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Methimazole treatment, and after drug withdrawal: Evidence that the activity of Thyrotropin Receptor Antibody and/or Thyroid response during the observation period", Thyroid, Vol. 16, pp. 295 - 302.
5. D Villalta, E Orunesu (2004), "Analytical and diagnostic accuracy of "second generation" assays for thyrotropin receptor antibodies with radioactive and chemiluminescent tracers", Journal of clinical Pathology, Vol. 57, pp. 378 - 382.
6. Jack DeRuiter (2002), "Thyroid hormone tutorial : Drug and other therapies", Endocrine Pharmacotherapy Module: Thyroid Section, Spring, pp.1 - 19.
7. Massart C, Maugendre D (2000), "Value of human binding TSH-receptor antibody assay in the follow - up of Graves'disease comparison with thyroid
stimulating antibody measurement", Endocrine Journal, Vol. 47, pp. 197.
8. Takasu N, Oshiro C, Akamine H, et al (1997),
"Thyroid-stimulating antibody and TSH-binding inhibitor immunoglobulin in 277 Graves' patients and 686 normal subjects", J Endocr Invest, Vol.
20, pp. 452 - 461.
9. Shooshtarizadeh P (2006), "Increased soluble Fas serum level associates with thyroid auto-antibody positivity in untreated Graves' hyperthyroidism: A case- control study", Biomedical Research, Vol.
17, Issue 3, pp. 211- 214.
10. Yoshino Kinjo, Nobuyuki Takasu (2002),
"Remission of Graves'Hyperthyroidism and A/G Polymorphism at position 49 in Exon 1 of Cytotoxic T Lymphocyte-Associated Molecule-4 Gene", J Clin Endocrinol Metal, Vol. 87, pp. 2593 - 2596.
N g h i e n c u u d a c d i e m l a m s a n g v a d i e n c o d a d a y t h a n k i n h d o s u y t h a n m a n o b e n h n h a n l o c m a u c h u k y
Studying on the clinical features and electromyography of uremic polyneuropathy in hemodialysis patient
Bui Anh Tuan Benh vien 175 Tom tat
Nghien cOu khao sat ty le mac benh, ban chat ton thUOng, moi tUOng quan lam sang va dien co ciia benh da day than kinh do suy than man d 62 benh nhan loc mau chu ky. Ti le benh da day than kinh do suy than man kha cao 67,7%. Ban chat la ton thUdng sdi true man tinh chiem chu yeu (83,3%), td'n thUdng hon hop .16,7%). Hoan toan khdng cd td'n thUOng huy myelin don thuan. 6 nhdm td'n thUOng sdi true man, cd nhu'ng benh nhan khdng cd trieu chdng lam sang nhUng van cd td'n thUOng than kinh ngoai vi tren dien cO (20%).
Summary
The study evaluates the disease ratio, nature of lesion, correlation between clinical and electromyography of uremic polyneuropathy in hemodialysis patients. Among 62 hemodialysis patients, 67,7% have uremic polyneuropathy. The nature of lesion are: axonal degeneration injury (83,3%), mixed lesion (16,7%). There is no single demyelinating lesion. 20% of axonal degeneration patients have lesion of peripheral nervous system although they don't have polyneuropathy clinically.
Phan bien khoa hgc: PGS TS. LE THU HA
1. Dat van de
Benh da day than kinh (BODTK) la mpt trong nhu'ng bien chirng rat hay gap d benh nhan suy than man (STM) giai doan cudi lpc mau chu ky (LMCK).
Theo cac nghien cdu cua Fraser CL (1993), Burn DJ (1998) ti le nay khoang 65%[3], BDDTK anh hudng trUdc het den chat lUdng song hang ngay cua benh nhan bang cac trieu chu'ng rdi loan cam giac, sau dd la nhu'ng ton thUdng khd hdi phuc ve van ddng nhU yeu liet, teo cd, va day cung la nhdng yeu td lam han che tdi thanh cdng cua lpc mau chu ky. Chfnh cac van de tren ddi hdi thay thudc can quan tam nhieu hdn tdi BDDTK, nham nang cao chan doan va dieu tri toan dien cho benh nhan STM giai doan cudi lpc mau chu ky. Van de nay d Viet Nam hien cdn it dUdc quan tam va chUa cd nhieu nghien cdu, bdi vay chung tdi dat van de nghien cdu de tai nay nham muc tieu: Nghien ctfu ty le mac, dac diem lam sang va bien ddi dien cd cua benh da day than kinh do suy than man d benh nhan lgc mau chu ky.
2. Ddi tu'o'ng va phurdng phap nghien cdu 2.1. Ddi tddngnghien ctfu
62 benh nhan suy than man giai doan cudi dUdc dieu tri ndi tru va ngoai tru tai khoa lpc mau A14- Benh vien 175 td thang 12/2008 den thang 6/2009, bao gdm: 32 nam (51,6%); 30 nd (48,4%). Tud'i trung binh 46,13 ± 12,68 tud'i. Thdi gian lpc mau trung binh: 50,98 ± 40,36 thang.
- Tieu chuan chpn benh nhan: nhdng benh nhan trpng nghien cdu &Mc chan doan STM giai doan cudi, dUOc LMCK bang than nhan tao 3 lan /tuan, moi lan 4 gid, trong thdi gian it nhat 6 thang.
- Tieu chua'n loai trd: loai trd khdi nhdm nghien cdu nhu'ng benh nhan mac cac benh ly cd the gay ra BDDTK : benh he thdng nhU viem nut quanh ddng mach, lupus ban dc he thdng... benh thoai hpa he thdng nguyen phat, da u tuy, dai thao dUdng, HIV, tai bien mach mau nao, da dung mpt sd thudc gay ddc than kinh ngoai vi nhU: Colchicin, Nitrofurantoin...
2.2. Phddng phap nghien cdu
Thiet ke nghien cdu: tien cdu, cat ngang, md ta.
Ndi dung nghien cuU: kham lam sang; can lam sang.
- Xet nghiem CTM (HC, BC, TC), dien giai dd, ure, creatinin dUdc thuc hien tren cac may huyet hpc Cell-Dyn 1700 va sinh hda tudpng Olympus 640 (AU-640).
- Dien cd (EMG) thud hien tren may Neurcpack 8 cua hang Nihcn Kpnden.
Tieu chuan xac dinh benh da day than kinh dira vac ket qua chan doan dien cd [1]:
Ban chat cua ton thUOng than kinh ngoai vi tren dien than kinh cd (EMG) chia 3 loai sau:
Ton thUdng sdi true: dac truhg chu yeu bang giam bien dp dien the va nhirng bat thudng tren dien cd kim.
Huy myelin: dac trUng chu yeu bang giam tec dp dan truyen, thdi gian tiem sdng F keo dai.
Td'n thUdng hdn hdp: bao gdm ca hai loai tren.
Xd ly so lieu; Sd dung phan mem thdng ke y sinh hpc SPSS 17.0.
3. Ket qua nghien ecru
Ti le benh nhan LMCK mac BDDTK dc suy than man kha cao 67,7%.
Trong nhdm mac BDDTK, ton thUdng sdi true man chiem 83,3%, ton thUdng hon hdp 16,7%, khdng cd huy myelin ddn thuan.
Bang 1. Cac trieu chdng cd nang cua benh da day than kinh
—~-__^ Nhdm
Trieu chung"" Nhdm mac BDDTK
(n=42) Nhdm khdng mac BDDTK
(n=20) P Tdng cdng
(n=62)
n % n % n %
Di cam 18 42,9 3 15,0 <0,05 21 33,9
Ndng rat ban chan 13 31,0 4 20,0 >0,05 17 27,4
Vop be 19 45,2 6 30,0 >0,05 25 40,3
Hdi chdng chan 24 57,1 5 25,0 <0,05 29 46,8
khdng yen (RLS)
Hdi chdng chan khdng yen (RLS) va di cam d nhdm benh nhan mac BDDTK cd ti le cao hdn nhdm benh nhan khdng mac rd ret (p < 0,05).
Tap 5 - so 4/2010 TAP CHI Y DUOC LAM SANG 108
50
H A _8.b
14.3 I I 7.1
Giam cam giac Giam cam giac Giam hoac Giam hoac Giam hoac Teo ccv nhiet rung am thoa mit phan xa mat phan xa mit phan xa
g6i got chi tren
Bieu do 1. Trieu chu'ng thUc the d nhom benh nhan mac benh da day than kinh
6 nhdm benh nhan LMCK mac BDDTK, gap nhieu nhat la giam hoac mat phan xa got 61,9%, ke den la giam hoac mat phan xa gdi 50%, giam hoac mat phan xa chi tren 28,6%.
Bang 2. Hinh anh dien cd kim cua nhdm mac benh da day than kinh
Ty le thep vi tri Chi tren Chi dudi
Hinh anh dien cd kim n % n %
Dien the dam kim Binh thudng 42 100 42 100
Tang 0 0 0 0
Hoat ddng tU phat Cd 0 0 0 0
Khdng 42 10 42 100
Hinh anh ket tap Binh thudng 23 54,8 22 52,4
Giam 19 45,2 20 47,6
Ddn vi van ddng da pha vdi
bien dp cao Khdng 1 2,4 0 0
Cd 41 97,6 42 100
Hinh anh dien cd kim cho thay: 100% dien the dam kim binh thudng, 100% khdng cd heat ddng tU phat, hinh anh giam ket tap gap 45,2% d chi tren va 47,6% d chi dUdi. Ddn vi van ddng da pha vdi bien dp cac 100% d chi dUdi va 97,6% d chi tren.
100 80 60 40 20 o
100 100
80 i 65.7 _M8___W
! i 60 H
P I
Trieu chu'ng co nang Tri$u chi>ng thuc the Lam sang Bieu do 2. Ti le dUdng tinh ve cac trieu chdng lam sang
d nhdm td'n thUdng sdi true man va ten thUdng hon hdp
Nhdm BN ton thUdng hdn hdp tat ca 100% deu cd day du trieu chdng cd nang va thud the. Nhdm ton thUOng sdi true man cd 20% am tinh ve lam sang.
4. Ban luan
Co nhieu gia thuyet khac nhau ve cd che benh sinh cua benh da day than kinh ciia benh nhan suy than man bao gdm:
- Nhu'ng phan td nhd hda tan trong nUdc:
Guanidines, Creatinin, Ure, Purines, Oxalate, Phophorus.
- Nhu'ng chat cd trong lUdng phan td trung binh:
san pha'm chuye'n hda cua glycosylate, Parahormone, nhu'ng san pham do qua trinh oxy hda, cac peptid (Beta Endorphin, Methionin - Enkephalin, Beta lipotropin, Protein I va II Oc che bach cau hat, Adrenodullin, Beta 2 microglobulin).
- Nhu'ng chat cd gan ket Protein: Indole, Hippuiric acid, P - cresol, Homocysteine, 3 carboxy - 4 methyl-5 propyl - 2 furanpropionic acid, Indoxyl sulfate, Polyamines...
Ti le benh nhan LMCK mac benh da day than kinh (BDDTK) do suy than man trong nhdm nghien cdu nay kha cao (67,7%). Ti le BDDTK do suy than man d benh nhan LMCK trong nghien cdu cua Nguyen Minh Tuan (2004) la 58,49%, Shieh S.D(1983) la 62%, Burn DJ (1998) va Fraser CL (1993) la 65%
[2][3][6].
Chung tdi nhan thay ton thUdng sdi true man tinh chiem chu yeu (83,3%), td'n thUdng hdn hdp (sdi true va bao myelin) chiem ti le 17,7%, khdng cd trUdng hdp nao ton thUOng bao myelin ddn thuan.
Nguyen Minh Tuan (2004) nhan thay td'n thUdng day than kinh d benh nhan LMCK mac BDDTK do suy than man chu yeu la ton thUdng sdi true man tinh (83,87%), td'n thUdng hon hop chiem it (16,13%), khdng cd ton thUdng bao myelin ddn thuan [2].
Neilsen V.K (1974), Dyck PJ (1971), qua nghien cdu deu nhan thay ton thUdng than kinh ngoai vi d benh nhan LMCK mac BDDTK do suy than man chu yeu la ton thUOng sdi true man. Ton thUdng thoai hda sdi true xuat hien dau tien, sau dd ton thUdng huy bao myelin se xuat hien tiep theo [4][5].
Cd 4 trieu chdng cd nang thudng gap d benh nhan LMCK mac va khdng mac BDDTK, trong dd hdi chdng chan khdng yen (Restless legs syndrome- RLS) chiem ti le cao nhat 46,8%, tiep theo la vop be 40,3%, di cam 33,9%, thap nhat la trieu chdng ndng rat ban chan 27,4%. So sanh ti le cac trieu chdng cd nang gida 2 nhdm mac va khdng mac BDDTK nhan
thay ti le ca 4 trieu chdng nay d nhdm mac BDDTK cao hdn nhdm khdng mac BDDTK, tuy nhien chi cd 2 trieu chdng di cam va hdi chdng chan khdng yen la cao hdn rd ret (p<0,05). Dragan J. va cdng sU (2008) qua nghien cOu lam sang d 131 benh nhan LMCK gap cac trieu chdng cd nang BDDTK do suy than gdm:
RLS 47%, vpp be d chan 39% va d tay 16%, dj cam d chan 29%, di cam d tay 14%, ndng rat d ban chan 28% [7].
6 nhdm benh nhan LMCK mac BDDTK ti le trieu chOng thud the: gap nhieu nhat la giam hoac mat phan xa got 61,9%, ke den la giam hoac mat phan xa gdi 50%, giam hoac mat phan xa chi tren 28,6%, giam cam giac rung am thoa d ban chan 21,4%, teo cd 14,3%, giam cam giac nhiet 7,1% (Bieu do 1).
NhU vay giam hoac mat phan xa chi dudi gap ddi chi tren. Teo cd chung tdi chi gap nhu'ng trUdng hdp teo cd kin dao mdc dp nhe d gan ban chan va giam cam giac nhiet d cang chan, khdng ghi nhan trUdng hdp nao bi liet, giam cam giac xuc giac va cam giac dau.
BDDTK do suy than man d benh nhan LMCK cd kieu hinh BDDTK ddi xdng ngpn chi, vi vay trieu chdng thieu sdt van ddng, cam giac xuat hien dau tien d cac ngpn chi, sau dd lan dan ve gdc chi. Trieu chdng giam hoac mat phan xa gan xUdng cung cd kieu phan bd tUdng to, mat d got trUdc khi mat d gdi, xuat hien 2 chi dudi trUdc 2 chi tren. Dac diem phan bd ngpn chi nang hon gdc chi lien quan mat thiet den chieu dai cua day than kinh, sdi than kinh cang dai cang bi sdm hdn va nang hdn. Trong BDDTK do suy than man, sdi true cd hien tUdng "chet trd lui" (dying back phenomenon) bat dau td ngoai vi cua cac sdi than kinh do dd sdi true cang dai cang de bi tdn thUdng. Td'n thUdng than kinh trong BDDTK do suy than man d benh nhan LMCK chu yeu la td'n thUdng sdi than kinh Idn cd nhieu myelin nen giam cam giac rung am thoa gap nhieu hdn giam cam giac nhiet.
6 nhdm benh nhan LMCK bi td'n thUdng sdi true man, lam sang chi dUdng tinh 80%, cd trieu chOng cd nang la 65,7% va kham cd trieu chdng thud the la 60%. NhU vay ti le am tinh ve lam sang la 20% d nhdm benh nhan ton thUdng sdi true man. 6 benh nhan bi td'n thUdng day than kinh hon hop (thoai hda sdi true va huy myelin ket hdp) 100% deu cd trieu chdng lam sang, khdng cd trUdng hdp lam sang am tinh. NhU vay dien cd gidp chan doan sdm BDDTK do
Tap 5- so 4/2010 TAP CHI Y DUOC LAM SANG 108 STM d the thoai hoa sdi true khi chUa co trieu chu'ng
tren lam sang. Khi BO DTK do STM d the td'n thUdng hon hdp thi cac trieu chdng lam sang da rd rang.
Nguyen Minh Tuan (2004) nghien cOu nhan thay:
64,52% cd trieu chu'ng cO nang, 70,7% cd trieu chdng thUc the, lam sang dUdng ti'nh 83,7% va am ti'nh 16,13% [2].
Mdi tUOng quan gida lam sang va dien cd: nhdm benh nhan lpc mau chu ky the tdn thUOng sdi true man cd trieu chdng cd nang la 65,7% va cd trieu chu'ng thUc the la 60%, lam sang chi dUdng ti'nh 80%, khdng cd trieu chdng thUc the va cd nang la 20%. Nhdm benh nhan the ton thUOng day than kinh hdn hdp 100% deu cd trieu chdng cd nang va thud the.
5. Ke't luan
1. Ti le mac benh da day than kinh do suy than man d benh nhan lpc mau chu ky la 67,7%.
2. Dac diem lam sang cua benh da day than kinh d benh nhan STM lpc mau chu ky:
- Trieu chdng cd nang thudng gap la: hdi chdng chan khdng yen (57,1%), vpp be (45,2%), di cam 42,9%, ndng rat ban chan 31%. Ti le hdi chdng chan khdng yen va trieu chdng di cam cua nhdm mac BDDTK cao hOn rd ret so vdi nhdm khdng mac (p<0,05).
- Trieu chdng third the thudng gap la: giam hoac mat phan xa got (61,9%), giam hoac mat phan xa gdi (50%), giam hoac mat phan xa chi tren (28,6%), giam cam giac rung am thoa d chi dUdi (21,4%), giam cam giac nhiet d chi dUdi (7,1%), teo cd d gan ban chan (14,3%).
3. Td'n thUdng day than kinh trong BDDTK do suy than man d benh nhan LMCK chu yeu la thoai hda sdi true man tinh (83,3%), td'n thUdng hon hop chiem (17,7%), hoan toan khdng cd huy myelin ddn thuan.
Tai lieu tham khao
1. Nguyen Hdu Cdng (1988), "CO sd kham din truyen than kinh - dien cd", Chan doan dien va benh ly than kinh cd, Nha xuat ban Y hpc, tr 7 - 70.
2. Nguyln Minh Tuan ( 2004), Danh gia lam sang va phUOng phap chan doan dien benh da day than kinh do suy than man, luan van thac si y hpc - Dai hpc Y DUdc TP HCM.
3. Burn DJ., Bates D. (1998), "Neurology and the kidney". J Neurol Neurosurg Psychiatry 65: pp 810-821, 1998.
4. Dyck P.J., Johnson WJ., Lambert E.H, et al (1971), "Segmental demyelination Secondary to axonal degeneration in uremic neuropathy", Mayo Clin Proc 46 : pp 400-431.
5. Nielsen V.K. (1974), "The peripheral nerve function in chronic renal failure IX", Recovery after renal transplantation electrophyiological aspects (sensory and motor nerve conduction), Acta MedScand, 195(3): pp 171-180.
6. Shieh S.D., Huang H.W., Luke P.C. et al (1983),
"Studies on Motor Nerve Conduction Velocity in Chronic Uremia", Med. Sci 5(2) : pp 1693-1983.
7. Dragan J. , Ante B., Dragan S., et al (2008),
"Clinical Course of Uremic Neuropathy in Long- Term Hemodialysis", Coll. Antropol. 32 (2008) 3:
pp 771-775.
