Tap 5- So 3/2010 TAP CHi Y DUOC LAM SANG 108
N g h i e n c u u r o i l o a n l i p i d m a u a b e n h n h a n s u y t h a n m a n Study on the dyslipidemia in chronic renal failure patients
Bui Anh Tuan Benh vien 175
Tom tat
Nghien cim roi loan lipid mau d 151 benh nhan suy than man cac giai doan dieu tri tai BVDK Cu Chi - TPHCM ttf thang 10/2008 - 10/2009. Ket qua cho thay: Ty le rdi loan lipid mau chung la (64,90%), chu yeu la tang Triglycerid (41,05%), giam HDL-C (39,07%) va tang dan theo giai doan suy than, cao nhat d nhdm suy than man giai doan cudi lgc mau chu ky (N3), ty le cd tang ve Cholesterol toan phan (35%) va Triglycerid (52%) d nhdm N3 cao hpn ro ret so vdi 2 nhdm (Nl, N2), lpc mau chu ky khdng lam giam dtfdc ty le rdi loan lipid mau. Ty le roi loan lipid mau do nguyen nhan viem cau than man cao nhat: 47.96%, tiep dd la viem than be than man: 28,57%, dai thao dtfdng: 13,27%.
Summary
The prevalence of dyslipidemia was 64.90%, mainly was the hypertriglyceridemia (40.05%), the percentage of low HDL cholesterol was 39.07%. The more serious stage of renal failure, the more frequence of dyslipidemia. In ESRD patients, prevalences of hyperglyceridemia (52%) and hypercholesterolemia (35%) were more than those in stage 1,2 renal failure patients (p<0.05). Chronic hemodialysis did not change the rate of dyslipidemia. The percentage of dyslipidemia was highest in glomerulonephritis (47.96%), secondly in the interstitial kidney disease (28.57%), and finally in the diabetes (13.27%).
1. Dat van de
Trong benh ly than man, cd hang loat yeu td thuc day lam tdn thtfdng than tien trien dd la: che dp an giau dam, hoat hda ctia he thdng Renin- Angiotensin - Aldosterol trong than, ket dinh tieu cau trong cau than, tang huyet ap va rdi loan chuyen hda Lipoprotein..., trong dd rd'i loan thanh phan Lippprptein gap kha php bien [3]. Cung nhtf tang huyet ap, rdi loan chuye'n hda Lipoprotein vtfa la nguyen nhan vtfa la hau qua ciia qua trinh suy than man. Rdi loan Lipoprotein cd the la mdt mat xich quan trpng trong vong xoan benh ly than. Cd tac gia con nhan thay cac bien chtfng thieu mau, nhiem triing, suy dinh dtfdng va dac biet bien chtfng tim mach la nguyen nhan hang dau gay ty le tir vong cao d benh nhan suy than man. Rdi loan lipid mau la yeu td trpng tam trong hinh thanh vtfa xd dpng mach vanh [4].
Hien nay, benh suy than man ngay cang gia tang tren toan the gidi ndi chung, trong cpng ddng ngtfdi Viet Nam ndi rieng. Vi vay, chung tdi tien hanh nghien ciru Phan bien khoa hoc: PGS TS NGUYfzN VAN QUYNH
de tai nay nham muc tieu: Khao sat dac diem va ty le rdi loan lipid mau d benh nhan suy than man.
2. Doi tirdng va phirdng phap nghien ctfu Nghien ciru tien ctfu, md ta cat ngang cd so sanh (tir thang 10/2008 - 10/2009 tai benh vien da khoa khu vtfc Cu Chi - TP HCM) tren 151 benh nhan suy than man cac giai doan, tud'i tir 18- 76, dtfdc chpn ngau nhien va dtfdc chia thanh 3 nhdm. Nhdm I (Nl) gom 70 benh nhan suy than man dp I-II, nhdm II (N2) gom 41 benh nhan suy than man dp Illa-IIIb (hai nhdm nay dtfdc dieu tri bao tdn), nhdm III (N3) gom 40 benh nhan suy than man giai doan cudi dieu tri bang lpc mau chu ky.
Tieu chuan chpn benh: benh nhan dtfdc chan doan suy than man, cd MLCT < 60 ml/phut, creatinin HT >130 umol/l.
Tieu chua'n loai trir: loai khdi nghien ctfu nhtfng benh nhan suy than man do benh he thdng, ung thtf,
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.5-N°3/2010 dang dieu tri bang corticoid, dang uong thudc ha lipid
mau.
Cac tieu chuan chan doan suy than man dffa theo phan loai cua Nguyen Van Xang (1997) [2];
Benh nhan dffdc kham lam sang ti mi, lam cac xet nghiem: huyet hgc, sinh hda, tdng phan tich nude tieu, ECG, sieu am, X-quang tim phdi va dffdc xac chan la suy than man cac giai doan, sau dd dffdc dinh Iffdng cac thanh phan lipid mau nhff: Cholesterol toan phan, Triglycerid, HDL-C, LDL-C.
Xet nghiem dffdc tien hanh tren may sinh hda tff ddng ADVIA 1650 cua Nhat Ban. Yeu cau tru'dc xet nghiem: benh nhan nhin ddi vao budi sang, toi horn trffdc khdng sff dung cac chat nhff rffdu, bia, an nhieu chat ngpt.
Phan loai rd'i loan lipid mau theo khuyen cao cua Hpi Tim mach Viet Nam (2004), chan doan roi loan lipid mau khi cd tff > 1 trong cac chi tieu sau:
Cholesterol tean phan > 5,2 mmol/l, Triglycerid > 2,3 mmol/l, LDL-C > 3,9 mmol/l, HDL-C < 0,9 mmol/l.
Phan tich va xff ly so lieu theo phffdng phap thdng ke y hpc cd sff dung phan mem SPSS.17.0.
3. Ket qua
3.1. Dac diem cua benh nhan theo tuoi va gidi
66 benh nhan nam (43,7%) va 85 benh nhan nff (56,3%). Trong ca 3 nhdm Iffa tudi 50-59 chiem ty le cao nhat (47,5%) va it nhat la Iffa tudi > 70 (2,6%).
3.2. Dac diem va ty le rdi loan lipid mau d benh nhan suy than man
Bang 3.1. Phan bd ty le benh nhan theo nguyen nhan suy than man Nhdm
Ng nhan Nhdm Nl (n=70) N2 (n=41) N3 (n=40) Tp'ng (n=151)
Ng nhan n % n % n % n %
VCTM 23 32.28 28 68.29 22 55.0 73 48.34
VTBTM 27 38.57 5 12.19 7 17.5 39 25.82
DTD 7 10.0 3 7.3 9 22.5 19 12.58
Than da nang 0 0 5 12.19 2 5.0 7 4.63
Ng nhan khac 13 18.75 0 0 0 0 13 8.6
Ceng 70 100 41 100 40 100 151 100
Nghien effu gap 5 nguyen nhan chi'nh gay suy than man, trong dd viem cau than man chiem cao nhat (48,34%), than da nang thap nhat (4,63%).
Bang 3.2. Ty le mdt sd trieu chffng toan than d cac nhdm Nhdm
Trieu chffng~-~~-^ Nhdm Nl (n=70) N2 (n=41) N3 (n=40) Tong (n=151)
Trieu chffng~-~~-^ n % n % n % n %
Met mdi 30 42.85 38 92.68 29 72.5 97 64.33
Gay sut 17 24.30 21 52.20 8 20.0 46 30.50
RL giac ngu 35 50.0 37 90.24 27 67.5 99 65.56
Sot 7 10.0 13 31.7 11 27.5 31 20.52
Phu 27 38.57 18 43.9 7 17.5 52 34.43
Thieu mau 13 18.57 31 75.6 18 45.0 62 41.05
Tang huyet ap 24 34.28 37 90.24 16 40.0 77 50.99
Gap 7 trieu chffng toan than chinh d cac nhdm nghien effu, trong dd rdi loan giac ngu chiem ty le cao nhat 65,56%, met mdi 64,23%, gay silt 58,94%, tang huyet ap 50,99, thieu mau 41,5%, phii: 34,43%, sot 20, 52%.
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Tap 5-So 3/2010 TAP CHi Y DUOC LAM SANG 108 Bang 3.3. So sanh ty le roi loan lipid mau giira cac nhdm
~~~~----____^ Nhdm
Mifc dd ~~ ~-~—________ Nl (n=70) N2 (n=41) N3 (n=40)
~~~~----____^ Nhdm P
Mifc dd ~~ ~-~—________ n % n % n % P
CT toan
phan Cd tang 10 14.28 10 24.40 14 35.00 pl,p2,p3 <0.05 CT toan
phan Khdng tang 60 85.72 31 75.60 26 65.00 pl,p2,p3 <0.05 TG Cd tang 17 24.30 17 41.5 21 52.50 pl,p2,p3 <0.01 TG Khdng tang 53 75.50 24 58.5 19 47.50 pl,p2,p3 <0.01 HDL-C Cd giam 27 38.60 22 56.40 26 65.00 pl,p2,p3 >0.05 HDL-C Khdng giam 43 61.40 17 43.60 14 35.00 pl,p2,p3 >0.05 LDL-C Cd tang 13 18.60 8 19.52 10 25.00 pl,p2,p3>0.05 LDL-C Khdng tang 57 81.40 33 80.48 30 75.00 pl,p2,p3>0.05 ty le cd tang TG cung tang dan rd ret tu" nhdm I den nhdm III(p<0,05).
Bang 3.4. So sanh ty le rdi loan lipid mau git/a cac nhdm
~~~~~~--___^^ Nhdm
Tinh trang~~\___ ~~~~~~--___^^ Nhdm Nl (n=70) N2 (n=41) N3 (n=40) Tdng (n = 151)
Tinh trang~~\___ n % n % n % n %
Cd rdi loan 24 34.28 35 85.36 39 97.50 98 64.90
Khdng RL 46 65.72 6 14.63 1 2.50 53 35.10
P < 0.05 < 0.05 < 0.01 < 0.05
Cpng 70 100 41 100 40 100 151 100
Ty le cd rdi loan lipid mau trpng nghien CLVU gap la 64.9% cap hdn rc ret vdi (35.1%) benh nhan khdng rdi loan (p<0,05).
Bang 3.5. Phan bd ty le rdi loan lipid mau theo nguyen nhan
~~~~~~---_____^ Ty le theo nhdm Nguyen nhan ~~~~^-_____^^
Nhdm I
(n = 24) Nhdm II
(n = 35) Nhdm III
(n = 39) Tdng sd (n = 98)
~~~~~~---_____^ Ty le theo nhdm
Nguyen nhan ~~~~^-_____^^ n % n % n % n %
Viem cau than man 10 41,66 18 51,42 19 48,71 47 47,96 Viem than - be than man 7 29,16 9 25,71 12 30,76 28 28,57
Dai thac dirdng 3 12,5 5 14,28 5 12,82 13 13,27
Than da nang 0 0 1 2,85 2 5,12 3 3,06
Nguyen nhan khac 4 16,67 2 5,71 1 2,56 7 7,14
Tdng cdng 24 100 35 100 39 100 98 100
Ty le rdi Ipan lipid mau trong nghien ciru gap nhieu nhat do nguyen nhan viem cau than man (47,96%;
bep den la viem than - be than man (28,57%), dai thao dirdng (13,27%), va thap nhat la than da nang (3,06%).
4. Ban luan
Theo Kerller M (1998) cac nguyen nhan gay suy than man thiTdng gap d chau Au la: VCT (20-35%) VT-F3T (10-20%), benh mach mau than (7-16%), tieu dirdng (3.8-17%), khdng rp nguyen nhan (10-18%).
6 My nguyen nhan gay STM chii yeu la cac benh chuye'n hda nho tieu duong (36,2 - 40,3%), tang huyet ap (27,1 - 29,7 %), viem cau than (11-12,9%).
Thep Dinh Thi Kim Dung (2004), nguyen nhan STM thiTdng gap la VCTM, VT-BT man, tiep dd la cac benh 13
JOURNAL OF 108 • CLINICAL MEDICINE AND PHARMACY Vol.5-N°3/2010 ve mach mau than. Ket qua cua nghien cufu nay phii
hdp vdi nhan dinh ciia cac tac gia tren.
Dittmer.ID (1998) gap rdi loan giac ngu 59.61%, met mdi 100%, gay sut 70,5%, tang huyet ap:
69.23%, thieu mau: 46.53%, phii 29,13%, sdt:
22,6% [5]. Ket qua ve ty le rdi loan giac ngu, gay silt, thieu mau, phii va sdt trong nghien cifu nay ttfdng ty nho ciia Dittmer ID, trong khi ty le met mdi trong nghien effu nay thap hdn tac gia. Sd dT nhii vay la vi suy than man la mdt benh toan than, chinh vi the d ddi tffdng benh nhan nay thffdng bi rdi loan ca ve tim mach, hd hap, tam than kinh, ndi mdi, tinh trang iff dong cac chat ddc trong mau nhu" ure, creatinin gay ngira, ia long... gay nen gay silt, met mdi. Tuy nhien, ty le met mdi ciia chiing tdi thap hdn tac gia cd the do day la mpt trieu chffng cd nang nen khdng dac hieu.
Ty le rdi loan lipid mau tang dan theo miic dp suy than man, cac nhat cf nhdm III (97,5%) va cao hdn rd ret so vdi nhdm I & II (p<0.05) ket qua nghien effu nay tffdng tff nhff ciia Monzani.G va Cs (1996), Dinh Thi Kim Dung (2004) [1], [6]. Cc the ndi ty le rdi loan lipid mau d nghien effu nay kha cao, tuy rang viec xac dinh cd hay khdng cd rdi loan lipid mau chi cd gia tri trong mpt thdi diem, bdi chi'nh vi cac chi so lipid mau cung bien ddi ndng dp tiiy thudc vao che dp an udng, mffc dp luyen tap the lyc va benh nhan cd dffdc diing thudc ha lipid mau hay khdng ?
Ket qua nay tffdng tff nhff nhan xet ciia Dinh Thi Kim Dung (2004), Nguyen Thi Ngoc Linh (2005). Nhff vay, rdi loan lipid mau gap d tat ca 5 nguyen nhan, roi loan lipid mau dp nguyen nhan viem cau than man da nang va nang ne hdn cac nguyen nhan khac, dieu nay cung phii hdp vdi tinh trang rdi ban cac thanh phan lipoprotein tram trpng 6 benh nhan viem cau than man khi chtfa cd suy than. Cd che day dii ve sff tang td'ng hdp va giam thoai hda Lipoprotein d benh nhan viem cau than man dffdng nhff chffa dtfdc xac dinh rd ret, mac dii da cd kha nhieu nghien effu dffa ra mdi lien quan giffa protein nieu, giam ndng dp albumin huyet thanh va tang ndng dp Cholesterol toan phan.
Ban ve sff thay dd'i ndng dp Cholesterol TP d benh nhan suy than man y kien nhieu tac gia cung rat khac nhau, cd tac gia thay ndng dp Cholesterol hau nhff khdng dd'i SP vdi ngffdi binh thffdng, tac gia khac lai thay nong dp nay tang len rp ret d benh nhan suy than man. Dinh Thi Kim Dung (2004) nhan thay ndng
dp Cholesterol tang dan theo mffc dp suy than man va cao nhat d nhdm suy than man lpc mau chu ky [1].
Ngffdc lai Bergesio F (1992) nghien effu d benh nhan chtfa lpc mau chu ky nhan thay rdi loan cac thanh phan lipoprotein xuat hien sdm ngay tff giai doan I va bieu hien chii yeu d CT va HDL-C, cdn TG va LDL-C khdng thay ddi so vdi gidi han binh thffdng [4].
5. Ke't luan
Qua nghien effu rdi loan lipid mau d 151 benh nhan suy than man cac mffc dp dieu tri tai BV Cii Chi- TP HCM tff 10/2008-10/2009 chiing tdi rut ra mdt sd ket luan ve dac diem va ty le rdi loan lipid mau d benh nhan suy than man nhff sau:
Ty le rd'i loan lipid mau chung la 64.9% va chii yeu la tang Triglycerid (41.05%), giam HDL-C (39.07%).
Ty le rdi loan lipid mau tang dan theo giai dpan suy than va cao nhat d nhdm suy than man giai doan cudi lpc mau chu ky (N3), ty le cd tang ve Cholesterol tpan phan (35%) va Triglycerid (52%) d nhdm N3 cao hdn rd ret sc vdi nhdm (Nl va N2), lpc mau chu ky khdng lam giam dffdc ty le rdi loan lipid mau.
Ty le rdi loan lipid mau do nguyen nhan viem cau than man cao nhat: 47.96%, tiep do la viem than be than man: 28,57%, dai thao dtfdng: 13,27%.
Tai lieu tham khao
1. Dinh Thj Kim Dung (2004), "Nghien ctfu rdi loan Lipoprotein huyet thanh d benh nhan suy than man"
luan an tien si y hpc - DH YHN.
2. Nguyen Van Xang (1997), "Mdt SP chuyen de chan dean, dieu tri benh than", tai lieu bd' tuc cho BS, phuc vu cho tap huan diuyen nganh npi khoa Ha Npi.
3. Attman P-0.(1997), "Lipid Abnormalities in proressive Renal Inuficiercy", Lipid and the Kidney.Contr.Nephrol.Basel, Kagrer, Vol 120, pp 1 -10.
4. Bergesio F (1992), "Lipid and apolipoprotein change during the progression of chroric renal failure", Clinical Nephrology, Vol.38, pp 264 -270.
5. Dittmer LD. (1998), "Pulmonary ospeets in patients with long term hemo dialysis", Clin. Nephrol, 49(1), pp.66.
6. Monzani. G, Bergesio. F (1996), "Lipoprotein Abnormalities in Chronic renal failure and Dialysis Patiens", Blood Punf, 14, pp 262-272.
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