Professional Documents
Culture Documents
GII THIU
GII THIU CAC TAI NGHIN CU KHOA HOC TAI HI NGHI NI KHOA TOAN QUC TAI THANH PH H CHI MINH THANG 7/ 2011
DEMA-CVN.COM
BS Nguyn Bch Khoa Thn- Lc mu, Bnh Vin Thng Nht Tp HCM
DEMA-CVN.COM
M U
CA LM SNG
-
BN nam, 75 tui, 50kg TS: THA, BCTTMCT Nhp vin do au ngc chp mch vnh Kt qu XN v chp mch vnh- mch thn
DEMA-CVN.COM
DEMA-CVN.COM
DEMA-CVN.COM
DEMA-CVN.COM
DEMA-CVN.COM
17/5
27/5
6/6
27/7
Ure (mmol/l)
6.2
10.4
12.1
23,7
Cre (mol/l)
Cr Cl (ml/p) V nt m niu
111
187
252
380
35.97
bt
-
bt
-
bt
bt
Tr/c LS
Khng
(Nhp vin)
Khng
(25/5: chp MV)
Khng
Khng
DEMA-CVN.COM
Chn on?
DEMA-CVN.COM
Hng triu ngi cht mi nm v nhng s xut v nhim trng trong lnh vc y t. Liam Donaldson (chuyn vin ph trch v an ton cho ngi bnh): "Nu ngy mai bn phi nhp vin, d l ang sng nc no i chng na th nguy c gp phi ri ro do s xut trong vic chm sc l 1/10. Cn nguy c t vong s l 1/300 Nguy c cht do tai nn my bay: khong mt phn 10 triu hnh khch.
Ngun: WHO- ng ti VN Express 25/7/2011
DEMA-CVN.COM
Yu t nguy c
+
Ngoi lai (can thip iu tr)
DEMA-CVN.COM
1. YU T T BNH NHN
1.1.Bin i cu trc Gim trng lng: P thn/ 80-90 tui= 75-80% P thn/ ngi tr S sinh (50 g)trng thnh (400 g) Tui 90 (300 g)(1). - Gim vng v, vng tu cn nguyn. - Ph thuc gii: NC trng lng thn ngi t thit tui 70-79 vs 20-29 (2) nam: 19%; n 9%. - Tu thuc chng tc: NC 240 mu t thit tui > 90 (3) trng lng thn ngi Chu u ( 32% ), ngi Nht ( 43%).
DEMA-CVN.COM
Tiu cu thn:
s lng (30-50%) x ho tng im (1). C ch: XVM mch thn do RL lipid mu v hot ng tng b. X ho vng v, vng tu cn bo tn. T l tiu cu thn b x ho tng im theo tui: < 5% (tui 40) 10-30% (tui 80). T l s cu thn x ho ton b: theo tui ngay c khi khng b cc bnh l nh THA, T (2). Tng s cu thn cn chc nng: theo tui (2).
(1) Froncht A (1984). Renal diseases in the geriatric patient. J. Am. Geriatric Soc 32, 28-43. (2) Hoang K (2003). Determinants of glomerular hypofiltration in aging humans. Kidney Int 64, 1417-24.
DEMA-CVN.COM
Din tch lc ca thn - mesiangial cell: khong gian bo= 8-12% din tch cu thn (>50 tui) (1). Nghin cu trn chut: khong gian bo gin rng ra theo tui. - cc t bo biu m Mng cu thn dy ln
DEMA-CVN.COM
DEMA-CVN.COM
ng thn: - kch thc, s lng. - chiu di ng thn - th tch ng thn - Teo ng thn - Dy mng ng thn - kch thc t bo biu m ng thn - x ho m k Mch mu ti thn (1) X ho tiu ng mch hp ng mch thn
(1) Epstein M (1996). Aging and the kidney. J. Am. Soc. Nephrol. 7, 1106-1122.
DEMA-CVN.COM
DEMA-CVN.COM
Cc 30-39
79,613,3
50-59
60-69
70-77
11018 16 (22-20)
10315 28 (24-32)
9715 44 (38-50)
9714 58 (47-67)
9012 73 (43-90)
Bin i S cre, LCT v t l phn trm cu thn b x ho theo tng nhm tui (1)
(3) Andrew D (2010). The association between age and nephroslerosis on renal biopsy among healthy aldults. Ann. Intern. Med 152,561-567
DEMA-CVN.COM
Chc nng iu chnh nc, mui - kh nng c c nc tiu thiu dch. Rowe (1): ALTT nc tiu ti a 1.109 mosmol/kg (2039 tui) vs 882mosmol/kg (60-79 t). - pha long nc tiu tha dch (2).
(1).Linderman RD (1990). Renal physiology and pathophysiology of aging. Am J. Kidney Disease 16, 272-285 (2).Sunderam (1983). Hyponatremia in the elderly. Age aging 12, 77-80.
DEMA-CVN.COM
DEMA-CVN.COM
yu t gy x ho cu thn tui (AII,TGF , NO, AGE, Oxidative stress, Lipid (1) chc nng thn.
sa cha tn thng v ti to m kh nng phc hi hi phc chm, hi phc khng hon ton. Roland (1): BN > 65 tui nguy c khng hi phc chc nng thn cao hn ngi tr l 20-30%.
(1). Roland S (2008). The impact of aging on kidney repair. Am J. Physiol 294, F 1265-1272.
DEMA-CVN.COM
DEMA-CVN.COM
DEMA-CVN.COM
Cu thn
S lng X ho Dy mng c bn Din tch lc
ng thn
S lng Kch thc Dy mng c bn
K thn
X ho
Mch thn
X va Tt, teo mch
- ti hp thu G, in gii OLG - kh nng c c v ho long OLX - Tn thng c ch t iu ho ngc ng- cu thn
ti mu thn
Suy thn cp
Gim khi lng thn X cu thn X ng thn k To hyalin mch thn X/teo ng thn Bin i cu trc Suy cp thn Thay i chc nng
Gim lu lng mu thn Gim lc cu thn Gim d tr thn Tng khng lc tnh mch thn
Bin i
H qu lm sng
Cu thn: Gim - lu lng mu ti thn - lc cu thn ng thn: Gim - ti hp thu v bi tit nc - kh nng pha long nc tiu - ti hp thu Na - bi tit acid Gim sn xut Erythropoetin
Gim thi insulin
D xy ra: - thiu dch v tng Na mu. - tha dch v h Na mu - thiu dch khi thiu mui - toan mu
D b thiu mu D ri lon G mu
Dinh dng Gim Albumin mu Gim chc nng thn theo tui
D xy ra STC NLT
Nhim khun
Sharon Anderson, Basil Eldadah, Jeffrey B Halter, William R et al. (2011). Acute Kidney Injury in older aldults. J Am Soc Nephrol 22: 28-38.
DEMA-CVN.COM
2. YU T NGOI LAI (Thuc) 2.1. Yu t nguy c ca nhim c thn do thuc - Ln tui Thn trng - Gim LCT khi k n - C bnh thn mn, cp - C tnh trng co mch thn sn do tha AII - Thiu dch iu chnh - Gim albumin mu trc khi k n - Liu thuc cao so vi LCT - Chuyn ho: h K, Mg, Ca; tng Ca; pH nc tiu <5,5 hoc >6,0. - C a: gen lin quan n chuyn ho toxin (CYP450, MRP2) - Thuc: tch in (+)
DEMA-CVN.COM
2.2. Thuc c lin quan nhim c thn NLT - Khng sinh nhm aminoglycosid (nepmycin>gentamycin> tobramycin ~ amikacin ~ neltimycin>streptomycin) - Thuc cn quang: gim ti mu + ng thn - NSAIDs: gim SX PG (GFR): cp ng thn k:mn. - ACEI, ARB: gim ti mu thn - Sucrose, Mannitol, HES: ng thn - Thuc iu tr K: Cisplatin,Ifosfamide, Mitomycin C, Azacitidine, Gemcitabine, Pentostatin, Methotrexate, Interleukin 2, Biphosphonates, Bevacizumab: ng thn
DEMA-CVN.COM
DEMA-CVN.COM
Cc thuc t dng hn Polymyxin (polymycinB, colistin): OLG AmphotericinB: co tiu mch n, tn thng OLX Adefovir, Cidofovir: tn thng OLG (chnh), OLX (t) Sulfonamides (sulfadiazine): ngng kt trong ng thn Acyclovir
DEMA-CVN.COM
2.3. Biu hin lm sng ca nhim c thn do thuc - STC: trc thn, hoi t ng thn, vim thn k, vim cu thn - Bnh ng thn: toan ng thn, bnh thn mt mui, h K, toan ng ln xa, i tho nht do thn - m niu: HCTH (MC, MN, FSGS) - Bnh thn mn: vim ng thn k mn
DEMA-CVN.COM
Yu t nguy c NLT d b STC: - Ni ti Ngoi lai C th d phng c? Khi b STC: biu hin nng do kh nng b tr gim (cu thn, ng thn). Lc mu sm ?
DEMA-CVN.COM
Biu hin LS ni bt STC NLT: - D b thiu dch - D b qu ti nc - D b toan mu nng - Thng c biu hin thiu mu.
Lu khi iu tr
Khi xy ra STC: kh nng hi phc chm, khng hon ton Theo di lu di chc nng thn BN c tin s STC
DEMA-CVN.COM
DEMA-CVN.COM