CC YU T NGUY C V C IM SUY THN CP NGI LN TUI

BS Nguyn Bch Khoa Thn- Lc mu, Bnh Vin Thng Nht Tp HCM

M U
CA LM SNG
-

BN nam, 75 tui, 50kg TS: THA, BCTTMCT Nhp vin do au ngc chp mch vnh Kt qu XN v chp mch vnh- mch thn

17/5

27/5

6/6

27/7

Ure (mmol/l) Cre (mol/l) Cr Cl (ml/p)

6.2 111

10.4 187

12.1 252

23,7 380

35.97
bt
-

V nt
m niu Tr/c LS

bt
-

bt

bt

Khng
(Nhp vin)

Khng
(25/5: chp MV)

Khng

Khng

Chn on?

1. STC bnh vin (Hospital Acquired AKI). 2. Nguyn nhn, yu t thc y ?

WHO: Vo vin nguy him hn c i my bay

Hng triu ngi cht mi nm v nhng s xut v nhim trng trong lnh vc y t. Liam Donaldson (chuyn vin ph trch v an ton cho ngi bnh): "Nu ngy mai bn phi nhp vin, d l ang sng nc no i chng na th nguy c gp phi ri ro do s xut trong vic chm sc l 1/10. Cn nguy c t vong s l 1/300 Nguy c cht do tai nn my bay: khong mt phn 10 triu hnh khch.
Ngun: WHO- ng ti VN Express 25/7/2011

Ni ti: bnh nhn (Bin i v thn hc NLT)

Yu t nguy c

+
Ngoi lai (can thip iu tr)

1. YU T T BNH NHN 1.1.Bin i cu trc Gim trng lng: P thn/ 80-90 tui= 75-80% P thn/ ngi tr S sinh (50 g)trng thnh (400 g) Tui 90 (300 g)(1). - Gim vng v, vng tu cn nguyn. - Ph thuc gii: NC trng lng thn ngi t thit tui 70-79 vs 20-29 (2) nam: 19%; n 9%. - Tu thuc chng tc: NC 240 mu t thit tui > 90 (3) trng lng thn ngi Chu u ( 32% ), ngi Nht ( 43%). nhn thn ghp t ngi cho ln tui ?.
(1). Linderman RD (1990). Renal physiology and pathophysiology of aging. Am J. Kidney Disease 16, 272-285 (2). Wald H (1937). The weight of normal adult human kidneys and its variability.Archive Pathol Lab Med. 23, 493-55. (3). Tauchi (1971). Age changes in the human kidney of the different races. Gerontologia) 17: 87-97.

Tiu cu thn:
s lng (30-50%) x ho tng im (1). C ch: XVM mch thn do RL lipid mu v hot ng tng b. X ho vng v, vng tu cn bo tn. T l tiu cu thn b x ho tng im theo tui: < 5% (tui 40) 10-30% (tui 80). T l s cu thn x ho ton b: theo tui ngay c khi khng b cc bnh l nh THA, T (2). Tng s cu thn cn chc nng: theo tui (2).

(1) Froncht A (1984). Renal diseases in the geriatric patient. J. Am. Geriatric Soc 32, 28-43. (2) Hoang K (2003). Determinants of glomerular hypofiltration in aging humans. Kidney Int 64, 1417-24.

 Din tch lc ca thn - mesiangial cell: khong gian bo= 8-12% din tch cu thn (>50 tui) (1). Nghin cu trn chut: khong gian bo gin rng ra theo tui. - cc t bo biu m Mng cu thn dy ln

Gim chc nng lc

(1) Goyal VK (1982). Changes with age in the human kidney. Exp Gerontol 17,321-331

(1) Jocelyn W (2009). Podocytes and glomerular function with aging.

Semin Nephrol 29, 587-593.

ng thn: - kch thc, s lng. - chiu di ng thn - th tch ng thn - Teo ng thn - Dy mng ng thn - kch thc t bo biu m ng thn - x ho m k Mch mu ti thn (1) X ho tiu ng mch hp ng mch thn
(1) Epstein M (1996). Aging and the kidney. J. Am. Soc. Nephrol. 7, 1106-1122.

1.2.Bin i chc nng

Lu lng mu ti thn (RBF) ngi 80 t 50% vs 20 t Mc lc cu thn (GFR): - Davis M (1): 50% LCT tui 90 vs tui 30. - Rowe (2): LCT theo tui (0,8 ml/p/1.73 m/nm) nhng 30% trng hp bnh thng k c ngi 90 tui. - Linderman (3): 36% khng Cl cre theo tui, mt s trng hp . - Andrew (2010) (4) C ch: ? gen, ch n, bnh km (THA, T, RL chuyn ho), Gim chc nng lc
(1) Davis. M (1950). Age change in GFR, effective renal plasma flow and tubular excretory capacity in aldult males. Journal Clin Invest 29,496-507 (2) Rowe (1976). The effect of age on creatinin clearance in man:A cross sectional and longitudinal study. J Gerontology 31,155-163. (3). Linderman RD (1990). Renal physiology and pathophysiology of aging Am J. Kidney Disease 16, 272-285. (4) Andrew D (2010). The association between age and nephroslerosis on renal biopsy among healthy aldults. Ann. Intern. Med 152,561-567

c im 18-29 S Cr mmol/l) LCT (ml/p) T l % c x ho thn (95% CI)

77,813,3

Cc 30-39
79,613,3

nhm tui 40-49

79,615

50-59

60-69

70-77

77,814,1 80,414,1 78,710,6

11419 2,7 (1,1-6,7)

11018 16 (22-20)

10315 28 (24-32)

9715 44 (38-50)

9714 58 (47-67)

9012 73 (43-90)

Bin i S cre, LCT v t l phn trm cu thn b x ho theo tng nhm tui (1)

(3) Andrew D (2010). The association between age and nephroslerosis on renal biopsy among healthy aldults. Ann. Intern. Med 152,561-567

Chc nng iu chnh nc, mui - kh nng c c nc tiu thiu dch. Rowe (1): ALTT nc tiu ti a 1.109 mosmol/kg (2039 tui) vs 882mosmol/kg (60-79 t). - pha long nc tiu tha dch (2).

(1).Linderman RD (1990). Renal physiology and pathophysiology of aging. Am J. Kidney Disease 16, 272-285 (2).Sunderam (1983). Hyponatremia in the elderly. Age aging 12, 77-80.

THT v bi tit K, acid ng thn:

- renin, aldosterone, LCT v teo ng thn K mu. - Bi tit acid (do h m thn hot ng ) toan mu. Chc nng ni tit: SX erythropoetin, cn bng Ca P, thi Insulin thiu mu, Ca, chuyn ho G Tng sinh v ti to m biu m thn hi phc chm.

 cht theo chng trnh: (1) chc nng thn.

yu t tng trng (growth factor) hi phc.

yu t gy x ho cu thn tui (AII,TGF , NO, AGE, Oxidative stress, Lipid (1) chc nng thn.
sa cha tn thng v ti to m kh nng phc hi hi phc chm, hi phc khng hon ton. Roland (1): BN > 65 tui nguy c khng hi phc chc nng thn cao hn ngi tr l 20-30%.

(1). Roland S (2008). The impact of aging on kidney repair. Am J. Physiol 294, F 1265-1272.

Cu thn
S lng X ho Dy mng c bn Din tch lc

ng thn
S lng Kch thc Dy mng c bn

K thn
X ho

Mch thn
X va Tt, teo mch

- Ph i b tr - Tng siu lc phn tu thn

- ti hp thu G, in gii OLG - kh nng c c v ho long OLX - Tn thng c ch t iu ho ngc ng- cu thn

X ho ton b cu thn Gim chc nng thn

Ngi ln tui/ i tho ng/ Bnh thn mn

ti mu thn

Tn thng lp ni mc Tn thng thn

lu lng mu ti thn Thuc Phu thut

Tn thng vi mch thn

Suy thn cp

Vng xon bnh l gy suy thn cp ngi ln tui

Gim khi lng thn X cu thn X ng thn k To hyalin mch thn X/teo ng thn

Bnh kt hp Can thip phu thut Thuc c thn Yu t ngoi lai

Bin i cu trc
Suy cp thn Thay i chc nng Kh nng hi phc thn b tn thng ngi ln tui cht theo chng trnh yu t tng trng qu trnh sa cha tn thng

Gim lu lng mu thn Gim lc cu thn Gim d tr thn Tng khng lc tnh mch thn

Cc yu t gp phn gy STC v kh nng hi phc chc nng thn NLT

Bin i Cu thn: Gim - lu lng mu ti thn - lc cu thn

H qu lm sng Gim chc nng lc

ng thn: Gim - ti hp thu v bi tit nc - kh nng pha long nc tiu - ti hp thu Na - bi tit acid Gim sn xut Erythropoetin
Gim thi insulin

D xy ra: - thiu dch v tng Na mu. - tha dch v h Na mu - thiu dch khi thiu mui - toan mu
D b thiu mu D ri lon G mu

Tm tt nhng bin i chc nng thn v cc nh hng lm sng

Bnh kt hp (T, tim mch)

Dinh dng Gim Albumin mu Gim chc nng thn theo tui

Can thip iu tr: Thuc, phu thut

D xy ra STC NLT

Thay i cu trc: x ho, gim trng lng, X mch thn

Nhim khun

Sharon Anderson, Basil Eldadah, Jeffrey B Halter, William R et al. (2011). Acute Kidney Injury in older aldults. J Am Soc Nephrol 22: 28-38.

2. YU T NGOI LAI (Thuc) 2.1. Yu t nguy c ca nhim c thn do thuc - Ln tui Thn trng - Gim LCT khi k n - C bnh thn mn, cp - C tnh trng co mch thn sn do tha AII - Thiu dch iu chnh - Gim albumin mu trc khi k n - Liu thuc cao so vi LCT - Chuyn ho: h K, Mg, Ca; tng Ca; pH nc tiu <5,5 hoc >6,0. - C a: gen lin quan n chuyn ho toxin (CYP450, MRP2) - Thuc: tch in (+)

2.2. Thuc c lin quan nhim c thn NLT - Khng sinh nhm aminoglycosid (nepmycin>gentamycin> tobramycin ~ amikacin ~ neltimycin>streptomycin) - Thuc cn quang: gim ti mu + ng thn - NSAIDs: gim SX PG (GFR): cp ng thn k:mn. - ACEI, ARB: gim ti mu thn - Sucrose, Mannitol, HES: ng thn - Thuc iu tr K: Cisplatin,Ifosfamide, Mitomycin C, Azacitidine, Gemcitabine, Pentostatin, Methotrexate, Interleukin 2, Biphosphonates, Bevacizumab: ng thn

C ch bnh sinh nhim c thn do aminoglycoside

Mark APerazella (2010). AJKD Vol55, N2,399-409

Cc thuc t dng hn Polymyxin (polymycinB, colistin): OLG AmphotericinB: co tiu mch n, tn thng OLX Adefovir, Cidofovir: tn thng OLG (chnh), OLX (t) Sulfonamides (sulfadiazine): ngng kt trong ng thn Acyclovir

2.3. Biu hin lm sng ca nhim c thn do thuc - STC: trc thn, hoi t ng thn, vim thn k, vim cu thn - Bnh ng thn: toan ng thn, bnh thn mt mui, h K, toan ng ln xa, i tho nht do thn - m niu: HCTH (MC, MN, FSGS) - Bnh thn mn: vim ng thn k mn

4. KT LUN Gim chc nng thn: thng gp

Lu pht hin sm, d phng ?.

Yu t nguy c NLT d b STC: - Ni ti Ngoi lai C th d phng c? Khi b STC: biu hin nng do kh nng b tr gim (cu thn, ng thn). Lc mu sm ?

Biu hin LS ni bt STC NLT: - D b thiu dch - D b qu ti nc - D b toan mu nng - Thng c biu hin thiu mu.

Lu khi iu tr

Khi xy ra STC: kh nng hi phc chm, khng hon ton Theo di lu di chc nng thn BN c tin s STC

XIN CM N S CH THEO DI CA HI NGH