Y HQC VlgT NAM THANG 6 - S6 1/2011 4. Steven M Haffner ( 2 0 0 2 ) , " Djch te hpc b^nh
tim mach tren benh nhSn tieu du'dng typ 2", HOI thao nhan phien hpp thudng nien ciia hi^p h$i DTD chau Au, Hungary; tr. 8 - 11.
5. Bulger A l , Aroson D (2001)," EfTiect of diabetes mellitus on heait rate variability in patients with congestive heart failure", Padng - Gin -Bedrophyslol, 24(1); pp. 214-32.
6. Duanping Uao, Mercedes C, Gregory W Evans, Wayne E Casdo, Gerardo Heiss (2002)," Lower
heart rate variability is associated with the development of coronary heart disease individuals with diabetes: the Atherosclerosis Risk in Communities study (ARIC)", Diabetes.
7. SukhIJa R, Dhanwal D, Gambhir D S, Dewan R ( 2 0 0 0 ) / " Silent myocardial ischaemia in patients with typ 2 diabetes mellitus and its relation with autonomic dysfunction", Indian - Heart - J, 2000 sep; 52 (5); pp. 540 - 6.
KIEM SOAT HBA1C iS TRE OAl THAO D U ^ G
Nguyin Phu Dat*
T 6 M TAT
Dai thao dudng Ici b|nh gay ra nhieu blen chuhg nguy hiem dan den tan phe ho§c ttT vong. Kiem so^t glucose huyet being xet nghiem HbAlc lc> cich tot nhSft de giam nhutig nguy cd bi@n chimg. Myc tieu: 1.
Nhan x^t tinh trang kiem soat HbAlc d tre em DTD dang diSu tn tai Benh vien Nhi Trung Udng. 2. Tim hieu mpt so yeu to anh hu'dng den ket qua kiem soat HbAlc. £>di tu'dng: 98 tre dai thao du'dng typ 1 dang duWc dieu tn va theo doi t?l Benh vien Nhi Trung u'dng. PhUdng phap: 1^5 ta. Ket qua: Kiem soat HbAlc tot 16,3%, kiem soat chu^ tot la 83,7%. Kiem soat HbAlc CO xu hudng tot c^n trong 10 nSm trd lai day. Co may do glucose huyet tai nha kiem soat glucose huyet tot hdn (vdi 0R= 2,89). So ^ n di kham benh £ 4 lan/ nSm kiem soat HbAlc tot hdn kham < 4 Sn/nSm (0R= 3,27). So lan xet nghiem HbAlc a 2
^n/nSm kiem soat HbAlc tot hdn(OR=2,68). Klem soat HbAlc d thanh pho tot hdn d nong thon. Ket lu^mTTk. OTD chu^ du'pc kiem soat tot HbAlc.
Tu'ldioa: Kiem soat HbAlc, dai thao dudng tre em.
ABSTRACT
CONTROL OF H b A l c LEVELS I N DIABETIC CHILDREN
Diabetes is a disease which causes serious complications leading to disability or death. Blood glucose control with HbAlc test is the best method to reduce the risk of complications. Objectives: 1. To review the control levels of HbAlc in diabetic children being treated at the National Hospital of Pediatrics (NHP). 2. To study some factors affecting control of HbAlc levels. Subject: 98 children with type 1 diabetes being treated and monitored at the NHP.
Methods: It is a descriptive study Results: 16.3%
of diabetic children had good HbAlc levels wheareas 8 3 7 % of them had not good HbAlc levels- The
* m&ngd^ihgcYMNgiK .^l-'-.
Phan bl^ kftoa hpc: GS.tS. Trin Binh Long " ' 70
management of HbAlc levels tends to be better in the last 10 years, resulted from having own blood glucose meter at home ( OR = 2.89). Attendence to hospital for follow- up a 4 bmes per year showed a good control of HbAlc levels than those witti s 4 times per year (OR = 3.27). Taking HbAlc testing for 2 2 times per year predicted the good control of HbAlc levels (OR = 2.68). The levels of HbAlc in diabetic children were controlled better in the cities compared to the rural areas. Conclusion: Children with diabetes were not welt controlled by HbAlc levels.
/fey wofds. Control of HbAlc teveb, diabebe chiWren.
I. OJB^T V A N O E
Oai thao dydng (DTD) la benh gay ra nhiSu bien chutig nguy hiem dan den lan phe hoac tif vong. Theo To chffc Y te the gidi (WHO) benh DTD la nguyen nhan dutig hang thff 2 gay mil Ida d ngu'di trydng thanh, cir sau 15 n i m thi 100% ngydi benh OTO co bien chutig ve mSt Benh than cung la bien chiTng pho bien, tai Hoa Ky gan 3 6 % ngydi bl benh than giai doan cuoi la do bien chiTng ciia OTD [ 6 ] . Ngoai hai blen ehffng mSt va than, DTD 6 tre em chii yeu la OTD typ 1 phai dieu trj suot dcfi bang insulin, viec kiem soat glucose h u y ^ t ^ dong vai tro rat quan trpng. Kiem soat glucose huyet bSng xet nghiem HbAlc (Glycated Hemoglobin A l e -Heniogkjbin co gSn glucoe) la each Irft nhat de giam nhulig nguy cd gay t}ien chutig.
0 Viet Nam dS co nhieu cong trinh nghien alfti v€ tam sang, xet nghiem va dieu trf benh OTO, nhutig chu^ cd d€ tai nao nghien culi dSy du ve kiSn soat HbAlc d tre bi OTD. Xuat phat tu-thut te tren, dS tai dudc tien hanh vdi hai muc tieu:
Y HQC VrET NAM THANG 6 - S6" 1/2Q11 1. Nhan xet trnh trang lam soat HbAlc 6 Ire em
BID dang d^ tli tai Benh vien Nhi Tdjng uang.
2. Tim hieu mpt so yeu to anh hudng den Icet qua idem soat HbAlc.
II. oo'l TUONG VA PHaONG P H A P NGHIEN C O U 2 . 1 Ddl tu'dng nghien c i h i
Tat ca cac benh nhan da du'dc chan doan dai thao du'dng typ 1 dang di/dc dieu trj va theo doi tai l<hoa Noi tiet-Chuyen hoa-Di truyen Benh vien Nhi Tmng u'dng, benh an theo doi ngoai tru tir nam 1999-2009, CO thdi gian dieu tri trSn 1 nam. Thdi gian kham' va danh gia til thang 10/2008-10/2009.
- Tieu chuan luS chpn benh nhan:
rieu chuan chan doan BTB: Theo WHO (2001), DTB du'dc Chan doan l(hi benh nhan co bat i(y mpt trong 3 tieu chuan sau:
+ Glucose huyet i. 11,1 mmol/l (200mg/di) d bat l(y thdi diem nao. Kem theo cac trieu chiiYig uong nhieu, dai nhieu, giam can va co giucose nieu, CO the CD ceton nieu.
+ Glucose huyet luc doi i. 7,1 mmol/l (126 mg/dl) (Benh nhan nhjn doi tren 8 gid)
+ Glucose huyet sau lam nghiem phap t§ng glucose huyet vdi 75 gam glucose sau 2 gid
>11,1 mmol/l (200 mg/dl).
- Tieu chuan chSn doan DTB typ 1;
Tlieo Oeu chuan ciia Hiep hpi dai thao du'dng quoc te (2005) [ 4 ]
+ Khdi phat ram rp, d i i cac trieu chirng + Bieu hien lam sang: Silt can, uong nhieu, tieu nhieu.
+ Nhiem Ceton, C-peptid thap hoac mat + Khang the : lAA, and- GAD, ICA duBng tinh + Oieu trj bat bupc dung insulin.
- Tieu chuan loai trir: Benh nhan khong tai feham hoSc khong lam xet nghiem HbAlc.
2.2. Phu'dng phdp nghien cu'u 2,2.1. Thiet ke nghien c&u
. Chpn mau: phu'dng phap chpn mau tien ch lay tat ca cac benh nhan-dii tieu chuan.
. Thiet ke nghien cuU: Nghien cilXi mo ta.
2.2.2. Cac chi so nghien c&u 2.2.2.1 Dac diem nhom nghien cuV:
- Tuoi luc ch^n doan - Gidi
2.2.2.2 Muc tieu 1: K l l m soat HbAlc - Kiem soat HbAlc tdt
- Kiem soat HbAlc khong tot (Kiem soat trung binh va kem).
2.2.2.3 Muc tieu 2: Cac yeu to lien quan den kiem soat HbAlc
Cac yeu tS anh hu'dng kiem soat glucose huyet: l^ay do glucose huyet tai nha, so lan kham benh/nam, so ian xet nghiem HbAlc/nam, gidi, dja du, thdi gian mSc benh.
2.2.3. Phu'dng phap thu thap so lieu va dAnhgi^:
2.2.3.1 Phuc vu muc tieu 1: Kiem soit glucose huyet
- Cich thu thap so lieu:
HbAlc trung binh du'dc ti'nh cho moi benh nhan qua viec cac lan kiem tra 3-6 thang mpt lan trong suot qua trinh theo doi khi benh nhan dieu tn; tai khpa va den kham d|nh kyj. Xet nghiem du'dc thu'c hien bang phu'dng phap mien dich, bang may Olympus AU400 tai Khoa Sinh hoa Benh vien Nhi Trung u'dng.
Cach danh gia kei qua;
Kiem soat HbAlc theo To chu'c DT€> quoc te 2006-2007 [4]:
- Kiem soat tot HbAlc < 7,5 %.
- Klem soat khong tot HbAlc > 7,5 . 2.2.3.2 Phuc vu muc tieu 2: Cac yeu to anh hu'dng den ket qua kiem soat HbAlc:
Dy^ vao ket qua phan loai mire dp kiem spat HbAlc, CO nhdm klem soat tot va khong tot. Tren cd sd ket qua ciia ttnh tr^ng kiem soat HbAic tien hanh tim cac yeu to anh hu'dng nhu': co may do glucose huyet tai nha, so lan kham benh/nam, so I3n xet nghiem HbAlc/nam, gidi, d|a du', thdi gian mac benh.
2.3. Xur l ^ s S lieu:
Nhap so lieu, phan tich bSng phan mem SPSS 13.0 va EpI 6.04, sir dung cac test Student, test Anova, test x2, test Fisher de xac dinh p vdi dp tin cay co y nghTa thong ke (p<0,05), ti'nh ty suat chenh (OR: Odds ratios).
Y HQC VlgT NAM THANG 6 - 861/2011
III. KET QUA NGHtEN COU
3.1. D$c diem nhdm nghidn curu 3.1.1 Tudi luc chS'n doin
Bang 3.1. Phan bo benh nhari theo tuoi luc chan doan benh
Tuoi luc ChSn doin (tu£l)<1 1-5 5-10 10-15
>15 Tonq Tuoi tmng binh (nSm)
n 7 21 38 31 1 98
7,1
%
21,4 38,9 31,6 1,0 100,0 8,3 ± 4,36
Nh$n xet: Ty le benh nhein du'dc chin doan dii th^o du'dng typ 1 nhlSu nhSt d nhom tir 6-10 tuoi (38,9%), sau dd la nhom ll-15tu6i (31,5%). Tuoi trung binh chin dean la 8,3 ± 4,36 tuSi.
3,1,2. PhSn bStheo gidi: Ty Ip mSc b?nh dai thao du'dng typ 1 d nam 46 (46,9%) va nif la 52 ( 53,1%) tu'dng dirdng nhau (p>0,05).
3.2. Kie'm s o i t H b A l c
BiSu do 3,1: Bleu do HbAlc trung binh qua cac nSm Nh$nx4t: HbAlc trung binh co xu hu'dng giam dan qua cac nSm.
Bang 3.2. Mu'c do klem soat HbAlc
Mu'c dp kiem soat HbAlcTot Khonq tot
Tonq so
n 16 82 98
T y M % 16,3 83.7 100
3.3. Mpt s5 yeu to anh hu'dng kiem s o i t HbAlc
Bang 3.3: l^ay dd qiucose huyet va HbAlc trung binh
Xetnghifm Mu'c kiem scat Co miy do glucose huvft | KhSna c6 itiiy do glucose
% n I %
HbAlc trung binh
Tdt Khonq tot
OR=2,89j g (1,4-lZ) Tonq I 40 I 100,0 j 58 I 100,0 I I
Nhan xet: Nhdm benh nhan co may do glucose huyet tai nha klem soat tot hdn gap 3 lan so v*
i n r o mav dn n l i i r n w hiiirof
khdng cp may dd glucpse huyet.
gang J.4; So lan kham benh, xet nghiem va HbAlc trunq binh tronq 1 nam
. Irion, cnn^ l l h & l r .riinn hinl. cH tH.. A: l . k £ _ / —H I p f .tt— £..MiJrc kiem soat HbAlc trung binh So lan di kham/ nam
< 4 r a n
SS ISn x a nqhijm HbAlc/ nim a Z l a n < l l a n
Tot 5 (33,3%1 11 (13,4%) 6 (28,6%) 10 (13%)
Khonq tot 10 (66,7%) 72 (86,7%) 15 (71,4%) 67 (87%)
Tonq 15 (100%) 83 (100%) 21 (100%) 77(100%)
OR=3,27 g (1,3-12) OR=2,68 CI (1.2-10.5>
Y HOC VI$T NAM THANG 6 -5dl/2D11
Nhan xet: Benh nhan di kham benh >4/nam va xet nghiem > 2 lan/nam kiem soat HbAlc tot gap 3 lan so vdi kiem tra it lan hdn.
Bang 3,5: Gidi, dia du'. thdi oian m i c benh va klem soat olucose huvet Xet nghiem
HbAlc
(%)
HbAlc trung binh nam 2009
PI HbAlc trung binh cac nSm
P2
Gidi Nam n = 4 6 9,9±2,68
Nil' n = 5 2 9,9±2,64
>0,05 10,4±2,34 10,8±2,04
>0,05
Thdi gian bi benh
£ 5 nam n=49 9,7±2,47
> 5 nam n=49 10,1±2,82
>0,0S 10,4±2,1 10,8±2,2
>0,05
D j a d u Thanh pho
n=34 9,2±2,36
Nong thdn n = 6 4 10,2±2,68
<0,05 9,9±2,15 10,9±2,14
<0,05 Nhan xet: Kiem soat HbAlc d thanh pho tot hdn d nong thon. Kiem soat HbAlc khong khac nhau giu^ nhdm co thdi gian dieu trj va giu^ 2 gidi.
IV. BAN LU$N
4.1. S$c di€m nhom nghiSn cili'u:
Tuoi luc chan doan vA Oidi gian hi itenh Trong 98 tru'dng tre OTO typ 1, chiing toi nhan thay tudi chan doan benh gSp nhieu nhat d ida tuoi tir 6 den 10 tuoi chiem t:^ le 38,9%, sau dd den liJTa tuoi tir 11-15 tuoi (31,6%). Ket qua nay phii hdp vdi nhieu nhan djnh cho thay DTD typ 1 la benh man b'nh hay gap d tuoi tre, co the xuat hien d moi lu^ tuoi va thu'dng du'dc chan doan tru'dc 20 tuoi [3]. Tuoi trung binh khi chan doan trong nghien ciru cua chung toi la 8,3 ± 4,36 tuoi (ket qua bang 3.1).
Trong nhom benh nhan nghien cutJ cua chung ^" t/ le tre gai gap 53,1%, khong co su" khac biet vdi so tn^ trai (46,9%). Ket qua nay cung phii hdp vdi nhieu tac gia trong nu'dc [1],[2] va nu'dc ngoai [5]. Sd di o6 sy tuHng du'dng gitici 2 gidi vi nhieu nghien ciili cho thay DTO typ 1 la mot roi loan di truyen thong qua phirc hdp gen nhay cam nam tren nhlkn sac the so 6, 7, 14, 18, khong lien quan nhiem sSc the gidi tfnh [3].
4.2. Kiem soat HbAlc
98 benh nhan DTD ciia chiing toi du'dc lam day du xit nghiem HbAlc. Ket qua bieu do 3.1 cho thay HbAlc trung binh co xu hu'dng giam dan trong vong 10 nam trd iai day chu'ng to viec kiem soat glucose huyet cua benh nhan ngay cang du'dc cai thien. So vdi nghien cdu ciia Pham Quang Thai (1998) [2]vdi HbAlc trung binh la 13,5± 3,4% chung toi nhan thay viec kiem soat glucose huy§t hien nay tot hdn rat nhieu.
So vdi mot so nu'dc trong khu vdc chau A, nghien cutJ ciia Maria Craig va cong sir [5], HbAlc trung binh cua chiing toi tu'dng ty ket qua t^i Trung Quoc (9,5±1,9%), Indonesia (10,5±2,7%). Tuy nhien ket qua cua chiing toi
con rat cao so vdi cac nu'dc phit trien nhu" Nhat Ban (8,2±1,4%) va Singapor (8,5±1,6%.), Thuy Olen (7,5 ± 1,2 %) [6]. HbAlc cd y nghTa quan trpng vi cy 1% thay doi, phan anh sy thay doi khoang 1,67 mmol/l lu'dng glucose mau. Benh nhan OTO typ 1 cang giy HbAlc gan vdi mu'c yeu cau bao nhieu thi glucose huyet cang dydc kiem soat tot bay nhieu. HbAlc cang tang thi nguy cd bien chiTng cung tang theo. Chi'nh vi vay trong cac nghien cyu tren the gidi ve kiem soat glucose huyet, chi so HbAlc rat dydc chii trong.
43. C k y ^ to lien quan vdi I d ^ soat HbAlc -May<^gkJCOsehuy^lainha ^lo^nsokitAlc Theo bang 3.2 so benh nhan co may do gluojse huyet tai nha, kiem soat HbAlc tot hdn gap 3 lan so vdi khong co may. Trong nghien cutJ ciia Maria Craig [5] cung cho thay moi lien quan g\da viec khong cd may do glucose huyet va chi so HbAlc cao vdi OR=l,76. May do glucose huyet giup benh nhan kiem tra glucose huyet thydng xuyen de cd che do an uong, hoat dgng the lyc va dieu chinh lieu insulin phii hdp, tir dd kiem soat tot glucose huyet trong dai han.
- So lan kham benh, sd lan xet nghiem HbAlc trong 1 nam ra Idem soat HbAlc:
K§t qua bang 3.3; benh nhan di kham ty 4 lan trd len co mufc kiem soat HbAlc tot hdn nhom benh nhan di kham dycfl 4 lan trong 1 nSm. So lan kiem tra HbAlc cung co lien quan vdi kiem soat HbAlc vdi OR tydng utig la 3,27 va 2,68. Ket qua nghien ciTu ciia chiing toi tydng ty trong nghien cyu ciia Maria Craig,
HbAlc la phan cau true hemoglobin ciia hong cau co kha nang gan glucose. Ddi song hong cau 100-120 ngay nen HbAlc co gia trj danh gia nong do glucose huyet trong- vong 3-4 thang. Theo khuyen cao cua To chute DTO quoc 73
Y HQC VlgT NAM THANG 6 • s61/2011 te, tiiy vao dieu kien xet nghiem d moi nydc,
nhyng toi thieu benh nhan can klem tra HbAlc 2 Jan/nSm va tot nhat la 4 lan/nSm [4].
- Dja dd, gidi, thdi gian mSc benh va kiem soat glucose huy&:
Theo ket qui bang 3.4; kiem soat HbAlc d thanh pho tot hdn d nong thon vdi HbAlc trung binh tu'dng dng \k 9,9% vh 10,9% (p<0,05).
Dieu nay c6 the giai thi'ch do benh nhan d thinh pho thydng co di@u klen di lai, c6 khi ndng kinh te hdn v i nhieu benh nhan cd may do glucose huyet tgl nhi. Ngoai ra, hieu biet ciia cha me benh nhan va benh nhan ve benh OTD tot hdn, quan tam tdi viec kham djnh ky de dydc klem tra, ty van va dieu chinh lieu insulin thfch hdp.
Nghien cihj cua chung toi cho thay thdi gian diiu trj va gidi khong anh hu'dng tdi kiem soat HbAlc. Ket qui niy phu hdp vdi ket qui nghien ciilj ciia cac tac gia khac [5].
V. KiT LUAN
Kiem scat HbAlc: Kiem scat tot 16,3%, kiem soat chu'a tot la 83,7%. Kiem soat HbAlc cd xu hydng tot dan.
Cac yeu to anh hu'dng den kiem soat HbAlc: Co miy do glucose huyet tai nha kiem soit HbAlc tot hdn so vdi khong co may do glucose huyet (vdi 0R= 2,89). So lan di kham benh > 4 lan/ nam (vdi 0R= 3,27). So lan xet
nghiem HbAlc a 2 lan/nSm (vdl OR=2,68). Kiem soat HbAlc d thinh pho tSt hdn d nong th6n.
TAI L||U THAM K H A O
1. V5 Thj MV H6a (2005), " Nghien cuv d^c dl&n ISm sdng vd c$n lam sdng cic bien didhg d mA vd th$n trong b^nh DTD d tre em dieu bf t^l B^
vl0n Nhi dung udn^', Lu$n v3n thac sy Y hp<;
Tru'dng D?i hpc YHa Npi.
-;. Ph^m Quang T h i i (1999), " D$c diim lam sdng vd diiu trf l3$nh DTD d tri em Vi0t Nanf, Lu|n van th?c 59 Y hpc, Tn/dng 0?i hpc Y H i NOi.
3. American Diabetes Association (2006), Standards of medial care fyr patients wSft Diabetes mellituf, Diabetes care, 29, pp: 4-35.
4. Donaghue e t all (2007),'* ISPAD Oinical Practice Cons&)sus Guidelines 2006-2008 ', Pediatric Diabetes:8, pp:163-170;408^18.
5. Maria E. Crafg, Timothy W. Jones et all (2007), "Diabetes care, glycemie conbol, and complications in children with type 1 diabetes from Asia and the IVestem PadHc Region", 3oumal of Diabetes and its Complication 21, pp: 280-287.
6. Maria Svensson, Jan. Eriksson (2004), " ^ glycemie conbol, age at onset and devek^mient^
microvascular complication in childhood' Diabetes Care, volume 27, number 4, pp: 955-969.
7. P a m l a n c o G , C o 5 t a c o u T e t a l l (2006), "77^.30 years natural history of type 1 diabetes complications, the Pittsburgh epidemidogy of diabetes complication study experience' DialMtes;
55, pp:1463-1469.
M 6 T stf DJ^C D I E M L A M S A N G VA THOtTNG T O N D O N G MACH V A N H or BENH NHAN KAWASAKI TAI BENH VIEN NHI TRUNG imNG
H o S y H ^ * v & c $ n g s t f nhSn du^c truyen Gamagiubulin. Co 107 trudng t i 0 ton thuWig OMV tren sieu Sm (28,1%); vdi 29 tm&ng hpp phinh (7,6%) v i giSn l i 78 (20,5%). Co 29 tnidng hpp DMV trd v l binh thudng sau 6 thing. ThuUng t ^ DMV d nhdm dieu tri sdm thap htfn nhieu so vdi nti6m mupn ho$c khong dieu trj, ty I? 14,3% so vofi 47,4%
(OR =5,59, P<0,001). c i c yeu to CO nguy cd dai thutfng t6n OMV l i tuoi dudi 12 t h i n g ; tre trai, b^h I nhan khang thuoc v i cac y€u t 5 nhu sot trIn 10 ngay, so lu^ng bach cau tSng cao, phan irng CRP di/dng tinh manh. Kit lu$nr. Benh Kawasaki gSp ngay m0t nhESflg T 6 M TAT
M{ic diu: Mo t i lim sang va thUdng ^ n DMV d benh nhan Kawasaki tai benh vien Nhi TU" tfr 2/1995- 2/2010 va tim hieu mdt so yeu td lien quan den ton tfiUdng DMV. 0di tu'dng va phWdng phipr. Sd dung phu'dng phap tien ciiu mo ta. Ooi tupng la benh nlian dupe chan doan va dieu tri Kawasaki tai benh vien Nhi t y thing 2/1995 - 31/1/2010. Ket qua tong so 381 tn/dng hpp, ty l§ b^i/gai 1,74; tuoi tmng binh 14,8±13,9 thing, fre em du'dl 24 thing chiem 84%.
TSt c i benh nhan du'pc dieu tri Aspinne. Cd 281 benh
* Benh vien Nhi Trung ddng
Phan bi$n khoa hpc: PGS.TS. Nguyin Cong Khanh 74