Nghien cuu Y hot Y Hoc TP. Hb Chi Minh * Tap 18 * Phy ban ciia So 4 * 2014
SO SANH HIEU QUA LOC CHAT CO PHAN TU" L U O N G TRUNG BINH G I C A PHU'ONG PHAP LOC MAU HDF ONLINE VA HD TREN BENH NHAN SUY THAN MAN LOC MAU DINH KY
Truang Hoang Khdi, Nguyen Minh Tuan * TOMTAT
M^ Hiu: Ddnh gid hiiu qud loc didi co phdn tie lugng tning binh giiia phuong pMp Igc mdu HDF online so vdi loc mdu thdng thudng HD d bmh nlidn suy than mqn dang loc mdu dinh ky.
Doi tugng: Binh nhan suy than mqn giai doqn aioi loc mdu dinh ky tqi khoa Than nhan tqo bmh znen Qig Rdy.
Phucmgphdp: Tien deu, mo td, cdt ngang.
Kei qud: Tie tMng 6/2012 din thdng 2/2013, nghiin cuu gom 36 benh nhan suy than mqn giai doan cuoi dang Igc mdu vdi Mi phuang thuc HD vd HDF online oxn ke. Trong phucmg thiic HD, PTH vd ^i - microglobulin (§2-m) mdu sau loc gidm ro rit so vai tnedc loc vdi ty ligidm tan lugt Id 44,52% vd 43,77%. Trong phuong thiec HDF online, PTH vd pi-m sau loc mdu gidm ro ret so vdi trudc Igc vdi ty le gidm lan lugt Id 46,17% vd 71,56%. Khi so sdnh, HDF online cd hieu qud inegt tioi han HD tiong loc ^-m v&i ty ligidm fii-m lan lugt la 71,56% so vdi 43.77% (pO.05).
Kei luqn: Phuang thiec loc mdu HDF online Idm gidm ^i-miavglobulin nhieu hon so vdi phuong thiec Igc mdu HD.CJti dinh loc mdu HDF online nin dugc khuyai cdo cho benh ididn da loc mdu thoi gian ddi, co trieu chiing lien quan dm su tich tu chai co trgng lugngpMn tie tiung binh tucmg tu^- microglobulin dendng cao chdi lugng soiig cho benh nMn.
Tit khoa: loc mdu tMm tddi sieu Igc bu didi tnec tiep, loc mau chu ky, mang loc hiiu qud cao, suy than man giai doqn cuoi, chat co pMn tie lugng trung binh, PTH, pi - microglobulin.
ABSTRACT
A COMPARISON OF ON-LINE HEMODIAFILTRATION AND HEMODIALYSIS IN MEDIUM MOLECULAR WEIGHT SOLUTES REMOVAL IN CHRONIC HDNEY FAILURE PATIENTS ON HEMODL^LYSIS
Tniong Hoang Khai, Nguyen Minh Tuan
* Y Hoc TP. Ho Chi Minh ' Vol. 18 - Supplement of No 4- 2014:178 - 182 Obfactives: To evaluate the capacity of medium molecular wdght solutes removal of on-line Mmodiafiltiation (OL HDF) and standard hemodialysis (HD) in chronic kidney failure patiaits on hemodialysis.
Patients: aid stage raial disease (ESRD) patiaits on chronic HD at Hemodialysis Departmait of Clvj Ray Hospital.
Method: Cross sectional, prospective study.
Results: From June 2012 to February 2013, tM study mrolled 36 ESRD patiaits on chronic HD with 2 methods standard HD and OL-HDF alternately. In the HD mdhod, PTH and ^ - microglobulinemia (^-m) after tM dialysis significantly deavased with the rate of 44,52% and 43.77% respedivdy. In the OL-HD method.
* Khoa Thin Nhan Tao, Benh vien Cho Ray, TP Ho Chi Minh
Tdc gin lien lac. BS CKII N'guyin Mmh Tuan, DT: 0903733211, Email: minhtuan2066(g'vahQo .COTTI . vn 178 Chuyen De Than Ni^u
Y Hoc TP. Ho Chi Minh * Tap 18 * Phu ban cua So 4 * 2014 Nghien ciru Y hoc
PTH and ^i - microglobtdinemia (p2-m) after the dialysis significantly decreased with tM rate gf 46,17% and 71.56% respectively. The comparison betzoeai these 2 methods shoioed the superiority of OL-HDF in ^m removal (decrease rate 71.56% vs 43,77%. p<0.05).
Conclusions: OL-HDF removes ^m more efficimtly tlian standard HD. OL-HDF sMuld be indicated to patiaits on HDfdr a Img time, zoith symptoms of medium molecular wdght solutes acaimulation sudi as^i- microglobulin to improve patiaits' quality of Ufa.
Keywords: on-line Mmodiafiltiation, haru)dialysis, high-flux membrane, aid stage raid disease, medium molecular wdght solutes, PTH, ^i - microglobulin.
MODAU
Sau mot thoi gian loc mau, cac biwi chiing suy than man giai doan cuoi xuat hien ngay mot nhieu, lien quan den su tich liiy p2- microglobulin va mpt so chat co trong lugng phan tu tmng binh khac. Cimg voi viec ap dung mang lpc c6 he so sieu lpc cao, phuong thiic lpc mau HDF online ap diing vao lam sang tu nam 1977 giup nang cao chat Iupng song ciia benh nhan do co hieu qua lpc cac chat co trong lupng phan tir trung binhi^. Tai Viet Nam, phuong thuc HDF online moi dupe dua vao sii dung trong nhiing nam gan day tai mpt so trung tam loc mau Ion. Hien tai, co rat it cac nghien ciiu trong nuoc danh gia hieu qua aia phuong phap HDF online. Vi vay, chiing loi lam nghien ciiu nay nhSm so sanh hieu qua lpc chat co phan hi lupng trung binh giiia phuong phap lpc mau HDF online so voi lpc mau thong thuemg HD mang Ipc high flux 6 b?nh nhan suy than man dang loc mau dinh ky.
MUC TIEU NGHIEN CUtJ
So sanh hieu qua loc chat co phan tir lupng tmng binh giiia phuong phap loc mau HDF online so voi lpc mau thong thuong HD mang lpc high flux 6 benh r\han suy than man dang lpc mau dinh ky.
DOITUONG-rai/ONGIHAPNGHIENaJU Thiet ke nghien cmi
Ti&i ciiu, mo ta, cat ngang, so sanh ket qua giiia cac nhom.
Dan so nguon
Benh nhan suy iiian man giai doan cuoi dang lpc mau dinh ky tai khoa I h ^ Nhan Tao Benh vien Chp Riy tir thang 6/2012 den thang 2/2013.
Phmmg phap chpn mau
Chpn mau tiiuan tien mau dupe lay tren 36 benh nhan dang chay tiian chu ky HD ^ n g thoi CO ket hpp chay than HDF online.
Tieu chuan nhan vdo Tuoi > 18 tuoi.
Thoi gian lpc mau > 2,5 nam.
Lpc mau dinh ky HD mang lpc hi?u qua cao (mang lpc HighQux).
Lpc mau th&i tach sieu lpc bii dich tmc tiep HDF online xen ke voi lpc mau chu ky HD.
Tieu chuan loqi trie
Benh nhan suy than man chay than nhan t?o khong deu hoac ch^y than < 3 fan/tuan.
B^nh nhan lpc mau do nguyen nhan khac:
suy than cap, dot cap suy than man...
Berth nhan suy tim nang.
Benh nhan mac hay nghi ngo co cac t>#nh ly ngoai khoa kem theo.
Ha huyet ap dang diing thuoc van mach khi lpc mau.
Benh nhan co van cJe ve 16 thong dpng - Imh mach: khong dap ling dii cho bom mau hoat dpng tren 250ml/phut (phuong thiic HD).
Xur ly so li?u
Nhap va xii ly so lieu bang phan niem Epi - info va Microsoft office Excel 2003.
Chuyen De Than Nieu
Nghien cmi Y hoc Y Hpc TP. Hb Chi Minh * Tap 18 * Phu ban ciia So 4 * 2014
Cac so lieu duoc phan b'ch giiia hai nhom ap dung phuong thiic lpc mau HD va HDF online.
Cac thuat toan dupe sir dung trong nghien ciiu:
tri so tnmg binh p() va dp l^ch ehuah (SD).
So sanh su khac biet giiia hai nhom, so sanh cac gia tri, so sanh timg cap bang nghiem phap t -student.
MOI SU khae bi|t duoc xem la co y nghia ttiong ke khi P< 0.05.
KET QUA
D^c diem chimg ciia dan so nghien ctru N^iien eiiu cua ehiing toi gom 36 b^nh nhan, trong do co 22 nam va 14 nir. Tuoi trung Hi^u qua Ipc oia hai phirong thirc HDF online faungbinh
binh la 47,28 ± 15,28 (20-88). Nguyen nhan suy than m£ui giai doan cuoi la tang huyet ap 41,7 lo, viem (au tiian man 27,8%, dai tiiao duong 16,7 % va chua ro nguyen nhan chiem 13,8%.
Van toe mau trong lpc mau HD la 276,67 ± 26,30 va trong lpc mau HDF online la 333,89 ± 23,58 khac biet co y nghia tiiong ke (p< 0,05).
Dieh thay the trong phuong thiic lpc mau HDF online trung binh la 18,93 ± 2,56 (14,4- 28,8) lit.
va HD doi voi chat co trpng lirpng phan tu
-—_,,_^PhiK]«ng thi>c Chi tieu ~~ ~-—~^^^
P h u w i g Xn\K HD Phipcmg thi>c HDF online P
PTH T a f o c l(jc mau(pg/ml)
Sau lpc mau{pg/ml) A PTH giam (pg/ml)
% giam PT>H (%)
243,06 ± 305.30 104,83 ±155,83 138,23 ± 2 2 8 , 4 1 44,52 ± 32,08
182.61 ± 1 8 9 , 3 1 87,65 ± 1 2 3 , 7 4 9 4 , 9 6 ± 123,43 46,17 ± 3 2 , 7 7
>0,05
>0,05
> 0 , 0 5
> 0 , 0 5 p2 - macroglobulin (Pz-m)
T m w ; Igc mau(|jgfl.) Sau Igc mau(pg/L) A p2-m giam (Mgfl-)
% p2-m giam (%)
25189,79±6203,13 13778,37 ±7044,65 11411,42±7437,13 43,77 ± 2 5 , 9
25258,77 ±6157,57 6864,72±2218,41 18394,05 ±5870,53
71,56 ± 1 0 , 9
>0,05
< 0 , 0 1
< 0 , 0 5
< 0 , 0 5
BAN LUAN
Ve dac diem dich thay the
Phuong phap lpc mau tham tach siSu Ipe bii dieh true tiep (HDF online) dua tren nguyen ly su ket hpp giiia khuech tan va doi luu tren cimg liic lpc mau. Ve co ban dich thay the la djch khong chiia cac chat gay sot va dich "sieu sach"
dupe tao ra bang sieu lpc kep va dupe truyen true tiep vao mau ciia benh nhan qua duong finh mach.
Toe dp bii dich thay the quy uoc lOOml/phiit (24 h't cho 4 gio lpc mau) cho pha loang sau mang va 200 ml/phiit (48 h't cho 4 gio lpc mau) cho che do pha loang truoc mang, tuong img voi toe do lam saeh ure.
De phong ngiia ap lue xuyen mang bao dpng, cac tac gia khuyen nen cai dat van toe truyen dich thay tiie theo luu lupng mau hieu qua de lam giam phan suat lpc. Mpt quy tac co ban trong cai dat van toe truyen dich thay the la cai dat van toe nay o miic 1/3 vsin toe mau trong phuong thiic HDF online pha loang sau mang va 6 miic ^h. van toe mau trong phuong thiic HDF online pha loang truoc mang"',
Tai khoa than nhan tao benh vien Chp Ray, phuong thijc tham tach sieu lpc bi: dich true tiep dang ap dung la pha loang sau mang va cai dat van toe bii djch tiiay thebang 1/3 v|n toe mau.
Do do, dieh thay the trong nghien ciiu aia ehiing toi thay d6'i, it nhat la 14,4 lit va cao nhat la 28,8 lit, trung binh 18,93 ± 2.56 h't. Trong nghi&n aiu Marta Kalousova va cpng su (2006) Chuyen D^ Than Ni^u
Y Hoc TP. Ho ad Minh * Tap 18 * Phu ban ciia So 4 * 2014 Nghien cihi Y hpc
gia tri trung binh dich tiiay tfie la 18,75 ± 2,69 h'tP'. Trong nghien cuu Francisco Maduell va cpng su (1999) gia tn trung binh dich thay the la 22^ + 4,31 lit!^'. Ch'eh thay the de nghi 24 lit cho 4 gio lpc mau HDF online voi pha loang sau mimg*^'. Trong nghien ciiu chiing toi dich thay the tirong tu nghien cuu Francisco Maduell va cpng su nhung chua dat den de nghi toi uu, eo tiie do van toe mau thap va tinh trang thich ling benh nhan lpc HDF online (13 benh nhan moi chay lan dau).
Dac diem ve van toe mau
Van toe mau trung binh trong cac ian lpc mau vcd phuong tiiiie HDF online ciia chiing toi la 333,89 ± 23,58 ml/phiit cao hon so vdi van toe mau trung binh lpc mau voi phuong thiic HD co y nghia tiiong ke (P < 0,05). Trong nghien eiiu Frandsco Maduell va cpng su (2011) van toe mau 393 ± 60 nil/phut(5). Ng^en ciiu oia Luciano A.
Pedrini va cpng su (2011), van toe mau 346 = 35 ml/phiif^. Van toe mau de nghi trong HDF online doi hoi 350 - 400 ml/phutt^. Nhu v$y van toe mau trung binh 6 nhom BN trong nghien ciiu chiing toi gan dat theo yeu i^u, co the do tinh tr^ng mgch mau va tiiich nghi ciia BN.
So sanh hieu qua ciia phirong thirc lpc mau thain tach sieu lpc b u dich true tiep HDF online va phirong thiic lpc mau chu ky H D doi voi chat c6 trpng lupng p h a n h i t n m g binh
Cac chat co TLPT trung binh PTH va pi - microglobulin (pi-m) mau sau lpc voi phuong thiic FID giam ro ret so voi truoc lpc (p < 0,05).
Ty le giam nong dp PTH va p2-m mau Bn lupt la 44,52% va 43,77%. Ty le nay tiiap hon trong nghien cihi ciia tac gja Nguyen Thi Thu Lanh (2005): ty le giam PTH va pa-m mau lan lupt la 69,87% va 51,72%. Dieu nay co the do mang lpc hieu qua cao high flux ehiing toi sir dung khong dong nhat, do dieu ki|n kinh te va lua chpn ciia bacsy.
Cac chat eo TLPT trung binh PTH va ^ m sau lpc mau voi phuong thiic HDF online giam
r5 ret so voi truoc lpc (p < 0,05). Ty le gjam nong dp PTH va p^m mau lan lupt Ia 46,17''<. v'a 71,56%. Ty Ie giam p^m mau trong nghien ciiu Clia chiing toi tuong tu cac nghien euu khac tren the gioi: nghien ciiu ciia Francisco Maduell (1999) la 71,1 ± 9,l%"i, nghien aiu aia \\\ Lomoy (2000) la 72,7%P> va n ^ e n a h i Manor R Gallardo (2006) 66,4W«.
Khi so sanh hieu qua lpc mau giua hai phuong thiie HD va PIDF online doi voi cac chat CO TLPT trung tsnh chiing toi nhan thay hieu qua lpc PTH khong khac biet Tuy nhien hieu qua Ipc p2-m o phuong thiic loc mau HDF online cao hon ro ret so voi phuong thiic lpc mau HD.
Ty le giam gia tri trung binh nong dp p2-m mau sau lpc 6 phuong thiic lpc mau HD la 43,77"o va HDF online la 71,56%. Su khac biet nay oo y nghia tiiong ke (P < 0,05).
Benh nhiem bpt lien quan den loc mau (dialysis - Associated - Amyloidosis) la mpt bien chiing mupn o cac trucmg hpp lpc mau lau dai kem theo nang mang xuong va hpi chiing ong co tay mot hay ca hai ben. Mpt trong nhimg bieu hien cua benh nhiem bpt thii phat la dau vai va xuong. Nhiing ton thuong nay rat kho dieu tri bang thuoc. De ngan ngira bien ehiing eiia benh nhilm bpt thii phat can phai lpc p>m cang hieu qua cang tot
Theo Sergio R. benh nhiem bpt 6 benh nhan lpc mau CO lien quan chat ehe vdi thoi gian lpc mau. Nghien ciiu tren benh nhan hi vong da phat hien p2-amyloid 6 eae khop Ion som hon so vol bieu hien ciia no tren lam sang. Su ling dpng Amyloid 6 cac to chiic som hon so voi bieii hien lam sang hay tren X - quang. Nguoi ta thay rang 21% benh nhan co su lang dpng Amyloid 6 benh nhan lpc mau hai nam, nhung co toi 90'*o co su ling dpng Amyloid 6 b^nh nhan Ipc mau lay nam. Nhimg nam ^ n day nguoi ta nhan thay fy le va miic dp nhiem bpt lien quan den lpc mau da giam. Co the nho chat lupng trang tiiiet bi cang ngay cang hoan tiiien, trong do co su dong gop cua viee sir dung mang lpc High - fluy*'.
Ngoai ra, ehiing ta co tiie can tiiiep tich cue lam 181
Nghien ciiu Y hpc Y Hpc TP. Ho Chi Minh * Tap 18 * Phu b a n ciia So 4 * 2014 giam nong dp p2-m hon niia bang ap dung
phuong phap lpc FIDF online. Nhu vay ehiing ta CO the nang cao chat lupng song ciia benh nhan suy tiian man chay than dinh ky eiing nhu ngan ngira bieh diiing benh nhiem bpt lien quan den Ipc mau. Tuy nhien gia thanh cua phuong thiie HDF online dat hon vai lan so voi phuong fluic HD thong thuemg. Do do, tai Viet Nam,khi ap dung thuc te, HDF online nen dupe sir dung xen ke voi lpc mau thong thuong voi tan suat thay doi (01 lan/ tuan hay 01 lan/thang) va tuy theo dKu ki^n kinh te ciia benh nhan. Chi dinh loc mau vdi phuong phap HDF online nen ap dung eho cac doi tupng nhu:
- Berth nhan da lpc mau thoi gian dai, de giam bieh chiing amyloid.
- B^nh nhan co trieu ehiing lien quan den su tich tu chat co trpng lupng phan hi trung binh tuong tu P^ - microglobulin.
- B?nh rihan co bien chiing lien quan hpi chiing ure huyet cao nhu tang huyet ap kho kiem soat bieh chiing than kinh ngoai bien ma chay th|n chu ky chua giai quyet dupe.
KETLUAN
Doi voi chat co trpng lupng phan tir trung binh, ty le giam pi-microglobulin ciia phuong thiic lpc mau thaan tach sieu loc bii dich true hep HDF online dat 71,56% cao hon ro ret so voi phucmg thiic lpc mau chu ky FID 43,77%. Vi vay nen ap dung phuong ihiie lpc HDF online tren nhimg benh nhan da lpc mau thoi gian dai hoac
CO trieu chiing lien quan den su rich tu chat co trpng lupng phan tir trung binh tuong tu' ^2 ~ microglobulin de cai thien va nang cao hon niia chat lupng song aia berth nhan.
TAI LIEU THAM KHAO
1 Bellomo R Farmer H Parfan G, Wright C Boj-ce N (1995) Severe acute renal faUure: a comparison of acute continuous hemodiafiltrabor and con\-entional dialytic thH^py Neffcon, 7159-64.
2 Kalousova, Marta, et al "No benefit of hetnodiafiltration over hemodialyas in lowering devated levels of as\-mmelnc dimethyl aipnine in ESRD patients "Blood puntication 24.5-6 (2006) 439-444
3 Lomoy, W., et al X)n-lme haemodiafillration. Remarkable removal of p2-microglobulin Long-terrn clinical observations." Nephrology Dialysis Tran^lantation IS.suppI 1 (2000) 49-54.
4 Madudl, Frannsoo, el al "Change from ccmventional haemodiafillration to on-line haemodiafillration." Nephrology Dialysis Transplantation 14 5 (1999)-1202-1207.
5 Maduell, Frandsco 'Tifteen years of experience with on-line hemodiafiltration." (2011)' 141-151.
6 MUNOZ, Rosa, et al. "Online hemodiafiltration: 4 years of dinical e>cpenence."Hemcidialysis International lOsl (2006) S28-S32
7 Pednni, Ludano A , et al. "Long-term effects of Hgh-effidency on-lirte haemodiafillration on uraenuc toxid^. A multicentre prospective randomized study," Nephrology Dialysis Transplantation 26,8 (2011): 2617-2624,
8 Tran Van Chat (2004), "Cac phuong pJiap lpc mau W?n t^u va tuong lai" -B^nh than ngi khoa, Nha xuat ban y hoc, trang 205-217.
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15/5/2014 27/5/2014 10/7/2014
Chuyen D^ Than Ni^u
