i hc Dc H Ni

10/2015

CA LM SNG
Bnh nhn nam, 64 tui,thng binh.C tin s T typ II 10 nm
v THA 7 nm,ang dung thuc vin Dimaicron MR 30 mg.Vo thng
8/2015,bnh nhn nm iu tr BV Ni tit TW c chun on suy thn
IIIa do i tho ng typ II .Sau bnh nhn ra vin tip tc iu tr
bng thuc h huyt p,thuc li tiu,thuc vin T.
Vo ngy 19/10/2015 bnh nhn nhp vin Bch Mai vi l do5
ngy nay ,bnh nhn mt mi nhiu,au u,chng mt,hoa mt,ho khc
c m trng,khng st.n ngy 19/10/2015,bnh nhn c a vo
khm ti BV Bch Mai
Ti bnh vin:
Ngy 19/10/2015:
Khm :da xanh,nim mc nht
Khng ph,khng st
Huyt p cao
Xt nghim thy:
- Xt nghim mu:
RBC : 2.34 T/l (4.3 - 5.8)
HGB : 69 g/l (140 - 160)
HCT :0.21 l/l (.0.38 - 0.5)
-Xt nghim ha sinh
Ure : 31.3 mmol/l (1.7 - 8.3)
Creatinin :469 umol/l(62 - 106)
Acid uric :589 umol/l(202-416)
Glucose : 7.2 mmol/l (4.1 - 6.7)
- in gii :
Natri : 139mmol/l (133 - 147)
Kali :4.4 mmol/l (3.4 - 4.5)
Calci :105 mmol/l (94-111)
-Xt nghim nc tiu
Protein niu:1.5g/l
ng:( - ) Dng trp:( - )
Hng cu (- ) Bch cu ( -)
1
T 5 Lp A5K68

i hc Dc H Ni

10/2015

Cu hi 1: Theo cc bn bnh nhn c th mc bnh suy thn mn giai

on my ? Ti sao?
Tr li: Suy thn mn giai on V
Gii thch:
MLCT c nh gi bng thi sch creatinin ni sinh
Clcr

(140 T ) M (kg)
ml / ph
Pcr (mg / dl ) 72

Trong : T: tui Bn
M: cn nng Bn, nu l n nhn h s 0.85
i n v umol/l 0.0113=mg/dl
Bn ny mc lc cu thn l 12,35ml/min
Phn loi bnh thn mn theo mc lc cu thn(GFR)
KDIGO 2012 chia bnh thn man thnh cc nhm 1-5
Hu ht nghin cu v hng dn u vn s dng giai on bnh thn
theo KDOQI 2002
KDIG GFR(mL/min/
ngha
Giai on tng ng
O
1.73m^2)
theo KDOQI
G1
>90
Bnh thng hoc cao Giai on 1 CKD
G2
60-89
Gim nh
Giai on2 CKD
G3a
45-59
Gim nh n trung
Giai on 3 CKD
bnh
G3b
30-44
Gim Tb n nng
Giai on 3 CKD
G4
15-29
Gim nng
Giai on 4 CKD
G5
<15
Suy thn
Giai on 5 CKD
Da vo bng suy ra bnh nhn b suy thn mn giai on V

Cu hi 2:Ti sao i tho ng v tng huyt p nguyn nhn gy bin

chng suy thn mn ?Gii thch?
Tr li:
Trong T,
1
T 5 Lp A5K68

i hc Dc H Ni

10/2015

+ Nng ng mu cao kch thch s ng ha cc phn t protein

trong c th. S ng ha ny thc ra l s gn cc phn t ng vo
cc phn t protein to nn mt ma trn cc protein gn ng. S thay
i lin kt ny dn n thay i chc nng cc phn t protein, thay i
cc hot ng in ca protein vn l nhng cht rt c bn ca lp nn
mng lc cu thn. Chnh cc phn t ng ha ny lm mng y ca
cu thn khng thc hin c chc nng .
+ Lp mng nn ca cu thn b dy ln v tr nn mt cc thuc tnh
chc nng.S dy ln ca lp mng y lm gin rng cc l siu lc, b
thay i lp in tch mng b mt, b x cng v mt tnh cht mm mi .
+ T lm tn thng cc mch mu ca cu thn . H qu to ra p lc
cao ti b lc cu thn. S tc ng trng din ca p lc cao ln mng
lc cu thn lm cho cu thn b x ha, h hng .
Do lm gim mc lc cu thn dn n suy thn mn.
- Tnh trng tng huyt p cao v ko di s lm tn thng v ph hy cc
mch mu trong c th => lm gim lng mu cung cp n thn. tn
thng cc mach mu thn lm gim nui dng, gy x thn => suy thn
cng nng.
Huyt p tng cao cn ph hy b lc cu thn, dn n hu qu l
thn khng th loi b nhng cht cn b c hi cng nh nc d tha
ra ngoi => nc tha trong h mch mu ngy mt nhiu lm huyt
p li cng tng cao hn.
Cu hi 3: Da vo triu chng trn ,bn hy cho bit bnh nhn c bin
chng gi?
Ti sao suy thn mn c bin chng ?
Tr li:
Triu chng: Da xanh,nim mc nht.
S lng hng cu gim,huyt sc t gim,dung tch hng
cu gim.
Bn c bin chng thiu mu.
V:
-Do thn gim bi tit Erythropoietin. Erythropoietin l mt Glucoprotein
c cc t bo ni mc mch mu bao quanh ng thn bi tit. Thn l c
quan sn xut Erythropoietin ch yu trong c th (90%). Erythropoietin
c vai tr bit ho dng hng cu t giai on hng cu non n hng cu
1
T 5 Lp A5K68

i hc Dc H Ni

10/2015

trng thnh. Mu ngoi bin s xut hin nhiu hng cu cha trng
thnh.
- Thiu mu trong suy thn mn cn c vai tr ca nhim c tu xng
do s c ch ca nng ure cao.
- Nguyn nhn thiu mu tip theo l gim i sng hng cu trong tnh
trng nhim toan chuyn ho, nhim c t bo do hi chng ur huyt cao
gy nn.
- Thiu mu cn do thiu nguyn liu to hng cu (st, axt folic, cc yu
t vi lng) do tnh trng km hp thu ca ng tiu ho, chn n,v b
tn thng do ur huyt cao.

Cu hi 4:Sau mt thi gian iu tr ,ngy 27/10/2015 bnh nhn c

lm cc xt nghim sau:
Yu cu xt
nghim
SINH HA
Ure

Kt qu xt

34.2
4

Creatinin

umol/l
umol/l

83
5

Acid uric
Pro ton phn
Calci
St

n v

nghim

96
67.2
1.88
14.9

umol/l
g/l
mmol/l
umol/l

Tr s bnh thng
Nam
N
1.7-8.3
Ngi ln: 62-

1.7-8.3
Ngi ln: 44-

106
Tr em: 15-77

80
Tr em:15-77

202-416

143-399

66-87
2.15-2.55
8.1-28.6

66-87
2.15-2.55
8.1-28.6

1
T 5 Lp A5K68

i hc Dc H Ni

in gii
Natri
Kali
Clo
Min dch
PTH

10/2015

135
5.2
100

mmol/l
mmol/l
mmol/l

133-147
3.4-4.5
94-111

133-147
3.4-4.5
94-111

36

Pmol/l

1.6-6.9

1.6-6.9

Da vo xt nghim no bit bnh nhn c nguy c bin chng cng

cn gip th pht,v lon dng xng ?Gii thch ?
Tr li:
Da vo xt nghim: Ca mu gim nhiu, pth mu tng cao.
Gii thch
- Canxi c nhiu trong thc phm ,trng hp nng Canxi trong mu
qu thp ,khi tuyn cn gip s tng tit pTH ,cht ny c tc dng rt
Canxi t trong xng nng Canxi trong mu tng ln.Nu qu trnh
ny ko di,tuyn cn gip tng cng hot ng,Caxi ly i t xng .
- Suy thn nng photpho trong mu tng cao lm gim nng canxi
mu.D cng lm cng cn gip th pht,hu qu xng s
tha,long,rt yu v b g
- Thn chuyn i vitamin D thnh mt Cacitriol c hot tnh sinh hc.
Calcitriol tun hon nh mt hormon trong mu, c tc dng tng hp thu
Calxi rut non, iu chnh nng canxi v phosphate trong mu v
thc y s pht trin khe mnh v ti to ca xng
Chc nng thn km, n khng th bin i vitamin D sang dng hot
ng lm gim Calcitriol gim nng Caanxi trong mu => tuyn cn
gip tng sn xut ra PTH huy ng canxi t xng, m bo nng
canxi mu lm tuyn cn gip lm vic qu sc b p cho vic mt
canxi dn n cng cn gip th pht, lon dng xng,vic huy ng
Caxi t xng ra mu nh s gy ra long xng,lon dng xng.
hc nng thn b hng, n khng th bin i c vitamin D t thc n
sang dng hot ng nn c th thiu ht vitamin D cng l l do gy long
xng. Mun phng chng long xng do suy thn, bn cn thc hin cc
bin php sau y: gim lng pht pho trong khu phn n, dng thuc
1
T 5 Lp A5K68

i hc Dc H Ni

10/2015

thm pht pho, b sung vitamin D, canxi, tp th dc thng xuyn va sc

cho xng c tng cng cht canxi, ct b mt phn tuyn cn gip

Cu hi 5:Cc bn hy xut hng iu tr cho bnh nhn trn?

Tr li:
Ch n nh ng huyt:
-Kim sot ng huyt cht ch ,HbA1C t mc 8% v
glucose lc i
8%-10%
-S dng cc thuc vin iu tr T c tnh an ton trong suy
thn v tim insulin vi liu lng thch hp
Ch chm sc:
-Ngh ngi trn ging bnh
Ch n gim mui ,gim m,gim kali(nu nng kali tng cao trong
mu),gim photpho ,b sung vitamin D,Canxi(nng Canxi gim)
-Ch n dinh dng hn ch thiu mu
- Gim a nc v dch vo c th
iu tr bng thuc:
Thuc h huyt p:- adalate 30mg dng ng ung
-Adalate 10mg nh di li
- Methydopa 250mg ng
ung,Nifedipin20mg theo ng ung
Thuc iu tr ph ,h huyt p:Furosemid 40mg ng
ung
Thuc iu tr thiu mu:
Ferlatum 40mg(iu tr thiu mu do thi Fe)
Betahema (thuc b mu)
Truyn khi hng cu
Thuc iu tr tng K mu: resonium A
Trng hp nng Calcitriol thp:dung thuc calcitriol
tng hp dng ung hoc tim,b sung them Calci.
Khng kim sot c nng pTH phi ct b tuyn cn
gip
iu tri thay th thn
Lc mu ngoi thn:
+Thn nhn to
1
T 5 Lp A5K68

i hc Dc H Ni

10/2015

+Lc mng bng

Ghp thn

1
T 5 Lp A5K68