VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017
DIEN BIEN TRONG 3 NAM CUA BENH NHAN DAU TIEN DXraC GHEP DONG THCTI TUY THAN TAI BENH VIEN QUAN Y 103
Nguyen Ngoc Chau*, Hoang Manh An*
T O M TAT
Mot tru'dng hdp dai thao du'dng t/p 1 c6 bien chirng suy than du'dc tien hanh ghep dong thdi tuy, than tai Benh vien Quan y 103, Hoc vien Quan y ngay 1/3/2014. Sau mo, tuy va than ghep hoat dong va on djnh. Theo doi sau 3 nam ghep, chiTc nang tuy ghep hoat dong tot, on dinh, benh nhan khong diing Insulin. Chirc nang than ghep on djnh.
SUMMARY
3 YEARS FLOW-UP THE FIRST PATIENT WITH SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT I N MILITARY HOSPITAL 103
One patient with type 1 diabetes mellitus with Iddney failure was performed simultaneous pancreas and kidney transplant at 103 Military Hospital on March 1st, 2014. Post-surgery, the pancreas and kidney graft worked well and stably. Following 3 years after the transplant, the pancreas graft has been working well and stably without using Insulin. The kidney graft has been stable.
I. OAT V A N BE
Ghep tuy la phu'dng phap duy nhat du'dc chu'ng minh c6 the phuc hoi du'dng huyet ve hoan toan binh thu'dng d benh nhan dai thao du'dng vdi ba loai hinh chinh ta: ghep tuy ddn doc (pancreas transplant alone - PTA); ghep tuy sau khi da ghep than (pancreas after kidney transplant-PAK) va ghep dong thdi tuy, than (simultaneous pancreas and kidney transplant - SPK). Ghep dong thdi tuy, than thu'dng du'dc chi djnh cho cac benh nhan dai tliao du'dng typ 1 c6 bien chirng suy than. Duy tri chirc nang ciia tang ghep lien quan chat che den Idi ich song eon cua benh nhan sau ghep. Vi vay van de theo doi d i l n bien sau ghep la van de cdc ky quan trpng [1].
Tai Viet Nam, da thu'c hien ca ghep dong thdi tuy, than dau tien vao ngay 1 thang 3 nam 2014 tai Benh vien Quan y 103, Hoc vien C^uan y.
Nghien ciTu nham muc tieu: danh gia dien bien lam sang sau 3 nam cua benh nhan dau tien du'dc ghep dong thdi tuy than tai Benh vien Quan y 103.
*Benh vien Quan y 103
Chju trach nhiem chinh: Nguyen Ngpc Chau Email: [email protected] Ngay nhan bai: 2/8/2017 Ngay phan bien khoa hoc: 28/8/2017 Ngay duyet bai: 18/9/2017
\l. DOI TUONG VA PHU'ONG PHAP NGHIEN COXJ 2.1.Doi tu'dng nghien cu'u
Benh nhan: Pham Thai H. 43 tuoi, nam gidi, nghe nghiep: bo doi
Chan doan: £)ai thao du'dng typ 1, bien chuhg suy than do 2, tang huyet ap giai doan 2.
- Du'dc chan doan xac dinh dai thao du'dng typ 1 tir 16 nam, dieu tri thu'dng xuyen bang Insulin, tru'dc ghep diing 28UI insulin/ngay. 2 nam tru'dc ghep tang, tinh trang du'dng huyet khong on dinh, kho kiem soat - lu'dng du'dng huyet cao nhat du'dc do la 29 mmol/l; Hang tuan, benh nhan c6 1 den 2 cdn ha du'dng huyet.
- 4 nam tru'dc ghep xuat hien bien chutig suy than. Ngay tru'dc ghep, suy than dp 2. Benh nhan phai diing Idi tieu hang ngay, chu'a chay than nhan tao.
- 5 thang tru'cfc ghep xuat hien bien chu'ng tang huyet ap 5, dung thuoc ha ap hang ngay.
2.2. Phu'dng phap nghien cu'u: Mo ta va danh gia ket qua thu du'dc so vdi gia trj xet nghiem binh thu'dng.
2.2.1. Cae xet nghiem: Benh nhan du'dc lam cac xet nghiem huyet hoc, sinh hoa, vi sinh vat, mien djch de danh gia tinh trang tru'dc ghep, sau ghep 1 - 7 ngay, 1 - 4 tuan, sau 1 - 3 nam.
Mot so chi so xet nghiem ngay tru'dc ghep (28/2/2014):
- Xet nghiem sinh hoa: Glucose: ll,3mmol/l;
Ure: 15,9mmol/l; Creatinin: 162 \irc\o\IV, Amylase: 61U/I; C peptid: 0,01ng/ml.
- Xet nghiem huyet hoc; Hong a u : 3,37T/I;
Huyet sac to: lOOg/l; Bach cau: 8,2 G/l; N;
51,0%; L: 44,2%
- Nhom mau [O]
- Xet nghiem vi sinh vat, truyen nhiem: Anti- HIV (-); HBsAg (-); Anti-HCV(-); Anti-CMV (+). ^ - Xet nghiem mien djch (so vdi ngu'di hien tang): Phii hdp nhom mau; Crossmatch (-); Tien man cam (-); HLA: phu hdp 0/6.
2.2.2. Ghep than. Vj tri ghep d khoang sau phuc mac viing ho chau trai.
2.2.3. Ghep tuy. Vj tri ghep d khoang sau phuc mac viing ho chau phai, mo hinh ghep;
trung tarn-bang quang.
2.2.4. Thuoc dieu tri sau ghep. phac do ire che mien djch, chong thai ghep: Corticoid + Cyclosporin + Mycophenolate mofetil.
TAP CHi Y HOC VIET HAM TAP 459 - THANG 10 - SO 2 - 2017
Hi. KET QUA
3 . 1 . Chu'c nang tuy, than trong 30 ngay dau sau mo:
Bing 1. Xet nghiem chu'c nang tuy ghep Chi so
theo doi Tru'dc ghep
Glucose mau ( m m o i / i )
C peptid ( n g / m l )
Amylase mau
Lipase mau
cu/n
Insulin mau ( u U / l )
Amylase nieu
tu/n
Lipase nIeu
Ngay 1 Ngay 2 Ngay 3 Ngay 4 Ngay 5 6,8
2,5 1825 3410
3,7 77 45 5625
on dinh trong khoang
2500- 6,800
3416 Tuan 2
Tuan 3 on dinh trong khoang 6,0 - 7,2
on djnh trorig khoang 0,5
-3,6
on dinh trong khoang 56-200
on dinh trong khoang
20-72 on dinh
trong khoang 2,5-18,1
on dmh trong khoang
5320- 28,000 Nhin xet: Chdc nang tuy npi tiet hoat dong tir ngay 2 sau mo va on dinh. ChiTc nang tuy ngoai tiet: hoat dong ngay sau ghep, eo bleu hien viem tuy phan li'ng d cac ngay 2, 3 sau md. Sau do, hoat dong ngoai tiet ciia tuy ghep on djnh.
Bing 2. Cic chi sd theo doi chu'c nang than chi so theo doi
Tru'dc qhep Ngay 1 Nqay 2 Ngay 3 Ngay 4 Ngay 5 Tuan 2 Tuan 3 Tuan 4 Nhan xet: Than g
Ure mau ( m m o i / i ) 15,9 15,7 16,4 23,4 21,1 21,5 16,5-18,7 10,2-16,0 7,8-8,5 hep hoat dong ngay sau
Creatinin mau (umol/i)
162 173 237 203 171 179 165-180 130-156 110-120
Lu'dng nu'dc tieu ('mi/24 gid)
1900 2478 4780 4300 4570
2500-3500 mo. Tuy nhien, phuc hoi chu'c nang than tu'dng do cham (bu'dc sang tuan thir 4 sau mo cac chi so Ure, Creatinin mdi ve mire binh thu'dng).
- Tinh trang chung: Benji nhan phuc hoi dan. Tuan 2 sau mo c6 phan iTng tran djch da^mang {p.
mang phoi, 6 bung) phai d i n lu'u khoang mang phoi toi thieu trong 3 ngay. Hai v e t m o nhiem khuan nhe, cham lien, dieu tri bang khang sinh va hut ap li/c am, lien d tuan thir 4 sau mo. Trong thdi gian thang d l u khong c6 bieu hien thai ghep.
3.2. Dien bien chu'c nang tuy, t h i n 3 nam sau ghep Bang 3. Xet nghiem chu'c nang tuy ghep chi so theo
doi Tru'dc ghep
N a m l Nam 2 Nam 3
Glucose mau ( m m o l / i )
11,3 4,5 5 5,3
C peptid ( n g / m l ) 0,01 1,81 1,74 1,93
Amylase mau ( U / i )
61 89 103
Insulin mau ( u U / i )
2,4 16 7,4 6,09
HbAlc 8,1 6,0 5,7 5,4 Nhan xet: Chu'c nang tuy npi tiet hoat dong tot trong 3 nam sau ghep; du'dng mau luon duy tri trong gidi han binh thu'dng, nong dp Insulin, C peptid binh thu'dng, HbAlc on dinh trong khoang 5,4- 6,0%; Chu'c nang tuy ngoai tiet: hoat dong ngoai tiet ciia tuy ghep on dinh trong gidi ban cho phep.
Bang 4. Cacchisotheo doi chu'c nang than Chi so theo doi Ure mau ( m m o t / l ) Creatinin m^u
(Mmol/l)
eGFR ( m L / m l n / l , 7 3 m ^ )
Nam 2 128,3
7,68 119,3
Nhan xet: Chdc nang than cai thien ro sau ghep va van duy tri tot lien tuc trong 3 nam dau sau
VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017
ghep, nong dp ure, creatinin trong gidi han cho phep, Tuy nhien miTc loe d mii'c tu'dng du'dng benh than man ti'nh giai doan 3.
Birig 5. Cac xet nghiem khac Chi so theo doi Sinh hoa
Cong thu'c mau
NaVK*
Hs - CRP Acid Uric Honq cau HST MCV MCH I^CHC Bach cau Neutrophil
Don vi mmol/L mm/L pmol/L T/L 3/L fL pg g/L G/L
%
N a m l 123/4,5
8.8 340 3,5 98 88,6 28,1 317,5 6,8 66,9
Nam 2 143/3
4.76 353 3,6 97 86,1 26,9 312 6,5 60.3
Nam 3 135/3,7 1,81 409 3,6 103 87,6 28,3 323 10,0 68.6 Nhin xet: Roi loan dien giai xay ra trong nam dau sau ghep sau do dan on dinh trong 2 nam tiep theo. Xet nghiem Hs-CRP trong gidi han cho phep. Bach cau, ty le bach cau da nhan trung tinh trong gidi han binh thu'dng. Co tinh trang thieu mau dang sac mire dp nhe.
IV. BAN LUAN
Benh dai thao du'dng la benh dien bien man tinh, tuy cac thuoc ha du'dng huyet da ed nhieu tien bp, tuy nhien chii yeu la cac thuoc diing cho dai thao du'dng typ 2, insulin van la thuoc bat bupe va duy nhat c6 hieu qua tren benh nhan dai thao du'dng typ 1. Du'dng h_uyet khong du'dc kiem soat tot nhanh chong d i n den cac bien chirng tren cae cd quan. Cae bien ehutig xuat hien sdm tren benh nhan ghep nay cung eo the ly giai la do insulin khong the kiem soat tot du'dng huyet tren benh nhan ngay ca khi kiem soat chat che tai vien. Noi trpl tren benh nhan do la van de tang huyet ap va benh than man tinh.
Vi vay, ghep tuy - than dong thdi la mot bien phap toi du dem lai Idi I'ch lau dai tren benh nhan nay [1].
Ket qua bao cao bu'dc dau sau ghep la mot minh chirng iing ho chi djnh ghep dong thdi tuy than tren benh nhan nay. Chirc nang tuy noi tiet va ngoai tiet deu hoat dong tot sau ghep. Chirc nang than cai thien hdi cham, phai 4 tuan sau ghep eacchi so trong gidi ban cho phep. Benh nhan du'dc quan ly chat che, djnh ky kham hang thang trong nam dau, 3 thang/lan trong cac nam tiep theo. Chirc nang tuy npi va ngoai tiet hoat dong tot, du'dng mau luon duy tri d mu'c toi du, benh nhan khong dung Insulin, nong do C- peptid, Insulin va Amylase mau luon trong gidi han binh thu'dng. Tuy nhien du'dng mau liie ddi CO xu hu'dng tang cao dan qua cac nam va Insulin cp xu hu'dng giam dan qua cac nam, dieu nay cung phii hdp vdi nghien ciru ciia Christoph D Dieterle (2007) tren cac benh nhan ghep dong thdi tuy than [1]. Dae biet la sd on dinh du'dng mau trong 3 nam sau ghep the hien d chi so
HbAlc luon d trong gidi han binh thu'dng (5.4- 6.0%). Trong nghien cuii ciia Christoph D Dieterle (2007) cung cho thay c6 sy" on djnh HbAlc trong gidi han binh thu'dng 10 nam sau ghep tuy cd sd tang dan rat it nong dp HbAlc qua cac nam [ 1 ] . Qua do Christoph D Dieterle cho rang nen diing nghiem phap dung nap du'dng de danh gia thi nhay hdn so vdi chi diTa vao du'dng mau liic ddi. Cac xet nghiem danh gia chirc nang than cho thay than ghep hoat dong tot, duy tri cae chi so trong gidi han cho phep, tuy nhien ed xu hu'dng tang dan, dieu nay cung phii hdp vdi ket qua ciia Christoph D Dieterle (2007).
Chirc nang than cua benh nhan sau ghep cung da du'dc cai thien ro ret va duy tri on djnh lien tuc trong 3 nam, the hien bang chi so creatinin mau trong khoang l i b - 120 pmol/L (bang 2 va bang 4). Tuy nhien, khi danh gia chi tiet chirc nang than bang mire Ipc cau than cho thay mire Ipe cau than duy tri on djnh d mii'c 53 - 57 mL/min/l,73m^. Dieu nay cung phii hdpvij^
benh ly ton thu'dng than do dai thao du'dng c6 s§n tir tru'dc ghep ciia benh nhan [4]. Thieu mau la tinh trang thu'dng gap d benh nhan sau ghep, mot so nghien ciru chi ra rang ty le nay khoang 40% mot nam dau sau ghep than [2]. Tren benh nhan nay cd tinh trang thieu mau dang sac miTc do nhe, tuy nhien on djnh khong cd xu hu'dng tang len. Mot so nghien cu'u cho rang dieu nay anh hu'dng ciia nhieu yeu to trong dd cd vai tro ciia sir dap iTng cua tang ghep va vai tro ciia cac thuoc ire che thai ghep [ 3 ] . Van de thieu mau sau ghep eo anh hu'dng den rriirc dp nang benh hay ty le tir vong hay khong van cdn la mot van de ban cai. Tuy nhien viec theo ddi thieu mau
TAP CHI Y HOC VIET NAM TAP 459 - THANG 10 - SO 2 - 2017 dai han luon du'dc cac tac gia de cap den [2],
Cae xet nghiem danh gia chiTc nang ciia cac ed quan khac: tim mach, ho hap, tieu hoa deu d trong gidi han binh thu'dng.
Tru'dc nam 2007, cac nghien ciru chii yeu tap trung vao danh gia cac ket qua sau ghep trong muc tieu ngan han, 2007 Angelika C. Gruessner va Cs bao cao cac ket qua dai han (>5 nam sau ghep) tren hdn 9000 benh nhan ghep tuy d ca 3 loai hinh. Trong do ghep dong thdi tuy than cho ket qua 72% tuy ghep song sau 5 nam va 80%
than ghep song sau 5 nam [4]. Du'a vao cac dien bien lam sang va cac ket qua xet nghiem cho thay tren benh nhan dang eo d i l n bien tot, va dat du'dc cac muc tieu ngan han sau ghep. Tuy nhien can tiep tuc quan ly chat c h i de danh gia them cac ket qua dai han. Di/a vao cac ket qua cita nhieu nghien euU tru'dc do cho thay sd kha quan ciia benh nhan trong cac muc tieu dai han.
V. KET LUAN
Tuy ghep tot, on djnh; chu'c nang than ghep cung on djnh va chu^ xuat hien tinh trang thai ghep. Ket qua nay md ra then vpng dieu tri cho cac benh nhan dai thao du'dng d Viet Nam.
TAI LIEU T H A M KHAO
1. Dieterle, CD., et al.. Metabolic follow-up after long- tenn pancreas graft survival European journal of endocnnology, 2007. 156(5): p. 603-610.
2. Vanrenterghem, Y., Anemia After Kidney Transplantation. Transplantation, 2009. 87(9): p.
1265-1267,
3. Winkelmayer, W.C. and A. Chandraker, Pottranspiantation Anemia: Management and Rationale. Clinical Journal of the American Society of Nephrology : GASN, 2008. 3(Suppl 2): p. S49-S55.
4. Gruessner, A.C., D.E. Sutherland, and R.W.
Gruessner, Long-term outcome after pancreas transplantation. Current opinion in organ transplantation, 2012. 17(1): p. 100-105.
HIEU QUA CAN THIEP NHAM CAI THIEN MOT SO CHI SO DANH GlA CHAT LU-gNG DIEU TRI HIV/AIDS TAI BENH VIEN DA KHOA HUYEN SONG MA, T I N H SffN LA
T O M TAT
Muc dich: Nghien cu'u nham danh gia hieu qua mot so giai phap can thiep nham cai thien mot so chi so danh gia chat \\iiir\g dieu trj HIV/AIDS tai Benh vien Da khoa huyen Song l^a, tinh SOn La tir thang 12/2014 den thang 12/2015. Phu'dng phap: Danh gia tru'dc - sau can thiep khong c6 nhom chu'ng. So lieu du'dc thu thap tai 02 thdi diem: thang 12/2014 va thang 12/2015 vdi 124 benh an ngoai trii (thang 12/2014) va 104 benh an (thang 12/2015) ciia benh nhan HIV/AIDS. Ket qua: Sau 01 nam thi/c hien cac can thiep nham cai thien chat lu'i?ng, ket qua do lu'cing mot so chi so cai thien dang ke:Ty le benh nhan HIV/AIDS mdi dang ky dieu trj trong 6 thang qua dUOc lam xet nghiem CD4 lan dau trong vong 15 ngay tang tir 12,77% Ign 23,26% vdi chi so hieu qua (CSHQ) la 82%. Ty le benh nhan HIV/AIDS mdi dang ky dieu tri dUOc du' phd'ng INH tang tir 50% len 64,86% vdi CSHQ 1^ 30%. Ty le benh nhan HIV/AIDS den tai kham diing hen trohg lan kham g'an nhat tang tir 82,41% len 93,88% va CSHQ la 14%. Ty le benh nhan HIV/AIDS du'dc danh gia tuan thii dieu tri ARV trong (an kham gan nhat du'dc duy tri 6 mire tren
*Cuc Phong, chong HIV/AIDS Chju trach nhiem chinh: Le Thj HUdng Email: [email protected] Ngay nhan bai: 18/7/2017 Ngay phan bien khoa hoc: 16/8/2017 Ngay duyet bai: 18/9/2017
Le Thi Hiromg*
99%. Ty le benh nhan dii tieu chuan dieu tri ARV du'dc bat ^ u dieu tn ARV trong vong 15 ngay tang 79,41% len 95,45% va CSHQ la 20%. Ty le benh nhan c6 ket qua xet nghiem CD4 <100 te bao/mm^
liic bat dau dieu tn ARV giam tir 25,67% xuong con 0%. Ty le benh nhan HIV/AIDS du'dc sang loc lao tai lan kham gan nhat duy tri d miTc i00%. Ty le benh nhan HIV/AIDS du'dc xet nghiem CD4 thu'dng quy (6 thang/lan) tang tir 45,97% len 67,62% vdi CSHQ la 47%. Ket luan: Cizc giai phap can thiep da tac dong tich cu'c den chat lu'dng dich vu dieu trj HIV/AIDS tai benh vien. Cac chi so dp lu'dng chat lu'dng dieu trj HIV/AIDS CO tac dong lan nhau. Khi mot chi so cai thien tot se tac dong den su' bien doi tot hdn ciia mot so chi so khac.
T^ khoa: ARV, cai thien chat lu'dng dieu tri HIV/AIDS.
SUMMARY
INTERVENTION EFFECTIVE TO IMPROVE PERFORMANCE QUALITY INDICATORS FOR
H I V / A I D S TREATMENT I N SONG MA HOSPITAL, SON LA PROVINCE Objective: The study evaluates the effectiveness of a number of intervention solutions to improve perfomance quality indicators for HIV/AIDS in Song Ma Hospital, Son La province, from 12/2014 to 12/2015. Methods: Evaluate before - after intervention without control groups. Data was collected at 02 bmes: May 12/2014 and 12/2015 with 124 outpatients (12/2014) and 104 medical records
