Thận tiết niệu

OAl MAU I O jNH NG HIA D m au la tin h tra n g nu ’O’C tieu co hong cau C o dai m au dai the va dai m au vi the - D a i m au dai the: nu’O’C tieu sam m au, nhan biet du’O’c b ln g m it thu’O’ng - D mau vi the: m at thu’O’ng khong nhan thay, chi phat hien du’O’c lam xet nghiem te bao hoc nu’O’C tieu voi so luong hong cau > 10.000 hong cau/ml li chAn ooAn C h a n d o a n x a c d jn h C o hong cau tron g n u o c t ilu cac m u c khac (vi the hoa c dai the) C o the phat hien n u o c tieu co m au b ln g m at th u d n g hoa c co the phat hien hong cau nieu vi the b ln g xe t nghiem tong phan tich n u o c tieu hay xe t n gh iem te bao nieu a T rie u c h u ’n g la m s a n g T uy th e o n gu yen nhan gay dai m au se co trieu c h u n g lam sang tu o 'n g ung - D m au dai the h o a c vi the + Co the kem th e o tieu buot, dai r it , kho, n g lt quang, bi tieu - Co the co sot, co ho a c khon g ret run - Co the c o n dau q u a n than, dau ho t h it lu n g m ot hoac hai ben - Co the dau tu c , nong rat vung bang quang b C a n la m s a n g - X et ngh iem n u o c tie u de khan g djnh dai m au: co hong c iu nieu d cac m u c - D e tim ngu yen nhan dai m au can lam them m ot so tham do, tu y th u o c lam sang: + T e bao nieu: tim te bao ac tin h + C ly vi khuan + Sieu am he th a n - tie t nieu + C hup bung khon g c h u ln bj + P rotein nieu g id + S oi bang q u a ng, co th e tien hanh tron g giai doan dang dai m au + C h up be th a n n g u a c dong (U PR ) + C h up c i t lo p vi tin h (C T scan) + C h up m ach + D in h lu o n g ca c g lo b u lin m ien dich (IgA, IgM, IgG, IgE) Ig + S inh th ie t than: hien vi quang hpc va m i§n djch huynh quang 574 H u nieu dao khong phu th u o c va o ca c lan di tieu tien - Nu’d c tieu lan m au: d phu nCr dang co kinh nguyet - M yoglobin nieu co tieu co - H e m og lobin nieu co tan m au tron g long m ach, p o rp h rn e nieu (nu’d c tieu sam khong co mau cuc) —> can xet n gh iem te bao hoc —* k h ln g dinh dai m au C h a n d o a n n g u y e n n h a n d a i m a u : th u o c va o ngu yen nhan C ac nguyen nhan co th e gay dai m au: a D a i m a u d o n g u y e n n h a n tie t n ie u : tru ’d c het phai ca n h g ia c v d i kh o i u th a n -tie t nieu gay dai m au - D m au soi than, tie t nieu - D m au khoi u: + Khoi u nhu m o than + U bieu m o tie t nieu + U bang quang + U tuyen tien Net - D m au nhiem tru n g tiet nieu - D m au chan thu’o ng : + C han thu’o n g vung th a t lu ng + C han thu’o n g vung vi + C han th u ’a n g nieu dao b D a i m a u d o n g u y e n n h a n th a n - V iem cau than: + V iem cau than cap + V iem cau than m an - V iem ke than - Di tat bam sinh he tie t nieu: nieu quan doi, than m ong n g a a , da nang than c D a i m a u d o c a c n g u y e n n h a n h ie m g a p - N ghen, t i c m ach than (dong m ach va tin h m ach) - T ac tin h m ach chu - San m ang C ac tham ch uye n sau co the th u c hien - Noi soi bang quang: tien hanh dang co dai m au - C hup nieu quan be than n g u 'o c dong co th u o c can q u a n g (U P R ), ch u p c i t Idp vi tin h (CT) chup m ach than (AG ): co dai m au tir m ot ben nieu quan can tien hanh de tim kiem khoi u than kich thirdc nho hoac di dang m ach m au - S in h th ie t th a n : kh i co d a i m a u t ir h a i b e n n ie u q u a n d b e n h n h a n tre tu o i n g h i n h ie u (Jen b e n h B e rge r H u Ong d An c h An o o An vA pi£u t r i b£nh Npi kh oa 575 III O l£U TRj D ie u trj trie u c h irn g a N o i k h o a - T h u o c cam m au: tra n sa m in d u o n g uong hoac truye n tTnh m ach - T ruyen m au neu m at nhieu m au - K h ang sinh neu co dau hieu nhiem trung: sulfam id, q u in olon, co the phoi h o p v o i nhom khac theo dien bien lam sang va ket qua cay vi khuan m au va n u o c tieu - T uy th u o c va o n gu yen nhan gay dai m au can phoi h o p th e m th u o c khac b N g o a i k h o a Trong m ot so tru o n g h o p neu co ta c nhieu d u o n g tie t nieu m au cuc tao thanh, can can thiep ngoai khoa tam th o i d in lu u , l l y m au cuc tai bang quang, tru o c giai quye t nguyen nhan D i§ u trj n g u y e n n h a n : Can thiep ngoai khoa vao nguyen nhan gay dai m au va tinh trang lam sang cu the cua benh nhan IV P H O N G B E N H Nen kham va kie m tra dinh ki de phat hien benh s o m va dieu tri kjp th o i tAi lieu tham khAo H e m a tu ria C a u s e s O r ig in a l D a te o f P u b lic a tio n : 15 J u n 1998, R e view ed by S tacy J C hilds, M D., S ta n le y J S w ie rze w ski, III, M D Last R eview ed: 10 Jul 2008 H e b e rt, D N ; N a d a s d y , T.; N a d a s d y , G ; A g a rw a l, G ; M a u e r, M ; A g a rw a l, A K ; K h a b iri, H.; N a g a ja , H N e t a l (M a r 0 ), “P ro p o s e d p a th o g e n e s is o f id io p a th ic lo in p a in -h e m a tu ria s y n d ro m e ", A m J K id n e y D is 47 (3): 419-27 R u s s o , D ; M in u to lo , R ; la c c a rin o , V.; A n d re u c c i, M ; C a p u a n o , A ; S a v in o , FA (S e p 1998), “G ross h e m a tu ria o f u n c o m m o n origin: the n u tc c k e r s y n d ro m e ”, A m J K id n e y D is 32 (3): E3 VIEM BANG QUANG CAP I DjNH NGHIA V iem bang quang cap la tin h tran g nhiem khua n cap tin h tai bang qua ng Bieu hien lam sang la co hoi c h u n g bang qua ng ro v o i dai buot, dai rat, co the dai m au, dai m u cu o i bai X et ngh iem nucrc tieu co bach cau nieu va vi khua n nieu Benh th u d n g gap o n u v o i ti le n u /n a m la 9/1 Vi khuan gay benh chu yeu la vi khuan G ram (-) va gay viem bang quang chu yeu th e o d u o n g n g u o c dong (tu nieu dao vao) T rong bai khong de cap den viem bang qua ng lao ii chAn d o An C h a n d o a n x a c d jn h a L am san g - Co hoi c h u n g bang q ua ng ro v o i dai buot, dai rat, co the dai m au, dai m il cu o i bai - Co the co dau nhe vung tren kh o p m u bang quang cang - D oi trieu c h u n g khon g dien hinh, ch i nong rat di tie u hoa c dai rat - T h u o n g khong sot hoa c ch i sot nhe (nhie t < 38°C ) b X e t n g h ie m nu’&c tieu - Bach cau nieu ro (s 104 bach cau/m l n u o c tieu), co bach cau da nhan th o a i hoa hoac > bach cau/ vi tru o n g - Vi khuan nieu: > 10 5/m l n u o c tieu cay - Khong co protein nieu h oa c protein nieu ve t tru co dai m au, dai m u dai the c X e t n g h ie m m a u - T h u o n g khong can xet nghiem - Bach cau va bach cau da nhan trun g tin h khong tang C h a n d o a n n g u y e n n h a n a C a c lo a i vi k h u a n thu’d’n g gap - E sch e rich ia c o li: kh o a n g 70 - 80% benh nhan - P roteus m irabilis: 10 - % benh nhan - Klebsiella - % benh nhan - S ta p h ylo co cu s s a p ro p h yticu s: - 10% benh nhan - P s e u d o m o n a s a e ru s g in o s a - 2% benh nhan - S ta p h ylo co cu s a u re u s : - 2% benh nhan b N g u yen n h a n th u a n la i - Phi dai tien liet tu ye n hoa c u tuyen tien liet - Soi, u bang quang H u o n g d An c h An b o An v A o i £u tri b£n h N O i khoa 577 - B a i th £ o d u d n g - C o thai - D a t ong dan lu’u bang quang nhieu nguyen nhan khac III O l£U TR! B i§ u t r j th e v ie m b a n g q u a n g c l p th o n g th u ’d n g - D ie u tri co the dung m ot n h u n g th u o c sau: + N h om trim e th o p rim - sulfa m e th o xa zo l: vi du B iseptol, Lysep to l vien 80 m g, uong vien chia lan, uong tro n g + N hom beta lactam in: vi du am oxicilin vien 500m g, uong - vien, chia lan, uong + N hom ce fa lo sp o rin th e he 2: vi du cephalexin: vien 500m g, uong - vien chia lan, uong + N hom hoa chat sat khuan: v i du n itrofura nto in vien 50m g, uong vien chia lan, uong 10 hoac M ictasol blue 500 m g vien chia lan, uong tron g 10 - U ong du n u d e : lu o n g n u d e tieu tren 24 g id tri khoa ng lit - Neu sau dieu tri benh khong dd, can thay doi ph a c dieu tri C o the dung thuoc nhom fiuroquinolon: N oroxin, F loxin vie n 00 m g, uong vien T h d i gian dung th u o c trung binh tu - D a c biet benh nhan can d u o c kham lam sang va lam cac xet ngh iem can lam sang de tim cac nguyen nhan th u a n lo i (phi dai tien liet tuyen, soi bang quang, ) va xet nghiem vi khuan (soi tu o i, nhuom gram , cay) D ie u tr j th e v ie m b a n g q u a n g c l p c o n g u y e n n h a n th u a n lo ’i + D ieu trj vie m bang q u a n g c lp co nguyen nhan th u a n lo i se kho khan h o n T o t n h lt la lu a chon khang sinh th e o khan g sinh neu co ket qua cay n u d e tieu, dong th d i dieu tri loai bo nguyen nhan thuan loi + T h d i gian dieu tri tru n g b in h nen tu 10 - + Co the dung khan g sinh d u d n g tiem hoac d u d n g uong + Neu dung d u d n g tiem chi nen dung tron g - ngay, sau tiep tu c b ln g d u d n g uong + U ong du n u d e D ie u tr j v ie m b a n g q u a n g c l p d p h u n u c o th a i + C an s u dung n h u n g khan g sinh khong co nguy c o anh h u d n g td i thai nhi T h d i gian dieu tri trung binh tu - C o th e lu a chon m ot n h u n g khang sinh sau: - N hom ce fa lo sp o rin th e he 2: vi du ce ph ale xin vien 500m g, vie n ch ia lan, uong - hoac ce fu ro xim : Iq 750 m g, nga y lo chia lan, tiem b ip sau ho a c tin h m ach cham - phut Tiem tron g - ngay, sau chuye n th u o c uong cho du 10 H o ac ce fta zid im : Ip 1000m g, - Iq , ch ia - lan, tiem b ip sau hoac tin h m ach cham tron g 3- phut Tiem tron g - ngay, sau chuyen th u o c uong cho du 10 - N h om beta - la cta m in : vi du A u g m e n tin , M oxiclav, A m o cla vic: vie n 500m g, vien chia lan, uong tro n g - H o ac A u g m e n tin tiem 1,5g - 2g tron g den ngay, sau chuye n uong cho du 10 + L u u y: can dieu tri nga y vie m bang quang c lp , ke ca tru d n g h o p chi co vi khua n nieu m a c h u a co bieu hien lam sang d phu nu' co thai de de phong viem th a n -b e than cap, m o t tin h tran g benh de d u a d en say thai hoa c de non C u ng can chu y dac biet khong dung nh o m q u in o lo n cho phu n ij co thai vi a nh h u d n g td i s u p h a t trie n x u o n g sun cua tre H u O n g dA n c h A n o o A n vA b i£u t r i bEnh 578 NOi khoa D id u trj v ie m b a n g q u a n g c a p h a y ta i p h a t B?nh nhan d u a c coi la hay tai phat co tu d o t nhiem khuan tiet nieu trd len tro n g nam Sau dieu tri tan cong can tiep tu c dieu tri tri C o the dung m ot tron g cac pha c sau - D ung m pt lieu khang sinh tru’d c hoac sau m oi lan g iao ho’P, neu nhiem khuan lien quan den quan he tin h due, vi du: + Biseptol: 480 m g x vien hoac + N oroxin: 400 m g x vien - D ung lieu th a p khan g sinh (thu’d n g 1/3 lieu), uong vao buoi toi tru ’d c di ngu, keo dai ti> thang V i du: + Biseptol: 480 m g x vien tru ’d c ngu hoac + N oroxin: 400 m g x 1/2 vie n tru ’d c ngu hoac + C ephalexin: 250 m g x vien tru ’d c ngu hoac + N itrofurantoin: 50m g x vien tru’d c ngu - U ong du nu’d c IV PHONG BENH - C an g id ve sinh bo phan sinh due ngoai - Uong du nu’d c de dam bao lu p n g nu’d c tieu > 1,5 lit/24 gid, di tieu deu dan thu’d n g xuyen 4-5 gio/lan - D ieu tri loai bo ngu yen nhan th u a n loi t Ai lieu tham khAo "B enh h o c n $ i khoa", tap I (2007), N h a xuat ban Y hpc "B enh th a n " (2008), N xuat ban Y hoc “ Texbook o f N e p h ro lo g y " (2002) "O xford te xtb o o k o f c lin ic a l n e p h ro lo g y ” (2005) VIEM THAN - BETH AN CAP • • I DAI CU’Q NG • V iem than - be than cap (V T B T cap) la tin h trang nhiem khuan cap tin h cac dai than, be than, nieu quan va nhu m o than hay goi la nhiem khuan du’O’ng tie t nieu tren • N hiem khua n cap tin h vi khuan gay nen theo du’d n g n g ira c dong tu bang quang len nieu quan roi den dai be than ho a c du’O’ng m au d ira den co nhiem trun g huyet Vi khuan gay benh thu’o n g gap la G ram am , • N guyen nhan gay benh - N hiem khuan tiet nieu n g u o c dong tron g tru d n g h o p trao n g u o c bang quang - nieu quan, sau soi bang quang - nieu quan, chup than n g u o c dong (U PR ) - Sau phau th u a t he tie t nieu - T i c du’o n g tie t nieu soi, khoi u, hoi c h im g cho noi, x o sau phu c m ac, hep be than - nieu quan va co thai, - Co o vie m khu tru: vie m bang quang, viem tuyen tien liet, vie m tru e trang, vie m ruot th u a , viem phan phu, - Do vi khuan: + Vi khuan G ram (-): th u o n g gap tren 90% : E coli, K lebsiella, P roteus m irabilis, E n te ro b a cte r, + Vi khuan G ram (+): it gap d u o i 10% : E n terococcus, S ta p h ylo co ccu s, li chAn ooAn C h a n d o a n x a c d jn h a L a m s a n g Benh th u d n g xu a t hien dot ngo t v d i n h u n g bieu hien sau: + Hoi c h u n g nhiem trun g: sot cao ret run, co the th a n h c o n 39°C - 40°C , kem theo dau dau va m et moi, m oi kho, lu d i ban, co th e m at n u d e sot cao Neu khon g pha t hien va dieu tri kip th d i se bi soc nhiem khuan + Hoi c h u n g bang q u a n g cap: dai buot, dai rat, dai kho, dai m au, dai due, dai m u la n h u n g dau hieu sd m tru d c co bieu hien V T B T cap + D au: dau hong lu n g , m ang s u d n nhieu, co cam u n g s d vao, th u d n g dau m ot ben, hiem hai ben C o th e xuat hien c o n dau quan than + V o hong lu n g (+): dau hieu lam sang hay gap V T B T cap + C h a m than, bap b en h than (+/-), co the s d thay than to b C an lam sa n g + C o ng th u c m au: so lu o n g bach cau tang ro ret, dac biet tang bach cau da nhan trung tinh + C a y m au cap: neu so t cao > 39°C -4 ° C kem th e o ret run, kh o a n g 80% ca c tru d n g h o p nhiem trung H u o n g d A n c h A n d o A n v A d i Eu t r i b En h N i k h o a 580 tiet nieu vi khuan G ram (-): E coli, it gap h o n la E n teroba cter, K lebsiella, P ro te u s va P se ud o m o n a s + Protein nieu thu’O’ng < 1g/24 gid + Te bao nieu: co te bao mu, nhieu te bao bach cau, hong cau + C ay vi khuan nieu (+) s 100.000 vi kh u a n /m l nu’d c tieu, cung co (-) T ru d n g ho’P c o n dau khong dien hinh, can phai cay vi khuan nieu de xac dinh chan doan va co khan g sinh cho dieu tn + Sieu am: dau hieu gian dai be than, gian nieu quan, hinh anh soi than - tie t nieu, khoi u chen ep la nguyen nhan gay V T B T cap se d u o c pha t hien de dang + C hup bung khong chua n bi: neu nghi n g d co soi th a n -tie t nieu + C hup than nieu quan co th u o c can quang (U IV): tien hanh sau tin h tran g sot nhiem trung da on dinh de tim kiem ngu yen nhan + C hup bang quang: tien hanh sau tin h tran g n h iim tru n g da d u o c giai qu ye t neu nghi ngo co trao n g u o c bang quang - than C h a n d o a n p h a n b ie t Can phan biet V T B T cap v d i d o t cap cua V T B T m an: tien s u nhiem khua n tie t nieu tai phat nhieu lan, co nguyen nhan thuan lo i (s o i ), tang huyet ap, kha nang co dac n u d e tieu giam , c h u c n§ng th§n suy giam , III l£ U TRj VIEM TH AN - B £ TH AN CAP N g u y e n ta c d ie u trj • Neu sot cao ret run can dieu tri noi tru, cac tru d n g h o p nhe co the dieu tri va th e o doi ngoai tru Can cay vi khuan nieu, m au (neu co sot cao) tru d c b i t dau d un g khan g sinh T rong c h b doi ket qua cay vi khuan co the bat dau dung khang sinh Neu sau - nga y dieu tri, trieu c h u n g lam sang khong d d can dieu chinh khan g sinh th e o ket qua cay vi khuan va khan g sinh - M ot tron g n h u n g th u o c khan g sinh d u o c lu a chon dau tie n doi v d i V T B T kho n g bien c h u n g - bang d u d n g uong neu trie u c h u n g khon g nang: + Am oxicilin: 250 - 500m g x - vien/ngay, chia lan, hoac + A m oxicilin + acid cla vu la n ic (u c che beta - la ctam ase ): A u g m e n tin 500 m g x vien/ngay, chia lan Neu tinh trang nang chuye n d u d n g tiem tin h m ach (TM ): 1g x lo/ngay, ch ia lan, hoac + C e phalosporin (the he 2, the he 3): ce fu ro xim (Z inn at) 250 m g x vie n/n gay, chia lan cach 12 gid, hoac + T rim ethoprim - su lfa m e th o xa zo l: B ise p to l 480 m g x vie n chia lan cach 12 gid, hoac + F luoroquinolone: nhom can lu u y khong cho phu n u co thai va dang cho bu, khong cho tre em < 15 tuoi, can giam lieu d benh nhan suy than T n tron g v d i benh nhan suy gan, hoac • C iprofloxacin 250 m g - 500m g x vien, chia lan hoa c n o rflo xa cin 0 m g x vien chia lan hoSc ofloxacin 200m g x vien chia lan - Ket h o p giam dau chon g co that: N ospa, B u scopan, B aralgin , - Uong nhieu n u d e hoa c tru ye n dich du de dam bao lu o n g n u d e tieu n hieu £ 1500 - 2000m l/24 g td Neu tin h trang lam sang khon g tien trien tot (hoi c h u n g n hiem tru n g ro, van sot, n u d e tieu due 4m m o l/l, de tranh HA, c in phai giam sieu b e xuong th a p tro n g th d i gian d iu cua ca Iqc m au + Do tru o n g lu c m ach m au Tat ca n h u n g yeu to du nho n h lt gay giam su e can m ach m au ngoai vi hoac lam giam the tich day cua tim deu co the gay nen tin h trang HA Tren 80% the tic h m au tro n g c o the luu thong he tin h m ach, do co s u thay doi ve tin h trang c h u a m au d he tTnh m ach se gay nen giam the tich day cua tim va gay nen HA - M pt so nguyen nhan co the gay nen tin h trang tren: + S u dung djch loc acetat: A cetat d u g c coi la m o t yeu to gay gian m ach, nong a cetat huyet tu o n g tron g qua trin h loc th u d n g tri khoa ng t u - 10m m ol M ot so benh nhan hay gap tin h trang H A loc m au dung djch lpc (dac biet d benh nhan nO hoac benh nhan dai th a o d u d n g ) Dung djch loc a ce ta t cung co the la nguyen nhan gay huyet ap d n h u n g benh nhan loc m au dung qua loc co sieu loc cao Tuy nhien, khong it n h u n g benh nhan khong co bieu hien HA dung loai djch ke ca n h u n g benh nhan co HA nen th u d n g thap X ir tri: thay b ln g d jch loc bicarbonat + Djch loc d u g c d ieu ch in h d n h iet th u d n g Thong th u d n g djch loc d u o c tri d m u c 38°C, benh nhan loc m au th u d n g d tin h trang co giam nhiet m u c nhe T rong qua trin h loc m au nhiet c o the th u d n g tang m ot chut N hiet cua djch loc tSng se dan den tin h tran g gian ca tTnh m ach va dong m ach X u tri: dung bo phan lam giam nhiet cua djch loc hoac dieu chinh nhiet djch loc d m u c 34 36°C Chu y, dung djch loc co nhiet thap n h u vay benh nhan co the co cam giac kho chju n h u on lanh + Q ua trinh tieu hoa th u c an loc m au Q ua trinh tieu hoa tic h c u e qua trin h loc m au co the gay nen HA Q ua trin h gay nen giam sue can m ach nha t la cac m ach m au noi tang, dac biet lam tang the tich tTnh m ach va gay nen tinh trang HA X ir tri: khuyen benh nhan khong nen an tru d c loc m au hoa c tro n g th d i gian loc m au vi hieu u n g th u d n g keo dai tro n g vong g id ke tu bat dau an + N guyen nhan th ie u m au T it ca cac tru d n g h o p gay nen tin h tran g H A deu gay nen th ie u m au to ch u c M at khac, thieu m au to c h u c se dan den tin h tran g giai phong a de nosin, a d e n o sin se ngan can qua trinh giai phong n orepineph rin t u he th o n g than kinh g iao cam va th u d n g gay nen hien tu o n g gian m ach C h inh 598 HudNG dAn chAn o o An v A d i Eu t r i b £ n h NPi khoa vi vay, tin h trang H A se cang them tra m Tren lam sang, tin h tra n g tre n th u d n g xay d nhung benh nhan co nong h e m a to crit < 20 - 25% XCr tri: dieu ch inh th ie u m au, can dung Epo va cac yeu to can th ie t ch o qua trin h tao m au, n h u n g tru ’d n g h p p loc m au cap can truye n m au bo sung tien hanh loc m au de tran h gay HA + Ton thu’a n g th an kinh tu1 d on g D a c biet hay g a p d nhu’ng benh nhan dai th a o du’dng & n h d n g benh nhan nay, phan d n g co m ach nhat la dong m ach doi v d i tin h tran g giam khoi lu’a n g tu a n hoan bj giam di dang ke do cung lu’a n g tim g ia m kha nang tri H A qua du’d n g co m ach gan n h a khon g gia tri XCr tri: dung m ot so ta c nhan co m ach, tu y nhien hieu qua thap + Do d u n g th u o c h u y §t ap C an chpn th u o c H A phu h p p cung n h a th d i gian dung thuoc, nen tra n h dung th u o c ap tru’dc loc m au d n h d n g benh nhan co xu h u d n g H A loc Tuy nhien, th d i g ian dung, khoa ng each dung, phu th u o c vao du’a c dong hpc cua td n g loai th u o c va kha nang d un g nap + Ha h u y e t ap tim • Do roi loan c h d c nang tam tru’a ng : T in h tran g phi dai cua c a tim se dan den giam cung lu’a n g tim p n d n g v d i tin h tran g giam ap la c day Phi dai ta m th a t phai va roi loan c h d c nang tam tru’a n g la n h d n g bieu hien thu’d n g gSp a benh nhan loc m au D ie u tri can dung cac th u o c tra tim lam tang s d c co bop cu a c a tim , chu y tinh trang dien giai, nhip tim cham , • D o roi loan nhip tim va kha nang co bop: C ung lu’a n g tim khon g phai ch i anh h u a n g b d i kha nang day m a bi anh h u a n g b d i nhip tim va kha nang co bop M ac du, hau het H A loc m au la co lien q ua n den tin h tran g giam the tich day, nhien khon g phai la tron g m oi tru d n g hap XCr tri: dung cac ta c nhan tang nhip tim neu nhip cham , dieu tri n g u ye n nhan cua roi loan nhip tim tang kha nang co bop co the lam giam tin h trang HA N h d n g n g u yen nhan hiem gap - H a H A tron g loc m au co the la bieu hien cua m ot so benh li kh a c kho n g lien quan den qua trinh lpc m au n h u : tran djch m ang ngoai tim , nhoi m au c a tim , chay m au tron g, n h ie m khua n huyet, roi loan nhip tim , phan d n g cua c a th e v d i m ang loc, tan m au, t i c m ach kh i, - X u tri th e o n gu yen nhan cu the - Ha H A co lien quan den m ang loc: S u dung m ang loc ce llu lo se co the gay nen tin h tran g HA, c a ch e d u a c ch o la qua trinh hoat hoa bo the va cac cytokin H ay xay tin h tran g d n h u n g lan loc dau tien hoa c qua loc d u p e sir dgng lan dau Tuy nhien, van de van can nhieu ngh ien c u u th e m de k h in g dinh XCr tri: neu nghi n g d H A m ang loc can: d u n g q u a trin h loc, bo hoan toan qua loc v& day lpc, cap c u u n h u tru d n g h o p H A soc phan ve t A i l ie u t h a m k h A o JohnT, D a u g ird a s , Tod S lng “H a n d b o o k o f D ialysis, fo u rth edition, 2006" N is e n s o n n Fine, “C lin ic a l D ialysis, fo u rth edition, 0 ” VIEM PHUC MAC BENH NHAN LOC MANG BUNG LllN TUC NGOAI TRU • • I OAl C U O N G Loc m ang bung lien tuc ngoai tru (C A P D ) la m ot tron g nhCmg phu’o n g phap dieu tri thay the cho nhu’ng benh nhan suy than giai doan cuoi Sau th u c hien cac kT th u a t ban dau tai benh vien, dat ong catheter khoa ng o bung n g u o i benh, benh nhan co the tu b e m au tai nha rieng thay vi m ot tuan phai den benh vien de chay than nhan tao, hang thang benh nhan chi can den benh vien de kiem tra dinh ki m ot lan M oi nga y n g u o i benh th u c hien bon lan b e m ang byng, d u a hai lit dich b e vao o bung moi lan, m oi lan th u c hien ch i m at 30 phut P h u o n g phap dieu tri co hieu qua tu o n g d u o n g vcri chay than nhan tao chu ki Viem phuc m ac la phan u n g viem cap tinh cua la phuc m ac v o i tac nhan vi khuan hay hoa hoc V iem phuc m ac la m ot tron g cac bien c h u n g hay gap o benh nhan b e m ang bung lien tuc ngoai tru Neu benh d u o c chan doan scrm va dieu tri kip th o i thi benh nhan nhanh chon g qua khoi va tiep tuc th u c hien d u o c p h u o n g phap b e m ang bung ii c h An o o An Chan doan xac djnh a Lam san g - D au bung: bao g io benh nhan cung co dau bung, dau rat nhieu, th u d n g khong keu la m a n im im, han che c u dong - Dau hieu d th a n h bung: co c u n g bung, cam u n g phuc m ac - Sot: th u o n g benh nhan co sot cao 39°C - 40°C - Dich loc m ang bung: djch b e m ang bung d u o c xa thi co m au due (m au cua djch b e xa co mau dgc khac th u d n g so v d i m au djch loc d u o c xa th u d n g ngay) b Can lam san g - Xet nghiem te bao djch: co nhieu bach cau da nhan trung tin h (> 10O B C /m m co > 50% la bach cau da nhan trun g tinh) - Xet nghiem vi sinh: nuoi cay djch b e m ang bung co the thay vi khua n E c o li hoac tru e khuan mu xanh, tu cau, - Cay m au cung co th e th a y vi khua n gay benh C han doan n g u y e n nhan - N guyen nhan th u d n g gap gay viem phuc m ac la benh nhan kho n g tuan thu che vo trung th u c hien thay tui djch C ung co the nhiem trung tu chan ca th e te r di ch uye n vao d u d n g ham ca theter va vao khoang phu c m ac - C ay m£u, cay n u d e djch lqc o bung th u d n g tim d u o c loai vi khua n gay vie m phuc m ac M ot so vi khuan co the gap: S ta p h ylo cco cu s aureus, E n terococu s, S tre p to co ccu s, P se u d o m o n a s, E coli, C han doan phan biet - V iem phuc m ac khon g tim th a y vi khuan nuoi cay: + Do kT thuat lay benh pha m hoac kT th u a t nuoi cay c h u a dung p h u o n g phap + Do benh nhan da s u d un g khang sinh tru d c 600 H u Q n g d An c h An b o A n v A o i £ u tri b e n h NOi khoa - V ie m p h u c m a c k h o n g d o d u ’O’ng v a o t u d ic h Iq c h o a c d u d n g h a m c a th e te r: v ie m p h u c m a c ruot th u a , th u n g ta n g ro n g , - Dich Iq c m ang bung m au due d u d n g chap: tim th a y d u d n g ch a p tro n g dich loc m ang bung III O l£U TR| P hac hay d u o c s u dung tron g x u tri ban dau vie m phu c m ac d benh nhan loc m ang bung lien tyc ngoai tru: ap dung cho da so cac tru d n g h o p d u o c chan doan vie m p h u c m a c d benh nhan loc m ang bung lien tu c ngoai tru m d i nhap vien c h u a co ket qua nuoi cay vi khu a n va khan g sinh - Khang sinh toan than: co the dung m ot cac nhom th u o c sau: + N hom ce p h a lo sp o rin the he 3: ce foperazo n, ceftazidim + N hom beta lactam Lieu th u o c tu y th u o c va o tu n g loai khang sinh ap dung doi v d i benh nhan suy giai doan cuoi dang loc m ang bung T h d i gian dieu tri: 14 - 21 - K hang sinh tai ch o (bang 1): th d i gian dieu tri 14 - 21 B a n g K h a n g sin h tai cho d ieu tri viem p h u c m a c Lan thay djch Chi djnh Lan Rira o bung lien tiep tu i dich loc nong 1,5, m oi tu i pha 1.000 don vi heparin Lan (ngam gid) Ngam o bung lit djch loc nong 1,5 co pha: -Cephazolin 1g x lo -G entam icin 40mg x lo -H eparin 1000 don vi Lan (ngam gid) Ngam o bung lit dich loc nong 1,5 co pha: - Cephazolin 250mg (1 g x 1/4 Ip) -H eparin 1.000don vj Lan (ngam gid) Ngam o bung lit dich loc nong 1,5 co pha: - Cephazolin 250mg (1g x 1/4 lo) - Heparin 1.000 don vi Lan (ngam gua dem) Ngam o bung lit dich loc nong 1,5 co pha: -Cephazolin 1g x lo - Gentamicin m g x1 lo -H eparin 1000 don vi Khi co ket qua nuoi cay va khan g sinh do: - Neu vi khuan nhay cam v d i cac th u o c khang sinh tren th i tie p tu c d u n g cho du th d i gian la 14 - N eu vi khuan khan g v d i m ot cac th u o c khang sinh tren thi nen c h u ye n benh nhan den tuyen chuye n khoa co kinh n gh iem dieu tri IV PHONG BENH - V e sinh sach se dam bao vo trun g tron g th a o ta c th a y dich: ru a ta y b in g xa phong, deo khau trang, dung nguon n u d e sach de ve sin h , - T y djch tron g phong da d u o c ve sinh sach se tay tru n g th u d n g xuyen t Ai lie u t h a m k h a o S a lim M u ja i M D , J o h n H C b tre e M D e t al (2006) C a re o f th e a d u lt p a tie n t on peritoneal dialysis: 30 - 43 “C h ristia n Verger, S o cie te de N e p h ro lo g ie " , Tours 21 -23 ju in 200 0: La P e rito n ite de l an 2000 THIEU MAU VA DIEU TR| THIEU MAU BANG ERYTHROPOIETIN BENH NHAN SUYTHAN MAN • • • I DAI C U Q N G Thieu m au la m ot tro n g cac bien chu’ng thu’O’ng gap d benh nhan (B N ) suy than m an Khi suy than cang nang thi tin h tra n g thieu m au cang gia tang than giam san xuat eryth opoietin D ay la chat can thiet qua trin h biet hoa hong cau tai x u o n g Thieu m au a BN suy th a n m an dan den gia tang nguy c o benh tat va tu vong D ieu tri thieu m au d BN suy than m an la m ot tro n g nhCmg m uc tieu quan trqng dieu tri bao ton va dieu tri thay the than Tat ca cac BN bi th ie u m au m an tin h co lien quan den benh than m an tin h deu du’o c xem xet chi dinh dieu tri, vao m u’c th ie u m au li chAn ooAn C han doan xac djnh D u a vao nong h e m o g lo b in (Hb) de chan doan xac dinh th ie u m au d BN suy than m an: - Thieu m au d g id i n u Hb < 115g/l - Thieu m au d nam g id i Hb < 135g/l a Trieu c h irn g la m s a n g • Trieu c h u n g th ie u m au M et m oi, da xanh niem m ac n ho t, m at ngu, nhip tim nhanh, suy tim , suy giam nhan th u c , suy giam chat lu o n g cu o c song, • Trieu c h u n g suy than M et m oi, phu, tie u it, ta n g h u ye t ap, ca c dau hieu cu a hoi c h u n g ure m au ca o (ch a n an, non, buon non, ) b C an lam s a n g • C ong thu'C m au: th ie u m au co Hb giam d u d i 95% cua n g u d i b in h th u d n g cung g id i, cung dp tuoi: - Hb < 115g/l v d i phu n u tru d n g - Hb < 135g/l v d i nam g id i tru d n g • C h u c nang than - Ure, cre a tin in m au tang - M u c loc cau th a n giam - D ien giai m au co thay doi (kali th u d n g cao, calci co the giam hoac tang theo giai doan benh ) • X et ngh iem n u d e tieu - Co protein nieu - C o hong cau nieu • Sieu am : h in h anh than tu y th u o c vao loai benh li than cu the 602 H u O n g d a n c h a n b o A n vA bi£u t r i bEnh NOl khoa C han doan phan biet Can phan biet v d i tin h tran g thieu m au cac nguyen nhan khac gay - Thieu m au m at m au: xuat huyet tieu hoa, ho m au, rong kinh, ch a n thu’a n g , - Thieu m au ta o m au khong du: suy x u a n g , la xe mi, th ie u n gu yen lieu tao m au, - Thieu m au tan m au: tan m au tu m ien, tan m au thuoc, benh lupus, C h an doan n g u yen nhan - T hieu hut E ryth ro p o ie tin (quan trpn g nhat) - Do giam d d i song hong cau - Do thieu hut cac yeu to tao m au ( s it, vitam in B12, acid folic, protein, ) - M at m au tru d n g dien, ill o i£ u t r ! C h i djnh dieu trj C o chi dinh dieu trj th ie u m au nong Hb < 110g/I M uc tieu dieu trj - D uy tri Hb 110g/I - 120g/l (Het 33% - 36% ) dat d u a c tron g vo n g th a n g ke tu b i t dau dieu trj bang E P O (e ryth ro p o ie tin n g u d i tai to hap) - Hb m uc tieu tre n day khong ap dung cho lieu phap truye n m au D a n h gia m o t so yeu to anh h u d n g den thieu m au d BN suy th an m an - C an danh gia tin h tran g d u tru s i t th u d n g xuyen de bo sung s i t day du (d u d n g tin h m ach hoSc d u d n g uong) cho den dat m u c Hb m uc tieu L u u y can n g u n g tru ye n s i t tin h m ach tuan tru d c xet nghiem tin h tran g s it - D anh gia so lu a n g hong cau lu d i - D anh gia tin h tra n g viem - D a n h gia tin h tran g dinh d u d n g - D a n h g ia tin h tra n g lo c m a u d a y du - D a nh gia tin h tran g m it m au m an tinh D ieu tri bang e ry th ro p o ie tin (rH u E P O ) a L o a i E P O - E poietin alfa: E prex, E p ogen, Epokin, Epotiv, - E poietin beta: N e o R e co rm o n , B e tap oietin - D a rb e p o e tin alfa: A n e sp - M eth oxyl p o lye th yle n glycol - epo etin beta: M ircera b D u ’d n g d u n g D u d n g dung co the duo'C lu a chpn tu y th u o c vao tu n g tru d n g h a p cu the: tie m tin h m ach hoSc tiem d u d i da - D oi v d i BN suy than m an giai doan dieu trj bao ton: co th e lu a ch o n m o t tro n g cac nhom thuoc EPO noi tren, nen tie m d u d i da - D oi v d i BN than nhan tao chu ki: nen tiem tin h m ach E P O va o cac buoi lo c m au Tuy nhien tiem d u d i da co the giam d u o c lieu EPO - D o i v d i BN Iqc m ang bung chu ki: E P O nen tiem d u d i da - C o the tiem la n /th a n g doi v d i loai E P O the he m d i n h u M icera c P h a c d o d ie u tr i - T an cong: v d i m uc tieu dieu tri dat m u c Hb tu 110 - 120g/l (K D O Q I 0 d ieu trj th ie u m au benh than m an) H u On g d An c h An o o An v A o i£u t r i b En h NOi khoa 603 - Lieu t i n cong cua E P O phu th u o c vao nhieu yeu to n h u m u c th ie u m au va nguyen nhan c o ban cua thieu m au + E P O alfa va beta tiem d u o i da: 20U I/kg x lan/tuan hoa c U I/kg x la n/tuan + EPO alfa va beta tiem tTnh m ach: 0U I/kg x lan/tuan hoac 120U I/kg x lan/tuan Tre em d u d i tuoi lieu 300 U I/kg/tuan + D a rbe poie tin: ,4 m cg /kg /tu a n tiem d u d i da hoac tin h m ach L w u y : can kiem tra Hb th u d n g xuyen 2-4 tuan/Ian + Neu Hb tang tu 10 - g /l/th a n g la h o p li + Neu Hb tang < 10g /l/th a n g thi can tang 25% lieu m oi tuan + Neu Hb tang > g /l/th a n g thi can giam 25-50% lieu m oi tuan - Duy tri: dat d u o c m uc tieu dieu tri v d i Hb tu 11 - 12g/dl d BN suy than m an Lieu tri th u d n g thap h o n tu tren 30% lieu tan cong Trong giai doan tri nen kiem tra Hb m oi 1-2 thang - Khong khuye n ca o Hb > 130g/l vi tang nguy c o tu vong benh tim m ach IV MQT SO NG UYEN NHAN GAY DAP UN G KEM VO I EPO + Thieu sat + N hiem tru n g /v ie m (nhie m trung, phau thuat, A ID S , benh lupus ban he thong, ) + M at m au m an tin h + C u d n g can giap + V iem x o x u o n g , nhiem doc nhom + Benh bat th u d n g Hb (di truyen: T lasse m ias, benh hong cau h inh liem ) + Thieu vita m in B 12 h oa c folat + D a u tu y x u o n g , suy dinh d u d n g , tan m au, Neu n h u n g yeu to tre n da d u o c loai tru , can xem xet kha nang bj khan g v d i EPO (bat san nguyen hong cau) Trong m ot so tru d n g h o p dap u n g kem v d i dieu trj co the phoi h o p them v d i truyen mau V TAC DUNG PHU C U A EPO - Hoi c h u n g gia cum - D au dau - Tang HA - N g ua - Noi m an - H uyet khoi - Bat san n gu yen hong cau, TAl LIEU THAM k h A o N ep h ro l D ial T n s p la n t, V o l.19 S uppl2, 2004 K /D O Q I, “C lin ic a l P ctice G u id e lin e s fo r A n e m ia o f C h ro n ic K id n e y D is e a s e ", 2000 A m J, K id n e y D ialysis, 2001; 37 (S uppl 1): 182-235 uE u ro p e a n B e s t P ctice G u id e lin e s fo r the M a n a g e m e n t o f A n a e m ia in P a tie n ts w ith C hronic R e n a l F a il ure" K /D O Q I, 'C lin ic a l P ctice G u id e lin e a n d C lin ica l P ctice R e c o m m e n d a tio n s fo r A n e m ia in C h ro n ic K id n e y D isease, 0 T NANG DON THAN I O Al CIFCTNG - N ang d a n than la nang n im rieng biet, khong thong v d i be than, c h i co m ot Idp bieu m o m ong d nang, ben tro n g nang c h u a dich dong nhat - Co the co m ot hoa c nhieu nang d a n (m ultikystic), d m ot ho a c ca hai than - V i tri nang co th e d c u c tren, c u c g iu a hoac c u c d u d i th an, co the d d u d i bao than, tron g nhu mo than hoac nam canh be than ii chAn d o An C h an doan xac djnh D u a vao trieu c h u n g lam sang va can lam sang n h u sau: a L a m san g - Trieu c h u n g lam sang cua nang d a n than th u d n g n gh eo nan, nhieu tru d n g h a p khong co trieu c h u n g gi dac biet m a tin h c d phat hien qua sieu am kiem tra s u e khoe - Tuy vay, nang d a n than co the gay trieu c h u n g nhu: + D a u t h lt lu n g hoac tu c nang vung t h it lu n g ben than co nang la trie u c h u n g hay gap kich th u d c nang Idn + Tang huye t ap: n h u n g nang than co kich th u d c Idn, lai n im d vu n g nhu m o than lam choan cho m ot so vung than gay th ie u m au tai vung do, dan den tang bai tie t renin va lam tang huye t ap th u phat + T n to: nang than qua to co the s d th a y hoac nh in th a y m ot khoi u d bung b C an lam sa n g - Sieu am than: sieu am rat co gia tri chan doan xac djnh nang d a n than Tieu chua n chan doan nang d a n than tren sieu am n h u sau: + Khoi tron g am (E cho free) + H inh tron hoa c bau due + T nh nang nhan, m ong, b d deu ro + Co h inh tang am p h ia sau cua nang - C hup UIV: d u a c ch i djnh tron g n h u n g tru d n g h a p kho, can chan d oa n phan biet g iu a nang dan than v d i gian dai be than hoa c nhCrng tru d n g h a p can can th ie p ch o c hut nang Tren phim UIV, co the thay bong cua nang than va h in h anh de day he th o n g dai be than nang chen ep, dong th d i xem nang co thong v d i dai be than hay khong - C hup cat Idp vi tinh: d u a c ch i djnh nghi nang co bien c h u n g n h u ch a y m au tron g nang nang ac tin h hoa - X e t nghiem : th u d n g khong dong gop nhieu tron g chan d oa n xac d jnh nang d a n than Khi nang nhiem trun g co the bach cau m au tang, co bach cau va hong cau nieu H u o n g d a n c h A n o o A n va o i£u tri b £n h Ndi khoa 605 C h an doan phan biet - T n da nang (p o lyk ysto se renale): + B enh di tru ye n th e o kieu gen troi (trong pha he gia d in h nhieu n g u o i bi benh) + Hai than to bi thay the b d i nhieu nang + K ich thu’d c nang to nho khong deu Co nang rat Idn (> 10cm ) n h u n g cung co nang rat nho (khoang 0,5cm ) + Co the kem th e o gan da nang - N ang than m ac phai d benh nhan suy than m an (ure m au cao) hoac chay than nhan tao keo dai - G ian dai be than: co h inh anh thong g iu a cac dai be than v d i tren sieu am hoac tren phim chup UIV C han doan bien c h u n g a C h ay m a u tro n g n an g C hiem ti le khoa ng 6% , ngu yen nhan tu phat hoac sau chan th u o n g Trieu c h u n g lam sang th u d n g co dau th a t lu n g , dai m au S ieu am co hinh anh dich nang tang am , co th e th a y Idp dich thay doi theo tu the benh nhan hay cac vach tang am di dong (so i to huyet) b N a n g n h ie m tru n g B$nh nhan co trieu c h u n g nhiem trung tiet nieu Sieu am co hinh anh dich tro n g nang tang am khong deu, nang day n h u n g khong co nu sui c Vcr n an g Hay gap d nang d u d i bao hoa c nang canh be than, co the v d tu phat hay sau chan th u o n g Tren lam sang benh nhan dau t h l t lu n g dot ngot, dai m au Sieu am co the co tu m au d u d i bao than d N a n g ung th w h o a Nang to nhanh, th a n h d a y co nu sui, co vach, dich khong dong nhat Tren chup c i t Idp vi tin h nang ngam m anh th u o c can quang III d i£ u t r i i4 u trj trieu c h u n g va bien chipng - D au t h it lu n g va tu c nang vung th a t lung: + T hu oc giam dau + T h u o c gian co - Tang huyet ap: co th e cho th u o c ap cac nhom - N hieu trung nang: khan g sinh (theo khang sinh neu co) - C hay m au nang: th u o c cam m au, khang sinh, n im bat dong C h pc hut djch n an g than - C hi dinh: ch p c hut dich nang than qua da co the tien hanh cho cac nang than co kich th u d c tu 6cm trd len D a y la m o t kT th u a t d o n gian, co the th u c hien d u o c d tat ca cac benh vien da co m ay sieu am - C hong chi dinh: roi loan dong m au, nang co nguy c o bien c h u n g nang canh be than gay chen day dai be than - KT thuat: ch p c hut dich nang than d u d i s u h u d n g dan cua sieu am (co quy trin h rieng) H 606 u Ong d An ch An oo An v A o i £u tri b £n h NOi khoa P h iu th u a t - C h i dinh: n an g co b ien ch u ’ng, nang canh be th a n gay ch e n d a y d a i-b e th a n , tai p h a t nang sau ch o c hut - C h ong ch i dinh: roi loan dong m au, benh toan than nang - KT thuat: co the phau th u a t qua noi soi hay m o m d TAI LIEU THAM K H A O A A O keke, A E M itc h e lm o re , F X K eeley, Jr., and A G T im o n e y , “A c o m p a riso n o f aspiration a n d s c le ro th e p y w ith la p a ro sco p ic d e -ro o fin g in the m a n a g e m e n t o f s y m p to m a tic sim ple renal cysts" BJU In te rna tional, vol 92, no 6, pp -6 , 2003 G M Israel and M A B o sn iak, “A n upd a te o f the B o s n ia k re n a l c y s t c la ssifica tio n system" Urology, vol 66, no 3, pp ^ 8 , 2005 F A tu g , S V B u rg ess, G R u iz-D ey a, F M e n d es -T o rres , E P C a s tle , and R T h o m a s 'L ong­ term d u b ility o f la p a ro s c o p ic d e co rtica tio n o f s y m p to m a tic re n a l cysts" U rology, vol 68, no 2, pp -2 , 2006 E Z e re m , G Im a m o v d c , and S O m e ro v d c , “S y m p to m a tic s im p le re n a l cyst: com parison o f co n tin u o u s n e g a tiv e -p re s s u re c a th e te r d in a g e a n d s in g le -s e s s io n a lc o h o l sclerotherapy" A m e rica n Jo u rn a l o f R oentgenology, vol 190, no 5, pp 1 -1 , 2008 E Dem ir, C A lan , M Kilciler, and S Bedir, “C om parison o f e th a n o l a n d so dium tetradecyl sulfate in the scle ro th e p y o f re n a l cyst" Journal of Endourology, vol 21, no 8, pp -9 , 2007 S T o u lo u p id is , G Fatles, V R o m b is, A P a p a th a n a s io u , and E B alax is, "P ercutaneous d in a g e o f s im p le cysts o f the kid ney: a n e w m ethod" U ro lo g ia In te r n a tio n a l, vol 73, no 2, pp -1 , 2004 N T erad a, Y A rai, N K in u k aw a , and A Terai, "The 10 -y e a r n a tu l h is to ry o f sim p le re n a l cysts’ U rology, vol 71, no 1, pp -1 , 2008 W J B ean, “R e n a l cysts: tre a tm e n t w ith a lc o h o l” R adiology, vol 138, no 2, pp 329—331 1981 M M R a skin , D O P o o le, S A R oen, and M V ia m o n te , Jr., “P e rc u ta n e o u s m a n age m e nt of re n a l cysts: re s u lts o f a fo u r y e a r study" R a diology, vol 115, no 3, pp 5 -5 , 1975 10 R M H a n n a and M H D ah n iya, "A spiration a n d s c le ro th e p y o f s y m p to m a tic sim ple renal cysts: value o f tw o in je ctio n s o f a scle ro sin g a g e n t” A m e ric a n Jo u rn a l o f R oentgenology, vol 167, no 3, pp -7 , 1996