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Добавлено: Пн апр 16, 2007 6:42 pm
Alon
dr.Ira писал(а):А с камнем-то что делать?
Я не об этом. Есть нечто более важное, что мы не сделали тогда. :)

Добавлено: Пн апр 16, 2007 10:48 pm
dr.Ira
Не...я не знаю...И, даже, не представляю, о чем Вы... :oops:

Добавлено: Пн апр 16, 2007 10:59 pm
Alon
Напоминаю:
"...в б\х анализе крови было обнаружено - общий кальций сыворотки - 15.9 mg/dL (4.0 mmol/L) (норма - 8.6 to 10.0 mg/dL [2.2 to 2.5 mmol/L]);альбумин - 3.9 g/dL (39 g/L) (норма - 3.2 to 5.1 g/dL [32 to 51 g/L]); ионизированный кальций - 9.12 mg/dL (2.28 mmol/L) (норма - 4.80 to 5.52 mg/dL [1.20 to 1.38 mmol/L]); форфор - 2.3 mg/dL (0.74 mmol/L) (норма - 2.7 to 4.5 mg/dL [0.87 to 1.45 mmol/L]);креатинин - 1.5 mg/dL (132.7 mcmol/L) (норма - 0.5 to 1.0 mg/dL [44 to 88 mcmol/L]). "
Делать ничего не надо было, кроме диагностического поиска? :)

Добавлено: Пн апр 16, 2007 11:01 pm
dr.Ira
ЭКГ?

Добавлено: Пн апр 16, 2007 11:02 pm
Alon
ЭКГ - это у нас тоже диагностический поиск :)

Добавлено: Пн апр 16, 2007 11:08 pm
Rodionov
Подумать о ХПН как о причине вторичного гиперпаратироза? Но вроде креатинин 1,5 по нашим меркам не большой криминал...

Добавлено: Пн апр 16, 2007 11:10 pm
Alon
А как насчет кальция - с ним надо что-то делать?
И что?

Добавлено: Пн апр 16, 2007 11:51 pm
dr.Ira
Капельник с изотоническим р-ром и диуретики назначить?

volume repletion with isotonic sodium chloride solution is an effective short-term treatment for hypercalcemia.

Once volume is restored, simultaneous administration of loop diuretics blocks Na+ and calcium reabsorption in the TALH.

Добавлено: Вт апр 17, 2007 9:58 am
Alon
Спасибо участникам обсуждения.
Доктор Родионов провел обследование lege artis.

Заключение.
Diagnosing nephrolithiasis in a pediatric patient requires a high degree of suspicion. The condition is suggested when hematuria, abdominal pain, urinary frequency, dysuria, and fever are present. A history of anatomic abnormalities of the urologic system, recurrent urinary tract infections, or diuretic treatment adds to the suspicion. The diagnosis often is made by a plain abdominal radiograph or ultrasonography. Intravenous pyelography or CT scan may be indicated for confirmation and to assess for obstruction.

An evaluation to determine the cause includes serum concentrations of calcium and phosphorus, uric acid, electrolytes, BUN, and creatinine. Urine should be analyzed for blood, leukocytes, casts, protein, pH, crystals, and culture. Ideally, a 24-hour urine collection should be assayed for calcium, oxalate, uric acid, citrate, magnesium, sodium, and creatinine. Chemical and radiographic diffraction analysis of a recovered stone is invaluable in determining the specific biochemical abnormality.
In the older child who is not acutely ill, outpatient management with analgesics and oral fluids may be appropriate. Patients can strain the urine to collect a stone for analysis. Younger and severely ill patients merit hospitalization. Extracorporeal shock wave lithotripsy can be used safely in cases of intractable obstruction. Surgical consultation may be necessary following failed lithotripsy treatment.

The presenting features of hypercalcemia include those referable to the GI, renal, neuropsychiatric, and cardiovascular systems. Teenagers often present with neuropsychiatric symptoms, including personality changes and mood swings, anxiety or depression, and altered cognitive function. Infants and younger children usually present with GI symptoms such as anorexia, constipation, and poor weight gain. The renal manifestations range from polyuria to nephrocalcinosis and nephrolithiasis to renal insufficiency. The latter is observed when serum calcium concentrations are greater than 12 mg/dL (3.0 mmol/L) and may be reversible. Cardiovascular findings include hypertension and a prolonged QT interval.

The finding of an elevated serum calcium value should be confirmed with repeat testing and measurement of serum albumin, ionized calcium, and phosphorus. A urinalysis and urinary calcium-to-creatinine ratio should be obtained. A history that includes nutrition, medications, family history, and review of systems is essential. Concomitant hypercalcemia and hypophosphatemia strongly suggest hyperparathyroidism, prompting measurement of an intact PTH concentration. In the absence of conditions causing secondary hyperparathyroidism (such as chronic renal insufficiency), an elevated PTH value confirms primary hyperparathyroidism.

Immediate treatment of hypercalcemia depends on the severity and cause of the condition. For patients who have serum calcium concentrations greater than 12 mg/dL (3.0 mmol/L), aggressive intervention is indicated to prevent continued adverse effects on the renal, cardiac, neuropsychiatric, and GI systems. Combined treatment with intravenous saline and furosemide enhances renal calcium elimination. Prevention of bone resorption with a bisphosphonate can lower serum calcium concentrations within 48 to 72 hours. Administration of glucocorticoids is useful in cases of increased intestinal calcium absorption.

Hyperparathyroidism in children most likely is due to a single parathyroid adenoma. A parathyroid adenoma is localized best by a radionuclide scan. Surgical intervention is necessary for children who have primary hyperparathyroidism due to glandular hyperplasia or adenoma. Intraoperative measurement of PTH should reveal at least a 50% decline 10 minutes following excision of an adenoma. Close evaluation and treatment of transient hypocalcemia are necessary following the removal of a parathyroid adenoma.

As many as 20% of parathyroid glands are positioned ectopically, as in this patient. Parathyroid adenomas also can occur in association with MEN types 1 and 2; both are inherited in an autosomal dominant pattern and are due to alterations in genes responsible for tumor formation. If MEN type 2 is suspected, preoperative evaluation for the coexistence of a pheochromocytoma is indicated and should include measurement of catecholamines.

Lessons for the Clinician
Nephrolithiasis is uncommon in otherwise healthy children. Management depends on finding the specific cause. A basic metabolic profile and urinalysis should be obtained at the time of presentation. Associated findings of hypercalcemia and hypophosphatemia support the probability of hyperparathyroidism. Aggressive management of hypercalcemia is necessary to prevent ongoing renal damage and adverse effects on the cardiac, neuropsychiatric, and GI systems. Appropriate radiologic evaluation for discerning the cause of hyperparathyroidism includes technetium-99m sestamibi scanning. A parathyroid adenoma should be removed by a skilled surgeon. Considering the diagnosis of MEN should prompt testing for pheochromocytoma prior to surgery to prevent life-threatening hypertensive crisis.

Добавлено: Вт апр 17, 2007 10:52 am
dr.Ira
Спасибо за замечательный разбор!

Добавлено: Вт апр 17, 2007 3:56 pm
Rodionov
Спасибо!