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rthop Relat Res. 405: p. 14-23.
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Influence of the Number and Concentration of Progenitor Cells", / Bone Joint Surg Am. 87: p. 1430-1437.
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p. 3-l2,DOI I0.1007/S00264-009-0892-0.
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p. 213-236.
BI/lDfC DAU DANH GlA HlEU QUA DifU TRj B | N H XUAT H U Y ^ GIAM TI^U cAu M l i N DjCH MAN TINH Of TRE EM BANG PHUDNG PHAP CAT LACH NOI SOI
So Thj Hai VSn*, V8 Thj Thanh Tri-c*, Phii Chi Ding*
T6iA TAT;
Dit v i n d i ; Xuit huyit giim tiiu ciu (XHGTC) la mflt trong nh&ng binh 1^ huyil hoc thudng gip nhit d t r i em, Viflo diiu trj cho cic tid em iJinh XHGTC min tinh hay XHGTC ning trin iim sing i i ftng eft viin eho eit iich hiin vSn cdn dang dupe bin cii. Myc t l i u : dinh gii hiiu qui diiu tri ITP min d trd em cua phuong pliip cit lich nfli soi tai BV TIVIHH TPHCM trong thdi gian 5 nim 1/2007 din thing 12/2012. D i i tirgrng v i phuong p h i p nghien cftu: h i i cftu qua 34 h i so bgnh i n , d i i u trj ITP m i n bing phuong phip cit lach ngi soi. K i t qui:
T} l i asp ftng sdm sau cit iich khoing 79.4%, 5 trudng hop thit bai, chiim 14.8% 1 tnrdng hpp xuit hiin viim phdi khdng die hiiu do Chlamydia pneumonia, chiim tJ Ifl 2 94%, trong khi dii 97.06% binh nhin khdng gip biin chdng
nio khic sau m i . K i t l u i n : Cit lich i i in(t phuong phip diiu trj xuit huyit giam tiiu ciu miin djch min tinh cd t^ 1$ dip ftng cao cing nhu cfl tuong dii an toin, giip binh nhi giim duoc cic biin chftng do phii ding thuic liu dii.
ABSTRACT:
Background: Immune thrombocytopenic purpura (ITP) is one of the most common hematologic disease in children. The treatment of chronic ITP with splenectomy is still controvereial.
Objective: To evaluate the effectiveness of splenectomy in the treatment of childiiood chronic ITP at HCIVI C Blood transfusion- Hematology Hospital in 5 years time from 1/2007 to 12/2012. Subjects, and Methods;
Rettospectively through 34 medical reconls, chronic ITP treated with
* Binh viin Tmyin miu - Huyit hpc TP. Hi Chi IVIinh Phin blin khoa hgc: TS Huynh Nghia
558
Y H Q C VigT NAM T H A N G 8 - s 6 OAC B I $ T ; 2 0 1 2 splenectomy m e t h o d . Results: The complete
remission early after splenectomy approximately 79.4%, 5 cases of failure, accounting for 14.8%.
one case appeared nonspecific pneumonia due to Chlamydia pneumoniae, accounting for 2.94%, while 97.06% of patients without any other complications after surgery. C o n c l u s i o n : Splenectomy in treatment of chronic ITP has high complete remission as well as relatively safe, helping patients to reduce side effects due to long-temi medication.
L O ^ T V A N O E :
Xuit huyit giim tiiu cau (XHGTC) li mflt ttong nhftng binh 1;^ huyit hgc tiiudng gip nhit d tt^ em vdi tin xuit binh khoing 3-8/IOOOOO/nim. XHGTC min tinh, dupe djnh nghia li sy giim tiiu cau kio dii hon 6 thing ki tft khi chin doin, xay ra d 20-30%
tri em'". Cho din nay ed nhiiu phuong phip diiu trj ttong bgnh ly XHGTC, cie lya chpn diu tien bao gom: corticoids, IVIg, anti D, cit lich.
Theo mgt bio cio tong kit 10 nim diiu t4 binh XHGTC tu 1990 din 2000 tai BVTMHH, chung tfli ghi nhan cd ting cgng 1282 bgnh nhan, ttong do tti em chiim 38.9% (499 BN). Ty I? chuyin sang man tinh sau 6 tiling diiu trj d tti em la 23.5%. Tai miin nam Viit Nam, d cie benh vign Idn nhu BVTMHH, Nhi Dflng I, Ung Budu, van chua CO mgt phac dfl tiling nhit eho b$nh ly nay.
Them vao do, vice diiu ttj benh XHGTC mjn tinh van cdn bd ngo, sy phoi hpp cac lo?i thudc khie nhau eung chua dat higu qua cao vi cd nhiiu biin chftng. Phuong phap cit lach di dupe di nghj d ngudi ldn bj XHGTC khflng dap ftng vdi diiu tti ban diu vi thudng duoc thyc hign sdm '^"". Vigc (tiiu trj eho cie tte em bgnh XHGTC man tinh hay XHGTC ning trin lam sang la ung oft vien cho cit lach hign van edn dang duoc
bin cii. <!> tti em, theo hudng din diiu trj cfta Anh vi Hoa Ky, cit lich nin dupe hoin lai tii tiiiiu li 12 tiling. Theo thdi gian, chi djnh vi diiu trj cit lich d tri em van chua dupe chuin hda vi tiin trinh niy chua dupe thyc hiin thudng xuyin vi nhftng nghiin eim tiin cftu vin chua dupe thyc hiin.
Do dd, chftng tdi thyc hiin nghiin ciru niy di dinh gii mflt cich toin diin higu qui diiu trj cfta phuong phip cit lich nfli soi trong tiidi gian 5 nim 1/2007 din tiling
12/2012.
Myc tiiu nghiin cftu: 1) Ddnh gid ddp ling diiu n't nic thai: si lupng TC ngay sau cdt lach: 2) Ddnh gid ddp dng diiu tri Idu ddi: si lupng TC sau I ndm, 2 ndm, 3 ndm, 4 ndm vd 5 ndm: 3) Dinh gid cdc biin chiing sau cdt ldch.
II. OdI TUQNG VA PHUONG P H A P NGHIEN COU:
2.1. Dii tugmg nghiSn cuu:
- Tit ea cie tti em < 15 tuoi da dupe chin doin xic dinh li XHGTC mien djch man tmh ed chi djnh cit lach npi soi tai BV.TMHH tft tiiang 1/2007 din tiling 12/2012.
Thiet ki nghien cftu: mfl ta hang loat ea, hfli cftu
2.2. Phuorng phip nghien cum:
a) Tiiu chuin chgn mau:
- Tri < 15 tuii
- Dupe chin doin XHGTC mien djch man tinh (thori gian mic bgnh tiin 6 thing ke tft Ifte chin doin)
- Cfl ehi djnh cit lich
- Khflng ed tiin cin bgnh iy ngi ngoai khoa ching chi djnh phau tiiuat
- Khong tiin cin dung thuic ching dflng trudc dd
b) Chi djnh cit iich: nhftng ttTidng hop XHGTC man tinh kio dii > 6 thing vi:
559
Qldrltlnh Nft Nam Tinq oOnfl
Silvong 20 14 34
TyliC/.!
58.8 41.2 100 T^ l i nft/ nam l i 1.4
D$c diim l i m sing trade cit lich:
Mftc dfl thiiu miu:
Hb (g/dl)
>10 8-10 Ting c^ng
Silurgmg 27
7 34
Tyl»(%l 79.4 20.6 100 CHUYSN Bi: Hpl NOHI KHOA HQC HUYfeT HQC • TRUYgN MAU TOAN QU6C 2012 - Thit bai vdi diiu tti bing corticoid bflnh vi tiiu chuin loji trft tm BV.TMHH tir vi/hoic IgG tinh mach thing 1/2007 din thing 12/2012.
- Cd biin chftng cfta corticoid Bing phin phfli gidi tinh:
- 14 tiiuflc corticoid vdi si lugmg TC <
20 X lO'/L kim chiy miu ning cfl nguy eo de dpa tinh mang
- Duy tii TC > 20.000 x lO'/L vflri corticoid liiu > 0.2 mg/kg/ngiy
c) Diiu kiin cit lich:
- Tri > 6 mil
- Dl dupe chftng ngfta vdi:
pneumocoecus, H.influenza type b, vi meningococcus
- Cic xit nghiflm dflng miu, sinh hda, siiu vi ttong gidi han binh thuflmg
Tfty di binh tiiudng d) Tiiu chuan lo?ii tift:
- Cie BN khong thda tiiu chuin chpn miu hoic hi so khdng diy.
2.3. Phuong phip tien hinh:
- Dua vio hi so bgnh in, chgn cic binh nhan thda tieu chi chgn mau.
- Ghi nhjn vio phiiu tiiu thip tiiflng tin.
2.4. Phuong phip thu th?p vi xir ly si ligu;
Tit ei cac tti em < 15 tuii di dupe chin doin xie djnh li XHGTC mien djch man tinh ed chi djnh cit iich nfli soi tai BV.TMHH tft tiling 1/2007 den tiling 12/2012 tiida tiiu chuin chgn miu. Cie dft ligu dupe tiiu thap theo phiiu thu thip dft ligu dya theo ho so bgnh in.
- Cac dft ligu dupe nhip vio miy tinh vi phan tieh bing chuong trinh Excel 2007 vi SPSS 18.0.
III. KiT QUA NGHllN COU - BAN LUAN:
Die diem chung cua dan so nghien cuu:
Cd 34 tre < 15 tudi da dupe chin doin xac dinh la XHGTC mien dich man tinh cd chi dinh eit iich ngi soi thda tiiu chuin chgn
Da si bgnh nhin dupe dua din bgnh viin kjp tiidi khi bit diu ed diu higu xuit huyit do dd h?n chi dupe tinh tt^ng chiy miu ning giy thiiu miu. Do dd, niu bgnh nhan dupe tiieo dfli sit vi phit hign, diiu ttj kjp flidi si him chi dupe nguy eo xuit huyit gay tinh tt^ng thiiu mau cin truyin miu.
MO^: dfl xuit huyit SJ Iwyng Tylj(%L Nhe
Tmng binh Njng
Tdng cflng 34 100
Qua bing trin, chung tfli nhan thiy tat ca binh nhi ttong nhflm nghiin eun diu cfl dau higu xuit huyit tft nhg din ning. Trong do, chiim da sfl li xuit huyit nhg (52.9%) va xuit huyit mftc trung binh (41.2%), tiiudng phoi hpp gifta xuit huyit dudi da vi niein mjc. Khflng ghi nhin ttTtdng hpp nao xuat huyit nio-ming nio.
s i lugng tieu ciu tnrd'c mo;
5000-10000 10000-20000 Ting cflng
s i lu^ng
jriJii%l_
117 . 35.3
53 _ 100
Y HQC VigT NAM THANS 8 • sti OAC BieTf2012 Tit ei nhttng bflnh nhin ttxmg nghiin
Cliu cua chung tfli diu cd si iupng tiiu ciu thip < 20000/mm', fliim chl < 5000/mm' (11.7%). Theo y vin, khi si lupng tiiu ciu
<10000/mm^ thi nguy oo xuit huyit nio- ming nao cao, nhung ttong nghiin cftu cfta chung tfli, khflng ed ttudng hpp nio xuit tuyet nio-ming nio. Do dfl, tiir khi cd diu hi?u xuit huyit i ^t cin truyin TCDD di dieu trj, mic dft si lupng tiiu ciu <
lOOOO/mm^ li khflng cin tiuit, jMiiiMB tnrdc t i t Mch;
Cushing ning, ki din ii biin chftng dau tiiupng vj, cic biiu hifln d da nhu myn tiling ci, rim long, Cic biin chiing khde nhu ting huyit ip, dii thio dudng xuit hifln it hon (chiim khoing 8.8%).
Chi djnh cit lich;
^ B l i n chftng
• M a N W u v i t i D
Oil i i o dudng Murila Riiri'lbnq igau thuong vj
s6 Ivomg 34
3 3 5 1 7
T»l»(%) 100 8.82 8.62 147 2.94 20.58
Chl dlnh c i t lich Khdng dip iing diiu tri
Biin chftng nhiiu do dCing corticoid Chiy miu ning, de doa tinh manq Phii hpp nhiiu chf djnh
S i lugrng 32/34
1/3 2/34 16/34
T* I«(%1 9411
2.94 5.88 47.05
PTheo bing trin, do vige dung corticoid keo dai nin biin chiing chu yiu trudc khi cit lach la cac biin chumg do dftng corticoid, trong dd 100% benh nhi cd biin chumg
Ty Ij dap ftng:
Ket qui cho thiy, 94.11% bgnh nhi cd chi djnh cit lach do khong dap ftng diiu ttj vdi cic phuong phip khac (corticoid vi gamma globulin), 47.05% bgnh nhi du tiiit bai vdi dieu trj bing cac phuong phip khic nhung ehi dupe ehi djnh cit lach do ed biin chftng ning do dung corticoid bay chay miu de dpa tinh mang.
Thdi diim danh g l i Sdm Sau 6 thanq Sau 1 nSm Sau 2 nim Sau 3 nim Sau 4 nim Sau 5 ndm
CR(TC>150k) Sfl lug-ng
27 19 17 17 10 7 1
Tyle 79.4 67.6 70.6 85 83.3
100 100
PR (TC 50k-149k) S i Iupng
2 7 7 2 2 0 0
T y l i 6,8 25,3 28, 10 167 0 0
NR (TC<50k) S i lug'ng
6 2 1 1 0 0 0
Tyle 14,8 7,1 4,0 5 0 0 0 Ty 1| dap ling som sau dt lach khoang 79.4%, 5 truong hgp that b^i, chiSm 14.8%. Do s6 luong benh nhan khong giong nhau a mSi thtn diem danh gi^ nen ty le thang c6ng khac nhau
% thoi diim. So voi cac tac gia khac, ty le thanh cong dao dpng tijr 58-94%.
Bien chirng sau ckt lach:
Blin chftng
Viim phoi khflnq die hiiu Chlamydia pneumonia Khfinq bien ehftnq
Tong cflnq
s i lu'png 1 33 34
T * l | 2,94 97,06
100
561
CHUYtN Bi: Hpl NOHj KHOA HQC HUYgT HQC • T R U Y S N M A U T O A N Q U 6 C 2012 Trong nghiin cftu efta chftng tfli chi ghi
nhin cfl 1 ttvdng hpp xuit hi^n viim phii khflng die hiiu do Chlamydia pneumonia, chiim t^ li 2.94%, ttong khi dd 97.06% binh nhin khflng gip biin chimg nio khic sau m i . Khflng cfl bfnh nhin tft vong sau m i . Diiu niy chftng tfl tinh an toin tirong dii eao cfta phuong phip diiu trj xuit huyit giim tiiu ciu bing phucmg phip cit lich nfli soi.
IV. K ^ LUijiNi
c i t lich l i m$t phuorng phip diiu trj xuit huyit giim tiiu c i u miln djch min tinh cfl ty li dip ftng cao cQng nhu ed tuong dii an toin, giftp binh nhi giim dugrc c i e biin chiing do phii dftng thuic liu dii.
T A I u f u THAM K H A O :
1. Kuhne T, Imbach P, Bolton Maggs PHB, et al. Newly diagnosed idiopathic thrombocytopetue purpura in childhood:
An observational study. Lancet 2001;
358:2122-2125.
2. Cines DB, Blanchette VS. Immune fluombocytopenie purpura. New Engl J Med 2002; 346:995-1008.
3. Blanchette VS, Price V. Childhood chronic immune thrombocytopenic purpura: unresolved issues. J Pediatt Hematol Oncol 2003; 25: S28-S33.
4. Nguyin Phunng Liin. Dinh gii hifuquidt lich trong diiu ttj bflnh giim tiin cau ty migD min tinh. Luin vin fliac sy y hpc (2003).
5. Altintas A, O z d A, Okur N, et aL Prevalence and clinical significance of elevated antinuclear anti-body test in children and adult patients with idio-pathic tiirombocytopenic purpura. J Thromb Thrombolysis. 2007;24(2):I63-I68.
6. Donate H., Picdn A., Rapetti MC. etil, Splenectomy and spontaneous remission in children with chronic idiopathic tiirombocytopenic purpura. Pediatric Blood Cancer. (2006);I5:47.
7. Schoonen W M , Kucera G, CoaUon J, et al. Epidemiology of uranune thrombocytopenic purpura in the general practice research database. British Journal Haematol. 2009;l45(2):235-244.
8. Neutnert C , Lim W. et aL The 4 American Society of Hematology 2011 evidence-based practice guideline for . immune tiuombocytopenia. Bllod 2001; ; 117 (16): 4190-4207.
9. Gibson IVI., Sebon JK., White S. et aL Splenectomy for idiopaftic .- thrombocytopenic purpura: a five-year - retrospective review. American Suigeiy (2000); 66 ( 1 0 ) : 952-4.