Y HOC VigT HAM THANG 5 - S01/2014
GIA TRI C O A N O N G DO PROCALCITONIN TRONG TIEN LiraNG 6" BENH NHAN VIEIVI TUY CAP
T6M TAT
Nhiem khuan la van de ldn trong chan doan, tien lu'ijng va dieu tri viem tuy cap. Muc tieu: Nghien cuU nhSm tim hieu gia trj cua procalcitonin trong tien lu'dng wgm tuy cap ning va bien chutig nhiem khuan. boi tU^ng vd phu'tfng phdp nghien cCfu: Chung toi nghien cOiU 104 b#nh nhan viem tuy cap tai khoa tieu h6a va Wioa dieu tri h'di ou'c b?nh vien Bach mai tu"
11/2012- 8/2013. Xet nghiem mau va chan doan hinh cinh du'^c tien heinh 24 gid sau khi benh nhan nhap vifn. Procalcitonin du'dc djnh lu'i^ng tai khoa Hoa sinh b^nh vi|n B^ch mai. Ket qua: Viem tuy cap mu'c do n^ng- 25,9% , mu'c do vCte gap d 74,1% benh nhan (theo AHanta). Procalcitonin 6 nhom nghien cuu 8,24
±20,79ng/ml. Procalcitonin cao hdn co y nghla thong kg d nhom viem tyy cap nSng (29,55 ±33,18ng/ml), hoai tor (16,38 ±25,73ng/ml), sot (13,74
±27,77ng/ml). Gia trj ngu'dng phan biet viem tuy cap c6 hogi tuf la 0,965ng/ml. Procalcitonin (AUROC=0,964) c6 gia tri cao hdn CRP (AUROC=0,666) trong tien lu'dng viem tyy cap co hoai tu* v^ viem tuy cap nSng. Ket lu$n: Procalcitonin la m$t dSu Sn ddn gian giup cho tien lu'dng bien chiing nhiSm khucin vd vl§m tuy cSp mu'c dp ning
Tit khda: Procalcitonin, CFIP-C reactive protein,Vlem tuy cap, AUROC
SUMMARY
THE VALUE OF PROCALCITONIN I N THE P R E D I C n O N OF SEVERE AND INFECTED NECOROSIS I N ACUTE PANCREATITIS
Infection of pancreatic neaosis has a major impact on clinical course, management and outcome In acute pancreatatis. Objectives: The aim of this study is to asess serum procalcitoin for early prediction of severe and Infected necrosisis in acute pancreatitis.
Methods: From 11/2012 to 8/2013; 104 patients with acute pancreatitis in Bach Mai hospital confirmed by radiological evidences, laboratory assessments, and dinkai manifestation were prospectively enrolled. All blood samples and image studies were obtained within 24 hours of admisson. PCT was measured prospectively by a semi automated immunoassay and CRP was routinely assessed. Results: Acute pancreatitis was graded as severe in 25,9% patients, and mild in 74,l%patients according to the Atlanta
'B^nh vi$n Oa khoa Phu Thg
"Tmdng Dili h(?c YHa Ngi
Phin bl$n khoa hgc PGS.TSNguY&t Thf ]^n Hong
Nguyen Thi Thuy*, Tran Ng^c Anh**
cnteria. Median ODncentration of PCT was 8,24 20,79ng/ml. Levels of serum PCT were significantly higher in severe acute pancreatitis (29,55
±33,18ng/ml), necrosis (16,38 ±25,73ng/ml), fever (13,74 ±27,77ng/ml) with p<0,05. The most effective cut off level of serum PCT was estimated at 0,965 ng/ml. In comparison to CRP, senjm PCT had more accurate value (AUROC=0,964) than C reactive protein (AUROC=0,666). Conclusions: Serum PCT was a promising simple biomarker as predicting severity of acute pancreatitis and complication of infected necrosisis
Keywords: Procalcitonin-PCT, C reactive protein- CRP, Acute pancreatitis AP, AUROC
I.OATVANDE
Khoang 2 0 % viem tuy cap co tien trien nang va trong so do co 10-30% tiT vong mSc du da du'dc dieu trj tfch ciTc [ 1 ] . Dien bien cua viem tuy cap rat phuTc tap, vi vay viec danh gia mirc dp viem tuy cap rat can thiet, nham lyS chpn bipn phap dieu t n toi uli, han che bien chCrtig cua benh. Tang nong dp cac cytokin 6 viSm tuy c^p da du'dc chutig minh qua nhieu nghi§n cutJ gan day cho thay co lien quan den sy" phat trien cua cac bien chirng suy tang, hoai tir, nhiem triing.
Tren cd s6 do Procalcitonin du'dc de cap den nhu' mpt cong cu de theo doi tien trien ciia benhva CO the danh gia du'dc mirc dp nang cua viem tuy cap tru'dc khi co suy tang [1,2]. Procalcitonin la tien chat ciia hormone calcitonin do te bao C tuyen giap (gan, phoi, tinh hoan) san xuat trong dieu kien sinh ly. Trong viem tuy cap, procalcitonin du'dc d u ^ ra de diT doan chi'nh xac sir phat trien ciia viem tuy cap hoai tu', procalcitonin du'dc danh gia la cong cu d i / doan tot cho sir nghiem trong va suy cd quan trong vong 24h dau sau khi nhap vien hoac khdi phat trieu chuTig [ 2 ] .
O Viet Nam chung toi chu^ tham khao dUdc tai lieu chi'nh thii'c nao nghien cuXi ve gia trj cua Procalcitonin trong theo doi tien trien va tien lu'dng ciia viem tuy cap. Nghien cOru du'dc tien hanh nham muc tieu sau: Nhan xet nong do Pnxaldtonin/ huyet thanh d BN w&n tuy cap vi mdi lien quan vdi nong do CRP/ mau trong danh gia tien ludng viem tuy cap.
Y HOC VIET NAM THAHG 5 - S01;2 II. BOI TUqlKG VA PHirOTNG PHAP NGHIEN CLTU
2.1.Doi tifdng nghien cihi: tir thang 11/2012 - 8/2013 Chung toi ngien diu tren 104 benh nhan viem tuy cap tai khoa tieu hoa ya klioa dieu tri ti'ch cut benh vien Bach Mai. Tieu chuan chan doan xac djnh viem tuy cap theo Atlanta 2012 khi co dau thu'dng vj dot ngot ket hdp vdi 1 trieu chiTng can lam sang hoac Amylase mau ting cao tren 3 lan gia trj binh thu'dng cao nhat hoac chan doan hinh anh: co hinh anh dien hinh ciia viem tuy cap ( sieu am hoac chup cat Idp vi tinh bung). Tieu chuan lo?i trif: viem tuy cap co kem theo cac benh; nhoi mau cd tim cap; viem khdp; lupus ban do; co nhiem khuan 6 cac cd quan khac (nhiem khuan huyet, nhiem khuan ho hlip); lao tten trien; cd dung dap to chirc; ung thu'; xd gan.
2.2. Phu'dng phap nghiSn cu'u: Nghien ciru mo ta tien cuu.
Xet nghiem huyet hoc cd ban va sinh hoa mau:tai khoa sinh hoa Benh vien Bach Mai. Chan doan hinh anh (tai khoa Chan doan hinh anh binh vien Bach Mai). Chan doan the viem tuy cap tren chup cat Idp vi tinh bung: viem tuy cap the phii: viem tuy cap the hoai tCT: Banh gia tien lll.KfTQUA
TO thang 11/2012 - 8/2C13 chung toi da tien hanh ngien cirli tren 104 benh nhan viem tgy cap vdi 49% viem tuy cap hoai tCr, 25,9% viem tuy cap mirc do nang. Nong do Procalcitonin trung binh B,24± 20,79 ng/ml: Nong do CRP la 15,79 ±27,9 mg/dl.
lu'dng viem tuy cap theo bang diem Balthazar.
OiSm (crsi) = 0-3 diem (nhdm nhe); 4-6 diem ( nhdm vila); 7-10 fflem ( nhdm nang) [1]. Oanh gia tien lu'dng viem tuy cap theo phan [oai Atlanta (1992): The nhe :viem tuy cap khong co mot hoac nhieu bien chifng quan trpng toan than hoac tai cho gay ra bdi ddt tan cong cua viem tuy cap.The nang : viem tuy cap kem theo mot hoac nhieu cac bien chifng quan trpng tai cho ho3c toan than [1]. Procalcitonin dUdc lam tai khoa Hoa sinh benh vien Bach Mai (24 gid sau nhap vien) theo phu'dng phap dien hoa phat quang LUMI test, sir dung kit xet nghiem tren may phan tich miln djch ti/ dong Cobas e 411, Elecsys Brahms PCT - Oirc. Kit thir dUdc bao quan d nhiet dp 2 - 8°C.
2.3. Xu' IV so lieu; Cac s5 lieu thu thap dUdc lam sach, phan tich va xi ly bang phan mem SPSS ie.O.Gla trj cat toi Hu du'dc xac djnh dUa vad do thj du'dng cong ROC
2.4. Sao dii'c nghien ed'u: Cac benh nhan tham gia nghien cCru deu dUdc giai thich v^ chap thuan tham gia nghien ciru. Thong tin ve benh nhan dUdc bao mat.
Yeutof NguySn nhan
P<0,05
crsi
(P<0,01) Hoai tir (p<6,oi)
Sot (P<0,01)
Sol mat Giun Tanq md mau
Khac
>7 diem
<7 diem Cd Khong
Co Khonq
NSng do Procalcitonin(ng/mi) 14,37±29,21
2,79±1,27 19,98±35,7 0^89 ± 1,00 29,55 ± 33,18
1,14 ± 1,17 16,38 ± 27,53
0,411 ± 0,51 13,74 ± 27,77 2,52 ± 4,79 Nii^n x4t: Nong dp Prpcalcitonin/huyet thanh
benh nhan viem tuy cap cao nhat d nhom tang m3 mau va soi mat, sy" khac nhau nay la co y nghia thong ke (p< 0,05).
Nong dp Procalcitonin trung binh d nhom viem tuy cap CO diem CTSI < 7 thap hdn co y nghTa thong ke va diem CTSI > 7 ( p < 0,01)
Nong dp Procalcitonin trung binh giife nhom viem tuy cap khong hoai tii thap hdn cd y nghia soV((l nhom viem tuy cap co hoai tu" (p < 0,01) Nong dp Procalcitonin trung binh d nhom viem tuy cap khong co sot thap hdn co y nghTa viem tyy cap co sot vdi p < 0,01
^ Y HOC VIET NAM THANG 5 - SO 1/2014
Biiu Sd 3,1, Xac djnh diem cat, dien tich du'di du'dng cong ROC ciia nong do procalcitonin trang viem tuy cap hoai tir
Nl^n xit: Di$n tich dudi dUdng cong ROC la 0,964 nong dp Procalcitonin kha nSng phan biet cao viem tuy cap hoai tir va viem tuy cap khong hoai tOr. Biem cut- off ciia Procalcitonin^ 0,965 vdi dp nhay 92,2%, dp dac hieu 96,2%.
Bleu So 3,2. So sanh gia tri chan doan cua nong do Procalcitonin huyet thanh, nong do CRP, so luffng BC trong chan doan viem tuy cap hoai tir va khong hoai tit
/K«#/i«if; Procalcitonin (AUC= 96,4%; P= 0,000) o6 gia trj cao nhat trong chan doan phan biet viem tgy cap ho?! tii' va khong hoai tir, ke den la CRP (AUC= 66,6%; P= 0,004), so luong bach cau co gia trj thap nhat (AUC= 48,4%; P= 0,772).
- Khdng c6 moi tUdng quan tuyen tinh giiiB nong dp Procalcitonin va nong CRP vdi, (ri50,10), p=
0,302, y = 0,137x + 14,665
- Khpng cp moi tu'dng quan tuyen tinh giiJa nong dp Procalcitonin va so lUdng bach cau vdi (r«- 0,15), p= 0,118, y = - 0,037x -l- 14,268
- Khong CO moi tu'dng quan tuyen tinh glDS nong dp Procalcitpnin huyet thanh vdi sp lUdng bach cau da nhan trung tinh vdi r = - 0,099, p = 0,315, y = - 0,039x+ 12,7.
IV. BAN LUijiN
Trpng nghien cihj cua chung toi nong dp procalcitonin/huyet thanh benh nhan viem tuy cap la 8,24±20,79 ng/ml [0,62ng/ml- 120ng/mi].
Chiing toi nhan thay nong dp prpcalcitonin d benh nhan viem tuy cap do nguydn nhSn tSng
Y HOC VIET HAM THAHG 5-s6 ti£ui,i
md mau (19,98±35,7ng/ml) va nguyen nhan do sdi dudng mat (14,37±29,21ng/ml) la cao nhat, tiep den la nguyen nhan do ru'du (4,52±11,14 ng/ml) va giun du'dng mat 2,79±l,27ng/ml, sU khac biet cd y nghla thdng ke vdi p< 0,05.
Muller, Brunkhost nhan thay cd sU khac nhau giii'a nong dp procalcitonin theo nguyen nhan viem tuy cap, procalcitonin tang cao ro ret d nhdm viem tuy cap do sdi mat [ 2]. Tuy nhien Bertsch Ial khong nhan thay moi lien quan nay [ trich 2]. Trong nghien citlj ciia chiing toi nong dp procalcitonin huyet thanh d nhom benh nhan viem tuy cap c6 diem CTSI >7 la 29,55 ± 33,18 ng/ml cap hdn viem tuy cap cd diem CTSI <7 la 1,14 ± l,17ng/ml, sU khac biet cd y nghTa thdng ke vdi p<0,01. Nong dp procalcitonin/huyet thanh benh nhan viem tuy cap nang cd hoai tiT la 16,38 ± 27,53ng/ml cao hdn viem tuy cap khong hoai tir 0,411 ± 0,Slng/ml, sU khac biet cd y nghTa thong ke vdi p<0,01. Muller cung cd nhan xet tu'dng tU chiing toi: procalcitonin cd gia trj phan biet viem tijy cap the phii va the hoai tiT, dieu nay lien quan vdi dap ii'ng viem he thong trong viem tuy cap [2]. Kylanpaaback nhan thay procalcitpnin cd gia trj tien lu'dng viem tuy cap n|ng (Se 92%, Sp 84»/o), dac biet gia tri dU bao Sm tfnh kha cao - 97% trong dir bad suy da tang [3]. Mofidi nhan xet: Procalcitpnin cd gia dU bao viem tuy cap nang vdi Se 72%, Sp 86%
AUC=0,817 [4]. Nghien ciru ciia Woo cang ciing c5 gia thuyet nay: Procalcitonin d nhom viem tuy cap nang (4,28ng/ml) cap hdn cd y nghTa so vdi nhdm nhe vira (0,43; l,66ng/ml) vdi p<0,01, ty I? Chan ddan dung la 77,3% [5]. Berger nhan thay procalcitonin >l,8ng/ml Apache II>8, CRP>120mg/dl Hematocrit >44% la nhu'ng yeu to chinh du bao tien lUdng nang d benh nhan viem tuy cap [6,7]. procaicitdnln>3,8ng/ml co gia tri dir bao suy da tang vdi ty le chan doan dung la 92% (Se 80% Sp 90%), dir bad tir vdng vdi ty le Chan doan diing la 82% [6]. Bien chuTig nhiem khuan trong viem tuy cap xuat hien d 30% benh nhan trong tuan dau va 70% tuan 3. Viec du bao viem tuy cap cd bien chirng nhiem khuan hay khong va diilu trj kjp thdi la mpt van de quan trpng trong thiTc hanh lam sang [1]. Trpng nghien ciru ciia chung tei, procalcitonin d benh nhan viem tuy cap nang cd sot la 13,74 ± 27,77ng/ml cao hdn procalcitonin d benh nhan viem tgy cap khong cd sot 2,52 ± 4,79ng/ml, su' khac biet nay co y nghTa thong ke vdi p<0,01.
Rau 2007 nhan thay prdcalcitdnin cao hdn co y
nghTa d nhdm viem tuy cap bien chimg nhilm khuan va suy da tang. Mofidi nhan thay procalcitonin cd gia tri du' bao bien chirng nhiem khuan la 80-91% vdi AUROC=0,91 [4]
Trong nghien ciru ciia chung toi dien ti'ch dudi du'dng cong ROC la 0,964 nhU vay nong do procalcitonin co kha nang cao phan biet viem tuy cap hoai tu" va viem tuy cap khong hoai tir. Oiem cut- off ciia procalcitonin= 0,965ng/ml vdi dp nhay 92,2%, dp dac hieu 96,2%. WopSM va cong sU thi mii'c cut-off procalcitonin huyet tiianh la 1,77 ng/ml AUROC= 0,797. A Muter va cong sg* duS ra cut off procaictonin >3,5ng/ml co y nghTa trong viec danh gia viem tyy cap hoai tO' va suy tang vdi dp nhay va dp dac hieu lan lirdt tUdng ii'ng la 93% va 98% [2]. Cd le vi doi tu'dng nghien ciru cua tac gia gom viem tuy cap nang cd nguy cd cao phai phau thuat trong vong 96ti sau khi khdi phat trieu chii'ng, cdn dpi tuttng nghien ciru ciia chung tdi la benh nhan viem tuy cap dieu tri tai cd sd npi khoa.
Trpng nghien ciru ciia chiing toi nong dp prdcalcitonin (AUROC= 0,964%) cd gia tri cao nhat trong chan doan phan biet viem tuy cSp hoai tir va khdng hoai tuT, ke d€n la CRP (AUC=
66,6%, P= 0,004), Sd lu'dng bach cau co gia tr|
thap nhat (AUC= 48,4%, P= 0,772). Trong viem tuy cap nong dp prpcalcitonin giif mu'c cao trong dien bien cua benh d benh nhan tir vong trong khi nhanh chdng trd ve binh thudng d benh nhSn song sdt. Ngu'dc lai, gia trj CRP khong bieu hi^n sg' ^khac nhau giiJa nhdm benh nhan hoai til nhiem triing cd roi loan chirc nang da phii tang vdi nhdm hoai tir nhiem triing khong suy phil tang va hoai tir vo triing [1]. Nghien cuXi cua chiing toi mdi chi tinh dUdc nong do Procalcitonin d thdi diem vao vien chiis theo doi dUdc nhiitig ngay sau. Rau nhan manh Prccalcltonin>3,5ng/ml tang cac 2 ngay lien tiip cd gia trj hdn (Se 93%-Sp 88% ) so vdi CRP>
430mg/l (Se 40%, SplOO%) vdi p<0,01. Trong du' bao bien chirng nhiem khuan prpcalcitonin pi, AUROC=0,76, CRP-AUROC=0,6, trong du' MO suy da tang procalcitonin-AUROC=0,83; SP AUROC=0,64; trong du' bao tuT vong la 0,91^
vdi 0,6. Oieu nay'rat cd gia trj trong dg' \A^
dung khang^ sinh d nhdm viem tuy cap co" nguy cd cao nhiem khuan. A Muler va cong si/ dn rang procalcitonin >3,5ng/ml tot lidn gia Si CRP>430mg/l d 24h dau trong vi|c danh gia viem tuy cSp hoai tir, gia M prdcalcitdnin>3.8ng/ml tot hdn gia tii procalcitonin>430mg/l d ngay ttiil 3-4 trong
42
Y HOC VigT HAM THANG 5 - SO 1/2014 danh gia viem tuy cap hoai tir [ 2 ] . Woo nhan
thay procalcitonin h u y ^ thanh c» gia tri chan doan dung 77,3%, kem hdn vdi thang diem Ranson 9 3 , 2 1 % , UTdng tu* APACHE-II, va tot hdn thang diem CTSI-^65,4% trong tien lu'dng mii'c dp n3ng ciia VTC. Ong cung de xuat procalcitonin huyet thanh co the thay the diem APACHE-II cho du'doan mu'c do nang cua viem tuy cap [ 5 ] .
^ Ket qua pghien CLTU cua chung toi thay rang khong co moi tu'dng quan tuyen tinh giife nong do procalcitonin va nong CRP vdi (r » 0,10), p=
0,302, y = 0,137x + 14,665. Muller nhan thay glu^ procalcitonin va CRP co moi lien quan vdi r=0,434 [ 2 ] , Trong nghien CUXJ cua chung toi thay ring khong c6 moi tu'dng quan tuyen ti'nh giu:a nong do procalcitonin va so ludng bach cau vdi (r
» - 0,15), p= 0,118, y = -• 0,037x + 14,268.
Khong co moi tu'dng quan tuyen tinh giu^ nong dp procalcitonin vdi so lu'dng tiach cau da nhan trung ti'nh vdi (r=0,063), p = 0,528, y = 0,352x+10,88.
Nhu" vSy nghien CLTU cua chung toi thay rang si/
tang hoac giam ham lu'dng procalcitpnin hpan toan dpc lap vdi nong dp CRP, so lu'dng bach CBU, so ludng bach cSu da nhan trung tinh, dieu nay mpt I3n nii^ npi len y nghia dac biet cua nong do procalcitonin huyet thanh trong viem tuy cap nang so vdi cac dau an viem khac.
V. Kil LUAN
N5ng dp procalcitonin trung binh d benh nhan viem tuy cap la: 8,24±20,79ng/ml.
procalcitonin cao hdn co y nghla thong ke d nhom CTSI>7 (29,55±33,18ng/ml) so vdi nhdm
c r s i < 7 ( l , 1 4 ± l , 1 7 n g / m l ) ; d nhom hoai tu' (16,38±27,53ng/mi) so vdi nhdm khong hoai tu":
0,411±0,51ng/ml. Procalcitonin la mpt dau an viem dang tin cay du" bao mu'c dp nang va bien chulig nhiem khuan cua viem tyy cap
TAI UEU T H A M KHAO
1. Norton 3., Berger G., Phillip P et al (2001).
Acute pancreatitis. Harrison's Pnncipal of Internal Medicine Mc Graw Hii: 1788-1804
2. Muller CA., Uhl W., Printzen et al (2000):
Role of procalcitonin and granulocyte colony stimulating lector in the early prediction of infected necrosis in severe acute pancreatitis. Gut;
46:233-238
3. Kylanpaa Back M L , Takala A., Kemppainen EA et al (2001) Procalcitonin strip test in the early detection of severe acute panaeaKtis. BriO^
Journal of surgery society 88:222-271.
4. Mofidi R., Suttie SA., PattI PV (2009). The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: Systematic review; 146: 72- 81
5. Woo SM., Noh MH., Kim BG (2011).
Comparison of serum procalcitonin with Ranson, APACHEII, Glasgow and Balthazar CT severity index scores in predicting severity of acute pancreatitis . Korean J Gastroenterol; 58:31-33 6. Berger HG., Rau BM (2007) Severe acute
pancreatitis: Clinical course and management . World! Gastroenterol; 13 (38): 5043-5051 7. Nguyen Viet Hung, N g u y i n Van Tir(2008).
Danh gia su* thay doi protein C, Lactate dehydrogenase, hematocrite trong b?nh nhan viem tuy cap. Tap chiy hgc thut hanh; 10:12-15
THirC TRANG NHIEM HIV TREN DOI TirgNG NGHIEN MA TUY TA! TRUNG TAM GIAO DUC LAO D O N G • PHUC H 5 I S U C K H O E
T H A N H P H O HAI PHONG - NAM 2 0 1 2
Khoa Nang Quyen*, Vu Oiirc Long**, Ph^m Van Hin***
T6MTAT
Nghien ciiU ve thi/c trang nhiem HIV tren doi tui^g nghidn ma tuy tai Trung tam Giao due lao dpng - Phuc h3l sufc khoe Hai Phong, k ^ qua cho thay ; Co
• Tnmg tSm Kiem dfch Y teHai Phdng
• * TnJkmg Cao dSng Y teHai Phdng '** Tmdng 0^1 hgc Y Dupc Hal Phong Phin bl$n khoa hgc: GS. TSKH Nguyen VSn Hieu
35,7% doi tu'dng nghien ma tuy nhiem HIV, trong do nhom tuoi 20-29 co ty le nhiem cao nhat (57,3%); hau het doi tu'dng nhiem HIV sinh song 6 thanh ph6(91,7%); chiem da phan la chu^ ket hon (55,8%);
hau het co trinh do trung hpc pho thong (52,6%) va trung hpc ca sd (38,9%); chiem da phan (60,4%) khong co viec lam on djnh; thdi gian sir dgng ma tily tru'dc l<hi vao trung t5m chiem ty le cao nhlit IS > 3 nam (38,5%).
