B Y T TRNG I HC DC H NI NGUYN TH LOAN NH GI TNH TRNG DINH DNG V KHO ST DCH TRUYN DINH DNG TRN BNH NHN SUY THN MN LC MU CHU K TI KHOA THN NHN TO BNH VIN ETRUNG NG KHA LUN TT NGHIP DC S H NI - 2013 B Y T TRNG I HC DC H NI NGUYN TH LOAN NH GI TNH TRNG DINH DNG V KHO ST DCH TRUYN DINH DNG TRN BNH NHN SUY THN MN LC MU CHU K TI KHOA THN NHN TO BNH VIN ETRUNG NG KHA LUN TT NGHIP DC S Ngi hng dn: 1.ThS.BS. Nguyn Vnh Hng 2.ThS. Nguyn Th Hng Giang Ni thc hin: 1.B mn Y hc c s 2.Khoa thn Tit niu bnh vin E trung ng H NI - 2013 LICM N Li u tin, ti xin chn thnh cm n Ban Gim Hiu trng i hc Dc H Ni cng cc thy c gio trong trng dy d ti trong sut 5 nm hc va qua. Cm n tt c cc cn b, bc s, cc anh ch ti khoa Thn-Tit Niu Bnh Vin E trung ng, cc thy c gio trong b mn Y hc c s cng nh cc thy c trong ton trng quan tm, gip v to iu kin cho ti thc hin kha lun ny. c bit ti xin gi li cm n ti thy Nguyn Vnh Hng - Trng khoa thn- tit niu bnh vin E trung ng v c gio Nguyn Th Hng Giang Ging vin b mn Y hc c s to iu kin v tn tnh hng dn ti trong sut qu trnh thc hin kha lun. Ti xin cm n c nhn Phm Vn Phng iu dng trng ti khoa TNT ca bnh vin E lun nhit tnh gip , ch bo ti ti hon thnh kha lun. Cui cng, ti xin c gi li cm n ti gia nh, bn b v nhng ngi thn lun chia s, ng vin ti trong sut thi gian qua. H Ni, thng 5 nm 2013 Sinh vin Nguyn Th Loan MC LC Trang DANH MC CC CH VIT TT DANH MC CC BNG DANH MC CC BIU T VN ..1 Chng 1. TNG QUAN...3 1.1.SUY THN MN.3 1.1.1.nh ngha..3 1.1.2.Phn loi suy thn..3 1.1.3.Phng php iu tr..3 1.2.IU TR SUY THN MN BNG THN NHN TO CHU K.5 1.2.1.Nguyn l ca thn nhn to..5 1.2.2.Cc phng tin tin hnh.5 1.2.3.Tin hnh lc mu..6 1.2.4.Bin chng bnh nhn suy thn mn lc mu chu k6 1.3.BIN CHNG SUY DINH DNG BNH NHN STM-LMCK.7 1.4.DINH DNG TRONG SUY THN MN LC MU CHU K...7 1.4.1.Nhu cu protein..7 1.4.2.Nhu cu nng lng...8 1.4.3.nh hng ca lc mu n tnh trng dinh dng..8 1.4.3.1.Yu t k thut.8 1.4.3.2.Mt cc cht dinh dng qua dch lc..8 1.4.3.3.Gim cc cht dinh dng trong khu phn n9 1.5.CC PHNG PHP NH GI TNH TRNG DINH DNG.9 1.5.1.Cc xt nghim sinh ha....9 1.5.2.Cc php o v nhn trc hc....11 1.5.3.Phng php iu tra khu phn n ca bnh nhn...12 1.5.4.nh gi tnh trng dinh dng bng phng php SGA.12 1.6.IU TR SUY DINH DNG CHO BNH NHN STM-LMCK..12 1.6.1.nh gi tnh trng dinh dng thng xuyn..12 1.6.2.T vn v dinh dng v ch n hp l....13 1.6.3.B sung dinh dng... 13 1.7.B sung dinh dng bng dch truyn dinh dng ng tnh mch...13 1.7.1.Khi nim...13 1.7.2.Thnh phn v cch dng..14 1.7.3.Ch nh..15 1.7.4.Tiu chun ngng s dng.15 1.7.5.Thc trng s dng dch truyn dinh dng ng tnh mch.16 1.7.6.Mt s dch truyn dinh dng ng tnh mch thng dng16 1.7.6.1.Protid ...16 1.7.6.2.Lipid. 17 Chng 2. I TNG V PHNG PHP NGHIN CU...19 2.1. i tng nghin cu19 2.1.1. i tng19 2.1.2. Tiu chun la chn bnh nhn..19 2.2. Phng php nghin cu...19 2.2.1. Thit k nghin cu19 2.2.2. Cc ch s nghin cu.19 2.2.2.1. Mt s c im ca mu nghin cu.19 2.2.2.2. Cc ch s nhn trc.20 2.2.2.3. Cc ch s ha sinh21 2.2.2.3. nh gi tnh trng dinh dng theo phng php SGA22 2.2.2.4. Kho st loi v s lng cc loi dch truyn dinh dng ng tnh mch22 2.3. X l kt qu..22 Chng 3. THC NGHIM, KT QU V BN LUN.23 3.1. c im chung ca bnh nhn.23 3.1.1. Phn b bnh nhn theo tui v gii tnh...23 3.1.2. Phn b bnh nhn theo ngh nghip.25 3.1.3. Phn b bnh nhn theo trnh vn ha..26 3.1.4. Phn b bnh nhn theo nguyn nhn v bnh mc km...26 3.1.5. Phn b bnh nhn theo thi gian suy thn v lc mu.27 3.1.6. Phn b bnh nhn theo s ln lc mu trong tun.29 3.2. Tnh trng dinh dng ca bnh nhn...29 3.2.1. Tnh trng dinh dng bnh nhn theo BMI..29 3.2.2. Tnh trng dinh dng bnh bnh nhn theo cc ch s ha sinh..31 3.2.2.1. Tnh trng dinh dng theo albumin ..31 3.2.2.2. Tnh trng dinh dng theo creatinin..34 3.2.2.3. Tnh trng dinh dng theo cholesterol...35 3.2.2.4. Tnh trng thiu mu36 3.2.3. Tnh trng dinh dng ca bnh nhn theo SGA...37 3.3. S lng v cc loi dch truyn dinh dng ng tnh mch40 3.3.1. Loi v s lng cc loi dch truyn thng dng40 3.3.2. T l bnh nhn s dng cc loi dch truyn40 3.3.3. Phn loi bnh nhn theo tn sut s dng 42 3.3.4. T l bnh nhn b suy dinh dng theo cc nhm dch truyn42 KT LUN V XUT...46 4.1. Kt lun..46 4.1.1. c im chung ca nhm bnh nhn46 4.1.2. Tnh trng dinh dng ca bnh nhn STM-LMCK..46 4.1.3. Thc trng s dng dch truyn dinh dng ng tnh mch (IDPN)47 4.2. xut..47 DANH MC CC CH VIT TT AlbAlbumin BMI Ch s khi c th (Body Mass Index) DPCA Thm phn lin tc lu ng (La Dialyse peritoneale continuousambulatoire) DPA Thm phn mng bng t ng (La dialyse peritoneale automatique) GH Hormon tng trng (Growth hormone) Hb Hemoglobin HDL Lipoprotein t trng cao (High Density Lipoprotein) IDPN Dinh dng ng tnh mch trong khi lc mu (Indialytic parenteral nutrition) KDOQIKidney Disease Outcomes Quality Initiative LMCKLc mu chu k NKFHi thn hc quc gia (National Kidney Foundation) SDDSuy dinh dng SGAnh gi tng th ch quan (Subjective Global Assessment) STMSuy thn mnTNTThn nhn to TTDDTnh trng dinh dng DANH MC CC BNG Bng 1.1: Phn loi suy thn theo KDOQI ca Hi thn hc Hoa K3 Bng 1.2: Khi qut v iu tr bo tn...4 Bng 1.3: Cc dch truyn m thng dng.....18 Bng 2.1: Phn loi BMI cho ngi chu ...21 Bng 2.2: Cc ch s ha sinh.21 Bng 3.1: Phn b bnh nhn theo tui v gii tnh...23 Bng 3.2: Phn b bnh nhn theo ngh nghip.25 Bng 3.3: Phn b bnh nhn theo trnh vn ha..26 Bng 3.4: Phn loi bnh nhn theo nguyn nhn gy bnh..26 Bng 3.5: Phn loi bnh nhn theo bnh mc km...27 Bng 3.6: Phn b bnh nhn theo thi gian suy thn v lc mu 28 Bng 3.7: Phn b bnh nhn theo s ln lc mu trong tun29 Bng 3.8: Cc ch s nhn trc...30 Bng 3.9: Tnh trng dinh dng ca bnh nhn theo ch s BMI.30 Bng 3.10: Tnh trng dinh dng ca bnh nhn theo ch s Albumin.32 Bng 3.11: Phn loi bnh nhn theo mc albumin mong mun.32 Bng 3.12: Tnh trng dinh dng ca bnh nhn theo ch s Creatinin.34 Bng 3.13: Tnh trng dinh dng ca bnh nhn theo Cholesterol35 Bng 3.14: T l thiu mu ca bnh nhn theo Hemoglobin..36 Bng 3.15: Nguy c kt hp gia thiu mu va v nng (Hb 1.5m2)vlulngmucao(250-300ml/pht).Sdngdch bicarbonate c th trnh c iu ny. 1.2.3.Tin hnh lc mu [12] -Mu ca bnh nhn c chng ng bng heparin, bm vo b lc t 200-400 ml/pht, dch lc c lm nng ln 37oC v bm vo khoang i din vi mu theo chiu ngc li, vi tc 500-800 ml/pht h s thanh lc ure t 200-350ml/pht,2microglobulint20-25ml/pht.Hiuqucaviclcph thuc vo tc mu, dch lc qua b lc v c tnh ca b lc. -Thi gian lc mu c xc nh da vo ln ca h s thanh thi ure trong cuc lc, trng lng ngi bnh, chc nng cn li ca thn, ch protein n vo, mc chuyn ha, d ha, nhng bin chng ca bnh, s dch gia 2 lnlcmu.asbnhnhnSTMphilcmutithiut9-12gi/tunv thng chia lm 3 ln chy bng nhau. Mi ln lc mu c coi l tt khi ure mu sau cuc lc cn ti a l 65% trc lc lc. 1.2.4.Bin chng bnh nhn suy thn mn lc mu chu k [2], [8], [10] -Ton thn: suy dinh dng, gim sc khng, d nhim khun. -Timmch(40-60%):suytim,dyvginthttri,lonnhp,xvang mch, tng huyt p (80-90%), -Phi: vim phi do ure mu cao, lng ng calci phi. -Tiu ha: vim trt hoc lot ng tiu ha do ure mu cao, chy mu ng tiu ha. -Thn kinh: trm cm, xut huyt no do tng huyt p, nhi mu no do x va ng mch, hn m do ure mu cao. 7 -Nitit:rilonkinhnguyt,gimhngphntnhdc,rilondungnp ng huyt, cng chc nng tuyn cn gip th pht. -C xng: teo c, lng ng calci c, tr em b ci xng, ngi ln b lon dng xng -Cc bin chng do lc mu gy ra [8]:+ Bin chng cp: h huyt p (20-30%), co git, chut rt (5-20%), nn, bun nn (5-15%), au u (5%), au ngc (2-5%), au lng (2-5%), nga (5%), tan mu, tc hi, chy mu, t mu ni chc, nhim khun, rch mng, st, + Bin chng mn khi lc mu ko di: bin chng tim mch, tai bin mch mu no, nhi mu c tim, 1.3.Bin chng suy dinh dng bnh nhn STM - LMCK SuydinhdnglmtvnphbinnhngbnhnhnSTMgiaion cui.Huhtccnghincuccncphttrin,nhgivTTDDcabnh nhn STM-LMCK u bo co mt t l SDD t 20 50 % [33], [35], [20]; khong 18-70% bnh nhn trng thnh STM-LMCK b SDD protein- nng lng [42]; t l albumin huyt thanh thp khong 25-50%, t l gim khi nc v khi m chim 40% [29], [37]. TTDD c lin quan cht ch vi kh nng sng st v tin trin ca bnh nhn LMCK. hu ht cc nghin cu u cho thy cc ch s dinh dng mc thp u i km vi tng t l t vong. TiVitNamchacnhiunghincunhgiTTDDbnhnhnSTM-LMCK, c bit nhng vn lin quan ti SDD protein-nng lng.1.4.Dinh dng trong suy thn mn lc mu chu k 1.4.1.Nhu cu protein [3], [8], [13], [42] Lng protein cho ngi bnh thng l 0.81.0g/kg/ngy. i vi bnh nhn STM-LMCKthnhucucaohnl1.21.4g/kg/ngynhmduytrcnbngnit cho nhng ngy khng lc mu. Theo KDOQI, cung cp protein khng c di 8 1.2g/kg/ngy v c t nht 50% protein n vo l nhng protein c gi tr sinh hc cao [46]. 1.4.2.Nhu cu nng lng [7], [8], [42]NhucunnglngtithiuchobnhnhnSTMT-LMCKphthucvo tiu hao nng lng hot ng v tnh trng bnh l ca bnh nhn. Nhu cu nng lng ti thiu l 35kcal/kg/ngy i vi ngi di 60 tui v 30 kcal/kg/ngy i vi ngi trn 60 tui [42]. Nhu cu ny tng cao hn trong nhng ngy lc mu v khi bnh nhn b bnh phi hp. 1.4.3.nh hng ca lc mu n tnh trng dinh dng 1.4.3.1.Yu t k thut -Bn thn lc mu l mt qu trnh d ha. - Mng lc c th hot ha h thng b th v gp phn gy ra qu trnh vim bnh nhn. S dng mng lc tng hp v mt sinh hc c khuyn co do li ch m n mang li nh c nng Alb, IGF-1 huyt thanh v cn nng cao hn so vi khi s dng mng lc khng ha hp sinh hc [20].-Liu lc l mt trong nhng yu t quan trng nht nh hng n TTDD. Lc mukhngylyutlmtngurehuytvlmTTDDcabnhnhn trm trng thm. -Tnh trng toan chuyn ha cng lm tng d ha protein [36]. Toan chuyn ha dnnuremucao,gimnhycainsulinvtngstchlybeta2-microglobulin, tng oxi ha leucin, tng qu trnh ging ha protein [18], [20]. 1.4.3.2.Mt cc cht dinh dng qua dch lc -Trongqutrnhlcmu,bnhnhnmtimtschtdinhdng.Trung bnh c khong 58g acid amin t do b mt trong mi cuc lc vi mng lc chssiulcthp,khidngmnglcchssiulccaolngacid amin mt trong cc cuc lc c th cao ti 30% [18], [22], [28]. Bnh nhn c nhng thay i bt thng v cc thnh phn acid amin trong mu, lng acid amincnthitgim,lngacidaminkhngcnthitlitngcao.Khong 9 25-30gproteincacthbdhablngacidaminmtqualc, albuminvccglobulinmindchcngbmttrongqutrnhlcmu. Trong mt cuc lc 4h c khong 25g glucose b mt qua dch lc [18], [20]. Do vy, s mt cn bng nit-nng lng s xy ra nu bnh nhn khng c mt ch n y . - Cc vitamin ha tan trong nc b gim thp do b mt nhiu qua lc v gim lngnvoquakhuphn.Dovy,nhucuccvitaminB6,acidfolic, vitamin C thng cao hn so vi ngi khng b bnh. [7] 1.4.3.3.Gim cc cht dinh dng trong khu phn n [21], [42], [25], [18] -u vo dinh dng khng y v cc bnh mc km l nguyn nhn chnh ca SDD bnh nhn STM-LMCK. a s bnh nhn lc mu ch tiu th 80% hoc t hn nhu cu nng lng cn thit, k c cc bnh nhn nhp vin cng ch tiu th khong 66% nhu cu protein v 50% nng lng [42]. Dinh dng khng y do rt nhiu nguyn nhn nh: chn n, km hiu bit, kh nng kinh t, stress tm l, s thch, thi quen n ung, -Tnh trng nhim c ure c ch trc tip qu trnh ng ha protein v gy nn cc du hiu v tiu ha nh: chn n, bun nn, nn, a chy, dn n gim lng dinh dng n vo, gim hp thu.-Tm l s n cc cht giu protein sau mt thi gian di iu tr bo tn vi ch n king cht ch cng lm gim cung cp protein. Tnh trng tng huyt p, suy tim,thiumu ko di vi nhng t nhp vin lm trmtrngthm cm gic chn n, gim hp thu.1.5.Cc phng php nh gi tnh trng dinh dng 1.5.1.Cc xt nghim sinh ha [6], [19], [27], [18], [42], [35] Albumin:-Lmtproteinhuyttngchim55-65%proteintonphn,ctnghp gan v bi tit vo mu. 10 -AlbkhngnhycmtrongvicnhgisthayiTTDDhaycccanthip dinhdngtrongmtthigianngndothigianbnhydi(20ngy).Alb trc lc l ch s lng gi tnh trng d tr protein. -Alb b nhhngnhiu nht bi lngprotein nvo, b gim nhanh do stress vnhimtrng.AlbccoilchshuchnhtnhgiTTDDdok thut phn tch n gin, d lm v c s tng quan ngha vi tin lng bnh nhn. -Khi nng Alb 5.2-7.8mmol/Lhoc xung