Y HOC VIET NAM THANG 1 0 - S O 1/2011
NGHIEN CLTU NONG DO PARATHYROID HORMON HUYET THANH 6 BENH NHAN SUY THAN MAN TINH
T O M T A T
Cd sd: cudng can giap thir phat vdi bi^u hidn tang parathyroid hormon trong huyet thanh, thudng gap d bdnh nhan suy than man tinh va cd lidn quan mat thiet ddn bdnh ly tim mach va loan dudng xuong. Muc dich: Nghidn ciru nong dp parathyroid hormon va mdi tuong quan vdi can xi, phdt pho, phosphatase kidm d b§nh nhSn suy than man.
Ooi ti/dng va phifcfng phap: 161 bdnh nhdn bj suy than man tfnh gdm 106 nam vd 55 nQ, tudi trung binh 54,7 ± 13,3, dieu tri tai BVTWQD 108 tCr 3/2008 10/2009. Cac benh nhdn dupe tham kham lam sang, xet nghidm mau:
Ure, creatinin, phospho, can xi toan phan, phosphatase kiem va parathyroid hormon (PTH).
Ket qua: - Ndng dd parthyroid hormon tang theo mirc dp suy than (p<0,05), nong dp parthyroid hormon tuang quan thuan vdi creatinin mau (r= 0,39, p<0,05). Nhdm suy than da Ipc mau chu ky, ty le benh nhan cd nong dp parthyroid hormon tang tang vupt qua gidi han la 73,3%.
Oac biet trong nhom nay cd 8 BN (13,3%) cd ty le ndng dp parthyroid hormon tang thap dudi gidi han cho phep.
Cd mdi tuang quan thuan giQa nong dp PTH vdi nong dp can xi mau va ALP huyet thanh d nhdm suy than da chay than nhan tao chu ky ( F 0,31 va r= 0,82; p< 0,05 vap<6,01).
Tif khoa. Suy than man, PTH, can xi, phdt pho, phosphatase kiem.
ABSTRACT
RESEARCH PARATHYROID HORMONE SERUM CONCENTRATIONS IN PATIENTS WITH CHRONIC RENAL
FAILURE
Base. Secondary hyperparathyroidism with expression of parathyroid hormone increased in serum is common in dialysis patients and closely related to cardiovascular disease and osteodystrophy.
Purpose. To study the concentration of parathyroid hormone and correlation with calcium, phosphorus, alkaline phosphatase in patients with chronic renal failure.
Subjects and Methods. 161 patients with chronic renal failure, including 106 males and 55 females, mean age (54.7 ± 13.3), treated at 108 hospitals from 3/2008 10/2009. Patients received physical examination, blood tests: urea, creatinine, phosphorus, total calcium, alkaline phosphatase, parathyroid hormone.
* Benl) vien TWQB 108 _
PBKH: PGS.TS. Nguyen Van Quynh
Nguyin Thj Kim Thuy*
Results PTH concentrations increased with the extent of renal impairment (p <0.05). PTH levels correlated with serum creatinine (r = 0.39, p <0.05). Group had renal dialysis cycle, the rate of patients with PTH levels exceeding the permitted limit is 73.3%. Especially in this group eight (13.3%) patients with a hormone ratio parthyroid lower than the permited concentration limits.
There is positive correlation between hormone concentrations parathyroid calcium concentrations and serum ALP in the controlled group had renal dialysis cycle, (r = 0.31 and r = 0.82, p <0.05 and p <0.01).
Key words: chronic renal failure, parathyroid hormon, calcium, phosphorus, alkaline phosphatase
I.
OAT VANo l
Suy than man (STM) cd xu hudng ngay cang tang, co nhieu bien chirng gay tan phe va tir vong cao, lam giam chat lupng cupc sdng va tang chi phi dieu tri.
d Viet Nam cd khoang 6 trieu ngudi bi STM chiem khoang 6,73% dan sd thdng tin bao dpng nay dupe dua ra tai hpi nghi "Than nhan tao va chat luang trong Ipc mau" diin ra nam 2009 tai thanh phd Ho Chi Minh.
Cudng can giap la bien chimg thudng gap ciia STM, thudng xuat hien sdm khi mirc Ipc cau than (MLCT) < 80 ml/phut va gia tang khi MLCT giam.
Cudng can giap gap hau het d cac benh nhan suy than giai doan cudi, dac biet tang d nhOng benh nhan chay than nhan tao (TNT). '
Muc dfch: Nghien ciru hilu nong 66 parathyroid hormone huyet thanh va mdi lien quan vdi can xi, phdt pho, phosphatase kiem d benh nhan suy than man.
II. Odi TUdNG VA PHUONG PhlAP NGHIEN COU 1. Ddi ti/dng nghien cCfU: g6m 161 b$nh nhan bi suy than man tinh 106 nam, 55 nO; tudi trung binh (54,7 ± 13,3), dao dong (30 78 tudi), di^u tri tai BVTWQD 108, tif thang 3/2008-10/2009.
2. Phi/dng phap nghien ciru
+ Ti6u chuan chpn benh nhSn: Chan doan STM theo tieu chuan cua KDOQI nam 2002 : Tang nito mau tren 3 thang. Sieu am than: giam kfch thudc than ca hai ben. MLCT < 60% tren 3 thang [5]
13
Y HOC VIET NAM THANG 10 - SO 1/2011 Ti&u chuan loai tri;: nhQng b6nh nhSn cudng
chirc nang tuyg'n can giap khCing phai nguyfin nhan suy than man
+ Phan loai mirc 66 suy than man: Dua vao phan loai CLia Nguy6n Van Xang [2]
+ Danh gia n6ng 66 PTH theo 3 mirc:
Thap: <70 pg/l,
Trung binh : > 70-<110pg/l;
Tang; > 110 pg/l
+ Tat ca cac b6nh nhan dupe kham x6t lam sang, ghi chep theo mau nghifen ciru va dupe iam cac x6t nghi6m
* Xet nghi§m mau:
Xet nghiSm sinh hoa: Ure, creatinin, phospho, can xi toan phan huy6't thanh, phosphatase ki§m
(ALP), parathyroid hormon (PTH). Nhdm suy than da Ipc mau chu ky dupe lay mau xet nghi§m trudc khi Igc mau. cac x6t nghiem duoc lam tai khoa sinh hoa B6nh vien TWQO 108
Dinh lupng parathyroid hormon: nguyen tac dinh lupng b^ng phuong phap miin dich di6n hoa phat quang (elecrochemiluminescence imumnoassay) theo nguy§n ly Sandwich. Dung cu may phan tich tu dfing Elecsys 2010. Dinh lupng can xi toan, phosphatase kiim, phdt pho tr§n may phan tfch AU 640
* X i t nghiem nude tilu: Sd lupng nude tilu 24 gid, Ure, creatinin niSu, Protein niSu
* SiSu am than
KET Q u A NGHIEN CCfU
Bang 1. Dac dilm chung cua nhdm nghiSn ciru Thong so
Nam Nu
Thai gian phat hien benh < 5 nam Thdi gian phat hien benh > 5 nam Thdi gian phat hien benh (nam) Tud'i trung binh
Nhom suy than (n = 161) 106
55 100
36 3,83 ±± 3,7 54,7 ± 13,3
Ty le % 65,8 34,2 73,9 26,1
- Da sd benh nhan co thdi gian phat hi§n b§nh < 5 nam (73,9%)
Bang 2. Cac xet nghiem theo mirc dd suy than Thong so
Odi n=31
06 suy than OdII
n=33
Dd III' n=37
Od lll^ IV n=60 Ure
(mmol/l)
7,4 ±2,1 8,6 ±3,9 21,1 ±8,2 21,7±9,1 < 0,001
Creatinin (lamol/l) 123,0 ±4,9 177,7 ±45,8 104,3 ±22,2 823,8 ±290,9 < 0,001 Can xi (mmo/L) 2,17±0,13 2,16±0,16 2,06 ± 0,21 2,06 ± 0,28 >0,05 Phot pho
(mmol/L)
1,24 ±0,21 1,14±0,44 1,47 ±0,28 1,81 ±0,52 <0,001 ALP (U/L) 164,3±0,36 177,24± 0,99 248,43 ±134,6 314,66 ± 306,8 <0,05 PTH pg/L 41,50±31,7 46,31± 26,11 115,21 ±129.68 222,65 ±340,86 <0,05 I
N6ng d6 ure, creatinin, PTH, phdt pho, ALP tang I6n heo mirc d6 suy than su khac bifet co y nghia thdng ke (p< 0,05 va p<0,0001). Rieng ndng dd can xi thay d i i khdng cd y nghia giii'a cac giai doan suy than
Bang 3. So sanh t^ le ndng d6 PTHd 2 nhom suy than chua va da chay than nhan tao Nong do PTH (pg/l) Nhom da chay TNT
(n=60)(n,'%)
Ty le %
Thap <35 8 13.3%
Trung binh > 70-< 110 8 13,3%
Tang qua mirc > 110 44 73.4%
Nhom da chay TNT chu ky c6 tdi 73,4% tang PTH qua mirc, song cd 8 BN (13,3%) cd ndng dd PTH huylt thanh thap hon gidi han cho phep.
14
Thong so PTH
Y HOC VIET NAM THANG 10 - S O 1/2011 Bang 4. Lien quan giira PTH vdi ning d i creatinin huyit thanh
Nong do creatinin huyet thanh r
0,39
P
<0,05
Phuang trinh tuang quan y= 200,57 + 0,56 x PTH - Nong dp PTH co tuong quan thuan vdi ning d6 creatinin mau (r= 0,39)
Bang 5. Tuong quan ndng 66 PTH vdi ning 66 can xi, phdt pho va ALP d nhom suy than chua va da Ipc mau chu ky Thong so
Nhdm suy than chua LMCK
Nhdm suy than LMCK
Canxi Phdt pho ALP Canxi Phdt pho ALP
Nong do PTH huyet thanh r
0,04 0,17 0,13 0,31 0,07 0,82
P
>0,05
>0,05
>0,05
<0,05
>0,05
<0,01
Phuang trinh tuang quan
y=2,0 + 0,001xpth y=150,05+0,74xpth 6 nhom chua Ipc mau PTH khdng tuong quan
vdi can xi huyit thanh.
Ngupc lai nhdm suy than da Ipc mau chu ky ning d i PTH tuong quan thuan vdi ning dp can xi va ALP huyet thanh (r= 0.31va r= 0,82; p< 0,05 va P<0,01).
IV. BAN LUAN
Qua nghien ciiru 161 benh nhan suy than man tinh, trong do nam chiim 65,8%, tudi trung binh kha cao 54,7± 13,3 tudi, thdi gian mac benh 3,83 ±3,7 nam. Kit qua nghien ciru cho thay ning dp PTH, ALP, phdt pho, ure va creatinin mau tang dan theo mirc dp suy than khac biet co y nghia (p<0.05 va p<0,01).
Rieng ndng d i canxi trong mau thay ddi khong nhiiu vdi p >0,05 (Bang 2). Suy than cang nang thi nong dp PTH cang tang, nong dd PTH huyit thanh tuong quan thuan vdi nong dp creatinin huyet thanh (r= 0,39; p<
0,05) (Bang 4). Dac biet d nhom benh nhan da chay than nhan tao, co 44 (73,4%) benh nhan co nong d i PTH vupt qua gidi han cho phep (Bang 3). Kit qua ciia chiing t i i phii hpp vdi kit qua nghien ciru ciia cac tac gia trong va ngoai nude.
Tdng Thi Thu Hang nghien ciru 60 benh nhan suy than chia thanh 2 nhdm, nhom chua Ipc mau 30 benh nhan va nhdm Ipc mau 30 benh nhan, ki't luan cCia tac gia nhdm chua chay TNT ty le benh nhan tang PTH thap hon nhom da chay TNT chu ky (p< 0,05) [1].
Nghien curu ciia Salem (1997) tren 612 BN chay TNT thay 50% sd BN nay co ning d i PTH cao gap 2 lan binh thudng (> 622pg/l). Cung tuong tu, nhdm tac gia ngudi Tay Ban Nha (1998) thay khoang 40% sd BN chay TNT co ning dp PTH > 250pg/l. J^ le ciJa cac tac gia nay thap hon cija chung toi do cac tac gia
lay ning d i PTH ciia BN > 200pg/l, nhung theo qui dinh cua KDOQI nam 2002, khi BN chay TNT co ning dp > 110pg/l la cao qua gidi han cho phep [6].
5 nhom benh nhan da chay TNT ngoai s i benh nhan CO ning dp PTH tang cao thi co met s i lupng it benh nhan lai co ning d i PTH giam thap hon mirc binh thudng chiim 8 BN (13,3%) (Bang 3) Van d i nay cung dupe cac tac gia nude ngoai quan tam rat nhiiu, cac nghien ciru ehi ra trong giai doan suy than chay than nhan tao ty le tir vong tang ien d nhOng benh nhan eo ning dp PTH < 65 g/l day la eupe tranh cai lien quan giii'a ning dp PTH huyit thanh va t^ le tir vong, mpt sd tac gia cho rang nong d i PTH < 65 pg/l la mpt yeu to du bao dpc lap vdi tir vong d BN suy than man [3]
Trong nghien ciru cua chiing t i i d nhdm suy than chua chay TNT ning dp PTH khong tuong quan vdi ning dp can xi huyet thanh. Nhung d nhom suy than da chay TNT nong dp PTH tuong quan thuan vdi ning dp can xi mau (r= 0,31; p< 0,05) va ALP mau (r= 0.82;
p<0,01) (Bang 5). Trong Co che benh sinh suy than, da sd BN suy than giai doan cui'i chay TNT chu ky co cudng can giap thir phat, liic nay ning 66 PTH tang cao kfch thich can xi tir xuong ra mau dan den tinh trang xo hoa xuong, loang xuong. Ngoai ra trong giai doan nay rdi loan chuyin hda chat khoang nang n i , do can xi mau tang phoi hpp vdi tinh trang phdt pho mau tang khing diiu chinh dupe. Mdi lien quan gi(?a can xi, phdt pho va PTH d i n den tinh trang thiiu can xi trong xuong nhung lai thira can xi va phot pho trong mau, hau qua voi hoa mach mau va m i mem xo cirng ding mach do v i i hoa, xo cirng co tim giam chirc nang that trai suy tim. Blacher va al. (1999) nghien ciru 241 BN chay TNT trong 11 nam, cho thay tang dp cimg 15
Y HOC VIET NAM THANG 10 - SO 1/2011 cua OMC (danh gia bang each do van t i c sdng xung)
k i t hpp vdi tang huyit ap t i m thu va tam truong, kit qua tang eing eo tim va giam tudi mau DMV, vi vay tac gia cho rang tang 66 cirng cua OMC la y i u t i tien lupng tir vong [4].
Qua nghien ciru, cho thay phat hien sdm tinh trang tang PTH, kiem soat ning d i t i t ning dd PTH can xi va phit pho se ngan ngira biln chimg tim mach va loan dudng xuong d BN suy than man gop phan giam t^ le tir vong d nhiirng b6nh nhan nay.
V. KET QUA
Qua nghien ei/u 161 benh nhan suy than man thay Ning de PTH tang theo mire d i suy than (p<0,05), ning d i PTH tuong quan thuan vdi creatinin mau (r= 0,39, p<0,05). Nhom suy than da Ipc mau chu ky, ty le benh nhan eo ning 66 PTH tang vupt qua gidi han la 73,3% eao hon nhom suy than man chua la 36,7% vdi p< 0,01. Dae biet trong nhom nay ed 8 BN (13,3%) ed ty le ning d6 PTH thap dudi gic!^ han cho phep.
- 0 nhim suy than da chay than nhan tao chu ky, CO mii tuong quan thuan giua nong d i PTH vdi ning dp can xi mau va ALP huyet thanh (r= 0,31va r= 0,82;
p<0,05vap<0,01).
T A I LIEU THAM K H A O
1. Nguyin Van Xang (2004), "Oidu tri suy than man", DiSu tri hQC n^i khoa, tap II, Nha xuS't b^n Y hpc: 245- 246.
2. Tong Thj Thu Hing (2010) Nghien ciru biln ddi chuyin hoa can xi, phdt pho, PTH va ALP va m§t dd xuang d bdnh nhan suy than man, Luan van Thac sy y hpc, Hpc vidn Qudn Y.
3. Coco. M., & Rush, H. (2000). Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone. American Journal of Kidney Diseases. 36,1115-1121.
4. Jacques Blacher. Alain P Guerln. Bruno Pannier, Sylvaln J. Marchals. Michel E Safar (1999). Impact of Aortic Stiffness on Survival in End Stage Renal Disease Circulation. 99; 434-2439.
5. K/DOQI (2002), 'Clinical pratice guidelines for chronic kidney disease: valuation, classification and stratification. Kidney disease outcome quaity initiative "Am J Kidney Dis. 39: S1- S 17.
6. Salem M, (1997), Hyperparathyroidism in fhe hemodialysis population: A survey of 612 patients, American Journal of Kidney Diseases, Volume 29. Issue 6, Pages 862-865.
OANH GIA KET QUA 7 NAM THAT TINH MACH THliC QUAN QUA NO! SOI 6 BENH NHAN XO GAN CO CHAY MAU TIEU HOA
DO GIAN VO T I N H MACH THUC QUAN
T O M T A T
Tir nam 05/2003-05/2010, cac tac gia da thSt tinh mach thUc quan qua npi soi cho 178 benh nhan xd gan cd chay mau tieu hoa do gian vd tinh mach thyc quan (TMTQ). Ket qua cho biet: Hieu qua cam mau tdt dat 92,6%; hieu qua lam mat biii gian TMTQ vdl mirc: Tdt, trung binh, kem tUdng irng la 63,7%;
24,6% va 11,7%; ty le chay mau tai phat < 1 thang; 1
< 6 thang; 6-12 thang; > 12 thang tUdng iTng: 5,0%;
9,5%; 12,9% va 17,4%. Khong cd cac bien chiTng nguy hiem sau that TMTQ. Oau ngUc (52,2%) la trieu chu'ng hay gap nhat. Cac bien chu'ng khac kem theo:
sdt (4,4%), viem phdi (1,1%), loet thUc quan (2,2%) chi keo dai 1-2 ngay va co dap iTng vdi cac thudc dieu tri noi khoa.
Vu Van Khien*, Nguyen Manh Hung*
SUMMARY
RESULTS OF SEVEN YEARS THE ENDOSCOPIC VARICEAL LIGATION IN PATIENTS LIVER CIRRHOSIS WITH ESOPHAGEAL VARICEAL
BLEEDING
From May/2002 to May/2007, we had operated the endoscopic variceal ligation in 162 patients having liver cirrhosis with esophageal variceal bleeding (Esophageal variceal EV). The results show that:
good effect in hemostasis made up of 92.6%, the percentage of good, average and bad effect in eradication are 63.7%), 24.6% and 11.7%, respectively; the proportion in rebleeding under 1 month, within 1-6 months, 6-12 months and more than 12 months are 5.0%, 9.5%, 12.9% and 17.4%, respectively. There is no fatal side-effect after the
* Khoa Nol Tieu hoa - Vien NCKH Y Du'dc lam sang 108
