CHUYEN eg: H^l NOHj KHOA HQC HUYgT HQC • TRUY£N IWAU TOAN Q U 6 C 2012
NXB Y hpc, 2005, tdi bdn lin thd tu.
Barbleri L j i . (1992): Labolatoiy management in Hematology and Hemostasis.
In Clinical Hematology, Pub by lippincott company, 1992, p: 710 - 717.
Donald L.Yee, el-al. (2009): Nonnal Blood values; Selected reference values for
Pediatric and Adult population, r^b Hematology, Ed. by Hoffman et-al. Pub b) Churchii Elsever, 2009, p: 2.431 - 2,442 WHO: Medical Labotatory Panicuiji requirements for quality and completfnce..
ISO 2007.
NGHIEN Cliu Hllu QUA DItU TR! CORTICUID mONG B | N H XUJT Hmtt GIAM TI^U C^U T^miH it NGUICn Ldm TAI B BlNH VlfN VN HU^
Nguyen Vdn Bong, Nguyen Duy TbSng, Nguyen VSn Tiliii^
Ton T h ^ t Minh Tri, Nguyin IVIinh Wtc, Phym T h j Ngpc Phm V8 The Hiiu, D$ng Triin Hihi H i i u , N g u y i n T h a n h S<ra, L e Thj Thanh Hoi(<
T6M ikr
MMC tlSu:
Danh gia hieu qua dieu trj cOa corticoid trong bpnh xuSt huyet giam tieu <au ty* mien d nguSi Idn l^i Bpnh vien Trung uang Hue.
Moi ilen quan giua iip utig dieu tri vdi ben sir b| UP.
eSI lu'png vi PhU'dng p h i p nghlSn cihi:
45 bpnh nhan ITP tCr 16 dSn 60 tu6i vdi so iupng tieu rau <20 x lO'/i.
Nghien ciili cSt ngang, mo ti timg b-Udng hdp benh. Xuf iy so ilpu bSng phan mem MedCalc 10, Epi Infor 6.
Ket qua vi b i n lu$n: b' ie dap utig vdi iieu trinh corticoid nhu sau.
l i m sang: d ngay thCr 3, cd 48,9% benh nhan con bleu bien xuat huyet, sang ngay thtr 7 thi chi con 4,4%, ngay thiJ 14 ia 6,7%, ngay thij (•) Trung tam Huyet hgc Truyen mau - Benh vien TW Hui Phan bifn khoa hpc: PGS.TS. Nguyin Duy t h i n g
21 thi ting ign den 11,1% benh nhan dm xuil huyet. Ghi nhan tinh trang xuat huyet cai thien sdm hdn si/ hoi phpc tieu (3u.
C$n lam sing: d ngay thii' 21 ti le dap utig tren x^t n g h i ^ cdng thiit mau i i 75,6%
(hoin toin 55,6% v i mot phan la 20,0%), a l t trung binh i i 148,2 x lO'/L.
Bpnh nhin c& bliu hien glim tieu an ipi i<hl giim iieu corticoid chion ti Ip 17,8%.
benh nhin t i i phat od ti ip dip litig i i 66,7%,' nhdm bj IT? Sn dau ti ie dap utig 88,9%.
Ket lu$n:
T! ip dip Otig 75,6% (hoin toan 55,611 v i mpt phan ia 20,0%), Hnh trang xuat huyaoi thien sdm hdn su" hoi phyc tieu tau.
Bpnh nhan b| lan dau co ti ie dap ^ cao hdn so vdi benh nhan t i i phat.
TCr khda: corticoid, xuat huyet giani,tie»
cau tu mien.
) , bLIL
i
Y H p c VI$T NAM T H A N G 8 - s 6 QJ^C BlgT/2012
SUMMARY Objective:
Research the effect in adults with ITP treated by corticosteroid.
The relationship between the response of treatment with patients having TTP prehistory,
M e t h o d s :
45 ITP patients from 16 - 60 years with platelets < 20x lO'/l-
Cross-sectional studies, describing Individual cases. Data pnxessing software MedCalc 10, Epi Info 6.
Results:
On the 3'^ day, 4 8 . 9 % patients is still ibieeding; to the 7 * day, there are 4 . 4 % patients with bleeding; on ttie 1 4 * day, there are 6.7%
patients with bleeding; but in the 2 1 ^ day, percentage of bleeding patients increases with .11.1% patients having this symptom. The Jmproving of bleeding symptom Is earlier than the recovering of platelet.
Laboratory testing: the response rate in the 2 1 * day is 7 5 . 6 % (complete response:
'55.6%; partial response: 20.0%), the mean of platelet Is 148.2 X I O V L
Tlie percentage of patients with the 'decreasing platelet count when we stop or to reduce the dose of corticosteroid is 17.8%. The response rate of new patients is 88.9%, and the 'patients with prehistory ITP is 66.7%.
Conclusion:
^' Ttie response rate is 75.6% (complete
•response: 55.6%; partial response: 20.0%), the improving of bleeding is earlier than the 'recovmng of platelet.
^ The effectiveness of treatment of new patients is higher than patients with ITP 'prehistory.
Keywords: corticosteroid, TTP.
if
I. D^J VAN 0 §
Ban xudt huy^t g i ^ ti^u c4u chua r6 nguyfin nhfin c6n gpi U ban xudt huy^t gi4m ti^u cdu tv miln nguyfin phdt, v6i biiu hi?n chfnh Id gidm tilu cdu sau khi dd lo^i trCr hit cdc nguyen nhdn gdy gidm tilu cdu thii phdt khdc [4]. Hi?n nay, 6 Vi§t Nam m§c du dd c6 nhthig tiln bO m6i trong diiu trj nhu cdc imminoglobulin, rixtuximab, nhung corticosteroid van dupe uu tien l\ra ch<?n vi hi^u qud diiu trj va ly do kinh tl.
Corticosteroid idn ddu tien dugrc sit dyng dl diiu trj cho nh&ng b$nh nhdn viem ru$t vdo cuoi nh&ng ndm 1940. C6 khodng hem 80% b?nh cdp tinh dugc diiu trj thdnh c6ng vin corticosteroid, hom 20% b^nh nhan chuyin sang mdn tinh vd trd nen phy thupc corticosteroid. Tren nguoi \6n bj ITP, ngodi ti 1$ ddp ling thdp hon tre em thi khd ndng tdi phdt sau khi giam lieu hodc ngung dieu tri corticoid Id vdn dl ddng quan tam.Vi vdy, chiing toi tiln hdnh nghien ciiu dl tdi nay nhdm 2 myc tieu:
Ddnh gid hi$u qud diiu tri cm corticoid trong benh xudt hi0>el gidm tieu cdu tu miin o nguoi Icen tgi B^nh vi^n Trung uang Hue.
Mdi lien quan giiia ddp ung dieu tri v&i tien sd b} ITP.
II. D 6 I n/pNG vA PHUONG PHAP NGHIEN COU 1. Doi typng:
45 bpnh nhdn tir 16 din 60 tuoi dupe chdn doan la xudt huyet gidm tieu cau tu miln, nhap vien va di6u trj tai Khoa Huyet Hpc Ldm Sang Benh vien Trung uong Hul.
Tieu chudn chpn benh: benh nhdn dupe chdn dodn ITP co s6 lupng tilu cau <20.10 /I
2. Phtfong phap nghien cihi:
Thilt kl nghien ciiu: Sii d\ing phuong phdp nghien ciiu cdt ngang, mo td timg
237
CHUYtN flg; H Q I NOHI KHOA HQC HUYgT HQC • TRUYJN M A U T O A N QUtic 2012
Theo <lBi dip ling di^u trj.
Khim lim sing mSi ngiy trutag h(?p b$nh.
Ky thujt chpn bjnh; theo tiSu chudn chpn b{nh d trSn.
Phdc ib diiu trj:
Methylprenisolon TM 5mg/kg/ngAy x 5 ngiy, sau dd dCing Prednisolon d^ng u6ng liiu 1,5 mg/kg/ngiy sau d6 gitoi liiu d ^ v4 c h ^ dirt vdo ngiy 21.
- X^t nghi$m c6ng thtrc miu theo dgi nhiiu lin.
S6 11^ dupe thu thip theo b ^ in nghife cuu di dupe th6ng nhit vi chuin hda. Xii ly s6 li§u theo phuong phip thong ki y hpc bSng phin mim MedCalc 10, Epi bifor 6.0
II. KET Q U A V A B A N L U A N : 1. D i p ihig diiu trj
1.1. Tinh trpng ngUng xuit huyit ke tir khi hit diu dieulri Ngiy
Xuit huyet Cbn HSt Tfinq
N3 n 22 23 45
»/o 48,9 51,1 100,0
N7 n 2 43 45
%
4,4 95,6 100,0
corticoid N14 n 3 42 45
»/o 6,7 93,3 100,0
N21 • n
5 40 45
11,1
%•
188,J mo"!
a ' ——' , 1 1 ' "-T—' ^
6 ngiy thii 3, c6 48,9% binh nhan c6n bieu bi$n xuit huyet, sang ngiy thii 7 thi ti l| ray chi c6n 4,4%. Ngiy thii 14 thi ti 1^ niy ting len lai 6,7%, sang ngiy thii 21 thi ting len fij|
11,1%. ^ 'l Nghien ciiu cua chiing toi gin gi^ng v6i nghien ciiu cua Nguyen HOu Chiu E)uc (2009).'
Ghi nhin hi?u qui cua corticoid tren 36 b?nh nhin ITP: ti 1? ngCmg xuit huyet sau 3 ngay dien tri d»t 66,7%, sau 7 ngay dat 77,7%, sau 14 ngiy dat 91,7%, sau 21 ngiy dat 94,4% [1].
1.2. So luprng tiiu ciu sau khi diiu Irj corticoid Oiputig
SLTC (X 1 0 ' / L)
> 100 50 - 100
< 5 0 Tieu cau trunq binh
Tonq
N3 n 3 12 30
%
6,7 26,7 66,6 39,8±37,4 45 1 100,0
N7 n 17 14 14
%
37,8 31,1 31,1 107.8±90,9 45 1 100,0
N14 n 25 13 7
%
55,6 28,9 15,5 147,1±116,4 45 1 100,0
N21 n 25 9 11
%
^ 5 , 6 _ 2 0 j J 148,2±12H 45 1 l O d l a ngiy thil 3, chi c6 6,7% binh nhan
dip ung hoin toin vi 26,7% bpnh nhan dip ling mpt phin, bpnh co dip iing tren diiu trj la 33,4%.Tieu ciu trung binh ngiy thii 3 li 39,8 X lO'/L.
C! ngiy thii 7, bpnh dap ling tot hem rat nhiiu so vdi ngay thii 3 (so lupng bpnh nhan chua dip ung giim nhiiu tir 66,6% cua ngay
thir 3 cdn lai chi 31,1% 6 ngiy thii 7). Tliu ciu trung binh ngiy thii 7 li 107,8 x 10 /L. |
Ti Ip dap ling ting cao vio ngiy thii H, ciia lipu trinh vdi dap img hoin toan la 55,6w vi ddp img mpt phin li 28,9%. Ti Ip dap H chung la 84,5%. Tiiu ciu trung binh ngiy thii 14 la 147,1 xlO'/L.
Tuy nhien, ti ie Ichong dip iing ting i™
238
Y HQC VI$T NAM T H A N G 8 - S 6 O/^C BI$T/2012
l^i 6 ngdy thii 21 vdi 24,4% b§nh nhdn so v6i 15,5% b$nh nhan cOa ngdy thii 14. Tl 1$ ddp ling cua ngdy thii 21 gidm c6n 75,6% (ddp ling hodn toan 55,6% vd ddp iing mOt phdn Id 20,0%) so vdi 84,5% ciia ngdy thii 14. Tilu cdu trung binh ngdy thii 21 Id 148.2 x lO'/L.
d ngudi Idn vi?c dieu tri ITP g$p nhieu kh6 khdn bdi ti 1^ ddp img thdp, dl tdi phdt vd phu thupc corticoid.
Nguyen Ngpc Minh (2007) trong mpt nghien ciiu tr6n 40 bpnh nhdn tuoi tir 45-91 ghi nh|in: c6 60% bpnh nhan tdng tilu cau
>50 X lO'/l vdi lieu prednisolone Img/kg/ngdy [4]. Douglas B. Cien vd cpng sv (2002) nhdn thay rdng ti !§ ddp Ong trong 3 tudn ddu cua lipu trinh diiu tri trong khodng tir 50% din 75%, ti Ip khdng trj 5%- 30% [9]. James N. George vd cpng su (1996) ,ghi nh^ trong 1761 tnrdng hpp thi chi co 64% b?nh nhan c6 ddp ling vdi dieu trj hodn jtoan [10]. Johanna E. A. Portielje (2001) theo doi dap ling diiu trj tren 124 benh nhan tir -15-85 tuoi CO gidm tieu cau ndng dupe dieu tri vdi prednisolone 1 mg/kg/ngdy trong 3-6 ,tudn ghi nhdn: co 62,1% dap iing hodn todn, (5,6% benh nhdn dap iing mpt phdn, ti 1^ ddp 'ling chung Id 67,7% [14].
Trong da s6 cdc nghien ciiu thi tilu cdu
^bdt ddu h6i phuc d ngay thii 3, ti 1? ddp iing cao sau ngay thii 7 cua lieu trinh corticoid.
Dap img vdi diiu trj khoang tir 50-70%, ti le tjdap ling hodn todn khoang 40-60%. Nghien
Cliu cua chiing toi cung co ket qua tuong tu.
1.3. Mdi Hen quan giira tinh trgng xudt fhuyet vdi sir hdi phyic tiiu chu cua li$u
trinh corticoid
6 ngdy thii 3 cda li$u trinh corticoid ghi n h ^ cd 6,7% bpnh nhdn hh\ phyc tilu cdu hodn todn. 26,7% bpnh nhdn ddp iing diiu trj mOt phdn. so b^nh nhdn c6 ddp ihig Id 33,4%, nhung ti 1§ b§nh nhan hit xudt huyet din 51,1%.
0 ngdy thii 7 ciia li§u trinh corticoid chi c6n 4,4% b^nh nhfin cdn xudt huyet, trong liic d6 vdn c6n din 31,1% b^nh nhan chua ddp irng vdi diiu trj trSn xdt nghi$m (SLTC
<50 xlO'/L). C6 37,8% bpnh nhdn hoi phyc tilu cau hodn todn, 31,1% b$nh nhdn ddp irng diiu tri nipt phan, ti 1§ ddp ling chung Id 68,9%, tuy nhien c6 din 95,6% benh nhdn hit xuat huyet tren lam sdng.
James N. George, Mujahid A. Rizvi (2001) ghi nhdn rdng: khi tilu cdu gidm ndng thi hang rao ch6ng xuat huyet trd nen mong manh hon vd npi m^c m^ch mdu de bi tin thucmg hon vd de bi xudt huyit, corticoid dd cdi thien phdn ndo su bat thudng nay. Do Id ly do gidi thich cho hien tupng khi benh nhdn dupe diiu tri cortiocoid, tinh tr^g xuat huyet cdi thipn sdm hon su hoi phuc ciia tieu cdu va ngay cd khi tieu cau thdm chi chua tdng [11].
Nhu v^y, trong nghien ciiu ndy, qua so sdnh vd tim moi lien quan giCta sy hoi phyc tilu cdu vd sy cai thien tinh trying xudt huyit tren lam sang sau khi dieu tri corticoid chiing toi nhdn thdy rdng tinh tr^g xudt huyit cdi thien sdm hon rdt nhiiu so vdi sy h6i phyc tilu cdu, diiu ndy rdt phii hpp vdi hai tdc dyng lie chi mien dich vd on dinh mao m?ch cua corticoid trong ITP.
' 1.4. rill bfnh nhin giim si licpmg tliu ciu Ird lai khi glam liiu corticoid SLTC giam l^i khi giam lieu corticoid
1
, Co
\ Khong Tong
n 8 37 45
Ti le % 17,8 82,2 100,0
239
CHUYSN Bi: HQI NOHj KHOA HQC HUYE'T HQC • TRUYJN MAU TOAN QUtfc 2012 Binh nhin c6 biiu hiin giim tiiu ciu trd
Ifii Ithi giim liiu corticoid chiim tl li 17,8%.
Trong diiu trj ITP ciia ngu6i Idn, ngoii ti li dip (mg khdng cao nhu tri em, m^t yiu ti lim cho ti li dip ling thip d6 li tinh trang glim si lupng tiiu ciu tr* l?i sau khi giim liiu hoic ngung corticoid, binh tr* nSn phy thuOc vi di khing vdi diiu trj corticoid. C6 hai thiri diim giim liiu d6 li liic chuyin tir vi^c sir dvmg methylpiednisonlon du&ng tTnh mach sang dudmg uing 6 ngiy thut 6 vi giim liiu din ki til ngiy IS ciia liiu trlnh piednisonlone bing duimg uing. Trong nghi£n ciiu ciia chiuig t6i cOng di ghi nhin c6 din 17,8% b^nh nhan giim SLTC trd lai khi thay dii liiu trlnh corticoid. Do viy, trong tiin triin dip ting ciia binh nhin chiing ta thiy tl Ip khong dip img ting trd Iji sau ngiy 21 vtH 24,4% binh nhin so vdi 15,5%
bpnh nhin ciia ngiy 14, ti li dip img giim cdn 75,6% so vdi 84,4% cua ngiy thii 14.
Nguyin Binh Huin ghi nhin tr&i 1J7 binh nhin cd 5,2% phy tu^c corticoid J^.
Trin Thi Qui Huong ghi nhjn trSn 763 bjnh nhin ITP d ngudi Idn nhin thay ring:13,0'/o binh nhin I? thuOc corticoid [3]. Hu^
NghTa ghi nhjn tr4n 74 b$nh nhin thiy co 6,2% phvi thuOc corticoid [5].
Michael E. Bromberg (2006) ghi nh^co khoing 50-80% binh nhin lui bpnh vdi diJii trj corticoid iiiu diu tiSn. Tuy nhien, klu giim liiu hoic ngung corticoid thi cd tin!
trying giim s6 lupmg tiiu ciu trd lai, sv Iui binh hoin toin chi cdn duy tri tii 10-30%.
Nghite cihi ciia James N. Geoige vi s\r ghi nhin c6 60,0% bpnh nhin ting tiiu du
>50 x lO'/l vdi lieu ban diu prednisolon Img/kg/ngiy. Tuy nhi£n, tiiu ciu giim l^i kbi giim liiu ho$c ngung corticoid, 64,0% iieoh nhin min tinh trd nen phvi thupc vi di khing vdi diiu trj corticoid [9].
2. Lien quan gifl'a dip trng dieu tri vi tien sir ITP ciia bpnh nhan
Til$%
Ijndau 88,9
Tii phat 66,7
Nhdm binh nhin tii phit c6 ti Ip dip img li 66,7% (18/27) trong khi dd nhdm binh nhin bj ITP lan diu thi dip iing tit hon vdi tiip 88,9% (16/18).
V. KET lU^U
Ngay thit 3cua lipu trinh corticoid cd 48,9% binh nhin cdn biiu bipn xuit huyit, sang ngiy thii 7 thi chi con 4,4%, ngiy thii 14 li 6,7%, ngiy thir 21 thi ting len den 11,1%. Ghi nhan tinh trang xuit huyit cii thipn sdm hon svr hoi phuc tiiu ciu.
Dip iing tren xet nghipm d ngiy thit
21: ti Ip dip iing 75,6% (hoin toin 55,6% vi mpt phin li 20,0%). Tiiu ciu trung bhih li 148,2 xlO'/L
Bpnh nhin cd biiu hipn giam tiiu cSu trd lai khi giim lieu corticoid chiem 17,8%.
- Nhdm bpnh bj ITP nhan tii phil nhiiu lin cd ti li dip ling li 66,7%, nh6mbi ITP lin diu ti li dip iing 88,9%.
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Idm sang cpn ldm sdng va hifu qua dieu HT^
bfnh nhdn xuat huyet giam tieu cdu tp phat^
Y HQC VigT NAM T H A N B 8 • 86" OAC BI$T/2012
tinh bing corticosteroid, Luin vin tit nghipp th^c sTy hpc, Dai hpc Y Dupe Hue.
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i I. George J.N. and Rizvi M.A. (2001),
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