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Chng 4

SINH L MU
Mu l mt loi m lin kt c bit gm hai thnh phn l huyt tng
v huyt cu. Huyt tng l thnh phn ca dch ngoi bo nm trong lng
mch (xem chng 2). Huyt cu l cc t bo mu c sn sinh t t bo
m trong ty xng. Qu trnh ny bt u t t bo gc vn nng, bit ha
thnh cc cc dng hng cu, bch cu v tiu cu. Mu c cc chc nng
chnh l h hp, dinh dng, o thi, bo v v iu ha hot ng c th.

SINH L HNG CU V NHM MU


Mc tiu:
1. Phn tch c qu trnh sn sinh hng cu.
2. Trnh by c cc c im chung v chc nng ca hng cu.
3. Phn loi c nhm mu h ABO v h Rh.
4. Trnh by c cc ng dng xc nh nhm mu h ABO v truyn mu.
1. QU TRNH SN SINH HNG CU
Qu trnh sn sinh hng cu l qu trnh tng sinh v chn ca dng
hng cu t cc t bo mu gc vn nng.
1.1. Cc giai on sn sinh hng cu
Trong nhng tun u ca thi k bo thai, hng cu c sinh ra t l
thai gia. T thng th ba, qu trnh sn sinh hng cu c thc hin gan
v lch. T thng th nm cho n lc sinh ra, ty xng l ni duy nht to
hng cu. C hai loi ty xng, ty o v ty vng, chi c ty o mi c
chc nng to mu. tre s sinh, ton b cc xng u cha ty o. Sau ,
cc xng di, ty dn dn b nhim m tr thnh ty vng. Sau 20 tui, ty
o chi khu tr cc xng dt nh xng sng, xng c, xng sn,
xng so, xng ch u v m t phn nho xng di (u trn xng ui v
xng cnh tay).
Qu trnh sn sinh hng cu bt u t t bo mu gc vn nng bit

ha thnh t bo dng ty t bo nh hng dng hng cu. T y s


hnh thnh tin nguyn hng cu nguyn hng cu a base nguyn hng
cu a sc nguyn hng cu a acid hng cu li hng cu. Trong
qu trnh sn sinh, kch thc hng cu gim dn, nhn ng c v b y ra
ngoi, hnh thnh hemoglobin.
1.2. Cc cht cn thit cho sn sinh hng cu
1.2.1. Vitamin B12
- Vai tr: vitamin B12 cn thit bin i ribonucleotid thnh
deoxyribonucleotid, mt trong nhng giai on quan trong trong s to thnh
AND duy tr s trng thnh bnh thng ca hng cu.
- Chuyn ha: vitamin B12 l m t vitamin tan trong nc c nhiu
trong thc n c ngun gc ng v t nh tht, trng, sa, khng c trong
thc c ngun gc thc v t. Lng B12 cn thit mi ngy l <1g, trong khi
gan c kh nng d tr mt lng B 12 khong 1000 ln nhiu hn. Sau khi
n vo, B12 s kt hp vi yu t ni ti ca d dy to thnh hp cht
thch ng cho s hp thu. Vitamin B12 c hp thu rut m ch yu l hi
trng.
- Bnh l lin quan: thiu B12 s ngn chn s phn chia t bo v s
trng thnh ca nhn dn n ngng bit ha dng hng cu, kch thc
hng cu to nhng gim s lng. Cc t bo nguyn hng cu ca ty xng
ln hn bnh thng c goi l i hng cu s vo mu tun hon. Chng
vn c kh nng chuyn ch O2, nhng d b v gy thiu mu c tnh,
thng gp trong trng hp bnh nhn b teo nim mc d dy hoc ct bo
d dy ton b m khng tim B12 thng xuyn.
1.2.2. Acid folic
- Vai tr: acid folic cn thit cho s trng thnh cc hng cu do tng
s methyl ha trong qu trnh thnh lp ADN.
- Chuyn ha: acid folic l mt vitamin tan trong nc c nhiu trong
rau ci xanh v m ng vt nh no, gan, tht. Nhu cu hng ngy cn 50100g. Acid folic c hp thu rut m ch yu l hng trng di th
monoglutamat.
- Bnh l lin quan: thiu acid folic s gy ra thiu mu vi cc nguyn
hng cu khng l ging nh thiu mu do thiu vitamin B 12, ch yu do ch

n khng , km hp thu, tiu chy ko di.


1.2.3. Cht st
- Vai tr: st l mt cht quan trong trong s thnh lp hemoglobin do
st tham gia vo thnh phn hem.
- Chuyn ha: st c nhiu trong thc phm c ngun gc ng v t
nh tht o, ph tng v cc loi thc v t c mu xanh m. Nhu cu st mi
ngy khong 0,6mg. ph n do mt mu trong chu k kinh nguyt nn nhu
cu cht st cao hn (khong 1,3mg/ngy). St c hp thu di dng Fe ++
(ferrous) hn l dng Fe+++ (ferric) ch yu t trng bng c ch ch ng.
HCl ca d dy v vitamin C c vai tr chuyn Fe +++ thnh Fe++ to iu ki n
thu n li cho s hp thu. Sau khi hp thu t rut, st nhanh chng kt hp vi
-globulin to thnh transferrin. Di dng ny, st kt hp mt cch long
leo vi phn t globulin, v kt qu l n d dng phng thch khi cc m cn.
Cht st tha trong mu s c d tr hu ht cc t bo ca c th, c
bit trong t bo gan (60%). Ti gan, st kt hp vi apoferritin to thnh
ferritin. Khi lng st trong huyt tng gim thp, st s c gii phng
khoi ferritin.
- Bnh l lin quan: thiu st s gy thiu mu nhc sc, hng cu
nho. Nguyn nhn thng do thiu cung cp, km hp thu, tng nhu cu (v
d ph n c thai) v chy mu ri r ko di.
1.2.4. Cc cht khc
Ngoi cc cht trn, qu trnh sn sinh hng cu cn c s tham gia ca
cc amino acid, cc vitamin nhm B khc v cc yu t vi lng nh mangan,
cobalt
1.3. iu ha sn sinh hng cu
iu ha sn sinh hng cu ch yu bng c ch th dch:
- Erythropoietin:
+ Ngun gc: erythropoietin c ngun gc ch yu t t bo biu m
ng thn, phn nho cn li l t gan.
+ Bn cht: glycoprotein.
+ Tc dng: kch thch s bit ha ca cc t bo tin thn dng hng
cu v lm tng qu trnh tng hp hemoglobin trong cc t bo bit ha.
+ iu ha bi tit: khi nng oxy m gim nh trong trng hp

thiu mu, lu lng mu thp ho c m t b nh l h hp, s kch thch th n


sn sinh erythropoietin do tng to hng cu; v ngc li khi oxy m
tng, c ch to erythropoietin, do gim to hng cu.

Hinh 4.1. iu hoa bai tit erythropoietin


- Mt s hormon khc cng tham gia vo qu trnh to hng cu:
+ Testosteron ca tinh hon: c th lm tng to erythropoietin hoc
kch thch trc tip t bo gc bit ha thnh t bo dng hng cu.
+ GH ca tuyn yn: gin tip lm tng to erythropoietin qua
somatomedin ca gan.
+ LH ca tuyn yn: lm tng to hng cu v tng tit testosteron v
tng to erythropoietin.
+ Thyroxin ca tuyn gip: cng lm tng to erythropoietin.
2. C IM CHUNG CA HNG CU
2.1 Hnh dng
Hng cu l nhng t bo hnh a, lm hai mt. ng knh ca hng
cu khong 7-8m, chiu dy trung tm l 1m v ngoi vi l 2-3m. c
im hnh a lm hai mt thch hp vi kh nng vn chuyn kh ca hng
cu v:
- Lm tng din tch tip xc ca hng cu.
- Lm tng tc khuch tn kh.
- Lm cho hng cu c th bin dng d dng khi xuyn qua cc mao
mch c ng knh rt nho.
2.2. Thnh phn cu to
Hng cu l mt t bo nn v mt cu to cng gm hai thnh phn:

mng hng cu v bo tng. Tuy nhin, hng cu khng c nhn, rt t bo


quan nn bo tng ch yu chi cha hemoglobin.
2.2.1. Mng hng cu
Mng hng cu c mt s tnh cht quan trong sau:
- Mng hng cu l mt mng bn thm c nhiu l nho ng knh
khong 3-4A0: mng khng cho cc cht keo thm qua (protein, lipid). Trong
khi tnh thm vi cc ion, mui khong cng khng ng u: cc ion H +,
OH-, HCO3- v mt s ion hu c thm qua d dng; cc ion K +, Na+, Ca++
thm qua rt t v chm, hoc khng qua c (Ca++, Mg++).
+ Do tnh thm ny, hng cu khng thay i hnh dng khi t trong
dung dch ng trng. Trong dung dch u trng, nc trong hng cu
thm ra ngoi, lm hng cu teo li. Trong dung dch nhc trng, nc t
ngoi thm vo hng cu lm hng cu trng to ln v cui cung v ra gy
tan mu.
Hng cu bt u v
Hng cu v hon ton
(sc bn ti thiu)
(sc bn ti a)
Mu ton phn
NaCl 4,6o/oo
NaCl 3,4o/oo
Hng cu ra
NaCl 4,8o/oo
NaCl 3,6o/oo
Hng cu trong mu ng mch c bn cao hn trong mu tnh
mch.
+ Trong trng hp s l trn mng tng (hng cu hnh lim), qu
trnh trao i cht s tng, lm hng cu mt nhiu nng lng nn d b v.
- Lp o glycocalyx ca hng cu c bao bi nhiu acid sialic: cc
phn t acid sialic to mt lp in tch m bn ngoi hng cu, y cc hng
cu lm chng khng dnh vo nhau. Trong xt nghi m o tc lng mu,
hi n tng ny lm cc hng cu lng chm. Tc mu lng bnh thng
ngi trng thnh sau 1 gi: nam l <15mm, n l <20mm. Trong mt s
trng hp bnh l v cu to mng, hoc do dung mt s thuc c kh nng
kt hp vi acid sialic, lm mt in tch m ca mt s hng cu nn cc
hng cu d dnh vo nhau; hoc trong cc trng hp vim, hm lng
protein thay i lm cho cn bng in tch protein thay i, nn in tch
mng hng cu bin i theo, hng cu d b kt dnh li vi nhau hn nn
tc lng mu s tng.
- Mng hng cu c rt nhiu khng nguyn: khng nguyn mng hng

cu chnh l nhng phn t protein xuyn mng, thng di dng


glycoprotein. Ngi ta tm thy khong 30 loi khng nguyn thng gp
v hng trm khng nguyn him gp khc. Cc khng nguyn mng hng
cu to thnh nhm mu thc hin chc nng tng tc min dch vi cc
khng th. Khi cc khng nguyn v khng th tng ng gp nhau s gy ra
hin tng ngng kt hng cu. Tuy nhin, phn ln khng nguyn c tnh
min dch yu nn khng gy tai bin khi truyn mu, chng thng c
dung nghin cu di truyn gen nhm xc nh huyt thng. Hai nhm
khng nguyn quan trong c th gy cc phn ng trong truyn mu l h
thng ABO v h thng Rh.
- Lp trong cung mng hng cu c nhiu protein ngoi vi bm dnh:
l nhng si vi th, nhng ng vi th v nhng phn t calmodulin, protein
gn hemoglobin, cc enzym. Cc phn t calmodulin iu ha hot ng cc
enzym mng. H thng enzym mng hng cu v cung phong ph v thc
hin nhiu chc nng quan trong khc nhau.
+ Cc enzym tham gia chuyn ha glucose to nng lng cho hng
cu hot ng nh G6PD (glucose 6 phosphat dehydrogenase) v nhiu
enzym khc: hng cu l mt t bo cha oxy nn cc cu trc ca n thng
xuyn c nguy c b oxy ha, nng lng sinh ra s gip bo v hng cu. Do
vy, gim hot tnh cc enzym ny s dn n gim kh nng chng oxy ha
v dp gc t do ca hng cu.
+ Cc enzym tham gia chuyn ha 2,3-DPG (2,3 diphospho glycerat)
nh pyruvate kinase, diphosphoglycerat mutase: 2,3-DPG c nh hng
quan trong n i lc ca hemoglobin vi oxy, do vy gim hot tnh ca cc
enzym ny s dn n thay i i lc ca hemoglobin vi oxy.
+ Enzym tham gia vo qu trnh vn chuyn CO2 l CA (carbonic
anhydrase): CA trong hng cu lm tng hng nghn ln vn tc ca phn ng
gia CO2 v H2O to ra H2CO3. Nh , CO2 c vn chuyn di dng ion
bicarbonat (HCO3-) t cc m v phi.
2.2.2. Hemoglobin
Hemoglobin (Hb) l mt protein mu nn cn goi l huyt sc t, trong
lng phn t 68.000, c kh nng chuyn ch cht kh. Hemoglobin chim
khong 32-34% trong lng ti v trn 90% trong lng kh ca hng cu.
Nng hemoglobin bnh thng trung bnh t 14-16g/100mL mu. Mi

hng cu c cha khong 34-36g hemoglobin.


* Cu to va phn loi hemoglobin:
Hemoglobin c cu to gm hai thnh phn l 1 phn t globin v 4
nhn hem.
- Hem: l mt sc t o ging nhau tt c cc loi.
- Phn t globin: l mt protein khng mu khc nhau tuy theo loi.
Mi phn t globin gm 4 chui polypeptid ging nhau thnh tng cp.
ngi c 4 loi chui polypeptid c k hiu l , , , ; s t hp ca cc
chui polypeptid ny to ra cc loi hemoglobin khc nhau. Bnh thng,
hemoglobin ch yu ngi trng thnh l HbA v hemoglobin bo thai
l HbF. Khi a tre ra i HbF c thay th dn thnh HbA, t l cc loi
hemoglobin ngi trng thnh bnh thng: 95% HbA1 (2 chui , 2 chui
), 2% HbA2 (2 chui , 2 chui ), 2% HbF (2 chui , 2 chui ). Th t
cc acid amin trong chui polypeptid ca phn t hemoglobin c xc
nh trong m gen di truyn.
Khi t bin xy ra trn cc gen qui nh trnh t cc acid amin trong
chui polypeptid ca phn t hemoglobin s xy ra s sn xut cc
hemoglobin khng bnh thng, v d HbS, HbC, HbE, HbJ C nhng loi
phn t Hb bt thng nhng khng gy nguy him, tuy nhin c mt s loi
gy ra cc trng hp bnh l, v d: bnh thiu mu hng cu hnh lim do
trong mu c HbS, bnh thalassemia do t bin lm gim tng hp chui
hoc .
* S tng hp hemoglobin:
Tng hp hemoglobin bt u t giai on tin nguyn hng cu n
giai on hng cu li. Qu trnh tng hp din ra theo nhng bc sau:
- Acid acetic c bin i trong chu trnh Krebs thnh succinyl CoA.
- 2 succinyl CoA kt hp vi 2 phn t glycin thnh lp hp cht
pyrrol.
- 4 phn t pyrrol s kt hp li thnh protoporphyrin IX.
- 1 phn t protoporphyrin IX kt hp vi st to thnh phn t
hem.
- 1 heme kt hp vi mt chui polypeptid ca globin to chui
hemoglobin.
- 4 chui hemoglobin kt hp vi nhau to thnh hemoglobin.

* S thoi bin hemoglobin:


i sng trung bnh ca hng cu trong mu ngoi vi khong 120 ngy.
Cc hng cu gi s b ph v trong h thng vng ni m nh gan, lch. Khi
hemoglobin c tch ra thnh globin v hem.
- Globin c chuyn ha nh cc protein khc trong c th.
- Hem c phn hy nh sau: u tin, st c tch ra v gii phng
vo huyt tng, transferrin s vn chuyn st n ty xng to hng cu
mi, hoc n gan v cc t chc khc d tr di dng ferritin. Phn cn
li ca heme bin thnh bilirubin c mu vng. Bilirubin vo mu v c
a n gan. Ti gan, bilirubin kt hp vi acid glucuronic ri bi tit qua
mt ra ngoi.
2.3. S lng hng cu v cc ch s hng cu
- S lng hng cu trong mu ngoi vi ngi Vit Nam trng
thnh bnh thng:
Nam : 5,11 M 0,3/mm3 mu
N : 4,6 M 0,25/mm3 mu
S lng hng cu ph thuc vo lng oxy n m, mc hot
ng, la tuiBnh thng ty xng sn xut mi ngy t 0,5-1% hng
cu, thay th 1% hng cu cht mi ngy. Khi c nhu cu, ty xng c
th tng sn xut gp 7-8 ln so vi bnh thng. Tnh trng tng sinh p ng
ny c biu hin bng s lng t bo dng hng cu trong ty tng, thi
gian trng thnh rt ngn, a ra mu ngoi vi sm nhng hng cu c kch
thc ln, i khi cn a sc, kim (hng cu cn nhn). S lng hng cu
thay i trong cc trng hp bnh l:
+ Tng trong b nh a hng cu, ngt, mt nc nhiu. Ngoi ra, trong
nhiu bnh l ca h tun hon gy thiu oxy m, s dn n tng sn xut
hng cu m bo chc nng h hp.
+ Gim trong thiu mu do tn huyt, xut huyt; suy th n; suy ty
- T l hng cu li: t l ny thng tng trong thiu mu tn huyt.
- Cc chi s hng cu:
+ MCV (th tch trung bnh hng cu): l chi s nh gi th tch hng
cu, MCV thp l hng cu nho, MCV cao l hng cu to.
MCV(femtolit)=(hematocrit x 1000)/s lng hng cu (triu/mm3).

+ MCH (lng Hb trung bnh hng cu): l chi s nh gi lng Hb


bn trong hng cu. MCH thp l nhc sc, MCH cao c th l u sc.
MCH(pg)=[Hb (g/100mL) x 10]/s lng hng cu (triu/mm3)
+ MCHC (nng Hb trung bnh hng cu): l t l gia Hb v Hct.
MCHC thp l nhc sc, MCHC cao c th l hng cu nho.
MCHC(g/100mL)=Hb (g/100mL)/Hct
3. CHC NNG CA HNG CU
3.1 Chc nng h hp ca hng cu
Chc nng h hp l chc nng chnh ca hng cu, c thc hin
nh hemoglobin.
3.1.1. Hemoglobin vn chuyn oxy t phi n cc m
- S to thnh oxyhemoglobin phi: sau khi ht vo, oxy c gn
vi Fe++ trong thnh phn hem, khi hemoglobin tr thnh oxyhemoglobin
(HbO2). Phn ng to thnh oxyhemoglobin xy ra rt nhanh trong hng cu
v tuy thuc vo phn p oxy.
Mt phn t Hb c th gn vi 4 phn t O2, s gn vi mt phn t O2
u tin vo Hb lm tng i lc ca Hb vi phn t O 2 tip theo. Lu : y l
phn ng kt hp O2 vo nguyn t Fe, khng phi l phn ng oxy ha, nn
Fe vn c ha tr 2 (Fe++).
V mt phn t Hb gn ti a 4 phn t O 2 nn 1 gam Hb gn c
1,34mL O2. Nh vy, trung bnh 100mL mu, c 14-16g Hb, gn c ti a
khong 20mL O2.
- S phn ly oxyhemoglobin m: khi n m, hemoglobin s nh oxy
cho m. Phn ng phn ly oxyhemoglobin xy ra ph thuc i lc ca Hb vi
O2. Cc yu t lm gim i lc, tng phn ly oxyhemoglobin cung cp O 2
cho m:
+ Phn p O2 gim.
+ CO2 tng, pH gim.
+ Nhit tng.
+ Cht 2,3-DPG (2,3-diphosphoglycerate) tng trong hng cu (2,3DPG tng khi ln vung cao, khi hot ng).
+ Hp cht phosphat thi ra lc hot ng.
- Lin h bnh l:
+ Trong trng hp mu tip xc vi nhiu loi thuc khc nhau, v

nhiu tc nhn oxy ho khc nhau, ion Fe++ tr thnh Fe+++, khi Hb s
chuyn thnh metHb khng c kh nng vn chuyn O2 na. MetHb c mu
sm v cht ny c nhiu trong tun hon s gy ra triu chng xanh tm
(cyanosis).
+ Kh CO (oxide carbon), mt sn phm ca s chy khng hon ton
carbon, c trong khi ca nhng v chy n, cc ng c n, than t... c i
lc rt mnh vi hemoglobin (gp 250-350 ln so vi oxy), rt d kt hp vi
hemoglobin trong mu thnh HbCO (carboxyhemoglobin) gy nn hi
chng thiu oxy mu, mu c mu o anh o. Tuy theo nng kh CO
trong khng kh m nng HbCO c hnh thnh trong mu s tng cao v
cc triu chng nhim c s nng dn ln.
3.1.2. Hemoglobin vn chuyn CO2 t m v phi
Mt phn nho, khong 20% CO2 trong mu c kt hp Hb to
carbaminhemoglobin. CO2 kt hp vo Hb qua cc nhm amin (NH 2) ca
globin. y l phn ng thun nghch cn goi l phn ng carbamin.
Hb + CO2 HbCO2
(R NH2 + CO2 R NH COOH)
Phn ng thun nghch ny xy ra theo chiu no tuy thuc vo phn
p CO2. cc m, phn p CO2 cao, phn ng xy ra theo chiu thun.
Ngc li, phi phn p CO 2 thp, HbCO2 s phn ly v CO2 c thi ra
khoi c th qua cc ng tc h hp.
3.2. Chc nng min dch hng cu
Hng cu c vai tr min dch do:
- Gi ly cc phc hp khng nguyn - khng th - b th to thun li
cho qu trnh thc bo.
- Cc khng nguyn mng hng cu l c trng ca cc nhm mu.
3.3. Chc nng iu ha thng bng toan kim
Hb trong hng cu l mt h thng m quan trong. Ngoi ra, hng cu
cn to ra HCO3- trong qu trnh v n chuyn CO2, do v y gp phn to ra
h m bicarbonat.
3.4. Chc nng to p sut keo
Nhng thnh phn cu to ca hng cu ch yu l protein nn gp
phn to p sut keo ca mu.

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4. NHM MU
4.1. nh ngha
Nm 1900, Landsteiner nhn thy c s ngng kt hng cu khi trn
mu ca cc c th trong cung mt loi vi nhau. T ng pht hin ra
c khng nguyn trn mng hng cu v khng th trong huyt thanh v ng
phn loi nhm hng cu trn ngi. Trong y hoc, ngi thng goi nhm
hng cu l nhm mu.
Nh vy, nhm mu l khng nguyn nm trn mng hng cu. Cc
loi mu c phn nhm da theo s hin din ca cc khng nguyn .
Cc khng nguyn thng c bn cht l glycoprotein.
Cc khng th nhm mu c th l khng th t nhin (IgM) nhng
cng c th l khng th min dch (IgG). Cc khng th min dch khc vi
khng th t nhin ch chi hnh thnh khi c tip xc vi khng nguyn; c
kh nng khuch tn mnh, qua c mng nhau thai nn c th t m sang
thai nhi; c hot tnh mnh 37oC vi cng , hiu gi v nhy cao hn
khng th t nhin, nu b kch thch lp li (tip xc khng nguyn) th hot
tnh s cng cao, nhng nu khng lp li th s gim dn n mt hn.
4.2. Phn loi nhm mu
Sau ny, ngoi nhng khng nguyn m Landsteiner tm ra, ngi ta
cn tm thy nhiu khng nguyn khc c trn mng hng cu v t phn
ra nhiu h thng nhm mu: ABO, Rh, MNSs, Kell, Kidd, Duffy, Lewis
Trong , hai h thng nhm mu c nhiu ng dng trn lm sng l ABO
v Rh.
4.2.1. Cc nhm mu h ABO
* Cc khng nguyn ca nhm mu h ABO:
Cc khng nguyn nhm hng cu h ABO l cc cht
mucopolysaccharid gm khng nguyn A v B. Cc khng nguyn ny l s
th hin ca cc gen A v B trn b mt hng cu. Khng nguyn A v B c
th pht hin c t lc bo thai 5-6 tun. Trong sut thi k bo thai lng
khng nguyn tng khng ng k. Sau khi sinh, lng khng nguyn tng
dn v t n mc n nh sau 2-4 nm v tn ti hng nh sut i.
Da vo s c mt hay khng c mt ca cc khng nguyn A v B trn
mng hng cu, Landsteiner phn loi thnh 4 nhm mu: A, B, AB v O
(bng 4.1). ngi Vi t Nam, khong 48% l nhm mu O, 28% nhm mu

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B, 20% nhm mu A v 4% nhm mu AB.


Cc nhm ph ca h ABO: nhm mu A c th chia lm 2 nhm ph
l A1 v A2. Hng cu A1 phn ng mnh vi anti-A, cn hng cu A2 phn
ng yu hn. 80% nhm mu A hay AB l thuc loi A1 v 20% l A2. Tng
t, nhm mu B cng c cc di nhm. Tuy nhin, vic xc nh cc cc
nhm ph cng t c gi tr trong thc hnh lm sng.
Bng 4.1. Thanh phn va genotype ca nhm mu h ABO
Nhm
Khng nguyn trn
Khng th trong
Genotype
mu
mng hng cu
huyt thanh
A
A
OA, AA
Anti-B ()
B
B
OB, BB
Anti-A ()
AB
A, B
Khng c anti-A v
AB
anti-B
O
Khng c A v B
Anti-A v anti-B
OO
* Cc khng th ca nhm mu h ABO:
tre s sinh hu nh khng tm thy s c mt cc khng th nhm
mu. 2-8 thng sau, c th tre bt u sn xut cc khng th trong huyt
thanh vi nng tng dn v t ti a vo khong 8-10 tui. Sau , gim
dn theo tui.

Hinh 4.2. Nng anti-A va anti-B trong huyt thanh ngi


(Ngun: Guyton A.C. (2006), Textbook of Medical Physiology).
Cc khng th anti-A, anti-B thng l khng th t nhin (IgM) nhng

12

cng c th l khng th min dch (IgG). Cc khng th min dch anti-A,


anti-B, m c bit l anti-A, c th gp mt s ngi nhm mu O, v vy
nhng ngi ny c goi l ngi c nhm mu O nguy him, khng dung
truyn ph thng nh cc nhm mu O thng thng. Cc khng th min
dch cng c th gp nhng ngi nhm mu A hoc B nhng him hn.
* Phng php nh nhm mu h ABO:
- Nghim php hng cu (nh nhm xui): y l nghim php trc
tip nhm xc nh khng nguyn h ABO trn hng cu (Nghim php BethVincent). Nguyn tc phng php ny l s dng nhng khng huyt thanh
chun ha, cha khng th anti-A, anti-B v anti-A, B trn vi mu cn
th, da trn phn ng ngng kt vi hng cu nh nhm mu ngi th.
- Nghim php huyt thanh (nh nhm ngc): nguyn tc l s dng
nhng hng cu cha khng nguyn bit, em lm phn ng ngng kt vi
huyt thanh ca ngi cn nh nhm mu, nhm xc nh s c mt hay
khng c mt ca khng th anti-A, anti-B trong huyt thanh. T suy ra
c nhm mu ngi th.
m bo chnh xc khi nh nhm mu ABO nn:
- Tin hnh ng thi c 2 nghim php ni trn v kt qu phi khp
nhau, nu khng phi dung thm k thut cao hn xc nh.
- Huyt thanh mu phi anti-A, anti-B, anti-A, B. Hng cu mu
phi hng cu A, B, O.
- Huyt thanh mu phi t nhy, mnh v hiu gi. Hng cu
mu phi l hng cu mi, ra sch 3 ln bng nc mui sinh l (NaCl
9) ri pha thnh huyn dch 5-10.
Bng 4.2. Bng kt qu nh nhm mu h ABO
Nghim php hng cu
Nghim php huyt thanh
Nhm
(dng huyt thanh mu)
(dng hng cu mu)
mu
Anti-A
Anti-B Anti-A,B
HC A
HC B
HC O
ABO
+
+
+
A
+
+
+
B
+
+
+
AB
+
+
O
4.2.2. H Rhesus
Nm 1904, Landstainer tm thy mt loi khng nguyn hng cu khi
Maccacus Rhesus, ng t tn cho khng nguyn ny l yu t Rh. Sau ,
13

ngi ta nhn thy mt s ngi hng cu cha ng yu t Rh, v mt


s ngi khc th khng. Ngi ta qui c, mu ngi no hng cu c cha
yu t Rh goi l Rh+, cn khng th goi l Rh-. Yu t Rh l mt h thng gm
13 khng nguyn trong yu t D l mnh nht, c ngha quan trong trong
truyn mu. Ngi Vit Nam hu ht l Rh+ (99,96%).
Cc khng th h Rh khng c sn trong mu, chi xut hin khi c s
tip xc vi khng nguyn. V vy, ngi ta goi khng th h Rh l khng th
min dch. Trong cc khng th ca h Rh, anti-D l khng th quan trong
nht cn cc khng th khc yu hn nhiu v mc gy phn ng cng rt
thp. Anti-D l mt loi IgG.
Nhng phn ng ngng kt do Rh thng xy ra trong hai trng hp:
- Ngi c mu Rh- nhn nhiu ln lin tc mu Rh+.
- M c nhm mu Rh- nhiu ln mang thai c mu Rh+.
4.2.3. Cc h thng nhm mu khc
Nhiu loi protein khc trn mng hng cu to cc khng nguyn
ngoi A, B, O, Rh dn n hnh thnh cc nhm mu nh: MN, Kell, Lewis,
Duffy, Kidd, Doego, Lutheran Nhng yu t khng nguyn ny khng c
tnh nguyn cao, tc l gy ra phn ng truyn mu rt yu, chm hoc th m
ch khng c phn ng.
4.3. ng dng nhm mu trong truyn mu
4.3.1. Ch nh
Chi nh truyn mu trong nhng trng hp: gim th tch mu, iu
tr thiu mu, cung cp cc thnh phn ca mu
4.3.2. Nguyn tc truyn mu
T nhng hiu bit v nhm mu trong h thng nhm mu, ngi ta
ra nhng nguyn tc trnh xy ra nhng tai bin trong truyn mu:
- Phi truyn mu cung nhm tc l khng cho khng nguyn va
khng th tng ng gp nhau trong mu ngi nhn. V d, A truyn cho
A, B truyn cho B
- Nhng nhiu khi khng c mu cung nhm truyn, nn ngi ta c
th cho truyn khc nhm theo nguyn tc: khng nguyn trn mang hng
cu ngi cho khng b ngng kt bi khng th tng ng trong huyt
tng ngi nhn. Nh vy, c 2 trng hp ng lu :
+ Nhm O khng c khng nguyn trn mng hng cu, nn khng b

14

khng th trong huyt tng ngi nhn lm ngng kt. Do nhm O c th


truyn cho c 3 nhm v cho chnh n.
+ Nhm AB khng c khng th trong huyt tng, nn khng th
ngng kt bt k hng cu ngi cho no. Do nhm AB c th nhn mu
ca c 3 nhm v ca chnh n.
A
O

ABo
B

Hinh 4.3. S truyn mu


Khi truyn mu khc nhm, nguyn tc khng cp n vn khng
th trong huyt tng ngi cho gy ngng kt hng cu ngi nhn. Nguyn
nhn l v khng th c truyn vo vi lng rt nho, nn b pha long
ngay trong mu ngi nhn, khng ngng kt hng cu ngi nhn. Ngoi
ra, khng th cn c th b trung ha bi nhng khng nguyn c trong cc t
bo v cc dch ca c th. Tuy nhin, cn lu khi truyn mu khc nhm,
mi ln truyn khng c vt qu 250mL v phi truyn tht chm.
4.3.3. Phn ng cho
Phn ng cho l mt k thut rt cn thit p dng trc khi truyn
mu du th nhm mu h ABO v Rh. K thut nh sau:
- Ly mt giot hng cu hoc mu ngi cho v mt t huyt thanh ca
mu ngi nhn trn u vi nhau, quan st k xem hin tng ngng kt xy
ra khng.
- Ri trn ln dch hng cu ca ngi nhn vi huyt thanh ngi cho,
quan st xem c hin tng ngng kt khng.
Nu khng c hin tng ngng kt xy ra, c th xem nh hai mu
khng tng k v truyn c. Nu thy ngng kt l hai loi mu tng k
nhau khng truyn c. Phng php ny trnh nhm ln khi truyn mu v
pht hin nhng khng th bt thng.
4.3.4. Phn ng trong truyn mu
- Nhng phn ng khng gy tn huyt: st, rt run, d ng, ly truyn

15

cc mm bnh qua mu truyn vo.


- Nhng phn ng gy tn huyt: phn ng gy tn huyt trong truyn
mu c th do 2 nguyn nhn:
+ Nguyn nhn min dch: khng ha hp khng nguyn v khng th
thuc h nhm mu hng cu; s gy ra phn ng kt hp gia khng nguyn
v khng th tng ng trong mu tun hon ngi nhn, dn ti tiu hy
hng cu (tn huyt).
+ Nguyn nhn ngoi min dch: c th do iu kin bo qun mu
khng tt (nhit ), dung dch gi mu khng nng ng dextrose,
dung dch chng ng pha ch khng ng nng v pH quy nh. Ngoi
ra, hng cu cng c th b v khi truyn vi p lc qu cao. V d: khi truyn
mu qua mt kim qu nho vi tc nhanh, hng cu c th b ph hy nu
mc bnh thiu men hoc nhng trng thi c myoglobin mu, myoglobin
niu t trc.

SINH L BCH CU V H THNG MIN DICH


Mc tiu:
1. Trnh by c qu trnh sn sinh bch cu.
2. Xc nh c s lng v cng thc bch cu.
3. Phn bi t c cc loi bch cu.
4. Phn tch c cc c tnh v chc nng ca tng loi bch cu.
5. Nm c khi ni m v min dch v h thng min dch.
1. QU TRNH SN SINH BCH CU
1.1 Ngun gc
Bch cu c ngun gc t cc t bo mu gc vn nng trong ty
xng, cc t bo ny s bit ha thnh 2 dng:
- Dng ty: cc t bo tin thn dng ty pht trin thnh dng hng
cu, dng tiu cu v ba dng bch cu l dng ht-mono to thnh bch
cu ht trung tnh v bch cu mono (s pht trin thnh i thc bo), dng
i toan to thnh bch cu ht a acid, dng i kim to thnh bch cu
ht a base.

16

- Dng lympho: cc t bo tin thn dng lympho pht trin thnh hai
dng l bch cu lympho T v bch cu lympho B. Hu ht bch cu lympho
ri khoi ty xng trc khi chn. Bch cu lympho T trng thnh trong
tuyn c, trong khi bch cu lympho B pht trin v trng thnh trong cc
m bch huyt rut, lch v ty xng.

Hinh 4.4. Qu trinh sn sinh cc dong t bao mu


1.2. iu ha sn sinh bch cu
iu ha sn sinh bch cu c thc hi n bng c ch th dch vi
cc yu t do chnh bch cu lympho, mono v i thc bo ch to ra trong
qu trnh tham gia cc phn ng min dch. Cc yu t ny s kim sot qu
trnh tng sinh, bi t ha ca cc dng bch cu:
+ Cc yu t pht trin a dng nh interleukin-3 (IL-3) kch thch s
pht trin ca dng ty.
+ Cc yu t pht trin n dng: G-CSF kch thch s pht trin ca
dng bch cu ht, M-CSF kch thch s pht trin ca dng mono, E-CSF
kch thch s pht trin ca dng bch cu ht a acid. Nhiu loi lymphokin
(interleukin) v monokin khc nhau cng kch thch s pht trin ca cc
dng bch cu ht, mono, lympho.
2. C IM CHUNG CA BCH CU
2.1. S lng v i sng bch cu
S lng bch cu ngi trng thnh bnh thng khong 4.00010.000/mm3 mu (4-10 x 109/L).
tre em v ph n c thai s lng bch cu cao hn. S lng bch

17

cu tng trong cc bnh nhim khun cp tnh v c bit tng cao trong bnh
bch cu cp hoc mn tnh. S lng bch cu gim trong nhim c, nhim
x, trong bnh suy ty.
i sng bch cu thay i theo tng loi. i vi bch cu ht, sau
khi c phng thch t ty xng s lu hnh trong mu trong 4-8 gi, sau
di chuyn vo trong m v tn ti thm khong 4-5 ngy. Nu m b nhim
khun, bch cu ht s c huy ng n thc hin chc nng v t tiu hy
sau th i sng c th ngn hn, thm ch chi cn vi gi. Bch cu mono
cng c thi gian lu hnh trong mu ngoi vi ngn khong 10-20 gi, trc
khi i xuyn mao mch vo m. Sau khi vo m, bch cu mono pht trin
thnh i thc bo trong m, c th sng nhiu thng, nhiu nm cho n khi
t tiu hy trong qu trnh thc bo. T bo lympho t cc hch bch huyt v
cc m lymphoid xm nhp vo h tun hon, sau vi gi chng vo m, ti
xm nhp bch huyt ri tr vo mu, v c nh th t bo lympho lin tc
tun hon i khp c th. i sng ca bch cu lympho thay i t nhiu
tun n nhiu thng tuy thuc vo nhu cu ca c th i vi t bo ny.
2.2. Hnh dng bch cu
Cn c vo hnh dng, kch thc trung bnh, s bt mu khc nhau ca
nhn v cc loi ht trong bo tng khi nhu m giemsa nhn dng cc loi
bch cu.
- Ba loi bch cu c ht khi nhum: kch thc khong 10-15m
+ Bch cu ht trung tnh (Neutrophil): nhn cha chia mi hoc chia
nhiu mi mu tm en. Bch cu cng gi, nhn cng nhiu mi. Bo tng
c nhiu ht rt nho, mn u nhau, bt mu hng tm. Hu ht cc ht ny l
cc tiu th cha enzym thu phn. Ngoi ra cn cc ht cha cc cht oxy
ho mnh c tc dng tiu dit vi khun.
+ Bch cu ht a acid (Eosinophil): nhn thng chia hai mi nh
hnh mt knh mu tm. Bo tng c nhng ht to, trn u nhau bt mu o
cam. Cc ht ny c cha nhiu enzym peroxidase v phosphatase acid.
+ Bch cu ht a kim (Basophil): nhn thng c gii hn khng r,
i khi cho ta hnh nh nh t bo b v nt hay hnh hoa th mu tm en.
Bo tng c nhng ht to nho khng u nhau nm c ln nhn, bt mu
xanh en. Cc ht ny c cha nhiu heparin, histamin v m t lng nho
bradykinin, serotonin.

18

- Hai loi bch cu khng c ht khi nhum:


+ Bch cu mono (Monocyte): l bch cu ln khong 20-25m, nhn
hnh ht u nm lch v mt pha, bo tng bt mu xm tro, khng ht
hoc c t ht azur.
+ Bch cu lympho (Lymphocyte): loi nho (9-12m) v loi to (12-18
m). Nhn to trn, mu tm sm chim gn ht t bo. Bo tng c mu
xanh l bao quanh nhn, khng c ht ho c c t ht azur.
2.3. Cng thc bch cu
C nhiu loi cng thc bch cu khc nhau, tuy theo mc ch thm
d nghin cu, ngi ta c th dung nhng tiu chun khc nhau phn loi
cng thc bch cu. C hai loi cng thc bch cu thng c s dng:
2.3.1. Cng thc bch cu ph thng
Cng thc bch cu ph thng l ti l phn trm cc loi bch cu trong
mu. Tuy nhin, cng thc ny cha ni ln gi tr tuyt i do cn c
so snh vi tng s bch cu suy ra s lng ca tng loi bch cu.
ngi Vit Nam trng thnh bnh thng, cng thc bch cu ph thng v
tr s tuyt i ca tng loi nh sau:
Bng 4.2. Cng thc bch cu ph thng va tr s tuyt i ngi trng
thanh binh thng
Loi bch cu
Cng thc
S lng/mm3
Bch cu ht trung tnh (Neutrophil)
60-66%
1700-7000
Bch cu ht a acid (Eosinophil)
9-11%
50-500
Bch cu ht a base (Basophil)
0,5-1%
10-50
Bch cu mono (Monocyte)
2-2,5%
1000-4000
Bch cu lympho (Lymphocyte)
20-25%
100-1000
Cng thc bch cu ph thng gip nh hng nguyn nhn gy bnh.
V d:
- Bch cu ht trung tnh: tng trong nhim trung cp nh vim rut
tha, vim phi; gim trong nhim c kim loi nng nh Pb, As, suy ty,
nhim siu vi (quai b, cm, si).
- Bch cu ht a acid: tng trong d ng, bnh k sinh trung, cc bnh
ngoi da; gim trong kch ng, chn thng tm l, dung thuc ACTH,
cortisol
- Bch cu ht a base: tng trong bnh bch cu dng ty; gim trong

19

d ng cp, dung thuc ACTH.


- Bch cu mono: tng trong bnh nhim khun mn tnh nh lao.
- Bch cu lympho: tng trong ung th mu, nhim khun mu, ho g,
si, lao; gim trong thng hn nng, st pht ban
2.3.2. Cng thc Arneth
Arneth nghin cu bch cu ht trung tnh nhn thy bch cu cng gi
nhn cng chia nhiu mi. V vy cng thc ny gip thm d tc sinh sn
v ph hy ca bch cu.
Cng thc Arneth ca ngi Vit Nam trng thnh bnh thng l:
Nhn c 1 mi: 2 4,5%
Nhn c 2 mi: 21 29%
Nhn c 3 mi: 36 42%
Nhn c 4 mi: 21 26%
Nhn c 5 mi: 3 10%
Gi tr lm sng:
Nu c t bch cu chia mi: bnh bch cu cp.
Nu bch cu 2 mi tng nhiu: nhim trung.
Nu bch cu 3 mi nhiu: bnh thng.
Nu bch cu 5 mi tng: thiu mu c tnh.
2.4. Cc c tnh ca bch cu
2.4.1. Tnh xuyn mch
Bch cu c th chui qua khe h gia cc t bo ni m ca mao mch
vo cc t chc quanh mao mch, mc du nhng l c kch thc nho
hn bch cu nhiu ln. Ring cc bch cu mono sau khi xuyn mch s hp
bo li thnh i thc bo.
2.4.2. Tnh chuyn ng bng chn gi
Mi khi c kch thch ti mt ni no trong c th, bch cu chuyn
ng bng cch th tua bo tng, goi l chn gi, di chuyn n tp trung ti
a im b kch thch. Bch cu c th chuyn ng vi vn tc trn
40m/pht.
2.4.3 Tnh ha ng ng
Mt s cht khc nhau do m tit ra, c kh nng hp dn bch cu di
chuyn goi l tnh ha ng ng (chemotaxis). Ha ng ng c th dng
tnh khi hp dn bch cu di chuyn ti gn, hay m tnh khi iu khin bch

20

cu trnh xa. Nhng sn phm hu hoi trong m vim ho c c t ca vi


khun thng l nhng cht gy ha ng ng dng.

Hinh 4.5. S xuyn mch va ha ng ng dng ca bch cu


(Ngun: Guyton A.C. (2006), Textbook of Medical Physiology, 11th ed.,
W.B.Saunders Co, Philadelphia).
2.3.4. Tnh nhn bit v loi b vt l
Cc bch cu c nhim v quan trong l tham gia p ng min dch
bo v c th, do chng c c tnh nhn bit vo loi bo cc vt l bng
nhiu cch khc nhau.
* Thc bao:
Khng phi bch cu no cng c kh nng thc bo. Kh nng thc
bo ln nht thuc v i thc bo, tip theo l bch cu ht trung tnh (tiu
thc bo), bch cu ht a acid cng c kh nng thc bo nhng yu hn.
Qu trnh thc bo gm cc giai on:
- Bt gi vt l: nhng ni vim l ni tp trung nhiu bch cu, ti ni
bch cu th chn gi bt gi cc vi khun, mnh t bo cht v c cc ht
bi bng c ch nhp bo. Kh nng bt gi vt l ca bch cu s tng ln
khi vt l c b mt th nhm, g gh, tch in tri du hoc b opsonin ha.

21

Opsonin ha l hin tng vt l c bao bng b th v khng th, khi


kh nng thc bo c th tng ln gp hng trm ln.
- Tiu dit vi khun: bch cu bt gi vt l trong cc ti thc bo.
Trc khi tiu ha vt l, cc tc nhn oxy ha mnh nh hydrogen peroxid
(H2O2), superoxid (O2-), hydroxyl c trong bch cu s thm vo ti thc bo
v git cht vi khun bng cch oxy ha nhng cht hu c ca vi khun.
- Tiu ha vt l: ti thc bo s ha mng vi lysosom thnh ti tiu
ha, cc enzym thy phn trong lysosom s phn ct cc cht c hp thu,
cc cht dinh dng c a vo bo tng t bo, cc cht c n b c
o thi bng c ch xut bo. Tuy nhin, kh nng tiu ha cn ph thuc
vo vic vt l c cu trc phu hp vi h enzym ca bch cu hay khng, ni
cch khc khng phi tt c cc vt l c bt gi u b tiu ha.
* Phn ng khng nguyn-khng th:
Hot ng ca bch cu lympho, bch cu ht a kim l nhng v d
in hnh ca c tnh tham gia phn ng khng nguyn-khng th chng
li cc vt l vi nhiu hnh thc khc nhau bng cc sn phm ca bch cu.
3. CHC NNG CA BCH CU
3.1. Chc nng ca bch cu ht trung tnh
Chc nng chnh ca bch cu ht trung tnh l tham gia p ng min
dch t nhin (min dch khng c hiu) bng hot ng thc bo gp phn
to phn ng vim cp.
T nhng gi u ca phn ng vim, khi cc tc nhn nh vi khun
gy tn thng v hy hoi t chc m, s dn n tnh trng tr tun tun
hon ti ch to iu kin cho cc bch cu ht trung tnh xuyn mch v tp
trung n vung b tn thng bng c ng amip. Trong 6-12 gi u, bch
cu ht trung tnh gi vai tr chnh chng vi tc nhn gy bnh bng
cch thc bo chng.
Bch cu ht trung tnh vn ng v thc bo rt tch cc nhng khng
chon loc (khng c hi u). Chng c th tiu ha nhiu loi vi khun, m tn
thng v cc sn phm ca m tn thng, cc si fibrin ca cc mu ng.
Sau khi thc bo chng s b nhim c v cht dn. Mi bch cu ht trung
tnh c th thc bo ti a khong 5-20 vi khun.
3.2. Chc nng ca bch cu ht a acid
- Thc bo: bch cu ht a acid thc bo yu hn so vi bch cu ht

22

trung tnh. Chng thng c hp dn theo ha ng ng dng n nhng


ni xy ra phn ng khng nguyn - khng th thc bo v tiu ha cc
phc hp khng nguyn khng th sau khi qu trnh min dch hon
thnh.
- Kh c cc protein l trc khi chng c th gy hi cho c th:
bch cu a acid thng tp trung nim mc ng tiu ha v h hp ni
m cc protein l thng xm nhp vo c th. Ngoi ra, bch cu ht a acid
cng tng trong phn ng d ng v phn ng d ng c cc protein l.
- Chng k sinh trung: bch cu ht a acid gn vo k sinh trung , gii
phng ra nhng cht dit k sinh trung nh men thy phn, polypeptid git
u trung ca k sinh trung.
- Lm tan cc mu ng: bch cu ht a acid di chuyn n cc mu
ng, ti chng gii phng ra cht plasminogen, cht ny c hot ha
thnh plasmin, lm tiu cc si fibrin dn n tan cc mu ng.
3.3. Chc nng ca bch cu ht a base
Bch cu ht a base him gp trong mu v c cu trc rt ging cc
dng bo c tr trong cc m lin kt ngoi mch mu. Bch cu ht a base
v dng bo khng c kh nng vn ng v thc bo, nhng chng c
nhng chc nng sau:
- Gii phng heparin vo mu ngn nga qu trnh ng mu trong
lng mch.
- Gii phng histamin v mt lng nho bradykinin, serotonin tham gia
vo cc phn ng d ng: globulin min dch gy ra phn ng d ng l IgE c
khuynh hng gn trn mng ca bch cu ht a base v dng bo. Khi c
mt khng nguyn c hiu phn ng vi khng th IgE s lm bch cu ht
a base v dng bo v ra v gii phng histamin, bradykinin gy dn mch,
tng tnh thm thnh mch.
3.4. Chc nng ca bch cu mono-i thc bo
Sau khi c sinh ra ty xng, bch cu mono i vo mu bng
hnh thc xuyn mch. Trong mu, bch cu mono l nhng t bo c kch
thc ln nht v cha trng thnh nn chng khng c kh nng tn cng
v ph hy cc tc nhn gy bnh. Bch cu mono chi tn ti trong mu
khong vi gi ri i vo cc m. m, nhiu bch cu mono nhanh chng
hp bo li thnh i thc bo: t bo phng to ln, kch thc c th tng

23

gp 5 ln, a nhn, trong bo tng cha mt lng ln lysosom, ty lp th


lm cho bo tng trng ging mt ci ti cha y ht, t bo thi k ny
c goi l i thc bo (macrophage) l dng trng thnh ca mono bo.
Cc i thc bo ny s gn vi m goi l i thc bo c nh vi nhng tn
goi khc nhau nh t bo Kupffer (i thc bo gan), t bo bi (i thc
bo ph nang), hy ct bo (i thc bo xng) Chng ti m hng
thng hoc hng nm, cho n khi c cc kch thch thch hp chng s tch
khoi m tr thnh i thc bo lu ng, i n vung vim nhim theo c
ch ha ng ng. Chc nng ca i thc bo l tham gia p ng min dch
khng c hi u :
- Thc bo: cng ging nh bch cu ht trung tnh, i thc bo c
kh nng thc bo khng chon loc cc tc nhn gy b nh, ht bi, m tn
thng v cc sn phm ca m tn thng trong phn ng vim khng c
hi u Tuy nhin kh nng thc bo ca i thc bo c nhng im khc
bch cu ht trung tnh:
+ Kh nng thc bo ln hn rt nhiu so vi bch cu ht trung tnh.
i thc bo c kh nng thc bo khong 100 vi khun v kch thc ca
nhng vt b thc bo cng ln hn rt nhiu nh hng cu gi, bch cu ht
trung tnh b cht, k sinh trung st rt, cc m hoi t
+ Trong vi pht u ca phn ng vim, i thc bo m tn
cng vi khun nhng s lng i thc bo lc ny cn t. Cung lc , mt
lng ln mono bo t mu vo m v bin i nhanh chng thnh i thc
bo xm nhp vo vung tn thng. Nh vy, giai on sau ca hin tng
vim, t gi th 10-12, cc bch cu ht trung tnh khng cn hiu qu thc
bo nh cc i thc bo na. i thc bo cng ng vai tr quan trong
trong nhng bnh nhim khun mn tnh.
- Khuch i phn ng vim khng c hiu: di s kch thch ca cc
yu t gy vim, i thc bo s phng thch mt lot cc cytokin nh
interleukin-1 (IL-1), yu t hoi t khi u (Tumor Necrosis Factor : TNF
), IL-6, IL-8, IL-12. Cc yu t ny c tc dng khuch i phn ng vim
ti ch v ton thn.

24

- Trnh di n khng nguyn: thc bo l mt phn ca p ng min


dch khng c hiu nhng ng thi n cng l bc khi u cho p ng
min dch c hiu m trong i thc bo ng vai tr quan trong. Sau khi
bt gi v tiu ha tc nhn xm nhp, i thc bo s x l v trnh din
khng nguyn ca tc nhn , ni cch khc l nhn din v truyn cc
thng tin v khng nguyn cho cc bch cu lympho B v T c tr ti cc
hch bch huyt gn khu vc khng nguyn xm nhp. Qu trnh trnh din
khng nguyn rt phc tp, c thc hin nh phc hp ha hp m lp II
(major histocompatibility complex class II: MHC II). MCH II ca i thc
bo s gn vi khng nguyn l v a n ra b mt i thc bo gii thiu
vi cc bch cu lympho.
3.5. Chc nng ca bch cu lympho
Bch cu lympho l nhng t bo tham gia p ng min dch c
hi u vi hai loi: lympho B - p ng min dch dch th v lympho T - p
ng min dch qua trung gian t bo.
3.5.1. Chc nng ca bch cu lympho B
- Qu trnh bit ha: khi i thc bo gii thiu cc sn phm khng
nguyn cho cc lympho B gn, nhng lympho B mn cm c hiu vi cc
khng nguyn ny s tng sinh v chuyn dng thnh nguyn bo lympho.
+ Mt s nguyn bo lympho bit ha thnh nguyn tng bo
(plasmoblast). Nguyn tng bo phn chia rt nhanh v bit ha thnh tng
bo l nhng t bo sn xut ra khng th globulin vi tc rt nhanh (2000
phn t/giy). Khng th c bi tit vo bch huyt ri vo mu.
+ Mt s nguyn bo lympho phn chia v bit ha thnh cc lympho
mi, l cc t bo nh, cc t bo ny khu tr trong t chc bch huyt
dng khng hot ng cho n khi chng b kch thch bi ln xm nhp th
hai cung mt khng nguyn. Khi , khng th c sn xut ra nhanh hn v
mnh hn rt nhiu so vi ln u.
- p ng min dch dch th: cc khng th c sn xut ra, vo mu
n ni c cc khng nguyn, n c th trc tip hoc gin tip tn cng cc
tc nhn l:
+ Tc dng trc tip: khng th c th lm bt hot tc nhn xm nhp
bng cc hnh thc: ngng kt, kt ta, trung ha, lm tan khng nguyn. Tuy
nhin, tc dng trc tip ny khng mnh bo v c th.

25

+ Tc dng gin tip: tc dng ny ng vai tr ch yu trong bo v


c th v c thc hin thng qua vic hot ha b th. Khi khng th gn
vi khng nguyn c hiu, v tr hot ng trn phn t khng th c hot
ha. Phn hot ho ny s gn vi phn t C 1 ca h thng b th gy ra mt
chui phn ng b th theo kiu dy chuyn. Cc sn phm hot ho ca h
thng b th c nhiu tc dng quan trong tiu dit tc nhn xm nhp
nh: hot ho kh nng thc bo ca bch cu ht trung tnh v i thc bo,
lm v mng ca vi khun hoc tc nhn l, lm ngng kt, trung ha virus,
hot ho dng bo v bch cu ht a kim gy phn ng vim.
3.5.2. Chc nng ca bch cu lympho T
- Qu trnh bit ha: khi i thc bo gii thiu cc sn phm khng
nguyn cho cc lympho T gn, nhng lympho T mn cm c hiu vi cc
khng nguyn ny s tng sinh v chuyn dng thnh lympho cm ng.
+ Mt s lympho T cm ng c hot ha to ra 3 loi lympho T
chnh l: T gip (Th: helper) kch thch s pht trin v sinh sn ca cc
lympho T c, T c ch, lympho B, hot ng bch cu ht trung tnh v i
thc bo; T c (Tc: cytotoxic) trc tip tiu dit cc t bo b nhim bnh v
khuch i kh nng thc bo ca i thc bo; T c ch (Ts: suppressor) c
tc dng c ch lympho Tc v Th lm cho p ng min dch khng pht trin
qu mc.
+ Mt s t bo lympho T cm ng phn chia v bit ha thnh cc t
bo nh. Khi khng nguyn ny xm nhp ln hai, nh cc t bo nh ny m
s gii phng cc lympho cm ng nhanh hn v nhiu hn.
- p ng min dch qua trung gian t bo: ti t chc, lympho T cm
ng s tiu dit khng nguyn trc tip hoc gin tip nh sau:
+ Tc dng trc tip: khi lympho cm ng loi Tc kt hp vi khng
nguyn nm trn mng t bo nhim bnh, n s phng to ln v gii phng ra
nhng men thy phn ca lysosom tiu dit t bo bnh.
+ Tc dng gin tip: khi lympho cm ng loi Th v Tc kt hp vi
cc khng nguyn c hiu trn mng t bo trnh din khng nguyn, n s
gii phng mt s lymphokin vo cc m xung quanh. Cc lymphokin ny s
khuch i tc dng ph hy khng nguyn ca lympho T ln nhiu ln (yu
t chuyn dng lympho bo: TF), hp dn i thc bo n gn (yu t hp
dn i thc bo) v ngn cn s di tn ca cc i thc bo ang gn t

26

bo lympho cm ng (yu t c ch di tn bch cu: M.I.F). Cc lympho T


cm ng cn khuch i tc dng thc bo ca bch cu ht trung tnh v i
thc bo, h tr lympho B trong qu trnh sn xut ra khng th.

Hinh 4.6. p ng min dch c hiu ca c th


(Ngun: Guyton A.C. (2006), Textbook of Medical Physiology, 11th ed.,
W.B.Saunders Co, Philadelphia).
4. H THNG MIN DICH
Min dch l kh nng nhn din v loi bo cc vt l. H thng min
dch c chia thnh hai loi: min dch khng c hi u (min dch t nhin)
v min dch c hiu (min dch thu c).
4.1. H thng min dch khng c hi u

Min dch t nhin l kh nng t bo v sn c, xut hin ngay t lc


mi sinh ra v khng i hoi phi c s tip xc trc vi cc khng nguyn
ca vt l. H thng min dch t nhin bao gm:
- Hng ro vt l: da, nim mc ngn cch n i mi v ngoi mi.
- Hng ro ha hoc:
+ Trn da v nim mc: acid lactic, acid bo ca da; lysozym ca dch
tit nim mc ngn cn s xm nh p ca vi khun.
+ Trong c th l huyt thanh c cha: lysozym, protein phn ng C (C
reactive protein), b th, interferon B th vi bn cht l protein, l mt h
thng gm nhiu thnh phn, c hot ha theo mt trnh t nht nh. Khi

27

c hot ha, b th s c ct thnh nhiu phn khc nhau, mi phn s


c vai tr ring, v d C3a, C5a c tc dng ha ng ng bch cu, gy gin
mch, gii phng cc ha cht trung gian t bch cu ht a base. Interferon
cng c bn cht l protein c sn xut bi nhiu loi t bo, c vai tr
chng s ly lan ca virus cc t bo cung loi mt cch khng c hiu.
Khi virus xm nh p vo t bo, t bo b nhim virus s sn sinh ra interferon
thm vo cc t bo xung quanh, gip chng khng b virus xm nh p tip.
- Hng ro t bo: cc t bo c kh nng thc bo m quan trong nht
l bch cu ht trung tnh v mono - i thc bo c di chuyn t mu ra
m, y l hng ro quan trong v phc tp nht. Hot n g ca hng ro
ny s to ra phn ng vim khng c hiu. Ngoi ra, hng ro t bo cn c
s tham gia ca t bo dit t nhin (NK: natural killer), mt bin th ca
bch cu lympho hin din lch, hch, tu o v mu, chng thng tn
cng v tiu dit khng c hiu cc t bo khi u tin pht v t bo cha
virus bng cht tit perforin ca chng.
- Hng ro th cht: c im v hnh thi v chc nng s quyt nh
tnh phn ng ca tng c th i vi cc yu t xm nhp khc nhau.
4.2. H thng min dch c hiu
Min dch c hi u l trng thi min dch xut hin khi c th
c tip xc vi khng nguyn, bao gm: min dch dch th vi vai tr ca
lympho B v min dch qua trung gian t bo vi vai tr ca lympho T. Trong
p ng min dch c hiu, c th c nhiu cch tng tc vi khng nguyn
khc nhau thng qua phn ng vim c hi u t mc ch cui cung l
v hiu ha khng nguyn v loi khng nguyn ra khoi c th.

SINH L TIU CU V CM MU
Mc tiu:
1. M t c qu trnh sn sinh, phn b, hnh dng v cu trc ca tiu cu.
2. Xc nh c s lng tiu cu ngi Vit Nam bnh thng.
3. Trnh by c cc c tnh v chc nng ca tiu cu.
4. Phn tch c c ch cm mu.

28

1. QU TRNH SN SINH TIU CU


Tiu cu c c hnh thnh t s v ra ca bo tng cc mu tiu
cu theo c ch ni phn bo. Mt mu tiu cu c th sinh ra khong 6000
mu tiu cu. Mu tiu cu c ngun gc t t bo dng ty hnh thnh t t
bo mu gc vn nng trong ty xng.
S sinh trng ca tiu cu c kim sot ch yu bi m t yu t th
dch l thrombopoietin. Thrombopoietin c ngun gc t gan v thn, bn
cht l glycoprotein. Thrombopoietin c hai tc dng quan trong:
+ Kch thch tng sinh s lng cc mu tiu cu.
+ Kch thch tng tc trng thnh bo tng ca mu tiu cu v tc
gii phng tiu cu.
2. C IM CHUNG CA TIU CU
2.1. Hnh dng v cu trc
Tiu cu l cc mnh t bo nho do hnh dng khng nht nh (trn,
sao, que, bu dc), khng nhn, ng knh t 2-4m v th tch khong
5,8fl.
Di knh hin vi in t, tiu cu c mt siu cu trc phc tp gm 4
vung:
- Vung ngoi vi: chnh l mng t bo c nhiu tnh cht quan trong:
+ Lp o glycocalyx ca mng tiu cu hp thu nhiu ion ha tr 2 v
mt s yu t ng mu nn c goi l lp kh quyn bao quanh tiu cu.
Lp kh quyn ny ng vai tr quan trong trong cm mu.
+ Cc glycoprotein (GP) trn mng tiu cu cng thc hin nhiu chc
nng quan trong m c bit l GPIb/IX v GPIIb/IIIa.
- Vung sol-gel di mng: nm ngay bn di mng tiu cu gm h
thng cc vi si, vi ng. Vung ny to nn b khung nng duy tr hnh
dng ca tiu cu, ng thi tham gia vo hin tng co tht to chn gi khi
tiu cu b kch thch.
- Vung tiu th (vung bo quan): gm cc ht c ng knh t 0,20,3m.
+ Cc ht m: cha cc cht hot ha tiu cu Ca++, ADP, ATP v
serotonin.

29

+ Cc ht alpha type I (20200/tiu cu): cha cc protein c bit ca


tiu cu nh yu t IV tiu cu, cc glycoprotein kt dnh, cc cht c ch s
phn hy fibrin
+ Cc ht alpha type II (2-10/tiu cu): cha cc enzym lysosom nh
N-acetylglucominidase, N-glucuronidase v N-galactosidase.
- H thng lin kt mng:
+ H thng ng dn m c: l li ni bo tng ng vai tr d tr
++
Ca , ng thi l ni tng hp cyclo-oxygenase v prostaglandin ca tiu
cu.
+ H thng ng dn b mt: l nhng ch lm vo trong ca mng bo
tng t bo lm tng din tch tip xc ca tiu cu v lm cho tiu cu c
tnh cht xp. H thng ny c vai tr trong vic thu nhn cc cht trong
huyt tng v gii phng cc cht cha trong cc ht.
2.2. S lng v i sng tiu cu
Sau khi ri khoi ty xng, khong 1/3 s lng tiu cu c lu gi
lch v 2/3 cn li lu hnh trong mu ngoi vi.
S lng tiu cu bnh thng trong mu ngoi vi l khong 150.000400.000/mm3 mu. i sng tiu cu trong tun hon ko di t 8-12 ngy.
Bnh thng mi ngy c khong 75.000 tiu cu mi c to ra, nh vy
cc tiu cu trong mu s c i mi hon ton trong vng 4 ngy. Tiu cu
gi b ph hy trong cc t chc lin vng, ch yu trong lch, t hn trong
gan v ty xng.
2.3. Cc c tnh ca tiu cu
- Kh nng hp ph v vn chuyn cc cht: l kh nng tiu cu hp
ph cc cht trong huyt tng to ra mt lp kh quyn bao xung quanh.
Nh kh nng ny cc cht thit yu cho qu trnh cm mu ni chung v
ng mu ni ring c vn chuyn n nhng ni cn thit.
- Kh nng kt dnh: l kh nng tiu cu kt dnh vo lp di ni mc
mch mu c bit l cc si collagen. Bnh thng s kt dnh khng xy ra
do lp ni mc mch mu che ph lp di ni mc.
- Kh nng ngng tp: l kh nng cc tiu cu gn kt ln nhau to
nn nt ch n tiu cu. Bnh thng cc tiu cu c gi khng ngng tp
trong mu nh nng lng t ATP. Hin tng ngng tp c th xy ra khi
xut hin nhiu ADP ngoi lai hoc thromboxan A2.

30

- Kh nng thay i hnh dng v phng thch cc cht: l kh nng tiu


cu thay i hnh dng v bi xut ra cc cht sau khi c hot ha.
3. CHC NNG CA TIU CU
- Tham gia vo qu trnh cm mu: tiu cu khng chi trc tip tham
gia vo qu trnh cm mu ban u m cn tham gia vo qu trnh ng mu.
- Bo v ni m: tiu cu c kh nng lm non ho cc t bo ni mc
v cng c mng t bo ni mc qua vai tr ca yu t tng trng t bo ni
mc c ngun gc t tiu cu.
- Ngoi ra, tiu cu cn trung ha hot ng chng ng ca heparin,
tng hp m t s loi protein v lipid, tham gia p ng vim...
4. CM MU
Cm mu l mt qu trnh gm nhiu phn ng sinh hoc c ngha t
v nhm hn ch hoc ngn cn mu chy ra ngoi khi thnh mch b tn
thng.
4.1. Cc giai on cm mu
C 4 c ch tham gia vo qu trnh cm mu hay cn goi l 4 giai on:
co mch, to nt ch n tiu cu, ng mu huyt tng v tiu si huyt.
Trong , co mch v hnh thnh nt tiu cu c goi l cm mu ban u.
4.1.1. Co thnh mch
Ngay sau khi mch mu b tn thng, thnh mch s co tht li lm
gim lng mu b mt qua ch tn thng. C ch ca s co tht ny l do
co c trn lp o gia mch mu. S co tht s ko di v mnh cc ng
mch, tnh mch ln. iu kin co mch tt l thnh mch phi vng chc
v c kh nng n hi tt, khi thiu mt trong hai iu kin ny s gy chy
mu bt thng trn lm sng. Nguyn nhn ca co thnh mch l do phn x
thn kinh au ti ch tn thng, ngoi ra cn do tiu cu bi tit ra serotonin,
adrenalin v thromboxan A2.
4.1.2. Nt chn tiu cu
Nt chn tiu cu c thnh lp bt kn ch tn thng trn thnh
mch. Qu trnh ny din ra qua 4 hin tng:
- Hin tng kt dnh tiu cu: khi mch mu b tn thng bc l lp
di ni mc, tiu cu kt dnh vo cc cu trc di ni mc qua protein kt
dnh Von-Willebrand c hp th trn cc si collagen v GPIb/IX trn
mng tiu cu.

31

- Hin tng hot ha tiu cu: hin tng kt dnh lm cho tiu cu
c hot ha v phng xut cc cht trong tiu cu nh ADP, thromboxan A2
v serotonin. Cc phn t ny s khuch i s hot ha.
- Hin tng ngng tp tiu cu: khi c hot ha tiu cu s bc l
phc h GPIIb/IIIa, phc h ny s gn kt vi fibrinogen. Nh c cu trc
nh mt phn t kp nn fibrinogen tr thnh cu ni gia hai tiu cu.
- Hin tng co cc mu: cc tiu cu lc u mong manh, d b dng
mu chy cun tri, sau s tr nn chc chn nh hin tng co cc mu
thng qua hot ng ca h thng vi ng vung sol-gel ca tiu cu.

Hinh 4.7. Hin tng kt dnh va ngng tp tiu cu


Trong m t s trng hp b nh l, nt ch n tiu cu s to thnhhuyt
khi tiu cu hay cc mu trng lm nghn tc mch mu.
4.1.3. ng mu huyt tng
Nt ch n tiu cu chi m bo cm mu tm thi nhng mch mu
nho. cm mu nhng mch mu ln b tn thng cn phi c s hnh
thnh cc mu ng (huyt khi hng cu hay cc mu o). Trn c s nt
ch n tiu cu, qu trnh ng mu s c khi pht nh cc yu t ng
mu ca huyt tng v m t s yu t ca tiu cu, ca m gii phng ra.
4.1.3.1. Cc yu t ng mu v chng ng
- Cc yu t ng mu:
Yu t I: fibrinogen

32

Yu t II: prothrombin
Yu t III: thromboplastin hay yu t t chc (TF)
Yu t IV: Ca++
Yu t V: proaccelerin
Yu t VII: proconvertin
Yu t VIII: yu t chng hemophilia A
Yu t IX: yu t chng hemophilia B
Yu t X: yu t Stuart
Yu t XI: yu t Rosenthal
Yu t XII: yu t Hageman
Yu t XIII: yu t n nh fibrin
Yu t Fletcher: prekallikrein
Yu t Fitzgerald: kininogen trong lng phn t cao (HMWK)
Cc yu t ng mu c th c chia thnh cc nhm sau:
+ Nhm cc yu t tip xc hay ng chm: gm cc yu t XI, XII,
prekallikrein, kininogen tham gia vo giai on u ng mu n i sinh (giai
on tip xc). Chng c c tnh khng ph thuc vo vitamin K khi tng
hp, khng ph thuc vo Ca++ trong qu trnh hot ha, n nh tt trong
huyt tng lu tr v l nhng yu t bn vng.
+ Nhm prothrombin: gm cc yu t II, VII, IX, X. Chng c c tnh
ph thuc vo vitamin K khi tng hp, cn c Ca ++ trong qu trnh hot ha,
n nh trong huyt tng lu tr v khng b tiu th trong qu trnh ng
mu tr yu t II (c mt trong huyt thanh).
+ Nhm fibrinogen: gm cc yu t I, V, VIII, XIII. Chng c c tnh
tc dng qua li vi thrombin, b tiu th trong qu trnh ng mu (khng c
mt trong huyt thanh), yu t V v VIII mt hot tnh trong huyt tng lu
tr.
+ Yu t t chc (III): y l yu t duy nht khng phi ca huyt
tng m nm trong m (lp di nim mc mch mu) v cng khng c
hot tnh men m tc ng nh mt ng yu t trong hot ha yu t VII, X.
+ Ca++ (IV): y l yu t ion, to thun li cho cc protein ph thuc
vitamin K kt hp vi phospholipid mng ng thi cng can thip vo cc
phn ng khng lin quan n cc protein ph thuc vitamin K. Ca ++ cng
cn thit cho s th hin hot tnh men ca yu t XIIIa, cho s n nh yu

33

t V v phc h yu t Von-Willebrand-yu t VIII.


- Cc yu t chng ng mu: cc yu t chng ng c vai tr ch
yu trong vic ngn cn s khi pht ng mu khng thch hp cng nh
iu ha gim sinh thrombin v tr tn thng. Cc yu t ny bao gm:
TFPI, antithrombin, heparin, protein C v protein S.
4.1.3.2. Cc giai on ng mu
ng mu xy ra qua 3 giai on lin tip nhau.
* Giai on 1: thanh lp phc hp men prothrombinase
y l giai on phc tp v ko di nht trong dy chuyn phn ng
gy ng mu. Prothrombinase c thnh lp theo hai ng: ni sinh v
ngoi sinh.
- ng ngoi sinh: khi mch mu b tn thng, mu s tip xc vi
ni b tn thng. M tn thng gii phng ra yu t III, l mt yu t c
tng hp t phospholipid ca mng t bo kt hp vi phc hp lipoprotein
c chc nng nh mt enzym phn gii protein. Yu t III s hot ha yu t
VII. Yu t III cung vi yu t VII hot ha, vi s c mt ca ion Ca ++ lm
hot ho yu t X. Yu t X hot ho cung vi phospholipid, ion Ca ++ v yu
t V hot ho (c hot ha bi thrombin v hnh thnh t rt sm) to ra
phc hp prothrombinase ngoi sinh.
- ng ni sinh: c kch hot bng nhm cc yu t ng mu tip
xc (yu t XII, kininogen cao phn t v prekallicrein), yu t XI. Yu t
Fitzerald tip xc trc tip vo thnh mch, tip nhn thng tin v tnh trng
b mt thnh mch, nu c s khc bnh thng th kch hot yu t XII
to yu t XII hot ha (XIIa). Yu t XIIa kch hot prekallicrein thnh
kallicrein v cht ny c kh nng kch hot ngc li yu t XII (hin tng
t khuch i). Yu t XIIa s hot ha yu t XI. Yu t XI hot ho cung
vi Ca++ hot ha yu t IX. Yu t IX hot ha cung vi yu t VIII hot ha
(do thrombin hot ha) v phospholipid ca tiu cu, Ca ++ hot ho yu t X.
Yu t X hot ha cung vi yu t V hot ha (bi thrombin), Ca ++ v
phospholipid tiu cu to ra phc hp men prothrombinase n i sinh.
* Giai on 2: thanh lp thrombin
Phc hp men prothrombinase to thnh s xc tc cho phn ng
chuyn prothrombin thnh thrombin. Phn ng ny xy ra trong vi giy.
Thrombin ng vai tr quan trong trong cc phn ng ca qu trnh ng

34

mu:
- Thnh lp fibrin: thrombin co vai tr chuyn fibrinogen thnh fibrin,
ng thi hot ha yu t XIII n nh si huyt.
- Lm tng tc hnh thnh ca bn thn (t khuch i): thrombin
gy hot ha yu t VIII dn n gia tng s hnh thnh yu t Xa bng c hai
con ng ni sinh v ngoi sinh. N cng hot ha yu t V.
* Giai on 3: thanh lp fibrin
Thrombin thy phn phn t fibrinogen to thnh cc monomer ca
fibrin v cc fibrinopeptid (A v B). Cc monomer ca fibrin t trung hp to
thnh phn t fibrin S (fibrin ha tan). Cui cung, yu t XIII hot ho s
polymer ha cc fibrin S thnh fibrin I n nh (fibrin khng ha tan) hay cn
goi l si huyt. Cc si huyt giam gi hng cu bn trong to thnh cc
mu ng.

Hinh 4.8. Qu trinh ng mu


Trong m t s trng hp b nh l, cc mu ng s to thnh huyt
khi hng cu hay cc mu o lm nghn tc mch mu.
* Tiu si huyt
Fibrin to ra c vai tr hn ch mu chy qua ch tn thng, tuy nhin

35

mng fibrin cn c tho d ng lc ti lp lu thng trong lng


mch. Do cn c s hin din ca h tiu si huyt, c tc dng don sch
cc cc mu ng nho ly ti trong lng mch mu, ngn nga s hnh thnh
huyt khi hng cu gy tc mch.
Hin tng tiu si huyt lm cc mu ng tan dn do cc si fibrin b
phn ly di tc dng ca plasmin mt enzym tiu protein rt mnh, m tin
cht ca n l plasminogen. Plasminogen mt protein lu hnh trong mu
gm 810 acid amin ch yu do gan tng hp. Plasminogen c hot ha
thnh plasmin bi cc cht sau:
- Thrombin.
- Yu t XII hot ho.
- Cc enzym ca lysosom t cc m tn thng.
- Nhng yu t hot ha do t bo ni m thnh mch bi tit.
- Men urokinase ca t chc thn.
- c t ca vi khun: streptokinase ca lin cu khun.
4.2. Cc xt nghim nh gi cm mu
- Cc xt nghim nh gi cm mu ban u:
+ Thi gian mu chy (TS).
+ Nghim php dy tht (Lacet): nh gi sc bn mao mch.
+ Cc xt nghim nh gi s lng v cht lng tiu cu: m s
lng tiu cu, pht mu ngoi vi, co cc mu, o kt dnh tiu cu, o
ngng tp tiu cu, cc yu t tiu cu.
- Cc xt nghim nh gi ng mu:
+ ng mu ngoi sinh: t l phc h prothrombin, nh lng yu t
II, V, VII, X.
+ ng mu ni sinh: thi gian phc hi calci ca huyt tng
(Howell), APTT (thi gian sinh thromboplastin hot ha tng phn), nh
lng yu t VIII, IX, XI v cc yu t tip xc.
+ Giai on hnh thnh fibrin: nh lng fibrinogen, yu t XIII, thi
gian thrombin.
- Cc xt nghim nh gi tiu si huyt, ng mu ni mch ri rc,
tng ng.
Cu hi lng gi:

36

1. S lng hng cu tng trong


cc trng hp bnh l sau y,
NGOI TR:
a. a hng cu.
b. Xut huyt.
c. Mt nc nhiu do tiu chy, nn
i.
d. Suy tim lu di.
2. Hemoglobin ch yu ngi
trng thnh bnh thng l loi:
a. HbA.
b. HbF.
c. HbS.
d. HbE.
3. Khi hng cu gi, thnh phn
sau y s thoi bin:
a. Globin.
b. Heme.
c. Ion Fe++
d. Acid amin.
4. Sn phm thoi bin ca
hemoglobin l:
a. Bilirubin.
b. Acid glucuronic.
c. Transferrin.
d. Glucuronyltransferase.
5. Vitamin B12 c d tr trong:
a. Ty xng.
b. Ty.
c. Lch.
d. Gan.
6. Nhm mu c xc nh da
trn:
a. S hin din ca khng nguyn

trong huyt tng.


b. S hin din ca cc khng th
trong huyt thanh.
c. Thnh phn protein trn mng
hng cu.
d. S hin din hay vng mt ca
cc khng th trn mng hng cu.
7. xc nh nhm mu bng
phng php nh nhm xui,
ngi ta s dng:
a. Hng cu mu.
b. Huyt tng mu.
c. Huyt thanh mu.
d. Mu ton phn.
8. Khng th h ABO l:
a. Khng th IgG.
b. Khng th t nhin.
c. Khng th min dch.
d. Khng th t min.
8. Tiu cu trong c th c phn
b:
a. 1/3 lu hnh mu ngoi vi v
2/3 b lu gi lch.
b. 2/3 lu hnh mu ngoi vi v
1/3 b lu gi lch.
c. 2/3 lu hnh mu ngoi vi v
1/3 b lu gi gan.
d. Ton b lu hnh mu ngoi
vi.
9. Cc yu t ng mu tham gia
vo con ng ng mu ni sinh:
a. II, VII, IX, X.
b. II, V, IX, X.
c. XII, XI, IX, VIII.

37

d. II, III, IV, V.


10. Cc c im no sau y lm
hin tng thc bo xy ra nhanh
hn, NGOI TR:
a. B mt vt l th nhm, g gh.
b. Vt l mang in tch tri du
vi bch cu.
c. Vt l c kch thc cng ln.
d. Vt l c opsonin ha.
11. Trong trng hp vim mn
tnh, t bo sau y s tng:

a. Neutrophil
b. Basophil.
c. Eosinophil.
d. Monocyte.
12. Cc t bo sau y c lin
quan n tnh trng d ng:
a. Neutrophil v eosinophil.
b. Neutrophil v basophil.
c. Eosinophil v basophil.
d. Basophil v monocyte.

38

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