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PROTEÎNÜRÎ: TANISI, HASAR MEKANİZMALARI VE TEDAVÎSÎ

PROTEINURIA : DIAGNOSIS, PATHOPHYSIOLOGY AND TREATMENT

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Abstract (Original Language): 
Fizyolojik koşullarda idrarla günlük protein atılımı 150 mgr'ın altındadır. Tekrarlanan ölçümlerde bu değerin üzerinde protein atılımının saptanması, yani proteinüri, gözardı edilmemeli ve ileri değerlendirme yapılmalıdır. Bu düzeyin üzerindeki protein atılımı genel olarak altta yatan böbrek hasarının önemli bir göstergesidir. İdrarda protein atılımının normal sınırlarda olup olmadığının değerlendirilmesi için yaygın olarak kullanılan yöntem 24 saatlik idrarda protein ölçümüdür. Son dönemde ise bu yönteme alternatif olarak spot idrarda kreatinin ve total protein oranının hesaplanması gündeme gelmiştir. Bu oran 1,73 m2 vücut alanına sahip bir bireyde günlük protein atılımının yaklaşık bir göstergesi olabilmektedir. Bu yöntemde elde edilen oran rakamsal olarak günlük protein atılımına denk gelmektedir (Örn: İdrarda total protein / kreatinin oranının 4,9 saptanması günlük protein atılımının 4,9 g/1,73 m2 olduğunu gösterir)(l). Bu yöntemin sağlıklı sonuçlar vermeyeceği durumlar da mevcuttur. İdrarda atılan kreatinin miktarının bekleneden farklı olduğu durumlar bunlardan biridir. Örneğin kas kitlesi yüksek ve buna bağlı olarak da idrarda atılan kreatinin miktarı fazla olan bireyde protein atılımı az görülürken, tersine kaşektik bireyde mevcutdan daha fazla protein atılımı hesaplanacaktır. Yine bu yöntemle iyi huylu proteinüri durumları (ortostatik proteinüri vb) tanımak mümkün değildir. Bu yöntemin diabetik nefropatili hastalarda uygulanması halinde de yanlış sonuçlar alınmaktadır. Klinikte, proteinüri varlığı çoğunlukla bu yöntemlerden önce, idrar çubukları vasıtasıyla farkedilmektedir. Bu çubuklar albumine karşı duyarlıdırlar ve bu nedenle albumin dışındaki moleküllerin atılımının arttığı iyi huylu durumlarda, multipl myelomda ve mikroalbuminüri düzeyindeki diabetik hastalarda tanı için yeterli olamamaktadırlar. Açıklanamayan böbrek yetmezliği varlığında idrarın sulfasalisilik asit ile test edilmesi halinde mevcut olan bütün protein miktarı tespit edilebilir. Bu yöntem Glomerüler hipertansiyonun, artmış angiotensin-II'nin de katkısıyla, glomerül duvarını gererek zarar görmesine ve 'pore'ların genişleyip protein filtrasyonundaki boyut-seçiciliği özelliğini kaybederek, multipl myelom tanısında faydalıdır. Diabetik nefropatili hastalarda ise idrar çubuğunda proteinin pozitifleşmesi hastalığın geç bir bulgusudur. Bunun nedeni bu çubukların ancak günlük 300-500 mg üzerinde albumin atılımı varlığında pozitifleşiyor olmasıdır. Bundan daha düşük düzeylerdeki proteinürinin tanısında faydasızdırlar.
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