aw r;?i , ,?• Y HOC VIET NAM THANG 11 - SO 2/2010
BIEN DOI HONG CAU LlTfln MAU NGOAI VI 0 BENH NHAN SUY THAN MAN TINH
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HirUi <..uX):ii 0'
Nguyen Hai Dang*, Hoang Trung Vinh''
TOMTAT
Nghien ciiu cat ngang md ta tren 68 benh nhan (BN) suy than man (STM) giai doan I I I , IV chUa dieu trj va 34 ngUdi khde manh tudi va gidi tu'dng dUdng, sii dung may Beckman Coutler LH- 780 xet nghiem hdng cau lUdi (HCL) thay: Sd lu'dng HCL nhdm BN STM khdng khac nhdm chu'ng (0,0795 ± 0,0464 (T/l) so vdi 0,0676 ± 0,0254 (T/l); p > 0,05). Chi sd kich thUdc te bao hong cau (RSf) nhdm BN thap hdn nhdm chu'ng (95,04 ± 8,83 (fl) so vdi 100,37 ± 4,4(fl); p <
0,05). Chi sd tao HCL (RPI) nhdm BN la 0,8 ± 0,63. Co 97,2% BN cd RPI < 2 va 23,5% BN cd RSf < 91,Ifl. So lUdng HCL tUdng quan nghjch vcfi the tich hong cau lUdi (MRV) (r = - 0,59; p <
0,001) va tUdng quan nghjch vdi RSf ( r = - 0,42;
p < 0,001). RPI tUdng quan nghjch vdi MRV (r = - 0,46; p < 0,001). Sd lUdng HCL tUdng quan vdi Hb (r = 0,34; p < 0,005). RPI tUdng quan vdi Hb (r= 0,52; p < 0,001). Cd the sii dung cac thdng so HCL de danh gia chiic nang tao mau, tinh trang thieu mau tren BN STM chUa dieu trj.
TH khda: Hong cau lUdi, chi sd tao hong cau ludi, chi sd yeu td kich thUdc te bao hdng cau, suy than man, Beckman Coutler LH-780.
SUMMARY
A cross-sectional descritive study conducted in 68 patients with chronic renal failure (CRF) at stage III and IV before initial treatment and 34 healthy subjects. Using LH780 hematolyser (Beckman Coutler - Miami - USA), we measured absolute reticulocyte count, reticulocyte production index (RPI), mean reticulocyte volume
* Vi^n Y hoc Hdng khong
**B?nh vien 103
(MRV), red blood cells size factor (RSf).
Result: No statistically significant differences were observed for absolute reticulocyte count between CRF patients and healthy subjects (0,0795 ± 0,0464 (T/l) vs. 0,0676 ± 0,0254 (T/l); p>0,05). In patients group, RSf were lower than controls (95,04 ± 8,83 (fl) vs. 100,37 ± 4,4(fl); p<0,05); RPI was 0,8±0,63 and 97,2%
patients had RPI <2. There were 23,5% patients with RSf < 91,lfl. We found inverse correlations between absolute reticulocyte and MRV (r = - 0,59; p<0,001), and RSf (r = -0,42; p<0,001);
between RPI and MRV(r = -0,46; p<0,001). And correlations between Hb and absolute reticulocyte count (r = 0,34; p<0,005); Hb and RPI ( r=0,52; p<0,001).
Conclusion: The results indicate that reticulocyte indices represents a measurement of eythropoietic activity and anemic state in CRF patients before treatment.
Key words: Reticulocyte, reticulocyte production index, red blood cells size factor, chronic renal failure, Beckman Coutler LH-780.
I. OAT V A N o f
Thieu mau la bieu hien rat thudng gap cua STM, xuat hien sdm va gay anh hudng khdng tdt len chat Iugng cugc sdng hau het cac benh nhan. [2]. Thieu mau trong STM thudng dang sac vdi the tich hdng cau binh thudng. Dac diem la giam sinh hdng cau, boat ddng tao mau d miic thap, cd lien quan den giam siit su kich thich tao mau cua erythropoietin. Kha nang tao mau cua tiiy
HOI NGHj KHOA HOC LAN THLf IV • HOI TIET NIEU • THAN HOC VIET NAM
xuong th8 hien thdng qua sd lugng te bao hong cau ludi (HCL) d mau ngoai vi va chi sd tao HCL (RPI).[6]
Chiing tdi nghien ciiu bien ddi HCL mau ngoai vi d benh nhan STM giai doan III, IV chua dieu tri nham muc tieu:
- Dac diim HCL mdu ngoai vi & BN STM giai doan III, IV chua diiu tri.
- Tim hieu mdi liin quan giiia HCL mdu ngoai vi v&i giai doan suy than, muc dp thiiu mdu & binh nhdn STM giai doan HI, IVchua diiu tri.
tl. 061 TUONG VA PHUONG PHAP NGHIEN COU 1. Doi tuong nghien cuu.
+ tieu chuan lira chgn: BN STM giai doan III, IV theo phan loai Nguyen Van Xang (1989), chua digu trj.
+ Tieu chuan loai trii: BN dang trong giai doan benh ly viem nhilm cap tinh, da truyen mau trong hai thang trudc khi lay mlu, mac benh he thdng.
2. Phirotig phap nghien cmi.
Thiit ki nghiin ciiu cdt ngang mo ta.
2.1. Hdi va kham benh theo mau benh an thdng nhit.
2.2. Cac xet nghiem can Iam: Sinh hoa mau, sieu am than, Xquang, ECG.... Miic loc cau than udc tinh theo cdng thiic Cockroft va Gauh(1976)
2.3. Xet nghiem cdng thiic mau va hong cau ludi
+ Xet nghiem cdng thiic mau va thong s6 hdng cau ludi. Cac thdng sd hdng cau luoi:
Sd Iugng, ty Ie %, the tich trung binh (MRV) va chi sd hdng cau ludi non (IRF)
+ Danh gia thilu mau (WHO 2003):
Thieu mau nhe khi 95 g/I<Hb < 130g/I d nam gidi (<120g/l 0 nii); trung binh:
80<Hb<95(g/I); nang: 70 < Hb < 80(g/l) va rdt nang:Hb < 70g/l.
+ Cac chi tieu tinh toan tii ket qua xet nghiem HCL:[10]
Chi sd tao hdng cau ludi: Reticulocyte production index (RPI) .cOO.n
[(% HCL X HCT ) ^ 0 , 4 5 ] ,,, .- , „ , ' -
RPI RMT Df-
Bang 2.1. He sd hieu chinh de tinh thdng Hematocrit (I/I)
0,30 - 0,45 0,35 - 0,39 0,25 - 0,34 0,15 - 0,24
<0,15
sd RPI theo hematocrit.
He so hieu chinh (RMT) 1
1.5 2 2.5
3
RPI <2: Giam tao hdng cdu tai tuy xuong. 2 < RPI < 3: Dap iing tao mau cua tuy xuong trong gidi han binh thudng. RPI>3: Tuy xucmg tang sinh hdng cau.
- YSu td kich thudc tk bao hdng cdu: Red blood cell size factor (RSf)
RSf = yliMCV xMRV (fl)
RSf < 91,1 fl: Cd tinh trang thidu sdt, tao mau kem hieu qua. RSf >91,1 fl: Khdng co tinh trang thieu sat.
m
3. Xu- ly so lieu Su dung phan m6m
Y HOC VIET NAM THANG 11 -
SPSS 17.0 dk tinh toan va xu ly
-..A^....rr,..AV
50 2/2010
sd lieu nghien ciiu.
III. KET QUA NGHIEN CUU
3.L Dac diem chung doi tugng nghien cmi.
Tuoi trung binh (nam) Gidi tinh
- Nam n(%) - Nii n(%)
Nhom benh nhan n=68 49,2 ± 15,2 ..12.(.61,8i ._
26 (38,2)
Nhom chu'ng n=34 45,6 ± 16,4
.22(64,7) 12(35,3)
P
>0,05
>0,05 3.2. Nguyen nhan va giai doan STM. Dac diem thieu mau nhom benh nhan nghien cihi Suy than giai doan Ilia chiSm 24/68 = 35,3% BN; giai doan Illb 26/68=38,2% BN; giai doan IV 18/68= 26,5% BN.
100% BN thi6u mau theo tieu chi cua WHO-2003; 23/68 = 33,8% BN thidu mau miic do nhe; 17/68 = 25% BN thidu mau miic do viia; 13/68 = 19,1%) BN thidu mau miic do nang va 15/68 = 22,1% BN thidu mau miic do rat nang.
r Co 8/68 = 11,8%) BN thidu mau nhugc sdc thd tich hong cdu nhd; 57/68= 83,8% bdnh nhan thidu mau dang sac thd tich hdng cau binh thudng va 3/68=4,4%) BN thidu mau ddng sdc the tich hdng cau Idm.
Bdng 3.1. Cac thdng Thong so huyet hoc
Hong cau (T/l) Hb (q/l) HCr (I/I) MCV(fl)
sd huydt hgc nhdm bdnh nhan va nhdm chiing Benh nhan (n=68)
{X±SD)
2,97 ± 0,71 84,94 ± 19,39
0,26 ± 0,06 89,98 ± 8,88
Nhom chu'ng (n=34)
{X±SD)
4,59 ± 0,36 144,76 ± 11,53
0,44 ± 0,03 95,16 ± 3,48
P
< 0,001
< 0,001
< 0,001
<0,05 Cac thdng sd huydt hgc nhdm bdnh nhan thap hon so vdi nhdm chiing (p < 0,05).
3.3. Cac thong so HCL nhom benh nhan va nhom chung.
Bdng 3.2. Cac thdng sd HCL nhdm bdnh nhan va nhdm chiing
Thong so hong cau lUdi
Benh nhan (n=68)
(X±SD)
Nhom chu'ng (n=34)
(X±SD)
HCL(T/I) 0,0795 ± 0,0464 0,0676 ± 0,0254 >0,05
% HCL(%) 2,69 ± 1,45 1,46 ± 0,51 < 0,001
RSf (fl) RPI
95,04 ± 8,83 0,8 ± 0,63
100,37 ± 4,4 <0,05
n
HOI NGHI KHOA HOC LAN T H Q IV • HQI TIET NIEU • THAN HOC VIET NAM
Ty Ie %HCL nhdm BN cao hon nhdm chiing (p < 0,001) va RSf nhdm BN thdp hon nhdm chiing (p < 0,05). Cd 66/68= 97,2% benh nhan cd chi sd RPI nhd hon 2.
Bdng 3.3. Bidn ddi RSf nhdm BN va nhdm c RSf
RSf < 91,lfl RSf > 91,Ifl
Benh nhan n
16 52
o/o 23,5 76,5
ning
Nhom chu'nq n
0 34
o/o 0 100
-> A « ) J p
< 0,01 Cd 23,5% BN STM cd RSf < 91,Ifl, sir khac biet cd y nghia thdng ke so vdi nhdm chiing (P<0,01).
Bdng 3.4. Tuong quan giiia cac thdng sd sd Iugng HCL mau ngoai vi vdi cac thdng s6 hinh +• Ul HCL nhdm bdnh nhan
Thong so hong cau lUdi
HCL(T/I) RPI
MRV (fl)
r -0,59 -0,46
P
< 0,001
< 0,001
IRF
r -0,03 -0,04
P
>0,05
>0,05
RSf
r -0,42 -0,24
P
< 0,001
>0,05
Sd lugng HCL tuong quan nghjch vdi MRV va vdi RSf ( p < 0,001). RPI tuong quan nghjch vdi MRV (p < 0,001). ,v h- Ai. ,;.„; ,; vn ,--.-\u VQ ,^c^
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: . : - " ,: MRV(n)
; r 5/#M <fo/. Tuong quan RPI vdi MRV
3.4. Lien quan giira bien doi thong so hong cau luoi vol giai doan suy than va muc do thieu mau.
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Bang 3.5 Lidn quan cac thdng sd HCL va giai doan suy
Thong so hong cau lUdi
HCL(T/I)
%HCL(%) RPI
than Giai doan suy than G.doan Ilia
(n=24) (X±SD) 0,0796 ± 0,0507
2,34 ± 1,39 0,68± 0,46
G.doan Illb (n= 26) (X+SD) 0,0851 ± 0,0492
2,89 ± 1,44 0,76 ± 0,52
G.doan IV (n=18) (X±SD) 0,0715 ± 0,0418
2,88 ± 1,52 0,55 ± 0,33
P
>0,05
>0,05
>0,05
Y HOC VIET NAM THANG 11 - 5 0 2/2010
MRV (fl) IRF RSf (fl)
102,15 ± 13,34 0,27 ± 0,05 94,84 ±10,14
98,20 ± 7,85 0,28 ± 0,06 93,87 ± 5,70
102,76 ± 15,94 0,3 ± 0,08 97,00 ± 10,68
>0,05
>0,05
>0,05
Khdng thay cd su khac biet cd y nghia thdng ke vd cac thdng sd HCL d cac nhdm bdnh nhan thudc cac giai doan suy than khac nhau.
Bdng 3.6. Lidn quan cac thdng sd HCL va miic do thidu mau
Thong so hong cau
ludi
HCL(T/I)
% HCL(%) RPI
* * . „ ^ r> AC
Mii'c dp thieu mau Nhe
(n=23) (X±SD)
0,0969±0,05*
2,57 ± 1,35 0,94 ± 0,53*
Vij'a (n=17) {X±SD)
0,0861 ± 0,051*
2,9 ± 1,63 0,73± 0,44*
Nang (n=13) (X±SD)
0,0603 ±0,031*
2,36 ± 1,37 0,45 ±0,25*
Rat nang (n=15) (X±SD)
0,0622
±0,0331*
2,95 ± 1,5 0,42 ± 0,23*
P ANOVA
<0,05
>0,05
< 0,001
Sd lugng HCL thap hon cd y nghia thdng kd trdn cac bdnh nhan thidu mau miic do nang va rat nang khi so sanh vdi cac bdnh nhan thidu mau miic do nhe va viia (p < 0,05). RPI giam di khi thidu mau nang Idn cd y nghia thdng kd vdi p < 0,001.
Bdng 3.7.
RSf
RSf < 91, Ifl RSf > 91,lfl
3idn ddi RSf lidn quan ddn miic Mii'c do t N
n 4 19
he
% 17,4 82,6
Vijra n 3 14
% 17,6 82,4
dd thidu I mau hieu mau
Nang n 4 9
o/o 30,8 69,2
Rat nang n
5 10
o/o 33,3 66,7
P
> 0 0 5
Ty Id bdnh nhan cd RSf thap tang ldn khi miic do thidu mau tang ldn. Song su khac bidt khdng cd y nghia thdng kd (p > 0,05).
Bdng 3.8. Tuong q Thong so
hong cau lUdi HCL(T/I)
% HCL(%) RPI
uan cac thdng sd HCL vdi cac thdng HC (Jl\)
r 0,34 -0,11 0,43
P
<0,01
>0,05
< 0,001
; sd huydt he Hb(g/I)
r 0,34 -0,07 0,52
P
< 0,005
>0,05
< 0,001
)C
HCT(I/I) r
0,34 -0,08
P
< 0,005
>0,05
HCL va RPI cd tuong quan thuan miic do vua ddn chat che vdi HC va Hb (p < 0,001).
HCT cd tuong quan thuan miic do viia vdi HCL (p < 0,005).
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1
HOI NGHj KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM
RPi.oot:«H>-ojse f .0.S2p<O,O0l
Hb m
Biiu do 3. Tuomg quan RPI vdi Hb mau
IV. BAN LUAN
Thidu mau la bidn chiing rat thudng gap trdn bdnh nhan suy than man tinh, thidu mau cd lidn quan ddn cac bidn chiing tim mach, anh hudng ddn chat lugng cugc sdng, boat ddng the Iuc va nhan thiic cua bdnh nhan, trdn cac bdnh nhan suy than giai doan IV thidu mau nang lam tang nguy co bdnh tat va tli vong. Nguydn nhan chu ydu la thidu hut erythropoietin do cac tdn thuong bdnh ly tai than.[5] - ' . •
Kdt qua nghidn ciiu cho thay 100%) bdnh nhan STM giai doan III, IV trong nghidn ciiu nay cd thidu mau trong dd thidu mau miic do nhe ~ vua la chu ydu chidm 58,8%) bdnh nhan. Ket qua nay phu hgp vdi cac nghidn ciiu vd thidu mau trong suy than man tinh, cac dii lieu tir NHANES TV va KEEP 2007. [2]
83,8%) bdnh nhan thidu mau dang sac thd tich hdng cau binh thudng, phan anh thidu mau do STM la thidu mau giam san ddng hdng cau. Tuy nhidn cd 11,8% thidu mau nhugc sac hdng cau nhd, chiing td tinh trang thidu sat. Day la didm dang luu y, vi thidu sdt tuyet ddi hay tuong ddi trong STM ddu cd y nghia tidn lugng xau.[3]
Sd lugng HCL cac BN STM khdng cd su khac bidt so vdi nhdm^ chiing; 97,2%) BN cd thdng sd RPI thdp dudi 2 chiing td tinh trang lie chd manh rae tiiy xuong dan den giam
sinh ddng hdng cau, phan anh thuc td ngugc vdi cac quy luat vd thidu mau trdn cac d6i tugng BN khac, khi thidu mau xay ra c6 hien tugng tang sinh hdng cau dd bu ddp cho lugng hdng cau mat di. Nguyen Thd Tiing (2009) nhan thay ngudi bidn mau tinh nguydn cd hien tugng tang sinh HCL dap ling vdi tinh trang mat mau.[l],[4]
RSf cua nhdm BN thap hon cd y nghTa thdng kd so vdi nhdm chiing, do tinh trang giam thd tich cua ddng thdi hdng cau va hong cau ludi vi cd 11,2 % bdnh nhan thidu mau nhugc sac, song ty Id RSf thap chidm toi 23,5%) bdnh nhan. Theo Urrechaga E. khi RSf giam thdp hon 91 ,lfl phan anh tinh trang thidu sat va tao mau kem hieu qua. Kdt qua nay cho thay bdn canh tinh trang giam san ddng hdng cau phan anh thdng qua sd lugng HCL mau ngoai vi khdng khac bidt so voi nhdm chiing cdn cd tinh trang giam vd chat lugng ciia cac td bao HCL va hdng cau a mau ngoai vi, tinh trang thidu sat tdn tai ngay ca khi MCV cua hdng cau chua giam thap.
Didu dd cho phep nghT ddn nhiing co che bdnh sinh khac gdp phdn lam nang nd hon tinh trang thieu mau trdn BN STM, trong do thidu sdt la ydu td quan trgng. Cac nghien ciiu khac ciing thay tinh trang thidu sdt tren BN STM dan ddn giam lugng Hb trong HCL,
Y HOC VIET NAM THANG 11 - SO 2/2010
tang cac hdng cau nhugc sac d mau ngoai vi va rdi loan HCL bdnh ly.[6]
> Cd tuong quan nghjch cd y nghTa thdng ke miic do vira ddn chat che giua sd lugng HCL cung nhu gia trj RPI vdi MRV va RSf, do vay khi tiiy xuong tang sinh HCL, tang RPI thi MRV va RSf giam di. Su bidn ddi dd CO lien quan ddn tinh trang chuydn hda sat thanh nhan Hem trong qua trinh bidt hda td bao hdng cau. Theo Urrechaga E. (2010) chi so RSf danh gia ddng thdi tinh trang thidu sat d td bao hdng cau cQng nhu danh gia tinh trang thidu sat xay ra sdm trong vdng 3 ngay trudc. Didu dd cd y nghia quan trgng, thidu sdt ddn ddn giam chat Iugng td bao HC mau ngoai vi, bu sat khdng diing se gay thira sat tren bdnh nhan. [6] . i " - ^ '•..• -(!.'"•• Nn:
Chiing tdi khdng thay sir khac bidt cd y nghTa thdng kd vd cac thdng sd HCL trong mdi lidn quan ddn giai doan STM, cd thd do trong STM thidu mau xuat hien sdm va miic do thidu mau khdng chi phu thudc vao giai doan suy than. Su dap iing tang sinh HCl vdi thidu mau trdn cac bdnh nhan STM la khdng thoa dang, thd hien d sd lugng HCL khdng khac bidt so vdi nhdm chiing. Cd le su lic chd tuy xuong xay ra ngay d giai doan Illa cua STM va duy tri lidn tuc ddn giai doan IV, the hien bang su khdng khac bidt vd cac thong sd HCL d cac giai doan suy than khac nhau. [4]
Cd su khac biet cd y nghTa thdng kd vd so lugng HCLlien quan ddn miic do thidu mau. HCL va RPI giam khi thidu mau nang len (p < 0,05). Didu dd cho thay trdn cac bdnh nhan cd miic do thidu mau nang va rdt nang tinh trang lie chd tiiy xuong nang nd hon, khdng phu thudc bdnh nhan d giai doan suy than nao. Tuy nhidn thidu mau nang xudt hien nhidu hon theo su tidn tridn cua suy than, do vay su lic chd tuy xuong dan den
giam sinh hdng cau nang hom khi suy than nang hon. [4]
Ty Id bdnh nhan cd RSf thdp tang ldn khi thidu mau nang hon, xu hudng dien bidn dd cho thay thidu mau nang d bdnh nhan STM ludn kem theo tinh trang thidu sdt, cd Ie do tinh trang mat mau qua dudng tidu hda keo dai, rdi loan dinh dudng va tinh trang vidm man tinh trdn bdnh canh STM.
Cac nhan djnh trdn day mdt ldn nua dugc nhan manh khi xem xet mdi tuomg quan thuan giira HCL, RPI vdi Hb cung nhu HCT va sd Iugng HC. Thidu mau nang hon cd sd Iugng HCL va PRI thdp hom. Mdi quan he nay cho thay cd thd sii dung cac thdng sd HCL trdn Iam sang, sd Iugng HCL va RPI dd danh gia thidu mau ciing nhu tinh trang giam sinh hdng cau cua tuy xuong do bj iic chd trdn cac bdnh nhan STM chua didu trj, chi sd RSf gdp phan chan doan sdm tinh trang thidu sat trdn bdnh nhan. [6]
V. KlTLUAN
S.L Bien doi hong cau Iiroi mau ngoai vi benh nhan suy than man giai doan HI, IV chua dieu tri
- Sd Iugng HCL BN STM chua didu trj la 0,0795 ± 0,0464 (T/I) khdng cd su khac bidt so vdi nhdm chiing 0,0676 ± 0,0254 (T/l) ( p > 0,05).
- Khdng cd su khac bidt giiia MRV, IRF nhdm BN va nhdm chiing.
- RSf nhdm BN la 95,04 ± 8,83 (fl) thdp hom cd y nghia thdng kd so vdi nhdm chiing 100,37 ± 4,4(fl) vdi p < 0,05. Cd 23,5% BN cdRSfthdphon91,lfl.
- RPI bdnh nhan la 0,8 ± 0,63. Cd 97,2%
bdnh nhan cd chi sd RPI nhd hom 2.
- Sd lugng HCL tuomg quan nghjch vdi MRV (r =-0,59; p <0,001) va tuong quan nghjch vdi RSf (r =-0,42; p <0,001). RPI
HOI NGHj KHOA HOC LAN THLf IV • HQI TIET NIEU - THAN HOC VIET NAM
tuong quan nghjch vdi MRV (r =-0,46; 2.
p<0,001)
5.2. Lien quan bien doi hong cau ludi mau ngoai vi vol giai doan suy than, muc do thieu mau
- Khong thay mdi lien quan co y nghia thong ke vd bien ddi HCL mau ngoai vi vdi 3.
giai doan suy than. , . ' ' • - S6 lugng HCL va RPI giam di khi thidu mau nang ldn (p < 0,05).
- Ty le benh nhan cd RSf thap tang len
khi thieu mau nang len (p > 0,05). 4.
- So lugng HCL cd tuong quan thuan vdi HC (r = 0,34; p < 0,001); vdi Hb (r = 0,34; p
< 0,005) va vdi HCT (r = 0,34; p < 0,005).
RPI cd tuong quan thuan vdi HC ( r = 0,43; 5.
p< 0,001) va Hb ( r= 0,52; p < 0,001) TAI LIEU THAM KHAO
I. Nguyen The Tung (2009). Nghien ciiu cac 6.
chi so huyet hgc va an toan truyen mau d nguai hien mau chuyen nghiep va ngudi hien mau tinh nguyen tai benh vien 103. Ludn vdn thgc syy hoc. Hoc vien qudn y 2009. 52-57.
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Urrechaga E (2010). The new mature red cell parameter , low haemoglobin density of the Beckman-Counter LH750 : clinical utility in the diagnosis of iron deficiency.
International Joural of laboratory hematology 2010:144-150.
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