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Harnsediment
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\begin{document} 
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\MYTITLE{Harnsediment}


805.011 FBL 2
Mag$^a$ Regine Daniel\\
Alexander \"Olzant\\

Quellen: MCW-Unterlagen Block 9\\
Classen - Diehl - Kochsiek: Innere Medizin, Urban und Fischer 
5. Auflage S. 1623ff

%%%%%%%%%%%%
%%%%%%%%%%%%%%%


\vspace*{.5in} % adjust this to makes things fit nicely 
\BS
\MYTITLE{0/6 \"Ubersicht}

\begin{enumerate} 
\item Indikation
\item Vorteile gegenüber Stix
\item Befundung
\item Klinik
\item Bestandteile
\item Typische Konstellationen
\end{enumerate} 


\BS
\MYTITLE{1/6 Indikation}
Sedimentbestimmung, wenn laut Teststreifen Erys im Harn

\begin{tabular*}{\textwidth}[t]{p{0.5\textwidth}p{0.5\textwidth}}
\includegraphics[height=3.0in]{eumorph.jpg} &
\includegraphics[height=3.0in]{dysmorph.jpg} \\
einige eumorphe Erythrozyten & dysmorphe Erythrozyten
\end{tabular*}

Ursachen f. Erys im Harn: meist extrarenal (Konkremente, Trauma, Prostata), seltener renal 

\BS
\MYTITLE{2/6 Vorteile gegenüber Stix}
\begin{itemize} 
\item Leukozyturie nachweisbar (ev. quantifizierbar)
\item Bakteriennachweis
\item Pilz- oder Trichomonadennachweis
\item Hämaturie (Nachweis spricht für Cystitis und gegen Urethritis)
\item Granulierte Zylinder (spricht für Pyelonephritis)
\end{itemize} 


\BS
\MYTITLE{3/6 Befundung}

\begin{tabular*}{\textwidth}[t]{p{0.3\textwidth}|p{0.3\textwidth}p{0.3\textwidth}}
(pro Tag) & Normalbefund (physiologisches Sediment)& pathologisch \\
\hline%
Zylinder & 2000 & $>$ 10000 \\
Erythrozyten & 130000 & 1 Mio \\
Leukozyten/ Epithelialzellen & 650000 & 2 Mio \\
\hline
\end{tabular*}

Routine: nur Erythrozytenbestimmung (Addis-Sediment)

\BS
\MYTITLE{4/6 Klinik}
Extrarenale Ursachen (h\"aufig):
\begin{itemize}	
\item Konkremente
\item Trauma
\item Prostataerkrankungen (m $>$ 50 a)
\item Blasentumor
\item Gerinnungsst\"orungen
\item parasit\"are Erkrankungen der Blase
\end{itemize} 

\BS
\MYTITLE{4/6 Klinik}
Seltener renale Ursachen:
\begin{itemize}	
\item Nierentumor
\item Glomerulonephritiden
\item Systemerkrankung m. Nierenbet.
\item Papillennekrose (DM/Analgetika)
\item Zystenblutung bei polyzyst. Nierendegeneration
\end{itemize} 

\BS
\MYTITLE{5/6 Bestandteile}

\begin{tabular*}{\textwidth}[t]{p{0.3\textwidth}|p{0.3\textwidth}p{0.3\textwidth}}
(pro Tag) & Normalbefund (physiologisches Sediment)& pathologisch \\
\hline%
Zylinder & 2000 & $>$ 10000 \\
Erythrozyten & 130000 & 1 Mio \\
Leukozyten/ Epithelialzellen & 650000 & 2 Mio \\
\hline
\end{tabular*}

fakultativ pathologisch: Kristalle, Bakterien


\BS
\MYTITLE{5/6 Bestandteile}
Glomerul"are/nichtglomerul"are Erys:
\begin{itemize}
\item glomerul"ar: osmot. Trauma - polymorph, oft ringf\"ormig mit Exo-/Endopodien (Zellknospen)
\item nichtglomerul\"ar: uniform (Form, Gr\"o\ss{}e, Struktur)
\end{itemize} 
Annahme einer glomerul\"aren Mikroh\"amaturie, wenn $>$ 30 % dysmorph
Eumorphe Erys $\rightarrow$ postrenal (Blase, Prostata, Urethra)
 
\BS
\MYTITLE{5/6 Bestandteile}
Zylinder: \\
im Tubuluslumen/Sammelrohr gebildet
\begin{itemize} 
\item hohe Osmolarit\"at
\item niedriger Urin-pH (sauer)
\item Stase (kein Harnfluss)
\end{itemize} 
ferner K+, Na+, Albumin, Kontrastmittel, freie Leichtketten

\BS
\MYTITLE{5/6 Bestandteile}
Zylinder:

\begin{tabular*}{\textwidth}[t]{p{0.5\textwidth}p{0.5\textwidth}}
\includegraphics[height=3.0in]{hyalin.jpg} &
\includegraphics[height=3.0in]{nephritisches_sediment.jpg}\\
hyaline Zylinder (physiologisch) & nephritisches Sediment
\end{tabular*}

\BS
\MYTITLE{5/6 Bestandteile}
Zylinderarten:

\begin{itemize} 
\item hyalin: zellfrei - physiologisch
\item Ery-Zylinder: renale H\"amaturie
\item Leuko-Zylinder: Entz"undung
\item Epithelzylinder: akutes Nierenversagen/Tubulussch\"aden
\item gemischte Zylinder (nicht eindeutig)
\end{itemize} 

\BS
\MYTITLE{5/6 Bestandteile}
Zylinderarten:

\begin{itemize} 
\item Pigmentzylinder \begin{itemize} 
\item H\"amoglobinzylinder: Glomerulonephritis, H\"amoglobinurie, Systemerkr. m. Nierenbet.
\item Myoglobinzylinder: Myoglobin + THP - Muskelzerst"orung (Trauma, Heroin-, Alkoholabusus, Immobilisation, Isch\"amie) = Rhabdomyolyse
\item Bilirubinzylinder: Hepatitis, Cholestase
\end{itemize} 
\end{itemize} 

\BS
\MYTITLE{5/6 Bestandteile}
Zylinderarten:
\begin{itemize} 
\item Fettzylinder: Fettk"ugelchen/Cholesterinkristalle $\rightarrow$ glom. Sch\"adigung
\item Wachszylinder: reno-parenchymat"ose Erkrankungen
\item Kristallzylinder/Kristalle: verschieden (Zystinurie, Hypercalciurie, Uratnephropathie ...)
\item Bakterien (95 % monobakteriell, evtl. Verunreinigungen!)
\end{itemize} 


\BS
\MYTITLE{6/6 Typische Konstellationen}

\begin{itemize} 
\item  Harnwegsinfektion: Bakterien, Leukos, (Erys, eumorph)
\item  Nephritis: granulierte Zylinder, Leukos, Tubulusepithelzellen, Erys (dysmorph)
\item  Nephrotisches Syndrom: oft unauffälliger Befund (oder vereinzelt Zylinder, Erys, Tubulusepithelien - Definition: Proteinurie > 3.5 g/d)
\end{itemize} 



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