Y HOC VIET NAiVI THANG 5 - SO DAC BlgT/2012 hdnh, 764(5).
Che Thj Bich Thuy (2003), Tim hiiu mirc chi phi diiu tri cita mgt si binh phdi can thiep bdng phdu thugt thdng qua chi trd bdo hiim Ytitgi Thita Thien Hue. Luan van thac sT y hpc, Tnrong Dai hgc Y - Dugc Hue, tr 41,74,75.
13. Nguyin Thi Xuyen & Cong sy (2007), Phi
^ dich vu binh vien phucmg thuc thanh .odn
^ trgn gdi theo trudng hgp benh. Nha Xuit , ban Y hgc, Ha Ngi.
14. Arthorn Riewpaiboon (2008), Cost Analysis in Health Care. Mahidol University, Bangkok Thailand, tr.9.
imc TiNH MUC LOC CAU THAN 0 BENH NHAN DAI THAO D U A N G TYP 2 QUA SO SANH GIUA CONG ThUC MDRO VA COCKCROFF-GAUU
Tran Van Huy*
T O M T A T
Mi^c dich. U'6'c tinh mi>c Igc cau th^n (MLCT) o b$nh nhSn d&\ thSo dubrig typ 2 dieu tii tgi b$nh vien tinh Kh^nh HoS b§ng cong thCcc MDRD vS Cockcroff - Gault (CG) qua d6 so s^nh SM" khSc nhau giOa hai c6ng thO'c nay, D6I t i l i n g B$nh nhan dang di6u trj tgi b?nh vi$n tinh KhSnh H6a ti> 9/2009- 4/2010 c6 chan doSn d&\
IhSo du-evng typ 2 Kfit qua 107 bgnh nhSn DTO typ 2 vdi tu6i trung binh 67,87 ± 12,19 d u g c nghien c u u ghi nh^n IVILCT tmng binh theo MDRD Id 48,77 ±27.40 {mL/phut/1,73m^ da) vS theo c6ng thi>c Cockcroft - Gault 43,96 ± 25,12 (mUphCit/1,73m^). Ty 1$ BTM tO' giai doan lll-V theo MDRD c6 ty le 71.96% vS CG IS 84,11%
Ph6i hg-p giO'a MLCT vS dtnh gid nucyc tieu ghi nh$n ty 1$ BTM theo MDRD Id 83.17% vS theo CG IS 88.78%. Tuy nhi&n trong ISm sSng c6 11,21% chan dodn BTM o- b^nh nhan DTD dang (Ji^u trj. GiO'a 2 cong thO'c u'<^c tinh MLCT MDRD vd Cockcroft - Gault c6 m6i t u a n g quan rat ch§c che v(^i r=0,945. So sdnh s y khdc biet trung binh v^ MLCT Udc tinh ghi nh$n khong c6 s y khdc bi§t (t nhcim tuoi 50-70, giai aogn BTM 4 vd 5, gi6'i nO' vd c6 thOa cdn b6o phi. So sdnh ty 1$
*Binh vien Da ichoa Tinh Khanh Hoa
BTM giua 2 cong thiJc cung kh6ng ghi nhdn s y khdc bi6t qua cdc giai doan. K§t luan. Lfdc tinh MLCT bdng c6ng thuc MDRD vd CG Id c6 gid tri tuang ty, trong 36 MDRD Id mgt c6ng thuc tinh toan dan gian nSn c6 the dp dung r^ng rdi a ddn dja phuong trong viec sdng Igc phdt hign BTM nhu cdc nu'b'c phuang Tdy. Tuy nhi6n n6 c6 hgn che a ngub'i gid > 70 tudi, ngu6'i g^y, vd MLCT
>60ml/phiJt/1.73m^ thi n6n xem x6t ddnh gid thSm qua c6ng thuc CG.
ABSTRACT
B a c k g r o u n d : The Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault (CG) equations are commonly used for estimating glomerular filtration rate (GFR) on the worldwide; however, the MDRD equation has been not yet validated in Asia population. The aim of this study was to compare for valuate of the MDRD with CG equations for estimating GFR among diabetic patients > 50 old years treating in Khanh Hoa and Daclak hospitals. Methods: W e enrolled 107 hospitalized diabetic patients's average values for age (66.8 years), serum
283
CHUYEN BE: HOI NGHI KHOA HOC NGANH YTE TJNH KHANH HOA - LAN THlJ II creatinine concentration (155.7 mmol/L). BSA
(1.5m^), and male female ratio (49:58). We estimated GFR using the MDRD equation versus Cockcroft-Gault equation normalized to 1.73m^ to confirm their correlation coefficient, mean bias of eGFR in the age groups, sex and BMI as well as the proportion of the stages of CKD foliow the standard of National Kidney Foundation guidelines 2002 Results The Pearson correlation coefficient between estimated GFR in MDRD and CG equations was r2 = 0.945. The mean eGFR of MDRD was 48,77 ±27,40 (mL/phut/1,73m^) and CG was 43,96 ± 25,12 (mL/phCit/1,73m^) with the median bias was 4.8 (95% CI 3 08 to 6.5) mL/min/1.73m^ Non significance between the mean eGFR in the 50- 70 old groups, the CKD in stages IV and V, women and overweight subjets. Companng for the proportion of the stages of CKD between two equations also showed not significantly different.
Conclusions: The MDRD equation can be used for estimating GFR in local population in early detection and treatment of CKD to decrease the incidence of ESRD and cardiovascular disease.
I. Ojj^T V A N OE
Benh than man (BTM) la mpt vdn dh siic khoe cgng dong tren toan cau, hien nay no dugc xem la mgt yeu to nguy co cua benh tim m?ch va tien trien den suy than benh than giai doan cuoi ma can phai dieu tri thay thh [4-6]. Trong do dai thao duong (DTD) la nguyen nhan hang dau din d^n benh than man giai doan cuoi (BTGDC) 6 Bdc My, Nhat ban, Han quoc va 6 hau het cac nuac ky nghe phuong Tay khac [5-7]. No chi6m 40- 50% cua cac truang hgp BTGDC ma cin phai dugc dieu tri thay the hay cay ghep than[6]. Tai Hoa Ky, theo bao cao cua Trung tam kiem soat benh tat (CDC) thi co dhn 16,8% nguoi tren 20 tuoi mac benh than [7].
CJ Viet Nam hien nay, benh DTD dang gia tang ve tan suat mac benh co 5-10% so vai thap nien truac khoang 1 %, ciing voi nhiing
tiln bo trong dilu tri benh, tuoi tho ciia nguoi benh DTD keo dai hon, lam cho biln chiing than 6 benh nhan DTD cung ngay cang tang [1-3]. Hien ca nuoc c6 khoang hon 5 trieu b$nh nhan suy than man (chilm 6,73% dan so) va hang nam c6 them khoang 8.000 benh nhan suy than man moi [3]. D I ngan ngira BTGDC va nguy ca benh tim mach a benh nhan DTD viec dau tien la som phat hien BTM 6 benh nhan DTD. Phat hien som BTM la do albumin nuoc tiSu ben canh danh gia MLCT. That khong may, mpt ganh nang Ion cua BTM van con chua dugc phat hien 6 benh nhan DTD. Trong do phuang phap danh gia chiic nang than khong thS chi dua vao chi so creatinin mau ma can phai tinh miic Ipc cau than (MLCT). MLCT co thi dugc do bang nhiing ky thuat dac hieu nhu do thanh thai insulin, 51Cr-EDTA, 1251- iothalamate, va iahexol. Dp thanh thai creatinine ngi sinh la thuang dugc diing mac dii CO nhieu han che [8]. Trong thuc hanh lam sang, MLCT co the tinh bang nhung cong thiic uoc tinh dua vao creatinine mau, tuoi, gioi, chung tpc va can nang. Hien a nguoi Ion, de uoc tinh MLCT, co hai cong thiic dang dugc dung rong rai tren the gioi la cong thiic Cockcroff - Gault (CG) dung tCr nam 1976 [9], va cong thiic MDRD dugc phat trien tu Levey va cgng sir nam 1999 [10] dung so lieu tir nghien ciiu Dilu chinh Tiet thuc trong Benh than [(Modification of Diet in Renal Disease) (MDRD)} dl uoc tinh MLCT hon la he.so thanh thai creatinine qua cong thiic CG va dugc gpi tat cong thiic MDRD. Hien Hoi Than Qu6c Gia Hoa Ky (NKF) [8] cQng nhu mpt s6 nuoc nhilu nuoc khac tren thi gai: Anh, Uc, New Zealand...
ap dung cong thiic MDRD dl uac tinh MLCT vi tinh don gian, nhanh chong va miic dp chinh xac ciia cong thiic nay. Tuy nhiSn cong thiic nay dua chu yeu vao dan s6 nghian ciiu a ngucri phuong Tay chilm da s6. Vay d6i voi ngucri Viet Nam chau A, chiing ta co
Y Hpc Vi6T NAM THANG 5 - SO BAC 8151/2012
thS sur dung cong thuc irac tinh nao thuan loi de d ^ g CO dp chinh xac cao, qua do co the phat hien som BTM dSc biet 6 benh nhan DTD benh canh sang loc albumin nieu? XuAt phat tir thuc te do, chiing toi tien hanh nghien cuu nay voi nhiJng muc tieu sau:
* Lfac linh MLCT va ly li BTM a benh nhan dai thao duang typ 2 dang diiu tri tgi bfnh vien tinh Khdnh Hod bdng cong thiic MDRD vd Cockcroff- Gault.
* So sanh su khdc nhau gma hai cong thiic nay qua MLCT uac tinh theo tudi, gidi, chi s6 thi trong (BMI) vd ty le cdc giai doan BTM,
Tit do CO huong chpn lua mot gidi phdp thugn Igi trong vi(c ddnh gid chiic ndng than Irong thuc hanh ldm sdng tgi dia phuang di sdng loc phdt hien sdm BTM a benh nhdn DTD hdu CO che do dieu tri can thiep sdm ngdn ngira ddn din BTGDC vd cdc biin chimg tim mgch.
II. PHUONG PHAP NGHIEN COfU:
2.1. Doi tu-ffng nghien ciiu: Tit ca cac benh nhan nhap vien diSu tri tai benh vien da khoa tinh Khanh Hoa dugc chSn doan DTD typ 2 trong thai gian tir 9/2009 ikn 1/2010, ca nam lln nO, tu6i tit 50 tu6i tro len.
2.2. PhiroTig phap nghien cihi:
Nghien cim mo ta cat ngang. Co mlu: Kilu thuan tien. Tit ca benh nhan didu duoc kham danh gia benh canh lam sang hien co, do cac chi so nhan trjc, xet nghiem duong mau va creatiniiie mau it nhlt 2 lln Ai xac dinh chin doan bang may Cobas cua hang Roche, cholesterol mau toan phin, LDL cholesterol, HDL cholesterol, triglyceride, mot mau nuoc tiju buoi sang d6 do albumin nieu. Danh gia chirc nang Igc cua cau th^n bing cac cong thuc uoc tfnh: MDRD va CockCroft - Gault CO di6u chinh theo dien tich b6 mat co th6
I,73m^
* Cong thu-c iro-c tinh MLCT MDRD:
eGFR MDRD mL/phiit/1.73m^ = 186 x |SCr(mmol/l)/88.4l'-"'' s neu la nir)
Chung toi dimg cong thiic nay qua chuong trinh true tuySn tai website:
httD://www.hdcn.com/ calcf/gfr.htm.
* Cong thii-c CockCroft - Gault (CG): u-frc tinh MLCT qua h| so thanh thai creatinine:
cCCr = {({140 - tu6i) X can njng) / (815 x SCr)} x 0.85 (neu la nir)
Trong do: CCr la he so thanh thai creatinine dugc tinh bang mL/phtit, Can nang: kilogam;
SCr la nong do Creatinine huyet thanh tinh bang mmol/L. Tuy nhien de so sanh phii hgp voi MDRD chung toi diing cong thuc CG dieu chinh theo dien tich b6 mat co thi dl tinh MLCT (mL/phut/l,73m^) theo cong thuc sau:
eGFR CG (mL/phut/1.73ni^) = {(140 - Iu6i) x can nang (kg) x k x c / SCr (mmol/L)) Trong do: k = 1.23 d6i vcri nam, nfr 1.04; c ^1.73/BSA. BSA (dien tfch bl mat co thi) dugc tinh theo cong thiic DuBois: BSA (m^)= [can nang (kg))° x[chilu cao (cm)]°"'x 0.007184.(17]
2.2.1 Tieu chudn chan dodn b^nh th^n man: dira theo cac tieu chuan ciia Hgi Than Hoa Ky NKF 2002
Giai doan BTM
1 2
Tieu chuin chan doan C6 hinh anh cau trOc bat thLFd'ng; c6 protein nt^u
MLCT (ml/phut/1,73m^da)
>90 60-89
Nguy CO- gay suy than man Thap; cao han a ngua-i co xuat
hien protein ni&u 285
CHUYEN BJ: HOI NGH! KHOA HpC NGANH Y TgTJNH KHAMH HOA - I ^ N THLt II
3 4 6
hoSchdng c i u nieu.
Giam MLCT trong it nhat 3 th^ng, kem theo co hay kh6ng co bleu hien khac cua BTM
3 0 - 5 9 1 5 - 2 9
<15
VCfa Cao Suy than, BTM giai doan cuoi
- Tieu chuan chan doan DTB du-a theo ADA 2006: + Do duong mau tinh mach luc doi > 7mraol/L. Hoac duong mau sau nghiem phap dung nap glucose > 11,1 mmol/L dugc xet nghiem toi thieu 2 lan.
2.2.2 Xac dinh tieu albumin nieu: O day chiing toi khong do creatinine nuoc tieu nen khong tinh ty albumin/creatinine nieu ciing nhu khong tinh thai gian thai nieu 24 gi6 ma chi xac dinh vi dam va dam nieu dai the nhu sau: Vi dam nieu: 30-299mg/24gia;
Dam ni^u dai the: =/>300mg/24 gio. Tuy nhien dS phii hop voi thuc hanh theo Jorge va cpng su (2005) x€t nghiem tim albumin qua mau nu6c tieu buoi sdng co the xac dinh vi dam nieu voi gia tri> 17mg/L co do nhay 100% va dp dac hieu 80% so mau nuoc tieu 24 gicr. Dam nieu dai the khi do tong protein nieu 24h =/>500mg/24gia tuong ducmg
=/>430 mg/L ciia mpt mau nuac tihu bu6i sang, nen chiing toi dung nhung tri s6 nly thay cho nuoc tieu 24 gio. [21]
2.2.3. Cac tieu chuan loai trir: Cac bieu hieu nhiem tning duang tieu, benh ly tit nghen duong tieu,. Nhilm HIV, Viem gan sieu B,C - Benh viem cau th^n c§p va man tinh. Suy than cap. Tien su tieu protein nieu
a tuoi nho hoac khi mang thai co tang huyet ap. Tihn su gia dinh co benh than. Benh lupus ban do hoac cryoglobulinemia. Dang su dung thu6c gay tSng duong mau, gay tang creatinine mau.
2.2.4. Cac dac diem khao sat: Khao sat MLCT uoc doan qua cong thiic MDRD 6 benh nhan DTD theo gi6i,tu6i. Xac dinh ty I^
BTM a benh nhSn DTD typ 2. Xac dinh m6i tuang quan giita MLCT uoc tinh giiJa 2 cong thirc. So sanh sir khac bi?t ve MLCT uoc tinh trung binh giiJa hai cong thiic theo nh6m tuoi, giai va chi so can nJing cung nhu so sanh ty le BTM theo MLCT uac tinh giua 2 cong thiic.
2.2.5. Phu-ong phfip thong kS: Cdc thong ke nghien ciiu dugc ti^n hanh phan tich bang dimg phan mem thfing ke hoan chinh SPSS 16.0 va chuong trinh Epical 2001, tinh tn so trung binh va do lech chudn, ty le phan tram, so sanh cac ty le phdn tram.
De kiem dinh tinh tuong quan giiia 2 cong thiic dimg he so tuang quan Pearson va phdn tich binh phucmg cua he s6 tuang quan dugc gpi he so xdc dinh boi R^ Gid trj co y nghia th6ng ke P<0,05.
III. KET QUA NGHIEN CCTU:
3.1. Dac diem chung nghien cihi va MLCT trung binh vt&c tinh theo cong thu-c MDRD va CG: Qua nghien cuu 107 trudng hpp DTD a nguai' 1cm tren 50 tu6i ghi nhan cdc dac di8m co ban ciia nghien ciiu va MLCT trung binh uoc tinh theo cong thiic MDRD va CG theo bang 1 nhu sau:
Bdng 1. Cdc dac diem ca ban va MLCT trung binh
Tuoi
Gia trj TB
Gia trj nho nhSt
Gia trj
l(7n nh^t Dp I?ch chuin
Y Hpc VIET NAM THANG 5 - SO BAC BIET/2012
HATT (mmHg) HATTr (mmHg) O u ^ n g mdu (mmol/L) Creatinine (mmol/L) Cholesterol TP (mmol/L) Tnglycehde (mmol/L) HDL (mmol/L) LDL (mmol/L) c a n n$ng (kg) BSA BMI
eMLCT theo MDRD e M L C T t h e o C G
151,51 92,33 12,23 155,68
5.90 1,75 1,22 3,47 52,55 1,50 21,21 48,77 43,96
118,00 60,00 7,1 47,00
2,52 0,40 0,11 0,37 39,00 1,23 15,62 4,04 5,0S
240,00 120,00 30,90 704,00 22,19 5,38 3,66 13,11 70,00 1,77 26,67 164,17 162,59
21,89 11,06 6,25 120,76
2,11 1,03 0,46 1,78 6,92 0,11 2,49 27,40 25,12
3.2 Moi tirtrag quan va sn khac biet trung binh giira hai c6ng thirc:
3.2.1 Moi tirffng quan vi ddnh gid MLCT giira hai cong thirc: Qua phan tich he so tucmg quan Xayhn tinh theo Person, chiing toi ghi nhan hai c6ng thiic co mot su tucmg quan thuan rdt ch^c che voi r2=0,97 qua bieu do hinh 1 sau:
Hinh 1. Biiu dh he s6 tuong quan giiia 2 cong thiic
Qua bilu dh tren cho ta thdy co su tuong quan rdt chat che R2=0, 97 nen hai cong thiic nay deu co gid trj gdn tuang d6ng nhau.
' 3.3.2. Sir khdc biet trung binh giira hai cdng thuc chung vd theo nhom tuoi theo hinh 2 vd bdng 2:
I - Jill A ^ n '••-- --'-
e C5FR C G ( r r i L / p n u t / 1 . 7 3 m 2 )
Hinh 2: BiSu dS phan tan sir khac biet trang binh giiia cong thilc MDRD va CG 287
C H U Y S N BE: HOI NGHI KHOA HOC NGANH Y Te'tiNH KHANH HOA - L A N THLt II Bdng 2: S u Ichac biet t r u n g b i n h g i i i a hai cong t h u c chung va theo n h o m t u o i
Nh6m t u o i 50-59 60-69 70-79
>30 TS
N 34 31 20 22 107
Khac biet TB mL/min/1,73m^
-1,03 2,63 8,08 13,92 4,80
Khoang tin cay (95%CI) - 2,63 - 0,55
0 , 7 9 - 4 , 4 9 4 , 6 5 - 1 1 , 5 2 8,91 - 1 8 , 9 3 3 . 0 8 - 6 , 5
P NS NS
<0,05
<0,01
< 0 , 0 5
3.3.3. Sir khdc biet trung binh theo MLCT udc tinh giau hai cong thiic MDRD - CG va cdc giai doan BTM:
Bang 3: Su Ichac biet trang binh theo MLCT uoc doan gifta hai cong thilc MDRD - CG va cac giai doan BTM.
Giai doan BTM
1 II III IV V TS
MDRD (n) 13 17 47 17 13 107
C G ( n ) 07 10 58 20 12 107
K h i c b l f t T B mL/min/1,73m^
10.32 11.7 3.86 1,05 -1,39
4,80
K h o a n g t i n cay (95%CI) 1.93-18,7
5 . 7 - 1 7 2.11 - 5 , 6 - 1 . 5 1 -3,62 -2,21 - 0 , 5 2 3 , 0 8 - 6 , 5
P
<0,02
<0.01
<0,05 NS NS
<0,05
Qua do xac dinh BTM theo MLCT <60ml/phut/l .73m dugc Idiang dinh Idii theo MDRD la 77/107 chilm ty le 71,96%, theo CG la 90/107 chiSm ty le 84,11%.
3.3.4. Sir khdc blfl trung binh theo MLCT giita hai cong thiic MDRD - CG va gidi:
Bdng 4. Su khac biet tmng binh theo MLCT giua hai cong thiic MDRD - CG va gioi
Gio'i Nam Nu
N (%) 49 (45.79) 68(54.21)
Khac b i i t TB mL/min/1,73m^
8.13 2,0
Khoang tin cay (95%CI) 5 . 3 8 - 1 0 . 9 9
0.08 - 3.9 P
< 0.001 NS
3.3.S Sif khdc biet trung binh theo MLCT giira hai cong thiic MDRD - CC va BML Bang 5. Su khac biet trung binh theo MLCT giOa hai cong thiic MDRD - CG va chi so the tryng (BMI)
BMI
<18 18-22.9
2 23
N 11 74 22
Khac biet T B mUmin/1,73m^
10.16 5,4 0,10
Khoang tin cay (95%CI) 4 , 1 7 - 1 6 , 1 5
3,29 - 7,52 - 1 , 3 3 - 1 . 3 3
P
<0,004
< 0,001 NS
Trong do BMI co su khac biet 7, nil 15
gay BM1< nam 9 nQ 2, trong liic thira can beo phi nam
Y HOC VigT NAM THANG 5 - SO BAC BIET/2012
3.4. Ty le BTIVI a&c ti'nh a benh nhan DTD typ 2
3.4.1. Ty te protein nieu & benh nhdn nghien ciru: Chung toi ghi nhan co 67 ca protein nieu duong tinh chiem ty le 62,61%, trong do vi nieu 25 ca (23,36%) bao gom 12 ca CO MLCT a giai doan I va 11 cua MDRD va 5 ca a giai doan 1 va II cua CG. 42 ca tieu protein dai thi (39,25%). Theo MDRD co 22/77 ca co MLCT <60ml/phut/l ,73m^
khong CO protein nieu chiem ty le 28,57%.
Theo CG CO 28/90 ca c6 MLCT <6bml/ phut/
1,73m khong co protein nieu chiem 31,11%.
3.4.2 Ty le BTM d benh nhdn DTD chan dodn theo khuyen cdo NKF du-a tren MLCT vd protein nieu: Qua phan tich uoc Bdng 6. So sanh ty le BTM a benh nhan MLCT va protein ni^u theo liai cong thiic u^c
doan MLCT theo MDRD va nuoc tiju ghi nhan ty le BTM d benh nhan DTD co 89/107 ca chi6m 83,17% voi giai doan 1 co 2 ca chiSm 1,8% giai doan II c6 10,chiime 9,35%, giai doan III co 10, 43,92% giai doan IV c6 17 ca c6 15,89% va giai doan V CO 13 ca ty le 12,14%. Ty le BTM giai doan III tro len la 77/107 chilm 7l',96%.
Theo CG CO 95/107 chilm ty le 88,78% voi giai doan 1 co 1 ca 0,9%, giai doan II 4 ca 3,73%, giai doan III 54,20%, giai doan IV 20 ca 18,69% va giai doan V 11,12%. Tyle BTM giai doan III tro len la 90/107 chilm 84,11%. (bang 6). Tuy nhien trong lam sang chi co 12 ca (11,21%) co chdn doan BTM a benh nhan dai thao duang.
DTD chan doan theo khuyen cao NKF dua tren doan
Giai doan BTM
1 II III IV V TS
MDRD (n)
2 10 47 17 13 89
Ty le BTM
(%)
1.87 9.35 43.92 15.89 12.15 83.18
CG (n) 1 4 58 20 12 95
Ty le BTM
(%)
0.93 3,73 54,21 18,69 11,22 88,78
P 0,56 0,09 0,13 0,59 0,83 0,24
IV. BAN LUAN:
4.1. Mii'c loc cau than irdc doan va ty le BTIVI it benli nhan DTD. Hien nay BTM dang la mpt vdn dl siic khoe cong ding tren toan ciu, no dugc xem la mot nguy co ciia benh tim mach, co khoang 6-11 %o dan so toan thi gioi mac BTM. [4,11]. Quan dilm vl tiln Mnh cua BTM hien nay da co nhiing thay doi dang kl, theo NKF da dua ra 5 giai doan cua BTM voi cac mile nguy co suy than tir thap din cao va suy than la khi BTM a giai doan culi thay cho tir suy than man noi chung truoc day. Khi tien trien din BTMGDC lam gia tang nguy eg tir vong, benh tim mach [8].
Qua nghien ciiu 107 benh nhan dai thao duong CO tuli trang binh 66,87 ± 11,19 ghi nhan MLCT uac lugng trung binh theo
MDRD la 48,77 ±27,40 (mL/phiit/l ,73m^ da) va theo cong thirc Cockcroft - Gault 43,96 ± 25,12 (mL/phut/l,73m^) cOng tuong tu voi Phan thi Lien Chi nghien ciiu tren 300 benh nhan tang huylt ap va dai thao duong typ 2 theo cong thirc CG dieu ghi nhan MLCT uoc tinh diu <50ml/phut [1]. Nhu vay da so benh nhan dugc nghien cim dang mac BTM giai doan 3 den giai 5 ma theo MDRD co ty le 71,96% va CG co dilu chinh theo l,73m^ da la 84,11%. Phii hgp giQa MLCT va danh gia nuoc tilu ghi nhan ty Ie BTM theo MDRD la 83,17% va theo CG la 88,78%. Day la mot ty le cao hon so voi cac nghien cim tren the gitM ghi nhan ty Ie BTM 6 benh nhan DTD la tu 50-70% [4-5] CO the do benh nhan nghien cim eua chung toi hau het c6 tang huyet ap 289
CHUYgN BE: HOI NGHI KHOA HOC NGANH Y TE T I N H KHANH HOA - LAN THtf I i ^ _ _ _ _
roi loan lipid mau di kem. Tuy niiien trong Iam sang thuong khong dugc quan tam phat hien ddnh gid som ma thuc te 6 dia phuong chi CO 11,21% chan doan BTM 6 benh nhan DTD dang dieu tri, de tu do co huong can thiep ngan chan tien trien den BTM giai dodn cuoi cung nhu tir vonng tim mach. Ben canh do van de diing thuoc dieu tri cac benh phoi hcrp cdn phdi dieu chinh lieu thich hgp khi da CO suy than nhung khong dugc chan doan nen de ddn den ton thuong than tien trien va nguy CO benh tim mach cao, ngodi ra trong dieu tri 6 nhiing benh nhan co biSu hien giam MLCT cGng can chgn loc thuoc voi chinh lieu thich hgp. Do do vdn de dugc dat ra o day la ldm sao de co the phdt hien som dugc BTM bang mgt cong thiic don gian tien Igi chinh xdc, tir do co ke hoach dieu tri, ngan ngira BTM tien trien, gidm nguy co tu vong va cdi thien chat lugng song cho benh nhdn
4.2. So sanh 2 cong thiic iro'c tinh MLCT MDRD va Cockcroft - Gault co dieu chinh theo 1,73m da: Qua tim hieu moi tuong quan tuyen tinh, cho thdy giGa hai cong thuc CO moi tuong quan rat chac che voi r2=0,97 nen vdn de co ban de dimg chiing trong uoc tinh MLCT la tuong dong, tuy nhien 6 ddy chung to! khong so sdnh voi MLCT chuan nhu do do thanh thai insulin hoac 125 I-iothalamate nhu Id tieu chudn vang thi viec danh gia se co gid tri hon. Bihu ndy la do dieu kien nghien cihi cua co so co han che nen chiing toi so sanh chinh giita CG Id mgt cong thuc dugc diing rpng rai tir nam 1976 [9] va da co nhieu nghien ciiru so sdnh voi MLCT chuan 6 nhieu chung toe khdc nhau, no co gid tri thuc te, tuy nhien vdn co nhung han che nhu CG can phai dua vdo nhieu thong s6 tinh todn phiic tap, thuong duoi gid tri thuc dac biet o benh nhdn DTD
[12,19], va cong thuc MDRD don gian chi dua vao tuoi gioi va creatine huyet thanh va da dugc nghien cuu xdc dinh muc chinh xac tir nam 1999, hien da dugc sir dung rong rai tren thh gioi [10-12]. Tuy nhien MDRD do so lieu nghien cuu tren nguoi goc chau A rat it nen nhieu y kihn cho rdng chua the dp dung doi voi nguoi goc chau A va o benh nhan DTD vdn con mgt s6 y ki^n [4, 5, 19], nen vice nghien cuu so sdnh giflra CG va MDRD a benh nhan DTD tai Khdnh Hoa- D5c Ldk la rat thiet thuc. Mgt van dh dat ra la khi so sanh giiia MDRD va CG la chiing ta can phai tinh CG quy ra theo MLCT ml / phiit/ 1,73 m^ da moi co the so sdnh chinh xdc va dp dung vdo sir phdn chia cac giai doan BTM chu khong the tinh he so thanh thai creatinin don thudn de dan den ket qua sai lech. So sdnh MLCT uoc tinh trung binh cho thdy co su chenh lech khoang 4,8ml/hiit/l .73m^
MDRD cao hon CG. Tuy nhien khi phdn tich chi tiet cho thay su khac biet ndy tap trung 6 Ilia tuoi tren 70 con 6 nhom tu6i 50 - 70 khong CO su khac biet c6 y nghia. DiSu ndy phii hgp voi nhdn dinh va nghien cinj cua nhi^u tac gid 6 nguofi gia CG co gia tri hon [12]. Ve cac giai doan BTM nghien cuu cho thay su khdc biet tap trung 6 MLCT > 60ml/
phiit/l,73m^, con o BTM giai doan 4 vd 5 khong CO sir khdc biet co y nghia thdng ke, dieu ndy ciing phii hgp voi nhimg nghien ciiu ve CG va MDRD tren thh gioi, no chi c6 gid tri trong tam sodt BTM som va khi MLCT <60 mL/phut/I,73m^ dac biet a benh nhdn DTD [14, 21 - 19]. Theo Richard vd cs (2007) o benh nhan DTD typ 2 co MLCT trung binh >60 mL/phut/l,73m^ thi MDRD CO gia tri R2 thdp (0,42) khi so voi miic loc chuan [18].
290
Y Hpc VIET NAM T H A N G 5 - SO DfyC BIET/2012
s o TOO 1 5 0 2 0 0 e G F R ( M D R D ) m ) / r n t n / 1 . 7 3 m =
Hinh 3: Nghien ciiu ciia Richard va cs so sanh giua MDRD va miic loc cdu than chudn 6 b?nh nhdn ddi tdo duong co miic loc trung binh >60 mL/phiit/1,73m^
Ngoai ra qua phdn tich sir khac biet vh gidi cho thdy khong co su khdc biet o nhom nC va 6 nhung nguoi thira can va beo phi BMI=/> 23. Dieu ndy la do s6 nii co tinh t r ^ g thira cdn va beo phi nhieu hem nam gioi (15/7). S\r khdc biet giu'a hai cong thiic v8 co bdn Id do chi so cdn nang vd dien tich be mdt CO th6. C6ng thiic Cockcroft - Gault Idy cdn n^ng nhu Id mgt bien so de u a c tinh MLCT va CO tuong quan thuan voi chi so BMI. Do do a nhihig benh nhdn co cdn nang cang Ion thi chi so uoc tinhn MLCT cang cao nen de ddnh gid sai chOrc nang than a benh nhan beo phi. Mat khac cong thiic MDRD khong dira tren can ndng ma dua vao dien tich be m^t CO the trung binh quy uoc 1,73m^ da. Vi vay doi vol nhiing b?nh nhan gdy, dien tich bl mdt co the < l,73m^ da thi chi s6 uac tmh MLCT se cao hon so vol thuc th [20]. Qua do da khdng dinh gid tri ciia MDRD la co gia tri u6c doan MLCT tuong tu CG o nguoi ddn dja phuong d^ic bi6t o nhom tu6i 50-70, miic loc <60 ml/phiit/l ,73m^. Ty le BTM qua cdc giai doan 1 dhn 5 qua so sdnh X ^ la khong co su khdc biet CO y nghia thdng ke. Di6u ndy khang dinh gid tri ciia hai cdng thiic ciing khong co su khac biet d ngudi ddn dfia phuang.
V. KET LUAN:
Qua nghien ciiu tren 107 benh nhan DTD vdi tudi trung binh 67,87 ± 12,19 dang dieu
tri tai Benh vien Da khoa tinh Khdnh Hod chiing tdi cd nhung ket luan sau:
1. Milrc loc cau than u-6'c tinh va ty l | BTM: Chung tdi ghi nhan MLCT trung binh theo MDRD Id 48,77 ±27,40 (mL/phiit/
l,73m2 da) vd theo cdng thiic Cockcroft - Gault 43,96 ± 25,12 (mL/phiit/l,73m2). Ty IS BTM tir giai doan III-V theo MDRD co ty le 71,96% vd CG la 84,11%. Phdi hgp giQa MLCT vd ddnh gid nude tieu ghi nhdn ty Ie BTM theo MDRD Id 83,17% va theo CG la 88,78%. Tuy nhien trong ldm sang cd
11,21% chdn doan BTM d b?nh nhdn DTD dang dieu tri.
2. So sanh 2 cong thirc irfrc tinh M L C T MDRD va Cockcroft - Gault: Giua hai cdng thiic cd mdi tuong quan rdt chac che vdi r2=0,97. So sdnh su khdc biet Uung binh vh MLCT udc doan ghi nhan khdng cd su khdc biet d nhom tudi 50-70, giai doan BTM IV va V, gidi nii va cd thira can beo phi. So sanh ty le BTM giua 2 cong thiic ciing khdng ghi nhan su khdc biet qua cac giai doan. Dieu ndy cho thdy giua hai cdng thiic Id tucmg ddng trong do MDRD la mgt cdng thiic tinh todn dan gian nen cd thh dp dung rdng rai a ddn dja phuang trong viec sdng Igc phdt hien sdmi BTM nhu cac nude phucmg Tay. Tuy nhien nd cd han che d nguai gid > 70 tudi, nguai gay, vd MLCT >60nil/phut/l ,73m^ thi nen xem xet ddnh gid them qua cdng thirc CG.
291
CHUYgN PE: HOI NGHj KHOA HOC NGANH Y TE TINH KHANH HOA-LAN THU II TAI LIEU THAM KHAO
1. Phan thi LIID Chi, Tran thi Nguyet Anh, Tran Thuy Dao, Nguyen thi Tuyet Huwng &
cs. ChiJc nang than, dilu can quan tam khi cho thuoc benh nhan cao tuoi; Ky yeu Hoi nghj khoa hoc chuyen nganh Tim Mach khu vyc phia Nam thang 11/1997; 103-9.
2. Tran Hiru Dang. Benh than dai thao duong.
Thong tin khoa hpc. DHYD Hue 2008.
http://www. huemed- univ.edu.vn/?cat_id=46&id= 174
3. Tran Van Huy. Djch te hgc cac yeu to nguy CO tim mach tai Khanh hoa Tim mach hgc Vi?t Nam. 2004; 37345-358
4. Samak MJ, Levey AS, Schoolwerth AC, et al. Kidney disease as a risk factor for development of cardiovascular disease. A statement fix>m the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology,and Epidemiology and Prevention.
Circulation 108: 2154-2169, 2003.
5. Levey AS, Atkins R, Coresh J, et aL Chronic kidney disease as aglobal public health problem: Approaches and initiatives « position statement from Kidney Disease Improving Global Outcomes.Kidney Int 72:
247-259, 2007.
6. Weiner DE, Tighiouart H, Amin MG, Stark PC, MacLeod B, Griffith JL, et al.
Chronic kidney disease as a risk factor for cardiovascular disease and all-causemortality:
a pooled analysis of community-based studies.
JAm Soc Nephrol 2004;15:1307-15.
7. Coresh J, Astor BC, Greene T et al.
Prevalence of chronic kidney disease and decreased kidney function in the adult US population: third National Health and Nutrition Examination Survey. Am J Kidney Z)w. 2003; 41:1-12.
8. National Kidney Foundation. K/DOQl clinical pracdce guidelines for chronic kidney disease: evaluation, classification, and sU^tification. Am J Kidney Dis. 2002; 39(2
suppl I):Sl-266.
9. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine.
Nephron. 1976; 16:31-41.
lO.Levey AS, Bosch JP, Lewis JB et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med. 1999; 130:461-70.
1 l.McCIellan WM, Knight DF, Karp H et al.
Early detection and treatment of renal disease in hospitalized diabetic and hypertensive patients: important differences between practice and published guidelines.
Am J Kidney Dis. 1997;29:368-75.
12.Murthy K, Stevens LA, Stark PC et aL Variation in the serum creatinine assay calibration: a practical application to glomerular filtration rate estimation. Kidney /«/. 2005; 68:1884-7.
B.Myers GL, Miller WG, Coresh J et aL Recommendations for improving semm creatinine measurement: a report from the laboratory working group of the National Kidney Disease Education Program. Clin CAem. 2006;52:5-18.
14.Stevens LA, Levy AS. Frequently asked questions about GFR estimates.
www. kidney .org/professionals/kls/pdf/faq_^
fr.pdf (accessed 2006 Dec 18).
15. Du Bois D, Du Bois EF. A formula to estimate the approximate surface area if height and weight be known. Arch Intern Med. 1916; 17:863-71.
16. Poggio ED, Nef PC, Wang X et aL Performance of the Cockcroft-Gault and modification of diet in renal disease equations in estimating GFR in ill hospitalized patients. Am J Kidney Dis.
• 2005; 46:242-52.
17. Froissart M, Rossert J, Jacquot C Paillard M, Houillier P. Predictive performance of the Modification of Diet in Renal Disease and Cockcroft- Gault
Y HQC V l f T NAM THANG 5 - SO BAC BIET/2012 equations for estimating renal function. J
Am Soc Nephrol 2005;16:763-73.
18. Richard AC, Gareth D, William E, John NH, Philip E. How Reliable Is Estimation of Glomerular Filtration Rate at Diagnosis of Type 2 Diabetes? Diabetes Care. 2007;
30:300-305.
19. Jorge LG Mirela JD Sandra PS Diabetic nephropathy: diagnosis, prevention, and treatment. Diabetes Care Vol 28:Nol; 176- 188,2005.
20.Holly K Mark EM. Screening for kidney disease in adults with diabetes. Diabetes Care 2005: Fo/28:No 7; 1813-1816
NGHIEN Ciiu TINH HINH TANG HUYET AP OTTHj XA NINH HOA, TINH KHANH HOA NAM 2011
T 6 M TAT
TSng huy^t dp Id mOt b$nh 1^ mgn tinh tSng d^n vd nguy hiem. Tan s u i t tang huyet ^p dang gia tdng tr6n the gidi cdng n h y tgi Vi^t Nam nhung chua cd dieu tra ndo ve tdng huy^t dp d Ninh hda. ChOng tdi nghifin c u u de t d i " Nghifin ci>u tinh hinh tdng huyet dp 6 thj xd Ninh Hda Tinh khdnh Hda ndm 2011". M y c tieu nghien cii'u: 1. Xdc djnh ty 1$ hi$n mSc tSng huyet dp d ngudi tCf 25 tuoi t r d Ifin tgi thi xd Ninh Hda, tinh Khdnh Hda; 2 Tim hieu mOt so yeu to liSn quan a^n tdng huyet dp d ngudi tO 25 tuoi t r d Idn tai thj xd Ninh Hda, tinh Khdnh Hda. T h i l t k§
nghien cu'u: Md ta cdt ngang. D d i tuxrng n g h i i n cii-u: 850 ngudi > 25 tudi c u tru tai thi xd Ninh Hda. PhuM^ng phdp nghien cu'u: Tat ca cdc ddi tuiyng dup-c do chieu cao. can nang, vdng byng, vdng mOng, tinh BMI, WHR, chi so huy^t Sp vd phdng van, CSc tidu chuan ddnh gia theo WHO, JNC VI vS Hdi tim mach Vidt Nam.
K i t qua: Ty 1$ hi$n mdc tdng huyet dp Id 26,5%
(khodng tin cdy 95%: 23,5-29,5). TSng huyet ap binh thLFdng cao 10,5% va tang huyet dp tdm thu don ddc Id 7,6% Mdt sd yeu to lien quan tang huy^t dp Id tudi, gidi, uong nhieu ru-au, hiit thuoc Id, dn rhdn, bdo phi Ket l u ? n : Ty le tdng huyet
* B4nh vi?n da khoa khu virc Ninh Hoa
Trirffng Phir&c An *
dp cao tu'ong t y cac dia phu'ong trfin toan quoc vd ty Id nay gia tang rd theo tuoi, uong nhieu ru'ou, hilt thuoc la, an mgn, qud cdn bdo phi.
ABSTRACT
Hypertension Is a chronic, Increasing and deadly disease. Incidence rate of hypertension has Increasingly elevated on the world over and also In Vietnam, yet no investigation on the issue ever carried out in Ninhhoa An investigation namely "Study on hypertension situation at Ninhhoa town, Khanh hoa in 2 0 1 1 " was accordingly conducted. Objectives To investigate the rate of hypertension in the adult aging > 25 years of Ninh Hoa, Khanhhoa. To reveal several related factors of hypertension In the adult aging > 25 years of Ninh Hoa, Khanhhoa. Study d e s i g n : Cross-sectional investigstion Subjects: 850 men and women aging > 25 years and residing at Ninhhoa, Khanh Hoa Methods: all enrolled participants underwent measurements of height, weight, waist, hip and BMI, WHR calculation, blood pressure and interview Evaluations were based on criteria Issused by WHO, JNC VI and Viettnam national heart association. Results:
293
