N g h i e n curu Y hpc Y Hoc TP. H o Chi Minh * Tap 20 * Sfi 1 * 2016
ROI LOAN LIPID MAU TREN BENH NHI M A C HOI CHIJ^JG T H A N HLf KHANG STEROID
Ho Thi Ngoc Bich*, Vu Huy Tru**
TOMTAT
B^t van de: Bat thuang lipid mdu la bim hien thuang gap tren benh nhdn mac hoi chieng than hu khdng steroid. Dim nay 1dm tang nguy aj binh ly mach vdnh vd thiic day su tim trim dia binh than man.
Muc tieu n^iien cCot: Phdn tuh tijth trang rm loan lipid mdu trin binh nhi mdc hdi chimg tlian hu Ididng steroid tneac vd sau 3 Ihang dieu. tri.
Dot tugng vd phucmg phdp nghien cdu: Nghiin deu mo td hdng loat ca trin 27 binh nhi mac hdi chieng than hu khdng steroid tai Binh Viin Nhi Ddng 1 tie thdng 6/2014 dgn thdng 4/2015.
Kei qwu Nong dd Cholesterol todn phdn tang 177%, triglycerid tang 350%t, LDL-C tang 186% so v&i tinh thu&ng. Khong co mm tuang quan giiea bilan lipid vdi turn, gi&i, th&i diem khdng steroid hay sang thucmg ^di phSu benh. O nhom khdng lui benh, nong do cholesterol todn phm, LDL-C vd triglycerid dm cao han ngi^ng binh thu^g ro rit. Bilan lipid van con trong bed. thu&ng a mdt sS^birih nhdn lui binh hoan todn.
Ket ludru Tai thM diem khdng stermd, tat cd benh nhdn deu co ndng do Cholesterol todn phan, triglycerid vd LDL-C tang ddng ke. Sau 3 thdng dieu tri, bilan lipid van con cao ro ret a nhom khdng lui binh. Trong nh&m lui binh, bilan lipid giam di ddng ktnhung mot so'van nam trong ngu&ng b^ thttang.
T^ khoa: Hdi chieng th&n hu khdng Stermd, bilan lipid mdu, bat thu&ng lipid mdu.
ABSTRACT
DISUPIDEMIA IN CHILDHOOD STEROID RESISTANT NEPHROTIC SYNDROME Ho Thi Ngoe Bieh, Vu Huy Tm* Y Hoc TP. Ho Chi Minh * VoL 20 - No 1 - 2016:76 - 80 Background: Dislipidemia is common finding in steroid-resistant nephrotic syndrome. It may predispose to the development of atherosclerosis and progression cf chronic rmal failure.
Objectives: To analyze lipid pnrfHe in pediatric patients zmlh stercrid-resistant nephrotic syndrome b^e and after 3 months of treatment.
Method: Case-series study included 27 patimts with steroid resistant nephrotic syndrome at Children Hospital 1 from June 2014 to april 2015.
Results: There was dgnificant rise in total cholesterol (177%), triglyceride (350%) and LDL-C (186%) tfwn normal level. There was no correlation between the lipid profile and age, gender, time cf steroid resistance or pathologiad lesions. In no remission group, serum total cholesterol, IDL - C and triglyceride were significantly higher than normal. Some patimts in complete remission group, lipid prcrfile remains in dbnonrud range.
Conclusions: In our study, at the stari of steroid resistance, cholesterol level, triglycerides and LDL - C were significantly increased. After 3 months cf therapy, in no remission group, lipid profiles remained abnormd.The lipid profiles reduced significantly vnth resolution cf protdnuria. However,there was persistent elevation in cholesterol, LDL-C levelsin cases of remission group.
Key words: steroid resistant nephrotic syndrome, lipid profile, dyslipidemia
* Benh Vien Nhi Dong 1, TP.HCM **B6 mon Nhi, Dai hoc Y Dupe TP Ho Chi Minh Tdc gid liin lac: BS. Ho Thi Ngoc Bich DT: 0908136873 Email: [email protected]
Y Hoc TP. H o Chi Minh * Tap 20 * S£i 1 * 2016 Nghien ctru Y hoc
D A T V A N D E
Hpi chiing than h u eung voi dieu tri lic che mien dieh keo dai dan d m nhieu biai chiing va tac dung phy. Mot trong nhiing bat thucmg do la tinh trgng rcS lo?n lipid mau®. Roi loan nay ttiuong thay trong giai doan ho?t dgng va mat di khi d?t lui b?nh. Tuy nhien, bat thuong lipid mau keo dai van dugc ghi nhan trenmgt sobenh nhan da dgt duoc lui benh va dgc biet la b^hh nhan mac hoi ehiing th$n hu khang steroid^^).
Bat thuang lipid mau lam tang ro r ^ nguy co benh ly m^eh vanh. Ordonez va cong su eho thay mot ti le tucmg doS cao b | n h nhan hoi chiing than h u bi nhoi mau co tim hay chet vi benh mach vanh voi nguy eo tuong doi tit 5,3 dan 5,5. Mot nghien ciiu khac bao eao ty le mac benh tim thieu mau cue bo tang gap 85 lah 6 benh nhan hoi ehiing th$n hu. Nguy eo tirong doi nhoi mau eo tim g&p 5,5 va nguy eo tii vong do benh tim gap 2,8 Ian 6 nhom h6i chiing than hu so voi nhom ehiing. B%n canh do, bat thuong lipid mau eon thiie day su tim trien ciia benh fiian man da dugc chiing minh qua nhieu nghien eiiui^'^.
Van de dieu trj bat thucmg lipid mau tren benh nhi hoi ehiing than h u eon nhi«i ban eai.
Cim CO them nhieu nghien eiiu eo den ehiing so sanh hi$u qua va an bDan ciia nhiing thuoc lam gjam lipid mau tren benh nhan hoi chiing than Tai Viet Ncun, viec danh gja va theo doi tinh trang bat thucmg lipid mau 6 benh nhan hoi chiing t h | n hu it dugc quan tam.
Vi nhmig ly do tren, chung toi tiai hanh nghien ciiu nay de gop phan danh gia dac diem r65 loan lipid mau tren tre mac hoi ehiing than hu khang steroid.
Muc tieu
- Phan tich dac diem roi loan lipid mau tren benh nhi mae hpi ehiing than h u tai thoi diein khang steroid.
- Xac dinh moi Uen quan giiia bilan hpid
mau voi eae yeu to gioi, thoi di&n khang steroid nong do albumin mau va sang thuong gjai phau benh.
- Khao sat dae dian rm loan lipid mau tren cac nhom benh nhan c6 cac miie dp dap iing khac nhau sau 3 tiiang dieu tri.
D6lTOt](NGPHUt)!NGPEIAPNGHIENCtllJ Thiet ke nghien ciru
Nghien eiiu mo ta hang loat ca Dan s d chgn m a u
Benh nhi duoe xac dinh hoi ehiing than h u khang steroid nhap khoa than benh vien Nhi Dong 1 hx 1/6/2014 doi 30/4/2015.
Tieu chi dMi vdo
Benh nhan mac hpi chiing than h u khong dat dugc tieu chuan lui benh hoan toan sau dieii tri Prednisone 2 mg/kg/ngay trong 8 tuah Tieu dli loai ra
Hpi chiing than h u kem cac bieu hien god y nguyen nhan thii phat, benh n h a n co tien can CO roi loan lipid m a u m a n g tinh gia dinh.
Toan bp dii lieu dugc xix ly bang phan mem IBM SPSS Statisties 21.0.
Thdng ke mo ta
Biai dinh lugng: Mo ta bang trung binh va dp lech chuan neii so lieu phan phoi chuain, bang trung vi neii solieu khong phan phm ehuan.BiOT dinh tinh: Mo ta bang t ^ so va ti le phan tram.
l l i d n g ke phan tich
Phep kiem t so sanh hai tmng binh neii phan phm chuan, kimi sign so sanh hai trung binh neii so lieu khong co phan phcS e h u ^ Chi binh phuong so sanh cac li le.
KET QUA
Nghien eiiu 27 truong hcrp hoi chiing than h u khang steroid 6 tre em tai khoa thgn benh vien Nhi Dong 1 t u thang 6/2014 den thang 4/2015, chiing toi ghi nhan dugc cac ket qua sau day.
Nhi Khoa 77
N ^ u e n cTjfu Y h p c Y H o c T P . H d C h i M i n h * T ? p 20 * So 1 * 2016
Bang 1. Nong do bilan lipid mdu tai thai diem khdng steroid so vai
Cholesterol todn phan Triglycerid
LDL-C HDL-C
Gid tri d o dipgrc(n=27) 555,35 ± 227,2 466,4(354-748.7) 291,85(235,38-454,6)
85,45 ± 28,75
nguang binh thuang Ngifong binh thi/^ng
200 130 130 45
P 0,000 0,000 0.000 Bang 2. So sanh bilan lipid giiea cdc rdiom sang thuang giai phau binh
Cholesterol todn phan TriglytKrid
LDL-C HDL-C
KMquagiaiphaub^nh Sang ttiuvng tdi thieu(n = 12]
633,8 ± 2 5 7 ^ 625,93 ±371,88 423,65 ±226,92 87,23 ±32,67
Xcy hda cdu th$n CMC b$ tteig p h ^ (n = 10) 510 ±219,7
615,08±451,28 353,02±177,93 86,3 ±32,41
P 0,24 0,95 0.45 0,895
f
'i
Bang 3. Bilan lipid giiia hai nh&m khdng s&m vd khdng muon
Chdestertil toan phan Triglycend
LDL-C HDL-C
Thoi d i ^ khang tOldngs6in(n = 16)
475,9(361,5-651,03) 479,7(317,23-744,5) 279,1 (220-360,5)
85.45 ±28.61
Klidngmu$n(n = 11) 598,07 ±262,96 423.9(354-776,1)
428 ±205.51 86.46 ±30.34
P 0.521
1.00 0.146
0.999
*; Marm-Vi/hitney U
Bang 4. Bilan lipid giiea 2 nhom nam vd nie
Cholesterol todn phan Tnglycefid
LDL-C HDL-C
Gi6itinh Nir(n = 11)
586.79 ±228.91 806,48±416.32 375.53 ±175,5
88,49 ±30,99
Nam (n = 16) 475,9(337,28-665,3)
383,6(247,8-481,7) 297,6(225.93-468.73)
83,56 ±28,14
P 0,537 0.006 0.958 0.679
••; Mflim-VWritney U
Chiing toi theo doi dugc 19 benh nhan sau 3 thang d i « i tri, va thu dirge k ^ qua duoi day Bang 5. Bdan lipid mdu giita 3 nhom ddp irng dieu tri khac nhau
Cholesterol toan phan Triglycend
LDL-C HDL-C
Lui bfnh Iraan todn (n =4) 290.93 ±85.34 332.98 ±239,77 219.25±76.86 53.68 ±13.03
Lui ti^nh m$t phan (n =4) 238.05 ±42.51 163.98 ±116.92 123.35 ±27,8
56.45 ±29.3
Khang lui b#nh(n =11) 457.7 ±254.76 398.3 (120.4-729i)
265,36 ±131.08 71.76 ±23.02 Bang 6. Bilan lipid giiea 2 nhom co lui binh vd nhom khdng lui bmh
Cholesterol todn phan Triglycerid
LDL-C HDL-C
Dap ung dilu b i Lui b#nh hodn loan iiay mot phIn (n = 8)
264.49 ±68.52 248.48 ±196,61 171,3±73,66 55,06 ±21,05
Khong lui benh (n = 11) 457,7 ±254,76 398,3(120,4-729,2)
265,35±131,08 71,76 ±23,02
P 0,048 0,186 0,086 0,124 Bang 7. Bilan lipid 4 benh nhan lui binh hoan toan
Cholesterollp Triglycerid
LDL-C HDL-C
Benh nhan 1 Ban d i u
304,6 466,4 192,6 34,7
3 bung 241,6 681,4 281,8 35,9
Benh nhdn 2 B a n ^ u 318.1
296.5 208,4 78,0
3 Ihang 244.3 163.7 138.2 68.3
Benh nhan 3 BandSu 955.7
421.3 790.1 130.1
3thang 259.4
94.7 171.0 53.7
B ^ h n h a n 4 Banddu
528.8 472,6 301.9 44.8
3tt<ang 418.4 492.1 286 66.8 1
Y Hpc TP. Hd Chi Minh * Tap 20 * So 1 * 2016 Nghien ciiu Y hoc
B A N L U A N
Ndng dp bilan Hpid trong nhom nghien cuu tai thai diem khang steroid:
Tat ca benh nhan deii eo nong do cholesterol toan phSn, triglycerid, LDL-C eao hon ro ret so voi binh thuang va su khac biet nay eo y nghia tiiohg ke (P = 0,000)Pi. Trong do: nong do cholesterol toan phan trung binh tang 177%, nong do triglycerid tang 350%, LDL tang 186%
so voi nguong bat thircttig. Nong dp HDL-C khong giam ma eiing eo xu huong tang len.
Ket qua nay phu hgp voi nhung nghien ciiu ciia cac tac gia khac: Theo Dnyanesh, tat ca eae gja tri nay deu eao hon han so voi binh thucmg va eo y nghia thong ke (P= 0,001). Nong do HDL thay doi khong eo y nghia so vdi gja trj binh thuong*^'. Jameela A, Kari va cong su cung eho thay CO su tang dang ke nong dp cholesterol, triglycerid va LDL mau d nhom hoi ehiing than hu khang steroid so voi nhom chiing eung nhu nhom hpi chiing than h u nhay steroid. Ndng do HDL-C trung binh trong nhom nay eiing eao hon so voi nhom chiing^^. Theo mot nghien ciiu khac ciia Kumia Dwi Astuti va epng su: Nong dp cholesterol toan phan, LDL deu tang eo y nghia 6 hpi chiing than h u khang steroid. Nong dp HDL thay doi khong eo y n ^ a P ^ l Mdi lien h^ gjiia bilan Hpid mau va thai diem khang steroid, g^oi, ndng dp albumin mau, sang thuong giai phau benh.
Khong CO su khac biet dang ke nao ve n&ig do bilan lipid gjiia eae nhom sang fhuong giai phau benh eung nhu thoi diem khang streroid.
Nong dg triglycerid giua hai nhom nam va nii khac nhau c6 y ngjiia thraig ke (P = 0,006).
Ben c^nh do, it eo sa khac biet ve nhiing thanh pheui khac eiia bilan lipid gjiia 2 nhom benh nhan nam va nii. Nhiing nghien cihi khae khong cho thay s^x khae biet ve nong dp cholesterol toan phan, triglycerid, LDL hay HDL dang ke giiia 2 nhom nam va nii CI.*AI4)_
Su tuong quan giiia nraig dp cholesterol toan phan va nong dp albumin mau la tuong quan nghich, kha ehgt (R = - 0,628, P = 0,000). Iheo Sreenivasa va epng su, co moi tuong quan nghich giiia nong dp albumin va cholesterol mau va su tuong quan nay co y nghia thong ke (p = 0,000) ("). Jameela A. Kari, Joven va Dnyanesh deu cho tha'y mc5 tuong quan nghich giiia ndng dp albumin va cholesterol maut*^^.
Tuong quan giiia ndng dp LDL-C mau va ndng dp albumin mau la tuong quan n ^ c h va su tuong quan tayea tinh nay co y nghia thong ke (P = 0,01). Dong thoi eo su tuong quan nghich giua ndng dp albumin mau va ndng dp triglycerid mau nhung khong co y nghia thong ke (P = 0,07), khong eo moi Hen he giiia nong dp albumin mau va HDL-C. Jameela A. Kari ciing eho Ihay tuong quan nghich giua ndng do triglycerid va albumin mau (P < 0,01), tuong quan nghich giua nong dp LDL va albumin (P <
0,004)'**. Theo Dnyanesh va epng su, khong eo mca lien he tuyen tinh giiia nong dp HDL-C, VLDL mau va nong dp albumin mau'*'.
So sanh bilan Hpid giiia 3 nhom b^nh nhan voi muc dap tmg dieu tn khac nhau:
Nong do cholesterol toan phan, LDL, triglycerid, HDL tai thoi diem 3 thang sau dieu tri giam dang ke so voi thcri di&n khoi benh. Tti do cho thay rang dieu tri benh nen co anh huong dSi su thay doi ciia bilan lipid mau tren benh nhan hpi ehiing than hu.
Khi xet d&x tCmg miic dap iing khae nhau cho thay: Trong nhom khong lui benh, nong dp cholesterol mau 6 tat ca benh nhan deu bat thuang v^ cao hon han nhom con lai (P < 0,05).
Trong khi do, ndng do triglycerid, LDL-C va HDL-C ding eao hon nhom co dap iing nhung su khac biet nay khong co y nghia thong ke.
Bilan lipid cung khong ve binh thucmg sau khi d?t dugc lui benh 6 mot so benh nhan trong nhom nghien eiiu.
Theo nghien ciiu eiia mpt sd tac gia khac cho thay mot so'ket qua nhu sau: Theo Dnyanesh va
Nhi Khoa
Nghien cuu Y hqc V HQC TP. m CM Minh * T|p 20 * S« 1 * 2016 epng su, tren nhom hoi chiing than hu tai phat,
ndng dp cholesterol eo giam nhung van con cao keo dai (p= 0,001)^'. Theo Merouani_va cong su, 48% truong hpp tre em hoi ehiing than h u co cholesterol toan phan va LDL-C a miic tr&i 95 bach phan v; theo tuoi du da dat dupe lui benh.
Tre em tai phat thuong xuyen co nhieu kha nang CO bat thuang lipid mau trong qua trinh hoi phuei^^. Jameela A. Kari va epng su cung ghi nhan dupe nong dp cholesterol toan phan, HDL, LDL deu cao hon 6 nhom hpi chung th$n h u khang steroid khong lui benh voi cac thuoc lic che mien dieh khac so voi nhom khang steroid nhung sau do lui benh voi thuoc khae. Hon niia, nong dp trung binh cac chat nay o nhom lui b^nh eiing eon eao hon han so voi binh thuong.
Tuy nhien ket qua nay eiing khong co y nghia thong ke'^.
KETLUAN
Cholesterol toan phan tang 177%, triglycerid tang 350%, LDL t5ng 186% so v6i nguong binh thuong. Khong co moi tuong quan giua bilan lipid voi thoi diein khang steroid hay sang thuong giai phau benh. Co mm tuong quan nghich gjiia nong dp albumin mau va nong dp cholesterol toan phan eiing nhu ndng dp LDL-C.
Nong dp Cholesterol toan phan khac biet eo y nghia giiia nhom lui benh va nhom khong lui benh. Trong nhom khong lui benh, nong dp cholesterol tp, LDL-C va triglycerid deu cao hon binh thuong va su khae biet nay co y nghia thraig ke. Sau 3 thang dieu tri, bilan lipid van eon cao ro ret 6 nhom khong lui benh. Trong nhom lui benh, bilan Upid giam di dang ke nhtmg mpt so truong hpp van nam trong nguong bat thuong.
TAI LIEU THAM KHAO
1 A d u EM (2013), "Senun lipid profile abnormahties among patients with nephrotic syndrome". International Journal of Medicine and Biomedical Research, 2{1),I3-17.
Z Astuti KD, Muhammad M R MeUyana O (2015), "Correlation between lipid profile and C-reacUve protein n children vnth nephrotic syndrome", Paedialnca Indoneaana, 55(1), 1-6.
3 Coleman JE, Watson AR (19%), "Hypedifridaemia, diet and simvastatm therapy m steroid-resistant nephrotic syndrome of childhood". Pediatric nephrdogi/, Berlin, 10(2), 171-174 4 Dnyanesh DK, et al {20I4)/'A Study of Serum Lipids in
Nqjhrolic Syndrome in C M d r s i " , lOSR Journal of Dental and Medical Sciences, 13 (3),l-6.
5 Eiland I S , Luttrdl PK (2010), "Use of Statins for Dyslifndemia in the Pediatac Population", / Pediatr Pharmacol Ther. I5(3],160- 172,
6 Eknoyan G, et al (2012), "Clinical Practice Guideline for Glomerulonephritis^, K i d n ^ disease outcome ^obal improving, 2(2).
7 Holmes KW, Kwiterovidi P O (2005), " Treatment of Dyslipidemia in Children and Adolescents", Current Cardiologi/
Reports^, 445456.
8. loven J, Villalxma C, Vilella E, Masana L, Alberti R, Valles M (1990), "Abnormalities of lipoprotein metabolism in patients witti nei^uolic syndrome", Tlie New En^and }oumal ^Medidne, 579-584.
9 Kan JA, et al (2012), "lipoprotein (a) and oflier dysbpidemia in saudi children with nephrotic ^rndnnne", Jourmd (f IMBi Sciena, 2(6), 57-63,
10. Kong X Yuan H, Fan J, l i Z, Wu T, Jiang L (2013), "lipid- lowering agents Cor nephrotic ^ n d r o m e " . The Codirane dalabale of systematic review.
11. IQishnaswamy D, Induinati V, et al (2011), 'Senim pio^nSt initial and follow-up lipid profile in children with nephrotic syndrome", Intematicmal Journal ot A [ ^ e d Biology and Pharmaceutical Technology, 2(3), 59-63
12. Merouani A, Levy E, Mongeau JG, Robitaille P, Lambert M, Delvin EE (2003), "HypErlipidemtc profiles during remissiiHi in childhood idiopathic nephrotic syndrome", Omica/
Biochemistry. 36(7),571-574.
13. Sanjad Sa, Al-Abbad A, Al-Siorafa S (1997), '•Management of hyperliiMdemia in children with refiractory nephrotic syndrome: tfie rffect of statin ftierapy". The Jourmd Of Pediatncs, 130(3),470474.
14. Sreenivasa B, Sunil Kumar P, Suresh Babu MT, Ragavendra K (2015), "Serum lipid profiles d u n n g onset and remission of steroid sensitive nephrotic syndrome in duldren", BMR Medidne, 1(1), 1-4.
13, Toto RD, et al (1993), "Mechanisms and treatment of dislipidemia of renal diseases". Current Opinion m Nephrology
& Hypertension, 2(5), 784-790.
Ngdy nhan bd bdo: 20/11/2015 Ngdy phdn biin nhdn xet bdi baa: 22/11/2015 Ngdy bdi bdo dime d&ng: 20/01/2016
