TCNCYH Phu truung 79 (2) - 2012
TINH TRANG DINH DUaNG COA BENH NHAN SUY THAN MAN
T I N H CO LOG MAU CHU KV B A N G C H I S O BMI, SGA VA
ALBUMIN HUY^T THANH
I/O Thi Thanh', Tran Thj Phuc Nguyit' 'Binh viin Bpch Mai, 'Truirng Dpi hpc YHi Nil Binh gii tinh trpng dmh dudng ciia binh nhin suy thin mpn tlnh cd ipc miu chu ky tpi khoa thin nhin tpo binh viin Bpch Mai Kit qui eho thiy tlnh trpng dmh dudng ciia tiinh nhin suy thin man tinh - Ipe miu chu kf theo BMI. Tl li thiiu ning lupng trudng diin (BMI < 18.5) li 37,3%, tl ii binh nhin na cao ban binh nhin nam (p < 0,05). Theo chl si SGA' Nguy ea suy dmh dud'ng mue dp ning (mire C) li 18%, nguy ca suy dinh duOng mite di nhp (mire B) li 44%. Tf ii bpnh nhin cd ning dp albumin huyil thanh thip (< 35 g/i) li 13.4%. cd 6% si tiinh nhin bl thiiu kit hap ci albumin huyit thanh vi BMI thip (BMI < 18,5 vi Albumin < 35 g/l). Tu dd cd thi kit luin, d binh nhin suy thin man tlnh ipe miu ehu kf vua ed tinh trang thiiu ning lupng tnrdng diin, vua thiiu d protein vi ning lupng
TIP khod: tinh tr^ng dinh du>&ng, suy thSn man tinh, I9C mau c6 chu ky I. DAT V A N Bt
Cl Vi$t Nam ngay cang co nhieu benh nhan suy than man tinh du-gc di^u tn bang iQC mau chu ky, hien nay 06 l<hoang hen 2.000 b^nh nhan dang du-o'c ipc mau tai cac trung tam th|n nhan tao tren ca nu-crc [1]
PhSn iim b$nh nhan deu du-gc c h i n doan a giai doan mupn va bat dau Ipc mau vi/i tinh trang dinh du-ang kem do hoi chu-ng ure mau cao, kem theo mpt ch^ dp an kieng dam kep dai tru-o-c do Nhu-ng bi^n chu-ng lau dai nhu-:
tang huyet ap khong kiem soat du-gc, bi4n chii-ng tim mpch, ho hllp, thieu mau, loang xu-gng...va d?c biet bi^n chirng suy dinh du-gng la ph6 bi^n hon ca. Theo nghien cii-u cua Mitch WE nam 2002 cong b6 kM qua nghiSn cCru t?i My cc tgi 50% sp bpnh nhan Ipc mau chu ky co nhu-ng dau hieu, hpi chii-ng lam sang, bi^u hien cua suy dinh du-gng [2].
Da sc benh nhan dang Ipc mau chu ky co hoan canh kinh te kho khan cCing vo-i su- hieu bik ve dinh du-o-ng con han che, nen ph^n 16-n benh nhan chl tap trung vao Ipc mau ma it chli y den ch^ d6 dinh du-gng ciia minh mpt c^ch phu hgp. Nghien cii-u tpan dien ve tinh
trang dinh du-gng ciia benh nhan suy than mgn tinh - Ipc mau chu ky, bac cao nay vgi muc tieu: Banh gia linh trang dinh duong cua binh nhan suy than man tinh - loc mau chu ky tpi khoa thpn niian lao benh vien Bach Mai. Trin co so do dua ra khuyen thich hop eho viic dieu chinh che do an ciia benh nhin.
11. B 6 | TU-aNG VA P H U O N G PHAP 1. Odi tu-ang ngtiien cu-u
Bpnh nhan suy than man tinh giai doan cuoi dang tpc mau chu ky tai l<hoa than nhan tao Bpnh vien Bpch Mai. Loai tru' benh nhan chin thu-ong, phlu thuat, liet
2. Phu-gng phap nghien cii-u 2.1 Thiit ke: Nghien a>u CSLI-CTC thiet ki la nghien cii-u mc ta c l t ngang Ti§n hanh ti>
thang 1/2011 d^n thang 6/ 2011 tai khoa Than nhan tap B$nh vien Bach Mai
2.2 Co mau: Thep cong thuc tinh co mlu ciia nghien cii-u mp ta c i t ngang
n = Zf pq d- 252
Trong di:
n: la tong so benh nhan c i n dieu tra, d: la sai so cho phep (0,05).
p: ty le benh nhan suy than mpn tinh - Ipc mau chu ky bj thilu protein va nang lu-gng dira vao nghien cu-ii tru-gc d6 la 0,10 % [3]. Tinh theo cong thu-c va lam tren la 150 benh nhan.
23. Cic lieu chi dinh gli tlnh trpng dinh duang
- Phuong phip nhin trie. Di,i-a vap chf s6 khoi eg the (BMI). Thilu dinh du-gng khi BMI
< 18,5, binh thu-gngiBMI 18,5- 24,9, thira can va beo phi: BMI a 25,0.
Phuung phap danh gia ting thi doi tupng cua Desky: Du-a vao chi so SGA bao g i m nhu-ng thay doi ve can nang, bilu hien ciia tinh trang dinh du-gng kem, nhti-ng danh gia v l lam sang ...[4]: Mire A (khong co nguy eg suy dinh du-o-ng); Mu-c B (nguy eg suy dinh du-6ng mu-c dp nhe); Mire C (nguy eg suy dinh du-ftng mire dp nang).
- Di/a vao chi s6 Albumin huylt thanh:
Tinh trang suy dinh du-gng do thilu protein nang lu-gng khi Albumin huylt thanh < 35 g/l.
3. Xu- ly s6 lieu: S l lieu dirge xu- ly tren SPSS16 0, EXCELL v6-i eae test thong ke y hgc
III. KfiT QUA
1. Tinh trang dinh du>gng cua benh nhan suy than man tlnh - loc mau chu ky Bang 1. Tinh trang dinh du>6-ng cua benh nhan theo chi sd khdi co- t h i (BMI)
Chi sd BMI Binh thu-o-ng (BMI 18,5 - 24,9) Thilu dinh du-gng (BMI < 18,5) Thira can va beo phi (BMI > 25)
Ting s l 'p<0,05(test/).
Bang 2. Danh gia nguy co
theo chi sd SGA Khong cc nguy eg SDD Nguy eg SDD mire dp nhe Nguy cg SDD mire dp nang.
Ting s6
n , 35 30 7 72
h i 53 17 2 72
suy Nam
%
73,6 23,6 2,8 48,0
n2 36 39 3 78
NO-
%
46,2' 50,0' 3,8 52,0
dinh du-d-ng bang chi sd Nam
%
48,6 41,7 9,7 100,0
Nir n2 22 36 20 78
%
28,2 46,2 25,6*
100,0
Tdnj n 89 56 5 150
SGA Tdng n 57 66 27 150
1 sd
%
59,4 37,3 3,3 100
sd
%
38,0 44,0 18,0 100 'P<0,05
TCNCYH Phu tnmng 79 (2) - 2012
Bang 1 ehi ra co 56 benh nhSn chilm 37,3% benh nhan bj thilu dinh du&ng, trcng do nir gioi la 50,0%, nhilu hgn cc y nghla (p < 0,05) so vo-i nam gidi 23,6%. Miro BMI trong gid-i hpn binh thu-gng cd 59,4%, nu- gigi cd chi s6 BMI trong gigi hpn binh thu-gng la 46,2%, t h i p hon eo y nghTa (p < 0,05) sp voi nam gigi 73,6%. Bpnh nhSn thira cSn va bee phi chilm 3,3%.
K i t qua nghien eiru tren 150 b^nh nhan chp thiy mire albumin huylt thanh thap (< 35g/l) ec 20 bSnh nhan chilm 13,4%, mire albumin huylt thanh a 35 g/l cd 130 benh nhan chilm chiem 86,6%.
Bang 2 eho thiy eo 57 b§nh nhSn chilm 38% khdng ed nguy eg suy dinh du-dng. Nguy eg suy dinh dudng mire dp nhe ed 66 b^nh nhSn chilm 44%. Nguy eg suy dinh du-dng mire dp npng \i 27 b^nh nhSn chilm 18%, cd su khSc biet ed y nghTa v l nguy eg suy dinh du-gng mire dp npng cup npm vi nir (p < 0,05)
2. M6I lien quan glu-a cac chi sd BIVII, Albumin huylt thanh va SGA Bang 3. S^p phan bd mu-c Albumin huylt thanh va BMI cua benh nhan
BMI
Mu-c albumin (g/l) <18,5 1 8 , 5 - 2 4 , 9 >25 n (%) n (%) n (%)
< 3 5 9 (5,0) 10 (6,7) 0 (0,0)
£ 3 5 48(32) 78(52,0) 5 (3,3) Bang 3 cho t h i y cd 9 benh nhan chilm 6,0% so benh nhan bj thilu k i t hop ca Albumin va BMI mire thap, cd 10 benh nhan cd mire albumin huylt thanh <35g/l nhu-ng BMI binh thu-gng chilm 6,7%, ed 48 benh nhan cc mire albumin huylt thanh £ 35 g/i nhu-ng BMI < 18,5 chilm 32%, cd 78 benh nhan co mire albumin huylt thanh > 35 g/l va BMI trong gidi han binh thu-ong chilm 52%, ed 5 benh nhan mire albumin huylt thanh > 35 g/l va BMI s 25 chilm 3,3%. Khcng ce su- phli hgp ed y nghTa.
Bang 4 .Su- phdi hgp glu-a chi sd SGA va chi sd BMI
Ngu-o-ng danh gia t i n g t h i ddi tu-o-ng (SGA) < 18,5 n (%)
Khdng ce nguy eg SDD (Mire A) 7(4,7) Nguy eg SDD nhp (Mire B) 26(17,3) Nguy eg SDD nang (Mire C) 26 (17,3)*
Tong 59 Chi sd BMI
1 8 , 5 - 2 4 , 9 n (%) 45 (30,0) 37 (24,6) 1 (0,7)
83
>25 n (%) 5 (3,4) 3 (2,0) 0 (0,0) 8(100,0)
*p<0,05.
Bang 4 chi ra ring co 26 benh nhan co nguy cc suy dinh du'O'ng nang k^t hp'p vai BMI <
18,5 chi^m 17,3%, nguy co suy dmh du&ng muc do nang co lien quan vol BMI thap co y nghTa (test x^ ; p < 0,05), CO 26 benh nhan co nguy cc suy dinh du'O'ng nhe k§t v&\ BMI < 18,5 chi^m 17,3%, khong co nguy ca suy dinh du&ng k§t hop v&i BMI < 18,5 la 7 benh nhan chiem 4,7%, nguy co' suy dinh du&ng miPC do nang ket hap vai BMI trong giai han binh thuang co 1 benh
254 -- - .
nhan chi^m 0,7%, nguy ca suy dmh du&ng (TiLPC dp nhe ket hpp v&i BMI trong giai han binh thu&ng co 37 benh nhan chi4m 24,6%, khong c6 nguy ca suy dinh du&ng k§t hap vdi BMI trong gi&i h^n binh thu&ng co 45 benh nhan chiem 30,0%, nguy ca suy dmh du'dng muc do nh? k^t hap v&i BMI £ 25 co 3 benh nhan chi^m 2,0%, khong co nguy ca suy dinh duang k i t hap v&i BMI > 25 co 5 benh nhan chiem 3,4%
IV. BAN LUAN
Tinh trang dinh du'd'ng benh nhan suy than man tinh Ipc mau co chu ky
Nghien cuu cua chiing toi chf ra rang co 37,3% benh nhan co cht so BMI & muc thap
<18,5, tl le nay th^p han Nguyin Thj Van Anh nam 2008 la 41 %> [5] va tuang tir nhu nghien cuu cua Nguyin Thj Thu Ha nam 2005 la 38,7% [3, 5]. BMI thap di6u do chucng to la giam ca khdi ca va khdi ma ca th§, trong nghien CLFU nay chung toi chu'a co diiu kien 6h danh gia khdi m& ca the Tf le benh nhan thua can beo phi cung chu-ng to co v l n d§ v§ sue khde. Hien nay nu'ac ta mot bo phsin xa hoi thuang tap trung & cac thanh pho Ion diiu kien kinh te kha gia, an u6ng a§y du va du' thCra cac chit dmh du-ang lam cho tl le thua can, beo phi tang len, gay nguy CO cao mac nhi>ng benh man tinh khong lay nhu- dai thao du'ang, roi loan ma mau, tang huyit ap ngu'ac lai nh&ng ngu-ai sing a nong thon, miin nui lai bj suy dinh du'ang, hay mac cac benh nhiim trung. Trong nghien CLPU cua chung toi co 3,3% b?nh nhan co BMI d muc tiin beo phi, ti le nay thip han ti '? trong nghien cuu cua Nguyin Thj Thu Ha nam 2005 la 14% [3].
Nghien CLKU cua Lowrie & Lew nam 1990 tren 12.000 benh nhan suy th^n man tinh loc mau chu kjf tai My cho thay nguy ca tu vong
tang gap 20 lin a nhom benh nhan co nong do albumin huyet thanh < 2,5 g/dL [6]
Phuang phap danh gia tong the doi tuang (SGA) hien nay duo-c nhiiu nghien cu-u tren t h i giai su dung de danh gia tinh trang dinh duang cua benh nhan suy than man tinh - Ipc mau chu ky Uu diem cua phuang phap nay la co the danh gia benh nhan trong suit qua trinh mac benh bao gom nhu-ng thay doi v i can nang, biiu hien cua tinh trang dinh du-&ng kem, nhu-ng danh gia v i lam sang cua thiy thuic. Theo phuang phap danh gia tong t h i doi tu-ang (SGA) tren benh nhan suy than man tinh loc mau co chu ky, kit qua nghien cu-u nay cho thay nguy ca suy dinh duong muc dp nhe co 44%), nguy ca suy dinh du&ng muc do nang la 18%.. Kit qua nghien cuu nay cho thiy mu-c do suy dmh du-&ng nhe thip han cua Nguyin Thi Van Anh nam 2008 la 77% nhung suy dinh duang a muc dp nang cao han la 3%> [5]. Kit qua nghien cuu nay thip han Tsai HJ va CS nam 2010 tai Dai loan [7] nguy ca suy dinh duang muc dp nhe la 51%), nhung nguy ca suy dinh du&ng muc do nang cao han ia 1%i & benh nhan chay than nhan tao, va thip han Shruti Tapiawala
& CS nam 2006 co 53,1%. benh nhan bj suy dmh duang muc dp nhe [8]
Moi lien quan gitpa cac chi sd BMI, Albumin huyit thanh va SGA
Albumin la protein hinh cau c6 tinh hoa tan cao (TLPT 69000) albumin duac phan b i &
djch ngoai bao va tren 60%) nam trong khu vuc ngoai mach. Albumin co chu ky tuin hoan la 15 - 20 ngay, 95%) albumin do gan san xuit, khi chuc nang gan giam, albumin giam, nuac khong duac giu lai a trong long mach ma vao khoang gian bao gay ra hien tuang phu (phu dinh duang). Albumin cua huyit thanh tham gia hai chLfc nang chinh la duy tri ap luc thim thiu keo trong huyit tuang chiim 70 - 80%
TCNCYH Phu tnmng 79 (2) - 2012 vi lidn k i t v$n chuyin cae ehlt cd trpng lu-gng phSn tip nhd nhu-: bilirubin, hormon sterpid, acid bep, va eSc thulc ec trpng mau.
Mpc du nlng dd albumin huylt thanh bi anh hggng boi mpt s6 y l u t l nhu-: tinh trpng viem, tinh trpng tSng d| hda trpng Ipc mau, mit acid amin qua dich ipc nhu-ng nd v l n Id m|t chi s6 thu-gng diing nhlt d l dSnh gia tinh trpng dinh du-e-ng. Thep nhilu tdc gia, albumin huylt thanh Id m^t chi s l rlt ed gid trj trpng tidn Iggng tinh trang b#nh.
Nlng d | albumin huylt thanh Id mpt chi s l thu-dng diing d l ddnh gid tinh trpng dinh du-dng eua b0nh nhdn trcng bpnh vi$n. Trpng nghiSn ciru eua chiing tdi 13,4% b$nh nhdn ec nlng d0 albumin huylt thanh < 35 g/l, k i t qua ndy thip hon Nguyin Thj Vdn Anh nam 2008 Id 32,3% [5], ciia Nguyin Thj Thu Hd nam 2005 Id 27% [3], ciia Le Thi Thu Trang vd CS nam 2007 [9] Id 61,31%, vd ede nghien ciru khdc tren t h i gidi nhu- Ikizler vd CS nam 2000 cdng bo k i t qua nghien ciru tpi My: 22% s l benh nhdn cd albumin huylt thanh < 35 g/l, 53% g mu-c tir 35 - 39 g/l.
Nghien cii-u ndy ccn k i t ludn rdng: Nhdm bpnh nhdn ce nlng dp albumin huylt thanh <
35g/l ed ti ip tu- vpng trpng bSnh vipn cap hgn 10% SP vdi nhdm cd nlng dp albumin huylt thpnh > 35 g/l. Khdng cc sy- hen quan ce y nghTp thing ke giUa nlng dp albumin huylt thanh vd mire BMI (p > 0,05). Cd 6% bpnh nhdn VU-P cd nlng dp albumin huylt thpnh thip (< 35 g/l) vira ce BMI t h i p (< 18,5) [10].
Thep nghiSn eiru ciia chiing tdi lien qupn giu-a BMI vgi albumin huylt thanh chga thiy rd mli lien quan ndy, co t h i dp s l bpnh nhdn trong nghien ciru nay chu-p du Idn. Trcng lu-gng lai, theo doi m l i tu-ong quan giti-a BMI, nlng dp albumin huylt thanh vgi tiSn lu-gng song sdt cua bpnh nhdn tpi Viet Nam cung Id mpt vln d l can du-gc tiln hdnh.
V. K t T LUAN
Tinh trpng dinh du-dng cup bpnh nhan suy thpn mpn tinh - Ipe mdu ehu ky:
Ti lp thilu npng lu-gng tru-gng diln (BMI
< 18,5) Id 37,3%, ti Id bSnh nhdn nu- cpc hon bdnh nhdn nam (p < 0,05).
- Thee phu-gng phdp danh gid t i n g t h i d l i tu-gng (SGA):
Nguy eo suy dinh du-ong mire d | ndng (mire C) Id 18%, nguy eg suy dinh du-gng mire dp nhp (mire B) Id 44%.
M l i lidn quan giu-a cdc chi s l BMI, Albumin huylt thanh vd SGA:
Ty Id bSnh nhdn cd n l n g dp albumin huylt thanh t h i p (< 35 g/l) Id 13,4%. cc 6%
s l bSnh nhdn bj thilu k i t hgp ca pibumin huylt thpnh vd BMI t h i p (BMI < 18,5 vd Albumin < 35 g/l).
TAI LIEU THAM K H A O 1. Trdn Van Chit, Nguyin Nguyen Khdi (2004). Cdc phu-gng phdp Ipc mdu hipn tpi vd tu-gng lai, Bpnh thpn ndi khpa, NXB Y hpc. Ha Npi, (10): 205-217.
2. Mitch WE (2002). Malnutritipn: a fre- quent misdiagnpsis fpr hemodialysis patient, J Clin Invest, 110 (63): 437-439.
3. Nguyin Thi Thu Hd (2005). Bu-dc dlu ddnh gia tinh trpng dinh dirgng g benh nhdn lpc mdu chu ky", Lupn van t i t nghiep chuyen khca 2. Tru-dng dai hpc Y Ha Npi, (14) 1 - 26;
5 - 2 2 .
4. Detsky AS, Wesson DE, et al (1982).
Nutritipnal assessment: Acpmparispn of clinical judgement and objective measurements. N Engl JMed; 306 (42): 969 - 72.
5. Nguyin Thj Van Anh (2008). Tlnh trpng dinh du-dng cua benh nhdn suy than mpn tinh
256
CO Ipe mau chu ky va mdt so yeu t l lien quan Iji BVBM. Ludn van tit nghiep cir nhdn YTCC, (1):32-33.
6. Lowrie E, Lew N (1990). Death risk in tiemodialysis patients: the predictive value pf commonly measured variables and an evalua- tion of death rate diffirenees between facili- ties. Am J Kidney Dis, 15 (59). 458 - 482.
7. Tsai HJ, Tsal AC, Hung SY, Chang MY (2010). Comparing the predictive ability of population-specific Mini-Nutritional Assess- ment with Subjective Global Assessment for Taiwanese patients with hemodialysis A cross-sectional study. (70): 900 - 920.
8. Shruti Tapiawala, et al (2006). Subjec- tive Global Assessment of Nutritional Status of Patients with Chronic Renal Insufficiency and End Stage Renal Disease on Dialysis.
Original Article. (69): 923 - 926.
9. Le Thj Thu Trang, D l Gia Tuyin, Oinh Thj Kim Dung (2008). NghiSn eiru nlng dp albumin mau vd mli tugng quan vdi mpt so y l u to nguy eg bpnh ly tim mach d bpnh nhan suy than man tinh Y hpc Idm sdng - benh vien Bach Mai, (28): 25 - 30.
10. Ikizler TA, HImmelfarb J (2000).
Nutritional complicaticn in chronic Hemcdiaiysis and peritoneal dialysis patients,Compl Dialysis. (46): 405 - 425 Summary
ASSESSMENTS NUTRITIONAL STATUS OF PATIENTS WITH CHRONIC RENAL FAILURE WITH DIALYSIS BY BMI, SGA AND SERUM ALBUMIN INDEX The study was to evaluate nutritional status of patients with chrcnic renal failure with dialysis in Bach Mai hcspital. The results shewed that nutntional status of patients with chronic renal failure with dialysis according to BMI: Percentage of energy defcieney (BMI < 18.5) was 37 3%, higher propcrtipn pf female patients than male patients (p < 0.05). Acccrding tp SGA index: The risk of malnutritipn severity (level C) was 18%, the risk of mild malnutrition (level B) is 44%.
There are 13.4% pf patients with lew serum albumin ccncentrations (< 35 g/l), 6% pf patients with a combinatipn pf lack of serum albumin and low BMI (BMI < 18.5 and Albumin < 35 g li). In conclusion. In patients with chrcnic renal failure on dialysis cycle is just lack of energy in place, just missing bpth prptein and energy.
Keywords: nutritional status, chronic renal failure, dialysis
