Y HOC VIET NAM THANG 1 - SO 2/2014
NGHIEN CU'U PHl DAI THAT TRAI TREN BENH NHAN LOC MAU CHU KY
^3
T O M TAT
Muc t i e u : Tim hieu moi lien quan giO'a phi dai that trai (POTT) va mpt sd yeu to nguy cd tren benh nhan lpc mau chu ky (LMCK),
DOI tu'dng: Chung toi chpn 81 benh nhan > 18 tuoi, CO thdi gian lpc mau chu ky > 3 thang tai benh vien Oa khoa Trung Udng Can Tho va Benh vien Da khoa Thanh phd Can ThO.
Phu'dng phap: Nghien cuU hen ciiU, mo ta cat ngang.
Ket qua: Ty le benh nhan LMCK co phi dai that trai la 81,48 % (81,82% la phi dai dong tam, 18,18%
la phi dai iech tam), Chi so khdi lUpng cO that trai co moi tu'png quan thuan vdi ndng dp BNP huyet tu'dng (r= 0,5, p<0,0001), tu'png quan nghich vdi cholesterol (r=-0,38, p=0,02), tryglycerid (r=-0,3, p=0,06), LDL-C (r=- 0,3, p=0,006) va EF (r=-0,41, p=0,0001 trong phan tieh don bien, Mo hinh hoi quy logistic trong chan doan phi dai that trai, chi eo InBNP c6 y nghia thdng ke vdi 0R= 2,02, CI 95%[1,01- 4,05], p= 0,04.
Ket luan: Benh nhan co POTT chiem ty le cao tren benh nhan LMCK. Chi so khoi lu'dng cd that trai (LVMI) CO mdi tUOng quan vdi BNP, cholesterol, triglyceride, LDL-C va EF. Trong mo hinh hdi quy logistic, chi co InBNP eo gia trj trong dir doan PDTT.
TLT khoa; Phi dai that trai, loc mau chu ky,
S U M M A R Y
LEFT VENTRICULAR HYPERTROPHY I N HEMODIALYSIS
Objective: Determine the relabonship between left ventricular hypertrophy and risk factors in hemodialysis pabents.
Subjects : We selected 81 pabents > 18 years of age, dialysis time period > 3 months at Can Tho Central General Hospital and Can Tho General Hospital.
Methods: A prospective, cross-sectional descriptive study.
The percentage of hemodialysis patients who have left ventricular hypertrophy (LVH) is 81,48% (81,82 % as concenthc hypertrophy, 18,18 % as eccentric hypertrophy). The left ventricular mass index had a positive correlation with BNP (r= 0,5, p<0,0001), negative correlated with cholesterol (r=-0,38, p=0,02), tryglycerid (r=-0,3, p=0,06), LDL-C (r=- 0,3, p=0,006)
' Tnidng DH YD/gc Can Thd '* Hgc vi4n Qu3n Y
Pban bi^n khoa bgc: GS.TS Le Gia Vinh
Nguyen Nhu- Nghia*, Ha Hoang Kiem**, Vu Dinh Hung**
and EF (r=-0,41, p=0,0001) In univanate analysis.
However, muJtivanate logistic regression modeling indicated that the factor associated with LVH is InBNP (0R= 2,02, CI 95%[1,01- 4,05], p= 0,04),
Conclusions: Left ventricular hypertrophy high percentage of hemodialysis patients in the first year.
Left ventricular mass correlated with BNP, cholesterol, tryglycerid, LDL-C and EF systolic blood pressure, hemoglobin and BNP, In the univariate logistic regression analyses in the HD patients, only InBNP was a positive predictor of LVH,
Keywords: Left ventncular hypertrophy, hemodialysis
I. DAT V A N OE
Phi dai that trai (PDTT) la yeu to nguy cd dpc lap doi vdi b/ le tir vong 6 benh nhan suy than man giai doan euoi. Tinh trang POTT ngay cang tang va sir suy giam chu'c nang tam thu that trai tren benh nhan dieu trj loe mau la yeu to tien lu'dng tang nguy ed X.<^ vong, tai bien tim mach va suy tim [8].
Sir dao ngu'de ciia LVH la mgt dau hieu thuan Idl ma dir doan lam giam nguy cd ttT vong sau benh nhan giai doan euoi Lf^CK [3], Nghien eiTu nay nham muc tieu tim hieu eac yeu td lien quan den tinh trang PDTT tren benh nhan LMCK, II. OOI TU'ONG VA PHU'ONG PHAP NGHIEN CU'U
2 . 1 . Ooi tu'dng n g h i e n cu'u: 81 benh nhan suy than man do viem eau than man LMCK ed thdi gian loe mau tir 3- 12 thang tai Benh vien Oa khoa Trung u'dng Can Thd va Benh vien Oa khoa Thanh pho Can Thd.
2.2. Phu'dng p h a p n g h i e n c i r u : Tien cu'u, eat ngang md ta.
+ Cac tieu chuan sii dung t r o n g nghien cuti [ 6 ] - Khoi lu'dng ed that trai (LVM) du'dc tinh theo cong thirc
LVr^ (g) = 0.8 X 1.04 x [(LVDd + IVSd + PWTd)^ - LVDd^] -f 0.6
Trong do:
• LVDd; OiTdng kinh that trai euoi tam tru'dng (cm)
• IVSd; Be day vach lien that cudi tam tru'dng (em)
Y HOC VIET NAM THANG 1 • SO 2/2014
• PWTd: Be day thanh sau that trai cuoi tam triTdng (cm)
+ Chi so khdi lu'dng cd that trai: LVMI (g/m^)= LVM (g)/ BSA (m^), b-ong do BSA (dien tfch be mat cd the du'dc tinh theo cong thurc:
BSA (m2) = Can nang (kg)"' X Chieu cao(cm)'''^x 0,007184
-i- Phi dai that trai du'dc xae dmh khi LVMI >
131 g/m^ d beph nhan nam va LVMI > 100 g/m^
d benh nhan niJ theo tieu chuan Framingham.
- Be day thanh bm tu'dng ddi- RWT (relative v/all thickness)
RWT = (2 X PWTd)/LVDd Trong do:
• PWTd: Be day thanh sau that trai cuoi tam tru'dng (em)
• LVDd: Du'dng kinh that trai cuoi iam tru'dng (cm)
RWT tang khi > 0,42 - Phan loai phi dai that trai:
H- Phi dai dong tam: Phi dai that bai + RWT tang H- Phi dai leeh tam: Phi dai that trai + RWT binh thu'dng
.KET QUA NGHIEN CU'U
Co 81 benh nhan du'dc du'a vao nghien eiru vdi ket qua nhu' sau;
Bang 3.1. Ty le va phan loai phi dai that trai d benh nhan LMCK Phi dai that trai
Nam NO- Tong
Phan loai phi dai that trai Phi dai dong tam Piii dai iecii tam
n 36/66 30/66 66/81 54/66 12/66
%
54,55 % 45,45 % 81,48 % 81,82%
18,18%
iVhanxet'Jy le benh nhan phi dai that trai 81,48%, trong dd phi dai that frai dong tam chiem ty le 81,82%
Bang 3.2. Mot so dac diem lam sanq va can iam sanq Thong so
Lam sang
Huyet iipc va sinii iioa mau
Sieu am tim
Tuoi (nam) Thdi gian lpc mau
(thang) BMI (l<g/m') HATB(mmHq)
Hb (g/di) Aibumin (g/i)
Cholesteroi (mmoi/i) Trigiycerid
(mmol/i) HDL-C (mmo!/l)
LDL-C (mmol/l) CRP (mq/dl)
EF(%) LVI^I(q/m') BNP (pg/ml)*
Phi dal that trai (n=
66) 40,47± 12,19 19,07± 15,32 20,01± 2,17 98,23± 7,62 9,28± 2,13 37,93± 3,47 3,76± 0,81 1,09± 0,S6 1,I2± 0,67 2,23± 0,63
0,84± 1,54 S5,88± 13,11 191,12± 57,52 2163[35,1-117S2]
is nhom POTT va khonq POTT Khong phi dai
(n=15) 43,46± 12,88
18,6± 11,48 20,16± 2,27 95,11± 9,98 10,6± 1,85 38,26± 3,39 4,3S± 0,94 2,19± 0,83 0,87± 0,17 2,79± 0,86
0,65± 0,8 68,13± 8,45 104,2± 20,34 162,7[28,2-1151,2]
P 0,39 0,91 0,81 0,18 0,03 0,74 0,01
<0,0001 0,15 0,005
0,54 0,0009
<0,0001
<0,0001 Nhan xet: Co sir khac biet cd y nghia
nhan khong phi dai that trai d cac bien:
* BNP khong phan phdl chuan
thong ke giu'a nhom benh nhan phi dai that trai va nhdm benh
Hb, cholesterol, triglyceride, LDL-C, EF, LVMI va BNP. Trong do:
Y HOC VIET NAM THANG 1 - SO 2/2014
+ Hemoglobin, EF, cholesterol, triglyceride, LDL-C d nhdm phi dai that trai thap hdn so vdi nhdm khong phi dai that trai (p<0,05).
+ Nong do BNP huyet tu'dng d nhdm phi dai that trai cao hdn nhdm khong phi dai (p<0,0001).
Bang 3.3. Moi tu'dng quan giu'a chi so khoi cd that trai vdi cae yeu to khac biet giiJa nhdm phi dai that trai va khdng phi dai that trai:
Hemoqiobin Cholesterol Triqiycerid LDL-C BNP EF
Chi so khoi CO t h a t trai f LVMI o / m ' l r
-0,19 -0,25 -0,3 -0,3 0,5 -0,41
p 0,07 0,02 0,006 0,006
< 0,0001 0,0001 Nhan xet:
-t- Co mdi tu'dng quan 6 mu'c trung binh giij'a LVMI vdi EF (r= -0,41, p=0,01) va nong do BNP huyet tu'dng ( r = 0 , 5 , p<0,0001)
+ Co moi tu'dng quan mii'c do yeu giiJa LVMI va cholesterol, triglyceride va LDL-C ( p<0,05) + Md hinh hoi qui logistic trong ehan doan phi dai that trai; Khao sat gia tri eiia BNP huyet tu'dng trong ehan doan phi dal that trai bang md hinh hoi quy logistic. Cae yeu to khae biet giu'a 2 nhdm ed phi dai that trai va khong phi dai that trai bao gom: Hb, cholesterol, trigiyeeride, LDL-C, EF, LVMI va BNP huyet tu'dng (bang 3.3)
Bang 3.4, Hoi qui loc
LnBNP Hb ( g / d l ) Cholesterol ( m m o I / 1 ) Triglycerid ( m m o l / l ) LDL-C ( m m o l / l ) EF(»/o)
istic tronq chan doan phi dai that trai H$ so hoi quy
0,7 0,05 0,009
•1,46 -0,52 -0,05
Do lech chuan
0,35 0,24 1,44 0,75 1,61 0,04 AUC= 0,94rCI 95%: 0,87- 0,98], p=0
P 0,04 0,82 0,99 0,06 0,74 0,24 02
OR ( C I 9 5 % )
2,02 [1,01- 4,051
Nh$n xit: Phan tieh da bien cho thay chi ed InBNP hen quan den ehan doan phi dai that trai (sau khi kiem soat cac yeu to cdn lai) vdi p= 0,04, OR 2,02,
IV. BAN LUAN
Ty le benh nhan phi dai that trai trong nghien cii'u cua chung tdi ehiem ty le 81,84 %, trong dd phi dai that trai dong tam ehiem b/ le cao hdn so vdi phi dai iech tam. So sanh vdi cac nghien eu'u khae sii'dung tieu chuan Framingham trong chan POTT tren benh nhan LMCK cung ghi nh^n ty le benh nhan phi dai that trai rat eao.
N^hlen ciiij ciia Ardeleanu [1] ghi nhan ed 83%
benh nhan LMCK cd phi dai that, trong dd pho bien nhat la phi dai dong tam (ehiem 47,57 % so vdi 37,2% PDTT i k h tam).
So sanh giijB hai nhdm benh nhan cd va khong cd phi dai that trai chimg tdi ghi nhan si/
khac biet co y nghia ve Hb, cholesterol,
triglyceride, LDL-C, EF, LVMI va BNP. Chiing toi ghi nhan ed moi tu'dng quan giUa LVMI vdi cholesterol (r= -0,38, p=0,02), Triglycerid (r= - 0,38, p=0,02), LDL-C ( r ^ 0,41, p=0,01), EF (r=
-0,38, p=0,02) va nong dd BNP huyet tu'dng (r=
0,51, p=0,002) trong phan tieh ddn bien. Tuy nhien, trong phan tich hdi quy losgistic, chung tdi ehi ghi nhan cd su' lien quan cd y nghia giu'a LVMI va InBNP (vdi 0R= 2,02, CI95%[1,01- 4,05], p= 0,04), cac yeu to cd lien quan vdi LVMI trong phan tich ddn bien trd nen khong cd y nghia (p>0,05).
Nhieu nghien ciru da ghi nhan moi tu'dng quan giUa nong do BNP tru'dc Ipe mau va LVMI tu'dng tir nhu' nghien ciru ciia ehiing toi [7],[2].
Y HOC VIET NAM THANG 1 - SO 2/2014
Bang 4.1. So sanh mdi tu'dng quan giu'a BNP va LVMI g i u ^ eae nghien cii'u Nghien cu'u
Mallamaci [7]
Bargnoux [2]
Chung tdi
Ooi tu'dng nghien cu'u Bol tu'dng 212 benh nhan than nhan tao va 34 benh nhan tham phan phuc mac 31 benh nhan than nhan tao 81 benh nhan than nhan tao
D T O 1 5 %
r 0,53 0,44 0,49
P
<0,0001 0,02
<0,0001 DTD: Ty IS benh nhan suy than man do dai thao du'dng.
Mdl tu'dng quan giu'a BNP va LVMI trong nghien eiru eiia chiing toi tu'dng du'dng vdi eac nghien eiru l<hae dii ddi tu'dng ehpn benh giu'a cac nghien CLTU khac nhau. Dieu do the hien anh hu'dng eiia cac yeu t d gay nhieu khae nhau nong dp BNP van la yeu t d dpc lap lien quan den LVMI.
Ket qua nay cho thay tiem nang ciia BNP trong chan doan phi dai that trai tren benh nhan LMCK.
Kha nang cai thien tinh trang phi dai that trai eung du'dc du'dc xem xet trong nhieu nghien eii'u.
Nghien eiru Foley [4] ghi nhan kha nang eai thien tinh trang phi dai that trai se khdng xay ra sau khi benh nhan bat dau Ipc mau do ty le tir vong cao tren nhdm benh nhan nay. Tuy nhien, eac nghien eiru trong thdi gian gan day ghi nhan ket qua eho thay kha nang giam khdi lu'dng cd that trai sau nhieu nam vdi mpt chien lu'dc dieu tri hdp ly. Cac nghien ciru cho thay viee kiem scat tinh trang thieu mau, the dich, siJ dung thudc ha ap hdp ly, thay dd'i phu'dng phap loe mau ( sir dung Ipc mau hang ngay),,, cho thay ed anh hu'dng den tinh trang PDTT [ 1 ] , [ 5 ] .
V. KET LUAN
Phi dai that trai chiem ty le cao tren benh nhan LMCK trong dd phi dai dong tam ehiem da so. Cd moi tu'dng quan giiTa LVMI vdi cholesterol, trigiyeeride, LDL-C, EF va BNP huyet tu'dng. Chi cd LnBNP co y nghia thdng ke lien quan den phi dai that trai trong phan tieh hoi quy logistic vdi 0 R = 2,02, CI 9 5 % [1,01- 4,05], p= 0,04.
TAI LIEU T H A M KHAO
1. S. Ardeleanu, L. Panaghiu, O, Prisada, R.
Sascau, L. Voroneanu, S. Hogas, N. Mardare, va A. Covic (2011), Regression of left ventricular hypertrophy in hemodialyzed patients is possible:
a follow-up study, Int Urol Nephrol, sd 43(4), tr, 1161-9
2. A. S. Bargnoux, K. Klouche, J. Fareh, I.
Barazer, S. Villard-Saussine, A. M. Dupuy, H.
Leray-Moragues, I. Giuliani, B. CanaudrVaJ.
P. Cristoi (2008), Prohormone brain natriuretic peptide (proBNP), BNP and N-terminat-proBNP circulating levels In chronic hemodialysis patient.
Correlation with ventricular function, fluid removal and effect of hemodiafiltration, Clin Chem Lab Med, so 46(7), tr, 1019-24.
3. R. N. Foley, P. S. Parfrey, G. M. Kent, 3. D.
Harnett, D. C. Murray, va P. E. Barre (1998), Long-term evolution of cardiomyopathy in dialysis patients, Kidney Int, so 54(5), tr. 1720-5.
1 , R. N, Foley, P. S. Parfrey, G. M, Kent, 3. D.
Harnett, D. C. Murray, va P. E. Barre (2000), Serial change in echocardiographic parameters and cardiac failure in end-stage renal disease, J Am Soe Nephrol, so 11(5), tr. 912-6, 5. S. Kutlay, I . Dincer, S. Sengul, G. Nergizoglu,
N. Duman, va S, Erturk (2006), The iong-tenv behavior and predictors of left ventricular hypertrophy in hemodialysis patients, Am J Kidney DIS, so 47(3), tr. 485-92.
6. R. M. Lang, M. Bierig, R. B. Devereux, F. A, Flachskampf, E. Foster, P, A. Pellikka, M. H.
Picard, M. J. Roman, 3. Seward, 3, Shanewise, S. Solomon, K. T. Spencer, M. St 3ohn Sutton, va W. Stewart (2006), Recommendations for chamber quantification, Eur J Echocardiogr, so 7(2), tr. 79-108.
/ . F. Mallamaci, C. Zoccali, G. Tripepi, F. A.
Benedetto, S. Parlongo, A. Catallotti, S.
Cutrupi, G. Giacone, I. Bellanuova, B.
Stancanelli, va L. S. Malatino (2001), Diagno^
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