JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY
Dac diim lam sang, can lam sang va ket qua dieu tri thay huylt tuong benh nhan viem gan nhiem doc cap nang
Clinical, laboratory characteristics and results of plasma exchange on the patient with severe acute toxic hepatitis
L§ Quang ThuSn*, Pham Due* *Benh vien Bgch Mm Ngo ©U'C Ngpc", **TrucmgDgi hoc YHd^i Vu Van Khien"* ***Vien Nghien cuu Kiioa hoc YDugc Ldm sang 108
Tdmtat
Muc tiiu: Md t l d i e diem lam sang, mpt sd xet nghiem can l l m sang cf benh nhan viim gan nhiem dde elp nang duac dieu trj bang thay huyet tUPng tich cue; Danh gia ket q u i thay huyet tuong trong dieu trj viem gan nhiem dde d p n l n g . Doi tdgng vd phuang phdp: Nghien cQu 62 b&nh n h i n viem gan nhiem ddc cap nang tai Trung tam Chdng dpc, Benh vien Bach Mai (01/2012 -12/2014). Kitqud: Nhom nghien cQu c6 tudi 41,5 ± 17,79 tudi; nam/nQ: 0,6; ndng dan ehiem nhieu nhat 58,1 %; luc vao vien ty le vang da 98,2%, x u l t huyet 22,6%; xet nghiem ALT 615,0 ± 80,04UI/L; bilirubin toan phan 390,4 ± 231,83Mmol/L; t i ' le prothrombin 41,3 ± 25,96%, INR 1,8 ± 0,20; ereatinin 81,5 ± 14,14pmol/L Thay huyet tuong giup tang Glasgow 0,3 ± 0,67 diem/1 lan thay; giam ALTtU 677,8 ± 69,49 xudng 354,7 ± 34,04UI/L;
bilirubin tU 338,0 + 232,86 xudng 208,2 ± 148,60Mmol/L; g i l m NH3 tQ 123,4 + 73,10 xudng 72,5 ± 58,94pmol/L tang ty le prothrombin tQ 37,8 ± 22,10 len 61,2 + 15,10%; tang dUdng huyet 1,3 ± 3,79mmol/L d mdt lan thay. Ket ludn: Viem gan nhiem ddc nang thudng gap d tudi trung nien, nguyen nhan va bi^u hien da dang; vang da, rdi loan dong m l u chi^m X^ le cao. Thay huyet tUPng giup cai thien diem Glasgow/, dao thai dpc (men gan, giam bilirubin), hd trp ell thien ehUng nang ddng mau ma khong gay ra nhi^u t i c ddng b i t lpi.
Tdkhda: Viem gan nhiem doc, ngo dpc, thay huyet tUpng.
Summary
Objective: To describe the clinical and laboratory characteristics of patients with severe acute toxic hepatitis treated by plasma exchange (PEX); To evaluate the effectiveness of plasma exchange on treatment of severe acute toxic hepatitis. Subject and method: The study was earned out on 62 patients with severe acute toxic hepatitis treated at Poison Control Center, Baeh Mai Hospital, from Jan 2012 to Dec 2014. Result Average age was 41.5 ± 17.79 years; male/female: 0.6; farmer 58.1%; on admission jaundice 98.2%, hemorrhage (22.6%); ALT 615.0 ± 80.04Ui/L; total bilirubin 390.4 ± 231.83Mmol/L;
prothrombin 41.3 + 25.96%, INR 1.8 + 0.20; creatinin 81.5 ± 14.14|jmol/L. Plasma exchange increased Glasgow Coma Scale 0.3 ± 0.67 points/1 course of PEX; decreased ALT from 677.8 ± 69.49 to 354.7 ± 34.04UI/L; bilirubin total from 338.0 ± 232.86 to 208.2 ± MB.eOpmol/L; NH3 from 123.4 + 73.10 to 72.5 ± 58.94pmol/L; increased prothrombin from 37.8 + 22.10 to 61.2 ± 15.10%; and serum glucose 1.3 ±
Ngdy nhgn bdi- 12/6/2017, ngdy chdp nhdn dang: 18/6/2017
Nguaiphdn hdi: Le Quang Thudn, Email: bslhuanbm@gmail com - Benh vien Bach Mai
AP CHlY DUOC LAM SANG 10. Tap 12-Sd 7/2017 3.79mmol/L per one course of PEX. Conclusion: Severe toxic hepatitis was common in middle ages, causes and clinical symptoms were diverse; jaundice and coagulation disorder were in high rate. Plasma exchange improved Glasgow Coma Scale, eliminated toxins (ALT, bilirubin), supported coagulopathy in patients with severe acute toxic hepatitis with little adverse events.
/feywords; Toxic hepatitis, poisoning, plasma exchange.
I . D a t v a n d e
Vidm gan nhiem ddc (VGND) la benh thudng gap, vdi nhieu nguyen n h i n khIc nhau nhQ ngd ddc :hude, hda chat, nam ddc... Tai Trung t i m Chdng 5de (TTCD), Benh vien Bach Mai, VGND d p nang ngly eang thQdng gap hPn vdi ty ie tQ vong eao.
Dieu trj VGND d n ngQng ngay chat g l y ddc, sdm iii dung thudc g i l i ddc dac hieu, dieu tri hd trp chd gan hdi phuc va ghep gan. Vdi VGND e l p nang vdi suy gan hole t i e mat n l n g khdng dap Cmg vdi dieu trj ndi khoa, thay huyet tQPng (Plasma Exchange - PEX) la mpt bien p h I p giup dao thai ddc t d ddng thdi hd trp gan suy rat hieu qua... [1], [5], [8], [9]. Thay huyet tQPng ket hop vdi Ipc mau lien tuc (LMLT) se giup keo dai thdi gian sdng, g i l m t^ le tQ vong.
Tai Viet Nam, de tai d p Bd Y te "Nghien cUu Ung dung d c ky thuat Ipe mau n g o l i co the trong dieu trj ngd dde d p nang cd bien chQng" da Qng dung ky t h u l t thay huyet tQPng trong dieu trj suy gan d p do VGND tQ nhQng nam 2007, den nay ky thuat nay n g l y d n g h o l n thien hon, vdi phac do thay huyet tuong tieh cQe bang each tang sd l l n thay huyet tuang trong ngay bang d c h thay sdm, rut n g l n khoang each glQa d e lan thay dQa vao theo ddi lam sang, xet nghiem va dat ra ke hoach cae cudc thay phu hop.
Nghien eUu nay cd muc tieu: Md td ddc diem Idm sdng, mdt sd xet nghiim can Idm sdng d binh nhdn VGND cap ndng dugc dieu tri bang thay huyit tdang tich cdc. Ddnh gid kit qud thay huyet tuang trong dieu tri viim gan nhiem dgc cdp ndng.
2. D d i tuang va phUcrng phap
2.7. Ddi tdgng
La 62 benh n h i n (BN) dugc chan doan va dieu trj VGND d p n l n g tai Trung t i m Chdng dde, Benh vien Baeh Mai, dis tieu chuan nghien eUu. Benh n h i n
dupe dieu tri hdi sQe gan ndi khoa theo phac d d thQdng qui ket hpp vdi thay huyet tQOng tieh eUc.
2. /. 7. Tiiu chudn chgn benh nhdn
Benh n h i n dUpc chan d o l n VGND cap nang thda m i n 2 tieu e h u I n :
(1) Tieu c h u I n c h i n d o l n viem gan nhiem dpc:
Cd phPi nhidm vdi tac nhan dde vdi gan dudi 6 t h i n g ; bieu hien lam sang (met mdi, chan an, vang da, rdi loan tieu hda, x u l t huyet dudi da, rdi loan y thQc (RLYT)...); xet nghiem cd tdn thQPng gan: ALT, AST>37UI/L;ALP>120UI/L.
(2) Tieu ehuan d i n h g i l mQc do nang, c l n 1 trong 4 tieu ehuan: Diem d i n h gia mQe dp vidm gan theo Fontana > 3 diem [6]; tang ALT v l / h o l c ALP va bilirubin > 42,75pmol/L; tang ALT va/hoae ALP v l INR > 1,5; tang ALT v a / h o l e ALP va phai nhap vien dieu trj keo dai hoac nhieu dot vl VGND.
2.1.2. Tiiu chudn logi trdbinh nhdn Loai trQ cae trUdng hpp: Viem gan do virus, tU mien, rdi loan chuyen hda s i t , ddng; tae mat co hpe;
benh gan tim; tdn thuong gan, suy gan do ngd dde paraquat, ngd dde rupu; suy gan e l p tren nen gan xa gan khdng ed kha nang phuc hdi; rdi loan ddng m l u do ngp dde chat k h I n g vitamin K; ed ehdng chi djnh thay huyet tUPng v l benh nhan khdng tuan thu p h l e do, khdng ddng y tham gia nghien cdu.
2.2. Phdong phip 2.2.1. Thiet ke nghiin cdu
Nghien cQu can thiep, md t l , tien cQu, so sanh t u chQng trQde v l sau can thiep thay huyet tuang.
2.2.2. Cdmdu
Thuan tien vdi thdi gian nghien eUu 01/2012 - 12/2014.
39
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VoL12-N7/20l7
2.2.3. Tien hdnh nghiin cdu
Benh nhan nghien eQu dQpc hdi bdnh sQ, kham l l m sang, ehi djnh xet nghiem ehan doan x l e djnh VGND, sau do phan mQc dp VGND nang theo Fontana v l edng sQ, dQa vao d e chi sd ALT, ALP, bilirubin toan p h l n , INR v l d i u hieu suy gan, suy tang (than, phdi). Benh n h i n du tidu chuan nghien cQu dupc lua ehpn vao nghien cQu.
Benh n h i n dQpc dieu trj theo phac do thudng qui:
NgUng thude gay ddc gan, truyen dUdng Qu trupng lien tue, dinh dudng, dung thude g i l i dde theo p h l e dd. Dat dng ndi khi q u I n , t h d may vdi hdn md gan giai doan 3 trd len. Theo ddi huyet ddng lien tuc, dam b l o huyet I p trung binh tren 60mmHg, thudc van mach uu
tien dung I I noradrenalin, dobutamin... Chi djnh thay huyet tuang tich cue nhU sau:
Chi djnh thay huyet tuang khi: (l) Tf le prothrombin < 40%; (2) Vl/hoac bilirubin toan phar tang > 250Mmol/L; (3) Lpe doe chat cd trpng luong p h l n tQ ldn, gan nhieu vdi protein huyet tUPng [>
80%), the tfch phan bd thap < 0,2L/kg.
Cach thUc thue hien thay huyet tUOng tfch ciic Cang sdm d n g tdt, ngay khi ed ehi ^ n h , quyet cljnh thay huyet tUong cudc tiep theo dua vao tJ 1^
prothombin va bilirubin toan p h l n cCia lan xet nghiem gan nhat sau moi l l n thay huyet ti/ong (Theo kd hoach BIng 1 [7]).
Bang 1 . Ke hoach theo doi va chi dinh thay huyet tUOng tich cUc theo muTc do viem gan, suy gan MUc do theo
lam sang Viem gan nang Benh nao gan do 1 - 2 Benh nao gan dp 3 - 4
INR
<1,5 1,5-3
> 3
Thcri gian chi djnh x^t nghiem ngay sau lan thay trUdc
24 - 48 gid/lln o - 1 2 - 2 4 g i d / l a n
i - D - 1 2 gid/lln
Cac chi tieu xet nghiem bSt budc Prothrombin, INR, bilirubin
TP, ALT Prothrombin, INR, bilirubin
TP, ALT Prothrombin, INR, bilirubin
TP, ALT
Sd lan chi djnh PEX
> 24 gid/lan 24gicJ/lan 8-12-24gicJ/lan
LMLT sau thay huyet tuong khi: Toan chuyen hda nang, suy than, q u i t l i djch, sde nhiem khuan, suy da tang, rdi loan dien g i l i nang...
Thu thap sd lieu tai thdi diem To- lue vao vien:
Dac di^m ehung (tudi, gidi, nghe nghiep); nguyen n h i n ; trieu chUng lam sang; d n lam sang (cdng thQc m l u ; ddng m l u ca b i n ; sinh hda ep b i n ; khi m l u , laetat, NH3, ndng dp ddc chat trong mau va nQde tieu nhQ paracetamol, ochratoxin A...). Tai thdi diem Tt,u<ic va Tsau (xet nghiem ngay trUdc va ngay sau cudc thay huyet tUPng) gdm cdng thUe mau, ddng m l u eo b i n , sinh hda ea b i n , NH3, khi m l u .
Tieu ehuan: Ra vien khi tinh, tiep xue tdt, vang da giam d i n , an dugc, trieu chQng cP nang khac c l i thien. Xet nghiem prothrombin t i n g dan tren 40%
va bilirubin g i l m dan dudi 2S0pmol/L trong 3 lan xet nghiem lien tiep; cle xet nghi§m khac xu hudng c l i thien. Benh nhan tQvong dUpc x l e djnh tai benh vien hoac benh nang gia dinh xin ve de chet.
2.3. Phuang tiSn nghien cdu
2.3.1. Phdong tiin nghiin cdu
M I y Ipe mau ngoai eP the: Prisma Flex (Gambro- Baxter, Hoa Ky), Diapaet (B-Braun, DQc). Ming loc TPE 2000 (Gambro-Baxter), Hemoselect L 0.5 (B-Braun|.
Catheter tTnh maeh: Certofix Duo HF (12F; B-Braun), Huyet tuong chuIn dQpc lay tQ ngudn Khoa Huyet hpe, Benh vien Bach Mai. The ti'eh huyet tUOng thay the = 0,065 X P (kg) x (1 - Hematocrit).
Xet nghidm thQc hien tai Khoa Hda sinh, Huyet hpc... - Benh vidn Bach Mai theo qui trinh chuan.
2.3.2. Qui trinh thay huyet tdang
Theo hQdng dan qui trinh ky t h u l t chuyen nganh Hdi sUc - Cap CQu va Chdng ddc (Bd Y td, 2014).
2.4. Xdly sd lieu vi dao ddc nghiin ciiU
Cac sd lieu dQpe xQ ly theo d c phep toan t h d n g ke phu hpp, chpn mQc y nghia thdng kefl=
AP CHf Y D U a c U M SANG 108 T|pl2-So7/2017
1,05. Bieu dl§n so lieu: Trung blnh ± 66 lech chuan bien phan bo chuan); t r u n g vj (l<hoang) (bien
;hong phan b d chuan). So sanh 2 t r u n g binh 2 ihom dpc iap: T-test student. Paired sample T test.
)ao 60c nghign CLfu tuan t h u dung theo cac qui tinh hien hanh cCia Bo Y te.
I. Ket q u i
3.1. Oac eltem chung va trieu chuing lam sang
Tu6i trung blnh 41,5 ± 17,79, nho nhat 12, cao ihat 82 tuoi, vj le nam/nO la 27/45 (0,6). Nghe ighiep: Nong dan 36 BN (58,1%), lao ddng tri 6c 10 iN (16,1%), buon ban 7 BN (11,3%), hoc sinh 8 BN 12,9%), cSng nhan 01 BN (1,6%).
Nguyen nhan gay viem gan nhiem doc: Thuoc (Hex khong ro nguon goe 17 BN (27,5%), dpc to iam amatoxin 11 BN (17,7%), npc ong va mat ca 8 iN (12,9%), thudc dieu tri lao 7 BN (11,3%), jaracetamol 04 BN (6,5%), thudc tan duoc khac 04 6,5%), ochratoxin A 01 BN (1,6%), nguyen nhan hon Ipp 10 BN (16,1%).
Met moi 62 BN (100%), chan an 58 BN (93,5%), tau bung 15 BN (24,2%), tieu chSy 11 BN (17,7%),
vang da 61 BN (98,2%), xuat huyet 14 BN (22,6%), rdi loan y thilc 20 BN (32,8%).
3.2. Oac diem trieu chiing can iam sang iuc vao vien
Cdng thufc mau luc vao vien: Hdng cau 3,8 + 0,99 (T/L), hemoglobin 107,6 ± 23,21 (g/L), hematocrit 30,96 ± 6,6 (%), bach cau 9,9 ± 1,29 (G/L), ti^u c3u 184,5 ±18,15 (G/L).
Odng mau co b i n INR 1,8 + 0,20, t^ le prothrombin 41,3 ± 25,96, APTTs 39,8 ± 4,45, APTTb/c 2,1 ± 0,17, fibrinogen 2,3 ± 1,25 (g/L).
Sinh hda: ALT 615,0 ± 80,04 (UI/L), AST 620,0 ± 529,65 (UI/L), bilirubin toan phan 390,4 ± 231,83 (|jmol/L). Creatinin 81,5 ± 14,14 ([jmol/L).
T h ^ viem gan nhi^m dpc; the hoai tCf 14 BN (22,6%), the tac mat 21 BN (33,9%), the hon hpp 27 BN (43,5%). B p viem gan theo WHO: Od 1: 20 BN (32,3%), d d 2:05 BN (8,1 %), dp 3:04 BN (6,5%), dp 4:
33 BN (53,2%). B d viem gan theo Fontana: B d 3:46 BN (74,2%), do 4: 16 BN (25,8%). Giai doan benh nao gan: Giai doan 0:27 BN (43,5%), giai doan 1:17 BN (27,4%), giai doan 2: 12 (19,4%), giai dpan 3: 6 BN (9,7%).
3.3. Ket qua dieu tri thay huyet twang
3.3,7. Hieu qud cCio thay huyet tuang
Bdng 2 . Hieu q u i lam sang cua thay huyet tUtfng
Chi tieu
Glasgpw Mach (Ian/phut) Huy^t ap tam truong (mmHg) Huyet ap tam thu (mmHg) 5p02(%)
n
213 174 182 182 160
TrUdc PEX X ± S D 13,6 ±0,22 92,8 ±16,77 71,4 ±10,07 116,7 ±12,34 97,9 ± 8,07
Sau PEX X ± S D 13,9 ±0,19 94,5 ±19,50 71,57 ±9,28 117,3 ±12,57 98,1 ± 7,98
fl(+) X ± S D 0,3 ± 0,67 1,6 ±14,77 0,2 ± 8,67 0,5 ±11,17
0,1 ± 0,99 P
<0,001 0,144 0,765 0,516 0,341 Nhdn xit Sau mdt lan thay huyet t u o n g , di^m Glasgow/ c l i thien 0,3 ± 0,67 (diem). Maeh, huyet ap va 3 0 ; khdng thay ddi trudc v l sau thay huyet tUOng.
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N"7/20i;
BSng 3. Hieu qui dieu chinh tinh trang gicim dong
DMCB
PT%
INR APHs APTTb/c Fibrinogen (g/L)
n
225 232 232 231 232
Truorc PEX X ± S D 37,8 ±22,10
2,6 ±1,60 65,7 ±34,31
2,5 ±1,41 1,9 ±0,93
Sau PEX X ± S D 61,2 ±15,10
1,4 ±0,27 41,4±21,84
1,5 ±0,79 1,9 ±0,83
i ( + ) X ± S D 23,5 ±16,29
1,2±1,54 24,3 ± 25,55
1,0±1,61 0,05 ± 0,67
P
<0,001
<0,001
<0,001
<o,ooi 0,215 Nhdn xet Sau mdt lan thay huyet tuang tinh trang ddng m l u d i thien ro ret vdi c l chi tieu ve hai con dudng ddng mau ndi sinh (APTT) va ngoai sinh (Prothrombin va INR); ham lupng fibrinogen khdng thay ddi.
Bdng 4. Hieu qua di^u trj ho trcf tdn thUtfng gan va dao thdi doc t o noi sinh (Bilirubin, NH3, laetat)
CM tieu
AST (UI/L) ALT (Ui/L) Bilirubin toan phan (Mmol/L) Laetat (mmol/L) NHs (|,mol/L)
n
228 228 221 47 17
TruAc PEX X ± S D 1142,2 ±164,79
677,8 ±69,49 338,0 ± 232,86
4,6 ± 3,74 123,4 + 73,10
Sau PEX X ± S D 612,3 ±75,75 354,7 ± 34,04 208,2 ±148,60 4,8 ± 3,26 72,5 ± 58,94
fl(+) X ± S D 529,9 ± 99,95 323,1 ±42,39 129,8± 111,80
0,09 ±2,22 50,9 ±31,95
P
<0,0001
<0,0001
<0,001 0,784
<0,001 Nhdn xet Sau mdt lan thay huyet tuong: Men gan, bilirubin toan phan v l NHj g i l m ro ret; iQOng laetat khdng thay ddi dang ke.
3.3.2. Anh hudng cda thay huyet tdang
Bang 5. Anh hUdng cua thay huyet tUtfng len cac chi sd huy^t hoc
Chi tieu
Hong cau (T/L) Hb (g/L) HCT(%) Bach cau (G/L) Trung tinh (%) Lympho (%) Tieu cau (G/L)
n
242 241 238 238 236 193 240
Trucrc PEX X ± S D 3,5 ± 0,77 99,9 ±17,97
29,1 ± 5,09 11,4 ±7,60 73,9 ±14,78 13,5 ± 9,85 152,9± 120,14
Sau PEX X ± S D 3,3 ± 0,72 93,3 ±16,83
27,3 ±4,80 12,4 ±9,04 79,7 ±11,89
9,8 ± 6,86 133,1 ±110,80
a(+) X ± S D
0,23 6,6 ± 7,26 1,8±2,17 0,9 ± 6,28 5,7 ±11,67
3,7 ± 8,02 19,8±31,85
P
<0,001
<0,001 i<aooi__
0,016
<0,001
<0,001
<0,001 Nhdn xit Sau thay huyet tUOng lupng hdng d u , hemoglobin, tieu c l u giam hon; sd lUpng bach cau va bach cau trung tinh t i n g .
TAP CHl Y DUOC L A M S A N G 108
Bdng 6. Anh hudng c(la
Chi tieu
Glucose (mmol/L) CaTP (mmol/L) Na (mmol/L) K (mmol/L) Cl (mmol/L) Ure (mmol/L) Creatinin (pmol/L)
n
172 110 243 243 241 205 214
Tap 2-So 7/2017
thay huy^t tUtfng len cac chi tieu danh gia chi^c nang than.
dUcmg huyet va dien gidi Tru«c PEX
X ± S D 9,7 ± 4,44 2,0 ± 0,25 136,8±5,15
3,4 ± 0,62 100,7 ±5,30
7,3 ±17,97 101,8 ±86,69
Sau PEX X ± S D 11,0 ±4,33
2,6 ± 0,45 138,1 ±10,04
3,8 ± 0,39 99,1 ± 5,33 7,7 + 19,72 101,2±88,15
i ( + ) X + SD 1,3 ±3,79 0,6 ± 0,49 1,4± 10,21 0,3 ± 0,39 1,6 ±4,45 0,4 ±4,38 0,5 ± 36,35
P
<0,0001
<0,001 0,053 0,406
<0,001 0,236 0,828 Nhdn xit Sau thay huyet tUOng dQdng huyet tang vdi mUc dp 1,3 ± 4,27mmol/L; d e c h i t dien giai Na, K d nhdm nghidn cQu khdng thay ddi, Cl g i l m nhe (1,6 ± 4,45mmol/L) va Ca t o l n p h l n tang nhidu (0,6 ± 0,40mmol/L); ure, creatinin khdng thay ddi.
' 4. Ban luan
4.1. Dac diem chung va trieu chuhg lam sdng
€>d tudi trung binh cda benh n h i n VGNB d p ' nang d nhdm nghien eQu la 41,5 ± 17,79 tudi, nhd -nhat 12, eao n h l t 82 tudi. Nhin chung, tudi trung ' blnh khdng khae bidt nhieu so vdi mdt sd nghien cUu cQa d e t i e g i l trong nude va qudc te. Ngd OQe
" Ngpc la 33,9 ± 14,3 (tudi) [2]; Bang Thi Xuan la 44,8 ± 16,29 [3]. Ve gidi, t y le nam/nQ trong nhdm nghidn cQu I I 0,6, nU gidi ehiem 40,3%, t h I p hon so vdi cac nghien cQu tren thd gidi.
Trong nhdm nghien cQu da sd benh n h i n VGND 1clp nang la ndng dan (58,1%), lao ddng trf dc ehiem ty le khdng nhd (16,1%), d c ddi tQpng khae nhU .budn ban, hpe sinh, edng nhin... ehiem t? le lan lUpt , 1111,3%, 12,9% va 1,6%. T y t d ndng dan m I e VGND
•.cung g i n gidng vdi d e thong ke khac nhU nghien 'cQu cQa Phung Thj Hang ve VGND tai Khoa Tieu Hda,
^Benh vidn Bach Mai t h I y t? le ndng d i n I I 54,5%
![4Error! Reference source not found.].
Nguyen nhan gay VGND rat da dang bao gom '•.cac thuoc dieu t n (thudc dieu tri benh lao, --paracetamol, thudc khang giap, thuoc didu tri ung
;thu...), d c c h i t ddc cd ngudn gde tQ ddng vat (nhQ . jnpc ong, mat ca...), thUc v l t (cay cd, nam sinh dpc t d
^amatoxin, ochratoxin A...). Thudc y hpe dan tde
khdng cd ngudn goe ro rang la nguyen nhan thUdng gap nhat trong sd ele benh nhan, ehiem ty le 27,5%
(17/62) d nhdm nghien cdu; da phan cac benh nhan deu t u ehe bien d c bai thude thdng qua kinh nghiem truyen midng ma khong mua thudc tU benh vien y hpc cd truyen h o l e d c n h i thudc da dupe dang ky. Cle nguyen nhan khac cd t J le cao la thudc dieu trj lao 07 BN (11,3%); thudc t i n dUpe va ngd dde paracetamol 08 BN (12,9%); ong ddt v l mat d 08 BN (12,9%); mdt phan khdng nhd la ngd dde hdn hpp 10 BN (16,17%) - thue te n l y eho t h I y khd k h I n eda ehan doan xae dinh VGND - lam the nao de chi ra chfnh xae t i e nhan gay VGND trong bdi d n h benh nhan sQ dung nhieu loai thude khIe nhau ed the gay nen tQPng tac cd hai cho gan la mdt van de khd, can dQpe nghien eQu sau hon.
Trieu chQng lam sang eua VGND ed d l y du d e d i u hieu gidng nhQ viem gan do cae nguyen n h i n khIc. Trieu chUng ehan an g i l m thudng bleu hien gan da va dang trong giai doan phue hdi. Trieu chQng roi loan y thUe 20 BN (32,8%) hoae x u l t huyet 14 BN (22,6%) lien quan vdi tien lupng nang v l tQ vong. So vdi nghien eQu cua Phung Thj Hang cho thay gidng 100% met mdi, 95,7% bleu hien vang da, tuy nhien ty le x u l t huyet ehi cd 4/46 (8,7%) do da sd
JOURNALOF 108-CLINICAL MEDICINE AND PHARMACY Vol.l2-N'7/2017
benh nhan trong nghien cQu nay nhe, ehi cd 6/46 BN ed dau hidu suy gan INR > 1 [4].
4.2. Dac diem trieu chdng can lam sang luc vao vien
Cd nhieu d i e diem can lam sang de d i n h g i l mQe dp viem gan, suy gan. Trong nghien cQu nay d c chi tieu dQpe lUa ehpn la ALT, bilirubin t o l n p h l n , INR theo phan loai mQc dp VGND cua Fontana de d i n h g i l tinh trang tdn thQPng gan v l suy tang kem theo [6]. Ket qua nghien cQu eho thay: Cdng thQc mau ed hien tuang thieu mau nhe vdi lupng hdng d u la 3,8 ± 0,99T/L va hemoglobin 107,6 ± 23,21 g/L; bach d u tang nhe vdi sd lupng trung binh 9,9 + 1,29G/I. Tdn thUOng gan nang vdi ALT la 615,0
± 80,4 (Ul/L), song hanh eung vdi bieu hien suy gan vdi INR I I 1,8 ± 0,20 va t J le prothrombin I I 41,3 ± 25,96. So sanh dp tdn thuong te b l o gan trong nghien cQu nay vdi mdt sd nghien cQu ve suy gan cap do VGND eho t h I y ALT cd nhd hon ddi chut, Ngd DQc Ngpc (704,7 + 1157,0UI/L) [2]; tQPng dUPng vdi nghien cQu eiia Dang Thj Xuan (914,1 ± 1258,78UI/L) [3]. Bleu hien tae mat v l rdi loan chdc p h l n eda gan vdi lUpng bilirubin toan phan rat cao 390,4 ± 231,83 (pmol/L), Idn hOn ddi chut so vdi nghien cQu cua Dang Thi XuIn (385,3 -•- 215,65Mmol/L)[3].
Cdc the viim gan nhiim ddc vd do viim gan Ket q u i nghien cQu ve p h l n loai viem gan nhiem dde theo Trudng mdn khoa hpc tieu hda My dUa vao t J le ALT/ALP eho thay d nhdm nghien eQu VGND the hdn hpp cd ty 1§ eao nhat vdi 27 BN (43,5%), cdn lai the tae mat 21 BN (33,9%) va 14 BN (22,6%) d the hoai tQ. Theo phan loai viem gan theo WHO chi dQa vao ALT cho t h I y cd 25 BN (40,4%) cd ALT dudi 250UI/L (dp 1 va 2), mac du mQe do hoai t d te bao gan khdng nhieu nhung vdi bilirubin t o l n phan la 488,2 ± 230,51 pmol/L va INR 1,9 ± 1,32 eho t h I y suy gan nang khdng tUPng Ung vdi mQc dp hoai t d te b l o gan thdng qua xet nghiem ALT lue vao vien (ed the ly giai la te bao gan hoai tQ nhieu tU trudc dd, nay lupng te b l o edn lai it, bieu hien tdn thuong gan van edn nhong khdng the hien bang ALT tang eao nhieu nhulue ban dau). Nhuvay, danh
g i l mQe dp VGND n l n g , suy gan khdng the dift vao mdt ehi tieu ALT don thuan m l can dQa vao t^ng hop ele chi sd. Vdi sd lieu va p h l n tich nhu tren, phan loai mQc d d VGND nang eua Fontana dap iJng dQOc d c tieu chf danh gia t o l n dien tinh trang ton thQPng va mQc dp suy gan d nhieu thdi di^m khac nhau. Ket qua nghien eQu cho thay 100% d nhom nghien eQu deu d mQe VGND nang (diem Fontana >
3 diem), trong dd ed 46 BN (74,2%) d mUc dp 3 vl 16 BN (25,8%) d mQc dp 4. Ve giai doan benh nao gan khi v I o vien, thdng ke cho thay d nhdm nghien ciiti ed 35/62 BN (56,5%) ed bleu hien benh nao gan vdi nhieu giai doan khae nhau.
4.3. Ket qua dieu tri thay huyet tdtfng
Trong nghien cQu nay mdi cudc thay huy^t tUOng sQdung lUpng huyet tUOngtUPng dUong mdt the tich tfnh theo cdng thUe the tich huyet tupng thay the = 0,065 X C l n n l n g (kg) x (1 -hematocrit). Ket qui cua mdt eude thay huyet tuong dUpc d i n h gia thdng qua kham xet cae dau hieu l l m sang va can l l m sang ngay trudc va sau mdt eude thay huyet tUPng.
4.3.1. Hiiu qud cua thay huyet tuang Sau mdi lan thay huyet tUong khdng lam thay ddi mach, huyet ap v l Sp02; thdng sd l l m sang duy nhat dugc d i thien rd ret sau mdi lan thay huyet tUPng I I diem Glasgow (Bang 2). Glasgow trung binh trUdc moi lan thay huyet tUOng la 13,6 ± 0,23 d i thidn len 13,9 ± 0,19 diem, vdi mQc thay d6l 0,3 i 0,67 diem/1 l l n thay (p<0,001). Mot sd nghien ciJu tren the gidi cho rang mae du lam giam ndng do NHa trong m l u , nhQng thay huyet tUong chi giup cai thien nhe tinh trang l l m sang d benh nhan hdn me gan. Nghien cQu cua Singer va edng sQ cho thay moi l l n thay huyet tQOng g i l m duoc 20pmol/L NHi, ddng thdi y thQc eua bdnh n h i n c l i thien rd ret sau l l n thay huyet tQOng dau tien [10]. Mdt sd dau hie«
lam sang khae ed the cai thidn sau khi thay huyet tUPng nhung rat khd ghi nhan tren lam sang nhu mQc dp vang da, nguy cP xuat huyet, benh nha"
d m t h I y khoan khoai, de chju hon...
Sau mpt lan thay huyet tQong men gan gilmf^
ret: AST (tQ 1142,2 ± 164,79 xudng 612,3 ± 75,75UI/L t^ le giam 46,4%) va ALT (tQ 677,8 ± 69,49 xuong
, TAP CHf Y Dapc LAM SANG 108 T$pl2-S67/2017
354,7 ± 34,04UI/L, t y le g i l m 47,7%) (BIng 4). So vdi nghien cUu t r o n g nudc, Ng6 DQc Ngpe g i l m AST 66,2%, ALT 65,9% [2]; Dang Thj Xuan; AST g i l m 45,6%, ALT g i l m 53,1%) d mdt lan thay huydt tUOng [3]; ngoai nUdc n h u Akdogan: AST g i l m 63,7%;
Singer: AST g i l m 65,6%, ALT giam 68,8% [10].
K h i nang boi phu d e yeu t d ddng mau dong thdi khdng lam qua t l i dich, hd trp chQc nang va chd gan hdi phuc dQpe eol la Ipi diem khdng t h ^ phu nhan eua bien p h I p thay thd huyet tuang, da duac edng bd d pham vi trong nude va qudc te [1], [5], [9].
Ket qua nghien cQu t U B I n g 3 khdng n l m ngoai nhan dinh trdn. Chinh viec tae dpng t d t tdi qua trinh ddng mau ma sau khi thay huyet tUOng tat e l d c chi sd xet nghiem ve con dudng ddng mau ndi (APTT) va ngoai sinh (INR v l ty le prothrombin) deu dUOC d i thien giup gan ed ea hdi va thdi gian phuc hdi.
N g o l i ra thay huyet tUPng edn giup dao thai bilirubin, NH3... sau thay huyet tuang bilirubin toan phan trung binh g i l m tQ 338,0 ± 232,86 xudng 208,2
± 148,60 ((imol/L), tUong dUong giam 38,4% lUOng bilirubin mdi l l n thay huyet tUOng. Sd lieu nay eua Singer 50%/l lan Ipe [10]; Pham Due va D i n g Qude Tuan 36,4%/1 lan Ipc [1]. NH3 g i l m tQ 123,4 ± 73,10 xudng 72,5 ± 58,94 (|imol/L) sau khi thay huyet tuong, giam 41,2% d mdt l l n thay, phu hpp vdi nhieu t i e gia nhU Singer nhan thay NH3 giam tQ 102,0 xudng 83,9 (pmol/L) (17,7%) [10], Dang Thi Xuan giam 36,4% cho mdt l l n loc. Ve dieu ehinh laetat, sd lieu thu dugc Xd nghien cQu n l y ddng thuan vdi mdt sd tae g i l tren the gidl khi cho rang thay huyet tQOng khdng lam thay ddi ndng dp laetat mau.
4.3.2. Anh hddng cOa thay huyet tdong Anh hddng thay huyit tdang tdi cdc chi tiiu huyet hgc So sanh ghep cap trQde va sau thay huyet tUOng eho thay sd lupng hdng cau giam tQ 3,5 ± 0,77 xudng 3,3 ± 0,72 (T/L), hemoglobin g i l m tQ 99,9 ± 17,97 xudng 93,3 ± 16,83 (g/L), hematocrit gram tQ 29,1 ± 5,09 xudng 27,3 ± 4,80 (%). Sd d i sd lUpng hdng eau, ty le hemoglobin v l hematocrit g i l m la do trong mdi l l n Ipc m l u p h l i bd di mdt lUpng m l u nhat d m h chQa t r o n g day va cdt Ipc, mdt iQpng djch n h l t dmh trong qua trinh thay huyet tQPng d n p h l i
sQ dung de lam loang mau, tieu d u eung giam do dinh vao day Ipe v l phin Ipc. Sd iQpng bach eau ed xu hQdng tang l^n (p=0,016), bach eau trung tinh tang rd ret tQ 73,9 ± 14,78 len 79,7 ± 11,89 (%) song h l n h vdi sd iQpng bach d u lympho gl^m 13,5 ± 9,85 xudng 9,8 ± 6,86 (%). Nhu v l y , hien tupng viem ed xu hudng xuat hien va t i n g len sau khi thay huyet tUPng. Hidn tUpng nay la do co the tang hoat ddng dap Qng viem vdi d c t i e nhan ben n g o l i bao gdm viec dat dng thdng tTnh maeh de Ipe mau, djch thay the I I huyet tQPng va cd the nguy cp nhiem khuan.
Anh hudng thay huyit tuang tdi cdc chi tieu sinh hda Thay huyet tQong khdng lam thay doi ndng dp ure va ereatinin trudc v l sau thu thuat, phu hpp vdi ket q u i cua nhieu nghien cUu [10]. Thay huyet tUPng lam dudng mau tang tU 9,7 ± 4,44 len 11,0 ± 4,33mmol/L sau khi thay huyet tupng vdi khoang dao ddng la 1,3 ± 3,79mmol/L (p<0,0001). Do day la mdt thu t h u l t x l m l l n , g l y ra stress kieh thich vdi cO the, do dd dan tdi hidn tupng nay.
Cac chat dien g i l i dn dinh trong qua trinh thay huyet tuang se gdp phan eho hieu q u i dieu trj tdt.
Nghien cQu cho thay sau khi thay huyet tuang Na tang nhe tU 136,8 ± 5,15 len 138,1 ± 10,04mmol/L vdi mUe t i n g 1,4 ± 10,21 mmol/L (p=0,053); K khdng thay ddi, tU 3,4 + 0,62 sang 3,8 ± 0,39 (p=0,406); Cl g i l m tQ 100,7 ± 5,30 xudng 99,1 ± 5,33mmol/L vdi mQc giam 1,6 ± 4,45mmol/L (p<0,001), ndng dp Ca tang tQ 2,0 ± 0,25 len 2,6 + 0,45 vdi mQe tang 0,6 ± 0,49 do tat d benh n h i n deu dQpc tiem tTnh maeh 2g canxi elorua trong qua trinh thuc hien thay huyet tuong. MQc tang g i l m cQa cae c h i t dien g i l i trong nghien cUu n l y kha phQ hop vdi nghien eUu cua nhidu tac gia trong va ngoai nude [10].
5. Ket luan
Viem gan nhiem ddc d p nang thudng gap d tudi trung nien, nguyen n h i n da dang va bleu hien l l m sang phong phu; vang da, rdi loan ddng mau chlem ty le cao. Thay huyet tUOng giup d i thidn diem Glasgow, dao t h l i doe, hd trp d i thien chQng nang ddng mau ma khdng gay ra nhieu t i e ddng bat Ipi.
JOURNALOF 108 - CLINICAL MEDICINE AND PHARMACY Vol.l2-N''7/2017
Ldi cdm an
Nhdm nghien cQu xin giii Idi d m Pn c h i n t h l n h tdi quy t h I y cd, quy ddng nghiep, nhdm toe mau cua Trung tam Chdng ddc, Benh vien Bach Mai da tao mpi dieu kien, giup d d , ddng vien cho nhdm nghien eQu thQc hien nghidn cQu nay.
Tai lieu t h a m khSo
1. Pham Du^, Dang Qudc Tuan (2012) Nghiin cdu dng dung cdc ky thudt Igc mdu ngodi ca thi trong dieu tn ngd dgc cdp ndng. Di tai Nghien cQu khoa hpc d p B6 Y t^.
2. Ngd DQc Ngpe, Nguyen Thj Du, Pham Du& (2011) Nghiin cdu hiiu qud cua bien phdp thay huyit tuong trong diiu tri benh nhdn suy gan cdp do ngd ddc ndng. Tap chi Thong tin Y DUpc, Sd 3-2011, tr.
23-27.
3. Dang Thi Xuan, Pham Du& (2011) Ddnh gid hiiu qud cda thay huyit tuang trong dieu tri suy gan cdp d binh nhdn viem gan nhiim dgc. Tap ehi Y Dupc Llm sang 108, Sd 4-2011, Tap 6, tr. 17-25.
4. PhCing Thj Hlng (2011) Nghien cdu ddc diem Idm sdng, can Idm sdng vd mo benh hgc cua viim gan do thudc. Luin van tdt nghiep bae sy chuyen khoa 11, Trudng Dai hpc Y H I Ndi.
5 Fin SL, Lars ES, Christine B et al (2016) High-volume plasma exchange in patients with acute liver failure:
An open randomised controlled trial. Journal of Hepatology 64:69-78.
Fontana RJ, Watkins PB, Bonkovsky HL et al (2009) Rationale, design and conduct of the Drug induced Liver Injury Network prospective study. Drug Saf 32:
55-68.
Kotoh K, Enjoji M, Nakamuta M et al (2006) Arterial steroid injection therapy can inhibit the progression of severe acute hepatic failure toward fulminant liver failure. World J Gastroenterol 12:6678-6682.
Muzaffer K, Serdar S, Leylagul K et al (2013) Treatment with plasma exchange may serve benefical effect in patients with severe hyperbilirubinemia: A single center experience.
Transfusion and Apheresis Science 48:323-326.
Joseph S, Anand P, Nicole A et al (2016) Guidelines on the use of therapeutic apheresis in clinical practice evidence based approach from the Writing Committee of the American Society for Apheresis:
The seventh special issue. Journal of Clinical Apheresis 31:149-338.
Singer AL, Olthoff KM, Kim H et al (2001J Role of plasmapheresis In the management of acute hepatic failure in children. Ann Surg 234:418-424.
