Y HQC VigT HAM THANG 6 • s 6 2/2011
^^ KIEM SOAT CHUYEN HOA BENH N H A N D A I THAO D10NG DIEU TRI NOI TRU TAI BENH VIEN TRUNG UffNG HUE
Oao Thi DuTa*
T 6 M TAT
D$t vSn de v i mMC t i i u nghlSn cu'u: B^nh d^i thao du'dng (OTO) 1^ b?nh ly n$l tiet-chuye?n h o i b§nh pho bien to^n cSu. Ccic Hi^p hpi da khuy§n do v§
chien lupc dieu trj theo nhOtig tieu chl ngiy cing nghiem ng§t hdn, nhSm nSng cao chft lUpng cupc sSng ngu'di b^nh. Chiing toi tien hcinh nghien ciru d i t i i nay nhSm 2 myc tieu sau: 1) Khio sit tinh trgng ki^m soit chuyen hoa d b^nh nhin d i i thio du'dng t^i thdi diem mdi nhgp vi?n. 2) Dinh g i i ki^m soit chuyen hoi d b#nh nh§n dii thio dudng sau dpt di§u tri n$i bii.
Doi hr^rng v^ phuung phip: 330 b ^ h nhin dul;fc chiin doan OTO theo tieu ctiuSn oia Hpi DTO Hoa Ky:
Quose huyet thanh lie da > 7 mmol/l. Phudng phip mota cit ngang va tien OXJ. B|nh nhan dupe khim lam sang va xet nghiem sinh hoi nhu' glucose miu doi, HbAlC v i bilanlipid sau dpt dieu tri npi tnj.
Ket qua: T^i thdi diem nhap v i ^ : nong dp glucose miu doi aia b|nh nhan DTD la i5,55±6,97mmol/l, ty so HbAlC la 11,58±3,95% va ty l§ benh nhan Idem soat glucose mau kem > 80%; nong dp cholesterol, triglyceride, LDL-C va HDL-C (an lUdt la 5,88±l,67mmoi/l, 3,90±2,18mmol/l, 4,ll±0,22mmol/l, l,01±0,35mmol/l, va ty le tang cholesterol, triglycende, L£»L-C > 40%. Tai thdi diem xuat v i ^ : glucose miu ddi va MbAlC giam cd y nghia thong ke so vdi khi mdi nhap vien (p < 0.01), ty le benh nhan dat mire kiem soat glucose mau tot va chap nh?n dupe > 70%; cac thong sd lipid deu du'pc cai thien t ^ so vdi khi mdi nhap vien (P < 0,01).
Ket luan: sau dot dieu dieu trj trung binh 22±15 ngay, kiem soit chuyen hoa d benh nhan dai thio du'dng cii thien tdt.
Td' khda: B^nh dai t h i o du'dng, glucose m i u doi, chuyen hoa.
ABSTRACT
STUDY CONTROL OF METABOLISM IN DIABEHC PATEINTS AT HUE CENTRAL HOSPITAL Background and objective: Diabetes are metabolic-endocrinologic diseases. They are popular throughout tfie world. The Associations recommendations of treated strategy were more and more severe standards to raise quality of life in diabebe patients. The objective of this study were:l) To Study control of metabolism in diabetic patients at hospitalized time. 2) J"o estimate control of metabolism In diabetic patients at discharged time
Patients and method: 330 patients were diagnosed diabetes belong to American Diabetes
* B$nh vi$n TW Hu^
Phan bign khoa hgc: GS.TS. NguySn HaJ Thdy
Association criteria fasting plasma glucose a 7mmot/l with method of cross description, clinical examination and blood biochemically examine such as festing plasma glucose, HbAlC, lipidemia.
Results: At hospitalized time. In diabetic patients, average fasting plasma glucose level were 15.55±6.97mmol/l, HbAlC value 11.58±3.95% and proportion of poor glycemie conbol was more than 80%; level of cholesterol, triglyceride, LDL-C, HDL-C were successive 5.88±1.67mmol/l, 3.90±2.18mmotA 4.11±0.22mmol/l, 1.01±0.35mmol/l and Inaeasing proportion of cholesterol, triglyceride and LDL-C were more than 40%. At discharged time, festing plasma glucose level were signifkantiy lower (p < 0.01) compared with ones at hospitalized time and proportion of good and optimal glycemie control were more Uian 70%; the parameters of lipid were improved (p< 0,01) compared with ones at hospitalized time.
Conclusion: Afer a course of treatment (22,15 days), metabolic control in diabetk: patients was improvement.
Key word: Diabete mellitus, festing plasma glucose, metabolism
I. Oi^l V&N D I
Benh dat thao du'dng (OTO) la mpt benh ly npi tiet-chuyen hoa da du'dc biet tir rat lau, la c3n benh pho bien toan rau. Theo bao cao cua Hiep hpi OTO quoc te (Internationa Diabetes Federation), benh co xu hu^ng phat trien rat nhanh trong mpt thap ky trd lai day. Tai Vi?t nam, ty le nay cung gia tSng nhanh, vdi ^ truhg la tSng glucose mau man tinh, DT 0 gSy ra nhieu bien chuhg cap tinh va man ti'nh. Cac Hiep hpi da khuyen cao ve chien l u ^ dieu bi theo nhii'ng tieu chf ngay cang nghiem ngat hdn, nhSm nang cao chat lu'dng cupc song nguifi benh. Xuat phat tu" nhuhg van de tren, chiing t^
nghien ciAi de tai nay nhim muc tieu sau:
Muc tieu nghiSn cuTu
1. Khao sat tinh trang kiem soat glucose mau va lipid mau d benl^ nhan dai thao du'dng tai thdi diem mdi nhap vien.
2. Oanh gia kiem scat chyen hoa d benh nhan sau ddt dieu tri ndi tru
Y HQC VigT NAM THAMG 6 - s6 2/2011
II. OOI TUQNG VA PHUONG PHAP NGHIEN COU 2.1 Coi tu'dng: 330 benh nhan OTO dieu tri noi tru tai benh vien Trung u'dng Hue tit thang 7-2006 den thang 7-2009.
2.1.1. Tieu chuSn chpn ddl tupng nghiin cifu: chan doan OTO theo tiSu chuan cua Hpi OTO Hoa l<y. Trong nghien cu\l nay chung toi dinh lu'dng glucose mau doi de chan doan: glucose huyet thanh luc doi > 126mg/dl.
(> 7 mmol/l).
2.1.2. Tieu chuan loai trCr: tSng glucose mau phan irtig nhu' bj sang chan Hnh than, benh tat...), t5ng glucose mau do thuoc nhu* rarticoit, chuyen dung djch co duicJng...
2.2. PhifOng ph^p: phu'dng phap tien ciiXi va mo ta c3t ngang.
2.2.1, Tong quit ve d6i tUpng nghien cihi: tuoi (nam), gidi, typ OTO, thdi gian phat hien benh OTO (nam), thdi gian dieu tri trung binh (ngay)
2.2.2. Binh gii kiem soit glucose miu nitc k l l m soit 1 Tot Glucose mau doi
Qii so HbAlc
< 6,7mmal/l
< 7%
theo hu'dng dSn cua hoi DTB Hoa Kv Chap nh^n
6,7-7,8mmol/l 7-8%
Kem
> 7,8mmol/l
> 8 %
2.2.3.Bllan lipid: Theo chiJng cua may, gia tri binh thudng cholesterol< 5,2mmol/l; triglycerid
<2,3mmol/l; HDL-C > Immol/I; LDL-C < tmmol/i.
2.2.4, XCfiy so ii$u: SiJ dung cac thuat toan thong ke y hoc
III. KlT QuA NGHIEN CCfU
3.1. Tong quat ve tfoi tu'dng nghien CIJ'U Bang 3.1. Tong quat ve doi tu'dng nqhien cutj
So lu'dng benh nhan f n l Gidi (Nam/Nu) DTOtvn Tuoi ddi fnSml
Thdi gian phat hien benh (nam) TTidi qian dieu tri trunq binh (nqay)
330 110/220 10,61%
52,7±19,6 S,5±6,70 22±15
Oieu trj npi tru benh nhan dai thao du'dng trung binh la 22 ±15 ngay.
3.2. Kiem soat chuyen hoa d benh nhan dai thao du'dng tai thdi di^m nhap vi§n Bang 3.2. Kiem scat glucose mau thdi diem nhap vien
Nhom nghien cAU 303 benh nhan
Glucose mau (mmol/l) 15,55±6,97
HbAlC C/o) 11,58±3,95 Mu'c kiem soat
T a ( % i Chap nhan f%) Kem(%) P
00 11,55 88,45
<0,01
00 13,60 86,40
<0,01 Gan 9 0 % benh nhan Idem soat glucose mau item
- 'Bana 3 . 3 . BIlin lipid mau d benh nhan thdi diem nhap vien va xuat vien Thong s£
Cholesterol (mmol/l) Triglycerid (mmol/l) HDL-ammoi/l) LDL-C (mmol/l)
Nh$p vien 5,88±1.67 3,90±2,18 1.01±0.35 4.11±0,22
XuS't vien 5,02±0,55 2,98±0,18 1,24±0.66 3,68±0,74
P
< 0,05
<0,05
>0,05
<0,05
il Bilin lipid mau 6 benh nhan thdi diem xuat vien da kiem soat tu'dng d5i tot
Y HQC VigT NAM THANG 6 - SO 2/2011
Bleu tfo 3.1. Ty le tSng cic thong so lipid mau Ty le tSng cic th6ng so lipid 6 thdi di^m xuSt viSn glim so vdi nhap vien.
3.3. Ki£m soM chuyen hoi d b$nh nhSn aU Vhio du'dng t^i thdi diem xuSt vi#n Bing 3.S. Kiem soat glucose mau d thdi diem xuat vien
Nh6m nghiSn cihi 330 benh nhSn DTD
Glucose m i u (mmol/l) 7.30 ± 2,19
HbAlc ( % ) 8,10 ± 1,38 Mi^c l(l£m s o i t
Tot (%) ChSp nhSn (%) Kim (%) P
13.62 61,09 25,29
<0,01
08,56 50,19 41,25
< 0,01
Glucose mau va HbAlC giam ro so vdi thdi diem nhap vien (p < 0,01).
3.4. So sinh kiem soit chuyen hoi d b^nh nhin dii thio du'dng d 2 thdi diem Bing 3.6. Nonq dd trunq binh glucose mau doi va chi so HbAlC
Thong so sinh hoa Glucose mau doi (mmol/l) (n=330) HbAlc (%) (n=255)
Nhap vien 15,55±6,97 11,58±3,95
Xuat vien 7,30±2,19 8,10±1,38
P
<0,01
<0,01
Khi xuat vien, nong dp glucose mau ddl va ty s5 HbAlc deu giam ro {p < 0,01) IV. BAN LUiBkN
4.1. Kl^m so^t chuyen hoa d b|nh nhan a&i th&o du'dng tai thdi diem nhap vifn
- Kiem soat glucose mau: qua nghien ciru 330 benh nhan OTO dieu tri npi tru trung binh 22 ngay, chiing tdi ghi nhan d thdi diem nhap vien, nong dd trung binh glucose mau ddi la 15,55±6,97mmol/l va ty so HbAlC la 11,58±3,95%, thuoc vung kiem soat kem > 80%.
Ndng dp glucose mau ddi phan anh tinh trang kiem soat glucose mau ddf tiTc thi trong ngay, nhieu nghien ciru ghi nhan glucose mau ddl cao hdn mire binh thu'dng ciJng lien quan den c^c bien chirng cap tinh va man ti'nh d benh nhan OTO [1], [4]. Nghien ciTu ciia UKPDF (United Kingdom Prospective Diabetes Study) da ket luan kiem soat glucose mau tot thi se giam ty- le bien chiing d benh nhan OTO cd y nghTa thong kie (P < 0,052). Nghien ciitj ciia Vo Bao Dung tren 317 benh nhan OTO dieu tn npi tni tai benh vien da klioa tinh Binh Oinh luc nhap vien la
15,19mmol/l. Theo Nguyen Hai Thuy va CS, 62%
benh nhan co miit kiem soat glucose mau kon va nong dp glucose mau tnjng binh la 13±4,6 mmol/l. Ty so HbAlc phan anh tinh trang glucose mau trong vdng 2 den 3 thang \3\.
Diabcare-Asia (2003), ty so HbAlc d benh nhSn OTO la 8,5±2,3%, va chi 28,4% benh nhan coti so HbAlC < 7%, thuoc viing kiem soat tot [5].
Nhu" vay, nghien cull ciia chiing toi phii hdp vdi mpt so nghien ciru trong nu'dc va ngoai nUdc.
• Kiem soiit cdc thong so lipid mau:
Nghien ciili cua chung tdi ghi nhan benh ntiSn OTO khi mdi nhap vien co nong do cholesterol, triglyceride, LDL-C, HDL-C lan lutttv la 5,88±l,67mmol/l, 3,90 ± 2,18mmol/l, 4,lli^
0,22mmol/l, deu 6 trong gidi han benh ly, rilng n3ng dp trong gidi han binh Xh\0i (l,01±0,35mml/l), va ty le tang cac thong s6 lipid deu tren 40%.
Theo Diabcare-Asia (2001), hau het cac
thong so lipid mau d benh nhan DTO deu bj rfi
72
Y Hpc VlgT HAM THAHG 6 • s 6 2/2011 loan Nghign ciru ciia To VSn Hal ghi nhan rdi
loan lipid mau d benh nhan OTO kha cao, dSc biet OTO typ 2 ts'ng cholesterol 54,5%; tSng triglycerid 43,00%, tang LDL-C 2 6 % va giam HDL-C 35,8% [ 2 ] , [ 3 ] . Nghien ciru ciia Nguyen Hai Thuy va CS cung cho thay 6 1 , 2 % benh nhan OTO cd rdi loan lipid mau [ 3 ] . Nhu' vay, nghien cuU ciia chung toi phii hdp vdi mpt so nghien cilhj trong nu'dc va ngoai nuTdc.
4 . 2 . K i ^ m s o M c h y e n hod d b g n h nhSn dSi t h a o d u d n g t ^ i t h d i d l € m x u a t v i ^ n ( s a u ddt d i e u t r j n p i t r u 2 2 n g a y )
- K i e m s o a t g l u c o s e m a u : nong dp glucose mau ddi la 7,30±2,198mmol/l va ty so HbAlC la 10±1,38, gtam cd y nghTa thdng ke vdi P < 0,01 so vdi thdi diem nhap vien va dat miTc kiem scat ixit va chap nhan diiUc > 7 0 % .
Nghien ciru ciia Vo Bao Dung trSn 317 benh nhan OTO dieu tri npi t r u , khi nhap vien la glucose mau ddi la 15,19mmol/l va xuat vien la 8,24mmoI/l, ty Ie benh nhan dat mu'c kiem soat tot la 7,57%, mite chap nhan "du'dc ta 17,66%.
Diabcare-Asia (2003), nong d p gtuoDse mau ddi benh nhan OTO la 8,9±3,5mmol/l, va chi cd 37,4% thupe vung kiem scat tot. Nghien ciitJ DCCT (Diabetes Control and Complication Trial) keo dai hdn 7 nam da khuyen cao rSng dieu tri tich ci/c cho benh nhan DTD typ 1 de dat du'dc Idem soat glucose mau d miTc binh thudng ^ i giam duWc nguy cd bien chiing mach mau. Theo Diabcare-Asia (2003), ty so HbAlc d benh nhan OTO la 8,5±2,3%, va chi 28,4% benh nhan cd ti sd HbAlC < 7%, thuoc viing kiem soat tot [ 3 ] . Theo Nguyen Hal Thuy va CS, 8 4 % benh nhan d mu'c kiem soat kem [ 3 ] . Nghien diu ciia chiing toi ghi nhan benh nhan dieu tri npi t a i nong do glucose mau cung nhu* t y so HbAlc sau mpt ddt dieu b i trung binh 22±15 ngay, co ty le tu'dng ddi cao dat mute kiem soat chap nhan du'dc.
- Kiem soat cdc t h o n g sS l i p i d : nghien aitj ciia chiing toi ghi nhan khi xuat vien cac thong so lipid cua b f n h nhan deu dude cai thien t£!t: nong d o cholesterol la 5,02±0,55mmol/l, triglycerid la 2,98±0,18mmol/l, LDL-C la 3,68±0,74mmol/l, HDL-C l,24±0.66mml/l va ty le tang cholesterol la 24,12%, tang triglycerid la 36,56% va LDL-C la 28,88%, giam cd )i nghia thdng ke v(S P < 0,05 so vdi thdi diem nhat vien.
Nghien ciilj ciia Ta v3n Binh trSn 150 benh nhan mdi phat hipn OTO da cd 65,3% roi loan lipid mau, trong dd tang triglycerid la 5 3 % , tSng cholesterol la 4 0 % va tang LDL-C ia 42,9%. Theo nghien ciru ciia Collis va CS,, nong dp cholesterol d benh nhan DTO la 5,7±1,03 mmol/l, triglycerid 2,3 ± 1,59 mmol/l, HDL-C 1,06 ± 0,36 mmol/l va LDL-C 3,2 ± 0,82 mmol/l, Nhu* vay, nghien ciitJ ciia Chung tdi phii hdp vdi mpt sd nghien ciiU trong nude va ngoai nUdc. roi loan lipid mSu la mpt roi loan chuyen hoa thu'dng gap nhat d benh nhan DTO, nhat la nhutig trudng hdp khong dutfc kieni soat glucose tdt.
V . KET LUiSiN
Gan 9 0 % benh nhan dai thao du'dng tai thdi cKem nhap vien kiem soat chuyen hoa kem. Sau ddt dieu trj npi trii, tren 7 0 % benh nhan ed kiem so^t chuyen hoa dat mire tdt va chap nhan du'dc.
TAI LIEU THAM KHAO
1. Tr^n Hihi Dang, Huynh VSn Minh va CS.
(2006), "Hpi chiihg chuyen hoa: mot van de thcfi dai, icet qua mpt so nghien edli d Hue", Ky yeu cac de tai khoa hpc-HQi nghi npi tiet & dai thao du'dng miSn trung lan thii' V, Bd Y te xuat ban, tr.
371-379.
2. Td V i n Hai vd CS. (2006), "Mpt so yeu to nguy cP gay benh dai thao dudng dieu tri. ngoai tni tei benh vien Thanh Nhan Ha Noi" Ky yeu cae de tai khoa hoc-Hpi nghj npi tiet 8t dai thcio dudng mien trung lan thii' V, B6 Y te xuat ban, tr. 91-99.
3. Nguyen Hai Thuy (2006), "Vai tro ciia glucose mao mach trong kiem soat dudng mau d benh nhan dai thao du'dng", T?p chf npi tiet va roi loan chuyen hoa. Bp Y te, tr. 37-42.
4. Cathy S., Rogers, David Lehmann. (2005), Bodily Pain, Poor Physical Functioning, and Poor Glycolic Control in Adults With Diabetes J. Diabetes Care (2001), A sun/ey- study on
diabetes management & diabetes complication status in Westem Pacific Region, pp. 21-30 6. International Diabetes Federation (2001),
•^Practical targets and treatments of type 2 diabetes Asian - Practic type 2 diabetes Policy Group", pp.18-19.
7. Diabetes Care (2003), A survey- study on diabetes management & diabetes complication status in Westem Pacific Region, pp. 21-30
