Method for choosing tactics for treating patients with purine exchange disorders

FIELD: clinical medicine, laboratory diagnostics.

SUBSTANCE: one should carry out complex laboratory survey including daily urinary sampling by Zimnitsky and blood sampling for analysis just after finishing sampling the last urinary portion. In every urinary portion one should detect pH, protein and relative density, in total urinary volume it is necessary to detect concentration and quantity of uric acid, creatinine and daily proteinuria, calculate clearances of uric acid and creatinine and fractional clearance of uric acid. On detecting purine exchange disorders including high concentration of urinary uric acid at low daily diuresis one should recommend to widen drinking mode; at altering urinary reaction towards acidic side one should prescribe alkalizing preparations; in case of pronounced purine exchange disorders and severe accompanied pathology one should carry out extracorporal therapy. The innovation enables to considerably improve the quality of diagnostics and match the most optimal schemes of therapy.

EFFECT: higher efficiency of therapy.

5 cl, 3 dwg, 5 ex, 20 tbl

 

The invention relates to clinical medicine, in particular to laboratory diagnosis, and can be used for choice of treatment in patients with abnormalities of purine metabolism.

Now for the choice of treatment in patients with abnormalities of purine metabolism it is necessary to conduct the following studies:

1. Study the concentration of uric acid in the blood and the amount of uric acid in the urine daily with the calculation of the clearance of uric acid [1, 4].

2. Determining the concentration of urea and creatinine in the blood and the amount of creatinine in urine daily[1, 2, 3, 4].

3. Analysis of daily urine by the method of zimnitsky tests, allowing to estimate the concentration ability of the kidney, including collecting daily urine every three hours (from 6 to 9 hours 9 to 12 hours 12 to 15 hours, from 15 to 18, 18 to 21 hours, from 21 to 24 hours, from 24 to 3 hours 3 to 6 hours) in a separate bowl during the day while maintaining regular eating and drinking regime. When it is determined daily diuresis, which is the norm 67-75% of the amount of fluid you drink, daily diuresis (from 6 to 18 hours), which is the rate of 65-80% of the number of urine taken during the day, and variations in specific gravity of urine in each 3-hour portion of urine during the day (usually from 1005 to 1025) [1, 2, 6, 7].

4. Determination of urine pH[1, 2, 4].

5. The definition in the urine daily proteinuria [2, 3].

In the monograph Ageplay "Gout" [1] discusses in detail methods of laboratory diagnostics in patients with gout on the basis of which define the tactics of treatment of patients that is generally closest to the proposed method and chosen as a prototype.

Currently in the practice of laboratory examination of patients on the basis of which assess the condition of the patient and the choice of optimal treatment requires consistent definition of indicators that takes one day as in outpatient examination and in the clinic. However, because uricemia and daily returned depend on a number of reasons (especially food and the amount of fluid consumption, weather conditions, physical activity, pH of blood and urine and other), the calculation of the fractional clearance (which reflects the ability of the kidneys to tubular transport of uric acid and is the ratio of clarensau uric acid and creatinine) becomes valid only when the clearance of uric acid and creatinine clearance are defined in one day. In addition, conducting these studies for several days leads to delays in receiving data by physician and as a consequence of delayed diagnosis requires that the patient is time-consuming and ODA is divided economic costs.

In patients with impaired purine metabolism, it is advisable to determine the concentration of calcium and phosphorus in the blood and urine daily, as the increased concentration of calcium and/or phosphorus in daily urine promotes the formation of microsurgical crystals of these compounds, which, in turn, can cause the formation and growth of crystals of calcium, phosphorus, uric acid and crystals of mixed composition. It should also be noted that intermittent increased excretion of urine calcium and phosphorus are found in patients suffering from gout and are in the syndrome called "gouty cycle" [1].

In patients with gout also advisable to determine the binding capacity of albumin. The increase in binding capacity is a factor that increases the solubility of urate and thereby preventing crystallization [8].

Determining the amount of creatinine in urine daily gives the opportunity to verify the completeness of the collection of daily urine, especially when conducting serial studies in the same patient [5].

The present invention is directed to improving the efficiency of detection of pathological changes in patients with impaired purine metabolism and selection of the optimal treatment regimen. We have analyzed discharge instructions 126 patients with gout, received the C 32 medical institutions. In none of the cases laboratory examination was not conducted in the form of this complex, which is the basis of our proposed method, the choice of tactics of treatment of patients with disorders of purine metabolism.

The method is that the choice of tactics of treatment carried out on the basis of data obtained from laboratory tests in which the above studies are carried out simultaneously during the day, while immediately after collection of the last portion of daily urine, fasting produce blood sampling for biochemical analysis, in each portion of the urine to determine pH, protein and relative density, after which portions are combined and in the total volume of urine to determine the concentration and amount of the uric acid, creatinine and daily proteinuria, calculate Clarence uric acid and creatinine and fractional clearance of uric acid.

This laboratory examination allows you to choose the optimal treatment tactics and, above all, to solve the question about the possibility of the basic therapy, including prescription of allopurinol. In the detection of creatinine and urea in the blood in patients receiving allopurinol conclude inappropriate use. If violations of purine metabolism, including high concentratively acid in urine at low daily diuresis, recommend expansion of drinking behavior. If violations of purine metabolism, including the change of the reaction in the urine acidic side, appoint oschelacivate funds. However, depending on the pH determined in different portions of urine during the day, oschelacivate funds can be assigned using the principles chronotherapy. When identifying marked disorders of purine metabolism and severe comorbidity spend extracorporeal therapy. Depending on the indications and General condition of the patient may be assigned to conduct plasmapheresis or other types of extracorporeal therapy.

Laboratory examination of appropriate conduct as usual the food regime, and after three days nizkoreninovoi diet.

Re-analysis on the background nizkoreninovoi diet, on the one hand, opens additional possibilities for detection of metabolic disorders in a patient, and on the other hand, some duplication of previous results dramatically reduces the probability of erroneous data (incomplete collection of patients daily urine, poorly treated dishes for urine collection, errors that occur while conducting laboratory tests, etc).

When using the proposed method may be extended set of indicators, including the military in complex laboratory tests. Determination of the concentration and quantity of uric acid in each three-hour portion of urine allows you to identify features of the circadian rhythm of urinary excretion of uric acid, and, on this basis, the choice of treatment to use the principles of chronotherapy. Determining the concentration of calcium and phosphorus in the blood and their number daily urine opens up additional possibilities in the treatment of mixed composition of urinary concrements. So, when detecting hyperuricosuria on the background of the high concentration of uric acid in the urine, low urine pH, hypercalciuria it is advisable to conduct additional preventive measures aimed at reducing the likelihood of kidney stones mixed composition.

Determination of the binding capacity of albumin in patients with gout helps to objectify control over the dynamics of the disease, to evaluate the effectiveness of nonsteroidal anti-inflammatory drugs and in vitro methods.

There is some preparation to a patient to collect daily urine. The patient is issued a numbered 8 clean, dry, non-sterile cans with tight-fitting lids and attached memo on methods of urine collection. Offered before urine collection a thorough washing of the external genital organs. Stresses the importance of keeping the mod is in a dark and cool place.

Based on the results of laboratory research clarifies the nature of the lesion and the question of the tactics of the patient. Further laboratory control is carried out for its treatment.

Illustrations of the choice of the optimal treatment regimen based on a comprehensive laboratory examination of patients with abnormalities of purine metabolism are the following clinical examples.

Example No. 1. Patient G, 72 years old, was hospitalized with a diagnosis of:

the gout. Chronic gouty arthritis. Tofus with the formation of fistulous course. Gouty nephropathy: a cyst of the left kidney, Hurtowy urolithiasis, arterial hypertension.

Was admitted to the hospital with complaints of pain in the first metatarsophalangeal joints on both sides, more on the right, aggravated by movement, swelling of these joints, redness of the skin over them considerable pain and swelling in region II of the toe of the left foot, flushing of the skin on the finger and the presence of white content, translucent through the skin in this area, aching pain in both ankle joints.

Patients considered himself since 1990, when for the first time at the age of 60 years, after copious consumption of meat food appeared sharp pain in the area I metatarsophalangeal joint on the right, swelling it. The skin over the joint was hot to the touch, krasnela, and after a few hours acquired a bluish-purple color. Diagnosed with gout assigned voltaren, the intake of which the attack of arthritis was stopped completely after 5 days. Further bouts of arthritis occurred 1-2 times per year, was provoked by alcohol (even in small quantities), excessive intake of animal food hypothermia. Gradually in the process involved I metatarsophalangeal joint of left ankle, knee, elbow joints. Were outpatients, was appointed reopirin, voltaren, indomethacin. The use of nonsteroidal anti-inflammatory drugs lead to arthritis pain within 10-14 days. Since 1995 began to grow the HELL up to 170/110 mmHg, antihypertensive drugs were taken irregularly. Since 1999 has changed the nature of the flow of arthritis is pain in the joints were not fully and exacerbation did not reach the same intensity. In 2001, for the first time recommended to take allopurinol. Allopurinol was taken within one month, then stopped because of allergic dermatitis.

The reason for the appeal was the exacerbation of arthritis after hypothermia.

State upon receipt of satisfactory. High power. There is defigure I and metatarsophalangeal joint arthrodesis. The skin over the metatarsophalangeal joints redness, hot to the touch is. There is defigure distal interphalangeal joint of the second finger of the right foot due to exudative phenomena, the skin on the finger hot to the touch, redness, through the skin translucent white pulp, periodically released through a fistulous passage.

In the lungs vesicular breathing, wheezing no, the NPV of 16 per minute.

Borders of relative heart dullness extended to the left by 2, see heart sounds rhythmic, muted, accent II tone of the aorta, heart rate (HR 56 min, BP 160/100 mm Hg

Common clinical analysis of a blood: a hemoglobin 138 g/l, leukocytes 8,5·109/l, stab neutrophils 4%, segmented neutrophils 56%, eosinophils 1%, lymphocytes 30%, monocytes 9%, ESR 32 mm/hour.

Urinalysis: relative density 1012, the reaction of the acidic, protein 0,033 g/l, leukocytes 2-4 in the field of view, salt urates.

Biochemical analysis of blood urea 9.2 mmol/l, creatinine 0,134 mmol/l, cholesterol 5.4 mmol/l, triglycerides 2.28 mmol/l, β-lipoproteins 61 optical, total protein, 70 g/l, albumin, 50%, globulins: α11,3%, α22,17%, β 10%, γ 20%, CEC - 196 used, MSM 0,42 optical

ECG : sinus rhythm, the deviation of the electric axis of the heart to the left. Signs of left ventricular hypertrophy.

Dynamic scintigraphy of the kidneys: the left kidney - ind 43,3%, Tmax6,7 min, T1/222,3 min, the right kidney - ind 56,7%, Tmax4,9 min, T/2 22,7 minutes

The radiographic examination of joints: foot - in the head of the first metatarsal and the proximal phalanx on both sides are racemose enlightenment, regional Uzury (right more than a third of the articular surface), narrowing of the joint space. Seal the soft tissues in the area I metatarsophalangeal joint right; knee joints - the narrowing of the joint space, marginal osteophytes, left - increased soft tissue.

Ultrasound of the kidney: right kidney is lower than the normal 4 see the shape of the normal kidney. Dimensions: right - 104·54·58 mm, left - 96·48·55 mm Both kidneys are uneven, finely tuberous contours. Parenchyma uneven (especially left) thinned up to 8-12 mm, without cortical brain differentiation. The echogenicity of the tissue is increased, there is a minor vysokoudojnye inclusion (salt crystals). Left in the middle segment of the medullary cyst - 2,3 see CLS not dilatrane. The structure of some cups high echogenicity, apparently due to fibrosis, we cannot exclude the presence of a single microliths.

The patient was examined by our proposed method. The study of the daily amount of urine. Urine was collected every 3 hours, starting from 6 o'clock. At the end of the urine collection patient was extracted venous blood. The results of the analyses are presented in tables 1(a) and No. 1(b).

Table. No. 1(a)

Biochemical analysis of blood
IndexResultNorma
Uric acid (mmol/l)0,4970,200-0,420
Creatinine (mmol/l)0,1320,062-0,124
Table. No. 1(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProteinRelative density
1100,07,0(++)1014
2100,07,5(+)1018
3150,06,0(+)1022
4100,06,5(+)1019
5150,07,0(+)1015
690,07,0(+)1021
790,06,5(+)1022
880,06,5(+)1020

In the study of the daily amount of urine obtained the following results: the total number of 860 ml, daily diuresis 450 ml, nocturnal diuresis 410 ml, minute diuresis 0.6 ml/min, the concentration of uric acid 4.77 mmol/l, the amount of uric acid 4.1 mmol/24 h, the clearance of uric acid to 5.7 ml/min, creatinine concentration of 10.5 mmol/l, the amount of creatinine 9,03 mmol/24 hour creatinine clearance and 47.5 ml/min, daily proteinuria 0.2 g/24 hours. Calculated fractional clearance was 12.0%.

The study proposed method showed the lowest daily diuresis, which indicates a lack of drinking mode this patient. Low daily diuresis resulted in high concentrations of uric acid in the urine daily.

Repeated examination of the proposed method performed after the patient's stay at nizkoreninovoi diet for three days. The results of the study are presented in tables No. 2(a) and 2(b).

150,0
Table. No. 2(a)

Biochemical analysis of blood
Index ResultNorma
Uric acid (mmol/l)0,4910,200-0,420
Creatinine (mmol/l)0,1370,062-0,124
Table. No. 2(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProteinRelative density
1220,06,5traces1016
2210,07,5Ref.1012
340,06,0traces1010
4230,07,0(+)1011
560,07,0(+)1015
650,07,0traces1016
7100,06,5(+)1013
86,5(+)1014

In the study of the daily amount of urine obtained the following results: the total number of 1060 ml, daily diuresis 700 ml, nocturnal diuresis 360 ml, minute diuresis of 0.74 ml/min, the concentration of uric acid 4,39 mmol/l, the amount of uric acid with 4.65 mmol/24 h, the clearance of uric acid to 6.58 ml/min, creatinine concentration of 13.4 mmol/l, the amount of creatinine of 14.2 mmol/24 hour creatinine clearance 72,1 ml/min, daily proteinuria 0.18 g/24 hours. Calculated fractional clearance was $ 9.13 per cent.

That is kept on a low fluid intake, which, in turn, leads to low daily diuresis and high concentration of uric acid in the urine daily. With this in mind, the patient is recommended to extend the water up to 2.5-3 liters per day. The presence of allergic reactions to allopurinol in history is not allowed to assign basic therapy of this patient. Laboratory examination carried out through the month showed the following results (see table No. 3(a) and 3(b)):

Table. No. 3(a)

Biochemical analysis of blood
IndexResultNorma
Uric acid (mmol/l)/td> 0,4180,200-0,420
Creatinine (mmol/l)to 0.1270,062-0,124
Table. No. 3(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProteinRelative density
1500,06,5Ref.1010
2400,06,5Ref.1012
3450,06,5Ref.1008
4320,06,0Ref.1011
5350,06,5Ref.1011
6160,06,0Ref.1010
780,06,5Ref.1012
820,06,5Ref.the/m

In the study of the daily amount of urine obtained the following results: total number 2280 ml, daily diuresis 1670 ml, nocturnal diuresis 610 ml, minute diuresis was 1.58 ml/min, the concentration of uric acid 2.14 mmol/l, the amount of uric acid 4,88 mmol/24 h, the clearance of uric acid 8,11 ml/min, creatinine concentration 6,13 mmol/l, the amount of creatinine 14.0 mmol/24 hour creatinine clearance to 76.4 ml/min Calculated fractional clearance of 10.6%.

As can be seen from the results, the expansion of the drinking water treatment resulted in a significant (more than twice) growth daily diuresis, resulting in a normalization of the level of uricemia, the decrease in the concentration of uric acid in the urine daily (more than twice) against the background of increasing its clearance, absence of proteinuria. With the re-examination after 2 months the level of uric acid in the blood remained at the upper limit of normal. Against this background, the marked improvement in clinical symptoms disappeared attacks of arthritis was significantly reduced in sizes tofus in region II of the toe of the left foot, closed tofunny fistula. The patient began to take allopurinol, allergic reactions followed.

Thus, selected on the basis of a comprehensive laboratory examination tactics of conducting the patient, which was at this stage in the expansion Pitjeva the on mode, led to a significant improvement of the patient.

Example No. 2. Patient-th, 67 years old, invalid of the great Patriotic war, was admitted to the hospital with complaints of pain in both ankle joints alone, aggravated by movement, swelling of these joints; pain in the calf muscles that you receive when you walk, approximately 100-120 meters, shortness of breath when walking, gripping pains in the heart area when walking.

Patients consider themselves to 1961, when for the first time at the age of 37, after a large intake of animal food and alcohol there was a sudden pain and swelling I metatarsophalangeal joint on the right, redness of the skin over it. To doctors did not address, the attack has passed completely through 5-7 days. The repeated attack of arthritis has developed a year after hypothermia, also involving the right I metatarsophalangeal joint, independently were stopped after 7 days without medication. After the attacks of arthritis occurred 1-2 times per year, was provoked by alcohol and eating meat, hypothermia. Gradually in the process involved I left metatarsophalangeal joint, ankle and knee joints, the episodes become longer. Since 1965 were outpatients compresses with ointment Vishnevskogo and medical bile without significant effect. Diagnosis of gout is not raised, respectively, and did not get the basis of what's drugs. Since 1969 when the attacks of arthritis is assigned phenylbutazone. In patients receiving butadiona attacks of arthritis were stopped for 8-10 days. In 1975, during an attack of arthritis occurs renal colic with the discharge of ureteral stones yellow-brown color. After that renal colic there twice, in 1978 and 1984. Since 1984 recorded permanent changes in urine: proteinuria, leukocyturia, intermittent hematuria. Since 1985 he began to urinate at night (2-3 times), there was difficulty urinating. The urologist diagnosed with prostate adenoma. Since 1982, there has been an increase AD, up to 170/100 mm Hg Antihypertensive drugs were taken irregularly, used raunatina, adelfan, corinfar. Since 1985 began to notice the chill of the feet, pain in the calf muscles when walking. Initially, the pains came through 500-700 meters. Gradually traveled distance without pain decreased since 1990 pains came after 120-150 meters. Since 1987 began to notice gripping pains in the heart area when walking, and since 1989 have shortness of breath when walking. Since 1985 changed the nature of the flow of arthritis: pain in the joints remain constant, despite the use of nonsteroidal anti-inflammatory drugs and acute not reach the same intensity. At the same time noted the appearance of subcutaneous formations above the elbow joint is the size of a cherry. Recent health decline since the spring of 1990, when noted increased pain in ankle joints, increasing pain in the calf muscles when walking, reduced tolerance to physical activity. Treated stationary, conducted therapy with nonsteroidal anti-inflammatory drugs, vascular drugs, but the effect was short-lived. From August 1990 again noted increased pain in the joints. Took non-steroidal anti-inflammatory drugs in maximum doses, however, completely arrest arthritis failed.

From the anamnesis it should be noted frequent eating of the meat of food and alcoholic beverages, shrapnel wound of the left leg during the great Patriotic war.

State upon receipt of moderate severity. There is defigure both ankle joints due to exudative and proliferative changes. Palpation of the joints moderately painful, there is a painful restriction of movement. Marked deformity of both feet. On both elbow joints are tophi size of a walnut, small tophi are marked on both ears.

Ripple on a. dorsalis pedis reduced, more to the left. There is a decrease of ripple on the popliteal artery to the left.

Borders of relative heart dullness extended to the left by 2, see the Colours, the heart is and rhythmic, muted, accent 2 tone of the aorta. HR 96 per minute, BP 150/100 mm Hg

The abdomen is soft, painless. The liver acts 2 cm from the edge of the costal arch. No edema.

In General clinical blood analysis: hemoglobin 150 g/l, leukocytes 8,6·109/l, stab neutrophils 1%, segmented neutrophils 66%, eosinophils 2%, lymphocytes 23%, monocytes 8%, ESR 44 mm/h.

Biochemical analysis of blood urea 8.4 mmol/l, prothrombin index 91%, total protein of 81.7 g/l, albumin 48%, globulins: α11,5%, α215%, β 12%, γ 20%, fibrinogen 9,1 g/l, CRP 3+, cholesterol 6.2 mmol/l, triglycerides 2.32 mmol/l, β-lipoproteins 62 optical

Urinalysis: specific gravity 1010, the reaction of the acidic, protein 0,29 g/l, leukocytes 18-20 in the field of view, erythrocytes 2-3 in eyeshot, hyaline cylinders 0-1 in the field of view, salt urates.

The results of the proposed method laboratory tests are presented in tables No. 4(a) and 4(b).

Table. No. 4(a)

Biochemical analysis of blood
IndexResultNorma
Uric acid (mmol/l)0,4300,200-0,420
Creatinine (mmol/l) 0,1100,062-0,124
Table. No. 4(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProteinRelative density
1220,06,5Ref.1012
2180,06,5Ref.1014
3150,06,5Ref.1010
4200,06,0Ref.1011
5420,06,5Ref.1009
6430,06,0Ref.1013
7210,06,0Ref.1012
8220,06,0Ref.1013

In the study of the daily amount of urine obtained the following results: total number 2030 ml, devnagiri 750 ml, nocturnal diuresis 1280 ml, minute diuresis of 1.41 ml/min, the concentration of uric acid 1.88 mmol/l, the amount of uric acid is 3.82 mmol/24 h, the clearance of uric acid 6,16 ml/min, creatinine concentration 6,09 mmol/l, the amount of creatinine 12,36 mmol/24 hour creatinine clearance 78,05 ml/min Calculated fractional clearance was of 7.90%.

Chest x-ray: pulmonary emphysema, moderate pneumosclerosis. Heart expanded in cross-section through the left ventricle. The aorta is enlarged, hardened.

ECG: sinus rhythm, the deviation of the electric axis of the heart to the left. Incomplete blockade of the right bundle branch. Signs of left ventricular hypertrophy. Degenerative changes in the myocardium.

Radioisotope renography: left kidney - Tmax7,5 min, T1/214 min; right kidney - Tmax9 min, T1/2more than 22 minutes

Ultrasound: liver 12 cm in diameter, the fabric structure is homogeneous. The gallbladder is medium in size, contours equal, walls thickened, in the cavity - calculus. Pancreas - the contours equal, the sizes of the normal gland tissue of a homogeneous structure. The kidneys on both sides of the usual dimensions, contours equal. CLS expanded deformed on both sides. Right concretions no. To the left in the upper pole of the cyst 1,0×0.9 cm in the lower pole calculus - 0,3×0.2 cm in diameter.

Urologist: benign hyperplasi the prostate I-II degree. Urolithiasis. Chronic pyelonephritis.

On the basis of the survey data was first diagnosed with "Gout, severe. Chronic gouty arthritis, acute exacerbation. Stage III. The tophi. Gouty nephropathy: Hurtowy urolithiasis, arterial hypertension. Secondary osteoarthritis deformans and FN-III. Ischemic heart disease. Angina FC-III. Atherosclerotic cardiosclerosis. N-II. Obliterating atherosclerosis of the lower extremities. Chronic calculous cholecystitis. Obesity II. Chronic pyelonephritis. Adenoma of the prostate gland".

Given the results of laboratory tests, the lack of effect from the previous conservative therapy within 6 months) and associated pathology - atherosclerosis of vessels of lower extremities and coronary heart disease, Hyper-fibrinogenesis, the patient decided to undergo IVF treatment is plasmapheresis (PA).

Performed procedure 3 PA with a total exusia plasma 2200 ml for the course. Plasmata-the premises were carried out with saline and reopoliglyukine.

As a result of the treatment condition improved (see figure 1) - was arrested arthritis, blood pressure has stabilized within 140/90-130/90 mm Hg, increased exercise tolerance is increased, the distance traveled without pain in his legs up to 230 to 250 meters, utensils is shortness of breath during physical activity, urodeles heart pain, decreased the content of fibrinogen to 6.1 g/l and cholesterol to 5.4 mmol/l, prothrombin index up to 80%, CEC, MSM, decreased CRP levels α2and γ-globulin, normalized ESR. The observed increase in GFR and daily diuresis. Improved renogram: left kidney - Tmax3,5 min, T1/210 min; the right kidney - Tmax4.5 min, T1/2of 17.5 minutes

Dynamics of uricemia, daily uricosuria, clearance of uric acid and fractional clearance in the process of conducting the PA presented in figure 2.

As can be seen from figure 2, showing the results of dynamic surveys in the proposed method, after the first treatment, a significant improvement of uricemia ("ricochet"syndrome), after the second procedure, the increase was not as significant, and after the third procedure, decreased levels of uric acid in the blood. Unlike uricemia has seen a growth in uricosuria on the background of the PA and to the end of the course it is 1.5 times the original level. There was also a significant increase in the clearance of uric acid and fractional clearance.

The results of recent laboratory examination of the patient by the proposed method are presented in tables No. 5(a) and 5(b).

Ref.
Table. No. 5(a)

Biochemical analysis of blood
IndexResultNorma
Uric acid (mmol/l)0,3600,200-0,420
Creatinine (mmol/l)0,1050,062-0,124
Table. No. 5(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProteinRelative density
1200,06,5Ref.1011
2210,06,5Ref.1010
3305,06,5Ref.1013
4290,06,5Ref.1014
5100,06,5Ref.1010
6110,06,0Ref.1011
795,06,51013
8100,06,0Ref.1014

In the study of the daily amount of urine obtained the following results: total number 1410 ml, daily diuresis 1005 ml, nocturnal diuresis 405 ml, minute diuresis of 0.98 ml/min, the concentration of uric acid a 3.83 mmol/l, the amount of uric acid 5.40 mmol/24 h, the clearance of uric acid 10,42 ml/min, creatinine concentration 9,07 mmol/l, the amount of creatinine 12,79 mmol/24 hour creatinine clearance 84,58 ml/min Calculated fractional clearance was 12,32%.

This clinical example shows how patients with severe gout and severe comorbidity proposed method allows to choose an effective method of treatment. When this complex laboratory testing, carried out in the treatment process, provides an opportunity to assess its effect in the dynamics (significant growth uricosuria, clearance of uric acid and fractional clearance, reducing uricemia).

Example No. 3. Ill H-th, 53 years, is observed in the clinic with a diagnosis of gout. Chronic gouty arthritis. Gouty nephropathy. Hurtowy urolithiasis. Arterial hypertension. Secondary deforming poliosteoartroz. Ischemic heart disease. Atherosclerotic to ticklers with rhythm-type atrial and ventricular arrythmia H-I. Varicose veins of the lower extremities. Chronic venous insufficiency of the lower limbs.

Onset refers to 1971, when at the age of 25 years after severe hypothermia (fell through the ice on a winter fishing) appeared pain and swelling of the ankle joints. The pain was more intense at the slightest movement. Went to a local therapist diagnosed infectious-allergic polyarthritis. Was treated with antibiotics, arthritis symptoms cropped approximately 2 weeks. Then felt satisfactory, pain in the joints are not disturbed. Re-arthritis has developed a year later, in 1972, after errors in diet appeared sharp pain and swelling I metatarsophalangeal joints, redness of the skin over them. The pain was more intense at the slightest movement, there was an increase of body temperature up to subfebrile figures. To the doctor did not address. Pain independently went through 2 weeks. Then during the year felt satisfactory. In 1975, a rheumatologist at the place of residence diagnosed with Rheumatoid arthritis and is assigned phenylbutazone. In 1976, after hypothermia develops acute arthritis of the ankle and metatarsophalangeal joints. The patient comes in artrologicheskoy centre, where the first detected hyperuricemia, diagnosed gout and destinations is fast allopurinol and nonsteroidal anti-inflammatory drugs (ortofen). Allopurinol was taken irregularly. After the attacks of arthritis are repeated 3-4 times a year. Gradually in the process involved the knee, elbow, wrist joints and small joints of the hands. During exacerbation of arthritis continues to take non-steroidal anti-inflammatory drugs. From approximately 1980 to the changing nature of the flow of arthritis attacks already do not reach the same intensity and pain in the joints are not fully, a gradual decrease in mobility. Since 1987, noted the appearance of subcutaneous lesions in the elbow joint the size of a bean.

Since 1988, the patient is observed in the clinic. When contacting the reduced mobility (moves with the help of crutches) due to pain in the knee and ankle joints. There is defigure knee, and ankle joints due to exudative and proliferative phenomena, hyperthermia and hyperthermia skin over them. Palpation of these painful joints, limited movement due to pain and secondary osteoarthritis. There defigure metatarsophalangeal joints on both sides and interphalangeal joints of both hands. Movement in them saved, the skin over the joint is not changed, palpation slightly painful. On the extensor surface of the elbow joints tophi size of the beans. In the distal region between falangovykh joints II finger to the right and the fourth finger on the left tophi size of a pea. Small tophi on the ears.

In General, the clinical analysis of blood accelerated erythrocyte sedimentation rate, up to 45 mm/h, WBC is not changed.

In the biochemical analysis of blood: SLO 4+, fibrinogen 844 mg %, uric acid 0.66 mmol/L.

Ultrasound: the kidneys are usually, contours equal, normal size. Parenchyma sealed. Cup-pelvis system is not expanded, cups small calcium.

Thermography: increase thermogenic activity above the ankle, right knee and I metatarsophalangeal joints (up to 2.5°).

The patient performed a laboratory study of our proposed method. The results of the analyses are presented in tables No. 6(a) and 6(b).

Table. No. 6(a)

Biochemical analysis of blood
IndexResultNorma
Uric acid (mmol/l)0,6600,200-0,420
Creatinine (mmol/l)0,1290,062-0,124
Table. No. 6(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProtein Relative densityThe concentration of MK (mmol/l)The number of microns (µm)Minute diuresis (ml)
12005,5traces10224,50,91,1
21706,0(+)1020the 4.70,80,9
32806,5traces10154,01,11,6
41606,0Ref.10194,10,70,9
51806,0traces1018the 4.70.81,0
61605,5traces10174,80,80,9
71105,0(+++)1025of 5.40,60,6
8 805,0(++)10235,90,50,4

In the study of the daily amount of urine obtained the following results: total number 1340 ml, daily diuresis 810 ml, nocturnal diuresis 530 ml, minute diuresis with 0.93 ml/min, the uric acid concentration of 4.8 mmol/l, the amount of uric acid 6.3 mmol/24 h, the clearance of uric acid of 6.7 ml/min, creatinine concentration 9.8 mmol/l, the amount of creatinine to 13.1 mmol/24 hour creatinine clearance to 70.7 ml/min, daily proteinuria of 0.13 g/24 hours. Calculated fractional clearance is 9.6%.

A repeat survey after conducting a three-day nizkoreninovoi diets: table. No. 7(a) and 7(b):

Table. No. 7(a)

Biochemical analysis of blood
IndexResultNorma
Uric acid (mmol/l)0,5780,200-0,420
Creatinine (mmol/l)0,1250,062-0,124
Table. No. 7(b)

Analysis of the daily amount of urine
no portionNumber (the l) pHProteinRelative densityThe concentration of MK (mmol/l)The number of microns (µm)Minute diuresis (ml)
12105,5traces10204,40,91,2
21506,0(+)1017the 3.80,60,8
31806,5traces1017a 4.90,91,0
41706,0Ref.10155,00,90,9
51906,0traces1016the 4.70,91.1
61506,5traces10164,80,70,8
71005,5(+++)10155,5 0,60,6
8705,5(+++)1016the 5.70,40,4

In the study of the daily amount of urine obtained the following results: total number 1220 ml, daily diuresis 710 ml, nocturnal diuresis 510 ml, minute diuresis 0.8 ml/min, the concentration of uric acid 4.9 mmol/l, the amount of uric acid 5.9 mmol/24 h, the clearance of uric acid and 7.1 ml/min, creatinine concentration 10.0 mmol/l, the amount of creatinine to 12.2 mmol/24 hour creatinine clearance 67,8 ml/min, daily proteinuria 0.11 g/24 hours. Calculated fractional clearance of 10.6%.

As can be seen from the test results, at night time there is steadfastly high concentration of uric acid in the urine, changes the reaction of the urine acidic side. On the basis of the received patient data extended drinking regime in the second half of the day and assigned oschelacivate means, also in the second half of the day. Two weeks later, a re-examination of the daily amount of urine, blood collection after collection of urine. The results of the study are presented in tables No. 8(a) and 8(b).

Table. No. 8(a)

Biochemical analysis of blood
IndexResultNorma
Uric acid (mmol/l)0,5460,200-0,420
Creatinine (mmol/l)0,1170,062-0,124
Table. No. 8(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProteinRelative densityThe concentration of MK (mmol/l)The number of microns (µm)Minute diuresis (ml)
12206,0traces10152,60,61,2
22406,0traces10162,90,71.3
32106,0traces10183,00,61,2
41906,0Ref.10172,90,6 1,1
52506,5Ref.10152,70,71,4
63006,5traces10142,90,91,7
71806,0traces10152,60,51,0
81406,0traces10182,90,40,8

In the study of the daily amount of urine obtained the following results: total number 1730 ml, daily diuresis 860 ml, nocturnal diuresis 870 ml, minute diuresis 1.2 ml/min, the concentration of uric acid 2.8 mmol/l, the amount of uric acid 4,8 mmol/24 h, the clearance of uric acid to 6.2 ml/min, creatinine concentration of 8.1 mmol/l, the amount of creatinine 14.0 mmol/24 hour creatinine clearance 83,1 ml/min, daily proteinuria 0.09 g/24 hours. Calculated fractional clearance was 7.4%.

When studying the tables in portions No. 7 and 8 there has been a shift reaction in alkaline urine side and a significant decrease in the concentration of uric acid.

Thus, Opredelenie the patient the concentration of uric acid in each three-hour servings allowed to reveal its high level at night and using the principles chronotherapy to achieve correct these violations. The purpose selecively means, which in this case was also conducted using the principles chronotherapy, resulted in normalization of pH of urine.

Example No. 4. L., 32 years of age, was treated with a diagnosis of gout, intermittent gouty arthritis. Obesity class II).

Was admitted to the hospital with complaints of pain in the right wrist joint alone, aggravated by the slightest movement, his swelling, hyperemia and pyrexia skin over it, moderate pain in the first metatarsophalangeal and ankle joints during walking, their swelling.

Patients considered himself since 1993, when, after excessive consumption of alcohol and meat food appeared sharp pain in the area I metatarsophalangeal joint on the right, his swelling, redness and local hyperthermia skin over it. Arthritis symptoms accompanied by a fever of 37.8°C. the Pain was more intense at the slightest movement, and therefore the mobility was severely limited. The local physician appointed indomethacin, the intake of which arthritis symptoms completely stopped after 5 days. Initially the attacks of arthritis occurred approximately 2 times per year, then increased to 5-6 times a year. Gradually in the process involved I metatarsophalangeal joint of left ankle and wrist joints. The attacks of arthritis Provotorov who were receiving alcohol and meat meal hypothermia. Arthritis symptoms stoped taking indomethacin or ortofena within 8-12 days. Diagnosis of gout is not set, so the basic treatment is not received.

State upon receipt of satisfactory. High power. There is defigure right wrist joint due to exudative phenomena, hyperthermia and hyperthermia skin over it. Pain limited mobility. Palpation of the joint is sharply painful. Less pronounced defigure due to exudative phenomena of both ankle joints and less marked limitation of motion in them.

Heart sounds, rhythmic, smooth, heart rate of 72 per minute. HELL 120/80 mm Hg

Common clinical analysis of a blood: a hemoglobin 146 g/l, leukocytes 6,5·109/l, stab neutrophils 2%, segmented neutrophils 74%, eosinophils 1%, lymphocytes 19%, monocytes 4%, ESR 31 mm/hour.

Urinalysis: relative density 1016, the reaction of the acidic, protein and glucose negative, WBC 1-2 in sight.

Urine analysis according to Nechyporenko: 250 leukocytes in 1 ml erythrocytes was not found.

Biochemical analysis of blood urea 5.1 mmol/l, prothrombin index 85%, total protein 70,0 g/l, albumin, 50%, globulins: α15%, α216%, β 12%, γ 17%, SLO 3+, cholesterol 5.4 mmol/l, triglycerides 2.2 mmol/l, β-lipoproteins 54 opticad, CEC 196,4 used, MS is 0,56 optical

ECG: sinus rhythm. The predominance of the left ventricle.

Ultrasound: liver slightly enlarged right lobe (157 mm), with smooth contours. The parenchyma is homogeneous, increased echogenicity. Biliary and vascular network is not extended. V. portae - 10 mm Gall bladder is normal in size, thin concretions no. The pancreas is normal in size (2,6×1,5×2.0 cm), cloth uniform, isoechogenic. Kidney normal position, shape and size. Parenchyma without structural changes. Cup-pelvis system is not expanded, without concretions. The bladder and prostate gland without features.

Dynamic scintigraphy of the kidneys: the left kidney - ind 65,5%, Tmax6,4 min, T1/2of 17.9 min; right kidney - ind 34,5%, Tmax7,2 min, Tmax24,4 minutes

ULTRASOUND densitometry: bone density is significantly reduced, osteoporosis (T=-4,1). The data obtained ULTRASONIC densitometry revealed osteoporosis, was the basis for research and phosphorus-calcium metabolism. The survey results by our proposed method are presented in tables No. 9(a) and 9(b).

Table. No. 9(a)

Biochemical analysis of blood
IndexResultNorma
Urinary to the slot (mmol/l) 0,5190,200-0,420
Creatinine (mmol/l)of 0.1330,062-0,124
Phosphorus (mmol/l)1,30,9-1,9
Calcium (mmol/l)2,692,15-to 2.57
Table. No. 9(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProteinRelative density
1180,05,0traces1019
2150,05,0traces1022
350,05,5traces1018
4150,05,0Ref.1015
5100,05,5Ref.1020
6200,06,0Ref.1021
7 350,06,0Ref.1018
8200,05,5Ref.1020

In the study of the daily amount of urine obtained the following results: total number 1380 ml, daily diuresis 530 ml, nocturnal diuresis 850 ml, minute diuresis of 0.96 ml/min, the concentration of uric acid is 4.21 mmol/l, the amount of uric acid of 5.81 mmol/24 h, the clearance of uric acid to 7.77 ml/min, creatinine concentration 10,34 mmol/l, the amount of creatinine 14,27 mmol/24 hour creatinine clearance 74,51 ml/min, the amount of phosphorus from 39.0 mmol/24 h, the amount of calcium of 7.65 mmol/24 hours, daily proteinuria 0.14 g/24 hour. Calculated fractional clearance was 10,43%.

Obtained using the proposed laboratory examination data (hyperuricuria on the background of the high concentration of uric acid in the urine, low urine pH, hypercalciuria) was the basis for an additional preventive measures aimed at reducing the likelihood of kidney stones mixed composition.

Example No. 5. Patient C., 61, within 7 years, suffers from gout. Was admitted to the hospital complaining of severe pains, swelling and hyperemia of the left wrist joint. The pain was more intense at the slightest movement. In terms of the left and right wrist had a fistula with a white curd-like discharge.

Deterioration of health within two months, when there is an acute arthritis of the specified joint. Ambulatory received nonsteroidal anti-inflammatory drugs per os and/m no effect. When you try to add to therapy allopurinol appeared and began to grow azotemia (creatinine 0.15 mmol/l; blood urea 10.4 mmol/l).

The survey results by our proposed method are presented in tables No. 10(a) and 10(b).

Table. No. 10(a)

Biochemical analysis of blood
IndexResultNorma
Uric acid (mmol/l)0,7270,200-0,420
Creatinine (mmol/l)0,1980,062-0,124
Table. No. 10(b)

Analysis of the daily amount of urine
no portionNumber (ml)pHProteinRelative density
1170,05,0traces1010
20
3120,05,0traces1010
4110,05,5(++)1011
5160,05,5(++)1009
6100,05,5(++)1010
7140,05,5(++)1010
8150,05,5(++)1011

In the study of the daily amount of urine obtained the following results: the total number of 950 ml, daily urine output of 400 ml, nocturnal diuresis 550 ml, minute diuresis of 0.66 ml/min, the concentration of uric acid 2.00 mmol/l, the amount of uric acid 1,90 mmol/24 h, the clearance of uric acid is 1.81 ml/min, creatinine concentration 15,02 mmol/l, the amount of creatinine 14,27 mmol/24 hour creatinine clearance 50,05 ml/min, daily proteinuria 0.24 g/24 hours. Calculated fractional clearance amounted to 3.63 percent.

Based on these data, given the lack of effect of previous therapy, and progressive renal failure, the Aulnay decided to hold the course PA. At the same time were cancelled nonsteroidal anti-inflammatory drugs.

Conducted 7 procedures PA with a total exusia plasma 8900 ml for the course. Plasmodesmata was conducted by reopoliglyukine, isotonic solution of sodium chloride. After two treatments the positive effect is significantly reduced pain and swelling of the left wrist joint, increased range of motion in the joint.

After a course PA disappeared completely pain and swelling, closed fistula in the area of the affected joint. Noted positive dynamics of laboratory indicators: decreased erythrocyte sedimentation rate from 55 to 25 mm/h, increased hemoglobin levels from 110 to 145 g/l, decreased uric acid levels to 0,547 mmol/L.

Thus, IVF treatment, assigned on the basis of the received data expressed in the human purine metabolism and progressive renal failure, helped in the short term to improve the condition of the patient.

In addition to survey our proposed technique in a patient with C. was investigated dynamics of indicators of effective concentration of albumin (ECA, g/l), total concentration of albumin (OKA, g/l) and binding capacity of albumin (SSA, used) during the first and final procedures PA. The results are presented in figure 3.

As can be seen from figure 3, the conducting each procedure is And was accompanied by increased binding capacity of albumin while reducing as effective and total concentration.

Comprehensive laboratory examination according to the claimed method conducted in the dynamics of the 320 patients with impaired purine metabolism in both residential and outpatient settings. It is established that the examination of patients by this method can significantly improve the quality of diagnostics. This gives an opportunity to choose the most optimal treatment regimen and take the necessary standardized control.

LITERATURE

1. Pihlak EG Gout, M., 1970.

2. Nephrology. A guide for physicians. Edited Yestereve, M, Medicine, 1992.

3. Reference "Clinical and diagnostic value of laboratory parameters" edited Dolgova V. M., 1995.

4. Wyngaarden J.B,, Kelley N. W. Gout and hypemricemia. New York, Grune and Stratton,1976.

5. "Clinical guide to laboratory tests; Third Edition. Edited by Norbert W.Tietz. W.B.Saunders Company, 1995.

6. The zimnitsky tests S. Introduction to functional diagnosis of kidney diseases. The wedge. the honey. Volume 5. No. 1, pp.2, 1927.

7. Great Medical Encyclopedia. Ed. 3. Volume 8. M., 1978, S.

8. Pihlak AE, Ryzhikov D.B, Pososhkov I., Taranov MB, Logatchev, VA, räpina EU Clinical significance of determination of binding capacity of albumin in patients with gout // Albumin serum in clinical medicine. Book 2 / ed Wagiswara and Hetorical. - M.: GEOTAR, 1998. - S-378.

1. The method of choice of treatment in patients with violation of renovage exchange, comprising determining the concentration of uric acid and creatinine in blood and urine daily, characterized in that conduct complex laboratory testing, including the collection of daily urine by the method of zimnitsky tests (three-hour portion of urine, starting from 6 h), immediately after collection of the last portion of urine produced blood sampling for analysis; in each portion of the urine to determine pH, protein and relative density, after which portions are combined and in the total volume of urine to determine the concentration and amount of the uric acid, creatinine and daily proteinuria, calculate Clarence uric acid and creatinine and fractional clearance of uric acid; if violations of purine metabolism, including a high concentration of uric acid in the urine with a low daily diuresis, recommend drinking expansion mode; if violations of purine metabolism, including the change of the reaction in the urine acidic side, appoint oschelacivate tools; identifying marked disorders of purine metabolism and severe comorbidity spend extracorporeal therapy.

2. The method according to claim 1, characterized in that the treatment carried out in patients with gout.

3. The method according to claim 1, characterized in that the purpose selecively means when the detection of changes in the reaction of the urine in cislo the side is carried out with the use of the principles of chronotherapy.

4. The method according to claim 1, characterized in that it further in each three-hour portion of urine to determine the concentration of uric acid and designate the extension of drinking behavior using the principles chronotherapy.

4. The method according to claim 1, characterized in that it further blood and urine daily to determine the concentration of calcium and phosphorus, with an increase in daily excretion of calcium and/or phosphorus carry out preventive measures aimed at reducing the likelihood of kidney stones mixed composition.

6. The method according to claim 1, characterized in that it further in the blood determine the binding capacity of albumin, which is used to assess the effectiveness of the chosen course of treatment.



 

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