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PROBLEME DE DIAGNOSTIC

VSCOZITATEA PLASMATIC N PRACTICA

CLINIC
Dr. Manole Cojocaru, Dr. Inimioara Mihaela Cojocaru
Spitalul Clinic Colentina, Bucureti

REZUMAT
Reologia sanguin studiaz curgerea i deformarea elementelor figurate ale sngelui. Comitetul Internaional pentru Standardizare n
Hematologie (ICSH) a publicat metodologia standard pentru msurarea vscozitii sngelui. n prezent, aplicaiile clinice ale reologiei
sanguine se suprapun urmririi reaciei de faz acut la pacienii cu afeciuni inflamatorii.
Cuvinte cheie: vscozitatea plasmatic, viteza de sedimentare a eritrocitelor, vscozimetre, sindromul de hipervscozitate

ABSTRACT
Clinicians use this test to demonstrate and monitor hyperviscous states, the viscosity measurements is the only test available. The
plasma viscosity has fewer variable and results correlate better with clinical conditions than the erythrocyte sedimentation rate
(ESR). We hope that we are able to play an important role for standardization of plasma viscosity. Plasma viscosity can be quality
controlled with absolute standards, but only secondary standards can be applied to the measurement of ESR. In the modern
laboratory as a variety of viscometers are now available, from point of-care single sample analysers, to laboratory information
management system (LIMS) linked, fully automated, 200 test station load and walk-away plasma viscometers.
Plasma viscosity can be performed on the same sample as the full blood count (FBC), while the ESR requires a separate sample. The
plasma viscosity test uses only 50 ml of plasma and takes 30 seconds for a result. An ESR must be carried out within four hours of the
sample being taken from the patient, whereas a plasma viscosity sample can be stored or in transit for up to seven days before test.
Plasma viscosity has the advantage over the ESR for predicting flare ups and in the monitoring of treatment with glucocorticoids.
Key words: plasma viscosity, erythrocyte sedimentation rate, viscometers, hyperviscous states

REACIA INFLAMATORIE DE FAZ ACUT

Reacia de faz acut (RFA) este probabil
situaia cea mai frecvent studiat n practica clinic.
Aceasta nseamn reacie inflamatorie sistemic cu
leziuni tisulare locale, care este mediat de citokine
proinflamatoare (IL-6, TNF-, etc.), eliberate n
circulaie de ctre monocite/macrofage la locul
stimulului inflamator.
Citokinele proinflamatoare stimuleaz ficatul s
sintetizeze proteine de faz acut (PFA), stimuleaz

hipotalamusul s produc starea febril, stimuleaz

mduva osoas s elibereze polimorfonucleare
neutrofile i activeaz sistemul imun.
n practica clinic se dozeaz unul sau mai muli
meditori ai RFA. Unele proteine macromoleculare
de faz acut, ca fibrinogenul i unele globuline
induc agregarea i sedimentarea eritrocitelor (VSH
este crescut).
n 1988 Comitetul Internaional pentru Standardizare n Hematologie (ICSH) a publicat metoda
standard pentru determinarea VSH. ICSH a abordat

Figura 1
Efectul activrii monocitelor/macrofagelor la locul inflamaiei tisulare cu eliberarea de
citokine n circulaie i stimularea consecutiv a ficatului, hipotalamusului i mduvei
osoase

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i alte teste ca vscozitatea plasmatic, agregarea

eritrocitelor i dozarea proteinei C-reactive (CRP).
Termenul de faz acut poate induce n eroare
prin faptul c pacieni cu boli cronice ca poliartrita
reumatoid prezint frecvent alterri recurente sau
persistente ale fazei acute. Dac clinicianul
dorete s urmreasc modificrile pe termen scurt,
CRP constituie fr ndoial cel mai indicat dintre
teste, deoarece concentraia sanguin de CRP crete
n 6-10 ore dup inflamaie, iar dac tratamentul
este benefic, CRP scade dup 48 de ore. Dozrile
repetate de CRP sunt utile n special pentru urmrirea evoluiei n faza acut la pacientul cu poliartrit
reumatoid sau pentru a monitoriza rspunsul la
antibiotice la pacientul cu infecie bacterian i care
prezint un deficit imun.
n cazul pacienilor imunodeprimai, semnele
clinice ale inflamaiei sunt absente: lipsa neutrofilelor de ex. poate s mascheze simptomele localizrii unei infecii bacteriene cu risc fatal.
Dozarea de CRP este mai puin util pentru a
urmri alterrile pe termen lung, datorit timpului
de njumtire scurt (6 ore), concentraia sanguin
poate s revin la normal n faza cronic a bolii. n
aceste condiii, proteinele cu rspuns latent, ca fibrinogenul (timpul de njumtire 4-6 zile) i
globulinele reflect mult mai bine starea clinic. Este
posibil, dar puin economic dozarea fibrinogenului,
orosomucoidului (alfa 1 glicoproteina acid), alfa
2 macroglobulinei i imunoglobulinelor IgG i IgM.
VSH se bazeaz pe sedimentarea eritrocitelor;
orice anomalie a eritrocitelor influeneaz rezultatul
VSH (ex. anemia va accelera sedimentarea eritrocitelor).
n poliartrita reumatoid, efectul anemiei se altur efectului proteinelor de faz acut, rezultatul
fiind creterea VSH. Vscozitatea plasmatic nu este
infuenat de anemie.
Comitetul Internaional pentru Standardizare n
Hematologie recomand metoda standard de msurare a vscozitii cu vscozimetrul capilar manual. Exist o variant semiautomat, precum i o
alt variant automat. Vscozitatea plasmatic
poate fi astfel msurat n cteva minute.
Pacienii cu policitemie adevrat primar sau
secundar prezint masa eritrocitar i hematocritul
crescute, de asemenea, hipervscozitate. Pentru
monitorizarea policitemiei, msurarea vscozitii
sngelui total este un indicator mai bun dect msurarea hematocritului.
Reologia sanguin joac un rol important n afeciunile vasculare. Pacienii cu boli ale arterelor (cere-

REVISTA MEDICAL ROMN VOL. LV, NR. 1, AN 2008

brale, coronariene sau periferice) prezint creterea

vscozitii sngelui.
Creterea concentraiei plasmatice a fibrinogenului provoac creterea vscozitii plasmatice.
Vscozitatea sngelui depinde n principal de
hematocrit i vscozitatea plasmatic. Concentraia
n fibrinogen este un factor determinant al vscozitii plasmei, Concentraia fibrinogenului n plasm
este un factor predictiv mai util dect concentraia
colesterolului. Modificrile reologice afectez debitul sanguin la nivelul arterelor. Hematocritul, concentraia fibrinogenului i numrul de leucocite
constituie factori de risc pentru accidentul vascular
(rspuns inflamator secundar n cadrul aterosclerozei
fr manifestri clinice).
Pacienii cu diabet zaharat de obicei prezint
modificri reologice. Creterea vscozitii plasmatice, vscozitii sngelui total i agregarea eritrocitelor reflect creterea concentraiei plasmatice a
fibrinogenului i a globulinelor de faz acut. Pacienii cu diabet zaharat care prezint complicaii
vasculare sunt predispui modificrilor reologice,
care pot s prezinte o etiologie similar cu aceea a
alterrilor reologice din ateroscleroza fr diabet
zaharat, un control metabolic deficient poate s
intensifice modificrile reologice.
Vscozitatea plasmatic (valori de referin)
1,380,08 uniti relative
Vscozitatea seric (valori de referin)
1,260,08 uniti relative

SINDROMUL DE HIPERVSCOZITATE
PLASMATIC
Pacienii care prezint mielom sau macroglobulinemie Waldenstrm pot s prezinte hipervscozitate plasmatic. Paraproteinele cresc agregarea
eritrocitelor (VSH depete 100 mm/or). Msurarea vscozitii sngelui la aceste cazuri s-a dovedit puin util. Cnd vscozitatea plasmatic este
crescut, pacienii prezint simptome respiratorii,
cardiovasculare, oculare sau neuropsihice. Vscozitatea plasmatic folosete la monitorizarea tratamentului cu glucocorticoizi (1-6).

CONCLUZII
Determinarea vscozitii plasmatice este superioar vitezei de sedimentare a eritrocitelor.
Se impune reintroducerea cercetrii reologiei
sanguine care prezint diverse aplicaii clinice.

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BIBLIOGRAFIE
1. Benson B Plasma viscosity versus erythrocyte sedimentation. Why
are we still doing ESRs? European Clinical Laboratory 2005; 23: 1011.
2. Lowe GDO Should plasma viscosity replace the ESR? British
Journal of Haematology 1994; 86: 6-11.
3. Ng T Erythrocyte sedimentation rate, plasma viscosity and Creactive protein in clinical practice British Journal of Hospital Medicine
1997; 58: 521.

4. Stuart J Applications cliniques de la rheologie sanguine. Essentialia

1991; 30: 9-15.
5. Somer T Rheology of paraproteinaemias and the plasma
hyperviscosity syndrome Baillieres. Clinical Haematology 1987; 1(3):
695-723.
6. Gudmundsson M, Nordborg E, Bengtsson BA, Bjelle A
Plasma viscosity in giant cell arteritis as a predictor of disease activity.
Annals of the Rheumatic Diseases 1993; 52: 104-9.

News Reuters Medical

Diabetic weight-loss plan yields long-term success
SAN FRANCISCO (Reuters Health) - Researchers at the Joslin Diabetes Center report that a
12-week weight-loss program they devised for patients with type 2 diabetes continues to have a
positive, long-lasting effect on weight loss 1 year later, long after patients are off on their own.
The findings of a 1-year follow-up of the 12-week Why WAIT weight-loss program were
presented here this week at the 68th Annual Scientific Sessions of the American Diabetes
Association by principal investigator Dr. Osama Hamdy.
The study involved 85 patients with type 2 diabetes, average age 54 years and a disease
duration of approximately 10 years. The average weight was 235 pounds, average body mass
index (BMI) was 38.4, average hemoglobin A1C was 7.5 percent, and average waist
circumference was 46.7 inches.
Patients completed the 12-week diet and exercise program and were followed for another
year without structured intervention.
Twelve weeks of the intervention resulted in an average weight loss of 24.6 pounds
more than a 10 percent reduction a waist circumference reduction of 3.6 inches, and an
average drop of 0.9 percent in A1C to 6.6 percent, indicating good control of blood sugar.
After 1 year of follow-up, weight remained lower than before the patients began the diet by
more than 18 pounds a long-term loss of 7.6 percent. However, A1C levels increased to
approximately 7.4 percent.
Overall, 55 percent of participants continued to lose weight on their own, Hamdy said. The
other 45 percent gained back approximately 5 pounds, but their final weight remained 2.0
percent lower than their pre-diet weight.
Blood pressure, both top and bottom readings, were significantly lower at 12 weeks and 1
year compared with pre-diet readings, he added. Cholesterol levels improved significantly at
12 weeks, but had returned to pre-diet levels at 1 year, except for HDL, the good cholesterol,
which remained significantly higher.
Hamdy said there was evidence that kidney function improved as well, with a small decrease
in protein in the urine.
The clinical implications are enormous, Hamdy told Reuters Health. Weve been glucosefocused for a long time. We need to be weight-focused. We need to focus on the cause of the
problem and not the result of the problem.
The mainstays of the Why WAIT? program are a low carb diet and tailored exercise. We
use significant calorie reduction and reduce carbohydrates to 40 percent of calories and increase
protein to 30 to 40 percent of calories this is key for patients to maintain muscle, Hamdy
said. In addition, we teach patients how to exercise, especially the type and the amount, and
make sure it is age-appropriate. This is very important.
He added, The main reason that patients regain weight is that they decrease their protein
intake and dont exercise as much. The weight they gain is mostly fat, and visceral fat.
There is also an economic benefit. Weight reduction leads to a reduction in need for
medications. We saw a 65 percent-reduction in medical costs, or about $560 per year per
patient and patients feel better, Hamdy reported.