1 T VN Bnh thn mn (BTM) v bnh thn giai on cui (BTMGC) l sc khe cú tớnh ton cu õy l mt bnh ph bin cng ng v thng khú phỏt hin nhng giai on u khụng cú cỏc triu chng lõm sng rừ rt Theo nhiu nghiờn cu ti M, chõu u, chõu cho thy 13% dõn s th gii mc BTM Hu ht nhng bnh nhõn ny sm hay mun cng s tin trin n BTMGC v cn iu tr thay th thn bng phng phỏp: lc mỏu ngoi c th (thn nhõn to - TNT), lc mng bng (LMB) (thm phõn phỳc mc) v ghộp thn [1] Hin trờn th gii cú khong 1,5 triu ngi mc BTMGC ang c iu tr thay th thn v s lng ngi ny c tớnh s tng gp ụi vo nm 2020 Theo nghiờn cu NHANES-III ca M cụng b 2007 thỡ c mi BN c iu tr thay th thỡ s cú tng ng vi ngoi cng ng cú khong 100 ngi ang b bnh thn mn cỏc giai on khỏc [2] Trong phng phỏp iu tr thay th thn, Lc mng bng liờn tc ngoi trỳ l phng phỏp iu cú nhng u vit riờng, c bit i vi cỏc bnh nhõn sng xa trung tõm thn nhõn to, nhng bnh nhõn cú chng ch nh thn nhõn to v khụng cú iu kin ghộp thn, khụng phi dựng Heparin ton thõn, trỏnh lõy nhim chộo v ớt lm bin i huyt ng ca bnh nhõn [2] Bnh thn mn tớnh tựy theo tng giai on m cỏc bin chng gp cú th khỏc Suy thn cng nng thỡ tn sut cỏc bin chng cng nhiu v mc nng ca bin chng cng thay i theo mc lc cu thn Cú th gp nhng bin chng liờn quan trc tip hay giỏn tip n s gim sỳt chc nng thn (hi chng tng ure mỏu, ri lon in gii) hoc iu tr (nhim trựng, ) Theo Foley v cng s [3] thỡ nhng nguy c trờn h tim mch nhng bnh nhõn ny l cao hn so vi dõn s núi chung Vớ d, s bnh nhõn c iu tr bng lc mng bng v thn nhõn to chu k, t l bnh ng mch vnh chim khong 40%, t l dy tht trỏi khong 75% v t l t vong tim mch c c tớnh l 9% mi nm Do vy, tỡm hiu cỏc yu t nguy c tim mch, bao gm cỏc yu t kinh in (tui, gii tớnh, h gen), cỏc yu t khụng kinh in (tha dch, thiu mỏu, ri lon calci phospho) cựng vi vic thm dũ cỏc ri lon tim mch nhúm bnh nhõn ang c lc mng bng chu k l rt cn thit, nhm gúp phn tiờn lng, phũng nga, khng ch bin chng tim mch tin trin, trỡ tt chc nng tim mch thi gian di, hn ch t l t vong nguyờn nhõn tim mch nhúm bnh nhõn ny Vỡ nhng lý trờn, chỳng tụi thc hin ti : Tỡm hiu mt s yu t nguy c tim mch bnh nhõn lc mng bng liờn tc ngoi trỳ ti khoa Thn tit niu Bnh vin Bch Mai vi hai mc tiờu sau: Tỡm hiu mt s yu t nguy c tim mch bnh nhõn lc mng bng liờn tc ngoi trỳ ti Khoa Thn tit niu Bnh vin Bch Mai Tỡm mi liờn quan gia cỏc yu t nguy c tim mch vi creatinin mỏu, acid uric, chc nng thn tn d nhng bnh nhõn trờn CHNG TNG QUAN 1.1 iu tr bnh thõn mn Bnh thn mn tớnh khụng th iu tr hon ton, cú mc tiờu iu tr bnh thn mn tớnh: - iu tr nguyờn nhõn v cỏc yu t nguy c cng nh cỏc bnh phi hp - Lm chm s tin trin ca bnh - iu tr triu chng v bin chng ca bnh - Thay th chc nng thn bng lc mỏu ngoi thn hoc ghộp thn [2] 1.1.1 iu tr bo tn iu tr bo tn hay cũn gi l iu tr ni khoa, c ỏp dng i vi cỏc bnh nhõn bnh thn mn tt c cỏc giai on: t giai on n 5, giai on cú can thip vi lc mỏu chu kỡ, hoc lc mng bng, hoc ghộp thn Riờng i vi BN bnh thn mn giai on cui (giai on 5), ch nh cỏc trng hp sau: - BN ang giai on cp ca bnh thn mn vi cỏc ri lon dinh dng, mt cõn bng nc- in gii, thiu mỏu, cỏc bin chng tim mch: cn tng huyt ỏp, phự phi cp, hen tim, ri lon nhp tim - BN bnh thn mn giai on cui chun b iu tr can thip vi lc mỏu chu kỡ, hoc lc mng bng, hoc ghộp thn - BN bnh thn mn giai on cui chng ch nh vnh vin hoc tm thi vi cỏc phng phỏp iu tr thay th thn suy: suy tim nng, cỏc bt thng phỳc mc, nhim trựng, suy kit iu tr bo tn bao gm: giỏo dc bnh nhõn bnh thn mn, tit thc, kim soỏt huyt ỏp v cỏc bin chng tim mch khỏc, iu tr thiu mỏu, iu tr suy dinh dng, iu tr cỏc ri lon nc- in gii, iu chnh ri lon canxi-phospho mỏu, tiờm phũng vacxin viờm gan B[4] 1.1.2 Lc mỏu chu kỡ bng thn nhõn to - Lc mỏu chu kỡ bng thn nhõn to c ỏp dng cho hu ht bnh nhõn bnh thn mn giai on cui khụng kốm cỏc bnh lớ tim mch nng, khụng cú cỏc ri lon ụng chy mỏu, bnh nhõn bnh thn mn kốm cỏc ri lon chc nng nóo, tng K+ mỏu khụng ỏp ng vi iu tr bo tn, toan mỏu khụng ỏp ng vi iu tr bo tn, h s thi creatinine mỏu < 15 ml/phỳt/1,73 [5] 1.1.3 Ghộp thn Ghộp thn c ch nh i vi tt c bnh nhõn bnh thn mn giai on cui ó lc mỏu hoc sp lc mỏu, vi iu kin bnh nhõn t nguyn ghộp thn v khụng cú chng ch nh Do nhng tin b iu tr sau ghộp, tui bnh nhõn ghộp hin ó cao hn rt nhiu Mt iu ỏng lu ý l c ba phng phỏp trờn khụng ỏp dng n c v cú th phi hp hoc thay th trờn cựng mt bnh nhõn, tựy tng giai on bnh c th [4] 1.1.4 Lc mng bng (LMB) 1.1.4.1 Ch nh v chng ch nh ca lc mng bng a Ch nh ca lc mng bng [6] - Suy thn cp: + Vụ niu, phự + Ure mỏu > 30 mmol/l + Creatinin mỏu > 800 àmol/l + Kali mỏu > 6,5 mmol/l + Natri mỏu < 120 mmol/l + Kim d < -10 mmol/l - Bnh thn giai on cui: mc lc cu thn < 15 ml/phỳt b Chng ch nh lc mng bng [6] - Viờm phỳc mc cú dớnh, mng bng mt kh nng siờu lc - So m c vựng bng - Thoỏt v c honh, rn, thnh bng - Bnh thn a nang, thn quỏ to - BN ri lon tõm thn, ngi quỏ ln tui, th lc kộm (chng ch nh tng i) 1.1.4.2 Cỏc phng phỏp lc mng bng - LMB ngoi trỳ liờn tc (CAPD): Dch lc c a vo bng, sau 4-6 gi c gi li, sau s trao i dch cú cha cỏc cht thi c dn lu vo tỳi cha dch v theo nguyờn lý trng lc, khụng cn mỏy bm dch S ln lc khong 3- ln ngy v mt ln vo ban ờm vi thi gian lu dch di hn, kộo di ton b gic ng ca bnh nhõn - LMB chu k liờn tc (CCPD): S dng mỏy chu k t ng tin hnh 3-5 ln lc ờm khi bnh nhõn ng Bui sỏng bnh nhõn tin hnh ln lc vi thi gian lu tr kộo di sut c ngy - LMB giỏn on v ờm (NIPD): Ging nh CCPD nhng s ln lc ờm nhiu hn (khong ln hoc hn), bnh nhõn khụng cn lc sut ngy Loi LMB ny rt thớch hp vi bnh nhõn mng bng cú tớnh thm cao v chc nng thn cha suy hon ton 1.2 Cỏc yu t nguy c tim mch bnh nhõn lc mng bng ngoi trỳ liờn tc Bnh nhõn suy thn giai on cui cú nhiu yu t nguy c cho bnh tim mch, bao gm cỏc yu t nguy c kinh in v cỏc yu t nguy c khụng kinh in Cỏc yu t nguy c kinh in nh gii tớnh nam, hỳt thuc lỏ, ỏi thỏo ng, tỡnh trng khỏng insulin, ri lon lipid mỏu, li sng tnh ti Cỏc yu t nguy c khụng kinh in nh l tỡnh trng viờm, ri lon chc nng ni mụ, tng hot tớnh giao cm, thiu mỏu, tha dch, tng cao PTH [7] Mt s cỏc yu t liờn quan n suy thn nh quỏ ti dch, tỡnh trng viờm v ri lon calci-phospho c cho l cú vai trũ quan trng dn n t l t vong cao nhúm BN ny Hn na, mt s yu t khỏc cng c chng minh l gúp phn thỳc y bnh bnh tim mch BN lc mng bng nh mt chc nng thn tn d (CNTTD) Túm li, cú rt nhiu yu t cựng nh hng lờn cỏc bin chng tim mch BN suy thn giai on cui LMB Cỏc yu t ny tỏc ng qua li ln nhau, gõy vũng xon bnh lý khin cho BN suy thn giai on cui núi chung v BN lc mng bng núi riờng cú t l bnh tt v t vong tim mch tng lờn [8] 1.2.1 Cỏc yu t nguy c kinh in 1.2.1.1 Tui Tui gi cú mt vai trũ nht nh vic hỡnh thnh cỏc bnh lý tim mch, nht l nhng BN suy thn mn Cng ln tui thỡ tim hot ng cng kộm hiu qu ú l quỏ trỡnh lóo hoỏ sinh lý ca cỏc t bo c tim, cỏc thnh tim dy lờn, thi gian ngh gia cỏc nhp p gim i, hn na quỏ trỡnh x va ng mch c tớch lu dn theo thi gian [9] Nhng nguyờn nhõn trờn lm cho quỏ trỡnh bm mỏu cng tr nờn khú khn hn Cỏc thay i trờn h tim mch ny cựng vi s suy gim chc nng thn tui gi hay bnh lý suy thn mn s kt hp vi gõy nờn s khú kim soỏt quỏ trỡnh tin trin bnh tim mch cng nh iu tr 1.2.1.2 Gii tớnh Vai trũ ca cỏc yu t nguy c tim mch s phỏt trin cỏc bnh lý tim mch l khỏ ging c hai gii V cỏc nguy c ny tng dn theo tui tỏc, nhng mc tng ph n l rừ rt hn, nht l sau giai on kinh T l mc bnh mch vnh nam gii cao hn n gii 3,38 ln, t l t vong cao hn ln gii tớnh n, estrogen l hormone gii tớnh chim u th Vic gim sn xut estrogen sau kinh lm thay i chuyn hoỏ lipid theo hng thun li cho vic hỡnh thnh x va mch mỏu hn: tng Cholesterol, Triglycerid, LDL C v gim HDL C Ngoi ra, estrogen cũn cú tỏc dng bo v tim mch thụng qua quỏ trỡnh chuyn hoỏ glucose v cỏc h thng ụng mỏu, v nú cng cú th cú nh hng trc tip n chc nng ca t bo ni mch [9] Hn na, hỳt thuc lỏ cng liờn quan n s khỏc bit gii tớnh cỏc yu t nguy c tim mch 1.2.1.3 Hỳt thuc lỏ Khúi thuc lỏ cha 4000 thnh phn khỏc gõy c cho c th Nicotin khúi thuc lỏ kớch thớch c th sn xut adrenaline lm tng nhp tim v huyt ỏp, dn n tng gỏnh nng cho tim, cng nh c quan lc mỏu- thn Hỳt thuc lỏ cng lm tng tip xỳc vi CO, chỳng gn vi hemoglobin bn vng hn vi oxy, lm gim ỏng k kh nng mang oxy ca hng cu Hu qu l thiu oxy t chc, khin cho tim tng hot ng bự tr li [10] Ngoi hỳt thuc lỏ lm tng nng cholesterol mỏu, iu ny xy cht acrolein, gõy nguy c x va mch mỏu V tc ca quỏ trỡnh ny c tng thờm bi rt nhiu cỏc cht c hi khỏc thuc lỏ, cho phộp cỏc mng x va hỡnh thnh vi tc nhanh hn so vi ngi khụng hỳt thuc Thờm vo ú l nguy c hỡnh thnh huyt nh hng ca thuc lỏ n fibrinogen v tng tớnh ngng tiu cu Cui cựng, hỳt thuc lỏ ó c chng minh gõy co cỏc mch mỏu bng cỏch gim oxit nitric v tng endothelin [10] 1.2.1.4 Tng huyt ỏp Tng huyt ỏp BN lc mng bng rt ph bin, mt bỏo cỏo ti M kho sỏt trờn 540 BN lc mng bng ti 27 trung tõm cho thy, cú ti 88,1% BN cú THA [11] mt s nghiờn cu, HATT vo lỳc bt u LMB l yu t d bỏo t vong Mt nghiờn cu hi cu trờn 2770 BN lc mng bng cho thy s khỏc bit cú ý ngha thng kờ v t l t vong sau 4- nm gia nhng BN cú HA tõm thu lỳc u khỏc [12] Tng HATT v HATTr liờn quan ỏng k n cỏc bt thng trờn siờu õm tim Nhng BN lc mng bng lõu di cú t l THA cao hn quỏ ti dch nng n hn so vi BN thn nhõn to Nguy c tai bin mch mỏu nóo, thiu mỏu c tim, PTT v suy tim liờn quan n HA tng lờn BN suy thn giai on cui (bao gm c BN lc mng bng v thn nhõn to) Silaruks nghiờn cu trờn 66 BN lc mng bng khụng cú tin s bnh lý c tim gión Kt qu cho thy 30,3% BN cú dy thnh TT > 12 mm dy thnh TT > 14 mm d bỏo nguy c mc bnh tim mch v t vong tim mch cao hn ỏng k T l sng cũn sau nm ca nhúm PTT l 56% Khong 82% cỏc trng hp t vong l bnh tim hoc tai bin mch mỏu nóo[13] 1.2.1.5 Ri lon Lipid mỏu Ri lon lipid rt ph bin BN lc mng bng v nhng BN ny thng cú ri lon x va nng n hn BN thn nhõn to vi cholesterol ton phn, LDL cholesterol, apolipoprotein B, triglycerid tng v HDL cholesterol gim [14] Mai Th Hin [11] nghiờn cu trờn 47 bnh nhõn lc mng bng, kt qu cho thy 63,8% s bnh nhõn cú ri lon ớt nht mt thnh phn Lipd mỏu Chc nng ca lipoprotein lipase cng b suy gim Mt protein qua mng bng cú th to nờn bnh cnh ging nh hi chng thn h, dn n gan sn xut quỏ mc cỏc apoB- lipoproteitein Ngoi cũn BN luụn tỡnh trng phi tip xỳc vi glucose dch lc, nng Insulin cao cng thỳc y quỏ trỡnh sn xut LDL Nng Tryglycerid tng nhiu bnh nhõn LMB v him tng n c m thng ng thi vi gim HDL v tng apoB bnh nhõn LMB, lipoprotein a cng thng tng v liờn quan n nguy c mc bnh mch vnh tng lờn Tỡnh trng suy dinh dng BN lc mng bng cú th gúp phn gõy tng lipoprotein nhng nguyờn nhõn sõu xa cha c bit rừ Túm li, BN lc mng bng cú nhiu dng ri lon lipoprotein 1.2.1.6 Bộo phỡ Bộo phỡ c xem l du n ca hi chng chuyn húa Trờn th gii, t l bộo phỡ v tỡnh trng tha cõn ngy cng gia tng Bộo phỡ liờn quan ti tng t l bnh phi hp vi mt s cỏc yu t nguy c tim mch khỏc Hi chng chuyn húa gúp phn vo tin trin ỏi ng, tng huyt ỏp, x va mch v bnh tim mch núi chung Bộo phỡ l yu t nguy c cho gim chc nng thn nng lờn cỏc bnh nhõn cú bnh thn t trc v cú th gõy tn thng thn nhng ngi khe mnh bỡnh thng khỏc Bộo phỡ cú th gõy suy thn hin tng iu hũa sm quỏ mc mt s lng ln cỏc yu t tin viờm (vớ d nh leptin, interleukin, adipolectin, yu t TNF- v cỏc yu t tng trng khỏc (angiotensin II, TGF-, leptin), dn ti sn xut cht mm gian mch, dy mng ỏy cu thn v ng thn, cỏc tn thng ny s gõy nờn x húa cu thn Hn na, ngi bộo cú nguy c b mc bnh phi hp v cú t l cht bnh tim mch cng nh bnh nhõn b bnh thn mn tớnh [15] Bộo phỡ cú th dn ti tng huyt ỏp tng tỏi hp thu mui ti ng thn, suy gim kh nng o thi natri niu, gõy nờn tha dch v gõy nờn hin tng ộp sinh lý ti thn Thờm vo ú, ỏi thỏo ng v ri lon v lipid thng gp ngi bộo, to thun li thờm cho cỏc bin chng tim mch v gúp phn thỳc 10 y tn thng thn Vic iu tr tớch cc gim bộo l rt cn thit ci thin tin trin bnh thn gõy nờn bi hi chng chuyn húa 1.2.2 Cỏc yu t nguy c khụng kinh in 1.2.2.1 Tha dch Bnh nhõn LMB cú CNTTD ngy cng gim, ng thi mng bng mt kh nng siờu lc b x húa sau mt thi gian di tip xỳc vi glucose hoc cỏc t viờm phỳc mc Vỡ vy, kh nng o thi mui- nc cng b gim i ỏng k Nguyờn nhõn ca hin tng tha dch bao gm nhiu yu t nh lng dch ung vo nhiu, lng dch dn lu ớt, BN cú mng chuyn cao Bnh nhõn T cng thng tng nguy c tha dch ngoi t bo hn Theo Ates [16], kh nng o thi mui- nc nh hng ỏng k n t l sng cũn ca BN, ú nhng BN vi kh nng o thi muinc kộm hn cú t l t vong cao hn cú tỡnh trng tha dch v hu qu ca nú l PTT v ri lon chc nng TT nng n hn Nhng BN lc mng bng cú CSKCTT tng > 75% sau thi gian trung bỡnh 18 thỏng cú nguy c t vong v nguy c mc cỏc bin c tim mch cao hn ln so vi BN cú CSKCTT tng ti thiu Vỡ vy, kim soỏt dch cht ch l bin phỏp iu tr quan trng vic lm hi phc PTT v gim nguy c mc cỏc bin c tim mch bnh nhõn LMB S quỏ ti dch BN LMB lõu nm cũn s gim albumin mỏu Mt nghiờn cu ó tỡm rng, c mi 1g/ lớt gim xung ca nng albumin mỏu s tng ng vi 330ml lng dch ngoi t bo tng lờn [17] Vỡ vy, gim albumin mỏu cng gúp phn gõy quỏ ti dch bnh nhõn LMB 1.2.2.2 Ri lon chuyn hoỏ calci phospho Tng phosphat mỏu v tng sn phm Ca x P gúp phn lm tng nguy c cho lng ng calci vo mch mỏu, van tim v cỏc mụ khỏc Nhng bng chng gn õy cho thy õy l mt ri lon ph bin trờn nhúm BN ny, 20 C.J Konings, et al (2002), "Fluid status, blood pressure, and 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RK, et al (2007), "Beta2microglobulin as a biomarker in peripheral arterial disease: proteomic profiling and clinical studies", Circulation, 116(12), pp 1396403 PH LC MU BNH N NGHIấN CU KHOA THN TIT NIU M BNH N: BNH VIN BCH MAI MU BNH N NGHIấN CU THễNG TIN BNH NHN H tờn bnh nhõn : Tui: Gii: a ch: Ngy xột nghim: Lc mng bng thỏng th: LM SNG: Chiu cao: cm Cõn nng:.kg Mch:.ln/phỳt Huyt ỏp: mmHg Da,niờm mc: 1.Xanh nht au u: 1.Cú 2.Hng 2.Khụng S lng nc tiu: ml/24h Phự: Chúng mt: Cú Khụng Ch s siờu lc UF :ml/24h Dch lc mng bng: Loi dch lc 1,5% 2,5% 4,25% S lng (tỳi/thỏng) CN LM SNG 3.1 Tng phõn tớch t bo mỏu ngoi vi RBC(T/l) MCV WBC(G/l) Hb (g/l) MCH PLT(G/l) Hct MCHC 3.2 Sinh húa mỏu Ure Glucose Creatinin Acid uric Protein TP Albumin St Ferritin 3.3 Transferin Cholesterol TP Triglycerid HDL C LDL C GOT GPT Phospho Calci ton phn Calci ion PTH Procalcitonin CRP 2microglobulin Na: K: Cl: Cỏc xột nghim khỏc in tõm : XQ: Khỏc: B GIO DC V O TO B Y T TRNG I HC Y H NI NGUYN NGC TRAI TìM HIểU MộT Số 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H Ni, ngy 19 thỏng nm 2016 Nguyn Ngc Trai LI CAM OAN Tụi xin cam oan õy l cụng trỡnh nghiờn cu ca riờng tụi Cỏc s liu, kt qu nghiờn cu lun l trung thc v cha tng c cụng b bt kỡ mt cụng trỡnh no khỏc H Ni, ngy 19 thỏng nm 2016 Sinh viờn Nguyn Ngc Trai MC LC DANH MC CC CH VIT TT BTM BTMGC CNTTD CSKCTT T HATT HATTr ISPD JNC VII KDIGO LMB MLCT NHANES-III NKF KDOQI PTT RLCN STMT THA TNT TT Bnh thn mn Bnh thn mn giai on cui Chc nng thn tn d Ch s c tht trỏi ỏi thỏo ng Huyt ỏp tõm thu Huyt ỏp tõm trng International Society for Peritoneal Dyalisis - Hi Lc mng bng quc t The Seven Joint National Committee - U ban Quc gia Hoa k Kidney Disease Improving Global Outcomes - Hi Thn hc Th gii Lc mng bng Mc lc cu thn The Third National Health and Nutrition Examination SurveyKho sỏt Nghiờn cu Sc kho v Dinh dng Quc gia Hoa Kỡ National Kidney Foundation Kidney Disease Outcomes Quality Initiative Hi ng lng giỏ Kt qu bnh thn Quc gia Hoa k Phỡ i tht trỏi Ri lon chc nng Suy thn mn tớnh Tng huyt ỏp Thn nhõn to Tht trỏi DANH MC CC BNG DANH MC BIU