BO V LUN VN BC S NI TR

NH GI S THAY I NNG LDH

DCH MNG BNG V C3, C4 HUYT THANH
BNH NHN X GAN - NHIM KHUN DCH MNG BNG
Nguyn Minh Ngc
Ngi hng dn: PGS. TS Trn Ngc nh

T VN
TNG QUAN
I TNG & PHNG PHP NGHIN CU

KT QU V BN LUN
KT LUN

T VN
X gan: bnh l tiu ha thng gp
Mt trong nhng nguyn nhn gy t vong hng u M
Nhim trng v NKDMB: bin chng nghim trng, hay gp
X gan + nhim trng: nguy c t vong cao gp 4 ln
Tnh trng suy gim min dch, thiu ht b th
C3, C4 huyt thanh, LDH dch bng: gp phn
chn on nhim khun dch mng bng
Cha c nghin cu ti Vit Nam

Mc tiu
1

Nghin cu s thay i nng LDH dch

mng bng v C3, C4 huyt thanh bnh
nhn x gan c nhim khun dch mng
bng (NKDMB)

2
nh gi nng LDH dch mng bng,
C3, C4 huyt thanh trc v sau iu tr
bnh nhn x gan NKDMB

TNG QUAN

LCH S NGHIN CU

X gan

Hi chng
suy t bo gan

Hi chng
tng p lc
tnh mch ca

Cc bin chng ca x gan

Nhim khun
mng
bng
LCH Sdch
NGHIN
CU
nh ngha
S nhim khun ca
DMB m khng c
bng chng ngun
nhim trong bng
c th iu tr c
bng ngoi khoa

Triu chng
au bng
St
Gim nhu ng rut
i tin phn lng
Cm ng phc mc
Hi chng no gan
Hi chng gan thn

Chn on

BCNTT dch
250 TB/mm3
Cy DMB tm
thy vi khun

A. Rimola, G. Garca-Tsao, M. Navasa et al (2000). Diagnosis, treatment and prophylaxis of

spontaneous bacterial peritonitis: a consensus document. Journal of hepatology, 32 (1), 142-153.

Nhim khun dch mng bng

Khng sinh
Cefotaxim 2 g/8h
Cc cephalosporin TH3
Tazocin, Augmentin
Quinolone

Albumin

iu tr
Chc tho

iu tr khc

European Association For The Study Of The Liver (2010). EASL clinical practice guidelines on the management of
ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of hepatology, 53 (3), 397-417.

C ch bo
v ca dch
c trng

Hot ng
thc bo ca
h lin vng
ni m

S bin i
h thng
min dch

Tng tnh
thm ca
rut

C ch
bnh sinh
S lan truyn
ca vi khun
Qu pht vi
khun ng
tiu ha

J. Lata, O. Stiburek and M. Kopacova

(2009). Spontaneous bacterial
peritonitis: A severe complication of
liver cirrhosis. World Journal of
Gastro-enterology, 15 (44), 5505-5510

B th, C3, C4
Gan: sn xut hu ht cc
thnh phn b th
Vai tr p ng MD,
chng nhim khun
Hot ha b th: 3 con
ng
Nhiu nghin cu: s suy
gim C3, C4 BN x gan
NKDMB
Shalabya SA: C3 45
mg/dl c hiu 100%,
nhy 85%
Adreu M: C3< 80: yu t
tin on cho t NKDMB
u tin

ng
thay th

LDH (lactat
dehydrogenase)
LCH S NGHIN CU
Gii phng t tn thng
ca nhiu t chc
Bnh l gan: tng cao trong
gan b nhim c; tng
nh/bnh thng vi tn
thng mn tnh, x gan
LDH dch: phn bit dch
thm dch tit
Tng trong NKDMB
T s LDH dch/mu:
Lee HH: 0.4: nhy 76%,
c hiu 71%. Nu thm
BCTT> 240 H 100%
El-Touny v CS: >0.6: ch
s gin tip ca NKDMB

I TNG V PHNG PHP NGHIN CU

i tng

36 BN x gan NKDMB, iu tr ti
khoa Tiu ha BV Bch Mai,
t 11/2015 10/2016

Tiu chun X gan: hi chng suy TB gan v tng ALTMC

la chn NKDMB: BCTT dch 250 TB/mm3 hoc cy (+)

Tiu chun Vim phc mc th pht

loi tr Nghi ng lao mng bng phi hp/ung th
gan chy mu vo trong bng
Lupus, VKDT, vim cu thn, NK mn tnh
C du hiu gi nhng khng lm c
XN dch bng
iu tr khng sinh 7 ngy va qua

Phng php nghin cu

Thit k
nghin cu

Nghin cu theo di dc

PP thu thp
s liu

Theo mu bnh n nghin cu

Phn tch & SPSS 16.0: thng k m t, T-test, ANOVA

x l s liu
test, kim nh tng quan (p < 0.05)
CTM, MCB, CN gan thn, G, bilan vim,
Cc ni dung
LDH, C3, C4 huyt thanh
ch yu DMB: LDH, m s BCTT, nui cy, protein,
albumin, glucose
Thm d li sau 5 ngy iu tr khng sinh

S nghin cu
Bnh nhn x gan
C c trng
C nhim khun DMB
LDH dch mng bng
C3, C4 huyt thanh

Mt s c im
LS, CLS

MT2

LDH dch mng bng

C3, C4 huyt thanh
sau t iu tr

MT1

KT QU V BN LUN
Mt s c im chung
N

Tui: 54.92 10.89

86.1%

Nam/n: 6.2
Nam

X gan ru: 66.7%

33.3%

12

Vim gan B: 47.2%

10
8
6
4
2
0

40

41 50

51 60

61 70

>70

Mt s c im chung
Biu hin

S BN T l (%)

St
au bng
i tin phn lng
Cm ng phc mc
Hi chng gan thn
Bnh no gan

24
20
12
2
7
14

66.7
55.6
33.3
5.6
19.4
38.9

El-Motasem 2015
Hui-quiong 2009
Li Linghua 2006

B: 11.4%

Child Pugh: 12.24 1.81

BCTT DMB: 5.31 9.1 G/l
Child-Pugh C: 88.6%

54.3% c protein dch < 10 g/l

5 BN cy (+): K.pneumonia, E. coli

LDH dch mng bng

Trung bnh

Thp nht Cao nht

146.73 141.01

13.3

689

LDH mu (U/l) 289.33 135.86

169

839

0.05

1.56

LDH dch (U/l)

LDH dch/mu

0.53 0.42

4 BN c LDH DMB > LDH huyt thanh

El-Motasem EM (2015): 185.07 58.39
Albillos A (2007): 186.2 187.94
Runyon BA (1984): 173 230

LDH dch mng bng

LDH DMB BN x gan khng NKDMB
trong mt s nghin cu
LDH (U/l)
El-Motasem EM 2015 (n = 50)

84.37 33.65

Albillos A 2007 (n = 11)

67.63 46.18

Quch Th Yn 2004 (n = 48)

51.14 21.24

Hassan AE 2003 (n = 15)

49 19

Runyon BA 1985 (n = 13)

43 20

Nhiu tc gi: LDH DMB nhm c NKDMB cao hn

nhm khng nhim khun
Albillos (2007), Runyon BA (1985): theo di dc LDH
DMB khi b nhim khun cao hn so vi thi im
khng NKDMB

LDH dch mng bng

51.85%

Khng c s khc bit theo phn

loi Child Pugh, MELD, protein

48.15%

DMB, lng BCNTT DMB

LDH dch/mu
0.4

22.2%

Lee HH (1987): 1.958 0.724

Albillos A (2007) 85% BN: 0.4
El-Touny M (1989): > 0.6: cn

78.8%

LDH dch/mu >0.6

LDH dch/mu 0.6

nhc nh mt ch s gin tip

ca NKDMB

LDH dch mng bng

Tng quan nghch bin vi mc gim BCNTT
(tr s tng i) sau iu tr: r: - 0.543, p = 0.045)
Khng c tng quan vi s lng BCNTT dch

Mc gim BCTT

U/l
LDH

C3, C4 huyt thanh

C3 (mg/dl)

Trung bnh
53.81 21.02

C4 (mg/dl)

13.03 6.36

100%
90%
80%
70%

71%

60%
50%
40%
30%

29%

10%
0%

C3
Gim

30

Shalabya SA 2011, n = 20:

28.6 7.87
Chang CS 2001, n = 45:
43.1 13.6 v 12.4 4

93.5%

20%

Thp nht Cao nht

19
106

C4
Bnh thng

Bird G (1992), n = 11 :
74 (CI: 56-92) & 20 (CI: 16-24)

C3, C4 huyt thanh

2 BN: C3, C4 bnh

thng
20 BN: C3 gim,
C4 bnh thng

G.Bird 1992: mt s BN
x gan vi tn thng
vim gan ru m
khng NKDMB c th
c tng nng b th
JJ Fromkers 1982: hot
ha ch yu ng thay
th

C3, C4 huyt thanh

C3, C4 nhm BN x gan khng NKDMB
trong mt s nghin cu
C3 (mg/dl)
Shalabya SA (2011)
n = 20
Chang CS (2001)
n = 22
Andreu M (1993)
n = 110
Bird G (1992)
n = 21
Runyon BA (1985)
n = 34

C4 (mg/dl)

80.15 55.27
73.2 26.4

16.9 6.6

81.2 2.4

16.9 0.66

113 (CI: 95-131)

28 (CI: 20-36)

117 46

21 11.4

C3, C4 huyt thanh

C3 (mg/dl)
< 45

S BN (n)
13

T l (%)
41.9

45

18

58.1

< 80

29

93.5

80

6.5

Shalabya SA v CS (2011): Ngng ct 45 mg/dl

Adreu M: C3< 80: yu t tin on cho t
NKDMB u tin

C3, C4 huyt thanh

C3 (mg/dl)

C4 (mg/dl)

Child Pugh 89.5 18.59 21 6.683

B (n = 4)
p1 = 0.000
Child Pugh 48.81 15.88 11.62 5.48 p2 = 0.004
C (n = 26)

Khng khc bit gia cc nhm BN phn chia theo s

lng BCNTT, nng protein v LDH dch bng (p
> 0.05)
C3, C4 huyt thanh nhm Child Pugh C thp hn nhm
Child Pugh B (p < 0.05)
(Shalabya SA 2011, Baumann M 2004. Ellison RT 1990)

 Andreu M
1993
Guarner C
1997
Danulescu
RM 2014

Tiu cu

C3 huyt thanh

C3
Tng quan ng bin vi s lng tiu cu
(r = 0.505, p < 0.01)
Tng quan nghch bin vi im Child Pugh
(r = - 0.432, p = 0.017)

S thay i sau t iu tr

Mc gim BCNTT

Gi tr tuyt i
(G/l)
Gi tr tng i
(%)

Trung bnh

Thp nht Cao nht

3.573 7.641

0.18

32.77

70.44 27.95

16.51

98.97

LDH dch mng bng

Trung bnh

Thp nht Cao nht

LDH DMB (U/l)

104.94 81,41
(n = 17)
LDH huyt thanh
287.33 113.47
(U/l)
LDH dch/mu
0.38 0.28
(n = 16)

32

363

165

536

0.12

LDH dch gim khng c ngha thng k (p = 0.067)

T s LDH dch/mu gim (p = 0.025)

LDHLCH
dch
S mng
NGHINbng
CU
Runyon
BA (1985)

Trc

Sau

C3, C4 huyt thanh

Thp

Cao

nht
53.67 25.37 22

nht
135

Trung bnh

C3 (mg/dl)
C4 (mg/dl)

12.88 6.8

33

p
p1 = 0.672
p2 = 0.866

C3 v C4 huyt thanh trung bnh thay

i khng c ngha thng k
Wang Chen 2015: tng sau 48 tun

C3, C4 huyt thanh

KT LUN
LDH DMB: 146.73 141.01 U/l.
T s LDH DMB/huyt thanh: 0.53 0.42
51.85% BN c t s 0.4, 22.2% trn 0.6
C3, C4 huyt thanh: 53.81 21.02 v 13.03 6.36 mg/dl
93.5% BN c C3 gim, 29% c C4 gim
C3, C4 nhm Child Pugh C thp hn nhm Child Pugh B
C3 tng quan ng bin s lng tiu cu, nghch bin
im Child Pugh
LDH dch tng quan nghch bin mc gim BCTT dch (%)
LDH dch mng bng sau t iu tr gim khng c
ngha thng k
Khng c s khc bit C3, C4 trc v sau iu tr
T s LDH MDB/huyt thanh gim

Xin trn trng cm n