory and digestive systems without significant deviations from the norm. Heart sounds are clear, correct rhythm, accent the 2nd tone of the aorta. The apical impulse is displaced to the left. Deep palpation of the kidneys moderately painful. Symptom "Pollachius what I" is positive on both sides.

Following studies were conducted:

1. Complete blood count: Hb - 137 g/l, erythrocytes - 3,9·1012/l, leucocytes - 6,8·109/l, eosinophils - 3%, stab - 5%, segmented - 56%, lymphocytes - 27%, monocytes 7%, and ESR - 16 mm/hour.

2. Urine analysis: beats. weight 1013 (fluctuations 1010-1015), protein - 1,11 g/l (daily proteinuria was 1.94 g), leukocyte count to 10 in sight, erythrocytes 3-4 in eyeshot. Nechiporenko L - 4.000; e - 10.000.

3. Biochemical parameters blood glucose - 4,6 mmol/l, bilirubin is 16.6 µmol/l, urea - 6.6 mmol/l, creatinine - 105 µmol/l, fibrinogen - 4.0 g/l, protein 66 g/l, albumin is 54.5%, α1to 4.5%, α2- 9,1%, β - 4,5%, γ - globulins is 27.3%, Alt - 0,48, ASAT - 0,36.

4. Sample Rehberg: glomerular filtration - 60 ml/min, the reabsorption of 98%.

5. Bacteriological examination of urine: the growth of microbial flora not.

6. Ultrasound: Kidney: left 105 cm, right 105 cm, nephroptosis on the right of the I degree. The ratio of the layers is 1:1. Cup-pelvis system is somewhat condensed, the contours blurred.

7. The immunological: CD2- 1,12, CD3- 1,04, CD20- 0,29, CD4is 0.55, CD8- 0,36, CD4/CD8-1,5, CD16to 0.15, CEC - 80 ed, Ig A - 3.6 g/l, Ig M - 2.1 g/l, Ig G and 9.8 g/l, HCT test - spontaneous - 12,4%, stimulated and 15.3%.

8. Excretory urography: signs of pyelonephritis and anomalies of the kidneys was not detected.

9. The coagulation tests: APTT - 45 Sekou is d; prothrombin index (PTI) 105%; prodominantly, ethanol and orthophenanthroline tests are negative. Preliminary diagnosis: CS, hypertensive form, a low degree of inflammatory activity.

10. The study according to the proposed method, including the determination of the rheological characteristics of a collapsible blood on device APR-01 "mednord and obtained the following results: Ar=-9 relative units; r=4 minutes 32 seconds; T=35 minutes; FA=8%. The data obtained allowed to conclude about the presence of the patient increased aggregation activity of formed elements, the acceleration of blood clotting and minor depression fibrolite that allowed us to exhibit the clinical diagnosis of CS, hypertensive form in the acute phase with the phenomena of a high degree of inflammatory activity. The patient fulfilled the diagnostic?.

11. Morphological study neobiota - signs of chronic mezangioproliferativnom glomerulonephritis with symptoms of high activity of the inflammatory process: epithelial populonia, the interposition mesangium, infiltration and proliferation mesangium, two glomerular sclerosis. Morphological activity index amounted to =9.0 points, the index sclerosis 6.8.

When comparing the data of the study negrobeat the TA and hemostasis, obtained using the proposed method of evaluation of the inflammatory process, we have established a high degree of their conformity.

On the basis of clinical, instrumental, laboratory and morphological data diagnosed chronic mezangioproliferativnom glomerulonephritis in the acute phase with the phenomena of high degree of activity. Nephrogenic arterial hypertension.

The patient is assigned pathogenetic therapy of cyclophosphamide for relief of the inflammatory process in the kidneys and prevent progression of the disease for 2 years in a total dose of 19,

During the observation period in two years, the patient had no evidence of exacerbation of the pathological process both clinically and according to the analysis of urine. Observed stabilization of the disease. Digit a/D ranged 130/80-140/80 mm Hg, daily proteinuria 200-300 mg/day, erythrocyturia Nechiporenko 3.000-4.000 in 1 ml.

In the immunological: CD2- 1.33, CD3- 1.24, CD20- 0,30, CD4- 0.71, CD8- 0,35, CD4/CD8-2,0, CD16- 0,19, CEC - 55 ed, Ig A - 2,42 g/l, Ig M - 1.92 g/l, Ig G - 11.5g/l, nst test - spontaneous - 13,5%, stimulated - 20,1%.

Sample Rehberg: glomerular filtration 75 ml/min, the reabsorption of 98%.

Indicators of biochemical parameters of blood serum within the normal amount is. Triglycerides: fibrinogen 3 g/l, PETIT-100%, APTT - 42 seconds, ethanol and orthophenanthroline tests are negative. Indicators of rheological properties of blood on hemocoagulase APR - 1: r=6 minutes; Ar=-6 relative units; K=5 minutes; MA=650 relative units; T=50 min, F=20%.

Conclusion: signs of hypercoagulability is not revealed and concluded that the low activity of the inflammatory process.

Conducted? to determine tactics. The morphological study nepaliputi identified mezangioproliferativnom glomerulonephritis with no signs of activity of the process (morphological activity index of 3.0 points). Established compliance indicators rheological properties of blood with the data of the study nepaliputi.

Decided to stop pathogenetic therapy recommendations observation nephrologist in connection with a reduction in activity of the inflammatory process.

Thus, the application of the proposed method of differentiated assessment of inflammatory activity in CS, which consists in registering the viscosity characteristics of a collapsible blood, revealed a high accuracy evaluation of the activity of the inflammatory process in the kidneys, which will allow to carry out an early pathogenetic therapy to prevent the development of sclerotic changes and progression of CS./p>

The nature of damage of the hemostatic system, identified using the proposed method of differentiated assessment of inflammatory activity in CS, allows you to determine if activity of the inflammatory process in the kidneys with a high probability (90% of cases) without biopsy, which is very important in cases where it is not possible or for dynamic monitoring to assess the effectiveness of therapy.

Thus, the application of the proposed method of assessing the activity of the inflammatory process in CS allows physicians to obtain accurate laboratory confirmation of the degree of inflammatory activity in a shorter time, which contributes to more effective treatment and better prognosis of CS.

Sources of information

1. Soludo B. I. Nephrology. - SPb, 2002. - s-217.

2. Nephrology. A guide for physicians /.editor Yestereve. - M.: Medicine, 2000. - s.138-139. 688 C.

3. The Stavskaya CENTURIES, Ryabov S. risk Factors for progression of chronic glomerulonephritis // proceedings of the II conference of Nephrology. Pskov, 1989. - s.

4. The Boretskaya H. Violation of hemostasis and antithrombotic therapy in patients with chronic glomerulonephritis in ezotericheskoj stage chronic renal failure: author. dis...Kida. the honey. Sciences. - SPb, 2003 - 22 C.

5. L is responsibility research methods of hemostasis // baluda VP, Baragan SS, Goldberg and others - Tomsk, 1980. - p.222-229.

6. Tiutrin I.I., Pchelintsev O.Y, Spizman mathematical SCIENCES. and other New way integrative assessment of functional state of hemostasis // Clinical laboratory diagnostics. M., 1994, №6. - p.26-27.

7. Patent of the Russian Federation No. 2063037 BI No. 18 of 27.06.1996.

8. Mikheeva US, Rumyantsev INC., Yesayan A.M. abnormalities in the hemostatic system and the problem of thrombosis in chronic hemodialysis. // Nephrology. - 2003, No. 2. - p.21-25.

9. Razdolina T.N., Pinelis VG, Sergeev G.B. platelet Aggregation at glomerulonephritis in children // Nephrology seminar. Sat. works - Petersburg, 2001. - s-236.

10. Zhdanov, T., Rozanov, PS, Mikhailova D.O., Solomatina L.V. State of hemostasis in patients with different types of mezangioproliferativnom glomerulonephritis // Nephrology seminar. Sat. works. SPb, 1997. - s-146.

11. Panchenko V.M. blood Coagulation system and fibrosis at glomerulonephritis // lab. Case, 1977, No. 8. - s-454.

The way of differentiated assessment of inflammatory activity in chronic glomerulonephritis, which consists in determining the viscosity of a collapsible blood - period reaction r, the constant of thrombin To, characterized in that it further determines the maximum amplitude MA, the time of the formation of perintalmanna patterns clot T, the intensity of spot is authorized platelet aggregation Ar and the total retraction and spontaneous lysis of the clot FA and the indices r within 5-7 min, Ar -2 to -6 relative units, within 4-6 min, MA in the range of 500-700 relative units, T within 40-60 min, F is equal to 10-20% define low degree of inflammatory activity, and when r is less than 5 min, Ar -8 to -12 relative units, T less than 40 min, F below 10%, but not less than 5%, in the absence of changes To, and MA determined by high degree of inflammatory activity in chronic glomerulonephritis.



 

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2 tbl

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2 ex

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1 ex, 4 tbl

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3 tbl

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3 dwg, 3 ex, 2 tbl

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1 tbl

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1 tbl

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2 ex

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