Egyptian Journal of Medical Microbiology, July 2009 Vol. 18, No. 3

Diagnostic Relevance of Pyuria in Haemodialysis Patients (Renal as an Aetiology of Sterile Pyuria)

Mohamed Saber1, Laila Aboul Fadl2, Hoda Helmi2, Ehab El-Dobaa1, Emam Waked3, Azza El Shamaa3, Manar A. Hussein3, Dalia Roshd4 Departments of Biochemistry1, Microbiology2, Nephrology3 Theodor Bilharz Research Institute and Internal Medicine Dep., Cairo University4

ABSTRACT

This study was designed to assess the significance of pyuria as a marker of urinary tract (UTIs) in haemodialysis patients and renal tuberculosis as a common aetiology of sterile pyuria. The study was conducted on 50 patients with end stage renal disease (ESRD) on regular haemodialysis (group I), as well as 10 healthy controls (group II). Fresh urine samples were cultured, examined microscopically for pyuria and tested by Bayer reagent strips for protein, blood, nitrite and leucocyte esterase (LE). Gram stain of colonies and their identification to the species level using API 20 E system were performed. Ziehl-Neelson (ZN) staining for acid alcohol fast bacilli and Polymerase chain reaction (PCR) for detection of Mycobacterium tuberculosis (MTB) DNA were performed on 24 hours collected urine samples. All patients had pyuria (≥5 WBCs/hpf). Protein, blood, LE and nitrite were significantly higher in patients than in controls (P value <0.01, <0.01, <0.001 and <0.05 respectively). A significant correlation was found between patients' symptoms and bacterial growth (p<0.1). Thirty one patients had sterile pyuria, three out of them (10%) were proved to be tuberculous by ZN or PCR. To conclude, pyuria is a common finding in haemodialysis patients and is proved to be a valuable parameter of UTIs in these patients. In symptomatic patients with sterile pyuria, renal tuberculosis should be excluded by ZN staining and/or PCR. In asymptomatic patients, periodic urine culture should be performed to confirm presence or absence of UTIs.

INTRODUCTION pyuria and white cell casts in their urine regardless of presence or absence of . (5) is the most Kim and Corwin have stated that pyuria in common bacterial infection in humans. It can be dialysis patients is not indicative of UTIs either symptomatic or asymptomatic. because of several clinical factors that may Symptomatic infection is associated with a wide confound this relationship. Other studies have spectrum of morbidity, from mild irritative defended pyuria as a good marker of UTIs in (6) (7) voiding symptoms to bacteremia, and those patients . Chaudhry et al. have found occassionally death. Asymptomatic urinary that asymptomatic dialysis patients with many infection is the isolation of bacteria from urine white cells in their urine are more likely to in quantitative counts consistent with infection, produce a possible urinary pathogen on culture. but without localizing genitourinary signs or They suggested to utilize the level of pyuria in symptoms, and with no systemic symptoms these patients to recognize infection. Urinary attributable to the infection(1). tract tuberculosis is one of the most common Fasolo et al.(2) reported that dialysis causes of sterile pyuria. It results of dependent patients have documented defects in haematogenous spread from a pulmonary site of (8) their immune responses, and are commonly primary infection . Sterile pyuria commonly predisposed to UTIs that contribute significantly associated with ESRD was found to be one of (9) to their morbidity and mortality. Diagnosis of the risk factors of extrapulmonary TB . The UTIs usually involve the appearance of value of pyuria in immunosuppressed appropriate symptoms, the finding of pyuria and haemodialysis patients is unclear. So the present the culture of possible urinary pathogens from study was designed to assess the significance of the urine(3). pyuria as a marker of UTIs in haemodialysis The value of pyuria as a marker of UTI patients and renal tuberculosis as common in haemodialysis dependent patients is aetiology of sterile pyuria. controversial. Cabuluna et al.(4) reported that end stage renal disease (ESRD) patients exhibit

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MATERIAL & METHODS KC1, 1.5mM MgC12, 0.001% gelatin (w/v) and 2.5units Taq DNA polymerase (Promega Inc.). The study was conducted on 50 patients Amplification program was as follows; one o with ESRD under maintenance haemodialysis in cycle of denaturing at 94 C for 5 minutes o Theodor Bilharz Research Institute (group I). followed by 40 cycles, each at 94 C for 1 They were on regular haemodialysis sessions 3 minute as denaturing step, annealing step at o o times weekly, 4 hours each using hemophan 55 C for 1 minute and extension step at 72 C for o filters and sodium acetate solution as dialysate. 1 minute, the final extension step was 72 C for 7 Ten healthy subjects were also included as minutes. In the second PCR (nested PCR), 2ul controls (group II). of first PCR amplification products and the Personal and present history was taken nested primers were added in a total volume of from all patients stressing on the aetiology of 100µl reaction mix containing the same renal failure, duration of haemodialysis components as in the first PCR. Annealing o treatment and symptoms of urinary tract temperature was 65 C in second PCR. The problems as dysuria, haematuria, frequency and amplification was done in the thermal cycler TM suprapubic pain. Patients were clinically PTC100 system (Mj, USA). The PCR examined for suprapubic tenderness and tender amplification products along with DNA ladder renal angles. Patients with positive urine culture were separated using 2.5% agarose gel were subjected to abdomino-phric electrophoresis, stained with ethidium bromide (12) ultrasonography to exclude pyocystosis. and visualized using UV illumination . A Sample collection: specific band at 400bp was expected. Morning midstream urine sample was Bayer reagent strips for urinalysis (Bayer freshly collected. It was used for culture, diagnostics MFg., Ltd. Bridgend, UK): urinalysis using Bayer reagent strips. Then it According to manifacturer's instruction, was centrifuged and the spun was examined fresh urine specimen was tested by Bayer microscopically. reagent strips which include test pads for Twenty four hours urine was also collected protein, blood, nitrite and leucocyte esterase and centrifuged. The precipitate was used for (LE). In cases of UTIs, gram negative bacteria ZN staining, and for detection of MTB DNA by converts diet derived nitrate to nitrite which is PCR. detected by testing the urine with reagent strips. Laboratory Investigations: The detection of LE in urine denotes the Detection of Mycobacterium tuberculosis presence of leucocytes especially granulocytic (MTB) DNA by PCR in urine samples: ones as they contain esterase enzymes. The 24 hours collected urine was Urinalysis result was considered positive by the centrifuged at 2000rpm for five minutes and the detection of leucocyte esterase LE or nitrite. precipitate was used for DNA extraction(10). In Microscopic examination of urine: brief, lysis of cells was done by proteinase K at Fresh urine sample was centrifuged at a concentration of 20µg/ml in 1% SDS. DNA 2000rpm for five minutes, then the spun is was extracted using guanidinium examined microscopically. Pyuria was defined isothiocyanate-phenol-chloroform method as greater than or equal to five white blood (alkaline phenol, pH 8). cells/high power field (5WBCs/hpf) according (2) (5) PCR for the extracted DNA has been done to Fasolo et al. ; Kim and Corwin . using a set of specific nested primers designed Urine culture: for detection of the gene coding for the 65KDa Morning midstream urine sample is freshly antigen (cell wall protein) (Gene Bank Acc. No. collected, cultured on blood agar, Mac Conkey's M15467). The sequence of the primers were: agar and sabouraud's dextrose agar using Forward 1: 5`AGATCGAGAACAGCGACTCC calibrated platinum loop (0.002ml), and o Reverse 1: 5`GCGAGCAGATCCTCGTAGAC aerobically incubated at 37 C overnight. On the The sequence of the nested primers were: second day, the plates were examined for Forward 2: 5`CATGTCGCCGCCACCGGGAA presence of growth. Gram stain and Reverse 2: 5`GTGGCCCAGATCCGCCAG identification to the species level using API 20E A total volume of 100µl PCR mixture was system (Biomérieux SA. Marcy L'Etoile, prepared for the first PCR(11). The reaction France) were performed. Culture was 5 mixture consisted of approximately 500ng considered positive when ≥10 colony forming genomic DNA, 200µM dNTPs, 1µM of both 5` unit/ml were isolated. and 3` primers, 10mM Tris-HC1, pH 8.3, 50mM

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Ziehl-Neelson staining of the urine: Results of Bayer reagent strips for The collected 24 hours urine sample was urinalysis were also illustrated in table I. centrifuged at 2000rpm for five minutes. The Protein, Blood, LE and Nitrite were deposit was stained by ZN stain for acid alcohol significantly higher in patients than in controls fast bacilli according to Ayers(13). with P value of <0.01, <0.01, <0.001 and <0.05 Statistical Analysis: respectively. A significant correlation was Results were expressed as percent. found between pyuria and LE, and between Comparison between the percent positivity of pyuria and nitrite with same P value of <0.01. the two groups was done using Chi Square (χ2). Table II showed the presence of patients' SPSS computer program (version 17 windows) symptoms and bacterial growth. Forty two was used for data analysis. P value less than percent of patients were symptomatic, whereas 0.05 was considered significant; less than 0.01 fifty eight percent were asymptomatic. None of was considered highly significant and less than the controls had UTI symptoms. Sixty two 0.001 was considered extremely significant. percent of the patients have no growth (sterile pyuria) while thirty eight percent gave bacterial RESULTS growth on urine culture. E. coli was the most common bacterial strain found in infected The study was enrolled on 50 patients with dialysis patients (31.5%). Klebsiells spp. ESRD on regular haemodialysis (group I), as (Oxytocea and Pneumoniae), Pnoteus mirabilis, well as 10 healthy controls (group II). The Mecithillin resistant Staphylococcus aureus patients' age ranged from 33-76 years with a (MRSA), Staphylococcus aureus, and mean of 57.93±13.83, they were 37 males and Enterococcus gallinarum were also detected in 13 females. The controls' age ranged from 25-72 infected patients' urine (21%, 16%, 10.5%, years with a mean of 49.4±16.12, they were 6 10.5%, 10.5% respectively). A significant males and 4 females. correlation was found between patients' Among patient group, ESRD was attributed symptoms and bacterial growth (p<0.01). It is to hypertense nephrosclerosis (34%), worthmentioned that a significant correlation obstructive uropathy (24%), diabetic was also found between pyuria and patients' nephropathy (10%), polycystic kidney disease symptoms, and between pyuria and urine culture (6%) and in 26% of patients the cause couldn't with same P value of <0.01. be ascertained. In the patients with urine volume Results of microscopic examination of <500ml/day, the mean WBCs count was urine was shown in table I. All patients had 44±36.95; while in those with urine volume WBCs count in urine ≥5 cells/hpf, with a mean >500ml/day, the mean WBCs count was of 28 WBCs/hpf. Four controls had WBCs 20±15.88. This result doesn't carry a significant count in their urine ≥5 cells/hpf, whereas 6 statistical difference. controls had WBCs ≤5 cells/hpf. The mean Three out of 31 patients with sterile pyuria WBCs count in urine was significantly higher in were proved to be tuberculous. One was patient group than in control group (p<0.01). As diagnosed by the presence of acid fast bacilli in regard the red blood cells (RBCs), the mean Zeihl-Neelsen stained 24h urine smear. The RBCs count in urine was also significantly other two cases were diagnosed by detection of higher in patient group than control group with MTB DNA using PCR in urine. a p value <0.02. Fig. (1) demonstrated the electrophoretic analysis of MTB amplification product. The 400bp product was obtained.

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Table (1): Results of microscopic examination and Bayer reagent strips Controls (n=10) Patients (n=50) P value Bayer reagent strips Protein 3 (30%) 43 (86%) <0.01 Blood 0 (0%) 27 (54.0%) <0.01 Leucocyte esterase 0 (0%) 36* (72.2%) <0.001 Nitrite 0 (20%) 15* (30.0%) <0.05 Urine examination WBCs 5±0.52 28±3.7 <0.01 RBCs 4±0.67 12±1.4 <0.02 P value significant between patients and controls. * p<0.01 significant bet. Nitrite and pyuria. * p<0.01 significant bet. Leukocyte esterase and pyuria.

Table (2): Presence of patients' symptoms and bacterial growth Controls (n=10) Patients (n=50) Urine culture No growth 10 (100%) 31 (62.0%) Bacterial growth 0 (0%) 19 (38.0%) Symptoms Yes 0 (0%) 21* (42%) No 10 (100%) 29 (58%) * p<0.01 significant between culture and symptoms in patients

Figure (1): Electrophoretic analysis of MTB second PCR amplification product: The 400 bp product was obtained. Lane (1): standard size marker. Lane (2): positive control. Lane (3): positive MTB sample. Lane (4-7): negative MTB samples. Lane (8): positive MTB sample. Lane (9): negative MTB sample. Lane (10): negative control.

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DISCUSSION of studies for using the old cut off standard, and they believed that their results might differ Infection is a common cause of morbidity when using the new standard cut off. and mortality in haemodialysis patients, being Our results demonstrate that WBCs count the cause of 23% of deaths and 22% of in a random urine sample was significantly hospitalizations(14). elevated in haemodialysis patients compared to Haemodialysis patients are more controls with an average of 28 cell/hpf in susceptible to UTIs. When undiagnosed and patients compared to 4 cells/hpf in controls untreated, significant complications may occur (p<0.01). This is in concordance with Hyodo et (15) leading to the need of drainage procedures, al. who found that WBCs count was nephrectomy or deaths. Delayed diagnosis is a significantly higher in dialysis patients than in (2) relevant issue because UTI is often overlooked healthy individuals. While Fasolo et al. as source of infection in dialysis patients, concluded that the presence of pyuria in especially because its symptoms are mostly haemodialysis patients is common but not rule. related to voiding which is reduced or absent. In this current study, all patients had pus When diagnosed in a timely manner, these cells in their urine ≥5 cells/hpf. This agrees with (4) infections are easily treatable, and early Cabuluna et al. who were the first to explore treatment prevents further complications(3). the occurrence of pyuria in haemodialysis In the present study, the rate of UTI in patients. They found that pyuria is a common haemodialysis patients was significantly higher finding in them and it often occurs in the than in controls. The prevalence was recorded presence of infection. Thirty-eight percent of as 38% and 0% in patients group and controls our patients gave positive urine culture making respectively. This agrees with Eisinger et al.(3) pyuria as a good marker of UTI in who stated that haemodialysis patients have haemodialysis patients. These results compromised immunity and are at high risk of demonstrate a significant correlation between UTI. Orlowska et al.(6) have also reported that WBCs count in urine and urine culture with a P immune system disturbance and renal failure value <0.01. Similar correlation has been can predispose to UTIs in continuous recorded in previous studies with higher (7) ambulatory peritoneal dialysis patients. positivity rates. Chaudhry et al. have reported The number of WBCs in urine is a useful that asymptomatic haemodialysis patients marker of UTI in patients with renal having high WBCs count in urine are more insufficiency, while its value in haemodialysis likely to produce urinary pathogen on culture patients is unclear and not mentioned in urology than those exhibiting modest level of textbooks(15). Kim and Corwin(5) reported that leukocyturia. In their study 70% of patients with the value of pyuria as a marker of UTI in heavy leukocyturia grew urinary pathogen. (6) dialysis patients is questionable. This is because Orlowska et al. have also demonstrated that of several clinical factors that may confound pyuria was present in 67% of asymptomatic this relationship, and the observations of some haemodialysis patients with positive urine authors that the presence of pyuria in these culture. Both of these two previous groups of patients is not indicative of infection. investigators concluded that pyuria is a good Confounding clinical factors include: the marker of UTI in dialysis patients. It is presence of low urine volume, bladder stasis worthmentioned that a wide range of the and the underlying aetiology of kidney disease. prevalence of pyuria in dialysis patients (28%- (16) The latter factor leading to terminal kidney 72%) has been reported . However, they failure is associated with sterile pyuria owing to considered the incidence of pyuria in these chronic parenchymal inflammation. For further patients variable and it should not be relied information, the present study was designed to upon for the diagnosis of UTI. (3) assess the diagnostic relevance of pyuria in On the other hand, Eisinger et al. haemodialysis patients. suggested that leukocyturia ≥10 cells/hpf in In our study, the cut off used for diagnosing asymptomatic ESRD patients does not strongly pyuria was ≥5 cells/hpf. Kim and Corwin(5) correlate with the presence of infection. They have used this new cut off as a standard for stated that counting WBCs in a urine specimen pyuria and they criticized most researchers for seems not a very productive way of anticipating (15) considering a cut off of ≥10 cells/hpf in their the growth of urinary pathogens. Hyodo et al. studies. In addition, Fasolo et al.(2) denied most have also studied the occurrence of WBCs in

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urine of haemodialysis patients using a cut off disease is due to reactivation of past disease ≥10 cells. They reported that pyuria is not rather than a primary infection. The appropriate to be a marker for bacterial infection recrudescence is often extrapulmonary(19). It has in these patients. The conclusion of these two been reported that the incidence of active groups of investigators may be attributed to the tuberculosis in patients undergoing maintenance use of the old cut off standard of ≥10 cells/hpf. dialysis for a long time is considerably higher Their results could be different if they used the than that in general population(20). These new cut off standard ≥5 cells/hpf. mentioned findings are in harmony with our Urinalysis for pyuria and infection was results, where three out of thirty one screened by Bayer's reagent strips. Leukocyte haemodialysis patients with sterile pyuria (10%) esterase (LE) was significantly higher in urine proved to be urinary tuberculosis. One of them of haemodialysis patients than that of controls had a positive Ziehl-Neelsen stained urine (p<0.001), demonstrating that urine of these smear. The other two were diagnosed by patients contains more pus cells than that of detection of MTB DNA using PCR on urine controls. Nitrite was significantly higher in being a high sensitive method. Tuberculous haemodialysis patients than in controls aetiology of sterile pyuria was reported in (p<0.05), confirming the susceptibility of these 66.6% of haemodialysis patients by Chaudhry et patients to bacterial infection. Protein and blood al.(7). In a study done by Marques et al.(21), were also detected more in haemodialysis extrapulmonary tuberculosis was diagnosed in patients than in controls with a P value of <0.01. 63.4% of haemodialysis patients. They This could be explained by the fact that ESRDs concluded that in areas with high prevalence of are associated with chronic parenchymal tuberculosis, there is an urgent need to inflammation and sterile pyuria that is investigate TB periodically in haemadialysis predominantly lymphocytic and not neutrophilic patients to exclude insidious infection and as in cases of bacterial infections. This reduce morbidity and mortality. distinction is not routinely made in clinical To conclude, patients with ESRD on laboratories. According to the above mentioned haemodialysis are immunosuppressed, and are urinalysis results, we agree with Fasolo et al.(2) commonly predisposed to UTIs that contribute who criticized ignoring the use of urine reagent significantly to their morbidity and mortality. strips for nitrite and LE to rule out UTI in Pyuria is a common finding in haemadialysis dialysis patients despite being routinely used in patients and it is proved to be a valuable clinical practice in the normal population. parameter of UTI in these patients. Diagnosis of Our study demonstrates a positive pyuria should be done using the new cut off correlation between urine culture and patients' standard of ≥5 cells/hpf. When pyuria is symptoms (p<0.01). The urine of these associated with dysuria, UTI should be symptomatic patients (i.e dysuria) was more considered and urine culture should be done. If liable to grow pathogens in culture. This is in urine culture is negative, renal tuberculosis concordance with Eisinger et al.(3), who being a common cause of sterile pyuria should suggested that we must look not only to the be excluded by ZN staining and/or PCR. laboratory investigations but mainly to the Asymptomatic patients having pyuria should be dialysis patients' symptoms and signs to submitted to periodic urine culture to confirm recognize UTI. presence or absence of UTI. In the current study, no correlation was found between WBCs count in urine and urine REFERENCES volume in 24 hours. On the other hand, a negative correlation between pyuria and urine 1. Nicolle LE (2005): Urinart Tract Infection. volume has been reported, suggesting that In: Primer on Kidney Diseases. Greenberg pyuria is not a good marker of UTI in oliguric A, Cheung A, Falk R, Coffman T and (17) patients . Jannette J (Eds). Saunders, Curtis Center, Sterile pyuria is the presence of pyuria in Philadelphia, Pennsylvania USA. 4th ed. absence of significant . One of its pp411-419. common causes is urinary tuberculosis resulting 2. Fasolo LR, Rocha LM, Campblle S, et al. of haematogeneous spread from a pulmonary (2006): Diagnostic relevance of pyuria in (18) site of primary infection . There are a number dialysis patients. Kid Internat; 70: 2035- of reports of tuberculosis developing in patients 2038. on regular haemodialysis. In most of cases, the

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3. Eisinger RP, Asghar F, Kolasa C, et al. manual. Cold spring harbor Laboratory (1997): Does pyuria indicate infection in Press. NY. 3rd ed. Vol. III. pp 5.14-5.18. asymptomatic dialysis patients? Clin 13. Ayers L (2007): Microscopic examination Nephrol; 47:50-51. of infected material. In: Diagnostic 4. Cabuluna CC, Gary NE and Eisinger RP Microbiology. Connie RM, Donald CL and (1977): Urinalysis in patients on chronic George M (Eds). Sauder, Missouri USA. 3rd haemodialysis. Urology; 10: 103-104. ed. pp 152-198. 5. Kim SM and Corwin HL (2007): 14. Allon M, Radeva M, Bailey J, et al. Urinalysis. In: Diseases of the Kidney and (2005): The spectrum of infection-related Urinary Tract. Schrier RW. (Ed). Lippincott morbidity in hospitalized haemodialysis Williams and Wilkins. Philadelphia USA. patients. Nephrol Dial Transplant; 20: 7th ed. pp 286-298. 1180-1186. 6. Orlowska A, Majdan M and Koziol- 15. Hyodo T, Yoshida K and Sakai T (2005): Montewka M (2002): Asymptomatic Asymptomatic hyperleukocyturia in bacteriuria in patients on continuous haemodialysis patients analyzed by the ambulatory peritoneal dialysis. Ann Univ automated urinary flow cytometer. Ther Mariae Curie Sklodowska; 57: 285-289. Alpher Dial; 9: 402-406. 7. Chaudhry A, Stone WJ and Breyer JA 16. Nicolle LE (2003): Asymptomatic (1993): Occurrence of pyuria and bacteriuria when to screen and when to bacteriuria in asymptomatic haemodialysis treat. Infect Dis Clin North Am; 17 (2): patients. Am J Kid Dis; 21: 180-183. 367-394. 8. Alvarez S and McCabe WR (1984): A 17. Saitoh H, Nakamura K, Hida M, et al. review of experience at Boston City (1985): Urinary tract infection in oliguric Hospital and other hospitals. Medicine; 63: patients with chronic renal failure. J Urol; 25. 133: 990-993. 9. Lin JN, Lai CH, Chen YH, et al. (2009): 18. Tolkoff-Rubin N, Catron C and Robert Risk factors for extrapulmonary R (2008): Urinary Tract Infection, tuberculosis compared to pulmonary , and Reflux Nephropathy. tuberculosis. Int J Tuberc Lung Dis; 13 (5): In: The Kidney. Brenner BM (Ed). John F. 620-625. Kennedy Blvd. Philadelphia. 8th ed. pp 10. Kathleen D, Eisenach M, Donald C, et al. 1203-1238. (1993): PCR detection Mycobacterium 19. Eastwood JB, Corbishley CM and tuberculosis. In: Diagnostic molecular Grange JM (2001): Diseases of the month, microbiology; Principles and applications. tuberculosis and kidney. J Am Soc Nephrol; Persing DH, Smith TF, Tenover FC and 12: 1307-14. White TJ (Eds). American Society for 20. Säv T, Tokgoz B, Sipahioglu MH, et al. Microbiology. Washington DC, USA. pp (2009): Extrapulmonary tuberculosis in 191-220. haemodialysis patients with unusual clinical 11. Innis MA, Gelfand DH, Sninsky JJ, et al. presentation. Int Urol Nephrol; 9540-9542. (1990): PCR protocols. In: A guide to 21. Marques LP, Rioja LS, Pacheco GG, et methods and applications. Acadimic Press al. (2008): Tuberculosis in haemodialysis inc., San Diego, CA. pp 4-36. patients in area of high incidence of 12. Sambrook J and Russell DW (2001): Mycobacterium tuberculosis and human Molecular cloning. In: A laboratory immunodefeciency virus infection. Dial & Transplant; 37 (12): 486-490.

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اﻟﻘﻴﻤﺔ اﻟﺘﺸﺨﻴﺼﻴﺔ ﻟﻮﺟﻮد اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ ﻓﻲ اﻟﺒﻮل ﻓﻲ ﻣﺮﺿﻲ اﻷﺳﺘﺼﻔﺎء اﻟﺪﻣﻮي [اﻟﺪرن اﻟﻜﻠﻮي آﺴﺒﺐ ﻓﻲ ﺗﻮاﺟﺪ اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ ﻓﻲ اﻟﺒﻮل دون ﻧﻤﻮ ﺑﻜﺘﻴﺮي ﻋﻠﻲ اﻟﻤﺰارع]

ﻣﺤﻤﺪ ﺻﺎﺑﺮ١، ﻟﻴﻠﻲ أﺑﻮ اﻟﻔﻀﻞ٢، هﺪي ﺣﻠﻤﻲ٢، إﻳﻬﺎب اﻟﻀﺒﻊ١، إﻣﺎم واآﺪ٣، ﻋﺰة اﻟﺸﻤﺎع٣، ﻣﻨﺎر ﺣﺴﻴﻦ٣، داﻟﻴﺎ رﺷﺪ٤ أﻗﺴﺎم اﻟﻜﻴﻤﻴﺎء اﻟﺤﻴﻮﻳﺔ١، اﻟﻤﻴﻜﺮوﺑﻴﻮﻟﻮﺟﻲ٢، ﺑﺤﻮث اﻟﻜﻠﻲ٣ ﻣﻌﻬﺪ ﺗﻴﻮدور ﺑﻠﻬﺎرس واﻟﺒﺎﻃﻨﺔ ٤ ﺟﺎﻣﻌﺔ اﻟﻘﺎهﺮة

ﺻﻤﻤﺖ هﺬﻩ اﻟﺪراﺳﺔ ﻟﺘﻘﻴﻴﻢ وﺟﻮد اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ ﻓﻲ اﻟﺒﻮل آﺪﻟﻴﻞ ﻋﻠﻲ ﻋﺪوى اﻟﻤﺴﺎﻟﻚ اﻟﺒﻮﻟﻴﺔ ﻓﻲ ﻣﺮﺿﻲ اﻷﺳﺘﺼﻔﺎء اﻟﺪﻣﻮي، وﺗﻘﻴﻴﻢ اﻟﺪرن اﻟﻜﻠﻮي آﺴﺒﺐ ﺳﺎﺋﺪ ﻟﻮﺟﻮد اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ ﻓﻲ اﻟﺒﻮل دون ﻧﻤﻮ ﺑﻜﺘﻴﺮي ﻋﻠﻲ اﻟﻤﺰارع٠ اﺷﺘﻤﻠﺖ اﻟﺪراﺳﺔ ﻋﻠﻲ ﺧﻤﺴﻴﻦ ﻣﺮﻳﺾ ﻳﻌﺎﻧﻮن ﻣﻦ اﻟﻔﺸﻞ اﻟﻜﻠﻮي اﻟﻤﺰﻣﻦ ﻷﻣﺮاض اﻟﻜﻠﻰ وﻳﺠﺮى ﻟﻬﻢ اﻷﺳﺘﺼﻔﺎء اﻟﺪﻣﻮي ﺑﺸﻜﻞ ﻣﻨﺘﻈﻢ (ﻣﺠﻤﻮﻋﺔ أ)٠ آﻤﺎ ﻳﺸﻤﻞ اﻟﺒﺤﺚ ﻣﺠﻤﻮﻋﺔ ﺿﺎﺑﻄﺔ ﻣﻜﻮﻧﺔ ﻣﻦ ﻋﺸﺮة أﺷﺨﺎص أﺻﺤﺎء (ﻣﺠﻤﻮﻋﺔ ب)٠ ﺗﻢ زرع ﻋﻴﻨﺎت اﻟﺒﻮل، وﻓﺤﺼﻬﺎ ﻣﻴﻜﺮوﺳﻜﻮﺑﻴﺎ ﻟﻠﻜﺸﻒ ﻋﻦ اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ، واﺧﺘﺒﺎرهﺎ ﺑﺸﺮاﺋﻂ اﺧﺘﺒﺎر Bayer reagent ﻟﻠﻜﺸﻒ ﻋﻦ اﻟﺒﺮوﺗﻴﻦ، ﺧﻼﻳﺎ اﻟﺪم، اﻟﻨﻴﺘﺮﻳﺖ وأﻧﺰﻳﻢ ٠Leucocyte esterase آﻤﺎ ﺗﻢ ﺻﺒﻎ اﻟﻤﺴﺘﻌﻤﺮات اﻟﺒﻜﺘﻴﺮﻳﺔ ﺑﺼﺒﻐﺔ اﻟﺠﺮام واﻟﺘﻌﺮف ﻋﻠﻴﻬﺎ ﺑﺎﺳﺘﺨﺪام اﺧﺘﺒﺎر ٠API20E ﺗﻢ ﺗﺠﻤﻴﻊ ﺑﻮل ٢٤ ﺳﺎﻋﺔ ودوراﻧﻪ واﺳﺘﺨﺪام اﻟﺮاﺳﺐ ﻓﻲ ﺻﺒﻐﺔ Ziehl-Neelson ﻟﻠﻜﺸﻒ ﻋﻦ ﻋﺼﻮﻳﺎت اﻟﺪرن اﻟﻤﻘﺎوﻣﺔ ﻟﻠﻜﺤﻮل واﻟﺤﺎﻣﺾ ٠ آﻤﺎ اﺳﺘﺨﺪم اﻟﺮاﺳﺐ ﻓﻲ اﺧﺘﺒﺎر ﺗﻔﺎﻋﻞ اﻟﺒﻠﻤﺮة اﻟﻤﺘﺴﻠﺴﻞ PCR ﻟﻠﻜﺸﻒ ﻋﻦ اﻟﺤﺎﻣﺾ اﻟﻨﻮوي ﻟﻤﻴﻜﺮوب اﻟﺪرن٠ ﻗﺪ أﺳﻔ ﺮت ﻧﺘﺎﺋﺞ اﻟﺒﺤﺚ ﻋﻦ وﺟﻮد اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ ﻓﻲ ﺑﻮل ﺟﻤﻴﻊ اﻟﻤﺮﺿﻲ ﺑﻨﺴﺒﺔ أآﺜﺮ ﻣﻦ ﺧﻤﺲ ﺧﻼﻳﺎ ﻓﻲ اﻟﺤﻘﻞ اﻟﻤﺠﻬﺮي٠ آﻤﺎ أن ﻧﺴﺒﺔ اﻟﺒﺮوﺗﻴﻦ، وﺧﻼﻳـــﺎ اﻟﺪم، وأﻧﺰﻳﻢ Leucocyte esterase واﻟﻨﺘﺮﻳﺖ، آﺎﻧﺖ ﺟﻤﻴﻌﻬﺎ أﻋﻠﻲ ﻓﻲ ﻣﺠﻤﻮﻋﺔ اﻟﻤﺮﺿﻲ ﻋﻦ اﻟﻤﺠﻤﻮﻋﺔ اﻟﻀﺎﺑﻄﺔ، وآﺎﻧﺖ P. value ﻋﻠﻲ اﻟﺘﻮاﻟﻲ (0.05> ,0.001> ,0.01> ,0.01>) آﻤﺎ أﺛﺒﺖ اﻟﺒﺤﺚ وﺟﻮد ﻋﻼﻗﺔ ذات دﻻﻟﺔ إﺣﺼﺎﺋﻴﺔ ﺑﻴﻦ أﻋﺮاض اﻟﻤﺮﻳﺾ واﻟﻨﻤﻮ اﻟﺒﻜﺘﻴﺮي (p<0.01). ﻣﻦ ﺑﻴﻦ واﺣﺪ وﺛﻼﺛﻮن ﻣﺮﻳﺾ ﻳﻌﺎﻧﻮن ﻣﻦ وﺟﻮد اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ ﺑﺎﻟﺒﻮل ﻣﻊ ﻋﺪم وﺟﻮد ﻧﻤﻮ ﺑﻜﺘﻴﺮي ﻋﻠﻲ ﻣﺰارﻋﻬﻢ، ﺛﻼﺛﺔ ﻣﺮﺿﻰ (١٠%) ﺗﻢ ﺗﺸﺨﻴﺼﻬﻢ آﻤﺮﺿــﻲ اﻟﺪرن اﻟﻜﻠـــﻮي ﻋﻦ ﻃـﺮﻳﻖ ﺻﺒﻐﺔ Ziehl-Neelson أو اﺧﺘﺒﺎر ﺗﻔﺎﻋﻞ اﻟﺒﻠﻤﺮة اﻟﻤﺘﺴﻠﺴﻞ ٠PCR ﻳﺴﺘﻨﺘﺞ ﻣﻦ اﻟﺒﺤﺚ أن وﺟﻮد اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ ﻓﻲ اﻟﺒﻮل ﺳﺎﺋﺪ ﺑﻴﻦ ﻣﺮﺿﻰ اﻷﺳﺘﺼﻔﺎء اﻟﺪﻣﻮي ٠ آﻤﺎ ﺛﺒﺖ أهﻤﻴﺘﻪ آﺪﻟﻴﻞ ﻋﻠﻲ وﺟﻮد ﻋﺪوى اﻟﻤﺴﺎﻟﻚ اﻟﺒﻮﻟﻴﺔ ٠ وﻟﺬﻟﻚ ﻓﻲ اﻟﻤﺮﺿﻰ اﻟﺬﻳﻦ ﻳﻌﺎﻧﻮن ﻣﻦ أﻋﺮاض ﻋﺪ وى اﻟﻤﺴﺎﻟﻚ اﻟﺒﻮﻟﻴﺔ وﺗﺘﻮاﺟﺪ اﻟﺨﻼﻳﺎ اﻟﺼﺪﻳﺪﻳﺔ ﻓﻲ ﺑﻮﻟﻬﻢ دون ﻧﻤﻮ ﺑﻜﺘﻴﺮي ﻋﻠﻲ اﻟﻤﺰارع، ﻳﺠﺐ اﺳﺘﺒﻌﺎد ﺗﺸﺨﻴﺺ اﻟﺪرن اﻟﻜﻠﻮي ﻋﻦ ﻃـﺮﻳﻖ ﺻﺒﻐﺔ -Ziehl Neelson أو اﺧﺘﺒﺎر ﺗﻔﺎﻋﻞ اﻟﺒﻠﻤﺮة اﻟﻤﺘﺴﻠﺴﻞ ٠PCRأﻣﺎ ﻓﻲ اﻟﻤﺮﺿﻰ اﻟﺬﻳﻦ ﻻ ﻳﻌﺎﻧﻮن ﻣﻦ أﻋﺮاض اﻟﻌﺪوى، ﻳﺠﺐ ﻋﻤﻞ ﻣﺰرﻋﺔ ﺑﻮل ﻋﻠﻲ ﻓﺘﺮات زﻣﻨﻴﺔ ﻣﻨﺘﻈﻤﺔ ﻟﻠﺘﺄآﺪ ﻣﻦ وﺟﻮد أو ﻋﺪم وﺟﻮد ﻋﺪوى اﻟﻤﺴﺎﻟﻚ اﻟﺒﻮﻟﻴﺔ٠

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