Y Hoc TP. Ho Chi Minh * Tap 18 * Phu ban oia So 4 * 2014 Tong Quan
CHAN DOAN VA DIEU TRI BENH THAN MAN TU" KDOQI2002 DEN KDIGO GUIDELINES 2012
Nam 2002, Hpi dong Than hpc Quoc gia My NFK-KDOQI 2002 (National Kidney Foundation- Kidney Disease Outcomes Quality Initiatives) dua ra guidelines dau tien ve benh than man. Day eiing la Ian dau tien thuat ngii 'benh th|in man" (Chronic Kidney Disease) duoc sii dung, bo sung cho dinh nghia cii cua " suy than man'. Qua guideline dau tien nay, benh than man da duoc trinh bay ve dinh nghia, phan loai, nguyen nhan va cac chiMi lupc dieu tri.
Ngay sau do, nam 2003, Hpi Than Hpc Quoc Te Cling dua ra guidelines oia KDIGO (Kidney Disease Improving Global Outcomes) bo sung nguoi ghep than nhu 1 nhom benh than man trong dinh nghia, va nhat tri hau het cae huong dan ciia KDOQI. Tu do, hang nam, trong he thong USRDS (United States Renal Data System) xuat hien them 1 muc la benh th§n man, cap nhat moi cuoi nam ve so lieu benh than man tai My. Phan loai ciia benh thgn m ^ ban ^ u cua KDOQI gay ra nhieu tranh cai trong y gioi, nhat la 6 nhom bn co dp Ipc cau than tii 30- 59ml/ph/l,/3 m-. Song van duoc chap nhan vi mac du mang tinh ap dat phan loai nay da dat dupe muc tieu ban dau la don gian, de nho de thong nhat trong y gioi tao dieu kien de dang cho viec trao doi thong tin d^t hieu cpaa nha't Gan 10 narn, sau ngay cong bo, vol nhieu chiing cu moi, nam 2012, KDIGO dua ra guidelines moi voi nhiing thay doi ve phan loai giai doan, nguyen nhan. Bai viet nay nhim muc tieu (1) trinh bay nhiing diem moi trong phan loai KDIGO 2012, ben c?nh viec so sanh voi nhimg quan diem eu ciia KDOQI 2002.
PHAN TANG KHUYEN CAO THEO CHLrNGCU"
De danh gia chat Iupng cua chiing ai, va siic
Tran Thi Bich Huong*
manh ciia khuyen cao, KDIGO guidelines xii dung phuong phap GRADE (Grading of Recommendations Assessment Development and Evaluation, Phan ^ g cac khuyen cao, luong gia, phat trien va danh gia). Sue manh eiia khuyrai cao duoc xep tir cao xuong thap tir miic 1 (level) la "khuywi cao" (recommend) (la miic ma bac si can tuan thii va ap dung cho moi benh nhan), miic 2 la "de nghi" (suggest) la miic bac si can chii thich trong ho so, neu khong th§' ap dung khuyen cao nay cho nhimg bn dac biet va khong phan ^ g (ungraded, UG) neii chua dii chiing cii va chi dya vao quan niem ehung.
Chat luong ciia chiing cii dugc phan thanh grade A-D voi grade A, neu chiing cii co chat Iupng cao, grade B, neu chat luong trung binh va grade C neu chat Iupng kem, va grade D, chiing cii CO chat lucmg rat kem. Thuc te, hiem co khuyen cao dupe xep loai lA. Trong KDIGO 2012, ve CKD, co S khuyen cao loai 1, trong do 4 grade B, 2 grade C, va 2 grade D. Co 9 khuyen cao ioai 2, trong do 1 grade C va 8 grade D.
Khac voi KDOQI 2002 dimg dio nguoi truong thanh, KDIGO 2012 bao gom cac khuyoi cao ve benh than man cho ea nguoi truong thanh va tre em. Trong pham vi bai nay, chiing toi chi trinh bay nhimg khuyen cao cho nguoi truong thanh.
DINH NGHIA VA PHAN LOAI BENH THAN MAN THEO KDIGO 2012 (KIDNEY DISEASE IMPROVING GLOBAL OUTCOMES-2D12)
Dinh nghia benh than m ^
B?nh than man (chronic kidney disease, CKD) duoc dinh nghia la nhiing bat thuemg ve cau true hoac chiic nang than, keo dai tren 3
* Bp mon Noi, Dai Hoc Y Duoc, Khoa Than, Benh \'ien Chgi Ray
Tac gin Hen lac. PGS. TS. BS Tran Tiii Bich Htamg DT: 0938817385 Email: [email protected]
Chuyen De Than Nieu
Tong Quan Y Hpc TP. Ho Chi Minh * Tap 18 * P h u ban cua So 4 * 2014
^
thang, va anh huong len siic khoe nguoi benh.
Tieu ehuan chan doan CKD: dua vao 1 trong 2 tieu chuain sau ton tai keo dai tren 3 thang.
Dau chiing tan thuang than (1 hoac nhieu) Co Albumine nuoc tieu (ty le albumine ereatinme nuoc tieu> 30mg/g hoac albumine nuoc tieu 24 gio >30mg,^4gi6)
Bat thuemg can lang nuoc tieu
Bat thuong dien giai hoac cac bat thuang khac do rm Ipan chiic nang ong than
Bat thuong ve mo benh hpc th|n Xet nghi#m hinh anh hpc phat hipn than bat thuong
Tien can ghep than
Bang 1. CAc giai doan cua beiih than man
Giam do loc cau than {Glomerular filtration rate: GFR) < 60ml/phlt73 m- (xep loai G3a dehGS)
Can luu y dp Ipc cau th§n va albumine nieu chi phan anh chinh xac giai dpan BTM khi chiic nang t h ^ on dmh (khong thay doi trong 3 thang xet nghiem lap 1^), va sau khi da losti bo cac yeii to lam nang them tam tiioi dnh t r ^ g suy than.
Phan giai dpan benh t h | n man
Nam 2002, NKF- KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiatives) phan benh t h ^ m ^ thanh 5 giai doan dua vao GFR
Giai do^n 1 2 3 4 5
M o t a
Ton thirong thgn v6i DLCT binh ttiirong hoac tang Ton thirong th^n v6i DLCT giam nhe
Giam 6 L C T tmng binh Giam DLCT n^ng B^nh th$n man giai 6a^n cuoi
0 $ loc c i u tti$n (ml/ph/1,73 rr^ da)
>go 60-69 30-59 15-29
<15 hoac phai chay ^ | n nhan lao
Nam 2012, voi cac chiing a i lien quan deh khac biet ve tir vong, KDIGO (Kidney Disease Improving Global Outcomes) ciia Hpi Th|n hpc Quoc Te, giai doan 3 ciia CKD dupe tach thanh 3a va 3b, kem theo bo sung albumine nieu vao trong bang phan giai dogn (hinh 1) ho trp cho vifc danh gia tien Iupng va dien tien ciia BTM.
Viec danh gia dien tien oia CKD va nguy co
dua vao CGA voi (1) Nguyen nhan cua BTM (C:
Cause), (2) Phan giai doan eiia GFR (G:
Glomerular Filtration Rate), (3) Phan loai cua albumine ni^u (A: Albumine ni?u). Thu§t ngii microalbumin nieu hau nhu khong con dupe dimg tai cac phong xet nghiem, fhay the bing albumine nieu binh thuong ho|c tang nh? (AOi
<30mg/g), tang trung binh (ACR 30- <300mg/g)
d i e n t i e n d e n s u y t h a n m a n g i a i d o a n r u o i c u n g
Ph Jn luai i h c o C i - R
. m l p h 1,7^ 1112) G3b
G4 0 5
Btnh tht/ong hoac tang Giam nhe Giam nhe <Jen trung binh Giam trung binh den nang
Gtam nang Suy than
> 9 0 60-89 45-59 30^M 1 5 ^ 9
< 1 5
v a t a n g n h i e u ( A C R > 3 0 0 m g / g ) Aibumine meu keo dai (ty 1$ albumin/creatinine) (mg/ql A l
Binh IhLfong den tang nhe
<30
A2 Tang trung binh
30-300 A3 Tang nhieu
> 3 0 0
Chuyen De Th?n Nieu
Y Hpc TP. Ho Chi Minh * Tap 18 * Phu b a n ciia So 4 * 2014 Tong Quan
1 Mau Nguy CC benh than tiln tnen Nguy CO thap WHHH Nguy CO trung binh
^ H Nguy CO'cao
mm
Nguy CO rat caoTan suit kliam benh m5i nam 1 lln/nam 2 l^n/nam 3 lan/nam ilnh^t4 lin/nam Hinh I: Plidn loai giai doan va tien Iwtmg cua CKD theo GFR va albumine nieu CAC BUbC DANH GIA BENH NHAN BENH
THANMAN
Danh gja tinh man tinh cua b^nh than m ^ O cac bn voi GFR < 60ml/ph/l,73 m' (xep loai G3a-G5) hoac co nhiing dau chiing bat thuong cua ton tiiuong than, csn danh gia tinh man tinh ciia b^nh than truoc khi xac dmh chan doan CKD qua viec (1) hoi tien can, (2) ket qua nhiing xet nghiem gan day de chan doan b|nh than da keo dai.
- Neu thoi gian b#nh tren 3 tiiang, co the khang dinh benh than man,
- Neu thoi gian benh khong ro, hoae chua d^t du 3 thang, K H 6 N G nen khang dinh benh
Bang 2: Phan loai nguyen nh&n benh than man (theo KDIGO 2012)
than man trong ^ dau tien xet nghiem, nen lap lai cac xet nghiem de loai tru benh than cap, ton thuang ttign cap, suy tiian tien trieh nhanh.
Danh gia nguyen nhan
Dua vao lam sang, tien can ca nhan, gia (finh, hoan canh xa hpi, yeii to moi truong, thuoe dung, kham lam sang, xet nghiem sinh hoa, hinh anh hpc, va tham chi sinh thiet than de chan doan nguyen nhan benh than man. Trong KDIGO 2012, nguyen nhan benh th|n man dupe phan dua vao vi tri ton thuong giai phau hpc va benh can nguyen chu yeu t ^ than, hoac thii phat sau cac benh ly toan than (bang 2)
Nguy§n nhan B$nh ck\} than B#nh 6ng than mo ke B^nh m^ch mdu than B^nh nang th|n v^ benh th|n biim sinh
B^nh than nguyen phat B$nh c^u th^n sang thmyng t6i thi^u,
b^nh c^u than mang Nhilm trCing tilu, b^nh thin tic nghen
s6ini#u Viem mach mSu do ANCA. Ipan
du-ong xo co Thilu san th^n, nang tuy th|n
Benh than thi> phat sau b^nh toan than Dai thao du'ong, thuoc, b#nh ac tinh, b#nh
tymiin
Benh ti^ miln, Isenh thin do thuoc, da u tuy Xo vOa d$ng mach, tang huyet dp, thuyen
tic do cholesterol B|nh than da nang, hgi chiing Alport Danh gia dp loc cau t h ^
Khuyen cao nen dimg creatinine huyet thanh, tu do uoc doan dp Ipc cau thgn theo cong thiic de danh gia so khoi GFR (lA) va khong nen dya chi vao creatinine huyet thanh don dpc (IB).
Cong thiec Codccroft Gault uoc doan DTL ereatinin tir ereatinin huyet thanh:
Dp thanh loc ereatinin (ml/ph) = (140-tu6i) x can nang (kg)
Tii creatinine huyet thanh uoc doan dp thanh loc creatinine theo cong thiic Cockcroft Gault, hoac uoc doan do Ipc cau than (estimated GFR, eGFR) theo cong thiic cua MDRD (Modification of Diet in Renal Disease).
72 X ereatinin HT (mg/dL) Neil In nir n)mn them vdi 0,85
Di#n ti'ch da (m= da)= ((can ii|ing(kg) x dueu cao {cm)/3600)«
E)TLcreatinm (ml/ph/l,73m-da) DTL ereatinin x l,73/di#n tich da
Cong thuc MDRD (Modification of Diet in Renal Disease Study) uoc doan dp loc cau than (estimated GFR, eGFR) tii ereatinin huyet thanh:
Chuyen De Than Nieu
Tong Quan > Hoc TP. Ho 1,86 X (ere huyet
[B Chi Minh * Tap 18 * Phu ban cua S6 4 * 2014
eGFR (mL/ph/73 m=) thanh)-'''^ x (tuoir^'
Nhan vtii 0,742 neu la nii, nhan voi 1,21 neu la nguoi My goc Phi.
- Khuyen cao cho cac phong xet nghiem lam sang(lB)
Khi tra loi ket qua eGFK, tan cong bo dong tiioi creatinine hu\et thanh, voi ket qua GFR uoc doan (eGFR) \a ten cong thiic dimg de uoc doan GFR tir creatinine huyet thanh
Do creatinine huyet tucmg bSng ky thuat dupe ehuan hoa dua vao cac chat Ii?u tham khao chuain quoc te, giam thieii nhimg sai lam khi so voi phuong phap doi chieu quang pho khoi pha loang phong xa (isotope-dilution mass spectrometry (IDMS) reference methodology).
- Co the dimg 1 so xet nghi?m (nhu cystatin C, ho^c cac do luong do thanh thai khac) de danh gia chiic nang than khi eGFR uoc doan tii creatinine huyet thanh khong chinh xac 6 bn eo khoi Iupng co teo (28)
3.4. Danh gid albumine niiu
- De nghi xet nghiem tim protein ni?u nen theo trinh tu uu tien tir tren xuong, voi mau nuoc tieu la nuoc tieu dau tien buoi sang (2B)
Ty le albumin/creatinine nuoc tieu (Albumin-to Creatinine Ratio, ACR)
Ty le protein/creatinine nuoc tieu (Protein- to- Creatinine Ratio,PCR)
Xet nghiem giay nhiing tim protein nieu voi he thong dpc tu dpng
Xet nghiem giay nhiing tim protein nieu dpc tiiu cong bang tay voi bang so mau.
- 0e nghi khi ti-a loi ket qua, can ghi chii tiioi diem lay mSu nuoc tieu neu la bat ky, ben canh ket qua ciia ACR va PCR (IB)
- Bac si can biet co nhiing nguyen nhan co tiie anh huong len ket qua albumine nieu (UG).
Neu giay nhiing vdi albumine nieu duong tinh, can dinh Iupng albumine va protein nieu
Neu dinh luong ACR > 30mg/g (duong tinh), can xet nghiem Igi ACR voi mSu nuoc tieu dau tien buoi sang neu mlu nuoc tieu thir truoe do la thoi diem bat ky,
Neu can danh gia chinh xac hon ve albumine nieu va protein ni|u, nen xet nghiem voi nuoc tieu luu giii trong 24 gia.
Neu protein ni^u duong tinh nhieu, nhung albumine nieu am tinh, can tien hanh xet nghi?m nuoc tieu chuyen bi^t hon nhu al-microglobulm, chuoi nang va chuoi nhe don dong, protein Bence Jones.
Bang 3: Kci qua timtg I'mg giira xet nghiem albumine va
Ty ^i albumine/creatinine nieu (ACR) Albumine nieu 24 gio Ty 1$ protein/creatinine meu (PCR)
Protein meu 24g\o Protein nieu giiy nhung
proton trong nmc tim Binh thirong
<30nig/g
<3nigAnmol
<30 mg/24 gio
<150mg/g
< 15 mg/mmol
<150mg/24gi6' am tinh
B i t thirong a 30mg/g a Smg/mmol
> 30mg/24 gio
>150mg/g
> 1 Smg/mmol
> 150mg/24gi6' V^t (J6n du-ong tinh Cac xet nghi?m khac
Xet nghiem khao sat can ISng nitac tieu (fim can ling bat thuang nhu hong cau, b^ch cau, cac tru ni?u)
Xcf nghiem dien giai do, pa siiih thiei than
Xet nghiem hinh anh: sieu am t h ^ va he raeu (tim soi, nang, do kich thuoc tii|n), nieu ky npi finh mach
Chan doan phan biet voi ton thuong than cap
Truoc mpi bn eo tang ereatinin huyet thanh, can phan biet CKD vai ton thuong than cap vi Chuyen De Than Ni?u
J
Y Hpc TP. Ho Chi Minh * T a p 18 * Phu b a n cua So 4 * 2014 Tong Q u a n ton thuong than cap co kha nang hoi phuc chiic
nang than neu duoc chain doan som va can thiep kip tiioi.
Dua vao ereatinin huyet tiiahli tien tang truac day
Neu ereatinin huyet Ihanh tnioe day binh thuemg thi ereatinin huyet thanh tang hien tai la do ton thuong than cap, chiic nang than co kha nang hoi phyc va khong phai benh t h ^ man.
Neu ereatinin huyet thanh truoc day neu da tang man tinh trong nhieu thang, se la bang chiing quan trcmg cua benh than man.
Neu khong biet creatinine huyet thanh truoc day, van CO the ca 2 benh ly tren ket hpp gay ton thuemg than cap (do giam the tich luu thong hieu qua, do nhiem trimg, dimg thuoe can quang duong finh mach, thuoc khang viem nonsteroid, aminoglycoside, tac nghen sau than...) tren hen benh than man. Trong truong hop nay, ran theo doi, lap lai ereatinin huyet tiianh trong nhieu ngay lien tiep ket hpp vdi cac bang chiing can lam sang khac se giiip chain doan phan biet Dua vao sieu am do kich tkimc 2 than
BN ton thuang than cap, hai than co kich tfiuoc binh thudng hoac to, trong khi BTM, hai than khong to, ho^c se teo
Sinh Ihiet than
Co gia tri trong xac dinh benh than nguyen nhan, khi benh than man a gjai doan 1-3. Mpt khi suy than man tien tri&i (giai doan 4,5) voi than teo, xa hoa, sinh thiet tiian khong co ehi dinh vi (1) kho thuc hien va tang nguy co chay mau, (2) mo than chii yeu la mo xo nhieu va che lap benh tiian nen tang nen it hieu qua chan doan berth can nguyen, (3) da qua thai diem chi dinh dieu tri b^nh than can nguyen.
C h & doan cac yeii to lam nang them tinh trang suy t h ^
Truoc mpi tiuong hpp tang dot ngpt ereatinin a Ijenh ntian benh than man, hoac truoc mpi truong hpp benh nhan co creatinine huyet thanh tang liie n h | p vien ma khong biet
creatinine huyet fhanh co ban, can S m soat cac yeu to lam nang them hoac dang thiic day tinh trang suy than
Giam the tich mau luu thong: mat dich, mat mau, suy tim sung huyet
Thay doi huyet ap nhu tang hgc h? huyet ap (thuong do thuoe ha ap).
Nhiem trimg.
Tac nghen duong tieu
Thuoc doc cho tiian: aminoglycoside, khang viem non steroid, thuoc can quang
Bien chiing mach mau than: tac dpng mach than do huyet khoi, hep dpng mach than, thuyen tac dpng mach than do cholesterol...
Chui doan b i S i ehung cua benh Q i ^ man Khi chiic nang than on djnh, o mpi bn CKD CO dp loc rau tiian < 60 m\/phll,73 nf da, ran danh gia cac bien chiing oia CKD nhir
Tang huyet ap: Tang huyet ap lam tang nguy CO benh ly tim mach
Thieu mau man: Theo WHO, thieu mau khi Hb <13 gIL a nam va <12 g/L 6 nii.
Tinh trang suy dinh duong: dua vao giam aJbumin huyet tiianh, can n?ng, bang diem danh gia dinh duong toan dien chii quan (Subjective Global Assessment SGA), che dp dinh duong.
Roi loan chuyen hoa calcium va phospho:
giam caldum, tang phospho, tang PTH huyet thanh gay cuong tuy&i pho giap thii phat giam vitamine D, ton thuong xuong,
Benh ly than kmh: ngoai bien, trung uong, he than kinh thuc \'at.
Bien chiing tim mach.
D I I N TIEN VA BIEN CHLfNG CUA BENH THAN MAN
Dien tien ciia benh than man
Benh than man c6 dien tien suy giam chiic nang than cham trong nhieu nam, va khong hoi phuc den giai doan cuoi. O nguoi binh thuong khong benh than, sau 30-40 tuoi, moi
Chuyen De T h ^ Nieu
Tong Quan Y Hoc TP. Ho Chi Minh * Tap 18 • Phu ban cua So 4 * 2014
nam dp Ipc cau than giam trung binh theo sinh ly lml/ph/1,73 m-. Trong KDOQI 2002, CKD goi la tien tiien nhanh khi eGFR giam >
4ml/ph/l,73mVnam. Theo KDIGO 2012, GFR la 1 bien so dpng nen se co nhiing giao dpng nho va khong phai la chi diem ciia benh than tien tnen (UG).
Theo KDIGO 2012, viec danh gia CKD tien trieh dua vao 1 trong cac van de sau (UG)
GFR dupe gpi la giam khi eo su sut giam eGFR tiong bang phan loai nhu tii Gl sang G2, G3a, G3b, G4 va G5, kem hoac khong kem giam 25% gia tri eGFR hen.
CKD dupe goi la tien tiien nhanh khi moi nam eGFR giam hon 5ml/ph/l,73 m^ va khang dinh tien trien qua su gia tang cua creatinine huyet tuong theo thai gian.
6 bn CO CKD dang tien trieh, can xem lai phuong thiic dieu tri gan day, ^ m soat cae nguyen nhan gay tien trien, va xem xet chuyen sang BS chuyen khoa Than (UG).
Cac yeu to anh huong len tien trien oia b^nh th$n m^n: 2 nhom
Nhom yeii to khong thay doi duoc Tuoi: nguoi Ion tuoi dien tien benh nhanh hon nguoi tre.
Gioi tinh: nam tien trieh b?nh than nhanh han nu'.
Chimg tpc: da den dai thao duong nguy ca suy than man giai doan cuoi tang gap 2-3 lan nhieu han nguoi da trang.
Yeu to di truyen: Than ciia tre sanh nhe can (duoi 2500 g), sanh thieu thang, th|n oia tie co Bang 4; Chicit luvc dieu tri benh than man theo giai doan
me bi benh hoac dimg thuoc doc than ti-ong tiiai ky nhay cam vai ton tiiuong hon ti-e khac.
Chiic nang tiian nen tang liic phat hien b?nh da giam.
Nhom yeii toco the thay doi dugc Miic dp tieu protein: tieu protein cang nhieu till toe dp suy than cang nhanh.
B^nh than can nguyen: dai thao duong, b|nh cau than co diln tien suy tiian nhanh hon tang huyet ap, benh ong than mo ke.
Miic do lan toa ciia ton thuang ong than mo ke tren sinh tiiiet tii^n cang nhieu thi suy tiian cang nhanh
Tang lipid mau
Hut tiiuoc la lam tiiiie day qua trinh xa hoa cau th§n, ong than va mach mau
DIEU TRI BENH THAN MAN Myc tieu dieu tri b?nh th$n man
E)ieu tri benh than can nguyen
E)ieu tri nguyen nhan gay giam GFR cap tinh CO the hoi phuc dupe
Dieu tri lam cham tien trieh ciia benh th|n man
E)ieu tri cac bien ehung tim mach, va cac yeu to nguy CO tim mach
Chuah bi dieu tri thay the than khi th$n suy nSng
Chien luoc dieu tri b^nh t h ^ m^n:
Theo KDOQI 2002, chien lupc ehung dieu trj b?nh than man dupe phan theo giai doan oia phan dp benh than m ^
Giai d^an 1 2 3 4 5
D$ 19c cau th?n (ml/ph/1,73}
>90 60-89 30-59 15-29
<15
Viec c i n lam (*)
ChSn doan va fli^u tri t>^nh can nguyen, gioi hpn y^u t6 nguy co' gay suy th^n cap, lam ch|m ti^n tnen benh th|n, di^u tn yeu to nguy co- tim mgch
+ Lfoc doan loc do tien tnin b^nh th|n +Danh gta va dieu In bi4n ehung + Chulin bi diau tn thay the th?n Difeu tn thay th6 than neu c6 hoi chi>ng ure huyet [*)^\dmnsQ\i tiep tuc vwc ciia giai dgan iruac
Chuyen De Than Ni?u
Y Hpc TP. Ho Chi Mmh * Tap 18 * Phu ban ciia So 4 * 2014 Tong Quan
Dieu tri benh than can nguyen
Giii vai tro quan trpng nhat trong bao v?
than va lam cham tien tnen benh than. Khi than da suy nang (giai dpan 4, 5), do viec ehah doan benh can nguyen tro nen kho khan, va viec dieu tri tro nen kem hi#u qua, nen can nhae giiia loi idi va tac hai oia thuoc dieu tri can nguyen a nhom bn nay.
Dieu tri lam cham tien trien cua BTM den giai dpan cuoi
Cac yeu to can can thi?p, muc tieu can dat va bien phap dupe tom tSt trong bang 5 va ehi tiet oia khuyen cao KDIGO 2012 dupe trinh bay sau do.
Dieu tri cy the theo KDIGO 2012 Ha dp vd thuoc He che he Renin Angiotensin
Aldosterone
Can ea the hoa huyet ap muc tieu va thuoc dimg tiiy theo tuoi, co benh tim mach hoac va nhiing b^nh khac di kem, nguy co CKD tien trien, CO kem hoae khong kem ton thuang day mat (trong CKD do dai fhao duong) va miic dp dung nap eiia bn voi dieu tri (UG)
Bang 5: Cac bien phap bao vi than toi ini
Can can nhac ve ha huyet ap tu the va thuong xuyen kiem tra finh trang ha huyet ap tu tiie khi dimg tiiuoc ha ap a bn CKD (UG)
Can dieu chinh phac do dieu tri huyet ap d bn CKD lan tuoi tren co so can nhac ve tuoi, yeu to nguy CO tii vong, va cac dieu tn khac, di kem tiieo doi cac tac dung ngoai y lien quan den dieu tri ha huyet ap, nhu roi loan dien giai, giam cap chiic nang than, ha huy^t ap tu the va tac dung phu cua thuoc (UG).
Khuyen cao a bn CKD dai thao duong va khong dai thao duong co albumine nieu 24 gio >
30mg {hole tuong duong) kem tai phong kham thuang xuyen HA tam thu >140nimHg, hoae HA tam truong > 90 mmHg, can dieu tri thuoc ha ap de duy tri huyet ap on dmh a miic <
140mmHg, va HA tam truong < 90mmHg (IB).
Vdi bn CKD do dai thao duong va khong dai thao duong co albumine ni?u > 30mg/24 gio (hoae tuong duong) va tai phong ktiam, thuong xuyen co huyet ap tam thu >130 mmHg hoae huyet ap tam truong > SOmmHg, de nghi dieu tri ha ap de duy tri huyet ap tam thu < 130 mmHg va HA tam ti-uong £ 80 mmHg (2B).
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Yeu t o can can thif p Giam t i l u protein, t i l u
albumin
K i l m soat h u y l t ap
An lat
Giam protein trong khiiu ph^n
Kiem soat 6\Kii\g h u y l t
Thay d6i l6i s6ng.
D i ^ u tn t h i l u mau
M v c t i ^ u Protein/creatinine <;0,5mg/g Albumine/creatinine nieu < 30mg/g
- N l u bn ACR< M m g / g , HA muc l e u <
140/90 m m H g - N 4 U A C R > 30mg/g, HA m y c tieu 5
130/80mmHg Sodium < 2g /ngay (hoac NaCI < Sg/ngay
A p dyng 6 bn GFR<30ml/ph/1,73, l u ^ g protein nhap < O.Sg/Kg/ngay,
H b A 1 C = 7 % HbA 1 C > 7%, 6' bn CO nguy c c h? duo'ng
huyet cao
Dat can n|ng IJ iLrang, tranh beo phi, Bo hut thuoc la
Hb11-12g/dL
Bi^n phap - Kiem soat h u y l t Ap -D\ku trj b$nh c i n nguyen - T i l t c h l protein trong k h i u ph^n
- Dung UCMC h o l e UCTT l / c c h l men c h u y i n v ^ LPC che thy t h i angiotensin I t u'u fien chpn, nh^t la 6" bn
cd ti^u albumin
Ti,Fn^u an, khong an thiic an che bien s i n , khong c h ^ m them Giam pnstein nhap, chpn cac Ipai dam CO gia tn sinh hoc cao (tu- van chuyen
gia dinh d u ^ n g ) Khong dung metfonnin khi GFR<60
ml/ph/1,73.
T i p t h i luc tuy theo tinh trang tim m^ch va kha nang dung nap (it n h i t 30 ph/lan
X 5 lan/tuan) Erythropoietin, sit, acid folic.
Chuyen D e T h ^ Nieu
Tong Quan Y Hoc TP. Hb Chi Minh ' Tap 18 * P h y b a n cua So 4 * 2014 Yeu t6 can can thiep
Kilm soat roi loan lipid mau
Diing thuoc Crc c h l nnen chuyen ho|c i> che thu thi
angiotensin II
Muc tieu LDL- cholesterol <100 mg/dL, HDL- cholesterol> 40 mg/dL, tnglycende <
200mg/dL
Wing lieu toi ini d l giam protein nieu, va kiem soat huyet ap
Statin, gemfibrozil Fibrate giam lieu khi GFR<60, v
dung khi GFR<15
Phong ngira, va theo doi cSc tic dgng phu- suy th|n cap va ting kali, hay xay
ra g bn GFR giam De nghi mpi bn dai thao duong CKD voi
albumine nieu 30-300mg/24 gio (ho|c tuong duong) dimg thuoc lic che men chuyen hoac lie che thu tiie (2D).
Khuyen cao bn nguoi truong thanh CKD kem dai thao duong va khong dai thao duong va CO albumine nieu >300mg/24 gio (hoac tuong duong) nen dimg thuoe lic che men chuyen hoac lie che thy the a (IB)
Chua du chiing cii de khuyen cao \iee phoi hpp lie che men chuyen \'»7i uc che thu the angiotensin de lam cham tien tnen CKD (UG) Benh than man vd nguy ca tan thuang than
cap
Khuyen cao moi bn CKD duoc xem la doi tupng nguy co cao oia ton thuang fhgn cap (Acute kidney Injury, AKI) (lA).
6 bn CKD, nhung khu)'en cao ve KDIGO AKI can ap dung nhung phuong thiie dieu tri cho doi tupng nguy ca bi AKI tiong giai doan b^nh, hoae khi tien hanh cac phuong thiic chan doan va can tiiiep thii thuat deu lam tang nguy coAKI(UG).
Tiel che protein nhap
Khi GFR < 30ml/ph/l,73 (phan lo?i GFR a giai doan G4-G5), de nghi giam protein nhap con 0,8g/Kg/ngay a nguoi truong thanh co kem {2C) hoac khong kem (2B) dai thao duong va kem tiieo che dp huah luyen thich hpp.
O bn CKD CO nguy co benh dang tien trien, de nghi tranh tang nhap protein (>l,3g/Kg/ngay) (2C).
Kiem soat duong huyet
Khuyen cao dat HbAlc khoang 7% de du phong hoac lam cham tien trieh eiia cac bien
chiing vi mach ciia dai thao duong, bao gom ea benh tiian dai tiiao duong (lA).
Khuyen cao khong dua HbAlc xuong <7% 6 bn CO nguy co ha duong huyet (IB).
De nghi HbAlc muc tieu nen noi long >7% 6 nhiing bn eo kem nhieu benh eo nguy ca tir vong dl kem, bn co tiioi gian song con ngSn \a CO nguy CO ha duong huyet {2C).
O bn CKD kem Dai thao duong, kiem soat duong huyet la 1 phan trong chien lupc can thiep da yeu to ben canh kiem soat huyet ap, nguy ca tim mach, su dung thuoc lic che men chuyen hoac lie che thy the angiotensin, statin, va thuoc chong tieu cau (UG).
Giai han muoi nhap
Khuyen cao giam luong muoi nhap
<90mMol (<2g) Sodium moi ngay (tuong ling voi 5g Natnehlorur) 6 nguoi truong thanh, ngoai trir CO chong chi dinh (IC)
Dieu tri tdng add uric mau
Chua CO chiing cii day dii ve viec dimg hogc khong dung cae thuoc giam add urie 6 cac bn CKD va tang uric acid kem hoac khong kem trieu chiVng de lam ch^m tien trien CKD (UG).
Thay doi loi song
Khuyen cao bn CKD nen duoc khuyen khich de tap luy^n sao cho phii hop vai tinh tiang siic khoe tim mach va bn dung nap dupe (muc tieu it nhat 30 ph moi Ian va 5 Ian trong 1 tuan), dat can nang ly hjong (BMI 20-25 Kg/m^, le tiiuoc vao dac diem ve dia ly ciia timg nuoe), va bo hiit tiiuoc ia (ID).
Tu van ve tiet chevd khau plian
Khuyen cao bn CKD can du<7c chuyen gia ve dinh duong tu van va nhiing thong tin ciia
Chuyen De Than Ni?u
Y Hpc TP. Hb Chi Minh * Tap 18 * Phu ban o i a So 4 ' 2014 Tong Quan chuong trinh giao d u t dieu chinh sao cho phii
hop vdi CKD va su can thiet can thiep tiet che muoi, phosphate, jxjtassium va protein nhap tiiy theo timg bn.
DIEU TRI CAC BIEN CHtfNG CUA BENH THAN MAN
Thieii mau
Iheo KDIGO 2012, chan doan tiiieu mau o lm CKD: khi Hb < 13g/dL 6 nam va <12g/dL o nif (UG). Nhiing bn CKD sau day, ran xet nghiem Hb de danh gia thieu mau (UG)
6 bn GFR > 60mVph/l,73 m2 (phan loai GFR G1-G2), neu lam sang co chi dinh
O bn GFR 30-59 ml/ph/1,73 m2 (phan loai GFR G3a-G3b) it nhat 1 Ian moi nam
6 bn GFR <30ml/phA,73 m2 (phan loai GFR G4-G5), it nhat 2 Kn moi nam.
Benh xuong chuyoi hoa va benh than man 6 bn GFR <^5mi/phA,73 m2 (phan loai GFR G3b-G5);
Khuyen cao ran do Iupng Caldum, phosphate, PTH, va phosphatase kiwn it nhat 1 Ian moi nam de xac dinh gia tri co ban (IC).
Khong nen do mat do xuong thuong xuyen vi thong tin thuong khong hihi ich (2B).
De nghi duy tri nong do phosphate huyet tuong 6 gioi han binh thuong (tiiv theo gia tii tham chieu ciia phong xet nghiem tai cho) (2Q.
Chua ro gia tri toi uu cua PTH huyet tuong.
De nghi bn co intact PTH rao hon gia tri binh thuang de danh gia tang phosphate mau, ha cala mau va thieu Vitamin D (2C)
Khong cung cap thuong quy Vitamine D hoac cac diat tuong tu Vitamin D khi khong co b ^ g chiing thieu hoac nghi ngo thieu, de lic che su tang nong dp PTH 6 bn CKD chua chay than nhan tao (2B).
Khong de nghi dung biphosphonate 6 bn GFR<30mI/phA,73 ni2 (Phan loai GFR G4-G5) khi khong co chiing cii ro rang ve lam sang (2B).
Toan chuyen hoa
De nghi mpi bn CKD co nong dp bicarbonate
<22mMoI/L can duoc bo sung bicarbonate duong uong de duy tri bicarbonate huyet thanh trong gia tri binh thuong, trir phi eo chong ehi dinh(2B)
Benh than man va benh ly lim mach Khuy&i cao mpi bn CKD dupe xem nhu la nguy eo rao ciia l>enh tim mach (1 A)
Khuy&i cao khong tha\' doi miic dp cham soc ve benh tim thieu mau cue bo 6 bn eo CKD (lA)
De nghi bn CKD co nguy ca xa viia dpng mach nen dimg fhuoe chong ket tap tieii rau trir phi can phai can nhac giiia tang nguy ca chay mau va Ipi ich t^ao \'e tim oia thuoc (2B).
E>e nghi miic dp cham soc \'e van de suy tim o bn CKD se tuong tu nguoi khong CKD (2A).
Bn CKD kem suy tim, bat ky viec gia tang thuoc dieu tri va hoae giam fhuoe, se dua vao eGFR va nong dp Kali (UG).
KhuySi cao can tham kham benh dpng mach ngoai bien thuang xuyen 6 bn CKD (IB)
De nghi bn CKD kem dai thao duong dupe diuyen gia bai chan thuong xuyen kham (2A).
Canh bao khi dpc cac thu nghiem ve tim m^ch 6 bn CKD
O bn CO GFR< 60ml/phA,73 m2 (phan loai GFR G3a-G5), can than trpng khi dpc xet nghiem:
Nong dp oia BNP/NT-proBNP va ran lien he vdi GFR truoc khi dua ra ehah doan ve suy tim va danh gia the tich tiian hoan (IB)
Nong dp troponin truoc khi ehah doan hpi chiing mach vanh cap (IB)
Dung ttiuoc va an toan dung Uiuoc 6 bn CKD
Khuyen cao thuoc ran dugc chinh lieu theo GFR(IA).
Xeu thuoc thupc nhom can dieu chinh h'eu ehinh xac (do giai han giiia hieu qua dieu tri va
Chuyen De Than Nieu 19
Tong Quan Y Hpc TP. Hb Chi Minh * Tap 18 * Phu ban ciia So 4 * 2014 dpc tinh hep) \'a,' hoac viec uoc doan eGFR se
khong chinh xac (do khoi luong co gjam), de nghi dua vao cystatin C hoae do true tiep GFR khong thong qua cac cong thiic uoc doan (IC).
Khuyen cao se ngung tam thai eae tiiuoc nguy ca doc than, va bai tiet qua than a bn co GFR < 60mVph/l,73 m2 (phan loai GFR G3a-G5) dang CO kem eae benh nang lam tang nguy ca bi ton thuong t h ^ cap. Cac thuoc luu y nhu: thuoc lie che he RAA nhu lie che men ehuyen, lic che thy \he, lie che aldosterone, va lie che true tiep renin), Ipi tieu, khang viem nonsteroid, metformn, lithium, va digoxin (IC).
Khuyen cao bn CKD nen tim nhiing huong din ve b?nh va thuoc truac khi dimg cae thuoc khong ke toa hoac cac che pham protein dinh duong (IB).
Khuyen cao khong dimg thao dupe a bn CKD (IB).
Khuyen cao can ngung metformin a bn CKD CO GFR < 45ml/ph/l,73 m^ (G3a-G5); can xem xet dimg khi GFR 30-44ml/ph/l,73m^ (G3b) va ngung dimg o bn GFR < 30ml/ph/l,73 irf
Khuyen cao can theo doi thuong xuyen GFR, dien giai va nong dp thuoc mpi bn diing cac thuoc dpc than nhu lithium, thuoc lie che ealeineurin (lA)
Khong nen tir choi dieu tri cac benh di kem nhu ung thu 6 bn CKD, nhung can phai chinh lieu cac thuoc dpc te bao dua vao GFR (UG) Cac khao sat hinh anh cf bn benh th|n man
Can can nhac giiia nguy ca suy than cap do thuoe can quang va gia trj mang lai ciia xet nghiem hinh anh va can thiep dieu tri sau do (UG).
6 mpi bn co GFR < 60mVph/l,73 m^ (phan loai GFR G3a-G5), khuyen cao can can nhac chi dmh va chpn lua dung fhuoe can quang iod duong tinh maeh theo huong dan ciia KDOGI ve AKI bao gom:
Tranli thuoc can quang co ap luc tham thau cao (IB).
Dimg thuoc can quang vdi lieu thap nhat (UG).
Ngung cac thuoc eo tiem nang dpe cho t h ^ truoc va sau khi lam thii thuat (IC).
Bu nuoe day du bang NaQ ti-u6c, trong va sau khi can thiep (lA).
Do GFR trong vong 48- 96h sau can fhi^p (IC).
Thuoc can quang co Gadolinium Khuyen cao khong dimg thuoc can quang chiia Gadolimium 6 bn GFR < 15ml/ph/l,73 (Phan loai GFR G5) trii phi khong con xet nghiem hinh anh khac thay the (IB).
De nghi bn eo GFR< 30ml/ph/l,73 m^ (Phan loai GFR G4-G5_ khi can dimg thuoe can quang chiia Gadolinium can uu tien chpn che pham chiia macrocycHc chelate (2B).
Thuoc can quang duong ruot
Khuyen cao khong dimg thuoc can quang duong ruot chiia phosphate o bn co GFR <
60ml/ph/l,73 m- hoac 6 bn co nguy co benh than do phosphate (lA)
Benh than man va nguy co oia nhiem trang, ton thuofng than cap, nhap vien va tuf vong
Benh thqn man vd nguy canhiem trung Khuyen cao mpi bn CKD duoc chich ngira vaccin chong influenza, trir phi chong chi djnh (IB).
Khuyen cao mpi bn GFR<30ml/ph/l,73 rrf , va nhiing bn co nguy ca cao bi ^dem phoi do phe cau trimg {nhu hpi chiing th§n hu, dai thao duong, hoac bn dimg thuoe lic che mien djdi) dimg vaccin da gia chong phe cau trimg ngoai trif chong ehi dinh (IB).
Khuyen cao mpi bn CKD da dupe chich vaccin chong phe cau faxing se dupe chich ngira lai sau 5 nam (IB).
Khuyen cao moi bn co nguy co cao tien trien CKD, va CO GFR < 30ml/ph/l,73 (phan loai GFR G4-G5) dupe chich ngira viem gan virus B va
Chuyen De Than Nieu
Y Hpc TP. Hb Chi Minh * T^p 18 * Phu b a n cua So 4 * 2014 Tong Quan kiem chiing hieu qua bao ve bang huyet thanh
(IB).
Can nhac dimg cac vaccin song tren co so danh gia tinh trang mien dich ciia bn va ran dua vao cac khuyen cao ciia ca so hoac chinh quyen (UG)
Benh than man vd nguy ca tan thuang than cap (AKI)
Khuyen cao mpi bn CKD dupe xem nhu nguy CO rao oia AKI (lA).
Bn CKD can tuan tiieo cae khuyen cao chi tiet trong KDIGO AKI guideline khi co nguy eo AKI trong qua trinh mac benh, hoac khi co nhiing can thiep thu thu^t, chan doan hinh anh lam tang nguy eo AKI (UG).
Benh than man vd nguy co nhap vien vd tu vong
Can thiet ke chuong trinh dieu tri CKD nham toi uu hieu qua dieu tri oia cpng dong vol bn CKD va giam nguy co nhap vien (UG)
Can luu tam dac biet den viec dieu tri cac benh di kem va nhat la benh tim mach nham giam nhap vien va tir vong a bn CKD (UG) Chuyen kham chuyen khoa Than
Khuyen cao chuyen kham chuyen khoa than o bn CKD trong nhiing tinh huong sau (IB).
AKI ho|c giam dot ngpt GFR
GFR<30ml/ph/l,73 m^ (phan loai GFR G4- G5).
Tieu albumine ni?u nhieu keo dai (ACR >
300mg/g (>30mg/mmol) hoae albumine nieu 24 gia > 300mg, hoac tuong duong voi PCR
>500mg/g (^Omg/mMol) hoae protein nieu 24 gib>500mg
CKD dang tien trien
Try hong cau trong nuac tieu, tieu hong cau>20/QT40 keo dai va chua co giai thich nguyen nhan
CKD va tang huyet ap de khang voi dieu tri
>4 thuoc
Nong dp Kali mau bat thuong keo dai
Soi nieu tai phat hoac gia tang Benh than bam sinh
Khuyen cao thai diem ehuan bi dieu tri thay the than 6 bn CKD tien trieh khi nguy co ciia s,\jy than trong nam dau tien la 10-20% hoac rao haiv xac dinh bang cong cy danh gja tien Iupng nguy CO (IB) (nham h ^ che chuyen tre <12 thang truac khi dieu tri thay the than).
Cham soc heiih than dang tim trien - De nghi ket hpp Hen diuyen khoa de cham soc cae bn CKD dang hen trieh {2B).
- Tap hop hen ehuyen khoa bao gom ca nhom lien quan den tao duong lay mau than nhan tao, den nhom chuyen vien dinh duong, giao due, va tu van ve cac bi?n phap dieu tri thay the than, ghep than, mo tao do dong tinh mach, va ea tinh than, va xa hpi (UG).
Thin diem Idwi dau dieu tri thay the than De nghi khoi dau dieu tn thay the than khi 1 hoae nhieu van de sau day xay ra
trieu chiing co nang va thuc the ciia suy than (viem cac mang, roi loan dien giai, thang bang kiem toan, ngiia)
khong CO kha nang kiem soat the tich tuan hoan va huyet ap
Suy dinh duong tien trien khong dap ling vdi can thiep oia chuj'en gja hoac kem hieu biet
Thuong dimg nhung khong hang dinh khi GFR 5-10ml/ph/l,73 m^ (2B).
Co the xem xet ghep than khong thong qua chay than nhan tao khi GFR < 20 ml/phl,73 va eo bang chiing eua CKD tien trien va khong hoi phuc trong 6-12 thang (UG).
KETLUAN
Benh than man thuang dien tien am tham, khong tneu chiing den giai dpan cuoi, nen muc tieu quan trpng la phat hien benh som 6 doi tugng nguy co cao (nhu bn dai thao duong, tang huyet ap, va gja dinh co nguoi l»nh than). Cac doi tupng nay ran dupe lam xet nghiem tam soat dinh ky hang nam va tich cue dieu tri som mot
Chuyen De Th?n Nieu
Tong Quan Y Hpc TP. Hb Chi M i n h * Tap 18 * Phu b a n ciia Sb 4 * 2014 khi phat hien co ton thuang tiian. Viec chan TAI LIEU THAM KHAO
doan xac dinh, va toan dien bn CKD bao gom I K D O Q I guidelme-Chronic Kidney Disease, N a b o n a l K d n e y
ehah doan nguyen nhan, chan doan tien h-ien, Foudatioii, Americm jounmi cf Kidney Disease,(2D02); 39 (2),
^ ^,, , 7 , ., , . , . , , . , . ,. Suppl,pl-242
y e u to lam b e n h n a n g tiiem, b e n h di kem^giup ^ ^.^^ ^^^^ ^ou. The chn.«l practice guideline for
BS lam sang CO the thiet lap chuong trinh dieu tri e\'aluation and management of Chnmic kidney disease
toan dien de lam cham tien trieh benh than man K,dnevinter,tatu,mi (ion), 3, i-i50.
den giai doan cuoi.
f
Chuyen De Than Nieu
