,P CHl Y DdOC LAM SANG 108 Tap 12 - So 6/2017
lanh gia kdt qua nghiem phap dung nap glucose va hang insulin 6^ benh nhan tang huydt ap co r6i loan lucose luc doi
assessment of oral glucose test tolerance and insulin resistance in ypertensive patients with impaired fasting glucose
guyen Thi H^ng Van*, "Benh vien Bgch Mai liam Thai Giang** "Vien Nghien cuu Khoa hgc YDugc Ldm sdng 108 i m t S t
Muc tiiu: Nghien edu nham danh gia ket q u i nghiem phap dung nap glucose va tinh trang khang insulin d b&nh nhan tang huyet ap eo roi loan glucose mau luc ddi. Ddi tugng vd phuang phdp: Nghien cdu tien edu, mo ta, cat ngang tren 230 benh nhan tang huyet ap co roi loan glucose mau luc ddi va 230 ngudi blnh thudng. Tieu ehuan ehpn benh nhan duoc chan doan tang huyet ap nguyen p h l t khi huyet ap tam thu a MOmmHg va/hoae huyet ap tam truong > 90mmHg va co rci loan glucose mau luc doi khi glucose mau IUc ddi t d 5,6 - 6,9mmol/L. Tieu chuan loai trd benh nhan da dupe ehan d o l n dai thao dudng t d trude, hoac ndng dp glucose mau lue ddi & 7mmol/L hoae < 5,6mmol/l. Tien hanh nghiem p h i p dung nap glucose dddng udng thde hien cho c l hai nhom nghien cdu va nhdm chdng. D i n h g i l khang insulin bang chi sd, nong 6g insulin mau lue ddi, ehi sd HOMA-IR, ehi sd QUICK!. Kitgud:Ty le dai thao dudng, rdi loan dung nap glucose d nhdm tang huyet l p cd rdi loan glucose mau luc ddi la 30,9%
va 43% cao hOn so vdi nhdm chdng la 7,0% va 27,8% (p<0,001). Ket q u i insulin mau luc ddi d nhdm nghien cdu cd gia trj trung binh la 13,09 + 11,76pU/ml cao hOn d nhdm chdng la 6,57 ± 2,61pU/ml (p<0,01). T^ le kh^ng Insulin theo HOMA-IR d nhom nghidn cdu la 64,8% cao hon nhom ehdng la 24,8%, (p<0,01). J^ le khang insulin theo QUICKI cua nhdm nghien edu la 63,9% cao hon d nhdm ehdng la 24,8% (p<0,01). Ketludn:Ty le dai thao dUdng, rdi loan dung nap glucose d nhom tang huyet ap cd rdi loan glucose m l u luc doi la 30,9% va 43% (p<0,001). T^ le khang insulin theo HOMA-IR va khang insulin theo QUICKI cua nhdm nghien edu cao hon d nhom chdng (p<0,01).
Td/r/jpo; Nghiem p h i p dung nap glucose, khang insulin, tang huyet ap, rdi loan glucose mau luc ddi.
i m m a r y
Objective: to assess the result of oral glucose test tolerance in hypertensive patients with impaired fasting glucose and insulin resistance. Subject and method: This was a descriptive cross-sectional study.
The study enrolled 230 patients with fasting blood glucose disorder plus hypertension and 230 healthy people. Result The prevalence of diabete and impaired glucose tolenanee in hypertensive patients with impaired fasting glucose is 30.9% and 43%, respectively, significantly higher than the prevalence of control group (7.0% and 27.8%, respectively), p<0.01. Evaluating the insulin resistance by using the HOMA-IR index. The plasma fasting insulin level are higher in the control group, significantly (p<0.05).
dy nhdn bdi: 04/5/2017, ngdy chap nhdn ddng: 10/5/2017
vm phdn hdi: Phgm Thdi Giang. Email: [email protected] - Vien Nghien cuu Khoa hgc YDuac Ldm sdng 108
JOURNAL OF 108 - CUNICAL MEDICINE AND PHARMACY Vol.12-N°6/2oi The prevalence of insulin resistance based on HOMA-IR model of the study group is 64.8%
correspondingly. This prevalence in the control group is 24.8%. The difference between prevalence o(
insulin resistance in study group and the control group is statistically significant (p<0.01). The prevalence of insulin resistance based on QUICKI model of the study group is 63.9%, correspondingly, This prevalence in the control group is 24.8%. The difference between prevalence of insulin resistance in study group and the control group is statistically significant (p<0.01). Insulin resistance status in the hypertension patients with impaired fasting glucose is higher than normal subjects. Conclusion: The prevalence of diabete and impaired glucose tolenanee in hypertention patients with impaired fasting glucose is 30.9% and 43%. Insulin resistance status in the hypertension patients with impaired fasting glucose is higher than normal subjects.
Keywords: Oral glucose test tolerance, insulin resistance, hypertension, impaired fasting glucose.
I.Oatvande
Dai t h I o dudng (DTD) la benh ly co tde dp p h l t trien nhanh tren the gidi eung nhu d Viet Nam. Tieu chf chan d o l n DTD n g l y cang ha thap tieu chuan so vdi ban dau vdi muc tieu se phat hien sdm, can thiep kjp thdi de phong chdng eac bien chdng ciia benh.
Nhung thue te cho den nay, ngay e l khi ap dung tieu chuan ehan d o l n mdi, benh DTO cung chi ddpc p h l t hien benh sau khi mac benh trung binh t d 5 ddn 15 nam [3].
Nam 1997 Hiep hdi DTD Hoa Ky de xuat tieu ehuan chan d o l n rdi loan glucose luc ddi (RLGLD) khi ndng dp glucose m l u lue doi t d 6,1 - 6,9mmol/L (110 - 125mg/dl). Den n l m 2003 Hiep hpi DTD Hoa Ky ha ngudng glucose lue ddi xudng 5,6mmol/L - 6,9mmol/L (100 -125mg/dl) [4].
Tren the gidi va Viet Nam d l ed nhieu cong trinh nghidn edu ve OTD, ro! loan dung nap glucose, song nghien cdu ve rdi loan dudng m l u khi ddi l p dung theo tieu ehuan mdi 2003 cua Hiep hdi DTO Hoa Ky d ddi tupng benh n h i n tang huyet I p CTHA) thi ft dupc nghien edu. Chung tdi tien hanh de t l i "Oinh gia ket q u i nghiem p h i p dung nap glucose va tinh trang khlng insulin d benh nhan t i n g huyet ap ed roi loan dudng mau lue ddi" vdi mue tieu:
Xdc dinh ty li ddi thdo dudng, rdi logn dung ngp glucose vd tinh trgng khdng insulin dUa vdo ch! so HOMA, QUICKI d binh nhdn tdng huyit dp cd rdi logn dddng mdu Idc ddi.
2. Doi tuong va phUOng phap
2.1.D6itUgmg
Nghidn cdu tien hanh tren 230 benh n h i n (BN) THA cd rdi loan glucose m l u luc ddi va 230 ngudi 40
trudng thanh khde manh l l m nhdm ehdng tai Khoi K h i m benh, Benh vien Bach Mai t d thang 9/2011 den t h i n g 9/2014.
2.2. Phuang phdp
Nghien edu theo phuong phap mo tS, cS ngang, ed so sanh;
Do huyit dp, chiiu cao, cdn ndng, tinh chi it BMI, vdng bung, vong mdng, tinh chi so vinj bung/vdng mdng.
Nghiim piidp dung ngp glucose dudng uong (NPDNG)
Thuc hien cho c l 2 nhdm nghien edu (NQ va nhdm chdng. BN nhjn an qua dem (tdi thi^u 8- lOtieng).
Ll'y mau lan 1 de dinh Idpng ndng dp glucose va insulin lue ddi (Go va lo), cho BN udng 75g d\Str^
glucose h o i tan trong 250ml nddc sdi de nguoi, udng het trong vdng 5 phut. Dung sau 2 gicf lay mau lan 2 de djnh luong glucose va insulin tai thcrt diem 120 phut (Gi2o va hjo). Danh gia ket q u i theo hoifiH) Hoa Ky (ADA) 2003 [4]:
Neu Gi2o < 7,8mmol/L: Dung nap glucose bln^
thudng (DNGBT).
Neu Guo t d 7,8 - 1 1 mmol/L: Rdi loan dung m giucose (RLDNG).
Neu Gi3o > 11,1 mmol/L; D l i t h I o dddng (BTDJ.
Dinh lugng insulin mdu luc ddi (lo) Phuong p h i p dmh ldpng; Insulin mau dW djnh lupng theo phdong phap mien dich dienhO' p h l t quang tren may xet nghiem "Mien diditi ddng - ELESYS - 2010" tai Khoa Sinh hoa, Benhvien Bach Mai.
' CHf Y DL/OC LAM SANG 108 Tap 12-566/2017
Ddnh gid khdng insulin theo cdng thde Chi sd HOMA-IR (Homeostasis Model Asessment ulin Resistance) - ehi so k h l n g insulin. HOMA-IR = MU/ml)xGO (mmol/1)/22,5.
lo: Ndng d p insulin mau ICie ddi. Go: Ndng dp leosemau luc ddi.
Diem c i t gidi ban: T d phan vi eao nhat trong
• m chdng.
Theo WHO khi g i l tri chi sd HOMA Idn hon g i l t d phan vj cao n h l t trong nhdm ehdng thl gpi la khang insulin [3].
Ch! sd QUICKI (Quantitative Insulin Sensitivity Cheek Index) - chi sd kiem tra dp nhay eua Insulin:
QUICKI = 1/log do + Go).
Diem cat gidi ban: T d phan vi nhd nhat trong nhdm chdng. Khi gia trj chi sd QUICKI nhd hon gia t n t d phan vj nho nhat trong nhdm chdng thi gpi la cd khang insulin.
2.3.X&lys6Ueu
Sd lieu ddpc x d If bang phan mem SPSS 15.0.
Ket q u i i
B I n g 1 . Dac d i e m chung cua d o i t d o n g nghi@n cdu
Dac diem chung
JOi hieu cao (cm) I n nang (kg) 3ng bung (cm) 'HR VII i6i (nuf)
Nhom chuTng (n = 230) (X + SD) 62,84 ± 8,47
1,58 ±0,07 56,7 ± 8,42 81,93 ±7,51 0,89 ± 0,05 22,56 ± 2,25 62,2%
Nhom nghien cihi (n = 230) (X + SD) 64,05 ±8,13
1,59 ±0,07 58,42 ±8,14 85,20 ± 6,70 0,91 ±0,04 23,09 ± 2,20 59,6%
P
>0,05
>0,05
>0,05
<0,05
<0,05
>0,05
>0,05 Nhdn xet: Cac thong sd tudi, chieu cao, can nang, BMI, t y le gidi tinh gida 2 nhdm la tUong dUOng
>0,05). Cd sd khac biet ve vdng bung, WHR gida 2 nhdm nghien cdu (p<0,05).
Bdng 2. So sanh n 6 n g d o glucose va insulin m a u t a i t h d i d i e m ban dau giuia hai n h o m n g h i e n cuTu Thong so
3 (mmol/L) (liUm/L)
Nhom chuTng (n = 230) 4,85 ± 0,47 6,57 ± 2,61
Nhom nghien ata (n = 230) 6,07 ±0,37 13,09 ±11,76
P
<0,05
<0,01 Nhdnxet: Nong d d Go, lo 6 nhom nghien edu cao hon so vdi nhdm chdng {p<0,01).
Bdng 3. So sanh n o n g d o glucose va Insulin t a i t h d i d i 4 m sau NPDNG gida hai n h o m n g h i § n cdu
Thong so 120 (mmol/L) o(^Um/L)
Nhom chu'ng (n = 230) 7,26 ±1,92 57,4 ± 43,61
Nhom nghien cuTu (n = 230) 9,52 ±2,53 80,65 ±69,63
P
<0,01
<0,01 Nhdnxit: Ndng dp G I M , hao d nhdm nghidn cdu cao hon so vdi nhdm chdng (p<0,01).
JOURNAL Of 108 - CUNICAL MEDICINE AND PHARMACY VOI.12-N-M01
Bdng4.KetquSnghiepphapdungnap glucose d hai nhom nghidn cuTu Ket q u i
NPDNG Nhom nghien cChj Nhom chijfng
DNGBT"! 1 n
60 150
T;ie%
26,1 65J
RLDNG'=>
n 99 64
TJ1e%
43 27,8
DTOm n 71 16
TJIe%
30,9 7,0
P
P"<0,I)1 P"<»,01 P*'<0,01 Nhdn xetT'y le BN ddpe chan doan DTO va RLDNG trong nhdm nghien cdu la 30,9% v l 43% eao hontjl tdong dng d nhdm ehdng la 7,0% va 27,8% vdi p<0,01.
Bang 5. So sanh chi so khang insulin trung blnh theo HOMA-IR vk QUICKI cua hai nhom nghidn dtu
Thdng so HOMA-IR trung blnh QUICKI trung binh
Nhom chihig (n = 230) 1,42 ±0,60 0,96 ± 0,09
Nhom nghien clhj (n = 230) 3,56 ± 3,27 0,83 ±0,12
P .'
<0,01
<0,01 Whdn xef: Chisd HOMA-IR va chisd QUICKI trung binh d n h d m nghien cdu khae biet vdi nhdmchuUgo y nghla thdng ke (p<0,01).
Bdng 6. So sanh chi so khang insulin theo HOMA-IR va QUICKI cilia hai nhom nghien cdu Thong so
Khang insullin theo HOMA-IR
Kh^ng insulin theo QUICKI
Nhom chufng (n = 230)
57 24,8%
57 24,8%
Nhom NC (n = 230) 149 64,8%
147 63,9%
P
<0,01
<0,01 Nhgnx^t:J)i le khang Insulin theo HOMA-IR va khang Insulin theo QUIKI cua nhom nghien ciJu khac bii vdi nhom chiJng co y nghTa thong ke (p<0,01).
Tuoi trung binh trong nhom nghien cu;u ciJa chiing toi la 64,05 ± 8,13. THA nguyen ph^t xay ra chu y^u cf do tuoi trung nien til 40 tuoi t r d len, khi cSu tnic thanh mach bat dau co suxo vBa, thoai hoa tang nguy co tdn thuang co quan dich. TJ le BN nO trong n g h i i n cilu la 59,6%, t) le nam la 40,4%. TJ le thifa can (BMI > 23kg/m') trong nhom nghien cilu 23,09 ± 2,2 cao hon nhom chufng 22,56 ± 2,25 nhung khdng co y nghTa thdng ke. Ngu6i Viet Nam co dac diem nhan trac BMI khdng qua cao, tuy nhien ty le ngudl cd bleu hl§n beo tang (vong bung to) lai chlem t J le cao dang ke. Du thira lUdng m d d bung dac biet la i! dong m d bao quanh vung bung va m d
bao quanh ca quan trong d bung la nhiing jreuti nguy cd tang khang insulin, la tien de ciia benh BTl type 2.
Tang nong do glucose mau luc ddi (Go) tM n h u tang ndng dp glucose tai thdi diem 120 plii*
(G,j„) khi thuc hien NPDNG la bieu hi«n ciia U trang khang insulin. Trong nghidn ciju cOa chung*
ket qua glucose mau luc ddi d nhdm nghidn oiuii gia trj trung blnh la 6,07 ± 0,37mmol/l, 4 " h * chiing cd gia trj la 4,85 ± 0,47mmol/l. Ket qL glucose mau sau 2 g i d lam NPDNG d nhdm nglit cUu cd gia tri trung binh la 9,52 ± 2,53mni4 nhdm chdng cd gia trj trung binh la 7,26- l,92mmol/l, su khac biet cd J nghTa thdng'
P CHfY DUOC LAM SANG 108 Tap 12 - So 6/2017
<0,01). Tang ndng do glucose liic ddi chu yeu do ang insulin tai gan va lam gan t i n g s i n xuat jcose, edn t i n g ndng dp glucose sau 120 phut n nghiem phap d u n g nap glucose chu yeu do de I n g insulin d cac m d co, m d md.
Trong nghien cdu eOa ehung tdi, khi tien hanh ihiem phap dung nap glucose cho c l 2 nhdm ket la nghien cdu cho thay trong nhdm THA t^ le lUdi cd d u n g nap glucose binh t h u d n g I I 26,1%, DNG I I 4 3 % va OTD type 2 la 30,9%, trong khi dd d ldm chdng ty le ngudi cd dung nap glucose blnh Udng la 65,2%, RLDNG 27,8% v l OTD la 27,0%, sU ae biet cd y nghla t h d n g ke (p<0,01).
Rdi loan glucose m l u luc doi (RLGLD) va rdi loan mg nap glucose (RLDNG) 11 tinh trang tien DTD, nh tien trien am tham, dl^n ti^n keo dai trong lieu nam trudc khi t r d t h l n h DTD rd tren l l m sang, eo t d n g ket eac nghien cdu eua David M.Nathan Jonathan E eho thay k h o i n g 25% BN RLGLD tien en thanh OTO, k h o i n g 25% t r d lai binh t h d d n g v l
% con lai van g i d nguyen RLGLO trong thdi gian 3 j nam. N h u vay neu chi quan tam den ehi sd jcose mau lue ddi ma khdng lam nghiem p h i p ng nap glucose thi cd mot ty le Idn BN cd OTO, DNG khdng 6dgc p h l t hien t d giai doan sdm. Dae
?t d c l e BN cd THA kem theo. Cac nghien cdu g i n y cho thay cd mdt X)f le k h i Idn cac trudng hop A va rdi loan glucose mau eo eung mpt nguyen an la khang insulin trong bdi c i n h hdi ehdng uyen h o i . Nghien edu eua mdt sd t i c g i l Marie - B Piehe, Vegt F, Vaecaro Olga, cho thay X^ le nay o d p n g t d 30% - 50% [5], [6], CJ Viet Nam, ty le DTD BN THA sau khi lam nghiem phap tang dudng yet trong cae nghien cdu eua Quach Hdu Trung la ,22%, Tran HOu Dang I I 31,5%, Huynh Van Minh I I 07%. Nghien cdu eua Pham Thj Ngpe Anh sau hiem phap d u n g nap glucose d BN THA phat hien pc 8,39% t r d d n g hpp RLGLO, 22,8% trddng hpp DNG, 9,79% trddng hpp DTD [2]. Sd khac biet n l y i o nhdm ddi tdpng k h l c nhau va sd dung tieu chi in doan theo tieu chuan cu eua ADA 1997.
Tang ndng dp insulin luc ddi hay eddng Insulin i g la mpt trong nhdng bieu hien cCia tinh trang ing insulin va cung la y^u t d nguy eo d u b l o su
tien trien cCia DTO type 2. Nhieu cong trinh nghien cdu deu eho thay nong dp insulin d nhdng binh nhan rdi loan glucose lue ddi deu eao hon so vdi nhdm cd ndng dp glucose luc ddi binh thudng. Trong nghien cdu eua ehung tdi ket q u i Insulin mau ICie ddi d nhdm nghien cdu ed gia t n trung blnh la 13,09 ± 11,76pU/ml, nhdm ehdng ed gia tri la 6,57 ± 2,61 MU/ml, sii khae biet cd ^ nghia thdng k^ (p<0,01).
Tang ndng dp glucose mau Idc ddi va tang insulin mau la b i l u hien eua tinh trang khang insulin. Tang ndng dp glucose luc ddi ehu yeu do khang insulin tai gan va lam gan tang san xuat glucose. Nghien cdu cCia Nguyen Kim LdOng ve khang insulin d ddi tupng THA nguyen phat va OTO type 2 nhan thay ket q u i Insulin m l u lue ddi d nhdm THA cd g i l t n trung binh la 10,53 ± 1,95|jU/ml, d nhdm DTD type 2 cd g i l tri trung binh la 13,27 + 2,20|iU/ml, nhdm ehdng cd gia tri la 4,37 ± 0,60nU/ml. Ket q u i cua chung tdi cung phu hpp vdi ket q u i cua Nguyen Ddc Hoan, Matthew DR Ferrannini, Haffner v l nhieu t i c g i l khae [1], [7],
Nhieu cdng trinh nghien edu deu eho thay rang:
Tang ehi sd HOMA-IR ddng thdi g i l m pha tiet sdm eua insulin la yeu t d dU doan eho sd phat then eCia benh OTO d ea nhdng ddi tdpng cd dung nap glucose binh thudng va rol loan dung nap glucose.
Ket q u i nghien cdu cua chung tdi ehi sd HOMA-IR d nhdm nghien cdu 11 3,56 ± 3,27, eao hon so vdi nhdm chdng la 1,42 ± 0,60, ehi sd QUICKI d nhdm nghien edu la 0,83 ± 0,12 thap hon so vdi nhdm ehdng la 0,96 ± 0,09, sd khac nhau cd y nghTa thdng ke (p<0,05). Ty le khang insulin theo chi sd HOMA-IR d nhom nghien edu la 64,8%, cao hon nhdm ehdng la 24,8% (p<0,05) va t;^ le khang insulin theo chi sd QUICKI d nhom nghien cdu 11 63,9%, eao hon nhdm chdng la 24,8% {p<0,01).
Theo nghien cdu cua Nguyen Ddc Hoan k h l n g insulin tren ddi tdpng cd rdi loan glucose m l u luc ddi, tac g i l nhan thay ehi sd HOMA-IR v l QUICKI d nhdm nghien cdu cd sd khac biet cd y nghia thdng ke so vdi nhdm khdng cd rdi loan glucose m l u [1].
Ket qua cua ehung tdi cung phii hpp vdi nhieu t i e gia n h d Nguyen Kim Luong, Matthew DR Ferrannini, Haffner [7].
JOURNAL OF 108 - CUNICAL MEDICINE AND PHARMACY Vol.l2-N'6/2i)i
5. K^t luan
T;^ le dai thao dudng, rdi loan dung nap glucose 6 nhdm THA eo rdi loan glucose m l u lue ddi la 30,9% va 43%. Tinh trang k h l n g insulin d nhdm THA rdi loan glucose mau luc ddi cao hon so vdi nhdm chdng (p<0,05).
Tai lieu tham k h i o
1. Nguyen Ddc Hoan (2008) Nghiin cdu rdi loan lipid mdu, khdng insulin vd ton thuang mdtsocaguan d binh nhdn nam cd roi logn glucose mdu lOc ddi.
Luan an Tien sy y hpc, Hpe vien Quan y.
2. Pham Ngpc Anh va Nguyen Kim Luong (2011) Ddnh gid tinh trgng dung ngp glucose mdu d binh nhan tdng huyet dp nguyin phdt. Tap chi Khoa hoc va Cong nghe nam 81 (05), tr. 141 -146.
3. Ta Van Binh v^ CS (2005) ThUc trgng benh ddo thdi dudng vd cdcyeu to nguy cad 4 thdnh phd Idn d Viet Nam (507, 508), xr. 37-5].
Association and American Diabetes (1997)flepo of the Expert Committee on the diagnosis on classification of diabetes meilitus. Diabetes a, (20): 1183-1197.
Vaecaro O, Gianluca R and lovino, Vineenzo (1999)^, of diabetes in the new diagnostic category of in^
fasf/ngg/t/cose.DiabetesCare(22): 1490-1495. n Vegt F et al (2001) Relation of impaired fasUnm postload glucose with incident type 2 diabetes In i Dutch population. The Boon study. JAMA (285 2109-2113.
Haffner SM, Miettinen H and Stern MP (I997) jjj homeostasis model in the san antonio heart stuiif Diabetes Care 20(7): 1087-1092.
