m
HOI NGHj KHOA HOC LAN THLf IV • HOI TlfeT NIEU - THAN HOC VIET NAM
ANH HirONG CUA TANG HUYET AP KHANG TRI LEN QUA TAI AP LOC VA HINH THAI HUYET AP 24 Of BENH NHAN SUY THAN MAN TINH
LOG MAU CHU KY
^ ^ 1? Hoang Tram Anh*, Hoang Trung Vinh'' TOMTAT
Tang huyet ap khang tri (THAKT) d benh nhan suy than man tinh (STMT) Igc mau chu ky (LMCK) lam gia tang nguy cd cac bien cd tim mach lien quan den tang ty le qua tai ap lUc (QTAL) va mat hdm huyet ap (HA). Muc tieu nghien cu'u: Danh gia ty le, dac diem qua tai ap lUc va hinh thai HA 24 gid d benh nhan STMT LMCK cd THAKT; Tim hieu mdi lien quan giu'a qua tai ap lUc va hinh thai HA 24 gid vdi hieu xuat Igc mau dUa tren chi sd Kt/V. PhUdng phap nghien cu'u: Oo HA 24 gid de xac dinh ty le QTAL tam thu (TT), tam trUdng (TTr) d ca hai nhdm benh nhan: 57 benh nhan THAKT (>130/80mmHg), 34 BN khdng cd THAKT (,130/80mmHg). Hieu suat Igc mau danh gia dUa vao chi sd Kt/V. Ket qua cho thay: Ty le QTAL TT, TTr deu tang (p<0,01). Ty le QTATT, TTr ban dem cao hdn ban ngay ( 92,8 ± 19,6% so vdi 82,1 ± 20,7%), (95,2 ± 11,8 % so vdi 80,8 ± 22,6%). Ty le BN cd bieu hien nondipper cao hdn (70,2% so vdi 38,2%). Ty le QTALTT, TTr lien quan cd y nghia vdi chi sd Kt/v (P<0,01). Ty le QTALTT 24 gid, ban ngay tUdng quan nghjch mu'c do viia cd y nghia vdi chi sd Kt/V. Ket luan:
Tang huyet ap khang tn lam gia tang ty le qua tai ap lUc TT va TTr. Hieu qua Igc mau tdt gdp phan lam giam ty le QTAL TT, TTr va nondipper
Td' khda: Tang huyet ap khang trj, HA lUu dgng 24 gid (ABPM), Igc mau chu ky.
SUMMARY
The efflciency of resistant hypertension on
blood pressure load and style of blood pressure of the chronic renal failure
patiens treated by hemodialysis Resistant hypertension (RH) in patients with chronic renal failure treated with hemodialysis icreased cardiological events and associated blood pressure load and nondipper. The objective of research: Evulating of proportion and characteristic of BPL and style of BP in patiens with chronic renal failure treated with hemodialysis with RH; Find out the reation between BPL and style of BP with performance of hemodialysis indicators based on Kt/v. The object of research including 91 patients in the chronic renal failure patiens treated by hemodialysis divede in two group: 34 patients with control hypertension (<130/80mmHg) and 57 patients with resistant hypertension (>130/80mmHg). Performance of hemodialysis indicators based on Kt/v. Results showed that:
Rate of systolic and diastolic BPL increased (p<0,01). Rate of systolic and diastolic BPL asleep higher than awake ( 92,8 ± 19,6% with 82,1 ± 20,7%), (95,2 ± 11,8 % with 80,8 ± 22,6%), rate of nondipper higher (70,2% with 38,2%). Rate of systolic and diastolic BPL associated significantly with Kt/V (p<0,01). Rate of systolic BPL 24 hours and awake have reverse corelating in moderate degree with Kt/V.
Conclution: RH increased the rate of systolic and diastolic BPL. The good performanceof hemodialysis reduced rate of systolic and diastolic BPL and nondipper..
Key work: resistant hypertension,
* Benh vien 103, Hoc Vien Qudn Y
hemodialysis, 24 hour ambulatory blood pressure monitoring
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I. O A T V A N O E -..A /d Tang buyfit ap d BN STMT la bilu hien rk thudng gap. Do cd hhiku y6u td anh hudng, kho diSu chinh cho nen d BN STMT GDC Igc mau chu ky cd ty Ie THAKT cao hom len tdi 35 - 40% [1]. THAKT Iam tang nguy co cac bien CO tim mach lien quan den ty le QTAL va mdt hom HA ban dem.
Hieu suat Igc mau anh hudng dang kl din viec kilm soat HA d BN STMT LMCK. Ty Ie THAKT ciing lien quan vdi hieu xukt Igc mau dugc danh gia dua vao chi sd Kt/V. Muc tieu nghien ciiu:
- Ddnh gid ty le qud tdi dp lite vd hinh thdi HA 24 gia a benh nhdn STMT LMCK co THAKT
- Tim hieu moi lien quan giUa qud tdi dp luc vd hinh thdi HA 24 gia vai hieu xudt lpc mdu dua tren chi so Kt/V
II. DOI TUQNG VA PHUONG PHAP NGHIEN COU 2.L Doi tuong:
+ 91 benh nhan STMT LMCK cd THA dugc chia lam hai nhdm:
- Nhdm chiing: 34 BN dugc kiem soat HA d miic muc tieu (< 130/80 mmHg) — THAKKT.
- Nhdm nghien ciiu: 57 BN vdi HA khdng dugc kiem soat d mde muc tieu (> 130/80 mmHg) - THAKT
-I- Tieu chuan chan doan THAKT: HA khdng dugc kiem soat d miic muc tieu khi BN da dugc dimg ddng thdi > 3 loai thudc trong dd cd lgi tieu vdi lieu td'i da hoac gin tdi da trong thdi gian >1 tuan. C) BN STMT LMCK che do si6u Igc (rut can) dugc coi nhu viec dung lgi tieu. Xac dinh THAKT dua vao phuong phap do HA thong thudng trong 7 ngay lien tuc.
+ Tieu chudn loai trii
- B6nh nhan dang di6n bien nang: rdi loan nudc - dien giai, rdi loan y thiic, nhilm trung ca'p tinh ,suy tim nang, dot quy nao....
- >15% k6't qua huyet ap 24 gid khong dat tieu chudn.
2.2. Phuong phap nghien ciiru
+ "Thie't ke nghien ciru: tie'n ciru, cat ngang, so sanh giQa hai nhdm.
-I- Ngi dung nghien ciiu
- Khai thac tien sir benh, kham lam sang.
- Xet nghiem: cdng Ihiic mau, hda sinh mau.
- Xac dinh chi sd Kt/v dugc tfnh theo cdng thiic:
-.^'-^h .:-::.l''-i Kt/v = Ln ...LL...
Trong dd: ^ y ' Co Ct K - do Igc ure cua bd Igc. * :
t — Thdi gian cude Igc.
V — Khd'i lugng nudc toan co thi cua benh nhan. V dugc xac dinh dua vao can nang (kg) benh nhan d l tinh lugng nudc co the hda tan ure: V= P(kg) x 0,55.
Ln: logarit bac n . _ CQ: Ndng dd ur6 mau trudc Igc , •
C,: Ndng do ure mau sau Igc.
Hieu sua't cugc Igc dugc danh gia la tdt khi gia tri cua Kt/v >1,3 . - Do huyet ap 24 gid vao ngay khdng Igc mau .
^
HOI NGHj KHOA HOC LAN THlf IV • HOI TIET NIEU - THAN HOC VIET NAM
• Thiet bi do: may hieu OSCAR 2. Ket qua dugc phan tich bang chuong tnnh Accu \
Win Pro V3 chuyen dung, dugc cai dat san. j
• Che dd do: ban ngay 06 gid - 22 gid, 30 phiit do mdt iSn; ban dem 22 gid - 06 gid sang \
hdm sau, 60 phiit mdt Ian. Ch6' dd dieu tri va sinh boat binh thudng. i
• Cac gia trj tfnh toan dua tren ket qua ABPM dugc Hi6p hdi tang buyft ap qudc t^ ; (ISH) quy dinh bao gdm: HATB, TT, Tr 24 gid, ngay, ddm. Hinh thai HA dipper, non-dipper, j
superdiper, huye't ap dao ngugc (reverse dipping). Qua tai ap luc (BPL). i
• Qua tai ap luc (BPL): ti le % huye't ap tam thu (HATT) va huye't ap tam truong I (HATTr) vugt len tren ngudng miic binb thudng.
-I-Xit lysd lieu bang phan mem SPSS 11.5, EPI-INFO 6.0. . .. •• j
i
III. KET QUA NGHIEN CQU
Bdng 3.1: So sanh mdt sd gia trj trung binh giiia hai nhdm
Doi tUdng Dac diem
Tudi (nam)
Thdi gian Igc mau (nam) Kt/V
Nhom NC (n=57) 42,47 ± 16,58
3,5 ± 2,2 1,32 ± 0,04
Nhom chu'ng (n=34) 39,21± 9,51
3,9 ± 2,5 1,38± 0,06
P
>0,05
<0,05 - Gia tri trung binh tudi, thdi gian Igc mau tuong duong nhau gifta hai nhdm.
- Gia tri trung binh Kt/V cua nhdm nghien ciiu thap hon nhdm chiing cd y nghia thdng ke (p<0,05)
Bdng 3.2: So sanh gia tri qua tai ap luc d 2 nhdm ddi tugng
Chi so
_Ow^tUdng
QTALTT(%)
QTALTTr(%)
24h Ngay Dem 24h Ngay Dem
Nhom NC (n=57) 88,2 ± 16,3 82,1 ± 20,7 92,8 ± 19,6 88,0 ± 17,3 80,8 ± 22,6 95,2 ± 11,8
Nhom chu'ng (n=34) 34,9 ± 26,9 24,5 ± 16,6 55,7 ± 21,2 41,7 ± 31,2 28,4 ± 21,4 64,7 ± 30,8
P
<0,01
Ty Ie QTALTT va TTr 24 gid, ngay va dem d nhdm nghien ciiu cao hon cd y nghia so voi chi sd tuong iing d nhdm chiing p<0,01
Bdng 3.3: So sanh qua tai ap luc ban ngay va dem d nhdm benh nhan THAKT (n=57)
Thdi gian Gia tri
Qua tai ap lUc tam thu(%) Qua tai ap lUc tam trUdng(%)
Ban ngay
82,1 ± 20,7 80,8 ± 22,6
Ban dem 92,8 ± 19,6
95,2 ± 11,8 <0,01
Ty le QTALTT va TTr ban dem cao hon ban ngay cd y nghia thdng ke (p<0,01).
Ty le % 120- 100
80 60 4 0 20 0
04.7
70.2
2 5 : 5 — I L42^ m y.
38.2
J I Z 17,gi^,7
1
N h o m NC N h o m chiimg
t + * -
Dipper* Nondipper* Superdipper* HA dao THAKT theo n g u o c ABPM
Hinh thai HA
Bieu d6 3.1 So sanh cac ty 16 hinh thai HA cua hai nhdm BN
Bang 3.4: So sanh qua tai ap luc d benh nhan THAKT dua theo Kt/v (n=57)
~~~~- ~ - _ J < t / V
Gia t r i _
Qua tai ap lUc tam thu(%)
Qua tai ap lUc tam trUdng(%)
24h Ngay Dem 24h Ngay Dim
< 1,3 (n=15) 96,3±6,9 93,2±10,2 97,5±9,7 94,8±8,7 88,8±13,0 98,9±6,4
> 1 , 3 (n=42) 85,2±16,2 78,0±12,1 91,2±11,9 85,6±15,6 77,9±12,5 95,2±13,0
P
<0,01
O BN cd Kl/v<l ,3, ty le gia hi qua tai ap Iuc tam fliu, tam truong 24h, ban ngay ban dem cao hon cd y nglua SO vdi nhdm cd Kl/v >1,3 (p<0,01).
T y l 9 % IOOT' 80 60- 40- 20 0-H
y
- . Dipper
86.8
^ < - H 6 4 . 3
Nondipper
21.4
HA dao ngu'O'c
p>0,05
ll]Kt/v<1,3 aKT/v>1,3
'
Hinh thai
T^ i i u ^ c i ayi a,^
BiiuS3.2: TyleHnhMhi^dt ^dbenhnhantanghi^lt^khangttidualheo Kl/v
Ty le dipper, nondipper, HA dao ngugc d nhiing benh nhan cd Kt/v <1,3 va Kt/v > 1,3 tuomg duong nhau
•-• = : « ; ? • ;
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1
HOI NGHj KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM
Bang 3.5: Tuon g quan giiia % qua tai ap Iuc vdi cbl
Ty le qua tai ap lUc (<»/o)
Qua tai ALTT
Qua tai ALTTr
24h Ngay Dim
24h Ngay Dim
Gia tri r
-0,31 -0,36 -0,2 -0,22 -0,23 -0,18
P
<0,05
<0,05
>0,05
>0,05
>0,05
>0,05
sdKt/v(n=57)
PhUdng trinh tUdng quan
%QTTT24h=235,3-ll,3*Kt/v
%QTTTnqay=258,6-133,6*Kt/v
Qua tai ALTT 24 gid, ban ngay tuong quan nghich miic do vua cd y nghia vdi chi sd Kt/v.
IV. BAN LUAN
1. Bien doi qua tai ap luc va hinh thai HA 24 gid 6- benh nhan STMT LMCK co THAKT.
Ty le benh nhan THAKT cd QTALTT va TTr cao hon cd y nghia so vdi nhdm chiing, ddng thdi ty le QTALTT va TTr giua ban dem cao hon ban ngay cd y nghia thdng ke (p<0,01). Vdi dac diem bien thien HA tren day d nhung benh nhan STMT LMCK cd THAKT thi cd the cho rang anh hudng cua chi sd HA ddi vdi cac co quan ndi chung la rat ldn. Ap Iuc ddng mach ludn d trong tinh trang tang cao, tim deu phai boat ddng gang siic cdn cac co quan khac deu trong tinh trang thieu mau. Dieu dd ciing giai thich vi sao d benh nhan STMT dugc LMCK cd THAKT ciing nhu benh nhan cd THAKT ndi chung ludn cd tan suat bien chiing va tu vong rat cao (McMahon LP va cdng su 2008) [4].
Hermida RC va cdng sir nam 2005 cung da nhan xet: mdt ty le cao benh nhan vdi THAKT thudng khdng cd su khac biet HA giiia ngay va dem. Cac tac gia kien nghj: ddi vdi benh nhan THAKT nen udng thudc theo sd Ian phu hgp vdi chu ky nghi va boat ddng ciia timg benh nhan de cai thien tinh trang kiem soat HA va lam giam sir chenh lech HA ngay-dem [2].
Gia trj rd net nhat cua phuong phap do HA bang ABPM la xac djnh dugc ty le benh nhan cd hay khdng cd hdm HA ve dem (dipper hay nondipper). Neu nhu d nhom chiing chi cd 38,2% trudng hgp thudc nhom nondipper (khdng cd hdm HA vao ban dem) thi d nhdm benh nhan THAKT cd 70,2%
trudng hgp thudc nhdm nondipper (p<0,05).
Day ciing la nhung benh nhan chiia dimg nguy CO cao ddi vdi cac bien chiing d co quan dich va tang ty le tu vong. Timio M va cdng su nam 1995 ciing nhan thay: d benh nhan STMT cd THA thi ty Ie trudng hgp co nondipper cao gap 2,6 lan so vdi THA khong cd STMT va ty le tli vong d nhdm benh nhan nay ciing tang gap 2 lan [7]. Neu nhu d nhom benh nhan khdng cd THAKT cd 6 trudng hgp ha HA qua miic ve dem (HATB liic ngii giam >20% so vdi HATB liic thiic) Uong khi d nhdm benh nhan cd THAKT lai khdng co trudng hgp nao. Day ciing la mdt dac diem rieng d benh nhan STMT cd LMCK co THAKT.
Ty Ie benh nhan cd HA dao ngugc d hai nhdm khac biet nhau khdng cd y nghia thong ke (14,7% so vdi 17,5%, p>0,05).
Rajakarthik K va cdng su nam 2008 ciing quan sat thay cd tu 10-20% trudng hgp bieu hien ILA dao ngugc nhat la khi hieu suat loc
Y HOC VIET NAM THANG 11 - SO 2/2010
mau chua dat dugc miic theo khuyen cao (Kt/v<l,2) [6].
2. Moi lien quan gifra qua tai ap luc va hinh thai HA 24 gid vol hieu xuat loc mau dua tren chi so Kt/V r !. , i ;.
Lge mau chu ky la bien phap dieu tri co ban va chu yeu thay the than suy, giiip dieu chinh dugc nhiing rdi loan xay ra d benh nhan STMT GDC. D8 danh gia dugc hieu su§t ciia cugc Igc thudng su dung he sd thanh thai timg phan ure trudc va sau Igc dugc ggi la Kt/v. Theo khuyen cao cua Hdi than hgc Hoa ky thi cugc Igc dugc coi la cd hieu qua khi Kt/v trong khoang 1,2-1,4, trung binh la 1,3. Trong nghien ciiu nay su dung ngudng Kt/v > 1,3 dugc coi la cugc Igc dat yeu cau (Lo WK va cdng su nam 2002) [3]. Gia trj trang binh Kt/v cua nhdm chiing cao hon cd y nghia so vdi nhdm benh nhan nghien ciiu (1,38 ± 0,06 so vdi 1,32 ± 0,04; p<0,05).
Dieu nay cho thay higu suat cugc Igc d nhdm b?nh nhan khdng cd THAKT tdt hon so vdi nhom benh nhan cd THAKT. Chi sd Kt/v cd anh rit rd len tinh trang qua tai ap lire tam thu va tam truong. Gia trj trung binh ty Ie phan tram qua tai ap Iuc tam thu va tam truong d nhdm benh nhan cd Kt/v < 1,3 cd gia trj cao hon cd y nghia thdng ke so vdi nh6m cd Kt/v >1,3. Ket qua tren day ciing tuong tu nhu quan sat ciia mdt sd tac gia nhu Lo WK va cdng su nam 2002; Peixoto AJ va cong sir nam 2000 d benh nhan STMT dugc LMCK[3], [5]. -
N6u nhu Kt/v anh hudng len tinh trang qua tai ap luc thi nd lai khdng cd anh hudng din hinh thai huySt ap, cu the la ty le dipper, nondipper va huydt ap dao ngugc d hai phan nhom Kt/v<l,3 va Kt/v > 1.3 la tuomg duong nhau (p>0,05) [3]. ,
Khi khao sat mdi tuong quan giiia cac chi sd huyet ap 24 gid vdi Kt/v d benh nhan STMT GDC dugc LMCK cd THAKT da xac lap dugc nhieu mdi tuong quan cd y nghia.
Khi khao sat mdi tuong quan giiia tinh trang qua tai ap Iuc tam thu, tam truong d benh nhan cd THAKT nhan thay: chi cd qua tai ap Iuc tam thu 24 gid va ban ngay cd tuong quan vdi Kt/v vdi r=-0,31 va -0,36, p<0,05.
Qua tai tam thu 24 gid va ban ngay tuong quan nghich vdi Kt/v nhung mirc do thip (r <
0, 3) va chua cd y nghia thdng ke (p>0,05).
White WB nam 2003 ciing cd nhan xet so bd:
hieu suat Igc cang tdt thi chi sd huyet ap do bang phuong phap 24 gid cang thap, ty Ie tu vong cua benh nhan ciing giam [8].
V. KET LUAN
Nghien ciiu anh hudng cua tang huyet ap khang trj len qua tai ap lire va hinh thai HA 24 gid do bang phuong phap ABPM d benh nhan STMT LMCK cd ket luan sau:
5.1 . Bien doi qua tai ap Iuc va hinh thai HA 24 gicr
+ Ty Ie qua tai ap luc tam thu, tam truong 24 gid, ngay, dem deu tang cd y nghia thdng ke.
-I- Ty le qua tai ap Iuc tam thu, tam truong ban dem cao hon ban ngay ngay (92,8
± 19,6% so vdi 82,1 ± 20,7%), (95,2 ±11,8
%)sovdi80,8±22,6%>).
+ Benh nhan cd bieu hien nondipper chilm ty Ie cao hon (70,2% so vdi 38,2%).
5.2 Moi lien quan giira qua tai ap Iuc va hinh thai HA 24 giu vol chi so Kt/V
+ Ty le qua tai ap luc tam thu, tam truong lien quan cd y nghia vdi chi sd Kt/v
+ Ty Ie benh nhan nondipper lien quan khdng cd y nghia vdi chi sd Kt/v.
HOI NGHj KHOA HOC LAN T H Q IV • HOI TIET NIEU - THAN HOC VIET NAM
+ Ty le qua tai ap lire tam thu 24 gid, ban ngay tuong quan nghich miic dd vira cd y nghia thdng ke vdi chi sd Kt/v.
, - . . , TAI UEU THAM KHAO
1. Dimenta E, Gaddam KK, Oparil S (2008).
Mechanism and treatment of resistant hypertension. J Clin Hypertens (Greenwich):
10: 239-44.
2. Hermida RC, Ayala DE, Calvo C et al (2005). Effects on time of day of treatment on ambulatory blood pressure pattern of patients with resistant hypertension.
Hypertension. Oct; 46 (4): 1053-9.
3. Lo WK, Ho YW, Li CS et al (2002). Effect of KT/V on survival and clinical outcome in CAPD patients in a randomized prospective study. Kidney international. Vol 64: 649-56.
4. McMahon LP, Parfrey PS (2008).
Cardiovascular aspects of chronic kidney
disease. Brenner & Reftor's the kidney, 8th edition, Vol 2, chapter 48: 1697-727.
Peixoto AJ, Santos SF, Mendes RB et al (2000). Reproducibility of ambulatory blood pressure monitoring in hemodialysis patients.
Am J Kidney Dis; 36(5); 983-990.
Rajakarthik K, Ghanshyam PSS, Georgi A et al (2008). Circadian rhythm of blood pressure in chronic kidney disease patients and the incidence of non-dipper. Nephrology;
13 (Asian Pacific society Nephrology): 034-
A30. ..H.V .
Timio M, Venanzis, Lolli S et al (1995).
"Non-dipper' hypertensive patients and progressive renal insufficiency: a 3 - year longitudial study. Clin Nephrol; 43: 382-7.
White WB (2003). Ambulatory blood pressure monitoring in clinical practice. N Engl J Med 348: 2377-78.
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