TS.BS.

LE XUAN TRUtYNG

HOA
SIKH
LAM
SANG

\TI NHA XUAT BAN Y HQC

 TS.BS. LE XUAN TRUtYNG

c-LY).,q 771-e-t' ko& Terri. -ate)

HOA SINH
LAM SANG

TAN TAO UNIVERSITY LIBRARY

NHA XUAT BAN Y HOC

Chi nhanh TP. H6 Chi Minh

2013
 L6'1 N ol DA U

Y hoc ngay cang tien bO va xet nghiem Haa sinh ngay cang phat trien, co nhieu
cleriu an sinh hoc mai chivy phat hien va nhieu ky thuat mai clei clwor trien khai ap dung
trong lam sang.
H6a sinh lam sang co mai quan he mat thiet vat cac mon hoc nine NOi, Ngogi, San,
Nhi va cac chuyen nganh khac nhiim gap phan chan clam, clieu tri, tien ltro.ng, theo dot
dien tien benh, tam soat benh trong Ong clang.
The& day, mon Haa sinh lam sang chtea clwor dtra vao chwang trinh giang day
; day no cltro.c duo vao
chinh thirc tgi cac trtrang clgi hoc Y khoa, nhung nhang nam gan
giang day chinh thiec a nam tha. 4 tgi cac trwang dgi hoc Ykhoa trong ca meat.
Hy vong quyen Haa sinh lam sang la tat lieu ciao two va tham khao haw ich cho
sinh vien Ykhoa, hoc vien sau dgi hoc va ngtrai lam xet nghiem Hoa sinh. Nha ng hieu bit
trong quyen scich nay la ste ket hop cap nhat h6a cac kien thiec tren the giai vai ste tick lay
tie thtec to 6. mak to trong nhieu nam qua, ch/ic chan se mang lgi cho cac sinh vien, hoc
vien, cac bac si" lam sang va can lam sang nhang kien thirc co. ban ve h6a sinh lam sang
de ieng dung trong tong tac chan down, phong va dieu tri benh.
Do thai gian bien sown sach bi hgn the nen khong the trcinh khoi nhang thieu sot
nhcit dinh, chac chiln clam lam hai long cac ban doc. Rat mong nhan &toy six clang g6p
kien cita cac ban clang nghiep, cac hoe vien sau dat hoc va sinh vien de lan tai ban sau
chew hoan thien how.

Thanh pita Ha Chi Minh, ngay 09 thang 7 nam 2013

Tic gia
TS.BS. Le Xuan Truirng
 CHU' VIET TAT VA KY HIEU

BC Bach cAu MD Mien dich

Bili GT.. Bili gian tier. MXV . Mang xu vita
Bili TT.. Bili tivc tiep NAHH Nhiem acid ho hdp
BMV.... Benh dOng mach vanh NBB .. Nhiem base bil
BN Berth nhan NBHH.. ..... Nhiem base ho hdp
BT Binh thu6ng NMCT.. ..... Nh6i mau co. tim
CNP C.type natriuretic peptid NMCTC .... Nh6i mau co tim cap
CRP C-reactive protein PCT .. Procalcitonin
CTM .... C6ng tithe mau NT . Nu& tieu
DMP... Dich mang phi TB . Te bao
DNT.... Dich nao -lay TBTH.. Te bao thoai hoa
DNTB.. Dich ngoai bao TC . Tieu cdu
DTTB.. Dich trong t6 bao TH Tudn hoan
DL..... Dinh luo.ng THBH.. Tun hoan bang he
DM.... Bong mau TM Tinh mach
DTD... Dai thao doing TP Toan phAn
GT.... Gian tier, TT Tieu thily
HA.... Huy& ap VG Viem gan
HC.... H6ng cdu VGSV Viem gan sieu vi
HCMVC... HOi chimg mach Vanh cap XN Xet nghiem
KN Khang nguyen XQ X-quang
KSTSR... I“T sinh tang sot ret XVDM Xo vita dOng mach
KT . Khang the
 Chu'o'ng

CHUYEN HOA NU'&C MUOI V6 Co

MUC TIEU
1. MO ra &coy b'ang sa do sec phan b a nu& va cac mu di vo ca trong co' the.
2. Trinh bay citrac ca the tac dung cita mot so hormon chinh trong chuyen hoa
ntrac — muai vo ca.
3. Neu &ro'c cac nguyen nhan chinh gay nil loan chuyen hoa nu'ac — mudi vo ca.
4. Liet ke &my cac trieu chirng, hOi chirng lam sang trong rai loan chuyen hoa
meat — mu ai vo ca.
5. Liet ke Avec cac xet nghiem h6a sinh quan trong de than doan rai loan
chuyen h6a nwac — mudi vo co..

1. CHUYEN HoA NU'&C

1.1. Dai cu'o'ng ye sty phan b6 nu'&c
Nuac chi6m khoang 60% trong luting can nang cua ca the truang thanh, 2/3 trong s6 dO
la dich trong to bao (DTTB), 1/3 con lai la dich ngodi to bao (DNTB). DNTB gom dich
ke (dich gian bao) chiem 15% va huyet Wong chiem 5%. Vi du mot ngueri throng thanh
70kg c6 khoang 42L neat, DTTB chiem 28L, DNTB chiem 14L, trong do có 10,5L dich
ke, chi khoang 3,5L huyet tircmg.
Trong dieu kin binh thuOng luon c6 su can bang gift luting neat vao va ra khoi co
the, ntrac &roc cung cap tlr che dO an &mg, cac qua trinh chuyen hoa, oxy hoa cac chat.
MOt luting mak tuung tu cling tieu hao qua than, runt, phoi va da. Leong nu& tai thieu
de bai tiet cac chat thai qua than la 500m1/24giO, luting nu& bat bu'Oc tieu hao o nhang
a
not khac la 600m1. Do do m8i ngdy tai thieu can phai dua vao co the 1.100mlnuov gift
thang bang not moi. Nhu cau nay se tang len khi luting ntrac mat nhieu (tieu chay, non,
mo luting nu& dua vao du thira se duot dao thai qua then.

1
An: 1 lit -) Ong tieu hoa
Uong: 1,2 lit) Phan: 0,1 lit

Dich nao tray A Phoi —> hai th&

1,2 lit
Bach huyet Huyet tu'ang 5% H2O Da -4 mo hei
Dich khap H2O Than —> nikYc tieu: 1,2 lit
Dich tiet khac
Thanh mao mach
Dich ke 15%

NiPac do Mang te. bao

oxy hoa: 0,3 lit Dich trong to bao 40%
H2O
Nutvc nhap: 2,5 lit Oxy hea cac chat Nutec xuAt: 2,5 lit

Hinh 1.1. Su do ph5n bó nu,ac va su, van chuyen nu,6,c trong ca the

Tay theo tuoi, gioi luang nix6c hien dien trong cac ngan dich cita ca the khac nhau.
Bang 1.1. Ph5n 136 dich trong co' the lien quan den tuoi va gidi

Tre em (1 tuiii) Nam (40 tad) Nu. (40 tali)

an nang (k
ucyng ntro.c toan Than
he. "ch DTT

Ngodi cac dich co the binh thuang Ice teen, trong met se qua trinh benh ly di the xuat
hien trail dich (trail dich mang tim, Mang phoi, mang bung), dich tran co the la dich tham
hay dich tiet.
Dich co the co chira cac chat Ilea tan nhat dinh, do do kin cc') nhang rei loan sly van
chuyen cac dich co the, ailing bi mat qua nhieu hay -Cr dong, ca the se chiu nhang fei loan
benh ly thir phat.

2
 CHU'O'NG 1 10- CHUYEN HOA NUCIC - MUOI VC) CG

Mau &mg vai tro trung tam trong van chuyen nu& va cac chit hoa tan (chat dinh
dtrO'ng va can ba), la not m6i cua ca the. Co the luon dam bao sir hang dinh not moi, nghia
là cac thong so cna mau (trong do c6 cac th6ng s6 h6a sinh) luon luon trong trang thai
on dinh,(chung dao d6ng trong nhung giai han sinh Vi,nhat dinh). Khi co met chi so cila
thong so nao do vugt khoi gigi han sinh 13i (cao hay thap han) thi chi:mg pilau anh nhang
trang thai benhVf nao do.
Thanh phan dien giai phan b6 khac nhau gifra DNTB va DTTB. Natri c6 nhieu 6
DNTB, kali c6 nhi6u a DTTB. Sir khac biet nay dugc duy tri bed barn NalCATPase.
Bang 1.2. Nling TO dm mot s6 ch6t din giai trong cac ngan dich

Dien giai DNTB (mmol/kg) DTTB (mmol/kg)

Natri damilik Ift 10
47mai 160
Calci
Magie
111

III
a
2,7 1111r
1,1 BMW 13
1,0

Clorua 111111116iallii■•■=r0
Bicarbonat MEM
11.1116,1111.111rMallk

Nu& trong ca the di chuyen qua lai giita cac ngan DTTB va DNTB tuy vao ap lirc
tham thau. Ap likrc tham thau (ALTT) a DNTB chiu anh hugng cua n6ng dO Nat, K-E, Cl-,
HCO3-, ure, glucose,... Doi vai huyet tucmg cac thanh phan chinh la Nat, K-F, Cr, HCO3-,
ure, glucose.

1.2. Ni.ro,c va nong do thArn thau dich ngoai t6 bac.

Nu& thuemg xuyen di chuyen qua lai giita hai khu vitt trong va ngodi to ban theo ap lgc
tham thau, ngoai nit a thin thi ALTT trong va ngoai to bao luon dugc giva trang thai
can bang.
ALTT DNTB chiu anh huang bai n6ng dO Na+ va cac anion cna no (Cl- va HCO3-,
ure, glucose) trong khi DTTB la va anion chiu yeu la protein va phosphat.
Dich ca the khac nhau co su khac nhau rat lan ve thanh phan cling nhu n6ng dO cac
chit ben trong, tuy nhien n6ng dO tham thau thi lai Wang d6i dong nhat. Cac dich the
dugc chia tach vai nhau bgi nhftng mang ban tham ma nix& c6 the di chuyen qua lai (18
dang de gift cho ALTT luon a mac hang dinh gift hai phia cua ming.

3
HOA SINN LAM SANG

Bang 1.3. Nemg dO cua mot s6 ch6t din giai trong mot s6 dich cCia co' th6

Na+ HCO3 Cl-

uyt.t Wong
ich da day 50 IS
ich riot non IA 140 141111111.161
ich tieu chat' - 141111111.AM0
ich mang 1111111 140.211111,511111
1 1()

NOng d0 tham thau cua mot dung dich d-upc tinh bang s0 mmol chat hoa tan trong 1
kg dung moi (thuemg la twat).
O nguoi, ntmg dO tham thau huy& tuong (va hault& cac dich co the khac, ngoai trir
ntrac tiL) dao dOng tir 285-295 mmol/L. NOng dO tham thau cua huy6t tuong có the duoc
do truc tip hay tinh toan dua teen cac thong s0 n0ng dO cac chit hoa tan cla ducic bi6t. Ta
có the tinh mot cach dcm gian bang ding thirc thu gon sau:
I■10ng di) Osmol/L = 2 x [Nat] + [Glucose] + [Ike] (mmol/L)

1.3. Nu'o'c va vai tro cua ADH

Co quan chinh ki'ern tra su mat nuarc dm co the la than. Thy theo tinh trang thira hay thiL
nuac cila co the ma \Tang duai doi ti& hay khong tiet vasopressin (ADH) de tac dOng len
Ong than tac dung tai hap thu ntrac tir dich loc tra vao mau. Su kich thich va bai tiet ADH
throe dieu hoa bai cac b0 phen 'then cam tham ap a yang clued doi va cac b0 phen nh4n
cam ap a tam
Cact3i) phen nhen cam tham ap dap ung khi su thay doi ALTT > 2%.
Cac bO phen nhen cam cam ap dap ung khi su thay d6i the tich nOi mach >10%.

4
 CHU'O'NG CHUYEN HOA NU'O'C - MUOI VO CO'

NEPHRON
H2O Na+

Ti6u cAu Ong xa

Ti6u dOng than
mach vao—

Veu Ong
mach vao N H2O
Ong gin
H2O
Na+ Aldosteron
N
Nhanh xuemg ADH

H2O Na+'
Ong Op
Nhanh On
H2O

Quai Hanle

Hinh 1.2. Vai tro cua ADH trong di6u h6a nuo'c
1.4. Roi loan chuyen hoa wen

1.4.1. AlMt weir

• Giam hrang dich trong ca the (tong lagng dich, chu y6u la dich ngoai bao) c6 hay
khong c6 giam Na+ kern theo.
• 3 loci mat wet: ding twang, ult tnxang (mat Na+ it han H20), nhugc truang.
✓ Mat nage ding truang: hrong nage va lucmg natri trong mau hoac huyet
thanh bi mat ding mgt dam de.
✓ Mat nage tru truang: mat natri it han mat nugc.,
✓ Mat ntrac nhirgc trucmg: mat natri nhieu han mat nage.
• Mat 5% la da c6 dau hieu lam sang, mat 20% de Oa nghiem tong.
✓ Nguyen nhan: non, tieu chay, re 'Ong tieu hoa, but dich tieu hoa, chay mau,
phong, co twang, tic met, toan ceton do dai than throng, ra mo
✓ Trieu chung: khat, nhip tim- nhip the. tang, mac tieu < 25m1/gier, thay doi hanh
vi, sang, vo nieu, de dan hoi da giam, niem mac mieng kho, mach tang, sut can.
✓ Xet nghiem: Na+ mau tang, Hct binh finding hoac giam nhe, hrong ntrac tieu
giam, ure tang.

5
HOA SINN LAM SANG

✓ Danh gia: kiem tra tinh mach (TM) ngoai vi a ban tay: cam tay cao hon vi tri
tim mot thai gian ngan red ha xu'ang duai vi tri tim. Neu the tich mau va (long
mau tuan hoan binh thuemg, TM ngoai vi tay cam ditch vi tri tim se it cang
trong yang 5-10 giay. Neu TM ngoai vi khong it cang trong 10 giay la c6 tinh
trang mat ntrac hay giam the tich mau.

1.4.2. Thera mrerc

• Thuemg xay ra a nhang b'enh nhan dirge truyen dich dieu tri, an qua nhieu muai
ma di& nang then binh thuang se gay tang thai mu6i a thdn. Tuy nhien, khi
tnlyen dich qua nhieu muai thi gay tang the tich dich ngoai bao.
• Cac nguyen nhan: suy then cap, giam tong hop protein gay giam Nat, phang-
viem gay phn khu tru, tac nghen mach bach huyet gay phn, suy tim, xo gan, thuoc
NSAIDs gay tang ADH ddn tai phu.
• Trieu chimg: nhirc ddu, mat phuang huang, r6i loan hanh vi, 111 Ian, tang ap hrc
tuy sang, lion me, co giat, vop be, phit, tang can, tran dich cac mang. Trieu chirng
a nao d u xay ra 6 tinh trang thieu hay thira dich.
Xet nghiem: Nat huyet giam, dO thdm thdu huyet thanh giam, protein — albumin — Hb
Hct giam, ap luc tinh mach trung tam tang han 12-15cm H20.

Ca2+
Mgt+
Hu* tuang Dich ngoai to bao Dich trong t6 bao

Hinh 1.3. Wing dO chgt diOn giai trong mot s6 dich ca th6

6
 CHUCYNG 1 IP- CHUYEN HOA NUCC - MUOI Vb CO

2. CHUYEN HOA NATRI

2.1. Dai cu'o'ng ve sty phan 136 natri
T6ng,lugng natri trong ca the nguai tnrang thanh khoang 3.000mmol (55-65 mmol/
kg the trong), 70% Wang nay c6 the trao doi dugc, phan con lai tan tai dang phirc hop
trong xuang.
Phan 16n Na+ a DNTB, n6ng dO Na+matt trong khoang tir 135-145mmol/L, trong khi
a DTTB la 4-10 mmol/L. Hau het cac mang to bao deu khong cho phep Nadi chuyen qua,
Na+ di chuyen tix DTTB ra DNTB ngugc gradient n6ng dO nha vao bom Na+KATPase.
MOt dac diem quan trong can luu y la tong Wang Na+ luu th6ng trong cac dich co
the la rat lan, khoang 1000mmol bai tiet qua runt trong 24gi6 va dugc lac tai than khoang
25.000 mmo1/24gia. Phan lan dugc tai hap thu a runt Ara than, cac qua trinh nay suy
giam se anh hating den sly can bang not mai. De dam bao hang dinh not m6i, luting
dm. vac) phai can bang vgi luting Na+ thai ra (nai thai natri la than).
Luang natri dua vao ca the thy thuOc th6i quen an tieing cua m6i nguai, trung binh
150-250 mmo1/24gia, trong khi luting that that bat buOc qua than, da va runt thuang <
lOmmo1/24gia. Do do tieu thu mot luting lan mu6i có the gay hai cho ca the, dac biet la a
nguai tang huyet tip. De dam bao stir can bang not moi, thong natri dua vao phai can bang
\Ted Wang natri thai ra, nai thai ra chinh la than, six dieu hoa cita than dugc kiem sok bad
the tich not mach.

2.2. Natri va dich ngoai to bao

An: 150-250mm1/24 gioe Phan: 3,5mm1/24 giey

DTH
Truy6n Jich • Da: Ma hai: 10-20mm1/24 giCy
HT: 135-145mm1/L
H2O

HC

Than nutec tieu

100-200mmo1/24 giey

Aldosteron
Na.

Hinh 1.4. Sa 155 chuyk hoa Na+

7
HOA SINN LAM SANG

Natri la cation chinh cua DNTB nen no xac dinh ALTT DNTB, do dO khi n6ng d6
natri thay d6i se lam thay ai n6ng d6 ap suit tham thau va su chuyen d6ng cua nuac giita
DNTB va DTTB.
Khi lugng natri o DNTB tang se lam tang n6ng d6 ap suit tham thau cua DNTB,
nuac tir trong to bao se chuyen ra ngoai to bao, to bao mat nuac. Ngugc lai khi lugng natri
a DNTB giam, se giam ap suit tham thau, nuac vao to bao gay to bao it nuac.
2.3. Vai tro caa natri
Natri giu vai tro quan trong trong hoat dOng thAn kinh co, bum NatIC, d6 tham than dich
trong mach va thing bang kiem toan.
Gia tri binh thuang trong huyet Wong 135-145 meq/L, trong nuac tieu la 40-220 meq/L

2.4. Vai tro cua th#n trong di4u hoa natri

M6i ngay c6 khoang 25.000mmol natri dugc loc qua cau than, duoi 1% lugng nay hien
dien trong nuac lieu (100-200 mmo1/24gia), 75% dugc tai hap thu a 6ng hrgn gin, 20%
dugc tai hap thu a nhanh len quai Henle, 5% dugc tai hap thud Ong lugn xa va 6ng
Dieu hoa su bai tiet natri dugc kiem soat bai aldosteron va ANP (atrial natri uretic peptid).
Aldosteron dugc bai tiet de dap irng lai su giam the tich nOi mach theo co ch6: khi
the tich nOi mach giam - tang tiet renin -> chuyen angiotensinogen thanh angiotensin I
4 angiotensin II duai tic dung dia. ACE (angiotensin converting enzym). Angiotensin II
kith thich tuyen thugng than bai tiet aldosteron de tai hap thu natri.
0 "Mat nu ,c
Gam Natri
Xuat huyet

® Gam the
tich mau 1uOt ap tang den

•0
61 tri so binh thuryng
0 Giam huyet ap ii. I
418inip.
®Tang co bop ca tim Tang the tich mau
f--)• Tang co that mach
0 rang Renin

Gan 011.11M- CrVO thuang thank

'
Tang Kali/
DNTB
Tang
Angiotensin I

Tang tai hap thu muoi-

Tang .../ 0 Tang nuor tai than
(ACE =Angiotensin ngiotensin II Aldosteron
Converting Enzym)

Hinh 1.5. Vai trO cua than trong diau hoa Na+

8
 CHUO'NG CHUYEN HOA NU'O'C - MUOI VO CO'

2.5. ANP (peptid bai natri ni4u)

Dirge tiet dr tam nhi phai, c6 chirc nang tai hap thu natri a doan 6ng g6p, ire the bai tiet
aldosteron va gay ha huyet dp. Hai peptid c6 cau truc tuung tu la BNP (tiet bai tam that,
tac deng tuning ttr ANP) va CNP (hien dien vai 'long dO cao a lap nei mac mach vanh, có
tac dung gia'n mach).

ANP
BNP

Gran mach -4 Ang II .010. Aldo

Giam th6 tich Giam tai hap thu

Giam huyet ap mau -41- muCii - nuac

Hinh 1.6. -lac dung cua ANP

2.6. IR6i loan chuyen hoa natri

2.6.1. Thigu natri
Cac nguyen nhan gay mat natri
o Duamg tieu hea:
✓ Da day: non, hint dich vi, re, xuat huyet.
✓ RuOt: m6 thong hed tang, re tuy, re met, tieu chay, xuat huyet, tac runt.
o Da: me) hoi, pheng, b'enh tang tiet a da.
o Nhap vao khong du so vai nhu cau va luting mat:
✓ Cap tinh: giai doan da nieu trong suy then cap, sau ghep then.
✓ Man tinh: han the mu6i trong suy then man, mat muoi trong cac b'enh then.
o Mat mu6i do cac b'enh thin Oat:
✓ Tang renin trong hOi chirng giam aldosteron.
✓ Benh Addison.
✓ Giam renin trong hOi chirng giam aldosteron.
✓ Chung gia giam aldosteron type I.
✓ Lai lieu.

9
HOA SINN LAM SANG

Thu6c va six thieu natri:

Bang 1.4. Cac thuoc gay threu natri mau
Thiazide, frusemidelfronolactoltramiloride,
Loi tieu
triamterene
Barbiturates, morphine, chlorpropamide, tolbu-
Tang tit ADH tamide, vincristine, cyclophosphamide, carbe-
mazepine, clofibrate, SSRIs
Ditu khee'n host thing
Chlorpropamide, NSAIDs, paracetamol
ADH
Doc diem lam sang
- Giam Na+ ket hop giam the tich ngoai bao (ECV): mu6i mat A/trot qua su mat
nuorc trong hOi chi ng giam chile nang then nguyen Oat (benh Addison), vo
thuong then bi hi:1y do benh to mien, viem nhi6m hoec benh dc tinh. Mat nhieu
qua then: lgi nieu tham thau (tang glucose va ure mau), o'ng then giam tai hap thu.
Mat ngoai then: non oi, tieu chay, m6 hoi...(Na+ nieu < 10).
Giam Na+ ket hop tang ECV: do tang cac chat hea tan khac trong DNTB lam
tang keo nuac kh6i to bao, kem theo natri di chuyen vao trong to bao nham can
bang ALTT trong va ngoai to bap. ThuOng gap nhat la tang throng huyet, met
each tong quat thi vOi moi 100mg/d1 glucose tang them (voi nong de glucose >
100mg/d1) thi nong dO natri giam khoang 1,6 mmol/L. Tren lam sang khi dieu tri
bang loi tieu tham thau (manitol) cling gay hien tugng nay.
- Giam Na+ vai ECV binh thuemg: stress (chan throng, phau thuet, bai tiet ADH
cao bat thuOng), ADH tang de nhay do met s6 thu6c nhu chlorpropamide,
tolbutamid.
- Giam Na+ gia: do to dinh lugrig Na+ bang phuong phap gian flap tren benh nhan
tang lipid mau hay tang protein mau.
Chan &tin
mau &red 130mmol/L.
- Ap tut tham thau huyet tucmg giam.
- Ap luc tham thau nuov lieu > 200mosm/kg.
nieu > 20mmo1/L.
- Chit benh nhan,khong bi mat nuac, khong benh 13'T tim mach-then-tuyen
yen-chiTc nang tuyen giap, kh8ng dOng thu6c gay giam Nat, dap *rig voi giam
dich truyen.

10
 CHU'O'NG CHUYEN HOA NU'O'C - MUOI V6 CO'

Ha natri mau gia

li ang lipid mi i
ng protein
i

IA
Suy giap
Threu glucocortic

Zvi tieu, nhik Vern,

u ' ralocorticoid

Hinh 1.7. Sa c16 chAn doan ha natri mau

Dann gia qua xet nghiem: khong c6 xet nghiem dec hieu, chon xet nghiem tuy nguyen nhan
- Ure huyat: nguyen nhan then.
- Na+ mau, albumin, nellig d) tham thau.
- Do Hct: danh gia mire clO giam DNTB
Hct binh tineerng
DNTB = 0,2 * Than trong * (1
Hct coo
- Danh gia sir thieu but Na+
ThiL Nat = 0,6 * than trong(kg)* (140 — [Nal/mationmod
- Nhu cau cung cap (trong ngO d'Oc mac cap)
Nhu c'au(..0 = (125 - [Nal/mau(minod * 0,6 * than trong(ko

11
 -

HOA SINH LAM SANG

2.6.2. Thipa natri

Nguyen nhan
- Thira Na+ kern theo phn: suy tim sung huyet, hOi chimg then hu, benh gan, phu nit
mang thai, phn tien phat.
- Thira Na+ khong kern theo phn: truyen dung dich muoi, giu natri tai then (cuamg
aldosteron tien — thir phat, thira glucocorticoid do benh Cushing), tang san tuyen
thugng than ham sinh, chimg gia cuamg aldosteron.
diem lam sang
Lien quan vai thira nuac: phu, tran dich, sung huyet tinh mach, cao huyet ap, tang
can neng, kh6 Oat am.
Bun non, non, hfai kho, nhip tim nhanh, cao huyet ap, lo rang, bon chon, may co.,
run, tang phan xa, da kho do.
Thuac vit su' thaw Na+
Corticosteroid (cortison, prednison).
Natrisalicylat, natriphosphat, natribicarbonat.
Thu6c ho.
Khang sinh: penicillin, carbenicillin, mezlolocillin.
Cholestyramin, amphotericin B, propoxyphen, lactulose.
Dank giti: tang Na+
Na+ man > 146mmol/L.
- nieu < 40 mEq/L.
- Ty trong NT < 1,025.
- D them theu HT >295 mosm/kg.

12
 CHUO'NG -I • CHUYEN HOA NUCYC - MUOI VC) ca

Tagibligh huyet

Met natri Va nirac

(Mat natri < nuxfyc)

Giam luting natri Luang natri ca the Tang luting natri

ca the binh thubng ca the

Ngoai Atha 1 111rNgoai then Tai than * Tang Aldosteron

* Tang hO hap * Tieu doting * Cushing
* MO h
* Tieu ch
111 16 hOi nhi6u
o,c
* WI-1g it
ntyac

Natri nieu
* Ding nhieu
NaHCO3, NaCI

Natri niOu

D'ang truan Nhuvc, d Dang trulyng

hoac nhtsa I hay turang hoac Lru
truang u tru, twang

> 20 mmoi/L > 10 mmoi/L Thay d6i < 20 mmoi/L

Hinh 1.8. Sce do ch6n down tang natri mau

3. CHUYEN HOA KALI

3.1. Dai cu'o'ng y6 sty phan be)

An: 50-100 mmo1/24 gity Phan: 100 mmo1/24 gi6

DTH
HT 3,5-5,5 mmol/L Da rn6 hoi 0-5 mmo1/24 gioe

K+ Than Nixo'c tieu

50-80 nnmo1/24 gier
DNTB 1,5%
Na+
DTTB 98,5% A Bald • ster n

A: Acid
B: Base

Hinh 1.9. Sa do chuy6n haa K±

13
FlOA SINN LAM SANG

K± la cation chi' yeu cua DTTB, 90% tong lugng dm co. the 6. dang tg do va co the trao
d6i, phan con lai barn vao hong ceu, xucmg va mo nao. Tuy nhien chi 2% (50-60 mmol)
Km hanh trong DNTB, la lugng to c6 the do dem dugc. Mang d6 mau a ngoai truang
thanh 3,5-5,5 mmol/L. Wong dO mau khong phan anh chinh xac tong krcmg kali co
the, tuy nhien lugng IC nay lai dong vai tro quan trong trong viec duy tri sir phan cgc cua
mang to bao.
Luang dua vao co the toy thu6c vao the d6 an u6ng, trung binh 50-100
mmol/24gia, hau het IC dugc tai hap thu a runt, mot luting rat it theo phan bai tiet ra
ngoai (10 mmol/L).
Sg phan b6 gitta DTTB va DNTB duce duy tri nher born NalCATPase nam
mang to bao.

3.2. Vai tro cua 1(4-

0 Mk day den truyen xung d6ng than kinh.
0 Co co ton — tim — van.
0 Tham gia dieu hoa d6 th'em theu dich nOi bao.
0 Tang cuong hoat dOng dm men len chuyen h6a cua to bac).
Tham gia duy tri can bang acid — base.
Ceti then loc 700mmol K±/24 gia, 95% dugc tai hap thu. Ong xa va 6ng gop bai tiet
duai six kiem sok cua ADH, tinh trang acid — base, lugng nhep vac., anh huang cua
mot so thuoc lgi tieu.
K+ nieu binh thuong 50-80mmol/L, thieu hoec met ICE ngoai then IC nieu van gift
mirc 20-30mmol/L trong 10-20 ngay deu. Do do, khi nieu < lOmmol/L la thieu K± man
du IC mau binh thuong.

3.3. Vai tro cua thOn

Can bang kali 0. DNTB dugc hem sok bai then va phan nao bai 6ng tieu h6a, binh
thuong kali dugc loc to do qua cau then m76i ngay khoang 700mmol, heu het dugc tai hap
thu tnroc khi den Ong lucm xa va dirge bai tiet tai 6ng 1-iron xa va 'Ong gop. Sg bai tiet kali
qua nu6c tieu chiu sir chi phoi bad:
0 NOng dO Na+ c6 the tai hap thu tai 6ng loon xa va 6ng gop. ,
11 Moi tuong quan giita va H+ tai cac to bao 'Ong lugn xa va 'Ong gop.
0 Kha nang tiet cac to bao.
Nong d6 aldosteron.
0 Tec d6 cua dich loc.
Aldosteron tac dung tang tai hap thu Na+ tai eng loon xa va 'Ong gop thong qua bum
Na+K-FATPase bang each gia tang tong hop enzym nay —> tang thai
CO sg canh tranh gifra viec bai tiet va 1-1± tong qua trinh tai hdp thu natri.

14
 CHU'O'NG 1 ► CHUYEN HOA NU'O'C - MUOI VO CO'

Anh htrang cua tinh trang nhiem acid-base rat quan trong trong phan be) kali. Khi
nhiem acid (I-I+ cao), c6 khuynh htrang di vao to bao, K± se di chuyen theo chieu ngagc
lai - tang K± mau.
Khi nhiem base (11±thAp), c6 khuynh huong di khoi to bao thay ch8 cho ngoai
bao 4 giant mau. Dieu nay giai thich vi sao khi giant mau - nhiem base: do khOng
dit IC de tai hdp thu Na+ nen ca the sir dung E1+4 tang bai Wet fl+.
Insulin fink day qua trinh tai hdp thu qua mang to bao bang co cite kich thich born
NalCATPase. Six thieu but insulin dran to i tham kali khoi to bao. Co. the nay coy nghla
quan trong trong viec dieu tri tang kali huyet. Catecholamin anh htrang len six phan bo
kali, (3-adrenergic gia tang qua trinh di& day kali vao trong to bao, a- adrenergic c6 tac
dung ngtrgc lai.
Sg dap irng kali nieu trong nhing trtrong hgp sinh benh VT c6 hieu lgc nhtmg cham.
Vi du nhtr trong tru6ng hop nhap thieu hay mast kali ngodi than (tieu chay) thi trong 10-20
ngay dau, kali nieu van giir a mire 2-30 mmol, sau do mai giam xu6ng con lOmmol. Do
do khi kali nieu < l Ommol co nghia la co the thieu but kali man mac du kali mau c6 the
binh thtrang hay hai giant.

3.4. R6i loan chuyen hoa kali

3.4.1.Giam kali
Nguyen nhan gay giam kali huyet
o Tieu hoa:
■ Luang kali dtra vao khong du.
■ R6i loan tieu hoa: non, tieu chay, re.
o Nhiem acid Ong than.
o Nhiem base chuyen hoa.
o Lgi tieu.
o Dung insulin.
o Mineralocorticoid: chirng tang aldosteron tien-thin phat, chung gia tang
aldosteron.
o Thuoc: penicillin, gentamycin, cysplatin.
o Leukemia.
o Thieu magi&
Thu6c anh haang gay giam
o Thu6c x6, chit thut raa.
o Corticosteroid, kayexalat.
o Levodopa (tang mat K±qua nuac tieu).
o Khang sinh: polymicin B, tetracyclin, gentamicin, neomycin, amikacin,
tobrammycin, cisplatin (dOc than).

15
 o Penicillin, carbenicillin, ticarcillin, piperacillin...tang ciao thai Kt
o Chat ire the adrenergic, insulin, lgi tieu thai
1111721111

< 20 mEq/24 gi& > 20 mEq/24 gitt

Mat Kali ngoal than,.

t ap
Binh thubng - th6p

11111116rbonat mau
Cao

Do renin man Toan chuyen hoa

Do Clorua NT
Thao

Do Aldosteron mau < 10 mEq/24 gia > 10 mEq/24 gia

NOn Trin
What p Binh thiygnq-cao Thieu Magie
Thi6u Kali nang
U tiet Renin Cu'&ng Aldosteron
Nhiem Mineralocorticoid tien •hat

Hinh 1.10. So' 6 cl- an doan ha kali mau

Dirc diem lam sang
o Tieu h6a: chan an, barn non, tieu chay, trtx&ng bung, giam nhu deng runt hoac Wet.
o Tim mach: loan nhip, ngimg tim.
o Then: tieu nhieu, gift Nat
o Than kinh co: yet' co, chong mat, lu lan, pha'n xa gan sau giam, liet co ho hap.
o Ni 6 tiet: giam bai tiet renin, aldosteron, insulin.
o Dien tim: T det hoac dri chieu, ST hep.
Ranh gia: xet nghiem mau-nieu, bicarbonat, renin, aldosteron de chan- doan
nguyen nhan.

3.4.2. Tang kali

Nguyen nhan gay tang kali huyat:
o In vitro:
■ Tieu huyat.
■ Phong thich tir Bach cau.

16
 CHU'O'NG 1 ► CHUYEN HOA NUOC MUOI VO CO

• Lull gift mau o nhiet dO thap.

• Gia tang kali huyk co tinh gia Binh.
o In vivo:
• Nli6m acid.
• Thiesii insulin trong benh dai thao duotng do tuy.
• Thuoc: succinylcholin, digoxin.
• Huy hoai to bao cap.
o Tang kali do in trong co' the:
• Nhap vac, qua. nhieu.
• Giam dao thai: giam dO loc cau than, giam bai tiet 6ng than.
• Lgi tieu gift IC, giam aldosteron.
ThuOc va tang IC: kali penicillin, thut rim bang dd chin. K3PO4, indometacin,
captopril, heparin, barbiturat, an than, NSAIDs, chen
Deic diem lam sang:
o Buon non, non, co that co thanh bung, nhip nhanh — nhip cham — ngimg tim.
o Met, cam gide te, dau nhoi, chi* Mt.
o Than: thieu — vo ni'eu, bai Na+ nieu, giam tai hap thu HCO3- 0. 'Ong than, giam
sinh amoniac.
o NOi tiet: giam bai tiet renin, tang bai tit aldosteron, tang bai ti't insulin.
o Dien tim: ST hep-nhon-cao, QT ngan, PR dai, mat P, QRS dai.
Daub gia: k6t hop nhieu y6u to, huyk, he s6 loc cau than, ure, creatinin.
Tang Kali mau

Tang Kali mau gia Tai phan b6 Kali: CY Kali

Tiou huyet - Nhiem toan
Tang tieu chu - Thieu Insulin
Tang bach chu - T6n thu'o'ng TB
nang (tan huyet,
phong...) GFR < 5 ml/p
Tang tong bung kali
- Ng6 d6c Digox-
in, Beeta-blocker

Giant Aldosteron
Aldosteron binh thireyng
Benh Addison
hay tang
Giarn Renin giam Aldoste-
ron
ThuOc, lai tieu:
- Spironolacton
tYc the men chu en
- Triamterene
- Amiloride

Hinh 1.11. So' d6 chan Goan tang kali mau

TAN TAO WORMY LIBRARY 17

HOA SINN LAM SANG

4. CHUYEN HOA CLORUA

4.1. Dai cu'o'ng
Clor la met khoang chit can thiet cho con ngugi. La khoang chat chil yeti cua dich co. the.
Clor la ion am chic yeu cua mau, chiem khoang 70% tong ham Wong ion am cua co the.
TOng gnat, ac,ngued tnIgng thanh chira khoang 115g clor, chiem khoang 0,15% tong
trong hrong co the.
Lirong clor tieu thu m6i ngay tir 750 den 900 mg m6si ngay, Itrong dao thai ty timg
ca the, trung binh khoang 530 mg m8i ngdy.
NOng de Cl- binh thuerng: 95-108 meq/L.

4.2. NguOn cung cap clor

Clor co trong thuc pham \Ted ham lugng binh throng it hon 0,36 mg trong moi gram thirc
an. Lugng clor trung binh trong the de an khong muoi la khoang 100 mg moi ngdy.
NguOn cung cap clor "lanh manh", it gay tac hai cho co the bao gOm: tao be (rong
bien), cac khoang chat ion, o liu, lua mach den, ca chua, rau diep, can Tuy nhien ham
lugng khong lem, khong du cung cap cho nhu cau dm met nguoi truOng thanh.
Luong cung cap clor chu yeti la muei an, ngodi ra cac thuc pham chi& xuat tit nam
men, pho mat ding cung cap met lugng lon clor cho co the.

4.3. Dieu hoa clorua

Than dong vai tro quan trong trong dieu hoa nong de clor mau thong qua qua trinh tai
hap thu hay dao thai clor, six tai hap thu clor tai cac nephron cua then nhg hai co the van
chuyen chit deng va thu &Ong. Ong lucyn gan chiu trach nhiem tai hap thu phan lon cac
clor dich loc, quai Henle tai hap thu met se Wong dang ke khac. Ong Mem xa va Ong Op,
mac du chi tai hap thu mot so Wong nho clor, tuy nhien lai &rig vai tre quan trong trong
su dieu hoa can bang clor. So luemg clor bai tiet vao funk tieu khong hang dinh, thay doi
tir Mng ngay My thuc vao viec then dang co gang de bao eon hoac loai b6 clor. Kha nang
dieu chin
' h lam bai tiet clor hang ngay cua then girt cho tong Wong clor co the luon
mirc tuong doi on dinh va duy tri nong do clor mau trong met pham vi hep bat chap su
thay doi cua Wong clor nap vao hang ngdy.

4.4. R6i loan chuyen hoa clorua

C1 la ion am chinh cua DNTB, nL co the khong bi roi loan thang bang acid - base, nong
de Cl- trong huyet tircmg thuong tuan theo su thay doi nong de Nat Dinh hremg C1 mau
co the giCip ich trong chan doan roi loan thang bang acid - base, ngodi ra con thuen lgi de
tinh anion gap. Thay doi nong de C1 mau it gay trieu chung tren lam sang, tuy nhien là
dau hieu canh bao‘ve six roi loan ve the tich hay thang bang acid - base dm co the. Ngoai
ra no cling phan giup chan doan phan biet cac nguyen nhan cua cac roi loan nay.

18
 CHUONG 1 ► CHUYEN HOA NUOC - MUOI VO CO'

4.4.1. Ha clorua mau

Ring quat thi nguyen nhan gay ha clor mau thuemg twang dog voi ha natri mau. Ha clor
mau th&mg gap trong nhang Nnh nhan nhi6m acid chuy'en

4.4.1.1. Ch an &An
Chan doan: ha clor mau khi < 95 meq/L.
Ha clor mau ket hop base chuye'n hoa khi pH man > 7,45 va nOng dO CO2 mau
>32meq/L.

4.4.1.2. Nguyen nhan gay ha clorua

Clam tong hrrg clorua co the-

Ngodi than
Nhap NaCithi6u 1
Mat dich qua duang tieu h6a
Non
Thong mui da day
Re runt non
Pilot-1g
Tai than
Lam dyng thuoc loi tieu
Mat muOi do benh than
Viem than ke
Suy thuong thin
litha loang (lam giam nong (10 clorua)
ng khi luting man hoan
Truyen dich Lru truing
Dai than &rang (giai doan dau)
IthOi luting tuan hoan khong doi
UOng nhi&I nu&
Benh than not khoa
giap

Barbiturates
Chlorpropramide
Clofibrate
Morphine
Nicotine
Tricyclics

19
HOA SINN LAM SANG
Giam khoi luong tuan hoan
Phu
Suy tim sung huy&
Xo gan
Hoi chirng than hu
Rot loan acid - base
BU acid ho hap
Base chuyen h6a
4.4.2. Tang clorua mau
Thu6ng di kern voi tang natri mau, gap nhieu o nhItng b'enh nhan nhiem acid chuyen h6a.
4.4.2.1. Chgn down
Tang clor mau: khi > 108 meq/L.
Tang clor ket hop nhiem acid chuyen hoa khi pH mat <7,35 va n6ng d6 CO2 mau
< 22meq/L.
4.4.2.2. Nguyen nhan gay tang clor mau
V1/1""c M.1111111=11111..11.101.1.11.1
&la da dillN■1111■11111111 1!".w
II Sot 11111■1111i
Illiatral;7"1■11111111/1111
g nhiet dO MPRIMEIMIIIIIMPRIMIN1110
khOn2 du ntr"
mAt c • lat
h7Tc chircuMbronic anh drase acet-m"

allraiMiniiiiiiiiiMM=IML
FL nu& nhuoc trUMMIMIE
Ilfgoai than
11, Tieu chay I
UMW
MID _moron
iai doan- pfiucioi uai IMO dean
Koos .. .. ..„. A

m ceton acid
111111111■Iiitg he) AIM _A
rn-Al 11111E
n g muoi
—1111=1111LAIR=MI
Truyen qua nhieu NaC1 q
20
 CHU'O'NG 1 ► CHUYEN HOA NUCYC - MUOI VC) CO'

5. CHUYEN HOA CALCI

5.1. Dai cu'o'ng 1/6 sky phan b6 calci
TOng luong calci a nguai truang thanh khoang lkg (25.000mmol), 99% lucmg nay nam
trong xucmg, khoang 1% calci a xucmg c6 the trao doi to do vai calci a DNTB.
Calci mau Binh thuang co nOng dO 2,1 — 2,6 mmol/L, trong do 45% gan kat ved
protein, 45% a clang ion hoa (phan co hoat tinh sinh VT) va 5-10% a dang pi-111c hop (phos-
phat, citrat...).
Co 3 ca quan chinh phan be) lung calci trong co the: &rang tieu hoa, xucmg va than.
0 Duirng tieu hoa
, Su hap thu calci met duoc diau Ilea bai 2 ca che: met la qua trinh hoat dOng duoc
dieu hoa bed calcitriol (1,25 dihydroxy vitamin D), hai la six hien dien cua cac phan tir c6
trong thirc an nhu cac anion phosphat, oxalat (co nhieu a rau xanh) va phytat (trong ngu
cac) giup hoa tan va hap thu calci.
Su hap thu calci a met ding c6 the theo co che khuech tan thu &Ong.
Luang calci dua vac) co the khoang 20mmol, 20-40% duce hap thu a runt.
0 Then
, Hang ngay than lac met luting calci khoang 250 mmol, 98% dirge tai hap thu lai
g than trong do 65% la a Ong luon gan, chi CO khoang 4 mmol la hien dien trong nuac
On
tieu. Neu calci nieu cao ten 12,5 mmo1/24gio. (hay 25 meq/24gia) thi c6 nguy co bi s6i
than va dong calci a than. Cuang can giap, calci nieu tang tren 5 mmol/24gia.
Su hap thu calci a than theo co elle chit &Ong ging nhu nhung kh6ng c6 sit diau
hoa cua hormon. Chi co 10% calci tai hap thu a Ong loan xa la chiu sr dieu hem cua PTH
hoac 1,25 (OH)2 D.
Nhitng yeu to lam gia tang sit tai hap thu calci a 6ng than la giam the tich tuan hoar',
nhiem base, lai tieu thiazide. Trong khi do tang the tich tuan hoan, nhie'm acid va lgi tieu
furosemid thi co tac dung ng-iroc lai. Su bai fiat calci nieu tang trong che dO an c6 nhiau
protein vi cac san pham acid trong chuyen h6a acid amin c6 chira nhom sulphat, phirc hop
calci vai sulphat trong nuac tieu gay ire che sit tai hap thu calci.
0 Xtrcrng
O nguai truang thanh, qua trinh tao va tieu xucmg &roc can bang, khoang 5% xtrong
luon luon &roc doi mai, qua trinh nay se khac tren nguai dang tang truang va gia yeti.
Co sit trao doi thuang xuyen gifra calci a xucmg va DNTB. Ngodi ra calci c6 the mat theo
duang me h6i (0,3 mmo1/24gia). Sfra c6 'long dO calci khoang 7,5 mmol/L va trong thai
kST cho con bit, luting calci cua nguai me c6 the mat mai ngdy tir 4-8 mmol.

21
HOA SINN LAM SANG

Th0'c an
o1/24gi6

25,000 mmo1/24gite

T o di by do
• to bao
600 mmo1/24gi:

/
/ Tao xuang
5 mmo1/24gitt
ealci Hap thu
8,3 mmo1/24gidr
Tieu )(Lyng
tan oan •

5 mmo1/24gide

Tai hap thu Loc

246 mmo1/24giCi 250 mmo1/24giCe

Phan
/24gio'
Mat Nuirc tieu
Trir hycyng

Hinh 1.12. Phan be) luvng calci trong cd the

5.2. Vai tro cilia calci

Can cho hoat tinh than kinh co, co co tim, tinh tharn binh thiremg cua to bao, dung
tao xuong — rang.
Gia tri binh thuemg: 4,5-5,5 meq/L, ion 2,2- 2,5 meq/L.
Bai tiet qua NT 200mg/ngay.
Nhu cau: 800mg/ngay.

5.3. Kim soat skr chuyen hoa calci

NOng clO calci mau duoc kiem soat chu yeti bai PTH, 1,25 dihydroxyl vitamin D, cac
yeu to khae nhu calcitonin, hormon giap trang, cac yeu to tang twang, prostaglandin Ara
cytokin co the anh huang len su chuyen h6a xuong.
Vitamin D
, Phan lan vitamin D ducyc sinh tong hop da dir6i tac dung tia cvc tim tien
chat 7-dehydrocholesterol (Provitamin D3), vitamin D cling cluot cung cap tit thirc an
(Vitamin D2).

22
 CHU'O'NG CHUYEN HOA NUCYC - MUOI VC) CO'

Ve phuung dien y hoc, ca 2 loci vitamin D nay c6 nhung hoat dOng va chuyen hOa
giong nhau, tan trong ma va mot luang lan du tat trong ma, tuy nhien no khong có tac
dung sinh hoc trir khi dugc hydroxy
1,25 dihydroxyl vitamin D la dang hoat thing ciia vitamin D, tac dung len:
o Ru6t: lam tang hap thu calci, kich thich,tong hop protein On calci.
o Xucmg: kich thich hoat Ong hily cot bao
o Than• kich thich qua trinh tai hAp thu calci.
kgithir

'Isji •\ jlt
ProD3 PreD3 Vitamin D3

1
Gan L. Vitamin D3
Vitamin D2

25(OH)D

Than

Tang hap thu Kich thich

Calci 1,25(OH)2D Xuang hoat Ong
Hy cot bao

Dieu h6a calci mau

Hinh 1.13. Vai trO dm vitamin D

Parathyroid hormon (PTH)

La mot peptid g6m 48 acid amin dugc fiat ra tit to bao cua tuyen can giap. Dieu hoa
bai tiet PTH bed nong d6 calci a DNTB, nong dO calci thap se kich thich bai tiet, con nong
dO cao thi tirc che. Trong ngdy, lugng PTH thaP vao luc chieu t6i va tang cao vao incsang
(2gig - 9gi6).
Tac dung cua PTH tren xuang la kich thich su tieu xuang cua hilly cot bao lam giai
phong calci va phosphat arthan, PTH lam tang hAp thu calci 6ng lugn xa, giam hap thu
phosphat bicarbonat 'Ong lucm gan, dAn den tang calci mau va bai tiet phosphat nieu.

23
HOASINH LAM SANG

Calcitonin
La mot peptid c6 32 acid amin, tao ra tir t6 ha° C cfra tuy6n giap, &rex chuyen hoa
than, c6 theri gian ban hiry IA 5 phut. Su bai tiet calcitonin (kw kich thich gia
tang nong dO calci mau va mot so hormon duemg tieu h6a (gastrin, glucagon, secretin...).
Tac dung cfra calcitonin:
o Tren xucmg: irc the hoat Ong cfra hay cot bao.
o Tai than: lam giam hap thu calci va phosphat, do do lam giam calci mau va phos-
phat mau.
Tuyen giap giai
phOng Calcitonin

Gam huy xuang Gam h5p Gam tai h5p

thu calci thu calci
Calci mau
qua cao
Calci mau Gam calci mau
binh thuteng Tang calci mau
Calci mau
qua th5p

,
111
1.4•••*Tang hi:1y mung T5ng h5p Tang tai h
thu calci thu calci
Tuy5n can giap
giai phOng PTH

Hinh 1.14. Di61.] hOa calci mau

Nheng hormon khac

Nhu hormon tuyen giap (T3, T4) lam gia tang toe dO lay calci khoi xuang (cuemg
giap keo dai lam mat calci xucmg) dan d6n tang calci mau. Prostaglandin E kich thich
six tieu xuang.

5.4. R6i loan chuyen hoa calci

5.4.1. Tang calci
Nguyen nhan tang calci
o Thong thuemg nhat:
• Cuemg can giap tien Oat.

24
 CHU'O'NG 1 ► CHUYEN HOA NUCC - MUOI VO

o Benh ac tinh:
• Ung thu vu, phOi, mau.
• PTHrP sinh ra do u.
• Tieu 'arcing do u.
o It phO bin hurl:
■ Tang calci huyet trong giam calci nieu gia Binh.
• MOt so b'enh nhu lao, phong.
• Thira vitamin D.
■ Sau ghop than.
o ThuOc anh hung gay tang calci:
• Steroid, vitamin D, kayexalate, androgen,...
DOc diem lam sang
o Than kinh: bun ngii, tram cam, lit lan, lion me, giam trucmg luc cu.
o Tieu hoa: chan an, non oi, dau bung, tao bon, viem tuy, loet da day.
o Tim mach: cao huy6t dp, QT ngan, PR dai, block-ngirrig thi tam thu, loan nhip.
o Than: da nieu, giam dO thanh thai, soi than.
o Xtrung: gay xuang benh 1ST, dau sau trong xuang.
Chcin cloan va clanh gia tang calci
o Do tY so thanh thai cua calci, creatinin trong nu& tieu 24gi6 — tang calci huyet,
giam calci nieu.
o Dien di protein huyet, protein nieu, X-quang xucmg, do vitamin D (tang trong u
hat, lympho, cuemg can giap tien phat).

25
HOA SINH LAM SANG

Tang calci huygt

Kim tra albumin

va ion calci huyet

Xac nhan tang calci huyet

Do PTH

Tang Giarn

Tang calci khOng do

Do calci nieu can giap

Tang Tang Vit D, PTHrP Tang

PTHrP 1,25 (OH)2D binh thireyng 25 (OH)D
Tang Giann
(>200 mg/24gio) (<100 mg/24gite,
Ca/Cr <0,01) Kik tra Nguyen nhan khac
benh ac tinh chyp nrang di can
1 then di protein mau
CurOng can Tang calci huyet
ben phat 'trong Om calci
U hat: lao, phong
nieu gia Binh Ngo dtic vitamin D
Lympho

Hinh 1.15. Sc do ch6n down tang calci rnau

5.4.2. Giam calci
Nguyen nhan gay giam calci huyet
o Chimg nhuge can giap:
• Bam sinh, tr phat, pljau thuat cat 1)6.
• p-thalassemia.
• Benh Willson.
o Chung gia nhuge can giap:,
• Bat thu6ng ve chuyen boa vitamin D.
• Thieu cung cap vitamin D.
• Thieu lot-hydoxyl suy than, nhi6m acid, thieu vitamin D trong cei xuong
type 1.
• C6i xuong phu thuge vitamin D type II.

26
 CHU'CYNG 1 ► CHUYEN HOA NU' C - MUOI VO CG

o Cac nguyen nhan kha.c:

• Viem tuy cap, tang phosphate huyet, cac benh cap tinh-di can xuo'ng, chat irc
the sir tieu xucmg.
o Thu& anh huang gay giam calci:
• Magie sulfat, propylthiouracil, colchicin, neomycin, dung nhieu natri citrat,
corticosteroid, lgi tieu quai, aspirin, acetazolamid, chong co giat, estrogen,
gentamycin, amitracin, tobramycin...

TOng luvng calci huy6t giam

Kiem tra albumin

va ion calci huyet

Xac nhCn giann calci huy6t

Lam sang

flo creatinin huvetal Tang Suy thCri

V
flo magie huvet Th'ap Giam magie huyet

V
Oo PTH

4 4
ThAp - binh thi.romg Tang

4
Gram Tang

Chiang gia nhuvc giap

Tang phosphat huyet
Vte to bac
Giam Tang
4
ThiCu Vitamin D

Giam

Hinh 1.16. Sa 6 chAn dban gi6rn calci

27
HOA SINN LAM SANG

Bcdc diem lam sang

o Than kinh ca: lo lang, co cling co, co that ban tay-chan-thanh quan-thanh bung.
o Tim mach: co ca tim, loan nhip, ngimg tim, suy tim.
o ECG: ST, QT dai.
o Mau: (tong mau bat thuamg, giam prothrombin.
o Xuang: gay xuong neu thieu keo dai.
Danh
o Do neng dO trong mau, ECG.
o Xac dinh tinh trang nhieM acid-base phosphat, magie, albumin, vitamin D.

6. CHUYEN HoA MAGIE

6.1. Dal cu'o'ng 1,4 su' phan b6 magie
Magie c6 nhieu trong xucmg va mo mem, là cation chinh cua to bao sau kali, la cofactor
dm ten 300 phan Vng enzym lien quan den chuyen hoa nang luang, sinh tong hop
protein va acid nucleic. Chi c6 khoang 0,5% lugrig magie trong ca the hien dien trong
huyet tucmg. Luong magie a tre em thap hon a nguai 16n (10 mmol/kg can nang so vai
16 mmol/kg 6 ngugi twang thanh).
Magie huyet: khoang 60% a duai clang ion va 15% a clued dang phirc hop (phosphat,
citrat, bicarbonat), phan con lai ket hop vai protein. Dang ion va phirc hop loc qua dugc
cau than.
Su phan b6 magie trong huyet tucmg bi thay dei bai su thay doi cua neng dO protein
va pH. Thay dad theo giai tinh ding nhu tuoi, hau nhu khong thay doi 6 tuoi man kinh.
Neng di) magie huyet a nguai tnrang thanh 0,8 — 1,0 mmol/L.
Magie c6 nhieu trong thvc pham, dac biet la rau xanh, luong magie dua vao co the
moi ngay tir 6 — 20 mmol (trung binh 12 mmol), dirge hap thu chu yeu a ruOt non theo 2
ca the chink• khuech tan thu d6ng va chuyen cha thu dgng. Ngoai ra magie cling dugc
hap thu a runt gia. Su hap thu tai ruOt phu thuOc vao nhu cau ca the, khi can c6 the hap
thu den 75%, ngugc lai khi ca the du thira, su hap thu chi con 25%.
Vai tro dm than: su on dinh not moi cua magie dugc duy tri bai su can bang Oita six
hap thu a runt va su bai tiet 6 than. 90 — 95% magie dugc tai hap thu lai sau khi loc qua
cau than.

28
 CHUO'NG 1 ► CHUYEN HOA NU'OC - MUOI VO CO'

ThCpc an

Trao doi
tcy do
to bao Hap thu
Xuang 6,2 mmo1/24gi6
(Tao xuang
Magie
0,1 mmo1/24gi&
tuAn oan Dich tieu h6a
1 Huy xuang
0,1 mmo1/24gioe 1,5 mmo1/24gi6

Tai hap thu Loc

955 mmo1/24gier 100 mmo1/24gi6

Phan
7,3 mmo1/24oitY
NuOc tieu
4,5 mmo1/24gio,

Hinh 1.17. Phan b6 luang magie trong co th6

6.2. Luvng magie phan bo trong cac mo

Bang 1.5. Phan be) luang magie tai cac mO

Tong Ong (mmol) Niing

Xtrong
rong to bap
o mem
Ong cash
Dich ngoai to b

29
HOA SINN LAM SANG

6.3. R6i loan chuy6n hoa magie

6.3.1. Giam magie
Nguyen nhan
o Dua tin ngodi vao khong
• Nghi'en ruou.
• Suy dinh duang.
• Thvc phalli co *mg magie thap.
o Bat thuemg hap thu:
• Viem runt gia, runt non.
• Benh ly duoug runt gay non oi, tieu chay, not runt.
o ROi loan chirc nang 6ng than:
• Nghien nrou.
• Cu6ng aldosteron.
• Cuang can giap.
• HOi chirng Barter.
• Tac nghen duamg tieu
• Sau,ghep than, lgi lieu, giam kali huyet.
o Thay doi trong to bao:
• Sau nhoi mau co. tim.
• Sau cat b6 can giap.
phuc sau nhiZm acid do dai thao du6ng.
• HOi phuc sau suy dinh du6ng.
o Thu& anh huerng: aminoglyoside, lgi lieu thai cortison, insulin, digitalis
Trieu chirng
o Chan an, buon non.
o Mk dieu hoa truang luc co.
o Tram cam, vo cam, run, co giat.
o Neu giam lau ngay: giam calci huyet do anh huOng len sir tong hop PTH-vitamin
D a than.
o Neu giam nang• giam kali huyet, rOi loan co tim, dien tim...
Danh gia
o Do lugng bai tit trong mr&c tieu (nett magie nieu duoi 0,7mmo1/24gier thi nen"
den nguyen nhan ngoai than).
o Do lugng magie phan.

6.3.2. Tang magie

Nguyen nhan
o Suy than cap-man.
o Dua vao nhieu: u6ng (thu6c cheing acid china nhieu magie), truyen dich.
o Neu tang nhieu: thay d6i din tim, ngirng tim, het co.

30
 CHUCYNG 1 ► CHUYEN HOA NUCC - MUOI VO CO

o Anh twang len to bao than kinh ca: irc the su giai phOng acetylcholin gay tac
nghen ngoai bien.
Trieu chung lam sang
is a-16 N than kinh trung umg, d6 dan, ngu lim, liet, mat phan xa gan sau, ha huyet
tip, block tim.
Danh gia:
o Tang 1,5-2,5 mmol/L: ha huyet tip nhung khong trieu chimg.
o Tang 2,5-5mmol/L: thay dOi ECG.
o Qua cao: liet h6 hap, ngung tim (Ix the acetylcholin giai ph6ng va tac nghen
ngoai bien).

7. CHUYEN HOA PHOSPHAT

7.1. Dai cu'o'ng ve su, phan 136 phosphat
Nguai truang thanh luting phosphat chiem khoang 1% trong luting co' the (25,8 mol
nguai 70kg) trong do 85% nam trong xuang va rang, 14% nam a m6 mem, chi khoang
1% tong luting phosphat ca the la o DNTB.
Trong mau phosphat hien dien dual clang him ca (phosphoprotein, phospholipid...)
va vo ca (phosphat), clang vo ca chinh la cac anion phosphat bi va monometalic HP042-
va H2PO4-.
Luang nhap m6i ngdy khoang 1 — 1,5g phosphat (32-50 mmol), ngtx6i c6 thai va tre
em c6 nhu can cao han.
Phosphat chu yeu dime hap thu tai runt (khoang 2/3 luting phosphat an vao), duac
bai tiet qua dich tieu hoa vai tS7 le khoang 0,1 mmol/kg/24gi6.

31
HOA SINN LAM SANG

ThUc an
45 mmo1/24gio'

Trao doi
tu' do 1-16p thu
33 mmo1/24gio'
Xuangi
Tao xuang
4
/ 7 mmo1/24gia
Huy xuang Dich tieu hoa
7 nnnno1/24giey 7 mmo1/24gia

Tai h6p thu Loc

135 mmo1/24gb 160 mmo1/24gb

Phan

Nuo'c tieu

25 mmoI/24gia

Hinh 1.18. Phan b6 luvng phosphat trong co' th6

7.2. Vai tro cCia phosphat

Phosphat can cho hog tinh than kinh cg, su ben viIng ada xucmg va rang, hinh thanh ATP,
sir dung vitamin nh6m B, chuyen boa glucid, protid va lipid, tham gia vao thang bang
acid - base va truyen nhitng dec diem di truyen.

7.3. Kiem soat

Calcihydroxyd alumin va cac chat khac tao voi phosphat nhiing mu6i kh6ng tan du can
tra su hap thu phosphat.
Su ciao thai phosphat qua then: phospho vo ca dugc loc qua than va 75% dugc tai hap
thu o ong lugn gan, 5-20% dugc tai hap thu 6 6ng 'iron xa, 'Ong gop, chi mot lucmg nho
xuet hien trong nu& tieu (15-40mmo1/24gi6 o ngu6i twang thanh).
Su tai hap thu bi ire the bai PTH, calcitonin, nhigrn base, thu6c lgi tieu...
Phosphat nieu giam trong nhirgc can giap, hormon tang trtrang, thieu vitamin D,
nhfem acid.
Thay d6i sinh 1ST:
o Giam: qua trong (5%), day thi (8%), thu6c ngira thai (15%).
o Tang: man kinh (10%), sau an (15%), hoat dOng the luc vita phai (7%).

32
 CHU'O'NG CHUYEN HOA NUtYC - MUOI VO CO

7.4. R6i loan chuyen hoa phosphat

7.4.1. Tang phosphat — huy6t
Cac nguyen nhan chinh gay tang phosphat huyet dirge liet ke a bang 1.6. Tang phosphat
- huyet c6 the do dua ter ngodi vao qua nhieu hoac giam bai tiet. Sau ding c6 the ket qua
tix su giam he s6 loc cau than hoac tang six tai hAp thu tei da cua to bao 6ng than.
Bang 1.6. Nguy8n nh5n caa tang phosphat - huy8t

phosphat - huyet gia

Tan huyet mau thin
9 U toy

iDua vao qua nhieu

9 Huy hoai to bao

L iam bai tit

0 Giam dO 19c cAu thAn: suy thAn cap, man
9 Tang tai hAp thu:
o Sinh IY: tre con, thieu vitamin D
o B8nh ly: giam PTH
9 NO d8c vitamin D
9 NO dOc 04 trang
9 B'enh to cue

Khong co triesu chi ng dac thu cho six ,xac dinh true tip tang phosphat huyet, tuy
nhien khi phosphat va calci huyet cao c6 the gay nen hi8n Wong voi hoa mot so ca quan
nhu mach mau, phoi, tim, than, khap. V6i h6a khoang ke ciia than gay nen nhung ton
thuang chirc Wang than, lam giam kha Wang ciao thai phosphat a thin. Su dOng can muoi
phosphat — calci a da la mot trieu chi ng cna hOi chirng tang ure huyet trong suy than.

7.4.2. Clam phosphat huygt

Phosphat huyet giam co the do su hap thu phosphat runt khong binh thuang hok su
thay doi phosphat tir ngoai to bao vao trong to bao hoac mat phosphat do bat thuang
duang tieu (bang 1.7).

33
HOA SINN LAM SANG

Bang 1.7. Nguyen nhan gay giam phosphat huyet

0 Ctrang can giap tien phat

0 Thieu vitamin D
0 Sau ghep th5n
El Giam phosphat huyet trong benh coi xuong, mem xuong
Nghi'en ruon
Ngo d'ac salicylat
PhOrm
Nhiem trimg
Dai thao duemg: nhiem acid do ceton mau cao
Suy gall
El Ding thuoc khang acid: cac hydroxyd nhom

Giam phosphat huy6t trung binh (0,35 — 0,80 mmol/L a nguai lan) thi khang thay
c6 ton thucmg giai doan dau nhung n'L lau ngay c6 th6 gay nen chtirng nhuyen xuong
(osteomalacia). Khi nong do phosphat huyet thap duai 0,35 mmol/L h6i chi mg cap tinh
cua thieu phosphat huye't c6 the phat trie'n (bang 1.8).

Bang 1.8. Trieu chiyng lam sang dm ha phosphat huyet

y& hoc
0 Giant 2,3 — Diphosphoglycerate trong h6ng cau
0 Giam kha tfang phong thich 02 dr hOng cau
Thieu oxygen mci
Tang kha nang viz hong cau —> tan huyet
Bat tint:Ong chirc rift:11g bath cau —> de nhiem trung
Bat thuOng chirc n5ng tieu cau foi loan thing mau

Giam co that:
o Co hoanh suy ho hap
Co tim —> cung luting tim giam
Co xuong kherp yeu co, nhuvc co, dau co, liet co.
He than kink
Nao: thong mat, hi l'an,hon me
Ngoai !nen: giam co that, liet
Tien Ma
0 Co troll: mat tr ong hrc da day, runt

34
 CHUONG 1 10. CHUYEN H6A NUOC - MU61 VO CO

A. CAU HOI TV LUVNG GIA

1. Vai tro ciia PTH (i• 6ng than là:
A. Tang tai hap thu magie B. Giam tai hp thu calci
C. Tang tai hAp thu phosphat D. Chi co A va C dimg
2. Nhirng dieu sau clay dung, ngoai trir:
A. Ion lit bai tiet d Ong g6p
B. Mac tai hap thud Ong luau xa chiu anh huong cna aldosteron
C. Ion K+bai tiet 6. 6ng lugn xa
D. Ion Nat tai hk) thud 6ng lugn gan chu y6u bang co the chit &Ong
3. Mat ngtroi can Ong 50kg, ltrong ntrov o khoang gian bao:
A. 7,5 lit B. 5 lit C. 9 lit D. 4 lit
4. Thanh phAn nao sau day anh hirerng nhieu den neng de osmol:
A. Creatinin B. Ure C. Natri D. Kali
5. Dien giai nao sau day en nhieu o dich not bao ho'n dich ngoai bao:
A. Nat, CF B. Kt, HCO3- C. 1(±, P043- D. Mg2+, Ca2t
6. Ngtroi binh thuirng, luvng natri thai ra trong nu'o'c tieu /24061
A. 150mmol B. 300mmol C. 500mmol D. 800mmol
7. Khi the tech not mach giam, dieu ciao sau day se xay ra:
A. Tang tiet ANP B. Tien nhieu C. Giam tiet ADH D. Tang tiet ADH
8. Cat yeu M sau day kich thich bai tiet ADH, ngoai trir:
A. Luy0. tap B. Nicotin C. Stress có dau D. Racal
9. Vai tro cua ANP:
A. Tic the bai tiet renin, tang tai hp thu natri
B. Tic chO bai tiet ADH va nuac
C. Kich thich bai tiet aldosteron va tang ciao thai natri
D. Cac y tren sai
10. Dieu nao sau day khong dting cMi vel'i vai tro ciia he th(ing Renin-Angiotensin-
Aldosteron:
A. Tang bai tiet calci, phosphat B. Co that mach mau
C. Tai hap thu muOi, nude D. Tang cam gide khat
11. Cat nguyen nhan sau day gay mit nuoc, ngoai trir:
A. Lai tieu B. Tang thong khi
C. Ti'eu duang D. SIADH
12. Nhom chit nao sau day anh inro'ng nhieu den tiling da osmol:
A. Natri, ure, creatinin B. Natri, ure, glucose
C. Natri, kali, protein D. Glucose, kali, calci

35
HO/0k SINH LAM SANG

13. ANP co cac vai tro sau ngoai trir:

A. r(J'c the bai tiet renin B. Giam hoat dOng co.
C. Kich thich bai tiet aldosteron D. Giam tai hap thu natri
14. Thanh phan nao sau day giam trong mau khi magie, PTH Ara vitamin D thitu
but Ian ngay:
A. Calci B. Phosphat C. Kali D. Aldosteron
Tra 10i cac can hoi tir 15 an 18 dip vao nhfing so lieu sau:
1. Giam natri-huyet nhugc tracing
2. Tang the tich tuan hoan
3. Giam the tich tuan hoan
4. Natri-nieu > 20 meq/L
5. Natri-nieu < 20 meq/L
6. The tich tuan hoan binh thuerng
15. Chon tap hop thing trong suy tim, hei chtimg than Mx:
A. 1, 2, 3 B. 2, 5, 4 C. 1, 4, 6 D. 1, 2, 5
16. Chon tap hop thing trong suy than man:
A. 1, 2, 5 B. 2, 5 C. 2, 4 D. 1, 4, 6
17. Lam dung thaw loi lieu:
A. 1, 2, 4 B. 1, 3, 4 C. 2, 5, 6 D. 1, 5, 6
18. Chon tap hop dung trong bOh tieu chay cap:
A. 1, 2, 4 B. 1, 2, 5 C. 1, 3, 5 D. 1, 5,6
19. Y&I to nao sau day khong anh hiromg dtn kali-huy6t:
A. Ap ltxc tham thau B. Insulin
C. Tinh trang kiem toan D. Vitamin D
20. Thanh pilau nal) sau day it thay doi khibOh nhan bi tieu chay cap, non oi:
A. Natri B. Kali C. Clorua D. Calci
21. Ion nao sau day mat nhi&I trong hei cluing than ha:
A. Natri B. Kali C. Magie D. Calci
22. Nguyen nhan nao sau day khong gay tang kali man:
A. Tieu huyet B. NhiJm base C. Giam insulin D. NhiJni acid
23. Clorua thiriing giam trong cac benh nao sau day:
A. Viem mang nao mu B. Viem mang nao do lao
C. Viem mang nao do ky sinh D. Viem mang lido do virus
24. Chon y thing:
A. Ty le nuac a ngoai- n6i bao la 2/3
B. Co tieu mau nhe tfmg dgt ten benh nhan bi h6i chimg than hu the dun thuan
C. BUN, creatinin mau tang trong her‘i chimg than hu

36
 CHUO'NG 9 ► CHUYEN HOA NU'O'C - MUOI VO CO

D. Calci, kali mau tang trong suy than man va h'Oi chimg than hu
25. Chcon 3'7 sai:
A. Phan irng ceton/NT (+) gap trong benh DTD nang
B. Phan ung nitrit (+) khi nuot tieu co nhieu vi khuan staphylococcus aureus
C. GGT tang trong viem gan do nxgu
D. Cholinesterase giam trong ngg dgc phosphore
26. Cac nguyen nhan sau day gay tang kali huyet, ngoai trir:
A. Luu tru mau o nhiet dg thap B. Nhiem acid
C. Thieu insulin D. Thieu magie
27. Co quan nao sau day khong tham gia qua trinh sinh tong hop Vit.D:
A. Da B. Gan C. Tim D. Than
28. Cac nguyen nhan sau day gay gram phosphat huyet, ngo3i trir:
A. U thy B. Cuerng can giap C. Thieu vit.D D. Sau ghep than
29. Luvng magie huyet chiem... % trong tong lircrng magie co• the:
A. 31% B. 20% C. 5% D. 1%
30. Nguo•ng magie huyet (mmol/L) nao sau day a* mirc nguy Mem:
A. <0,4 va >2,0 B. <0,6 va >1,5
C. <0,8 va >1,8 D. <1,0 va >2,5

B. CAU HOI NGHIEN CU'U

1. Mgt benh nhan nam, 70 tuOi, bi cao huyet dp tir 10 nam nay. Nhttng nam gan day
thuong xuyen tix dieu tri benh cao huyet ap cua minh voi thuOc lgi tieu loai thiazid
(2 vien/ngay). Cach nhap vien 4 ngay, benh nhan bi tieu chay (4-5 l'aningay) kern
nhirc dau, chong mat. B'enh nhan co di kham bac si ter nhung benh khong giam. Mgt
ngay tnrac khi nhap vien berth nhan lu ldn, la ma nen dugc ngued nha dua vao benh
vien. Tai benh vien, benh nhan dugc chan doan la hon me do roi loan mac — dien
giai. Theo anh/chi tren benh nhan nay neu lam ion 6, thi thanh phan dien giai nao
thay d61 nhieu? benh nhan bi benh do nguyen nhan gi?
2. Tren cac benh nhan bi hgi chimg than hu, ion nao mat nhieu lam cho benh nhan bi
vop be (chugt rut)? giai thich con dugng mat dm ion ten.
3. Trong cac ion sau day: natri, kali, calci, clor, magie. Benh nhan bi rixa da day do
Wing thu'oc ray to tir hoac non of do nhiem dgc thai nghen, ion nao giam nhieu va
ion nao it thay 6i nhat? tai sao?

37
 Chu'o'ng 2
THANG BANG ACID-BASE

MUC TIED
1. Liet ke &eye cac ye'u to anh &rang den pH mau.
2. Viet duce phwang trinh Henderson — Hasselbach cho cac he dem bicarbonat,
phosphat, va phan tich co' the dein caa chang.
3. Trinh bay clwac co• the dem cfia he dem Hb.
4. Liet ke cac thong so danh gia thang bang acid — base.
5. Phan tich dwor ca the bit cfia phoi khi nhiern acid chuyen hoa ho ac base
chuyen how.

1. DAI CUO'NG
Chirc nang trao doi khi cua ph6i, chirc nang tai hdp thu va bai tiet dm then, ding cac he th6ng
am gift vai tro dieu h6a sg on dinh pH mau, &roc danh gia bang sy thang bang acid - base.
Thing bang acid -, base binh thuOmg phan anh tinh trang sinh 13'T binh,thu6ng dm co
the, nhung cling c6 the la do co the ve ho hdp hay chuyen h6a de tao ra six can
bang, nham chong lai nhang r6i loan benh 13'f. Khi sir can bang do bi phi vo se dua den
tinh trang nhiem acid hay base.
Khan sat six thay d'6i cac thanh phAn khi trong mau la can thiet de tim hieu tinh trang
thang bang acid - base, lam co. so danh gia chirc nang trao doi khi 6 nhung nguei c6 benh
phoi, xac dinh,tinh trang suy ho hAp, theo dOi dinva heu qua dm no de tri va tien
hxong benh, de phat hien cac benh ngodi phoi.
Cling nhu cac thanh phAn khac cua dich ngoai bao, neng de ion El+ anh huong nhieu
den pH mau. Qua trinh dieu hoa neng de 1-1+ c6 lien quan an 3 co the sau:
He thong dem cua dich nei va ngoai bao.
Sir kiem soat dp suit rieng phan dm CO2 (PCO2) trong mau b6i six thay doi toe
do thong khi cna ph6i.
Sy kiem soat neng do bicarbonat (HCO3-) trong huyet tuong bang each thay d6i
t6c do bai tiet EP a than.

39
HOA SINN LAM SANG

1.1. Khai nrem acid — base

Theo dinh nghia cua Bronted thi:
Acid la chat c6 kha n'ang giai ph6ng ion IT, vi du:
HC1 —> + Cl-
H2C03 4- H+ + HCO3
Base là chat có kha nang nhan ion H+, vi du:
HCO3 + H+ H2CO3
OH- + H2O
NH3- + H+—* NH4
Mire dO phan ly cua cac acid thi khac nhau. Nhfing acid phan ly hoan toan, phan img
mot chieu la acid manh:
HC1 H++ Cl-
Nhiing acid phan ly khong hoan toan, phan img 2 chieu (H2CO3 NH4, H2PO4-) la
nhitng acid yeti. N6 dung vai tro dem trong ca the.
Ve ca the dieu h6a acid - base nguOi to phan biet 2 loai acid
+ Acid carbonic
+ Acid khong phai la acid carbonic.
Su phan biet nay rat quan trong vi co sir khac nhau ve san pham tao thanh va con
dung loai trir cac acid nay.
Acid carbonic, hang ngay do chuyen hoa glucid, lipid dm ca the, mor ngay sinh
ra khoang 15.000 mmol CO2. CO2 nay ket hop vai nu& tao thanh H2CO3 Nen se
c6 su tich to H2CO3, trong matt neu nhu no kh6ng &roc loai trir va ca the da thai
CO2 theo duemg phoi.
Acid khong phai la acid carbonic, c6 ngu6n gee tir chuyen hoa protein.
Vi du oxy hoa cac acid amin CO luu huS/nh se sinh ra H2SO4. Co khoang 50-100
mmol acid tao ra trong mot ngay tir ngu6n goc nay va cluing &roc dao thai bai then.

1.2. Khai nrern pH

Nu& c6 the phan ly theo phucmg trinh
H2O + OH-
[H+ ] [OH]
= K = 1,8.10-16
H20
[1-1+][0H-] = K * [H2O]

40
 CHLIO'NG 2 PI* THANG BANG ACID-BASE

O 25°C 1 lit mreic có 1000/18 mol nuac

[111[011-] = 1,8.10-16 * 55,5
[RI [OH-] = 10-14
[H+] = [OH-] = 10-7
Theo Binh nghia pH la gia tri logarit am dm n'ong
1
pH = - log[H+] = log —7
[H]
pH thay doi ngtro.c chiL voi n6ng dO ion IP

Binh
Acid thuevng

6 9 7.0 7. 7.2 7.'1 7.4 7.5 7.6 7.7

pH

Mk' d6 2.1. Twang quan giCra pH va nong dO ion H+

Dinh luat tac dung khiii hxcmg có th6 vi& cho bat kS7 acid y'L nao trong co. th6
[11+][A-]
K —
a [HA]

Ka la hiing so phein ly cue: acid, trong cc the mg'i acid c6 mot hang sa phcin ly rieng.

1.3. Phuxong trinh Henderson — Hasselbalch

HNO3 + NO3- Acid manh
H2CO3 +—> H± + HCO3- Acid yen
Dang tong pat str phan ly dia acid y&i:
HA H H± +A-
[1-11[A-] [HA]
—K [H+]= K
[HA]

[HA]
K la hang s6 [H+ phu thuOc
[A1

41
FIOA SINH LAM SANG

Lay logarit am dm 2 ve phuang trinh to c6:

[HA]
-log[H-1 = -logK
[A]
Thay: -log[Hr] = pH, -logK = pK. Ta c6 phuang trinh:
[A-]
pH = pK + log
[HA]
Day la phuang trinh Henderson - Hasselbalch.
Trong do: A- la mot base, HA la mot acid.
Phaang trinh Henderson -,Hasselbalch c6 nglga ca ban vai khai niem thang
bang acid —base. Vi pK la met hang s6 nen pH chi con phu thuec vao tY so base/acid.

1.4. Cac yeu t6 anh hu,ifvng d6n pH mau

Co nhieu yeti to anh huang den pH mail
- Cac N dem dm ca the
o Trong h6ng cau c6 cac N dem:
• KHb /HHb
• KHbO2 /HHbO2
• K2HPO4/KH2PO4
o Dich ngoai ban c6 3 N dem chinh-
• NaHCO3/H2CO3
•• Na2HPO4/NaH2PO4
• Proteinat/Protein (Pr/HPr)
Six tham gia cua ph6i, than trong dieu hoa thang bang acid-base.

42
 -

CHUO'NG 2 ► THANG BANG ACID-BASE

Cac yeu to anh htrang den pH mau

An kieng va
chuy6n h6a

Hcq

1:1100 HCO3-

Dem khOng Bicabonat

Phuang trinh Henderson-Hasselbalch
Hemoglobin
huyet twang. Pic Ivy [HCOIT:
proteins 1Q9 [HI] PH 1CO21
phosphat

Hinh 2.1. Su' tham gia cua ph6i, than trong di'eu hoa thong bkg acid-base

2. VAI TRO CUA HE THONG DEM TRONG DIEU HOA THANG BANG ACID
- BASE
MOt he th6ng dam bao g6m mOt cap acid yeu \Ta muai base dm no:
Neu cho mOt acid manh vao mOt dung dich dam thi acid manh nay se k& hop vai
phAn muai base lam giam n6ng (210 dm acid do va lam tang n6ng dO dm acid yeu.
Nghia la mOt acid manh da dixgc thay the bang mOt acid yeu.
- Neu cho vao dung dich dam mOt base manh thi no kat hop vai phan acid yeu,
lam giam n'Ong dO ciia no va lam tang n6ng dO cua phan base trong dung dich
dam. Nghia la mOt base manh da ducyc thay the bang mOt base yeu.
Voi he thong cVm bicarbonat/acid carbonic thi:
RH+ + NaHCO3 RNa + H2CO3
ROH- + H2CO3 —* H2O + NaHCO3

43
HOA SINN LAM SANG

Trong co the cac acid yeu va mu6i ciia no c6 mat 6. trong va ngoai bao tao
nen cac N thong dem dm dich not va ngoai bao. Sau day la co. the dem dm mot vai
he dem chinh.

2.1. H4 dOm bicarbonat/acid carbonic (NaHCO3/H2CO3)

Trong ca the H2C031uon dugc can bang duai cac
CO2 + H2O 4-> H2CO3 4-> H++ HCO3
Ca the la 11* he th6ng ma, no c6 the trao d6i khi CO2 qua phi nen c6 the viet:
CO2 phe nang 4-* CO2 hoa tan 4-> H2CO3 4-> + HCO3-
Theo dinh lust Henry: n'ong d8 khi hoa tan trong dung dich t-ST le thuan vai ap luc
rieng phan cua khi do tren be mat dich. D6i vai CO2 trong ca the nhiet d8 = 37°C, to
c6 phucmg trinh:
CO2 Ilea tan = 0,03 PCO2
+ 0,03: he s6 hoa tan.
+ PCO2: Sp suit rieng phan dm CO2 trong phe nang hay trong mau &Ong mach
Ta c6 the viet phuong trinh Henderson - Hesselbalch cho he dem bicarbonat
nhu sau:
[[HCO]3-]
pH = pKa + log [0,03PC0
(2)]
He dem bicarbonat la he dem quan trong nhat cua dich ngoai bao. N6 chi c6 tic dung
dem khi ca the nhi6m acid khong phai la acid carbonic.
Vi du: chuyen hoa acid amin china hru huSTnh se tao thanh H2SO4. Ca the dem dm
he bicarbonat nhu sau:
H2SO4 2NaHCO3 —> Na2SO4 + 2H2CO3 —> 2CO2 +2H20
CO2 tao ra dugc dao thai qua ph6i. Nher thong khi a phi nang suit dem dm he dem
bicarbonat dugc tang len gap b8i.
He dem bicarbonat kh8ng c6 tic dung khi ca the nhigm acid carbonic, bai vi:
H2CO3 + HCO3- —> HCO3+ H2CO3
Acid carbonic phai dugc dem bang cac he dem khac nhu he dem phosphat, proteinat.

44
 CHU'O'NG 2 I. THANG BANG ACID-BASE

HO Om acid carbonic - bicarbonat Bicarbonat dui trir

„ > NaHCO3
H2CO3 HCO3 I Na*
CO2 + H2O H'
411E1 acid carbonic 411=1 ion bicarbonat HCO33" < ==D Natri
bicarbonat
I [
(a)

Tang acid

Tang Na'
CO2 + H2O H' HCO3 <=1 NaHCO3
HCO3-
(b)

Hinh 2.2. HO dem bicarbonat

2.2. He dem phosphat: Na2HPO4/NaH2PO4 (HP042-/H2PO4-)

Hog &Ong oh he dem Phosphat Wong tv nhu hoet &ling cua he bicarbonat
+ Khi them acid manh (1-1±):
W+ HP042--> H2PO4- (acid yeu)
+ Khi them base manh (OH-):
OH- + H2PO4- HOH + H P042- (base yeu)
, Su di acid hay base manh mot acid hay base yeu lam cho dich the it thay
dOi. Nhtmg nong dO cua N Clem phosphat trong dich ngoai bao chi bang 1/6 so vai dem
bicarbonat, nen kha nang dem cud no thap hon kha tang dem dm he bicarbonat.
He dem phosphat có vai tro dec biet trong nuerc tieu vi:
+ Nong dO phosphat trong dich Ong then cao.
+ pH cila dich Ong then hai thep han huyet tucmg do do gen voi pK cita he phosphat
hcrn (pK = 6,8).
He dem phosphat cling co vai tro quan trong trong to bao vi neng (16 dm chUng trong
dich nOi bao lan han nhieu len so voi dich ngoai bao.

2.3. He dem hemoglobin

La he dem quan trong nit& trong Wong ceu.
Ca the tac dung dm he dem nay lien quan deft qua trinh trao d6i khi CO2 va oxy
phi va to chirc. (5 phei:
HHb + 02 + HbO,

+ HCO3- H2 CO3 CO2 /+ H2O

45
HOA SINH LAM SANG

o theo ink gong mach den cac to chirc, 6. do do ap luc oxy thip
Hb02 tao thanh phi
nen HbO2 phan ly oxy tao ra Hb khu. CO2 tao thanh do qua trinhchuyen hoa o to eh& ket
hop vai H2O tao H2CO3, chit nay phan ly thanh H+ va HCO3- dual tac dung dm carbonic
anhydrase (CA).
Hb clang khir nhan 1-1± tao thanh HHb, chit nay theo mau den phi nhin oxy.
Hb02 o- 02 Hb
CO2 + H2O H2CO3 H+ + HCO3-
H++ Hb i HHb
Gan v(51 protein
CO2 ■Ile CO2 trong mau
co, co, • H2O cOm H2CO2 --pm. MC03- H•

To chirc
1. HCO3-

CI-

anhydrase

CO2 4. Hb y HbCO7 (Carbamlno-

homogiol,oln)

_ 0,
Agir4

P hC>i lir
CO2 CO,
cham
CO2 • co, • H,o H 2CO3 HCO3 • H•

HCO3

alliega
CO2 1111111111111111.111111=111. CO2 . 2120 Via- H,CO,+--
+-- HCO,
Carbonic
anhydr•sa

CO2 CO, Hb HbCO2 (Carbanbno-

homegtobin)

02 02 HHb

Hong cau
0,

Hinh 2.3. He Om hemoglobin

2.4. H4 dem protein: Pr-/HPr

Protein hien dien vOi so prong lon trong to bao va trong huyet Wong.
Phan tir protein bao gem cac acid amin not vbi nhau bang lien ket peptid.
Tren phan tir protein c6 cac nhanh tt do -COOH va -NH2
-COOH c6 the cho H±va hoat dOng nhir mot acid:
-COOH —> COO- +

46
 CHU'O'NG 2 II. THANG BANG ACID-BASE

-NH2 c6 thJ nhjn H+va hoat dOng nhu mot base:

-NH2 + NH3+
Khi them acid manh (fit): -NH2 + Ht —> NH3+
Khi them base manh (OH-): -COOH + OH- –4 -COO- + HOH

H H 0 H H 0 H H 0
\

/
N —C—C
//

\
pH tang \

/
N
I
C
1
C
//

\
pH gi6rn

I
. \
H+ — N — C—C
/ 1 \
I //

H R 0- H+ H R OH H+ H R OH

Trong moi trueing base, acid amin Trong moi truerng acid, acid amin
hog dOng nhu mot acid, thai H+ hog dOng nhu mot base, nligi H+

Hinh 2.4. He dem protein

2.5. Tac dung dem cCia xu'o'ng

Khi ca th6 bi nhiJm acid hoc base xucmg cling c6 tac dung Om.
Khi nhi6m acid, xuang co thJ hjp thu mot phan thUa trao de>i voi Nat, Kt tren be
mat. Su phan ly chat khoang cua xuang giai ph6ng ra cac phirc hop Om nhu NaHCO3,
KHCO3, CaCO3, CaHPO4 vao dich ngoai bao. Phan Ung dUm caa xuang thuamg xuat hiUn
trong nhi6m acid chuyen hoa, (giam HCO3-) hon la nhi6m acid ho hAp.
, Su mat chjt khoang xucmg trong nhi6m acid chuy6n h6a khong don thuan la do
mat Ca trong phan irng dUm ma con c6 su roi loan ve hoat dung to bao: giam hoat dOng
cua tao cot bao va tang hoat Ong dm hily cot bao. Co thuyet cho rang hormon can giap
(parathyroid hormon = PTH) cling c6 anh huang tren qua trinh dUm cua xuang.
Khi nhie'm base ngoai to thy tang rang can carbonat vao xucmg va tang qua trinh
giai ph6ng H+ tir protein, hemoglobin lam cho pH chuyen dich ve gioi han binh thuang.
MUt hau qua do dUm cua xucmg la tang Ca2+ dao thai qua than trong tivong hop
nhiJm acid. DO c6 the la nguyen nhan hinh thanh soi. Tang protid trong khau phan An se
lam tang ciao thai Ca2+ va rang dong calci oxalat trong mac ti6u. Su hinh thanh soi calci
con chiu anh huamg cua citrat va urat.
Su giam pH lam tang tai hjp thu citrat a 'Cing lugn gan nen giam bai tit citrat. Trong
nu& tieu citrat ket hop vai calci lam thanh mot phirc hop khong phan ly, nhung van hoa
tan do do lam giam luang Ca2+ tax do c6 the ngung ta. \Rai oxalat tao thanh soi.
Nhi6m acid do An nhiJu protein con gay nen ha pH nuac tiJu tao diJu kin cho urat
chuyen thanh acid uric (rat it tan). Tip theo sir tila acid uric c6 the don tad hinh thanh soi.

47
HOA SINN LAM SANG

2.6. Kha !fang dem cua cac h0 dem khac nhau

Dua vao pK va s6 luting cua tang he dem trong dich co the.
Neu cho kha nang dem cita he bicarbonat trong mau la 1, kha nang dem Wang d6i
cua cac he dem con lai la:
- Bicarbonat: 1
- Phosphat: 0,3
- Protein: 1,4
Hemoglobin: 6,5
Neu xet den ca dich ke, thi:
- Bicarbonat: 1
- Phosphat: 0,3
Protein: 0,8
Hemoglobin: 2
, Neu xet toan ble dich co the, ta they 3/4 kha nang dem dm dich the nem trong
to bao, do sit hien dien s6 luting Ian cua phosphat va cac hop chat hcru co khac, nhat
la protein.

3. VAI TRO CUA PHOI TRONG DIEU HOA ACID-BASE

Su dieu hea acid - base dm he th6ng dem ma chit yeti la he dem bicarbonat tuy eat nhanh
ch6ng nhung khong triet de. Co the phai tiep t-uc giai quye't cac heu qua:
- Su tang H2CO3 va giam HCO3 khi co the nhiem acid.
- Sg giant H2CO3 va tang HCO3 khi co the nhiem base.
Nhitng heu qua nay c6 nguy co lam chuyen dich pH mau, nhung dieu do da khong
xay ra hay bi hen the nh6 sit phi hop dieu hoa cua phi Ira then.

48
 1 INC031 mmol/L
6.1 +log pH
(Plc) [CO21 mmol/L
Z 111(.03-1 Henderson-Hasselbalch

24

24mmoift.

Them H+

4
2HCO3+2H* -4 2CO2+2H20 2HCO34211*--) 2CO2+2H20

118.0 8.0
7A ipar,7 A
7.0 jo 7.0

He thong kin pH 6,93 He thOng me, pH 7,36

Hinh 2.5. Vai tro cua ph& trong can bAng acid - base, gibp co the hoat dOng
nhty mot he thong rn&

Phoi dieu chinh ltrong H2CO3 hay PCO2 trong mau bng each tang hay giam thong
khi nen lam tang hieu qua dem cita he dem bicarbonat:
111 Neu [H+] trong dich ngoai bao tang thi thong khi se tang lam giam lung PCO2.
Neu [H+] giam thi se lam giam thong khi ya tang PCO2.
DO la six dap frng to dieu hoa an den lam tang hieu qua dem.

49
 He clem Bicarbonat (HT ma)
1 H' 2 OH
4 .1111100111
Tissue
CO, CO2

Tang 1-1+ 0
Tang OH-
o PCO2 PCO2
+ OH-
Binh
+H + thLyeyng Binh thin:mg
0 Hang dinh 0 Hang dinh

PCO2 PCO2,
constant constant
4C2
PCO2
Giam thai
Tang 1 ti

Hinh 2.6. Dap Ong cua ph6i v61 di'au kiOn tang hay giam H+

4. VAI TRO CUA THAN TRONG DIEU HOA ACID - BASE

Than dieu hoa thang bang acid - base bang cach ciao thai 11±. Ca the bai tiet H+ a then rat
phi tap, lien quan den nhieu qua trinh khac:
+ Su tai hap thu va tan tao HCO3-.
+ Su dao thai cac acid chuan dO.
+ Su hinh thanh NH4.

4.1. Siy tai hAp thu bicarbonat 6, 6ng thin

Tat ca. luang HCO3- bi loc c6 the dugc tai hap thu.
MOt ngtrai binh thuang c6 t6c dO loc cau than la 180111:L0y (125m1/phAt), [HCO3-]
huyet Wang = 24mmol/L, thi luang HCO3- bi loc sau do tai hap thu lai 180L x 24mmo1/1
= 3.240mmol/L.
Gan 90% HCO3 , loc dugc tai hAp thu phAn 6ng loon gan, 10% con lai 6 cac
doan xa hcm, chit yeu nhanh len cua quai Henle va rat it 6 doan 6ng gop trong phan

50
 CHUO'NG 2 ■ THANG BANG ACID-BASE

Huy6t tuang ,T6 bac,

dich gian bao L6ng 6ng than
ong than
Na' Na+ Na+ HCO3-

HCO3 HCO3- H' ► H+

H+ HCO3-

H2CO3

CO2
it
CO2 ÷ H20

H20

So' d6 2.2. TN h6p thu bicarbonat a than

4.2. Sy' tan tao HCO3- O, t6 bao 6ng than

Su tan tao nay có lien quan mat thiet vai su tiet H+ có 2 giai doan:
0 Sr phan ly cim phan tir' H2O —> + OH-, II+ Wet vao long ong than
CA
0 OH- + CO2 -->TIC03-
HCO3- mai sinh dugc dua vao he tun hoan qua mao mach ong than.
Hieu qua thyc la:
0 Six bai Wet mot 1-1+ thi ket hop sinh ra mot HCO3- dua vao huyet Wang
0 Neu It bai tiet ra ket hop vai mot HCO3- dirge loc thi HCO3- mai sinh ra duac coi
nhu la HCO3 tai hAp thu de bit lai cho HCO3 bi loc —> co the khong bi mat HCO3-
0 Neu IT tiet ra ket hop vai HP042- hay NH3 thi co the dtroc them mot HCO3- mai
bit cho HCO3- mat di.
LOng ong than Te bao Ong than Huyet tuong
DNTB
------ Na+
Nat HPO4 Na+

K+
NaHPO4 + H+
2
OH-
NaH2PO4 H003
1--■ OH-
CA HCO3 Tan tao
—
CO2
--------- Na`

Hinh 2.7. Tan tao HCO3 & to lobo ong than

51
HOASINH LAM SANG

4.3. Vai tro cua enzym carbonic anhydrase (CA)

Trong to bao 6ng then CA c6 vai tro trung gian trong qua trinh tai hap thu HCO3- vi no lam
cho sit hinh thanh HCO3- tir OH- va CO2 duoc de dang.
Trong long Ong then On to bao c6 chira nhieu CA, CA c6 vai to kich thich sit bai
tiet H+ va tai hap thu 1-1CO3-:
+ HCO3 H2CO3 —> CO2 + H2O: bi tai hap thu —+ H2CO3 giam —> [H+] giam
trong long 6ng then—> kich thich bai tiet 1-1+ va tad hap thu HCO3-.
Su phan bO,CA cac doan khac nhau 6ng then c6 vai quan trong dOi Arai sr
acid hoa nuac tieu.
O doan dau cua 6ng lugn gan: c6 nhieu CA nen tai hap thu den 95% HCO3-.
0 phan trung gian cua 6ng g6p cling con CA nen no la phan quan tong tai hap thu
HCO3 cua Ong loon xa.
Phan con lai cua 6ng loon xa khong c6 CA nen han cite tai hap thu HCO3-, nhung no
lai clang vai tro quan trong bai tiet NH4+ vi sit giant pH & day kich thich bai tiet NH3 vao
long 'Ong a do no ket hop vai H+ —> NH4+.

4.4. Acid chuan do

Mot s6 acid yeti bi lac a cau then co the hoat deng dem trong nuac tieu. Dem dat tai da
khi pH trong nuac tieu pK t 1.
Acid phosphoric c6 nOng dO cao, co pK = 6,8 nen la dem chit yeu. Cac acid yeu khac
nhu creatinin (pK = 4,97), acid uric (pK = 5,75) cling tham gia.
Mang acid nay goi la nhitng acid chuan dO vi chi:mg c6 the duoc dinh luting bang
each chuan de Arai NaOH cho den khi pH nuac lieu tra ye gia tri pH huyet tucmg (7,4).
Co the cua sit bai Wet acid la hoan ai ion 1-1± lay ion Nat:
Na2HPO4 + 2H+ —> NaH2PO4 + 2Na (hap thu).
(lac qua call then) (thai ra nuac lieu).
Heu qua la pH dich lac giam tir 7,4 —> 4,4 (Ong g6p). Luang H+ bai tiet gan chat vai
phosphat va bi giai han nhieu vi khi da tao H3PO4 tir H2PO4 se khong con 11+ nao &roc
bai fiat them va pH nuac tieu se thdp hen.

4.5. Skr bai tiet NH3

NH3 duac tao ra trong to bao 6ng then, tan dtrorc trong lipid nen khuech tan qua mang to
bao vao long 6ng then, a dO:
NH3 + H+ —> NH4+
NH4+ khong tan trong lipid nen khong khuech tan qua mang de tra lai t6 bao &roc va
bi dao thai ra nuac tieu.

52
 CHU'O'NG 2 10- THANG BANG ACID-BASE

Do do 11+ duet bai tiet theo NH3 duai dang NH4+. He NH3/NH4+ co tac dung dem
(pK = 9,0).
Khi H+ tang len thi se lam luting NH3 giam din, khi toan be NH3 chuyen thanh NH4+
thi tac dung dem ana N thong ding het.
Thuc to NH3 giam se kich thich qua trinh khuech tan NH3 tir trong to bao vao long
6ng than, nhanh ch6ng bu lai s6 NH3 da mat.
Huy& tuang Te bao eng than Long 6ng than
DNTB
CO2 + H20

HCO3 HCO3 Tr H+

Na+ Na+ Na+Na+HPO4

glutamin 11+A-
NH4+ —4. NH3 NaH2PO4

glutamat NH4+A-
NH4+ NH3
`IT
a-ketoglutarat Nuov tieu

So' d6 2.3. Tan tao bicarbonat, thai H+, bai tiet NH3 6' than

4.6. San xuAt NH4+

NH4+ duce sinh ra trong to bao eng than tir s r chuyen hoa acid amin, dac Net la glutamin.

ED H
ED e
H3 N II COO I
H3N`c/coo 0 COO
C Glutamat
NC
1
CH2 Glutaminase CH dehydrogenase CH2
2
CH CH CH2
1 2 H20 NH3 2 NAD NADH
,C, C 7C N
0' 'NH2 0 N OH NH4 OH
Glutamin Glutamat 2-Oxyglutarat

NH® NH3 + He

53
HOA SINN LAM SANG

Chinh NH4+ dugc tao ra dau lien, sau do NH3 tach ra tir NH4+ va khu'ach tan qua mang
nhanh ch6ng (vi tan trong lipid).
NH4+ vi khong tan trong lipid nen chi c6 th6 qua mang nha chdt van chuyan mat
ten mang trong long 6ng de vao long ong then.

4.7. Su' bai tit NH3 vao long 6ng gop o' phAn vo va tuy
O 6ng g6p nuac ti6u 66 n6ng dO NH3 thdp vi da di chuyan qua quai Henle va kh6ng
c6 CA.
Er tip tuc bai tit bai born Er-ATPase tao ra mot lugng acid lan trong nuac ti6u
cang lam giam lugng NH3 do dO kich thich khuach tan NH3 tir khoang ke vao long 6ng
r6i kat hop vai —* NH4+.
doan cu6i quai Henle, NH4+ thdm ma NH3 khong thdm diau nay cho phep NH4+ tai
hap thu va NH3 khong khuech tan trO lai vao long 6ng.
'ang gap, NH3 tinh thdm cao, NH4+ thdm thdp nen NH3 tir khoang ke bai tint vao
long ong va bi gift lai a clang NH4±.

4.8. Sy' tai hap thu NH4+

Co tren 75% NH4+ dugc tai hdp thu d6 quay \Tang lai trong phdn My lam cho n6ng dO NH3
cao trong khoang ke.
Su tai hdp thu xay ra a phdn len cua quai Henle.
NH3 va tao ra nhieu trong to bao.
dugc fiat vao long 6ng qua su trao d6i Na+- fr, 6 dO chiing thiic ddy qua trinh tai
hdp thu HCO3-.
NH3 khu'ach tan ra ngoai vao khoang ke, cac khoang ma NH3 thdp.
N6ng dO NH3 cao ddn trong khoang ke (My) va ti6t ra a 6ng gop a phdn tuy da k6t
hop vai fr tao thanh NH4+ thai ra ngoai.

54
 CHUO'NG 2 IN. THANG BANG ACID-BASE

Glutamin Glutaminase
-HCO3-
NH,*

Na* NH4'

2CI-
Na-
NH: NH4* • NH4'
201-
,! Na*
' NH4{

+
\ ... NH4

NH4*
Nhanh xuong h---..„
Quay
II
vong
H NH3 NH4*
'.----)1 j
L.
Quaff HenlO Ong gap phAn tuy

Hinh 2.8. Sy, tai hap thu NH4+ va bai tit NH3

4.9. Dieu hoa bai tit NH4+

Su bai tiet NH4+ chin anh huang dm pH mau, pH nuarc tieu.

- Anh hueng cila pH mail: chuyen boa glutamin phu thuec vao pH mau.
Tang khi nhiem acid, khi acid mau tang lam tang thu nhan va chuyen hoe glutamin
thanh NH4+ tai to bao Ong then.
Giam khi nhiem base.
Su bai tit NH4+ co the tang tir 30 — 40mmolingdy len tren 300mmolingay. Su dap
Iiing nay khac vai su dap Ung co gioi han dm acid chuan de.
- Anh hung dm pH nuac lieu: theo nguyen fac isohydric thi pH dm nu& tieu co,
the tinh theo cac he dem nhu sau:

, [HCO-3 ] , [HP0421 [NH3]

pH = 6,1 +log = 6,8 + log = 9,0 + log rya+,
ri2u031 [H2CO3 ] P-1114

Ion El+ tit ra dugc dem voi he dem nao có neng de cao han hay vai pK — pH nu& tieu.
O 'Ong than gan, [HC01-] rat cao nen hau h6t H+ d'eu dugc trung hoa bai HCO3 tao
thanh H2CO3, rei dirge tai hap thu o clang.
Ong than tier, theo, khi pH nuarc lieu giam con khoang 5,8 thi phan lon HP042-
dtrgc huy deng de dem.

55
HOA SINN LAM SANG

O eng gop khi pH nuac tieu xueng thap con khoang 5 thi tiet ra ket hap vai NH3
lam NH3 giam se kith thich khuech tan NH3 tir khoang ke vao long 6ng than (do doan nay
hau het so HCO3 da dirge 61 hap thu va HP042- da dirge dem).
T6m lai:
✓ Thang bang acid - base duac phoi hap dieu hoa bai he thong dem, phoi va than.
✓ He thong dem dieu hoa nhanh nhung lai lam thay dei luting HzCO3 va HCO3-.
✓ Sr tang hay giam thong khi phoi dieu chinh lai luting H2CO3, Wong de HCO3 dieu
chinh nher 2 qua trinh tai hap thu HCO3 va bai tiet El+ a than.

5. CAC THONG SO DANH GIA THANG BANG ACID - BASE

pH man: binh thuang dao dOng tir 7,36 — 7,42. pH giam la nhiem acid, pH tang
la nhiem base. Neu chi danh gia pH don thuan thi it c6 gia tri vi kha nang bia trir
cua ca the rat lem (qua phoi va than), doi khi do co die bu trir du pH binh thuang
nhung thirc to da co nhang rei loan thang bang acid - base. Trong dieu tri can phoi
hap do pH \Ted cac thong so khac.
PCO2: la ap suat rieng oh CO2 trong mau, binh thuemg dao dOng tir 36 - 42mmHg
Gift PCO2 va CO2 boa tan lien quan vai nhau theo dog thirc:
CO2 Ilea tan = a PCO2
6 nguai vai than nhiet la 37°C, he se Ma tan a = 0,03
- Bicarbonat thtrc (AB: actual bicarbonat = 25mmol/L): la bicarbonat do dirge hIc
benh nhan lay mau xet nghiem.
Bicarbonat chuin (SB: standard bicarbonat = 25 mmol/L): bicarbonat do dugc
trong dieu kien tieu chuan dm co the (PCO2 = 40mmHg, than nhiet = 37°C).
- Base Om (BB: buffer base): toan be base dm cac he dem trong mau: HCO3, Pr,
a
KHb, HP042-. Trong do he Hb rat quan trong, tinh thong so nay dung,can phai
do khi ding \Ted dinh luting Hb va cung cap gia tri Hb cho may. Neu khong
may se cho Hb = 15g/d1.
Base Om trong trurovg hcrp binh thuimg (normal buffer base = NBB): NBB la
toan bid base oh cac N dem do trong dieu kien binh thuang (PCO2 =40nunHg,
than nhiet = 37°C), binh thuemg NBB # 46mmol/L.
Base du (Excess base—EB): dirgc tinh theo tong thirc EB = BB — NBB, binh
thuang EB khoang ± 1. Theo 1ST thuyet thi EB = 0.
Neu EB c6 gia tri ducmg la nhiem base.
Neu EB c6 gia tri am là nhiem acid.
EB giup nhieu cho lam sang trong dieu tri thi loan thang bang acid — base. Can cur
vao gia tri cua EB c6 the tinh ra se ml dung dich bicarbonat can truyen cho benh nhan bi
nhiem acid chuyen hoa.

56
 CHU'CYNG 2 I* THANG BANG ACID-BASE

- Base dir dfch ngoai bao: (base excess of extracellular fluid = BE ecf): binh
thuemg la ±3. Base du dich ngoai bac> hay can goi la SBE: Standard Base Excess.
Dai dien cho luong base du toan ca the. Dau (+) la du base; (-) la thieu base.
Cach tinh luting acid hay base can
Acid hay Base can bu = BE ecf ( ova) x BW (kg/2
- Total CO2: g6m CO2 hoa tan + bicarbonat (24 - 32 mmol/L).
Cac chi s6

Dinh gia kha nang cung cap oxy Chan (Wan red loan acid - base
pH
PCO,
HCO3
BE (ecf)
SB
TCO2

6. ROI LOAN THANG BANG ACID - BASE

R6i loan thang bang acid - base (RLTB A-B) khi co sir thay d6i n'6ng d6 va HCO3-
trong man. Thy theo nguyen nhan, RLTB A-B duce chia lam 4 loai chinh• nhi'e'm acid ho
hap, nhiem base ho hap, nhi'em acid chuye'n h6a, nhie'm base chuyen h6a.
o R6i loan nguyen nhan ho hap: pCO2.
o Roi loan nguyen nhan chuyen hoa: HCO3-.
o R6i loan co bu hay mat pH.
Nhi'em acid c6 the do 1 trong 3 co the hay ket hop ca. 3 co. the yeti nhau:
o Tang luting acid vao mau: do an u6ng hay r6i loan chuyen h6a lam tang tong
hop acid.
o Giam qua trinh loai trix acid ra khoi mau.
o Tang dao thai base.
NhiLi base c6 the do 1 trong 3 co the hay ket hop ca. 3 co the vai nhau:
o Tang luting base trong man..
o Giam qua trinh loai trix base.
o Tang dao thai acid.
Nhung ltru y khi lay mau des xet nghiem khi mau:
- Loai 6ng chich: thily tinh, nhua thong thuemg, nhua dac biet de lay mau phan
tich khi.
- Mau dOng mach: thuerng dimg, thuemg chon dOng mach nong, an toan, c6 tuan
hoan bang N tot, lay ben khong thuan cua b'enh nhan.

57
HOA SINH LAM SANG

o Ngu6i lon: 3 dOng mach thuOng lAy la: dOng mach quay, dOng mach canh tay,
d6ng mach diti.
o Tre em: dOng mach quay, dOng mach thai throng.
o So sinh: dOng mach roil.
- Khi lay mau 6 dOng mach quay phai lam test Allen truac khi lay (vi c6 30%
khong c6 d6ng mach tru hay &ling mach tru nh6). Ca.ch lam test Allen:
o DfIng 2 tay chan mau den long ban tay bang cach ep 2 dOng mach tilt va quay.
o Bitting tay phia dOng mach try.
o Quan sat so thay doi mau sac dm long ban tay lam test: n6u mau d6 long ban
tay tra 10 trong yang 5, - 15 giay: d6ng mach quay ban tay c6 nhanh not voi
dOng mach tilt —> c6 the lay mau Ong mach nay throe.
Mau kh6ng a tip xuc voi khi, khong c6 bot khi.
- Khong km gift lau, phan tich ngay 5 phitt).
Qua nhi6u heparin: luting heparin chi can vim 0,05m1 (heparin 1.000U/
ml)/1m1 mau.
- Mau bi &Ong: phai trOn lan mau \Teri heparin ngay sau khi lay mau de tranh mau &rig.

6.1. Cac r6i loan acid - base dun thuan

- Thu6ng danh gia thong qua khi mau d6ng mach
- Cac chi s6 phai tinh toan tir gia tri trung binh.

GIOI HAN BINH

CHI SO TRUNG B1NH
THVONG

- Cac r6i loan acid-base ho hAp tien phat dun thuan.

Nhijm base ho hap (NBHH)
Nhiem base ho hAp la do tang dao thai CO2 qua dueng phi lam cho n6ng dO CO2
h6a tan giam —> ty s6 HCO3- /CO2 hoa tan tang, giant nong d6 14+, tang pH. Nhiem base
ho Ilk) a bit trir va pH nhanh chong tree ve binh thu6ng.

58
 CHUUNG 2 ► THANG BANG ACID-BASE

Tang thong khi

Tang ciao thai CO2

Gram nOng do
H2CO3

Gram n6ng do H+

Ki6m ho hAp

So' c16 2.4. Ca ch4 base ho hAp

Cu cite bit trix trong NBHH: c6 2 giai doan:
a
o Giai doan 1: dem to •chirc va h6ng cau cung cap IP trung hem mot phan HCO3-.
o Giai doan 2: neu th6i gian keo dai, bu chit yeu do than, giam tai hap HCO3-.
Nguyen nhan nhiem base ho hap:
o Tang th6 do rei loan he thong than kinh trung trung:
• Do tam than: lo Fang, hysteria.
• Do sinh c6 thai.
• Benh giam oxy mau, nao: nhi6m khuan, chan thucmg hoac khi u, benh
nao do gan, dung qua lieu salicylat.
o Tang filo do benh phei:
• Phil (suy tim sung huyet).
• Hen.
• Viem phei.
o Tang tiler do thong khi co. hoc.
Xet nghiem
o Cac thong s6 CO; h6a tan, CO2 toan phan, PCO2, HCO3- giam.
o pH tang, c6 the den 7,6. Neu pH tang cao ban nixa thu6ng la nhigm base h6n hop.
, •
Nhiem acid ho hap
Nhiem acid ho hap xay ra do Om dao thai CO2 qua phi dan den tang pCO2 va tang
CO2 hem tan lam giam ty s6 HCO3-/CO2 hem tan pH giam.

59
HOASINH LAM SANG

Nguyen nhan nhigin acid ho hap:

o L7 c the than kinh trung 'rang:
• Chan thuong, nhiem khuan.
• Tai hien mach mau nao.
• Dung thuoc qua lieu.
o B'enh than kinh co:
• Bai liet, b'enh ca (Mastin Gravis).
• HOi chimg Guillain — Barrre.
o Giam the do:
• Tran dich, tran khi mang phoi.
• Manh nguc va, ho hap nghich thuemg.
o Benh phe quan ph6i:
• Vat la, hen, nhi6m khuan.
• COPD.
• Phil phi nang.
He dem bicarbonat Dem kh6ng phai bicarbonat

HCO3 NBB- NBB-H

118,0
/GE: 7,5
7,0

Binh thtromg pH 7,4

Giann thai CO2 tr.,
qua ph6i 2

1
0
NBB- + H+
•
Toan he, hAp pH -Dem bal he dem khOng phai bicarbonat ,

Hinh 2.10. Ca ch6 nhi6m acid ho hap

60
 CHU'O'NG 2 ■ THANG BANG ACID-BASE

Co cite bu trong nhigin acid he, hdp (NAHH): trong NAHH dirge bu ngay he dem
r6i den than, phei.
o He dem: H2CO3 thaa dirgc dem cha yell bang Hb va protein, six dem nay lam tang
nhe HCO3- va xuat hien kiem chuyen h6a ngay sau do.
o Than: co the bu trix dm than bao g6m: tang trao doi Na+ - 1-1+, tang tong hop NH3,
tang tai hdp thu HCO3.
o Trong NAHH man tinh nhu. COPD sly ba tra caa than kha tot, cap tinh thi six bu
dm than khong c6 hieu qua truorc 6 - 12 gier.
Xet nghiem:
o Cac thong s6 CO2 h6a tan, PCO2, CO2 toan phdn va HCO3- deu fang, nhung tST s6
HCO3-/CO2 hem tan lai giam lam cho pH giam.
o Trong pha cap HCO3- tang khoang lmmo1/1 cho moi lOmmHg tang dm PCO2.
o Neu NAHH keo dai HCO3- c6 the tang 3,5mmo1/1 cho moi 15mmHg PCO2 tang.
o pH c6 the thay deli 0,1 don vi/cdp tinh va 0,05 dun vi /man tinh.

H2O + CO2
BO trir bai th0

I"
+ HCO3 CO2
Tang thai CO2 qua phoi

Tang tai
hAp thu

4— HCO3

Ca ch6 bu ciaa Than giup

Nhung HCO3 va PCO2 tang

Hinh 2.11. Co cha. 136 cua than trong nhi6m acid 116 hap

61
HOASINH LAM SANG

Nhijin acid chuy'6ih6a

Deu hieu clau tien la giant HCO3- (hay mot BE (-) cua dich ngoai bao).
HCO3- giam la do phai dem cho luting acid thira. Nhi6m acid chuyen hoa có the do
nhfing nguyen nhan sau:
o Cu the san xuat nhieu acid him co, vuot kha nang dao thai cua than nhu: tang
tong hop acid acetoacetic, acid 13 hydroxybutyric trong bnh dai thao doting hay
tang tong hop acid lactic trong berth nhi6m acid do acid lactic.
o Giam ciao thai acid (RE) trong suy then hay be‘nh 'Ong then do do tieu thu nhieu
HCO3- a trung hem.
o Tang thai qua nhieu HCO3 theo doting then do giam tai hap thu o Ong then hay
mat theo cluemg runt trong tieu chay, do do nOng dO HCO3- giam, tS7 so HCO3-/
aPCO2 giam —> pH giam.
Dem bicarbonat Dem khong phai bicarbonat
HCO3 NBB-H
NBB-
C°2 80
7,4 004.107,4
7,0 411P'

Binh thixtmg pH 7,4

CO2

NBB- + H' -› NBB-H

_ _ . -------- ..Li
, —
7,

DOm 1361 NBB

Toan chuyen hoa pH 4

Hinh 2.12. Ca the nhi6m acid chuyen hoa

Co the bit frit bang cach tang thong khi d ciao thai CO2 ra ngoai lam cho PCO2 giam
—> aPCO2 giam —> phan so ten va pH den tro lei birth thuang.

62
 Toan chuy6n hoa pH 4
Kich thich cac cam bier' hoa hoc
Tang thong khl
Tang thai CO, qua phi CO2
a BO trip boi Ho HAp

pH tang

Tang sir dung

C HCO3 NBB tai lap can bang
+ CO2 + H20

Toan chuyen h6a bu trill, boi hO hap giCip pH $

Nhu'ng [HCO3 ] va PCO2 giam

Tang th6i H+va NH4+ qua than HCO3- duvc b6 sung

Hinh 2.13. Ca ch6 !Du fru, trong nhi6m acid chuyen hoa

Nhiem acid chuyen h6a co the c6 tang khoang trong ion (Anion Gap - AG) hay AG
binh thirong. Khoang trong ion (AG) la nhimg anion th&mg khong doge do trong lam
sang nlux: S042-, HP032-, protein nhung chung van c6 mat trong huyet twang.
AG = (Nat) – (HCO3-) – (CO
AG = 12 +/-2
o AG tang: do tang H+ fix'nOi/ngoai sinh —+ HCO3- cilia co the trung hoa nen giam
HCO3- —> tang AG.
o AG khong tang: HCO3- bi mat di —> Cl- tang bit trfr.

63
HOA SINH LAM SANG

Ta c6 the phan loai nguyen nhan acid chuyen h6a nhu sau:
NGUYEN NHAN ACID CHUYEN HOA:
TANG AG KHONG TANG AG
- Toan lactic: choang, giam 0, mau nan Tang hap thu acid: truyen tinh mach
dai thao throng, nge dee CO, ethane_ dung dich acid amin.
Toan ceton: dai thao duang, doi, Cu . Mat HCO3- qua duang tieu h6a: tieu
giap, nge dec ethanol chay, dan luu dich tuy, dich met.
Suy than wrAt NCO,- qua then: acid mau 6ng than
Ng6 dec salycilate, methanol, S gan (type2) sau dieu tri dai thao duang
Ly giai ca van nang. nhiem acid ceton bang insulin.
Giam tiet acid qua then: acid mau 6ng
dikAa (type .1.). do aldosteron (type 4).
Tang AG: nhlem acid hat ca, kh6ng tang AG: nhiem acid vo co.
Nhigm acid chuyen hoa do benh 6ng then voi loai I va loai II:
Su mat HCO3- do giam bai tiet 6ng then xa goi la loai I. Giam tai hap thu HCO3-
6ng then gan goi la loai II.
+ Loai I Ong then xa): pH nu& tieu > 5,5.
+ Loai II (6ng then gan): pH nuac tieu < 5,5.
1Vhijm base chuy'n boa
Nguyen nhan nhie'm base chuyen hoa:
o Non keo dai, tac mon vi, tac met doan tren lam mat HC1 tir da day va giam the
tich mau. dirge tai hap thu de lam cho the tich mau tang Ara HCO3-, Na+ duac
tai hap thu de trung hoa dien tich. 1-1± va throe bai tiet.
o Ming thuorc lqi tieu keo dai nhu furosemide, acid ethacrynic. Chung irc che tai
hap thu Na+ va C1, lam tang n6ng Na+ 6 6ng luon xa, kith thich tiet aldosteron
va tang dao thai 1-1± va Kt
o Thira mineralcorticoid hay glucocorticoid: thira nOi tiet to vo thuang then, IC hay
dao thai a than la do hieu qua tang tai hap thu Nat do kith thich cud aldosteron
hay cortisol, HCO3- cling duac tai hap thu ding Nat
o Nhiem base ngodi sinh: du HCO3-
o Nhie'm citrat do truyen met khoi luong mau lan hay truyen tinh mach met luong
lan bicarbonat, dieu tri loet da day, diing thu6c ire the born IP, dUng antacid hay
trao doi ion ten benh nhan suy then deu c6 the an den base chuyen h6a.
Ca the bi trong base chuyen hoa:
o Bit do phoi: pH tang —+ in the trung tam ho hap giam dao thdi —> tang CO2
hoa tan giam t-ST s6 HCO3-/CO2 hoa tan, pH dan dan ter lai binh thuemg nhung
HCO3- va PCO2 van cao.

64
 CHU'O'NG 2 11.- THANG BANG ACID-BASE

o Bu do than: than giam trao d6i Na+ - 1-1+, giam tao NH3 va giam tai hap thu HCO3.
Xet cac thong s6 HCO3-, CO2 hoa tan, PCO2, CO2 toan phn, ty s6 HCO3/
CO2 Ma tan: deu tang.
Neu PCO2 tang qua cao thi co nguy co nhiem acid do bU thai qua.

r
Cac xet nghi'em danh gia.
: hf6m acid chuyen hoa him base chuyen h6a do thieu acid
: pH 1, hoac thira HCO3-
HCO3- 1., EB (-) pH
- PCO2 1 PCO2't
'EB (+)

6.2. Cac r6i loan acid - base hon hop

Khi c6 > 2 r6i,loan acid - base tien phat cimg xay ra thi goi la r6i loan acid - base h6n hop.
Cach nhan Net nhtr sau:
o PaCO2 va HCO3-, thay d6i ngugc chieu: acid ho hdp + acid chuyen h6a /base ho
hAp + base chuyen h6a —' pH thay doi rat Ong.
o PaCO2 va HCO3- thay doi ding chieu nhung vugt qua giai han bu frit dm co the:
acid ho hap + base chuyen hoa /base ho hap + acid chuyen hoa —> pH c6 the hoan
toan tra ve binh thugng.
o PaCO2 va HCO3- thay doi rat nhieu nhung pH hoan toan binh thugng met each
b'At thuong.
o Anion gap > 30 —> chac chan acid chuyen hoa tang anion gap du pH bang
bao nhieu.
Nguyen nhan r6i loan acid - base h6n hop:
Acid chuyen h6a + Ngung tim ngung thg
ion Suy ho hap co thieu oxy mo
A
Base hon hop hong nluem trimi
em khuan/Suy tim xung huyet + suy than
an + non
ase chuyen hoa „Dai Mao dugng nhi6m ceton + non
ieu tri thuoc loi tieu va toan do ceton
,.
hoa + a hoac dung Igi tieu

phoi + thuoc loi tieu

Base h6n hop Suy tim sung buy&

65
HOA SINH LAM SANG

A. CAU HO! LUVNG GIA

1. Truirng hop nlo nhiem base ho hap:
A. Non keo dai
B. Digu tri lgi tiL lau ngdy
C. Hep mon vi
D. Tat ca ST teen
2. Khi giam the tich mau do the bi:
A. Nhiem acid chuyen hoa
B. Nhigm base chuyen h6a
C.Nhi6m acid ho hap
D. Nhie'm base ho hap
3. Dung thu6c l07 tieu furosemide keo dai se lam cho:
A. tic the tit aldosteron
B. Giam dao thai H+ qua then
C. Lam tang ngng cig Na+ & 6ng then xa
D. Giam dao thai IC qua then
4. Tim cau dung:
A. Nhire'm base ngoai sinh c6 the an sau mgt nhiem acid chuyen hoa
B. HCO3- c6 the giam trong nhi6m base chuyen hoa
C. Cortisol lam tang tiet aldosteron
D. Di'eu tri bang corticoid c6 the gay nhi6m acid chuy'L hoa
5. Co' the bu trir trong nhiem base chuyen h6a là:
A. Trung tam ho hap bi kich thich B. Tang dao thai CO2 & phi
C. Giam tai hap thu HCO3- D. Tang hinh thanh NH3 a then
6. Tim eau sai: trong nhiem base chuyen Ma:
A. CO2 toan phan giam B. CO2 hoa tan tang
C. PCO2 tang D. HCO3- /CO2 hea tan tang
7. Nham acid ho hap xay ra do:
A. An nhiL protid B. Viem phe quail phi
C. Then tai hap thu nhiL acid D. Ty so HCO3- /CO2 him tan tang

66
 CHU'CYNG 2 10- THANG BANG ACID-BASE

8. Nguyen nhan nao c6 the gay nhiem acid ho hip:

A. Nge dee barbiturat B. Bien dang long ngirc
C. Kh6i u SO nao D. Tdt ca 3'T tren
9. Trong nhiem acid ho hip, ltrcrng acid thira duvc trung him chic yeti WA:
A. HCO3- B. Dem phosphat
C. Na+ D. Hb va protein
10. Truirng hop nao nhiem acid chuyen hoa c6 tang khoing tiling anion:
A. Suy ho hap B. Giam the tich mdu
C. Benh dai thdo duemg D. Viem gan sieu vi
11. Truirng hop nao nhiem acid chuyen hoa khoang trong anion binh thuinig:
A. Tieu chay B. DM thdo dugng
C. Viem phe quan D. Tang tai hap thu HCO3-
12. Tim cau dung:
A. NH3 tan trong lipid
B. NH4 tan trong lipid
C.pH nu& tieu cang giam thi dugc dem bai HP042- ding giam theo
D. HP042- ca ai lirc voi deng tai to nhieu hcm la H2PO4-
13. Str acid hoa o ling lugn xa khac ling limn gin 6' nhirng diem ilk,:
A. Trao dei va nhg barn - ATPase
B. Barn 14+ ATPase
C.Na+ dirge van chuyen vao to bao ling than
D. Tat ca
14. Tim can dung:
A. Six tan tao HCO3- tong to bao ling than lien quan mat thiet vai six tiet H+
B. Six tan tao HCO3- can c6 met phan tir mac phan ly thanh 11+ va 0H-
C. Six bai tiet met fr ket hop vai six sinh ra met HCO3- dua vao huyet trong
D. Tdt ca dung
15. Trong truomg hop nhiem acid chuyen hoa, sir dem cua xtrung gay ra 114u qua gi?
A. Tang Ca2+ dao thai qua than B. Giam bai tiet citrat
C. Urat chuyen thanh acid uric D. Tat ca hau qua tren.

67
HOA SINN LAM SANG

B. CAU HOI NGHIEN CfrU BAI HOC

1. TO sao noi NH3 c6 kha nang dem khong gi6i han?
2. Tai sao an qua nhieu thit c6 nguy ca gay seli duemg tiett?
3. O ngued dai thao clueing thuemg gap loci r6i loan thang bang acid — base nao?
tai sao?
4. Vi sao nhie'm acid chuyen hoa vai khoang trong anion binh thuong lai c6 the
tang Cl- trong mau?
5. Ng6 d6c mem c6 the clan den r6i loan thang bang acid-base loci nao? tai sao?

68
 Chu'o'ng 3

HOA SINH LAM SANG

BENH Ls/ THAN
MUC TIED
1. MO to cluvc chirc nang chinh cfia cau than va ang than.
2. Liet ke &Ivy mat sa xet nghiem dfing de tham do chirc nang eau than va ang than.
3. Thiet lap cac bilan xet nghiem trong hai chi:mg than kr, suy than cap, suy than
man, viem cau than cap.
4. Phan tich va Nen luan mat sa xet nghiem lien quan den benh hai chfing than htr,
suy than cap, suy than man, viem cau than cap.
5. Phan tich va Nen luan k'et qua ccic xet nghiem tren que thin nook tieu 10 thong sa.

1. DAI CU'O'NG VE CAU TROC THAN

1.1. Ceu trOc dai the

Hai than nam phia sau Mang bung va fru& OA
song lung, phia sau cua than la ca hoanh, phia
fru& dm than la philc mac. mg truac dm than
trai lien quan den da day, toy, lach va nhanh
xtiong dai tang. M4t truck dm than phai lien
quan den gan, doan hai cua to trang va nhanh
len dai tang. Cue ten m8i than dime phit bai
tuyen thuang than.
O nguai truang thanh, than nang khoang
150 g va có kich thuoc khoang 13 x 6 x 4 cm.

1.2. Cita trim vi the Hinh 3.1. Vi tri cua than trong the

Moi than có khoang mot trie'u don vi than goi la nephron. Moi nephron gom hai phan la
cau than va 6ng than. Cau than di eh-ire nang loc mau tao nook tieu dau, nam a phan vo
than. Ong than có cau true Om Ong Man gan (nam a va than), quai Henle (di sau vao

69
FICA SINH LAM SANG

yang toy va u6n cong tra lai \ding vo than), 6ng Mon xa (nam a vimg vo than) va 6ng gop
(dam sau vao \rang My de r6i do vac) gai than, be than).
Cau than: gem mot dam mao quan (khoang 50 mao quan) chay song song dirge
boc bai nang Bowmann.
Ong luvn gan: not tiep cau than, thanh 6ng cau tao bai mot lap to bao bieu mo xep
lien tiep nhau, 136 hirang ve long 6ng c6 cau tao ging nhu ban chai gem nhieu vi
nhung mao,,trong to bao c6 nhieu ty lap tbe, phan u6n cong 6ng Mon gan d6
vao phan thing va tao nen phan dau cua quai Henle.
Quai Henle: c6 cau tao hinh chir U, gem c6 2 phan: phan day va phan m6ng ciia
quai Henle. Doan xu6ng va doan len dm phan mong quai Henle, to bao bieu mo
thap, khong c6 ba ban chai va chira rat it ty lap the.
Ong loon xa: nam a vo than, to bao bleu mo thap, c6 it vi nhung mao va ty lap the
hem so \Teri 6ng loon gan.
Ong gdp: qua vo than vao My than, r6i den thap than, sau d6 d n-u.ac tieu vao be than,
cac to bao bleu mo cua 6ng gop c6 dang kh6i, ba bang phang va chira fat it ty lap the.
Co su khac biet ve cau true to bao cua cac doan 6ng than.
Moi nephron la mOt dcm.vi d6c lap ve chirc nang; do d6 khi mOt s6 nephron bi ton
thirung thi cac nephron khac hoat dOng bu. Mac khac khi danh gia chirc nang than can
loai trir cac benh 1.3'7 a &TON tieu duoi nhir soi nieu quan, btrau bang quang, u xu tuyen
tien liet Cac ton thuung nay c6 anh hirang len cac xet nghiem tham do chirc nang than.

CuOn bet., chi,.

HO th6ng loc cua than
Tieu dOng mach_
den vao Tieu guarrthaR
ChaTking duvc ICC di
gua tir he'thOng mao
ao tieu guarNhan
Tieu Ong mac
Cuon tieu cau
Eking mach veng t1
• leu
ach da
vao
Dal

Nang than

DOng mach
yang cung
Ding mach than

Tinh mach tha

BO than

Dai
ac thanh ph
on ich caa cha
NiOu quan

Ntrac tieu
Tieu quan
tap hap
I
king duvc tai
ap thu vao
gong mau
Quai Hanle
•
Hinh 3.2. C6u true vi th6 cua thn

70
 CHU'O'NG 3 l■ HOA SINH LAM SANG BENH L? THAN

Bang 3.1. Tom tat c6u tao va chi:pc nang cua nephron
cau trtic CA u tao Vi tri Chtire nano
Gam nit dam mao quan (khoang 50 mao
Cu than quan) chay song song duvc bao boc beyi o than oc mau
nang Bowmann.
Tao thanh bai mot lap to bao Neu mo xep
Ong luon ai lap thu va
lien tip nhau, nhiL vi nhung mao, trong
gan ai tiet cdc chat,
bao nhieu ty lap the.
Hinh chCr U, gom phan day va phan mong,,
Quai doan xu6ng va doan len cila phAn mOng to 6 va to Ai hap thu va
Henle bao biOu mo thap, khong bey ban chai, it ty fan ai tiet cac chat
the.
Ong lupin Te bao bieu mo thdp, it vi nhung mao, ai hap thu va
o th
xa nhieu ty the.
Te bao bieu mo clang kh6i, bOr phang, rat it
Ong gop ty the.
lly than
ifai tiet cdc chat
di hap thu va
'Ai tiet cdc chAt

D6ng
mau
ch6y

.Ittt ApA, e$/ 'e II

Ntnfrc
it#0 1100 o
ivicoutit 4$ 0.4 okioffici .• • $
tieu
T6 bao bi6u mo Ong luvn ghn Ong luvn xa Quai Henle Ong gOp

Hinh 3.3. Cau truc nephron va to bac) bieu m6 ong than

2. CHU'C NANG CUA NEPHRON

Thin la mot co quan hoat &Ong manh va mau tai than rat nhieu, then nhan 25% mau cua
cung luvng tim (1,1- 1,3L/phut), mau nay dirge cung cap tit' dOng mach than di tit d6ng

71
HOA SINN LAM SANG

mach chii. Chi c6 khoang 10% lircmg mau tai than dung de nuoi then, 90% con lai dung
cho viec loc nu& tieu (then co dac nu& tieu de thai ra mot lacing lan cac chat can ba cua
co the), có 2 giai doan tao thanh nu& lieu:
Giai doan loco cau then: cac thanh phan cua huyet tirang dugc loc qua nang Bow-
man tao thanh nu& tieu dau khoang 1801Ingdy (air cac thanh phan hitu hinh, cac
dai phan ta).
Giai doan tai hap thu va bai tiet a ong then: nithc, cac chat vo co va hau co dugc
tai hap thu 6 'Ong then, cac chat can ba dugc bai tiet ra nu& tieu, nu6c tieu co dac
don, cu6i cimg thai ra ngoai khoang 1-1,51,/ngay.
Mar vay d6i vai sir tao thanh nuot tieu, có 3 chirc nang then can dugc nghien dm,
chirc nang loc cua cau than, chirc nang tai hap thu va bai tiet cua Ong then.
Ngoai nhiem vu chu y'eu la tao thanh nu& tieu, then con có chirc nang hormon, tham
gia dieu hoa thang bang nu& dien giai, dieu hoa thong bang acid-base (toan-kiem) va mot
s6 qua trinh chuyen h6a.

2.1 Chin nang loc cua cau thn

Te boo nOi mb cua mao mach
Mang day
Te bac !Dieu mb cua boc Bowman

Huyet tuang loc

L6 loc

Hinh 3.4. Cu
A true cua cau than

Chirc ming loc cua cau than citecfc xac dinh bang cac he sa:
- Dong mau qua than (Renal Blood Flow: RBF): binh thuong khoang 1200 ml/phirt
(10%: nuoi then, 90% tao mac tieu dau).
- Deng huyat tuung qua then (Renal Plasma Flow: RPF): binh thuong khoang
650 ml/phia.
He s6 loc cau than (Glomerular Filtration Rate: GFR): do la the tich dich loc dugc
loc qua cau then, binh thuong khoang 120 ml/phia.
- Phan s6 loc (Filtration Fraction: FF): GFR/RPF = 120/650 = 20%.

72
 -

CHU'ONG 3 II- HOA SINH LAM SANG BENH LVI THAN

Ap hrc dich 19c cau than chiu anh &thug cita nhiu yju to:
Ploc=P mao mach—(P
do keo
+P
nang
)
- Luu luting mau qua than.
lirc mao mach cau than (gong mach d6n, gong mach di).
Ap suat thily tinh cua nang Bowmann (soi than,
N6ng do protein mau.

2.2. Chic nang cua 6ng than

Ong than c6 chirc nang tai hap thu va bai ti& cac chat, six tai hap thu va bai tiet cac chat
tay theo nhu cau dm co. the. Thong thuemg cac chat trong qua trinh chuyen hoa sinh ra
nang luting cho co the (glucid, lipid, protein) thi dugc ca the tai hap thu vo dieu kien, tai
hap thu hoan toan. Cac,chat khac nhu muoi khoang, vitamin, nuac dtrgc tai hap thu tuy
theo nhu cau ca the, mat luting du thira cac chat nay se duct bai tiet, neu qua trinh
bai ti& khong dtrgc thirc hien se gay ra benh 1ST. Sau day la bang tarn tat mat so chat dugc
tai hap thu va bai tiet o 6ng than.
Bang 3.2. Vi tri tai hgp thu va bai tiet cac ch6t

Thanh phdn Vi tri Co. cht va dnh htrii•ng ctia hormon

':Ong gan di hap thu — chit clang
Henle .di hap thu — thu dang
Ong xa ti_i hap thu—chil (Icing (aldosteron)
Ong-, g6p ,ai hap thu — chit clang (aldosteron, ANP)
Ong gan .di hap thu - thu clang

r
Henle ai hap thu
it — thtt dOng (aldosteron)
..,
. . - ap thu — thu (tang
._ ,
. ap thu — chn dam;
.
, - hap , thu — chit Ong
Ong gop .ai tiet — chit dang
Ong gan ;- ái hap thu— chit clang (PTH irc ch6)
1 di hasp thu — chit clang (PTH ire" cite)
di hap thu — chit dang (PTH irc 66)
'i hap thu — chit thing
ap thu — chili Ong

i
- ap thu — thy clang
Ong gap di hap thu — chit dang (ADH)
ci ;Ong xa di hap thu va bai tiet — chit dang
lucose Ong gan di hap thu — chit Ong
cid ng gan 'i hap thu va bai tiet — chit Ong
itrat Ong xa ai hap thu — chit tong

73
HOA SINN LAM SANG

TOM TAT QUA TR1NH VAN CHUYEN CAC CHAT DOC NEPHRON
Tai hap thu chi) dOng va Na+:Tai hap thu chu Ong nguyen phat
thu dOng nguyen phat C Tai hap thu cht:i dOng thin phat
Tai hap thu &ICJ NaCI
dOng tht:r phat ..A,
H.
NH3

Glucose,
acid amin, ,
phosphat;
lactat,
sulfat

Tai hap thu j4

chu do, ng thu' phat
Cl- Urea Chuyen
H2O hOa, thu6c,
PAH

Hinh 3.6. Tom tat cd ch6 van chuyen cac chat doc nephron

Sau khi dugc tai hap ae Ong than, cac chat glucid, lipid, protid se dugc chuyen hoa
ben trong to bao, trong qua trinh chuyen h6a, cac san pliant d6c hai dugc sinh ra (vi du
ft, NH3) se dao thai ra ngodi bang duatng tieu.
Khoang khe -Fa bao Ong than L6ng 6ng than

I
Na+ )-- Na+ 1 NaHCO3

NaHCO3 HCO3 H+ > H+-F HCO3+

J[ Jr
H2003 H2CO3
carbonic
lrelanhydrase
van chuyen tich ct,rc
H20 + CO2 CO2+ H20
Evan chuyen thu d6ng

Hinh 3.7. Bai tiet H+ va tai hap thu NaHCO3 a t6 Pao Ong than

74
 CHU'O'NG 3 ► HOA SINN LAM SANG BENH L? THAN

Met se hormon ding anh hitting len qua trinh tai hap thu va bai tiet cac chat.
Bang 3.3. Tac dung cua hormon len cac of-1M a ong than
Hormon Vi tri Tac dung
Aldosteron a, Ong gop

Angiotensin II

A DH ng xa, Ong gap di hap thu H,0

Peptid bai Natri-nieu (ANP) Ong xa, onv, gop ai tiet Na', Cl-

Honnon tuyen can giap

(PTH)

3. CAC XET NGHIEM HOA SINH THAM DO CFRIPC NANG THAN

Than la not dao thai chu yeu cac chat dien giai va cac san ph'am thoai hoa cua protid va
acid nucleic (muoi amon, ure, creatinin, acid uric ...) nen cac xet nghiem Ung voi cac chat
dO throng dirge dung trong cac rei loan chirc Wang than va cac benh than.

3.1. Tharn do t6 chipc than 13Ang he s6 thanh thai (clearance)

M so thanh thai (HSTT) cua met chat la the tich do oda huyet tuong, tinh ra ml/giay, ma
than c6 the loc sach hoan toan chat do trong mot giay.

U.V
C— trong do C: la HSTT (ml/giay)
U: nOng de chit do/NT: mg/L
V:the tich NT/giay
P: nOng de chit do/HT: mg/L
Tren day la ding thirc chung ap dung cho nguai truong thanh c6 chieu cao va can
nang 13'7i-11611g, c6 dien tich be mat da khoang 1,73m2. Neu dien tich da cua co' the nho hon
1,73m2 (truang hop tre em, nguoi c6 chieu cao va can nang khong ly -Luang) chtitng to c6
cong thirc dieu chinh:
Cong thirc dieu chinh•

C x 1,73 Ss: dien tich da that sw cz,ia ca the

Cc — Cc: he so thanh thai dieu chinh
Ss

75
HOA SINN LAM SANG

Binh thtramg 116 s6 thanh thai = 2 ml/giay hoc 120 ml/phut.

Vi du: din tich da oda co th6 la 1,63m2, n6ng dO creatinin-huy6t la 90pmol, niang dO
creatinin trong mac ti6u la 15mmo1/1,6 lit.
Ta c6 U = 15/1,6 = 9,4 mmol/L. P = 90 Knol = 0,09 mmol/L, V = 1.600/86.400 =
0,018 ml/giay.
C = 9,4 x 0,018 /0,09 = 1,9 va Cc = 1,9 x 1,73 /1,63 = 2 ml/giay.
D6 therm do chic Wang loc cua cau than, chit therm do phai:
a
- Loc qua cau than dang, qua mang day mao,mach ma khong bi can tr6 nao ve
din tich va kith thuac phan dr, khong bi tai hap thu, bai tit them va bi6n during
6ng than.
- Khong gan ket \Teri protein huy6t tuong.
- Khong bi bien doi va bi chuy6n hoa nhanh hay du. trri a 6ng than.
Khong d0c, khong lam bien d6i chic nang than.
- De dinh Wong, chinh xac va re ti6n.
- Inulin, mannitol, creatinin, cystatin C... la nIding chat &roc chon, c6 HSTT =
120 ml/phut (= the tich nu& ti6u dau/phirt).
- V6i ure con phan bi'k:
+ Khi ltru ltrong nuOc ti6u > 2m1/philt (Cmax)
U.V
Cm
P
Binh thu6ng 60-100m1/phut, trung binh 75 ml/phirt.
+ Khi tau lucmg nuac ti6u < 2m1/plifit (C chuan)
U.V
Cs
P
Binh tludyng 40-70 ml/phut, trung binh 54m1/phirt.
Therm do char tieing tai hap thu cita ang than:
- Chat duce chon ngoai cac tinh chat tren (giong phan loc qua cau than), phai &roc
tai hap thu tr6 lai sau khi loc qua cau than.
- Ure, glucose, acid amin... thuang duoc dung de therm do chic nang tai hap thu,
cac chat nay c6 HSTT < 120 ml/phirt.
Therm do chic ming bai tiet caa ang than:
- Chat &roc chon ngoai cac tinh chat tren (giong phan loc qua cau than), sau khi
loc qua cau than phai dirge bai tit them a sting than.
- Acid hippuric, para amino hippurat (PAH), iodopyracet (diodrast)... thuemg
duot dung de therm do chile nang bai tik, cac chat nay c6 HSTT > 120 ml/phut.
- N6u xac dinh d0 thanh thai cua timg loai chat 1(6 tren thi c6 th6 danh gia drug
chic nang cua cat' than va 6ng than.

76
 CHLIO'NG 3 • HO' A SINH LAM SANG BENH LY THAN

Bang 3.4. DO thanh thai cua mot s6 ch6t

Chat C ml/phut C
U re 60 — 100 1,0 — 1,66
Creatinin 90— 130 1,5 — 2,17
Inulin 100— 130 1,66 — 2,16
PAH 400 - 700 ,64 — 11,62

, D6 thanh thai inulin, chi loc qua cau than, khong tai hap thu va kh6ng bai tiet
Ong than.
DO thanh thai cua ure, loc qua cau than, tai hap thu o Ong than.
DO thanh thai dm PAH, loc qua cau than, bai tiet them a 6ng than, kh6ng tai hap thu
6ng than.
Sau day la nhang thay d6i cua mot s6 d6 thanh thai trong mot s6 b'enh than.

Bang 3.5. Thay dOi ctila mot s6 do thanh thai trong mot s6 bOnh than

Do thanh Nfr Viem can than Viem Xo. cling

Nam
thai Man than, ding
(m1/ (m1/
phut) Cap Than Giai loan be than mach
phut) htr man than
cuoi

3.2. Tham d6 chipc nang bai tiet chAt mau

De danh gia kW. Wang bai tiet cua than, nguai to dung cac chat mau tiem vao cu the de
nghien cuu Su bai tiet qua than.

3.2.1. Nghiem phap PSP (phenol sulfo phtalein)

- Muc dich: tham do chirc Wang bai Wet dm than.
- Nguyen fac nhix sau: tiem tinh mach cham lml dung dich PSP 0,6%, lay =ere tieu
sau 15 phut, 70 phut de dinh him PSP.

77
 - Danh gia ket qua: chirc nang than binh thuemg, PSP bai tiet sau 15 phut la 25%,
sau 70 phut la 70%. Neu than suy, kha nang lac va bar tiet cila than bi rOi loan,
luong PSP bai tiet thdp hun.
- Can cha y loai trir twang hop co ,chtrang ngai bai tiet nhu sai than, u chen vao
nieu quan c6 the lam can tra den loi thoat nuac tieu cling nhu ap luc lac ciia than.

3.2.2. NghiOm phap bai tiet xanh methylen

- Muc dich: tham do chirc nang bai tiet cira than.
- Nguyen tac nhu sau: tiem tinh mach cham lml dung dich xanh metylen 1/20, theo
dOi mau nuac tieu tong khoang thai gian mot.
- Danh gia ket qua: chirc nang than binh thu?mg, sau tiem 30 phut nuac tier' se
nhuOm xanh, dinh cao vao gia tiler 3 - 4, sau do nhat dan trong ngay. Neu than suy,
su bai tiet xanh metylen se thay
• Bai tiet cham, keo dai nhieu ngay: viem than ke.
• Bai tiet som va nhieu: viem than ban cap.

3.3. Tham d6 chi:Pc 'fang co dac va pha bang r.r6,c tieu

Tinh linh hoat cua cac to bao iSng than la mot dac diem khi c6 nhieu nuac vao co the thi
nuac dugc dao thai nhieu nen nuac tieu bang, tST tong thdp (toi thieu la 1,003). Khi u6ng
it nuac thi luong nuac tieu it, tST trong cao. Khi to chirc than bi Van thuo'ng thi tinh linh
hoat nay kern di va c6 tinh trang clang ty trong. Khi 6ng than giam chirc nang (kem hap
thu cling nhu Wong bai tiet) thi ty trong bang nuac tieu lac a cdu than tire la 1,010. DO
la nguyen ly cua xet nghiem Volhard. Cach tien hanh torn tat nhu sau: benh nhan nam tai
giuemg 24 gia, truerc va trong Riot thai gian xet nghiem chi dimg co 500m1 nuac wing
con toan la thirc an dac, it nuac. Himg nuac tieu 3 gia mai ran va do tY trong do phai thay
doi luc cao lac thap, mire cao phai dat it nhAt là 1,025. Trong suy than (than xu, suy than
man) tY trong do thap duai 1.020 va c6 tinh tang dong t-ST trong thdp, chang to than &In
kha nang co dac. Ngiroc lai, trong viem than cap thi có tinh trang dong tY trong cao, chirng
to cau than bi ton thucmg de lot qua nhieu chat hoac Ong than bi ton thuong de nuac tham
tra lai qua nhieu, nen nuac tieu bi co dac.

3.4. Tinh Iu'u luvng t6 bao trong nu,6,c tieu

3.4.1. Xet nghiem can Addis

Tinh s6 luong cac thanh phdn hau hinh bai tiet trong 24 gia, can cu vao s6 luong nuac
lieu thu &roc trong thai gian 9 gia lien (thuang ldy mau tir 22 gia tai den 7 gia sang).

3.4.2. Tinh ILPU &ging to bao/phut: tinh luvng nuac tieu trong 3 gia' lien
Ket qua binh thuang trong mot phut: hong cdu: 500-1.000 to bao; bach au: 1.000-2.000
t6 bao; tru hinh: 1-3 tru.

78
 CHU'O'NG 310- HOA SINN LAM SANG BENH Ll% THAN

Trong viem cAu than, o giai doan diu Wang cAu c6 the tang 1-2 trieu, benh nhe:
30.000 t6 bao.
Trong h'Oi chirng than hu, h6ng cAu tang tir 20.000- 30.000 t6 bao.
Khi co the nhiem tang nieu, bach eau tang teen mot tri'eu.

3.5. Ket hqp cac xet nghiem khac

- Ure (BUN).
- Creatinin
- Acid uric.
- Dien giai do (Na, Ka, Ca, Cl...).
- Thang bang acid - base.
- Tong phan tich mac tieu.

3.5.1. Ure
Ure dirge tao thanh o gan. Gan la cu quan duy nhit tong hop ure tir NH3. Ure &roc dao
thai ra ngodi bang throng tieu. Binh thuang nong d6 ure-huyet tit 20 — 35 mg% va ure-
nieu tir 25 — 30 g/24gier.
BUN (Blood Urea Nitrogen) la nito cua ure trong mau.
28
BUN (g/L) =
60
Xet nghiem ure &roc chi dinh trong cac twang hop sau:
- Chin doan phan biet suy than throe than va suy than tai than vai tY s6 ure mau/
creatinin mau.
Ty s6 binh thuang tir 20-35
- Neu < 20: giam di h6a protein (nhap giam, suy dinh &fang, xa gan), giam tai
hap thu 6ng than (hoai tir cap).
- Neu > 35: tang nito do nguyen nhan tnxac than (tang thodi hoa do nhap nhieu
chit dam, ph6ng, set, xuat huyet tieu hoa...). Tang nito do nguyen nhan sau than
nhu tac nghen duemg tieu, giai doan cuoi cua suy than khi ure mail tang co nguy
co ng6 d6c, nhat la c6 xuat huyet tieu h6a.
Theo doi ket qua thim phan plific mac, chay than nhan tao.
Luu Y: ure mau tang khi GFR giam 75% tucmg ung khoing 30m1/phin.
- Benh truck than, niing dO creatinin mau binh thuemg, n6ng dO ure maxi tang cao
—> tY so ure/creatinin tang rat nhieu.
- Benh tai than, ure va creatinin mau deu tang, c6 the ure tang nhieu hon creatinin.
Phan biet xuat huyet do gan (vo. tinh mach thuc quail) va xuat huyet tir dtremg
tieu hoa (la& da day-ta trang). Trong benh gan NH3 tang, ure khOng tang; Nnh
throng tieu hoa ure tang, NH3 tang rat cao.

79
HOA SINN LAM SANG

3.5.2. Creatinin
Creatin dugc gan tang hop roi theo dung mau van chuyen den mo co, tai do creatin gan
a
veri phosphat dr ATP to thanh creatin-phosphat, met clang du tiff nang luting dung cho
co co. Chuyen hoa creatin-phosphat se tao ra creatinin, chat nay Ichong clinic co sir dung,
vao mau roi dao thai ra ngodi theo duOng tieu. Creatinin la thanh phan dam trong mau on
dinh nhat, khong phu thu6c vao the de an hoac nhirng thay crOi sinh 1ST khac ma chi phu
thuoc vao kha nang dao thai dm than nen hien nay dugc sir dung nhieu de theo doi chirc
nang than, coy nghia trong, chan down suy than hon xet nghiem ure. Luang creatinin nieu
khOng bi anh huang the tich nuac tieu dugc bai tiet hoac thirc
Chi dinh xet nghiem trong cac throng hop suy giam GFR, xet nghiem tong quat,
phat hien bat thuong nuov tieu, ,suy than, cap, man, tieu chay, non 6i, cao huyet tip, phu
nu CO thai, nhiem trong huyet, sew, da chan thuong, tam soot benh than, dieu tri thuoc CO
anh hung den than.
Gia tri binh thueing: creatinin huyet binh thuong < 1,5 mg%, thay doi trong mot s6
truong hop sinh, benh 1ST.
- Tang trong cac truOng hop sinh 1ST nhu tu6i gia (5%), dung thucic loi lieu (15%),
van deng nhieu (20%); tang trong benh 1ST nhu suy than cap, man, viem cau than,
suy tim, cao huyet tip, gut, cuong giap, leukemia.
- Giam trong cac throng hop sinh 1ST nhu dung thuoc chOng dOng kinh (10%), tre
em (20%); giam trong benh 1ST nhu benh ve co nhu liet, teo co.
Creatinin nieu binh thuong a nam giai thay d6i tir 1 -1,8 g/24gier, nu gioi thay doi
tir 0,8 — 1,2 g/24gier.

3.5.3. Acid uric

Acid uric thodi boa dr base purin, ciao thai ra ngoai bang doting dell. Binh thuOng
n6ng dO acid uric huyet dr 3 den 6 mg%.
Xet nghiem acid uric dugc chi dinh trong cac truemg hop:
- Kham tong quat (nhat la ngued gia), ngueri c6 nguy co benh mach vanh.
- Tien sir gia dinh co benh gut, benh soil than.
- Dot cap cua benh girt, theo doi dieu tri benh gut.
H6a tri lieu, nghien ruou, suy dinh du'dng.
Tang acid uric khi n'ong de acid uric > 7mg/d1. CO nhieir nguyen nhan gay tang acid uric.
- Nguyen phat: giam hypoxanthine phospho-ribosyl transferase (HPRT) gap trong
hOi chimg Lesch-Nyham (thieu hoan toan), hei chimg Kelly Seegmiller (thieu met
phan); tang hoot phospho-ribosyl pyrophosphate synthetase (PRPP synthetase).
- ThU phat: an nhieu purin, dung huyet, hoa tri, x4 tri lieu, thieu G-6-phosphatase,
suy than, doi thao clueing, cao huyet tip, nhiem acid, cuang can giap, nhuoc giap,
hoi chinig Down, hei chimg Butter.

80
 CHU'O'NG 3 ► HOA SINH LAM SANG BENH L11 THAN

3.5.4. 'fling Oar) tich nutic tieu

Ntrac tieu la dich bai tiet quan trong nhdt, trong do china phan lan cac chat can bd dm co
the. Phan tich nu& tieu thuong quy gem 2 nh6m xet nghiem, xet nghiem sinh hoa vai
que thir nhanh phat hien cac chat bat thtremg co trong ntrac tieu va soi can nieu phat hien
cac to bao, tinh the bdt thtfang.
3.5.41. X& nghiOm nu&c tieu bang que thCp nhanh 10 th6ng s6

Hinh 3.8. Que thir ntrtfrc tieu 10 thOng s6

1. pH 2. Ty trong (specific gravity)

3. Nitrit 4. Bach can (leucocytes)
5. Glucose 6. Ceton
7. Protein 8. Urobilinogen
9. Bilirubin 10. Mau (blood)
- tru diem dm xet nghiem que tit*: cho ket qua nhanh, nhay, re tien, ai cling lam
duce va lam 6 bat cir not nao.
- Nhucc diem dm xet nghiem que thir: ngodi ket qua duong tinh that, am tinh that
con c6 ket qua throngtinh gia, am tinh gia.
- Chi dinh dimg xet nghiem trong cac truang hop nhu nhi6m trimg duemg tieu,
benh suy than cap va man, theo &el chirc nang met se co quan va theo &el ket
qua dieu tri.
KST' thuat: mkt nu& tieu ttrai duac lay dimg each china trong binh kho, vo khuan.
Que dr* c6 cac vach chi thi mau, nhimg que tit* vao tupe china nu& tieu sao cho
ngap cac vach chi thi mau roi dem ra ngay, gat bo nuac tieu thira, doc ket qua.
De c6 &roc met ket qua tot phai chudn bi mau tit*: mau phai vo khudn, ldy dung each.
Soi can nieu: mau tit* phai tuoi, sach, chuan bi mau (long be, quy trinh phai thong nhat,
quan sat mau phu thuec vao ky /fang ngtrai doc.

81
HOA SINN LAM SANG

Tinh chit vat ly

S6 luting: trong 24 gi6 luting nuac tieu bai tiet tir 600 den 2500m1, s6 luting nay thay
d6i thy theo tu6i, gi6i, th6i tit trong nam.
Thay doi sinh VT: thy theo the dO an uong, Tong nuac nhieu thi fiat nhieu; thy theo
tiled bet, mita he tieu it, mita &zing tieu nhieu.
Thay d6i benh 1ST: tang trong benh dai thao du6ng, benh dai thao nhat, suy than man,
thoi ky h6i phnc sau vo nieu. Giam trong tatting hop sot cao, met nuac cep tinh (do tieu
chay), h6i chimg then hu (giai loan toan phat), suy then man (thoi lcST cu6i).
Mau va mui nuac tieu: nuac tieu mai ra co mau trong hoc hai yang nhat, threw tieu
c6 mui kha dee thit. Tithe an, thuoc, chuyen hoa chat, nhigm khuan lam thay doi mau sac
va mui. nuac tieu.

Bang 3.3. K6t qua tinh chat vat Ij/ ctila wag tieu va cac y6u to anh hue:mg

Mau sic Nguyen nhan benh 137 Thaw, va thirc pham

Phosphate nieu, lipid nieu,

Due
tang oxalate nieu,...

evodopa, metronidazole,
Nau sac to mat, myoglobin
antoin.
sac to mat, melanin,
Nat sam
moglobin
line (Elavil), indi-
anh la cay go carmine, IV cimetidine
NhiLl pseudomonas
•ac Tagamet), IV promethazine
nieu, biliverdin
anh duang (Phenergan), methylene blue,
iamterene (Dyrenium)
Phenothiazines, phenazopyri-
. (Pyridium
Dai mau, dai hemoglobin, tie Phenolphthalein, rifampin
myoglobin, porphyrin nieu • adin)

82
 CHUO'NG 3 00- HOA SINE/ LAM SANG BENH LV1 THAN

Bang 3.4. Cac y6u to lam xet nghiOm &pang gia va am gia
Kh qua Dtro'ng gia Am gia

azopyridine (Pyridium) Chlorpromazine (Thorazine), seleniu

at mac, tap the luc, tieu

Captopri capoten , y trong cao
moglobin, matt kinh, tie
, 2 ■, 4
5.1, lieu protein, vit. C

tt toati ty trong cao,

sna (Mesnex), phenolphth Xet nghiem nuac t
levodopa,

trong cao,

y trong cao, duang nieu, ceto

ieu, protein Dieu, mot so thuoc oxyss
Bach cau oa (cephalexin [Keflex], nitrofu-
antoin [Furadantin], tetracycline,
entamicin), vit. C

y trong cao, urobilinogen cao, nitrat;

iem khan, que thin ngo
vi khuan gram am khu, pH < 6.0,
"ng khi, phenazopyridin
itamin C

oc tieu Vern oac co ac, trot lieu acid hoac pha loung, pro-
-otein enazopyridine, bon phan ein nguyen Oat nhung khong phai
amoniac ke't hop nhau ti . albumin

Truyen dextrin, try „

t.1(,Ye tie,u e
thuoc can quang, protein nieu
Nong do nit 't, cao henazo
robilinogen ridine

83
HOA SINN LAM SANG 4110111011116,
Bang 3.5. Tinh chat vat ly va thanh pha'n hoa hoc dm nuac tieu
' Ty trop _:,. 1,003 — 1,03 1
pH 4,7 — 9 (trung binh: 6
The tich 600 — 2500m1
Chat vo co, (trong 24 gio-)
Clorua 10 (9 — 16)g
Natri 4g
Phosphat 2,2 (2 — 2,5)g
Kali 2g
Sulfua 2 (0,7 — 3,5)g
Calci.e 0,2 (0,1 — 0,2)g
Mag 0,15 (0,05 — 0,2)
Iod (50 — 150)µg
Chat hitu co (trong 24 gio)
Ure (25 — 30)g
Creatinin 1,4 (1 — 1,8)g
Amoniac 0,7 (0,3 — 1)g
Acid uric 0,7 (0,5 — 0,8)g
Acid amin, protein (0 — 0,2)g
Creatin, (60 — 150)mg
Cac chat hiru co khac (trong
Acid hippuric ,1 — 1)g
Base purin 10mg
Acid oxalic (15 — 20)mg
The ceton (3 — 15)mg
Alantoin 30mg
Indican (4 — 20)mg
Phenol (0,2 — 0,5)g
Coproporphyrin (60 — 280)gg
Acid ascorbic (15 — 50)mg
Ket qua xet nghiem h6a sinh ten que thin nhanh:
TS, trong: tSr le vai so hrong, ty trong, trong luting chat hoa tan trong nu& ti6u
(NT). Phan anh nong dO ion trong NT. Do tST tong gulp danh gia kha nang co
dac va pha loang cua than.
■ Nguyen tac: v6i six hien dien dm chat chi thi mau (xanh bromothymol), nong
de cac chat dien ly tao ra cac mau tit xanh luc — xanh la — yang nau.
• Binh thu6ng -EST trong nu6c tieu thay d6i tir 1.012 —> 1.020.
• Duai 1.012 lien quan vOi thira mr6c (suy chirc nang than, hei chirng aldoste-
ron), tren 1.020 lien quan thieu mrac (hOi chirng tiet hormon ch6ng bai nieu
khong thich hop).

84
 CHUCYNG 3 ID. HOA SINH LAM SANG BENH Ll! THAN

- pH: thay d6i tuy theo tinh trang sinh 1ST va benh 1ST.
• Nguyen tac do pH dua tren chit chi thi mau kep do methyl va xanh
bromothymol.
• K'y thuat cho nhang mau sac phan biet r'6 rang vai sir thay doi dm pH ta
5 --> 9.
• Binh thuang pH nu& tieu thay d6i tit 5,8 ----> 6,2
• Thay cloi sinh 1ST: an nhieu thit nuac tieu hai toan, an nhieu rau nuac lieu hai
kiem. Sau bia an, pH tang va nu& tieu hai kiem. Van (King nhieu ca bap c6
the lam nu& lieu hai toan.
• Thay d6i b'enh 1ST: kiem nhieu trong nhiem trang duang tieu, nhiem tang
than, nhiem trang bang quang do vi khuan sinh ra enzym urease phan hay ure
thanh amoniac. Toan nhieu trong roi loan chuyen h6a nhu dai thao clueing,
suy dinh duo'ng, nhin doi lau ngay.
- Mau (h6ng au, hemoglobin, myoglobin):
• Nguyen tac do dua tren hoat &Ong dm hemoglobin giong nhu peroxidase.
Gidy thin thuang bieu thi duai hai dang nhang Tam lam cham mau va su thay
d6i mau. H6ng cau tuai bieu thi tren o flat bang sty xuat hien ciia nhang lam
cham. Mat su hop nhat cac denn lam cham xay ra khi c6 tren 250 HC/ml.
■ XN.(+)gia gap a phu nir co kinh, tY trong NT cao, tap luyen Wang, mat nuOc,
vit.0cao,
lieu chat oxy-h6a.
• XN (-) gia khi co formaldehyd hien dien trong NT.
• Bat thuang khi c6 tieu mau, Hb, myoglobin. Can soi can ni'eu de phan biet
lieu do hang cau va Hb, myoglobin (tieu mau tir cau than hay duang tieu
cluai bang each nhan dang hang cau).
- Protein:
■ Binh thuang protein-nieu < 150 mg/24gia, cha yeti la albumin dm huyet
tuang. Protein c6 ngu6n g6c tir huyet tuang (chiem 60%) va -ta 6ng than
(chiem 40%).
Bang 3.3. Protein nreu trong mot s6 be'nh Iy

ProteinTP (g/24gia)

Albumin (mg/24gia)

p2-microglobulin (mg/24giel) 20
T so 2-micro(TIo/alb 20/22 # 1/2

• Cac 1c5T thuat xac dinh: so c16 duc, so Neu do mau, gidy nhang va may piaci
tich nuac tieu, clang kit rieng.

85
HOA SINH LAM SANG

• Giay thin nhay Arad albumin ham globulin, hemoglobin, protein Bence-Jones,
mucoprotein.
• XN (+) khi protein-nieu > 10mg/d1. Xet nghiem (+) gin khi NT kiem (pH
> 9), chat sat trang, chat tay rixa, tS7 trong NT cao, thuOc phenazopyridine,
PNC, tolbutamide, para-aminosalycylate, protein-nieu + tieu mau dai the.
Xet nghiem (-) gia: protein Bence-Jones.
Albumin nieu vi hromg: binh thuong 30-300mg/24gie% Dung k'S'T thuat mien ,
dich de )(de dinh, phat hien sam va theo dai bien chirng than ten benh nhan
dai did° duemg, tang huyet ap \To can, thieu mau ca tim.
Glucose: dinh hrong dua ten phan ung glucose-oxidase/peroxidase. XN nhay vai
hzong glucose 40-70mg/d1. Phan biet tieu throng do nguang than thap va DTD.
+ XN (+) gia: chat sat trong có tinh oxy-hoa manh.
+ XN (-) gia: Vit.0 (_? 50mg/d1), ceton 50mg/d1).
- Ceton: dinh hrong dua ten nguyen tac dm Legal, nhay vai acetoacetat han vai
aceton.
+ Xuat hien khi ca rOi loan chuyen hoa: DTD, suy dinh duOng, kieng an, nhin
doi, phu nu có thai.
+ XN (+) gia: NT toan, mau mac tieu dam, thuOc...
- Nitrit: kST' thuat dinh luang Griess, dua tren w ket hop gift acid sulfanilic va
ot-naphthylamin thong qua phan ung diazo hoa vai nitrit tao ra mau do azo. Binh
throng khong có nitrit trong NT.
• XN (+) khi lam nitrat -Ur 0,06 0,1 mg/dl: nhiern khuan nieu.
■ 3 yeu to anh huang den ket qua (+).
• SO luting vi khuan hien dien trong mau thin, vi khuan Gram am.
■ Su hien dien cua nitrit trong NT, so luemg nitrat du de vi khuan bien nitrat
- nitrit.
a
• Thai gian vi khuan ' tiep xac vai nuac tieu, thuong thai gian > 3,5 gia.
• XN (+) gia nhu da ban mail thin: lo chin., de nuorc tieu ngodi khong khi
qua lau.
■ XN (-) gia: vi khuan Gram throng, thai gian NT a bang quang < 3,5 gia, NT
toan (pH < 6), bang, Vit.0 cao >25mg/dl, urobilinogen.
- Bach cau (leucocytes): enzym esterase tir bach cL tiet ra thay phan ester indoxyl
acid carbonic indoxyl, indoxyl oxyd hoa muoi diazonium tao ra sari pham lam
thay doi matt sac (mau tim).
• Xet nghiem nay khong bi anh huang bai su hien dien cua vi khuan, tricho-
monas hoac hOng cau.
• DO nhay giam theo thai gian do su ly giai caa bach cL.
• XN (+) gia: nhiem khuan mau thin, formaldehyd va mau NT.
• XN (-) gia: tST trong cao, glucose-nieu (> 2 g/dl), protein-nieu (> 500 mg/dl),
vitamin C, thuoc (rifampin, nitrofurantoin...).

86
 CHU'ONG 3 Po. HOA SINN LAM SANG BENH Ll/ THAN

Bilirubin: phan img dga tren six ket hop bilirubin \Teri mu6i diazonium.
• XuAt hien trong ntrOc tieu khi c6 yang da fac mat tai gan, sau gan,
• XN (+) khi n6ng do > 0,4mg/d1. XN (+) gia: phenazopyridin. XN (-) gia.: vit.0
lieu cao ((? 25mg/d1), anh sang.
- Urobilinogen: xet nghiem dkra ten phan img Ehrlich (ket hop voi mu6i diazonium).
• XuAt hien trong b'enh 1ST Hb: thieu G6PD, tan huyet...
Tom lai khi sir dung que thir nuov lieu nen kat hop nhieu xet nghiem, vi du: dai thao
duemg: glucose-nieu (+), ty tong cao, pH giam, ceton-nieu (+).
Luau ld'y NT ngau nhien, tST trong giam, n6ng d'9 thay d6i.
• Viern au than: c6 lieu mau nen h6ng cau (+), protein-nieu (+), tST trong cao.
• Can phan biet ngu6n g6c lieu matt tir dau: au than, duemg tieu du6i...
• Nhi8M trang lieu: nitrit (+), bach au (+/-), protein (+/-), pH cao.
Lu-u dieu kien fay mau.
Vang da eac mat: bilirubin, urobilinogen...
3.5.4.2. Spi can nieu
nhan dien h6ng au, tinh the,... trong nu& lieu. ,
- Yeu au mau NT Mai, qui trinh mau dung va doc ket qua tot.
- Tim gi trong can nieu: HC, BC, tru nieu, tinh the, to bao bieu mo, vi khuAn,
men nam.
Nhan dien HC: tieu mau tai than hay sau than.
Lim ST cac loai tru nieu, TBBM da xac dinh vi tri, nguyen nhan.
Nhan dien cac loai tinh the a xac dinh loai soi.
Nu& tieu binh thiremg: it to bao bieu mo throng tieu, tinh truing (co the co), mot vai
tru trong tir 6ng than thoat ra, mot vai HC, BC da nhan.
- Tinh the: oxalat calci (tinh the c6 goc nhon), phosphat-amoni-magie (hinh nap
quan tai), cystin (co hinh luc fang), urat calci, Mg, Kali (vo dinh hinh)

87
HOA SINH LAM SANG

Hinh 3.9. Try ma

. Te bao !Dieu ma nhey

•

1.%941 4
r•• Te bao bleu ma than
PIS ALAI eh t';1 )1
...4.0101V441

Calcium Oxaft

Xuet hien b nutYc tieu bAt oil, pH nao

Amorphous phosphat
co khuynh hung xuAt hien trong nutyc tieu kik]

Hinh 3.10. Cac Ioai to bao va tinh the

88
 CHU'O'NG 3 • HOA S1NH LAM SANG BENH L)'' THAN

Triple phosp at Sulfonamid

Cholesterol

Leucin

Sulfadiazin

Hinh 3.11. M6t s6 tinh th6 khac trong niyac tieu

4. HOA SINH LAM SANG MOT SO BENH THAN

Viem cau than
Suy than cap
Suy than man
Viem cau than cap
Viem cau than man
Viem than ke
HOi chi ng than hu
Nhiem dOc thai nghen

89
HOA SINN LAM SANG

4.1. Viem cAu thOn

La mot qua trinh viem cua ceu then (va mo ke - 6ng then).
Ca the benh sinh cna viem au than
Kich thich c6 tinh khang nguyen

Dap irng mien dich gay viem than

Ten thuang do cac chit trung gian

Viem ceu than

Tieu mau Tieu dam Suy than

Trieu chung lam sang dm viem ceu then

Tieu HOi chung viem than
Tieu dam - H6i chirng then hu
Suy then 4 Suy then cep hoac suy then man.

4.2. Suy than cap

Suy then cep la six suy,giam d6t ngOt va tram trong chirc nang then, benh xay ra nhanh
chong nhung c6 the hoi phuc hoan toan. Trieu chimg lam sang not bat la vo nieu va ure
huyet tang cao. Benh chiem khoang 5% benh nhan nam vien tai khoa than. 60% nguyen
nhan suy than cep lien quan den phau thuat hoac ellen thucmg, 40% con lai lien quan den
thu6c hoac dOc chat.
Sinhl5T benh hoc: nguyen nhan 0'6 bin nhet dua den suy than cap la thieu mail than.

90
 -

CHU'O'NG 3 10- HOA SINH LAM SANG BENH THAN

Giam the tich mdu Co thdt mach Tang angiotensin II

Ton thuong cau then Giam mau den then Tang bai tiet renin

Giam GFR Hoai tir Ong then Giam tai hap thu Na

Tdc long Ong then

DOC to than

Vo nieu -4-- Them dich loc trO tai khoang ke

Suy than cap

' thudeng dijn tien qua 3 giai cloan:
Giai clop ddu thuerng -Ur 2-4 ngdy:
Tieu it (vo nieu hoc thieu nieu), lieu mdu, protein-nieu (+), ure va creatinin ink
bdt dk tang.
Giai doan suy then duy tri keo ddi 1-2 tudn:,
• Nu& tieu do due, chira nhieu dam yd. hong eau.
• Na+ -nieu > 40 meq/L. Creatinin-nik/huyet < 20.
• Ure va creatinin-huyet tang 10-20 ldn yd. tang 0,5-1 mg% m8i ngdy.
• IC-huyet tang 0,3-0,5 meq/ngdy —> 6-6,5 meq/L.
• Ne-huyet binh thuOng hay giam do phil.
• Phosphat-huyet tang: 6-8mg%, magie-huyet tang: 2-3 mg%, calci-huyet gidm
(6-9mg%).
• Uric-huyet tang 9-12mg%.
• NhiZm toan chuyen hod: ion II+ it dong lineq/kg/ngdy, bicarbonat-huyet giam
1-2meq/L ngdy.
Giai doan binh phuc:
• Ure ya creatinin-huyet bdt ddu giam.
• Nu& tieu tang lugng (2-3L/ngdy).
• Chile nang than tra lai binh thuOng, rieng chirc nang co ddc khong tro. lai
nhu cu.

91
HOA SINN LAM SANG

Phan biet suy than thuc the (tai than) vai suy than chic nang (truck than):
Nuac tieu: can nieu binh thuang, tY trong cao > 1.020, the tich nuac tieu =
500m1/ngay.
Luting Na-nieu < 20 meq/L (suy than thuc the: Na-nieu > 40).
- Ure-nieu > 166mmol va ure-nieu/ure-huyet > 10, (suy than thgc the < 5).
- Osmolality-nieu/Osmolality-huyet > 1,5 (suy than thgc the: 1,1).
- Creatinin-nieu/Creatinin-huyet > 40.
Chi clinh clieu tri phuc hai chew nang than.
1i dich ngay cang nhieu de doa phg phi cap.
- Tinh trang lam sang ngay cang x'au theo thai gian benh.
Kali-huyet tang > 7 mmol/L.
Nhiem toan nang: nang dO H+ > 70 nmol/L, pH < 7,15, nang do HCO3 < 12
mmol/L.
Ure-huyet > 35 mmol/L hoac tang > 16 mmol/m6i 24gia.

4.3. Suy thO'n man

Benh xay ra tit tg, cham chap, khi c6 hon 50% nephron bi tan thucmg, c6 nhieu nguyen
nhan khac nhau gay nen suy than man (viem au than, viem than Ice, hOi chirng than hu,
soi than, cao huyet ap, dai iliac, duang, thuoc ...). Benh tien trien ding dot, chirc nang
than giam clan, tinh trang nhi'em dec ca the ngdy cang tang, tien luting xau vi than khong
hai phuc.
Danh gia suy than man c6 the dua vao he s6 thanh thai creatinin: binh thuemg he so
nay la 2m1/giay = 120m1/phin, khi dO lac au than giam thi he se) nay se giam theo.
Neu he so giam con 0,83m1/giay: dau hieu bao ciOng thieu mau, cao huyet ap, teen
lam sang benh nhan hay nhgc dau, ch6ng mat. ,
- Neuhe. se giam 0,33 den 0,08m1/giay: c6 nhieu thay dai trong xet nghiem h6a
sinh. Leong nuac, mu6i, protid cung cap cho benh nhan qua khau phan an hang
ngay can dirgc kiem soat chat che.
- Neu he s6 giam tg 0,083 clan 0,016m1/giay: 95% nephron bi tan thuang, chi con
khoang 5% don vi than hoat dOng, phircmg phap chay than nhan tao, therm phan
phac mac dugc chi dinh.
Mot so
rai loan chuyen hoct trong suy than man:
- Albumin, protein toan phan trong mau giam, mgc de giam by thuOc vao luting
protein-nieu mat nhieu hay it.
- 1 J cac san pham dao thai niter huyet: ure, creatinin, acid uric mail.
Creatinin va acid uric-huyet tang do giam chirc nang lac cua cau than. Creatinin-huy6t
c6 the tang tir 2,5 den ten 10mg/d1.
Thong thuong a giai doan bao deng cua suy than, ure-huyet tang ten l Ommol, tang
theo mgc de suy than, ure-huyet c6 the tang tren 50mmol Khi ure-huyet cao, ure c6 nhieu

92
 CHU'ONG 3 ► HOA SINN LAM SANG BENH L).1 THAN

trong m6 hoi gong lai thanh phAn tren da, ure trong nuac bot Nen thanh amoniac trong
mieng lam cho benh nhan co mui nu& lieu trong ho'i tha.
Natri-huy& giam: mot s6 benh nhan suy than bai tiet rat nhieu mu6i trong mak
tieu, nguai to goi truang hop do la viem then mat mu6i (gap trong cac benh ten
thuang ong then nhu viem mo ke then, than da nang ...). Natri-huyet con giam
do non 6i, tieu chay, khau phAn an han the.
Kali-huyet tang: thuang a giai doan dau cua suy then kali-huyet it thay doi, neu co
là do sai lam trong dieu tri (khau phan an, thu6c...) hoec tan huyet co the lam cho
kali-huyet tang d6t ng6t. Kali-huyet tang, \Tao giai doan cu6i, giai doan co nhieu r6i
loan ve nuac, dien giai, r6i loan thang bang acid-base, tixong ung vai he s6 thanh
thai cua creatinin vao khoang 0,33 ml/giay.
Calci-huyet giam, magie va phosphat-huyet tang. N6ng d6 phosphat-huyet bat
dau tang khi c10 loc oda cau then giam khoang 25% so voi binh thuang. Phos-
phat-huyet tang lam giam neng d6 calci ion Ma trong mau, do do kich thich tuyen
can giap lam tang hormon tuyen can giap, hormon nay tacd6ng len ong then lam
giam hap thu phosphat va ten he Ktrang lam xuong matclan calci.
- R6i loan chuyen hoa glucid, lipid, protid
- R6i loan not tiet to tang twang (GH), tuyen giap (TSH, T3, T4), sinh due...
Ion El+ va nhiem toan chuyen hem: tinh trang nhiem toan trong suy then man do
kh6ng gift,ducc can bang in H+, cac san pham acid it lai trong co the. Binh thuang
than bai tiet moi ngay khoang 40-60meqH± do six chuyen hoa oda cac chat protein
c6 nhom sulfat, phosphat. Then suy chi bai tiet 2/3 khoi luong tren, trong mat so
triramg hop ion HCO3- ding bi mat ra ngodi theo duang lieu tren nhang benh nhan
suy than man.
Khi nhiem toan chuyen hoa, ca the bit tra bang each tang h6 hap de thai khi carbonic va
then thai ion 11+ trong nuac tieu duai dang phosphat acid (NaH2PO4) va amoniac (NH4C1)
nhung khong du. Tinh trang toan hoa mau nay throe goi la nhi'em acid chuy'en hoa.
Nuac tieu: phan lan cac nephron bi ton thuang nen mat so it nephron can lai phai hoat
d6ng bu tra, gay nen tinh trang loi nieu tham,thau, nuac tieu co trong thap 1,010,
tinh trang nay cho benh nhan tieu dem, tieu nhieu lan, kha nang co dec ntrac tieu
oh then khong con nth. Trong mac tieu co sg hien dien dm protein, glucose.
Nghiem phap tham do chirc nang then r6i loan.

4.4. Viern cau then cap sau nhigm lien cau khuan tre em
(sau viem hong 1-2 tuan do nhiem lien eau khuan).
Day la hien thong viem lan t6a, cap tinh xay ra a‘cau than. Thai diem tir
lien cau khuan cho den Mc cac trieu chimg viem cau then xuat hien thay d6i tir 1 den
4 tuan, trung binh la 2 tuan.
Tren lam sang trieu chimg not bet la phii mat, cao huyet dp, tieu it va tieu mau, dau
viing h6 then,...

93
HOA SINN LAM SANG

Can lam sang cho ket qua nhu sau:

Nu& tieu giup char' doan nhanh va chinh xac nhat, tieu mau c6 the dai the holac
vi the. The tich nu& tieu giam (300-500m1/24 gia), trong cao 1.020; mau
mrac tieu d6 dvc do c6 nhieu hong cau, try hong cau (chimg to nguyen nhan tieu
mau tai then); c6 the c6 bach cau, try bach cau khi c6 bien chimg nhiem trang
duang tieu tren; ngoai ra c6 tru to bao hat, to bao bieu mo, sgi huyet va protein
(thuang < 2g/24 gia,,cang c6 the tang cao tai 6-8g/24 gia).
Ure va creatinin-huyet binh thuang hoac tang. Tang ure:huyet vai tY trong nuac
tieu cao va bai tiet PSP binh thuang co nghla la viem cau than cap.
GFR giam.
Protein mau: binh thuemg ho4c giam, a2 globulin tang, dai khi tang f3 va
globulin.
Cholesterol va triglycerid-huyet c6 the binh thuang hoac tang.
Der heu: benh hen tri6n thuen lgi a tre em, 90-95% tre em binh phvc khOng de
lai di chi mg, trong khi nguai lan chi c6 khoang 50% dugc binh phvc. Thai gian
binh phvc tinning tir 2 den 3 tuan, cac trieu chimg lam sang giam bat, he so lac
cau then dugc cai thien, ure va creatinin-huyet tra lai binh thuang. Protein-nieu
va tieu mau c6 the mat dan tir vai tuan den mot nam.

4.5. Viem eau than man

Viem cau then man c6 the là bien chang caa viem cau than cap sau nhiem lien cau khuan
ho4c cua m6t benh toan than nhu lupat ban do rai rac. Sang thuang cha yeu a cau than la
viem nhiem va sau do h6a seo.
Tay theo truang hgp benh c6 the din tien nhanh (vai thang den mot nam) ho4c
chem (keo dai nam, muai nam).
B'enh co the,xuat hien can kich phat sau khi nhiem trang throng ho hap vai sir tang
ro protein-nieu, heti mau va giam chug nang then.
Benh thuang dien tin lien tuc a mac dO nhe, protein-nieu each qua'ng hoac lien tug
ho4c ngau nhien. Hong cau va try h6ng cau thinh thoing xuat hien hay keo dai hang nam,
chirc nang then binh thuong hay suy then rat chem. Ure va creatinin-huyet di the binh
thuang hay tang nhe.
So Wei viem then be than thi viem cau than man c6 nhilng giot lipid, try nieu to bao
bieu m6 va hong cau; protein-ni'eu ro han (hcm 2-3g/24 gia). Tien lugng kern hcm khi c6
su gia tang ure-huyet tuang ducmg.

4.6. Viem th#n ke

Viem than ke la h6i chi:mg do nhieu nguyen nhan khac nhau (nhiem trong va kh6ng
nhiem trong, ...) gay nen. Sang thirang chinh la cac phan ang viem trong mo ke (mo ke la
khoang each gala cac Ong than va khoang each gift cac 'Ong then vai cau then).

94
 CHU'O'NG 3 ► FIN SINN LAM SANG BENH Ll./. THAN

Benh tin trien tham Fang den suy than man vai hOi, chirng ure-huyet cao, tieu it,
thieu mau, có the cao huyet ap (nhung it han so vai viem cL than man) neu khong dugc
dieu tri nguyen nhan
Dien lien qua 3 giai doan: tieu it va hoi chi ng tang ure-huyet giai doan toan phat
(vai ngay den vai tuan), bai nieu tra lai va hoi phuc.
HOi chirng ure-huyet: ure-huyet tang trang ngay a giai doan dAu tir 8-10mmol (0,48-
0,6g/L) r6i c6 the dat 80-100mmol (4,8-6g/L); ure-nieu giam (clued 80mmo1/24 gig hay
4,8g/24 gig); Ca-huyet giam.
H6i chung nuoc lieu: lieu it,(duoi 400m1/24 gig), ure-nieu giam (duai 80mmo1/24
gig hay 4,8g/24 gig), dO tham that' dm nuac tieu thap han cua mau, Na-nieu cao (qua
80mmol hay 1.840mg), tST so Na/Ka han 1. TAt ca nhang trieu chirng do da6 ngugc
khi bai nieu tra lai.
Do nhieu lAn va so sanh nhung ntrac dien giai va acid-base, thAy trang thai
thira mac.
Moi nguy chu yeu la nhiem toan chuyen hoa gay tang kali-huyet (qua 6,5mmol/L
hay 6,5meq/L) do ten thuang cua 6ng than, ion 1-1± Ichong dugc bai tiet binh thuang de ket
hop vai NH3 Na2HPO4. Deng thai su tong hop NH3 cling giam, dieu nay cling can tra su
bai tiet W. Do do giam bicarbonat trong mau.
TAt ca cac trieu chirng c6 the giam neu dugc dieu tri nguyen nhan seam

4.7. HOI chi:mg thin hu'

1-16i chirng than ha gem tieu protein nhieu va keo dai lien tuc (ten 3g/24 gig), pro-
tein-huyet va albumin-huyet giam, a2-globulin-huyet tang, lipoprotein-huyet tang, b'enh
nhan thuang c6
- Nhung thay doi v6‘ Lac tieu: lieu it, lugng nuerc tieu bai Wet tuy thugc vao tinh
trang phu toan than. Protein-nieu thuang to 3-10g/24gia va keo dai,(Le Xuan
Truang: có tnrang hop protein-nieu tang cao 30, 40g). Co nhieu chat beo: hat
ma trong to bao bieu mo, tru ma, the luang chiet quang. Dien di protein-nieu:
protein chon loc, hat nieu...
- Nhung thay doi huyet twang: protein toan phan giam duai 50g/L. Dien di pro-
tein man: albumin giam <30g/L, a2 2 globulin tang cao (14g/L), (Le Xuan
Tnrang: a2 globulin tang 25-30%, albumin giam con 30-40%), y globulin giam.
Lipid mau tang: cholesterol tang, triglycerid tang. Rei loan chirc nang than nhe.
Albumin-huyk giam gay nen phit bang 2 cc,. chk
- Giam ap tham keo, gay that dich tit mau ra gian bao, có Wang quan ra ret giaa
mire d6 phu va Wong d6 protein mau.
Giarn the tich mau tuan hoan dua den viec tang tiet rennin, angiotensin va do do
tiet aldosteron tang hap thu natri a than. ngodi ra con có six tang tiet ADH khion
ca the gia Truck.

95
Tham do chiec ming than, có rdi loan nhe cac chtiv nang
Nhcmg thay d6i thin Oat do tang protein-nieu va giam albumin-huyet: Ca-huyet
giam, ceruloplasmin giam. Khi c6 Nen chi ng sang suy than man: ure, creatinin-
huyet tang cao, trong intik tieu c6 nhieu hong eau.

4.8. Nhigm dim thai nghen

Protein-nieu c6 the it hoc nhieu (tai 15-20g/24 gi6), tru nieu trong ya hat.
Ure, kha nang co dec ya bai tiet PSP cua then deu binh thuong, tru khi c6 benh
nang hoec c6 ton thucmg than tix tnrefc (ure-huyet tinging giam khi co thai do su
tang toe de loc cau then).
Acid uric thirOng tang (giam de thanh thai than cua urat).
Sau day là bang tom fat xet nghiem ntrac ti'eu trong met so benh then thirong gap.

The tich Protein Wing Bach rirt'

Ti.trong Try nre'u

■
(L/24 giii) (g/24 gib') cau cau ban
I Binh
thirOn
loi c1111111
6-2,5L
° 03
"030 Iw ng, sap, hat,
hu^
cau,
iem ng cau, scri
ca ach cau.
4-1 'a ten me), 1
•

cap ach cau, hat.

iaund --

ieni than
F Sri 11
11 P, , to bao
mu thtrol tang

Xa cimg
binh 11111thh at, trong
i;Ing mach
thtremg t *,

an 11111

96
 CHUO'NG 3 ► HOA SINN LAM SANG BENH Ll! THAN

Hinh 3.12. Phu bung trong hOi chUng than hu

a) Phi] 2 chi b) Phi] mat

Hinh 3.13. Cac clang phu thuOmg gap

5. GIOl THIEU MOT SO BENH AN

Benh an 1
Benh nhan nam, 67 tuei, 17 do nhap vien: met, phi]. 2 chan.
- Benh six: each nhap vien 1 thang, berth nhan tieu it, tieu tat nhat nhieu Fan, phii mat,
sau do phi' town than benh nhan met, kho the ngdy cang nang --> nhap vien.
- Tien sir: 8 nam nay thuOng xuyen tieu gat, fiat tat nhat, 4 thang nay phi'. 2 chan,
buon non.
- Kham: huyet ap 150/100mmHg, phil 2 chan, da xanh tai, tuyen tin Rt to, mat ranh
giaa, cimg, bar khong deu.

97
HOA SINN LAM SANG

- Xet nghiem: Cong thirc mau (HC=1.800.000, BC-8.000 (N:68%, L:30%),

TC=210.000/mm3)
Glycemia: 70mg%. BUN: 105mg%, Cre: 9,7mg%.
Nuot HC=25/ml, protein: 75mg%.
Dien giai: 144meq/L, 5,8meq/L, Ca2+: 2,3meq/L; Cl-: 112meq/L, CO2 cont:
8,4meq/L (lAn 2: Nat: 145, K+:5,1; Ca2+: 2,8; C1: 112, CO2 cont: 10,9meq/L).
Chan cloan xac clinh: Doi cap cact suy than man /K tuyi1/2 tin

13011 an 2
Benh nhan nit, 45 tuoi,1y do nhap vien: cao huy& dp
- Benh sir: cao huy& ap 3 nam nay: 20-25/10-16 mmHg -> nhap vien.
benh nhan gay xanh, da kho nhot nhat, tim có am tit& tam thu =3/6, mat
giam thi luc, nhirc dau tirng dot.
Xet nghiem: cong thirc mau (HC=1,3trieu, BC=8.000 (N=75%, L=10%, E=15%),
TC: 218.000/mm3).
BUN: 44mg%, Cre: 8,3mg%, CO2 cont: 19meq/L.
Dien giai: Ian 1: Na: 134meq/L, K: 2,6meq/L; Ca: 4,8meq/L; Cl: 96meq/L. Lan
2: Na: 128meq/L, K: 6,5meq/L; Ca: 3,5; Cl: 91meq/L. Lan 3: Na: 136meq/L, K:
4,4meq/L; Ca: 3,3meq/L; Cl: 97meq/L.
Chan clam xac clinh: Suy than man /Cao huyet ap/Rai loan clie'n giai.

Benh an 3
Benh nhan nix, 44 tu6i, 1ST do nhap vien: phu town than
Benh sir: each nhap vien 3 thang, dOt ng'Ot phu town than, ti'e'u it # 500m1/24gief,
nhap vien.
Kham: HA = 180/90mmHg, phu town than.
Ke't qua xet nghiem: CTM (HC = 1,8trieu, BC = 9600 (N: 74%, L: 25%,
TC=320.000/mm3).
NT: alb: 1430mg%, can nieu: HC: 200, BC: 500/4
BUN: 118mg%, Crea: 5,4mg%, xet nghiem phan: giun moc (+).
Protid TP = 4g%, lipid = 1833mg%, dien di protein: alb: 41%, a2 glo: 24%.
Chan
i clocin xac clinh: suy th(m/HCTH.

98
 CHU'O'NG 3 ► HOA SINH LAM SANG BENH LY THAN

Be'nh an 4
BLh nhan nir, 40 tu6i, ly do nhap viL: met, phu toan than.
BLI1 sir: 10 ngay truot nhap viL, bLh nhan phu chan, phu toan than, met, nhirc
dau, ch6ng mat —> c6 diL tri bac si nhung khong giam nh4p viL.
TiL sir: 2 nam tar& cao huy& ap, phu chan.
Kham: phu toan than, huy6t ap = 170/90mmHg, thi hyc gia'm can 8/10.
Ke't qua xet (cong thirc mau: HC = 2,3triL, BC = 16.500 (N: 71%,
L: 22%), TC = 230.000/mm3)
BUN: 143mg/d1, Crea: 15,9mg/dl, protidTP: 6,4g/L.
DiL giai: Na: 140meq/L; Ka: 6,7meq/L; Ca: 4,4meq/L; Cl: 101meq/L.
Chan cloan xac Suy than man /Cao huyk ap.

14nh an 5
BLh nhan nam, 30 tu6i, VT do nhap viL: phis toan than.
BLh sir: 1 nam truck bLh nhan bi hOi chirng than hu, diL tri khong tot tad
phat nen nhap
K6t qua xet din di protein-huy6t: albumin 32,6%; a2 globulin: 17%.
Cong thirc mau: HC:3,4 triL; BC: 5.800 (N:68); TC: 300.000/mm3.
BUN: 7,1mg%; Cre: 1,8mg%. Can Addis: HC: 500; BC:550/phitt.
Protein-niL: 6.140mg/d1, lipid: 856mg/dl.
Chjn dam xac clinh: Hai cluing than hit tai phat.

A. CAU HO! TI1 LU'VNG GIA

1.U ngtriri truo'ng thanh khoe monh, tong lu•gng cua thOn Ong:
A. 100g B. 150g C. 250g D. 300g
2. Ve co' the hoc, ting gap Wain r vi tri nao sau day:
A. V6 than B. V6 Ira toy then C. Thy then D. Be than
3. Trong nghi:On phap bai tit xanh methylen, ntrav tieu se nhuOm xanh, dot dinh
cao:
A. 30 phut sau tiem B. 1-2 gier sau tiem
C. 3-4 giifr sau tiem D. 6 gio sau tiem

99
HOA SINN LAM SANG

4. Nghiem phap Volhard:

A Tham do chirc nang co ac va pha loang nugc tiL
B. Tham do chlic nang bai tiet chit mau
C. D6m s6 lugng t6 bao /phut
D. Danh gia Milt 10C cdu than
5. Cie nguyen nhan sinh 1ST sau day lam tang creatinin mau, ngo0 trir:
A.Tu6i gia B.Vdn dOng
C.Thu6c lgi tiL D. Thu6c ch6ng dOng kinh
6. Que di* mak deli 10 thong so XN protein nhay vo'i chit nao sau day nhit:
A. Albumin B. Globulin C. Hemoglobin D. Protein Bence Jones
7. Ceton nieu &rang tinh trong cac benh sau day, ngoai trir:
A. DTD B. Suy Binh duang C. Phu nu c6 thai D.Cuemg tuy6n Op
8. Xet nghiem nitrit dulyng tinh trong cac benh sau:
A. Nhi6m khuan B. Nhi8M khudn Gram clueing
C. Nhigm khudn Gram am D. Virus
9. Xet nghiem nitrit am tinh gia g4p trong cac trirOng hyp sau:
A. Nhijm khudn Gram duang
B. Th6i gian nuac tie'u hm 6 bang quang < 3 giO
C. Mau thir d6 lau ngoai khong khi
D. Chi co A va B dung
10. De xet nghiem nitrit throng tinh, yeu au mau thin:
A. Nu& ti'L luu trong bang quang > 3,5 gio•
B. Lugng nitrat du nhiL a phan ling ducmg tinh (nitrat -+ nitrit)
C. Lugng vi khudn Gram am hiOn din trong nu& ti'L nhiL
D. Tit ca. dling
11. Dieu nao sau day khong dung trong hOi chfrng th4n Mr:
A. Ure va creatinin mau tang
B. DiOn di albumin giam, a2 globulin tang
C. Dam trong nuac tiL rat nhiL
D. Phil

1 00
 CHLIO'NG 3 ► HOA SINH LAM SANG BENH LSI THAN

12. Dich ban trong mang bung benh nhan bi hoi chirng than hit':
A. Dich them
B. Dich tier
C. Co nhieu hong au
D. Co nhieu duang trap
13. Ket qua dich Wet co protein nieu (+) nhung phan thig rivalta (-), giai thich dieu
nay:
A. Ket qua lam sai
B. Co the g4p khi protein nieu c6 pilau -lir lugng nh6
C.A va B dung
D. Giai thich theo mot y khac
14. Dieu nao sau day dung trong benh hoi cluing than hu tre con:
A. Chii yeti là dang sang thuang t6i thieu
B. 50% chuyen sang suy than man
C. Trong nu& tieu c6 nhieu hOng au va protein
D. Ure va creatinin mau tang cao
15. Cac ion nao sau day thuirng giam trong mau teen benh nhan bi h6i chting than ME
A. Natri, kali B.Natri, clorua C.Kali, magie D.Calci, natri
16. Khi he s6 thanh thai cue creatinin = 0, 166 —> 0,083 ml/giay, tuo•ng
A. 50% don vi then bi ten thuang
B. 65% dan vi than bi fan thuang
C. 80% don vi then bi ten thuang
D. 95% dan vi than bi tem thuang
17. Xem la suy than man khi:
A. > 30% den vi than bi ton thuang
B. > 50% dun vi than bi ton thuang
C. > 70% don vi than bi ten thuang
D. > 80% den vi then bi tem thuang
18. Str khac biet gitla h6i chting than hu voi suy than man:
A. Trong nuac tieu khong c6 h6ng au 6 h6i chimg than hu.
B. Trong nuac tieu co hOng au han a h'ei chimg than hu
C. Protein va hong au trong nuac lieu 6. 2 benh kh'Ong khac biet
D. Ty trong nuac tieu trong 116i chimg than hu cao han suy than man

101
HOA SINH LAM SANG

19. Trong soi than, soli loci acid uric chitin tjTle khoang:
A. 2% B. 6% C. 16% D.23%
20. Xet nghiem nao sau day giup phat hien Rim thieu man nuoi than trong cac pilau
thuat co ho tro tuan hoan ngoai co. the:
A. MPO B. PLGF C. Creatinin D. NGAL
21. The sang thtro'ng t6i thieu trong hoi cluing than ha nguiri chiem t-ST le:
A. 5% B. 10% C. 20% D. 25%
22. So voi suy than man, the sang thtivng toci thieu trong hoi cluing than Mr
A. Ure va creatinin mau tang cao han
B. Ure va creatini mau tang nhung thap han
C.Ure tang cao nhung creatininmau khong tang
D. Ure va creatinin mau khong tang
23. Diu hien vop be thuirng gap trong benh nao sau day:
A. Viem cau than B. Suy then cap
C. Suy then man D. MI chimg than hu
24. Nhiing chit nao sau day luon of) hien dien binh thikeng trong nu& tieu:
A. Glucose, ure, creatinin
B. Protein, ceton, acid uric
C. Ure, creatinin, acid uric, hemoglobin
D. Khong cau nao dung
25. Chon eau dting doi vbi microalbumin-nieu, duvc goi la duvng tinh khi:
A. Co xuat hien protein trong luang phan M. rat nho trong nuo.c tieu
B. Xuat hien albumin trong nude tieu xac dinh dixac bang phuong phap dUng giay
nhUng nuac tieu 10 thong so
C. Xuat hien albumin trong nuac lieu voi ham luang 30-300mg/24 gio
D. Xuat hien albumin trong nuefc tieu voi ham luang < 30mg/24 gief
26. NH3 dOc doi voi cac mo, nen dime chuyen hoa thanh khong d'Oc:
A. Glutamin B. Acid amin C. Glutaminase D. Acid a-cetoglutamic
27. Khi ure mau = 0,32g/L thi tri s6 tturng duong ciia BUN vao khoang:
A. 0,16g/L B. 0,32g/L C. 0,64g/L D. 0,32mg%

102
 CHLICYNG 3 lo• HOA SINE/ LAM SANG B6NH LY THAN

B. CAU HO! NGHIEN CAT

1. Nghi den benh gi khi ket qua xet nghiem met ngueri trong mrac tieu co nhieu protein
(4,5g/24 gi6) va trong mau dien di albumin 34%, a2-globulin 29%? Sau nhieu dot
dieu tit ket qua xet nghiem On day nhAt,6 benh nhan tren c6 ure va creatinin-huyet
tang cao, nuac tieu co nhieu protein va h6ng du. Nghi den benh gi a benh nhan khi
chi doa vao cac xet nghiem hoa sinh?
2. Nghi den benh gi khi met be gai 13 tuei co cac tri'eu chimg nhirc dAu, chong mat, sung
meng mi mat sau buoi,sang ngii day, m6i khi di tieu co dau hieu lieu bunt, gat; xet ng-
hiemmrac tieu c6 nhieu hong cau (++), tru hong cau (+) va protein-nieu (250mg%)?
Sau died gian dai dieu tri xet nghiem g'an day cho ket qua ure va creatinin-huyet tang
cao, nix& tieu co nhieu protein va hong cau; c6 the nghi den benh gi a benh nhan khi
dira vao ket qua cac xet nghiem hoa sinh tren?
3. Met benh nhan 65t, nhap vien vai tri'eu chimg di -lieu nhieu l'An,,mei fan tieu c6 &Au
hieu tieu buet, gat, benh xay ra trong suOt 3 nam qua. Kham thay‘tuyen lien litto,
mat ranh bey ran chac; xet nghiem mac tieu c6 protein (+), hong cau (+); trong
mau c6 ure va creatinin-huyet tang cao. VIM ket qua dm cac xet nghiem tren cho phep
to nghi den benh gi tren benh nhan nay?

103
 Chu'o'ng 4
HOA SINH LAM SANG
BENH LS' GAN MAT
MUC TIEU
1. LiOt ke claw mot s a char tieing chinh cfia gan.
2. LiOt ke claw cac xet nghiem clanh gia char Wang suy giam t" bao gan.
3. LiOt ke dtcor cac xet nghim danh gici ch&c nang hay hoai to bao gan.
4. Liet ke &coy cac xet nghiOm clanh gia chic nang rai loan 'long mau.
5. Phan bityang da trtrac gan, tai gan va sau gan bang cac xet nghiOm h6a sinh.

1. SO' LUVC GIAI PHAU HE GAN MAT

Gan la mot nei tang lan nhat, chiem 2% than trong. Gan Om 4 thity: thity phai, thity trai,
thity vuOng, thity clued, hop thanh tir vo so cac lieu thity (TT).
Tieu thity la don vi ceu tao chirc nang cua gan. M'Oi TT la 1 to chirc dang khei, ranh
giai la lap mo lien ket va he tuan hohn (TH) hop thanh bO 3 dm tinh mach dm, &Ong
mach gan, Ong den met. 75% Kiang mau den gan la tir he tinh mach dm, 25% tir dOng
mach gan.
Te bao nhu mo gan chiem 60% khOi luang gan, la nhi'mg dai to bao dOng tam, bao
quanh la nhang khoang lien ket, cac to bao nOi bi: to bao Kupffer.
Te bdonhu mo gan c6 kha nang hOi phuc tai sinh cao, dap irng cac vai trO rat da dang
cua gan.
, Gan là mot co quan quan trong dong vai fro tich cuc trong qua trinh chuyen h6a cac
chat. Gan c6 nhieu chirc nang:
Tuen hoan: du tilt mau, dua mau tir he tinh mach cfra,— he tunhoan chung.
Huyet hoc: tao mau thai bao thai, san xuat cac yeu to dong mau: fibrinogen,
prothrombin...
Bai tiet met xuong runt, bao ve va khir dOc.
Chuyen h6a glucid, lipid, protid vai mot he thong enzym rat phong phit.

105
NC:A SINH LAM SANG

1.1. So' Iu'o'c ve he gan mat

Gan phai
Gan trai
TM TM vi trai
dra
Day chang tr6n
TO mat TM vi mac
not phi TM vi ph5i
Thiry duoi TM gan trai TM chu
TM mac
treo trang
TM lach
trOn

TM mac treo
trang du'&i

TM cira
DM
gan Thiry Ong
vuong mat Tui
chu mat

Hinh 4.1A. Giai phgu hoc cua gan Hinh 4.1B. HO tinh mach gan

1.2. Ceu tao vi the to bao gan

Tieu thily gan Nhanh TM

011/11;1•
TB deing tam
TM trung tam Ma lien ke

TM trung tam

Hinh 4.2. C'au trOc vi th6 cua tieu they gan

106
 CHUONG 4 10- HOA SINH LAM SANG BENH L).' GAN MAT

IR thong bai tie't mat: mat tao thanh tip cholesterol a gan, sau do theo vi tieu quan
mat d6n Ong mat lien tieu thity 4 Ong gan trai, phai 'Ong gan chung (4 tai mat4 Ong tai
mat) 4 Ong mat chia 4 td trang.

Gan Ong mat gan phai

Ong mat
Tui mat _ gan trai

Caing
tui mat

Ong mat chia

Ta trang

Ca yang
Da day
oddi

Bong Vater

Tuy
Ong tuy

Hinh 4.3. WO city&ng mat

2. CHIJ'C NANG HOA SINH CUA GAN

Gan c6 nhang chirc nang sau:
Chirc nang glucid, chic Wang lipid, chirc nang tao mat, chirc nang khir dac, chirc
nang (tong mau, chirc nang du frit chat, chirc nang khac.

2.1. ChCrc nang glucid: gan co vai tr6 trong di6u hoa du,6,ng huyet
Gan tang hop glucose thanh glycogen, khi glucose mau >1,2g/L gan giam san xuAt glucose,
tang tong hop glucose thanh glycogen du tril, do do giam six giai phang glucose vao mau.
Gan phan ly glycogen thanh glucose, khi n'ang do glucose trong mau giam tad 0,7g/L,
a
gan tang cuong six pilau ly glycogen tao thanh glucose cung cap cho maw Gan c6 th6
tao glucose tu do nha c6 enzym glucose 6 phosphatase trong khi ca khong c6 enzym nay.

107
HOA SINN LAM SANG

Ngtedei ta dung nghiem phcip tang glucose huy& de clanh gia chac Jiang du trie glucose
caa gan.
Cho Nnh nhan nhin doi, u'Ong glucose lg/lkg co th6. Lay mau dinh luting glucose
truac khi uOng, sau do cur 1/2 gio lay mau dinh luting glucose, lay mau trong yang 2 -
3 gier. Binh throng glucose trong mau tang 1,50g/L trong yang nira gief roi giam dan,
khoang 2 giey ru'ai sau thi ha dan r6i trey ve binh throng sau 3 gier.
Gan giam chile nang du tilt, clueing huye't sau 2 gio tang cao nhtmg giam rat nhanh.
0 nguoi b'nh dai thao throng, luting glucose trong mau cao han va trey ve binh thirOng
chdm hon.
Gan tong hop glucose va glycogen tit cac monosaccarid khac nhu fructose,
galactose, ...
Nguoi ta lam nghiem phap galactose nieu de tham do char nang tang hop caa gan:
Cho b'nh nhan tieing 40g galactose, sau do lay nuac ti6u 2 gio. dau, 2 gier tip theo,
6 gik 14 giey va dinh luting galactose O. cac thoi di6m do. N6u gan binh throng thi ltrang
galactose trong nuarc fiat thap, neu gan suy thi galactose bi thai ra mac tie'u nhieu.

Bang 4.1. Ham luvng galactose dao thai binh thuVng va benh ljt trong nghiem
phap galactose nie'u

Xo: gan Xo gan

Thai gian Binh thtrerng Viem gan
(chtra co chtning) (c(5 chmfmg)

Gan tong hop glucose va glycogen tit pyruvat, lactat, acid amin qua oxaloacetat tao
thanh phospho enol pyruvat --> F.1.6 Di P F60—> G60 —> Glucose —> Glycogen.
Gan tong hop glucose tao thanh lipid: thoai He glucose cho pyruvat tao acetyl CoA.
Acetyl CoA la nguyen lieu tong hop acid beo, tong hop triglycerid.

2.2. Chin nang lipid

Thoai hoa:
Gan ld nai chit y6u thoai hoa p oxy Ha acid beo cho nang luting ca th6 sir dung.
Gan la nai cung cap cac the ceton (aceton, a.acetoacetic, acid R hydroxy butyric)
cho mau chuyen toi cac mo sir dung. Tai cac mo, cac the ceton lai chuyen hOa tao
thanh acetyl CoA dOt chay trong chu trinh Krebs cho CO2, H2O va nang luting cho
cac mo sir dung (nit& la mo nao).

108
 CHU'O'NG 4 ► HOA S/NH LAM SANG BENH LY GAN MAT

Tang hop:
Gan tong hop phospholipid (phosphatid) van chuy6n ma ra ,khoi gan, lam ma
khong bi dong gan. Khi gan bi ten thucmg nang, kha nang tong hop phosphatid
giam, clan tad gan nhiem ma.
Gan tong hop cholesterol tir acetyl CoA, trong gan lai xay ra qua trinh este hoa.
Do vay khi gan ton thucmg, to bao gan bi suy:
Luting cholesterol este (CE) bi giam nhieu,
11 Cholesterol toan phan (CT) có the giam, binh thuong hay tang do bu trir
Nhung ty se CE/CT: hien luon giam
11 Binh thuang ty le nay la 2/3 (65% - 70%) neu ty le nay giam: gan bi ten thuang.
Gan san xuat acid mat tir cholesterol.
Noi Chung gan tong hop tat ca lipid: cholesterol, cholesterol este, triglycerid, phos-
phatid, HDL, LDL, VLDL. Do do gan 'Jong vai tro quan trong trong chuyen hoa va van
chuyen lipid.

2.3. Chirc nang protid

Qua trinh trao del va khir amin xay ra manh me a gan, enzym hog dong manh nhat la
GOT (AST) va GPT (ALT). Khi to bao bi hoai tir thi GOT, GPT tang cao.
Gan có kha nang tong hop ure dr NH3, khi suy gan nang thi NH3 tang cao trong mau
(ure giam).
Gan tong hop toan be albumin va met phan lan globulin cung cap cho huye't Wong.
Khi gan suy, nong de albumin trong mau giam.
Ring hop nhang protein phan ung trong giai doan cap: haptoglobin, a- 1 antitrypsin,
CRP, C3,...Tang trong dap ung cac chan thuang dm m6.
Cae xet nghiem danh gia• dinh luting AST, ALT, NH3 mau, dinh luting protid mau,
albumin mail, tY s6 A/G. Ty se nay binh thuang thay dei tir 1,2 —> 1,8. Dien di protein
huyet thanh xac dinh the thanh phan albumin, globulin al, globulin a2, globulin (3, glob-
ulin y Dinh luting CRP, C3 trong man.
Nhan dinh:
Khi protid mau giam nhat la albumin giam thuong gap trong viem gan cap
hay man, dac biet viem gan man la chan doan quan trong (albumin giam,
globulin y tang).
Globulin mau tang trong truemg hop nhu ma gan ten thuong nhat la so thay dei (3
va a2 -globulin la quan trong trong nhang benh nhan bi viem gan tai phat.
Khi ty albumin/globulin < 1,2 tien luting va tintrien benh xau trong qua trinh
diet' tri.
Phan ung Gros va Mac Lagan (+) khi gan bi ten thucmg.

109
HOA SINH LAM SANG

2.4. Chirc nang tao va bai tiet mat

Gan la not duy nhat tong hop acid met tir cholesterol va mu6i met tir cac acid mat.
Tao sac to mat (bilirubin TT) tir bilirubin GT:
• Tai gan bilirubin GT dirot gan 1 hay 2 g6c a.glucuronic —> bilirubin TT —4
6ng den met trong xu6ng runt non.
• Neu diremg clan met N tac nghen, bilirubin TT —> vao mau bai tiet ra mac tieu.
• Tai tao bilirubin TT tir urobilinogen:
• Bilirubin TT theo met d6 vao met non, tai met bilirubin TT dirge vi khuen
diremg runt —> urobilinogen.
• Met phan urobilinogen dirge tai hap thu tro ve gan qua TM dm Tai gan phan
1O.n urobilinogen nay bi oxy h6a tai tao biliGT —+ bili TT —> dO vao met, met
so it thoat vao tuan hoan va thai ra ngodi throng tieu dual dang urobilinogen,
va bi oxy hoa trong khong khi Wen thanh urobilin.
• Met phAn urobilinogen theo phan ra ngoai clued dang stercobilinogen, va ster-
cobilinogen N oxy h6a bien thanh stercobilin.
Tac dung cua mu6i met: WI tircmg hoa chat beo tix thirc,an bang each lam giam sire
cang be met oda chat beo va tang din tich tiler) xiic oda chat beo voi enzym lipase, de
a
enzym lipase clang thily phan triglycerid.
Bai tiet met: lien toc tir to bao gan, gian doan trong cac bfta

2.5. Chirc nang khir dOc

Gan (Tong vai trO chu yeti trong viec ch6ng chat dec nOi sinh.
Qua trinh khir dec c6 the chia lam 2 giai doan:

2.5.1. Co Binh Ira thai tn.)

Met s6 ion kim loaf (mu6i cl6ng, chi...) cac chat mau (clan xuat phtalein) vao co the bi gan
gift lai r6i thai trir nguyen von ra met. Ngirai to dung cac nghiem phap sau de tham do
chirc nang khir dee cua gan:
- Nghiem phap Bromo Sulfo Phtalein (B.S.P).
- Nghiem phap h6ng Bengal (Rose Bengale).
- Nghiem phap xanh Indocianin.
Trong do nghiem phap BSP la ph6 bien nhat: tiem 5mg BSP/kg co the bang dirang
tinh mach sau 15 phitt, 30 phut, 45 phut, 60 phut lay mau dinh lugng BSP. Binh thtrang
gan gift BSP lai de thai qua met nen hremg BSP trong mau giam nhanh, sau tiem:
+ 15 phut BSP con 25%
+ 30 phut BSP con 15%
+ 45 phfit BSP cOn 5%
+ 60 plifit BSP con 0%
Neu b'enh nhan bi suy gan thi s6 hrcmg nay se tang len.

110
 CHUCYNG 4 00- HOA SINN LAM SANG BUNH LY GAN MAT

2.5.2. KW, c10, c h6a hoc

Chat d6c not sinh, ngoai sinh bi thay d6i cdu tao hoa hoc thanh chat khong d6c r6i thai ra
ngoai qua duemg mat hay duemg tieu.
Nghi'em phap Quick (nghi'em,phap gay acid hippuric nieu):
- Muc dich: tham do ca the khir d6c Ma hoc cua gan.
- Tien hanh: cho u6ng 6g Na benzoat, sau 4 gier lay nuarc lieu dinh luting acid
hippuric.
- Danh gia ket qua:
• Chirc nang gan binh thuong: acid hippuric bai tiet > 3g.
• Gan suy: luting acid hippuric giam di nhieu. Six thanh thai phu thuOc vao: luu
luting mau cua gan. Six thong su6t cna dtrong mat.
Chirc nang cna to boo gan:
Bien NH3 thanh ure: la qua trinh khir d6c thuamg xuyen cna co. the.
Bien H2 02 thanh HBO do tac dung cna catalase: day ding la mot qua trinh khn d6c
thuamg xuyen cua ca the.
Khir d6c bang oxy hoa:

CH3 - CH2 - OH --=21—>

i CH3 - CHO 1/20' > CH3 - COOH
Alcol ethylic Aldehyd acetic Acid acetic
CI Khir d6c bang phan img klin (+2H)
Chirc aldehyd va ceton bi khir cho alcol
CI 2H C1 \
\
CI —C —CHO s CI —C —CH2OH
Cl ' / Cl

Chloral Treloroethanol

0 KIM d6c bang methyl hoa: là qua trinh ph6 bien trong co' the:

,NH2 CH3 / NH2

HN= C\ HN= C\
NH - CH2–COOH N–CH2 COOH

CH3
Acid guanidoacetic Creatin

111
HOA SINN LAM SANG

❑ Khir dOc bang cach lien hop: lien hop vai glycin:
Vi du: acid benzoic (d0c) lien hop vai glycin qua trung gian benzoyl CoA
to thanh acid hippuric (khong d6c).
Lien hop vai sulfonic: cac chat dOc phenol, indol sinh ra trong qua trinh th6i rira o runt
dirge hap thu mit phan qua gan roi dao thai ra nu& tieu o clang mixed kiem dm este
sulfuric.(R-O-S).
Lien hop glucuronic: rat nhieu chit dirge dao thai ra nuac lieu duai dang lien hop
glucuronic. Vi du: phenol, alcol therm, alcaloid, steroid dao thai duai clang lien
hop nay.
Bilirubin + acid glucuronic Bilirubin lien hop
Phenol + acid glucuronic –+ Acid phenyl glucuronic

2.6. Chic 'fang clang mau

Gan tong hop nhieu yeu to &Ong mau: fibrinogen, prothrombin, cac yeu to ang mau
khac: V, VII, IX, X, ...
T6ng hop plasminogen —> plasmin tac dung len fibrin tan cuc mau &Ong.
Do do gan ccing &rig vai tro quan trong trong qua trinh cam mau.
Khi bi b'enh gan Ong gan suy nhting r6i loan &Ong mau:
+ XN fibrinogen giam.
+ Thai gian Quick keo dai (TP giam).

2.7. ChCpc nang trir cac chAt

Gan du till nhieu chat nhat la vitamin A, ke an la vitamin D va B12. Gan cang du nit it
vitamin E va K.
Tac dung dem Fe dm gan: dg trir Fe nhieu nhat duoi dang ferritin. Khi Fe trong
huyet thanh giam --+ gan phong thich Fe vao mau.

2.8. Chirc nang chuyen hoa porphyrin

Ngodi nhang benh tieu ra porphyrin di truyen, trong truang hap suy gan hoc fac mat CO
the xuat hien coproporphyrin I va III trong nuac tieu; trong twang hop xa gan do ruou
coproporphyrin III chiem uu the; trong cac twang hop xa gan khac va viem gan chu yeu
la tang coproporphyrin I trong nirac tieu.

2.9. Chuyen hcia cac chAt khac

Gan gill vai tr6 chinh trong su chuyen h6a nhimg ion kim loai nhu Fe, Cu, Zn, Mn... nha
vao 3 kha Ong:

112
 CHU'ONG 4 10- HOA SINE/ LAM SANG SENN L? GAN MAT

+ Phan phi Chung tro lai trong to chirc.

+ Du trcr va bai tiet cac kim loai nay.
Gan c6 vai tr6 trong chuyen h6a ethanol nh6 alcol dehydrogenase (ADH) va met
s6 cac enzym khac.

CH 3CH 20H NAD+ ADH > CH3CHO + NADH + 1-1+

2.10. Chic Wang chuyen hoa va thai trU' thu6c

+ Oxy hoa phan ti thu6c nh6 he CYP450 (phase I).
+ Phan cue hoa phan tit thu6c (phase II) —> bai tiet.

2.11. Chirc nang van chuyen nu,6,c

Gan la co. quan tiep nhan hang ngdy met lueng mau lon, do do gan dong vai tro trong van
chuyen mac. Trong cac benh ve gan, c6 roi loan ve six van chuyen do.

3. CAC XET NGHIEM THLYO'NG DUNG TRONG CHAN DOAN BENH GAN MAT

3.1. Bilirubin—huy6t, sac to mat va urobilinogen trong nu'o'c tieu

3.1.1. Dinh luvng bilirubin huye't thanh

Xet nghiem nay cho phep phat hien met truang hop tang bilirubin mau vira phai Cita
yang da tiem an ma lam sang chua phat hien dtrov bat dau tix 2mg% (binh thuang
bilirubin < 1,5mg%).

Bang 4.2. N6ng c16 bilirubin huyett thanh

Binh thuirng BOh

ng da niem re khi > 2mg%

a'ng da truac gan va tai gan

Benh 1S1 gay yang da tai gan va sau gan

113
3.1.2. Dinh tinh sac to mat trong nutyc tieu
+ Binh thuemg khong c6 bilirubin trong nuac tieu.
+ Neu c6 thi la bil.TT: b'enh 1ST yang da tai gan va sau gan.

3.1.3. Dinh luvng urobilinogen trong way tieu

+ Binh thuemg co mot luting nho urobilinogen trong nuac heti.
+ Giam urobilinogen nuac fiat: tac mat khong hoan toan.
+ Urobilinogen nuac tieu (-): tac mat hoan toan.
+ Tang trong tan huyet.

3.2. Xet nghiem ve enzym gan

CO nhiau xet nghiem enzym trong chan doan va theo dOi benh ly gan mat.

3.2.1. Phan 1°0: có 2 loci enzym

Bang 4.3. Phan loai enzym
Theo vi tri Enzym nghia Roi loan b'e'nh 151
a nang tong hop Ton thucmg do ngo dcic
Enzym ngo.i bathohnester
ua gan phosphor hall co.
LT, AST, LD irc (10 huy to bao Benh lY co hoai tii t
nzym not bao (ba DH an bao gan
ong, bao quang) ty, GGatinh trang lull
Benh tac mat
hong cua mat

3.2.2. Cac enzym quan trong trong chin doan Onh gan mat
+ ALT (alanin aminotransferase — GPT: glutamat pyruvat transaminase).
+ AST (aspartat aminotransferase — GOT: glutamat oxaloacetat transaminase).
+ ALP (alkalin phosphatase).
+ GGT (gamma glutamyltransferase).

3.2.2.1. Aminotransferase: 16 nhung enzym chuy6n nh6m amin

Co hai enzym ph6 bien la AST va. ALT.
+ AST co nhiau 6 gan (ty the).
+ ALT có nhiau d gan (bao toting), tim nao, co..
AST/GOT
Aspartat + a ceto glutarat < >Oxalo acetat + Glutamat
ALT/GPT
Alanin + a ceto glutarat Pyruvat + Glutamat
* ALT/huyet thanh va AST/huyet thanh

114
 CHU'O'NG 4 ► HOA S1NH LAM SANG BEM Ll! GAN MAT

- Hoat dO ALT va AST/huyet thanh < 40 U/L.

- Hoat dO ALT va AST/hong eau > 4-8 lan trong huyet thanh, do do tranh tan huyet
khi lay man_
ALT AST
Huy& thanh 1
Te bao gan 2.7504EL 7.100
Te bao tim 444 7.800
- Hoat tinh enzym ALT va AST nOi bao cua gan rat cao so vai huyet thanh
- Khi c6 hOi chirng huy to bao gan, ALT va AST thuong T > 10 — 100 1An, do do có
gia tri trong chan doan viem gan cap.

3.2.2.2. Alkalin phosphatase (ALP)

Enzym thity phan cat lien ket phosphat cua eac chat lulu co. phosphat.
- CO nhieu a to bao gan, duemg 'Ong dan mat, xuang,,nhau, runt.
Tang len trong benh 1y tac mat, cuang can giap, thieu vitamin D, benh xtrang (col
xucmg, ung thu, lao xuang benh Paget, dau tty xucmg, Kahler ...).
La mot chi so quan trong de chan doan tac mat ding vai GGT.
De phan biet tang ALP do xuong hay gan, nguai to dung phuong phap dien di
isoenzym ALP.

3.2.2.3. Gamma glutamyl transferase (GGT)

- La enzym co vai tro trong chuyen hoa acid amin va dieu boa luang glutathion
trong co the.
y-glutamin-peptid + as y glutamin-aa + peptid
CO nhieu a gan (mang TB gan va 6ng clan mat), than.
- Tang len trong benh 1)'T tac mat, benh gan do moth
- Binh thuong: < 40 U/L.
3.2.3. Y nghia cua cac xet nghiOm enzym trong huyet thanh
Hoat tinh enzym tang cao bat thuOng có the do 4 yeu to:
Hiiy to bao.
Te bao bi ten thuong.
- 12.6i loan chuyen hoa trong to bao.
- Tang sinh tong hop enzym (cam img tong hop enzym).

115
HOA SINH LAM SANG

3.3. Xet nghiem v6 protein, cac clan xuAt nit°,

Bang 4.4. Cac xet nghirri nita mau
Nhom XN Ten XN
1. Dinh hrong albumin/mau
2. Di8n di protein/man
3. Dinh hrong fibrinogen/mau
4. Dinh TP
. Dinh lixong yen to V
6. Dinh hrong ure/mau
7. Dinh lixong NFI,/mau

3.3.1. Dinh luvng albumin trong mau

* Nguyen tac XN:
+ Phuong phap h6a hoc: Bromocresol green.
+ Phurong phap mien dich vai khang the don dung khang albumin.
* Muc dich XN: danh gia mire dO tong hop dm to bao gan.
- Giam trong cac b8nh 1ST gdy suy to bao gan (xo gan).

3.3.2. Hien di protein/mau

- Nguyen tac XN: kha nang tich din va di chuyen trong dien tnrong khac nhau cua
tirng loai protein.
- Muc dich XN: danh gia chirc 'fang tong hop va tinh trang viem cua gan.
+ Khi viem gan cap: al globulin, a2globulin: tang.
+ Khi viem gan man: y-globulin tang.
+ Trong xo gan: albumin giam, y-globulin tang, hinh anh bloc f3-y.
+ y globulin tang cao not lien voi plidn p globulin ► vet lan chung, do tang
IgA ldp ddy khoang trong P va y goi la bloc 0-y.

116
 CHUO'NG 4 ► HOA SINN LAM SANG B6NH L'? GAN MAT

Alb

1 Alb al a2 y 2
41

Thieu
al - antitrypsin
Binh thtrevng

V
a2
al
4,

3 4

Hinh 4.4. DiOn di d6 trong mot s6 benh

3.3.3. Xcic dinh ccic .01,1 to hong mciu
- Xac dinh cac protein DM: I, II, V, VII, X ...Khdo sat duemg DM ngoai sinh (yeu
fa: II,V,VII, X) = Thai gian Quick (PT).
- Trong suy gan, it met: tY le prothrombin giam (binh thuemg: >80%);
PT keo dai (binh thuang: 11-14").
Six tong hop cac yeti to II, V, VII, X phi thuec \Tao vit. K, yeti to V khong phg
thuec vit. K.
- Trong tac mat keo dai, do giam hap thu vitamin K PT keo dai va tra ve binh
thuemg khi tiem vitamin K tinh mach: thin nghiem Koller ducmg tinh.
- Test Koller (+): phan biet PT keo dai do tac met hay do suy to bao gan: test
Koller (-).
- Neu dinh luting yeu to V thi chi giam trong suy gan.

117
HO/0k SINN LAM SANG

XII
Duteng not sinh XI
Du,o'ng ngoai sinh
IX VII
aPTT VIII PT
X

• "..m."11
V tbeiiaden- Fibrin
(I) (14)

Prothrombin (II) Thrombin

000•■•,*

Fibrin
(14 )

Hinh 4.5. Ca the clang cam mau

3.3.4. Dinh lucvng urefinau va NH/rnau

- Ure-huy6t: giam trong suy gan Wang.
- NH3-huy6t (amoniac): tang trong suy gan nang, c6 gia tri theo dOi tinh trang Nnh
nao do gan, trong dinien suy gan nang, xa gan giai loan cuoi.
- NH3-huy6t tang la 1 trong nhirng nguyen nhan gay nhi6m dOc nao.
Xuat huy'et tieu h6a, an chat dam qua cao, tao bon, nhijm trang, c6 mach not chu
- cfra la nhang ye'u to g6p phan lam NH3 tang nhanh.
* Ch6 y: NH3t + urel —+ xa gan.
NH3 T + uret Xuat huye't tieu hoa tren.

118
 CHU'O'NG 4 lo. HOA SINH LAM SANG BENH L? GAN MAT

Theo dal b§nh nao do xcv gan

NH3t f MAU

The ty

Carbamoyl
2ATP t HCO3 t NH3 --o- Phosphat t 2ADP r Pi
Carbamoyl
MAU
Phosphat
Synthetase I
Ornithin
Transcarbamoylase
Ornithin Citrul

18 bac)
URE
GAN
UREA
Arginas Argininosuccinat
CYCLE
Synthetase

Arginin Argininosuccinat
Argininosuccinat
Lyase,/

7-
Fumarat

Hinh 4.6. Chu trinh ur8

119
HOA SINH LAM SANG

3.4. Xet nghiem Ve virus viem gan

3.4.1. Cac xet nghiem cua viem gan virus

Bang 4.5. Cac xet nghiem viem gan sieu vi

Ban chAt XN Ky thulat XN Niue dick XN

ELISA Xac dinh sty hien din cua KN cua
Mi& dich hus rus va KT (neu co)
ID
uang o luting dap irng mien dich (DL KT.
Hoa phat quang .

3.4.2. Cac chi to huye't thanh hoc cua virus viem gan
Bang 4.6. Cac xet nghiOm huy6t thanh chart down viem gan
XN MIEN DICH
VIRUS XN SHPT
NG NGUYEN KHANG THE
• nti-HA DL
nti-HAV
BsAg (KN be mat) Anti-HBs (DL
BeAg (KN hoa tan) Anti-HBe
acA KN IOI ati-

HCV-RN

1111111k i 1111111k
Cac xet nghiem nay nham xac dinh c6 sty nhiZm virus viem gan:
• HAV: Hepatitis A virus
• HBV: Hepatitis B virus
• HCV: Hepatitis C virus
• HDV: Hepatitis D virus
trng voi cac khang nguyen HAV, HCV, HDV thi c6 cac khang the Wong img: anti
HAV, anti HCV, anti HDV.
ting vol cac khang nguyen cua HBV thi c6 cac khang the:
• HBcAg (KN 161 c cua HBV) c6 KT: anti-HBc
• HBeAg (KN hoa tan e cua HBV) anti-HBe
• HBsAg (KN be mat s oda HBV) anti-HBs

120
 r-,771FrIprrVIIPIr.

CHLIO'NG 4 lb- HOA SINH LAM SANG BENH L'? GAN MAT

a
Cac chit IgA, IgG, IgM kem theo cac KT chi ban chdt loci imunoglobulin cua
cac KT: antiHBc IgG, anti HBc IgM...
Khi sieu vi xam nhAp vao co the —> cac chi s6 KN tang dAn r6i giarn dAn —> bin
mit, khi do cac KT xuAt hien tang dAn T goi la sir dao huyat thanh.

4. SO' DUNG CAC XET NGHIEM TRONG CHAN DOAN BENH GAN MAT

4.1. Sir clung xet nghi6m trong chAn doan bOnh gan mat,
CAn kat hop hoi tien sir banh, dick quen cua banh nhan (u6ng rlrou, thu6c la, banh gan, c6
truyen mau, tipVic h6a ch'At, di du lich,...), kat hop \Teri tham- kham qua do cho nhung
xet nghiam co ban phil hop.
Neu thyc6 b'anh gan thi can lam cac xet nghiam chuyen bitlion de c6 the chAn
doan, theo doi, danh gia mire da cua banh.
Bang 4.7. Xet nghiem trong ch6n doan benh gan

XET NGHIEM CNC, DUNG

gialkaallah an doan vane; da va vi tri ton thtrong
an doan tinh trang hoai tt2r to bao gan
,410111Millit pan doan tinh trang tac mat
an doan tinh trang tic mat, tinh trang ton
cmg to bao gan
14

umin h cua tinh trang

agi Jai MENEM

BilTP, BilTT, BiIGT J an a

Vi du: banh nhan c6 di du lich mrac ngodi, qua khir có tiem chich ma tay, nghi'an thu6c
AST, ALT tang, GGT tang vita, bili-NT(+), Uro-NT(+): viem gan (cAp, man ton
luu) -+ can XN flap: Bili-mau, cac KN, KT dm viem gan virus...

121
FIOA SINN LAM SANG

4.2. Cac hOi chi:mg xet nghiem trong viem gan

Bang 4.8. Cac xet nghiem trong bOnh gan

110I CHUNG SIJ' TRAY DOI CUA XN

albumin/mau
ien di protid: 1 albumin, T y-globulin...
chloesterol ester Ilea
fibrinogen
TP, khong T sau chich vitK
NH3, j. ure

T, T ALT
LP, GGT
Bi1TP, T BilTT
urobilinogen/nt hoac (-)
TP, ve binh thtremg sau chich vitK

CRP
ien di protein: hinh anh viem cap (T al, a2-globulin) hoc
viem man (Ty-globulin)

4.3. Cac xet nghiem chuyen biet khac

Thy theo ding trtrong hop dm b'enh can lam them nhung xet nghiem chuyen biet:
Cac tumor marker: a-FP, CEA, CA19-9...
- Cac to khang the: khang ADN, khang the khang nhan ANA, khang the ty AMA,
khang co. trop SMA...
- Dinh ltiong Fe/huyet thanh — Ferritin; Cu/huyet thanh — Ceruloplasmin
- Cac XN huyet hoc: benh 1ST ve mau, ctremg
- XN kST sinh trung sot ret, amib,...
- XN huyet thanh chan doan cac tnreyng hop kST sinh trimg lac chi): giun cho, giun

- XN chin doan hinh anh: X quang, sieu am, nei soi 6 bung, chup can quang
duemg met, &mg vi phong xa, CT scan: chup cat lop, MRI...
- Sinh thiet gan.

122
 CHU NG 4 ► HOA SINH LAM SANG E3SNH L? GAN MAT

4.4. Xet nghiem chin nang gan theo phan Ioai va chan doan cac the Penh
gan
Xet nghiem chirc nang gan bat thinteng

AST > 3x URL AST < 3x URL

ALP < 2x URL ALP > 2x URL

Benh to bao gan Benh t6c runt

Albumin Albumin
binh giam
thLreyng

Viem gan Viem gan Tac mat Tac mat

cap man cap man

N
So' c16 XN chirc !fang gan theo Sieu am/
phan Ioai va theo d6i cac the chup du,o'ng
benh gan khac nhau mat
URL: upper reference limit -
binh thiremg trOn

Tac mat Tac mat

gan trong gan ngoai

Hinh 4.7. Sc' do theo doi cac the benh gan

4.5. Phan loai benh gan

- Nhi6na trang: viem gan sieu vi.
Nhijrn d'Oc: viem gan do nrou.
- Di truy'en: Nnh it dong sat.
- Mien dich: viem gan tkr mien, xa gan mat nguyen phat.
- U buoru: K to bao gan nguyen phat.

123
 -

HOASINH LAM SANG

4.6. Dien bren nhien ctla benh gan

Lanh benh Ung thly to

bao gan
Tai tao

Ton thiyang T6n thtyang Xa Xcy Tix

gan cap gan hoa gan vong

Tai tao
that bai

Viem gan Tang ap TM cCra

toi cap

Tix vong H6i phyc

Hinh 4.8. Tian tri6n trong bOnh gan

4.7. Lou ich ctla xet nghiem chAn down cac benh gan
- Phan loai ton thuung: ton thuang to bao gan va tac mat.
- Xac dinh din bien dm ton thuang: cap tinh va man tinh.
- Xac dinh dO nang dm ton thucmg: nhe va tram trong.

5. HOA SINH LAM SANG MOT SO BENH GAN

5.1. Xce gan
- La hau qua dm ton thuo'ng gan man tinh dan den thodi h6a nhu mo gan
—> Xo hoa lan rOng va tan tao not, de dien tien den K to bao gan nguyen phat.
- phat trien cua to chirc lien ket chen ep nhu mo gan va he th6ng tinh mach cira.
- Su tang san nhung nhom to bao mai bi bao vay bed mo soi khong can cau frac
chirc nang cda to bao gan binh thuemg.
Hau qua dua den nhang bieu hien lam sang:
- HOi chirng suy to bao gan.
I-10i chimg tang ap luc tinh mach cUa.
- HOi chi mg kern dinh duOng: phan anh tren su thay doi, r6i loan dm cac xet
nghiem Wang irng.

124
 CHU'O'NG 4 ■ HOA SINH LAM SANG BENH L1.1 GAN MAT

HOi chirng tang ap Arc tinh mach dm co chuthig, tun hoan bang he, gian tinh
mach thuc quan,, tivc tang, cuemg lach, thieu mau...
- HOi chimg suy to bao gan: giam kha. Wang tong hop cac chat e gan, giant six khir
dec va dao thai cac chit. BiL hien qua cac XN:
• Cac XN: albumin, ty A/G, CE, ty' CE/CT, fibrinogen, cac y6u to &rig mau,
ure deu giam. NH3 tang.
• XN &Ong man roi loan: TQ tang hay prothrombin giam, khong dap timg vei
tiem tinh mach vitamin K.
• Nghiem phap BSP, galactose nieu, tao acid hippuric rei loan.
• Phan iing trung me: cac to bao Kupffer tang san, tang hog deng —> tang cac
imunoglobulin va thay doi tinh chat cac globulin. Albumin giant, y globulin
tang, A/G <1. Da'c Net tang tong hop IgA manh.
• Dien di: y globulin tang cao not liL vei phan /3 globulin —+ tao met vet len
chung do IgA tang nen lap day khoang giita 13 va y goi la Bloc I3-y.
• Tong hop transferrin giam, ty s6 IgA/transferrin tang.
• Ngodi cac thay dei teen, luon luon kem met mite de hei chirng hity to bao
gan, fac mat va viem nhi6m.
• Hei ch rung kem dinh &fang keo dai —> giam sirc de khang mien dich cua co.
the —> de nhi6m trung...
• HOi chtimg suy t6 bao gan c6 the dua den giam kha nang dao thai, pha huy
met se hormon nhu tang estrogen —> hien Meng nit hoa, vii to a nam gied
hay tat kinh, vo kinh him muon 6. nit... tang aldosteron thir phat, c6 khang
th6 khang nhan, khang ca tun, khang th6 ty...
Hinh anh sinh thik gan, nhat la xa gan do ruou rat dac trung.
Cac the xce gan:
+ Con bit: kw dau vi kha nang tv h6i phuc cua to bao gan con tot nen cac xet
nghiem con chua re rang,,khi benh din tin nhiL thi xet nghiem mei re rang.
+ Mat bit: cac xet nghiem deu throng tinh re va suy gan 'tang.
+ Xa gan nguyen phat.

125
HOA SINN LAM SANG

SUY GAN TANG AP TM CCM

Benh
ly nao
yang mat

Sao mach

Rung
long ngtyc Dan TM
NO, h6a thtyc quan
tuyen vu
Lach to
Ton thuung gan
Dan TM
thanh bung
D'au ban
tay son

Thay doi phan b6 Bang bung

long mu
Bien doi
Teo tinh hoan xu'o'ng

Mang b'am mau Teo ca

tip chi

Phu mem

Hinh 4.9. Dail hiOu lam sang trong xa gan c6 tru&ng

Hinh 4.10. Tun hoan bang h0

126
 CHU'O'NG 4 ► HOA SIKH LAM SANG BeNH L? GAN MAT

Hinh 4.11. Da( u sao mach

5.2. Viern gan sieu vi cap

5.2.1. Ba giai doan din tign caa bOnh
- Giai doan u benh: to bao gan bat dau bi tiny, tiep theo la sac to mat/NT (+) tnx6c
khi biliribin matt tang, transaminase matt tang (nhat la ALT), tee de man Lang
binh thuong.
- Giai doan yang da, benh toan phat: to bao gan bi fray nhieu, chirc nang gan bi anh
huong, nett yang da ro —> Hu het cac XN deu (+) rO, neu yang da nhe thi cac XN
khong deu: c6 (+), c6 (-).
- Giai doan hoi phue: kha nang khoi benh, cac XN dan tr6 ve binh thuemg hay
chuyen sang cac the mang nguen nhijm, cac the viem gan man.

127

• LS: chu'a yang da
• XN: sac to mat/nt (+);
transaminase/mau
GE) u b'Onh
• LS: v6 binh thiyeyng
• XN: v6 binh thLromg
• LS: yang da hoan toan; the mang
, • XN: HC huy tb gan, ngu6n nhrem; the
HC viem nhrem viem gan man

Hinh 4.14. Tien -Ink benh trong viem gan sieu vi

5.2.2. Co, ch6 sinh ly — hem sinh

• Viern chung hit)/ to bao gan ---> tang ALT, AST.
• Viem nhic j in --> plan ne Vac mot phan nhirng ong mat nho trong gan --> tang
bilirubin.
XN cac chi to huye't thanh hoc: xac dinh loai virus viem gan va din tin benh.
Bang 4.9. Thay doi chi s6 huyet thanh trong viem gan slot.] vi B

128
 CHUO'NG 4 ■ HOA SINH LAM SANG BENH Ll! GAN MAT

U benh Toan phat Man/Ho'i phut

Total anti-HBc

Chuan HB sAg IgM anti-HBc

do anti-HBe anti-HBs

?HBeAg
/ .

0 4 8 12 16 20 24 28 32 36 6.211_1_1
S6 tuan hoan sau CI blenh

Hinh 4.15. Bi6u d bieu din cac chi s6 huye( t thanh trong VGSV B cap

5.3. Cac benh ly gay yang da

5.3.1. Cac nguyen nhan gay yang da

Bang 4.10. Thay doi xOt nghiOm trong yang da t6c mat

Nguyen nhan
BilGT/nniu BilTT/mau SAc to mat/nt Co' the benh
thuirng gap
san xuat Bil. An huyet
Thieu glucuronyl ang da sa sinh
se

gan

Tac nghen, then ep 01 dixo7g-- 1-a

Layng can mat trop .
dau tuy
ngoai gan
L

129
HOA SINH LAM SANG

5.3.2. Cac thay doi ye xet nghiem trong cac loaf yang da
Bang 4.11. XOt nghiem trong yang da t6c mat

Xet nghi01 yang da truck gan Vang da tai gan yang da sau gan

BiliTP > 2mg% TT

BiIiGT
Bi1iTT hoac bt
n gan Khong da.c hieu
trot tieu:
Sac to mat
Urobilinogen
of mat

ercobilinogen
ac XN khac HC hay to bao gan
(XN hu et hoc) Huy6t thanh than
down VGSV

6. GIO'1 THIEU MOT SO BENH AN

A. CAU H6I NGHIEN OAT

Truirng hop 1
Benh nhan NguyL Thi A., phai nit, 58 tu6i.
LST do nhap vien: tieu phan den, la ma.
TiL can: xor gan c6 ehuang 4 nam, vo gian TM thgc
Tham kham lam sang: mach 1001L/phut, HA 120/70 mmHg, nhiet d6 37° C. Bung
ascit (+++), sao mach (+), THBH (+), yang da yang mat. Am pile bac) 4, 2 day ph6i.
Tri giac la ma, kh6ng
Can lam sang
CTM: HC 2,85 trieu/mm3, Hct 27%; BC 12000/mm3 (Neutro. 81%; Lympho
16%; Eos. 3%).
Sinh h6a mau: glucose 5.55 mmol/L, ure 3.82 mmol/L, creatinin 80 umol/L,
NH3: 279 ug/d1 T, GOT 196 U/L, GPT 89 U/L, GGT: 320 U/L. Na± 136 mmol/L,
K± 2.56 mmol/L. Albumin: 2,1g/di, PT:19". Khi mau DM: pH = 7,45; pCO2:
24 mmHg, p02: 80mmHg, 02 sat: 96.5%, HCO3-: 17,1 mmol/L.
Dich mang bung: mau yang chanh, khong &mg, HC 10.000/mm3, BC 3.500/m3
(chii ye'u la lympho), Rivalta (-), protein 90mg%.

130
 CHU'O'NG 4 • HOA SINH LAM SANG BE:NH Ll! GAN MAT

- XQ phOi: phe quail phe viem ben (P), ECG: theo doi thieu mall co. tim, Echo bung:
xo gan co chirang — lath to dO II. Polype + can bun titi mat, dich ascit co can.

Truimg hop 2
Benh nhan Lim Tuyet M., phai nit, 23 tuOi.
LY do nhap vien: sot, not man da sau uOng thuOc khong rO loai.
Tien can: dOng kinh.
Tham kham: not man do toan than + bong mrac.
Mach 114 lan/phdt, nhip tho. 20 1an/phut, HA 100/60 mmHg, nhiOt dO 39°C.
Cac co quan khac binh thtremg.
Can lam sang:
Ngay nh4p Sau 8
)(et nohiem 1111 Sau 24g Sau 4 ngay
vien ngay
HOng cau (trieu/m ,26 ,97 3,8
Hb (g/dl) 2,4 0,6 10,4 I
Hct (%) 6,1 6,7 29,6
Bach cau (/m1) 7 500 9 80 14 500
eutro — Lympho (%) 0 — 29 4 6,6 — 2 57,5 — ,
jeu cau (/m1) 97 96 166
OT (< 40U/L)
x.45.

411110omme

ZINI■11111111. JIMIEMICINCLIEL

Van d tren BN:

■ Nhie'm trang da do di img thuOc.
• Viem gan cap tinh do thuoc.
• BOi nhiem co quan khac sau dieu tri corticoid 1 Man.
E16' nghi: XQ phi thang, tong phan tich ntrofc tieu.

131
Trtrimg hop 3:
Benh nhan Tran Thanh D, phai nam, 48 tutii.
LST do nhap vien: sot lanh run + co giSt.
Tien can: Siit ret khi di nghia vu quan sir.
B'enh sir: 4 ngdy nay s& cao lanh run. N3 sot lanh run + tieu it < 200m1Mgay + yang
da + la ma vao BV tinh Binh Ducmg sau do co gist nen chuyen den BVCR.
Tham kham: nhip tim 84 fan/phut, HA 120/80 mmHg, nhiet de, 37,8°C. Tha bop bong,
yang mat, yang da; Phi rales no 2 ben; Gan to do II, lath to dO II, di tieu qua sonde;
Tri gide: li bi, la ma; dL cimg gay (-), dau Kemig (-), di tieu qua sonde.

Xet nghiem Ket qua

ipreatinine dl) 5,2 0,8 (48 gia)
hi mau DM H qua toan khong do &lac
CO, = 69 mmHg
0, = 93 mmHg
KST sot ret 11111.11ciparum (3+)
&rig cau (trieu/ml) 2,43 1,
Hb (g/dl) 7,9 1,
,Hct (%) 22,4
Bach cau (/ml) 34 300
Neutro. — Lympho (%) 35,6 — 52,3
6,Tieu cau (/m1) 67 1,
lOT (< 40 U/L) 47
Vi
o
PT (< 40 U/L) 82 T
it TP (< 10mg/L)
w
24,3 T
ilGT - BilTT - ' 22 - 2,3
Glucose huyet (mg/di) sr obi"
TP (> 80%) MP%
Na+ /K - /C1- (mmol/L) 133 /4,2 /99
Van de tren b'enh nhan-
• Tinh trang nhiem tang ho hip: sot lanh run, BC T, rale n(''5.
• Tinh trang tan huyet: HC Hb Hcti. yang da yang mat, Bil T chit yeu la Bi1GT.
• Tinh trang suy to bao gan: GOT, GPT T, TP J,.
• Tinh trang suy than cap: Creatinine T T.
• Tinh trang roi loan tri
• Toan hoa mau.
• P.falciparum ( I ).

132
 CHU'O'NG 4 IP. HOA S/NH LAM SANG BeNH LY GAN MA: T

B. CAU HO! TV LONG GIA

1. Xet nghiem nao sau day danh gia chtic nang tong hop glucid elm gan:
A. Nghiem phap gay tang glucose huyet
B. Nghiem phap galactose nieu
C. Dinh luting albumin mau
D. Dien di protein mau
2. Xet nghiem nao sau day danh gia chtic nang dy tar glucid ctia gan:
A. Nghiem phap gay tang glucose huyet
B. Nghiem phap galactose nieu
C. Dinh luting albumin mau
D. Dien di protein mau
3. The ceton ding tong hop co' quan nao sau day:
A. Gan B. Then C. Tuy'en thuong then D. Tat ca tren
4. Gan la cif quan duy nhit tong hop:
A. Protein B. Cholesterol ester Ma
C. VLDL D. Vitamin D
5. Xet nghiem nao sau day danh gia chfrc Jiang tong hyp lipid dm gan:
A. Ester hoa cholesterol B. to'ng hop chylomicron
C. T'Cing hop ure tir NH3 D. T6ng hop vitamin K
6. Chtic nang gan binh thiroug, ltryng BSP/mau gram sau khi tiem 30 phut con:
A.30% B.25% C.15% D.5%
7. Chon y kitting dung:
A. GOT, GPT tang cao trong viem gan do virus
B. GGT, phosphate ki&n tang cao trong yang da tec met
C. GGT tang cao trong viem gan do di'eu tri thu6c lao
D. GOT > GPT trong xo. gan
8. Thanh phin nao sau day kitting có trong mare tieu khi tic throng mat hoan toan:
A. MuCii met B. Sec to met C. Urobilinogen D. Tat ca cac y tren

133
HOA SINN LAM SANG

9. Chon ST dung nhit khi not v'e din di do protein man trong gan:
A. Albumin giam + globulin tang
B. al-globulin tang + ''-globulin tang
C. a2-globulin tang + '-globulin tang
D. 0-globulin va ''-globulin tang cao, tao thanh mat trien nui thing dimg
10. Xet nghiem nao sau day gitip phan biet suy giam chtic nang gan do thieu vita-
min K:
A. Test Koller B. Test TQ, TCK C. Test Quick D. Test BSP
11. Duimg lay truytn nao sau day khong thy trong VGSV B:
A. Me con B. Mau C. Tieu hoa D. Quan he tinh due
12. Viem gan sieu vi B man tinh khi:
A. HBsAg (+) va Anti HBe (+) B. HBsAg (+) va Anti HBc (+)
C. HBsAg (+) va Anti HBs (+) D. HBsAg (+) va HBeAg (+)
13. Phat bieu nao sau day khong dung:
A. Ty le ung thu h6a a VGSV B cao hon VGSV C
B. Duang lay truyen VGSV C bao gam mau, quan he tinh due, me con
C. Khoang 80% VGSV C —> viem gan man
D. Chin doan VGSV C tren lam sang chic ytu dui vao xet nghiem HCVAb
14. Mom enzym nao sau day gifip phan biet yang da tic mat tai gan va sau gan:
A. AL.P, GGT, TP, Bili, Urobilinogen-NT, CE/CTP
B. GOT, GPT, GGT, ALP, Bili, Uro-NT
C. CE/CTP, GGT, ALP, LDH, Bili
D. Bili, GGT, AL.P, GOT, GPT, CE/CTP
15. Nhom xet nghiem nao sau day phan anh suy to bao gan:
A. CE/CTP, albumin-huytt, BUN, NH3 B. GOT, GPT, GGT, LDH, CE/CTP
C. GGT, ALP, albumin-huytt, BUN D. BUN, albumin-huytt, Bilirubin
16. Nhom xet nghiem nao sau day phan anh hei chirng viem nham to bao gan:
A. GPT, CRP, GGT B. GGT, ALP, GPT
C. GOT, GPT, Albumin, CRP D. Bili, GGT, CRP, GOT

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 CHU'O'NG 4 ► HOA SINH LAM SANG BENH Ll! GAN MAT

17. Nhom xet nghi'On nao sau day phan anh hotii chiing huy hoal to bao gan:
A. GGT, ALP, LDH B. GOT, GPT, Ferritin
C. Muti mat, Ferritin, GOT D. GOT, GPT, Ferritin, ALP
18. Nhom xet nghilem nao sau day phan anh ho)i chfrng yang da tac mat:
A. GPT, GOT, LDH, GGT B. GGT, ALP, GOT, GPT
C. GOT, GPT, Albumin, CE/CTP D. Bili, Uro-NT, GGT, ALP
19. Dieu nao sau day khong they trong tac mat hoin toan:
A. Phan trang nhtx v8i B. Trong nu& titu c6 sac to mat
C. Trong mr6c titu c6 mu6i mat D. Trong nu& titu c6 urobilin
20. Bilirubin gifin tit') khong có trong ntrov ti'eu tren cfic 4nh nhan:
A. Viem gan sidu vi B. Tac mat hoan toan do sal duemg mat
C. Tan huytt do truytn nham nhom mau D. Tat ca. y tren
21. Cap xet nghqm nao sau day có the dinh gifi mire 119' viem gan va xo' gan:
A. GOT va GPT B. GPT va GGT
C. GOT va GGT D. Tat ca y tren
22. Ch9n tap hop dung nhAt: cac xet nghqm nao sau day ghip phan brio yang da
tfic mat tai gan va sau gan:
A. GOT, GPT, GGT, Phosphatase Kitm, Bilirubin
B. GPT, GGT, LDH, Phosphatase Kitm, Bilirubin
C. GOT, GPT, GGT, Phosphatase Kitm, C.E/C,rp
D. Bilirubin, GPT, GOT, LDH, C.E/CTP
23. Enzym nao sau day thay doi nheeu trong viem gan do ruvu:
A. GOT B. GPT C. GGT D. Phosphatase kiem
24. Nguyen nhan nao sau day killing gay yang da tan huyet:
A. Stt let B. Thitu men G6PD
C. Nhiern trang nhiem d8c D. Gentamycin
25. Enzym nao sau day tang cao trong xo' gan do viem gan sieu vi B:
A. GOT B. GPT C. GGT D. LDH

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HOA SINH LAM SANG

26. Nhom xet nghiem nao sau dfiy thwong dung de phan biet gifra xuat huyet tieu
hoa do xo• gan ya xuat huyet do boat d# day to tring:
A. BUN, Crea, NH3 B. BUN, Crea, GOT, GPT
C. BUN, Crea, GGT D. NH3, BUN
27. Mtn nao sau dfiy khong thy trong yang da tac mat sau gan:
A. Phan trang nhu phan co tong dot
B. GGT tang
C. Phosphatase kiem tang
D. Cholesterol ester /cholesterol toan phan tang
28. Cfic y sau dfiy dung khi not ye GGT, ngoai trir:
A. Tang cao trong viem gan do ruou
B. Tang cao trong yang da t'ac mat
C. Tang cao trong viem gan sieu vi
D. Khong tang cao trong tan huyet
29. Dieu nao sau day khong dung khi not ye cholinesterase huyet:
A. Co ngu6n g6c tir gan
B. Giant khi co the ng6 CVC phosphor btu co
C. Cholinesterase huyet tang cao khi co the ng0 dee phosphor him co
D. Day la enzym ngoai bao
30. Khi to bao gan hoqi fir thi enzym nao sau dfiy tang nhieu nhit:
A. GOT B. GPT C. GGT D. LDH
31. Nguyen nhfin nao sau day lam enzym phosphatase kiem tang cao trong man:
A. yang da tarot gan B. yang da tai gan
C. yang da sau gan D. Tat ca y tren dimg
32. Cfic y sau day dung khi not ve GOT, ngoai trir:
A. La enzym ngoai bao B. La enzym not bao
C. Tang cao trong xo gan D. Tang cao trong nh6i matt co tim
33. Cfic y sau day dung khi not ve bilirubin gian tiep-huytt, ngoai trir:
A.Tang khi co the bi tan huyet
B. Xuat hien nhieu trong mac lieu khi c6 nguyen nhan yang da tax& gan
C. Khong xuat hien trong ntrov tieu khi viem gan sieu vi cap
D. Kh6ng xuat hien trong mac lieu khi tac duOng mat hoan toan

136
 CHLICYNG 4 ► HOA SINN LAM SANG BENH L1.1 GAN MAT

34. Trong ung thin gan, xet ngh4m nao sau day dime sir dung a chin doan:
A. aFP B. Decarboxy prothrombin (DCP)
C. Alpha-fructose (AFU) D. Tat ca xet nghiem tren
35. Xet ngh4m nao sau day danh gia chirc 'fang protid clia gan:
A. AST, ALT, NH3 mau B. Dien di protein man
C. Dinh ltrang CRP, C3 mau D. Tat ca xet nghiem tren
36. Mutii 111'0 c6 vai tro nao sau day:
A. Gifip nhu tuong boa chit boo
B. Lam giam sire cang be mat dm chit beo de enzym lipase de thiiy phan
C. Lam tang dien tich tier, Vic gitta enzym va chat beo a lipase a thity phan
D. TL ca y tren dung
37. Ngh4m phap Quick (ngh4m phap gay acid hippuric WO):
A. Thum do co the khir dee Ma hoc cua gan
B. Gan suy ltrang acid hippuric tang rat nhieu
C. Khong phu thuac vao luu hong mau qua gan
D. Tat ca Y ten dung
38. Chun ST dung trong viem gan sieu vi B, ngoui trir:
A. HBeAg (+) o theri ky sao chop, lay lan benh
B. HBsAb (+) khi co the có dap ling mien dich
C. HBeAb (+) khi co the có cita so mien dich
D. HBcAb-IgM (+) khi benh chuyen sang giai doan man tinh
39. So volviem gan sieu vi C, trong viem gan sieu vi B ty 4 ung thif
A. Cao hon B. Thar) hon C. Ttrong tir D. Thy thuac ca nhan
40. Fe du tar trong gan dm% dung:
A. Transferrin B. Fe" C. Ferritin D. ceruloplasmin
41. Xet ngh4m dung trong hoi chtrng viem nham d bao gan:
A. AST, ALT B. CRP, dien di protein
C. Albumin mau, ure, NH3, fibrinogen D. ALP. GGT, Bili, urobilinogen

137
HOA SINH LAM SANG

42. Xet nghiem dung trong 110 cluing tic dtromg m0:
A. AST, ALT B. CRP, dien di protein
C. Albumin mau, ure, NH3, fibrinogen D. ALP. GGT, Bili, urobilinogen, PT
43. Xet nghiem dung trong hOi cluing suy to bao gan:
A. AST, ALT
B. CRP, dien di protein
C. Albumin mau, dien di protein, ure, NH3, fibrinogen, fibrinogen
D. ALP. GGT, Bili, urobilinogen, PT
44. Diu sao mach, tan hohn bang he gap trong:
A.Xa gan B. H'Oi chirng than hu
C.Benh gan va benh than D. Benh gan, than, tim
45. Ngoai ung tha gan, aFP con &rang tinh:
A. U to bao mam
B. Co th6 ducmg tinh trong xa gan
C. Tang thoang qua trong viem gan cap, man tinh
D. Tat ca deu dimg
46. Xet nghi0-1 nao sau day khong x6p vao cac xet nghiem thuirng qui trong khdo
sat hoa sinh lam sang cac 130h gan:
A. ANA B. CEA C. aFP D. Tat ca xet nghiem teen
47. Cac ket qua xet nghqm nao &mil day c6 the gap trong mot 4nh canh xo' gan
mat
A. Ure va creatinin mau tang rat cao
B. Protein/TP = 81g/L vai albumin = 18g/L, A/G = 0,28
C. GOT, GPT, GGT va bilirubin mau tang vita phai
D. Dien di protein mau co hinh anh albumin bloc beta-gamma
48. Tic hoin town ong din m0 chinh keo dal do the dna tot
A. Tang ALP \TA. GGT mau
B. PT keo dai
C. Sac to mat trong mac tieu throng tinh
D. Tat ca cac y tren dung

138
 CHIANG 4 ■ HOA SINN LAM SANG BeNH L'Y GAN MAT

49. Trong viec theo cloi benh ly gan mat, xet nghiem nao sau day tang trong man
cho bik có sty tic mat:
A. Phosphatase kiem B. Bilirubin C. GGT D. GPT, GOT
50. Xet nghiem nao sau day dtgrc lam ca trong man va ntrerc tieu:
A. Acid uric, bilirubin gian tiep B. Amylase
C. AST, ALT D. GGT, ALP
51. Truirng hop nao GOT thuoug nho ho'n GPT trong man:
A. Nguoi binh thuo'ng B. Vial gan sieu vi cap
C. Viem gan man D. Xa gan
52. Trtrirng hop nao GGT thuirng nho ho.n GPT, GOT trong matt:
A. Xa gan do mou B. Nghien rtro-u.
C. Tac mat D. Tat ca. 3'T teen
53. Xet nghiem nao dung chin doan phan biet yang da viem gan va yang da tic
mat hoan toan:
A. Bilirubin lien hop trong huyet Wang
B. Muei mast trong nuoc tieu
C. Sac to mat trong nuerc tieu
D. Stercobilinogen va urobilinogen
54. Xet nghiem nao kitting gifip chin doan phan biet yang da tan huyk va yang da
viem gan cap:
A. Bilirubin town phan
B. Bilirubin to do
C. Muei mat trong nude tieu
D. Sac to mat trong nu& lieu
55. Tim tap hop enzym danh gia sir hily hoai to bao gan tot nhat:
A. AST, ALT, LDH
B. GGT, ALP, CK
C. ChE, GGT, CK-MB
D. LDH1, LDH3, LDH5

139
HOA SINN LAM SANG

56. rep hop xet nghqm nao tham do chfic 'tang tong hop cac chit dm gan:
A. GOT, GPT, GGT B. NH3, ure, creatinin
C. Cholinesterase, cholesterol, albumin D. Phosphatase kiem, bilirubin
57. Xet nghiOt nao tham do oiling thoi chtirc 'fang gan ya then:
A. Nghi'em phap BSP B. Nghi'em phap galactose ni'eu
C. Nghi'em phap hippuric D. Tat ca cac xet nghiesm ten
58. Suy chtic nang gan enzym nao giam:
A. HBDH B. Cholinesterase C. CK D. GOT
59. Enzym nao danh gia chtk 'fang tong hop protid ctia gan:
A. GOT B. GPT C. LDH D. Cholinesterase
60. Yang da tan huyect ya yang da tic met killing khat nhau ik xet nghi,em nao:
A. Bilirubin toan phan B. Bilirubin ni'eu
C. Mu'6i mat mac tieu D. Bilirubin trvc tiep
61. O met nguiri nghi0 ruvu kinh nien co ke't qua xet nghFe'm GGT tang cao, di'eu
nay di the"1S7 giai beri:
A. Hien Wong cam ung tong hop enzym do rtrou
B. Hien tuong cam frng tong hop enzym do tac mat
C. Rtrou có the da gay ton thrrang chirc nang gan
D. fled chimg hl ty to bao

140
 Chu'o'ng 5
HOA SINN LAM SANG
BENH Li' MACH VANH CAP
myc TIEU
I. Phan tich cac kieu rai loan lipoprotein mau.
2. Liet ke cac xet nghiem haw sinh truay hal chiing mach vanh cap.
3. Liet ke cac xet nghiem hoa sinh trong hai chting mach vanh cap.
4. Liet ke cac xet nghiem Wei sinh sau hai chting mach vanh cap.

1. DAI CU'O'NG
1.1. Benh tim mach

Benh ly tim mach (Cardio Vascular Diseases = CVDs): la nguyen nhan gay tir vong hang
dau so voi cac benh 1y khac trong ca the, ty le tir vong chiem 30% trong cac loaf benh tat.
Thong ke nam 2005, c6 khoang 17.5 trieu nguoi chet, trong d6 c6 khoang 7.6 trieu ngtthi
(43.4%) tir vong do benh mach vanh (Coronary Artery Disease). Du doan den nam 2015,
CVDs van la benh lY gay tir vong hang dau, gay tir vong khoang 20 trieu ngueri.

• 1995

• 2000

13"anh tim BOnh mach genii phOi Ung thu'

mail tido

Hinh 5.1. TS', 10 gay tCr vong cua cac benh theo thong ice

141
HOA SINH LAM SAN

Tai bian
mach mau nao
Bann 6 mat

Benh a tim Benh 1y tim:

Tang huy6t ap Benh tim bam sinh
Benh d than
Benh tim mac phai
Benh 1ST d6ng mach:
- Benh dOng mach mau nao
Benh dOng mach vanh
Benh dOng mach than
- Benh d'Ong mach ngoai hien
Benh 1ST finh mach:
Dau va han the - Suy van fmh mach
4n Ong chi duai
do giarn tutil mau - Thuyen tac tinh mach
Benh o' day thAn
kinh ngoai hien

Hinh 5.2. Cac bOnh Ijr a tim va mach mau

1.2. Lipid, apolipoprotein, lipoprotein (LP) huliet twang

1.2.1. Lipid huyeit twang

1.2.1.1. Lipid toan phan

Lipid than phan huyet tuong bao g6m: triglycerid, cholesterol, phospholipid, acid beo...
Lipid toan phan dao dOng tit 3,6 — 8,2 g/L.
S6 lieu Viet Nam: 5,1 ± 1,13 g/L.
Ve sinh 1ST lipid toan phan tang theo tu6i cho an 60 tu6i thi bat dau giam.
Lipid toan phan có the tang nguyen phat trong benh tang lipid huyat gia dinh hoac
tang thir Oat trong cac benh suy giap, dai thao dtromg, xo vita dOng mach...
Ngay nay xet nghiem lipid toan phan it duoc chi dinh trong lam sang. Viec xet nghiem
tirng thanh phan lipid coy nghia nhieu hon trong chan doan, dieu tri va phong benh.

1.2.1.2. Cholesterol

Cholesterol huyat Wang c6 hai ngu6n g6c: ngoai sinh (thfic an) va not sinh (do co
the tong hop).
Cholesterol ngoai sinh dirge van chuyen tit runt den gan boi chylomicron (CM).
Cholesterol not sinh &roc tong hop chi' yell o gan, trong do mot phan duoc van chuyen

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 CHU'O'NG 5 00" HOA SINH LAM SANG BENH LY MACH VANH CAP

tai to bao ngoai hien bgi cac lipoprotein: VLDL (Very Low Density Lipoprotein), IDL (In-
termediate Density LP), LDL (Low Density LP), met phan ducyc dua vao mat xueng met.
Khoang 1/3 cholesterol huyet tuong a duai clang to do, 2/3 dugi dang ester hoa vai
acid beo, hai dang nay dugc do chung vai nhau goi la cholesterol than phan (CT).
Tri s6 binh thuemg: 150 — 220 mg/dl (3,85 — 5,67 mmol/L).
S6 lieu Viet Nam: 185 ± 23 mg/d1 (4,76 ± 0,59 mmol/L).
Cholesterol tang nguyen phat trong benh tang cholesterol huyet gia dinh va tang thir
phat trong cac benh suy giap, hei chung than hu, dai thao duang,...
Dac biet c6 mei tuang quan tSr le thuan gicra neng de cholesterol huyet Ira tan suat
bi benh &ling mach vanh (BMV) da dugc khang dinh qua nhieu nghien ciru.
Theo khuyen cao cua Hei xa vita deng mach Chau Au: benh mach vanh c6 nguy ca
cao khi neng de cholesterol > 250 mg/dl.
Ty se: C TP/HDL-C < 4 la tat nhat, it c6 nguy co benh mach vanh.
Khi neng de cholesterol M. do tang cao, to bao se tkr dieu him bang ba ca
- Hoat hoa enzym LCAT (Lecithin cholesterol acyl transferase) de chuyen
cholesterol to do thanh cholesterol este dkr trir a to bao.
- Lrc che enzym HMG-CoA-Reductase (13-hydroxy (3metyl Glutaryl CoenzymA
Reductase) lam ire die tong hop cholesterol nei sinh.
ch6 tong hop receptor clac hieu vai LDL, diet' h6a,s6 luting receptor mang
to bao, de phong tich lily qua mite cholesterol trong to bao.

1.2.1.3. Triglycerid
Triglycerid la ester dm glycerol vai acid beo.
Triglycerid c6 hai nguen g6c: ngoai sinh (thirc an) va nei sinh (do gan tong hop).
Trong huyet tuang triglycerid ngoai sinh &roc van chuyen bai chylomicron va
triglycerid nei sinh throe van chuyen bai VLDL.
Tri se binh thugng theo se lieu Viet Nam: 112 ± 40 mg/dl (1,27 + 0,45 mmol/L).
Triglycerid huye't tang thir phat trong cac tatting hop: an nhieu ma, xa gan do rucru,
dai did() duang, vi'em tuy, viem gan...
Triglycerid huy6t tang nguyen phat trong cac benh tang lipid huyet gia dinh...
Neu triglycerid huyet tang keo dai sau an la met nguy co tiem L benh IST tim mach.

1.2.1.4. Phospholipid: chiem khoong 30% lipid toan phAn

Phospholipid bao gem: lecithin, sphingomyelin, cephalin.

143
HOA SINH LAM SANG

Tri so binh thuerng theo so lieu Viet Nam: 207± 0,28 g/L (2,67± 0,36 mmol/L).
Phospholipid tang trong yang da tac met, xa gan mat thir pilaf va nguyen phat...
Phospholipid giam trong xo gan mat bit I-Ong_
Xac Binh t-ST so phospholipid/cholesterol la mot thir nghiem v'e nguy ca sinh xa vita
dOng mach tot han la cholesterol.
TS, so nay binh thuang tit 1-1,2.
Ty so nay cang giam thi cholesterol cang de tang dong ten dung mach.
Bang 5.1. Xet nghiem triglycerid va cholesterol mau 6 tharn dO r6i loan chuyen
h6a lipid (theo "HOi xo' viya dOng mach Chau Au")

Triglycerid (TG) va cholesterol (C) Rifli loan chuyen boa lipid

C < 200 mg/dl (5,2 mmol/L) KhOng
TG < 200 mg/di (2,3 mmol/L
C: 200 — 300 mg/di (5,2 - HDL-C < 35 mg/di
TG < 200 mg/di (2,3 mmol/L)
C > 300 nig/dI (7,8 mmol/L)
TG > 200 mg/dl (2,3 mmol/L)

1.2.2. Apolipoprotein (Apo)

Bang 5.2. ChU'c nang cCia mot s6 Apo

Apo Chtiv nang

float boa LCAT (Lecithin Cholesterol Acyl Transferase)
an ch xt n u c holesterol. Tong hop a runt, gan
immimins
op runt, gan
11.11Wi sinh tir runt ye gan duoi clang CM
an chuyen lipid not sinh (gan tong hop) den cac to bao ngoai bien du
B100 arta VLDL IDL LDL. Ring hop a gan
u the LDL) dua LDL vao not bao
CI oat hoa LCAT
CII oat boa LPL (LP Lipase)
CIII che LPL
11.1111.1111111111Ptp cho su loc CM du V VLDLdurakhoi
11111 uyet Wong
Apo AI la apo chinh cua HDL. Giam apo AI tim thy o Nnh nhan bi .13'tth mach
vanh. Vi Vay Apo AI nhu la mot dau hieu tien down benh mach vanh.

144
 CHUONG 5 ► HOA SINH LAM SANG BeNH L)% MACH VANH CAP

Tri s6 binh thuong La Apo AI: nam 105 - 175 mg/dl, nit 105 - 205 mg/dl
Apo B 100 c6 trong tat ca cac LP sinh xa vita, d'ac biet la LDL c6 tY le Apo B >
95%. NhiL nghien cuu da chirng minh c6 m6i Wang quan thuan Oita n6ng d6 Apo B 100
v6i tan suat bi benh mach vanh.
Tri s6 binh thuang La Apo B 100: nam 60 — 140 mg/dl, nit 55 — 130 mg/dl,
Va ty s6 binh thuong cila: Apo B/Apo AI < 1.
Apo A + HDL- C = Yeu to bao vie ch6ng xa vita Ong mach.
Apo B + LDL- C (VLDL- C) = Yeu to gay xa vita dOng mach.

1.2.3. Lipoprotein (LP)

Bang 5.3. Tinh ch6t, thanh phAn hoa hoc dm LP
Tinh chat va VLDL LDL HDL
CM
thanh phAn Pre F. LP 13 LP a LP

Triglycerid
olesterol to d
olesterol este
Phospholipid

145
 Bang 5.4. M6t s6 chtirc nang cua cac LP

Chylomicron VLDL LDL

rugt Do chuyen hoa

VLDL nhO

Van chuyen an c uyen TG Van chuyen n chuyen C

do runt hap t o gan tao thanh gan tao thanh de the thira tir to
ye gan den to bao ngoai to bao ngoai bie o ngoai bien
bien ve gan

Vay: VLDL va LDL la hai yeti to gay xa vita dOng mach.

HDL la yeu to cheng sinh xa vita d6ng mach.
1.2.3.1. HDL-C
Khoang 25% cholesterol huyet tuang dirge van chuyen trong HDL.
Gia tri binh thuong cua HDL- C > 35 mg/c11.
Gia tri HDL- C bi anh huang boi nhieu yeu to nhu but thu6c la, tu6i, tap luyen,

Nhieu cong trinh nghien cuu da chi:mg minh c6 moi throng quan nghich gift HDL-C
va tan suat benh mach vanh.
HDL-C < 35 mg/dl chi rO nguy co benh mach vanh a ca nam va
1.2.3.2. LDL-C
LDL-C c6 m6i tuang quan thuan vgi tan suAt fir' vong do benh mach vanh.
Gia tri binh thuong: < 130 mg/dl.
Neu c6 them yeti to nguy co khac thi LDL- C can giam xu6ng < 100 mg/dl.
LDL-C la yen to rat manh gay xa vita d6ng mach.
1.2.3.3. VLDL
Cling la yeu to manh gay xa vita dgng mach (XVDM).

146
 CHU'O'NG 510- HOA SINH LAM SANG BENH L'? MACH VANH CAP

1.2.3.4. Rdi loan LP huye't

Bang 5.5. Cac kieu r6i loan LP huy6t

Mil loan Mticdi) nguy

Ricii loan DO trong Tan so
K'eu hiem voi
LP huyet lipid huyet huyet tuvng xuat hiOn
XVDM
ismommorimoimmiiiiM1111000
ay ga
LDL i
in

nrkr7are.
1.3. Xcv viva Ong mach - ha'u qua
mar nm
XVDM la mot benh dien lien tham fang trong nhieu nam den khi xuat hien Nnh canh lam
sang tram trong nhu can dau th& ngtrc, nhei mau ca tim, tai bien mach man nao.
Nguyen nhan la do cac mang xo vita phat trien lam hep va gay fac long d'Ong mach
lam giam cung cap mau va oxy tai cac mo.
Thtramg tem thucmg chi xay ra a cac dOng mach lam va vita, khong thay ten thucmg
xay ra o tinh mach va demg mach nho.
XVDM la rang dung cholesterol ding vai calci o cac to bao not mac &Ong mach.
Benh XVDM lien quan den chuyen h6a lipid va LP.

1.3.1. Nguyen nhan

Nguyen nhan duy nhat la LDL tang cao trong mau thuang xuyen.
Nguyen nhan lam LDL tang cao: the (10 an nhieu va thuamg xuyen lipid bao
an nhieu cholesterol ngoai sinh.
Yeu to gop phan gay XVDM nhu suy giap, suy tny, huyet ap cao, nghi'en thu6c
nghien rugu, thieu van dOng, the cao an uong khong lanh manh, stress keo dai,

1.3.2. Cach thhm lipid vac) thanh ding mach

Thanh dOng mach co ba l6p: not mo, clued not mo va lap glib_ Noi mo la l6p tiep
Vic true tiep vairmau va là hang rao dau lien ngan can lipid tharn vao thanh mach. Lipid,
dtr6i clang LP tham vao thanh mach bang cach di qua khoang ke ciia cac to bao not mo.
Cac enzym trong he thong lysosom thiiy phan LDL tao acid amin va cholesterol tu
do. Cholesterol tix do la nhiing phan tit alcol gay d'Oc cho to bao.

147
FICIA SINN LAM SANG

Trong truong hop 16p not mo binh thuong chi c6 cac hat c6 kich thuov nho mai lot
qua duoc nhu HDL, LDL, VLDL c6 kich thuov < 70 nm. Khi cac hat LP loai nh6 nay tang
cao nhat la LDL va ton thuo'ng thanh mach thi luong lipid tham vao cang nhie‘u, nguy co
dOng mach cang cao.

1.3.3. Vai tro caa LDL trong sinh bOnh xa visa dOng mach

Mang tong cua I LDL-C huyet tang dong

DM binh thu,Ong lipid

Mang Su, tang sinh

XVDM tiep tuc

Thay doi, thoai h6a, khuynh Kich thich Lu,u luvng

hiyO'ng tao CVC mach I6'n

Thi6u mau cuc be) 61,

Nhoi mau .111(

to chi:pc

Hinh 5.3. Co' the gay XVDM va nhoi mau a to chi:pc

1.3.4. Hau qua ctia xo' vika Ong mach: tit na"ng ne, gay ra b6n hOu qua
1.3.4.1. Tana huyet ap
Nguyen nhan do thanh mach day, thanh mach cirng lai, long mach hep lai, mat tinh
dan h6i, long mach g6 ghe.
Bien chirng dm tang huyet dp: nh6i mau ca tim, nh6i mau nao, xuat huyet nao...

1.3.4.2. Tac mach

Do hep long mach khien duong kinh long mach hep chi con < 30 %.

148
 CHU'O'NG 5 ► HOA SINH LAM SANG BENH L? MACH VANH CAP

1.3.4.3. T6c mach hoar) town

Do mau gong trong long mach, nguy hiem nhat la tim va

1.3.4.4. V& mach

Do thanh mach cirng, chen ep \Tao mach mau nuoi lam mach eh& va phinh mach
du6i ap lurc lam be tung mach mau.
NhUng xet nghi'em hoa sinh co' ban danh gia nguy co. XVDM: theo th6a thuan cud
Hei XVDM Chau Au thi nguy ca XVDM dirge at ra khi cac xet nghiem ve lipid va LP
huyet tucmg vuot qua cac gi6i han sau:
Cholesterol toan phan > 200 mg/dl
- Triglycerid > 200 mg/dl
- LDL — C > 130 mg/di
- HDL — C < 35 mg/di
- Apo B > 130 mg/di
- Apo A < 120 mg/di
Ty s6: Cholesterol TP/HDL-C > 4,5
- Lp (a) > 30 mg/di
Trong thlyc to lam sang,dieu tri r6i loan LP mau, con phu thu6c vao viec benh nhan
c6 hay khong c6 nhang yeti to nguy co khac. Doi khi nhfing gidi han tren con phai ha thdp
xuong neu benh nhan c6 nhieu yeu to nguy co ket hop.

V gay tic h9
M duoi don

MXV gay tac OM

Chau 2 ben

Hinh 5.4. Hinh anh xo' vita dOng mach

149
HOA SINH LAM SANG

MXV KHONG ON DINH

V6 fibrin m6ng

VO fibrin day

Loi mee Ian

LO1 m& nho

Qua trinh hinh thanh, MXV c6 the On dinh hoc met on dinh.
MXV mat on dinh c6 the v&, bong d'Ot ng0t, nguy cd de doa
tiem tang

Hinh 5.5. MXV on dinh va MXV khong on dinh

Hinh 5.6. Mang xo' viya on dinh

Co vó fibrin chdc, day, mire dO viem nhijm thdp. Loi chira it lipid thixOng dAn d6n
ldp day long mach (lam hep).

150
 CHU'O'NG 5 ► HOA S/NH LAM SANG BENH L)! MACH VANH CAP

Hinh 5.7. Mang xo' vt:ra khong on dinh. Co khuynh hung va va

cran den tac mach

Vo• mang ?co vu•a K6t tap lieu c'au Huy6t kh6i

Hinh 5.8. Cuc mau dOng xuat hien o ch6 va mang xo' vCra tao huyet khoi gay
tac mach

151
HOA SINH LAM SANG

Tai bin
mach mat] nao
Benh & mat
Benh mach
vanh Banh d tim

Benh mach Tang huyat ap

nao
Benh de than
Benh mach
Tien then sang thuang ngoai hien

Khong co Khong ro CO
trieu chivng trieu chirng trieu chumg

K4o dpi nhiki nSm

Oau va han the
van dOng chi &Fiji
do Om ttpai mau
Banh di' day than
kinh ngoai Pion

Hinh 5.9. Qua trinh tin trik xa vu'a dOng mach va hau qua

1.4. HO chirng mach vanh cap

Hinh 5.10. Hinh anh giai phau tim va mach mau

152
 CHUUNG 5 l• HOA SINH LAM SANG BENH L1.1 MACH VANH CAP

Hinh 5.11. Can dau that ngtyc

Vi tri
hoai fix

VOng
ton thu'ang
Wing thi6u mau

Hinh 5.12. Nh6i mau ca tim

Deic diem sinh ly mach vanh:

Mach vanh tirOi mau cho tim nhung chiu anh Inrong tnyc tip hoat &Ong cua co' tim.
Mach vanh chi nuoi tim nhung c6 nghia nuoi toan b8 ca the. Mach vanh kh8ng c6 nhanh
not thong, n6u mot nhanh bi eac thi ca viing tim do mach mau d6 nuoi &fang se khong
&roc cung cap mau.
Dinh nghia: HCMVC la mit tap hop nhung trieu chirng lam sang gay ra boi tinh
trang thieu mau co tim cap. B'enh 13'7 dm &Ong mach vanh ding nam trong Nnh canh toan
than dm ton thucmg he thong Ong mach trong co the.
Nguyen nhan: do va mang xa vita vai thuyen t'ac cap tinh, t'ac nghen ca hoc, tinh trang
viem nhi6m, dau that ngkrc khong on dinh thin phat, co that mach vanh.

153
HOA SINH LAM SANG

HOi chat-1g cap (HCMVC)

ECG

D6u an sinh hoc tim

Hinh 5.13. Nhang banh nhan co HCMVC dugc phan chia thanh hai mang Ign co ban
(Rya vao ECG va doan ST cila ECG

Xet nghiem ve cac dau an sinh hoc tim c6 vai tro quan trong trong chan doan, tien
luting va theo dOi dieu tri benh nhan c6 HCMVC.

1.4.1. Can dau that ngu'c

1.4.1.1. Nguyen nhan
Do thieu mau co tim. Chine 'tang co tim tST le thuan luting matt den a dap irng nhung
nhu eau chuyen h6a cua co. the.
Con dau that nguc xay ra khi nhu cau oxy cua co tim lam hon luting oxy dugc cung
cap. Cuong dO cna con dau that nguc tST le thuan vai cutting d6 lao dOng.

1.4.1.2. Co' ch6

Khi mot nhanh dOng mach vanh hep, lam duamg kinh long mach nho hon 30% hoac long
mach bi tac do cue mau Tong thi phan tim do nhanh dOng mach vanh d6 nuoi,du6.ng se
kh6ng duoc mau nuoi. Phan co tim se tan dung het phan mau con lai clued chi') tac. Nhang
chat chuyen h6a bi it Tong lai do kh6ng duos rim di gay gian mach va tang tinh tham
thanh mach. Huyet tucmg tham ra khoang ke gay phut, cac to bao con lai trong long mach
gay dong mau. Cac sgi co tim khong chuyen h6a rift bat dau thodi hoa, hoai tix va chet.

154
 CHLICYNG 5 110' HOA SINH LAM SANG BENH Ll! MACH VANH CAP

1 Ich da
"' kin
hydrolase
u to bao co' tim

Dau dOi

Hinh 5.14. Ca the gay dau do thi6u mau co' tim

Kh6ng do tim
Nguyen nh5n khac

Benh nhan den cap d

dau ngcrc

Do tim
HOi chU'ng MVC

Hinh 5.15. Xet nghiem dau an sinh hoc 15 cong CI) chk down giCip ph5n loci
nguy cap d6i vai benh nhan bi dau 6 ngt,rc

155
 CON DAU NGLYC
Dien tam do (ECG)

ST ST Song T (-) Binh thubng

Dau an troponin

(+) 1 Ian (+) 2 Ian

Hinh 5.16. Thai do xCr tri dau that ngu'c

1.4.2. Nhoi mau ca tim

Tren the gibi trong met nam co khoang 2.5 trieu nguiyi ch& do nhei mau ca tim.
Chin doan NMCT la met viec lam At kho khan vi khong phai tat ca b'enh nhan deu
có trieu chung dien hinh va can dau dir dei.
NMCT clang "tham Lang" chiem khoang_20Vo
Lcac tnremg hop.
\Tay de chan doan ch'ac chAn NMCT, to can phai hoi tin sir ley, kham lam sang, do
ECG, do hog de cac enzym trong huyet thanh.

1.4.2.1. Dinh nghia

NMCT la tinh tang dm met phan ca tim bi hity khi ltrang mau cung cap den phan do bi
giam sift. B'enh nang ho:dc nhe phu thuec vao yang ton thucmg cita ca tim nhieu hay it.

Hinh 5.17. Hinh anh mot viing co' tim bi nh'oi mau

156
 CHUO'NG 5 II.' HOA SINH LAM SANG BNH LV" MACH VANH CAP

1.4.2.2. Nguyen nhan: NMCT do cac nguyen nhan sau

Do cue mau (long trong long d'Ong mach gay tac deng mach vanh hoac‘do XVDM va vor.
mang XVDM gay tac dOng mach vanh. Do co that Ong mach vanh (Om ca do cocain).
Do bac tach dOng mach chit lan den dOng mach vanh. Thuyen tac clOng mach vanh (do
viem nei tam mac, van tim nhan tao, huyet kh"Oi thanh tim, u nhay). Viem mach mau (benh
Takayasu, hOi chimg Kawasaki). Viem co tim (hoai ttr co' tim: du khong gay benh Ong
mach vanh).

Than chung
DM doan ghn DMLTTR doan ghn
Nhanh nut xoang Nhanh cheo 1
Nhanh non Nhanh ntif trai
DMVP doan gan DMLTTR
Nhanh vach
doan giCra
thin nhat
Nhanh that phai NhAnh bey 1 Nhanh cheo 2
DM mu doan xa
DMVP doan giCra

Nhanh sau ben DMLTTR

Nhanh bey phai doan xa

DMVP doan xa Nhanh lien that sau

Hinh 5.18. Giai phAu Ong mach vanh

157
HOA SINN LAM SANG

Xa vCra dung mach vanh

v
Mang xo' vDa Huye't khoi mach vanh

Nhei mau ca tim

Loan
nhp

WV

Xung huy6t tim

Ch et

Hinh 5.19. Nguyen nhan tir vong do xo' vira dOng mach vanh
Theo Te chirc Y to The glad de chan doan NMCT phai có 2 trong 3 tieu chuan sau:
1. Trieu chimg lam sang: dau thAt noc kieu mach vanh.
2. ECG: dien hinh.
3. Deng hoc: thay del men tim va cac dau An sinh hoc tim mach.

158
 CHU'O'NG 5 ► HOA SINN LAM SANG BENH Ll'" MACH VANH CAP

2. XET NGHIEM CHI DAU SINH HOC

2.1. Cac chi clAt., sinh hoc tru'&c hOi cht"png mach vanh cap

Mat On dinh MXV tim

MPO
i l
MPO BNP, NT-proBNP
PLG

CRP

CHOLIN CRP hoai tCy

cTn I, cTn T

ThiL mau
Cholin

Hinh 5.20. Cac da( u An sinh hoc tnyevc HCMVC

2.1.1. Myeloperoxidase (MPO)

MPO la yeti to xay ra khi mang xo vita bi viem, mat tinh on dinh.
MPO la mot dang hemoprotein c6 hai chu8i. N6 clugc tiet ra bai cac to bao neutrophil,
monocyte va macrophage trong qua trinh duce hoat hoa, va &roc tich luy a mang xo vita
mem de bi b6c tach.
MPO c6 vai tro phat hien tinh trang mang xo vita mat tinh on dinh truac khi no bong
ra, giup naafi ngira NMCT ngay tit giai doan hinh thanh mang xo vita.
MPO tien luong nguy co bien chi ng tim mach teen benh nhan c6 HCMVC. Khi
dinh luang neng dO MPO tang trong huyet thanh, no có cac gia tri sau:
- Tri so dOi chiau: 60pmol/L (45 - 950).
- Chuyen dOi don vi: ng/ml x 7,14 = pmol/L.
- Gia tri trong chan doan NMCT.
- Tien luong dal han nguy co NMCT tit 1 den 6 thang.
- Lien quan den gia tang mUc dO suy tim.
- La dau an sinh hoc cua trong giai doan mang xo vita mat tinh on dinh.
Tap hop cac gia tri theo dai cua MPO rat hint ich trong du bao nguy co NMCT
ma dinh lugng troponin am tinh.
- Co gia tri du bao am tinh cao khi nOng dO MPO thap, nguy co c6 HCMVC thap.

159
FIOA SINH LAM SANG

2.1.2. Placental Growth Factor (PLGF)

PLGF la yell to tang tnrang not mac mach mau.
PLGF thuOc nhom Cysteine-knot, có trong luting phan tir 50kDa heterodimer. No
gan ket vOi sFit-1 (soluble FMS like tyrOsine kinase-1).
Nhiem vu cua PLGF la kich thich to bao ca tran mach mau, va huy &ling dai thuc
bao vao yang ton thircmg xa vita dOng mach.
Gia tri nguiitg thuang dung cua PLGF: 27ng/L.
, Christopher Heeschen va Ong sit (2004): nghien ciru ten 626 benh nhan nhap vik
cap ciru vi dau floc trai (can lam sang c6 ECG voi ST binh thireyng), lay mau xet nghiem
PLGF ket qua cho thay nhOm c6 PLGF > 27ng/L, nguy co tit vong hay NMCT tang cao
gap 2 tan sau 24 gia, tang cao gap 2,6 lan sau 72 gia, tang cao gap 4,8 Ian trong 30 ngay.
Nemg dO PLGF tang cao trong huyet thanh c6 cac gia tri sau:
- PLGF la yeu to du bao dOc lap tit vong hay NMCT trong yang 30 ngdy.
- PLGF c6 gia tri chan cloth' cho nhom dei Wong dau that nguc tai phong cap cum
- PLGF c6 gia tri tien luting dai han 4 nam.
- N'Ong dO PLGF tang cao trong mau, du hau )(Au cho ca hai nh6m benh nhan c6
troponin am tinh va duang tinh.

2.1.3. Cholin
Cholin có m6'i lien he chat the trong tien trinh mat tinh on dinh cua mang xa vita
mach vanh.
MXV khong on dinh Thie'u mau cuc 1D6'

Phospholipase D host h6a

Cholin phong thich vao mau

Hinh 5.21. Six phong thich cua cholin khi MXV mat tinh On dinh
Tom lai: cholin co lien quan voi tien trinh chinh cua thieu mau cuc bO va sit mat tinh
on dinh cita Mang xa vita dOng mach.

160
 CHliCYNG 5 l■ HOA SINH LAM SANG BENH LV4 MACH VANH CAP

H6i chirng mach yanh cap (HCMVC)

ECG, troponin, WBCHOIACHO

Troponin (+) Troponin (11111, roponin (-) Troponin (-)

WB/PLCHO (+Al WB/PLCHO (- 0 (+) PLCHO (+)

NMCTC (ST Lap lai XN „guy co' tim-1

sau 6 — 12 gi• MXV khong on
dinh

Di6u tri NMCT Chup DMV Chup DMV

Ch6ng k6t tap T reu th sem
Ch6ng huye't kh.

Hinh 5.22. Phac do chin down trong HCMVC

*WB: whole blood, PL: plasma, CHO: cholin

2.2. Cac chi d'au sinh hoc trong hoi chirng mach vanh cap

Mat On dinh M Suy tim

MPO BNP, NT-iLoBNP
imam

Thi6u mau
. Cholin

Hinh 5.23. Cac chi au sinh hoc trong hOi chirng MVC

161
HOA SINH LAM SANG

RIA doi vs:51

BNP va
MYOGLOBIN proANP RIA doi vdi
proBNP
CK-MB POCT d6i vai
AST CK CK-MB mass cTnT myoglobin CK-MB,
cTnI
cTnT Immuno
LD
ANP assay doi
yOi
I A
I Genetic
arker
1V V V VV V V
1950 1960 1970 1980 1990 2000 2005

Hinh 5.24. Qua trinh phat hien cac chi dau sinh hoc tim
Cac chi dau sinh hoc tim trong HCMVC giup chan doan NMCT dua den ca sd xac
dinh ham lucmg cac chat co trong to bao ca tim ducyc phong thich ra khi co tim bi ho4i tir,
bao gam cac xet nghiem GOT, CK, CK-MB, LDH, myoglobin, troponin.
Cac xet nghiem nay lam cang sam cang tot, nhac lai dinh ky de theo doi tien trien
va mUc do lan r6ng ctia o ho4i
ECG xuat hien soma han cac enzym khi benh nhan bi NMCT nhung c6 flitting vi tri
nh6i mau ma ECG khong phat hien &rye, chiem khoang 10%.
Vay de chan doan NMCT can ket hop ECG va cac xet nghiem ve chi dau sinh
hoc tim.

2.2.1. Aspartat amino transferase (AST)

Tri se) d6i chieu dm AST -dr 10 — 40 U/L, trong NMCT c6 the tang: 300 — 500 U/L.
Trong NMCT, enzym nay tang hog tinh ngay trong nhfing gia (tau va con keo dai
trong nhfing ngay tiep theo, vi vay no co gia tri trong chan doan NMCT muon va theo dOi
tai phat. Gia tri cila hog tinh enzym nay con co the dugc dung de phan biet ngu6n goc
tang cUa CK là tix ca tim hay ca xuo'ng.
AST bat dau tang tir 10 gia sau NMCT, dat dinh sau 36 gia, va tra ve binh thuang
sau 72 gia.
AST can coo gan va a ca xuung vai mot luang nho.

2.2.2. Lactat Dehydrogenase (LDH)

LDH la enzym c6 trong bao tuang to bao, c6 nhieu trong cac ca quan nhu gan, tim,
ca xuang, thin._

162
 CHU'O'NG 5 ■ HOA SINH LAM SANG BENH LY MACH VANH CAP

Dien di LDH to c6 5 clang isozym LDH dtrac danh se tir 1 den 5. Trong do LDH 1
la clang isozym tim va LDH 5 la clang isozym gan, cg.
Tri s6 d6i chieu cua LDH tir 250 — 450 U/L
Trong NMCT, LDH bat dau tang tir 20 gia sau NMCT, dat dinh cao sau 72 gia, va
tra ve binh thuang sau han 1 tuan. Vi vay LDH c6 gia tri chan doan NMCT cham, hoac
chart doan hoi citu Ara theo dOi six h'6i phuc cua NMCT.
Ngoai ra LDH can tang trong cac truemg hop b'enh 13i ve gan, co, ung thu...

LDH LDH

4 3 2 1 5 4 3 2
LDH - isoenzym LDH - isoenzym

Hinh 5.25. Hinh anh diOn di do LDH

2.2.3. Creatin kinase (CK) va CK-MB (M: Muscle, B: Brain)

CK la mat enzym c6 chirc nang chuyen h6a giira creatin va creatin phosphat (dang
du tit nang luting ATP tai cac to bao co). CK Co trong cac co quan nhu tim, Co xtrang
(chiern nhieu nhat, gap 6 lan a tim), nao, co trop. Khong coo gan va ph6i. 95% hoat tinh
CK a trong mau la c6 ngu6n gee tit co.
CK la xet nghiem dinh huang tot cho chan doan NMCT neu co xuang khOng c6
ton thuong.
- Neu ty le CK/AST khoang 5 (giai han tir 2 - 9): gap trong benh NMCT.
- Neu ty le tren la 27 (giai han tit 13 - 56): gap trong ton thuong co xuong.

2.2.3.1. CK
CK la mat dimer g6m hai ban don vi: M (muscle) va B (brain), no c6 3 dang isozym:
- CK-BB: c6 nhieu a to bao nao, nhung kh6ng qua dugc mang nao de vao matt.

163
 - CK-MB: c6 nhi6u a co. tim, CK-MB < 5-6% CK toan phan.
- c6 nhieu a co xuang va tim.
Trong NMCT, hoat firth CK tang ngay trong nhfing gia dau, bat dau tang dr 4 gia
sau NMCT, muon nhat la 6 gia, dat muc toi da dr 12 - 24 gia, va tra ve binh thuang sau
3 den 4 ngay. Hoat tinh cao nhat cua CK c6 the dat tai 2.000 U/L.
Tri s6 d6i chieu cua CK: 24-190 U/L.

2.2.3.2. CK-MB
Trong NMCT, hog tinh CK-MB tang sam va giam nhanh hon so vai CK.
CK-MB bat dau tang tir 3 gia sau NMCT, dat mire t6i da tir 12 — 24 gia, va tra v6
binh thuang sau 2 den 3 ngay.
Tri s6 d6i chieu cua CK-MB: < 25 U/L.
CK-MB tang sam va giam nhanh la chi dau hiru ich trong vi& chart doan NMCT
tai pith va sit lan rOng dm 6 nh6i matt
Trong chain doan NMCT ngtrai to con chit y den tY le gifra CK va CK-MB:
Neu CK > 160 U/L va CK-MB > 5% CK toan phan cho phep nghi den NMCT.
Ngoai ra hog dO tang CK va CK-MB con g'Op a nhirng ton thuang ca tim: viem co
tim, loan nhip tim nlang, sau chan thuong tim...
Su tang hoat dO CK-MB trong matt a cac dang cap tinh cua ton thuong co: viem
loan dtrOng co lien trien,... nghi den mire do ton thuong co tim kem theo.

Bang 5.6. Hoat do cac enzym trong HCMVC

ENZYM TWA gian b'At dam tang Dinh cao Thai gian N4' binh thuong

CK-MB 12 — 24 giiiwitik 2 — 3 ngay

CK RIO gia(r! 121411111 12 — 24 glib 3 — 4 ngay
AMER 10gia (6 — 111111. 18 — 36 gia 1W 3 — 4 ngay
LDH 71IPIP 20 gia > 8 ngay
LDH1 t6 - 12 gia 1111 32 gia 10-20 ngtly

164
 CHU'ONG 5 I. HOA S/NH LAM SANG BENH LV/ MACH VANH CAP

2 3 4 5 6 7 8 ngiy

Hinh 5.26. -Dtromg bib" u den crOng hoc cac enzyme trong HCMVC

Nhitng xet nghiem mod trong chin doan NMCT.

Vi cac enzym CK, CK—MB khong du nhay va cung khong du dac hieu de giiip phat
hien hoai tir to bao ca tim. Do do ngueyi ta d'a Oat hien 0. to bao co' tim c6 cac protein,
peptid mai c6 du de nhay va du do dac hi'eu.hon giup chin doan NMCT chinh xac hon.
- Myoglobin
- Troponin
Myoglobin: myoglobin la mgt chromoprotein c6 trong cac to bao ca. N6 c6 nhiem
vu cung cap oxy tai cac ca van. Khi to bag co tim bi hoai tfi, myoglobin se giai ph6ng
ra huyet twang hoac huyet thanh va c6 the phat hien dugc. Nhung khi co van bi ton
thirong nhu dung dap ca... cling giai phong ra myoglobin, va enzym nay c6 trong co
van nhieu hon trong co tim. Vi vay, xet nghiem nay hien nay ngugi ta it dfing den de
chin down NMCT.
Myoglobin dugc ph6ng thich vao mau rat som ngay khi to bao co tim bi ton thuang.
N6 bat dau tang -lir'2 giO. den 4 gig sau NMCT, Ira tro ve binh thuemg ter 10 gig den 12 gig
sau NMCT. Vi vay myoglobin khong dugc thing ey nhitng b'enh nhan dugc xet nghiem muon.
Myoglobin la chi dau dugc biet den semi va nhay nh'at trong nhitng gig dau tien bi
NMCT.
Troponin: troponin giup chin Joan ca seem va muon NMCT. Troponin la met chat
phirc hap gem ba protein ket hap ved nhang sgi cua co. van (tim va xuang), nhung khong

165
HOA SINN LAM SANG

coo co trop. Phirc hop Troponin troponin T (TnT), troponin I (TnI), troponin C
(TnC). Tat ca cac troponin deu c6 tac dung dieu hoa su co co.
Tat ca cac loai co deu co troponin nhung troponin ,a co tim mang tinh dac hieu cua
tim, khac vai troponin cac co khac ye cau true bac nhat dm protein (ve so luting, trinh
to sap xep va thanh phan cac acid amin). Vi vay khi,te bao co tim Nva, viec phat hien
troponin la dac hieu va khong the nham ran vai cac to chirc khac.
Co the hoat dOng: su trugt cua cac sgi myosin tren cac sgi actin gay co co. Xay ra
khi ion Ca" gan vao vi tri protein tiep nhan.
Troponin tang nhanh trong nhang gio dau ging nhu CK-MB.

PHU'C HOP TROPONIN

Phivc hap Troponin

TnC TnI TnT

Tropomyosin

Ca2+

Hinh 5.27. Phiyc hap troponin

Troponin C: calmodulin, ga'n Ca", c6 4 vi tri ga'n calci.

Troponin T: ga'n phirc hop troponin T vao tropomyosin.
Troponin I: ire the myosin ATPase cho den khi Ca" g'an vao troponin C, lam bien
doi cac tuong tac protein va cho phep dien ra su co co.
cTn I va cTn T la khang the &lac hieu cua tim.

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 CHU'O'NG 5 lo• HOA SINH LAM SANG BENH MACH VANH CAP

A: Myoglobin
20 B: Troponin
C: CK-MB
D: Troponin sau DTNKOD
10

Gieri han ch6n down MI

Gi(ri han tham chi6u tren

3 4 5 6 7
Hinh 5.28. DOng hoc dm troponin, CK-MB, myoglobin

Troponin I (TnI).
TnI rat dac hieu vai m8 tim, do do TnI la mot chi au v6i ngay ca hxcmg hoai tirrat
nh6 cua tim.
Tri se ci6i chieu cua TnI trong huyet tuang cuc kST nho: < 0,01ng/ml. Nen bat ky mot
luting nh6 TnI nao co the Oat hien duoc cling deu coy nghia benh 1Y.
TnI bat dau tang tir 3 gi6 den 6 gi6 sau khi khai phat NMCTC. Dat dinh cao trong
vong tir 14 gi6 den 20 gi6 va tra ve binh throng sau 5 den 10 ngay. TnI tang cao hurl so
voi CK-MB hoac myoglobin trong NMCTC.
Tang n6ng dO TnI clang d6ng nghia vai tang nguy co tir vong &ei vdi benh nhan.
Troponin T (TnT):
Tri se doi chimg cua TnT trong huyet Wang: < 0,1 ng/ml.
N6ng dO TnT huyet thanh bat dau tang trong yang tir 3 gi6 den 4 gi6 sau khai phat
ton thuong co tim, dat dinh cao trong -yang tir 10 gia den 24 gi6 va tang keo dai tit 10 ngay
tai 14 ngdy sau NMCT cap.
TnT cling tang trong benh thieu mau co tim cap.

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TnT throng tinh gia o b'enh nhan than.

Tri s6 binh thuong cua TnT trong huyet Wang rat nho, nen khi phat hien dirge mgt
lugng TnT nao deu coy nghia benh 13'f.

Bang 5.7. DOng hoc cac chi clau sinh hoc tim trong NMCT

Chat chi di6m Xu'at hilen Cao die'm Trey ve binh thtr&ng

Bang 5.8. -ID6 nhay cCia CK- MB va troponin trong phat hien NMCT khong r6 c6
ST chenh len

Enzym Trtarc 6 06. Sau 6 gi& sau khi bit dim bi NMCT

CK- MB > 4,7na/m1 53% 91%

hge on in T > 0,18ng/m1 51% 94%

Irp
r onin I > 0,1 ng/ml 66% 100%

Can xet nghiem cac enzym dinh lcSr sau con NMCT de Oat hien nhitng bien chirng
c6 the xay ra nhu NMCT tai dien, xuat hien tang con tram trong cua nh6i mau...
Trong NMCT tai di8n, hoat dO tang cac enzym c6 gia tri chin doan hon ECG (vi
ECG ton tai lau hon).

2.3. Suy tim sau hOi chivng mach vanh cap

Beta Natriuretic Peptid (BNP), va NT- proBNP (NT: N-Terminal):

BNP la mgt hormon peptid, c6 tic dung sinh hoc Wong to nhu peptid bai nieu natri
oh tam nhi — ANP (Atrial Natriuretic Peptid).

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 CHUONG 510- HOA SINN LAM SANG BENH L.1.1 MACH VANH CAP

BNP dugc du tit chi' yeti a ca tim cua tam that. NOng dO BNP trong mau tang khi
co tang the tich mau nhu sung huyet tim, tang huyet
Pro-BNP c6 trong co tim g6m 108 acid amin, khi yao mau dugc tach thanh hai
chd6i polypeptid: chdOi c6 trinh tu dan dau c6 ten la NT-proBNP Om 76 acid amin va
BNP Om 32 acid amin. Ca NT-proBNP va BNP luu thong trong tuan hoan. BNP c6 hoat
tinh sinh hoc.
Co m6i lien quan tuy6n tinh giaa sir tang BNP va mire dO tram trong dm sung
huyet tim.
NT-proBNP va BNP dirge giai phOng \Tao mau khi co tam that bi cang qua mirc.
Tri s6 d6i chieu oda NT-proBNP va BNP: < 100 ng/L.
Phu nix tren 45tu6i c6 nOng dO NT-proBNP cao han nam giai 50%.

Tg bac) ca tim Pre-proBNP

(134 aa)

Pro-BNP Peptid
(108 aa) (26 aa)

NT-proBNP
(76 aa)

Mau

Lai ti6u, tang bai rOu Na

Hinh 5.29. Sinh tong hap BNP va NT-proBNP

Tac dung cua BNP ya NT-proBNP:

,NT- proBNP ya BNP c6 tac dung: gay giain dOng mach, tang thai nuac ya natri, 1.rc
che to bao ca tim tang truang, phi dai.
Dinh lugng nOng dO NT-proBNP ya BNP &mg de sang loc suy tim khi chua c6 Neu
hien lam sang a nguai cao tuoi, tang huyet ap, dai did° duemg, benh d'Ong mach vanh
khong co trieu chimg.

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HOA SINH LAM SANG

NT-proBNP va BNP ngoai tang trong suy tim, no con tang trong cac tnratng hop nhu
tuoi cao, co dia beo phi, shock, suy then, tang trong tang ap phoi, hed chirng suy ho hap
cap, benh plied man tinh tic nghen
NT-proBNP danh gia r6i loan chirc Wang that trai tot hem BNP. Vi v4y NT-proBNP
c6 tinh on dinh va ben vcrng hcm BNP.
Gia tri cua BNP va NT-proBNP:
NT-proBNP va BNP có gia tri trong chin doan suy tim sung huyet, chin doan cac
giai doan suy tim, chin doan phan bit suy tim sung huyet cap v6i cac nguyen nhan gay
khO th6 khaa. Ngoai ra no con c6 gia tri theo doi ket qua dieu tri suy tim sung huyet.

KhO tho' cap

X-quang, ECG, NT-proBNII

NT-proBNP (pg/ml)
<300 300-1800 >1800

Khong co it co khaivain FC6 nhreu ha nan

Hinh 5.30. NgLYO'ng NT — proBNP trong suy tim cap theo tu6i

Bang 5.9. Ngu,Cvng NT — proBNP trong suy tim cap theo tu6i

NT — pro BNP (pg/ml)

It c6 kha nang suy tim Co kha nang suy tim
> 450

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 CHU'O'NG 5 ► HOA SINN LAM SANG BENH LY MACH VANH CAP

Khong suy tim Suy tim

ANP
NT - proANP
ANP
NT - proANP
BNP
NT - proBNP
BNP
NT - proBNP

Hinh 5.31. Cac hinh anh suy tim va kh6ng suy tim

Nghi ngo' suy tim

ECG VA NT - proBNP

125 pg/ml > 125 pg/ml

Khong có kha nang Bleu am tim

suy tim Cac phu'ang tien khac,

Hinh 5.32. Phac do cha'n down suy tim

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I-16A SINN LAM SANG

1800 _ 1707
1600 _ 1571
1400 _
1200 _
1000 _ 951
800 _
600
400 _ 342
200 _
56 125
0
I II III IV

Hinh 5.33. Wing TO NT — proBNP ya MI:PC d() suy tim cap

T6m lai cac dau an sinh hoc dung de xac dinh nguy co., tien luting, chan doan, theo
dOi trong ya sau dieu tri NMCT.
Tay theo tang giai doan ton thuo'ng mach mall de lam cac xet nghiem uu tien ye
cac dau an sinh hoc.

Mat on dinh MXV Suy tim

MPO BNP, NT-proBNP

Phan Crng yiem cap - Threu mau

hsCRP Cholin

Hinh 5.34. Xet nghiem truac, trong va sau HCMVC

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 CHLIO'NG 5 ► HOA SINN LAM SANG BENH LY MACH VANH CAP

3. Glo'l THIEU MOT SO BENH AN

A. CAU HOT NGHIEN CiefU
Truirng hop 1
Benh nhan: Nguy8n Thi H., phai nil, 78 tuai.
Nhdp vien luc 12g20' ngdy 21/11/1998. L3'T do nhdp vien: dau noc trai, lan len vai.
Tien cao HA, nhan ndo.
Tinh trang luc nhdp vien: mach 96 ldn/phat, huye't ap 190/100 mmHg, nhip tha
12 ldn/phitt.
ECG: ST chenh len 3mm a V2, V3, V4, V5, T(-) a V2, V3, V4.
Chin doan sa b6: Nhai mau co tim cap.
Ket qua xet nghiem sinh h6a ngdy 21/11/1998: cholesterol: 230 mg% T, triglycerid:
329 mg% 1‘, HDL: 20 mg% 1, LDL: 144 mg% t, glucose: 137 mg%.
Ion do: Nat: 145 mEq /L, 4.1 mEq /L, C1-: 104 mEq /L, Ca': 4.6 mEq /L.
Men tim:

SGOT SGPT CK LDH

Chin dam xac dinh:

Trtdrng hop 2
Benh nhan HuSmh Minh T., phai nam, 69 tu6i.
Nhdp vien liic 9 gia ngdy 18/11/2000. I4T do nhdp vien: dau noc trai.
Tien sir: benh tim khong rO.
Tinh trang luc vao vien: mach 92 ldn/phirt, huye't ap 100/60 mmHg.
ECG: ST chenh lenh tir V1 d8n V5 5mm
Chdn doan so ba: NMCT.
Sinh hod: glucose: 97 mg%, BUN: 46 mg%, creatinin: 1.6 mg%, cholesterol: 129
mg%, HDL: 36 mg%, LDL: > 2mg% (<130mg%).
Ngdy 4 (18/11/98) NO), 6 (20/11/98)

Chrin dam xac dinh:

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HOA SINH LAM SANG

Tryon hop 3
B'enh nhan Tran Thi M., phai nu, 89 tuei.
Nhap vien luc 21g55 02/12/2002 vi met, kilo the..
Tien sir: cao huyet dp, thieu mau co. tim, suy tim.
Tinh trang luc vao vien: mach: 88 lin/ph-rat, huyet 160/100mmHg, nhip the.: 24
lin/phut, Sp02:83%.
ECG: ST chenh xueng 6 V2 — V6, Tame. V1 — V5.
Chin doan sa be: theo del nhei mau ca tim.
Ket qua xet nghiem sinh h6a: ure: 18 mg%, Cre: 1.1 mg%, Ion do Nat: 143 mEq/L,
K.±: 4.3 mEq/L, Ca": 2.6 mEq/L, cholesterol: 289 mg%i, TG: 129 mg%, HDL: 58 mg%,
LDL: 206 mg%T.
Men tim:
SGOT SGPT CK LDH MB Tnl

ESL
Chin clocin xeic Binh

Truirng hop 4
B'enh nhan Phan Anh T., phai nam, 65 tuei.
Nhip vien: ngay 22/10/1999. LST do: dau ngvc trai lan len vai —> lan xueng tay trai.
Tien six: khoe manh, but thuec la ngdy 30 di'eu.
Luc vao vien: mach 100 lin/phik, huyet ap: 120/80 mmHg, nhiet de: 37°C.
Do ECG: ST chenh len V1 — V5, c6 s6ng Q va T 6 V2 — V5.
Chin clown sa be: nhei mau co tim cap.
Ket qua xet nghiem sinh h6a: cholesterol: 275 mg%T, TG: 149 mg%, HDL: 39
mg%, LDL: 224 mg%t, glucose: 85 mg%. BUN: 14 mg%, Cre: lmg%, Ion de): Nat: 140
mEq/L, K±: 3.7 mEq/L, Cl-: 99 mEq/L, Ca': 5.0 mEq/L.
Men tim:
MEN SGOT CK LDH MB TnI

Chcin °loan xeic Binh:

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 CHU'O'NG 5 ON- HOA SINH LAM SANG BENH LY MACH VANH CAP

B. CAU HOI LCONG GIA

1.Niing de cholesterol mau tang trong car benh sau day, ngoai trir:
A. Suy giap B. EICii chgng than hu
C. Dai than duerng D. Viem gan
2. Khi niing de cholesterol ttr do mau tang, to bao tir ditu hoa bang co' elle:
A. Hoat hoa enzym HMG-CoA reductase de ire che tong hop cholesterol tu)i. sinh
B. ch6 enzym lipase a giam thily phan TG bin thanh acid beo tg do —> cho-
lesterol
C. Hoat hoa enzym LCAT de chuy'en cholesterol tg do cholesterol este dg trir
to No
D. Tat ca.3'r tren dUng
3.0 ngtrori trtrOvg thanh kluie manh, tST s6 PL/C IA:
A. < 4,5 B. > 4,5 C. 1-1,2 D. < 1
4. Theo "Ilei xif vita Ong mach Chau Au" co rei loan chuyen hoa lipid khi:
A. Cholesterol = 200-300mg%, TG = < 200mg% va HDL-C > 35mg%
B. Cholesterol > 300mg%, TG > 200mg%
C. Cholesterol = 200 – 300mg%
D. Tat cd3itren thing
5. O ngtroi binh thiromg khoe manh ty se ApoB/ApoAl là:
A. < 1 B. > 1 C. 4,5 D. 20
6. Yeu to nao sau day bao ve cluing xo' vita dOng mach tot nhat:
A. HDL-C B. LDL-C C. ApoB D. ApoA va HDL-C
7. Thanh phan nao sau day thay del nhitu khi mang xo' vita viem, mat on dinh:
A. CRP B. MPO C. Cholin D. PLGF
8. Thanh phin nao sau day thay doi nhitu khi mang xo' vita thieu man cue be, mit
on dinh:
A. CRP B. MPO C. Cholin D. PLGF
9. Enzym nao sau day tang sour nhat trong nhtui mau co' tim cap:
A. AST B. LDH C. HBDH D. CK

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HOA SINN LAM SANG

10. Gii tri cua xet ngh*n BNP Ira NT-proBNP:

A. Chan doan suy tim sung huye't
B. Chan doan phan biet suy tim sung huy& cap voi cac nguyen nhan gay kilo th6 khac
C. Theo &Si k6t qua di'eu tri suy tim sung huye't
D. Tat ca y tren &mg
11. CO Apo nao sau day c6 chin tang tic dung ngtro;c:
A. AI va B48 B. All va B100 C. Al va B100 D. All va. B48
12. Cip LP huyk nao sau day c6 chirc nang tic dung ngiryc trong b'e'nh 1ST XVDM:
A. VLDL va LDL B. VLDL va HDL C. IDL.va HDL D. LDL va HDL
13. Nhom xet ngh*n nao sau day c6 nguy co' cao trong XVDM:
A. TG>150mg%, Cholesterol>200mg%, HDL-C<35mg%, Apo B >130mg%
B. TG>200mg%, Cholesterol>200mg%, HDL-C<35mg%, Apo A >130mg%
C. TG>200mg%, Cholesterol>200mg%, Apo A<120mg%, Cholesterol TP/
HDL-C >4.5
D. TG>300mg%, Cholesterol>200mg%, HDL-C<35mg%, Apo A >130mg%
14. Tip hop xet nghFOn nao sau day sir dung trong chin doin trtr6c HCMVC:
A. MPO, CRP, PLGF, cholinesterase B. MPO, cholin, BNP, NT-proBNP
C. Cholin, CRP, MPO, GOT D. MPO, cholin, CRP, PLGF
15. Diu an sinh hoc nao sau day tang cao khi ming xo yea co nguy CO' Vtr:
A. MPO B. PLGF C. CRP D. Cholin
16. Ming di cholesterol not sinh chiu anh hifirng cua enzym nao sau day:
A. LCAT B. HMG-CoA Synthetase
C. LP.Lipase D. HMG-CoA Reductase
17. Triglycerid ngoii sinh duvc yin chuy6n
A. CM B. VLDL C. LDL D. HDL
18. Triglycerid not sinh duvc yin chuye'n hot
A. CM B. VLDL C. LDL D. HDL
19. Phospholipid min giam trong b'Onh nao sau day:
A. Suy than man B. Xo gan mat bu nang
C. Tang lipid matt D. Suy giap flan phat

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 CHUCYNG 5 ► HOA SINH LAM SANG BE-NH L'? MACH VANH CAP

20. Ch9n cau c6 3"7. dung nhit:

A. VLDL ciugc tong hop er gan va rut
B. Triglycerid ngoai sinh va nOi sinh dirge van chuy'en boi CM
C. LDL va HDL dugc tong hop a gan
D. TAt ca.3"T tren clang
21. Xet nghiem nao sau day do gia tri thy bao am tinh cao khi nOng do thip, nguy
co c6 hOi chfrng mach vanh cap thap:
A. Cholin B. PLGF C. CRP D. MPO
22. Xet nghiem nao sau day lien quan nheiu dtn tin trinh chinh elm thieu man c9c
bO va mat tinh on dinh dm ming xo' vita &Ong mach:
A. Cholin B. PLGF C. CRP D. MPO
23. Trong nhOi man co. tim, clang isozym LDH nao sau day tang cao:
A. LDH1 B. LDH2 C. LDH4 D. LDH5
24. Ditu nao sau day khong dung khi not ve xet nghiem CK:
A. TS, le CK/AST # 5: gap trong NMCT
B. Ty lO CK/AST # 27: gap trong ton thuong ca xuang
C. CO nhi'L a gan, phOi, tim
D. CK là mot dimer Om 2 ban don vi M va B
25. Xet nglife'm nao sau day tang soin nhit trong NMCT:
A. CK B. GPT C. LDH D. GOT
26. Xet ngh*n nao sau day tang rat som khi tim bi hoai fir nhung teen lam sang
it dung de chin down NMCT:
A. Troponin B. GOT C. Myoglobin D. LDH
27. Cac y sau day dung, ngoai trir:
A. BNP có tic dung sinh hoc tucmg to ANP
B. NOng dO BNP trong mau tang khi co tang the tich ink nhu xung huyat tim,
tang huyet ap
C. Gia tri binh thuang cua NT-proBNP va BNP: < 10Ong/L
D. Nam giai tren 45 tuOi có nOng dO NT-proBNP cao ban nix giai 50%
28. Nhom xet nghi'e'm nao sau day tang s6in nhit trong NMCT:
A. CK, CK-MB, troponin B. Troponin, BNP, ANP
C. AST, ANP, troponin D. AST, LDH, HBDH

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HOA SINH LAM SANG

29. Thieu enzym nao sau day gay nen tinh trong huyet tuong duc nhur sira sau bira
an nhieu
A. LP.lipase B. LCAT C. HMG-CoA reductase D. Cholinesterase
30. 'Prong plarang phap din di, thanh phin nao sau day tu'ung timg voi LDL:
A. CM B. pre-LP C. LP D. LP
31. C#p Apo nao sau day có chuic ning tic dung nguvc trong XVDM:
A. AI va B48 B. AII va B100 C. AII v B48 D. AI va B100
32. Clap LP huyet nao sau day có chtic nang tic dung nguvc trong4nh ly XVDM:
A. VLDL va LDL B. VLDL va HDL C. IDL va HDL D. LDL va HDL
33. Nhom xet nghiOn nao sau day có nguy co' cao trong XVDM:
A. TG>150mg%, Cholesterol>200mg%, HDL-C<35mg%, Apo B >130mg%
B. TG>200mg%, Cholesterol>200mg%, HDL-C<35mg%, Apo A >130mg%
C. TG>200mg%, Cholesterol>200mg%, Apo A<120mg%, Cholesterol TP/HDL-C >4.5
D. TG>300mg%, Cholesterol>200mg%, HDL-C<35mg%, Apo A >130mg%
34. TOp hop xet nghi?m nao sau day sir dung trong chin doan trmit HCMVC:
A. MPO, CRP, PLGF, cholinesterase B. MPO, cholin, BNP, NT-proBNP
C. Cholin, CRP, MPO, GOT D. MPO, cholin, CRP, PLGF
35. Xet nghi?m nao sau day có the throng tinh gii tren bOh nhan suy th4n:
A. AST B. Troponin I C. Troponin T D. Myoglobin
36. Protein nao xuit hqn semi nhwng khong dac hien trong nhii man co' tim:
A. CK-MB B. Myoglobin C. TnT D. GOT
37. Protein nao khong tang nhieu trong ton thwang co' van:
A. CK B. LDH C. GOT D. TnI
38. Gia tri cua xet nghqm nao sau day khong the tang cao neu huyet thanh trong:
A. Triglycerid B. Phospholipid C. HDL-C D. LDL-C
39. Lecithin co nhieu trong lipoprotein nao:
A. HDL B. LDL C. VLDL D. CM
40. C4p lipoprotein nao trong mau có tic dung nguvc chieu nhau:
A. CM va HDL B. IDL va VLDL
C. LDL va HDL D. CM va LDL

178
 t*

41. Qui trinh van chuyen nguvc cholesterol bi giam khi:

A. HDL-C giam B. ApoAl giam
C. HDL-2 giam D. Tat ca y tren
42. Ty le lipid cao nhAt trong lipoprotein nao:
A. CM B. LDL C. HDL D. VLDL
43. Ty 1" protein cao nha't trong lipoprotein nao:
A. CM B. LDL C. HDL D. VLDL
44. Co' the bi nhie'm toan chuyen hoa trong truivng hop nao:
A. Dal thao duong B. Nhin doi lau ngdy
C. Suy than D. Tk ca tren
45. Cac dien giai nao sau day co nhieu trong not bao hurl ngoai bao:
A. Natri, clorua B. Phosphat, clorua
C. Calci, natri D. Kali, magie
46. Trong phifung phap sieu ly tam, thanh phAn nao sau day tuong !Ling voi LP:
A. CM B. VLDL C. LDL D. HDL
47.Protein nao sau day tang sOm nhit trong nhOi man co' tim cap:
A. Myoglobin B. AST C. LDH D. CK
48. Protein nao vira dac hieu, vira co cira so chAn doan eking trong nhOi mau co'
tim cap:
A. Myoglobin B. Troponin T C. LDH D. CK
49. Protein nao có mire di) tang cao nhit trong nhoi mau tim cap:
A. CK B. LDH C. HBDH D. Troponin
50. ROi loan lipid, lipoprotein man kieu nao có nguy co' cao nhit voi XVDM:
A. CM tang, HDL-C giam B. Cholesterol tang, HDL-C tang
C. LDL-C tang, HDL-C giam D. LDL tang, VLDL tang
51.Ts, so nao tang co nguy XVDM:
A. ApoB/ApoA 1 B. LDL-C/HDL-C
C. Cholesterol toan ph'an/HDL-C D. Tat ca y tren
52. ApoAl co nhieu nlidt trong lipoprotein nao:
A. LDL B. HDL C. VLDL D. CM
53. ApoB100 co nhieu MIL trong lipoprotein nao:
A. LDL B. HDL C. VLDL D. CM

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 Chu'o'ng 6
HOA SINH LAM SANG
BENH LY TUYEN NOI TIET
MUG TIEU
1. Trinh bay Ave d6 lieu hoa ngtroc truc dtroi dai-tuyn yen-tuyen
2. Liet ke cluvc she thay doi cac xet nghiem hoa sinh trong twang giap.
3. Liet ke Ave su• thay doi cac xet nghiem h6a sinh trong nhuvrc

DPJ CU'O'NG
Co the song la met kh6i th6ng nhat hoan chinh, vai tre chuyen hoa cac chat trong co the
la do'cac to chic va ca quan dam nhiem. Cac chirc nang cua cac co quan, be phen trong
co the duct dieu hoa boi hai he th6ng là N than kinh va he nei tiet.
He th6ng than kinh: &rig vai tre dan truyen tin hieu hay th6ng tin di qua met he
th6ng co dinh ve eau trite.
He th6ng nei tiet: g6m nhieu hormon do the tuyen dee biet bai tiet va dirge van
chuyen trong mau nhtr nhung thong tin di dOng de tat &Ong len cac co quan.
Hai N thong nay c6 m6i lien quan rat tinh vi. Vi du catecholamin la nhiing chat dan
truyen than kinh a mot to chirc nay nhtrng lai la hormon o to chic khac.
Tuyen nei tiet la cac tuyen khong e6 6ng dan xuat, cac hormon cua no tham trgc tier,
qua N mao mach do thong vao mau. Hau ha c6 nguon gee tir cac to bao Welt me, ngoE
ra o tinh hoan (san xuat testosteron) Aid buong tang (san xuat estrogen) c6 nguon gee tir to
chirc lien ket, trong he th6ng than kinh tuyen yen va cac to bao tiet c6 nguon gee than kinh.
Cac tuyen nei Wet nam rat rat trong co the nhtr tuyen yen, tuyen giap, tuyen can giap,
tuyen thuong then, tuyen tay nei tiet, tuyen sinh due. Ngodi ra cac co quan khde ding co
chirc nang nei tiet nhu viing duai doi, cac dau ten clang eila cac sqi than kinh, 'Ong tieu
h6a, then...
T6 chirc dich CO lien quan met thiet den cac he thong nei tiet. Tin hieu tir he than kinh
trung uong dtroc truyen qua met boat he tir dieu chinh toi to chirc dich cuoi clang.
‘Viing duoi doi la trung tam phihop chirc nang th6ng nei tiet. N6 nhen va
truyen tin tir N than kinh trung uong, san xuat ra nhfing hormon dieu hoa di tai tuyen tien

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I-16A SINN LAM SANG

yen, mot s6 dugc goi la "yeu to giai phong" c6,tac dung kich thich tien yen tiet ra mot
hormon Wang *rig, so khac goi la "yeu to ire che i c the tien yen tiet hormon. Khi dugc
kich thich, tien yen se tiet hormon vao mau de van chuyen tai cac tuyen n6i tiet khac nhu
v6 thugng than, tuyen giap, tinh hoan, buong trimg, tuyen tuy nOi tiet...
Cac hormon vimg duoi d6i dugc san xudt vai mot lugng rat nho.

1. DANH GIA CHCPC NANG TUYEN YEN

Hinh 6.1. Tuyen yen

Tuyen yen là tuyen nOi tiet nh6, kich thuac 1 cm, trong lugng 0,5 — 1 g, ndm a day
nao. Tuyen yen c6 hai
ThUy truac goi la tien yen hay yen tuyen, c6 5 loai to bao tiet ra 6 hormon, dong vai
tro chinh trong su ki'em sok chirc /fang chuyen hoa cua toan co th6, do la somatotroph
tiet growth hormon (GH), corticotroph ti& adrenocorticotropic hormon (ACTH), thyro-
troph tiet thyroid stimulating hormon (TSH), gonadotroph tiet follicle stimulating hor-
mon (FSH) va luteinizing hormon (LH), lactotroph ti& prolactin (PRL). 30 - 40% to bao
thily truoc la somatotroph, 20% corticotrop, moi loai con lai 3-5%, tuy nhien cac hormon
nay rat manh giap ki6m soat chirc nang tuyen giap, sinh duc va bai tiet sua cua tuyen yd.

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 CHUO'NG 6 ► HOA SINE/ LAM SANG BUNN LY TUYEN NOI TIET

Cac hormon nay c6 nhfing dac di6m sau:

- V6 eau frac, la nhang polypeptid Wang d6i dai (ACTH c6 39 acid amin).
- Ve tac dung:
+ Kich thich cac tuyen not tit san xuat hormon ttrang frng.
+ Die‘u hoa chuyen hoa glucid, lipid, protein va din giai cua nhieu to chirc, ca,
mo gan...
- Co. ch6 hoat dOng cda hormon tin yen la tao phirc hcrp H-R o mang bdo ttrang va
hoat hoa adenylatcyclase (AC).
- Su bai tit va tong hop hormon tin yen not Chung dtrov ki6m soat bed h6 th6ng
feed-back.
Thily sau hay hau yen hay yen thAn kinh khong san xuat ma chi china 2 hormon Id
anti-diuretic hormon (ADH) con goi la arginin-vasopressin (AVP) va oxytocin.

1.1. ChCpc nang sinh ly thOy tru'o'c tuy6n yen

HAu h6t cac hormon cua thiiy truerc tuy6n yen du c6 tac dung kich thich t6 bao tuy6n dich
nhu tuyen giap, vo thugng than, buong thing, tinh hoan va tuyen vu. Rieng co GH tao ra
tac dung tren hdu h6t t6 bao o cac mo ca th6.

1.1.1. Growth Hormon (GH)

Hinh 6.2. Hormon GH cua they tru&c tuyen yen

GH la mot protein di 191 acid amin trong mot chai don, trong hrong phan tin la 22
kDa. N6 lam phat tri6n hau h6t cac m6 ca th6, lam tang kich thuac t6 bao, tang phan bao,

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HOA SINH LAM SANG

phut trien se luting to bao, va da'c biet la gay biet h6a mot s6 to bao nhu to bao xuang va
to bao co, sau khi truemg thanh xuang ngimg phut hien, trong khi cac mo khac van tiep
tuc phut trien.
Tac dung chuyn hoa
Chuyen hoa protein: GH lam tang mire tong hop protein trong tat ca to bao co the
bang cac tac dung:
- Tang v'a'n chuyen acid amin qua mang to bao, lam tang neng de acid amin not
bao tuo thuan loi cho tong hop protein.
- Lam tang dich ma ARNm de tong hop protein.
Tang sao chop ADN trong nhan de too thanh ARNm, qua do gidp thitc day sir
tong hop protein va phut trien ca the. ,
- Giam hoa protein va cac acid amin to bao. N6 huy &Ong mot luang ,lan acid
boo tu do dr cac to chirc de cung cap cho nhu cau nang luting co the.
Chuyen hoa lipid: huy dOng acid boo tir cac to chirc lam tang acid boo to do trong
mau, tang sir dung acid boo cho nang luting. Nhu vay ca the clanh glucose va protein cho
so phut trien. Khi tang qua nhieu GH se tang sir dung acid boo sinh ra nhieu the ceton va
viec huy dOng nhieu acid boo ve gan ding gay ra chimg gan nhiem
Chuyen hod glucid:
- Giam tieu ding glucose cho nang lugng do tang huy dOng acid boo nhu trinh bay
a tren.
- Tang du till glucose duai dung glycogen trong to bao: glucose khong tieu di cho
nang luting se vao trong to bao.
- Tang glucose mau: glucose vao trong to bao clued tac dung ciia GH nhung tac
dung nay chi keo dui 30 phut den 1 gia, sau do to bao da nhan glucose qua mire se
khong nhan them lam tang glucose mau (c6 the den > 50% so vai binh thuemg)
va c6 the xuat hien glucose nieu goi la dui thao dueing do tuyen yen.
- Tang bai tiet insulin do hai tac dung: GH lam tang clueing huyet dong thai kich
thich truc tiep to bao beta dia tuyen toy tiet insulin. Su kich thich nay doi khi qua
mire gay kiet quo kha nang tiet insulin dm to bao beta gay dui thao clueing do toy
that stx. Vi vay GH dirge coi la nguyen nhan gay benh dui thao clueing.
Hog dOng cua GH can c6 su phei hop dm insulin va glucid, neu thi'eu insulin va
glucid, GH se khong gay phut trien co. the.
Kich thich sun va phut trien xuang
Tac dung rO rang nhAt cua GH la tang phut trien xuong, bao gem: (1) tang gift protein
cho to bao sun va to bao sinh )(mug, lam xuong phut trien, (2) tang mire sinh san cua to
bao nay, (3) chuyen to bao sun thanh to bao sinh xuong, nhu the se to xuong mei. Co hai
co the phut trien xuong:
- Cac xuang dui phut trien chieu dui a sun dAu xuang, a do dau xuong lien ket
vai than xuong qua sun n6i. DAu tien la tao sun mai va sun nay se chuyen thanh

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 CHU'O'NG 6 ► HOA SINH LAM SANG BENH LY TUYEN NOI TIET

xuong lam keo dai than )(strong va day dau xuong ra xa. D6ng thai ban than sun
dau xuong ding citroc sir dung clan de sau tu6i twang thanh, dau xuong not vai
than xtrong va xuong khong dai them duce nua. GH kich thich tat ca cac qua
trinh nay, nhtmg khi dau xuong not vai than xuong thi GH khong the lam dal
xuong duce nita.
Cac to bao tao xuong nam a chung quanh xuong va mat s6 h6 xuong, chimg tao
xtrcmg mai tren be mat dm xuong cit. Wong thi cac to bao hay xuong hity di cac
xuong cu, khi mac d6 tao xuong 16n hon hity thi xuong ngdy cang day len. GH
kich thich manh tao cot bao lam xuong to ra va qua trinh nay din ra suot dai, dac
biet la cac xuong mang.
GH kich thich gan va mot so to chirc tao ra nhieu protein nho goi la somatomedin,
no c6 tac dung manh lam tang sty phat trien xuong. CO 4 somatomedin &roc phan lap,
quan trong nhat la somatomedin-C con goi la Insulin-like growth factor 1(IGF-1), nemg
do dm no trong,huyet tuong c6 quan mat thiet vai mac bai tiet GH. Ngugi to cho rang
tac dung chit yeu caa GH là th6ng qua somatomedin hon la true tiep len xuong va cac
mo khac.
Didu boa bai tiet GH
Bai tiet GH thay cf6i timg,phirt va tang trong cac trirang hop nhin doi, giam tram
trong protein, giam dtrang huyet, Ming d6 acid beo trong mau giam thap, tap luyen, lao
dgng, chan thuong. Hac biet no tang trong 2 gig dau sau khi ngit say.
N6ng de GH binh thugng trong huyet tuong a ngtrai lan tir 1,6 den 3ng/ml, 6 tre em
va Med trtrang thanh khoang 6ng/ml. Khi nhin dOi keo dai, du tilt dm protein va glucid
dia co the bi giam, neog c/6 GH tang len den 5Ong/ml.
Vimg cluai d6i bai tiet hai hormon de dieu hoa bai tiet GH la growth-hormon-re-
leasing hormon (GHRH) la polypeptid c6 44 acid amin, kich thich tiet GH va growth
hormon-inhibiting hormon (GHIH) c6 14 acid amin, irc cite giai ph6ng GH.
Su dieu boa bai tiet GH phirc tap, ma sir dieu hea lau dai la tinh trang dinh dual-1g,
chit yeu la ham luting protein trong to bao, cang thieu protein cang kich thich bai tiet GH.
Cac bat tlaco'ng bai tiet GH
Bai tiet qua mire GH goi la cuang tuyan yen va giant hoac khong bai fiat GH goi la
suy tuyen yen.
Thieu GH:
Co the bam sinh hay mac phai. Su giam bai tiet GH c6 the xay ra trong thai nien thieu
lam co the cham phat trien, tre 10 tuei chi phat trien bAng tre 4-5 tu6i va den 20 tuei chi
bang tre 7-10 tu6i. Tre khong day thi vi khong c6 dit hormon hung sinh duc. Tuy nhien
c6 mat phan ba twang hop, chi suy hormon GH van c6 kha nang sinh san.

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HOA SINN LAM SANG

Nguai suy tuyen yen chi thieurGH don thuen, c6 the duoc dieu tri khoi hoan toan,
GH con có tac dung cai thin cac roi loan chuyen hoa khac, vi no co chirc nang chuyen
h6a kha rung.
Suy tuyen yen,tren ngued lan hay gap do u chen ep hay tac mach mau tuyen yen,
thuemg la do s6c tun hoan sau sinh (h6i chirng Sheehan).
Suy tuyen yen se den den met chirc nang Binh due, suy giap gay phis niem, tang can,
giam san xuat hormon glucocorticoid tuyen vO thuong then.
ngurori giam hay met kha nang bai tiet GH, qua trinh gia se phat trien nhanh Nhur
vey gia la mot qua trinh do giam dan six bai tiet GH cua tuyen yen tithe.
Tang tiet GH:
Benh kh6ng 16 (gigantism) thuang do u trong tuyen yen a to bao somatotroph,
hay can goi to bao ua acid gay nen. Vic san xuat qua In& GH lam cho tat ca. ma
ca the Oat trien nhanh, va neu xay ra truck tu6i day thi khi chua dung den xucmg
thi co the phat trien nhanh ve chieu cao, thanh ngued khong 16, có the cao ten 2m.
Nguai kh6ng to bi tang throng huyet va to bao beta bi thodi hoa do lam viec qua mix
duai su kich thich cua duang huyet cao va do kich thich true tiep cua GH. Khi u tien trien
qua mix c6 the den den suy yen.
Benh to dau chi (acromegaly): neu u tuyen yen a to bao somatotrop, xay ra sau
tuoi truang thanh. Xucmg khong dai ra dirge tuy nhien van day len, to ra dec biet
là cac,xuang det tao nen hinh clang dec biet g6m ham va tran nho ra tnxac. Cac
ma mem van tiep tuc phat trien lam mlai to ra gap doi binh thuremg, ngon tay, chan
to ra va cac co quan nhu gan, then ding 16n dan.

1.1.2. Adrenocorticotropic Hormon (ACTH)

La met polypeptid c6 39 acid amin.
Tac dung: Kich thich to bao lap 136 va Wed cua vo thuong then, no lam tang bai
tang sinh va phi dai cac to bao nay.
Dieu Ma bai tiet: Chu yeu do kich thich cua corticotropin-releasing hormon (CRH)
yang duai doi, do la met polypeptid c6 41 acid amin. Ngoai ra con c6 stress tinh than va
the xac, chi trong vai philt den den su tang bai -het ACTH va cortisol den 20 lan.
Nhip ngdy dem: su tiet CRH xay ra theo chu kST ngay-dem lam cho su tiet ACTH
clang tuang tu. Nhip tiet khoang 15 phat/len, dat dinh lfic 8 gia sang va thap nhat khoang
22 gia den 2 gia.
Cac stress ve the xac nhu kich thich dau hay pha hi:1y to chirc (dachen thuong),
dau tien dirge truyen den ndo, r6i den yang du6i doi, a day CRH dirge tiet vao he thong
dm yang duai doi-tuyen yen. Trong vai phut, CRH gay tang bai tiet ACTH va cortisol
vao

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 CHU'O'NG 6 0- HOA SINH LAM SANG BENH L).1 TUYEN NOI TIET

Cac stress tinh than lam tang nhanh stx hal tiet ACTH. N6 lam tang hoat gong cila he
limbic, dac biet la vtlng hanh nhan hai ma, r6i ca hai viing nay truyen thong tin den viing
duai doi.
Dieu hoa ngugc cua cortisol len yang dirai doi, tuyen yen: khi n'ang de cortisol trong
mau tang len no tac dung dieu hoa ngugc am tinh len yang duai doi lam giam bai tiet
CRH va len tuyen yen lam giam ACTH. Ca hai tac dung nay ginp gift on dinh n6ng de
cortisol trong mau.

1.1.3. Prolactin (PRL)

La met hormon do to bao tra acid dm tien yen net ra, c6 cau true la chai don poly-
peptid c6 198 acid amin, trong luting phan tir' 23 kDa.
Tac clung
,
Kich thich tuyen bai tiet sita, nhung chi ea tac dung that su khi tuyen vu da dirge
Oat trien day du clued tac dung cila estrogen va progesteron. Do do trong chu kST bung
trimg binh thiremg prolactin duet bai tiet ra it, va khong c6 the dung kich thich tuyen vu
bai tiet sua. Trong thai Icr co thai, prolactin dirge bai tier tang len tir' tuan thir nam, va
tiep tuc tang den thai ky sinh con, Mc nay no tang den 10-20 lan so vai binh thuong. Ben
canh do nhau thai cung tiet ra met luting hormon somatomammotropin c6 tac dung sinh
sua nhe, nhu vay hai hormon nay phihop de gay bai tiet sfra. Tuy nhien truck khi sinh
tuyen vu van chua bai tiet sita vi hai hormon estrogen va progesteron ire che sir bai tiet
sua cila tuyen
Ngay sau sinh, ca hai hormon estrogen va progesteron do nhau thai tiet ra ngung dot
nget, cho pile") tac dung sinh sita prolactin. Sir bai -het sib can sir phoi,hop cila met so
hormon khac nhu GH, insulin, cortisol va thyroxin, nhung hormon nay can thiet de cung
cap acid amin, acid beo, glucose va calci can cho sir tao sita.
Di'du hda bai tiet prolactin
Vai tuan sau khi sinh, muc bai tiet prolactin ve binh thixemg nhu luc chua c6 thai. Tuy
nhien khi cho con bu, nhirng kich thich co' hoc se truyen den viing ha doi cila nguai me,
thong qua prolactin releasing hormon (PRH) den tuyen yen trirac gay tang tiet prolactin,
mire bai tiet tang dr 10-20 lan, va keo dai khoang 1 gia, cai do duy tri sir bai tiet sita cho
dot bu tie') theo. Ngung cho con bu, tuyen yen cling ngirng bai tiet prolactin va tuyen vu
ngirng bai tiet scra. Su san xuat sita al the keo dai trong nhieu nam, neu tre van tiep tuc
bu, nhung mire tao sua se giam dang ke sau 7-9 thang.
Trong thai gian cho con bu phan lon ba me khong co chu ky bu6ng,trang va sir rung
tr(rng nen kh6ng c6 thai tiep., Ca che la khi tre milt xung clang truyen len vung clued
doi roi den tuyen yen an den tang prolactin nhu trinh bay a tren. Prolactin se ire the
ngugc lam giam GnRH lam giam bai tiet cac hormon huang sinh, due FSH va LH dm
tuyen yen nen khong co chu bung trirng va rung trong. Vai tuan sau khi ngung cho
con bib cac hoat Ong se tra ve binh thuang nhu nu& khi mang thai.

187
 Vimg duai d6i con tiet ra prolactin-inhibiting hormon (PIH) lam irc the su bai tiet
prolactin cua tien yen, cc') the giam den 10 lan. Dopamin va cac chat dopaminergic ding
c6 the dung irc che tiet PRL.

1.1.4. Follicle Stimulating Hormon (FSH) va Luteinizing Hormon (LH)

A) Hormon tuyen yen

FS
I I I i 1 i

B) Bu6ng ft-Ong Rung truing Hoang the

Nang
• • GoCNO •

C) Hormon bung trCmg Progesteron

Estrogen

D) Noi mac tix cung

Hinh 6.3. Dieu hba bai tiet FSH va LH

Ca hai deu la glycoproteinsclugc tiet ra cac to bao ua base cila tuyen yen, chiing
tac dOng den to chic dich là bung trCmg va tinh hoan.
Tac clung
Bung trung: FSH kich thich mot s6 nang &mg trixong thanh, trong do di mot
truCmg thanh nhanh nhat, chin va xay ra hien tugng rung‘trimg. LH kich thich t6
bao hat, lop vo trong oda to bao nay se tiet ra hormon buong trnng la estrogen.
Tinh hodn: FSH kich thich to bao sertoli trong 6ng sinh tinh, lam cho cac to bao
nay phat trien va bai tiet cac chat sinh tinh trung. Chat nay ding v6i hormon tes-
tosteron co tac dung dinh &fang manh tren ong sinh tinh, lam to bao mam cua
a
6ng nay trigmg thanh nhanh ch6ng, qua cac giai doan trung gian tr6 thanh tinh

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 CHU'ONG 6 IN.- HOA SINH LAM SANG BENH LY TUYEN NOI TIET

trang. LH kich thich to bao ke Leydig bai tiet testosteron, mire bai tiet testosteron
phu thuOc vao n6ng dO LH mau.
Di& hoa bai tiet FSH va LH
Bai tiet FSH va LH cua tuyen yen truac la do hormon yang dual doi gonadotropin-re-
leasing hormon (GnRH) hay con goi la luteinizing-hormon- releasing hormon (LHRH)
dam nhiem, la mot decapeptid.
GnRH dugc bai tiet cach quang 1 den 3 giO, moi lAn chi bai tiet khoang it phut.
Cuing dO kich thich cua hormon nay phu thuOc vao hai yeu to: tan so va lugng GnRH
dugc bai tiet a moi chu kST. Su bai tiet a tuyen yen truac ding c6 chu lcSr theo chu IcSf cua
bai tiet GnRH. Do lien quan chat the nhu the nen GnRH con dugc goi la hormon giai
phOng LH viet tat la LHRH. Trong khi d6 su bai tiet FSH chi thay doi nhe theo GnRH, no
thay doi chum sau nhieu
frc the ngugc cua hormon sinh due len Wing ha doi-tuyen yen: co' the dieu hoe
ngugc am tinh cua testosteron la khi no dugc bai tiet nhieu, se tac dung ix the \Tung clued
doi, lam giam bai tiet GnRH do lam giam bai tiet LH dm tuy'en yen. Testosteron con
tac dung live tiep len to bao yen truac lam giam bai tiet LH. Ngugc lai testosteron mau
giam se cho phdp yang duai doi bai tiet mot lugng han GnRH clan den tang tiet LH
va tang nOng dO hormon testosteron trong mau.
DOi vai FSH, no kich thich to bao sertoli bai tiet cac chAt sink tinh trang, Sing died
to bao nay ding fiat ra hormon la inhibin, IA mot glycoprotein. Khi ong,sinh tinh san xuat
qua nhieu tinh trimg, thi bao sertoli cling san xuat nhieu inhibin. Chat nay c6 tac dung
dieu hoa ngugc am tinh, ire the lai tuyen yen truac, lam giam su bai tiet FSH, do d6 lam
giam san xuat tinh trung. N6 cling c6 tac dung uc the nhe len yang ha doi lam giam n6ng
dO GnRH.
Tac dung dieu hoa ngugc cua estrogen va progesteron len tuyen yen: LH c6 tac dung
duy tri hoang the va kich thich hoang the tiet ra estrogen va progesteron. Khi ming di) hai
hormon nay tang cao trong mau se c6 tac dung *c che ngugc lam tuyen yen truac giam
bai tiet LH va yang duai doi lam giam bai tiet GnRH, tuy nhien mac clO it ham so vai 111C
che ngugc len tien yen va chu yeu la no lam giam tan so nhip Wet GnRH.
Cac t6 bao hat dm hoang the ding tiet ra inhibin, tac dung *c the manh su bai tiet
FSH cua tuyen yen Ira uc the LH vai mire ciO it hon. Khi LH N. uc the thi hoang the bi
teo di.
Dieu hem ngugc ducmg tinh dm estrogen tnreec khi rung truing: 12 ngay sau khi thay
kinh, mot nang truing truing thanh va chin, lap vo dia,te bao hat tiet nhieu estrogen, lac
nay estrogen khong uc the ngugc ma kich thich tuyen yen tiet mot lugng lin LH, gap
6 — 8 lAn so vai binh thuamg, va mot lugng FSH gap doi so vai binh thaerng. Chinh su
tang LIT,Sit ngOt lam truing rung vao ngdy 14 dm chu,kSr kinh 28 ngay. Hien tugng nay
goi la dieu hoa ngugc throng tinh dm estrogen len tuyen yen. Sau khi rung, 17,0 phAn con

189
HOA SINN LAM SANG

lai cua nang trimg, chit yeti la cac to bao hat chuyen thanh hoang the, LH tiep tuc duy tri
hoang the.

1.1.5. Thyroid Stimulating Hormon (TSH)

La mot glycoprotein trong lugng phan tit 28 kDa, co quan dich la tuyen giap.
Tac clung:
- Tac dung quan trong nhdt cita TSH la giai phong T3, T4 vao mau, no gift') phan
giai thyroglobulin, tach T3, T4 ra khoi globulin nay va ph6ng thich chimg vao mau
trong khoang 30 phut.
- Kich thich to bao giap tang kich think va tang san xudt hormon giap.
Tang se lugng to bao tuyen Ara chuyen clang to bao tir hinh khi sang hinh tru.
Die'u boa bai ilk:
Tiet TSH dugc dieu,hoa Thyrotropin-releasing hormon (TRH) dm \rang duai
deli. TRH tac dung true tip len to bao tuyen yen lam tang giai phong TSH.
Lanh kich thich yang &PM deli bai tiet TRH lam tang tiet TSH cua tien yen. Cam xitc
gay tang bai tiet TRH va TSH, kich dOng hoac lo tang kich thich manh 118 giao cam gay
giam hal tiet TRH va TSH, c6 le do tang than nhi8t va tang chuyen h6a lam *c the v-Ung
duai deli.
Dieu hoa ngugc: bai tiet TSH cua thiiy tilt& tuyen yen se giam khi c6 su tang
hormon giap trong mau. Hormon giap tang 1,75 lan so vai binh thuong thi TSH giam tad
khong. Ca the nay gifip duy tri nOng dO hang dinh hormon giap trong ca the.

1.2. Chirc 'fang sinh 19 they sau tuy6n yen

Arginin vasopressin (AVP)

Cys — Tyr — Phe — Gin —Asn Cys Pro Arg — Gly-N H2

Oxytocin (OT)

Cys Tyr Ile Gln Asn Cys Pro Leu Gly-N H2

Hinh 6.4. C6u tr0o cua ADH

Thiry sau tuyen yen khong bai tiet hormon, ma cac,te bao tuyen yen sau chi
trq gifip nhung tan cling than kinh vang dugi xuong. Nhiing tan cling than
kinh nay china nhieu hat bai tiet va Chung nam tren be mat eac mao mach, 6. do chfing
tiet ra hai hormon la anti diuretic hormon (ADH) hay con goi la arginin-vasopressin
(AVP), acid amin tit* tam trong chit& peptid cua vasopressin khac nhau tity loci vi
duo nguoi la arginin, 6 heo la lysin...Do do ten chinh xac cua vasopressin ngtr6i la

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 CHU'O'NG 6 0- HOA SINH LAM SANG BENH LY TUYEN NOI TIET

arginin8-vasopressin (AVP) va hormon thin hai la oxytocin. Hai hormon nay dugc tong
hop bgi nhan ten thi (chit yeu tong hop ADH, chi mot it oxytocin) va nhan canh nao
that (chi yeu tong hop oxytocin, chi mot it ADH). Sau khi dtrgc tong hop chung ket
hop vai protein mang la neurophysin, chuyen den dau tan cling than kinh n'am a hau
yen. Khi xung citing than kinh tuyen tlr nhan tren thi va nhan canh nao that xuong vimg
hau yen, hormon &roc bai Wet ter cac hat nam a tan cling than kinh, qua co the xuat
bao va dugc hap thu \Tao matt bai cac mao mach ngay ben canh. Ca hai neurophysin
va hormon dugc ph6ng thich &mg thai, nhung do gin long leo nen neurophysin tach
thi hormon ngay va khong c6 tic dung se bi thodi hoa.

1.2.1. Anti diuretic hormon (ADH)

Mc dung
Khang lgi ni'eu: ADH lam tang tinh tham cua 'Ong xa va 6ng gop doi vai nuac lam
cho phan lon nuac dugc tai hap thu tra lai co the, nuac thai ra dual clang nuac tieu it,
giup co dac nuac tieu.,Thieu ADH Ong g6p than hau nhtr kh6ng doi vai nuac,
nuackhOng dugc tai hap thu se thai ra clang nuac lieu, lam nuac tieu loang, giam ty trong
(b'enh dal thao nhat).
ADH trong mau cao con c6 tic dung co lieu dOng mach cila toan co the, lam tang ap
suit dOng mach, nen ADH con dugc goi la vasopressin.
Di'du hoa bai tiet ADH
- Tham thau: khi ap suit tham thau cao, no qua Ong mach den yang °huh d6i tic
dung den cac thu the tham thau a day, tao ra tin hi'eu than kinh ttrang trig truyen
theo sal than kinh den hau yen va tang tiet ADH, mdc tang c6 the den 20 lan so
vai binh thtremg. Ngtrgc lai suit than' thau mau giam, vimg dugi doi ngimg
phat xung va ngimg tiet ADH. Thai gian ban huy ADH chi trong 15-20 phitt, do
do n6ng dO ADH trong mau thay d6i nhieu chi trong it phdt.
- The tich Man hoan cling anh liming den bai tiet ADH, khi the tich mau giam chi
con 15 -25% thi ADH c6 the tang 50 lin so binh thuang. Ca che la cac thu the sic
cang a thanh tam nhY se nhan biet hru luting tuan hoan, xung deeg se truyen den
nao de dieu hoa bai tiet ADH. Tuan hoan giam se tang tiet ADH va ngtroc lai.

1.2.2. Oxytocin
Tac dung: gay co ca trcm Ur' cung luc mang thai dac Net manh trong lac chuyen da.
Oxytocin c6 vai tro quan tong trong bai xuat &Cm, no lam ep cac nang sira, day sira
ra ngoai. Khi tre bit me, tic thing milt a dau vu gay ra cac xung than kinh truyen len nao,
den halt yen gay bai tiet oxytocin vao mau den tuyen vii lam co to bao co bieu mO quanh
cac tuyen slta a vu lam chay stta. Tac dung nay nhanh chua day 1 phut sau khi bat dau bit
me, stra bat dau chay theo co che nay.

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HOA SINH LAM SANG

1.3. 13§nh ly tultin yen

1.3.1. Suy tuydn ydn &war
La thieu but chirc nang tuyen yen tn.rdrc lam anh huOng den cac hormon tuyen yen.
Phan loai:
Suy tuyen yen toan phan: c6 khi phi hop vai suy thily sau tao nen benh canh suy
toan b6 tuyen yen.
Suy tuyen yen tirng phan: c6 2 loai
- Don dOc: chi mot loaf hormon bi thieu hut.
- Mei hop: it nhat hai hormon bi thieu.

1.3.2. U tuydn yen

La u to bao mo tuyen yen hay u tir cac di tich pilot thai tuyen yen (tai Rathke).
Phan loci:
- Lanh tlnh tire cac adenom (u tuyen) tuyen yen: c6 hai nhom la (1) kh6ng bieu hien
not tiet, loai nay chiem 20% va (2) Well hien not tiet hay con goi adenom chirc
nang. Loaf adenom chirc nang 14i chia 2 nh6m: nguyen phat la adenom tiet met
hay,nhieu hormon tuyen yen va thir phat la suy cac tuyen ngoai bien, vi du suy
tuyen giap lau ngay khong dieu tri se gay adenom tuyen yen tang blest TSH.
- Ac tinh hay u throng mO: dang nguyen phat rat hiem, throng la thin Oat ttr K vu,
K phoi,...0 loan san nhu u SO halt hay hiem han nhu u quad, u day song.
Bieru hien bang hai koi chung:
H6i chimg not tiet:
Throng la bieu hien d'au ti'en bang tinh trong suy hay cu6ng tuyen yen hay c6 hOi
chimg than kinh - ha 6i.
- Adenom kitting tiet hormon: cac hormon throng la trong gfoi han Binh throng.
Dang nay tier' trien chant va hay tai phat sau dfeu tri.
- Adenom tuyen yen tiet hormon (u tuyen chic nang): try theo hormon &roc tiet ra
LH, ACTH
Nguyen Oat: benh Cushing.
Thu Oat: h6i chimg Nelson.
LH-FSH not chung la hien' c6 the nguyen phat, thir Oat gap sau suy sinh due lau
ngay khong duoc dieu tri.
GH: la adenom tuyen yen tiet qua mire GH (STH), chiem 30% tong s6 adenom tuyen
yen. Xay ra o ngoai truang thanh gay berth to dau chi.

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 CHUO'NG 61. HOA SINH LAM SANG BENH LY. TUYEN NOI TIET

Prolactin: la adenom tuyen yen tiet qua mire PRL, la loci ademon tuyen yen pile Nen
nhat chiem 40% tong s6 adenom tuyen yen.
TSH
Nguyen phat: cac hiem.
Thir phat: suy giap lau khong dieu tri tat.
- U thucmg m6: thir phat hay gap han nguyen phat (rat hiem), di can vao tuyen
yen gap trong 25% tru6ng hop K vu, thuemg khong c6 bieu hien not tiet met vai
truemg hop gay dal than nhat va sau do la suy yen.
Hei chUng khoi u: tuy kich thuac va huang phat trien khei u ma c6 Neu hien
khac nhau.

1.4. Them do chirc nang tuy6n yen

Tuan theo met so nguyen tac
- Khdo sat hormon tuyen yen:
Dinh lucmg tinh: can chU3'7thay doi n'eng de theo nhip sinh hoc.
Dinh lucmg deng: cac nghiem phap fic the hoac kich thich.
- Kith() sat dap Ung‘ngoai vi: kich thich tuyen dich true tip hoac ca quan thgc hien
bang hormon tuyen yen thich hap.
- Khdo sat hieu (mg cua hormon: dinh lucmg hormon tuyen dich.
Trong bai nay chUng toi trinh bay chn yeu la khdo sat hormon tuyen yen.

1.4.1. Tham d6 chav nang U67 yen

1.4.1.1. Chur nang tit GH
GH &rex tiet ra bed tien yen theo xung nhip, viec bai,tiet nay anh huemg bari nhieu
yeu to nhu nhip ngay dem, van deng, stress, dinh du6ng, nong do glucose mau,...va chiu
sly lieu khien cua cac hormon vimg ha doi, IGF-1 cua gan,... Do do, c6 su thing lap gifta
ranh gi6i binh thuong va benh ly ve Deng de GH, met xet nghiem nong de GH ngau nhien
khong giup ich cho chan loan, ngay ca a nguai binh thu6ng. De danh gia tinh trang lam
sang lien quan den tiet GH nguai to khuyen phai phoi hop cac xet nghiem khac (vi du
IGF-1, TSH, ff4, fTs) va vai cac nghiem phap khich thich hay irc the fiat GH.
Ky thuat: tucmg to cac hormon tuyen yen khac.
Mau dung huyet thanh (co the &mg huyet tucmg tuy theo yeu cau cua nha san xu't
thuOc thir), de &Ong to nhien va tach huyet thanh ngay. De a 4°C duac 48 gier, lau hem phai
tril a -20°C. Cho phep ra long den 5 lan.
Tri se tham khao: mk thu thap tit 214 nguai truemg thanh cho mau tir mot nghien
neng de GH (ng/ml) do bang ky thOt CLIA, ket qua nhu sau:

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Bang 6.1. Wing do trung binh GH

DOi tugng N Trung binh Trung vi 5th-95th

0,75 0,06 — 6,88

0,05 0,02 — 1,23
0,21 0,02 - 4,77
Dcm vi thuerng dung la ng/ml va p,IU/ml, he so chuy6n d6i: ng/ml x3µ1U/ml.
MOt so nguang nhu sau dang dugc ap dung:
Binh thugng < 5 ng/ml 6 nguoi truer/1g thanh lay mau kw 8 gig sang.
Neing clO,GH rat nhay voi cac kich thich, ngay ten ding mot ngugi nghiem phap phai
thuc hien nhieu lan hoac phoi hop it ra hai nghiem phap truck khi ket luan: arginin-insu-
lin, glucagon-propranolol hay betaxolol.
Khi danh gia phai xet den su giam tiet do tueii hoac có cac thieu but not tiet phihop.
Dinh luting IGF-1 tirc somatomedin-C:
La cach danh gia, gian tiep sg tiet GH, (lac biet khi có su khong thOng nhat giita ket
qua Binh luting GH va lam sang nhu trong hOi chimg Laron.
MOt so nghiem phap lien quan
- Nghiem phap kich thich:
Chi dinh: khi có nghi ng6 thieu GH nhu tre phat trien cham va lun ham tre cimg trang
lira trong khi hormon giap binh thuong (suy giap ding lam chum phat trien), X-quang
thiremg quy thyxuang chum phat hien. O ngugi trirang thanh bieu hien bang met mai,
giam dam do xuang va rei loan lipid. Tuy nhien can nh6 la thieu GH la benh hiem va benh
a ngugi 16n thugng la có tien can thieu GH tir nho hoac benh dm ha doi - tuyen yen, do do
can có chi dinh cila bac s'Sr chuyen khoa sau khi da loai trir cac benh gay benh canh Wong
ter va Binh luting cac hormon lien quan.
Thuc hien: mau man tinh mach dirge lay sau nhin an 10-12 gig (qua dem), sau do
tiem chat kich thich tiet GH, cac mau mau se clugc lay each khoang 30 phut trong 3 gi6
de Binh luting GH. Cac chat gay kich thich:
+ Deng van -adrenergic: dimg clonidin 4 mg (100 g/m2 6 tre)_uOng. Dap img xay ra
sau 60 phut. Ca the la kich thich tiet GH-RH.
+ Doi van -adrenergic: propranolol hoac betaxolol, lieu 30-40 mg uemg. Dung phi
hop vai glucagon de tang six marsh, co the ging &mg van -adrenergic.
+ Gay ha throng huyet bang insulin dirgng tinh mach, lieu 0,05 — 0,1 clan vi/kg. Can
theo doi chat the lam sang va duorng huyet, có the phihop vai arginin. Ca the
thong qua N adrenergic.
+ Acid amin truyen tinh mach: arginin 0,5 gam/kg trong 3 gig, hoac ornithin. Ca
the tac dung la irc the SR-IH.

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 CHU'O'NG 6 ► HOA SINN LAM SANG BENH LY TUYEN NOI TIET

+ Glucagon: 0,03 mg/kg tiem tinh mach, throng phi hop vai propranolol.
+ GH-RH: 1 µg/kg tiem tinh mach, dung nap tot.
K6t qua: duac xem la binh thuang ne'u dinh GH = 7 ng/ml (21 gIU/m1) sau khi lam
nghiem phap kich thich.
nghia: nong de GH khong dap irng (thap hon mire no nen co) vai nghiem phap
kich thich, nong de IGF-1 thap a doi tuong c6 trieu chimg thieu GH se gifip ket luan benh
nhan thiL GH va quye't dinh dieu tri.
- Nghiem phap ire die:
Chi dinh: nghi nga hei chimg khong le (gigantism) er tre em hoac to dau chi (acro-
megaly) a nguai tn.rang thanh, nghi u tuyen yen, phoi hop vai do nong de IGF-1 trong
danh gia di'eu tri benh 1)'T tuye'n yen va theo del tai phat.
Cach tin hanh Prong tir nghiem phap kich thich, cac chat ix ch6 gem:
+ Tang dueng huy& bang Ong 75 g glucose.
+ Somatostatin 100 gg tiem clued da.
Ket qua: binh thtremg nong de GH < 2 ng/ml (< 6 uIU/m1) sau khi lam nghiem phap
ire che.
Y nghia: nong de GH sau khi irc che van cao hon mUc le ra no nen c6 (nghiem phap
throng tinh) a nguai CO bieu hien hei chimg khong le hoac to dau chi kern theo IGF-1 tang
giup chan doan xac dinh benh. Ne'u nghiem phap duong tinh or nguai dang theo doi benh
sau di6'u tri thi c6 the la truemg hop tang tiet GH tai phat.

1.4.1.2. ChCfc nang tiet ACTH

Lay mau: rat can than vi no rat nhay vai six thay del protein. Do do can lay mau dung
ca.ch nhu bao quan lanh, cheng dong EDTA.
Cac nghiem phap lien quan:
Nghiem phap i c che bang dexamethason: dexamethason la met steroid nhan tao,
c6 kha nang ire che tiet ACTH sinh ly tai tuy6n yen, hau qua la cortisol va cac
corticosteroid se bi
Nghiem phap kich thich:
+ Nghiem phap metyrapon chat nay irc che khau cuei trong tong hop cortisol lam
chat nay giam di va Nu qua lam tang tiet ACTH (gian tiep) cua tuyen yen.
+ Nghiem phap kich thich bang CRH (corticotropin releasing hormon stimula-
tion test): benh nhan dtrac chuan bi tir horn truerc, ngimg cac thuoc c6 lien
quan,...Tnreic khi tiem CRH lay mau gib. 0. Tiem tinh mach CRH ly trich tix be
(dm) Arai luting lug/kg can nang hoac 100mg, sau dO thy mau vao cac kw 15,
30, 45 philt va 1 gib.. Dinh luting ACTH va cortisol trong cac mau mau.
Dinh nong do ACTH tang 130% so vai nong de nen xay ra trong khoang 30 - 60 phut
sau tiem, dinh nong do cortisol tang 100% va xay ra khoang 45-60 phut sau tiem.

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HOA SINH LAM SANG

nghia: tang tiet ACTH gap trong thieu but CRH cita viing ha doi va kitting Wet
ACTH gap trong suy tuyen yen. Nghiem phap con giup phan biet benh Cushing (tang
tiet ACTH va cortisol) \Teri cac truerng hop u lac ch76 tiet ACTH va 116i chirng Cushing do
tuyen thuemg than (ACTH va cortisol khong dap Aug).
Chit 3'7: dap irng thay d6i theo gio trong ngay, bu6i chieu ACTH va cortisol tang
nhieu hon.
+ Nghiem phap kich thich bang Lysin-vasopressin (LVP): LVP la d6ng van cua AVP
c6 tac dung nhu CRF/CRH, kich thich tiet ACTH va cortisol. Hien nay nghiem
phap nay khong con diing vi dap Aug kern \Ta nhieu tac dung phu.
Tri so tham khao: mau huyet thanh ley vao buoi sang a 252 ngued kit& manh tien
hanh dinh lugng PRL bang phuong phap CLIA.
Bang 6.2. Ntrig cit) trung binh ACTH

Tuoi sinh san

Man kinh

Dun vi chuyen d6i: 1 ng/ml = 21,2 mIU/L.

Nghiem phap lien quan:
It có gia tri trong chan doan nhung lai c6 gia tri trong dieu tri. Nghiem phap kich
thich bang TRH: neu la adenom prolactin thi chi tang nhe khi lam nghiem phap, ngugc lai
se biing no trong da tiet prolactin phan *rig.
Nghiem pita') nay con dimg danh gia mire dO suy tuyen yen, trong do su thieu but
prolactin thuemg xay ra muon.
Neu prolactin binh thuOng hay chi tang nhe sau kich thich thi cac bieu hien suy tuyen
yen la do ha Mi.
MOt s6 nghiem phap khac nhu ire the thu the dopaminergic (sulpirid, domperidon),
gay kich thich tiet PRL, bien d6 kich thich giam trong cac twang hop do khoi u. Nghiem
phap xac dinh tinh nhay cam voi dopaminergic nhu parlodel va hieu qua dieu tri. Test vOi
clan xuat dopamin (L-DOPA 500mg u6ng).

1.4.1.4. Chirc nang tiet FSH, LH

Dinh lugng FSH va LH.
Phuang phap: RIA, ELISA, CLIA, FPIA.
Noi chung cac the N may sinh boa mien dich tu dOng hien nay deu co the dinh him
cac hormon nay. Tuyan tinh vao khoang 0,2 — 250 mIU/m1 (LH) va 0,25 - 400 inIU/m1

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 CHU'O'NG 6 Ow HOA SINH LAM SANG BENH LY TUYEN NOI TIET

(FSH) thay d'6i My may va kyr thuat.

Lay mau va tilt:
Mau huyet thanh hoac huyet tuang có ch6ng &Ong EDTA dugc dimg, mau phai ly
tam va thch huyet thanh (huyet tuong) ngay. Dung trong ngdy, neu khong phai de lanh
ngay, de 4°C dugc 24 gig, lau hon phai trir - 20°C. Khong dugc ra &Ong lap lai va phai
•deu truck khi thin.
1\1-611g dg thay d6i theo chu kST kinh nguyet va thai kST nen in& chit y khi ban Juan.
Gia tri tham khao: d6i tugng nguoi khoe manh, thy mau bu6i sang.
Bang 6.3. N6ng d6 trung binh FSH va LH

KT: CILA/Liaison FSH (n =251) LH (n=183)

- Nang 3,5 - 9,2 mIU/m1 1,9 - 9,2 mIU/ m1

- Phong noan 4,7 - 25,9 mIU/m 6,1 -49,1 mIU/m1
- Hoang the 1,7 - 5,6 mIU/m1 1,3 -10,8 mIU/ml
- Man kinh
* Khong dung hormon 13,9 103,1 mIU/ 15,4 - 53,3 mIU/ml
*Ming hormon thay the 1,7 - 96,8 mIU/m 0,7 - 52,7 mIU/m1

Nam 1,3 - 11,8 mIU/m1 Ulml

Nghiem phap kich thich bang Gn-RH/LH-RH danh gia kha Wang hoat dOng cua
tuye'n yen va cho phap phan biet six thieu but la & ha doi hay tuyen yen. Sau‘kich thich
neu tuyen yen dap (frig binh thuong hay chi giam nhe thi nguyen nhan a ha doi, con neu
khong dap (mg, ngay ca sau khi nhac lai thi nguyen nhan thugc tuyen yen. Dap img cna
LH doi vgi Gn-RH thay doi then chu lcST kinh nguyet,,dap img giai doan hoang the gap
doi giai doan nang. Dap Ung tit FSH khong thay doi theo IcST kinh.
Tian hanh: 100 µg Gn-RH dugc tiem tinh mach hay clued da. Mau mau do n'6ng dg
FSH, LH dugc lay vao cac thoi diem 0, 15, 30, 45 Va. 60 phi&
Ngdy nay vai cac xet nghiem dinh lugng FSH, LH có dg nhay cao, de clang xac dinh
cac mitt ni5ng dg thap (dO' nhay phan tich tot) lam cho nghiem phap nay it dugc &mg.

1.4.1.5. Chipc nang ti6t TSH

Dinh lugng hormon TSH: ngdy nay nlig irng dung ky thu4t cap khang the don clang
dugc chon loc giup tang dg nhay cua xet nghiem dinh lugng TSH (test TSH sieu nhay),
nhg do ma nghiem phap TRH it can thiet hon.
Nghiem phap kich thich bang TRH:
Chi dinh: khi TSH giap g gigi han clued hoac lam sang nghi ngg suy giap trong khi
hormon giap lai trong han binh thugng.

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HOA SINN LAM SANG

Cach thgc hien: tiem tinh mach 200g TRH (protirelin) se lam tang n6ng dO TSH, t6i
da sau 30 phut va trey v6 mire ban dau 6 phut thin 120.
Then trong vai ngtr6i c6 tin can hen, b6nh phi tic nghen man tinh, suy tim cung
luting thap, c6 thai.
)".(- nghia: ginp chan loan suy giap c6 nguyen nhan 6 tuyen yen hay ha d6i. Ngay nay
hau nhu khong con dung nghi6m phap nay vi protirelin khong throe san xuat

1.4.2. Tham d6 chav nang thily sau tuyen yen

Dinh luting AVP trong huy& tuang:
- Mau tinh mach dung ch6ng dong heparin hay EDTA gift 6 4°C
- N6ng dO binh thuang thap 1- 5 ng/ml, ti& AVP thay d6i theo nhip bai tit nen dinh
luting don dOc it c6 gia tn.
Dinh luting AVP trong nuac
- DUng nuac tieu 24 gi6, d6 lanh 4-10°C. Nhtroc di6m la cac true:mg hop benh 1ST
c6 luting ntrac tieu qua nhi6u (thir6ng > 2,5 lit) se lam giam n'ong dO AVP xuong
du6i dO nhay cua xet nghi6m.
M6t s6 nghi6m phap lien quan:
Nghiesm phap kich thich nhin uong: nage Bich la tang dO tham thau huyet tuang
gay kich thich tit AVP. Dinh luting AVP trong mau, AVP nirac tieu c6 th6 dinh
luting kern theo. Khi nhin u6ng tit 6-8 gi6 (hoec den khi mat 3% trong luting
co the) se lam tang thai AVP qua duong nieu va giam luting mrac tieu, tang dO
tham than.
Nghi6m phap phai dirge thgc hi6n trong 136nh vin bai bac si (c6 nai den hed phai
c6 chuyen gia lam nghi6m phap nay). Trong qua trinh thgc hi6n phai theo dOi can neng,
than nhi6t, huyet ap va cac dau hi6u mat nuac cap. Tinh tang mat nuac hay xay ra som
6 ngir6i dai thao nhat.
Chi dinh: nghi ng6 dai thao nhat (tieu chuan "yang" cho chin doan) va giup phan bit
nguyen nhan cua dai thao nhat (do Ply& yen hay then). Chu ST chi dinh nay kha han ch6 va
khong can tin hanh tren cac ct6i tuong c6 bi6u hi6n tuang d6i re, vi du da niesu ten b6nh
nhan tin can c6 pheu thuet \Tung sang SO hay chan thuong so nao kem theo tang natri mau
va tang ap lgc tham thau mau thi khong lam nghi6m phap nay.
Khong nen chi dinh 6 ngu6i suy then, tang natri mau, tang ap lgc tham than man, dai
than duemg khong ki6rn soar, giam the tich tuan hoan, suy tuyen yen phoi hop.
Ti6n hanh: lay 3 man mau vao cac gi6 0, 3 hay 4 va 6 gi6 (1(6t thiic nghi6m phap) d6
lanh. Nuac tieu tuoi dirge lay mizii gi6 va gift lanh. Th6 tich nu& tieu, ap lgc tham thau
mau va ni6u throe do.
MOt so nghi6m phap kich thich khac da duoc b6 vi hai nhi6u han loi nhu truy6n NaC1
un truang, nicotin.

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 CHU'O'NG 6 OA- HOA SINH LAM SANG BENH LY TUYEN NOI TIET

- Nghiem phat kich thich vai AVP (desmopressin).

Dimg phan biet nguyen nhan dai than nhat do trung acing hay do than.
Tiem duoi_da 2gg desmopressin, ap luc tham thau mau ya nuoec lieu, the tich nu&
tieu &roc do mai gia trong 4 gig.
Ket qua: neu nguyen nhan trung uang se lam giam the tich nu& tieu ya tang ap Arc
tham thau > 50%. Ngugc lai neu do than thi it có dap Ung, the tich nuac lieu khong doi,
dp luc tham thau khong tang hay tang < 50%.
- Nghiem phap Ire the tit AVP: tang ganh were.
Benh nhan dugc huang dan nhin an lir chieu horn truck, tieing nuac nhu binh thuemg.
Sang cho benh nhan di tieu het, cho uong nuac loc 20m1/kg trong 20 philt. Lay nuac tieu
mai gig trong 5 gia giir lanh. Lay 3 mau mau lac bat dau, gitta ya cu'Oi nghiem phap.
Nghiem phap dUng con hoac diphenylhydantoin tiem tinh mach da bi be).

2. DANH GIA CHOC NANG TUYEN GIAP

2.1. Chivc n5ng sinh ly tuy-
en giap
2.1.1. So' luvc cgu frac tuyen giap

THOY THOY
TRAI PHAI
TUYEN TUYEN
GIAP GIAP

Hinh 6.5. Ca the hoc tuyen giap

Tuyen giap la mot tuyen not tiet quan trong cua ca the.
,Tuyen giap (TG) nam ngay clued thanh hai ben ya phia truac khi quan.
Tuyen giap gem hai thily phai va trai, nod yeti nhau bai eo tuyen giap bat ngang tir sun khi
quail thir nhat den sun khi quail thir tu. ThUy phai to hem thily trai mot it.

199
HOA SINN LAM SANG

Moi thity dai tir 5 - 8cm, rOng 2 - 4cm, day 1 - 2,5cm.

Hai thity can nang binh thuong khoang: 40 - 42g.
Khi tuy6n giap phi dai tao thanh buOu giap.

Hinh 6.6. Cu
A tao mo hoc tuyen giap
COu tao mo h9c: TG duoc tao thanh bed hai loai t6 bao: t6 bao nang va t6 bao quanh nang.
T6 bao nang la don vi tong hop va bai tiet hormon tuyen giap: thyroxin va triiodothy-
ronin. MOi nang có hinh cau &rang kinh to 100 -300 Rm, bao boc mot chat keo (chat tiet)
gom chit yeu thyroglobulin, duce tiet ra bai tuye'n giap. Thyroglobulin la mot glycopro-
tein china iod va la co chat quan trong cho su gan iod vao tyrosin trong qua trinh tong hop
hormon giap. Ngoai ra chat keo con china mot luting nho thyroalbumin china iod.
Thanh cua nang tuyen la nhang t6 bao bi6u mo hinh tru, bai ti& chat ti& vao trong
king nang.
Hormon giap dirge hap thu trO. lai qua to bap bieu mo tuyen giap vao mau va phan
phi khap co the.
T6 bao quanh nang (holac t6 bao C): t6 bao C khu tit 6 gifta cac nang ho4c dinh lien
vai cac nang. T6 bao C san xuat ra calcitonin, mot hormon peptid co vai trO trong sty di6u
hoa calci a co the.

2.1.2. Chin ming sinh ly ctia MAI giap

Tuye'n giap tong hop hai hormon quan trong tit iod va tyrosin la thyroxin (T4) va
triiodothyronin (T3). Ngoai ra tuyen giap con tiet ra mot luting nho monoiodotyrosin
(MIT) va diiodotyrosin (DIT). Tuyen giap con bai tiet calcitonin, gitlp tang hap thu calci
tit mau vao xuang.

200
 CHU'O'NG 610- HOA SINH LAM SANG BENH LY TUYEN NOI TIET

Hai hormon giap nay c6 eh& nang giong nhau, nhung khac nhau ve ciremg dO va
died gian tac dung: triiodothyronin manh han thyroxin khoang 4 lan, nhung no c6 mat
trong mau vai so luting nh6 han nhieu, va tac dung trong thoi gian ngan han nhieu so vai
thyroxin.
Nhu cau iod cho su. tao thimh hormon giap:
Moi tuan, mot ngu0i binh thuong can lmg iod de tao hormon giap. Iod an vao dugc
hap thu qua 6mg tieu h6a vao mau. Binh thuong phan lem iod nay dugc thai nhanh qua
than, va chi khoang mot phan nam so d6 clime van chuyen tir mau Wan hoan vao to bao
tuyen giap de tong hop hormon giap.
Giai doan dau dm sir tao thanh hormon giap la van chuyen iodur tir mau vao to bao
giap va cac nang. Mang day cila to bao giap bom iodur mot each tich circ vao trong to
bao _giap.
Tuyen giap binh thuong, nang dO iodur trong tuyen cao gap 30 Fan nang do dm no
trong mau. Khi TG hoat dong 6. mire tai da, nang dO dm no c6 the cao gap 250 lan.
Tang hop hormon tuy in gicip
Six tao thanh va bai tiet thyroglobulin cua to bao giap: luoi not bao tuong va b0 Gol-
gi cua to bao giap tong hop va bai tiet vao trong nang mot phan tir glycoproteinkin, goi la
thyroglobulin, trong luting phan tir khoang 335.000. M8i phan tO thyroglobulin chda 70
acid amin la tyrosin, day la chit chinh ket hop vai iod de tao thanh hormon giap.
Sy' oxid h6a ion iodur:

Iod gan trirc tiep vai acid amin tyrosin phai a dang oxid hoa. Iod dua vao co the dugc
hap thu runt clued dang iodur. Sau do nhey xuc the cua enzym peroxidase oxid h6a io-
dur thanh iod, phan Wig nay bi,Irc the irc che enzym nhu thioure. Enzym peroxidase
c6 trong mang dinh to bao bieu mo tuyen giap.
Six iod hoa tyrosin va sir tao thanh hormon giap: khi phan ttir thyroglobulin dirge giai
ph6ng tir b0 Golgi, hay dugc bai tiet qua mang dinh cua to bao vao trong nang giap, iod
oxid hoa gan khoang mot phan sau oh acid amin tyrosin trong phan tix thyroglobulin, nhO.
xuc tac cua enzym iodinase. Tyrosin dau tien dugc iod hoa thanh monoiodotyrosin (MIT),
r6i diiodotyrosin (DIT). Sau do it phut, hang gia, di the hang ngdy, mot phan tO monoio-
dotyrosin ket hop vai mot phan tix diiodotyrosin de tao thanh triiodothyronin (T3) chiem
khoang mot phan muoi lam cua hormon dg tril, hay hai phan tir diiodotyrosin ket hop voi
nhau de tao thanh mot phan tix tetra-iodothyronin (T4) hay thyroxin, la hormon chinh. Moi
phan tir thyroglobulin chira 30 phan tir T4 va vai phan tir T3. Hormon giap dugc du tat
trong cac nang, vai so luting du dung yeti yeu cau binh thuong tir 2 den 3 thang.

201
 HO CH2CHCOOH

NH2

HO CH2CHCOOH Monoiodotyrosine (MIT)

NH 2

Tyrosine HO CH2CHCOOH

NH 2
Diiodotyrosine (DIT)

I I

HO CH2CHCOOH HO CH2CHCOOH

I I NH 2 NH 2
3.3' 5.5' - Tetraiodothyronin
3.3'.5 Triiodo Thyronin (T3)
(Thyroxin, T4 )

Hinh 6.7. Sty tao thenh hormon giap

Su giai phong thyroxin va triiodothyronin tit tuyen giap: thyroxin va triiodothyronin

tach kh6i phan tit thyroglobulin va giai phong vao mau. Qua trinh xay ra nhu sau: mang
dinh cua to bao giap the ra gia tuc, va bao lay mot phan nhe cilia chat keo trong nang
tuyen, de tao thanh tin am bao, va di vao qua phan dinh to bao giap. Ngay lap tire cac
lysosom hea mang \Ted nay, de tao tdi tieu hoa chita enzym tieu hoa tit lysosom hoa
vai chat keo. Cac protease trong enzym se tieu cac phan tit thyroglobulin va giai ph6ng
thyroxin va triiodothyronin. Cac hormon nay se khuech tan qua mang day dm to bao giap
vao cac mao mach quanh tuyen.
Khoang ba phan to tyrosin iod h6a trong thyroglobulin khong bao gio tra thanh
hormon giap, ma chi a clang mono va diiodotyrosin.
Khi thodi hoa phan tit thyroglobulin, cac tyrosin iod hoa dime giai phong nhung
chimg khong &roc bai tiet vao mau, phan iod cua chung bi tach rei nha enzym deiodinase,
de tai sit dung trong to bao tuyen giap.
Khoang 93 phan tram hormon dime tuyen giap bai tiet la thyroxin, va chi c6 7 phan
tram la triiodothyronin.Trong vai ngay, hau het thyroxin bi khit iod mot each chain chap
de tao thanh triiodothyronin. Vay cuoi ding, hormon duet phan phoi tai cac mo la triiodo-
thyronin, moi ngay c6 khoang 35 lig.

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 CHU'O'NG 6 ► HOA SINH LAM SANG BENH L`? TUYEN NOI TIET

Te bao bleu mo nang giap

Chat keo giap
3

Thyroglobulin
DIT

Tyrosine
MIT

MO ngoai
bien

Hinh 6.8. Thyroglobulin va sty tao thanh T3 va T4

Van chuyen hormon tuyan giap trong mau: khi vac) matt, phdn lan T4 va T3 ket hop
voi nhang protein van chuyen. Co ba loai protein van chuyen, theo thin tu ai luc,giam
dan: thyroxin ket hop vai globulin - TBG (thyroxin - binding globulin), thyroxin ket hop
voi prealbumin - TBPA (thyroxin - binding prealbumin) va albumin. T4 ket hop manh hon
voi nhang protein van chuy'en tren so vai T3. Chi có mot luting nho: 0,4% T3 va 0,02% T4
khong ket hop vai protein van chuyen, tac ld a dang to do.
T4 giai ph6ng vap mo rat ch4m, mot phdn hai T4 dirge giai phong tir mau vdo mo
khoang 6 ngdy, con T3 vi Oi lirc thap hon nen mot nira ducyc giai phong vdo mo chi trong
mot ngdy. Khi vdo trong to bdo ca T3 va. T4 lai gan voi protein cila mo nen duac du tru lai
trong to bac).
T4 thai gian tiem tang ddi. Khi có tac dung, mac dO no tang ddn va dat toi da tir 10 -
12 ngdy, thai gian ban hily ld 15 ngdy, mot so hoot &Ong keo dai, có khi toi 6 tuan, hoac
sau 2 thang.
T3 tac dung nhanh hon T4 khoang 4 ldn, Mai gian tiem tang ngan tit 6 den 12 gia, va
tac dung thi da trong 2 den 3 ngdy.
Chi có hormon T3 yd. T4 to do mai có tac dung sinh hoc len to bao dich.

2.2. Vai tr6 cCia hormon tuy6n giap trong to chCrc t6 bao
Mc clung lam tang sao chep mot so lan gen
Tac dung chung ciao hormon giap 1a gdy ra su sao chep nhan cna mot so 'ern gen.

203
HOA SINN LAM SANG

Vi vay, mot s6 lan protein enzym, protein eau truth, protein van chuyen, va cac chat khac
dirge tao thanh trong tAt ca cac to bao dia co. the. Ket qua là hoat dOng chirc nang cua toan
bO co the tang len.
Khoang 90 phan tram hormon giap gan vai thu the la T3, chi c6 10 phan tram la T4.
Cac thu the hormon giap gan vai chu7Oi gen dm ADN,,khi no kat hop hormon giap,
cac thu the duac hoat hoa va kited dau sao chep. Wit so 16.n cac ARN thong tin throe tao
thanh, sau do it phat hay hang gia din ra qua trinh dich ma ARN ribosom mang not
bao tuong, de tao hang tram loai protein khac nhau trong to bao.
Tac dung lam tang hogt clOng chuyn hog cfig to bao
Khi mot luting lan hormon giap dirge bai tiet, mire chuyen hoa co so c6 the tang tit
60 den 100 phan tram tren binh thtremg. Mire ding hop protein tang len, nhung &Ong thai
mirc di h6a protein cling tang.
Teen ty the, hormon giap lam hau het to bao tang len ve kich thuac va s6 KNIT, vi
vay lam tang s6 lining va hoat dOng cua ty the, de tang tao nang luting du frit a clang ATP.
Khi hormon giap tang cao trong mau, no tao ra mot luting lan nhiet, nhung rat it ATP
dugc du tit'''.
D6i vai sir van chuyen cac ion qua mang to bao, lam tang mirc van chuyen ion Na+
va IC qua mang to bao do hormon giap hoat h6a enzym Na,K-ATPase. Vi qua trinh nay sir
dung nhieu nang luting va sinh nhieu nhiet, nen do la mot trong nhitng co the ma hormon
giap lam tang mix chuyen h6a cua co the.
Tac dung cita hormon giap tren sit phat trien the
Hormon giap lam phat trien co the,o. tre em. Ngued bi suy giap, phat trien chain
lai, ngued cueing giap, xuong phat trien nhanh lam cho tre,em truang thanh nhanh. Tuy
nhien, xuang cling truang thanh nhanh han, lam dong cac dau xuang dai, chieu cao cling
khong han ngued binh thuang.
Hormon giap lam phat trien bO nao a thai kST bao thai va nhitng nam dau sau khi sinh.
Neu bao thai khong bai tiet du so luting T4, sir phat trien va tnxang thanh cua nao ca tn.rot
va sau sinh se cham lai va nao nho hon binh thuang, anh huang lan den tri tue.
Mc dung tren chuyen hog glucid
Hormon giap lam tang cac enzyme chuyen h6a trong to bao nen kich thich tAt ca
cac clang cua chuyen hoa glucid, bao dua nhanh glucose vao to bao, tang tieu thu
glucose, tang sinh duang mad, tang hap thu glucose tit he tieu hoa, tang bai tiet insulin do
tang duang huyet.
Tac dung tren chuyen hog lipid
Hormon giap lam tang sir huy dOng lipid tit cac mo,ma, do do lam tang n6ng dO acid
beo tir do trong huyet tucmg. Hormon giap cling fink day sir oxid h6a cac acid boo tit do
trong to bao.

204
 CHUUNG 6 ► HOA SINN LAM SANG BENH LY TUYEN NOI TIET

Hormon giap lam giam s6 luting cholesterol, phospholipid, triglycerid trong huyat
nrcmg. Trong suy giap, nong d6 cholesterol, phospholipid, triglycerid trong huyet Wang
tang, gan du frit nhiau lipid, do la diau kien thuan lgi de phat trian benh xo vita dOng mach.
Tac dung tren nhu cau cac vitamin va tren trong luvng ca the
Hormon giap lam tang nhu cau cac vitamin. Kay tang bai fiat hormon giap gay thieu
twang doi cac loci vitamin.
Tang hormon giap lam giam trong luting co the. Suy giap lam tang trong luting ca the.
Tac dung tren he tuan hoan
Dong mau va luu luting tim, hormon giap lam tang dong mau, dac biet la tang clang
matt a da do nhu eau thai nhiat. Vi tang clang mau ngoai bi'en, nen luu luting tim ciing
tang. Trong suy giap, km luting tim 0am.
Nhip tim, hormon giap lam tang nhip tim do no tic dung five hap den tinh chiu kich
thich cua tim, ngoai ra no con tic dung gian tiep qua he giao cam.
Ap suit d6ng mach, ap suit d6ng mach trung binh thuemg khong thay doi. Tuy nhien
vi no lam tang nhip tim nen ap suit tam thu tang, nhung vi no lam gian mach ngoai bi'en
nen ail suit tam truing giam twang irng.
Tac dung tren ho hap, tieu h6a, he than kinh trung wing, chtir nang caa ccr
Ho hap, vi hormon giap lam tang chuyan h6a, nen sir dung oxy tang va tao ra nhiau
CO2. Chat nay lam tang nhip va dO sau cua ho hap, th6ng qua cac trung tam dieu h6a.
Tieu hod., hormon giap lam tang ca mire bai het cac dich tieu haa va cir d6ng cua duemg
tieu hoa, nhu d6ng manh c6 the gay tieu chay. Thieu hormon giap thuemg gay tao b6n.
Than kinh trung uang, hormon giap lam tang hoat d6ng Gila nao va N than kinh, khi
suy giap hoat dOng nay 0am. (3 nguai ctrang giap, N than kinh bi kich thich manh nhu
lo ling, bvc tire qua mire.
Chirc nang cua ca, tang nhe hormon giap lam cho co hoat d6ng manh, nhung khi
luting hormon giap cao, co tra nen yeu. Suy giap, co tra nen chasm chap va gian chain sau
khi co.
Run co, mot trong nhitng dau hieu dac biet cua cu6ng giap la run co nhanh, khong
phai run kieu benh Parkinson. Run la &au hieu quan trong danh gia mire dO tic dung cita
hormon giap tren N than kinh trung nang.
Tac dung tren cac tuyen not tiet khcic
Hormon giap lam tang mite bai fiat cua phan lem cac tuyan not tiet khac. Ctrang giap
lam tang glucose mau, kich thich tuy tiet nhieu insulin.
Hormon giap lam tang hoat dOng chuyan hoa lien quan den su tao xtrang, lam tang
nhu cau dai vbi hormon can giap.

205
HOA SINN LAM SANG

Hormon giap lam tang luting glucocorticoid cua tuyen thuong than bi bat hoat hoa
do gan, lam kich thich tuyen yen trtrac bai tiet nhieu ACTH va kich thich vó thtryng then
bai tiet nhieu glucocorticoid.
Mc dung tren chic ming sinh duc
O nam giai, thieu hormon giap se lam mat kha nang sinh duc. Con cuamg giap gay
bet luc sinh due.
O nit giai, thieu hormon giap gay nen rong kinh, chay mau nhieu, mat kha nang sinh
duc. Con el/Ong giap gay nen it kinh, doi khi khong có kinh.

Bang 6.4. Tam tat tac dung cita hormon giap

Mo dich Tac dung Co. the
Tang nhi g so luting Aid di hrc veri to the f3 - adrenergic
tang co b g ddp img vai catecholamine
g ti le myosin a chuZi Ong (hoat tinh ATPase c

c su t tlg t n thubrig ya phat t

xuang

AL AL As. A
'ch sum tong hap thu the LDS..
our
toc do chuye'n hem.

206
 CHU'O'NG 6 lo HOA SINN LAM SANG BE:NH LY TUYEN NO1 TlET

2.3. Di6u hoa bai tiet hormon tuy6n giap

TRUC HA DOI - TUYEN YEN - TUYEN GIAP

MO DICH
Tim
Gan
Xu'o'ng
Than
kinh
trung
u'o'ng

Hinh 6.9. Dieu hoa !Jai tiet hormon giap

True vang dual d6i - tuy6n yen - tuy6n giap la he than kinh not tiet, no dieu hem
san xuat va tiet ra cac hormon tuyen giap. Sir tong hop va giai phong hormon giap tir
thyroglobulin trong tuyen giap &roc dieu hoa bai TSH, hormon nay duce san xuat bai
tuyen yen. Sir tiet TSH chiu six kich thich ducmg tinh bai TRH, TRH dugc san xuat b6i
\Tang dtrai dOi va chiu sir dieu hoa am tinh ngtroc b6i hormon tuyen giap trong tuan hodn;
sir tang hormon giap trong mau lam giam tiet TSH cua tuyen yen, qua do Jam giam tiet
hormon giap. Chi c6 T3 va T4 ty do c6 hoat dOng sinh hoc lid co tac dung dieu h6a ngiroc.
Cac chat khang giap: la cac thu6c &rale. tiet hormon giap nhu:
- Cac ion thiocyanat giam sir bat gift iodur cua tuyen giap.
- Propyithiouracil lam giam sir tao thanh hormon giap.
- Iodur lam giam hoat doing cna tuyen giap, khi Wong dO iodur rat cao trong mau
(gap 100 lan mire binh thirong) thi phan lan hoat dOng tuyen giap bi giam nhung
chi trong vai ba tuan 16.
Vay khi thieu hormon giap, lam tang bai tiet TSH, lam tuy6rt giap na to.

207
HOA SINN LAM SANG

2.4. R6i loan chin nang tuy6n giap

2.4.1. Cueyng gi6p
Tuyen giap tang kich thirefc len gap tix hai den ba lam binh thirOng. Te bao tang sinh
va tang mire bai tiet len gap tir 5 den 15 Ian so voi binh thuong. Neng de TSH huyet
tuong thap.

2.4.1.1. Nguyen nhan

Do benh to mien, u cua to chire giap, hoac do iod.
Do u cua to chirc giap.
U cua to eh& giap bai Wet met lacing len hormon giap. Phan u bai tiet qua nhieu
hormon giap, phan lanh con lai thi hau nhu bi irc the hoan toan. Vi tuyen yen bi ire che,
nen khong bai tiet TSH.
Do benh to mien.
Do co. dia di truyen, hoac rei loan mien dich do yeu to mai truemg (nhiem khuan),
rei loan mien dich to bao c6 vai tro chu yeti ban au, rei loan mien dich the dich c6 khang
the khang tuyen giap trong mau.
Benh tar mien lam to bao giap tiet qua nhieu khang nguyen, clan den su tao thanh
khang the chong 10 ngay chinh tuyen giap. Nhang khang the nay duuc goi la globulin
mien dich, no gan len thu the mang cua TSH va gay ra hoat h6a lien tuc he thong cAMP
cUa to bao, clan den etremg giap. Chung c6 tac dung kich thich keo dai ten tuyen giap, gap
12 lan so vai TSH, &mg tiled mire hormon giap cao, c6 tac dung irc the tuyen yen, giam
bai tiet TSH.
Do iod:
Do dUng iod qua lieu mac du tuyen giap binh thuOng hoac da c6 benh truac do, hoac
do thuoc: iod vo co hoac hiru co, hoac do dieu tri bang iod a \ding co buou co dia phucmg.
Neu phat hien sam, benh se khoi neu ngung diing iod qua. lieu.
Xet nghiem theo doi benh: dinh hrung iod man va iod nieu trong 24 gia.

2.4.1.2. Trieu chi:mg

Cac trieu chimg cua cuong Op gem cac tac dung qua mire cua hormon giap, bao
gOm tang san nhiet, khong chiu dirge nong, chuyen hoa co so tang cao, giam can nang,
than kinh bi kich thich, tang tiet mo heti, yeu co., r6i loan than kinh va tam than, ngued met
mei, kho ngu, va run tay.
Lei mat: khoang met phan ba se ngir6i ming giap, do plia to chirc sau nhan cau va
thodi hoa cac co ngodi mat.

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 CHLYO'NG 6 OP' HOA SINH LAM SANG BENH LY TUYEN NOI TIET

2.4.1.3. ChAn loan sinh hoc

Dinh lugng hormon giap va TSH bang ky thuat mien dich enzym.
Dinh lixo.ng neng de FT3 va FT4 trong mau tang cao.
N6ng do TSH sieu nhay trong mau khong dinh lugng duo.c hoac rat thap. Ngoai ra:
dinh lugng iod, thyroglobulin trong mau,... de tim nguyen nhan gay cu6ng giap.
Bang 6.5. ChAn down sinh hoc cuong giap
Cac thong so hoa sinh
T3,TT4, FT3, FT4: tang
Nghi
SH sieu nhay: giam
Chan down &rang tinh T3 , TT4, FT, FT4: tang
Khang dinh SH sieu nhay: khong dinh lixong dte
ong do rat thap
4, FT FT4 va TSH sieu nha'
Chan down phan biet (ming giap gia, - TT
nh thueent;

2.4.2. Suy giap

Can phan biet suy giap tien phat va suy giap tit* phat.
Ve lam sang, suy giap tien phat c6 phu ni'em, Ira suy giap title phat khong c6 phi]. niem.
Ve can lam sang, suy giap tien phat c6 TSH tang, va suy giap thin phat c6 TSH giam.
Suy giap tit* phat.
Suy giap title phat do thieu but dieu hoa viing clued d6i va/hoac tuyen yen, tong vii
six thi'eu but kich to TSH can thi'et de kich thich six phat trien cua to bao tuyen giap.
Suy giap thin phat c6 the rieng biet hoac ket hop vii nhfing thieu but khac, dac biet
dei kich to sinh duc va kich thich to tuyen thucmg than.
Suy giap tien phat: c6 nhieu nguyen nhan, thuong do benh tir mien, gap chii 37611
phu nit sau tiled ky man kinh, pha huy tuyen giap thay vi kich thich. Dau tier' la tuy'en giap
bi viem, dan dan dan den hay hoai va cuoi ding la xa h6a tuyen, ket qua la giam hoac
ngimg bai tiet hormon giap.
Sau phau thuat c6 the gap 6 flitting benh nhan sau khi cat b6 toan phan tuyen giap
(ung thu giap), gan hoan toan (basedow)...
DUng thu6c khang giap tong hop: propylthiouracil, clang nay c6 the gap &bat ky th6i
gian nao ctia qua trinh dieu tri.
Do thieu iod: ducc the hien qua hei chirng than o ngu6i truing thanh. O tre em suy
giap do thieu iod c6 the clan den chirng dan den.

209
HOA SINH LAM SANG

Trieu chfrng suy giap.

Cac trieu chimg cua suy giap gem met mei, buen ngu va co the ngii ter 12 den 14 gia
met ngay, co yeu nhieu. Long, toe, ming kern phat,trien. tim cham, giam hru Wong
tim, giam the tich mau, tang trong, tao bon, tinh than cham chap.
Trong truing hop nang c6 the bi phi) niem dich, c6 quang 16n dtrai mat, mat phil (pha
cimg, An khong
Tang cholesterol mau thuang ket hop veil sir tang xa vita ding mach.
Chan doan sinh hoc: dinh lugng T3, T4, FT3, FT4, TSH
Suy giap tien phat: chan doan dga vao TSH tang, TT3, TT4, FT3 va FT4: giam
Suy giap thin phat: Chan doan dua vao TSH thap hoc khong dinh hrcmg dugc. TSH
rat nhay vai sir thay dei rat nho cua hormon giap.
Bang 6.6. ChAn doan sinh hoc suy giap a ngLyeyi tru'i'ng thanh

Cac thong s6 hoa sinh

Dieu nhay tang (>10gU/m1)

Chan doan phan biet
TSH sien nhay giam
Neu suy tuyen giap tit thai con boo thai, sau khi sinh, hay tuei tha au, se lam co the
kh6ng phat trien, dac biet la nao khong phat trien, lam tinh than, tri khan rat cham chap,
goi la benh dAn den.
Nguyen nhan la do thieu hormon giap ham sinh, khiem khuyet ve di truyen tuyen
giap, hay do thieu iod trong khau phan
Su tram trong cua benh do mix de thieu iod va mire thieu hormon giap, nIumg
thuong nang hon a nguailCm.

2.5. X6t nghiem chin nang tuy6n giap

2.5.1. Total T4 (TT) va free T4 (FT) (T4 toan phAn va T4 tug do)
Chi dinh: xet nghiem TT4 va FT4 dugc chi dinh trong nhang taxing hop nghi nga
cuang giap, nghi nger suy giap tien phat hoc thin phat, hoac dung de kiem soot dieu tri T4.
Gia tri binh thirang:
TT4: 55 — 1101AWL (77 —142 nmol/L).
FT4: 8 — 18 ng/L (10 — 23 pmol/L).
Phuong phap do: nang de TT4 va FT4 dugc dinh lugng bang k'Sk thuat mien dich
phong xa, enzym, huSmh quang

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 CHU'ONG 6 ► HOA SINE/ LAM SANG BENH LY TUYEN NO! TIET

nghia cua xet nghiem: xet nghiem TT4 phan anh sty san xuat hormon giap tryc tiep
han la TT3, no la xet nghiem clang tin cay doi \Teri giam nang tuyen giap. FT4 kh6ng phi
thu6c vao nong do protein ket hap nen co. y nghia han ve mat lam sang so voi TT4 va FT4
dai dien cho ti le TT4 hoat Ong.
Tuy nhien trong met s6 truomg hop khong c6 nguyen nhan tai tuyen giap c6 the lam
tang FT4, vi vay to phai dinh luang TT4 va FT4.
Bang 6.7. Danh gia nong de.) FT4 va TT4

FT4 ± TT4 Dinh gia ram sang

Trong gioi han Binh thuang
Binh thuang Phinh giap do thieu iod
Dieu tri hormon giap

Bissau giap Basedow

Cuong giap gia

tab ap nguyen phat

Dieu tri khang giap
Thieu but iod tram trong
• Suy Oar) thin phat

2.5.2. Total T3 (TT3) va free T3 (FT) (T3 toan phaen va T3 ty, do)
, Chi dinh: xet nghiem TT3 va FT3 dirge chi dinh trong cac true:mg hop: nhiem dee
tuyen Op (tang nang tuyen giap), nong do TT,3 va FT3 tang re ret. Hoac duac chi dinh
trong cuOng giap clued lam sang (TSH bi ire che, FT4 va FT3 binh thuemg), hoac dung de
danh gia de nang cua suy giap nguyen
Chi s6 binh thirang:
TT3: 0,9 — 1,8 tg/L (1,4 — 2,8 nmol/L).
FT3: 3,5 — 8,0 pg/mL (5,4 — 12,3 pmol/L).

2.5.3. Reverse T3 (rT3) (T3 chuyen)

Khi nhu cau hormon giap thap, T4 se clugc chuyen thanh 3,3%5' triiodothyronine (rT3).
Kay rT3 gian tiep phan anh mire de chuyen T4 thanh T3 trong me co the. Xet nghiem nay
dirgc chi dinh de danh gia nhung truemg hop FT3 hoac FT4 thap kh6ng re nguyen nhan.
Chi se binh thiremg cua rT3: 0,10 — 0,30 nmol/L.

211
 Bang 6.8. Wing do TSH
VET NGHIEM TSH DO NHAY (mIU/L)

2.6. Cac x6t nghiem lien quan

2.6.1. TSH: hormon tuyen yen - kich to tuyen giap
Viec xac dinh TSH huyet ttrang nham xac dinh ca the dieu hoa gift yang duai
tuyen yen va tuyen giap. TSH la thong s6 co ban trong viec chan down chirc nang tuyen
giap: ctremg giap, suy giap (tien phat va thir phat), binh giap. Chi c6 phuang phap mien
dich phong x4 hoac mien dich enzym sieu nhay (co do chinh xac va d6 nhay cao hon) mai
dugc sir dung trong thuc hanh.
Chi dinh xet nghiem TSH dugc dung ket hop voi FT4 va T3 khi nghi ng6 de khang
hormon giap, hoac ket hop voi FT4 khi nghi ng6 suy giap thin phat, hoac dimg de sang loc
suy giap sa sinh.
Gia tri binh thtrang cua TSH:
- Tre so sinh: nho hem 20 mU/L (ha4c µU/ml).
- Tre em va nguai lom: 0,49 — 4,67 mU/L.
Trong tnxemg hop cuang giap, n6ng de TSH rat thdp: < 0,15 mU/L.
Trong truong hop suy giap, n6ng de TSH tang cao: > 7 mU/L.
Khi dinh luting n6ng dO TSH tralai binh thuang chimg to viec dieu tri benh ve tuyen
giap co hieu qua.

2.6.2. Nghiem phap TRH

TRH la mot hormon cua vimg duai d6i, no kich thich tuyen yen bai tiet,TSH. TSH
14i kich thich tuyen giap bai tit cac hormon giap. Sr phan hoi nproc &roc kiem sok boi
luting cac hormon giap.
Nghiem phap TRH dugc chi dinh 6 benh nhan not tru nghi ng6 c6 r6i loan chirc nang
tuyen giap, hoac roi,loan chirc nang tuyen yen tnrac hoac vimg clued doi. Nghiem phap
TRH dua vao co the irc che nguoc cua true vUng duai doi - tuyen yen - tuyen giap. De
tin hanh nghiem phap, nguai to dinh luting TSH tnrac khi dung TRH, sau do tiem 200
ggTRH tong hop cho benh nhan. Ket qua:

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 CHUO'NG 6 111- HOA SINN LAM SANG BENH LV/ TUYEN NOI TIET

Binh thu&ng, a ngu6i co chirc nang tuyen giap binh thuang, sau khi tiem TRH,
n6ng d6 TSH huyet tircmg tang tit'10 mU/m1 den 30 mU/m1trong yang 30 philt.
BenhlY, benh nhan ctrerng giap nguyen pilaf khong dap ung voi TRH (TSH khong
tang). B'enh nhan suy giap nguyen pleat c6 dap frng cao vai TRH (TSH tang).
Hoc nguai ta c6 the &mg 200 mg TRH xit mue, va lay mau sau 2 gia de dinh luting
TSH. Hoac ung 40 mg TRH, va lay mau sau 3 den 4 06' de dinh luting TSH.

TSH sieu nhay

> 51.1U/m1 < 0,101111/ml

FT4 FT4

Giam Binh thuang Binh thuang Tang

Suy giap Suy giap Cuang giap Cuang giap

dtrai lam sang du6i lam sang
1'
Nghiem phap TRH

Hinh 6.10. Sa do tharn de chipc hang tuyk giap (khi chu'a duac di6u th)

2.6.3. Thyroglobulin

Thyroglobulin duvc dinh luting bang phirong phap mien dich phong xa, mien dich
enzym...
Tri s6 binh thuang cila thyroglobulin: < lOng/m1 (< 10n/L).
Tri s6 benh ly: 50 — 500ng/ml.
N6ng d6 cua thyroglobulin tang trong cac tn.remg hop nhu K tuyen giap, viem tuyen
giap, Basedow, u d6c tuyen giap. Nguai ta thay c6 m6i tuang quan gifra luting kh6i u va
nong d6 thyroglobulin.
Viec dinh luting thyroglobulin chi co gia tri trong viec theo doe ung thu tuyen giap.

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HOA SINN LAM SANG

2.6.4. Xet nghiem khang the khang giap

Thong thuoltg viec san xuat hormon giap dugc dieu hoa bai true ha dei - tuyen yen,
hormon giap dugc san xuat nhieu,bat thuemg gay,h0i chung cuong giap va it hon binh
thueng la nhugc giap. Ngodi cac roi loan dieu hoa neu tren, cuang 04 hay nhugc
giap con do viem tuyen giap trong do chit yeu la viem giap man (benh ti,r mien). Trong qua
trinh viem giap tir mien, cac khang the to mien tan ding mot hoc nhieu khang nguyen
tuyen giap gem thyroglobulin (Tg), thu the TSH (TR) va thyroid peroxidase (TPO). Xet
nghiem dinh luting cac khang the to mien nay c6 gia tri giitp xac dinh, theo dOi benh.

2.6.4.1. Anti-thyroglobulin antibodies (Tg-Ab)

Cac khang the khang thyroglobulin dugc sinh ra bai cac to bao mien dich ch6ng lai
khang nguyen tuyen giap thyroglobulin sau khi tuyen giap N ton thuong hay viem. Khi
khang the nay hien dien chimg se pha tuyen giap:
Tang trong viem giap Hashimoto's, suy giap, benh Graves, thyrotoxicosis, myxedema
va ung thu giap.
MOt s6 truemg hop ngoai tuyen giap nhu lupus do he th0ng, dai thao clueing va thai
ky ding duong tinh vai anti-Tg.,Ngoai ra s6 ngu6i binh thuang cling c6 anti-Tg cao,
phi c6 anti-Tg cao de dan den say thai ha4c vo sinh, chimg can to phoi lam to trong
tir cung nhung co the chua
Gia tri lam sang:
Dugc chi dinh xet nghiem dinh luting anti-Tg trong truemg hop theo dOi sau phAu thuit
ung thu giap hay sir dung iod ph6ng x4. Cac nghien ciru hei ciru cho thay sau pilau thuat
cat b6 khi u thanh ding n'ong dO anti-Tg se giam dan va bien mit, nett nong dO chi dAu
(marker) nay duy tri 6 mUc cao hay tang la bang chimg benh van con hoc dang tin trien.
Anti-Tg thu6ng dugc chi dinh cling vai anti-TPO a tam soat benh to mien tuyen giap.
KS'T thuit dinh luting: hien nay thong dung nhat la 1Cy thuat mien dich teen the he
th6ng mien dich tu dOng: mien dich h6a phat quang (Architect- Abbott, Advia centaur —
Bayer, Liaison-Diasorin, Immulite-Siemens), Luminescent Immunoassay (PCT analyzer-
B. R. A. H.M.S). Ngodi ra con c6 ky thuat ELIA hay RIA.

2.6.4.2. TSH Receptor Antibody (TRAb)

Thu the TSH (TSHR) la protein dugc ma He tren gen thuOc nhiem sac the 14q, la
mot trong cac khang nguyen chinh cua berth to mien tuyen giap, chit y6u o cac to bao bieu
mo cua nang giap. Tu khang the khang TSHR la TSH Receptor Antibody (TRAb).
La chi dau c6 tan suat duong tinh cao trong benh Basedow, o d'Oi Wang Basedow
mai chan doan ty le throng tinh vao khoang 80%, Basedow khong dieu tri tSTle doting tinh
den 88,3%. Cac hiep hOi cac nha nOi tiet dL de nghi them xet nghiem TRAb vao b0 xet
nghiem than doan benh Basedow.

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 CHU'O'NG 6 I. HOA SINN LAM SANG BENH LY TUYEN NOI TIET

Kyr thulat Binh luong: tixang tix Tg-Ab (thuOc 136 xet nghiem tix mien tuyen giap).

2.6.4.3. Thyroid peroxidase antibody (TPO-Ab) (ho0c antimicrosomal antibody)

La enzym tham gia qua trinh tong hop not ti6t to tuye'n giap, no gill') gan phan tir' iod
vao khung protein la phan tir thyroglobulin. TSH kich thich hoat dOng cira enzym TPO.
Tu khang the tan dog enzym TPO se gay giarn hoac cham dirt qua trinh tr'en.
TPO-Ab (+) gap trong: benh viem giap Basedow, viem giap Hashimoto's, viem giap
11.0 san, benh xay ra trong 1 den 4 thang sau sanh thuang a san phu c6 tien sir ban than
haac gia dinh c6 r6i loan chirc Wang tuyen giap. MOt so benh ngodi tuyen giap nhu viem
khop dang thap, benh Addison's, Lupus do he thong, thieu mau ac tinh...va 3% nguai
TPO-Ab (+) khong co benh.
ting dung lam sang:
- Chan doan xac dinh viem giap to
- Chan doan phan biet benh giap do to mien va khong do tv mien.
- Quyet clinh dieu tri a benh nhan nhugc giap dual, lam sang.
Kyr thu4t dinh luong: tuang to Tg-Ab (thuOc 130 xet nghiem to mien tuyen giap).

3. G161 THIEU MOT SO BENH AN

A. CAU HO! NGHIEN CtrU

Truimg hop 1
Ho ten: Tran N., phai nam, sinh nam 1969.
Dia chi: TP Qui Nho'n — Binh Dinh. Nhap vien ngdy 06/12/2012.
LS?' do nh4p vien: tieu chay nhieu laningdy.
Chan doan luc nh4p vien: r6i loan tieu hoa.
Benh sir: that nh4p vien 10 ngay, BN thay,ngued met mai, chart an, so lanh. 3 ngay
gan day BN tieu chay 5 laningdy, phan nhay matt, kern met moi nhieu nen xin vao
vien. Tien sir: kh6e manh.
Tham kham: benh nhan da xanh tai, they a, tip Vie kern, tieu chay khoang 5 lan/
ngdy, phan nhay mau, so lanh. Mach 77 lan/philt, HA 115/70mmHg, nhiet do 38,5°C.
Xet nghiem:
* Glucose — Ure — creatinin- binh thuang.
* GOT: 67 U/L t; GPT: 77 U/L T.
* TG: 0,85mmol/L (1,7 — 2,29)) 1. Cholesterol: 2,9 mmol/L (4 — 6,7): 1.
* Ion d6 - Tang phan tich nuac tieu: binh thuang. Phan: ly, amip (+).
* Cong thirc mau: binh thuang.

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HOA SINN LAM SANG

* Sieu am tuyen giap: binh

* Cortisol: 8 gi6: 32,22 ng/ml (50 -230)1.
* Hormon giap: FT3 = 1,6 pg/ml (1,5 — 3,5); FT4 = 7,8 pg/ml (8 — 20);
TSH = 2,9 mIU/ml (0,4 — 7).
* Hormon tuyen yen: ACTH: 5,9 pg/mL (7,9 - 66,1) FSH: 5,46 mIU/mL
(30 - 118) I,. LH: 2,44 mIU/mL (16 — 66) J,. GH: < 0,1 ng/mL (0,1 - 7)1.

Truiyng hop 2
Ho ten: Nguygn T Minh T., phai nix, sinh 1970.
Dia chi: TP Qui Nhon — Tinh Binh Dinh.
Vao vien: ngay 19/10/2012. LST do: sot cao + met m6i.
Benh each nhap vien 3 thang, BN thay met m6i, sg lanh, khong mu6n tier. xiic
\Ted ngu6i xung quanh. Cach day 3 ngay, BN c6 sot nhe, sau do sot tang cao dan kern
ret run, dau dau, sot ca ngay, met m6i nhieu, BN to mua thu6c uong nhung khong
d6 nen xin vao vien.
Tien sir: bang huyet sau sinh each day 1 nam. Mat kinh each day 7 thang.
Tham kham: nhiet d6 39°5C, mach 96 fan/phirt, HA 100/60 mmHg, nhip th6 29 lan/
phut. T6ng trang trung binh, da xanh tai, tiep xirc kern, moi kho, dai tieu tien
binh thu6ng. Bung mem, di dOng theo nhip tha. Gan, lach khong 16n.
Tim — Ph6i: khong pith hien benh 1ST.
Xet nghiem:
* Cong thirc mau: binh thuemg.
* Glucose mau: 98 mg/dl; GOT: 42 U/L; GPT: 45 U/L; BUN: 9,2 mg/di;
creatinin: 0,71 mg/dl: binh thu6ng. TG: 0,88mmol/L (1,7 — 2,29)1.
Cholesterol: 3,1 mmol/L (4 — 6,7): 1. Ion 6: Nat: 136 mmol/L; IC: 3,8
mmol/L; C1-: 92 mmol/L; Ca town phan: 2,1 mmol/L: binh thuemg.
*T6ng phan tich nu& lieu: binh thuong. Cay mau: am tinh.
* Sieu am tuyen giap: binh thu6ng. Hormon cortisol: 8 gig: 34,6 ng/ml (50 —
230)1. Hormon giap: FT3 = 1,24 pg/mL (1,5 — 3,5)1. FT4 = 2,99 pg/mL
(8-20)1. TSH = 1,4 mIU/mL (0,4 — 7). Hormon tuyen yen: FSH: 19,2
mIU/mL (30 - 118)1. LH: 4,2 mIU/mL (16 — 66) 1. Prolactin: 3,1 ng/mL (6 —
29) 1.GH: < 0,1 ng/mL (0,1 - 7) 1.

Tryon h9p 3
Ho va ten: Do T Thu H., phai nu, 20 tu6i.
Dia chi: An nhan — Binh Dinh.

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 CHU'O'NG 6 ► HOA SINE/ LAM SANG BENH LY TUYEN NOI TIET

Nhap vien ngay: 22/2/2013. Ly do: dau dau + giam thi tuc.
Benh sir: tilt& nhap vien 2 thang, BN thdy sita chay (chua ca con), kinh nguyet
thua dan va s6 luemg kinh it. Cach 10 ngay BN dau dau nhieu han, giam thi luc,
nhin ma, kern bunnon va non khan nen xin vac, vien.
Tien sir. Kinh nguyet khong deu.
Kham: mach 87 fan/phut, HA 108/70mmHg, nhi'et d6 37°C.
T6ng trang trung binh, da niem mac h6ng, tinh tao. BN than dau dau nhieu, mat nhin
ma. Tim — ph6i: khong phat hien benh ly. Tuyen giap: binh thuemg. Khong thay ddu
hi'eu cira viem nao — mang nao. Khong thay ton thuong giac mac, ket mac...
Xet nghiem:
* CTM — Chirc nang &mg mau: binh thuemg. DNT: binh thuang.
* Sinh hoa: chirc nang gan-than-glucose-lipid-ion d6: binh thuemg.
* Hormon tuyen yen: FSH: 69 mIU/ml (30 - 118). LH: 71 mIU/m1 (16 — 66)1.
Prolactin: 80 ng/ml (6 - 29) T. GH: 4 ng/ml (0,1 - 7). Cortisol: 8 gia: 144 ng/ml
(50 -230). TSH = 2,1 mIU/ml (0,4 — 7).
* MRI so nao: a tuyen yen c6 1 kh6i u d # 8mm, be mat tuyen I6i, khong d6i
cu6ng tuyen yen bi d'dy Lech, nen h6 yen bi bao men. K'et Juan: u tuyen yen.

Truimg hop 4
Benh nhan: Trdn Thi My H., phai nit, 39 tu6i.
LY do nhap vien: to tay, to chan.
Benh BN c6 tien sir cuemg giap, dang dieu tri. Khoang 5 ngay nay to tay, to chan
nhieu nen xin nhap vien.
Chan doan liic nhap vien: ha kali mau/cuang giap.
Kham lam sang: nhiet d6 38,6°C, mach 117 ran/phut, HA: 120/75 mmHg
Xet nghiem: Cong thirc mau: bach cdu: 9.300/mm3 (N: 60,5%, L: 18,8%); h6ng
eau: 3.970.000/mm3, Hb 10,9g/L, Hct 23,9%; tieu eau: 277.000/mm3 ASO: (-),
CRP: (-);
Ion 6: Na: 139 mEq/L, K: 2,6 mEq/L 1, Ca: 4,9 mEq/L T, Cl: 92 mEq/L;
Cdy mau (-); S6t ret (-); Widal (-); IgG Dengue (+); ANA (-).
Chirc nang tuyen giap: TSH sieu nhay: < 0,01 mU/1 (0,49 — 4,67 mU/1) FT3: 5,1
pg/ml (3,5 — 8,0 pg/ml); FT4: 16,2 pg/ml (8 — 20 pg/ml).

217
HOA SINN LAM SANG

Truing hop 5
Benh nhan: NguyL Thi L., phai nu, 44 tu6i.
LY do nhap vien: dau dau + non nhieu.
Kham lam sang: mach 120 Fan/phut, huyet ap 115/70 mmHg, nhip tha: 20 Lan/
phut, nhiet do: 39°C.
Xet nghiem:
C6ng thirc mau: bach cau: 11.700/mm3i (N. 84,2% I, L. 10,3%); h6ng cau:
5.020.000/mm3; Hb 10,7 g/L.
Sinh h6a: glucose huyet: 122 mg% (75 — 115) T; GOT: 40 U/I; GPT: 84 U/I T;
BUN: 15 mg%; creatinin: 0,8 mg%; Ion 6: Na: 139 mEq/1; K: 2,6 mEq/1 1; Ca:
4,5 mEq/1 T, Cl: 100 mEq/1. S6t ret (-); Dengue (-);
Cay DNT: coagulase negative Staphylococcus (+); Nam/DNT (-); PCR lao/
DNT (-)
SH/DNT: protein: 37 mg% (15 - 25) t; glucose 97 mg% (45 — 80) T. Clo: 710
mg% (700 — 750). Wing can rat it; Bach cau 556 mm3 (1 — 3) 1- (N: 93%, L:5%).
Chac nang tuyen TSH sieu nhay: < 0,01 mU/1 (0,49 — 4,67 mU/1) FT3:
10,2 pg/ml (3,5 — 8,0 pg/ml) 1-; FT4: 37,8 pg/ml (8 — 20 pg/ml) T.
Sieu am tayan giap: nhan giap 2 they.

Truirng hop 6
Benh nhan: Pham Thi H., phai nit, 40 tu6i.
Ly do nhap vien: sot + gay nhanh + tay run nhieu.
Benh sir: each nhap vien 7 ngay, BN cam thay met moi, tay run, nguoi wing, nil&
dau, danh trong ngvc, an u6ng kern. BN tkr di mua thuoc u6ng nhung kh6ng
met nhieu hcm va gay nhanh nen xin vao vien.
Tien sir: kh6e manh.
Tham kham: mach 117 fan/phut; HA 120/70 mmHg; nhip tha 17 lan/phat; nhiet
d6 38° 3C. BN gay, than nhirc dau, tay run va am u6t. Tuyen giap to, di dOng theo
nhip nuot, c6 rung miu khi so. Nhip tim nhanh, khong phat hien tieng tim benh ly.
Xet nghiem: C6ng thirc mau: bach cau: 8.400/mm3 (N: 68%; L: 7,5%); hong cau:
4.200.000/mm3; Hb 12,3g/L; lieu cau: 223.000/mm3.
Sinh h6a: glucose huyet: 95 mg/dl (75 — 115); Ion 6: Na: 140mEq/L; K: 3,8
mEq/L; Ca: 4,3 mEq/L 1-, Cl: 99 mEq/L.
Sieu am: beau giap da nhan 2 they. ECG: nhip nhanh xoang deu.

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 CHU'ONG 6 Po- HOA SINN LAM SANG BENH LY TUYEN NOI TIET

Chirc nang tuy'L giap: TSH sieu nhay: 0,25 mU/1 (0,49 — 4,67 mU/1)1; - FT3: 6,8
pg/ml (3,5 — 8,0 pg/ml); FT4: 25,8 pg/ml (8 — 20 pg/ml) T.
Sieu am: buau giap da nhan 2 thily.

Truirng hop 7
Berth nhan: Thai Thi T., phai nit, 44 tu6i.
L3'T do nhap vien: La ma.
Benh truck nhap vien 6 ngdy, BN cam thay on lanh, met, an u6ng kern, bun oi,
6i, tao bon dai ding, hoi hOp, sau do la ma nen xin vao vien.
Tham kham: mach 55 lan/phut; HA 100/70 mmHg; nhip the 16 l'an/phAt, nhiet do
36°6. T6ng trang trung binh, tip Vic kern, \To cam, the a, tay chin lanh va kho, dau
ca. Nhip tim chum, kh6 the khi gang sire, c6 can dau that nguc, ti'eng tim ma deu.
Xet nghiem: CTM: HC: 3.100.000/mm3.1, Hb: 101g/L (120-180): 1, BC: 8.600/mm3.
Sinh TG: 0,9mmo1/L (1,7-2,29)) i; cholesterol: 3,1 mmol/L (4 — 6,7): 1.
Chirc nang gan: binh thuang. glucose - ure — Cre - protein: binh thuang. Ion d'O: Na:
138 mEq/L; K: 2,7 mEq/L (1,); Ca: 3,9 mEq/L; Cl: 109 mEq/L.
ECG: nhip tim chum.
Chirc nang tuy'en giap: TSH sieu nhay: 0,06 mU/1 (0,49 — 4,67); FT3: 0.35 pg/ml
4,(3,5 — 8,0 pg/ml); FT4: 6,2 pg/ml (8 — 20 pg/ml).
Chirc nang tuy'L yen: cortisol mau: 66 ng/ml (50 — 230); GH: 0,1 ng/ml (0,1 - 7);
Prolactin: 0,9 14/1 (2 - 18) 1; LH: < 0.1 mIU/ml (5 - 25) FSH: < 0,1 mIU/m1
(5 - 20)1.

Truirng hop 8
Benh nhan: VO Thi H., phai Mt, 61 tuOi.
Dia chi: Tay San — Binh Dinh. Nhap vien ngdy: 8/3/2013.
Ly do: met moi keo dai.
Benh sir: each nhap vien 4 thing, BN cam thay nguai met mai, hay bi chuOt rut
mac di' kitting hoat &ling gang sire, sq lanh, rat hay bi tao bon. Cac trieu chimg ten
ngay tang tang kern sa sut tri tue, da,dieu tri nhieu lin nhung khong giam nen xin
vao vien. Tien sir: .khong c6 benh ve tim mach, khong dimg cac thuoc khang giap.
Khong bi viem giap, khong ton thuang that the hay pilau thuat tuyen giap.
Tham kham: mach: 811an/phitt, HA: 115/70mmHg, nhiet dO: 37°C. Da niem mac
hong, tra lei chain chap, tip xuc chum, met mai nhi'eu, sq lanh. Tuy'en giap khong
to, khong se thay kh6i u. Tim — ph6i: khong phut hien benh

219
HOA SINN LAM SANG

Xet nghiem: CTM + chirc nang (long mau: trong gioi han binh thuamg.
Sinh hoa: TG: 2,4 mmol/L (1,7 — 2,29)) T; cholesterol: 7,0 mmol/L (4 — 6,7): i; chirc
nang gan + then + glucose + ion di3: binh thuamg. ECG: binh thuamg.
Tuy6n giap: TSH sieu nhay in 1: 8,9 mU/1 (0,49 — 4,67); TSH sieu nhay lin 2: 8,7
mU/1; T4 lin 1: 6,2 1.1g/d1 (4 — 11 µg/dl); T4 Ian 2: 6,0 µg/dl; FT4 len 1: 12 pg/ml (8
— 20 pg/ml); FT4 lan 2: 12,5 pg/ml; T3: 155 ng/dl (75 — 220); FT3: 6,2 pg/ml (3,5 —
8,0 pg/ml); cortisol man: 137 ng/ml (50 — 230); GH: 3,4 ng/ml (0,1 - 7); prolactin:
7,2 p,g/1 (2 - 18); LH: 10,5 mIU/m1 (5 - 25); FSH: 12 mIU/m1 (5 - 20). MRI so Tao:
kh6ng phat hien benh 1ST.

Truimg h9p 9
Benh nhan: Tran D., phai nam, 45 tu6i.
Dia chi: Tuy phirOc — Binh Dinh Nhap vien ngay: 14/1/2013.
L'/- do: BuOu co.
Benh BN phat hien c6 to ra each day 8 ngay, di sieu am phong mach tir voi
chan doan: buom giap nen xin vao vien. Tien six: khOe manh.
Them kham: mach 731an/phiit, HA 110/70mmHg, nhiet d6 37°C. T6ng trang trong
binh, tinh tao, tip xuc tot, da niem mac h6ng, dai ti6u tien binh thuamg.
Khong run tay, run chan, khong met, khong h6i h6p — danh trong ngirc, met kh6ng
loi —> khong c6 tri'eu chimg r6i loan chic nang giap.
Kham c6: o they T tuy6n giap c6 nhan, d # 1,5cm, di d6ng theo nhip nu6t.
Sa nen thay nhan c6 hinh bau dire, deu den, an vao dau nhe, met d6 chic, tai chis;
khong thay hach. Tim — ph6i: khong phat hien b'enh 1ST. Gan — lach: trong gioi han
binh thuamg.
Xet
* CTM + chirc nang (long trong gioi han binh thuamg.
* Chirc nang gan + then + glucose + ion do: binh thuamg.
* Tuy6n giap: TSH sieu nhay: 2,6 mU/1 (0,49 — 4,67); FT3: 6,7 pg/ml (3,5 — 8,0
pg/ml); T3: 155 ng/dl (75 — 220); T4: 5,9 µg/dl (4 — 11 lig/d1); FT4: 10,2 pg/ml
(8 — 20 pg/ml).
* ECG tim: binh thuOng. XQ c6: 1 nhan o thiiy T tuy6n giap, car cac di6m calci
h6a o ben trong nhan. Thiry T tuy6n giap, d # 1,5cm.
* Sinh thik: cac t6 bao tuy6n binh thuong, c6 cac dam chat keo, c6 nhung vang
calci hoa —> k6t Juan: adenom tuy6n giap.
* Xa hinh TG: nhan tang xa, bet nhi6u tia phong xa, khong x6a phan nhu mo can
tai cua TG.

220
 CHUO'NG 6 ► HOA SINH LAM SANG BENH 01 TUYEN NQI TIET

B. CAU HO! LU'ONG GIA

1. Dieu nao sau day khong dting khi not ve hormon T3:
A. Khi tad mo phan lan T4 chuyenthanh T3
B. Manh hon T4 khoang 4 lan
C. S'O' ltrang it hon T4
D. Thai gian tac dung dai hem T4
2.O tuyen giap binh thtriing, niing do iod/TG gacp bao nhieu fan so voi nOng do iod/mau:
A. 250 B. 150 C. 75 D. 30
3. Enzym nao sau day tham gia vao qua trinh oxid hOa iod:
A. Dehydrogenase
B. Peroxidase
C. Transferase
D. Synthetase
4. Ty le hormon giap dtrov tao thanh:
A. 70% la T4 va 30% la T3 B. 80% la T4 va 20% la T3
C. 83% la T4 va 13% la T3 D. 93% la Ti va 7% la T3
5. Dieu nao khong dting khi not ve T4 :
A. Ai lue cita protein vai T4 cao hcm T3
B. Chi có 0.02% hottnon T4 at clang to do
C. Khi vao mau T4 gan ket chit yeti vai globulin
D. MOt y1(1-16,e
6. Ditu nao sau day khong thing khi not v'e hormon giap tren chuyen hoa glucid:
A. Tang hap thu glucose tir he lieu hoa
B. Tang sinh &rang mai
C. Giam tieu thu glucose
D. Dua nhanh glucose vao to bao
7. Dieu nao sau day khong dung khi not ve hormon giap tren chuyen hoa lipid:
A. Tang su huy dOng lipid tir cac mo ma —› tang AB to do trong huyet tucmg
B. LJc che su oxid hoa cac AB to do trong to bao
C. Lam gia.m cholesterol, TG, PL huyet tuang
D. Khi suy giap thi tang lipid mau benh XVDM

221
HOA S1NH LAOANG

8. Dieu nao sau day khong dung khi not ye tic dung cua hormon giap:
A. Tim: tang nhip tim, tang co bop
B. Me' m'a: di hoa, kich thich thdy phan lipid
C. Cu: d6ng hoa, tang tong hop protein
D. Xuong: phat trien, kich thich sir tang truong binh thuemg va phat trien cua xucmg
9. Dieu nao sau day killing thing trong suy giap thir Oat:
A. TSH tang
B. TSH giam
C. TT4 FT4: giam
D. TT3, FT3: giam
10. Nen d'6 TT4 FT4 giam trong cac throw hop sau, ngo4i trir:
A. Suy giap nguyen phat B. Suy giap thin phat
C. Thi'eu but iod tram trong D. U tuye'n yen
11. Ming d'6 TT4 FT4 tang trong cac truirng hop sau, ngoai
A. Cueing giap do tu mien B. U tuy6n yen
C. Buell," giap Basedow D. Di'eu tri khang giap
12. Dieu nao sau day thing trong suy giap tien phat:
A. Phd mem
B. TSH tang
C. TSH giam
D. TT4, TT3 tang
13. Xet ngiqm nao sau day gifip chin doan b'e‘nh giap to mien:
A. Tg-Ab
B. TRAb
C. TPO-Ab
D. Tat ca, dung
14. Dieu nao sau day khong dung trong suy giap thin Oat:
A. Tang cholesterol man B. TSH tang
C. TSH giam D. TT4, TT3 giam

222
 CHU'O'NG 6 ► HOA S1NH LAM SANG BENH LY TUYEN NO1 TIET

15. Enzym nao sau day tham gia vao qua trinh oxid hem iodur thanh iod:
A. Myeloperoxidase B. Peroxidase
C. Tyroxidase D. Protease
16. Dieu nao sau day khong dting khi not ve hormon tuye'n giap T4:
A. Gay tang throng huye't B. Chie'm tY 7% hormon giap
C. Co di luc cao khi gan ke't vai protein D. 0,02% 6 du6i dang tu do
17. Chit nao sau day tang trong mau khi suy giap:
A. Glucose B. Cholesterol C. Protid C. Vitamin
18. M& phan tir thyroglobulin china bao nhieu acid amin la tyrosin trong nang giap:
A. 70 B. 350 C. 700 D. 950
19. So vori T3, thoi gian ban hay ciia T4:
A. Dai han B. Ngan han
C. Tucmg duang D. Thy theo mo dich ma no tac dung
20. Khi nhu eau hormon giap thip:
A. MOt phan T4 chuy'en thanh T3
B. MOt phan T3 chuye'n thanh T4
C. T4 va T3 c6 th6 chuy6n d6i qua lai
D. Thyroglobulin khong ph6ng thich ra tuan hoan
21. Tim cau dung, cac chit nao ket hop to nen triiodothyronin:
A. Tyrosin, diiodtyrosin B. Thyronin, monoiodotyrosin
C. Monoiodotyrosin, diiodotyrosin D. Thyroglobulin, tyrosin
22. Tim cau dung:
A. Thyronin la nguyen lieu dau tien tong hop hormon tuyen giap
B. The dung sinh ly dm T3 manh hcm T4
C. Trong mau T4 c6 n6ng dO thap hcm T3
D. Hormon tuyen giap chi hoat tong khi ke't hop vai TBG
23. Tim xet nghiem co gia tri nhit trong dieu tri ung thy tuyen OAP:
A. TPO-Ab B. Tg C. TR-Ab D. Tg-Ab
24. Tim Op hop xet nghiem chi ra cuirng giap dtroi lam sang:
A. TSH T, T4 J,, T4 B. TSH st, FT3, FT4 binh thuang
C. T31, FT31 D. T41, FT4,1,

223
HOA SINN LAM SANG

25. Tim tap hop xet nghi.01 cho bit b'e'nh nhan c6 cubing giap:
A. TSH i, FT4 binh thuong
B. TSH 1, FT4 I
C. TSH t, FT3 1
D. TSH 1, FT4 binh thuong
26. Tim tap hop xet ngliFe'm chi ra suy giap dtred lam sang:
A. TSH t, FT4 binh thuemg B. TSH 1, FT4 binh thuemg
C. FT4 J,, FT3.1, D. TSH i, FT4i

224
 Chu'o'ng 7
DICH SINH VAT

MUC TIEU
1.Phan tich thanh phan h6a sinh a dich nab thy binh thweeng.
2. Phan tich tactic khcic bier gift.' a cac thanh ph an dich nao thy trong mot sa
trtrang hop Nnh 1)5:
- Viem mang nao
- Lao mang tido.
- Viem mang nao do kY,sinh
- Viem mang nao do nam.
- Viem mang nao do virus.
3. Phan tich thanh phan hoa sinh trong dich tham va dich

1. DICH NAO TUY

Dich nao try (DNT) (cerebrospinal fluid = CSF) la met loci dich dm he than kinh
trung uong, khong mau, duoc san xuat dr dam r6i mach mac cua nao. DNT dong vai tr6
quan trong, bao boc va dem cho vo nao, dieu hoa to Ong qua trinh tudi mau nao.
DNT dugc china trong khoang dual nhen va he th6ng nao that xung quanh - ben trong
nao va try song, cau thanh cac nao that, cac be nao that, kenh ding nhu Ong trung tam
cua try song. Khu vdc cua DNT throe phan each vai mau bai met mang, goi la mang mau
dich. Mang nay ngan khong cho to bao mau Ira phan lan protein huyet tin:mg vao DNT,
trong khi do nhirng phan tin nho tan trong nu& nhu glucose, Cl- tham qua mang.

1.1. Siy tao thanh va chin Wang cua dich nao try
Leong DNT dirge tao thanh khoang 500m1/ngay va the tich DNT g ngueri trirang
thanh binh thugng khoang 120 — 150m1. DNT thay d6i sau m6i 7 gig, tine la 3 — 4 lan
moi ngay. Chirc nang cua DNT c6 the tom tat a 4 diem chinh.

1.1.1. To h,pc nfing Archimede can bAng vai trong cua nao
Trong luting thoc cua nao khoang 1400 g, tuy nhien trong luting tinh sau khi dugc
treo trong DNT chi, Wang throng khoang 25 g. Dieu nay cho phep nao duy tri mat dO cau
true ma khong bi ton thuang bai trong luting cua chinh no. Khong c6 DNT, nao se then
ep cac mach mau nuoi va cac neuron than kinh.

225
HOA SINH LAM SANG

1.1.2. Bao ves nao khoi cac tac Ong do va dip, gang xoc
Trong mot s6 tinh trang nhu tai nan giao thong, chen thuang the thao, DNT khong
the bao Are not nao tarot cac luc va dap vao khung so. Dieu nay se dan den xuat huyet nao,
ton thucmg mo nao va them chi tir vong.

1.1.3. Duy tri su' hang dinh h6a hoc

DNT chay qua cac nao that va &roc tai hero thu tref lai mach mau. Trong qua trinh
nay, no dua cac chat thai chuyen hoa ter he than kinh trung ucmg qua hang rao mau nao.
Dieu nay cho phep duy tri su on dinh trorig qua trinh phan phoi cac yeu to than kinh not
tiet. Su thay doi nong d6 cua cac chat nay du nho ding co the gay ra ton thircmg cho he
than kinh. Vi du nong d6 cao glycin trong DNT gay irc the qua trinh dieu hem nhiet d6
va huyet ap co the, pH cao trong DNT gay chong met va bet tinh. Cac co chat hinh thanh
trong qua trinh chuyen hoa dm m6 than kinh duoc khuech tan nhanh ch6ng vao DNT va
sau d6 &roc dua vao mach mau khi DNT dirge hap thu.

1.1.4. Chin nang phong ngu'a thieu mau nao

Khi DNT giam the tich trong khong gian c6 dinh ben trong hOp SO, no lam giam ap
luc not so va do d6 lam tang tirai mau.

1.2. TuAn hoan dich nao tuy

Khoang 50-70% luting DNT dirge san xuet trong nao boi cac t6bao bieu mo trong dam
r6i mach mac. Phan con lai &roc tao ra quanh cac mach mau va doc thanh nab that. DNT di
chuyen ter nao that ben an be gian nao that, nao that ba, qua c6ng nao, vao nao that ban, qua
to gifra va f6 ben vao khoang clued nh'en cua nao va My song. DNT &roc tad hap thu vao cac
tinh mach xoang qua cac hat mang nhen (hinh 2). Ngoai ra, con &roc hap thu qua cac mach
bach huyet. Tac nghen trong tai hap thu dich nao My gay ra benh nao (mg thily.

1.3. Khao sat dich nao WI/

Hinh 7.1. Ong chtira dich nao tuy nvol

226
 CHUCYNG 7 ► DICH SINH VAT

1.3.1. DOc didm vat ljr

1.3.1.1. Ap line DNT: dugc do bang each choc dO tuy song la 10-18 cmH2O (8-15 mmHg
hay 1.1-2 kPa) khi nam nghieng va 20-30 cmH2O (16-24 mmHg hay 2.1-3.2 kPa) khi
ng6i. O tre so sinh, dp liyc DNT tir 8 - 10 cmH2O (4.4-7.3 mmHg hay 0.78-0.98 kPa).
Thay dOi dp hyc DNT xay ra khi ho hay tang op hie tinh mach c6. Khi nam dp luc DNT
do bang choc do tuy song Wong d6ng voi ap hyc not so.
Dam r6i mach mac nao th5t ben (bong)
Xoang doc tren
Be the chai Khoang dual nhen
Mang nao sung Cac hat mang nhen
Mang nhen,

Be gian nao th5t

Be giao thoa
Dam r6i mach mac nao th5t ba
Be gian cu6i
COng nao (Sylvius),
Be cau nao Be tinh mach nao 16'n
LO ben (10 Luschka) } Be hanh tieu nao
Dam r6i mach mac nao that bon LO giO'a (10 Magendie)
Mang cOng
Mang nhen
Khoang nhen -
Ong trung tam cua tuy gai

Hinh 7.2. So' d6 tun hoan cua dich nao tuy

Ap lue DNT c6 the tang trong nao ung thug, ung thu nao, nhlem trung, giam trong
de DNT.

1.3.1.2. Mau sac cua dich nao tuy

Dich binh thu&ng trong sueyt, khong matt Su thay d6i mau sac DNT ggi 3'T c6 them
co chat trong dich. Vi du mau anh yang, yang chanh gap trong lao mang nao; mau hong
trong xuat huyet nao hay cham mach khi choc do; van duc, duc hay nhu mu gap trong
viem mang nao mu. Doi khi DNT co the c6 mau luc, do bilirubin hay nhieM khuan nang.

227
HOA SINN LAM SANG

s DO duc DNT sir xuat hien cila hang cau hay bach cau, vi sinh vat hay tang
ming dO protein. DO nhot binh thtrong cua DNT tircmg to nuot. DNT trar nen (lac han
trong truemg hop ung thu hay viem mang nao.

1.3.1.3. Thanh phan h6a hoc

MOt so thong so thuamg dirge danh gia thuemg quy d6i A/6i DNT gom c6 glucose,
protein, lactat. Bang (1) mo to tri so binh thiremg cac thong so sinh hoa trong dich nao tiiy.
Glucose: n'ang de glucose trong DNT binh thtremg bing 2/3 nang dOglucose trong
mau. Ty le glucose giita DNT va huyet thanh thap trong cac trirang hop nhiem khuan, lao,
nam hay u mang nao.
Tuy nhien, giam nang de glucose trong DNT ding gap trongOt so truong hop
nhijrn sieu vi nhu s6i, enteroviruses. Nhung trung hop nay nen kat hop lactat trong DNT
da chan doan phan biet.
Lactat: niing dO lactat trong DNT dOc lap v6i nang de lactat trong mau. Duce sir
dung phan biet trong viem mang nab do vi khuan hay virus. Lactat trong DNT tang nhieu
trong viem mang nao do vi khuan (6-20 mmol/L), trong khi ngued binh thueeng nong de
<3mmol/L hay chi tang nhe (3-6mmol/L) trong viem mang nao do virus.
Protein: kich thuac phan tin lan, kilo qua hang rao mau nao nen hien dien Arad so
S le
luting it. DNT china khoang 0.3% luting protein huyet tircmg, xap xi 15-40 mg/dl. Ti
protein DNT/protein huyet thanh phu thuec vao do virng chic dm hang rao mau-nao.
Giant protein/DNT khong coy ngliia lam sang. Tang protein/DNT kat hop \raj tang
tS7 le protein DNT/protein huyet thanh c6 the gap trong viem mang nao do vi khuan (50-
1000 mg/dl), apxe nao, lao mang nao (50-200 mg/dl), u nao-tily song, da xa cirng, hOi
chiing Guillain-Barre, giang mai ding gay tang protein/DNT.

1.3,2. Thanh phAn t4 bao

DNT binh thuong hau nhu khong c6 to bao hoac c6 rat it < 3, chi' yau la lympho.
, Six hien dien h6ng cau trong DNT c6 the do xuat huyet nao hay nhiau trong luc
lay mau (cham mach). Tang bach cau gqi y c6 viem do virus, to mien (da xo cirng, hOi
chirng Guillain-Barre) hay nhi6m trung mang no.
Tang to bao ding c6 ilia do ung thu di can, leukemia.
Khi c6 tang to bao > 5/mm3 thi tin hanh phan loai, ly tam DNT lay can, nhuOm
giem-sa va dam bach phan. Khi nghi ng6 ung thu hoac da c6 chan doan tir Mr& thi dem
bach phan to bao bat ke so luting. Tang bach cau da nhan trung tinh gap trong viem mang
nao mil, tang lympho bao gap trong lao mang nao, tang bach cau ai toan trong niam ky
sinh trung.

228
 CHU'O'NG 7 ► DICH S1NH VAT

Khdo sat to bao trong DNT nen dugc tin hanh trong \Tong 30 phut den 2 gig sau choc
a
de My sang tranh ly giai to bao.

1.3.3. Xet nghiOm vi sinh

Khi c6 nghi ng6 benh viem nao-mang nag. Nhu6m Gram, cAy hoac PCR DNT gip
phat hien chimg vi sinh gay benh. Ngoai ra, tim khang nguyen va khang the dac hieu/DNT
cling giup chan doan tac nhan gay benh. Vi du: xac dinh cryptococcal antigen, nhuem
AFB tim lao, PCR lao, VDRL xac dinh giang mai,...

1.3.4. Cec xet nghiesm chuyen bit khec

0 Chi s6 IgG: do bAng (IgGDNT/IgGhuy6tthanh)/(a1buminDNT/a1buminhuy tthanki)*Ngtr.ang
binh thuemg la 0.73, tang trong hei chimg da xo cu•ng.
0 Oligoclonal bands: trong da xa cimg, khang the vugt hang rao mau nao tan
cong myelin quanh day than kinh. Do do 'long de khang the trong DNT cao
han binh thugng va cao hon trong mau. Liic nay, nhieu vach bat thugng tren
anh dien di DNT so vai huy'et thanh vai de nhay 95%.
0 beta-2 transferrin: c6 de nhay va dac hieu cao trong do DNT
0 LDH, CRP va PCT: gip phan biet gifia viem mang nao vi khuan va virus.
NOng de LDH tang vai vi khuan, kh6ng tang vai virus. Tang LDH/CSF con c6
the gap trong da u My hay det quy. Tang CRP trong viem nhi8m va tang PCT
trong nhi'em khuan huyet.
0 Dau an ung thu: carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), va
hCG c6 the tang trong DNT khi c6 di can tir not khac.

229
HOA SINH LAM SANG 41111h 191=11
Bang 7.1. NgtsO'ng Binh thLrOng cCia cac th6ng s6 trong DNT

Cu chk Gioi han du&i Gioi han teen Don vi % so vei huyk tuung

mm `g

230
 CHUO'NG 7 lo• DICH S/NH VAT

Bang 7.2. Cac nguyen nhan bOnh ly va sy thay d6i cac thong s6 dich nao tuy
twang Ong
Nguyen Bach cau
Cam quan Lymphocyte Protein Glucose
nhan da nhan
lem man Duc, duc nhu
rat cao t ue'n ng nhie

Dich

2. DICH MANG BUNG

2.1.Dinh nghia
La dich hinh thanh a khoang phiic mac, giira la thanh va la tang, con goi la dich co
truang. Dich mang bung xuat hien trong cac twang hop benh 1ST nhu xo gan, ung thu.

2.2. Phan loai

Trail dich mang bung dirge phan loai theo mac de tan dich
Do 1 : chi phat hien nho. sieu
Do 2 : có the phat hien duac bang kham lam sang.
11 Da 3 : nhin thay
Theo ca benh sinh, có 2 loai dich la dich tham dich tiet. Cach phan loai nay
ginp ich rat nhieu trong viec giai han chan doan nguyen nhan gay tran dich mang bung.
Nguyen. nhan cilia dich tham là do tang ap luc tinh mach cilia Ong Wei giam ap luc
keo, throng thay trong xo gan. Trong khi dich Wet la ket qua cna vi'em hay benh ac tinh.
Su khac biet ve tinh chat cua hai loai dich nay the hien trong bang 1.
Ngodi ra, tuy thuec vao thanh phan co trong dich to con có
Bang bung xuat huyet: khi lugng HC > 1.000/mm3
Bang bung duang trap: khi luang triglicerid > 110 mg%.

2.3.Cac xet nghi,em khao sat dich mang bung

Dinh luang protein.
11 Dinh luang glucose.
11 Tim to bao.

231
HOA SINH LAM SANG

11 Tim vi khuan.
11 Xet nghiem dac biet

o Do amylailliq Do dtrOmg trap.

LDH Do pH.
ty trong.

2.4. Wit s6 tieu chuan chgn doan phan biet dich thArn, dich tit
Bang 7.3. Tinh chAt dich th6nn, dich xu6t

Dich xufit
Dich thAm
Lao Ung thtr

yang trong, trang trong

chitc chAn khi < 20,4,

e ao

3. DICH MANG PHOI

Dich mang phOi (DMP) la dich huye't thanh duoc tit bai mang ph6i, nom trong
khoang mang phOi. Mang ph6i &roc cAu tao bai hai lop la la thanh va la tang, trirot len
nhau de clang nhO c6 mot it dich. Khoang gifra hai la la khoang mang phoi, chira DMP.
, Binh thiremg, mot vai ml dich lam luon hien din trong khoang mang ph6i, dugc
tit ra tir dicing mach lien won va tai hap thu bai he thong bach huyet. NM" vlay, DMP
dirge san xifat va tai hap thu lien tvc. Tich to dich trong khoang mang phoi xay ra khi
t6c d6 san xuAt vircrt qua ty le tai hAp thu. Thong thirang, 1-ST le tai hp thu tang len

232
 CHUO'NG 7 10.- DICH SINH VAT

den 40 lan t6c dO binh thugng khi mot so luting &Jig ke cua chat long tich to trong
khoang mang phoi. Do do, chi khi c6 six gia tang rat lan trong viec san xuat dich
hoac tac nghen he thong bach huyet trong tai hap thu thi xay ra tich to dich trong
khoang mang phoi.

PHOI LANH PHOI BeNH

Cd hoanh

Hinh 7.4. Ph6i binh thuOmg Hinh 7.5. Tran dich mang ph6i do ung thu

3.1.Cac Ioai dich mang phOi

CO 4 loai dich c6 the tich to trong mang phoi:
- Dich huyat thanh,
- Mau,
- Duefng trap,
-

3.2.Cac nguyen nhan gay tran dich mang phOi

Bang 7.4. Cac nguyen nhan gay tran DMP

Dich thAm Dich xuAt

1111.111r
Suy dinh duang ao,11111 trimg, virus, kY sinh trong, nam
o gan iem my cap
Oi chirng than hu ng thu
barn phan phac mac 'Ibuyen tac phoi
y that trai 6i chi ng Meigs

233
HOA SINN LAM SANG

3.3. Xet nghie'm dich mang phOi

Sau khi da có than down tran DMP, can xet nghi'e'm dich nhAm xac dinh cac nguyen
nhan gay tich to bat thuong nay. Cac xet nghim bao
1. D4c tinh vat 1ST nhu mau sic, (14) nhat, tY tong.
2. Xet nghiem sinh hoa nhu protein, glucose, LDH, amylase, pH.
3. Xet nghi&m vi sinh nhu nhuOm Gram, cay dich choc do, PCR.
4. Xet nghi'e'rn to bao tim htmg cau, bach cau, to bao de tinh, cac sinh vat gay nhigm.
5. Cac xet nghi&n khac nhu dau an ung thu, lipid, globulin mien dich.

3.3.1. Xet nghiem phan biet dich tham va dich Het

Day la bulk dL tien gift') ggi y tim nguyen nhan gay tran dich.W ca ban, dich thAm
la dich duce tao ra do su mast can bang gifta ap suit mao mach va dp lye keo, loc qua
thanh mach binh thuemg khong bi ton thtremg. Trong khi do, dich tiet la dich viem bi ri ra
tir cac to bao. Cac nguyen nhan gay ra dich tham thuemg mang tinh he thiLg trong khi cac
nguyen nhan gay ra dich xuat thugng mang tinh cue b0.
CO th6 chin down phan biet dich tham va dich tiet dua vao cac xet nghiLi sinh hoa
theo tieu chuAn Light (Light, et al. 1972) vii dO nhay 80-98%. Theo do, DMP duct chin
down la dich tiet nL có it nhat mot trong cac tieu chuan sau:
1. Protein DMP/Huy& thanh > 0,5
2. LDH DMP/Huy& thanh > 0,6
3. LDH MDP > 2/3 x gibi han tren cua LDH/huy& thanh
Ngoai ra, nL albumin huy& thanh/albumin DMP > 12 g/L (4) hay cholesterol
DMP < 45 mg/dl thi cling ggi y cho chin down dich tham. Glucose giAm, pH <7,2 d6i
vai dich tiet.
Xac dinh tinh he th6ng hay clic bO ding c6 ich trong tim nguyen nhan tran dich.
Trong tran dich mang phoi do suy tim, 60% trueing hop xay ra ca hai ben ph6i, mang tinh
doi xirng. Neu xay ra mot ben, hoc hai ben nhung khong doi ximg thi ben phai thugng
có lien quan han ben trai.

3.3.2. Cac xet nghiTem khac gitip chin doan nguyen nhan tran dich
0 Viem tuy cap: amylase thugng tang cao
Ung thu: acid hyaluronic tang cao/u trung biL mo.
trimg: nhuiim gram
0 Lao:
- NhuOm AFB
- Adenosine deaminase (ADA) > 47 U/1
- Lysozym DMP/huy& thanh > 1,1
- Lymphocyte DMP/Neutrophil DMP > 0,75

234
 CHU'ONG 7 ► DICH SINH VAT

- y interferon DMP > 140 pg/ml

- PCR lao (+)
0 Lupus:
- Be the: giam
C3, C4 giam
- RF: (+), LE Cell (+)

4. DICH MANG NGOAI TIM

4.1.Dac diem khoang mang ngoai tim
Mang tim dugc eau tao bCri la thanh va la. tang. Khoang nam gifta 2 la mang ngoai tim
goi la khoang ngodi tim nhu khoang ngang, khoang chech. Binh thuong, khoang mang
ngodi tim chira khoang 15-50 ml thanh dich. Trong tnremg hgp cap tinh, hxcmg dich có
the len den 200m1, trong truong hop man tinh, lucmg dich len an 1.000m1 mai du gay
chen ep tim.

yt DM chu

TM ch6 tren DM ph6i

Xoang ngang TM ph&

TM phi

TM chu duOi

Hinh 7.6. Wt cat ngang cCia tim

4.2. Nguyen nhan tran dich mang ngoai tim

0 Suy tim it huyet
0 Thai) tim
0 Tam phe

235
HOA SINH LAM SANG

Hinh 7.7. Hinh anh tran dich mang Hinh 7.8. Hinh anh tran dich mang tim
ngoai tim va tran DMP trai do di can ti:r mot kh6i
u ác tinh a thOy du'ai phi trai

Giam albumin huyet tuang.

Benh ly mo lien ket toan than.
11 Lanh tinh: u nhAy nhi, u soi.
11 Ac tinh: u trung mo (mesothelioma), lymphoma, leukemia, di can t-ir phoi, vu.
Viem mang ngoai tim:
Do vi trung sinh mu (pneumococci, streptococci, staphylococci,
neisseria, legionella species).
Do lao.
Do nAnt (histoplasmosis, coccidioidomycosis, candida).
Nhi6m trung khac (giang mai, protozoal, ky sinh trung).
Do virus (coxsackie virus A and B, virus viem gan, HIV).
Nguyen nhan khac.
11 Phu niem (nhugc giap).
Sau chieu xa.
Chan thucmg (tran mau, du'ang trap mang tim).
Thu& (procainamide, hydralazine, isoniazid, minoxidil, phenytoin, nticoag-
ulants, methysergide).
Roi loan (long mau.
HOi chi mg sau ma mang tim.
HOi chimg sau nhoi mau co. tim.
Phinh boc tach Ong mach chit.

236
 CHLYO'NG 7 II- DICH SINH VAT

4.3.Xet nghiem dich tim nguyen nhan

Dich tiet c6:
o Ty trong tren 1.015.
o Nang de protein tren 30 g/L.
o LDH tren 300 U/L.
o Ty le neng de glucose dich/glucose huy6t tuong nh6 han 1.
Chan doan tran dich mang tim do lao dugc xac dinh n'eu Oat hien vi khuan lao trong
dich mang tim hay ten mang tim.
GO 3'T lao mang tim khi:
o BN bi nhi6m lao 6 cac tang khac va trail dich mang tim chug xac dinh nguyen
nhan.
o Dich mang tim la dich tiet vai six vugt trei cua lympho bao va c6 neng de ade-
nosine deaminase tang cao.
o Benh nhan c6 dap ung vgi tri lieu lao.

5. MOT SO THANH PHAN KHAC CUA DICH ca THE

5.1. Nutec bot
Do 3 dei tuyen, tiet ra: tuyen mang tai, dugi ham, duel 1u6i. Nuac bet tuyen
mang tai la loang nhat. Nu& bet tuyen duai ham: quanh hen (chin nhieu mucin) va nuec
bet cua tuyen clued luei la quanh nhat, chay thanh day.
Ty tong khoang 1.003 — 1.005.
Thanh phan ve co cua nuac bet (g/L)
Bang 7.5. Thanh phAn v6 ca ciaa ntyac bet

K 0 5— 1
Allii
11110 _ Zaii
, mMillillil 0,2 0z:3 Ai
r 111111•11111111P 01.

ivel=11111111. AMIN
I HCO3 Air
CI
19191111111111
I 11111.1111.111116P 8
PO4 ip --ty-r - 0 2 1"4"111

5.2. Dich vi
Do cac tuy6n 6ng a da day tiet ra, khoang 1 — 2,5 L/24 gig. Tinh chat khong mau,
khong mixi, trong. Co 2 chat hog deng chinh la HC1, pepsin.

237
HOA SINN LAM SANG

5.3. Dich runt

Do to bao niem mac runt non ti6t ra, khoang 1 — 3 L/24 gib. Dich runt china nhieu
Nat, Cl-, HCO3-, va mot sO. enterokinase.

5.4. Dich tuy

Do tayen tuy ngoai ti6t ra, khoang 1 — 1.5 L/24 gib. Tinh chat trong, hai quanh, china
khoang 13g chat hoa tan trong mot lit.
Thanh phan quan trong clang chic y nil& la cac enzym nhir amylase, lipase, lexitinase
B, cholestero lesterase, trypsinogen, chymotrypsinogen. Hai enzym sau se &roc chuyen
hoa thanh dang hoat dOng khi xuong runt. Neu vi 1ST do nao do, su hoat hoa dien ra ngay
trong tuyen tuy se gay nen benh canh viem tuy cap.

5.5. Dich mat

La mot dich tieu hoa ctac b* do cac t6 bao gan bai tiet, luu luting khoang 800 — 1000
ml/24 gib.
Thanh phan quan trong nhat dm mat là muOi mat, sac to mat va cholesterol.

5.6. Dich bach huy6t

Thanh phan hoa hoc thay dOi dry theo ngutni g6c, vi du mach bach huy6t o chi duari
china 5 — 7g Protein, a Ong floc 30 — 40g ...
Thanh phan hoa hoc dm dich bach huyet (bang 6).

5.7. Dich kho'p

La mot dich that do c6 nhieu acid hyaluronic (2 - 3g/L).
Protein: 18 — 25%, trong do
Albumin: 70%
al = a2 globulin: 5%
13 = y globulin: 10%
Dich khap c6 tinh chat nhat nen lam cho khop trirat len nhau (16 clang.

238
 CHLTONG 7 ► DICH SINN V./LT

Bang 7.6. Thanh phan hda hoc cua dich bach huy6t

Cac chact Niing (14) Than - Co

Ntroy
kh
' rotein
ibrinogen
lusose
atri
ali
alci
agi
lorua
ospho vo ca

6. Glo'l THIEU MOT SO BENIN AN

Truirng hop 1

B'enh nhan Trdn TunN., phai nam, 29 tuOi.

Vao vien voi 13'T do: nhiirc cidu + sot.
Tham kham: mach 801dn/phitt, huyet ap 110/60 mm Hg, nhiet d'() 38°C, ho hdp 20
Ian/phut.
Xet nghiem:
CTM: BC 18.900/mm3 (N 93.2%; L 2.5%); TC 21.400/mm3; HC: 4.780.000/mm'
Glycemia: 216 mg%; BUN: 12mg%; Cre: lmg%; GOT: 59 U/L; GPT: 27 U/L; TQ:
15"; TCK 38".
Choc do DNT: dich trdng dijc, cAy khong thay vi khudn.
Te bao/DNT: 1.240/mm3 (N: 84%, L: 5%, TBTH: 11%).
SH/DNT: protein: 800 mg%; glucose: 1/216; C1-: 117 meq/L.
PCR lao: (-); nam/DNT: (-); HIV/DNT: (-).
PCT: 19,36 ng/ml.
Chan down: Viem mang ndo

TriAnig hop 2

Benh nhan Mai Thanh T., phdi nam, 53 tuOi.

239
HOA SINN LAM SANG

Vao vien vai 1ST do: nhirc cfau + sot.

Benh sir: benh khoi Oat each nhap vien 5 ngay, \Teri s& am i, lien tuc, khong ho,
khong dau bung; sau do nhirc clLt nhiau nen nhap vien.
Tham kham: mach 86fan/phitt; HA 120/80 mmHg; nhi'et (10 39°C; ho hAp 201Arilphitt.
Xet nghiem
CTM: BC 5.400/mm3 (N 47%; L 53%); TC: 211.000/mm3; HC: 5.080.000/mm'
Ndm/DNT: (-); KSTSR: (-); Widal: (-). Trang thai DNT: dich có matt anh yang.
TB/DNT: HC 160; BC 207/mm3 (N:0.1%; L: 96,5%; M: 3,4%).
SH/DNT: protein: 111mg%; glucose: 60/107 mg%; Cl-: 113 meq/L.
PCT: 0,1 ng/ml. ADA: 44 U/L. Neopterin: 7nmol/L.
XQ tham nhiem lao.
Chan dam: Lao mang nao.

Truirng hop 3
Benh nhan Nguy6n Thi Thu H., phai na, 37 tu6i.
Vao vien voi 1ST do: s& keo dai.
B'enh sir: 1 nam nay BN dau nhirc cac Ichap, to mua thuoc uong, sau Ong thuOc
thay an ngon va phit mat, phit chan tay. 1 thang nay s'& am i, dau nhirc nhi'eu cac khcrp,
nhap vien.
Xet nghiem:
CTM: BC: 5.300/mm3 (N: 92,6%; L: 5,5%).
Glycemia: 217mg%; BUN: 6mg%; Crea: 0,9 mg%; GOT: 34U/L; GPT: 34U/L;
Na+:134; K+: 3; Ca2+: 3,9; C1-: 100 meq/L. Trang thai DNT: dich trong khong mau.
SH/DNT: glucose: 27/217mg%; protein: 46mg%; C1-: 127 meq/L.
TB/DNT: HC: (-); BC: 3/mm3.
NAm/DNT:. cryptococcus neoformans (+).
Chan clo an: Viem mang nao do cryptococcus neoforman.

Truimg hop 4:
1341h nhan Le Thi Kieu D., phai nit, 57 tuOi.
Vao vien Wri 1ST do: bang bung.

240
 CHU'O'NG 7 ► D1CH SINH VAT

Benh sir: 10 ngay nay bung to ddn, sot on lanh, an u6ng kern ngon, sut can.
Tham kham: bung bang nhe, hach diroi ham, hach ben 2 ben.
TiL sir: m6 hach dui ham trai 3 nam nay (lao hach).
Xet nghiem:
CTM: HC: 4.800.000/mm3; Hct 38%; BC: 5.600/mm3 (N: 44%; L: 56%).
VS: gier &du 40mm - gief sau 50mm.
IDR: 14mm; BK/dam: (-); XQ ph6i: binh throng.
Sieu am: ascite bung (++), hach mac treo sau phiic mac.
Choc de dich mang bung thin Rivalta: (+); albumin: 85,5g/L.
HC: khong; BC: 690/mm3 (N: 2%; L: 98%).
ADA: 41U/L.
Chein cloan: Lao 'pang bung.

Truimg hop 5:
Benh nhan Le Thai H., phai nam, 72 tu6i.
\Tao vien voi lY do: sot, ho khan, gdy sirt.
Benh dien tien 2 thang nay, veri sot, ho khan, gdy silt. Qua tham kham va hoi benh
thdy: S6t nhe keo dai, thiL mau (+), da, niem mac nhot. Ho, khong c6 arm, hOi chirng 3
giam 1/3 dirai phi trai. Gdy silt 6kg/2 thang.
TiL sir khoe manh.
Xet nghiem:
CTM: BC 4.700/mm3 (N: 63,8% L: 22,6%)
HC 3.300.000/mm3, Hb: 91 g/L, Hct: 28,4%; TC: 447.000/mm3.
VC: giey 1: 63 mm, giOr 2: 104 mm
Glycemia: 5,6 mmol/L, protein: 68,8 g/L, creatinin: 98 iumol/L, albumin: 27,2 g/L,
billirubin TP: 19,21.11-non, billirubin TT: 4,4 mmol/L, billirubin GT: 14,8timo1/L, GOT:
26 U/L, GPT: 20 U/L, a FP:2,61ng/ml,
Nat: 137 mmol/L Ca: 2,17mmol/L
: 3,7 mmol/L Ca2+: 1,21 mmol/L
Cr : 97mmol/L

241
HOASINH LAM SANG

XN dich mang phi trai

Dich trong, mau yang chanh
Dich viem, nhieu lympho bao
Protein 52g/L; Rivalta (+)
AFB (-); Cay vi khuan (-)
ADA: 34U/L; Dom: AFB 31An (-) Sinh thiet mang phi trai: to chirc lien ket cua
mang phei c6 tang sink nhe sgi collagen. Khong thy ten thoang dlac biet khac.
XQ ph6i: thy 2 ben phe twang c6 dam me' rang ben phia phi phal, phi trai c6
rai rac 1 vai not tham nhiem, deg thoi to chirc ke cua phi dAy len nhin
Chlm clocin: Lao mang ph6i.

Triarng hop 6
Benh nhan Nguyen C.L; phai nam; 21 tu'6i.
Dia chi: Ca Mau, nghe nghiep: lam ruOng.
LS/ do nhap vien: dau nguc (T) + ho.
Benh sir: khoang 2 tuAn nay, benh nhan thinh thoang cam thy sot nhe ve chieu,
kem ra'ng nguc (T), thinh thoang ho khan. Trieu chirng nang nguc va ho ngay cang
tang dan, benh nhan an kern hon, sot khoang 2kg/2 tuan. Benh nhan den kham tai
y to huyen va dugc chop X-quang. Ket qua X-quang ggi y tran dich mang phei.
(T), benh nhan dirgc khuyen len kham tai Benh vien Chg Ray.
Kham lam sang: benh nhan tinh, tiep xuc tot, the trang trung binh (1m70, Ong
62kg), khong kh6 they, da niem hung, hach ngoai bien khong so' thay.
Mach: 80 fan/phut, huy& ap: 120/70mmHg, nhip they 20 lAn/philt, nhiet d6 37°C.
Tim deu, hOi chirng 3 giam day phi (T), bung mem.

242
 CHLYO'NG 7 I,- DICH SINH VAT

Can lam sang.

Cong thirc mau: RBC=4.600.000/mm3; Hct 40%, MCV 86,9 fL, MCH 28,8
pg; CHCM 328 g/L. WBC 8.050/mm3 (%NEU: 62, %LYM: 22,5; %MONO:
8,9; %EOS: 1,8; %BASO: 0,7).
Sinh h6a mau: glucose: 98mg%; LDH: 327,6 U/L; protein 6,7 g/dl; ALT: 26 U/L;
AST 31 U/L; creatinin: 0,8 mg%; Ion do (mmol/L): Nat: 142; IC': 3,3, Cl-: 104,
Ca2+: 2,2.
X-Quang: tran dich mang phi(T) hicmg nhieu.
Sieu am: trail dich mang phi(T) luting nhieu.
Dich mang bung: mau sac: yang chanh.
HC: 3400/mm3, Te bao: 2.274/mm3 (Neutro: 1%, Lympho: 87%, re bao lien vOng:
12%); protein: 4,8 g/dl; albumin 3,1 g/dl; glucose: 48mg%; LDH: 526 U/L; ADA:
36,8 U/L (0-24).
Bien luau:
B'enh nhan tre c6 tran dich mang phi1 ben luting nhieu, c6 trieu chi ng sot nhe ve
chieu, kernuong kern, sut can. Nguyen nhan nghi nhieu nhat la tan dich mang plied do -
lao; nguyen nhan can phan biet la tan dich mang ph'6i do ung thu.
Ket qua cong thirc mau binh thuemg, khong thieu mau, khong nhiem trimg cap tinh.
Ket qua sinh hoa mau dam trong gi6i han binh thuemg, Kali mau giam nhe.
Dich mang bung:
- Dich Wet vi: protein DMP/Protein matt = 0,79 (>0,5); LDH DMP/LDH Mau = 1,6
(> 0,6).
- Cac gia tri goi y lao:
Mau sac: yang chanh.
Te bao dich mang phic6 lympho chiem ti le cao (87%).
0 Glucose DMP/Glucose mau = 0,49.
ADA tang cao.
Clidn clocin: Nghi nhieu tan dich mang phido Lao.

Trtrong hop 7
Benh nhan Tran V.T; phai nam; 59 tu6i.
Dia chi: Vinh Long, nghe nghiep: lam rueng.
LY do nhap vien: dau bung

243
 HOA SINH LAM SANG

Benh sir: Benh nhan la benh cu khoa not heti hoa BV Chg Ray Bang dieu tri ngoai frit
vai chan doan: xa gan mat biilviem gan sieu vi B - tang huyet ap - viem da day ta. tang.
Cach nhep vien 5 ngdy benh nhan xuAt hien dau khep bung am i, lan taa kem sot
nhe, chan an, tao bon. Sot, dau bung ngay tang tang kern la ma dan, nguoi nha lo
lung dua benh nhan di kham BV Chg Ray.
Kham lam sang: benh nhan ma met tu nhien, tiep xitc chum, BMI khoang 19.5 (can
Ong luc kh6ng bang bung), khong kh6 tha, niem htmg nhat, ket mac mat yang nhe.
Sao mach rai rac met, nguc. Long ban tay son.
Mach: 96 lan/phitt, huyet ap: 100/70mmHg, nhip tha 22 Fan/phut, nhiet dO 39°C.
Tim deu, am thtii (-). Phi giam am phe bao 2 day. Bung bang 2 (+), An dau nhe
khep bung, gan lath kh6
Can lam sang.
Cong thirc mau:
HC: 3,6; Hct 40%, MCV 87 fL, MCH 27.6 pg.
BC: 11,05 (%NEU: 76.9, %LYM: 11,5; %MONO: 8,9; %EOS: 1,8).
Sinh hoa mau: Glucose: 156 mg/dl; protein: 5,9 g/dl; albumin: 2,9 g/dl; bill TP
3,1 mg/dl; NH3: 87µg/dl.
ALT: 43 U/L, AST 45 U/L; creatinin: 1,2 mg%; Ion do (mmol/L): Na±: 139; K.':
4,9, Cr: 108, Ca2+: 2,5.
X-Quang: dong voi cung dOng mach chit. ECG: chua phut hien bAt thuamg.
Sieu am bung: gan eau true tho, ascite luting vita den nhieu lam can.
Dich mang bung
Mau sec: yang duc. HOng eau: 2.100/mm3, bach cau 3.911/mm3 (da nhan 2.933 /mm3
(75%).
Protein 0,9g/dl, Albumin 0,2 g/dl; Glucose: 48mg%. Cay (-), soi nhuOm Gram: song cAu
Gram ducmg.
Bien luan:
Benh nhan tien can xa gan mat bit nay xuat hien dau bung cl'cit ngOt kern sot va tao
bon, tri gide kern dan ggi ST. tinh trang viem phitc mac nhfern khuan nguyen phut phan biet
\Ted viem phitc mac thir phut sau thimg tang rang hay viem runt
Cong thirc mau ggi y tinh trang nhi'em trimg.
Cac xet nghiem khac cho thay xa gan giai doan Child C, c6 the c6 tinh trang hon me gan
kem thitc day bai tinh trang nhie'm trimg.
Chan doan: Theo d'Oi viem phitc mac do phe cau trimg.

244
 CHU'O'NG 7 ► DICH SINH VAT

A. CAU HO' LUVNG GIA

1. Dieu nao sau day khong thing khi n6i ve dich nao ttiy ngtrei kit& manh:
A. Glucose = 2/3 glucose-huyat B. Lactat < 19mg%
C. Protein = 0.5g/L D. Alb-DNT/Alb-huye't = 0.7
2. Chon 57 thing nhit: trong viem mang nao mu:
A. Co sty phan ly gift glucose va protein B. CRP tang
C. Dich due nhu mu khi to bao > 1.000 D. Tdt ca dung
Dkra vao cac so lieu sau cua dich nao tily de tra loi cho cac cau hoi tir 3 den 6:
1.Co su phan ly gitta glucose va protein
2. Neutrophil tang
3. Lymphocyt tang
4. Eosinophil tang
5. Ong thitc to bao binh thuemg
6. CRP, PCT tang
7. Dich nao tuy có the trong
3. Chop tap hoyp thich hop nhit cho viem mang nao mu:
A. 1, 6, 7 B. 1, 5, 7 C. 1, 3,6 D. 1, 2, 7
4. Ch9n tap hop thich hop nhAt cho viem mang nao lao:
A. 1, 2, 7 B. 1, 3, 7 C. 1, 3, 6 D. 1, 3, 6, 7
5. Chon Op hop thich hyp nhit cho viem ming nao sieu vi:
A. 2, 7 B. 3, 7 C. 3, 5 D. 5, 7
6. Ch9n tap hop thich hop nhit cho viem ming nao do 14 sinh:
A. 2, 7 B. 3,7 C. 4, 7 D. 1,4, 7
7. Dieu nao sau day khong dung khi not ve thanh ph'in dich tiet/citch ming
A. Protein-DMP/Protein-HT > 0.5 B. LDH-DMP/LDH-HT > 0.6
C. Cholesterol-DMP < 45mg% D. ADA > 45U/L trong TDMP do lao
8. Dieu nao sau day khong thy trong dich nao tity benh nhan viem nao-mang
nao do nhigm ky sinh
A. Dich trong
B. Ta bao Eosinophil tang
C. Co sit phan ly cao gitta glucose va protein khi banh n'ang
D. Eosinophil mau ngoai bien tang

245
9. Dieu nao sau day khong dung trong viem ming nao do lao:
A. Dich nao tuy c6 the trong hoac tang trong
B. Te bao lympho > neutrophil
C. Thai diem choc do thich hop nhat 6 ngay thin 3-5 dm benh
D. So vii viem ming nao mil, sir phan ly dm glucose-protein trong DNT it Ilan
10. Chou y diing nhat trong viem ming nao sieu vi:
A. CO su phan ly lan giita glucose va protein trong dich nao tuy khi benh nang
B. re bao trong dich nao tny chn yeti la neutrophil
C. Lactat/DNT > 19mg%
D. Thai gian choc do thich hop nhat a ngay thin 3-5 da benh
11. Xet nghiem nao sau day dung de chin doin lao ming nao:
A. Procalcitonin B. Adenosin deaminase
C. Neopterin D. hsCRP
12. Thinh phan nao sau day thir?rng giim trong lao ming nao:
A. Natri B. Kali C. Clor D. Magie
13. Dieu nao sau day khong dung trong viem ming nao mu:
A. Glucose giam
B. Protein tang
C. Adenosin deaminase c6 the tang nhe
D. Neopterin tang cao
14. Thinh phan to bio trong dich nao my benh nhan nhiem k57 sinh trimg:
A. Neutrophil tang B. Lympho tang
C. Eosinophil tang B. Basinophil tang
15. Thinh plan nao sau day dm dich nao tiiy glop phan biet VMNM va Lao
ming nao:
A. Procalcitonin va adenosine deaminase
B. Glucose va protein
C. Neutrophil va Lympho
D. Mau sac dm dich nao thy

246
 CHU'O'NG 7 ► DICH SINH VAT

16. Thiri diem choc dich dich nao by o ngay thin 1—* 2 sau benh khol phat gifip
chin down:
A. Lao mang nao B. Viem mang nao do virus
C. Viem Mang nao mu D. Tat ca, cac benh tren
17. Dieu nao sau day lam gap trong viem ming nao do 14 sinh trUng:
A. Glucose giam nhe B. Protein tang nhe
C. Ngita D. Dich nao toy duc
18. Chop y killing dung, trong dich choc dich:
A Phan ung Rivalta (+) khi luong protein > 3g/L
B. Phan irng Rivalta (+) gap trong cac benh cap tinh
C. Mau trang duc hoac due thuong gap trong viem mang nao mu
D. Mau yang chanh thuemg thay trong lao mang tido
19. Dich thim gap trong cac nguyen nhin sau day, ngo0 trir:
A. HOi chi:mg than hu B. Lao mang bung
C. Xa gan co twang D. Suy tim sung huye't
20. Cac dieu sau day dung trong VMNM, ngoai trir:
A. Neutophil > lympho B. Dich choc dich trong
C. Protein tang D. Glucose tang

B. CAU HO! NGHIEN Cf.YU

1. Nghi den benh gi khi mot benh nhan có cac trieu chirng sot cao, nhirc dau, non oi, dau
nhirc khi gap ngtrei hoac co chin lai? Xet nghiem DNT o benh nhan ten cho ket qua
dich tang duc, glucose DNT/glucose huyet = 12mg%/125mg%, protein 235mg%, to
bao bach cau/DNT = 850 (N = 93%, L = 11%), cay DNT = (-), ADA = 5U/L.
2. MOt benh nhan bi dau nhirc khop kinh nien nen thuemg xuyen dung thuoc khang
viem loai corticoid, gan 10 ngay nay benh nhan co tri'eu chirng sot, nhirc dau, non
6i nen nhap vien dieu tri, k& qua choc do DNT cho thay: dich trong, glucose DNT/
glucose-huy& = 67mg% /163mg%, protein = 105mg%, to bao bach cau/DNT = 85 (N
= 52%, L = 44%), nam/DNT = Cryptococcus neoformans, HIV (-), PCR lao (-), Cay
DNT (-).
Benh nhan bi benh gi? giai thich co the sinh benh.

247
HOA SINN LAM SANG

3. Benh nhan nam, 47 tu6i, thireng xuyen an hai san bien, each nay 10 ngay có an thit
kS, da. Sau an 3 ngay benh nhan nhuc dau nhieu, to tay than, minh may not man do
va ng-fra nhieu. Hai ngay nay benh nhan yeu ta chi, kern sot va nhirc dau,dit dOi nen
nguiri nha dua vao benh vien. Ket qua xet nghiem mau ngoai bien cho thy bach cau
= 12.500/mm' (N = 53%, L = 34%, E = 13%); choc do DNT: to ban bach cau = 108 (N
= 34%, L = 43%, E = 23%), glucose = 44mg%, protein = 89mg%; huyet thanh chin
down KST: Toxocara canis (+).
Benh nhan bi benh gi? giai thich co. ch6 sinh benh.

248
 Chwang 8
CHI DAU UNG THU
(TUMOR MARKERS)

IVIVC TIEU
1. Trinh bay Ayr dinh nghia cua chi dau ung thtr.
2. Trinh bay dtrcic y nghia lam sang cua chi dau ung thee.
3. Sir dung eltro.c chi dau ung thy ddi vai m5t so benh hay gap nhu' ung thin da day,
gan, tuy, vu, buong trteng, tuyen tien liet, phoi, tuyen

1. DAI CLYO'NG

1.1. Ung thu' là gi?

Ung thu la benh 1ST to bao, do su phat trien khong binh thiramg va c6 xu huong tang
sinh nhanh chong ve s6 luong mot each kh6ng ki6m sok oda the to bao, trong mot so
truong hop chung di can tad cac co quan a xa.
Ung thu con dirge goi la u tinh, c6 ngu6n g6c bat cur t6 bao nao dia. co the va.
c6 rat nhieu loai khac nhau trong moi yang cua co the. Benh ung thu khong lay truyen.
Ten goi ung thu xuat phat fix'tieng Latin la cancer (chi con cua), ngu6i xua diing tir
nay de not len su dc tinh cua khoi u vi khoi ung thu tea ra nherng nhanh giong nhu chan
cua bam chac vao cac m6 ma no xam nhap.

1.2. Chi dAu ung thu' IA gi?

Chi dau ung thu (tumor markers) hay d'Au an ung thu la cac chat ski xuat bai cac t
bao ung thu hoac bed co the (m6 binh thuong) dap ung vai kh6i u. Co the do clugc chang
trong huyet thanh, huyet tuong, cac loai dich trong co the, m6 ly trich hoc mo co dinh
bang paraffin de giiip 118 try ch'an doan, theo dOi dap ung dieu tri, danh gia tien ltrong
benh. Cac chi dau ung thu hien dang sir dung rat rung rai. M6t chi dau ung thu ly tuarng
can 2 dac diem: dugc tiet vao mau a mire nong d6 c6 the do dirge sau khi co subin dui
ac tinh to bao sari sinh ra no va yiec phat hien ra chi &du nay cho ket luan vi tri
phat sinh kh6i u.

249
2. DICH TE HOC BENH UNG THU'
Tai cac nuac phat trien, ung thu la nguyen nhan thir hai gay tir vong sau,benh tim
mach. Mei nam c6 tren 10 trieu throng hop mai mac &roc chan doan tren toan cau va teen
6 trieu nguai tir vong vi benh. Trong do, 1/3 tnrong hop c6 the ngan ngira throe va 1/3
khac c6 the dieu tri hieu qua neu phat hien va dieu tri sam.
D6i vai nam tnrang thanh, thuang gap nhAt là ung thu ph6i (khoang 34/100.000
dan), ke den là ung thu tuyen tien liet, ung thu dai true tang... Nguyen nhan tCr vong do
ung thu phi thuang gap nhat, ke den la ung thu da day, ung thu gan...
D6i vai phu nu truamg thanh, ung thu va hay gap nhat (khoang 38/100.000 dan), ke
den la ung thu,c6 cung, ung thu dai true trang...,Nguyen nhan vong do ung thu vu
thuang gap nhat, ke den la ung thu phoi, ung thu c6 tir cung...
TS/ le mac ung thu tang theo tu6i, co the do tu6i cang cao thi eh& nang cua he th6ng
mien dich cang suy giam.
Tai Viet Nam, hang nam c6 khoang 100.000 — 150.000 truemg hop mai mac va
khoang 70.000 nguai chat do ung thu. Nghien cfru cho thay 10 loai ung thu thuamg gap
o Viet Nam.
Bang 8.1. Wit s6 ung thu' hay gap & ngu61 tnyeYng thanh

STT Nam

Ve tien luting, so vai cac ung thu khac, ung thu phi co lien hrong sting thap nhat
sau 5 nam.

250
 CHUO'NG 8 ► CHI' DAU UNG THU' (TUMOR MARKERS)

CZ:Lwaimmimmainnum.

Phi 13,1% Phi 17,6%

Da day 23,1% Da day 27,3%

Dai - tru'c trang 64,5% DO - ft-cm trang 64,3%

Bang quang 81,2% Than tin cung 83,9%

Tuyen tien liOt 98,9% Vu 88,7%

Hinh 8.1. Ty Ie song sau 5 nam cua bOnh ung thu,

3. CO' CHE SINH BENH UNG THU'

Ca the sinh benh ung thu cho den nay van con nhieu dieu chua biet rO.

3.1. Ngu6n g6c ung thu'

Su phan chic (hay tang sinh) to bao la qua trinh sinh 13i xay ra trong nhung dieu kin
nhat dinh 6 hau ha cac m6 trong ca the sinh vat da bao. Binh till/Ong toc d6 tang sinh va
a
chet to bao dugc can bang dam bao tinh toan ven oda m6, co. quan. Khi to bao xay ra
dOt bien trong ADN, chUng có the pha vo ca. che dieu hea nay va dan den ung thu.
CO nhieu gia thuyet khac nhau ve ngu6n g6c to bao ung thu
+ Thuyet don dong: cho rang kh6i u pith sinh tit mot to bao me nhan len.
+ Thuyet da clang: kh6i u tin nhieu to bao ban diu khac nhau.
+ Thuyet ve kern on dinh gen oh t6 bao ung thu:, co the ban diu la mot clang, do
gen ung thu khong on dinh nen có cac to bao bin di sinh ra hang boat cac t6 bao
h6n

3.2. DOc tinh t6 bac, ung thu'

3.2.1. 1/6 hinh thai hoc
Nhan tang kich thuac, da dang, nhieu they, mang nhan day.
Nguyen sinh chit thoai hoa có nhieu hang, h6c china chit the ti6t, chit vai.
Thay d6i ve m6i quan he gift cac to bao: cc') nhieu to bao non, kich thuac 16n, kh6ng
16 nhung chirc nang kern.
Khong con kha nang tint the tiep Vic nen de bong ra khOi u.

251
HOA SINN LAM SANG

Binh Tang Loan san Ung thty tai ch6

thubng san nhe (loan san nang)

Ung thu,
(xam Ian)

Hinh 8.2. Hinh thai to chCyc mo tiy binh thty6ng d'an khi phat tri6n thanh khi u

3.2.2. Ve chtic nang

Kha nang phat trien vo han (bat tir), tranh &uge chit theo chuang trinh.
Thay doi kha nang biet h6a to bao, khong lam duac chirc nang binh thuemg,
de hoai
cung cap cac yeti to Oat diem
Khong c6 kha nang irc chi tiep Vic;
Khong nhay cam vai cac yeu to ch6ng tang sinh.
T6c d8 phan bao gia tang.
Co kha nang tang sinh mach mau.
Kha nang xam Fan m6 xung quanh va di can den not xa.
Co the tiet ra nhimg chit chi diem (goi la chi dau ung thu).

3.3. Co so, phan tO, cCia t6 bac) ung thu'

3.3.1. Pith') quy dinh sinh san oda ADN oda nhan to bao
Trong ung thu, viec thay doi ADN dan din sinh san v8 to chirc la Nu qua Gila qua
trinh d8t -hien gen.
Nhitng chat gay &it bien gen chinh la cac yeti to 1ST, hoa gay ung thu. Ngugc 141
nhung tac dOng gay ung thu cling gay nen dOt Wen gen.

3.3.2. Co, chg gen

Cac gen quan tong trong qua trinh phat tri6n ung thu g6m: phan chia, biet h6a, tao
mach mau, xam lan va chat to bao. Qua trinh nay lien quan chat the 2 nhom gen: sinh ung
thu va khang ung thu. Ca 2 loaf nay luon ton tai trong moi,te bao binh thuamg, c6 vai tro
quan tong trong kiem sok qua trinh sinh biet h6a va chest theo eh-acing trinh cua to bao.

252
 CHU'O'NG 8 OP' CHI DAU UNG THU' (TUMOR MARKERS)

Gen sinh ung (gen tao u) la gen dal bi dOt bien lam bien doi chirc nang hay su bieu
hien, tac dOng den su phan chia va tang truang to bao. Hien c6 khoang 50 loai.
Gen khang ung la gen ma h6a cho protein kiem sok phan bao theo huong ire che,
lam chu ky phan bao bi dirng 6 mot phase nao d6, lam biet hoa hoac ma hoa to bao chet
theo chuong trinh. Khi cac gen nay bi bat hoat do dOt bien se lam bien d6i to bao lanh
thanh to bao dc tinh.
Ngoai ra con c6 gen irc che tao khoi u la gen c6 kha nang irc che su phat trien kh6i
u, khi bi dOt bien gay nen hOi chimg ung thu gia dinh.
Vi du: gen p53 la gen lieu hem chu kY to bao va dong vai tro eh& theo chuang trinh
cua to bao, tren 50% tnremg hop ung thu c6 dOt bien gen nay.
Ba gia thuyet giai thich cho viec hinh thanh gen sinh ung thu:
+ La nhung gen de phat trien to bao, hoat h6a nh6 yeu to tang tru6ng. Khi bi r6i
loan, yeu to tang tnxong boat h6a manh kich thich gen nay sinh ung thu.
+ La nhung doan ADN bi ton thuung ben tac nhan ly, hoa, sinh hoc. Cu the da
sira eh-1'ra nhung kh6ng hoan hao, tren ding mot tac nhan nhung nguen mac
benh nguoi khong.
+ Gen sinh ung thu c6 the do cac genome oh virus bum vao ca the ngueri vi nguen
to da xac dinh duoc cac gen nay ging ADN cila virus.

DOt bien at hoat

chi
gen tivc che kh6i u inh flan:mg
TOn thu'o'ng to bao
TE BAO TANG SINH khong siva chir
•

DOt bien bat host

gen sire china ADN

DOt bien gen Wen ung

teo gen ung thu
4,
DOt bien bet host
them vai
gen Cpc oho khoi u

UNG THU'

Hinh 8.3. Tang sinh loAt thubng cCia t6 bao ung thu'

253
HOA SINH LAM SANG

• Khiern khuyet trong giai doan cuoi cua qua trinh biet hda
• Khiern khuyet ye kiem soat tang trithrig
• De khang vai tac nhan diet bao

Bien di Banh twang Bi6n doi Bik dOi Bik dOi

on loc cio gen gen r6 111 -12:106.1pi
gen
if4°
IL

Te bac Te bao &Ivo TOn thiyang Ung thu, Ung thu phat Ung this phat
binh thuang khai mat) ten ung hien ten lam hien ten lam
Cfc the sang sang

I I

• DOA bVen Oncogen

• BAt host gen khang ung thu,

Hinh 8.4. Tom tat co' ch6 benh sinh cua ung thu'

3.3.3. Co, the to bao

Nguai twang thanh binh thuang có khoang 1 trieu ty t6 bao xuat phat tix,met trimg
duet thy tinh. Hang ngay, so luting to bao dirge tao ra (khoang 1012) bang vai so
luting to bao chat di va luon giir a mirc hang dinh. Khi s6 luting to bao sinh san qua mac
(nhiau hon luting chat di) lam pha v6 sy can bang nay va gay ra ung thu.
Ca the tang throng se luting cac quan the to bao co the do:
- Chu trinh to bao rat ngan lam tang so luting to bao tao ra ten 1 dan vi thai gian.
- Giam van toc to bao chat di lam nhiau to bao duet tao ra hon.
- Mat sir irc che tiep to bao binh thuang khi clang 6 qua trinh phan chia nett
tiep xuc vai to bao binh thuang khac ding clang phan bao thi qua trinh phan bao
cham dirt. Trong ung thu ca the nay kh6ng con, cac to bao ung thu giam hoac mat
tinh kat dinh.

3.3.4. Co' the khac

Wei loan kiem sok qua trinh tang truang, cac bin dei duang clan truyan tin hieu gay
chat to bao, suy giam mien dich...

4. NGUYEN NHAN VA YEU TO NGUY CO' GAY UNG THU'

, Met tac nhan sinh ung thu có the gay ra met se loai ung thu va mot loai ung thu có

the do met so tac nhan khac nhau gay ra. Hau het cac ung thu c6 rat nhieu nguyen nhan
va yeu to nguy ca.

254
 CHU'O'NG 8 CHI
► DAU UNG THU' (TUMOR MARKERS)

4.1. Y6u to hcia hoc

, La tac nhan chit yeti gay ung thu ngtrai, 65% cac benh ung thu la do but thuc la,
the dO an, uong khong hop ly va mit so yeu to khac gay nen.
ThuOc la la nguyen nhan chit yeti gay ung thu ph6i, ltrai, ha hong — thanh quan, attic
KhOi thuoc là china tren 4000 loai hoa chat, trong do tren 200 loai c6 hai cho sirc
kh6e bao gom chat gay nghi'en va chat gay d8c, dac bit co tai 43 chat da &roc chirng
minh gay ung thu nhir benzopyren, nitrosamin, cadmium, nickel...
, Cite' dO an va 8 nhiem thuc pham: ban than thuc pham kh6ng gay ung thu nhung cac
chat bao quail thuc pham, cac chat trung gian chuyen hoa va cac chat sinh ra tin nam ink
la nguyen nhan clan den ung thu. Ngoai ra, su mat can bang trong the dO an, nhieu chat
beo qua mire ding lam tang nguy co ung thu. Khoa hoc da chirng minh throc tren 30%
truang hop ung thu lien quan cite dO
a
MOt s8 loai thuc pham gay ung thu nhu dua muOi (nitrit), mam tom (nitrosamin),
thit ntrang than hoac )(Ong khoi (benzopyren), gao nhiem nam moc Aspergillus flavus
(aflatoxin gay ung thu gan)...
Ruou khong sinh ung thu nhung molt manh gay b6ng man tinh niem mac ha hong
a
va thuc quart, c6 the gay ung thu sau nay.

Hinh 8.5. Sang thuang ung thu' g6c

4.2. Y6u t6 vast I9

Buc xa cuc tim: tia cuc tim c6 trong anh sang mat trai chu yeu gay ung thu da. Tia
cuc tim manh nhat trong mita he tir 11 gia sang den 3 gier chieu, vi the nen tranh anh mat
trai khi bong ngan han than ngtrai.
El& xa ion h6a: tir cac chat phong xa to nhien hoc tix nguOn nhan tao dung trong
khoa hoc, y hoc c6 the lien quan den ung thu tuyen giap, ung thu mau...

255
HOA SINN LAM SANG

4.3. Yau to sinh hoc

Viem gan sieu vi B, sieu vi C có the gay ung thu gan nguyen phat. Helicobacter
Pylori có the gay ung thu da day.

5. CAC GIAI DOAN TIEN TRIEN CUA UNG THU'

5.1. Giai doan kheyi phat

Tir khi to bao tiep xuc voi tac nhan gay dOt bien lam thay doi khong h6i phuc cua t6
bao, qua trinh din ra trong vai giay va khong the dao ngucyc dugc. Tuy nhien khong phai
tat ca cac to bao deu phat sinh benh. Da so cac to bao khi pilaf hoc la khong tien trien,
ho4c la chet di, ho4c la bi co the mien dich vo hieu

Ung thu' sa cap

Lan tai ch6

Angidgenesis
Khoi ung thu' tu, lap mach mau

- Mach bach huy6t

•Ranh gieyi

Ung thu' di can: Cac t6

bag di chuyan khOi ung thu'
sa cap va xam rang cac ca
phan khac cua co the qua
du,eYng mach mau va mach
bach huye't
Mach mau

Hinh 8.6. Kho'i phat cua ung thu'

5.2. Giai doan tang trixdong, thCic day, chuyen bian

G6m su chon loc &mg to bao, thay d6i the hien o gen va tang sinh cua to bao khoi
Oat. Tuy nhien, mirc do tang sinh to bao con nho va cu tru o mot mo nhO nao do.

5.3. Giai doan Ian tran

banh truomg clang ke, nhung van con qua nho de có the phat hien dugc bang
Kh6i u
cac phucmg phap phan tich (vai thang den vai nam).

256
 CHU'O'NG 8 10. CHI DAU UNG THU' (TUMOR MARKERS)

Ta bac, bat Ung thu d6c

Ta bao Ta bac, bat binh thuomg SDI hoac ung thu'
binh thu'Ong binh thubng (Ung thu' tai ch6) binh truomg

Ranh giO1
Mach bach huyat

Mach mau

Hinh 8.7. Cach Ian truyen cOa ung thu,

Hinh 8.8. Ung thu' bung tn:rng )(am 16n vac) hach Iympho va cAc ca quan khac

5.4. Giai doan ti6n then - xam Ign - di can

Giai doan lien trien la su tang kich thuarc khi u, có the rat ngan,ho4c keo dai nhieu
nam (ung thu giap khoang 15 nam) chiem 75% thefi gian pilaf trien cua benh; Do do
có the phat hien dkra vao xet nghiem can lam sang. Lam sang chi phat hien khi khoi u tren
1cm3 (khoang 1 tY to bao).
Giai doan xam lin: chirc ung thu xam lin nhar (lac tinh di dOng, kha Wang tieu dam
a( cac mo ke can, mat sir irc the tiep xuc cua to bac,.
Giai doan di can: theo duemg bach mach (thuong gap trong ung thu Neu mo), theo
doing ke can (ung thu da day), theo duo.ng mau (ung thu mo lien ket).

257
HOA SINN LAM SANG

6. HE THONG TNM
La he thcing phan giai doan ung dm sir dung rOng rai nhat va duot chAp nhan baci
Hiep hOi Kiem soat Ung thu Quoc to (UICC - Union for International Cancer Control) va
Uy ban ling thu Hoa KST (AJCC - American Joint Committee on Cancer).
TNM dva vao pham vi lan rOng cua kh6i u (T), anh huemg den cac hach bach huyet
(N) va sit hien dien dm di can xa (M). Con so them vao phia sau moi chit cai xac dinh
kich thuac hciac pham vi cua kh'6i u va di can.

6.1 Khoi u nguyen phat (primary tumor)

Tx: khong danh gia duoc kh'6i u nguyen phat.
111 TO: khong c6 bang chirng ve sit hien dien cim khoi u nguyen phat.
Tis: ung thu tai cho, c6 hien dien cac to bao bat thueng nhung khong lan sang mo
lan can, c6 the tro thanh ung thu, goi la giai doan tien xam lan.
Ti, T2, T3, T4: kich thuac va ho4c pham vi cua khOi u nguyen phat.

6.2. Hach vung (regional lymph nodes)

Nx: khong danh gia duoc hach \Tung
NO: khong c6 hach vimg lien quan
II N1, N2, N3: c6 hach vimg lien quan

6.3. Di can xa (distant metastasis)

D Mx: khong the danh gia duot di can xa
MO: khong co di can xa
Ml: co di can xa

6.4. Phan giai doan

Giai doan 0 - Tis, NO, MO
Giai doan IA - Ti, NO hay N1, MO
Giai doan IB - Ti, N2, MO hay T2a/b, NO, MO
Giai doan II - T1, N2, MO hay T2a/b, N1, MO hay T2, NO, MO
Giai doan IIIA - T2a/b, N2, MO hay T3, N1, MO hay T4, NO, MO
Giai doan IIIB - T3, N2, MO
Giai doan IV - T1-3, N3, MO hay T4, N1-3, MO, hay T, bAt ky N, M1

258
 CHUO'NG 8 l■ CHI DAU UNG THU' (TUMOR MARKERS)

7. GIOI THIEU MOT SO CHI DAU UNG THU'

7.1. Theo &mg lich sir
1847: Sir Bence Jones tim thay protein Bence Jones trong nugc lieu benh nhan bugu
tuy xuung.
1867: Sir Michel Foster tim thay amylase trong nuac ti'eu benh nhan ung thu t-uy.
1930: Tim thay phosphatase acid trong ung thu tuy& tien het.
1932: Tim thay phosphatase ki'em trong ung thu xuang.
1940: Tim thay vai tr6 hCG trong ung thu to bao mam.
1965: Garry Abelev va Tatarinov tim ra AFP (Alpha Feto Protein).
Phil Gold Ira Samuel Freedman tim ra CEA (Carcino Embryomic Antigen).
Ky nguyen khang the don dOng: no' r6 CA125, CA15-3, CA19-9...
Hien nay da phat hien ra nhieu chi dau ung thu mai nhu HE4, NSE, CYFRA...

7.2. U'u diem cue chi dau ung thu'

Cac chi dau ung thu ngdy cang dugc six dung rgng rai tren lam sang va da chimg
mink &rue vai tro thuc six cna chung, gop phan chan doan benh, theo dOi six dap ung dieu
ngu6i benh, xac dinh ung thu tai phat.
+ Dac hieu cho ung thu (vi tri khu trii),,phat hien dugc tit giai doan sem benh.
+ N6ng d6 chi au ung thu ty le yeti the tich kh6i u.
+ Xac dinh dugc mgt each chinh xac n6ng 61) chi dau.
Nhin chung, cac chi au ung thu rieng le khong the diing de chan doan va theo dOi
benh ung thu ma can kei hop vai nhau va vai cac xet nghiem khac.
Cac xet nghiem chi dau ung thu dugc thuc hien nhanh chong va chinh xac vai mdu
benh pham la mau hay nu& tieu, ten cac may mien dich to dgng vai cac ky thuat nhu
mien dich enzym, hu3Tnh quang, h6a phat quang, dien hoa phat quang...
Bang 8.2. Mot s6 chi au ung thu' ph6 bin

Chi dam ung thur Chi dinh Ban chat

thu dai true trari .... lycoprotein, 180 kDa

1111161111/' 41111111.11111ycoprotein, 70 kDa

MEM g tr non nr'lig illycoprotein, 200 kDa
Iligithu toy' dugng mallIMILcolipid, 36 kDa

TTITIIIIIIrrthu.
W u da day, bu6ng trong iddroprotein
vu 11 lycoprotein, 300 kDa
PSA —ling thu tuyen den bet illilycoprotein, 33 kDa
thLYFRA 21-1 ng thu• to bao phoi khong nhil ytoket atm 19 frag, 30 kDa

259
HOA SINH LAM SANG

Thu'c quan Tuy6n giap

Thyrcgiobulin. C at Oorsar
(CEA. SCC) (C-cell. CEA)
Ph6i
Tlbao nn45: NSE ■ C',FRa. Vu
!Chang If DA* ni16: C EA C - CA 15-3, CEA

Gan. du,o,ng_mal Da day

AFP, CA19-9 CA 72-4, (CEA)
Bong dai T_yy tang.
(CYFRA 21-1) CA 19-9 (CEA)
Tu' cung trans_
.CEA (CA 19-9 )
SCC (CEA)
Buono trirnd,
TTL
FSA
Tinh hoan
AF P C

Hinh 8.9. Cac chi au sinh hoc cua btrau (tumor markers)

• AFP (ALPHA — FETOPROTEIN)

AFP la glycoprotein, trong do glucid chiem 4%, PTL 70kDa, duoc tong hop a the yang, to
bao gan chua truang thanh va 'Cing,da day met thai nhi. Tre so sinh có nOng de AFP trong
mau ttrang doi cao va se. ha thap ve mirc bang voi ngtrai tre duoc khoang met tuoi.
Chi dinh
Tuyet + Ung thu to bao gan.
+ U to bao mAm.
+ Theo dal sau dieu tri benh u gan, to bao m'am
Tucmg + Theo dal benh nhan xo gan ung thu hoa, u to bao main.
+ Theo dal benh nhan sau dieu tri cat bo u tinh hoan.
+ Theo dal nguy ca u to bao mam- tinh hoan an, anh em sinh doi
dOng hop tir cua nguiyi bi u tinh hoan.

260
 CHU'O'NG 8 ► CHl DAU UNG THU' (TUMOR MARKERS)

nghia lam sang

Tri s6 den chieu (nguai twang thanh): AFP < 10 ng/ml.
AFP tang cao trong benh ung this gan
AFP tang cao trong 70 — 95% ung thu gan nguyen phat va 60% u to bao mam.
- D6 nhay va dO dac hieu cua AFP thay doi theo cac doi Wang nghien cfru va gia
tri ngu'ang, dO nhay khoang 52-80% va d6 dac hieu khoang 90-98%.
Trong ung thu t6 bao gan, AFP tang theo stx lan rOng cua khiu, trung binh 50
— 500ng/ml.
- D6i v6i ung thu di can gan, AFP cling tang nhung thuemg < 400 ng/ml.
AFP c6 gia tri trong tien luang benh, lien luceng tot khi half-life < 5 ngay. Benh
nhan c6 half-life AFP > 7 ngay sau 2 chu kST has tri c6 tST le song thap hon.
AFP rat c6 ich trong viec theo doi benh nhan nguy co cao mac ung thu gan nhu
xo gan, viem gan sieu vi B, C Mang benh gan c6 tang AFP thi nguy co tien
d6n ung thu gan rat cao va tien lugng de dat sau 5 Warn theo d'Oi.

Viem gan man Xo, gan Ung thu to bao gan

Hinh 8.10. Viem gan man, gan, ung thu' gan

AFP cling tang trong cac benh lanh tinh

- Khoang 10 — 60% benh nhan xo gan c6 n6ng d6 AFP tang cao tr'en mirc sinh 1ST
(tang nhe va hang dinh hoac tang thoang qua): 17% tang tir 15-100 ng/ml; 2%
tang < 500 ng/ml va khoang 1% > 500 ng/ml. Ngodi ra, AFP tang thoang qua
trong viem gan cap va man tinh.
Cac tumor markers gan khfic
A FP-L3
AFP-L3 la d6ng ding (Isoform) cua AFP (L1, L2, L3) dira vao phan fing gan vao
LCA (Lectin culinaris agglutinin). Ket qua cua AFP-L3 la tST le phan tram c6a AFP gan
kest vai LCA va toan b6 AFP.

261
I-0A SINN LAM SANG

Tri se dei chieu: 0,5 — 9,9 %.

AFP-L3 tang >10% goi y giai doan sam u to bao mam, doi khi sam horn cac k'y thuit
chin doan hinh anh (co the tir 3-21 thing tnroc) va khi AFP-L3 tang gap 7 lan thi c6 nguy
co chuyen thanh u to bao mam.
Do dugc tao ra to cac to bao ac tinh nen AFP-L3 c6 the gulp phan biet benh gan
c6 de tinh hay kh6ng. Te ban gan ac tinh tao ra AFP-L3 hay c6 khuynh huang phat trien
nhanh va som di can gan. Vi vay AFP-L3 la chi diem tien luting xau cua benh.
Duong tinh gia: c6 the g'4p trong viem gan cap/tei cap, tre em clued 18 thing tu6i.
Decarboxy prothrombin (DCP)
La prothrombin bat thuang do to bao ung thu gan tiet ra, c6 de nhay Wang throng
AFP nhung rat dlac hieu (neu co the khong thieu vitamin K).
Nam 1984, Liebman va cong sty di phat hien nhung neng de huyet thanh tang cao
cua DCP a nhitng benh nhan u to bao mam, u to bao gan.
Binh thuang prothrombin duoc carboxy h6a trong to bao gan duai tic dung dm
enzym carboxylase phu thuec vitamin K. Trong ung thu gan, do thieu enzym nay nen gay
tiet ra trong huyet thanh met prothrombin bat thuang la DCP.
Nhieu nghien ciru cho May su tang DCP thuang phan anh tinh trang benh, kich
thuac u va xam lan tinh mach dm_ Tuy nhien, can loai trir benh nhan dung thuoc chOng
&Ong hay thieu Vitamin K do nguyen nhan khac nhu a tre so sinh.
De nhay khoang 70% va de d;ac hieu khoang 100% trong chin doan u to bao mam,
u to bao gan (nhung chi to ra uu viet horn AFP a benh nhan c6 khi u teen 5 cm).
Tri se binh thuang: dirai 16mU/ml.
Trong ung thu gan DCP tren 200mU/ml O. 75% twang hop.
Alpha-fructose (AFU)
Alpha-fructose (AFU) la met enzym do lysosom tiet ra. AFU to ra kem dlac hieu
nhung benh nhan Chau Phi da den bi u to bao mam, u to bdo gan va de d4c hieu kem horn
so vori AFP.
Binh thuang ten 400 nmol/ml. De nhay 65% va de d'a'c hieu 90%.
Dinh luting Sing thai AFP va AFU giup lam giam 5,5-13% cac truing hop am tinh
gia cua AFP. Nhu viy, AFU c6 the c6 ich khi phi hop yeti AFP a nhung \ding tan suit u
to bao mam va u to bao gan thap.

❖ CA 125 (CANCER ANTIGEN 125)

CA 125 la met glycoprotein c6 trong luting phan tir cao (200 — 1000kDa), dirge
tim thay met luting nh6 trong bieu mo voi truing, nOi mac tir cung, co tir cung va tang cao

262
 CHU'O'NG 8 lo• CHI DAU UNG THU' (TUMOR MARKERS)

trong ung thu bung trong va mot so ung thu khac.

Chi dinh
- Phu nil c6 khiu \rang ch;au (a phan biet lanh hay ac).
- Theo dOi dieu tri va doan tien lircmg ung thubuong
- Thong d6i: nghi nger ung thu tuy.
Khuyen nghi cua Vien Han lam H6a Sinh Hoa Ky (NACB) va nhom chuyen gia
Chau Au ve cac d'Au an ung thu (EGTM):
+ Nen do CA125 m6i 6 thang ket hop sieu am qua am dao (TVS — transvaginal
sonography) hang nam nham phat hien sam ung thu bung trirng a nguai c6
holac khong c6 tien sir gia dinh mac ung thu vu ho4'c buong trung, c6 bieu
hien d6t bingen BRCA 1, BRCA 2 hocgen sira f6i bat Op nhi6m sac the.
+ CA 125 huyet thanh khong nen sir dung a sang loc nguai khong c6 trieu
chirng nham phat hien ung thu bung trong rai rac vi xet nghiem cho keta.
,qu
throng tinh gia cao va gia tri tien doan chi dat 2% khi tam soat cong &rig.

Bung triPng
binh thubmg

Hinh 8.11. Ung thu' bung ft-Ong

Y nghia lam sang

Tri s6 d6i chieu: CA125 < 35 U/ml.
CA125 tang cao trong ung bung trirng
D6 nhay: 82 — 96% (mirc quyet dinh: 35 U/ml).
D6 d'a'c hieu: 74 — 78% (mix guy& dinh: 65 U/ml).

263
 100

80

(z-• 60
.c
40. 40

20

Hinh 8.12. DO nhay dm CA 125 6' cac giai doan ung thu, bung tnlyng

CA 125 coy nghia tien luang trong ung thu Neu ma Wang trung.
Tang nhe: giai doan sarn, u nho, dap irng diL tri tat, tai phat thap.
Tang cao: giai doan muon, dap ung kern vai hoa tri.
CA-125 tang cao trong 50% ung thu bung trirng giai doan I va 60% ung thu bung
trung giai doan II.
CA 125 c6 lien quan voi din tien benh trong 87 — 94% twang hop:
Berth nhan sau khi phdu thuet cat u bung trung khoang 3 thang ma CA 125 con
cao, chirng to khoi u cat b6 khang hat, can 1ai tren 1 cm.
- Doi voi benh giai doan III/IV, sau len hoa tri deu tien can xac dinh half-life dm
CA 125 vi no coy nghia tien lugng kha nang sang con cua benh nhan. Neu half-
life < 20 ngdy thi tien luang tat; 20 — 40 ngay: trung binh; > 40 ngay tien hrcng
xeu. Sau 2 nem theo dai, mat so tac gia nhan they tST le sang sot theo thin to la
76%; 48% \TA 0%. Do do nen lam xet nghi'em nay sau khi h6a tri 1 thang.
CA 125 tang con gap trong
B'enh 1ST ac tinh khac: ung thu tir cung, phai, ang tieu
Benh 1ST lanh tinh:
+ Lac not mac -dr cung, u nang bung
• U ca (10%), dinh mang phai hoec pink mac.
+ Viem phen phu (20% > 65U/m1), viem \rang cheu (60% > 65U/ml).
+ Co thai, hal chirng then hu, tran dich mang phai, mang

264
 CHU'O'NG 8 ■ CHI DAU UNG THU' (TUMOR MARKERS)

+ HE4 (Human epididymal protein 4 — Protein mao tinh)

HE4 (con goi WAP 4-disulphide core domain protein 2) la mot glycoprotein, PTL
25kDa v6i 4 eau not disulfua, thuOc nhom WFDC (Whey Acidic four-disulfide core) cac
protein nghi c6 tinh chat ire ch6 trypsin. HE4 dugc pilaf hien dau hen trong bi6u mo mao
tinh ngoai bien, c6 ty le rat thap trong biL mo ho hap va sinh san (lce ca buong trimg),
nhung tang cao trong ung thu buong trirng.
Nhi6m sac th6 20q12-q13,1 chira locus voi nhi6su thanh vien gia dinh WFDC.

Locus gen WFDC

20p13

20p12

20p 11.2
WAP 1
20p11+1
WAP2
20q11+1
WAP3/Elafin
20q11+2 WAP4/SLP1
20q12 WAP5/HE4
WAP6
20q13+1 WAP7/Eppin
WAP8
20g13+2
WAP9
20g13+3 WAP10
WAP 11
WAP12
WAP13
WAP 14

Hinh 8.13. Vi tri cue HE4 troll gen WFDC

Tri s6 d6i chi6u: < 40 tu6i: 100 pmol/L
> 40 tu6i: 130 — 140 pmol/L
HE4 tang cao trong ung thu buong trimg, tang vita trong ung thu phi t6 bao
khong nho.

265
HOA SINN LAM SANG

0/0
gia tri b6t trareyng
100
90
79,3
80
70
60
50
40 31
30
20
7 9'7 6,3 5
10
0 ig 0 (
0
NI■.> ,‘3, .oq
\ \QC'
,c;\ b\-.A .-\\K, \vie-
\s‘.1
P\c‘

Hinh 8.14. DO d'a'c hieu cua HE4 trong cac bOnh Ac tinh

HE4 dugc tiet ra trong ung thu thanh mac, ung thu bung trimg dang lac not mac
ttr cung.
HE4 con tang cao trong tat ca cac giai doan ctia ung thu not mac tit cung.
Duang tinh gia trong suy than, vi vay khong ding HE4 khi có suy than, tran dich,
Nnh gan.
Phi hop CA 125 va HE4
+ HE4 it tang trong cac b'Oh lanh tinh so vai CA 125 (ngoai trix suy than).

% gia tri bat thireyrig % gia tri bgt thuong % gia tri bat thuOng

90 84,6 90 50
79,7 45.5
80 80 45
70 70 40
35
60 59 60 29,2
H E-4 30 -
50 50
•CA 125 25
40 35,3 40 35,6
30,9 20
30 30 15
20 20 10 --
6,1 ,5
10 10 2,71 5 2,51
0 0 0
Tran dich Khong Benh gan Kh6ng
Suy Khac bOnh gan
tan dich
Hinh 8.15. Gia tri bat thveyng dm HE 4 va CA 125 trong cac benh lanh tinh

266
 CHU'O'NG 8 IN. CHI DAU UNG THU' (TUMOR MARKERS)

+ Trong ung thu bung trtng: HE4 c6 dO nhay va dac hieu cao hon CA 125 trong
giai doan sam cita benh.

100
93,8 93,2
90 75 8_8 6

80
73,7 73,7 75
70

60
H E-4
50
MCA 125
40 • ROMA
30

20

10

0
III IV

Hinh 8.16. DO dac hieu cOa ung thu' bung trUng theo giai doan

+ Hien nay HE4 duac xem la chi ddu ung thu mai b6 sung cho CA 125 trong ung
thu buong trong, giCip tang them dO nhay a cac mitt dO dac hieu co dinh.
CA 125 ket hop vai HE4 cho ket tot hon net' do CA 125 rieng le.
Do HE4 va CA 125 trong huyet thanh con gifip phan biet ung thu bung trong va
nang lac not mac tit cung bung trirag.
HE4 tang cao trong ung thu not mac tit cung va ung thu bung tang (p<0,001),
khong tang trong u niem mac tit cung va nang lac not mac.
CA125 tang cao trong ung thu bung trong, lac not mac tit cung tin trien vai ton
thuong pfrac mac, khong tang trong ung thu niem mac tit cung.

❖ CEA (Carcinoembryonic antigen)

CEA la glycoprotein, PTL 180KDa thuOc nh6m khang nguyen ung thu bao thai,
sinh ra trong giai doan phoi thai va ngung san xuat sau sinh. CEA Om khoang 17 gen
hoat dOng trong 2 phan nh6m: phan nhom chira CEA ket hop khang nguyen phan irag
cheo khong dac hieu, phan nh6m chta nhang glycoprotein dac hieu khi mang thai.
CEA dirge tim did)/ chi" yeti trong duang tieu h6a va huyet thanh thai nhi, mot luong
nh6 trong runt, toy, mo gan cua nguai twang thanh kh6e manh.

267
HOA SINH LAM SANG

Chi dinh
116 tr.g ch'an doan ung thu dai tivc trang phan giai doan).
Theo d'Oi dap ung dieu tri va din bin cua ung thu dai tivc trang.
Y nghia lam sang
Tri s6 dai chiau: khong but thu6c < 2,5 ng/ml.
Hut thu6c la: < 5,0 ng/ml.
CEA tang thu.o.ng gap trong ung thu dal trot trang
CEA thueng tang cao trong ung thu dai trgc trang, tuy nhien dO nhay th'Ap trong giai
doan som cua benh va tang len theo giai doan benh.
Nghien ciru tren 358 benh nhan ung thu dai trkrc trang da pilau thuat: chi 4% 6 giai
doan I co tang CEA; o giai doan II, III va IV là 25%, 44% va 65% (diem cat la 5,0 ng/
ml). Nghien cola dm Fletcher R.H: 6 giai doan I va. II CEA c6 do nhay 36%, dO dlac hieu
87%; giai doan III va IV c6 de nhay 74%, de d4c hieu 83% (v6i diem c& la 2,5 ng/ml).
Do do, CEA kh6ng ducc khuyan nghi trong sang loc ung thu dai-tivc trang vi c6 de nhay
thap trong giai doan som cua benh va CEA binh thuong clang khong loai ducic chan doan.
CEA > 2Ong/m1c6 the benh da di can, khi da co di can thi CEA c6 the tim thay trong
cac dich cua co the (ngoai mau) nhu dich nao My (di can N th'an kinh trung ucmg)...
CEA c6 gia tri trong tien lucmg,benh: neng de CEA cang cao triroc phAu thu4t thi
thoi gian tai phat benh cang aim. Chang han, benh nhan o giai doan III co Med gian tai
Oat trung binh là 13 thang nau CEA trix6c phau thuat > 5ng/ml va 28 thang nau < 5ng/ml.
CEA la yau to tien lucmg 6 benh nhan phL thu4t gan do di can tir dai truc trang:
CEA cao Mr& phki thuat gan lam tang nguy co tai phat benh va giam kha nang song con,
khong phi thuec vao kich thuot va so lung di can.
Tuy nhien, CEA khong nen chi dinh ngay sau phau thu4t vi CEA c6 the &roc ph6ng
thich vao mau trong th6i gian phau thuat lam kat qua tang gia.

BueYu

Hinh 8.17. Ung thu, dai tnyc trang

268
 CHU'O'NG 8 ► CHI DAU UNG THU' (TUMOR MARKERS)

CEA cling tang trong cac benh 1j) khcic

Benh dc tinh: ung thu vu, ph6i, tuy, tuyen giap, carcinoma nieu-sinh due... CEA
thuong tango pliu nu c6 ung thu vu di can.
Benh lanh tinh: CEA tang trong polyp dai trang, viem runt non, xo gan, viem gan
man, viem tuy, viem dai trang, COPD, phu phoi.
Ngu6i but thu6c la cling lam tang CEA.

❖ CA 15-3 (Cancer Antigen 15-3)

CA 15-3 la chi dau ung thu dac. hieu cho ung thu vu, duoc xac dinh bad 2 khang
the don d6ng la DF3 va 115D8. Tuy nhien, CA 15-3 khong thich hop trong sang loc hoac
chan doan benh vi dO nhay th'ap.
Chi dinh
- Theo dOi din lien benh ung thu vu.
- Theo dOi hieu qua dieu tri Ira tai phat benh.
Y nghia lam sang
Tri s6 d6i chiL: < 25 U/ml.
CA 15-3 tang cao trong benh ung due vu
- Tang theo giai doan oda benh.
- CA 15-3 thay d6i theo giai doan va kich thuac khi u, khi u lan hoac da di can thi
CA 15-3 tang rat cao. Tuy nhien, n'ong dO CA 15-3 con tuy thuOc vao vi tri di can,
di can da c6 do nhay thap, di can gan cao nhL.
- Trong theo dOi benh: trong theo dOi dap Ung dieu tri va phat hien tai phat thi nong
dO CA 15-3 duoc xem la c6 thay d6i khi tang hoac giam > 25%.
- Phat hien soul tai phat benh.

Hinh 8.18. Ung thu vu xam Ian sang cac mO Ian can

269
HOA SINN LAM SANG

Duang tinh gia

Nhiem HIV (> 50%), viem phe quan (15%), viem gan man (5%), nhi6m khuan,
suy than, benh phu khoa, clang mang thai...

• CYFRA 21-1
Cytokeratin la cac protein, trung hop, san xuat tetramer, gulp san xuat cac vi sgi
trung gian va on dinh to bao bieu mo. Co 54 gen ma h6a cac cytokeratin. Cytokeratin
chiem -au the trong bieu mo vay, tiled gian ban hily: 10 — 15 gia.
Co lion 20 loai cytokeratin dugc biet an va chia thanh 2 nhom I va II, trong do
cytokeratine 19 chiem tru the trong phoi. Cytokeratin polypeptid not sinh it Ma tan, nhung
phan doan Ma tan c6 the tim thay trong huyet thanh.
Xet nghiem CYFRA 21-1 do phan doan cytokeratin 19 hoa tan trong huyet thanh,
co PTL 301cDa.
CM dinh
- Theo doff dieu tri va tien lugng ung thu ph6i.
- Giup phan loai mo hoc ung thu phi (ding cac chi au khac).
- Theo clOi dieu tri ung thu bang quang lan toa.
Y nghia lam sang
Tri s6 doi chieu: < 3.2 ng/ml (< 5ng/ml khi benh nhan c6 suy than).
CYFRA 21-1 kh6ng có m6i tuang quan ve tu6i, giai, but thu6c la, kh6ng thay d6i
khi cc') thai.
CYFRA 21-1 tang cao trong ung thu ph di to hew khong nho (NSCLC)
NSCLC la clang ung thu phi thuang gap, chiem 80% cac truOng hop.
CYFRA 21-1 tang cao trong NSCLC.
CYFRA 21-1 tang cao khi u phat trien (cang cao khi c6 di can). Tuy nhien, niing dO
binh thiromg hay tang nhe ding Ichong loai trir Icha nang u clang phat trien.
Lam sang nghi ngO. va CYFRA 21-1 > 3Ong/m1thi benh nhan co nguy ca cao bi ung
thu phi giai clop au.
- CYFREA 21-1 co dO nhay cao nhat doi voci NSCLC, nhung six ket hop cac dau an
SCC, CEA va CYFREA 21-1 se cho phep phan nhom mo hoc trong phan 16n cac
trirong hop ung thu ph6i.
- CYFRA 21-1 co gia tri tien lugng benh sam han dau hieu lam sang va chan doan
hinh anh: CYFRA 21-1 tang cao thi tien lugng xau; CYFRA 21-1 giam tren 27%
sau dot hoa tri clau tien chirng to benh c6 dap irng tot voff dieu tri. CYFRA 21-1 clugc
xem la yeu to tien lugng dOc lap doi voi ca. 2 giai doan sam va muOn cila NSCLC.

270
 CHU'O'NG 8 ► CHi DAU UNG THU' (TUMOR MARKERS)

Phithubng Phibi ung thu,

Hinh 8.19. Ph6i bi ung thu,

Cac benh l)5 khac
- CYFRA 21-1 cling tang trong SCLC va c6 the giup tien lugng khi ket hop vai
NSE, TPA. Tuy nhien, de nhay va de dac hieu khong bang dei voi NSCLC.
- CYFRA 21-1 tang nhe trong )cg cung phei, viem phei, hen phe quan, giai doan
dau ten thucmg gan lanh tinh va suy than.

❖ SCC (Squamous cell carcinoma)

SCC c6 de dac hieu cao doi \Ted ung thu to bao vay nhung khong hien dien trong
ung thu phibao nh6.
SCC tang > 1,5ng/m1 trong NSCLC (nhung de nhay kern CYFRA 21-1). Vi vay
SCC c6 the &me dung chart doan phan biet NSCLC trong ung thu to bao vay khi ket hop
vai CEA va CYFRA 21-1.
SCC cling ginp ich trong tien lucmg NSCLC.
Ngodi ra, SCC con tang trong ung thu co tir cung, thirc quart, mieng...

❖ NSE (neuron-specific enolase)

Enolase la met enzym phan hay duemg co PTL 80 kDa, gem 3 tieu don a, 13 va
'y. Co 5. isoenzym, trong do isoenzym yy (NSE) dirge xem nhu enolase dac trtmg cho he
than kinh, co the phat hien vai 'tong do cao trong to bao than kinh, to bao than kinh not
tiet, cling nhu cac u nguen gec tir chfing.
Chi dinh
- Ho trg chart doan ung tint phibao nho (SCLC).
- Theo doi hieu qua dieu tri b'enh SCLC va ung thu than kinh not tiet.

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HOA SINN LAM SANG

Y nghia lam sang

Tri s6 d6i chiL: < 17 ng/ml.
Ung thu phai to bao nho (SCLC)
NSE tang trong nhiL b6nh ly ac tinh khac nhau, nhung tang chit yet trong ung
thu phi to bao nh6 va ung thu than kinh not
Sarcoma-Lymphoma 13
Than kinh not tie 65
Bang quang 8.1
Tuya'n ti6n1i0t 1 2.2
VO 1 2
80
PhOi TB nh
PhOi khong TB nh 1
2.3
Phu kho 'IMP 5.2
lieu h6 _4
0 20 40 60 80 100

Hinh 8.20. Min NSE huy6t thanh oe 1471 bOh nhan ung thu' n'ang

NSE la chi dau dugc lua chon dau tien trong ung thu phi to bao nho, n6ng d6
NSE tang cao (>100 ng/ml) trong 60 — 81% cac tnx6ng hop SCLC.
Co m6i tuong quan thuan gift nemg do NSE va giai doan b6nh lam sang,
nhung khong tuong irng v6i vi tri di can haac di can nao.
NSE gift') danh gia hi6u qua diL tit nL co dap irng voi h6a tri thi n6ng d6
NSE se tang tam th6i trong 24 — 72 gi6 sau dot hoa tri dau tien do tinh trang
ly giai to bao ctia to bao khoi u, sau do NSE giam nhanh trong wing 1 tuan va
n6ng d'6 ve binh thuemg trong 80 — 96% truing hop.
NSE cfmg tang khi b6nh tai phat, thuong sau 1 — 4 thing, n6ng dO NSE tang
theo ham s6 mu (dat nong dO gap doi sau 10 — 94 ngay) va co tuong quan voi
thai gian song con ctaa b6nh nhan.
NSE giap tien luting b6nh nhan SCLC. Tuy nhien, khi phi hop NSE va CY-
FRA 21-1 se giap tien luting b6ith ducc chinh xac han: NSE va CYFRA 21-1
tang thi,b6nh nhan c6 tien luting xau hon la chi c6 tang NSE. NSE dugc xem
la yeu to tien luting d6c lap trong theo d6i di6u tri va din bin ci a b6nh SCLC
voi dO nhay chin loan la 93% va gia tri tien doan duong 92%.

272
 CHUO'NG 8 II- CHI DAU UNG THU' (TUMOR MARKERS)

Cac benh 1j, khac gay tang NSE

Benh dc tinh: u nguyen bao thAn kinh; U tinh hoan; U nao hoac u di can nao, ung
thu.
Benh lanh tinh: NSE huyet thanh tang nhe va trung binh trong mot s6 benh lanh tinh
cua ph6i, benh nao, benh gan, tuy, suy than...
NSE trong dich tang c6 the gap trong viem nao — mang nao, thieu mau nao, nh6i
mau nao, xuat huyet &rod nhen...

• ProGRP (Progastrin-releasing peptid)

Chi dinh: Ung thu phi to bao nh6 (SCLC).
Tri s6 d6i chitu: < 50 pg/ml.
Y nghia lam sang
ProGRP la dau an (lac hieu cho SCLC veri dO nhay va dO d'ac hieu cao. ProGRP tang
tir giai (loan sam cua benh, tang trong 60 — 70% tru6ng hop khi u tai ch6 va 75 — 90%
trtremg hop u di can, nhung khong tuang ximg vai mirc dO lan rOng cua khi u. Trong ung
thu phi ProGRP tang rat cao: ProGRP > 200pg/ml goi y ung thu phi va > 300pg/mlgoi
SCLC (net' khong co suy than kern theo).
ProGRP ciing giup theo doi dieu tri va tai phat benh SCLC. ProGRP dtrac xem la
dau an c6 dO nhay cao hon NSE trong benh SCLC. Ket hop ProGRP + NSE se giup theo
d'Oi dap ung voi dieu tri SCLC.
ProGRP con tang trong cac trtrong hop sau:
- Benh Ac tinh (ngoai ung thu phi va u thAn kinh nOi tiet): thuang clued 120pg/ml.
- Cac benh lanh tinh: thuong duoi 80pg/ml, ca biet, suy than c6 the lam tang Pro-
GRP den 300 pg/ml. Do d6 can xem xet chirc nang than khi doc ket qua ProGRP.

• CA 72-4 (Cancer Antigen 72-4)

TAG-72 (Tumor-Associated Glycoprotein 72) la mot glycoprotein, c6 PTL > 1.000
kDa, glycoprotein nay dirge bieu hien b6i nhieu loci to bao ung thu nhu da day, My, buong
trung, dai five trang,' vu.
Xet nghiem CA 72-4 sir dung 2 khang the don dong B72,3 va CC49 de phat hien
glycoprotein lien ket kh6i u, to bao tiet nhAy TAG-72 trong huyet thanh.
Chi dinh
- Theo dOi hieu qua dieu tri va din lien benh ung thu da day.
- Theo doi hieu qua dieu tri va din lien ung thu bluing trirng (Mang d6i).

273
HOA SINH LAM SANG

Y nghta lam sang

Tri so doi < 6 U/ml.
CA 72-4 tang cao trong ung thu da day. Co six tuang d6ng gift tinh trong benh va
n'Cing dO CA 72-4.
Sau phau thuat CA 72-4 ve binh thuemg sau 1-2 tuan va duy tri trong khoang binh
thuamg khi khong con t6 bao ung thu.
Trong tnremg hop tai phat, nOng dO CA 72-4 tang truac hay ding luc có bieu hien
lam sang. Do dO CA 72-4 tang la chi clan gift') theo doi benh va chan doan tai phat.

Ung thu da day

Hinh 8.21. Ung thu' da day

CA 72-4 trong benh ac tinh khac
Ung thu bung trong: do nhay khoang 47 — 80% (cao han a giai doan III W), dO
dac hieu 97%. CA72-4 CO do nhay cao han CA125 trong ung thu bieu mo bung trimg.
Ket hop CA72-4 va CA125 gifip tang dO nhay len 73% (so vai chi dimg CA125 la 60%).
Ung thu dai true trong: dO nhay khoang 20 — 41%, dO dac hieu la 98%. Sau phau
thuat cat bo khi u, CA 72-4 tra ye tri so binh thuemg trong khoang 18 ngay. Khi ke't hop
voi CEA, dO nhay tang tir 43% den 60% doi vai chan doan ung thu nguyen phat, va tir
78% den 87% dOi vai phat hien ung thu tai phat.
CA 72-4 con tang trong mot so benh lanh tinh
CA 72-4 tang nhe < 20U/m1 trong mot se) truamg hop viem khop dang thAp, benh
lanh tinh da day, benh ph6i, xa gan.

274
 CHU'O'NG 8 ■ CHI DAU UNG THU' (TUMOR MARKERS)

CA 72-4 tang vira < 80 U/ml a benh nhan sir dung thuOc NSAID hay corticosteroid,
2% tn.remg hop CA 72-4 có the tang 500 U/ml. Do do khi nghi ng6 CA 72-4 cao c6 lien
quan lieu phap corticosteroid thi nen xet nghiem 14i sau 3 tuan.

+ CA 19-9 (Cancer Antigen 19-9)

Chi dinh
Theo dai dieu tri va tai pilaf ten benh nhan u tuy, gan, mat, da day.
Y nghia lam sang
Tri s6 &Si chieu: < 37 U/ml.
Ung thu tuy: ri6ng dO CA 19-9 tang khoang 100U/m1 c6 the h6 trg chan down phan
biet ung thu tuy vai cac benh lanh tinh khac cUa tuy tren benh nhan sut can, dau bung.
Trong ung thu bieu mo tuy: do nhay 70 — 87%, dO d'ac hieu 97%. Khong c6 sir tuang
quan gift khi hien mo va nong dO CA 19-9. Tuy nhien benh nhan al CA 19-9 >10.000
Um' hau nhu luon c6 di can.

Hinh 8.22. Ung thu' toy

Ung thu gan va duang met: Os nhay CA 19-9 trong ung thu bieu mo gan: 50 - 75%;
ung thu tui mat: 55 — 79%.
Ung thu da day: CA 19-9 có dO nhay la 26 — 46%, dO d;ac hieu la 72 - 80%.
Ung thu dai true tang: CA 19-9 co do nhay la 18 — 58%, tuy thu'Oc vao giai doan.
Total PSA (Total Prostate specific antigen — tPSA)
PSA la mot glycoprotein, PTL 30.000 — 40.000Da.
PSA dirge tao ra tirs bleu mo kich thich bai ti6t tuyen tien liet (TTL) nen dac hieu cho
co quan TTL, PSA tang trong ca benh lanh va ac tinh cua TTL.

275
FlOA SINH LAM SANG

Chi Binh
Nghi nga ung thu TTL.
Sang loc ung thu TTL a nam gioi tren 50 tu6i (ket hop vai tham kham true trang
bang ng6n tay - DRE).
- Theo dOi tien hien benh va hieu qua dieu tri a b'enh nhan ung thu TTL.
- Theo din dieu tri bang lieu phap hormon.

Tuy6n Wen liet

Hinh 8.23. Ung thu' tuy6n tien lit

)",7 nghia lam sang
Tri so d6i chieu: < 4 ng/ml.
tPSA tang cao trong ung thu tuyn tien het
Dinh Krung tPSA ket hop tham kham truc trang lam tang kha nang phat hien ung
thu TTL. Gia tri tien doan ducmg: 30 - 39% (vai gia tri nguang 4 ng/ml).
Sau phau thuat cat b6 TTL van c6 the phat hien dtrac tPSA nhung n6ng d6 rat thap
(khoang 3 — 6 thang), nau tPSA cao chung to khai u con sot lai.
Thai gian ban hiiy cua PSA khoang 3,2 ngdy.
Sir dung tPSA nhu la mat xet nghiem sang loc c6 the phat hien dirac khod'ng 3%
tnrang hop ung thu TTL.
Vien han lam Hoa sinh lam sang Hoa KST (NACB) va nh6m chuyen gia chau Au v'e
cac chi dau ung thu (EGTM) khuyen nghi khong dirgc sir dung xet nghiem PSA don d6c
ma nen kat hop vai tham kham true trang bang ngon tay (DRE).
Khi tPSA tang thi xac suat phat hien ung thu TTL tang. Khi tPSA tang rat cao,
chimg to khOi u khong con giai han a ca quan: PSA > 20 ng/ml gan nhu kh6ng con kha
nang cat b6, PSA> 50 ng/ml thi da c6 di can hach vimg chau.
Ngoai ra, PSA con giiip du doan kha nang thanh cong cua x4 tri 1an dau.

276
 CHU'CYNG 8 ► CHI DAU UNG THU' (TUMOR MARKERS)

Bang 8.3. Xac suat phat hien ung thu' TTL (PCa) khi sinh thiet bang kim tren
nhu'ng ngu,61 kham tru'c trong bang tay khong co nghi ngO'
tPSA (ng/ml) Xac suat bi PCa (%) Khoang tin cay 95%
MIIININMINIPM16.6111111
12,4 — 21,6
4 - 10 26,8 — 33 ,

Dei \Ted neng do tPSA 4 — 10 ng/ml.

phan biet gifia phi dai TTL va ung thu TTL c6 the dua vao:
Ty s6 PSA vai the tich TTL.
Free PSA hay free PSA/totalPSA.
- Khi PSA tang 0,7 hay 0,8 ng/ml/nam thi c6 kha rang 70% trueng hop bi ung
thu TTL vai de nhay la 90% va dO dac hieu 90 — 100%.
tPSA tang trong tan thuang lanh tinh
- Viem tuyen tien liet.
Phi dai TTL lanh tinh: 21 — 86% c6 tPSA 4 — 10 ng/ml.
25% c6 tPSA > 10 ng/ml.
Chin thuang TTL: sau th6ng tieu, nOi soi bang quang, sinh thiet nieu dao,
kham tnxc tang (PSA c6 the tang 0.5 ng/ml d6i vei PSA < 4 ng/ml)... va PSA
thuang trey ve binh thuang sau 3-6 tuan.
- Vi PSA con hien din trong tuyen hau mon va can nieu dao, mo vu hoac ung thu
vu, nen luting nho PSA ding duoc tim thay trong huyet thanh phu
Free PSA (Free Prostate specific antigen - fPSA)
Free PSA (PSA to do) chiem met luting nho cua PSA toan phan va kitting c6 hoat
tinh phan hily protein.
Ty le phan tram PSA tiy do (%fPSA) = fPSA /tPSA fat hat ich khi dung phi hop
vai tPSA de chan doan phan biet ung thu TTL -ay cac benh canh TTL lanh tinh a nam giai
tit 50 Mei to. len ma khong c6 nghi ng6 ung thu khi kham TTL qua trirc tang bang ngon
tay va tPSA trong xam" 4 — 10 ng/ml.
Tri se d6i chieu cua %fPSA: 25 — 30%
Nhieu nghien ciru cho thay ty le % fPSA 6 benh nhan ung thu TTL thAp hcm rat
nhieu so vai mac benh lanh tinh hay nguei binh thuCmg trong nh6m chimg.
(fPSA va tPSA phai ducyc dinh luting tren cUng 1 may )(et nghiem).
6 nhilng benh nhan dang dieu tri, dac biet sau khi ngtmg lieu phap dieu tri bang hor-
mon thi kh6ng the dung ty le %fPSA de chan doan phan biet tang san TTL va ung thu TTL.
Ty le %fPSA c6 the &mg danh gia nhu eau can lien hanh sinh thiet TTL.

277
HOA SINH LAM SANG

Bang 8.4. Xac suit phat hien ung thu, TTL khi sinh thiet bang kim theo do tu6i
(khoang tin cay 95%)

Ty le %fPSA 50 — 59 tuai 60 — 69 tail > 70 tali

57'5 111,5
morum =2,1911111111111”79,7
111•12.7E1
INMAN 111.1111111 15'8

• MOT SO CHI DAU (TUMOR MARKERS) KHAC

hCG va 13hCG (human Chorionic Gonadotropin)
hCG la hormon thai nghen do the nguyen bao nuoi tiet ra, nOng d6 hCG tang cao
chung to co su tang sinh manh cua cac nguyen bao nuoi.
hCG va 13hCG c6 vai tro quan trong trong chin down, theo dOi benh nhan c6 ung
thu to bao main.
Tri so d6i chi6u: < 5 UI/1
s 84% carcinoma dem nuoi ducmg tinh vai hCG. Carcinoma dem nuoi la mot u to bac)
main do cac to bao hop bao nuoi tiet ra. No xay ra a phu nu chu yeu nhu cac nguyen bao
nuoi nhau thai va 6 nam giai nhu cac u tinh hoan khong phal seminoma. Cac to bao u
berth nhan b6c 10 vai clau an hCG, clac bit cac hop bao nuoi ducmg tinh manh vai hCG.

Hinh 8.24. Ung thu tinh hoan

Thyroglobulin
Thyroglobulin la glycoprotein &tot tong hop trong to bao giap. Do do tang
thyroglobulin la dau hi'eu quan trong trong ung thu giap bia h6a.

278
 CHU'O'NG 8 ► CH% DAU UNG THU' (TUMOR MARKERS)

Chi dinh: theo dai ung thu tuy6n giap sau khi phau thuat va dieu tri iode phong xa;
Viem giap tdc nghen.
Tri s6 doi chiL: < 50 ps/1.

Hinh 8.25. BLrau giap

p2-microglobulin
La chit chi diem trong benh da u My, leucemia dong lympho man, u lympho ac tinh.
Tn so doi chieu < 2g/ml.
Bladder tumor antigen (BTA)
La chdt chi diem trong ung thu bang quang. Xet nghiem ducmg tinh khi có BTA
xuat hien trong nuarc ti6u.
Calcitonin
La chdt chi diem trong ung thu tuyen giap the thy.
Xet nghiem chdn doan ung thu giap: test Pentagastrin
- Chich TM trong yang 3phUt voi 0,5µg/kg chdt Pentagastrin (Peptavlon) hoa
trong 5m1 muoi dang truang.
Ldy mau vao cac tiled diem -5; 0; 3 va 5 phut de dinh ltrong calcitonin.
- Binh thtremg: 10 — 30 pg/ml.
- Tnremg hop nghi nger: 30 —100 pg/ml.
- Ung thu tuy giap trang: > 100 pg/ml.
CA 27-29
Ddu an trong ung thu vu.
Tn so binh thu mg: 38-40U/ml.

279
HOA SINN LAM SANG

KET MY CAC TUMOR MARKERS TRONG UNG THU'

+ Ung thu bung trtirng: CA 125, HE4, CYFRA 72-4
+ Ung thu tuyen tien liet: total PSA, free PSA, %fPSA (= fPSA /tPSA)
+ Ung thu gan: AFP, AFP-L3, DCP, AFU
+ Ung thu phi to bao khong nh6 (NSCLC): CYFRA 21-1, SCC
+ Ung thu phi to bao nho (SCLC): NSE, ProGRP
+ Ung thu CA 15-3, CEA
+ Ung thu dai trgc trang: CEA, CA 72-4, CA 19-9
+ Ung thu da day: CA 72-4, CA 19-9
+ Ung thu tuy, mat: CA 19-9
+ Ung thu to bao many hCG, (3 hCG
+ Ung thu giap: thyroglobulin, calcitonin
+ Ung thu bang quang: BTA.
Ghi chu
im DAu an deu tiLn
cung cap huang
den quan tong
trong qua trinh
n ; ra quyat dinh

5 g g
i § cal
•
rn.t MO Deu en thin hai
Ung guano • h6 tn. viec ra
ytj • • guyet dinh ket
ho) vai pluming
Te bbo C phap ban deu
06111 cung
IAalg f** •
Doi tang •
Dau An thin ba
Tai-MN-Hong ern ho trg viec ra
quyet Binh Irk
ThYa Wan
Ti Woo mim • • hop vai cac quy
trinh cher' down
Gan • khac
P11& (SCLC) • •
(NSCLC) • •
U bmpho •
U MC 16 ic Wh •
Buling Wing • •
Toy •
• •
liOn tin NI
Oa day • •

laYin 010 • •
Ihkiu mau Nan wen ung tfiu •

Hinh 8.26. Cec xet nghiem (JAL] An ung thu' theo chi dinh

280
 CHUONG 8 10. CHI DAU UNG THU' (TUMOR MARKERS)

8. Glo'l THIEU MOT SO BENH AN

A. CAU HO! NGHIEN CIAT

Truirng hyp 1
Benh nhan Hoang Thanh H., phai nix, sinh nam 1987.
Nghe nghiep: nOi trg, dia. chi: Nghia Hoa, Tan Binh, TP. HCM.
Nhap vien ngay: 28/2/2012. LST do: nuet nghen, dau thugng
Benh stir: cach nhap vien 2 thang, BN an cam thi bi nghen, cam giac bi chen o ngtrc
khi nuot thirc an, khoang 5 — 10 phut thi het nghen. Trieu chi:mg nghen ngdy cang tang,
kern theo 6i ra thirc an (khong c6 mau), benh nhan phai chuyen sang an chao dac, roi
chuyen sang an chao loang, an cham terng chat met. Khoang 2 tuan tn.rac xuat hien them
trieu chimg dau thuang vi, can dau cireeng,de nhe, khong lan, dau khi dOi. Di kham dugc
chan doan benh 1ST da day, dieu tri thuc ung kh6ng giam. Khoang 10 ngay nay, can dau
tang len, lien tuc ca ngay. Benh nhan sey thlremg vi thay c6 khi u, an vao thay dau tang
len. BN den BV Hoa Hao kham dtrgc chan doan la K da ddy. BN sat 8 kg so voi each day
2 thang, dai tieu tien khong dau, khong c6 mau. Phan dac ldn voi phan king.
Tien sir ban than: cao HA. Khong benh 1ST tim mach, lieu throng, gan-than-phei trtrac
do. Kh6ng hat thuc la, khong ung men bia. Tien sir gia dinh: kh6ng ai bi benh dac biet.
Tham kham lam sang: mach 861an/phat, huyet ap 130/80mmHg, nhiet de 37° C, nhip the).
20 lan/phut. Da xanh, niem mac nho:t nhat. M6ng tay hong nhat, con bong.
SeY thay co 1 khi u troll yang thircyng vi hai Lech (T), be mat trap lang, gioi han re,
mat de chac, kich think 3x5cm, chi di deng xuong clued khi BN hit sau. Cdc ca quan khac
kham binh thuang.
Can lam sang:
COng thirc mau: BC: 8,5 K/aL (4,0-9,0), HC: 3,83 WO (4,04-6,13), Hb: 12,2 g/dl
(12-18), Hct: 35,3 % (37,7-48), PLT: 308 K/al.
Sinh hod. mau: AST: 24 U/L (9-48), ALT: 20 U/L (5-49), ure: 3,4 mmol/L (1,7-8,3),
creatinin: 60 umol/L (53-106), glucose: 4,1 mmol/L (3,8-6,1), protein: 63 g/L (60-80),
HbsAg:(-), HIV: (-). Tong phan tich nu& tieu: bach cau-ni'eu (+), keton-ni'eu (+).
Chi dau ung buou: CA 19,9: 20 U/ml (< 37): 11, CEA: 23 ng/ml (< 5): Tr, AFP: 5,4
ng/ml (<10), CA125: 6,6 U/ml (<35), CA15-3: 5,8 U/ml (0-28), CA 72-4: 89 U/ml (< 8,2).
Sieu am bung: tham nhi'jm vach da day lan 1/3 dual thuc quan + hach ba cong nh6.
Chap da day can quang: ten thucmg tham nhie'm Gang toan be da day va 1/3 clued thuc
quan. XQ da ddy — thuc quan: theo dOi u phinh vi xam lan tam vi gay hep va lam gian thuc
quail doan tren ch8 hep. Nei soi thuc quan — da day — to trang: U than da ddy (tip Linitis
Lastique). ECG: theo doi thi6u nang vanh. Sieu am tim: ha van 2 la 1/4, ha van DMC 2/4.
XQ nguc thang: tim phi binh thuang.

281
HOA SINH LAM SANG

Truirng hop 2
Benh nhan HuYnh Thi T., phai nir, sinh nam 1942.
Dia chi: Long Thanh-DOng Nai. Nhap vien ngay 27/02/2012. LY do: dau bung vimg ha vi.
Benh sir: each nhap vien vai ngay benh nhan thay dau bung yang ha vi. Tieu tieu binh
thuOng. Den kham tai BV DK KV Go Cong, dirge sieu am va than doan ung thu buong
trang di can o bung —> Nhap benh vien Ung Buou TP.HCM.
Tien sir: ban than: PARA 6006, kinh dau nam 16t. Lay chOng nam 17t. Con dau: 19t.
Khong dimg thuOc ngira thai. Sa sinh duc de II (1 nam-BV DKKV GO Cong). Tien sir gia
dinh: me va chi khong ai bi ung thu va, hay ung thu buong trimg.
Tham kham lam sang: mach 78 fan/phut. HA=120/80 mmHg. Nhiet de 37°C, nhip
th6 =20 lan/phitt.
Vimg chau có buau to khoang 7 cm, di deng, An dau. Tham am dao: sa sinh duc di)
II. Co tit cung tran lang, tir cung khong to. Cac ca quan khac chua thay gi dac biet.
Can lam sang: cac xet nghiem tong thirc mau, chUc nang gan, than: trong gioi han
binh thuOng.
Chi dau ung AFP: 5,67 ng/ml (<10), CA 125: 74,23 U/ml (<35): TT, HE4:
520pmol/L (<150), HCG: 0 U/L (< 5).
Sieu am: ung thu buOng trimg (T). CT scan vimg bung chau co va khong tiem thuOc
can quang: birou buting trung kith thuOc 9x10cm, thanh day c6 vach + choi dinh xung
quanh nghi toi ung thu.
Giai phdu benh• hinh anh carcinom tuyen giap dang nhit, cac TBBM tuyen giap
tang san,,tao nhit. U quai giap buong trimg la dang u quai truang thanh, có nguon goc tit
to bao mam, rat hiem gap.

Tryon hop 3
Benh nhan: Tran Thi 0, phai nti, sinh nam 1950.
Dia chi: Campuchia. Nhap vien: 6/4/2012. Ly do: rong kinh.
Benh sir: khoang 7 thang nay, benh nhan bi rong kinh ngay tang nhieu ung thuOc khong
giam. Khoang 1 thang nay, ra huyet nhieu, nhap vien benh vien Ung Buou TP.HCM.
Tien sir ban than: PARA: 2032. Kinh dau nam 17 tuOi, kinh deu. Khong tien can
benh ly not ngoai khoa. Gia dinh khong ghi than benh ly gi.
Tham kham lam sang: mach 80 lan/phitt, huyet ap 120/80 mmHg, nhiet dO: 37°C.
Cac ca quan khac khong có gi dac biet.

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 CHUO'NG 8 ► CHI' DAU UNG THU' (TUMOR MARKERS)

Can lam sang:

C6ng thirc mau: bach au: 8,510 K/mm3 (4.0-9.0), Hong eau: 3,39 M/mm3 (4,04-
6,13), Hct: 29% (37,7-48); Hb: 9,28 g/dl (12-18); Tieu cau: 324 K/min3 (140-440).
Sinh Ma: AST: 27 U/L (9-48), ALT: 28 U/L (5-49), glucose: 5,6 mmol/L (3,8-
6,1), Ure: 3,4 mmol/L (1,7-8,3), creatinin 79p.mol/L (53-106), Protein: 68g/L (65-80).
Chi dau ung beau: CA 125: 210 U/ml (<35): TTT, HE4: 360pmol/L (<150).
XQ phoi trong giai han binh thuang. Sieu am: theo dei K nei mac tir cung. Sinh
thiet nOi mac tir cung: met so tuyen nghich san Ong.
Chan doan xac dinh: K nei mac tir cung.
Giai plau benh dai the: tir cung to 8x5x12 cm, xa hoa nhieu, nOi mac co che hoa
nang, nghi benh tuye'n trong ca.

Thrirng hop 4
B'enh nhan Tran Thi Ngoc M., pilaf nu, 37 Wei.
Dia chi: 166/6 HuS/nh Van Nghe, P15, Q. TB. Nhap vien: 27/4/2012; LSi do: dau bung.
B'enh sir: cach NV khoang 1 tuan benh nhan xuat hien dau bung, chtrang bung. Den
kham tai BV NDGD, thay c6 khei u mat de deng nhat phia ten tir cung, kich thirot 165
x 90 x 130 mm, dich 6 bung hrong nhieu. nhieu ten thtrang dang not a ch6m xucmg
va 2 ben phoi. Chin doan K bung trimg di can phoi, xtrang. Dai tieu tien binh thirang. 2
ngay nay BN &et nget dau bung nhieu nen den BV Ung
Tien sir: c6 kinh life 19 Wei, deu. PARA 0000 (da lap gia dinh 1 nam nay). Khong
benh ly nOi ngoai khoa.
Tham kham lam sang: da niém nhot, buou ha vi Lech phai, d=8 cm, chac, giai han
re, kh6ng dau, di &Ong kern. Tir cung khong to, co tir cung ya am dao trop lang Kharn cac
co quan khac binh thtrang.
Can lam sang:
COng thirc mau: c6 thieu mau. Bach au: 8,5 K411 (4,0-9,0), hong calf: 3,85 M/111
(4,04-6,13). Hct: 28% (37,7 — 48). Hb: 8,64 g/dl (12 - 18), tieu cau: 320 K/µ1(140-440).
Sinh hoa: protein, glucose mau, TQ, TCK, chile nang gan-than, mrac tieu, mat: binh
thiremg. Sat/HT: 1,9 lag/d1: i (nam 11-27, air 7-26). Feritin: 375,2 ng/ml T (20-300).
Chi dau ung birou: CA 125: 140 U/ml: TT (< 35), CA 19,9: 30 U/ml (< 37), CEA:
2,4 ng/ml (< 5), AFP: 7,67 ng/ml (<10), HCG: 0 UI/L (< 5).
Sieu am: khei u bung trirng phai, theo &A K.

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HOA SINH LAM SANG

X-Q tim phai thing: viem mo Ice ha don T.

Giai Platt Benh: K bung trung to bac) mArn (Carcinoma boc tuyen tiet dich nhay
Grad 2).

Trierng hop 5
Benh nhan Le Biet Nhu H., phai nu, sinh nam 1992.
Dia chi: Long An. Nhap vien ngay: 22/04/2012. 1y do: dau bung.
Benh sir: each -nhap vien 3 thing benh nhan d'Ot ngOt dau bung. Den benh vien Quy
Nhcm dirge chin doan la viem runt thira, dieu tri cat runt thira. Sau mo kheing dau, bung
ngay cang lon din. Cach nhap vien 1 thing thay bung to va dau, den BV Quy Nhon duce
chin doan theo dai K bung trung, chuyen BV Chg Ray ma sinh thiet each day 10 ngdy
chin doan K bung &rag. Nay dau bung nhieu xin nh4p vien BV Ung
Tien six: ma cat runt thira each day 3 thing. Mo sinh thiet Wang trirng phai each
day 10 ngay.
Tham kham lam sang: mach 90 l'An/phitt, HA 110/60 mmHg, nhiet dO 37°C.
BN tinh, tier) xftc tat. Da niem nhgt nhat, Mao they nhe. Tang trang trung binh. Vet
mO bung duemg glib clued ran 10 cm cang chua cat chi, con ri dich. v6t me) ngay ten
xucmg mu lanh seo, lon nhon, nghi reo rac buou tren duemg mo cu. Cac co. quan khac
binh thuong.
C4n lam sang:
Giai phau benh - BV CR c& lanh: Carcinom tuyen bung trirag.
Cong thirc mau: CO thieu matt hang c'au nho nhugc sac, tang nhe Bach ca.0 trung tinh.
BC: 11,5 K/µ1(4,0-9,0), HC: 3,15 M/µ1(4,2-6,3), Hb: 7,52 g/dl (12-18), Hct: 21,9.
% (34-48), MCV: 70 fl (80-100), MCH: 22,1pg (27-32).
Giai Phau Benh: u xoang not bi phoi ac thuOc U to bao m'am, di can to chirc mac
not ion.
Chi dau ung buou: AFP: > 350 (0-10 ng/ml) TT, CA 125: 159,8 (0-35 U/ml) TT,
P-HCG: <1,20 (0-5 mill/nil), CA 19,9: 23,12 (< 37 U/mL), CEA: 4,0 (< 5 ng/mL), CA
15-3: 14,8 (0-28 U/ml).
Chirc nang gan-th4n: binh thuong. Ntrac tieu: binh thuong.
CT Scan: K bung trirng + Carcinom bung chau + gieo fac thanh bung -yang ha vi P.
X-quang Phai: binh thuong.
Sieu am: K bung ft-Crag + carcinom o bung.
ECG: nhanh xoang.

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 CHUO'NG 8 10- CHI DAU UNG THU' (TUMOR MARKERS)

Truirng hop 6
Benh nhan D8 Thi H, phai nit, sinh nam 1966.
Dia chi: Da Lat, Lam Wong. Nhap vien: 5/3/2012. L3'r do: dau ha suem phai + u ha won P.
Benh sir: khoang 1 thang nay benh nhan xuat hien dau nhe \Tang ha soon phai kern
them to phat hien c6 khoi u vimg ha suem phai. Dai tieu tien binh thuong. N6i soi thay u
dai trang, xin nhap vien.
Tien sir ban than: khoe manh
Tham kham lam sang: mach 60 lan/phAt, HA 95/70 mmHg, nhiet 37°C; nhip
the,: 201an/phirt.
BN tinh, flap xAc tat, da niem Wong. Tuyan giap khong to. Hach ngoai vi (-). Tim
deu. Phoi em trong. An ha wan phai dau nhe. SO thay khoi u kich thirac 16n, mat d6 chac,
di d6ng. Cac ca quan khac khong thay gi dac biet.
Can lam sang:
COng thirc mau: binh thuong, BC: 4,88 (4,0- 9,0 K/R1); HC: 4,16 (4,2-6,3 M/µ1),
Hb: 12,1(12,0-18,0 g/dl), Hct: 37,1 (34,0-48,0 %); TC: 265 (140-440 K/u1). Dong mau:
binh thuong. Sinh hoa: Glucose mar, eh& nang gan-than, dam mau binh thirang. Ion do
trong giori han binh thuong. N6i soi dai true trang: TD K dai tang. Sieu am: Dai trang
phai c6 hinh anh day thanh ong tieu h6a kich thuac 17-20 mm. Kat luau: u dai trang.
Marker ung buou: CEA: 26,33 (0-5 ng/ml) Tr, CA19-9: 254.9 (0-37 U/ml)
AFP: 3,27 ng/ml (<10).
Giai Phu Benh- sinh thiat: carcinoma tuyan niem mac dai trang, biet hoa trung
binh, xap d6 II mo hoc.
X-quang tim ph6i: binh thuong. Dien tim: binh thuong.

Truo'ng hop 7
113nh nhan: Trucmg Thi Thu C., phai nu, sinh Mtn 1983.
Dia chi: Ninh Kieu, Can Tho. Nhap vien: 2/3/2012. L3'f do: dau vu trai + u vu T.
Benh sir: b'enh nhan tkr phat hien nhieu khoi u cimg dau e, vu T. Da sieu am va xet
nghiem phat hien K vu nen xin nhap vien.
Tien sir ban than: khoe manh
Tham kham lam sang: mach 721an/philt, HA 95/60 mmHg, nhiet di): 37°C.
BN tinh, flap mile tat, da niem h6ng. Tuyan giap khong to. Hach ngoai vi (-).. Tim
deu. Phi em. Bung mem. VA trai thay nhieu khoi u mat do chac, di d6ng kern, an dau nhe.

285
FIOA SINN LAM SANG

Can lam sang:

Cong thirc mau: c6 thieu mau nhe; BC: 5,2 (4,0-9,0 Kiii1); HC: 4,09 (4,2-6,3 M/i11),
Hb: 10,7 (12,0-18,0 g/dl), Hct: 36,5 (34,0-48,0 %); TC: 300 (140-440 K/iul).
Dong mau: binh throng. Sinh hoa: glucose, protid, chic nang gan-than binh throng.
Marker ung birou: CA 15-3: 120 (0-28 Um') ; CEA: 19 ng/mL (< 5): i; AFP:
5,39 ng/ml (<10); CA 125: 14,03 U/ml (<35).
Sieu am: TD K vu trai da 6. VII trai c6 4 sang throng kich thuac to 10-20 mm, e cac
vi tri khac nhau, echo rat kern be( gai. Vu phai binh throng. Hach nach 2 ben khong thay.
Sinh thiet vu trai qua sieu am: Carcinom tuyen vn, hien dien to bao bieu mO tuyen
vu xep rai rac, nhan len, bat throng, ac tinh.
X-quang tim phOi: binh throng. Dien tim: binh throng.

Truirng hop 8
B'enh nhan: Doan Thi N, phai nir, sinh nam 1961.
Nghe nghiep: buon ban. Dia chi: Hoai Nhon, Binh Dinh. Nhap vien: 21/11/2012.
Ly do vao vien: Phat hien u vu trai.
Benh sir: Cach nhap vien 10 ngay, BN ti phat hien co 1 u vu trai, u cimg, khong
dau, kern met mai, kern an nen xin vao vien.
Tien sir: PARA: 2002. Ban than: khong bi benh DTD, kh6ng bi cao huyet ap. Cac
thueic ngira thai: thinh thoang ding, khong ding cac thuOc nOi tiet. Kh6ng c6 tien sir tang
san tuyen vu, khong bi k bung trung Kinh nguyet dau tien lie 13t, hien tai con kinh nguy'et.
Gia dinh: khong ai c6 benh ly gi dac biet.
Tham kham lam sang: nhi'et dO: 37,5°C, mach: 801an/phiit, HA: 125/70mmHg, nhip
tiler 201an/philt. TOng trang chung trung binh, BN tinh tao, tiep xuc tot, da hoi xanh, niem
mac Wong nhat. Nhip tim nghe deu, ro, kh6ng phat hien benh ly. Phoi: ri rao phe nang rO,
khong c6 ran. Bung mem, khong chuang, an khong dau. Cac co quan khac khong phat
hien benh
Kham trai: c6 1 khOi u O. vu trai, kich thuot khoang 2cm, ranh giai khong
th, mat dO chic, cing, khong dau, di dOng kem, khong gay viem loot da, dau num vu bi
tut sau vao trong, be m'a't loi lour khong deu, da teen khOi u bi lom xuong. VA phai: khong
phat hien u.
Hach: c6 nhieu hach nach ben trai, teen va dirai xuang don (khoang 6 hach), kich
think 0,5 — lcm, mat dO chic, cimg, dinh vao nhau va dinh vao to chic xung quanh, di
dOng, an dau nhe. Nach phai khong phat hien hach.

286
 CHU'O'NG 8 ► CHI DAU UNG THU' (TUMOR MARKERS)

Can lam sang:

Cong -auk mau: HC 3,5 M/µ1 (3,4-5,8 M/µ1): binh thuang. Hb 112g/1(120-140g/1):
giam nhe. BC 8,1 K/µ1(3,5 — 10 K/R1): binh thuang.
Sinh hoa: Glucose, chirc nang gan, than, moo mau, albumin: trong giai han binh thuong.
Marker ung thu: CA15-3: 26,4 U/ml (0-28): binh thuang. CEA: 99 ng/ml (0 — 5): Tang.
Cac Marker ung thu khac cling trong giai han binh thiremg.
Siesta. am: VA phai: Khong phat hien u. VA trai: co 1 u kich think 2cm, echo kern. Co
nhi'eu hach nach trai, nach phai khong thay hach. Dien tim: binh thuemg.
Giai phau benh: c6 cac t6 bao bieu mo tuyen vu xep red rac, nhan lan, bat thuang,
ac tinh.
Ket Juan: Carcinoma tuyen vu trai.
Chup vu: tren phim chup vu trai c6 vet rang gong canxi, hinh cac 6ng tuyen vu bi
xoan van, c6 1 hinh khei dac, da vAng tuyen vu va num vu day len.

Truimg hop 9
Ho ten BN: Nguyen T, phai nam, 68t.
Nghe nghiep: Buell ban. Dia chi: TP Qui Nhan — Tinh Binh Dinh.
Ngay nhap vien: 12/12/2012. Ly do vao vien: Dau bung + chart an + slit can.
Benh sir: cach nhap vien khoang 10 ngdy, benh nhan thay dau bung, cam giac dau
tire v-Ang ha wan phai, kern an kho tieu, chart an, buon non, non, is chay, met mei, slit can
nen xin vao vien.
Tien sir ban than: bi VGSV V cach day 9 nam. X° gan each day 3 nam. HBsAg: am
tinh. Khong nghien rugu. Gia dinh: c6 Ong not bi ung thu gan.
Thant kham lam sang: nhiet dO: 38°C, mach 75 lan/phitt, HA 120/75mmHg, nhip
tha: 22 lan/phAt.
Tong trong chung gay slit, BN tinh tap, tiep xitc tot, da va niem mac yang, dau tirc
vung gan. Dau sao macho noc (+), titan hoan bang he (-), hach (-). Bung mem, gO duc
vimg thap. Lach khong lan. Gan lan khoang 3,5 cm dual ha wan P, mat dO cimg, an tirc
nhe, be mat khong deu, khong di dOng theo nhip tha, nghe c6 tieng thoi tren vimg gan.
Cac co quan khac khong phat hien benh
Can lam sang:
Cong thirc mau: HC 2,9 M/pil (3,4-5,8 Wit1): giam. Hb 95g/1 (120-140g/1): giam.
BC 8,1 K/µ1(3,5-10 K/u1): binh thuang, N: 66%. TS = 6ph, TC = lOph.

287
FIOA SINN LAM SANG

Sinh hoa: glucose/mau: 3,7 mmol/L (4,2-6,4): j; AST: 405 IU/L (0-40): T, ALT:
32 U/L (0-45), GGT: 226 U/L (9-69): 1; Bili TT: 255,6 !Amon (< 4.3 [Imola): Bili
TP: 505,8 !Amon (< 17 Inno1/1): t; Albumin: 21 g/L (35 — 50 g/1) 1; ion 6: Ca TP: 2,9
mmol/L 2,2mmo1/L): T; TG: 1,1 mmol/L (1,7-2,29): 1, Cholesterol: 3,6 mmol/L (4-
6,7): 1,; Ure -Creatinin: berth thuang. Phosphatase kiem: 165 IU/L (30-110): T.
Marker ung thu: AFP: 897,2 ng/ml (0-7 ng/ml) i; CA19-9: 105 U/ml (0-37 Wm]) 1-;
CEA: 3,9 ng/ml (0-5 ng/ml). Anti HBV: Am tinh, HBsAg: Am tinh, Anti - HCV: Duong tinh.
Sieu,am: dich bung luting it, khong thay hach. Gan: cau trite tang am, mat dO the',
ba gho ghe, kh6ng dung clang. Gan phai c6 1 khi u kich thirerc khoang 4,8 cm tang am,
ba khong rO, x6 day mach matt va duang mat, tang sinh mach mau trong u.
Ket luan: K gan/xo gan.
CT scan: c6 1 khi kich thirac khoang 4,7 cm, giam mat dO, bat mau khong deu.
Theo clOi: ung thu gan.
Xquang tim - phi - xtrong: khong phat hien benh
7. Ban luan: dua vao,cac yeti to LS, va CLS, c6 the ket luan BN bi K to bao gan. De
nghi lam them XN GPB gap phan chin doan. Khong phat hien u a cac co quan khac,
nen day la K gan nguyen phat. BN c6 tin sir VGSV C, vay c6 the K gan nguyen nhan do
VGSV C.

Trtromg hop 10
Ho va ten BN: Le Thi Minh T, phai nit, 55 tuOi.
Ngh'e nghiep: Bu6n ban. Dia chi: Phil Cat — Binh Dinh. Ngay vao vien: 12/01/2013.
L3T do vao vien: Nu& kho.
Benh sir: each nhap vien 10 ngay, benh nhan thay nu& kho khi an corn, c6 cam giac
nghen a co, kern phat hien u buou 6 co to len nen xin vao vien.
Tien sir ban than: cao huyet ap each day 1 nam, da duoc dieu tri on dinh. Bi u tuyen
giap each day 3 nam va duoc chan doan u tuyen giap don dOc, binh giap. Da duoc dieu tri
nhieu tan. Gia dinh: Khong c6 ai mac benh 13'T gi dac biet.
Tham kham lam sang: mach: 821an/phitt, huyet 120/75mmHg, nhiet dO: 37°3C,
nhip tha: 211an/phirt. TOng trang chung hoi gay, tinh tao, tiep xitc tot, da niem mac hOng.
NuOt kho khi an thirc an dac.
Kham tuye'n giap: c6 mot nhan giap thity phai, duang kinh 2,5 cm, mat dO citng,
chac, khong dau. Co 2 hach co phai, duang kinh 1 cm. Kham tim: nhip tim deu, ro, khong
phat hien ifeng tim benh 13T. Kham phOi: ri rao phe nang nghe rei 2 phOsi, kh6ng phat hien
benh 13T. Cac co quan khac khong co gi dac biet.

288
 CHU'O'NG 8 ■ CHl DAU UNG THU' (TUMOR MARKERS)

Can lam sang:

Cong thirc mau: HC: 4,2 x 10'2 /L (3,8 — 5,4), Hb: 135 g/L (120 — 180). BC: 6,7 x
109/L (5 — 10).
Gial pi& benh: co nhieu dai thuc bao va nhung mang to bao bieu ma giap tao nhu
voti nhan bien doi max khia, hoac the vui trong nhan.
Ket Juan: Carcinoma tuyen giap clang nha.
Dien tim, XQ tim ph6i, Sieu am: binh thirang.
Theo (Jai: lay mau do n'ong da Thyroglobulin (Tg) va lam x4 hinh c6, toan than.
- Neu: Tg < 2 ng/mL va khong c6 yang nao trong co the bat xa, benh khong tai phat.
- Neu: Tg > 4 ng/mL va c6 vOng bat xa, benh nhan bi tai phat va se dugc dieu tri
bang
- Neu: Tg > 4 ng/mL, khong phat hien dugc vimg bat xa tren xa hinh, se phai
lam sieu am tuyen giap, CT hoac MRI de phat hien u tai phat va dieu tri bang
phAu thuat.
- Trong thdi gian theo dai mai 6-12 thang neu phat hien duce khiu c6 tren lam
sang phai choc but bang kim nho de xem c6 to bao ac tinh hay khong.

Trtrong hyp 11
Ho ten BN: Nguyen V, phai nam, 58t.
Nghe nghiep: K'y su. Dia chi: TP Qui Nhon — Binh Dinh.
Ngay vao vien: 7/11/2012. LY do vao vien: sat can + dau bung.
Benh stir: khoang 1 thang‘tnxac, BN thay dau bung yang thugng vi, con dau kh6ng
lan, chung do dau nhe, kern bunnon va non, bung day hal. BN c6 di kham phong mach
tur, dugc chan doan viem da day va &mg thu6c nhung khong giam. Cach nhap vien 1 tuan,
BN cam thay dau bung Wing thugng vi nhieu ban, dau dai clang kem nuot nghen, sat can
nen xin vao vien.
Tien sir ban than: HUt thu6c la 1/2 goi/ngay, u6ng rugu bia nhieu. Cach day 5 nam bi
viem da day, benh tai di tai lai nhieu lan va da dieu tri nhung khong do. Cach day 3 nam
co XN: HP (+), co dieu tri nhung khong triet de. Khong c6 benh ly ve tim mach, DTD...
Gia dinh• khong co ai mac benh ly gi lien quan.
Tham kham lam sang: mach: 801an/phut, huyet ap:125/70mmHg, nhiet de: 37°3C,
nhip tha: 201an/phlit. T6ng trang chung gay, da xanh xao, niem mac nhat mau, khong
yang mat yang da. SO. thay c6 1 kh6i u yang thugng vi, kich thuac khoang 2,5 x 4 cm,
gioi han fa, be mat u tam lang, mat de chac, kern di dang, dau tang len khi an vao. Khong

289
HOA SINH LAM SANG

so thAy hach e. thuong don, nach va quanh ran. Kh6ng xudt huyet da day — met, khong
tran dich o bung. Gan — lach: khong lan. Cac co quan con lai: khong phat hien benh
Can lam sang:
CTM: HC: 3,2 x 1012/L (3,8-5,4): 1,, Hb: 95 g/L (120-180): 1,; BC: 6,7 x 109/L (5-10).
Sinh hoa: Ure — Cre — Glucose — lipid: binh thiremg. Albumin: 20 g/L (35 — 50 g/1)
1,; HP: (+).
Marker ung buau: CA 19-9: 15.7 U/ml (< 37), CEA: 2.3 ng/ml (< 5), CA 72-4: 11.4
U/ml (< 8.2).
Sieu am bung: co u a 2/3 clued da day, d = 4cm, tham nhigm vach da day + hach e.
bo cong nho (4 hach). Gan — lach — met khong phat hien benh 13'f.
CT scan '6 bung: u da day, d = 4cm. Khong thay tinh trang xam ldn vao cac to chirc
xung quang cua u. Chap da day — to trong c6 can quang: ton thuong tham nhiem cirng 2/3
da day. Nei soi + sinh thiet: u 2/3 &rod da day, kich thuac 4cm, tham nhie'm da day. Vi
the: u dang Neu mo tuyen.
XQ tim - phei: binh thuang.

Truimg htYp 12
Ho ten BN: TrAn Thi L., phai nix, 62t.
Nghe nghiep: nei tra. Dia chi: An Nhcm — Binh Dinh.
Ngay vao vien: 16/01/2013. LST do: phat hien u vi mg bung duai.
Benh sir: each nhap vien 3 thang, BN thdy dau quan bung, dau nhieu yang bung
dual, mat ran, kem di tieu chay phan nhAy mai, xen k'e tao ban nhieu fan. Co khi di cAu
phan den, se locmg khong nhieu nhung nhieu ldn. Khoang 1 tun nay, BN phat hien c6 1
u viing bung duai nen xin vao vien.
Tien sir ban than: Ly, amip (+) each day 3 nom. Cao HA. Kh6ng mac benh 1ST gi dac
biet khac. Gia dinh: khong c6 ai mac benh ly gi lien quan.
Thom kham lam sang: mach: 781An/phirt, Huyet ap:140/80mmHg, nhiet sae: 36,8°C,
nhip the.: 191dn/phitt. BN tinh tao, tiep xuc tot. GAy, da xanh, niem mac nhat nhat. Kham
bung:-bung mem, khong chuemg, di thing theo nhip the.. Sa thAy c6 1 khi u Wing he chau
P, kich thuac khoang 5cm, giai han IA mat de chdc, di deng, an vao dau nhe. Khong so
thay hach e. o bung, thircmg don. Gan — lach: trong giai han binh thirong.
Dai tien phan den, nhAy mai, so luang it. Cac co quan con lai: khong phat hien b'enhlY.
Can lam sang:
CTM: HC: 3,4 x 1012/L (3,8-5,4): Hb: 99 g/L (120-180): BC: 7,4 x 109/L (5-10).

290
 CHU'ONG 8 10. CHI DAU UNG THU' (TUMOR MARKERS)

Phan: Ly amip (+), HC (+++), BC (+).

Sinh h6a: Ure — Cre — Glucose: giefi han binh thuOng. TG: 3,9 mmol/L (1,7-2,29)
T, Cholesterol: 8,2 mmol/L (4-6,7): T. Albumin: 27 g/L (35 — 50 g/1) 1i . Fe2+: 5,1 [anon
(6,6-26)
Marker ung buou: CA 19-9: 305 U/mL (< 37) T, CEA: 31,6 ng/mL (< 5) T, CA 72-4:
7,3 U/mL (< 8,2). Ni
e soi dai true trang — sinh thiet: c6 khi U d = 5cm, nam a dai trang
len gan gOc h6 chau P, gay loet. Kitting thay hach.
Vi the: K Neu mos tuyen typ Liberkhunier, biet hoa trung binh.
Chup khung dai trang co can quang: hinh anh cat cut, khuyet.
Sieu am bung: c6 u a goc dai trang len gait h6 chau P, d = 5cm, khong c6 dich 6
bung. Gan — lach — rut khong phat hien berth 13i.
CT — Scan 6 bung: u dai tang len a h6 chau P, d = 5cm, khi U xam Ian den lap
co'. Khong thay tinh trang xam lan cua u vao cac to chirc xung quanh. XQ tim-phoi:
binh thuong.

Trtrimg hop 13
H9 ten BN: Tran Van A, phai nam, 56t.
Nghe nghiep: ke toan. Dia chi: TP Qui Nhan — Binh Dinh.
Ngay vao vien: 12/02/2013. Ly do: lieu mau.
Benh cach nhap vien 5 thang,,BN thay dau nhirc viing xuang chau — viing hong
— lung vo sau do thay tieu va tieu son, kern buot,khi di tieu, cam thay bang quang
cang sau khi di tieu xong. Gan 10 ngdy nay, BN thay tieu ra mau, so luang it kem ngtred
met men, sut can nen xin vao vien.
Tien sir ban than va gia dinh: khong c6 ai mac benh 1ST gi la.
Tham kham lam sang: mach: 841an/phirt, huyet ap:115/70mmHg, nhi'et dO: 37,2°C,
nhip tha: 221an/philt. T6ng trang trung binh, da niem mac h6ng nhat, tinh tao, tiep xuc tot.
Kham bung: bung mem, khong chtrang, di &Ong theo nhip tha. Gan-lach: trong giai
han binh thuang. An yang ha vi BN cam thay tits va mot tieu. Xuang kitting dau.
Kham true trang bang tay: so thay tuyen tien liet 1 u to, d # 2,5 x 4cm, mat dO
khong &du, cirng chac, gio.i han khong ro. Cac ca quan con lai khong phat hien benh
Can lam sang:
CTM: HC: 3,6 x 1012 /L (3,8-5,4): 1, Hb: 116 g/L (120-180): ,j. BC: 7,4 x 109/L (5-10).
Sinh h6a: Ure-Cre-glucose-lipid: giai han binh thuoug. Albumin: 33 g/L (35-50 g/L)
Marker ung buOu: PSA: 19 ng/ml (4-10 ng/ml): T. fPSA/tPSA = 16%.

291
HOA SINN LAM SANG

Sieu am qua hue trong: u tien liet tuy6n, d = 2,5 x 4cm.

CT scan: kh6i u khu tru 6 1 thity trai cua TLT, gi6i han khong rd, khong thay hach
va khong thay di can cac co quan khac.
GPB: cac tuyen c6 kich thuac nh6 voi 1 lop thuong mo tni, dang nhit, to bao u c6
nhan tron, bao tuong nhat mau va c6 hat. XQ xtrong: birth thuong.

Truro.ng hop 14
Ho ten BN: Nguy6n xuan H, phai nam, 64t.
Nghe nghiep: lai xe. Dia chi: B6ng San— Binh Dinh.
Ngay vao vien: 15/01/2013. L3'T do: giam can + dau bung.
Berth sir: BN thay dau quan bung kern tieu chay, vang mat yang da each day 5
thang. Gan day yang mat yang da tang len, dau bung nhieu han, cam gide barn non va
non, chart an nhieu kern giam can khong rd. BN c6 di kham phong mach to va dirge chan
doan u tuy nen xin vao vien.
Tien sir ban than: viem tuy 2 lan. Khong bi berth DTD, khong mac cac b'enh 1ST ve
tim mach. Hilt thuoc la nhieu: 2 goi/ngay, ung nrou bia nhieu. Gia dinh: song kh6e.
Tham kham lam sang: mach: 781an/phitt, huy& ap: 120/70mmHg, nhiet dO: 37,7°C,
nhip tha: 191an/phitt. Gay, yang mat yang da, met mai, van dau bung nhieu. Kham bung:
bung mem, khong chuang, di Ong theo nhip tha. So Wing thuong vi c6 1 u nho, d = 2cm,
mem, di dOng. Lach - gan trong giai han binh thu6ng. Nhip tim deu ro, khong phat hien
b'enh 1ST.
Ph6i: ri rao phe nang nghe I'd 2 ph6i, kitting c6 ran b'enh 1ST. cac ca quan con lai
khong pith hien benh
Can lam sang:
CTM: HC: 3,2 x 10'2/L (3,8-5,4): 1, Hb: 96 g/L (120-180): J,. BC: 8,4 X 109/L (5-10).
Sinh h6a: glucose: 7,1 mmol/L (4,2-6,6) T. TG: 1,2 mmol/L (1,7-2,29)) I. Choles-
terol: 3,4 mmol/L (4-6,7): 1. Albumin: 29 g/L (35-50 g/1),1,. AST: 37 IU/L (0-40), ALT: 50
U/L (0-45), GGT: 85 U/L (9-69): T. Bili TT: 199 umol/L (< 4,3 umo1/1): T. Bili TP: 246
umol/L (< 17 !Imola): T. Ure-Cre: trong giai han binh thuong. Nu& tieu: Bilirubin (+).
Marker ung btrau: CA 19-9: 199 U/mL (< 37) T, CEA: 4,4 ng/mL (< 5).
Sieu am bung: gian &Tong mat trong gan, 6ng mat chung gian (d # 1,4cm), c6 1
khoi giam am a dau tuy d # 2cm, titi mat cang to, nhu me gan binh thuong. La.& khong
lan. Khong thay hach.

292
 CHU'O'NG 8 • CHI DAU UNG THU' (TUMOR MARKERS)

CT scan: khoi u a diu toy, d # 2cm, giam mat dO va kern tang quang han so vai mo
try xung quanh. Gian 'Ong by va duemg mat, hOi hru TM cira — lach bi khoi u chen ep, chir
mo toy bi teo. XQ =crag: binh thuang.

Truang hop 15
Ho ten BN: Phan Q, phai nam, 59t.
Nghe nghiep: Thq hO. Dia chi: Phil My— Binh Dinh.
Ngay vao vien: 04/02/2013. LY do: ho ra mau + kho tha.
Benh sir: khoang 4 thing nay, BN thay ho nhieu, ho dai ding, ho khan kern dau
floc, BN c6 di kham pi-long mach to va duac chin doan: lao ph6i, dung thuOc nhung
khong do. Cach nhip vien 3 ngay, BN thay ho nhieu hcm, ho ra it mail, kh6 tha, clau noc
tang len nen xin vao vien.
Tien sir ban than: tip xi c nhieu vii bOt di., hay bi viem phOi. Hut thuOc la nhieu:
1,5 goi/ngay. Gia dinh: khong ai mac benh lYT dac biet.
Tham kham lam sang: mach: 771An/phirt, huyet ap: 115/75 mmHg, nhiet dO: 37,2°C,
nhip tha: 281'an/philt. BN hai gay, khong yang mit yang da, da niem mac nhat mau, met
m6i, kh6 tha, ho nhieu, van dau floc. Kham phoi T: ri rao ph'e nang nghe di 2 phoi, khong
nghe ran benh ly. Phi P: c6 HC 3 giam, ro nhat a day phOi, cac khoang lien wan hep,
long ngvc P xep. Khong thay hach thuang don. Kham bung: Bung mem, khong chuang,
di idOng theo nhip tha. Lich - gan trong giai han binh thuang. Nhip tim deu ro, khong
phat hien benh 1Y.
Can lam sang:
CTM: HC: 3,6 x 1012/L (3,8-5,4): 1, Hb: 109 g/L (120-180): BC: 8,9 x 109/L (5-10).
Sinh hoa: glucose-lipid-Ure-Cre: trong giai han binh thuang. Albumin: 30 g/L (35-
50 g/l) ,I,. AST: 47 IU/L (0-40) T, ALT: 87 U/L (0-45) T. Ca2+: 3,2 mmol/L (2,2-2,6) T.
Marker ung bueru: CYFRA 21-1: 34 ng/ml (< 3,2 ng/ml) T. CEA: 5,9 ng/mL 5) T.
XQ: Phi T khong ph& hien benhlY. Phi P: 1 khOi ma, troll deu, ranh giai ro er day
phOi, d # 2,8cm, clang u dac, tham nhi6m phOi, hinh anh xcp phOi, rOn phOi to, gian rOng
trung that, c6 vii hach a phOi.
, CT scan lOng noc: khOi u day phOi P, d # 2,8 cm. U khong xam lin trung that,
phoi T va mach mau. Vai hach a phoi P.
Sinh thiet: carcinoma bieu mo tuyen.

293
HOA SINN LAM SANG

B. CAU HOI TV LUVNG GIA

1. Chon f dfing nhifit: aFP dircrng tinh cao trong:
A. Ung thu gan B. Ung thu Tuy
C. Ung thu dirang tieu hoa D. Tat ca f tren diing
2. Chon f dung nhfit: CEA throng tinh cao trong:
A. Ung thu gan B. Ung thu Tuy
C. Ung thu duang fiat Ma D. Ung thu dai tang
3. Chi dfiu ung thy nao sau day tang cao trong ung thy tuy.:
A. AFP B. CA 15-3
C. CA 19-9 D. CA 125
4. Chi dill ung thu nao sau day tang cao trong ung thu vii:
A. CA 72-4 B. CA 15-3
C. CA 19-9 D. CA 125
5. Chi dfiu ung thy nao sau day tang cao trong ung thu bung trthig:
A. CA 72-4 B. CA 15-3
C. CA 19-9 D. CA 125
6. CM dau ung thu nao sau day tang cao trong ung thu d# day:
A. CA 72-4 B. CA 15-3
C. CA 19-9 D. CA 125
7. Chi dfiu ung thu nao sau day tang cao trong ung thu tuy.:
A. HE4 B. CA 15-3
C. CA 19-9 D. CA 72-4
8. Met se; dot Men ifr gene BRCA1 va BRCA2 lien quan d6n tang nguy ca ung thin
A. Dai tang B. Tuy C. Vu D. Da day
Dkra vao cfic dir lieu sau d chop cau tra loi dung nhit cho cfic cau tir 9 dtn 12:
A. CEA (+) va CA 19-9 (+++) B. CEA (+) va SCC (+)
C. CA19-9 (+++) D. CA72-4 (++) va CA 125 (+++)
9. Ung thu buong trifing:

294
 CHUUNG 8 P■ CHI DAU UNG THU' (TUMOR MARKERS)

10. Ung thin toy:

11. Ung thu Hug quail:

12. Ung Hu dtrimg mat:

13. Ditu nao sau day khong dung khi not vt AFP:
A. Tien luting t& khi half-life < 5 ngdy
B. 1\16ng do AFP tang theo kich thuac khoi u
C. N6ng de AFP tang thoang qua trong viem gan cap, man tinh
D. 5% benh nhan xo. gan cc') AFP tang cao hon 500t,tg/L
14. Dieu nao sau day killing dung khi not vt CA72-4:
A. Theo dCii din tin benh ung thu da day
B. Duang tinh trong ung thu bung trong
C. Ducmg tinh trong ung thu dai true trang
D. Duong tinh trong ung thu tuy
15. Xet nghim nao sau day dirge chi OM de theo dal ung thin vu:
A. CA19-9 B. CA 15-3 C. CEA D. CA 125
16. CA27-29 la chit chi diem trong ung thin
A. Tuy B. VU C. Dueng mat D. Bang quang
17. Chit chi ditm sinh hoc nao sau day tang trong ung thu bang quang:
A. CEA \fa CYFRA 21-1 B. CYFRA 21-1 va BTA
C. SCC va BTA D. CA 15-3 va CYFRA 21-1
18. Ditu nao sau day khong dung:
A. CA 15-3 dUng de -Cam soat ung thu vu
B. CEA tang cao trong ung thu dai truc trang
C. HE4 dung de chin doan ung thu bung trong
D. CA 125 tang cao trong ung thu bung trimg

295
HOA SINH LAM SANG

19. Cac xet nghiem sau day tang cao trong ung thy gan, ngoai trir:
A. FP B. DCP C. AFU D. NSE
20. Chi dill nao sau day tang cao trong btrov bang quang:
A. CEA B. BTA C. AFU D. hCG

296
 Chu'o'ng 9
CAC DICH ca THE, NGHIEM PHAM
VA CAC XET NGHIEM
HOA SINH LAM SANG

MUC TIEU
1. Trinh bay cluvc so. do phian ba mrck trong the.
2. Liet ke nhang clang nghiem pham trong xet nghiem.
3. Trinh bay cheat cac loci xet nghiem hoa sinh trong lam sang, he thong dun vi
SI va cach trinh bay ket qua xet nghiem.
4. Phan tich &coy su. phan ba chuan cUa cac so lieu, tri sa dai chieu va khoang
cloi chieu, cho vi du kern theo.

1. DICH CO' THE VA NGHIEM PHAM

1.1. Sy, phan b6 nul9c va cac dich co' the
,Nu6c chie'm khoang 60% than trong nguai tru6mg thanh, g6m 40% là dich trong to
bao va 20% la dich ngoai to bao. Dich ngodi to bao g6m 15% la dich gian bao va 5% la
huye't Wong. Co su trao d6i nu& throng xuyen gift 3 khu viyc mac. Mat khac c6 su trao
doi nuac Ira nhieu chat khac gift huyet Wang va cac dich co. the (dich nao My, dich khop,
bath huyet, dich tieu hoa, nu& tieu, mo hoi, dich tiet...). Hang ngay c6,khoang,3-10 lit
dich tieu hoa dugc ti6t ra va tai hap thu vao mau; khoang 180 lit nugc tieu ban dau dugc
filet qua c'au than va Ilan 99% duct tai hap thu a 6ng than.

297
HOA SINN LAM SANG

An: 1 lit Ong tieu hoa

U6ng: 1,2 lit) Phan: 0,1 lit

Dich nao tuy A A0110r. 20 Ph6i ho'i they

1,2 lit
Bach huyat Huy'et tuang 5% H2O Da —> m6 hOi
Dich khan H2O Than nt.pac ti4u: 1,2 lit
Dich bat khac
Thanh mao mach
Dich ke 15%

Nuac do Mang t6 bao

oxy hem: 0,3 lit Dich trong to bao 40%
H2O
Mick nhap: 2,5 lit Oxy boa cac chat Nu ac xu6t: 2,5 lit

Hinh 9.1. So' d6 phan b6 wen va ay van chuyen wen trong ca the
Trong mot s6 benh VT c6 the xuat hien dich tan, la dich tham (do mach mau bi 6.c
nghen hoac bi chen ep) hoac dich tiet (do viem).
,
Trong cac dich co. the deu chtra cac chit hoa tan nhat dinh, vi vay khi co nhung roi
loan s‘r van chuyen cac dich ca the, chi mg bi mat qua nhieu ho4c bi it lai, co the se chiu
nhung r6i loan benh VT thir Oat.

1.2. Nghiem phArn

Nghiem pham la vat lieu duce xet nghiem, nghiem pham lay dr benh nhan dugc
goi la benh pham.

1.2.1. Mau
Mau la nghiem pham quan tong va dugc dung nhieu nhdt, mau dong vai tro trung
tam trong qua trinh van chuyen nuac va cac chat hoa tan. DO la not moi cua ca the, ca the
luon luon dam bao sir hang dinh not moi, nglda la cac thong s6 cua mau luon o trang thai on
dinh dOng (dao dOng trong nhitng gio7 han sinh ly nhat Khi cac tri so dm mot thong
so nao do vugt khoi giori han sinh VT thi chfing phan anh nIding trang thai benh ly nao do.
Tir mau to co the thu &rot nhitng nghiem pham khac nhau:
Mau toan phan: lay mau cho vao 'Ong nghiem có chat chong dong (heparin, Na
oxalate, Na flourua..., theo m6i xet nghiem).
Huyet tucmg huyet cau: ly tam mau toan phan có chL chOng dong se thu
dugc huyet Wang (dich o tren) va huyet cau (phan cac duai).

298
 CHUO'NG 9 • CAC DICH CO THE, NGHIEM PHAM VA CAC XET NGHIEM HOA SINH LAM SANG

- Huy& tuang c6 chira fibrinogen. Co the thgc hien cac xet nghiesm hOng cau va
bach cau.
- Huyet thanh: lay mau cho vao 6ng nghi'em khong c6 chat ch6ng gong, cue mau
&rig hinh thanh tit ra huyet thanh. Huy& thanh khac huy& Wong 6 ch6 khong
chira fibrinogen (vi fibrinogen hoa tan bin thanh sgi fibrin khong tan).

Huy6t tuang

Bach cau & Tieu cau

H6rig cau

Hinh 9.2. Mau town phAn va cac thanh phan mau sau ly tam

1.2.2. A/war tieu

Co nhieu co. the duy tri six hang dinh not moi, trong d6 than &mg vai tro rat quan
trong nh6 chirc nang tao thanh nirac tieu tua no. Nu& tieu dirge tao thanh qua 2 giai doan:
Giai doan loco cau than: cac to bao mau va cac dai phan tir (protein, lipoprotein)
dugc gift lai trong mau, nueic va cac chat hoa tan khde co phan tir luting nho
(glucose, acid amin, cac ion...) qua nang Bowmann tao thanh mere tieu ban dau
(dich loc), moi ngay khoang 180 lit.
Giai doan tai hap thu va bai tie't a 6ng than: nu& va cac chat Ilea tan dugc
tai hap thu a 6ng loon gan,quai Henle, Ong lucm xa, Ong gop, tST le hap thu
cua cac chat khac nhau (glucose 100%, nix6c tren 90%, ure 50-60%...). ADH
(antidiuretic hormon — hormon ch6ng lgi niesu) lam tang tai hap thu nuac,
aldosteron lam tang tai hap thu Nhung luting nho acid uric, creatinin
dugc bai tit 6,ong than. Ket qua la dich loc dugc c6 dac thanh nu& tieu,
cuOi ding qua 6ng g6p vao be than.

299
HOA SINH LAM SAN e

Ong luvn gan Ong Itycyn xa

NaCI ChAt dinh du'&ng HCO3-
HCO3 t H 0 f 1 K+ NaCI H 0

t K-

Nhanh len quai

Nhanh xu6ng quai Hanle
Hanle

Ong g6p

•■•4NaCI

Hinh 9.3. Tai hap thu va bai tit cac ch6t a ong then

1.2.3. Cac nghiOm philm khac

Phan, dich nao My, mrac bot, clom, dich but (dich mang phoi, dich c8 chuang, dich
khop, dich vi, dich met, dich tuy, dich runt), to bao va mo, soi nieu, soi met.

1.3. Cac xet nghiem hoa sinh lam sang

Co ban 400 xet nghiem hoa sinh lam sang, CO the chia lam 3 nhom:

1.3.1. Nhom cac xet nghiOm co, ban

1C+' Cl-, glucose, ure, creatinin, acid uric, protein toan phan, albumin, amylase,
bilirubin, ALT, AST, CK, khi matt, lipid...

1.3.2. Nh6m cac xet nghte'm dOc biOt

Hormon (TSH,, T3, T4), protein dec biet (f32-microglobulin, ceruloplasmin ...),
nguyen to vi ltrong (sat, dng, kern ...), vitamin (C, B 1, A, D ...), thu8c dieu tri (digoxin,
theophylin ...), phan tich ADN...

300
 CHU'O'NG 9 Ir. CAC DICH THE,NGHIEM PHAM VA CAC XET NGHIEM H6A SINH LAM SANG

1.3.3. Nhom cac xet nghiOm cap CePU

Dien giai, ure, khi mau, calci, amylase, salycylat, paracetamol, glucose.

1.4. Xet nghiem va ndi thu'c hien cac ky thuet xet nghiem

1.4.1. Pining xet nghiOm chinh

Gem cac trang thiet bi hoan chinh theo trang cap (huyen, tinh, trung trang) c6 the
c6 may phan tich ban tu Ong, may phan tich tu cleng; thu6ng sir dung nhiing be thaw
thir pha scan (kit), nhung c6 nal ding con dung cac phuang phap thu cong (tu pha the
thuec thir).

1.4.2. Xet nghiem ngoai phong xet nghlOm chinh

(dugc lam a cac be phan xet nghiem nho ngay tai benh phong tuong irng).
Xet nghiem danh cho yiec giam kiem (monitoring) nhcing benh nhan bi me lam
(ghep co. quan).
Xet nghiem glucose-huy'et va glucose-ni'eu a benh phong cac benh nhan bi
lieu throng.

1.4.3. XN tai noir cham soc hay xet nghiem tai ch6
Benh ph6ng, cong deng,, phong mach tu... Time :mg la xet nghiem nhanh,
dung giay thir hoc hep, thir, ket qua thu dugc sau yai phut den vai chuc phut, thuan lgi
cho yiec dinh huang chan doan, tam soat, sang loc.

1.5. Nghiern phap

La nhcing thir nghiem deng dugc thuc hien met phAn a benh phong, met phAn
phong xet nghiem. Vi du nghiem phap gay tang glucose-huyet dugc thu hien 6 benh
phong, dieu Mang lay mau benh nhan a tang th6i diem qui dinh roi gai ye ph6ng xet
nghiem dinh luting glucose-huyet.

2. MINH BAY KET QUA XET NGHIEM

Co 2 loai XN:
I Xet nghiem dinh tinh: xac dinh su c6 m'a't dm met chit trong dich co the.
Xet nghiem dinh luting: xac dinh neng do cila met chat nao do trong dich co the.
Nong de la luting chat do trong dung dich. Thuong dung he thong don vi gale
t6 a Neu thi neng de.

301
2.1. HO th6ng dun vi qu6c t6 (SI)
2.1.1. Ti6p cial u ngli, SI
Bang 9.1. Tip dau ngCr SI

101 exa
101' peta
10'2 tetra
10' giga
mega
ki
e
10' deca

micro "
10' nano
pico
10- femto

2.1.2. Cac don vi SI

Cac don vi SI ca ser
Cac dan vi SI dan xu'at (tao thanh tir cac dan vi SI ca so)
Cac dan vi phi

302
CHU'ONG 9 ► CAC DICH CO' THE, NGHIEM PHAM VA CAC XET NGHIEM HOA S1NH LAM SANG

Bang 9.2. Dan vi SI ca so'

Dal lulyng Ten Ky hieu

De' dal met rn
Khoiluong kilogarn kg
Thai gian pay

Cueing d(5' dung dien ampe A

Nhie't d() nhiet d(ing hyc kelvin K
CiParng d() anh sang candela (nen) cd
Luang chat mol mol

Bang 9.3. mOt s6 dun vi SI d5n xuat dan gian

Dien tich met vuong

The tich met 016i n-13

Van t6c met cho giay m/s (m.s-')

Gia t6c met cho giay binh phoning m/s2(m.s-2)

1
N6ng dO (ve luting cha mol cho met kheii mem' (mol.m-3)

N6ng d(i (ve khen Mon kilogam cho met kho'i kg/m3 (kg.m-3

303
HOA SINN LAM SANG

Bang 9.4. MOt s6 dan vi dan xu6t co ton dac biet

DO luting Ten K'hien Bleu thi bin. don vi khac
an So

yr

p swat

Cong

ong suat (long nang hrov

ien tich
3 ien the
3 ien dung /V
ien tro V/A

o roi rn-2.cd.Sr

hiet dO ceic K

oat dO ion hoa becquer

ap thki
Dem vi Ow: 2
Dan vi goc phang: radian (rad)
11 Dan vi goc kh6i: steradian (sr)

304
 CHLICYNG 9 • CAC DICH Ca THE, NGHIEM PHAM VA CAC /YET NGHIEM HOA SINN LAM SANG

2.1.3. Cac don vi ngoai SI

Bang 9.5. Dan vi ngoai SI duvc sCp dung dung vai he th6ng dan vi qu6c t6
mai lucmg Dan vi KST hien Tri s6 tinh bA.ng dan vi SI
60 s
3600 s

Bang 9.6. NhCpng dan vi ngoai SI duiac giCp lai tam th6i va c6 lien quan den
nganh y t6
Ten KST hien Tri se; tinh bing dan vi SI
Angstrom (d0 dai) A 10-1°m (0,1 nm)
Bar (ap slat) bar 100.000 Pa (0,1 Mpa)
Khi quye'n (ap sugt binh atm 101.325 Pa
hu&ng)
Ci 3,3 x 1010 Bq (=3,7 x 101"5-1)
Curie (hoat hit ion hoa)
R 2,58 x 10-4C/kg
ontgen (din tich)
rad, rd 101/kg
ad (nang luting hap thu)

305
HOA SINH LAM SANG

2.1.4. NM:Mg dor vi duvc sir dung trong hem sinh lam sang
2.1.4.1. NhU'ng don vi thuong dung
Kh6i hrong:
Kilogam (kg): kh6i hrong nuOc Ce 4°C
Gam (g): 0,001kg (10-3kg)
Miligam (mg): 0,001g (10-3g)
Microgam (lig): 0,000.001g (10-6g)
Nanogam (ng): 0,000.000.00g (10-9g)
Picogam (pg): 0,000.000.000.00g (10-12g)
Lircmg chat:
Mol (mol): chira 6 x 1023 thgc the hoa hoc (NT, PT, ion).
Milimol (mmol): 10-3 mol
Micromol ()mop: 10-6 mol
Nanomol (nmol): 10-9 mol
The tich:
Met kh6i (m3)
Lit (1 ho4c L): 10-3 m3 = 1 dm3
Mililit (ml, mL). 10-3 L = 1 cm3
Microlit (il, ti,L): 10-6 L = 1 mm3
Thai gian:
Giay (s)
Phitt (min): 60 s
Gier (h): 60 min = 3.600s
Ngay (d): 24 h = 36.400s

306
 CHUGNG 9 ► CAC DICH CG THE, NGHIEM PHAM VA CAC XET NGHIUM HOA SINN LAM SANG

2.1.4.2. Nguyen tu, Itrong, phan tir mol

Bang 9.7. Nguyen tCr luvng (A) cua mot s6 nguyen to thir&ng gap

Nguyen to Ky hieu Nguyen to prang (A)

Nhom . Al 27
Bac Ag 108
Asen As 75
\Tang Au 197
Bari Ba 137
Brom Br 10
Cadmi Cd 112
Calci Ca 40
Carbon C 12
Ceci Ce 140
Clo Cl 35,5
Crom Cr 52
Coban Co 59
Hong Cu 64
Sat Fe 56
Flo F 19
Hydro H 1
Iod 1 127
Kali K 39
Liti Li 7
Magie Mg 24
Mangan Mn 55
Molypden Mo 96
Nita N 14
Natri Na 23
niken Ni 58,7
Oxy O 16
Phospho P 31
Platin Pt 195
Chi Pb 207
Luu huynh S 32
Urani 238
Tungste 184
Ken
Phdn tie luvng M ciia glucose C61- I „06 = 180
1 mol dm ion natri = 23g (ion-gam)
1 mol cua phan to glucose C6H1706 = 180g (phan tir gam)

307
HOA SINH LAM SANG

2.1.4.3. Don vi nong c70

Bang 9.8. Nong do kh6i luvng va n6ng do luting chAt

Niing coo khiti ltnyng Niing di) ltro.ng chAt

Gam/lit g/1 Mol/lit mo1/1
Miligam/lit mg/1 mmol/1
Microgam/lit ttg/1 Micromol/lit um/mol
Nanogam/lit ng/1 NanomoUlit nmo1/1
Chuy'n c of gag cac dan vi njng c10

Nong do khoi luting = Nong do luting chat

X (g/L) x 1/(A hoac M) Y mol/L

NiSng do luting chat = N6ng d() kh6i luting

X (mol/L) x (A ho1c M) Y 9,-/L

Vi du 1: glucose huy6t lg/L:
1/180 = 0,00555 mol/L = 5,55 mmol/L

Vi du 2: calci-huy6t 2,5 mmol/L = 0,0025 mol/L

0,0025 x 40 = 0,100g/L = 100 mg/L
Dteang luting va mili cluvng listing
- Doting luting: (eq)
1 mol
l eq —
dien tich ion

- Mili duong luting:

1 mmol
leq —
diesn tich ion

308
 CHU'O'NG 9 10- CAC DICH CO THE, NGHIEM PHAM VA CAC XET NGHIEM HOA SINH LAM SANG

VI du 3:

DiC,n tich ion

Ion 1 mmol chilra 1 meq chtia
(Wm tri)
Na • (23) 3 mg .23 mg
KJ39) 39 mg 39 mg
Ca.'2 (40 0 mg 2,0 mg
Mg'''. (24 24 mg 12 mg
Chuy'n clai gift' a nang cla ltrong chjt va nang cla mili &rang luvng

NOng dO mmol/L = nOng dO meq/L

X x din tich Y meq/L
NOng dO meq/L = nOng di) mmol/L
X /diOn tich Y mmol/L

Vi du 4: calci-huye't = 4,5 meq/L

4,5 /2 = 2,25 mmol/L
natri-huy6t = 135 mmol/L
135 x 1 = 135 meq/L

2.1.4.4. Dan vi luceng

- LIM luting la luting chit thai ra trong mOt don vi thai gian mmol/s,
nmol/s ho4'c d.
- DO thanh thai (clearance) la the tich huy6t tircmg can cho than thai het mOt chit
nhit dinh trong mOt thoi gian nhit dinh (ml/min ho'k ml/s).
Chu& d6i:

x 0,01667
X ml/min Y ml/s
60

Vi du 5: DO thanh thai cua creatinin = 132 ml/min

hay 132 ml x 0,016667 = 2,2 ml/s
DO thanh thai cua creatinin = 1,2 ml/s
hay 1,2 ml x 60 = 72 ml/min

309
HOA SINN LAM SANG

2.1.4.5. Dan vi enzym

Don vi cu (U): la luang enzym xuc tac stx bin ai 1 i.tmol co. chat trong 1 phut 6.
nhfing di6u kin nhat dinh.
1U = 1 gmol/min
Dan vi Katal (kat) la luang enzym xuc tdc sir bin d6i 1 mol co chat trong 1
gidy o nhttng di6u kin nhdt dinh.
lkat = lmol/s
Dun vi dung trong thkrc t6: microkatat (j_tkat = 10-6 kat) va nanokatat (nkat = 10-9 kat).
Chuy6n de)i

x 16,67
X U/L Y nkat/L
0,06 x
(cimg phucmg phap, ding di6u ki6n)

2.1.4.6. Don vi ap suAt

Dan vi pascal (Pa) thay cho milimet thily ngan (mmHg)

x 7,502
X kPa Y mmHg
0,1333 x

2.1.4.7. Dan vi thAm thAu

Osmol (osM). Dung dich c6 n6ng d6 1 osM la dung dich c6 ap suat tham thdu 22,4
atm. Thuang dung miliosmol (mosM) = 1/1000 osM.
1\16ng d6 thdm thau hay thdm dO (osmolality) n'ong d6 tinh theo osM hay mosM
trong 1 kg nuo.c.
1\16ng dO tham thdu phan -Lir hay thdm dO phan to (osmolarity) n6ng d6 tham than
tinh theo osM hay mosM trong 1 lit dung dich.

310
 CHUO'NG 9 0- CAC DICH CO' THE, NGHIEM PHAM VA CAC XET NGHIEM HOA SINH LAM SANG

2.2. Trinh bay va bielu thi cac kgt qua XN

2.1.1. Yeti chu
Can neu dugc 4 diem theo quy dinh pee th:
0 Ten hay chir viet tat cua he thong dugc phan tich (mau, huyet thanh, nueic
tieu...).
Vi du: matt, huyet thanh, nu& lieu.
0 Ten cua thanh phan dugc dinh luting.
Vi du: ure, glucose.
0 Tri se theo don vi dugc chon, uu lien &mg cac don vi cua he thong SI
Vi du: glucose = 5mmol/L.
0 Khoang hay tri so d6i chiau
Vi du: creatinin = 8,84mmol/L (7,07 — 15,91mmol/L).
2.1.2. Phan phoii chugn cua cac s6 lieu va tri s6 d6i chieu
2.2.2.1. Phan phoi chuAn cua cac s6 lieu (gia tri thu clucec)
Cac de thi.
Xet nghiem n mau tit*, thu dugc n ket qua c6 cac gia tri Wong Ung x (gem x l, x2,
x3,...x.). Tan so la so Ian Op dm met tri so do. So tan slat la tST so giaa tan so va so n.
Vi du: ket qua xet nghi'em natri dia. 20 man huyet thanh.
Xi Tan so (I) Tan suat
130 0,15
135' 0,25
138 0,35
150' 0,25

1,00 100%

, Co the trinh bay cac se lieu bang de thi gap kirk ho4c de thi hinh cot. Nhtmg neu
mau tit* n tang tang thi duemg gap kirk tien toi met duang cong phan phoi xac suat,
duemg cong nay có the la met throng cong phan phoi chuan dm Gauss (hinh chuong up
doi ximg) hocduemg cong phan phoi khong dei xirng.

311
 Tan so

M2
12

10

8
6
4
2
0
161 164 167 170 173 Gia tri

Hinh 9.4. in thi gap khuc

0.35•

0.30.

0.25.

P(r) 0.20

0.15.

0.10.

0.05-

Hinh 9.5. in thi hinh cot

312
CHU'O'NG 9 ► CAC D/CH CU THE, NGH1EM PHAM VA CAC XET NGH1EM HOA S1NH LAM SANG

2.1% 2.1%
0.1% 0.1%

-3a -20 -la tt la la 30

Hinh 9.6. Dua -1g cong phan phoi chAn

)11

Hinh 9.7. apeYng cong phan ph& khong cloi xt:Png (nghiOng)

- Tinh dal lucrng dlac tnrng

Tri so trung binh
x•
i=1 1
3—

313
HOASINH LAM SANG

llech chitin (s): phan anh mix dg phan tan dm cac so lieu, s cang ton thi so
lieu cang phan tan va ngugc lai.
n > 30:

E(X-7)2
S= V

n < hoac = 30:

iEX -
S=
n-1

BiL thi duoi dang do thi:

p-- pa-2•3 p.-1•7 p, p+le µ+2v p+30

• 1 I 1 I I
1 1 6111-81127%40•1 I
I
i1 I
Ii LI--95.4514.---}1 i
1•411--- 9973% ---IpJ

Percent 99.73% 99% 95.45% 95% 90% 80% 6827%

No. of ± o's 3.00 258 200 1.96 1.645 1.28 1.00

Hinh 9.8. Dubmg cong ph5n phoi chAn

314
 CHU'ONG 9 10- CAC DICH CO' THE, NGH1EM PHAM VA CAC XET NGH1EM HOA S1NH LAM SANG

1.0 • 111111111111111111111111M111111111111•111
p=o, 0=0.2,1
p=o, 0 2=1.0,--
p=0, az=
=-2, a z= 05,—
I I

I rAlpill
02 1 1111P41111,
CLO11111EllidiEMPINI
11111MIN1111111111•1111111NIPMEIMMIAMNImnis imilmmilmun
-0 -3 -1 0 1 2 3 4 5
X

Hinh 9.9. Dual-1g cong phan ph6i chu6n

He so bien thien: la dO lech chuan tucmg doi

CoV = = x 100
x
Dual 1%: cac tri sa clang cfeu (khong phan tan)
1% - 5%: cac tri so it clang cleu (it phan tan)
Tren 5%: cac tri so khong clang cleu (phan tan)

2.2.2.2. Cac khai niOm ve d6i chi&

Khi clanh gia hoc xac Binh nhung trang thai b"enh 1Sr, ngued ta phai so sanh hay
cr6i chiL nhang tinh chdt va thong so cua nveri benh \Tod nhang tri so binh thuemg ma
nguefi ta coi la nhitng tieu chuan de so sanh.
- Ca the idol chieu: ca the dirge chon theo nhang tieu chuan xac Binh ve six
khoe (tuOi, gioi, can rang),
Quan the doi. chieu: Om tat ca ca the d6i chiL a mot qudn the.
- Mau ct6i chieu: gam mot so thich hop cac ca the criii chieu &roc chon.
Tri so doi chieu: la mot tri so cila mot d'ac tinh thu clugc do quan sat hoc do
luemg &roc tren mot ca the ciff)i chi6u.

315
FIOA SINN LAM SANG

Phan phi d6i chi6u: la phan phi xac suat cua d4c tinh sinh hoc teen quan th6
doi chieu, dugc xac dinh dua tren nhung tri so thu dugc voi mau doi chieu.
Khoang doi chiLL (khoang binh thireng, sinh la khoang 95% nhang tri
so thu dirge tren met quan th6 d6i chiL (mL d6i chiL). Khoang do dugc
gioi han bai 2 gigi han d6i chi6u.
Vi du: Nit, 20 — 30 tuei, khong ueng thuec ngira thai, khong thira can. O Thanh
phe He Chi Minh. Lay 100 mL tai cac co quan hay 1 se phireng. Dinh hrong glu-
cose-huy& thu dugc 100 tri so. Sau do xac dinh phan phei: phan phi chuan voi trung
binh la 5 mmol/L, de lech chuan la s= 0,28mmol/L.
Tan suat

2.5 2,5

-2s +2s
4,4 5mmol/1 5,56

Hinh 9.10. Khoang doi chi4u cua glucose-huy6t

2.2.2.3. NhCmg tri s6 bOnh

La khi nhung tri se do cao hoac thap bon gioi han d6i chi6u.
Khi xac dinh met thong se sinh hoc nao do tren nhiu benh nhan mac dung met
loai benh, to thu dugc nhung ket qua khac nhau. Sau do lap dirge met se do thi phan
phi xac suat vai tri se trung binh va dO lech chuan Mang 'Mg.
Vi du: calci-huy6t
- Binh thireng: x + 2s = 2,4 + 2. 0,1 = 2,6 mmo1/1
x - 2s = 2,4 - 2. 0,1 = 2,2 mmo1/1
- Benh x + 2s = 2,9 + 2. 0,15 = 3,2 mmo1/1
x - 2s = 2,9 - 2. 0,15 = 2,6 mmo1/1

316
 -

CHLTO'NG 9 ► CAC DICH CO THE, NGHIEM PHAM VA CAC XET NGHIEM HOA SINH LAM SANG

Nhirng tri so doi chi6u Nhivng tri s6 doi chi6u

binh thu'&ng benh 19 tang calci huy6t

Co kha nang am gia CO kha nang chrong gia

Hinh 9.11. NhCrng tri s6 d61 chieu binh thixerng va benh Ijr ciaa calci huyet

Nhu vay có nhimg tri se; benh ly chOng len tri so binh thuemg va nguoc lai. Do do nhcmg
cho chong nhau có kha nang am tinh gia (nhang tri so coi nhu binh thuong nhung thgc ra la
benh 1y) va duang tinh gia (nhu'ng tri so coi nhu benh ly nhtmg thgc ra la binh thuong).
Gioi hgn quy't dinh
Vi du: transaminase
I: Nit, 20 — 30 tuOi. 1,2: glad han doi chiecu.
II: Nix', 20 — 30 tu6i, u6ng thu6c ngira thai. 3,4: gioi han doi chien.
III: Nhom nhang benh nhan bi benh gan. 5,6: giai han phan ph6i.
Giai han quyect dinh:
- Moi tri so thap hon A au loaf trig tang transaminase-huye't.
Moi tri s6 thap hon B a phu nig uo'ng thu'c')c ngita thai au khong phai tang
transaminase-huyet benh
S6 d6i tuc"ng A B

3 2 4 5 6 Hopt dO

Hinh 9.12. GiOi han el& chieu va gieri han quy4t dinh
Phan phoi I va II: ngt_kri khoe manh, III: bOnh ly

317
 A. CAU HOT TU. LUVNG GIA
1. Choi] cau thing:
A. Nirac chi6m khoang 70% tong luang ca the.
B. Khu Argc nu& trong to bao chi6m 40%
C. Nuac trong not mach chi6m 15%
D. Hang ngay có khoang 2,5 lit mac tieu dtrac loc qua cau than.
2. Chou cau dung:
A. Dich tit do nguyen nhan viem nhi6m man tinh tao thanh.
B. Dich tham gap trong cac benhiSr lanh tinh.
C. Dinh Luang cac chat dien giai vai chat ch0ng &Ong la EDTA
D. Huy6t thanh có thanh phan cac chat ging nhu huye't twang.
3. Di&I nao sau day khong dting:
A Phan tit hrang dm glucose la 180
B. N'ong de, cua Na = 140mmol/L = 140meq/L
C.1\16ng di) dm Ca = 4mmol/L = 4meq/L
D. Nguyen dr h.rang dm Kali = 39.
4. Chton cau dung:
A. Dan vi SI co sac Nr' d0 dai la centimet (cm)
B. Dan vi SI ca so. v . khOi ltrang la kilogram (kg)
C. Dan vi SI co. so. Ar' luting chat la milimol (mmol)
D. Dan vi SI ca so v'e thOi gian la gier (h).
5. Chou cau dung:
A. Transaminase thuCic nhom cac xet nghiem cap ciru.
B. Ca2+ huyat thu0c nhom cac xet nghiem dac biet.
C. Nghiem phap la nhang xet nghiem dirac diing a tam soat benh va nguy ca
bi benh.
D. Trong xet nghiem tai ch8 ngueri to thiremg dung cac test nhanh.

318
 CHLICYNG 9 ► CAC ()ICH CO' THE, NGHIEM PHAM VA CAC XET NGHIEM HOA SINN LAM SANG

B. CAU HO1 NGHIEN CITU

1. Xet nghiem glucose huy6t 20 lan ten mot benh nhan c6 k6t qua lan hrot la 85, 86, 85,
88, 90, 91, 86, 90, 91, 90, 88, 87, 93, 84, 94, 93, 86, 91, 92, 90 (mg%). Hay tinh tri s6
trung binh, dO lech chuan va he s6 bin thien. Bi6u thi khoang d6i chi6u nong dO kh6i
luting va nong d6 higng chat.
1. M6t ngiroi can O'ng 70kg, luting nu& c6 trong dich ke va huy6t Wang la bao nhieu?
Neu tre em can Ong 7kg thi luting nuot e huyet tircmg nho, bang hay lan hon 1/10
cua ngued can Ong 70kg.
2. MOt pheng xet nghiem tra led ke't qua xet nghiem glucose huy6t la 200mg%. Bi6u thi
ket qua do theo nong d6 luting chat va cho bi6t k6t qua nay binh thuong hay benh
5. Pha 54g glucose vao mrac vita du 1 lit. Hay bi6u thi nong d6 glucose do theo nong dO
kh6i luting, nong do luting chat va tham do.
6. Pha 2,22g calci clorua (CaC12) vao nuac vira du 1 lit. Tinh nong do tham thAu cua
dung dich nay. Bieu thi nong dO dm ion calci theo nong dO hryng chat va mili
duong h.rcmg.

319
 Chu'o'ng 10
XET NGHIEM TIN CAY VA KIEM TRA
CHAT XET NGHIEM

MUC TIEU
1.Phan tich cluvc cdc yeu to anh htrang den cl0 chinh xac cita mot xet nghiem.
2. Phan tich duvr cdc yeu to anh hudwg c on ctd xac thyr aid mot xet nghiem.

1. XET NGHIEM TIN CA Y

1.1. Di) chinh xac (dc) tin hay do 10)
MCA mau thir, vi du buy& thanh cua mot benh nhan &roc xac dinh mot thong so
(throng huyet) lap di lap lai nhieu lan (n lan, thuemg la 20 - 30 lan). Dang le, chi c6 mot
ket qua nhung thuc to bao gi6 ding thu dirge nhi'eu ket qua khac nhau (x1 , x2, x3,...x.) tir
do to tinh /roc tri so trung binh x va d6 loch chuan s. Phurang phap xet nghiem dtroc goi
la chinh xac khi nhang tri s6 thu dirgc phan tan it so voi tri s6 trung binh. Vi vay dO loch
chuan phan anh dO chinh xac hay dO tin hay d6 lap lai. DO loch chuan con goi la sai so
bat ng6 hay sai so Wang doi (kong tranh &roc khi lam xet nghiem, do cac nguyen nhan
bdt ng6 khi lam thao tac). DO loch chuan (sai s6 bat ng6) cang be thi (16 lap lai cang cao.
DO chinh xac cao
9•

5 DO thi vai gia tri s nho

— DO thi vbi gia tri s Ibn
4

3
DO chinh xac th6p
2

00 2 4 s18 s210 12

Hinh 10.1. flo l'Och chuan 1 (s1) phan anh do chinh xac cang be do tin cang
cao va ngucyc lai
321
HOA SINH LAM SANG

Thuaing dung de Lech chuan Wong d6i, tirc he s6 bien thien (HSBT), vi no giup
dugc ta thay re han su phan tan hay dao deng cac tri se.
Vi du: do chieu dai cila 1 cay g6 lap di lap lai nhieu fan thu dugc nhieu ket qua khac
nhau va tinh dugc tri se x trung binh la 5m, s = 1mm. Vay HSBT: 0,002%.
Neu do met chieu dai khac, vi du 5mm vgi s ding = lmm thi HSBT = 20%.
LAn do truerc chinh xac hem rat nhieu so vai ran do sau. Doi voi da s6 cac xet nghiem
c6 the chap nhan.HSBT duai hoac bang 5% (cholesterol, creatinin, bilirubin, enzym...).

99.7% between *384.

95.4% between a s.d.

I _66 3% between sl s.d.

-3 .2 +2 43
s d. s.d s.d. s.d. s.d

Hinh 10.2. Duang cong ph5n phi chu5n

1.2. DO xac thvc (do diing)

Met xet nghiem dugc coi la dung khi cac tri s6 thu dugc xap xi tri s6 thuc. Xet
nghiem lap lai n lAn met chat teen met mdu thir ma ta biet tnrac neng de chat do (dung
dich matt va huyet thanh mdu) ta tinh dugc tri s6 trung binh x va de Lech chuan s (sai se
bat ng6). Tri s6 trung binh x cang xa tri so thuc thi xet nghiem cang khong dung. Hieu
so giaa tri se thuc va x la sai s6 he thong, hay sai so tuyet doi, no phan anh de dung cila
phuong phap xet nghiem.

322
 CHU'O'NG 10 lo• XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

4.5
A Sai s6 h0 thong
4

3.5

2.5

1.5

0.5 Tri
M/ s6
0
Lis thvc
0 0.2 0.4 0.6 0.8 1 1.2 1.4

Hinh 10.3. Sai s6 he thong (d=M-R) phan anh do dOng

Sai s6 he th6ng I d l= M-
Sai s6 he th6ng d = M —7(

CO the bleu thi sai s6 he th6ng theo ti le % nhu. sau:

d
D %— x100
M

D6i voi da s6 cac xet nghiem to chap nhan D% bang hoac duoi 5%.

2. DAM BAO CHAT LIPO'NG XET NGHIEM

Hinh 10.4. Cac trong qui trinh xet nghiem

323
HOA SINH LAM SANG

2.1. Lay mau

2.1.1. Chun bi bOnh nhan
Tru.ac khi benh nhan (BN) c161 phong xet nghlem
- Nhin doi tnthc,10 (trix nhung chi dinh dac
- Khong but thuoc la, uong ruou, cafe tn.x6c 10 gia.
- Ngirng cac hinh thirc tap luy'e'n threw 24-48 giar.
- Quy dinh gio• lay mau: 7gi6.
- De lam cac gia tri doi chieu, can km y them cac di6m sau:
+ Ngii it nhAt 7gi6 trong dem.
+ Khong dung bat cir thu6c gi.
Khi BN ctjn phong xet nghi'em
Tiep don, h6i ten tiled, giai thich cho BN yen tam.
Cap ma s6 cho moi Nnh nhan, nhap ma xet ngh*n, neu tn.rong hop cap elm
can &roc uu tien lam truck.
To th6: to th6 ng6i.
Nghi 15 phut tnxac khi lay mau.
Dui tay khi lay mau.
Bang 10.1. Nong d6 cac chgt thay d6i trong ngay

Ten XN Th?ri diem cao nhit Thai diem dull) nhgt

trong ngeiy (Sib) trong ngay (gib')
ACTH 5-10 0-4
Cortisol 5-8 21-3
20-2 7-13

Prolactin 5-7 10-12

Aldosteron 2-4 12-4

Hemoglobin 6-18 22-24

Natri 4-6 ta-16

kali 4-16 23-1

2.1.2. Vi tri lay mau

La)) mau tinh mach: tinh mach khufm, mu ban tay, mu ban chan.
Luu y khi ciat garo:
- Choc kim xong, ma gag) ngay.

324
 CHU'O'NG 10 110. XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

- Thai gian tir khi garo den chac kim: <2 philt.
- Tranh lam co ca hay xoa bap truac lay mau.
- Nen lay trgc tiep vao Ong nghiem.
Thai gian buec garo: thirang buec garo a vi tri lay mau tinh mach, six CO mau trong
thai gian 3 phut sau khi buec gar() cao han so vai thai diem 1 phut. Tai thai diem 3 phut,
six it dong mau lam tang six phan huST yem khi glucose mau va lam giam pH mau ding six
tich to cua latat. •
Hien Wang thieu oxy clan den giai phong bao. Co six tang nOng de ion Ca
va Mg a mau trong thai gian buesc gar6. Tot nhat la thao gar6 ngay sau khi kim da vao
tinh mach.

Hinh 10.5. Lay mau bOnh pharn

109( ALT

2
% they 661
0

-2

-4

Hinh 10.6. N6ng d6 cac ch6t thay doi tru,6,c va sau khi dat gar6

325
HOA SINH LAM SANG

Lay mau mao mach: thithng ap dung cho tre em, xet nghiem lam nhanh (tim KST
sot ret hay tim au trimg giun chi)
Vi tri thy mau:
- Dai tai
Hai ben dau ng6n tay 3,4 (nguoi 16n).
Got chan hay dau ngon chan cai (tre em <1 tu6i).
Lay mau mao mach (dai tai, dau ng6n tay, ngOn chan, hoc o 2 phia ciia gan ban
chan) khi can mot the tich nho mau o tre so sinh va tre em, de tranh sai so do su hod
bang khi lay mau mao mach thi phai dam bao cho mau chdy to do, khong 14n b6p vi
tri lay mau.
Lay mau dOng mach: de do khi trong mau
Yeu cau:
- Lam yen tam BN.
- Tieu chuan hoa vi tri lay mau (dOng mach quay ho4c dOng mach
- Nen phan tich mau ngay trong yang 5 phut.

2.1.3. Chualn bi dung cc, thy mau

Chon dung cu ldy mau phi" hop.
, Lay mau tinh mach: b0 mau c6 kim eing chan kh6ng sao cho mau vac)
thing ong.
Lay mau mao mach: dung cu c6 sin (lancet).
Lay mau dOng mach: dung cu chuyen biet, co phAn kim ya tube gin li&t.
Du6ng kinh, d0 dai va d6 vat dm kim dirge chuan hoa.

Hinh 10.7. M6t s6 dung cu ray mau

326
 CHUO'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

2.1.4. Dung dich sat khugn khi thy mau

Cac loai dung dich sat khuan
- Acol iodin 1% ho4c 2%.
- Dung dich Povidin-Iodin 10% (betadin).
- Con 70°C.
Cach sat tang
- Sat trung nhieu tan, theo met chieu.

2.1.5. Chat chOng clang

Nguy ca chit ch6ng &mg can thiep vao k'et qua dm xet nghiem: anh huong true
tiep, gian tiep, anh Inremg len cac phan img trung gian cua xet nghiem.
Chon chit ch6ng dong phit hop timg loai xet nghiem:
Neng dO chit ch6ng Tang: da duoc xac dinh tn.rac, c6 six tucmg irng gitla chit ch6ng
&Ong va lugng mall lay (quy dinh rO giai han the tich mau can lay).
Lay mau cho nhting xet nghiem d:ac biet: xet nghiem hoa sinh, xet nghiem
huyet hoc...

Hinh 10.8. Cac loei tube ia'y mau

327
HOA SINH LAM SANG

Tube chiet tich huy6t thanh (nip do):

Dugc sir dung cho h6a sinh lam sang va mien dich hoc.
Chira cac hat silica micronized.
Ngan than su trao dOi chat gitra cac to bao mau va huye't thanh.
Gifr cac thanh phan hoa hoc dm huy'L thanh kh6ng thay dOi trong then giandai.
Khong china chat khang &Ong.
Cho mau vao tube day nap, trOn 'Ong nghiem len xuOng nhe nhang nhi'eu lan:
+ Mang luai fibrin-te bao nhanh chong bao phu cac hat silicamicronised tao
thanh cuc mau 'Jong.
+ Huyet thanh (serum) dugc tach rat nhanh trong vai phut sau khi lay mau
thay vi phai chg tin trinh dong mau binh thueng (15 — 30 phut).
+ Sau khi ly tam, cac hat silica micronised ngan cach rieng biet: huyet thanh
phia ten va cuc mau &mg a phia duai.

328
 CHUO'NG 10 ► XET NGHIEM TIN CA Y VA KIEM TRA CHAT XET NGHIEM

Tube chOng thing heparin (nip den):

Nguon gee:
- Dugc Mac Lean va Howell tim ra nam 1916.
- Dugc sir dung Ian dAu tien vao nam 1924.
- Co nhieu o gan nen dugc dat ten la heparin.
Cau truc:
- Kh6ng phai la mgt clan chat ma la mgt anion mucopolysaccharid hoac glycosami-
noglycan.
Trong lugng phan tin khoang 17.000 dalton.
- Trong cau tine phan tin c6 nhom sulfat va nh6m carbocylic.
Ca the tac dung:
- Tao phirc voi antithrombin III (ATIII): thiic day rat manh phan img antithrom-
bin-thrombin va ca phan irng antithrombin voi cac yeu to ke ten gap 1.000 lan so
voi khi kh6ng c6 mat heparin. ,
Nhom sulfat can thiet cho sirgan antithrombin III voi thrombin: nhey tich nhieu
dien am do china nhieu ggc SO4, nen heparin lam thay dgi hinh dang cna
thrombin va prothrombin.
- tao phirc voi antithrombin.
- Duni dung cac mu& nhu amon, Li, Na, K.

329
HOA SIKH LAM SANG

- Dugc sir dung theo tST l' 25U/ml mau, hay 0,01- 0,1 ml heparin/ml mau.
- Thithmg ching trong xet nghiem h6a sinh.
- Kh6ng thich hop cho xet nghiem huyet hoc vi lam thay d6i hinh thai to bao.

Tube chum sodium citrate: (C6H5Na 307) (xanh la cay)

lad, 2m1, 3m1, 4m1, Sat

K6t hop voi Ca' tao Calcium citrate: Ca3(C6H507)2 lam bat hoat calcium ngan
can con duerng &fig mau.
a
Hieu 1mg nay c6 the clang da'o ngugc bang each b6 sung calcium vao mau.
Ming trong xet nghiem khao sat qua trinh dong cam mau.
Khong ching trong xet nghiem h6a sinh:
• Giam gia tao ion Ca'
• Tang gia tao ion Na+
• ffc the ALP, ALT
• Anh hating ket qua dinh luting phosphat.

3.30
 17.

CHU'O'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

Ethylene diamin tetraacetic acid: (EDTA) (Xanh throng ho4c tim)

a
- La mOt acid amin thong dung co lap ion kim loaf c6 h6a tri II va III.
- EDTA ket hop vai kim loci bad 4 nhom carboxylat Ira 2 nhom amin. Tao phirc
dac bit manh lied 4 nhom Mn(II), Cu(II), va Co(III).
- Tube EDTA thirong dung trong cac phong xet nghi@n y khoa la EDTA-K2 hay
EDTA-K3 thtramg clang trong xet nghiOm huye't hoc:
• ado ton hinh clang va khOi firong cua t6,bao mau trong mOt then gian dai.
• Trong mOt so it tnrong hop, sir giam tieu cau gia (pseudothrombopenia) cam
*fig bari EDTA c6 the xay ra.
• Co the kim tra lai bang mau khang (long sodium citrat.
• Khong dung trong xet nghiOm din giai 6:
- EDTA tao phirc vai Ca2+ va Fe 2+: lam k6t qua Ca" va Fe' trong mau giam gia tao
Tube EDTA-K2 \TA. EDTA-K3 chfra K±: lam ice't qua trong mau tang gia. tao.

331
 - -

HOA SINH LAM SANG

Sodium fluoride-kali oxalat: (NaF)

a
- Dung dinh luting glucose mau, lactat mau.
- Dugc sir dung theo tST le 2,5 mg sodium fluoride + 2.0 mg kali oxalat/ml mau.
- Mau sau khi rat ra khoi ca th& n6ng d6 glucose moi gi6 giam tit 5% - 7% o d6i
tugng kh6e manh (hay 0,56 mmol /1 a 25°C) va 24% a tre sa sinh.
Kali oxalat cheing &mg mau (ca ch6 twang to Na citrat).
Fluoride irc the men enolase trong chu trinh duang phan, bao quan luting glucose
trong mau on dinh den 48 gi6. Tuy nhien ne'su tien hanh dinh luting glucose ngay
trong yang 30 phirt thi khong can sir dung tube NaF.
Khong clang de dinh luting xet nghiem dien giai do:
+ Lam ket qua K±, Na+ trong matt tang gia tao.
+ Lam ket qua. Ca2+ trong mau giam gia tao.

2.5.6. Lgy bOnh phgm khac

2.5.6.1. Cach lay nu'&c tieu
Nu& tieu bat 1cST: bu6i sang ngil day, cho xet nghiem dinh tinh.
Nugc tieu 24 gi6: xet nghiem dinh *mg.
Khi phan tich nuac tieu can phai chu y:
Co mot sir khac nhau r6 rest trong ngay ve su bai tit cua mot s6 chat, vi du nuoc
tieu phai dirge xir 1ST truot de on dinh cac catecholamin va can phai lay mau tat
cd,nuerc tieu bai tit trong th6i gian quy dinh.
De xac dinh calci, toan b6 luting nu& tieu trong 24 gi6 phai dugc acid boa va
duvc dun nong.

332
 CHU'O'NG 10 ► XET NGHIFM TIN CAY VA KIEM TRA CHAT XET NGHIEM

2.5.6.2. Cach lay dich nao teiy

Do bac si lam sang holac kyi thuat vien chuyen nghi0 thy.
Yeu can:
Ong 1 (vai giot au), cing 2 (5-7m1).
Danh gia mau sac dich tido tuy trtrac khi cho lam cac xet
Dich nao tuSr dirge lay Mau de phan tich hod sinh lam sang phai dirge xir ly vai
EDTA de ngan ngira sir hinh thanh cuc &mg fibrin, tranh cho vi& lam sai lac so
Wang t6 bao dem dirge.

2.5.7. X& ly nhanh, bao quart va van chuyen bOnh phgm

2.5.7.1. Xer ly nhanh
Di6u kin cam tay ngay sau khi ldy mau: n6u c6 chang Tong can xa.c dinh thai gian,
cach lac Win de tranh bi slang —> Can c6 may lac dr.
DiL kien tach huy& thanh (huy& Wong):
Tach huyet thanh: can ton trong cac di6u kien Tong mau: sau khi cuc mau da co
Tach huy& tucmg: xac Binh thai gian tip xuc tai da gift mau va chat chang
Tong, thai gian, van toc, thai gian ly tam.
Huy& thanh: huy6t thanh thu dirgc bang each a mail Tong to nhien trong khoang
thai gian dr 30 phut an 1 gia, ly tam at khoang 3.000 yang/phut trong 10 phin, phan dich
not (supernatant) phia tren la huy& thanh.
Huy& twang: huy& Wong thu dirge khi loaf ion Ca2+ trong mau bang each them vao
mau chat chang (long la cac chat tao phirc (chelators) a tao phirc vai ion Ca2+ nhu EDTA,
citrat, oxalat hoc heparin.
EDTA-K2 va EDTA-K3 vai nang dO 1,5-2 mg/ml man clugc sir dung cho cac
)(et nghi&n huy& hoc thong thirang.
Heparin &raj dang cac muai nhu amon, Li, Na, K duot sir dung theo t-ST le 25U/ml
mau, hay 0,01-0,1 ml heparin/ml mau.
Fluoride (mu6i Na) &roc sir dung vai nal-1g dO 2 mg/ml mau. Fluoride c6 tac dung
can tra su dong mau va s‘r &zaftig phan (glycolysis), nen thirang dirge sir dung de dinh
luting glucose mau;
Dung dich citrat Na) nOng dO 3,8% hoc 0,11 mol/L dirge sir dung cho cac
xet nghi&ri Tong mau vai tST le 1 the tich Na citrate va 9 th6 tich man toan phan ho4c dirge
sir dung de Lang hong cat' vai tST le 1 phan Na citrat va 4 th6 tich mau toan phan;
Kali oxalat it khi &roc sir dung chang Tong mau a thy huy& twang.
Sau khi chang dong, ly tam khoang 3.000 yang/phut trong 10 phut, dich not phia
tren thu duce la huy& twang. Su khac nhau giita huy6t thanh va huy& twang finding

33 3
HOA SINN LAM SANG

chi dia.)/ trong su xac dinh IC-, phosphate vo co., lactat dehydrogenase (LDH) va dien di
fibrinogen.
cac benh nhan bi chimg tang tieu cau (thrombocytosis), gia tri lieu cau vugt tren
800.000/4, viec dinh lucmg khong the thuc hien dugc trong huyet thanh, can phai sir
dung thay the bang huyet tucmg chong &Ong vai heparin.
Ccich lay mail mau toan phcin
Mau toan phan c6 the thu dugc bang each sir dung cac chat ch6ng (long nhu dal neu
ten (khong ly tam). M6t so xet nghiem doi hoi sir dung cac chat chong dong khac nhau,
chang han:,
Lay mau mau de dinh lucmg glucose mau: vi t6c d6 throng phan (glycolysis) la
khoang 7% m6i gio nen can phai them mot chat *c the qua trinh duerng phan,
nhu NaF (sodium fluoride) ho4c iodoacetat vao mau mau tnrac khi xac dinh
n6ng dO glucose mau.
Lay mau mau de xet nghiem huyet hoc: phan lem cac phan tich ve huyet hoc,
nguoi to thuemg s* dung mau tinh mach ch6ng citing bang EDTA. Trong tru6ng
hop riag biet, su giam tieu cau gia (pseudothrombopenia) cam irng bed EDTA
c6 the xay ra,, mlac du diet' nay khong cO nghia lam sang. Vic sir dung mau
chong dong bang citrat se lam s6 luong tieu cau tro ve binh thuemg.
Lay man mau de xet nghiem (long mau: trong cac xet nghiem &rig mau, huyet
tuung ch6ng dong bang citrat dugc sir dung cho cac muc dich phan tich. Can
phai trOn dung dich.Na citrat vao mau chinh xac theo tST le la 1 the tich Na citrat
3,8% va 9 the tich mau toan phan.
Chi' y, mau ch6ng dong bang hop chat EDTA ho4c axalat khong sir dung dugc
cho cac xet nghiem v8 thing mau. Phai loaf b6 cac mau mau bi tan huyet hoc
bat dau &Ong mau.

2.5.7.2. Bao guar) bOnh phAtn

Nhiet dO: nhiet dO phong, to lanh, &Ong lanh.
Th6i gian bdo quan: thu6ng di kem nhiet dO.
Chat bao quail thich hop tirng loci benh pham va then gian bao
Dieu kien lam nOng lai benh pham tai nhiet dO lam phan img (nhiet dO phong,
dimg n6i each thay).
Bao quan huyet thanh va huyet tucmg: tay thin gian can thiet ma chon nhiet dO
thich hop.
- <2 gib.: nhiet dO phong.
- 2-48 gier: 4°C.
- >48 gier: (long lanh.
Th6i gian va nhiet dO cO anh huang ket qua xet nghiem.

334
 CHUCYNG 10 Po. XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

❑ Coch bao quan va van chuyen cac mau xet nghiem:

Viec ly tam thuong dugc thuc hien trong khoang 1 gio sau khi mau duoc thu
loam.
Neu cac mau dugc glri di, chi dirge sir dung huyet thanh hoac huyet tuong, trir
tnrong hop that dac biOt, mau toan phan mod dugc van chuyen di xa de phan tich.
- Vi vay, trong moi loci xet nghiem can phai c6 each bao quan khac nhau.
Mau bOnh pham We'd: thed gian tir luc lay mau cIL khi lam xet nghiOm 5 4 giey.
Bao quan cac enzym
a
Cac mau huye't tuong sir dung do hoat do enzym not chung, thuong c6 the
bao quail 6. 4 °C c/L 5 ngdy ma hoat de enzym khang giam qua. 10%.
Rieng d8i \Ted LDH, khang bao quan trong to lanh vi hoat do dm no giam khi
cac isoenzym LDH4 va LDHS dm no khang on dinh trong dieu kin lanh.
- Con ACP chi on dinh khi mau huy& Wang dugc acid hod.
Bao quan cac ca Ciljt
- Cac chat chuy6n hod trong huye't tuong thu mg on dinh 6. 4 °C trong 6,ngay ma
nong dO khOng c6 su thay doi clang ke. Rieng d6i ved triglycerid c6 the bi giam
do bi lipase thus' phan. Tuy nhien, nong do nay khang thay ded n'L phuong phap
phan tich qua glycerol toan phan.
- Neu su xac dinh dua tren phan irng Jaffe thi bao quan nhiOt do phong c6 th6
lam giamnong de cua phosphat, acid uric va creatinin.
- Bilirubin bi pha huY. khi bi anh sang chieu vao trong qua trinh bao
Glucose se chi dugc bao quan sau khi tach protein Ichoi mau mau hoac them
chat On dinh.
Bao quan cac protein, cac khang nguyen va khang the
- Cac protein, cac khang nguyen va khang the throe bac) quan et 4°C trong 1 tan.
Bao quan cac hormon va clau an ung thu.
Cac hormon steroid tuong d6i bL, c6 the bao quail o nhiOt de phOng (25°C)
trong 3 ngdy; cac dk an ung thu ciing c6 the bao quan nhu very.
Cac hormon peptid, clac bit la cac hormon khong ben la ACTH, renin, insulin,
GH va calcitonin muon bao quail qua 1 ngdy phai de vao to lanh sau.
Bao quan mau et xet nghiem cac chat clang mau
- Huye't Wang ngheo tiL cau sir dung de xac dinh tiled gian prothrombin khang
dugc de qua 8 gib.. ,
- Hoat de cac chat &Ong mau phai &roc xac dinh trong khoang 3 giey, neu
qua theyi han tren, huy6t tuong phai dugc bao quail & 4°C.
Bao quan mau lam tang phan tich mau
- ML mau toan phan ch8ng dung bang EDTA chi dugc sir dung clued 24 gief.

335
HOA SINN LAM SANG

Bao quan mau de phan tich hinh thai to bac. mau

- Sg dan mau ten phien kinh chi dirge thixc hien trong yang 5 gig sau khi lay mau.
Neu sir dung mau de phan tich cac thanh phan cua mau, mau mau dirge sir dung
khong qua 8 gig.
Bao quan mau trong mot then gian dai
- Neu muen bao quan benh pham trong tiled gian dai hcm thin gian neu tren, benh
pham can dirge bao quail a nhiet de thap han -20°C.
- Khi can sir dung, mau can dirgc tan deng met each tir tir a 4-8°C qua met dem
hoac trong met be dieu nhiet có lac.
- Tuy nhien, viec deng bang va tan Tong khong nen l'a'p di, 10 lai.
Bao quan nzroc tieu cue xet nghiem can nzthc tieu
- Can mac tieu phai dirge danh gia trong khoang 2 den 3 gia.
Khong dixgc bao quan mAu nage tieu trong to lanh hoac Tong bang vi dieu hen
lanh co the gay ket tua muei.
Bao quan dich nao tuf)
- Viec dem cac to bao trong dich tido tuy phai dirge thgc hien trong vong 1 gia.
Bao quan mau cid do khi mau va thang being acid-base
Cach van chuyen cac mAu xet nghiem
chuyen benh pham not nay sang not khac trong nuac hoac ra quOc te, can
cn a

bao quan benh ph'Am trong phich da. kho.

Noi Chung, six thay dai hoat de enzym va neng de cac chAt chuyen hod khong
qua ± 10% trong khoang 2 ngay, neu nhiet de bao quan mAu duai 25°C.
Anh inrang cua tinh trang mAu den ket qua xet nghiem
Mau mau trong dieu kien nhAt dinh ce the anh hirang den ket qua dm met se
xet nghiem:
Su tan mau.
Viec xac dinh Mg2+ hoac LDH khong the thgc hien dirge ngay ca khi huyet
thanh chi bi tan mau rat it.
Six tan mau rei rang cling anh hirong den cac xet nghiem khac.
Neu thAy mau bi tan mau, can loai be mau mau Ay va phai lAy ngay met mau
mau mai de thay the.
Bilirubin mau
Cac neng do bilirubin tren 5 mg/dl (861.tmol/L) anh hirang den su xac dinh acid
uric (phurcmg phap PAP).
Cac n'ong de bilirubin tren 10 mg/di (170 iumol/L) anh hirong den sir xac dinh
triglycerid (theo plurcmg phap GPO-PAP) va six xac dinh creatinin (plurcmg
phap Jaffe va PAP).

336
 CHUO'NG 10 0, XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

- Phucmg phap xac dinh creatinin mai khong bi anh hung cua bilirubin ngay ca
khi n6ng d6 bilirubin len den 25 mg/dl (430 gmol/L).
Sly tang lipid mau
- Lipid cao trong mau ca the can trey viec do cac chat bang phuang phap do quang.
Trong truemg hop nay can loai b6 cac lipoprotein trong huyet Wang bang each
sir dung Freon.
Bao quan mirk ti&t
Cac th6ng so" nu& tieu deu chiu 'drib huang cua chat bdo (man, tiled gian va nhiet do.
Rio quail DNT
Thy thu6c thai gian can bao quan
- <1 gia: khong can clang lanh
- <3 gio.: 4°C, khong can them chit bao quan
- >3 gia: ly tam loai TB, lam lanh -70°C

Bang 10.2. Thai gian fru, mau

Ten xet nghiem Thai gian on dinh o nhietd6

4°C Dong lanh
MEM am
4111111 -gay
rh(lreTrol "1"11111111111111=5 rifTwr nam
Triglycerid 111111
Glucose 1.11.1111110111411
-20°C < 1 nam

Bang 10.3. Cac ch6t ID60 guar) nlyo'c tieu

atilt bao quan Cac thanh phAn on dinh

Thymol(5m1 thymol 0%/psup cac
ME W 10 mmol/L N
of rum carbonat 2g/L NT
s
111MEMPIPTIME _
,orp nn uro Toen
/25m

337
HOA SINN LAM SANG

2.2. Cac giai loan xet nghiem

2.2.1. Ltra chon "Fang phap xet nghiOm
Throng khoa chiu trach nhiem, Giant d6c chuyen mon ky duyet — tinh chdt phap 1ST.
KS''T thuat xet nghiem có day du cac quy dinh sau:
- Ten phucmg phap xet nghiem.
Cach tien harsh xet nghiem.
- nghia lam sang dm xet nghiem.
- Nhang gia tri quy chieu.
Nguyen tac cua phucmg phap xet nghiem.
Chit thich.
- Benh phdm nao dugc lay a lam loai xet nghiem
Tai lieu tham khao
- Dung cu va thuoc thin.
Tieu chudn hoa cac dung cu va may moc (can, may do quang, dung cu gong do...)
thuoc thir, cac k'y thuat xet nghiem cu Nhcrng sai so se phat sinh neu dung cu, may
moc, thuOc thin khong tot, kST thuat vien thao tac sai...

2.2.2. Con ngutei

Phong xet nghiem la met ekip lam viec bao can be quan 1y, bac si lam sang,
can be ky thuat, can be van thu...
Yeu cau dOi vai moi ngued tong phong xet nghiem
1:1 Xac dinh vai tro ban than
Hieu rO nhiem vu va mix tieu
HiL va lam tron ven, day du theo quail 1S'r chat luting
Phai dugc dao tao lai lien tuc.
Moi quan he ngoai phong xet nghiem: can be quan 1y' benh vien, bac si lam sang,
dieu du'ang, benh vien khac, phong xet nghiem khac de cut chit luting cao hon.

2.2.3. BiOn phap an toan

Xay dung bien phap.
Huan luyen thirc hien.
- Phan cong thirc hien.

2.2.4. Khi nao Xet nghiOm d'uvec lam tren BN

- Co the lam 10 tong btrerc cua xet nghiem, khong can giam sat.
- Dam bao hieu ra nguyenrtac sir dung may, thuoc thin.
Danh gia dugc cac yeu to gay nhieu.
- Bao dam cong tac bac) tri, bao dtfang may moc.

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 CHU'O'NG 10 ■ XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

- Tieu chuan hoa cac cong viec ky th4t.

- Thu duac ket qua xet nghiem c6 d6 lap lai cao.
- Bao dam moi cong viec phuc vg cho xet nghiem tran tru, khong bi gian doan.

2.2.5. Kim tra chht hpong

NOi ki6m tra: mgc dich cua not ki6m la theo dOi giam sat moi khia canh cua
qua trinh xet nghiem thgc hien tai pilot-1g xet nghiem. Thireng xuyen danh gia
cac cong viec cua phong xet nghiem, cac k6t qua xet nghiem c6 du d6 tin cay
nu& khi tra cho lam sang.
Kim tra chat luang la nhung phuorng phap giup xac dinh d6 chinh xac va d6
xac thgc cna mot phuong phap )(et nghiem. Quan ly va ki6m tra hai y6u to nay
c6 y nghia quyet dinh doi vai chat luting xet nghiem, nham mgc dich giam d6
kern chinh xac va kern xac thgc, dam bao k6t qua xet nghiem dat gia tri tin cay.
N6i ki6m tra duce thgc hien beoi chinh phong xet nghiem/khoa xet nghiem d6
theo doi trgc tip va lien tvc hoat dOng cilta phong xet nghiem, nham dua ra
bien phap sira china kip tiled, dap limg moi yeu cau cna lam sang.
- TL ca cac tai lieu lien quan den ki6m tra chat luting phai dtrac luu giu trong
3 nam.
Bat kY phong xet nghiem nao cling phai c6 chucmg trinh to ki6m tra ve cac loai
xet nghiem dang lam, trang thi6t bi, hod chat sinh pham, tay nghe nhan vien. It
nhat mot s6 chuang trinh sau phai duac th%rc hien:
Tat ca moi tiled diem: ,
m6i tucmg quan thong:
+ Tap hop nhang mau bao cao.
. + Sr tuning quan gicra tieu ban mau va so dem.
+ Sg Wang quan gift k6t qua xet nghiem vai tinh trang lam sang.
Hang ngay
Kim tra bang nhcing "mau ki6rn tra"
Kimtra mau xet nghiem trong timg lo.
Kim tra bieu do ket qua.
- Do lap lai mot so mau benh pham cua benh nhan, thuemg 3 — 4 mau trong moi lo
Kim tra mot s6 mau benh pham cua benh nhan tin lo xet nghiem truac.
- Kim tra nhung khac biet quan trong gifra cac ket qua khi xet nghiem lap lai
mau cua benh nhan "delta check".
Tinh gia tri trung binh hang ngay d6i vai cac thong s6 da ch9n:
- D6i vai may d6m t6 bao tin d6ng: tinh gia tri trung binh cua MCV, MCH,
MCHC.
- D6i voi phuong phap thu cong: tinh gia tri trung binh cna MCHC.

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HOA SINN LAM SANG

Dinh 19', hang ngay hoeic hang tuan

Hieu chudn may dm to bao hoc may quang ke do huyet sac to.
Huy& sic to: * Chuan bi dung dich chuan.
* Hemolysat.
- S6 luting h6ng cau: chuin bi mau kiem tra.
- S6 lacing bach cau: chuan bi mau kiem tra, bach cau nhan tao.
- S6 lacing tieu cau: chuan bi mau kiem tra.
Dinh 1c)) lfic bat clan va theo lich
Hieu chuan cac loai pipet va cac may phan phi to dOng.
Dinh 19) (/fic bat dau va lap lgi theo lich, it nh at 6 thong mot lan)
Hieu chuan do thi cua cac may quang ke, may quang ph6 ke d6i voi cac xet nghiem
clic biet.
Ngoai kiem tra: de kiem tra dO xac thuc cua cac phuang phap trong mot phong xet
nghiem ngoai to con tien hanh ngoai kiem tra.
Muc dich
- Dam bao su tin cay cua xet nghiem.
- Danh gia chat luting cua mot phong xet nghiem mot cach khach quan.
- Xac dinh nhung sai s6 ve keit qua xet nghiem va c6 bien phap khac phuc.
- Khuyen khich sir dung phuong phap chuan, may m6c thuoc thin c6 chat luting tot.
- Khuyen khich not kiem thirong xuyen.
Doi chieu so sanh keit qua xet nghiem cua moi ph6ng xet nghiem voi keit qua &la
cac labo tham chieu trong nu& hoic qu6c to nham khong ngirng nang cao chat
lacing xet nghiem cita cac labo.

2.3. Giai doan sau xet nghiem

2.3.1. Bao cao keit qua xet nghiem
2.3.1.1. VI nghia cua keit qua xat nghlOm
- Ket qua xet nghiem la mot thong tin quan trong de chin doan va dieu tri benh.
- Ket qua xet nghiem la thanh qua dm su keit hop nhieu khau.
- Su I'T ten vao phieu tra keit qua xet nghiem: xac nhan keit qua tin cay, c6 hieu lac
sir dung.
- Nen dung mau bao ca.() keit qua xet nghiem truc tier) (tranh sai sot do sao chep).

2.3.1.2. Agu bao cao 1(41. qua )(et nghiem

- Thong tin ve BN: ten, tu6i, gieri, clia chi, dien thoai...
- Ma so ciia ban bao cao xet nghiem.

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 CHU'aNG 10 ► XET NGHIEM TIN CAY VA K1EM TRA CHAT XET NGHIEM

Ten va dia chi bac si chi dinh xet

- Thong bao ngan gon ve lam sang.
Thong bao ve Nnh pham va thin diem lay mau, xir 1ST, lam xet nghi6m, tra k6t qua.
- Nen g6p tirng nhom,xet CO lien quan.
Don vi va khoang doi chieu.
- Bi@.1 luan.
- Nguoi lam xet nghi6m va truOng khoa kST ten v4o ke't qua xet

2.3.1.3. Bac cao nhiPng ket qua xOt nghiem da"c biet
- Can uu tien tra k6t qua seem.
- Phai neu rO kin
y phan tich cua triremg khoa xet

2.3.1.4. Thai gian tra ket qua xet nghiem

- Phu thu6c loai xet nghi@n, diL kien lam xet nghi6in va mire d6 khan cap cua
lam sang.
- Can cur die'u kien phong xet nghiem va loai xet nghiem c6 nhang tieti chuan ye
tiled gian cho xet nghiem th6ng thuemg hay xet nghi@n cap dm

2.3.2. Quan he xet nghiem - lam sang

Mire d6 quan he phn thu6c vao nhiL y6u. to.
- Mire d6 ren luy6n, trinh d6 chuyen mon dm can b6.
Xet nghi@n va lam sang
Mire d6 phirc. tap trong bin luan cua turng loai xet nghi6m.
- "\;7 nghia cu the Gila mot ran trao d6i.

Thanh lap mang h.roi trao doi gift xet nghiem va lam sang.
- Huan luyn
Tham gia cac chucmg trinh ciao tao lien tnc.
Tham gia cac bu6i di Nnh phong.
- Co van cho bac si lam sang chon xet nghi@n, bien luan ket qua, theo dOi dieu
tri thu6c.
Thong tin ve nghien cua cila phOng xet nghiem trong cac tap san chuyen nganh.

2.3.3. Lu'u trip Chi lieu tai phong xet nghiem va bOnh vin
2.3.3.1. Nguyen t6c chung
- Bao cao k6t qua XN, to lieu ve BN, b6nh pham, XN phal dirge luu lai trong b6
phan km tra phong XN va Nnh vien theo thir tkr Med gian.
- Nhirn vu cua b6 phan hru tra: truy ngucyc tang birac cna qua trinh lam XN theo
k'ST thuat hien hanh va sao chep &roc k6t qua cua mot XN.
- CO kha nang lam lai bao cao XN khi bao cao goc bi mat.

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HOA SIKH LAM SANG

2.3.3.2. ThOl gian ITC!

- Thai gian luu tilt khac nhau gifra 1)(3 phan luu trtt cua phong XN va Nnh
- Thai gian luu trix phu thuOc tang loci Nnh nhan.

Phong cap cu'u Trung tam lAy mau

- Phieu yeu cau

- Benh pham

BO phan kru trip PXN

Ghi s6 tur lieu - Phieu yeu cau

nhan vao va - Ban sao ket qua XN
Ouia ra (3 thang)

Bo ph'On lu'u trip benh vien

BS girl XN
OF
- Benh not trO 5 nam
enh nhan ngoai tru 5 nam
enh nhan PK va ngoai vien 5 nai
l

Hinh 10.9. So' d6 v6 theei gian triy

2.3.3.3. NOi dung lull trig

Di6'u kien:
- Luu trot, tim lai to lieu.
- Tich trir thong tin v'e cac buac thvc hien XN.
Nei dung:
Ng-trod gni BN hay benh pham den phong XN, ngtrOi nhan.
Tu lieu v'e BN: ten, tu6i, giai, la BN khoa, phong, so gitrong, BS di6su tri, chan
doan...
Tu lieu v6s benh pham: benh pham giri den hay phong XN lay, ngay gio lay benh
pham, yeu cau XN...

342
 CHU'O'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

- Tu lieu ve XN: ten XN, phucmg phap phan tich, don vi do, khoang 6i chieu, gia
tri bat thuOng, chi phi XN...

2.3.4. Vhn de bac) mat

Co so.: luat bao mat, nhang cam ket, nguyen tic dao ly nghe nghiep cua cac h6i, to
chirc y te.
Quy tic:
- Han che tiep can nhang viec lam cua pilot-1g XN, chi nhang nguoi tnyc tiep chiu
trach nhiem thi hanh nhiem
- Han cha den gin nai hru trir, phang km trir dat rieng.
- Khu vuc kiem tra chat che.
- Han cite tiep can may vi tinh.

A. CAU HO! TIj LONG GIA

1.DO 10h chuin (sai se bit ngir) cang be thi do lap 10 cang cao.
A. Wing B. Sai
2. Huyet thanh khac huyet turong:
A. Co fibrinogen B. Khong co fibrinogen
3. Dem thanh phin to bao man, nen cho mau thin vat) tupe nao sau day:
A. EDTA B. Heparin
4. Do ion d nen cho mau man vao tube nao sau day:
A. EDTA B. Heparin
5. Ngan qua trinh doting phan, nen chop tube 1iy man co china:
A. Calci B. Magie C.Clorua D. Flor

B. CAU HO' NGHIEN CeU

1. M6t benh nhan lay matt de dinh luting doing huyet tren tube cheng &Cog heparin, 3
gia sau khi lay mau nhan vien y to m6i dinh luting duang. Nong d6 throng co thay
doi khong sau 3 gi6 dinh luting? Neu c6 thi nen cho chat gi vao de ngan qua trinh
throng phan?
2. Thanh phan ion 6 nao sau day thay 6i nhieu khi mau mau bi tan huyet (Na+,
Ca2±, C1, Mg2±)? Giai thich.
3. Ket qua xet nghiem c6 phu thu'6c vao trinh d6 tay nghe ana mot ky thu4t vien
khong? Neu co thi lien quan den d6 chinh xac hay d6 xac thuc?

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HOA SINH LAM SANG

DAP AN
CHIXONG 1: CHUYEN HOA NU'OC - MUOI VO CG
A. Cau hot to luvng gia
1.A 2.B 3.A 4.0 5.0
6.A 7.D 8.D 9.D 10.A
11.D 12.B 13.0 14.A 15.D
16.D 17.B 18.0 19.D 20.D
21.D 22.B 23.B 24.A 25.B
26.D 27.0 28.A 29.D 30.A
B. Cau hill nghien cult
Cau 1:, ion natri, kali thay dOi nhieu, nguyen nhan do lam dung thu6c loi tieu
gay mat natri, kali.
Cau 2: ion calci mat nhieu qua duamg lieu, calci gdn ket vai protein huyet, khi
protein mat qua duamg tieu thi keo theo mat ion calci
Cau 3: ion clor giam nhieu vi benh nhan mat HC1 trong dich vi. Cac ion khac
nhu calci, magie it mat hon.

CHVOING 2: THANG BANG ACID - BASE

A. Cau hoi ty luting gia
1.A 2.B 3.0 4.A 5.0
6.A 7.B 8.D 9.D 10.0
11.A 12.D 13.D 14.D 15.D
B. Cau hoi nghien cum
1.Co ten 75% NH4+ duov tai hdp thu a quay vOng lai thanh NH3.
2. An nhieu dam lam pH mac tieu giam -> acid uric kilo hoa tan trong mac lieu
-> sad duamg tieu.
3. Nhi8m acid chuyen hoa vi tao nhieu cetonic
4. Do mat HCO3- nen C1 ducfc tai hdp thu cnng Nat, IC- a trung hoa ve dien, do
do lam tang C1 mau.
5. Nhiem toan chuyen hoa do tao nhieu acid acetic va có the ca cetonic.

344
 CHUO'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

CHUtiNG 3: HOA SINH LAM SANG BENH LiT THAN

A. Cau hdi fix Wong gia
1.B 2.0 3.0 4.A 5.D
6.A 7.D 8.0 9.D 10.D
11.A 12.A 13.0 14.A 15.D
16.D 17.B 18.A 19.B 20.D
21.0 22.D 23.D 24.D 25.0
26.A 27.A
B. Cau hni nghien cum
1.B'nh hiii chImg then hu va sau do chuyen sang dot cap dm suy then man.
2. Viem cdu then cap va sau do chuyen sang dot cap suy then man.
3. U xo tuyen tin liet va sau do chuyen sang suy then man.

CHUtiNG 4: HOA SINH LAM SANG BENH I.4)",7 GAN MAT

A. Cau lied nghien con
1.Pile quail phe viem - Theo diii xuat huyet tieu hoa/tien lion me gan/Xo gan co
tnramg.
2. HOi chling Stevens Johnson do di frng thuOc khong rii loai.
3. S6t ret ac tinh the nab - Suy gan - Suy then cap - Viem phOi.
B. Cau hiii tty luvng gia:
1.B 2.A 3.A 4.B 5.A
6.0 7.0 8.0 9.D 10.A
11.0 12.B 13.A 14.A 15.A
16.A 17.B 18.D 19.D 20.D
21.A 22.0 23.0 24.D 25.A
26.D 27.D 28.0 29.0 30.A
31.0 32.A 33.B 34.D 35.D
36.D 37.A 38.D 39.B 40.0
41.B 42.D 43.0 44.A 45.D
46.D 47.D 48.D 49.A 50.B
51.B 52.D 53.D 54.A 55.A
56.0 57.0 58.B 59.D 60.A 61.B

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HOA SINH LAM SANG

CHUtiNG 5: HOA SINH LAM SANG BENH LY MACH VANH CAP

A. Cau hoi nghien env
1. Nhei mkt co tim cap
2. Nit& mau ca tim cap
3. Nit& mau co tim cap
4. Nhei mau ca tim cap
B. Cau WA tv luvng gia
1.D 2.0 3.0 4.B 5.A
6.D 7.B 8.0 9.D 10.D
11.0 12.D 13.0 14.D 15.B
16.D 17.A 18.B 19.B 20.A
21.D 22.D 23.A 24.0 25.A
26.0 27.D 28.A 29.A 30.0
31.D 32.D 33.0 34.D 35.0
36.B 37.D 38.A 39.A 40.0
41.D 42.A 43.0 44.D 45.D
46.D 47.A 48.B 49.D 50.0
51.D 52.B 53.A

CHIXONG 6: HOA SINH LAM SANG BENH TUYEN NOI TIET

A. Cau hdi nghien ciru
1.Ly, amip - Suy thily tmac tuy6n yen
2. Stit sieu vi - Suy tuyen yen truac
3. U tuy6n yen tit prolactin
4. Ha kali matt - Cueing giap dang dieu tri
5. Cueing giap/Nhan giap 2 thity - Viem mang nao mu do to cau yang
6. Cueing giap/Bueru giap da nhan 2 thily
7. Suy giap thin phat
8. Suy giap clued lam sang
9. Buou giap don nhan/Binh giap
B. Cau hoi tir lugng gia
1.D 2.D 3.B 4.D 5.D

346
 CHUONG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

6.0 7.B 8.0 9.A 10.D

11.D 12.B 13.D 14.B 15.B
16.B 17.B 18.A 19.A 20.A
21.0 22.B 23.B 24.B 25.B 26.A

CHIAING 7: DICH SINH VAT

A. Cali hoi ttr luvng gia
1.D 2.D 3.D 4.B 5.D
6.0 7.0 8.0 9.0 10.D
11.B 12.0 13.D 14.0 15.0
16.0 17.D 18.A 19.B 20.D
B. Cau hal nghien cfru
1.Benh nhan bi viem mang ndo mu
2. Benh nhan bi viem mang tido do nam. 1_,3'r do vi lam dung thuOc giam dau
gay nen hau qua suy giam he mien dich, giam sirc de khang dm co. the.
3.110h nhan bi viem mang tido do 1(- T sinh trimg. 14T do an nhieu hai san song
va citing vat hoang dd.

CHUCING 8: CHI DAU UNG THU

A. Can hoi nghien cum
1.K da day
2. K bung trUng
3. Sarcom mo dem nOi mac tix cung
4. K bung trimg phai
5. K bung trimg - Carcinom bung chau
6. K dai trang phai
7. K vu trai
8. K vu trai
9. K gan nguyen phat
10.Carcinoma tuy6n giap dang nhit di can hach co phai
11.K da day

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HOA SINH LAM SANG

12. K dai tang phai

13.K tuyen tin liet
14. Carcinoma tuyen tuy
15.Carcinoma bieu mo tuyen phi phai.
B. Cau hid tiar lining gia
1.A 2.D 3.0 4.B 5.D
6.A 7.0 8.0 9.D 10.A
11.B 12.0 13.D 14.0 15.B
16.B 17.B 18.A 19.D 20.B

CHIMING 9: CAC DICH CO THE, NGHIEM PRAM VA CAC XET NGHIEM

HOA SINH LAM SANG
A. Cau hoi tu. lurig gia
1.B 2.B 3.0 4.B 5.D
B. Cau hoi nghien cum
1.X trung binh = 89 mg%; S = 3,1 mg%; HSBT = 3,5%; khoang dei chieu X +
2S = 89±2.3,1 mg% = 82,8 - 95,2 mg% (4,6 - 5,29 mmol/L).
2. 10,5L va 3,5L; lucmg nu& eY huyet Wang oua tre em nhieu hun a huyet
tucmg ngueri lan.
3. 11,1 mmol/L, b'enh 13'r.
4. 54 g/L, 0,3 mol/L, 0,3 osmol/L.

CHIA:NG 10: XET NGHIEM TIN CAY VA KIEM TRA CHAT LUVNG XET
NGHIEM
A.Cau hoi tu. luting gia
1.A 2.B 3.B 4.B 5.D
B.Cau hoi nghien aim
1.Glucose c6 thay dei, chAt cho la flor
2.Ion K±, Mg2+
3.Có anh huong, 0 chinh xac

348
 -

CHU'O'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

2.5.6.2. Cach lay dich nao tay

Do bac si lam sang hoac k'yf thuat vien chuyen nghiep
Yeu cau:
- Ong 1 (vai giot dau), 6ng 2 (5-7m1).
Danh gia mau sac dich nao tuy nu& khi cho lam cac xet nghiem.
Dich nao tuy dugc lay mau 6 phan tich hod sinh lam sang phai dugc xi ly vai
EDTA de ngan ngira su hinh thanh cuc dong fibrin, tranh cho viec lam sai lac so
luting to bao dem dugc.

2.5.7. X& ly nhanh, bao quan va van chuyen bOnh pha'm

2.5.7.1. XU' ly nhanh
Dieu kien cam tay ngay sau khi lay mau: neu c6 ch6ng dong can xac dinh thai gian,
cach lac trOn de tranh bi clang Can c6 may lac tir.
Dieu kien tach huyet thanh (huyet Wong):
- Tach huyet thanh: can ton trong cac dieu kien clang mau: sau khi cuc mau da co
Tach huyet twang: xac dinh then gian tiep xuc tai da gifra mau va chat chang
dong, died gian, van tac, thai gian ly tam.
Huy& thanh: huyet thanh thu dugc bang each de mau dong to nhien trong khoang
th6i gian tir 30 phut den 1 gia, ly tam 6 khoang 3.000 yang/phut trong 10 phirt, phan dich
not (supernatant) phia tren la huyet thanh.
Huy& twang: huyet tuung thu dirge khi loai ion Ca2+ trong mau bang each them vao
mau chat chong dong la cac chat tao phirc (chelators) de tao phirc vai ion Ca' nhu EDTA,
citrat, oxalat hoac heparin.
- EDTA-K2 va EDTA-K3 vai nang d6 1,5-2 mg/ml mau dugc sir dung cho cac
xet nghiem huyet hoc thong thuang.
Heparin duai clang cac muai nhu amon, Li, Na, K dugc sir dung theo tY le 25U/ml
man, hay 0,01-0,1 ml heparin/ml mau.
Fluoride (muai Na) duce sir dung vai nang da 2 mg/ml mau. Fluoride c6 tac dung
can tra sly &mg matt va su du6ng phan (glycolysis), nen thuemg dugc sir dung de dinh
luting glucose mau;
Dung dich citrat (mu6i Na) nang d6 3,8% hoac 0,11 mol/L dugc sir dung cho cac
xet nghiem clang mau vOi ty le 1 the tich Na citrate va 9 the tich mau toan phan hoac dugc
a
sir dung rang hong cau vai ty le 1 phan Na citrat va 4 the tich mau toan phan;
Kali oxalat it khi dugc sir dung chang clang mau de lay huyet twang.
Sau khi chemg dong, ly tam khoang 3.000 yang/phut trong 10 phut, dich not phia
teen thu duce la huyet twang. Su khac nhau giira huyet thanh va huyet twang thu6ng

333
HOA SINN LAM SANG

chi thay trong sir xac dinh K+, phosphate ye co, lactat dehydrogenase (LDH) va dien di
fibrinogen.
cac benh nhan bi chirng tang tieu cau (thrombocytosis), gia tri tieu cau virgt tren
800.000/4„ viec dinh lucing khong the thgc hien dugc trong huyet thanh, can phai sir
dung thay the bang huyet tucmg ch6ng Tong vai heparin.
Cach Z&y mau mau toan phan
Mau toan phan c6 the thu dugc bang each sir dung cac chat ch6ng &rig nhu Ta neu
teen (khong ly tam). Met se xet nghiem doi hei sir dung cac chat cheng Tong khac nhau,
chang han:,
Lay mau mau de dinh luting glucose mau: vi tec de &ran phan (glycolysis) la
khoang 7% m8i gia nen can phai them met chat irc the qua trinh throng phan,
nhu NaF (sodium fluoride) haac iodoacetat vao mau mau huge khi xac dinh
nong de glucose,mau.
- Lay mau matt xet nghiem huyet hoc• phan lam cac phan tich ve huyet hoc,
nguai to thuang sir dung man 'firth mach ch6ng Tong bang EDTA. Trong trtramg
hop rieng biet, sir giam tieu cau gia (pseudothrombopenia) cam irng bad EDTA
c6 the xay ra,‘Ma'c dieu nay khong c6 nghia lam sang. Vic sir dung mau
cheng Tong bang citrat se lam s6 luting tieu cau tra ve binh thuang.
- Lay matt matt de xet nghiem (Tong matt: trong cac xet nghiem (long mau, huyet
tuang chong &mg bang citrat dugc sir dung cho cac muc dich phan tich. Can
phai ten dung dich Na citrat vao mau chinh xac theo tST le la 1 the tich Na citrat
3,8% va 9 the tich mau toan phan.
- ChU y, matt ch6ng 'long bang hop chat EDTA hoc axalat khong sir dung dugc
cho cac xet nghiem ve (long mau. Phai loai 136 cac mau mau bi tan huyet haac
bat Tau Tong mau.

2.5.7.2. Bac, guan bOnh pha'm

- Nhiet de: nhiet de phong, tit lanh, Tong lanh.
- Thai gian bao thuang di kern nhiet de.
- Chat bao quan thich hop tirng loai benh ph'am va thai gian bao quan.
Dieu kien lam nong lai benh pham tai nhiet de lam pilau img (nhiet de phong,
dung not each thity).
Bao quail huyet thanh va huyet tucmg: tity thai gian can thiet ma chon nhiet de
thich hop.
- <2 gig: nhiet de phong.
- 2-48 gia: 4°C.
- >48 gia: Tong lanh.
Thai gian va nhiet de co anh huong ket qua xet nghiem.

334
 CHU'O'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHI6M

❑ Cach bao quart va van chuy'en cac matt xet nghiem:

Viec ly tam thtrang dugc thuc hien trong khoang 1 gia sau khi mau dugc thu
lugm.
- Neu cac mau dugc giri di, chi duce sir dung huyet thanh hoc huyet tucmg, trir
truang hop that dk biet, matt toan phan mai dugc van chuyen di xa de phan tich.
- Vi vay, trong Doi loci xet nghiem can phai c6 each bao quan khac nhau.
- ML berth pham tuai: thai gian tir lac lay mau den khi lam xet nghiem 5 4 gia.
Bao quan cac enzym
a
- Cac mau huyet ttrcmg sir dung do hog de enzym not chung, thuong c6 the
bao quan 4 °C den 5 ngdy ma hog de enzym khong giam qua 10%.
Rieng doi ved LDH, khong bao quan trong to lanh vi hoat de dm no giam khi
cac isoenzym LDH4 va LDH5 ciia no khong on dinh trong dieu kien lanh.
- Con ACP chi on dinh khi mau huyet tuang dugc acid hod.
Bao quan cac ca chat
Cac chat chuyen hod trong huyet tucmg thuerng on dinh a 4 °C trong 6 ngdy ma
niing de kh6ng c6 six thay doi dang ke. Rieng d6i ved triglycerid c6 the bi giam
do bi lipase thug phan. Tuy nhien, nong de nay khong thay doi neu phuang phap
phan tich qua glycerol toan phan.
Neu six xac dinh dua tren phan irng Jaffe thi bao quan a nhiet de phong c6 the
lam giam nOng de cua phosphat, acid uric va creatinin.
Bilirubin bi pha huS7 khi bi anh sang chieu vao trong qua trinh bao quan.
Glucose se chi dirge bao quan sau khi tach protein khoi mau mau hoc them
chit on dinh.
Bao quart cac protein, cac khang nguyen va khang the
- Cac protein, cac khang nguyen va khang the dirge bao quan a 4°C trong 1 tuan.
Bao quan cac hormon va dau an ung throe
Cac hormon steroid tuang d6i ben, c6 the bao quart a nhiet de phong (25°C)
trong 3 ngay; cac dL L ung thu ding c6 the bao quail nhu vay.
Cac hormon peptid, dac biet la cac hormon khong ben la ACTH, renin, insulin,
GH va calcitonin mu6n bao quan qua 1 ngdy phai de vao tit lanh sau.
Bao quan mitt de xet nghiem cac chat clang matt
- Huy& tucmg ngheo lieu cau sir dung de xac dinh thai gian prothrombin khong
a
dugc qua 8 gia.
Hoat do cUa cac chat &mg mau phai dugc xac dinh trong khoang 3 gia, neu
qua thai han tren, huyet tuang phai dirge bao quart a 4°C.
Bao quart mau lam tang phan tich mau
- Mau matt toan phan cheag dong bang EDTA chi dugc sir dung dual 24 gia.

335
HOA SINH LAM SANG

Bao quan mau de phan tich hinh thai to bao mau

- Sy dan mau ten phien kinh chi dirge thyc hien trong yang 5 gief sau khi lay mau.
- Neu sir dung mau de phan tich cac thanh phin cua mau, mau mau dugc sir dung
khong qua 8 gia.
Bao quan mau trong mot then gian dai
- Neu muon bao quan benh pham trong thai gian dai han thai gian neu ten, benh
pham,can dugc bao quan nhiet han -20°C.
- Khi can sir dung, can dugc tan (long mot cach tir tir a 4-8°C qua mot dem
hoac trong mgt be diet' nhiet có lac.
- Tuy nhien, viec dong bang va tan &Ong khong nen lap di, lap lai.
Bao quan nu ac tieu de xet nghi'm can ntrefc tieu
- Can nuac tieu phai dugc danh gia trong khoang 2 den 3 gib.
- Khong dugc bao quan mau nu& tieu trong to lanh hok dong bang vi dieu kien
lanh co the gay ket tua muei.
Bao quan dich nab tuf;
- Viec dem cac to bao trong dich nao tuY phai dugc thuc hien trong yang 1 gia.
Bao quan mau de coo kid mau va trang bang acid-base
Cach van chuyen cac mau xet nghiem
- Khi chuyen benh pham tir nal nay sang not khac trong nuoc hoac ra quec ta, can
bao quan benh phdm trong phich da kho.
- Noi chung, sir thay &di hoat do enzym va nong do cac chit chuyen hod khong
qua ± 10% trong khoang 2 ngay, neu nhiet de, bao quan mau duai 25°C.
Anh huemg cua tinh trang mau den ket qua xet nghiem
mau trong dieu kien nhat dinh có the anh huomg din ket qua ciia melt se
xet nghiem:
- Sy tan mau.
- Viec xac dinh IC', Mg' hok LDH khong the thyc hien dugc ngay ca khi huyet
thanh chi bi tan mau rat it.
- Sy tan mau di rang cling anh hung den can xet nghiem Ude.,
Neu thay bi tan mau, can loci be) mau mau 'ay va phai lay ngay mot mau
mau mai de thay the.
Bilirubin mau
Cac nOng do bilirubin tren 5 mg/di (86 umol/L) anh hirong den su xac dinh acid
uric (phucmg phap PAP).
Cac nOng dei bilirubin ten 10 mg/dl (170 p,mol/L) anh huong den sir xac dinh
triglycerid (theo phucmg phap GPO-PAP) va su xac dinh creatinin (phucmg
phap Jaffe va PAP).

336
 CHU'O'NG 10 lo XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

- Phuang phap xac dinh creatinin mai khong bi anh huang cua bilirubin ngay ca
khi nOng dO bilirubin len an 25 mg/dl (430 [anon).
Sr tang lipid mail
- Lipid cao trong mau c6 the can tro• vice do cac chit bang phuong phap do quang.
- Trong truong hop nay can loai b6 cac lipoprotein trong huyet Wong bang each
sir dung Freon.
Bao quern mak ti&i
Cac thong so nu6c tiCu deu chin anh htrang dm chat bao quern, tiled gian va nh*
Bao quern DNT
Thy thuloc then gian can bao quern
- <1 gier: khong can dong lanh
- <3 gia: 4°C, khong can them chat bao quail
- >3 giey: ly tam loai TB, lam lanh -70°C

Bang 10.2. Thai gian Iu'u trip mgu

Thai gian On dinh nhie't do

Ten xet nghietn
4°C Mina lanh

-20°C 10 ngay
° <.1 nam

-20°C < 1 narn

Bang 10.3. Cac chAt bac) quail ntydc ti6u

Chat bao (wan Cac thanh phan on dinh

mot 5m1,th n Ul

6 ilinogen.
calci, magic

337
HOA SINH LAM SANG

2.2. Cac giai loan xet nghiem

2.2.1. Ltpa chon phu'o'ng phap xet nghiOm
11 Twang khoa chiu trach nhiem, Giant dec chuyen mon ky duyet — tinh chat phap 1S.T.
Ky thuat xet nghiem co day du cac quy dinh sau:
Ten phtrang phap xet nghiem.
Cach lien hanh xet nghiem.
nghia lam sang dm xet nghiem.
Nhfing gia tri quy chieu.
Nguyen Vac cua phucmg phap xet nghiem.
Chit thich.
Benh pham nao dugc thy de lam loai xet nghiem nao.
Tai lieu tham khan.
Dung cu va thu6c thin.
Tieu chuan h6a cac dung cu va may moc (can, may do quang, dung cu dong do...)
thuoc thir, cac k'S'r thuat xet nghiem cu the... Nhitng sai so se phat sinh neu dung cu, may
mac, thu6c thin khong tot, k'y thuat vien thao tac sai...

2.2.2. Con nguNfri

Phong xet nghiem la met ekip lam viec bao gem: can be quail. 1Sr, bac si lam sang,
can be Icy thuat, can be van thu...
Yeu cau d6i voi moi nguiri trong pheng xet nghiem
Xac dinh vai tr6 ban than
U Hieu re nhiem vu va mut tieu
Hieu va lam tron yen, day dii theo quan 1y chat lucmg
U Phai dugc dao tao lai lien Mc.
Mei quan he ngoai ph6ng xet nghiem: can be quan ly b'enh vien, bac si lam sang,
dieu duong, benh vien khac, phong xet nghiem khac de dat chat lucmg cao hart.

2.2.3. BiOn phap an toan

Xay dung bien phap.
Huan luyen that hien.
Phan tong thgc hien.

2.2.4. Khi nao Xet nghi#m dupc lam tren BN

Co the lam lai tirng huge cua xet nghiem, khong can giant sat.
Dam bao hieu re nguyentac sir dung may, thuoc thin.
Barth gia dugc cac yeu t gay nhieu.
Bao dam tong tac bao tri, bao du'ang may m6c.

338
 CHU'ONG 10 ■ XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

- Tieu chudn hoa cac cong viec ky thuat.

- Thu dugc ket qua xet nghiem co de 14 lai cao.
- Bao dam moi cong viec phuc vu cho xet nghiem tan tru, khong bi gian doan.

2.2.5. Kiem tra chat luvrg

1\10i kiem tra: muc dich cua fled kiem la theo dei giam sat moi khia canh cua
qud trinh xet nghiem thuc hien tai phong xet nghiem. Thuong xuyen danh gia
cac cong viec cua phong xet nghiem, cac ket qua xet nghiem c6 du de tin cay
trirac khi tra cho lam sang.
Kiem tra chdt luting la nhang phuang phdp gifip xac dinh de chinh xac va de
xac thuc cua met phuang phap xet nghiem. Quan ly va kiem tra hai yeu to nay
coy nghia quyet dinh doi vai chat luting xet nghiem, nham muc dich giam de
kem chinh xac va kern xac thuc, dam bdo ket qua xet nghiem dat gid tri tin cay.
NOi kiem tra dtrot thuc hien bed chinh phong xet nghiem/khoa xet nghiem de
theo dOi true tier, Ira lien tuc hog deng cilta phong xet nghiem, nifam dua ra
bien phap sera china kip died, dap ung moi yeu cau dm lam sang.
Tdt ca cac tai lieu lien quan den kiem tra ch'dt luting phai &roc lu-u gift trong
3 nam.
- Bat ky phong xet nghiem nao cling phai c6 chuang trinh tu kiem tra ve cac loaf
xet nghiem dang lam, trang thiet bi, hod chat sinh pham, tay nghe nhan vien. it
nhdt met se chuang trinh sau phai duqc thuc hien:
- T'dt ca moi thoi diem: ,
m6i Wang quan thong:
+ Tap hop nhang mdu bap cao.
+ Su twang quan gicra tieu ban mdu va so dem.
+ Su Wong quan giaa ket qua xet nghiem vai tinh trang lam sang.
Hang ngay
Kiem tra bang nhang "mL ki6m tra"
Kiem tra mau xet nghiem trong trang 18.
Kiem tra bieu de ket qua. ,
Do 14p lai met se benh pham cua benh nhan, thuong 3 — 4 mL trong moi 16
- Kiem tra met se mau benh pham cua benh nhan tin 16 xet nghiem tnreic.
- Kiem tra nhang khdc biet quan trong gift cac ket qua khi xet nghiem rap lai
mL cua benh nhan "delta check".
Tinh gid tri trung binh hang ngay doi vai cac thong se da chon:
Doi ved may dem to bao tcr deng: tinh gid tri trung binh cua MCV, MCH,
MCHC.
Doi v8i phuang phap thu cong: tinh gia tri trung binh cna MCHC.

339
HOA SINH LAM SANG

Dinh ky hang ngay hoac hang tun

Hieu chuan may dm t6 bao hoac may quang k6 do buy& sac to.
Huy& sac to: * Chuan bi dung dich chuan.
* Hemolysat.
SO luong hOng cau: chuan N matt kiem tra.
SO luang bach cau: chuan bi mau kiem tra, bach cau nhan tao.
SO hrong tiL cau: chuan bi mau kiem tra.
Dinh kfr hic bat cldu va theo lick
Hieu chuan cac loci pipet va cac may phan phi to d'Ong.
Dinh li-j) (1fic bat clau va lap Zgi theo lich, it nhat 6 thing mot Zan)
Hieu chuan do thi cua cac may quang ke, may quang phO ke d6i vai cac xet nghiem
dac biet.
Ngoai hem tra: d kiem tra dO xac thuc cua cac phuang phap trong mOt phOng xet
nghiem ngoai to con tien hanh ngoai kiem tra.
Muc clich
Dam bao su tin cay cua xet nghiem.
Danh gia chat liming dm mOt phOng xet nghiem mOt each khach quan.
Xac dinh nhang sai se; ve Ic6t qua xet nghiem va c6 bien phap khac phuc.
Khuye'n khich sir dung phuang phap chuan, may m6c thuoc thir c6 chat luemg tot.
Khuye'n khich nOi kiem thuemg xuyen.
DOi chiau so sanh ket qua xet nghiem ciia m6i phOng xet nghiem vii kat qua cUa
cac labo tham chieu trong nuac hoc quoc to nham khong ngimg nang cao chat
hrung xet nghiem cua cac labo.

2.3. Giai doan sau xet nghiem

2.3.1. Bao cao lc& qua xet nghiem
2.3.1.1. VI nghia caa k6t qua xet nghi6m
- Kat qua xet nghiem la mOt thong tin quan trong de chin doan va diL tri benh.
- Ket qua xet nghiem là thanh qua dm su kat hop nhieu khau.
- Su 14T ten vao phiL tra kat qua xet nghiem: xac nhan kat qua tin cay, c6 hieu luc
sir dung.
- Nen dUng mau bao cao kat qua xet nghiem true tip (tranh sai sot do sao chap).

2.3.1.2. Agu bao cao kat qua xet nghi6m

- Thong tin v'e BN: ten, tuOi, gied, dia chi, dien thoai...
- Ma s6 dm ban bao cap xet nghiem.

340
 CHU'ONG 10 10- XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

Ten va dia chi bac si chi dinh xet nghiem.

- Thong bao ngan gon ye lam sang.
Thong bao ve benh pham va then diem lay mau, xix ly, lam xet nghiem, tra ket qua.
- Nen Op tang nh6m xet nghiem c6 lien quan.
- Dan vi va khoang d6i chiL.
- Bien luan.
- Nguoi lam xet nghiem va truang khoa ky ten vao ket qua xet nghiem.

2.3.1.3. Bao cao nhe-rng ket qua xet nghiOm dOc bit
- Can uu tien tra ket qua soul.
- Phai neu r6 y kien phan tich cua twang khoa xet nghiem.

2.3.1.4. Thai gian tra ket qua )(et nghlOm

Phu thu6c loai xet nghiem, di'eu kien lam xet nghiem va mUc d6 khan cap dm
lam sang.
Can cir diet' kien ph6ng xet nghiem va loai xet nghiem co nhang tieu chuan ve
thai gian cho xet nghiem thong thuang hay xet nghiem cap cfru.

2.3.2. Quan he xet nghiem - lam sang

- Mac d6 quan he phu thu6c vao nhi'eu ye'u to.
Mire d6 ren luyen, trinh d6 chuyen mon cua can b6.
- Xet nghiem va lam sang
- Muc d6 pink tap trong bien luan efia tirng loai xet nghiem.
Y nghia cu the dm mOt lan trao
- Thanh lap mang luai trao doi gitra xet nghiem va lam sang.
- Huan luyen
Tham gia cac chuang trinh ciao tax) lien tac.
- Tham gia cac buoi di benh phong.
CO van cho bac si lam sang chon xet nghiem, bien Juan k6t qua, theo doi diL
tri thu6c.
- Thong tin ve nghien ciru cua ph6ng xet nghiem trong cac tap san chuyen nganh.

2.3.3. Lu'u tiff tai lieu tai phong xet nghiem va benh vien
2.3.3.1. Nguyen tgc Chung
- Bao cao ket qua XN, M lieu ve BN, benh pham, XN phai dirge km lai trong bo
phan km tilt phong XN va benh vien theo thin tr thai gian.
- Nhiem vu dm b0 phan km tra: truy nguac tirng buorc dm qua trinh lam XN theo
ky thuat hien hanh va sao chep dirge ket qua ciia mOt XN.
- Co kha nang lam lai bac) cao XN khi bao cao g6c bi mit.

341
HOA SINN LAM SANG

2.3.3.2. Thai gian trir

- Tiled gian luu tnz khac nhau gift bO phan km tra cua phong XN va benh vien.
- Thai gian luu till phi thuec timg loci benh nhan.

- PhiOu you chu

- BOnh pham

Phong X Bo phO'n Iu'u trip PXN

Ghi s6 tu' lie - Phu yeu cau

Thu'ky - Ban sao kOt qua XN
nhan vao va
nhan B PXN (3 thang)
diva ra

BS givi XN
Bo ph,an Iu'u trip benh viem.
I
- Banh not trO 5 nam
- BOnh nhan ngoai tru 5 nam
- Banh nhan PK va ngoai vien 5 nam

Hinh 10.9. Scy do v6 thOl gian lu'u trip

2.3.3.3. NOi dung luv trCr

DiL
- Lim trot, tim lai to lieu.
- Tich trot thong tin ve c- ac buoy thuc hien XN.
NOi dung:
Ngueri gixi BN hay benh pham den phong XN, nguefi nhan.
Tir lieu ye BN: ten, tuk gioi, la BN khoa, phong, s'6 giuemg, BS dieu tri, chan
doan...
Tir lieu ve benh pham: benh pham girl den hay phong XN lay, ngdy gio• lay benh
pham, yeu cau XN...

342
 CHU'O'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

- Tu lieu ve XN: ten XN, phtrong phap phan tich, dun vi do, khoang d6i chieu, gia
tri bat thuong, chi phi XN...

2.34. yen de bao mat

Ca s6: luat bao mat, nhung cam ket, nguyen tac dao ly nghe nghiep cua cac hoi, to
chirc y te.
Quy tac:
- Han che tiep can nhang viec lam cua ph6ng XN, chi nhang nguoi trvc tiep chiu
trach nhiem thi hanh nhi'em vu.
- Han che den gan nui luu trtt, phong luu tit dat rieng.
- Khu vuc kiem tra chat che.
- Han che tiep can may vi tinh.

A. CAU HO! Tif LUVNG GIA

1.DO 10h chuin (sai so bit ngo) cang be thi do lap lai cang cao.
A. Dung B. Sai
2. Huy6t thanh khfic huy6t tirong:
A. Co fibrinogen B. Khong di fibrinogen
3. Dem thanh phin 4 bao mau, nen cho mau thin vac) tupe nao sau day:
A. EDTA B. Heparin
4. Do ion clo nen cho mitt man vao tube nao sau day:
A. EDTA B. Heparin
5. Ngan qua trinh diromg phan, nen chip tube 14 man co chira:
A. Calci B. Magie C.Clorua D. Flor

B. CAU HO! NGHIEN CeU

1. Met benh nhan lay mau de dinh luting cluing huyet tren tube ch6ng clung heparin, 3
gi6 sau khi lay mau nhan vien y to m6i dinh luong dtramg. Ming de cluing c6 thay
dei khong sau 3 gi6 dinh ltrong? Neu c6 thi nen cho chat gi vao de ngan qua trinh
duemg phan?
2. Thanh phan ion do nao sau day thay d6i nhi'eu khi tau man bi tan huyet (M.+, K±,
Cl-, Mg21? Giai thich.
3. KM qua xet nghiem c6 phu thuec vao trinh d'6 tay nghe dm met 1(57 thuat vi'en
khong? Neu c6 thi lien quan den de chinh xac hay de xac thuc?

343
 DAP AN
CHIXING 1: CHUYEN HOA NU'OC - MUOI VO CO
A. Cau hdi tir hrong gia
1.A 2.B 3.A 4.0 5.0
6.A 7.D 8.D 9.D 10.A
11.D 12.B 13.0 14.A 15.D
16.D 17.B 18.0 19.D 20.D
21.D 22.B 23.B 24.A 25.B
26.D 27.0 28.A 29.D 30.A
B. Cau hal nghien cum
Cau 1:, ion natri, kali thay d6i nhieu, nguyen nhan do lam dung thuo'c lai lieu
gay mat natri, kali.
Cau 2: ion calci mAt nhieu qua dueyng tieu, calci gAn kect voi protein huyet, khi
protein mat qua throng tieu thi keo theo mat ion calci
Cau 3: ion clor giam nhieu vi benh nhan mat HC1 trong dich vi. Cac ion khac
nhtr calci, magie it mat hon.

CHUONG 2: THANG BANG ACID - BASE

A. Cau hoi to hryng gia
1.A 2.B 3.0 4.A 5.0
6.A 7.B 8.D 9.D 10.0
11.A 12.D 13.D 14.D 15.D
B. Cau hoi nghien cuu
1.Co ten 75% NH4+ dugc tai hAp thu a quay yang lai thanh NH3.
2. An nhieu dam lam pH nuac tieu giam -+ acid uric kh6 hea tan trong ntrOt tieu
-> soi &rang tieu.
3. Nhi6m acid chuyen h6a vi tao nhieu cetonic
4. Do mAt HCO3- nen Cl- dirge tai hap thu ding Nat, IC a trung hoa ve dien, do
do lam tang Cl. mau.
5. NhiZm toan chuyen h6a do tao nhieu acid acetic va c6 th6 ca cetonic.

344
 CHU'O'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

CHIJONG 3: HOA SINH LAM SANG BENH IA( THAN

A. Cau hoi tu ltrutig gia
1.B 2.0 3.0 4.A 5.D
6.A 7.D 8.0 9.D 10.D
11.A 12.A 13.0 14.A 15.D
16.D 17.B 18.A 19.B 20.D
21.0 22.D 23.D 24.D 25.0
26.A 27.A
B. Cau hoi nghien aim
1.Benh Nii chirng than hu va sau do chuyen sang dot cap dm suy than man.
2. Viem call than cap va sau do chuyen sang dot cap suy than man.
3. U xo' tuyen tien liet va sau do chuyen sang suy than man.

CHIA/NG 4: HOA SINH LAM SANG BENH I.4)'( GAN MAT

A. Cau hot nghien cum
1.Phe quail phe viem - Theo d'oi xuat huyet tieu hoa/tien lion me gan/Xo. gan co
throng.
2. Hoi chirng Stevens Johnson do di ung thu6c khong ro loai.
3. SOt ret ac tinh the nao - Suy gan - Suy then cep - Viem phOi.
B. Cau hoi ter lu•gng gia:
1.B 2.A 3.A 4.B 5.A
6.0 7.0 8.0 9.D 10.A
11.0 12.B 13.A 14.A 15.A
16.A 17.B 18.D 19.D 20.D
21.A 22.0 23.0 24.D 25.A
26.D 27.D 28.0 29.0 30.A
31.0 32.A 33.B 34.D 35.D
36.D 37.A 38.D 39.B 40.0
41.B 42.D 43.0 44.A 45.D
46.D 47.D 48.D 49.A 50.B
51.B 52.D 53.D 54.A 55.A
56.0 57.0 58.B 59.D 60.A 61.B

345
HOA SINN LAM SANG

CIRAING 5: HOA SINH LAM SANG BENH 'AT' MACH VANH CAP
A. Can hoi nghien cam
1.Nh'ai mau ca tim cap
2. Nh6i matt co tim cap
3. Nh'oi mau co tim cap
4. Nit& mau ca tim cap
B. Cau hoi tty hroyng gia
1.D 2.0 3.0 4.B 5.A
6.D 7.B 8.0 9.D 10.D
11.0 12.D 13.0 14.D 15.B
16.D 17.A 18.B 19.B 20.A
21.D 22.D 23.A 24.0 25.A
26.0 27.D 28.A 29.A 30.0
31.D 32.D 33.0 34.D 35.0
36.B 37.D 38.A 39.A 40.0
41.D 42.A 43.0 44.D 45.D
46.D 47.A 48.B 49.D 50.0
51.D 52.B 53.A

CHO:NG 6: HOA SINH LAM SANG BENH LY TUYEN NOI TIET

A. Cau hoi nghien cuu
1.Ly, amip - Suy thity tnrac tuy6n yen
2. S6t sieu vi - Suy tuyen yen tnrefc
3.U tuyen yen tit prolactin
4. Ha kali mau - etrang giap clang di'eu tri
5. Ctremg giap/Nhan giap 2 thity - Viem mang nab mu do At cau yang
6. Cuemg giap/Btrem giap da nhan 2 thity
7. Suy giap thin phat
8. Suy giap clued lam sang
9.&rem giap don nhan/Binh giap
B. Cau hoi ttr luvng gia
1.D 2.D 3.B 4.D 5.D

346
 CHLIO'NG 10 ► XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM

6.0 7.B 8.0 9.A 10.D

11.D 12.B 13.D 14.B 15.B
16.B 17.B 18.A 19.A 20.A
21.0 22.B 23.B 24.B 25.B 26.A

CHLYCING 7: DICH SINH VAT

A. Can hoi tir lircnig gia
1.D 2.D 3.D 4.B 5.D
6.0 7.0 8.0 9.0 10.D
11.B 12.0 13.D 14.0 15.0
16.0 17.D 18.A 19.B 20.D
B. Cau hoi nghien cum
1.Benh nhan bi viem mang nao mil.
2. Benh nhan bi viem mang nao do nam. Ly do vi lam dung thuOc giam dau
gay nen hau qua suy giam he mien dich, giam sue de khang cua ca the.
3. Benh nhan bi viem mang nao do ky sinh trimg. Ly do an nhieu hai san song
va dOng vat hoang

CHVONG 8: CHI DAU UNG THU'

A. Cau hoi nghien eau
1.K da day
2. K bung triimg
3. Sarcom mo dem not mac tix cung
4. K bung truing phai
5. K bung it-11'11g - Carcinom bung chau
6. K dai trang phai
7. K vu trai
8. Kvutrai
9. K gan nguyen phat
10. Carcinoma tuy'L giap dang nhil di can hach co phai
11.K da day

347
HOA SINN LAM SANG

12. K dai tang phai

13.K tuyen tien liet
14.Carcinoma tuyen tuy
15. Carcinoma bieu mO tuyen phi phai
B. Cau hal ttr luting gia
1.A 2.D 3.0 4.B 5.D
6.A 7.0 8.0 9.D 10.A
11.B 12.0 13.D 14.0 15.B
16.B 17.B 18.A 19.D 20.B

CHIIONG 9: CAC INCH CO THE, NGHIEM PHAM VA CAC XET NGHIEM

HOA SINH LAM SANG
A. Cau hoi to gia
1.B 2.B 3.0 4.B 5.D
B. Cau hoi nghien colt
1.X trung binh = 89 mg%; S = 3,1 mg%; HSBT = 3,5%; Ichoang d6i chi6u X
2S = 89±2.3,1 mg% = 82,8 - 95,2 mg% (4,6 - 5,29 mmol/L).
2. 10,5L va 3,5L; lucmg nuac o huy'et tuang cua tre em nhi'eu hall a huyet
Wong nguai lom.
3. 11,1 mmol/L, benh 1ST.
4. 54 g/L, 0,3 mol/L, 0,3 osmol/L.

CHIfONG 10: XET NGHIEM TIN CAY VA KIEM TRA CHAT LUONG XET
NGHIEM
A.Cau hoi to hvyng gia
1.A 2.B 3.B 4.B 5.D
B.Cau hoi nghien cum
1.Glucose có thay doi, chit cho la flor
2.Ion Mg2+
3.CO anh hucmg, do chinh xac

348
 BANG TRA TO'

1,25 dihydroxyl vitamin D, 22, 23 Aaminotransferase, 114

la-hydoxyl, 26 Ammoniac, 87, 118
132-microglobulin, 280, 300 Angiotensin I, 8, 76, 92
f3-thalassemia, 26 Angiotensin II, 8, 76, 92
ANP, 8, 9, 74, 76, 169
A Apo, 145, 146, 150
Acid - base, 14, 39, 40, 56 Apo AI, 145, 146
Acid amin, 21, 23, 24, 40, 44, 46, 47, 53, 64, 74, Apo B, 146, 150
77, 108, 115, 148, 167, 170, 183, 184, 185, Apolipoprotein, 143, 145
186, 187, 190, 194, 201, 299, 331
Aspartat aminotransferase, 114
Acid carbonic, 40, 43, 44, 88
AST, 109, 114, 115, 121, 122, 123, 128, 163,
Acid chuen dO, 50, 52, 55 164, 165, 173, 174, 244, 245, 282, 284, 289,
Acid hippuric, 77, 111, 112, 125 294, 300
Acid uric, 47, 52, 74, 76, 80, 81, 93, 97, 299, 300, AVP, 183, 190, 191, 196, 198, 199
335, 336
ACTH, 182, 183, 186, 187, 192, 195, 196, 206, B
216, 335
Bai tit chit mau, 78
ADH, 5, 6, 7, 10, 14, 74, 76, 96, 113, 183, 190,
191, 299 Bai ti et mat, 100, 107, 110
Base am, 56
AFP, 230, 260, 261, 262, 263, 281, 282, 283, 284,
285, 286, 287, 289 B'kih 13'T gan met, 100
AFP-13, 262, 263, 281 Bilh1Simach vanh, 132
AFU, 263, 281 B'kih Willson, 26
AG, 63, 64, 307 Bicarbonat, 3, 16, 23, 28, 39, 43, 44, 45, 48, 49,
Alanin aminotransferase, 114 50, 51, 53, 56, 57, 62, 64, 96
Bicarbonat chuen, 56
Albumin, 6, 11, 26, 27, 28, 87, 88, 93, 96, 97,
100, 109, 116, 121, 122, 123, 125, 130, 203, Bicarbonat thirc, 56
231, 235, 237, 239, 242, 244, 245, 288, 289, Bilirubin, 82, 89, 110, 112, 113, 114, 128, 228,
291, 292, 293, 294, 300 294, 300, 322, 335, 336, 337
Aldosteron, 7, 8, 9, 12, 14, 15, 16, 17, 30, 64, 74, Bilirubin GT, 110
76, 86, 96, 125, 299
Bilirubin huyk thanh, 113
Alkalin phosphatase, 114, 115
Bilirubin mall, 113, 336
Alpha - fetoprotein, 261
Bilirubin TT, 110
ALT, 109, 114, 115, 121, 122, 127, 128, 174, 244,
Bilirubin-huyk, 113
245, 282, 284, 289, 294, 300, 330, 337

349
HOA SINH LAM SANG
Bladder tumor antigen, 280
BTA, 280, 281
C Cholin, 160, 161, 173
C3, 109, 236
CA, 26, 46, 47, 51, 52, 54, 80, 96, 97, 99, 100,
216-219, 231, 242, 260, 263-265, 267, 268,
270, 274-276, 280-285, 287, 288, 289, 291,
292, 294, 307, 309, 325, 330
CA 125, 260, 263, 264, 265, 267, 268, 281, 282,
283, 284, 285, 287
CA 15-3, 260, 270, 281, 282, 285, 287, 288
CA 19-9, 260, 276, 281, 291, 292, 294
CA 27-29, 280
CA 72-4, 260, 274, 275, 276, 281, 282, 291, 292
Calci, 3, 20-27, 30, 33, 47, 89, 92, 94, 148, 167,
187, 200, 240, 301, 307, 308, 309, 316, 332
Calci mau, 21, 22, 23, 24, 26
Calci n*, 21, 25, 26
Calcitonin, 22, 24, 32, 200, 280, 281, 335
Can Addis, 79, 100
Can n*, 82, 87, 89, 93, 99
Cancer antigen 125, 263
Cancer antigen 15-3, 270
Cancer antigen 19-9, 276
Cancer antigen 72-4, 274
Carbonic anhydrase, 20, 46, 75
Carcinoembryonic antigen, 230, 268
Cu than, 8, 14, 17, 28, 33, 50, 52, 65, 70-74, 77-
79, 87, 89, 91-95, 97, 295, 299
Cu true dai th6, 65
Cu true vi th6, 70
CEA, 122, 230, 260, 268, 269, 270, 271, 272,
275, 281, 282, 284, 285, 286, 287, 288, 289,
291, 292, 294
Ceruloplasmin, 97, 122, 300
Ceton, 5, 20, 34, 64, 65, 82, 88, 89, 108, 111, 184
Chi deli sinh hoc, 160, 163, 169
Chi &Au ung thu, 245, 250, 253, 260, 268, 270, 277
350
Cholesterol, 95, 96, 107, 109, 110, 143, 144, 145,
146, 147, 148, 150, 174, 175, 205, 210, 215,
216, 219, 220, 233, 235, 239, 289, 292, 294,
322, 337
Chuy'L hoa, 1, 5, 7, 9, 14-16, 18-24, 26, 28, 30,
32, 33, 39, 40, 44, 46, 47, 53, 55-57, 61-65,
73-75, 77, 81, 83, 87, 88, 93, 94, 100, 108,
109, 112, 113, 115, 145, 147, 148, 155, 164,
175, 182-184, 186, 190, 204-206, 208, 227,
239, 256
Chuy'L Ma, 1, 7, 18, 20, 28, 31, 64
Chuy& h6a glucid, 32, 40, 94, 100, 183, 204
Chuy"C'n Ma lipid, 145, 148, 184, 204
Citrat, 21, 27, 28, 47, 64, 74, 333, 334
CK, 163, 164, 165, 166, 167, 168, 169, 173, 174,
175, 300, 337
CK-MB, 163, 164, 165, 167, 168, 173
Clor, 18, 19, 20
Clorua, 3, 16, 18, 19, 20, 240
Can dau that nguc, 148, 155, 219
Creatinin, 17, 25, 27, 52, 76-78, 80, 81, 92-95,
97, 130, 131, 174, 215, 216, 218, 242, 244,
245, 282, 284, 289, 299, 300, 309, 311, 322,
335, 336, 337
Creatinin mau, 80, 92
CRP, 109, 122, 131, 160, 173, 217, 230
Cyfra 21-1, 260, 271, 272, 273, 281, 294
Cytokin, 22
D
DCP, 263, 281
Decarboxy prothrombin, 263
Dich bach huy6t, 239, 240
Dich khap, 239, 295, 300
Dich mang bung, 130, 232, 242, 244, 245
Dich mang ngoai tim, 236, 237
Dich mang ph.6i, 233, 234, 235, 243, 244, 265,
300
Dich met, 64, 239, 300

Dich Vac. tuy, 220, 227, 228, 229, 232, 269, 295,
300, 333
Dich ruOt, 4, 239, 300
Dich sinh vat, 220
Dich tham, 220, 232, 233, 234, 235, 298
Dich ti&, 220, 232, 233, 235, 238, 244, 295, 298
Dich tuy, 64, 239, 300
Dich vi, 9, 300
DNTB, 1-3, 7, 8, 10, 11, 14, 18, 20, 21, 23, 31, 53
DTTB, 1, 2, 3, 7, 8, 14
D 325, 332, 333, 334, 335, 337
Di&I di, 25, 26, 96, 99, 100, 109, 115, 116, 122,
125, 164, 230, 334
Dien di protein huy& thanh, 109
Do chinh xac, 212, 322, 339
DO thanh thai, 25, 77, 78, 97, 309
DO xac thvc, 322, 339, 340
Dirong huy&, 10, 107, 108, 184, 185, 186, 194,
195, 204, 322
E
Enzym, 8, 14, 28, 52, 87, 88, 100, 107, 109, 110,
113-115, 144, 148, 157, 163, 164, 165, 166,
169, 201, 202, 204, 209, 211, 212, 213, 215,
239, 260, 263, 272, 310, 322, 335, 336
Enzym carbonic anhydrase, 52
Enzym gan, 114
F HbsAg, 120, 128, 282, 288, 289
Fibrin, 112, 151, 299, 328, 333
Fibrinogen, 100, 112, 116, 122, 125, 240, 299,
334
FSH, 182, 187-189, 192, 196, 197, 216, 217, 219,
220
FT3,193, 209, 210, 211, 216, 217, 218, 219, 220
FT4,193, 209-211, 212, 213, 216-220
BANG TRA Tif
G
Galactose ni&I, 108, 125
Gamma glutamyltransferase, 114
GGT, 114, 115, 121, 122, 130, 289, 294
GH, 94, 182, 183, 184, 185, 186, 187, 192, 193,
194, 195, 216, 217, 219, 220, 335
Glucid, 74, 75, 107, 184, 185, 206, 261
Glucose, 10, 74, 77, 82, 88, 89, 94, 107, 108,
130-132, 174, 184, 187, 193, 195, 204, 205,
215, 216, 217, 218, 219, 220, 229, 231, 232,
235, 238, 240, 241, 244, 245, 282, 284, 286-
289, 291-294, 299, 300, 301, 308, 311, 316,
Glucose huy&t, 108, 131, 132, 218, 238, 308
Glutamat oxaloacetat transaminase, 114
Glutamat pyruvat transaminase, 114
Glycoprotein, 188, 189, 190, 200, 201, 260, 261,
263, 266, 268, 274, 276, 279
GOT, 109, 114, 130, 131, 132, 163, 215, 216,
218, 240, 241, 242
GPT, 109, 114, 130, 131, 132, 215, 216, 218,
240, 241, 242
H
W, 14, 15, 39, 40, 41, 42, 44, 45, 46, 47, 49, 50,
51, 52, 53, 54, 55, 56, 57, 58, 59, 61, 62, 63,
64, 65, 74, 75, 76, 92, 93, 94, 96, 113
H2CO3, 40-44, 46, 48, 49, 52, 55, 56, 61, 75
HbcAg, 120
HbeAg, 120, 128
hCG, 230, 260, 279, 281, 283, 284, 285
HCO3-, 4, 17, 39, 40, 41, 44-48, 50-52, 54, 56-
59, 62-65, 74, 93, 94, 130, 238, 239
Hct, 5, 6, 11, 130, 131, 132, 217, 242, 244, 245,
282, 284, 285, 286, 287
HDL, 109, 144-147, 149, 150, 174, 175
HDL-C, 144, 145, 147, 150
He dem Hb, 39
M am hemoglobin, 45, 46
351
HOA SINH LAM SANG

He dem phosphat, 44, 45 Lipid, 10, 32, 40, 52, 54, 74, 75, 94, 95, 96, 99,
He dem protein, 46, 47 100, 107, 108, 109, 143, 144, 145, 146, 148,
149, 150, 151, 183, 194, 204, 205, 206, 217,
He s9 19c cdu then, 17, 33, 73, 95 235, 291, 293, 294, 300, 337
He so thanh thai, 76, 77, 93, 94
Lipid huyet tuang, 143
He thong don vi qu9c te, 301, 302, 305
Lipid toan phdn, 143, 144
He thidng TNM, 258 Lipoprotein, 96, 132, 143, 144, 146, 206, 299, 337
HE4, 260, 266, 267, 268, 281, 283, 284
Lipoprotein mau, 132
Henderson - hasselbalch, 41
LP, 115, 143, 144, 145, 146, 147, 148, 149, 150
Heparin, 17, 58, 198, 298, 329, 333, 334
LP huyect, 148, 150
119i chi ng mach vanh cap, 132
HP042-, 31, 45, 51, 55, 56
M
HPr, 42, 46
Magie, 3, 15, 27, 28, 29, 30, 89, 92, 94, 240
Human chorionic gonadotropin, 279
MDH, 114
Human epididymal protein 4, 266
MPO, 160, 173
Mu9i mat, 110, 130, 239
I
Myeloperoxidase, 160
Iod, 200-202, 208-211, 214, 215, 307
Myoglobin, 87, 163, 166, 168, 169
Iodur, 201, 207

K Nat, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 18,
K+, 3, 4, 7, 8, 14, 15, 16, 17, 30, 47, 64, 74, 76, 92,
99, 130, 132, 175, 204, 216, 231, 238, 241, 242,
244, 245, 300, 309, 325, 331, 332, 334, 336
Kali mau, 15, 16, 17, 217, 244
Kali nieu, 15
Khoang mang ngoai tim, 236
L Natri nieu, 9
Lactat dehydrogenase, 163, 334
LCAT, 144, 145
LDH, 114, 163, 164, 165, 173, 174, 175, 230,
233, 235, 238, 244, 334, 335, 336
LDL, 109, 144, 145, 146, 147, 148, 149, 150,
174, 175, 206
LDL-C, 147, 149
LH, 182, 187, 188, 189, 190, 192, 196, 197, 216,
217, 219, 220
N
21, 47, 52, 53, 54, 61, 63, 64, 65, 74, 75, 76,
92, 99, 130, 132, 175, 204, 216, 231, 238, 239,
241, 242, 244, 245, 299, 300, 330, 332
NaHCO3, 42, 43, 44, 47, 75
Natri, 3, 5, 7, 8, 9, 10, 11, 12, 14, 19, 20, 27, 76,
94, 96, 169, 170, 198, 240, 307, 309, 311
Natri mau, 10, 11, 19, 20, 198
Nephron, 18, 70, 71, 72, 75, 93, 94
Neuron-specific enolase, 272
Nghiem phap bai -Wet xanh methylen, 79
Nghiem phap PSP, 78
Nghiem phap TRH, 212, 213
NH3, 40, 47, 51, 52, 53, 54, 55, 56, 61, 65, 75,
80, 96, 109, 111, 116, 118, 122, 125, 130, 245
NH4+, 52, 53, 54, 55
Nhfem lien cdu khudn, 94, 95
Nhiem toan chuy9n Ma, 94, 96

352

Nh6i mall co' tim, 30, 148, 149, 157, 175, 237
Nita mall, 116
NSE, 260, 272, 273, 274, 281
Nuoc bot, 94, 238, 300
Nulk tiL, 5, 7, 8, 10, 14, 15, 18, 21, 25, 30, 32,
45, 47, 52, 53, 54, 55, 56, 64, 65, 70, 71, 73,
77, 78, 79, 80, 81, 82, 83, 86, 87, 88, 89, 92, 93,
94, 95, 96, 97, 99, 108, 110, 111, 112, 113, 114,
130, 131, 191, 198, 199, 215, 216, 259, 260,
280, 282, 284, 285, 294, 299, 311, 332, 336, 337
0 Pr, 42, 46, 56
Ong Op, 8, 9, 14, 18, 32, 50, 52, 54, 56, 71, 76,
191, 299
Ong lugn gAn, 8, 21, 23, 32, 47, 50, 52, 70, 71, 299
Ong loan xa, 8, 14, 21, 23, 32, 52, 64, 71, 299
Ong than, 10, 15, 16, 17, 21, 30, 33, 45, 50, 51,
52, 53, 54, 55, 56, 62, 64, 65, 70, 71, 73, 74,
75, 76, 77, 78, 79, 80, 87, 89, 91, 92, 94, 95,
96, 295, 299, 300
Oxalat calci, 89
Oxytocin, 183, 191
P
Parathyroid hormon, 23, 47
PCO2, 39, 44, 49, 56, 57, 59, 61, 62, 64, 65, 130,
132, 231
pH, 19, 20, 28, 39, 40, 41, 42, 44, 45, 47, 48, 52,
55, 56, 57, 58, 59, 61, 62, 64, 65, 82, 87, 88,
89, 93, 130, 132, 182, 227, 231, 233, 235, 285-
288, 290-293, 294, 325
pH mall, 19, 20, 39, 42, 48, 55, 56, 325
Phenol, 78, 112
Phosphat, 3, 21, 23, 24, 27, 28, 31, 32, 33, 34, 39,
45, 48, 52, 81, 89, 92, 94, 109, 115, 164, 335
Phosphat mau, 24
Phosphat ni.@.1, 23, 32
Phosphate huyk 27
Phospholipid, 31, 109, 143, 144, 145, 146, 205
Phu, 6, 12, 20, 59, 60, 74, 92, 93, 94, 96, 98, 99,
BANG TRA TO'
100, 121, 128, 155, 186, 208, 209, 210, 237,
241, 270, 289, 294, 326, 327
Phucmg trinh Henderson - Hasselbach, 39
pK, 42, 45, 48, 52, 53, 55
Placental growth factor, 161
Plasmin, 112
Plasminogen, 112
PLGF, 160, 161, 173
P02, 130, 132, 231
Porphyrin, 112
PRL, 182, 187, 188, 192, 196
Progastrin-releasing peptide, 274
ProGRP, 274, 281
Prolactin, 182, 187, 188, 192, 196, 216, 217, 219, 220
Prostaglandin, 22, 24
Prostaglandin E, 24
Protein, 6, 10, 21, 23, 25, 26, 28, 40, 42, 46, 47,
48, 61, 63, 74, 77, 80, 82, 87, 88, 89, 92, 93,
94, 95, 96, 97, 99, 100, 109, 116, 117, 122,
130, 146, 166, 167, 183, 184, 185, 191, 195,
203, 204, 206, 211, 214, 215, 218, 219, 220,
228, 229, 231, 232, 235, 238, 239, 240, 241,
242, 243, 244, 245, 254, 259, 260, 266, 271,
278, 282, 284, 299, 300, 335
Protein huy6t, 25, 77, 220, 229
Protein niN, 25, 87
Prothrombin, 28, 100, 112, 117, 121, 125, 263,
329, 335
Protid, 32, 47, 75, 76, 93, 94, 99, 100, 109, 122, 287
PTH, 21-24, 26, 27, 30, 32, 33, 47, 74, 76
PTHrP, 25, 26
Pyruvat, 108, 114
Q
Quai Henle, 50, 54, 70, 71, 72, 74, 76, 299
R
Renin, 8, 9, 16, 17, 92, 335
353
HOA SINN LAM SANG

S Tuyen not net, 175, 182, 183, 199, 205

'a to met, 110, 113, 114, 127, 129, 130, 239
Sc Tuyen yen, 10, 175, 182, 184, 185, 186, 187, 188,
SCC, 271, 272, 281 189, 190, 192, 193, 194, 195, 196, 198, 206,
207, 208, 209, 211, 212, 214, 216, 217, 219
Squamous cell carcinoma, 272
Tyrosin, 200, 201, 202
Stercobilin, 110
Stercobilinogen, 110, 130
U
Suy than cap, 6, 9, 30, 33, 65, 81, 82, 90, 91, 92,
97, 132 Ung thu, 25, 115, 124, 164, 209, 213, 214, 228,
229, 230, 232, 233, 234, 235, 244, 245, 250,
Suy then man, 9, 65, 79, 83, 90, 91, 93, 94, 96,
251, 252, 253, 254, 255, 256, 257, 258, 259,
97, 99, 100
260, 261, 262, 263, 264, 265, 266, 267, 268,
269, 270, 271, 272, 273, 274, 275, 276, 277,
T 278, 279, 280, 281, 283, 288, 289, 335
T3, 24, 94, 190, 200, 201, 203, 204, 207, 210, Ure, 5, 10, 11, 17, 33, 74, 76, 77, 78, 80, 81, 87,
211, 212, 220, 259, 300 91, 92, 93, 94, 95, 96, 97, 109, 111, 116, 118,
T4, 24, 94, 190, 200, 201, 203, 204, 207, 210, 122, 125, 130, 175, 219, 282, 284, 299, 300,
211, 220, 259, 300 301, 311
Te bao ung thu, 250, 252, 253, 255, 263, 274, Ure-huyet, 80, 93, 95, 96, 97, 118
275 Urobilinogen, 82, 88, 89, 110, 113, 114, 122, 130
Tg-Ab, 214, 215
Than hu, 12, 20, 65, 80, 83, 90, 91, 93, 96, 97, V
100, 234, 265 Yang da, 89, 100, 113, 114, 121, 127, 129, 130,
Theng bang acid - base, 43, 56, 57 132, 145, 291, 293, 294
Thay sau tuyen yen, \ 190, 198 Viem eau than, 65, 80, 81, 89, 90, 91, 93, 94, 95,
Thuy truov tuyen yen, 183, 190, 216 96, 97
Thyroglobulin, 190, 200, 201, 202, 207, 209, Viem gan sieu vi cap, 127
213, 214, 215, 279, 280, 281, 290 Viem than ice, 19, 79, 90, 93, 95
TPO-Ab, 215 Virus viem gan, 120, 128, 237
TPSA, 276, 277, 278, 281, 293 VLDL, 109, 144, 145, 146, 147, 148, 149
TRab, 214
Triglycerid, 96, 108, 109, 110, 144, 145, 146, X
150, 205, 335, 336, 337 Xet nghiem tin cay, 322
Triglyceride-huyet, 95 Xo. gan, 6, 20, 80, 112, 116, 118, 123, 124, 125,
TSH, 94, 182, 190, 192, 193, 198, 207, 208, 209, 129, 130, 131, 144, 145, 232, 234, 245, 261,
210, 211, 212, 213, 214, 215, 216, 217, 218, 262, 270, 275, 288, 289
219, 220, 300 Xa vita deng mach, 143, 144, 145, 146, 147, 148,
TT3,209, 210, 211 149, 161, 205, 210
TT4,209, 210, 211
Tuyen giap, 10, 24, 94, 175, 182, 183, 190, 192,
199-203, 207-220, 245, 251, 256, 270, 280,
283, 286, 287, 289, 290

354
 MUC LVC

CHVONG 1: CHUYEN HOA NUtiC — MUOI VO CO 1

1. CHUYEN HOA MAC 1
1.1. DO ctrcmg ve su phan b6 ntroc 1
1.2. Nu& va n6ng c16 them th'eu DNTB 3
1.3. Nu& va vai tro cue ADH 4
1.4. R6i loan chuy6n hoe nu& 5
2. CHUYEN HOA NATRI 7
2.1. Dai cuong ve sir phan b6 natri 7
2.2. Natri va DNTB 7
2.3. Vai tro cue natri 8
2.4. Vai tro cila then trong diL hem. natri 8
2.5. ANP (peptid bai natri 9
2.6. R6i loan chuy6n hoa natri 9
3. CHUYEN HOA KALI 13
3.1. Deli ctrung v" sur phan b6 13
3.2. Vai tro cue IC 14
3.3. Vai tro cila than 14
3.4. R6i loan chuy6n hem Kali 15
4. CHUYEN HOA CLORUA 18
4.1. Dai ctrcmg 18
4.2. Ngu'on cung cap clor 18
4.3. DiL hoa Clorua 18
4.4. R6i loan chuy6n hoa clorua 18
5. CHUYEN HOA CALCI 21
5.1. Dai cuang ve su phan b6 calci 21
5.2. Vai tro cue calci 22

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HOA SINN LAM SANG

5.3. Kim sodt sir chuyen h6a calci 22

5.4. R6i loan chuy6n haa calci 24
6. CHUYEN HOA MAGIE 28
6.1. Dai cuang v6 str phan b6 magie 28
6.2. Luang magie phan b6 trong cdc mO 33
6.3. Rai loan chuy6n h6a magie 30
7. CHUYEN HOA PHOSPHAT 31
7.1. Dai cuang ves six phan b6 phosphat 31
7.2. Vai trO cua phosphat 32
7.3. Kim sodt 32
7.4. R6i loan chuyen hoa phosphat 33

CHUCiNG 2: THANG BANG ACID-BASE 39

1.DAI CUONG 39
1.1. Khdi niem acid — base 40
1.2. Khal niem pH 40
1.3. Phucmg trinh Henderson — Hasselbalch 41
1.4. Cdc y6u to dnh huang d6n pH mdu 42
2. VAI TRO CUA HE THONG DEM TRONG DIEU HOA
THANG BANG ACID - BASE 43
2.1. He dem bicarbonat /acid carbonic (NaHCO3/H2CO3) 44
2.2. He dem phosphat: Na2HPO4/NaH2PO4 (HP042-/H2PO4) 45
2.3. He dem hemoglobin 45
2.4. He Om protein: Pr/HPr 46
2.5. Tdc dung dem cua xuang 47
2.6. Khd Wang Om cua cdc he Om khdc nhau 48
3. VAI TRO CUA PHOI TRONG DIEU HOA ACID-BASE 48
4. VAI TRO CUA THAN TRONG DIEU HOA ACID - BASE 50
4.1. Su tai hdp thu bicarbonat o 6ng than 50
4.2. Six tan tao HCO3- d t6 bdo 6ng than 51
4.3. Vai tr6 cud enzym carbonic anhydrase (CA) 52

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 MUG' LUC

4.4. Acid chuen dO 52

4.5. Sir bai ti& NH3 52
4.6. San xuet NH4+ 53
4.7. Sir bai tiet NH3 vao long 6ng gop a phen vo va tuy 54
4.8. Su tai hap thu NH4+ 54
4.9. Dieu Ilea bai tiet NH4+ 55
5. CAC THONG SO DANH GIA THANG BANG ACID - BASE 56
6. ROI LOAN THANG BANG ACID - BASE 57
6.1. Cac r6i loan acid - base don thuen 58
6.2. Cac r6i loan acid - base hiin hop 65

CHVONG 3: HOA SINH LAM SANG 13tNH IA( THAN 69

1.DAI CUONG VE CAU TRUC THAN 69
1.1. Cau truc dai the 69
1.2. Cali truc vi the 69
2. CH(JC NANG CtJA NEPHRON 71
2.1. Chirc nang loc cua ceu then 72
2.2. Chirc nang cua 6ng than 73
3. CAC XET NGHIEM HOA SINH THAM DO CEItt NANG THAN 75
3.1. Tham dO to chic than bang N s6 thanh thai (clearance) 75
3.2. Tham do chic Wang bai tiet chat mau 77
3.3. Tham do chirc nang c6 dee va pha loang mac lieu 78
3.4. Tinh hru luong to bao trong nu6c tieu 78
3.5. Ket hop cac xet nghi&n khac 79
4. HOA SINH LAM SANG MOT SO BENH THAN 89
4.1. Viem ceu than 90
4.2. Suy than cap 90
4.3. Suy then man 92
4.4. Viem eau then cap sau nhi6m lien eau khuen o tre em 93
4.5. Viem ceu than man 94

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HOA SINH LAM SANG

4.6. Viem than Ice 94

4.7. 110i chirng than hu 95
4.8. Nhi'em dOc thai nghen 96
5. GIOI THIEU MOT SO BENH AN 97

Chuang 4: HOA SINH LAM SANG BENH I.Ar( GAN MAT 105
1. SO LU'OC GIAI PHAU HE GAN MAT 105
1.1. Sa lugc ve he gan mat 106
1.2. Cu tao vi th6 to bao gan 106
2. CHOC NANG HOA SINH GOA GAN 107
2.1. Chirc nang glucid 107
2.2. Chirc nang lipid 108
2.3. Chirc nang protid 109
2.4. Chirc nang tao va bai tiet mat 110
2.5. Chirc rang khir d'ec 110
2.6. Chirc nang long mau 112
2.7. Chirc nang du frit' cac chat 112
2.8. Chirc nang chuyen hoa porphyrin 112
2.9. Chuyen hoa cac chdt khac 112
2.10. Chirc nang chuyen hoa va thai trir thu6c 113
2.11. Chirc nang van chuyen nuerc 113
3. CAC XET NGHIEM THUUNG DONG TRONG CHAN DOAN
BENH GAN MAT 113
3.1. Bilirubin—huyet, sac to mat va urobilinogen trong nuerc tieu 113
3.2. Xet nghiem ve enzym gan 114
3.3. Xet nghiem ye protein, cac d'An xuAt Nito. 116
3.4. Xet nghiem ve virus viem gan 120
4. Sfi DUNG CAC XET NGHIEM TRONG CHAN DOAN BENH GAN MAT 121
4.1. Sir dung xet nghiem trong than doan benh gan mat 121
4.2. Cac hei thong xet nghiem trong viem gan 122
4.3. Cac xet nghiem chuyen biet khac 122

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 MliC LUC

4.4. Xet nghi'em chi c nang gan theo phan loci va chan doan cac the benh gan 123
4.5. Phan loai benh gan 123
4.6. DiL bien tlr nhien cua benh gan 124
4.7. Loi ich cna xet nghiem chan doan cac benh gan 124
5. HOA SINH LAM SANG MOT SO BENH GAN - 124
5.1. Xo gan 124
5.2. Viem gan sieu vi cap 127
5.3. Cac benh lY gay yang da 129
6. GIOI THIEU MOT SO BENH AN 130

CHCONG 5: HOA SINH LAM SANG BENH I.S/ MACH VANH CAP 141
1. DAT CUONG 141
1.1. Benh tim mach 141
1.2. Lipid, apolipoprotein, lipoprotein (LP) huyet tucmg 142
1.3. Xa vita dOng mach — hau qua 147
1.4. Fltii chimg mach vanh cap (HCMVC) 152
2. XET NGHIEM CHI DAU SINH HOC 159
2.1. Cac chi dau sinh hoc truac HCMVC 159
2.2. Cac chi cldu sinh hoc trong HCMVC 161
2.3. Suy tim sau HCMVC 168
3. GIOI THIEU MOT SO BENH AN 173

CHUONG 6: HOA SINH LAM SANG BENH LY TUYEN NOI TIET 181
1. DANH GIA CHI C NANG TUYEN YEN 182
1.1. Chirc nang sinh 1y thny truck tuyen yen 183
1.2. Chirc Wang sinh ly thny sau tuyen yen 190
1.3. Benh 1ST tuyen yen 192
1.4. Tham do eh& nang tuyen yen 193
2. DANH GIA CHUG NANG TUYEN GIAP 199
2.1. Chirc nang sinh 13'T tuyen giap 199

359
HOA SINN LAM SANG

2.2. Vai tro ciza hormon tuyen giap trong to chirc to bao 203
2.3. Diet h6a bai tiet hormon tuyen giap 207
2.4. Rei loan chile nang tuyen giap 208
2.5. Xet nghiem chirc nang tuyen giap 210
2.6. Cac xet nghiem lien quan 212
3. GIOI THIEU MOT SO BENH AN 215

CHUONG 7: DICH SINH VAT 225

1. DICH NAO TUY 225
1.1. Su two thanh va chirc nang cua DNT 225
1.2. Tudn hoan dich nap My 226
1.3. Khao sat dich nao tuy 226
2. DICH MANG BUNG 231
2.1. Dinh nghia 231
2.2. Phan loci 231
2.3. Cac xet nghiem khao sat dich mang bung 231
2.4. M6t se tieu chuan chdn clown phan biet dich thdm, dich tiet 232
3. DICH MANG PHOI 232
3.1. Cac loci dich mang phi 233
3.2. Cac nguyen nhan gay tran dich mang phei 233
3.3. Xet nghiem dich mang phi 234
4. DICH MANG NGOAI TIM 235
4.1. Daz diem khoang mang ngoai tim 235
4.2. Nguyen nhan tran dich mang ngoai tim 235
4.3. Xet nghiem dich tim nguyen nhan 237
5. MOT SO THANH PHAN KHAC CUA DICH CO THE 237
5.1. Nuot bot 237
5.2. Dich vi 237
5.3. Dich runt 238
5.4. Dich tuy 238

360
 MUC LUC

5.5. Dich mat 238

5.6. Dich bach huy6t 238
5.7. Dich khop 238
6. GIOI THIEU MOT SO BENH AN 239

CHCONG 8: CHI DAU UNG THU' (TUMOR MARKERS) 249

1. DAI CUONG 249
1.1. Ung thu la gi? 249
1.2. Chi du ung thu la gi? 249
2. INCH TE HOC BENH UNG THU' 250
3. CO CHE SINH BENH UNG THU' 251
3.1. Ngu'on g6c ung thu 251
3.2. Dac tinh to bao ung thu 251
3.3. CosophanBrcua te baoungthu 252
4. NGUYEN NHAN VA YEU TO NGUY CO GAY UNG THIS 254
4.1. Y6u to hoa hoc 255
4.2. Ye'u to vat 13'7 255
4.3. Yecu to sinh hoc 256
5. CAC GIAI DOAN TIEN TRIEN CUA UNG THU' 256
5.1. Giai 'loan khoi phat 256
5.2. Giai loan tang twang, thiic day, chuye'n bin 256
5.3. Giai doan lan tran 256
5.4. Giai doan tin tries'n - xam Ian - di can 257
6. HE, THONG TNM 258
6.1. Kh6i u nguyen phat (primary tumor) 258
6.2. Hach viIng (regional lymph nodes) 258
6.3. Di can xa (distant metastasis) 258
6.4. Phan giai doan 258
7. GIOI THIEU MOT SO CHI DAU UNG THIS 259
7.1. Theo dung lich sir 259

361
FIOA SINN LAM SANG

7.2. Uu di6m dm chi dau ung thu 259

❖ AFP (ALPHA — FETOPROTEIN) 260
❖ CA 125 (CANCER ANTIGEN 125) 263
❖ HE4 (Human epididymal protein 4 — Protein mao tinh)• 265
❖ CEA (Carcinoembryonic antigen) 267
❖ CA 15-3 (Cancer Antigen 15-3) 269
❖ CYFRA 21-1 270
❖ SCC (Squamous cell carcinoma) 271
❖ NSE (neuron-specific enolase) 271
•S ProGRP (Progastrin-releasing peptide) 273
❖ CA 72-4 (Cancer Antigen 72-4) 273
❖ CA 19-9 (Cancer Antigen 19-9) 275
•3 MOT SO CHI DAU (TUMOR MARKERS) KHAC 278
hCG va (3hCG (human Chorionic Gonadotropin) 278
Thyroglobulin 278
132-microglobulin 279
Bladder tumor antigen (BTA) 279
Calcitonin 279
CA 27-29 279
8. GIOI THIEU MOT SO BENH AN 281

CHIXONG 9: CAC DICH CO THE, NGHIEM PHAM VA CAC

XET NGHIEM HOA SINH LAM SANG 297
1. DICH CO THE VA NGHIEM PHAM 297
1.1. Sr phan 1716 nuo.c va cac dich co. the 297
1.2. Nghi'm pham 298
1.3. Cac xet nghiem hoa sinh lam sang 300
1.4. Xet nghi"e'm va not thgc hien cac IcST" thu4t xet nghiem 301
1.5. Nghilem phap 301

362
 MUC LUC

2. TRINH BAY KET QUA XET NGHIEM 301

2.1. HO thOng don vi quOc t6 (SI) 302
2.2. Trinh bay va biL thi cac k6t qua XN 311

CHVOING 10: XET NGHIEM TIN CAY VA KIEM TRA CHAT XET NGHIEM 321
1. XET NGHIEM TIN CAY 321
1.1. DO chinh )(de (d0 tin hay dO lap) 321
1.2. DO xac thkrc (dO dung) 322
2. DAM BAO CHAT LU'ONG XET NGHIEM 323
2.1. LAy mau 324
2.2. Cac giai doan xet nghiOrn 338
2.3. Giai doan sau xet ngh*n 340
BANG TRA 349
TAI LIEU THAM KHAO 364

363
HOA SINN LAM SANG

TM lieu tham khdo

1. Trinh Binh Dy, D8 Dinh HO..., 1982; Ve nhirng thong s6 sinh hoc ngireti Viet Nam;
Nha xuat ban Y hoc.
2. D8 Dinh H6, 1994; Lipid va r6i loan chuy'en h6a lipid; Tap chi Y hoc-DHYD
TP.HCM; S6 chuyen de lipid.
3. D8 Dinh H6 va cong su, 2010; H6a sinh lam sang; Nha xuat ban Y hoc- chi nhanh
TP.116 Chi Minh.
4. D8 Dinh H6 va cong su, 2010; Xet nghiem dich tan va dich nao thy; H6a sinh y
hoc; Nha xuat ban y hoc - chi nhanh TPHCM; trang 249.
5. Le Dire Trinh, Lucmg Tan Thanh, 1995; Chin doan sinh hoc mot s6 benh nOi
khoa; Nha xuat ban Y hoc.
6. Le Xuan Throng, D8 Thi Thanh Thuy, Nguygn Thi Bang Sucmg, Trail Thanh
Vinh, 2013; Nhirrig xet nghiem hoa sinh hien dai sir dung trong lam sang; Nha
xuat ban Y hoc-Chi nhanh TP.116 Chi Minh.
7. Cundy and Reid, 1995; Calcium, phosphate and magiesium; Clinical Biochemis-
try; William J., Marshall and Stephen K. Bangert; Churchill Livingstone; Chapter
6, pp: 87-116.
8. Heffner J, Brown L, Barbieri C,1997; "Diagnostic value of tests that discriminate
between exudative and transudative pleural effusions; Primary Study Investiga-
tors". Chest 111 (4), pp: 970-80.
9. Hische, E. A, Van Der Helm, H. J, Van Walbeek, H. K., 1982; The cerebrospinal
fluid immunoglobulin G index as a diagnostic aid in multiple sclerosis: A Bayes-
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10.Kaplan A, Szabo L.A, 1988; Clinical Chemistry; Lea & Febiger Philadelphia.
11. Lawrence A. Kaplan, Amadeo J.Pesce, 2010; Clinical Chemistry; 5th edition;
Mosby Elsevier.
12. Light R, Macgregor M, Luchsinger P, Ball W, 1972; Pleural effusions: the diag-
nostic separation of transudates and exudates; Ann Intern Med 77 (4), pp: 507-13.
13.Lothar Thomas, 1998; Clinical laboratory diagnosis; TH-Books Verlagsgesellschft
mbH, Frankfurt/Main; Germany; English edition.
14. Michael Penney, 1995; Sodium, water and potassium; Clinical Biochemistry; Wil-
liam J Marshell and Stephen K. Bangert; Churchill Livingstone; chapter 4, pp:
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15.Moore K. P; Wong F; Gines P; Bernardi M; Ochs A; Salerno F; Angeli P; Po-

rayko M; Moreau R; Garcia-Tsao G; Jimenez W; Planas R; Arroyo V, 2003; The
Management of Ascites in Cirrhosis: Report on the Consensus Conference of the
International Ascites Club. Hepatology 2003 (38), pp: 258-66.
16.Norman G, Levinsky, 1987; Fluids and electrolytes; Harrison's Principle of inter-
nal medicine; 11th edition; Chapter 44; pp: 198-208.
17.Reginald H. Garrett, Charles M. Grisham, 2007; Biochemistry; 3rd edition; Thom-
son-Brooks/Cole.
18.Ronald Hoffman, Edward J.Benz, Sanford J.Shattil, Bruce Furie, Harvey J.Co-
hen, Leslie E.Silberstein, Philip McGlave, 2005; Hematology Basic Principles
and Practice; 4th edition. Elsevier Churchill Livingstone.
19.Roth BJ, O'Meara TF, Gragun WH, 1990; The serum-effusion albumin gradient
in the evaluation of pleural effusions; Chest 98 (3), pp: 546-9.
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365
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