SUY THN CP

ThS BS Hynh Ngc Phng Tho

Ging vin B mn Ni i hc Y Dc
 MC TIU
1.Nu c nh ngha suy thn cp, tn
thng thn cp (TTTC) v tiu chun RIFLE.
2. Trnh by c ch sinh l bnh ca TTTC
chc nng, hai t ng thn cp, TTTC sau
thn.
3. Trnh by cc nguyn nhn ca STC.
4. Trnh by cch tip cn STC, v cc yu t
gip phn bit STC v STM.
5. Bit nghi v phn tch cc xt nghim
trong chn an phn bit STC trc thn v
ti thn.
 NH NGHA
SUY THN CP (ACUTE RENAL FAILURE)
- S gim chc nng thn mt cch t ngt v thng hi phc
din ra trong vng vi gi, n vi ngy
- Thut ng lch s, khng phn nh c nhng thay i ca
nhng giai an khc nhau trong qu trnh tn thng thn cp.
- Vn cn dng trn lm sng.
- Suy thn cp c th din ra trn thn trc bnh thng hoc
trn thn c bnh thn mn.,
TN THNG THN CP (ACUTE KIDNEY INJURY)
- L hi chng vi cc mc trm trng thay i qua nhiu giai
an, c trng bng lc cu thn gim cp (tng BUN,
Creatinin huyt thanh) trong vi gi n vi ngy.
 NH NGHA
TN THNG THN CP l mt hi chng c trng
gim nhanh lc cu thn trong vi gi n vi ngy.
Dn n ng nhng sn phm bi tit c ngun gc nit nh
Ur v Creatinin
Lm sng din tin qua nhiu giai an khc nhau v thi gian v
mc nng, t khi u, suy thn tin trin v hi phc.
Hi phc chc nng ty thuc vo cn nguyn, bnh thn c trc
v iu tri.
 PHN BIT CC KHI NIM
V niu (khng to ra nc tiu), B tiu (Tc nghn ng tiu
di).
Suy thn cp (vi gi, vi ngy, thng hi phc), Suy thn mn
(nhiu thng, nhiu nm, khng hi phc)
Suy thn cp v suy thn cp trn nn mn (khng c hoc c
bnh thn mn gy suy thn mn lm nn tng)
Tn thng thn cp (chc nng), Hai t ng thn cp (bnh
hc)
 CC TIU CHUN V TH TCH NT
TRONG SUY THN CP
Thiu niu: Th tch NT < 400 mL/24 gi.
Khng thiu niu: Th tch NT > 400mL/24 gi.
V niu: Th tch NT < 100mL /24 gi.
V niu han tan < 50mL/24 gi.
SUY THN CP TH KHNG THIU NIU

Th tch NT > 500mL/24 gi..

Gim lc cu thn nhanh (BUN, Creatinin tng nhanh
trong vng vi gi, vi ngy)
Nguyn nhn: Khng sinh, thuc cn quang, vim OTMK
cp, bnh thn do tc nghn mt phn, vim cu thn cp,
ly gii c vn.
 CC MARKERS DNG TRONG TN
THNG THN CP
Creatinin huyt thanh.
BUN, Ur
Cystatin C
Cc Biomarkers trong tn thng thn cp
Cratinine HT v suy thn cp

Stars R, Kidney Intern (1998), 54, 1817-1831

 CREATININ HUYT THANH
c lc qua cu thn, c bi tit OT v khng c ti
hp thu.
Cc yu t gy nh hng Creatinin m khng nh hng
chc nng thn:
- Tng Creatinin mu do c ch bi tit Creatinin:
Trimethoprim, Cimetidine..
- Tng Creatinin mu do nh hng o lng Creatinin:
Ascorbic acid, Cephalosporins
- Cc yu t khc: tnh trng dinh dng, th tch phn b,
tui, gii, chng tc, thi quen n ung, ct ct chi..
BUN:
- Tng ti hp thu khi thiu nc
- Tng BUN m khng nh hng chc nng thn: tng d
ha, nhp nhiu protein, xut huyt tiu ha, liu cao
corticoid.
- BUN thp gp trong: ch n t protein,, suy dinh dng,
bnh gan nng.

Cystatin C: l 1 protein to ra bi t bo c nhn, c lc t do

cu thn, ti hp thu han tan ng thn gn, khng c bi tit.
-Khc phc nhng nhc im ca Creatinin: lin quan n khi
c.
- Thay i sm hn Creatinin trong tn thng thn cp.
CC BIOMARKERS CA AKI:
- c bi tit trong mu v nc tiu khi c tn thng thn
cp, tng t Troponin t tb c tim sau nhi mu c tim cp.
- nhy v c hiu i vi AKI hn so vi BUN,
Creatinin.
- ang c nghin cu: Urinary Interleukin 18 (IL-18),
Neutrophil gelatinase associated lipocalin (NGAL), kidney
nury molecule 1 (Kim-1)tng sm hn BUN, Creatinin 1-
2 ngy trong trng hp thiu mu cc b..
Tiu chun R.I.F.L.E. trong tn thng thn cp
(ADQI 2004)
 TIU CHUN RIFLE

Nguy c (Risk): Creatinin mu tng 1,5 ln hoc nc tiu < 0,5 mL/Kg/gi trong 6 gi.

Tn thng (Injury): Creatinin mu tng gp 2 ln hoc nc tiu < 0,5 mL/Kg/gi trong 12

gi.

Suy thn (Failure): Creatinin mu tng 3 ln hoc Creatinin >355mol/L hoc nc tiu <

0,3 mL/Kg/gi trong 24 gi.

Mt chc nng thn (Loss): STC ko di hoc mt han tan chc nng thn trong hn 4

tun.

Bnh thn giai an cui (End Stage renal disease): mt han tan chc nng thn trong

hn 3 thng.
 DCH T HC

1. Mc phi trong cng ng: chim khang 1% BN nhp

vin, hn phn na s BN c bnh thn mn i km.
Nhng nguyn nhn thng gp: trc thn (70%), sau
thn (17%). T l t vong tan b l 15%.
2. Mc phi trong bnh vin: Dng tiu chun RIFLE, c
20% BN nhp vin c kh nng b AKI. Cc nguyn
nhn thng gp: thiu mu cc b, nhim trng huyt,
thuc, thuc cn quang. AKI trc thn thng gp
bnh phng nhng hai t ng thn cp thng gp
trong ICU, l mt phn trong tn thng a c quan.
3. Suy thn cp l mt yu t nguy c c lp vi t vong
trong bnh vin v tng quan vi thi gian nm vin.
AKI mc phi trong cng
ng
 TIP CN BNH NHN SUY THN CP
Xem k h s bnh n (trong BV, thuc)
Hi bnh s v khm lm sng
Th tch nc tiu v TPTNT
Xt nghim: BUN, Creatinin HT, Ion mu,, CTM.
Kho st cc ch s sinh ha Nc tiu
Siu m bng lai tr tc nghn ng tiu.
Cc xt nghim chuyn bit khc ty theo bnh cnh lm
sng.
iu tr th v theo di din tin.
Sinh thit thn
PHN BIT SUY THN CP V SUY THN MN

1. Ghi nhn tin cn: cc ch s BUN, creatinin trc y, hoc

tin cn bnh thn gi suy thn mn nn tng.
2. Siu m thy thn teo, mt ranh gii v ty gi STM.
3. Thiu mu mn ng sc ng bo khng gii thch c
bng cc nguyn nhn khc BN c GFR < 30mL/pht gi
suy thn mn.
4. H Canxi mu
 NGUYN NHN

1. Tng azote mu trc thn (55 - 60%)

2. Tn thng thn cp ti thn (35 - 40%).
3. Tn thng thn cp sau thn (<5%).
TN THNG THN CP TRC THN
(Tng azote mu trc thn)
(Suy thn cp trc thn)
 SUY THN CP TRC THN

1. GIM TH TCH NI MCH THC S:

- Xut huyt.
- Mt dch qua ng tiu ha: i, tiu chy, ht dch d dy.
- Mt dch qua thn: thuc li tiu, i tho ng (li tiu
thm thu), i tho nht, suy thng thn, bnh thn mt
mui.
- Mt nc qua khang th ba: bng, vim ty, vim phc
mc, gim albumin nng, HC p ng vim.
- Mt qua da: bng, m hi, tng thn nhit
- Lng nhp gim: n ung t, ri lan tm thn.
Trieu chng mat nc
 SUY THN CP TRC THN

2. GIM TH TCH NI MCH HIU QU:

a/ Gim cung lng tim: suy tim sung huyt, chang tim,
trn dch mng ngai tim vi chn p tim cp, thuyn tc
phi nng.
b/ Dn mch ngai bin: nhim trng huyt, chang phn v,
thuc h p, thuc gy m, x gan v cc bnh l gan khc..
 SUY THN CP TRC THN
3. THAY I HUYT NG HC TI THN:
a/ Co tiu M n.
Thuc khng vim NSAID (prostagandin inhibition)
Cyclo-oxygenase 2 (Cox-2) inhibitors (prostaglandin inhibition)
Cyclosporin, Tacrolimus
Tng Canxi mu
b/ Dn tiu M i:
Thuc c ch men chuyn
Thuc c ch th th Angiotensin II..
C CH BNH SINH
P NG CA CU THN V C TH
KHI GIM TH TCH TUN HAN

Kch thch h giao cm

Kch thch h renin Angiotensin Aldosterone
Tng phng thch ADH
Phng thch cc cht gy co mch ni tng
C ch t iu ha ti cu thn: Khi HA gim (70-80
mmHg), dn tiu M vo, co tiu M ra duy tr GFR.
BNH CNH LM SNG
BNH CNH LM SNG
 CHN AN STC TRC THN

1. Bnh cnh lm sng gi , du mt nc, suy tim

2. CLS:
BUN/Creatinin mu > 20
U Na < 20 meq/L, FE Na < 1%
Nc tiu c c
T trng > 1,018
Osmolality > 500 mOsmol /Kg H20
Cn lng NT sch, khng c tr niu
TN THNG THN CP SAU THN

(Suy thn cp sau thn)

 SUY THN CP SAU THN
1. TC NGHN NQ HAI BN HOC TC NGHN MT
BN TRN THN DUY NHT:
a/ Trong lng niu qun
Si
Cc mu ng
M, hoc nh thn trong hai t nh thn
Ph n sau chp NQ ngc dng
Carcinoma tb chuyn tip.
b/ Ngai niu qun
U trong bng, chu
X ha sau PM

 SUY THN CP SAU THN

2. TC NGHN NIU O HOC VNG C BQ:

Bu lnh TLT
K BQ hoc TLT
BQ thn kinh hoc dng thuc anticholinergic gy ng
NT
Co tht N
Si BQ
Nhim nm (Bu nm)
Cc mu ng.
 CHN AN STC SAU THN
Bnh cnh lm sng gi
Hnh nh hc:
Siu m: thn nc, nguyn nhn tc nghn.
CT Scanner khng cn quang.
MRI h niu.
CHN AN STC SAU THN
TN THNG THN CP TI THN

(Suy thn cp ti thn)

 TN THNG THN CP TI THN

1. MCH MU
2. CU THN
3. M K
4. NG THN
 SUY THN CP TI THN
1. MCH MU
a/ Mch mu kch thc ln v trung bnh
- Thuyn tc hoc huyt khi M thn,Kp M thn.
- Thuyn tc TM thn hai bn.
- Polyarthritis nodosa
b/ Mch mu nh
- Atheroembolic disease
- Huyt khi vi mch
- HUS/TTP
- Scleroderma renal crisis
- THA c tnh
 SUY THN CP TI THN

2. CU THN
a/ Hi chng thn h
b/ vim cu thn cp, vim cu thn tin trin nhanh
 SUY THN CP TI THN
3.. M K:
a/ Vim thn k cp do thuc
Khng sinh: methicillin, cephalosporin, rifampicin,
sulfonamides, erythromycin, ciprofloxacin
Li tiu: furosemide, thiazide, chlorthalidone
NSAIDS
Thuc chng co git: phenytoin, carbamazepine
Allopurinol.
b/ Vim thn k lin quan nhim trng
Vi trng (Staphylococcus, Streptococcus)
Virus (CMV, EBV)

 SUY THN CP TI THN

4. NG THN (HAI T NG THN CP)
a/ Thiu mu cc b thn
Chang
Xut huyt
Chn thng
Nhim trng huyt Gram m
Vim ty cp
Tt HA do bt k nguyn nhn no
b/ c cht
c cht ngajio sinh (thuc)
c cht nio sinh: Myoglobin (ly gii c vn), Hemoglobin
THUC GY HAI T NG THN CP
Aminoglycoside
Amphotericin B
Pentamidine
Foscarnet
Acyclovir
Indinavir
Thuc iu tr K (Cisplastin)
Thuc cn quang
Dung mi hu c (carbon tetrachoride)
Ethylene glycol
Thuc gy m (enflurane)

CHN AN PHN BIT AKI TRC THN V TI THN

 C CH GIM LC CU THN
TRONG HAI T ng thn cp

1. Tn thng ng thn: that dch ph n m k, xp ng

thn, tc nghn lng ng thn
2. Ri lan huyt ng hc trong thn
3. Phn ng vim trong thn
4. Co mch trong thn.
Muddy brown cast
 LM SNG HAI T ng thn cp

Qua 4 giai on
Giai on khi pht ( initiation phase)
Giai on tn thng lan ta (extension phase)
Giai on duy tr (maintenance phase)
Giai on hi phc (recovery phase)
SINH BNH HC AKI
DIN TIN CA HTOTC
 DIN TIN HTOTC
1. Giai an khi pht: vi gi, vi ngy.
- lc cu thn do gim ti mu thn
2. Giai an tn thng lan ta:
- Thiu mu ko di gy ri lan phn cc t bo, apotosis, hai t
tb ng thn.
- tb bong trc, dnh vo nhau, gy bt tc lng ng, ph n m k,
phn ng vim, tp trung BC.
3. G duy tr: ko di 1-2 tun, mc d gim ti mu thn, nhng
tn thng tip tc tin trin.
-Thiu niu ko di, lc cu thn gim nng.
4. G hi phc: nh du bng s gia tng th tch NT
- Bin chng vn c th xy ra, gim V lu thng gy suy thn tr
li, RL nc in gii
BIN CHNG SUY THN CP
 KT LUN

Chn an sm, ngn nga suy thn trc thn tin trin thnh
ti thn.
Chn an nguyn nhn gii quyt nhm phc hi chc nng
thn.
Pht hin sm bin chng trnh li hu qu nghim trng.