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Tm tt
Basedow l mt bnh tuyn
gip thng gp vi cc triu chng
cng gip, li mt, bu gip lan
to, gy ra bi khng th khng th
th TSH. C mt mi lin quan cht
ch gia nng ca khng th ny
v triu chng li mt trong bnh
Basedow. T l bnh nhn bnh gip
hay cn cng gip sau iu tr 1311
c lin quan vi nng TRAb cao
hay thp. Nng TRAb trong huyt
tng c gi tr trong chn on,
theo di v tin lng bnh
Basedow sau iu tr bng I311.
Trong nghin cu ny, chng ti
nh gi s thay i ca nng
TRAb trn nhng bnh nhn
Basedow trc v sau khi iu tr
bng I311.
T VN
Basedow l mt bnh ni tit thng gp nc ta cng nh trn th gii.
Basedow c xp vo loi bnh c c ch t min dch.
Hin nay c 3 phng php iu tr c bn l:
- iu tr ni khoa bng thuc khng gip trng tng hp (KGTTH)
- iu tr bng phu thut ct b tuyn gip
- iu tr bng iod phng x (131I)
Nm 1978 ln u tin 131I c p dng iu tr Basedow ti khoa Y hc ht
nhn Bnh vin Bch Mai
n nay, trong c nc c hng ngn bnh nhn Basedow c iu tr bng
131
I . Trn th gii cng nh nc ta c kh nhiu nghin cu v hiu qu cng
nh cc bin chng ca vic s dng 131I trong iu tr bnh cng gip ni chung v
bnh Basedow ni ring.
S0
S5
: standard0
standard5
2.2.6. X l s liu.
S liu c s l theo chng trnh EPI INFO 6.0 v SPSS ca M.
2.2.7. Ni tin hnh nghin cu.
Bnh vin Ni Tit trung ng v khoa Y hc ht nhn Bnh vin Bch Mai.
3. KT QU V BN LUN
3.1. Tnh hnh bnh nhn Basedow trc iu tr 1311:
- Tng s bnh nhn c iu tr l 64.
- Tui trung bnh 46,9 11,13
- Gii: n > nam (47/64) 73,4%
- Cc triu chng lm sng v cn lm sng khng c g khc bit ln so vi
mt s tc gi Phan S An, Phan Vn Duyt, Trn nh Ngn v Harbezt J.C.
3.2. bin i mt s triu chng lm sng v cn lm sng bnh nhn Basedow
trc v sau iu tr
Bng 2. So snh nhp tim trc v sau iu tr 6- 24 thng ( n = 46) .
Ch s thng k
Trc iu tr
Sau iu tr
3-5 thng
Sau iu tr
6-24 thng
102,2 13,7
84,3 13,5*
77,6 7,9**
Sau iu tr 6-24thng
(X SD)
(X SD)
Hng cu
(tb/mm3)
4.696.000 512.000
n=42
4.871.000 409.400
n=21
> 0,05
Bch cu
(tb/mm3)
6.535 1.498
n=60
6.519 1.313
n=23
> 0,05
Bch cu NTT
(nghn/mm3)
4.156 1.303
n=60
3.940 908
n=22
> 0,05
Xt nghim
40,4 18,3
14,5 7,2
< 0,001
n = 64
n = 15
83 12,2
31,4 14,7
tp trung 131I sau 24h (%)
< 0,001
n = 64
n = 15
Nng T3 huyt thanh
4,2 2,26
2,13 0,94
< 0,001
(nmol/l)
n = 64
n = 39
270,37
Nng T4 huyt thanh
85,20 57,73
< 0,001
102,17
(nmol/l)
n = 13
n = 36
Nng FT3 huyt
63,56 43,45
15,83 19,88
< 0,05
thanh(pmol/l)
n = 27
n=5
Nng TSH huyt
0,048 0,046
10,58 18,642
< 0,001
thanh(mU/l)
n = 64
n =39
- TG nh i so vi trc iu tr 33,1 12,0ml so vi 17,5 4,6ml (p< 0,001)
ph hp vi cc tc gi Phan Vn Duyt, Phan S An v Hazberrt
3.3. Kt qu chung sau iu tr.
- Vi liu iu tr trung bnh: 6,33 1,34 mCi cho mt bnh nhn
- S ln iu tr 1,33 ln cho mt bnh nhn c 75% v bnh gip, 11,7% cn
cng gip 13,3% suy gip.
tp trung 131I sau 2h (%)
SD
Median
Min-Max
Ql-Qu
X
Nam
24
2,08
1,86
2,28
0-9,20
1,33-2,54
N
22
3,01
2,87
2,28
0-10,15
1,80-2,90
Chung
46
2,52
2,42
2,28
0-10,15
1,35-2,89
Khng c s khng khc bit v nng TRAb gia nam v n (p>0,05). Nng
TRAb ngi trng thnh l 2,28U/l (Median); Min: 0U/l; Max: 10,15U/l; Q1:
1,35U/l; Qu: 2,89U/l.
Gi tr ln nht TRAb ngi bnh thng l 10,15 U/l theo hng CIs bio
international ( Php)
Chng ti chn ngng:
+ TRAb < 11U/l coi l (-)
+ v TRAb > 11U/l coi l (+)
Tng t gi tr ca Hng v mt s tc gi khc
Bng 8. Nng TRAb ngi bnh thng trng thnh
Gii
Tc gi
71
106
TRAb (U/l)
[TRAb (-): TRAb m tnh
< 15
< 14 (nh lng theo kit Dyno
test TRAb-assay Brahms)
< 2(nh lng theo kit TRAbhuman Brahms: siu nhy)
<2
<8
< 10
296
< 11
56
Massart C v CS (2000)
Shibayama K v cs 92000)
Pedersen B v cs (2000)
Hng C Bio International (Php)
(2002)
< 11
Bi Thanh Huyn v CS
46
Min: 0 ; Max: 10,15 ; Median:
2,28
Gii hn bnh thng TRAb trong mu ngi bnh thng khc nhau theo tu
tng tc gi, tu quc gia v phng xt nghim khc nhau. S khc bit ny ch yu
ph thuc vo phng php nh lng TRAb c nhy khc nhau>
3.4.2. Nng TRAb bnh nhn Basedow trc iu tr.
Bng 9. Nng TRAb (U/l), TRAb (+) v TRAb (-) bnh nhn Basedow trc khi iu tr 131I.
TRAb(U/l)
TRAb +(>11)
53
TRAb (<11)
X
452,8
1
6,37
SD
Median
Ql-Qu
87,94
457,63
425,44499,40
2,22
6,25
5,03-9,32
Min-Max
TRAb (+) v
344,8
2,3662
207,33 432,26 31,54-475,64
(-) (chung)
0
592,61
Trc iu tr TRAb cao gp hng trm ln so vi ngi bnh thng 457,63U/l
so vi 2,28U/l (Median) (p<0,0001)
Bng 10: T l TRAb (+) bnh nhn Basedow trc iu tr mt s tc gi.
Tc gi
n
TRAb (+) trc iu tr (%)
Aiawa Y (1995)
225
78% (126)/225)
Sato K. v cs (2000)
> 90%
Massart C. v cs (2000)
140
98,6%
Schifferdecker E. (1986)
53
94,3% (50/53)
Bi Thanh Huyn v cs
62
85,5% (53/62)
Kt qu nghin cu:
T l TRAB (+) l 85,5% v TRAb (-) l 14,5% (p< 0,0001)
Nhn xt trn ph hp vi Pedersen B., Laurbeg P., v csl Moagenthaler,
Phel Z
3.4.3.Nng TRAb bnh nhn basedow sau iu tr
Bng 11. So snh nng TRAb gia ngi bnh thng vi bnh nhn
Basedow trc v sau iu tr 131I.
TRAb
n
Median
Min-Max
Ql -Qu
a
Ngi bnh thng
46
2,28
0-10,15
1,35-2,89
b
Basedow trc iu tr
62
432,6
2,36-592,61 31,54-475,64
c
Basedow sau iu tr 3-5
60
49,92
1,80-93,21
9,20-93,21
thng
d
Basedow sau iu tr 6-24
58
8,71
0-19,31
5,21-19,31
thng
So snh:
a - b: P < 0,0001
b - c: P < 0,0001
a - c: P < 0,0001
b - d: P < 0,0001
a - d: P < 0,001
c - d: P < 0,001
Nng TRAb c xu hng gim dn khi thi gian sau iu tr tng ln.
Nhn xt trn ph hp vi Shfferdeckez E v cng s (1986)
Bng 12. T l % bnh nhn Basedow c TRAb (+) v ( -) trc v sau iu tr.
TRAb (+)
TRAb (-)
n
%
n
%
Trc iu tr
53
85,5
9
14,5
Sau iu tr 3-5 thng
45
75
15
25
Sau iu tr 6-24
19
32,7
39
67,3
thng
p
< 0,001
< 0,01
(%)
80
TRAb(-)
70
60
50
40
30
20
10
0
Tr c iu tr
S bnh nhn
T l %
45
75,0
11,7
13,3
Cng gip
ti pht
(n=7)
Bnh gip
(n=45)
Suy gip
(n=8)
532,87
50,84
541,34
29,73
10,18
35,78
410,99 109
,87
427,58
12,49
11,96
8,66
9,84 8,98
7,07
6,36 5,33
4,24
<0,0
01
<0,0
01
>0,0
5
4. KT LUN
4.1.Vi liu iu tr trung bnh l 6,32 1,3 mCi 131I v s ln iu tr trung bnh l
1,33 ln cho mt bnh nhn: c 75% (45/60) bnh nhn Basedow tr v bnh
gip, 11,7% (7/60) vn cn cng gip v ch c 13,3% (8/60) b suy gip trng. Thi
gian sau iu tr cng di, chc nng tuyn gip cng tr v n nh. Sau iu tr 6-24
thng, tnh trng cng gip c bn tr v bnh thng. Khng c s thay i v s
lng cc t bo mu trc v sau iu tr. Ring tnh trng li mt it c ci thin.
4.2. Nng TRAb ngi bnh thng trng thnh l: 2,28 U/l (Median), thp nht
l 0 U/l v cao nht l 10,15 U/l. Khng c s khc bit v nng TRAb gia nam
v n (p>0,05)
- Trc iu tr 131I, nng TRAb ca cc bnh nhn Basedow l 432,26 U/l
(Median), thp nht l 2,36 U/l v cao nht l 592,61 U/l. Nng ny cao gp hng
trm ln so vi ngi bnh thng (p<0,0001).
- Nng TRAb cao nht cc bnh nhn Basedow trc iu tr, sau gim
mnh khi thi gian sau iu tr tng ln t 49,92U/l (Median), sau 3-5 thng xung cn
8,71U/l (Median) sau 6-24 thng (p<0,0001).
- T l TRAb(+) trc iu tr l 85,5%, ri gim t 75% sau 3-5 thng xung
cn 32,7% sau 6-24 thng (p<0,001)
- T l TRAb(-) trc iu tr l 14,5% tng t 25% sau 3-5 thng iu tr ln
67,3% sau 6-24 thng (P<0,01)
- Nng TRAb trc iu tr c gi tr cao nht cc bnh nhn Basedow cn
cng gip, thp hn nhm bnh gip v thp nht nhm suy gip sau iu tr
(532,87 U/l so vi 410,99 U/l v 9,84 U/l) p<0,001.
- Sau iu tr nng TRAb nhm cng gip v bnh gip u gim i r rt
so vi trc iu tr (p<0,001), nhng thay i khng r nhm bnh nhn b suy gip
(p>0,05)
- Trc iu tr 100% (7/7) bnh nhn b cng gip sau iu tr c TRAb(+),
t l ny l 95,7% (45/47), nhm bnh gip v 12,5% (1/8) nhm suy gip sau iu
tr.
- T l TRAb(-) trc iu tr cao nht nhm suy gip (87,5%:7/8), thp hn
nhm bnh gip (4,3%:2/47), v thp nht (0%) nhm cn cng gip sau iu tr.
5. KIN NGH
Nng TRAb mc cao v t l cao TRAb (+) trc iu tr l mt du hiu
quan trng cho vic tin lng kh nng ti pht sau iu tr 131I cc bnh nhn
Basedow. Nhng bnh nhn Basedow c nng TRAb thp v t l TRAb (-) cao
trc iu tr l du hiu tt tin lng kh nng suy gip sau iu tr 131I. Do vy
nh lng nng TRAb l mt xt nghim cn c a vo thng quy trong chn
on, theo di bnh nhn Basedow.
TI LIU THAM KHO
1.
Phan S An., Phan Vn Duyt., Mai Trng Khoa v cs. (1999), Tng kt qua
20 nm iu tr bnh cng gip bng iod phng x131I ti khoa Y hc ht nhn
Bnh vin Bch mai, H Ni,Tp ch Y hc Vit Nam, S 8-9,Tr.68-71
2.
Trn Khnh D (1987), Bnh l ca tuyn gip, Nxb Tp H Ch Minh, Tr. 39
3.
ng Trn Du (1996), Bnh tuyn gip v cc ri lon do thiu iod, Nxb. Y
hc, H Ni, Tr. 451-489.
4.
Mai Trng Khoa (1996), Nghin cu bng phng php kim nh mim dch
phng x hm lng ni tit t T3, T4, TSH trong mt s iu kin bnh thng v
bnh l, Lun n PTS khoa hc Y dc, H Y H Ni, Tr. 28-30.
5.
Thi Hng Quang (1989), Bnh Basedow, Bnh Ni tit, Hc vin Qun Y,
Tr. 62-82.
6.
Trn c Th (1999), Bnh hc tuyn gip, Bi ging bnh hc, Nxb. Y hc,
H Ni, Tp 1, Tr. 246-273
7.
Mai Th Trch, Nguyn Thy Kh (1999), Ni tit hc i cng, i hc Y
dc thnh ph H Ch Minh, Tr. 204-291.