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BNH HC THN TIT NIU

TI LIU SU TM TNG HP DCH

Gii thiu Information Mc lc

Bin son ebook : L h S g

I HC Y KHOA H NI

Trang web : www.ykhoaviet.tk

Email : Lesangmd@gmail.com, bachkhoayhoc@gmail.com

in thoi : 0973.910.357

THNG TIN

THNG BO V VIC XUT BN BCH KHOA Y HC 2010 :

Theo yu cu v nguyn vng ca nhiu b c, khc vi Bch Khoa Y Hc cc


phin b t c, bn cnh vic cp nht cc bi vit mi v cc chuyn khoa
mi, g h tha i cch thc trnh by, Bch Khoa Y H c chia ra
lm nhiu cun nh, mi cun bao gm mt ch ca Y H , h th s gip
b c tit ki c thi gian tra cu thng tin khi cn. Tc gi xin chn thnh
tt c nhng ki g g p ph h a u c gi trong thi gian
qua. Tt c cc cun sch ca b sch Bch Khoa Y Hc 2010 b c c th tm
thy v ti v t trang web www.ykhoaviet.tk L h S g dng v
pht trin.

NG H :

Tc gi i h th h i s ng h v mt t i h h gip cho Bch


Khoa Y H c pht trin tt h g g hu h h .

Mi tm lng ng h cho vic xy dng mt website dnh cho vic ph bin ti


liu hc tp v ging dy Y Khoa ca cc c nhn v Doanh nghip xin gi v :

T g h g : NGN HNG U T V PHT TRIN VIT NAM

Tn ti kho g h g : L h S g

S ti khon : 5111-00000-84877

CNH BO :

TI LIU NY CH MANG TNH CHT THAM KHO nhm m h g ao hiu bit v Y


khoa. Tuyt i kh g c t p d g th g ti t o g e ook chn
o t iu tr bnh, nht l vi nh g gi khng thuc nghnh Y . Tc gi
ebook ny khng chu bt c trch nhim g li ua n vic s dng thng tin
trong cu s h p dng vo thc tin ca b . l t i liu su tm t
nhiu tc gi khc nhau, nhiu cu s h kh hau, ha c kim chng , v
th mi thng tin trong cu s h u ch mang tnh cht t g i . Cun
s h c phn pht min ph vi m h s d g phi th g i, bt c
h h i o li ua n vi ua , t ao i, chnh sa, in n cun sch ny
vo bt c thi i o u l bt hp l . Ni dung cun ebook ny c th
tha i v b sung bt c lc no m khng c th g o t c.

GII THIU
B s h L S g su tm , bin dch v tng hp vi m h u g p
mt ngun ti liu tham kho hu ch cho cc bn sinh vin y khoa, v tt c
nhng ai c nhu cu tm hiu, nghin cu, tra cu , tham kho thng tin y hc.

Vi tiu h l sch m , dng da trn ngun ti liu ca c g ng ,


khng mang m h li, khng gn vi m h th g i h a di bt k
hnh th o , t c khi s dng b sch ny bn phi ng vi nhng
iu kin sau . Nu kh g ng , bn khng nn tip tc s dng sch :

B s h u g p n tay bn , hon ton da trn tinh thn t nguyn


ca bn. Khng c bt k s th g l g, ua huc, mi gi hay lin kt no
gia bn v tc gi b sch ny.

M h a b s h phc v cng tc hc tp cho cc bn sinh vin Y khoa l


chnh, ngoi ra nu bn l nh g i t g a g l i t o g gh h Y g
th s dng b s h h l t i liu tham kho thm .

Mi thng tin trong b s h u ch t h h h t g i, th g ti ha


kim chng bi bt c ua Ph p lut, Nh xut bn hay bt c ua
c trch nhim lin quan no . V vy, hy lun cn tr g t c khi bn chp nhn
mt th g ti o u g p trong b sch ny.

Tt c cc thng tin trong b s h su tm, tuyn chn, phin dch v


sp xp theo trnh t nht nh . Mi bi vit d ngn hay di, d hay d d g
u l cng sc ca chnh tc gi bi vit . L h S g ch l gi su tm v
phin dch, ni mt h kh , gi gip chuyn ti nhng thng tin m cc tc
gi bi vit u g p, n tay cc bn .

B sch ny l ti liu su tm v dch bi mt sinh vin Y khoa ch khng phi l


mt gi o s ti s hay mt chuyn gia Y hc dy dn kinh nghi ,do th
c rt nhiu li v khim khuyt kh g l g t c , ch quan hay khch quan,
cc ti liu b tr c th ha hp l , nn bn cnh vic thn tr g t c khi thu
nhn thng tin , b g c k phn mc lc b sch v ph hng dn s
dng b s h s dng b sch ny mt cch thun tin nht.
Tc gi b s h in t ny khng chu bt c trch nhi o li ua n vic
s dng sai m h , g hu qu khng tt v sc khe, vt cht, u t a
bn v bnh nhn ca bn .

Khng c chuyn mn , khng phi l nhn vin y t , b kh g ph p t s


dng nhng thng tin c trong b s h ch o iu tr. T t c ti
ny, cc thy thu IU TR BNH NHN ch khng phi l IU TR BNH. Mi
gi bnh l mt thc th c lp ho to kh hau, do ic b nguyn xi
tt c mi thng tin trong b sch ny vo thc tin s l mt sai lm ln . Tc gi
s khng chu bt c trch nhim g do s bt cn ny gy ra.

V l b sch c g ng, to ra v m h c g ng, do c g ng , b sch ny


c pht tri ha kh g t phn rt ln, khng ch da vo sc lc, s
kin tr ca gi to ra b sch ny , th nh g g g p, dng, gp , b
sung, hiu chnh ca gi h h l ng lc to l b s h ph t
trin. V mt mc tiu tr thnh mt b sch tham kho y khoa tng hp ph hp
vi nhu cu v tnh hnh thc ti t o g l h c y t ni ring v trong cuc sng
ni chung . Tc gi b sch mong mi b c nhng li g g p h thnh
mang tnh xy dng, nhng ti liu qu m bn mun san s cho c g ng , v
mt t g lai tt p h . l tt c nim mong mi m khi bt u xy dng
b sch ny , ti v ki t theo ui .

Ni dung b sch ny, c th ch g t o g t thi im nht nh trong qu


kh v hin ti ho t o g t g lai gn. Trong thi i cch mng khoa hc cng
ngh ti ha h h o h hin nay, khng ai bit t liu nhng
kin thc m b th p d g o t g lai ha kh g . tr li cu
hi ny, ch c chnh bn thn bn , phi lun lun khng ngng-T MNH-cp
nht thng tin mi nht trong mi l h c ca i s g, t o g l h c y
khoa. Khng ai c th, tt nhin b sch ny khng th, l iu tha n.

Nghim cm s dng b s h di bt k m h u no, kh g


ph p th g i ha sn ph di bt c da h gha o. T gi b sch
ny khng phi l tc gi bi vit ca b s h , h g t rt nhiu cng sc,
thi gian, v tin b to ra n, v li ch chung ca c g ng. Bn phi chu
hon ton trch nhim vi bt k vic s dng sai m h kh g tu th ni
dung b sch ny nu ra.

Mi l thuyt u ch l mu xm, mt cun sch hay vn cu s h g h l l


thuyt, ch c thc t cuc sng mi l cun sch hon ho nht, n khng
phi l c gi m l din vin chnh. V Bch Khoa Y H g h l mt ht thc
nh, vic s d g xo nu hay nhn ging l hon ton ty thuc vo bn
. V gi to ra ht thc ny s vui m g c truy th ng l
tip tc c gng nu bit rng chnh nh bn m bit ao gi khng cn phi
xp h g ch cu tr.

Mi g g p li ua n b sch xin gi v cho tc gi theo a ch trn. Rt


mong nh phn hi t cc b c gi cc phin b sau tt h .

Knh chc b c, gia quyn v ton th gi Vit Na lu c sng trong


khe mnh, cuc sng ngy cng m no hnh phc.

L g, Ngh An. Thng 8/2010

ABOUT

ebook editor: Le Dinh Sang


Hanoi Medical University
Website: www.ykhoaviet.tk
Email: Lesangmd@gmail.com, bachkhoayhoc@gmail.com
Tel: 0973.910.357
NOTICE OF MEDICAL ENCYCLOPEDIA PUBLICATION 2010:

As the request and desire of many readers, in addition to updating the new
articles and new specialties, as well as changes in presentation, Medical
Encyclopedia 2010 is divided into many small ebooks, each ebook includes a
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CHNG . SINH L TIT NIU


1. SINH L THN
2. SINH L BNH TIT NIU
3. THN IU HO CN BNG NI MI
4. IU HO CHC NNG THN
5. NGHIM PHP THM D CHC NNG THN
6. QU TRNH TO NC TIU
7. C QUAN SINH SN NAM
8. SINH L SINH SN N

CHNG . TRIU CHNG HC TIT NIU


9. PHNG PHP KHM THN TIT NIU
10. TRIU CHNG HC THN-TIT NIU
11. SIU M TRONG BNH THN TIT NIU
12. XT NGHIM NC TIU
13. XN MU TRONG BNH THN TIT NIU
14. X QUANG TRONG BNH THN TIT NIU
15. XT NGHIM THM D CHC NNG THN
16. I BUT-I RT
17. I T-I NHIU-V NIU
18. HI CHNG THN TO
19. HI CHNG I DNG CHP
20. HI CHNG PH DO BNH THN
21. HI CHNG PORPHYRIN NIU

CHNG . CP CU NIU KHOA


22. TIU RA MU
23. B TIU
24. XON THNG TINH
25. CN AU BO THN
26. SUY TUYN THNG THN CP
27. PH I TUYN THNG THN BM SINH
28. THUYN TC NG MCH THN
29. THUYN TC TNH MCH THN
30. B TIU
31. BU V TNG SINH MN
32. DNG VT
33. RI LON PHN X T NG TY

CHNG . NI TIT NIU


34. PHN LOI BNH THN
35. SI THN - TIT NIU
36. HI CHNG SUY THN CP TNH
37. CU TO SINH L H TIT NIU
38. IU TR VIM QUY U - DA QUY U
39. VIM, P XE TIN LIT TUYN
40. ABCES THN
41. VIM THN B THN, LAO THN
42. VIM THN- B THN MN TNH
43. IU TR VIM MO TINH
44. NHIM TRNG TIU DO VI KHUN HOC NM CANDIDA
45. IU TR VIM BNG QUANG
46. VIM I B THN
47. HI CHNG NIU O CP
48. VIM THN B THN
49. SUY THNG THN CP
50. S DNG CORTICOID
51. SUY THN CP CAO HC
52. SUY THN CP- BSK
53. SUY THN MN TNH
54. SUY THN MN
55. VIM THN K MN TNH
56. PROTEIN NIU
57. NHIM KHUN TIT NIU V THAI NGHN
58. HI CHNG THN H
59. THN H TH PHT
60. GHP THN
61. IU TR THN H
62. BNH I MU
63. NHIM KHUN TIT NIU
64. HI CHNG SIADH
65. BNH CU THN MN
66. CH HOT NG TH LC TRONG BNH THN
67. CH N UNG TRONG BNH THN
68. HI CHNG CU THN CP TNH
69. LAO THN - TIT NIU
70. LC MNG BNG
71. LC MU NGOI THN
72. A NANG THN
73. N NANG THN
74. S DNG THUC LI TIU
75. VIM CU THN CP TNH
76. VIM CU THN MN TNH
77. VIM CU THN I THO NG
78. VIM CU THN SAU NHIM LIN CU
79. VIM CU THN LUPUS
80. VIM CU THN DO LNG NG IgA
81. LIN QUAN THN TRONG MT S BNH NI KHOA

CHNG . NIU NHI


82. CC D TT BM SINH
83. L TIU NG CAO
84. L TIU NG THP
85. VALVE NIU O SAU V TRC
86. BNH L NANG THN BM SINH
87. HI CHNG BU CP
88. D TT BM SINH NIU SINH DC
89. HP KHC NI B THN NIU QUN

CHNG . NGOI TIT NIU


90. GII PHU SINH L THN
91. CHUN B BN TRC M V CHM SC SAU M TIT NIU
92. UNG TH THN
93. U BNG QUANG
94. U PH I LNH TNH TUYN TIN LIT
95. U X TIN LIT TUYN
96. SONDE TRONG TIT NIU
97. SI TIT NIU
98. DN LU B THN
99. DN LU H THN
100. VIM NG TIT NIU KHNG C HIU
101. X-QUANG H TIT NIU
102. CHN THNG THN KN
103. XT NGHM NH GI CHC NNG THN
104. HP BAO QUY U
105. CHN THNG TRONG NIU KHOA
106. CC TRIU CHNG V HI CHNG TRONG TIT NIU
107. CHN THNG NIU O
108. I CNG V CC PHP O NIU NG HC
109. PHU THUT LP GHP B PHN GI (PROSTHETIC SURGERY)
110. SUY THN CP V GHP THN
111. BC U P DNG K THUT CT NANG THN QUA NI SOI HNG LNG
112. VI KHI NIM V GHP THN

CHNG . BO CO KHOA HC
113. NHN MT TRNG HP CT BU TUYN THNG THN QUA NI SOI SAU
PHC MC VNG HNG LNG
114. NHN MT TRNG HP TC NIU QUN SAU M LY THAI
115. NI SOI SAU PHC MC NG HNG LNG TRONG M SN NIU QUN ON
TRN: KINH NGHIM BAN U QUA TRNG HP
116. SO SNH VAI TR CA HAI LOI LASER:REVOLIX V KTP TRONG IU TR BU
LNH TUYN TIN LIT
117. NHN MT TRNG HP PHU THUT CT TIN LIT TUYN TON PHN QUA
NG TNG SINH MN
118. NHN MT TRNG HP PHU THUT KT HP NI SOI LY NHIU SN LN
BNG QUANG TO HNH BNG RUT

CHNG . SINH L TIT NIU

1. SINH L THN
T o g th thng xuyn c nhng cht c o thi a go i. l
nhng cht c sinh ra do qu trnh chuyn ho, nhng sn phm do s phn
hu t bo v m gi i, cc cht c l bng nhiu ng khc nhau xm
nhp o th. Nhng cht trn nu khng thi ra ngoi s lm mt tnh hng
nh ca ni mi. V v h g c mu vn chuyn ti ua i tit. Phi
o thi kh carbonic, mt ph c. B tiu ho o thi cc cht cn b
ca th , c, cc mui , ht c, l theo phn. H th g da o
thi c, mui theo hi. Th o thi cc sn phm chuyn ho
p otid h u , a id u i , eati i ht c cha it kh , cc sn phm
chuyn ho khng hon ton ca glu id, lipid h a id la ti , th cetonic cc
mui , ht in gii, cc cht c, l do th to ra trong qu trnh
chuyn ho, trong qu trnh kh c ho a t ngoi vo b g ng khc
nhau v cui g l . Nh y, thn l mt ua ua t ng nht ca h
bi tit. Mt ch g th o gi khng th tn ti c.
Trong mt g th thi ra ngoi:
Nc: 1,2-1,5lt.
-
Cl : 6-10g.
Na+ 5-6g.
K+ 2-3g.
Ca++ , Mg++ 0,1-0,2g.
Sulfat: 3-15g.
phosphat: 1-5g.
NH3 0,6-0,8g.
ur 20-30g.
Creatinin 1-1,5g.
acid uric 0,1-2g.
GII PHU V M HC THN
Hai thn nm hai bn ct sng, ngoi phc mc, h tht l g. Nu b dc thn
t pha ngoi v nhn vo mt ct thy th c chia lm hai vng r rt: vng
v u ) v vng tu (mu trng). Vng v c chia thnh hai vng nh
h l g ngoi v vng v trong (cn gi l vng cn tu). Vng tu g
c chia thnh hai vng nh h l g tu ngoi (cn gi l vng cn v) v
vng tu trong. S phn chia ny c lin quan ti ch g n ca nephron:
nephron ngoi v nephron trong (cn gi l nephron cn tu).
T chc thn g thn (ng sinh niu), cc ng gp v ng ni, b my
cn tiu cu, cc mch mu, thn kinh thc vt cng cc t chc lin kt.
. N V THN.
thn (cn gi l nephro l cu trc - ch g thn. Mi thn c
kho g h t triu thn. Mt thn c hai phn: tiu cu thn v
tiu qun
Tiu cu thn (tiu th Malpighi) l mt th hnh cu ng knh 200mm, gm
bao Bowman v cun mch. Bao Bowman l mt ci bc c hai lp, m ly cun
mch. Gia hai lp l khoang Bowman, trong khoang cha dch siu l c
tiu u). Khoang Bowman thng trc tip vi g ln gn. Ming bao rt hp l
i i o i a a ng m h. ng m h n (nhnh ca ng mch thng)
sau khi vo bao Bowman n chia ra khong 50 mao mch chy song song v c
nhng ch thng sang nhau, to nn mt m g li ao ng mch(cun mch)
nm gn
t o g ao Bo a . Sau ao ng mch tp trung li th h ng m h i
ra khi tiu cu. Th g th g ng m h i h h ng m h n.
Tiu qu gi cn gi l ng thn) c ba phn khc nhau: g ln gn,
quai Henle v g ln xa. g ln g g i t quanh co, un khc.
Thnh ng l mt lp t bo biu m hnh lp ph g. Mt t do ca t bo c
nhiu lng xp theo hnh bn chi. Trong t bo c nhiu ty lp th. g ln gn
ng knh 50 mm, di 15 mm. Tip theo g ln gn l quai Henle. Quai
Henle hnh ch U, nm su trong vng tu. Nhnh xung mng v nh h h h
ln. Thnh quai Henle l mt lp t bo biu m dt. g l a l on cui
ca eph o . g i g u ln quanh tiu cu thn. C mt phn st vo
ng m h , ng m h i tiu cu to nn b my cn tiu cu. Thnh
g ln xa l mt lp t bo biu m hnh lp ph g, t t do ca t bo
khng c lng.
Chiu di mt nephron l 35-50mm. Nu cng chiu di ca ton b nephron hai
thn, c th ln ti 70-100 Km, cn din tch mt trong ca chng l 5-8m2.
Trong qu trnh to thnh c tiu, ng gp (tip theo g l a g l
thnh phn kh quan trng, v n c ch g t g ng ti hp thu c. Do
g g p g c xp vo thnh phn ca ng sinh niu.
V mt ch g gi ta chia nephron ra lm hai loi: nephron v v nephron
tu (nephron cn tu). Nephron v chim 70% c tiu cu nm vng v ngoi,
quai Henle nm vng tu ngoi. Cc nephron ny thin v ch g i tit.
Nephron tu chim 30% c tiu cu nm vng v trong v quai Henle rt di
nm su trong vng tu trong. Cc nephron ny thin v ch g t i hp thu.
B h thng ch cn 25% s nephron hot g m bo cho ch g
ca th. Tu t g iu kin c th m ta thy cc nephron v hay nephron tu
hot ng m h h 2. B MY CN TIU CU.
B my (hay phc b) cn tiu cu gm phn g ln xa tip gip vi ng mch
ng m h i a tiu cu v mt phn ca tiu cu. Cu t c bit ny
ch yu cc nephron v gm cc t o sau .
- T bo macula densa.
l t bo ca g l a, s t o ng m h i. C t bo ny
hp ao h t bo khc. Nhn t bo st v mt t do. Mt t do ca t
bo c nhiu lng. B my Golgi v cc bo quan rt pht trin trong t bo ny.
T bo Macula densa va l cc t bo nhn cm va l cc t bo ch tit, sn
xut ra cc cht o u ng m h , ng m h i c tiu.
- T bo cn tiu cu (t bo ht).
T bo cn tiu cu n u g ua h ng m h c bit nhiu xung quanh
ng m h n). Cc t bo cn tiu cu tip xc trc tip vi cc t bo ni m
ca ng mch vo tiu cu thn. T bo cn tiu cu kh a dng, nguyn sinh
cht c nhiu si fi il. c bit trong t bo c rt nhiu ht (nn cn gi l t
bo ht). Trong ht c renin khng hot ng.
- T bo lacis.
Cc t bo ny nm ri rc phn gia cc t o ng m h , ng m h i
ca tiu cu, gia cc t bo g ln xa v tiu cu. Cc t bo ny c tnh thc
bo (hnh 8.3).
3. H MCH MU.
Sau khi ra khi tiu cu th , ng m h i hia thnh h mao mch th hai chi
phi ton b tiu qun. Cc mao mch ny sau khi chuyn t ng mch sang
t h ch, tp trung v t h ch ln ri o t h ch thn. Mng mao
mch quanh tiu qun c p lc mu thp (18-13-10mm Hg), to iu kin thun
li cho hp thu ng thn. Ring cc nephron tu cn c h mch thng, h mch
ny chy song song vi uai He le, g ai t ua t ng trong ch g t i
hp thu ca cc nephron tu.
Do ch g a cc nephron khc nhau nn s cung cp mu cho tng vng
th g kh hau. -90% mu l cung cp cho vng v, 10-15% cho vng tu
ngoi, ch c 3-5% cho vng tu trong. iu ny chng t cc nephron v c nhu
cu oxy l h t nhiu so vi cc nephron tu. Cc t bo nephron v khng c
kh ng thoi bin y kh h t bo nephron tu v v , khi lu lng tun
hon qua thn gim th vng v d b ri lon ch g h g tu.
4. H THN KINH.
H thn kinh thc vt c bit l h giao cm) c cc tn cng chi phi ti h
mch mu thn. V vy h thn kinh giao cm c kh g iu ho lu
lng tun hon qua thn.

2. SINH L BNH TIT NIU

NGUYN HU M

B my tit niu bao gm nhiu b ph t o h th g ai t h yu.Thn


c hai ch g: h g i tit(to renin v erithropoetin) v ch g
ngoi tit.Ch g goi tit ca thn nhm duy tr tnh trng h g nh ca ni
mi,c th l thng qua bi tit c tiu :
-Thi tr cc cn b ca chuyn ha protein
-Thi tr cc cht c
- nh cc thnh phn l ha ca ni mi
-iu tit cn bng axit- az
-iu tit cn b g i gii
Qu trnh bi tit c tiu thc hi c l nh c ch g lc ca cu
thn,ch g t i hp thu v ch g tit ca ng thn.
m bo cho thn hot g,lng mu ti thn kh nhiu:tr g lng ca
thn ch chim 5% tr g l g th so g lng mu ca thn ln ti % lu
lng tun hon ca th(trung bnh mi pht khong 1,2l mu qua thn).
I.NHC LI C IM CHC NNG TIT NIU
A-C IM V CU TO CA THN
Nu i t pha mao mch ca cu th ti ao Bao-man,l lt qua cc lp sau:
-Lp t bo ni mao mch:to thnh mt mng r ng knh 0,1 micromet)
-Mng nn ca thnh mao mch.
-Lp t bo lt c nhiu chn xen k vi nhau (gi l t bo chn) bm vo mt
ngoi mng nn mao mch.
-Lp t o l t a bao Bao- a l th h a bao ny cn c l tng do t
bo chn to nn.
Qu trnh lc cu thn l s khuch tn qua mang nn mao mch.
Nhng lp t o h thng cho lt qua mi thnh phn ca huyt t g
vo nang thn,tr h g p otei t g lng phn t ln,trn
.He oglo i ua c cu thn, cn albumin huyt thanh(70000)
b cu thn gi li.Khi cu thn b t th g h t o g i p otei u
th a c tiu(protein niu).
Cnh cu thn c mt t chc gm nhng t bo rt nhy c i vi tha i
ca huyt p(gi l b my cnh cu thn):khi huyt p gim th t bo ny tit ra
men renin,men ny vo mu gy co m h ng thi g t g tit aldosteron
nhm phc hi huyt p.
mi thn c ti 1-1,5 triu nh g d thn(tiu thn),lin kt vi nhau bng
t chc lin kt(cn gi l t chc khe t o g ch mu,mch bch
huyt,dch gian bo v thn kinh.Cc tiu thn khng hot ng cng mt lc m
ch tng phn mt,thay phin nhau hot g.Do thn c kh g t
mnh nht l khi ct mt thn.Song v mt b h l g l t kh kh ,
nhng t th g phn ca t chc thn nhiu khi khng c biu hin r rng
kp thi pht hin.
ng mch ti thn ng ,i thng t ng mch ch vo ri chia nhnh ti cc
cu thn,to ra b mao mch ri tp trung thnh mch ra,ti ng thn li phn
chia thnh mng mch bao quanh ng thn ri mi v t h ch,to ra h
thng tun han gnh ca thn.Do trc tip vi ng mch ch nn huyt p ti
mao mch cu th ao h ua t ch kh h thng t 65-75
mmHg),to iu kin cho qu trnh l a h h h g ng thi g l ho
thn d chu h hng ca s tha i huyt p.
Ngo i a, g h a l vng ranh gii gia khu vc v thn v li thn,c
nhng mch ni gia ng m h t h ch,to ra mt h th g s
(shunt h thng khng hot ng;trong s s ra cho mu chy
qua nhm dn mu cho cc tng quan tr g h ti , o t ng thi ny gi l
trung tm ha tu ho ,so g ng thi gy thiu mu v thn dn ti gim
thm ch khng tit c tiu(suy thn cp).
B h thng,mt ph t 650ml huyt t g u thn l l c
tiu vo nang th .Nh y,tnh ra trong mt ngy,thn l c khong
190lt.Nu khng c ch g t i hp thu ca ng thn ch t o g hua y mt
gi th s kit nc.
B-CHC NNG LC CA CU THN
Cu th oi h l t ua siu lc,tc l hu ht cc thnh phn ca
huyt t g i ua, h gi li cc t bo v hu ht protein.
Nc tiu l c cu thn l nh c p lc lc.p lc lc ph thuc vo nhiu
yu t:
Pl = Pc-(Pk+Pn)
T o g :
-Pl l p lc lc,nh c tiu.
-Pc l p lc cu thn tc l huyt p cu th h thng t 65-75 mmHg).
-Pk l lc ko ca mu,c tc dng gi li lng m h h thng l
28mmHg).
-Pn l p lc ca nang thn,tc l p lc th t h a c tiu nang,p lc mu
t h ch v t chc thn co tc dng chng li sc lc ca cu th h thng
l 10 mmHg).
Nh y Pl h thng khang 40mmHg.
Qua cng thc trn th l g c tiu chu h hng ca nhiu yu t.Th
d:
-Khi P t g h t o g su ti to ),thy Pl gi ,do l g c tiu gim.
-Khi Pc gi h t o g sc,suy tim m h , g thy Pl gim.
Ngoi yu t k trn cn c vai tr quan trng ca thn kinh v ni tit trong qu
t h iu h a c tiu.
C-CHC NNG TI HP THU V BI TIT CA NG THN
ng thn c hai ch g l tai hp thu v bi tit,thc hi c l nh lp t
bo ng thn c mt h thng men phong ph.Khi mt cht e o kh g
hot ng,s pht sinh ri lon ch g ng thn.
1.Ch g t i hp thu:
Phn ln cc cht ca c tiu a g h g, c, mui c ti hp thu
gn ht trong ng th . g c ti hp thu hon ton,tr khi t gng
ca thn.C nhng cht ch c ti hp thu mt ph h axit amin, phosphat,
sufphat, u e
Qu trnh ti hp thu c, Na+,K+ din bi ua hai giai on khc nhau:
a)Giai o u: ph u ca ng thn ( g ln g , % c v Na+ c
hp thu, K+ c hp thu gn 100%.S hp thu ca giai on ny khng chu nh
hng ca cc hocmon.
b)Giai on sau: phn cn li ca ng thn (quai Henle, g ln xa, ng gp),
c v Na+ c hp thu theo yu cu ca th di s iu ha ca hocmon
h:
-ADH ca tuy t g t i hp thu c nhnh xung ca quai Henle v ng
gp.
-Aldosteron ca tuy thng th t g t i hp thu Na+ nhnh ln ca quai
Henle, g ln xa v g g p, ng thi t ao i K+ g ln xa.(Hnh 1)
Ti hp thu Na+ l mt h thch nghi ca th t o g u t h iu ha cn
bng axit- az e i lon cn bng axit- az .
2.Ch g i tit:
Bi tit ng thn l mt hi tng ch ng, kt qu ca s hot ng tch cc
ca cc t bo ch yu on xa ca ng thn. Ngoi hot ng bi tit cc cht
in gii nhm duy tr cn b g a it az, ng thn cn bi tit mt s cht khc
h a it hu th , a it hippu i , pe i ili , PSP phe ol sulfophtalei ,.
ch ha g.Nhng cht ny khng nh g c lc qua cu thn m cn
c bi tit ng thn nn n g cc cht ny c tiu ao h trong
mu.
D-MT S XT NGHIM THM D CHC NNG THN
h gi h g lc,ti hp thu v bi tit ca t chc th , gi ta
thng dng hai xt nghi sau :
-Xt nghim thanh thi.
-Th d h g c ca thn.
-Sinh thit thn.
-Ph g ph p d g ng v phng x.
1.Xt nghim thanh thi.
Thanh thi l ph g ph p th d h g tng b phn ca t chc thn.
Nu mt cht t o g u c thi tr a c tiu vi mt U (tnh bng
mg/1) v khi l g c tiu trong 1 pht l V (tnh bng ml) th UV s l lng
cht c thn thi tr khi mt khi lng huyt t g C t h ng
ml/pht). V nu P l m cht t o g hu t t g t h ng mg/ml) th
chnh l khi lng C gi ta gi l h s thanh thi ca cht iu din
bng cng thc sau :
C=
Nh y h s thanh thi ca mt cht l khi lng huyt t g ua u thn
trong mt ph t c thn tr b han ton cht khi huyt t g chuyn
o t o g c tiu.
T s nguyn l ny:
a)Mu th d h g lc ca cu th gi ta dng nhng cht ch lc
qua cu thn m khng b ti hp thu g h kh g c bi tit qua ng thn:
nhng cht ny phi khng b kt hp vi cc protein huyt t g, kh g
nhanh chng chuyn h a.t nhng yu cu ny l inulin, creatinin, manitol, Na
h posulfit
Vi nhng cht ny h s thanh thi b g l/ph t gha l ng khi lng
c tiu nang trong mt pht (hnh 2).Th d i vi
Manitol,P=2mg/ml,U=120mg/ml v V=2ml/ pht, ta c :
Cmanitol = = 120 ml/pht
b)Mu th d ch g t i hp thu ca ng thn gi ta tm h s thanh
thi ca nhng cht sau khi lc qua cu thn li c ti hp thu ng th h
u e, glu oza, a it a i , a it u i , phosphat.
Vi nhng cht ny h s thanh thi nh h l/ph t. Th d i vi ure
P=3mg/ml, U=112,5 mg/ml v V=2ml/pht. Ta c :
Cure = = 75 ml/phut
c)Mu th d ch g i tit ca ng thn gi ta tm h s thanh thi
ca nhng cht va c lc qua cu thn va c bi tit qua ng th h
PSP, a it hu th , a it h ppu i , PHA, a it pa aa i o hippu i
Vi nhng cht ny h s thanh thi l h l/ph t.Th d h s thanh thi
ca PHA h thng l 650ml/pht (hnh 3)
Di l t s kt qu thng gp trong bnh l:
-Trong vim cu thn th cp din thy C manitol gim cn C diodrast bnh
thng chng t ch g lc ca cu thn gim, song ch g i tit ca
ng thn v h thng.Trong th t ng din, th C a itol C PSP u
gim chng t khng nhng chc g lc m c ch g i tit g gim.
-Trong suy tim mt b,C inulin c th gim ti 30- %, C PHA g gim chng t
lng mu qua thn gim.Trong sc g thy vy.
-Trong bnh huyt p cao, thy ch g th tha i ua giai on:
+ Giai o u: h s thanh thi h th g do ha thiu mu r rt ti
thn.
+ Giai on hai: C PHA v diodrast gim cn C inulin v h thng chng t bt
u c t th g ng thn.
+ Giai on ba: h s thanh thi ca ng thn v cu th u gim chng t ton
b th u b t th g.
.Th d h g c ca thn
Mt im ca t chc thn l tnh mm do:khi c nhiu o th th
o thi nhiu c tiu long, t trng thp (ti thiu 1003); khi
t o th thid c tiu it, c v t trng cao (ti a . Khi t chc
thn b t th g th t h m do ny gim v c tnh tr g ng t trng. Khi
ng thn khng lm vic (t l g kh g t i hp thu g kh g i tit) th
t trng b g c tiu lc cu thn, t la . l gu l a xt
nghim Phn-ha v Strao (Volhard-Straus), ti h h h sau:
Bnh nhn nm ti ging 24 gi t c v trong sut thi gian th nghim ch
d g l c u g to hng th c.H g c tiu 3 gi mt
l o t trng mi mc cao phi t t nht l 1025.Trong suy thn t tr g
thp, di c bit t tr g c tiu cc ln ly khng khc nhau
my.Tnh trng ng t trng thp l mt triu chng xu h g t thm gim
kh g c.Tri li trong vim thn cp c tnh tr g ng t tr g ao gha
la t tr g c tiu cacs ln ly khng chnh lch nhau m so g u cao chng
t cu thn b t th g lt qua nhiu cht hoc ng thn b t th g
c thm tr li qu nhiu, c tiu tr c.
3.Cc xt nghim khc.
ch o ti lng chnh xc v cc bnh th , gi ta c th lm sinh
thit thn: quan st vi th cho php kt lun chng xc b phn b t th g
m t th g.
Hi a gi ta cn dng cht ng v phng x a o u theo di thi
gian mu ti cu thn, ng th . l t k thut hi i gip ta theo di mt
cch chnh xc ton b qu trnh hot ng ca thn.
II.NGUYN NHN GY RI LON TIT NIU.
Rt nhiu yu t c th gy ri lon tit niu.i c th xp thnh hai loi ln:
Nhng yu t ngoi thn.
Bnh thn.
A-NHNG YU T NGOI THN GY RI LON TIT NIU
1. h hng ca thn kinh v thn kinh-th dch.
V no chi phi ch g tit niu thng qua ph di v v h ni tit. Khi gy
mt cm xc mnh trn con vt th c tiu gim do co tht mch v
thn.C th g t g tit niu b g ph g ph p phn x iu kin, c th kt
hp ho c vo d dy kt hp rung chung; khi phn x d c thnh lp ch
c u g hu g g g t g tit niu.
Ph di v g h hng r rt ti ch g tit niu: nhiu t ng hp u
no gia g t g tit niu, dng kim chc vo sn no tht IV ho o g di
th th c tiu t g t. g di thi (sn no tht III) c th th thm
thu v khi lng: khi thiu c th th ny b kch thch v t u g ng
c truyn ti hu g t g tit ADH c tc d g t g t i hp thu gi c
li. iu ho ph p gii thch s gi c tiu thng gp trong sc, chy
mu, mt c.
Thn kinh thc vt g h hng ti tit niu kch thch dy giao cm bng gy
gim tit niu do co mch; tri li khi ct t dy ny th t g iu.
Hocmon tuyn yn v v thng thn h hng su sc ti tit niu: khi
aldoste o u t g,Na+ b gi li, k o theo c gy gim niu. Tri li khi thiu
hocmon v thng thn (b h Addiso th mt Na+, k o theo c, bnh
nhn c tnh trng mu c, d dn ti try tim mch. Cht renin cu thn tit ra
khi lng mu qua thn gim c tc dng kch thch tit aldosteron, dn ti gim
niu.
.Tha i thnh phn v trng thi l ha ca mu.
Tt c nh g t ng hp b h l l tha i thnh phn v trng thi l ha ca
mu, nht l nhng ri lon chuyn ha, c th lm t g t s cht h thng
v t o g c tiu hoc lm xut hin nhng cht h thng khng c
t o g c tiu.
Trong nhim toan c nh th c tiu c nhiu cht toa .T o g i th o
ng ty th t o g c tiu ng.Trong bnh vng da tc mt thy axit
mt ili u i t o g c tiu.Khi tan mu t (st t , t u n mu nhm
loi th t o g c tiu he oglo i ..
Ni tm li, c tiu phn no ph h c trng thi l ha ca mu, cho
nn ki t a c tiu l mt ph g php khng th thiu c trong khm
nghim lm sng.
3.Ri lon huyt ng hc
p lc l , h t ph t h, hu h hng su sc ca huyt p hay ni
ho g h , a lu lng mu qua th .Khi lu lng mu gim trong
sc,chy mu ,try tim mch ,mt c nghim tr g th s tiu gim v
khi huyt p cu thn gim ti 40mmHg s pht sinh v niu.
Ri lon tun hon quan trng nht thng xy ra ti thn l tnh trng thiu
mu v thn do h th g s i trc tip ng mch vi t h ch)
d n thiu niu v v niu.Tt c nhng ch th g,k c nhng chn
th g t l u lm cho nhng ng thng ny hot ng ,gy gim tit niu.
Ri lon huyt ng hc ni chung hay ri lon tun hon ti thn nhng nu ko
di c th gy thiu mu t chc thn, gy ra nhng t th g thc th
nghim trng.
B-BNH THN
Bnh l thn c nh g i sau :
- Thn l mt ua hu nhiu h hng ca s xm nhp cc cht c, cc vi
khun, cc ri lon tun hon, cc ri lo in gii, cc bi i sinh l
ca th h thai gh hu h hng nhiu ca cc bnh ton thn.
- Nhng yu t di truy u h hng ti s hot ng ca ng thn, nhiu tt
b si h l tha i ch g a thn.
- Nhu m thn b t th g t o g hiu bnh v thn. T g a s suy sp
ch g a thn r nht l trong hi chng suy thn ton b.
1.Vim ng thn cp (VOTC)
Th a l hoi t ng thn cp nhanh chng dn ti suy thn cp. g h
l suy thn cp thng do VOTC. Bnh ny c nh g im sau:
- T th g ti ph t hi u th ng thn.
- Biu hin lm sng ni bt l i t, iu v ure mu cao.
- C kh g phc hi hon ton nu ua giai on nguy him.
Thc ra t th g ng thn m khc nhau ty theo bnh nhn, song tnh
trng ph v vim khe th thng xuyn c, ch c cu thn v cc mch mu l
khng b.
VOTC do nhiu nguyn nhn gy ra:
- Thng l nhi c: cht c c th t bn ngoi ti (Hg, sunfamit, asen,
cyanua, bitmut, mt c tr hoc nhng cht c t t o g th h
VOTC sau khi truyn mu nhm loi, sau bng nng , hi ch g p, hn
th g dp nt nhiu, ga t u l u
- Ngoi ra cn do thiu mu nghim trng v thn gp trong sc, try tim mch,
mt L u ch l suy thn ch g, u kh g iu tr kp thi s gy
t th g thc th ng thn, thm ch gy hoi t v th , ti l g thng
rt nng.
Nh it t chc thn c mt h thng men rt phong ph khng km g
ga . Theo Pit Pite s th h sinh bnh ca VOTC do nhi c l mt qu
trnh c ch cc men chuyn ha ca t bo ng thn m tc gi gi l t th g
sinh ha. Cc cht t ng ln nhng men ca ng thn ta ra nhng kt
hp bn vng lm cho nhng men y mt hot tnh, d n nhng t th g
thc th ng thn, Thn li d b nhi h t ch kh lng mu
qua thn rt ln.
2.Vim cu thn cp (VCTC)
l t b h i kh g g xy ra tin pht ,cp t h thng lan ra
khp cc cu thn. Vim mao qun bao gm hai hi t g t g si h ut tit
u xy ra nhanh chng cu th . h gha hm loi tr nhng bnh cu
thn khc c vim nh g g ,tm thy vi khun thn v nhng bnh cu
thn khc xy ra th pht sau mt s bnh nhng ni khoa.
B h thng xut hin sau khi c vim nhng ch khc ca th: / t ng
hp xy ra sau vim hng ,nht l vim hnh nhn c hc m nguyn nhn ch
yu l lin kt cu khu ta u h A , / t ng hp cn li xy ra sau
nhim trng nh g i kh g, i,phi,da .Ngo i t dng gy bnh ca
vi khun, cn phi k ti nh g iu kin thun li cho pht sinh b h h
lnh,m thp, th yu.
Hi a gi ta ni nhiu ti h d ng trong bnh sinh ca VCTC, ch yu
a o hn xt lm sng v thc nghi sau :
- B h thng gp tr em sau vim hng khong 10-15 ngy(thi giai cn thit
cho qu trnh mn cm sinh khng th.
- cc bnh nhn c nh g tha i huyt thanh v mt min dch h h gim
b th ,pht hi c khng th chng thn v khng th chng lin cu khun.
- c bit sinh tit cho thy nhng cht l g ng gia g n v nhng
ni mc mao mch (trong vim cu thn do khng th chng mng nn)
Nhng cht l g g ng l cc phc hp min dch gm
khng nguyn v cac globulin min d h h IgG IgM.
- Xt nghim gii phu bnh cho thy VCTC khng c hnh nh ca vim nhim do
nhim khun (khng thy bch cu trung tnh xm nhp ,khng phn lp c vi
khun ),m c hnh nh ca vim d ng (nhng ni m t g si h , t g ch cu
a a it
-Trong thc nghim ,Madughi (Masugi) nghin thn th ri tim cho vt c
huyt thanh vt chng thn th.Sau ,ti hu t thanh ny cho th lnh , vai
ngy sau thy xut hin VCTC ging h gi (protein niu , tr niu , i t ,
ur mu cao, ph,huyt p t g Ca e ti Ca elti ghin thn nh ri trn vi
c lin cu khu ta u h A ,sau ti ho th lnh th g g
c VCTC ( ,thn th trn vi c t vi khu t thnh khng nguyn
i vi th th ti .Theo h Di kso ti hu t thanh khc
loi nh i hc li nhiu l g g c l g ng khng nguyn-khng th
bn ngoi mng nn ca cu thn th. Hyman (Heyman) dng thn th nghim
vi t cht Froi (Frennd) tim vo bng th lnh, th g VCTC do ng
khng nguyn khng th quanh g ln gn.
Nhng ti liu k trn dn ti mt kt lun :
VCTC c th ph t si h theo h min dch.C th c th b mn cm vi khng
ngu o , y gi phc hp khng nguyn-khng th s ti ng cc
mch mu thn. B th khi gn vo phc hp t hot ha, to ra mt vim
c hiu ca VCTC. Ngoi ra, cn phi k n h t in: c t vi khun hay
phc hp min d h khi ng li thn co th l bi i t chc thn, to ra mt
khng nguyn, by gi th to ra khng th (t khng th) chng li t chc
thn ca chnh mnh.
L thuyt v min d h tu s thc nghim, c mt ng dng thc t trong
iu tr, song cn nhiu im v h bnh sinh VCTC gi v ha c
sng t. Ngoi ra cn c nh g t ng hp VCTC p t si h kh g do h min
dch.
3.Vim cu thn mn (VCTM)
Bnh ny c nh g im sau:
-T th g la a to cc cu thn.
-Tin trin ko di dn ti suy thn mn tnh khng hi phc.
VCTM thng khng r nguyn nhn, hay gp tui 10-40. Mt s t xy ra sau
khi b VCTC.
Biu hin lm sng ni bt l protin niu, i a u, hu t p ao
4.Hi chng th h (HCTH)
l t loi t th g cu thn vi i sau :
- protein niu nghim trng (t nht l 3,5 g/24h).
-gim protein u di g/l , c bit l gi al u i u di 30g/l)
-t g glo uli , c bit l haptoglobin.
Mt s triu ch g ki h in ngy nay c t gi tr : ph to ton thn l mt triu
chng c gi tr song khng phi th g u , lipit u t g, holeste ol u
t g l hng triu chng hay gp h g kh g nh.
V mt nguyn nhn,HCTH c th xp thnh hai loi :
HCTH tin pht (gp 2/ t ng hp . Thng phn bit :
- HCTH thu ha gu h thng gp la tui 2- HCTH in
hnh, ti l g thng l tt, th khi ho to . loi bnh th h
nhim m c m t t .
-HCTH ghp vo VCTC hoc VCTM : trong vim cu thn . HCTH c th ch xut
hin trong mt giai on tm thi, h g hiu khi, nht l gi ln , t xut
hin HCTH phi coi l mt t tin trin cp trn mt VCTM t tim
tng.
HCTH c th gp trong tt c cc loi VCTM, song hu ht l nhng hi chng
kh g thu , u k theo i a u , hu t p ao, iu tr kh , t c
kh g hi phc.
HCTH th pht.
-Sau mt bnh ton thn : bnh th h h dng tinh bt, i th o ng, luput
a
-Sau mt ri lon tun hon: t t h ch thn, suy tim mt
-Do nhi c, d ng, nhim khu
-V mt bnh sinh, hi a HCTH oi h l t biu hin lm sng ca tn
th g u thn, do nhiu nguyn nhn gy ra. Tnh trng nhim m t bo ng
thn do cu thn b t th g cho cht m thot ra ngoi
c tiu nang qu nhiu, mt ph c ng thn ti hp thu, m ng dn
trong t bo ng thn v gy nhim m. Nh y, t th g u tin l cu
th m lt qua qu nhiu , dn dn d n nhim m ng thn.
Dng huyt tha h gi khe m h h du b g ng v phng x ri tim
cho bnh nhn th p otei h du ha h h g lc qua cu thn b tn
th g cho protein huyt t g lt qua, gy protein niu nghim
trng gi c HCTH (20-50g/l ).
M holeste ol c gi l hi t g p duy tr p lc ko ca mu
gim do protein niu m h. D g ng v phng x h du m v cholesterol
thy t s dng m gim do thn thiu cc men chuyn ha m h
tributyraza, lipaza, lipop-roteinlipaza (nn th lipop otei t g t o g u gi
bnh).
G ho HCTH g h i u thn c th pht sinh theo h d ng:
trong thc t l s g iu tr HCTH bng thuc chng d g e li kt qu
tt.
C h bnh sinh ca HCTH c th tm tt h sau: i lo u tin l cu thn
t g th lipit mu lt qua qu nhiu gy nhim m ng th ng thi
protein mu lt qua gy protein niu nghim trng dn ti gim protein mu. Ph
do gim p lc keo huyt t g ng aldosteron th pht. Cc ri lon v
protein mu, lipit mu l hu qu ca gim protein mu.
5.Vim thn k (VTK)
Cn gi l vim khe thn, vim b thn-thn, vim b thn-th gc dng,
vim b thn-th theo g u
l nh t th g thc th thn vi im t th g ti ph t
hi u th khe thn.
Trong vim thn k mn, ch g u th c bo v lu di, ch g ng
thn v khe thn sm b ri lon, to ra trng thi mt cn bng v ch g
gia cu thn v ng thn v l ngun gc ca mt s im v triu chng.
Nguyn nhn ch yu l do nhim khun trc tip t ng tit niu ngoi, gy
t th g si h ti b thn ri lan ln t chc k ca thn.
Bnh hay gp ph n % . iu kin thun li pht bnh l khi c c tiu
(do d d g ng tit niu, u p, si hoc vim bng quang vi khu i
gc dng ln khu tr b thn gy vim m, ri t i la l i thn, k
thn v t chc lin kt ca thn. Vim ko di lm cho t chc lin kt v t chc
t g si h, h p t chc nhu m th c bit l ng thn b teo r rt (tri
li ch g u th c bo v l u d i ng m h g ng theo
nn hn ch lu lng tu ho g t g tit renin dn ti t g hu t p- triu
chng hay gp trong VCT). Cui cng cu th g h a, ng thn b bp
nght, thn b h a to , teo nh li, a n suy thn khng hi phc.
Ch g ng thn gi t o g VKT g a t s triu ch g sau :
- Ch g c tiu gim: Triu chng sm nht c khi l triu chng
duy nht t c khi c suy thn ton b. i hiu, t trng thp t tha i. C
khi i hiu h i ht, tim ADH khng c tc dng.
- Ch g toa h a c tiu gim : gim ti hp thu i a o at, n thi gim
thi tr ion H+. g h l i lon thi axit trong VKT nghim tr g h so i
cc bnh khc.
- T g o thi Na+ theo c tiu kh nhiu, gy ra cc th lm sng sau:
+ Mt c, gim Na+ u o ui vi s l g i h thng c th c.
+ Mt qu nhiu Na gy hi ch g i th o ui l mt hi chng ch gp trong
+

VKT.
+ Mt Na c, khng song song vi cc ri lon ch g kh a ng thn
c tiu, toa h a c tiu) to ra th bnh VTM mt mui
C nn qun VKT chim 30-50% cc nguyn nhn gy suy thn mn v l nguyn
h h g u gy cht do suy thn mn.
[newpage]
III-NHNG S THAY I CA NC TIU TRONG BNH L
Khi c ri lon tit niu, thng pht sinh nhng s tha i v c tiu, v
l g g h cht.
A-THAY I V S LNG NC TIU
S l g c tiu c th t g a iu), gim (thi niu) hoc hon ton khng
c (v niu).
a iu:
a iu ph t si h khi l g c tiu qu 2l/ngy vi l g c vo bnh
thng. Do p lc lc cu th t g c tiu mang ra ngoi nhiu) hoc
ch g t i hp thu ca ng thn gim (khi ho kh g c ti hp thu
).
a iu do nhiu nguyn nhn gy ra:
a iu do nguyn nhn ngoi thn:
- Trong b h i th o g , do g u ao, t gng th , o
th ra ngoi, ko theo , g a i hiu.
- Trong b h i ht, do gim tit ADH nn ti hp thu ng th g gim gy
i hiu.
- Ngoi ra, trong bnh huyt p cao, giai o u mch ra ca cu thn co li,
g t g p lc l i hiu. V sau mch ti cu th g o i t.
a iu do nguyn nhn thn.
- Trong vim cu thn cp, giai o u khi mi c xung huyt cu thn, m
ha t th g thc th , do mu ti nhiu, p lc l t g, i hiu
song sm chm dt.
- Trong vim cu thn b phn, hay th i hiu, c th do t g hot ng b
p ca thn cn li.
- Trong vim thn k t h, h t ph t h, do t ch ph t t i
chn p ng thn v m h u u i dng nn ng thn gim ti hp thu i
nhiu.
2. Thiu niu v v niu.
Thiu niu ph t si h khi l g c tiu gi di m h th g di
500ml/ngy) vi l g c tiu o h thng v khng phi do ri lo o
thi c tiu. Cn v niu l ho to kh g c tiut hoc ch c vi chc
ml, c tc gi u nh v niu l di 100ml ho di 300ml.
Ty theo nguyn nhn c th xp thiu niu v v niu thnh my loi sau :
a) Do bnh thn. Thiu niu thng gp trong vim cu thn do cu thn gim lc
(song ng thn vn ti hp thu bnh thng) : (hnh 4) trong ng thn cp nng c
th pht sinh v niu. V niu thng gp trong vim ng thn cp. V sinh l
bnh hc, mt hi tng g h t i gc l t th g ng thn khng gy
i hiu (do mt h g t i h p thu , li gy v niu. C h bnh sinh
ca v niu trong vim ng thn cp phc tp, c nhiu cch gii thch
- Do ng thn b t th g, c nh g on ng b ph h , do c tiu t
lng ng thn trn vo t trc k v hp thu vo mu : hi tng lan ta o
gc ca c tiu. T o g l s g, h ha c chng minh c th.
Nu d g h ch ph hp vi mt s c t ph hy ca ng thn gn.
-Do tc lng ng thn. Nhiu yu t gy tc :
+ T bo ng thn b t g to a.
+ Trong lng ng thn c nhiu hnh tr, nhiu mnh t bo, cc sc t, nht l khi
c tan mu nghim trng.
+ Cc tinh th sulfa it
- Do chn p ng thn. Trong ng thn cp, ph t chc k l mt t th g
sm v quan tr g. Nc tiu t lng ng thn trn vo t ch k li lm cho ph
t g. Ph t chc k chn p ng thn v cc mao qun quanh ng th , do
gim p lc lc c hiu qu cu th . Tu hi , o c (thc nghim v lm
sng) thy p lc ca t chc khe thn khi v niu khng cao ho kh g g k.
- Do ri lon tun hon ti v thn : Theo mt s tc gi th bt c nguyn nhn
no gy vim th u thiu mu vng v th , do g gim lc cu
thn.
b) Do nguyn nhn ngoi thn. C th k :
- Ngu h t c thn : Khi ng mch thn b u chn hay b tc mch, mu
khng ti c th , c tiu khng c. Tr b c tr ngi , thn li hot
ng tt.
- Nguyn nhn sau thn : cn gi l v niu gi v ch g tit niu vn bnh
th g t a l u) song do c tr ngi v g tho t c tiu (si
c tiu li trong thn, ch g lc ca thn b hn ch. Thn c to dn
gy bnh th c, nhu m ca thn b chn p teo li, ch g tit niu mt
dn.
- Nguyn nhn xa thn : Nh sc, chy mu nng, try tim mch, mt c
nghim trng (nm ma, i a l gi lng mu ti thn, h hng ti
p lc lc, gy v niu (khi huyt p cu thn gim ti 40mmHg).
- V niu phn x: au n qu m au un gan, qun thn, ch th g
n g th gy v niu th g ua h phn x: co mch vo cu th ng
thi t g tit ADH v aldosteron gy gim lc cu th ng thi t g t i hp
thu ng thn. Ngay nhng ch th g t l h s hi, tc gi g th
gy v niu (v niu h khi ho i din vi mo).
Cn phn bit v niu vi i: t o g i, u bng quang) v thng bng
quang s h g c nhiu c tiu.
V niu cp din l mt hi tng c th hi phc: t chc b t th g th
hon ton lnh v lm vic tt h t .Nc tiu bt u xut hin li vo ngy
6-12, song c khi phi hng thng mi hi phc. Nh g g u, do ch g
ng th ha kh i phc h c tiu th g ha h t g.
B-THAY I V CHT LNG NC TIU
Nc tiu h thng mu vng nht, i hi khai, t trng l 1018, cha mt
s cht h h h lo ua, phosphat, sulfat, u e, a its u i , eati i t s t
bo lt ca ng tit niu, bng quang v mt s t tr trong. Khi c ri lon tit
niu, khng nhng cc cht t tha i thnh phn v t l m cn xut hin
nhng cht bt th g t o g c tiu h p otei iu, huyt niu, tr niu.
1.Protein niu
Nn gi l protein niu, g h l al u i iu v ngoi albumin cn c cc loi
p otei kh : h thng, khi cu thn l , that ra mt t p otei h g
n ng thn, hu ht c ti hp thu ,pht hi c; vi ph g ph p tht
h h gi ta th t o g c tiu 24h ch c 50-1000mg protein, ch yu l
protein ca nhng t bo long ra ng tit niu, mt s t bch cu,v cht
nhy do cc tuyn ng tit niu tit.
Ch khi o lng protein trn 150mg/l mi ni l c protein niu. Tr mt vi
t ng hp protein niu sinh l xy ra, cn protein niu thng l mt triu
chng ca t th g thn c gi tr ch o ti lng. Protein niu bnh
l thng xuyn c, cn protein niu sinh l c tnh cht bt thng.
a)Protein niu sinh l: c th gp gi tr thng la tui 10- khi ng
l u, do t th ng ct s g l g l t h ch thn tri ho ga l t h
mch ch di lm cho tun hon ti th k i, p otei iu ph n c cha
g ph t si h theo h ny. Ngai ra, cn c th gp protein niu bt thng
nh g gi lao ng nng, hoc mt s gi c h thn kinh khng vng
bn, sau khi t c lnh, sau nhng ch th g t l un gi . h
c th l do co tht mch thn lm cho thn bt cht thiu mu.
b) Protein niu bnh l: protein niu ch coi l bnh l khi c trn 150mg/l v phi
th g u .C khi lng protein ln ti 40-50g/l 24h. Protein niu bnh l
ch yu do thnh mao mch cu thn b t th g d lt qua nhng phn t
protein ho i khi do ng thn b t th g kh g t i hp thu c, hoc c
hai h phi hp (H5).
Protein niu bnh l c th do nhiu nguyn nhn gy ra:
- Ngu h t c thn: B h thng cu thn ch nhng protein phn t
l g di 70000 qua khi trong mu c nhng protein ny, th s o thi qua
cu th . Thng gp l:
Hemoglobin (phn t l g h thng Hb t hng cu c gii phng
ra s kt hp vi haptoglobin mt loi -2 globulin v li c ti hp thu ng
th . Do H h xut hi t o g c tiu khi t kh g kt hp ca Hb.
Protein Benxe gin (Bences Jones) l nhng protein bt thng (chui nh Lamda
hay Kappa) gp trong mu bnh nhn b u t g o gi l bnh Kale
(Kahler(, c phn t lng nh v xut hi t o g c tiu nu ca
h g t o g u ao h kh g t i hp thu ca ng thn.
Trong nh g t ng hp trn, cu thn vn hot ng tt.
- Nguyn nhn ti thn: th g thng protein niu l do t th g u thn. C
khi ch l triu chng duy nht, c trong mt thi gian di (bnh vim cu
thn mn). Khi thnh mao mch b t th g, th hng protein c phn t
l g t g th ua o c tiu a g. T c tin l
albumin huyt t g i ti globulin. Nu vim cu thn nh, thng ch c
albumin niu cn trong vim cu thn nng , thy hu ht cc protein ca huyt
t g k c a oglo uli . Ngi ta c th dng t s A/G h gi
t th g a cu thn. Khi t s ny cng thp th bnh cng nng v tn
th g ng nn globulin thot ra nhu h .
Protein niu cn c th do ng thn c v . Nh it, ng thn c kh g
ti hp thu mt phn cc protein lc qua cu thn. Kh g th gim do
t th g ng thn, ho do t o g c tiu c nhiu p oti t qu kh g
ti hp thu ca ng th . C h protein niu trong nhi c Hg, hay khi thn
thiu oxy, thiu u g th do t th g ng th hn ch ti hp thu
protein.
2.Huyt niu
B h th g t o g c tiu c mt s t hng cu: c tiu 24 gi c khong
70000 hng cu v 322000 bch cu. Huyt niu c th quan st bng mt
thng hoc phi quan st bng knh hin vi. Khi ly tm c mt lp cn gm nhiu
hng cu v lp dch trn mu trong sut: l s phn bit i a u
i a c tiu u do th , do thuc u g, do i a uH
Huyt niu c th do:
- V mch mu ng tit niu h t th g cu thn, ng thn hay b
thn hoc ng tit niu di (bng quang, niu o). Ch o i hy
mu khng phi bao gi g d dng .
- Hng cu thot khi mao mch do b i c bit vim cu thn cp) hoc
thnh mch thoi ha.
Vi m s lng hng cu v bch cu t o g c tiu gip ta theo di s bin
chuyn cua bnh th , h gi t ng thi nh hay tin trin ca bnh.
Huyt niu ha i g h hng cu niu, c th do nhiu nguyn nhn gy ra:
- Nu l huyt niu hon tan gha l u lm xt nghim ba cc, c ba c u
), th c th gh ti:
+ Si thn nu huyt niu xut hi sau khi lao ng nng (b i hnh qun,
chi u
+ Lao nu c km theo vim bng quang.
+ U c thn nhngu huyt niu xy ra lun.
+ Hoc mt bnh khc ca th h vim cu thn cp hoc mn
- Nu l huyt niu v cui (ch c cc th a u , gu h thng
bng quang (si, lao, i ,u
-Nu l huyt niu v u (ch c cc th nht u , gu h thng
niu o (vim niu o) hoc tin lit tuy lao ph i).
Ngoi hng cu, trong b h ng tit niu, gi bnh c th i a , tc l
i a hiu bch cu. i a c thy bng mt th g c tiu c, bn)
hoc phi qua knh hin vi mi th c tiu kh g c, vn trong). Bch cu c
th b h h t o g loi m khc, bach cu c th h thng hoc ch hy
hoi rt t.
3.Tr niu.
Tr l nhng khun ca ng th do p otei ua g li v gi hnh ca
ng thn. Nhng yu t h hng ti hng thnh tr c th l :
- pH c tiu khi pH thp, d pht sinh v lm cho protein d kt ta. Nh H
gp pH c tiu thp s ng li thnh nhng tr hem-atin lm tc ng thn.
- v tnh cht ca p otei t o g c tiu : globulin d b kt ta h
albumin, cho nn khi c glubulin niu th bao gi g t .
Quan st cc tr c th phn no bit c tnh cht t th g ti t chc thn
v tr l i h h th h, theo c tiu ra ngoi, s mang theo hnh nh ti i
.
C vo thnh phn ca tr niu, c th bit c hai loi tr chnh :
- Tr khng c t bo do protein v lipit to nn.
- Tr t bo do t kt hp to nn (hng cu, bch cu, lin bo ng th H
a)Tr trong; b) Tr ht; c) Tr sp; d) Tr li o; T hn hp; e)Tr mu; g)
Tr m; f) Tr m; i) Tr lipoit; k) Hng cu; l) Bch cu; m) lin bo thn; n) t
bo thoi ha m; o) git m; p) git lipoit; q v r) dng tr; s) lin bo ca niu
qu , g i iu o (theo Alpern)
IV. NHNG HU QU CA RI LON TIT NIU
A-NHNG THAY I TRONG MU
Khi thn b t th g, hng cht cn b cn thi s li t o g th g t g
N phi protein mu, nhim axit, thiu u
N phi p otei u t g h u e, NH3, eati i t o g ua t ng
nht l ure.
Nhim toan do a it t o g u kh g c kp thi o thi, cc gc
phosphat, sulfat t g t o g u.
- Thiu u: t ng gp trong vim cu thn mn tnh do thiu p oti to
hng cu, thiu erthopoetin (hocmon sinh hng cu do thn tng hp); ngoi ra,
cn c th do cc cht kh g c o thi li c tc dng c ch ty
g si h hng cu.
B-PH
Ph thng l biu hin ca mt bnh thn ch yu l th h, i u thn.
1. Ph trong hi chng th h
Do nhiu yu t kt hp vi nhau gy ra. Trong bnh ny ph rt r, do mui v
. L g NaCl o thi theo c tiu 24 gi gim t 10-15g xung ti 0,1g.
Thiu niu trong th h kh g do i lon lc cu th . Lng mu qua thn
v ch g lc cu th th g l t g so i h thng. Na t o g th
th h g l do t g tit aldosteron (tim cho con vt cc cht khng
aldosteron thy ph khng pht sinh)
Ph trong th h do gim protein huyt t g dn ti gim p lc keo. Gim
protein huyt t g do p otei iu nghim trng, hu qu ca t g thm
cu thn (v gim ti hp thu protein ng thn). Trong th h ng, 24 gi c
th mt ti 60g protein (ch yu l albumin) v n g protein c th gim 3-2%
hoc thp h . Nc thot khi mao mch dn ti gim th t h u lu th g,
do g t g tit aldosteron v ADH, m hu qu l t o g th. Tuy
nhin gim protein huyt t g kh g gy ra trng thi ph
nghim trng v nh gp trong th h.
Ph trong vim cu thn
Cho ti a , h sinh bnh loi ph ny v ha ho ton sng t. c v
Na trong vim cu thn cp, trn lm sng v trong thc nghim, l do ri lon
tun hon cu thn gy gim lc v thiu niu. Ngo i a, tho t c cn do
gim protein huyt t g, gu h h yu l t g thm mao mch cu
thn gy ra protein niu.
Ngoi yu t thn k trn, ph trong vim cu thn cp do t g thm thnh
mao mch, hu qu ca vim mao mch ton thn : trong thc t, im ca
loi ph ny l dch ph c nhiu protein (ti 2-3%).
Trong vim cu thn cp, th t g tit aldosteron song vai tr bnh sinh ra sao
th ha .
C-SUY THN
Cc bnh thn cui g u d n suy th , gha l t h t ng gim nghim
trng thm ch mt ch g i tit c tiu ca thn, lm cho nhng cht
c o thi ra khi th b li t o g ug hi c.
Nn gi l hi chng suy th h l hi chng ure mu cao v :
-Ure mu khng phn nh trung thc ch g a thn : t g hp th
mt 60% ch g so g u e u h thng ; ngoi ra, ure mu cn ph
thuc vo nhiu yu t ngoi thn.
- Ure l mt cht kh g i vi th (t ra l vi gp trong suy thn).
Nhng cht i vi th h phe olii dol, s atol h thng t rut
th o u c gan gii, o thi qua th . Nhng trong bnh thn,
c t kh g o thi, tch li g hi c. Ngoi ra, tnh trng
nhi hu g to th hn ch ch g gii c ca ga . Nh y,
t g u e u hng t rng cn c nh g ho th kh g o thi,
v chnh nhng snh ph , g u l phenol, mi g c.
- Thi tr ure mi ph h c mt phn ch g a cu thn, thn cn
nhiu ch g ua t ng khc.
1. Nguyn nhn gy suy thn.
C th xp thnh hai loi :
a) Suy thn do t th g thc th. Nguyn nhn c th l :
- Bnh thn : vim ng thn cp, vim cu thn cp v kinh, vim thn k..
- Bnh ton thn : gy t th g th : i th o ng, huyt p cao, bnh
olage
b) Suy thn ch g, do cc nguyn nhn ngoi thn :
- Sc, chy mu nng, try tim mch.
- Mt c nghim trng (nn ma, i lng n g
Nu k thi tr b cc nguyn nhn ngoi thn, thy ch g thn c th hi
ph . Nh g t suy thn ch g t d tin tri n suy thn thc th :
h t o g sc, thiu niu, v niu l u do gi lng mu ti cu thn gy
gim lc, ti giai on mt b trng thi thiu oxi nghim trng v thn gy hoi
t ng thn (tc vim ng thn cp) lm cho thn nng thm.
Cc th lm sng ca suy thn
Trng thi suy thn c th l cp tnh hay mn tnh.
Suy thn cp tnh:
l t ng thi suy sp nhanh chng ch g thn, c kh g hi phc hon
ton.
Triu chng ni bt l: thiu niu, v niu, u e u t g ha h t o g i g ti
2-3-4g%)
Suy thn cp do t th g thc th thn (vim ng thn cp, vim cu thn
cp hoc do nhng ri lon ch g h hng su sc ti ch g tit
niu (sc, chy mu, try tim mch, mt c nghim tr g
Suy thn cp rt t khi chuyn sang mn tnh.
b) Suy thn mn tnh
l trng thi suy sp dn ch g th , h p h g khng hi
ph c. Th g thng, suy thn mn tnh l s suy sp ton b ch g
thn. Suy thn tng phn t khi gp.
Suy thn mn tnh l mt trng thi bnh l ton thn, h hng su sc ti ton
b ch g a th , th kh g iu ch h c s cn bng v th dch
v vy triu chng rt a dng trong thi gia u: huyt p cao, gy yu, thiu
u, th su hc, ri lo tiu h a, ph So g ti thi k cui, triu chng
h suy thn cp: thiu niu, v niu, u e u t g ha h khi ti 7-8%).
Nhng ri lon tm thn kinh (chut t, au d thn kinh ngoi vi, ht
hong, vt v, l , u m, cui cng l hn m) do t th g ga ti o, t g
p lc s no, ri lon in gii (Na+, K+, Mg++) ri lon pH.
Suy thn mn tnh l do nhng t th g thc th ti thn. Bnh tin trin
nhanh hay chm (6-7 thng hoc 20- t thuc vo :
- M t th g ti thn.
- Cc tai bin c th xy ra : bi nhim, ri lon tun hon, ri lon h hp.
- Ch ung v sinh hot.
- C h iu tr v nhng sai st v iu tr.
- Suy th t h iu tr t kt qu, ch c tc dng tm thi, t o g t ng
hp ny t th g thn khng hi ph c. Tt nht hin nay l ghp thn
lnh, h g kh kh l ch phi t c mt gi cho cng gien vi gi
nhn.

3. THN IU HO CN BNG NI MI

Thn c mt vai tr v cng quan trng l bng ch g i tit c tiu


trc tip tha gia o iu ho tnh h g nh ni mi.
1. THN IU HO CN BNG ACID - BASE CA MU.
Trong qu trnh s g th lun to ra cc sn phm lm bi i tnh h g nh
ca ni i. T o g ng acid- ase. Ngi ta nhn thy rng phn ng
iu chnh pH mu ca thn c mu h h g li rt c hiu qa. S iu ho
c thc hin mt cch hon ho vai tr ca thn trong s bi tit H+, ti hp
thu HCO3-, tng hp v bi tit NH3.
1.1. Bi tit H+
T o g iu kin sinh l, th o thi khi th phn tha a id do h h
th to ra trong qu trnh chuyn ho m phi khng th m nhi c.Thng
th g c tiu thi ra ngoi c phn ng acid, pH ca n bng 4,5 v n g
H+ t do ti 800 l ao h hu t t g. N g H+ t o g c tiu vo khong
, E /l. B h thng hai thn thi 0,03-0,06 mEq H+/24h.
Nh t h trn, H+ c to ra do qu trnh CO2 + H2O to thnh
H2CO3 e z a oa h d ase t . Sau H2CO3 phn ly thnh H+ v
HCO3-. H+ c vn chuyn qua mng t bo, c mt phn nh H+ khuch tn qua
mng t bo vo lng g ln, c s t ao i vi Na+ cho Na+ ti hp thu cng
HCO3- vo dch gian bo
S bi tit H+ c lin quan cht ch vi cc h m ca ng thn: h m
phosphat, h m cc acid hu u (creatin, acid citric, acid lactic, cc b oxy
a id o . T o g h m phosphat l quan trng nht. Vi h m phosphat
khi pH mu bng 7,36 trong mu c 80% phosphat tn ti dng HPO4-- v 20%
dng HPO4-. T o g c tiu, khi pH c tiu =6,8 th n g cc ion ny ngang
hau, khi pH c tiu=4,5 th trn 99% phosphat tn ti dng H2PO4-. Nh
vy trong qu trnh to th h c tiu a id y ra hi tng: HPO4-- + H+
H2PO4- (H2PO4-- b siu lc cu thn. Mt phn t gam phosphat b o thi s
ko theo l 0,8mEq H+ a c tiu (hnh 8.5).
Vi h m cc acid hu u th b oxy acid bo l chi u th. Trong mu
chng ch yu tn ti dng anion (A- . T o g c tiu khi pH=4,5 th 80% b oxy
acid bo dng t do l mt phn t t u g t h AH . Khi o thi 1 phn t gam
b oxy acid bo s ko theo 0,45 mEq H+ a c tiu. Phn ng ny di a h
sau: A- + H+ AH (A- b siu lc tiu cu).
Nh y trong qu trnh to thnh acid c s kt hp ca H+ vi cc h m ca
ng thn, hoc lm gim ho tr ca cc anion, hoc chuyn anion thnh phn t
trung tnh. Phn tha atio t g i b ti hp thu o u thng l Na+). S
to thnh H+ trong t bo g l l ut hin HCO3- v n s hp thu vo
mu cng vi Na+.
1.2. Ti hp thu HCO3-.
HCO3- l cht kim ch yu ca huyt t g. N c ti hp thu khi o thi
acid v b o thi khi pH mu ki . B h th g khi pH c tiu=4,5 th HCO3-
h lng qu thp (ch c vt). Trong 24h c khong 400mEq HCO3- b siu
lc, m ch c 1-2mEq HCO3- b thi a go i. Ngha l , % HCO3- c ti
hp thu. S ti hp thu HCO3- c lin quan rt cht ch vi enzym carboanhydrase
(carboanhydrase nm ph a g nh t bo g ln gn). C mt phn HCO3-
c khuch tn vo d h gia o, i b phn HCO3- khng phi c vn
chuyn trc tip qua mng t bo m thng qua s khuch tn d dng ca CO2
vo t bo g ln.
CO2 l lng g ln do to ra t H2CO3 (H2CO3 H2O + CO2) m H2CO3 c to
thnh trong lng g ln t HCO3- + H+ H2CO3 (HCO3- b lc tiu cu). C mt
phn CO2 t dch gian bo khuch tn vo t bo. trong t o u t h
bn CO2 + H2O -> H2CO3 (c enzym carboanhydrase xc tc). H2CO3 phn ly thnh
H+ v HCO3-. Chnh HCO3- c to ra trong t bo g ln mi c hp thu
vo dch gian bo ri vo mu (hnh 4). Nu ti o th cc cht c ch
enzym carboanhydase (v d h a etasola id th c tiu c rt nhiu HCO3-.
T o g t ng hp ny ta li thy HCO3- c ti hp thu cn H+ li o thi.
T o g iu kin ngh gi h th g c tiu g h kh g kim HCO3-.
1.3. Tng hp v bi tit NH3.
Thn c mt ch g t quan trng l to ra NH3. T s o thi NH3 thn
mt ln na li o thi acid. N g NH3 u ng mch thn rt thp, v d l
th t o g u t h ch n g ca n kh cao, l 2- c bit n g
cht t o g c tiu l n 100 l ao h . Theo t gi NH3 c to
ra t bo g ln l do qu trnh kh amin rt mnh ca cc tin cht l:
gluta i , ala i , histidi , gl i , leu i , ethio i , l si ... T o g gluta i l
quan trng nht (hnh 8.6). 60% NH3 c to ra t glutamin. NH3 sau khi c
to thnh d dng khuch tn qua mng t bo (NH3 d ho tan trong lipid) vo
lng g ln do chnh lch phn p. Trong lng g ln n kt hp ngay vi H+
to ra NH4+ v dng NH3 o thi a theo c tiu l dng kt hp NH4Cl (Cl-
c phn ly ra t NaCl trong lng g l gl t h na c lin
+
quan ti bi tit H ca thn. Trong 24 gi -60mEq NH4+ o thi ra
go i theo c tiu.
Ngi ta phi tha nhn rng mt trong nhng ch g ua t ng nht ca
th l iu chnh cn bng acid-base ca mu. Nu pH u t g him kim),
thn s gim bi tit H+, gim ti hp thu HCO3-, gim tng hp v bi tit NH3;
c tiu kim. Nu pH mu gim (nhim acid), thn s t g i tit H+, t g t i
hp thu HCO3-, t g tng hp v bi tit NH3; c tiu rt acid. V vy, th
m bo cho pH mu h g nh.
2. THN IU HO CN BNG NC-CC CHT IN GII CA MU.
Th iu ho cn b g c-cc cht in gii ca u, h h l iu ho cn
bng th tch-p sut thm thu dch ngoi o. T o g th, thc cht khng
th tch ring r gia cn b g c v cn bng cc cht in gii. Hai mi cn
bng ny ph thuc v chi phi ln nhau. Nu th iu ho c cn b g c
th thn mt ph iu ho cn bng cc cht in gii. Nu th iu ho
c cn bng cc cht in gii th thn mt ph iu ho cn b g c.
Cc qu trnh siu lc, ti hp thu v bi tit tch cc l th hin s iu ho cn
b g c - cc cht in gii mu cu thn.
. . iu ho cn bng cc cht in gii.
- Ion Na+.
Na+ l ion chi u th, n chim gn 90% tng s cc cation dch ngoi bo v
quyt nh p sut thm thu dch ngoi bo. Na+ a th theo ng
, u g, iu tr. N c thi ra ngoi theo phn, theo m h i, theo c tiu,
t o g ua t ng nht l theo c tiu.
l t s cht c lc v ti hp thu so snh.

Mt s cht Trong mu mEq/24h

mEq/l mMol/l Lc Ti hp thu Bi tit

Na+ 143,0 143,0 22420,0 22330,0 90,0

K+ 4,5 4,5 770,0 690,0 80,0

Ca++ 5,0 2,5 540,0 535,0 5,0


Mg++ 2,0 1,0 270,0 255,0 15

Cl- 105,0 105,0 19850,0 19760,0 90,0

HCO3- 26,0 26,0 4900,0 4888,0 2,0

HPO4-- 2,0 1,1 208,0 187,0 21,0

SO4-- 1,0 0,5 180,0 125,0 55,0

Glucose 5,5 990,0 989,8 `0,2

ur 6,0 1080,0 580,0 500

Nc - - 169,2 167,2 1,5

Qua bng trn ta thy ch tnh ring Na+ v Cl- t qu tng s lng tt c
cc cht b ti hp thu cn li. S ti hp thu Na+ cc ng thn khc nhau l khc
nhau. g ln gn, 60-80% Na+ b siu l c ti hp thu theo h
khuch tn v vn chuyn tch c , h g h yu l vn chuyn tch cc. T
hp thu l 76 x 10-7mEq/cm2.gy.
S ti hp thu ph thu o lu lng cu thn, p lc keo- thm
thu, p lc thu t h gia lng g ln - dch gian bo - u. c bit n ph
thuc vo tnh trng h thng vn chuyn tch cc Na+ v s hp thu H2O cc
nephron v hay nephron tu.
Ti quai Henle, Na+ c ti hp thu theo h vn chuyn tch cc phn ln
lm cho dch gia o u t g g a hi tng ti hp thu th g c
phn xung. Nu tnh v s lng th s ti hp thu Na+ v H2O phn g ln
a t h hiu so vi g ln gn 5 - 6 ln. Na+ g h kh g t i hp thu th
ng s cn ca t bo g l a kh ao i vi s chuy ng ca
Na+. Ti Na+ c hp thu gc gradient n g v s iu ho n g
Na+ u c quyt nh t i hp thu Na+ phn g ln xa thc s mi
a g gha iu ho v s hp thu Na+ l theo nhu cu th. H th na ng
ln xa l phn cui ca nephron. Na+ c khuych tn c cht mang mng
nh v vn chuyn tch cc g g o dch gian bo nh
hormon aldosteron.
N g Na+ ni mi quyt nh s iu ho ti hp thu Na+ ng ln xa theo
h phn x thn kinh-th dch. Thc ra khng ch aldosteron c tc dng lm
t g t i hp thu Na+ hos o DOC, glu o o ti oid g t dng
+
t g t i hp thu Na , h g k h hiu.
+
Tc d g t g t i hp thu Na ca aldosteson m h h DOC ti 20-25 ln, mnh
h o tisol ti 40 ln. C tc gi cho r g aldosteso t ng ln c ng
ln gn, quai Henle v g g p t g t i hp thu Na+. C th tc dng ca
aldosteron l hot ho h ge tng hp ln protein vn chuyn Na+. C mt s
cht kh g si h h a te o i D, pu o i c ch tng hp protein s lm
gim tc dng ca aldosteron.
- Ion K+.
Mi g gi ta cn 70-100 mEq K+ trong th . Thc t n g h thi ra
ua c tiu hon ton. C 700-800 mEq K+ b siu lc tiu cu,v ch c 10%
tng s K+ siu lc l b thi ra ngoi.Phn K+ siu lc cu th , c ti hp
thu g h ho to g ln gn. Nu trong khu ph thiu K+ th
c th K+ c ti hp thu g ln xa v ng gp. Ti hp thu K+ ti cc phn
ca ng thn l qu trnh vn chuyn tch cc nh cu trc nm ph a g nh
a t bo g ln gn.
S bi tit tch cc K+ t bo g ln xa thc s l mt h iu ho v
cng quan trng, n quyt nh n g K+ dch ngoi bo. Bi tit K+ g ln
xa l nh vai tr ca aldoste o . Aldoste o ng thi ti hp thu Na+ th bi tit
K+. C h vn chuyn tch cc ny nh mt protein vn chuy c hiu. S iu
ho n g K+ mu l ph thuc vo aldosteron. V vy cc phn x thn kinh th
dch c h hng ln s bi tit ca aldosteron s h h g l iu ho nng
K+ a . ng thi gi ta g thy khi n g K+ cao trong mu th
Aldoste o g c bi tit v K+ b bi tit ra g ln xa.
- Ion Ca++ v Mg++.
Bt k mt tha i no ca n g Ca++ u u ko theo nh g tha i
t g ng s o thi n th . Ngi ta th lng Ca++ c hp thu rut
t g g i lng Ca++ b thi ra th . T g Ca++ trong khu ph th
Ca++ c tiu t g gc li. T o g h iu ho c mi lin quan gia hp
thu Ca++ rut o thi Ca++ th . i vi Mg++ g th t g t. Ngoi
o thi Mg++ theo c tiu cn th o thi Mg++ theo phn (1%) . Sau qu
trnh siu lc thy c khong 60 - 70% Ca++, Mg++ c ti hp thu cng vi c
g ln gn, c khong 10% Ca++, Mg++ c ti hp thu g ln xa. Cc ion
g th c ti hp thu c quai Henle khi cn.
Cc t bo g l a g kh g i tit ion Ca++ v Mg++ iu ho
n g cc ion ny trong mu. S ti hp thu, bi tit Ca++, Mg++ ng thn ph
thuc vo chnh cc cht ny trong mu, ph thu o ho o iu ho
n g Ca++, phosphat mu:, PTH hormon cn gip tr g l t g, al ito i
hormon gip trng lm gi o thi Ca++ ua c tiu. Ngoi ra s iu ho
n g Ca++, Mg++ mu ca thn cn ph thuc vo cn bng acid - base ca
mu, ph thu o h hp thu Ca++, Mg++ rut, h to g
mt s h khc.
T g ng Ca++ mu (cp di ha t ng di u lm ri lon ch g thn.
Khi suy thn th n g Mg++ u th g t g l . Thiu Mg++ c th gy tch lu
al i t o g th do gi o thi Ca++ th t g hp thu Ca++ rut.
-Ion Cl-.
Cl- chi u th anion dch ngoi bo. Ti hp thu Cl- li ua n ti hp thu
Na+. Ti hp thu Cl- theo h th g do g adie t in tch. C th Cl- cn
c vn chuyn tch cc g ln xa.
- Ion phosphat.
Sau khi b siu l , io phosphat c ti hp thu g ln gn khong 80%.
Ti hp thu phosphat theo h vn chuyn tch cc. H thng cht vn chuyn
phosphat nm g g nh. Ti g ln xa ion phosphat li o thi. S
o thi ion phosphat nhiu hay t lin quan cht ch vi PTH. PTH l hormon
tuyn cn gip trng c tc dng lm gi gng phosphat ca thn, v th
phosphat t g c tiu v gi t o g u. Phosphat hu ng t g
o u duy tr n g phosphat mu h g nh. Do phosphat t g o
mu nn ko theo Ca++ t g t o g u l t g Ca++ t o g c tiu. Hin
tng trn b gi i di tc dng ca calcitonin, GH v vitamin D.
-Ion sulphat.
S ti hp thu ion sulfat g ln gn v g l a theo h vn
chuyn tch cc. Th iu ha nng ion sulfat mu b g h ti hp thu
ion ny nhiu hay t ng th sau khi lc ra tiu cu thn.
. . iu ho cn b g c.
B g h siu lc v ti hp thu c, th iu ho cn b g c
t o g th. Trong 24h tiu cu th lc ti 170 - l , h g h c 1,2
- , l c thi ra ngoi. G h to c ti hp thu.
Kho g % c ti hp thu g ln g , % c ti hp thu
uai He le, % c ti hp thu g ln xa v ng gp. S ti hp thu
c g ln gn v quai Henle ch yu ph thuc vo ti hp thu cc cht c
lc thm thu cao v d h Na+. S ti hp thu c g ln xa v ng gp
ph thuc vo ADH . ADH l mt hormon ca g di i, c d tr thu
sau tuy . ADH o u theo h phn x thn kinh- th dch theo nhu
cu ca th. ADH t ng ln t bo g ln xa v g g p l t g ng
ti hp thu c.
C h tc dng ca ADH l thng qua cht truyn tin th 2 l AMPv hot ho
e z h alu o idase. l e z tha gia o phn ng thu phn acid
hyaluronic trn mng t o t o g h vn chuy c. S ti hp thu c
g ln xa gi mt vai tr rt quan trng trong s iu ho cn b g c. Th
tch dch ngoi bo c h hng r rt l h iu ho cn b g c ca
thn. Nu l g t o g th cao th thn s hn ch ti hp thu c ng
l a c tiu s nhiu h h th g. Ngc li nu l g c trong
th thp th thn s t g ng ti hp thu c g l a c tiu s
gi h h thng. Nu v mt l do o thiu ht ADH th c khng
c ti hp thu g ln xa v g g p l g c tiu nhiu, c tiu
h t g kh g g i th o ht . Ngi ta g gp i th o ht
do thiu ht e z tha gia o h ti hp thu c ca ADH, m d lng
ADH v h th g t o g th.
3. THN IU HO HUYT P.
Th iu ho huyt p thng qua b my cn tiu cu. Khi huyt p gi , khi lu
lng tun hon qua thn gim, t bo ht ca b my cn tiu cu t g tit
Renin. Renin c bn cht cu trc l mt glucoprotein, bn cht ch g l t
e z , t ng ln mt ht c trong mu v bch huyt do gan sn xut l
angiotensinogen (bn cht l a2- globulin, c 14 acid amin), chuyn
a giote si oge th h a giote si I a id a i . Di tc dng ca convertin
enzym (CE), mt enzym ca phi, angitensin I chuyn thnh angiotensin II (8 acid
amin). Angiotensin II l mt cht c hot tnh sinh hc cao, c kh g g o
m h k h th h u t h t g tng hp v bi tit aldosteron. Aldosteron lm
t g t i hp thu Na+ g l a l t g Na+ mu v gi c. Chnh v hai tc
dng ny m angiotensin II lm cho huyt p t g l
Trong lm sng ta c th gp b h t g hu t p do vim thn mn tnh, do cht
hp ng mch thn. Da theo h t g hu t p do a giote si , gi ta
s dng cc thuc c ch enzym chuy , g n qu trnh to angiotensin II.
4. THN IU HO SINH SN HNG CU.
Thn l mt trong nh g ua sn xut e th opoieti tham gia vo qu
trnh sn sinh hng cu trong tu g.
Khi thiu u, lng oxy mu gi t ng ln thn (t bo b my cn tiu
cu v mt s t bo khc) lm cho cc t bo ny sn xut ra yu t kch thch
to hng cu ca th e th oge i . ng thi lng oxy mu gi k h
thch gan sn xut mt glo uli . Glo uli di t ng ca e th oge i
to ra yu t kch thch to hng cu ca huyt t g l e th opoieti , t
glucoprotein c hot tnh sinh h ao. E th opoieti t ng ln cc t bo
tu g si h a tin nguyn hng cu t ng chuyn nhanh hng cu non
thnh hng cu t g th h o u s 8.8). Trn lm sng ta c th gp
thiu mu trn bnh nhn vim thn mn tnh.
Bn cnh qu trnh sinh sn hng cu, th g sn xut ra cht c ch s
to hng cu khi mu tha o . Nh y s bo ho oxy mu c vai tr quan
trng trong s iu ho sinh sn hng cu ca thn.
5. THN IU HO QU TRNH CHNG NG MU.
Cc t bo b my cn tiu cu sn xut ra urokinase. Urokinase l mt cht c
kh g hu fibrin nn kch thch qu trnh tan c u g. V c
ng d g t o g iu tr, trong lm sng. Th l ua d tr heparin nn
n c th c ch u t h g u.

4. IU HO CHC NNG THN

Ch g th iu ho b g h phn x thn kinh v thn kinh th


dch.
1. CC PHN X THN KINH-TH DCH.
1.1. Phn x t th th thm thu.
Th th thm thu l cc t bo thn kinh v cc tn cng thn kinh nhn c c
hiu s bi i ca p sut thm thu dch ngoi o. Nh y cc th th thm
thu ny nm hai i: goi i t u g g. ngoi i, h g c b tr
khp trong m lin kt, thnh m h c bit ca cc m gan, lch, tu, phi,
tim...), t th th u g g h g t i theo ng cm gic ti vng
di i. t u g g g di i), vng gn nhn trn th v nhn cnh tht,
l mt cu trc thn kinh m cc t o c tnh th th thm thu. Nhng th
th ny b kch thch khi p lc thm thu t g c ch khi p lc thm thu
+
gim (ch yu l s tha i n g Na dch ngoi bo).
Khi th th thm thu b kch thch (c ngoi i t u g g , u g g h g
phn s kch thch nhn trn th v nhn cnh tht lm gii phng ADH
(vasopresin), kch thch thu sau tuy t g ng bi tit ADH. ADH vo mu
s l t g t i hp thu c g ln xa v g g p. ng thi u g ng
h g phn t th th thm thu (ngoi i t u g g n cc trung khu dinh
dng thuc h Li i g di i cho c gi kh t c. Khi u g c
c hp thu t rut vo mu. Nh nh g h t c gi li
t o g th v lm gim p lc thm thu.
T o g t ng hp p lc thm thu gim, cc th th thm thu kh g h g
ph , ADH t c sn xut v bi tit, u g t , t o g th b thi ra
go i theo g iu lm cho p lc thm thu t g l
1.2. Phn x t th th th tch.
Th th th t h c phn b m lin kt thnh mch phi, th , oa g ng
mch c h, c bit l th h t h t i. C th th ny rt nhy cm vi s
tha i th tch dch ngoi bo v khi l g u lu h h.
Khi th tch dch ngoi bo gim, khi l g u lu h h gim, s kch thch ny
g hng phn cc th th th t h. Xu g g hng tm truyn v g di
i lm bi tit hormon gii ph g CRH g di i (nhn trn th). CRH kch
thch tuyn yn gii phng ACTH c tc d g l t g tng hp v bi tit
aldosteron tuyn v thng thn. Nh aldosteron m Na+ t g ng ti
hp thu g ln xa v g g p. ng thi khi Na+ u t g l l t g i
tit ADH. N c gi li nh Na+ do t g hp thu t rut v thn. Th tch
u c khi phc
S tng hp v bi tit aldostero do h renin-angiotensin-aldosteron
(vng R.A.A). Khi khi l g u lu h h gi lu lng tun hon qua thn
gi , h tit e i ph t ng v aldosteron s l t g t i hp thu Na+,
gi l t g khi l g u lu h h h u mc 3: th iu ho
huyt p)
Ngo i a aldoste o c bi tit khi n g K+ u t g. T ng hp ny
hay gp l do thiu oxy t bo lm cho knh vn chyn Na+, K+ b ri lon d n
K+ t ni bo vo u. Do aldoste o t g Na+ c ti hp thu l t g th
tch dch ngoi o. C h thng gp trong suy tim.
S iu ho th tch dch ngoi bo v p lc thm thu dch ngoi o c
m bo nh h siu lc ca thn. Nu lu lng tun hon qua thn
t g th p lc l tng v mc lc tiu cu t g l t g l g c tiu, v
gc li lu lng tun hon gim th s gi l g c tiu.
T o g th ton vn hai loi phn x t th th thm thu v th t h thng l
chi phi ln nhau v lin quan ch yu ti hai thnh phn rt n ca dch
ngoi bo l n g Na+ h l g . iu ho cn b g c c lin
quan cht ch ti iu ho cn bng Na+ gc li.
1.3. Cc phn x thn kinh.
H th ki h t u g g h hng r rt ti s iu ho ch g thn.
- Nu kch thch vo mt s vng ca v no, ta c th l t g ha l gim s
l g c tiu.
- Ngi ta th h lp c phn x iu kin gim s l g c tiu do
au. Nh g t h k h th h iu ki , k h th h g au, i k theo
sau chng, gy nn gim bi tit c tiu. Phn x ny l c s tham gia ca h
th ki h t u g g.
- H thn kinh thc vt c bit l h giao cm) c vai tr rt quan trng trong s
iu ho mc lc cu thn. H thn kinh thc vt c th iu ho lm t g ha
gi lu lng tun hon qua th . Lu lng tun hon quan th tha i th
s tha i mc lc cu th l tha i l g c tiu.
Cc phn x th ki h t , h yu nh iu ho dng mu thn. Khi dng
mu th iu ho th s iu ho c mc lc cu thn.
Nh h phn x thn kinh v thn kinh th dch, th t c tip tham gia
iu ho cc chc ph th, l ho th th h ghi c vi mi bi i
ca i t ng, gi vng cn bng ni mi.

5. NGHIM PHP THM D CHC NNG THN

. PHNG PHP THANH THI


T ph g ph p tha h thi creatinin ca Rehberg (1926), ho ph g ph p
thanh thi ur ca Mole Meh tosh Va Sl ke , g a gi ta t
c nhiu cht th thch hp cho vi th d tng phn ch g thn:
inulin, creatinin, ur, P.A.H, Cr 51, E.D.T.A ...
N , Va Sl ke hn thy trong mt iu kin nht nh (s bi
niu> l/ i , lng mt cht c bi tit t o g c tiu (U.V) t l thun vi
n g cht t o g u P , ha :

T o g :
U: (mg%) cht t o g c tiu
V: l/ i l g c tiu/min
U.V: g/ i lng cht o thi/min
P: (mg%) n g cht c trong mu
C: l/ i lng huyt t g c lc sch mt cht/min
Hng s C c Van Slyke gi l thanh thi. thanh thi lea a e l lng
huyt t g t h ng ml cha mt cht trong mt thi gia lc sch
cht .
Nu nhn hng s C vi nng cht t o g hu t thanh, th bit c
lng cht o thi ra ngoi trong mt thi gian.
Nh y ch trong mt iu ki c bit, mt cht ch i ua thn mt l
loi tr ho to , th thanh thi mi t g g lng huyt t g ua
th . iu ny rt kh x a t o g th. V th, l t khi nim tru
t g, h g ta n c th hiu v ng d g c.
V d, trong mt pht c mt lng cht c bi tit ra 75ml huyt t g
iu ta g th cho: trong mt ph t / lng cht c bi tit ra
150ml huyt t g. Nh th, khi nim lc s h c hiu mt cch d
d g h .
Trong nghin cu th d h g th , gi ta c gng tm cc cht th c
tnh cht:
- B o thi m khng ti hp thu.
- Kh g c.
- Khng b cc b phn khc ca th bi tit v chuyn ha.
- Khng tch lu thn.
Hin nay c hai ph g ph p c dng:
- Cc cht t o g th (ni sinh): ur, glucose, creatinin, acid amin, mt s
cht in gii ...
- Cc cht a t ngoi vo (ngoi sinh): inulin, manitol, PAH ...
2. MT S CH S NG DNG
2.1. Ch s h gi h g lc.
h gi h g lc thng qua h s thanh thi ca cht ch lc qua cu thn,
m khng b ti hp thu v bi tit thm ng thn, h ht inulin.
U.V
----- = C (const )
P
C inulin =120-125ml/min.
2.2. Ch s h gi h g t i hp thu.
Th g h gi kh g t i hp thu ca ng thn thng qua h s thanh thi
ca cht sau khi lc qua cu thn, mt ph c ti hp thu tr li, h ur v
so vi C inulin.
C inulin - C ur = V huyt t g ha u t i hp thu. Th g thng C ur =
75% C inulin.
2.3. Ch s h gi Ch g i tit tch cc.
h gi h g i tit tch cc thng qua h s thanh thi ca cht sau khi
lc, khng b ti hp thu c bi tit thm ng th h PAH, PSP.
C PAH = 655ml/min; CPSP = 450ml/min.
6. QU TRNH TO NC TIU

c tiu, thn c ba qu trnh: siu lc tiu cu thn, ti hp thu


v bi tit tch cc tiu qun thn.
1. QU TRNH SIU LC.
Qu trnh siu lc thc hin tiu cu thn. Qa trnh ny l mt qu trnh th
ng, l c v cc cht ho ta t o g c t huyt t g ao ch cun
mch sang khoang bao Bowman qua mng siu l . Nh y, mun c dch siu
lc ( dch l , c tiu u) , cn phi c hai yu t n l mng siu lc v p
lc lc.
Mng siu lc v p lc lc quyt nh s lng v thnh phn cc cht dch siu
lc.
1.1. Mng siu lc.
Mng siu lc cn gi l mng tiu cu th . M g g h gia huyt
t g ao ch cun mch v dch siu lc trong khoang bao Bowman. Mng c
ba lp: lp t bo ni m mao mch, lp mng nn v lp t bo biu m (l
trong) bao Bowman.
Lp t bo ni m mao mch lng trn lp g . Trn t bo ny c nhng l
thng gi l ca s fe est a . ng knh ca s ny l 160 A0.
Lp mng nn l mt m g li cc si collagen v proteoglycan, c to ra cc l
nh ng knh 110 A0. Cc l t h in m (do cu trc ca
proteoglycan).
Lp t bo biu m bao Bowman l mt lp t bo biu m c chn (tua) mi t
bo c rt nhiu chn bm ln mng nn. Gia cc tua nh ny c cc khe nh
(slit-po e ng knh khong 70-75 A0. Trn siu cu trc, cc l ny khng
phi thng trc tip m trn b mt chng c mt mng bt siu mng
Mng siu lc c rt nhiu lp h h g li l mt mng sinh hc c tnh
thm chn lc rt ao. K h thc phn t v s t h in m ca cc phn t
quyt nh kh g thm ca n qua mng siu lc:
Cht ho tan Tr g lng phn t Kh g thm qua
Inulin 52000 1,000
Cc protein phn t nh 30.000 0,500
Albumin 69.000 0,005
Inulin c tr g lng phn t nh nn thm qua 100%. Albumin c tr g lng
phn t ln, li t h in m nn ch thm qua c 0,5%. Cc t o u, g
nhin l khng th ua c mng siu lc. V vy trong dch siu lc khng c
cc t bo mu, khng c cc hp cht hu ph t lng cao trn 70.000.
Cc protein phn t lng thp c th thm qua mng siu l , h g t t, v
v h lng ca n trong dch siu lc ch l , %, gha l h bng
/ h lng protein huyt t g. Do s chnh lch v h lng protein
gia huyt t g dch siu lc (chnh lch din tch m) nn trong dch siu lc
s c n g ion Cl- v HCO3- ao h % so i huyt t g gi cn bng
in tch m (cn bng Donnan).
Nhn chung, tr nhng thnh ph t t kh g ua c mng siu
lc, cn li g h to cc cht trong huyt t g dch siu lc c nng
ngang nhau v dch siu lc c p sut g t g so vi huyt t g.
1.2. p lc lc: FP (filtration pressure).
p lc lc l p l t ng ln huyt t g a mao mch cun m h, y
c v cc cht ho ta t o g c sang khoang bao Bowman. p lc l c
to nn bi s tng hp ca cc p lc mu mao mch cun mch , p lc keo
ca huyt t g ao ch cun mch v p lc trong khoang bao Bowman.
p lc mu mao mch cun mch: GP (glomerular pressure). Mao mch cun
mch c p lc mu rt cao, cao nht trong cc h thng mao mch, thng
thng l Hg. l ng l n nht to ra p lc lc. Ap l y
c v cc cht ho ta t o g c t mu mao mch cun mch vo khoang
bao Bowman.
p lc keo ca huyt t g ao ch cun mch: GCP (glomerular colloid
os oti p essu e . GCP c to nn nh cc hp cht hu ph t lng
ao, c bit l cc protein huyt t g. C ht ny c kh g gi c li
cho huyt t g. GCP ng m h l Hg l p lc keo ca mu),
ng m h i l Hg tho t o khoang bao Bowman) nn p
lc keo ng m h i ao h p lc keo ng m h n. GCP trung bnh ca
mu mao mch tiu cu thn l 32mm Hg.
p l t o g khoa g ao Bo a : CP apsula p essu e . l p lc ca dch
siu lc nm trong khoang bao Bowman to nn, cn gi l p lc trong bao. p
l c t khoang bao Bowman tr li huyt t g ao ch cun
mch. p lc ny b g Hg. Nh y p lc keo ca huyt t g ao ch
cun mch v p l t o g ao l gc chiu vi p lc mu mao mch cun
mch.
Mun c dch siu lc th FP phi l h , gha l GP phi l h tng GCP +
CP v cng thc p lc lc l:
FP = GP-(GCP + CP)
= 60 - (32 + 18)
= 10 (mmHg)
T g lng dch siu lc trong 24 gi l rt ln, trung bnh l 170-180l. V vy vic
nghin cu h gi h g lc ca tiu cu thn l v cng quan tr g i vi
h l s g c bit l cc nh gy m-hi sc.
Ngo i FP a, h gi hc g lc ca tiu cu, gi ta nh mt s
ch s h sau:
Phn s lc ca tiu cu:FF (filtration faction) l t s (%) gia dch lc (ml) v
lng huyt t g ua thn (ml) trong mt ph t: h thng t s ny bng 19-
21%.
GFR
FF=--------------
RPF
H s lc ca tiu cu (filtration coefficient), k hiu l Kf. H s lc Kf l s ml
dch siu lc c trong mt pht, khi p lc l l Hg, h thng
Kf=12,5ml/min. mmHg.
Mc lc cu thn: GFR (glomerular filtration rate). Mc lc cu thn cn gi l lu
lng lc cu thn. GFR l s ml dch siu lc c trong mt ph t. N c tnh
bng tch ca h s lc vi p lc lc ca tiu cu.
GFR = Kf x FP = 12,5 x 10 = 125ml/min.
Ngi ta g nh GFR bng h s thanh thi ca inulin (h s thanh thi ca
inulin bng 125ml/min).
1.3. Nhng yu t h hng ti qu trnh siu lc.
- C h t iu ho mc lc cu thn ca b my cn tiu cu.
C h t iu ho mc lc cu th l h iu ho gc ng thn-tiu cu
tu uloglo e ula feed a h e ha is . l h iu ho gc vn
m h g gi ng m h o ng m h i u l h iu ho
gc m tnh.
Khi lu lng lc cu thn gim th t dng dch qua ng thn b chm li.
Hi t g l ho t g ng ti hp thu ion Na+ v Cl- nhnh ln quai
He le. Nc tiu i ua g ln xa s c n g ion Na+ v Cl- gi h h
thng. Cc t bo macula densa nhn c c s gim n g ion Na+ v Cl-
trong dch lng ng thn khi cc cht ny qua chng. Cc t bo macula densa cho
nhng tn hiu th g ua l gi ng m h n v kch thch t bo
cn tiu cu gii phng renin.
Khi gi ng m h , lu lng tun hon qua thn (RBF: renal blood flow) s
c t g l , l t g p lc l h y s t g c lc cu thn. Chc
g lc ca tiu cu thn tr v h thng.
Khi t bo cn tiu cu gii phng renin, n s tham gia vo mt trong nhng
khu quan trng xc tc cho qu trnh chuyn angiotensinogen thnh agiotensin
II. A giote si II l o ng m h i t o th h ng m h i t mn
cm vi a giote si II . ng m h i o, s lm cho p lc mu trong mao mch
cun m h t g. Lu lng lc cu th t g l h g lc ca tiu cu
thn tr v h thng.
Hai h gi ng m h o ng m h i hm m h t duy tr mc
lc cu thn h g nh, mc d huyt p ng mch c th tha i trong mt
phm vi kh rng t 75-160mm Hg.
- C h iu ho ca h thn kinh giao cm.
Cc tn cng thn kinh giao c c phn b ti tn t o t th h ng
m h ng m h i a tiu cu thn. Cc t o g hng th
th nhn c i vi cc cht trung gian ho hc ca h thn kinh giao cm. V
vy khi h thn kinh giao cm b h g phn hay b c ch, cc cht trung gian ho
hc h thn kinh giao c t g l hiu hay t trong phn ng thch nghi ca
th i vi mi bi i ca i t ng, s l ho lu lng tun hon qua
thn bi i (dng mu thn bi i). Khi lu lng tun hon qua thn thay
i th mc lc cu th g tha i theo h y, ch g lc ca tiu
cu s c duy tr tr g th i si h l h thng.
- S bi i p lc lc khi c s bi i ca huyt p ng mch, p lc keo ca
huyt t g p lc trong bao (trong thn).
Trong tt c t ng hp c huyt p ng mch gim (shock, mt mu, suy
tim v.v...) d n gim p lc mu mao mch cun mch v lm gim p lc lc.
p lc lc gi th lu lng lc cu thn gim. Khi huyt p ng mch gim
xung ch cn 40-50mm Hg th v niu. Nh g kh g phi t ng hp t g hu t
p o g l t g p lc lc. Mt s t ng hp t g hu t p do co mch,
mc d huyt p ng m h t g t ao, h g lu lng lc cu thn li rt
gi , o ng m h n, lm gim dng mu thn. Tri li, c mt vi
t ng hp c gim huyt p ng m h, h g do gi ng m h n, lm
t g lu lng tun hon thn, nn v lu lng lc cu th . Nh y,
huyt p ng mch, dng mu thn c mi lin quan cht ch vi mc lc cu
thn.
Khi b bng, b ra nhiu m h i do lao g t o g i t ng nng m), b nn
ma hoc a ch , th b mt rt nhiu c, p lc keo ca u t g t cao
dn ti mc lc cu thn gim.
Bnh nhn b bnh vim ng thn, si thn v niu qun gy cn tr ng dn
c tiu l t g p lc trong thn v lm gi lu lng lc cu thn.
Ngi ta nhn thy rng khi p lc trong th l n 30-40mm Hg th p lc lc
b g kh g th s v niu.
- S bi i cu trc mng siu lc.
Khi mng siu lc bi i v cu trc do rt nhiu nguyn nhn khc nhau, chc
g h thng ca mng siu lc khng cn na. Tnh thm ca mng siu lc
t g l ho c lc cu th t g, t h thm ca mng siu lc gim lm cho
mc lc cu thn gi . ng thi khi t th g g siu lc, dch siu lc s
c hng cu, p otei l ho c tiu c hng cu i a u , p otei
i a p otei .
2. QU TRNH TI HP THU.
Qu trnh ti hp thu c thc hin ng thn. Trong qu trnh ny ton b cc
cht cn thit ho th u c ti hp thu tr li mu. C nhng cht c
ti hp thu hon ton, c nhng cht c ti hp thu mt phn hoc phn ln,
c nhng cht kh g c ti hp thu l ht khng cn thit ho th. Ti
ng thn c c h vn chuyn tch cc v khuch tn th ng.
Khi cc cht t lng ng th c hp thu vo dch gian bo.T dch gian bo cc
cht c v cc cht ho ta t o g c) vo mu theo s chnh lch p lc
thu t h v p lc keo: ti mao mch ng thn c p lc keo l 32mmHg, p lc
thu t h l Hg. Nh y p lc gi c li l 32 - 13 = 19 (mmHg).
Ti dch gian bo c p lc keo l 15mm Hg, p lc thu t h l Hg. Nh y
p lc gi c l 15-6 =9 (mmHg). Thc t s chnh lch p lc gia mu mao
mch ng thn v dch gian bo ng thn l 19 - 9 = 10 (mmHg). Nh c p lc ny
c v cc cht ho ta t o g c chuyn t dch k vo mu mao
t h ch ng thn, ri theo tu ho hu g i khp th.
Nu c ch g lc m khng c ti hp thu, o gi khng tn ti c.
Mt v d gi l c lc trong 24 gi l 170- l, h g c
o thi chnh th theo c tiu l 1,5 lt, g h to c ti
hp thu.
2.1. Ti hp thu g ln gn.
Nhn chung c khong 80% cc cht c ti hp thu g ln gn. V
vy khi ra khi g ln g o uai He le, c tiu v g t g c
d t rt nhiu c v ion Na+.
- Ti hp thu glucose.
Glucose c ti hp thu ho to theo h vn chuyn tch cc g ln
gn khi n g glucose mu thp h gng glucose ca thn. Khi n g
glu ose u ao h gng glucose ca th > , g/l th glu ose kh g c
ti hp thu hon ton, mt phn glu ose t o g c tiu, mc d g ln gn
kh g t i hp thu glu ose ao h khi g glu ose h thng
trong mu.
- Ti hp thu HCO3-.
HCO3- c ti hp thu ch yu g ln gn, c mt phn g ln xa. S
ti hp thu HCO3- theo ch vn chuyn tch cc, c lin quan cht ch vi
a oa h d ase C.A , g t phn HCO3- c ti hp thu theo h
khuch tn th ng.
Trong lng g ln gn: HCO3- + H+ H2CO3 CO2 + H2O.
CO2 khuch tn vo trong t bo g ln gn v CO2 + H2O CA HCO3- + H+. ion H+
c vn chuyn tch cc vo lng g ln cn HCO3- c chuyn vo dch gian
bo cng vi Na+. Nh y HCO3- theo h vn chuyn tch cc khng phi
chnh HCO3- m thng qua s khuch tn ca CO2 c to thnh t HCO3-.
Trong 24 gi c 4000 mEq HCO3- b lc vo dch siu l , h g h c 1-2 mEq
- -
HCO3 b thi ra ngoi. C ti 99,9% HCO3 c ti hp thu.
- Ti hp thu protein v acid amin.
Protein phn t lng nh a id a i c ti hp thu hon ton ng ln
g theo h vn chuyn tch cc. Protein g t g h c chuyn
vo trong t o theo h "m bo". Cc protein trong "ti" b cc enzym thu
ph th h a id a i . C aid a i c vn chuy ua g o dch
gian bo theo h khuch tn c cht mang. Cc acid amin t do trong lng
g l c vn chuyn tch cc nh cht ti c hiu ua g nh.
+ + -
- Ti hp thu K , Na v Cl .
Ion K+ c ti hp thu hon ton g ln g theo h vn chuyn tch
cc. Ion Na+ c ti hp thu ti % theo h khuch tn c gia tc mng
nh, vn chuyn tch cc g g . Io Cl- c ti hp thu theo
g adie t in tch.
- Mt s g su fat, phosphat, it at... c ti hp thu theo h vn chuyn
tch cc.
- Ti hp thu c.
N c ti hp thu l hu qu ca ti hp thu cc cht c lc thm thu cao:
Na+, K+, Cl-, HCO3-... Nu a ht c lc thm thu ao o u, sau
c lc qua tiu cu, cht t c ti hp thu, n s b o thi ra ngoi gy
a h li niu thm thu.
- Ti hp thu ur.
Khi io c ti hp thu, c bit l cc ion c tnh thm thu ao h Na+,
l ho c ti hp thu theo. Nh y n g ur trong g ln gn s
ao h g ur trong dch gian bo. V vy ur khuch tn vo dch k, ri
vo mu, theo gradient n g ti 50-60%.
2.2. Ti hp thu quai Henle.
Quai Henle c hai nhnh: xu g l gc chiu nhau. S cu to ca hai
h h g kh hau. Nh h ung v ph u nhnh ln mng. Phn cui
nhnh ln dy. Ph u nhnh ln c tnh thm Na+, u , h g kh g thm
c. Na+ c ti hp thu th ng vo dch gian bo. Phn cui nhnh ln
khng ti hp thu th ng Na+ m li vn chuyn tch cc Na+. Dch gian bo
quanh quai Henle rt u t g, ht l g h p uai He le, c bit l vng
tu thn. Nh hi t g t c ti hp thu th ng nhnh
xung, v nhnh xung c tnh th ao i vi u , h g li khng cho
+
Na thm qua.
Nc tiu i o uai He le l g t g, h g g i ung quai Henle,
g u t g, h p uai l u t g ht. Chnh s u t g l
cho Na+ la d ti hp thu phn ln. nhnh ln Na+ c ti hp thu c
tiu s g t g i h t g Na+ c vn chuyn tch cc.
Ti g l a c tiu rt h t g, d ua uai He le ti
hp thu rt nhiu c. Kh g t i hp thu ca quai Henle rt ln ti 25% Na+
% c.
2.3. Ti hp thu g ln xa.
g ln xa l phn cui ca nephro , do s ti hp thu ph thuc vo
hai yu t n th nht l nhu cu ca th, th hai l s lng v cht
l g c tiu qua n.
- Ti hp thu c
Nc tiu ua l c tiu h t g, t u g h mt pht c 20ml
c tiu qua g ln xa. Trong 20ml ny, thc t ch c l ho tan
vt cht t o g c tiu. S cn li 18ml khng tham gia vo ho tan vt cht,
ph c gi l c "khng tham gia thm thu". Ph c ny cn
c ti hp thu ch yu ng ln xa v mt phn ng gp. Ti hp thu c
theo c hai h ch ng v th g, h g h yu l vn chuyn tch cc.
S vn chuy theo h ch ng nh tc dng ca ADH. ADH l hormon
ca h pothala us, c d tr thu sau tuyn yn v vo mu theo nhu cu
ca th. ADH t ng ln t bo g ln xa v g g p t g ng ti
hp thu . C h ca ADH l thng qua AMP vng hot ho enzym
hyaluronidase trong phn ng thu ph a id h alu o i m rng l mng
trong qu trnh vn chuy c. Nh h ti hp thu c tiu qua
g ln xa v g g p c li.
- Ti hp thu Na+.
Na+ c ti hp thu g h theo h khuch tn c cht mang v theo
h vn chuyn tch cc g g . S ti hp thu Na+ theo
ch vn chuyn tch cc l nh tc dng ca aldosteron. Aldosteron l hormon
ca tuyn v thng thn (lp cu sn xut) c tc d g l t ng ln t bo
g l a l t g ng ti hp thu Na+. C h tc dng ca aldosteron l
ln s tng hp protein ca t bo g ln thng qua hot ho h gen. Protein
va c tng hp l protein ti v protein enzym tham gia vo vn chuyn tch
cc Na+.
- Ti hp thu HCO3-.
S ti hp thu HCO3- theo h vn chuyn th ng v tch cc h g ln
gn. Song s vn chuyn ny c mi quan h cht ch vi s i thi ion H+.
3. QU TRNH BI TIT TCH CC.
Khi so s h h lng cc cht c trong dch siu l t o g c tiu chnh
thc chng ta nhn thy c rt nhiu cht c mt t o g c tiu chnh thc
h g li khng c trong dch siu lc.
Mt s cht c n g rt thp trong dch siu l , h g t o g c tiu chnh
thc li h lng rt ao. iu ny ch c th gii thch l ng thn, trong qu
trnh to th h c tiu, n chuyn mt s cht t mu vo lng ng thn,
hoc t bo ng thn sn xut mt s cht chuy o c tiu thi ra
ngoi. Ch g i tit tch c c thc hin ch yu g ln xa v c
mt phn g ln gn.
3.1. S bi tit H+.
Qu trnh bi tit H+ l mt qu trnh c lin quan ti n g CO2 mu. CO2
khuch tn qua mng t bo g ln, trong t bo c phn ng CO2 + H2O
+ - +
H2CO3 H + HCO3 . H c vn chuyn qua mng t bo vo lng g ln. Ion
H+ c bi tit, ng thi Na+ c ti hp thu. H+ trong g ln s c kt
hp vi ion phosphat, vi NH3, vi cc gc acid hu u hoc vi cc gc khc
thi ra ngoi. H+ cn kt hp vi HCO3- to ra H2CO3 CO2 + H2O. CO2 li vn
chuyn vo trong t o to ra HCO3- hp thu vo mu.
3.2. S tng hp v bi tit NH3.
Trong t bo g ln c qu trnh kh amin ca glutamin (chim ti % to
ra NH3. NH3 d dng khuch tn qua mng t bo vo lng g ln. NH3
c kt hp vi H+ to thnh NH4+ thi ra ngoi.
3.3. S bi tit K+.
Ion K+ b ti hp thu hon ton g ln g . N c bi tit ra g ln xa
theo h vn chuyn tch cc nh tc dng ca aldosteron. Aldosteron c tc
d g ng thi ti hp thu Na+ o thi K+.
3.4. S bi tit cc cht khc.
T bo g ln xa cn bi tit phenol, acid hippuric, P.A.H, creatinin, cc acid
mnh, cc sn phm ca thu a t ngoi vo, cc cht c l khc do qu
trnh chuyn ho to ra hoc xm nhp t bn ngoi bng nhiu ng khc
nhau.
Ba qu trnh siu lc, ti hp thu v bi tit tch cc nhm m h to a c
tiu. Nh g s lng v cht l g c tiu h th no li l hu qu ca qu
t h iu ho cn bng ni mi ca thn.

7. C QUAN SINH SN NAM

.C ua SD nam g ti h ho , d g t v mt s tuyn ph thuc.


2.CHC NNG CA TINH HON
C 2 CN: ngoi tit v ni tit.
2.1- Ch g si h ti h t g:
Mi tinh hon c # 900 ng sinh tinh.
1 g s/ti h d i i SX ti h t g.
Thnh ng s/t gm TB dng tinh (tinh nguyn bo) v TB Sertoli.
Tinh nguyn bo bit ho tinh trng.
TB Sertoli gn nhau = lp c T/D bo v TB dng tinh.
Tinh nguyn bo typ A p/chia 4 ln to 16 TB ln (typ B) v/c vo khoang gia 2
TB Sertoli thnh tinh bo I (c 46 NST).
- Tinh bo I p.chia tinh bo II (c 23NST).
Sau 2-3 ngy Tinh bo II p/chia nguyn nhim thnh tin tinh trng (23 NST).

- T.gian to 1 tt 74 ngy, c 2 loi tt mang 1 loi NST gii tnh X hoc Y.


- Th tinh: XX con gi; XY con trai.
- T/t t ng thnh g : u, c u i.
C u cha h alu o idase phn hu lp cemen gia cc TB v men thu
ph t/t xm nhp trng.
* S thnh thc ca tinh trng:
T ng sinh tinh, tt mo tinh g t i ti h t g th h k/ g th
tinh.
TB Sertoli v TB b/m mo tinh b/tit cht d/dng v men cn cho s t/thnh
ca tt.
T/t kho d/chuyn vi t : 1-4mm/ph.
M i t ng thun li: pH kim, t/tnh.
T/t sng ng SD n t 1-2 ngy.
* iu ho SX tinh trng:
+ H ng hormon:
- GnRH, FSH v LH
- FSH: lm p/trin ng s/tinh v TB Sertoli tit cht di h dng.
- LH: t g si h TB Le dig tit testosteron.
- Testosteron: p/chia tinh nguyn bo to TT
- GH: cn cho SX tinh trng.
+ Cc yu t khc:
- V no, h limbic: h hng SX tt qua Hypothalamus.
- Nhit : t/t c SX / thp h / th 1- .
C Da tos bu o gi theo / mt...
ng dng bo qun t/t / -175oC.
- Tia X, fng x, virut quai b lm t th g TB u dng tinh
- pH, Khng th mu...
- Ru, ma tu lm gim SX t/trng.
2.2- CHC NNG NI TIT CA TINH HON.
Tinh hon tit testosteron v inhibin.
2.2.1- Testosteron
- Ngun gc:
TB Leydig tit
Tit tun th , n sau sinh: ngng.
T tui dy th: tit n ht i.
T androgen v thng thn.
- B/C: l steroid 19C, c nhm OH C17.

- Tc dng ca testosteron:
* Thi k bo thai:
+ Lm bit ho t u g t hng d g di i theo gii tnh nam
+ Lm p/tri quan SD ngoi.
+ KT di chuyn t/hon t bng xung bu.
* T tui dy th:
+ Lm p/tri ua SD to 8-20 ln).

Lm xut hi c tnh SD ph ca nam.


C g FSH d/dng ng s/ tinh v p/trin tt
* T/D ln CH.
. T g t/h p otei , pt h g d g l thu t g ng ho v doping).
. X g: t g t/h khu g g, p/t in v ct ho sn lin hp u g d i,
t g h/ TB to g, t g hiu dy v l g g al i t o g g t g sc
m h g.

- T g CHCS %, tch mui, c.


- T g s lng hng cu (nhiu > n)
- Gy nam ho trn n.
* iu ho bi tit:
Thi k u ca o thai do HCG, t/k t ng thnh do LH.

2.2.2-Inhibin:
Do TB Sertoli tit.
- B/C ho hc: l polypeptid,
TLPT: 25.000 -1000.000.
- T/D: iu ho SX t/t g ua h iu ho gc (-) FSH khi t/t SX qu
nhiu.
3- DY TH V SUY GIM SD NAM:
3.1- Dy th:
L m h du kh g si h sn.
- Tinh hon hot ng bi tit HM v SX tinh trng.
- Xut hi c tnh SDc th pht.
- Tui dy th: 13-16.
3.2- Suy gim sinh dc:
Hot ng SD t tui d th n ht i, song v gi c gim.
1/3 nam gii > 60 tui bt lc SD.

8. SINH L SINH SN N

1- C IM CU TRC, CHC NNG CA BUNG TRNG V T CUNG:


Gm: bung trng, vi trng, t u g, o, m h, tuyn tit nhy v tuyn
v.
1.1- Bung trng:
L tuyn va ngoi tit SX t g i tit (tit HM SD n).
Non cp II ph hia th h o t ng thnh (c 1n NST: 22NST thn v X).
1.2- Nim mc t cung. c 2 lp:
- Lp NM n s t t/ , kh g t/i t o g CKKN. M u i dng t si
hi.
- Lp NM ch g. Th h M hiu si hi.
Lp NM / g tu n bi tit nim dch v b bi i theo CKKN.
Nu th thai, NM ch g s tn ti.
2- CC HORMON BUNG TRNG
2.1- Estrogen:
* Ngun gc:
- Lp o trong ca nang tit na u CKKN. - na sau CKKN do hong th tit.
- Khi c thai, do nhau thai tit.
- V thng thn tit t (t androgen).

* BC ho hc:
Estrogen l Steroid c 18 C, tng hp t cholesterol, c 3 cht chnh:
b-Estradiol, Estrion, Estradiol
* Tc dng:
- Lm X/hin v bo t c tnh SD th pht n.
- Vi t cung:
+ P/trin NM t cung trong CKKN.
+ Ptri t/ khi thai.
+ T g o p t/ khi mang thai.
+ T g lu l g u n t/c.
+ T g hy cm ca t/ i oxytoxin.

t g tit dch nhy, kim, qunh gip tinh trng di chuyn vo t/c.
- Vi tuyn v:
Ptrin ng tuyn, lp m m.
- Vi o: s g ho TB o.
- Vi vi trng: t g hu g, t g h/ TB l g u g t ng di chuyn vo t/c.
- Vi chuyn ho:
+ CH p otid: t g t/h ADN, ARN ,p otei .
+ CH lipid: t g lng m d/d h gc, mng to dng n, gim cholesterol mu
+ CH mui c: n g cao tch Na+
+ CH Ca++ v x g:
. T g hot tnh TB to g.
. T g hp thu Ca++ rut.
. T g ng Ca++ g.
- Vi a : / cao estrogen lm gim p/trin tinh hon v ngng SX t/trng.
* iu ho bi tit:
N/ cao LH k/t bung tr g BT est oge gc li.

. T g p/t v ct ho sn lin hp u g d i h h testoste o .

2.2- Progesteron:
* Ngun gc:
Do hong th Btit na sau CKKN.
Nhau thai v 1 t do v tthn BT.
* B/C ho hc:
L steroid 21 C

* Tc dng:
- Trn t cung:
+ KT NM t/c p/trin na sau CKKN.
+ KT cc tuyn NM t/c p/trin, b.tit dch, glycogen.
+ KT cc mch mu p/trin.
+ C o p t/ td a thai .
- Trn Vi tr g: t g tit dch v cung cp cht d/d cho tr g th tinh.
- T/ : t g si h TB a g pt c t/v.
- C ng trng.
+ T g tho i ho p otei .
+ T g th hit ( na sau CKKN- thn nhit t g , oC
+ N g ao t g gi Na+ g ln xa.
* iu ho bi tit:
Do GnRH, LH v FSH .
3- CHU KZ KINH NGUYT
3.1- N: l s chy mu c chu k NM t/ di t/d ca HM bung trng v tuyn
yn.
CKKN l khong thi gian gia 2 ngy ch u u tin ca 2 chu k k tip (28
ngy).
3.2- C giai on ca CKKN:
* G a g t ha G t g si h :
- Tuyn yn:
Di h hng ca GnRH, T.Y bi tit FSH LH t g dn.
- Hi tng rng trng
* G i tit ha G ho g th t).
- Vo 2 ngy cui g/
Thi gian xoa kinh (mu chy) 3-4 ngy, khong 40ml mu v 35-40ml dch
4- DY TH V MN KINH
4.1- Dy th:
- i h du: KN u tin, #13-14 tui (Nam tinh trng p/t, #15-16 tui).
- Tuyn SD bt u t g h/ kh g si h sn.
- c tnh SD th pht xut hi : , g, phn SD ngoi p/t...
- D con n rng, tuyn v p/t, v n to...
- T g ti t G RH FSH, LH tu n SD hot ng.
4.2- Mn kinh
- L mc chm dt hot ng sinh sn n (45-50 tui).
- Khng cn k/n lm nang trng chn, nang trng thoi ho.
- Lng estrogen, progesteron gi n m s.
- Khng c kinh nguyt.
- Du hiu SD th pht gim, RL thc vt RL vn m h c ho , T l tha
i...
5. QA TRNH TH THAI V MANG THAI
5.1- Th thai:
-Trng (non) vi t cung (tn ti 24-48h). -T/t g f g o o, d/c 3-
4mm/min; ch vi T.tr sng st qua 2-3 ngy.
Trng gp t/t #1/3 ngoi vi trng.
Ch c 1 tt kho nht gp v bm vo trng, tit enzym Hyaluronidase tiu a.
H alu o i . M g t c t/t ho tan, gf cc enzym tiu lp protein quanh trng.
1 T/t chui vo trng v th tinh.
NSTca trng v t/t to b NST hon chnh (2n = 46NST):
nu t/t X phi XX = con gi;
t/t Y phi XY = con trai.
Phi va phn chia, va di chuyn vo t cung (mt 3-4 ngy).

.6Phi d/c xung t cung lm t (vo ngy th 7). Cc t bo l nui hnh thnh
v p.tri , s u o NM t cung.
T o l u i NM t/ u g t g si h ha h au thai g thai.
NM t/c tit dch rt nhiu cht dd, NM n to gi l mng rng.
Thai nhn cht dd qua mu rau thai t cui tun th 8.
Rau thai c CN: v/c cht dd, tit hormon v chuyn cc cht o thi t thai
mu m.
5.3- Cc hormon rau thai:
* HCG (Human chorionic gonadotropin):
do rau thai bt t ngy th 8, cao nht tun 10-12, ri gim dn v ht sau .
+ BC l protein, TLPT: 39.000.
+ T/D ging LH:
- Duy tr v KT hong th tit est. v pro.
- K/t TB Leydig tit testo., p/t SD nam v di chuyn tinh hon xung bu.
LS: - N dng ch o sm c thai
- Na d g iu tr tinh hon n.
* Estrogen:
Hong th: th g u, sau au thai tit, / t g dn, gn s thai gim.
T/D: lm n rng t/c, n to v, pt ng tuyn v, n rng b phn SD ngoi.
* Progesteron:
Hong th: th g u, sau au thai tit, cao gp 10 ln bt, cao nht vo thng
cui.
T/D: - pt NM t/ , u i dng phi.
- gim co bp T/C
- t g tit dch ng dn tr g, u i d g hng trng di chuyn vo T/C.

* c ch LH c ch rng trng.
* HCS (Human chorionic somatomammotropin):
do nhau thai tit, TLPT 38.000.
N/ cao nht t khi .
T/D: - t g tng hp protein
- t g g/p a. o t do t th m.
* Relaxin: do rau thai SX cui tk c thai.
T/D: lm mn c t cung; gin dy chng khp mu, khp cng chu... s thai.
5.4- Nguyn tc ch o sm c thai
Da vo c mt HCG l HM c hiu ca au thai, td h LH, i tit t ngy th 8
- thng th 4, thi qua n.tiu.
C cc nghim php sinh hc v min dch hc:
- Nghim php sinh hc: Gallimainini, Friedman-brouha, Ascheim-Zondek...
- Xt nghim min dch dng Kth khng HCG (nghim php Qiuck stikct).
5.5- Cc bin php trnh thai:
* Dng cho n:
-Thuc tch thai: gm Progesteron (chnh) v estrogen c ch tit LH v FSH
C ng trng.
- t thuc dit tinh trng.
- M g g o.
- Dng c t/c.
* Dng cho nam:
- Xut ti h a go i o, Bao cao su.
* Dng cho c nam v n:
- Tnh ngy rng trng (PP Ogino Knaus).
- h s a , h sn n.
HT
7- SINH L CHUYN D V BI TIT SA
7.1- Sinh l chuyn d:
Do bi i HM hc t cung
- P ogeste o l C o p t/ , est oge l t g o p. T thng th 7
estrogen vn tip t t g, p ogeste o li gim d , do l t g o p
ca t/
- o to i : l t g o p t/c (g g tit cng nhiu)

- Yu t h : t/ gi ti a, u hng co li. Khi thai xung c t/c, gy fx


tit o to i t g o p t/ g s thai.
au l do t/ o p g thiu mu.
au khi s thai l do g t/ , hu hoc t th g g o.
7.2- Bi tit v bi xut sa:
- T khi , est oge , p ogeste o C tit sa. Sau 2 HM ny gim thp.
Prolactin pht huy t/d lm tuyn v tng hp v bi tit sa.
- Mt nm v to fx tit o to i o t a g tu y sa vo ng sa v
sa chy ra.
Thnh phn sa: c, cht bo, lactose, casein, khng th...
5-HOT NG SD N
Bt u t tui dy th, c nhu cu tnh d k/ g si h .
m vt cu to bi th hang, th xp, m LK- hiu hc mu.
Kch thch tnh dc: tm l v ti ch.
Khi giao hp, m vt g, tu n Bertholin tit cht nh l t ...

CHNG . TRIU CHNG HC TIT


NIU

9. PHNG PHP KHM THN TIT NIU

1. Gii phu v ch g si h l a thn.


1.1. Gii phu:
Thn gm hai qu nm pha sau phc mc. Trn phim X quang, cc trn ca thn
t g ng vi t g sn th XI - XII, c di t g ng vi mm ngang
L3 . Nu thn nm ngoi v t t c gi l thn lc ch, c di ca thn
t qu mm ngang L3 l du hiu thn to hoc thn sa.
Th c cu to bi ch g gi l nephron. Hai thn c
khong 2 - 2,4 triu ch g. ch g gm: cu thn v ng
thn
- Cu thn hnh khi cu ng knh 250 mm. Cc trn ca cu thn gm c
tiu ng m h n (afferent arteriole) v tiu ng m h i effe e t a te iole .
K h thc ca ng m h i g / k h th ng m h n. Tiu ng
m h n khi vo cu thn s phn thnh 50 nhnh v to nn m g li mao
mch trong cu thn. Cc mao mch hi t to nn tiu ng m h i. Gia cc
mao mch l t chc gian m h, t o g t bo gian mch. Cun mao mch
cu th c nm trong mt ti gi l khoang Bowmann. Khoang Bowmann cu
to bi hai l: l thnh v l tng. L thnh nm pha ngoi to bi mt lp biu
m dt, l t g c cu to bi cc t bo biu m ca cun mao mch thn.
Khoang Bowmann ngc ngch, len li gia cc cun mch. C di ca cu thn
ni thng vi g ln gn.
- ng thn bao gm: g ln gn, quai Henle, g ln xa, ng gp. g ln
gn, g ln xa nm vng v thn, quai Henle v ng gp nm vng ty.
1.2. Ch g si h l a thn:
- To c tiu: lng dch lc vo ng thn khong 170 lt. ng thn hp thu
g h ton b s lng dch lc vo ng thn, ch o thi mt l g c va
ho tan nhng cht cn b, trung bnh l 800 - 1500ml/24 gi.
- iu ho kim-toan: hp thu carbonat g ln g , o thi ion H+ ng
l a, t g lc cc axit hu ca cu thn, duy tr pH mu trong khong 7,35 -
7,45. Nhim toan xut hin khi suy thn cp tnh v suy thn mt b. Nhim toan
do bnh l g ln gn hoc g l a kh g li ua n suy thn. Phn ln
nhim toan ng thn l do d tt bm sinh di truyn ca ng thn.
- iu ho huyt p: Thn tit renin hot ho h thng RAA, c ch h gin
mch bradykinin. Khi suy thn, thiu mu th , e i t g thng xuyn gy co
mch, gi mui d t g hu t p thng xuyn.
- Tham gia vo qu trnh to mu: Thn tit erythropoietin, l mt hormon
kch thch bit ho tin nguyn hng cu tr thnh hng cu t ng thnh. Khi
suy thn mn tnh s xut hin thiu mu do thiu erythropoietin.
- Tha gia iu ho chuyn ho canxi: Thn tng hp 1,25 dihydroxy
cholecanxi (1,25 dihydroxy vitamin D3). 1,25 dihydroxy vitamin D3 c tc dng kch
thch t bo rut non tng hp mt loi protein c tc dng vn chuyn canxi ion
ho. Khi suy thn, 1,25 dihydroxy vitamin D3 gim d n gi a i u, ng
cn gip th ph t, tha g, hu g.
2. Khm bnh thn-tit niu.
2.1. Triu ch g to th li ua n bnh thn-tit niu:
2.1.1. Thiu mu:
Biu hin da xanh, nim mc nht, gan bn tay v lng bn chn trng nht
nht, da kh, nga, nhiu vt c do gi. S lng hng cu v huyt sc t
gim. Thiu mu trong bnh thn do hai nguyn nhn ch yu:
- Bnh ko di trong nhiu , ung king qu mc, mt nhiu protein qua
c tiu.
- Thiu mu do suy thn mn tnh: thiu mu nng hng cu di 2,0 1012/l,
huyt sc t trong khong 50-70g/l. Ngoi triu chng thiu mu, cc triu chng
thng gp: t g hu t p, ri lon tiu ho: bu , , y bng. Trn bnh
nhn b bnh thn xut hi t g hu t p v thiu mu phi gh n suy thn
giai on mt b.
2.1.2. Ph:
Ph l triu chng rt thng gp trong bnh cu thn. Ph mm, ph trng n
lm, khi ph t t ngt kh g gu u h g t g dn. Ph hai
h : t g h , ua h t c, n mu bn chn, n vng cng ct di
da u. Trn dch bng (c t ng), trn dch mng phi, trn dch mng tinh
hon. Khng c du hiu ca su ti : i kh g t , t h ch c khng ni,
nhp tim v u, khng c ting thi tm thu mm tim; gan khng to, c
t ng khng c tun hon bng h, ch g ga h thng.
2.1.3. Tun hon:
- T g hu t p: trn 90% suy thn mn tnh mt t g hu t p v khong
20 - % t g hu t p kch pht gy hen tim, ph phi e do tnh mng ca
b h h , gu t qy no, xut huyt vng mc.
- Suy tim: suy tim mn tnh gy kh th khi gng sc, kh th khi nm, nhp tim
ha h, ga to, t h ch c ni, phn hi gan-t h ch c d g t h. Su ti
cp tnh xut hin b h h tng huyt p kch pht: kh th d di, tot m
hi tm ti, phi c nhiu ran (ran ngy, ran rt, ran m, ran n . Su ti thng
gp trong suy th t h do t g hu t p, t g gi mui c, thiu mu,
vim mng ngoi tim.
- Vim mng ngoi tim :
Biu hin lm sng ca i g go i ti l au g t c tim, kh th
m nh, c ting c mng tim. Vim mng ngoi tim l du hiu xu ca suy
th giai on cui. Nu khng chy thn nhn to th bnh nhn s t vong.
2.1.4. Tn th g t:
T th g t do t g hu t p v mt phn do nhi c ur. Da
trn kt qu ca soi t, gi ta chia t th g g t c 4
giai on:
- Giai on 1: Co tht h thng mch mu vng m , t g t g lc mch cc
mch mu lan to. Cc tiu ng mch vng m l h th g t h ch, cc
t h h i g ng mch gin to: du hiu Salus-Gunn (+).
- Giai on 2: Ngoi cc du hiu ca giai on 1, xut hin ho kh g ng
u h thng tiu ng mch vng mc.
- Giai on 3: Vng m t ph n xut tit v xut huyt.
- Giai on 4: T th g h giai on 3 km theo ph n gai th.
3. Khm thn v niu qun.
3.1. Nhn:
- Bnh nhn ngi ngay ngn v quay v pha thy thuc. Thy thuc quan st
hai h l g so snh. Nu thn to mt bn, h tht l g thn to s vng
h so i i din, thn to s di ng theo nhp th. Ngoi du hiu thn to,
ta c th thy cc du hiu bt thng khc: da vng h tht l g t , ph n
do vim ty quanh thn (p xe quanh thn) hoc ph n do tnh tr g d c
tiu bnh nhn phu thut ly si nhiu ln.
- Bnh nhn nm nga: h hi o hoc dui thng, thy thuc quan st vng
h s hai pht hin thn to. Vng h sn bn thn to s v g ao h
so vi i din. Th to thng gp trong thn c, m do si niu
qun, u thn. Pht hin c t ng: bng to b, rn li; c t ng t do khng c
tun hon bng h.
Nhn c th pht hin cu bng quang: khi bt thng vng cao so vi bnh
thng vng h v ga t g u, i khi t to d nhm vi khi u trong
bng. Ch o hc chn cu bng quang b g siu th g i.
3.2. S thn:
T th: bnh nhn nm nga, chn ch g, i hi gp vo b g l h g
bng, bng mm. Nh g t ng hp thn to s s thy d dng. Th a a g
bm sinh: hai thn to, mt g g. Thn to mt bn: thn c, m, u thn.
Tuy nhin, nhiu t ng hp vn nhm gia thn to vi u trong bng, bn tri
d nhm vi lch to, bn phi d nhm vi ga to. nh chc ch , gi
ta phi lm nghim php chm thn v nghim php bp bnh thn.
+ Nghim php chm thn:
Bnh nhn nm nga, hai ta l u, bc l ton b vng b g. Ngi thy
thuc ngi cnh bnh nhn, bn tri hoc bn phi t theo iu ki i kh
bnh. Nu thy thuc ngi bn phi th khm thn phi t c, thn tri khm sau
h g kh g tha i v tr ca thy thu . Th g thng, thy thuc ngi
bn phi, hng dn bnh nhn cch th bng bng, bnh nhn nm quay mt
i din.
- Nghim php chm thn phi:
Bn tay phi ca thy thu t vo h tht l g, ta t i t vo vng mng
sn tri. Bo bnh nhn th u. Tay phi vng h tht l g gi yn, tay tri
pha trn v dng lc cc ngn tay tri n mnh v dt khot thi k th vo
(thn sa xung thp h t o g th th vo). Nu thn to s chm vo lng bn tay
phi ph a di gi l nghim php chm thn (+), cn phi thao tc nhiu l
t h d g t h gi.
- Nghim php chm thn tri:
T th bnh nhn v thy thu t g t h t o g ph g ph p hm phi,
h g khi l ghin php chm th t i, ta t i t h tht l g t i, ta
phi t pha trn (vng h sn tri). Thao tc chm thn tri gi g h thao
tc chm thn phi.
+ Nghim php bp bnh thn:
T th b h h t th thy thuc gi g h t th ca bnh nhn v
thy thuc trong thao tc nghim php chm thn. Trong nghim php bp bnh
th , ta t vng h sn phi gi gu , ta t vng h tht l g
dng l u cc ngn tay ht mnh vo h tht l g. Nu thn to, thn s chm
ol g ta t vng h sn gi l bp bnh thn (+).
Chm thn (+) v bp bnh thn (+) l du hiu ca hi chng thn to: thn to
do th a a g, hm thn v bp bnh thn (+) c hai bn, thn c, m.
C nh thn to b g ph g ph p siu , hp th thng, thn thuc
v CT (chp ct lp in ton) .
3.3. G thn:
- T th bnh nhn nm nga, ngay ngn, bc l ton b thnh bng.
- T th thy thuc: ngi cnh bnh nhn (bn phi hoc bn tri).
- Thao tc: tay tri ca thy thu t song song vi kho g gia sn t V -
VI, dng ngn tr bn tay phi g ln ngn gia bn tay tri. Tin hnh g lin tc
t g gia sn V - VI xung vng h chu. Nu thn to th g vang v pha
t c thn l cc tng rng (rut non, rut gi); nu u trong bng hoc gan, lch
to th g s c lin tc t trn xung.
3.4. Rung thn:
Ngi thy thuc ngi pha sau bnh nhn, bnh nhn ngi ph a t c quay
l g pha thy thuc. Bn tay tri ca thy thu t ln vng h tht l g
bnh nhn, tay phi m nh ln mu bn tay tri, nu b h h ku au th gi
l rung thn (+). Rung th + thng gp:
- Si niu qun: khi lm nghim php rung thn b h h ku au do di
chuyn ca hn si v c th i u i th ho i u i th. Khi ha
chp X quang, nghim php rung th c s d g ch o si thn. Sau
khi lm nghim php rung thn nu i u i th hoc vi th phi gh n si
thn.
- Vim b thn-th : au l g, st, bch cu niu, protein niu.
- p xe quanh thn, vim ty quanh thn.
- Thn c, m.
. . Kh im niu qun:
- im niu qun trn :
K ng ngang rn vung gc vi ng trng gia. im giao nhau gia b
ngoi ca th g to ng ngang r l im niu qun trn. Thy thu t
bn tay phi ln thnh bng, dng ngn tr o im niu qun, quan st tnh
trng bnh nhn. Nu au nh nhn s gt tay thy thuc ho h t ku
au gi ta thng gi im niu qun trn bn phi hoc bn tri hoc c
hai bn (+).
- im niu qun gia:
X h im niu qun gia: k ng ni hai gai chu t , im tip ni
gia 1/3 ngoi v 2/3 trong ca ng lin gai chu t t l im niu qun
gia. Thao t kh im niu qun gia t g t h thao t kh im niu
qun trn.
. . im s l g:
Ch gp nhau ca b di g sn XII v b ngoi khi l g c gi
l i s l g. Khi d g g ta gia o i s l g nh nhn
ku au th gi ta gi i s l g + . i s l g + gp trong vim
ty cp tnh.
4. Khm bng quang.
T th bnh nhn nm nga, thy thuc ngi ho ng cnh bnh nhn, ln
lt tin hnh cc thao tc sau:
- Nhn: B h thng, bng quang nm trong khung chu ph a sau g u
ch nhn thy khi bng quang to. Bng quang to s t ao h g u. Qua
s t ph a t g u ta thy mt khi trn vng ln. Nu bng quang to do b
i gi ta gi l u g ua g . Nhiu t ng hp bng quang rt to t g
t h khi u vng h v.
- S: S pha trn gai mu nu bng quang to ta c th s thy d dng. Bng
quang to do c tiu, bnh nhn c c gi au tc rt kh chu, bnh nhn
rt s khm, nht l nh g t ng hp i p tnh do u tin lit tuyn. Ngoi
g ua g to do i, g ua g to th do u bng quang, ph n thng
gp u t cung, thai thng th 3 tr i.
- G: G gi p h g ta nh ranh gii khi u, k h thc ca khi u. xc
nh cu g ua g do i ha khi u vng khung chu , gi ta tin
h h th g i, siu m: siu m bng quang, t cung, tin lit tuyn, bung
trng. Nguyn nhn ca cu bng quang: u tin lit tuy , t qy no, u ty,
vim ty, thot v a m.

10.TRIU CHNG HC THN-TIT NIU

TS. H Hong Kim

1. TRIU CHNG LM SNG

1.1. Triu ch g g:
. . . au:
C th gp au vng tht l g, au vng niu qu , au vng bng quang.

. . . . au vng tht lng:

* C au un thn:

+ C au u th l au in hnh trong mt s bnh ca th ng


niu, au c im:

. Khi ph t au: thng xut hin sau v ng mnh, sau ch th g g tht


l g, tu hi g th xut hin c lc ngh gi.

. C g au: au thng d di thnh t g , th ngn 20-30pht


c th ko di nhiu gi hoc c ngy. Khng t th gi au.

. V t hng lan ca au: au thng xut pht vng tht l g, la a ph a


t c xung vng bng quang, xung bu ( nam) hoc b phn sinh dc ngoi (
n . Th g thng ch au t , t o g au th c bun nn hoc nn.
i sn-tht l g h tht l g nh nhn rt au.

. Din bin ca au: au thng kt thc t t, h g g khi kt


th t ngt. Sau au th g i a u i th hay vi th, c th c ri
lon tiu ti h: i kh , i t, i ut. C au u th thng hay ti
pht.

Trn l au in hnh, trong lm sng c nhng th kh g in hnh, ch


au tho g ua ho gc li au k o t di t mt g n 2-3 ngy.

+ Ch o au un thn da o: au t ngt d di vng tht l g la


xung bu v b phn sinh d go i; i a u i th hoc vi th; im
au g th v niu qun; tin s c th h g au un thn hoc
i a si.

+ Ch o ph bit: ch o au u th i h h thng d
h g g n ch o ph bit vi t ng hp:

- bn phi hay nhm vi:


. C au u ga : au vng h sn phi la l ai, sau au st, vng
da; khm vng gan v ti mt au, du hiu Murphy (+).

. au rut tha: au g h chu phi, c st, c bch cu t o g u t g,


n im

Ma u e au.

- bn tri hay nhm vi:

. C au tht ng : au tht ng kh g in hnh khng lan ln vai v


cnh tay m lan xung b g; i ti t o g h h nh thiu u ti ;
cho ng it ogl e i th au ht nhanh.

- Chung cho c hai bn c th nhm vi:

. C au do lo t d dy, thng d d : au g thng v khng lan xung


di, c th la a sau l g, i thng v au. Nu thng d dy th c
phn ng thnh bng, bng c g h g, g a g g t c gan. Tin s c th
c hi chng lot d dy- hnh t trng; chp X quang bng thy c li hi.

. Vim tu chy mu, hoi t: au t d di g thng v, bu , ; im


thng v im sn-ct s g au; gi bnh trong tnh trng sc: v m
hi, mt ti, huyt p h; n g a laza t o g u t g t cao.

. Tc rut: au ng, nn, b trung ti , i tin, b g h g hi, t iu


chng rn b, X quang c m c-mc hi.

+ C h ca au un thn: t ng d c tiu t ngt do si di


chuyn, hoc do si kch thch gy co tht niu qun, lm c tiu i-b
th , g t g p l t o g th th c bao bc mt v . Khi ng
dn c tiu lu thng (chng hn si di chuy l c tiu c th lt qua
c, p lc trong b thn gim xu g , au gim hoc ht.

+ Nguyn nhn: chn o gu h au u th i khi kh,


cc gu h thng gp l:
. Si thn ng niu: si i-b thn t khi g au un thn; si niu
qu th g g au u th i h h. l gu h thng gp
nht ca au un thn.

. Lao thn: c ti % t ng hp lao th au un thn do cc mnh t


chc, t ch u t i theo d g c tiu xung gy tc niu qu . C g
th do lao niu qun gy cht hp niu qun,

. Cc nguyn nhn gy hp niu qu kh h: th di ng d dng gy gp


niu qun, u vng b thn-niu qun, u trong b g p o iu qu u c
th g a au un thn.

* au vng h tht l g:

au g h tht l g , khng th h hoc ch c cm gic nng tc vng


h tht l g. Loi au th g l im ca cc b h th hai h
vim cu thn cp, vim cu thn mn, hi ch g th h, i ty t chc
quanh thn. Vim thn-b thn cp ho t tin trin ca vim thn-b thn
m thng ch au mt , h g g th au hai bn. au
thng khng lan xuyn, ch khu tr ti ch.

Nu vim m quanh th th au th k theo g, , ph n vng h tht


l g.

. . . . au im niu qun:

Ngo i gu h do au u th , au im niu qun cn c th


gp khi c si niu qun, vim niu qun, lao niu qun thng lin quan vi
cc qu trnh bnh l thn v bng quang.

. . . . au vng bng quang:

au g g ua g thng gp do si bng quang, vim bng quang, lao


bng quang, bnh l ca tuyn tin lit. au g g ua g thng km theo
cc ri lon bi niu: i rt, i ut.

. . . . au do t o gc nc tiu bng quang-niu qun:


l th au c bit, thng gp tr em do suy yu tht ch niu qu
o g ua g, thng l b si h. Ngi bnh th au g h tht l g t
hoc hai bn khi rn i, au t i khi i o g.

C h ca au ny l do: khi r i, p l t o g g ua g t g l do
g h niu qu vo bng quang yu, c tiu t bng quang tro
gc ln niu qu , l t g

p lc b th g au. au thng nh, m , bnh nhn chu ng c,


h g i khi au hiu lm bnh nhn khng dm r i. i xong p lc
trong bng quang gim xu g, c tiu t niu qun xung bng quang, bnh
nhn ht au.

nh ch o , ho hp X quang bng quang sau khi thuc cn


quang vo bng quang (150-200ml) cc thi i t c, trong v sau khi rn
i. Kt qu s cho thy thuc cn quang tro ln niu qun khi r i.

1.1.2. Ri lon bi niu

+ i dt:

i dt l hi tng phi i i hiu ln trong ngy, s l g c tiu mi


ln t ch i ilil t. i dt c th do bnh l bng quang, tin lit tuyn, niu
o, niu qun hoc th g k h th h t i; g th ch l hu qu ca
cc bnh l ca ua l n ca ua si h dc n.

+ i ut:

i ut l hi tng khi i i ti cui bi, bnh nhn thy but vng h v


la a d g t ( nam) hoc b phn sinh dc ngoi ( n . i ut th g i
km vi i t. Nguyn nhn c th do vim bng quang, lao bng quang, vim
niu o do vi khun hoc do lu, si bng quang.

+ i kh :
i kh l hi tng phi rn mi i , c tiu chy chm khng thnh
tia, khi i gt u g. i kh hng t c cn tr vng c g ua g h:
u vng c bng quang, u tuyn tin lit; hoc cn tr niu o h: si niu
o, cht hp niu o do vim, do ch th g.

+ B i:

B i l t ng hp kh g i t o g khi c tiu v c bi tit t thn


xung v b li bng quang. Phi ch phn bit vi v niu: v niu l
khng c tiu t thn xu g g ua g, kh g c tiu trong bng
quang nn khng c cu bng quang v thng i kh g

c tiu; cn b i l c tiu b bng quang nn c cu bng quang,


thng i hiu c tiu v cu bng quang xp xung.

+ i kh g t ch:

i kh g t ch l hi t g c tiu t ng chy ra, ngoi mun ca bnh


h . i kh g t ch c th do nguyn nhn ti bng quang hay niu
o h chn th g vng bng quang hay niu o); c th do nguyn nhn
t tu s g h h th g hoc vt th g g t th g t tu cng);
g th do bnh nhn b i k o d i l th h g ua g kh g kh
g od , g ua g t thnh mt h ha c tiu t o g khi c
tiu tip tc

c bi tit t thn xu g, do c tiu t bng quang chy ra theo niu o


tng git v lun c cu bng quang.

+ i :

i c coi l bnh l khi bnh nhn phi i i hiu l t o g k o


di nhiu th g. i l biu hin ca gim kh g c tiu ca
thn. Khi lm nghim php Zimniski thy s l g c tiu a hiu h
ban ngy.
i thng gp trong cc bnh gy gim kh g c tiu ca thn
h i th -b thn mn, vim thn k mn do thuc, suy thn mn...), hoc
gi gi do kh g

c tiu ca thn b suy gim.

1.2. Triu chng thc th

1.2.1. Ph do thn:

Ph l triu chng s thng gp ca cc bnh cu th . Ph do th c


im l xut hi u tin mi mt (v mi mt c nhiu t chc lng lo, p lc
trong t chc thp), mt ri mi ph ton thn. Ph n g h o ui sng, ph
trng, mm, l , t g l khi n v gi khi ht.

Tu theo tng bnh thn, ph c th c nhng biu hin khc nhau. Vim cu
thn cp hoc m th ph thng m trung bnh. Trong hi chng
thn h th ph tin trin nhanh v nng, c th c trn dch mng bng, mng
phi, mng tinh hon, mng tim. Bnh ca ng-k th thng khng c ph, ph
ch xut hin khi c suy thn nng ho su ti do t g hu t p.

1.2.2. Thn to

+ Ch o th to khi khi u vng thn, du hiu chm tht l g d g


tnh, bp b h th d g t h. Th to thng km theo cc triu chng khc
h: i a u, i a , au g h tht l g.

+ ch o nh thn to cn lm cc xt nghim c l s g h: siu


m thn, chp hi sau ph c, chp thn c tim thuc cn quang vo
t h ch (UIV), chp b th thuc c ua g gc dng, chp CT-
scanner, chp MRI.

+ Nguyn nhn thn to c th do:


- c, m b thn: nguyn nhn ca c, m b thn c th do si i-
b thn, si niu qun, khi u ca niu qun hay u trong b g p o iu
qun, lao b thn-niu qun gy cht hp niu qun.

- Thn nang: c th a g t bn hoc c hai bn, c th th a a g, nh


nang tu thn... S thy b mt thn ln nhn khng u. Siu l ph g
php rt c gi tr ch o nh thn c nang.

- U g th th : thng gp gi gi; thn to, c g, thng k theo i a


mu.

. . . Thay i s l g c tiu

gi l h thng, khi u g l g c trung bnh theo nhu cu ca


th th s l g c tiu trung bnh mt ngy khong 800- l. Tha i s
l g c tiu tu theo m h sau:

+ V niu:

- Khi s l g c tiu < 100ml/24gi th c gi l v niu. Ch c v niu


bnh l, khng c v niu sinh l. V niu l trng thi bnh l rt nng, gy ra
nhiu ri lon ni i e do tnh mng bnh nhn.

- Nguyn nhn: c th gp v niu do suy thn cp, t tin trin ca suy thn
m , giai on cui ca suy thn mn.

+ i t thiu niu):

Khi s l g c tiu t n < 500ml/24gi th c gi l i t. i t c


th do sinh l hay do cc bnh l ngoi thn hoc cc bnh l ca th . Ngi ta
hia i t a l hai loi:

- i t, c tiu c n g cc cht ho ta ao: c tiu thng xm mu; t


tr g c tiu ao t , ; thm thu c tiu cao trn 600mOsm/kg
H2O; n g u t o g c tiu cao. Nguyn nhn thng do u g t c, do
tnh trng mt c ca th, do suy thn ch g...

- i t, c tiu c n g cc cht ho tan thp: c tiu thng nht


mu; t tr g c tiu thp; thm thu c tiu thp; n g ur trong
c tiu thp. Ngu h thng do suy thn cp thc th hay suy thn mn.

+ i hiu a iu):

Khi l g c tiu l h l/ gi th c gi l i hiu.

Nguyn nhn ca i hiu thng l do ung qu nhiu ; giai on hi phc


ca mt s bnh nhim tr g h i ga i ut p); l triu chng ca mt s
bnh ni tit h i th o ht, i th o ng); do mt s bnh thn c gim
kh g c tiu ca th h: giai

on i t li ca suy thn cp), cc bnh ca ng-k th h i thn-b


thn mn); mt s bnh nhn suy thn mn...

. . . Thay i mu s c tiu

1.2.4.1. Nc tiu u n nu thm:

* i a u i th:

- i a u i th l i a u i s lng nhiu, l tha i mu sc


c tiu. Nc tiu c mu h g ho u , khi lu th hng cu s
lng xu g di. Lng mu ti thiu bt u l tha i mu s c tiu vo
kho g l u ho l t c tiu.

+ ch o tr chy mu c th nh h s bng nghim php 3 cc.

Cch lm nghim php 3 c h sau: ho h h i t bi chia lm 3 phn


t g i bng nhau, l lt vo 3 cc thu tinh. Nu lng mu nhiu nht
c u ti th thng l chy mu niu o. Lng mu nhiu nht cc th
th thng l chy mu b g ua g. L g u t g g hau c 3
c th thng chy mu t thn hoc niu qun. Tuy nhin, nghim php ny ch
c tnh cht t g i, v nu chy mu nhiu bng quang hay niu o u c
th gy i a u to i, 3 c u t g g hau.

+ Mu nh chnh xc v tr chy mu, c th soi bng quang trong thi gian


bnh nhn

i a u. Khi soi g ua g th th u a g hy t thnh bng quang,


hoc th d g c tiu u pht t g t t l niu qun xung bng
quang theo nhp co bp ca niu qun.

+ Ngu h i a u th do cc bnh ca th h i u thn cp,


b h th IgA, u g th th , h th g th ; th do bnh ca ng niu
h si i thn, si niu qun, si bng quang, vim b g ua g, u g th
bng quang...); c th do cc b h to th h nh ca h thng to mu, do
ri lo u t h g u . C th gp (khong 1% s b h h i a u
khng h c nguyn nhn.

* Cn phi ch o ph bit i a u i i a he oglo i , i a


oglo i i a po ph i .

+ i a he oglo i :

- i a he oglo i gi l i a hu t cu t. Nc tiu u hoc xm


e , khi lu hoc ly tm khng c lng cn hng cu. Soi di knh hin vi
khng c hng cu t o g c tiu.

- i a he oglo i kh g phi do bnh l ti thn do ta u. B h thng


ch c 1-4mg

hemoglobin/100ml huyt thanh, trong c tiu khng c hemoglobin.


Khi c tan mu cp, hemoglobin t hng cu gii phng vo huyt t g i s
lng ln, gan khng chuyn ho kp th h ili u i , o thi nguyn
d g a c tiu.

- Ngu h i a he oglo i :

. St rt c tnh i a hu t cu t thng do Plasmodium falciparum).


. Nhim khu thng do Clostridium perfringens).

. Nhi c ho cht h ase i , c cc loi rn, mt s thu h


amphotericin...).

. Truyn nhm nhm mu gy tan mu cp.

. i a he oglo i kch pht do lnh (him gp): sau nhim lnh, bnh nhn thy
rt run,

au g, au g tht l g, au p i a he oglo i .

. i a he oglo i k h ph t a : gp bnh nhn c hi chng


Marchiafara-Micheli vi biu hin t g t i a he oglo i kch pht ban
, thng gp tui 30-40.

. i a he oglo i do ng: v ng bt th g k o d i h hy xa
gi ha ue lu n tp. Sau luyn tp th i a he oglo i ; hng cu trong
mu c hnh th h thng.

. i a he oglo i do thuc c th gp gi thiu men G6PD.

+ i a oglo i :

Gi g h i a he oglo i , c tiu u hoc x e , khi lu hoc


ly tm khng c lng cn hng cu. Soi di knh hin vi khng c hng cu trong
c tiu.

Myoglobin l sn phm thoi bin ca . i a oglo i y ra khi dp t


nhiu h t o g hi chng vi lp). i a oglo i gu ph t, m si h i
khi c tnh cht gia h. Bnh nhn th au , p otei iu t, c hng cu
niu, c myoglobin niu, c th c v niu.

+ i a po ph i :

- L u c tiu u xm gi g h i a u, h g sau vi gi c
tiu xm li do b o ho . Khi lu hoc quay ly tm, khng thy c lng cn
hng cu. Xt nghi c tiu c porphyrin.
- Po ph i c to a t o g th ch yu do tng hp t glucocol v
axt sucinic, mt phn

c to ra do phn hu hemoglobin v oglo i . Po ph i o


thi ua c tiu di d g po ph i oge , sau ho to
thnh po ph i . B h thng gi ln mi ngy

o thi khong 75 mg porphyrin, vi s lng ny khng l tha i mu


s c tiu.

- Chng porphyrin niu c nh g t cp tnh tr thnh mt cp cu, v c th


gy t vong do lit h hp. Biu hi l s gl au ng cp, lit vn
ng, i khi lit h hp xut hi sau au ng vi ba ngy. Chng
porphyrin niu l biu hin ca mt s bnh gia truyn v ri lon chuyn ho lm
sn xut ra nhiu porphyrin v cc cht tin thn ca po ph i t o g

th.

- C h bnh l do thiu mt trong cc enzym (c khong 8 enzym) tham gia vo


tng hp Hem trong qu trnh to hng cu. Thiu mt trong cc enzym ny s
gy ra mt trong 3 chng porphyrin sau: chng porphyrin gan, chng porphyrin
do ri lon to hng cu, chng porphyrin phi hp.

1.2.4.2. Nc tiu u c:

+ i a :

- Nu m nhiu c th nhn thy bng mt th g, c tiu u c bn, c


nhiu si m,

lu m lng xung thnh mt lp di. Nu m t th c tiu c trng, c


cc dy m ln vn. Xt nghi c tiu thy c nhiu t bo m l cc
bch cu a h tho i ho .

- phn bit vi i c do c phosphat, ho o c tiu vi git axt acetic


ho e u s i c tiu. Nu i a th c tiu vn gi nguyn mu
c, nu i a n phosphat th c phosphat ta c tiu tr nn trong.
- Nguyn nhn: do nhim khun thn ho ng niu, c th chia thnh hai
nhm:

. Nhim khun thn v b thn: vim m b th , lao th , th a a g bi


nhi , u g th th bi nhim.

. Nhim khu ng niu: vim niu o do lu hoc do cc vi khun khc, vim


hoc p xe tin lit tuyn, vim bng quang.

Nu s lng m t o g c tiu t th khng l c tiu, ch pht


hi khi soi di knh hin vi gi l i a vi th. pht hi i a
vi th, tt nht l lm xt nghi Addis.

+ i a phosphat:

- Nc tiu c, nu lu th cn phosphat lng xung. Nh vi git axt acetic


o th c tiu tr nn trong. Nu c tiu v c th c th l i a , i
a dng chp hoc cc mui kh h o alat ha u at . X t ghi c tiu
thy c nhiu cn phosphat.

- Nguyn nhn: st ao k o d i, sau g thng v th ki h, sau ng kinh,


su hc thn

kinh. Nu i a phosphat k o d i thng do ri lon chuyn ho.

- B h th g th bi tit kho g g phosphat/ l t c tiu, nu trn


g/l t c tiu l i a phosphat. Nu i a phosphat k o d i th dn
n si ng niu.

+ i a dng chp:

- Nc tiu h sa ho h c vo go, nu k theo i a u th


c tiu u ho olat. Khi l u th c tiu s to thnh 3 lp: lp trn
g h thch, lp gia c mu trng sa, lp cui l cn (gm nhng ht m,
t bo biu m, bch cu). Khi nh ethe o th dng chp ta l c tiu
trong li. Xt nghim sinh ho thy c nhiu lipit, mt phn protein v fibrin.
- Nc tiu h th g kh g dng chp, ch i a dng chp khi c mt
l d t bch mch o ng niu, thng l vo g i-b thn, t khi
niu qun hay bng quang. C th thy ng thng gia bch mch vi
ng niu bng cch chp X quang h bch mch, hoc chp b th
thuc c ua g gc dng.

- Nguyn nhn: c th do giun ch W. a ofti, h g thc t him khi tm thy


u trng giun ch gi i a dng chp. C th do giu a, s
Echinococcose, do vim nhim, do khi u g h p l t g p lc h bch
mch, do ch th g.

- i a dng chp c th xut hin sau mt gng sc m h, h g g th


t pht khng lin quan vi v g. Sau khi i gi, nht l cc ba
nhiu m s th c tiu t g l do l g dng chp t o g c tiu
t g.

- i a dng chp ni chung l lnh tnh, t h h g n sc kho. Bnh c


th ko di vi thng ri t mt i t h t ngt.

2. CN LM SNG CHN ON

Biu hin lm sng ca nhiu bnh thuc h thng thn-tit niu thng ngho
nn v khng

c hiu. Cc xt nghim cn lm sng gip ch rt nhiu cho ch o , t o g


nhiu t ng hp cc xt nghim c gi tr ch o nh. Cc xt nghim
ch o nh thuc h thng thn- tit niu c rt nhiu. Trong phm vi bi
ny chng ti ch trnh t ghi th g thng

c s dng trong lm sng.


2.1. Phn tch thnh phn sinh ho ca mu:

2.1.1. Ur :

- Ur l mt it phi p otei t o g u, ph t lng 60,1; l sn phm ca


chuyn ho

c o thi ch yu qua thn. N g ur mu h thng l 1,7-


8,3 mmol/l (10-

50mg/l). Khi c suy thn (mc lc cu thn <60ml/ph) th n g ur trong mu


t g.

- M t g u t o g u kh g ho to t g ng vi m nng ca
suy thn, v c nhiu yu t ngoi thn h hng ti n g ur trong mu
h: h hiu protein, st, c m t o g th, ch u ng tiu
ho...).

- B th u u t , h g u i di ho it phi p otei t ong mu


khc rt c vi th h: hp cht ca guanidin, cc cht c phn t lng
trung bnh... Cc cht ny b

ng trong mu t g so g so g i ur mu bnh nhn suy thn mn. V ur


d h l g, t o g l s g, h lng ur trong u th g c s
d g h gi theo d i suy thn.

2.1.2. Creatinin:

- C eati i g l t it phi p otei t o g u, l sn phm thoi bin ca


eati ; eati i kh g c, c n g nh trong mu o thi qua
thn. N g h thng trong

mu ca creatinin l 44-106mol/l (0,5-1,5mg/dl).

- N g creatinin trong mu khng ph thuc vo ch tha i


sinh l khc m ch ph thuc vo khi l g a th (khi l g a
mt c th rt t tha i t ngy ny qua ngy khc). Khi c suy thn th creatinin
t o g u t g. M t g eati i t o g u t g ng vi m nng
ca suy thn. V vy, n g creatinin trong mu phn nh ch g th tt
h g ur mu.

2.1.3. Protein:

- B h thng, n g protein ton phn trong huyt thanh l 60-80g/l; trong


al u i -

55g/l, globulin 25-35g/l , t l albumin/globulin (A/G) l 1,3-1,8.

- Trong cc bnh thn mn tnh th protein trong mu gim do: mt ua c


tiu; ri lon tng hp protein; ch hn ch p otei . c bit l trong hi
ch g th h, p otei u gim thp

<60g/l, albumin mu gim <30g/l, t l A/G <1.

2.1.4. Lipit:

Trong cc bnh cu th thng th lipit u t g, c bit l trong hi chng


thn h th

lipit u t g t cao.

. . . in gii:

+ Natri: trong cc bnh thn th n g at i t o g u thng gi , c bit


trong cc bnh ng-k thn mn tnh.

+ Kali: khi i t, ht l khi c v niu th kali mu c th t g. C u t lm


t g ha h g kali mu l: nhim toan, chy mu tiu ho, cc tnh trng
hu hoi t bo nhiu h m t o g th), ch hiu kali... Khi kali
u t g ao t , ol/l th th gy ngng tim v l mt trong nhng
nguyn nhn gy t vong bnh nhn v niu.

2.2. Phn tch nc tiu:

2.2.1. Tnh cht vt l ca nc tiu:


+ Th t h c tiu:

- i hiu a iu): khi s l g c tiu >2000ml/24gi.

- i t thiu niu): khi s l g c tiu 100-500ml/24gi.

- V niu: khi s l g c tiu <100ml/24gi.

+ Mu s c tiu:

- Nc tiu c: i a ; i a n phosphat, c u at, i a dng chp.

- Nc tiu u nht n nu th : i a u.

- Nc tiu c mu nu n nu: i a he oglo i ; i a oglo i ; i a


porphyrin.

+ pH c tiu:

Phi xt nghi c tiu ti c tiu ga sau khi i tiu . pH c tiu c


th tha i t

4,6-8, trung bnh l . l u, c tiu c phn ng kim v ur phn hu gii


phng ra amoniac.

- Nc tiu c phn ng axt ko di c th do: lao thn, st ko di, nhim axt


chuyn ho, a chy n g, i , hi eto do i th o g, t g ur mu
v mt s t ng hp nhi c.

- Nc tiu c phn ng kim ko di c th do: nhim khun sinh dc-tit niu,


nhim kim chuyn ho, dng nhiu bicacbonat hoc cc cht kim khc, kim h
hp do t g th g kh .

+ T tr g thm thu c tiu:

- T tr g c tiu l t s gia tr g lng ca mt th t h c tiu trn trng


lng ca cng mt th t h c ct. Nh y, t tr g c tiu ph thuc vo
tr g lng ca cc cht ho ta t o g c tiu. T tr g c tiu phn nh
kh g c tiu ca th . B h th g, c tiu c t trng 1,015-
, . Nc tiu long ti a t tr g , ; c tiu c ti a t
trng

1,030.

- thm thu c tiu l i lng phn nh s cu t cht ta t o g c


tiu, cc cu t ny l cc phn t, nguyn t, io . thm thu c tiu
khng ph thuc vo tr g lng ca cc cht ho ta t o g c tiu, do
phn nh kh g c tiu ca thn tt h l t tr g c tiu. Bnh
th g, c tiu thm thu t 400- Os /kg H O. Nc tiu long
nht c thm thu 40-50mOsm/kg H2O, c tiu c c c
ti a c thm thu

1200mOsm/kg H2O.

T tr g c tiu thm thu c tiu gim l biu hin ca gim kh


g c tiu ca th , thng gp trong cc bnh ca ng-k th h:
vim thn-b thn mn, vim thn k m , th a a g, a g tu thn, giai
on i t li ca suy thn cp, sau ghp thn, suy thn mn.

2.2.2. Phn tch cc thnh phn sinh ho nc tiu:

Phn tch cc thnh ph si h ho c tiu pht hin cc thnh phn bnh


thng v t o g c tiu, h g t o g nh l ca h thng thn-tit niu
th cc n g ny b tha i. Hoc cc thnh ph h thng khng c trong
c tiu, khi c bnh l li xut hi t o g c tiu.

+ Protein:

- gi h thng, ch c mt lng rt nh protein trong mu c lc


qua cu th , h g c cc t bo ng thn ti hp thu hon ton hoc gn
hon ton. Ch c <30mg protein

c bi xut ua c tiu trong mt ngy, bng cc xt nghim sinh ho


thng thng, khng

pht hi lng protein ny v cho kt qu m tnh.


- Nu c tiu c trn 30 mg protein/24gi l ch im cho thy c t th g
th t c khi xt nghim cn phi chc ch c tiu khng c mu, m,
phi l c tiu t c khi xt nghim):

. Nu lng protein t 30-300 mg/24gi th c gi l microalbumin niu. Vi


l g p otei , ph g ph p si h ho th g thng cho kt qu m tnh,
mun pht hin phi xt nghim b g ph g ph p in dch phng x (RIA).
Microalbumin niu l thng s c s d g chn

o sm cc t th g th hng hn trong b h t g hu t p, trong bnh


i th o ng).

. Nu lng protein >300mg/24gi th cc xt nghim sinh ho thng thng cho


kt qu

d g t h, l biu hin ca t th g th .

- Mt s t ng hp c tiu p otei h g kh g c t th g th th
cn phn bit:

. Protein niu t th ng: c th gp tui di 20, protein niu xut hin khi
g l u h g khi ho nh nhn nm ngh th protein niu li t h, khi ng
lu > 1gi protein niu li d g t h; kh g k theo hng cu niu v cc triu
chng khc ca bnh thn.

. Protein niu Bence-Jone: gp trong b h a u tu g, u g th. Loi protein


c gi l protein nhit ta : khi u g oC th c tiu c
do protein kt ta h g khi u s i th p otein li ta l c tiu trong,
ngui d th c tiu c tr li. Bn cht ca protein nhit tan l
cc chui nh lamda v kappa ca gama globulin do cc t chc bnh l to ra v
c lc qua cu thn.

. Protein niu do bnh l mt s ua kh h: su ti huyt c thiu niu,


ch th g s no, chy mu mng no. Protein niu trong cc bnh l trn
thng ch xut hin tm thi trong thi gian b bnh.

- Protein niu gi c thai l u:


Khong 3 thng cui ca thi k thai nghn thy c protein niu, ph , t g hu t
p; l iu hin ca nhi c thai nghn. Nu nng th sn ph c th b sn
git, thai cht lu. Sau vi tun, cc triu chng mt i p otei iu tr li
m tnh. Nu protein niu vn tn ti k o d i sau th c kh g h h
c bnh thn tim tng t t c.

- Protein do bnh thn:

. L g p otei t o g c tiu t (<2g/24gi thng gp trong cc bnh l ca


ng-k th h: i th -b thn cp hoc mn, vim thn k do nhi c,
ch thn do t g hu t p.

Protein niu trong cc bnh ca ng-k th thng c t l albumin thp; cc


glo uli , , ,

thng cao.

. Lng protein niu trung bnh (2-3g/24gi , thng gp trong cc bnh cu


thn cp hoc mn. Protein niu trong cc bnh cu thn c t l
al u i /glo uli t g t trong huyt thanh (1,2-

1,5).

. Protein niu nhiu (>3,5g/24gi) l biu hin ca hi ch g th h. Th h phn


protein niu trong hi chng thn h phn ln l albumin (kho g % lng
p otei ; lng globulin t.

+ Cc thnh ph si h ho kh t o g c tiu h u , eati i , in gii..., t


c s dng

trong lm sng.

2.2.3. Bi i cc thnh phn t bo trong nc tiu:

+ Hng cu niu:

- B h th g, t o g c tiu c 0-1 hng cu/ i t ng hoc 3 hng cu/ml


c tiu hoc
<1000 hng cu/pht. Nu s lng hng cu t o g c tiu t g l i a
mu.

- i a u i th nu:

. 1-2 hng cu/ i t ng l (+).

. 3 hng cu/ i t ng l (++).

. 4-5 hng cu/ i t ng l (+++).

. 6-7 hng cu/ i t ng l (++++).

- i a u i th: khi hng cu d i t ng, hay >5000 hng cu/pht;


c tiu u nht ho .

- Tha i hnh dng v th tch ca hng cu t o g c tiu rt c gi tr


ch o ph

bit bnh ca cu thn v bnh ca ng niu. Nu hng cu b bin dng mo


m, th tch co nh th chng t hng cu t o g c tiu c ngun gc t cu
thn, do bnh l cu thn gy nn. Nu hng cu gi nguyn hnh th h h
thng l hng cu c ngun gc t ng niu (b thn, niu qun, bng quang,
niu o), do bnh l ca ng niu gy nn.

+ Bch cu niu:

- B h th g, t o g c tiu c 0-1 bch cu/ i t ng hoc 3 bch cu/ml


hoc < 2000 bch cu/pht.

- Bch cu niu t g khi him khun:

. 3-5 bch cu/vi t ng l (+).

. 6-10 bch cu/ i t ng l (++).

. 11-20 bch cu/ i t ng l (+++).

. > 20 bch cu/ i t ng l (++++).


Khi c >10 bch cu/ i t ng, hoc >5000 bch cu/pht l chc chn c nhim
khun. Nu c

3-10 bch cu/ i t ng hay 2000-5000 bch cu/pht th nghi ng c nhim


khun.

i a : nu bch cu d i t ng, c bch cu a h tho i ho t bo


m , c tiu c.

+ Xt nghim cn Addis:

- bit h h i a hng cu hay bch cu khng nh m


nng ca i ra hng cu v bch cu th phi lm xt nghim cn Addis.

-C hl h sau:

L c tiu trong 3 gi, o s l g c tiu ri tnh ra s ml/pht (ly s


l g c tiu trong 3 gi chia cho 180 pht). Ly l c tiu trong
mu c tiu 3 gi, ly tm 3000

vng/pht trong 10 pht. Ht b 9ml pha trn, khu u 1ml cn li ri dn tiu


b m s lng hng cu, bch cu. S l g e hia ho i nhn vi
s ilil t c tiu/ph t c s lng hng cu v s lng bch cu/pht.

- Nh nh kt qu:

. B h th g, c tiu c <1000 hng cu/pht v <2000 bch cu/pht.

. Khi c >5000 bch cu/pht l chc chn c nhim khun. Nu c 2000-5000


bch cu/pht th nghi ng c nhim khun.

. Khi c >1000 hng cu/ph t l i ra mu; nu >5000 hng cu/ph t l i


ra mu i

th, c tiu u .

+ Vi khu t o g c tiu:
tm vi khu t o g c tiu cn phi c c tiu ti c tiu ngay sau
khi i tiu). C nhiu cch l c tiu nui cy vi khun:

- Ch ki ua da ph a t g u khi g ua g c tiu l c
tiu. Ph g

php m bo v khu , h g l ph g ph p hp d gy nhim


khun khoang t o t c bng quang, nn hu h kh g c p dng trong
lm sng.

- t ng thng bng quang qua niu o l c tiu. Ph g ph p


khng m bo v khun tuyt i v c th y vi khun t niu o vo
bng ua g. Ngo i a, t ng thng d gy nhim khu g d g g t
c s dng trong lm sng.

- C c tiu gia d g: l ph g ph p th g c ng dng trong lm


sng. Cch ti h h h sau:

Ti h t c, bnh nhn phi v sinh sch vng sinh dc-tit niu bng x
phng v c s h. S g h sau, t c khi l c tiu li phi v sinh mt
ln na, sau s t khun l niu

o bng thu . Cho bnh nhn i tiu, loi b ph u ca i c tiu,


dng ng nghim v

khun hng ly ph c tiu gia i, y ng nghim bng nt bng v


khun; gi ln phng xt nghi nui cy. Nh nh kt qu h sau:

. Khng mc vi khun: khng c nhim khu c tiu.

. Nu s lng vi khun <1000 vi khu / l c tiu: khng c nhim khun


c tiu.

. Nu s lng vi khun 1000-100 000 vi khu / l c tiu: nghi ng c nhim


khu c tiu, cn phi cy li.

. Nu s lng vi khun >100 000 vi khu / l c tiu: c nhim khu c


tiu.
2.2.4. Tr hnh v tinh th trong nc tiu:

- Tr h h t o g c tiu:

Tr hnh l cc cu trc hnh tr th t o g c tiu. Bn cht ca tr l


mucoprotein, l mt loi protein do t bo ng thn b t th g tit ra (gi l
protein Tam-Horsfall) v protein t huyt t g c cu th lt a c
tiu. T o g iu ki pH c tiu axt, chng b

g khu trong g ln xa ri o g a t i theo c tiu.

Tr niu l biu hin t th g thc th thn, hoc cu thn hoc ng


thn. C hai loi tr: tr khng c t bo v tr c t bo. Tr c t bo l cc tr
c cha xc cc t bo (t bo biu

m ng thn, t bo bch cu, t bo hng cu...). Th loi tr c gi tr gi cho


ch o nh, cn s lng tr khng c gi tr ni ln m nng hay nh
ca bnh.

Ngi ta phn ra cc loi tr sau:

. Tr trong hay tr hyalin: khng c t bo.

. Tr m: cha cc git m; hay gp trong hi ch g th h.

. Tr ht: cha xc cc t bo biu m ng thn; hay gp trong vim cu thn


mn. Tr ht mu nu bn gp trong suy thn cp.

. Tr hng cu: cha cc hng cu t cu thn xung; hay gp trong vim cu thn
cp.

. Tr bch cu: cha xc cc t bo bch cu; hay gp trong vim thn-b thn cp
hoc m . K h thc ca tr g gha t o g hn o : u >2/3 s
lng tr k h thc to

ng knh ca tr > 2 l ng knh ca mt bch cu a h th rt c gi


tr ch o su th n.
- Cc tinh th t o g c tiu: tu thuc thnh phn cc cht ho ta t o g c
tiu pH c

tiu c th gp:

. Tinh th phosphat canxi.

. Tinh th oxalat canxi.

. Tinh th urat.

Nu mt loi tinh th c mt vi s lng nhiu t o g c tiu kt hp vi


nh g iu kin nht h h pH c tiu kim hoc axt; nhim khu ng
niu...) chng c th d to si. Chng hn, si urat d h h th h t o g iu kin
pH c tiu toan; si phosphat d h h th h t o g iu ki pH c tiu
kim; si truvit d h h th h t o g iu kin nhim khun ng niu. Ngoi ra,
vic hnh thnh si cn ph thuc vo t l gia cc thnh ph t o g c
tiu.

2.3. Cc ph g ph p th d h g th :

Thn c nhiu ch g, do t nhiu nghi ph p th d h g


thn. Trong bi ny, chng ti ch trnh by mt s nghi ph p th g thng
c s dng trong lm sng.

. . . Th d h g lc mu ca cu thn:

th d h g lc mu ca cu th , gi ta o mc lc cu thn. Mc
lc cu thn l s mililt dch l c tiu u) c cu thn lc trong 1 pht.
Trong thc t, khng th o t c tip mc lc cu thn gi ta o
gin tip n qua h s thanh thi ca mt s cht. H s thanh thi ca mt cht
l s mililt huyt t g thc t l th tch o khi i ua th t o g ph t,

c cu thn lc sch cht . C ht tho m iu ki sau th h


s thanh thi g ng

mc lc cu thn, v c th d g nh mc lc cu thn:
. Khng b chuy ho t o g th.

. c lc d dng qua cu thn.

. Khng b ng thn ti hp thu hay bi tit.

Inulin l cht l tng nht o mc lc cu thn. Ngoi ra, c th dng


a ito , at i thiosulphat. Nh g k thut o h s thanh thi cc cht ny kh
phc tp t c s d g t o g l s g. T o g l s g, gi ta thng
d g ph g ph p o h s thanh thi creatinin ni sinh.

+ C h o h s thanh thi creatinin ni sinh:

- Ly c tiu trong 24gi, phi ly tht chnh , sau t h a th tch


c tiu/pht

(Vml/ph) bng cch chia th t h c tiu l c cho 1440pht.

- L l c tiu ca mu c tiu trong 24gi, a l ph g t ghi


h lng n g creatinin.

- Ly 2ml mu sau khi kt thc ly c tiu trong 24gi, a l ph g t


nghi h lng n g creatinin.

- Tnh h s thanh thi creatinin theo cng thc:

Ucre x V(ml/ph) 1,73

Ccre = ----------------------------- x --------

Pcre S

T o g :

Ccre: h s thanh thi creatinin ni sinh (ml/ph).

Ucre: n g eati i t o g c tiu mmol/l c i a ol/l cng


vi creatinin mu).
Pcre: n g creatinin trong mu (mol/l). V(ml/ph): th t h c tiu/pht
(ml/ph).

1,73: l di t h da t th ca mt gi chu u chu ha th g s


t gi Vit Nam).

S: din tch da ca th bnh nhn (m2).

Tnh din tch da ca th bnh nhn c th s dng hai cch sau:

. S dng b g Du ois: i chiu chiu cao, cn nng ca bnh nhn s cho kt


qu din tch da.

. Tnh theo cng thc ca Haycock:

S = cn nng0,94(kg) x chiu cao0,4(cm) x 0,024

B h thng h s thanh thi creatinin ni sinh c gi tr trung bnh l 120ml/ph.


Khi h s

thanh thi creatinin ni sinh <60ml/ph l c suy thn.

+ lng h s thanh thi creatinin ni sinh qua n g creatinin huyt


thanh:

V nh g kh kh t o g ic thu thp h h l g c tiu trong 24gi


tnh h s thanh thi creatinin ni sinh, nn vi c o h s thanh
thi creatinin ni sinh t n g creatinin huyt tha h c c nhiu
tc gi nghin cu.

C s o h s thanh thi creatinin ni sinh t n g creatinin huyt


thanh l : l g eati i c bi xut h g g ua c tiu l t g i
h g h i vi mi c nhn, do U e V = k U e: g creatinin trong
c tiu; V: th t h c tiu/pht; k: l hng s), thay vo cng thc tnh h
s thanh thi creatinin ta c Ccre=k/Pcre nn Ccre tha i khi k/Pcre tha i
(Ccre: h s thanh thi creatinin ni sinh, Pcre: n g creatinin huyt thanh);
t l C e tha i khi P e tha i.

Cng th c dng ph bin nht i vi gi ln l cng thc ca Cockroft


v Gault

(1976):

[140-tui t g l g th (kg)

Ccre = ---------------------------------------------------------

72 x Pcre(mg/dl)

i vi n phi nhn kt qu vi 0,85 v khi l g n thp h a . Nu


o P e l ol/l th h s 72 mu s c thay bng 0,814.

Cn ch vic s dng n g creatinin huyt tha h c o h


s thanh thi creatinin ni sinh s cho kt qu ao h h s thanh thi creatinin
ni sinh thc bnh nhn suy thn. Suy thn cng nng th chnh lch ny cng
ln v s bi tit creatinin ca g th t g t creatinin qua rut. C g n
ch thm, bt u t 35 tui th mc lc cu thn v h s thanh thi creatinin
ni sinh gim dn khi tui t g l , s lng nephron ch g a thn gim
theo

tui. gi 50 tui th s lng nephron hot ng gim t 1%-30%; trong khi


tr em th nng

eati i u t g dn do khi l g t g theo tui. Do vy, s dng cng


th o t s d h gi sai c lc cu thn.

. . . Th d h g ng thn:

C nhiu nghim php th d h g ng thn: c nghi ph p th d


ch g t g on ng thn, c nghi ph p th d h g to ng
thn. Chng ti ch trnh by mt s nghi ph p th d h g to ng
th th g c s dng trong lm sng. Sau

l t s ph g ph p th d kh g c tiu ca ng thn.

+ Ph g ph p o thm thu c tiu mu sng sm:

l ph g ph p t gin, d p dng, c gi tr t o g l s g h
gi kh g c

c tiu ca thn. Cch ti h h h sau:

B h h , ung v sinh hot h thng. Ti h t c, bnh


nhn khng c dng cc cht c tc dng li tiu, t khi i g bnh nhn
phi i tiu ht i, t o g kh g c u g th c, khng c
truyn dch. Nu i tiu t o g th kh g ly mu c tiu . Nc tiu
ca l i tiu u tin bui sng sm lc ng dy (t 4gi n 7gi sng) c
gi l mu c tiu sng sm. Mu c tiu ng trong b sch, ly
l o thm thu. Kt qu thm thu c tiu mu sng sm:

- Gi tr h thng: 800 30mOsm/kg H2O.

- Nu Os /kg H O: kh g c tiu ca thn l bnh thng;


khng cn phi lm thm bt k mt nghi ph p th d kh g c no
khc.

- Nu <600mOsm/kg H2O: kh g c tiu ca thn gim; mun kt


lun chnh xc cn lm li xt nghim 3 ln hoc lm nghim php nhn kht ca
Wolhard.

+ Ph g ph p o h s thanh thi c t do:

o ng thi thm thu c tiu mu 24gi (c th o mu c tiu


3gi, 6gi, 12gi... thm thu u tnh cc thng s:

- H s thanh thi thm thu:


Uosm x V

Cosm = ------------------

Posm

T o g :

Cosm: h s thanh thi thm thu (ml/ph).

Uos : thm thu c tiu (mOsm/kg H2O). V: th t h c tiu/pht


(ml/ph).

Pos : thm thu huyt thanh (mOsm/kg H2O).

- H s thanh thi c t do:

H s thanh thi c t do l s ilil t c cn phi thm vo (mang gi tr


m) hay bt i

(mang gi tr d g khi c tiu c tiu g t g so i mu.

CH2O = V - Cosm

T o g :

CH2O : h s thanh thi c t do (ml/ph). V : th t h c tiu/pht


(ml/ph).

Cosm : h s thanh thi thm thu (ml/ph). Nh nh kt qu:

Nu : CH O = : c tiu g t g so i mu.

CH O < : c tiu u t g so i mu.

CH O > : c tiu h t g so i mu.

- T s thm thu c tiu/thm thu mu (Uosm/Posm):

Uos /Pos = : c tiu g t g so i mu.


Uos /Pos > : c tiu u t g so i mu.

Uos /Pos < : c tiu h t g so i mu.

+ Nghim php Zimniski:

Khi lm nghim php, bnh nhn vn sinh hot , u g h th g. g


gi sng (hoc vo mt gi no khc) cho b h h i tiu v loi b mu c
tiu ; sau g i

3gi li l c tiu go c tiu vo mt mu ho g gi sng


hm sau. Tng s 8 mu, mi mu c tiu o s lng v t trng. Nhn
nh kt qu h sau:

- Kh g c tiu ca thn l bnh thng khi:

. S lng v t tr g c tiu ca cc mu chnh lch nhau nhiu.

. t nht c 1 mu c tiu c t tr g , .

- Kh g c tiu ca thn gim khi:

. S l g c tiu ca cc mu c tiu gn bng nhau, th t h c tiu ban


hiu h a g .

. T trng cc mu c tiu chnh lch nhau t, khng c mu no c t trng


, .

+ Nghim php hn ch c:

Nghim php hn ch c cho php nh nh chnh xc kh g c


tiu ca th . C hai ph g ph p ti h h: ph g ph p hn kh t ph g
php tim arginin vasopresin.

- Nghim php nhn kht ca Volhard:

Bui sng cho bnh nhn i tiu ht bi, t kh g c u g c. Ba sng,


t a ti phi
h kh (bnh m . L g c c , ung, tim truyn khng qu
50ml/24gi. Thi gian nhn kht c t l 18gi, cn b h h t c v trong
qu trnh lm nghim php. Khi cn nng gim 3-5% so vi t c khi lm nghim
php ho thm thu u t g i t yu cu. C mi 3 gi l c tiu
mt l , o s l g o thm thu (ho o t trng) ca tng mu c
tiu.

Nh nh kt qu h sau:

. Kh g c tiu ca thn l bnh thng khi: s l g c tiu ca


cc mu gim dn; t nht c mt mu c tiu thm thu Os /kg
H2O (hay t trng >1,025).

. Kh g c tiu ca thn l gim khi: s l g c tiu ca cc


mu xp x bng nhau; khng c mu o thm thu t ti 800mOsm/kg
H2O (hoc khng c mu no c t tr g t ti 1,025).

- Nghim php tim arginin vasopresin (AVP):

Bui s g t c khi tim AVP, cho bnh nhn i tiu ht i, sau ti di da


AVP. Bnh nhn khng c u g c trong thi gian lm nghim php.
Ly cc mu c tiu sau tim 1gi, 2gi,

3gi. Nh nh kt qu h sau:

. Kh g c tiu ca thn l bnh thng khi: s l g c tiu ca


cc mu gim dn; t nht c mt mu c tiu thm thu t 750-
1200mOsm/kg H2O.

. Kh g c ca thn l gim khi: s l g c tiu ca cc mu xp x


bng nhau;

khng c mu c tiu o thm thu t ti 750mOsm/kg H2O.

. . Th d h h th i hc:

2.4.1. Siu m thn, bng quang:


Ch o ng siu l ph g ph p h o kh g xm nhp, khng c
bin chng, c th lp li nhiu l c ng dng rt rng ri. Siu m cho
bit h h th i, k h thc thn, s bi i nhu m thn, gi i-b thn, si
thn, hnh th bng quang...

B h th g, k h thc thn trn siu m: di 10cm, rng 5cm... Nhu m


thn u v rt t c , i-b thn cn m v khng gin. T l hu / i-
b th o hiu di thn/chiu d i i-b

thn) l 1/2. Ranh gii gia nhu i-b thn r.

- Suy thn mn do vim cu thn m : k h thc thn nh t g i u c hai


, hu th t g n m lm ranh gii gia hu i-b
thn khng r.

- Suy thn do vim thn-b thn mn: hai thn nh khng u, i-b thn gin,
chu vi thn li l kh g u. Nu c th th to, i-b thn gin to.

- Si i th : h h t g m m g i-b thn, c bng cn m.


Nu h h t g n m m khng c bng cn m th c th l t ch ho .

- Si niu qun thp: khng th c si, h g th i thn gin l


hnh nh gin tip cho thy c cn tr lu th g c tiu niu qun.

- Thn c nang: siu m rt c gi tr ch o nh thn c nang. Nang


thn l cc khi long m hnh trn, b mng. Nu th t o g a g t g n
m th c th l do chy mu trong nang hoc nhim khun nang.

2.4.2. X quang thn-tit niu:

+ Chp thn khng c thuc cn quang:

- Tht tho hai ln cho sch phn v cho ht hi t o g i trng, chp phim
b g t th thng v nghing t D n ht khung chu. Nu k thut chp tt
th phi th g hai i hu, th c r bng ca hai qu thn.

- B h thng: thy hai thn c hnh dng k h thc h thng, cc trn


ngang mm ngang ca t sng l g , di ngang mm ngang ca t tht
l g ; th phi thp h th t i t t sng. Khng c hnh cn quang
thn hay d g i a niu qun v bng quang.

- Bnh l:

. Thn to hoc nh h h thng: cn chp thn c thuc cn quang xc


nh.

. Si thn, si niu qun hay bng quang: thy hnh cn quang trn hay bu
d ; h h g ta i g g hoc hnh san h ; b trn, nhn hoc nham nh.

Chp thn khng c thuc cn quang ch yu tm si cn quang. Si canxi


phosphat, si canxi cacbonat, si canxi oxalat, si amonimagiephosphat th thy
c hnh cn quang. Si urat, si xanthyl, si systin th khng cn quang nn
khng th c trn phim.

C th nhm si vi m ga g t sng, cc vi ho, hch bng vi ho, cc


phn, si ti mt (chp nghing th si ti mt t c ct sng, si thn sau
ct s g . phn bit cn chp thn c tim thuc c ua g o t h ch.

+ Chp thn c tim thuc c ua g o t h ch:

- M h: th d h h th i th , i-b thn th d ch g th .

- Ch nh: si h thng thn-tit niu, lao th , u g th th , i a u, i


a dng chp;

ch o ph bit thn to vi mt khi u trong bng...

- Chng ch nh:

. Khi su th : t c khi lm phi xt nghim n g ur, creatinin mu, khi


n g ur >8mmol/l th khng c lm.

. Khi c d ng vi iod. T c khi lm phi th phn ng vi iod: tim 0,5-1ml


thuc c ua g iod o t h h, sau theo d i phn ng, mch, huyt p.

. a g i a mu i th.
. a g su ti ng.

. C thai hoc bng c c hng.

- Ph g ph p: tht tho 2 l t c khi chp.

. Chp phi th th g khi ha ti thuc c ua g, sau ti thuc cn


quang v dng 2 qu p p vo 2 h chu, m h l p vo 2 niu qun
kh g ho c tiu c thuc cn quang xung bng quang.

. Giai on p: 2-3 pht sau khi tim chp phi , sau 15 pht chp 1 phim,
cn chp

2-3 phim.

. Giai on b p: sau khi tho b qu p, chp ga phi xem niu qun v


bng quang

- Nh nh kt qu:

. Hnh h h thng: sau 5-6 pht thy hin hnh thn, sau 15 pht hin hnh
i-b thn. Thn i-b thn h h d g, k h th h thng. C 3
h i th , i i th to

chia ra 2- i th nh, mi i th nh tn cng bng hnh cng cua. Nhm


i th trn h g l t , h i th gia h g a go i, h i
di hng xu g di v ra ngoi.

Niu qun c ch phnh, ch tht h g kh g to, ng knh khong 0,5-0,7cm,


niu qun c th b cong.

. Bnh l:

C th thy s tha i v k h thc, v tr v hnh th th h th to, th


nh, thn sa, thn lc ch, thn di dng...

i-b thn c th b gin, b bin dng; c th thy cc bt thng niu qun


v bng quang. Thn ngm thuc chm hoc khng ngm thuc l biu hin chc
g th su gim.
+ Chp b th gc dng c thuc cn quang:

- Ph g ph p: d g soi g ua g a t g th g theo ng niu


qun ln ti b

th . B thuc cn quang theo ng thng vo b thn ri chp.

- u i : a thng thuc vo b thn, thuc khng b pha lo g h h i


thn v b thn r. Ngoi ra cn c th kt hp ra b th , a thng thuc
khng sinh vo b thn, l c tiu t b th xt nghim tng bn thn.

- Ch nh: mi t ng hp khng chp thn c tim thuc c ua g g t h


m h c hoc chp th ua g t h ch cho kt qu kh g ; i a
dng chp.

- Nh im: ch bit c hnh dng i th thn, khng bit c


hnh thi thn v ch g thn; d gy nhim khu gc t di ln; nu
thuc mnh c th gy v i-b thn; k thut phc tp.

- Chng ch nh: khi c nhim khu ng niu.

+ Chp hi sau g ng:

Ph g ph p hi a t c p dng v siu th , ch cn
c p dng trong mt s t ng hp h: nh nh hnh thi tuyn
thng thn.

- Ph g ph p:

. Dng kim chc thng vo vng bao m quanh thn ri hi: ph g ph p


h im l d chc vo thn; ch l c mt bn; kh chc g
o ao th do hi kh g tp trung h thn.

. B hi o t t g g t: dng kim chc vo st mt t g


cng ct, o , -1,7lt khng kh (tt nht dng kh oxy). Nu ch chp 1
bn th ch l t kh g kh . B hi o g, bnh nhn ngi dy trong vng
5-10 pht hoc cho bnh nhn nm ph phc
hi i l h thn ri cho bnh nhn chp X quang. Nu ch chp 1 bn thn
th cho bnh nhn nm nghing, th nh chp h g l t . nh
hi l h thn ha th th g vng h thn, nu g th t o g l hi
ln h thn; tt nht l chiu X ua g ki t a e hi l h th ha.
Sau chp, cho bnh nhn nm t th u thp trong 24 gi.

- Ch nh: chp tuy th g th th d h h thi, phn bit u thng


thn vi u thn; phn bit u trong bng vi u thn ho thng thn.

- Tai bi : g au l g, au g, t kh di da, trn kh trung tht, tc mch


hi, hc kim vo trc trng.

+ Chp ng mch thn:

- Ph g ph p: a ng th g ua da o ng m h i i l ng mch
ch bng, khi

u ng thng ln trn ch ph hia ng mch thn 1- th thuc cn


quang mnh v chp. Th u c 3 giy chp 1 phim, cn chp phi ; sau
giy chp 1 phim na. C th dng ph g ph p ua a e a li tc t khi
thu n khi thn bi tit ht thuc. Nu ph g tin, tt nht nn chp theo
ph g ph p s ho, xo nn lm hnh h t h . C th chp tng bn
thn b g h a g th g o ng mch thn ri thuc.

- Kt qu:

. Giy th 1- th ng mch): th ng mch thn v cc nhnh ca ng


mch thn.

. Giy th 3-6 (th thn): thy hnh thn.

. Giy th th t h ch): th t h ch thn.

. Giy th 60 (th bi tit): th h h i thn.

- Ch nh:
. Nghi ng c hp ng m h th : l h nh chnh ca chp ng mch
thn.

. Khi u th : i khi u c nhiu mch mu tn to, thy m g li mch mu


d c. Hi a siu , CT-scanner, c g hng t l cc ph g ph p
khng xm nhp, cho kt qu chnh xc nn ch h t c p dng.

. Bnh thn bm sinh.

- Chng ch nh: khi c suy thn.

+ X hnh thn bng 99Tcm DTPA.

Tim 2-3mCi DTPA (diethylene triamin penta acetic acid) gn vi T o t h


mch, ri d g m phng x ti hai thn, quan trng nht l thi gian sau
tim 2 pht. nh chp cho thy hnh dng thn, phn b x trn mi thn, hnh
dng v s lu th g a niu qu . ng cong biu din hot phng x ca
mi th pha: pha ng mch, pha bi tit, pha bi xut.

o hot phng x theo thi gian, t h gi c ch g hai th v


tnh c mc lc

cu thn tng bn thn.

2.5. Sinh thit thn:

Sinh thit thn l th thut xm nhp, c gi tr ch o ao, c p dng ch


yu cho cc bnh ca thn.

+ Ph g ph p: ph g ph p:

- Sinh thit k : nh v tr thn bng chp X quang thn khng c thuc cn


quang v c thuc c ua g ti t h ch; hoc sinh thit
di hng dn ca siu m. Dng kim Vim- Silverman hoc kim Tru-cut, chc
ga g t tht l g b go i l g to o di ca thn

sinh thit.
- Sinh thit m: rch mt vt m nh t g ng vi b ngoi thn, dng kim
Ducrot Montera ct 1 ming thn.

Mnh sinh thit thn s c xt nghim t bo hc, xt nghim min dch hu nh


quang v soi trn knh hi i in t.

+ Ch nh:

- Hi chng thn h gu ph t.

- Suy thn cp: khi kh kh ch o , khi n ch o ph bit vi cc


nguyn nhn khc ca v niu.

- Vim cu thn tin trin nhanh.

- Suy thn mn: ch sinh thit khi k h th th h thng. Khi c s thay


i t suy thn tin trin chm chuyn sang suy thn tin trin nhanh th sinh
thit tm nguyn nhn tin trin.

- Bi i c tiu khng c triu chng lm sng: khi c ri lon ch g


thn; protein niu t g; tin tri t g hu t p.

- Bnh h thng: b h i th o ng, b h luput a .

- Sinh thit th gh p ch o thi ghp cp, thi ghp mn, nhi c


thuc cyclosporin

A, nhi mu thn, bnh cu thn sau ghp.

- Vim thn b thn mn.

+ Chng ch nh:

- Th a a g.

- Thn c, thiu sn thn.

- Nhim khu ng niu, lao thn, p xe quanh thn, nhi t g g da i


sinh thit.
- Thn c.

- T g hu t p.

- Ri lo g u.

- Ri lon tm th , ng kinh, bo ph, tnh trng sc kho ton thn nng,


gi gi > 60tui, tr em < 10 tui.

+ Bin chng:

- i a u i th: gp khong 5-7% s bnh nhn.

- Chy mu quanh thn gy ri lon ch g th : gp 0,2-1,4%.

- Th g ng-t h ch: gp 15%.

- Ri lon ch g th : him gp.

- ki o ua kh : goi l.

2.6. Soi bng quang:

+ Ph g ph p: d g soi g ua g ua ng niu o quan st trc


tip nim mc bng quang v tm d vt.

+ Kt qu:

- Hnh h h thng: nim mc vng tam gic c bng quang c mu hng, cc


i kh u t ng nht; c vi mch mu nh, thnh tho g c tiu t niu
qun pht xung.

- Hnh nh bnh l:

. Khi lng bng quang nh: ch c rt t c vo bng quang (50-


60ml). Khi lng bng quang nh chng t c vim mn tnh, lao bng quang.

. Si bng quang: c th gp si ra hoc dng kp kp vn si.

. Vim bng quang cp: ton b nim m g ua g , xung huyt, c th c


ch xut
huyt.

. Vim bng quang mn: nim mc bng quang nht mu, c cc di t ng


cu t h

xoy lc.

. Cc khi u bng quang.

. V tr chy mu: c th thy chy mu bng quang hoc chy mu t thn


xung nu th c tiu t thn pht xung c mu.

- Chng ch nh:

. Niu o a g vim cp.

. Tnh trng ton thn nng.

11.SIU M TRONG BNH THN TIT NIU

1. Nguyn l.
Siu c to ra do s u g hc nhng m thanh vi tn s rt cao, t 1
Mega Hertz (MHz) - 12 MHz (1 MHz = 1 triu u g ng trong 1 giy).
T s g siu c lan truy t o g i t ng vt cht ph thuc vo s
hi ca i t ng.
S g siu ua i t ng thun nht s i th g, h g khi ua tip gip vi
hai i t ng c mt khc nhau th sinh ra hi tng phn x, khc x v
hp thu. Hi t g c ng dng trong ch o nh qua th hin trn
mn nh hoc chp ghi hnh. Tu theo sng m phn x trn mn hnh nhiu hay
t m cho cc hnh nh khc nhau: s c ca mt khi u th cho sng giu m (c
hnh sng); cht dch, kn ho hi, t ch g s cho phn x tr li t th cho
hnh ngho m (c hnh ti). Da t gu l , siu c ng dng vo
ch o nh thn-tit niu.
2. Siu m thn.
2.1. Ch nh:
Siu m thn-tit niu d g x nh v t , k h thc, hnh dng, cu
trc v s lin quan gia thn vi cc t g kh . c bit, siu m c gi tr cao
trong ch o nh l khu tr th h: a g thn, si thn, p xe thn,
thn c.
Nh g siu li cho kt qu rt m h trong cc bnh l thn lan to h: hi
chng th h, i u thn cp, vim cu thn mn v nhim tinh bt thn.
Tuy nhin, khi cc b h tin triu ti giai on suy thn, h hng
nghim trng ti k h thc thn, th siu m li cho kt qu r rng (thn nh
h h th g . Nh g, t o g a s t ng hp khng c t l gia gim
k h thc v suy gim ch g thn. Do vy, trong lm sng phi kt hp cc
xt nghim v thn-tit niu v nu cn siu m nhiu l c ch o h h
gi p t hiu qu ao t o g iu tr.
Siu c ch h o t ng hp sau :
- i u. - Ch th g thn.
- i kh , i . - au g thn-niu qun.
- Suy thn cp, mn. - Nghi ng thn to.
- Nghi ng th a a g. - Khng thy thn trn X quang.
- Nghi ng d dng hi chng thn-tit niu.
- Theo di qu thn ghp.
- T g hu t p.
2.2. Hnh nh siu m th h thng:
- Thn hnh ht u, rn thn pha trong.
- K h thc 2 th thng khng gi g hau, tha i 1-1,5cm, chiu di 9 -
12cm, rng 4-6cm, dy 0,3 , , ng b u, t i l h o
nhu m thn tri c hnh tam gic.
- Niu qun khng thy trn siu m, nu th thng l d dng ch c mt
niu qun, hoc niu qun b gin to (ch th / t / di st bng
quang).
- g t h ch thn th , thng l mt ng mch mt t h ch.
2.3. Hnh nh siu m thn bnh l:
2.3.1. Bnh l thn lan to: thng thy hai thn.
+ Vim cu thn cp: k h thc thn l h h th g, ng vi g
nhn, gii hn tu-v r.
+ Vim cu th : k h thc nh, ng vi kh g u, gii hn tu-v
khng r.
+ Bnh l th a a g: k h thc thn l , ng vi kh g u, gii hn tu-
v mt, ton b thn c rt nhiu nang, cc nang khng thng vi nhau, c th c
gan- t a a g.
+ Lao thn:
K h th tha i kh g g, ng vi kh g u, hay gp c tng
vng v c nhng nt vi ho trong mi thn, mt s t ng hp c ton b
do hp niu qun do vim lao.
2.3.2. Bnh l thn khu tr:
+ Thn c: hnh h siu h gi ua s t th g gia b thn
vi i thn v niu qun, c th c 3 m :
- 1: vng phn m trung tm c mt vng siu m trng gia do c
li gy gin b th , i thn gin nh.
- 2: b thn gin r rt chn p lm nhu m thn hp li.
- 3: b th i thn gin thnh mt nang ln, khng phn bit c b
th i thn. Nhu m thn cn rt mng.
Thy v tr v nguyn nhn gy tc nghn:
. Si niu qun.
. D dng khc ni niu qun-b thn.
. Teo niu qun bm sinh.
. Lao thn.
. Chn p t go i o h: hch, u vng chu, thai, u g th t u g, u
tuyn tin lit, K tuyn tin lit, cc bnh l vng sau phc m u ha ho ... ,
chy mu thn gy c u g t tc niu qu , t o gc bng quang do
g ua g g to g ua g thn kinh).
+ Si thn: hnh nh siu m l bng siu m dy c hnh vm (c th thn c
do si niu qu , thng gp si b th , i thn, si nhu m thn, si
sa h thng c dng nhiu si nm lin tc ni tip nhau.
+ Abces th : thng l khi siu m hn hp trong c ho dch, gii hn khng
, tha i trong qu trnh bnh l.
+ Abces quanh thn: quanh thn c lp d h kh g ng nht, c khi th hi
trong.
+ Mu t quanh thn: hnh nh c lp siu m trng hnh lim g di bao
thn c th y lch th , thng c nguyn nhn gy ch th g thn.
+ Ch th g thn: c th thy cc hnh h t siu t g ho
t th g.
- Dp hu thu : thng l vng c hnh siu m km mt cc ca
thn, gii hn khng r.
- Dp nhu m c t u di bao: thy lp siu m tr g di bao thn, nu
n g h to ra mt mu t ln quanh th , th g i k theo dch trong
bng nn cn phi khm k khng b st t th g gan lch (phi theo
di 6-24h).
- Dp nt thn: thn mt, ln vo khi mu t sau phc mc.
+ U thn: siu m ch h u h g kh g ph it c u lnh, u c,
tr t ng hp: angiomyolipoma: c hnh nh khi siu m rt dy c th nh hay
ln, c th mt hay nhiu khi, gii h , thng cc trn vng lin quan vi
m quanh th . Thng gp n nhiu h a , l s g kh g t iu
chng.
+ D dng thn tit niu bm sinh: siu m c th pht hin d tt bm sinh h tit
niu, thng gp n v kt hp vi d tt ph khoa, c th gp l:
- Teo thn bm sinh.
- Thn lc ch thng nm vng chu.
- C mt thn.
- Thn hnh mng nga (ging tuyn gip): hai thn dnh vi nhau c di v
bt ngang qua ct sng.
- Th i: hai thn, hai niu qu thng c tc nghn mt trong hai niu
qun).
- B thn ngoi thn.
. . . h gi u thn ghp:
Siu Dopple d g h l t ph g ph p h yu nh suy
ch g a qu th gh p l do gu h g : gii (tc nght b thn, tc
m h ha do gu h o thi qu thn ghp.
3. Siu m bng quang.
Th g c ch nh khi c siu m thn tit niu, tuy nhin trong mt s
t ng hp c ch nh siu m bng quang.
3.1. Ch nh:
- au tc vng bng quang (h v).
- C biu hin vim nhi ng tit niu di: i dt, i but.
- i a u ha gu h .
3.2. Cc b h l g ua g c pht hin qua siu m:
. . . U g th g ua g:
C dng u chi si nh vo lng bng quang.
Thng nhiu v t , h g ha gp l ta gi g ua g. Lu t s
t ng hp sm ch thy dy vch khu tr mt g o , h h i kh
b h i a u.
- Khi siu m c mu cc trong bng quang lm kh ch o :
. Mu cc c th gy v hnh nh gi g h u.
. Mu cc c th che lp hnh nh thc s ca u.
- Khi thy K hay nghi ng qua hnh nh siu m phi e di a cc tn
th g t h l kh g, thng gp nht l: tin lit tuyn, t u g, i
trng sigma.
3.2.2. Cc bnh l khc ca bng quang:
+ Si g ua g: thng d ch o t cn tr, i khi si rt ln, hnh
trn nh n mc kh tin l si.
+ Vim bng quang: vi hnh nh vim bng quang cp v mn khng r trn siu
m, ch c tnh cht gi h: d h ph lp nim mc, gim kh g
cha c tiu, c nhiu cn trong bng quang.
+ Mu trong bng quang: ty theo m t hay nhiu:
- Nu c mu s lng t: c th c hnh nh cn bng quang.
- Nu c mu s lng nhiu v mi: do ch th g thn hay do u bng quang,
cho hnh h siu d th h c gii hn r rt, c th c fibrin ho thnh
hnh m g li.
4. Siu m ch o nh l tin lit tuyn.
4.1. Ch nh:
Tiu tin kh, c cm gic ngt ng g, i ut, i dt thng gp nam gii
tui > 50.
4.2. Hnh nh tuyn tin lit bt thng qua siu m:
B h thng tin lit tuyn c hnh tam gic trn mt ct ngang d t g
mu, vi tr g l g k h thc: ngang 2,5-3cm; cao 3- , ; t c sau 2,5-
3cm.
4.3. Hnh nh bt thng tin lit tuyn qua siu m:
+ Ph i lnh tnh tin lit tuy u , k h thc tin lit tuy to h h
thng (quan trng nht cao > 4cm), b u, c chm vi ho nh, 2 thy bn c
th nh hn vo lng bng quang, thy r ming niu o, gianh gii bng quang
v tin lit tuyn r, khng xm ln.
Ch : C th hnh nh siu m v triu ch g l s g kh g t g ng vi
nhau: tin lit tuyn rt ln khng gy b tiu, h g t ng hp tin lit
tuyn khng to l h g li gy b tiu, nguyn nhn do s ph i xy ra
nhng phn khc nhau ca tuyn.
+ U g th tin lit tuyn:
- Tin lit tuy to kh g u.
- T th g khu t bn tri hay bn phi, siu m km hay dy.
- Bao tuyn b ph v v xm ln ra ngoi vng chu hay vch bng quang.
+ Vim tin lit tuyn:
- Cp tnh:
. K h thc tin lit tuyn to c bit gi tr tui).
. Siu k s g h h thng.
. Nu nng c th c t th g khu t l hng p xe.
. Thng km vi vim mo tinh hon, tinh hon.
- Mn tnh:
. Cu trc tuy kh g ng nht.
. Nhiu chm vi.
+ Cn c nhng biu hin bt thng khc ca tin lit tuy ua siu h:
- Vi ho tin lit tuyn.
- Nang tin lit tuyn: c th sinh ra do nhiu nguyn nhn, khi nang qu to hay
nm ngang c bng quang c th gy ra cc triu chng tc nghn.
12.XT NGHIM NC TIU

. C ph g ph p ly bnh phm.
Ly bnh phm l yu t rt quan tr g ch o nh bnh thn. Yu
cu phi tun th g ph g ph p i cho kt qu chnh xc. Bao gm cc
cch ly bnh ph h sau:
1.1. Ly c tiu 24 gi:
Ly ton b s l g c tiu trong mt g 24 gi).
+ Ch nh:
- h lng protein niu 24h, glucose niu/24h.
- Creatinin niu/ h tnh mc lc cu thn.
- Qun l ch , u g c ca mt s bnh l (cn da vo s l g c
tiu h cho l g c vo cho ph hp.
+ Cch tin hnh:
- Ti h t c tm ra, v sinh sch b phn sinh dc-tit niu, chun b b c
np g c tiu, c ra sch, trng 5ml dung d h HCl
st khun.
6 gi sng b h h i i, t u ghi thi gia . Lu l g c ung
trong ngy: nu ph th l g c ung bng s l g c tiu trong 24h +
l do c mt ua da hi th, nu khng ph th ung khong 2 lt/ngy.
- Sau g c tiu ng vo b, k c l g c tiu lc
i ti g phi gom cho vo.
- 6 gi s g h sau i tiu ln cui cng vo b.
o s l g c tiu trong b (th t h c tiu 24h), ghi vo giy xt nghim
v bnh n. Ly 10ml mang ti lab xt nghim.
1.2. Ly c tiu gia dng:
+ Ch nh: Cy tm vi khun niu, kh g si h .
+ Tin hnh:
- Ti h t c cho bnh nhn tm ra v v sinh sch b phn sinh dc-tit niu
bng x phng.
- Sng hm sau (ngy lm xt nghim) cho bnh nhn v sinh li b phn sinh dc-
tit niu.
- Cn c v tr sch v thun tin cho vic l c tiu ca bnh nhn.
- D g c mui sinh l v gc v khun ra sch li l niu o v xung quanh.
- Cho b h h i ph u b i.
- Gia bi hng vo 2 ng nghim v khun, l l c tiu vo 1 ng nghim
nui cy tm vi khun niu kh g si h ; ly 10ml vo ng nghi kh soi
ti hum Gram, gi ga n phng xt nghim vi sinh, nu ha kp a
ngay phi bo qun trong t lnh.
Cn ch : Vi khun ngoi c th theo vo ng nghim khi m ho g t,
nn phi i g g ta khu trnh tnh trng trn.
1.3. Ly mu c tiu bui sng:
L ph g ph p p d g th g thng nht v thun ti , gin, t l chnh
ao. V c tiu c sau mt g, cc thnh phn bt thng
bnh l, k c vi khun niu s c t l cao nn d pht hin.
+ Ch h: nh tnh protein niu, vi khun niu v cc thnh phn hu hnh trong
c tiu.
+ Cch tin hnh: Sng sm, bnh nhn v sinh b phn sinh dc-tit niu t c
khi ly c tiu. i tiu ph u bi b i, i hng vo 1 hoc 2 ng nghim
(theo yu cu) mi ng t 5- l c tiu gi i t ghim.
1.4. Ly c tiu qua sonde niu o:
+ Ch nh: Xt nghim tm vi khun niu, kh g si h .
+ Tin hnh:
- Chun b bnh nhn: v sinh vng tit niu-sinh d h hun b l c tiu
qua chc ht bng quang.
- Chun b ph g tin:
. ng thng phi va k h th ho i tng: nam, n, tr em. Thng
th g gi ta hay dng sonde Nelaton.
. ng thng phi c kh khun tuyt i: loi mi kh khun sn, hoc kh
khu theo ph g ph p th g thng (hp, lu s i , g g, s g l v
khun, thuc st khun.
- Thao tc: Nn l c tiu vo bui sng sm sau khi v sinh tit niu-sinh dc,
cho b h h i i y sch cc vi khun v cc cht bn niu o, v
khi g th g i o g ua g th y vi khun t o g ua g, h
khi g ua g c tiu th tin hnh th thut:
. T th bnh nhn: nm trn bn soi ho t ging.
. Kh khun b phn sinh dc-tit niu bng thuc st khu kh g g au t
h: c mui u t g, etadi .
. Cho b h h i i o t t c tiu ri ng g i t ng
thng v khun vo bng quang, b i t t c tiu u, ri hng vo 2 ng
nghim v khun, mi ng 5- l c tiu gi i t ghim.
T ng hp c ch nh soi bng quang th phi kt hp l c tiu xt nghim
ga t khi t ng soi vo bng quang.
1.5. Ly c tiu qua chc ht bng quang:
+ Ch nh: Cy tm vi khun niu, kh g si h , nht l i vi tr em.
+ Tin hnh:
- Chun b bnh nhn: gii thch cho bnh nhn, v sinh sch v co lng vng
b g di t g u h t c phu thut. Bui sng, cho bnh nhn ung
l c, ch g ua g g y s tin hnh chc ht.
- Chun b ph g tin:
. S g l, gc, bng v khu , g g khu , g d h.
. Kim ch h t c tiu (kiu kim chc ty sng l c no ty).
. B ki ti thuc gy t novocain 1%.
- Thao tc chc ht:
. T th bnh nhn nm nga trn bn soi ho t ging sch, 2 chn co.
. X nh cu bng quang, gy t.
. V tr ch : t ng trng gia, t g u .
. Chc kim th g ng qua da, t ch di da ri qua thnh bng quang (dn
bnh nhn nh i . Khi ki ua th h g ua g th a chc va ht (cn
b l c tiu u loi b hng cu kim chc khi qua thnh bng v bng
quang).
-H t l c tiu cho vo ng nghim v khun gi i y vi khun, lm khng
si h .
-H t l c tiu cho vo ng nghim v khu kh soi ti hum
Gram.
- Ht 10 ml vo ng nghim th g xt nghim thm cn lng v protein nu
cn thit.
1.6. Ly c tiu qua soi bng quang:
+ Ch nh: C c tiu tm vi khun niu, khi h nh soi bng quang
th vi u tin l l c tiu nh vi khun niu.
+ Thao tc ti h h: l h th g th g h g phi lu kh khun k b
phn sinh dc-tit niu t c khi cho ng soi vo bng quang.
2. Cc xt nghi c tiu.
2.1. Xt nghim protein niu:
B h thng khng c protein niu, nu c ch cho php < 30mg/24h.
Nu: Protein niu > 30mg/24h l bt u t th g
thn.
Protein niu 30mg-< g/ h th c gi l microalbumin niu.
300mg/24h c gi l macroalbumin niu.
Xt nghim protein niu l xt nghi thng qui c gi tr trong ch o
nh cc bnh l t th g u thn (vim cu thn cp, vim cu thn mn, hi
chng th h... t s bnh l ni khoa khc c th gy tn th g th i
th o ng, bnh h th g, t g hu t p...). Ty theo yu cu v tnh cht bnh
l gi ta xt nghim protein niu h t h ha h lng.
. . . nh tnh protein niu bng acid sulfosalicylic 3%.
+ Tin hnh:
- L l c tiu e li t ho lng 10 pht.
- L , l c tiu sau khi l t ho o ng nghim ri cho tip 7,5ml axit
sulfosalisilic 3% l u.
+ h gi kt qu:
- Mu trng khi thuc l: c vt protein niu.
- C ta: c protein niu (ty theo m ca kt ta h gi p otei iu t
hay nhiu):
. C ta nh: (+).
. C ta v c: (++).
. C ta m: (+++).
. C ta c: (++++).
+ Cc yu t c th gy sai kt qu:
- Cch l c tiu kh g g ph g ph p th c dch phn ph ln vo
c tiu g th c protein.
- Nc tiu c mu ca gi a g ki h.
Ngo i a ph g ph p kh nh tnh protein niu h: t c
tiu trong ng nghim, vt c ct chanh vo g c tiu, dng giy th
h g o c tiu, h g ho kt qu khng chnh xc bng dng axit
sulfosalisilic 3%.
. . . h lng protein niu 24 gi:
+ Tin hnh:
- Go c tiu chnh xc trong 24h.
- L u, o s l g c tiu ghi vo giy xt nghim.
- L l c tiu gi ti khoa sinh ho.
Kt qu s cho protein niu 24h hoc c th cho protein niu trong mt pht,
g ph g ph p:
. h lng protein niu b g ph g ph p o : c dng l my quang
ph k s g a o et . M o t c tip c ca c tiu
khi c protein niu.
. h lng protein niu b g ph g ph p o u:
c da trn nguyn l: protein cho cng vi pyrogallol/molybdate s to
nn phc hp u . M u ny t l thun vi p otei c my quang
ph k o t c tip. Ph g ph p h o lng protein niu t >
g/l t g/dl g hn ch (v khng bit > 300mg/lt l bao nhiu v <
300mg/lt th my li khng pht hi c).
Nh ph g ph p t h h c macroalbumin niu m thi,
khng pht hi c microalbumin niu.
h lng microalbumin niu c s dng b g ph g ph p: k thut
min dch phng x RIA: adio i u o assa ; ph g ph p in dch enzym
trong dung dch ho t g th.
+ Trong lm sng da vo protein niu/ h ch o nh mt s bnh
thn.
- Protein niu < 1g/24h: gp trong vim thn k, vim thn-b th , t g
huyt p, a g thn (nephroangiosclerosis), th a a g, thn trong hi
chng nhim khun nng, st cao.
- Protein niu 2 - 3g/24h: biu hin ca vim cu thn tin pht hoc th pht.
- Protein niu > 3,5g/24h: biu hin hi chng th h. Hi chng thn
h thng bao gm:
. Protein niu > 3,5g/24h.
. Protid mu < 60g/l.
. Albumin mu < 30g/l.
. Cholesterol > 6,5 mmol/l.
. Triglycerid > 2,5 mmol/l.
. Ph rt to v nhanh.
2.2. Xt nghim cn l g c tiu:
tm cc thnh phn hu h h t o g c tiu h: hng cu, bch cu, t bo
biu m, cc loi tr hnh, tinh th. C h: soi ti n Addis.
. . . Soi ti: C th l c tiu gia dng vo bui sng hoc bt k trong
ngy cho vo ng nghim, ly mt git c tiu kh g l t soi ti ua k h
hin vi vi vt knh 10 X.
2.2.2. Cn Addis:
- 6 h sng cho b h h i ht c tiu t o g , ghi gi, u g l c
s i ngui. Sau nh nhn nm ngh i go o c ra sch bng
x phng). 9 gi cho b h h i ln cui sau o s l g c tiu v ghi
vo giy xt nghim. L l c tiu mang ti khoa xt nghim.
. . . h gi kt qu:
+ B h thng:
- Hng cu, bch cu niu khng c hoc c rt t, mt vi t bo dt do t bo
nim mc niu qu tho i ho , i khi t vi tinh trng (nu nam gii).
- Soi ti - 1 hng cu trong mt i t ng, hoc 3 hng cu/1ml.
- Cn Addis: < 1000 hng cu v < 2000 bch cu/pht; khng c tr hng cu, tr
niu, tr bch cu.
+ i a hng cu vi th:
- Soi ti: hng cu/ i t ng (++).
5 hng cu/ i t ng (+++).
- Cn Addis 1000 hng cu/pht.
+ i u i th: i u i s lng nhiu, mt thng nhn th c tiu
c mu h g h c ra tht ho u , lu hng cu s lng xung.
Lng mu ti thiu bt u l tha i mu s c tiu vo khong 1 ml
u t o g l t c tiu. Soi ti thy hng cu d i t ng.
C th lm nghim php 3 c ch o tr chy mu. Cch lm: cho bnh
h i t bi chia lm 3 phn l lt vo 3 cc thu tinh. Nu lng mu
nhiu nht c u ti th thng l chy mu niu o; lng mu nhiu
nht cc th thng chy mu g ua g; l g u t g g c 3
c thng chy mu thn hoc niu qun. Tuy nhin, liu php ny ch c tnh
cht t g i. Mu nh chnh xc th cn phi c nhiu xt nghim khc.
T o g l s g, i a hng cu gp trong cc bnh vim cu thn, lao thn v si
tit niu (si i-b thn, si niu qun, si bng quang), vim bng quang, ung
th g ua g; th do cc bnh ton thn (bnh h thng to mu, ri lon
u t h g u . Kho g % t ng hp i a u kh g t thy
nguyn nhn.
+ i a ch cu:
- Soi ti:
i a BC khi: - BC/ i t ng (+)
> BC/ i t ng (++)
> BC/ i t ng (+++)
> BC/ i t ng (++++).
- Cn Addis > 2000 BC/pht.
Trong lm sng khi BC (+++) hoc (++++) l c nhim khun tit niu. Nu c tr
BC cng chc chn l i ng tit niu. > BC/ i t g BC d c vi
t ng) v c nhiu BC tho i ho : c gi l i a . T o g t ng hp
, c tiu nhn bng mt thng c nhiu v c gp trong vim thn-b
thn cp v mn.
+ i a t hnh: tr hnh l cc cu trc hnh tr t o g c tiu. Bn cht ca
tr l mucoprotein, l mt loi protein do t bo ng thn b t th g tit ra
gi l protein Tam-Holsfall v protein t huyt t g lt qua cu th o c
tiu. T o g iu ki pH c tiu axit, chng b g
khun trong g ln xa ri o g a theo c tiu.
Tr niu l biu hin t th g thc th cu thn hoc ng thn. C hai loi
tr: tr khng c t bo v tr c t bo. Tr c t bo l cc tr c cha xc cc
t bo (t bo biu m ng thn, t bo bch cu, t bo hng cu . Th loi tr
c gi tr gi cho ch o nh, cn s lng tr khng ni ln m nng
hay nh ca b h. Ngi ta phn chia cc loi tr h sau:
. Tr trong: hay tr hyalin bn cht l p otei ha tho i ho ho to , kh g
c t bo.
. Tr keo: do t bo thoi ho.
. Tr s p: p otei tho i ho .
. Tr m: cha nhng git m, gp trong HCTH.
. Tr ht: cha protein v xc cc t bo biu m ng thn, hay gp trong vim
cu thn mn. Tr ht mu nu bn gp trong suy thn cp.
. Tr hng cu: cha cc hng cu t cu thn xung, gp trong vim cu thn
cp.
. Tr bch cu: cha xc cc t bo bch cu, tn th g t nhu m thn, gp
trong vim thn-b thn cp v mn.
+ Cc thnh phn cn l g kh t o g c tiu:
. Tinh th: phosphat, oxalatcanxi, tinh th urat, tinh th cystin. Nu cc tinh th c
nhiu s gu to si.
. T bo u g th: gp t o g u g th thn-tit niu.
. T bo biu m: nu thy nhiu l vim nhi ng tit niu.
. Th lng trit quang: l thnh phn ester ca holeste ol di dng ht m, tr
m gp trong hi chng th h.
2.3. Xt nghim tm vi khun niu:
2.3.1. M h: ch o nh c nhim khun tit niu khng v lm
kh g si h . Xt nghim tm vi khun niu l rt cn thit, song yu cu phi
h h , g ph g ph p i cho kt qu c gi tr. C 3 cch l c tiu
c trnh by phn 1.1).
. . . C ph g ph p v h gi kt qu:
+ Soi ti: L t u c tiu g/ph t t o g , i gn ly 1 git soi
trn knh hin vi vi vt knh 40 X.
Nu c > 20 vi khu / i t ng th c kh g him khun tit niu.
+ Nhum Gra : phn lp cc loi vi khun gy bnh do trc khun Gram (-)
hoc cu khun Gram (+).
+ C c tiu:
Nc tiu ly vo bui sng, gia dng:
. S lng vi khun > 105 vi khun/ml: nhim khun tit niu r.
. S lng vi khun > 104 - 105 vi khun/ml: nghi ng nhim khun tit niu.
. S lng vi khun > 104 vi khun/ml: cn theo di, c th do ly lan vi khun t
ua l n ti ng tit niu.
- Vi c tiu chc ht bng quang th ch cn 103 vi khun/1ml l c th gh
n nhim khun tit niu.
Ch : Nhim khun tit niu thng ch c mt loi vi khun, khi nui cy c 2 - 3
loi vi khun tr ln l nghi ng c ly nhim do thao tc k thut khng bo m
v khun.
Khi c nghi ng th cn lm 3 l so snh kt qu.
2.4. Cc xt nghim khc: ch lm khi cn thit.
+ U , eati i , in gii.
+ h l g dng chp: dng chp l lipid, t igl e id. B h th g c tiu
kh g dng chp, nu l d g lu th g t bch huyt sang h tit
niu thng gp trong bnh giun ch.
+ pH c tiu: h thng t 5,8 - , . l u c tiu c phn ng kim v
ur b phn hu gii phng ra ammoniac. S ki ho ha toa ho g l
nguyn nhn gy mt s b h, h s hnh thnh si (si utat d hnh thnh
t o g iu ki c tiu toan, si pht pht d h h th h t o g iu ki c
tiu kim, si truvit d h h th h t o g iu kin nhim khun tit niu).
+ T tr g c tiu:
T tr g c tiu l t s gia tr g lng ca mt th t h c tiu trn
tr g lng ca cng mt th t h c ct. Nh y, t tr g c tiu ph
thuc vo tr g lng ca cc cht ho ta t o g c tiu. T tr g c tiu
phn nh kh g c tiu ca th . B h th g c tiu c t trng
l 1,015 - , . Nc tiu long ti a c t tr g , ; c tiu c
ti a t trng 1,030. T tr g c tiu gim l biu hin gim kh g
c tiu ca th , thng gp trong cc bnh ca ng- k th , h: i
thn b thn mn, vim thn k mn, th a a g, a g ty th , giai o i
nhiu ca suy thn cp, sau ghp th th g u tin.
13.XN MU TRONG BNH THN TIT NIU

1. Huyt hc.
1.1. HC, HST, hematocrit: gim r rt khi c suy thn t IIIa tr i;
gim ny t l thun vi giai on suy thn, nhiu t ng hp HC ch c > 1 triu.
1.2. BC: t g s l g, BC a h t u g t h t g, CTBC hu n tri, fibrin
t g thng gp trong vim thn-b thn cp v mn, nhim khun tit niu.
. . g u: C th c ri lo g u t o g su th giai on cui.
2. Sinh ho.
2.1. Ur: l mt it phi p otei ph t lng 60,1. Ur l sn phm ca
chuy ho , o thi ch yu qua th . B h thng n g ur 1,7 -
8mmol/l (10-50mg/l). Khi suy thn, mc lc cu thn < 60 ml/pht th n g ur
u t g.
C nhiu yu t ngoi thn h hng ti n g u u: hiu protid, xut
huyt tiu ho, st, dng mt s thu t g d ho h o ti oid...
B th u kh g c hoc rt t , h g ht it phi p otei kh li
rt . Khi u t o g u t g th it phi p otei kh g t g. nh
lng ur li gin d thc hin nn c h l g u u h gi theo
di m suy thn.
2.2. Creatinin: g l t it phi p otei o thi qua th . B h thng
n g creatinin trong mu l 44 - 106 mmol/l (0,5 - 1,5mg/dl). Khc vi ur,
creatinin khng ph thuc vo cc yu t ngoi thn, nn n g creatinin mu
c mt gha t quan tr g d g h gi h g thn chnh xc
h u . L s g ng eati i u c coi l tiu chu h h h
gi bnh nhn d suy th ha su th giai on no.
2.3. Protein: h thng n g protein ton phn trong huyt t g l - 80
g/l, t o g al u i l - 55 g/l, globulin l 25 - 35 g/l, t l albumin/globulin
(A/G) l 1,3 - 1,8. Trong cc bnh thn mn tnh th protein trong mu gim do
mt ua c tiu; ri lon tng hp protein, ch hn ch p otei . c bit
l trong hi chng th h, protein mu gi c coi l mt trong hai tiu
chun chnh ch o nh (protein mu < 60g/l v albumin < 30g/l, t l Al/G <
1, alpha2-glo uli t g t %.
2.4. Cc cht m: trong mt s bnh th c bit l trong hi chng th h
thy thnh phn mt s cc cht m t g l lipid u ton phn, cholesterol,
t igl e id . N c dng cc xt nghi h lng cc thnh phn trn trong
xt nghim ch o nh thn.
Lu :
- Choleste ol h th g tha i t g theo tui:
< 30 tui: < 5,2mmol/l.
< 40 tui: < 5,7mmol/l.
> 40 tui: < 6,2mmol/l.
Nn khi nh h h gi kt qu phi da vo yu t ny.
- T igl e id h thng < 2,3 mmol/l.
Cc ch s t t g khi t qu gii h h th g thng gp trong hi
chng th h.
2.5. Cc cht khc.
- Axit uurric: l sn phm ging ho cui cng ca u leop otitd. B h thng nam
< 420mmol/l, n < ol/l; t g t o g nh vim thn, suy thn, si thn.
- Cc cht in gii: mt s cht in gii lin quan ti bnh th g c
xt nghim trong ch o nh thn.
- Natri: bnh thng 135-145mmol/l, natri gim trong bnh vim t chc k ng
thn mn tnh, suy thn cp giai o i hiu, iu tr bng thuc li niu ko
di.
Nat i t g t o g i thn c ph.
- Kali: kali h thng 3,5- ol/l, t g khi > ol/l gp trong vim
thn, i t, ht l khi c v niu.
Ngu h t g K+: nhim toan, chy mu tiu ho, hy hoi t bo nhiu (c
m t o g , hiu th K+ c bit trong suy th giai on cui, khi K+
mu > 6,5 mmol/l s d n ngng tim do rung tht, l nguyn nhn t vong
bnh nhn suy thn mn.
Lu : kali th t g khi :
- Ly mu buc garo qu cht gy toan t chc ti ch.
- Ta u do pht mu vo ng nghim qu mnh.
- T g tiu cu > 700.000/mm3.
3. Min dch.
C nhiu phng php, hi a th g c dng:
3.1. K thut min dch hunh quang (Immunofluorescence): dng khng th
t g g h du bng mt cht pht nh sng hu h ua g nhum
cc tiu bn sinh thit th ua s t di knh hin vi hu nh quang. Trng
hp kt qu d g t h s thy hnh nh l g ng cc globulin min dch gm
cc khng th thng l cc t khng th) bn trong cc mao mch cu thn.
Thng gp trong cc bnh khng th khng mng nn cu thn v vim cu thn
qua trung gian phc hp min d h. l d t g ho hng bnh thn mc
phi tin pht.
3.2. Xt nghi kh g guy c hiu tuyn tin lit (prostate specific antigen,
PSA : c s d g h t xt nghim sng lc cho nhng bnh nhn nam gii
> 50 tui.
+ Ch nh:
- Gim st qu trnh din bin v m p ng vi iu tr ca K tin lit tuyn.
- Gim st cc bnh nhn b ph i lnh tnh tin lit tuyn nhm pht hin sm K
tin lit tuyn.
+ Ph g ph p tin hnh:
Da trn nguyn l chnh l mi t g t c hiu gia khng nguyn khng th.
Hai khng th c x dng l Khng th bt gi v Khng th h du.
Hai k thut c dng ph bin l K thut min dch hp ph enzym (enzyme
linked immunosorbent assay, ELISA) v k thut min dch phng x
(Radioimmunoassay, RIA).
+ Kt qu:
PSA < g/dl: thng gp gi c tin lit tuy h thng.
PSA < g/dl: thng gp t o g ph i lnh tnh tuyn tin lit.
PSA > g/dl: hng nhiu ti K tin lit tuyn.
Tu hi , ch o h h nh l tuyn tin lit cn phi phi hp ng
b nhiu ph g ph p h o theo d i nh.
3.3. Cc xt nghim min dch dng trong ghp thn:
Ghp th l ph g ph p ti u iu tr thay th thn suy. Mun thc hin
c k thut ny cn phi c nhiu tiu chu . T o g tiu hun v min
dch l v cng quan trng khng th thiu c. Nhng xt nghim min dch
bao gm:
+ Nh u A, B, O: c Landsterner pht hin t , h v gi
ta tin hnh thun li trong truyn mu v trong ghp ty x g, gh p tng.
V trn b mt hng cu thuc cc nhm mu khc nhau c quyt nh cc tnh
kh g gu kh hau c gi l khng nguyn ca nhm mu, chng khng
g a p ng min dch gi g h u, h g h g li g a p
ng min dch gi khng cng nhm mu. Cho nn trong ghp th gi
nh gi cho phi c cng nhm mu.
+ h o oss at h : cho gia gi ho gi nhn phi (-) 37oC
22oC v 4oC . l phn ng gia huyt tha h gi nhn vi t bo lympho T
v B ca gi ho, gc li huyt thanh ca gi cho vi t bo lympho T
v B ca gi nhn. Nu phn g + th kh g gh p c, nu ghp s xy ra
phn ng ti cp.
+ Tin mn c t c ghp vi gi nhn thn, tc l tm khng th chng
mnh ghp.
- Nguyn l:
Ly mu ca gi, tch ly t bo lympho. Ly huyt thanh ca gi nhn
cho kt hp vi 20 loi t bo lympho thc cht ta a g t hu t thanh bnh
nhn c khng th khng. Nu c khng th th khng th bm vo t bo lympho
v cho b th vo t bo lympho s cht v pht mu xanhtrypam. Nu t bo
sng (khng c khng nguyn + khng th th s g h thng).
- K thut tin hnh:
Cho bch cu lympho ca gi vo 20 ging khc nhau v cho huyt thanh
bnh nhn vo 20 ging , 30 pht nhit ph g. Sau ho th th
(huyt thanh ca 20 con th 60 pht.
c kt qu: tnh xem huyt thanh ca bnh nhn git c bch cu ca bao
hiu gi.
- Nu git c bch cu ca gi ta c 2/20 = 10%.
- Nu git c bch cu ca gi ta c 4/20 = 20%.
Nu 20% l tt, gh p c.
Nu tin mn c ao > % kh g gh p c, nu ghp s c th xy ra
thi ghp ti cp.
+ HLA hu a l pho te a tige : u tin tm thy trn bch cu lympho
gi nn gi l khng nguyn bch cu gi, v sau n cn c mt trn tt c
cc m, bch cu, tiu cu (tr trn hng cu) nn cn gi l khng nguyn ho
hp t ch . N gha ua t g t o g gh p ua , t o g gh p
thn. gi, cc kh g gu c m ho bi mt on nhim sc th
s 6.
T gi c trn 150 loi HLA. Gm HLA-A: 17 khng nguyn; HLA-B: 31 khng
nguyn; HLA-C: 8 khng nguyn; HLA-D: kh g gu . c chia lm 2 lp:
- HLA-A, HLA-B, HLA-C: gi l lp mt, c trn b mt tt c cc t o t o g
th, c pht hin bng khng th vi k thut nh tp m.
- HLA-D (gi l lp 2): ch c trn t o l pho B, i thc bo, cc t bo
th g , t u g , c pht hin bng nui cy lymphocyt hn hp v cc k
thut huyt thanh hc.
Trong ghp thn, m ph hp ca cc khng nguyn HLA l quan trng, nht
l i vi gi cho th l gi sng. Cc khng nguyn lp 2 quan tr g h
lp 1 trong vi nh s sng cn ca qu thn ghp.
- Nu cc khng nguyn HLA ca gi nh gi cho ging nhau hon ton
l ho hp t ch %, c gi l identical.
- Nu ch c 50% gi g hau c gi l Haplotyp. Tt nht l ho hp t chc
100%, ti thiu l 50%, thp h % th g kh g c ghp vi gi cho l
gi sng. Thc t ghp thn Vit Na p dng nghim ngt cc ch tiu
ny.
Ngoi ra, mt s xt nghim min d h kh g c s dng trong ch o
khi c nghi ng bnh lao thn-tit niu:
- Phn ng Mantoux.
- PCR (polymerase chain reaction): l k thut sinh hc phn t khuy h i c
hiu ADN ca trc khun lao.
- Glutahydrat l xt nghi nh fibrinogen v gamma globulin trong huyt
thanh bnh nhn c lao thn.
- Test nh khng th khng nguyn ca BCG (IgM, IgG, IgA).

14.X QUANG TRONG BNH THN TIT NIU


C g h t ghi c tiu v mu, trong ch o nh thn X quang l
ph g ph p kh g th thiu , c bit l cc bnh thn-tit niu gy nn
do tc ngh ng dn niu, vim do yu t vi khu h gi h g
thn trong cc b h l . C hiu ph g ph p hp X ua g, h g tu theo
tng loi bnh cn c cc ch nh ph hp.
1. Chp thn khng c thuc cn quang.
Th g c ch nh rng ri nht.
1.1. Ch nh:
- Pht hin si c ua g ng tit niu i-b thn, niu qun, bng quang,
niu o).
- X nh bng thn.
- Ch o ph it au l g, tht l g g g t vi au do si tit
niu.
1.2. Chun b bnh nhn:
- Tht tho 2 l t c khi chp loi tr cc hnh nh c th gy nhm ln do
b th hoc si phn gy nn.
- Khng ung cc loi thuc c tnh cht c ua g t g h: is uth
v cc thuc cn quang chp d d , i trng, thc qun...
. . h gi t phim th h thng v bnh l chp t th thng:
. . . B h thng: Vi k thut chp tt phi th g hu, thy
r
bng ca 2 th h thng:
- Cc trn ngay m ga g t s g l g .
- C di ngay m ga g t sng tht l g ; thn phi thp h thn tri
mt t sng. Khng c hnh cn quang thn v niu qun, bng quang.
1.3.2. Bnh l:
+ Bng thn to nhiu gp trong: c, m th , u g th thn, khi mu t
trong thn sau ch th g.
+ Bng thn khng v t h thng gp trong sa thn hoc thn lc ch.
Khi n chp thn c thuc c ua g UIV nh.
+ Thy hnh nh cn quang ca si: to hoc nh, hnh th khng c nh thn,
niu qu , g ua g l si cn quang (si canxi phosphat, canxi carbonat,
amonimagie phosphat...), khng th c cc si khng cn quang (si urat,
xanthyl, systin...).
+ Lu t s t ng hp c th nhm ln l si:
- vng tht l g-h chu: si ti mt, si tu, cc hch vi ho, si phn, cc
khi u trong bng b vi ho , i ho t o g ph g ng mch thn, cc
m ga g t sng.
- vng tiu khung: c nhiu hnh nh d nhm vi si tit niu: cc hch vi
ho, cc dy ch g i ho , im vim t t h ch (phlebolites).
- Vng bng quang: d nhm vi cc khi u bng quang b i ho , u i ho .
+ Khi c nghi ng nhng hnh nh cn quang khng phi ng tit niu h:
m ga g t sng, cc hch mc treo b vi ho, vi ho ty, si phn, si ti
mt th cn phi chp thm mt phim nghing (si th thng thy sau ct
sng, cn li do cc nguyn nhn khc th t c ct sng).
- Nu t ng hp cn nghi ng ch o , th tin hnh chp thm mt
phim sau vi gi hoc sau vi ngy.
2. Chp thn c thuc c ua g v o t h ch (UIV: urography intravenous).
2.1. Nguyn l, m h:
2.1.1. Nguyn l: K thut ny da trn nguyn l dng mt loi thuc cn quang
c cha iod ta t o g , c tnh chn lc ch thi ua ng tit niu sau
khi tim vo mch mu.
2.1.2. M h:
- h gi h g i tit ca th lu th g ng tit niu.
- h gi h h th i thn-tit niu: pht hin bnh l d dng, ch th g, u, lao
thn.
- Pht hin si, nht l si khng cn quang.
2.2. Ch nh, chng ch nh:
2.2.1. Ch nh:
- Si thn-tit niu, u g th thn, lao th , i a u, i dng chp.
- Ch o ph it thn to vi cc khi u khc trong bng...
- Si thn-tit niu cn quang khng r v si khng cn quang.
- U nang thn, thn c.
- Thiu sn thn.
- T g huyt p nghi do hp ng mch thn.
- Vim thn-b thn mn.
- Lao th i dng chp.
2.2.2. Chng ch nh:
- Suy thn: khi ur huyt thanh > 8mmol/l hoc > 50mg%.
- D ng vi iod.
- i u i th a g tip din.
- a g su ti , a g t ng.
- a g thai.
2.3. Chun b b h h , ph g ph p tin hnh:
2.3.1. Chun b bnh nhn:
- Xt nghim ur, creatinin huyt thanh.
- Th phn ng vi iod: ti di da 0,5 - 1 ml thuc cn quang c iod, theo di
phn ng d ng:
. Nh: nng bc ho, nga m a , ph Qui k.
. Va: nn, bun nn, tt huyt p, nhp tim nhanh hoc chm, t th g th h
mch ti i ti .
. Nng: kh th, co tht thanh qun, ph phi cp, try tim mch.
- Tht tho 2 l t c khi chp.
- Thuc v dng c chun b cho x tr cp cu:
. . . Ph g ph p tin hnh:
*Chp theo ph g ph p th g thng:
- Bnh nhn nm nga, hai chn thoi mi.
- Chp mt phim th th g t c khi tim thuc c ua g, ga sau
tim 1 ng thuc cn quang 20 ml t t o t h ch trong 10 pht. Dng 2 qu
p p vo 2 h chu (m h p iu qu gi thu l u t i
th kh g ho c tiu c thuc cn quang xung bng quang).
- Giai on p: 5 - 7 pht sau khi tim thuc cn quang th bt u chp phim.
Tip , hp phim vo cc pht 15, 30, 45 sau tim. pht th 60 b p v
chp
thm mt phim. Nu c nghi ng th chp thm mt phim na pht th
120.
* Chp theo ph g ph p gi git t h ch:
- Ch nh: si thn san h hai bn, chp UIV thn khng bi tit, ur mu cao,
ch th g thn, nghi c dp v thn.
- Ph g ph p: t g liu thuc cn quang gp 2 - 3 l h thng (1 - 1,5 mg/kg
cn nng), ho thuc trong 100 ml dung d h glu oza g t g. Gi git t h
m h t g i nhanh trong 10 pht. Khng p niu qun.
- Chp phi u tin ngay sau khi truyn ht thu . Sau 10 pht chp 1
phi ho n ht pht th 60. Nu cn nghi ng th chp mt phim pht th
120.
2.3.3. Nh nh kt qu:
* Th h thng:
- phim chp 5 - 7 pht sau tim thuc c ua g thy thuc hin hnh
ng u 2 thn, chng t thu gm vo nhu m thn v bi tit qua
ng niu.
- 15 pht sau tim thy hin hnh thuc r i-b thn, c th thy thn v
i thn c hnh d g k h th h thng, mi qu th h i
thn to, mi i to hia a - i thn nh, mi i thn nh tn cng bng hnh
g ua. Nh i th t h g l t , h i thn gia hng ra
go i, h i thn di hng xu g di v ra ngoi.
- Niu qun: c ch tht, ch ph h, h g kh g to, ng knh 0,5 - 0,7 cm,
niu qun chy dc theo hai bn ct sng.
* Bnh l:
+ Ch g:
- Khng thy thuc cn quang ngm qua thn do:
. Thn mt hon ton ch g.
. C th do mt gu h o g phn x c ch thn, thn im lng
kh g p ng vic ngm thuc.
. Khng c thn v t h thng, thn lc ch.
- C ngm thuc c ua g h g hm so vi h thng do ch g
thn b suy gi h g ha t hon ton (nu trn 30 pht khng thy thuc
bi tit i-b thn th ch g i tit gi . T o g t ng hp ny cn
chp th phi sau h h gi th t ch g ho to ha
ha.
+ Hnh th: c th c bin dng v hnh th h sau:
- Hnh h i-b th d g th h tng chm trn do cht tc pha
di.
- Hnh nh khuyt i-b thn do cc khi u c tnh.
- Hnh h i-b thn ko di khong cch gia i thn rng do cc khi
nang trong thn.
- Hnh h i-b thn nham nh, gp trong lao thn.
- Cc hnh nh d tt bm sinh: thn lc ch, th , thn mng nga, cht
hp ch ni niu qun-bng quang.
3. Chp niu qun b thn th gc dng c thuc cn quang (uretero
pyelographie retrograde, UPR).
3.1. M h:
- Pht hin hp hoc tc niu qun do si hoc cc nguyn nhn khc; nu cn
nghi ng si cn quang niu qun th chp th g d g l ph g ph p hn
o nh c gi tr.
- Nhm pht hi h h i-b thn niu qu t o g t ng hp chp thn thuc
t h ch khng ngm.
3.2. Ch nh, chng ch nh:
+ Ch nh: Tt c t ng hp khng chp c UIV hoc chp UIV cho kt
qu khng r. Tm c g d lu th g t thn sang h thng bch huyt.
+ Chng ch nh:
Khi c nhim khu ng niu: vim bng quang, vim niu o v d gy vim
b th gc dng.
. . Ph g ph p: a so de gc dng t niu o vo bng quang ln niu
qun vo b thn qua g soi g ua g, - 15 ml dung dch thuc cn
quang qua sonde ri chp phim th nht ga sau khi thuc v phim th hai
sau 5 pht.
. . h gi kt qu: C th thy cc hnh nh bt thng:
- Thy r hnh h i-b thn- niu qun vi cc hnh nh b h l h phn chp
UIV t.
- X nh v tr cc d vt ho on cht tc trn thn hoc.
- Th g d lu th g t thn sang h bch huyt.
+ u im ca ph g ph p: a thuc trc tip vo b thn, thuc khng b pha
lo g, i thn r; c th kt hp ra b thn ri a thuc khng sinh
vo b thn v l c tiu t b th xt nghim tng bn thn.
+ Nh im: ch bit h h d g i-b thn m khng bit c hnh thi
thn, ch g thn, d gy nhim khun t di ln, nu nh c th gy
v i thn, l k thut t g i phc tp c ch nh khi tht cn
thit.
4. Chp bng quang.
4.1. Ch nh:
Pht hin cc bnh l bng quang, pht hin d dng bng quang v th tch bng
quang vi b h h c nhn th t c ghp.
. . C ph g ph p hp bng quang:
4.2.1. Chp bng quang th thuc xung bng quang: theo ph g ph p hp
UIV.
4.2.2. Chp g ua g gc dng: t mt ng thng mm vo bng quang,
thuc cn quang qua ng thng vi khi lng va chp mt phim vng
tiu khung.
4.2.3. Chp hi v o g ua g: t mt ng thng mm vo bng quang,
g hi o g ua g i s lng va , rt ng thng chp phim
vng tiu khung.
. . h gi kt qu:
. . . B h thng: Dung tch bng quang 200 - 300 ml, thnh bng quang mm
mi, nhn, nim mc hng, khng c xung huyt, gianh gii g t g
mu.
4.3.2. Bnh l: Th tch bng quang qu nh < 50 - 100 ml, hnh h t o gc
thnh bng quang niu qun. L d bng quang vi rut, bng quang vi o,
khi u t o g g ua g, g ua g d g, i g ua g p th xung
huyt , mn th nim mc nht nht, bng quang d dng, hnh nh u tin lit
tuy i ln c bng quang.
5. Chp th hi sau ph et o pe ito eal p eu og aph ha
kh t g g p esa al p eu og aph .
Chp X quang th sau khi hi o ua h h thn sau phc m , hi c
vo t chc quanh th , hi s tch thn v t chc nn nhn thy r thn v
tuy thng thn.
5.1. Ch nh:
- Pht hin bng th , k h thc thn, tuy thng thn.
- Pht hin cc d dng ca thn.
- Pht hin cc khi u sau phc mc, cc p xe cnh thn.
5.2. Tin hnh:
- B kh o khoa g ph c qua kim chc v o im sau tr t g t c
g g t: kh o t o g thy nh l g tr.
- Kh c dng l: xy hoc kh tri, l g kh o - 500ml.
Ch : khi kh o o phi nm nghing v , hp X quang ngay
sau khi kh . B kh o g BN nm ph phc 5- hi i l h thn
ri mi chp, t c chp c h l g hi l h th ha th g
vng h thn thy trong, hoc tt nht l chiu X quang kim tra.
- Sau khi chp cho bnh nhn n t th u thp trong 24h.
5.3. Tai bin: Tai bi thng gp l au l g, au g, t kh di da, trn khi
trung, tht tc m h hi. c bit c phng c th c phn x ng g ti t
ngt do khi kh p k h th h l ho h. Hi a , ph g ph p t
c dng v c siu m thn, n ch c dng trong mt s t ng hp
nh nh hnh thi tuy thng thn.
6. Chp ng mch thn.
6.1. Ch nh, chng ch nh:
6.1.1. Ch nh:
- ch o h g tha i ng mch thn: hp, tc, thng, ph g ng
mch thn.
- T g hu t p m n g iu tr thuc h p km c tc dng km hoc
khng c tc dng, nht l vi gi tr tui.
- U, th a a g.
- Ch th g g rch nhu m th t mch mu.
- h gi t h t g ng mch thn ca gi cho th t c khi ly th
ghp.
- h gi phc hi mch mu v ch g u thn sau ghp.
Hin nay, siu m, CT scanner, c g hng t l nh g ph g ph p kh g
nhp cho kt qu chnh xc nn ch h t c p dng, ch dng khi cn
thit.
6.1.2. Chng ch nh: khi c suy thn.
. . Ph g ph p tin hnh:
- Lun g th g athete ua ng mch b l ng mch ch bng theo kiu
Seldinger. Khi ng thng ln trn ch ph hia ng mch thn 1 - th
thuc cn quang b g ao p vi t tim v p lc mnh khong
10ml/giy mi c th to cho thuc cn quang chon ch c lng mch v yu
cu phi chp vi thi gian pht tia ngn (< 0,5 giy). C th d g ph g ph p
quay camera lin tc t khi thu n khi thn bi tit ht thuc; c th
chp tng bn thn b g h a g th g o ng mch thn cn chp.
. . h gi kt qu:
+ B h thng:
Giy th 1-3: th ng mch th h h th ng mch).
Giy th 4-6: thy hnh thn (th thn).
Giy th 12: thy t h ch th th t h ch).
Giy th 60: th h h i-b thn (th bi tit).
+ Bnh l:
- T g si h ch v tr c khi u c tnh ca thn.
- Gim sinh mch mu nhng vng c khi u nang.
- Ph h ng mch thn, hp ng mch thn b h h t g huyt p, c th
thy nhnh ph ca ng mch thn.
7. Chp bch mch.
7.1. Ch nh v tin hnh:
7.1.1. Ch nh: ch o t ng hp r bch mch.
7.1.2. Tin hnh: tm bch mch vng mu chn b g h ti a h E a s di
da s ngm chn lc vo bch mch.
Bc l bch mch: dng kim nh lun vo bch m h, thuc cn quang du
loi lipiodol cc lng (lipiodol ultra fluide) b g p lc.
Chp phim th sau n 1h.
7. . h gi kt qu: sau khi tim, thuc cn quang ngm vo h thng bch
mch quanh th . T ng hp bnh l c th th d ng bch mch,
hoc thy ngm thu o i th l d dng chp vo th i dng
chp).
8. Chp ct lp vi tnh trong ch o h h th i CT s a e .
8.1. Nguyn l:
N , CT s a e c ng dng l u ti chp s no. T ti nay,
CT scanner pht trin khng ngng v phm vi ng dng ca k thut c
m rng vo nhiu hu khoa, t o g h o h h th i thn-tit niu.
Nguyn l ca chp ct lp vi tnh da vo s khc nhau v ca cc cht
cu to nn t chc- ua c chp hin ra trn mn hnh ti cc lp ct khc
nhau qua x l bng my vi tnh.
T o g th, , ua kh hau c cu to nn bi cc cht c trng
lng phn t kh hau khc nhau. Cc t chc c tr g lng
phn t l , cao s cn nhiu tia X; Khi , h h hp ct lp i t h c
th hin bng hnh sng trn phim, v d h h h g. C t chc c trng
lng phn t nh, thp s t c tia X; Khi , hp CT scanner s cho
hnh ti ha h h e t phi , h: h h a d h, , hi.
Cc kt qu thu ua c cc phim chp ct lp vi tnh gip ta c th chn
o nh hoc ch o ph it h h hi, h h dch, hnh mu mi
ch , h h u g, dch thm, dch tit, p xe, cc khi u tt c ua ,
t o g thn-tit niu.
8.2. Ch nh v k thut:
8.2.1. Ch nh: Chp ct lp i t h ch o nh thn khng phi l k
thut rng ri m ch c dng trong mt s t ng hp: nghi ng u tuyn
thng thn, u sau phc mc, u thn, kn thn, lao thn, ch th g thn.
8.2.2. K thut:
Trong k thut chp ct lp vi tnh, cc lp ct dy l 10mm, bt u t t
s g D t sng tht l g L . Trong mt s t ng hp cn phi lm r
nhu m th ng tit niu th c th tim thuc c ua g g t h ch
t c khi tin hnh lm k thut chp vi tnh ct lp.
8.3. Hnh nh bnh l:
- U nhc thn: trn phim chp ct lp vi tnh thy c khi t g t trng, lm to
mt cc ca th , h p i-b th g t g ng.
- U h y niu qu g gi i-b thn pha trn.
- U tuy thng thn: thy khi u t g t trng dng kn vng cc trn thn, c
th mt bn hoc hai bn. Sau tim thuc cn quang khi u khng ngm thuc
cn quang.
- Kn thn: ch thy mt k k h thc ty thu o ln ca kn.
- Th a k : l hng gim t trng hnh trn, b , k h thc khong vi
e ti et, kh g u, thng km theo kn trong gan.
- Ch th g thn: chp ct lp vi tnh cho thy hnh dng, v t ng dp
v.

15.XT NGHIM THM D CHC NNG THN

. Th d h g lc ca cu thn.
. . o c lc cu th ua t h thanh thi creatinin ni sinh:
. . . gha v guyn l: T o g l s g, gi ta o c lc cu thn (MLCT,
cn gi l lea a e ua t h thanh thi creatinin ni si h, l ph g ph p
hu hiu c gi tr quan trng trong ch o nh suy th giai on suy
th . thanh thi creatinin ni si h l s cho ch ph g ph p iu tr ph
hp I IIIa l iu tr bo tn, t IIIb tr i phi iu tr thay th: lc
mu chu k hay ghp thn).
Creatinin ni sinh trong huyt thanh l sn phm ging ho cui cng ca
eati i c lc qua cu th , h g kh g ti hp thu v rt t c bi tit
ng thn, nn creatinin bi xut khng chu h hng ca l g c tiu. Do
lng creatinin huyt tha h kh g tha i t o g g lng creatinin ni
si h t g ng vi mc lc cu thn (glomerular filtratron rate).
gi h thng, n g creatinin huyt thanh l 44 - ol/l, t g
ng vi 0,8 - 1,2mg/dl (mg%) v mc lc cu thn l 80 - 120ml/pht. Khi suy
thn, ty t g giai on m c mc lc cu thn gi lng creati i t g
t g ng trong huyt thanh.
. . . Ph g ph p tin hnh:
- Th g go c tiu 24h (nu phn 1) ho g th t iu ki
go c tiu h, h, h tnh s l g c tiu trong mt pht.
- L l c tiu vo ng nghim gi i h lng creatinin niu. Thng
nn kt hp vi xt nghim protein niu, ur niu, p lc thm thu in gii
gi p ho theo d i iu tr.
- Ly 3ml mu cho vo ng nghim gi i h l g eati i u. Th g g
cho kt hp xt nghim ur u, in gii, kim-toa theo d i ph g
ph p iu tr ph hp.
1.1.3. Tnh mc lc cu thn (MLCT):
Ucr V (ml/pht) 1,73
MLCT = ----------------------- ------------
Pcr S
MLCT: h s thanh thi creatinin ni sinh (ml/pht).
Ucr: n g eati i t o g c tiu (mmol/l, c i a ol/l d g
vi creatinin mu).
Pcre: n g creatinin trong mu (mmol/l).
V (ml/ph): th t h c tiu/pht (ml/ph).
1,73: di t h da t th ca mt gi u Chu chu ha th g s
cho
gi Vit Nam),
S: di t h da t th bnh nhn (m2) theo b g Du ois. i chiu chiu cao
cn nng s cho kt qu din tch da.
Trong thc t thng ch tnh mc lc cu thn theo cng thc sau:
Ucr V
MLCT = ----------------- (ml/pht).
Pcr
gi h thng MLCT l 120 ml/pht. Khi MLCT < 60 ml/pht l c suy
thn.
1.2. Tnh MLCT vi gi ln tui da vo n g creatinin mu, tui, cn
nng, theo cng thc ca Cockroft v Gault (1976):
(140 - tui) cn n g th (kg)
MLCT (ml/ph) = --------------------------------------------
72 creatinin huyt thanh (mg/dl)
Ph g ph p kh g h h g ph g ph p go c tiu 24h.
S l g o h s thanh thi creatinin ni sinh cho kt qu ao h h s
thanh thi creatinin ni sinh thc bnh nhn suy thn. Suy thn cng nng th
chnh lch cng ln, v s bi tit creatinin ng th t g t creatinin
qua rut. Th o l tui 35 tr ln th mc lc cu thn gim dn cho
go i tui 50 th s lng nephron gim t 1- %. T o g khi , tr em
th n g eati i t g dn do khi l g t g theo tui. Do vy, s dng
cng thc trn s c th d h gi sai c lc cu thn.
Cho , ph g ph p h lm cho nh g t ng hp c bit (khng th
gom c tiu trong 24h) v kt qu ca n v mc lc cu thn khng th
l s h h ch o h h iu tr (lc mu hay ghp thn).
Ch : Ph g ph p lng ny vi n gii phi tr 15% v khi l g n
thp h a . g l l do phc tp, gi ta t s d g ph g ph p
ny.
Bng 7. Ph hia giai on suy thn da vo MLCT v n g creatinin mu.

Giai on Mc lc cu thn Creatinin mu


suy thn ml/pht
mmol/l mg/dl

B h thng 120 44-106 0,8-1,2


Giai on I 60-41 < 130 < 1,5
Giai on II 40-21 130-299 1,5-3,4
Giai on IIIa 20-11 300-499 3,5-3,9
Giai on IIIb 10-06 500-900 6,0-10
Giai on IV 5 > 900 > 10

. Th d h g ng thn.
Ngi ta th d h g ng thn b g h gi kh g c tiu.
. . Nguy l gha: Dch lc cu th khi i ua h thng ng thn, thng
qua qu trnh ti hp thu v bi tit s c ho ho lo g p sut
thm thu dch lc ngang vi mc thm thu huyt t g khong gn 300
os ol/kg . B h th g, c tiu c gp 2 - 3 ln, c th ti a
gp 4 ln (600 - os ol/kg c). Khi c t th g ng thn v k thn,
c tiu kh g c v hu qu l t tr g c tiu gim. Khi t trng
c tiu gim l th hin ch g ng thn gim st. Trong lm s g gi ta
dng ch s pht hin mt s bnh:
- Bnh ng thn v k thn: hoi t ng thn cp, vim k thn do ung nhiu
thuc gi au, i thn - b thn cp v mn, bnh nang ty thn...
- i th o ht.
- Suy thn cp giai o i hiu).
- Suy thn mn...
. . C ph g ph p h gi h g c ca ng thn:
. . . o t tr g c tiu bng t trng k:
+ [ gha gu l :
L o t g lng ca cht ho tan trong mt th t h c bng t trng
k.
+ Ph g ph p tin hnh:
- o t tr g c tiu bng t trng k nhit chun l 16oC. Khi nhit ti
v t o t g l 3oC th s o gim xung 0,001. Khi nhit gim 3oC th s
o phi t g , . Cho i chiu vi nhit ph g tr hoc thm
vo.
- Mu c tiu: l l c tiu ti o ui s g vo bnh tr nh,
nhng t trng k o h kh g o ga sau khi i, phi t pht cho
nhit c tiu bng nhit ph g . T khi o n xem nhit phng,
chun t trng k trong c ct phng sai s (nu t trng k chun tt
khi trong bnh cha c ct, s o t trng k phi l 1 vi nhit phng l
16oC).
- o: c s o t trng k ngp c vi nhit phng (cng vo hay tr i .
- Nhng yu t gy sai s: c tiu c nhiu protein, glucose, cht cn quang
(chp UIV t h ch thn) hoc dng cht kh khun lau t trng k.
+ h gi kt qu:
B h thng, t tr g c tiu u tin vo bui sng t 1,018 tr ln l kh
g c tiu tt.
. . . o p sut thm thu c tiu b g o thm thu vi mu c tiu
sng sm:
+ Ngu l ph g ph p:
o h g im ca cht d h, d g o thm thu s cho kt qu p lc
thm thu ca cht t g ng vi h g im ca dung dch c o tnh
a os ol t o g kg c, khng ph thu o in th, k h thc, trng
lng ca tiu phn cht ho tan trong dung dch.
h g im
p sut thm thu (ASTT) = -----------------------
os ol/kg c) 0,00186
l ph g ph p gin, d p dng c gi tr trong ch o .
+ Cch tin hnh: B h h ung sinh hot h thng, ti h t c khng
c dng cc cht c tc dng li tiu, t khi i g phi i tiu ht bi,
t o g kh g c ung thm , kh g c truyn d h. Nc tiu u
tin sng sm lc ng d , ng trong b sch l l o thm thu.
+ h gi kt qu: Nu thm thu 60 os ol/kg c l kh g c
c tiu ca th h thng. Nu thm thu < os ol/kg c kh
g c tiu gim. Mu h gi h h phi lm xt nghim li 3
ln.
2.2.3. Nghim php Zimniski:
L ph g ph p o t c tip s lng v t tr g c tiu nhiu ln trong 24h
h gi h g ng thn.
+ Tin hnh:
Ngy lm xt nghim, bnh nhn v ung v sinh hot h thng.
Nghim php: ly 8 mu c tiu/24h, cch 3h ly mt mu o s lng v t
tr g c tiu ca mi mu: 6h b h h i i , sau cch 3h: 9, 12,
15, 18, 21, 24, 3, 6h sng hm sau).
+ h gi kt qu:
. B h thng:
Trong cc mu c tiu phi c mt mu c t tr g , thng mu
24h, 3h).
Cc mu khng c hi t g ng t trng (chnh lch t tr g kh g g k).
S l g c tiu cc mu trong ngy nhiu h a thng gp 2 ln).
. Kh g c tiu gim:
Khng c mu no c t trng 1,025.
Cc mu c hi t g ng t trng.
S l g c tiu a m nhiu h g .
2.2.4. Nghim php nhn kht ca Volhard:
+ Ph g ph p tin hnh: Bui sng, cho b h h i tiu ht bi, t kh g
c u g c (cc ba s g, t a, ti phi h kh ng bnh m ),
l g -ung-tim truyn khng qu 500ml/24h. Nghim php ny ch t
yu cu vi ch nhn kht nghim ngt sao cho: thi gian nhn kht c t
18h m cn nng bnh nhn phi gim 3-5% so vi t c khi lm nghim php.
C h o s l g thm thu hoc t tr g c tiu mt ln.
+ Nh h h gi kt qu:
- B h thng:
S l g c tiu cc mu gim dn theo thi gian.
C mt mu c tiu thm thu t os ol/kg c (hoc
t
trng 1,025).
- Kh g c tiu ca thn gim khi:
S l g c tiu cc mu xp x bng nhau.
Khng c mu c tiu o thm thu os ol/kg c (hoc t
trng 1,025).
Ngoi ra cn mt s ph g ph p kh th d h g ng th , h
ph g ph p o h s thanh thi c t do, nghim php hn ch c,
nghi ph p ti a gi i asop esi AVP h g t c s dng.

16.I BUT-I RT

. i ut, i dt.

+ h gha: i ut l au ut t c, trong ho sau khi i, au m gic


g t th g t g dn ln v sau i, l ho nh nhn rt kh chu, tr em
c th ku kh , th g k theo i dt.

+ Ngu h v h bnh: h thng khi bng quang c khong 300ml


c tiu t g i c phn x kch thch bng quang co b p ng thi tht
g ua g g c m c tiu tng ra ngoi.
i ut, i dt l do bng quang b kch thch bi yu t vim hoc yu t ngoi
lai ho do gng kch thch h thp.

i ut, i dt thng gp trong cc bnh:

- Vim bng quang cp tnh.

- Si bng quang, nht l khi gp si lt vo niu o.

- Vim tin lit tuyn, vim niu o, vim quanh hu mn, vim b phn sinh
dc n h t cung).

- U bng quang, u tin lit tuyn, nht l khi c nhim khun km theo.

. i hiu ln.

+ h gha:

B h h kh g au g ut t , t o g sau khi i, i l i u c
c tiu, h g s lng t c th 30ml ho l i hiu ln trong ngy
(c th 20-30 ln).

+ Ngu h h:

- Do bng quang gim dung tch hoc gi gng kch thch phn x i; thng
gp trong cc b h: lao g ua g t hg teo g ua g; u, u g
th g ua g him ch th tch cha ca bng quang, khi u ngoi chn ln
vo bng quang.

- Do ri lon thn kinh ch g, thn kinh chi phi g ua g l gng kch


thch co bp bng quang v m c bng quang s h h th g; thng gp
gi b ch th g thn hoc b bnh ty sng.

. i kh g t ch.

+ h gha: l t g th i gi bnh khng ch g iu khin c cc ln


i t o g g , c tiu t r a thng xuyn hoc tng lc, c nhn bit hoc
khng nhn bit c.
C 3 lo i kh g t ch:

- i kh g t ch ho to : c tiu thng xuyn r ra, khng c phn x


t i i.

- i kh g t ch khng hon ton: bnh nhn vn cn phn x t i i


h g ha kp i c tiu c r ra qun khng t ch, khng nh c
ho i so g c tiu r ra vi git.

- Bnh nhn khng cm nh c: khi thy qu l t t mi bit l c tiu


chy ra v song song vi i ra khng t ch, gi bnh v iu khin cc ln
i t o g g . Loi thng gp n c niu qun lc ch c o o
mt bn.

+ C h bnh sinh:

- B h th g c tiu t thn xu g g ua g c tch tr khong 300 ml


s t g g k h th h, l th h g ua g o tht, tht c bng
quang m ra v hot g i c thc hin.

- iu khin qu trnh ny din ra phc tp c s tham gia ca h thn kinh trung


g, h khu no, h thng ngoi thp, cu o h g t ng tm l cung phn
x i i li nm ty sng ngang S2, S3, S4.

- Do v h i kh g t ch c th l:

. C h thn kinh: t th g v no, no ty sng.

. C thnh bng quang mt t h hi.

. C th h g ua g tht bng quang niu o b suy yu.

. Mt cn bng gia kh g ha ca bng quang, h th g tht c bng


quang v niu o.

. D d g ng tit niu.

+C gu h g i kh g t ch:
- Nguyn nhn thn kinh: ch th g t sng, tai bin mch mu no, tn
th g th ki h t o g i th o ng, bnh Parkinson.

- Ngu h go i tht: r niu o o o; g ua g o o;


niu qun d dng c o o n.

- Nguyn nhn khng phi thn kinh:

. i kh g t ch do hc: tin pht hoc th pht do s t o g c tiu


t o g i a nam gii, p g ua g kh g h i so g ra vi git
gp u tin lit tuyn.

. i kh g t ch do kch thch do bng quang qu nhy cm; gp trong vim


bng quang, vim lao v u bng quang.

. Do dng thuc: an thn, thuc ng qu nhiu.

17.I T-I NHIU-V NIU

. i hiu.
+ h gha: T o g l s g, u thng xuyn b h h i l t/ g l i
nhiu.
B h thng, mi ngy mi gi i t 1,2 - 1,5 lt; u g t c hoc ma h
nng b ha lao ng i t ng nng ra nhiu m h i th l g c tiu s
t h .
+C gu h g i hiu:
- Ngi h thng do ung qu nhiu c hoc truyn dch qu nhiu g
g i hiu.
- Vim thn k, vim thn-b thn gy t th g ng thn h hng ti chc
g ng th l c tiu khng thc hi i hiu.
- Vim ng thn cp (suy thn cp) giai o i t li do ng th ha hi
phc ch g c tiu g i hiu.
- i th o ng: l bnh ri lon chuyn ho, biu hi l s g g
nhiu, ung nhiu, i hiu.
- i th o ht: l bnh ni tit do gim ADH, l yu t chng bi niu g i
nhiu.
. i t, v iu.
+ h gha:
- i t l l g c tiu < 500ml/24h.
- V niu l l g c tiu < 100ml/24h.
+ Ngu h h bnh sinh:
- L do thn gim ch g kh g sn xut c tiu do suy thn cp v
suy th giai on cui.
- Cc bnh thn nht l vim cu thn mn c hi chng th h hoc hi chng
th h thun (l loi bnh th im l ph to, ph nhiu g
c th thiu niu, v niu) trong vim cu thn cp ho t cp ca vim cu
thn mn.
- Thiu niu, v niu cn gp trong cc b h su ti , ga giai on mt b
iu tr su ti , ga thuc li tiu kh g p ng).
- Mt s bnh nhim trng gy st ao g g thiu niu, v niu.
+ Nhng nguyn nhn gy suy thn cp lm thiu niu, v niu:
- T c thn: mt mu, mt c, tt huyt p, suy tim.
- Ti thn: vim cu thn cp v mn, ng c gy t th g ng thn cp, st
rt c tnh, ng c mt c trm.
- Sau thn: do si, do u.
+ Vi suy thn mn: l hu qu ca nhiu bnh th t o g giai on cui.
C h:
. Do mt mu lm gim p lc lc cu thn.
. Hoi t ng thn cp, tc ng thn.
. T g p lc t chc k thn.
. Suy th giai on cui lm thn mt ch g a cc nephron khng to
c tiu.
18.HI CHNG THN TO

1. Khi nim.
B h thng, mi gi c 2 thn hnh ht u nm sau phc mc, dc 2 bn ct
sng t t sng ng t s g l g , thn phi thp h thn tri.
Tr g lng mi thn ca gi Vit Nam t 130 - g a . K h thc thn: di
9 - 12cm, rng 4 - 6cm, dy 3 - 4cm.
T o g l s g khi k h thc thn v/hoc tr g l g t qu gii hn bnh
th g c gi l thn to.
C nhiu nguyn nhn gy th to h: m, c th , u g th thn, th a
nang...
Ch o thn to da o th kh l s g l nhn, s, g...) v cn lm
s g h X ua g, siu ... . T tng nguyn nhn gy thn to m c thm cc
biu hi t g a gu h .
2. Ch o thn to.
+ Ngi bnh c th au ko di nhiu thng, nhiu , k m gic tc
nng v g sau sn c 2 bn hoc mt bn. Triu chng ny c th h
kh nhn th , h g g th biu hin cp tnh, ph thuc vo nguyn nhn
gy thn to v cc triu ch g kh h: i u, i .
+ Khm lm sng:
- Nh g sn hoc vng h th t g ng pha sau c th thy ni
v g, d l h h thng hai bn hoc mt bn thn.
- S o g sn 2 bn nu c thn to s thy cm gic khi ch di tay.
Du hiu chm th d g t h, p bnh th d g t h.
. Du hiu chm thn: bnh nhn n t th nga, 2 gi gp th u. B ta t
ln trn vng m s t g ng vi v tr ca thn, n xung theo nhp th t
trn xu g, hng t ngoi vo ri t trong ra nhiu l . B ta kia t pha sau
vng h tht l g, u c cm gic chm vo mt khi c gi l chm thn
hay chm tht l g d g t h. Du hiu chm thn (+) l biu hin thn to,
h g g th mt khi u khc nm sau phc mc m khng phi thn. Bn
phi nu gan to, bn tri nu lch to hoc mt khi u khc trong bng th chm
thn (-), nu ga l h to th g c v t t g ng trn thnh bng v du hiu
bp bnh thn (-).
. Du hiu bp bnh th : t th b h h h l du hiu chm thn. Bn tay
trn thnh b g g s t g ng vi v tr ca thn n xung nh ri
, ta kia t ph a di t g g, d g g ta y ht ln ri
yn, dng cc ngn tay ca bn tay trn n xu g. g t l h y cn rt
khot, nhiu ln.
Khi ta t ta di c cm gic chm phi mt khi trn, chc, di
ng bp b h, c gi l du hiu bp bnh thn (+). Du hiu ny rt c gi tr
trong ch o thn to.
- Cn lm sng:
ch o nh thn to cn phi lm thm cc xt nghim cn lm sng:
siu m thn, chp th hi sau ph c, chp thn c tim thuc cn
ua g t h ch, chp th thuc c ua g gc dng, chp CT
scanner, chp MRI...
Nh g gu h thng gp gy thn to trong lm sng l m thn, c
th , u g th thn v th a a g. Mi loi u c triu chng lm sng v cn
l s g t g.
2.1. Thn to do m:
L mt tnh trng bnh nng, do ng m ti thn d n s ph hy nhu m
thn v t chc xung quanh thn lm thn mt ch g. T iu chng ca thn
to do m c th hin:
+ Lm sng:
- Biu hin tnh trng cp tnh, din bin nhanh do tnh trng nhim khun: bnh
nhn st 39-40oC, rt run, m h ha h, li bn, tnh trng nhi c-nhim
trng.
- B h h au tc nng vng m g sn v/hoc h tht l g t hoc c hai
, au ko di, c khi sut g ng bi tit ca thn b gi g
do c tiu chuyn sang m.
- Nc tiu u c do c ln m, i khi i u to i.
- Khm: thn to m , di g, au khi kh , du hiu chm thn r. Tuy nhin,
nhiu t ng hp thn m li vim dnh vi t chc xung quanh nn khi khm
thy th to h g kh g di ng, du hiu chm thn khng r nn phi nh
ph g ph p l s g nh.
+ Cn lm sng:
- Xt nghim mu:
. Bch cu t g, khi ti 30.000/mm3, t o g ch cu a h t u g t h
t g g thc bch cu chuyn tri), t mu l g t g.
. Hng cu thp nu c suy thn hoc bnh thn mn tnh lu ngy gy thiu mu.
. U , eati i u t g, c lc cu thn gim nu c suy thn.
- Xt nghi c tiu:
. C t bo m, bch cu (c th c hng cu v vi khu soi ti khi s lng vi
khun 105/ l c tiu ly gia d g g ph g ph p l hiu khun
niu; hoc l c tiu chc ht trc tip t bng quang nui cy vi khun c vi
khun gy bnh mc > 103 vi khun/ml.
- X quang h tit niu: bng thn to, c th c hnh nh si gy t ng niu.
- X quang UIV:
. Thn cm / t ng hp m, thn cn hot g h g gim ch g,
biu hin: bi tit thuc chm, i-b thn gin, nhu m mng, b th g
phng, c khi thy si t o g i-b thn.
. Hnh nh hot ng thn bn lnh. Nu to ra l ch g hot ng thn lnh
cn tt, b tr cho bn b bnh.
- X quang niu qu gc dng: th c v tr tc b thn v nguyn nhn gy
t ng niu.
- X quang chp b thn-niu qu u i d g: ho k h thc thn to, hnh nh
d i thn.
- Siu m: rt quan trng, cho thy hnh nh gin tip ca th to l i thn
gin, c th t c nguyn nhn, v tr tc v pht hin t th g hoc dch
ng t chc quanh thn.
T l im lm sng, cn lm sng ca thn to do m thn. Trong
lm sng cn phn bit vi thn to do c thn: khng c biu hin nhim
khun. Thn c th g to h g kh g au, m, khng rn chc. Chp UIV
thn c th cn ch g siu l dch ng trong khng c vt cn m
ca m thn.
2.2. Th to do u g th:
+ Lm sng: Khm: s thy khi u vng m sn vi im: rn chc, b u
hoc g gh, di ng nhiu hay t.
Cc du hiu chm thn v bp bnh thn (+) r. Ngoi ra cn c th thy:
- Gi t h ch thng tinh cng bn thn b bnh.
- Chy mu sau phc mc: b h h au gi di, st v cc triu chng ca chy
mu trong khi khi u v t ngt.
- Hi chng cn u (paraneoplasic syndrome): hi chng c u c th hin trn
lm sng:
. St 39 - 40oC trong nhiu thng do hoi t trong thn hoc cc cht sinh nhit
ca K thn l nguyn nhn gy st.
. a hng cu: nguyn nhn do u phng ra nhiu erythropoietin.
. N g a i u t g do u g th tit cht ging hormon tuyn cn gip hoc
di o t o g g g k h th h hy ct o l a i t g t o g u.
. T g hu t p do u tit e i ha do u h p ng mch thn gy thiu mu
th l t g tit renin.
- U g th di ti ua kh h: phi, g, ga ...
- Ngoi cc triu ch g t , i u gp 80% vi i : i u i th,
to i, kh g au, kh g st (nh g khi i a u hiu c c u gg
tc ngh ng dn niu g th au un thn).
C h : i a u t cch bt ng, bng nhin dng li ri li ti pht khng
r nguyn nhn l mt du hiu lm sng c gi tr trong K thn.
- au g tht l g, au la a t c hoc xu g di do u pht trin to
l g ao th , au t g ha au un thn do mu di chuyn xung
bng quang.
+ Cn lm sng:
- Siu m: c hnh nh mt khi u , kh g ng nht, b kh g u.
- Chp UIV: bng th to h h thng, b g kh g u, c hnh nh vi
ho. Mt s t ng hp thy mt bi tit v mt s hnh h kh : h p y
i thn.
- Chp ng mch thn: thy mt khi u t g ti mu, hnh nh hn lon ca h
ng mch hoc hnh nh co mch do hoi t, ho % u g th thn khng
ti mu.
- Chp ct lp in ton thn: thy mt khi d , kh g ng nht, t trng
ngang hoc km nhu m thn, cc vng hoi t cng gim t trng.
+ c bit, t o g l s g thng gp loi K nguyn bo thn l loi K nguyn
pht, hay gp tr em 3 - 4 tui, thng kt hp d dng bm sinh v tit
niu v mt s ua kh .
Lm sng: khi u bng pht trin nhanh, lm b g to ha h, u thng trn, rn,
chc, b u, t i a u i tri l ri lon tiu ho, ton thn gim st
nhanh. Bnh nhn thng s g di 10 tui.
2.3. Thn to do th a a g:
+ Lm sng:
- Qu trnh din bin kh di v cc nang tht l u cn nh u thng vi ng
th thnh nang l . Thng gp tui thnh nin vi cc triu ch g a
dng:
. au l g a ha au d di lan v t c ln ngc do nang chn p.
. i a u l gu h a h h i kh i a u l do nang
hay si thn).
. T g hu t p do ng mch trong thn b chn p.
. Nhim khun niu.
- C th thy 30% trong th a a g ang gan, cn c th gp nang bung
trng v phi.
- Ngoi ra cn thy cc biu hin kt hp h: h a ng mch ch, h van 3 l,
tai bin m h u o do ph h ng mch no (gp 10% trong bnh nhn thn
a a g .
- Th a a g k si urat (12%).
- Khi su thn th c cc triu chng ca suy th t giai on suy thn).
+ Cn lm sng:
- Hng cu c th t g do a g thn tit erythropoietin.
- Hoc hng cu, huyt sc t gim khi c suy thn; ho i a u, ph
thu o giai on suy thn v m i a u.
- U , eati i t g khi su thn.
- Cc men SGOT, SGPT c th t g /hoc c suy ch g ga khi ga a
nang.
- Chp thn vi thuc c ua g t h ch cho php ch o g % thn
a a g: hai th to h h th g, i th h h k o d i, i hng, b
chn p to ra nhiu hnh khc nhau.
- Chp ng mch thn c hnh nh khong v mch cc ch c nang.
- Chp ct lp i to pht hin si khng cn quang, ch o nh
vi K th ng thi pht hin t th g ga , ty, phi, lch, bung trng...
- X ua g kh sau ph c + chp UIV thy c hnh th to h i
thn lm m h i thn.
- Siu : k h thc th to, ng vi kh g u, gii hn ty v mt, ton b
thn thy rt nhiu nang, c th thy nang gan, ty.

19. HI CHNG I DNG CHP

H thng bch mch quanh thn rt pho g ph , l i hi lu a bch mch hai


hi di, i o ng ng vo hi lu Pi ugo . Khi tc bch mch vng thn
s g i dng chp.
1. Biu hin lm sng.
i dng chp l mt b h thng gp, iu tr ni khoa cho kt qu tht
thng v hu ht i dng chp kh g gu . Biu hin lm sng:
- Nc tiu h sa, lu s g li h th h. i dng chp
thng xut hin t g t, c th t h. i h sa xut hi t g sau
khi tht, c, trng. Thnh phn ca dng chp ch yu l lipid, protein,
fibrinogen. B h h i dng chp c th trng gy ty theo m i a
dng chp nh g n sinh hot h thng, khng gp tnh trng nhim khun
tit niu: kh g i dt, kh g i ut, kh g au un thn.
- i dng chp thng xen k vi nh g t i u i th ton bi, c
tiu h c ra tht, kh g g, lu hng cu lng xu g ng
nghim.
i dng chp c th b mt bn hoc hai bn thn, c soi g ua g
h i dng chp thn tri hay thn phi hoc c hai bn. Chp thn
gc dng p lc cao, trn phim X quang s d dng nhn thy tnh trng gin
ton b h thng bch huyt quanh thn.
2. Nguyn nhn ca dng chp niu.
- Do giun ch (W. Bancrofti):
u trng giun ch th g t t o g h thng bch mch lm tc bch mch,
c bit l bch mch chn gy bnh chn voi v gy tc bch mch quanh thn,
d bch mch vo b thn d i dng chp. u trng giun ch thng
xut hin trong mu ngoi i o a . B h th g lu h h mt s vng
ng bng Bc b h H g Y , H Na , Th i B h. Bnh ly truyn theo ng
mu, vt trung gian truyn bnh l mui. Nh g t thc t khng tm thy u
trng giun ch trong mu ngoi vi b h h i dng chp ko di, hu ht
nh g t ng hp i dng chp khng c du hiu ph chn voi.
- Tc bch mch do vim: mt s t ng hp i dng chp c kh g khi
khi iu tr kh g si h, h g ha t i ph t.
- Do u chn p vo h thng bch mch quanh thn.
- Do ch th g.
C gu i dng chp phc tp kh nh, cn tin hnh xt nghim
u tm u trng giun ch, phi xt nghim mu nhiu ln vo lc 9 - 10 gi
h g g ; y khu c tiu, bch cu niu.
Chp bch mch th nh tnh trng h thng bch mch quanh thn. S
xut hin bch mch quanh thn chng t c hi tng d bch mch quanh
th o i thn.
iu tr da o gu , u khng r c th iu tr bo tn bng
kh g si h. i dng chp m nng gy thiu dng cn tin hnh phu
thut ct b h thng bch mch quanh thn, tuy th sau khi phu thut vn c
gu t i ph t.

20.HI CHNG PH DO BNH THN

Ph l tnh trng c khoang gian bo, do nhiu nguyn nhn khc nhau.
Ph l triu chng lm sng hay gp v xut hin sm trong bnh cu thn. V tr:
ph hai mi mt, ph t g h , quanh mt c, mu bn chn, vng cng
ct lm mt np h t da, t cc hm t nhin quanh mt c chn, ph
mm n lm r rt. Ph nhiu v sng, chiu gim ph to nn s thuyn gim gi
to. Ph m nh, k o thng khng c triu chng, nhiu t ng hp
bnh nhn khng bit b ph t bao gi km theo nhng triu chng tn mn
h t mi, au vng tht l g, kh g go , kh g h h g n th
l . Ph to, t g hiu gy cm gic kh chu: mt mi, khng mu i li,
bu , , i l g, i t, ut hin tnh trng bng m ch kh tiu, nng
b g, g tc kh th, tc th khi nm do trn dch bng, trn dch mmg
phi.
- Trn dch bng (c hng t do): bng to b, mt np h thnh bng,
rn li, khng c tun hon bng h, g c vng thp, du hiu a ng (+).
Chc dch bng c dch, dch thm khng mu, phn ng Rivalta (-).
- Trn dch mng phi thng xut hin mng phi phi, m
nh hoc trung bnh, mt s t ng hp trn dch mng phi m nng. Du
hiu thc th khi th kh l hi chng 3 gim: rung thanh gi , g c, r ro
ph nang gim. X quang c hnh nh trn dch, chc dch mng phi: dch thm
khng mu, phn ng Rivalta (-).
- Trn dch mng tinh hon: hai tinh hon to, g, trong bung ti soi pi
mu hng.
1. Bnh sinh ca ph.
1.1. Gim p lc keo ca mu:
S t ao i dch kho g gia o c chi phi bi hai p lc: p lc thy
t h p lc keo. S chnh lch gia p lc thy tinh v p lc keo trong v
ngoi mao mch duy tr s t ao i dch khong gian bo.
S 9. Qu trnh vn chuy c ao t h h ao ng mch.

ALTT= 30

ALK= -10

ALK =- 25

ALTT=8

Mao ng mach

ALK=-10

ALTT= 8

ALK =- 25

ALTT=15

Mao t h a h

+ ph a ao ng mch:

- p lc th t h ALTT t o g l g ao ng mch: 30 mmHg, p lc keo


(ALK): - 25 mmHg (tri chiu vi p lc th t h . T o g t chc k: ALTT= 8
mmHg, ALK = - 10 mmHg.
- p l c t ao ng mch vo khong k l: (30 mmHg- 8 mmHg)
+ {(-25 mmHg) (- 10 mmHg)} = 7 mmHg
+ ph a ao t h ch:
T o g ao t h ch ALTT = 15 mmHg, ALK =-25 mmHg. Trong dch k ALTT =
8 mmHg, ALK = -10 mmHg. p lc ht dch t khong k o ao t h mch: (15
mmHg- 8 mmHg) + {(-25 mmHg) - (-10 mmHg)} = - 8 mmHg.

S . C h bnh sinh ca ph trong hi chng th h


Khi protein mu gim <60g/lt, albumin <30 g/lt d n gim p lc keo ca
u, l t g n chuyn dch t ao ng mch vo khong k v gim vn
chuyn dch t khong k v ao t h ch gy dch khoang gian bo d n
ph n. Ph do gim p lc keo gp trong:
- Hi chng th h: p otei hiu > 3,5g/di t h th 1,73 m2/ngy
d n gim albumin mu, gim p lc keo.
- X ga giai don mt b: gan gim kh ngang tng hp albumin, gim
plc keo.
- Thiu dng do tui gi, do b h l t h ung km, suy kit do
bnh l c tnh gy gim protein mu.
1.2. Gim mc lc cu thn:
Do tr dch khong gian bo v t t g hu thn (ph n, xut tit,
t g si h lu lng tun hon gi , l g u n thn gim, ch g lc
ca cu thn gim. Gim mc lc cu thn gy c, mui t o g th,
lm t g khi lng dch ngoi bo.
1.3. Cng aldosteron th pht:
L g u n thn gim kch thch b my cnh cu th t g tit renin,
mt kh l g u n thn gi , lu lng dch trong g ln gn gim tc
ng ln b phn nhn cm vng muculadens, nh g th g ti c
truy n t bo cnh cu thn (phn x kh hi ng-cu thn) hot ho t bo
cnh cu th , t g ng tit e i , t g tit aldoste o , t g hp thu mui
c ng thn, hu qu s t g khi lng dch ngoi o. T g aldoste o th
pht gp trong cc bnh sau: hi chng th h, ga t b, suy tim .
. . T g tit ADH:
Gi lu lng tu ho k h th h t ng ln b phn nhn cm p lc
oa g ng mch cnh cnh hot ho h giao c , t g tit ADH, mt kh lu
l g u n thn gim mc lc cu thn gim g t g at i u ng c tc
dng kch thch tit ADH.
. . T g t h thm ca thnh mch:
Do tc dng ca cc yu t gin m h h hista i , ad ki i , s hot ng
ca h thng b th ch yu l C a C a, leu ot ie l t g t h thm
thnh mch gy ph n.
. C gu a ph thn.
+ Vim cu thn cp.
+ Vim cu thn mn.
+ Hi chng th h.
+ T th g thn do cc bnh trong cc bnh ni khoa:
- Luput a , g da, i a , i t chc lin kt hn hp.
- Hi chng Goodpastur: vim cu thn v khi huyt.
- Vim cc vi mch (microscopic arteritis).
- Bnh u ht Wegener (Wegener granulomatosis).
- Amyloidosis.
- Nhi c thai nghn: ph, protein niu, hi chng th h.
Ph ch xut hin trong bnh l cu thn, bnh l ng k thn, b h ng
mch thn khng bao gi gy ph.
Cn phn bit ph thn vi ph do nguyn nhn khc:
+ Ph do suy tim:
Ph xut hin sau cc du hiu suy tim phi, suy tim ton b: kh th khi gng
sc, i t , t h ch c ni, gan to, phn hi ga t h ch cnh (+). Ph xut
hi u tin hai chn.

S 11. Sinh l bnh ph trong vim cu thn cp tnh

Ph th g t g chiu. Nhp tim nhanh, ting thi tm thu mm, ting nga
phi, huyt p gim, tim to trn X quang, gin cc bung tim, ch g tht tri
gim trn siu m. Bnh sinh ph do suy tim: mu git l i, t g p lc th t h
ao t h m h, t g t h thm thnh mch do thiu , ng aldosteron
th ph t t g tit AVP a gi i asop essi do l g u lu h h gim,
l g u n thn gim. Protein niu (-).

+ Ph do ga :
- C t g do t g p l t h ch ca: bng to rn li, g c vng thp,
du hiu a g + , l h to, e ga SGOT, SGPT ili u i t g, phn ng
Gros v maclagan (+), cholesterol ester gim, prothrombin gim.
- Ph hai chn do gim albumin mu v do gim thoi bin aldosteron gan,
t g hp thu mui c ng thn. Ph hai chn, ph mt xut hin sau c
hng.
+ Ph do thiu dng: protein mu v albumin mu gim, protein niu (-),
ch g ga h thng, nguyn nhn ca ph do thiu dng:
- L o su : u g k , h , kh g tiu, ha un nn.
- Suy kit do b h l t h giai on cui.
+ Ph do thiu vitamin B1 :
Vi a d thn kinh: ri lon cm gic (t b, kin b), gim cm gic. Phn x
g g gim, cm gic hai chn yu, hay khuu chn. Ph nh hai chn. Mt
s t g hp suy tim vi biu hin kh th, nhp tim nhanh, huyt p thp, tim
to trn film X quang.

21.HI CHNG PORPHYRIN NIU

Porphyrin niu l bnh bm sinh do s thiu ht cc men trong qu trnh tng


hp He , He c tng hp t succinyl CoA v glycine. Qu trnh tng hp
h sau:
S thiu ht mt trong nhng men trn s d n porphyrin niu, bnh c tnh
cht di truy , thng hay thiu men proto-oxidase. Biu hin ca chng
porphyrin niu: c tiu u , xut hin thnh t g t, quay ly tm khng
c hng cu lng ng nghi . i po ph i thng gy t th g
nhiu ua :
- T th g ga : i ga p t h t g ili u i u, t g SGOT,
SGPT).
- au bng d di thnh t g kh g gu .
- T th g o g lit v ng, lit h hp.
- T th g da, h yu tnh trng da d nhy cm vi nh sng, sm
da.
- Mt s t ng hp thiu mu.

S 16. Qu trnh tng hp Hem v h thng men tham gia tng hp Hem
(ALA: d- aminolevulinate, HMB: hydroxymethylbilane, URO: uroporphyrinogen)
HI CHNG PROTEIN NIU
B h thng, protein niu khng c hoc protein niu di 0,2g/24gi. Protein
niu + khi lng protein niu t qu 0,2g/ngy. Protein niu khng mu, kt
ta khi u g, hoc ta khi nh axit sulfosalicylic, axit nitric, axit acetic. Khi
protein niu t qu 3 g/24 gi s xut hin hi chng th h.
C 3 loi protein niu:
- Protein niu ngun gc l protein ca huyt t g.
- Bence-Jones protein l chui nh ca i u oglo uli do t g o sn
xut.
- Tamm-Horsfall protein l nhng muco protein do t bo biu m ng thn
sn xut.
1. Thnh phn ca protein niu v gu .
Thnh phn ch yu ca protein niu th g thng l albumin v globulin. Da
vo kt qu i di p otei , gi ta chia protein niu chn lc v khng chn lc.
1.1. Protein niu chn lc:
Khi albumin niu chim > % lng protein niu c gi l protein niu
chn lc, nu albumin niu > % c gi protein niu rt chn lc. Protein niu
chn lc gp trong hi chng bi i ti thiu (bnh th h him m). Protein
niu chn l th g ti lng tt, p ng tt vi iu tr bng corticoid.
1.2. Protein niu khng chn lc:
Khi albumin niu < % lng protein niu. Protein niu khng chn lc gp trong
cc bnh sau:
+ Vim cu thn cp do lin cu khun.
+ Vim cu thn mn tnh kh g gu :
- Vim cu th t g si h gia ch.
- Vim cu thn mng
- Vim cu th g t g si h.
- Vim cu th t g si h go i ao ch.
- Vim cu thn on.
- X ho u thn on
+ Vim cu thn th pht:
- Vim cu th do luput a h thng.
- Vim cu th do i a .
- T th g th do ng b ton th.
- Hi chng Goodpasture.
- Bnh u ht Wegener.
+ T th g th do i ng: protein niu xut hin l du hiu xu,
th g k theo ho tiu ng mch thn lnh tnh ho ho tiu ng
mch thn c tnh, hi chng th h, su thn xut hin sm.
+ T th g thn do thai nghn: protein niu > 3 g/ngy, hi chng th h,
t g a it u i , t g eati i t g hu t p. l hng du hiu ca tin sn
git.
. . C h bnh sinh ca protein niu:
1.3.1. Mt in th m tnh mng nn:
Mng lc lc ca cu th c cu to rt phc tp gm 3 lp:
- Lp trong cng l t bo biu m lng khng hon ton trn b mt mng
nn to nn nhng l nh k h thc 160Ao. Mng nn cu th c cu to
bi cc si gl op otei a h o hau to nn cc l k h thc 110Ao. Lp
ngoi cng l t bo biu m c gi tc bm chi cht trn mng nn, gia cc chn
c cc l nh k h thc 70Ao. Cc l nh mng l h h d g, k h thc khc
nhau. Trn cc l nh pha trong v ngoi mng n u in tch m tnh to
bi cc anion ca axit sialic. Cc l nh mng nn cho php cc phn t protein
trung ho ho a g i t h + k h thc phn t < 42Ao t qua mng
lc d d g, h g kh g ho ph p tt c p otei u k h thc phn
t t 22Ao tr ln a g in tch (- t qua mng lc vo khoang Bowmann.
Trong mt g gn 60 kg protein u i ua u th h g h thi ra
go i , g/ g . Ng a , gi ta nh chc ch ai t in tch
(-) trong vi g , y tt c nh g p otei u a g in tch m c t
o
22A tr ln quay tr li u, kh g ho ph p t qua mng nn vo khoang
Bowmann. Trn thc nghi , khi ti pu o i ho ng vt thc nghim s
lm mt in th (-) ca mng nn cu thn lm xut hin protein niu. Hnh nh
m bnh hc th do pu o i t g t h t th g nh hc ca hi
chng thn h i i ti thiu. Ngi ta cho rng chnh cc cytokin, interleukin
t it tiu in th (-) mng nn cu thn.
1..3.2. Ri lon huyt ng:
T g p lc th t h t o g un mch cu th l t g t h thm ca mng
nn cu th i vi p otei u, l t g p otei iu. Al u i k h thc
phn t 36Ao d d g t qua mng nn vo khoang Bowmann. Bnh sinh ca
t g p lc th t h l do hot ng angiotensin t chc, lm co tht ng mch
i hoc do hot ng cu h thng gin mch l t g l g u n cu thn.
Da t s ca gi thuyt , gi ta s dng thuc c ch men chuyn
v thuc ch g i kh g ste oid t o g iu tr gim protein niu. Cc thuc c
ch e hu l gi ng m h i, gim p lc lc lm gim protein niu.
Cc thuc khng steroid c ch tng hp prostaglandin gin mch lm gim
l g u n cu thn, gim p lc lc, gim protein niu. S trit tiu mng
in th t h t g p lc th t h t o g un mch cu thn hnh thnh
protein niu chn lc.
1.3.3. Bi i cu trc mng nn cu thn:
S bi i cu trc mng n do t ng ca cc yu t vim, s t ng
ca phc hp b th C7, C8 v C9 ; s hot ng ca i thc bo, cc t bo Tc v
NK tit toki g bi i tnh cht sinh hc ca mng nn cho php
protein c phn t lng l t qua mng lc vo h thng dn niu, to nn
protein khng chn lc.
. . . T g t h thm mng nn do cc yu t vim:
Hot ng ca cytokin, bradykinin, histamin, leucotrien, C3a v C5a c tc
d g t g t h thm mng nn.
2. Paraprotein.
2.1. Bence-Jones protein:
Bence-Jones protein l chui nh globulin min dch gp bnh huyt hc c
tnh, ch yu b h t h d g t g o h a u t . im ca Bence-
Jones protein l s g nhit 60-70oC, tan nhit 100oC nn cn gi
protein niu nhit tn. Bence-Jones protein c th kt ta trong lng ng thn
gy suy thn cp tnh. Thuc c ua g g t h ch c kh g gy kt ta
Bence-Jones protein. Protein niu nhit tn l g ng trong mng nn cu thn
v mng nn ng thn gy t th g ng thn, cu thn d n suy thn mn
tnh. Suy thn mn tnh l mt trong nhng nguyn nhn t vong ca a u ty.
2.2. Tamm -Horsfall protein:
Tamm-Horsfall protein thc cht l nhng mucin do t bo ng thn bi tit,
c tc dng bo v t bo biu m trnh nh g t g c hi ca c tiu.
Tamm-Ho sfall p otei t g nh l ng k thn v rt d g khi t g t
vi cc thuc c ua g g t h ch lm tc ng thn v d n suy thn
cp tnh.

CHNG . CP CU NIU KHOA

22.TIU RA MU

PGS TS BS. Ph V B i

1. Bnh s:cn khai thc

Ngh nghip (ngh gu u b g i ao

Ch th g, dng thuc.

S lin h gia tiu a u i vi d g c tiu, v d nu ch tiu ra


mu cui d g th i ph t si h tiu a u thng nm c B g i ha
Niu o.

C cc triu chng ti ch, Niu khoa ho to th i k : tiu but, gt,


au o Thn, st, lnh run....

C cc v ni khoa h i h g t c khi tiu ra mu.

2. Du hiu:

Ton trng b h h h th no.

C st, cao huyt p hay ph thng.


C cm nhn khi u bt th g gh g l g.

C s thy khi cu b g i.

C nhng du hiu ca di g hu.

. Th d n lm sng:

a/ Nc tiu:

Nu c nhiu P ot i es, c bit c s hin din ca cc tr niu gi p gh


n vim vi cu Thn.

Quay ly tm v nhu c bit bng k thut Papanicolaou gip pht hin


t bo c tnh.

Gip phn bit gia tiu ra mu tht s vi tiu Hb hay Myoglobine.

b/ UIV: Tt c bnh nhn c c chp UIV

Nu c mt t th g him mt v tr trong Thn c l th siu xc


nh:

Khi siu m cho hnh nh cho km, c th ch d di hng dn siu


m v xt nghim dch ht tm t bo c tnh, c th thuc cn quang
chp hnh nang nu trn siu m th h h a g t l g.

Khi siu m cho hnh nh cho sng hay hn hp th t th g phi c


e l t h ho n khi chng minh c nguyn nhn khc, v thng
thng t khi cn phi ti h h th th d h g kh
th tin hnh phu thut ct b thn. Nu ch o ghi g cn thc
hin chp ng mch Th , t o g t ng hp c tnh s cho hnh h t g
sinh mch u, i khi u c c th chch mt cht lm t ng
mch Thn s gip phu thut d h .

Ngo i a UIV g th cho thy hnh nh si, lao, ti m khu tr hay


Bu ng tiu l cc nguyn nhn khc gy tiu ra mu.
c/ Soi b g i:

Gip pht hi u b g i u c cn sinh thit h gi h h


bit ho xm l h g iu tr thch hp.

d/ UPR:

i khi g gi p th h h h nh khuyt trong vng b Thn, Niu


qun.

4. Tiu a uv :

Mt s t t ng hp, bnh nhn c biu hin tiu mu lin t h g i


ph g ph p l s g u khng ch g i h c ngun gc ca tiu ra
u Kh g u, khng sn, khng nhim trng...). Nhng bnh nhn ny
c c theo di, kho s t c tiu nhiu l i khi cn lm li UIV chc
chn rng khng c b h l t h b st. Trong mt s t ng hp c th
tm thy nhng bt th g gha h lm dng thuc gi au hoc c sn
khng cn quang.

23.B TIU
PGS TS BS. Ph V B i

1. Khng c tin triu:

T ng hp ny c th x a i nh nhn hu phu nht l nh g gi


phi n ging lin tc khng th ng d i tiu.Sau khi t thng tiu
lu th g t thi gian bnh nhn c th tiu h thng khi cuc m n
nh v b h h i li h thng.

. Sau t gia t g t iu chng ca Tin Lit Tuyn:


Ni nh nhn nam ln tui c gh n nguyn nhn b tc vng c
B g i iu o th g l do Bu Tin Lit Tuyn. B h h thng
nhp vin trong tnh trng vt v, lo s, ku la, au tc vng B g i.

Khm thy c khi cu b g i, n nh b h h tha au tc d di.


Th T t g l th g kh h gi ln ca Tin Lit Tuyn v
B g i g to, u bnh nhn cn c th chu g c tnh trng b
i p tnh ny, Siu m s gip ch o gu h tiu trong phn
l t ng hp h l h ho Bu c Tin Lit Tuyn, si kt c bng
i iu o.

Thng tiu b g thao t g h h h g, sau tho t lu c tiu


bnh nhn s cm thy thoi mi tc th v khi cu B g i kh g
khm thy.

3. B tiu mn tnh:

T o g t ng hp ny, v tht s quan trng l phi h gi to din bnh


nhn v thc hi th d h g . B h h thng khng vt
, kh g l ln, khng au tc hoc ch c cm gic nng vng h v, khi cu
B g i th khng s thy v ch pht hin nh g cho thy mt g c
hnh cu khi l n tn rn. C h gi k tnh trng thiu c, thiu mu,
tim mch.

Nu bnh nhn khng suy Thn v thiu c, c t thng tiu mt cch


v trng tuyt i nu khng c th lm bnh nhn nng thm do nhim
trng t th thut t thng, thng tiu ch nn dng loi mm v kch
thc nh khng gy sang ch b g i c gii p t t,
khng qu nhanh, bi ho in gii v theo di tnh trng tim
mch tht cn th t h gu su ti do i hon th dch qu vi
v.

Ngu h g th do b tc mn tnh vng c b g i iu o do


u tin lit tuyn, hp niu o hoc do ri lon h th ki h iu khin
co bp b g i t o g tiu ng, tai bin mch mu no, cao huyt p,
ch th g t sng.
4. B tiu vi v niu:

T o g t ng hp v niu hon ton, s khng c hoc c rt t c tiu trong


B g i di 500ml/24gi h g i khi nh nhn v khng bit hoc do thi
quen vn c cm gic tc vng h v v khai l b tiu h g khi t thng tiu,
ng thng vo B g i d d g h g c tiu li khng c hoc c rt t (vi
chc ml), khm khng c cu B g i k c khi s v g, c th ph nhiu hay t
tu theo thi gian v m suy Th . Siu g kh g th c tiu trong
b g i, u nguyn nhn suy Thn do b tc hai Niu qun c th thy hnh nh
t g c hai Thn.

24.XON THNG TINH

L mt cp cu t g i him, c th xy ra bt c tui o h g
thng khong tui dy th. Cn nh rng vim mo tinh cc k him
tr em v vim tinh hon do quai b g kh g ao gi th t c tui dy
th v vy khi mt a n bnh vin v tinh ho s g au, hn
o t c tim c gh l Xon th g ti h, l t cp cu ngoi
khoav c c thc hin trong vng 3-4 gi v mch mu nui tinh hon
tc nghn, nu mu h ti h ho th b hoi t hoc teo.

Ngu h thng l do TUNICA VAGINALIS qu ln ph ln ti thng


tinh khin cho Tinh hon c th xoay t do trong ti TUNICAVAGINALIS v
yu t khi pht l s co tht ca CRMASTER l Ti h ho t i oa
gc chiu v Tinh hon phi xoay theo chiu ki ng h (khi thy thuc
nhn t di h ging bnh). Khi c b tc mch mu s c ph n Tinh
hon v Th g ti h n vng b tc hu qu l Hoi t Tinh hon v Mo
tinh.

Ch o gh n khi mt thanh nin tr xut hi t ngt


au d di Tinh hon km theo l s g ph , g da u t g ng,
au g g di v i ma. Tuy nhin, Xon thng tinh la tui thanh
i i khi h g au t ha kh g au h s g ph g da u
t g ng.

Khm th Ti h ho s g, s o au m co trn cao so vi i


din do Thng tinh xon b rt ngn li. au c th t g l khi g ao
tinh hon v pha khp mu. au do Vim mo tinh cc k him tr em,
thng gim bt khi lm th thut ny. Khi xo k o d i i gi c th
c st t g ch cu.

Ch o th sm khi s thy mo tinh v tr bt thng (mt t c


tinh hon), tuy nhin sau vi gi c khi s s g l kh g ph it
c vi Tinh hon.

- Ch o ph it gm: Vim tinh hon mo tinh cp, vim tinh hon


do quai b cp v do ch th g.

*iu tr:Nu b h h n sm ngay sau khi xon, c, th th tho xon


bng cch xoay hai Tinh hon theo chiu gc li, nu tht bi cn gii phu
ngay tc kh tho xon v c nh Tinh hon v sau 4-6 gi Tinh hon s b
hoi t nu b xon 7200 (xo g . Do Ti h ho i di g thng b
nhng d tt t g t g c phu thut g l c nh,
phng nga xon.

25.CN AU BO THN

Bnh nhn m t au ut hi t ngt v d di, g tha i


vi nh g au un ri gim d sau ut hi au kh ,
t o g khi au d di bnh nhn c th b bu ha . C au kh
nh v h g t o g l au nh nhn c gng tm v tr gi au, in
h h au t u t g h g l g, la ung h chu ri ti vng
bn hay bu hoc m h phi n, nu trong ti tiu ra si th
c th chc chn l au g do g t nguyn nhn v bnh nhn
c th s i a i si khc. Ngoi ra, nu c cc triu chng hn lo i
tiu k theo h tiu kh , c tiu t, , tiu nhiu l th g th
chc ch l au o thn.

Cn ch o ph it vi nh g au gi do nh g gi nghin ma
tu m t h la thy thuc hu c chch nhng thuc gi
nghi . C au u g th xut hi o giai o u ca vim
rut tha cp, tc rut, u bung trng xon, thai ngoi t cung v g
c th gy ra nhng triu ch g t g t.

T o g t ng hp nghi ng, c nh ch o ht l khi trn film


bng khng sa son khng thy hnh nh si cn quang hoc c nhiu hnh
h i ho t h ch gy ch o lm th UIV s gi p h, t ng
hp l au o thn th thn cng bn s khng bi tit, hnh nh Thn
s xut hin chm hoc ngay c hnh nh gi g h Thn vi thuc
cn quang thot vo c ua h Thn, nu hnh nh Thn v Niu qun
ho to h th g, th au gun gc khc ngoi h Niu.

S hin din ca hng cu t o g c tiu g l t xt nghim c gi tr


trong ch o au o thn. Hnh h h g c i b Thn
niu qun th t siu g gi p h o . Nh g h h nh Thn
Niu qu h thng trn siu m th khng loi c ch o , t ng
hp nghi ng c th phi thc hin siu m trong nhng ngy sau hoc
thc hin UIV.

26.SUY TUYN THNG THN CP

ThS. BS. Nguy Ho g c


Suy v tuy thng thn c th chia thnh hai nhm. Suy v tuyn
thng thn nguyn pht (bnh Addison): % t ng hp do qu
trnh t mi , % t ng hp c kt hp vi bnh lao. Cc nguyn
nhn khc bao gm xut huyt tuy thng th , di tu thng
thn t u g th phi, u g th , him siu vi gim min dch gi
(HIV), nhim trng huyt do no m cu (hi chng Waterhouse-
Friderichsen) v sarcoidosis. Cc loi thuc c th gy suy tuy thng
thn bao gm ketoconazole, aminoglutethimide v mitotane. Suy v tuyn
thng thn th pht thng nht l do y thut g a sau khi iu tr
bng glucocorticoid ko di. Mt nguyn nhn khc him gp h l thiu
cht hng v thng thn (ACTH), h t o g t ng hp u tuyn
yn, thm nhim tuyn yn, nhi mu tuyn yn. Nguyn nhn th ba l
thiu e z a ph i tuy thng thn bm sinh.

Suy tuy thng thn b si h t g i him gp, su thng thn th


ph t thng gp h do ic s dng steroids ngoi sinh ngy cng nhiu.
Suy v thng thn cp Addiso th xy ra cp tnh sau nhim
trng huyt, xut huyt tuy thng thn hoc phu thut tuy thng
thn. Suy v thng thn cp g th xut hin nhanh v ni bt mt
b h h su thng thn mn b nhim trng, ch th g, hoc b
stress do phu thut.

A. Bnh cnh lm sng

1. Triu chng: T c mt b h h su thng thn mn c biu hin yu


mt, st , h i / hoc st, phi nghi ng su thng thn
cp. Nu kh g iu tr, bnh nhn s tt huyt p, ng g. Suy tuyn
thng thn mn c biu hi l s g khi h % tu n b ph hy.

2. Du hiu: Tt huyt p l du hiu ch yu. T g sc t (hi chng


Nelson),hu qu ca vi t g ACTH, l du hiu t g i bt ca h %
bnh nhn suy tuy thng thn, tuy nhin du hiu ny khng gp nhng
bnh nhn suy thng thn th pht. Cc du hiu ny c th khng c trong
nh g t ng hp cp t h kh g thi gian cho chng pht trin.
B. Ch o

Tam chng h at i u, t g kali u, v hu t p thp l du hiu ch


yu ch o . Gi o tisol a n h ng huyt mau chng. Mc
o tisol t o g u tha i mt cch bt thng hoc gim sau khi
t g s d g ACTH g l t du hiu ch o . S tit Aldosterone
thp, hu qu ca vic thiu mui d t g g renin trong huyt
t g.

C. iu tr:

iu chnh tnh trng gim th tch v h natri mu bng truy t h ch


dung dch Dextro 5% pha vi huyt thanh m g t g ng thi s
dng glucocorticoids.

Truy t h ch bolus 100 mg hydrocortisone sodium succinate hoc 2mg


dexamethasone. iu tr duy tr bng cch cung cp 50mg
hydrocortisone sodium succinate truy t h ch mi n 8 gi.
Mi e alo o ti oids ha n thit t o g giai on ny. Trong 24 gi u,
cc ri lon th tch v ri lo in gii phi iu chnh bng cch s
dng Dextrose 5% pha trong dung d h o al sali e theo hng dn ca
p sut t h h t u g g.

Thuc vn m h h Dopa i e th cn thit nng huyt p. Khi bnh


h nh v huyt ng hc, mi bt u truy tm nguyn nhn tht
s g su thng thn cp.

Phi lu loi tr cc nhim trng hoc p xe. Vo ngy th nh, liu


l g glu o o ti oid c gim phn na. Khi bnh nhn c th dung np
tt thuc ung, cn cho bnh nhn khm bnh vi s i tit.
27. PH I TUYN THNG THN BM SINH

Ph i tuy thng thn bm sinh (CAH) l khim khuyt ch yu ca qu


trnh sn xut cortisol. Kt qu ca vic tha ACTH l to ra tnh trng ph
i tuy thng th k theo t g tit Androgen lc cn trong t cung.
Tnh tr g c nhn bit sau sanh nh vo cc bt thng v sinh dc
- lng gii b gi v c i sinh dc preacox b trai. Bn nhm CAH
chnh l: thiu 21- hydroxylase; thiu 17a hydroxylase; thiu 11b
hydroxylase; v thiu 3bhydroxydehydrogenase. Thiu 21- hydroxylase
chi % t ng hp CAH. l gu h thng gp nht ca
t ng hp kh phn bit gii tnh tr s si h l gu h du
nht e do i sng ca tr (hu qu ca vic mt mui). tr s si h g i,
c tnh trng nam ha vi l tiu g thp trm trng . Tr s si h a
th c hnh d g h th g sau si h h g th d g t s ln bt
thng v sau nu kh g iu tr. Nu g i kh g iu tr s b rm
lng, pht tri p qu mc v v kinh. Tnh trng ln qu nhanh dn
g s u g g gi l khi t ng thnh. Hai
phn ba cc tr khu h hng mt mui d n hu qu l thiu
Aldoste o e, i hi phi iu tr cp cu.

A. Ch o nh vo cc pht hin trn lm sng v nh vo tnh tr g t g ao


17 hydroxyprogesterone trong huyt t g, ho t g ht chuyn ha ca
p eg a et iol t o g c tiu.

B. iu tr bao gm s dng glucocorticoid mi g loi b s tit ACTH ca


tuy lm gim bt s sinh androgen qu mc. Prednison l thuc
c chn la, tr e th thng dng hydrocortisone. Nu vn cn tnh trng
thiu mui, iu tr tn cng bao gm truyn dch b g g t h ch, cc
cht lm gim kali/ mu, thay th mineralocorticoid vi . n 0.1mg
fludrocortisone mi ngy. Bt thng v b phn sinh dc c th iu chnh v
sau bng phu thut.
28.THUYN TC NG MCH THN

chi % t ng hp thuyn t ng mch. Thuyn t ng mch chnh


ca th thng do thuyn tc h thng t t h t i kt hp u g h, a ti
nhn to, si ca vim ni tm mc hoc c u gt o g gun gc t
nhi u ti . Thu tc do y thut a g t g d do khu h hng can
thip vo mch mu khng xm hi. ng mch trong th l ng mch tn do
, thu t ng mch ny s hnh thnh mt vng nhi mu hnh chm
trong nhu m thn. Vng nhi mu ny c th mt bn hoc hai bn,bn tri
thng gp h . L s g: th khng c triu chng ho au p tnh hng
l g la n bn, bun nn, nn i v st khi xy ra nhi mu. Bnh cnh ny
hon ton ging ht mt t ng hp si niu qun. Tiu u i th hoc tiu
mu vi th chi % t ng hp . C th k theo m niu, bch cu v t
bo biu m trong nuc tiu. Nhi mu th l gu h th g t g
SGOT (glutamic- oxaloacetic transaminase huyt tha h , sau l s t g la tate
dehydrogenase.

1. Ch o c gi khi niu k ni t h ch (IVU) hoc chp in ton


ct lp (CT) c tim thuc cn quang khng nhn thy tt c hay mt phn thn.
M d t o g t ng hp si niu qun , thn c th bi tit km hoc chm bi
tit, h g th (nephrogram) vn nhn thy. S hin din ca t th g ti
hay t th g ch mu gip gi ch o n. Chp th ng v phng x
b g Te h etiu ng cho thy th kh g ti mu v chp ng mch thn
chn l gi p nh ch o .

2. iu tr chn la l kh g g to th Hepa i . Ti u t lm tan


fi i o t o g ng mch (Streptokinase) nu pht hin sm trong vng 4- 6 gi
c th ci thi g k ch g thn. B h ti di lu c loi tr
bng phu thut ly c u g nhng b h h gu t cao. Hu
qu ca vic thiu mu thn d n vic hot ha h Renin v v sau c th gy
cao huyt p, khi th phi ct thn
29.THUYN TC TNH MCH THN

Him gp gi ln, thuyn t t h ch th thng xy


ra mt bn th thng kt hp vi bnh vim cu thn
mng, hi chng th h, l t h ch th t h
mch ch do u hoc bnh sau phc mc. tr em v tr
s si h, h thng b hai bn vkt hp vi tnh trng mt
c nng dohu qu ca tiu chy hoc nn i. Biu hin
lm sng ca thuyn t t h ch thn gn gng vi mt t ng hp vim thn-
bn thn cp v si niu qun. B h h au d di h g l g, tiu mu v
st. Du hiu nhim trng v sc rt tha i. T o g a s t ng hp, c th s
c mt mass nhn h g l g, do t h t ng sung huyt ca thn.

1. Ch o Tiu u i th hoc vi th do cc nhi mu thn l du hiu


thng gp. Gim tiu cu g thng gp thuyn t t h ch thn giai
on cp, khng c gim tiu cu gi thuyn t t h ch th hu n giai
on. m niu thng gp t o g t ng hp thuyn tc gi ln, c th m
niu rt nhiu. Vi t g it oge t o g u ea u BUN ati i t thng
gp, ngay c t o g t ng hp thuyn tc mt bn. Chp UIV thy bng thn ln,
th m hoc khng xut hin. Siu m thy th to, echo km km vi cc
u g t o g t h ch thn ho t o g t h ch ch. CT v c g hng t
MRI nh ao h g h o nh phi da vo kt qu chp t h
mch thn chn lc.

2. iu tr Vi iu tr ph thuc vo la tui ca bnh nhn. tr s si h


tr nh c thuyn t t h ch th hai ti lng rt xu. iu tr ch yu
bao g c, khng sinh khi c nhi t g, iu chnh cc ri lo in gii.
gi ln s dng heparin s ti t h ch cht ln tan fibrin
(streptokinase ho u oki ase thu c nhiu kt qu tt. Phu thut ly cc
u g h d h ho t ng hp thuyn t t h ch ch. Sau khi thuyn tc
t h ch thn, ch g th thng phc hi. mt s t t ng hp, thn
khng hot g a n cao huyt p hoc nhim trng thn mn cn phi ct
b thn.
30.B TIU

B tiu cp l cp cu h g u ca bng quang khng do ch th g.

A. Ch o C gu h thng gp l ph i ho u g th tin lit


tuyn, vim hoc ap xe tin lit tuyn, nhi mu tin lit tuyn, hp niu o,
mu cc, dng thuc, v bnh thn kinh, tm thn. Bnh s phi bao gm tnh
tr g i tiu t c khi b tiu, cc phu thut niu khoa t , thu
dng c tc dng ph kh g holi e gi , c bit l thuc cm c cht chng sung
huyt nim m i thuc khng histamin. Khm lm sng phi ch vo vng
t g u, nh c cu bng quang phi s, g . T o g a s t ng
hp n vo bng quang khi khm s gy kh chu au. Nu b tiu lu ngy,
bnh nhn khng thy kh chu khi n vo cu bng quang. n chn trc trng c
th ho ph p l g k h thc tin lit tuyn v pht hi c ap xe
tin lit tuyn.

B. iu tr t thng Foley ti ch l iu tr la hn. C vi t ng hp


kh t th g h hp niu o, ph i? ho u g th tin lit tuyn. Cc dng
n ca ng thng niu o c gii thiu h g .

1. T ng hp kh t thng tiu Nu thng tiu kh g o c bng quang


d d g gu h th g l do co tht g go i, sau khi hp niu o,
co tht ha ph i c g ua g. Ph i tin lit tuyn him khi cn tr ng
i a ng thng v ng thng c th d d g y cc thu ca tin lit tuyn qua
hai i ua, t bit l vi ng th g ng knh s 22Fr. Nu bnh
nhn bit hoc nghi ng c hp niu o, phi chp niu o g d g
h gi t h t ng niu o e h g . Nu hnh nh cho thy r rng ch
hp kh t kh g ua c, phi m th g g ua g ua da t g u
chuy lu c tiu tm thi. Nu khng c ch hp r, cn s dng ng thng
c ch cong- h th g th h g khi i ua bng quang. ng thng c
ch cong phi h h g t khi t vo niu o.
2. ng thng ru tm ng thng ru tm l g th g ng knh nh, c,
c nhiu hnh th khc nhau u (xem hnh 3.4). Do ng thng c th gy ra
nh g th g tn nng cho niu o, ng thng phi c s dng bi gi c
kinh nghim hoc phi ki so t c. g th g th g c s d g
vut qua ch hp niu o v ch l ng. Vi cht i t a , ng
thng ru tm s t t t ua c ch cn niu o. g th g u tin s
t t i t thm mt g th g kh ga di. Nu vn
ha , c th t thm ng thng th ba, th t. B g h oa a o
tng g th g u t , gi ta hy vng c th a c mt trong s cc ng
th g ua c ch hp vo trong bng quang. Nu c mt ng thng ru
t ua , gi ta ly ht cc ng thng khc ra v xon ni vi mt ng
thng nh 8Fr hoc 12Fr theo ru tm vo bng quang. Sau khi g th g u
ti o c bng quang, rt thng ny ra khi l so m khng rt thng ru
t , sau li tip tc v t thng th hai vo bng quang. Tip t t cc
g th g o ho n khi niu o o g a .

3. ng thng Council Sau khi nong ch hp niu o, i t tt t vo


niu o mt ng thng d g Cou il u c xon c vo trong ng thng Council
e h h . t vo niu o thng Van Buren. u xon c gn vo thng
ru tm v thng ru tm s hng dn g th g i o t o g g ua g. R t
thng stylet v thng ru tm qua lng g th g o g g gi thng.

31.BU V TNG SINH MN

au s g u p m khng c bnh s, ti h th g l
thng phi gii quyt khoa cp cu. Ch o ph it gm: vim
mo tinh- tinh hon cp, xon phn ph tinh hon, vim tinh hon do quai
b, that v bn nght., h g h a t ng hp phi iu tr cp cu:
xon tinh hon cp, ap xe quanh niu o, hoi t bu (Fournier).

A. Xon tinh hon Xon tinh hon l hu qu ca vic tinh hon xoay quanh
thng tinh v tc ngh t h h ng mch ca tinh hon. V vy, xon tinh
hon tht s l mt t ng hp cp cu v mch mu. Nu kh g iu tr
cp cu t o g g n 6 gi t khi bt u au ti h ho s b nhi mu
hon ton v hu qu l teo tinh hon v sau. Mc d xon tinh hon c th gp
bt k la tui o h g tn sut cao hai h , thng gp nht l trong giai
on thiu i n 20 tui) v t gp h l giai o s si h. %
t ng hp xon tinh hon xy ra trong lc ng. Xon tinh hon chia lm hai
nhm chnh.

1. Ngoi tinh mc D g thng gp tr s sinh. Ton b tinh hon v


tinh mc xon quanh trc dc ca thng tinh do hu qu ca vic dy treo tinh
hon c h kh g ho to o h u, iu ny lm cho tinh hon xoay t
do trong bu.

2. Trong tinh mcD g thng gp thiu nin v gi l h . Do m


sinh tinh mc bm cao vo thng tinh gy nn tnh trng bin dng hnh qu lc
chung, cho php tinh hon xoay quanh thng tinh. Do tnh trng ny gp hai
, gu on tinh hon bn kia l rt cao. Co tht ca g u l nguyn
nhn lm cho tinh hon phi xon theo chiu ki ng h v tinh hon tri xon
gc chiu ki ng h (nhn t h ging ln).

a. t g l s g Biu hin c i l au t ngt v d di tinh hon,


bun nn, nn i, tinh hon b ko ln cao v rt au khi s chm. B h h
tng c nh g t au t g t h th. Khm thc th cho thy tinh hon rt
au khi s ch . T th tinh hon n ga g h ao h so i h thng.
Nu c th s c th thy mo tinh nm ph a t c, lc ny ch o on
tinh hon hu h hc chn.

b. Ch o ph it Ch o ph it thng gp nht l t ng hp
vim mo tinh- tinh hon (b g . . T o g t ng hp vim cp t h thng c
km theo nhim trng tiu hoc vim tin lit tuyn. C mt nghim php: nmg
ti h ho l l au t g th t o g t ng hp xon tinh hon v lm gim
au t o g t ng hp i ti h ho , h g kh g phi l o g thc hin
c (Prehn's sign) . Mc d him gp, xon phn ph ca tinh hon, di tch ca
g Mulle , g nh c h t g t. Tu hi , i au a tinh hon khu
tr r nht c di v du hiu t g l m xanh da bu.
c. Ch o Phi lun coi mt tnh tr g au, s g u p tnh mt thiu
nin l xon tinh ho ho n khi c bng chng v mt bnh khc. Siu m
Doppler mu v Doppler duplex cho thy dng ch ng m h ng v phng
x vi 99m T chnh xc ti %. Hai ph g ph p u da trn nguyn tc
dng chy ca ng mch tinh hon s gim trong t ng hp xon tinh hon v
s t g t o g t ng hp i . Tu hi kh g ph g ph p o ho kt qu
chc chn v ch o phi da trn khai thc bnh s v khm lm sng t m.

d. iu tr ph thuc vo thi gian t lc bt u au n khi ti phng cp


cu. Trong vng 4 gi, c th tho xon tinh hon b g ta di gy t ti ch
(cn nh l tinh hon xon v pha trc gia nhn t chn bnh nhn). Nu tho
xon bng tay thnh cng, phu thut c h hai ti h ho c ch nh trong
vi ngy sau. Nu tho xon tht bi, phu thut th d c ch nh ngay lp
tc. Nu b h h n t 4- 24 gi sau khi au, phu thut th d c ch
nh ngay, tho xon v c nh hai tinh hon vo bu. Nu b h h n sau 24
gi, phu thut c ch h h g ha hc gi c tinh hon. Nu ct b
tinh hon c t ti ch mt dng c gi, t o g t ng hp ny, cn d t n
kh g him trng v phn ng min dch ca tinh hon cn li.

Bng 4-1. Phn bit gia xon thng tinh v vim mo tinh- tinh hon cp

Xon Vim
Thi gian bnh t ngt Vi gi n vi
ngy
Biu hin ca tinh hon Cao h kia Kh g tha i t
th
Mo tinh Khng s thy S c v nhy
cm
Tnh trng niu o Khng c biu hin C th c biu hin
Phn x u C th khng c Lun lun c
p g g u P eh ' s Kh g tha i au au nhiu h
sign)
St Lun lun khng c C th c

B. p xe quanh niu o p xe quanh niu o thng l hu qu ca mt p


xe niu o b v, p xe ny c ngun gc t hp niu o. m t m biu hin
tng sinh mn l mt khi s g, g, , au, i khi du php phu. Nu
c d lu tt, m s ht nhanh. Ch o ng chp niu o gc dng,
s th c hnh nh hp niu o v vi ch d t niu o ra p xe. M tho
lu phi c nhum gram v cy. Phu thut bao gm vic d lu m,
chuy lu c tiu bng thng niu o hoc tt h l ng cch m bng
quang ra da.

C. Hoi th fou ie Do Jea Alf ed Fou ie , s da liu gi Php m t


l u, hoi th Fou ie l t h t ng hoi th a ua si h dc ngoi v
tng sinh mn xut hi t ngt mt gi c v kho mnh. y l mt dng
vim cn hoi t, thng xut hin bt u t bu ho d g t, lan rng theo
lp cn ( S a pa , n tng sinh mn, bng, c th la n nch.

1. Ch o Hoi th Fou ie iu hin mt h t ngt bi tnh trng


s g t b phn sinh dc, st, n lnh v kh chu. Thi gian xut hin
triu chng trung bnh l 5 ngy. Kh l s g l s quan tr g chn
o . Da u da d g t c m c bn trn mt vng vim m k cha
dch vng nu do hoi t lp di. giai on ny, c th c ting lo
xo v mi thi do vi trng ym kh. Nu kh g iu tr, cc mnh hoi t
nhanh chng b trc ra. Tinh hon v th g ti h thng khng b t th g.

Nu nghi ng hoi th ut pht t niu o do tin s c hp niu o


ho t thng niu o, cn ch nh chp niu o gc dng. Nu n
chn trc trng nghi ng nguyn nhn t , n phi soi trc trng. Cy
dch cho thy c nhiu chng vi trng gm vi trng gram m (Escherichia
coli, Pseudomonas species, Klebsiella species), cu t g g a d g
hemolytic strep tococci, Staphylococcus aureus, Enterococcus), v vi trng
ym kh (Bacteroides fragilis, Clostridium perfringen). M hc cho thy c
thuyn tc mch mu v tc nghn lp ni mch, l hu qu c s lan rng
ca i t g. Th g thng, tnh trng ny gp nhm b h h c
phi mt bnh h thng: nghi u (50%), tiu ng (33%). Ngun
nhi t g thng t ng niu dc (50%), hu mn- trc trng (33%),
da % . Thng l do tnh trng suy gim min dch do nghi u v
tiu ng lm c ch h thng mim dch.

2. iu tr : nguyn t n bao gm:

a. Ct lc tn gc: tt c m hoi t, hoi th phi c l i gay.

b. Cc m g g p e khoa g kh g c ct l l u s
c r h tho t lu v d lu.

c. Ti t h ch khng sinh ph rng bao vy c hai nhm vi trng hiu kh


v vi trng y kh , sau s s dng khng sinh tu theo kt qu kh g si h .
Th g thng, chng ti s dng 4g Piperacillin mi 6 gi, 80 mg gentamycine
ti t h ch mi 8 gi v 60mg clindamycine mi 8 gi. Xen k vi clindamycin,
g et o idazole c truy t h ch mi 8 gi.

d. Cc bin php h tr:

(1) Oxy cao p liu php nhng bnh nhn b nhim trng ym kh lan rng cho
nhiu kt qu tt.

(2) M bng quang ra da hoc m i trng ra dal bi ph p c p d g


chuy lu tm thi khi bnh nhn c khi t m cnh niu o hoc ap xe cnh
hu mn.

(3) Corticoid ton thnch c s d g t o g i t ng hp ring l khng


p g i cc bi ph p iu tr tiu chun.

(4) Ch s vt th gsau khi ct lc bao gm vi g t th g ng


dung d h c mui sinh l.

(5) Ghp da muncho phn b phn sinh d lt tr a i khi n thit.


T o g a s t ng hp, da bu cn li c th che ph tinh hon.

e. Ti lng: Mc d c nhng bi ph p iu tr t g h th, t l t


vong vn chim kho g %, do n phi ch o s iu tr thch
hp. Cc bin chng sau m thng gp l nhim trng ko di, ri lo g
mu, v suy h hp.

32.DNG VT

A. Hp ao ui u: l tnh tr g da ui u ca d g t khng th tt ln
c.S nhim trng m t h da k hi v to so co rt da qui
u. B h h lu ni m , nga au khi giao hp. Th g thng, hp
ao ui u kt hp vi nhim trng (vim r h ui u hnh), bt buc phi
iu tr bng khng sinh ph r g h t t a li e g ung 4 ln mi ngy).
Hp ao ui u phi iu tr b g h l g da ui u hoc ct da qui
u. Thnh tho g t ng hp hp da ui u km theo vim rnh ui u
hnh nng, lc ny ch c th ct l g da ui u d th at lu, khi o kim sot
c tnh trng nhim trng th mi ct da ui u sau. Him khi hp da ui u
c biu hin b t ng tiu.

B. Bn hp da ui u l tnh tr g da ui u tt l h g kh g tt xung
c, n ga t ui u. Tnh tr g thng gp bnh nhn c hp da
ui u t . Sao da ui u ph n ui u b tht nght. Rt him khi
c t th g ch mu ca ui u. iu tr bao gm lm gim s chn p, lm
gim ph n v tht nght ca da ui u kt hp vi ly li tnh trng bnh
th g ho ui u. i khi phi phong b g d g t bng lidocain 1%. Nu
kh g c, phi ct b vng nhn tht ga g ui u bng cch gy t ti ch.
Sau khi bt ph n n 4 ngy sau) mi ct da ui u.

C. C g au d g vt biu hin bi tnh tr g g d g t ko di


h gi k theo au hy cm. Bnh sinh hc ca g au d g t
c th chia thnh cc nhm sau:

1. Nguyn pht hoc khng r nguyn nhn: (30%- % t ng hp)

2. Th pht
a. Bnh huyt khi thuyn tc: bnh hng cu lim, b h a hy mu, gim
tiu cu, a tiu cu.

b. Thuc: tim thuc gin mch trong th hang, trazodone, thorazine, alcohol,
marijuana, thuc lm h huyt p, heparin.

c. Thm nhim: bnh bch cu, u l ph , u g th g ua g ho u g th


tin lit tuyn.

d. Cc nguyn nhn khc: ch th g d g t g au d g t flow


cao), thn nhn to, u i dng hon ton b g ng t h ch.

e. Nguyn nhn thn kinh: t th g h th ki h t u g g tu sng,


bnh thn kinh do tiu ng.

3. Sinh l bnh hc: D g t kh g u c c nguyn nhn l do s gim


dng mu ra khi d g t hoc him gp h l do t g d g u d g
vt. Da t s , gi ta chia thnh hai nhm:

C g au d g vt

nhm I (flow thp, thiu mu hoc tc ngh t h ch)

nhm II (flow cao, khng thiu mu ho do ng mch).

D g t g g k o d i a n hu qu ph n t h ch th
hang, lm mu hoc thuyn tc trong th hang, lm tc ngh ng dn
lu u t h ch. Thiu oxy trong th ha g, t g a o i toa h a l
gu h e do ni m a h a, to so v gy lit d g t o g
50% cc t ng hp. Chnh v v , g au d g t phi c coi l mt cp
cu v m h u, e da n ch g d g t.

4. Ch o : bt c mt s g d g t o k o d i h gi phi c
oi l g au d g t, gi bnh phi n khm niu khoa ngay. Trong
vng 6- 8 gi u, au ha a h g t o g thc t, a s b h h n
kh khi g d g t k o d i h gi. iu tr ngay lp tc thi im
ny c th bo t c ch g g, h g u x l tr, kh g i lon
ch g g t cao. Khi khm phi lu hi bnh s pht hin cc
gu h g g au d g t. Ngu h thng gp nht hin nay
l t chch thuc gin mch vo th ha g. C g phi hi bnh nhn v cc loi
thuc b h h a g ung. Nu trong ti h g t b g au
d g t t khi l gi ca bnh hi chng li . V a s t ng hp
g au d g t l dng flow thp nn tnh trng thiu mu rt tha i
h g au lu lu , u c ti h th g d g t hoc chn
th g g hi sau i k t h t g g au d g t th phi
gh ga l t h t g g au d g t flo ng mch cao. Khm lm
s g xc nhn tnh tr g g au d g t vi g d g t bnh
th g, t o g g au d g t ch li ua n th hang m thi cho nn
ui u v th xp vn mm.

5. iu tr : M h iu tr l l ho d g t xp (detumescence) nhanh,
gi au o tn ch g g. Thi gian ko di ca g au d g
vt l rt quan tr g quyt h ti lng v sau. Nu g k o d i h
gi, tn sut lit d g p x % ho d iu tr ngay lp tc. Phi lun lun
bo cho b h h gi nh bit c tnh trng lit d g th xy ra cho
d iu tr thnh cng g au d g t.

a. Chc h t v ti ra th hang l iu tr ch yu nu b h h n trong


vng 24 gi. M u c ht ra t th hang vi ki G e gi th kh
u nh m thiu u. C g au d g t in hnh th I (flow
thp u e pO2 <30, pCO2 >60, phc hi .7,25. Tri li nu mu th hang
ti g O2 cao xyra bnh nhn c ti h th g hu
th phi lm Doppler Duplex ngay. Siu m s gp th i d ng mch v
hng d ho iu tr. Th hang s ti ra vi c mui sinh l cho ti
khi u h t a ti. Nu ch h t ti ra tht bi, o th hang cht
ng vn a dgrenergic, cht c la chn l phenylephrine , liu 0,5- 1mg cho
mi th hang v t gy tc dng ph ton thn. Cc thu kh g th s dng
bng 4.2.

b. iu tr g : bao gm gi au phin, m hay lnh. Ktamine


ti t h ch c th gy ra o gic, cc thuc h huyt p v thuc ch g g
c th s dng trong nh g t ng hp t bit. Ketamine c th thnh cng
trong vic gy xu % t ng hp ti sm. Nu c bnh tim n l nguyn
h g g au d g t phi iu tr b h ga lp tc.

c. Bnh hi chng lim: phi iu tr c, kim ha v truy u


t g g H > g/dL. Nh y s lm gim tnh trng toan ha trong th
hang. Nu b h h g au d g t t g t c th iu tr bng chch
leuprolide acetate (cht ng vn LHRH) mi thng mt ln.

d. U g th u th himvo th hang c th p ng vi x tr d g t
v ha tr ton thn.

e. iu tr phu thut: nu b h h n sau 24 gi ho d g t khng


u sau khi h h phe leph i e hiu ln phi c ch nh phu thut to shunt
th hang- th xp bng cch to mt ng d gia ui u v th hang hoc bi
mt th hang- th xp shunt.

Th thut Winter l mt ph g ph p gi a to ao gm vic


to ra mt ng d gia ui u v th hang bng kim sinh thit Travenol
(hnh 4- 3). Th thut to a ng d? tm thi v c th thc hin ngay
ti ging vi v cm ti ch. Kt qu rt tha i g d thng t
g sm.

Phu thut Al- Gorab to ra mt shunt gia ui u v th hang bng cch


l i t mu 0,5 cm bao trng t mi th hang. i khi cn c nhng
shunt trit h hng h h shu t gia t h h l g d g t v
th ha g; shu t t h ch hin- th hang; shunt bn- bn th hang- th
xp. T ng hp g au d g t flo ao do d ng m h c
iu tr bng thuyn tc mch chn l . Sau khi d g t xp, bnh nhn
phi theo d i s t pht hi ga g au d g t ti pht.
Ct cht d g t sau m b g g th gy ra ph n v hoi t cn
nn trnh.

6. Ti lng: Cho d iu tr sm v c hu qu, tn sut lit d g k o d i


v ao % .T o g g th g u sau phu thut to ng d phi theo
di tnh tr g g d g t, nu kh g g phi nh c b h a th
hang hoc b mt g d h in. Siu m th hang s cho th ng d do
phu thut, nu cn thng th phi phu thut g li, nu h a th hang th
phi l d g t nhn to.

33.RI LON PHN X T NG TY

Ri lon phn x t ng t t t g i tnh trng cao huyt p tm thu


nguy him, ra m hi v nhp tim chm kch pht. Hi chng ny ch gp
nhng bnh nhn t th g tu t on tu ngc 6 (T6). on tu bn
di v h th g ng dn truyn giao cm ngc- tht l g
vn cn nguyn vn. Cc nguyn nhn niu khoa thng gp nht l nhim
trng, b g ua g g hng v si. Ri lon phn x t ng ty c th
x a t o g l a g o p l bng quang, soi bng quang, phu thut
qua ni soi hoc tn si go i th. C th phng nga bng v cm ty,
v cm ton thn th khng c hiu qu tr khi m su. Cc nguyn nhn
khc bao gm to bn nng, v lot da. C nhiu m ri lon phn x
t ng tu , gp 85% cc bnh nhn b lit t chi. Nu bnh nhn khng
iu tr, s b tai bin mch mu no, co git v t vong.

A. Ch o : B h h ph au u, chy m hi nhiu, huyt p tm


thu t g h Hg, hu t p t t g t g h Hg so i mc bnh
thng, nhp tim ch h ln trong mt pht, trung bnh gim 20 ln trong
mt pht.

B. iu tr: m tiu iu tr cp thi l lm h huyt p v loi tr nguyn nhn


th , th g th g l g g ua g. Nu cn h huyt p nhanh nn dng
sodium nitroprussiidevi liu 25- 50 mg/ pht, liu tt a th dng ti 200-
300 mg/ pht. Mt cch khc c th dng diazoxidebolus ti 50- g ti t h
mch mi 5 pht hoc truy t h ch. Nu khng cn h huyt p tc th th c
th dng Nifdipineung hoc ng di li vi liu 10- 30 mg. Phn x chm
nhp tim c th iu tr b g At opi ti t h ch vi liu 0,4- 0,6 mg. D
phng lu di bng Prazosin 1- 4 mg ung 2 ln trong ngy.

CHNG 4. NI TIT NIU

34.PHN LOI BNH THN

(ICD 10).

TM TT

1. Bnh cu thn

- Cc hi chng lm sng ca cu thn.

- Cc bnh cu thn nguyn pht.

- Cc bnh cu thn th pht.

2. Bnh k - ng thn.

3. Bnh bng quang niu o.

4. D d g ng tit niu.

5. Bnh thn di truyn.

6. Suy thn.

BNH CU THN
I. CC HI CHNG LM SNG CA BNH CU THN

1. Hi chng cu thn cp

Xut hi t ngt vi cc biu hin:

- Ph

- T g hu t p

- i u i th hoc vi th

- C protein niu

- Gim mc lc cu thn.

2. Hi chng cu thn tin trin nhanh

Xut hi t ngt vi cc biu hin sau:

- i u i th hoc vi th

- C protein niu

- Thiu mu

- Tin tri ha h n suy thn.

3. Hi chng th h

- Ph, protein niu cao (> 3,5 g/24gi).

- Protid mu gim (< 60 g/l).

- Albumin mu gim (< 30 g/l).

- Choleste ol u t g > , ol/l .

- C th c m, tr m t o g c tiu.

. i u dai dng, lnh tnh

- i u t i pht nhiu l , i th hoc vi th.


- Khng c protein niu.

- Khng c bnh tit niu khc.

5. Hi chng cu thn mn

- Tin s c bnh cu thn (ph, c protein niu).

- T g hu t p.

- C protein niu ko di.

- C hng cu niu, tr niu.

- Tin tri n suy thn m , u , eati i u t g, MLCT gim.

II. CC BNH CU THN NGUYN PHT

1. Bnh cu thn t th g ti thiu: Vi cc biu hin chnh l:

- Hi chng th h gu ph t, thun - protein niu chn lc cao.

- Cu trc cu thn bnh thng qua knh hin vi quang hc ho t g h t


bo v cht gian mch.

- Mt chn li ca t o g podo tes di knh hi i in t.

- Khng c l g ng cc thnh phn min dch cu thn qua hin vi hu nh


quang.

- p ng nhy vi Co ti oste oid thng ti pht.

2. Bnh cu thn t th g /cc b (vim cu thn ): Vi cc biu hin chnh


l:

- Hi chng th h - protein niu chn lc thp.

- i u i th - c tr hng cu.

- T g hu t p.
- p g iu tr km, d n suy thn mn.

- T th g u thn tng (focal), mi cu thn ch b t th g t gc, cc


b (segmental).

- C l g ng IgM, C3, C4 cc cu thn.

- C l g g c hnh ht cu thn, c t th g h a.

3. Bnh cu thn mng: Vi biu hin chnh l:

- Hi chng th h - protein niu chn lc thp.

- Ph - protein niu dai d g. i u i th.

- C p ng vi iu tr.

- Tin ti suy thn mn (20-30%).

- Dy lan ta g ao un cu thn - c hnh gai kha lp ngoi mng


to g t kch pht qua nhum bc Methenamin (PAM).

- L g ng IgG v C3 g ao un cu thn.

- C l g g c lp go i g , tin ti d kh g u ton b
g giai on cui.

4. Bnh cu th t g si h gia ch: Cc biu hin chnh l:

- Hi chng cu thn cp hoc hi chng th h t o g t s t ng hp.

- T g hu t p (25%).

- i u i th.

- Protein niu chn lc cao.

- ASLO h th g. p ng tt vi iu tr.

- T g si h t bo v cht gian mch khng c d g .

- C l g ng IgG, IgM, C3, C4 khoang gian mch.


- C l g g c khoang gian mch.

5. Bnh cu th t g si h t o g ch lan ta (vim cu thn cp, in hnh l


sau nhim lin cu):

- Tin s vim hng, nhim khun ngoi da (7-14 ngy).

- Ph.

- T g hu t p.

- i u i th hoc vi th.

- Protein niu khng cao.

- ASLO t g A tist eptol si O , ASK t g A tist eptoki ase .

- C th c suy thn cp.

- p g iu tr tt.

- Mt s t hng cu niu. Protein niu tn ti dai dng d u thn, suy


thn mn.

- Xm nhp t bo vim lng mao qun cu thn.

- Ph n t g si h la ta t bo ni mc mao qun - t g si h t bo v cht


gian mch.

- L g ng cc thnh phn IgG, C3, Properdin thnh mao qun v khoang gian
mch - khng c l g ng IgA.

- L g ng hnh ht th h g lp go i g ao ch qun cu thn.

- X h a, teo th u 2 bn khi tin ti suy thn m giai on cui.

6. Bnh cu th g t g si h vi u thn gian mch, mao mch, vim cu


th g t g si h : Cc biu hin chnh l:

- Hi chng th h - % kh g thun.
- Hoc ch c protein niu v hng cu niu.

- ASLO h thng.

- T g hu t p.

- Suy th , ti lng xu.

- T g si h nh t bo gian m h, t g si h t bo ni mch, xm nhp bch cu


lng mch - d g ao un cu thn.

- L g ng thnh phn min dch IgG, IgM, IgA, C1q, C4 v nhiu nht l C3
thnh mao qun cu thn v khoang gian mch.

-M g ph i, u th h a.

III. BNH CU THN TH PHT

1. Bnh cu thn h thng:

1.1. Vim cu thn Lupus:

Lm sng l mt b h Lupus a h thng c protein niu thng xuyn


v/hoc hng cu niu, tr niu. Ba h m hai bn s g i, i au
khp khng bin dng, thiu mu, c khng th khng nhn, khng th khng
ADN d g t h l hng biu hi thng gp nht. T th g n thn
bao gm 4 hnh thi t th g u thn:

- T th g ti thiu - cu thn g h thng.

- Vim cu thn Lupus .

- Vim cu th Lupus t g sinh lan ta.

- Vim cu thn Lupus mng.

B h ti lng xu d n suy thn trong vng 2- .

1.2. Vim cu thn IgA (bnh Berger):


L s g thng gp tui tr, i u t i ph t hiu t i th hoc vi th.
C protein niu t di 1 g/ g , t g IgA hu t thanh (50%), ASLO, ASK, khng
th khng nhn, khng th kh g AND h thng. T th g n cu
thn bao gm cc hnh thi:

- T th g ti thiu.

- T th g .

- Vim cu th t g si h gia ch.

- T th g c hiu l c l g ng IgA khoang gian mch v thnh mao


mch cu thn (qua hin vi hu nh quang).

- Ti lng c th d n suy thn mn sau 10- ua hiu t ti pht.

1.3. Vim cu thn Scholein-Henoch (ban dng thp):

Lm sng biu hi t c ht l cc ban chm xut huyt da, thng l hai


cng chn (95- % , au g, ph e , au khp, i u i th, c protein
niu u g ua h g/ g , t g IgA hu t thanh (50%). ASLO, khng th khng
nhn, khng ADN m tnh. T th g n cu thn bao gm:

- T th g ti thiu.

- T th g /cc b t g si h la ta gian mch.

- T th g c hiu l c l g ng IgA khoang gian mch ging bnh vim


cu thn IgA.

- Ti lng tin ti suy thn mn t 5-25%.

1.4. Hi chng Goodpasture:

L hi chng phi - th i u ho a u, thuc nhm bnh t min m


khng nguyn thuc collagen typ IV, v c khng th kh g g u thn v
g phi. Biu hi l s g in hnh l:

- i u.
- Ho a u m ln mu).

- Tin trin nhanh n suy thn.

T th g n cu th l t g si h , cc b, c xm nhp bch cu a
nhn trung tnh thnh mao qun cu thn, ri tin ti hoi t , huyt khi, to
hnh lim, xm nhp t o i , h a k, teo hoc gin ng thn. C l g ng
hnh thnh IgG v khng th kh g g thnh mao qun cu thn.

2. Bnh cu thn chuyn ha:

2.1. X u th i th o ng: Vi cc biu hi t g l :

- Tin s i th o ng.

- Albumin niu vi th giai on sm (10- .

- Protein niu thc th sau .

- Protein niu cao (> 3,5 g/24gi): hi chng th h, hi chng Kimmelstiel-


Wilson.

- Ph , t g hu t p, protein niu, hng cu niu.

- Vim vng mc, vim thn kinh ngoi vi, tc mch.

- Suy thn.

T th g n thn l t g si h la ta cht gian mch. C nt t a


eosin, nhu PAS d g t h cc cu th , d g ao ch cu thn,
hyalin ha tiu ng m h ng m h i. Tc mao mch cu thn.

2.2. Bnh thn dng bt:

C th l tin pht khng r ngun gc. C th b h h a u t g,


vim khp dng thp, nhim khun mn, lao phi. C th sau nhiu lc mu,
thn nhn to t h l - microglobulin).

- Biu hi t g l :
. Hi chng th h.

. Hng cu niu.

. Thn to.

. T g hu t p.

. Suy thn.

. C t g glo uli in d h d g hui nh v/hoc chui nng).

. Ti lng xu do suy thn.

- Biu hin t th g n l:

. C l g ng cht dng bt cu thn.

. Kh g t g si h hp t bo.

. C l g ng chui nh ca globulin min dch cu thn.

2.3. Bnh th a u t g:

Biu hin lm sng v cn lm sng bao gm:

- Hi chng th h.

- i th o ht do thn (gim kh g c).

- Hi chng Fanconi.

- Toan ng mt. T g alci mu.

- Protein niu Bence jones.

- C km thn dng bt (10%).

- Suy thn - ti lng xu.

- T th g n thn bao gm:

. Xm nhp vim k do t o a h khng l.


. Teo ng thn.

. Tr a eosi .

. Protein Bence jones, chui nh IgA trong tr niu.

.D g .

. Mt chn li.

. T g si h ht gian mch.

2.4. Bnh Waldenstrom:

Biu hin lm sng, cn lm sng bao gm:

- T g t bo lympho dng plasmocyt trong t g.

- Hi chng th h.

- T g IgM hu t thanh.

- L g ng IgM thnh mao qun v khoang gian mch.

- Ti lng xu.

- Suy thn.

2.5. Bnh Cruoglobulemia:

L b h i u oglo uli g lnh. Biu hin thn bao gm:

- i t,

- C protein niu.

- Hi chng th h.

- Suy thn.

- Trong huyt thanh c immunoglobulin b g do lnh.

- T th g thn xy ra sau hot ha lnh.


- C t g si h t bo v cht gian mch ging vim cu th g t g si h.

2.6. Hi chng gan-th u th do ga :

- B h t c: vim gan m , ga .

- Ri xut hin: protein niu, hng cu niu, tr niu, gim mc lc cu thn, ur,
eati i u t g.

- T th g n thn l:

. Vim cu th t g si h.

. X u thn , cc b.

Ti lng ph thuc vo bnh gan.

3. T th g thn cc bnh vim mch h thng:

3.1. Bnh thn vi ua h ng mch nt:

Biu hin nhiu ua c bit l phi, thn, khp;

- Biu hin thn bao gm:

. Protein niu.

. i u i th hoc vi th.

. T g hu t p.

. Suy thn.

. Ti lng xu.

- T th g n bao gm:

. Dy lp ni m ng m h g u g, ng m h li th , ng m h n,
ng m h i a cu thn.

. C th c hoi t t hu t mch, xm nhp vim t chc k.


3.2. Hi chng ur mu - tan mu (bnh vi mch huyt khi):

Biu hin chung l mt vim cu thn c thiu mu tan mu vi tam chng c


in l:

- Thiu mu tan mu.

- Gim tiu cu.

- Suy thn cp.

T th g n cu thn l c l g ng fibrin/fibrinogen gy tc mao qun


cu thn.

3.3. Bnh cu thn ng b:

Biu hin thn b h h ng b do dy, hp ng mch lin thy khi c


thng l n g do t g hu t p c tnh (nh u, m mt, ph gai) v suy
thn tin trin nhanh.

4. Bnh thn nhi c thai nghn:

- Biu hin lm sng bao gm:

. Ph

. T g hu t p

. Protein niu

. Sn git (xut hin t thng th 7 ca thai k , thng gi con l u).

- T th g th n l:

. Ph n t bo ni mch.

. Dy thnh mao mch cu thn.

. Cu thn n to.

. Kh g t g sinh t bo.
. Khi c sn git, th thng c hoi t ng thn, tc mch do l g ng
fibrin.

BNH K - NG THN

1. Vim k ng thn cp (Vim thn b thn cp).

2. Vim k ng thn mn (Vim thn b thn mn).

- Vim thn - b thn mn c tro gc bng quang niu qun.

- Vim thn - b thn mn tc nghn.

3. Thn c (do si, do cht hp on ni, kh g nh).

4. Thn m - p xe thn - p xe quanh thn.

5. Bnh k ng thn do thuc v kim loi nng.

6. Bnh k ng thn nhi c.

7. Bi i k ng thn trong cc bnh khc: nhim khu , k si h t g, u g th,


bnh mu, bnh chuyn ha, bnh t chc lin kt.

. i th o ht do thn (do si hoc nguyn nhn khc).

BNH BNG QUANG - NIU O

1. Vim bng quang cp, p xe bng quang.

2. Vim bng quang mn.

3. Ri lon ch g th ki h g ua g.

4. R bng quang - trc trng, r bng quang - o.


5. Ti tha bng quang.

6. Lao bng quang.

7. Vim niu o.

8. Hp niu o, ti tha niu o, sa niu o.

9. R niu o, sinh dc, trc trng.

D DNG NG TIT NIU

1. Thn teo nh mt bn, hai bn khng r nguyn nhn.

2. Cc bi i thn niu qun: thn mng nga, thn sa, niu qu i, iu


qun cm lc ch a ng sinh dc n).

3. Cc d dng khc.

BNH THN DI TRUYN

1. Hi chng Alport:

L mt bnh di truy ha nh sinh, suy thn s , ti lng xu.

Biu hin lm sng v cn lm sng bao gm:

- i u i th: c th i u i th, i v khun.

- Protein niu + , thng khng qu 3,5 g/24gi.

- ic thn kinh nht l nam gii.


- T th g n th l t g si h t bo gian mch, tin ti h a g
Bo a , h a t chc k, teo ng thn. Khng c l g ng globulin min dch
cu thn.

2. Hi ch g g g: i u t i pht lnh tnh.

L mt bnh lnh tnh di truyn theo kiu gen tri, biu hin bng:

- i u i th tui nh hay ti pht, c tnh cht gia h, sau - th


ht.

- Khng c vim hng hoc b h ng tit niu.

- T th g t g cu thn l g m g i t phn hoc ton


b (m g h so i 300-400 nm).

3. Hi chng t bo bt: bnh Fabry.

- Biu hi u ti thng lm gim tit m hi, c ch , nt tm u chi.

- C protein niu - suy th , u , eati i u t g, ti lng xu.

- T bo biu m v t bo ni mch cu thn thoi ha hnh hc (t bo bt).

4. Bnh th a a g.

L bnh di truyn gi ln theo kiu gen thn tri v tr em theo kiu gen
thn ln. tr e , th g c pht hi ga sau , tui s si h ho di
10 tui, ti lng xu, t bnh nhn s g n tui thanh nin.

gi l t g l s g l thn to, c nhiu nang c hai bn, trong nang


c dch. Cc nang to nh kh g u v to dn, tr g lng mi thn c th t
qu 1kg. Th g c ch o ph t hin vo tui n 40. Vi siu m th c
th pht hin s h . Tin trin d n suy thn, trung bnh vo tui 50. Tin
lng xu. a s t o g t c tui 60. Cn phn bit vi a g thn, mt
nang hoc nhiu nang lnh tnh, tin pht hoc mc phi (sau lc mu thn nhn
to di ngy).
SUY THN

1. Suy thn cp:

- Thiu niu-v niu, u u, kali u t g ha h.

- C th hi phc.

2. Suy thn tin trin nhanh:

- i u

- T g hu t p

- U , eati i u t g khng hi phc. T vong trong vng 6-12 thng.

3. Suy thn mn:

- Tin s c bnh thn-tit niu.

- Mc lc cu thn gim d , u , eati i u t g dn qua nhiu .

- Cui cng l hi chng ur mu cao.

35.SI THN - TIT NIU


(Bnh thn Ni khoa. Nh xut bn Y hc 2004)

Si thn - tit niu l mt b h l thng gp chim khong 3% dn s c


ph g T . Vit Na ha o s thng k trong dn s. Ti khoa Thn
Bnh vin B h Mai, t o g -1996) c 216/2256 bnh nhn nm vin
c vim thn - b thn do si chim t l 9,5%.

I. NGUYN NHN V C CH BNH SINH


Si thn tit niu do nhiu gu h g . Thng do nhiu nguyn nhn
cng phi hp to si. C h to si g t tng nguyn nhn m khc
nhau. Nhng si thng gp l:

1. Si calci: chi % t ng hp.

Th g l do c tiu qu bo ha mui calci.

C th do thiu, gim citrat niu. Citrat c tc dng c ch kt tinh cc mui


calci. Khi c toan mu, nhim khun tit niu, h K+ mu, citrat niu thng gim
to iu kin thun li cho vic to si.

2. Si acid uric:

Do t g a id u i u hG t g c tiu qu bo ha acid uric v to si.


T o g iu ki c tiu acid th acid uric cng d kt tinh.

3. Si struvit:

Ngun gc l nhim khun tit niu. Vi khun tit ra men urease lm phn hy
ur, to thnh amoniac (NH4OH). Amoniac b phn hy to thnh amonium NH4+
v OH- gy ki h a c tiu. Struvit (MgNH4PO4.6H2O c to thnh v trong
iu ki c tiu kim ha th kh ha tan v to si.

4. Si oxalat:

Ngun gc c th do di truyn gen ln trn nhim sc th thng gy lon


d g o alat. T g o alat iu to iu kin to si oxalat calci ngm 1 phn t
c. Si oxalat phi hp h g nh vi l g ng calci.

5. Si cystin:

Do ri lon vn chuyn cystin ng thn v nim mc rut, nguyn nhn do di


truyn gen ln nm trn nhnh ngn ca nhim sc th th 14. Si sti thng
i i mt bnh cnh bnh l ng thn di truy a iu, h K+ mu).
Trn thc t lm sng, si thn tit niu thng l si hn hp. T mt si u
tin khng c calci (si st u it, a id u i , sti h g sau l g ng calci. V
vy si thn tit niu thng l si cn quang.

II. BIU HIN LM SNG V CN LM SNG

1. Biu hin lm sng:

Biu hin lm sng ca si thn rt a dng. Ty thuc vo v tr ca si, o


to nh ca si, vo cc bin chng do si gy ra. Triu chng lm sng cn c th
li ua n loi si al i, st u it, sti do gu h nh sinh c khc
nhau.

a. C th c tin s i si hoc nhim khun tit niu ti pht nhiu ln: i ut,
i t, i , i ti pht nhiu ln. C th i a si.

b. au:

- C au d di, th g c gi l au un th . au thng khi pht


t im niu qun, lan d theo g i a niu qun xung pha g mu.
C g khi au u a h g, l g. C khi , u . Ngu h au
thng do si di chuyn t t i, thn xu g g g iu qu , t g p
lc trong lng niu qun v co tht niu qun.

- au gp nhng si va v thm ch l h g m v tr b thn.

- Cc si niu qun rt nh di chuy g th g g au du h .

- au h g l g th do c b thn do si trung bnh v to niu qun


gy tc nghn niu qun.

- au h g l g i khi th l mt biu hin lm sng ca vim b thn


cp do si.

- au k theo i th l do si h t tc c bng quang hoc lt ra niu


o.
c. i u: C th i th hoc vi th v l bin ch g thng gp ca si thn
tit niu, nht l khi si a g di hu n bn trong niu qu g au k i a
mu.

d. i ut, i t, i : L biu hin ca nhim khun tit niu.

e. St: St cao, rt run km theo vi triu ch g au h g l g, i ut, i t,


i l du hiu ca vim thn - b thn cp.

f. Cc du hiu tc ngh ng bi niu:

- i tc t g l , i gp ngng: si bng quang.

- i tc hon ton: si niu o.

- Thn to: c b thn do si niu qun hoc si b thn ch ra niu qun.

2. Cn lm sng:

a. Ch o h h nh:

- Chp bng khng chun b: pht hin si cn quang.

- Chp UIV: X nh chnh xc v tr ca si c ua g, ng thi h gi c


ch g thn tng bn. Chp UIV g pht hin nhng si khng cn
quang.

- Chp thn gc dng (UPR) khi cn thit: c tnh trng tc ngh h g phi
chp thng khng pht hi c si, chp UIV thn khng ngm thuc do tnh
trng tc nghn.

- Chp b thn, niu qun qua da v qua b thn: Khi c tc nghn r m UPR
kh g l c (chng ch nh do nhim trng bng quang nng hay do lm b
tht bi).

- Siu m: pht hin si b thn v mt s si niu qun (si o u on


cui ca niu qun). Siu m thn cn cho bit tnh trng nhu m th h a
tnh tr g i thn (gin).
- Soi bng quang: pht hin si bng quang, tnh trng vim nim mc bng
quang.

b. Cc xt nghim khc:

- Protein niu.

- T bo niu.

- Vi khun niu.

Xt nghim protein, t bo, vi khun niu tm nhim khun tit niu.

- Ch g thn:

. Ur mu.

. Creatinin mu.

. Mc lc cu thn.

Xt nghim ch g th pht hin tnh trng suy thn.

c. Cc xt nghim khc:

Cc xt nghim khc gip tm nguyn nhn:

- Acid uric mu, niu.

- Th d n gip trng.

- h lng cystin niu

III. CHN ON

1. Ch o nh da vo:

- Tin s.

- au h g l g ho au un thn.

- i u.
- Cc triu chng ca bin chng:

. Nhim khun tit niu.

. Thn to nghi c, m.

- X ua g: X nh si cn quang (chp bng khng chun b), hoc si khng cn


ua g UIV . T o g t ng hp cn thit chp UPR hoc chp b thn niu qun
qua da.

- Siu m: Pht hin si b thn v mt s si niu qun.

2. Ch o gu h :

- Ch ung: nhiu calci, nhiu a id u i

- Nhim khun (si struvit).

- Cng cn gip (si calci).

- Lo d g sti , o ali

3. Ch o in chng:

a. Nhim khun tit niu: Thng gp: i ut, i t, i a u, i cui


bi l hi chng bng quang. Xt nghim c vi khun niu v bch cu niu.

b. i u: i u i th th g i k au un thn. C th ch i
mu vi th.

c. B i: Do si cht c bng quang, si niu o.

d. Vim thn - b thn cp, mn:

- Vim thn - b thn cp: Biu hin st ao, t u , au h g l g t hoc hai


, i ut, i t, i X t ghim c biu hin nhim khun tit niu
(bch cu niu, vi khun niu), c protein niu, c bch cu u t g h yu l
bch cu a h t u g t h. i khi y mu (+).
- Vim thn - b thn mn: l hu qu ca vim thn - b thn cp ti pht nhiu
ln hoc ko di d n tnh tr g h a t chc k thn gy gim ch g
c ca th . L u d i h a cun mao mch cu thn gy suy gim ch g
lc.

e. c b thn:

L bin chng cp tnh nng. Nu tc nghn hon ton niu qun, b thn gin
to v sau 6 tun nhu m thn c th khng hi phc. Hu qu ca c l hy
hoi v cu trc d n s hy hoi v ch g. Khi tc ngh , g gi i
b thn, trc tip g t g p lc sau l . ng thi gin tip g t g
p ostagla di t o g th o o a A2 l mt dn xut ca prostaglandin H2
gy co mch thn nng. Chnh nhng ri lon ny m gy thn thiu mu. Nhiu
nephron ngng hot ng d n nhng ng thn teo dn, ty thn b hy hoi
v sau 6 tun v th g h cn li l mt t chc lin kt .

f. m b thn:

L mt cp cu ni khoa nng c th hy hoi nhanh nhu m thn nn c c


ch o s iu tr tch cc.

m biu hi : au g th , i ut, rt, thn to, st c tiu c, siu


i thn gin, X quang c si niu qun hoc b thn ch vo niu qun,
xt nghi c tiu biu hin vim r (bch cu, vi khun niu).

g. Suy thn cp:

Suy thn cp c th do tnh trng tc nghn nng (hon ton hoc gn hon
ton) c hai bn niu qun.

Suy thn cp g th xy ra bnh nhn ch c si niu qun mt bn


h g g phn x co mch c hai bn gy v niu. Biu hin lm sng l v niu,
xt nghim ur, creatinin, K+ u t g ha h, toa hu n ha.

h. Suy thn mn:

Do vim thn - b thn mn l hu qu nng n nht ca si thn, tit niu v


khng cn kh g hi phc do th h a dn.
IV. PHNG BNH V IU TR

1. Vi bt k loi si no:

- Cn phi ung nhiu m bo l g c tiu t nht l t 2,5 lt/24gi


tr ln.

- Cha t nhim khun tit niu, vim thn b thn.

- Cha cc triu chng v cc bin chng khc: c, m b th , i ...

2. Vi si cystin:

- Ung nhiu m bo l g c tiu , l t/ gi.

- Ki h a c tiu:

. Natribicarbonat 6 g/24gi chia 4 ln.

. Kalicitrat liu t g t.

. M h t pH niu: 7 - 7,5.

3. Si acid uric:

- Ung nhiu m bo l g c tiu , l t/ gi.

- Hn ch th hiu a id u i m 0,6 g/kg/24gi).

- Ki h a c tiu bng Natribicarbonat hoc Kalicitrat.

4. Si struvit:

- Ung nhiu c.

- iu tr tch cc nhim khun tit niu.

- Sau khi m ly si vn cn ki so t, iu tr tt nhim khun tit niu.

5. Si calci:

- Cn ung nhiu c.
- Ch hn ch calci.

- Hn ch hp thu calci rut:

. Trnh dng Vitamin D, du , c bit l 1-25 hydroxycalciferol D3.

. C th cho tim: Thiazid (Hypothiazid 25mg x 2 ln/24gi), m h h o


thi calci niu. Orthophosphat: 1000-1500 mg/24gi chia 3 ln, m h o thi
p ophosphat a c tiu s c ch kt tinh phosphatcalci.

- Th d t gu h i lon chuyn ha:

. Cng cn gip tin pht, th pht: ct b tuyn cn gip.

. Bnh l toan ha do ng thn: cho citrat kali liu 4-6 g/24gi chia 4 ln.

. iu tr can thip t sang chn:

a. Tn si go i th:

- Si ng knh < 2 cm.

- V tr si b thn, ho o u, on cui niu qun.

b. Tn si qua ni soi: Si bng quang hoc si niu qu on cui.

c. Ly si qua soi niu qun:

- Si nh.

- V tr: si ung thp on cui niu qun.

- Khng c nhim khun bng quang.

d. Ly si niu o: si nh, ra st niu o ngoi.

. iu tr ngoi khoa:

- Si to, si san h b thn.

- Si gy bin chng nng: c, m


- Si do nhim khun (si struvit).

- Si trn d tt tit niu.

- Bo ph khng thun li cho tn si.

- t si h g tht bi.

- tr bng cc bin php t sang chn khng kt qu.

- iu tr ngoi khoa hoc tn si xong, cn tip t iu tr d phng ni khoa


trnh ti pht.

. iu tr cc triu chng v bin chng khc:

- iu tr nhim khun tit niu, vim thn b thn cp, mn.

- iu tr suy thn nu c (xem ph iu tr suy thn cp, mn).

- iu tr i u, au qun th

36.HI CHNG SUY THN CP TNH

. h gha.
Suy thn cp tnh l tnh trng suy sp ch g thn mt cch nhanh chng v
nht thi. Thn mt kh g o thi cc cht cn b, mt kh g iu ho ni
mi, d n ri lon chuyn ho in gii, ri lo th g ng kim-
toan. Biu hin lm sng ch yu ca suy thn cp l thiu niu, v niu v cc
triu chng ca hi ch g t g u u. Bnh din bin cp tnh v rt trm
trng, bnh nhn c th t vong do nhim toan chuyn ho, ng g ti t ngt
do t g kali u, do ph phi cp tnh v nhim khun. Nu iu tr kp thi,
g ph g ph p th nh nhn c th hi phc hon ton.
Suy thn cp l mt cp cu ni khoa. Hin nay, tuy c nhiu bin php tin tin
t o g iu tr suy thn cp, h g t l t vong vn cn cao.
2. Nguyn nhn ca suy thn cp.
2.1. Nguyn nhn suy th t c thn: gi lu lng tun hon ti thn do tt
huyt p, gi lu lng tun hon do mt c, suy tim.
2.2. Nguyn nhn suy thn cp ti thn: hoi t ng thn do thiu mu, hoi t
ng thn do nhi c, vim ng k thn cp tnh.
2.3. Nguyn nhn sau thn: do chn p h thng dn niu.
3. Bnh sinh ca suy thn cp.
3.1. Bnh sinh ca suy thn cp guy h t c thn:
Tt c cc nguyn nhn gy suy thn cp t c thn l do gi lu lng tun
hon qu mc, thn mt kh g t iu chnh p lc l duy tr ch g
lc ca cu th .T o g t ng hp lu lng tun hon gim, huyt p ti a
gim s kch thch b phn nhn cm p lc vng xoa g ng mch cnh, kch
thch s hot ng thn kinh giao cm, hot ho h thng RAA (renin
a giote s i oge e aldoste o t g tit epinephrin, angiotensine II, AVP (arginine
vasopressine), co tht mch mu ngoi i d u ho ua ua t ng
h o, ti l t g l g u n thn.
Ti thn, khi huyt p gim s d n gi l g u n th . T o g t ng
hp lu l g u n thn gim, thn c nh g h t iu chnh vi tun
hon ti thn nhm duy tr p lc lc h m bo cho chc g lc ca cu
thn. Phn ng ca th t c tnh trng gi lng mu: th t g ng tng
hp prostaglandin I2 (PGI2) v prostaglandin E2 (PGE2 , t g t h hy cm ca t
bo ca uai He le i vi ANP (atrial natriuretic peptide) nhm m h gi
ng m h n, gin cc mao mch cu th l t g lu lng tu ho , t g
din tch lc ca cu thn, gim ti hp thu c v mui ng th duy tr
mt l g c tiu nht h, m bo kh g o thi cc cht cn b ra
khi th. Mt khc, thn sn xut angiotensin II v thromboxan A2 t chc lm
o ng m h i, l t g p lc cun mch cu thn. Kt qu ca s iu chnh
vi tun hon ti thn nhm gi cho mc lc cu thn gii h h thng nh
vo s t g d g u n th , t g p lc l t g din tch l . l
ch t iu ho ht sc quan tr g. Khi lu lng tun hon gim trm trng,
huyt p gi di 60 mmHg, kh g iu chnh vi tun hon ca thn mt
hiu lc th ch g lc ca cu thn gim hoc mt hon ton, biu hin lm
sng l thiu niu, v niu, t g u u eati i u. Nu iu tr kp thi,
b su g lng d h t, a hu t p tr v gii h h th g th c
tiu t o g g t g dn, ur v creatini mu gim..

S 12. Bnh sinh ca suy thn cp t c thn

3.2. Bnh sinh suy thn cp ti thn:


3.2.1. Suy thn cp do thiu mu:
Suy thn cp do thiu mu chim t l 60%.
Nh g t ng hp suy thn cp ti thn, nu kh g iu tr kp thi, v niu v
thiu niu ko di 72h, t suy thn chc g s tr thnh suy thn cp thc th.
Tnh trng thiu mu ko di d n hu qu hoi t ng thn cp t h. C h
suy thn cp ti thn l:
* Ri lon huyt ng:
Lu lng tun hon ca th gim, huyt p gi < Hg, th mt kh
g iu chnh vi tu ho duy tr ch g thn. Tnh trng thiu mu
khng hi phc d n t th g t bo ni m mch mu thn. T bo ni m
mch mu thn s t g ng sinh tng hp v gii phng endothelin, gim tng
hp NO (nitric oxide) gy co tht mch mu trong thn v co tht t bo gian
mch ko di. Tnh trng ti phn phi mu gy thiu mu, thiu xy g di
v v vng ty ngoi gy t th g t o on thng ca g ln gn (pars
resta) v nhnh ln ca quai Henle vng ty mTAL (medullary thick ascending
limb).
S co tht mch mu vng ty ch yu do vai tr ca endothelin. Trn thc
nghim- gi ta dng khng th khng endothelin cho nh g t ng hp suy
thn cp do thiu mu, th tnh trng thiu mu vng t c ci thin hon
ton. T th g t bo ng thn ch yu l do thiu xy, p lc xy vng ty
th thng xuyn gim k c khi lu lng mu vng ty hi phc hon ton.
Ngi ta gi thit trong suy thn cp do thiu mu, cc shunt ni gia mch mu
vng ty ngoi vi vng v v vng t t o g t g ng hot ng lm gim
phn p xy vng ty ngoi.
S ri lon hp thu c v mui g ln gn lm xut hin phn x kh hi
ng-cu thn (tubuloglomerular feedback) thng qua h thng macula densa gy
co tht ng m h n ca cu thn v lm t th g thn do thiu mu.
S 13. Bnh sinh thiu xy vng ty v hoi t t bo on thng

* Tc nghn ng thn :
Tc nghn ng thn l mt trong nh g h bnh sinh ch yu ca suy thn
cp tnh. S tc ng thn lm mt kh g lu th g dch trong ng thn, lm
t g p lc trong ng thn d n trit tiu p lc lc, ch g thn suy gim
nhanh chng. Nguyn nhn ca tc ng thn ch yu do hoi t t bo ng thn:
+ S thiu ht ATP:
- Do thiu xy, qu trnh chuyn ho to g lng b hn ch.
- Thoi bin ATP khng hi phc (ATP-ADP-AMP-adenosine), tch t nhiu
hypoxanthin, hot ho men xanthinoxidase.
+ c ni bo:
ATP l ngu g lng cung cp ho Na+-K+ , t d g a
+ +
3Na ra ngoi t o a K vo trong t bo khi phn hy mt phn t ATP.
Khi ATP gim, c ch hot ng ca Na+- K+-ATP ase, gy Na+ d n c
ni bo lm t bo biu m ng thn s t g to n tr lu th g a ng thn
v chn p vng ty ngoi gy thiu mu. S mui c ni bo lm ri lon
vn chuyn cc cht ua g, t g n chuyn canxi vo ni bo, tr cc cht
cn b trong t bo.
+ T g a i t do trong t bo:
B h thng, n g Ca++ ngoi bo cao gp 10 ngn ln so vi n g Ca++ ni
bo (n g Ca++ ni bo bng 100 nmol). Khi ATP gim gy Na+ ni bo, s vn
chuyn Na+ ra khi ni bo thchin trn knh Na+/Ca++ d t g n chuyn
canxi vo ni bo, mt khc thiu ATP g t g hu ng Ca++ t li ni bo vo
t g o, khi g canxi ni bo > 500 nmol/l s gy nhi c, tc dng
ch yu ca t g a i i bo l:

S 14. Vai tr ca t g a i u t o g t th g t bo ng thn


S 15: Bnh sinh ca t th g ht t bo trong suy thn cp tnh

- Ph n ty lp th: ty lp th t g to, t g t h thm ca ty lp th, gim kh


g tng hp v ti to ATP t ADP v AMP (grave pathy).
- T g t h thm ca ty lp th to thun li cho superoxide (O2. tho t o t g
b o. Supe o ide t g t i NO- to nn ONOO- (peroxide nitrite), l mt cht
c kh g ho nh. S superoxide cn li, di tc dng ca superoxide
dismutase to thnh peroxid (H2O2).
- T g a i i bo hot ho mt s men: men proteinase ph thuc calmodine,
men dehydroxgenase, men xanthinoxidase. Men xanthinperoxydase bin
hypoxanthin thnh xanthin v sn sinh peroxide (O2.).
+ Toan ho ni bo:
Toan ho ni bo xut hin trong mi t ng hp thiu xy. Chuyn ho glucose
t o g iu kin thiu xy sn sinh nhiu sn phm ca axit lactic. S phn hy
hydrogen ca ATP lm toan ho ni bo, pH ni bo gim, tuy th toan ho tm
thi l phn ng t v, c ch e - nucleotidase nhm chng li s phn hy
cc nucleotide (ATP, ADP v AMP), c ch hot ng ca h thng men
phospholipase. Toan ho ni bo ko di khng hi phc s hot ho xanthine
oxidase to nn cc gc t do lm cht t bo.
+ Hot ho men phospholipase:
Hot ho men phospholipase s ph hy phospholipid mng t bo v cc mng
tiu th trong t bo: mng ty lp th, mng lysosom. Khi lng lipid t bo mt
dn v xut hin nhiu loi axit bo t do trong t o g i vi t bo, hy
hoi mng t bo v cc mng ca cc tiu th trong t bo.
+ T th g t bo do xy ho ROS (reactive oxygen species):
Mt s lng superoxide v peroxide sn sinh ra do thiu xy, do nhi c,
gi ATP, do t g a i i bo. H thng chng xy ho ca t bo (bao gm:
e dis utase, atalase, gluthio e gluthio pe o idase kh g
khng ch qu trnh xy ho. S d tha O2., H2O2 s sn sinh cc gc t do m
ch yu l anion hydroxyl (OH-). Cc gc t do peroxide nitrite (ONOO-) v anion
hydroxyl s g c lm cht t bo. Tc dng ca xy ho l:
- Peroxide ho mng t bo, bin cc axit bo khng bo ho thnh cc axit bo
bo ho, ph hy mng t bo v to ra nhng gc t do mi.
- Lm mt kt xon ca cc chui DNA v RNA.
- Bt hot cc h thng men ni bo v cc men trn mng t bo.
* R tho t c tiu nguyn thy vo t chc m k thn:
T bo ng thn b hoi t, ng thn mt kh g iu ch h lng dch trong
lng ng thn, p lc ng th t g do tc nghn. Hu qu l l g c tiu
nguyn thy t trn vo m k thn gy tnh trng ph n trong k thn. Chnh
tnh trng ph n k thn chn p vo ng thn, lm hp lng ng thn cn tr
lu th g a ng th , t g p lc trong ng th . T g p lc trong khoang
Bowmann do tc ng thn lm gim p lc lc.
S gi lu lng dch trong g ln xa do tc g ln gn v quai Henle lm
xut hin phn x kh hi ng thn-cu thn (tubuloglomerular feedback).
Ngoi tc ng thn do hoi t t bo, tc ng thn cn do hemoglobin,
myoglobin, tinh th axit uric, oxalat, canxi, phospho.
4. Lm sng ca suy thn cp tnh.
. . Giai o I giai on m u):
Triu ch g giai on mthaanjoajcuar suy thn cp ph thu o gu .
Triu chng bo hiu ca suy thn cp tnh l thiu niu hoc v niu, creatinin v
u u h thng ho t g kh g g k. Trong suy thn tim tng, mc lc
cu thn thp di m h thng.
. . Giai on II:
Giai on thiu niu, v niu :
Giai on II ko di 10 - g . l giai on din bin trm trng nht ca
suy thn cp v c nhiu bin chng nguy hi n tnh mng bnh nhn. Nhng
triu ch g thng gp l :
4.2.1. Thiu niu v v niu :
T o g giai on ny, mc du lu lng tu ho h thng, HA nh trong
gii h h thng, p l t h h t u g t hi t g h g nh nhn vn
trong trng thi v niu, thiu niu, c tiu 24 gi khong 300ml/ngy, thm
ch v niu hon ton. V niu l do tnh trng thiu mu v nhi c d n
hoi t t bo ng thn. Tnh trng v niu din ra trong khong thi gian t 10 -
g , h g g th ch ko di trong vi gi, hoc ko di 6 - 8 tun. Khi
thi gian v niu ko di qu 4 tun phi gh n hoi t v thn, vim cu thn
tin trin nhanh, vim hoi t mch mu cu thn, huyt khi lan to trong cc
mao mch thn.
4.2.2. Hi ch g t g u u:
Song song vi v niu, u u eati i u t g dn. M t g a ur
u t g eati i u ph thuc tnh trng thiu niu nhiu hay t v thi
gian v niu di hay ngn.
Biu hin lm sng ca hi ch g t g u u t phong ph, t th g hiu
ua i t g, h g kh g t iu ch g l s g o t g ho t h
tr g t g u u. T iu chng lm sng ph thuc vo m t g a hi
ch g t g u u, eati i u nhim toan chuyn ho. Biu hin
lm sng ca hi ch g t g u u:
* T th g h thng tiu ho:
l t triu chng bao gi g gp, rt kh chu i vi bnh nhn. Biu
hin lm sng: bu sau khi , sau li tc, nn ra mt xanh
mt vng, ra dch tiu ho, khng c thuc chng nn no c hiu nghim lm
gim hoc ht nn. Mu h a, xut hin tnh trng lot nim mc ming,
vim nim mc d dy, lot nim mc d dy- rut.
Xut huyt ng tiu ho l mt bin chng nng c t l t vong cao chim 8%
tng s t vong do suy thn cp tnh. Xut huyt c th bt k on no ca
ng tiu ho. Biu hin lm sng ca xut huyt tiu ho : i go i a u hoc
nn ra mu, huyt p thp, c th h do t g u u t c thn.
Vim ty cp, t g a lase u - 3 l , t g ilirubin mu chim t l 43%.
Nguyn nhn ca t g ili u i u do i ga tr, truyn mu, nhi c
thuc (hydrocarbon, acetaminophen), nhim khun (vim t ng mt,
leptospirosis, vim gan virus B, vim gan virut C). S xut hin ca vng da l mt
du hiu xu, c gi tr ti lng.
* Tm thn kinh:
Cm gic bt rt kh chu, bun b, ri i o t ng thi ng li b, ngy rt to;
tr g th i l , l ln ri dn dn xut hin hn m trong trng thi hong lon
la ht, co c g , u si , o git; phn x g g t g, ng t co nh;
hn m su, ri lon nhp th, nhp th Kussmaul v c th ngng th t ngt
d n t vong. Triu chng ca no l biu hin ca tnh trng nhim toan, ri
lo in gii do t g u u.
* Tim mch:
Bin chng tim mch chim t l 35%, bao gm: suy tim, lon nhp, vim mng
ngoi tim, nhi u ti thng gp bnh nhn ln tui, ngng tim.
+ Ri lon nhp tim :
- Nhp nhanh xoang, tn s 120-130 ck/pht.
- Nhp nhanh trn tht.
- Ngoi tm thu tht.
Nguyn nhn ca ri lon nhp tim do suy tim, do vim mng ngoi tim, do ri
lo in gii. Theo mt s tc gi, nhp ti g ha h th ti lng cng xu,
t l t vong cng cao. Ri lon nhp tim nguy him nht l rung tht, nhp t tht,
v tm thu do t g kali u.
+ T g HA h gp 15 - 20% bnh nhn suy thn cp t h do t g lu lng tun
hon, gi mui, t g tit renin. S t g hu t p l ho ti lng bnh tr nn
xu h .
+ Vim mng ngoi tim:
Vim mng ngoi tim vi biu hi : au gc, kh th, c ting c mng tim,
th g i k i nhiu triu chng khc ca suy thn cp h u , , i
lng, xut huyt di da, trng thi bn chn vt v xen k tnh trng l ln.
+ Suy tim :
Su ti do t g lu lng tun hon, do vim mng ngoi tim, gim s p
tim do ri lon chuyn ho trong tr g th i t g u u, him toan, ri lon
in gii, su ti t g lu lng do ng . iu tr suy tim trong suy thn
cp tnh cc k kh kh i v dng digoxin d b nhi c, dng li tiu khng
c hiu l , gu d n ph phi cp l kh trnh khi. Thng c ngng
ti t ngt kh g gu , h h t ngt mt thc, ngng th,
t t i, t in tim xut hin nhp t tht ri rc.
* Bi i v h hp:
Bin chng phi chim t l 50% bnh nhn suy thn cp tnh, bao gm: suy h
hp, ph phi, ngng h hp, vim mng phi, bi nhim phi, bnh phi do
ng, bnh phi ht, ngng th t ngt.
* Nhng bi i v huyt hc:
Thiu u g l t iu ch g thng gp. Nguyn nhn ca thiu u thng
gp l:
- Do gim hot tnh ca erythropoietin: t g c ch tm thi, do tnh
trng nhim khun.
- Tnh trng , lo g u i sng hng cu gim.
Bch cu t tha i ho t g kh g g k. Nu t g hiu phi gh n tnh
trng nhim khun. Mu tiu cu gim, s lng tiu cu v hot tnh tiu cu
gim. S gim s lng v cht lng ca tiu cu, gim yu t VIII kt hp vi
tnh trng t th g th h h do t g u u d n tnh trng xut
huyt. Xut huyt di da, ch tim, xut huyt tiu ho, xut huyt vng mc,
khng loi tr xut huyt do hi ch g g u i rc trong lng mch.
4.2.2.6. Ri lon chuy ho v in gii:
+ T g lu lng tun hon:
Trng thi v niu v nhu cu v truyn d h lm gim ur mu, gim kali mu,
chng nhim toan, nhu cu v di h d g d n mt cn bng gia lng
o l g a. L g c vo l h l g c ra d n
t o g th, biu hin b g: thng ph nh hai h , t g lu lng tun
ho , t g p l t h h t u g g t g p l t h ch ngoi vi. S
l t g khi lng mu tu ho , t g g h tht tri d n suy tim cp
tnh gy hen tim, ph phi.
+ Gim natri mu:
Gi at i u th g i k i tnh trng tha t o g th thng gi
l gi at i u h t g g c ni bo, ph n t o, c bit l t
bo no, gy ph n no vi cc triu ch g: au u, bun nn, nn.
+ T g kali u:
Tnh tr g t g kali u li ua t thit vi tnh trng thiu niu v tnh trng
nhi toa . T g kali u l t trong nhng nguyn nhn gy t vong hay gp
nht ca suy thn cp do ng g ti t ngt thi k t t g.
Nguyn nhn ca t g kali u: iu lm mt kh g o thi kali, tnh trng
nhim toan d n ng th t g ng hp thu kali, do nhim toan gy nn ri
lon vn chuy kali ua g; t g n chuyn kali t ni bo ra ngoi bo.
V lm sng, khng c triu ch g l s g o t g ho t h t g t g kali
mu. Bnh nhn cm gic kh chu, bt rt, cm gic kh th, tc ng . T g kali
mu > 6,5 mmol/lt l mi nguy hi e do tnh mng ca bnh nhn. Chnh v
vy cn phi thng xuyn theo di tnh tr g t g kali u da trn s bi i
i ti h lng kali u. T i ti , khi t g kali u th s g T ao
nh i xng, QRS gin rng, QT ngn.
+ Nhim toan:
- Nhim toan l hu qu tt yu ca suy thn cp tnh. Nhi toa , t g K+ mu
v nu kh g iu tr th bnh nhn s i o t ng thi vt v cu knh l
ln, dn d i o h s u dn, co git; ri ln nhp th, nhp th Kussnaul,
ngng th, try tim mch v t vong .
- pH mu gim < 7,35.
- D tr kim gim < 20 mEq/lt.
- BE (ki d t h.
+ T g phosphat u, gim canxi mu:
- T g phosphat u th g i k theo gi a i u. T g phosphat u l
do thn mt kh g o thi phosphat t g u t h d ho gii phng
phosphat t cc m.
+ Ca i u thng gim, bnh sinh ca gim canxi mu do thiu ht sinh tng
hp 1,25 dihydroxycholecanxiferol.
T g phosphat u thng khng c biu hin lm sng, cn gim canxi mu
thng gy d cm quanh ming, chut rt, o gic, du hiu Chvostek (+)
Trousseaus (+). Hai du hiu ny (+) th c ph g o git ton thn. Ngoi
t g u eati i , a it u i th g t g t o g su thn cp tnh.
4.2.3. Nhim khun:
Tnh trng nhim khun khng phi l triu chng trc tip ca suy thn cp tnh
h g t hay gp i ng h hp trn, vim ph qu , i ng tit niu,
nhim khun vt m v nhim khun huyt. Vi khu thng gp l c Gram (+)
ln gram (-). T l nhim khun trong suy thn cp chim t 30 - 70% bnh nhn.
Nguyn nhn ca nhim khun l gim s khng ca th, h thng nim
mc mt kh g o v. Trong l , h h i hi phi tim truy , t
athete t h h di , t catheter chy thn nhn to l iu kin thun
li cho vi khu t nhp o th gy nhim khun, khng loi tr nhim
khun huyt. Tnh trng nhim khun lm bnh cnh lm sng cng nng n phc
tp. c tnh 75% t vong bnh nhn suy thn cp tnh l do nhim khun.
. . Giai o III giai o i hiu):
Giai on III ko di t vi tu i th g. L g c tiu t g dn t
1000ml ln ti 3000 - l/ g , l du hiu tt l h, h g n cn nhiu
nguy him, khng loi tr tnh trng t vong giai o i hiu. Tu i hiu
h g u u eati i u n cao, ch g ng thn vn cn ri lon,
kh g c vn gim, t tr g c tiu thp; xut hin tnh trng mt c,
ri lo in gii: gim natri mu, canxi mu v mt s t ng hp gim kali mu.
Nu kh g iu chnh kp thi, tnh trng v niu xut hin tr li. l du
hiu hoi t v th , ti lng xu, c kh g su thn khng hi phc. Ur
u, eati i u t g t li h giai on II, thiu niu xut hin tr li. V
vy, giai on III bnh nhn c theo d i hu o, gu t
vong.
. . Giai o IV giai on hi phc):
Giai on hi phc, bnh nhn cm thy d chu, ht bu , ung tt h ,
ht tnh trng thiu mu; ur mu, creatinin mu gii h h thng, khng
c tnh trng ri lo in gii, ch g c pha long ca ng thn bnh
thng hoc g h thng. Protein niu (-), khng c tr hng cu v tr bch
cu. T o g giai o II, giai on III protein niu 0,5-1g/ngy, hng cu niu bch
cu niu, tr hnh ht, tr bch cu, tr hng cu.
4.5. Tin trin v nguyn nhn t vong:
Suy thn cp t c kh g t hi phc, nu iu tr kp thi th bnh nhn c th
khi hon ton. Nguyn nhn t vong:
- T g kali u.
- Nhim toan chuyn ho.
- Nhim khun
- Suy tim, ph phi.

37.CU TO SINH L H TIT NIU


GS. Tr V Cht
H tit niu bao gm th ng d c tiu: niu qun, bng quang, niu
o.

1.1 Thn

. . i th

Ngi ta c 2 qu thn nm dc hai bn ct s g, o u g t sng tht l g


v 3. Thn phi, n s t g s hi thp h thn tri.

Thn nm sau phc mc, st vi thnh sau ca bng, xung qua h


quanh thn bao b . Ph a go i quanh thn, c l cn (hnh 1).

Mi thn nng khong 120g, t ngoi vo trong

Bao quanh thn l mt mng lin kt c th t h c.

- Nhc thn:

+ V th u , c cc g ln, cu thn v mt s quai Henl.

+ Tu thn c hnh kha cnh qut mu xm, c cc nhnh ca quai Henl v cc


ng gp.

Rn thn gm:

- T h ch thn n ph a t c.

- ng mch thn nm gia.

- B thn nm pha sau. B thn ni tip pha trn vi i thn v pha


di vi niu qun.

Thn gm nhiu thu .

Mi thu l mt khi t chc hnh thp. Gia cc thp l ct th . nh thp c


hnh nm. Cc nm ny c nhiu l o i th . i th vo b thn (hnh
2).
ng mch thn:

Xut pht t ng mch ch b g ga di ng mch mch treo trng trn,


qua rn thn phn thnh nhiu nhnh chy gia i thn. Vo nhc thn,
ng mch chy gia cc thp, gi l ng mch lin thu . Ti ranh gii v v tu
th , ng mch lin thu un vng cung st th p. C ng mch vng cung
ny khng ni vi nhau m tch thnh nhiu nhnh chy thng ra lp ngoi v
thn gi l tiu ng mch lin phn thu . C ng mch lin phn thu cho
nhiu nhnh ngang, mi nhnh chy vo mt cu th c gi l ng mch
n. Tiu ng m h n chia thnh cc xoang v to thnh cun mao mch cu
thn. Khi cu thn ra, cun mao mch ny hp li thnh tiu ng mch ri i
phn thnh mt li mao m h u i dng h thng ng th . Li mao mch
ny cui g vo t h ch lin phn thu , t h h g u g, t h ch
lin thu ri t h ch thn (hnh 3).

Nh y h thng mch mu cu thn v ng thn l mt h thng gnh v c


hai m g li mao mch.

1.1.2 Vi th

Nephron: mi thn c khong 1,2 triu nephron: Neph o l cu trc v


ch g a thn bao gm:

- Cu thn: c hai cc: mt cc c tiu ng m h n v tiu ng m h i,


cc kia l ch xut pht ca g ln gn

Cun mao mch cu th c bao bc bi g .M g un thnh


nang Bao- a cha dch lc t u a ua g . Mt t o g g
t bo ni mc. Mt go i g tip gip vi khong trng Bao - man c lp
lin bo cn gi l t bo c chn. Gia cc gian mch c t bo gian mch. B
my cn cu thn bao gm vt c, t bo ht, t o li Lacis (H.4b & H.5).

- ng thn: gm g ln gn, nhnh xung quai Henl, g ln xa, ng gp


(hnh 4a).
Ngoi ra cn c t chc k thn, mch mu nh, bch mch v thn kinh trong
thn.

1.2 ng d c tiu:

1.2.1 Niu qun:

L ng hnh tr, di ch g . ng knh niu qu kh g u. Gm nim


mc, lp , ngoi.

1.2.2 Bng quang:

N sau g u, t c trc trng. Dung tch trung bnh 250ml. Mt trong bng
quang c tam gic bng quang to bi hai l niu qun v l niu o. Thnh bng
quang c 3 lp: nim m , t , tha h c. nam gii xung quanh c bng
quang c tuyn tin lit.

1.2.3 Niu o: ca a d i h .

Ch g si h l a thn.

Th l ua to v bi xut c tiu m bo ch ng sinh l thng


qua hot ng chnh: lc mu cu thn, ti hp thu v bi tit ng thn. Thn
cn sn xut mt s cht ni tit h e i , ki i , e th opotei , p ostagla di
chu h hng mt s cht ni tit h ho o kh g li tiu, hormon cn gip,
atrial natriuretic peptid.

2.1 Lc mu ca cu thn

Qu trnh to c tiu c khi u bng lc mu ca cu thn. S l c


thc hin b g h siu lc. Mi pht c 1000 - 1200ml mu qua hai thn. Mi
pht, thn lc t huyt t g c 120ml dch l a u. D h ng
t g so i huyt t g. Mc lc cu thn ph thuc vo 3 yu t: huyt p h
thng, kh g lc ca h lc mao qun cu thn, din tch ca h mao qun cu
thn.
2.2 Ti hp thu v bi tit ca ng thn.

2.2.1 Ti hp thu ca ng thn:

Nhm ch s vn chuyn ca mt s cht t lng ng thn tr vo t chc k


quanh ng thn ri o u. Qu t h c thc hin c th theo h
khuch tn th ng do chnh lch n g hoc ch ng do chnh lch th
g in ho tiu hao g lng.

Cc cht c ti hp thu c xp vo hai nhm:

- Nhm cc cht kh g gng ti hp thu.

- Nhm cc cht gng ti hp thu. Nhm ny li chia lm 2 loi:

+ Loi cc cht gng ti hp thu ti a T h a i oa id, glucose, a.uric.

+ Loi cc cht m kh g t i hp thu ph thuc vo n g ca chng trong


dch lc cu th h Bi a o at.

2.2.2 Bi tit ca ng thn: nhiu cht c t bo ng thn bi tit thm vo


c tiu h PSP, PAH, phenol, diodrast, hippuran, penicillin

. . C h c tiu.

thi s h c t do . Nc t do l l g c phi thm vo hoc bt i


c tiu c n g thm thu ngang vi huyt t g.

thi s h c t do (CH2O c tnh theo cng thc:

C H2O g t g th c tiu cng b pha lo g h t g. CH2O ti a l


15ml/pht. C H2O th c tiu s u t g k hiu bng TCH2O. Ti hp thu
ti a c c th n 5ml/pht.

C H2O = c tiu s g t g.
Thuyt gc dng

Qu t h c tiu c thc hin ch yu quai Henl v ng gp v


c gii thch theo thuyt gc dng ca WIRZ (1951).

- g ln g , c tiu g t g: 300 mosm/l.

- Vo nhnh xung quai Henl n g thm thu: 1200mosm/l.

- nhnh ln khng th c v Na+ ra khi g, c tiu li long dn. Nng


Na+ quanh ng rt cao v c tc dng gi gradient thm thu ao ti hp
thu c.

- C g l n g l a, c tiu cng long v tr th h h t g:


100mosm/l v th on ny gi l on pha long.

- g l a, c tiu tr th h g t g. t dng ca ADH.

- Nc t do khuch tn tr vo theo gradient thm thu s ). Cui g c


tiu s u t g. N g thm thu khi l n 1200mosm/l.

Ri lon kh g c tiu c th do t th g ng - k thn, thiu


ADH, i thm thu (suy thn, dng li tiu).

Hot ng ni tit ca thn.

3.1- Cc hormon bi tit ti thn.

3.1.1 Renin:
Renin c bn cht l protein do cc t bo ht ca b my cn cu thn tit ra.
Re i c tit ra khi gim dng mu qua thn, gi u g lng tim v vy c vai
tr quan tr g t o g iu ho huyt p qua h renin - angiotensin II.

3.1.2 To vitamin D (1,25 dihydroxycholecalciferol).

Thn chuyn monohydroxycholecalciferol (25HCC) thnh dihydroxycholecalciferol


(1,25 DHCC) do gn vo v tr a mt nhm OH. 25DHCC l cht c hot tnh sinh
hc yu. 1,25 DHCC c hot tnh sinh hc m h, l t g t i hp thu calci rut,
t g g al i o g.

Khi suy thn thiu 1,25DHCC s g lo g g, hu g.


3.1.3 Sn xut erythropoetin:

c tit ra t th , ga . T o g , thn sn xut 90% v thn, do cc t bo


ni mch ca li mao mch quanh ng thn. Erythropoetein kch thch tu
g to hng cu. Khi suy thn s thiu u. Nh g h g g gi
ta s d g Epoeti a c sn xut bng k thut ti t hp ADN iu tr thiu
mu trong suy thn.

Sn xut prostaglandin:

S tng hp, hot ng v phn hu prostaglandin xy ra ti th . N c tng


hp t o ho a a hido i a id a id o kh g o ho kh s ). Hnh
h p ostagla di do thn sn xut ch tc d g iu ho ti ch. Prostaglandin
c chia lm 2 nhm, mt nhm c tc dng dn mch, li tiu, ch g g
nhm kia c tc d g gc li s )

3.1.5 Sn xut Kallikrein - Kinin


Kallikrein v bradykinin l mt cht dn m h c tm thy v thn. N c tc
dng:

- Gim sc cn mch mu.

- T g i tit Na+ c.

- T g tng hp p ostagla di g ai t li i vi cc cht iu ho khc.

. C ho o t ng ln thn

3.2.1 Hormon chng li tiu.

3.2.2- Hormon steroid v thng thn: Aldosteron; Glucocorticoid.

3.2.3- Atrial natriuretic peptid:

c gii phng t cc ht t h, t dng li tiu thi Na+ v gim huyt


p. N lm mt tc dng ca renin v aldosteron.

3.2.4- Dopamin:
c phng thch bi thn kinh thn, c th l th pht do kch thch vascular
baroreceptor. N gy nn dn mh mu thn v li thi Na+. iu y ra t
kch thch h KalliKrein - Kinin.

3.3- Th iu ho chuyn ho.

Th hu ng v ho ging mt s ho o peptid h i suli , ho o n gip,


p ola ti , ho o t ng thnh, vasopressin, glu ago , ho o tiu ho iu
ho chuyn ho.

38.IU TR VIM QUY U - DA QUY U

Tc nhn gy ng iu tr ng ung
bnh iu tr ti t h
mch

Vi khun Gardnerelle Khng c Metronidazole 2g (po) x 1 liu


vaginalis ch nh
Candida Hoc
Mobiluncus
Metronidazole 500mg (po) q12h x 7
Prevotella ngy

Mycoplasma Hoc
hominis
Clidamycin 300mg (po) q12h x 7 ngy

Hoc

Moxifloxacin 400mg (po) q24h x 7


ngy

Candida Khng c Fluconazole 150mg (po) x 1 liu


ch nh Hoc

Itraconazole dung dch 100mg (po)


q24h x 7 ngy

39.VIM, P XE TIN LIT TUYN

Tc nhn gy iu tr ng iu tr ng iu tr ng
bnh tim chch chn tim chch ung ho i
la h g u chn la thay t ng chch
th sa g ng
ung

Vim Entero- TMP-SMX Quinolone (po)


tin lit bacteriaceae 2,5mg/kg q6h x 2 tun
Quinolone (IV) x
tuyn x 2 tun
2 tun Hoc
cp/
Hoc
abces Hoc Doxycycline
tin lit Aztreonam 200mg (po)
Ceftriaxone 1g
tuyn q12h x 3 ngy,
(IV) q24h x 2 2g (IV) q8h x 2
cp sau g
tun tun
(po) q24h x 11
ngy

Hoc

TMP-SMX 1 vin
(po) q12h x 2
tun
Abces Entero- Khng c ch Quinolone (po) x 1-3 thng
thn bacteriaceae nh
Hoc
vng
ty thn Doxycycline 100mg (po) q24h x 1-
3 thng

Hoc

TMP-SMX 1 vin (po) q12h x 1-3


thng

Vim tin lit tuyn cp/ abces tin lit tuyn cp

Triu chng: Vim tin lit tuyn cp biu hin bng st tiu au, tiu but h g
kh g au g s l g. A es tin lit tuyn cp biu hin bng nh g t st
khng km du hiu nh v.

Ch o :. Ch a i tin lit tuyn cp gm khun niu, m niu v n


chn tin lit tuy au h i, thng thy gi true. C c tiu (+) l do
c tiu b l t g khi i ga g tin lit tuyn nhim trng.Abces tin lit
tuyn ch a ng TRUS, CT/MRI.

Ch : ng qun vim TLT cp bnh nhn namb khun niu khng km


duhiu nh v, hoc abces TLT bnh nhn nam c ti vim TLT.

Tc nhn gy iu tr iu tr ng tim iu tr
bnh ng tim chch chn la thay th ng
chch chn ung hoc
la h g u i t
ng
chch sang
ng
ung

Nhim Entero- Ceftriaxone Gentamycin 240mg (IV) Quinolone


trng bacteriaceae 1g (IV) q 24h q 24h x 7 ngy (po) x 7
huyt 7 ngy ngy
Hoc
t
Hoc Hoc
ng Aztreonam 2g (IV) q 8h
niu Quinolone x 7 ngy TMP-SMX
do (IV)x 7 ngy 1vin (po)
mc q 12h x 7
phi ngy
trong
cng
ng Enterococus Ampicillin 2g Meropenem 1g (IV) Amoxicillin
(E.faecalis) (IV) x 7 ngy q8h x 7ngy 1g (po) q
8h x 7
Streptococus Hoc
ngy Hoc
nhm B
Imipenem 1g (IV) q6h x
Quinolone
7 ngy
(po) x 7
ngy

Nhim P.aeruginosa Ciprofloxacine Piperacillin/tazobactam Quinolone


trng 400mg (IV) q 4,5mg (IV) q 8h x 7 (po) x 7
Enterobacter
huyt 12h x 7 ngy ngy ngy
t Klebsiella
Hoc Hoc
ng
Serratia
niu Cefepim 2g Aztreonam 2g (IV) q 8h
sau (IV) q8h x 7 x 7 ngy
can ngy
Hoc
thip
Hoc
niu Gentamycin 240mg (IV)
khoa Meropenem q 24h x 7 ngy
1g (IV) q8h x
7ngy

Khng phi TMP-SMX Meropenem 1g (IV) TMP-SMX


do 2,5mg/kg (IV) q8h x 7ngy 1vin (po)
P.aeruginosa q6h x 7 ngy q 12h x 7
Hoc i
(B.cepacia, ngy
u
S.maltophilia Imipenem 1g (IV) q6h x
Hoc tr:
7 ngy
i
Quinolone
u
(po) x 7
tr
ngy
vi
m
TLT cp 2 tun nhm gi gu tin trin thnh vim TLT m . iu tr
abces TLT ging vim TLT cp km theo d lu gai khoa.

Ti lng: tt nu iu tr s thi gian dng khng sinh (km theo dn


lu gai khoa nu abces TLT)

Vim tin lit tuyn mn (enterobacteriaceae)

Triu chng: triu ch g ng niu h (tiu au ut nh k au g


l g thp), ti i TLT, st nh hoc khng.

Ch o : h a gm khun niu, m niu v TLT cng chc - c th au


nh. C c tiu hoc dch tit TLT (+). Vim TLT mn km si TLT (ch a
nh TRUS) s kh g iu tr khi vi kh g si h thun, can ct t ni soi
TLT.

Ch : nguyn nhn ph bin nht ca iu tr khng hiu qu l thi gia iu tr


kh g .

iu tr: bnh nhn d ng sulfamide, c th d g TMP c th cho TMP-


SMX.

Ti lng: tt nu iu tr 1-3 thng. Abces TLT l 1 bin chng nng t gp (c


th gy nhim trng huyt).
Thi gia iu tr l tng thi gian dng thu ua g ti h h , ng
ung ho g ti h h ng u g. a s bnh nhn dng thuc qua
ng tim chchnu u g c nn chuy ua ng ung ngay khi c ci
thin v lm sng.

Ciprofloxacine 400mg (IV) hoc 500mg (po) q 12h hoc Gatifloxacine 400mg (IV
hoc po) hoc Levofloxacine 500mg (IV hoc po) q 24h.

Nhim trng huyt t ng niu do mc phi trong c g ng

Triu chng: cc triu chng nhim trng niu.

Ch o : u c tiu (+) vi cng mt lai vi khun. Nu bnh nhn


khng b tiu g, lupus a h th g, ga , h a u ty, dng
corticoide, c bnh thn hoc b tc, chp CT/MRI ng niu lai tr abces/
b tc. Abces TLT t khi l nguyn nhn gy nhim trng huyt t ng niu.

Ch : c c tiu m ng thi gram (-) v gram (+) c th do ly trng hoc


d bng quang - rut.

iu tr: iu tr khi u da trn kt qu nhu g a c tiu: nu thy cu


t g g a + iu tr h him streptococcus nhm B/D (ch khng phi S.
Aureus/S. pneumoniae); nu thy trc trng gram (- iu tr h him
enterobacteriaceae (ch khng phi P.aeruginosa/B.fragilis).

Ti lng: ty thuc nguyn nhn ng niu gy nhim trng huyt v ty


thu a gi bnh.

Nhim trng huyt t ng niu sau can thip niu khoa

Triu chng: triu chng nhim trng huyt trong vng 24 gi sau khi can thip
th thut t ng niu.

Chn o : u c tiu (+) vi cng mt lai vi khun. Dng kt qu cy


c tiu t c khi can thip th thut nh dng vi khu h g iu tr.

Ch : nu cy mc Pseudomonas khng phi ae ugi osa, i sang TMP - SMX


ho n khi c kt qu kh g si h .
iu tr: iu tr theo kinh nghi i vi P.aeruginosa s ao c hu heat
cc vi khun ng niu gy NTT.

Ti lng: ty thuc nguyn nhn t ng niu gy nhim trng huyt v ty


thu a gi bnh.

Tc nhn gy bnh iu tr ng iu tr ng
tim bp ung

Gonococcus N.gonorrhoeae Ceftriaxone 125mg Azithromycin 2g


(IM) x 1 liu (po) x 1 liu

Cephalosporin th Hoc
h 3 250 - 500mg
Quinolone 100mg
(IM) x 1 liu
(po) x 1 liu

Cefixime 400mg
(po) x 1 liu

Abces thn vng Entero-bacteriaceae Khng c ch nh Doxycycline 100mg


ty thn (po) q12h x 7 ngy

Hoc

Azithromycin 1g
(po) x 1 liu

Hoc

Quinolone (po) x 7
ngy

Hoc

Erythromycin
500mg (po) q6h x 7
ngy

Trichomonas Khng c ch nh Metronidazole 2g


(po) q12h x 1 liu
Vaginalis
Hoc

Metronidazole
500mg (po) q12h x
7 ngy

Ciprofloxacine 500mg (po) q12h hoc Gatifloxacine 400mg (po) q24h hoc
Levofloxacine 500mg (po) q 24h.

Vim niu o do gonococcus (Neisseria gonorrhoeae)

Triu chng: sau giao hp 3-5 ngy, ra m l tiu, c gi au ut khi i tiu.

Ch o : hum gram cht tit niu o thy song cu gram (-). Cy bnh
phm t c hng v tr t g t N.go o hoeae. Thng km theo nhim cc
tc nhn gy bnh khcthou huyt thanh VDRL v HIV.

Ch : nhim N.gonorrhoeae khng c triu ch g t o g % t ng hp.

iu tr: kh g p ng vi iu tr c th do ti nhim hoc nhi ng thi vi


t h kh T i ho o as, U eaplas a . iu tr nhim N.gonorrhoeae c
hng v trc trng gi g h i iu o do N.gonorrhoeae.
Ti lng: nhim N.gonorrhoeae c hng v tr t gl t g gu ph t
tn nhim trng.

Vim niu o khng do gonococcus (Chlamydia, Ureaplasma, Mycoplasma)

Triu chng: khang 1 tun sau giao hp, tiu au but, l tiu khng c m.

Ch o : test t kh g gu Chla dia, y cht tit niu o tm


ureaplasma, Mycoplasma. Cy cht tit niu o lai tr N.gonorrhoeae.
thng km theo nhim cc tc nhn gy bnh khcth huyt thanh VDRL v HIV.

Ch : nhim tracomatis khng c triu ch g t o g % t ng hp.

iu tr: kh g p ng vi iu tr vi khng Chlamydia c th do ti nhim hoc


ng nhi t i o o as/ u eaplas a/ M oplas a. Qui olo e g t dng
i vi N.gonorrhoeae.

Ti lng: v sinh nu nhim trng mn tnh.

Vim niu o do tricomonas:

Triu chng: dch tit o c bt, nga, khng c mi thi.

Ch o : soi ti hoc c t i t ng c c bit thy tricomonas.

Ch : nhim tracomatis khng c triu chng trong % t ng hp.

iu tr: nu iu tr vi liu duy nht that bi, iu tr li khang 1 tun.

Ti lng: tt nu i tc ca b h h g iu tr.

40.ABCES THN

Abces thn hoc t m trong nhu m thn hay quanh thn

Tc nhn gy iu tr ng iu tr iu tr ng
bnh tim chch chn ng tim ung ho i t
la h g u chch chn ng chch sang
la thay th ng ung

Abces S. aureus MSSA: MSSA: MSSA:


thn
Nafcillin 2g (IV) Clindamycin Clindamycin
vng v
q4h
thn 1g (IV) q8h 300mg (po) q8h
Hoc Hoc
MRSA:
Ceftriaxone 1g (IV) Meropenem
Linezolid 600mg
q24h
1g (IV) q8h (po) q12h
Hoc
Hoc Hoc
Clindamycin
Ertapenem Minocycline
600mg (IV) q8h
100mg (po) q12h
1g (IV) q24h

MRSA:
MRSA:
Linezolid
600mg(IV) q12h Vancomycin

Hoc 1g (IV) q12h

Minocycline
100mg(IV) q12h

Abces Entero- Quinolone (IV) TMP-SMX Quinolone (po)


thn bacteriaceae 2,5mg/kg q6h
vng
ty thn

MSSA/MRSA: S. aureus nhy hoc khng vi methicillin. Thi gia iu tr l tng


thi gian dng thu ua g ti h h , ng ung ho ng tim chch
ng u g. a s bnh nhn dng thu ua ng tim chchnu ung
c nn chuy ua ng ung ngay khi c ci thin v lm sng.

iu tr c tip t n khi abcs th c hp tuh han tan hoc kch


thc khng gim thm na trn CT/MRI.

Ciprofloxacine 400mg (IV) hoc 500mg (po) q 12h hoc Gatifloxacine 400mg (IV
hoc po) hoc Levofloxacine 500mg (IV hoc po) q 24h.

Triu ch g: t g t h i thn - b thn cp h g st vn cao sau 72 gi


dng khng sinh.

Ch o :CT/MRI gi p h a a es t o g thn v quanh thn v gip lai


tr cc khi u. Abces vng v th thng th pht sau nhi t g ua ng
mu ho ng k cn. Abces vng ty th thng do cc nhim trng tin
trin trong thn.

Ch : c c tiu c th t h t o g t ng hp abces vng v thn.

iu tr: a s cc abces l a c d lu. Nhng a es ho a i c


iu tr ni khoa. Cn thm vn chuyn khoa niu.

Ti l g: li ua n m suy gim ch g thn.

41.VIM THN B THN, LAO THN

Tc nhn gy bnh iu tr iu tr ng tim chch iu tr


ng tim chn la thay th ng ung
chch chn ho i t
la h g u ng chch
sa g ng
ung

Vim Enterobacteriaceae Ceftriaxone Aztrionam 2g (IV) q 8h x 4 Quinolone


b 1g (IV) q 24h tun (po) x 4 tun
thn x 4 tun
Hoc Hoc
cp do
Hoc
vi Gentamycin 240mg (IV) q Amoxicillin 1g
khun Quinolone 24h x 4 tun (po) q 8h x 4
(IV) q 4h x 4 tun
tun

Enterococus faecalis Ampicillin 1g Quinolone (IV) q 4h x 4 tun Amoxicillin 1g


(IV) x 4 tun (po) q 8h x 4
tun Hoc
Hoc
Linezoid
Linezoid
600mg (po) q
600mg (IV) q
12h x 4 tun
12h x 4 tun
Hoc

Quinolone
(po) x 4 tun

Enterococus faecium Linezoid Quinupristin/dalfopristin Linezoid


(Enterococus khng 600mg (IV) q 7,5mg/kg (IV) q 8h x 4 tun 600mg (po) q
vancomycin) 12h x 4 tun Hoc 12h x 4 tun
Hoc
Doxycycline 200mg (IV) q
h g , sau g Doxycycline
(IV) q 12h x 4 tun 200mg (po) q
12h x 3 ngy,
sau
100mg (po) q
12h x 4 tun

Vim Enterobacteriaceae Khng c ch Quinolone (po) x 4 - 6 tun


b nh
Hoc
thn
mn do TMP-SMX 1vin (po) q 12h x 4 - 6 tun
vi
khun Hoc

Doxycycline 200mg (po) q 12h x 3 ngy, sau


g po h - 6 tun

Lao M.tuberculosis Khng c ch iu tr gi g h lao phi


thn nh

Thi gia iu tr l tng thi gian dng thu ua g ti h h , ng


ung ho g ti h h ng u g. a s bnh nhn dng thuc qua
ng tim chchnu u g c nn chuyn qua ng ung ngay khi c ci
thin v l s g thng < 72 gi).

Ciprofloxacine 400mg (IV) hoc 500mg (po) q 12h hoc Gatifloxacine 400mg (IV
hoc po) hoc Levofloxacine 500mg (IV hoc po) q 24h.

Vim b thn cp do vi khun (enterobacteriaceae, E.faecalis/ E.faecium):

Triu ch g: au g s l g t bn, st ? 390C (102 0F).

Ch o : khun niu, m niu, au g s l g st ? 390C (102 0F).


du khun huyt thng thy trong vim thn b thn cp nn can cy mu v
c tiu.

Ch : st s gim trong vng 72 gi d c ho kh g iu tr. Nu st khng


gim sau 72 gi dng khng sinh, c th do abcs trong thn hc quanh thn.

iu tr: iu tr a u da trn nhum gram mu c tiu: nu thy trc


trng gram (- iu tr h e terobacteriaceae; nu thy cu trng gram (+) hnh
chui e te o o us iu tr h fae alis. Nu e te o o us nh dng l
E.fae iu , iu tr thch hp h hng dn. Vim b thn cp th g c
iu tr khi u b g kh g si h g t h ch tro g g , sau hu n
sa g ng u g du t 4 tu gim thiu gu tin trin thnh vim
thn b thn main. Chp CT/MRI nu bnh nhn st ko di sau 72 gi dng
kh g si h lai tr si thn, b tc, abcs hoc vim thn - b thn dng u ht
vng.
Ti lng: tt nu l u iu tr kh g si h 4 tun.

Vim thn - b thn main do vi khun (enterobacteriaceae)

Triu chng: ti i thn - b thn cp, cc triu chng gi g h i


thn cp h g au g s l g st nh h .

Ch o : CT/MRI ho thy nh g tha i trong vim thn - b thn mn km


khun niu v m niu. C c tiu t khi iu tr c th t h gi an.
Vim thn - b thn mn l bnh l ca 2 th h g iu hin lm sng li ch
mt bn.

Ch : c c tiu c th d g t h gi a sau iu tr; c c tiu mi


tun trong vng 4 tu chc mu c tiu m tnh.

iu tr: iu tr 4-6 tun. Gi ti mu vng ty thn v bi i gii phu hc


ca thn lm vic lai b t i khun gp kh kh .

Ti lng: ty thuc m hy hai ch m thn.

Lao thn (M. tuberculosis):

Triu chng: khi u thn km theo cc bt thng niu qun (gp gc, xon) v
m niu v trng. B h h kh g au t khi bin chng lm tc niu qun.

Ch o : kt hp cc bt thng ng tiu t di, c th km tiu


mu vi th pH c tiu5,5, c c tiu thy trc khun lao.

Ch : chp x-quang phi h th g t o g % t ng hp, h g nh nhn


PPD d g t h. Lai tr cc nguyn nhn vim nhim khc gay m niu v
trng (trichomonas, vim thn m k .

iu tr: iu tr ging lao phi.

Ti l g: t g i tt nu iu tr t c khi ch m thn b h hi hoc


c b tc niu qun.
42.VIM THN- B THN MN TNH
TS. Hong Mai Trang (Bnh hc ni khoa HVQY)

. i c g.

. . h gha:

Vim thn-b thn mn tnh l mt bnh t th g n tnh nhu m, m k


ca thn, do hu qu ca qu trnh nhim khun t i-b thn vo thn ko di
ti pht nhiu ln, lm hy hoi ho t chc thn d n suy thn.

1.2. S thng gp:

Vim thn-b thn mn tnh l b h thng gp, chim 30% cc bnh thn mn
tnh; n gp nhiu h a .

1.3. Lch s:

1882, Wagner m t u ti t ng hp cht hp niu o, c m t o g c


tiu, 2 thn b teo nh kh g u.

1890, Thiemrich thy nhiu t ng hp vim b thn kt hp vi vim nhu m


thn.

1917, Lohlein thng o t ng hp cht do ur mu cao, m t thi thy c tn


th g i-b thn thn v tn th g nhu m thn. Thut ng vim thn-b
th c bt ngun t .

2. Nguyn nhn bnh sinh v cc yu t thun li.

2.1. Nguyn nhn nhim khun:

2.1.1. Nhim khun ngc dng:

Vim thn-b thn mn tnh do vi khu i theo o ng tit niu i gc ln


thn gy vim thn-b thn mn; bnh gp c nam v n do v sinh khng bo
m, hoc do can thip cc th thut th kh h: soi g ua g, soi iu
o...

n gii, gi ta cn thy cn thy vim thn-b thn mn tnh t l thun vi


hot ng tnh d iu kin v sinh yu km.

nam gii trn 60 tui, do u tin lit tuy l c tiu ng trong bng
quang l yu t thun li gy vim thn-b thn m t h gc dng.

2.1.2. Nhim khu theo ng mu:

T l nhim khun theo ng mu thp h hiu so vi nhim khun gc


d g h g li rt quan trng. V s lng mu qua cc mch mu vo thn
chim khong 1/4 s l g u lu th g t ti , do khi t o g u i
khun (xut pht bt c t nhim khun no ca th g d gy nhim
khun thn, nht l khi t ng niu c tc v t th g. im loi
ny l t th g nhu m th t c ri mi i-b thn.

2.1.3. Nhim khu theo ng bch huyt:

t gp h so i nhim khun theo ng mu, vi khun i trng c th


theo h thng bch huyt vo h tit niu ri vo thn.

N , F a ke h g i h ng bch huyt t rut tha v manh trng


thng vi thn phi. Vim c t cung c th gy vim thn-b th theo ng
bch mch qua niu qun.

2.2. Cc yu t thun li:

2.2.1. Tc nghn v ng nc tiu:

- Tc nghn v g c tiu l yu t thun li nht gy vim thn-b


thn m t h. ng tit niu c s tc nghn phn ln do si ngay b thn;
hoc nguyn nhn gy t a h : si niu qun, si bng quang, khi u ng
tit niu, u sau phc m , u tin lit tuy , u t cung; ho i a
gi lit / hi di lu ngy.
- D d g ng dn niu l ho c tiu ng pha trn niu o-bng
quang, niu qun- i thn... Vi khun d c iu kin gy vim nhim ti ch
gc dng ln thn.

- Hi t g t o g c tiu t o gc bng quang-niu qun) do d dng


l ni niu qun-bng quang b suy yu bm sinh hay mc phi, do khi d i
ho khi g ua g u g van ny khng g k , c tiu t bng quang
pht gc ln niu qun ri vo b thn vo nhu m thn mang theo vi khun
bng quang gy vim thn-b thn cp v mn tnh.

2.2.2. S khng ca th:

Khi s khng ca th km hoc c cc bnh mn tnh ko di, vim thn-


b thn mn d x a. c bit l gi thai, gi c bnh chuy ho i
th o ng, bnh Gt, bnh oxalat); bnh mu c tnh (bch cu ty cp,
lymphosarcoma) t o u g th hp vo vng v th g th gy vim
thn-b thn mn.

2.2.3. Cc loi vi khun hay gp trong vim thn-b thn mn:

- Cc loi vi khun hay gp trong vim thn-b thn m thng l trc khun
Gram (- , t o g : E. oli: -80%, Proteus:10%, Klebsiell:5%, trc khun m
xanh: 5%. Trc khun G a + g th gp khong 10%: Streptococcus
facealis, Staphylococcus ...

Ngoi ra, 26% vim thn-b thn m kh gt c nguyn nhn.

3. Tn th g gii phu bnh.

. . i th:

- Th k h th h thng hoc nh t theo giai on tin trin ca bnh


g h thi gian mc bnh.

- V thn mu nht, b mt th thng l m v c nhng ch ho , t


thn g gh li, lm khng u, t g ng vi cc so l gia h gii phn
cch r rt vi nhu m lnh.
- Ct ngang thn: gianh gii gia ty v v th th g tn mu nht v so
.

- i thn bin dng: gin, t, nham nh t g ng vi ch lm ca v thn.

- Khi thn m, th to h h thng, nhu m b hy hoi, v thn mng.

3.2. Vi th:

- X ho t chc k, thng bt u t i thn lan vo, xm nhp nhiu t bo


lympho, plasma v bch cu a h t u g t h.

- ng thn gin rng, lng ng thn c nhiu bch cu v tr colloid ging t chc
tuyn gip. Lu ngy ng thn b teo.

- Cu thn cha y cht ging collagen, hyalin ho, ho ho go i hoc


trong mng Baoman lm mt hnh th h thng.

- Mch thn c ch b g ao t o g.

4. Lm sng v cn lm sng.

4.1. Lm sng:

- C tin s nhim khun tit niu ti din nhiu ln.

- C tin s si, th a nang, d d g ng tit niu, u tin lit tuyn...

- Hi ch g g ua g: i ut, i dt, i u, i c, i t i i t i li
nhiu ln.

- au h s l g t bn ho , khi au t g di sn lan xung


g u. Ho au qun thn kiu si tit niu: au tc vng hng-l g,
au t g khi tha i t th ho sau lao ng nng.

- St cao, rt run 39-40oC.

- au u khi t g hu t p.
- Hoa mt, chng mt do thiu u khi su thn.

- Khng ph, tri li bnh nhn c du hiu da kh , k hi kiu mt c do


ri lon ch g c ng thn. Bnh nhn ch b ph khi su thn nng,
di h dng km hoc c th thiu niu, v niu.

- C th c thn to c hoc m du hin chm thn (+), bp bnh thn (+),


rung thn (+).

- C khi i hiu, kh t c, kh g c tiu gim.

- T g hu t p.

- Khi su thn th c triu chng thiu mu: da xanh, nim mc nht, v c


hi chng ur mu cao: chut t, au u, vt v, u m.

- 10% c tai bin xut huyt no- g o do t g hu t p.

4.2. Xt nghim:

4.2.1. Xt nghim nc tiu:

+ Vi khun niu: l c tiu gia dng nui c g ph g ph p; khi t


105 vi khun/1 ml th chc chn c nhim khun tit niu. Nu l c tiu trc
tip t bng quang (bng kim chc khng phi dng sonde) th ch c n
103/vi khu / l g th nhim khun tit niu.

+ Bch cu niu: bnh nhn vim thn-b thn m thng c nhiu bch cu
t o g c tiu, nu thy trn 5000 bch cu/pht, hoc 5 bch cu/1ml l chc
chn c nhim khun tit niu; c nhiu bch cu thoi ho l i .

+ S lng hng cu th g t h ch cu. Khi c nhiu h th th biu


hin ca vim bng quang cp hoc cc nguyn nhn khc.

+ Tr niu: nu c tr bch cu l nhiu kh g i thn-b thn mn.

+ Protein niu thng c t, ti a l g/ h.

4.2.2. Xt nghim mu:


Bch cu t g, ch cu a h t u g t h t g, t mu l g t g, p otit
huyt t g h th g, in gii h thng. Nu ha su thn th ur v
eati i h thng.

. . . Th d h g thn:

o c lc cu thn, h s thanh thi creatinin ni si h h gi h h xc


m suy thn. Lm nghi ph p c tiu h gi h g t i
hp thu ca ng thn. Qua 2 xt nghim ny c th h gi s phn ly ch g
ca cu thn- ng thn. Nu mc lc cu th h thng m ch g ng
thn gim r (t tr g c tiu < 1,018 ho thm thu c tiu < 600
Os ol/ kgH th gha l t th g ng th . l du hiu chn
o sm vim thn-b thn mn.

5. X quang.

+ Chp X quang thn khng chun b c th thy b th kh g u; thn teo nh


mt hay hai th t theo th g tn mt hay hai bn, c th thy si thn
hay n t ng tit niu. Nu th to h h thng l c hoc m.

+ Chp th t h h thuc c ua g o t h mch) l ch nh bt


buc

chn o i thn-b thn mn: b thn g gh, li-lm khng u, thn


nh h h thng c hai bn hoc mt bn, v thn m g, i-b thn
gin, bin dng to ra thnh hnh chy, t vt, c khi ko di v dt do hi tng
thoi ho m l hu qu ca qu trnh vim thn b thn mn.

+ Chp niu g d g g ho hng hnh h t g t.

+ C th chp hi sau ph c kt hp vi chp thn thu t h ch


pht hin hnh thi ca thn.

+C th d hu khoa s u:

- Chp ng mch thn c th thy cc tiu ng mch nhu m th tha tht,


hp, ngon ngoo.
- Th phng x cho thy pha bi tit gim; ghi hnh x thy phn b hot
cht phng x kh g u, k h thc thn gi , i-b thn gin.

6. Ch o v h o ph it.

6.1. Ch o nh:

- C tin s nhim khun tit niu, ti pht nhiu ln, c si, c u, hoc c d
dng

ng dn niu.

- Khi ph t thng c st.

- au vng hng-l g ho au un thn.

- C hi chng bng quang.

- Bch cu niu nhiu: > 5000 ci/pht.

- Vi khun niu: > / l c tiu.

- Protein niu > 0,45g/24h.

- Kh g c tiu gim, t tr g c tiu thp < 1,018 ho thm


thu c tiu < 600 mOsmol/kgH20.

- C th t g hu t p.

C lu t th vim thn-b thn mn: th a thog a ulo atose l t


th tin tri c bit ca vim thn-b thn mn nhim khun, bnh rt kh
ch o ph it vi khi u thn. th ny, thn b ph hy ton b, bnh
h au hiu h tht l g bnh; khm thy th to au; chp niu
t h ch thy thn cm, c hnh nh mt khi u l ta gh ti khi u thn.

Hnh h i th: khi b thn thy c nh g h u g g h hng di


.

Hnh nh vi th: c nhiu t bo histocyte cha nhng ht mu vng


(xanthomatouse) nhiu thc bo cha lipit v nhng p xe nh.
6.2. Ch o ph it:

6.2.1. Vim bng quang cp v mn tnh:

Triu chng lm sng gi g h t cp ca vim thn-b thn mn ti pht, vic


chn

o ph bit da vo chp bng quang v chp thn.

6.2.2. Lao thn:

C triu chng lm sng ging vim thn-b thn m , h g khi t ghim


c tiu khng c vi khun v t bo m. Hnh nh chp thn thuc thy c nt
vi ho nhu m thn v hnh h lo t i-b thn. Mun ch o nh
phi nui cy vi khu t o g i t ng Lowenstiem-Jase t o g n 6 tun th
vi khun lao (BK) s mc.

6.2.3. Vim thn k do cc nguyn nhn khc:

- Vim thn k do nhi : thng do qu lm dng thuc phenacetin lm hy


hoi t chc thn, sau nhiu dn n suy thn; ngoi ra cn do cc mui ch,
cadmium, platin hoc cht polyvinylpironidone.

- Vim thn k do nguyn nhn min dch: xy ra trong qu th c ghp, ri


lon min dch.

- Vim thn k trong cc bnh chuy ho : t g a it u i u, t g a i u:


triu chng ging vim thn-b thn m h g kh g him khun m l do
cn urat v canxi t chc k thn.

- Vim thn k l do c t, u g th, i lon v m h u thn tiu


ng mch, tc nghn do va , nh thn hng cu lim, hoi t ng thn cp).

7. Bin chng v Tin trin.

7.1. Bin chng:


Bin chng ca bnh nng hay nh ty thuc vo bnh xy ra mt bn thn
hoc c hai bn thn, bnh mi x a ha t i ph t l u g , nh c do
nguyn nhn tc ngh ng niu phi hp khng.

+ Bnh mt bn thn:

Thng m thm, khng c triu chng r rt, ch pht hin khi c bin chng
h: au un thn ho t nhim khun bt pht. Nu nguyn nhn do
tc khng c gii quyt th thn c- m, t ch ph t t in thay th
t chc lnh ca thn, thn b ph hy teo nh ho g ao hu t p.

+ Bnh c hai bn:

Bnh xy ra 2 thn hoc mt thn duy nht, bnh tin trin nhanh d t g
huyt p; u , eati i u t g d i o t h t ng suy thn. Khi c tc nghn
ng tit niu th bnh nhn b v niu; u , eati i u g t g hanh
chng, nu khng c gii quyt cp cu kp thi th bnh nhn c th i o
hn m v cht.

+ Bnh din bin t t c nh g t bt pht, ti pht:

Thng do gu h t o gc c tiu t g t, xut hin rm r do


nhim khun bt pht sau li tip din im lm, ri li ti din, c h th b
thn dn b ph hy d n suy thn ngy cng nng, c th t vong do suy thn.

7.2. Tin trin:

Tin trin ni chung chm, c khi ht vi khun m bnh vn tin trin.

- Th g t ti din kch pht.

- Cui cng d n suy thn sau nhiu .

- Suy thn cng nhanh, khi c:

. Nhiu t vim kch pht ti din, khng iu tr kp thi.

. T g hu t p.
. Dng cc thu c cho thn: colistin, polymicin, gentamycin, cyclophosphorin
A, cephaloridin, amphotericin, kanamycin, streptomycin, methycillin, oxacillin,
tetracyclin, vancomycin, sunfonamid, phenylbutazon, piroxicam...

. iu tr v Phng bnh.

. . iu tr:

* iu tr vim thn-b thn mn theo nguyn tc:

+ Cn xt nghim cy c tiu h lng vi khun v lm khng si h


chn khng sinh thch hp.

+ Gii quyt kp thi cc yu t to iu kin d nhi t g h: tc nghn do


si hoc cc nguyn nhn khc phi nh.

+ Ht cc triu ch g l s g kh g gha l khi ht vi khun gy bnh, nn


phi cy khu theo d i n 4 tun sau khi ng g kh g si h h gi iu
tr thnh cng hay tht bi.

iu tr tht bi khi m cc triu chng lm sng khng ht hoc vi khun vn


t o g c tiu ngay trong u t h iu tr ho ga sau iu tr.

iu tr thnh cng l ht cc triu chng lm sng v ht vi khu t o g c


tiu.

+ Cc nhim khun niu ti pht cn phi c phn loi nh cng mt


chng hay do khc chng.

- Nu ti pht sm xy ra trong vng 2 tun k t khi kt th iu tr l cng


mt chng.

- Nu ti pht sau 2 tu thng l nhim do mt chng mi.

Tuy nhin c lu : u iu tr g ui h m bnh khng cn phi xt


li ch o , in chng g mi xut hin, cht lng thuc, hn dng, thc hin
y l h g kh g.

* Mt s thuc khng sinh c th dng:


+ Nhm bta lactamin:

Penicillin G, tim bp tht: 2-5 triu /ngy x 7-14 ngy.

Ung 4-5 triu /ngy x 7-14 ngy. Ampicillin, ung 2-6g/ngy x 7-14 ngy.

Cloxacillin, ung 1-3g/ngy x 7-14 ngy.

+ Nhm cephalosphorrin:

Cephaloridin, ung 2g/ngy x 7-10 ngy. Cephapirin, ung 2g/ngy x 7-10 ngy.
Cephalecin (keflex), ung 2g/ngy x 7-10 ngy.

+ Nh a i ogl osid: d g khi ha su thn.

Streptomycin, bp tht 1-2g/ngy x 10-14 ngy. Kanamycin, bp tht 1-2g/ngy x


10-14 ngy. Tobramycin (nebcin), ung 3-5mg/kg/ngy x 7-10 ngy.

+ Nhm quinolon:

Ofloxacin, ung 400-600mg/ngy x 7 ngy.

+ Dn cht su fa id: d g khi ha su thn.

Sunfonamid, ung 2-4g/ngy x 10-14 ngy. Sunfamethoxazol (bactrin), ung


1g/ngy x 7-14 ngy.

Ch : ph n c thai, tr e gi gi khi s dng khng sinh cn phi cn


nhc k, ch nn dng penicillin, ampicillin.

+ Nu t g hu t p: phi iu tr cc nhm thuc ch g t g hu t p.

+ Khi c suy thn nng: c iu tr suy thn, lc mu hoc ghp thn.

+ Nu mt thn b ho hoc c- m, mt ch g hoc bnh nhn c


t g hu t p th ct thn.

8.2. Phng bnh:

+ Phi u g c mi ngy 2-2,5 lt. Gi v si h ua si h dc-tit niu; vi


n gii phi v sinh kinh nguyt. Trong thi k tn hn, nu khng gi gn v sinh
sinh dc- tit niu c th nhim khun tit niu cp v gy vim thn-b thn
mn; ma h hoc lm vic i t ng nng phi ung nhiu h , n
m bo l g c tiu 1,5- , l t/ g . c bit nh g gi c tin s i a
si ho a g si thn-tit niu phi lu t n ch u g c nhiu v
ch gim bt cc th ha a i g, s , ua .

+ Ngi nhim khun tit niu phi iu tr g ph g ph p v trit ngay


t u.

43.IU TR VIM MO TINH

Ph iu tr

Tc nhn gy iu tr ng iu tr iu tr
bnh tim chch chn ng tim ng ung
la h g u chch chn ho i t
la thay th ng chch
sa g ng
ung
Vim C.trachomatis Doxycyline Ciprofloxacin Doxycyline
mo 200mg (IV) q 400mg (IV) q 200mg (po)
tinh 12h x 3 ngy, 12h x 7 ngy q 12h x 3
cp sau g g , sau
Hoc
gi (IV) q 12h x 4 100mg (po)
tr ngy Gatifloxacin q 12h x 4
400mg (IV) q ngy
24h x 7 ngy
Hoc
Hoc
Azithromycin
Levofloxacin 1 g (po) x 1
500mg (IV) q liu
24h x 7 ngy
Hoc

Ciprofloxacin
500mg (po)
q 12h x 7
ngy

Hoc

Gatifloxacin
400mg (po)
q 24h x 7
ngy

Hoc

Levofloxacin
500mg (po)
q 24h x 7
ngy
Ngi P.aeruginosa Cefepime 2g (IV) Ciprofloxacin Ciprofloxacin
tr q 8h x 10 ngy 400mg (IV) q 750mg (IV) q
tui 12h x 10 12h x 7 ngy
Hoc
ngy
Piperacillin/tazo-
bactam 4g (IV) q
8h x 10 ngy

Vim M.tuberculosis iu tr ging nhim lao phi hoc nhim


mo blastomyces
B.dermatiditis
tinh
mn

Thi gia iu tr l tng thi gian dng thu ua g ti h h , ng


ung ho g ti h h ng u g. a s bnh nhn dn thuc qua
ng tim chchnu u g c nn chuy ua ng ung ngay khi c ci
thin v l s g thng < 72 gi).

Vim mo tinh cp (C. trachomatis, P.aeruginosa)

Triu ch g: au ti h ho t bn cp tnh, c th km st.

Ch o : siu u loi tr son thng tinh ho u tinh hon.

Ch : bnh l vim m h h i a ng mch d g t l pho a g


c biu hi l s g t g t.

iu tr: gi g h iu tr nhim lao phi hoc nhim blastomyces.

Ti l g: t g i tt .
44.NHIM TRNG TIU DO VI KHUN HOC NM
CANDIDA

Tc nhn gy bnh iu tr

NTT do VK do E.coli Nitrofurantoin 100mg 5 ngy


t thng tiu hoc
E.faecalis
Amoxicillin 500mg (po) q 12h5
ngy

E.faecium Nitrofurantoin 100mg (po)5


(Enterococcus khng ngy
Vancomycin)

C.albicans Fluconazole 200mg (po)1 liu


sau g po h
ngy

NTT do nm C. albicans khng Ti ra bng quang lin tc


Candida do Fluconazole vi Amphotericin B 50mg/l 1l
t thng c v trng) q 24h x 1-2
Candida khng phi
tiu. ngy
albicans (C.krusei,
lusitaniae, dublinensis, Hoc
tropicalis, lipolytica,
Ti ra bng quangcch
Pseudotropicalis,
qung vi Amphotericin B
glabrata, guilliermondii)
(50mg/l) 200- l c v
trng) q 6-8h x 1-2 ngy

Triu chng: khng c triu chng lm sng, tiu m km c c tiu mc vi


khun trn b h h t thng tiu lu fole .

Ch o : tiu m, v b h h thng khng st hoc st < 3805 (1010F).


Ch : khun niu hoc candida niu l do vi khun ho a dida h t
ng niu ch khng phi do nhim trng. Candida niu k o d i sau khi ti
ra bng quang vi amphotericin B c th do nhim candida thn.

iu tr: c th c iu tr trong thi gia lu th g tiu nhng bnh nhn suy


gim min dch (dng corticoide ko di, tiu g, lupus a h th g,
gan, b h a u tu). Nu khun niu hoc candida niu khng ht d iu tr
thch hp, nn thay thng tiu. bnh nhnSTM hoc lc mu b candida niu,
ti ra bng quang bng amphotericin B.

Ti lng: tt gi h thng. bnh nhn suy gim min dch, khun


niu hoc candida niu kh g iu tr c th gy nhim trng tiu gc
dng (vim thn - b thn) hoc nhim trng huyt, nhim candida huyt.

45.IU TR VIM BNG QUANG

Tc nhn gy bnh iu tr

Vi Enterobacteriaceace Amoxicillin 500mg


khun (po)xq 12h x3 ngy
E. Faecalis
Hoc
S. saprophyticus
TMP-SMX 1 vin (po)x q
12h x3 ngy

Hoc

Quinolone (po)* q 24h x


3 ngy

Nm C. albicans Fluconazone 200mg (po)


x 1 liu sau g
(po) q 24h x 4 ngy

C.albicans khng Amphotericin B


fluconazole candida 0,3mg/kg (IV) x 1 liu
khng phi albicans
(C.krusei, Lusitaniae,
dublinensis, tropicalis,
glabrata, lipolytica,
guilliermondii)

* Ciprofloxacine XR 500mg hoc Gatifloxacine 400mg hoc Levofloxacine 500mg.

Vim bng quang do vi khun

Triu chng: tiu au, tiu nhiu ln, tiu gp, au g di, st < 390C (102
0F).

Ch o : niu, c c tiu mc vi khun.

Ch : a suy gim min dch (dng corticoides ko di, tiu ng, lupus
a h th g, ga , h a u tu iu tr 3 - 5 ngy. Vim bng quang cp
khng bin chng gi h thong c th dng amoxicilline hoc TMP-SMX
liu duy nht.

iu tr: Pyridium 200mg (po) q 8h sau ba - 48h gip gim triu chng
tiu au lu c tiu c mu cam).

Tin lng: tt gi h thng.

Vim bng quang do candida:

Ch o : niu nhiu, test nitrite (-), c th c hng cu niu. C nh


chng candida nu khng phi l albicans.

Ch : nu kh g p g iu tr, c th nhim candida thn hoc c bi nm


t o g i - b thn.
iu tr: nu fluconazole khng hiu qu, dng amphotericin. bnh nhn STM
hoc lc mu b nhim candida niu, ti ra bng quang bngamphotericin B.

Ti lng: bnh nhn suy gim min dch, c bt thng v ng niu, bnh
nang thn hoc si th thng b nhim trng tiu ti pht hoc nhim trng
huyt.

46.VIM I B THN
(Bnh hc Ni khoa. Tp 2. Nh xut bn y hc 2006)

I. I CNG

. h gha:

Vi i thn l nhim khun t chc k ca thn nguyn nhn do vi khun.


giai on cp ca bnh c th cha khi hon ton nu c loi b gu
nguyn nhn gy bnh. Nu b ti pht nhiu ln s chuyn thnh mn, v hu
qu cui cng s d n suy thn mn. Bnh nhn c th t vong do bin chng
suy thn mn, do u c pht hin s , iu tr g t it bnh nhn
phc hi hon ton.

. im dch t:

Vi i thn cp v mn l mt bnh gp nhiu n, gp mi la tui nht


l la tui lao ng v hot ng sinh dc nhiu. N gii c s lin quan vi tnh
trng c thai. Theo J.Conte khi nghin cu c g ng bnh chim t l 10% dn
s. Ti khoa Thn Bnh vin Bch Mai (1997-2000) c 17% bnh nhn b suy thn
l gu h do i i thn mn (PGS. Tr V Cht . T o g h
nguyn nhn do si chim 27% v nhiu thng k cho th i i thn mn
l gu h ng hng th hai d n suy thn. Qua trn ta th i i
thn mn l bnh hay gp gu d n suy th do ic tuyn truyn
gio dc cho c g ng nh g gu g nh s gim bt t l mc bnh.
II. NGUYN NHN GY BNH V C CH BNH SINH

1. Nguyn nhn:

1.1. Nguyn nhn do vi khun:

- Vi khun Gram (-) chim kho g % t ng hp:

+ E. Coli: 60-70%

+ Klebsiella: 20% (15-20%)

+ Proteus mirabilis: 15% (10-15%)

+ Enterobacter: 5-10%

+ V mt s vi khun Gram (-) khc.

- Vi khun Gram (+) chim < 10%

+ Enterocoque: 2%

+ Staphylocoque: 1%

+ Cc vi khun khc: 3-4%.

1.2. Nguyn nhn thun li:

L nguyn nhn gy tc ngh ng bi xut c tiu, gy tr d g c


tiu, to iu kin cho nhi t g khi him trng th duy tr nhim
trng.

V v i i thn xy ra trn mt bnh nhn c tc ngh d g c tiu


thng rt dai dng v nng.

-C gu h thng gp l:

+ Si thn tit niu.

+ U thn tit niu.

+U go i p o iu qun.
+ U tuyn tin lit.

+ D dng thn, niu qun.

- Cc nguyn nhn khc:

+ Th a a g.

+ Thai nghn.

+ i th o ng.

Cn khm ton din, chp thn khng chun b, UIV, siu m th , UPR pht
hin cc nguyn nhn thun li iu tr trit trnh tin trin bnh nng thm.

. C h bnh sinh:

- Ch yu l g gc dng c th l nhim khun ngu nhin. n t l


th g ao h , nam t l thng t gp h do ng niu o di, hp h ,
xa l hu h . Cht tit ca tuyn tin lit g kh g s t khun.

- Vi khun c th n g i i th ua g u ng bch huyt


h g him gp h .

III. TRIU CHNG LM. SNG V CN LM SNG CA VIM I B THN CP


V MN

. Vi i thn cp:

- Hi chng bng quang: i ut, i dt, i u, i cui bi.

Tuy nhin hi chng bng quang c th xut hi t khi i i thn


cp. Khi c triu ch g i i thn cp th triu ch g i g ua g
nn d b qua ch o .

- au v g tht l g:

+ Th g au t , h g g khi au hai bn.

+ au thnh thong tri thnh t g .


+ V h g l g + l t iu chng rt c gi tr, nht l t o g t ng hp ch c
au t bn.

- Khm c th thy th to v au.

- Triu chng ton thn: Bnh nhn c hi chng nhim trng: st cao, rt run,
i kh , li bn, c th thy du hiu mt c do st.

- Nc tiu c c th i i th, bch cu niu d g t h, i khun niu


d g t h, P otei iu h g < l g/ h.

- Xt nghim mu:

+ Bch cu a h t u g t h t g.

+ i khi suy thn cp: u u, eati i u t g.

+ Cy mu khi c st > 38,5C c th d g t h.

- Siu m thn:

+ Th hi to h h thng.

+ i thn gin.

+ C th thy nguyn nhn thun li h si, th a a g...

- X quang:

+ Chp bng khng chun b nu nghi ng c si.

+ C th thy nguyn nhn thun li gy tc ngh ng bi niu.

. Vi i thn mn:

2.1. Vi i thn m giai on sm:

- Tin s nhim khun tit niu, i i thn cp nhiu ln hoc c tin s c


bnh gy tc ngh ng bi tit c tiu.

- au g tht l g.
- Tiu tin v t g t ht mt hoc nhiu ln trong mt gi ch g
c ca thn gim.

- C th c cao huyt p.

- Thiu mu nh hoc khng.

- Protein niu th g u h g thng < l g/24h.

- Bch cu niu nhiu, bch cu a h tho i h a d g t h s bch cu a


h t g khi t cp.

- Vi khun niu d g t h khi t cp.

- Kh g c tiu gim:

+ Lm nghim php c c, t trng ti a kh g t qu 1,025.

+ Lc ny mc lc cu th h thng gi l c s phn ly ch g u
thn, ng th . l t xt nghim c gi tr trong ch o i thn mn
t o g giai on sm.

- Siu m thn c th thy b thn g gh, thn teo nh t, i thn gin t.

- Chp thn (UIV) thy t th g i thn m khc nhau.

2.2. Vi i thn m giai on mun:

Ngoi nhng triu chng trn xut hin thm:

- Suy thn (suy ch g lc):

+ M suy thn t nh n nng, khi suy thn m nng c th c cc triu


chng ca hi chng ur mu cao trn lm sng v c th c ph.

+ U u t g, eati i u t g: h h triu chng ca hi chng


t g it u iu hin ua : tiu h a, thn kinh, tun hon, h hp, c
th c xut huyt...

+ Mc lc cu thn gim.
- Thiu mu r: m nng nh ca thiu u i i i giai on ca suy thn
mn.

- Da xanh, nim mc nht, s lng hng cu, hemoglobin v hematocrit mu


gim.

- T g huyt p: (> 80%) c th t g a ho t g t cao.

- Siu m v X quang thn: hai thn teo nh h g kh g u, h a th thy


nguyn nhn thun li: si, d d g ng niu...

IV. CHN ON

1. Ch o nh:

- Vi i thn cp: Da vo tam chng c in:

+ Bnh nhn c hi chng nhim trng: st cao, rt run.

+ au i vng tht l g.

+ i ut, i dt, i u, i , c tiu c bch cu, t bo m v vi


khun.

- Vi i thn mn: Da vo cc triu chng sau:

+ C tin s vi i thn cp ti pht nhiu ln.

+ Suy thn: hi ch g t g u u, t g hu t p, ph, thiu mu.

+ Siu m thn hoc chp X quang thn thy thn teo nh kh g u.

2. Ch o ph it:

2.1. Vi i thn cp phn bit vi t cp ca vim i thn mn:

Vi i thn m t cp c cc triu chng ca vim i thn cp, ngoi


ra c thm triu chng suy thn, siu m thn v X quang thn thy thn teo nh
kh g u.

2.2. Vi i thn mn:


- Giai on tim tng phn bit vi cc b h g i hiu h: i th o ng,
i ht... Ch yu phn bit da vo triu chng ca cc bnh trn.

- Vim thn k do ung qu nhiu thuc gi au, hng vim: da vo tin s.

- Vim thn b thn k do t g a id u, t g al i u: da o in gii


v khng c triu chng nhim khun.

- Thn teo mt bn bm sinh: thn teo nh mt h g kh g t iu chng


nhim khun, da vo X quang v siu m th ch o nh.

Nh y tuy s c th da vo bnh nhn c hi chng nhim trng, hi


ch g g ua g au i vng tht l g gh ti i i thn cp. Nu
bnh nhn c tin s nhi t g ng tit niu ti pht nhiu ln, c hi
ch g g ua g i tiu nhiu v l th gh i i thn
mn.

V. IU TR

. iu tr vi i thn cp:

Dng khng sinh chng nhim khun:

- Tt nht l c c tiu tm vi khun gy b h l kh g si h , da vo


kt qu kh g si h dng khng sinh cho thch hp. Trong khi ch kt qu
cy vi khu kh g si h cn cho khng sinh ngay. Nu i a g iu tr,
triu chng lm sng khng bt s iu chnh khng sinh theo kt qu khng sinh
.

-C kh g si h thng dng hi a ho i i thn cp l:

+ Nhm Quinolon: Peflacin, Nonoxacine...

+ Cephalosporin: Zinnat, Fortum...

+ Nhm Aminosid: Amikacin, Gentamycin...

+ Nh -lactam: Ampicillin, Unasyn...


- Dng liu cao v phi hp khng sinh, thi gian dng khng sinh t nht l 2 tun
l. T o g t ng hp c bit h t c khun m xanh hoc t cu vng hoc
khi vim t tuyn tin lit, khng sinh c th dng ko di 1 thng.

- Khi ngng khng sinh 5 ngy cy li c tiu tm vi khun niu (m tnh), UIV
khng c t th g oi h khi hn.

. iu tr vi i thn mn:

- Khng sinh chng nhim khu d g kh g si h khi t cp ca i i


thn mn. C lu la ch kh g si h kh g c vi thn, khng lm gim
mc lc ca cu th lu hnh liu khng sinh theo m suy thn.

- iu tr triu chng:

+ iu tr t g hu t p.

+ iu tr thiu mu.

+ iu tr suy thn b g iu tr bo tn ni khoa ho iu tr thay th thn suy


ty t g giai on ca suy thn.

. iu tr hu g ho vi i thn cp v mn:

- Ung nhiu m bo c tiu > l,5 lt/24h.

- Loi b c cc nguyn nhn thun li: m ly si, iu tr u tuyn tin lit...

VI. PHNG BNH

- m bo v sinh trnh vim th gc dng.

- Trnh cc th thut khng cn thit: th g i...

- Loi b cc yu t gu .

- Khi c suy thn:

+ m bo ch .

+D g kh g si h kh g c vi thn.
+ iu tr t g hu t p, ph, thiu mu (nu c).

47.HI CHNG NIU O CP

iu tr
iu tr
Tc nhn gy bnh b g ng
b g ng ung
tim chch

Hi S. saprophyticus Khng c ch Doxycycline 100mg (po)


chng nh q 12h x 10 ngy
C. trachomatis
niu o
Hoc
cp E. Coli
Quinolone (po)* x 7
(s khm vi khun
ngy
thp)

* Ciprofloxacine 500mg q 12h hoc Gatifloxacine 400mg q24h hoc Levofloxacine


500mg q 24h.

Triu chng: tiu au, tiu nhiu ln, tiu gp, au g di, st < 390C (102
0F).

Ch o : t iu chng kch thch bng quang, m niu, c c tiu m tnh


hoc mc E. Coli vi s khm103 khm/ml. du hiu gi S. saprophyticus : pH
c tiu kim v hng cu niu.

Ch : phn bit vi vim bng quang do vi khu h g c tiu m tnh.

iu tr: S. saprophyticus nhy vi mi kh g si h d g iu tr nhim trng tiu.

Ti lng: tt
48.VIM THN B THN

A. Ch o nh VTBTC:

I. nh gha.

* Khi NKTN l ti b thn vo t chc k th th c gi l VTBT.

* Khi VTBT b l u tin ho t i ph t h g ha hng biu hi gh n


ho k, vi nhng TCLS rm r: st ao, t u , au h g l g k i ut,
i t, VK niu (+), BC niu v protein niu + th c gi l VTBT cp.

* Khi VTBT cp ti pht nhiu ln hoc m k o d i g ho t chc k thn,


lm gim ch g c, lu di c th g ho cun mao mch cu thn,
gy gim ch g lc, gi l VTBT mn.

* Nguyn nhn.

- Vi khun: Gram (-) chi h %, thng gp l E.coli (60-70%), Klebsiella


(20%); vi khun Gram (+) ch di % h e te o o us % , Staph lo o us
(1%).

- Cc nguyn nhn thun li l nguyn nhn gy tc ngh ng bi xut c


tiu, gy tr d g c tiu, to iu ki ho NT khi NT th du t NT.
Thng gp l si, u thn tit niu, u go i p o NQ, u TLT, d dng thn
NQ, th a a g, thai gh

II. Triu chng lm sng, cn lm sng:.

1. Ton thn.

- Biu hin rm r, suy sp nhanh.

- St ao, t u , i kh , li bn, c th c du hiu mt c do st.


- TH nng: c bnh cnh ca nhim trng huyt: st cao lin tc, rt run, c gan
lch to, di b h i kh

2. TC lm sng.

- au h g l g:

+ au vng h s l g, hoc 2 bn.

+ C khi au d di, th g l au tc m .

+ au la u g di (b phn sinh dc ngoi)

+ V h g l g + l TC t c gi tr, nht l trong TH ch au .

+ Nhiu TH au un thn do si.

+ Khm c th thy thn to, chm thn, bp bnh thn (+).

- Hi chng bng quang.

+ Th g h g kh g phi TH o g .

+ i ut, i dt, i u, i cui bi. Tuy nhin, HCBQ c th xut hin


t c khi c VTBT cp. Khi c TC ca VTBT cp th TC i BQ lm b qua
ch o .

3. Cn lm sng.

3.1 Nc tiu.

- c, c th c m i th r.

- i u th i th hoc vi th.

- Bch cu niu nhiu.

- Protein niu h g lng rt t (thu g di 1g/24h) ho d g t h +, ++.

- Vi khun niu . k/ l c tiu. Thnh ph VK h t .

3.2 Mu.
- Bch cu t g, a h t u g t h t g.

- Khi u e, eati i u t g ao l STC ho t cp ca STM.

- Cy mu khi st > 3805 c th thy (+).

3.3. Siu m thn: th hi to h h thng, i thn gin t hoc nhiu,


i khi thy vim trong nhu m thn, hoc thy nguyn nhn thun li h si,
d d g ng tiu

3.4. X-quang:

- Chp bng khng chun b nu nghi ng c si .

- UIV ch chp t o g giai on cp khi nghi ng c nguyn nhn thun li gy tc


ngh ng bi xut c tiu (tc nghn niu qun).

4. Tin trin.

- Tin tri thng tt nu iu tr kh g si h g liu, TCLS thng


khi nhanh, nhit gi , i tt ln. BC niu gi , BC u g gim.

- Nc tiu tr li h th g sau n 2 tun.

- Nu iu tr kh g g, ht l kh g liu th bin chng lu di c th l:

+ Ti pht nhiu ln.

+ Chuyn thnh mn tnh, THA, suy thn.

iu quan trng l phi loi b c cc yu t thun li gy b h h si, u tin


lit tuy nh c th khi hon ton. Nu khng bnh c th nng gy bin
chng hoi t nm thn gy suy thn cp, hoc NKH, sc nhim khun.

I. Ch o nh:

Da o TC LS CLS t h g h yu l st ao, t u , i ut, i dt,


tc h l g, hiu bch cu niu, c vi khun niu v protein niu.

Cn phn bit vi t cp ca vim thn b thn mn, da vo:


- Tin s NKTN ti pht nhiu ln

- C nguyn nhn thun li h si tit niu

- C nhng biu hin ca vim thn b thn m h gim kh g c


tiu, suy cn lc m t h, THA

- Chp phi UIV i thn t vt, b thn gin.

II. iu tr VTBT cp.

1. Chng nhim khun.

1.1. Nguyn tc dng khng sinh.

- Liu cao, t nht l kh g si h ng TM phi hp vi 1 KS ung trong giai


on c st

- C VK t c khi dng KS. Trong khi ch kt qu c VK KS , cn cho KS


ngay. Nu sau i g iu tr, TCLS khng bt, s chnh KS theo kt qu cy VK
KS .

- Thi gian dng KS t nht l 2 tu . T o g TH VK c bit h TKMX hoc t cu


vng, hoc vim khi u t tuyn tin lit, KS c th ko di 1 thng hoc
h tu TH.

- Thng phi hp nhm -lactamin v Aminoglycosid hoc Fluoroquinolone (c


iu chnh tu theo cn thn).

1.2. C KS thng dng hin nay cho VTBT cp:

- Nhm Fluoroquinolone: (tt nht) Pefloxacine (Peflacin), ofloxacin (Oflocet),


ciprofloxacin (Ciflox), norfloxacin (Noroxine)

- Nhm Cephalosporin th h II, III: Cefuroxime (Zinnat), cefoperazone (Cefobis),


ceftazidime (Fortum), ceftriaxo e Ro ephi e , efepi e A epi

- Nhm Aminosid:Amikacin, gentamycin, tobramycin, kanamycin .


- Nhm -lactamine: Ampicilline, amoxicilline, amoxicilline + a.clavulanic
(Augmentin), ampicilline + Sulbactam (Unasyn).

1.3. Mt s ph iu tr.

- Phc 1:

+ g u dng: Ampicilline 1g x 6 l/ngy (tim TM chia 3 ln)

Gentamycine 80mg x 2 l/ngy (tim bp chia 2 ln)

+ 10 ngy sau dng: Amoxicilline 0.5g x 6 vin/ ngy

Biseptol 0.48g x 2-4 vin/ngy

+ Ngh 5 ngy KS, cy li VK niu (-), UIV khng c t th g th oi h khi hn

- Ph 2:

+ Trong 3- g u c st: Peflacin 400mg x 2 l (truyn TM chia 2 ln)

Augmentin 500 mg x 3-4 vin/ngy

+ Khi ht st 1-2 ngy, duy tr Augmentin u g ho 3 tun (trung bnh 3


i / g , gi gi: 2 vin/ngy).

+ Cy li VK v chp UIV sau g iu tr h gi li kt qu.

- Ph 3:

+ Claforan hoc Cefobis 1g x 2 l (truyn hoc tim TM) chia 2 ln

+ Norfloxacin hoc Peflacin 400 mg x 2 vin/24h hoc Oflocet 200 mg x 2 vin/24h

Sau 5 ngy nu ht st, duy tr bng KS u g ho 3 tun.

2. D lu c tiu khi c tc nghn: t catheter niu qun hoc m b thn


qua da.

. iu tr tho tc iu tr nguyn nhn):

- Tn si, ly si qua ni soi hay m.


- iu tr hp niu qun hay g b tc (t ngoi p vo).

- iu tr t o gc BQ-NQ.

- iu tr UPTLT ng phu thut ni soi hoc laser.

4. Ct b thn khi m, d lu h thn, d lu abcess.

. Di h dng:

- h, ung nhiu c, u g c l , c qu trong nh g g u


t g t o thi VK qu c tiu. Nu c v niu th king rau qu v hn
ch c.

-B , in gii b g ng TM nu mt c nhiu.

- Nu c suy thn th phi cho ch gi m.

6. Phng bnh: gi v sinh c nhn tht tt, trnh dng th thut soi BQ, thng
tiu khi ko cn thit.

49.SUY THNG THN CP

Bs Nguy t Anh

I. M khn cp

- L mt cp cu ni khoa c th gp song d b b st. Bnh nhn nghi ng chn


o su thng thn cp c nhanh chng chuyn ti khoa cp cu
h iu tr chuyn khoa
- Tnh trng ny c th gp cc bnh nhn b su thng thn mn hay suy
thng thn tim tng (dng corticoid di ngy) v biu hin tnh trng mt b
cp nhn khi c mt bnh l nhim khun ton thn nng

II. Nh g im c lu

- Tt c cc b h h su thng thn mn tnh ( bnh Addison) c c


hng dn k cch t theo di v thng bo kp thi cc bc s iu tr iu chnh
iu tr nhn khi c tnh trng stress, b mt bnh l thm vo, chu mt phu
thut d nh

- Nghi vn ch o t h t ng mt su thng th ha su thng


thn cp khi thy xut hin b h h a gi ( Addison, dng corticoid
di ngy) cc du hiu h t mi, kh chu, h ng huyt, h ha tt
huyt p

III. Thuc v trang b cp cu cn thit

- Dung dch truy t h ch loi g t g: NaCl , %, glu oza %

- Hydrocortisone (Solu- Cortef) ng 100 mg/2ml hay Dexamethson 4 mg/ng

- Syncortyl (10 mg tim bp): dng cho t mt su thng thn mn v


Synacthen (1mg tim bp) dng cho bnh nhn s dng corticoid di ngy

IV. Ch o l s g

- Tnh trng ny c th x a t ngt ha c bo hiu bng mt s triu


chng gi kh g c hiu h u phn nh g im c lu

- Bnh nhn thng c tnh trng ri lon tiu ho ( bun nn, nn, a chy, au
bng)
- Du hiu xm da v nim mc mi g t g ho nh Addison song c th
khng thy c nu bnh nhn mi b bnh hay cc b h h su thng thn
ngun g " ao" h gi dng corticoid di ngy)

- M n g c biu hin bng: tnh trng mt c nng v xy ra nhanh,


st i khi t cao v tt huyt p nng, c khi l tnh trng sc thc s

- Phn bit mt su thng thn "thp" (ti tuy ha " ao" di i- yn) gip
khu tr nguyn nhn g su thng thn cn tm:

+ Ngun gc ti tuy : lao, iu tr bng thuc ch g g ha mt bnh l t

min

+ Ngun gc cao: suy tuyn yn, sau phu thut tuyn yn v nht l trn cc
bnh

nhn dng corticoid di ngy

V. x tr cp cu

- Bo m bi ph th tch tun hon nhanh bng G 5% 500-1000 ml + 4g


NaCl/l t o g g h. Sau tin hnh bi ph bng NaCl 0,9%. Tng th tch dch
truyn vo kho g l t o g g u.

- B xung Kali trong dch truyn: 1g KCl/1000 ml dch truyn

- iu chnh thiu ht Glucocorticoid


+ Dexamethasone: 4mg tim bp t h ch x 12 gi/ln trong bnh cnh cp cu
(khng c h h g giao thoa i vi test h l g o isol , sau g t h
mch ung vo cc bui sng

+ Hydrocortisone 200 mg liu t g t h h, sau g t h ch x 8


gi/l , sau g ung vo cc bui sng v 10 mg ung vo cc bui chiu.
Liu gp i khi t h t ng stress

+ Prednisolon 5mg ung vo cc bui sng v 2,5mg ung vo cc bui ti

- iu chnh thiu ht i e alo oi ti oid t o g su thng thn ti tuyn)

+ Nn dng corticoid loi khong (mineralocorticoid) nu truyn dch v


dng h d o o tiso e kh g iu ch h c tnh trng gi at i u t g
kali mu

+ Fludrocortisone (Florinef) 0,1-0,2 mg/ngy ung

+ Desoxy corticostone acetat (DOCA, Syncortyl) 5-10 mg tim bp

- iu tr cc yu t th y

Nht l nhim khun

VI. nhng xt nghi u tin cn lm

- in gii ( natri mu gi , kali u t g ; g thc mu v hematocrit (tnh


tr g c mu vi t g he ato it

- Xt nghim chuyn khoa: Test kch thch ACTH bng Synacthene. c ch nh


khi nghi ng su thng thn mn

VII. Nhng kinh nghim ch o v tr

- C iu tr ngay khi lm sng gi bnh nhn b su thng thn cp ha t


cp ca su thng thn mn
- Cc b h h su thng th sau khi c ch o nh c c
hng dn k tnh trng bnh l v cch b xung ngay cc hormon b thiu ht
t h gu mt su thng thn cp. B h h gi h c
hng dn k cch dng hydrocortisone khi c tnh trng stress. C th l

+ Khi b cm hay c tnh trng mt mi: tim ngay 50 mg/ngy

+ Nh g ha l tiu phu thut: tim 40 mg x 2ln/ngy

+ Cn phu thut: tim 150-250 mg/ngy

50.S DNG CORTICOID

Chng ta bit rng v thng thn tit ra ba loi ho o l : a d oge ,


corticoid tham gia chuyn ho mui c v glucocorticoid c tc dng chng
vim v tham gia chuy h a t o g th. Cc thuc chng ta dng hin nay l
nhm th ba nhm m h hng vim.Khi dng loi thuc ny v l thuyt c
th d su thng thn.

1. Cc thnh ph d ng hc:

Corticoid loi t nhin hay tng hp c tc dng chng vim nh on gc gn


vi nhn chnh l cortison.

Cu t n ca o ti oid l g gm 21 nguyn t cacbon. Trong phn


t c mt ni i v tr 4-5, mt nhm ceton v tr 3 v 20, mt chui hai
nguyn t cacbon nhnh C17, mt gc OH v tr 17 v 11. Prednison v cotison
c nhm ceton v tr 11 v khng c tc dng ho hc, n hot ng ch khi
c hyoxyl ho v tr 11 gan. Ni i C -C2 l lin kt fluor gn vi mt gc
eth l l t g hot tnh chng vim. Cc dn cht fluo e h de a ethazo
tc dng rt mnh, tuy khng lm ri lon chuyn ho mui c nhiu h g
l t g gi g ho hiu p otei g teo ha h h g.
C o ti oid c phn loi ph thuc vo thi gian tc dng. Loi tc thi gm
cortisol, hydrocortison, prednison. Tc dng trung bnh gm prednisolon,
methylprednisolon, triamcinolon. Tc dng ko di gm dexamethazon,
betamethazon.

Cc thuc c tc dng ko di th mnh nht h g g l c ch tr di i


thng thn r nht. Trong thc t khi dng corticoid bui sng l tt nht v
c g c c hai loi ni sinh v ngoi si h. H a khi thi gian bn hu ca
thuc ngn, n g gim xung vn kch thch tuy thng thn sn xut tip
tc. Cc ch phm t gy c ch thng thn l prednison, prednisolon,
methylprednisolon. Hi a p ed iso c s dng nhiu v tc dng
ngn,mnh v r.

C nhiu thuc khi s dng cng corticoid s t g t d h a itu i ,


rifampicin. Cc thuc cnh tranh g p otei h e th o i , sal ilate, ha
t o g t ng hp gi al u i ul tha i n g corticoid trong mu.

2. Tc dng mc t bo

Glucocorticoid l mt dn cht ca cholesterol, tan trong m v vn chuyn tch


cc qua mng t bo. Mi t o h u c th th vi cht ny. Phc hp
gia th th vi corticoid ti nhn t bo tc dng vo ADN. T l sn xut
p otei c hiu v cc enzym c tc dng ho hc.

3. Tc dng sinh ho ca corticoid.

- tc dng chuyn ho.

+ Ln chuy ho g: T g gi g ho ng ga go i ga l t g
ng huyt.

+Ln chuyn ho protein: Gim tng hp t g gi g ho p otei , o gc


cn b g it. G tho i ho h g l lo g g, tiu i d
dy( cng vi h l t g tit HCl), bin d g da h n da, ban da.

+Ln chuy ho lipid: T g tiu lipid c ch tng hp do t g i suli th pht.


ng thi c c ri lon phn phi m thn mnh v cc chi.
+Ln chuy h a in gii: c tc dng gi g h aldoste ol khi d g liu
cao

+Ln chuyn ha calci:gim g al i o g,gim hp thu rut gy nhuyn


g.

- Tc dng chng vim v h min dch:

+Co mch: tc dng trc tip ln m h u, t g hot ha cathcholamin, tc


dng ln prostaglandin. Hu qu l h huyt p, gim tp trung cc t bo min
dch ti ch vim.

+H st: Gim sn xut v gii phng interleukin1, cc cht gy st, c to ra t


cc t o h .

+Tc dng tng hp prostalandin v cc yu t hp dn bch cu: tc dng trn


phospholipase A.

4. Ch nh dng corticoid

Co ti oid c ch nh rng ri trong nhiu t ng hp:

- iu tr thay th ni tit

-t o g t ng hp d g h he , i i d ng

- iu tr ti ch h da liu, h hp, tai i hng, mt, khp.

Trong cc bnh h thng:

- Lupus h thng

- Vi da , i da a

- Vi a khp dng thp, vim khp d ng mn tnh.

- Vim mch hoi t, vim mch dng ht.

- Vi ng m h h nh horton, bnh takayasu


- B h phi

- Ghp tng.

- Hi chng th h.

- Vim khp dng thp cp tnh

- Xut huyt dng tiu cu o , thiu mu tan mu t min.

- Bnh Crohn, vim trc trng chy mu.

- Bnh th ki h h ho dng , yu .

Bnh Pemphigus.

5. Nguyn tc s dng chung:

- Ch dng liu , liu ti thiu c tc dng, c th ch l g. Tha i liu theo


tnh trng bnh v gim liu t t khi c th.

- Khi cn chn la ng dng tim hay ung phi theo ch nh chuyn khoa,
t o g t ng hp th g thng th nn dng cc sn phm chung nht thng
dng.

- Nn dng thuc vo bui sng v l do sinh l, gim ti a gu c ch gc


trc tuyn yn - d i - thng thn. S d g h g g th hn ch
gu . T o g t ng hp c bit h he th g n tun th cc nguyn
tc ny.

- Khi gim liu phi t t trnh cc bin chng:

+Su th g thn cp: mt c ngoi t bo, h huyt p, au ng ,mt mu


da,h at i u, t g kali u. T o g thc t ch g thng thn tr li bnh
thng rt chm sau khi dng thuc. Nh g t ng hp su thng thn hu
h h xy ra gi gi g him gp. Lc ny c iu tr b xung hormon
thay th. Lu bin chng ny c th n ngay khi dng nhng liu thuc nh
nht 5-10mg.
+Bnh ti pht: lc ny cn dng li liu a u v phi gh ti tnh trng ph
thuc corticoid.

6. Mt s cch dng thuc:

- Liu cao tn cng trong thi gian ngn.

- Liu tn cng 0,5- g/kg/ g , sau gim liu t t tu theo bnh cnh,
cch dng ny hay dng trong cc bnh h thng.

Liu duy tr l dng ko di vi liu nh kho g g/ g , c dng khi cn


gim liu tn cng hoc trong cc bnh phi dng lu di.

7. Cc chng ch nh:

Cn cn nhc k cng gia hiu qu v vic cn thit ca thuc vi gu .

- i ng.

- Lot d dy t trng tin trin.

- T g hu t p.

- Nhim trng nng.

- Tm thn.

- Lo g g.

- Thi u thng.

Cc tc dng ph:

- H tiu ho: lot d dy t trng, chy mu tiu ho, thng rut, vim ty cp,
gan mt.
- Bnh chuy ho : i g, o ph g th h, t g mu, gi c,
ph , t g hu t p, gim kali mu.

- Nhim trng: nhi t g th g thng, lao, nhim vius, nhim nm.

- Ri lon tinh thn: kch thch, lon thn.

- H g: lo g g, hu g, i g, hm pht trin.

- Tc d g kh : au tht l g i cc ch phm fluore), nhim trng da, trng


c, chm lin so, c thu tinh th.

- Tc dng ti ch: vim khp nhim khun khi tim ni khp, teo da, teo .

Theo ri vi iu tr corticoid lu di:

- Theo ri cc tc dng ph iu tr d phng:

+ch ht khi dng corticoid trn 15mg/ngy.

+thm kali khong 2gr/ngy.

+ph g lo g g bng calci v vitamin D.

+iu chnh thu i ng.

+khi gu tiu ho th ho th thuc bao bc nim mc, khng histamin.

- Theo ri lm sng:

+ cn n g: khi t g phi kim tra ph v roi lon chuyn ho.

+huyt p, mch.

+tnh trng da, c.

+ ri lon tiu ho phi soi d dy.

- Theo ricn lm sng:

+ chp phim tim phi.


+ in gii mu.

+ ng mu.

+ calci mu, niu.

S dng corticoid liu cao thi gian ngn

D g olus l h d g g t h ch liu cao trong mt thi gian rt ngn.


Tin ch ca cch dng ny l tc dng m h k o d i t o g khi t h c bin
chng nht nh.

1. Tc dng ca dng bolus:

C h ca ph g ph p ha c lm r. Dng bolus c tc dng


chng vim v min d h h hiu ph g ph p d g corticoid c in biu
hin qua hai cch: gim tp trung bch cu a h ti ch vim, th hai l thay
i phn b lympho , lm gim lympho T. Mt tc d g c hiu ca bolus l lm
suy gim hot lc ca t bo T h tr v cc cht c t bo. S tha i ca hot
ng min dch t bo thng qua phn ng lympho hn hp v ph thuc vo
n g corticoid trong mu. Trong cc sn phm th methlprednisolon c tc
dng c ch t bo T mnh nht.

Bolus corticoid tc dng trc tip vo th l tha i lu lng huyt t g


qua th tha i tnh thm ca p otei ua g u thn.

2. Cch dng bolus:

Thuc hay dng l solumedrol. Liu th g thng 1-2 gr( khong 20mg/kg) pha
cng 120ml hoc 250ml dung dich glucose 5% hay natriclorua 0,9%, truy t h
m h t o g ph t. Kh g c truy ha h u , di 30 pht.
Mi t iu tr l 1-3 ngy. C th dng mt t hay nhiu t tu theo bnh v
tin trin ca bnh.

Khi truyn cn theo ri st huyt p, nhp tim, tt nht l bng monitoring trong
24h. Xt ghi in gii , si h ho u t c v sau truyn.

3. Cc ch nh chnh:

Cc bnh ni khoa:

- Bnh Lupus: th tin trin n g, kh g p ng b g ph g ph p th g


thng, t th g thn nng.

- Vi a khp dng thp kh g p ng vi iu tr th g thng.

- Bnh sarcoidose nng.

- Mt s b h kh : i da a , i t ua h ng mch, hi chng cogan.

Cc bnh thn:

- Ghp thn.

- Vim cu thn tin trin nhanh.

- Hi chng th h t th g ti thiu.

- Hi chng Goodpasture.

Cc bnh h hp:

- X phi .

- Hen c tnh.

- Hi chng suy h hp gi ln.

Cc bnh khc:

- Nhi u ti .

- Shock nhim trng huyt.


- X ho dng .

- Ho tr liu khng hp thu ua ng tiu ho.

4. Tc dng khng mong mun:

- T vong: Rt him gp. C ch hin nay khng r. C th do ri lon nhp do


tha i n g kali trong mu. cc yu t l t g gu ao gm vic dng
li tiu, truyn thuc qu nhanh. V vy khi dng bolus phi theo i in tim
trong 24 gi.

Cc tc dng ngoi khc: Mi tc dng ph u c th gp. Hay th l au u,


au khp, vim khp. Tuy nhin cc bin ch g t h so i cc dng thng
thng.

51.SUY THN CP CAO HC

TS. H Hong Kim

1. Phn m u.

Suy thn cp c gi bng nhiu tn khc nhau: vim ng thn cp; vim
ng- k thn cp; hoi t ng thn cp. Thc t, ngoi t th g ng thn cn
lun c ph n v vim t chc k thn, ch c cu thn v mch mu thn l
c bo ton, v vy thut ng vim ng-k thn cp l thch hp nht, n
nhn mnh ti t th g nh h . T o g l s g, gi ta thng dng
thut ng suy thn cp (STC) l mun nhn m h n t th g h g a
vim ng-k thn cp.

+ Suy thn cp l hi chng suy gim hoc mt ch g tm thi, cp tnh ca


c 2 thn, lm ngng hoc suy gim nhanh chng mc lc cu thn dn ti thiu
niu hoc v niu, it phi p otei t o g u t g, i lon cn b g c-in
gii, ri lon cn bng kim-toan...Sau mt thi gian t vi ngy n vi tun, khi
nguyn nhn gy t th g th c loi tr, ch g thn c th dn dn
phc hi tr li h thng hoc g h thng. Tuy nhin, trong thi gian
thn mt ch g, nh nhn c th cht v cc bin lon ni mi. Lc mu v
ph g ph p iu tr bo tn s gi p iu chnh cc ri lon ny, bo v bnh
h n khi ch g thn hi phc hon ton.

+ Nh y suy thn cp c mt s im sau:

- im lm sng ca suy thn cp l thiu niu hoc v niu ko di, trung


bnh t 1-3 tu , i khi d i h , dn ti tnh tr g t g it phi p otei t o g
mu cp tnh, ri lon cn b g c-in gii v ri lon cn bng kim-toan...

- Suy thn cp c t l t o g ao, h g u c ch o iu tr kp thi


th ch g thn c th phc hi hon ton hoc gn hon ton. Hin nay
ph g ph p iu tr hu hiu nht l lc mu bng thn nhn to, kt hp vi
iu tr bnh chnh.

- Suy thn cp do nhiu gu h kh hau g , h g li ging nhau v


bnh cnh lm sng v t th g nh hc.

2. Nguyn nhn:

2.1. Nguyn nhn trc thn:

Ngu h t c thn l cc nguyn nhn gy gim dng mu ti thn, lm


gim p lc lc cu thn, hay gp l sc do cc nguyn h kh hau h:

+ Sc do gim th tch:

- Chy mu: ch th g, ln, ph thai, chy mu tiu ho.

- Mt c: nn, a chy, bng din rng, dng thuc li tiu.

+ Sc do tim: nhi u ti p, hi chng p tim (Temponade), vim ti


cp, lon nhp tim.

+ Sc do nhim khun: nhim khun huyt, nhim khu ng tiu ho, nhim
khun t cung, vim tu cp.
+ Sc do qu mn: sc phn v.

+ Sc do ch th g: hi chng vi lp, g g ln.

+ Sc do tan mu cp: gy tc ng thn do hemoglobin, myoglobin:

- Dp ln trong hi chng vi lp (crush syndrome).

- Tan mu cp: do c t nc rn, do truyn nhm nhm mu, st t i a hu t


cu t.

- Hemoglobin niu do lnh.

-
Hemoglobin niu do thuc gi thiu men G6PD (glucose 6 phospha
t dehydrogenase). Khi hemoglobin trong huyt thanh trn 100 mg/dl s c
hemoglobin niu.

+ Cha : nhim khun do ph thai, sy thai, sn git.

Thi gian thiu mu thn rt quan trng, nu thiu mu thi gian ng di 72


gi th ch g thn c th phc hi sau khi mu v dch (suy thn
cp ch g , u thi gian thiu mu ko di trn 72 gi th hoi t ng thn
cp c th xy ra v gy suy thn cp thc th.

Nhng nghin cu g ho thy: cc thuc chng vim nhm non-steroit lm


thn gim tit prostaglandin (l yu t gy gin m h , do th gy thiu
mu thn. V vy, s dng cc thuc ny cc b h h gu gim dng
mu th su ti , ga , hi chng th h, i u thn) c th gy ra suy
thn cp.

2.2. Nguyn nhn ti thn:

+ Do t h g c cho thn:

- T ha gp: nhi c kim loi nng, nhim khun, nhi u, cc


t h c trong ngh nghip i t ng.
- Cc cht c t nhin: mt c trm, mt cc loi c ln.

- Cc cht c l thuc: thuc khng sinh nhm aminoglycozit, thuc gy m


(methoxyfluran, enfluran), cyclosporin A, manitol dng qu liu.

- Cc loi thuc c ua g g ti t h h, c bit l khi s dng cho cc


bnh nhn cao tui, bnh nhn c tnh trng mt c, bnh nhn b b h i
tho ng, b h a u t g ultiple elo a).

+ Cc bnh th c bit:

- Bnh mch mu th : t g hu t p c tnh, nghn t ng mch ho t h


mch thn.

- Vim cu thn: bnh khng th khng mng nn cu thn (hi chng


Goodpastur), vim cu thn hnh lim (vim cu thn tin trin nhanh).

- Vim k thn: do thuc, do tinh th axit uric, tinh th canxi, nhim khun lan
to.

+ Tc nghn trong thn do cc tinh th: tinh th axt uric, thuc sulfamit,
methotrexat...

2.3. Nguyn nhn sau thn:

Bao gm cc nguyn nhn gy tc nghn ngoi thn: tc nghn b thn, niu


qun, bng quang do si ho do u p. Lit bng quang do t th g thn
kinh. Tht nhm niu qun khi m vng chu hng.

3. Sinh l bnh hc:

. . C h ca tn th g thn:

C hai h chnh gy t th g t bo ng thn l do c t v do thiu mu


thn.

+ c t lm t th g t bo ng thn: cc t bo ng thn d tip xc vi c


t n g cao v hu ht cc cht c thn o thi. Tuy vy, cht c
t ng ln t bo ng thn khng phi l tc nhn duy nht m cn c vai tr
quan trng ca ri lon tun hon thn v cc ri lon ni mi gp phn gy tn
th g t bo ng thn.

V tr t th g a t bo ng thn c lin quan vi phn bi tit cht c: thu


ngn gy hoi t g ln gn, cacbontetraclorit gy hoi t g ln xa.

+ Thiu mu thn: thiu mu thn do gi d g u n thn, ngoi ra cn c


th do cc cu ni tt (shunt) ca mch mu trong thn. Khi thn thiu mu,
gi ta thy s ti mu vng v thn gim, u u ti cung cp cho
vng tu thn do hnh thnh cc cu ni tt ca m h u duy tr phn s lc.

. . C h ca v niu:

Ngi ta thy c bn yu t tham gia gy v niu bnh nhn b suy thn cp


l:

+ Tc nghn ng th : h ca v niu do tc nghn ng thn


c Ponfick (1875) nu ln l u. Bywaters v Beall (1941) quan st thy
cc tr trong lng ng thn gi cht do hi chng vi lp (crush syndrome).

Tc nghn ng thn c th do tr, do ph n t bo ng thn v t chc k thn


gy chn p ng thn v mao qun th l t g p lc thu t h t o g khoa g
niu, do l gim mc lc cu thn.

+ Gim mc lc cu thn: mc lc cu thn gim l do gim dng mu qua


thn v do co tht ng mch thn.

+ T g th gc khng chn lc dch lc qua vng t th g a ng thn:


bnh

thng vic ti hp thu dch lc v cc thnh phn trong dch lc ca ng thn l


c chn lc. Khi ng thn b hoi t th dch lc trong lng ng thn th gc
vo t chc k v

vo mu qua vng ng thn t th g mt cch khng chn l gp phn


gy ra v niu.

+ Gim tnh thm qua mng mao qun cu thn.


Trn mt bnh nhn b b suy thn cp, h t thng phi hp vi
nhau, him khi ch do mt h gy nn. V d: khi thiu mu thn gy gim
mc lc cu thn, lm t dch lc trong lng ng thn gim dn ti d thm
gc dch lc v hnh thnh tr gy tc ng thn. Ngoi ra cn c lin quan gia
cc tc nhn, gia h v lin quan gia pha sm v pha mun ca suy
thn cp.

Hin nay, ngi ta cn t hiu bit v ch suy thn cp do myoglobin v


hemoglobin niu he oglo i h h h t t c cho th . Ngi ta cho rng,
ri lon ch g thn khng phi do nhi c thn bi hemoglobin m do tc
nghn ng thn bi cc tr hemoglo i . Ngo i a, c t do hu hoi c
vai tr nht nh. M nhiu hay t ca hemoglobin niu khng thy lin quan
vi m t th g thn. C bnh nhn hemoglobin niu nhiu h g kh g
thy c t th g thn, tri li c bnh nhn hemoglobin niu t li b v niu
trm trng. T th g th thng ch xy ra khi c kt hp hemoglobin niu
vi ri lon tu ho h: t c, tt huyt p, thiu mu th ... Ngi ta
thy trn lm sng, nh g gi c hemoglobin niu gy suy th thng trong
tnh trng s , h ca n phi l s gii phng hemoglobin hay
myoglobin vo mu kt hp vi ri lon tun hon.

4. Tn th g nh hc ca suy thn cp:

Mt iu g h l mc d bnh nguyn gy ra suy thn cp rt khc nhau,


h g li gy ra cng mt bnh cnh lm sng, cng kiu v niu, ko di trong
cng mt khong thi gia . gii thch v ny phi khm nghim tn
th g gii phu bnh, hnh nh m bnh hc cho thy tt c cc dng tn
th g l t g t nhau v qu trnh tin tri g t g t nhau cc bnh
nhn.

4.1. Hnh nh i th:

K h thc thn to ln do ph n, tr g lng mi th t g th ti 250g. V


thn d bc tch khi nhu m thn. Trn mt ct vng v thn nht mu, tri vi
vng tu thn li b xung huyt xm.

4.2. Hnh nh vi th:


+ Cu thn: cu thn cn nguyn v , h g uai ao ch xp do thiu
mu. Mt s t ng hp thy tc cc mao m h t o g li mao mch cu thn.

+ ng th : t g t th g a suy thn cp thy ng thn. g ln gn


t th g ng trong nhi c do g ln gn l vng bi tit cht c ca
thn. g ln xa t th g ng trong sc v tan mu cp. M t th g
ng thn nng hay nh khc nhau:

- M nh: t bo biu m ng thn ph n, lng ng thn hp li.

- M va: t bo biu m ng thn b hoi t, ty lp th bin mt, t bo mt


h o t g, g n.

- M nng: th t on ng thn, t bo ng thn b hoi t km theo mt


c mng n , thng vo ngy th 4 hoc th 5 ca v niu. C th thy hoi t
bt k on no ca ng thn t g ln g n g g p, h g c
bit hay xy ra on th 2 ca g ln gn (ng thng), on ny nm ranh
gii v-tu. C th thy mt nhm nephron b t th g, vng t th g
thy ng thn b hoi t, mng nn b t on khng cn nguyn vn.

Hnh nh chung cho c 3 m t th g: thy lng ng thn c hng cu,


bch cu, tr ht mu nu bn (tr cha xc cc t bo biu m ng thn), c th
thy tr sc t...

+ T chc k thn:

T th g k thn xy ra sm trong nhng gi u ca v niu, ph n k thn


thy r vng ni v-tu. Giai on s ha thy xm nhp t bo vim;
mu h o g th

5 hoc th 7 s c xm nhp t bo vim vo t chc k thn. Ph n k thn


thy tt c cc bnh nhn v niu, c bit trong t th g do hi c.

+ Mch mu thn:

Cc mch mu l h th g, h g hng mch mu nh vng v thn


thng b xp. Vng tu, c bit vng ni v-tu thng b t th g trm
tr g h do thiu mu, c th thy tc nghn cc mch mu nh.
+ Qu trnh tin trin ca t th g nh hc:

- Giai o u ca pha v niu: hnh nh gii phu cu th h th g h g


cc quai mao mch xp v khng c mu, c l g ng protein trong khoang
niu, ph k thn v xung huyt cc mao mch vng k thn. ng thn tn
th g h h g t bo biu m g ln gn b ph n, lng g ln xa gin
cha y tr v hng cu.

- Giai on sau ca v niu: thy t th g hoi t t bo ng thn, c nhng


ng thn b t on, c tc nghn cc mch mu nh.

- Giai on i t li: cu thn tr li h thng, cc quai mao mch trong cu


thn gin v cha y hng cu. T th g ng thn c c hoi t t on
ng th , th o s ti sinh ca t bo biu m ng thn. C ch t bo
biu m ng thn tr li h thng vi dim bn chi nguyn vn. C ch t
bo biu m ng thn dt, lng ng thn gin rng, ch khc vn c ph n t bo
v tc nghn ng thn.

- Giai on phc hi: t chc k thn gim ph n v gim thm nhim, mt s


eph o bnh phc hon ton; mt s khc bnh phc t v t th g u
nng. ng thn gin vi cc t bo biu m dt, bn cnh c nhng t bo vn
cn ph n.

5. Bnh cnh lm sng.

Din bi l s g th g th g ua giai on.

. . Giai on khi u:

Giai on ny bt u t khi tc nhn gy b h t ng n khi xut hin thiu


niu hay v niu. Vic pht hi pha u cc k quan tr g, iu tr tch c
loi tr nguyn nhn phng suy thn cp th c th bin suy thn cp th
v niu thnh suy thn cp th c bo t c tiu, l th ti lng tt h
v thun li h ho iu tr.

Giai on ny, triu chng ca cc bnh nhn din bin rt khc nhau tu theo
bnh nguyn:
+ Nu do nhi g tiu ho : thng khi pht bng cc triu chng tiu
ho h: , u , au ng, a chy...

+ Bnh cnh ca sc: trng thi th , da t i lnh, v m hi, mch nhanh nh,
huyt p tt.

+ Nu b th g ha bng: c triu chng mt mu, mt c.

+ i a he oglo i ha oglo i u do tan mu hoc gip hiu.

Trong mi t ng hp cn ch ti tnh trng tim m h, c bit bnh cnh tt


huyt p, nht l tt huyt p ko di; tnh trng thiu niu, ur niu thp. Theo
mt s tc gi, triu chng ur niu thp t o g giai on ny l triu chng c gi
tr ch o t th g thn thc th, gip phn bit vi suy thn cp t c
thn.

. . Giai on thiu niu hoc v niu:

Giai o thng bt u sau gi th n gi th ; k o d i n 14


g , g th ch 2- g , t ng hp ko di 4-8 tun. Nu v niu ko
di trn 4 tun th c th c hoi t v thn lan to hoc vim cu thn tin trin
nhanh hoc bnh mch mu thn.

Khng ging vi giai o t c, bnh cnh lm sng ca mi bnh nhn trong


giai on ny ging nhau. Ngoi ra, cn c thm bnh cnh ca b h gu .
l giai on ton pht ca suy thn cp. Tuy nhin, mt s bnh nhn suy thn
cp khng c v niu m phi nhn bit bng ur u t g, c lc cu thn
gim, ri lon kh g c tiu.

5.2.1. Triu chng lm sng:

+ Thiu niu hoc v niu: l du hiu l s g h h, l g c tiu khc


nhau gia cc bnh nhn. C th v niu hon ton hoc ch c vi ml/24gi,
th g thng l 50-

100 ml/24gi. Nu di 100 ml/24gi th c coi l v niu, di 500ml/24gi


l thiu niu. V niu l biu hin ca hoi t ng thn cp, tuy nhin vi ngy
u c th v l g c tiu di 100 ml/24gi. Nc tiu xm mu, c
th c mu, m, i khi i khun.

+ Trong nhiu t ng hp thy th to au, i khi au d di, c phn ng


t g m thnh bng v h tht l g, i sn tht l g au, du hiu v h
tht l g d g t h. C t iu chng trn gi c tc nghn ng dn niu.

+ Ph: tu theo l g c v mui a o th, nu a o hiu th c th


gy ra ph phi cp. Phi theo di cn nng bnh nhn, tt nht l theo di p lc
t h h t u g t CVP iu chnh cn b g in gii cho thch
hp.

+ Triu chng tiu ho: mi g li kh, nn, bu , h , th c a


chy.

i khi au ng cp gi g h i ph c cp, cn ch o
phn bit vi vim phc mc thc s; nu au g do t g u u p s
gim v ht nhanh sau lc mu.

+ Triu chng tim mch:

- Huyt p thng thp ho h thng trong pha thiu niu hoc v niu. Nu
v niu ko di th huyt p s t g dn, huyt p t thu t g hiu h hu t
p t t g. C g hng ngy sau huyt p g t g, thm ch thy huyt p
t g dn trong cng mt ngy. Huyt p t g ph thuc vo cn b g c-in
gii, c bit l tnh trng qu ti natri.

- Tim c th h thng c v l s g in tim. V niu ko di s g t g


kali mu dn ti lm bi i in tim v gy ngng tim, nhng ri lon ny s
iu chnh sau lc mu. Suy tim rt him gp, nu th im l suy
ti t g t d g u, t g u g l g ti , t g p l t h ch trung
tm. Nu bnh nhn c bnh tim t t c, c th thy c ri lon nhp, ph phi
cp, try mch.

- Vim mng ngoi tim c th gp trong suy thn cp. Biu hin ca vim mng
ngoi tim l c ting c mng ngoi tim ho au g t ti . Ngi ta thy
c mi lin quan gia vim mng ngoi tim vi vim nim mc ng tiu ho.
+ Triu chng thn kinh: chut rt, co git c th xy ra nu c ri lo c-in
gii, h g him gp; tr em c th c co git khi t g hu t p do qu ti
natri, qu ti th tch. Hn m do ur mu cao hin nay him gp do c nhiu tin
b t o g iu tr. Nhng triu chng thn kinh s mt i ha h h g sau lc
mu.

+ Bi i v mu: thiu mu hay gp h g kh g ng, tr t ng hp mt


mu, st rt c tnh hay tan mu cp. Bch cu th g t g, th t g ti 20 x
109/l n 30

109/l. S lng tiu cu thng l bnh thng.

+ Triu chng h hp: b my h hp ch b h hng th pht bi cc bin


ch g h ph phi do qu ti mui v th tch. Ri lon h hp c th gp trong
t ng hp v niu nng v ko di do toan mu, do ri lon tun hon hoc
bin chng vim ph qun-phi.

+ Tnh trng ton thn: ph thuc vo nguyn nhn v cht l g iu tr. Thn
nhit c th h th g, t g ao hoc gim thp. St khi c nhim khun hay
mt c t o. T g ur mu cp gy gim thn nhit mt s bnh nhn,
h g nhng bnh nhn khc cng mc ur mu, thn nhit li khng gim.
Cho a , h ha c r. Mt s bnh nhn c cn nng gim trong
giai on ny.

5.2.2. Triu chng cn lm sng:

* T g it phi p otei t o g u:

+ U u t g dn, t t g u g ha h th ti lng cng nng. T


t g u u ph thuc phn ln vo qu trnh d ho p otei . iu ny gii
thch cng mt mc suy thn (mc lc cu thn hu h = nhng bnh
nhn v niu h g t g u u li khc nhau gia cc bnh nhn. Thm
ch cng mt bnh nhn, m t g u u g kh hau gia ngy ny v
ngy khc giai on v niu.

+ C eati i u t g dn: nhng bnh nhn gip hiu, thy t g eati i


u ha h h t g u u do gii phng creatin t .
+C it phi p otei kh t o g u kh g phi u g t g: a it u i u
t g t sm do gim bi xut ua c tiu. Cc a i o a t t o g u t g
chm h hiu, amoniac kh g tha i, t s u / it phi p otei t o g giai
o t g t 40- % l n 80% ho %. N i h kh , t g it kh g
phi ur ch h t g u .

* Mt cn b g in gii:

+ Cc anion:

- Clo gim: nu clo thp nhiu th th g li ua n nn, a chy.

- Bicacbonat gim: gim bicacbonat trong mu l do trung ho axt v cn do


cn bng vi a io kh phosphat sulphat t g.

- Sulphat t g: sulphat t g hiu h a io kh , c bit t ng hp t g


rt cao. M t g sulphat t o g u h h h li ua t gn vi m t g
ur mu.

- Phosphat t g: t s bnh nhn c mc phosphat vn h thng trong khi


nhng bnh nhn khc c th t g h hai ln so vi m h th g. Ngi ta
khng thy c mi lin quan gia m t g phosphat i cc ri lo in
gii khc, t s canxi/phosphat rt tha i.

- Axt hu : ng cc axt hu trong u h thng t 5-6


mmol/l, trong suy thn cp cc axt hu t g mc va phi.

- P otei u thng gim t o g giai on v niu: thng thy gim albumin;


t g , glo uli . Gi al u i t g glo uli l do gim tng hp
ho t g ph hu qu mc protein mu.

+ Cc cation:

- Natri: natri chi / l g atio t o g u. Do , gim ho t g n g


at i t o g u u h hng l n cn b g in gii. N g at i thng
m h thng hoc gim nh. Gim n g natri mu l do qu ti c
hoc do nn, a chy lm mt natri. Him gp t g at i, u t g at i thng
l do hu qu ca iu tr a o th nhiu natri.
- Kali: m kali u l u h th g, sau t g d ho n khi bt
u i t li. T g kali l t trong nhng nguyn nhn chnh gy t vong
bnh nhn suy thn cp.

T t g kali ha h thng do c cc nguyn nhn ni si h h:

. T g ph hu t o do u , phosphat, sulphat t g.

. Do nhim axt trm tr g H+ t ao i vi K+ lm K+ t ni bo ra ngoi bo gy


t g K+ u .

. V niu kh g o thi c kali.

. c ni bo: natri ni o t g g hu n kali t ni bo ra ngoi bo.

. Do hiu th hoc ung cc thuc c kali.

T o g iu kin pH = 7,34 th t g l g kali t o g th c t g hoc gim 150-


200 mmol th kali mu s t g hoc gim 1 mmol/l.

Mt s yu t lm nng kali mu khng ph h g t g lng kali trong


th:

. Nhim axt, gi at i, t g hu n ho protein, c ni bo. Cc yu t trn


gy chuyn kali t ni bo ra ngoi bo.

. Nhim ki , t g at i, t g glu oza. C u t trn lm chuyn kali t ngoi


bo vo ni bo.

Triu chng lm sng ca t g kali mu (c th gp khi kali mu > 6 mmol/l):

. Yu , t phn x gn, i khi lit.

. Th , l ln, tm thn.

. Nga, t, d c : c bit hay xut hin vng quanh ming v chi di.

. Tiu ho: nn ma, a chy, i khi lit rut.


Kali u t g h h g t ti n tim, triu ch g in tim xut hin sm
khi kali mu > 5,5 mmol/l. M nng ca t g kali iu hi t in tim c 4
giai on:

. Giai on 1: Nhp tim chm, tr u hng chuyn tri. Sng T cao, nhn, hp
, i ( T > 2/3R t V3 - V6 ).

. Giai on 2: PQ di ra, QRS gin rng.

. Giai on 3: gi i s gP s g R, t g i sng S gy cm gic


o g on ST.

. Giai on 4: Nu kali mu tip t t g s d in tim c dng hnh sin,


blc b

His, hi chng Adams-Stockes, rung tht v ngng tim.

Thi gia in tim chuyn t giai o giai on 4 c th ko di nhiu gi


h g g th rt nhanh trong vng vi pht. V vy vic pht hi iu tr
kp thi rt quan trng.

- Magi t g: gi ta cn bit rt t v h hng lm sng ca t g agi t o g


u, h g t g agi th g i k i t g kali. Khi agi u t g t cao
ti 5-10 mmol/l (m agi h thng trong mu l <1,5mmol/l) th c th
thy mt s ri lon th ki h h: g g , g th gp ri lo i ti h
khong QT ko di.

- Ion H+ v i a o at: t o g giai on v niu thy n g bicacbonat lun


lun

gim, nu pH mu , l iu hin ca nhim axt chuyn ho nng. h hng


lm sng ca nhi a t ha c bit , gi ta thy ri lo in tim
ca t g kali, i lon thc, ri lon h hp. Hu ht cc ri lon ny bin mt
sau lc mu.

* Xt nghi c tiu:

- T bo t o g c tiu: c hng cu, bch cu, t bo biu m, vi khun.


- Protein niu lun lun c, s l g tha i t 0,1- g/l, th g thng l 0,3-
0,5g/l.

- Tr niu: trong hu ht t ng hp c hoi t ng th , thng thy tr


niu mu nu bn. Nu c nhiu tr hng cu v/hoc protein niu nhiu trn
3g/24gi th gi c t th g u thn. Nhiu bch cu, tr bch cu trong
c tiu th gi do vim thn k. Nhiu bch cu i toan th gi vim thn k
do d ng.

- Tinh th niu: tinh th niu c gi tr gi cc nguyn h h: ti h th urat


thy trong hi chng ly gii khi u, canxi oxalat c th do nhi c glycol.

+ T o g giai on thiu niu hoc v niu, bnh nhn c th t vong do cc


nguyn nhn sau:

- T g kali u g u g tht v ng g ti khi kali u t g ti 7-8mmol/l l c


gu gng tim).

- Ph phi cp: th g th g do a o th nhiu dch trong thi gian bnh


nhn b v niu.

- Cht trong hi chng ur mu cao: nguyn nhn ny hin nay t gp do c thn


nhn to.

- Cht do bnh nguyn qu n g h: ht do sc, do cc chn th g ln, do


bng nng...

. . Giai o i t li:

Giai on ny c tnh t khi b h h i t li ho n khi n g ur v

creatinin trong mu bt u gi . Giai on ny thng thng ko di 3-5 ngy.

Khi pht ca giai on i t li ty theo t g t ng hp, c th rt sm vo


ngy th 2-3 sau v niu h g g th rt mun vo ngy th 20 ho h ,
th g th g i t li vo ngy th 9-15 sau khi v niu. Th tch c tiu
t g d , i khi i t li nhanh ti 1 - l t c tiu t o g g u. Phn ln
t ng hp phc hi c tiu ch , l g c tiu t g i ngy ch
khong 100 ml, thm ch vi ngy gi mc 500 - 600 ml.

i khi giai o i t li, l g c tiu mi g t g gp i. a iu tip


t t o g giai o u khng ph thuc vo tnh trng cn b g . Nc
tiu giai on ny c hng cu, nhiu bch cu, cc t bo biu m, lun lun c
protein niu mc trung bnh <1g/24gi. N g ur niu rt thp, cc cht
kh h eati i a i g thp. Kh g t i hp thu ca ng thn vn
gim nghim trng, kh g i tit PAH vn thp. Cc du hiu khc ca tn
th g ng th h p ng vi asop essi k ; lng natri v kali niu thay
i gia cc b h h , i khi t nhiu natri b h h h g li
khng mt natri bnh nhn khc; t s natri/kali ca c tiu khc nhau ln so
vi t s natri/kali ca mu. Nu natri niu thp, kali niu cao th gi t th g
ng thn nh h .

Mc d bnh nhn i t li h g u u t g t o g i g tip theo.


Do i hiu, bnh nhn c th c ri lo c-in gii v tr g l g th
c th gi i kg/ g . P otei u t g dn trong vng vi ngy, n g natri
v clo mu cn gim ko di vi ngy, kali mu tr v h thng thm ch gim
thp h h thng, gim canxi vn tn ti. Sulphat, phosphat v cc axt hu
t o g u gim dn v h thng. Huyt p nu t g th t v bnh
thng. Giai on ny bnh nhn vn c th b t o g, thng do cc bin
chng. T l t o g t o g giai on ny gim nhiu t khi c thn nhn

to.

. . Giai on hi phc:

Giai on hi phc bt u t khi ur mu gim v tin trin dn v h thng.


Cn bng ni mi tr li sau vi ngy hoc vi tun. Ur niu vn cn thp mt
thi gian vi

tu , h g h s thanh thi u t g dn v h thng; ch g thn (mc


lc cu thn v nht l ch g ng thn) bnh phc chm sau nhiu thng tip
theo.
6. Ch o n v ch o ph it.

6.1. Ch o nh:

- C nguyn nhn c th gy suy thn cp, tuy nhin i khi kh g tm c


nguyn nhn.

- Thiu niu hoc v niu xy ra cp tnh.

- U , eati i u t g ha h d , kali u t g dn, nhim toan (pH mu


gim), d tr kim gim (BE gim).

- Ph do c.

- Sinh thit thn c gi tr ch o u t nh.

6.2. Ch o gu h :

- T c thn: cc nguyn nhn gy gim dng mu ti thn.

- Ti thn: thn nhi c, bnh cu thn, k thn, mch thn.

- Sau thn: cc nguyn nhn gy tc ngh ng dn niu.

6.3. Ch o ph it:

. . . t tin trin nng ca suy thn mn:

Nu l t tin trin nng ca suy thn mn th bnh nhn s c cc triu chng


sau:

+ Tin s c bnh thn-tit niu, tin s c protein niu.

+ Thiu mu nng.

+ U , eati i u t g t t c ho t g ao ga t nhng gi u ca v
niu.

+ Hai thn teo nh u ho kh g u.


+ Tr t o g c tiu to (2/3 s tr t o g c tiu ng knh l h ln
ng knh ca mt bch cu a h .

+ Huyt p t g k o d i t t , do in chng ca t g hu t
p h: t th g t, dy tht tri...

+ Sinh thit thn cho ch o nh.

6.3.2. Suy thn cp ch g suy thn cp thc th:

+ Suy thn cp ch g th g l do gu h t c thn, suy thn cp


thc th

thng l do nguyn nhn ti thn.

+ Ph t h si h ho u c tiu gip ch nhiu cho ch o .

B g . Ph t h si h ho u c tiu:

Thng s STC ch g STC thc th

1. Thm thu c tiu (mOsm/kg H2O) >500 <350

2. N g at i t o g c tiu (mmol/l) <20 >40

3. T s eati i c tiu/creatinin mu >40 <20

4. Phn s thi natri (EFNa+%)* <1 >1

* Phn s thi Na+ (EF

N g at i c tiu/n g natri mu

%) = 100

Na
N g eati i c tiu/n g creatinin mu

. iu tr.

. . Giai on khi u:

Cn nhanh chng loi b nguyn nhn gy suy thn. Vic nhn bit giai on ny
rt quan trng, nu pht hin s iu tr kp thi c th bin suy thn cp th
v niu thnh suy thn cp th c bo t c tiu (khng c v niu).

- C u; iu tr i go i, nn; loi tr nguyn nhn gy t ng d c


tiu (m ly si, u nu sc kho bnh nhn cho php). Loi b cht c nu c
nhi c (ra d dy, dng cht kh g c hiu).

- B mu, dch; nng huyt p: da vo p l t h ch trung tm (CVP), nu c


gim th tch th p l t h ch trung tm gim.

- Khi dch m huyt p t thu ha t trn 90mmHg th nng huyt


p bng dopamin pha vo huyt thanh ngt 5%, truy t h ch 5-10g/kg/ph.

. . Giai on ton pht:

+ Gy bi niu rt quan trng. Ch dng li tiu khi khng cn du hiu


mt c, huyt p tm thu trn 90 mmHg.

- Lasix 20 mg: ti t h ch 4 ng/ln, cch 4 gi tim 1 ln. Tu theo p ng


iu chnh liu, c th cho ti 24 ng/ngy, nu cho 2 ngy khng th p
ng th phi ngng.

- Manitol 20% x 100 ml, truy t h ch nhanh. Ch cn truyn 1 ln m khng


thy

p ng th phi ng g ga trnh hoi t ng th do t g thm thu.


Nu p g th l g c tiu 3 gi >120 ml (> 40 ml/gi, c t thng
g ua g thu c tiu); c th cho tip liu th hai.

+ iu chnh cn bng ni mi:


- Cn b g c nn gi mc m tnh nh t h t g hu t p gy ph phi
cp.

L g c vo (g , ung, truyn)/24gi = l + l g c
tiu trong 24gi.

Khi t g th tch khng iu chnh c bng ni khoa, c triu ch g e do


ph phi cp (huyt p t g, ran m phi, kh th, X quang c ph t chc k,
p l t h ch trung tm (CVP) > 12 cmH2 O, p lc phi bt >20 mmHg) th
phi ch nh lc mu bng thn nhn to.

- Hn ch t g kali u:

Khng dng cc thuc, dch truyn, th hiu kali; loi b cc hoi t,


cc nhim khun. Nu c ch u ng tiu ho, cn loi nhanh mu trong
ng tiu ha ra...

Nu kali mu < 6 mmol/l th ch c iu chnh bng ch .

Nu kali mu t n 6,5 mmol/l th phi dng thu lm gim n g kali


mu:

. Glu oza u t g % hoc 30% + insulin (c 3- g g ho i suli


nhanh) truy t h h, lng glucoza phi dng ti thiu 50 - 100g. Insulin c
tc dng chuyn kali t ngoi bo vo trong ni o, do l gim kali mu.
Cn loi tr b h Addiso t c khi dng insulin, v c th gy h ng huyt
ti mc nguy him (bnh nhn b b h Addiso thng c tnh trng h ng
huyt m t h t g hy cm vi insulin).

Khng nn dng loi dung d h glu oza u u t g -50%), v khi truy t h


mch s g u t g dch ngoi bo nhanh, lm mt c t o, do kali s
t trong t bo ra ngoi o l t g t kali mu gy nguy hi t c khi kali
mu gim.

. Bicacbonat 8,4%, dng 50ml cho mi l , ti t h ch; nn ch t h ch


l truyn; cn thn trng v c th gy qu ti natri. Thuc gy kim ho mu,
c tc dng chuyn kali t ngoi bo vo trong ni bo.
. Canxi gluconat hoc canxi clorua 0,5 x 1 g ti t h ch chm trong 2 pht,
c th nhc li sau 5 pht di s gi s t in tim trn monitoring. Canxi c tc
d g i khng vi tc dng ca t g kali u l ti . Chng ch nh tim canxi
khi b h h a g d g digitalis.

. Cht nha eso iu t ao i ion: cht ny l cc ht nha gn natri. Khi ung


vo rut, chng nh natri v gn vi kali khng hi ph , sau o
thi theo phn ra ngoi lm gim hp thu kali t rut. Thuc ca Php c bit
dc l kayexalat: cho ung 20 - 30 g/24gi, chia 2-3 ln,

Nu kali mu > 6,5 mmol/l, ho kali u t g g bi i i ti giai on


3, 4 th phi ch nh lc mu bng thn nhn to hoc lc mng bng cp cu.

+ Huyt p phi h gi tc kh iu chnh ngay:

- Huyt p gim phi b d h, in gii, mu; dng thuc vn m h nhanh


chng nng huyt p tm thu ln 100-120 mmHg.

- Huyt p ao thng do qu ti th tch, c iu tr tch c phng ph


phi cp.

+ Hn ch u u t g:

- Ch : u g p calo t 35-40 kcalo/kg/ngy bng glucoza v lipit.

- Gim protein: cho kh g u , g p otei /kg ng/24gi; ho vitamin.

- Cho vin ketosteril: 1vin/5kg cn nng/ngy chia lm 3- 4 ln / ngy.

-L t g g ho m c th cho cc thuc: nerobon, durabolin, testosteron.

+ Chng nhim khun, chng lot :

Ch kh g d g kh g si h c cho th . Kh g si h t c nht cho thn l


h -lactam (penicilin, amoxixilin...) nhm erythromycin; cn nhm
aminoglycozit (streptomycin, kanamycin, gentamycin...) th rt c vi thn.
+ iu tr nhim toan chuyn ho:

Khi nng bicacbonat trong mu >16 mmol/l th ha cn iu tr,

Khi bicacbonat < 16 mmol/l ho pH u , l iu hin c nhim toan nng


cn phi iu tr.

Lng kim c a o th t h to h sau:

Kim thiu (mmol/l) = (25 - [HCO3 -] ) x 0,2 x kg; Hoc kim thiu (mmol/l) = BE
x 0,2 x kg.

[HCO3 ] l n g bicacbonat trong mu bnh nhn; kg: l cn nng ca bnh


h ; BE ase e ess : l lng kim tha hoc thiu ca bnh nhn o
b g ASTRUP h thng = 2).

Ta c cc loi dung dch kim sau:

Bicacbonat 1,4% c 0,16 mmol kim/1ml.

Bicacbonat 4,2% c 0,5 mmol kim/1ml.

Bicacbonat 8,4% c 1,0 mmol kim/1ml.

Lactat natri 11% c 1 mmol kim/1 ml.

Cn thn trng khi dng dung dch ki , a th t lng at i o th


v gy gim canxi mu. Khi cn hn ch c th nn chn loi c.

+ Ch nh lc mu khi bnh nhn c 1 trong cc triu chng sau:

- Kali mu > 6,5 mmol/l.

- Ur mu > 30 mmol/l.

- pH mu < 7,2.

- Qu ti th t h g e do ph phi cp vi biu hin: huyt p t g cao, ph,


kh th, phi c nhiu ran m, X quang c ph t chc k; p l t h ch trung
tm > 12 cmH2O; p lc phi t > Hg; c bit ch nhng bnh nhn
c t th g phi.

Cc ch s t t g g ha h th cng cn ch nh lc mu sm.

. . Giai o i t li v hi phc:

+ Giai on ny ch yu l c-in gii bng truy t h ch cc dung


d h g t g: glu oza %, at i lo ua , %, i ge la tat.

+ Vn phi hn ch t g kali u tng ur mu bng ch thuc.

+ Khi n g ur mu v h thng th phi ho m v vitamin.

+ Tip t iu tr bnh chnh v cc bin chng khc.

+ Th d c lc cu thn v ch g ng thn h gi hi
phc ch g thn sau mt vi thng.

8. Tin lng.

Ngi ta kh a a c mt ti lng chung cho cc bnh nhn b suy thn


cp v ph thuc vo nguyn nhn bnh; m t th g nh hc; mc
v thi gian thiu niu hoc v niu; ph g ph p iu tr; cc bin chng.
Theo Ha u ge , khi ha thn nhn to th t l t vong chim 71% s bnh
nhn suy thn cp; t khi c thn nhn to th t l t vong ch cn 10,5% s bnh
h . Ti lng m nng ca suy thn cp c th da vo:

+ Nhng nguyn nhn c t l t vong cao: phu thut ln, ch th g, ng


rng v su, vim tu cp, nhim khun huyt...

+ Thi gian v niu v t tin trin ca cc triu chng suy thn cp l mt


yu t gi p ho ti lng: v niu ko di; t t g u , t g eatinin mu
ha h th ti lng xu.

+ Cc bin chng: nu c bin chng th lm xu th ti l g h him


khun th ph t, t g kali u, ph phi cp...).
+ Ti lng cn ph thuc vo chn o sm hay mu , ph g ph p iu tr
h s g hay sai.

52.SUY THN CP- BSK

. h gha: Su thn cp l mt tnh trng ch g thn b suy sp nhanh


chng do nhiu nguyn nhn cp tnh gy nn. Bnh nhn thiu niu, v niu,
it phi p otei u t g dn, ri lo , in gii v th g ng toan
kim. T l t vong cao. Tuy nhin nu iu tr kp thi v chnh xc th nhiu
t ng hp ch g thn c th hi phc hon ton hoc gn hon ton.

. Ngu h v h bnh sinh

2.1. Nguyn nhn

Nguyn nhn gy suy thn cp rt nhiu, chia l h t c thn, ti thn


hoc sau thn.

. . Ngu h t c thn

L nhm nguyn nhn gy suy thn cp ch g

- Sc: gim th tch (mt c, mt mu), sc tim, sc nhim khun, sc qu


m .

- Cc nguyn nhn c th gy gim khi lng tun ho kh h: hi chng


th h, ga , thiu dng.... gy gi p otid u c bit l albumin mu
trm trng.

2.1.2. Nguyn nhn ti thn

Cc bnh l cu thn cp: Ch chim khong 3 12% bnh nhn suy thn cp

- Bnh cu thn nguyn pht: Suy thn cp c th l bin chng ca vim cu


thn cp sau nhim lin cu.
- Bnh cu thn th pht: Vim cu thn lupus trong nh g t tin trin cp
tnh, hi chng Goodpasture, Scholein Henoch c t th g thn.

Cc bnh ng k thn cp tnh: chim ti 58 n 65% bnh nhn suy thn cp.

- Cc nguyn nhn gy vim ng k thn cp tnh (cn gi l hoi t ng thn cp).

+ Nhi c:

. Tetrachlorua carbon

. Glycol ...

. Mt c trm

. Thu a

+ Thuc

. Khng sinh: Aminosid, cephalosporin, cyclosporin A....

. Cc thuc khc: chng vim gi au No -Steroid (glafenin, paracetamol....),


lithium, li tiu nhm thiazid, cc thuc ch g u g th, thuc cn quang c
iod...

+ Tan mu cp tnh

. Truyn nhm nhm mu ABO.

. Nhim virus, st rt c tnh...

. Mt s thuc gy tan mu: quinin, rifampycin, AINS, analgesic...

+ Tiu p tnh

. Ch th g .

. Thiu u

. Hn m ko di, co git

. Nghin heroin, lm dng thuc ch g ng kinh....


+ Cc tnh trng s : l u l suy thn cp ch ng, sau c th d n hoi
t ng thn cp.

. Sc gim th tch

. Sc tim

. Sc nhim khun....

- Cc nguyn nhn gy vim k thn cp tnh:

+ Nguyn nhn nhim trng

. Th g ua ng mu: nhim trng huyt, leptospirose, salmonellose.

. Ho theo g gc dng: vim thn b thn cp

+ Ngu h th g ua h min dch d ng

. Khng sinh: blactamin, cephalosporin, rifampicin, sulffamid...

. Cc thuc khc: AINS, analgesic, li tiu thiazid, thuc chng co git, allopurinol,
cimetidine...

+ Nguyn nhn do ri lon chuy ho : T g a id u i u

+ Cc nguyn nhn khc: myelome, lymphomes....

Cc bnh l mch mu c t th g thn

- Vi t ua h ng mch

- Vim mch d ng

- Cryoglobulin

- Wegener

- Takayasu

- Ch th g thn
- Tc mch thn...

2.1.3. Cc nguyn nhn sau thn

L cc nguyn nhn gy tc ngh ng bi niu

- Si b thn niu qun

- U chn p, t ng bi niu

- Ngu h do i , h t hp: lao thn- tit niu, giang mai

- X ho sau ph c.....

. . C h bnh sinh

Suy thn cp do nhiu nguyn nhn, cho nn kh c th a a t h bnh


si h thun.

C th tm tt gu h h sinh b h theo s sau:


Ni chung c th c 5 yu t h h gg p o h b h si h h sau:

- Khuch tn tr li ca dch lc cu th khi i ua ng thn do mng t bo ng


thn b hu hoi.

- Tc ng thn do xc t bo, do sc t, hoc cc sn phm protein

- T g p lc t chc k ca thn do ph n.

- Gim st dng mu hiu dng v thn d n gim mc lc cu thn mt


cch cp tnh

- Tha i tnh thm ca g ao un cu thn

Tt c nhng yu t u gp phn t nhiu d n v niu. Yu t no chnh,


yu t no ph l tu theo nguyn nhn v din bin ca qu trnh bnh l.

3. Lm sng v cn lm sng

Suy thn cp thng tri ua giai on:

- Giai on khi u

- Giai o i t, iu

- Giai o i t li

- Giai on hi phc

Cc triu chng lm sng v cn lm sng tu thuc vo t g giai on ca bnh.

. . Giai on khi u

L giai on tn cng ca tc nhn gy bnh, din bin tu theo tng nguyn


nhn. bnh nhn ng c th din bin nhanh, c th dn ti v niu ngay.
bnh nhn sc th din bin nhanh, chm tu theo nguyn nhn gy sc v k
thut hi s a u.
3. . Giai o i t, v iu

V niu c th din bin t t, b h h i t dn ri v niu, h g iu


g th x a t ngt, nht l t o g t ng hp ng c hoc nguyn nhn
gii. i t, iu c th ko di 1-2 ngy, c khi 3-4 tun, trung bnh 7-12
g . i t, iu gy ra nhng triu chng sau:

L g c tiu < 500 ml/24h. Nhiu t ng hp v niu ho to c tiu <


100ml/24h ).

Ri lo in gii:

- Ph : do i t iu v ph thu o l g c tiu a o. C th d n
ph phi cp, ph no.

- K+ u t g d : thng l nguyn nhn gy t vong. K+ mu cao gy nn


nhng hu qu sau:

+ Triu chng tim mch: l hu qu nguy him nht. K+ mu cao gy nn nhng


ri lon v dn truy t g t g lc. Biu hin lm sng c th l nhp chm,
lon nhp, ng g ti . T i t thy sng T cao, nh , i xng, c th
phi hp vi PQ ko di, QRS gin rng, ST chnh ln hoc chnh xung.

+ Triu chng th ki h : th thy yu, lit .

+ Khi K+ mu 6,5 mmol/l l mt cp cu ni khoa, c iu tr tch cc v


lc mu cp.

- Na+ mu v Ca++ u thng gim hoc c th h th g do ht v b pha


long..

Nit phi p otei u t g ao dn

-U e u t g dn

- C eati i u t g dn
- Acid uri u t g dn

Khi t t g u , eati i u g ha h th ti lng cng nng. Ur mu


t g ph thuc vo m v niu, ph thuc ch hiu hay t protid, ph
thuc vo ging ho nhanh hay chm ca chuyn ho protein. Creatinin, sn
phm ging ho cui cng ca Creatin ( c ch yu t o g kh g ph thuc ch
, phn nh ch g th h h h u e. Khi u u t g >
mmol/l/ngy ho eati i t g > m ol/l/ g th ti lng rt xu, t l t
vong cao.

Toan mu: l khng th trnh khi do tch t cc acid c nh. Bicarbonat s


gim t 1- 2 mmol/24gi. N c toan mu nng, Bicarbonat < 20 mmol/l, pH
u g gim l mt trong nhng tiu chun ca lc mu.

Cc triu chng khc:

- Cao huyt p thng m va.

- Cc biu hin tim mch, h hp, thn kinh, tiu ho...... ca hi chng ur mu
cao.

- Nc tiu c protein niu, hng cu niu, bch cu niu, tr niu tu theo tng
t ng hp. T tr g c tiu thp tr t ng hp suy thn cp ch g.

3.3. Giai o i t li

L g c tiu t g d , t ti trn 2 lt mi g . t ng hp i -5
lt/ngy ho h . i hiu ph thuc vo nguyn nhn gy bnh v ph thuc
o l g a o t o g giai o i t. Ngu h h a giai on ny l:

- Mt c

- Mt in gii ( K+ mu h, Na+ mu h).


- V gu u , eati i u t g giai o u ca thi k i t li.
Sau 3- g i hiu, ur, creatinin mu gim dn. Ch g thn dn hi
phc.

Thi gia i hiu trung bnh khong mt tun l, sau l g c tiu gim
dn tr v h thng. Tuy nhin nhiu t ng hp, sang thng th hai k t
g i t li c tiu vn trn 2 lt/24 gi.

. . Giai on hi phc

Khi l g c tiu dn tr v h thng.

Cc ri lon v sinh ho dn tr v h thng: Ur, creatinin mu gim dn;


Ur, creatinin niu t g dn; lm sng tt ln.

Tuy nhin kh g c tiu ca ng th khi h g i hi phc


hon ton. mc lc cu thn hi ph ha h h , thng sang thng th hai
c th h th g, t ng hp n g th g c 30- 40 ml/pht. S hi phc
nhanh, chm tu thuc vo tng nguyn nhn, vo tnh tr g a u, ch
iu tr v cng tc h l i vi bnh nhn.

4. ch o

4.1. Ch o nh:

Da vo:

C nguyn nhn cp tnh: ung mt c trm, ng c kim loi nng, a chy mt


c, vim cu thn cp....

Xut hin:

- Thiu niu, v niu t ngt

- Nit phi p otei u t g dn


- K+ u t g dn

- Toan mu chuyn ho

- din bi ua giai on ( xem phn 3)

4.2. Ch o ph it:

Ch yu phn bit suy thn cp vi t cp ca suy thn mn.

suy thn mn:

- tin s c bnh thn, tit niu.

- Thiu u t g ng vi m suy thn.

- Cao huyt p, su ti : thng n g h t nh nhn suy thn mn.

- Siu m c th thy hai thn teo nh.

4.3. Ch o th bnh

4.3.1. Suy thn cp ch g

Cn gi l suy tht cp t c thn, v nguyn nhn l do gim th tch tun hon,


tt huyt p.

Ch o n da vo bnh s c ri lon huyt ng h t mu sau phu


thut, mt c do a chy ho i hiu, sc tim...

- Huyt p tt, mch nhanh, nh, du chi l h, hi da gim, mt t g, t


hc hc.

- Natri niu thp, kali niu ao h at i, thm thu v t tr g c tiu cao


hoc bnh thng.

- Nu khng cha tr kp thi s chuyn thnh suy thn cp thc tn, tc l hoi
t ng thp cp thng sau 72 gi tr ln).
4.3.2. Suy tht cp thc tn:

Cn gi l suy thn cp ti thn. Thn b t th g thc th c th do:

- Hot t ng thn cp (sc, ng c...)

- Vim cu thn cp, t cp ca vim cu thn mn.

- Nhi mu thn...

4.3.3. Suy thn cp do gii: Cn gi l suy thn cp sau thn, c th do:

- Si

-U

- Cht hp

- Tht nhm niu qun khi m...

4.4. Ch o gu h e phn nguyn nhn)

. Ti lng:

T nh g a , ti l g hiu tha i tt h , h c s
g g p a cc k thut hi sc hi i. Tuy nhin t l t vong cn cao.

nhng trung tm c lc mu bng thn nhn to hoc lc mng bng, t l t


vong vn cn 20-40%, tu theo tng nhm b h h . i vi nhng bnh nhn
suy thn cp sau m ln, ch th g ng, bng nng, nhim trng t cung sau
hoc can thip, ng c kim loi n g, ti lng rt nng.

Nguyn nhn gy t vong c th do bnh chnh, do nhim khun, hi chng Ur


mu cao, K+ mu cao.

Ti lng ph thuc vo bnh chnh, ph thuc vo k thut hi s . Ti lng


cn ph thuc vo cng tc h l v cc bi ph p phng bi nhim, nht l
bi nhim phi v nhim khun t cc vt th g, t lot.
6. X tr

6.1. Nguyn tc chung:

- Nhanh chng loi b cc nguyn nhn suy thn cp c th iu tr c (nng


huyt p trong sc, loi b cht c bng ra d dy trong 6 gi u...)

- Tp t u g ph g tin cha tr cho ph hp vi t g giai on v tng nguyn


nhn ca bnh, lc mu ngoi thn khi cn thit.

- Ch gt iu dng v chng nhim khun.

. . iu tr c th: Tu theo t g giai on ca bnh.

. . . Giai o u:

Cn loi b tc nhn gy suy thn cp: b dch, b mu, loi b cht c, m ly


si niu qun...

. . . Giai o i t iu

M h n ca iu tr t o g giai on ny l:

- Gi cn bng ni mi

- Hn ch t g K+ mu.

- Hn ch t g Nit phi p oti u

Nc:

bnh nhn v niu c ph m bo cn b g , gha l o t h a. Thng


ch cho 500ml mi ngy k c ung. Ma h c th cho nhiu h . Mun cho
thm cn tnh ton cn th . Ch t ng hp v niu do mt c, mt mui
th phi b dch.

Trong tnh ton, c lu l g c mt do nn, a chy. Phi t h lng


c sinh ra do chuyn ho (vo khong 300ml mi g . L g c mt qua
m h i, hi th khong 600ml/24gi. St cao hoc ma h c th mt nhiu h .
iu gii v toan mu:

- iu tr t g K+ mu:

. Hn ch a K+ vo: Rau qu nhiu K+, thuc, dch truyn c K+ .

. Loi b cc hoi t, chng nhim khun.

. Li tiu: Nh o thi in gii, c bit l K+ :

Ch nh khi khng c nguyn nhn tc nghn sau thn.

Liu dng: d liu. C th cho 200 - 500mg/24 gi ho h tu vo m p


ng bi niu. Liu khi u thng l 40 - 80mg, liu cao l 1000mg/24 gi c th
c ch nh.

. Truyn Natribicarbonat:

Khi c mt l g c tiu nht nh (VD: 300- 500ml/24gi), th vic truyn dch


s d dng h . th truyn Natribicarbonat 14%0 hoc 4,2%; ho ti t h
mch Natribicarbonat 8,4% nu mun hn ch l g a o. B
Natribicarbonat gip ci thin tnh tr g toa u, ua K+ kh g i t trong t
bo ra ngoi t bo.

. Truy Glu za u t g pha i suli h a t K+ t ngoi t bo vo


trong t bo.

. Cho Cal i ti t h h g hn ch c h hng ca K+ mu cao.

. C th d g Resi t ao i ion (30g/24 gi ko Kali mu ra qua nim mc


rut. Cc thu thng dng: Resonium A, Kayexalat.

. Nu K+ mu 6,5mmol/l th cn ch nh lc mu ngoi thn.

- iu tr cc ri lo in gii khc:

. Natri v clo: Natri mu h do c. Tt nht l hn ch c. Khi Natri mu h


nhiu, bnh nhn c bun nn, cn phi b Natri.
. Calci mu: t khi c h calci mu. Nu c xut hin Tetani do Calci mu thp th
cho Calci gluconat hoc Calci clorua.

- Hn ch t g Nit phi p otei u; h yu hn ch t g U u:

. Ch : Gi m 0,4g/kg/24 gi, calo t nht 35 kcalo/kg trng l g


th, vitamin.

. B sung thm vin Ketosteril: c mi vin 600mg/5kg tr g l g th.

. Loi b cc nhim khun.

. Ch nh lc mu: Nn ch nh lc mu sm, c th chy thn nhn to hoc lc


mng bng:

+ Khi K+ mu 6,0 mmol/l.

+ Khi Ure mu > 35 mmol/l.

+ Khi Creatimin mu > 600mmol/l

+ C biu hin toan mu.

+ Lm sng vn thiu niu, v niu.

6.2.3. X t t o g giai o i t li:

giai o , tu i hiu h g h g th ha hi phc. Nhng ngy


u i hiu Ure Creatimin v t g, ng thi i hiu c th gy mt
c, mt in gii. iu tr nhm:

- Tip tc hn ch Protid trong th , h t g P otid khi U u gim ti


mc an ton (<10mmol/l). Ch cho hoa qu khi kh g gu t g Kali u.

- Truyn dch hoc u g chng mt c v mt in gii. Trong nh g t ng


hp i hiu va phi, ch cn b bng ung Orezol (2-2,5/24gi . Khi c tiu
>3lt, nn b b g ng truy t h h. Lng truyn tu theo l g c
tiu. Tuy nhin nu sau 5- g i hiu nn th hn ch lng dch truyn v
theo di tnh trng b h h l g c tiu 24 gi th i b dch
thch hp v th th bt u hi phc ch g c.

- C theo d i s t in gii u, c bit l Na+ v K+ mu.

6.2.4. X t t o g giai on hi phc sc kho:

- Sc kho bnh nhn hi phc dn. Khi Ur mu tr v h thng th c t g


dn Protid trong khu ph m bo calo v vitamin.

- C h gt h s iu dng ngay t u chng lot, chng


bi nhim do nm lu. Trung bnh sau 4 tu iu tr th ch g thn bt u
hi phc tt v bnh nhn c th xut vin.

Theo d i nh k h g th g ho n khi ch g thn hi ph ho to . i


vi cc bnh l c th tr thnh mn tnh (bnh cu thn, bnh l k thn do
thuc hay do nhim trng) c kh nh k cho bnh nhn lu di.

- Tip t iu tr nguyn nhn nu c: Nguyn nhn tc nghn, cc bnh ton


th: Lupus, myelome...

TI LIU THAM KHO

1.Ti liu pht tay

2.Bnh hc ni khoa tp 1. Nh xut bn y hc.2002

.iu tr hc ni khoa tp 1. Nh xut bn y hc.2001

53.SUY THN MN TNH

Suy thn mn l hu qu ca cc bnh thn, tit niu mn tnh gy gim st t


t s lng nephron ch g l gim dn mc lc cu thn .

I. i g :
Khi mc lc cu thn gim xu g di 50% (60ml/pht) so vi m h thng
l/ph t th c coi l suy thn mn . Th kh g kh g du t
tt cn bng ca ni mi v s d n hng lot nhng bin lon v sinh ho v
lm sng ca ua t o g th. Suy thn m g g a in lon v
ch g i tit ca thn: thiu Erythropoietin gy thiu mu, thiu 1,25
dihydroxycalciferol D3 d n gim ti hp thu Ca++ rut v gim Na+ mu,
t g tit e i g t g huyt p ...

Suy thn mn l mt hi chng din bin theo t g giai on ca bnh, t ch


ch c mt s triu ch g k o t o g giai o u khi mc lc cu thn cn
40- l/ph t ho n nhng biu hin rm r ca hi chng ur mu cao trong
giai on cui khi mc lc cu thn ch cn < 5 ml/pht. Qu trnh c th ko di
t nhiu th g n nhiu .

II. Nguyn nhn gy bnh:

1. Bnh cu thn mn :

Thng gp nht chim t l khong 40% .

Do vim cu thn cp d n .

Do vim cu thn c hi chng th h .

Do vim cu thn th pht : Sau b h lupus a h th g , i th o ng ,


Schnlein-Henoch ...

2. Bnh vim thn , b thn mn tnh :

Chim t l khong 30% do nhi t g gc dng , c hoc khng c nguyn


nhn thun li (si , ph i lnh tnh tuyn tin lit...).

3. Bnh vim thn k :

Thng do dng thuc gi au h g i l u d i h phe l utazo , asp i


... ho do t g a id u i u , t g Ca++ u .
4. Bnh mch thn :

X ch th l h t h do t g hu t p).

X ch th t h do t g hu t p c tnh).

Huyt khi vi mch thn .

Vi t ua h ng mch .

T t h ch thn .

Tc hp ng mch thn .

5. Bnh thn bm sinh, di truyn :

Th a a g

Lon sn thn

Hi chng Aport (vim cu thn k theo ic)

Bnh thn chuyn ha (Cystino , Oxalo)

III. Triu chng lm sng v cn lm sng :

A. Lm sng :

1. Ph :

L triu ch g thng gp ca suy thn mn. Bnh cu th ph thng xut


hin sm ngay c khi ha su thn. Bnh vim thn b thn m thng
khng c ph, th h i hiu thm ch gy mt c do t th g ng
k thn h h g n ch g c ca thn . Tuy nhin giai on nng
ca suy thn, vim thn b thn vn c th c ph do mc lc cu thn suy gim
nng.

2. Thiu mu :
Thng gp, nng nh tu theo giai on suy thn. Suy thn cng nng thiu mu
cng r. suy th giai on cui giai o III giai on IV) hng cu thng
< 2,5 T/1 , Hb < 70 g/l .

St huyt tha h i hu g l h thng hoc thiu nh thng l thiu


u ng sc. Thiu u thng l kh hi phc do thn khng sn xut
Erythropoietin, yu t cn thit bit ho tin hng cu .

. T g hu t p :

T g hu t p l thng gp, khong 80% b h h t g hu t p giai on


suy thn III, IV. C bit c b h h t g hu t p c tnh lm ch g thn
suy gim nhanh chng.

4. Suy tim :

Thng xut hin giai on mun ca suy thn mn. Suy tim l hu qu ca
t g hu t p , gi mui c v thiu mu lu ngy.

5. Ri lon nhp tim: c th do Kali mu cao .

6. Vim ngoi tm mc :

Ting c mng ngoi tim l biu hin nng ca hi chng ur mu cao bo hiu t
vong nu kh g iu tr tch cc.

7. Nn, a chy :

Triu chng tiu ho ca suy thn m giai o u th g l h . giai


on III tr i th un nn, a chy. Phn c th km theo nhy hoc mu .

8. H hp :

C th thy th nhanh su hoc ri lon nhp th do tnh trng toan ha mu


suy thn m giai on cui. Khm phi khng thy c t th g.

9. Xut huyt :
Xut huyt l thng gp bnh nhn suy thn mn mu . Ngu h thng
do gi tp trung v kt dnh ca tiu cu. i khi g th gy xut huyt
tiu ha n g th u u t g ha h.

10. Nga :

L mt biu hin ngoi da thng gp, do l g g Ca++ t o g da . l t iu


chng ca ng cn gip th pht.

11. Chut rt :

Thng xut hi a th do gim Ca++ v Na+ mu.

12. Vim thn kinh ngoi vi :

T dn truyn thn kinh ngoi vi gim. Bnh nhn c cm gic rt bng, kin
b. Cc triu ch g th g l kh iu tr k c lc mu ngoi thn.

13. Hn m :

Hn m do ur mu cao l biu hin lm sng nng nht ca suy thn mn. Bnh
nhn c th co git, ri lon tm thn giai on tin hn m.

B. Cn lm sng :

1. Mc lc cu thn gim (<60ml/pht):

Cng gim nhiu, m suy thn cng nng.

. Nit phi p otei u t g ao :

U u> ol/l, > ol/l l t g .

C eati i u t g ao > mmol/l, >130 m ol/l l t g .

A id u i u t g.
Ur mu ph thuc vo ch u t h gi g h a a th (nhim
khun, xut huyt). Nu a o u hiu p otei t g u t h gi g h a ,
ur mu s t g ha h .

U u eati i u t g so g so g l iu hin ca suy th thun.


U u t g hiu, eati i t g t l iu hin ur ngoi thn.

. in gii mu :

Na+ u thng gi do ht, li tiu v ph .

K+ mu c th h thng ho t g . K+ u t g thng l biu hin ca mt


t cp (c thiu niu, v niu) ca suy thn mn hoc suy th giai on cui.

4. pH mu gim :

suy th giai on III, IV d tr kim gim, pH mu gim .

5. Calci mu gim :

Khi Ca++ u t g th l u hiu ca ng cn gip trng.

6. Hng cu, hematocrit, huyt sc t gim:

Suy thn cng nng hng cu v huyt sc t cng gim r.

7. Protein niu:

Protein niu bao gi g . Nu l bnh cu thn, protein niu thng r


khong 2-3 g/24h. vim thn b thn mn, protein niu thng ch t di 1
g/24h.

8. Hng cu niu :

Vim cu thn m th g i u i th. Nu i u i th gh


n bnh l tit niu (si, u, nhim trng).

9. Bch cu niu v vi khun niu :

Gp bnh nhn vim thn b thn m t cp .


10. Tr niu :

C tr ht, tr trong kch thc ln l du hiu ca suy thn mn.

11. ur, creatinin niu :

Cng suy thn, ur, creatinin niu cng thp.

12. Siu m thn :

Hai th thng teo nh khi c suy thn mn r. Teo nh u ha kh g u tu


theo tng nguyn nhn .

IV. Ch o :

1. Ch o nh da vo :

C tin s bnh thn, tit niu mn tnh: vim cu thn cp mn , vim cu


thn c hi chng th h , i thn b thn mn, th a a g...

Ph

Huyt p cao

Thiu mu

Protein niu

U , eati i , a id u i u t g cao, mc lc cu thn gim (<60 ml/pht).

Siu m thn: hai th thng teo nh, teo u ha kh g u tu tng nguyn


nhn.

2. Ch o giai on :

Chia giai on :

suy MLCT Ur Creatinin Lm sng


thn (ml/ph)
(mmol/l) (mmol/l)

I 60-40 <8 <130

II 40-20 8-16 130-299 t triu chng

IIIa 20-10 16-24 300-499 HA t g, thiu mu va ,


HC <3,0T/l

HA t g, thiu mu r, c
tr/c ca hi chng ur
IIIb 10-5 24-30 499-900
mu cao

HC:2,5-3,0T/l

IV <5 >30 >900 Nhiu triu chng, HA


t g , thiu mu nng ,
HC <2,5T/l, c nhiu tr/c
ca hi chng ur mu
cao

3. Ch o ph it :

- Vi suy thn cp :

C nguyn nhn cp: ng c, shock...

ur, creatinin, K+ u t g ha h

Sau mt thi gian ch g thn hi phc .

- t cp ca suy thn mn:

T s mt suy thn m gu h th y nng ln: mt

c, nhi c thn (do thuc khng sinh, thuc c ch min dch...

Thiu niu , v niu , suy th t g ha h.


Thiu u kh g i i i m suy thn (thiu mu nh trong khi m
suy thn n g h .

T l ur mu/creatinin mu >40.

V. iu tr suy thn mn :

Bn c h iu tr gu h iu tr si , nhi t g ng niu, i th o
ng, lupus...) cn c ch iu tr thch hp suy thn mn theo tng giai
on suy thn bao gm :

iu tr bo tn:

Suy th giai o I giai on III b .

iu tr thay th:

Khi suy thn cui giai o III giai o IV. iu tr thay th c th bng
bin php lc mu chu k (thn nhn to, lc mng bng) hoc ghp thn.

* iu tr bo tn.

1. Chng cc yu t gy nng bnh g t cp suy thn mn):

- Khc phc tnh trng gim khi lng tun hon nu c: b dch, mu.

- Khng dng cc thuc, ho cht c cho th kh g si h c cho thn, thuc


nam...)

-T iu tr cc nguyn nhn gy t ng niu( si, ph i lnh tnh tin


lit tuyn...).

- iu tr chng nhim khun nu c.

2. Ch UGG:

L ch gi g l g, vitamin v cc yu t i lng. (Xem


bi ch .

3. iu tr cao huyt p:
Huyt p ao th ha h u t h ho un mao mch cu th . iu tr
cao huyt p sm v duy tr lu di huyt p nh lm gim t suy thn
bao gm:

- ht: lng mui t: 2-4 g/ 24h.

- Li tiu: furosemid vn l li tiu c la chn bnh nhn suy thn mn c


t g hu t p. Liu lng li tiu tu theo tng bnh nhn( lasix 40 mg 2-8
vin/24 ho h duy tr khi l g c tiu thi natri.

- Cc nhm h p u d g c. Khi c suy thn nng cn ch nhm thuc c


ch men chuy gu l t g kali u eati i u. Khi su ti
cn thn trng vi nhm chn b giao cm. Liu thuc dng tu t g t ng hp
nhm m h t c con s huyt p h thng, nh.

V d: Amlor 5mg 1-2 vin/ 24h chia 2 ln.

Logimax 5/50 1-2 vin/ 24h.

Renitec 5mg 1-2 vin/ 24h.

C th phi hp -3 loi thuc h p nu ha t c hiu qu h p h


mong mun.

. iu tr ri lo , in gii:

Ph:

- Ch ht, hn ch khi l g a o.

- Li tiu: ch yu l nhm furosemid. Liu lng tu theo tng bnh nhn, t


liu thp 40 g n liu cao 1000mg/24h. M h l h t lng
c tiu/ h h o g u . Thng mi ngy l i kho g kg c tha
l hp l.

T g K+ mu.
Thng l kt qu ca thiu niu, v niu giai on suy thn mn nng. K+ mu
t g h hoc trung bnh( < 6,5 mmol/l) c th iu tr ni khoa. K+ mu > 6,5
mmol/ l l mt trong nhng ch nh lc mu cp.

iu tr ni khoa t g kali mu bao gm:

- Hn ch lng kali vo do th a , hui, hoa qa nhiu kali...) Li tiu


nh gi p o thi kali a c tiu.

-D g esi t ao i kali.

- Resonium A, Kayesalat... c th gp kali i.

- Calci clorua 0,5 g 1-2 ng (t/m) g g p phn hn ch tc dng ca K+ t


tim.

-Truy t h ch natribicacbonat 1,4% ho ti t h ch natribicacbonat


, % gi p iu chnh tnh tr g toa u, g ho kali khi i t trong t bo ra
khu vc ngoi t bo.

- Truy glu ose u t g ho i suli gi p kali i t khu vc ngoi t bo vo


trong t bo.

- Khi kali mu > 6,5 mmol/l cn ch nh lc mu cp. Ch nh lc mu sm c th


mc K+ > 6.0 mmol/ l.

H natri mu.

C th gy nn, tt huyt p, c c b bng ch n, truyn natri


clorua o,9% hoc tim t h ch natri clorua 10% 2ml, mi ln t 1-4 ng (t/m).
T o g t ng hp h natri mu n g < ol/ l, e do tru m h, kh iu
chnh v ni khoa c th ch nh thn nhn to cp.

. iu ch h th g ng toan, kim:

Suy th giai on III, IV c th d n tnh trng toan mu chuyn ho. C th


iu chnh bng truy t h ch natribicacbonat 1,4% ho ti t h ch
natribicacbonat 8,4%. Khi d tr kim gim < 20 mmol/l th bt buc phi b. T
20-25 mmol/l l ch h t g i b natribicacbonat.

. iu tr thiu mu:

- C th truyn hng cu khi khi thiu mu nng.

- Tim Erythropoietin l bi ph p iu tr tt nht v hiu qu nht iu tr


thiu mu trong suy thn m . T c khi cho erythropoietin c m bo st,
axit folic, vitamin B12 l cc nguyn liu cn thit cho to hng cu.

- Liu tn cng erythropoietin:

-3 ln/tu ti di da ho t h ch, tu thuc vo m thiu


mu.

- M h t c l duy tr Hemoglobin t 90-110g/lt.

. iu tr ri lon calci, phospho mu:

- Cho thm calci khi suy thn mc cui II.

- suy th cui IIIa tr ln (creatinin > 400-500 mmol/l) cn xt cho thm


1,25 dihydrocalciferon D3 gip hp thu calci rut.

- Hn ch th hiu phospho, c th dng thuc nhm h phospho mu khi


cn thit.

8. Cc thuc v bi ph p iu tr khc:

- Cho vin ketosteril (vin ketoanalogue) 600 mg x 8-12vin/24h, tu giai on suy


thn. suy th giai on trung bnh v nng liu dng l 1 vin 600 mg cho mi
5kg cn n g th. Vin ketosteril c cng thc ho hc gi g a it a i
b h g thiu h a i , khi o th, vin ketosteril s kh nhm amin
ca ur, to a a it a i n cn thit ho th, ng thi lm gim ur mu.

- iu tr chng nhim khu iu tr cc triu chng v bin chng khc nu


c.
*iu tr thay th:

Bao gm lc mu ngoi thn v ghp thn

8.1. Lc mu ngoi thn gm:

- Thn nhn to

- Lc mng bng

Ch nh v chng ch nh ca thn nhn to

- Ch nh sm: suy th giai on IIIb (MLCT 5- l/ ph t . Tu hi thng ch


nh cho bnh nhn suy thn cui giai on ny khi creatinin mu > 700mmol/l v
bt u c nhng du hiu lm sng r ca suy thn: bun nn v nn, tha
c....

- Ch nh bt buc: ch nh bt buc cho bnh nhn suy th giai on IV


(MLCT< 5ml/pht).

- Chng ch nh

Khng c chng ch nh tuyt i.

Chng ch h t g i khi:

- C gu h u t c hoc sau phu thut, th thut, ting c vim mng


ngoi tim....

- Ri lon huyt ng: suy tim nng, huyt p tt....

Trong nh g t ng hp ny cn khc phc bng:

- Chy thn nhn to vi liu Heparine ti thiu hoc khng c Heparin tu tng
t ng hp bnh nhn.

- Chy thn vi lu lng mu thp t o g t ng hp suy tim (t 200ml/


pht)
- Bi ph khi lng tun hon, nng huyt p bnh nhn c huyt p tt t c
khi tin hnh chy thn.

C th chn la ph g ph p lc mng bng nu thy thch hp h ho nh


h gu h u t, gu h h g n huyt ng t).

Ch nh v chng ch nh ca lc mng bng

- Ch nh: Suy thn m giai o III giai on IV

- Chng ch nh:

So m g ng

Vim phc mc

8.2. Ghp thn

- Ngi sng cho:

+ Cng huyt thng

+ Khng cng huyt thng

- Ngi cht cho: cn c ngn hng ph tng

54.SUY THN MN
(Bnh thn ni khoa. Nh xut bn y hc 2004)

I. NH NGHA

1. Suy thn:
Suy thn mn l gim mc lc cu th MLCT di m h thng. Suy
th c gi l mn tnh khi mc lc cu thn gi thng xuyn, c nh, c
li ua n s gim s lng nephron ch g.

Suy thn mn l mt hi chng lm sng v sinh ha tin trin mn tnh qua


nhiu th g, hu qu ca s h a eph o h g g gim st t
t mc lc cu thn d n tnh tr g t g it phi p otei u h u ,
creatinin mu, acid uric ...

t g a suy thn mn l:

- C tin s bnh thn tit niu ko di.

- Mc lc cu thn gim dn.

- Nit phi p otei u t g dn.

- Kt thc trong hi chng ur mu cao.

2. Mc lc cu thn (MLCT):

L l g c tiu u trong 1 pht (glomerular filtration rate - GPR), l ch s


cn v h gi suy thn mn.

Trong th h h l s g MLCT o g thi sch creatinin ni sinh


lea a e eati i . B h thng MLCT trung bnh bng 120 ml/pht hoc 2
ml/giy. Creatinin mu trung bnh l 1 mg/dl (0,8-1,2 mg/dl) tc l ol/l -
ol/l . Khi MLCT gim xu g di l/ph t, eati i u t g , g/dl
ho ol/l t ln, suy th . Nit phi p otei u ao gm ur, creatinin,
a id u i , t o g u hi % oi l i din ca nhm. Trong lm
sng c th s d g u u h gi m ti lng nng nh ca suy
th . h gi ti lng v c bi ph p iu tr thch hp cho tng thi k ,
cc nh thn hc chia suy th th h giai on ho t g ng vi s gim
MLCT tng creatinin mu.

Gi tr o da vo creatinin mu. Ch h iu tr v ch da vo
MLCT.
. Giai on suy thn:

Tin trin ca suy thn mn c th t 5- ho l u h t theo s gim


st t t s lng nephron ch g MLCT. C th chia suy thn mn thnh 4
giai on da vo mc lc cu thn:

- Suy thn nh giai on 1).

- Suy thn va giai on 2).

- Suy thn n g giai on 3).

- Suy th giai on cui giai on 4).

B g: C giai on suy thn (Phn loi m suy thn mn v ch h iu tr


theo Nguy V Xa g

M MLCT Creatinin mu Creatinin mu Ch h iu


suy thn (ml/pht) (mg/dl) ol/l tr

B h thng 120 0,8 - 1,2 70 - 130 Bo tn

Suy th I 60 - 41 < 1,5 < 130 Bo tn

Suy th II 40 - 21 1,5 - 3,4 130 - 299 Bo tn

Suy th IIIa 20 - 11 3,5 - 5,9 300 - 499 Bo tn

Suy th IIIb 10 - 5 6,0 - 10 500 - 900 Lc mu

Lc mu bt
Suy th IV <5 > 10 > 900 buc hoc
ghp thn

II. CHN ON
Suy thn m c pht hin qua khm nh k theo di bnh l thn tit
niu mn tnh, hay khi tm kim nguyn nhn thiu u, t g hu t p, tai bin
mch no xy ra.

1. Ch o nh: C hai c:

1.1. Ch o su thn: Da vo s suy gim MLCT (h s thanh thi creatinin


ni si h t g eati i u> ol/l.

1.2. Ch o t h ht mn tnh: Da vo mt s biu hin sau:

- Lm sng: C tin s bnh th , a da i c nht, c xut huyt


di da, t g hu t p.

- Xt nghim: gim calci mu r rt, thiu mu bnh s , i khi t iu chng thiu


mu b lu m (bnh th a a g .

- X quang: gi k h thc th u c 2 thn. UIV rt nguy hi t o g t ng


hp ny, ch gha khi ghi g c bnh l tit niu.

- Siu m: thy gi k h thc thn trong vim cu thn mn hoc nhu m thn
m g, gi i thn trong c thn do si.

mt s t ng hp khc th k h thc thn khng gi gc li t g l


(th a a g, t thn, thn , i th o ng v t t h ch thn).

2. Ch o ph n bit: Cn phn bit vi t cp ca suy thn mn.

3. Ch o gu h :

Sau khi ch o nh suy thn mn, cn ch o gu h . Chn


o gu h da vo hi k tin s, tin trin b h, soi t, xt
nghim sinh ha, huyt hc, X quang, siu m ty thuc vo din bin lm sng.
Nhiu t ng hp ch o gu h t d dng v b h l in hnh, xt
nghim chnh xc, thuyt ph h i u thn mn tnh, vim ng k thn
mn tnh, bnh thn c ngun gc mch mu, bnh thn di truyn. Tuy nhin c
mt s t ng hp kh g t c nguyn nhn.
III. CC BIU HIN LM SNG CA SUY THN MN

Cc biu hin lm sng ca suy thn mn c hi ch g u u ao c trnh


t o g s sau.

giai o u ca suy thn mn ( I, II), cc biu hi thng ngho nn


h thiu mu nh, h , t mi, tc 2 bn h l g. T o g thi gian ny,
b h h thng khng bit l h suy thn. Cc biu hin lm sng bt
u xut hi o giai on III, khi MLCT gim xung di 20 ml/pht, creatinin
u t g t ol/l. Su thn cng nng th biu hin lm sng cng rm r.

Tm tt cc triu chng lm sng v cn lm sng ca hi chng ur mu cao.

IV. CC BIN CHNG THNG GP TRONG SUY THN MN


Nhiu bin chng khc nhau xut hin, suy thn cng nng th bin chng cng
nhiu. C nhng bin chng lin quan trc tip n s gim st ch g thn,
h g g hng bin chng li do ph g ph p iu tr thay th gy ra.

1. Bin chng tim mch:

Tm tt cc yu t h hng ln tim bnh nhn suy thn mn:

Nhng bin chng tim mch bnh nhn suy thn chim t l cao v l nguyn
nhn t vong chnh (40-60%). nhm bnh nhn suy thn m iu tr lc mu
go i th, gu a h ao h nhiu so vi qun th dn s bnh
thng. Vi h gi g in chng v tim mch c vai tr quan trng
t o g iu tr v ko di cuc sng ca nhng bnh nhn ny.
1.1. Bnh l mng ngoi tim:

Biu hin ca nhm bin chng ny l vim mng ngoi tim v trn dch mng
go i ti do t g u u. l t bin chng rt c i . T c kia bnh l
g go i ti c coi l du hiu o t c ci cht. C 2 hnh thi bnh l:
hnh thi c in sm v hnh thi mun.

- Hnh thi sm:

Thng xy ra o giai on cui ca suy thn m , t khi u t qu 40


mmol/l, biu hin bng trn dch mng ngoi tim v trn d h a g, kh ph
bit vi vim mng ngoi tim c thanh dch si huyt trn lm sng, trn X quang
tim phi siu . l t h trng nhi do u u t g ao. iu tr
b g ph g ph p lc mu s nhanh chng gim bt dch mng ngoi tim v tin
l g c ci thi g k.

- Hnh thi mun:

Thng xy ra nhng b h h c chy thn nhn to chu k , t gp h


bnh nhn lc mng bng chu k . T th g loi ny khc vi loi trn ch n
khng lin quan trc tip n hi ch g u u ao. Ngu h thng gp:
lc mu khng hiu qu lm tch t cc cht chuy h a c hi c phn t lng
t u g h, ng cn gip, tha c, s dng thuc ch g g him virus.
Triu ch g thng gp: c ting c mng tim, st, au gc, gan to v ri lon
nhp tim. Ch o da vo X quang tim phi, siu ti i ti . Siu
ti g ai t ua t ng trong nhng t ng hp triu chng lm sng
kh g . iu tr da vo ch nh lc mu thch hp: t c nhiu da vo
siu lc, gim liu Heparin ho d g Hepa i go i th trong khi lc mu. Khi
c p tim cn d lu g go i ti p. iu tr kt hp vi Corticoid hoc
ch g i kh g c hiu khi c st v triu chng nhim khun.

1.2. B h ti do u u ao o a diopathie u i ue :

ng d g siu Dopple t o g th d ti h ho ph p h g ta g
cng hiu h h bnh sinh ca b h ti do u u ao. C tha
i v h h th i h ph i v gin tht tri c th ko theo s tha i chc
g t thu t t g. Su ti t i l t trong nhng nguyn nhn t
vong ca bnh nhn thn nhn to chu k , chim t l 15-25%.

1.3. T g hu t p:

T g hu t p gp 80-90% trong s bnh nhn suy thn m giai on cui v


chim 10-25% s bnh nhn thn nhn to chu k . Trong suy thn m thng
gp t g hu t p t thu, t t g, t g hu t p t thu c, hoc
t g hu t p tm thu ni tri h .

Suy th g t g hu t p theo nh g h ch yu l gi mui c,


t g hot tnh ca h thng renin-angiotensin-aldosteron, h thn kinh ph thuc
catecholamin, hormon chng bi niu , t g sc cn mch ngoi bin, gim hot
tnh ca h thng gi p

T g hu t p bnh nhn suy thn mn v bnh nhn suy thn lc mu chu


k g d n hng lot cc bin chng nng n tim, no, mt l t g t
l t vong nhng bnh nhn ny.

1.4. Ph i tht tri trong suy thn mn:

Ph i tht tri l h hng rt thng gp bnh nhn suy thn mn, chim
t l cao 40% s bnh nhn suy thn m giai on cui v 60-80% s nhng bnh
nhn thn nhn to chu k . C th ph i ng tm hay lch tm.

Cc yu t h h g n ch g tht tri c th tm tt h sau:

- T g hu t p.

- Thiu mu.

- mui v dch.

- R th g ng - t h ch.

- Cng cn gip trng th pht.

- Ri lon h thng thn kinh t ng.


1.5. Bnh l mch vnh bnh nhn suy thn:

Suy vnh v nhi u ti g him mt t l g k chim 24% bnh


nhn suy thn mn. Nhiu tc gi g ho thy tm quan trng ca bnh l mch
vnh bnh nhn suy thn mn, nht l nhng bnh nhn chy thn nhn to
chu k . Ri lon chuyn ha lipid mu nhng bnh nhn ny l mt yu t nguy
a suy vnh. Ch o da t i t , nghim php gng sc, siu
m tim gng sc v chp mch vnh.

1.6. Bnh l van tim:

Nguyn nhn ch yu l do vi ha van v cc t ch di van. Ngoi ra, gin


cc bu g ti g g a nh l van tim. Theo Rostand, vi ha van 2 l chim
21% s bnh nhn chy thn nhn to chu k . Mt s tc gi kh g thy
t g t h . Thng gp h l vi ha van 2 l, tip n l vi ha van
ng mch ch, gy ra h hoc hp van. Siu m Doppler tim gip ch o
c cc t th g a ti .

1.7. Vim ni tm mc nhim khun:

Suy thn mn, nht l nhng bnh nhn chy thn nhn to chu k v lc
mng bng chu k l t g gu i i tm mc. Siu m tim, nht l siu
m qua thc qun s gip ch o g.

1.8. Ri lon nhp tim:

Nguyn nhn ch yu l do ri lo in gii t g kali u , su ti , nh


m h h Ri lon nhp tim cng lm nng thm ri lon ch g ti . iu
tr bng thuc chng lon nhp phi ht sc thn trng nhng bnh nhn ny.

2. Ri lon cn b g , in gii v kim toan:

2.1. Natri:

S cn b g l g o = lng ra) v c duy tr nhng nephron cn li


do t g lng lc v gim hp thu ng thn tng phn. Tuy nhin, c th c gi
mui khi suy th giai on cui do a hiu mui o th qua ch
hoc truyn d h. Ngc li, c khi gp bnh thn km theo mt mui h thn
a a g, i k thn m t h thng gp gi ln tui khi iu tr li
tiu. C h n cn b g lng mui o a, thng ch cho 2 g NaCl/ngy.

2.2. Nc:

Cc ri lon ch yu l tiu nhiu v tiu , li ua n gim hormon


khng bi niu ADH v gim chnh lch thm thu ng - k thn, do hi tng
thi s h ash out a cc nephron cn li. Thng khng thy c hi tng
tha c. Thiu niu nng n thng t xut hin suy th giai on cui,
h g s gp sau khi bt u l u i th g i . Khi u g t c
u , lu l g c tiu s gi gu t g thm thu u. N a
c vo khong 1,5-2 lt/24gi nu cn tiu tt, gi a o khi thiu
niu.

2.3. Kali:

B h thng gi cn b g kali c thc hi do t g tit kali g ln xa,


do s tham gia ca cc yu t ngoi thn (thi ua g tiu h a t g hu n
i vo trong t o . T o g t ng hp c bit, t g kali u l do t s yu
t phi hp o h: iu, dng mt s thuc (khng Aldosteron, c ch men
chuyn, khng vim khng Steroid, c ch bta giao c , a o u hiu kali,
toan chuy h a

V iu tr: ty theo m t g kali u h g ph g ph p iu tr


thch hp.

2.4. Cn bng kim toan:

Ri lon toan - ki thng xut hin khi MLCT gi di l/ph t. Khi


xut hin toan chuyn ha vi khong tr g a io t g h thng t 8-17
ol/l . i khi ut hi toa u kali u ao toa u t g lo k
theo kali u h thng, xy ra nhng bnh nhn b bnh thn c mt mui.
Khi MLCT gim s lm tch t cc acid hu d n toan mu, ty theo m
suy nng nh cn b sung Bicarbonat.

. Tha i v huyt hc trong suy thn mn:


3.1. Thiu mu:

Thiu mu l mt biu hi thng xuyn ca suy thn mn v khng hi phc.


Thn cng suy thiu mu cng n g, thng xut hi khi MLCT di 25
l/ph t. giai on cui, hng cu ch cn khong 1,5 tera/lt, huyt sc t
cn khong 50-60 g/l, hematocrit < 0,20 l/l.

Cc yu t tha gia o h bnh sinh ca thiu mu trong suy thn mn:

- Gim i sng hng cu.

- Mt mu.

- Thiu ht erythropoietin.

Erythropoietin (EPO) l mt ni tit t kch thch sinh hng cu. gi ln c


> % EPO c sn xut thn ti cc t bo quanh ng thn. Th l ua
ch o iu ha sn xut EPO theo h t g gc (feed- a k p ng
vi lng oxygen cung cp cho t chc. Khi p sut ring phn oxy trong t chc
nhu m thn gim, thn s t g sn xut EPO. EPO t ng ln t bo tin sinh
hng cu (erythroid progenitor cell) t g, hng cu s c sn xut
nhiu l , l t g kh g ti oxy ca u. Khi oxy th t chc thn li
p g gc li, gim sn xut EPO. Erythropoietin khng c d tr t o g
th hoc trong thn. Thn phi thng xuyn tng hp 2-4 UI/kg/24gi duy tr
n g h thng trong huyt t g -25 UI/l (1000-1500 U/tun).

bnh nhn suy thn mn, do t th g hu n tnh nn thn khng


sn xut e th opoieti , do kh g k h th h c t g si h hng cu.
V v gi suy thn bao gi g thiu mu, hu qu l cht lng cuc sng
cng gim m d c lc mu chu k .

Ngy nay nh k thut ti to ge , gi ta sn xut c erythropoietin


gi g h gi v gi tt l e th opoieti gi ti t hp (rHu-EPO =
recombinant human erythropoietin). Vic s dng rHu-EPO iu tr thiu mu
cho bnh nhn suy thn m , t c v trong khi lc mu chu k c kh g a
he oglo i l n mc g h thng ho h thng.
3.2. Ri lo g u:

Ngu ut huyt bnh nhn suy thn m i n t nhiu


a , t c khi xut hi ph g ph p iu tr l u, d g h t thng gp
trong suy th giai on cui. Xut huyt tiu h a thng l nguyn nhn t vong
nhng bnh nhn ny.

Nh g tha i v huyt hc rt phc tp: c th do ch g a tiu cu b


ri lo h gim kt dnh, gim kt tp v gim sn xut yu t III tiu cu; c
th do cc yu t c ch sinh l ca u t h g u ri lon, v v thng
hay c xut huyt nhng bnh nhn suy thn nng.

3.3. Thiu ht min dch trong suy thn mn:

l t h t ng gim min dch va phi. Nhi t g thng hay gp nhng


bnh nhn ny. nhng b h h c lc mu chu k , nhim trng do t cu
g thng gp; ngoi ra nhim virus i ga B g l cn ch
nhng bnh nhn ny.

4. Bin chng tiu ha:

V o giai on cui, h l t iu chng ph bin, nht l i vi th


protid. Bun nn v nn l du hiu ca ur mu cao cn xem xt lc mu.

Xut huyt tiu ha v thng tng r g do lo t ti lng rt nng. Vim


lot d dy c xut huyt chim gn 1/3 s bnh nhn suy thn m . C h bnh
sinh rt phc tp, mt ph do c t gy cho nim mc, mt phn do ri
lo g u g a. Tit gast i tng ln nhng bnh nhn c creatinin mu
ao t ol/l. S t g tit gast i kh g iu chnh li sau khi chy
thn nhn to chu k , h g h thng tr li sau khi ghp thn.

Qua cc kt qu m t thi cho thy nhng bi i ty chim 60% s bnh


nhn suy thn mn. Cc t th g ng n thng gp nhng bnh nhn c
n g ni tit t tuyn cn gip (PTH) cao. Vim ty cp thng gp h
nhng bnh nhn lc mng bng chu k vi t l t vong 20-30%.

5. Bin chng phi:


Ph phi, vim ph qun, vim phi v trn dch mng phi l nhng bin
ch g g thng gp bnh nhn suy thn mn.

nhng bnh nhn suy thn mn nng, hay nhng bnh nhn l u, thng
gp nh g ph phi cp h l t g g h n tnh, c th hoc khng km
trn dch mng phi, thng c suy tht tri hoc tha dch ngoi t o. Phi
u ao i hnh h X ua g in hnh l m h h h m rn phi,
nguyn nhn c th l do t g t h thm mch mu.

Trong mt s t ng hp ur mu cao, c trn dch mng phi mn tnh khng


gii th h , i khi t u. Tin trin bt thng, c th t ngt ht
dch, nu ko di c th d h a g hi chng hn ch.

i vi nhng bnh nhn suy thn khng triu chng, c X quang tim phi bnh
thng, ch g h hp c th tha i: hi chng hn ch, gim kh g
khuch tn phi i vi kh carbonic. Vi ha phi g c pht hin thy
dng vi th, c th do hu qu ca ng tuyn cn gip th pht, ghp thn ci
thi c tnh trng ny.

i vi bnh nhn thn nhn to chu k , gi ta cho rng chuyn ha ion


acetat l nguyn nhn ca gim h hp h po e tilatio do t g s dng oxy v
gim sn xut CO2. S d g i a o at g g a t m thiu o o
lin quan n hi tng khng ph hp sinh hc phc tp.

6. Lo d g g bnh nhn suy thn mn:

Lo d g g l t b h g gun gc chuyn ha, hu qu ca


s ph hy nhu m th tha i cn bng v calci-phospho. T th g
g ut hin giai on sm ca suy thn mn. Khi MLCT gi di 50% th
c ti 50% trong s h c biu hin t th g m hc g. T o g thn
nhn to chu k , hu ht cc b h h u c t th g g. Chy thn
nhn to cht lng tt c th ci thi c mt phn tnh trng trn. C 2 loi
t th g g:

- Cng cn gip th pht vi t th g i g.

- Lo d g g do thn bao gm nhuy g h g t hot.


6.1. Cng cn gip th pht:

Cng cn gip th pht l kt qu ca t g gl khi lng tuyn cn


gi p t g i tit PTH bi tng t bo. N g PTH trong mu bt u cao
nhng bnh nhn suy thn mn c MLCT gi di 80 ml/pht. Mt khc
nhng bnh nhn suy thn mn th p ng ca tuyn cn gip vi h calci mu
t g h so i gi h thng.

- Vai tr ca phospho: Khi MLCT cn < 20 ml/pht, kh g o thi phospho ca


thn b gim v xut hi t g phospho u. N t ng ln s bi tit PTH bng
3 cch:

. Gim calci ion ha huyt t g.

. Gim tit calcitriol.

. Kch thch trc tip t g tit PTH.

- Vai tr ca calcitriol: Th l ua hu trch nhim sn xut calcitriol thng


qua 25-OH-D3. Khi MLCT > 60 ml/pht, n g al it iol h thng. Khi MLCT <
40 ml/pht, nng calcitriol gim v n g ca n t l thun vi s gim
MLCT. Gim sn xut calcitriol trong suy thn mn l hu qu ca:

. S ph hy cc nephron.

. S gi phospho ni biu m ng thn v ngoi t bo.

. S thiu 1,25-(OH)2-D3 trong nhng t ng hp thiu nh nng mt tri, thiu


ht di h dng v vitamin.

Gim calcitriol huyt t g d ng c gi p th g ua h:

. Gim calci mu do gim hp thu calci ca PTH.

. S khng ca g i vi tc d g t g al i a PTH.

. S ri lo iu ha trc tip vic sn xut PTH.


- Vai tr ca h calci mu: Gim calci ion ha v calci huyt vi ri lon ch g
thn d n cn bng m v calci. N l hu qu ca gim vn chuyn tch cc
calci rut, t g phospho u, thiu calci, n g calci thp < 1,7 mmol/l
trong dch lc thn nhn to. Calci mu thp s kch thch tit PTH v d n tn
th g i g.

- Vai tr ca toan mu: Toa u g tha gia o u t h g ng cn


gip. N lm thun li h t g phospho mu, bilan calci m v qu trnh tng
hp calcitriol b h hng.

6.2. Lo d g g: Bao gm nhuy g h g t hot. C


nhiu h tham gia vo qu trnh ny:

- Nhuy g:

. Vai tr ca s thiu ht Vitamin D: khng phi bnh nhn suy thn mn giai
on cui o g hu g, h c nhng bnh nhn c thiu ht
25-OH-D3 do thiu nh nng mt tri v thiu ht ita i , di h dng mi b
nhuy g.

. Vai tr ca phospho huyt t g: h phospho mu v thiu ht vitamin D l


nhng yu t quan trng ca nhuy g.

. Vai tr ca nhm: bnh nhn suy thn m thng c biu hin nhi c
nhm do gi o thi h g ua c tiu g th do a o th
qu nhiu bng th thc ung. Aluminium s lm gim s h h th h g
v c ch tit PTH.

- B h g t hot: Bnh ny d n bt sn t ha g ht, gha l


khng c hot ng t bo to g, thng l hu qu ca suy cn gip
t g i hoc tuyt i. Bnh l ny rt thng gp gi gi.

Triu chng lm sng ca lo d g g bnh nhn suy thn mn xut


hin mun giai on lc mu chu k h: hi chng mt do vi ha cng
mc mt. au g gp 20% bnh nhn vim khp v vim quanh khp. Vim
thng t gp h . V i ha quanh khp ho t dy ch g, g g t gp.
Tr em c th gp bin dng ct sng hoc chm ln. Xt nghim ngho nn, da
vo calci mu gi , phospho u h thng hoc gim giai on suy thn
nh t g giai on suy thn nng; phosphatase kim ton ph t g ao.
N g PTH ty thuc, rt cao trong hi ch g ng cn gip v trong tn
th g hn hp. Du hiu X quang ch yu l t g tiu g ua h g
v g a u chi. C th thy s h g u g . R g ut
hin u t g ng chn, c g i, g h ta . T g s,
tiu g to thnh dng ht.

T th g hu g t kh phn bit c trn phim X quang, ch c


sinh thit g i cho bit u l t th g hu g ha nh g
bt hot. Vi ha cc m m g th c quan st thy bnh nhn suy
thn mn. Vi ha cc m h u thng thy sm m h u g ta , ng
mch ch, ng mch chu.

T th g g ut hin suy th giai on sm, v vy vi iu tr d


phng l rt cn thit, nhm gi cho n g phospho v calci mu trong gii hn
h thng v b sung s thiu ht v hormon calcitriol.

. Kim sot phospho mu: Hn ch th hiu phospho. Nn gi mc


phospho mu mc 1,45-1,9 mmol/l. L g phospho a o th nn khong
800 mg/24gi. B sung mui calci (carbonat calcium, acetat calcium). Khng nn
d g it at al iu l t g t i hp thu nhm rut. Lng calci hng ngy
cn khong 1-4 g/ngy.

. B sung calcitriol: B sung al it iol ng u g , g/ g ho t h ch


i vi bnh nhn suy thn mn s lm gim n g PTH t o g u l t g
nhy cm ca tuyn cn gip vi al i. Cal it iol l t g hp thu ca th i
vi calci, v v l t g al i u.

. Phu thut ct b tuyn cn gip: G h ki t a c n g


phospho u iu tr calcitriol d phng nn ch nh ct b tuyn cn gip
gim. Ch nh ct tuyn cn gip khi n g PTH u ao k theo t g al i
mu m d iu tr calcitriol, nga nhiu, vi ha nhiu i.

7. Bin chng thn kinh:


7.1. T th g th ki h t u g g:

Thng l cc bin chng nng n h ph o, tai in m h o c bit do


t g hu t p; ri lon thc, l ln th pht sau ri lo in gii nng n h
h natri mu.

- Bnh no do ur mu cao:

Bnh no do ur mu cao xy ra khi bnh nhn giai on suy thn nng, khng
th gu h g a h g c thuc, thiu ht vitamin B1, h natri
mu, h phospho mu n g, t g hu t p hay xut huyt no.

Cc bt thng c th l o gi , au u chng mt, khng ni, co git i l


ln v hn m. B h o do u thng kh phn bit vi bnh no do vim gan,
do chuyn ha.

- Ri lon th ki h t u g g do thn nhn to:

. Hi chng mt cn bng: c th gp ln chy thn nhn to u tin, biu


hin l bu , au u, ri lon th gic, mt th g ng, run ry v co git, ri
l ln v hn m. Tuy nhin c th hi phc vi gi sau khi ngng l , i o
ho to h thng. Hi ch g thng gp tr em, nh g gi nh
cn v nh g gi chy thn giai on qu mun c n g ur, creatinin
qu cao vi t nhanh. C th l do ph no v lc ur dch mng nhn chm
h so i trong mu, v v c s trn vo t o o. Ph o g l hu
qu ca s gim pH trong ni t bo v o li ua t g sn xut
acid.

. Bnh no do nhm: ch gp nhng bnh nhn thn nhn to chu k ha


h thng x l c tt.

7.2. T th g thn kinh ngoi bin:

Vi a d thn kinh xut hin khi MLCT < 10 ml/pht, gp mt s t bnh


nhn lc mu chu k , biu hin bng gim t dn truyn thn kinh v ng
v cm gic. Triu ch g l s g thng l mt mi ton thn, cm gic nng
bng chn, chut rt teo , th c , thng gp nht hi di. iu
tr bng thn nhn to tt c th ci thi c tnh trng trn. Rt kh phn bit
s khc nhau gia t th g thn kinh ngoi bin do suy thn mn hay do
chuy h a do i th o g

8. Ri lon v chuyn ha:

8.1. Khng Insulin:

Gim chuyn ha thn ca Insulin d n ko di thi gian v n g nh


ca n trong huyt t g, t un u g ng. Mc d vy, biu ng
huyt l bt thng, chng minh cho s khng Insulin mc t bo.

8.2. Ri lon lipid mu:

Ngay t giai on suy thn nh, c th thy thnh phn ca apoprotein thay
i. T g lipid u ut hin r nht khi MLCT gi di 30 ml/pht, ch yu l
t g t igl e id. Thng gp t g lipid u t p IV k t g VLDL v LDL, c th
km theo gim HDL-C. T g LDL gi HDL i l ut hi t khi t g
triglycerid. Cho d suy thn mn do nguyn nhn no th thnh phn Apo AI, Apo
AII g gim, cn Apo B c th t g h ho kh g t g, c bit Apo CIII t g
r rt. Nh y, t l Apo AI/Apo B v Apo AI/Apo CIII gi . T g holeste ol
thng him gp. HDL-C gim v t l HDL-C/LDL-C g gim. Gim HDL-C ko
theo cng mt lc gim HDL2 v HDL3. Gi HDL li ua t g tn sut
ca t l t vong do tim mch nhng bnh nhn thn nhn to chu k .

Sau khi ghp th , gi ta khng thy c s h thng ha tr li v lipid,


m thy c s tha i tnh tr g lipid u. T g holeste ol li biu hin r nt
th g u h t o g khi t igl e id li gim xung.

T g holeste ol h yu li ua n LDL-C, n c th do iu tr Corticoid v


C lospo i . Ng a gi ta cp nhiu n lipoprotein (a), mt yu t
gu c lp ca va ng mch trong qun th h thng, yu t ny
t g ao trong suy thn mn.

8.3. Ri lo di h dng:
Ch ki g m cht ch l mt trong nhng nguyn nhn ca ri lon
di h dng nng nhng bnh nhn suy thn mn. Khi lc mu chu k , ch
r g i h hn ch c tnh trng suy dinh dng nhng bnh nhn
ny. Thiu p otei g lng lin quan ti hiu qu d h a h bnh
nhn suy thn m . H a trong qu trnh chy thn nhn to, hi tng
khng ph hp v sinh hc s kch thch d h a , a th glu ose o t o g
dch lc c th hn ch s mt acid amin. Qu trnh lc mng bng chu k ko
theo s thot mt albumin v acid amin vo trong dch l c cn b li
bng ch gi u p otid, t o g khi a th glu ose o th qua mng
bng li lm gim ngon ming nhng bnh nhn ny.

T giai on thn nhn to chu k , bi xut ur hng ngy l mt ch s tt


v khu phn protid. Cholesterol thp < , g g l t ch s su di h dng.
V ch di h d g ho gi suy thn, nhiu tc gi cho rng cn 35-40
calo/kg cn nng/24 gi, v 1-1,2 g Protid/ kg cn nng/24 gi cho thn nhn to
chu k , 1,3 g protid/kg cn nng/24 gi cho bnh nhn lc mng bng chu k , v
0,8-0,4 g protid/kg cn nng/24 gi cho bnh nhn suy th ha h nh lc
mu. H lng m khng qu 30% trong tng s calo cn thit ho th.

9. Ri lon v ni tit:

nam gii nhng ri lon v ch g si h d thng xut hin khi b suy


thn mn, c th c bt thng v to tinh trng. N g testosteron huyt
t g ton phn hay t do gim va phi. p ng ca testosteron vi human
chorionic gonadotropin (HCG) b ngng h . T g p ola ti u thy 1/3 s
bnh nhn nam chy thn nhn to chu k .

bnh nhn n b suy thn, ri lo g di i g t vai tr quan trng


v ri lon ch g ung tr g d g h l gu h t c tip ca v
sinh. Trong suy th giai on cui c th gp rong kinh hoc mt kinh. Estradiol
v progesteron huyt t g h thng ph u chu k , sau hu ht u
thiu ht lutein. Bi tit LH v FSH b ri lon. Cc ri lon ny g di i.
Sau khi mn kinh, n g LH FSH t g l h thng.
Mt qu trnh rng trng d n mt cn bng hormon v gy ra rong kinh,
i khi g a hiu nang bung trng. iu tr bng progesteron c 2 tc dng:
t h c rong kinh do vy gi gu thiu mu nng v khng cn dng
thuc trnh thai cha estroprogesteron na. Trn thc t, nu s th thai ph
n b suy thn nng l thp th c thai vn c th xy ra ngay c nhng ph n
ki h. T o g t ng hp suy thn va, mang thai c th trn v n k sinh
h g thai hi thng nh v d nguy him cho m t g hu t p, tin sn git
v suy thn s trm tr g h . T o g giai on l u g th c thai nh g
ti lng v thai hi thng khng tt. Ghp thn s lm ch g si h dc
h thng tr li h g h nn c thai sau khi ghp thn 1- n ch
cho ch g thn thc s h h ti lng v thai nhi s tt h .

V. IU TR

1. iu tr nguyn nhn:

Gii quyt cc nguyn nhn d n suy thn mn nu c th.

. iu tr bng ch :

- Ch ki g ui ch p d g khi ph , t g hu t p. Kh g khu
nht k o d i, c bit trong nhng bnh l thi tr mui nhiu (th a a g .

- Cn b g c: ty thuc vo tnh trng kht. Hn ch c khi c h natri mu.

- B sung thm kali b g u g, tu hi kh g hiu chui, chocolat,


hoa qu kh

- B sung thm kim vo: cn gi cho mc kim 20-24 mmol/l (u g c


khong hoc bicarbonat).

- Ch g l g: m bo 35-40 kcal/kg cn nng/ngy.

-H l g p otid a o t 0,4-0,8 g/kg cn nng/ngy.

. iu tr triu chng:

3.1. iu tr ri lo in gii:
- Nu Kali mu cao:

. Hn ch a kali vo qua th .

. Cho nha t ao i io : Reso iu A, Ka e alat

. Cal i g t h ch.

. Truyn Glucose 20% + Insulin TM chm.

. Truyn Natri bicarbonat 1,4%, 4,2%, 8,4%.

. Lc mu khi n g kali mu > 6,5 mmol/l.

- Nu Kali mu thp: cn b sung kali ty theo m thiu ht, c th bng


ng ung ho ng truy t h ch chm.

3.2. iu tr toan mu:

Bnh nhn suy thn m kali u ao th g gu toa hu n ha,


t g ng thiu bicarbonat. Kt qu xt nghim kh mu s cho bit m
ri lon cn bng kim toan.

Th g thng x tr bng truy Nat i i a o at , % t h h, t ng hp


khn cp ngng tim hay cn hn ch dch vo s truy t h ch Bicarbonat
4,2%, 8,4%.

3.3. iu tr t g hu t p:

- Hn ch mui: 2 g/ngy.

- Li tiu: Lasix, Natrilix.

- Thuc c ch men chuy : Co e s l, Re ite lu kali u.

- Thuc c ch al i: Nifedipi Adalat , A lo , Ple dil

- Thuc c ch P op a olol, Ate olol, Pi dolol .

3.4. iu tr thiu mu:


- iu chnh cc yu t tham gia vo thiu mu: chy mu, thiu st, thiu acid
foli

- E th opoieti Ep e , Epoki : -3 ln x 50 UI/kg cn nng/tu , ti di da,


gi n g Hb mc 10-11 g/dl.

- Truyn mu: nn hn ch, tr t ng hp mt mu cp v thiu mu nng.

3.5. iu tr lo d g g:

- B sung calci: Carbonat calci 4-5 g/ngy.

- Thu : Ro alt ol , g i / g , , OH D3 (Dedrogyl).

- Hn ch phosphat: hn ch sa v phomat v cc thuc cha thnh phn


phospho.

3.6. Thuc khc: B sung Vitamin v cc acid amin (Ketosteril hay Nephrosteril).

3.7. Lc mu ngoi thn:

- Thn nhn to.

- Lc mng bng.

3.8. Ghp thn:

- T gi sng:

. Cng huyt thng.

. Khng cng huyt thng.

- T gi mt no, cht lm sng.

55.VIM THN K MN TNH


TS. H Hong Kim
1. Quan nim v thut ng.

T , nh l t th g ng-k thn k c do nhim khun v khng do


nhim khu u c gi chung l vim thn k. Nguyn nhn ca bnh thn
k i hu g c hiu bit g h c bnh thn khc.

Hi a , gi ta phn bit ra hai loi vim thn k:

+ Vim thn k do vi khu c gi l vim thn-b thn.

+ Vim thn k khng do vi khun c gi l vim thn k. Nguyn nhn thng


thng ca vim thn k l do nhi c hoc do ri lon chuyn ha.

Trong bi ny chng ti ch trnh by vim thn k mn tnh.

2. Cc bnh vim thn k mn tnh.

2.1. Vim thn k mn tnh do nhi c:

T c 1950, ch i t ng hp vim thn k mn tnh do nhi c


pht hin do cc thuc v ha cht, c bit l nhm thuc sulfonamit.

N , Spuehle Zoli ge ph t hi t ng hp vim thn k mn tnh


qua t thit c lin quan ti dng ko di thuc gi au, c bit nhm thuc
c cha gc phenaxetin. cc b h h , gi ta thy c vim thn k v
hoi t nh thn. T , ic pht hi t ng hp vim thn k mn tnh do
cc nguyn nhn khng lin quan ti nhim khu c ch .

2.1.1. Vim thn k mn tnh do thuc gi au, c bit thuc c gc


phenaxetin:

+ Hnh nh m bnh hc:

- Hnh nh m bnh hc l hnh nh ca vim vng k thn: c 2 thn teo nh v


ho , ho t chc k c th thnh h g thng l lan to. Ngi ta thy
ng thn teo cng vi dy mng nn ng thn. Vi cu thn vn cn nguyn vn
h g phn ln b hyalin ho v nang Bowman b d ho .
- C im ca t th g gii phu bnh gi cho ch o i thn k
mn tnh v gip cho ch o ph bit vi vim thn-b thn mn l: xm
nhp t bo vim t chc k thn nh h g hoi t nh thn li nng.

. Xm nhp t o i thng m nh v to thnh cc , ch yu l t


o h , hp t o a h h thy khi c nhim khun th pht.

. Hoi t nh thn gp 40-70 % s bnh nhn:

Hnh h i th ca hoi t nh thn thy: nh thn mu vng xm v b, d


vn.

Hnh nh vi th ca hoi t nh thn thy: kin trc nh thn b ph hu, t chc


k ph n khng c t bo vim v khng c mch mu. Ch ni vi m lnh c
phn ng vim cng vi xm nhim t bo, phn g ho .

Hoi t nh th thng xy ra c 2 th , h g g th ch mt thn. C


th c nhiu nh thn b hoi t h g g th ch c mt vi nh thn b
hoi t. Nh thn b hoi t, c th b bong ra lm tc niu qun gy thn c
ho t i theo c tiu ra ngoi.

- Qu trnh t th g nh h hia l giai on:

. Giai o ho i m ng niu trn: ho g i thn v b thn


xy ra sm, chim ti 80 - % t ng hp bnh thn k do thuc c gc
phenaxetin. Mc

nng ca ho i c biu hin lp nim mc dy ln t i thn ti b


thn.

. Giai on hoi t nh thn: sau nhiu ung thuc gi au gc


phe a eti , gi ta thy cc thp Malpighi vng tu thn chuyn sang mu
vng. T th g thng gii hn vng trung tm ca tu trong; vng tu
ngoi v vng v h thng. Cht gian m h t g l , ao ch quanh ng
thn on ln ca uai He le ho . Biu m ng th on ln ca quai
Henle v t bo ni mc mao mch quanh ng thn b ph n, hoi t, i khi
l g ng tinh th canxi vng nh thn.
. Giai on bi i nhu m vng v thn: t th g g thn chu nh
hng ca t th g h thn. Nu t th g k o d i i mi rng nh thn
s gy teo ng thn, xm nhp t bo vim vo vng k thn. Nu nh
thn rng nhanh th vng nhu m cn nguyn vn.

+ C h bnh sinh:

Phenaxetin c tc d g c cho th , gi ta thy c mi lin quan gia m


nng ca t th g thn vi thi gian v liu lng thu c ung. Ngoi gc
phenaxetin, c th cn c vai tr ca cc cht phi hp khc gy nhi c cho
thn. Chng hn, aspirin c th gy protein niu, hng cu niu, t g a t u i ,
tha i c c tiu.

Phenaxetin v cc thuc nhm nonsteroit khc c ch men cyclo oxygenaza, lm


gim tng hp prostaglandin (l cht gin mch c vai tr quan tr g t o g iu
ho dng mu th go i h c trc tip cn c th c thiu mu thn,
c bit l nh thn do tp trung n g thuc cao.

Yu t thun li cho nhi c thn c th do thiu c lm n g thuc


t g l t o g c tiu; yu t a, yu t di truy g ai t ht nh.
Ngi ta thy vim thn k do thuc gi au u t gia h, tn s mc
b h ao h nh g gi mang HLA-B12.

+ Triu chng lm sng:

Biu hi l s g thng kn o ho n khi c triu chng ca suy thn.

- Bnh nhn ung thuc gi au gc phenaxetin hoc cc thuc thuc nhm


non- steroit mt thi gian di c th thy c gim kh g c c tiu ca
thn: bnh nhn c triu ch g i tiu ; t tr g thm thu c tiu
gim; lm nghi ph p c tiu thy kh g c tiu ca thn
gim.

- Giai on hoi t nh th : t o g c tiu c th thy c nh thn, c protein


niu. Nu nh thn bong ra gy t ng d c tiu s th au i vng h
tht l g; l siu thn thy gin i thn. Nu chp thn thu t h
mch c th thy nhu m thn b tch ra bi mt di trng vng nh thn,
khng thy vng v thn.

- Xt nghi c tiu c th c bch cu t o g c tiu, p otei t o g c


tiu h g s lng t, ch khong 1g/24gi. Lm siu m thn thy hai thn teo
nh, nhu m th t g siu , a h gii gia nhu m thn i-b
thn khng cn r rng.

- Sinh thit thn thy hnh nh ca vim thn k mn tnh vi im: xm nhp
cc t bo vim (ch yu l t o h vo vng k thn nh h g hoi
t nh thn th li nng.

- Khi c suy thn th c triu chng ca suy thn v xt nghim thy n g ur


v

eati i t o g u t g, c lc cu thn gim.

+ iu tr v d phng:

Kh g ph g ph p iu tr c hiu cho bnh nhn b vim thn k mn tnh


do nhi c thuc c gc phenaxetin v cc thuc nhm non-steroit kh , iu
tr theo nguyn nhn v triu chng ca bnh.

Phng bnh: khng dng thuc gi au gc phenaxetin hoc cc thuc thuc


nhm non-steroit khc ko di lin tc trn 3 thng. Khi phi dng cc thuc trn
th phi u g c v thn trng vi cc bnh nhn cao tui, cc bnh nhn c
cc bnh mn tnh c h h g n dng mu th h: t g hu t p, i
tho ng...

2.1.2. Vim thn k mn tnh do ch v kim loi nng:

+ im lm sng ca bnh thn do nhi h t g t h nh


vim thn k mn tnh khc:

- Bnh tin trin chm, ri lon kh g c tiu ca thn xy ra sm


gi nhi c ch v c protein niu s lng t (khong 1g/24gi).
- Ri lo t nh Gt c th gp: bnh Gt gp 50% s bnh nhn b
vim thn k do nhi c ch.

- Tr em b bnh thn do nhi c ch th tui th khng cao (khong 20 tui).

+ Ngo i a, gi ta cn gp vim thn k do cc kim loi n g kh h: g,


thu g , ng, uranium, bismuth, st, asen...

+ Hnh nh m bnh hc cho thy ho k thn m n g, thng


thy c l g ng urat trong t chc k thn.

+ iu tr: kh g ph g ph p iu tr c hiu cho bnh nhn b vim thn k


mn tnh do nhi c ch v cc kim loi n g kh . iu tr theo nguyn nhn
v triu chng ca bnh.

2.2. Vim k thn do ri lon chuyn ho:

+ T g a i u: a i l g ng k thn gy phn ng vim ho ao


quanh tinh th a i g t g th tch k th ; ng thi a i g th lng
ng th pht do vim k thn.

+ Bnh Gt c th gy vim thn k th pht do l g ng mui urat t chc k


thn v trong ng th ha ng niu. Triu chng lm sng v m bnh hc tu
thuc vo v tr l g ng ca urat, c th c tc ngh ng niu do si urat v
i khi gy nhim khun th pht.

+ iu tr: ch yu l iu tr b h h h. Ngo i a, iu tr theo nguyn nhn v


triu chng ca bnh.

2.3. Bnh thn k do tui gi:

gi cao tui, ngay c khi khng c tc ngh ng niu, kh g t g


huyt p g th t g th tch k thn ho t chc k thn c xm nhp
t o h . ng thn v cu thn b t th g th ph t do ho t chc
k. Mc lc cu thn v dng mu thn gim.

Nguyn nhn ca bnh thn k do tui gi ha c bit , gi ta cho rng,


ho k thn c th do vim thn-b thn cp t , g th do tc
ngh ng niu do u tu n tin lit hoc thiu mu thn, do bnh l ca cc
mch mu ln hoc ca m g li mao mch thn.

Triu chng lm sng biu hin s gim kh g c tiu ca th : i


tiu ; t tr g thm thu c tiu gim; cc xt nghi h gi kh
g c tiu ca thn c biu hin gim.

2.4. Bnh thn k do cc bnh c tnh:

M k thn c th b xm nhp bi cc t bo t h h: t o g nh bch cu


tu cp, bnh bch cu tu mn, bnh bch cu lympho. T bo c tnh thng
xm nhp vo vng v thn nhiu h g tu thn; cu thn v ng thn bnh
thng. S xm nhp cc t bo c tnh vo t chc k l t g k h c thn,
th g t g k h kh g u hai thn, c th pht hi c trn siu m
X ua g. Nh g h c 50% s bnh nhn b xm nhp t bo c tnh vo t
chc k thn nh trn t thit c thn to.

56.PROTEIN NIU

1.Cc loi protin niu: phn chia theo ngun gc

1.1 Protein ng thn: bt khng c ,ti hp thu hon ton khi t th g ng


thn mt s nh kh g t i hp thu

1.2 Protein t cu thn:

do t th g u thn vd vim cu thn .

1.3 Protin t ng tit niu t v di:do si ,u, ht khi khng nhim trng.

1.4 Protein niu do t g s u c ca t g o gy protein chui nh ,chui


nng
. Dng chp:Do tc h bch huyt d n d vo h tit niu th g do u,
KST.

. P otei t th(lnh tnh):

Thng gp g i t khi ng mt khi n khoa g it g/ H t i


gi t ng thnh.

2.cc xt nghim protin niu:

Ph g ph p ch nh Gi tr BT Nhn xt

1.Que th vt <100mg/l Dc hiu cho


Albumin

.C th d g
tnh gi trong
ki c tiu
hoc t trng
>1.025

2.Th bng BN BT albumin <30mg,til


mu ngu ngu T,THA Albumin/crea<30/1000mg
ngu nhin

.in di md Cc BN c Trong pro th Albumin nhiu


tm pro pro niu nht dn cc chui nh nng
khng r khc
nn

4.Protein niu
24/h
[ NGHA LM SNG CA MICROALBUMIN NIU TRONG MT S BNH

.T t p / thn Khi c microAlbumin niu l s ho


cu thn c T sm

.T t p / thn Biu hin ca s ho u thn v nguy


ti ch cao,suy thn ch h
T t p

.T g HA c b/c thn Khi pro niu > g gu su


thn cao,v bnh tim mch.

4.Cc bnh thn tin pht hoc th Khi pro niu >1g suy thn din ra nhanh
pht

Cc b ph p iu tr lm gim qu trnh suy thn:

1.Kim soat HA: Tt nht HAt< Hg u bn chu g c

2. Cc thuc c ch men chuyn: C tc dng bo v liu thp

. gim mui v gim pro lm gim pro niu v qu trnh suy thn

57.NHIM KHUN TIT NIU V THAI NGHN

h gha: Nhi t g hu v ng niu xy ra khi c thai.

Hay gp 6 thng sau, him khi th g u(8%).

79,4% Nhim trng tit niu thp

10,8% Nhim trng tit niu cao.


5,1% Nhim trng tit niu khng triu chng.

4,7% Nhim trng tit niu ti pht.

Cc vi khun hay gp:

E. coli 80%

Proteus, Klebsiella : 10%

Ga d g e te o o ue, staph lo o ue : %

Bnh sinh

- Do c tiu trong bng quang

- Do gi i thn, h p, thng bn phi.

- Gim kh g ph g nh

- T o gc bng quang niu qun.

- Tha i tnh cht c tiu.

C gu

- Con so

- Sn ph c bnh l h tit niu t , him trng niu ti pht.

- C nhim trng khc.

Biu hin lm sng

- C thai

- Hi chng nhim trng: st, v m hi, rt run

- au tht l g t , thng l bn phi

- V h g l g t au.

- Thn to thng kh pht hin.


- i ut, i dt, i , i u.

Biu hin cn lm sng

- CTM: bch cu t g ao, h yu l a h t u g t h.

- Cy mu

- C c tiu

- Bch cu niu, hng cu niu, nitrit niu, m niu

- Siu i thn gin, c, m b thn, bng quang .

- Siu m v theo ri tim thai.

Bin chng thai sn do nhim trng tit niu

. non

Tr th g non.Theo bo co ca E.H.Kass th cc tr thng thp cn


h so i tr h thng. Cc tc gi Romeo v McGrady thy rng a s cc tr
b thiu cn v c ti 17,9% b cht lu.T o g ghi u ca J.C.Colau cho con s
12,5% b non. Mc d vic dng khng sinh rng ri c lm gi gu
h g lu t % t ng hp nhim khun tit niu non v thai
thiu cn.

2. Chm pht trin

Trong cc nghin cu mi thy rng khi m b nhim khun tit niu, thai
thng chm pht tri h , gp , % t ng hp. Nguyn nhn c th do
vic can thip khi , do st ko di.

3. Thiu mu

Nghin cu ca COX th h t phn ba sn ph b nhim trng tit niu c


thiu mu. Nguyn nhn l do tan mu, cc bnh mng hng cu. Theo J.C.Colau
th , % t ng hp thiu mu. Hng cu di 3,3triu, he oglo i di100g/l,
he ato ite di 35%.

4. Nhim trng tr s si h

c bit hay gp tr thiu cn.

5. T th g thn.

Th g th g th sau khi iu tr vim thn b thn bnh nhn khi hon ton v
khng c di chng.Tuy nhin c nh g t ng hp chuyn thnh mn tnh, v
h hng ch g thn.

iu tr

1. Nhp vin

Hu ht t ng hp phi vo vi iu tr ni tr v theo ri.

Cc khm nghim phi l ga h gi t h t ng nhim trng, tnh trng sn


ph v thai nhi.

Cc xt nghim cn lm ngay : cng thc mu,cy mu, c c tiu, siu m


thn, thai, theo ri tim thai... s gi p iu tr kp thi.

C kh g si h c dng ngay, tt nht l sau khi c kt qu c u, c tiu.


a s thuc nhm chng vi khun gram m.

Cc thuc khng sinh hay dng l nhm Betalactamin, cc Cephalosporin th h 3.


C mt s thuc c tc dng ngoi vi thai v sn ph phi ch . Ngoi ra c
nhng thuc d b kh g g n cn nhc khi dng.

g d g th g th g l ti t h ch. Sau khi ht t cp th d g ng


ung.

Trong nh g t ng hp nhim trng nng phi iu tr khng sinh phi hp.

2. Thi gia iu tr khng sinh


Theo nhiu tc gi, dng lin tc 3 tun, trong nhiu t ng hp c th phi dng
ti 6 tun hoc ti khi .

Sau khi dng thu ti th d g ng ung. Khi ht st, xt nghim v bnh


th g, siu h thng.

Tuy nhin phi theo ri lin tc lm sng v xt nghi iu tr kp thi v


nh g gi ny rt d ti pht.

. Theo i sau 3 thng v 6 thng kim tra li ch g thn v h tit niu


loi tr cc nguyn nhn thc th.

. iu tr khc

Ung nhiu th g tho g ng tiu.

5. Trong mt s t ng hp, nu thn b tc nghn nhiu, gy m c thn


lm h hng ch g, th dt sond niu qu gii phng s chn p.

S dng khng sinh khi c thai

1. nh h g d ng hc do thai sn

- Gim kh g gn ca thuc vi protein mu.

- T g ph thuc ti ua do t g u g l g ti , t g th tch d h
th.

- T g thi thu ua ng tiu, tr v h th g sau .

- T g hp thu ti ng tiu ho do gi hu ng rut.

- T g hu n ho ti gan

- Thuc vo thai nhi

- N g thu t o g u thng thp h phi chnh liu khi cho thuc.

2. Cc khng sinh c th dng:


- Nhm Betalactamin:

Ch thuc ny c th d ng.

Thuc hay dng:

+Penicilline G (t cu, ph cu,xon khu , h kh g t cu vngv


gnocoque)

+Penicilline M (oxacilline, methylcilline).

+Penicilline A ( ampicilline): hemophilus influenza, gonocoque, e.coli, proteus,


shigella, samonella.

+Carboxypenicillin, Ureidopenicilline.

- Nhm Cphalosporine

+Th h 1,2 c tc dng ging Ampicilline.

+th h 3: ph tc dng rng, khng c tc dng ph, t khng thuc. Ch nhm


ny tc dng hn ch vi vi khu g a d g, t cu.

- Nhm thuc phi hp c ch men Betalactamase: sulbactam,clavulinic,


tazobactam.

- Nhm Macrolide v lincosamide: erythromycine, clindamycine. c tc dng vi


giang mai, chlamydia.

3. Cc khng sinh thn trng:

- Met o idazol: kh gd g t o g a th g u.

- Sulfa ide: g g da s si h, kh gd g th g u.

- Polymycine hay dng vi nhim trng ti pht.

- Quinolon.

4. Cc thu kh g c dng:
- Aminoglycoside: gentamycin, streptomycin, tobramycine.

- Vancomycin

- Tetracycline.

- Phenicole

5. Thuc chng lao:

Cc thuc lao khng thy gy qui thai gi h g thy ng vt. Nh


rifampicin, ethambutol, pyrazinamide.

Cc thuc c th dng: isoniazide, rifampicine, ethambutol.

Hay dng phi hp: INH v Ethambutol, hoc INH v Rifampicine

6. Thuc chng nm:

Nu cn vn phi dng ton thn, bi ti ch: nystatin, amphosterinB, miconazol

7. Thuc chng Virus

GIM AU H ST

PRACETAMOL

GIM CO THT

PHLOROGLUCINOL

PENICILLINE M,G,A

CEPHALOSPORINE

KHNG SINH

MACROLIDE ERYTHROMYCINE, SPIRAMYCIN


CHNG LAO ISONIAZIDE,RIFAMPICINE,ETHAMBUTOL

KHNG NM NYSTATIN,AMPHOSTE
RIN B

TIM MCH DIGITALIQUE, DN ALDOMET,CATAPRESSAN, HYDRALAZINE


XUT NITRE

NI TIT HORMON GIP, VIT D, CALCI, KALI.


INSULINE,

TIU HO MUI
NHM,LACTULOSE

SN KHOA SALBUTAMIN,
TERBUTALIN,DYDROG
ESTEROL

MU ST, HEPARINE,
VITAMINE K

THN KINH CHNG NG KINH PHENOLBARBITOL,CLONAZEPAM,SEDUXE


N

MT ACETAZOLAMIN,ACECL
IDINE

KHNG K SINH TRNG CHLOROQUIN,QUININ


E

H HP SALBUTAMOL,TERBUT ACEMUX,MUCOLATOR
ALIN,THEOPHYLIN
VACCIN CHNG VIM GAN B,
UN VN

58.HI CHNG THN H

Hi Chng TH h l t hi ch g si h ho v l s g t g i s mt
nhiu p otei ua c tiu, gy gim albumin huyt t g, iu hin bng
ph v nhiu ri lo kh h i lon lipid mu, ri lo g u. C h
bnh sinh

. T g t h thm g u thn

- T th g h g o k h thc lm cho nhng phn t c tr g lng l h


p otei i ua.

- T th g h g o in tch m v cu trc ca g u thn lm thot


protein ra ngoi.

2. Ph

- Gim albumin mu gy gim p lc keo d n hi tng thot dch ngoi bo


t trong lng mch ra khong k.

- Hot ho h renin-angiotensin-aldosteron v h thn kinh giao cm gy gii


phng ADH (vasopressin) kt qu l gy gi mui bo tn th tch
tun hon hu dng v tip tc lm thot dch ra khong k.

- Gi thuyt gi mui c nguyn pht ti thn: khng c hot ho h renin-


angiotensin-aldosteron m c tnh trng tha th tch.

3. Ri lon lipid mu
- T g lipid u: t g holeste ol, t g t igl e id, in lon HDL

- Ri lon chuy ho lipop otei : t g tng hp lipoprotein, gim ging ho lipid,


gim lipoprotein lipase, gim lecithin cholesterol acethyltransferase, gim LDL

4. Ri lo g u

- T g nht mu

- T g alpha a oglo uli

- T g u t ng mu II, V, VII, X, XII

- Gim antithrombin III

- Tha i n g v/hoc hot tnh ca protein C v S

- T g g fibrinogen

- Ri lon qu trnh tiu fibrin

- T g kt tp tiu cu

Nguyn nhn gy bnh

1. HCTH nguyn pht

+ Bnh cu thn thay i ti thiu

+ X u thn -cc b

+ Bnh cu thn mng

+ Vim cu thn mng-t g si h

+ Vim cu th t g si h gia ch

+ Vim cu th t g si h goi m h t g si h h h lim)

+ Vim cu th t g si h i mch lan to

2. HCTH th pht
- Bnh h thng v chuyn ho:

+ i th o ng

+ Lupus a h thng

+ Thn thoi ho bt

+ Hi chng ban dng thp Schonlein-Henoch

+ Vim mch hoi t. . .

- Nhim khun:

+ Nhim khun cp tnh, nng, ko di, nhim khun huyt

+ K sinh trng (st rt P. Malariae, Schistosomiasis, Filariosis)

+ Virus (vim gan B, C; HIV)

-Bnh c tnh:

+ U g th t bo biu m (phi, i trng, d dy, thc qu , u g th hc t. . . )

+ Bnh Hodgkin ho ul pho t g si h t h

+ a u tu g

-Thuc:

+ Mui vng, thu ngn, lithium

+ Trimethadion, D-penicillamin

+ Thuc chng vim khng steroid

+ Captopril, Rifampicin, IFN alfa

- Cc nguyn nhn khc: thai, bnh hng cu hnh lim, s dng heroin,
sarcoidosis, hi chng Guillain-Barr, sau ct thn, bm sinh. . .
T th g nh hc cu thn trong HCTH

1. Bnh cu th tha i ti thiu: hnh nh trn hin vi quang hc trong gii hn


h thng, mt chn li ca t bo biu m trn hi i in t, khng c hoc
rt t l g ng phc hp min dch trn hin vi min dch hu nh quang

. X u thn -cc b: cc hyalin ho h ho mt phn cu thn v ch


c t th g mt s cu thn, hay gp cc cu thn vng tu v lan dn v
pha v thn

3. Bnh cu th g: d g u thn do cc l g ng phc hp min


dch (l g ng dng ht IgG, C3, C5b-9 dc thnh mao mch cu thn), khng c
hi t g t g si h t bo.

4. Vim cu th g t g si h: d g u th t g si h t bo gian
mch

- Tp I: l g ng phc hp min dch ni m v gian mch

- Tp II: l g g t o g g u thn (t hoc khng c Ig) phi hp vi


thnh phn C3

- Tp III: biu hin ging tp I v bnh cu thn mng

5. Vim cu th t g si h gia h: t g si h t bo cu thn lan to chim


80% s cu thn, ch yu l t bo gian mch, ni mch v c thm nhim t bo
h , th c l g ng IgA, IgG, IgM v/hoc b th hoc khng c lng
ng min dch.

6. Vim cu th t g si h goi m h: t g si h t bo biu m ca bao


Bowman to thnh lim t bo, l g ng fibrin trong cc lim t o t g si h
ngoi mch

7. Vim cu th t g si h i mch lan to: ph n t g si h t bo ni m


lan to lm hp lng mao mch cu th , t g k h thc cu thn v lm hp
khoang niu

Triu chng lm sng


1. Ph: l triu chng chnh

+ Hay gp ton thn, vi nhiu m t k o ti rt nng n

+ C th trn d h g h t ng, trn dch mng phi , mng tim, mng


tinh hon, ph n b phn sinh dc

+ Ph trng, m , kh g au

. i t: c tiu gi di 500ml /24h.

3. THA: t gp

. i u: t gp

5. Thiu mu nh

Cc xt nghim cn lm sng

1. Xt nghi c tiu

+ h lng protein niu 24 gi: >3,5g/1,73m2/24 gi. Nhiu t ng hp c th


ln ti 30-40g/24h. Thnh phn ch yu l albumin, ngoi ra cn c cc loi
p otei kh h IgG, IgM, Fi i oge .

+ Tm t bo niu, tr niu: T o g c tiu thy th m lng chit , tr m, tr


ht, hng cu niu, bch cu niu.

2. Xt nghim mu

+ h lng protid ton phn trong huyt t g gi di 60g/l.

+ h lng albumin huyt thanh thp h g/l.

+in di protein huyt t g th alpha glo uli t g. Ga a glo uli thng


trong gii h h thng hoc gim, tuy nhin ch s t g t o g t s
bnh h thng.
+ h lng m u: holeste ol th g t g t , ol/l, t igl e id, LDL-C,
HDL-C

+Xt nghi in gii: natri huyt t g gim, kali gim.

+Mu l g t g, s lng hng cu, hemoglobin gim nh

+Xt nghi h gi h g thn:

- Ur, creatinin huyt t g , acid uric

- o c lc cu thn

Tiu chun ch o

1. Ph + i t

2. Protein niu nhiu trn 3,5g/1,73m2/24 gi (trong thc hnh trn 3-3,5g/24
gi)

3. Protid mu gim di 60g/lt, Albumin mu gi di 30 g/lt

4. Ri lon m u: t g holeste ol t igl e id, t g LDL-C, c th gim HDL-


C. . .

5. C ht m lng chit, tr m t o g c tiu

Tiu chun th 2 v th 3 l bt buc, cc tiu chun khc c th kh g .

Phn loi th bnh

1. Th thun khit: ch c protein niu, kh g i u, t g hu t p, suy thn

2. Th khng thun khit: c protein niu cng vi t mt trong s cc triu


ch g i u, t g hu t p, suy thn.

Tin trin v bin chng

Tin trin

- Khi hn
- Ti pht nhiu ln

- Chuyn thnh bnh cu thn mn tnh v tin trin thnh suy thn mn tnh

Bin chng

1. Suy thn cp: do tin trin ca b h, ng thi vi tnh trng gim tun hon
hu dng gy suy gim ch g thn. c bit khi c s tham gia ca cc ho
cht hay thu h thuc chng vim gi au kh g steroid, khng sinh hoc
tnh trng nhim trng km theo.

2. Nhim khun

+ ng h hp h i phi, lao phi.

+ Vim t chc t o di da.

+ Vim phc mc tin pht.

+ Nhim khun khc.

3. Tc mch: Do nguyn nhn ri lo g u, nht mu cao, cc yu t


g u in lon, th tch tun hon gim dn ti l t g gu tc mch

+ Tc mch no gy ra cc biu hin th ki h t u g g.

+ T ng mch ho t h ch ngoi vi gy thiu mu hoc ph khu tr. hay


gp l t h ch chu, t h ch nch, mch phi.

+ Tc mch phi gy suy h hp cp.

+ Tc mch thn gy suy thn cp, nhi mu thn cp.

. Su di h dng: do mt nhiu p otide ua ng tiu, h do t ng,


gim ch g tiu ho dn ti mt lp m di da, teo c, thiu mu. . .

5. Cc bin chng khc: ph no, ri lo in gii gy ri lon thn kinh, ph


phi gy kh th, bin chng do thu iu tr (li tiu, corticoid, c ch min
dch).
iu tr
Nguyn t iu tr

- iu tr nguyn nhn gy bnh nu c

- iu tr nhm lm gim protein niu

- iu tr bo tn ch g thn

- iu tr gim triu chng

- Phi hp ch di h d g iu tr

iu tr c hiu

1. Co ti oid: l thu ha c s dng nht gm prednisolon hoc


prednison

+Liu tn cng g/kg/ g i vi gi l , g/kg/ g i vi tr em


trong 4-8 tun;

+Liu cng c bng 1/2 liu tn cng trong 4-6 thng;

+Liu duy tr 5- g/ g k od ih g .

Cn gim liu thuc t t, kh g t ngt ngng thu phng suy


thng thn cp. Theo di pht hin cc bin chng do thu THA, t g ng
huyt, xut huyt tiu ho, ri lon tm thn, nhim khu , lo g g c
iu tr ph hp v gim liu thuc hoc ngng thuc khi cn thit.

2. Cc thuc c ch min dch bao gm cc thu c t bo: ch nh khi khng


p ng steroid, ph thuc steroid hoc hay ti pht.

+Cyclophsphamid 2mg/kg/ngy 4-8 tun, duy tr 50mg/ngy trong 4-8 tun khi
protein niu m tnh

+Chlorambucil 0,15-0,2mg/kg/ngy 4-8 tun, duy tr 0,1mg/kg/ngy.


+ Cyclosporin A: 4-6mg/kg/ngy chia 2 l t o g n 12 thng

Cn theo di cng th u, iu chnh liu duy tr s lng bch cu trn 4,5


G/L)

iu tr triu chng

- Gim ph: Ch gim mui, c.

- Cc thuc li tiu: hay dng l furosemide, c th phi hp nhm li tiu tit


ki kali h spi o ola to .

- Nng p lc keo huyt t g ng truyn Albumin phi hp ch gi u


protein

- T g hu t p: ch gim mui. Cc nhm thuc h p hay c dng l


thuc c ch men chuy a giote si u ti , thuc chn knh calci.

- B sung Can xi, vitamin D, st v c yu t i lng khc.

- iu tr ri lon m mu

iu tr bin chng

- Nhim khun: gim liu hoc ngng s dng corticoid v thuc c ch min
dch, cho khng sinh ph hp theo kh g si h )

- Tc m h: t o g t ng hp cp cu dng ch g g hepa i , kh g ita i


K. iu tr d phng bng Aspirin .

- iu tr cc bin chng do thuc

Ch iu tr

- Hn ch mui, c khi ph , t g HA, h hn ch mui cn c th lm


gim protein niu.

- Cung cp lng protein cn thit ho th v b li lng protein mt i


ua c tiu.
- Hn ch protein khi c suy thn tm thi

h gi p g iu tr

- p ng hon ton: protein niu<0,2g/24 gi

- p ng mt phn: protein niu di 2g/24 gi

- Ph thuc steroid: bnh ti pht khi ngng thu p ng tr li khi dng li


thuc

- Kh g ste oid: kh g p ng sau 2 thng dng liu tn cng

Xt nghim theo di

Theo d i in gii u, ng mu, cng thc mu

Theo d i lng protein niu 24 gi.

Theo di cc ch s ch g thn.

Theo di protein ton phn, albumin huyt thanh, m mu

iu tr hi chng th h
C h gy ph
59.THN H TH PHT
(Bnh hc Ni khoa. Tp 1. Nh xut bn y hc 2006)

I. I CNG

. h gha:

Hi chng th h l t hi chng ca bnh cu thn xy ra mt h t ngt


do t th g cu th t g i:

- i u.

- i t.

- T g hu t p.

- Protein niu.

- Ph.

. im dch t:

Hi chng th h th pht gp ch yu gi ln tui. Theo thng k ca Trn


V Cht v Trn Th Thnh t -1995 ti khoa thn tit niu Bnh vin
Bch Mai c 31,5% s bnh nhn nm ti trong khoa vi s tui trung bnh t 36-
54 tui chim 98,32%, bnh khng lin quan v gii a d, h y bnh gp
nhiu la tui lao g t o g in chng suy thn mn chim 26%.
Vi iu tr ch o g gha t quan tr g trnh bin chng ca
hi chng th h th ph t gnh n g ho gia h hi.

II. NGUYN NHN V C CH BNH SINH

1. Nguyn nhn:

1.1. Bnh h thng v chuyn ha:


- Lupus a h thng.

- Hi chng ban xut huyt dng thp.

- i ng.

- Thn nhim bt.

1.2. Thu v c cht:

- Phenindion, Tridion.

- Captopril.

- Li tiu thu ngn.

- O g t.

- Heroin.

1.3. Tim mch:

- Vim ngoi tm mc.

- T g hu t p c tnh.

- Hp ng mch thn.

1.4. Nhim khun - k sinh vt:

- St rt.

- Giang mai.

- AIDS.

- Vim gan B.

1.5. U g th (v, ph qu , i trng).

1.6. Sau tim (Bismuth, vacxin bi lit).

. C h bnh sinh:
- Bnh sinh ca hi chng th h ha c hiu bit . V gii phu bnh
hc, th t th g g u thn l ch yu. B h th g g
khng cho cc phn t l h p otei i ua. Khi t gu h o
l g t th g in th ca g tha i th protein lt qua
c. Protein niu cng nhiu th Protein mu cng gim, albumin ra nhiu nht
(80%) lm gim p lc keo ca huyt t g. Nc thot ra ngoi lng mch hu
qu l gy ph v gim th tch tun hon hiu dng. T t mt trc tip gy
ti hp thu c v natri g ln gn, mt khc gin tip qua h th g iu
ho ni tit l t g ADH Aldoste o .

- ADH t g s ti hp thu c ng gp.

- Aldoste o t g s ti hp thu Na+ c g ln xa v ng gp.

- Kt qu ca qu trnh trn l qu trnh gi Na+, gi , do s i t dn


n ph ton thn ko theo cc ri lo in gii.

S h gy ph:
III. TRIU CHNG LM SNG V CN LM SNG

1. Ph:

th in hnh th triu chng lm sng ch yu l ph.

- Ph to ton thn, ph mt.

- c bit l mi mt, ri xu g hi di v b phn sinh dc.


- C t ng, trn dch mng phi mt hoc hai bn.

- T ng hp nng c th ph no.

2. i t: Nc tiu th g di 500 ml/24h.

3. Mt mi, k .

4. Thiu mu nh.

5. Protein niu cao.

Protein niu thng l h hoc bng 3,5 g/24h, thnh phn ch yu l


al u i , go i a c tiu cn c th m, lng chit quang, tr m, tr ht,
hng cu niu v bch cu niu.

6. Protein mu gim:

Do mt lng ln albumin b mt ua c tiu, kt qu d n albumin huyt


t g gim.

- T ng hp nng albumin gi di 30 g/l.

- Alpha glo uli th g t g.

- Ga a glo uli h thng hoc gim trong hi chng th h sau i u


th lipid th g t g ao.

7. Lipid u t g:

T g lipid u e h l t t g n ca hi chng th h. C
th t g > g/l. T o g holeste ol > , g/l.

8. Na+ t o g u thng thp.

9. Na+ niu thng thp.

10. Mu: Mu l g th g t g, s lng hng cu, hemoglobin v hematorit


gim nh.

11. Mc lc cu thn: B h thng, khi suy thn th gim.


12. Sinh thit thn: Thy t th g cu thn.

Nh y triu chng lm sng quan trng l ph vi tnh cht ph rt to v nhanh


c th c trn dch cc mng. c g ng c th gh n hi chng th h.
Nu trn mt bnh nhn c cc bnh khc hoc ph ti pht nhiu l th gh
n hi chng th h th pht.

IV. CHN ON

1. Ch o nh: Da vo tiu chun ch o :

- Protein niu > 3,5 g/24h.

- Protein mu < 60 g/l, albumin < 30g/l.

- Lipid mu > 900 mg%, Cholesterol mu > 250 mg%.

- T o g c tiu c ht m, tr m, th lng chit quang.

Tiu chun 2 v 3 l tiu chun bt buc, cc tiu chu kh g th khng


g c coi l hi chng th h.

2. Ch o in chng:

- Nhim khun:

+ Cp tnh: vim t chc t bo, vim phc mc tin pht, vim phi, i ...

+ Mn tnh: lao phi, lao phc mc...

- Tc mch:

+ T t h ch thn.

+ T t h ch ngoi vi.

+ T ng mch ngoi vi.

- Suy thn cp: do gim th tch tun hon hiu dng t th gy nn suy
thn cp t c thn hoc hoi t ng thn cp.
- Thiu di h dng: do mt nhiu p otei ua g c tiu k theo h
k do t ng.

V. IU TR

1. Chng ph:

- Li tiu: phi theo d i in gii v rt hay gy gim kali mu.

- B p otei ho th:

+ T g p otei t o g khu phn th l, -2 g/kg cn n g t g alo, hn ch


mui c.

+ Truyn cc dung d h h Plas a, Mo ia i ...

2. Liu php Corticoid:

- Liu tn cng l-1,5 mg/kg/24h, ko di 1-2 thng.

- Liu cng c bng 1/2 liu tn cng, ko di 4-6 thng.

- Liu du t g/ h, k o d i h g .

- Cn theo di cc bin chng do dng Corticoid ko di.

3. Thuc gim min dch khc:

- Dng khi kh g p ng vi Corticoid:

Cyclophosphamid 2-2,5 mg/kg/24h ko di 1-2 thng. Khi protein niu m tnh th


duy tr 50 mg/24h, ko di 1-2 thng.

Ch : Mt s bin chng do dng thuc gim min d h h:

+ Nhim khun.

+ Gim bch cu, nu bch cu di 3000 bch cu/mm3 mu th phi ngng


thuc.

. iu tr cc triu chng v cc bin chng khc:


- iu tr nhim trng tt nht da o kh g si h .

- iu tr t g hu t p.

- iu tr phng tc mch: nn cho thuc ch g g ho tt c cc bnh nhn


hi chng th h.

- iu tr suy thn cp (nu : , in gii, truyn Plasma.

. iu tr bnh chnh d n hi chng th h th pht:

C iu tr theo nguyn nhn.

Hi chng th h th pht do cc bnh khc t th g gii phu bnh hc ch


yu cu thn. Ch o h yu da vo:

- Ph, protein niu cao, protid mu gim.

- iu tr ch yu bng Corticoid v thuc gim min dch, b h thng ti pht


nhiu ln cui cng d n suy thn trong khong 10- , thi gian di hay
ngn tu thuc vo vic ch o iu tr hi chng th h nh chnh
gy nn hi chng th h.

60.GHP THN
( GS. Tr V Cht )

Ghp th l ph g ph p iu tr thay th th su giai on cui tch cc.

1. i g:
Ghp thn l nh cao tin b ca y hc ni chung v ca ngnh thn hc, niu
hc, min dch h i i g. C g h t o g gh p t g, gi ta phn bit:

- Ghp t thn (Autograft)

- Gh p ng loi g ge S og aft, t gi Isograft).

- Gh p ng loi khc gel Allog aft, t gi Homograft).

- Ghp khc loi Xe og aft, t gi Heterograft).

T k t nh g th h g hai t ng hp ghp thn Boston ca


kp Merril v Paris ca kp Hamburger gia nhng anh ch e si h i kh
trng, trn th gii t . t ng hp ghp th , t o g khong
t . t ng hp Php.

Vit Nam t , tin hnh ghp th n thi i thc hin 36


t ng hp 4 trung tm.

Nh nhng hiu bit v h thi ghp v nhng pht minh cc thuc gim
min dch mi, ghp tng ni chung v ghp thn ni ring c nhiu thnh cng
gi l g h tr em. Thn cho, c th t gi sng - ho gi cht
no c ho hp m - vi gi nhn.

2. Nhc li min dch ghp.

Thnh cng ca ghp thn ph thuc nhiu yu t t o g ua t ng nht l


p ng min dch ca gi nhn vi khng nguyn ho hp m - c gi
ho h g kh g gi nhn. M h a vic la chn l nhn ra cc yu
t khng thch hp min dch d n thi ghp. Mt s yu t g a c
nhn din mt cch hon ho. Cc khng nguyn ho hp m - nh v
gen trn b mt cc phn t v khc nhau tng c th.

H thng HLA l mt trong nhng h thng di truy a h h th i ht nm


cnh tay ngn ca nhim sc th s 6.
Vng HLA bao gm 3 loi gen. Cc gen m ho cho cc khng nguyn nh v
mt huyt thanh ca lp I: HLA-A, B v C. Cc gen m ho cho cc khng nguyn
nh bi c tnh cc lympho bo lp II. HLA-DR. Cui cng nhm gen m
ho yu t C2, C3 v yu t B ca h thng b th. Hin nhin, cc gen m ho
khc cho cc khng nguyn quan tr g t o g gh p ha c nhn din.

Hiu qu ca nhm HLA-A,B rt quan tr g t o g gh p gi cho cn sng


cng huyt thng. Vai tr ca h thng HLA-A,B cn t r rng trong ghp t thn
ca t thi so vi vai tr ca HLA-DR.

S khng ho hp trong h thng ABO l mt chng ch nh tuyt i trong


ghp. Tri li vai tr ca khng nguyn Rh khng ln trong ghp.

3- Tuyn chn gi nh v gi cho thn.

3.1- Ngi nhn thn:

3.1.1- Ch h c ghp thn.

- gi ln: 16 - 50 tui.

- tr em: cho tr nng trn 10kg tt h .

- Thi im ghp: sau lc mu hoc ghp ch t ha lc mu).

- Trng thi ton thn: bo m ghp.

- Suy thn m giai on cui.

- C nguyn vng.

3.1.2- Chng ch nh ghp thn.

Trng thi ton thn:

- U g th.
- Nhi u ti .

- Tai bin mch mu no.

- Nhim khun cp.

- Nhim HCV

- Nhim lao

- Vim cu th t g si h g.

- Vim cu thn c khng th kh g g .

- Vim cu thn IgA (bnh Berger)

Xt nghim:

- Tin mn c d g t h t %.

- Phn g h o d g t h.

3.2- Ngi cho thn:

3.2.1 T gi sng:

- Tui t n 65 tui.

- T nguyn

- Trng thi sc kho tt

- Khng mc cc bnh ly nhim: Lao, giang mai, st rt, HIV, CMV, HBV, HCV.

- Khng mc cc bnh h thng, b h u, u g th, i th o g, t g hu t


p.

- C hai qu thn.
- Xt nghim ho hp t g g: h u ABO, Rh, o h o, kh g
nguyn ho hp m ca bch cu HLA p ng yu cu.

U ban ghp thn Vit Nam nu ln 60 ch s hu tuyn ch gi


nh gi cho.

3.2.2 T gi mt no:

- Do tai nn giao thng, tai nn sinh hot.

- C ho hp m.

4- Chun b gi nhn thn.

4.1- Chun b v min dch:

- Truy u: t khu t u u t c ghp. G , t chc


ghp ca Php khuyn khng thc hin truy u t c ghp.

- Tim chng: nn tim phng HBV, thu u t c.

4.2- Chun b v ni khoa:

Cn loi tr cc vim nhim da, g, c tiu, phc mc, catheter.

4.3- Chun b v ngoi khoa:

- Ct th t g hu t p c tnh, th a a g u to, him khun tit niu ti


pht nhiu ln.

- Chun b h tit niu, c bit l tr em v hay gp d dng tit niu.


4.4- Chun b v mt tm l.

5- K thut ly thn, ra thn, ghp thn

Thng c 3 kp:

5.1- Ly thn.

- Phi an ton tuyt i ho gi cho thn nu ly t gi cn sng.

- Bo v ti a gii phu (bao m quanh thn, niu qun) v chc g u


thn ly ghp. Khng s, ng chm kch thch thn, cung thn.

- ng m ly thn rng c ph a t ph a di. C quy trnh thc hin cho


phu thut vin khi ly thn phi hay thn tri.

5.2- Ra thn: C u nh v dng c, ph g tin v cch tin hnh.

S dng cc dung dch: Euro-Collins, Xylocain nhit 40C. Thi gian ra: 5-10 -
pht. Ra lin t ho n khi thn c mu tr g u, g u, dch chy t
t h ch thn ra trong.

5.3- Ghp thn.

V tr ghp h chu phi hoc h chu tri theo cc trnh t:

- Ni t h ch: tn-tn hoc tn-bn gia t h ch thn vi t h ch chu


ngoi ho t h ch chu gc.

- Ni ng mch: tn-tn hoc tn-bn gia ng mch thn vi ng mch chu


ngoi ho ng mch chu gc.

- Ni niu qun-bng quang hoc niu qun-niu qun.


C bin bn ghi cc mc thi gia thc hin cc k thut trn. Thi gian thiu
mu nng, thiu mu lnh rt quan trng h hng nhiu n thi gian bo
him sng ca thn ghp.

6- Bin chng - cch x tr.

6.1- Vim ng k thn cp tnh:

- Cc yu t: Tnh tr g gi cho, k thut hi sc trong cht o, ph g ph p


ly thn, thi gian thiu mu lnh.

- C cc biu hin: thiu niu, v niu.

6.2- Thi ghp:

- Thi ghp ti cp: xut hin ngay lp tc sau khi tho kp. Thn to nhanh, mu
tm nht do hoi t v thn. Cn ly b thn ghp.

- Thi ghp cp t h: thng xy ra vo thng th 3, thng th sau gh p h g


c th gp bt c thi im no sau ghp. C cc biu hin: st, th to, i t,
protein niu, u u eati i u t g. Ch o h siu m nht l nh
sinh thit thn.

- Thi ghp mn tnh: suy gim ch g th do h min dch ca thi ghp.


Tin trin chm trong nhiu . Thi ghp mn tnh min dch cn phn bit vi
tn th g thc th dn dn ca th gh p do h khng phi min dch, do
nhi c thuc chng thi.

Vic s dng cc thuc c ch min dch m h to ra nhng tin b trong vic


phng chng thi ghp cp. Tu theo kinh nghim ca cc trung tm m c cc
ph chng thi ghp vi cc thuc:

+ Corticoide:
Corticoide c nhiu h hng ln h min dch. N c ch s hot ho lympho T
giai on sm, c ch cc gen ca l phoki kh hau, c bit IL1 v IL6. c
ch IL1 gii thch hiu qa ca Corticoide trn bnh nhn st v c ch tng hp
IL2 bi Lymphocyt T. Corticoide ko theo gim lympho bo trong mi quan h vi
vic phn b li cc lympho bo gia u ua l pho. Co ti oide t
dng chng vim mnh bng cch tng hp hypocortin v c ch phospholipase
A2. S tng hp TNF g c ch.

Liu Co ti oide thng cao lc khi u (1,5- g/kg/ g sau gim t t


n liu 0,5mg/kg/ngy.

Bit dc: Methyl - Prednisolone l 500-1000mg.

+ Azathioprine:

C tc dng chng sinh sn t bo. N c ch tng hp ARN v phong to hot


ng men, c ch s ph i t bo. Tc dng tt trong d phng thi ghp v
dung np tt.

N c cc bin chng: gim bch cu, gim tiu cu, gim sn tu, vim phi k,
vim tu cp.

Liu 1mg/kg/ngy.

+ Anticalcineurine.

C lospo i e Sa di u , Neo al : c pht hin t t nm


Tolypocaldium inflatum:

H thng calcium calci-neurine can thip vo s hot ho ca cc lymphocyt T v


c ni m mch mu thn. N c ch phn ng min dch ca cc lymphocyt h
tr bng cch c ch s sao chp ca ARN thng tin, c ch tng hp IL2.
C lospo i g c ch chuyn cc du hiu hot ho ca IL2, IL6 v interferon
gamna.
Liu lospo i e c khuyn dng l 250mg/m2/ngy, chia lm 2-3 ln. Trong
nh g th g u sau ghp, n g t d n 150-200mg/l.

Cc bin chng:

Run, d c , au u, trm cm, l ln.

M l g, t g sn li.

T g hu t p, K+ u t g, Mg++ mu gim.

Ng a gi ta h l g a C lospo i b g ph g ph p in dch-
hu nh quang vi khng th d g.

FK506 (Tacrolimus, Prograf):

Ta oli us l i phn t vng thuc lp cc anticalci-neurine c hot tnh c ch


min dch 10-100 ln m h h lospo i . N hiu qu h lospo i
trong chng thi cp t . Gi g h lospo i , t ng ln t hp
calcineurine- al oduli e h g v tr khc trong phn t. Chuyn ho gan
ph thuc vo cytochrome P450.

Liu: 0,3mg/kg/ngy chia 2 ln. N g t d t o g u n 5-15mg/l.

+ Huyt thanh chng bch cu lympho.

Cc globuline chng bch cu lympho. N lm gi l pho t T lu h h


lymphocyt ca cc t chc lympho nh hiu qa g c t o. N g th
tc dng ln cc th cm ca cc t o g hn hot ng ca chng.
Sau khi d g iu tr, s l g l pho t t g h g phn ng min dch qua
trung gian t bo vn gim. Thi gia iu tr thng kho g g trnh cc
tc dng ph: st, bnh huyt thanh gim tiu cu, gim bch cu, phn ng da.
c s d g d phng thi ghp ho thi thp. Liu lng ph hp
duy tr s l g l pho t di 300/mm3.
+ Cc khng th d g.

- Cc khng th OKT3

- Khng th d g hng CD25 (Basiliximab: Simulect, Daclizumab: zenapax).

+ Cc thuc c ch min dch khc.

Mycophenolat mofetil - MMF ell ept . l thuc c ch mnh, chn lc v


hi phc ca e n ca ng tng hp cc cht nn tng puric. N c ch
sinh s l pho t T B hot ho, gim tng hp khng th v c ch sinh
sn t bo c t a thnh mch.

Liu: g/ g gi ln. Cellcept dung np tt, t g c thn.

Rapa i e Rapa u e ha Si oli us . a g t o g u t h th nghim lm


s g giai on 3.

+ Thay huyt t g.

Tu theo t g t u g t ph chng thi ghp vi:

* 3 th thuc: Corticoide

Azathioprin/Mycophenolat moftil.

Ciclosporin/Tacrolimus.

* 4 th thuc: Corticoide

Azathioprin/Mycophenolat moftil.

Ciclosporin/Tacrolimus.

Globulin khng lympho


6.3- Bin chng ngoi khoa sm:

- Tc ngh ng mch ho t h ch.

-D c tiu.

6.4- Bin chng ngoi khoa mun:

- T ng bi niu do hoi t :

Ming ni niu qun - niu qun.

Ming ni niu qun - bng quang.

- Ri lon ch g g ua g.

- Hp ng mch thn.

- Nang lympho.

6.5- Nhim khun: C th lin quan vi dng thuc gim min dch:

- Do virus: cytomegalovirus (CMV).

- Do vi khun: vim b thn cp, Lao, Listeria monocytogen.

- Do nm: Candida albican.

6.6- Pht trin khi u:

- U g th da

- U lympho c tnh.

6.7- Bin chng lu di sau ghp.


- Vi h tim mch:

+ T g hu t p.

+ X a mch mu.

+ Nhi u ti .

- Vi h tiu ho.

+ Vim gan mn tnh do HBV

+ Vim gan mn tnh do HCV

+ Peliose gan.

+ Vim lot d dy - hnh t trng.

- Vi chuyn ho.

+ i ng

+ Hoi tu g khun.

+ Lo g g

+ Thng phong

+ a hng cu

+ Ri lon m mu

+ c thu tinh th.

6.8- Thn ghp mc bnh cu thn gi g h th .

7- Kt qu ghp.
Ngi ta phn bit thi gian sng thm ca bnh nhn v thi gian sng ca thn
ghp. Thi gian sng ca thn ghp l thi gian th gh p ch g kh g
cn lc mu.

Cc yu t chnh h h g n thnh cng ca ghp l thn cho t gi sng


cng huyt thng hoc khc huyt thng ho gi cht no, tui gi nhn,
tui gi cho, s ho hp HLA.

Theo cc Hi ghp thn Bc M v chu u:

+ Thi gian sng thm ca b h h : sau %; sau %.

+ Thi gian sng bo him ca th gh p: sau %; sau %.

Kt qu ca th gh p g h gi ng s phc hi ch g, to
tr g gi nhn tt ln, ht thiu mu, hc tp v cng tc tr v h thng,
cht lng cuc s g c ci thin.

Tt nhin s theo ri sau ghp rt quan tr g, gi nhn ung thuc chng thi
g h nh v tm l phi c n nh.

61.IU TR THN H

h gha

Hi chng th h l tp hp nhng du hiu v triu chng g : c tiu


c protein (trn 3.5 grams/ngy), gi p otei t o g u, t g holeste ol u
ph ede a . Nc tiu cn c cha m c th th di knh hin vi.

Nguyn nhn v yu t gu

C nhiu nguyn nhn khc nhau gy ra hi chng th h, l t th g thn,


c bit l t th g g u thn. L nguyn nhn bt thng lm xut
hi p otei t o g c tiu.
Ngu h thng gp nht tr em l bnh cu thn vi sa g th g ti
thiu, cn gi l gu h thng gp l vim vi cu thn mng(sang
th g g.

Hi chng th h th xy ra sau khi nhim trng, do thuc, nhi c thai


nghn, ri lon do di truyn, bnh t min, bnh h th g h tiu ng, lupus
a h th g, a u tu, v thoi ho dng bt. Hi chng th h th km
theo suy thn bao gm: vim vi cu th , ho u thn khu tr v tng vng.

Hi chng th h th xy ra mi la tui. tr em, hi chng th h


thng xy ra tui t 2-6 tui. g t h ph n.

iu tr

M tiu iu tr l nhm gim triu chng, nga bin chng v ko di thi gian
lui bnh, tlm chm qu trnh t th g thn. M tiu l e li cuoc sng
tt h ho gi bnh.

Thuc Corticosteroid, c ch min dch, h p v li tiu c th gip kim sot


triu chng.Khng sinh cn thit kim sot nhim trng. Thuc c ch men
chuyn lm gi g k l g p otei t o g c tiu v v v th g c
ch nh t o g iu tr hi chng th h.
Nu c cao huyt p, th cn phi iu tr mt cch nghim tc. Vi iu tr
holeste ol t igl e ide t o g u ao g th g c khuy o gim
gu a ng mch. Ch hn ch cholesterol v m bo ho g
mang li li ch , v s t g d g h l do s sn xut qu mc ca ga h
l do cung cp qu mc. Mt s thuc lm gim cholesterol v triglycerides c th
c khuyn dng.

Ch hiu protein v ha s khoa h t o g iu tr hi chng thn


h. nhiu bnh nhn, gi l g p otei o s gi lng protein
xut hi t o g c tiu. Trong nhiu t ng hp , a phi protein (1g
protein/ kg cn n g / g th g c khuyn co. Hn ch mui nghim ngt
gip kim sot triu chng ph. Vitamin D c th cn thit b sung nu hi chng
th h t h kh g p ng vi iu tr.
Ti lng

Kt qu rt tha i; hi chng th h th l cp tnh v din tin trong thi


gian ng , ha t h kh g p ng vi iu tr. Nguyn nhn v bin
chng ca b h g h h g n kt qu iu tr.

Bin chng

X a ng m h li ua n bnh l tim mch.

Thuyn t t h ch thn.

Suy thn cp

Suy thn mn

Nhim trng, gm ph cu trung

Su di h dng

Qu ti dch, suy tim sung huyt, ph phi

Khi no cn phi gi cho nhn vin y t ?

Bn hy gi cho nhn vin y t bit s u bn c triu chng ca hi chng


th h.

B g h gi o ho s it nu hi chng th h a bn khng thuyn


gim, d da, ha hng triu chng mi xut hi h : h u, st,
i da, ho, tiu kh, tiu t i.

B h n ngay phng cp cu hoc gi xe cp cu ti a ph g n (Tp HCM


bn gi s 115) nu b co git.

Phng nga

iu tr nguyn nhn gy ra l bin php phng nga hi chng th h.

Triu chng
Ph : ton thn, quanh mt, h , c bit l bn chn v mt c chn, b g g
ph, ph mt
Tiu t, c tiu c bt

T g do c
Ch
Cao huyt p

Du hiu v xt nghim

Khm thc th c th pht hin mt s triu chng. Mt s triu chng v du


hiu bnh nguyn nhn c th pht hin khi khm.

Ph t h c tiu c th pht hin mt lng l p otei t o g c tiu.


Th g g th c m t o g c tiu .

Xt nghim tm nguyn nhn gm

Xt nghim dung np glucose

Khng th khng nhn

Yu t thp

g lnh globulin

Xt nghim tm b th

Khng th vim gan B v C

Huyt thanh ch o gia g ai VDRL

in di protein trong huyt thanh

Sinh thit thn

Bnh ny c th c nhng kt qu xt nghi tha i:

Tr niu

Triglyceride
in di protein

St huyt thanh

Chosterol

Albumin

Nhi t g ng niu gi ln (Phn 1) ng tit niu l g?

ng tit niu l h thng bao gm thn, niu qun, bng quang v niu o.
T o g , g ai t the ht l 2 qu th , l ua u u hi
n di g s hng vo gia l g. Thn l u thi cc
cht khng cn thit di d g c tiu, duy tr nh s cn bng gia mui
v cc cht kh t o g u ng thi to ra mt hormone h tr cho s to
thnh hng cu. Niu qun l nhng ng hp d c tiu t th n bng
quang - mt khoang hnh tam gic h chu. Nc tiu c cha trong bng
ua g a a go i ua niu o.

Trung bnh mt gi ln thi kho g , l c tiu mt g . L g c tiu


tha i ph thu o l g c v th t gi tiu th. Th t h c
tiu to th h o a ng mt na vo ban ngy.

Tc hi ca nhi t g ng niu

Nhi t g ng niu l mt v sc khe quan trng h h g n hng


triu gi mi .

S nhi t g ng niu kh ph bin ch ng sau nhi t g ng h


hp. H g , hi t g ng niu l gu h th kh a khong
8 triu b s.

c bit, ph n d b nhi t g ng niu h do hng l do v ha


c bit r. C 5 ph n th c mt gi b nhi t g ng niu trong sut
thi gian sng.

Cc nguyn nhn gy nhi t g ng niu


Nc tiu h thng v trng. N cha dch, mui v cc cht thi h g
khng cha vi khun, virus v nm. Nhim trng xy ra khi vi sinh vt, thng l vi
khun t ng tiu ha, bm vo l m ca niu o v bt u nhn ln. Hu
ht cc nhi t g u khi pht t 1 loi vi khun l Escherichia coli (E. coli)
h thng sng trong trc trng.

Trong hu ht t ng hp, vi khun bt u h l u tin trong niu o.


Nhim trng ch gii hn niu o gi l nhim trng niu o. T , i khun
thng xm nhp vo bng quang gy nhim trng bng quang ( vim bng
quang). Nu kh g iu tr ngay, vi khun c th ln niu qun gy nhim
trng th i i thn).

Cc vi khu Chla dia M oplas a g th gy nhim trng niu c


nam v n gii h g h g khu h hng t gii hn niu o v h sinh
dc. Khng ging E. coli, Chlamydia v Mycoplasma c th ly nhim qua giao hp
do i hi iu tr ng thi c gi.

H thng tit niu c cu t gi p g ga nhim trng. Niu qun v bng


ua g thng g kh g ho c tiu ch gc v th d g c tiu
t bng quang s lm tri vi khun ra khi th. nam gii, tuyn tin lit to
ra cc cht tit lm chm s pht trin ca vi khun. Ngoi ra, c 2 gii, hng
ro min d h g gi p g chn nhim trng. Tuy vy, nhim trng vn c th
xy ra bt k nhng s bo v trn.

Nh g i t g gu

Mt s gi d b nhi t g ng niu h h g gi khc. Bt c mt


khuyt tt no ca ng tit niu g n dng chy ca c tiu ( v d si
th g th gy nhim trng. Tuyn tin lit ln c th lm chm dng chy
ca c tiu do g l t g gu him trng.

Ngun nhi t g th g thng l ng thng tiu hoc nhng g t vo


bng quang. Nh g gi khng c kh g tiu tin do bt tnh hoc bnh
n g th g t ng thng tiu trong mt thi gian di. Mt s gi, c
bit l gi gi hoc nh g gi b ri lon thn kinh nng mt kh g iu
khin qu trnh tiu tin c th cn ng thng tiu sut i. Vi khun trong ng
thng tiu c th gy nhi t g g ua g, do h i nh vin phi
c bit quan tm gi cho ng thng tiu v trng v rt ra cng sm cng tt.

Nh g gi b tiu g gu him trng niu ao h i nhng thay


i ca h thng min dch. Bt k ri lon no gy suy gim h thng min dch
g s l gia t g gu hi t g ng niu.

Nhi t g ng niu c th xy ra tr em b khuyt tt bm sinh ng


tit niu, nhng khuyt tt i khi phi c n s can thip ca phu thut.
Nhim trng niu him khi xy ra tr em nam v nam thanh nin. ph n, t l
nhim trng niu th g gia t g theo tui.

Cc nh nghin cu v ha gii thch chc chn v sao ph n d nhim trng


niu h a gii. Mt l do c th l niu o ca n ng h i khun d
xm nhp o g ua g h . B h , l m niu o ph n g gn
ngun vi khun t hu o h . Vi rt nhiu ph n, s giao hp c
v h khi u cho s nhim trng mc d nguyn nhn ca mi lin h ny vn
ha c bit r.

Theo nhiu ti liu, nhng ph n dng mng trnh thai d nhim trng niu h
d g ph g ph p t h thai kh . G , h ghi u pht hin
rng nu gi g d g ao ao su ha bt dit tinh trng khi giao hp th
gi ph n khu h h g gia t g s pht trin ca E. oli t o g o.

Cc v v s ti nhim.

Nhiu ph n b nhi t g ng tiu thng xuyn. Gn 20% ph n nhim


t g ng niu b ti nhim 1 ln na, v 30% nhng ph n ny s li b ln
tip theo, trong s % s tip tc ti nhim nhiu ln sau na.

Th g thng ln nhim trng sau gy ra bi mt dng hoc mt loi vi khun


khc vi ln nhi t g t , iu gha l hng ln nhim trng
hon ton ring r vi nhau. (Ngay c khi rt nhiu nhim trng c nguyn nhn
t E. oli h g n c s khc bit nh gia nhng vi khun ny cho thy s
nhim trng ring bit).
Cc nghin cu ca Vin Sc Kho Quc Gia M NIH a a t nguyn nhn
gy ti nhi t g ng niu c th l do kh g tn cng cc t bo biu m
ng niu ca vi khun. Mt ti liu g a NIH g ho thy nhng ph
n b ti nhim c th c cng mt h u o . Mt s nh khoa hc xem
xt rng nhng ph n c cc nhm mu ny d b nhi t g ng niu v t
bo biu o v niu o cho php vi khun tn cng d d g h . C
nghin cu t o g t g lai s tip tc nghin cu a a n cht mi lin h ny
g ph g ph p hn bit nhng ph n gu hi t g ng niu
cao

Nhi t g ng niu gi ln (Phn 2)

Ph g ph p iu tr nhi t g ng niu

Nhi t g ng niu iu tr bng thuc khng sinh. Vic chn la


thuc v thi gia iu tr ph thuc vo tin s bnh nhn v loi vi khun gy
nhim bit c qua xt nghi c tiu. Th nghi nhy cm gip ch rt
nhiu ho s t o g ic chn la loi thuc tt nht. Loi thu th g c
dng nht iu tr nhi t g ng tiu thun l trimethoprim
(Trimpex), trimothoprim/sulfamethoxazole (Bactrim, Septra, Cotrim), amoxicillin
(Amoxil, Trimox, Wymox), nitrofurantoin (Macrodantin, Furadantin), v ampicillin.

Th g thng, nhi t g ng niu iu tr t o g g n 2 ngy


nu tnh trng nhi t g kh g i k i s tc nghn hay ri lon thn kinh.
Tuy nhin, nhiu s ho nh nhn u g kh g si h t o g g n hai tun
m bo rng s nhi t g ho to ht. Ph g ph p iu tr bng
mt liu duy nht khng nn dng cho mt s nhm bnh nhn, v d, nhng
b h h iu tr tr hay c du hiu nhim trng thn, bnh nhn b tiu
ng hay bt thng cu trc hoc nh g gi g nhim trng tuyn
tin lit. Thi gia iu tr g phi l u h nhng bnh nhn b nhim
M oplas a ha Chla dia, t ng hp th g iu tr bng
tetracycline, trimethoprim/sulfamethoxazole (TMP/SMZ), hay doxycycline. Cn
lm thm mt xt nghi c tiu na chc ch l ng niu ht
nhi t g ha. iu ny rt quan tr g i vi ton b ti t h iu tr bi
v nhng triu chng c th bin mt t c khi tnh trng nhi t g y
li hon ton.

nhng bnh nhn nng b nhim trng thn c th phi nm vi n khi h c


th t ung thu c. Nhim trng th thng phi iu tr bng khng sinh
trong vi tun. Mt s nghin cu i hc Washington cho thy liu php 2
tun b g TMP/SMZ g hiu qu h ph g ph p iu tr trong 6 tun vi
cng loi thuc nhng ph n b nhim trng thn m kh g li ua n tnh
trng tc nghn hay ri lon h thn kinh. Trong nh g t ng hp ny, nhim
trng thn t khi gy hy hoi th ha l h thn tr khi h kh g iu tr.

Rt nhiu loi thuc c tc dng gi au t o g hi t g ng niu. Mt ci


m nng hay t c g t dng. Nhiu s khu ung
nhiu gip lm s h ng niu. Trong lc ny, tt nht l trnh dng c
ph, u, v th hiu gia v. (iu m mt gi ht thuc c th l
tt cho bng quang ca h l b thuc. Ht thu l c bit l mt nguyn
h h h g u g th g ua g .

Nhi t g ng niu thai ph

Ph n thai kh g gu hi t g ng niu ao h hng ph n


khc. Tuy nhin, khi thai ph b nhi t g ng niu, vi khun li d xm nhp
th h .

Theo mt s bo co, kho g n 4% ph nh c thai b nhi t g ng


niu. Cc nh khoa h gh ng s tha i v ni tit v s dch chuyn v tr
mt s ua a h niu trong thai k to iu kin thun li cho vi khu i
gc niu qun ln th . Do , hiu s ngh nn xt nghi c tiu
nh k .

Nhng triu chng ca nhi t g ng niu.

Khng phi tt c mi gi b nhi t g ng niu u c triu chng,


h g hu ht mi gi u c t nht mt vi biu hin bt thng. Nhng
triu chng ny bao gm cm gic mu i tiu cp h au t g g
quang hoc niu o trong khi tiu. Bnh nhn t khi cm thy mt mi, run ry,
a h ao ha au khi kh g i tiu. Ph n thng cm thy nng kh chu
di g u, t s nam gii th th y trc trng. Bnh nhn nhim
t g ng niu thng than phin ch tiu c rt t mc d cm gic rt mc
tiu. Nc tiu thng tr g c hoc ln cn thm ch c th hi nu c
mu. Nu b st th gha hi t g l ti thn. Cc triu chng khc ca
nhim trng thn g au sau l g hoc hai bn h g di g sn, bun i
hoc i.

tr em, cc triu chng nhi t g ng niu c th kh g c ch hoc


b che lp bi nhng ri lo kh . N gh n nhi t g ng niu khi thy
a tr kh chu, k , st khng gim khng r nguyn nhn, tiu khng kim
so t i dm) hoc tiu chy, hoc chm l . N a t kh s
nu thy c nhng triu ch g t , c bit khi c nh g tha i bt thng
t o g c tiu ca tr.

Ch o hi t g ng niu h th no ?

pht hin nhi t g ng niu, s s xt nghim mu c tiu tm m


v vi khun. B h h ngh a u c tiu "sch" bng cch ra k
vng sinh dc v ly mu c tiu "gia dng" vo l cha v khu . Ph g
php l c tiu gn chn s xm nhp ca vi khun quanh vng sinh dc
vo mu xt nghim lm h h g n kt qu . Thng mu s c gi n
phng xt nghim mc d mt s ph g kh s th c trang b thc
hin cc xt nghim ny.

Trong xt nghi ph t h c tiu, c tiu s c ki t a pht hin t


bo hng cu, bch cu v vi khu . Sau i khun s c nui cy trong mi
t ng thch hp c th nghim vi cc loi kh g si h kh hau tm ra
loi thu iu tr hiu qu nht. Bc cui g c gi l xt nghim th
nhy.

Mt s vi khu h Chla dia M oplas a h c th c pht hin vi mi


t ng nui c c bit. B s ghi g bnh nhn b nhim trng loi ny nu
gi bnh c triu chng nhi t g ng tiu v c m t o g c tiu
h g kh g c vi khun trn nh g i t g th g thng.
Khi nhi t g kh g iu tr trit v st li cng mt dng vi khun,
s s ch nh mt xt nghi a a h h h ng niu. Mt trong cc
ph g ph p l hp X quang b th ua t h ch (intravenous pyelogram-
IVP). N s a a h h nh X quang ca bng quang, thn v niu qun. Mt cht
nhum c ua g ti o t h h t c khi chp mt lot phim X
quang. Phim X quang s cho thy lp lt ca ng niu, bc l nh g tha i
d rt nh trong cu trc ny.

Nu b ti nhi t g, s th ngh siu a a hng hnh nh


phn m ca nh g ua t o g. Mt xt nghim hu ch khc l soi bng
quang. ng soi bng quang l mt dng c to bi mt ng ngn c rt nhiu
thu knh v ngu s g ho ph p s ua s t t o g g ua g ua iu
o

Nhi t g ng niu gi ln (Phn cui)

Ph g ph p iu tr nhi t g ng niu

Nhi t g ng niu iu tr bng thuc khng sinh. Vic chn


la thuc v thi gia iu tr ph thuc vo tin s bnh nhn v loi vi
khun gy nhim bit c qua xt nghi c tiu. Th nghi
nhy cm gip ch rt nhiu ho s t o g ic chn la loi thuc tt nht. Loi
thu th g c dng nht iu tr nhi t g ng tiu thun l
trimethoprim (Trimpex), trimothoprim/sulfamethoxazole (Bactrim, Septra,
Cotrim), amoxicillin (Amoxil, Trimox, Wymox), nitrofurantoin (Macrodantin,
Furadantin), v ampicillin.

Th g thng, nhi t g ng niu iu tr t o g g n 2 ngy


nu tnh trng nhi t g kh g i k i s tc nghn hay ri lon thn kinh.
Tuy nhin, nhiu s ho nh nhn u g kh g si h t o g g n hai tun
m bo rng s nhi t g ho to ht. Ph g ph p iu tr bng
mt liu duy nht khng nn dng cho mt s nhm bnh nhn, v d, nhng
b h h iu tr tr hay c du hiu nhim trng thn, bnh nhn b tiu
ng hay bt thng cu trc hoc nh g gi g b nhim trng tuyn
tin lit. Thi gia iu tr g phi l u h nhng bnh nhn b nhim
M oplas a ha Chla dia, t ng hp th g iu tr bng
tetracycline, trimethoprim/sulfamethoxazole (TMP/SMZ), hay doxycycline. Cn
lm thm mt xt nghi c tiu na chc ch l ng niu ht
nhi t g ha. iu ny rt quan tr g i vi ton b ti t h iu tr bi
v nhng triu chng c th bin mt t c khi tnh trng nhi t g y
li hon ton.

nhng bnh nhn nng b nhim trng thn c th phi nm vi n khi h c


th t ung thu c. Nhim trng th thng phi iu tr bng khng sinh
trong vi tun. Mt s nghin cu i hc Washington cho thy liu php 2
tun b g TMP/SMZ g hiu qu h ph g ph p iu tr trong 6 tun vi
cng loi thuc nhng ph n b nhim trng th kh g li ua n tnh
trng tc nghn hay ri lon h thn kinh. Trong nh g t ng hp ny, nhim
trng thn t khi gy hy hoi th ha l h thn tr khi h kh g iu tr.

Rt nhiu loi thuc c tc dng gi au t o g hi t g ng niu. Mt ci


m nng hay t c g t dng. Nhiu s khu ung
nhiu gip lm s h ng niu. Trong lc ny, tt nht l trnh dng c
ph, u, v th hiu gia v. (iu m mt gi ht thuc c th l
tt cho bng quang ca h l b thuc. Ht thu l c bit l mt nguyn
h h h g u g th g ua g .

C ph g ph p iu tr ti nhim

Khong 4 trong 5 ph n b nhi t g ng niu s b li trong vng 18 thng.


Nhiu ph n cn b th g u h . Mt ph n thng xuyn b mc bnh
ny (t 3 ln tr ln trong mt hi s mt trong nhng cch sau
:

Ung khng sinh liu thp v d h TMP/SMZ ha it ofu a toi mi ngy trong
6 thng ho l u h . Nu u g t khi i g, thuc s c gi li trong
g ua g l u h th s hiu qu h . Mt cuc nghin cu i hc
Washi gto c ti tr bi NIH cho thy liu php ny t ra hiu qu v khng
gy tc dng ph nghim trng no.

Ung mt liu khng sinh sau khi giao hp.


iu tr bng khng sinh trong thi gian ng n 2 ngy) khi xut hin triu
chng.

C th dng que th nhanh, que th s i mu khi c s nhim trng.

Que th s d tm nitrite, cht c to thnh khi vi khun bi i nitrate trong


c tiu thnh nitite. Th nghim ny c th pht hi % t ng hp nhim
t g ng tiu v rt hu h i vi ph n hay b nhim trng.

Mt s s ngh thm mt s ph g ph p ph n c th t phng trnh


nhim trng:

1. Ung tht nhiu c mi ngy. Mt s s ngh u g c tri man


vit quc, n tc dng tt trong vic c ch s pht trin ca vi khun bng cch
a id h a c tiu. B sung thm Vitamin C (Ascorbic Acid g t dng
t g t.

2. i tiu ngay khi bn cm thy cn, khng nn c nhn.

3. Lau t t a sau trnh vi khun xung quanh hu mn xm nhp vo


o hay niu o.

4. Tm bng vi sen thay v tm trong bn.

5. Lm v sinh vng sinh d t c khi giao hp.

6. i tiu ga t c v sau khi giao hp.

7. Trnh s dng thuc xt v sinh ph khoa i h g se , th gy kch


thch niu o.

Ph g ph p iu tr nhi t g ng niu thai ph

Mt ph n a g a g thai nhi t g ng niu c iu tr ga


trnh sanh non v nh g gu kh d h ao hu t p. Mt vi loi khng
sinh khng an ton cho ph n mang thai. Trong vic ch ph g ph p iu tr,
s hc rt nhiu yu t h hiu qu ca thu , giai on mang thai, sc
khe ca gi m, v nhng h hng c th xy ra cho thai nhi.
Cc bin ch g v h iu tr

Nhi t g ng niu c th xy ra bin ch g khi d g c tiu b tc nghn


(tnh trng tc nghn), nhim trng mt i kh ha to th him trng
huyt), v h huyt p mt cch nguy him (sc). Nhng tnh trng tim n sau
l h hi ng d c tiu (v d h si thn hay cc bnh v h thn
kinh d n suy bng quang) c th gy ra bin chng. iu tr nhim trng xut
pht t s tc ngh ng tiu hay ri lon h thn kinh ph thuc vo vic tm
ra cc tnh trng tim n v x l h g, i khi n phu thut. Nu gu
gy b h kh g iu tr, nhm b h h gu b t th g
th . H a, s nhi t g thng do nhiu loi vi khu h , i khi
th do nhiu loi vi khun cng mt lc.

Nhi t g ng niu nam gii

Nhi t g ng niu t gp nam. Nhi t g thng do c mt s tc


nghn, v d, mt vin si ng niu hay tuyn tin lit to hay mt th thut y
khoa c s dng g th g. B u tin l tm ra vi sinh vt gy nhim trng v
thuc m n nhy c . Th g thng, nam gii, s ngh mt qu trnh
iu tr l u h trnh nhim trng tuyn tin lit. Nhim trng tuyn tin
lit kh iu tr h i v khng sinh khng th xm nhp vo m tuyn tin lit
mt cch hiu qu c. V v , g nhim trng tuyn tin lit thng
phi iu tr lu v chn la k khng sinh.

Nh g iu cn nh v nhi t g ng niu gi ln

ng niu bao gm thn, niu qun, bng quang, niu o.

Mt s gi gu nhi t g ng niu nhiu h gi khc.

Mt ph s ph n b nhi t g ng niu t nht mt ln trong cuc


i h.

Khng phi ai b nhi t g ng niu g t iu chng. Triu chng


thng gp l hay mc tiu v rt, but khi i tiu.
Nhng tnh trng tim l h hi ng d c tiu c th gy ra nhim
t g ng niu c bin chng.

62.BNH I MU

G i u i th v i u vi th

i u i th

i/ h gha

L tnh trng c tiu c mu, vi s lng hng cu trn 300.000/mm3, hoc


500.000/mn

Nguyn nhn chnh hoc do t th g ng niu hoc dot th g hu


thn

ii/ Ch o :

1/ Nghim php ba cc:

l c tiu u bi , gia bi, cui bi.

+ C u c mu, do chy mu niu o , tuyn tin lit.

+ Cc cui c mu: mu chy t bng quang.

+ C ba cc c mu: nguyn nhn do nhu m thn, ho do ng niu trn.

2/ Cn addis: cho b h h i ht bui s g, sau h l c tiu xt


nghim( ly 10ml li tm, gi li l m cc thnh ph t o g c tiu) bnh
thng hng cu< 1000 v bch cu< 2000.

3/ Cc triu chng lm sng km theo:


+ au un thn

+ Ri lon tiu tin

+ C c u g t th g ng niu)

+ Thn to.

+ Bt thng bng quang, tuyn tin lit khi th t c trng.

4/ Cc xtt nghim khc:

+ Proteine niu 24h:

- Nu > , g / h, gu h thng do nhu m thn.

- Nu t th g l i u do ng niu.

+ Tr hng cu nu c l do t th g hu .

+ suy th u e, eati i e u ao thng do nguyn nhn cu th , i khi


g do ng niu h g t h .

+ T bo niu, cy vi khu tha i trong nhim trng tit niu.

+ UIV: c ch nh vi hu ht t ng hp i u i th. tuy nhin khi


khng c biu hin bt th g th g khng th loi tr cc nguyn nhn
khng phi cu thn. uiv cho thy hnh nh:

- Khi u thn ho ng niu

- Si.

- Du hiu lao thn.

- th thy u bng ua g, ph i tuyn tin lit...

+ Siu m tm cc bt thng ti th ng niu.

+ Soi g ua g nh t th g iu o, bng quang, tuyn tin lit. quan


st v tr mu chy t niu qun bn no.
+ Chp ct lp.

+ Chp mch thn.

+ Sinh thit thn trong bnh l cu th , t o g i u k o d i.


iii/ Ch o gu h :

1. Khi u:

- U g th thn

- U ng niu, u g th tu n tin lit, polype niu o n, u g th g ua g,


polype bng quang

2. nhim trng:

- Lao thn

-Giun ch.

- Vim bng quang.

- Vim thn b thn.

3. D dng

- D dng mch mu.

- Th a a g.

4. bnh l v thn, cu thn

- Hoi t nhu m thn.

- Bnh l cu thn cp tnh v mn tnh.

- Bnh l ng thn

5. Bnh l tuyn tin lit.

- Nhim trng.

-U

- Vim.

6. Nguyn nhn do si thn, niu qun, bng quang.


7. B h to th h nh mu. ng c

iv/ Ch o ph it:

- Chy mu sinh dc n.

- Chy mu sinh dc nam.

- ih oglo i e

- i oglo i e.

- Nc tiu sm mu do mui mt, melanine.

- Porphyrine niu c tiu u porto

- Thuc riphampicine, phenolphtaleine.

i u i th

. h gha: c tiu c hng cu trn 5/ mm3 hoc 5000/mn

2. xt nghi nh bng que th c th d g t h gi vi t ng hp:

- hb, myoglobuline trong c tiu.

- ch u ng sinh dc.

- nhim trng

3. xt nghim

- cc thnh ph c tiu: so lng hnh dng hng cu, tr ht.

- creatinine mu, proteine niu 24h, uiv, soi bng quang, siu m...
4. nguyn nhn

- bnh l cu thn hay gp nht, phi hp vi tr niu, proteine niu.

- nhim trng.

- khi u th , ng niu.

- si tit niu.

- bnh mu: gim tiu cu.

- bnh tim gy nhi mu nh thn

- thuc: aspirine, ch g g.

Ch : tt c t ng hp i u phi gh ti nguyn nhn khi u

63.NHIM KHUN TIT NIU

1. Dch t hc

- L bnh rt thng gp trong c g ng (v d Thu in 7,8% tr gi v 1,6%


tr t ai n tui i hc c triu chng NKTN, mt na s ny l do vim bng
quang cp; M mt na s ph n c t nht mt ln b NKTN t o g i); Vit
a ha s liu thng k chnh xc;

- Tn xut mc bnh nam gii thp h hiu ln so vi n gii (v d M


khong 5- t ng hp/10 000 nam gii tui tr t u g i / ;

- NKTN cp tnh c th iu tr khi hn; tuy nhin nu khng c bin php


phng nga iu tr thch hp c th ti pht nhiu ln v d n suy thn
mn tnh

2. i g v gii phu h tit niu


- V tr: 2 thn nm sau phc mc, trn thnh bng sau; thn phi thp h thn
tri.

- K h thc trung bnh: nam gii khong 11 x 6 x 3cm

n gii khong 10 x 6 x 3cm

- Lin quan

Th t i: l h, u i tu, mt sau d d , i trng (ph t i i trng ngang v


g i trng tri);

Thn phi: gan, ti mt, cu g ga , o hai t t g, i rng (phn phi i


trng ngang v gc phi);

Tuy thng thn p ln cc trn mi thn.

- Bao thn

Bao mc (mc thn);

Bao m (lp m quanh thn);

Bao thn thc s ao .

- Nhc thn: gm tu thn trong nu sm, v thn ngoi st bao thn v nht
u h .

-Rn thn: g t h ch th , ng mch thn, b thn, cc mch bch huyt


v cc si th ki h i ua.

- B thn: bn trong th th hia th h i thn.

- Neph o : l ch g thn bao gm cu thn, ng thn ( g ln gn,


ng ln xa, quai Henle v ng gp), b my cn cu thn v m k thn.

- Niu qun
Niu qun di khong 25cm, g o : on b g, on chu h g on
trong thnh bng quang (b th c gi l b niu qun v v th conf
oi h t phn ca niu qun).

Niu qu on bng: nm trn b trong ca tht l g to;

Niu qu on chu hng: chy trn thnh bn ca chu h g, t ng mch


chu trong, ti ga t c gai ngi niu qu g a t o t o g i o
bng quang;

Niu qu on trong thnh bng quang: chy chch qua thnh bng quang trn
mt on di khong 2cm.

S cp mu: t trn xu g di ng mch ch, ng mch th , ng


mch tinh hon (hoc bung tr g , ng mch chu t o g ng mch bng
quang cp mu cho niu qun.

Niu qu t g i hp ti i

- ch tip ni gia b th u trn ca niu qun;

- eo trn ch niu qun bt h o ua ng mch chu;

- ch niu qu vo bng quang.

-Bng quang

- Ph a t c: lin quan vi khp mu;

- Ph a t : c phc mc bc, cc quai rut o i t g sig a l g


quang. n t cung ta trn mt sau ca bng quang;

- Pha sau: a li ua n trc trng, phn ni cc ng dn tinh v cc ti


tinh; n lin quan vi o v phn c t cung trn m o;

- Pha ngoi: lin quan vi g hu t trong;

- C bng quang nam dnh lin vi tuyn tin lit, n c bng quang nm ngay
trn phn mc chu bao quanh niu o.
-Niu o

- Niu o nam: di kho g , hia th h o : on tin lit, on mng


on xp.

+ Niu o tin lit di kho g , i ua tu n tin lit;

+ Niu o mng di kho g , u ua tht vn niu o v l m


chu ph mt di ca tht vn;

+ Niu o xp di kho g i ua t xp ca d g t.

- Niu o n: di kho g , i ua tht vn niu o v n t o.

-Tuyn tin lit: c hnh thp, di khong 3cm v bao quanh niu o tin lit.

Lin quan

- Pha trn: lin tip vi c bng quang, niu o i o t trn ca tuyn tin
lit gn b t c ca mt trn;

- Ph a di: nh tuyn tin lit n t tht vn niu o;

- Ph a t : li ua n khp mu;

- Pha sau: lin quan vi mc Denonvilliers v qua mc ny vi trc trng;

- hai bn: lin quan vi g hu mn.

. h gha

-NKTN thp: vim bng quang. Nhim khun bng quang (BQ), c th xut hin
c hoc trong bnh cnh chung ca vim thn b thn (VTBT) hay vim
tuyn tin lit.

- Vim bng quang (VBQ) khng bin chng: l VBQ cp ph n tr khng mang
thai.

- VBQ c bin chng l khi c phi hp vi cc tnh tr g l t g kh g iu


tr tht bi (v d NKTN cao hay c vi khu kh g a thuc)
-NKTN cao: vim thn b thn. Vi khun xm ln vo h th g i thn v c
th c nhu m thn gy t th g i him khun.

4. Nguyn nhn

Nguyn nhn vi khun

- Vi khu G a > % t ng hp), vi khu g a d g < %

+ E. Coli

+ Staph. Saprophyticus

+ Proteus mirabilis

+ Klebsiella species

+ Enterococci

+ Chlamydia

- Vi khun bnh vin/nm/virus

+ Pseudomonas aeruginosa

+ S. aureus

+ Ca dida, o idioido osis, to o us eofo a s

+ Ade o i us, pol o a i us

Yu t thun li

- Tc ngh ng tit niu: si, u, d dng thn-niu qu

- Cc nguyn nhn khc: th a a g, thai gh , i th o ng, pht gc


BQ-niu qun, can thip ng tit niu

. C h bnh sinh

- Ph n: vi khun gy bnh t hu o o, ln niu o & BQ thng


thng qua quan h tnh d . Ngu NKTN t g khi s dng bin php trnh thai
bng ho cht dit tinh trng, nht l khi dng phi hp vi g g o
do l tha i i t g o vi khun gy bnh nhn ln)

- T h c ca vi khun: 1 s VK mang nhm quyt h c tnh, cht dnh b


mt gn vi cc th th trn t bo biu m nim m ng tit niu; 1 s VK
bi tit 1 s c t/enzym gy t th g t bo hoc gy phn ng vim.

- ng vo

+ ng mu: t gp. Hay phn lp c S. aureus, P. aeruginosa, Candida spp.


c bit khi c tc nghn.

+ g gc dng: l ch yu.

6. Ch o

a/NKTN thp

Triu chng lm sng

- VBQ khng bin chng

- Hi ch g BQ: i ut, i t, au h v v/ho i u

- Thi gian 6- g sau t ht.

- VBQ c bin chng

- Hi chng BQ

- Km theo mt hoc vi yu t gu sau:

+ gii nam

+ tui cao

+ nhim khun mc bnh vin

+ c thai

+ so de BQ lu
+ mi c can thip ng tit niu

+ c bt thng v gii phu hoc ch g h tit niu

+ NKTN tr em

+ mi s dng khng sinh

+ triu chng ko di trn 7 ngy

+ b h h i th o ng

+ tnh trng c ch min dch

+ tr c tiu i : ph i lnh tnh tuyn tin lit

Cc xt nghim cn lm sng

-Xt nghi c tiu

- Bch cu niu nhiu (>5000/pht), l bch cu a h tho i ho + hng cu


(khng bin dng);

- Nitrit + khi s d g ue h g nhy 75- %, c hiu 94- % i vi s


lng bch cu > / i t g t g ng > 105 VK nhm Enterobacteriaceae/ml
c tiu); test c th m tnh gi khi nguyn nhn l cc chng vi khun khng
chuy c nitrat thnh nitrit (enterococci, staphylococci) v khi s lng vi
khu t o g c tiu t;

- VK niu >100 000/ml (c c tiu gia dng), mi s lng (c c tiu ht


ua g u , t s phng th nghim ly gi tr gii hn l >103 VK/ml; cn
xem xt ch o khi > 2 VK/ l c tiu gia d g nhy ca test 88%);

- Protein niu + + khi i u, i , trong bnh cnh chung ca VTBT)

-C th d kh :Th d h h nh c th thy nguyn nhn thun li (tc


nghn, d d g ng tit niu, d vt

b/ NKTN cao
Cc triu chng lm sng

-Vim thn b thn cp

- St (>38oC) + rt run + hi chng nhim trng

- au h g l g + au g sn-ct sng

- Nn, bun nn

- Nc tiu c +

- Hi chng bng quang +

-Vim thn b thn mn

- Giai on s ha su thn

+ t VTBT cp ti pht nhiu ln + nguyn nhn thun li

+ i tiu : t g s l i tiu v s l g c tiu a

- Giai on mun c suy thn: triu chng v din bin ca suy thn m , h

+ thiu mu

+ THA thng gp khi c suy thn nng

+ cc triu chng ca suy th giai on mun (tham kho thm bi "Suy thn
mn")

Cc xt nghim cn lm sng

-VTBT cp

- Xt nghi c tiu

+ Bch cu niu nhiu (>5000/pht) + tr bch cu + hng cu (khng bin dng)

+ VK niu >100 000/ml (c c tiu gia dng), mi s lng (c c tiu ht


ua g u
+ Protein niu thng <1g/ngy)

+ Nitrit pht hin bng que nhng khng nhy (35-38%) v vy khng phi l mt
test g ti , go i a kh g nh c vi khun gy bnh;

- Xt nghim mu

+ Bch cu u t g, h yu l bch cu a h t u gt h

+ T mu l g, CRP t g

+ Cy mu c th + c bit khi t st + rt run)

+ Khi c suy th : t g u , eati i u

+ C th t g ng mu

- Th d h h th i X ua g, siu , s i tig aph : thn b b h to h h


th g + i thn gin + vim nhim khun + p xe + nguyn nhn thun
li (si, u, d d g ng tit niu

VTBT mn

- Giai on sm

+ khi t cp: ging VTBT cp

+ t tr g c tiu gim (ti a < , ,t u g h ,

+ protein niu thng xuyn, s lng t <1g/ngy

+ mc lc cu th MLCT h thng

+ th d h h th i: th kh g u (so co ko v thn) + dn v/hoc bin


dng h th g i thn cc m khc nhau

- Giai on mun

+ thiu u, t g ng vi m suy thn

+ cc ch s ch g thn suy gi t g u , eati i u; gim MLCT)


+ th d h h th i: thn bnh nh h h th g k h thc 2 thn khng
g u), b g gh + bin dng h th g i thn.

Ch o nh NKTN da vo kt qu xt nghi c tiu

- xt nghi c tiu (bch cu niu nhiu + tr bch cu + hng cu niu khng


bin dng, cy c vi khun).

7. Ch o ph it

-Hi chng BQ khng do nhim khun

+ u BQ

+ vim phn ph, i trc trng, si BQ hoc niu qun thp khng nhim khun

- VBQ do thuc, tia, d vt

- Vim thn k

- Thiu sn thn bm sinh

- Cc nguyn nhn khc gy suy thn (bnh l cu thn, mch th

. iu tr

- Nguyn t iu tr

- Chng nhim trng

+ khng sinh: trong c g ng la chn theo kinh nghim, trong bnh vin la
ch theo kh g si h

+ thuc st khu ng tit niu

- U g c, v si h, di h d g

- iu tr nguyn nhn thun li


- Dn lu khi tc ngh bo tn ch g thn

- iu tr NKTN thp

- VBQ khng bin chng

+ Ph 1 ngy (liu duy nht): Pefloxacin 800mg, Ofloxacin 400mg.


Cip oflo a i g ng ung

+ Ph 3-5 ngy: thuc st khu ng tit niu, quinolon hoc


fluoroquinolon, beta-la ta i , t i ethop i /sulfa etho azole ng ung;
cc thuc nhm beta-lactamin nn s d g g h l g

+ Ph 7-10 ngy: c th s dng nitroxolin, nitrofurantoin. Ngoi ra cc khng


sinh trimethoprim/sulfamethoxazole, nhm beta-lactamin, quinolone,
fluo o ui olo e g th s dng 7- g h g kh g thy r s t g
hiu qu iu tr m c th g t g t dng ph ca thuc

+ T l khng ampicillin v sulfamid rt cao, v vy khng nn s dng cc loi


khng sinh ny trong la ch iu tr theo kinh nghim c g ng

+ T l khng trimethoprim v/hoc trimethoprim-sulfa etho azole g a g


t g dn (tu theo vng), v vy cn xem xt khi la ch t o g iu tr a u

+ T l khng nitrofurantoin ca E. Coli < %, h g thuc khng c tc dng


i vi cc chng Proteus, mt s chng Enterobacter v Klebsiella

+ T l vi khun khng fluoroquinolon trong hu ht cc nghin cu cn <5%.

- VBQ cp ph n c thai

+ Ph ki h in 7-10 ngy: nitrofurantoin (100mg x 2 ln/ngy), nitroxolin


(200mg x 3 ln/ngy);

+ Ph 3-7 ngy: mt s tc gi xut thi gian dng khng sinh l 3-7 ngy
cho ph n c thai c triu chng VBQ cp (khi chc chn khng c vim thn b
thn), thi gian dng ng h hm m h gim thi gia phi him vi
khng sinh ca thai nhi. C th s dng amoxicillin (250mg x 3 ln/ngy),
cephalexin (500mg x 2-4 ln/ngy), amoxicillin-clavulanat (500mg x 2 ln/ngy
hoc 250mg x 3 ln/ngy), trimethoprim/sulfamethoxazole (160/800 x 2 ln/ngy
v khng dng 3 thng cui), cefpodoxim (100mg x 2 ln/ngy); cefixim
(400mg/ngy);

+ Khng nn s dng fluoroquinolone cho ph n c thai.

- Vim bng quang c bin chng

+ Cc khng sinh nhm fluoroquinolone l la ch h g u; c th s dng


ciprofloxacin (500mg x 2 ln/ngy), pefloxacin (400mg x 2 ln/ngy), levofloxacin
(500mg x 2 ln/ngy), ofloxacin (200-300mg x 2 ln/ngy), norfloxacin (400mg x 2
l / g ng ung;

+ C th s d g kh g si h g t h ch trong mt s t ng hp (khi nghi


vi khu kh g a thuc hoc khng dung np thu ng u g , h
levofloxacin (500mg/ngy), ceftriaxon (1g/ngy), aminosid (gentamicin hoc
tobramycin 3-5mg/kg/ngy). Nu nghi ng c vi khu G a d g sung
ampicillin 1g 6 gi 1 ln hoc amoxicillin 500mg ung 8 gi 1 ln;

+ Thi gia iu tr th g thng 7-14 ngy; triu chng lm sng c c ci


thin sau khi bt u iu tr n 48 gi nu ch o g iu tr thch
hp;

+ Nu triu chng khng ci thin cn cy li c tiu th d th tm


cc b h l ng tit niu

- Vim bng quang cp nam gii tr

+ Fluo o ui olo e l h c la ch h g u v tc dng dit khun v c


kh g i o tu n tin lit;

+ Thi gia iu tr thng ko di 7 ngy

+ Khng nn s dng nhm beta-la ta i it ofu a toi do kh g t nng


dit khun v khng c kh g th hp vo tuyn tin lit;
+ Khi c NKTN ti pht nhiu ln cn tm nguyn nhn tai tuyn tin lit hoc cc
bt thng v gii phu ng tit niu.

- iu tr NKTN cao

- Nguyn t iu tr

- Chng nhim khun

- B d h, di h dng

- D lu c tiu khi c tc nghn

+ d lu iu qun

+ d lu thn

+ m b thn qua da

- iu tr loi b tc nghn

+ tn si go i th, ni soi gc dng hoc qua da, m m

+ to hnh niu qun

+ loi b tc nghn t ngoi chn p

- iu tr pht gc bng quang - niu qun

- D lu p xe thn, h thn, ct thn khi c m lu

-Vim thn b thn cp khng bin chng:

u tin l phi quyt nh c cn cho bnh nhn vo vin hay khng. Cc yu t


quyt nh cho b h h iu tr trong bnh vin l:

+ Bnh nhn khng th u g c hoc ung thu c;

+ Bnh nhn khng tun th iu tr;

+ Ch o ha hc chn;
+ Bnh nhn trong tnh trng nng, st ao, au hiu, khng c kh g di
chuyn.

Nhng bnh nhn tun th iu tr tt, khng mang thai, bnh m nh hoc
va iu ki c theo di cht ch c th iu tr ngoi tr sau khi
dch v tnh trng chung nh.

La chn khng sinh c g g thng theo kinh nghim. Khng nn chn


ampicillin, trimethoprim hoc trimethoprim/sulfamethoxazole v vi khun c t l
khng thuc cao. Cc thuc nhm fluoroquinolon v aminosid c n g trong
nhu m th ao h so i cc thuc nhm beta-lactamin. C th s dng
fluo o ui olo ng ung (ciprofloxacin 500mg x 2 ln/ngy, pefloxacin 400mg
x 2 ln/ngy, levofloxacin 250-500mg/ngy, ofloxacin 200-300mg x 2 ln/ngy,
norfloxacin 400mg x 2 ln/ngy). Nu vi khun gy b h l G a d g th th
b sung thm amoxicillin (500mg x 3 ln/ngy);

Nhng b h h iu tr trong bnh vin c th s d g kh g si h ng


ti , th g thng theo kt qu kh g si h . Cc thuc nhm cephalosporin
th h I, II, III, IV (v d eft ia o g/ g ti t h ch) hoc nhm aminosid
(3-5mg/kg/ngy) c hiu qu iu tr tt. Nu vi khun rgy bnh l enterococcus
c th s dng phi hp ampicillin (1-2g 6 gi ti t h ch 1 ln) v gentamicin
g/kg ti t h ch 8 gi 1 ln, ho iu chnh liu theo ch g thn)
hoc piperacillin-tazo a ta , g ti t h ch 8 gi 1 ln). Thi gia iu
tr trung bnh 14 ngy, c th ko di ti 21 ngy tu theo tnh tr g gi bnh.

-Vim thn b thn cp c bin chng:

cc yu t gy vim thn b thn cp c bin chng l:

+ Tc ngh ng tit niu;

+ L r;

+ Bng quang thn kinh;

+ Pht gc bng quang-niu qun;

+ So de BQ lu;
+ Stent niu qun;

+ ng d lu thn; dn hi t g, ng tit niu;

+ Ph n c thai;

+ i th o ng;

+ Suy thn;

+ Ghp thn

+ Tnh trng c ch min dch;

+ Cc vi khu kh g a thuc;

+ Nhim khun bnh vin.

Bnh nhn c iu tr trong bnh vin. Khng si h c s dng qua


ng tim truyn. C th dng phi hp beta-lactamin vi aminosid hoc
fluoroquinolon; aminosid vi fluoroquinolon. Thi gia iu tr trung bnh 14 ngy
h g th k o d i h . Cn c c tiu kim tra sau khi ng g iu tr 1-2
tun.

- Vim thn b thn cp ph n c thai:

c iu tr trong bnh vi , d g g t h ch beta-lactamin (cephazolin,


ceftriaxon) hoc gentamicin, sau khi bnh nhn ht st 24-48 gi c th chuyn
sa g ng ung, thi gia iu tr 10- g ; iu tr d phng ti pht bng
nitrofurantoin (50-100mg ung bui ti) hoc cephalexin (250-500mg ung bui
ti) trong sut thi k c thai; cn theo di cht ch khi dng khng sinh nhm
cephalosporin th h I v c th c khng thuc. Nu triu chng NKTN khng ci
thin sau 24-48 gi cn cy li c tiu th d h h h siu tm cc
bt thng v ng tit niu.

- Vim thn b thn ti pht:

thi gia iu tr k o d i g sau iu tr d ph g. C ph u tr


d ph g ha ghon ton thng nht, mt s tc gi khuyn co dng mt liu
khng sinh sau mi ln quan h tnh dc; hoc dng na liu h thng hng
ngy ko di, hoc dng c liu h thng 3 ngy/tun ko di.

-Vim thn b thn mn tnh:

- t cp: iu tr h vim thn b thn cp. Cn la ch kh g si h kh g c


cho thn v/ho iu chnh liu ph hp vi m suy thn.

- iu tr nguyn nhn/yu t thun li

- iu tr triu chng ca suy thn khi c suy thn m t h e i "iu tr suy


thn mn tnh").

9. Tin tri , ti lng

- NKTN cp thng khi hn;

- NKTN c bin chng c th ti pht nhiu ln v chuyn thnh mn tnh nu


kh g iu tr thch hp v/hoc khng loi b c yu t thun li; hu
qu l suy thn mn tnh;

- Vim thn b thn cp c th b p e ho , i khi th gy t vong trong giai


on cp do nhim trng huyt, hoi t nm thn v suy thn nng;

- Vim thn b thn mn tnh tin trin d n suy thn mn tnh, tuy nhin
bnh c th nh lu di nu c th loi b c cc yu t thun li.
Vim niu o

1. Vim niu o: t th g i niu o c th l c hoc phi hp


vi vim vng tam gic c bng quang, c th nm trong bnh cnh ca nhim
khun tit niu thp, vim thn b thn, c th phi hp vi cc triu chng ca
vim trc trng, vim mo tinh hon, 1 s t ng hp c vim tuyn tin lit, hi
chng Reiter.

2. Nguyn nhn: 2 nhm

- Vim niu o do lu kho g % t ng hp

- Vim niu o khng do lu, c th l

+ Chlamydia trachomatis l gu h h g u trong s cc bnh ly qua


ng tnh dc gy ra triu chng vim niu o (19-31%);

+ Ureaplasma Urealyticum (9-42%);

+ Mycoplasma genitalium;

+ Trichomonas vaginalis

+ Candida Albicans;

+ Herpes simplex virus.

3. Triu chng lm sng:

- Triu chng chung

+ Tin s mi c quan h tnh dc, quan h vi gi c triu chng vim niu


o hoc vi gi c ch o lu;

+ Tin s b lu;

+ Sinh sng trong khu vc cht chi mt v sinh, cc khu nh chut;

+ Thi gian b h: th g thng 5-10 ngy (Chlamydia), 2-5 ngy (lu sau phi
nhim; tuy nhin c th d i h n 2 tun);
+ Chy dch/nhy/m niu o, chy m t c t cung;

+ i ut;

+ Kh g i u i th;

+ Khi pht "ngp ngng" khng r rt (trong 1-2 ngy) (Chlamydia).

4. Ch o nh

+ Xt nghi c tiu c nhiu bch cu h g y khng thy vi khun (trong


i t ng nui c th g thng);

+ Cy dch niu o ho c tiu c vi khun (Chlamydia, lu cu);

+ Nhum Gram c th pht hin lu cu khu G d g

+ Phn ng khu h i AND (k thut ligase chain reaction LCR, polymerase chain
ea tio PCR , nh c hiu cao gip pht hin vi khun trong dch
tit niu o ho t o g c tiu.

. iu tr

+ Penicillin khng 18%, tetracyclin khng 26%, fluoroquinolon khng <0,1% khu
vc Bc M h g th ln ti 50% khu vc Trung Quc, Triu ti , g
Nam chu ;

+ Vim niu o do lu khng bin chng: cephalosporin th h III (cefixim


400mg ung, ceftriaxon 125mg tim bp), fluoroquinolon (ciprofloxacin 500mg,
ofloxacin 400mg u g , az th o i g ung;

+ Vim niu o do Chlamydia: azythromycin 1g ung 1 liu, Doxycyclin 100mg x


2 ln/ngy x 7 ngy;

+ Vi iu o ti pht: c iu tr cho c gi c quan h tnh dc cng


bnh nhn. Nu bnh nhn khng tun th iu tr hoc tip tc c quan h vi
gi b nhim khu sau t nhi u tin c th nhc li mt t iu tr th
hai. Nu bnh nhn b ti pht m khng c cc yu t nu trn c gh ti vim
niu o do Trichomonas v c th dng Metronidazole 2g ung (1 liu) phi hp
Erythromycin 500mg x 4 ln/ngy x 7 ngy (hoc erythromycin ethylsuccinate
800mg x 4 ln/ngy).

64.HI CHNG SIADH

(VIT TT : SIADH = Syndrome of Inappropriate Antidiuretic Hormone Secretion


Hi chng bi tit hormone chng bi niu khng ph hp )

Bnh nguyn: * Do thu sau tuyn yn bi tit qu mc hoc mon chng bi niu
ADH (arginine vasopressine)

* Bi tit lc ch ADH hay cc cht ging ADHaa ADH ti thn.

Ch o ph it:

A. Cc hnh thc khc ca h kali u e h g 37)

1. H at i u ALTT u h th g t g.

2. Bao gm h at i u k t g th tch mu (vd tnh tr g ph th g

3. Bao gm h natri mu km h th tch mu (vd biu hin lm ssng tnh trng


mt c)

4. Nguyn nhn gy h natri mu c th t h u h thng.

a. Ng c (ALTT niu <100 mosm/kg H2O)

b. Suy thn

c. reset osmostar

d. Su thng thn
e. Suy gip trng

B. Hi chng bi niu khng ph hp (SIADh)

1. Do u (c bi tit lc ch ADH hay cht ging ADH)

a. U g th phi, c bi l u g th t bo nh.

b. U trung biu m

c. U trung tht

d. U g th tu

e. U g th t t g

f. U g th tin lit tuyn

g. Sarcoma.

h. U tuyn c

i. U lym pho

j. U g th iu qun v bng quang.

2. Do phi (khng do khi u)

a. Vim phi do virus, vi khun, lao, nm.

b. Ap xe phi, p xe trung tht, vim m mng phi.

c. Thng kh nhn to p l d g.

d. Bnh phi mn tnh tc nghn v hen ph qun cp.

e. Khc: nhi mu phi, g g sn, hi chng Goodpasture, bi phi, trn


kh mng phi, trn mu mng phi, ho phi, gin ph qun.

3. Do nguyn nhn thn kinh:


a. Vim mng no, vim no, p xe no

b. Ch th g u.

.U o: gu ph t ha di , l h t h ha t h.

d. Nhi mu no, xut huyt no, t mu mng no, xut huyt mng no.

e. Lon thn

f. Khc: Guillain- Barre, sau s in, vim no lupus, hay vim mch mu h thn
kinh TW, no ng thu, huyt khi oa g ha g, ha hoa g tng.

4. Do tim mch:

a. Nhp nhannh xoang

b. Sau pphu thut ct mp van hai l.

5. Nguyn nhn chuyn ho v ni tit.

a. C phosph i p cch qung.

. Su thng thn,

c. Suy giap trng.

6. Do thuc:

a. Do hoc mon chng ba niu ADH v cht ging ADH vd vasopressine, oxytoxin,
demopressine.

b. Thuc kch thch gii phng ADH:vd opiate, opioids, barbiturate, nicotin,
thiazides, isoproterenol, carbamazepin, thuc chng trm cm dng vng (vd
amitrityline, desipramine, protrityline), fluphenazine, thioridazine, thiothixine,
monamine oxydase inhibitors , haloperidol, risperidol, vincristin, vinblastine,
vinorobine, clofibrate, acetylcholine, carbachol, bethanecol, bromocriptine,
ifosfamide.
c. Thuc lm t g hy cm ca ng thn vi ADH vd thuc khng vim non
streroide, acetaminophen.

d. Thuc kch thch gii ph g ADH l t g hy cm ca ng thn vi ADH:


Chlopropamide, tolbutamide, cyclophosphamide, chlormbucil.

e. Thuc c ch phosphodiesterase: vd theophyline.

f. Cc thuc khc: Amiodazone, c ch ti nhp serotonin ( vd fluorexetine,


paroxetine, sertraline, fluvamine), men c ch chuy i angiotensin
(lisinopril), li tiu vng v li tiu thiazide, polymycine B, thiopental, thuc gim
au ni chung.

7. Hi chng suy gim min dch mc phi.

8. Cc stress kch thch gii phng ADH

a. Ch th g

b. Phu thut

c. Gy m

d. au

e. Bun nn

f. Alcohol withdrawal

g. X ng

Lu lm sng

* Biu hin ca h natri mu

* Cc du hiu ca b h gu h t .

Ch o ph it:

A. Th kh l s g:
1. Th tch dch ngoi o h thng (khng ph hay gim th tch)

2. Khng c chng c v bnh tim mch, gan, th , thng thn hay tuyn gip.

B. Xt nghim

1. Mu:

a. Gim natri mu (natri mu < 135 mmol/l)

b. Ap lc thu gim ( ALTT <280Mosm/kg H2O)

c. N g u ate u thng thp.

d. Khng c ri lon ch g thn, gan, tuyn gip v htng thn.

. Nc tiu:

a. Pha lo g c tiu khng ti a < os /kg H O

b. ALTT niu thng > 300 mosm/kg H2O

c. N g natri niu thng > 300 mmol/L, c th thp h u l g at i a


vo thp hay hn ch dch.

C. Hn ch d h a o th ci thin gim natri mu.

D. Kim tra ti l g thng khng cn thit)

1. Ch cho php p dng nhng BN nh

a. Ch thc hi sau khi loi tr cc nguyn nhn gy h natri mu.

. T c tin phi iu chnh n g natri mu > 125 mmol/L.

c. Ch ti h h test khi BN kh g au, un nn, gim th tch mu, hay h


HA.
d. Theo di theo gi.

e. Patient recumbent except to avoid.

2. Truyn dch : vd 20 ml/kg ti 1,5L trong vng 10-20 pht

3. Tp tu g c tiu theo gi trong 5 gi.

. p g h thng:

a. t nht % l g c ruy c bi tit trong 4 gi

b. t nht % l g c truy c bi tiwts trong vng 5 gi

c. ALTT niu thp nht < 100 mosm/kg H2O

d. Hn ch dch sau khi ngng test v trnh h natri mu thm.

Tiu chun ch o SIAD

* Gim natri mu km gim p lc thm thu mu

* Th tch dch ngoi o h thng (khnh ph)

* Khng c ri lon ch g v tim mch, gan, th , thng thn, v tuyn


gip trng.

* pha lo g c tiu khng ti a.

* N g Natri niu thng > 30 mmol/L

* Hn ch dch vo s ci thin tnh trng gim natri mu.

iu tr

A. Xe h g h g iu tr, H natri mu c p lc thaamr thu


u h thng .

B. Theo di n g at i u thng xuyn trong sut ua t h iu tr.


C. Theo di cht ch lng dch vo ra.

D. o p lc thm thu mu v niu

E. Ngng ngay cc thu g t g i tit ADH t g t dng ca ADH

F. Ngng truyn ngay tt c cc d h h t g u khng cn thit.

G. Bt buc phi hn ch c: ( duy tr 600- 1000ml/d v ph thuc vo m


nng ca h natri mu)

H. Nu h natri mu nng c biu hin triu chng thn kinh, cn truyn c kim
sot

at i u t g e h g

I. Trnh hu qu mt myelin th ph t do iu chnh h natri mu qu nhanh.

a. Khng nng natri mu qu 8 mmol/L trong vng 24 gi.

b. Khng cho php b qu m g t g at i u.

J. Nu h t ln khng th iu chnh cc nguyn nhn gy SIAD th xem xet


kh g d g thuc nhng BN SIAD mn tnh .

1. Demeclocycline

a. Nh hu g c u th h d g h

b. Lm gim hot ng ca ADH ti thn

2. Nhng thu kh t d d g h

a. Phenytoin: Lm gim bi tit ADH, gim tc dng ADH.

b. Lithium: Gim tc dng ca ADH trn th h g hiu t dng.

. U ea: thng khng s dng ph bin.


65.BNH CU THN MN
(Bnh thn Ni khoa. Nh xut bn Y hc 2004)

I. NH NGHA

Bnh cu thn mn l mt bnh c t th g u thn, tin trin t t, ko


di nhiu . C t iu ch g t g l ph , hu t p cao, protein niu, hng
cu niu, h g g th ch c protein v hng cu niu c. Cui cng
s d n suy thn mn ngy cng nng dn. Do c nhiu nguyn nhn v tn
th g gii phu bnh h g kh hau hin nay nhiu tc gi ngh gi
l hi chng cu thn mn .

II. NGUYN NHN

Nguyn nhn khi u ca vim cu thn mn c th l:

- Sau vim cu thn cp.

- Sau vim cu thn c hi chng th h.

- Sau cc bnh h th g Lupus hoc chuy h a i th o g

- Sau cc bnh di truyn (hi ch g Alpo t .

- Khng r nguyn nhn khi u: b h h n trong tnh trng vim cu thn


mn r, th h giai on mun m khng thy c tin s bnh vim cu thn.

III. TN THNG M BNH HC

giai o ha su thn hoc suy thn nh, sinh thit thn c th cho bit
cc th t th g nh hc:

- Vim cu th t g si h la ta.

- Vim cu thn mng.

- Vim cu th g t g si h.
- Vim cu thn , mnh.

- X h a u thn .

- Vim cu thn IgA (bnh Berger).

IV. LM SNG V CN LM SNG

1. Lm sng:

- Ph: nh, trung bnh hoc nng, ti pht nhiu ln.

- i t: l g c tiu tha i ty tng bnh nhn v t g giai on bnh.

Vim cu thn mn giai on cng tin trin th tnh trng thiu niu cng r.

- Cao huyt p: giai o ha su thn hoc suy thn nh t l bnh nhn


cao huyt p thp. suy th giai on III, IV t l bnh nhn c cao huyt p >
80%.

- Thiu mu: Khi ha su thn, khng c thiu mu hoc ch thiu mu nh.


Khi c suy thn, thiu mu xut hin v ngy cng nng d , i khi li ua ht
ch vi giai on suy thn.

- Cc triu chng biu hin hi chng ur mu cao: khi su thn r).

Nn, ri lon tiu ha, xut huyt, cc biu hin tim mch, thn kinh, cc biu
hin lm sng ca toan mu (th su, ri lon nhp th) v nng nht l hn m
do ur mu cao.

2. Cn lm sng:

- Protein niu: Thng r. Khi protein niu , g/ gi l c hi chng th h


i k . Tu hi , khi su th giai on nng th protein niu thng < 1
g/24gi.

- Hng cu niu: Hay gp i u i th, t khi i u i th. Khi i u


i th ti pht nhiu l t l s g th thng l biu hin ca bnh cu thn
IgA.
- Tr niu: Bao gm tr hng cu, tr ht. Tuy nhin khng phi tr niu lc no
g .

- U , eati i , a id u i u t g, c lc cu thn gim khi c suy thn.

- in gii:

. K+ u th g t g khi su thn.

. Ca++ mu gim suy thn cui giai on II tr i.

. Na+ u thng gi do ph ht.

. Hng cu, huyt sc t gim khi c suy thn.

- Siu m th : K h thc th h th g khi ha su thn. Thn teo nh


u 2 bn khi c suy thn. M teo nh ty thu o giai on tin trin ca
suy thn v ty theo nguyn nhn khi u.

- X quang: Bng thn teo nh, u hai bn giai o su th . Khi ha


suy thn, nu chp UIV s thy hnh h i th h thng.

- Sinh thit th : T o g giai o ha su thn hoc suy thn nh I, II c


th tin hnh sinh thit thn. Qua sinh thit thn, s cho bit loi t th g
bnh hc.

V. CHN ON

1. Ch o nh: Da vo:

- Ph: tin s ph, ti pht nhiu ln.

- i t.

- Cao huyt p.

- Thiu mu.

- Protein niu.

- Hng cu niu, tr ht, tr hng cu.


- Suy thn: ur, creatinin mu, acid uric u t g, c lc cu thn gim.

- Siu m, X quang thn: hai thn teo nh u (r giai o su thn).

- Sinh thit thn: sinh thit th kh g nh vim cu thn mn tim tng


ha t iu ch g l s g ch o loi t th g bnh hc.

2. Ch o giai on:

2.1. Giai on vim cu thn mn tim tng: Cha t iu chng lm sng, ch c


protein niu, hng cu niu c.

2.2. Giai on vim cu thn mn c triu chng: Cc triu ch g h: ph , ao


huyt p xut hi h g ha su thn.

2.3. Giai on vim cu thn mn c hi chng th h: Vim cu thn km hi


chng th h t i ph t hiu t.

2.4. Giai on vim cu thn mn suy thn: Suy thn mn l hu qu cui cng
ca vim cu thn m , khi ut hin th ngy cng nng dn t giai o I n
giai on IV.

3. Ch o ph it:

3.1. X ch thn lnh tnh (cao huyt p): cao huyt p xut hi t c cc triu
chng khc. Protein niu thng < 1 g/24gi.

3.2. X ch thn c tnh (cao huyt p c tnh): Huyt p cao n g, kh p ng


vi iu tr, nhiu bin chng ph tng, c th c suy thn cp tin trin nng
nhanh trong mt thi gian ngn.

3.3. Vim thn b thn mn tnh:

Trong vim thn b thn mn tnh, b h h thng c tin s nhim trng


tit niu, vim thn b thn cp, si thn tit niu Bnh khng c ph trong
mt thi gian di, tr khi c suy thn mn tnh nng. Protein niu thp, t khi qu
1 g/24gi. Bch cu niu nhiu, vi khun niu + khi t cp.

Khi c suy thn, siu m thn thy 2 thn teo nh kh g u, b thn g gh.
Nu iu kin lm UIV (suy thn nh, eati i u< ol/l th i
thn t, bt, b thn gin.

IV. IU TR

Khng c thu iu tr c hiu. Ch yu l iu tr triu chng ty theo tng


giai on ca bnh.

. Giai on vim cu thn m ha su thn:

Nu vim cu thn mn tim tng khng c triu chng lm sng th ch cn


theo d i nh k .

Nu c triu chng lm sng th ch yu l iu tr triu chng:

- iu tr ph:

. ht, hn ch l g a o.

. Li tiu Furosemid t liu thp 40mg x 1 vin/24gi n liu ao h h t


l g c tiu h o g un: 1,5-1,8 lt/24gi.

- iu tr cao huyt p:

. ht, hn ch l g a o.

. Li tiu: Furosemid 40mg x 1 vin/24gi n liu ao h u cn ph.

. Thuc h p, cc nhm thu u d g c. Khi c suy tim khng dng thuc


chn bta giao cm. C th chn 1 trong cc thuc:

Nifedipin 20 mg x 1-2 vin/24gi.

Amlor 5 mg x 1-2 vin/24gi.

Renitec 5 mg x 1-2 vin/24gi.

Logimax 5/50 x 1-2 vin/24gi.

Coversyl 4 mg x 1-2 vin/24gi.


Nu b h h p ng tt vi nhm c ch men chuyn (Renitec, Coversyl) c
th gip bo v nhu m thn lu di.

iu tr c th g u , theo d i nh k v lm sng v ch g thn.

Nu bnh nhn vim cu thn c hi chng th h, nh vi iu tr triu


chng, c iu tr thuc c gim min d h theo ph iu tr hi chng thn
h Co ti oid, C lophospha id, .

Nu c nhim khun hng c iu tr kh g si h kh g c thn kt hp mt


t t 7-10 ngy.

iu tr bnh chnh nu : i th o g, Lupus

. Giai on vim cu thn mn, suy thn mn:

giai on c suy thn mn, ngoi vi iu tr triu chng c iu tr suy thn


mn ty thu o giai on suy th . iu tr bo tn vi suy thn t giai on I
giai on II, ho iu tr thay th thn suy giai on suy th giai on
cui.

66.CH HOT NG TH LC TRONG BNH THN

I. NHNG NGUYN TC PHN LOI KH NNG HOT NG TH LC

1. Hot ng th l h thng:

Y h d g da h ph p chuy h a t g g eta oli e ui ale t


u it: MET ch 1 nam gii 40 tui nng 70kg cn tiu th mt lng oxy tnh
bng ml lc ngh gi. MET khi gi s dng 3,5ml oxy trong 1 pht cho 1kg
th trng.

Kh g lao ng c th tnh ton bng tch s ca MET v ch s c


d g hng dn hot ng th lc trong bnh thn.
- 3-5 METs trong cng tc d n, th mc ni tht, hg , i 3-4
dm/gi.

- 5-7 METs trong cng tc th a, h g , a g a.

-T METs t o g lao ng n g, h g , chy t 6 dm/gi.

2. Bng phn m lao ng theo METs:

1. Ngh gi.

2. Tm vi hoa sen, nu , i chm.

3. Git l , i , hg .

4. Cng vic th mc ni tht, d n.

5. Vic nh nng (nh).

6. Vic nh nng (n g , h g .

. g, a g ng.

8. Chy t /ph t, h g , g .

Bng: Phn loi hot ng th lc v gii hn ca METs:

Ni dung cng Thi gia i


Loi Gii hn
vic hot Hc tp Ni tr ti t ng
lao ng ca METs
ng hoc CQ

Ngh gi
1-2 (-) (-) (-) (-)
A

Hc tp bnh gi
B 3-4 Cng vic nh thng ,
i h
Th dc (-) ph t

C 4-5 Cng vi Th dc (+) Ni tr a


quan bnh g
thng

Hot ng th
D 5-6 l g Th thao (+)
va

Lao ng
Khng gii nng.
E
hn Hot ng th
lc mnh

II. CH LAO NG TRONG MT S BNH THN

C g h h ung, vic thc hin ch lao ng trong bnh thn rt


quan tr g. Ngi thy thuc cn nm v g k khu nh nhn. N
l s php l cho vic tuyn dng, tip tc hoc thi vic, thi hc.

1. Trong vim cu thn cp:

- Giai o i t, ph : gh gi, h lao ng loi A.

- Giai on hi phc: ngh gi, h lao ng loi A.

- Giai on hi ph a in: lm vic nh, hc tp h thng, ch lao


ng loi B.

- nh trong 6 thng: lm vi h thng, th dc nh nhng, ch lao


ng loi C.

- h t o g :l i h thng, c th tp th dc th thao, ch
lao ng loi D.

2. Trong vim cu thn th tin trin nhanh:

T theo giai on v ch g th su gim t hay nhiu m c ch


hot ng th lc thch hp.

- B h a g giai on tin trin:


. Suy thn I hay II cn ch lao ng loi A, ngh gi ho to .

. Suy thn III v IV cn ch lao ng loi A, ngh gi ho to .

- iu tr c kt qu:

. Suy thn I hay II cn ch lao ng loi C.

. Suy thn III hay IV cn ch lao ng loi B.

- Bnh h a g iu tr:

. Suy thn I hay II cn ch lao ng loi D.

. Suy thn III hay IV cn ch lao ng loi C.

- Bnh h sau iu tr:

. Suy thn I hay II cn ch lao ng loi E.

. Suy thn III cn ch lao ng loi D.

. Suy thn IV cn ch lao ng loi C.

3. Trong hi chng th h:

T theo giai on bnh v ch g thn, ch hot ng th lc thch hp


h sau:

- a g tin trin:

. Suy thn I hay II cn ch lao ng loi A.

. Suy thn III v IV cn ch lao ng loi A.

- iu tr khng kt qu:

. Suy thn I hay II hoc III cn ch lao ng loi B.

. Suy thn IV cn ch lao ng loi A.

- iu tr khi va:
. Suy thn I hay II cn ch lao ng loi C.

. Suy thn III v IV cn ch lao ng loi B.

- iu tr khi nhiu:

. Suy thn I hay II cn ch lao ng loi D.

. Suy thn III v IV cn ch lao ng loi C.

- Khi hon ton: ch lao ng loi D hoc E.

- Ti pht: ch lao ng loi A.

4. Trong vim cu thn mn tnh:

- Nu protein niu < 1 g/24gi:

* Kh g t g hu t p, khng suy thn: cn ch lao ng loi E.

. Suy th I: cn ch lao ng loi E.

. Suy th II, IIIa: cn ch lao ng loi D.

. Suy th IIIb: cn ch lao ng loi C.

. Suy th IV: cn ch lao ng loi B.

* T g hu t p, khng suy thn: cn ch lao ng loi E.

. Suy th II, II: cn ch lao ng loi D.

. Suy th IIIa, IIIb: cn ch lao ng loi C.

. Suy th IV: cn ch lao ng loi B.

- Nu protein niu > 1 g/24gi:

* Kh g t g hu t p, khng suy thn: cn ch lao ng loi E.

. Suy th I, II: ch lao ng loi D.

. Suy th IIIa, IIIb: ch lao ng loi C.


. Suy th IV: ch lao ng loi B.

* T g hu t p, khng suy thn: ch lao ng loi D.

. Suy th II, II, IIIa: ch lao ng loi C.

. Suy th IIIb, IV: ch lao ng loi B.

5. Trong vim cu thn Lupus:

- a g iu tr Corticoid, gim dn liu:

. Ch g th h thng: ch lao ng loi C.

. Suy th II, II, IIIa: ch lao ng loi B.

. Suy th IIIb: ch lao ng loi A.

- a g du t liu Corticoid trn 10mg:

. Ch g th h thng, suy th I: ch lao ng loi D.

. Suy th II, IIIa, IIIb: ch lao ng loi C.

- a g du t liu Co ti oid di 10mg:

. Cha su thn, suy th I, II: ch lao ng loi E.

. Suy th IIIa: ch lao ng loi D.

. Suy th IIIb, IV: ch lao ng loi C.

67.CH N UNG TRONG BNH THN

I. NHNG NGUYN TC C BN
Co gi c duy tr cuc sng, lm vi , lao ng v c kh g h g
bnh tt nh s cung cp g lng qua th , ung.

Thnh phn cu to ca mt gi nng 60kg bao gm kho g kg c, 13kg


protein, 4,5kg cht bo, 3kg cht khong, 0,5kg cht glucid.

C th gi cha hng nghn loi cc phn t hu . Ngoi ngu g lng


a, m bo cho nhu cu sc khe cn c 9 acid amin thit yu, 2 acid
bo v cc vitamin, cc cht i lng. Trong cc thnh ph a o,
cht c xem l thit yu l : al i, phospho, iod, agi, k , ng, kali, natri,
clo, coban, crm, mangan, molibden v seleni.

duy tr tr g l g th, phi c s cn bng gia g l g a o


g lng thi ra.

. N g l g a v o:

L g alo i a o do th h phn v s hp dn ca thc phm, ba . Cc


cht di h dng cu to th khng phi l nhng vt liu c nh m lun
lu c thay th i mi. Cc vt liu xy d g, i mi ny hon ton l
do th , c ung cung cp.

Nh y, ba phi p ng cc yu cu phc tp ca th. Yu cu ca ba


ao gm:

- l g, calo.

- cht: glucid, protid, lipid, cht khong, vitamin, cht , i lng.

-C i, hp l gia cc thnh phn:

. Glucid vo khong 50-55%

. Protid vo khong 15%

. Lipid vo khong 30-35%

- Cm gic ngon: ngon ming, ngon mt, go i, go tai.


. N g lng thi ra:

S tiu hao g lng hng ngy c th h gi ng tng s g


lng ca nhu cu th, g lng sinh nhit ca ch hot ng th
lc.

HARRIS-BENEDICT ngh mt cng th tnh s tiu hao g l g


s da trn gii tnh, tui, chiu cao, cn n g h sau:

BEE (Kcal) nam: 66,47 + (13,75 x W) + (5,0 x H) (6,8 x A) x H s hot ng x H


s bnh l.

BEE (Kcal) n: 655,09 + (9,6 x W) + (1,85 x H) (4,7 x A) x H s hot ng x H


s bnh l.

T o g :

- BEE (basal energy expenditure) trung bnh 30 Kcal/kg/ngy.

- W: Tr g l g th l tng tnh bng kg.

- H: Chiu cao tnh bng cm.

- A: Tui tnh b g .

- H s hot ng: nm ti ging 1,2; ngoi tr 1,3.

Bnh nhn vt , , .

- H s bnh l: St , , .

Nhim khun cp , , .

Ch th g , , .

Bng , , .

u g tu gi p , , .

Ngi ta o s tiu hao g lng lc ngh gi esti g e e g


expenditure (REE) b g ph g ph p o gi tip bi calo k trong mt khong
thi gian bit t sau t h a 4 gi. REE sau c nhn vi h s tnh
cho tng c th. N FAO/WHO/UNU a a hng s 11.000 REE gi
h thng.

. h gi g it h g g :

* Nit to ph t o g c tiu / Ur ton ph t o g c tiu = 0,55.

Do : U / l c tiu x th t h c tiu 24 gi , = Nit to phn


c tiu. Chng ta bit 100g protein chuy h a g it. Do un c
g it n 100/16 = 6,25g protein.

V vy c th t h it to ph c tiu bng protein ton ph c tiu x


6,25.

V d: mt gi c cung cp 98g protein, bi tit u / l c tiu l 15g,


l g c tiu trong ngy l 1.700ml, theo tnh ton trn ta c:

- Nit to ph c tiu = (15 x 1700 x 0,55)/1000g = 14g

- Protein ton ph c tiu = 14g x 6,25 = 87,5g

c bit protein mt theo phn b g % p otei c tiu nn ta c:

- Protein ton phn thi ra = Protein ton ph c tiu + Protein phn = 87,5 +
8,75 = 96,25.

T o g t ng hp ny, cn bng protein l 98g 96g = 2g.

* h gi s cn bng protein v tnh tr g di h dng theo nguyn tc:


th g g khi l g a o = lng thi ra.

. Cn b g + khi l g a o > lng thi ra.

. Cn bng (- khi l g a o < lng thi ra.

. Nu cn bng (-) ko di s dn ti bnh tt v cht.

. Nu cn bng (+) nhiu, ko di s g o ph , i th o g, t g mu.


* C th theo di khi lng v thnh phn ca cc khoang ca th h gi
ti ging s cn b g it h g g theo g thc:

P otei oh g g g / , = Nit u c tiu 24gi (g) + 2,5g.

T o g : , g l s g g a it iu phi ur cng vi s mt it ua ph
v m hi.

* i vi cc bnh nhn nh v lm sng c th h gi :

P otei o g = it u iu 24gi (g) + 2,5g] x 6,25.

C g nh gi nhu cu ti thiu v mc chu ng ti a g lng.

Tm li, i vi gi khe mnh, khng bnh tt, ch n cung cp:

(1) s nhu cu g lng:

Ngi ln: 25-40 Kcal/kg th tr g/ g : K al.

Tr em: 1000 Kcal + (100 x tui)/ngy.

T o g : g glu id ho K al, g p otid ho K al, g lipid ho K al.

Thnh phn S Kcal/Tng s Kcal/ngy S gam/ngy

Glucid 60% 5/1000 1200 200 - 300 g/ngy

Protid 10% 5/200 300 1 - 3 g/kg/ngy

Lipid 30% 10/300 400 1 - 5 g/kg/ngy

(2) C i nhu cu tng cht:

- Glu id: ng < 20% (saccharose)

cht bt (c vitamin B1, cellulose, pectin).

- Lipid: acid bo thc vt ln trn 30% tng s a o:

lipid thc vt: 20-30%


a id o ha o HDL t g : %.

- P otid: p otid ng vt ln trn 50% tr em, 25% gi ln:

c t l hp l gia cc acid amin

c 9 acid amin thit yu

c 2 acid bo.

(3) C t g ua :

1g it = , g p otei = g u = g tht = 1,5 mmol K.

1g mui g at i.

1g m chnh c 400mg natri.

Nhu cu ti thiu ca th c g at i/ g gha l t g g g


mui hoc 1g bt m chnh.

Trong ch th g thng c khong 3- g at i t g g i 8-15 g


mui ty tng vng.

Trong ba , , au u, tht, c c th c 400mg natri tc 1g mui


cho nhu cu ti thiu.

(4) Ch u g t o g giai on hin nay Vit Nam.

T s nhng yu cu cho cc ba , g, hp l, qua nhiu


nghin cu, Vi di h d g a a th p di h d g i vi nhu cu thc
phm trung bnh cho mt gi t ng thnh, trong 1 thng.

T o g th p di h d g kg l g thc (go, m, sn); 10kg rau; 1,5kg tht;


2kg thy s , t , ua ; kg u ph; 600g du m, vng, l ; di 500g
g; di 300g mui.

Cc thnh phn cung cp g l g t c ch bi th h . Nh


h ua a mt gia h gi ta bit c ba hay thiu
di h d g. N g l t trong nh g s h gi ho nh kinh t v
t h h a a mt gia h.

M l gun cung cp g lng chnh, yu cu o. M gi u


m, bo (c, tht, tr g, u ph, vng, lc). Mn rau cung cp vitamin, cht
khong, cht . M a h u g p c v cht di h dng b sung. Mn
trng ming bng hoa qu hoc ko bnh ngt kt thc ba . T o g t s
ba t o g tun hoc ba li hoa th ht khai v, thc ung.

ung g c v sinh v tit kim. Tm li ba l gun cung cp


g lng chnh, phi m bo nhu cu sinh h , tha i theo gii, chiu cao,
cn n g, tha i sinh l (c thai, cho con b), hot ng th l , tha i thi
tit v bnh tt.

II. CH N BNH L TRONG MT S BNH THN

Ch u g i vi gi sc khe h th g ua t ng, nay b bnh


thn cng quan tr g h . N th lm bnh n g l ph t g u kh g
nht), thiu dng, suy kit nu cn b g it t h hiu trong suy thn mn
tnh, lc mng bng ngoi tr lin tc.

1. Ch ht:

Khi b ph do bnh th , su ti , ga t g hu t p cn thc hin ch


ht.

Ngi ta phn bit: ht ho to , ht va , ht t.

* ht hon ton: L g at i h g g c cung cp vo khong 200-300


g, t g g i 9-13 mmol, c sn trong thc phm ca ba . V th khi
ch bin cn:

- Khng dng mui, c mm, m chnh, bt canh trong nu ng.

- Chn thc phm cha t at i h go, m, khoai c, rau qu ngt. Tht, c t


khong 100 g/ngy.
- Khng dng cc thc ph ng rn sn c mui p, cc d g hp,
phomt v cha nhiu mui.

- g iu g kh g hp l v s mt i thnh phn cc
cht, gy thiu dng.

* ht va: Lng natri hng ngy khong 400- g, t g g i 18-


30 mmol tc khong 1-2 g mui .

- Dng 1g mui ho th a o c mm trong ch bin ba h g g .

- Ngoi ra cn c sn khong 1g mui t o g g c, rau qu, tht, c ca khu


phn. Nu thm m chnh, bt canh th phi gim mui vi l g t g g.

- Chn thc phm t natri. Khng dng cc th h bin s h hp,


phomt. Tm, c bin nu dng cn ra k, b v t c khi ch bin.

* ht t: Lng natri h g g c cung cp khong 800- g, t g


g i 35-50 mmol tc khong 2-3 g mui .

- Dng 2g mui ho th a ph c m ch bin thc phm. Ngoi ra


cn c sn khong 1g mui t o g g c, rau qu, tht, c ca khu phn.

- Khng dng th h p s , hp, phomt.

- Nu dng m chnh, bt canh th gim mui i s l g t g g.

2. Ch c ung:

Trong mt s t ng hp bnh l: ph, suy thn cp giai on thiu niu-v


niu, cn thc hin nghim ngt hn ch natri km theo hn ch c hiu
qu t o g iu tr.

Cn tnh cn b g o, c ra.

L g c vo bao g l g c u g, l g c canh trong th ,


l g c chuyn ha th khong 300 ml/ngy v dch truyn vo (nu c).
Lng nc ra bao g l g c tiu 24 gi, l g c mt theo m h i, hi
th, phn khong 500-600 ml/ngy.
V d: mt gi bnh n g kg, ph to, c tiu 400ml trong 24 gi. Ta c:

- L g c thi ra: 400ml + 600ml = 1000ml.

- L g a o kh g c qu 1000ml l= l c cn bng
c m tnh.

Tm li khi b ph, thiu niu, v niu, l g a o kh g c qu


l g c tiu + 500ml.

3. Ch t o g vi u thn cp tnh:

Ph thu o ph , t g hu t p, suy thn. Khi cha su thn, ch


nn:

- g lng: 30- K al/ g ; t o g glu id ao g , , khoai cc


loi, bnh ko, ng mt.

- m: 1 g/kg th trng/ngy.

- t bo.

- t mui: khong 1,2,3g mui v m chnh.

- t : l g a o kh g u l g c tiu 24 gi + 500
ml/ngy.

- Hoa qu: va phi.

4. Ch t o g hi chng th h gu ph t ha su thn:

Nguyn tc:

Gi u g lng

Gi u ng, cht bt

Gi u m

t m
t mui

t ha c

Nhiu rau qu, u .

C th: Cung cp khong 1800-2000 Kcal cho mt gi nng 50kg.

- Cht ng, bt c trong go, m, khoai c. C o. B su g ng, bnh ko


ngt. l gun cung cp g lng chnh.

- Cht m: c nhiu trong tht nc, c, tm, cua, sa, u , go, m.

Lng 1-1,2 g/kg th tr g/ g + Lng mt theo c tiu 24 gi.

V d: mt gi nng 50kg cn kho g g p otid/ g , t g g i 300g


tht nc, c nc.

hp l th chuy h a c cn cung cp ng vt chim 2/3 tng


s protid a o. T l m thc vt chim 1/3 v c trong go, , u , sa
u nnh.

C tha i khu v, nn ch bin xen k tht b, tht l , ,t t o g g


trong tun.

Trng ch -2 qu trong 1 tun.

Nu a g iu tr bng Corticoid nn hiu t , ua, , g s cung


cp calci.

- Cht bo: kh g hiu, tri li c t. Kh g ng vt. Dng


du thc vt, du u t g ch bin th . Kh g , ph t g ng
vt (c, gan, bu dc, da) v cha nhiu cholesterol.

- cht kho g, ita i i lng. C nhiu trong hoa qu, u .

- t mui, m chnh.

- ho t c. Da o l g c tiu hng ngy. Cn b g c khng


d g t h.
5. Ch t o g su thn cp tnh:

Suy thn cp tnh l hi chng suy gi t ngt ch g i tit ca thn m


t h thng. Vic ch o gu h iu tr triu chng rt
quan tr g t o g h ung.

T theo giai on ca suy thn cp t h p dng ch ung thch hp:

* Trong suy thn cp t h giai on v niu:

Nguyn t : g l g, glu id, t p otid, t lipid, t c, t mui, t kali.

C a alo gim ti thiu d ha protein.

V d mt gi nng 60kg, khi b suy thn cp giai on v niu, ch n


1840 Kcal, 350g glucid, 6g protid, 58g lipid v truyn 200-500 ml glucose 20%.

* Trong suy thn cp t h giai o i hiu:

Nguyn t : alo, glu id, t p otid, lipid, nhiu , t ha mui.

Trong v d t , giai on ny cn cung cp 2.100 Kcal, 256g glucid, 40g protid,


79g lipid v Na+ 814mg.

6. Ch t o g su thn mn tnh:

Suy thn mn tnh c hi chng lm sng, th dch ca s suy gim ch g


ngoi tit v ni tit ca thn xy ra t t, ngy cng nng v khng hi phc. V
th n din bin t giai on nh giai on cui vi cc triu chng rm r
ca hi chng ur mu cao.

Trong suy thn mn tnh c s tr cc sn phm ca s thoi ging protein


h u , eati i , a id u i t s cht vi lng rt nh h a .
Guanidinosuccinic, methyl-guanidin, acid phenolic, indol. C khong trn 200 cht
it i lng bt thng trong suy thn mn tnh.

S iu tr nhng ri lon chuyn ha protid trong suy thn mn tnh t lu da


o di h d g, u g. L u gi ta p dng ch ki g m hon
ton v th gi bnh chng suy kit, thiu dng. V sau, trn thc nghim v
lm sng nhiu cng trnh xc nhn, nu khi su thn, ch u hiu
protein s pht tri h a u thn lm bnh n g l , gc li ch t
protein lm chm tin trin ca bnh. Khu phn protein hn ch kh g c
t qu kh g i tit ur ca thn, vo khong gp 3 ln ur niu 24 gi,
g / l p otid ng vt cung cp nhng acid amin thit yu.

Ty theo m suy thn v km theo cc triu ch g ph , t g hu t p, gim


mc lc cu thn ho a g p dng lc mng bng hay chy thn nhn to chu
k to ch gia gim.

Nguyn tc:

ho gi u g lng.

glucid.

Gim protid.

Bnh lipid.

hoc nhiu c.

Bnh hoc gim natri.

p dng thc t:

Theo t ng phi Bnh vin Necker, ch , g/kg th trng/ngy cho bnh


nhn n g kg ph hia h sau:

- N g lng: 30-35 Kcal/kg th trng/ngy, 55% t glucid, 33% t lipid.

- Protid: 0,7 g/kg th tr g/ g , % p otei g lng sinh hc cao.

- Lipid: / o h a, / kh g o , / kh g o k p.

- Glucid: go, , ng hp thu chm.

- Nc: b g c tiu d tr.

- Mui natri: t 500-1000 g natri.


- Kali: hn ch th gi u potasio.

Theo Nguy V Xa g, da vo nguyn l chung v st vi hon cnh Vit


Nam, ch t o g iu tr bo tn suy thn mn va v nng cn theo cc
nguyn tc:

- t , d g m qu: tht c tm nc, trng sa. Mi g t g


g g tht ti hoc 2 qu trng. B sung 1 cc sa long. Suy thn
nng ln th tht c phi rt bt.

- Nhiu g lng (calo) bng cc cht bt t h khoai la g, khoai s, khoai


ty, bt sn, min dong. C th hiu cc th theo kh g k theo
ng, mt ong, ma, qu ngt, bnh ko ngt. C , i ba ch t
y ho t l g.

- Du, , kh g ki g, cung cp g lng.

- au h ci, h bu , u ngt, kh g hoa u chua.

- t mn, t bt ngt khi ph t g hu t p.

- Nc u g , b g l g c tiu 24 gi thm 500ml.

Th th nn ch theo hng d sau : Cn ch bin cho hp khu


v, tha i mn trong ngy v trong tun.

a sng (chn 1 trong nhng mn sau hoc ch bi t g t).

1. Hai lt bnh m c pht ngon km 1 c c tr long pha ng, sa


ng long hoc c ph sa ho th ng.

2. Khoai lang, khoai s luc chm mt ong km 1 c t lo g pha ng.

3. Bnh cu g a lo g tho g tht ruc hoc t gi la thi ch v hnh


m.

4. Ph c bo, long thong tht, khng m chnh (bt ngt), c gia v v rau
th .
.B iu ua, c bo, khng m chnh (bt ngt).

Ba t a (c th i lm ba ti).

. C t, a g g tt.

. Khoai t , o.

3. Canh ci hoc cc loi g ti, tt ho t ti.

4. C nc 1 lt mng hoc vi lt tht kho.

5. Trng ming bng qu ngt.

Ba ti (c th lm ba t a .

. C t l g.

2. Min dong xo gin vi ht tiu.

3. Khoai s hm nh vi t sn hoc tht chn gi na nc na m, b da. n


khoai nhiu h tht.

4. Trng rn (chin) na qu vi khoai ty thi nh.

5. Rau luc hoc rau s g. Kh g au g t, au dn, rau mung ho t t.

6. Trng ming bng qu ngt ho c ngt.

Ba ph (gia bui, a . Chn 1 trong cc mn sau:

- Khoai luc ch ng, mt ong, mt c.

- Bt sn vi ng.

- Bnh ko ngt, h u , ke gt.

- Hoa qu ngt h h , g u, mt, su ring, hng xim, nho ngt, xoi


ngt, da hu, ma.
Nc ung thm hng ngy b g l g c tiu ng h t c vi: c lc,
h a h, h lipto lo g g, kho g, c ngt. Khng ung
c chanh chua. Khng ung cc loi r l cy v gy suy thn nhanh.

7. Ch gi m kt hp vi acid amin thit yu:

Hn ch nhu cu protein h g g i vi 0,5-0,6 g/kg th trng/ngy s to


gu thiu nhng acid amin thit yu. gii quyt, ta dng ch p otei
thp c chn l , p g c nhu cu v acid amin thit yu bng cch chn
lc cc protein c gi tr sinh hc cao, cha h lng cao cc acid amin thit
yu. Be gst o ngh mt ch di h dng Th in (Schwedisch diet)
mi ngy ung 16-20 gam cc cht acid amin thit yu, to c cn bng v
chuy h a it du g p tt.

C s xy dng khi nim v b sung acid amin thit yu l thy histidin cn


ho gi t g u hu t. Th , t o g su thn c gim chuyn ha t
phenylalanin sang tyrosin.

Walser v cng s chng minh c th ung cc alpha-keto t g ng vi acid


amin thit yu, khng cha it, va gim cung cp it n cung cp c
nhng acid amin thch hp. phn ng thun nghch chuyn amin t acid
a i sa g ketoa id t g g gc li.

Tnh tr g t g t g t vi valin, phenylanin v methionin. Cn cc cht


keto t g t ca tryptophan v histidin th kh to nn. Cc cht t g t ca
l si th eo i kh g tha gia c vo phn ng chuy a i , do kh g
thay th c lysin v threonin.

Khi a ketoa id o th bnh nhn suy thn th cc ketoacid ny s


tip nhn nhm amin (NH2) ca mt s acid amin khng thit yu t o g th
v c th c NH2 ca u ti tng hp nn cc acid amin thit yu t g t.

Ketoacid dng mui calci nn ngoi vic cung cp di h dng cn b sung


calci v c tc dng gn phosphat.
U g ketoa id t g ng vi cc acid amin lm gim r rt s cung cp
it. Kh i a id a i , gi ta thy ketoacid khng kch thch s t g lc cu
thn.

Cung cp ketoacid theo cng thc Zimmermann: 35% trng g v 65% khoai ty
s cho hn hp protein gi tr sinh hc cao.

Thuc ketosteril ca hng FRESENIUS dng vin nn bao gm cc alpha-ketoacid


l ketoleucin, ketoisoleucin, ketovalin, ketophenylalanin cng cht alphahydroxy
t g ng vi methionin. Ngoi ra cn c lysin, threonin, tryptophan, histidin v
t osi . Nh y, ketostril cha tt c nhng acid amin thit yu v/hoc cc
alpha-ketoa id t g ng c ho gi h thng.

Ch gi m vi b sung ketostril c cc li ch:

- Lm gim cc triu chng ca t g u hu t.

- Ci thin cc du hiu ca gim calci.

- Hn ch s ha ging ca h h p otei t o g th (t thc).

- Lm chm t tin trin xu ca suy thn.

- Lm gim protein niu.

- Lm gim nhng cht gn phosphat cha nhm.

- iu chnh ri lon chuyn ha hydrat carbon.

Ngoi vin ketostril ca hng FRESENIUS cn c cc dung dch acid amin truyn
Amiyu (hng Roussel), Nephramin (hng Mc Gaw), Nephrosteril (hng Fresenius)
t o g ha cc acid amin thit yu v c cc acid amin khng thit yu.

8. Cc ch c bit khc:

- Ch gh o pu i . Lng tin cht acid uric gim ti thiu h l t bin


ph p iu tr b sung trong bnh Gt v si acid uric.

C t tht nht l gan, thn, lch, c n , thu, t , c p, rau kh.


Ki g ia, u.

- Ch gim kali: gi l g kali h g g , t u g h t 6g (153 mEq)


xung cn 2g (51 mEq) khi b t g kali u.

- Ch t g kali: cung cp lng kali qu 5,8g (150 mEq). Ch nh khi dng


li tiu quai, hypothiazid k o d i, iu tr bng glucocorticoid ko di.

- Ch gim calci. Hn ch s d g al i h g g , t u g h t 800mg


xung cn 200-400 mg. Ch h t o g iu tr t g al i u t s loi si
thn.

- Ch t g al i. Ch g alci/ngy. Ch nh khi suy thn, calci


mu gim, c du hiu ca ng tuyn cn gip th pht.

- Ch t phospho. H lng ch t 700- g/ g g ga t g


phospho u ng tuyn cn gip th pht trong suy thn.

- Ch gim oxalat c ch h gim ngun ngoi sinh ca oxalat mn


tnh, b h t g o alat iu v si thn do oxalat calci.

68.HI CHNG CU THN CP TNH


(Bnh thn Ni khoa. Nh xut bn Y hc 2004)

I. NH NGHA

L 1 trong 5 hi chng ca bnh cu thn, xy ra mt h t ngt do tn


th g cu th t g i:

- i u.

- Thiu niu i t .

- T g hu t p.

- Protein niu.
- Ph.

II. NGUYN NHN

Hi chng cu thn cp rt d nhn bit. D g a u l vim cu thn sau


nhim lin cu. Nguyn nhn hay gp tr e . Ngi ln t gp h .

l hi chng c th d n vim cu thn tin trin nhanh v ti suy thn.


V vy vi nh nguyn nhn l rt cn thit iu tr, theo di v tin
lng.

Nguyn nhn ca hi chng cu thn cp:

- Vim cu thn sau nhim khun (postinfection glomerulonephritis - GN):

. Vim cu thn sau nhim lin cu.

. Sau nhim t cu.

. Vim ni tm mc vi khun.

. Sau nhim virus: vim gan B, Herpes zoster.

- Vim cu th t g si h gu ph t v (idiopathic proliferative GN):

. Vim cu th t g si h la ta nguyn pht.

. Bnh thn IgA.

. Vim cu th g t g si h.

. B h Lupus h thng (Systemic lupus erythematosus).

- Bnh vim mch (vasculitis):

. Vi a ng mch.

. Bnh u ht Wegener.

. Ban xut huyt Schonlein-Henoch.

- Hi chng Goodpasture.
- Bnh cu thn vi mch (microangiopathic glomerular disease):

. Hi chng ur mu tan mu.

. Xut huyt gim tiu cu.

. T g hu t p c tnh.

. o thi thn ghp.

III. M BNH HC

T th g h h y ra cu thn, lm cho cc cu thn n to a t g si h


t o. Ba u l cc bch cu trung tnh v bch cu a eosi ; sau l ch
cu h . T g t bo biu thng biu hin sm, thong qua sau khi
xut hin hi chng lm sng. Lim t bo c th tm thy mt vi cu thn. T
bo ni t g si h s lng, ph n g a, kh g h thy l o t g.
Vng gian mch rng ra v cha cc t bo bch cu trung tnh, t bo cht, cc
mnh vn v cc l g g in t.

t g g h a g u thn l c nhiu l g ng b mt ca
t bo biu m, gn hoc trong gian mch. C th hnh thnh ti ch. Cc t bo
biu m ph n chm ln cc l g ng to thnh cc chn li (d g u l
ha vi nhau hoc bin mt. Knh hin vi hu nh quang ch ra rng c l g ng
ht lan ta ca IgG, IgM v C3, phn b kh g u d theo g u thn v
trong gian mch.

IV. LM SNG V CN LM SNG

1. Lm sng:

t g l s g quan trng l khi pht cp t h, thng 2 tun sau vim


hng hoc nhim khun khc, b h h t nhin xut hin:

- i u: Th g i u i th, c tiu s u h u o a- ola


ho h c ra tht.
- Thiu niu i t : L g c tiu di 500 ml/24gi. i khi nh nhn khng
, nng c th xut hin v niu.

- Ph: Thng ph nh mt hoc ph ngoi bin.

- T g hu t p:

. C th t g hu t p nng, kt hp vi gi c gy nn suy tim tri, ph phi


cp. Bnh nhn kh th c khi nm. Tin trin xu i u c km theo thiu mu.

. Soi t c th pht hin cc du hiu bnh vng m do t g hu t p.

- Triu chng ton thn: Mt mi, kh chu, au l g l do th g phng.


Mt s t ng hp thn c th ph n v rt nhy khi th kh .

2. Cn lm sng:

- Nc tiu:

. Protein niu th g di 3,5 g/24gi. Trung bnh t 2-3 g/24gi. i khi lng
protein niu xp x vi gng ca hi chng th h, c bit i g u ca
bnh.

. Hng cu niu: thng > 105/ml.

. Tr hng cu, tr ht.

- Mu:

. Thiu mu nh ho h thng, mt s bnh nhn c th do tnh trng gi


c lm cho mu b pha long, d n gim s lng hng cu v protein mu.

. U , eati i u h thng ho t g h.

. Mc lc cu th , thanh thi eati i thng gim nh. Gim nghim


trng trong bnh cu thn tin trin nhanh.

. in gii u h thng hoc K+ mu cao do thiu niu hoc v niu.

. Cc xt nghim khc:
* Khng th khng lin cu (Antistreptococal antibodies): ASLO
(Antistreptolysin-O), ASK (Antistreptokinase), AH (Antihyaluronidase).

* Hiu gi khng th cao trong vim cu thn cp sau nhim lin cu: Cc yu
t khng nhn, b th C3, C4 (cho bnh Lupus); mu lng (ESR) cao (trong Lupus v
vim mch mu); khng th kh g g u thn.

- X quang tim phi:

. Ki t a k h thc tim, ph phi.

. Chy mu phi (hi chng Goodpasture, vim mch mu).

- Siu m thn:

. Bnh cp t h th k h thc ca 2 th h thng ho hi to.

. Bnh m t h th k h thc 2 thn nh.

V. CHN ON

1. Ch o nh da vo:

Khi pht cp t h, t ngt vi cc biu hin:

- i u: th g i u i th.

- Thiu niu: i t < l/ gi.

- T g hu t p: nh, va v nng.

- Protein niu < 3,5 g/24gi.

- Hng cu niu: tr hng cu, tr ht.

- Sinh thit th : t g si h t bo ni m v gian m h. T g si h hp


bch cu. C cc l g g in t d g u l di biu m trn nh
siu cu trc.

2. Ch o guyn nhn:
Vim cu thn sau nhim lin cu l gu h thng gp tr em. Bnh h
th g h Lupus, i ch mu l nguyn nhn hay gp gi ln. Sau khi
hi tin s b h th kh , c bit ch cc triu ch g h au
hng, nhim trng da, nt ban ngoi da, vim khp (Lupus, vim mch mu).
Chy mu phi ho i u hch Wegener, Goodpasture). Tin hnh lm huyt
thanh ch o . Kt qu s cho khc nhau vi tng tnh trng lm sng.

Nh g t ng hp biu hi kh g in hnh, phi sinh thit thn cng sm


cng tt tm nguyn nhn.

VI. TIN TRIN V BIN CHNG

1. Tin trin:

Ty thuc vo tui ca b h h giai on t th g thn.

- tr em: tin tri thng l tt, 90% hi ph ho to h g g th t


vong do suy tim tri, ph phi cp hoc chy mu no.

- gi l t ng thnh: b h thng n g h . T l hi phc ch khong


50%.

- Mt s t ng hp pht trin thnh vim cu thn tin trin nhanh v suy thn
rt nhanh.

Nh g t ng hp cn li, cc t thng cu th kh g c hi phc nhanh


v biu hi i u i th, t g hu t p, protein niu tn ti dai dng, dn dn
d n vim cu thn mn ri ti suy thn mn.

2. Bin chng:

- Su ti t i do t g hu t p v gi c.

- Bin chng no: chy mu no, ph no, co git.

- Suy thn cp do thiu niu.

. Vim cu thn tin trin nhanh.


. C th c hoi t ng thn cp.

- Bin chng ca b h h h h Lupus, i ch mu.

VII. IU TR

Kh g iu tr c hiu cho tt c t ng hp. iu tr ty thuc vo


nguyn nhn.

- Thuc gim min dch v Corticosteroid khng c hiu qu.

- Khng sinh: dng khi c nhim khun.

- H p: d g c tt c cc nhm thuc h p.

Ch : Khi c suy tim khng dng thuc nhm chn giao cm, khi c suy thn
khng dng nhm c ch men chuyn.

- Li tiu: cho nu ph, hay dng Lasix (vin, tim).

- Ch hn ch mui, gi m.

- Suy thn: nh th iu tr bo tn, nng th phi lc mu.

- iu tr bin chng.

Kt lun:

- Hi chng cu thn cp thng xy ra cp t h, t ngt. Nguyn nhn c th


nguyn pht hoc th pht. T th g nh h t g g tha i
xm nhp vim lan ta cu thn.

- Ch o da vo:

. i u i th.

. T g hu t p.

. Protein niu trung bnh.

. Ph nh, ch yu mt.
. Nc tiu c hng cu, tr hng cu v tr niu.

- iu tr ty thuc vo nguyn nhn. Thuc gim min dch v Corticosteroid


khng c hiu qu. iu tr ch yu l h p, li tiu v ch hn ch mui.

- Bin ch g thng lin quan ti gi , t g hu t p v suy thn.

- Hi chng cu thn cp sau nhim lin cu th kh g hi phc tt h tr


em. B h thng n g h gi ln. Nu hi phc khng hon ton, hi
chng cu thn tn ti ko di d n vim cu thn mn; suy thn mn sau
nhiu . S t t ng hp tin trin xu thnh vim cu thn tin trin nhanh.
C th t vong do suy tim, ph phi, ch u o do t g hu t p.

69.LAO THN - TIT NIU

I. I CNG

Lao thn l mt b h thng gp, l giai o khi th nhim trc khun


lao. Hin nay, c u M a g ph t t in, lao phi cng vi
cc lao sinh dc, tit niu c chiu h g t g.

Lao thn gy t th g hai thn, c th bn nng bn nh h g t t gp ch


lao mt bn.

Lao thn gp la tui 20-40, nam nhiu h . T iu tr lao thn


bng ngoi khoa l chnh; ngy nay nh cc thuc chng lao hu hiu iu tr
ni khoa g ai t ua t ng, song vic ch o lao thn v kh kh ,
hoc b st hoc qu lm dng.

II. NGUYN NHN V C CH BNH SINH:

1. Nguyn nhn:

Do trc khun Mycobacterium tuberculosis, mt trong gn 30 loi thuc chng


Mycobacteria.
. C h bnh sinh:

- Trc khun lao xm nhp o th, ch yu ua ng h hp. ph nang,


trc khun lao b th o. i thc bo mang vi khu n hch lympho, sn
sinh y ri b y vo mch ra ca h h, i o ng bch mch ngc ri vo
mu. T s gy nhim lao ua go i phi, c bit l lao g, lao
sinh dc tit niu.

- Trc khun lao xm nhp vo th theo g u thng khu tr v


th . Do p ng min dch t bo, cc c lao c to thnh cnh cu thn
( g ln gn). Trc khun lao tip tc sinh sn, cc t o h t chc
o t g l l cc c lao. Trc khu lao sau s xm nhp vo cc ng
thn v to thnh c lao ty thn. Dn dn, cc c lao ny b ph hy, hoi t,
u ha v o i thn hoc gy hoi t nm thn. Trc khun theo bch
mch niu qu c tiu, xung bng quang, ti tinh v mo tinh hon.

- Mt s t ng hp b p e, u h a, kh g o i thn m ch khu
tr th sau i h a.

- giai on mun, lao thn c th g h a l hp b thn, hp tc niu


qu , teo g ua g. N g h s b hy hoi nhu m thn, thn mt chc
g iu hin th t phi UIV.

III. TRIU CHNG

1. Lm sng:

- St ko di, st v chiu.

-S t ,k .

- m h i .

- i u.

- au h g l g, tht l g.

- i ut, i t, i kh .
- Nam gii s g au o tinh hon, s thy nhn cng u i o ti h ho ,
hu mn; n gii au h chu hai , kh h, kh ph khoa pht hin lao
phn ph, vi trng, t cung, c t u g

2. Cn lm sng:

a. Nc tiu:

- Protein (-) hoc (+) nh.

- Hng cu (+++).

- pH thp, khong 5,6 (toan tnh).

- Tp khun (-).

- Trc khu lao: l t ghi n, tiu chu g ch o lao


thn:

. Cn l c tiu c bui sng, nhum Ziehl-Nielson, lm 3-5 ln cc ngy


lin tip.

. C c tiu c trn mi t ng Lowenstein ho i t ng Petraguani.


Cc tc gi nhn mnh gi tr ca kt qu c o i t ng Lowenstein.
Eisendrath th , t o g t ng hp nui cy (+) ch t ng hp soi trc
tip c vi khun lao (BK); Weingarten: trong 24 bnh n ch gp t ng hp
nui cy BK (+) cn soi trc tip (-).

Tu hi , iu khng thun tin l kt qu nui cy phi sau 3 tun mi c


c.

Tim truyn vo chut b h, g tin hnh trong nh g iu kin ging nui


c . g l tiu hu g ch o lao thn. Secretane ch thu c 2
kt qu (-) trong 146 l ti c tiu ca bnh nhn b lao th c chn
o hc chn. Tuy nhin, mt kt qu (-) khng cho php loi tr lao thn.

b. Chp X quang thn:


Chp X quang thn khng chun b vi 1 phim thng v 1 phim nghing, c th
thy hnh h hi c ua g t g ng vi vng lao th u ha thnh
hang hoc vi ha. Hnh h Ru pel u l c gi l thn
mastic.

Chp X quang c tim thuc cn qua g o t h h UIV oi l u th


trong cc bin php ch o lao thn.

Ty theo bnh nhn c suy th ha kh g ch nh chp UIV. Phi chp


phi c th nh h c nh g tha i hnh dng ca i th , i i
b thn - niu qun, niu qu g ua g, ng thi h gi h g i
tit ca tng bn thn. Do m nh hay nng ca t th g lao, h g ta
th thy nh g tha i: i thn hp, b gm, b ct ct v co ko. C cc hnh
gai ho h h t h h ho, h hoa do gi i thn hoc hang lao
cha thuc cn quang. Niu qu g h h h i h t hp, i ph h to,
thng thy xp khu t i i b thn - niu qu ha on niu qun tiu
khung st bng quang. Niu qun ngm thu kh g u, ln khc hoc hnh
h h hic gy.

T theo giai on bnh, c cc hnh nh bng quang: gim th tch, thnh dy


c b nham nh, nhiu g u g, k h thc bng quang nh nhiu so vi bnh
thng.

Chp th gc dng (UPR) l mt ch nh rt thn trng trong lao thn v c


th gy nhiu bin chng, t th g lao thn lan rng hoc bi nhim tp
khun.

c. Soi bng quang:

Ni soi tit niu kh g c ch nh mt cch c h th g ch o lao


th ng tit niu v c th gy bi nhim. Gi tr thng tin gip cho chn
o kh g hiu h hp UIV. Th thut ny li kh tin hnh khi bng quang
, h a hoc hp niu o.

giai o u, t th g lao h, c th thy t th g khu t xung


quanh l niu qun hoc vng tam gic bng quang. Khi thy mt vt lot bng
ua g h h i (casquette), theo Marion c gi tr c bit trong ch o
lao thn v xc minh bng sinh thit.

Nhng t th g lao c hiu tha i lu : l u vt lot mu vng, xung


ua h , sau i mu xm hoc hng vng.

d. Siu m: C th pht hin:

- C lao nhu m thn.

- Hang lao nhu m thn.

- Hi tng tr c tiu, tc nghn.

- Bng quang b, thnh dy.

e. Cc xt nghim cn lm sng khc:

Cng vi ph g ph p t t c khu lao t o g c tiu, chp UIV, soi


bng quang, xt nghi sau g c ch h ch o lao thn:

- Cng thc mu, mu lng.

- Phn ng trong da vi Tuberculin (IDR-Mantoux).

- Chp X quang phi.

- Xt nghim min dch hc: ELISA, PCR.

3. Cc th bnh: C th gp thun hay th phi hp:

a. Th thun: gp khi t th g t, iu hin nh giai on sm.

- i u: c Tuffier nu ln.

- i p otei .

- au tht l g ha au un thn.

- Gi u, s thy thn to.

- St.
- Thn m: st, th to, i c.

- Theo tui: < 20 tui v > 50 tui.

b. Th phi hp:

- Vi suy thn.

- Vi t g hu t p.

- Vi si tit niu.

- Vi cc b h kh : u g th th , a g th , a a g thn.

- Vi thai nghn.

- Lao thn cn li sau ct 1 thn do lao.

4. Din bin:

Theo nhiu tc gi, lao sinh dc tit niu c th c cc din bin sau:

a. Suy thn mn tnh do hy hoi t chc thn hay vim thn k:

- Cibert gp / t ng hp, chim 5%.

- Trager gp / t ng hp, chim 20%.

- Truc v Mirouze gp / t ng hp, chim 12%.

b. Suy thn cp tnh:

Biu hin bng thiu niu, v niu, u u t g, eati i u t g do:

- Vim niu qu co hp.

- Vim thn - b thn cp do bi nhim.

- Si t ng tit niu.

- Suy v thng thn cp.

- Sau m lao thn.


- Sau dng mt s thuc ch g lao, thng gp do PAS, Rifamycin.

c. T g hu t p trong qu trnh lao thn:

Cc tc gi gii thch do vim thn k, teo thn mt bn hoc thiu mu thn


cc b (Tcherdakoff v Milliez).

d. Thn nhim bt:

N gh ti khi mt gi b lao thn nay b ph nhiu, xt nghi c tiu


u cc triu chng ca hi chng th h, t ghi Congo (+).

IV. IU TR

Ng a , iu tr ni khoa tha th vai tr ca ngoi khoa t .

1. Ni khoa:

Cho n nay, ch c 6 loi thu c WHO coi l cc thuc chng lao chnh.
Cn tun th mt s nguyn t t o g iu tr bnh lao: sm, phi hp ti thiu 3
th thu , g liu, d g u , thi gia theo giai on (tn cng v
duy tr), tt c cc thu u dng cng mt lc vo mt gi nht nh trong ngy,
di s kim sot ca nhn vin y t, iu tr ton din vi ch ung, ngh
gi.

- Isoniazid (INH-Rimifon): K hiu H.

. im: c cu t t g t Pyridoxin, tc ng vo qu trnh hnh thnh vi


khun.

. Chng ch nh: suy gan nng, thiu men G6PD.

. Tc dng ngoi mun: nhi c gan, mt ng, co git, i, i lon tm


thn.

. Liu dng: 5 mg/kg/24gi gi ln.

- Rifamycin: K hiu l R.
. im: l dn xut bn tng hp ca Rifamycin c ch ARN polymeraza cn
cho s tng hp ARN v ADN ca vi khun. Khng thu thng xut hin nhanh.

. Liu lng: 8-12 mg/kg/24gi gi ln.

. Tc dng ngoi mun: nhi c gan, thn, mn nga, gim tiu cu.

. T g t thuc: Warfarin, Ketoconazol, Chloramphenicol.

- Pyrazinamid: K hiu Z.

. im: cu trc ha hc gi g h Iso iazid, l dn xut ca Nicotinamid.

. Liu lng: 1,5-2,5 g/24gi gi ln.

. Tc dng ngoi mun: nhi ga , au khp.

- Ethambutol: K hiu E.

. im: khng thu thng xut hin nhanh.

. Liu lng: 15-25 mg/kg/24gi gi ln.

. Tc dng ngoi mun: gim th lc, vim thn kinh th gic.

- Streptomycin: K hiu S.

. im: l khng sinh nhm Aminoglycosid, chit sut t dch nui cy sinh
vt, c ch tng hp protein vi khun mc ribosom.

. Liu lng: 0,75-1 g hay 20 mg/kg/24gi, kh g t u g t o g t iu


tr.

. Tc dng ngoi mu : ic, d cm quanh ming, gim t o u, c thn.

- Thioacetazon: K hiu Tb1. t s dng.

Hin nay, nhiu ph phi hp thuc ch g lao c chng minh l c


hiu qu c p dng ty thu iu kin khc nhau nhiu i t th gii.
ta, h g t nh chng lao quc gia hi a g s d g ph iu tr
lao ngn hn p dng cho cc loi b h h kh hau, c bit t o g iu tr
lao phi. T o g iu tr lao th ha c nghin cu nhiu.

1. Ph iu tr 8 thng, cho bnh nhn lao mi (2SHRZ/6HE):

Hai th g u: giai on t g, iu tr hng ngy bng 4 loi thuc:


Streptomycin, Rifamycin, Isoniazid v Pyrazinamid.

S u th g sau: giai o du t , iu tr hng ngy bng 2 loi thuc: Isoniazid


v Ethambutol.

2. Ph iu tr 8 thng, cho b h h lao (tht bi hoc ti pht vi phc


t c) 2SHRZE/1HRZE/5H3R3E3.

Hai th g u: iu tr hng ngy bng 5 loi thuc: SHRZE.

Thng th : iu tr hng ngy bng 4 loi thuc: HRZE.

N th g sau: iu tr 3 ln/tun bng 3 loi thuc: HRE.

3. Ph iu tr 6 thng, cho bnh nhn lao tr em: 2HRZ/4RH.

- Vit Na , iu tr lao bng ha tr liu ngn ngy c gim st trc tip (DOTS)
a g c p dng rng ri.

2. Ngoi khoa:

Ty theo t th g c ch nh:

- Ct bn phn thn.

- Ct thn.

- Chnh hnh, sa cha, ti to ng dn niu.

3. Thay th: khi gim nng ch g n lc ngoi thn.


70.LC MNG BNG

(Peritonealdialysis)

TS. V h H g Bnh hc ni khoa HVQY)

Lc mng bng (LMB) l truyn 1-3 lt dch lc cha glucose vo trong khoang
mng bng ri li rt ra sau 2- 4 gi. C g h thn nhn to (TNT), cc cht c
c l i ua g ng bi siu lc v khuy h t do chnh n g . Tc
lc gim dn theo thi gian gi dch lc trong bng v ngng hn khi c cn
bng cc thnh phn gia huyt t g dch lc. Cc cht ta , c hp th
t khoang mng bng qua phc mc vo tun hon mao mch mng bng. T
hp thu tha i theo t g gi bnh v c th tha i do nhim
khun mng bng, do dng thu lo k, thuc chn dng canxi) v nhng yu
t vt l h t th, lao ng).

1. Nh g c tnh ca mng bng lin quan n thanh lc mu.

Din tch mng bng xp x bng di t h th. Phn mng bng bao ph ni
tng thanh lc mu tt h c treo v phc mc cn li. Nhng phn t trung
bnh t 500- dalto h ita i B c thanh lc trong lc mng bng
ha h h t o g thn nhn to. H s thanh thi vitamin B12 lc mng bng
lin tc l 50 lt/tun, thn nhn to l

30 lt/tu gi h thng 1008 lt/tun). Lc mng bng thanh lc nhng


phn t c khi lng nh k h thn nhn to. V d: h s thanh lc ur
lc mng bng l 84 lt/tun, thn nhn to l 135 lt/tu gi bnh thng
l 604 lt/tun).

Kh g tha h lc ca mng b g t g l u t g s l tha i dch lc.


Nhng thuc gin mch l t g kh g tha h lc v nhng thuc co
mch li c tc d g gc li.

2. Cc k thut lc mng bng.


C nhiu loi h g lm sng hay p dng 2 k thut sau:

- Lc mng bng lin tc (Continuos ambulatory peritoneal dialysis: CAPD).

- Lc mng bng chu k lin tc cn gi l LMB gi o o a .

Trong k thut CAPD, gi ta a o bng dch lc v rt ra 3-4 ln/ngy


(thao tc bng tay).

Trong k thut lc mng bng gin o o a , dch l a o


b g tha i t ng bng my chy tun hon dch l o a , nh
nhn vn ng.

My t ng thay dch chu k 4-5 l / . Ln thay dch mi v sng s c gi


li trong bng.

Dch lc mng bng c bn sn trn th t ng v g t i t 2,5- l t. Ngi ta


dng lactat lm cht m thay cho axetat v cht th ha h
mng bng; cn nu dng cht m l bicacbonat s gy ta Ca++ v caramen
ho glucose. Khi b vim mng bng cp, gi ta thm vo dch lc heparin v
khng si h. I suli g th thm vo nu bnh nhn b tiu ng.

Thnh phn ca dch lc mng bng

Na+ 132 mmol/l

K+ 0 mmol/l

Cl- 96 mmol/l

Ca++ 3,5 mmol/l

Mg++ 0,5 mmol/l

D, L- Lactate 40 mmol/l

Glucose vi cc n g 15 g/l; 25 g/l ; 42,5 g/l.

pH 5,2.
3. Ch nh, chng ch nh.

Lc mng b g ph g ph p: lc trong mt giai on ngn v lc lu di.

+ Lc mng bng trong mt thi gian ng khi iu tr suy thn cp hoc trong lc
ch to l th g ng- t h ch (chun b cho thn nhn to) hot ng.

+ Lc mng bng lu di khi bnh nhn b suy thn mn tnh giai on cui c
nhng

im sau:

- Khng to ng vo mch mu cho chy thn nhn to.

- Trng thi tim mch khng nh d b tai bin khi chy thn nhn to.

- C lot d dy-t t g; kh gd g hepa i chy thn nhn to.

- Bnh nhn trn 65 tui.

+ Chng ch nh ca lc mng bng rt t. Ngi ta khng lc mng bng khi


khoang mng bng b nhim trng, dnh mng bng nhiu, ho h khng kn
dch trn ln khoang ngc, thot v bn rng, hoc do kh g tha h lc ca
mng bng thp.

4. Cc ph g ph p to ng vo khoang bng.

Ngi ta a ng thng (catheter) vo trong bng.

- Nu ch cn lc trong mt giai on ngn (bnh cp t h , gi ta lm ngay


ti ging bnh, trch mt l nh thnh b g t c, lun ng th g u, c
nhiu l bn vo bng vi s tr gip v lc ca mt nng kim loi trong ng
thng (guidewire), lm kiu ny hay b nhim trng, nht l duy tr ng thng
trong vng qu 72 gi.

- Nu cn lc lu di (bnh m t h , gi ta hay dng ng thng lm bng cao


su sili o Te khoff athete u (mt a dch vo, mt l ng
ly a . Th g t ng thng qua mt ng h di da ri mi vo bng
(lm ti phng m t h c trong bng chy ra v trnh nhim khun t
ngoi vo bng.

5. K thut lc mng bng.

Vi CAPD, thot u gi ta truyn 2 lt dch lc 1,5% glucose vo bng, ngm


t o g gi ph t. Sau d lu a ht t khi a tip mt t dch lc
mi vo khoang bng. Nn lm nng dch ln 370 C. Lc chun l thay 3 ln ban
ngy v mt l o a .

Phi h gi c kh g lc ca mng bng bnh nhn bng t s: ur dch


lc/ur mu, creatinin dch lc/creatinin mu trong 2 thng k t ln l u tin
phn loi ra:

Loi mng bng T l gp (% s bnh nhn LMB)

Vn chuyn qua mng thp 1-5

Vn chuyn qua mng thp va 25 - 30

Vn chuyn qua mng cao va 50

Vn chuyn qua mng cao 10 - 17

Ngi bnh c mng bng loi vn chuyn qua mng cao th lc cht tan rt tt,
h g g hp ph glucose nhanh nn siu lc ti a h xy ra lc va truyn
dch vo b g, sau c li b ti hp thu li. Nhng bnh nhn c mng
bng vn chuyn qua mng cao thch hp vi NIPD hoc CAPD khng truyn gi
dch l t o g .

Liu lng ca lc mng b g ha . Tu hi , lc mng bng c hiu qu khi


to c h s thanh thi creatinin > 65 lt/tun/1,73m2 (tnh ton bng thu gom
dch l th o a c tiu trong 24 gi). Nu khng t, phi t g s ln
thay dch l , t g th tch lc mi l a o, hoc kt hp CAPD vi lc mng
b g gi o a .
6. Bin chng.

Lc mng bng c nhiu bin chng. Bin chng nguy him nht l nhim trng
bng do vi khun nhim qua thnh b g g t ng thng, ch yu l cc vi
khun gram (+) (chim 75%). Bnh nhn st, au v c phn ng thnh bng,
dch l t a c, soi knh hin vi c nhiu bch cu. iu tr bng khng sinh
mn cm vi vi khun (cho vo dch l ng ton thn).

71.LC MU NGOI THN


(Hemodialysis)

TS. V h H g Bnh hc ni khoa HVQY)

. i c g.

- Lc mu ngoi thn l qu trnh l i khi th nhng sn phm cn b v


d tha.

- N , h ho h p dng k thut th ph tch chit cc


cht tan t dung dch cha . Nh g phi i gn mt th k sau, ph g ph p
lc mu bng thn nhn to mi c p dng trn lm sng.

- Do s pht trin ca rt nhiu ph g tin lc mu, cuc sng ca h g t


g gi suy th giai on cui STGC c ci thin. Nhiu bnh nhn
suy thn mn

s g t h thn nhn to. Ch i g c M, c khong 300.000


gi STGC gi/1 triu d / ; t l b h t g hng l 8%.

- iu tr bng chy thn nhn to tiu tn khong 13,5 t USD M),


gi mi ln lc mu ngy mt gim do dng li b lc, cht lng cuc s g gi
bnh tt h do liu l u, di h d g, iu tr thiu u, t g hu t p c
tin b. T l bnh cht h g do STGC o khong 18%. Nguyn nhn cht
ch yu do bnh tim mch (50%), nhim trng 15%.
2. Ch nh lc mu bng thn nhn to.

+ C hi chng suy th g i lon ch g o.

+ C t g K+ u iu tr ni khoa khng hiu qu.

+ Toa u kh g iu tr ni khoa c.

+ H s thanh thi (HSTT) eati i < l/ph t/ , th.

Bnh nhn b STGC t u lc mu sm, mc d vi hn ch protit


nghim tc c th duy tr n g ur mc chp nh h g s gy
thiu dng n g, l t g t l t vong v bin chng sau ny khi lc mu.

Khi iu tr suy thn cp (STC) c th ch ph g ph p thn nhn to hay lc


mng b g l u. Khi iu tr suy thn mn c th chn chy thn nhn to,
lc mng bng hoc ghp thn. Chy thn nhn to hin vn l cch la chn ph
bin nht. Lc mng bng thch hp cho bnh nhn tr v t phc v c v
khng mun ph thuc vo my. Nhng bnh nhn to ln, nng trn 80kg b suy
thn m giai on cui cn chy thn nhn

to v c o thi mt lng ln ur m lc mng bng khng l c.


Nhng bnh nhn khng c kh g l th g ng-t h mch cho chy thn
nhn to nn chuy sa g ph g ph p lc mng bng.

3. K thut thn nhn to.

3.1. Qu trnh khuch tn trc tip qua 2 bn mng lc ca b lc:

Chy thn nhn to l k thut thm phn mu nh hai nguyn l: khuch tn v


siu lc. Khu h t g ai t ua t ng nht trong chy thn nhn to h g
khng ging ch g a thn. Siu l tu t g vai tr quan trng trong
chy thn nhn to h g li ging vi ch g th gi.

Khuch tn l hi tng nhng ht cht tan nh lt qua l mng bn thm sang


kia theo chnh lch n g . Nhng ht to h l mng bn thm s b
gi li khng khu h t c. S khuch tn ph thuc vo tnh cht mng lc
(din tch, k h thc v s lng l th g , chnh n g cc cht cn lc
gia mu v dch lc, t mu v t dch lc qua hai bn mng lc (t
nhanh to a chnh n g ln).

Siu lc ph thuc vo l y cc cht ta c qua mng. trong thn nhn


to, lc gy siu lc ch yu l u t o g h thng tu ho go i th.

3.2. B lc:

Thn nhn to gm 3 thnh phn chnh: b l , ng to dch lc v dn vo b


lc,

ng mu tu ho go i th qua b lc.

C 2 loi b lc: b lc si rng v b lc tm. Hi a , gi ta dng b lc si


r g lng mu mi t h -90ml so vi 100-120ml b lc tm). Din tch
mng b l ho gi l dao ng t 0,3-1,2 m2. Mu vo b lc chy trong
cc si rng, dch lc vo b lc chy bn ngoi b si gc chiu vi ng
mu chy. Hi a , gi ta dng nhng mng lc tng hp khng
cha nhng gc OH- t do (mng polysulfone, polymethylmethacrylate,
polyacrylonitrile) do vy khng hot ho h thng b th v tr thnh nhng
mng ho hp sinh h i vi th gi.

Vic dng li b lc cho bnh nhn suy thn m a g c p dng rng ri


cc trung tm lc mu do qu l t, dng li s gim gi thnh v tt h ,
gim hot tnh b th, gim t l nhng phn ng dng phn v i vi mng
(gim hi chng dng l u) v gim t l cht cho bnh nhn lc mu. M,
gi ta ch dng li qu l . Nh g a g ph t t i , gi ta dng li
c ng dn mu. C th ra qu lc bng tay hoc t ng bng my vi
c, ri tit trng bng formaldehyt, peracetic axit, hydrogen peroxit.

3.3. Dch lc:

Thnh phn dch l i a o ate h sau ol/l :

Natri 137-143
Kali 0-4

Clo 100 - 110

Canxi 0 - 3,5

Magi 0,75 - 1,5

Acetate 2 - 4,5

Bicarbonate 30 - 35

Glucose (mg/dl) 0 - 0,25

Ngi ta ha d g i a o at tha a etat t xy ra h huyt p khi lc


mu. N g natri trong dch lc thp hay gy nn tt huyt p, rt run, nn, ti
nht...trong lc lc nn n g natri dch l c ch h l ao to chnh
thm thu, cn b g gc vi chnh thm thu do ur to ra. Trong k
thut ny, n g natri dch lc

c h dn dn t 148-160 mmol/l xung m g t g ol/l cui


cuc lc. Dch lc cha g% glu ose gi n g ti u ho glu ose u.

Mi ln chy thn nhn to c l t c, do vy nu c khng c x l


s gy nhim bn ni i ho gi b h. Nc chy thn nhn to c lc
trong, lm mm, loi b cc ion v cui c g c thm thu gc c
c p mnh qua mng bn thm p lc rt ao lc b cc nhim bn vi
sinh vt h % io ta .

3.4. H thng phn phi mu:

- H thng phn phi mu bao gm h tu ho go i th trong my thn


nhn to u, h thng ng dn mu v rt nhiu im cnh bo an
ton...). T u tha i t 200-400 ml/pht. p lc m tnh bn
khoang dch lc to thun li cho dch t mu chuyn sang (siu lc). Mi mng
lc c h s siu lc khc nhau (tc l s l c chuyn qua mng
/pht/mmHg).
- C ba cch ly mu chy thn nhn to: ni th g ng-t h mch (fistula),
gh p ng-t h ch, ly qua ng thng (catheter). Ni th g ng-t h ch
thng lm t h h u vi ng mch quay vng c tay (Cimino-Breschia
Fistula ng mch ho t h h u, to thun li cho vic chc ht mu
bng kim to. Bin chng hay gp nht

ti ch ni thng l nghn m h do t g si h i mc lm hp l g t h ch.


Nhng bnh nhn cn lc mu nht thi (suy thn cp th ng ly mu thc
hin bi catheter 2 nng ch o t h h i ho t h h di hoc
t h ch cnh trong. Dng cch ny tin li h g d b nhim khun v hay b
tc lm gim dng mu ly ra, do vy ch thng dng 2-3 tun.

3.5. Hot ng ca thn nhn to:

Mu ca b h h c ch g g ng hepa i , c o b lc t
200- 400ml/pht, dch l l g l C o khoa g i din
vi mu theo chiu gc li, vi t 500- l/ph t h s thanh lc ur
t 200- l/ph t, i oglo uli t 20-25 ml/pht. Hiu qu ca vic lc
ph thuc vo t mu, dch lc

qua b l c tnh ca b lc. Thi gian l u nh da o ln


ca h s thanh thi ur trong cuc lc, tr g l g gi bnh, ch g
li ca thn, ch p otei o, chuyn ho, d ho, nhng bin
chng ca bnh, s dch gia hai ln chy thn. Vi a s bnh nhn suy thn
m i hi chy thn t 9-12 gi/tu thng chia lm 3 ln chy bng nhau.
Mi ln l u c coi l tt khi ur mu sau cuc lc cn ti a l %l
t c lc.

4. Bin ch g t o g iu tr bng thn nhn to.

- Tt huyt p l bin chng cp tnh hay gp nht trong lc mu. C rt nhiu yu


t gy tt huyt p: siu lc qu mc (lm gim khi lng tu ho , p ng
hot mch suy gi , tha i thm thu mu, dng thuc h p, gin mch do
dch lc qu nng. V acetate c ch tim v lm gin mch nn dng acetate lm
cht m trong thnh phn dch lc s gy tt huyt p. Khi b tt huyt p th
phi ngng siu lc, truyn 100-250 ml dung dch mui g t g; nhng
bnh nhn albumin mu h c th truyn albumin t mui. Tt huyt p c th d
ph g c bng cch h gi n thn tr g lng kh, khng ung thuc h
p ngy t c lc v ngy lc mu, loi b kim loi nng trong dch lc.

- Chut t gl in chng hay gp. Tuy nhin, t ngy c my thn nhn to


chnh

c th t h, iu ho chu c Na+, t l chut rt t gp h . Ngu h


gy chut rt cn cha . Nh g tha i ti u do t dch qu m , c
bit di tr g lng kh v vic dng dch lc n g Na+ thp c th gy
chut rt. Mun d phng chut rt th khi lc mu cn gim siu lc, dng dch
lc n g Na+ cao.

- Phn ng dng phn v vi b l , c bit hay xy ra trong l d g u tin b


lc cellulosa (do khng ph hp sinh hc). Hi chng ny c th l phn g t g
mn cm do

IgE vi oxyt ethylen (dng lm cht kh trng b lc) hoc l mt phc hp triu
chng

au l g, au ng kh g c hiu xut hin do hot ho b th v gii phng


cytokine.

- Nguyn nhn chnh gy cht b h h STGC lc mu chu k l bnh tim


mch. T l cht do chy thn chu k l h do lc mng bng v ghp thn.
Nguyn nhn bnh tim mch ngi lc mu bng thn nhn to th ha c
hiu, c th l do iu tr t g hu t p ha tt, t g mu, thiu mu, vi
ho ng mch h do t g sn vt canxi-phospho v c th do nh g tha i
ng lc hc tim mch khi chy thn nhn to.

72.A NANG THN


(Bnh thn Ni khoa. Nh xut bn Y hc 2004)
I. I CNG

L tnh trng c nhiu nang to nh kh g u vng v v vng ty ca c hai


thn. Nguyn nhn do di truyn gen tri nhim sc th thng (t th g
nhnh ngn ca NST h g g th l bm sinh.

Bnh th a a g gu h do di t u n gen tri. T l nam n h hau.


Mc d biu hi l s g thng ch xut hin sau 30-40 tui, h g n c th
thy bnh xut hin tui nh nn thut ng bnh th a a g gi ln khng
tht chnh xc. V vy cc nh thn hc thch dng mt thut ng h h h l
bnh th a a g di t u n gen tri nu c bng chng r rt v di truyn.

II. M BNH HC

Thn gm rt nhiu nang c 2 thn. Tr g lng ca thn c th ch nng h


h thng mt h t ho n nh g t ng hp thn rt to, n g n 4kg. Cc
nang rt nhiu kh g . K h thc ca nang to nh kh g u, t 1-2
g k h n nhng nang to 4- ng knh ho h .

D h t o g a g th g l ng nht, t o g, i khi l dch mu ho c m do


b bi nhim. Xt nghim thnh phn dch ca nang c th gip phn bit nang
thuc g ln gn, g ln xa, quai Henl hoc ng gp. Nhng nang thuc
ng gp hoc g He l th g k h thc l h .

a nang thn t khi phi hp vi mt d dng nh g ua kh . Tu hi


c khong 1/3 bnh nhn th a a g k theo hng nang gan. Nang
ga thng c s lng t v ch mt ph th , k h thc khong mt vi cm
g k h. T g p l t h mch ca v ri lon ch g ga him gp. Ngoi
nhng nang thn, phn cn li ca nhu m thn c cu t h thng.

III. CHN ON

1. Ch o nh:

Da vo triu chng lm sng v cn lm sng. Khi nang th ph t t in to r


th vic ch o th g kh g kh kh .
a. Lm sng:

- Thn to c hai bn.

- C th thy b mt th kh g u khi s nn.

- Nu th ga to c bit s thy nhng khi nghi nang trn b mt gan cng


gi p gh n ch o .

- Cao huyt p: Cao huyt p thng xut hi khi in chng nhim trng,
si th , c bit l khi su thn.

- i u: do him trng, do chy mu thnh nang hoc do si.

- Nhim trng tit niu g d g g t thng gp vi i ut, i t v


au h g l g.

- au g thn: do nang qu to.

b. Cn lm sng:

- giai on sm ca bnh, xt nghi c tiu th g h thng.

- giai on mu h : khong t 20-40 tui c th thy protein niu > 0,2


g/24gi gp 20- % t ng hp. Protein niu nhiu 2-3 g/24gi him gp. Nu
c protein niu nhiu c th do nguyn nhn bnh cu thn phi hp ngu nhin.

- Khi ha su thn: s lng hng cu, hematocrit c th t g do t g tit


erythropoietin ca a g. C g h h y m bnh nhn th a a g, khi
c suy thn giai on cui h g t h t ng thiu mu khng n g h hng
bnh nhn suy thn do nhng nguyn nhn khc.

- Bch cu niu nhiu l biu hin ca bin chng nhim trng.

- Hng cu niu nhiu: do chy mu thnh nang.

- Ch o nh ch yu da vo nhng xt nghim ch o h h nh:

. Chp UIV thy c hnh nh bin dng ca h thng ng gp, ng gp b gin ra


thnh hnh chm nho hoc ngn la.
. Siu m thn thy nhiu nang c hai thn.

. Tuy nhin chp ct lp CT scanner cho hnh nh r nt nht.

- giai on sm ca bnh, ch o kh kh h . Siu thn cho thy hnh


nh nghi ng a g k h thc cn nh. Chp CT scanner cho hnh nh r
h th pht hi c nhng nang nh < 1 cm.

2. Ch o th bnh:

- Th th a a g gi l i h h h t h .

- Th th a a g t bn do di truyn gen tri nhim sc th thng rt him


gp v kh ch o . Ch c ch o nh hc mi kh g h c th
b h c bit ny.

- Th phi hp vi a a g ga : gp khong 30-60% bnh nhn. Tuy nhin biu


hi a a g ga thng nh v t khi gy h hng ch g ga .

- Th phi hp vi ph h ng mch:

. Phnh mch no nu th ti lng nng, d dt v bin chng ca n. T l


phnh mch no phi hp gp 10-20% bnh nhn. Nhng phnh mch no nh
h g k h thng khng hoc t triu chng lm sng v t gy bin
chng v phnh mch. Nhng phnh mch l h g k h thng gy
triu chng lm sng v thn kinh v cn xt phu thut. Ch o ch yu da
vo CT scanner.

. Ph h ng mch trong b g ph h ng mch ch b g g h g t


l mc khng cao.

- Th k theo t g hng cu do t g tit erythropoietin.

3. Ch o ph it:

a. c thn hai bn:

- Nguyn nhn do si hoc cc nguyn nhn gy tc nghn niu qun khc.


- Thn to c hai h g u c theo di th thy thn to nhanh v chc
g thn gim nhanh.

- Cn tm cc nguyn nhn tc nghn niu qun nu nghi ng.

- Siu m thn gip ch o ph it vi iu ki gi lm siu m rt c


kinh nghim.

- Chp UPR hoc chp b thn niu qun qua da trong nh g t ng hp cn


thit.

b. Thn thiu sn c nhiu nang:

- Thng ch mt bn, thn teo nh khng c ch g hiu nang.

- Thn nhiu a g : th mt bn th h g g th c hai bn;


k h thc th h thng v khng d n suy thn.

- Thn suy mn tnh c nhiu nang: bnh nhn suy thn m t h, c bit chy
thn chu k hiu , thn c th xut hin nhiu a g, k h thc nang
thng nh v hai thn teo nh.

4. Ch o in chng:

a. Nhim trng:

Bin chng nhim trng nang l mt bin chng nng. Mt hoc nhiu nang c
th b nhim trng.

Nguyn nhn nhim trng nang c th thng qua nhi t g gc dng hoc
khng.

Nu nguyn nhn nhim trng do nhi t g gc dng th thy bch cu


niu r v vi khun niu. Nu khng do nhi t g gc dng, xt nghim
c tiu th h thng th ch o kh kh h .

Ch o da vo:

- t ng hp nhim trng nng:


. Bnh nhn xut hin st, c th st cao.

. au hiu vng th , thng mt bn.

. C th i ut, rt, c tiu c.

. Xt nghim: Bch cu u t g. C th bch cu niu nhiu v vi khun niu.

. Siu m: thnh nang dy, dch t o g a g c. C th thy si gy tc nghn l


nguyn nhn thun li.

- nh g t ng hp kh g in hnh ch c st nh, khng c bch cu v vi


khun niu. T c mt bnh nhn th a a g st, khng r nguyn nhn
nhim trng ngoi th , au g thn r, siu m nghi ng d h c, thnh nang
dy, bch cu u t g th h o g l hi t g a g iu tr theo
h g .

b. i uv hy mu thn:

L mt triu ch g thng gp, nhiu khi khng c nguyn nhn thun li.
Nhng nguyn nhn thun li g i u thng l nhim trng v si. Chy
mu thnh nang c th g i u h, trung bnh ho i u ng. Tuy
nhin ch u th h a g g th kh g g i u h khu tr trong
nang. Ch u g th chy ra ngoi bao thn.

Ngoi triu ch g i u, t iu ch g kh h au g thn, thn to


nhanh gi ch o . Siu thn gip ch cho ch o hy mu ra ngoi
bao thn v nghi ng chy mu trong nang.

c. Si thn tit niu:

Si thn tit niu gp khong 10-20% b h h a a g thn. C th l si


acid uric hoc cc si khc. Si thn tit niu l mt trong cc nguyn nhn lm
nng bnh. V vy, c kh nh k b h h pht hin si sm v c thi
iu tr d phng vic hnh thnh si nhng bnh nhn ny.

d. T g hu t p:
T g hu t p gp khong 50% bnh nhn, c th gp t c khi xut hin suy
th th y s suy gim ch g thn. Huyt p c th t g h, trung
bnh hoc nng v c iu tr sm.

e. Suy thn:

- Suy thn ch g th xy ra bnh nhn c ch gim mui nghim


ngt hoc dng li tiu ko di.

- Suy thn mn thc tn l mt bin chng nng. Nguyn nhn l do cc nang


ngy mt to dn gy h hng nhiu n ch g lc ca thn, cng vi vic
xut hin cc bin ch g h si, nhi t g, t g hu t p. Suy th giai on
cui xut hin trung bnh sau 10- ph t hin triu ch g l s g u tin.
Tu hi g t s bnh nhn khng xut hin suy th ho n cui cuc
i. T l bnh nhn suy th giai on cui phi lc mu chu k dao ng trong
khong 4-8% bnh nhn lc mu c pht trin.

f. U g th h a:

U g th h a him gp tuy v u a t o g :

- Bnh nhn xut hin g s t, au hiu vng thn mt , i u ng hay


ti pht, thn to nhanh.

- Siu c bit CT scanner gip ch o nh.

IV. IU TR

- Kh g iu tr c hiu.

- Ch yu l iu tr triu ch g iu tr bin chng.

. iu tr ri lo v in gii:

giai on sm ca bnh th a a g th gy gim kh g . i


l iu hin lm sng ca triu chng ny. Tuy nhin giai on sm c th
ha n c s can thip ca iu tr.
Khi creatinin mu bt u t g th kh g g gim r, c th gy nn
tnh trng mt mui , c bit l mt natri. Bnh nhn c c ung t
nht t 1- l t c mi ngy. Nu c si thn, tit niu hoc nhi t g ng
niu th l g a o n nhiu h . C th gi lng mui a o khi
cao huyt p, nh g ht khng phi l ch nh bt buc cho tt c cc bnh
nhn th a a g in ch g t g hu t p v suy thn v kh g t mui
nhng bnh nhn ny.

nhng bnh nhn suy th giai on cui th g t g Clo u gu


h kh g c bit r. C th do vi t g Bi a o at at i t o g khu phn
. T g kali u g th gp v c iu tr bnh nhn suy thn mc
t u g h n m suy thn nng.

. iu tr triu ch g au:

au g thn l triu ch g thng gp nht bnh nhn th a a g. T


t g gu h au ph g ph p iu tr khc nhau.

- iu tr triu chng bng cc thuc gi au th g th g h A algesi .

- i vi nh g a g to, ng knh 4-5 cm, ch nh chc ht nang qua da c th


gi c triu ch g au.

- Cc nguyn nhn khc c c ch o th i x t g:

. Si thn tit niu.

. Chy mu trong nang hoc ra ngoi bao thn.

. U g th h a th gp.

Ni chung tnh tr g au th qua khi nhanh chng khi b h h c nm


ngh ti ging v dng thuc gi au. i khi g hy mu d di phi
truyn mu hoc can thip ngoi khoa.

Si thn, tit niu c c ch o iu tr s . i vi si niu qun


hoc b thn gy tc nghn, c b thn cn gii quyt ngoi khoa.
. iu tr i u hoc chy mu trong thn:

Nh t t h , h yu l ngh gi ti ging.

Truyn mu hoc can thip ngoi khoa g c ch nh khi cn thit.

. iu tr nhim trng thn, tit niu:

Nhim trng nang l mt bin chng nghim trng ca bnh nhn th a a g.


Mt hoc nhiu nang b nhi t g, g gi g h t tnh trng nhim trng
nung m su khc, rt kh iu tr. Cc vi khun gram (+), gram (-) v vi khun k
kh u c th gp. Tuy nhin vn dng liu php khng sinh mc d nhiu t ng
hp khng c vi khun niu khi khng phi nhi t g gc dng v nhng
nang khng thng vi b thn.

Thng phi dng phi hp 2 loi kh g si h, t o g t khng sinh


g t h ch v thi gian ko di t nht 3 tun l.

Cn pht hin nhng nguyn nhn thun li gy nhi t g h si thn, tit


niu gy tc ngh

. iu tr t g hu t p:

T g hu t p c c pht hi iu tr s t g hu t p gp phn
th y xut hin suy thn v lm nng thm tnh trng suy thn.

iu tr t g hu t p bnh nhn th a a g g gi g h t bnh


h t g hu t p do cc nguyn nhn bnh l thn tit niu khc. M h
nh a hu t p v tr s h thng.

. iu tr si thn, tit niu:

Si thn, tit niu gp khong 10-18% b h h a a g thn v l nguyn


nhn thun li cho nhim trng.

Nhng si trong nhu m thn v nhng si h i th thng khng


can thip ngoi khoa. iu tr ch yu l gi au hng nhim trng.

Si niu qun gy tc nghn, c b thn c iu tr ngoi khoa.


. iu tr suy thn:

iu tr suy th c ch nh gi g h t tnh trng suy thn do nhng


nguyn nhn khc: bao g iu tr bo t iu tr thay th thn suy.

a. iu tr bo tn:

- iu ch h th g g in gii.

- iu ch h th g ng kim toan.

- iu tr t g hu t p.

- iu tr thiu mu.

. Truyn mu.

. Erythropoietin liu thch hp.

- iu tr ri lon calci, phospho nu khng c si thn.

.B al i t o g giai on sm ca suy thn.

. Cho thm 1,25 OH D3 bnh nhn suy th giai on III-IV.

- Tm cc yu t thun li th y suy thn n g l iu tr loi tr nhng


nguyn nhn ny:

. Tnh trng mt c, nhng ha cht kh g si h c vi thn.

. Trnh nhng yu t v cc nguyn nhn lm nng bnh.

. Cho thm vin Ketosteril nu iu kin nhm hn ch t g u . Ch nh cho


suy thn t cui giai on II. Liu t 6-12 vin x 600 mg/24gi ty m suy
thn, trung bnh l mi vin 600mg cho 5kg tr g l g th.

b. iu tr thay th thn suy:

- Bng lc mu ngoi thn.

- Hoc ghp thn.


73.N NANG THN

Na g thn l mt hnh thi bnh l lnh tnh hay gp ng hng th hai


trong nhm bnh thn c nang.

Na g thn pht sinh v pht trin ti thn. Hu ht cc nang th c


mc ln t t chc v th , do th nm bt c ch no vng v thn, c
khi nm quanh b th . Na g thn nm trong s bnh nang thn khng di
truyn, phn ln do mc phi. C nhiu loi a g: a g c, nhiu a g ,
nang ch u, a g p e

Theo nghin cu ca nhiu tc gi, t l a g th gia t g theo la tui.


Bnh hay gp la tui trn 40, him khi gp la tui t c 20. Na g thn
tuy hay gp h g t iu hin triu chng lm sng, nht l khi nang cn nh,
ha g h p o i thn.

T c kia, vic pht hi a g thn ch yu da o X ua g th g thng


h hp thn thu t h ch. Ngy nay, vi cc ph g tin ch o h h
nh hi i h: hp ct lp i t h, c bit nh k thut siu , a g
th c pht hin ngy cng nhiu. Vic ch o iu tr tr nn d
d g h h h .

I. NH NGHA V PHN LOI

. h gha:

Na g th h gha l a g h c mt thy thn, nm ring bit,


khng thng vi b thn. C th mt hoc nhiu nang, mt hoc c hai bn
thn.

2. Phn loi:
a. Phn loi chung bnh thn c nang:

- Brurstein v Gardner (1985) phn loi bnh thn c nang lm cc nhm:

+ Th a a g.

+ Bnh thn c nang cc hi chng di truyn.

+ Bnh th a g :

. Na g c.

. Nhiu a g .

. Bnh thn c nang khm v mt bn.

. Bnh thn c nang mc phi.

. Bnh thn c nang ty thn.

+ Lc sn thn: bao gm cc bnh thn c nang bm sinh.

- Theo Ga i J.Be ke ; Judith A. White o th P is illa Ki aid S ith h


sau:

+ Bnh th a a g gi ln (Adult polycystic kidney disease).

+ Bnh th a a g ty (Medullary cystic kidney disease).

+ Bnh th a g thun (Simple cystic of the kidney disease).

+ Bnh ty thn bt bin (Medullary sponge kidney disease).

+ Bnh lon sn nang thn (Dysplastic kidney disease or cystic renal dysplasia).

+ Bnh th a a g tui thanh thiu nin (Juvenile polycystic kidney disease).

+ Bnh nang thn mc phi (Aquired cystic kidney disease).

b. Phn loi a g thn:

- Theo s lng nang:


+ Na g c (Solytary).

+ Nhiu nang (Multiple).

. Mt bn (Unilateral).

. Hai bn (Bilateral).

- Theo v tr nang:

+ Theo v t t g i vi h i thn:

. Nang cc trn.

. Nang gia thn.

. Nang c di.

+ Theo v t t g i t b ngoi vo rn thn:

. Nang vng chu vi thn.

. Nang nhu m thn.

. Nang cnh b thn.

II. C CH BNH SINH

. C gu si h nh:

C gu si h nh ca a g th ha c bit r rng. Nhiu tc gi


a a hng ki kh hau gii th h gu . C gi thuyt v
ngun g a g thn:

- Gi thuyt bm sinh:

. Hidebrand (1984) cho rng trong qu trnh pht trin phi thai hc ca thn, c
s khim khuyt ca mm hu thn (Metanephrogene) vi ng Wolff sinh ra nang
thn.
. Ka p ei e hng minh, trong s pht trin bo thai ca thn, cc giai
on phn chia th 3 hoc th 4 ca niu qun, mt phn ca g ln c th
tch ra khi g g p, sau ln dn v tr thnh nang thn.

- Gi thuyt mc phi:

. Nguyn nhn vim nhim: B h a g th thng gp gi trung


nin, cao tui v c s gia t g t l bnh cng vi la tui nn Rujssenaers v
Wirchow cho rng: nang thn l bnh mc phi, c hnh thnh th pht,
nguyn nhn do vim nhim gy tc nghn ng thn. Thc nghim trn hai thn
th bng cch kt hp buc ng thn v tht mch mu cung cp cho nh thn
ca g , kt qu d n hnh thnh nang thn.

. Nguyn nhn tc ng thn: Mt s tc gi cho rng: ti tha i thn c th tr


th h a g thn. Tc g ln gn hoc yu g a ng thn c th
to thnh nang thn.

. Nguyn nhn nhi : a g thn c th l mt bin chng ca nhim


acid g ln xa tin pht.

2. Gii phu bnh hc:

- Hu ht a g thn mc ln t t chc v thn, hnh trn, hoc bu dc, kch


thc khc nhau. C th t n hng ch . Thng ch c mt nang
mt bn th h g g th c nhiu nang mt hoc c hai bn thn.

- Thnh nang dy khong 2mm, cu to hu ht b g , gm 3 lp:

. Lp trong l biu m hnh tr.

. Lp gia l lp lin kt gm 1 lp si v 1 lp t .

. Lp ngoi cng l v nang c cu to ng th teo.

- D h t o g a g: th g t o g, u g . T ng hp nang b nhim trng


hoc chy mu, dch nang s c, mu hng, nu ho e .

III. CHN ON
1. Lm sng:

Na g th thng khng gy cc triu chng lm sng rm r nn bnh


h kh g . Phn l a g th c pht hin tnh c trn siu m
hoc chp ct lp vi tnh. Du hiu lm sng ph thu o a g g
h p i thn v lm c thn hay khng. Mt s t t ng hp,
nang th c pht hi khi do ch th g.

Tuy v , a g thn c th gy triu chng:

- au tht l g hoc tc nng vng tht l g bn thn c nang l triu chng hay
gp khi k h thc nang ln khin bnh nhn phi i kh .

- T g hu t p: nhng nang th k h thc ln, li nm vng nhu m thn


lm chon ch mt vng thn gy ra thiu mu ti g , d t g i tit
Re i l t g hu t p th pht.

- Thn to: khi nang thn qu to, c th s thy hoc nhn thy mt khi u bng.

- Triu chng v ng tit niu: i ut, i t, i kh , i a u ho c


tiu c.

2. Cn lm sng:

a. Xt nghim:

- Mu: cng thc mu, ch g th u , eati i h thng. Tr t ng


hp nang b nhim khun, bch cu mu c th t g.

- Nc tiu: bch cu, hng cu t ++ d c ty theo tnh trng vim


nhi ng tit niu ho i u; p otei iu thng rt thp (< 0,5 g/l).

b. Siu m thn:

Siu m l k thut c la ch u ti ch o h a g thn.


Nh c siu m m nang th g g c pht hin nhiu h , h o
h a g thn ch yu da vo k thut siu m vi cc tiu chun sau:

- Khi trng m (Echo free).


- Hnh trn hoc bu dc.

- Thnh nang nhn, mng, b u r.

- Cho sng m xuyn qua tt. L t g ph a sau a nang.

c. Chp thn thuc - t h ch (UIV):

- L th thut c s dng nhiu khi ha siu hn o .

- Nh g a g k h thc nh ha g h p i thn hoc nhng


nang khng nm vng nhu m thn th rt kh pht hi t phi UIV. Do
chp thuc thn - t h h c ch nh cho nhng b h h k h thc
nang t 4 cm tr ln ho t ng hp nghi ng nang vi gi i thn.

- Trn phim chp UIV, c th thy bng ca nang thn v hnh h y h


th g i th do a g h p, ng thi cn xem nang c thng vi i
thn hay khng.

d. Chp ct lp vi tnh (nu cn thit):

3. Ch o ph it:

- Th a a g:

. Bnh di truyn theo kiu gen tri (trong ph h gia h hiu gi b bnh).

. Hai thn to do b thay th bi nhiu nang.

. K h thc nang to nh kh g u nhau. C nang rt l > h g ng


c nang rt nh (khong 0,5cm).

. C th k theo ga a a g.

- Nang thn mc phi bnh nhn suy thn mn (ur mu cao) hoc chy thn
nhn to ko di.

- Gi i thn: c hnh nh thng gia i thn vi nhau trn siu m


hoc trn phim chp UIV.
IV. IU TR

. iu tr triu chng:

- au tht l g tc nng vng tht l g:

. Thuc gi au.

. Thu gi .

- T g hu t p: c th cho thuc h p cc nhm.

- Nhi t g ng tit niu:

. Kh g si h theo kh g si h nu c).

. Xem ph iu tr bi Nhim khun tit niu.

2. Chc ht dch nang thn:

T c kia phn ln cc nang th u iu tr bng phu thut ct b


nang, ct bn phn thn c nang ho iu tr ni soi ct b mt phn nang thn.
Nhiu gn , h c k thut siu m, vi iu tr a g th
nhiu tin b.

Ph g ph p hc ht dch nang thn qua da phi hp n tuyt i


Etha ol % l h a a g di hng dn ca siu e li nhiu
kt qu tt.

Chc ht dch nang thn qua da c th tin hnh cho cc nang thn c kch
thc t 6cm tr l . l t k thut gin d lm, r tin v an ton, c
th thc hi c tt c cc bnh vi siu .

V. BIN CHNG

- T i thn do nang to chn p.

- Vim nhi ng tit niu hoc to si do tc ngh hc.


- V nang vo h th g i th g i u th pht hoc c th v ra ngoi
bao th g au d di, n g h th d n sc mt mu (him gp).

- Ch ut o g a gg au l g d di, km theo cc triu chng ca ng


tit niu c tiu.

- Nang thn c th p xe ho u g th h a t gp).

VI. KT LUN

B h a g thn l mt b h l h t h, thng gp gi ln. La tui


gp nhiu nht t 40 tr l . Na g thn t c biu hin triu chng lm sng
g kh g h h g n ch g thn. Du hiu lm sng ch xut hin
khi a g k h thc ln gy chn p nhiu vo nhu m th ha i thn
gy nn cc triu ch g: au tht l g hoc tc nng vng tht l g c nang,
t g hu t p th pht v thn to do nang.

Cc bin chng ca b h a g thn hay gp khi a g k h thc l h


i ng tit niu, i u si thn tit niu.

Siu m l k thut c ch ch o a g th . l ph g
ph p gin, an ton v d thc hi , e li hiu qu cao. Qua siu m, gip
ta h k h thc, v t a g hng dn chc ht dch nang khi c
ch nh.

74.S DNG THUC LI TIU

TS. H Hong Kim (Bnh hc ni khoa HVQY)

T o g iu tr, nhiu t ng hp gi thy thuc phi dng thuc li tiu gii


quyt tnh trng qu ti c v mui h t o g iu tr ph) ho lm gim
mui h t o g iu tr t g hu t p). Thuc li tiu l nhng thuc c kh
g l t g thi tr qua th c, mui v cc thnh phn khc ca c
tiu. s dng thuc li tiu c hiu qu, chng ta cn hiu r qu trnh vn
chuy at i c cu t bo ng th ; h tc dng ca cc loi thuc li
tiu, g h t dng ph ca thuc li tiu.

1. Nhc li qa trnh vn chuyn natri, nc ca t bo ng th v h


tc dng ca thuc li tiu.

Qu trnh to v bi xut c tiu ca thn c thc hi th g ua h


chnh:

lc mu cu thn, ti hp thu v bi tit cc cht ng thn. gi t ng


thnh, mi ngy c 2 thn to ra khong 180 lt dch l , h g ng th
ti hp thu li khong 178,5 lt v ch , l t c tiu (b g % lng dch lc)
c bi xut trong 1 ngy.

Mi ngy c 2 thn c khong 22420 ol at i c lc ra dch lc cu thn,


sau ng thn ti hp thu li 22330 mmol natri, ch c khong 90 mmol natri
c o thi/ngy. Qu trnh ti hp thu natri xy ra theo sut dc chiu di ca
ng thn, phn ln ti hp thu at i theo ch ch ng. Qu trnh ti hp thu
c ch yu theo h th ng v ph thuc vo ti hp thu at i. Ngi ta
th , l t g l g c tiu ln gp

i th n phi t g c lc cu thn ln 100 l iu ny kh thc hin) hoc


lm gim 1% qu trnh ti hp thu ca ng th . Do , phn ln cc thuc li
tiu hin nay l thu t ng ln qu trnh ti hp thu natri ca ng thn.

Qu trnh ti hp thu bt k mt cht o t dch lc trong lng ng th u

li ua a c vn chuyn: vn chuyn t lng ng thn vo t bo biu


m ng th c vn chuyn vo), vn chuyn t trong t bo ng thn ra
dch k c vn chuyn ra), ti hp thu cc cht t t chc k vo huyt
t g ca li mao mch bao quanh ng th c th a . Bc th a c
vn chuyn ch yu do lc Starling.
Hnh 1. Qu trnh vn chuyn ion ca t bo ng thn

(S: l cc cht glucoza, amino axt...)

+ Bc vn chuyn vo: ion natri v c glu oza, phosphat, la tat, it at i o t


bo ng thn qua mng t bo nh h thng cc cht vn chuyn. Mt cht vn
chuyn c th mang mt hay nhiu ion natri. N g cao ca ion natri dch lc
trong lng ng thn c tc dng kch thch cc cht vn chuyn hot ng.

+ Bc vn chuyn ra: ion natri trong t bo c vn chuyn ra t chc k do


hot ng ca Na+, K+-ATPaza . C 3 ion natri trong t o
Na+, K+-ATPaza n chuyn qua mng t bo ra dch k, th c 2 ion kali t trong
dch k c vn chuyn vo trong t o. B Na+, K+-ATPaza mng bo
t g a t bo pha t chc k, g l g d g ho Na+, K+-
ATPaza hot ng do qu trnh thu phn ATP cung cp.

1.1. Qa trnh vn chuyn natri v nc ca t bo ng ln gn ( H. 3 ):

g ln gn ti hp thu 60- % lng natri ca dch lc, mt ph at i c ti


hp thu th g h g phn l c ti hp thu theo h tch cc.

+ Qu trnh ti hp thu natri c thc hi ua hai o ng:

- Co ng qua t bo: qu trnh vn chuyn natri t dch lc trong lng ng


ln vo trong t o c thc hin nh cht vn chuyn Na+/H+. Cht vn
chuyn ny l mt loi protein. T vn chuy iu ho bi v tr
nhy cm vi pH ca cht vn chuyn; t vn chuy t g khi pH t bo tr
nn axt. Qu trnh vn chuyn natri t t bo vo dch k c thc hin do
Na+, K+-ATPaza .

- Co ng qua khe gian bo: on g ln g , at i i ua o ng khe


gian bo d dng h l o ng vn chuyn qua t bo do c s chnh lch
in th d g ph a l g ng. V v , l g at i c ti hp thu cng vi c
theo o ng ny nhiu h theo o ng vn chuyn qua t o. N g
lng cung cp t ATP ch tiu th ho o ng vn chuyn qua t bo, qu
trnh vn chuy at i theo o ng qua khe gian bo khng tiu th ATP.

+ Io lo c ti hp thu th g ua khe gia o. Co ng qua khe gian


bo g ln gn c tnh thm chn lc, clo c tnh thm cao nn di chuyn t
dch trong lng g ln qua khe gian bo vo dch k do s chnh lch n g .

+ Ti hp thu i a o at iu chnh bi n g ion hydro dch lc trong


lng g l . Io h d o c vn chuyn t trong t bo vo lng g ln do
t ao i Na+/H+, sau io h d o kt hp vi bicacbonat trong lng g ln
to thnh H CO . Sau , H CO c phn gii thnh H2O v CO2. CO2 d
d g i ua g o t g o i bo ri kt hp vi to li
H2CO3 nh men cacbonic anhydraza c mt mng t bo pha lng ng, sau
H CO phn ly thnh H+ v HCO3- . HCO3- c vn chuyn t trong t bo
vo dch gian bo nh h thng vn chuy c bit. Kt qu l i a o at c
ti hp thu, lm cho n g bicacbonat ca dch lc trong lng g ln thp
h g t o g dch k li ao. Co ng qua khe gian bo ng ln gn
c tnh thm thp vi bicacbonat, nn bicacbonat khng th th gc tr li
lng g ln.

+ Cc cht ho ta h D. glu oza, a i o a t ho phosphat c vn chuyn t


lng g ln vo trong t bo nh cc cht vn chuyn. Mng ca dim bn
chi ca t bo g ln gn pha lng ng c nhiu cht vn chuy h y.

Vi h trn gi rng, nu c ch vn chuyn natri hoc bicacbonat ng


ln gn s gy li tiu mnh. Mun vy, cn c ch cht vn chuyn Na+/H+
hoc c ch Na+,K+-ATPaza hoc cht vn chuyn bicacbonat. Trong lm
s g, gi ta s dng thuc li tiu c thu ngn l nhm thuc li tiu c ch
cht vn chuyn Na+/H+ v nhm thuc li tiu c ch men cacbonic anhydraza
a etazola it gy li tiu. Acetazolamit c ch men cacbonic anhydraza, lm
gim ti hp thu i a o at, h g t dng li tiu b gi i i ti hp thu
natri g l a t g t g d g c tiu ti o , do kh g li
tiu ca acetazolamit l rt yu. Mt khc, bicacbonat b mt ua c tiu nhiu
c th d n toan huyt chuyn ho v ki ho c tiu, do thuc
thu h t c s dng trong cc bnh thn.

1.2. Qa trnh vn chuyn natri v nc ca t bo quai Henle:

Lu l g c tiu qua quai Henle trung b h l/ph t; c ti hp thu


th ng nhnh xu g do t h u t g a dch k vng tu th ; at i c
ti hp thu ch ng nhnh ln ca quai Henle nh Na+,K+-ATPaza .

+ nhnh ln phn dy ca quai Henle, natri c vn chuyn t dch lc trong


lng ng vo trong t bo nh cht vn chuy Na+, Cl-, K+ . Cht vn chuyn
ny c mng t bo nhnh ln quai Henle pha lng ng. Qu trnh vn chuyn
natri t trong t bo vo dch k nh Na+,K+-ATPaza mng t bo pha
dch k.

Nat i c vn chuyn t lng ng vo dch k theo o ng qua khe gian


o do in th d g ph a l g ng. Qu trnh vn chuyn natri ao gm:
3 ion natri vn chuyn qua t bo nh Na+,K+,ATPaza , io at i kh
c vn chuyn qua khe gian bo, cn 6 ion clo kt hp ho to c vn
chuyn qua t bo nh cht vn chuy Na+, Cl-, K+ h h .

+ Io kali c vn chuyn t dch lc trong lng ng thn vo t bo nh


cht vn chuy Na+, Cl-, K+ . Sau khi qua mng vo trong t bo, ion kali
hu h ho to ua t li lng ng qua knh kali mng t bo pha lng
ng. Qu trnh quay tr li lng ng ca io kali iu chnh bi pH ni bo,
u t h t g khi pH i bo kim, pH ni o u h g t g kim gim
axt.

+ Qu trnh quay tr li lng ng ca ion kali cng vi ti hp thu clo to ra lng


g a g in th d g -15 mV. Do lng g a g in th d g s y
dng ion canxi, magie v c natri qua khe gian bo vo dch k. Khe gian bo
on ny c tnh th c rt thp; phc hp ni hai t bo l cc si a h o
hau h n thng ch cho cc ion nh io d g i ua t cch chn lc.

C h trn gi rng, nu c ch ti hp thu ion natri nhnh ln quai Henle s


gy li tiu mnh. T o g l s g, gi ta thng dng thuc li tiu
furosemit. Cc thuc thu h g h l gn vo v tr gn clo ca
cht vn chuy Na+, Cl-, K+ c ch cht vn chuyn ny. Do c ch ti
hp thu natri s lm gi t h u t g a dch k vng tu th , do g
t g thi tr at i c rt mnh. V thuc li tiu furosemit c ch cht vn
chuy Na+, Cl-, K+ l t g l g io at i i ti g l a, do s
g a t g i tit ion kali g ln xa, v vy thuc li tiu furosemit l thuc
li tiu gy mt ion kali.

1.3. Qa trnh vn chuyn natri v nc ca t bo ng ln xa:

Lu l g c tiu g ln xa l 20 ml/pht, qu trnh vn chuyn natri t


lng g ln xa vo trong t bo nh h vn chuyn Na+/Cl- mng t bo pha
lng ng. Qu trnh vn chuyn natri t trong t bo vo dch k do Na+,
K+-ATPaza thc hi . T o g on g ln xa, qu trnh ti hp thu at i c
ho o aldoste o iu chnh.

T o g l s g, gi ta dng thuc li tiu nhm thiazit l cht c ch


cht vn chuyn Na+/Cl- ph u ca g l a gy li tiu. V t g thi
natri ph u ca g l a thiazit l t g g NaCl ti phn cn
li ca g l a, do g t ng ln maculadensa. Tc ng ny gy ra
hiu qu lin h gc cu-ng thn, v vy lm gim mc lc cu thn. Ngay c
khi c, mc lc cu thn vn gi , do gi ta g t s dng thiazit
bnh nhn b bnh thn. on cui ca g ln xa v ng gp, ti hp thu
io at i t ao i vi bi tit ion kali v ion hydro, v v h pothiazit g l thuc
li tiu gy mt kali (hnh 5).

1.4. Qa trnh vn chuyn natri v nc ca t bo ng gp:

Lu l g c tiu g g p l l/ph t, io at i c vn chuyn t dch lc


trong lng ng gp vo trong t bo qua knh natri chn lc. Qu trnh vn
chuyn natri t trong t bo vo dch k nh Na+, K+, ATPaza (hnh.6).
Theo Burckhardt v Greger, on ny tiu th mt phn t ATP ch ti hp thu
c 1 ion natri, do hiu qu vn chuyn natri k h on khc.
Qu trnh iu ho ti hp thu ion natri ng gp do hormon aldosteron chi
phi, khi g aldoste o th at i c ti hp thu t g l . on ny, ti
hp thu io at i t ao i vi bi tit io kali io h d o, khi t g aldoste o
s l t g t i hp thu at i l t g mt kali.

T o g l s g, gi ta s dng cc cht kh g aldoste o hn ch ti hp


thu ion natri s l t g i iu. Hn ch ti hp thu natri on ny s lm
gim bi tit kali, do hng thuc li tiu khng aldosteron l cc thuc li
tiu khng gy mt kali. Cc thuc khng aldosteron c cng thc ho h t g
t aldosteron, nn c ch cnh tranh vi aldosteron.

Ti hp thu ion natri ng gp cn b c ch bi cc thuc amilorit v triamteren,


hai thuc ny c ch knh natri mng t bo pha lng ng gp. Do c ch knh
natri nn n gin tip lm gim bi tit ion kali qua knh kali, v vy chng l thuc
li tiu khng gy mt kali, tc dng li tiu ca cc thuc ny mc trung bnh.

2. Cc loi thuc li tiu.

2.1. Nhm thuc li tiu gy mt kali:

2.1.1. Thuc li tiu c thu ngn:

+ Bit dc: novurit, ng 1ml c 0,1g mui thu ngn v 0,05g theophylin. Thuc
tim bp ho ti t h ch: 1ng/ln x 1-2 ln/tun (khng dng qu
0,1g/ln). Hin nay thu t d g c tnh ca thuc cao (thu c
b g B loi thuc li tiu mnh t h tha th.

+ V tr tc dng: thuc c ch ti hp thu natri g ln gn.

+ Hp thu v thi tr: thu c hp thu nhanh, gy bi niu ti a sau gi, tc


dng ko di 5-6gi, thu c bi tit qua thn 97%.

+ Ch h: ph do su ti , ga t ng hp cp cu khi cc thuc li
tiu

mnh khc khng cn tc dng.


+ Chng ch nh: bnh thn, suy gan nng, hi chng chy mu.

+ Tc dng ph c tnh:

- Ng c: khi dng liu cao c th gy ng c thu ngn. Biu hin ca ng c:


bnh nhn thy c v tanh kim loi ming, vim li, bun nn, nn, a ch . iu
tr ng c: dng dung d h BAL %, ti t h ch 3-4ml/ngy, trong 2-5 ngy.

- Khng dung np thuc: mn nga, ni m a , a dng si, ban xut huyt,


phn ng ton thn (v m hi, rt run, chng mt).

- Ri lo in gii: gim natri, kali, clo trong mu.

2.1.2. Nhm thuc c ch men cacbonic anhydraza:

+ Bit dc:

- Acetazolamit: d g i h lng 0,25; dng ng tim 5ml cha 0,50g natri


acetazolamit; tim bp ho ti t h ch 5-10mg/kg, cch 6gi/ln.

- Funorit (diamox): dng vin h lng 0,25; cho ung 2-4 vin/ngy, trong 3-5
ngy.

Nu iu tr ko di th thuc s b mt tc dng v toan ho mu.

+ V tr tc dng: thuc tc dng ln g ln gn do c ch men cacbonic


anhydraza lm gim ti hp thu i a o at, do l t g o thi cacbonic.
Trong mt s cu to ca mt g e a o i a h d aza, di tc dng
ca acetazolamit thy nhn p gim nn thu c s d g t o g iu tr
nh g gi t g h p.

+ Hp thu v thi tr: tc dng ti a sau ung 4gi, tc dng ko di 8gi.

+ Ch nh:

- Ph do suy tim.

- Bnh t g h p n tnh.
- Ch g g ki h g ki h h, ng kinh sau chn th g thuc c
ch men cacbonic anhydraza nn lm gim s lng dch no tu.

+ Chng ch nh:

- Suy thn, bnh ng thn gy nhi a t t g lo.

- X ga : thuc gy toan mu nn d lm xut hin hn m gan.

- Bnh tm-ph mn hoc cc bnh phi mn tnh, suy h hp... Cc bnh ny gy


t g a o i u, t o g khi thuc li lm gim ti hp thu bicacbonat (l
cht c trung ho trng thi tha cacbonic trong t chc) nn d gy nhim
toan mu.

2.1.3. Cc hp cht ca sulfonamit:

+ Bit dc:

- Indapamit (fludex): dng vin 2,5mg, cho ung 2,5-5mg/ngy.

- Natrilix: dng vin 1,5mg, cho ung 1-2 vin/ngy.

+ V tr tc dng: c ch ti hp thu natri g ln g do g li tiu, ngoi


ra thuc cn gy gin mch. Thuc khng hoc t h h g lu lng mu
qua thn, tuy nhin tc dng li tiu gim khi ch g thn gim. Thuc lm
gim sc cn ngoi vi m khng h h g u g lng tim, khng h hng
xu ln n g lipit huyt t g, l gim chiu dy thnh tht tri bnh nhn
t g hu t p nn l thu c la ch t o g iu tr t g hu t p.

+ Hp thu v thi tr: tc dng sau ung 1-2gi, ko di 18gi; thi tr ch yu


qua thn.

+ Tc dng ph:

- Gim kali mu.

- T g a t u i u, t g glu oza u.

- D ng: mn nga, ni m a .
- Chng ch h: gi suy thn, suy gan nng, tai bin mch mu no mi.

2.1.4. Nhm thuc li tiu quai:

+ Bit dc:

- Furosemit (lasix, lasilix): dng ng tim 20mg, dng vin 40mg.

- Axt etacrynic (edecrin, urgit): dng ng tim 50ml c 0,05g, dng vin 0,05g.

+ V tr tc dng: thuc c ch ti hp thu natri nhnh ln quai Henle, tc dng


li tiu mnh v lm gi t h u t g a dch k vng tu th do l
gim ti hp thu c c nhnh xung ca quai Henle v g g p, ng thi
to ra mt lng ln dch i ti g l a t kh g t i hp thu natri v
c g ln xa.

+ Hp thu v thi tr: tc dng sau ung 30pht, tc dng ti a sau 1-2 gi,
ko di 4-6 gi. g ti t h ch tc dng sau vi pht, ko di 2gi. Thuc
c g ln gn bi tit, do ht kh c bi tit g ln gn c
tc dng c ch cnh tranh vi furosemit (chng hn allopurinol). Nu ti t h
mch, thuc c tc d g g gi t h h do l gim nhanh chng tin
g h, im ny rt c li khi iu tr suy tim nng, hoc ph phi cp.

+ Ch nh: ph nng do mi nguyn nhn, c bit t ng hp cn li tiu


m h ha h h ph phi cp, hen tim...).

+ Chng ch nh:

- D ng vi sulfamit.

- Suy gan nng.

- C thai, nht l thng cui gu t c v tai bin v mu thai nhi.

+ Tc dng ph: thuc rt t c, h g u dng liu cao v ko di, nht l


gi gi v nh g gi c triu chng mt c hay nh g gi c suy gim
ch g thn nng c th c mt s tc dng ph sau:

- Tt huyt p: v tc dng li tiu mnh gy gim th tch tun hon.


- Ri lo in gii: lm gi kali, agie a i t o g u, do th gy
triu chng chut rt, tetani; khi phi hp vi corticoit c th gy gim kali mu
nng.

- Lm gim clo nn c th gy nhim ki k o.

- L t g a t u i u, th gy khi ph t G t p tnh gi c bnh


Gt.

- L t g glu oza u, ht l nh g gi c ri lon dung np glucoza hoc


i th o ng.

- C th g ic do lm t th g d thn kinh s VIII, nht l khi phi hp vi


thuc khng sinh nhm aminoglycozit (streptomycin, gentamycin, kanamycin...)
hoc s dng liu cao gi gi hoc gi c triu chng mt c.

- Gim sn tu g: gim bch cu, gim tiu cu.

2.1.5. Nhm thuc thiazit:

+ Bit dc:

- Hypothiazit: d g i h lng 0,025 v 0,1; cho ung 50-100mg/ngy.

- Chlorothiazit: d g i h lng 0,25; cho ung 250-500mg/ngy.

- Cyclothiazit: d g i h lng 0,001; cho ung 1-2mg/ngy.

- Polythiazit: d g i h lng 0,001; cho ung 1-4mg/ngy.

+ V tr tc dng: thuc c ch ti hp thu natri ph u g ln xa.

+ Hp thu v thi tr: thuc tc dng ti a sau ung 2-4gi, tc dng ko di


18gi; bi xut ch yu qua thn, khi mc lc cu thn < 25ml/pht th thuc mt
tc dng. Thu c s d g t o g iu tr i th o ht, thuc c tc dng
gi g h ADH, h ha .

+ Ch nh:

- Ph do su ti , ga .
- Gi do iu tr corticoit, oestrogen.

- T g hu t p.

- i th o ht.

+ Chng ch nh:

- Suy thn v thuc lm gim mc lc cu thn.

- Thai gh gi cho con b v thuc qua nhau thai v sa.

- D ng vi sulfamit.

- Bnh Gt v b h i th o g gu l nh nng ln.

+ Tc dng ph:

- Khng dung np thuc: bun nn, a chy, mn nga, ni m a , st.

- Ri lon ch g thn: gim mc lc cu thn, t g u eati i u


gi c bnh thn.

- Ri lo in gii: gy gim kali, magie v canxi mu.

-G t g a t u i u, t g glu oza u.

- T g lipit u t g LDL-C.

2.2. Thuc li tiu khng gy mt kali:

2.2.1. Nhm thuc khng aldosterol:

+ Bit dc:

- Spironolacton: d g i h lng 0,1; cho ung 4-8vin/ngy.

- Aldacton: d g i h lng 0,1; cho ung 4-8 vin/ngy.

+ V tr tc dng: thuc tc dng ln phn cui g ln xa v ng gp. Do c cng


thc gn ging vi aldosterol nn thuc c ch cnh tranh vi aldosteron lm
gim ti hp thu natri g ln xa v ng gp. Thuc c tc dng tt bnh
h g aldoste ol h: ga , hi chng th h, su ti huyt.

+ Hp thu v thi tr: hp thu v thi tr chm; tc dng ti a h t c sau


khi ung thuc 4-5 ngy.

+ Ch nh:

- B h t g aldoste ol gu ph t.

- T g aldoste ol do d g thuc li tiu khc.

- Ph km theo t g aldoste ol th ph t h: ga , hi chng thn h, suy


tim huyt.

+ Chng ch nh:

- Suy thn cp v suy thn m t h gu t g kali u.

- T g kali u.

- Su ga giai on cui.

- Ngi cho con b v thai nghn.

+ Tc dng ph:

- V thuc c tc dng ko di nn c th gy mt c v tt huyt p nu dng


thuc ti khi ht h ph , do phi ngng thu t c khi ht hn ph.

- Thuc khng gy mt kali nn c th g t g kali u, t g g ur mu


bnh nhn suy thn.

2.2.2. Nhm triamteren:

+ Bit dc: triamteren; thuc c dng vin 50mg, cho ung 50-150mg/ngy.

+ V tr tc dng: thuc trc tip c ch t ao i Na+, K+ v H+ g ln xa v


g g p theo h gn ging vi aldosterol; nu d g c th thuc c tc
dng km.
+ Ch nh:

- Ph , c bit l ph do gan v hi chng th h.

- Phi hp vi cc thuc li tiu gy mt kali.

+ Chng ch nh:

- Suy thn cp v suy thn m gu t g kali u.

-C t ng hp t g kali u.

2.2.3. Nhm amilorit:

+ Bit dc: amilorit; thuc c dng vin 5mg, cho ung 5-10mg/ngy.

+ V tr tc d g: t g t h t ia te e .

+ Hp thu v thi tr: tc dng sau ung 2-4gi; thu o thi nguyn dng
qua thn nn s dng tt khi c suy ch g ga h g h g thn bnh
thng.

+ Ch nh v chng ch nh: gi g h t ia te e .

Cc thuc li tiu trn khng gy mt kali kh g g t g ng mu hoc


axt uric mu, c th dng cho cc bnh nhn d b cc tc dng ph khi s dng
cc thuc li tiu gy mt kali. Phi cho thuc trong thi gian t nht 2 tun
t khi iu chnh liu l g h gi g kt qu.

+ Tc dng ph ca nhm thuc li tiu khng gy mt kali: kch thch ng tiu


ho, ng g, v to, lit d g, t kinh, ko di thi gian bn hu ca digoxin.

2.3. Thuc kt hp:

khc ph h im ca cc thuc li tiu gy gi kali u, gi ta phi


hp

2 loi thuc li tiu: thuc li tiu gy mt kali v thuc li tiu khng gy mt


kali.
+ Modurtic: amilorit + thiazit.

+ Aldactazin: spironolacton + thiazit.

+ Cycloteriam: triamteren + thiazit.

2.4. Thuc li tiu thm thu:

Thuc li tiu thm thu bao gm cc cht c p lc thm thu ao, c lc d


dng qua cu thn, t b ti hp thu ng th do g t g p lc thm thu
ca dch lc trong lng ng thn nn ko theo c gy li tiu. Thu ha c
dng l manitol.

Manitol: dung dch 10%, 15%, 20%; liu c th dng 100-300ml/ngy, truy t h
mch nhanh. Thn trng khi dng trong suy tim v lm t g g h tun hon.
Trong suy thn cp c v niu, liu a u dng dung dch 20%x100ml, truyn
t h ch nhanh. Nu p ng, c th truyn tip liu th 2. Nu khng c
p ng phi ngng v c th gy hoi t ng th do t g p lc thm thu.
Thuc c tc dng chng ph no rt tt.

2.5. Mt s cht c tc dng li tiu:

+ Nhm xanthyl: theophylin d g i h lng 0,1; synthophylin,


aminophylin dng g ti h lng 0,24. Thu l t g tn s tim v gin
mch do l t g d g u ti thn l t g mc lc cu thn. Thuc
gy tc dng li tiu nh v c li t o g iu tr ph phi cp v c tc dng lm
gi t ph qun.

+ Nc sc tm gi cy go; c s u g ; c sc bng ; c sc r
c t a h; c sc tua r a l thu g t dng li tiu.

+ Canh rau ci, ci bp... g t dng gy li tiu nh.

3. s dng thuc li tiu trong mt s bnh.

3.1. Suy tim:


S dng thuc li tiu phi hp vi hn ch mui c c tc dng lm gim
tin gnh, ci thin triu chng lm sng ca suy tim nh v va. Vi suy tim cp,
mc tiu cn

t l o thi c 0,5- l t c tiu/ngy (lm gim 0,5-1kg cn


nng/ngy). Phi theo di cht ch phng gim th tch tun hon, tt
huyt p, ri lo in gii, gim n g kali u do d gy nhi c
digoxin. Khi s dng thuc li tiu t o g iu tr suy tim cn b sung kali hoc
phi hp thuc li tiu gy mt kali vi thuc li tiu khng gy mt kali.

+ Thuc li tiu nhm thiazit: ung 50-100mg/ngy, cho t g t ngn


3ngy/tun; cn b sung kali: cho vin kaleorit 0,6, ung 2-
4 vin/ngy hoc panalgin ung 2 vin/ngy, g l ti t h ch.

+ Thuc li tiu quai (lasix, lasilix, axt etacrynic): dng khi cn li tiu nhiu h
suy tim nng hay ph phi cp. Suy tim nng c th p ng km vi thuc li
tiu ng ung v ph rut lm gim hp thu thu , h g p ng nhanh
h g khi ti ua g t h ch vi liu t g g. Thu d g ng
ung cho 40-80mg/ngy ho g ti t h ch cho 20-40mg/ngy, tu theo
p ng ca b h h iu chnh liu, cn b sung kali.

+ Thuc li tiu khng gy mt kali (spironolacton, triamteren, amilorit): tc dng


k t o g iu tr suy tim nu d g c, h g u phi hp vi nhm
thiazit hoc thuc li tiu uai th thng gi c nh n g kali mu.
Nu d g c phi theo di n g kali mu, nht l khi dng km vi
nhm thuc c ch men chuy ACE gu l t g kali u.

+ C th dng thuc phi hp: modurtic, andactazin, cycloteriam.

. . T g hu t p:

- Nh thiazit c ch d g u ti iu tr t g hu t p m nh.
Thuc lm gim nng natri thnh mch, lm gim s nhy cm ca
thnh mch vi athe ola i , do l gim sc cn h tu ho , h g phi
iu tr trong nhiu tun mi thy r tc dng. Liu th g thng ca
hypothiazit (vin 25mg) cho ung 1vin/ngy, ung ko di trn 4 tun.
Khi mc lc cu thn < 25ml/pht th thuc khng cn tc dng, phi thay bng
loi thuc li tiu m h h h thuc li tiu quai).

+ Nhm sulfonamit: l thu c la chn hi a iu tr t g hu t p v


thuc c nhiu u im: va thi natri va c tc dng gin mch, lm gi
dy thnh tht tri, khng gy bi i lipit u h h thiazit.

Fludex vin 2,5mg, ung 1-2 vin/ngy; natrilix vin 1,5mg, ung 1-2 vin/ngy
trong 3-4 tun. C th phi hp vi cc thuc h huyt p khc h thuc chn
bta giao cm, thuc chn dng canxi, thuc c ch men chuyn.

+ C t g hu t p kch pht ho t g hu t p c tnh cn dng thuc li tiu


mnh: nhm thuc l tiu quai furosemit: ung 80-160mg/ngy hoc tim
t h ch 20- 40mg/ln, cch 2-4gi/ln.

+ Khi t g hu t p c suy thn, mc lc cu thn < 25ml/pht th nn dng nhm


thuc li tiu quai.

3.3. Ph phi cp:

Tt nht l dng furosemit hoc axt etacrynic 40- g, ti t h ch chm,


nu cn c th dng li sau 15- ph t. Khi ti t h ch furosemit th thuc c
tc d g g gi t h h, do t h t ng ph phi gim ngay tc kh t c
khi c tc dng li tiu.

3.4. Bnh thn:

Trong cc bnh thn, khng nn dng thuc li tiu thu ngn c vi thn; khi
c suy thn, khng nn dng nhm thiazit v thuc lm gim mc lc cu thn v
khng dng nhm thuc li tiu khng gy mt kali gu g t g kali
mu.

+ Suy thn cp c v niu hay thiu niu:

- Furosemit dng g g, ti t h ch 4 ng/ln, cch 4gi/ln, tu theo


p g iu chnh liu. Nu sau 48gi khng c tc dng th phi ngng
thuc v ch nh lc mu.
- Manitol dung dch 20%, truyn tnh mch nhanh 100ml. Nu sau 3gi lng
c tiu t c 120ml (40ml/gi l p ng th c th truyn tip liu th
hai. Nu kh g p ng th phi ngng truy ga trnh gy hoi t ng
thn do tnh u t g a manitol.

+ Hi chng thn h:

Nn dng furosemit: nu ph nhiu th nn ch g ti t h h ng


ung hoc tim bp thuc hp thu chm v ph. Lasix g g, ti t h ch
1-2 ng/ln, c th c mi 4 gi tim 1 ln tu theo p ng ca b h h
iu chnh liu.

i khi cn truy m hoc dung d h keo t c khi dng thuc li tiu ko


c t khoang gian bo vo lng mch nu protein mu qu thp. Nng p lc
keo ca mu ln mi g p ng vi thuc li tiu hoc phi hp vi thuc
li tiu khng aldosterol th g ng aldosterol th pht. Dng thuc li
tiu phi ng thi vi iu tr h bnh sinh bng prednisolon hoc thuc c
ch min dch th mi du t c kt qu.

Cn ch trong hi chng th h, c d b h h ph to h g th tch


tu ho thng gi , khi p ng vi thuc li tiu th cn ch ri
lo c-in gii, c th gy tt huyt p. Khi phi hp thuc li tiu quai vi
prednisolon c th gy gim kali mu nng.

+ Suy thn: khi mc lc cu thn < 25ml/pht th phi dng thuc li tiu mnh
mi g p g. Thng dng thuc li tiu quai t g t ngn. Ch
khng tnh trng mt c xy ra v s lm ch g thn xu i.

. . X ga :

Do ga , h g ga gim khng phn gii c aldosterol, do thng


c tnh tr g ng aldosterol, v vy nn chn thuc li tiu nhm khng
aldosterol.

4. Tc dng ph v tai bin khi dng thuc li tiu.

4.1. Ri lon nc-in gii:


Hu ht cc thuc li tiu u gy thi natri, lm gim n g natri, clo, kali v
canxi mu; bnh nhn thy mt mi, chut t, hng bng; khi kali mu gim
d gy nhim

c digoxin.

. . T g ng mu:

Cc thuc li tiu gy mt kali c th lm khi pht b h i th o ng hoc


lm nng thm b h i th o ng v lm gi kali u do g i lon
dung np glucoza ngoi vi.

. . T g a t u i u:

C th lm khi ph t G t p tnh bnh nhn b bnh Gt hoc lm cho


bnh Gt nng thm.

. .G tai, ic khng hi phc:

Tai bin ny gp nhm thuc li tiu quai (furosemit, axt etacrynic) khi dng
liu cao v ko di, nht l gi gi , gi a g t h t ng mt c, bnh
nhn suy thn nng hoc khi phi hp vi nhm thuc khng sinh aminoglycosit
(streptomycin, gentamycin, kanamycin...).

4.5. Ri lon cc xt nghim ch g ga :

Thuc li tiu c th gy ri lon cc xt nghim ch g ga ut hin vng


da.

4.6. Phi hp thuc cn lu :

+ Khi phi hp thuc li tiu quai vi corticoit c th gy gim kali mu nng.

+ Thuc li tiu l t g tc dng ca thuc khng g h u a i , phi


gim liu thu kh g g khi d g phi hp.
75.VIM CU THN CP TNH
BS. Ho g

. h gha.

Vim cu thn cp tnh (VCTC) (hay cn gi l vim cu thn sau nhim lin cu
khun) l tnh trng vim lan to khng nung m tt c cc cu thn ca hai
thn. Bnh xut hin sau vim hng hoc sau nhim khun ngoi da do lin cu
khun tan mu bta nhm A. Bnh vim cu thn cp l bnh l phc hp min
dch. Bnh din bin cp tnh vi cc triu ch g: ph , t g hu t p, i u v
protein niu; i b phn l hi phc hon ton trong vng 4- 6 tun l.

. C gu .

- Lin cu khun tan mu bta nhm A: tt c cc tp ca lin cu khun tan mu


ta h A u c th gy thp ti , h g h c mt s tp gy vim cu thn
cp tnh. Nh g t p thng gp l: tp 4, tp 12, tp 13, tp 25, tp 31, tp 49...

VCTC thng xy ra sau nhim lin cu t n 15 ngy.

c ta, vim cu thn cp hu ht xy ra sau nhim khun ngoi da do lin


cu, chim t l trn 60% v 40% vim cu thn cp xy ra sau nhim khun
ng h hp t . Ngc li, chu

u, vim cu thn cp hu ht xy ra sau nhim khu ng h hp trn. Bnh


thng xy ra la tui 4 -7 tui, t l bnh gim dn theo la tui v t gp
gi l . Ngi ta c th nh s c mt ca ca lin cu cc nhim
khun b g ph g ph p u i , h g ic nui cy c th gp mt s kh
kh do h h d g kh g si h i hi k thut nht h. Xu hng
nh s hin din ca lin cu khun tan mu bta b g h nh cc
khng th chng li mt s men do lin cu tit ra trong qu trnh pht trin.
Nhng khng th l :

- ASLO (anti streptolysin 0).


- ASK (anti streptokinase).

- AH (anti hyaluronidase).

- ANADase (adenine dinucleotidase).

- ADNAse (anti deoxy ribonuclease).

Trong s cc khng th trn, ASLO c gi tr nht, ASLO t g sm v ko di


trong nhiu thng. 95% vim cu thn cp tnh do lin cu khu t g hiu gi
ASLO. V v , ASLO c s dng trong ch o him lin cu khun

Ngoi lin cu khun, vim cu thn cp c th do t cu, ph cu i ut h g


rt him gp.

Vim cu thn cp do nhim lin cu khu thng gi l vim cu thn cp c


in, hay gi l bnh vim cu thn cp. Nhng t ng hp vim cu thn cp do
gu kh gi l hi chng vim cu thn cp (HCVCTC). Nguyn nhn
ca HCVCTC thng gp l:

- Vim cu thn do luput.

- T th g th do i ng.

- Vim mch nh dng nt.

- Henoch-Scholein.

- Vim cu thn trong bnh osler.

- Bnh Berger (bnh thn do IgA).

- Hi chng Goodpastur.

- t bt pht ca vim cu thn tin pht.

3. Gii phu bnh l.

. . i th:
Hai th to h h th g, u hi ht, v d t h; iu hng t qu
trnh vim cn khu tr trong nhu m thn, trn mt ct c mt s nt xut huyt.

3.2. Vi th:

- Nhn trn knh hin vi quang hc:

Cc cu th to h h th g, t g si h t bo gian m h, t g si h t bo
ni mc m h u c bit l s xm nhp ca mt s bch cu a h t o g
cun mch cu thn. Hu qu ca u t h t g si h l l ho l g ao ch
thu hp. Khoang Bowmann thu nh, mt s cun mch dnh vo l
thnh Bowmann. Mng nn cu thn khng dy hoc dy khng g u. T
chc m k th h thng.

- Nhn trn knh hi i in t:

Ngoi tnh tr g t g si h t bo gian m h, t g si h t bo ni m v s


nhp ca bch cu a h , gi ta c th pht hi c nhng l g ng
phc hp min dch (PHMD) pha ngoi mng n di b mt t bo biu m.
Nhng l g PHMD t g i l , hi t to nn nhng hnh g, hnh
u (humps) pha ngoi mng nn; khng c l g ng PHMD trong gian
mch v trong mng n di b mt ni m.

- Min dch hu h ua g d g t h i IgG v b th (C3). Nhng l g ng


bt mu hu nh quang to nn nhng chm nh nm ri rc dc theo mng nn
cu thn. Nhng l g ng PHMD ch t ng trong thi gian tin trin ca
bnh, mt i sau i th g.

. C h bnh sinh v sinh l bnh hc.

. . C h b h si h: s 1)

Bnh vim cu thn cp l mt bnh l gy ra do phc hp min dch. S xm


nhp ca lin cu khun k h th h th sn sinh khng th chng li nhng
khng nguyn ho tan ca lin cu khun. S u g t khng nguyn-khng th
to nn phc hp min dch trong thi gian t n 15 ngy k t lc nhim lin
cu khu . T o g iu kin khng th d tha s to nn mt PHMD c phn t
lng ln, d kt ta s b h th g li ni m bt gi v tiu hu loi khi vng
tu ho . Ngc li, t o g iu ki kh g gu d tha s to nn PHMD
khng nguyn-khng th c phn t lng nh thot khi s kim sot ca h
th g li ni lu h h t o g u v lng

ng ti cu thn. S t g t gia khng nguyn-khng th v s l g ng


PHMD trong cu thn

hot ho h thng b th, hot ho h th g g u, h thng kinin, hot


ho bch cu a h t u g t h, ch cu i kim, t bo Mast v tiu cu, nhm
m h loi phc hp min dch khi tun hon v dn sch cc l g ng
PHMD trong cu th . T ng ca cc h thng sinh hc v s hot ng ca
cc t bo d n s hnh thnh qu trnh vim cp tnh cu thn vi tnh
tr g t g si h t bo, ph n xut tit.

S : C h bnh sinh ca vim cu thn cp


Khc vi vim cu thn m kh g gu , kh g gu t o g i u
thn cp

tnh l cc khng nguyn ho tan ca lin cu khun lu hnh trong mu c


tnh nht thi, ph thuc vo s tn ti ca nhim khun. Phc hp min dch
trong vim cu thn cp c phn t lng thp, t qua mng nn mt cch d
dng, to nn nhng l g g h h u (humps) ngoi mng n di b
mt biu m. Nu h g ta iu tr nhim khun bng khng sinh hoc

bng phu thut loi b nhim khun (tc l loi b ngun cung cp khng
nguyn, g n hnh thnh phc hp min dch) th bnh c th khi hon
ton.
4.2. Sinh l bnh hc ca vim cu thn cp s 2).

- S u g t khng nguyn-khng th t ng ln ton b h thng mch mu


ngoi vi v

mao mch cu thn gy vim cu thn.

- Tc dng trn mao mch ngoi vi:

. T g t h thm mao mch gy dch khoang gian bo.

. Co m h ul t g sc cn ngoi vi.

- Tc dng trn mao mch cu thn:

. T g t h thm mao mch cu th . P otei t qua mng nn vo khoang


Bowmann, lm xut hin protein niu.

. T g si h, ph lm gi d g u n thn d t g tit renin, hot


ho h RAA g t g hu t p. C th t g hu t p kch pht gy co git, hn m
v suy tim cp tnh, hen tim, ph phi cp.

. Mc lc cu thn gim gy mui c, mt khc mui c cn do tc


dng ca s t g tit aldosteron v ADH. Hu qu ca c v mui d n
ph.

. Mc lc cu thn gim gy thiu niu, v niu, t g u u, t g eati i


ri lo c-in gii, ri lo th g ng kim-toan.

S 2 : Sinh l bnh hc ca vim cu thn cp.


5. Triu chng hc ca vim cu thn cp.

Triu chng hc ca vim cu thn cp rt a dng. Bnh c th din ra mt cch


thm l g k o, nh nhn khng bit mnh b bnh, khng c triu chng lm
sng, ch c hng cu niu vi th v protein niu. Nh g h g th pht
trin ht sc rm r. Triu chng ch yu ca vim cu thn cp tnh l:

5.1. Ph:

Ph l mt triu chng lm sng rt thng gp, l du hiu l s g u


tin m bnh nhn cm nh c. Bnh nhn cm gic nng mt, n hai m mt,
ph hai h . Ph t g h hy quanh mt c; ph mm, n lm r.
Thng ph nhiu v sng, chiu gim ph gy nn cm gic khi gi to. S
l g c tiu t v xm mu, ph cng nhiu th s l g c tiu cng t.
Ph thng gp t o g g u v gi i ha h h g khi nh nhn i
nhiu. i hiu l du hiu m u ca s hi phc v lm sng: ph gim, huyt
p gim, bnh nhn cm gic d chu, nh h , go

. . i a u i th:

i a u to i, c tiu h c ra tht ho h c luc rau dn,


kh g g, i ngy i i a u to i -2 l , kh g thng xuyn, xut
hin trong tu u, h g th xut hin tr li trong 2-3 tun. S l i a
u tha dn, 3-4 ngy b mt ln ri ht hn.

i a u t o g i u thn cp tnh khng h h g n tnh trng chung


ca th. i a u i th c th k o d i i th g. i a u l t du hiu
quan trng trong ch o i u thn cp tnh, nu kh g i a u n
xem li ch o .

. . T g hu t p (THA):

T g hu t p l mt triu ch g l s g thng gp. T g hu t p l du hiu


gin tip v tnh trng vim, ph n, xut tit, t g si h t bo trong cu thn gy
t g tit renin, hot ho h thng co mch d t g hu t p. T g huyt p
giao ng: tr em 140/90 mmHg, gi ln 160/90 mmHg. Mt s t ng
hp THA kch pht t g i h g nh ko di trong nhiu

ngy vi huyt p / Hg, nh nhn c gi au u d di, chong


vng, co git, hn

m do ph no d n t vong.

5.4. Suy tim:

Su ti thng km vi THA kch pht, mt kh do t g khi lng tun hon


t ngt g th do b h l ti t o g i cu thn cp tnh. Suy
tim cp tnh vi biu hin kh th, khng n c v c th d n ph phi:
bnh nhn kh th d di, tot mi hi, th nhanh v nng; co rt h trn c, h
t , o t khoa g gia sn; ho v khc ra bt mu hng; nghe phi c
nhiu ran m, nhp tim nhanh, huyt p gim. Nu khng c cp cu kp thi
th bnh nhn s t vong.

Hin nay, tnh trng THA d n co git, hn m, suy tim cp tnh, ph phi ngy
mt t d do iu kin phc v y t tt h d t c nng cao.

. . i t thiu niu, v niu):

Tnh trng thiu niu bao gi g , khi l g c tiu di 500ml/ngy,


thng gp trong tu u ca bnh v ko di 3- g ; kh g t g ur v
creatinin mu ho l t g khng g k. Tnh trng thiu niu c th ti pht
tr li trong 2-3 tu u. Mt s t ng hp xut hin suy thn cp tnh: thiu
niu, v niu k o d i, t g u u, t g eati i u. Nu suy thn cp ti din
nhiu t l mt du hiu xu, gu th d n vim cu thn tin trin
nhanh, vim cu th t g si h go i ao ch.

5.6. Mt s triu chng khc:

- St nh 37,5oC - 38,5oC.

- au tc vng thn, c th au un thn.

- au ng, b g hng nh, bun nn, i lng; khng t t ng hp vim cu


thn cp m u b g au ng cp tnh.

5.7. Bi i nc tiu:

- Nc tiu mu vng, s lng t.

- Protein niu 0,5- g/ g . Lng protein khng nhiu v c th thi cch hi


nn phi lm protein niu 24h hoc xt nghim protein niu vo bui sng sau khi
ng dy.

Thi gian tn ti ca p otei gha ti lng ca bnh v l mt yu t


quan tr g

h gi kt qu iu tr. Bnh c phc hi khi v ch khi protein niu (-).


- Hng cu niu vi th bao gi g , th ko di vi thng. Tr hng cu l
mt du hiu

i u nhu m thn.

- Ngoi ra, c th gp mt s tr niu kh h: t trong, tr sp l du hiu


protein niu. Tr trong cu to bi p otei ha thoi ho hon ton, ho c
cu to bi mucoprotein. Tr sp

c cu to bi p otei tho i ho , kt ta di tc dng ca i t ng toan


trong ng thn.

6. Tin trin v tin l g s 3).

6.1. Tin lng gn:

6.1.1. Hi phc hon ton:

Tuy lm sng biu hin trm tr g h g i b phn bnh nhn hi phc hon
ton: ht cc triu chng lm sng, protein niu (-); t l hi ph t ti 95%.

6.1.2. T vong:

Him gp, nguyn nhn t vong do:

- T g hu t p d n co git, hn m ri t vong.

- Suy tim cp tnh.

- Ph phi cp.

- Suy thn cp tnh khng c cp cu kp thi, t vong do nhim toan chuyn


ho.

- T g kali u, g g ti t ngt.

6.1.3. Tin trin mn tnh:

Protein niu ko di trn 6 thng, bnh khng cn kh g t hi phc, vim cu


thn cp tnh tr thnh vim cu thn mn tnh vi cc hnh thi lm sng sau:
- Vim cu thn mn tnh tim tng: protein niu v hng cu niu khng c triu
chng lm sng.

- Vim cu thn mn vi biu hin: ph, protein niu, hng cu niu. Tin trin
thnh t g t ko di trong nhiu .

- Hi ch g th h: ph to, protein niu, gim protein mu v gim albumin


u, t g lipit u. Hi chng thn h kh g thu thng km theo hng
cu niu, th b h thng gp l vim cu th g t g si h.

- Vim thn tin trin nhanh hay cn gi l vim cu thn t g si h go i ao


mch, vim cu thn bn cp, vim cu thn c tnh. Bnh tin trin lin tc vi
nh g t suy thn cp tnh, dn dn xut hin suy thn mn tnh khng hi
ph : t g u u, t g eati i u tun ti , t g hu t

p, thiu mu; bnh nhn t o g t o g g .

S 3: Din bin ca vim cu thn cp.

6.2. Tin lng xa:

HCTH

Mt s VCTC hi ph ho to h g sau t 15- li xut hin suy thn


m giai on
cui v m u b g THA kch pht vi biu hi au u d di, chong
vng, tai , n o

, un nn v nn. Sau mt vi thng xut hi su th giai on mt


, i hi phi chy thn nhn to.

7. Cc th bnh.

7.1. Th tim tng:

Triu chng duy nht l protein niu v hng cu niu. Hu h khng c triu
ch g l s g, kh g ph , kh g i u, kh g t g hu t p. Bnh ch tnh
c pht hi c khi kim tra sc kho.

Th tim tng rt d b qua v c th l ci ngun ca nh g su th giai on


cui la tui

20-30 m trong tin s khng c bnh cnh lm sng ca vim cu thn.

7.2. Th i a u:

i a u i th chi u th, mi ngy i a u i th 1- 2 ln v c th


ko di trong 7-

10 ngy. Ph nh ho kh g ph , kh g t g hu t p ho hi t g giao ng
khng lin tc, protein niu khng nhiu.

7.3. Th t g hu t p:

T g hu t p l triu chng ch yu, t g h g nh ko di gy tnh tr g au


u hai th i d g g hm; huyt p xp x trong khong 160/90
mmHg; cc triu chng biu hi k o. Nhng t ng hp t g hu t p c
tnh cht nht thi tr e gi tr phi gh t g hu t p do vim cu
thn cp tnh v cn phi xt nghi c tiu mt cch c th tm protein
niu v hng cu niu vi th.

7.4. Th suy thn cp tnh:


Biu hin bng i a t, s l g c tiu 200-500 ml/ngy, ko di 6 -7 ngy
k theo t g u u, t g eati i u u u ol/l, eati i -
500 mol/l). Nhn chung th khi iu tr d hi phc; him gp suy thn cp
trm trng.

8. Ch o v ch o ph it.

8.1. Ch o :

Da vo tiu chun sau:

- Ph.

- i a u i th hoc vi th.

- Protein niu (++).

- T g hu t p.

- Xut hin sau nhim lin cu khun vng hng hoc ngoi da, ASLO (+); xy ra
tr em .

Tiu chun bt buc l protein niu v hng cu niu, kt hp vi du hiu


nhim lin cu khun.

8.2. Ch o ph it:

- Vim cu thn do IgA: bnh Berger do Berger m t 1968; biu hin lm sng l
vim cu thn mn tnh, i a u i th c tnh cht chu k .

- t bt pht ca vim cu thn m t h ti ph t, g th bt pht sau


nhim khu h g kh g i lin quan cht ch vi nhim khun, ch cn
st mt vi ngy ut hin bnh cnh ca vim cu thn. B h thng gp
gi ln tui, khng t hi phc trong vng 6 thng.

. iu tr.

9.1. Ch ngh gi:


Bnh nhn c c ngh gi ti phng trong thi gian bnh tin tri ho n
lc protein niu

m tnh. Khng lm vic nng, trnh nhim lnh v trnh b nhim khun thm
(bnh ti pht vi bt k mt nhim khun no k c nhim virut) v khng nn
tip xc vi gi nhim khun cp tnh c tnh ly truyn. Nhim khun, nhim
l h, lao ng nng l nhng yu t gu g t i ph t.

9.2. Khng sinh:

Khng sinh chng lin cu khun nhm m h loi ngun cung cp khng
nguyn cho s hnh thnh phc hp min d h. Kh g si h thng dng l:

Pe i illi . . / g , ti p tht lm 2 ln (th phn g t c khi


tim). Penixilin vn c hiu qu vi lin cu khun, va kinh t v hiu qu. Nu
c phn ng vi penicillin th c th dng:

Ro a i . . / g i tr e . . / g i gi ln).
Ho e th o i g/ g i vi tr e g/ g i vi gi ln).

. . iu tr ph:

Ph nh th g p ng tt vi li tiu furosemid vi liu 40 mg x 2-3


vin/ngy, chia lm 2 ln, u g du t l g c tiu trn 1000ml/ngy.

Nu p ng km ho k theo t g hu t p kch pht, km theo suy tim cp


tnh th nn cho furosemid tim bp tht ho t h ch 1-2 ng/ngy.

. . iu tr t g hu t p:

- Ch cn dng li tiu furosemid, khi b h h a iu th c th t iu chnh


huyt p tr v h thng 110/70 - 120/80 mmHg.

- Nu huyt p v t g, th cho kt hp vi cc thuc c ch bta hoc c


ch canxi. C th la chn mt trong cc thuc sau:

. Tenormin 50-100 mg/ngy.

. Concor 5 mg/ngy.
. Adalat (nifedipin) 10 mg x 1-2 v/ngy.

. Plendil 5mg x 1 v/ngy.

. Amlor 5mg x 1 v/ngy.

i vi tr em, nn dng 1/2 liu trn ho iu chnh theo cn nng.

. . iu tr suy thn cp:

- Lasix 20 mg x 1-2 g, ti t h h, t g liu d ho l p ng, duy tr


c tiu trn 1000 ml.

-Truyn dung dch glucose 30% x 300- l+ insulin nhanh, truyn


t h ch 40 git/pht.

- Dung dch Nabica 1,25% x 250 ml, truy t h ch 40 git/pht.

T o g iu tr suy thn cp, cn phi cn b g l g a l g c vo


trnh ng

c. Nu bnh nhn khng i lng, khng nn th s lng dch cn truyn


bng s l g c tiu + 500-700 ml.

. . iu tr d phng:

- Gii quyt cc nhim khun m t h, c bit l nhng nhim khun mn tnh


vng hng; ct Amydal hc m, iu tr vim tai gia..., gii quyt tnh trng
ch u, nhng nt nhim khu s g ty lm m ngoi da.

- Dng khng sinh: penicillin chm 1,2 triu / g . Mi thng tim bp tht mt
ln, tim trong vng 6 thng.

- Kh g lao ng qu mc, trnh nhim khun, nhim l h; c bit l trong 6


th g u.
76.VIM CU THN MN TNH
(Chronic glomerulonephritis)

BS. Ho g

. h gha v kh i im.

Vim cu thn mn tnh l mt qu trnh t th g thc th xy ra tt c cc


cu thn ca hai thn; bao gm cc tnh tr g t g si h, ph , xut tit v
hoi t h ali , ho t phn hoc ton b cu thn. Bnh tin trin mn tnh
qua nhiu thng, nhiu d teo 2 thn.

Biu hin lm sng ca b h a dng, triu ch g thng gp l: ph, protein


niu, hng cu niu, t g hu t p. Bnh din bin thnh t g t, sau 10-15
th s xut hin suy thn mn tnh khng hi phc.

Ng a , gi ta cho rng vim cu thn mn l mt hi chng-hi chng vim


cu thn mn tnh (HCVCTM). HCVCTM tnh c th gp trong nhiu th tn
th g nh hc khc nhau. Mt th t th g nh hc din bin lm
sng kh i u t h sau:

Cc th t th g nh h h i u th t g si h gia ch, vim


cu thn mng,
vim cu th g t g si h, ho u thn , vim cu th t g si h go i
mao m h u c th din bi kh i u t h t . Nh g t l gia cc hi
chng lm sng th khc nhau. C nhng th t th g nh hc biu hin
lm sng ch yu l hi ch g th h, h g th khc li biu hin bng protein
niu v hng cu niu m khng c triu chng lm sng.

Bnh l cu thn mn tnh gm c 4 hnh thi lm sng:

- Hi chng vim cu thn cp (HCVCTC).

- Hi chng vim cu thn mn (HCVCTM).

- Hi chng thn h HCTH .

- Bi i kh g h thng c tiu (protein niu, hng cu niu khng c


triu chng lm sng).

4 hnh thi lm sng trn bi i lun phin trong qu trnh tin trin ca bnh,
ko di hng thng, h g v hu qu cui cng l suy thn mn tnh.

Tu hi , g a gi ta vn dng danh php vim cu thn mn tnh theo


mt np quen t lu nay.

. C gu a vim cu thn mn tnh.

2.1. Vim cu thn m t h kh g gu :

2.1.1. Vim cu th t g si h gia ch:

im ca bnh vim cu th t g si h gia ch l t g sinh t bo gian


m h, t g si h t bo ni m m h u, t g si h t chc gian mch. Min dch
hu nh quang (+) vi IgM, IgG, IgA v b th. Cc l g ng nm trong khong
gian m h. Nh g g t ng hp min dch hu nh quang (-). Ngy nay,
gi ta thy vim cu th t g si h gia ch phn ln l bnh l cu thn do
IgA, cn gi l b h Be ge , c m t 1968. Ch 10% vim cu th t g
sinh gian mch biu hin bng hi ch g th h; s khc biu hin lm sng
thng gp l hi chng vim cu thn cp, hi chng vim cu thn mn v
protein niu, hng cu niu khng c triu chng lm sng.
2.1.2. Vim cu th t g si h , on:

Tnh trng vim xy ra mt phn ca cu thn hoc ton b cu thn, cc cu


thn b t th g m xen ln gia nhng cu thn cn nguyn vn. Hu ht
vim cu th t g si h , on l bnh l cu thn do IgA. Biu hin lm sng l
i a u hu k , xy ra sau mt nhim khun

ng h hp trn v protein niu g/ h, th g kh g ph , kh g t g


huyt p.

. . . X ho u thn , on:

B h c m t do Ri h. im m bnh h l ho , hyalin
ho mt phn hoc ton b cu thn m khng h c hi t g t g si h t bo.
T th g u tin xut hin cc cu thn vng cn ty lan dn ra ton b
vng v. Cc cu thn t th g m xen ln gia cc cu thn b h thng.
Trong k thn c hi tng teo ng thn, xm nhp t bo vim cc b, min
dch hu nh quang (+) vi IgM v C3 vng t th g. % t ng hp
ho cu thn , on biu hin bng hi ch g th h.

2.1.4. Vim cu thn mng:

im m bnh hc ca bnh l dy mng nn cu thn do phc hp min


dch l g ng pha ngoi ca mng nn cu th di b mt biu m, dy
mng n thun, khng c hi t g t g si h t bo trong cu thn. 80%
t ng hp vim cu thn mng c biu hin lm sng bng hi chng thn
h, s cn li biu hin bng hi chng vim cu thn mn hoc protein niu,
hng cu niu khng c triu chng lm sng.

2.1.5. Vim cu th g t g si h:

im m bnh h l t g sinh cc t bo gian mch, t chc gian mch kt


hp vi cc l g ng phc hp min dch trong v ngoi mng n di t
bo biu m, trong gian mch v c trn mng nn. Thnh phn ca l g ng
ch yu l C3, v mt t IgG. B h thng km theo
gim b th c gi l bnh vim cu thn gim b th. Da vo v tr
ca l g ng phc hp min d h, gi ta chia vim cu th g t g si h
lm 3 tp:

-Tp I chim t l 45%: nhng l g ng nm pha trong mng n di b mt


ni m v

trong gian mch.

-Tp II chim t l 35%: cc l g ng trn mng nn, mng nn gi g h c


ph mt di g.

-Tp III chim t l 20%: cc l g ng nm pha trong v


pha ngoi mng n , di b mt ni m v biu m, trong cc gian mch.

% t ng hp vim cu thn m g t g si h hi ch g th h, s cn
li biu hi l s g di dng hi chng VCTM, hi chng VCTC hoc protein
niu, hng cu niu khng c triu chng lm sng.

2.1.6. Vim cu th t g si h go i ao ch:

T g si h t bo l thnh ca bao Bowmann v tnh trng thm lu fibrin vo


Bo a , t g si h t ch si v t bo lp y khoang Bowmann, m gn
ht cun mch cu th gi ta thng gi l t g si h h h lim. Biu hin
lm sng ch yu l vim cu thn cp tnh, du hiu ni bt nht l thiu niu,
suy thn cp tin trin thnh t g t. Bnh tin tri n suy thn mn tnh
khng hi phc, b h h thng t o g t o g g th g . Vi
cu th t g si h go i ao ch cn gi l vim cu thn tin trin nhanh, hay
cn gi l vim cu thn c tnh.

2.2. Vim cu thn mn th pht:

Vim cu thn mn th pht xy ra sau nhiu bnh l ni khoa khc nhau. Nguyn
nhn ca vim cu thn m a dng, phong ph. Nguyn nhn ch yu l:

2.2.1. Bnh l cu thn do Collagenose:


- Luput a h thng: l mt bnh t mi , thng gp ph n (95%), rt
him gp nam gii. Biu hin ch yu l a h m mt, st cao ko di,
tc rng, vim mng ngoi tim, vim mng phi, gim bch cu, t bo Hargraves
(++), khng th khng nhn (++). T th g th : -100% c vim cu thn
mn tnh v c hi ch g th h. i b phn b h h luput a h thng
b t o g do su th giai on cui.

- X ng b ton th: l mt bnh t min, gp c hai gii nam v n. Tn


th g hiu ua , t o g th .

- Bnh vim a da- .

- Bnh t chc lin kt hn hp: ng b kt hp vi luput a h thng,


vim da- .

2.2.2. Tn th g u thn do bnh l mch mu:

- Vim cc vi mch mu nh dng nt.

l t bnh l mch mu nh li ua n khng th kh g o t g a


bch cu a h t u g t h ANCA: a ti eut ophil toplas i a ti od . Tn
th g nhiu ua , h yu l phi v thn.

phi l tnh trng thm nhim, biu hin lm sng b g kh th kiu hen.

thn biu hin bng vim cu th t g si h hoi t , on; vim cu thn


t g si h h h lim.

- Bnh u ht Wegener.

Bnh gy t th g nhiu ua : i ng h hp trn hoi t, vim


oa g, i i, i tai gia, vim mng phi, vim phi, hp thanh-kh qun,
t th g tim. 80% bnh u ht Wegener c t th g thn. Trong mu bnh
nhn tn ti khng th ANCA- toplas i . Ngc li, trong vim vi mch dng
nt th li tn ti khng th ANCA-p (perinuclear).
- Xut huyt dng thp (bnh Scholein- Henoch): xut huyt dng bt tt hai cng
chn thnh tng chm nh h ui t; k theo au g, i go i ra mu,
vim cu thn mn tnh: ph, protein niu, hng cu niu.

2.2.3. Hi chng Goodpastur:

B h c m t t 1919 mt bnh nhn nam 18 tui. Biu hin lm sng


l khi huyt, c th khi huyt t d n t vong, kt hp vi vim cu
thn m t h thng l vim cu th t g si h go i ao ch. Trong mu
b h h lu hnh khng th khng mng nn cu thn.

. . . i th o ng:

i th o ng l mt bnh ri lon chuy ho thng gp nht v l mt bnh


x hi. Bnh gy t th g t nhiu ua t o g th : ho u thn,
ho t o g khoa g Bo a to thnh mt g si m ly cun mch cu
thn.

Biu hin lm sng bng hi chng vim cu thn mn tnh, hi ch g th h,


tiu ng mch thn-thn lnh tnh ho ho ng mch thn-thn c tnh.
Su th giai on cui l mt trong nhng nguyn nhn t vong ca i
tho ng.

2.2.5. Vim cu thn do nhim khun:

+ Vim cu thn do cc virut vim gan:

Vim gan mn tnh do virut B v virut C (HBV-hepatitis B virut v HCV-hepatitis C


virut) l mt trong nhng nguyn nhn gy vim cu thn mn tnh. Khng t
t ng hp va c tn th g ga SGOT, SGPT ili u i t g , HBsAg ++ ,
anti HCV (++)] kt hp vi vim cu th . Ngi ta ph t hin cc khng
nguyn virut vim gan B cu thn.

+ Vim mng trong tim bn cp (bnh osler):

B h Osle thng xut hin trn bnh nhn b bnh van tim hoc bnh nhn
nghin ma ty. Biu hin ch yu ca bnh l st cao, ko di hng thng, thiu
mu, bch cu t g, l h to, g ta d i t ng, vi p xe ngoi da, mng tay khum,
cy mu c mc vi khun, siu m tim thy cc si a ng mch ch hoc van
hai l; vim cu thn hnh lim cc b vi biu hin lm sng l i a u
protein niu...

+ Vim cu mn tnh do st rt, do bnh phong, giang mai.

2.2.6. Vim cu thn do nhi c:

- Nhi c mui vng.

-Nhi c penicillamin.

2.2.7. Vim cu thn mn tnh do l g ng cc protein bt thng:

- Bnh thn do chui nh.

- Bnh thn do chui nng.

- Bnh Waldenstrom b h i phn t globulin (Waldenstroms macroglobulin).

- Amyloidosis tin pht v amyloidosis th pht.

2.2.8. Bnh cu thn do cc bnh l c tnh:

Bnh bch cu cp, bnh bch cu mn, sarcoma hch, bnh Kahler.

. C h bnh sinh ca vim cu thn mn tnh tin pht.

Vim cu thn mn tnh tin pht hay cn gi vim cu thn mn tnh khng r
gu l nh l min d h. i b phn vim cu thn mn tin pht l
bnh l gy nn bi phc hp min dch, khc vi vim cu thn cp do nhim
khun, khng nguyn trong vim cu thn m t h kh g gu t
a dng. Khng nguyn c th ngoi lai h kh g nguyn ho tan ca vi khun
hoc khng nguyn ni ti bao gm nhng protein bt th g c sn xut t
nhng khi u t o g th hoc l nhng protein ca th b bi i tr thnh
kh g gu ho ta lu h h t o g u k h th h th sn xut khng th.
S kt hp gia khng nguyn-khng th to nn phc hp min dch. Trong
t ng hp tha khng th th phc hp min d h k h thc ln s b t bo
li ni m bt gi v tiu hu loi khi tu ho . Ngc li, t o g t ng hp
tha khng nguyn th phc hp min d h c to thnh k h thc nh,
c kh g t qua s kim sot ca t o li ni lu h h t o g u,
l g ng ti cu thn. S t g t gia khng nguyn-khng th, s l g ng
phc hp min d h hot ho h thng b th, h thng

g u, h thng kinin, hot ho bch cu a h t u g t h, ch cu


i kim, t bo Mast nhm m h loi phc hp min dch khi vng tun
hon v dn sch cc l g ng phc hp min dch ti cu thn . Hu qu l:

+ T g t h thm mng nn cu thn do:

- Tc dng ca C3a v C5a.

- Tc dng ca hista i c gii phng t t bo Mast.

- Tc dng ca ad ki i c hot ho b yu t XII v men kininogenase.

+ T g g u: g u l t phn ng t v nhm ng n cc yu t
c hi xm nhp vo t ch hu g ua h, h g t o g i u thn nu t g
g u u c d n t th g u thn. Cc sn phm thoi ho ca
fibrin (PDF: product degenerative fibrin) xut hi t o g c tiu l minh chng
cho s hnh thnh v l g ng fibrin trong cun mch cu thn.

+ T g ho g ng bch cu, thu ht bch cu n i , t g u t h thc


o, t g tiu
hu bi cc men c gii phng t lyzosome, bradykinin, C5a, v NCF (n
eutrophil chemota i is fa to . l hng cht ho g ng bch cu ch yu
ca vim. Bradykinin c tc dng gin m h t g t h thm gp 15 ln histamin.

+ S hot ho ca C5b kch thch qu trnh kt dnh ca C7, C8 v C9 trn mng


nn t bo v mng nn cu thn l tha i cu trc ca mng nn.

Hu qu hot ng ca cc h thng sinh hc v ca cc t bo g tn


th g u thn vi hi t g t g si h t bo, ph n, xut tit, hoi t ,
ho cu th e s s 6).

S 5. Vai tr ca b th trong bnh sinh ca vim cu thn tin pht


S 6. Vai tr ca min dch trong vim cu thn
4. Triu chng ca vim cu thn mn.

Triu chng vim cu thn mn tnh ht s a dng, vi nhng hnh thi khc
nhau. C th biu hin kn o h c protein niu, hng cu niu khng c triu
chng lm sng; hoc biu hin rm r vi cc triu chng: ph to ton thn,
protein niu nhiu, gi p otei u, t g lipit u v khng t t ng hp
biu hin ca suy thn m t h giai on mt b. Triu chng ch yu ca vim
cu thn mn tnh l:

4.1. Ph:

Ph l mt triu ch g l s g t g ho nh l cu thn, cc loi bnh


thn khc khng c ph. Chnh v vy, khi xut hi ph kh g gu l
phi gh n ph do bnh l cu thn, cn ki t a c tiu c th xc
nh nguyn nhn ca ph. Rt nhiu t ng hp, triu chng lm sng duy nht
ca vim cu thn mn l ph, c th ph k o kh g h h g n sc
kho, b h h lao ng lm vi , g sinh hot h thng, thm ch bnh
nhn khng bit mnh b ph ; h g th ph rt to: ph di da, quanh mt c
t g h , g g t, ph di da u; ph mm n lm r; c th c
c t ng, trn dch mng phi, trn dch mng tinh hon.

+ C h bnh sinh ca ph:

- Do t g t h thm ca thnh m h, t g t h thm cc h thng mao mch


ngoi vi.

- c v mui do gim mc lc cu th , ng aldosteron th pht v


t g bi tit

ADH, kch thch g th t g hp thu mui c.

- Gim p lc keo ca mu do gim protein mu, gim albumin mu d n ri


lon vn chuy c v mui, gy c v mui khoang gian bo.

. . T g hu t p (THA):

T g hu t p c th xut hin bt k giai on no ca bnh.

- T g hu t p xut hin ngay t u cng vi cc triu chng ca vim cu thn


m t h, t g hu t p khng th g u , t g t g t. Mt s t ng hp
t g hu t p xut hin sau mt thi gian tin trin ca b h. Khi su th ha
xut hi , t g hu t p l mt triu chng bo hiu b h a g thi k tin
trin, bo hiu mt t bt pht ca bnh, mt u t h t g si h ph xut
tit cu thn d t g tit renin, hot ho h thng RAA (renin angiotensin
aldosterone).

T g hu t p xut hin trong vim cu thn m t h gha ti lng,


tnh trng suy gim ch g su th t b din ra s h so i nhng
t ng hp

vim cu thn m kh g t g hu t p. V vy, trong vim cu thn mn tnh


cn phi theo di huyt p thng xuyn v phi duy tr huyt p mc bnh
thng bng mi bin php. Mt s t ng hp t g hu t p l du hiu m
u ca suy thn mn tnh nhng bnh nhn vim cu thn mn tim tng t
t c v go i t g huyt p thng xut hin tnh trng thiu mu .
- T g hu t p ko di gy t th g t d ng tm tht tri, suy
tim mn t h; t g hu t p kch pht gy suy tim cp tnh d n ph phi cp.

4.3. Thiu mu:

Mt bnh nhn vim cu thn c th c thiu mu, da xanh, nim mc nht, hay
chng mt, au u, tr lc gim. Thiu mu x a t o g t ng hp:

- Do bnh lu ngy ko di hng thng, th h h g , ki g khe t cch


kham kh, kh g d tht, trng, c... d n thiu mu do thiu m, thiu
cc yu t i lng; thiu mu do thiu st.Thiu mu do thiu di h dng
thng l loi thiu mu m nh v trung bnh, t khi thiu mu nng.

- Thiu mu xut hin khi c suy thn m t h: % t ng hp suy thn


m t h u c thiu mu, m thiu mu ph thu o giai on ca suy
thn. bnh vim cu thn mn tnh, va t g hu t p va c thiu mu,
l nhng du hiu ca suy thn mt b. Nguyn nhn ca thiu mu l do thiu
erythropoietin.

4.4. Nhng bi i nc tiu:

Triu chng lm sng ca vim cu thn mn tnh c khi rt gho , n ni


bnh nhn khng bit mnh b bnh nu khng lm xt nghi c tiu. Ngc
li bi i c tiu bao gi g h g nh.

- Protein niu trong 24 gi g h thng xuyn d g tnh v giao ng


trong khong 0,5-3 g/ngy. Protein niu +++ thng gp mu c tiu lc
sng sm mi ng dy. Nhng mu c tiu k tip sau th m tnh;
protein niu cch hi. V vy khi protein niu (-) th phi lm protein niu 24h.

S lng protein niu t c gi tr v ti l g h g gha ch o v


l ch tiu h gi kt qu iu tr.

- Hng cu niu: 60- 80% vim cu thn mn tnh c hng cu niu. Theo nhiu
tc gi, hng cu niu l mt du hiu chng t b h a g giai on tin trin.
bnh nhn vim cu thn m t h, sau iu tr m protein niu t h h g
hng cu niu v d g t h th gu nh ti pht vn cn.
- Tr niu:

. Tr trong l nhng protein khun theo lng g th ha tho i ho ho to ,


gi g h hng si min chn.

. Tr sp: l nhng protein niu tho i ho do i t ng toan ca c tiu.

. Tr hnh ht, t o g hiu ht nh: t gi ta cho rng tr hnh


ht l du hiu t g a vim cu thn mn tnh. Mt s tc gi cho rng
thnh phn ca tr hnh ht l IgM. Hi a , gi ta cho rng cc tr trong, tr
sp, tr hnh ht l biu hin ca protein niu.

5. Cc th lm sng ca vim cu thn mn.

5.1. Th tim tng:

Biu hin lm sng bng protein niu v hng cu niu h g kh g t iu


chng lm sng. Bnh c th k o d i h g th g, h g kh g du hiu
no khc. Bnh nhn c th lao ng lm vi h th g h g kh g
gha l khng nguy him, cn phi thn trng, phi c ch cng tc, ch
sinh hot hp l , iu tr protein niu bng cc thuc khng tiu cu, nonsteroid
v cc thuc c ch men chuyn.

5.2. Th t g hu t p (THA):

Triu ch g t g hu t p chi u th v h g nh, huyt p 140/90 - 150/90,


h g th t g hu t p k h ph t. Thng km theo vi protein niu (++),
hng cu niu (+). Nu bnh nhn ln tui (trn 40 tui) d nhm vi tn
th g th do THA, ho tiu ng mch thn - thn lnh tnh hoc c tnh.

5.3. Th suy thn:

Khng c tin s vim cu thn. Bnh nhn vo vin vi bnh cnh lm sng ca
suy thn m t h: t g hu t p, thiu mu, ri lon tiu ho, bun nn v
nn; ur mu eati i u t g; t siu thy hai thn teo nh ng
u. Hu ht suy thn mn mt b do vim cu thn mn tnh xut hin la tui
t n 30 tui.
5.4. Th c hi chng thn h (HCTH):

M u bnh cnh lm sng l hi ch g th h, g th HCTH xut hin


sau protein niu, HC niu tim tng khng c triu chng lm sng t c
. Biu hin ca HCTH l: ph to, protein niu > 3,5g/ngy, protein mu < 60g/lt,
al u i < g/l t, holeste ol t g > 6,5 mmol/lt.

Hi chng thn h kh g thu thng km theo hng cu niu, t g


huyt p, t g u u, t g eati i , p otei iu khng chn lc

Hi ch g th h thun do vim cu thn mn t gp, h g khng him


gp trong qu trnh tin trin ca bnh.Vim cu thn mn tnh biu hin lm
sng bng hi chng thn h th g ti lng xu.

6. Ch o :

Ch o i u thn mn tnh phi da vo 4 triu chng ch yu h sau:

- Ph.

- Protein niu.

- Hng cu niu.

- T g hu t p.

C 2 triu chng bt buc l protein niu v hng cu niu. Khi ch o


vim cu thn mn tnh phi da o iu kin sau:

- Gp gi t g th h t , di 20 tui).

- Khng r gu .

- Bnh ko di trn 6 thng.

- T g u eati i .

Vim cu thn m t h th g ti lng xu, ti lng ph thuc vo thi


gian b bnh, c hay khng c hi ch g th h, t h t ng THA, ph thuc
nguyn nhn ca bnh v cc bnh kt hp. Suy thn mn tnh xut hin sau 10-
k t lc b bnh.

. iu tr.

. . iu tr triu chng:

+ Chng nhim khun: nhim khun c th l ngun cung cp khng nguyn


hoc l yu t khi pht, v vy s dng khng sinh l cn thit. Dng khng sinh t
c tnh vi thn, dng ng ung l ch yu. Cc khng
sinh thng dng l: ampicilline, erythromycine, rovamycine. Thi gian dng
khng sinh t n 10 ngy.

+ iu tr ph: dng cc thuc li tiu uai h lasi , fu ose ide :

Lasix 40 mg x 2- 4 v/ngy, tu theo khi l g c tiu 24 gi iu


chnh liu

lasix cho hp l , l g c tiu 24 gi phi trn 1000 ml, nu l g c tiu t


h phi t g liu li tiu.

+ iu tr t g hu t p: phi s dng cc thuc h p khng h h g n


ch g th , h thu thng dng l:

- Thuc c ch canxi: dng mt trong nhng thuc sau:

. Adalat L.A 30mg x 1-2 v/ngy.

. Amlor 5 mg x 1-2 v/ngy.

. Plendil 5 mg x 1-2 v/ngy.

. Madiplot 10 mg x 1-2 v/ngy.

- Thuc c ch bta: dng mt trong nhng thuc sau:

. Tenormin 50 mg x 2-4 v/ngy.

. Concor 5 mg x 1-2 v/ngy.


. Dilatrend 25 mg x 1-2 v /ngy.

- Li tiu quai: lasix.

C th kt hp hai loi thuc li tiu khc nhm, thn trng khi s dng cc thuc
c ch men chuyn, resecpin, guanethidin, hypothazid.

7.2. Corticoid liu php v cc thuc c ch min dch:

7.2.1. Ch nh:

- Vim cu thn mn tin pht c hi ch g th h.

- T th g th t o g nh h th g: luput a h thng, vim da- ,


bnh t chc lin kt hn hp.

- Cc bnh mch mu: vim mch mu dng nt, bnh u ht Wegener.

- Hi chng Goodpastur.

- Vim cu th t g si h go i ao ch.

7.2.2. Cc thuc v liu dng:

+ Corticoid:

- Prednisolon 1-1,5 mg/kg/ngy, ung 1 l sau khi s g -7gi sng), dng


k o d i ho n lc protein niu m tnh hoc protein niu di 0,5 g/ngy, sau
gim liu dn; thi gia iu tr l 6 thng.

- Methylprednisolon liu 1000 mg/ngy, tim truy t h ch, mi t dng 3


ngy, mi thng dng mt t, c th dng trong 6 thng.

+ Cc thuc c ch min dch:

- Cyclophosphamide.

. ng ung: 2-3 mg/kg/ngy x 12 tun.


mt ln.

. ng tim truy t h ch: 500-700 mg/m2/ngy, mi thng tim truyn

- Azathioprin 2- 4 mg/kg/ngy x 12 tun.

- 6-mercaptopurine: 2- 4 mg/kg/ngy x 12 tun.

Ngi ta thng kt hp 1 loi thuc corticoid vi 1 loi thuc c ch min dch.


Ngoi cc thuc corticoid v cc thuc c ch min d h, gi ta cn s dng
cc thuc khng tiu cu (persantine-dipyridamole),
thuc chng g (heparin), cc thuc tiu fibrine (urokinase, streptokinase).

77.VIM CU THN I THO NG


(Bnh thn Ni khoa. Nh xut bn Y hc 2004)

I. I CNG

Thut ng Bnh cu th i th o g h bnh l cu thn th pht do


h hng ca i th o g T l thn. T th g u thn ny c hnh
th i c hiu c Kimmelstiel v Wilson m t .

T l t b h thng gp c pht trin v c a g ph t


trin. T l mc b h t theo a d, hng tc, mc sng, li sng v ngy
g t g. T t p ha gp, chim khong 80-90% tng s cc b h h T,
t o g g % ha c ch o iu tr g.

Theo di cc bin chng ca T, gp microalbumin niu 40% bnh nhn b


T di % h h T t .

Theo JSDT (Nht Bn, 2000), nguyn nhn suy th giai on cui c lc mu
chu k , do vim cu th i th o g ng hng th hai sau vim cu thn
mn tnh.
Bnh cu th i th o g h do tha i thnh phn ha hc
ca g u thn v t chc gian mch. Phn tch ha sinh v ha min dch
ch ra rng cht mm ngoi t bo (extracellular matrix: ECM) ca gian mch cu
thn bao gm collagen typ IV, laminin v fibronectin.

Hi a gi ta cho r g t g t h t cht mm ngoi t o ECM do t g


hot ha yu t t g t ng chuyn d g t a sfo i g g o th fa to li
quan cht ch vi h a u th t o g T.

Yu t gen lin quan vi s bt u v tin trin ca bnh th T t p


c cng b v tip tc nghin cu.

Theo d i iu tr tt T i ch gim glucid, khng ch huyt p vi


thuc c ch men chuy , iu ch h t g mu vi Statin km theo hot
ng th lc hp l c th lm chm xut hin vim cu th i th o ng v
chm din bi n suy th giai on cui, g h lm gi gu tai in
mch no, gim nhi u ti .

II. BNH SINH CA VIM CU THN I THO NG

Da vo thc nghi , gi ta gii thch bnh sinh ca vim cu th i th o


ng bao gm:

1. Vai tr quan trng ca huyt ng:

- T g p lc th t h t o g ao ch cu thn trong khi p lc h thng bnh


thng.

- T g t s lc.

- T g siu lc.

- Nhng cht trung gian hoc cc yu t c kh g i lon huyt ng thn


to nn bnh cu th i th o ng l:

. T g ng mu.

. Thiu Insulin / khng Insulin.


. T g th tch ngoi t bo.

. Bt th g th g ng cu - ng thn.

. Sn phm ca glycosyl ha khng enzym.

. Bt thng ca ng polyol.

. Bt thng chuyn ha calci.

. Thiu oxy t bo.

. Tha peptid li niu bi natri ca t h peptide at ial at iu ti ue .

. Tha endothelin.

. Tha acid nitric (NO).

. Tha Kallicrein.

. Tha prostaglandin gin mch.

. Suy h renin - angiotensin.

. Tha yu t t g t ng c ngun gc tiu cu (PDGF: platelet derived growth


fa to .

. Tha yu t t g t ng chuyn d g t a sfo i g g o th fa to .

. Heparin sulfat khng chun.

. Tha angiotensin II hay nhy cm vi angiotensin II.

. Thiu catecholamin hay nhy cm vi catecholamin.

. Tha glucagon.

. Tha ho o t g t ng (GH).

. Tha yu t t g t ng 1 ging Insulin (IgF1: Insulin - like growth factor 1).

. Tha th ceton.
2. S glycosyl ha khng men c th l tha i bn cht ca protein:

T g qunh, d gy tc m h, t g g g tp tiu cu, gim tiu si huyt.


Th , t g sn phm cui glycosyl ha mun (advanced glycosylation end
products - AGE).

3. Gim chuyn ha ca polyol v myoinositol mc t bo ng thn v t chc


gin mch:

X h a u thn v t chc k thn:

III. CHN ON

1. Ch o d g t h + :

- X nh b h T da vo tiu chun ch o T gim dung np


glucose ca Hi i th o ng M :

+ ng huyt l i> ol/l g/dl .

+ ng huyt bt k > 11,1 mmol/l (200 mg/dl).


- Th o :

+ Protein niu:

. t: microalbumin niu (t 30-300 mg/ngy hay 20- g/ph t .

. Trung bnh: microalbumin niu > g/ g ha > g/ph t .

. Nhiu: khi c hi chng th h t , g/ g .

+ Huyt p t g th pht.

+ Mc lc cu th : t g giai o u, gi khi su th theo v


giai on.

+ Ri lon m mu.

+ Bnh s t nhin ca vim cu th i th o ng.

2. Theo Mogensen, gi ta ph hia giai on ca vim cu th i th o


ng:

- Giai o g g - ph i: t g ti mu th , t g lc cu th , t g k h
thc thn, bt u c protein niu.

- Giai on im lng vi bi tit albumin niu h thng, lc cu thn bnh


thng, ko di hng ch .

- Giai on bnh th i th o ng bt u c hiu bi microalbumin niu


thng xuyn, lc cu th h th g ha t g. Hu t p t g.

- Giai on bnh th i th o ng thit lp h, c hiu bi protein niu


lm sng. Huyt p t g. Mc lc cu thn gim v suy thn nhanh chng nu
kh g iu tr.

- Giai on suy thn nng, suy th giai on cui. Ngi bnh b tn ph, nhiu
bin chng (mt, thn kinh, tim mch).

3. Sinh thit thn vi m bnh h ch o t th g:


- T g si h ht mm gian mch v t bo gian mch.

-M g d , t on, l g g fi i kiu vng thp (wire loop).

- X h a u thn lan ta.

- X h a u thn kt hp vi k h h a

IV. IU TR

1. Ch ung: L bi ph p iu tr quan tr g t o g T, g p phn nh


ng huyt. Phi gim Glucid. Cn cung cp g lng ty theo mc lao
ng v theo gii t 30 - 40 kcal/kg th trng/ngy vi t l:

- Glucid t 45 - 50%

- Protid t 15 - 20%

- Lipid khong 35%

Nu c suy thn cn gim thm Protid.

2. Ch lao ng hp l.

3. Thu iu tr T:

Ty theo th b h, giai on bnh v tng c th ch ph iu tr.

im chnh l ki so t ng huyt cht ch vi theo d i ng huyt l i,


ng huyt sau H A .

Tt Trung bnh Km

ng huyt l i ol/l 4,4 - 6,1 , > 7,8

ng huyt sau ol/l 4,4 - 8,0 , > 10,0

HbA1c < 6,5 , > 7,5

Cc thu iu tr T gm:

a. Insulin:
- Tc dng nhanh.

- Tc dng bn chm.

- Tc dng rt chm.

b. Thuc ung h ng huyt:

- Nhm Sulfonylure:

. Th h 1: Tolbutamid, Chlorpropamid.

. Th h 2: Daonil, Predian, Diamicron.

- Nhm Biguanid: Metformin (Glucophage).

- Nhm c ch men glucosidase:

. Glucobay.

. Basen.

4. Thuc khng ch t g hu t p:

Trong vim cu th i th o g t g hu t p l mt yu t gu ,
mc tiu c t c:

- L tng: Huyt p ti a < Hg < Hg.

- B h thng: Huyt p ti thiu < 130 mmHg v 85 mmHg.

T t ng hp, chn cc thu sau iu tr:

- c ch men chuyn: Captopril, Enalapril, Lisinopril.

- Chn th th a giote si II: Losa ta , Tel isa ta

- Chn bta giao cm: Propranolol, Atenolol, Pindolol.

- Chn calci: Nifedipin, Verapamil, Diltiazem.

- Thuc c tc d g t u g g: Meth ldopa, Clo idi .


- Thuc gin mch ngoi bin: Dihydralazin.

Cc cng trnh nghin cu thy rng c ch men chuyn bo v tim mch v


khng th th angiotensin bo v thn.

5. Thu iu ch h t g mu:

Ri lon m mu c bit l lipoprotein t trng thp (LDL cholesterol) v


lipoprotein t trng cao (HDL cholesterol) l nhng yu t gu a nhi mu
ti , nh mch vnh v tai bin mch mu no trong bnh vim cu th i
th o ng. Cng vi iu tr tha i li sng, cc thuc Statin, Fibrat v
Ni oti i a id c s d g iu tr.

6. Thuc ch g g u, h g g g tp tiu cu bao gm Aspi i , Aspegi

7. Thu iu tr triu chng khi:

- Toan ha mu vi dung dch Natri bicarbonat.

- T g kali u i dung d h Nat i i a o at, Cal iu ti t h ch v nha


t ao i ion.

8. Khi suy thn nng giai on III ho giai on IV: Cn lc ngoi thn chu k .
Cc tc gi khuyn nn lc mu sm trong suy thn c mc lc cu thn khong
15 ml/pht do vim cu th i th o ng so vi cc nguyn nhn khc.

Lc mng bng ngoi tr lin t CAPD g c thc hi h g d c bin


chng vim mng bng.

Chy thn nhn to chu k hng ngy trong 2 gi ci thi c cht lng cuc
sng cho bnh nhn.

Ghp th g l t ph g ph p c p dng. C th cng ghp thn v


ghp t ng thi khi cc tng cho c ha hp m vi gi nhn.

9. Chi lc lm gim suy thn trong vim cu th i th o ng:

- Kim sot cht ch ng mu.


- Khng ch t g huyt p.

- Dng c ch men chuy /i khng th th angiotensin II.

- Gim m mu.

- Ch gim protid, gim phosphat.

- Kim sot toan ha.

- Bin php ton din:

. Kh g t g .

. Hot ng th l .

. Kim sot thiu mu.

. Ngng ht thuc.

78.VIM CU THN SAU NHIM LIN CU


(Bnh thn ni khoa. Nh xut bn Y hc 2004)

I. I CNG

- Vim cu thn sau nhim lin cu l mt bnh cu th gu ph t, thng


xut hin sau nhim lin cu hng hoc da t 1-4 tun. Bnh xy ra ph bin
tr e h g gi l g th b bnh.

- C h bnh sinh:

. Ch mt s chng lin cu khun tan huyt thuc nhm A typ 12, typ 4 v typ 1
gy nn (> 90%).
. L mt bnh trung gian min dch. Thi gian tim tng gia nhim khun v
khi pht bnh thn l ph hp vi thi gia i hi cho vic hnh thnh khng
th.

. C h min dch d ng do cc phc hp khng nguyn-khng th (KN-KT lu


hnh l g g t g u thn.

II. TN THNG M BNH HC

Cu thn n to h h thng do:

- T g si h t bo ni m v gian mch c tnh cht lan ta.

- Xm nhp bch cu, c a h t u gt h h .

- Hnh nh m hc trong knh hi i in t l nhng l g g in t c


d g u l . C th l cc phc hp KN-KT mt ngoi ca g ,
di lp biu m c chn.

- Hu nh quang min dch c l g ng dng ht ca IgG, IgM v C3 gian mch,


d theo g .

- C th pht hi c khng nguyn lin cu sm, nu sinh thit trong 1-2 tun
u.

III. LM SNG V CN LM SNG

1. Lm sng:

Bnh khi ph t t ngt sau khi b au hng 1-2 tun do nhim lin cu vi hi
chng cu thn cp:

- Ph: Thng ph nh quanh hc mt v gim nhanh trong vng 1-2 tu u.

- i t hoc v niu: Nc tiu thng < 500 ml/24gi, t o g t ng hp v niu


ch i c 100-200 ml/24gi.

- i u:

. Th g i u i th, c tiu sm mu ho h c ra tht.


. i u i th nhanh sau vi tu h g hng cu niu vi th tn ti
trong nhiu tun hoc vi thng.

. C th i u i th.

- T g hu t p: T l b h h t g hu t p > %. T ng hp t g hu t p
n g, t ngt, bnh nhn c biu hi au u, chong vng, nn, co git v c
th c bin chng xut huyt no, ph phi cp.

- Suy tim:

. Thng t gp, nu th ti lng xu.

. Suy tim do gi c, gi mui, t g hu t p.

. C th suy tim ton b hoc suy tim tri.

2. Cn lm sng:

- Nc tiu:

. Protein niu trung bnh t 1-3 g/24gi, him khi c hi chng th h.

. Hng cu niu, bao gi g .

. Tr hng cu, tr ht.

. Sn phm ging ha ca fibrin xut hi t g t o g c tiu.

- Mu:

. Thiu mu nh ho h thng.

. Mu l g t g.

. Khng th khng lin cu t g c bit nu c hiu gi khng th cao). ASLO


(Antistreptolysin-O), ASK (Antistreptokinase), AH (Antihyaluronidase).

. B th gim, ch yu C3.

.U u t g ho h th g, t g hiu khi c suy thn cp.


. Mc lc cu th h thng hoc gim khi c suy thn.

. in gii mu bnh thng: K+ mu cao do thiu niu, v niu, Na+ mu thp do


ph.

IV. CHN ON

1. Ch o nh:

- Khi ph t t ngt vi hi chng cu thn cp sau nhim lin cu t 1-3 tun.

- Ph: nh hoc trung bnh, ch yu ph mt.

- i t< l/ gi

- i mu: vi th ho i th.

- T g hu t p.

- Protein niu < 3 g/24gi.

- Hng cu niu, tr hng cu, tr ht.

- B th gim.

- ASLO t g.

- Sinh thit th : t g si h t bo ni mao mch, l g g h h u l


mt go i g .

2. Ch o ph bit:

. . t cp ca vim cu thn mn.

2.2. Hi chng cu thn cp do cc nguyn nhn khc.

V. BIN CHNG

1. Suy thn cp:

Vim cu thn tin trin nhanh xy ra kho g % t ng hp. U u t g,


thiu niu hoc v niu ko di d n suy thn nhanh.
2. Ph phi cp: Do gi t g hu t p.

3. Ph no hoc chy mu no: Kt qu ca t g hu t p t ngt.

4. Suy tim tri hoc suy tim ton b.

IV. IU TR

1. Ch ngh gi, ung:

- Ngh tuyt i ti ging.

- h, hn ch mui v gi m.

2. Khng sinh:

Nu cn nhim lin cu hng v da cn ch nh khng sinh nhm bta


la ta h Pe i illi .

3. Cc thuc gim min dch v Corticosteroid: Khng c kt qu.

4. iu tr triu chng:

- Ph: ht, li tiu Lasix (vin hoc tim) ty theo m ph.

- H huyt p: c th dng 1 hoc 2 loi kt hp nu huyt p kh khng ch. Kinh


nghim hay dng thuc h p nhm ch al i h: A lo , Ple dil, Nifedipi RT
kt hp vi thuc h p nhm c ch th ki h t u g g h: Aldo et hay
Dopeg t, Catap esa

- Thuc tr tim: ch dng khi c suy tim.

- K+ mu cao:

. Hn ch a K+ o theo g ung (hoa qu c nhiu kali h hui,


a , ho .

. Li tiu: Lasix tim hoc ung, c th dng liu cao.

. Truyn Natri bicarbonat loi 4,2% ho ti t h ch loi 8,4% (ng 20ml).


. Truy t h h Glu ose u t g -30%) c Insulin.

. Dng Resin hp th K+: Ka e alat. Reso iu A

. Cal i lo ua ti t h ch.

- Nu suy thn cp nng, K+ mu cao > 6,5 mmol/l: ch nh lc mu cp.

5. Theo di: nh k .

- T o g th g u, mi thng 1 l , sau 3 thng 1 ln.

- Sau p otei iu t h, oi h khi.

VII. TIN LNG

Trn 90% tr em c vim cu thn cp sau nhim lin cu khi hon ton vi
iu tr bo tn. mt s bnh nhn c hng cu niu vi th, protein niu nh c
th tn ti vi tu i th g h g s khi.

gi ln b h thng n g h , % t ng hp c hi phc hon


ton, mt s tin trin thnh vim cu thn tin trin nhanh, s cn li chuyn
thnh vim cu thn mn.

79.VIM CU THN LUPUS


(Bnh thn Ni khoa. Nh xut bn Y hc 2004)

I. I CNG

Vim cu thn Lupus chim khong 60-75% b h h Lupus a h thng.


B h c ch o da vo 11 tiu chun ca Hi khp hc M a a
1982. Khi c 4/11 tiu chu t o g tiu hun biu hin thn (protein niu,
tr niu th c ch on l vim cu thn Lupus. Bnh c th c nh g t
kch pht xen k nh g t lui bnh di hay ngn. Trong nh g t kch pht,
biu hin thn c th l hi chng cu thn cp, hi chng th h, hoc
khng km suy thn.

Biu hin th gha c bit t o g ti lng b h Lupus a h thng.


Tnh trng suy thn cp nng trong nh g t kch pht c th d n t vong.
Lu di, bnh d n suy th giai on cui phi lc mu chu k hay ghp thn,
c bit bnh nhn vim cu thn Lupus typ IV (vim cu th t g si h la
ta).

V vy vic ch o nh, ch o th b h iu tr tch cc cho tng


th bnh l rt quan tr g t o g ti lng bnh.

II. NGUYN NHN V C CH BNH SINH

1. Nguyn nhn:

Lupus a h thng v vim cu thn Lupus l mt bnh t min m nguyn


h ha c hon ton sng t. Nhiu yu t h ge , i tit, mi
t ng, virus v min dch gp phn vo vic khi ph t g h k o d i nh.

Cc th g k u nhn thy, bnh gp ch yu n vi t l n/nam = 9/1.

Nhiu tc gi kh g nh l bnh c th c tnh cht gia h khong 5% bnh


nhn). Nh g gi c nhm khng nguyn HLA-DR2 v HLA-DR3 t l mc bnh
ao h . Ret o i us t s i us kh g ghi g g g p o ic khi
pht bnh. C mt s thuc gy bnh Lupus th pht.

. C h bnh sinh b h Lupus a h thng v vim cu thn Lupus:

Nh g h v min dch h g ai t h g u trong bnh sinh Lupus


a h thng v vim cu thn Lupus.

Cc khng th c tm thy trong b h Lupus a h thng l:

- Khng th khng ADN t nhin.


- Khng th kh g AND ph gii.

- Khng th khng nucleoprotein ha tan v khng ha tan.

- Khng th khng Sm.

- Khng th khng La.

- Khng th khng Ro.

- Khng th khng ribosom v lisosom.

- Khng th khng phospholipid.

- Khng th khng yu t mng t bo, khng hng cu, khng bch cu, khng
tiu cu.

- Khng th khng khng nguyn nhn t bo.

Trong vim cu thn Lupus, ch yu l do l g ng cc phc hp min d h lu


hnh trong tun hon hoc hnh thnh ti ch cc phc hp min dch m pht
ng qu trnh vim ti cu thn g : d g , t g si h t o, h a ti
cu thn v c nhng t th g ng, k thn phi hp.

III. TN THNG M BNH HC

Vim cu th Lupus c chia lm 5 typ t th g da theo bng phn loi


t th g hc ca T chc Y t th gii (WHO).

- Typ I: Cu th h th g di knh hin vi quang h . i khi th pht


hi c nhng l g ng min d h di knh hin i in t v min dch
hu nh quang.

- Typ II: T th g gia h thun: gin r g t g si h t bo gian


mch.

- Typ III: Vim cu thn , cc b: ch di 50% s cu thn b t th g.


mt cu thn ch c mt vi chm mao mch b s g phng, t g si h t bo ni
m v gian mch, c th km theo t th g h a.
- Typ IV: Vim cu th t g si h la ta l typ nng nht ca vim cu thn
Lupus. Nh g tha i m hc ni bt l t g si h t bo ni m, gian mch v
i khi t bo biu m Bowman to thnh lim t bo. Hu ht cc cu thn
u b t th g t ht c 50%). C th c xm nhp bch cu a h ,
lympho bo v bch cu h , k theo l g ng cc globulin min dch, b
th v cc t th g hoi t cc b. Cc t th g phi hp h hp
vim m k, t th g th h ch mu trong th g thng gp v nng.

- Typ V: Vim cu thn mng Lupus. Vim cu th g Lupus tha i n


ca cu thn l dy lan ta ca thnh mao mch cu th . D g u thn
l do l g ng ca cc phc hp min dch. Cc t th g ng k thn phi
hp thng nh h t p IV.

IV. LM SNG V CN LM SNG

Lupus a h th g i l a dng v lm sng. Biu hin nhiu


ua , t c ht l ngoi da, khp, thn, huyt hc, tim, no.

1. Biu hi a u:

- St nh, mt mi.

- T mu l g t g.

- Km theo mt hoc nhiu biu hi kh : a , au khp, r g t

2. Biu hin ca thi k ton pht:

t g i t kch pht ni tip hau, t sau thng n g h


t t c hoc c thm nhng biu hin mi ua kh . Nhp v mc
nng nh ca t kch pht tng b h h g t khc nhau.

11 tiu chun ch o a Hi khp hc M a a gm:

. Ba h m m.

2. Ban d g a.

. T g m th vi nh sng.
4. Lot nim mc ming hng.

5. Vim khp khng t th g.

6. Vim mng:

. Trn dch mng phi v/hoc

. Trn dch mng tim.

7. Biu hin thn:

. C protein niu thng xuyn v/hoc

. C tr niu (tr ht, tr hng cu).

8. Biu hin thn kinh, tm thn:

. Co git khng r nguyn nhn c th khc.

. Ri lon tm thn khng r nguyn nhn c th khc.

9. Huyt hc: c mt hoc nhiu biu hin sau:

. Thiu mu tan mu, hng cu < 3,7 tera/l

. Gim bch cu < 4 giga/l

. Gim tiu cu < 100 giga/l

. Gim lympho bo < 1,5 giga/l

10. Ri lon min dch:

. C t bo LE.

. C khng th khng AND t nhin.

. C khng th khng Sm hoc cc t khng th khc.

. C phn ng giang mai (+) gi trn 6 thng.

11. Khng th kh g h d g t h.
Cng vi 11 tiu chun ch o a a a Hi khp hc M, nhiu nh
thn h ghi cu tm hiu nh c hiu ca 11 tiu chun ny.

Bng: Phn loi nh v c hiu ca Tan v CS.

STT Tiu chun nhy (%) c hiu (%)

1 Ba 57 96

2 Ba a 18 99

3 T g m th nh sng 43 96

4 Lot ming 27 96

5 Vim khp 86 37

6 Trn dch mng phi, mng tim 56 86

7 T th g thn 51 94

8 Ri lon thn kinh, tm thn 20 98

9 Ri lon huyt hc 59 89

10 Ri lon min dch 85 93

11 Khng th khng nhn 99 49

3. Cc biu hin thn:

Cc biu hin thn c th l:

- Hi chng cu thn cp:

. Ph

. T g hu t p

. Protein niu

. Hng cu niu r, tr ht, tr hng cu


- Hi chng th h:

. Ph

. Protein niu o , g/ gi

. Protid mu gim < 60 g/l

. Albumin mu < 30 g/l

. Lipid u t g > g/l

. Choleste ol u t g > , ol/l.

- C th ch c protein niu c, hoc km theo hng cu niu m nh v


cc triu ch g l s g kh h: ph , t g hu t p.

- Cc triu chng v hi chng trn c th km theo hi chng suy thn hoc


khng.

- Khi c suy thn:

. U , eati i u, a id u i t g.

. Mc lc cu thn gim.

. C nhng triu chng lm sng ca hi chng ur mu cao khi suy thn nng.

- Siu m th : k h thc th h thng trong mt thi gian di, c nhiu t


suy thn cp trong nh g t kch pht. Sau nhiu , th h a teo h dn
khi c suy thn mn nng (thi gian ty thuc vo tng typ t th g s p
ng vi iu tr).

V. CHN ON

1. Ch o nh:

Ch o h c da vo 11 tiu chun ch o a Hi khp hc


M 1982. Khi c 4/11 tiu chu t o g tiu hun biu hin th th c
ch o l i u thn Lupus. Vi 4/11 tiu chu th nhy cm l
% se si ilit c hiu (specificity) l 98%.

Qua kinh nghi l s g h t ng hp c sinh thit thn, khoa


Thn bnh vin B h Mai a a hng kinh nghim ch o i u thn
Lupus h sau:

- C biu hi i kh g c hiu:

. St ko di khng r nguyn nhn nhim khu , c bit l lao.

. T mu l g t g.

. g glo uli u t g.

- C 4/11 tiu chu t o g tiu hun v min dch hc hoc khng th


khng nhn (+), hoc khng th khng ADN (+), hoc t bo LE (+). Cng c nhiu
biu hin ri lon min dch th cng khng nh.

- Biu hin thn: phi c protein niu (+) tr ln (0,2 g/24gi tr ln), c th c
km theo hng cu niu, tr niu.

- Ch nhng biu hi thng gp ca nh g t k h ph t h:

. Ni a h h h m r.

. Vim khp cp.

. Lot ming hng khng nhim khun.

. Trn dch mng tim, mng phi.

. Thiu mu tan mu nng.

. Suy thn tin trin.

. Ri lon tm thn khng do thuc hoc ur mu cao.

. T g phc hp min dch tun hon v gim b th mu.

2. Ch o ph it:
Vim cu thn Lupus c biu hin lm sng rt a dng nn vic ch o ph
bit c t ra vi rt nhiu triu ch g kh hau: au khp, trn dch
mng tim, mng phi, thiu u do hng nguyn nhn khc. C 2 bnh l cn
c bit ua t ch o ph it vi vim cu thn Lupus.

a. Phn bit vi lao ton th:

Trn thc t l s g o u th k XIX, bnh ni a mt chn


o hm l Lupus lao. Sau ny, trong ch o g hiu ca nhm vi lao
ton th. V v ng trc mt bnh nhn st ko di, c biu hin nhiu
quan ph tng bao gi g t v ch o ph it vi bnh l ny v
iu tr hon ton khc nhau.

Cc biu hin chnh ca nhim lao:

- St v chiu.

- Bch cu t g h yu l lympho bo.

- Phn ng Mantoux (+).

- Phn ng PCR (+).

- Khng th khng nhn (-).

- Khng th khng ADN (-).

- Biu hin lao phi d pht hin nht, ng thi tm biu hin lao ua
kh lao g o .

b. Phn bit vi cc bnh l cu thn do cc nguyn nhn khc, c bit l vi


vim cu thn mn c suy thn. Rt d nhm ln v c biu hin bnh cu thn, c
suy thn v biu hin ca thiu mu.

Ch o da vo:

- Tin s c bnh cu thn.

- Thiu u i i i m suy thn.


- Thn teo nh, h a.

- Khng th khng nhn (-).

- Khng th khng ADN (-).

VI. IU TR

. iu tr vim cu thn Lupus:

V iu tr vim cu thn Lupus, nhiu tc gi i s u ghi u v thng


nht kin: sinh thit th h gi t th g nh hc l mt yu t
quan tr g gi p h h g iu tr. Vic kt hp gia nhng biu hin thn trn
lm sng v xt nghi c tiu vi nh g tha i trong huyt thanh bnh
nhn (khng th khng nhn, khng th kh g AND, kh g S t th g
m bnh hc thn gip cc nh lm sng c nhng quyt h iu tr thch hp.

Nhng bnh nhn c hi chng cu thn cp hay vim cu thn tin trin nhanh
m m bnh hc typ III hoc IV cng vi nhng du hiu hot ng ca bnh
c ch nh ngay t u liu cao Methyl prednisolon, tip theo l liu ung
k o d i. ng thi nn kt hp vi thu g c t bo.

Nu bnh nhn c hi chng th h h g h g th h thng, sinh


thit thn th vim cu th g thun, t du hiu hot ng v mn
tnh c th iu tr bo tn bi liu php Corticoid liu trung bnh v thuc chng
st rt, tr nhng bnh nhn c hi chng th h ng v t th g nh
hc thn t p V k theo t g si h t bo).

Nhng bnh nhn c nhng bt thng v c tiu thng xuyn (protein


niu, hng cu niu, tr niu h g h g th h thng, sinh thit thn
c t th g nh hc typ I hoc typ II, vi t du hiu bnh hot g c
iu tr bng liu php Corticoid liu thp, ch yu khng ch nhng biu hin
ngoi thn. Nhng bnh nhn c bt th g thng xuyn c tiu, ha
suy th h g si h thit cho thy t th g nh hc typ III c c xem
xt cn th iu tr xen k nhng liu mnh Corticoid nu du hiu huyt
thanh chng t b h a g t o g t tin trin.
Nhng b h h hng du hiu suy thn mn tin trin t t, c th
iu tr bo tn vi liu thp Corticoid, ch gi m v thuc chng
st rt. Suy thn m giai on cui c lc mu chu k hoc ghp thn. Bnh
Lupus a h thng ti pht trn thn ghp l t gp.

Nhng bnh nhn vim cu thn Lupus tin trin nng, nu liu trnh truyn liu
ao Pulse the ap Meth l p ed isolo phi hp vi liu ung duy tr bng
Prednisolon v Cyclophosphamid khng kt qu, hoc nu phi hp vi nhng
biu hin thn kinh, tm thn nng th nn tin hnh lc huyt t g.

Nh hu g ho a th ph iu tr vim cu thn Lupus c th tng


hp h sau:

1. Prednisolon ung 1-1,5 mg/kg/24gi t 1-2 thng, c th k o d i n 3 thng


nu cn thit, ri gim liu xung liu cng c v duy tr 0,5-0,3 mg/kg/24gi.

2. Cyclophosphamid ung 2,5-4 mg/kg/24gi t 1-2 thng ri gim xung liu


cng c bng liu tn cng trong 2 thng tip theo. Sau duy tr liu 50
mg/24gi hoc cch nht.

3. Azathioprin (Imurel) ung 2,5-4 mg/kg/24gi t 1-2 thng ri gim xung liu
cng c bng liu tn cng trong 2 thng tip theo. Sau du t liu 50
mg/24gi hoc 100mg cch nht.

4. Kt hp gia Prednisolon v thuc gim min dch vi liu trung bnh.

5. Truyn Methyl prednisolon 1g trong 3 ngy lin tc vi liu trung bnh, dng
Prednisolon 0,5-0,3 mg/kg/24gi cng c v duy tr trong thi gian tip theo.
Meth l p ed isolo c pha trong dung dch Glucose % c truyn trong
thi gian t nht l trn 1 gi.

6. Truy C lophospha id t c s d g h liu 0,7 g/m2da/24gi, mi


thng 1 ln trong 6 thng, phi hp vi Corticoid ung 0,5 mg/kg/24gi hng
g . Sau t u n 3 thng 1 l t o g t t ng hp, ph thuc vo s
p g iu tr. Nhng bnh nhn hi phc tt c th duy tr bng Prednisolon
v Azathioprin ung.
7. Cyclosporin A 2,5-4 mg/kg/24gi t 1-2 thng phi hp vi Corticoid ung liu
thp (20 mg/24gi) nu iu tr Corticoid v cc thuc gim min dch khc khng
p ng.

8. Lc huyt t g plas aphe esis khi t tin trin cp tnh nng v c bng
chng v t g phc hp min dch tun hon.

Vic la chn v phi hp thuc c c xem xt k lng da vo lm sng,


t th g nh hc thn v cc ri lon huyt thanh hc (cc t khng th)
h t s gi t h . Cn theo di tt tc dng ph ca tng loi thuc
th i x tr tha g.

. iu tr cc biu hin ngoi thn ca b h Lupus a h thng:

Cc biu hin ngoi thn ca Lupus a h th g th g p ng tt vi liu


thp Corticosteroid v cc thuc khng vim Non-ste oid. Vi au khp thng
p ng tt vi liu php khng vim Non-steroid. Aspirin liu thp (2,5-5
mg/kg/24gi) vn c s d g iu tr d phng ch g g nhng
bnh nhn c khng th khng Cardiolipin. Thuc chng st rt Hydroxycloroquin
Clo o ui g th g c s dng vi liu 400 mg/24gi, chia 2 ln trong
24 gi.

Nhng biu hin ngoi thn nng h ao gm: vim khp kh g p ng vi


thuc khng vim gi au No -steroid, vim trn d h a g, i phi do
Lupus, biu hin thn kinh tm thn cn s dng liu php Corticoid. Mt s
t ng hp cn truyn Methyl prednisolon liu cao (1000 mg/24gi trong 3 ngy
lin t sau du t liu ung 0,5 mg/kg/24gi.

Thuc kch thch min d h ti g glo uli g c nghin cu s dng


h g ha ho kt qu chc chn.

80.VIM CU THN DO LNG NG IgA


(Bnh thn Ni khoa. Nh xut bn Y hc 2004)
I. I CNG

Bnh cu thn do l g g IgA t thnh mt trong nhng b h thng gp


trong vng 3 thp k g c pht trin, bnh ny thay th v tr ca
vim cu thn cp sau nhim khu t . l nh ca gi l g
h ca tr em. Vi th thu c gi l bnh Berger. C l nh cc xt
nghim min dch v sinh thit thn vi knh hin vi quang hc, knh hin vi min
dch hu nh quang v knh hi i in t b h c pht hin nhiu h .
Bnh gp nhiu c chu , Nht, Singapore ri n chu u, Bc M, Anh
v nam nhiu h .

Trong khun kh chung cc bnh thn IgA, cc bnh khc c th phi hp vi s


c mt ca IgA trong cu thn: Lupus, vim gan, nhim HIV.

V h b h si h, ha c bit r hon ton. C tc gi nu ln hi tng


t g tng hp IgA1 trong ty v trong t chc lympho tiu ha gy ra bi s kch
thch ca virus hoc do cc khng nguyn. S k h th h c h tr vi s
t g t h thm ca rut l ho kh g gu i ua nhiu h . Th ,
g ghi u thy rng c tnh trng bt thng ca chuy h a ng
ca phn t IgA1 lm gim mc lc ca n. Cc IgA1 bt th g g g kt
vi nhng khng nguyn khc nhau to nn nhng phc hp min d h lu h h
m h l t bo gian mch ca cu thn. S kch thch ny to nn nhiu bin c
t o g s cu thnh ni sinh ca cc yu t pht trin, s tng hp cht keo
v phn g t g si h.

Ngi ta g gii th h ai t a min dch do cui nh g 970 pht


hin mt s nhm HLA-B53 v DR4 bnh nhn b vim cu th IgA. i
t ng hp thng bo bnh c tnh cht gia h.

II. TRIU CHNG

1. Lm sng:

Phn l t ng hp khng c cc triu chng rm r. Triu ch g kh c


hiu nam thanh nin v thiu nhi vi t i u y ra trong hay sau
nh g t nhim khu kh g c hiu ng h hp trn. S t ng hp b ph
t g hu t p khng nhiu. Mt s t ng hp km theo ban xut huyt th
thp khp (cc chm xut huyt cng ch , au khp, au ng).

2. Xt nghim:

- Nc tiu:

. P otei d g t h i n g trung bnh (1-2 g/l) ko di hoc t g t.

. Hng cu +++ ko di.

- Mu: Nhiu tc gi cho rng khng c test sinh h c hiu trong vim cu thn
IgA. Tuy nhin thng gp t g IgA hu t thanh vi mt hiu gi cao trn 350
mg/dl gi ln.

t th cc xt nghim ca hi chng th h t o g i u thn IgA.


Ur, creatinin mu v mc lc cu th tha i khi suy thn.

3. M bnh hc:

Quan st cu thn trn tiu bn sinh thit th l ph g ph p h o du


nht ca vim cu thn IgA.

Trn knh hin vi quang hc th t g si h t bo gian m h thun hoc


phi hp vi t g si h t bo ni mch, vim cu thn , vim cu th t g si h
mng typ I.

Trn knh hin vi hu nh quang vi nhum kt hp vi khng th hoc khng th


lin kt thy t th g l g ng IgA lan ta xut hin ch yu khong gian
mch. C th km thm l g ng C3 v C5b9.

Trn knh hi i in t thy l g g in t cao ch yu khoang


gian m h p o g u thn.

III. TIN LNG

Da vo t th g cu thn, t chc k v mch mu trong tiu bn sinh


thit ti lng b h. Ngi ta phn chia 4 nhm:
1. Nh ti lng tt, hu h kh g c kh g phi lc mu. Trn tiu
bn th t g si h h t bo gian m h t g si h m. Khng th h a
tiu cu thn ho tha i khong k, ng thn hoc mch mu thn.

2. Nh ti l g t g i tt, kh g phi lc mu thp. Trn tiu bn


th t g si h h t bo gian m h t g si h m. Cu th h a, u
thn hnh lim hoc dnh vo bao Bowman chi di 10% s cu thn sinh thit.

3. Nh ti lng xu, kh g phi lc mu trong vng 5- . T tiu


bn th tng sinh m trung bnh v lan ta cc t bo gian m h t g si h
. X h a u thn, cu thn hnh lim hoc dnh vo bao Bowman chim
khong 10-30% s cu thn sinh thit. Xm nhp t bo m nh ti khoang
k. Teo ng thn m nh. X h a mch mu m nh.

4. Nh ti lng rt xu, kh g phi l u ao t o g g . V


m bnh hc th t g si h nng l lan ta cc t bo gian m h t g
si h . X h a tiu cu thn, cu thn hnh lim hoc dnh vo bao
Bowman chim trn 30% s cu thn sinh thit. Mt s cu th ph i b
tr. T l h a l u t quan trng nht h gi ti lng. Xm nhp t
bo vim t chc k. Teo ng thn. Thnh ca mt s tiu ng mch th t g
sinh hoc thoi ha.

IV. IU TR

T theo giai on bnh v tt nht l da vo kt qu sinh thit, phn nhm


ti lng b h ch ph g ph p iu tr thch hp.

1. Phng vi khng nguyn:

- Khng sinh.

- Ct amygdal.

- Ch kim sot: khng c sa b hoc gluten, natri cromoglicat.

2. Dng cc thuc c ch min dch:

- Corticosteroid. K c liu ph p t s g .
- Cyclophosphamid.

- Azathioprin.

- Cyclosporin.

3. Thi phc hp min d h lu h h ng thay huyt t g.

4. T ng ln t th g u thn:

- Thuc khng tiu cu: Aspirin, Aspegic, Dipyridamol.

- Thuc ch g g: Hepa i , Lo e o , Wa fa i .

- c ch men chuyn angiotensin (ACEI)

5. Lm tan l g ng min dch cu thn: Danazol.

6. iu tr triu chng: Li tiu, h huyt p, chng thiu mu, chng kali mu


t g. Lc ngoi thn khi suy th III-IV.

C th tham kho ph hng d iu tr vim cu thn do l g ng IgA


theo t ng phi Nht Bn:

Nhm Ch lao ng Thu c hiu

. Ti lng tt Khng cn hn ch Khng

. Ti l g t g i tt Khng cn hn ch Khng

3. Ti l g t g i xu Tun th va phi Thuc khng tiu cu.


C th dng Steroid hoc
thuc ch g g.

Thuc khng tiu cu.


. Ti lng xu Tun th nghim ngt
Thuc ch g g.

iu tr triu ch g: t g
huyt p, suy thn mn.
81.LIN QUAN THN TRONG MT S BNH NI KHOA

I. THN TRONG SUY TIM SUNG HUYT

Th g ai t ua t ng trong suy tim sung huyt v phi p ng s th g


bng ni mi mi. C nhiu biu hin lm sng v th dch nhng bnh nhn
ny v kh g th h ghi a thn vi cc yu t t c th kh g . Mt
s t ng hp c ur mu cao v s o thi cc sn phm ha ging protein b
gim.

Suy tim sung huyt l hu qu ca s mt cn bng gia u g lng tim v


lu g u t h ch v ti . B h thng c s th g ng gia p lc tun hon
trung bnh, p l h phi v lu g u t h ch. Khi p lc tun hon trung
bnh s t g lu g u t h ch v ti gc li khi gim p lc tun hon
trung bnh s gim s tng mu ca t h g t g p l h phi. T
d t g th tch tu ho ng mch hiu qu gy tr c v natri.

Huyt ng hc h hng ti thn do tim mch c th t ng bi:


- Mt cn bng ti tim: bnh van tim, b h tim, bnh vch tim.

- Mt cn bng ngoi tim: hp eo ng mch ch, t g hu t p, cu ni ngn


ng - t h ch.

- Bt thng v chuy h a: ng gip, thiu mu, thiu vitamin B1.

- T g th tch mu do: c v mui, truyn dch qu liu.

Trong nh g t ng hp trn s g t g p l t h ch v gi u g lng


tim mt phn hoc ton b, ri d n gim th t h ng mch hu dng.

a. Triu chng lm sng:


- Ph va hoc nhiu.

- i t, i dm.

b. Triu chng cn lm sng:

- Nc tiu: protein (+), hng cu (++), tr trong, tr hng cu, t tr g t g, p


lc thm thu t g.

-U u t g, eati i u t g.

- Mc lc cu thn (MLCT) gim.

c. Triu chng gii phu bnh:

- i th: hai thn to. Trn b mt th gi t h h, u hng - sao


Verheyen. V d bc v c ph.

- Vi th: mao mch cu thn gin, sung huyt, c nhiu hng cu. Khoang
Bowman c hng cu, lng ng thn cha albumin, tr trong, hng cu, t bo
ng thn. T chc k ph . Li mao mch quanh ng thn sung huyt.

d. Xt nghim ch g thn:

- Lu g u ti thn gim mt na ho / . Lng mu ti thn ch cn 7,8%


lng mu tun hon ton b v ch cn 600-200 ml/pht.

- Mc lc cu th g gi h g t l t h lu g u ti thn. Ph s xy
a khi MLCT di l/ph t. Khi lu lng mu ti thn gim nhiu trong khi
MLCT gi t h th s mt cn bng v phn s lc s t g n 40-50% trong
khi gi h thng ch 14%.

C h ca tnh trng trn v:

- C thiu mu cc b thn do gim th t h u ng mch hu dng bi gim


u g lng tim v c s di chuy c trong lng mch ra t chc k v gy nn
t g p l t h h. iu ny d n thiu oxy ri gy t th g g
cu thn v t bo ng th , o ng m h ng m h i a cu thn,
t g sc cn ngoi bin ton thn v thn. Cc yu t thn kinh v th d h g
b h hng.

- T g t i hp thu ng thn vi at i c. Lc ny mi ngy ch cn thi c


1-2 mmol natri.

- Mt cn bng cu-ng thn. S phn b th tch tun hon hu hiu b tha i.


Nc lc qua cu th t c s cung cp u theo thi gian b gi h
h th g. T o g t ng hp ny huyt t g ua ao ch cu thn mt
nhiu c v cc tinh th h h thng (40-50% so vi % g t g
nng p otei t g p lc thm thu.

Huyt t g khi i cu thn bi ng m h i ti li mao mch quanh ng


th t g p otei g s di chuy c v mui t lng ng thn ti lng
mch mu.

Trn thc t c 2 typ suy tim sung huyt:

- Typ ph gim nhanh vi ch ht, thuc li tiu, thuc tr tim.

- Typ ph khng vi ph g ph p iu tr trn. h hng ca ng


aldosteron th pht nn phi dng li tiu loi khng aldosteron: Spironolacton
(Varospiron, Aldacton).

Tm li trong suy tim sung huyt, ch g thn b h hng nhiu theo


nhiu h phi hp v phc tp.

II. THN TRONG BNH GAN V BNH TY

Thn chu t g tha i ch g, h h th i t o g t s bnh gan, ty.


C h v s li ua ha c bit .

Khi b bnh gan ni khoa hay ngoi khoa, gi bnh c th b ph , i t, u


u t g, su thn v d n t vong.

. Tha i gii phu thn, ch g thn trong cc bnh gan:

a. Gii phu:
- i th: k h thc th h thng ho hi to. V d bc.

- Vi th:

. M g d , t g si h t bo ni mch hoc ngoi mch, gian m h, h a


quanh cu thn biu hin ca vim cu th g t g si h.

. T o thng b ng thn to, c hc, bong vy do hoi t t bo.

. T chc k thn ph v xm nhp t bo lympho.

Trong mt s t ng hp t th g gn ging vim cu thn sau nhim lin


cu hoc vim cu thn hoc vim cu thn hnh lim.

b. Ch g:

- Lung mu ti thn gim.

- Mc lc cu thn gim.

- Phn s l t g.

- Bi tit ng thn gim.

- T g t i hp thu c v natri ca ng thn.

- T g sc cn mch mu trong thn.

- Kh g c ti a c tiu c th cn gi c m h thng trong


giai o u ca bnh.

- H natri mu.

- Nh g kh g s t g ng gia t th g tin trin ca bnh v chc


g thn.

2. Nhng biu hin lm sng:

Ngoi triu chng ca bnh chnh, c th km theo:

- Ph do ri lon cn b g , in gii, t g th t h c ngoi t bo.


- i t.

- Natri mu gim do pha long.

- Protein niu (+).

- T tr g c tiu t g do c.

Gp trong mt s bnh gan lit k di :

(1) Vim gan virus: giai on tin trin, protein mu gim gy p sut keo mu
gim v ph.

Ngoi ra khi vim gan, s chuyn ha ca cc steroid v ADH b h hng dn


t g t i hp thu c v natri ca ng thn.

(2) X ga t ng: C hi tng thiu mu cc b ga t g p l t h


mch ca.

Do thiu mu cc b gan s gii phng VDM (material vaso depressor) hay


ferritin v kch thch gii phng ADH s t g khuch tn ng thn vi c.

Do t g p l t h ch ca cng vi h protein mu s t g di hu n dch t


trong lng mch ti khoang mng bng v hnh thnh c t ng.

Hu qu l g aldoste o g t g t i hp thu c v natri ca ng thn.


T o g iu tr cn dng thuc khng aldosteron phi hp vi thuc li tiu quai.

(3) Hi chng gan thn cp:

C th gp trong nhim xon trng, st rt c tnh, ng c mt c trm, no


ph thai bin chng, truyn mu khng hp. T o g iu tr, t t ng hp c th
phi hp ph g ph p lc mu, thm tch mu, siu lc mu, hp ph mu,
lc mu lin tc.

(4) Vim ty cp:


Trong qu trnh din bin ca vim ty cp c th b suy thn cp tnh vi cc
triu ch g i t hoc v niu. Bnh s c hi phc khi ch b suy thn cp
ch g do t y tim mch hoc ri lo in gii c x tr tt.

Khi b g u i rc trong lng mch do gii phng nhiu cc cht


thromboplastin, amylase hoc b tiu si huyt do trypsin s gy hoi t v thn
hai bn, hi chng Sanarelli-S h a tz a , ti lng rt xu m d c lc
mu hoc siu lc mu lin tc.

CHNG . NIU NHI

82.CC D TT BM SINH

PGS TS BS. Tr L Li h Ph g

HP KHC NI NIU QUN B THN

1. Cc nguyn nhn?

T l nam: n l 5:2

T l phi: t i l : . % t ng hp xy ra hai bn.

Chia lm hai nhm: bm sinh v mc phi. Hp khc ni


niu qun b thn b si h thng pht hi t c
si h. Ngi ta cho rng c s ri lon t chc ca t o t khc ni
niu qun b thn xy ra trong qu trnh to phi. Hu qu l gy ra tnh
trng ri lo hu ng ca khc ni. Ngoi ra c s ri lon thnh phn
collagen gy hp.
Hp khc ni niu qun mc phi c th l hu qu ca cc can thip trn
niu qun, sn niu qun hoc bnh l sau phc mc.

tr e , t o gc bng quang niu qun c th gy ra tnh trng hp


khc ni niu qun b th pht.

gi ln, cc gu h thng gp l:

- Mch mu bt ngang khc ni

- S ng tit niu

- C thao t t ng tit niu (soi niu qun, soi thn)

- Bnh l sau phc mc gy chn p (h h l pho ph i, vim nhim sau


phc mc).

- Nhi t g theo ng mu ho theo g gc chiu

2. C ph g ph p h o ?

Da vo siu m th , UIV, ng v phng x thn vi thuc li tiu.

3. Ph g ph p iu tr?

To hnh b th theo ph g ph p t ri hoc l to hnh qua ni soi qua


da.

NANG NIU QUN

1. Th no l nang niu qun?

Do on niu qun nm trong bng quang dn ra thnh nang.

C th xy ra trn h th g i th , t ng hp ny xy ra nam
nhiu h (nang niu qu t th: orthotopic ureterocele). Tuy nhin
rt thng gp nang niu qun trn hn th g i th i a g niu
qun lc ch . T o g t ng hp th hai, a g iu qun xut pht t niu
qun ca h thng trn v t l gp n ao h .

% t ng hp nang niu qun lc ch xy ra hai bn.

2. Cc nguyn nhn ca nang niu qun?

Hin ti c 3 gi thuyt gii thch s hnh thnh ca nang niu qun:

Hp l niu qun.

Khim khuyt trong qu trnh to a on niu qu di.

Dn qu mc ca on niu qu di trong qu trnh pht trin ca niu


qun.

3. Biu hin lm sng ca nang niu qun?

T , t iu ch g thng gp nht l nhi t g ng tit niu.

Ngy nay nang niu qu th g c ch o ua siu t c sinh.

Nh g g th pht hi t o g th kh l s g. Na g iu
qun lc ch c th sa ra khi niu o.

4. Cch tt nht ch o ?

Siu m c th thy thn c v th c khi dng nang on cui


niu qun v trong bng quang.

Nu trn siu m nghi ng th c th nh bng chp bng quang niu


o gc dng c rn tiu.

X hnh th h gi h g a h th g i thn trn

10. iu tr nang niu qu t th trn h th g i th ?


iu tr a u l ni soi x nang. Nu co tnh tr g t o gc bng
quang niu qun v thn cn bo t c th phu thut cm li niu
qun.

11. C ph g th iu tr nang niu qun lc ch?

Ni soi x nang

Ct cc trn ca thn ct niu qun nu thn trn khng cn ch g.

Ni tt b thn- b thn nu cc trn thn cn hot ng.

12. T o gc bng quang niu qun c xy ra trong nang niu qun hay
khng?

% t ng hp xy ra niu qun cng bn v mt s t ng hp c th


xy ra niu qu i bn.

TRO NGC BNG QUANG NIU QUN

1. Th o l t o gc bng quang niu qun?

L tnh tr g t o g c tiu t bng quang ln niu qun.

T o gc p sut thp: x at o g u t h y ca bng quang.

T o gc p sut cao: xy ra trong qu trnh tng xut c tiu ca


bng quang.

T l n: nam khong 10:1.

2. Gii phu hc ca khc ni niu qun bng quang?

C t a h th g i th on niu qun ngoi bng quang gm


cc th si xon li gip cho h th g i thn v niu qu c
hu ng. Niu qu i h o ua th h g ua g t on 1- 2cm.
th si kt ni vi nhau theo chiu d on ny khng cn c
hu ng na.

Cn Waldeyer l mt lp ngoi cng ca lp t p theo chiu dc


xung quanh niu qu . L i u ua th h g ua g. Khi o
n bng quang n ni kt vi l cn ca niu qun to thnh lp su ca
vng tam gic.

3. T o gc bng quang niu qun x a h th no?

X a khi on niu qun ni thnh bng quang qu ngn. T l bnh


thng ca on niu qun ni thnh bng quang so vi ng knh ca l
niu qun l 2,5:1.

4. C gu h g t o gc bng quang- niu qun?

C rt nhiu gu h g t o gc bng quang- niu qun. Nguyn


nhn ph bin nht c gi l t o gc nguyn pht, y l mt tnh
trng bnh l bm sinh. Xy ra khi chi niu qun nm qu gn xoang niu
dc trn g Wolff, khi s kh g trung m cn thit chung quanh
chi niu qu h tr ch g t o gc.

T o gc th pht l do bt thng v gii phu. T o gc c th xy


ra do p l ao khi i tiu, thng gp trong van niu o sau, mt s
t ng hp bng quang thn kinh v bt ng vn gia Det uso
g. Ngo i a t o gc c th xy ra trn mt h th g i th i.
tr em c nang niu qun lc ch, niu qu di c th cm vo bng
quang mt v t kh thng. Tuy nhin nu niu qun lc ch cm vo
c bng quang th c th t o gc ln niu qun c t . T o gc
g th xy ra sau phu thut bng quang nu c phm vo l niu
qun.

T o gc niu qun (c hoc khng c nhim trng niu i k s gy ra


bnh th do t o gc.
5. Nhim trng niu gy t th g th h th no?

Nu vi trng t g ua g i l thn v nhu m thn (rt d xy ra khi c


t o gc), t th g thn c th xy ra theo nhiu h:

Vi trng sinh ra ni c t t ng trc tip ln ng thn.

C s tch t bch cu ht ti i i t g l tc nghn mao mch gy


ra thiu mu thn tng vng. Khi thiu mu Purine s b tiu th do chuyn
ho y kh . Khi t i ti mu tr li, lng hypoxanthine s c
chuyn ho thnh xanthine. Nu c s hin din ca xanthine oxidase th
xanthine s b chuyn ho thnh acid uric v superoxide. Superoxide c th
chuyn ho thnh peroxide v cc gc hydroxyl l nhng cht gy tn hi t
bo.

6. T o gc nguyn pht tr em km theo nhim trng niu c ph bin


khng?

Khong 50% nhim trng niu tr e l do t o gc. Chnh v vy bt


c tr em no c vim thn bn thn, tt c tr em trai c nhim trng
niu, tt c tr em gi <5 tui c nhim trng niu v nhng tr em gi >5
tui c nhiu h t nhim trng niu u phi t so t t o gc
bng quang- niu qun.

7. Lm sao pht hi t o gc?

Bng cch chp bng quang c rn tiu.

Ngoi ra c th chp nhp nh bng quang.

Hin nay h thng phn loi t o gc quc t :

1: Thuc cn quang ln niu qu h g ha l n b thn (chim


5- 8%)
2: Cn quang ln ti b th h g ha l d h th g i thn
(35%).

3: Thuc cn quang l n b thn, h th g i thn dn n va phi


(25- 35%).

4: Niu qun dn n, xon v , i thn dn n g k (15- 25%).

5: Ton b h th g i thn dn n xon vn (5%).

H th g ph gha ti lng quan trng v kh n g t ht tro


gc.

8. Thun li v khng thun li ca chp bng quang c r i vi chp


nhp h bng quang?

H th g ph t o gc ca quc t da trn hnh chp bng quang


c r i. Chp bng quang c r i ho ph p th c cc bt
thng t o g g ua g g t o gc, chng h h iu qun
i, t i tha cnh niu qun, niu qun cm lc ch. Bt li duy nht ca k
thut chp ny l tip xc vi tia qu nhiu. Nhp h bng quang ch
c 1- % lng tia X chiu o ua si h dc.

9. Siu m c th pht hi t o gc hay khng?

Ch % t o gc nguyn pht c thn l u t c th pht


hi c qua siu m). Chnh v vy vn phi chp bng quang c rn tiu
ch o .

10. Th o l t o gc trong thn?

T o gc trong th l t o g c tiu trong ch m thn trong lc


i tiu. Nu t o gc trong thn xy ra cng vi nhim trng th gy ra
vim th . T o gc trong thn xy ra cc nh thn nm 2 cc ca
thn. a s cc nh thn li v l vo h thng ng gp nm trn mt
phng cho so vi nh thn. nhng nh thn lm hoc phng, l ca ng
gp nm vung gc vi kh th g a t o gc.

11. Nc tiu v trng c th gy ra vim thn hay khng?

V mt tng th, c tiu v trng khng gy ra t th g th h g


nu t o gc vi p lc cao (van niu o sau, bng quang thn kinh, bt
ng vn gia D t uso tht) c th gy ra t th g thn.

12. Kh g g so thn trn nhng b h h t o gc?

5- % t o g , % t o g , % t o g 3, 50%
t o g % t o g 5 c so thn.

Bin chng ca so thn l cao huyt p (10%) v suy thn.

13. M t gi thuyt "big bang" trong tro ngc?

Theo gi thuyt ca Ransley v Risdon: trong ln nhim trng niu km tro


g u tin tr e , c tiu nhim trng s vo thn gy ra tnh
tr g t o gc trong thn. Hu qu l s gy so a ch m thn.
Cc so g n thn pht trin. Ngoi ra n cn lm xon vn cc nh
thn ln cn khi ho t o gc d dng xy ra cc vng ln cn. Hu
qu l g ho khp thn.

14. Cc du hiu ca t o gc trn UIV?

i thn b cn v dn, ch m mng, thn teo nh, c.

15. Xt nghim hnh h d g pht hin so thn?

X hnh thn vi DMSA cho thy nhng vng gim hp thu phng x v
th . SPECT Si gle Photo E issio Co puted To og aph l t g
nhy ca DMSA trong vic pht hin cc so thn. X hnh thn vi DMSA
l xt nghim nhy nht. C th x hnh thn vi MAG3 hoc
glu ohepto ate h g k h h .
16. nh lut Weigert- Meyer?

nh lut ny p dng cho tr em c h th g i th i, do hi


niu qun ring bit to thnh 2 niu qun ring bit vi mt thn. Niu
qun ca cc trn ca thn bt ngun t on trn ca ng trung thn v
thi gian gn vo ng trung th l u h s di chuy a h . N s
tn cng ph a t o g di so vi niu qun ca c di. Chnh v
vy rt d b lc ch. on ni thnh ca niu qun cc trn ng h
d b t o gc.

Niu qun ca c di nm bn trn v bn ngoi.

1/125 dn s c thn niu qu i. % t o gc vo c di, 15%


t o gc vo c cc trn v c di

17. Din tin t nhin ca t o gc?

Khi ch g a b g i t g th h h , th t o gc s c th t
ht % , % , % , % , % 5). Kh g t ht
nhng h th g i th i thp h h th g . % h g t ng
hp tro g , 3 s t ht.

La tui trung bnh pht hi t o gc l 2- 3 tui v la tui trung bnh


t ht l 5- 6 tui. Th g thng sau 10- 11 tui khng th t ht, tuy
nhin mt s t ng hp t o g n 14- 15 tui vn c th t ht.

18. iu tr ni khoa t o gc?

N i tiu thng xuyn. Nu c tiu gp th dng anticholinergic.


g ga nhim trng niu th phi dng khng sinh d phng. Thng
th g gi ta dng trimethoprim/ sulfamethoxasone hoc
it ofuda toi l nhng khng sinh c ph khng khn rng chng vi
t g ng rut l nhng tc nhn gy nhim trng niu. Liu d phng l
1/3- 1/4 liu iu tr nhim trng niu. 25- % t ng hp c nhim trng
niu d a g s dng khng sinh d phng.
Phi lm TPTNT v/ hoc c c tiu mi 3- 4 thng. Mi 12- 14 thng
phi chp bng quang c ua g h gi t h t g t o gc. Cc
t ng hp t o g 1- , sau khi iu tr ni khoa t o gc t
ht (bng quang c ua g h thng) vn c 20% kh ng ti pht tro
gc tr li ua theo d i nh k . nhng tr em ch t o gc mt
1- 3 th c 20% kh g a t o g i din trong qua
trnh theo di.

Ngoi ra phi lm UIV ho DMSA h gi t h t ng so ca thn.

C t ng hp tht bi vi iu tr ni khoa:

Nhim trng niu d a g kh g si h d phng

Dung np km hoc d ng vi thuc khng sinh.

V t o g ho n la tui 10- 11

19. Th no l bng quang khng nh?

l tnh trng nh g o ca detrusor bt thng khng c ch c


tn ti sau 2- 4 tui l la tui c th hun luyn cho b t i i c).
Triu ch g thng gp l tiu gp v tiu nhiu ln. Bng quang khng n
h thng gp tr e t o gc v lm cho m tro ngc
nng n thm. iu tr vi anticholinergic km vi khng sinh d phng th
c kh g t h t g t o gc t ht nhiu h l h iu tr vi khng
sinh d ph g thun.

20. Ch h iu tr ngoi khoa nhng tr e t o gc.

Ch nh cho tt c cc tr b t o g , t ng hp tht bi sau


iu tr ni khoa. Nguyn t iu tr ch yu l to mt h chng tro
gc bng cch lm cho niu qun ni th h d i h - 5 ln so vi chiu
ngang ca niu qun. Niu qu t gia lp nim m
detrusor.

Ph g ph p m li niu qu o g ua g thng s dng nht l


Cohen (m g ua g, di ng niu qun v cm li bt cho nhau v tr
a h . C th d g ph g ph p Lead ette - Politano (cm li t mt v
tr cao h m t o g g ua g h k o ing niu qun
xung v t h thng) ho theo ph g ph p Li h- Gregoire (cm niu
qun vo bng quang khng m bng quang).

T l thnh cng chung l 95- 98%. Cc bin chng bao gm: hp ch ni


(1- 2%), v t o gc (1- 2%).

21. nhng thn niu qu i t o gc vo c di iu tr h th


no?

C t ng hp ny c 2 niu qun cng nm trong mt bao chung v c


cng mt h thng mch mu chi phi. Do khi m li niu qun phi
cm 2 niu qun cng lc. Hoc c th cm li niu qu di vo niu
qun trn .

22. Th no l hi chng cm niu qun cao (niu qun hnh mc cu ch J)?

T o g t ng hp cm li niu qu theo ph g ph p Lead ette -


Politano, nu niu qu c cm vo ph di ng ca bng quang, tnh
trng gp khc ca niu qun c th xy ra ti i iu qu i o g
quang: khi bng quang tr g th c tiu lu th g h th g h g
khi g ua g on niu qu di b gp khc gy ra tnh trng thn
niu qun b c.

23. Nu niu qun dn qu rng th khi m cm li niu qun phi lm g?


Nu niu qun dn th chiu di cn thit ca on niu qun ni thnh kh
t . Do phi lm hp li niu qun bng 2 cch: xn bt niu qun
mt on 2- 3cm hoc gp niu qun li.

24. Hnh nh ni soi bng quang ca l niu qu t o g t o gc?

B h thng ming niu qun c hnh nn. Ming niu qun trong tro
gc c th c hnh dng sn v ng, hnh mng nga, hnh l h
golf (theo din tin nng ca tnh tr g t o gc).

25. iu tr ni soi t o gc?

B o g ta gi t cht to nn mt ng hm ni thnh
bng quang. Th thut ny gi l STING. C th pol tef ao gm cc
phn t teflon vi glycerin), tuy nhin mt s nghin cu trong phng th
nghim cho thy teflon c th di chuy n hch chu, gan, phi, no.
Hi a a g a g ghi u s dng collagen hoc m t thn. T l
thnh cng sau l u tin l 70% v nhng l lp li l 90-
95%.

BNG QUANG L THIN

1. Th no l bng quang l thin?

L mt bt thng bm sinh bng quang l ra khi thnh b g di v


bng quang b l gc ra ngoi, xy ra 1/35000 tr mi sinh, tr em
nam nhiu h t em n 3- 4 ln.

2. Nguyn nhn ca BQLT?


Do mng ca nhp khng co li c. Mng ca nhp ph di ca
bng trong nhng tun l u ca phi thai. Vo tun th 4 mng nhp
co v ph a u i to iu kin cho trung m nm hai b ra ca mng di
chuyn vo gia to nn thnh b g, ng thi cun bng quang li thnh
dnh cu trc hnh cu. Nu mng nhp vn nm v t kh g g th
thnh bng on ny khng to th h c v khi mng nhp b v th
bng quang s b l ra ngoi v b l gc ra m khng cun li thnh
hnh khi cu h h g g ua g h thng .

3. Cc bt th g i k ?

T o gc bng quang niu qu l thng gp nht. t ai g


thng gp that v bn. Ngoi ra c th gp l tiu g ao nam v
n , g u t h ng. i khi c thn mng nga v thn d sn
(dysplasie).

4. Cch x t i vi nim mc bng quang b l ra ngoi?

V ch yu l bo v nim mch trnh cc sang ch g ga oh


n nim mc (ph n lm cho vi g g ua g kh kh . Ni c
ca g ua g c che ph bng mt mi g silasti h s kh g
cho nim mc b kch thch do t t v kp rn c xt.

5. Cc phu thut phi thc hin mt b trai b bng quang l thin?

ng bng quang ngay trong nh g g u sau si h. B g ua g c


g li h g g ua g g kh g g ht, v vy b hon
ton tiu khng t ch. ng thi m g hu p hai g u li
h tr cho vi g g ua g.

Sa li tnh trng l tiu g ao l e - 18 thng tui. Th thut


ny, ngoi vi iu tr l tiu g ao g p ph l t g k h thc
g ua g to thun li cho phu thut th 3.
Ti to c g ua g ng thi vi vic cm li hai l niu qun vo bng
ua g t h t o gc.

Khong 70% b h h t c mc tiu c kim sat chp nh c.

6. Nu sau phu thut tr vn cn tiu khng kim sot th phi lm g?

Ngu h thng gp nht l do bng quang dung tch nh, v vy phi


phu thut m r g g ua g. Do khi l phu thut to hnh c
bng quang, nu thy dung tch bng quang < 70- 80 ml th nn m rng
bng quang lun. Nu vn cn tiu khng kim sat do khng lc ca niu
o thp th ollage ho t tht nhn to. Nu vn cn tiu
khng kim sot th phi chuy lu c tiu c kim sot.

7. Cc bin chng sn ph khoa thng xy ra nhng ph n c ti


BQLT?

Sa t cung, ngi thai bt thng.

8. iu g s xy ra nu kh g iu tr cho nhng tr c BQLT?

Nu kh g iu tr tr vn c th sng khe m h h g h g gu sau:

Tiu khng kim sat lin tc

Adenocarcinoma do nim mc bng quang b kch thch mn tnh

Kch thch nim mc l niu qun c th gy ra thn c

M H GII TNH

1. S bit ha thnh bung trng v tinh hon x a h th no

sinh dc s bit ha vo tun l th 6. S hin din ca nhim sc th Y


v cc cht liu di truyn trn nhnh ngn ca nhim sc th Y s lm cho
sinh dc bit ha thnh tinh han. Nu khng c nhim sc th Y th sinh
dc bit ha thnh bung trng

2. Cc ni tit t do tinh han sn xut quyt nh s bit ha gii tnh ?

Testosterone v cht c ch Mulle . Testoste o e k h th h ua si h


dc trong v ng Wolf pht trin. nam ng Wolf s tr thnh mo tinh
han, ng dn tinh v ti tinh. n ng Wolf tr thnh ng Gartner ( 1
u) v ng cn trung thn ( u gn bun trng).

Cht c ch ng Muller l mt ni tit t lm c ch s pht trin ca ng


Muller. n, ng Muller s tr thnh vi tr g / t o .
nam, ng Muller thai ha thnh mm ph tinh han ( mt u) v xoang
tin lit tuyn ( u cn li)

3. Phn loi lng gii

Ri lan di truyn gii tnh: hi chng Turner, hi chng Kleinefenter, nam


46XX, d sn sinh dc hn hp

Ri la ua si h dc gii tnh: d sn sinh dc thun ty, hi chng


bin mt ti h h a , lng gii tht

Ri lan kiu hnh:

Lng gii gi n: t g si h thng thn bm sinh, m s dng


progesteron trong khi mang thai,

Lng gii gi nam:bt thng tng androgene, bt thng hat ng ca


androgen (n ha tinh han hon ton, n ha tinh han khng hon ton,
hi chng cn tn ti ng Muller)

4. Cc ni tit t n gip bit ha gii tnh?

n khng c s sn xut androgen v cht c ch ng Muller. V vy, ng


Wolff khng pht trin m ng Muller li pht trin. mt tr khng c
bung trng hoc tinh han th kiu hnh ca tr s pht tri h? t
gi n ua si h d t o g g l gi n.
5. Ngu h thng gp nht ca tnh tr g h gii tnh tr mi
sinh?

C g thng thn b si h. gl gu h th e do n
tnh mng do mt mui.

6. nh gi mt t ng hp h gii tnh?

Bnh s: bnh s gia h thai k

Kh l s g: k h thc ca d g t hoc m vt, v tr ca niu o,


np mi ho u, ti h ho , t g sc t, trc trng .

nh nhim sc th

h lng 17 OH progesteron

Siu m vng chu

Soi bng

Ni soi ng tit niu

Sinh thit tinh han

7. T h g a h a ua si h dc ngoi ca nam?

Di t ng ca 5 alpha reductase, testosteron chuyn thnh 5 alpha


dihydro testosteron l mt androgen hat ng. Andrgene ny kch thch
ua si h d go i ha c bit ha bit h a th h ua si h dc
ngoi ca nam. Vo khong cui thng th 3 ca thai k , s pht tri
quan sinh dc ngoi ca nam han tt v mt thi gian ng t c sinh
d g t to ln

8. i l s g o gi p h c s bit ha nam ca tr s
sinh?
Nu s ua si h d th th g l ti h h a l t h t ng
bit ha nam tnh. Mt s rt t t ng hp bung trng c th s c khi
c thot v ln b h g th g thng, s ua si h d th
l tinh hon.

9. T o g t g si h thng thn bm sinh, thiu e z thng gp nht?

Thiu 21 hydroxylase chi % t ng hp

10. Xt nghim? mu no x h c tnh tr g t g si h thng thn bm


sinh?

17 hydroxy progesteron l mt du n rt nh pht hin tnh tr g t g


si h thng thn bm sinh.

11. C t ng hp thiu 21 hydroxylase v thiu 11 betahydroxylase khc


hau h th no v mt lm sng?

Tr thiu 11 betahydroxylase c th c cao huyt p do tch t deoxycortico


steroid (DOCA).

12. Cc yu t khng thu thng thn c th d n tnh trng rm lng


tr s si h ?

Cc cht progesteron do me s dng trong tam c nguyt u thai k hoc


u c th gy rm lng m c th gy rm lng cho con.

13. h gha lng gii tht?

Lng gii tht l tnh trng va c bung trng va c m tinh hon. 50%
t ng hp l 46 XX 50% cn li l th khm hoc l 46 XY.

14. h gha lng gii gi nam?

L mt a tr ti h ho h th g ua si h d go i
h v gii t h. C gu h g lng gii gi nam l do bt thng
tng hp androgen ho do ua h kh g hy vi Androgen
15. Trong cc t ng hp n ha tinh han hon ton th testosteron v LH
bi i h th no?

C hai u t g ao c hiu bi v tuyn yn khng th pht hi c


testosteron do c tnh trng khng nhy vi androgen, gonadotropin s
t g k h th h ti h ho tit ra testosteron

16. Ngu h thng gp th hai ca tnh tr g ua si h d h


tr s si h?

l tnh trng bt sn sinh dc hn hp. Kiu ge l XO/ XY. C


quan sinh dc trong bao gm mt tinh han mt? bn v mt di sinh
dc bn kia. pha tinh hon th ng phng tinh v mo tinh han bnh
thng. pha di sinh dc th c vi trng v t cung.

17. M t hi chng Denys- Derash?

Tr c biu hi h ua si h dc, vim cu th u Willm's

83.L TIU NG CAO


ThS. Bs Nguy Ho g c

1. Th no l l tiu g ao

L mt bt thng do ming niu o m ra trn


l g a d g t. D g t thng b cong mt
l g da ui u khim khuyt mt b g. D g
vt thng ngn v c dng dt, hai th hang khng dnh vo nhau.

n, l tiu g ao t g i tnh trng m vt ch i, idda xe


ra v c bng quang khng hon chnh.
2. V mt phi thai hc, l tiu g ao ging vi l tiu g thp hay
khng

Khng. y l mt dng ca tnh trng l ua . Khi g nhp khng


di chuyn trong qu trnh to phi th l thin bng quang s xy ra (lun
lun km theo l tiu g ao . Nh g u mng nhp di chuyn mt
phn th ch c l tiu g ao. Tn sut l tiu g ao c:
1/100000 b trai v 1/500000 b gi.

3. Bt th g t g t KUB a l tiu g ao

Khp mu b tch rng

4. L tiu g ao i k vi tnh trng tiu khng kim sot hay khng

Tt c bnh nhn n v 70% bnh nhn nam tiu khng kim sot.

5. M t cc bt thng ca g ua g i k vi l tiu g ao

Bng quang dung tch nh

T o gc bng quang- niu qun (90%)

6. Nguyn t iu tr l tiu g ao

Lm th g d g t, sa li chordee v to hnh niu o.


84.L TIU NG THP

ThS. Bs Nguy Ho g c

1. Th no l l tiu g thp

L tnh trng ming niu o thay v nm nh ca d g t th li nm


mt bng ca d g t. a s t ng hp khng c tnh cht l
b h gia h. % h g a tr l tiu g thp c cha b l tiu g
thp v 14% anh em trai b l tiu g thp. Nu t o g gia h kh g
ai b l tiu g thp, mt tr sinh ra b l tiu g thp th gu
trai k tip b l tiu g thp l 12%. T l ny l 19% nu t
th h i kh t o g gia h l tiu g thp ( anh em h . Ngu
l n 26% nu tr c cha b l tiu g thp.

Do im pht trin phi thai ca d g t v niu o nn nhng


tr b l tiu g thp lu da ui u b khim khuyt. Duy nht ch c
t ng hp l tiu g thp m ming niu o r g l o da ui u ton
vn.

Tn sut xy ra l tiu g thp: 1/200 tr em trai sinh ra.

2. V t thng gp ca l tiu g thp l khc ni u d g vt hay


on xa ca d g vt

V t thng gp nht l on xa ca d g t (80- 85%). y l th nh


nht, ming niu o thng nm rnh vnh. 10- % t ng hp xy ra
th d g t, ch c 5% xy ra khc ni u d g t hoc hi m.

3. Cc b trai b l tiu g thp c c h gi v mt niu khoa pht


hin cc bt thng khc hay khng
Khng. Ch c nhng b b l tiu g thp n g h v gii tnh
(bao gm c nh g t ng hp bt thng tinh hon) th mi c h gi
m thi. Khong 25% nhng b h h ph i utricle hoc c cc
cu trc ca ua si h dc n. Th kh thng xuyn trong l tiu
g thp khng cn thit v tn sut ca nhng bt thng khc ngang vi
tn sut chung trong dn s.

4. La tui thch hp sa cha l tiu g thp

La tui thch hp nht l 6- 15 thng.

5. Phu thut iu tr l tiu g thp tt nht l g

Cho n hin nay c > 150 loi phu thut l tiu g thp c m t
h g kh g phu thut no l tt nht. Cc phu thut ph bin nht
l dng flap MAGBI ming so v dng flap mt trong ca da ui u.

6. Cc yu t quan trng nht m bo s thnh cng cho phu thut l


tiu g thp

D g c cung cp mu tt.

Trong qu trng m cm nm cc m nh nhng cn thn.

Mi ni kh g g

Cm mu tht k.

May khng chng mp.

Ch khu tht nh

Chuy lu c tiu tht tt


7. Cc bin chng xy ra trong phu thut l tiu g thp

Hp niu o

Hp ming l tiu

Ti tha niu o

D da

Vn cn chordee hoc vn cn l tiu g thp

8. Trong phu thut l tiu g thp c lun lun cn thit phi chuy lu
c tiu hay khng

a s t ng hp chuy lu c tiu l cch tt cho php lm lnh


m v gim thiu gu d iu o ng thi lm gim t l bin chng.
C th dng thng niu o thay v m bng quang ra da

9. C h iu tr l tiu g thp n g t o g t ng hp d g vt nh

C th d g testoste o k h th h d g t pht trin. Trong nhng


t ng hp phc tp khi d g t nh h g n phi to hnh sm th c
th d g testoste o h h t c m

10. Nu to hnh nhiu ln m vn cn tht bi th phi lm g

T o g t ng hp ny, tt nht l phi to hnh li vi vt liu ly t i


kh h l i c m, ming v cc vt liu ti ch hp do m
to hnh nhiu ln.
85.VALVE NIU O SAU V TRC
ThS. Bs Nguy Ho g c

1. Th no l valve niu o sau

Valve niu o sau l mt bt thng bm sinh do mt np gp ca nim


mc niu o sau to nn gi g h t mng chn m g g hn s
t g tho t c tiu t bng quang. Tn sut l 1/8000 tr em nam, khng
gp tr em n.

2. Ch o valve iu o

Chp g ua g gc chiu cn quang c rn tiu. Kt hp vi C- arm s


th c hnh nh niu o tin lit tuyn dn r g, l al e, g
ua g ph i c th c ti tha. C g ua g ph i, niu o d g
vt hp v khng tng xut ht c tiu.

Siu m c th thy 2 thn c.

3. Nu cc loi valve niu o sau bm sinh

C 3 loi theo Hugh- Young:

Loi 1 (90- 95%): l valve tri di t 2 bn i i pha niu o mng


v nhp li vi nhau.

Loi 2: l al e i t i n c bng quang

Loi 3: l mng chn ch cn mt l gia, nm on xa ca ni.


4. T l b trai c valve niu o sau t o gc

% t o gc, 25% b mt bn v 25% b hai bn.

5. Hu qu lu di ca valve niu o sau t o gc

Valve niu o sau l mt nguyn nhn tc nghn gy suy th h g u.


1/3 nh g gi g valve niu o sau cn sng c suy thn.

6. Biu hin lm sng ca mt tr c valve niu o sau

Th g th g gi ta pht hi t c sinh qua du hiu trn siu


m l thn c hai bn v bng quang dn to. Khi sinh ra c th s c
mass bng , c th do cu bng quang, thn c, bng bng hoc c
du hiu suy h hp do thiu sn phi. Nhiu tr c biu hin st lnh run
ca nhim trng niu, c ure huyr cao v ri lo c, in gii.

7. X t a u i vi mt b trai c valve niu o sau

N tho t lu g ua g ng thng niu o, l tng nht l dng


feeding tube 5 Fr hoc 8 Fr. Khng nn d lu ng foley v bong bng ca
Fole khu h hng chn vo l niu qun hoc co cng bng quang v
sau l tc niu qun. Khng sinh ph sinh ph r g g t h ch
lm gim nhi t g hi. iu chnh cn bng kim toan.

8. iu tr valve niu o sau

Ph g ph p iu tr gin nht l lm b hi al e ua g iu o.
X valve v tr 5 gi v 7 gi hoc v tr 12 gi.
Nu niu o qu nh khng th dng resectoscope th c th soi b g i
t b g in cc Bugbee.

Bin ch g thng gp ca t valve l hp niu o xy ra khi dng


resectoscpoe hoc cystoscope qua ln. Kh g t th g h th g
tht ngoi rt thp.

Nu Creatinin vn cn cao, th phi chuy lu c tiu b g i hoc


thn.

9. Cc yu t ti lng tt sau phu thut

Creatinine huyt thanh gi di 1mg/dL mt th g sau khi iu tr, khng


t o gc trn UCR rn tiu, gii hn v-ty ca thn cn r trn siu
m, hoc c hnh nh X quang ca "pop-off valve" (25- 30%).

10. Cc yu t ti lng xu ca bnh valve niu o sau

Biu hin bnh <1 tui

th g sau khi iu tr creatinine khng tr v <1 mg/dl.

T o gc hai bn

V i dm sau 5 tui

11. Ti lng ca tr b valve niu o sau

30% c ch g thn km, 10% s cht v suy thn, 15% suy thn giai
on cui, 5% suy thn mn c th sng bng l u nh k
12. Th no "pop-off valve" nu 3 tinh hung c th gy ra hi tng ny
b trai b valve niu o sau

"Pop-off valve" l hi tng xy ra sau khi tnh trng p lc cao trong


b g i hoc trong th c gii to, lm cho mt hoc hai thn pht
trin tr li h thng. Cc tnh hung c th gy ra hi tng ny (1)
d h g do c tiu thot ra t i thn hoc t 1 ch thng ca
b g i; c tiu t o gc ton b ln 1 bn th t chc
g; t i tha ln b g i, i khi tiu th c tiu tro vo ti
tha nn lm gim p lc thn.

13. iu tr d h g do c tiu

D h g do c tiu trong bnh l valve niu o sau thng do thot


c tiu t mt hoc hai thn hoc do thng bng quang v p lc
cao.iu tr bng m bng quang ra da.

14. Nu gii p ng tiu t c khi sinh c ci thi c thi gian sng c


tr b valve niu o sau hay khng

Cho n nay, c rt t ti liu ni v thi gian sng ca tr sau khi gii p


bng quang ca thai nhi b valve niu o sau cn nm trong t cung.
Ngi ta thit lp mt shunt nh t bng quang vo khoang i gii
quyt tc nghn niu o. Th thut ny l di hng dn ca
siu m. Ch h t o g t ng hp thiu i? g ga tnh trng thiu
sn phi (v nu th t h c i h thng th tr khng b gu
v h hp).

Nu tnh trng thiu i c pht hin mun khi thai > 20 tun, chc chn
s c d sn thn. Nu c lm shunt bng quang- khoang i sau thi im
g kh g phc hi c s pht trin ca thn.??
V quan trng nht khi lm shunt l phi c ch o h h nh
valve niu o sau v hi ch g p u e ell ng c hnh h siu t g
t.

15. Th no l hi chng "full- valve bladder"

cc b trai b valve niu o sau, s pht trin ca bng quang rt bt


thng v b tc nghn nng n di c bng quang. Ngoi ra cn c nhng
khim khuyt kh g c tiu l ho l g c tiu sn xut
ra rt nhiu. Cc bt thng ch g g ua g ao gm: (1) gim
compliance bng quang; (2) nh g o tht khng kim ch c ca
bng quang km theo tnh trng co tht c bng quang (bt ng vn
detrusos- tht ; ph i c bng quang v (4) gi si h s l
ho g ua g kh g o c.

Hi chng ny m t tnh tr g g ua g lu lu y do hu qu ca
mt trong cc yu t u. T h t g l t g p lc trong bng
ua g, t g p lc ca ng tiu trn v lm gim ch g thn (nu p
l t o g g ua g > th c tiu t ng tiu trn khng
xu g g ua g c).

16. iu tr hi ch g h th no

i tiu hai ln, thng tiu sch cch qung v thuc anti cholinergic

17. nhng b trai b valve niu o sau c b hp khc ni bng quang- niu
qun khng

Mt s tr c tnh tr g do t o g u t h y ca bng quang, p


l t o g g ua g t g ao l ho c tiu t ng niu trn
klhng xu g c bng quang gy ra tnh trng hp t g i.
18. Khi no c ch nh m rng bng quang nhng tr c valve niu o sau

Ch h t o g t ng hp bng quang c compliance thp, bt ng vn


nng ho o g ua g t ph t kh g p ng vi iu tr ni
khoa.

Vt liu dng m r g g ua g thng l d dy v d dy s tit ion H+


o c tiu, lm gim tnh trng toan ho (hu qu ca valve niu o
sau . Nh g g th dng rut gi hoc hi trng.

19. Ti lng ca nhng tr valve niu o sau c ghp thn so vi nhng


tr ghp thn do bnh cu thn

Thi gian sng ca m h gh p t g t hau h g ti thi i


sau ghp, creatinine trong huyt thanh ca nhng tr b valve niu o sau
th g ao h do g ua g kh ng dn n hoc khng nh.

20. Th no l valve niu o t c

Khng phi l mt valve tht s, l t ti tha niu o t c,


t o g u t h i tiu ti tha g a y mi sau ca ming ti tha ln
p vo niu o t c.

Tt c t ng hp u xy ra niu o hnh hoc niu o d g


vt. Khm thy c mass dng nang mt di niu o ti ch ni gia
niu o vi u, k h th t g l khi i tiu. o a g th c
tiu nh git ra ngoi.

Ch o da vo chp bng quang cn quang rn tiu

21. iu tr valve niu o t c

Tu thu o k h thc ca ti tha v ch g thn. Nu ti tha nh


th c th ct t mp sau qua ng niu o hoc c th m h. Nu chc
g thn suy gim th phi m g ua g a da, iu chnh cc ri lon
ki toa t , sau i phu thut

86.BNH L NANG THN BM SINH


ThS. Bs Nguy Ho g c

1. Phn bit s khc nhau gia bnh th a a g v


thn nhiu nang

Bnh th a a g l nh l nang bm sinh ca thn.


Cc thnh phn h thng ca thn dn ra thnh
nang. Tri li cc nang ca mt thn nhiu nang khng
phi do s dn ra ca cc yu t ca thn m ton b
thn khng co dn v bao g kh g t ng thnh v cc nang
nhiu k h thc khc nhau.

2. Ti lng ca mt em b c thn nhiu nang hai bn

Dysmal. Thn nhiu nang khng hat ng. Hu qu l kh g c i


trong bung t cung v thiu sn phi thai nhi.

3. Nguy h thng gp nht ca khi u bng tr em

Thn nhiu nang dysplastic. Thn thng do hp khc ni niu


qun- b thn l nguyn nhn th hai.

4. Lm th no ch o c thn nhiu nang

B g siu t c sanh.
5. Cc yu t no c th nhm ln vi thn nhiu nang

Bt c cc bnh thn c nang bm sinh no g th nhm ln vi thn


nhiu a g h g nh l ny rt hi . Th g thng nht cn phn
bt thn nhiu nang vi t ng hp hp khc ni niu qun- b thn nng.

Mun phn bit c th x hnh thn vi DTPA (di ethylene triamine penta
acetic acid) hoc vi MAG3 (mercapto acetyl triglycine. Thn nhiu nang
gim bt cht phng x trong hkhi thn c do hp khc ni niu qun-
b thn d rt nng thn vn cn bt ng v phng x trn x hnh. Trong
mt s t ng hp kh c th m thn ra da qua da chp b thn- niu
qun xui chiu. Cc nang ca mt thn nhiu nang dysplastic khng ni
vi nhau.

T o g khi i thn dn n ca mt thn hp khc ni niu qun- b


thn th c thng ni vi nhau.

6. C cc bt thng niu khoa no kh i k vi thn nhiu nang


dysplastic khng

C. Hp khc ni niu qun - b th t o gc bng quang- niu qun


i b l thng gp nht.

7. Ch nh tuyt i ca phu thut t o g t ng hp thn nhiu nang

Cao huyt p ho k h thc khng l

8. C im phn bit gia bnh th a a g him sc th ln vi thn


a a g him sc th tri
Th a a g him sc th ln Th a a g him sc th
tri

i th Th to h g n cng hnh Thn b xon vn do cc nang


dng ca thn nhiu k h thc khc nhau

Thnh phn ca ng gp Tt c cc thnh phn ca


nephron b dn thnh nephron k c cu thn
nang

C sa g th g T g si h d ng mt cng Nang ca gan, ty, lch v


nh g ua kh vi h a ua h t h ch ca phnh lu mch mu no.

Tui khi pht Thng tr em Thng gi ln

9. Ti lng ca bnh nhn bnh th a a g him sc th ln

T l s g t o g t ng hp th hin b t o g giai o s si h
l 50% v hu h tt c nhng b h h u tin tri n suy thn mn
o giai o t ng thnh (50% l tui dy th). Mt s bnh nhn phi
iu tr t g p t h ch ca. Suy gan khng xy ra.

10. Bnh th a a g him sc th ln c th pht hi ua siu t c


sinh khng

Kho g % t ng hp c th pht hi c.

11. bnh th a a g him sc th tri c biu hin tr em khng

Him khi biu hin tr em. Nu c biu hin tr h hi th t h


trng thn to hoc thiu sn phi. tr l h th c cc triu chng
gi g h nh xxy ra gi ln: tiu mu, nhim trng niu, au h g
l g, ao hu t p, tiu m, thn to, xut huyt no.
12. Kh g ph t hin bnh th a a g him sc th tri qua siu m

Siu m c th pht hin 22% bnh nhn thp ni u ca cuc sng v


66% nh g gi 1 10- 20 tui. Siu t c sanh th kh g ph t
hin rt thp.

13. Ti lng ca bnh th a a g him sc th tri m c biu hin tr


em

Khong 50% cc tr c biu hin lm sng s cht v suy h hp hoc v


nhim trng. Nu bnh biu hin lm sng tr ln th him khi din tin
n suy th t c khi vo la tui t ng thnh.

14. Bnh th a a g do him sc th tri tr e iu tr h th no

T g t h gi ln: iu tr cao huyt p iu tr nhim trng


niu

15. Cch x tr mt t ng hp thn nhiu nang dysplastic pht hin qua siu
t c sinh

Cc kh g chn la l:

Ct b thn hoc theo di.

Nhng lu im bo v cho vic ct b thn l tnh trng cao huyt p v


t h u Wilm's hoc RCC) xy ra nhng bnh nhn c thn nhiu
a g. Tu hi gu nhng bnh ny th rt nh v khng x g g
chu nh g gu a phu thut. Chnh v v gi ta khuyn co
nn theo di bnh nhn b g siu o hu t p nh k . Nu bnh
nhn cao huyt p hoc pht hin thy c khi u thn th phi ct thn.
Mt s gi khuyn nn ct b thn nu thn khng nh i ua theo d i
bng siu m.

87.HI CHNG BU CP
ThS Bs Nguy Ho g c

1. Nu cc nguyn nhn ca hi chng bu cp tr em

Xon thng tinh

Xon mm ph tinh hon

Vim mo tinh, tinh hon

thot v bn

Trn dch tinh mc

Bu tinh hon

2. Lm sng ca xon thng tinh

Xon th g ti h in hnh l dng xon trong tinh mc. tr s si h, ti h


mc khng dnh vo cn Dartos. V vy thng tinh v tinh mc c th xon
cng vi nhau gi l xon thng tinh ngoi tinh mc. Sau vi tun l u sau
sinh tinh mc s dnh vo cn Dartos v tnh trng xon thng tinh ngoi
tinh mc s khng xy ra na.

Bin dng bell- clapper l do s bi i ca tinh mc v tr bm vo tinh


hon. nhng bnh nhn b bin dng ny, tinh hon nm ngang v c
trc d theo hng trc- sau. Bin dng ny lun hai bn.
3. Xon th g ti h iu tr phu thut h th no

Phu thut th s t c ch nh bt c bnh nhn no nghi ng c


xon thng tinh. a s nh g ti h ho c m thm st trong vng 6 gi
sau khi bt u c triu ch g u c th bo t c. Nhng tinh hon
c m sau 24 gi u khng th gi li c. Nu nh l xon tinh
hon th thc hin phu thut h ti h ho o u l hai .

4. Ch o on mm ph tinh hon

C du hiu mt im mu xanh nm cc trn tinh hon khi nhn vo da


bu. Nu khng c du hiu ny vn c th nghi ng n xon mm ph
ti h ho khi u au khu t mt nhn cng cc trn v khng c cc
du hiu gi n xon thng tinh. iu tr bng khng vim khng c
corticoid trong 1- 2 tun.

5. Xt nghim cn lm sng ch yu trong hi chng bu cp.

T g ph t h c tiu: nu tiu m th gi n vim mo tinh- tinh


hon.

6. Cn lm sng no c th phn bit c xon thng tinh vi cc nguyn


nhn khc ca hi chng bu cp

X hnh tinh hon: Nu xon thng tinh th gim bt phng x. Tri li nu


c vim mo tinh- ti h ho th t g d g u t g t phng
x. Kt qu d g t h gi khi c p xe ho i k i hydrocele. m
tnh gi khi u t g hit hoc nh g t ng hp xo l u g
p ng vim.

Siu m Doppler: nu xon th g ti h th kh g d g u n tinh


hon.
7. b trai c vim mo tinh- tinh hon cn lm xt nghim g

Siu m thn bi v niu qun lc ch cm vo cc cu trc ca ng Wolff


(ti tinh hoc ng phng tinh) v biu hin lm sng l vim mo tinh- tinh
hon. Trn siu m nu thn, niu qun lc ch s c tnh trng thn v
niu qun c.

8. mt tr c hi chng bu cp sau khi ch th g h vo bu th phi


gh n chuyn g

Xut huyt t o g u tinh hon.

88.D TT BM SINH NIU SINH DC

PGS TS BS. Ph V B i

I. THN - NIU QUN

I.1.Thn v Niu qu i

Mt hoc c hai bn.

Theo nh lut WEIGERT - MEYER.

C ba bin chng quan trng:

a/- Niu qun lc ch:

b/- T o gc dng (Reflux):

c/- Nang Niu qun:


I.2. Bt thng v v tr Thn

a/- Thn xoay

b/- Thn dnh nhau

Thn hnh mng nga (HORSESHOE KIDNEY):

Thn lc ch cho (CROSSED RENAL ECTOPIA):

Thn vng chu:

Thn trong lng ngc:

I.3.Bt thng v s pht trin ca Thn:

ng WOLFF khng pht trin: thn v sinh (AGENESIS).

Khng c Thn, niu qun

Na vng tam gic B g i kh g ti tinh, ng dn tinh cng bn

Thn lon sn (DISPLASISA) hay bt sn (A PLASIA) cu trc ging Thn hoc


mt t chc khc l vng h l g. T o g hai t ng hp Niu qun
u km pht trin.

I.4. Bt thng v nang:

a/- Th a a g (POLYCYSTIC KIDNEY):

B h di truyn theo kiu tri

Nang tht ln

Kh g u

b/-Bnh xp ty Thn (MEDULLARY SPONGE KIDNEY):

ng thu thp b dn rng v g c tiu gip cho s hnh thnh si v


nhim trng,
Nu bnh ch gii hn mt phn ca Thn? c th iu tr bng cch
ct b mt phn Thn

Nu b c hai bn s tin trin s gy suy Thn.

Tiu ng do Thn, tiu Phophate, tiu A id A i es, i th o ht do


Thn hoc toan ho mu do bm sinh ng Thn.

II. BNG I

1.B g i v si h:

Rt him.

2. B g i h i:

3. Tn ti ng cung rn (PATENT URACHUS)

Bt kn hon ton -----> cung rn

Bt kn khng hon ton

o M trn: draining umbilical sinus -----> nhim trng -----> m

o M di -----> thng ni b g i kh g t iu chng

o M gia ----->nang nhim trng.

----->ha c.

Khng bt kn rn -----> d c tiu rn

4. B g i l thin (EXTROPHY)

L d tt gy ra do thiu hon ton mt bng ca xoang Niu sinh dc v


thiu c h th g he ph mt t c B g i do phn trung tm
vng h v c thay th bng mt trong ca thnh sau B g i dnh
lin vi vi da u g ua h, c tiu t hai l Niu qun phun lin tc ln
mt thnh bng. Trong d vt , hai h sau g u g h a
nhau lm khung chu mt vng ch hai g i oa go i khi a
d g i gi g h t. Do hai thng bng gn vo hai cnh sau
g u cch xa nhau nn chng cch ri nhau v to nn mt ti thot
v gm B g i l thin bc quanh bng lp da v lun c l Niu o
g gn mt l g d g t phi hp.

Thn s d b nhi t g h g c do hp khc ni Niu qun -


B g i. Niu mc h g d b kch thch lin tc v nhim trng dn dn
c th b d s g u g th t bo vy hay tuyn.

Ngoi ra n cn phi hp vi sa trc trng v Tinh hon n hai bn.

S iu tr tn g thng kh, kt qu khng tt nht l phi nam.

III. NIU O - TINH HON

1. Hypospadias:

L mt d vt gy gp o g d g t v pha mt b g d g t, ming
Niu o m ra mt b g d g t thay v ui u, th h ra
tng sinh mn hay bu. Khi ming Niu o nm hai v tr ny, bu thng
ch i t g gi g h hai i ln ca m h. T ng hp n g d g
vt c th nh gi g h t b ph i.

iu tr gm sa th g d g t v to hnh Niu o.

2. Van Niu o sau:

Trong d vt ny cn tn ti np xp nim mc nm trn sn Niu o Tin


Lit Tuy . l gu h th ?g gp nht gy b tc Niu o bm
sinh b trai. Do b tc, Niu o Tin Lit Tuyn s dn rng ra, thnh v
tam gic B g i ph i, din bin tip theo l b tc hai Niu qun ni
th h g h g c Niu qun - b - i Thn. giai on tin trin
h t o gc dng B g i - Niu qun v nhim trng ri suy Thn
h in c th xy ra.

Tiu kh tia c tiu yu l nhng triu chng chnh, c th c khi cu


B g i do tiu mn tnh. Khi c nhim trng s gy tiu nhiu ln tiu
but i dm. giai on mun, khi c suy Thn b s h st cn
thiu mu.

Chp hnh c cn quang B g i, Niu o khi i tiu s thy Niu o


Tin Lit Tuyn dn rng vi mt g e t g ng vi v tr ca van. Soi
Niu o, B g i th thy chnh xc v tr van vi cc bin chng ca
n trn B g i h t hm ti tha ph i tam gic B g i. D tt
d km theo ri lon bm sinh th ki h B g i.

Ti lng tu thuc vo s h hng ca a i vi ng tiu t , a


s bnh ch c ch o u khi in chng suy Thn.

3.Tinh hon n hay lc ch:

a/- Tinh hon n: tinh hon nm v t o dc theo ng bn thay v phi


xung nm v t h thng trong bu.

B/- Tinh hon lc ch: tinh hon nm ngoi v tr ng b g kh g m


t o g u, i thng gp l: vng bn nng, t g si h , i, g d g
vt.....

Nguyn nhn ca d tt ny khng r c th do bt thng ca Gubenaculum, do


Tinh hon kh g p ng vi kch t hng dc hoc do gim bi tit kch t
hng dc.

Cc t bo sinh tinh, ngoi tr t bo Leydig rt nhy vi thn nhit v bu


e h l ua iu ho nhit ca Tinh hon gip gi nhit
ca vng ny khong 340c , l nhit ti ho nht cho s sinh tinh. Khi
Tinh hon ngai v tr ny nhit th s hu hoi hi tng sinh tinh
do g si h u b c hai bn.
Triu ch g l s g in hnh nht l s khng thy Tinh hon trong
mt hoc hai bn ca u, g da u t g ng vi bn Tinh hon n, b
teo. i khi c th s thy Tinh hon nm trong hoc ngoi ng b h g
khng th a o t o g u.

Cn phn bit vi Ti h ho di ng (Retractile or Nigratory Testis): Tinh


hon c th ch di ng t trong ng bn ti bu. Khi thi tit lnh chng
hn, Tinh hon s b co rt vo trong ng bn. Trong d vt ny, vng da bu
h thng v khi s thy Tinh hon c th a t v v tr bnh
thng trong bu.

Tinh hon n c th phi hp vi thot v bn b xon thng tinh hoc nguy


him nht l u g th ho .

iu tr chnh l phu thut a Ti h ho t v v tr bu cng sm


cng tt di hai tui).

89.HP KHC NI B THN NIU QUN


ThS. BS. L Anh Tun
I. C n:

1. M t:

Hp khc ni b thn - niu qun (Ureteropelvic Junction Obstruction -


UPJ) l s cn tr d g c tiu t b thn xung niu qu on gn.

Hp khc ni b thn - niu qun l nguyn nhn ph bin nht i vi


bnh l tc nghn tr em.

Tn sut hay gp nht vo khong 5 tui.


T 30-50% tr b hp khc ni b thn - niu qun ngy nay c th c
ch o t c sanh.

gi ln tui th g c ch o 30-40 tui.

2. Sinh l bnh hc:

Bm sinh: chim hu ht cc nguyn nhn

Mt on niu qun hot ng: chim 55% trong bnh l hp khc ni b


thn - niu qun tr em.

Hp thc th: chim 25- % th g i k i hp ch g.

Van niu qun: nguyn nhn him gp.

Mch mu ph c di: chim 10- 33% tr em v > 50% gi ln.

Gn cht to s xon v dnh nhiu.

Mc phi:

T o gc bng quang niu qun (VUR) chim 15% tr em c hp khc


ni.

Vim nhim to so to hp: ch th g, a g gi niu nhi t g,


ha sau phc mc.

Th g tn do th thut: to hnh b thn tht bi, th g tn do soi niu


qun.

Khi U c tnh: carcinoma t bo chuyn tip (TCCa), cacinoma t bo gai


(SCCa), b h l di .

U lnh tnh: polyps biu h a, U t u g .

3. Yu t gu :

Gii: T l nam: n l 2:1, khu h h g gia h.


B u th: Hp khc ni b thn - niu qun hai bn chim t 10- 30%
tr s si h. B tri nhiu h phi hai ln.

Bt thng bm sinh: 50% bnh nhn c bt thng v h tit niu sinh


d i k .

T o gc bng quang niu qu VUR i k t 0,5- 5%.

Thn hnh mng nga km 15%.

Thn lc ch chim 35% km hp khc ni b thn - niu qun.

II. Ch o ph it:

Dn do tc nghn:

Si niu qun b khm.

Cun nm (fungal balls)

Nh gai hoi t (sloughed papilla)

Sa g th g t o g l g iu qun: u tn sinh.

Dn khng tc nghn:

T o gc bng quang niu qun .

Hi chng prune-belly

Nang thn hoc quanh thn.

III. D liu:

1. Bnh s:

au h g l g mt : au h lu ngy ho au un, chi, cp tnh


v nng (75% gi ln, 50% tr em)

Thn c tng hi C Dietls : au h hi km vi bun nn v nn


do hp khc ni b thn - niu qun khi ung nhiu c hay dng li tiu.
Km vi triu ch g ng tiu ha (5% gi ln, 10- 40% tr em)

au g h: thng quanh rn.

Bun nn v nn

Tiu u i th ( 20% i ln v 5- 10% tr em)

Si b thn (20% gi ln 5% tr em)

Nhim trng tiu (15% gi ln, 45% tr em)

Suy thn (5% gi ln)

2. Khm thc th:

au g s g sn (ph bin gi l h t em)

S thy mt khi l g hoc bng ( hu ht tr s si h t em)

St hoc yu t ( ch yu s si h h hi

Cao huyt p ( th ph t do au kch hot h thng renin angiotensine)

IV. Xt nghim ch o :

1. Xt nghim:

T g ph t h c tiu

Tiu mu vi th (t khi tiu u i th)

t o g c tiu: vt

Tiu m v tiu bch cu ( nhim trng tiu a g hot ng)

Creatinine mu

C th t g bnh nhn b hai bn.

2. V hnh nh hc:
Niu k g t h ch (IVP, UIV): Thng dng nht cho vic chn
o tr e g h gi ln.

Thn bi tit thuc chm.

Thn cm

Khng th c niu qun hoc thy ch hp v tr khc ni b thn -


niu qun

V thn mng

X k th ng ( Dynamic renal scintigraphy) : cung cp s khc bit v


ch g tc nghn thn.

Thng s dng Tc-mm MAG 3

Chu k bn h h thng < 15 pht

T 15- 20 pht: nghi ng

H ph t: tc nghn

Siu m thn: Hu ch trong ch o t khi thn v hnh nh dn


niu qun khc bit ho n khc ni i tc nghn. Hu ht siu c dng
kho s t i tr trn cc tr.

3. Xt nghim chuyn bit:

+ Ni soi bng quang v chp b th gc dng

X nh chiu di ca niu qun b h hng

t ste t JJ gii p tm thi s tc nghn

Vi hnh nh hp Khc ni b thn - niu qun


+ o p lc trong thn

Thc hin qua da, thu i t / i dng c o p


lc trong lc truyn.
B h thng < 15 cm/H2O; nghi ng 15- 22 cm/H2O; c tc nghn >22
cm/H2O.

+ CT Scanner xon c: cho php ti to hnh nh 3 chiu ca h thng bi tit


g h ch mu th t o g t ng hp ng mch thn bt cho. Hin
din mch mu bt cho c th t g in chng khi phu thut to hnh b thn.
To hnh v tr thp th th h g ao h .

V. iu tr a u:

Bo tn ch g th : c bit nhng bnh nhn b hai bn hoc bnh


nhn c ch g thn cn li km hoc mt ch g:

+ M thn ra da/ ho t stent double J niu qun

Gii quyt cc triu chng nng: D lu thn ra da tm thi/ t thng


dou le J t c khi quyt h iu tr.

iu tr thn m nu c: C c tiu kh g si h ho t double J


vi s chc ch l d lu.

iu tr bo t : Ngi ln khng triu chng trn th i bn, khng du


hiu e da sinh mng. Hay thn c tr s si h: Tc ngh thng
km vi thn c mt bn t khong 15% v hu ht khng c iu
tr.

iu tr phu thut:

+ M h: l ph g ph p c ch i vi la tui hi ng b g h i
ng b g l g.

+ Ct to hnh b thn ( Anderson Hynes): hu ht cc ca m m t l thnh


cng > 90%, thch hp ho t ng hp ch xut pht cao, cc mch mu ph,
hay b thn dn do mt khi chn p, hoc niu qun di. Loi b vng bt
thng v gii phu v ch g.

+ Phu thut Y foley: thch hp nht cho cc hp khc ni b thn xut pht cao.
+ X dc hay cho thch hp cho cc hp khc ni b thn - niu qun c km b
thn dn ngoi thn v hp niu qu on gn mt khong di.

+ M thng niu qu v i thn trong t ng hp c gn bo tn hoc tht bi


trong to hnh b thn ho t o g t ng hp hp khc ni b thn - niu qun
km th oa thng vic ct b phn c di thn l cn thit.

+ Ct thn: c th thc hin khi thn bnh mt ch g thn cn li chc


g tt.

Ch nh ct thn khi ch g thn gi di 10- 15%, bnh l si lan rng v/


hoc m t h, phu thut nhiu ln tht bi v ch g thn c du hiu
mt ch g. Ni soi iu tr: L ph g ph p c chn gi ln cho
d hp khc ni b thn - niu qun nguyn pht hay th pht.

+ M thn qua ni soi: ct lnh xui dng bng dao. T l thnh cng khong
80% cho c hp khc ni b thn - niu qun nguyn pht v th ph t. i hi
phi i g ng qua da. ng m thn ra da c t t 24- 48 gi, v double J
cn gi t 4- 8 tu . Ph g ph p th h p co nhng hp khc ni b thn -
niu qun c chiu d i on hp < 2 cm. N cn thch hp cho cc hp khc ni
b thn - niu qun c km si thn v tr em b hp khc ni b thn - niu
qun th pht.

+ M thn qua ni soi gc dng vi do rch c bng (cutting balloon


catheter) Acucise). T l thnh cng khong 80% cho c nguyn v th pht. ng
th g a g dao t qua ng bng quang, vic m th hc dn
ca mn hu h ua g. Ste t dou le J c ly ra t 4- 8 tu . Ph g ph p
thch hp nht cho hp khc ni b thn - niu qun nguyn v th pht. Thn
c t nh n trung bnh v chiu d i on hp < 2cm. ng dng v tr em
hn ch do thngc s hin din ca cc mch mu bt h o iu l t g
gu in chng v lm gim t l thnh cng. th thut ny di hi phi c
thit b chuyn dng qua ni so v nh ni soi niu y kinh nghim. Cho php
nhn trc tip khi rch i ua da. t l thnh cng trn mt lng bnh nhn t
t 85- 90%, Stent c t trong 6 tun.
+ Nong ch hp khc ni b thn - niu qun bng bng: B g t qua
mt dy d n ngay ch hp b g g gc hay xui dng. Khc ni b x
v a khi g l i p l ao t k h thc khong 24- F di
hng dn ca mn hu nh quang. Stent niu qu t t n 8 tun. T
l th h g t khong 70- 80%, ch yu dng cho cc hp khc ni th phc
c chiu d i di 2 cm. Ph g ph p kh g c p dng cho b tc hon
ton khc ni. Vi t stent hay m th a da c dng cho nhng bnh nhn
khng c ch nh m. dou le J tha nh k mi 8- 12 tu . iu ny
l t g gu him trng, hnh thnh si, gy t th g thn.

+ To hnh b thn qua ni soi bng: i phi ph g tin v k thut


chuyn bit. ng chn c th sau phc mc hay qua ng bng. K thut: Phu
tht Y-V; thun li: gi au n sau m, thi gian hi phc nhanh ci thi c
khong cch gia nh phu thut v nh thm m. T l thnh cng > 90% ( gii
hn trong l nghin cu).

VI. Theo di:

1. iu tr bo tn: Hp khc ni b thn - niu qun tr s si h: Siu


thn x hnh th ng sau 1 thng, theo di vo thi im 3- 6 thng. Phu thut
can thip nu cn: khi c triu chng, ch g thn gim > 10% v tnh trng
c thn cng t h .

2. iu tr phu thut: Chp niu k ni t h ch ( IVP) hoc x hnh thn


ng sau m 6 tun v 3 thng. c 91% c ci thin trn x hnh th ng thi
im 6 v 12 thng. S ci thin gi ln trn 30 tui x hnh th ng th
him. chp IVP thng thy thn bt c v thn b u tit thuc. Chp IVP
v x hnh th g c lm mi h gi ic m b thn: 10-
13% tht bi mun.
CHNG 6. NGOI TIT NIU

90.GII PHU SINH L THN

1. Gi phu thn.

1.1. K h thc v v tr.

Thn tri Thn phi

K h thc - giy 3cm, ngang 6cm, cao 12cm. Nng 150gam.

Rn th i - Ngang mc mn v cch - Cao h t cht


chiu ln thnh ng trng gia 4cm.
b g t c

Rn th i - Ngang mc mm - Cao h t cht


chiu ln thnh ngang t LI, hay giao gia
bng sau. khi dng gai v b di
sn XII.

u trn. - B t g sn XI. - B di g sn XI.

u di. - C h im cao nht mo - C h im cao nht mo


chu 3cm. chu 5cm.

1.2. Mc thn.

- Gm 2 l:

+ L sau ho vo m tht l g o th t sng.


+ L t i t c b mch th MC i lin tip vi l t c th i din.
Do l t c dnh vo cung thn v t chc lin kt quanh mch mu rn thn
nn hai thn khng thng ni vi nhau.

- Mc th g h i ao a thn bi mt lp m gi l lp m
quanh thn.

1.3. Lin quan.

Thn phi Thn tri

Ph a t c - u trn: tuy thng - u trn: tuy thng


thn. thn.

- B trong: t trng, TMC. - Mt sau d d , u i ty,


l h, g i t g t i i
- Mt t i trng ln,
trng xung, rut.
gan, rut

Pha sau. X g sn XII chia lm 2 tng:

- Tng ngc trn: lin quan ch yu vi g sn XI,


XII, ho h, g sn honh ca mng phi.

- Tng tht l g di: lin quan v cc khi l g.

Pha trong. - C tht l g phn bng ca thn kinh giao cm.

- B mch tuy thng thn, b mch thn, phn trn


niu qu , t h ch ch di bn phi MC ng bn
phi.

1.4. ng mch.

- Tch ra t MC b g di M t eo t g t , i chiu ln ct sng:


nguyn u khong ngang thn LI.
- Khi phu thut ly si b th thng rch pha sau v ph sau t cc nhnh
M.

- Gia cc vng phn b ca h h M th t c v sau c mt vng rt


t mch mu chi phi gi l ng Hyrtl l mt ng cong cch b ngoi v pha
sau 1cm thng r h theo g ly si.

2. Niu qun.

- g k h khi g, d i t u g h hia l o : on
b g on chu hng.

- Niu qun c 3 ch hp: ch ni b thn niu qun, ch bt h o M hu,


i i o th h g ua g.

- Niu qu on b g: i t b thn ti g u g g hu

+ Pha sau lin quan vi tht l g ga g t sng tht l g ui: bt


h o M hu v t h ng trng gia 4 , M chu chung phn chia
ngang mc gc nh cch gc nh 3.5cm bn phi v 4.5cm bn tri. Mun tm
niu qun tm ch bt h o M t g h ha ng trng gia khong
4.5cm.

+ Ph a t c niu qu c phc mc che ph, M ti h ho ha M ung


trng bt h o ph a t c.

+ trong niu qu li ua TMC di bn tri v vi MC ng bn phi.

- Niu qun chu hng: t u g g hu ti bng quang. Niu qu on


i h MC t o g ri ch h a go i a sau theo ng cong ca thnh
bn chu ti nn chu ch gai ngi niu qu g a t o t o g ti bng
quang.

3. Sinh ly thn.

3.1. thn.
- L nephron gm c tiu cu thn v tiu qun (OLX, OLG, Henle, OG).

- V ch g eph o hia a l : eph o chim 70% thin v ch g


bi sut, nephron tu 30% thin v ch g hp thu.

- Th g thng ch 25% s nephron hot g l m bo cho ch g a


th.

3.2. B my cn tiu cu.

Gm phn OLX tip gip vi M M i a tiu cu thn v mt phn ca


tiu cu. Cu trc ny ch yu nm nephron v, gm cc loi t bo sau:

- T bo macula densa: t bo ca OLX va l TB nhn cm va l TB ch tit.

- T bo cn tiu cu (t bo c ht c nhiu M n) trong TB c cha nhiu


rennin khng hot ng.

- T bo lacis: nm ri rc c tnh thc bo.

3.3. H mch mu.

- M i hia th h h mao mch bao quanh tiu qun lm nhim v ti hp


thu.

- 80 90% mu cung cp cho vng v, mt khc cc t bo vng v khng c


kh g hu n ho y kh lu lng tun hon gim thiu O2 th vng v
d b RLCN h g tu.

3.4. Qui trnh to th h c tiu.

1. Qu trnh siu lc: do 2 yu t chi phi l mng siu lc v p lc lc.

- Mng siu lc gm 3 lp: t bo ni m, mng nn c cc l t h in m, lp


TB biu m bao Bowman.
- p lc lc l tng hp ca cc p lc sau:

+ p lc mu mao mch cun mch (GP glomerula p essu e h thng:


60mmHg.

+ p lc keo huyt t g ao ch cun mch ( GCP glomerular colloid


osmotic pressure): 32mmHg.

+ p lc trong khoang Bowman (CP capsular pressure): 18mmHg.

FP = GP (GCP + CP) = 10mmHg.

Mun c dch siu lc FP phi l h . Tng s lng dch siu lc 170


180l/24h.

- Nhng yu t h h g n qu trnh siu lc:

+ C h t iu ho mc lc cu thn ca b my cn tiu cu: Khi lu lng


cu thn gim s t g t i hp thu Na+, Cl nhnh ln quai Henle, khi t bo
nhn cm Macula densa OLX s nh c s gim n g Na+, Cl n s kch
th h l gi M n v kch thch t bo cn tiu cu tit rennin m kt qu l
l o M i, s l t g c lc cu thn.

+ C h iu ho ca h thn kinh giao cm: c cc th th t th h M


th cm vi cht trung gian ho hc ca h giao cm, khi h th ki h giao h g
phn hay c ch s l tha i lu lng tun hon qua thn.

+ S bi i p lc lc khi c s bi i ca HA ng mch, p lc keo ca


huyt t g p lc trong bao.

+ S bi i cu trc mng siu lc.

2. Qu trnh ti hp thu: theo h vn chuyn tch cc v khuych tn theo


o ng: ng thn -> dch gian bo -> ao t h ch ng thn.

- Ti hp thu OLG: khong 80% cc cht c hp thu , y khi vo


uai He le c tiu v g t g.
+ Ti hp thu Glu ose: theo h vn chuyn tch cc ph thuc n g
glucose trong mu.

+ Ti hp thu HCO3-: theo h vn chuyn tch c li ua n


cacbonanhydrase (CA).

+ Ti hp thu protein v aa: hp thu hon ton OLG theo h m bo.

+ Ti hp thu: Na+ khuych tn, K+ theo h vn chuyn tch cc, Cl theo


gradien n g .

+ Ti hp thu c: theo cc cht c p lc thm thu ao c hp thu: Na,


K, Cl

+ Ti hp thu u e: do c ti hp thu lm n g ure trong ng thn cao


h g trong d h gia o c ti hp thu theo h khuych
tn theo gradient n g .

- Ti hp thu uai He le: %Na, % c.

+ Dch gian bo quanh quai Henle rt u t g t khc nhnh xu g on


u nhnh nn m g t h thm cao vi u e, h g kh g ho Na+
i ua

+ Ti h h l uai He le d h dch trong quai rt u t g Na+ c vn


chuyn tch cc , v th ti OLX c tiu h t g.

- Ti hp thu OLX: ph thuc vo 2 yu t n l nhu cu ca th v


cht l g c tiu ua .

+ Ti hp thu c nh ADH nh h ch ng. ADH thng qua AMP vng


hot ha ezym hyaluronidase trong phn ng thu ph a id h alu o i m
rng l mng trong qu trnh vn chuy c.

+ Ti hp thu Na+: theo h khuych tn c cht mang v vn chuyn tch cc


g g h aldosterol: hormone tuyn v thng thn
hormone ny kch thch t bo g ln tng hp protein thng qua hot ho h
gen: protein ny l protein ti v protein enzym tham gia vo vn chuyn tch cc
Na+.

+ Ti hp thu HCO3-: th g h OLG.

3. Qu trnh bi tit tch cc.

- Bi tit H+: do t bo ng thn thc hin. S bi tit ph thuc n g CO2


mu.

- Bi tit NH3: do t bo ng thn to at ha gia o u t h o thi H+.

- Bi tit K+ OLX nh tc dng ca aldoste ol t s cht khc.

3.5. Th iu ho cn bng kim toan mu.

1. Bi tit H+: theo h khuych tn v ch yu l vn chuyn tch cc: ti t


bo ng thn CO2 + H2O - > H2CO3 di xc tc ca CA. Sau H2CO3 phn ly
thnh H+ v HCO3-. H+ c vn chuyn tch cc qua mng t bo c s t ao i
vi Na+. Ti ng thn H+ tc dng vi h th g m ca phosphate v acid hu
yu o thi ra ngoi. Cn NaHCO3 vo dch gian bo v vo lng mch.

2. Ti hpthu HCO3-: khuych tn mt phn v ch yu theo h vn chuyn


tch cc khng phi trc tip m thng qua CO2: trong lng g ln HCO3- + H+ -
>H2CO3 ->H2O + CO2. CO2 khuych tn vo t bo ng thn x a u t h h
phn 1. HCO3- c to ra hp thu vo dch gian bo v vo mu.

3. Tng hp v bi tit NH3: do t bo ng thn tng hp ch yu t glutamine -


> NH3 to a c khuych tn vo lng ng th . l h quan tr g o
thi H+, thng qua to ra NH3.

3.6. Th iu ho cc yu t khc.
Th iu ho cn b g in gii h h l iu ho cn bng th tch - p
sut thm thu dch ngoi bo. Cc qu trnh siu lc, ti hp thu, bi tit tch cc
l th hin s iu ho g in gii ca thn.

1. iu ho cn b g in gii.

- Ion Na+: chim 90% ion dch ngoi bo quyt nh p sut thm thu dch
ngoi bo.

+ OLG: 60 % c hp thu ch yu l vn chuyn tch cc, mt phn khuych


t

+ He le: t i h p thu theo h vn chuyn tch cc phn ln.

+ OLX: t i h p thu gc gradient n g di tc dng ca aldosterol v


mi thc s a g gha iu ho - v s hp thu theo nhu cu th theo
ch phn x thn kinh th dch - h h g n s bi tit aldosterol.

- K+: c hp thu g h ho to OLG thng qua qu trnh vn chuyn


tch cc nh cu trc nm ph a g h a OLG. Bi tit tch cc
+
OLX, n quyt nh n g K dch ngoi bo, s iu ho thng qua Aldosterol.

- Ca++, Mg++: li ua n hp thu rut o thi thn. Ti thn c qu


trnh ti hp thu v bi tit ph thuc vo n g cc ion ny trong mu. PTH
hormone c gi p l t g o thi Ca++, Calcitonin hormone gip lm gi o
thi Ca++.

- Cl: li ua n tc dng hp thu ca Na+.

2. iu ho cn b g c.

- OLG 80%, Henle 5%: ph thuc vo s ti hp thu cc cht c p lc thm


thu cao.

- OLX 15%: ph thuc vo ADH tit theo h phn x thn kinh th dch, n
gi vai tr rt quan tr g t o g iu ho cn b g li ua n th tch
dch ngoi bo
3. iu ho HA:HA gim hot ha h thng RAA: Angiotensin II gy co mch,
Aldosterol t g t i hp thu Na+ hai yu t t l t g HA.

4. iu ho sinh sn hng cu: khi lng O2 mu gim kch thch thn to ra


erythrogenin l enzyme xc tc to erythropoietin t 1 glubolin do gan tng hp.
E th opoieti t ng ln t g si h tin gu HC t ng chuyn
ha h HC o tha h HC t ng thnh vo mu

5. iu ho qa trnh ch g g: sn xut ra Urokinase hu fibrin lm tan cc


u g.

4. iu ho ch g thn.

- Phn x thn kinh th dch:

+ Phn x th th thm thu:Cc th th: ngoi vi nm khp cc m lin kt,


thnh mch. t u g g m g di i. Khi p lc thm thu t g
th th b k h th h t g tit ADH, k h th h t u g khu di h dng gy cm
gic kht, khi p lc thm thu gim cc th th ny b c ch gy gim tit ADH
v mt cm gic kht.

+ Phn x th th th tch:

Cc th th nm thnh mch phi, th , oa g M h c bit thnh


t h t i. C th th b kch thch khi V dch ngoi bo gim kch thch vng
di i gii phng CRH hormone ny kch thch tuyn yn tit ACTH -> kch thch
tuy thng thn tit aldoste ol l t g t i hp thu Na, khi Na+ u t g li
kch thch tit ADH.

Lu lng tun hon gim kch thc h RAA.

Thiu O2 knh vn chuyn Na, K b ri lon d t g K dch ngoi og t g


tit aldoste ol h gp trong suy tim)

Lu lng tun hon qua th t g th p lc l t g l t g l g c tiu


gc li.

- Phn x thn kinh:


+ Nu kch thch vo mt s vng ca v no c th lm t g ha gi lng
c tiu.

+ H thn kinh thc vt c th l t g ha gi l g c tiu.

5. Mt s nghi ph p th d h g thn.

- o gi tip:

+ T h l g o thi ca mt cht t o g c tiu 24 gi: n ph thuc vo ch


, chuy ho , g hot g p.

+ Th d gi tip b g h o g h gt o g u: h h h .

+ o t tr g c tiu:

Nu ng t trng cao: l gim ch g u thn trong khi ch g c


ca ng thn v h thng gp trong vim cu thn cp hay mn tnh.

Nu ng t trng thp: suy gim kh g c tiu. T o g thn vim


cu thn mn.

- o t c tip:

+ o t lc cu th : l lu l g c tnh b g l/ph t c cu thn lc


xang ng thn..

+ o h s thanh lc ca mt cht: l th tch huyt t g l c thn lc


sch cht t o g t pht.

p dng: t ng hp th g thng ch c th d gi tip, khi kh g nh


c suy thn mo c th d t c tip nh h gi su giai o
p dng ch iu tr

91.CHUN B BN TRC M V CHM SC SAU M


TIT NIU
1. Chun b BN t c m. c tin hnh khi c ch o nh v c ch
nh m.

1. Bc s phi lm g:

- Cho lm cc XN cn thit v khm xt ton din tt c mi ua lin quan


phc v cho PT.

- S kt t c m:

+ Cc tiu chu ch o .

+ BN cn PT th PT dng no, cn lm g.

+ Ti lng cuc phu thut, d ki kh kh . D ki ph g ph p m.

- Tip xc vi gi nh v BN gii thch tnh trng phi phu thut v cuc PT


c thun li kh kh g , u u BN gia h l i .

- T c ngy m BS kim tra ton b h s th tc bn giao li cho PTV.

- PTV nghin cu ton b h s nh n, tip xc nm li t tng BN d kin


ph g ph p PT, kh kh h khc phc, nu tha i chin thut theo d kin
thng qua m cn bo li ch nhim khoa v bo co ln th t ng cao nht xin
m nu ng y mi tin hnh can thip.

2. Y t phi lm g:

- Thc hin cc mnh lnh ca BS v a BN i l XN, i kh hu


khoa cn thit phc v phu thut, c kt qu phi dn vo BA bo co BS.

- Theo di tnh tr g ung din bin tm ly ca BN nu c bt thng phi


o o BS. c hoc cng BN lm cng tc v si h t c m:

+ Vi BN phu thut bng tit niu cn v sinh s h ua SD t c m, v sinh


g t g g t c hm phu thut.

+ Tht th o ho BN g t c m.
- Ly M, T, HA ghi vo BA sng hm m v nhn BN nh ui sng hm
phu thut.

2. Ch s BN sau tit niu.

Thc cht l theo di phng cc bin chng, pht hin cc bin chng kp thi
th i s tr hp ly.

1. Bin chng do thuc v c ph g ph p m: trong tit niu l gy t


ty sng.

- Tt huyt p:

+ Nguyn nhn: do c ch giao c , l ng giao c t g i gy tt HA.

+ S t : ti Ephed i l ng giao cm ln, cho th O2.

- Nhim khun: vim mng no tu, vim tu ngang, vim tu leo. Cn khm
v ng cm gic sau m ca BN di vng gy t, cn khai thc sau bao lu BN
phc hi v ng v cm gic.

- Sc tu: l bin chng nng nht do a u liu thuc vo tu, cn theo di


M, T, HA nhp th c bin php s tr.

2. Bin chng ca PT.

Bin chng sm:

- Chy mu.

Thnh bng H thn Thn


Pht Thng qua Thng qua d lu h thn Thng qua d lu
hin dch thm quan st mu sc s lng ctiu ca b thn v
g, t h dch, nu m dn hoc d lu g ua g. Nu
trng vt m mu chy ra mi g l mu s thy thn to. BN
g chy mu. Nu mu khng au tc d di vng thn.
khng. thot qua d lu th thy
h th g g, BN au
tc, triu chng mt mu.

S tr Nh g Khi pht hin bt buc phi iu tr bo tn ti a: Bt


p. phu thut li kim tra ng, dng thuc cm
mch mu v khu buc li u, t g ng truyn
Nu ko cm
v chy mu trong h thn dch nu cn c th truyn
mu cn ct
khng bao gi t cm, s mu theo di st. Nu d
ch tc vt
lng mu thng ln c kin ko di khng nh
m kp khu
th gy t vong. mi quyt nh PT v nu
cm mu.
PT kh g t thn ln.

- Nhim khun:

Thnh bng H thn Trong nhu m thn

Pht - C g: au tc D h c theo d lu Theo d i ua c


hin vng vt m. h thn ra ngoi. khi tiu, thng tiu, xt
m quanh thn c nghi c tiu.
- Thy s g ty vt
biu hin st cao rt
m, biu hin vim, c
run, b g hng nhu
th chy dch m, st.
ng rut gim, thy
h th g g, c
th tha i mu sc
trn.
S tr Khi nghi ng NK cn Khi pht hin cn tc Khng sinh liu cao,
ct ch tha t h t vt m a sch. li tiu, truyn dch,
m, a sch vt gi t , t g
m. ng ch
ung.

- Suy thn:

+ Nu c m si 2 bn, bt t ng dn niu, hoc mt thn mt ch g,


khi t th g / thn.

+ Theo d i u tin cn xem BN c nn khng, st kh g, l g c tiu vo v


ra, ki t a ALTMTW e ha.

+ S t h iu tr suy thn cp: li tiu, gi t , kh g si h

Bin chng mun

- R thn.

Nguyn nhn S tr

Mu cc gy tc niu qun. Mu cc ph mu cc.

Vim tc niu qun b thn gy cht hp C gu h kh t sonde JJ =


Dou le J, t 1 th g sau t
Dy chng lm cht hp b thn niu
tip tc s tr cc nguyn nhn: nu do
qun.
si iu tr si, nu do NK m ct bn
Khu b thn niu qun b cht hp phn hoc ct ton b thn

Mt s t ng hp do st si.

Nhim khun hoi t thn qu ln


khng li c

- Si ti pht: sau khi m kim tra li khng thy si sau ut hin gi l


si ti pht.

Phng si ti pht:
+ Ch : hn ch th hiu canxi.

+ Kh g c ung vitamin C.

+ T g ng ung nhiu nc 2.5 3 lt. Tt nht l ung li tiu g .

+ Trong vng 3 thng sau m cn v ng nh nhng sau 3 thng lm vic luyn


tp h thng.

+ C ch ki t a nh k : th g .

Teo thn HA cao.

92.UNG TH THN

U g th thn l u c tnh nguyn pht trong nhu m thn, ngoi cc triu chng
ki h i l i u khi u th , ph g tin ch o h h nh hi i
gip cho vic ch o h, iu tr ch yu l phu thut

1. Dch t hc:

U g th thn chim 90 % cc u c tnh nguyn pht th , thng gp la


tui 40-60 tui, nam gp nhiu h t l nam/ n l 2/1.

Yu t gu :

- Ht thuc l

- Tip xc vi cc ho cht

- Bnh nhn c hi chng thn kinh da

Yu t gia h g cp n.

2. Gii phu bnh l:

- i th:
U xut pht t v thn ri chn p ton b nhu m thn. Lc ct u, c th thy u
mu vng, l m c vng hoi t v chy mu. C ch vi ho, c nhiu mch
u u i dng.

- Vi th:

U g th thn gi l l u g th biu m tuyn xut pht t biu m ca


g ln gn trong nhu m thn. Sau cng cc t o u g th kh g
t g si h di dng sarcom gi.

- Cc loi u g th kh t gp:

. Neph o lasto g c gi l u Wil s, thng gp tr em 3 hay 4 tui.


Xut pht t cc phn cn li ca m phi.

Cc t o u g th c to thnh bi s hn hp cc t bo biu m, t bo
trung m v cc t bo mm.

. Loi sa o g t him bao gm cc loi sa o t , sa o , u


mch t bo quanh mao mch.

. Sau cng cc loi u g th a g tu n nh, cc u t bo ln Hamperl v cc u


hn hp li cng t gp.

. U g th th l u cn khu tr trong thn khi u g th to dn, ph v bao


thn, v lan ra ngoi ti lp m quanh thn, xm ln cc tng g h i trng,
gan.

3. Ch o nh:

3.1. Lm sng:

3.1.1. Cc triu ch g ki h in

- i a u l t iu chng hay gp % t ng hp . i a u i th, ton


b, kh g au, kh g k theo st. Nh g u i a u hiu c mu cc,
g th c au un th . i a u t cch bt ng, bng nhin dng
li ri ti pht khng c nguyn nhn.
- au g tht l g, au , la a t c hay lan xu g di, do u pht trin
to a l g ao th . au t g au un thn do mu cc di chuyn
xung bng quang.

- Khi u vng tht l g, d s thy nu b h h n khm mun, vi cc du


hiu chm thn hay bp bnh th . th kh phi nh h g trnh gy di
u g th. Nhiu khi thy mt u rn chc, b u hay g gh, di ng nhiu
hay t.

- Nu th kh k, c th pht hi t h ch tinh cng bn c bnh l.

- Chy mu sau phc mc c th gp, k theo au d di, st v cc triu


chng ch u t o g, khi u g th t ngt v bao.

3.1.2. Cc triu chng khc:

Bn cnh cc triu chng tit niu k t , gi thy thuc phi ch ti cc


triu ch g kh , gi ta gi l cc '' hi chng c u g th '':

- St 390 - 400 C trong nhiu thng, sc kho gim st. Hoi t trong thn hay cc
cht sinh nhit ca u g th thn c th l nguyn nhn st ca u g th.

- Tnh trng ton thn gi s t ha h h g, h , su hc, thiu mu, st


nh, t huyt tr t g.

- a hng cu, k theo au u, mt mi, chng mt, nga t cc chi, ri lon


th gic. Nguyn nhn l do u phng ra nhiu erythrropoietin.

- Gan to, nh kh g au, k theo phosphatase ki t g, t l prothrombin


gim, albumin mu gim.

- N g al i u t g, do u g th tit cht ging hormon tuyn cn gip,


ho di o g g kch thch v hu t bo hot ng.

t g hu t p do u tit nhiu e i ha do h p ng mch thn.

Nu cc triu chng c u g th kh g gi i sau t thn c th ti o ti


lng xu.
- C th thy biu hin cc triu chng ca cc tng b di

3.2. Cn lm sng

3.2.1. Cc xt nghim sinh ho

Cc xt nghi si h ho h g thc mu, xt nghim t lng mu, calxi


mu, ch g ga , i lon ni tit cho php pht hin cc du hiu trong
cc '' hi chng c u g th''.

3.2.2. Ph g ph p h o h h nh

- Siu m: Nn s d g t c tin, v d s dng, khng nguy him v kh g


pht hin rt tt, ngay c nhng u nh ha iu hin lm sng. Siu m cho
php ch o u g th c ca th di

- Chp niu ti t h ch:

Chp khng chun b cho thy bng th kh g u, to h h thng, c th


km theo hnh nh vi ho trong thn hay ra thn. Cc khi u c vi ho vng
trung tm thn v 20 % c vi ho ngoi vi c biu hin c tnh.

Lc tim thuc cn quang, trong cc phim chp sm, c th thy mt khi u


t ra khi b ngoi ca thn. cc phim chp sau, thy ngay mt g y
mt hnh khuyt, c th thy cc hnh chn p, ko di, ct ct, y tr h hng
i thn. U c di th y li vo trong phn trn ca niu qun.

Chp ng niu ti t h ch l mt ph g ph p n, tuy nhin nn kt


hp vi siu khi lt cc khi u thn nh di ha . Ph g ph p
ny cn cho thy ch g thn bn kia.

Trong mt s t ng hp gc li u g th thn qu to, hu hoi gn ht


nhu m thn, hay lm t t h ch thn, hoc mu c h p i thn.
V vy thn khng ngm thuc cn quang.

- Chp ng m h: T l t ph g ph p ch o n quan tr g i
vi cc u thn.
Hi a ph g ph p d c thay th bi chp t trng ct lp.

- Chp t trng ct lp: Cho ph p nh tnh cht ca u h gi s xm ln


ca u. T c ht nn chp kh g thu pht hin cc hnh nh vi
ho , sau hp vi thu pht hin u.

U g th th th g c biu hi h t khi , kh g ng nht, t


trng ngang hoc km so vi nhu m thn. Sau khi tim thuc u ni r ln mt
thong ri tr nn km t trng so vi nhu m thn. Cc vng hoi t cng km t
trng.

- C g hng t ht nhn: Gip cho vic phn bit mt khi u nang v mt khi
c, pht hin cc m u g th h t o g h t h ch v gip cho vi h gi
s xm ln ca u g th.

4. Ch o ph it

4.1. Cc nang th kh g in hnh

- Na g c cha mu, cc cht d h... c ch o h siu m, t trng ct


lp v c khi cn chc ht.

-U g a g g : ph it gia a g thng vi a g u g th g dy
v u nang bo sn.

- U nang vi ho: 2-5 % cc u nang c th i ho h g h phn ngoi vi v c


dch lng bn trong. Cn ch h t di siu m.

- U nang b kh g u c ch o ng siu m v chp t trng ct lp.

4.2. Cc u thn c tnh v lnh tnh

-U thn c nhng vng m nht do m trong u.

- C c bit ch cc th xm ln ca u ng tit niu trn.

4.3. Cc khi vim.

Nh p e, i thn b thn, u thn ht vng hoc bnh vim thn mng trng.
. iu tr:

Ch yu l iu tr ngoi khoa ct thn ton b ly b m quanh thn, tht ng


mch thn ngay t u t h g di , o vt hch quanh cung th , t h
mch ch ho ng mch ch tu theo bn thn b u g th, th ct b cc
tng b xm l u g th. iu tr b tr bng ho cht, min dch, quang tuy
iu tr di phi.

93.U BNG QUANG

I - i g:

1- im:

- U bng quang l loi u chim t l cao nht trong cc loi u ng tit niu v
hay gp th t o g u ng tit niu sinh dc ( sau UTLT).

- T l nam > n.

- Triu chng gho , thng pht hin giai on mun.

2 - C gu :

+ Do di truyn: C s tha i bt thng trong qu trnh sao chp t AND sang


ARN dn ti s th i trong qu trnh tng hp protein.

+ Do thuc l.

+ Do ha cht: Benzidine, b- Naphthylamine v 4 aminobiphenyl.

+ Da sn: sn mng ( sn mu : schistosoma).

3 - Gii phu bnh:

%u g ua g l u g th t bo chuyn tip.

+ U biu m lnh tnh:


- Lp biu m gm 3 -7 lp t bo chuyn tip nm trn lp mng nn.

+ Papilloma: chim 2%

Ln u c cung gm t bo biu m ca t bo chuyn tip bao trm ln mt ct


tr l t ch si mch mu.

+ U g th t bo chuyn tip:

- U thng phng, t bo to v mt s phn c h thng.

- U thng tin trin xm ln v d ti pht.

+ U g th t bo khng chuyn tip: chm 2%

- U g th t bo khng bit ha: him gp

- U g th hn hp: gm t bo tuyn, t bo chuyn tip, v t bo khng bit


ha.

- T bo bit ha cng cao th cng lnh tnh.

II Triu chng:

1 - Lm sng:

+ i u: i u , v ch g, i a u c, hay ti pht.

+ C th k theo i t, i ut.

+ C th au g g t, au tht l g u U di o g, ph c
v niu qun.

2 Cn lm sng:

+ Xt nghi c tiu:

- HC niu (+).

- Thy t bo l t o g c tiu ly t bng quang.


+ Min dch: tm khng nguyn b mt t bo.

+ Ch o h h nh:

- Siu : khi BQ g c tiu.

- Soi BQ v sinh thit lm gii phu bnh l.

- Chp CT: h gi k h thc v s xm l , di a khi u.

- Chp UIV: h gi h hng ca U ln h tit niu.

III Ch o :

1 Ch o nh:

+ i u: i u , v ch g, i a u c, hay ti pht.

+ Cn lm sng: HC niu, SA, CT, Soi sinh thit ch o nh.

2 Ch o giai on:

Theo Jewett v Story:

a a : da o su m u xm l o th h g ua g di .
Marshall pht trin thm chia UBQ t gia o A n D2

- Giai on O : khng xm ln ti lp h nim mc.

- Giai on A: xm ln ti lp h nim mc.

- Giai o B: G B1: Xm ln lp g.

G B2: Xm ln lp s u.

- Giai on C: Xm ln ton b thnh bng quang v lp m quanh bng quang.

- Giai on D: Lan rrng ti bch mch v hch.

Theo TCYTTG:
+ Da vo xm ln ca u ( T: Tumor): T0 n T4

- Tis ( T0): U ti ch lp nim mc, dng phng.

- Ta: U ha ln lp di nim mc.

- T1: U xm l n lp di nim mc.

- T2a: U xm ln ti lp g

- T2b: U xm ln ti lp s u

- T3a: U xm ln ti lp v tha h c.

- T3b: U xm ln ti lp m cnh bng quang v phc mc.

- T4: U xm ln ti ua l : TC, o, TLT.

+ Da di hch (N: Nodes )

- N1: hch ti ch.

- N2: H h di 1 vng, hch ln 2-5cm

+ Di tng ( M : Metastasis)

- M0: Kh g di a

- M1: Di a

IV - iu tr:

1 B thu v o g ua g trng ra bng quang.

+ M h hm lm s h g ua g t c phu thut iu tr chng ti pht


sau phu thut.

+ Thuc:
- Doxorubicin ( BD: Alriamycin) 50mg pha 50ml dung d h HTM , %, o BQ,
cho BN n t th ( sp, nga, nghing tri, nghing phi), mi t th 15 pht,
sau ung nhiu ho i i.

- Cc thu kh : Thiotepa, ito i , BCG

- Sau phu thut th t g tun 1 ln x 6 -8 tu , sau th t g a 1


thng 1 ln.

2 Phu thut:

2.1 Ct ni soi:

2.2 - Ct bn phn bng quang:

-U g ua g c, xm nhim T1 T3, nm thnh sau ho nh BQ.

- U nm ti tha BQ.

2.3 Ct bng quang trit :

- Ct ton b bng quang, t chc m xung quang, TLT, ti tinh, bng tinh, niu
o.

- L T l g ua g tha th.

2.4 - iu tr ha cht:

Th g iu tr sau phu thut t ha cht.

- t g ng tc dng v hn ch tc dng ph gi ta thng phi hp


nhiu loi ha cht:

MVAC: Methotrexate + Vinblastin + Doxorubicin + Cisplastin

CMV: Cisplastin + Methotrexate + Vinblastin

CISCA: Cisplastin + Doxorubicin + Cyclophosphamide


94.U PH I LNH TNH TUYN TIN LIT

. i g:

U ph i lnh tnh tuyn tin lit UPLTTTL l loi u l h t h, kh g di .


Bnh gp nh g gi cao tui. Hi a ha hiu thng k dch t hc v
UPLTTTL. Theo Be , t l gi UPLTTTL t g theo la tui. Da
vo s liu ly trn t thi, Berry nhn thy t l UPLTTTL l % tui 40 v
t l t g l -80% tui 60-70. Cc triu ch g l s g g hiu
h g t g theo tui th vi m khc nhau. Theo Clinte, t l nam gii c
triu chng va v nng ca UPLTTTL l % tui 40-49 v 28% tui trn 70.
Kho g % gi UPLTTTL l iu hin lm sng. Bnh c th gy ra
nhiu bin chng do lm t ng dn niu.

2. Gii phu sinh l ca tuyn tin lit:

Tuyn tin lit nm t c chu hng b, trn honh chu hng, gia hai
hu , di bng quang, sau khp u, t c trc trng v dnh cht o
g ua g o u ca niu o nam, phn tuyn nm pha doi sau niu
o to h phn tuyn nm pha trn niu o.

ngi trung nin, tuyn tin lit k h thc ngang g l ,d hiu


t c sau) l 2cm. Tuyn hnh ht gi, hay hnh nn, dt theo chiu t c sau,
nng khong 20g ( tr s si h ng khong 1g).

Tuyn tit ra dch nhy trng, dch ca tuyn c tc d g t u g ho i t ng


axit long ca tinh dch, nh v ti h t g iu kin d di chuyn t o
vo t cung v vi trng. Theo mt s tc gi th dch ca tuyn tin lit c tc
dng kch thch cho tinh trng sau mt thi gian di gi li mo tinh hon tip
tc di chuy t u g ho i t ng axit ca o, ngoi thi gian phng
tinh tuyn tin lit khng tit dch. Tuyn tin lit u i dng bi hai ngun
mch, t ng m h g ua g di (a.vesicalis inferior) v t ng mch trc
trng gia (a.restalis media).
. C h bnh sinh:

. . iu ki h h th h UPLTTTL:

- Tnh hoan phi c ch g.

- Tui i trn 45 tui.

- Bi : Testoste o e h t tin hocmon, v cn phi chuyn thnh


Dihydrotestosteron qua trung gian ca alpha edu tase, t ng phi hp
vi Ostrgen trn tuyn tin lit k h th h h h th h UPLTTTL.

3.2. Dch t hc:

- Tn s xut hi UPLTTTL t g theo la tui, h g kh g s lin quan ti


chng tc, ch th h phn x hi.

- U g th tu n tin lit UPLTTTL kh g li ua g i hau, h g hai


bnh ny c th cng xut hin gi cao tui.

4. Gii phu bnh:

. . i th:

- UPLTTTL hiu lp c th h g h c lp trong cng l bnh din


bc tc hp l nht.

4.2. Vi th:

UPLTTTL gm nhiu nhn c mu trng ng, chc. Trong mi nhn c nhiu hay
t thnh phn: Tuy . T o g t ch m c cc s t si
Collagen.

5. Triu chng:

5.1. Triu ch g g:

+ Giai on1:

- L giai o g, ha t th g thc th.


- i kh , phi r i l u, d g c tiu yu, thi gia i i k o d i.

- i hiu ln v .

+ Giai on 2:

- t th g thc th.

- Nc tiu t d t l.

- i kh i hiu l t g l g h hng ti sinh hot v gic ng.

- C biu hin ca nhi t g. ng tit niu do s g c tiu.

+ Giai on 3:

- h hng ti ch g thn v s thch ng ca th gim st nhiu.

- L g c tiu t d t g.

- Tnh trng nhi t g ng tit niu nng n h .

- i kh t g l n lc g h l o g i.

- C khi li d n tnh trng ngh h l l i lin t do c tiu t y.

- Xut hin cc triu chng ca suy th h u , hm tiu, mt mi...

S tin trin ca giai on ny khng phi l o g theo t h t xut hin,


n ph thuc vo cc yu t: s t g t ng ca tuyn, s thch ng ca th
v cch sinh hot ca t g gi. Tuy nhin bt c giai on no ca b h, i
cp t h g th x a t bnh nhn trong tnh trng cp cu.

+ C th tm tt triu ch g g th h hai hi chng sau:

- K h th h I itatio s d : i hiu l , i o a , i i, i
khng t ch do u t i i.

- Tc ngh O t ue s d e : i ngp ngng, ngt u g. i s t ui cng,


i kh g ht c tiu. Tia c tiu hai d g, d g c tiu yu. C gi i
khng ht c tiu. B i, i kh g t ch do c tiu t y.
5.2. Triu chng thc th:

+ Th t t g: l ng tc khng th thiu, rt c gi tr cho ch o . Kh


thy tuyn tin lit to, hi, ng nht, kh g au, kh g h n cc
thu , ranh gii r, khng c hi tng xm ln. Ch tuyn tin lit c th nh
h g th gia chn vo c bng quang gy ri lon tiu tin.

+ Khm vng h v: c cu bng quang.

+ Tha g im IPSS:

- Hi a tha g im ca hip hi tit niu M c s dng rng ri, sau


khi t chc Y t th gii cng nhn (International Prostate Symptom Score-IPSS).
Tha g im ny da trn cc triu chng: C c gi c tiu trong bng
quang sau moi l i tiu kh g. Sau khi i tiu li phi i tiu li trong khong
thi gia ha n 2 gii l bao nhiu ln. Khi mu i tiu kh g i c ngay
m phi ch mt lc mi i . Khi i tiu d g c tiu c ngt qung
kh g. Tia c tiu c nh v yu khng. Trong mt ao hiu ln phi
d i i.

- Tha g i IPSS, h gi h sau: Nu di im, cc triu chng


h gi l h. Nu t 8- im, cc triu ch g h gi l t u g
bnh. Nu t im, cc triu ch g h gi l ng.

5.3. Triu chng cn lm sng:

+ Xt nghi : PSA P ostate Spe ifi A tige : h thng khng nguyn ny ch


c trong lng tuy a g, t o g t ng hp ung th tu n tin lit, g
ph v lm khng nguyn ny tro vo trong mu. Xt nghi phn bit
gia UPLTTTL u g th tu n tin lit. B h th g l g PSA di 6ng/ml
huyt tha h. Ch kh g soi g ua g, th t c trng, dng finaste de t c
khi lm xt nghim ny.

+ Photphataza axit: nu t g h ph it vi u g th tu n tin lit.


+ Siu m: l khm nghim quan tr g, gi p ho theo d i u t h iu tr ni
khoa. Siu o khi lng ca tuyn tin lit v pht hin cc vng gim m
gp t u g u g th tu n tin lit.

+ Chp h tit niu khng chun b: pht hin si bng quang ca h tit niu
km theo.

+ Chp niu t h h: h gi h g nh l km theo ca h


tit niu. C th thy niu qun dn, niu qun hnh mc cu (du hiu Marion),
hnh khuyt ca tuyn tin lit.

+ Chp niu o g ua g g d g: kh o g ua g, ph g ph p
ny cho php th c hnh nh ca tuyn tin lit t g i r nt.

+ Soi g ua g: ph g ph p ch yu ch o ph it vi mt s
b h g g i lon tiu tin (u bng quang, si bng quang....).

+ o lu l g d g c tiu:

B h thng: 20 ml/giy.

C tc ngh : di 16 ml/giy.

Tc nghn cn phi iu tr: di 12 ml/giy.

+ Sinh thit:

Kim sinh thit c 2 loi: Silverman v Trocut.

X nh t chc ca tuyn.

h lng t l LDH5/LDH1, nu t l ny l h phi gh ti u g th tu n


tin lit.

6. Ch o :

6.1. Ch o nh da vo cc yu t:

- La tui.
- Ri lon tiu ti c bit l i kh .

- Th t c trng thy tuyn tin lit to v tnh cht ca tuyn.

- Chp niu o g ua g gc dng.

- Siu m.

- Sinh thit.

- Tha g im IPSS.

6.2. Ch o ph it:

+ Phn bit vi mt s nguyn nhn ti g ua g g gy ri lon tiu tin:

- B i do hp niu o.

- X ng c bng quang.

- Bng quang thn kinh.

+ Phn bit vi mt s bnh l do tuyn tin lit gy nn:

- U g th tu n tin lit.

- p xe, vim tuyn tin lit.

7. Bin chng v tin trin.

7.1. B i ho to : th gp bt k giai on no ca b h, g l l do
thng gp buc bnh nhn phi ti vin.

. . B i kh g ho to : gp giai o giai on 3 ca b h, khi


c tiu t d t o g g ua g ga sau khi i tiu, t thng niu o c
tiu cn trn 100 ml).

7.3. Si bng quang: si c hnh thnh th pht do s g c tiu trong


bng quang. Khi si g ua g c hnh thnh li gl t g t iu
chng ri lon tiu tin.
. . i u: UPLTTTL thun rt him gp bin ch g i u. Bin chng
th g do t thng i kh g g k thut, do nhim trng, do si bng
quang.

7.5. Ti tha bng quang: do g c tiu, g ua g g d u c,


bng quang mt tnh cht hi.

7.6. Nhim trng ng tit niu: l bin chng kh trnh, n lm cho qu trnh
bnh l ca bnh thm phc tp. Cc triu chng ton thn v ti ch xut hin
rm r h st ao, t u , c tiu , h , t mi ...).

7.7. Suy thn: gp giai on cui ca bnh. L kt qu g c tiu ko di


gy dn niu qu , d i th , i i th gc dng. Bnh nhn
trong tnh trng thiu mu, bu , h , t mi, ph, huyt p cao, thiu
niu, v niu, hn m do suy thn.

. iu tr:

Do nguyn nhn gy b h ha nh r nn vic phng bnh thin v


g ga cc bin chng v pht hi giai on tin trin ca b h ra
ph g iu tr thch hp. Khuyn b h h u g iu , trnh ung
u, c ch lao ng, sinh hot, v ng v ngh gi hp l, khng nn
ngi, nm lu mt ch g g t mu vng chu, luyn tp v v ng cc
h g iu ho khi i tiu ti i ti h th h g,
ho h tng sinh mn, trnh cc yu t g i ng tit niu, ngm
0
c m tng sinh mn (37 C trong 20 pht).

. . iu tr ni khoa:

8.1.1. Cc thuc tho mc:

+ Cc thu c pha ch t cc loi cy Pygeum africanum, Serenoa repens.


Cht c chit xut t nhng cy ny l Sitostol c kh g l gim cht
Cholesterol cn thit cho s pht trin ca tuyn tin lit.

+ Cc bi thuc y hc dn t h Cao a lo g, B g , Nhc qu, R c


tranh.
. . . iu tr dc l:

+ Cc thu i khng Androgen: Flutamide, Cyproteron acetat, Megestrol acetat.


Khi dng cc thuc ny nn dng thm cht c ch men 5 alpha reductaza, cht
ha c dng l Finasteride.

+ Cc thuc chn Alpha-1: Prazosin, Terazosin, Dxazosin.

. . iu tr b g ph g tin vt l:

8.2.1. Nong niu o tuyn tin lit:

+ Dng loi ng thng c bng nh u nong niu o tuyn tin lit


(Burrhenne - 1984, Castaneala - 1987).

+ t 1 ng nng l xo vo niu o tuyn tin lit (Fabian - 1980).

. . . Siu : iu tr t g hit ph hu cc t bo trong m tuyn tin lit.

8.2. . Lase : c s dng qua ni soi ha a thng vo m tuyn tin lit


t hay gy b hi tu n tin lit.

8.2.4. S dng sng Radio tn s thp: vi dng c c bit t trong m tuyn


tin lit tiu hu phn ln t bo tuyn tin lit.

8.3. iu tr ngoi khoa:

8.3.1. Ch h iu tr ngoi khoa c thc hi t o g t ng hp sau:

+ B i ho to kh g khc ph c sau t nht 1 ln rt g th g i.

+ Nhim khun ko di, hay ti pht.

+ i a u g, ha t i ph t do UPLTTTL.

+ Si bng quang.

+ Ti tha ln bng quang.

+ Suy th do UPLTTTL.
+ Cc ch h t g i c thc hin khi bnh nhn b cc bnh ni khoa kt
hp ho thng xuyn mt ng h h g n cng vic hng ngy.

. . .C ph g ph p phu thut:

+ M d lu g ua g t g u La stosto ie .

+ Phu thut u: ph g ph p H ts hak, ph g ph p F e e , ph g ph p


Millin.

+ Ph g ph p t ni soi qua niu o.

8.3.3. Tai bin v bin chng:

+ Chy mu: l bin chng hay xy ra, chy mu lm tc ng thng gy chy mu


thm v gy nhim trng.

+ Nhi t g: g l in chng hay gp, th g do t g th g i lu


g ha h n khu v khun.

+ Suy thn sau m:

+ Hi chng ni soi: i vi ph g ph p t ni soi cn phi phng tai bin


ny, do ti hp thu o th gy long mu v tan hng cu.

+ Ri lon tiu ti : i kh , i , hp niu o, i kh g t ch.

+ Ri lon ch g si h dc: phng tinh yu, ph g ti h gc dng.

+ Vi g, lo g g u:

+ Thng trc trng:

III. Ti liu tham kho.

1. Triu chng hc ngoi khoa - NXB Y hc 2000.

2. Bnh hc ngoi khoa - NXB Y hc 1999.

3. Bnh hc tit niu - NXB Y hc 1994.


95.U X TIN LIT TUYN
BS Nguy V B h, BS Ngu V T ng

I- Tng qut:

Tin lit tuyn l tuyn nh, chiu cao khong 3 cm, chiu su 2,5cm, nng
khong 20g tui t ng thnh, rt nh lc mi sinh, c nhim v tit tinh dch
(khng phi tinh trng, do testicules). Tuyn n ga di bng quang v bao
quanh ng dn tiu.

Vi nhng l do ha c bit, tin lit tuyn ca nhiu gi bt u gia t g


k h thc vo khong tui 60 t nhng t bo lnh tnh. S gia t g k h thc
ca tin lit tuyn gy cn tr c tiu thot ra t bng quang. giai o u,
i ph vi s cn tr, g ua g gia t g sc co bp, biu hin lm sng ch
l gi g c tiu hi u h a d su ie . Khi

tin lit tuy gia t g th k h th , g ua g kh g s y ht c


tiu a go i, c tiu cn li trong bng quang sau mi ln tiu. Do g
quang ch cn t thi gia c tiu, khin bnh nhn c nhu cu i tiu
g g g ha h h . Mi nh nhn phi thc dy 1 ln, 2 ln ri 3
ln, v c th nhiu h a tiu tin...
II- Triu chng lm sng:

Thc t lm sng cho thy c rt nhiu tha i ty theo mi bnh nhn, c th


c rt t triu chng d tin lit tuyn kh ln, ho gc li triu chng rt
nhiu gy rt nhiu xo tr , kh kh t o g uc sng hng ngy d tin lit
tuy k h thc nh.

Nhng triu ch g thng gp:

i tiu nhiu l , c bit o a .

Nhu cu tiu tin khn cp.

Cn phi gng sc khi tiu.

Cm thy v c tiu trong bng quang mi khi ngng tiu.

Gi g c tiu yu, ch , thng b ngt qun mi ln tiu, c th chy


tng git khi gn ht tiu.
Ph i tin lit tuyn l bnh rt ph thng: cc thng k cho thy khong 50%
gi c tui ao h bnh ny, con s ny s t g l % u tnh t tui
60 v l 90% nu tnh t tui 70.

Cc triu chng lm sng k t dc gi chung l ''ri lon tiu tin ph di


ca h thng'' (TUBA), gy nhng xo trn h h g n phm cht cu cuc
s g h g g c xp hng theo m theo bng chun quc t sau :

B g im quc t v triu chng ca bnh ph i tin lit tuyn (I-PSS):

Cho im t n 5 theo Khng Khong Khong Khong Khong Lun


s h gi t nh n bao 1ln/5 1 ln/3 1ln/2 3 ln/5 lun
nng ca mi triu chng gi c
1) Trong thng qua, bao O 1 2 3 4 5
nhiu ln bn cm thy cn
c tiu trong bn quang,
sau khi tiu xong ?
2) Trong thng qua, bao O 1 2 3 4 5
nhiu ln bn cn phi i
tiu ln th 2, d bn mi
i tiu t ha u
gi ?
3) Trong thng qua, bao O 1 2 3 4 5
nhiu l gi g c tiu b
t o ? Ngha l t u
tiu, ngng tiu, tiu tr li
?
4) Trong thng qua, bao O 1 2 3 4 5
nhiu ln bn c nhu cu i
tiu v khng kim ch ni?
5) Trong thng qua, bao O 1 2 3 4 5
nhiu ln bn cm thy
gi g c tiu b nh hoc
yu h h thng?
6) Trong thng qua, bao O 1 2 3 4 5
nhiu ln bn phi rn,
hoc gng s bt u
tiu ?
7) Trong thng qua, mi Khng 1 ln 2 ln 3 ln 4 ln 5 ln
n phi i tiu bao O 1 2 3 4 5
nhiu ln, t l i g n
lc th h in

Tng c g im t 7 cu hi trn = 0 - im: Tnh trng nh , 8 - im : Tnh


trng trung bnh, 20 - im: Ri lon tiu tin nng.

B g i t g cho php theo di tin trin cc ri lon tiu tin do bnh


ph i tin lit tuyn gy ra.

T l s bnh nhn b ph i tin lit tuyn c TUBA m trung bnh hoc


trm tr g c tnh khong 8% l tui 60, 15% la tui 70, v 27%
la tui 80.

Tuy nhin ch c 4% dn s tui t gi g c tiu yu h


l/se l g c tiu ng trong bng quang sau khi tiu nhiu h
50ml.

Nu da vo kt qu m t thi, kho g % gi c tui t 31-50 b h ph i


tin lit tuyn, 50% t tui 51- , h % h g gi c tui l h .

Cc bin ch g thng gp l: b tiu (0,4%- 6% mi , hi t g ng


tiu hoc nhim trng tin lit tuyn. Khi b h tin trin nhiu , th
thy ti phnh thnh bng quang (diverticules vsicaux), sn bng quang, suy
thn. Tuy nhin b h ph i tin lit tuyn him khi l nguyn nhn gy t vong,
ch gy h hng xu cho phm cht cuc sng hng ngy l chnh.

III- Xt nghim cn thit:

Xt nghim cn thit tha i ty theo mi bnh nhn, nhng xt nghi a u


thng cn :

R qua hu mn (TR-tou he e tal : ho ph p o l , cng v


b mt g gh ha t phn.
Siu g ua g o l g ln ca tin lit tuy l g c tiu
ng sau khi tiu xong.
Ni soi bng quang.

o lng khng nguyn chuyn bit cu tin lit tuy PSA t o g u


t u g th tin lit tuyn.

Siu m qua trc trng v sinh thit nu nghi ng kh g u g th.

Kho s t tiu v cy tm vi trng (ECBU).


IV- iu tr:

Sau khi loi b kh g u g th , ph g h g iu tr b h ph i tin lit


tuyn ty thuc nhiu yu t.

A- iu tr ni khoa: bnh nhn b ph i tin lit tuy , kh g c


dng nhng thuc c cha anticholinergiques, sympathomimtiques v cc dn
th cu thuc phin. Tt c cc nhi t g ng tiu cn phi c tr liu
bng tr sinh mt cch hiu qu.

1- T ng hp nh (0- im theo I-PSS): khng cn tr liu bng thuc.

Nhiu nghin cu lm sng cho thy khong 1/3 bnh nhn giai on nh cc
triu chng lm sng s bin mt, hoc gim thiu khng cn tr liu sau mt thi
gian tin trin. Do giai on ny ch cn theo d i iu ng mi mt ln
bng khm lm sng (b g im quc t), r qua hu mn (TR-toucher rectal) v
o lng khng nguyn chuyn bit cu tin lit tuy PSA t o g u tm
u g th tin lit tuyn.

2- iu tr bng thuc: l iu tr u ti c ch nh cho b h ph i tin lit


tuyn. Cc thu c cng nhn c hiu qu bao gm:

* alpha bloqueurs: tc dng gi g i bng quang v niu o, gy gim


g c tiu sau tiu tin: terazosin (Hydrin, dysalfa), doxazosin
(Zoxan,Cardura), tamsulosin (Josir, Omix), alfuzosin (UroXatral), Prazosin
(Minipress).

Theo ua th nh hiu qu tr liu cu b Y t Php, thuc alpha-bloqueurs


c kh g gim thiu 7- im theo bng triu ch g IPSS gia t g g
gi g c tiu (Q.max) khong 15-40%.
Tc dng ph: H huyt p khi tha i v th, ri lo tiu ho h un nn,
au thng v, tiu chy.

Cn tip t iu tr 3-4 tu t khi h gi hiu qu cu thuc.

* 5 alpha-reductase inhibiteurs: l men c ch testosterone tr thnh


dih d otestoste o e DHT do t dng lm nh k h thc tuyn tin lit
tuyn khong 2 % sau th g iu tr h finasteride (Proscar) v dutasteride
A oda t . Do n phi iu tr t nht th g bit thuc c tc dng
tt hay khng.

Theo ua th nh hiu qu tr liu cu b Y t Php, thuc 5 alpha-


rductase inhibiteurs c kh g gim thiu im theo bng triu chng IPSS
gia t g g gi g c tiu (Q.max) khong 2,3- 5,6 ml/sec.

Tc dng ph: gim tnh dc, gi lng tinh trng.

Cc nghin cu mi ho it dng kt hp alpha bloqueurs v 5 alpha-


reductase inhibiteurs c hiu qu h iu tr bng mi thuc ring bit. iu tr
kt hp 2 thuc lm gim triu chng lm sng do tin lit tuyn trong 67% (39%
nu ch dng doxazosin, 34% nu ch dng finasteride).

B- Prostatic stents: Ph g ph p iu tr khng phi ni khoa, g kh g hn


ngoi khoa. B g h a o iu qun vng tin lit tuyn mt stent (ging
h t l xo nh nng r g ng tiu.

Ph g ph p c p dng cho nhng bnh nhn b chng ch h i vi


iu tr ni khoa g h goi khoa.

u im cu ph g ph p:

Th thut ch cn kho g ph t hon tt, gy m vng niu o.

Chy mu t trong lc tin hnh v sau khi hon tt.

Bnh nhn c th xut vin cng ngy hoc sng hm sau.


Nh im cu ph g ph p:

Stent th g g k h th h g i tiu nhiu ln trong mt thi gian .

C th g au tiu sn (khng kim sot).

Khi cn l a / t ng hp), c th gp kh kh .

C- iu tr phu thut: Vi m h t b mt phn hay ton th tin lit tuyn


ph i. Dnh cho nhng bnh nhn giai on trm trng, vi nhng triu
ch g h:

Ch u ng tiu.

Gy t th g thn.

Thng nhi t g ng tiu.

Thng b b tiu.

Sn trong bng quang.

1- Ct tuyn bng ni soi ua ng tiu-Transurethral resection of the


prostate (TURP):

oi l ph g ph p u mc, lm chun so snh hiu qu ho ph g


php phu thut khc, hi a c chn dng cho 90% tng s cc phu thut
iu tr b h ph i tin lit tuyn. Phu thut dnh cho nh g ph i kch
thc khng ln qu 70g (nu qu ln p d g ph g ph p t tuyn qua
ng m bng), gy m tng qut. Phu thut thng khng qu 90 pht, s
d g ese tos ope a o g tin lit tuyn qua l tiu cu d g t.
2- Ct tuyn bng laser Holmium ni soi- Holmium laser enucleation of the
prostate (HoLEP):

Ph g ph p gn ging vi TURP h g d g lase ct tuyn v cm mu, t


gy chy mu v bnh nhn c th xut vin 1 ngy sau phu thut.

3- Ct tuy ua ng m bng hoc vng hu mn (Prostatectomie):

Nu tin lit tuy ph i ln qu 70g, ct tuy ua ng m bng hoc vng


hu l ph g ph p th h ghi.

4- TUIP (transurethral incision of the prostate):

c ch nh cho nh g ph h i k h thc nh. Mt hoc nhiu vt ct


c thc hin vng c g ua g i li kt vi ng dn tiu, vi m h
ni rng l tr g c tiu c thot d dng.

5- TULIP (Transurethral ultrasound-guided laser incision of the prostate):

L ph g ph p t g i mi, gn ging vi TUIP, ch khc l vt ct c thc


hin bng laser.
Hu phu:

Sau gii phu: V v chy mu vt m nn tt c ph g ph p gii phu


u c ti ch ng dn tiu bng quang (Foley catheter) vi h th g c
vo ra -continuous bladder irrigation (CBI)- ra g ua g t h u g
c , ho ph p g ua g gh gi. Bnh nhn cn ung nhiu c (khong 2
l t/ g , i khi n phng nga nhi t g ng tiu bng tr sinh.

Sau khi xut vin:

Bnh nhn xut vin sm hay tr ty theo ph g ph p gii phu, v c c


gh gi t thi gia t c khi tr li hot g h thng.

Trong thi gia gh gi, nh nhn nn:

Trnh khun vc n g, l i e, iu khi kh .

Ung nhiu c.

Xo trn ch g hu phu thng gp:

Ch u thng xy ra trong thi gian ngn sau khi m, do gng sc hoc


cng vi lm.
Trong thi gian ngn hn: tiu ti thng, tiu bn.

Bin ch g thng gp : Tiu sn, tinh kh ch gc v bng quang (khng th


c con).

D- Tr liu vi can thip ti thiu (Minimally Invasive Treatment):

Bao gm nhng phu thut mi, p dng nh g ph g tin ti tn nht hin


nay.

u i : It au, nh nhn bnh phc sm, t tn km, ch cn gy m cc b.

Thng dng nhit t hy tuyn, p d g iu tr nh g ph i c kch


thc nh. Nhiu k thut khc nhau do khc nhau ngun pht nhit, cch pht
nhit v s ln cn thit tr bnh.

C th k:

a- K thut d g lase h PVP (Photoslective Vaporisation de la Prostate),


HoLAP (Holium Laser Ablation de la Prostate).

b- K thut dng sng ngn (micro-o des h TMTU (Thermothrapie par


microondes transurethrals).

c- K thut d g s g adio h TUNA (Transurral needle ablation), la


thermothrapie par radiofrquence.

V- Kt lun:

B h ph i tin lit tuyn l bnh lnh tnh, rt ph th g, g kh kh tho t


tiu t bng quang v c th lm xo trn trm trng cuc sng hng ngy cu
bnh nhn.

Sau khi nh bnh v loi b kh g t h, ph g h g iu tr da vo


m h hng cu ri lon ch g tiu ti i vi cuc sng hng ngy
(xem b g im IPSS).

Nu nh, theo di b h h g da vo lm sng v xt nghim thch nghi.


Khi c iu tr, ni khoa l iu tr u tin, da vo thuc alpha bloqueurs v 5
alpha reductase inhibiteurs, dng ring r hoc kt hp 2 thuc.

Nu iu tr ni khoa tht bi, phu thut ni soi TURP hi a c p dng cho


% t ng hp ph i tuy kh g u g. C ph i l h g n phu
thut m vng suprapubic hoc retropubic.

Cc ph g ph p phu thut kh c p d g ho ph i k h thc nh


t ph g tin thit b, kh g hu ghip.

96.SONDE TRONG TIT NIU

1. Cc loi sonde.

- Sonde c g: th g i a .

- Sonde mm:

Tn im v tc dng Hnh dng

Nelaton Sonde th g u t , thng


tiu

Sonde Bequil u cong, c g h so de


elato th g i ho B

Petzzer H h u rn c tc dng dn
lu BQ t g u.

Malecote Hnh cnh kh g t


dng d lu BQ t g
mu.
Foley 2 chc hoc 3 chc c nh
bng bng. Cc ch s c lu
y:

16F: c sonde s F ~
CH = chu vi sonde l 16mm. S
o Be i ue = s o CH.

30ml/CC l dung tch ti a


g h th g
10ml, trong m UTTL
25ml).

5.5mm l ng knh sonde.

Tc dng d lu BQ ua liu
o hoc chc d lu BQ t
g u ua T o a, d lu
b thn t dng.

Dy truyn D g d lu iu qun b th , lm nng niu o trong


dch phu thut to h h iu o.

ng ht Dn lu thn niu qun, d lu BQ t g u


nha

JJ D lu thn niu qun xung BQ l d lu k .

2. D lu h thn

M h

- D lu c tiu r r qua vt m ra ngoi.

- D lu u dch tit nu c.

L nguyn tc khi m thn v


- H thn l khoang o s u h thng khng c dch, khi c dch chy vo s
to thnh khoang tht cha dch, bn thn h thn nhiu t chc lin kt m nn
d b nhim trng, mt khc gn cc mch mu ln NK d lan rng v d b NK
huyt.

- Bao th l ao Geota l ao t mng khi b rch vic khu phc hi


kh g sc bo v thn.

- Nhu m thn rn d v, khi b rch hoc khi r h phu thut vic khu
phc hi li khng cho php tht qu cht nn vic h vt m l khng trnh khi.

- B thn v niu qu c bao bc bi t ch t t v d b cht hp


ho kh g c php khu dy (tt nht ch khu thanh m li nim
mc ) nn vic h vt m l iu tt yu.

- Th l ua i tit c tiu nn p l t o g ua tit niu bao gi


g ao h go i t khc do vt m h nn d r l iu khng th trnh
c.

- Nc tiu h th g PH a id l i t ng VK kh hot g khi c


tiu d r ra ho vi dch tit v mu dn dn s chuy a g i t ng kim to
iu kin choVK pht trin v vy nu t ng vic nhim khun h thn l
iu chc chn.

D lu h thn tt

- L d lu d c tiu, mu, dch tit v m ra ngoi.

Mun d lu h thn tt phi lm g?

- Chn sonde:

+ Kch c phi ph hp: nu d lu c tiu v dch tit chn c sonde nh,


nu d lu u chn c to khng b tc trong qu trnh d lu.

+ Mt cng khng qu mm.

- Chn v t t sonde:
+ u trong ngang st c di thn, cc l ca sonde phi hng v pha
l g hoc thn v nu hng v pha bng s b thanh m n gy bt tc.

+ u thnh b g t t ng nch gia cch mo chu 1.5 2cm.

Dch d lu h thn ra th no l tt.

- Nu c dch phi c d lu a ht v vy c th ra nhiu hoc t khng


quan trng v s lng vi iu kin dch phi c d lu a ht v vy ngy
u c th ra vi ch , i t ho h g l t h g:

+ Dch phi mu hng nht.

+ Gim d , thng sau m 72 gi ht dch.

- Nu khng c dch l d lu tc phi kim tra li d lu n thit phi


p, h t, t ng hp cn thit cn rch ch chnh li d lu.

iu kin rt d lu.

- Ht dch:

+ D lu kh g hy dch.

+ H th kh g au, g BN kh g hng, khng st.

+ BN t u g tin: v ch khi ng mi xp, ng thi p c dch chy


ht.

- Thi gia t u g h ht dch l 72 gi sau m.

Cc kiu rt d lu.

C hai kiu rt d lu t th v 2 th.

- Khi no rt d lu hai th ?

+ Khi lng dch qua d lu g k h g ha ht hn, 24 h ch ra chng vi


chc ml.

+ Thi gia d lu u 72h.


+ Din bin ton thn tt t u g ti , u g kh g s t kh g au.

- Cch rt d lu:

+ Ct ch c nh d lu.

+ Rt ngn d lu h li mt o ua th h .

+ Ct ng u go i sau d g ki ti u ua c d h kh g ho u
sonde tt vo trong, dng g g p li.

+ Thi gia 24 gi sau th rt ton b sonde.

- M h:

+ lng dch cn li trong hthn v g a, ng thi to iu kin


ho p li y ra nt.

+ Rt ng cc cquan trong bng p st h th dn ht dch ra.

+ Do ct ngn DL BN c th ngi d i li t h c bin chng nm lu,


v nu d lu khi ng d lu ng c th lm rch mch mu v cc
tng ln cn, phc mc.

+ Nu d lu u hl t thng do bin chng: chm lin, r th

3. D lu thn.

Cc kiu d lu thn

- D lu ua hu th thng dng sonde Malecote, sonde Petzze.

- D lu iu qun b thn qua nhu m th : thng dng ng ht dy


truyn dch.

- D lu thn qua niu qu i ua iu qun ra ngoi d lu t c tip.


Thng dng dy truyn ng ht.

- D lu thn niu qun qua da.

- D lu thn bng quang (d lu k d g so de JJ.


D lu thn qua nhu m thn.

1. Ch nh:

- Khi m vo thn phi rch nhu m th ng rch phc tp (rch ln,


rch nhiu i hoc trong ch th g ng rch nhu m thn phc tp, vic
khu c u kh kh gu hy mu sau m v th cn d lu thn
trnh to mu cc..

- Khi m vo thn c tnh trng nhim trng trong thn biu hi c tiu
c m ho t o g t ng hp thn c gin qu to cn phi d lu thn.

- Khi m thn niu qun c to hnh niu qun b thn th phi d lu.

- T o g t ng hp v mt gu h o g t tc niu qun: si, cht


hp, u chn p, mt s tai bin trong phu thut s khoa h g t ly do
o ha a thip gii quyt gu h SK kh g m bo,
t h PT i , t h gy m hi s ha p g c, trang thit b ha
) th cn phi dn lu thn, cn gi l d lu thn tm thi hay d lu
b thn ti thiu.

2. M h d lu thn:

- D lu c tiu gim p, d lu to c tiu cu thn.

- D lu u trnh mu cc trong b thn.

- D lu m nu c m.

- T o g t ng hp to hnh b thn niu qun, d lu kh g h gim p


l l g ch to h h im ta to iu kin cho lin vt m trnh
r trnh hp.

Th no l d lu thn tt.

1. Chn sonde:

- Kch c: nu d lu c tiu ch cn chn sonde nh, nu d lu u


cn chn c sonde to, to hnh niu qun chn dy truyn hoc ng ht.
- Mt : kh g c cng v c th chc vo th , kh g c qu mm.

- Chn sonde: Malecote hoc Petzzer.

2. V t t.

- V tr trong thn: nu hu h i t g i bng nhau th d lu


th g ua h i gia ra ngoi. Nu hu h i h giy
mng khc nhau th chn ch nhu m dy v d lu tt a so de ua
(kh g t h i th di gu d thn sau rt d lu, kh g
t h it d lu hiu qu khng cao.)

- V tr trn thnh b g: a ua ng nch gia i chiu thng gc


vi v t t d lu t o g thn.

iu kin rt d lu thn.

- Nc tiu qua d lu phi trong, khng cn mu khng cn m.

- Ton thn phi tt: khng st kh g au, u g i li h thng.

- thi gian: 12 g . T o g t ng hp to hnh phi 3 tun tr ra.

- Phi c s lu th g tt t b thn xung niu qun.

C ph g ph p kim tra s lu th g t b thn xung bng quang.

1. Kp th.

2. B thuc xanh v trng: xanh Methylen, xanh Evan.

3. B thuc c ua g ta t o g c v kp sonde li i hp.

Kp th B thuc mu B
thuc cn
(kp u sonde li dng dy cao l thuc
quang
su buc cht kh g ho c tiu xanh Methylen v
chp kim
chy ra) trng kp sonde li v
tra.
theo di)
Lu - Ton thn khng tha i, ti - i c tiu xanh - B
thng th kh g au, kh g st, bng ngay, mu xanh sau 10ml
tt kh g hng, kim tra thn mi l i tiu nht thuc cn
khng to. dn v ch c i tiu quang
vi ba l c tiu Terebrit.
- Nc tiu i ua g di
trong tr li.
t g l t so vi t c khi - Khi
kp, theo di 24 48 ting tnh - Kh g au kh g chp pht
trng BN tt h t t th rt st, thn khng to ta hi c
sonde. c th rt sonde. ngay s
lu thng,
Tc - Sau kp hoc vi ba ting sau - Sau khi
bn tc
BN au tc vng thn, st cao rt thuc kp li BN i
hay tc
run, b g hng, kim tra thn tiu khng c mu
ng thi
thy th to g au, c tiu xanh.
nh
c th theo chn sonde ra ngoi
- Biu hi h c v tr
t g t o.
t ng hp tc trong gy tc
- Nc tiu g di khng kp th, c tiu c hoc bn
t g l th t i. th qua chn sonde tc.
mu xanh.
- X tr: m sonde cho chy ra
chai hoc ti, dng khng sinh, - X t : h
truyn dch, li tiu, gi t , t ng hp bn.
ho n khi BN nh: ht st
ht au t gu h g tc
x tr.

Bn tc - Sau khi kp xong vi gi u - Sau khi


c th na ngy (10 12 ting) thuc kp sonde li BN
din bin tt: kh g au, kh g i tiu c mu xanh
st, kh g c tiu r theo nht v ko di sau
h so de a go i. Khi c nhiu l i tiu.
tiu g di t g h g
- Thi gia u BN
kh g g k. h sau biu
hi h t ng hp
- Sau khong thi gian ny BN
bn.
dn d au tc vng thn, st
cao rt run, b g hng, kim tra - X t h t ng
thy thn to c th th c tiu hp bn.
theo chn sonde th t g.

- X t : h t ng hp tc.

Trong m thn phi thng tiu BN i do g t tu sng, sonde tiu g a


t sau h khi ht tc dng ca thuc t BN c th t i tiu c.
Nh g thc t th g 72h v BN phi truyn dch, mt kh do t d lu h
thn, b thn nn phi bt ng nu khng ng d lu th chc lm tn
th g th pht.

4. D lu g ua g.

Ch nh.

- Tt c t ng hp m vo BQ cn phi d lu BQ.

- B i h g kh g h h t thng tiu ho t thng tiu khng


c (hp niu o, ch th g iu o, u chn vo niu o)

M h.

- D lu c tiu.

- So de thng dng: Malecote, Petzzer. Nu chc d lu BQ t g u


dng sonde Foley hoc ng ht.

Mun d lu tt.

- Chn ng d lu.

- V t t ng d lu:
+ T o g BQ g t t nh cng tt t h t st c BQ v s gy kch thch
lm BN mt tiu lin tc.

+ Thnh b g t khong 1/3 gia ng ni rn v khp mu.

- D lu tt l d lu c tiu mu m a go i t c m h
d lu .

Khi no rt d lu.

- Ty theo ch nh thi gian rt c th khc nhau: c th 5 7 ngy nu tc


niu o ha gii quyt c nguyn nhn gy tc c th ko di, nu ko
d i nh k 2 3 tun thay sonde mt ln.

T o g t ng hp to hnh BQ phi l u h thng 2 3 tu . T c khi rt


phi kp th bnh nhn t i, khi i tt mi rt d lu. Khi t d lu t
BQ t d lu BQ ua iu o m bo cho l trn lin tt khng b x r,
thng tiu 2 3 ngy.

97.SI TIT NIU

. i g:

Si tit niu l b h thng gp, b h thng hay ti pht, cc nh dch t h


v trn b th gii g ai si tit niu t o g Vit Nam (Theo
Hu e ge Higgi s th g ai si tit niu g c thu a Trung Hi,
, Trung Quc, Hoa K , Bc u v Vit Nam).

Bt k v tr no ca ng dn niu g u c th b si, t o g : si thn gp


khong 40-50%, si niu qun gp khng 28%, si bng quang gp khong 30%,
si niu o gp khong 5%.

1.1. Thnh phn ho hc ca si:


Thnh phn ho hc ca si bao gm cc cht hu , t o g %
trng lng l cht , % l c, 3% l Protein, 2% l nguyn t i lng. Si
tit niu thng phi hp nhiu thnh ph . phn loi si, gi ta chia si
tit niu thnh 5 loi: Canxi oxalat, Canxi phosphat, Amino Magephosphat, Urat
at i, C sti . T o g Ca i o alat l th h phn chnh ca si tit niu gi
Vit Nam. Thnh phn ho hc ca si gi Vit Nam khc vi gi cc
c Chu u.

. . Ngu h h bnh sinh:

Si tit niu c hnh thnh ch yu t th . hiu gi thit gii thch


gu h h bnh sinh ca si tit niu.

- Gallen (131 - 201) cho rng: S hnh thnh si tit niu li ua n ri lon
chuyn ho, di truyn, ch .

- Phazes (860 - 932) cho r g: hiu mui, nhit cao d hnh thnh si.

- Aricenna (980 - 1036) cho r g: Do t g qu mc cc cht kho g t o g th.

- Paracelrus (1493 - 1541) cho rng: Ri lon cht khong ton thn c o thi
qua h tit niu.

- Thuyt Randall v Carr (1937) cho rng: Nhng nguyn nhn d ng, nhim trng
gy nn t th g t c tin gai thn, cc phn g di nim mc v ti ch
gai thn to nn s l g ng Canxi v hnh thnh mng Randall, hnh thnh si
i thn. Qu trnh l g ng tip tc si i thn ln ln bong ra di chuyn sang
b thn v pht trin thnh si b thn. Hin nay c 6 thuyt g h l :

- Thuyt v s qu bo ho cc cht kt tinh.

- Thuuyeets v thiu yu t c ch.

- L thuyt "khun".

- Thuyt v ht nhn c nh trong thn.

- Thuyt v ht nhn t do trong v ngoi thn.


- Thuyt Robertson (1973) v Gill (1974): Nhm c g g kt hp tt c cc vn
m cc thuyt t u.

Tm li: ho a ha thu t no gii thch tho g h hnh thnh


si tit niu. Mc d vy cc thuyt g h a c nhng nguyn nhn thun
li gy nn si tit niu. C th tm tt gu h h sau:

+ Ri lon chuyn ho:

- T g a i t o g c tiu, t g a i u h phospho mu, do u tuyn cn


gi p ha ng tuyn cn gip nguyn pht.

- C t ng hp t g a i c tiu khng r nguyn nhn, trong khi canxi mu


v h th g, phospho u h thng hoc thp.

- Ri lo g hp thu canxi ca rut h t g ita i D g t g hp thu canxi.

- Toan ho ng th g t g i tit a i a i c tiu t g.

- Gim ti hp thu cc amino axit dibasic.

+ Cc yu t thun li:

- Tha i pH c tiu h thng: 5,8-6,2 pH):

pH c tiu kim ho do qu trnh nhi t g ng tit iu (hay gp l vi


khu p oteus l pH c tiu tha i (6,6-7,2), thun li cho qu trnh hnh
thnh si canxi, amino magie phosphas.

pH c tiu toan ho do ch hiu tht (5,5 pH), ri lon chuyn ho cc


cht hu t o g h Gutte t g a it u i thun li cho qu trnh hnh thnh si
urat calci.

- Do d d g ng tit niu v g c tiu h: d dng ca b thn,


niu qu , g ua g, ng mch cc thn.

- Do gi bnh phi nm bt g l u g h t g g g, g t
sng... gy g c tiu d hnh thnh si tit niu.
- Ngoi ra cc yu t: tui, gii, v t a l, chng tc, ngh nghip, ch ...
g ph t g n s hnh thnh si tit niu.

2. Si thn:

Si thn chim 2/3 si ca h tit niu. Nam gp nhiu h , t gp tr em,


tui thng gp l 30-50 tui.

2.1. Gii phu bnh l:

2.1.1. Si:

- V tr: c th b th , i thn ho g khu theo i thn.

- Hnh th si: c th l h h ta gi , a din, hnh san h.

- S lng: c th t mt n hng ch i k h thc to nh khc nhau.

- Mu sc: tu theo tng loi si m c mu sc khc nhau. Si Oxlat Calci c mu


e t rn. Si phosphat canci v si amino magie photphat c mu trng
c d bp nt. Si urat c mu nu. Si cystin c mu vng sng hoc xanh.

2.1.2. h hng ca si i vi thn.

- Si c th nm gn mt i thn, cn tr khng nhiu ng dn niu, t nh


h g n thn v ton thn.

- Si c th gy cn tr ng dn niu hon ton hoc khng hon ton, s gy


g c tiu b thn, lm nhu m thn dn mng dn, nu phi hp thm
qu trnh nhi t g ng tit niu lm cho thn b ph hu d ho .
Hu qu l suy thn.

- Si b thn l nguyn nhn ca hi t g d i thn, g c tiu,


nhim trng, gy hnh thnh si i thn, cc thn gi l si th pht.

- Hi tng nhim khu ng tit niu cn l nguyn nhn ca nhiu bin


ch g kh : i i thn, vim thn k, thn m, p xe quanh thn.

2.2. Triu chng;


. . . C g:

- au: ut hi au un thn. Xut pht t vng tht l g thn c si.


C au th ko di hng gi, g khi au h m vng tht l g,
bnh nhn c c gi h " l g". au la ung vng h chu, au thng
xut hin sau v ng mnh, nm ngh gi th , au thng hay ti din.

- i a u: thng xut hi sau au, i a u ton bi, c th i th


hoc vi th. Nm ngh gi i a u s gim dn.

- i a : do i i th . T o g c tiu c nhiu t bo bch cu thoi


ho, t bo biu i th . C khi c tiu c l do qu nhiu tinh th
Oxalat, Phosphas.

2.2.2. Ton thn.

N i hu g to th t tha i. Nhng si i th ha g in chng, bnh


nhn c th chu ng trong nhiu . Kho du hiu nhim khu , l
bin chng biu hin: st cao, rt run, st ko di. Suy thn tim tng biu hin:
Ure mu cao, toan ho mu, ri lo in gii. Hai bin chng: nhim trng
ng tit niu v suy thn do si th g l ho th bnh nhn suy
sp.

2.2.3. Thc th.

Si th thng t biu hin r rng.

+ Khi th ha to:

- Ngo i au: th c cc triu ch g h o g g l g, tht l g,


b g hng, bun nn. Cn phn bit vi au a gan mt, co tht i
t g, au t s g, au a nh g t ng hp g thng c bng
hng, bun nn.

- Khi th to:

Si gy bin chng t ng dn niu, l i thn dn, c, m, nn


t o g t ng hp ny khm thy c du hiu chm thn v bp bnh thn.
Tm li: si thn khng phi lc no triu ch g l s g g i h h y
. Triu chng lm sng ch cho ph p hng ti b h th i, ch o
nh phi da vo triu chng c l s g, c bit l triu ch g in
quang.

2.2.4. Cn lm sng:

+ Chp h tit niu khng chun b:

- Tiu chun ca phim: phi l c t g s XI n b di ca g


mu, phi th c b ca hu, th c bng ca thn.

- M h a phim: tm hnh nh cn quang, trn phim l mt khi cn quang r


t g ng vi vng th . im si ca gi Vit Nam 95% l si Calci, nn
cn quang r, d nhn bit. Ch cn phn bit hnh cn quang ca si thn vi
hnh nh cn quang ri rc nhu m thn do thn nhim Calci (Nephro Calcinose).
Phn bit vi im vi ho ca lao th . Ph it vi si ti mt cn quang
tu hi im ca si ti mt gi Vit Nam t gp loi si cn quang).

+ Chp niu t h ch (U.I.V: Uretero Intra Veinography).

M h a phi : l h gi h h th i a h tit niu, c bit trong


t ng hp l h gi h h th i a b th . h gi h g a thn. V
t t g i ca si so vi i thn.

+ Siu m ch o :

M h a ph g ph p: l nh hnh thi ca h tit niu i thn).


X i h h h th i, k h thc, v tr ca si.

Ch : siu m ch o kh g h gi c ch g i tit ca thn.

+ Xt nghim huyt hc:

- S lng hng cu: c th gi do i u, do su thn.

- S lng bch cu: t g khi hi t g ng tit niu.

+ Xt nghi c tiu:
- Tm vi khu t o g c tiu, vi khu thng gp l Proteus v E. Coli.

- Tm cc tinh th lng c h o alat, photphat, u at.

-X h pH c tiu.

+ Xt nghim sinh ho:

Lm cc xt nghi si h ho h gi h g a thn.

- H s thanh thi ure, creatinin.

- Cc cht in gii, u c tiu.

- Canci, photpho, u c tiu.

2.3. Bin chng:

Si thn l d vt i thn, bnh din bi k o t o g hiu , s


g c tiu v nhim trng s dn ti cc bin ch g h sau:

- Vi i thn, nhi t g ng tit niu.

- Vim thn k.

- Thn c, m.

- p xe quanh thn.

- Suy thn, ure mu cao, toan ho mu.

Si thn hai bn th cc bin chng cng phc tp v suy th g kh iu tr.

. . iu tr:

. . . iu tr ni khoa:

iu tr ni khoa rt quan trng vi gha d phng.

+ Ch nh:

- Si nh i thn.
- Si ti pht mi sau m mt thi gian ngn.

- Si san h ca gi gi.

+ C th:

- Li tiu: ch yu l khuyn bnh nhn ung nhiu c, ung 2 - , l t c


mt ngy. M h l t g lu l c tiu, trnh l g ng cc tinh th.
Khng nn lm dng thuc li tiu.

- Chng nhi t g ng tit niu: trnh mi iu kin gy nhi t g ng


tit niu h t thng niu o bng quang nhiu l , lu so de l u g ...
d g kh g si h theo kh g si h .

- iu chnh pH c tiu: nu pH < 6 th ung dung dch citrat natri, kali. Nu pH


> 6 th cho ung vitamin C1g trong ngy hoc dung dch phosphas natri.

- iu chnh ch : hn ch th hiu canci.

- Thuc tan si: cho ti a ha loi thuc no c hiu qu thc s, h g


c tc dng chng l g ng, pht trin si, gim cc bin chng.

. . . iu tr ngoi khoa:

+ Ch nh:

- i vi si mt bn.

* si i thn gy bin ch g au hiu, i u, i .

* Si i thn khu tr ti mt cc.

* Si b thn.

- i vi si thn hai bn.

*u ti a thip t i vi bn thn c ch g tt.

* u ti a thip t i vi bn thn d ly si c bo t c thn.


* Khng nn can thip c hai bn trong cng mt k m. Tuy nhin mt s s
iu kin phu thut v hi sc thn tt mt s tc gi ch t g a thip c
hai bn trong cng mt k m.

+ Yu cu phu thut:

- Khng lm hng nhiu t chc thn.

- Ly ht si.

- m bo lu th g a ng tit niu, trnh g c tiu.

- Sau m phi theo d i iu tr ni khoa chng nhim trng v si ti pht.

+C ph g ph p phu thut:

- M b thn ly si.

- M nhu m ly si.

- M b thn kt hp vi m nhu m ly si.

- Ct mt phn thn ly si.

- Ct thn ton b.

. . . iu tr bng ni soi v siu m cao tn:

Nh g g h c nhng tin b khoa hc, vic p dng ni soi v sng


siu m cao t iu tr si tit niu ni chung v si thn ni ring ngy cng
chi u th h . Nh g g g p ua t ng ca nhiu tc gi to mt c
ngot ln lao trong ngnh tit niu.

N Yutki h to a u tin cc pht ra sng thu l ph v si.

N Nitze h to ra dng c ni soi bng ng sng lnh.

N Causa .C.H, Miet.E, Eise eg.F ph t i h p dng sng siu m


t ao ph v si.
Hi a a ph g ph p a g c p d g, a g tha th dn cho cc
ph g ph p phu thut ki h in:

- Ph g ph p t c tip: cn gi l ph g ph p ph si qua da
(Nephrolithotomie Percutane: N.P.C). Trc tip qua da vo b th , a
nghin si, in cc sng thu lc hoc sng siu m cao tn vo ph si.

- Ph g ph p gi tip: cn gi l ph g ph p si go i th (Lithotrie Extra


Corproelle: L.E.C), dng sng siu m cao t t ng t go i ph si.

- Ph g ph p ua ng ni soi tit niu ph si: a soi ua iu o,


bng quang, niu qun ti b th ph si.

3. Si niu qun:

Si niu qun ch yu t th i ung (chim 80%), ngoi ra cn c th do


nguyn nhn ti ch h d dng ca niu qun (phnh to niu qun, niu
qu t h i, iu qun ch sau t h ch). Si niu qun gy tc niu qun
lm gim ch g thn rt nhanh chng v trm trng.

3.1. Gii phu bnh:

3.1.1. Si:

-V tr ca si: kho g % t ng hp gp si on niu qu / di, 20%


t ng hp gp si on niu qun 1/3 treenvaf 1/3 gia.

_ Hnh th: thng c hnh bu dc nh h ht lc ho h u du.

- S lng: c t 1-2 vin, c khi xp thnh chui (gi l chui si niu qun).

3.1.2. Niu qun:

- Ti ch c si: nim mc niu qun ph n, ng, thnh niu qun dy.

- Trn ch c si: niu qu d to khi h kh ut.

- Di ch c si: thng b hp li do vim, c khi b tc hon ton.

3.1.3. Thn:
- Nu t t ngt c th ngng bi tit.

- Thn dn to c, m.

- Ch g thn gim dn, dn ti mt ch g ho to .

3.2. Triu chng:

. . . C g:

+ au: do si niu qun di chuyn gy co tht niu qun, vim ph n niu qun,
c cp t h i th . u m vng tht l g, h g th g l au d
di l t iu ch g in hnh ca si niu qu . au sau g. au la
xung vng h v v booh ohaanj sinh d go i. C au k o d i i gi, c khi
ko di 2- g . C au gim khi ngh gi hoc dng thuc gim co tht, trong
au th c nn.

+ i a u: ai a u to i, i a u thng nh, thong qua.


i a u thng xut hi sau au.

+ i ut, i t: khi si niu qun nm st thng bng quang, gy kch thch


bng quang h d vt trong bng quang.

3.2.2. Ton thn:

+ To th t tha i khi ch c si niu qun mt bn.

+ St khi si niu qianr gy tc niu qun v c nhi t g ng tit niu.

+ Nu si niu qun hai bn hoc si niu qun mt bn v si thn mt bn th


gy h hng ton thn nhanh chng v nguy him: Ure huyt cao, thiu niu,
v niu.

3.2.3. thc th:

+ T o g au si niu qun khm thy ci c g g tht l g, g hn.


Ch cn phn bit vi au a gan mt, tu, vim rut tha, i i trng,
vim phn ph.
+ Nu si niu qu g in chng c, m, khm s thy c du hiu
chm thn v bp bnh thn.

3.2.4. Cn lm sng:

+ in quang:

- Chp h tit niu khng chun b: thy hnh cn quang n t g i a


niu qun. Ch cn phn bit vi hnh nh cn quang ca hch vi ho cnh ct
sng (m c ua g kh g g u, b khng r nt), nh g t ng hp
kh cn phi da vo phim chp UIV UPR phn bit. Cn phn bit vi si
t h ch (Phlbolithe).

- Chp niu t h h: nh v tr ca si t ng niu qu . h gi hc


g, h h th i a h tit niu. Ngo i a pht hin cc d dng ca niu
qu . Tu hi t o g t ng hp si niu qu l gim hoc mt ch g
ca thn th vic d g ph g ph p ch o si niu qu l kh kh .

- Chp niu qun b th g d g: nh v tr si ch o ph


bit c gi tr h ph g ph p hp niu t h ch.

+ Xt nghim huyt hc: S lng bch cu t g t o g t ng hp c nhim trng


ng tit niu.

+ Xt nghi c tiu: c tiu c hng cu, bch cu, tinh th cn.

+ Xt nghim sinh ho: Ure mu v ure niu, creatinin mu v creatinin niu. Natri
mu gi , kali u t g, d tr kim gim gp t o g t ng hp thiu niu,
v niu.

Cc xt nghim sinh ho c gi tr h gi h g a thn, h hng ca si


niu qu i vi thn. Ngoi ra cc xt nghim ny cn gip cho vi ti lng
v theo di s tin trin ca bnh. Si niu qun mt bn cc ch s thng
trong gii h h thng v c th i din b tr. Khi ure mu v
eati i u ao, gha l h h a g sng vi thn c si niu qun,
t ng hp ny cn phi nh ch g nh l ca thn c si niu qun,
t ng hp ny cn phi nh ch g nh l ca th i din.
3.3. Bin chng:

- Nhi t g ng tit niu.

- c, m thn.

- Suy thn, v niu trong nh g t ng hp niu qun hai bn hoc si niu qun
mt bn v si thn mt bn th bin chng ny cng d xy ra.

. . iu tr:

. . . iu tr ni khoa:

Si niu qun ph hu thn nhanh chng v trm trng nn ch iu tr ni khoa


khi c theo di ht sc cht ch.

+ Ch nh:

- Si nh g k h di 0,5cm.

- Si nhn (trn phim khng chun b thy hnh cn quang c b r nt).

- Ch g, h h th i thn, niu qu t g i h thng.

+ C th:

- Gi au, hng co tht niu qun: Atropin, papaverin, dolacgan...

- U g c hoc truy t h ch dung dch ngt g t ng 2,5-3 lt/ngy.

- Chng nhi t g ng tit niu.

. . . iu tr ngoi khoa:

+ Ch nh:

- i vi si niu qun mt bn:

* Si ng knh ln.

* Si x x on niu qu / di.
* Si g h hng ch g, h h th i a thn niu qun.

* Si niu qun bt thng (niu qu i, ph h to iu qun...)

- i vi si niu qun hai bn:

* u ti bn ch g thn cn tt t c.

* Tu theo trang thit b, kh g phu thut c th m c hai bn cng k m.

+C ph g ph p phu thut:

- M niu qun ly si, khu phc hi lu th g iu qun.

- M niu qun ly si, khu phc hi lu th g iu qun, d lu thn.

- D lu th thun.

- Ct thn ton b on niu qu n ch c si.

3.4.3. Ni soi tit niu ly si:

Ni soi niu qu ph si, hoc dng cc loi so de c bit ly si h


sonde Dormia, sonde Zeius.

3.4.4. Tn si niu qun bng my tn si go i th: c th tn si niu qun


go i th vi iu kin:

- Th gi t I ho II).

- Khng c nhim trng b thn.

- Lu th g iu qu ph a di si tt.

- Si khng nm on niu qu ua g hu.

4. Si bng quang:

Ngoi nh g im chung ca si tit niu, si bng quang cn c nh g c


im ring. Si g ua g li ua n s g c tiu. Bnh gp
nam nhiu h . Ch o thng d dng.
4.1. Nguyn nhn:

- Si c tnh cht a ph g: do th thiu cht m v tnh trng mt c


ko di.

- Si th pht: do ng v nhi t g c tiu (v d h t o g nh: u


ph i tuyn tin lit, hp niu o, bng quang thn kinh, ti tha bng quang,
ng c bng quang, sa sinh dc...)

- Si t niu qu i ung: hu ht t ng hp si niu qu i ung bng


ua g u c tng ra ngi, n ch b lu gia bng quang khi c bin dng c
bng quang hoc niu o.

- Do c d vt bng quang: ch khu, vng trnh thai...

4.2. Gii phu bnh:

- im ca si: thng l mt i g khi hiu i . K h thc c th


bng ht g g khi to ng nm tay. Thnh phn ca si to thnh nhng
g ng tm.

- Nim mc bng quang: nim m g ua g i , ph n. Si oxlat x x


cng gy t th g i c bng quang nng n h .

4.3. Triu chng:

- au: au ut vng h v khi gn cui i i, au la ung tng sinh mn v b


phn sinh dc ngoi.

- i dt i t : t i li tc, thnh thong b i t . Khi t tc th cng


but v khi ddais but li g i dt. i tc l triu ch g t g i t g
cho si bng quang.

- i a u ui i: c tiu cui i u , g l t iu ch g t g
i t g ho si bng quang.

- Nu c nhim khun th cn c cc triu chng cu i g ua g: i dt,


i ut, c tiu c.
- Th d iu o bng quang bng sonde Guyon: c du hiu chm si (Contrac
- Mtanique).

- Th t t g, o: c th pht hi c nh g t ng hp si to.

- Chp h tit niu khng chun b: va pht hin si bng quang va pht
hin si nhng v tr khc ca h tit niu.

- Chp niu t h h: t c s dng, ph g ph p h yu pht hin


t ng hp si khng cn quang, tm nguyn nhn ca si u ph i tuyn
tin lit, d dng bng quang ...).

- Soi g ua g: l ph g ph p h o h h ht, ng thi n cn l


ph g ph p tm nguyn nhn ca si.

. . iu tr:

- Ni soi tn si: ph g ph p c ch h t o g t ng hp bng quang


khng b qu, niu o h thng, si khng to qu.

- M ly si: c p d g t o g t ng hp kh g iu kin ni soi tn


si hoc va kt hp ly si va kt hp gii quyt nguyn nhn gy si u ph i
lnh tnh tuyn tin lit, ng c bng quang, d dng bng quang ...).

5. Si niu o

5.1. Nguyn nhn:

- Si t g ua g i ung.

- Si do ti tha niu o gy nn.

5.2. Triu chng:

- Thng c triu ch g o t , l t iu chng ca si g ua g: i


but, i a u ui bi.

- t hi i t , i kh , i ho to .

- ua ut vng tng sinh mn, lan xung b phn sinh dc ngoi.


- S dc theo niu o c th thy si.

- Th d iu o bng sonde Guyon thy c du hiu chm si.

- Chp h tit niu khng chun b va ch o nh va pht hin


si cc v tr khc ca h tit niu.

- Nu si nm trong ti tha niu o th thng ch c triu chng ca vim


nhim: vim niu o, c tiu c.

. . iu tr:

Si kt niu o g i ho to th tr cp cu gii quyt si ly


si tu v tr ca si niu o.

- Si nm h thuyn v gn h thuyn th m mi g s o ly si.

- Si nm xa h thuy th y si vo bng quang v x t h si bng quang.

- Si kt niu o kh g l c hoc nm trong ti tha niu o th m


niu o v tr 12 gi ly si gii quyt nguyn nhn gy si.

. iu tr theo tuyn

7. Cc bin php phng trnh si tit niu ti c g ng.

- Tuyn truyn b g ph g ti th g ti i chng cho nhn dn hiu r s


nguy him ca si tit niu.

- Tuyn truyn mi gi ung nhiu c trong ngy.

- Khng nn nhn tiu qu lu.

- Gi gn v sinh tt, chng nhim khu ng tit niu.

- Khi c triu ch g i u, i t, i kh , i ut phi i kh ga ti y t


s.

IV. Ti liu tham kho.

1. Bnh hc ngoi khoa . T g i hc Y H Ni, tp 2


2. Bnh hc ngoi khoa. Tr g i h Y Dc TPHCM, tp 4

. B h khoa th nh hc (1997). Trung tm Quc gia bin son t in bch


khoa Vit Nam, tp 1

98.DN LU B THN

1 M h:

- Gim p l i b thn

- D lu c tiu ( tr to h h i thn)

- D lu u, , ly si st, ly c u g.

- Theo di tin trin sau m: chy mu sau m, st si, vim m, lu th g

2 Cc loi d lu thn:

- D lu thn qua nhu m .

- D lu thn qua b thn .

- D lu thn qua niu qun.

T o g : d lu thn qua nhu m thn l hp sinh l nht khi t DL cn


t g DL k h thc ln, nu t g kia th kh g m bo, h a
t qua nhu m gn thnh b g h . h im l gy chy mu nhiu trong
t ng hp nhu m th d h thng nhu m th d , , lng mu
qua thn chim u g lng tim). V v gi ta dng ng DL c kch c va
phi.

3 Ch nh:
- Sau phu thut ly si thn, niu qun m thn c, m.

- Si san h, lm t th g hu th , gu hy mu th pht sau m.

- Si nhiu i gu s t si sau m.

- Ch th g h hu thn phc tp, c u kh kh , gu hy


mu sau m v c c u g.

- To h h i thn.

- Ch th g, t th g th iu tr bo tn.

- D lu thn ti thiu khi khng can thip phu thut c.

4 K thut:

- Chn sonde: Malecot, Pezzer to nh kh hau, vo m h phu thut,


trong to h h i thn th dng dy chuyn nh.

- V t : t h i gia i t khi a a d chc vo mng phi, nhm


i di thp d r).

. Kh g t t b thn v d gy r v hp.

. khi to h h th t sonde xung ti niu qun trn.

. a d lu a th h ng th g g ga g ng nch gia.

5 - iu kin rt d lu:

- Rt d lu khi t c m h d lu.

- Thi gian: 12 -14 ngy.

- Ton thn khng st, kh g au.

- Ti ch: vt m kh, h th kh g g g.
- Nc tiu trong khng c mu, khng c m.

- B thn niu qun g ua g lu th g tt.

6 Ki t a lu th g: 3 cch:

6.1 Kp th:

- Lu th g tt; BN kh g au, kh g st, h th kh g g g, khng x r


c tiu ua h so de, BN i hiu h .

- Kp th sau 24h m v h th g th t c.

- Nu sau khi kp 1 - h BN au tc vng thn, st, h thn g g, c


tiu ua h so de, BN i t th phi m sonde hot ng tr li.

- Bn tc: sau khi kp 4 h BN au tc vng thn, st, h th g g, x r


c tiu ua h so de, c tiu t g t th phi m sonde hot ng tr li.

- Cn t gu g tc hoc bn t x tr.

6.2 B thuc mu qua sonde ri kp th:

Thng dng xanh methylen ho a h e a s, khong 10ml.

- Nu lu th g tt: c tiu xanh.

- Nu bn t : c tiu xanh nht.

6.3 B thuc cn quang qua sonde chp:

Va h lu th g a pht hi c v tr , nguyn nhn gy tc.

99.DN LU H THN

L nguyn tc bt buc khi m thn


Ti sao dn lu h thn phi bt buc (c nguyn tc):

V:

1. Gp :h thn bnh thng l khoang o,khi c dch d tr thnh khoang tht

2. T chc xung quanh h thn l cc t chc m d nhim trng.Quanh


cung thn l nhng mch mu l ng mch thn,bn phi l t h ch ch,
bn tri l ng mch ch khi nhim trng d la i a d gy nhim trng huyt

3. Bao th l ao ng (bao gerota) khi b rch ho h th ic khu


phc hi kh g bo v

4. B thn ch yu ao ,khi ch b thn hoc nq vic phc hi ch c php


khu tha v ly mp ct m g trnh hp

a. Nhu m thn rn d v khi rch hoc rch nhu m thn vic khu phuc hi ko
cho php tht qu cht,ch c php p 2 mt ct vi nhau.Chnh v vy d rch
hoc rch nhu m thn th vic h vt m l chc chn

5. Th l ua i tit nc tiu p lc trong h tit niu ao h ngoi


do vt m hnn vic x r ra h thn ko trnh khi

6. Trong nc tiu c vi khun nhng ko hot ng vi PH nt l mi trng acid


nn vk ko hot g c.Khi nc tiu hy ra h thn ha cng dch tit,mu
to mi trng kim vk hot ng

V vy phi dn lu h thn

Dn lu h thn th no l tt:

Khi t c m h l dn lu nc tiu mu ,m

iu kin dn lu tt:

Ch so de cng ,ko qu mm( hay dng g ao su cng

v t t th g ng nch gia cch mo chu 2 cm

thi gian rt bnh thng l 72 h


iu ki t: thi gian,ht dch,b h h t u g ti v khi ut hat
ng bnh thng p lc b g p ton b cc tng trn bng ra thnh
b g l khoa g h thn mi tr thnh khoang o thc s

S l g dn lu h thn

Rt dn lu h thn :2 th:rt ng li on trn thnh bng,l ki kh u h


vo thnh bng>ch nh trong cc trng hp:dn lu qu 72 h

B h h t u g tin

i u kin kin quyt l lng dch h th gim nhng cha ht

u im ca rt 2 th: vn cho dch cn d trong h th a c v rt ngn o cn


on dn lu trong h th t h c khoang tn d to iu kin ho
quan bng p dn ht dch ra

Bnh nhn ngi i li c ko chc v g ua ,t h i phi .trnh lot


im t.

100. VIM NG TIT NIU KHNG C HIU

Khi nim

L tt c cc loi vim nhi ng tit niu t o g loi tr t ng hp


vim do lao, KST, bnh hoa liu, gia g ai

I. Vim thn b thn cp.

B h nh sinh.

- Do vi khun Gram (-): ecoli v para coli.

- g o: ng mu, bch huyt, ng tit niu, g gc dng t


di l , ng ln cn.
- Hay gp trong: si thn, si niu qun, U TTL, hp niu o, do th thut.

Ch o .

1. Lm sng.

- St cao rt run: do m b thn.

- au p tnh vng th : g do m b thn.

- i c tiu c: do xc BC, xc t bo m, t bo nim mc b thn bong


chc ra.

Cc triu chng trn xut hin t g t kiu chu k mang tnh cht lch pha
hau, gi ta cn gi i c kiu phong cm: khi st ao t u , au hiu
vng th th c tiu t o g, khi i th au st gim dn. Ngoi cc triu
chng trn cn thy ri lon tiu ti : i au, i t g ln.

2. Thc th v CLS.

- S nn vng thn th au, du hiu l g + i khi thn to.

- Nc tiu thy BC, TB m d i t ng.

Mu: s l g BC t g, g thc BC chuyn tri, t mu l g t g, h g


chc g th U e, C eati i t tha i.

Ch o ph it

- C au un thn: khc nhau l hi tng vim nhi : c tiu nhim


t g, BC t g.

- C au un gan, VRT cp, vim bung chng v ng dn chng: da vo


triu ch g au i c, khng c phn ng phc mc.
Din bin.

- Nu pht hin kp thi iu tr g gu h nh s thoi lui.

- Nu pht hin mu iu tr khng hiu qu s chuyn xang mn tnh, khng


khng sinh nhu m thn b teo v suy thn.

iu tr.

Giai on cp tnh:

- Bt ng bnh nhn tt, t g ng li tiu bng truyn dch v ung nhiu


c li tiu g .

- D g kh g si h theo kh g si h 5 7 ngy gia t d g ho


cht st khu ng niu: Neg a , Nit ofu a toi dng phi hp thuc
khng sinh.

+ Negram (khng khun ph rng tc dng vi hu ht gram (-) h l cn


tr sao chp ca DNA . C h d g: i . , . ; g. Ngi ln 4g/ngy chia lm
4 ln x 7 ngy, nu ko di trn 2 tun phi gim liu xung mt na. Chng ch
nh: suy thn, ri lon to u, ng kinh.

+ Nitrofurantoin: 50 100mg/ln cch 6 gi 1 ln. Mt liu trnh t nht 1 tun


kh g t qu 14 ngy, lp li liu trnh sau mt thi gian ngh thuc.
Chng ch nh: suy thn, thiu niu v niu. Vi h lng: 50mg;
100mg.

- Ch h, kh g hp, gi ng vt, gim mui.

- Gii quyt trit nguyn nhn.

II. Vim BQ cp.

B h .
- Do nhim khun nht l trc trng coli, loi vi khun Gram (-): trc khun m
a h P oteus

- Do ch th g khi a thip: tn si, th g i. Do d vt.

- gi hp niu o, UTTL

Ch o .

- Lm sng:

+ i hiu ln: mt phn do ph n xung huyt, mt phn do t th g i


m PH c tiu li acid nn ch vi git c tiu xung gy phn x thn kinh
t i tiu l BN i t g ln.

+ i au ai ut) ch yu cui bi.

Ngoi ra cn c th i u ui bi: do bng quang co bp nim mc xung huyt


cc mch mu c th ng dp g i u. i khi i c do c BC trong
vim BQ m.

- Cn lm sng: xt nghi c tiu tm VK c t g l kh g si h .

Tin trin.

- Pht hin s iu tr g ph g ph p s khi.

- Nu pht hin mu iu tr khng trit chuyn xang m t h tai i t i li,


nng gy xut huyt hoi t.

iu tr.
- Chng nhim khun: da t kh g si h v khng sinh thch hp 5 7
ngy, k hp iu tr ha cht khi gu hu n xang bn cp, mn v nhim
trng thn b thn.

- iu tr vim nhim phn ph ln cn.

III. Vim niu o cp

Ch o .

- Lm sng:

+ i au u bi sau chuyn d a g i au to i.

+ i c ch yu u bi.

+ T g ut tit v chy mu hoc chy m t mi g s o go i i i.

- Cn lm sng: xt nghim VK trong dch niu o

iu tr

- iu tr ton thn v ti ch da theo cy khu kh g si h . Kt hp


vi ho cht dit khun.

- Ti ch loi b gu h : h t g iu o, ra niu o bng


dung dch khng sinh, dung dch Fracilin 1/4000, thuc tm pha long, dung dch
Rivanol.

IV. Vim TTL cp.

B h nh sinh.

- C g g i : g u, ng bch huyt ng ln cn: vim


niu o.
- Cc vi khun hay gp l: trc E.coli, cu trng cc loi, trc trng m xanh,
proteus.

Ch o .

- Lm sng:

+ i t g ln.

+ i au ui bi.

+ i c nhiu v cui bi.

+ Chy dch m ua u ming so.

+ Th t c trng: TLT to, mm, ranh gii r v bnh nhn rt au.

+ St 38 38.5, st cao 39 400C khi h h th h p e TLT.

- Xt nghi c tiu 3 cc tm BC v t bo m.

iu tr.

- Bt ng ti ging.

- Khng sinh ph rng, kt hp vi ho cht st khu ng niu.

T ng hp p e TLT e da ph r, nhim trng huyt: phi trch cho m vo


bng quang d lu g ua g t g u, tin hnh song song vi nh git
thuc st trng (thuc tm 1/4000)

101. X-QUANG H TIT NIU

Bao gm

1. chp th thng
2. chp thn thuc(UIV=urography intra venous

3. chp niu qu thu gc dng(UPR

4. chp kh sau ph c

5. 2+4

6. Chp niu o c ua g gc dng

7. Chp bng quang

8.

Chp CT

9. AG

I. Chp th thng ko chun b

1. M h:

Pht hin cc hnh nh bt th g t g i h tit niu

Chp c th thy bng ngoi ca thn

2. Yu cu:

Bnh nhn tht tho

k h thc phim:D10-khp mu

ngang ly 2 cnh chu

pht tia nhn thy b go i tht l g hu

3. C h c xq

Hnh h ua a h tit niu

v tr l g t s g i chiu,ly m ga g th t sng, khe lin


t
t sng tht l g m t trn xu g di(v d: h khe li t L2-3 v
bn phi t g ng mm ngang ca L3 cch v go i t sng 3cm

M t hnh dng:hnh san h .hnh bn san h,hnh m vt ,m chim,hnh


tr(si ,h h t ng tm(si bng quang)

k h thc

Ch k h thc ch ln nht ga g g d i

S lng si

Mt cn quang

H g i t trn xu g di,t ngoi vo trong

II,Chp thn thu t h ch (UIV)

M h:

o Cho bit ch g i tit v bi xut ca thn

o Cho bit c hnh dng h tit niu(hnh dng ca cy tit niu)

o Cho bit s lu th g a h tit niu trn

o Cc hnh nh bnh l ca h tit niu ,c bit l si ,v tr ca n nm trn


g i a h tit niu(k c si ko cn quang)

o Hnh nh t th g nh l ca bng quang ging chp bng quang

Phn loai v ch nh:

Chp UIV nh git liu ao: : nh nhn c suy thn

Bnh nhn c ch th g thn

T c chp xn ure v creatinin mu

Dng 1-2 ml dd cn quang Telelabrix\kg+100mlHTN5% truy t h ch nhanh


trong 15 pht th chp,c 15 pht chp 1 ln
Chp UIV ch nh cho cc t ng hp cn li 0,5-1ml /1kg/tim trc tip vo
t h ch

III, Chp kh sau ph c

M h:

Bit hnh thi ngoi ca thn 2 bn nhm ch o ph it thn to v cc


khi u khc ngoi thn

Cch lm:a kh o sau phuc mc v bc tch vo phn quanh th a o


sau tr t g t c xoang cng,dng C02 ho t 800ml-1200ml

IV. UPR(Urotero pfelo retro grade):chp gc dng b thn

L khi UIV ko h c

V. Chp thn thu t h h+ hi sau ph c

h gi thn cng chnh xc hoc c th o dy nhu m thn

VI, Chp g ua g gc dng

Ch o h h nh bnh l ca bng quang c bit l u.Hin nay t dng


v c siu m...

B kh u tin lit tuyn hnh nh mt tri mc :hnh nh khi u trong khi


sng

B thuc cn quang hnh h gc li

U th h g ua g khuyt b nham nh

VII. Chp niu o c ua g gc dng

M h : nh t th g a niu o ,v tr m ca t th g t o g
bnh l ch th g iu o v hp niu o do nhiu nguyn nhn

VIII. Chp ng mach thn AP

ch o nh l v mu
Cc khi u ca thn

Mt s hnh nh b h l in hnh

1, Hnh nh si:

Si i thn :hnh san h hoc bn san h

C th c bin chng do si g : i thn gin.thn mt hoc gim chc


g

Gi :so s h l h i th gt

2, hnh nh u tt ni

Hnh nh l u th : i thn b khuyt hoc nham nh i khi u , i


cn li b h y(UIV)

Chp hi sau ph c:th c ranh gii ,k h thc khi u

3, hnh nh ca vim

Vim lao :hnh nhe thuc vng c t th g lao hoc ng thuc hang
lao to nn

102. CHN THNG THN KN

I - i g:

1 - im:

- Th l ua m su trong phc mc, vng tht l g hai , c bo v


bi th h khu g g h th g th thng t gp.

- Nhu m thn li rt gin, v vy rt d v do ch th g h g s ti mu


v c s u i dng tt nn rt d lin so v nhanh chng phc hi ch g.
- Khi b t th g, c bit khi h ao Ge ota u c tiu trn ra t
chc quanh thn d gy s nhi c, nhim khun.

- Nguyn nhn ch th g th thng do tai nn giao thng, tai nn sinh hot,


tai n lao ng.

- Ngoi t th g thn c th t th g phi hp ua kh .

2 C h ch th g:

+ Ch th g t c tip: do a p trc tip vo vng thn.

+ Ch th g gi tip: Nng vt nng, nhy trn cao xung.

3 T th g gii phu bnh l:

c chia lm 5 loi:

- Nt hu di v .

- Nt nhu m thn km theo rch v .

- Rch v , t nhu m thng vi i thn.

- Gip nt khu tr mt phn ca thn: c di hoc cc trn.

- Gip nt ton b thn, t th g ung thn.

II Triu chng:

1 Lm sng:

+ Ton thn:

- Shock l triu ch g thng gp chim 40 % t ng hp.

- H/C nhim khun: x a khi BN n mun.

+ Ti ch:

- au g sn tht l g sau h th g, khi ut hi au un


thn khi c u g t tc niu qun.
- i a u to i sau hn th g.

- Khi g g vng m sn tht l g:

+ Cc triu chng t th g kt hp.

2 Cn lm sng.

+ XN mu: HC v Huyt sc t gim trong t th g nng, va.

+ XN c tiu: C HC, BC t o g c tiu, Protein niu d g t h

+ Cc xt nghim ch o h h nh:

- Chp XQ th thng: c khi m lan rng vng thn b ch th g, ngoi


tht l g hu b xa.

- Chp XQ thn thu TM: g i thn bi t th g ho thuc, thuc cn


quang c th qua cc t chc quanh thn.

- Siu m ( siu m mu): c hnh h ng nt nhu m v d h ng trong h


thn.

- CT ( Computer Tomography): c hnh nh r nt ca t th g hu thn v


cc ng dch quanh thn.

III Ch o :

1 Ch o nh:

- C ch th g g tht l g.

- i u to i sau h th g.

- au g g vng tht l g.

- XN c tiu c HC.

- Siu m, UIV, CT cho hnh nh t th g.

2 Ch o t th g phi hp.
3 Ch o in chng:

- Vim ty h thn

- Apxe quanh thn

- R thn.

- au ko di, st ko di.

- c tiu do h t ua h iu qun do cc mu t h a.

- X teo thn sau ch th g g THA.

- Ph g M sau h th g o M thn.

IV - iu tr:

1 Nguyn t iu tr:

- Bt ng ti ging.

- Phng v chng sc tch cc bng mi bin php.

- Phng v chng nhim khun bng cc loi khng sinh.

- Cm mu.

- Theo di st din bin ton thn v ti ch th i can thip kp thi.

2 - iu tr bo tn:

iu tr bo tn khi t th g h, ng rch nhu di v, mu t nh


c th t cm, mch , HA h, i u ht dn.

+ Chng sc nu c:

+ Bt ng ti ging trn 3 tu trnh chy mu th ph t m bo thi


gian lin so.

+ Chm lnh vng m sn tht l g.


+ Truyn dch, truyn mu, tr tim.

+ Chng nhim trng bng khng sinh, li tiu.

3 - iu tr phu thut:

3.1 Ch nh:

- C t ng hp BN c st ko di khng hi ph khi iu tr ni khoa tch


cc.

- Tnh tr g i a u, g g vng th , au t g dn.

- C t ng hp nghi ng c t th g kt hp cc tng trong bng cn can


thip.

- C t ng hp t th g thn nng: v nt th , t cung thn, chong


khng nh, khi mu t m sn tht l g to dn.

-C t ng hp bin chng apxe thn.

3.2 K thut:

+ ng m:

- ng cho thnh bng bn ngoi phc mc nu chc chn c t th g thn


thun.

- ng tr g t di rn qua phc mc khi c nghi ng c t th g tng


trong bng kt hp.

+ X t : vo t th g:

- Khu vt rch nhu m thn, ly b c u g, d lu h thn.

Hoc c d lu thn nu cn.

- Ct thn bn phn nu t th g dp nt khu tr mt phn thn.

- Ct thn ton b ch t ra khi thn b gip nt ton b, cung thn b tn


th g kh g th khu phc hi.
=> Ch : . Phi kim tra th i din trong qu trnh m.

. X tr cc t th g phi hp nu c.

. D lu thn kt hp sau khi tr t th g thn.

4 Ct thn:

4.1 - Ch nh ct thn :

- Thn mt ch g.

- THA c tnh do thn .

- K thn.

- Ch th g, t th g thn khng c kh g o tn.

- Ct thn sau phu thut ghp thn.

4.2 Tai bin ca ct thn.

- T th g ung mch ln gy chy mu.

- Rch phc mc, t th g tng xung quanh.

4.3 Bin chng sau phu thut.

- Chy mu sau m.

- R mm ct niu qun.

- dch trong h thn.

- Nhim khun vt m, nhim khun ton thn

103. XT NGHM NH GI CHC NNG THN


1. Ure v creatinin huyt tha h t o g eati i h h h v :u e ph
thuc vo:

Ch

Tnh trng hoi t t chc

Tnh trng st sau m

U e c thi qua cu th c ti hp thu ng thn cn creatin th ko

2. H s thanh thi eati i h thng 60-120 m l)

. in gii

4. D tr kim

5. Cng thc mu

.U ev eati i c tiu

7. T tr g c tiu

Cc xt nghi h gi h g a mt thn

1. UIV

. ng v phng x

3. Siu m doppler mu

4. Soi bng quang thuc mu

5. Chp ng mch thn

6. Xt nghi c tiu t g t catether vo tngbn b thn)

104. HP BAO QUY U


I. Gm 4 th:

Th th g thng

Th bn hp

Th hp cht

Th hp tht

1. Th th g thng : t l khi d g t mm hay c g u c th ln


bao u u c

2. Th bn hp: khi d g t mm mi l c

3. Th cht : khi u t h i him

II. iu tr

Hp ao u u tht:l cp cu ngoi khoa cn gii thot vng tht,nu khng


vng tht s gy hoi t.

B h h n s di vng tht ha hoi t,nu c ph n th dng kim


chc mt s g gii phng dch ph n.sau ln ao u u tr v trng thi
h thng

cch ln: hai g i t ph a h ao u u,hai ngn tr kp vng tht tnh


tin v ph a nh. sau khi ln xong hn b h h n s ct ao u u k
2.Nu b h h n mun ta cn phi phu thut ,gy t ti ch bng
LIDOCAIN ph a l g d g t.rch ngang qua vng tht ti tr d g t ,ti
cn, khu cho bnh nhn v h n khm li v ct k 2 th bn hp ( to hnh
bao u u hay x t a )gy t g d g t ,s ng ao u u d i
khong 3cm v pha l g d g t, sau m khu l ngang
Hnh nh hp ao u u

105. CHN THNG TRONG NIU KHOA

PGS TS BS. Tr L Li h Ph g

CHN THNG THN

1. Ba gu h thng gp nht ca ch th g thn

Tai nn giao thng, t t trn cao, tai nn th thao.

Ch th g thn chim t l 60- % t ng hp


th g tn thn khng do phu thut, t l cn li l do vt
th g thn.
2. Cc du hiu lm s g thng gp nht gi n ch th g thn?

C du hiu ch th g gh g l g g g sn, mu t di da
g h g l g

Tiu u i th

Tiu mu vi th v huyt p tm thu < 90 mmHg

3. Bnh nhn tiu mu vi th sau ch th g thn c cn lm xt nghim


hnh h ch o v mt niu khoa khng?

Khng cn thit. Bnh nhn c tiu mu vi th v du hiu sinh tn nh


khng c h gi th mt niu khoa. Nu tiu mu vi th km theo
chong th phi lm UIV hoc CT scan bng. Hin nay ti nhiu trung tm
ch th g, CT s a g tha th vai tr ca UIV nhy cao
h t o g h o h th g th ng thi pht hi c cc
th g t kh i k t o g bng.

Tuy nhin nu tr em <16 tui c tiu mu vi th sau ch th g ng th


phi lm xt nghim hnh nh hc. Thn ca tr e gu d b tn
th g sau h th g k th c bo v km, d di ng v to
h thn ca gi ln, ngoi ra c th c cc bt thng b si h i k .

4. M tiu u t g ua vi m nng ca ch th g ha
khng?

Khng.Thn b ng dp c th tiu u i th trong khi thn b t


cung c th khng c tiu mu.

5. K thut lm UIV bnh nhn b ch th g thn?


Nu bnh nhn nh th c th l UIV h t ng hp khc. Nu
sinh hiu ca bnh nhn khng nh th phi dng thuc cn quang vi
liu lng gp i. Chp cc phim 1 pht, 5 pht, 10 pht.

6. Mc tiu ca UIV trong ch th g thn?

h gi chn th g thn, t k ho h iu tr thch


g. ng thi bit c ch g hot ng ca th i din.

7. Th no l ch th g thn nh?

Ch th g thn nh chi % t ng hp ch th g thn. Cc


sa g th g ao g ng dp thn hoc rch khu tr lp v ca thn

8. iu tr ch th g thn nh?

Nu c tiu u i th th phi nhp vi iu tr bo t ho n khi


c tiu trong. Nu tiu mu vi th UIV h thng th c th iu tr
ngoi tr.

9. Th no l chn th g thn nng?

Ch th g thn nng c th chia lm hai loi: c t th g ung v


khng c t th g ung. Cc t g th g t o g h th g thn nng
lan r g i gi p a h gia v v ty thn. Nu i thn b tn
th g th th gy tho t c tiu ra ngoi.

T th g ung thn bao gm rch hoc nghn tc mch mu ca thn.

10. iu tr ch th g thn nng?

iu tr cn nhiu bn ci. Tu thuc vo m c ca sa g th g


pht hi c trn CT scan. Nu bnh nhn nh, c th iu tr bo
tn bng cch truyn mu, truyn dch, khng sinh ph rng v ngh gi
ti ging. Theo di st s nh ca sinh hiu v din tin ca chn
th g ng cch chp CT scan nhiu ln, so snh cc phim. Nu lm sng
khng ci thin v c du hiu chy mu din tin th c ch nh m thm
st.
11. Nu c hi t g tho t c tiu ra ngoi, c ch nh can thip phu
thut hay khng?

Hi t g tho t c tiu ra ngoi cho th l t th g thn nng.


Tuy nhin nu ch c s thot c tiu ra ngoi m thi th khng c ch
nh can thip ngoi khoa. Nu c du hiu nhim trng ho c tiu vn
tip tc thot ra ngoi th c ch nh m thm st v d lu.

Phi h gi c tnh trng ca niu qun v c t th g l t khc


ni niu qun - b th g iu hin bng s tho t c tiu ra ngoi)
cn phi c sa cha ngay.

12. Biu hin trn hnh nh hc ca tnh trng huyt khi ng mch thn?

Trn UIV: khng thy hnh nh thn

Trn CT scan: thn khng bt thuc cn quang

13. iu tr t th g ung thn do ch th g?

T th g ung thn c c can thip phu thut ngay lp tc. Nu


t th g hai bn th phi tin hnh phu thut ti lp tun hon ca
cung th . T ng hp t th g t bn v th i din cn bnh
th g h iu tr cn nhiu bn ci. C th m ni li mch mu hoc
iu tr bo tn. Nu iu tr bo tn bnh nhn phi c theo di huyt
p cht ch. Khi c biu hin cao huyt p do hp ng mch thn th phi
m ct thn

14. iu tr vt th g thn do ha kh?

Tt c nhng bnh nhn b vt th g thu b g do n b u c t nht


t th g t tng trong bng, v v u phi m thm st. Nu UV
hoc CT scan thy c t th g a nhu m thn th phi m thm st
th ct lc
15. C ch h iu tr bo tn trong vt th g thn do ha kh khng?

Nu i n khng xuyn thng phc mc (dch ra bng m tnh), CT


scan cho thy t th g g v thn, lm sng bnh nhn nh th
c th iu tr bo tn.

16. Cc vt th g th do dao iu tr ngoi khoa khng?

iu tr vt th g th do dao tu thuc vo m t th g a
nhu m thn v tnh trng t th g a cc tng khc trong bng. Cc
vt th g ph a t ng nch gia thng xuyn thu bng, c
kh g t th g tng trong bng nn cn m thm st. Trong lc
m s kim tra tnh trng thn.

Cc vt th g ph a sau ng nch gia him khi gy t th g


tng trong bng. Nu dch ra bng m tnh, khng c du hiu mt
mu nng v CT scan cho thy t th g g thn th c th iu tr
bo tn.

TN THNG NIU QUN

1. T l t th g iu qu t o g t ng hp vt th g ng do ha kh

Khong 2,5%

2. Mch mu nui ca niu qun

Niu qu c cp mu ch yu t mt nhnh ca ng mch thn. Ngoi


ra c mt s nhnh t ng mch ch, ng mch sinh dc, h v, bng
ua g t di

3. Vt th g iu qu do dao ph bi h do ha kh hay khng?


Khng. Cc vt th g ha kh chi t % t ng hp t th g
niu qun

4. Tiu mu c phi l du hiu thng gp trong t th g iu qun hay


khng?

Khng. Kho g % t ng hp t th g iu qun c kt qu tng


ph t h c tiu h thng

5. Ch a h h nh no cn lm khi nghi ng t th g iu qun

Phi lm UIV khi nghi ng t th g iu qun. Khi c t th g iu qun c


th thy cc du hiu sau:

Thn bn t th g hm phn tit hoc khng phn tit

Thn c

Tho t c tiu ra ngoi

Khng thy ht ton b niu qun

6. Khi m nu thy t mu sau phc mc v niu qun b ng dp, lm sao


h gi c s ton vn ca niu qun?

Ti t h ch Indigocarmine s gip pht hi t ng hp thot


c tiu ra ngoi niu qun

7. Trong thi k hu phu, du hiu no gi c t th g iu qun?

Cc du hiu u kh g c hiu, c th c tnh trng lit rut k o d i, au


bng ho au h g l g, kh thy c khi u bng. i khi thy ng
d lu a dch lin tc ko di. C th c tnh tr g t g u u, t h
trng nhim trng.

8. T th g iu qun do y thut?

Tn sut t th g iu qun do y thut khong 0,5- %, thng xy ra


sau cc phu thut sn ph khoa. T th g iu qun do ct hoc kp
nt niu qu thng gp nht. Ngoi ra, niu qun c th b ct t
ga g, ng dp, gp gc trong qu trnh phu thut.

9. Trong cc phu thut sn ph khoa, khi no d gy ra t th g iu


qun nht?

Trong lc ct dy chng infundibulopelvic

Trong lc kp v ct ng mch t u g on bt ngang qua niu qun.

Trong lc no hch chu (trong phu thut ct t cung tn gc)

Trong lc cm mu g hu

10. C h iu tr khi niu qun b ct tht?

Nu pht hin ra ngay trong lc m ch cn ct nt ch ct.

Nu pht hin v m li sau phu thut 24 gi: ct mi ch ct t stent


niu qun. C th ct on niu qun v ni ngay

Nu m li sau khi phu thut 72 gi th hu h lu lu phi ct niu


qun v ni li.

11. iu tr t o g t ng hp niu qun b ct dt on 2/3 trn?


Ct lc v ni niu qun vo niu qun cn li.

12. Chng ch nh ni niu qun- niu qun?

T th g iu qun do x tr

Ti si niu

Ti u g th t bo chuyn tip niu qun trn

Lao niu

X ho sau ph c

Bt t g g g k k h thc ca hai niu qun

Bt thng ca niu qun cn li

13. iu tr t th g iu qu / di?

Cm li niu qun vo bng quang

14. Nu niu qun mt mt on di th c th lm c h o ni niu qun


tn tn m khng b g

C th di ng thn xu g ph a di ri c nh th . C g th di ng
bng quang ln pha trn ri h o psoas ng thi vi lm cung
Boari ca g ua g ni vo niu qun

15. Th no l niu qun hi trng?

L s dng mt on hi trng thay th mt on niu qun b t th g


khi on t th g kh d i
16. Vai tr ca soi bng quang v chp niu qu g d g t o g t ng
hp nghi ng t th g iu qun

Chp niu qu gc dng s h c v t di ca on niu


qun b t th g. Nu m t th g h, c th ti h h t
thng niu qu lu iu tr

CHN THNG BNG QUANG

1. Cc loi thng bng quang?

Thng bng quang c 2 loi: trong phc mc v ngoi phc mc

2. C h v bng quang trong phc m t o g t ng hp ch th g?

V bng quang trong phc m thng xy ra trong nh g t ng hp


ch th g k o g g di, nht l khi g ua g g y. p
lc trong bng quang b t g l t ngt lm cho bng quang v im
yu nht l g nh.

3. Gii th h h v bng quang ngoi phc mc

C 2 gi thuyt gii th h h v bng quang ngoi phc m c chp


nhn:

T o g t ng hp c gy khung chu i k vi ch th g, ht l gy
u g t . Hai u g g hoc cc m h g n rt d thng
bng quang, lm thng bng quang gn vng c bng quang.
Gi thuyt ny cho rng khi bng quang khng cha c tiu, mt chn
th g ng n vo vng b g di g kh g h g ua g
t g t nhu lm rch bng quang g h l g ua g g y
c tiu.

4. Nhng bnh nhn gy khung chu km tiu mu vi th th c cn phi


h gi t h t ng ca bng quang hay khng?

Mt s nghin cu cho thy nu khng c tiu u i th th tn sut v


bng quang rt thp nn khng cn chp bng quang c cn quang trong
t ng hp ny.

5. Cch chp bng quang c cn quang?

Dng mt th g Fole F o g ua g, o ng thng 300-


500ml thuc cn quang pha vi c mui si h l . Sau th - 15
ml thuc c ua g c. Kp ng thng v chp. Sau phi chp
thm mt phi t ht thuc cn quang.

6. Hnh nh ca chp bng quang c c ua g t o g t ng hp v bng


quang ngoi phc mc?

Bng quang c hnh git c do b khi mu t vng chu chn p km


vi s thot thuc cn quang ra ngoi vng chu. phim x thuc, vn cn
thy c thuc cn quang vng tiu khung.

7. Hnh nh v bng quang trong phc mc khi chp bng quang c cn


quang?
Khi chp phi y thuc, v bng quang trong phc mc c hnh nh thot
thuc cn quang vo trong bng. Thuc cn quang c th ng li vng
tiu khung lm xo m ng vin trn ca bng quang gy ra hnh nh
"knh m". Thuc cn quang c th nm rnh c h i trng

8. iu tr v bng quang trong phc mc?

Bt buc phi m b g khu bng quang

9. iu tr v bng quang ngoi phc mc?

Cn nhiu tranh ci. Nu bnh nhn c cc t thng khc trong b g i


km cn phi can thip ngoi khoa th trong lc m bng s tin hnh khu
bng quang lun. Nu bnh nhn ch thun mt th g tn v bng
quang ngoi phc mc th c th iu tr ni khoa b g h t thng niu
o lu dng khng sinh ph rng. T ngy th 7- 14 sau ch th g
s tin hnh chp bng quang c c ua g t c khi rt thng niu o.
Nu bnh nhn vn cn tiu mu cc ko di, nhim trng, chp bng
quang cn quang thy c hnh h tho t c tiu th l c ch nh can
thip ngoi khoa khu li l thng.

V NIU O

1. im gii phu ca niu o v cu trc cc cn mc quanh niu o?

Niu o t c bao gm niu o d g t v niu o hnh, bt u t


mi g s o hu. Ton b chiu di ca niu o t c
bao bc bi th xp.

Niu o sau bao gm niu o mng v niu o tin lit tuyn, bt u


t hu n c bng quang. Niu o g c bao quanh bi
tht vn niu o cn niu oo tin lit tuy bao bc bi tin lit
tuyn

Cn Buck bao quanh th hang v th xp, mt u gn vo mt di ca


ui u h h, u cn li bao ly hai tr ca th hang v phn hnh
ca th xp. Khi v niu o t c, nu cn Buck cn nguyn v th c
tiu v mu thot ra ch lm ph n v b t d g t m thi.

Cn Colles che ph hu nng, hai bn gn vo ngi, g h di


g u g a i. Ph a t c cn Colles lin tc vi cn Dartos
ca bu v cn Scarpa ca thnh bng. Khi cn Buck b ph v, u c
tiu lan ra nm trong cn Colles to a h h h , i khi th lan
dc ra thnh b g t c.

2. C gu h thng gp ca v niu o t c?

Ch th g g hu l gu h thng gp nht gy v niu


o t c. Cc nguyn nhn khc bao gm: vt th g iu o do ho kh
ho do dao , h th g iu o sau cc th thut niu khoa, chn
th g iu o i k i g d g t

3. Ngu h thng gp ca v niu o sau?

a s l do gy khung chu do tai n , thng nht l tai nn giao thng.

4. Cc du hiu gi n v niu o?

Tt c cc bnh nhn c bnh s ch th g g hi , c bit nu c


gy khung chu, phi lu lu lu n tnh trng v niu o km theo.
Hai du hiu thng gp nht l ra mu l so v b h h kh g i
tiu c. Tuy nhin khng phi l o g hai du hiu ny.
Nh g t ng hp ch th g iu o nng c th c mng mu t lan
rng d g t v / ho hu..?

5. Khi gy khung chu c v niu o sau, th kh t c trng s thy g?

C th th c tin lit tuyn b y ln cao do khi mu t vng chu.


Trong nh g t ng hp v niu o sau phc tp, c th s c ch
rch mt t c trc trng, qua ch rch ny c th s thy m h g
g . Khi t ta , u d h theo g g ta .

6. Cn lm g khi nghi ng c v niu o?

Nu cc du hiu lm sng gi c v niu o, tuyt i kh g t


thng vo niu o v s l ho th g tn niu o cng nng n h .
Vic cn lm l phi m g ua g a da chuy lu c tiu. Ch tin
hnh chp niu o- g ua g gc chiu c c ua g khi th g
tn niu o nh v s chp trong vng 24 gi t c khi tin hnh
phu thut ti to niu o.

7. iu tr v nio o t c?

X t a u ca mt t ng hp v niu o t c, d v hon ton hay


v khng hon ton bao gi g l hu lu c tiu bng cch m
g ua g a da t g u. Sau t vi tun, bnh nhn s c
nh gi li tnh trng niu o bng cch chp niu o- bng quang
gc chiu. Nu c hp niu o th s iu tr tip theo h t o g i
hp niu o.

C t ng hp vt th g iu o t c phi c m ga . T c ht
phi x t th g t i km. Nu on niu o b t th g t th
c th tin hnh to hnh niu o ga th u. Nu on niu o b tn
th g d i th phi ct lc (c gng gi li m niu o cng nhiu cng
tt), chuy lu c tiu t g u. Niu o s c m to hnh
th hai?

8. iu tr v niu o sau?

iu tr a u l chuy lu c tiu bng cch m b g i a da t


g u. T o g l bng quang, cn quan st tnh trng ca bng
ua g sa cha kp thi th g tn. Sau 4 - 6 thng, s tin hnh
to hnh niu o.

9. nhng b h h c to hnh niu o sau, khi ct tin lit tuyn


qua niu o cn phi lu iu g?

Khi v niu o sau, thng c h h g n h th g tht vn niu


o. Sau khi to hnh niu o sau thnh cng, vic tiu c ki so t c
m bo nh h th g tht t c bng quang. Khi tin hnh ct tin
lit tuyn ni soi, h th g tht c bng quang b tn hi rt nhiu, d
gy tiu khng kim sot nhng b h h . Do , hng bnh nhn
c m to hnh niu do sau, khi c triu chng ri lo i tiu ca
u tin lit tuyn tt nht iu tr ni khoa.

CHN THNG TINH HON

1. Cc loi ch th g ti h ho thng gp?

Ch th g k l gu h h th g ti h ho thng gp nht,
k l t th g ti h ho . a s cc ch th g ti h ho gp
la tui t lc d th n 40 tui. Mt s t t ng hp ch th g ti h
hon c th xy ra trong lc sinh.
2. Mc tiu ca iu tr ch th g tinh hon?

M tiu h g u l bo tn cng nhiu m ch g a tinh hon cng


tt. Rt? nhiu nghin cu cho thy r g t ng hp ch th g ti h
hon m cng sm th cng bo t c ch g a tinh hon.

3. Xon tinh hon ho u tinh hon c phi l hu qu ca ch th g


tinh hon hay khng?

Ch th gt c tip tinh hon khng bao gi gy ra xon tinh hon hoc


u tinh hon. Xon tinh hon c th xy ra sau cc hot ng th lc
gng sc. Mt t ng hp t th g ng n kh g t g ng vi
ch gy ra t th g u phi c nghi ng l ch th g y ra trn
mt ti h ho u.

4. X tr mt t ng hp ch th g ti h ho ?

Hi bnh s tht k l g h gi h v m nng ca chn


th g. Chn th g k g ti h ho thng do mt lc m h t
ngt y tinh hon v ph a g u. a s t ng hp khi bnh nhn
ti khm b h th u s g to, au kh kh s c tinh hon, mo
tinh v thng tinh. Tt nht l l siu u nh m
th g tn. Nu lm sng hoc ch o h h nh nghi ng c v tinh
hon th phi can thip phu thut ngay. Trong khi m, nu bao trng tinh
hon b rch th cn ct l ti h ho n m lnh ri khu li bao trng
bng ch ta . T khi ng tinh mc nn d lu pe ose t o g ti h c
qua vt m.

5. X tr vt th g ti h ho

Tt c t ng hp vt th g ti h ho u phi m thm st v x tr
h t ng hp v tinh hon. Ngoi ra cn phi x t th th g tn
i k a ua l n. Nh g t ng hp vt th g ti h ho
do ho kh, v t u ao, go i th g tn nhn thy ngay, c
th xy ra tnh trng hoi t mun ca tinh hon vi ngy sau khi b th g.
V v , t ng hp vt th g ti h ho n do ho kh nn ct tinh hon.

6. Th no l ch th g g di lch tinh hon?

Ch th g k kh g h g a ng dp hoc v tinh hon. Nu mt lc


t g t ngt vo bu c th y tinh hon ch gc vo trong ng
bn, thm ch tinh hon c th chy vo trong bng. T th g loi ny
c th g au t d di. Thng tinh c th b xon v bao trng ca tinh
hon c th b v. a s t ng hp thng xy ra trong bnh cnh
a h th g h th g ti h ho d b b st. Khi khm c th
thy mt bn bu khng c tinh hon hoc c th s c tinh hon nm
vng bn. Nu tnh trng chung ca b h h ho ph p kh g th g
tn n g kh i k s c tinh hon nm na ngoi ca ng bn th
c th cho bnh nhn thuc gi au, tin m b g g t h h
c gng dng tay nh h g y tinh hon tr v v tr trong bu. Nu cch
lm ny tht bi hoc nu nghi ng c v tinh hon th phi phu thut
thm st v sa cha th g tn ca tinh hon.

7. Cc ch th g ti h ho , v lu di c h h g n kh g si h
sn hay khng?

Ngay sau khi c t th g, t h t ng sn xut tinh trng b tha i, thm


h a n v tinh. Sau 3- 9 thng, tnh trng sn xut tinh trng c th
phc hi tr li. Mt s nghin cu trong phng th nghim cho thy tn
th g ti h ho t bn c th gy ra nh g th g t h in tinh
hon cn li v lm gim kh g th thai. Tt c nh g gi b chn
th g ti h ho u phi theo d i ti h t g .

Nam gii b si h g lu n ti h th g ti hho .


8. Cc nguyn t h h iu tr ch th g ti h ho

X nh nguyn nhn ch th g u c th)

S d g siu h gi t h t ng tinh hon, bao trng ca tinh hon

Lm sng vn l yu t quyt h, kh g ua ti tng vo siu m

Nu c nghi ng t th g g h t h t g ng dp th nn phu
thut s tha iu tr bo tn. V phu thut bao gi g o t c
ch g a tinh hon nhiu h

106. CC TRIU CHNG V HI CHNG TRONG TIT


NIU

. Hi h g au

. au g th , iu u

C au u th

. au g g ua g

. au g t g si h

T g si h :

. au g u

. Hi h g i lo tiu ti

. i ut i au :

+ i ut u i

+ i ut ui i
+ i ut to i

. i t i t g l

+ l / a g , l / a .

ph it: a iu, i th o ht, t g hp t l

2.3 i kh

. B i

ph it: iu, khi u g h h p k h th h g ua g ha


gp ph l tui u a g u g t g, u t u g .

. Mt s t iu h g kh

is

i s t tiu

i , tiu

i gt g g.

. Hi h g tha i v th h ph tiu

. i u

+ i u i th

+ i u i th

- i u u i

- i u ui i

- i u to i

h phi l ghi ph p
. i

+ N tiu t o g, hi h g a U o ili .

. Mt s tha i u s tiu

N tiu u : do d g hp o phosphat

N tiu u u s : do po phirin, Hb.

. Tha i t t g tiu

+ , , , a > a g

. i a P otei

+ Kh g o t t P otei t o g tiu.

. Hi h g tha i v s l g tiu

+ , , l/ h, ph thu o iu ki u g, thi tit, hit ,

. a iu

. Thiu iu

. V iu

107. CHN THNG NIU O

. Mt s t i g

+ Nh li gii phu: iu o sau g :

- Niu o sau

. Niu o tu ti lit

. Niu o g
- Niu o t

. Niu o th h

. Niu o t g si h

. Niu o d g t

. Ngu h v h:

C h: C h t tip h gi tip

. Ch th g iu o sau

C h gi tip l h u, h t tip do s g to g g t
o g, soi iu o.

. Ch th g iu o t

. C h t tip, th g gp g gi t t g

. T iu h g

. T iu h g l s g

a. To th

+ Shock

+ Nhi khu

. T iu h g a t th g iu o

+ CMMSNB h u i g s o go i i i

+B i u g ua g +

+ M u t

- Ch th g iu o t

- Ch th g iu o sau
. T iu h g a t th g ua kt hp

d. T iu h g a g hu

. T iu h g l s g

a. X t ghi

BC, HC, HST

. Ch o h h nh:

+ X quang:

+ Chp iu o ua g g d g

+ Ultrasound

4. iu tr

Ngu t

+ Ph g & h g sho k

+ Ph g & h g hi khu

+ C u

+ Ph t hi s t th g kt hp & t theo th t u ti

+ D lu tiu

+ Bt g t th ga, h g t gi B ol

+ X t t th g iu o o thi i th h hp

* X t t th g iu o

. Niu o dp:

t Fole ua iu o o g ua g & lu d g

. Niu o th g, t:
+ Vi iu o t iu o : kh u i ga t Fole do loi h
th g / t th g h, t sho k,

+ Vi iu o sau:

- Nu iu ki / ho ph p s hu khoa Phu thut th


d lu g ua g + t th g iu o

- Nu iu ki / kh g ho ph p kh g s hu khoa Phu
thut th d lu g ua g t g u + to h h iu o)

t h o s :

CTN = CCCT + CMMSNB

CTN + V g hu = CTN sau do g hu

108. I CNG V CC PHP O NIU NG HC

Nguy V

B s CK Niu, Ti s Y hc - T ng phng Ch o Niu ng hc, bv Bnh


Dn

I- M U

T u ,T u gt Ch o Y khoa Medi t i khai ph p o


Niu ng hc. Bnh vi B h D g a khai t g Ph g Ch o Niu
ng h o u thng 9/2002. Vy Niu ng hc (NH) l g? Bi vit ny
nhm gii thiu nhng nt khi qut v ph p o .

Nghin cu niu ng hc (urodynamic studies) l mt phn quan trng trong


h gi nh nhn b ri lon ch g ng tiu di, bao gm nhng
h gi khch quan v ch g ng tiu di h h g a b g i,
h hot ng ca tht niu o, dng thc ca s i tiu, nhm cung cp
nhng thng tin hu ch cho lm sng. Nh g ph p o ao gm vi o
lng v p l , du g t h, lu lng, th g in- th bao gm cc
h gi X- ua g i vi ng tiu di.

Ch nh: Hu ht nhng bnh nhn b ri lon ch g ng tiu di u c


li t mt s ph p o NH, tu hi kho s t NH c bit hu ch cho mt s
nhm b h h tiu khng kim ch, b tc dng ra ca b g i outflow
obstruction), ri lon ch g th pht t b g i thn kinh, v mt s tr em
c v v sn tiu i tiu phc tp (Webster, 1998)

II - GII THIU CC PHP O CN BN CA NIU NG HC:

2.1. PHP O P LC BNG I - cystometry:

Kho st s tha i p lc bn trong b g i theo du g t h g i. p lc


b g i c theo di lc b g i y th ng v lc b g i o p
ch g. Khi o gi ta ghi nhn cm gic mc tiu, dc ca ng biu
di t o g l y v s co bp ca h p g i.

2.1.1. Cm gic b g i:

B h thng, cm gic y b g i y ra khi dung tch b g i khong t 100


- l. Sau l m gic mc tiu, thng xy ra khi dung tch b g i
khong 350 - 400 ml.

Nhng bt thng v cm gic mc tiu bao gm gim hoc khng c c gi


y hoc cm gic mc tiu. Kh chu hoc mc tiu gp khi dung tch cn t l
in hnh ca tnh trng vim chng h h hi t g ng tiu di, vim
b g i do tr, vim b g i k .
2.1.2. Giai on cha g hay y:

Do tnh cht vt l c bit ca thnh b g i t o g giai on cha ng,


dung tch b g i th gia t g t nhiu h g p lc bn trong b g i t g
rt t. V th, h thng th biu p lc b g i t o g giai on ny g h
n ga g. Ngi ta dng khi nim dn n b g i (compliance) (DV/DP
t o g giai on cha g h gi im ny ca b g i.

T g dn n b g i c th gp trong g c tiu m t h o t k
nguyn nhn no.

Gim dn n b g i c th do nhiu nguyn nhn, bao gm vim b g i


mn tnh, vim b g i do tr, vim b g i k, carcinoma b g i .

. . . Giai on co bp b g i:

Co p h p g i th hin bi s gia t g p lc chm v nh trn


ng biu di n 60 - 120 cm H2O. gi h th g, giai o c
o t c bi cm gic mc tiu, tuy nhin nu mun th c th km hm s co
bp ny.

T g hot h p - do nguyn nhn thn kinh hoc khng - biu hin bi dung
tch b g i th hin trn p l di l iu quan tr g h l kh g
c kh g c ch s o p h p. Ngi ta thng dng t t g phn x
chp (detrusor hyperreflexia) cho nh g t ng hp do nguyn nhn thn kinh,
v t bt h h p (detrusor instability) chnh g t ng hp khng do
nguyn nhn thn kinh hay khng r nguyn nhn.

Kh g o p h p - khng thy s o p h p khi o p lc b g i. Lu


rng do s c ch t l t o g l o kho g % g % ph n
v i tiu h thng li khng th biu hi o p h p t p l
b g i. Ngi ta dng t bt phn x h p det uso a efle ia cho nhng
t ng hp do nguyn nhn thn kinh, cn kh g o p h p det uso
acontractile) cho nh g t ng hp khc.

Suy yu o p h p - biu hin bi nhng co bp yu v ng , thng gp


gi gi thuc c hai phi, c l do s thay th t g i ng thnh
phn collagen.

2.2. PHP O NIU DNG - uroflowmetry:

l ph p o du ht khng xm nhp (noninvasive t o g ph p o NH.


C h o li rt kh gin: ch cn b h h i tiu mt l g c tiu thch
hp vo phu hng ca o c gn kt vi mt my bi g, i
tr g lng ca c tiu s c chuyn thnh dung tch v ghi li thnh biu
vi t l/gi . Ph p o iu dng l thng dng nht t o g ph p o
NH, c th d g h l t xt nghim tm sot v ch g ng tiu di,
nhanh chng v r tin.
T dng tiu l kt qu sau cng ca hot g i tiu, do hu h hng
ca nhiu yu t h s o p h p g i, s dn lng ca tht niu
o v s thng sut ca niu o. Do b t ng bi nhiu bin s h th nn
mt s tc gi khuyn r g kh g d g ph p o iu d g h l t xt
nghim ch o . Tu hi u phi hp niu d g vi vi o lng tiu
t lu, ta th o tnh hiu qu ca hot g i tiu.

Hnh dng ca niu d g c th cung cp nhng thng tin hu ch, chng hn


ng biu din khng khng u n c th do sc rn ca bng hoc bt ng
vn b g i- tht.

iu quan trng nht khi h gi t dng tiu h th g l nh dung


t h i tiu. a s cc tc gi khuyn nn c mt lng tiu trn 150 ml th xt
nghim mi c gi tr, tt nht l trong khong 200 - 400 ml.

Si ok K a e a a t s h thng ca t dng tiu ti a - Q max


d g nh) ty theo tui v phi:

Bng 1 - Cc gi tr Q max h th g i vi lng tiu trn 150 ml.

Nhm bnh nhn Tui Q max h thng (ml/gy)

Nam < 40 > 22

40 - 60 > 18

> 60 > 13

N < 50 > 25

> 50 > 18
Tr em, thiu nin < 10 > 15

10 - 20 > 20

Thc ra, ch i g ph p o iu d g th kh g cung cp thng tin chnh xc


v dng thc ca ri lo i tiu. Nhiu khi ta khng thy s khc bit ca niu
d g gia b t d g a su o p h p. Tu hi theo ghi u
ca Abrams v Griffiths (1979) trn cc bnh nhn nam: khi Q max < 10 ml/s th
% c chng minh l c b tc dng ra.

2.3. PHP O IN C CA C VN Y CHU - electromyography:

Ngi ta dn cc b in cc ln vng tng sinh mn hoc cm nh g in cc


o h g hu ghi nhn kh g hot ng ca tht vn niu
o. Ri g i c th cho nhng thng tin hu ch v hot g tht
t , h g u phi hp ng thi vi ph p o p lc b g i th s rt c gi
tr.
gi h th g, i cho thy khng c tnh trng mt kim sot thn
kinh, phn x thi g h thng, v bnh nhn c th t o tht g
tng sinh mn theo mu . T o g giai o y ca b g i, p lc trong
b g i s t g d l , gi ta g ghi hn s t g dn ca hot ng
in- a tht vn niu o nhm trnh xy ra s sn tiu trong pha cha
ng. Trong giai on t g tho t, h p g i o p, ng thi c s gim
i i g g hn hot g in- a tht vn niu o trong sut qu
t h i tiu.

Nu t o g l h p g i a g o p g tng sinh mn khng


dn ra th gi l bt ng vn b g i- tht (vesicosphinter dyssynergia). Php
o i l ph g tin tt nht nh tnh trng ny.

2.4. PHP O P LC NIU O (urethral profilometry) :

Ph g ph p th g c p d g l o p lc ct dc niu o theo cch ca


Wickham. Mt ng thng nh c l bn s a t c tin vo b g i.
Truyn vo b g i t l g c vi dung tch khong dung tch cha ng
ti a. Khi t u o, c s c truyn qua ng thng vi t 2 ml/s, sau
t ng ra t t vi t h g nh 0,5 hoc 1 ml/s. p lc ca niu o s
khc nhau ty theo v tr ca niu o, v s c ghi nhn li bng cc gi tr
tha i trn biu ghi nh c khi rt thng niu o.
Hai tr s th g c ghi nhn l p l nh ca niu o? (maximal
urethral pressure) v chiu di ch g a niu o (functional urethra length).

Bng 3 - B o Bi kha a a t s h thng ca p lc niu o


nh v chiu di ch g iu o ty theo phi v tui.

Phi Tui P max L ch g

< 50 65 - 105 3,5 - 4,5


Nam
> 50 65 - 105 4,0 - 5,5

< 50 60 - 90 2,0 - 3,5


N
> 50 50 - 80 2,0 - 3,5

III - PHI HP CC PHP O NIU NG HC:

T h g t i gii thiu t g ph p o NH n. Hin nay, vi s tr


gip ca nhng dng c ti t h , gi ta c th phi hp nh g ph p o
trn hoc phi hp gia NH vi k thut ch o h h nh nhm gip cho cc
nh Niu khoa c th c nhng nh nh tinh t v ton di h chc
g a ng tiu di.

3.1. O P LC C CHP BNG I: Ph p o p lc b g i in ch cho


ph p h gi p lc bn trong b g i P ves). p lc ny b h hng bi p
lc bng (P abd), chng hn trn mt b g i lit h flaccid), nu bnh
nhn rn mnh vi s tr gip ca ng ho ho h th ta s ghi nhn
s gia t g p lc trn biu p lc b g i, c d khng h c s co bp
b g i. khc phc tnh tr g , gi ta t mt ng thng trong lng
tr t g ghi nhn p lc bng trong cng thi gia o p lc b g i. M
o s t ng tnh ton p lc ca h p g i theo g thc:
P det = P ves - P abd

Kt qu o s ghi nh g l ng biu din ca 3 biu p l , t o g p


l h p s th hin trung thc tnh trng co bp ca b g i.

3.2. PHI HP CC PHP O P LC BNG I, NIU DNG V IN C

m . , h g ta thy s kt hp gia p l b g i i .
Nu phi hp thm vi niu d g v thc hi ph p o t o g thi gian
y ln thi gian rn tiu s ho ph p h g a t cch ton din v ph g
di ng hc c ch g ha ng ln ch g tng thot ca ng tiu
di.
3.3. PHI HP PHP O P LC BNG I V QUAN ST BNG I CN QUANG
DI MN HUZNH QUANG NHM NH GI P LC LC SN TIU (leak point
pressure):

o p lc lc sn tiu l mt ph p o gi t nh h gi ha kh g t h
tr g su tht niu o. iu c thc hin b g h t t vo
b g i du g dch c pha thuc c ua g ho n kho g l. Ph p o p
lc b g i g c ti h h ng thi. Sau ho nh nhn ho hoc dng
th thut Valsava nh l t g p lc b g i, i ghi nhn p lc thp nht c
th gy ra sn tiu. Nu p lc sn tiu < 60 cm H2O th c th xem l niu o
bt ton. Th a t o g ph p o , ta th xem trc tip s sn tiu qua
ming niu o m khng cn dng ti thuc cn quang v mn hu nh quang.
Tuy nhin nu quan st hnh nh cn quang th s g h h h .

3.4. QUAY PHIM - NIU NG HC (Video-Urodynamics) :

Hnh h di ghi hn s phi hp gia nhiu ph p o NH i php quay


phi di mn hu nh quang. Hnh nh ca cc biu NH v hnh nh video
ca ng tiu di g c ghi nhn trn mn hnh trong sut giai on
y ri giai o i tiu. Hi a , ph p o phi hp c xem l ton din
nht nh h gi h g a ng tiu di.
IV - KT LUN:

g t c mt t ng hp ri lon ch g ng tiu di, thy thuc m


c bit l mt nh Niu khoa cn phi bit v ngun gc, m , phn loi g
h t o t o g ng tiu di chu trch nhim cho tnh trng bnh l. Cc
ph p o iu ng hc hin nhin l nhng kho st ht sc cn thit nu mun
c mt ch o v bnh l ri lo i tiu.

iu g tic l trong gn 3 thp nin qua, do thiu trang thit b nn ngnh


Niu khoa Vit Nam hu h tr g l h c ny, khin cho vic ch o
ri lon ch g ng tiu di gp rt nhiu kh kh . Hin nay, vi s xut
hin tr o iu ng hc bnh vin Bnh Dn v Trung tm Ch o
Y khoa Medic, chng ti hy vng s gip cc thy thu c nhng d kin
hu h gp ph iu tr thnh cng mt mt bnh rt thng gp trong Niu
khoa.
TI LIU THAM KHO:

1. Abrams PH, Griffiths DJ: The assessment of prostatic obstruction from


urodynamic measurements and from residual urine. Br J Urol (1979) 51: 129-134

2. Buzelin JM, Glemain P, Labat JJ, Le Normand L: Les methodes d'exploration


fonctionnelle de la voi excretrice inferieure, dans: Physiologie et explorations
fontionnelles de la voie excretrice urinaire, edit. par Synthelabo (1993): 60-92.

3. Siroky MB, Krane RJ: Neuro-Urology and urodynamic testing, in: Siroky MB,
Edelstein RA, Krane RJ, eds. Manual of Urology - Diagnosis and Treatment, 2nd
edit., Lippincott Williams & Wilkins (1999): 294-306.

4. Tanagho EA: Urodynamic studies, in: Tanagho EA, McAninch JK, eds, Smith's
general urology, 15th edit (2000): 516-537.

5. Wein AJ, Broderick GA: Voiding function and dysfunction, in: Hanno PM,
Wein AJ, eds. Clinical Manual of Urology, 2nd edit, McGrow-Hill (1994): 305-376.

6. Wein AJ: Neuromuscular dysfunction of lower urinary tract, in: Walsh PC,
Retik AB, Vaughan ED, Wein AJ, eds., Campbell's Urology, 7th edit, WB Saunder
(1998): 953-1006.

109. PHU THUT LP GHP B PHN GI


(PROSTHETIC SURGERY)

1. Thit b khng dng thy lc:

-Loi b iu ch h c (malleabe): l mt thanh do, hi, bn cng c th


u o g . Ngi ta phu thut t vo trong hai th hang mt ng cht do
cng bng silicone hay cao su, nhiu hng cng ty cn ch to c thm si kim
loi bn trong, c chiu di ph hp vi t g g i, l ho d g t lun lun
cng c th giao ho bt c lc no

-Loi hc (machanical).

2. Nhm thit b dng thy lc: c nhiu loi, cu to chnh l cc ng thy lc


lm bng cht do c tnh chu l ao, hi l , d g ht lng
vo nh thng ni vi mt i . ng thy l t trong th hang.

Hin nay trn th t ng c 3 loi chnh:

-Loi c 1 thit b (AMS Dynaflex)

-Loi c 2 thit b gm ng thy lc s dng cng mt hu g Me to


G.F.S)

-Loi c 3 thit b gm 2 ng thy l , t i ha cht lng (AMS


Ultrex) sn xut 1990.
Cc loi vt gi t trong th hang: loi c 1 thnh phn

The (An Atlas of Erection Disfunction, 2005.Parthenon Publishing Group)

Cc loi vt gi t trong th hang: loi c 2 thnh phn

The (An Atlas of Erection Disfunction, 2005.Parthenon Publishing Group)


Cc loi vt gi t trong th hang: loi c 3 thnh phn

The (An Atlas of Erection Disfunction, 2005.Parthenon Publishing Group)


Phu thut t vt gi vo th hang lm ph hy hon ton h thng mch mu
trong th hang, lm mt ho to h g t nhin to ra mt s g
c g h in gi to. Cho nn ch nh phu thut thng giai on cui cng
khi khng c bi ph p iu tr c kt qu, th g c ch nh trong nhng
t ng hp sau:

-Tt c ph g ph p iu tr ni khoa, bng th thut, phu thut u


khng c kt qu.

-B ho th ha g sau g au d g t ho g d g t iu tr
kh g g.

-T o g t ng hp a ng mch lan to.


-B h Pe o ie l ng v bin dng th hang.

To ra s g cng gi to cu d g t l mt ph g ph p gng p
bi v bnh nhn s mt nhiu khoi cm t nhin. Mt kh t vt gi vo th
hang c th gy cc bin chng sau:

-X ho to th hang.

-T th g iu o hoc chc thng u g i .

-Thng th hang do vt gi chc thng cn Albuginea li a di da d g


vt hoc tng sinh mn.

-Nhim khu d g t do qu trnh phu thut ho do s o thi cc


vt l t o g th. T l nhim trng c t l cao h gi tiu ng, c chn
th g t sng, ghp thn phi dng thuc c ch min dch (Jordon, 1993).

-T mu vng bu do qu trnh c xt cu vt gi gy chy mu.

-Di ng b phn gi.

-au g hi m.

-Thiu mu cc b u u v hoi t d g t: bin chng ny him gp,


c th xy ra bnh nhn tiu ng, bch cu n g, t thng tiu

-Ri lon phng tinh lm mt cc khoi cm.

-ng m di h u u: ch thun tin khi vt gi l mt khi.

-ng m bu-d g t: c p dng nhiu ng m d bc l th hang,


khng lm t th g th ki h l g d g t v d c nh b ph .

-Ri lon c gi d g t.

K thut m t p othese d g t :

ng m: ng m ch yu

-ng m di g u: gu g t th gth ki h l g d g t .
-ng m di h u u: ch thun tin khi vt gi l mt khi.

-ng m bu-d g t: c p dng nhiu ng m d bc l th hang,


khng lm t th g th ki h l g d g t v d c nh b ph .

K THUT T PROTHESE TH HANG LOI IU CHNH C

Hnh 1: rch da mt di
d g t b l th hang

H h : kh u h i h
lm mc, rch dc m th
hang
H h : No g o hiu di th
hang.

H h : t p osthese o on
gn th hang
H h : t prosthese vo
on xa th hang.

Hnh 6: khu li bao trng th


hang

K THUT T PROTHESE AMS700 ULTREX

Hnh 1:ba thnh phn vt gi: hai th hnh ng tr t trong th


ha g, m trong bu, ti cha c mui 60- l, t
trong khoang ngoi phc m t c bng quang

-Ph g ph p m: m ni kh qun hay t ty sng.

-T th bnh nhn : nm nga.

-ng m: r h ga g di vng tip gi p u d g t 1cm, bc tch


qua lp Da tos o n bao trng th hang.

H h : ng m rch d da u d g t
Hnh 3:phu t h n cn mc cu hai th hang

Kh u i h g ga g l c, b l v x dc gia th hang

Hnh 4: Rch dc hai th hang bc l cc mch mu g t o g th


ha g, d g o g Hega o g on g , on xa 14
mm, nu on g o g kh g c s ln th thay loi prosthese
AMS 700CXR loi nh h ha loi prosthese Mentor Titan Narrow
Base

H h : No g o on xa ca th ha g o hiu di cu on xa
(9cm).
H h : o g o on gn cu th hang (11cm)

Hnh 7: Chun b cc thnh phn ca prosthese

H h : t th hnh tr silicon vo th ha g h h kh u ki
a u u, ki t trong th ha g a ui u v ko hnh tr silicon
vo th hang ra t u xa.

H h : t phn cn li cu hnh tr sili o o on gn cu th


hang.

Ton b hnh tr nm chnh xc vi k h thc cu th hang

Hnh10: khu li th hang


Mi h th g bu c 3 ng

H h : t h th g ot o g
bu

Hnh 12: ni ng t h th g oh ht
trong th hang
o hiu d i d g t (t g u u d g t khi ha
l g d g t (12,5 cm
o hiu d i d g t (t g u u d g
vt sau khi l g d g t (15,5 cm)

Dng ko Metzenbaun hay km Kelly ch thng cn ngang l bn nng,


sau phu thut vin dng ngn tay tr t h khoa g sau g
u, t g ua g t ti cha dch.
Dng m vt t o g a h kh i g ta a t i ha dch
(sau khi ht ht kh bn trong) vo khoang va bc tch

Hnh11: Ht ht khi trong ti cha, t vo khoang


t c bng quang v kt ni vi bu
TI LIU THAM KHO

1.Frank Hinman, JR (1998). Atlas of Urology Surgery, second edition, pp 185-


193. W.B Saunders Company, California.

2. Roger S.Kirby MD, An Atlas of Erectile Dysfuntion, second sdition, pp 82-92,


Parthenon Publishing, London UK.

110. SUY THN CP V GHP THN

NH GI SUY THN CP

PGS.TS. BS. Tr L Li h Ph g

1. Th no l suy thn cp?

Suy gi t ngt ch g thn (t l vi s suy gim


GFR). Suy thn cp c th qua khi nu h c
gu h iu tr g n. Nu khng s d n
nhng t th g h in thn.

2.Xt nghim chnh xc nht ch o su thn cp

o GFR gin tip qua clearance ca creatinine. Creatinine l mt sn phm


ni sinh ca qu trnh d h a . T sn xut creatinie nh: 1mg/
pht.

Cng thc tnh: U x V/ P.


80% clearance ca creatinin l do GRF v 20% l do bi tit qua ng thn.

3. Cc yu t h h g n creatinine huyt thanh

K h th th: v creatinine l mt sn phm ca qu trnh d h a .

Tui: thn gi ln tui th GFR gi l t g g creatinin.

Ch th g g

Thuc: cephalosporine, cimetidine, trimethoprim h h g n qu trnh


lc v qu trnh bi tit ca ng th l t g eati i e hu t thanh.

4. Mi t g ua gia creatinine huyt t g v lea a e a creatinin

Ch g thn c th c theo di bng tr s creatinine trong huyt


t g. C eati i e hu t t g t l nghch vi clearance ca creatinin. Nu
creatinine 1mg/dl th GFR l 120 ml/pht. Nu creatinine l 2mg/dl th GFR
l 60 ml/pht. Nu creatinine l 4mg/dl th GFR l 30 ml/pht..... Khi
eati i e t g t 1 ln 2 mg/dl th 50% ch g thn b mt.

5. Cc ri lo i k vi suy thn cp

Cao huyt p, qu ti tun hon, suy tim huyt, nn, bun nn, mt mi,
lassitude, bnh l no v xut huyt. Cc ri lon chuyn ha khc bao
gm:

T g Gim

Creatinine huyt thanh Bicarbonat (toan chuyn


ha)
BUN
Kali huyt thanh Calcium

Phosphore, Magne Hng cu

Ch g tiu cu

6. Suy thn cp t c thn

Suy thn cp t c thn: chim 50- 70% cc nguyn nhn suy thn cp,
thng do gi l g u n thn, lm co tht cc tiu ng m h n
v lm gim p l ti mu ca mao mch cu thn, hu qu l gi
lc cu th , a n tnh trng ng th t g t i hp thu c v mui
gy ra thiu niu.

Cc nguyn nhn bao gm:

Gim th tch dch ngai bo: do mt c, xut huyt, s dng li tiu qu


mc, tiu chy, bng, nhim trng,hi chng vi lp, vim ty cp.

Gi u g lng tim: b h l ti , i lon nhp, bnh l mch vnh, sc


tim. Tnh trng suy tim huyt l u g g s lm gi ti mu thn

Tnh trng co mch thn trc tip do hu qu ca nhim trng, bnh l gan
v thuc.

Cc thuc gy suy thn cp t c thn bao gm thuc c ch men chuyn


(ACEI) v khng vim khng corticoid (NSAID). ACEI lm gim angiotensin II
a n s gim p l ti mu ca th , ng thi lm dn cc tiu
ng m h i, hu qu cui cng l lm gim p lc lc mao mch cu
thn. Nhng b h h t h t ng hp ng mch thn rt d b suy
thn cp do nguyn nhn ny. NSAID c ch cyclooxygenase lm gim cht
eicosanoid (c ch g d ch thn) hu qu l lm co tht tiu ng
m h n ca thn.
7. Suy thn cp ti thn

Chim 20- 30% cc nguyn nhn suy thn cp thng gp nht l do


hoi t ng thn cp. Cc yu t th y gy ra hoi t ng thn cp l:
suy thn cp t c thn ko di, thu c thn (aminoglucosid, thuc cn
ua g t h ch c iod, cisplatin, amphotericin B, pentamidine - nhng
bnh nhn tiu ng ho a u ty rt nhy cm vi cc thu c thn
ny) v tiu sc t (do tn huyt ni mch hoc do ly gii sau chn
th g .

Cc nguyn nhn him gp khc bao gm cc ri lon mch mu ca thn:


huyt khi ti ch, thuyn tc mch, cao huyt p c tnh, hi chng tn
huyt uree huyt cao, vim mch mu. i khi vim cu thn cp v vim
m k thn c th a n suy thn cp.

8. Suy thn cp sau thn

Chim <10% cc nguyn nhn suy thn cp. Bt c nguyn nhn no lm


tc ngh d g c tiu t g g p u tn cng ca niu o g
u gy suy thn cp sau thn.

9. Xt nghi c tiu hu ch g trong ch o su thn cp

Nu c tiu m: nhim trng

Tiu mu: gi bnh l si, ch th g, u ng tit niu

Tr hng cu, m niu: gi bnh l cu thn.

Nu c cc tinh th c bit: acid uric, cystein: gi sn niu.

Nguyn nhn Xt nghi c T l bi tit Na niu v n g


tiu Na niu

T c thn B h thng <1%; <30 mEq/l

Ti thn

Hoi t ng thn T bo biu m ng >1%; >30mEq/l


thn, tr ht

Tiu m, tr bch
Vim thn k >1%; >30 mEq/l
cu

Vim cu thn >1%; >30 mEq/l


m niu, tr hng

cu, hng cu

Bnh mch mu >1%; >30 mEq/l


Hng cu
thn

Sau thn

Sn niu Tiu mu, tiu m, Kh g c hiu


tinh th

T bo c tnh
Bu Kh g c hiu
B h thng
Chn p t ngoi Kh g c hiu

10. Nguyn t iu tr suy thn cp

iu kin tin quyt l phi c ch o g. iu tr ch yu bao gm:


g g thu c thn, bi hon th tch tun hon, phc hi ch g
tim mch, gii ta b t ng tit niu, iu chnh cc ri lo in
gii. Nu suy thn cp nng gy ra tnh trng ng c do ri lon chuyn
ha ton thn th phi c ch nh lc mu.

SUY THN GIAI ON CUI

1. Cc nguyn nhn ca suy th giai on cui

gi ln:

Tiu g h g u)

Cao huyt p

Vim cu thn

Bnh l nang thn

Vim thn m k

Bnh thn tc nghn

Bnh l collagene mch mu

Bnh l c tnh

tr em:

Vim cu thn (chim t l cao nht)

Bnh l bm sinh hoc cc bnh l di truyn

Bnh l collagene mch mu

Bnh thn tc nghn

Bnh nang thn


Vim thn k

Cao huyt p

Tiu ng

Cc bnh l c tnh

2. Tn sut bnh th giai on cui h hau mi la tui hay khng

Khng. Tn sut suy th giai on cui gia t g theo la tui. la tui 0-


19: 12 cas/ 1triu dn. tui 65- 74: 680/ 1 triu dn.

3. Nguyn nhn gy t vong ch yu nhng bnh nhn suy thn mn giai


on cui

Bnh l tim mch, tnh trng nhim trng,

4. Biu hin ca nhng bnh nhn suy thn m giai on cui

B h h thng c nhng triu ch g h h t mi, h ,


nn, bu , i khi th c nga. Thng c nhng du hiu ca tnh
trng qu ti dch. C th c cc biu hin ca suy tim sung huyt hoc ph
phi. Tuy nhin c nhng du hiu ni bt cn ghi nh:

-Thiu u: thng nng v lun lun c triu chng ny

-Cao huyt p

-Bnh l thn kinh ngai i : thng xy ra khi bnh tin tri o giai on
cui

-La d g g do t h t ng ri lan chuyn ha ca calcium v


phosphore
-Gim ham mun tnh dc nam, khng rng trng ph n, lit d g s
lng tinh trng gim thp nam.

a s b h h t >95% ch g thn mi c biu hin lm sng r rt.

5. Cc ri la in gii o thng gp trong suy th giai on cui

T g kali u l ri la thng gp v nguy him nht,. Bnh nhn c th


c tnh trng toan chuyn ha km theo gim bicarbonnate trong huyt
thanh

6. Qu trnh tin tri n suy th giai on cui c th g ga c


khng

nhng b h h gu ao nh tiu ng), c mt s bin php


c th lm chm qu trnh tin tri n suy thn. Ch yu l khng ch
tnh trng cao huyt p tht hu hiu bng cc th thuc c ch men
chuyn v chn knh calcium. Ch t proteine, hn ch mui c

7. C ph g ph p iu tr thay th c dng trong bnh th giai on


cui

C iu tr thay th bao gm:

L u nh k

Thm phn phc mc

Ghp thn

Lc mu cn phi to mt g d ng- t h ch, mu s c ht ra khi h


th g ng m h, i ua t mng lc nhn to v quay tr v th ua ng
t h ch.
Thm phn phc mc thc hin b g h t mt catheter vo trong phc mc.
Dung dch l o phc m n t o g t thi gian.
Thi gia ho ph p u t h t ao i cht gia h tun hon ca mc treo v
ca dch lc

8. Cc bin chng ca lc mu v thm phn phc mc

Bin chng ca lc mu:

Huyt khi ti ch.

Nhim trng mch mu ch tim kim.

Bin chng do t g kali u, do u ti d h thng xy ra gia hai k lc


mu)

Bin chng ca thm phn phc mc: nhim trng v tc ngh athete , c bit
l tc nghn do mc ni l . T o g u ca thm phn phc mc th c 40%
bnh nhn c tnh trng nhim trng catheter v c 60% bnh nhn c t nht
mt ln vim phc mc.

9. Ghp thn c tt h lc mu cho nhng bnh nhn suy th giai on


cui khng

Tt c nhng nghin cu u cho thy t l sng nhng bnh nhn ghp


th c ci thi h so i nhng bnh nhn lc mu. Tuy nhin c mt
yu t gy nhiu l v cc b h h t tiu chu c ghp th u l
nhng bnh nhn nh v khe mnh. Sau ghp th a s cc bin
chng ca suy thn m h thiu mu, ri lan chuyn ha, ri lan tnh
dc, bnh l th ki h... u c gii quyt. Ngoi ra, cht lng sng
c ci thi g k nhng bnh nhn ghp thn so vi lc mu
10. Khong thi gian cho php ch i t khi th c ly ra khi th
gi ho khi c ghp l bao lu

a s cc trung tm ghp thn chp nhn thi gian thiu mu (thi gian
thn b ly ra khi h tun hon) l 24- 36 gi. T o g t ng hp gi cho
l gi sng, hu h th c ghp ngay sau khi ly ra khi th
gi cho. Nu thi gian ch i t qu 24- 36 gi th t l thn khng
hat ng sau ghp s t g. D y vn c nhng bo co v t ng hp
ghp thn thnh cng d thi gian thiu mu >24- 36 gi.

Mt ph g ph p o qun thn ph bin l cha trong dung dch lnh.


Th ti ra ti ch t c khi ly ra khi th bng dung dch lnh
c thnh phn ging dch ni bo. g t ti ra ny s gip lm lnh
th , do gim nhu cu chuyn ha ca th ng thi y ht mu ra
khi thn. Sau khi ly ra khi th, thn s t trong bao nha v
trng c cha d h t g t h d h ti ra h g th h phn
Magnesium gi i ag esiu s kt ta trn b mt ca th . Sau
ti nylon ny s t vo thng v trng cha c vn chuyn
i gh p thn. Nhng dch bo qun mi: dung dch ca t g i
hc Wisconsin c cho thm nhng cht gi u g l g l i thin
g k kh g hat ng sm ca thn sau khi ghp.

Mt ph g ph p kh bo qu l ti ra b g . Sau khi a
thn ti ch, th c t vo mt b ti ra lin tc thn
0
4 C h g l i lipop otei th h ph g g u.
Ph g ph p tn tin v phin ph t khi c s dng.

11. Bnh nhn b u g th gh p thn hay khng

U g th a g hat ng l mt trong nhng chng ch nh ca ghp thn


v thuc c ch min dch c kh g l th y qu trnh tin trin ca
u g th. Nhng b h h iu tr u g th th h hp khi
bnh 1- th th l g i c ch ghp thn.
12. T c khi ghp thn cn phi h gi hng yu t g

V cc thuc c ch min dch mi c s dng v cc kt qu ca vic ghp


th c ci thin nn vic chn la b h h g c r g i h . C
yu t gu a ghp thn bao gm:

Tui: tt nht t 15- 50 tui

Bnh l ton thn: chng h h tiu ng c t l bin chng v t l


cht sau gh p ao h gi nhn thn khng c tiu ng. Cc bnh l
kh h nh mch vnh, lot d dy t trng c c cha tr khi
t c khi ghp.

Cc bt thng ca ng tiu di (bng quang th ki h, u tin lit


tuyn) cn phi h gi tht k v phi iu tr cc bt thng
t c khi ghp. Cc b h h a g th g tiu sch cch qung vn c
th ghp th h g gu him trng niu rt cao.

13. Khi ghp thn c cn phi ct thn ca gi nhn khng

Cc ch nh ca ct thn bao gm:

Cao huyt p khng khng ch c bng thuc

Vim thn b th do t o gc

Sn thn

Nghi ng u thn

14. Th gh p t cng v tr vi thn ca bnh nhn khng

Th gh p th g t h chu. V tr ny cho php d dng cm li


niu qun vo bng quang v d dng tin hnh ghp mch mu ca cung
thn vo mch mu chu. Ngoi ra sau ghp d dng theo d i c tnh
trng ca mi ni mch mu (nghe, s, ch o h h nh). Nu tr em
nh nhn thn ghp ln phi t thn vo b g ng mch thn ni v
ng mch ch ho ng mch chu hu g t h ch thn ni o t h
mch ch

15. Cc nguyn nhn tht bi ca ghp thn

Cc bin chng v k thut (huyt khi ti ch ng mch thn ho t h


mch thn hoc tc nghn niu qun) c th lm cho ghp thn tht bi
h g t l ch < 1%. Mc d c mt t l nh ghp thn tht bi do cc
bin chng ca nhim trng, do b h t i ph t h g a s t ng hp
tht bi u do thi ghp.

Thi ghp ti cp xy ra trong vng 24 gi u sau ghp gy ra bi cc


khng th c t bo (yu t dch th). Cc khng th c hnh
thnh t t c do hu qu ca vic tip xc vi khng nguyn qua truyn
mu, qua cc ln ghp th t ho ua si h . Cc khng th hat
ha h th g g u a n hut khi cc mch mu nh v nhi
mu ton b thn. Qu trnh khi hat h thng ny khng th g chn
c.

Thi ghp tin trin nhanh xy ra trong vng 4- 6 ngy sau ghp, va do cc
yu t dch th, va do cc yu t t bo. C th iu tr c tnh trng
ny vi cc thuc chng thi ghp.

Thi ghp cp: thng xy ra 2- 4 tu sau gh p h g th xy ra trong


th g u. Biu hin lm sng l gi l g c tiu, st nh, t g ,
cao huyt p, t g eati i u. i khi h c mt du hiu l t g
creatinin mu. Sinh thit thn s cho thy s thm nhim t bo bi
immunoblaste, lymphoblaste v plasmacell. y l loi thi gh p p ng
tt vi cc thuc chng thi ghp.
Thi ghp mn xy ra mu sau khi gh p gi ta gh ng do cc yu
t dch th. N c th l do hu qu ca th g tn tin trin v tnh
trng thu mu m do nhng ln thi gh p t . Si h thit thn s
th i ca m h u: t g si h i m , h a k, c
nhng vng nhi mu v nh g g teo t. Loi thi gh p thng
kh g p ng vi iu tr chng thi ghp

16. Vai tr ca nh danh m v phn ng cho trong thi ghp

Nh g gi nh gi cho phi nh danh m bng cch xc


nh khng nguyn ph hp m (HLA) nm trn nhim sc th s . Ngi
ta h n HLA A, HLA B v HLA D. Nhiu nghin cu cho th gi nhn
c ph hp HLA tt th thi gian sng ca mnh ghp tt h gi
nhn khng ph hp HLA. Ngo i a gi ta g hn thy rng nhng
gi nhn nh c thn ph hp c 6 khng nguyn s c kt qu sau
ghp tt h . Khi gh p th gi nh c t s at kim cc khng
th c t o t t c bng phn ng cho gia hut thanh ca
gi nhn v t bo ca gi cho. Nu phn g h o d g t h ho
thy c s hin din ca khng th th khng nn ghp.

17. Ng ga v iu tr thi gh p h th no

Cc thuc c ch min dch ch yu s d g g ga thi ghp l


o ti oid, azathiop i i lospo i . Co ti oste oid c dng vi liu
ao iu tr nh g t thi ghp. Ngoi ra c th dng cc ch phm
kh g l pho o d g ho a d ng). Cc ch phm chng lympho
bo c th c dng "dn truy " t c khi bt u s dng c ch min
d h lm gim kh g thi ghp, gim tc dng ph, c bit l tc
dng ph ca ciclosporin. Tuy nhin cc thuc c ch min dch hin nay
khng c tc dng chn lc m tc dng ln ton b h min dch.
Cc cht c ch min dch mi bao gm OG- 37- 325 (ciclosporin G), FK 506,
Rapamycin, RS 61443 (micophenolate mofetin), misoribine, brequinar
sodium, 15- deoxyspergualin, leuflonamide a g c nghin cu v s
d g lm gi c tnh ca thuc c ch min dch.

18. Tc dng ph ca thuc c ch min dch

Corticosteroid:

T g ng huyt, t g lipid u

Hi chng Cushing

Bo ph

Gim kh g l h t th g

Hoi t g t g

c thy tinh th

Cao huyt p

Lot d dy

Chm pht trin

Ciclosporin:

c thn

Cao huyt p

T g Kali/ u

T g a id u i u

c gan

Rm lng
g ki h u g

Azathioprin:

c ch t g

Ri lan tiu ha

c gan

Rng tc

Thuc ch g l pho o a d g:

St lnh run

Gim bch cu, gim tiu cu

Vi t h ch ti i ti h h

Thuc ch g l pho o d g

Hi chng gi cm liu u

Vim mng no v trng

Ri lan h hp, ph phi, h huyt p.

19. Nu thn ghp tht bi c phi ly ra khng

Nu tht bi trong nh g th g u th cn ly th a g ga
nhng bin ch g i k i qu trnh thi gh p a g din tin. Nu tht
bi mu thng khng cn ly thn ra v t khi gy ra nhng v
nghim trng v v phu thut ly thn ra kh do so vim dnh. Khi ghp
tht bi th gim liu d g g hn thuc c ch min dch. Nhng
b h h u c th c ghp thn li h g t l thnh cng s
thp h to nn cc khng th c hiu t nhng ln thi ghp
t c.
111. BC U P DNG K THUT CT NANG
THN QUA NI SOI HNG LNG
(Kystectomie rnale par lomboscopie)

Nguyn Ngc Tin- V L Chu - Nguy

Nguyn Phc Cm Hong- Nguy V Hip *

I/ t v :

Vic ng dng k thut m ni soi bng trong niu khoa


ngy cng pht trin trn th gii g h ti Vit Nam.

Bnh Vi B h D p d g th h g g k cc k
thut m ni soi b g c bit l phu thut ct nang
thn ni soi qua ng trong phc mc.

Cc bin chng m ni soi trong b g h: d , thng


cc ua t o g bng, dnh rut hu phuC l hiu u t ho phu
thut vin.

g o ua g h g l g sau ph c trong niu khoa th g c la


chn p dng cho nhiu loi phu thut

Nn k thut m ni soi ua g h g l g sau ph t ra cho phu


thut vin niu khoa vi nh g u im ring ca n.

II/ Mc tiu nghin cu:

p d g ng vo qua ng ni soi g h g l g sau ph c cho phu thut


ct nang thn nh ph t h u khu t im ca g o c th ng
dng cho cc loi phu thut ni soi khc trong niu khoa.
III/ B h h v ph g ph p:

1.Bnh nhn:

Tt c nhng bnh nhn nang th c c triu chng vi k h thc >5cm.

Khng c tin s ngoi khoa trong b g ha gh g l g g phu


thut.

Kh g t nhim trng nang thn mi < th g

Bng 1: Cc d kin b h h t c m

_______________________________________

Phi nam/ n 2/8

Tui 49(36-61)

au l g 10

_______________________________________

Bng 2: C c tnh ca nang thn

____________________________________________

K h thc 60 mm(51-85)

Nang nghi ng c tnh 0

Ht dch lm TB hc 0

Nang bn tri/phi 5/5

Nang cc trn 2
Nang c di 7

Nang cnh b thn 1

____________________________________________

. Ph g ph p:

p dng k thut m ct nang thn qua ng ni soi h g l g

B h h t t th n ghi g h h t th m h g l g in,
b phn vido t c bng BN, phu thut vin v ph m sau l g BN. Dng c
bao gm:

Dao m

Kp Kelly

1 Trocart 10mm

2 trocarts 5mm

Opti ue

Ko ni soi

Kp ni soi

Babcock ni soi

Dng c ht ni soi

Hp dng c m h sn sng

K thut: R h da ga g di g sn cui 2cm v bn ngoi khi


l g . Kp Kelly tch vo h tht l g theo chiu so vi mt phng
th g g so vi mt phng ngang, chiu su khong 5- 9cm, khi c
c c gi t qua s khng ca cn ngang, Kelly s c ng theo nhp
th. Dng ngn tay tr tip t t h g h g l g to khong hng l g
sau phc mc cng rng ti a u c th c. Trocart 10mm vi opti ue c
t v ti h h CO ua s t h gi g .

Tip t t trocart th 2 v t g h t c trong vng gii h t c khi


bc tch phc mc v ga u tn ca ng r h da theo ng m c in
t o g t ng hp phi chuyn m h. Trocart th t ng nch sau, vi
centimtre trn mo chu.

Mt khi nang th c thy qua phu t ng, k thut g ging qua ng trong
phc mc: tch nang thn, m nang th , th d t o g a g, t nang ti b
nhu m thn, cm mu v d lu.

IV/ Kt qu:

C t ng hp u ti c ng dng k thut ny t th g / n
thng 12/2002. Kt qu h sau:

Bng 3: D kin bnh nhn trong lc m

_____________________________________________________________

Thi gian m 113 pht(70-140)

Chuyn m h 3

Mu mt 30ml(10-100)

CO2 tiu th 70-100 lt


Bng 4: D kin bnh nhn sau m

_____________________________________________________________

Thi gian nm vin 4 ngy(2-7)

Nhu ng rut 1,8 ngy(1-3)

Thi gian rt dn lu 2,7 ngy(2-4)

Bin chng 1(10%) nhim trng l trocart

Gii phu bnh l nang nang th h a ho a g gin thn

_____________________________________________________________

V/ Bn lun:

Nang th n khm ti cc phng khm chuyn khoa niu kh g t h g a s


l nhng nang nh hoc khng triu chng, khng c iu tr. Theo mt s tc
gi 24% nang thn xy ra BN trn 40 tui v 50% BN trn 50 tui pht hin
tnh c qua khm tng qut hoc qua scanner [2]. Ch nh can thip khi nang
th g au hoc hnh dng bt thng nghi ng t h. T g t nghin cu
ca Nguy Hip- Bi mnh Cn v cng s g t ng hp nang thn
u c triu chng [11].

Nang thn c th iu tr b g ph g ph p h ki h i g
th iu tr bng ch h t ht g h a i alcool ho btadine. Chc ht
c th thc hin bng t ti ch, hiu qu i vi a g< , gc li
i vi nhng nang >7cm, t l tht bi cao, nn m ni soi, khi h g ta li
im na l c bnh phm m hc.
10 bnh nhn c ch nh can thip, l u tin chng ti thc hin k thut ct
nang thn qua ng ni soi g h g h g sau ph kh g nh tnh kh
thi ca k thut ny vi kt qu t g t vi mt s tc gi h: Bell a ng
s (10 BN)[1], Rubenstein v cng s (10 BN)[2], Guazzoni v cng s (20 BN)[3],
Brown v cng s (13 BN)[4].

Bin chng khng c trong lot nghin cu ny, tuy nhin theo mt s tc gi
bin ch g h h thng gp nht l xut huyt i khi phi chuyn m h cm
u , i khi g th iu tr bo tn trong nghin cu ca Rubenstein [2].
Bin chng xut huyt thng xy ra khi thc hin sinh thit a g, m mu
thng rt kh kh , khi t s tc gi ngh x dng Argon c th hiu qu
h .

ng vo m ct nang thn ni soi rt i. a s tc gi hn


ng m qua phc m , , , , , , h g ng m ua g g h g l g
gl g c p d g , t h gu a ng m qua ng
trong phc mc. Trn thc t hnh dng v v t a g hng cho chng ta quyt
h g o: a g k h thc va phi v khng cc trn c th thc
hin d d g h ua g sau ph , gc li cc nang to, mt t c, hoc
cc trn c l d tm v ct c nang qua ng trong phc m . T o g t ng
hp chuyn m h ca h g t i u l nhng nang cc trn, rt kh kh
tip c c nang, nht l l h g t ng hp u tin thc hin lm ko
di qu nhiu thi gian phu thut. H a, hng nang cnh b thn chn p
b thn ho y niu qun, chng ta c th bc tch nang thn d d g h ua
ng trong phc mc.

Trong lot nghin cu ca chng ti tt c t ng hp u khng thc hin


s a e t c m. Theo mt s tc gi scanner rt c li cho vic d o
h gi t h t g a g g h kh g u g th dng nang [13,14,15]. Theo
, kh g tin hnh phu thut ct nang thn qua ng ni soi i vi nhng
nang thn nghi ng c tnh.
So snh cc kt qu ca lot nghin cu ny vi tc gi thc hin k thut m qua
ng trong phc mc, nghi nh h sau:

Bng 5: so snh cc d kin vi phu thut qua ng trong phc mc

_____________________________________________________________

Chng ti NV Hip- BM Cn

Thi gian m 113 pht(70-140) <90 pht

Chuyn m h 3 0

Thi gian nm vin 4 ngy(2-7) 3-5 ngy

_____________________________________________________________

Thi gian m qua ng sau phc m d i h , th do phu t ng hp h


l h g t ng hp u tin, thi gian phu thut c th s rt ngn nu
phu thut c thc hi th g u h i cng mt -kp nhp nhng.

Tt c t ng hp m h u l cc nang thn cc trn, trong phu t ng hp


v thao t ha ue , h g t i ko di thi gian phu thut qu lu nn
u t nh chuyn m h. Tu hi t ng hp ny, chng ti rch da t
l trocart th 1 sang l trocart th , n gi g h t cuc m h c
in m b h h lu c gii thch r rng truc m.
Thi gian nm vin ca ng m h hau, n ng h hiu so vi m h.

VII/ Kt lun:

u im:

Vng m sau phc mc l vng m quen thuc ca PTV niu khoa

Khng h hng ti bng

T h c cc bin chng tn th g ua t o g ph c

Trnh bin chng tc rut hu phu

Nu phi chuyn m h, ng m h c in

Nhu ng rut sm phc hi

Khuyt im:

Phu thut k o d i h ua g t o g b g khi ha ue

Phu t ng hp h .

Bnh nhn mp phu thut c th s ko di.

i vi nang thn cc trn phu thut s gp nhiu kh kh .

S lung nghin cu cn t, cng trnh s c thc hin tip tc v rng ri c


kt lun thuyt ph h t th p d g ng vo qua ng ni soi hng
l g sau phc mc cho cc phu thut niu khoa kh h: nh l khc ni, sn
to niu qu g l g, sn b th

Ti liu tham kho:


1/BELLMAN G.C., YAMAGUCHI R.,KASWICH J.

Laparoscopic evaluation of indeteminate renal cyst. Urology, 1995,45,1066-1070.

2/RUBENSTEIN S.C., HULBERT J.C., PHARAND D., SCHUESSLER W.W., VANCAILLIE


T.C., KAVOUSSI L.R.

Laparoscopic ablation of symptomatic renal cyst. J.Uro.,1993,150,1103-1106.

3/GUAZZONI G., MONTORSI F., BERGAMASCHI F. et al.

Laparoscopic unroofing of simple renal cyst. Urology, 1994,43,154-159.

4/BROWN J.A., TORRES V.E., KING B.F., SEGURA J.W.

Laparoscopic marsupialization of symptomatic polycystic kidney disease. J.Urol.,


1996,156,22-27.

5/DENIS E., NICOLAS F., BEN RAIS N., CLOIX P. ET coll

Traitement coeliochirurgical des kystes simples du rein. Progres en urologie.


1998,8,195-200.

6/Mc DOUGALL E.M., CLAYMAN R.V.

Avances in laparoscopic urology part I. History and development of procedures.


Urology, 1994,43,420-426.

7/NIEH P.,BIHRLE W.: III

Laparoscopic marsupialization of massive renal cyst. J.Urol,1993,150,171-172.

8/STOLLER M.L.,IRBY P.B.,III, OSMAN., CARROLL P.R.

Laparoscopic marsupilization of a simple renal cyst. J.Urol.,1993,150,1486-1490.

9/BARRETO H., DOUBLET J.D., PERALDI M.N., GATEGNO B., THIBAULD Ph.

Chirurgie rnale par lomboscopie: exprience initiale. Prog. Urol,1995,5,384-389.


10/HOENIG D.M., LEVEILLEE R.J., AMARAL J.F., STEIN B.S.

Laparoscopic unroofing of symptomatic renal cyst: three distinct surgical


approaches.J.Endourol.,1994,9,55-57.

11/NGUYEN V.H., BUI M.C. v cng s

Phu thut ct nang thn qua ni soi bng

Tp ch y hc thc hnh s 426. 2002, trang 317-320.

12/GELET A., SANSEVERIONO R., MARTIN X. et al

Percutaneous treatment of benign renal cyst. Eur.Urol.,1990,18,248-251.

13/CLOIX P., MARTIN X., PANGAUD C., MARECHAL J.M., BOUVIER R., BARAT D.,
DUBERNARD J.M.

Surgical management complex renal cyst: a series of 32 cases. J.urol.,1996,156,28-


30.

14/ARONSON S., FRAZIER H.A., BALUCH J.D., HARTMAN D.S., CHRISTENSON P.J.

Cystic renal usefulness of Bosniak classification. Urol.Radiol.,1991,13,83-90.

15/BOSNIAK M.A.

The cuurent radiological approach to renal cysts. Radiology, 1986,158,1-10.

112. VI KHI NIM V GHP THN

CC NH NGHA:

GHP T THN: (AUTOGREFFE) Mang mt ua a mt c th


ghp vo mt v tr gii phu kh t th ca c th .
GHP D CHNG (XNOGREFFE): Mang mt ua a mt c th gh p o
th ca mt c th khc loi .

GHP NG CHNG (ALLOGREFFE): mang mt ua a mt c th ghp vo


th ca mt c th cng loi.

1/ CC GIAI ON THIU MU:

1. 1 THIU MU NNG (ISCHMIE CHAUDE): Bt u t khi kp ng mch ch


(ho ng mch thn) ca gi cho v kt thc khi bt u truyn dung dch
lm l h o ua c l a. T o g t ng hp gi cho l t thi thi
gian ny bng khng, nu gi ho l gi sng, thi gian thiu mu nng
kh g t qu 10 pht. Trn l thuyt, thn s b nhng t th g kh g
hi phc nu b thiu u ng nhit qu 30 pht. Thi gian thiu mu nng ko
d i thng l nguyn nhn ca t ng hp v niu hoc thn ghp khng
hot ng sau m.

1. 2 THIU MU LNH (ISCHMIE FROIDE): L thi gian th c gi trong mi


t ng bo qun vi nhit thp.

1.3 THIU MU M (ISCHMIE TIDE): L thi gian t khi th c ly ra khi


i t ng bo qu ho n khi cc ming ni m h u c thc hin xong,
thn nh c s ti mu ca gi nhn thn.

2/ CC NGUYN TC LY C QUAN:
C BA IU KIN CN BO M:

1/Bc tch ua g t h th g g tt, nht l khi c nh g tha i v


gii phu ca ua .

2/Truyn dung dch bo qun v lm l h ua hiu qu bo m tt


nh g iu kin bo qun.

3/Thi gian m cng ngn cng tt v nn d tr vic t chc ghp cng sm cng
tt ua c ly ra.

K THUT LY THN:

LY THN THNH KHI

LY TNG THN RING R

3/ K THUT BO QUN THN

3.1 CC DUNG DCH BO QUN THN

C nhiu dung dch bo qu ua c s dng l:

Cc dung d h bo qun thun bng cch h nhit

Cc dung dch s dng cho my truyn theo m h p

Cc dung d h truy t khi a g g lnh

3.2 LCH S
C h u tin v vic bo qun th ng bi LOEBELL
, CAREL LINDBERG

N CALNE, PEGG u l hn xt rng vic h thp nhit


cho php bo qun thn t n 12 gi

N ,HUMPHRIN, N , MANAX STEVEN khu


nn s dng my truyn lin tc vo th u c hparine ha v
oxygne ha vi mt p sut truyn gn vi p sut t thu. N ,
BELZER s dng mt my truyn theo m h p lin tc vo thn dung
dch huyt t g o g e h a ta , du g dch ny cho php bo qun
th ho n 72 gi.

N COLLINS s dng mt dung dch bo qun thn mang tn ng.


l dung d h in gii thm thu gn vi ni i trnh ph
t bo.

C g t o g giai an ny, 1973 SACKS dng dung d h Ma itol t c s


xm nhp vo t bo.

N gi ta tha i cht t thnh phn dung dch COLLINS bng


cch ly ra cc dn xut ca magnsium v to nn dung dch
EUROCOLLINS, cho php bo qun th n 48 gi, l dung d h a g c
s d g thng xuyn hin nay chu u.

Dung dch Eurocollins c hiu qu i vi th h g kh g t h c


mt t l quan tr g ua gh p kh g phc hi ch g, t o g t ng
hp thiu mu ko di, dung dch ny khng th chng li tc d g c ca
cc gc t do , ng thi khng c kh g o qun trong thi gian di
gan v tu. Do s pht trin ca vic ghp gan , ty, BELZER v cc cng s
kt hp vi nhm chuyn vin sinh ho ca SOUTHARD ngh mt lai
dung dch bo qun mi: dung d h BELZER UW CSS Viaspa bo qun
tt c ua t o g bng: gan, ty, thn...

4/ CC BIN CHNG CA GHP THN


. TRNG HP THI GHP:

4.1.1 THI GHP TI CP (REJET SURAIGU): Biu hin sm vi pht hoc vi gi


sau khi ti phn b mch mu trong thn ghp. Hi tng ny lm tiu hy
nhanh chng thn ghp. Hin nay, tnh trng ny rt t gp nh vo vic thc hin
phn ng cho (cros-match) gia huyt thanh ca ngi hn v t bo ca
gi ho. C h thi ghp ti cp l do phn ng min dch dch th.

4.1.2 THI GHP CP TNH (REJET AIGU): L hi tng suy thoi nhanh chng
ch g thn: cratini e u t g, thiu hoc v niu, thn ghp c th t g
th tch. Thi ghp cp thng xut hin trong nhng tu u sau gh p. C h
l do phn ng min dch t bo, c th iu tr rt hiu qu b g h t g
liu thuc c c min dch.

4.1.3 THI GHP MN TNH (REJET CHRONIQUE): L bin ch g thng gp, xut
hin mt cch m thm, hoc l s suy thoi dn dn ch g thn, hoc sau
mt ha i giai o? thi ghp cp tnh khng phc hi hon ton.

4.2 BNH L NG THN (TUBULOPATHIE):

Tnh trng hoi t thong qua ca cc ng th gu h thng l do


thi gian thiu u k o d i l gu h thng gp nht lm cho thn
ghp khng hot ng ngay sau m.

Triu ch g tha i theo tnh cht t th g. Thng gp nht l tnh


trng suy thn khng v niu, BN v i tiu nhiu h g h s
si h ho kh g tha i ha tha i ch . i khi l t h t ng v niu,
i hi phi lc mu cp cu.
Trong vng 15 ngy sau m, tnh trng thiu, v niu ny c th l mt
bnh l ng thn cp sau thiu u, h g g th l mt t ng hp
thi ghp cp kt hp hoc thuyn t ng mch thn ghp cp tnh. o
cho thn vi Dopple ng mch gip ch o ph it: khng lc
m h u d g u phu h th g t o g t ng hp hoi t ng
thn. Scintigraphie thn v bt bit l chp ng mch thn chn lc cho
thy tnh tr g ti u h thng trong hoi t ng thn cp. Nu sau
15 ngy tin trin, ch g thn khng phc hi, bt buc phi sinh thit
th . V ph g din m hc, cc t th g ng thn rt in hnh, gin
cc ng gn, t bo ng thn dp. i khi, m k ph n va. Hi h
na, i khi ut hinvi t bo vim v vi ch vi thuyn tc mch. Vi du
hiu thoi ho ng thn lun lun tm thy trn mu bnh phm ny. i
khi, c hi tng thi ghp cp kt hp.

4.3 CC BIN CHNG NIU KHOA

4.3.1 TC NGHN NG TIU

Biu hin bng tnh trng gim bi niu v c gin n khoa g i, thn
trn hnh nh siu m, ch o gii quyt tc nghn niu qun l mt
iu tr cp cu. Trong vi gi u sau m, hi tng gim bi niu phi
c truy tm tnh trng thuyn tc khc ni niu qun- bng quang do
mu cc hoc mu cc trong bng quang. Tnh trng tiu mu sau m c
th t thu xp c nh o ti ra bng quang lin tc. Rt him khi
tiu mu l do hoi t nh thn trong khung cnh thi ghp mch mu cp
t h, thng phi ct b thn ghp.

Trong nhng ngy sau m, tc nghn niu qun- bng quang c lin quan
n hi tng ph n hoc thiu mu ming ni.Cc bin chng nhim
trng hoc hoi t ming ni c th iu tr b g h t ti ch
sonde JJ, nu niu qun qu ngn, c th m ni niu qun ca thn ghp
vo niu qun ring.
Hp khc ni niu qun- g ua g thng xut hin tr, l nguyn nhn
ca vic suy t t ch g thn, cn phn bit vi thi ghp mn. Tn
sut ca hp tha i t , n 3,2% ty theo lot nghin cu v ty
theo ph g ph p m niu qun vo bng quang.

Si niu qun him gp, thng gy tc nghn khng hon ton, do


nguyn nhn nhi t g thng gp.

. . D NC TIU

T l 0,6%, ch o da vo lm sng, vi tnh tr g t g lng dch qua


cc ng d lu, i khi ph vng bu.

. . TRO NGC NIU QUN - BNG QUANG

4.3.4 LYMPHOCELE:

T l 1-10% do ct khng cn thn cc tm mch trong qu trnh bc tch


vng chu hoc do din bc tch qu rng. Chng c th gy chn p niu
qun do khi t dch quang thn, hoc gy cn tr ng tr v ca cc
t h h hi di, lm ph n hi di cng bn.

4.4 BIN CHNG NG MCH

4.4.1 THUYN TC CP TNH NG MCH:

Thng gp tr em < 15 kg.

gi l , thng gp trn tnh trng hp ng mch c t t c. Biu


hi l s g t ngt vi st (khong 38- . C), v niu, au g
thn ghp, thn ghp l , au, i khi in mt mt m thi tm thu
hp ng mch th t t c. Ch o t t o g t ng hp
ny l ti khn cp v ch cn sau 3 gi thiu mu nng, mi c g g lm
t i ti mu th u tr nn v ch v ct th l ph g ph p iu tr
duy nht.

4.4.2 THUYN TC MT NG MCH MT CC THN VI NHI MU KHU


TR:

Rt thng gp, thng tim , c ch o h chp ng mch


chn lc thc hin khi c tnh trng suy ch g thn khng gii thch
c, hoc khi c cao huyt p lin tc sau m.

4.4.3 HP NG MCH THN GHP:

T l tha i t n 30%. C th xut hin do bi ch th g t o g u


trnh m ly thn hoc ghp th . C g th l do hu qu ca thi ghp
mch mu mn.

Nu tc nghn > hoc = 75%, cao HA khng tr vi iu tr ni khoa, suy


ch g th do iu tr bng IEC, cn phi can thip loi tr ch tc.
Ph g ph p l to hnh mch mu bng cch nong ni mch, cho kt qu
tt ngay tc th > 80%.

Ti pht rt thng gp: % sau , th c ti can thip bng


cch nong nhiu ln. Phu thut c nhiu rc ri, ch c ch nh khi nong
nhiu l u tht bi.

4.5 BIN CHNG TNH MCH

Thuyn t t h ch him gp, thng c yu t to thun l lymphocle


hoc mu t quanh thn c cn tr g u t h ch v.
CHNG . BO CO KHOA HC

113. NHN MT TRNG HP CT BU TUYN


THNG THN QUA NI SOI SAU PHC MC
VNG HNG LNG

Nguyn Phc Cm Hong* , Ng Thanh Mai *, Tr Thng Phong **

* Bs Khoa Niu B bnh vin Bnh Dn; ** Bs Ni tr Khoa Niu B bnh vin Bnh
Dn

T lc:

Tc gi trnh by mt t ng hp u tuy thng thn phi k h thc 40mm


trn CT, pht hin tnh c, khng ch g t t tha h i c phu thut
ni soi sau phc m g h g l g. Bnh nhn n t th nghing tri c in.
Bong bng bc tch vng sau phc mc l mt g g , Sali e l. S
trocar s d g: , t theo ng nch . Thi gian m: ph t. lng mu
mt: 40 ml. Hu phu: au sau m t; Thi gian dng thuc gi au sau m: 5
g ; C hu ng rut tr li: hu phu 2; Rt ng d lu g hu phu 4, nm
vin sau m: 6 ngy. Kt qu bnh h u: u hch thn kinh
(ganglioneuroma). Kt qu ca t ng hp t g hp vi kt qu ca cc tc
gi.

Ch g t i ha nhiu kinh nghi h g ki h ghim ca cc tc gi cho thy


ni soi sau phc m g h g l g l a to h , t l h t hk h
thch phc mc v t th g tng, ngy nay thch hp ho u tuy thng
thn mt k h thc nh-va phi.
RETROPERITONEAL LAPAROSCOPIC ADRENALECTOMY BY FLANK APPROACH:
INITIAL CASE REPORT

Abstract:

We present one case of right adrenal tumor, size of 40 mm (CT scan), non-
functional, incidentally discovered, in a young man , operated on by lateral (flank)
retroperitoneal laparoscopy. Patient was on full left lateral decubitus position.
Expanding balloon made by a surgical glove, inflated to 400 ml with Saline.
Number of trocars used: 5 , distributed alongside the axilliary lines. Operating
time: 165 minutes. Estimated blood loss: 40 ml. Post-op. period: Moderate post-
op pain; Duration of analgesics administration: 5 days; Recovery of bowel
movements: 2 days; Drain removal after 4 days; Post-op hospital stay: 6 days.
Pathology of tumor: ganglioneuroma. These intial results - through this case- is
the same as those of the authors. We are not really experienced but according to
the authors, retroperitoneal laparoscopic adrenalectomy on flank approach is
safer, less invasive because it avoids peritoneal irritation and intestinal injury. It is
currently selected for small-to-moderate size, unilateral adrenal tumors.

T VN :

Phu thut tuy thng thn l mt phu thut niu khoa kh ua


nm su trong vng sau phc mc trn thn st vi ho h. T o g h g
qua ti Khoa-B mn Niu bnh vin Bnh Dn phu thut ch yu ua ng m
ng [11]. T , Chu ng s [12] bt u thc hin ct u tuyn
thng thn qua ni soi bng qua phc mc vi kt qu tt.

Trong tin trnh pht trin phu thut ni soi bng chng ti p dng song song
ni soi bng qua phc mc v sau phc mc. Phu thut ni soi sau phc mc c
nh g u im ring, trong thi gian t / h gt i l nhng
b h l ng tiu trn kh g u kh h: ly sn b thn, sn niu qu on
trn, to hnh khc ni b thn-niu qun, ct chp nang thn, .. M tiu a h
l ct thn, ct tuy thng thn. Bi ny trnh by mt t ng hp ct u
tuy thng thn phi qua ni soi sau phc m g h g l g a c thc
hin trong thi gian qua.

LCH S: [9]

1 / 1992 Go v cng s l u tin thc hin ct tuy thng thn qua ni


soi bng trn b h h u tuyn (adenoma) tit aldosterone. Suzuki v
cng s thc hin cng loi phu thut vo 2 / 1992 trn bnh nhn
pheochromocytoma.

Phu thut c Gagner v cng s o ot l u ti


1992.

1992 sau khi Gaur gii thiu k thut ni soi sau phc mc, ct tuy thng
thn qua ni soi sau phc m g h g l g c thc hin trn bnh nhn
u nh mt bn t 7 / 1994.

T / ng bn qua phc m d g ho u tuy thng


th t g i ln.

Ni soi sau phc mc ct u tuy thng thn ngy nay t thnh rt


thng dng. Theo Hip hi Niu khoa Ph p AFU t o g -1999) trn
156 b h h c m ct tuy thng thn qua ni soi bng [1 ] th n
2/3 (105) l qua ng sau phc mc, ch 1/ 3 (51) ng xuyn phc mc.
TRNH BY BNH N:

1. Bnh nhn tn: Bi Hiu L. , a , si h .

S h s: /

Ngh: g h kh

a ch: C L Xu Oai, Lo g T ng, Q.9 , thnh ph H Ch Minh.

L do vo vin: khm sc khe nh k siu m pht hin tnh c u tuyn


thng thn phi.

2. Lm sng: khng c triu ch g g c hiu.

3. Cn lm sng:

Siu m: hai th h th g, u tuy thng thn bn phi k h thc


303527 mm

Chp thn c ua g g t h ch (UIV): khng pht hin g l.

CT scan th : u tuy thng thn bn (P), 304040 mm, d g c, khng bt


thuc cn quang.

Nc tiu: 17-h d o ste oids / c tiu h= , g h thng: 5 - 9 )

17-keto ste oids / c tiu h= , g h thng: 9 - 16 )

Cate hola i / c tiu 24h = 100 mg ( bnh thng: 100 50 )

T g ph t h c tiu: BC: (-); Protein (- ; HC ; ng (-)

pH=6; SG=1,010; Nitrite (-)


4. Phu thut: ngy 9 / 12 / 2003

Ph g ph p phu thut: ni soi h g l g go i ph c .

T th bnh nhn: n ghi g t i t th m thn ly sn c in.

Bong bng bc tch vng sau phc mc: lm b g g g , Sali e l

S trocar s d g: , t theo ng nch;

p l gaz CO2: 14 mmHg

Thi gian m: 165 pht

lng mu mt: 40 ml

Hu phu: au sau m t

Thi gian dng thuc gi au sau : 5 ngy

C hu ng rut tr li: hu phu 2

Rt ng d lu g hu phu 4, nm vin sau m: 6 ngy.

Kt qu bnh h : u hch thn kinh tuy thng thn (Ganglioneuroma). Vi


th: t bo hch giao c a dng, nhiu cc, bo t g ln, cha th Nissl t
thn kinh, t o S h a t g sn, nhiu nguyn bo thn kinh, nguyn bo si
km t bo vim.

BN LUN:

1. Ch o t c m v ch nh phu thut:

Trn c g hng t ht h MRI , u ao thng l


a i o a h g du hiu g kh g c hiu [7]. Chng ti khng c MRI.

V ch nh m, cc tc gi thng nht: u e h l
a i o a ho khi c ch g i h gc li bng phu thut ct tuyn
thng thn . Theo Vaughan v Blu e feld , u tuy thng thn 3- n 6
, u c, khng ch g, ph t hin tnh c l vng tranh ci gia ch nh
theo di v phu thut. Mt s tc gi h Glaze ng s ngh phu
thut ho u -4 cm; Prinz [7] li nhn mnh phu thut ho gi tr c
u.

y l mt t ng hp khi u tuy thng thn mt bn pht hin tnh c,


khng triu chng (incidentally discovered adrenal mass, incidentaloma), khng
ch g o -fu tio al , k h thc va phi ng knh ln nht trn CT =
40 mm) , gi tr nn chng ti quyt nh can thip bng ni soi, ng sau
phc m . V u nh h -5 cm v khng phi pheochromocytoma nn hon
ton thch hp cho ni soi sau phc mc [9].

2. K thut to ng vo v phn b trocar:

T th bnh nhn nm nghing c in, phu thut i h h g sau l g, t


video pha bng b h h . l t th hon ton quen thuc vi phu thut
vin niu.

Tch vng sau phc m d g o g g du g dch Saline bng mt g g


m ca Gaur [8], phn b t o a theo ng nch ca Abbou [2,3] m chng
t i ki h ghim v thi quen trong lot phu thut sn niu qun v nang
thn qua ni soi sau phc mc [10]. Trong phu thut l h t thn, ct tuyn
thng thn,.. chng ti thy rng dng bong bng tch vng sau phc mc l bt
buc v cn phu t ng rng. V s t o a , l phu thut phi bc tch su
s t ho h i ng mch nn phi dng s trocar ti a l i
trocar cho ng soi n t ng nch gia ngay trn mo chu. Dng c phu
tch c th c lun chuyn gia t o a g h sau di ng nch
t c trn.

K thut t o a theo ng nch Phu thut hon thnh

3. K thut bc tch tuy thng thn:

Abbou [4,5] ch t g o t t h h thng thn v x l t c khi bc


tch tuyn. C th bn phi s bc tch d t h ch ch di, n cung thn
s bc tch tip ln trn 5 cm s th t h h thng thn. Suzuki [9] li ch
t g vo cn Ge ota t c, bc tch nguyn khi tuy thng thn v cc
trn thn, tch gia tuy thng thn v thn, x l t h h thng thn sau
g. T o g t ng hp ny chng ti th tch d t h ch ch di t
tm cung th , h g t h l t ung th t t h h thng thn qu
su nn chng ti chuyn qua tch quanh tuy t c, cui g g t thy
t h h thng thn kh nh. T ng hp ny l mt u khng ch g
nn khng tht cn thit phi khng ch cu g t . i o t h mch ch di
t h t h h thng th t gu h u h g u thc hin
c th phn cn li ca phu thut s rt ha h h g. H a, l k thut
ti n ct thn tn gc ng sau phc mc.

Khng ch TM thng th t c (nh: Bc tch nguyn khi cc trn thn-


Abbou [4 ] ) thng th t c

4. Cc thng s ca cuc m:

Trong nhm phu thut ni soi sau phc mc: [5, 9 ]

Tc gi S BN Thi gian Mu mt Nm vin Chuyn m


PT (pht) h (%)
(ml) (ngy)

Mandressi et 7 170 100 4,8 1 (14)


al., 1995

Takeda et al 11 248 151 - 1


., 1997

Heintz et al., 18 180 170 5 3 (16)


1996
Suzuki et al., 30 178,4 64,5 - -
2001

Abbou , 1999 44 98 75 4,7 0

BN ny 1 165 40 6 -

So vi nhm phu thut ni soi qua phc mc: [ 5, 9,12 ]

Tc gi S BN Thi gian Mu mt Nm vin Chuyn m


PT (pht) h (%)
(ml) (ngy)

Suzuki et al., 30 142,2 58 - -


2001

Takeda et al 27 231,8 155 - (6)


., 1997

Guazzoni et 20 170 100 3,4 0


al., 1996

Brunt et al., 24 183 104 3,2 0


1996

Chuyn et 18 134 - 4,5 33,33


al., 2003

BN ny 1 165 40 6 -
Bnh h u tuy thng thn phi: u hch thn kinh
(Ganglioneuroma)

KT LUN:

Qua t ng hp trn, chng ti thy rng ct u tuy thng thn qua ni soi
sau phc m g h g l g l phu thut kh thi, an ton, kt qu t g hp
vi kt qu ca cc tc gi, mang li kt qu tt cho b h h t o g iu kin
thc t ca chng ti.

Ch g t i ha hiu kinh nghi h g ki h ghim ca cc tc gi cho thy


ni soi sau phc m g h g l g l a to h , t l h t hk h
thch phc mc v t th g tng, thch hp ho u tuy thng thn mt
k h thc nh-va phi.

TI LIU THAM KHO:


1. Abbou C.C., Antiphon P., Hoznek A.: Rapport sur lactivit de laparoscopie
lA.F.U. La laparoscopie en urologie. Progrs en urologie. Rapport du Congrs 1999
de lA.F.U. Volume 9, Numro 5, Novembre 1999. pp 845-47.

2. Abbou C.C., Doublet J.D., Gaston R., Guilloneau B.: Les espaces de la chirurgie
laparoscopique. La laparoscopie en urologie. Progrs en urologie. Rapport du
Congrs 1999 de lA.F.U. Volume 9, No 5, Novembre 1999. pp 867-71.

3. Abbou C.C.: Installation du patient, instruments, voies dabord. Laparoscopie.


Chirurgie urologique. Masson - Didactik dition multimedia, Novembre 2001.
Production Principes Actifs.

4. Abbou C.C.: Surrnalectomie droite. Laparoscopie. Chirurgie urologique.


Masson - Didactik dition multimedia, Novembre 2001. Production Principes
Actifs.

5. Abbou C.C., Doublet J. D., Gaston R., Guillonneau . B.: Surrenalectomie . Haut
appareil urinaire. Progrs en urologie. Rapport du Congrs 1999 de lA.F.U.
Volume 9, Numro 5, Novembre 1999. pp

6. Blake D. Hamilton: Laparoscopic adrenalectomy: transperitoneal and


retroperitoneal approaches. Atlas of laparoscopic retroperitoneal surgery. W.B.
Saunders company, 2000, pp191-208.

7. Darracott Vaughan E., Jon D. Blumenfeld: The adrenals . Campbells Urology , 7th
Ed. Vol.3, W.B. Saunders company, 1998, pp 2915-2972.

8. Gaur D.D.: Retroperitoneoscopy. Urologic laparoscopic surgery. McGraw-Hill


Companies, Inc,1996, pp 175-86.

9. Kazuo Suzuki: Laparoscopic adrenalectomy: retroperitoneal approach.


Advanced urologic laparoscopy. The Urologic clinics of North America, Vol.28, No
1, Feb. 2001, pp 85-95.

10. Nguyn Phc Cm Hong, Nguy V Hip, Phm Ph Pht, Nguy V ,


Nguyn Ngc Tin, o Quang Onh, Nguyn T Kha, Nguyn Hong : Bc
u p dng k thut ni soi sau phc mc ng hng l g t o g ct chp nang
thn v sn niu qu on trn. Y hc thnh ph H Ch Minh. S c bit Hi
ngh Khoa hc K thut bnh vin Bnh Dn. Ph bn ca Tp 8* S 1* 2004, trang
247-58.

. V c Hp, V L Chu : Mt s nhn xt v iu tr u tuy thng thn


ti bnh vin Bnh Dn t 1992-1999 . tp ch Y hc Vit Nam s 4-5-6 / 2001.
Chu Tit niu - Thn hc, trang 193-195.

. V L Chu , L V Ngha, V V T , Phm Ph Pht: Ct b u tuyn


thng thn qua ni soi bng trong hai -2002. Y hc thnh ph H Ch
Minh * Tp 7* Ph bn ca s 1* 2003, trang 7-11.

114. NHN MT TRNG HP TC NIU QUN


SAU M LY THAI

PGS. TS. BS. Tr L Li h Ph g - ThS. BS. Nguyn Hong c

TM TT

Th g tn niu qun l bin ch g g s trong cc loi phu thut vng


chu. Cc tc gi trnh by mt bnh n thn m v mt hon ton ch g
thn do hp niu qun sau m l thai kh g t iu chng lm sng
r rng.

M U

Th g tn niu qun l bin ch g g s trong cc loi phu thut vng chu.


Hu qu nng n nht l lm hu hoi dn ch g th . Tu hi , th g
t th g c pht hin sm trong lc m hoc ngay trong thi gian hu
phu gn nh vo cc biu hin lm sng r rt. Nh g t ng hp khng c
triu chng him gp h thng b b st trong thi gian di. Chng ti xin
trnh by mt bnh n thn m v mt ch g ho to do hp niu qun
sau m l thai . T iu chng lm sng bnh nhn ny khng r rng v
trong mt thi gian di, bnh nhn ch iu tr bng thuc gi au, h
cu.

TRNH BY BNH N

Bnh nhn: NGUYN TH NG. 45 tui

Ngh nghip: bun bn.

L do nhp vi : au l g.

Bnh s: B h k o d i i triu ch g au h g l g hai ,


khng c du hiu gi ca nhim trng tiu. B h h kh nh ti nhiu
i, iu tr bng thuc gi au, h u h g t h t g au kh g
tha i. Thnh thong c nh g t st lnh run t khi au tc hng tri
t g dn nn b h h n khm .

Tin s: Cch nhp vi c m ly thai do chuyn d ko di, suy tim


thai. Em b nng 3 kg, con so, s g. Sau thai l hai, si h thng.

Khm lm sng: Khng pht hin du hiu g bt thng.

Cn lm sng:

- Siu m bng: Thn tri III, niu qu t i gi n vng chu.


Thn phi h thng.
- KUB: Bng thn tri to, khng c si cn quang h niu.

- UIV: Thn phi: hnh dng v ch g h thng. Thn tri: bng thn
t i to, ha t thuc c ua g ha ph tit trn cc phim chp 90 pht,
12 gi, 24 gi.

- Soi bng quang: Thy bng quang b mo m bin dng ko xch ln pha
nh bn tri. L niu qun phi v tr 8 gi, h h khe, phu c tiu trong. G
lin niu qun b bin dng, ko xch ln v ph a t nh, khng tm thy l niu
qun tri.

- Th ng v phng x: Thn phi v t h thng, hp thu v thi


cht phng x tt, ch g thn phi chim 96%. Thn tri khng hp thu cht
phng x, khng thi cht phng x sau Lasix test ch g thn tri chim 4 %.
Kt lun: Thn tri mt ch g ho to .

Ch o : Thn tri mt ch g do hp niu qun tri sau m ly thai.

Ph g ph p phu thut: ct thn niu qun tri.

Gii phu bnh l:

- i th: Thn tri to, d= 17 x 8 x 6 cm nhiu mi, bn trong cha 700ml m


g c, long, khng hi.

- Vi th: Thn c nhng vng vim lan to t v n tu thn. Thm nhp


nhiu t bo vim trong m k, i to p xe. ng thn b ph hu, thay bng
m si. Nim mc niu qun vim, lot trc, km thm nhp nhiu lymph bo
lp di nim mc.
Hu phu: Din ti h thng, xut vin ngy th 7 sau m. Hin bnh nhn
kho, kh , t m lnh, sinh hot h thng.

BN LUN:

1. V th g tn niu qun: l in ch g g s trong cc loi phu


thut vng chu.

- Tn sut: 0,1- 1,5% [2].

- V tr d b t th g ht l 3 cm cui (gia mch mu t cung v bng


quang)

- Cc phu thut thng gy t th g NQ:

Ct TC ng bng: 0.5- 1%

Ct TC g o: 0,1%

Phu thut Wertheim: 1- 2%

Ct hai phn ph: 0,1%

Marshall- Marchetti- Krantz: <0,1%

- <30% cc t th g c pht hi c lc m.

B h h c m l thai, th g tn niu qun rt nhiu kh g l


do phu thut g a h g kh g c pht hin trong lc m g h
trong thi gian hu phu. Sau m nh nhn bt u au h g l g
h g h ung thuc gi au, kh g kim tra bng siu m nn khng pht
hi c tnh trng ca thn. Trong sut qu trnh mang thai l hai g kh g
c kim tra v hnh nh hc.

2. Hu qu ca t th g iu qun:[2]

- T ht: khi t th g h, thong qua.


- Th teo: t o g t ng hp ct NQ hon ton khng pht hi c trong
v sau phu thut, ch g thn b ph hu t t, i khi kh g t iu chng
ln sng. Nu c nhim trng, vic ch o s s h d d g h h
vo bnh cnh nhim trng rm r. V t ra l phi ch o s cu
ly ch g thn. Trn thc nghim, him khi ch g thn tr v bnh
thng nu ct niu qu ho to h 40 ngy. Shapiro v Bennett [2]: chc
g thn c th phc hi nu thi gian ct niu qu tha i t 28- 158 ngy.

- Hoi t niu qu , g tho t c tiu a go i ng niu, to thnh nang


gi niu hoc p xe sau phc mc. Nu niu qun b ct t trong lc phu thut
bng, c th g tho t c tiu vo trong phc m , a n bnh cnh
vim phc m do c tiu. Nu niu qun b ct n t o g o s gy ra
tnh trng d niu qun- o sau m.

- Hp lng niu qun th pht sau t th g iu qun gy teo thn m


thm hoc thn- niu qun m.

- T g u e u t o g t ng hp tc niu qun hon ton hai bn hoc ct


niu qun ca th c nht.

Trn bnh nhn ny, tnh trng thn- niu qun m xy ra khng r thi im v
b h h kh g c kim tra bng hnh nh h thng xuyn. Ngoi ra bnh
cnh lm sng ca nhi t g u h nn b xem nh, d n ch g
thn b ph hu hon ton.

3. C ph g tin ch o :

- Siu m bng: ch nhm pht hin tnh trng c, gin n ca thn- niu
qun, khng gip pht hin ch g th , g kh g h a c v tr tc
h h . Tu hi l t ghim d lm, khng xm hi v t tn km nn
c c ch vi m h t u t t h trng c thn- niu qun.

- Niu k ni t h ch (UIV): L xt nghim rt c ch, va ch o hc


g thn (quan trng l ch g a thn cn li), va ch o tr tc nu
im dng thu g t g i a h niu. Trong t ng hp thn
khng phn tit hon ton th kh pht hi c v tr tc.
- Chp niu qun- b th gc dng (UPR): L th thut gip tm v tr tc
khi trn UIV thn khng phn tit.

- Chp b thn- niu qun xui dng (PUD): Nhm pht hin v tr tc khi
trn UIV thn khng phn tit m khng thc hi c UPR. Chp PUD c
thc hin bng cch chc ht th ua da thuc cn quang xui dng.

- CT Scan: L xt nghim h tr ho UIV, gi p nh v tr t g


bit c ch g thn.

- Th ng v phng x (renal scan): l xt nghim quan trng, c gi tr


ao h gi h g thn, m tc nghn vi s tr gip ca vic tim
thuc li tiu (Lasix).

- Niu ng lc h ng tiu trn (upper tract urodynamic).

Bnh nhn ny, vic ch o c thc hin theo trnh t t ch o tr


t n xem xt ch g th : siu , UIV, UPR, e al s a . Khi nh
c thn b mt ch g ho to th m to h h kh g t ra
na. Tuy nhin, thn m l ch o h c sau khi ct th t c m bnh
nhn khng c du chng g ca tnh trng nhim trng.

KT LUN

Th g tn niu qun l bin chng ca phu thut vng chu, c th d n


nhiu hu qu nng n, ng s nht l mt ch g thn. Vic ch o tai
bin ny c c thc hin s can thip kp thi. Tuy nhin c nhng
t ng hp vic mt ch g th sau th g tn niu qun li din ra m
thm khng c triu ch g. T o g iu kin hin nay, c ta c nhiu ph g
ti gip ch o sm. Vic ch o i theo t h t t pht hin
thn- niu qun nh v tr t , h gi h g thn b
th g t g h h g thn cn li c quyt nh x tr kp thi,
chnh xc.
TI LIU THAM KHO

1. A. R. STONE, M. E. MORAN. Management of the ureteral defect.


Reconstructive urology. Blackwell Scientifiic Publication 1993: 343- 359.

2. J. D. THOMPSON. Operative injuries to the ureter: prevention, recognition


and management. Operative gynecology. J.B Lippincott copany 1993: 749- 780.

3. P. H. O?REILLY. Functional evaluation of the upper urinary tract.


Reconstructive urology. Blackwell Scientifiic Publication 1993: 107- 119.

115. NI SOI SAU PHC MC NG HNG LNG


TRONG M SN NIU QUN ON TRN: KINH
NGHIM BAN U QUA TRNG HP

Nguyn Phc Cm Hong **, Nguy V Hip *, Nguy V **,

Ph Ph Ph t ***, o Qua g O h ** Nguyn B Minh Nht****

* B s Nguy Ph Gi c bnh vin B h D , ** B s khoa Niu B ,


*** B s khoa Niu A , **** B s Ph g NCKH nh vin Bnh Dn

T lc:

Mc tiu: Niu khoa c th l phu thut i a s vng sau phc mc nn


vic pht trin phu thut ni soi vng sau phc m l h g i thch hp v
nhiu trin vng. Khoa-B mn Niu bnh vi B h D ph t t in phu thut
ni soi bng t u i soi sau phc mc t thng 8 / 2002. Bi
vit ny tng kt t ng hp u tin m sn niu qu on trn qua ni soi
sau phc m g h g l g.
T liu v ph g ph p ghi u: 36 bnh nhn sn niu qu on trn c
ch nh can thip c p dng k thut u tin t / n cui 8/2003.
Vo vng sau phc m g h g l g sau khi t i c tch vng hng
l g hi CO2 to khong trng lm vi , t 3 hoc 4 trocar vi trocar
cho ng knh ni soi nm pha trn mo chu t ng nch gia, 2 trocar
lm vi t g h sau. h gi kt qu ngay trong thi gian nm vin
hu phu.

Kt qu: Ba i s u nh nhn c tui trung bnh 46,6, vi 17 nam v 19 n, m


ly ra 21 sn bn phi v16 sn bn tri vi 37 sn / 36 bnh nhn. V tr sn: khc
ni b thn-niu qun: 7 ; mm ngang LIII: 10; mm ngang LIV: 5; gia L III-LIV: 12;
gia LIV-LV: 2. K h thc sn trung bnh l 16,56 mm. Phim h niu c cn quang
c 3 thn I, 27 thn II, 3 thn III, t ng hp
kh g ; t ng hp ch g thn tt, 11 ch g t u g h hc
g thn xu. Hai t ng hp u t thng niu qu t c m. Th tch ti
: l; d g t o a t o g t ng hp, dng 4 trocar trong 8
t ng hp. Ct x niu qun bng dao lnh ni soi t ch, ch t ng hp x
bng dao nng, khu li niu qun t 1- i. Ba t ng hp t lu th g
niu qun khi m. Thi gian m trung bnh:105,4 pht. B h h hu ng
rut li sau 1,78 ngy; thi gian dng thuc gi au sau : 4,4 ngy; rt ng
d lu sau , g ; m vin sau m: , g . C / t ng hp (11,1%)
chuyn m h t o g t do lm thng phc mc tm khng thy niu qun,
mt do chy mu do t th g t h ch sinh dc, mt do t g ao th kh
(CO2) trong mu, mt do bnh nhn mp.Tai bin khi m: t ng hp t g th
kh trong mu lc m t o g 1 phi chuyn m h, t ng hp chy mu do
t th g t h ch sinh dc phi chuyn m h. Thi k hu phu c 5/ 32
t ng hp (15,6%) phi t thng JJ niu qu , t sau m , g c
tiu nhiu. Bin ch g kh : t kh di da bng, 1 nhim trng vt t
trocar.

Kt lun: kt qu trn l khch l vi t l thnh cng l 88,9% ( 32/ 36 ), t l


chuyn m h:11,1% ( 4 / 36 ), bin chng sau m t. Phu thut ct m niu
qu on trn ly si l t g i d thc hin v hi a th h thng
u , thng ch nh cho sn niu qu on trn ln, dnh cht, s ti lng
kh khi ni soi niu qun. Hi a h g t i thc hi c to hnh khc ni
b thn-niu qun, hp niu qu o t , u ti n ct thn, ct
tuyn thng thn.

LAPAROSCOPIC RETROPERITONEOSCOPY FOR UPPER URETEROLITHOTOMY: I


NITIAL EXPERIENCE IN 36 CASES

Abstract:

Objectives: Minimally-invasive endoscopic procedure is the current trend in


surgery. Urology has the characteristic of operations mainly in the
retroperitoneum, hence, retroperitoneoscopy is the appropriate and promising
approach. At the Department of Urology of Binh Dan hospital, we have developed
laparoscopy since the beginning of year 2001 and laparoscopic
retroperitoneoscopy since August 2002. This paper is to summarize the
operations for upper ureterolithotomy using the flank retroperitoneoscopic
approach.

Materials and method: 36 patients with upper ureteral calculi not responding to
medical treament initially operated on from March 2003 till the end of August
2003. We applied the same technique of entering the retroperitoneum in the
flank region by using an expanding balloon and insufflation of carbon dioxide to
create a working space. We used 3 to 4 trocars with the trocar for laparoscope
placed over the iliac crest, in the mid-axillary line, 2 working trocars in the
posterior axillary line. Assessment of outcome performed right in the post-op
period.
Results: Thrity six patients with upper ureteral stones have the average age of
46.6, with 17 males and 19 females, 21 ureteral stones removed on the right-
hand side and 16 ureteral stones on the left-hand side with 37 stones for 36
patients. Stone sites: 7 UPJ stones, 10 LIII stones, 5 LIV stones, 12 L III-IV stones, and
2 LIV-V stone. Mean stone size: 16.56mm. IVU revealed 3 mild hydronephrosis, 27
moderate hydronephrosis, 3 severe hydronephrosis, 3 of unknown; 20 cases with
good renal function, 11 with fair renal function, and 5 with poor renal function. In
2 initial cases was a ureteral catheter placed pre-operatively. Mean balloon
inflation: 387ml. Three trocars were used in 28 cases, and 4 trocars in 8 cases. We
performed ureterolithotomy using a home-made endo-cold knife, in only 2 cases
did we use a hot one. We put one to three stitches for ureteral repair. In 3 cases
did we place an indwelling ureteral catheter. Mean operation time: 105.4
minutes. Post-op bowel movements in 1.78 days; post-op analgesic
administration time: 4.4 days; removal of drain in 5.2 days; post-op hospital stay:
5.47 days. In 4 / 36 cases ( 11.1%) did we resort to lumbotomy in which one was
caused by peritoneal penetration and ureter not found, one severe haemorrhage
because of gonadal vein injury, one severe intraoperative hypercarbia, and one
because of obesity. Intra-operative incidence: two intraoperative hypercarbia of
which one lead to lumbotomy, one haemorrhage by gonadal vein injury leading to
lumbotomy. In post-op period, 5 / 32 cases (15.6%) needed placement of a
ureteral stent at 6.8 days because of urine leakage. Other complications
comprise: one subcutaneous emphysema, one infection at the trocar site,

Conclusions: these results are encouraging in terms of good success rate: 88.9% (
32 / 36 cases ), acceptable lumbotomy rate: 11.1% ( 4 / 36 cases), complications
in post-op period were quite few. Upper ureterolithotomy are easy-to-do
procedures, it has become routine and currently indicated for big, chronically
impacted stones, difficult stones for ureteroscopy. By this approach, we can now
perform dismembered pyeloplasty, repair of upper ureteral strictures, and initiate
simple nephrectomy, adrenalectomy.
I. T VN :

Phu thut ni soi bng c hai ng vo: ng xuyn phc mc v ng sau phc
mc. Phu thut niu khoa im l can thip ch yu vng sau phc mc
nn vic p dng phu thut ni soi qua ng sau phc mc ngoi nh g u im
trnh tip xc trc tip vi ua t o g b g l ng vo trc
tip v quen thu i vi s iu khoa. Ti Khoa-B mn Niu bnh vin
B h D t u thc hin phu thut ni soi bng t u
bng ng qua phc mc trong phu thut u tuy thng thn, nang thn,
d t h ch tinh, si niu qu .. i kt qu khch l. T thng 8/2002 chng
ti bt u thc hin ni soi sau phc m g h g l g ct chp nang thn
[22], t 3/2003 bt u m niu qu on trn ly sn. Bi vit ny tng kt 36
t ng hp ct m niu qu on trn ly sn qua ni soi sau phc mc vng
h g lng thc hin t / n cui 8/2003.

II. TNG QUAN:

Lch s: [14, 20]

N , Ba tel thc hin l u tin thc hin ni soi sau phc mc vi


my ni soi trung tht. N , So e ka p si h thit thn bng k thut
na m (semi ope d g soi h g l g lu os ope . Whi kha ln
u ti hi g sau ph ct m niu qun ly sn qua ni soi sau
phc mc vi mt my ni soi bng tiu chun. Kaplan v cng s (1979) ni soi
sau phc mc ch dng kh nitrous oxide. Wickham v Miller bo co ni soi sau
phc mc t thi kh CO2 .

Hald v Ramussen (1980) thc hin ni soi vng chu sau phc mc trong
nh g t ng hp u g th g ua g tin lit tuyn. Mazeman (1986) v
Wurtz (1985) bo co kinh nghim no hch chu -bt ng sau phc mc.

Eshghi v cng s (1985) dng my soi b g theo di mt t ng hp ly


sn thn san h qua da trn mt t ng hp thn lc ch vng chu. Weinberg
v Smith (1988) ct thn qua ni soi qua da heo bng cch ht ch m thn qua
ng m thn ra da vi mt my ht siu m ni soi (CUSA) sau khi lp mch
ng m h t h ch thn. Meretyk v cng s (1992) bo co mt t ng
hp gp vt l vng sau phc mc qua mt ng hm qua da. Mc d Clayman
v cng s thc hin ct thn qua ni soi sau phc mc trong bui u h g sau
h li ng h ng qua phc mc. Vic Gaur (1992) [11] m t k thut ni soi
sau phc mc vi mt o g g lm n rng khong sau phc mc ra
chn tri mi trong ni soi bng trong niu khoa.

Ti Vit Na : L h Kh h o o t ng hp phu thut ni soi sau


phc m iu tr si niu qu o th g / , sau o T D g o
o t ng hp vo 3/ 2003.

Ch nh ni soi sau phc mc trong ct m ly sn (lithotomy):

C th m thn ly sn, m b thn, m niu qun ly sn nu kh g iu


kin tn si go i th, ni soi niu qun tn sn, hay ly si qua da hay khi cc
bin php trn tht bi. Ch h thng l sn ln v cng b thn ngoi
xoang, sn dnh kt (chronically impacted) niu qu on trn, sn niu qun
v c hp niu qun, s t o g t i g h i th , ha t o g i thn gin vi ch
m thn bn trn gin mng [13,14,15]. Gaur [15] cho rng sn niu qun cng
kh iu tr bng tn si go i th hay ni soi niu qun th cng d vi ni soi
sau phc m g h g l g.

III. TIU CHUN CHN BNH V PHNG PHP THC HIN:

1. Tiu chun chn bnh:

Bnh nhn sn niu qu l g t vng khc ni b thn-niu qun (b thn


go i oa g n trn mo chu, thng l sn niu qu l g d h kt
i pa ted kh g p g iu tr ni v tn si go i th (ESWL). Nhng
b h h t c vng h g l g sn b loi tr.

2. Ph g ph p thc hin:

2.1. Xt nghim tin phu: khng qun c c tiu t c m.

2.2. Ch o h h nh: siu m bng v chp thn c ua g g t h ch


(UIV). Trn UIV, nh g t ng hp thn 3 hoc c m thn gin
ln hoc ch g thn trn UIV km khng b loi tr.

2.3. Khng c t th g i-d dy v thng tiu ga t c m .

. . t thng niu qu t c m: chng ti khng ch t g t thng niu


qu di s t c m h th g tu t o g hai a u ha ki h ghim
chng ti c lm.

2.5. Phu thut ni soi sau phc m v gh g l g:

2.5.1. V cm: gy m ni kh qun.

2.5.2. T th bnh nhn: t th nm nghing c in vi mt gi c nng cao


eo l g, c gp khong 10-15o ngang mc hng. B h h c
c nh bi 3 vng ta: vng ta g u, l g, mng.

2.5.3. Cch bc tch vng sau phc m v t trocar:

Bc tch vng sau phc mc: r h da ga di u g s t ng


nch sau, di 1,5- ,t h l g th ct g dao in - mini
lu oto , d g g ta t h khoa g h g l g t . Sau d g o g
g c theo kiu ca Gau , , , t vo khoang cnh thn
sau. Bo g g c lm bng mt g g ho g ta g g t vo mt
g th g Nelato , - l Sali e bc tch. Chng ti khng c loi
trocar bong bng kiu PDB alloo , O igi Meds ste s . Sau khi c v
l o g g a t ga t o a u tin ( Storz 10-mm hay trocar Versaport 5-
, kh g t g o ng r h da u ti , kh u t k ng rch
da quanh trocar, dng ch vicryl 1-0. Chng ti khng c loi t o a k hi kiu
Origin Medsystems. Ni trocar ny vi g d hi CO2 hi sau phc
m n 14 - Hg. t g soi o t o a , d g u g soi , di
quan st trc tip ua h h, y tip nhng vng m cnh th lm
rng thm khoang lm vi . Sau s t tip t o a kh di quan st trc
tip di mn hnh.

2.5.4. V t t trocar v dng c: cch phn b cc trocar theo Abbou [2, 3]: hai
trocar lm vic g h sau ho gi m chnh (m mt l t o a u tin),
thng l trocar 10-mm v 5-mm hoc hai trocar 10- , ua gi m s
d g k o in v km phu tch; mt trocar 10-mm ngay trn mo chu trn
ng nch gia, t ng soi t o a ; hai t o a d h ho gi ph t
g h t , thng dng trocar 5-mm. Ti a l t o a h g t o g sn
niu qun chng ti ch cn 3-4 trocar vi t o a t g h t c l ty
chn. Cch phn b v t t o a h y l hp l, d thao tc, d phi hp gia
cc thnh vin kp m h l h t trocar c ng soi nm gia thng hng vi
hai trocar lm vi t ng m th h a Gaur [12,13] hay hnh tam gic
ca Ballanger [4, 5].
Phu thut i h h g ga sau l g h h , gi ph mt g i
di , gi dng c vin (gi a e a ng pha mng bnh nhn cng bn
phu thut vin chnh. Mn hnh ideo t i din phu thut vin,v ph a u
bnh nhn. (nh: Abbou [3]).

. . . C h i v o h thn v tm niu qun-thn: u ti theo th


ph a sau, i theo th ph a t o g n ti a, u g g i trc ca trocar
di sn ca phu thut vin. Dng mt ha d-like et a to y vn phc
mc v Gerota. Khi mt t th kh g th i a h a s x cn ph
th vo khoang tht l g t thy cc mc gii phu: t h ch sinh dc,
niu qu , t h ch ch di, cung thn.

2.5.6. Bc tch niu qun quanh ch sn nm, x niu qun gp sn: x niu
qun bng dao l h. Ret a ta le e dok ife a chng ti l mt dng c t ch:
d g li dao m s , i hn, tra vo cn dao ni soi lng trong mt thanh
st rng c np k hi u, a ua t o a -mm v x niu qun sau khi
dng mt kp endo-Babcock kp niu qun ngay trn ch sn nm. Ny sn ra,
gp sn ra ngoi bng km ni soi qua trocar 10-mm. Kim tra s th g th g
ca niu qu di bng cch lun mt thng th oxy s 8 vo ming x niu
qu , c mui sinh l vo ng thng. Khu li niu qun bng ch vicryl 4-
, i i (1- i , t t o g th. V c khu niu qun nn chng ti ch
t g kh g t thng nng niu qun h thng ha. Lau hay ht sch vng m
v d lu khoa g tht l g ng ng thng th oxy s t qua trocar 5-mm
pha mo chu. g l trocar vi kh u l trocar 10-mm.
2.6. Theo di hu phu: bnh nhn nm vi n khi ng d lu kh h rt
g t khi cho xut vin. Ghi nhn ngy bnh nhn c li hu ng rut, mc
au thi gian dng thuc gi au, g t th g d lu g l g
xut vin).

IV. KT QU:

Trong thi gian t / n ht 8 / 2003: c 36 bnh nhn vi 37 vin sn.

1. Bnh nhn:

1.1. Tui: t 20 70 tui. Trung bnh: 46,6 tui.

1.2. Gii: Nam: 17 N: 19

. . a d: TPHCM: 12 Cc tnh mi g: 12

Cc tnh min Ty: 10 Cc tnh min Trung: 2

1.4. ASA: I:
17 II : 18 III : 1

2. Si:

2.1. V tr: Si bn tri: 16 Si bn


phi: 20
Si khc ni: 7 Si L3 (mm
ngang): 10

Si L3 L4: 12 Si L4 (mm ngang): 5

Si L4 L5: 2

2.2. K h thc (mm): T: 8 30 , Trung bnh: 16,6

2.3. S lng: 37 sn/ 36 bnh nhn,1 bnh nhn c 2 vin sn niu qun
l g P .

2.4. c ca thn v niu qun (UIV) :

I : 3 II: 27 III: 3 Khng r: 3

2.5. Ch g thn (UIV): Tt: 20 Trung bnh: 11 Xu: 5

3. C c tiu t c m: Thc hin: 15 / 36 t ng hp

D g t h: 3 / 15 t ng hp

4. Phu thut m niu qun ly sn:

4.1. t thng niu qu t c m: ch t ng hp u tin.

4.2. B t i c tch vng sau phc mc: t 300 - 600 ml, trung bnh: 387 ml

t ng hp sau cng khng c d g t i c.

4.3. S trocar s dng: 3 trocar: 28 4 trocar: 8

4.4. Ch yu dng dao lnh ct x niu qun (30 / 32), ch t ng hp dng


dao in.

4.5. S i kh u iu qun:

i: / ; i: / ; i: / ; i: /

4.6. Thi gian m (pht): t 60 200 , trung bnh: 105,4 pht

. . t lu th g iu qun khi m: / t ng hp
4.8. Chuyn m h: / t ng hp:

t ng hp t h a ph a t c nhiu u , h t h ch sinh dc gy chy


mu.

t ng hp lm lng phc m , hi CO2 khng tt, tm khng ra niu


qun.

t ng hp ri lon nhp tim trong khi m c l do t g kh CO2 trong mu.

t ng hp bnh nhn mp, tm niu qun ko di, sn nm mt phn ni


xoang.

4.9. Tai bin trong khi m:

4.9.1. V o g g c: t ng hp vn tip tc m ni soi; 1


t ng hp sau phi chuyn m h v thng phc mc l ln m khng phi do
v bong bng ).

4.9.2. Thng phc mc: t ng hp thng l kh g hi c, chuyn


m h ).

. . . T g kh CO2 mu nng khi m: 2 , t ng hp c ri lon nhp tim phi


chuyn m h).

4.9.4. Chy mu do ph t h ch sinh dc, phi chuyn m h: 1

4.9.5. M ko di trn 3 gi: t ng hp m quanh niu qun vim dy tm niu


qun rt kh kh ; t ng hp bnh nhn mp, m quanh thn nhiu, sn
t g i nh .

5. Hu phu:

5.1. au sau : Nhiu: 2 / 32 Trung bnh: 24 / 32 t: 6 / 32

5.2. Thi gian dng thuc gi au g : t 2 8 , trung bnh: 4,4

. . Nhu ng rut tr li (ngy): t 1 - 3 , trung bnh: 1,78

5.4. Thi gian rt ng d lu g : t 2 17 , trung bnh: 5,2


5.5. Thi gian nm vin sau m (ngy): t 2 17 ngy, trung bnh: 5,5

6. Bin chng sau m:

T kh di da bng : 1

Nhim trng ch t trocar : 1

X d c tiu lu phi t thng niu qun: 4 t ng hp nghi c si thn


rt xung), ngy hu phu phi t thng niu qun trung bnh: 6,8.

V. BN LUN:

. ng tip cn sau phc m g h g l g:

Chng ti ch ng tip cn sau phc mc b g h t t i c bc tch


ngoi cn Zuckerkandle theo kiu ca A ou , h g l g t h
v chng ti s v t i . Theo h th sau khi t trocar th ba v bt u
phu thut s phi ct x vo lp m quanh th , t th ly
l b tm niu qun n s t ga ph a t c. Gaur [14,15]
ch t g t t i c di cn Zuckerkandle v vo thng vng quanh thn-
niu qun. Chng ti khng ch t g kh g kh s bin chng tc mch
do kh nu b v bong bng.

Trong nhng ca sau ny chng ti khng c d g t i c na: sau khi tch


vng sau phc mc bng ngn tay s t trocar 10- hi CO2 ngay, soi
vng sau phc m , d g ga u g soi tip t y m cnh thn ra khi
thnh b g lm rng khoang lm vi t tip cc trocar cn li. Kt qu
h d g t i h g tit ki c nhiu thi gian. Trocar 10- t u
tin nu dng loi Versaport 5-12 mm s gip tit kim thm thi gian m v
s l mt trocar lm vic.

. C h t trocar v v tr cc thnh vin kp m:

Ch g t i l h A ou [2, 3]: dng c i ng cng bn vi phu thut


i h h gi g soi ng hn v pha chn bnh nhn, phu thut vin s
s dng hai trocar ca mnh mt cch thun li thoi mi (khng chong tay dng
c vin). C th hon v ng soi ln trocar 10- t u tin v phu thut vin
phu tch qua 2 trocar cn li.

3. Ct m niu qun ly sn:

Chng ti ch t g niu qun bng dao l h trnh bin chng hp niu


qun khi dng dao i . Dao e dok ife t ch ca chng ti bo m an ton,
c kt qu tt.

Chng ti khng ch t g t thng niu qun h th g h a t c m


h D g thy khng cn thit (tr hai a u). Khu niu qun s dng
ch vicryl 4- , i i, ct t o g th thy khng tn thi gian nhiu. Th
khu niu qun quyt nh vi d c tiu sau m v thi gian nm vin sau
m v chng ti cho rt ng d lu i cho bnh nhn xut vin. Nu c tiu
c lc m ho d c tiu sau m g kh g g hiu lo lng v vng
sau phc mc. Nhng ca sau ny v thnh th h kh g d c tiu
na v bnh nhn xut vin sau m 2-3 ngy.

Nhng ca sau ca lot ny thi gian m thng kho g h ph t. C u t


lm cuc m k o d i: ha ki h ghim, bnh nhn bo ph (m quanh thn
nhiu), vim dnh quanh niu qu g h g l g sn kt niu qun lu
ngy), sn nm cao gn b thn. Cc yu t gip lm gim thi gian m: kinh
nghim v s thun th , kh g d g t i c, niu qun cn mm mi, sn nm
thp, dng trocar Versaport 5-12mm.

Coi chng cc yu t d d n chuyn m h: lm lng phc mc l ln


kh g hi c vng sau phc m hi tho t o bng gy tc dng
gc, phm mch mu sinh dc gy chy mu, vim dnh quanh niu qun nhiu
tm niu qu kh kh , o g g c gy th c m v chi
ua g t ng.

Kt qu phu thut sn niu qu l g ua i soi h g l g


Tc gi S Bong S Dao Thn Khu Thi Rt N
bng trocar/ x g niu gian ng m i
B
niu nng qun m dn vin
N tch, kiu m
qun lu sau

v tr t m
h

Gaur, Ti 3, Dao Khn Khn


c, g g
1996 [15 21 thng lnh 60 10 1
] 750ml, hng endo / clip ng ng
pht 3/
ng - y y
di trn 21
mth
knife khu
Gerota n
vt

Ballanger Ti Dao C,
, c,
- 3, lnh t Vicryl
1999 [5] 600ml, endo , i
tam t c - - - -
- ri
ngoi gic m
knife
Gerota

Khnh, Bao 3-4, Dao


cao thng in
2001 7 Vicryl 140 2 4
su,kh hng (mc
[19] ng ng
tri, ng cu) Khn 4-0, pht -
y y
800- mth g i
n ri
1000m
l

D g, Bao
cao
2002 [10 14 3-4, C, Vicryl
su,kh
]
4-0, 2
tri, tam - t i 121 ng 5,26 -
ri y
800ml, gic t c pht ng
m y
ngoi
Gerota

Lot ny, Ti
c,
2003 36 3-4, Dao 3/ Vicryl 105, 5,2 5,5 4/
387ml, lnh 32, 4 ng 36
theo 4-0, ng
y
ngoi ng (dao t i pht y
nch ri
Gerota m trong
/ 11) m

Khng

VI. KT LUN:

p dng k thut ni soi sau phc m g h g l g ho phu thut ct m


niu qu on trn ly sn ca h g t i t kt qu khch l v hi
th h thng quy vi thi gian m di ph t. N gi p ra trin v g y
mnh k thut ny cho cc phu thut niu khoa khc.

C u im t thn ca ph g ph p i soi sau phc m g n nhc li


: hp si h l h a thip ch yu vng sau phc m , t ng m quen
thuc vi phu thut vin niu, trnh cc bin chng tng ca ni soi qua phc
m , c tiu d c tiu kh g g ua gi. Hi h g t i c
u thc hi c cc phu thut phc tp h : t thn, tuy thng
thn, to hnh khc ni b thn-niu qu ,.
TI LIU THAM KHO:

1. Abbou C.C., A tipho P., Hoz ek A.: Rappo t su la ti it de lapa os opie


lA.F.U. La laparoscopie en urologie. Progrs en Urologie. Rapport du
Co g s de lA.F.U. Volu e , No , No e e . pp -47.

2. Abbou C.C., Doublet J.D., Gaston R., Guilloneau B.: Les espaces de la
chirurgie laparoscopique. La laparoscopie en urologie. Progrs en Urologie.
Rappo t du Co g s de lA.F.U. Volu e , No , No e e . pp
867-71.

3. Abbou C.C.: Installation du patie t, i st u e ts, oies da o d.


Laparoscopie. Chirurgie Urologique. Masson - Didactik dition multimedia,
Novembre 2001. Production Principes Actifs.

4. Ballanger Ph., Chemasle C., Renger B.: Nphrectomie gauche par


lomboscopie. Dpartement de Communication audiovisuelle. Universit de
Bordeaux II, 1995.

5. Ballanger Ph.: Urtrotomie pour lithiase sous lomboscopie. Dpartement


de Communication audiovisuelle. Universit V. Segalen Bordeaux II, 1999.

6. Barreto H., Doublet J.D., Peraldi M.N., Gategno B., Thibauld Ph. Chirurgie
rnale par lomboscopie: exprience initiale. Prog. Urol, 1995, 5, 384-389.

7. Capelouto C.C., Moore Silverman S.G., Kavoussi L.R.: Retro-peritoneoscopy:


anatomical rationale for direct retroperitoneal access. J Urol
1994;152:2008.

8. Chin A. K. and Moll F. H.: Balloon-assisted extra-peritoneal sursergy.


Retroperitoneoscopy. Isis Medical Media, pp 104-118.
9. V L Chu ng s: Mt s phu thut niu khoa qua ni soi bng
ti bnh vi B h D t o g hai -2002. Y hc TPHCM, tp 7, ph
bn ca s , , t g i h Y dc TPHCM, tr. 21-26.

10.o T D g: Mt s nhn xt v phu thut m niu qun ly si qua


ng ni soi sau phc mc. Y hc TPHCM, tp 7, ph bn ca s 1, 2003,
t g i h Y dc TP HCM, tr. 12-15.

11.Gaur D. D.: Laparoscopic operative retroperitoneoscopy: use of a new


device. J. Urol., 148: 1137,1992.

12.Gaur D. D.: Retroperitoneal endoscopic ureterolithotomy: Our experience


in 12 patients. J. Endourol 1993; 7:501.

13.Gaur D.D., Agarwal D.K., Purohit K. C.: Retroperitoneal laparoscopic


ureterolithotomy and renal biopsy. J Urol 1992; 2:149.

14.Gaur D. D.: Retroperitoneoscopy. Urologic laparoscopic surgery. McGraw-


Hill companies, Inc,1996, pp 175-86.

15.Gaur D. D.: Retroperitoneoscopy and ureteric surgery. Retroperitoneoscopy.


Isis Medical Media, pp 52-65.

16.Gaur D. D.: Retroperitoneoscopy and nephrectomy. Retroperitoneoscopy.


Isis Medical Media, pp 37-51.

17.Gill I. S., Grune M. T., Munch L. C.: Access technique for


retroperitoneoscopy. J Urol., 156: 1120,1996.

18.Himpens J. M.: Video endoscopy of the retroperitoneum.


Retroperitoneoscopy. Isis Medical Media, pp 16-23.23.

19.L h Kh h, Ph Nh Hip, D g g H: Phu thut ni soi bng


ua ng sau phc m iu tr si niu qun ti bnh vi t u g g
Hu. Y hc TPHCM, ph bn ca tp 6 , s , , t g i h Y dc
TPHCM, tr. 329-332.
20.Puttick M., Nduka C. C., and Darzi A. W.: Retroperitoneoscopy: history and
background. Retroperitoneoscopy. Isis Medical Media. PP 1-8.

21.Rassweiler J. J., Seemann O., Frede T., Henkel T. O., Alken P.:
Retroperitoneoscopy: experience with 200 cases. J. Urol. 1998; 160:1265.

22.Nguyn Ngc Ti , V L Chu , Ngu V , Ngu n Phc Cm


Hong, Nguy V Hip: B u p dng k thut ct nang thn qua ni
soi h g l g Kystectomie rnale par lomboscopie). Y hc TPHCM, tp 7,
ph bn ca s , , t g i h Y dc TP H Ch Minh, tr. 27-31.

23.Wu tz A.: Le dos opie de lespa e t op ito al: Te h i ues, sultats et


indications actuelles. Ann Chir 43:475,1985.

116. SO SNH VAI TR CA HAI LOI


LASER:REVOLIX V KTP TRONG IU TR BU
LNH TUYN TIN LIT

Mc tiu nghin cu: h gi nh g u khu t im ca 2 loi laser KTP v


Thulium

Ph g ph p ghi u: hi cu t ng hp u tuyn tin lit iu tr


vi laser KTP t a t ng hp mi s d g lase Thuliu . h
gi kh ca th thut, kh g m mu, kh g l u, hiu qu lm
s g gi th h t o g iu tr

Kt qu: t ng hp iu tr vi lase KTP t ng hp iu tr vi laser


Thulium

To g t ng hp iu tr vi laser KTP c 87% ci thi d g c tiu,


90,6% ci thin cht lng cuc sng, nhim trng tiu 5,8%, tiu mu ko di
10,6%, b tiu sau rt thng 4,8%, hp niu o 5,8%
Trong 3 b h h iu tr vi laser Thulium khng c bin chng no ngoi 1
bnh nhn b tiu sau rt thng

Kt lun: Cho ti hi a iu tr u lnh tuyn tin lit vi laser Thulium c l


l tt nht h g iu tr vi lase KTP g t c hiu qu h g gi th h
qu cao

Abstract

Purpose: To evaluate the advantages and the inconvenience of two kinds of laser:
KTP and Thulium

Materials and method: retrospective from 2004 : evaluate the difficulty of the
procedure, the ratio of complication, and the efficacy of the procedure

Result: 85 patients treated by KTP laser are included, among them 87% has
improvement on the Q max, the ratio of UTI is 5,8%, of hematuria is 10,6% , of
urinary retention is 4,8% and of urethral stenosis is 5,8%

3 patients treated by Thulium laser in which one experiences urinary retention


after withdrawing the catheter

Conclusion: treating BPH by Thulium is the best solution so far but by KTP is also
good. However the latter is limited by the high cost

1. M u:

Bu tuyn tin lit l mt bnh l ph bin gi ln tui , ph g ph p


iu tr hiu tha i t m m u, ct t ni soi soi, dng sng vi
ba TUMT)(2), dng sng v tuy TUNA h g tt c ph g ph p u
cn c nhng khuyt i ph g ph p t t ni soi v l ph g ph p
iu tr ph bin nht. khc phc cc khuyt im ca ph g ph p h
ch u, hai g ua g hiu tc gi ghi u iu tr vi Laser
v loi Laser ha hn thay th ct t ni soi c p dng ti Vit nam t 2004
l KTP h g i tin b khoa hc cng ngh g ut hin mt loi Laser
mi l Re oli . nhn xt v vai tr ca hai loi Lase h g t i ghi u
u v nh g u khu t im ca hai ph g ph p t .
2. i t g v ph g ph p ghi u:

Chng ti hi cu tt c t ng hp thc hi t u tuyn tin lit t


/ n nay s so s h s khi vi t ng hp mi bt u thc hin
b g ph g ph p t t tuyn tin lit vi laser revolix v mt s mt sau:
- kh ca th thut
- Kh g m mu khi ct t.
-Kh g l u.
-Ghi nhn cc bin chng
-Hiu qu l s g sau khi t u
- Gi thnh ca hai ph g ph p .

3. Kt qu nghin cu:

Ch g t i t ng hp t u vi lase KTP t ng hp s dng laser


Re oli . T o g t ng hp s dng laser KTP kt qu ci thi d g c tiu
r l 87,1% , v cht lng cuc sng th 90,6% bnh nhn rt hi lng, 1,2%
khng hi lng. V bin chng nhim trng chng ti ghi nhn c 5,8%, bin
chng tiu u k o d i h g , %, tiu sau khi rt thng l 4,8%,
hp niu o l 5,8%

i vi laser Revolix do chng ti ch mi thc hi t ng hp nn kinh


nghim khng nhiu chng ti ghi nhn c t ng hp b tiu tm thi sau rt
th g, kh g t ng hp no tiu u, ha ghi hn bin chng hp niu
o

4. Bn lun:

4.1. Nguyn tc to ngun laser vi tnh cht khc nhau: cc tnh cht khc nhau
ca lase ui nh bi d i c sng l ch yu. T ng hp laser KTP
h h s g c chiu qua tinh th potassiu tita l phosphate sau khi
qua tinh th ny th c s tha i d i c sng v tn s. nh sng KTP c
c sng l 532nm, vi c sng ny tia laser khng b hp thu t o g c m
c hp thu trong cc m c cha nhiu o he oglo i u vi
xuyn thu di , t o g t ng hp laser revolix nh sng s i ua
tinh th Thuliu th d i c sng kho g h s c tnh cht l hp
thu khng ph thuc vo mu ca xuyn thu kho g . Nh ta
bit laser KTP c i lc vi he oglo i l u tnh cht ny xem l
mt u im tuyt vi trong nhim v hi tu n tin lit h g t im
c ghi nh l sau khi t qua lp nim mc c nhiu m h u th n lp
di nim s khng cn mch mu nn rt kh cho b hi g
lng a ra ch l g c trong bng quang v nng vng chung quanh
tuyn tin lit kh hi c nhiu u t o g khi i vi laser
Revolix (Thulium) th khng chn la m no ht nn vic b hi c thc hin
tt h , l c nhiu h .
4.2. V hiu qu: chng ti ghi nhn laser KTP c hiu qu tt t o g iu tr b tc
ng tiu di d khng ly ht u m ch to ng h i vi
laser Revolix th s lng b h h u t c th so s h h g h g t i
nhn th u c l i hiu h hc tuyn tin lit c khot rng
nhiu h h h nh ct t ni soi nn hiu qu s khng km
4.3. V cc bin ch g: i vi bin chng chy mu sau th thut th t l ny
kh g ao h t t ni soi i vi lase Re oli th h g t i ha ghi hn
h g kh g th gy bin chng th theo chng ti nhn thy l laser KTP t
h loi laser ny khng ly nhiu u h iu tr l b hi b
mt tip xc vi tia lase t o g khi lase Re oli th th gy b hi, th
ct t u v c th i s u u g di v cu trc gii phu hc
kh nh h h ht l dy pht ta l nm u nn d i a sau bng
quang nn thc hin th thut kh h hiu.
. . c tnh ca dy d lase : i vi laser KTP dy dn laser v tia thot ra
chung quanh nhiu nn khi thc hin th thut nhn vin phi eo k h o v
mt v knh ny lm cho hnh nh c mu cam nn kh nhn bit hnh nh tht
khi lm vi i vi laser Thulium th tia khng thot ra nn phu thut vin
khng cn mang knh bo v h a l laser ny pht tia u dy dn nn c
th ct bt d khi s dng tip trong khi laser KTP th pht tia bn hng
nn khng th dng li. do kinh t th lase Thuliu u i t tri
4.5. Thit k dng c i k : th g lase Thuliu u th h d lase
c c nh vo c iu khin v phu thut i thao t h t o g t t
ni soi t o g khi i laser KTP th si dy laser khng c nh c th tt vo
trong my soi ph v thu knh ni soi v c v my soi bng kim loi

Laser KTP

5. Kt lun:
iu tr u lnh tuyn tin lit bng laser l mt c tin mi trong lnh vc
niu khoa, tuy nhin khng phi loi lase o g gi g hau. Cho n hin nay
chng ti nhn thy laser Thulium c l l gii php tt nht hin nay tuy nhin
lase KTP g t ra hiu qu t o g iu tr h g gi th h u ao

TI LIU THAM KHO

1. Chute CG, Panser LA, Girman CJ, Oesterling JE, Guess HA, Jacobsen SJ,
Lieber MM.The prevalence of prostatism: a population based survey of
urinary symptoms. J Urol 1993; 150: 85-89.

2. Dahlstrand C, Walden M, Deirsson G, Pettersson S.Transurethral microwave


thermotherapy versus transurethral resection for symptomatic benign
prostatic obstruction: a prospective randomized study with a 2-year follow-
up. Br J Urol 1995; 76: 614-618.

3. Oswald M, Schmidlin F, Jichilinski P et al.Combination of thermocoagulation


and vaporisation using a Nd:YAG/KTP laser versus TURP in BPH treatment:
preliminary results of a multicenter prospective randomized study. J Urol
1997; 157: 42A.

4. Schatzl G, Madersbacher S, Lang T, Marberger M.The early postoperative


morbidity of transurethral resection of the prostate and of four minimally
invasive treatment alternatives. J Urol 1997; 158: 105-110.
117. NHN MT TRNG HP PHU THUT CT
TIN LIT TUYN TON PHN QUA NG TNG
SINH MN

Purpose: evaluating the feasibility of transperineal prostatectomy through the first


case

Material and method: prospective the first case concerning the difficulty in the
operation, the advantage and the inconvenience of tis technique

Result: With the precise indication this technique seems to have advantage on the
patie t ualit of life concerning urinary continence and cosmetic

I.T VN :
M h: h gi kh g thc hi ph g ph p ct tuyn tin lit tn
gc qua ng tng sinh mn ua t ng hp u tin.

II. I TNG V PHNG PHP NGHIN C:


Hi cu t ng hp thc hin phu thut u tin v nh g kh kh t o g phu
thut, nhng li h v h im ca ph g ph p.

III. KT QU NGHIN CU:


BNH N:

H TN BNH NHN: NGUYN MINH .V Si h : Na

A CH:885/3Q Nguy Du T i h, phng Bnh Tr g, un 2, TPHCM

NGY VO VIN: 9h15 12/6/2009

S H S: 9/10218
L DO VO VIN: Khm sc kho nh k pht hin K TLT

BNH S: Bnh nhn khm sc kho nh k pht hi PSA u t g, c sinh


thit TLT chuy BVBD iu tr

SIU M: ph i TLT

PSA mu: Free PSA 4.67 (ng/ml)

F.PSA/T.PSA 10% (F.PSA/T.PSA >20%)

PSA 46.755 H (<4ng/ml)

X Quang phi: BT
ECG: Block nhnh P khng hon ton.

Gii phu bnh: Carcinome tuyn, Gleason 7(3+4) cu tuyn tin lit
(Prostatic Carcinoma)

MRI: TLT k h thc 453325mm (ngang-cao-t c sau)

-TLT c vng trung tm, vng chuyn tip c tn hiu ao kh g ng nht trn
T2WI. Vng ngoi vi 2 bn c nhiu t th g gim trn T2WI. B TLT u.

-Hnh h t i ti h hai h thng.

-Khng thy hch vng chu hai bn.

-Khng thy tn hiu g t o g g kho st.

KL: K.TLT ha ln v bao.


X h h g h thng.
Ch o : K tin lit tuyn T2NXMX

TNG TRNH PHU THUT

Ngy phu thut: 22/6/09

Ph g ph p : ct tin lit tuyn ton phn qua ng tng sinh mn

Thi gian m: t h n 12h

PP v cm: m NKQ

PTV: TS.Vinh, BS.Kit, BS.Ho

Gy m: BS.D g, T i h

Lc trnh PT: Bnh nhn n t th s khoa, u thp, t thng niu o.

Rch da vng tng sinh mn hnh vng cung ni lin 2 ngi, t h h h


hang, b l niu o, ct nt th trung tm, tch dc niu o vo TLT, khu ct
v ct hai dy chng mu-TLT TM l g d g t. Bc tch trn TLT-ti tinh,
khu hp c b g i i l -0. Khu ni tr li niu o vo c b g i i 6
i monoryl 3.0. Khu phc hi nt th t u g t .

D lu g tiu khung vi 2 penrose

Khu da.
Lng mu mt: kh g g k.

Din tin sau m:

Rt penrose ngy th 2, rt thng tiu xut vin ngy th 7.

Vi nhng ch h g ph g ph p v c li v mt ci thin cht


lng cuc sng bnh nhn v ki so t c tiu v c mt thm m

IV.BN LUN:
Phu thut ct TLT ton phn qua t g si h c Buchler gii thiu
1,3
t , You g thc hi ti M , h g do hn ch n cu
phu thut l khng no h h, h gi giai on tin trin cu u t c m.
Nh g t c nhiu tc gi chn la do nhiu l do1,3: vi s pht
trin cu cc k thut ch o h h nh hc v kho st PSA mu gip chn
o KTLT giai on sm (PSA < 15ng/ml, Gleason <7, MRI ni tr t g u
khu t 3. Ngoi ra nhu cu v cht lng cht lng cuc s g t ra
h l t bc thit cu cuc sng, th d h phi gi c ch g g
phi ki so t c hot g i tiu, gi g k lng mu mt, thi gian
nm vin ngn, gi gi th h iu tr, th phu thut c p dng rng
1,3
ri tr li .
3*

. C ng tip cn tuyn tin tin lit trong phu thut ct tuyn tin lit tn
gc qua tng sinh mn

-Ba k thut n l tip c TLT l go i tht You g , di tht (Belt) v


u tht (Hudson). C ba k thut u c th bo t c thn kinh
g e e-sparing technique ,Weldon v Tavel)1,2,3,4. Chng ti p dng k
thut You g tip cn tin lit tuyn.

. L do ch ng m tng sinh mn bnh nhn ny:

- Bnh nhn cn rt tr nn yu cu ph g ph p iu tr t h h g n
cuc sng.

- Tu PSA ao h g t ghi u cho th u g th khu t h


Vit nam ch quan chng ti nhn thy tr s PSA c v ao h cc bnh
nhn ngoi quc v chng ti gii thch v cc bt li cu ph g ph p ny
c s g t h cu bnh nhn.

- Siu m cho thy khi lng tuyn tin lit khng ln lm

3. Kt qu cu cuc m:
- V hu phu gn: bnh nhn khng th au, c tiu trong, d lu a t t
dch, c gaz ngy hu phu th nht,sau khi rt thng bnh nhn t tiu c
v hon ton kim sot c v . C t gi khc ghi nhn c th xy ra bin
chng g h: i t bo vng t si h , d c tiu hay dch bch
huyt ko di, ph n sinh d , t s bin ch g to th h: thu tc
phi, thuyn tt t h ch su, vim ty hoi t, nhi u ti , u g h 1

- V mt thm m: bnh nhn b ph u hi l u h g h g li so


m g k ho to to p ng v mt thm m

4. V nh g kh kh t o g uc m: v khng c dng c thch hp nn phu


t ng rt su v hp nht l khi tuyn tin lit qu to, cc mc gii phu kh xc
h i hi phu thut vin cn phi quen thuc v gii phu hc vng
tng si h h g li im l c u t h h l g d g t v d t
kh trong m ng bng li d trong phu thut ng tng sinh mn v th khu ni
niu o c bng quang c th thc hin vi 5- u gi p hn ch x d trong
hu phu

V.KT LUN:

T o g t ng hp c ch h g h u chc chn cn khu tr v tuyn tin


lit khng qu to, ct sng v khp hng bnh nhn cn tt th phu thut ct
tuyn tin lit tn gc c th thc hi c vi nhng li h h i thin cht
lng cuc sng v mt ki so t c tiu, bo tn ch g g tt h ,
mt mu t, t au t o g hu phu v c tnh thm m cao.
T th b h h , t th ph khoa,
Rch da hnh vng cung
mng cao.

R h ua di da v ct ri nt Bc tch cn Denovilliers vo mt
th trung tm tng sinh mn. sau TLT
Ct ri c g ua g TLT, sau Khu ni c bng quang v niu o
bc tch ly ton b ti tinh v TLT sau.

TI LIU THAM KHO

1.. Eric A.Klein, MD (2004). Management of Prostate Cancer, second


edition, chapter 13, pp 263-293. Humana Press, Totowa, New Jersey.

2.. Frank Hinman, JR (1998). Atlas of Urology Surgery, second edition, section 11.
pp 446-464. W.B Saunders Company, California.

.Gle s . U ologi Su gery, 6th edition, chapter 33, pp 270-277. Lippincott


Williams & Wilkins, Virginia.

4.. Rudolf Holhenfellner (2005). Advanced Urologic Surgery, , Third dition, chapter
27, pp 142-155. Blackwell Publishing Ltd, Massachusets.

118. NHN MT TRNG HP PHU THUT KT


HP NI SOI LY NHIU SN LN BNG QUANG
TO HNH BNG RUT

Trong nh g g , ti cc trung tm niu khoa thc hin nhiu phu


thut bng quang thay th bng rut. Bin chng sn trong bng quang bng rut
rt thng gp, h g sn to bng quang rt hi , iu tr hin nay ch yu phu
thut. Hi a ha t gi t o g c bo co v kinh nghim phu thut
sn ln trong bng quang,. Qua mt t ng hp chng ti phu thut nhiu sn
to bng quang bng rut trn mt bnh nh c lm phu thut Camey II
ti bnh vin FV thnh ph H Ch Minh.

TRNH BY BNH N

Hnh chnh:
-H tn: Mr. J. Gallat Tui: 65 Phi: nam

-Quc tch: Php

Ngy nhp vin: 26/07/2007

L do nhp vin: B tiu

Bnh s: bnh nhn b u g th g ua g, iu tr ct bng quang ton


phn v to hnh bng quang bng rut theo ph g ph p Ca e II h
ti Php. Ngy qua b h h au h v v tiu mu, nhp bnh vin Nha
Trang pht hin sn bng ua g, t thng tiu chuyn bnh vin FV.

Khm

Tng qut: tng trng kho, nim hng, hch ngoi vi khng to.

M: 66 ln/pht HA/80mmHg N:

Cn nng: 70,9kg Glasgow: 15 SpO2: 98

Khm niu: -Chm thn (-), bp bnh thn (-), rung thn (-)

-Cu bng quang (-)

-So m c ng gia di rn lnh tt.

Cn lm sng:

-KUB :4 sn to nhiu sn bng quang


-Uroscanner + UIV: -Sn nh thn

-4 Sn to bng quang tn to

-Kh g tha i hnh dng v ch g thn

-Khng c b tt niu qun.


Phu thut: g th g

Ch o t c v sau m: sn bng quang/ bng quang hi trng (Phu thut


Camey II)

X tr: M bng quang ly sn.

Kp m: TS.Vinh, BS. Tin, BS. Kit

Gy m: BS. Nguyn Th Lm Giang

Tng trnh phu thut:

Rch da ng gia di rn, qua lp cn bc l bng quang tn to, chc


d bng quang v bng quang bng rut ly ra 3 sn to, sn th t m trong ti
ngch bng quang bng rut. Kt hp ni soi mm qua niu o, nong c ti
ngch bng quang lu s th t.

g g ua g t to bng Vicryl 3-0 hai lp. t lame d lu t c


g ua g. g ng.

Kt qu phn tch sn: -Mu: trng sa

-Tr g lng: 21g

-Thnh phn ho hc: Phosphate, Magnesium

(Magnesium phosphate)
BN LUN

Sn trong bng quang bng rut l bin ch g thng gp, h g sn to


th rt him (2), ch as c ghi nh t o g . Theo Ngu V
n, trong 100 ca theo di t , % h h t i kh t ng
hp c sn t nh. C g theo t gi V V T theo d i h c 2 ca c sn
bng quang.

C h hnh thnh si: on cui hi t g l i hp thu chnh vitamine B12 v


acid mt. Khi l i on cui hi t g lm bng quang tn to bng rut s
lm gim hp thu acid mt,. Acid mt kh g c hp thu s l gi on chu
trnh gan rut, gan tng hp kh g mui v acid mt nn d n km hp thu
m, lm trong phn c m (acid bo), acid bo s kt hp vi calcium trong rut
nn l t g o alate iu a id o ali ue kh g c gn kt vi calcium trong
rut) to gu to si oxalate trong bng quang bng rut.(1)(3)(4)(5)

Ngoi ra, thnh phn sn cn ph thuc rt nhiu vo s g c tiu


trong bng quang bng rut, ch di h dng v nhim trng niu. Bnh nhn
cu chng ti c thnh phn si magnesium phosphate c th lin quan vi nhim
trng niu. Thnh phn si cu bnh nhn l magnsium phosphate nn chng ti
gh hiu n nguyn nhn nhim trng. Proteus mirabilis v hot ng cu men
urease l nguyn nhn chi a s (5)(8) to sn do nhim trng bng quang
bng rut, mt khc cc cng trnh nghin cu g hn thy cht nhy nim
mc rut t ng ln s khng thuc ca vi khun (5)(6).
iu tr ch yu i vi cc sn nh a s cc tc gi ch t g d g i
soi, tn sn v s thng mm (7)(8)(9) , nu sn ln phu thut ly sn qua da
v kt hp ni soi trnh lm t th g i c bng quang bng rut
. T o g t ng hp cu chng ti, do khng th s c si v bng quang
dn qu l , h g t i gp sn bng km qua ng m di hng dn
cu ng ni m t qua niu o vo bng quang.

KT LUN:

Khi thc hin phu thut ly sn bng quang thay th bng rut nn ch cc
im sau:

-ng vo bng quang phi trnh cung mc treo cung cp mu nui cho
bng quang thay th. Phu thut m bng quang ly s t t l thnh cng cao
(8)

-Thao tc ly sn phi h h trnh lm t th g i c rut


cu bng quang thay th bng rut. Nu t ng hp bng quang bng rut kh
to, ngn tay phu thut vin khng ch kh g h c sn nn dng
ni soi kt hp gp sn (9).

-Hu phu a bng quang bng rut th g u trnh


nght thng niu o hu phu d g d c tiu.

Phng nga sn trong bng quang tn to ch yu l u g c nhiu, ch


di h dng hp l v phng nga nhim trng niu.

TI LU THAM KHO

-(1) Nguy V . Phu thut chuy lu c tiu t ch t o g iu tr bnh


l bng quang thn kinh, 2000.

-(2) M. Gacci, T. Cai, F. Travaglini, M. Rizzo, R. Bartoletti, M. Carini Department of


Urology, University of Florence, Italy, Giant Stone in Enterocystoplasty
,Urologia Internationalis 2005;75:181-183.

-(3) Robertson WG, Woodhouse CR.Metabolic factors in the causation of urinary


tract stones in patients with enterocystoplasties.
Urol Res. 2006 Aug;34(4):231-8. Epub 2006 Mar 8

-(4)Woodhouse CR, Robertson WG. Urolithiasis in enterocystoplasties.

World J Urol. 2004 Sep;22(3):215-21. Epub 2004 Sep 3.

-(5) Mathoera RB, Kok DJ, Verduin CM, Nijman RJ. Pathological and therapeutic
significance of cellular invasion by Proteus mirabilis in an enterocystoplasty
infection stone model.Infect Immun. 2002 Dec;70(12):7022-32.-Mathoera RB,
Kok DJ, Visser WJ, Verduin CM, Nijman RJ. J Urol. 2001 Dec;166(6):2329-36

-(6) Mathoera RB, Kok DJ, Visser WJ, Verduin CM, Nijman RJ. Cellular membrane
associated mucins in artificial urine as mediators of crystal adhesion: an in vitro
enterocystoplasty model.J Urol. 2001 Dec;166(6):2329-36.

-(7)Woodhouse CR, Lennon GN. Management and aetiology of stones in


intestinal urinary reservoirs in adolescents. Eur Urol. 2001 Mar;39(3):253-9.

-(8)Blyth B, Ewalt DH, Duckett JW, Snyder HM 3rd Lithogenic properties of


enterocystoplasty. J Urol. 1992 Aug;148(2 Pt 2):575-7; discussion 578-9.

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"Cuc sng bao gi g hai t t i ti g u ho to l u ,
mt na l u e i V v , g i ua " (ng Thy Trm)

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