BNH THIU MU

Ds L-vn-Nhn Li ni u : Chng trnh o to dc s ca Php v Vi.t-nam u c phn thc tp xt nghim m mu ( CBC hay Cells Blood Count). Dc s Hoa-k khng cn phi lm xt nghim nhng tri li phi c c kt qu xt nghim v hiu c kt qu xt nghim. Bi ny khng phi l bi gio khoa, m ch n li mt s im cn bn, gip qu ng nghip bit nhn u v phn on nh th no hiu r nh bc s, gii thch cho bnh nhn v theo di iu tri.. iu cn l ngi bc s dng kt qu xt nghim i chiu vi bnh s, triu chng bnh trong khi chng ta ch c t giy xt nghim, nn phi dt v kt qu xt nghim c khi khng phn nh ng tnh trng b.nh. Trong xt nghim m mu, chng ti ch gii hn phn hng cu v ch tho lun phn thiu mu do thiu st, do thiu sinh t, do thiu ni tit t erythropoietin thn v lt s bnh thiu mu thalassemia thng gp ngi Vi.t-nam. Xt nghim m mu CBC : ngha cc t ng trong xt nghim CBC : RBC : Red blood cells lng hng cu trong mm khi mu tnh bng triu HGB : Hemoglobin hay huyt sc t. Hemoglobin chuyn ch dng kh n cc t bo, nu hemoglobin cu to sai lc nh trong bnh thalassemia, s khng hu dng v cng ging nh khi thiu

hemoglobin. Ngi bnh thng, hemoglobin trn 14, nhng ch khi no xung qu thp di 8 lc mi ng quan ng HCT : hematocrit hay t s huyt cu trn th tch mu, HCT thp khi huyt cu b suy gim. HCT ph n thng trn 40% v phi nam trn 45%. Ngi suy thn kinh nin HCT gim xung thng di 35% c khi di 30%. MCV : mean corpuscular volume hay th tch trung bnh ca hng cu. Bnh thng MCV khon 80 n 90, nu di 80 th xem nh hng cu teo li ( microcytic) v nu ln hn 100 th xem l ph ra ( macrocytic). Hng cu nh hn bnh thng khi b thiu st hay b bnh thalassemia. Hng cu ln hn bnh thng khi b thiu folate ( do ung ru chng hn) hay thiu sinh t B-12. MCH : mean corpuscular hemoglobin, lng hemoglobin trung bnh trong mi hng c MCHC : mean corpuscular hemoglobin concentration hay t s trung bnh ca hemoglobin trong hng cu. Khi t s ny thp tc l ngi ny thiu sc t ( hypochromic anemia). RDW : Red cell Distribution Width hay s thay i hnh dng hng cu. con s ny ln khi ngi bnh ang thiu mu hay sp b thiu mu mc du cc s o khc vn bnh thng. Retic : reticulocyte count hay hng cu mng li hay hng cu non. Bnh thng hng cu non t khi xut hin ngoi vi, ch tng cao khi b xut huyt hay tim thuc kch thch sinh huyt nh epoietin v cho thy h sinh huyt trong ty xng bnh thng. Tri li, khi RBC, HBG, HCT u thp m retic cng thp, th c th h sinh huyt b trc trc hay thiu cht erythropoietin thn. Mt trng hp thiu mu : th c kt qu xt nghim sau : Mc bnh thng RBC 4.91 HGB 4.93 12.0 3.85 11.9-

14.9 HCT 44.5 MCV 98.0 MCH 33.8 MCHC 35.7 RDW 14.0% 38.0 77.1 24.3 31.5 18.8 35.0 81.5 27.6 33.3 11.0

Chng ta thy lng hng cu mc bnh thng, mc HGB v HCT tuy c hi thp nhng khng mc trm trng, MCV v MCHC thp hn bnh thng thuc nhm hng cu nh hn bnh thng v thiu sc t microcytic v hypochromic anemia. iu ng ngc nhin l RDW rt cao, chng t c s giao ng a n chng thiu mu nhng khng r nguyn nhn. Trng hp ny phi hi bnh nhn bnh g, ang dng thuc g, hay hi bc s bnh trng ca bnh nhn, mi c th gii thch r rng v chnh xc kt qu xt nghim mu n Thiu mu do thiu st : Khi xt nghim m mu cho thy thiu mu v MCV thp, MCHC thp, bc s c th nghi ng thiu mu do thiu st. Bc s c th yu cu th thm nhng xt nghim sau : Serum iron: lng st trong huyt thanh. St do transferrin chuyn ch, nn xt nghim ny c th sai khi lng transferrin xung thp. Tranferrin : protein chuyn ch st trong mu

* TIBC ( Total Iron Binding Capacity ) : kh nng transferin c th nhn thm st n mc bo ha. TIBC ln khi thiu st v xung

thp khi c tha st. * TSAT : transferrin saturation hay ch s cho bit lng st d tr sn sng cung ng cho s thnh lp hng cu. Ch s ny phi t 20% n 50%. Ferritin : lng st d tr. Ferritin khng ph thuc transferrin nn s cho mt kt qu chnh xc hn l ngi bnh c thiu st khng. Tuy nhin xt nghim ny t tin hn, nn thng thng bc s ch cho th st v TIBC. Th d thng RBC 5.40 HGB 16.0 HCT 47.0 MCV 99.0 MCH 31.0 MCHC 37.0 RDW 14.5 Serum iron 140 TIBC 400 3.96 10.8 32.9 83.0 27.3 32.8 13.8 32 256 Mc bnh 4.2012.037.081.0 27.033.011.535245-

Ferritin 47

13-

150

Trong trng hp ny chng ta thy RBC, HGB, HCT u xung thp nhng MCV v MCHC li bnh thng, nn gi l bnh thiu mu vi th tch v sc t bnh thng normocytic v normochromic anemia. RDW cng trong mc bnh thng. Chng ta khng thy reticulocyte, nu cao th c th on c bnh nhn b mt mu do xut huyt. Lng st thp v TIBC ph hp vi thiu st, ferritin cn trong gii hn nhng gn n mc thiu ht. Nu xem h s thuc dng, s thy bnh nhn ang dng thuc chng ng m Thiu mu do thiu sinh t : Khi bnh nhn thiu mu v MCV cao, bc s s ngh l macrocytic anemia v cho th lng acid folic v sinh t B- 12 trong mu. Acid folic thng c trong thc n ti, v c thm vo trong cereal hay bt ng cc nn t khi b thiu tr trng hp ngi bnh ung ru b n v dng mt s thuc lm thiu acid folic nh thuc cha ng kinh phenytoin (Dilantin). Khng nn t tin cha ngay bng folic acid v nu ngi bnh thiu sinh t B-12 triu chng bin mt m bnh vn cn c th sinh bin chng nguy him.

Th d : RBC HGB 18.1 HCT 53.7 MCV MCH MCHC 35.4 3.2 11.5 35.9 114 36.6 32.1

Mc bnh thng 4.514.143.5802631.897 32 6.5

RDW 14.8 Folic acid 17.0 Vit B-12 950 HIV

15.5 27.6 1,959 pos

11.63.0200-

Chng ta thy ngi ny thiu mu, MCHC bnh thng tc sc t bnh thng nhng MCV cao tc th tch hng cu ln, gi l macrocytic, normochromic anemia. iu ny ph hp vi chng bnh nhim HIV. iu ngc nhin l lng sinh t B-12 v folate rt cao, ng l MCV phi bnh thng. Chng ti khng d kin tm hiu thm, nhng on l bc s cho dng hai sinh t trn ri mi cho lm xt nghim. Phi ch i khon 120 ngy cho hng cu c cht thay bng hng cu mi sinh, khi th tch hng cu mi bnh thng tr l Bnh thiu mu do suy thn mn tnh : Bnh thn mn tnh thng km theo bnh thiu mu. Thn lnh mnh sn xut ni tit t kch thch ty xng sinh huyt gi l erythropoietin hay EPO. Thn suy s khng sn xut EPO nn ty xng s to t hng cu hn. Ngoi ra, lc mu cng lm mt hng cu, v thiu acid folic hay sinh t B 12 do thiu dinh dng cng lm cho cng thiu mu. Ngi b suy thn vi Cr> 2mg/dl s xem l thiu mu khi: ph n tui c kinh nguyt v HCT < 33% v HCT < 11 g.dl

n ng hay ph n tui mn kinh v HCT < 37% v HGB < 12 g/dl Bnh nhn s c tim epoitein gi xho HGB mc 11 n 12

g/dl. Th d : RBC 5.20 HGB 18.0 HCT 52.0 MCV 100.0 MCH 31.0 MCHC 36.0 Iron 170.0 TIBC 428 Ferritin Albumin 3.11 9.3 27.9 88 30 34.1 31 159 261 3.0 Mc bnh thng 4.6014.042.080.027.032.065228273.5377 4.5

Chng ta thy HGB v HCT rt thp do ty xng khng sinh huyt c. Lng st o c thp hn bnh thng, do thiu transferrin chuyn ch ch khng phi thiu tht s, v ferritin cho thy lng st d tr vn cao. Nu c c retic chng ta s thy retic thp v mu khng sinh thm khi thiu mu. Trng hp retic cao phn nhiu do bc s cho chch epoietin ( Procrit hay Epogen) sinh huyt. Nu bc s cho vin st km vi Procrit, th phi hiu dng bo m c cht st trong khi sinh huyt, ch khng phi bnh nhn thiu st.

V st c ti sinh khi hng cu cht,nn lng st cn a vo c th rt nh. Mc du sch v bo liu lng vin st l 325mg ngy 3 ln, nhng l trng hp thiu st trm trng, dng 3 vin mt ngy c th khng s dng ht ch gy to bn, v vin st trong nh khng y k d gy tai nn khi tr em t m ly ung. Vin st cng cn mi trng acid ha tan trc khi hp th vo mu, dng cc thuc mnh tr au bao t nh nhm c ch bm proton lm gim acid trong bao t lm sao ha tan ht st c ! Th d 2 : thng RBC HGB HCT Iron TIBC Retic Albumin Transferrin saturation Cng nh trng hp trn, ngi ny suy thn, albumin thp nn kh hn nn mc st cao hn mc du TIBC vn thp v vn cha transferrin.. Retic 1.9 l cao hn bnh thng, do c tim epoietin kch thch sinh huyt. Bnh thiu mu thalassemia : Thalas l bin nn Thalassemia c dch l thiu mu vng bin. Nn hiu bin y l a trung hi v bnh thng xy ra cc nc gn i Trung hi nh , Hy-lp. Bnh ny cng 3.46 10.1 32.4 39 206 1.9 3.3 35 Mc bnh 3.5 12.0 36 30 230 < 0.5 3.4 20 5.2 55 4.5 16.0 48 160 405

thng xy ra ngi VN nhng khng phi ch ngi vng bin mi c bnh n Hemoglobin l huyt sc t cn thit chuyn ch oxy n cc t bo. Hemoglobin c 2 chui alpha v 2 chui beta. Khi c s sai lc trong cu trc ca cc chui ny, hemoglobin mt kh nng chuyn ch oxy. Ty theo sai lc chui alpha hay beta chng ta c thalassemia alpha hay beta. y l bnh di truyn v nu ngi con ch nhn c 1 gene sai lc t cha hay m, ngi ch c thalassemia trait nn bnh nh, thng khng phi chuyn mu, trong khi nu b c hai gene t cha v m th bnh nng gi l major v phi chuyn mu. Do hng cu b ph v do truyn mu cao, nhng ngi ny thng b sng l lch v tch t nhiu st, i khi phi tim Desferral ly bt st ra khi c th. May mn l ngi Vn phn nhiu ch c trait nn khng cn chuyn m Xt nghim mu s thy ging nh ngi b thiu mu do thiu st, ngha l hng cu nh v thiu sc t, nhn di knh hin vi s thy mu nht v c mt chm m gia nh hng tm nn cn gi l target cells. Sau y l mt s im khc bit gia bnh thiu mu do thiu st v thiu mu thalassemia: Thiu mu do thiu st thalssemia RDW thng RBC triu MCV HGB MCHC cao thp thp hay bnh thng thp < 30% bnh >5 thp < 9 g/dl > 30% Thiu mu

Ngoi ra nu lm in dung s thy HB 2 v HG F cao hn trng hp thalassemi

Sau y l mt trng hp thiu mu thalassemia ca mt ph n Vi.t-nam: Mc bnh thng RBC HGB HCT MCV MCH MCHC 4.90 10.1 33.0 67.3 20.6 30.6 4.8012.03681263210.80 16.0 48 99 33 37

Morphology ( Hnh dng hng cu ): 1+ hypochromic 1+ microcytic 1+ target cells 1+ anisocytosis ( hng cu khng u nhau)

Mc du c bng so snh trn, chng ta kh lng phn bit gia bnh thiu mu do thiu st v thiu mu do thalassemia, nu khng thy mc st v ferritin. Mt trng hp th hai cng ca mt ph n VN b thalassemia km theo chng rong kinh do x ha t cung ( fibrosis) nn cng thc mu khng khc g ngi b thiu mu do thiu st : Mc bnh thng RBC HGB 4.02 10.7 4.4 13.5 5.8 16.5

HCT MCV MCHC RDW Iron TIBC % saturation Ferrtin

33.0 82 32.4 20.1 43 429 10 7

40.0 80 -

50.0 98 36.0 15.5 158 428 408 50

32.0 0.0 59 228 20 15 -

Chng ta thy mc hng cu, hemoglobin v HCT khng n ni thp lm v MCV cng bnh thng, nhng RDW rt cao cho bit ang thiu mu nng. St thp, TIBC cao v ferritin rt thp cho bit thiu st. Nu c retic y ln cao chng ta mi on c do xut huyt, nu khng, phi hi bnh nhn hay c bc s cho thm bnh s mi on c. DS LVN

(*) Bi post li vi s ng ca Din n Y Khoa :