D-dimer: Versiyalar orasidagi farq

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„D-dimer“ sahifasi tarjima qilib yaratildi
(Farq yoʻq)

21-Sentyabr 2022, 20:38 dagi koʻrinishi

D-dimer (yoki D dimer ) fibrin degradatsiyasi mahsuloti (yoki FDP) bo'lib, qon laxtasi fibrinoliz bilan parchalanganidan keyin qonda mavjud bo'lgan kichik protein bo'lagi hisoblanadi. U shunday nomlanishiga aosiy sabablar bor, chunki u o'zaro bog'lanish bilan birlashtirilgan fibrin oqsilining ikkita "D" fragmentini o'z ichiga oladi va shuning uchun oqsil dimerini hosil qiladi. [1]

D-dimer kontsentratsiyasi tromboz tashxisini qo'yish uchun qon testi bilan aniqlanishi mumkin. [2] 1990-yillarda amaliyotga joriy etilganidan beri u venoz tromboemboliya kabi trombotik kasalliklarga shubha qilingan odamlarda o'tkaziladigan muhim tekshirish usuliga aylandi. [2] [3] Salbiy natija trombozni amalda istisno qiladi, ijobiy natija trombozga oid patologiyani ko'rsatishi mumkin, ammo boshqa mumkin bo'lgan sabablarni istisno qilmaydi. [3] Ushbu tekshiruv amaliyotini o'tkazilishining asosiy sababi tromboembolitik kasalliklarni istisno qilishdir [1] [2]

D-dimer darajalari qon aylanishi buzilishi, tarqalgan intravaskulyar koagulyatsiya va COVID-19 infektsiyasi bilan bog'liq koagulyatsion buzilishlar uchun eng muhum diagnostik masalani hal qiluvchi biomarker sifatida ishlatiladi. [1] [3] Proteinning to'rt baravar ko'payishi COVID-19 bilan shifoxonaga yotqizilgan odamlarda yomon patofiziologik jarayon kechayotganligini ko'rsatuvchi asosiy ko'rsatkichidir. [1] [3] [4]

Prinsiplari

D-dimer shakllanishi. Ko'rsatilgan fibrinogen, uning bitta E va ikkita D domenlari bilan, kaskadda, quyidagi fermentlar tomonidan ta'sir qiladi: Fibrin protofibrillalari to'rini yaratish uchun trombin ; XIII omil fibrin to'rini o'zaro bog'lash uchun kerak bo'ladi (protofibril D domenlarini bog'lash), laxta shakllanishi uchun esa ikkala; Fibrinolizdagi ta'sirida fibrin parchalanish mahsulotlarini ( FDP ) ishlab chiqaradigan plazmin, eng kichiki D-dimerlar, bir E va ikkita o'zaro bog'langan D domeniga ega bo'lgan oqsil parchalari asl fibrinogendan foydalaniladi. [1] [5]

Koagulyatsiya, qon ivishi yoki trombning shakllanishi, koagulyatsion kaskadining oqsillari yoki shikastlangan qon tomir devori bilan aloqa qilish va to'qima bo'shlig'ida (ichki yo'l) kollagen ta'sirida,shuningdek, asosan eng muhim bo'lgan ikkita sabab bor: VII omilning faollashishi natijasida sodir bo'ladigan to'qimalarni faollashtiruvchi omillar (tashqi yo'l) tufayli sodir bo'ladi. Ikkala yo'l ham trombin hosil bo'lishiga olib keladi, bu ferment eruvchan qon oqsili fibrinogenini fibringa aylantiradi va u proteofibrillarga aylanadi. Trombin ishlab chiqaradigan yana bir ferment:

XIII omil, so'ngra D fragmenti joyida fibrin proteofibrillalarini o'zaro bog'laydi va qon laxtalarini shakllanishi uchun asosiy omil bo'lib xizmat qiladigan erimaydigan gelsimon modda hosil bo'lishiga olib keladi. [1]

Aylanma ferment plazmini va fibrinolizning asosiy fermenti, fibrin gelini bir qator joylarda parchalaydi. Olingan bo'laklar, "Yuqori molekulyar og'irlikdagi polimerlar" plazmini tomonidan bir necha marta ko'proq hazm qilinadi va oraliq hamda keyin kichik polimerlar hosil bo'lishiga ( fibrin parchalanish mahsulotlari yoki FDP) olib keladi. Natijada ikkita D fragmentlari orasidagi o'zaro bog'lanish butun bo'lib qoladi va ular fibrin bo'laklari yetarlicha hazm bo'lganda sirtda namoyon bo'ladi. D-dimerning tuzilishi ikki D domenining 180 kDa [6] yoki 195 kDa [7] og'irlikdagi molekulasi, shuningdek ikkita D domenining 340 kDa [7] molekulasi va asl fibrinogen molekulasining bir E domenidir. [1] Qondagi D-dimerning yarimparchalanish davri taxminan 6 soatdan 8 soatgacha sodir bo'ladi. [8]

D-dimerlar odatda inson qon plazmasida mavjud bo'lmaydi, Koagulyatsion tizim faollashgan hollar bundan mustasno bo'lib, masalan, tromboz yoki tarqalgan tomir ichidagi koagulyatsiya mavjudligi sababli tahlil o'tkazilganda natija ijobiy ko'rsatgichni beradi. D-dimer tahlili monoklonal antitelaning D-dimer fragmentidagi ma'lum bir epitopga bog'lanishiga bog'liq. Tahlilda bir nechta aniqlash usullari mavjud; ularning barchasi D-dimerga qarshi boshqa monoklonal antitelaga tayanadi. Ulardan ba'zilari uchun antitela bog'laydigan D-dimerning maydoni ma'lum. Keyin antitelaning bog'lanishi turli xil laboratoriya usullaridan biri bilan miqdoriy jihatdan o'lchanadi. [1]

Ko'rsatkichlari

D-dimer tahlili chuqur venoz tromboz (DVTl), o'pka emboliyasi (PE) yoki tarqalgan intravaskulyar koagulyatsiya (DIC) kasalliklariga shubha tug'ilganda klinik qo'llaniladi. [1] [3]

Chuqur venoz tromboz (DVTl),va o'pka emboliyasii uchun ushbu kasalliklarning laboratoriya tahlili klinik ehtimolini aniqlash uchun ishlatiladigan turli skorlama tizimlari mavjud; ulardan eng mashhuri - Wells ball tahlilidir. [5]

  • Plazmadagi D-dimer darajasining oshishi bilan COVID-19 kasalligining og'irligining ortishi o'rtasida sezilarli bog'liqlik mavjud. Tizimli tekshiruv shuni ko'rsatadiki, 3,48 mkg/ml darajasi, bu og'ir bo'lmagan/omon qolish holatlariga qaraganda besh baravar yuqori, kasalxonaga yotqizilgan COVID-19 bemorlarida yomon natijalarga olib kelishi mumkin. [9]
  • Yuqori ball yoki testdan oldingi ehtimollik uchun D-dimer kam farq qiladi va test natijalaridan qat'i nazar, antikoagulyant terapiya boshlanadi va DVT yoki o'pka emboliyasi uchun qo'shimcha tekshiruv o'tkazilishi mumkin.
  • O'rtacha yoki past ball yoki testdan oldingi ehtimollik uchun:
    • Salbiy D-dimer testi tromboemboliyani deyarli istisno qiladi: [5] D-dimerning trombolitik kasallik ehtimolini kamaytirish darajasi klinik sharoitda qo'llaniladigan maxsus testning sinov xususiyatlariga bog'liq: eng mavjud D-dimer salbiy natijaga ega bo'lgan testlar, agar testdan oldingi ehtimollik 15-20% dan kam bo'lsa, tromboembolik kasallik ehtimolini 1% dan kamroq kamaytiradi. Ko'krak qafasining kompyuter tomografiyasi (KT angiografiyasi) D-dimer tahlilining salbiy natijalari bo'lgan odamlarda o'pka emboliyasini baholash uchun ishlatilmasligi kerak. [10] Testdan oldingi past ehtimollik ham O'pka emboliyasini istisno qilishda muhim ahamiyatga ega. [11]
    • Agar D-dimer yuqori bo'lsa, tromb borligini tasdiqlash uchun qo'shimcha tekshiruvlar (oyoq tomirlarining ultratovush tekshiruvi yoki o'pka sintigrafiyasi yoki KT skanerlashi ) talab qilinadi. Antikoagulyant terapiya shu nuqtada boshlanishi mumkin yoki klinik vaziyatga qarab keyingi testlar tashxisni tasdiqlamaguncha to'xtatilishi mumkin.

Ba'zi shifoxonalarda kasallikka shubxa tug'ilganda tekshiruv natijalaridan so'ng va faqat tahminiy tahlil natijasi ko'rsatilgan normadan past yoki o'rta bo'lsa, ular laboratoriyalar tomonidan o'lchanadi. Bu ehtimolligi yuqori bo'lgan bemorlarda keraksiz natijalarga bo'lgan ehtiyojni kamaytiradi. [12] Avval D-dimer tahlilini o'tkazib ko'rish tahminiy tashxis qo'yishning muhim qismini oldini oladi va kamroq invaziv hisoblanadi. D-dimer diagnostikaga bo'lgan ehtiyojni istisno qilishi mumkinligi sababli, maxsus professional tashkilotlar shifokorlarga D-dimer testini dastlabki tashxis sifatida qo'llashni tavsiya qiladi. [13] [14] [15] [16]

Izoh

Malumot diapazonlari

Quyida D-dimer uchun hos bo'lgan ma'lumotlar diapazonlari keltirilgan : [17]

Birliklar Homilador bo'lmagan



</br> kattalar 		Birinchi trimestr Ikkinchi trimestr Uchinchi trimestr
mg/l yoki mkg/ml < 0,5 0,05 - 0,95 0,32 - 1,29 0,13 -1,7
mkg/L yoki ng/ml < 500 50 - 950 320 - 1290 130 - 1700
nmol/l < 2.7 0,3 - 5,2 1,8 - 7,1 0,7 - 9,3

D-dimer inson yoshi kattalashgan sari ortib boradi. Shuning uchun venoz tromboemboliya (VTE) shubha bo'lganda 50 yoshdan oshgan bemorlar uchun bemorning yoshiga teng bo'lgan yil × 10 mkg/L (yoki x 0,056 nmol/L) chegarani qo'llash taklif qilingan, chunki bu noto'g'ri natijani kamaytiradi. noto'g'ri salbiy davolash choralarini sezilarli darajada amalga oshirmaslikka kafolat bo'ladi. [18] [19]

D-dimerning muqobil o'lchovi fibrinogen ekvivalent birliklarida (FEU) keltiriladi. Fibrinogen molekulasining molekulyar og'irligi D-dimer molekulasining o'lchamidan taxminan ikki baravar katta va shuning uchun 1,0 mkg/ml FEU 0,5 mkg/ml d-dimerga teng. [20]

Tromboz kasalligi

D-dimer qondagi bo'lgan o'zgarishlarining deyarli 93 - 95% gacha sezgirlikka ega (haqiqiy ijobiy ko'rsatkich). Shifoxonaga yotqizilgan har bir bemorlar uchun trombolitik kasalligi tashxisi uchun amalga oshirilgan o'ziga xos tekshiruv usullarining taxminan 50% aniq tashxis qo'yish uchun aniqlik (noto'g'ri ijobiy ko'rsatkich bilan bog'liq) ekanligini aniqladi. [21]

  • Noto'g'ri ijobiy ko'rsatkichlar turli sabablarga ko'ra bo'lishi mumkin: jigar kasalligi, yuqori revmatoid omil, yallig'lanish, malignite, travma, homiladorlik, yaqinda o'tkazilgan jarrohlik, shuningdek, keksa yosh. [22]
  • Agar namuna tromb hosil bo'lganidan keyin juda erta olingan bo'lsa yoki sinov bir necha kunga kechiktirilsa, noto'g'ri salbiy ko'rsatkichlar paydo bo'lishi mumkin. Bundan tashqari, antikoagulyantning mavjudligi testni salbiy ko'rsatishi mumkin, chunki u trombning kengayishini oldini oladi. Antikoagulyatsion dorilar dabigatran va rivaroksaban D-dimer darajasini pasaytiradi, ammo D-dimer tahliliga xalaqit bermaydi. [23]
  • Namuna yig'ish trubkasi etarli darajada to'ldirilmagan bo'lsa, noto'g'ri qiymatlar olinishi mumkin (agar kam to'ldirilgan bo'lsa, noto'g'ri past qiymat va ortiqcha to'ldirilgan bo'lsa, noto'g'ri yuqori qiymat). Bu antikoagulyantning suyultiruvchi ta'siriga bog'liq (qonni antikoagulyantga nisbati 9: 1 nisbatda to'plash kerak).
  • Imtihondan oldingi ehtimollikni sozlash uchun ehtimollik nisbatlari sezgirlik va o'ziga xoslikdan kelib chiqadi.

D-dimer tahlilini talqin qilishda, 50 yoshdan oshgan bemorlar uchun (bemorning yoshi) × 10 mkg/L qiymati anormal bo'lish ehtimoli mavjud. [24] [25]

Tarixi

D-dimer dastlab 1970-yillarda tasvirlangan va 1990-yillarda ilmiy izlanishlar natijasida uning diagnostik qo'llanilishiga oid ma'lumotlar topildi. [1] [5]

Manbalar

Tashqi havolalar

  • D-dimer - Onlayn laboratoriya testlari
  1. ↑ 1,00 1,01 1,02 1,03 1,04 1,05 1,06 1,07 1,08 1,09 Asakura, Hidesaku; Ogawa, Haruhiko (2020). "COVID-19-associated coagulopathy and disseminated intravascular coagulation". International Journal of Hematology 113 (1): 45–57. doi:10.1007/s12185-020-03029-y. ISSN 0925-5710. PMID 33161508. PMC 7648664. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=7648664.  Manba xatosi: Invalid <ref> tag; name "asakura" defined multiple times with different content
  2. ↑ 2,0 2,1 2,2 Khan, Faizan; Tritschler, Tobias; Kahn, Susan R; Rodger, Marc A (2021). "Venous thromboembolism". The Lancet. doi:10.1016/s0140-6736(20)32658-1. ISSN 0140-6736. PMID 33984268. 
  3. ↑ 3,0 3,1 3,2 3,3 3,4 Ponti, G; Maccaferri, M; Ruini, C; Tomasi, A; Ozben, T (2020). "Biomarkers associated with COVID-19 disease progression.". Critical Reviews in Clinical Laboratory Sciences 57 (6): 389–399. doi:10.1080/10408363.2020.1770685. ISSN 1040-8363. PMID 32503382. PMC 7284147. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=7284147.  Manba xatosi: Invalid <ref> tag; name "ponti" defined multiple times with different content
  4. ↑ Velavan, Thirumalaisamy P.; Meyer, Christian G. (25 April 2020). "Mild versus severe COVID-19: laboratory markers". International Journal of Infectious Diseases 95: 304–307. doi:10.1016/j.ijid.2020.04.061. PMID 32344011. PMC 7194601. https://www.ijidonline.com/article/S1201-9712(20)30277-0/fulltext#%20. Qaraldi: 25 April 2020. D-dimer]]
  5. ↑ 5,0 5,1 5,2 5,3 "Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis". The New England Journal of Medicine 349 (13): 1227–35. September 2003. doi:10.1056/NEJMoa023153. PMID 14507948. https://www.nejm.org/doi/10.1056/NEJMoa023153.  Manba xatosi: Invalid <ref> tag; name "wells" defined multiple times with different content
  6. ↑ "Monoclonal antibodies with equal specificity to D-dimer and high-molecular-weight fibrin degradation products". Blood Coagulation & Fibrinolysis 27 (5): 542–50. July 2016. doi:10.1097/MBC.0000000000000453. PMID 26656897. PMC 4935535. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=4935535. 
  7. ↑ 7,0 7,1 "D-dimer: simple test, tough problems". Archives of Pathology & Laboratory Medicine 137 (8): 1030–8. August 2013. doi:10.5858/arpa.2012-0296-CP. PMID 23899057. 
  8. ↑ "Biochemical markers for the diagnosis of venous thromboembolism: the past, present and future". J Thromb Thrombolysis 30 (4): 459–71. November 2010. doi:10.1007/s11239-010-0460-x. PMID 20213258. 
  9. ↑ Roy. „Elevated D-dimer is Associated with Severity of COVID-19 | Science Trend“ (en-US) (2020-yil 14-sentyabr). Qaraldi: 2021-yil 15-avgust.
  10. ↑ American College of Chest Physicians; American Thoracic Society (September 2013), „Five Things Physicians and Patients Should Question“, Choosing Wisely: an initiative of the ABIM Foundation, American College of Chest Physicians and American Thoracic Society, qaraldi: 6 January 2013.
  11. ↑ Cochrane Vascular Group, ed (August 2016). "D-dimer test for excluding the diagnosis of pulmonary embolism". The Cochrane Database of Systematic Reviews (8): CD010864. doi:10.1002/14651858.CD010864.pub2. PMID 27494075. PMC 6457638. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=6457638. 
  12. ↑ "Clinical utility of D-dimer in patients with suspected pulmonary embolism and nondiagnostic lung scans or negative CT findings". Chest 125 (3): 851–5. March 2004. doi:10.1378/chest.125.3.851. PMID 15006941. PMC 1215466. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1215466. 
  13. ↑ American College of Physicians, presented by ABIM Foundation, „Five Things Physicians and Patients Should Question“ (PDF), Choosing Wisely, American College of Physicians, June 24, 2012da asl nusxadan (PDF) arxivlandi, qaraldi: August 14, 2012
  14. ↑ "Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism". Annals of Emergency Medicine 57 (6): 628–652.e75. June 2011. doi:10.1016/j.annemergmed.2011.01.020. PMID 21621092. 
  15. ↑ "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". European Heart Journal 29 (18): 2276–315. September 2008. doi:10.1093/eurheartj/ehn310. PMID 18757870. 
  16. ↑ "Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians". Annals of Family Medicine 5 (1): 57–62. 2007. doi:10.1370/afm.667. PMID 17261865. PMC 1783928. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1783928. 
  17. ↑ Reference Values During Pregnancy at perinatology.com. Retrieved October 2014.
  18. ↑ "PURLs: It's time to use an age-based approach to D-dimer". The Journal of Family Practice 63 (3): 155–8. March 2014. PMID 24701602. PMC 4042909. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=4042909. 
  19. ↑ "Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians". Annals of Internal Medicine 163 (9): 701–11. November 2015. doi:10.7326/M14-1772. PMID 26414967. 
  20. ↑ „Clinical Education Center“. Quest Diagnostics. Document FAQS.149 Version: 3 effective 07/23/2019 to present
  21. ↑ "Comparison of diagnostic accuracies in outpatients and hospitalized patients of D-dimer testing for the evaluation of suspected pulmonary embolism". Clinical Chemistry 49 (9): 1483–90. September 2003. doi:10.1373/49.9.1483. PMID 12928229. 
  22. ↑ "Factors associated with positive D-dimer results in patients evaluated for pulmonary embolism". Academic Emergency Medicine 17 (6): 589–97. June 2010. doi:10.1111/j.1553-2712.2010.00765.x. PMID 20624138. PMC 3538031. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3538031. 
  23. ↑ "Effects on routine coagulation screens and assessment of anticoagulant intensity in patients taking oral dabigatran or rivaroxaban: guidance from the British Committee for Standards in Haematology". British Journal of Haematology 159 (4): 427–9. November 2012. doi:10.1111/bjh.12052. PMID 22970737. 
  24. ↑ "The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded". Thrombosis and Haemostasis 107 (1): 167–71. January 2012. doi:10.1160/TH11-08-0587. PMID 22072293. 
  25. ↑ "Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts". BMJ 340: c1475. March 2010. doi:10.1136/bmj.c1475. PMID 20354012. PMC 2847688. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2847688.  
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