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ABOUT
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MC LC
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
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.
NGUYN HU M
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
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.
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
- 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).
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
* 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.
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)
1.1. Triu ch g g:
. . . au:
C th gp au vng tht l g, au vng niu qu , au vng bng quang.
* C au un thn:
+ 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:
Ma u e au.
* au vng h tht l g:
. . . . au im niu qun:
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
+ i dt:
+ i ut:
+ 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:
+ i kh g t ch:
+ i :
1.2.1. Ph do thn:
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
. . . Thay i s l g c tiu
+ V niu:
- 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):
+ i hiu a iu):
. . . Thay i mu s c tiu
* i a u i th:
+ i a he oglo i :
- Ngu h i a he oglo i :
. 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 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 oglo i :
+ 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
th.
1.2.4.2. Nc tiu u c:
+ i a :
+ i a phosphat:
+ i a dng chp:
2. CN LM SNG CHN ON
Biu hin lm sng ca nhiu bnh thuc h thng thn-tit niu thng ngho
nn v khng
2.1.1. Ur :
- 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...).
2.1.2. Creatinin:
2.1.3. Protein:
2.1.4. Lipit:
lipit u t g t cao.
. . . in gii:
+ Mu s c tiu:
- Nc tiu u nht n nu th : i a u.
+ pH c tiu:
1,030.
1200mOsm/kg H2O.
+ Protein:
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.
thng cao.
1,5).
trong lm sng.
+ Hng cu niu:
- i a u i th nu:
+ Bch cu niu:
+ Xt nghim cn Addis:
-C hl h sau:
- Nh nh kt qu:
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
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
- Tr h h t o g c tiu:
. 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
tiu c th gp:
. Tinh th urat.
2.3. Cc ph g ph p th d h g th :
. . . 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,
mc lc cu thn, v c th d g nh mc lc cu thn:
. Khng b chuy ho t o g th.
Pcre S
T o g :
(1976):
[140-tui t g l g th (kg)
Ccre = ---------------------------------------------------------
72 x Pcre(mg/dl)
. . . Th d h g ng thn:
l t s ph g ph p th d kh g c tiu ca ng thn.
l ph g ph p t gin, d p dng, c gi tr t o g l s g h
gi kh g c
Cosm = ------------------
Posm
T o g :
CH2O = V - Cosm
T o g :
Nu : CH O = : c tiu g t g so i mu.
. t nht c 1 mu c tiu c t tr g , .
+ Nghim php hn ch c:
Nh nh kt qu h sau:
3gi. Nh nh kt qu h sau:
. . Th d h h th i hc:
- 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.
- 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.
- Bnh l:
. 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.
- M h: th d h h th i th , i-b thn th d ch g th .
- Chng ch nh:
. a g i a mu i th.
. a g su ti ng.
. Giai on p: 2-3 pht sau khi tim chp phi , sau 15 pht chp 1 phim,
cn chp
2-3 phim.
- 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
. Bnh l:
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:
- Ph g ph p: a ng th g ua da o ng m h i i l ng mch
ch bng, khi
- Kt qu:
- Ch nh:
. Nghi ng c hp ng m h th : l h nh chnh ca chp ng mch
thn.
+ Ph g ph p: ph g ph p:
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.
+ Ch nh:
- Hi chng thn h gu ph t.
+ Chng ch nh:
- Th a a g.
- T g hu t p.
- Ri lo g u.
+ Bin chng:
- ki o ua kh : goi l.
+ Kt qu:
- Hnh nh bnh l:
xoy lc.
- Chng ch nh:
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).
. 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.
. 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.
- 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.
. i kh g t ch.
+ C h bnh sinh:
- Do v h i kh g t ch c th l:
. 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.
. 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.
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:
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.
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.
22.TIU RA MU
PGS TS BS. Ph V B i
Ch th g, dng thuc.
2. Du hiu:
C s thy khi cu b g i.
. Th d n lm sng:
a/ Nc tiu:
d/ UPR:
4. Tiu a uv :
23.B TIU
PGS TS BS. Ph V B i
3. B tiu mn tnh:
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.
25.CN AU BO 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.
C. iu tr:
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.
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.
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. 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.
(1) Oxy cao p liu php nhng bnh nhn b nhim trng ym kh lan rng cho
nhiu kt qu tt.
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.
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 g au d g vt
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.
d. U g th u th himvo th hang c th p ng vi x tr d g t
v ha tr ton thn.
(ICD 10).
TM TT
1. Bnh cu thn
2. Bnh k - ng thn.
4. D d g ng tit niu.
6. Suy thn.
BNH CU THN
I. CC HI CHNG LM SNG CA BNH CU THN
1. Hi chng cu thn cp
- Ph
- T g hu t p
- i u i th hoc vi th
- C protein niu
- Gim mc lc cu thn.
- i u i th hoc vi th
- C protein niu
- Thiu mu
3. Hi chng th h
- C th c m, tr m t o g c tiu.
5. Hi chng cu thn mn
- T g hu t p.
- i u i th - c tr hng cu.
- T g hu t p.
- p g iu tr km, d n suy thn mn.
- C l g g c hnh ht cu thn, c t th g h a.
- C p ng vi iu tr.
- 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.
- T g hu t p (25%).
- i u i th.
- ASLO h th g. p ng tt vi iu tr.
- Ph.
- T g hu t p.
- i u i th hoc vi th.
- p g iu tr tt.
- L g ng cc thnh phn IgG, C3, Properdin thnh mao qun v khoang gian
mch - khng c l g ng IgA.
- Hi chng th h - % kh g thun.
- Hoc ch c protein niu v hng cu niu.
- ASLO h thng.
- T g hu t p.
- 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.
- T th g ti thiu.
- T th g .
- T th g ti thiu.
- i u.
- Ho a u m ln mu).
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.
- Tin s i th o ng.
- Suy thn.
- Biu hi t g l :
. Hi chng th h.
. Hng cu niu.
. Thn to.
. T g hu t p.
. Suy thn.
- Biu hin t th g n l:
. Kh g t g si h hp t bo.
2.3. Bnh th a u t g:
- Hi chng th h.
- Hi chng Fanconi.
. Tr a eosi .
.D g .
. Mt chn li.
. T g si h ht gian mch.
- Hi chng th h.
- T g IgM hu t thanh.
- Ti lng xu.
- Suy thn.
- i t,
- C protein niu.
- Hi chng th h.
- Suy thn.
- 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.
. 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.
. Ph
. T g hu t p
. Protein niu
- T th g th n l:
. Ph n t bo ni mch.
. 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
3. Ri lon ch g th ki h g ua g.
7. Vim niu o.
3. Cc d dng khc.
1. Hi chng Alport:
L mt bnh lnh tnh di truyn theo kiu gen tri, biu hin bng:
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.
- C th hi phc.
- i u
- T g hu t p
2. Si acid uric:
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:
5. Si cystin:
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:
2. Cn lm sng:
a. Ch o h h nh:
- 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).
b. Cc xt nghim khc:
- Protein niu.
- T bo niu.
- Vi khun niu.
- Ch g thn:
. Ur mu.
. Creatinin mu.
. Mc lc cu thn.
c. Cc xt nghim khc:
- Th d n gip trng.
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:
. Thn to nghi c, m.
2. Ch o gu h :
- Lo d g sti , o ali
3. Ch o in chng:
b. i u: i u i th th g i k au un thn. C th ch i
mu vi th.
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:
Suy thn cp c th do tnh trng tc nghn nng (hon ton hoc gn hon
ton) c hai bn niu qun.
1. Vi bt k loi si no:
2. Vi si cystin:
- Ki h a c tiu:
. Kalicitrat liu t g t.
. M h t pH niu: 7 - 7,5.
3. Si acid uric:
4. Si struvit:
- Ung nhiu c.
5. Si calci:
- Cn ung nhiu c.
- Ch hn ch calci.
. Bnh l toan ha do ng thn: cho citrat kali liu 4-6 g/24gi chia 4 ln.
a. Tn si go i th:
- Si nh.
. iu tr ngoi khoa:
- t si h g tht bi.
- iu tr i u, au qun th
. 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..
* 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:
1.1 Thn
. . i th
- Nhc thn:
Rn thn gm:
- T h ch thn n ph a t c.
1.1.2 Vi th
1.2 ng d c tiu:
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.
2.1 Lc mu ca cu thn
. . C h c tiu.
C H2O = c tiu s g t g.
Thuyt gc dng
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.
Sn xut prostaglandin:
- T g i tit Na+ c.
. C ho o t ng ln thn
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.
Tc nhn gy ng iu tr ng ung
bnh iu tr ti t h
mch
Mycoplasma Hoc
hominis
Clidamycin 300mg (po) q12h x 7 ngy
Hoc
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
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
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.
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
Ciprofloxacine 400mg (IV) hoc 500mg (po) q 12h hoc Gatifloxacine 400mg (IV
hoc po) hoc Levofloxacine 500mg (IV hoc po) q 24h.
Triu chng: triu chng nhim trng huyt trong vng 24 gi sau khi can thip
th thut t ng niu.
Tc nhn gy bnh iu tr ng iu tr ng
tim bp ung
Cephalosporin th Hoc
h 3 250 - 500mg
Quinolone 100mg
(IM) x 1 liu
(po) x 1 liu
Cefixime 400mg
(po) x 1 liu
Hoc
Azithromycin 1g
(po) x 1 liu
Hoc
Quinolone (po) x 7
ngy
Hoc
Erythromycin
500mg (po) q6h x 7
ngy
Metronidazole
500mg (po) q12h x
7 ngy
Ciprofloxacine 500mg (po) q12h hoc Gatifloxacine 400mg (po) q24h hoc
Levofloxacine 500mg (po) q 24h.
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.
Triu chng: khang 1 tun sau giao hp, tiu au but, l tiu khng c m.
Ti lng: tt nu i tc ca b h h g iu tr.
40.ABCES 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
MRSA:
MRSA:
Linezolid
600mg(IV) q12h Vancomycin
Minocycline
100mg(IV) q12h
Ciprofloxacine 400mg (IV) hoc 500mg (po) q 12h hoc Gatifloxacine 400mg (IV
hoc po) hoc Levofloxacine 500mg (IV hoc po) q 24h.
Quinolone
(po) x 4 tun
Ciprofloxacine 400mg (IV) hoc 500mg (po) q 12h hoc Gatifloxacine 400mg (IV
hoc po) hoc Levofloxacine 500mg (IV hoc po) q 24h.
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.
. i c g.
. . h gha:
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:
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.
- 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 ...
. . i th:
3.2. Vi th:
- 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.
- Mch thn c ch b g ao t o g.
4. Lm sng v cn lm sng.
4.1. Lm sng:
- Hi ch g g ua g: i ut, i dt, i u, i c, i t i i t i li
nhiu ln.
- au u khi t g hu t p.
- Hoa mt, chng mt do thiu u khi su thn.
- T g hu t p.
4.2. Xt nghim:
+ 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 .
. . . Th d h g thn:
5. X quang.
+C th d hu khoa s u:
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.
- C th t g hu t p.
+ 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 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.
. 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:
Ung 4-5 triu /ngy x 7-14 ngy. Ampicillin, ung 2-6g/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.
+ Nhm quinolon:
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
Ti l g: t g i tt .
44.NHIM TRNG TIU DO VI KHUN HOC NM
CANDIDA
Tc nhn gy bnh iu tr
Tc nhn gy bnh iu tr
Hoc
Triu chng: tiu au, tiu nhiu ln, tiu gp, au g di, st < 390C (102
0F).
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).
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:
. im dch t:
1. Nguyn nhn:
+ E. Coli: 60-70%
+ Enterobacter: 5-10%
+ Enterocoque: 2%
+ Staphylocoque: 1%
-C gu h thng gp l:
+U go i p o iu qun.
+ U tuyn tin lit.
+ 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:
. Vi i thn cp:
- au v g tht l g:
- 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.
- Xt nghim mu:
+ Bch cu a h t u g t h t g.
- Siu m thn:
+ Th hi to h h thng.
+ i thn gin.
- X quang:
. Vi i thn mn:
- 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.
- Kh g c tiu gim:
+ 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.
+ Mc lc cu thn gim.
- Thiu mu r: m nng nh ca thiu u i i i giai on ca suy thn
mn.
IV. CHN ON
1. Ch o nh:
+ au i vng tht l g.
2. Ch o ph it:
V. IU TR
. iu tr vi i thn cp:
- 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:
- iu tr triu chng:
+ iu tr t g hu t p.
+ iu tr thiu mu.
. iu tr hu g ho vi i thn cp v mn:
- Loi b cc yu t gu .
+ 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).
iu tr
iu tr
Tc nhn gy bnh b g ng
b g ng ung
tim chch
Triu chng: tiu au, tiu nhiu ln, tiu gp, au g di, st < 390C (102
0F).
Ti lng: tt
48.VIM THN B THN
A. Ch o nh VTBTC:
I. nh gha.
* Nguyn nhn.
1. Ton thn.
2. TC lm sng.
- au h g l g:
+ C khi au d di, th g l au tc m .
+ Th g h g kh g phi TH o g .
3. Cn lm sng.
3.1 Nc tiu.
- c, c th c m i th r.
- i u th i th hoc vi th.
3.2 Mu.
- Bch cu t g, a h t u g t h t g.
3.4. X-quang:
4. Tin trin.
I. Ch o nh:
1.3. Mt s ph iu tr.
- Phc 1:
- Ph 2:
- Ph 3:
- iu tr t o gc BQ-NQ.
. Di h dng:
-B , in gii b g ng TM nu mt c nhiu.
6. Phng bnh: gi v sinh c nhn tht tt, trnh dng th thut soi BQ, thng
tiu khi ko cn thit.
Bs Nguy t Anh
I. M khn cp
II. Nh g im c lu
IV. Ch o l s g
- 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)
- 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:
min
+ Ngun gc cao: suy tuyn yn, sau phu thut tuyn yn v nht l trn cc
bnh
V. x tr cp cu
- iu tr cc yu t th y
1. Cc thnh ph d ng hc:
2. Tc dng mc t bo
+ Ln chuy ho g: T g gi g ho ng ga go i ga l t g
ng huyt.
4. Ch nh dng corticoid
- iu tr thay th ni tit
-t o g t ng hp d g h he , i i d ng
- Lupus h thng
- Vi da , i da a
- Ghp tng.
- Hi chng th h.
- Bnh th ki h h ho dng , yu .
Bnh Pemphigus.
- 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.
- 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.
7. Cc chng ch nh:
- i ng.
- T g hu t p.
- 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.
- H g: lo g g, hu g, i g, hm pht trin.
- Tc dng ti ch: vim khp nhim khun khi tim ni khp, teo da, teo .
- Theo ri lm sng:
+huyt p, mch.
+ ng mu.
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:
Cc bnh thn:
- Ghp thn.
- Hi chng th h t th g ti thiu.
- Hi chng Goodpasture.
Cc bnh h hp:
- X phi .
- Hen c tnh.
Cc bnh khc:
- Nhi u ti .
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.
2. Nguyn nhn:
+ Sc do gim th tch:
+ 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.
-
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.
+ Do t h g c cho thn:
+ Cc bnh th c bit:
- 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...
. . C h ca tn th g thn:
. . C h ca v niu:
+ T chc k thn:
+ Mch mu thn:
. . Giai on khi u:
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.
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.
- 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.
- 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.
+ 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.
* T g it phi p otei t o g u:
* Mt cn b g in gii:
+ Cc anion:
+ Cc cation:
. T g ph hu t o do u , phosphat, sulphat t g.
. Th , l ln, tm thn.
. Nga, t, d c : c bit hay xut hin vng quanh ming v chi di.
. Giai on 1: Nhp tim chm, tr u hng chuyn tri. Sng T cao, nhn, hp
, i ( T > 2/3R t V3 - V6 ).
* Xt nghi c tiu:
. . Giai o i t li:
to.
. . Giai on hi phc:
6.1. Ch o nh:
- Ph do c.
6.2. Ch o gu h :
6.3. Ch o ph it:
+ Thiu mu nng.
+ U , eati i u t g t t c ho t g ao ga t nhng gi u ca v
niu.
+ 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...
B g . Ph t h si h ho u c tiu:
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).
L g c vo (g , ung, truyn)/24gi = l + l g c
tiu trong 24gi.
- Hn ch t g kali u:
+ Hn ch u u t g:
Kim thiu (mmol/l) = (25 - [HCO3 -] ) x 0,2 x kg; Hoc kim thiu (mmol/l) = BE
x 0,2 x kg.
- Ur mu > 30 mmol/l.
- pH mu < 7,2.
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:
+ 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.
. . Ngu h t c thn
Cc bnh l cu thn cp: Ch chim khong 3 12% bnh nhn suy thn cp
Cc bnh ng k thn cp tnh: chim ti 58 n 65% bnh nhn suy thn cp.
+ Nhi c:
. Tetrachlorua carbon
. Glycol ...
. Mt c trm
. Thu a
+ Thuc
+ Tan mu cp tnh
+ Tiu p tnh
. Ch th g .
. Thiu u
. Hn m ko di, co git
. Sc gim th tch
. Sc tim
. Sc nhim khun....
. Cc thuc khc: AINS, analgesic, li tiu thiazid, thuc chng co git, allopurinol,
cimetidine...
- Vi t ua h ng mch
- Vim mch d ng
- Cryoglobulin
- Wegener
- Takayasu
- Ch th g thn
- Tc mch thn...
- U chn p, t ng bi niu
- X ho sau ph c.....
. . C h bnh sinh
- T g p lc t chc k ca thn do ph n.
3. Lm sng v cn lm sng
- Giai on khi u
- Giai o i t, iu
- Giai o i t li
- Giai on hi phc
. . Giai on khi u
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.
-U e u t g dn
- C eati i u t g dn
- Acid uri u t g dn
- 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
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
4. ch o
4.1. Ch o nh:
Da vo:
Xut hin:
- Toan mu chuyn ho
4.2. Ch o ph it:
4.3. Ch o th bnh
- 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:
- Nhi mu thn...
- Si
-U
- Cht hp
. 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.
. . . Giai o u:
. . . 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.
Nc:
- iu tr t g K+ mu:
. Truyn Natribicarbonat:
- iu tr cc ri lo in gii khc:
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 ...
1. Bnh cu thn mn :
Do vim cu thn cp d n .
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).
Vi t ua h ng mch .
T t h ch thn .
Tc hp ng mch thn .
Th a a g
Lon sn thn
A. Lm sng :
1. Ph :
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 .
. T g hu t p :
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.
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 :
8. H hp :
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 :
11. Chut rt :
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 :
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 .
. in gii mu :
4. pH mu gim :
5. Calci mu gim :
7. Protein niu:
8. Hng cu niu :
IV. Ch o :
1. Ch o nh da vo :
Ph
Huyt p cao
Thiu mu
Protein niu
2. Ch o giai on :
Chia giai on :
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
3. Ch o ph it :
- Vi suy thn cp :
ur, creatinin, K+ u t g ha 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:
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.
- Khc phc tnh trng gim khi lng tun hon nu c: b dch, mu.
2. Ch UGG:
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:
. iu tr ri lo , in gii:
Ph:
- Ch ht, hn ch khi l g a o.
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.
-D g esi t ao i kali.
H natri mu.
. iu ch h th g ng toan, kim:
. iu tr thiu mu:
8. Cc thuc v bi ph p iu tr khc:
- Thn nhn to
- Lc mng bng
- Chng ch nh
Chng ch h t g i khi:
- Chy thn nhn to vi liu Heparine ti thiu hoc khng c Heparin tu tng
t ng hp bnh nhn.
- Chng ch nh:
So m g ng
Vim phc mc
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.
t g a suy thn mn l:
2. Mc lc cu thn (MLCT):
Gi tr o da vo creatinin mu. Ch h iu tr v ch da vo
MLCT.
. Giai on suy thn:
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:
- 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.
3. Ch o gu h :
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.
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:
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.
- T g hu t p.
- Thiu mu.
- mui v dch.
- R th g ng - t h ch.
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.
2.1. Natri:
2.2. Nc:
2.3. Kali:
- Mt mu.
- Thiu ht erythropoietin.
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.
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.
. S ph hy cc nephron.
. S khng ca g i vi tc d g t g al i a PTH.
- 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 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.
- 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.
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 .
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.
9. Ri lon v ni tit:
V. IU TR
1. iu tr nguyn nhn:
. 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 .
. iu tr triu chng:
3.1. iu tr ri lo in gii:
- Nu Kali mu cao:
. Hn ch a kali vo qua th .
. Cal i g t h ch.
3.3. iu tr t g hu t p:
- Hn ch mui: 2 g/ngy.
3.5. iu tr lo d g g:
3.6. Thuc khc: B sung Vitamin v cc acid amin (Ketosteril hay Nephrosteril).
- Lc mng bng.
- T gi sng:
+ C h bnh sinh:
- 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.
+ iu tr v d phng:
56.PROTEIN NIU
1.3 Protin t ng tit niu t v di:do si ,u, ht khi khng nhim trng.
Ph g ph p ch nh Gi tr BT Nhn xt
.C th d g
tnh gi trong
ki c tiu
hoc t trng
>1.025
4.Protein niu
24/h
[ NGHA LM SNG CA MICROALBUMIN NIU TRONG MT S BNH
4.Cc bnh thn tin pht hoc th Khi pro niu >1g suy thn din ra nhanh
pht
. gim mui v gim pro lm gim pro niu v qu trnh suy thn
E. coli 80%
Ga d g e te o o ue, staph lo o ue : %
Bnh sinh
- Gim kh g ph g nh
C gu
- Con so
- C thai
- V h g l g t au.
- Cy mu
- C c tiu
. non
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
4. Nhim trng tr s si h
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
. iu tr khc
1. nh h g d ng hc do thai sn
- T g ph thuc ti ua do t g u g l g ti , t g th tch d h
th.
- T g hu n ho ti gan
Ch thuc ny c th d ng.
+Carboxypenicillin, Ureidopenicilline.
- Nhm Cphalosporine
- 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.
- Quinolon.
4. Cc thu kh g c dng:
- Aminoglycoside: gentamycin, streptomycin, tobramycine.
- Vancomycin
- Tetracycline.
- Phenicole
GIM AU H ST
PRACETAMOL
GIM CO THT
PHLOROGLUCINOL
PENICILLINE M,G,A
CEPHALOSPORINE
KHNG SINH
KHNG NM NYSTATIN,AMPHOSTE
RIN B
TIU HO MUI
NHM,LACTULOSE
SN KHOA SALBUTAMIN,
TERBUTALIN,DYDROG
ESTEROL
MU ST, HEPARINE,
VITAMINE K
MT ACETAZOLAMIN,ACECL
IDINE
H HP SALBUTAMOL,TERBUT ACEMUX,MUCOLATOR
ALIN,THEOPHYLIN
VACCIN CHNG VIM GAN B,
UN VN
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
2. Ph
3. Ri lon lipid mu
- T g lipid u: t g holeste ol, t g t igl e id, in lon HDL
4. Ri lo g u
- T g nht mu
- T g g fibrinogen
- T g kt tp tiu cu
+ X u thn -cc b
+ Vim cu th t g si h gia ch
2. HCTH th pht
- Bnh h thng v chuyn ho:
+ i th o ng
+ Lupus a h thng
+ Thn thoi ho bt
- Nhim khun:
-Bnh c tnh:
+ a u tu g
-Thuc:
+ Trimethadion, D-penicillamin
- 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
4. Vim cu th g t g si h: d g u th t g si h t bo gian
mch
+ Ph trng, m , kh g au
3. THA: t gp
. i u: t gp
5. Thiu mu nh
Cc xt nghim cn lm sng
1. Xt nghi c tiu
2. Xt nghim mu
- 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)
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
- iu tr bo tn ch g thn
- Phi hp ch di h d g iu tr
iu tr c hiu
+Liu duy tr 5- g/ g k od ih g .
+Cyclophsphamid 2mg/kg/ngy 4-8 tun, duy tr 50mg/ngy trong 4-8 tun khi
protein niu m tnh
iu tr triu chng
- 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 )
Ch iu tr
h gi p g iu tr
Xt nghim theo di
Theo di cc ch s ch g thn.
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:
- i u.
- i t.
- T g hu t p.
- Protein niu.
- Ph.
. im dch t:
1. Nguyn nhn:
- i ng.
- Phenindion, Tridion.
- Captopril.
- O g t.
- Heroin.
- T g hu t p c tnh.
- Hp ng mch thn.
- St rt.
- Giang mai.
- AIDS.
- Vim gan B.
. 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 .
S h gy ph:
III. TRIU CHNG LM SNG V CN LM SNG
1. Ph:
- T ng hp nng c th ph no.
3. Mt mi, k .
4. Thiu mu nh.
6. Protein mu gim:
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.
IV. CHN ON
2. Ch o in chng:
- Nhim khun:
+ Cp tnh: vim t chc t bo, vim phc mc tin pht, vim phi, i ...
- Tc mch:
+ T t h ch thn.
+ T t h ch 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:
- B p otei ho th:
- Liu du t g/ h, k o d i h g .
+ Nhim khun.
- iu tr t g hu t p.
60.GHP THN
( GS. Tr V Cht )
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:
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.
- gi ln: 16 - 50 tui.
- C nguyn vng.
- U g th.
- Nhi u ti .
- Nhim HCV
- Nhim lao
- Vim cu th t g si h g.
Xt nghim:
- Tin mn c d g t h t %.
- Phn g h o d g t h.
3.2.1 T gi sng:
- Tui t n 65 tui.
- T nguyn
- Khng mc cc bnh ly nhim: Lao, giang mai, st rt, HIV, CMV, HBV, HCV.
- 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.
3.2.2 T gi mt no:
- C ho hp m.
Thng c 3 kp:
5.1- Ly thn.
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.
- 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.
+ 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.
+ Azathioprine:
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.
Cc bin chng:
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.
- Cc khng th OKT3
+ Thay huyt t g.
* 3 th thuc: Corticoide
Azathioprin/Mycophenolat moftil.
Ciclosporin/Tacrolimus.
* 4 th thuc: Corticoide
Azathioprin/Mycophenolat moftil.
Ciclosporin/Tacrolimus.
-D c tiu.
- T ng bi niu do hoi t :
- 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:
- U g th da
- U lympho c tnh.
+ T g hu t p.
+ X a mch mu.
+ Nhi u ti .
- Vi h tiu ho.
+ Peliose gan.
- Vi chuyn ho.
+ i ng
+ Hoi tu g khun.
+ Lo g g
+ Thng phong
+ a hng cu
+ Ri lon m mu
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.
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
Nguyn nhn v yu t gu
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.
Bin chng
Thuyn t t h ch thn.
Suy thn cp
Suy thn mn
Su di h dng
Phng nga
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
Yu t thp
g lnh globulin
Xt nghim tm b th
Tr niu
Triglyceride
in di protein
St huyt thanh
Chosterol
Albumin
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.
Tc hi ca nhi t g ng niu
Nh g i t g gu
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.
Ph g ph p iu tr nhi t g ng niu
Ch o hi t g ng niu h th no ?
Ph g ph p iu tr nhi t g ng niu
C ph g ph p iu tr ti nhim
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.
Nh g iu cn nh v nhi t g ng niu gi ln
62.BNH I MU
G i u i th v i u vi th
i u i th
i/ h gha
ii/ Ch o :
+ C c u g t th g ng niu)
+ Thn to.
- Nu t th g l i u do ng niu.
+ Tr hng cu nu c l do t th g hu .
- Si.
1. Khi u:
- U g th thn
2. nhim trng:
- Lao thn
-Giun ch.
3. D dng
- Th a a g.
- Bnh l ng thn
- Nhim trng.
-U
- Vim.
iv/ Ch o ph it:
- Chy mu sinh dc n.
- ih oglo i e
- i oglo i e.
i u i th
- ch u ng sinh dc.
- nhim trng
3. xt nghim
- creatinine mu, proteine niu 24h, uiv, soi bng quang, siu m...
4. nguyn nhn
- nhim trng.
- khi u th , ng niu.
- si tit niu.
- thuc: aspirine, ch g g.
1. Dch t hc
- Lin quan
- Bao thn
- Nhc thn: gm tu thn trong nu sm, v thn ngoi st bao thn v nht
u h .
- 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 trong thnh bng quang: chy chch qua thnh bng quang trn
mt on di khong 2cm.
Niu qu t g i hp ti i
-Bng quang
- 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 xp di kho g i ua t xp ca d g t.
-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 t : li ua n khp mu;
. 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.
4. Nguyn nhn
+ E. Coli
+ Staph. Saprophyticus
+ Proteus mirabilis
+ Klebsiella species
+ Enterococci
+ Chlamydia
+ Pseudomonas aeruginosa
+ S. aureus
Yu t thun li
. C h bnh sinh
- ng vo
+ g gc dng: l ch yu.
6. Ch o
a/NKTN thp
- Hi chng BQ
+ gii nam
+ tui cao
+ c thai
+ so de BQ lu
+ mi c can thip ng tit niu
+ NKTN tr em
+ b h h i th o ng
Cc xt nghim cn lm sng
b/ NKTN cao
Cc triu chng lm sng
- au h g l g + au g sn-ct sng
- Nn, bun nn
- Nc tiu c +
- Giai on s ha su thn
- Giai on mun c suy thn: triu chng v din bin ca suy thn m , h
+ thiu mu
+ 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
+ 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
+ C th t g ng mu
VTBT mn
- Giai on sm
+ mc lc cu th MLCT h thng
- Giai on mun
7. Ch o ph it
+ u BQ
+ vim phn ph, i trc trng, si BQ hoc niu qun thp khng nhim khun
- Vim thn k
. iu tr
- Nguyn t iu tr
+ khng sinh: trong c g ng la chn theo kinh nghim, trong bnh vin la
ch theo kh g si h
- U g c, v si h, di h d g
- iu tr NKTN thp
- VBQ cp ph n c thai
+ 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);
- iu tr NKTN cao
- Nguyn t iu tr
- B d h, di h dng
+ d lu iu qun
+ d lu thn
+ m b thn qua da
- iu tr loi b tc nghn
+ 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.
+ L r;
+ So de BQ lu;
+ Stent niu qun;
+ Ph n c thai;
+ i th o ng;
+ Suy thn;
+ Ghp thn
+ Cc vi khu kh g a thuc;
- 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
+ Mycoplasma genitalium;
+ Trichomonas vaginalis
+ Candida Albicans;
+ Tin s b lu;
+ 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;
4. Ch o nh
+ 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 ;
Bnh nguyn: * Do thu sau tuyn yn bi tit qu mc hoc mon chng bi niu
ADH (arginine vasopressine)
Ch o ph it:
1. H at i u ALTT u h th g t g.
b. Suy thn
c. reset osmostar
d. Su thng thn
e. Suy gip trng
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
g. Sarcoma.
h. U tuyn c
i. U lym pho
c. Thng kh nhn to p l d g.
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:
. Su thng thn,
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.
a. Ch th g
b. Phu thut
c. Gy m
d. au
e. Bun nn
f. Alcohol withdrawal
g. X ng
Lu lm sng
* 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:
. Nc tiu:
. p g h thng:
iu tr
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
1. Demeclocycline
a. Nh hu g c u th h d g h
2. Nhng thu kh t d d g h
I. NH NGHA
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 th g t g si h.
- Vim cu thn , mnh.
- X h a u thn .
1. Lm sng:
Vim cu thn mn giai on cng tin trin th tnh trng thiu niu cng 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:
- in gii:
. K+ u th g t g khi su thn.
V. CHN ON
1. Ch o nh: Da vo:
- i t.
- Cao huyt p.
- Thiu mu.
- Protein niu.
2. Ch o giai on:
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.
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
- iu tr ph:
. ht, hn ch l g a o.
- iu tr cao huyt p:
. ht, hn ch l g a o.
1. Hot ng th l h thng:
1. Ngh gi.
3. Git l , i , hg .
6. Vic nh nng (n g , h g .
. g, a g ng.
8. Chy t /ph t, h g , g .
Ngh gi
1-2 (-) (-) (-) (-)
A
Hc tp bnh gi
B 3-4 Cng vic nh thng ,
i h
Th dc (-) ph t
Hot ng th
D 5-6 l g Th thao (+)
va
Lao ng
Khng gii nng.
E
hn Hot ng th
lc mnh
- h t o g :l i h thng, c th tp th dc th thao, ch
lao ng loi D.
- iu tr c kt qu:
- Bnh h a g iu tr:
3. Trong hi chng th h:
- a g tin trin:
- iu tr khng kt qu:
- iu tr khi va:
. Suy thn I hay II cn ch lao ng loi C.
- iu tr khi nhiu:
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.
. N g l g a v o:
- l g, calo.
T o g :
- A: Tui tnh b g .
Bnh nhn vt , , .
- H s bnh l: St , , .
Nhim khun cp , , .
Ch th g , , .
Bng , , .
u g tu gi p , , .
. h gi g it h g g :
- Protein ton phn thi ra = Protein ton ph c tiu + Protein phn = 87,5 +
8,75 = 96,25.
T o g : , g l s g g a it iu phi ur cng vi s mt it ua ph
v m hi.
c 2 acid bo.
(3) C t g ua :
1g mui g at i.
1. Ch ht:
- g iu g kh g hp l v s mt i thnh phn cc
cht, gy thiu dng.
2. Ch c ung:
Cn tnh cn b g o, c ra.
- L g a o kh g c qu 1000ml l= l c cn bng
c m tnh.
3. Ch t o g vi u thn cp tnh:
- m: 1 g/kg th trng/ngy.
- t bo.
- t : l g a o kh g u l g c tiu 24 gi + 500
ml/ngy.
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
- t mui, m chnh.
6. Ch t o g su thn mn tnh:
Nguyn tc:
ho gi u g lng.
glucid.
Gim protid.
Bnh lipid.
hoc nhiu c.
p dng thc t:
- Lipid: / o h a, / kh g o , / kh g o k p.
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.
Ba ti (c th lm ba t a .
. C t l g.
- Bt sn vi ng.
Cung cp ketoacid theo cng thc Zimmermann: 35% trng g v 65% khoai ty
s cho hn hp protein gi tr sinh hc cao.
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:
I. NH NGHA
- i u.
- Thiu niu i t .
- T g hu t p.
- Protein niu.
- Ph.
. Vim ni tm mc vi khun.
. Vim cu th g t g si h.
. Vi a ng mch.
. Bnh u ht Wegener.
- Hi chng Goodpasture.
- Bnh cu thn vi mch (microangiopathic glomerular disease):
. T g hu t p c tnh.
III. M BNH HC
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.
1. Lm sng:
- T g hu t p:
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.
- Mu:
. U , eati i u h thng ho t g h.
. 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.
- Siu m thn:
V. CHN ON
1. Ch o nh da vo:
- i u: th g i u i th.
- T g hu t p: nh, va v nng.
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.
1. Tin trin:
- Mt s t ng hp pht trin thnh vim cu thn tin trin nhanh v suy thn
rt nhanh.
2. Bin chng:
- Su ti t i do t g hu t p v gi c.
VII. IU TR
- 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.
- Ch hn ch mui, gi m.
- iu tr bin chng.
Kt lun:
- Ch o da vo:
. i u i th.
. T g hu t p.
. Ph nh, ch yu mt.
. Nc tiu c hng cu, tr hng cu v tr niu.
I. I CNG
1. Nguyn nhn:
- 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.
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:
- Hng cu (+++).
- Tp khun (-).
- i u: c Tuffier nu ln.
- i p otei .
- au tht l g ha au un thn.
- St.
- Thn m: st, th to, i c.
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.
4. Din bin:
Theo nhiu tc gi, lao sinh dc tit niu c th c cc din bin sau:
- Si t ng tit niu.
IV. IU TR
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.
- 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.
. Tc dng ngoi mun: nhi c gan, thn, mn nga, gim tiu cu.
- Pyrazinamid: K hiu Z.
- Ethambutol: K hiu E.
- 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.
- 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.
(Peritonealdialysis)
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).
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
K+ 0 mmol/l
Cl- 96 mmol/l
D, L- Lactate 40 mmol/l
pH 5,2.
3. Ch nh, chng ch nh.
+ 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:
- Trng thi tim mch khng nh d b tai bin khi chy thn nhn to.
4. Cc ph g ph p to ng vo khoang bng.
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 .
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).
. i c g.
+ Toa u kh g iu tr ni khoa c.
3.2. B lc:
ng mu tu ho go i th qua b lc.
Natri 137-143
Kali 0-4
Canxi 0 - 3,5
Acetate 2 - 4,5
Bicarbonate 30 - 35
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
IgE vi oxyt ethylen (dng lm cht kh trng b lc) hoc l mt phc hp triu
chng
II. M BNH HC
III. CHN ON
1. Ch o nh:
- Cao huyt p: Cao huyt p thng xut hi khi in chng nhim trng,
si th , c bit l khi su thn.
b. Cn lm sng:
2. Ch o th bnh:
- Th th a a g gi l i h h h t h .
- Th phi hp vi ph h ng mch:
3. Ch o ph it:
- 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.
Ch o da vo:
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.
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:
f. U g th h a:
U g th h a him gp tuy v u a t o g :
IV. IU TR
- Kh g iu tr c hiu.
. iu tr ri lo v in gii:
. iu tr triu ch g au:
. U g th h a th gp.
Nh t t h , h yu l ngh gi ti ging.
. 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.
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.
. h gha:
2. Phn loi:
a. Phn loi chung bnh thn c nang:
+ Th a a g.
+ Bnh th a g :
. Na g c.
. Nhiu a g .
+ Bnh lon sn nang thn (Dysplastic kidney disease or cystic renal dysplasia).
. Mt bn (Unilateral).
. Hai bn (Bilateral).
- Theo v tr nang:
+ Theo v t t g i vi h i thn:
. Nang cc trn.
. Nang c di.
. C gu si h nh:
- 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:
. Lp gia l lp lin kt gm 1 lp si v 1 lp t .
III. CHN ON
1. Lm sng:
- 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 .
- Thn to: khi nang thn qu to, c th s thy hoc nhn thy mt khi u bng.
2. Cn lm sng:
a. Xt nghim:
b. Siu m thn:
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).
. 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.
. iu tr triu chng:
. Thuc gi au.
. Thu gi .
. Kh g si h theo kh g si h nu c).
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
VI. KT LUN
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.
+ 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.
+ Ch h: ph do su ti , ga t ng hp cp cu khi cc thuc li
tiu
+ Tc dng ph c tnh:
+ Bit dc:
- Funorit (diamox): dng vin h lng 0,25; cho ung 2-4 vin/ngy, trong 3-5
ngy.
+ 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:
+ Bit dc:
+ Tc dng ph:
- 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.
+ Bit dc:
- Axt etacrynic (edecrin, urgit): dng ng tim 50ml c 0,05g, dng vin 0,05g.
+ 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.
+ Chng ch nh:
- D ng vi sulfamit.
+ Bit dc:
+ 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:
- D ng vi sulfamit.
+ Tc dng ph:
-G t g a t u i u, t g glu oza u.
- T g lipit u t g LDL-C.
+ Bit dc:
+ Ch nh:
- B h t g aldoste ol gu ph t.
+ Chng ch nh:
- T g kali u.
- Su ga giai on cui.
+ Tc dng ph:
+ Bit dc: triamteren; thuc c dng vin 50mg, cho ung 50-150mg/ngy.
+ Chng ch nh:
-C t ng hp t g kali u.
+ 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 .
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.
+ 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.
+ 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.
. . 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).
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.
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.
+ Hi chng thn h:
+ 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 :
c digoxin.
. . T g ng mu:
. . T g a t u i u:
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...).
. 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 .
- AH (anti hyaluronidase).
- T th g th do i ng.
- Henoch-Scholein.
- Hi chng Goodpastur.
. . 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:
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.
. . C h b h si h: s 1)
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).
. Co m h ul t g sc cn ngoi vi.
5.1. Ph:
. . i a u i th:
. . T g hu t p (THA):
m do ph no d n 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.
- St nh 37,5oC - 38,5oC.
5.7. Bi i nc tiu:
i u nhu m thn.
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:
- T g hu t p d n co git, hn m ri t vong.
- Ph phi cp.
- T g kali u, g g ti t ngt.
- Vim cu thn mn vi biu hin: ph, protein niu, hng cu niu. Tin trin
thnh t g t ko di trong nhiu .
HCTH
7. Cc th bnh.
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.
7.2. Th i a u:
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:
8. Ch o v ch o ph it.
8.1. Ch o :
- Ph.
- i a u i th hoc vi th.
- T g hu t p.
- Xut hin sau nhim lin cu khun vng hng hoc ngoi da, ASLO (+); xy ra
tr em .
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 .
. iu tr.
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.
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:
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:
. . iu tr t g hu t p:
. Concor 5 mg/ngy.
. Adalat (nifedipin) 10 mg x 1-2 v/ngy.
. . iu tr d phng:
- Dng khng sinh: penicillin chm 1,2 triu / g . Mi thng tim bp tht mt
ln, tim trong vng 6 thng.
BS. Ho g
. h gha v kh i im.
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.
. . . 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.
2.1.5. Vim cu th g t g si h:
% 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.
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:
phi l tnh trng thm nhim, biu hin lm sng b g kh th kiu hen.
- Bnh u ht Wegener.
. . . i th o ng:
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...
-Nhi c penicillamin.
Bnh bch cu cp, bnh bch cu mn, sarcoma hch, bnh Kahler.
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
+ 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.
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:
. . T g hu t p (THA):
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:
- 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:
5.2. Th t g hu t p (THA):
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):
6. Ch o :
- Ph.
- Protein niu.
- Hng cu niu.
- T g hu t p.
- Gp gi t g th h t , di 20 tui).
- Khng r gu .
- T g u eati i .
. iu tr.
. . iu tr triu chng:
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.
7.2.1. Ch nh:
- Hi chng Goodpastur.
- Vim cu th t g si h go i ao ch.
+ Corticoid:
- Cyclophosphamide.
I. I CNG
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.
- T g t s lc.
- T g siu lc.
. T g ng mu.
. Bt th g th g ng cu - ng thn.
. Bt thng ca ng polyol.
. Tha endothelin.
. Tha Kallicrein.
. Tha glucagon.
. Tha ho o t g t ng (GH).
. Tha th ceton.
2. S glycosyl ha khng men c th l tha i bn cht ca protein:
III. CHN ON
1. Ch o d g t h + :
+ Protein niu:
+ Huyt p t g th pht.
+ Ri lon m mu.
- 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 suy thn nng, suy th giai on cui. Ngi bnh b tn ph, nhiu
bin chng (mt, thn kinh, tim mch).
- X h a u thn kt hp vi k h h a
IV. IU TR
- Glucid t 45 - 50%
- Protid t 15 - 20%
2. Ch lao ng hp l.
3. Thu iu tr T:
Tt Trung bnh Km
Cc thu iu tr T gm:
a. Insulin:
- Tc dng nhanh.
- Tc dng bn chm.
- Tc dng rt chm.
- Nhm Sulfonylure:
. Th h 1: Tolbutamid, Chlorpropamid.
. 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:
5. Thu iu ch h t g mu:
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.
Chy thn nhn to chu k hng ngy trong 2 gi ci thi c cht lng cuc
sng cho bnh nhn.
- Gim m mu.
. Kh g t g .
. Hot ng th l .
. Ngng ht thuc.
I. I CNG
- 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 th pht hi c khng nguyn lin cu sm, nu sinh thit trong 1-2 tun
u.
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:
- i u:
. 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:
2. Cn lm sng:
- Nc tiu:
- Mu:
. Thiu mu nh ho h thng.
. Mu l g t g.
. B th gim, ch yu C3.
IV. CHN ON
1. Ch o nh:
- i t< l/ gi
- i mu: vi th ho i th.
- T g hu t p.
- B th gim.
- ASLO t g.
2. Ch o ph bit:
V. BIN CHNG
IV. IU TR
- h, hn ch mui v gi m.
2. Khng sinh:
4. iu tr triu chng:
- K+ mu cao:
. Cal i lo ua ti t h ch.
5. Theo di: nh k .
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.
I. I CNG
1. Nguyn nhn:
- Khng th khng yu t mng t bo, khng hng cu, khng bch cu, khng
tiu cu.
1. Biu hi a u:
- St nh, mt mi.
- T mu l g t g.
. Ba h m m.
2. Ban d g a.
. T g m th vi nh sng.
4. Lot nim mc ming hng.
6. Vim mng:
. C t bo LE.
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.
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
7 T th g thn 51 94
9 Ri lon huyt hc 59 89
. Ph
. T g hu t p
. Protein niu
. Ph
. Protein niu o , g/ gi
. 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.
V. CHN ON
1. Ch o nh:
- C biu hi i kh g c hiu:
. T mu l g t g.
. g glo uli u t g.
- 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.
. Ni a h h h m r.
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.
- St v chiu.
- Biu hin lao phi d pht hin nht, ng thi tm biu hin lao ua
kh lao g o .
Ch o da vo:
VI. IU TR
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.
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.
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.
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.
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.
1. Lm sng:
2. Xt nghim:
- Nc tiu:
- 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.
3. M bnh hc:
IV. IU TR
- Khng sinh.
- Ct amygdal.
- Corticosteroid. K c liu ph p t s g .
- Cyclophosphamid.
- Azathioprin.
- Cyclosporin.
4. T ng ln t th g u thn:
- Thuc ch g g: Hepa i , Lo e o , Wa fa i .
. Ti l g t g i tt Khng cn hn ch Khng
iu tr triu ch g: t g
huyt p, suy thn mn.
81.LIN QUAN THN TRONG MT S BNH NI KHOA
- i t, i dm.
-U u t g, eati i u t g.
- 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:
- 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%.
a. Gii phu:
- i th: k h thc th h thng ho hi to. V d bc.
- Vi th:
b. Ch g:
- Mc lc cu thn gim.
- Phn s l t g.
- H natri mu.
- T tr g c tiu t g do c.
(1) Vim gan virus: giai on tin trin, protein mu gim gy p sut keo mu
gim v ph.
82.CC D TT BM SINH
PGS TS BS. Tr L Li h Ph g
1. Cc nguyn nhn?
T l nam: n l 5:2
gi ln, cc gu h thng gp l:
- S ng tit niu
2. C ph g ph p h o ?
3. Ph g ph p iu tr?
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 .
Hp l niu qun.
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 ?
Ni soi x nang
12. T o gc bng quang niu qun c xy ra trong nang niu qun hay
khng?
5- % t o g , % t o g , % t o g 3, 50%
t o g % t o g 5 c 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?
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.
C t ng hp tht bi vi iu tr ni khoa:
V t o g ho n la tui 10- 11
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).
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%.
3. Cc bt th g i k ?
M H GII TNH
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?
nh nhim sc th
h lng 17 OH progesteron
Soi bng
7. T h g a h a ua si h dc ngoi ca nam?
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.
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.
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?
1. Th no l l tiu g ao
3. Bt th g t g t KUB a l tiu g ao
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
6. Nguyn t iu tr l tiu g ao
ThS. Bs Nguy Ho g c
1. Th no l l tiu g thp
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.
D g c cung cp mu tt.
Mi ni kh g g
Cm mu tht k.
Ch khu tht nh
Hp niu o
Hp ming l tiu
Ti tha niu o
D da
8. Trong phu thut l tiu g thp c lun lun cn thit phi chuy lu
c tiu hay khng
9. C h iu tr l tiu g thp n g t o g t ng hp d g vt nh
2. Ch o valve iu o
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.
T o gc hai bn
V i dm sau 5 tui
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
13. iu tr d h g do c tiu
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.
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
B g siu t c sanh.
5. Cc yu t no c th nhm ln vi thn nhiu nang
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 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.
Kho g % t ng hp c th pht hi c.
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:
87.HI CHNG BU CP
ThS Bs Nguy Ho g c
thot v bn
Bu tinh hon
4. Ch o on mm ph tinh hon
PGS TS BS. Ph V B i
I.1.Thn v Niu qu i
Nang tht ln
Kh g u
II. BNG I
1.B g i v si h:
Rt him.
2. B g i h i:
----->ha c.
4. B g i l thin (EXTROPHY)
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.
1. M t:
Mc phi:
3. Yu t gu :
II. Ch o ph it:
Dn do tc nghn:
Sa g th g t o g l g iu qun: u tn sinh.
Dn khng tc nghn:
Hi chng prune-belly
III. D liu:
1. Bnh s:
Bun nn v nn
St hoc yu t ( ch yu s si h h hi
IV. Xt nghim ch o :
1. Xt nghim:
T g ph t h c tiu
t o g c tiu: vt
Creatinine mu
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 cm
V thn mng
H ph t: tc nghn
+ o p lc trong thn
V. iu tr a u:
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.
+ 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 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.
1. Gi phu thn.
1.2. Mc thn.
- Gm 2 l:
- Mc th g h i ao a thn bi mt lp m gi l lp m
quanh thn.
1.4. ng mch.
2. Niu qun.
- g k h khi g, d i t u g h hia l o : on
b g on chu hng.
- Niu qu on b g: i t b thn ti g u g g hu
3. Sinh ly thn.
3.1. thn.
- L nephron gm c tiu cu thn v tiu qun (OLX, OLG, Henle, OG).
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.
2. iu ho cn b g c.
- 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 ch g thn.
+ Phn x th th th tch:
5. Mt s nghi ph p th d h g thn.
- o gi tip:
+ Th d gi tip b g h o g h gt o g u: h h h .
+ o t tr g c tiu:
- o t c tip:
1. Bc s phi lm g:
- S kt t c m:
+ Cc tiu chu ch o .
+ BN cn PT th PT dng no, cn lm g.
2. Y t phi lm g:
+ 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.
Thc cht l theo di phng cc bin chng, pht hin cc bin chng kp thi
th i s tr hp ly.
- Tt huyt p:
- 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.
- Chy mu.
- Nhim khun:
- Suy thn:
- R thn.
Nguyn nhn S tr
Mt s t ng hp do st si.
Phng si ti pht:
+ Ch : hn ch th hiu canxi.
+ Kh g c ung vitamin C.
+ C ch ki t a nh k : th g .
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:
Yu t gu :
- Ht thuc l
- Tip xc vi cc ho cht
Yu t gia h g cp n.
- 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:
- Cc loi u g th kh t gp:
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.
3. Ch o nh:
3.1. Lm sng:
3.1.1. Cc triu ch g ki h in
- 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.
3.2. Cn lm sng
3.2.2. Ph g ph p h o h h nh
- 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.
- 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
-U g a g g : ph it gia a g thng vi a g u g th g dy
v u nang bo sn.
Nh p e, i thn b thn, u thn ht vng hoc bnh vim thn mng trng.
. iu tr:
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.
2 - C gu :
+ Do thuc l.
%u g ua g l u g th t bo chuyn tip.
+ Papilloma: chim 2%
+ U g th t bo chuyn tip:
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 (+).
+ Ch o h h nh:
III Ch o :
1 Ch o nh:
+ i u: i u , v ch g, i a u c, hay ti pht.
2 Ch o giai on:
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 o B: G B1: Xm ln lp g.
G B2: Xm ln lp s u.
Theo TCYTTG:
+ Da vo xm ln ca u ( T: Tumor): T0 n T4
- 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.
+ Di tng ( M : Metastasis)
- M0: Kh g di a
- M1: Di a
IV - iu tr:
+ 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.
2 Phu thut:
2.1 Ct ni soi:
- U nm ti tha BQ.
- 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:
. i g:
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.
. . iu ki h h th h UPLTTTL:
. . i th:
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:
- i hiu ln v .
+ Giai on 2:
- t th g thc th.
- Nc tiu t d t l.
+ Giai on 3:
- L g c tiu t d t g.
- i kh t g l n lc g h l o g i.
- 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.
+ Tha g im IPSS:
+ Chp h tit niu khng chun b: pht hin si bng quang ca h tit niu
km theo.
+ 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.
+ Sinh thit:
X nh t chc ca tuyn.
6. Ch o :
6.1. Ch o nh da vo cc yu t:
- La tui.
- Ri lon tiu ti c bit l i kh .
- Siu m.
- Sinh thit.
- Tha g im IPSS.
6.2. Ch o ph it:
- B i do hp niu o.
- X ng c bng quang.
- U g th tu n tin lit.
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.
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 ...).
. iu tr:
. . iu tr ni khoa:
. . iu tr b g ph g tin vt l:
+ i a u g, ha t i ph t do UPLTTTL.
+ Si 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 .
+ Vi g, lo g g u:
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.
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.
u im cu ph g ph p:
Khi cn l a / t ng hp), c th gp kh kh .
Ch u ng tiu.
Gy t th g thn.
Thng b b tiu.
Ung nhiu c.
C th k:
V- Kt lun:
1. Cc loi sonde.
- Sonde c g: th g i a .
- Sonde mm:
Petzzer H h u rn c tc dng dn
lu BQ t g u.
16F: c sonde s F ~
CH = chu vi sonde l 16mm. S
o Be i ue = s o CH.
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.
2. D lu h thn
M h
- D lu u dch tit nu c.
- 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.
D lu h thn tt
- Chn sonde:
- 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.
iu kin rt d lu.
- Ht dch:
+ D lu kh g hy dch.
Cc kiu rt d lu.
- Khi no rt d lu hai th ?
- 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.
- M h:
3. D lu thn.
Cc kiu d lu thn
1. Ch nh:
- 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.
2. M h d lu thn:
- D lu m nu c m.
Th no l d lu thn tt.
1. Chn sonde:
2. V t t.
iu kin rt d lu thn.
1. Kp th.
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.
- X t : h t ng hp tc.
4. D lu g ua g.
Ch nh.
- Tt c t ng hp m vo BQ cn phi d lu BQ.
M h.
- D lu c tiu.
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.
- D lu tt l d lu c tiu mu m a go i t c m h
d lu .
Khi no rt d lu.
. i g:
- 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.
- 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 :
- L thuyt "khun".
+ Cc yu t thun li:
- 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:
2.1.1. Si:
+ Khi th ha to:
- Khi th to:
2.2.4. Cn lm sng:
+ Siu m ch o :
+ Xt nghi c tiu:
- Tm vi khu t o g c tiu, vi khu thng gp l Proteus v E. Coli.
-X h pH c tiu.
Lm cc xt nghi si h ho h gi h g a thn.
- Vim thn k.
- Thn c, m.
- p xe quanh thn.
. . iu tr:
. . . iu tr ni khoa:
+ Ch nh:
- Si nh i thn.
- Si ti pht mi sau m mt thi gian ngn.
- Si san h ca gi gi.
+ C th:
. . . iu tr ngoi khoa:
+ Ch nh:
- i vi si mt bn.
* Si b thn.
+ Yu cu phu thut:
- Ly ht si.
+C ph g ph p phu thut:
- M b thn ly si.
- M nhu m ly si.
- Ct thn ton b.
- 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.
3. Si niu qun:
3.1.1. Si:
- S lng: c t 1-2 vin, c khi xp thnh chui (gi l chui si niu qun).
3.1.3. Thn:
- Nu t t ngt c th ngng bi tit.
- Thn dn to c, m.
. . . 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.
3.2.4. Cn lm sng:
+ in quang:
+ 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.
- 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:
+ Ch nh:
- Si nh g k h di 0,5cm.
+ C th:
. . . iu tr ngoi khoa:
+ Ch nh:
* 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.
* u ti bn ch g thn cn tt t c.
+C ph g ph p phu thut:
- D lu th thun.
- Th gi t I ho II).
- Lu th g iu qu ph a di si tt.
4. 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.
- 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.
. . iu tr:
5. Si niu o
- Si t g ua g i ung.
- t hi i t , i kh , i ho to .
. . iu tr:
. iu tr theo tuyn
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.
2 Cc loi d lu thn:
3 Ch nh:
- Sau phu thut ly si thn, niu qun m thn c, m.
- Si nhiu i gu s t si sau m.
- To h h i thn.
- Ch th g, t th g th iu tr bo tn.
4 K thut:
. Kh g t t b thn v d gy r v hp.
. 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.
- Ti ch: vt m kh, h th kh g g g.
- Nc tiu trong khng c mu, khng c m.
6 Ki t a lu th g: 3 cch:
6.1 Kp th:
- Kp th sau 24h m v h th g th t c.
- Cn t gu g tc hoc bn t x tr.
99.DN LU H THN
V:
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
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:
S l g dn lu h thn
B h h t u g tin
Khi nim
B h nh sinh.
Ch o .
1. Lm sng.
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.
Ch o ph it
iu tr.
Giai on cp tnh:
B h .
- Do nhim khun nht l trc trng coli, loi vi khun Gram (-): trc khun m
a h P oteus
- gi hp niu o, UTTL
Ch o .
- Lm sng:
Tin trin.
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.
Ch o .
- Lm sng:
+ i au u bi sau chuyn d a g i au to i.
+ i c ch yu u bi.
iu tr
B h nh sinh.
Ch o .
- Lm sng:
+ i t g ln.
+ i au ui bi.
- Xt nghi c tiu 3 cc tm BC v t bo m.
iu tr.
- Bt ng ti ging.
Bao gm
1. chp th thng
2. chp thn thuc(UIV=urography intra venous
4. chp kh sau ph c
5. 2+4
8.
Chp CT
9. AG
1. M h:
2. Yu cu:
k h thc phim:D10-khp mu
3. C h c xq
k h thc
Ch k h thc ch ln nht ga g g d i
S lng si
Mt cn quang
M h:
M h:
L khi UIV ko h c
U th h g ua g khuyt b nham nh
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
ch o nh l v mu
Cc khi u ca thn
Mt s hnh nh b h l in hnh
1, Hnh nh si:
Gi :so s h l h i th gt
2, hnh nh u tt ni
3, hnh nh ca vim
Vim lao :hnh nhe thuc vng c t th g lao hoc ng thuc hang
lao to nn
I - i g:
1 - im:
2 C h ch th g:
c chia lm 5 loi:
- Nt hu di v .
II Triu chng:
1 Lm sng:
+ Ton thn:
+ Ti ch:
2 Cn lm sng.
+ Cc xt nghim ch o h h nh:
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.
2 Ch o t th g phi hp.
3 Ch o in chng:
- Vim ty h thn
- R thn.
- au ko di, st ko di.
- c tiu do h t ua h iu qun do cc mu t h a.
- Ph g M sau h th g o M thn.
IV - iu tr:
1 Nguyn t iu tr:
- Bt ng ti ging.
- Cm mu.
2 - iu tr bo tn:
+ Chng sc nu c:
3 - iu tr phu thut:
3.1 Ch nh:
3.2 K thut:
+ ng m:
+ X t : vo t th g:
. X tr cc t th g phi hp nu c.
4 Ct thn:
4.1 - Ch nh ct thn :
- Thn mt ch g.
- K thn.
- Chy mu sau m.
- R mm ct niu qun.
Ch
. 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
Th th g thng
Th bn hp
Th hp cht
Th hp tht
2. Th bn hp: khi d g t mm mi l c
II. iu tr
PGS TS BS. Tr L Li h Ph g
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
4. M tiu u t g ua vi m nng ca ch th g ha
khng?
7. Th no l ch th g thn nh?
8. iu tr ch th g thn nh?
12. Biu hin trn hnh nh hc ca tnh trng huyt khi ng mch thn?
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.
1. T l t th g iu qu t o g t ng hp vt th g ng do ha kh
Khong 2,5%
Thn c
8. T th g iu qun do y thut?
Trong lc cm mu g hu
T th g iu qun do x tr
Ti si niu
Lao niu
X ho sau ph c
13. iu tr t th g iu qu / di?
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
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.
V NIU O
2. C gu h thng gp ca v niu o t c?
4. Cc du hiu gi n v niu o?
7. iu tr v nio o t c?
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?
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?
4. X tr mt t ng hp ch th g ti h ho ?
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.
7. Cc ch th g ti h ho , v lu di c h h g n kh g si h
sn hay khng?
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
. 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 .
2.3 i kh
. B i
. 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
. 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
. a iu
. Thiu iu
. V iu
. Mt s t i 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
. 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 / 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 :
Nguy V
I- M U
2.1.1. Cm gic 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.
. . . Giai on co bp b g i:
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.
40 - 60 > 18
> 60 > 13
N < 50 > 25
> 50 > 18
Tr em, thiu nin < 10 > 15
10 - 20 > 20
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. 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.
-Loi hc (machanical).
-B ho th ha g sau g au d g t ho g d g t iu tr
kh g g.
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.
-au g hi m.
-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.
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.
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
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)
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 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)
NH GI SUY THN CP
PGS.TS. BS. Tr L Li h Ph g
Ch th g g
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
Ch g tiu cu
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.
Tnh trng co mch thn trc tip do hu qu ca nhim trng, bnh l gan
v thuc.
Ti thn
Tiu m, tr bch
Vim thn k >1%; >30 mEq/l
cu
cu, hng cu
Sau thn
T bo c tnh
Bu Kh g c hiu
B h thng
Chn p t ngoi Kh g c hiu
gi ln:
Tiu g h g u)
Cao huyt p
Vim cu thn
Vim thn m k
Bnh l c tnh
tr em:
Cao huyt p
Tiu ng
Cc bnh l c tnh
-Cao huyt p
-Bnh l thn kinh ngai i : thng xy ra khi bnh tin tri o giai on
cui
L u nh k
Ghp thn
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.
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 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.
Vim thn b th do t o gc
Sn thn
Nghi ng u thn
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.
17. Ng ga v iu tr thi gh p h th no
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
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
Vi t h ch ti i ti h h
Thuc ch g l pho o d g
Hi chng gi cm liu u
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)
I/ t v :
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.
1.Bnh nhn:
Bng 1: Cc d kin b h h t c m
_______________________________________
Tui 49(36-61)
au l g 10
_______________________________________
____________________________________________
K h thc 60 mm(51-85)
Ht dch lm TB hc 0
Nang cc trn 2
Nang c di 7
____________________________________________
. Ph g ph p:
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
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:
_____________________________________________________________
Chuyn m h 3
Mu mt 30ml(10-100)
_____________________________________________________________
_____________________________________________________________
V/ Bn lun:
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 .
_____________________________________________________________
Chng ti NV Hip- BM Cn
Chuyn m h 3 0
_____________________________________________________________
VII/ Kt lun:
u im:
T h c cc bin chng tn th g ua t o g ph c
Nu phi chuyn m h, ng m h c in
Khuyt im:
Phu t ng hp h .
9/BARRETO H., DOUBLET J.D., PERALDI M.N., GATEGNO B., THIBAULD Ph.
13/CLOIX P., MARTIN X., PANGAUD C., MARECHAL J.M., BOUVIER R., BARAT D.,
DUBERNARD J.M.
14/ARONSON S., FRAZIER H.A., BALUCH J.D., HARTMAN D.S., CHRISTENSON P.J.
15/BOSNIAK M.A.
CC NH NGHA:
2/ CC NGUYN TC LY C QUAN:
C BA IU KIN CN BO M:
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:
3.2 LCH S
C h u tin v vic bo qun th ng bi LOEBELL
, CAREL LINDBERG
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.
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.
. . D NC TIU
4.3.4 LYMPHOCELE:
* Bs Khoa Niu B bnh vin Bnh Dn; ** Bs Ni tr Khoa Niu B bnh vin Bnh
Dn
T lc:
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 :
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]
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.
S h s: /
Ngh: g h kh
3. Cn lm sng:
lng mu mt: 40 ml
Hu phu: au sau m t
BN LUN:
1. Ch o t c m v ch nh phu thut:
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.
4. Cc thng s ca cuc m:
BN ny 1 165 40 6 -
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.
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.
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
7. Darracott Vaughan E., Jon D. Blumenfeld: The adrenals . Campbells Urology , 7th
Ed. Vol.3, W.B. Saunders company, 1998, pp 2915-2972.
TM TT
M U
TRNH BY BNH N
L do nhp vi : au l g.
Cn lm sng:
- 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.
BN LUN:
Ct TC ng bng: 0.5- 1%
Ct TC g o: 0,1%
- <30% cc t th g c pht hi c lc m.
2. Hu qu ca t th g iu qun:[2]
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.
- 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.
KT LUN
T lc:
Abstract:
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.
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.
2. Ph g ph p thc hin:
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]).
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:
1. Bnh nhn:
. . a d: TPHCM: 12 Cc tnh mi g: 12
1.4. ASA: I:
17 II : 18 III : 1
2. Si:
Si L4 L5: 2
2.3. S lng: 37 sn/ 36 bnh nhn,1 bnh nhn c 2 vin sn niu qun
l g P .
D g t h: 3 / 15 t ng hp
4.2. B t i c tch vng sau phc mc: t 300 - 600 ml, trung bnh: 387 ml
4.5. S i kh u iu qun:
i: / ; i: / ; i: / ; i: /
. . t lu th g iu qun khi m: / t ng hp
4.8. Chuyn m h: / t ng hp:
5. Hu phu:
T kh di da bng : 1
V. BN LUN:
Ballanger Ti Dao C,
, c,
- 3, lnh t Vicryl
1999 [5] 600ml, endo , i
tam t c - - - -
- ri
ngoi gic m
knife
Gerota
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:
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.
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.
21.Rassweiler J. J., Seemann O., Frede T., Henkel T. O., Alken P.:
Retroperitoneoscopy: experience with 200 cases. J. Urol. 1998; 160:1265.
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%
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:
3. Kt qu nghin cu:
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
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.
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.
S H S: 9/10218
L DO VO VIN: Khm sc kho nh k pht hin K TLT
SIU M: ph i TLT
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)
-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.
PP v cm: m NKQ
Gy m: BS.D g, T i h
Khu da.
Lng mu mt: kh g g k.
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
- Bnh nhn cn rt tr nn yu cu ph g ph p iu tr t h h g n
cuc sng.
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.KT LUN:
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.
2.. Frank Hinman, JR (1998). Atlas of Urology Surgery, second edition, section 11.
pp 446-464. W.B Saunders Company, California.
4.. Rudolf Holhenfellner (2005). Advanced Urologic Surgery, , Third dition, chapter
27, pp 142-155. Blackwell Publishing Ltd, Massachusets.
TRNH BY BNH N
Hnh chnh:
-H tn: Mr. J. Gallat Tui: 65 Phi: nam
Khm
Tng qut: tng trng kho, nim hng, hch ngoi vi khng to.
M: 66 ln/pht HA/80mmHg N:
Khm niu: -Chm thn (-), bp bnh thn (-), rung thn (-)
Cn lm sng:
-4 Sn to bng quang tn to
(Magnesium phosphate)
BN LUN
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)
TI LU THAM KHO
-(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.