NGHIÊN cứu đặc điểm lâm SÀNG, cận lâm SÀNG và SIÊU âm DOPPLER THẬN ở BỆNH NHÂN TUẦN đầu SAU GHÉP

B GIO DC V O TO B Y T TRNG I HC Y H NI NGễ TH VN NGHIÊN CứU ĐặC ĐIểM LÂM SàNG, CậN LÂM SàNG Và SIÊU ÂM DOPPLER THậN BệNH NHÂN TUầN ĐầU SAU GHéP Chuyờn ngnh: Ni khoa Mó s : 62722040 LUN VN TT NGHIP BC S NI TR Ngi hng dn khoa hc: PGS.TS Gia Tuyn PGS.TS V ng Lu H NI 2016 LI CM N hon thnh lun ny tụi ó nhn c s giỳp nhit tỡnh ca cỏc thy cụ, ng nghip, bn bố v gia ỡnh Nhõn dp ny tụi xin by t lũng bit n sõu sc n: Ban giỏm hiu, Phũng o to sau i hc, B mụn Ni tng hp Trng i hc Y H Ni ó quan tõm v giỳp tụi sut quỏ trỡnh hc v lm lun tt nghip Ban giỏm c, Phũng k hoch tng hp Bnh vin Bch Mai, khoa chn oỏn hỡnh nh, khoa Thn Tit niu, Bnh vin Bch Mai ó to mi iu kin tt nht cho tụi sut quỏ trỡnh hc v lm lun tt nghip PGS.TS Gia Tuyn, trng khoa Thn- Tit niu Bnh vin Bch Mai, phú trng b mụn Ni tng hp trng i hc Y H Ni, ngi thy ó tn tỡnh ch bo, dỡu dt v trc tip hng dn tụi sut quỏ trỡnh hc tp, nghiờn cu v thc hin ti ny PGS.TS V ng Lu, phú trng khoa Chn oỏn hỡnh nh, ngi thy ó giỳp tụi tng bc lm quen vi siờu õm Doppler thn v cng ó trc tip hng dn tụi thc hin ti ny Vi tt c lũng kớnh trng ca mỡnh tụi xin chõn thnh cm n cỏc thy cụ hi ng thụng qua cng, cỏc thy cụ hi ng chm lun tt nghip ó úng gúp cho tụi nhng ý kin quý bỏu tụi cú th thc hin v hon thnh lun tt nghip ny Tụi xin chõn thnh cm n th cỏc bỏc s v iu dng ca khoa Thn - Tit niu, khoa Chn oỏn hỡnh nh Bnh vin Bnh Mai, ó tn tỡnh giỳp tụi quỏ trỡnh nghiờn cu v hon thnh lun ny V tn ỏy lũng mỡnh, tụi vụ cựng bit n nhng bnh nhõn nhng ngi phi mang trờn mỡnh ni au bnh tt, tri qua nhng cuc m khú khn cng l nhng ngi thy giỳp tụi luụn sỏng to, tỡm tũi hc v nghiờn cu khoa hc, h khụng th tỏch ri cụng tỏc nghiờn cu ca tụi Cui cựng, t trỏi tim mỡnh, tụi xin by t lũng bit n sõu sc ti nhng ngi thõn gia ỡnh tụi v bn bố tụi, nhng ngi ó luụn bờn tụi, ng viờn, chm súc, giỳp tụi sut quỏ trỡnh hc v nghiờn cu tụi yờn tõm hc tp, vt qua nhng khú khn cuc sng v hon thnh lun ny H Ni, thỏng 11 nm 2016 Ngụ Th Võn LI CAM OAN Tụi l Ngụ Th Võn, bỏc s ni trỳ khúa 38 Trng i hc Y H Ni, chuyờn ngnh Ni khoa, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca PGS.TS Gia Tuyn v PGS.TS V ng Lu Cụng trỡnh ny khụng trựng lp vi bt c nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, thỏng 11 nm 2016 Tỏc gi lun Ngụ Th Võn CC CH VIT TT AG Antigen Present (Trỡnh din khỏng nguyờn) BN Bnh nhõn BQ Bng quang M ng mch HA Huyt ỏp HAT Huyt ỏp ti a HATT Huyt ỏp ti thiu Hb Hemoglobin HLA Human leukocyte antigen (Khỏng nguyờn bch cu ngi) MLCT Mc lc cu thn MMF Mycophenolat mofetil NM Nhu mụ NQ Niu qun RI Resistive index (Ch s sc cn) T Thi gian THA Tng huyt ỏp TM Tnh mch CMD c ch dch XN Xột nghim MC LC PH LC DANH MC BNG T VN Hin cú hai phng phỏp iu tr thay th thn cho nhng bnh nhõn b bnh thn mn tớnh giai on cui l lc mỏu ngoi thn (gm thn nhõn to, lc mng bng) v ghộp thn C hai phng phỏp ny u c ng dng rng rói trờn th gii, ú ghộp thn c chng minh cú nhiu u im hn so vi lc mỏu ngoi thn Khi ghộp thn thnh cụng, thn ghộp chng nhng thc hin c chc nng lc v bi tit cỏc cht c c th m cũn cú kh nng iu hũa huyt ỏp, bi tit hormon, iu chnh cỏc ri lon nc v in gii, phc hi chc nng sinh dc.S phc hi v ci thin cht lng sng sau ghộp l u im c bn nht ca ghộp thn Mt khỏc, chi phớ cho ghộp thn nhng nm u tiờn sau ghộp tn kộm hn, nhng nhng nm v sau, chi phớ iu tr trỡ chc nng thn ghộp s thp hn so vi lc mỏu ngoi thn [1] Ngy vi cỏc tin b k thut phu thut ghộp tng cng nh thuc c ch dch, thi gian sng ca thn ghộp ó tng lờn ỏng k, khong 93% v 83% tng ng vi t l sng sau ghộp nm v nm Tuy nhiờn, cỏc tng ghộp cũn d b mt chc nng theo thi gian, vi khong 34 41% thn ghộp mt chc nng sau 10 nm [2] Thi gian hot ng chc nng ca thn ghộp ph thuc vo rt nhiu yu t bao gm th trng ngi cho v ngi nhn, thn c chn cy ghộp, cuc phu thut ly thn v ghộp thn, liu phỏp dch c s dng Trong ú, yu t gúp phn quyt nh s thnh cụng ca phu thut ghộp thn v nh hng n thi gian hot ng chc nng ca thn ghộp l quỏ trỡnh theo dừi thn ghộp giai on sm c Hip hi thn ca Vng Quc Anh quy nh l giai on hu phu, thng ly mc 10 ngy sau ghộp [3] Chớnh vỡ th vic theo dừi sỏt lõm sng, cn lõm sng ca bnh nhõn tun u sau ghộp vụ cựng quan trng 10 Ngoi ra, mt s nghiờn cu cng ch rng cỏc ch s siờu õm Doppler thn (ch s sc cn RI) cú tng quan vi chc nng thn ghộp giai on sm, c i din bi nng creatinin huyt hoc thi creatinin [4] [5] Trong ú, mi quan h ca cỏc ch s ny vi chc nng lõu di ca thn ghộp cũn nhiu tranh cói, vi kt qu mõu thun cỏc nghiờn cu [5] [6] [7] Cú th núi m bo thnh cụng ca ghộp thn thỡ khụng ch dng li cuc m cy ghộp m l c mt chng ng di theo dừi bnh nhõn sau ghộp Nhn thy tm quan trng ca vic theo dừi bnh nhõn sau ghộp thn v mong mun nghiờn cu thờm v mi tng quan ca cỏc ch s siờu õm Doppler thn ghộp giai on sm vi chc nng thn, chỳng tụi t nghiờn cu ti: Nghiờn cu c im lõm sng, cn lõm sng v siờu õm Doppler thn bnh nhõn tun u sau ghộp vi mc tiờu sau: Nhn xột c im lõm sng, cn lõm sng bnh nhõn tun u sau ghộp thn t ngi cho sng Mụ t c im siờu õm Doppler thn v nhn xột mi liờn quan vi cỏc yu t lõm sng, cn lõm sng bnh nhõn ghộp thn tun u t ngi cho sng 80 KT LUN Qua nghiờn cu 76 BN (39 BN tin cu t thỏng 11/2015 n thỏng 10/2016, 37 BN hi cu t thỏng 07/2013 n thỏng 10/2015) c ghộp thn t ngi cho sng v theo dừi ti khoa Thn tit niu Bnh vin Bch Mai, chỳng tụi rỳt cỏc kt lun nh sau: c im lõm sng, cn lõm sng ca bnh nhõn tun u sau ghộp - Tt c BN u cú nc tiu sau ghộp v a niu tun u sau - ghộp HA tõm thu gim so vi trc ghộp cú ý ngha thng kờ (p < 0,05) BN cú tỡnh trng thiu mỏu nh sau ghộp (Hb mỏu: 98,40 9,95 g/l), gim so - vi trc ghộp (Hb mỏu: 112,8 13,8 g/l) (p < 0,05) 70 BN (92,1%) creatinin mỏu tr v gii hn bỡnh thng sau ghộp (creatinin mỏu < 120 àmol/l) Cú BN (7,9%) chm chc nng thn mt s nguyờn nhõn khỏc phi lc mỏu tun u, ú cú BN ng c - tacrolimus Protein niu õm tớnh tun u sau ghộp chim 89,5% BN Cú trng hp chy mỏu sau ghộp phi m li vũng 24h sau ghộp, nguyờn nhõn rũ ming ni ng tnh mch thn ghộp T dch quanh thn ghộp gp khỏ ph bin, sau ghộp 24h cú 40 BN (52,6%) t dch quanh thn vi kớch thc trung bỡnh l 15,4 13,3 mm Sau ghộp 24h cú 10 trng hp (13,2%) t mỏu song kớch thc nh khụng nh hng nhiu n huyt ng, chc nng thn ghộp nờn khụng cn can thip ngoi khoa c im siờu õm Doppler thn v mi liờn quan gia mt s yu t lõm sng, cn lõm sng vi hỡnh nh siờu õm Doppler thn bnh nhõn tun u sau ghộp 81 - Thn ghộp giai on sm ó tng nh kớch thc so vi thn trc - ghộp (p < 0,05) RI M thn, M nhu mụ thn ghộp sau tun tng hn so vi sau ghộp 24h - nhng gii hn bỡnh thng (0,65 0.75) RI M thn ngy th sau ghộp nhúm HAT 140 mmHg cao hn nhúm - HAT < 140 mmHg RI M nhu mụ thn ngy th sau ghộp b nh hng bi cỏc yu t: tui - ngi cho - ngi nhn, HAT v tỡnh trng t dch quanh thn Khụng thy mi liờn quan gia tui ngi cho ngi nhn, BMI ngi nhn, hũa hp HLA, thi gian thiu mỏu m v HA vi hỡnh thỏi thn tun u sau ghộp TI LIU THAM KHO Gabriel Danovitch and et al (2001) Handbook of kidney transplantation Third Edition, Lippincott Williams & Wilkins National Health Service Blood and Trans - plant (2009) Statistics and audit directorate transplant sur-vival Transplant Activity Report 20082009, National Health Service Blood and Trans-plant The renal association (2011) Post-operative care of the kidney transplant recipinet N Nezami, MK Tarzamni, H Argani and et al (2008) Doppler ultrasonographic indices after renal transplantation as renal function predictors Transplantation proceedings, Elsevier, 94 99 S Kahraman, G Genctoy, B Cil and et al (2004) Prediction of renal allograft function with early Doppler ultrasonography Transplantation proceedings, Elsevier, 1348 1351 Bernd Krumme, Wolfgang Grotz, Gunter Kirste and et al (1997) Determinants of intrarenal Doppler indices in stable renal allografts Journal of the American Society of Nephrolgy, 8(5), 813 816 Jorg Radermacher, Michael Mengel, Sebastian Ellis and et al (2003) The renal arterial resistance index and renal allograft survival New England Journal of Medicine, 349(2), 115 124 D Th Ngc Thu, Trn Th Thanh Nga, Vừ Th Chi Mai v CS (2005) Tỡnh hỡnh nhim virus Cytomegalo bnh nhõn ghộp thn ang theo dừi ti Bnh vin Ch Ry Tp Y hc Vit Nam, (Tng hi Y- Dc hc Vit Nam), 313, 555 560 D Th Ngc Thu (2006) Rỳt kinh nghim v k thut ghộp thn ti Bnh vin Ch Ry vi ngi cho sng cú quan h huyt thng Lun ỏn chuyờn khoa Cp II, i hc Y Dc Thnh ph H Chớ Minh, 10 WHO Meeting Report (2005) Consultation meeting on transplantation with National Health Authorities in the Western Pacific Region pp.6 53 11 Council of Europe (2005) International Figures on Organ Donation and Transplantation Foundation Renal Newsletter Transplant, 10(1), pp.6 33 12 Nguyn Trng Giang, Hong Mnh An, Lờ Trung Hi v CS (2012) Nhn xột mt s bt thng v mch mỏu thn ghộp qua 98 trng hp ti Bnh vin 103 Tp y - 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Kidney transplant donor size determines kidney function among living donors Clinical Kidney Journal, 78 N Nouri-Majelan v R Nafici (2007) Duplex sonographic measurements in allografted kidneys: a cross-sectional study Transplantation proceedings, Elsevier, 1103 1107 79 Claudia Parolini and et al (2009) Renal resistive index and long-term outcome in chronic nephropathies Radiology, 252(3), p.888 896 80 Sander D, C Kukla and J Klingelhofer (2000) Relationship between circadian blood pressure patterns and progression of early carotid atherosclerosis a -year follow-up study Circulation, 102, p 1536 1541 PH LC TIấU CHUN ACR 1997 STT Tiờu chun Ban cỏnh bm mỏ Ban dng a Tng cm th vi ỏnh sỏng Loột niờm mc ming hng Viờm khp khụng tn thng Viờm mng - Trn dch mng phi v/ hoc - Trn dch mng ngoi tim Biu hin thn - Cú protein niu thng xuyờn v/ hoc - Cú tr niu (tr ht, tr hng cu) Biu hin thn kinh tõm thn - Co git khụng rừ nguyờn nhõn c th khỏc - Ri loỏn tõm thn khụng rừ nguyờn nhõn c th khỏc Huyt hc:cú mt hoc nhiu biu hin sau: - Thiu mỏu tan mỏu, HC < 3,7T/l - Gim bch cu < G/l - Gim tiu cu < 100 G/l - Gim lympho bo