Thận tiết niệu

VIEM BANG QUANG CAPI... SUY THAN CAPI... Khi co tin h tran g lam sang nang, can sinh th ie t lai than.

OAl MAU

I O jNH NG HIA

D ai m au la tin h tra n g n u ’O’C tie u co hong cau C o dai m au dai th e va dai m au vi the

- D a i m au dai the: khi nu’O’C tieu do sam m au, nhan biet du’O’c b ln g m it thu’O’ng.

- D ai m au vi the: m at thu’O’ng khong nhan thay, chi phat hien du’O’c khi lam xet nghiem te bao hoc nu’O’C tieu voi so lu ong hong cau > 10.000 hong cau/ml.

li c hAn o oAn

1 C h a n d o a n x a c d jn h

C o hong cau tro n g n u o c t ilu 6 ca c m u c do kh a c nha u (vi th e h o a c dai the) C o the p ha t hien n u o c tieu co m au b ln g m a t th u d n g h o a c co the phat hien hong cau nieu vi th e b ln g xe t ng h ie m to n g phan tich n u o c tie u h ay xe t n g h ie m te b a o nieu

a T rie u c h u ’n g la m s a n g

T uy th e o n g u ye n n h a n g a y dai m au se co trie u c h u n g lam sang tu o 'n g u n g

- D a i m au dai th e h o a c vi the

+ C o th e kem th e o tie u buot, dai r it , kho, n g lt qu a n g , bi tieu

- Co th e co sot, co h o a c kh o n g ret run

- C o th e c o n dau q u a n th a n , dau ho t h it lu n g m o t h oa c hai ben

- C o th e dau tu c , n o n g rat vu n g bang qua ng

b C a n la m s a n g

- X e t n g h ie m n u o c tie u d e kh a n g djnh dai m au: co hong c iu nieu d ca c m u c do

- D e tim n g u ye n n h a n d a i m a u can lam th e m m ot so th a m do, tu y th u o c lam sang:

+ T e b a o nieu: tim te b a o ac tin h

+ D in h lu o n g c a c g lo b u lin m ien dich (IgA, IgM, IgG, IgE ) Ig

+ S inh th ie t th a n : hien vi q u a n g hpc va m i§n djch huyn h qu a n g

- C h ay m au nieu dao: ch a y m au ti> nieu d a o kho n g phu th u o c v a o c a c lan di tie u tien.

- Nu’d c tieu lan m au: d phu nCr dan g co kin h nguyet

- M yo g lo b in nieu khi co tie u co

- H e m o g lo b in nieu khi co tan m au tro n g long m ach, p o rp h rn e nieu (nu’d c tie u do sam khon g co mau cuc) —> can xe t n g h ie m te b a o hoc —* k h ln g din h dai m au

3 C h a n d o a n n g u y e n n h a n d a i m a u : tu y th u o c v a o n g u ye n nha n

C a c ngu yen nhan co th e g a y dai m au:

a D a i m a u d o n g u y e n n h a n t ie t n ie u : tru ’d c het p h a i c a n h g ia c v d i k h o i u th a n -tie t nieu gay ra dai m au

- D ai m au do soi than, tie t nieu

- D ai m au do khoi u:

+ Khoi u nhu m o than

+ U bieu m o tie t nieu

+ U bang quang

+ U tu ye n tien Net

- D a i m au do nhie m tru n g tie t nieu

- D a i m au do chan th u ’o n g :

+ C han th u ’o n g vung th a t lu n g

+ C han th u ’o n g vu n g ha vi

+ C han th u ’a n g nieu dao

- N ghen, t i c m ach th a n (d o n g m a ch va tin h m ach)

- T a c tin h m ach chu

- San m ang

C ac th a m d o c h u ye n sau co the th u c hien

- Noi soi ban g qu a n g : tie n han h khi d a n g co dai m au

- C h up nieu q u a n be th a n n g u 'o c d o n g co th u o c can q u a n g (U P R ), c h u p c i t Id p vi tin h (CT) chup

m ach than (AG ): khi co dai m au t ir m o t ben nieu qua n can tie n h a n h d e tim kiem khoi u th a n kich thirdc nho hoac di d a n g m a ch m au

- S in h th ie t th a n : k h i co d a i m a u t ir h a i b e n n ie u q u a n d b e n h n h a n tre tu o i n g h i n h ie u (Jen

b e n h B e rg e r

H u O n g d A n c h A n o o A n v A p i £ u t r i b £ n h N p i k h o a 5 7 5

III O l£U TRj

1 D ie u trj trie u c h ir n g

a N o i k h o a

- T h u o c c a m m au: tra n s a m in d u o n g uong hoac tru ye n tTnh m ach

- T ru ye n m a u neu m at nhieu m au

- K h a n g sin h neu co dau hieu nhie m trung: sulfam id, q u in o lo n , co the pho i h o p v o i nho m khac tuy

th e o die n bie n lam sang va ket q u a cay vi khua n m au va n u o c tieu

- T u y th u o c v a o n g u ye n nhan g ay dai m au can pho i h o p th e m th u o c khac

1 H e m a tu r ia C a u s e s O r ig in a l D a te o f P u b lic a tio n : 15 J u n 1998, R e vie w e d by S tacy J C hilds,

M D , S ta n le y J S w ie rz e w s k i, III, M D Last R e vie w e d : 10 Jul 200 8

2 H e b e rt, D N ; N a d a s d y , T.; N a d a s d y , G ; A g a r w a l, G ; M a u e r, M ; A g a r w a l, A K ; K h a b iri, H.; N a g a r a ja , H N e t a l (M a r 2 0 0 6 ), “P ro p o s e d p a th o g e n e s is o f id io p a th ic lo in p a in -h e m a tu ria

s y n d ro m e ", A m J K id n e y D is 47 (3): 4 1 9 -2 7

3 R u s s o , D ; M in u to lo , R ; la c c a r in o , V.; A n d re u c c i, M ; C a p u a n o , A ; S a v in o , FA (S e p 1998),

“G ro ss h e m a tu ria o f u n c o m m o n o rig in : the n u tc ra c k e r s y n d ro m e ”, A m J K id n e y D is 32 (3): E3.

VIEM BANG QUANG CAP

I DjN H NG HIA

V ie m bang q u a n g ca p la tin h tra n g nhie m kh u a n cap tin h tai b a n g q u a n g Bieu hien lam sang la co hoi c h u n g bang q u a n g ro v o i dai buot, dai rat, co the dai m au, dai m u 6 c u o i bai X e t n g h ie m nucrc tieu

co bach cau nieu va vi kh u a n nieu

Benh th u d n g g a p o n u v o i ti le n u /n a m la 9/1 Vi khu a n g a y ben h chu ye u la vi khua n G ram (-) va gay viem bang q u a n g chu yeu th e o d u o n g n g u o c d o n g (tu nieu d a o vao) T ro n g bai nay khong de cap den viem bang q u a n g do lao

ii c hAn d oAn

1 C h a n d o a n x a c d jn h

a L a m s a n g

- C o hoi c h u n g b a n g q u a n g ro v o i dai buot, dai rat, co th e dai m au, dai m il c u o i bai.

- C o th e co dau nhe vu n g tre n k h o p m u khi ban g q u a n g cang

- D o i khi trie u c h u n g kh o n g dien h in h , c h i nong rat khi di tie u h o a c d a i rat

- T h u o n g khon g so t h o a c c h i sot nhe (n h ie t do < 38°C )

b X e t n g h ie m nu’&c tieu

- Bach cau nieu ro (s 104 b ach c a u /m l n u o c tieu), co b ach cau d a n h a n th o a i hoa h oa c > 3 bach cau/

vi tru o n g

- Vi khua n nieu: > 10 5/m l n u o c tieu cay

- K hong co p ro te in nieu h o a c p ro te in nieu ve t tru khi co dai m au, dai m u d a i the

c X e t n g h ie m m a u

- T h u o n g kho n g can x e t n g h iem

- Bach cau va b ach cau da nha n tru n g tin h kho n g tang

2 C h a n d o a n n g u y e n n h a n

a C a c lo a i vi k h u a n th u ’d’n g g a p

- E s c h e ric h ia c o li: k h o a n g 70 - 80% ben h nhan.

- P ro te u s m ira b ilis: 10 - 1 5 % ben h nhan.

- K le b sie lla 5 - 1 0 % b e n h nhan.

- S ta p h y lo c o c u s s a p ro p h y tic u s : 5 - 10% b e n h nhan.

- P s e u d o m o n a s a e ru s g in o s a 1 - 2% ben h nhan.

- S ta p h y lo c o c u s a u re u s : 1 - 2% ben h nhan.

b N g u y e n n h a n th u a n la i

- Phi dai tien liet tu y e n h o a c u tu ye n tie n liet

- Soi, u ban g qua ng

- D ie u tri co th e dun g m o t tro n g n h u n g th u o c sau:

+ N h o m trim e th o p rim - su lfa m e th o x a z o l: vi du B iseptol, L yse p to l vie n 4 8 0 m g , ngay uong 3 vien chia

2 lan, uon g tro n g 5 ngay

+ N hom beta lactam in: vi du a m o xicilin vien 500m g, ngay uong 4 - 6 vien, chia 4 lan, uong trong 5 ngay.+ N hom c e fa lo s p o rin th e he 2: vi du ce p h a le xin : vien 5 00 m g, n ga y uong 3 - 4 vie n chia 3 lan, uong trong 5 ngay

+ N h om hoa c h a t sa t kh u a n : v i du n itro fu ra n to in vien 50m g, n ga y uong 4 vien chia 4 lan, uong tron g

10 n ga y h oa c M icta so l b lu e 5 0 0 m g n ga y 4 vien chia 2 lan, uon g tro n g 10 ngay

- U ong du n u d e : lu o n g n u d e tie u tre n 24 g id duy tri k h o a n g 2 lit

- Neu sau 3 n ga y d ie u tri ben h khon g d d , can th a y doi p h a c do d ie u tri C o the dun g th u o c nhom fiu ro q u in o lo n : N o ro xin , F lo xin vie n 4 0 0 m g , ngay uong 2 vien T h d i g ia n dun g th u o c tru n g binh tu 3 - 5 ngay D a c biet ben h nha n can d u o c kh a m lam sang va lam c a c xet n g h ie m can lam sang de tim cac nguyen nhan th u a n lo i (phi dai tie n liet tuyen, soi bang q u a ng, .) va x e t n g h ie m vi khua n (soi tu o i, nhuom g ram , cay)

2 D ie u t r j th e v ie m b a n g q u a n g c l p c o n g u y e n n h a n th u a n lo ’i

+ D ie u trj v ie m b a n g q u a n g c lp co ngu yen nhan th u a n lo i se kho kh a n h o n T o t n h lt la lu a chon khang sinh th e o kh a n g sin h d o neu co ket qua cay n u d e tieu, d o n g th d i die u tri loai bo nguyen nhan thuan loi

+ T h d i gian dieu tri tru n g b in h nen tu 10 - 1 4 ngay

+ C o the d u n g k h a n g sin h d u d n g tie m hoa c d u d n g uong

+ Neu dun g d u d n g tie m chi nen d u n g tro n g 3 - 5 ngay, sau do tie p tu c b ln g d u d n g uong

2 - 3 Iq, ch ia 2 - 3 lan, tie m b ip sau hoac tin h m ach ch a m tro n g 3- 5 phut T iem tro n g 3 - 5 ngay, sau do

d e n sa y th a i h o a c d e non C u n g can chu y d a c biet kho n g d u n g n h o m q u in o lo n ch o phu n ij co thai vi

a n h h u d n g td i s u p h a t trie n x u o n g sun cua tre

5 7 8 H u O n g d A n c h A n o o A n v A b i £ u t r i b E n h NOik h o a

4 D id u tr j v ie m b a n g q u a n g c a p h a y ta i p h a t

B ?nh nhan d u a c coi la hay tai p ha t khi co tu 4 d o t nhie m khu a n tie t nieu trd len tro n g 1 nam Sau dieu tri tan cong can tie p tu c dieu tri d u y tri C o th e d u n g m o t tro n g c a c p h a c d o sau

- D ung m pt lieu khan g sin h tru ’d c h oa c sau m oi lan g ia o ho’P, neu n hiem khu a n lien q u a n den quan

he tin h due, vi du:

+ Biseptol: 4 8 0 m g x 2 vie n h oa c

+ N oroxin: 4 0 0 m g x 1 vien

- D ung lieu th a p kh a n g sin h (thu’d n g 1/3 lieu), uong va o buo i toi tru ’d c khi di ngu, keo dai ti> 3 6 thang V i du:

+ Biseptol: 4 8 0 m g x 1 vie n tru ’d c khi ngu hoac

+ N oroxin: 4 0 0 m g x 1/2 vie n tru ’d c khi ngu hoac

+ C e p h a le xin : 2 5 0 m g x 1 vie n tru ’d c khi ngu hoac

+ N itro fu ra n to in : 50m g x 1 vie n tru ’d c khi ngu

- U ong du nu’d c

IV PHONG BENH

- C an g id ve sinh bo pha n sinh due ngoai

- Uong du nu’d c de da m bao lu p n g nu’d c tieu > 1,5 lit/24 g id , di tieu deu dan thu’d n g xuyen 4-5 gio/lan

- D ieu tri loai bo n g u ye n nha n th u a n loi

1 "B enh h o c n $ i khoa", ta p I (2 0 0 7 ), N h a x u a t ban Y hpc.

2 "B enh th a n " (2008), N h a x u a t ban Y hoc.

3 “ Texbook o f N e p h ro lo g y " (2002).

4 "O xfo rd te x tb o o k o f c lin ic a l n e p h ro lo g y ” (2005).

VIEM THAN - BETH AN CAP• •

• N g u ye n nha n g a y b e n h - N h ie m khuan tie t nieu n g u o c d o n g tro n g tru d n g h o p tra o n g u o c bang quang - nieu qua n, sau khi soi b a n g q u a n g - nieu quan, ch u p th a n n g u o c don g (U PR )

- Sau pha u th u a t he tie t nieu

- T i c n gh en d u ’o n g tie t nieu d o soi, khoi u, hoi c h im g ch o noi, x o sau p h u c m ac, hep be than - nieu quan va co thai,

- C o o vie m khu tru: v ie m ban g quang, viem tu ye n tie n liet, vie m tru e tra n g , vie m ruot th u a , viem phan phu,

Benh th u d n g x u a t hien d o t n g o t v d i n h u n g bieu hien sau:

+ H oi c h u n g n h ie m tru n g : so t cao ret run, co th e th a n h c o n 39°C - 4 0°C , ke m th e o dau dau va m et moi, m oi kho, lu d i ban, co th e m a t n u d e do so t cao Neu kh o n g p h a t hien va dieu tri kip th d i se bi soc nhiem khuan

+ Hoi c h u n g b a n g q u a n g cap: dai buot, dai rat, dai kho, dai m au, dai due, dai m u la n h u n g dau hieu

s d m tru d c khi co bie u hien V T B T cap

+ D au: dau hon g lu n g , m a n g s u d n nhieu, co cam u n g khi s d va o , th u d n g d a u m o t ben, hiem khi hai ben C o th e x u a t hien c o n dau qua n than

+ V o hon g lu n g (+): dau hieu lam sang hay gap tro n g V T B T cap

+ C h a m th a n , b a p b e n h th a n (+/-), co the s d th a y th a n to

b C a n la m s a n g

+ C o n g th u c m au: so lu o n g bach cau ta n g ro ret, d ac biet ta n g b a ch cau da nha n tru n g tinh

+ C a y m au cap: neu so t ca o > 39°C -4 0 ° C kem th e o ret run, k h o a n g 8 0 % c a c tru d n g h o p nhie m trun g

5 8 0

tie t nieu do vi khua n G ra m (-): E coli, it gap h o n la E n te ro b a cte r, K le bsiella, P ro te u s va P se u d o m o n a s

+ P rotein nieu thu’O’ng < 1g/24 g id

+ Te bao nieu: co te b a o m u, nhieu te b a o bach cau, hon g cau

+ C ay vi khua n nieu (+) s 1 0 0 0 0 0 vi k h u a n /m l nu’d c tieu, cu n g co khi (-) T ru d n g ho’P c o n dau khong dien hinh, can pha i ca y vi khua n nieu de xa c dinh ch a n doa n va co kh a n g sin h d o ch o dieu tn

+ Sieu am : dau hieu gia n dai be than, gian nieu qua n, h in h anh soi th a n - tie t nieu, khoi u chen ep

la nguyen nhan g ay V T B T cap se d u o c p h a t hien de dang

+ C h up bung khon g ch u a n bi: neu nghi n g d co soi th a n -tie t nieu

+ C hup th a n nieu qua n co th u o c can q u a n g (U IV ): tien han h sau khi tin h tra n g sot n hiem trun g da on dinh de tim kiem n g u ye n nhan

+ C h up bang q u a ng: tien hanh sau khi tin h tra n g n h iim tru n g da d u o c gia i q u y e t neu nghi n g o co tra o n g u o c bang q u a n g - than

2 C h a n d o a n p h a n b ie t

Can phan biet V T B T cap v d i d o t cap cua V T B T m an: tien s u n h ie m kh u a n tie t nieu tai phat nhieu lan, co ngu yen nhan th u a n lo i (s o i ), ta n g hu ye t ap, kha nang co d a c n u d e tieu giam , c h u c n§ng th§n suy giam ,

III 0 l£ U TRj VIEM TH AN - B £ TH AN C AP

1 N g u y e n ta c d ie u tr j

• Neu sot cao ret run can dieu tri noi tru, ca c tru d n g h o p nhe co th e die u tri va th e o doi ngoai tru Can cay vi khua n nieu, m au (neu co sot ca o ) tru d c khi b i t dau d u n g kh a n g sinh T rong khi c h b d o i ket qua cay vi khuan co th e b at dau dun g khang sinh ngay Neu sau 3 - 5 n g a y d ie u tri, trie u c h u n g lam sang khong d d can dieu chinh kh a n g sinh th e o ke t qua cay vi khu a n va k h a n g sin h do

- M ot tro n g n h u n g th u o c k h a n g sin h d u o c lu a ch o n dau tie n d o i v d i V T B T kh o n g b ie n c h u n g trong

7 - 1 4 ngay ban g d u d n g uon g neu trie u c h u n g k h o n g nang:

+ A m oxicilin: 250 - 500m g x 3 - 6 vien/ngay, chia 3 lan, hoac

+ A m o xicilin + acid c la v u la n ic (u c ch e be ta - la cta m a se ): A u g m e n tin 5 0 0 m g x 3 vie n/n gay, chia 3 lan Neu tin h tra n g nang ch u ye n d u d n g tie m tin h m ach (TM ): 1g x 2 lo/ngay, c h ia 2 lan, hoac

+ C e p h a lo sp o rin (th e he 2, th e he 3): ce fu ro x im (Z in n a t) 2 5 0 m g x 2 vie n /n g a y, chia 2 lan cach nhau

12 g id , hoac

+ T rim e th o p rim - s u lfa m e th o x a z o l: B is e p to l 4 8 0 m g x 4 vie n ch ia 2 lan ca ch nhau 12 g id , hoac + F lu o ro q u in o lo n e : nh o m nay can lu u y khon g ch o phu n u co th a i va d a n g cho con bu, khon g cho tre

em < 15 tuoi, can g iam lieu d benh nha n suy than T h a n tro n g v d i b e n h nha n suy gan, hoac

• C ip ro flo xa cin 2 5 0 m g - 5 0 0 m g x 2 vien, ch ia 2 lan h o a c n o rflo x a c in 4 0 0 m g x 2 vie n chia 2 lan hoSc oflo xa cin 2 0 0 m g x 2 vie n ch ia 2 lan

- Ket h o p g iam dau ch o n g co that: N o spa, B u sco p a n , B a ra lg in ,

- Uong nhieu n u d e h o a c tru y e n dich du de da m bao lu o n g n u d e tie u n h ie u £ 1500 - 2 0 0 0 m l/2 4 g td Neu tin h tra n g lam sang kh o n g tien trie n to t (hoi c h u n g n h ie m tru n g ro, van sot, n u d e tieu due <Jau

m at n u d e , .), nen c h u ye n v a o dieu trj noi tru h o a c c h u ye n len tu y e n tren

H i /(J n g d A n c h A n o o A n VA p i E u t r i b £ n h N p i k h o a

- C e fo ta x im 1g x 3 lan/ngay, tie m TM Hoac:

+ C e ftria x o n 1 g /n g a y tie m TM Hoac:

+ C e fo p e ra z o n (C e fo b is ) 1-2g x 2 la n /n g a y tie m TM Hoac:

+ F lu o ro q u in o lo n d ird n g uong: tro n g 3 - 7 ngay, co th e td i 10 ngay

- C ip ro flo x a c in 2 5 0 m g - 50 0 m g x 2 vien, chia 2 lan, hoac:

- N o rflo xa cin 4 0 0 m g x 2 vie n chia 2 lan, hoac:

- O flo xa cin 2 0 0 m g x 2 vie n ch ia 2 lan trong

- C o th e tru y e n 3 ngay, sau do ch u ye n sang du’d n g uong tiep C an lu’u y: th u o c co the gay ra roi loan tieu hoa nhu1 non, buo n non va khon g du’O’c dun g cho phu n ir co thai, tre em du’d i 15 tuoi

+ Ket h g p v d i m o t tro n g c a c th u o c tre n v d i nhom a m in o g ly c o s id tie m tTnh m ach (TM ) h oa c tiem bap (TB): g e n ta m ic in h o a c to b ra m ic in 4 - 6 m g /k g /2 4 g id T h a n tro n g v d i n g ird i gia, can giam 1/2 lieu d n g u d i suy than co m ire loc cau th a n d ird i 30 m l/p h u t

• N eu c a y nu’d c tieu co tru e kh u a n G ram am (-): c e p h a lo s p o irin th e he 3 h o a c flu o ro q u in o lo n

• Neu ca y n ird c tie u co vi kh u a n G ram d ira n g (+): a m o x ilin /a m p c illin 1g x 6 la n /m o i 4 g id tiem TM

Co the ket h a p v d i n h o m a m in o g ly c o s id de ngan chan nguy c a n hiem vi khu a n d u d n g ruot tron g khi c h d

d a i ket q u a ca y m au, nu’d c tie u va co khan g sinh do

• Neu kho n g co bien c h irn g , h et sot, t ir ngay th ir 10 den n ga y th ir 14 c h u ye n sang khan g sinh du’d n g uong K h a n g sinh d u y tri tro n g 3 tu a n ke ca khi dien bien lam sang da d u a c cai th ie n n ha nh chong Can cay n ird c tieu kie m tra lai sau 1 tu a n n g u n g thuoc

• Neu v ln sot, vi k h u a n nieu ton tai 48 g id den 72 g id h oa c tie p tu c co dau hieu nhie m tru n g sau 3 ngay dieu tri, can tim kie m ta c ng h e n , o nhiem tru n g lan rong h o a c h in h th a n h o ap xe than Sieu am , chup c i t Idp (C T ) th a n co th e p h a t hien d ira c vi tri ta c n gh en va o ap xe q u a n h th a n de co ch i dinh ngoai khoa dan lu'u

• N goai c a c th u o c k h a n g sin h can pho i h a p them :

- Bu du dich b a n g du’d n g u o n g va h oa c du’d n g tru ye n TM : N aC I 9%0 h o a c R in g e r la cta t 5% , g lu co se 5% dam bao lira n g nu’d c tie u > 5 0 m l/g id

- G iam dau, gia n c a tra n khi dau:

+ P h lo ro g lu c in o l h yd ra t, trim e th y lp h lo ro g lu c in o l: S p a sfo n vie n uon g - dat, ong tie m x 4 lan/ngay.+ P a p a ve rin h y d ro c h lo rid vie n uong, ong tie m x 2-3 lan/ngay

+ T iem o niu m m e tylsulfat: V is c e ra lg in e vien uong, ong tiem x 1 - 3 lan/ngay

3 M o t s o tru ’d n g h g p k h o n g d ie n h in h

- C ay vi kh u a n kh o n g m oc: d o ta c n gh en n u d e tieu hoa n to a n vi kh u a n kh o n g di ch u ye n d im e hoac

da dung kh a n g sin h tru ’d c do C h i d jn h ch u p U IV cap co th e d ira c d a t ra de x a c m in h chan doan

- D ien bien lam sa n g kh o n g th u a n la i m ac du da dieu trj: tin h tra n g to a n th a n kho n g cai th ie n h an ,

c h ira c i t so t co c h i djn h c h u p U IV cap de xe m xe t d ie u trj can th ie p n g o a i khoa

- T ru ’d n g h a p dai - be th a n g ia n kem th e o kho n g d a p irn g th u o c ca n xe m xe t ch u p U IV de tim ngu yen

n ha n g a y ta c n g h e n c a g id i va th a n trp n g chi djn h ngo ai khoa

- M oi th a m d o h in h th a i k h a c ch i tien hanh sau khi de

b V T B T ca p tai p h a t n h ie u lan

- M oi lan tai p ha t se lam bien dan g dai than, tai p ha t nhieu lan se g a y x a hoa va te o nhu m o th^n

- Nen dieu tri kha n g sinh keo dai de d u p ho ng tai p ha t va tim n g u ye n nha n

c VTB T cap vd n ie u

- C o the do ta c n gh en a th a n duy nhat co c h u c nang hoat d o n g h o § c d o so c n h ie m khuan

- C a hai tru’d n g h a p deu rat nang va tien lu’a n g tu vong cao

- G iai q u ye t n g u ye n nhan t i c ngh en la c h i dinh cap c d u

5 T h e o d o i s a u g ia i d o a n d ie u tr j

- N eu dap d n g th u o c to t va kho n g con trieu c h d n g lam sang, c a y vi k h u a n sau 5 ngay n g u n g thuoc neu khon g m oc coi n h u da khoi

- Neu khon g d a p d n g tot, sau 2 tu a n dieu trj, can thiet: ch u p X q u a n g , c a y lai n u d e tieu de xet can

th iep soi va ap xe q u a n h th a n neu co

- Neu khon g co bat th u d n g d he tie t nieu: dieu trj lai b in g kh a n g sinh k h a c pho i h a p tro n g 2 tu in

- N eu benh nhan tcii p h a t v d i vi khua n cung loai: tie p tu c dieu trj 6 tu in

6 D i iu t r j diF p h o n g

- C in die u trj trie t d e khi co n h ie m k h u in tie t nieu d u d i

- D ie u tri s d m ca c n g u ye n nhan g ay nhiem k h u in tie t nieu, g ay t i c n g h e n d u d n g tie t nieu

- U ong du n u d e han g ngay, khong nhjn tieu

3 K r ie g e r J N U rin a ry tr a c t in fe c tio n s ‘ W h a t's new ?", J U rol 2 00 2; 168: 235 1-8

4 P a n g o n B, C h a p la in C, “P y e lo n e p h h te aig u e : b a c te rio lo g ie e t e v o lu tio n d es resistances’,

P a th o lo g ie B io lo g ie 2003; 51: 503-7

5 U rin a ry tr a c t in fe c to n s , “The M e rc k M a n u a l e ig h te e n th e d itio n 200 6: 1968 - 1975'

R e co m m a n d a tio n s

SUY THAN CAP

I OjNH NG HIA

Suy th a n ca p la tin h tra n g g ia m m u’c loc cau th a n d o t n go t x u a t hien tro n g vong tu vai g io den vai ngay do c a c n g u ye n n h a n c a p tin h g ay ra C h o den nay, ca c nha th a n hoc tre n the g id i c h u a d u a ra du’o c m ot dinh n g h ia th o n g n ha t ve tieu chua n chan doa n suy th a n cap va chu yeu thu’O’ng d u a vao toe do gia ta n g c re a tin in m au Khi toe d o gia tang nong do cre a tin in h u ye t th a n h Ion h o n 4 5 p m o l/l tron g vong 24 den 4 8 g io ke m th e o c a c dau hieu lam sang n h u dai it, vo nieu th i co th e chan doa n xa c dinh

(y phan chan d o a n va d ie u trj nay, c h u n g toi khong de cap den c a c doi tu o n g ben h nhan nang can d u o c

nam dieu tri ta i kh o a H oi s u e tic h cu e

- D o n h ie m tru n g (n h ie m tru n g huye t, vie m th a n -b e th a n c lp , )

- D o m o t so n g u y e n n h a n khac: th u o c g iam dau, th u o c c h o n g co giat

• M o t so n g u ye n nha n b e n h li m ach m au than

- C ry o g lo b u lin huye t

584 H u O n g d A n c h A n o o A n v A d i £ u t r i b £ n h N O i k h o a

- T a c m ach than

- B enh W egne r

- N h om ngu ye n nhan sau than:

+ C a c ngu ye n nhan ta c nghen sau th a n dot ngot: soi, u

III D l£ u TR!

1 N g u yen t i c ch u n g

- N hanh ch o n g loai b o ngu ye n nhan neu co the

- C o g in g phu c hoi so lu a n g n u d e tieu

- D ie u tri trie u c h u n g phu h a p v d i tu n g giai doa n cua benh

- C h i dinh loc m au d u n g luc khi can

2 D ieu trj th e o giai d o a n benh

a G ia i d o a n tan c d n g cu a tac n h a n g a y b en h

- C o gan g dieu tri loai bo ngu ye n nhan gay benh: bu du n u d e khi co m a t n u d e , loai bo t i c nghen

d u d n g tieu, ru a da d ay khi uong m at ca t r im tro n g 6 g id d iu

- T h e o doi sa t tin h tra n g th ie u nieu, vo nieu de co c h in doa n suy th a n c lp sd m

b G ia i d o a n d a i it vd n ie u

• G iu can b ln g n u d e , dien giai:

- N u d e d benh nhan vo nieu, dai it da co phu, dam bao can b in g (-): lu a n g n u d e va o it han luang

n u d e ra

- L a i tieu: dung la i tieu q u a i fu ro se m id do lieu Lieu k h d i d iu co th e 4 0 - 8 0m g Lieu toi da 1000mg Khi t h ly benh nhan co th e da dai d u a c khon g do thuoc, phai d u n g n g a y la i tie u vi sau do benh nhan co the dai r i t nhieu (> 10 lit) T h d i gian ta c dung cua fu ro s e m id d u d n g tie m keo dai 4 g id

• D ie u tri ta n g kali m au:

- Han che d u a K + vao: rau q u a nhieu K*, thuoc, dich tru ye n co K*

- Loai bo c a c o hoa i tu , ch o n g n hiem k h u ln

- T huoc:

+ C a lc ig lu c o n a t h oa c clorid: c in tie m tin h m ach ngay khi K* m a u ca o > 6 ,5 m m o l hoac khi co nhung bieu hien tim m ach ro (m ach cham , loan nhip, Q R S gian rong), lieu tru n g b in h 1 g, tie m tin h m ach cham tro n g it n h lt 5 phut N h lc lai lien sau 30 p hu t khi c in

+ G lu co se ket h a p in su lin d in kali vao tro n g te bao, b i t d iu ta c d u n g sau k h o a n g 30 phut Luong

d u a va o kh o a n g 2 0 0 - 2 5 0 m l dun g dich g lu co se 20% co th e g ia m d u o c 0 ,5 m m o l/l kali

+ T ru ye n h oa c tie m tin h m ach cham natri b ica rb o n a t khi co to a n m a u de han ch e kali di tu tro rg te bao ra ngo ai te bao

+ R e sin tra o doi ion q u a m em m ac ruot: R e sin ca lcio , R e s in s o d io c u m oi 15g uong phoi hop ven

S o rb ito l co the g iam 0 ,5 m m o l/l T h u o c p ha t huy ta c dun g sau 1 g id N e u b e n h nha n khong uong d u o c

co the th u t th u o c qua hau m on (1 0 0 m l dich d in g tru a n g )

+ L o i tie u thai n u d e va kali

+ Lpc m au c lp : khi d a n g con th ie u nieu, vo nieu, K* > 6 ,5 m m o l/l

• D ie u tri ca c roi loan d ie n giai kh a c neu co

• Han ch e ta n g m ta phi p ro te in m au:

- C h e do an g iam dam

- Loa i bo o n hiem k h u ln

H u o n g d A n c h A n o o A n v A o i £ u t r i b E n h N d i k h o a

• D ie u tri c h o n g to a n m au neu co

• D ie u tri c a c trie u c h u n g va bien chipng khac neu co: ta n g hu ye t ap, su y tim

• C h i din h loc m a u cap

- K hi d a n g con th ie u nieu, vo nieu

- Khi dai < 3 lit, kh o n g co roi lo an die n giai nang: cho uong O reso l

- Sau k h o a n g 5 n g a y neu ben h nhan van dai nhieu cung se han ch e lu’a n g dich tru ye n va uong vi than da co th e b at dau p h u c hoi c h d c nang co dac T h e o doi sat nu’d c tieu 24 g id de co thai do bu dich

IV PHONG BENH

- H an ch e toi da c a c th u o c g ay d oc cho than Khi cho th u o c can th e o doi c h u c nan g than

- D uy tri du th e tic h tu a n hoan, g ay ta n g bai nieu khi co n g u y c a ca o cua suy th a n cap: sau phau thuat, sau ch u p X q u a n g co tie m th u o c can qua ng,

- G iai q u y e t s d m c a c n g u ye n nhan g ay t i c nghen d u d n g nieu

VIEM CAU THAN LUPUS

I.O jN H NGHIA

Lup us ban d o he th o n g la m ot benh t y m ien dien hinh Bieu hien ton th u ’a n g th a n rat th o a n g gfip

a n h a n g benh nhan (B N ) lu pus ban do he th o n g m a ton thu’a n g chu yeu la a cau than Viem cau thdn (V C T ) lu pus da du’a c nhieu ta c gia coi la m o t m au h in h ben h li kie u "p h a c h a p m ien d ic h ’ , do la dap

u n g qua m an typ 3 T h e o nhieu ta c gia thi ti le bieu hien th a n a BN lu p u s d a o dQng ta 60-75% Suy than nang co th e g ay t a vong a n h a n g d o t cap, nhieu tru a n g h a p tie n trie n den s u y th a n giai doan cuoi can phai dieu trj th a y th e th a n suy

II CHAN D O AN XA C D jN H

C h an doa n xa c dm h V C T lu pus pha i k h in g dinh d u a c 2 yeu to sau:

1 D u tie u c h u an c h a n do an lu p u s ban do he th o n g th e o tieu c h u a n q u o c te (xem bai lupus).

2 C o t o n t h u ’O’ n g c a u t h a n b i e u h i e n b a n g p r o t e i n n i e u t h u a n g x u y e n v a / h o a c h o n g c a u , tru

h a t m a c h u y e u la t r u h o n g c a u

Q u a kinh n g h ie m lam sang va sinh th ie t than, khoa T h a n -T ie t nieu, B e nh vie n Bach Mai da dua ra

n h u n g kinh ng h ie m chan doa n vie m cau th a n lu pus n h u sau:

+ C o bieu hien vie m khon g d a c hieu:

- S ot keo dai khon g ro ngu ye n nhan nhiem khuan, d ac biet la lao

- Toe do m au lin g tang, g a m a g lo b u lin m au tang

+ C o 4/11 tie u c h u a n chan doa n lu p u s ban do he th o n g tro n g do co 1 tieu ch u a n ve m ien dich hoc [h o a c khan g th e khan g nhan (+) h oa c khan g th e kha n g D N A (+) h o a c te b a o LE (+)]

+ Bieu hien than: p h a i co p ro te in nieu d u a n g tin h 1 (+) tra len ( > 0 ,2 g /2 4 g ia ), co the co kem theo hong cau nieu, tru nieu

- C an nha c g iu a ta c d u n g c h in h va ta c dung phu cua thuoc

- N eu co d ie u kien, dieu trj d u a tren phan loai m o ben h h oc la to t nhat

- D ie u trj ca c bieu hien n g o a i th a n cua ben h lupus

2 M u c tieu cu a d ieu trj

- N h a n h c h o n g p h u c hoi c h u c nan g than

-T ra nh g a y ton th u a n g th e m cho than

H u o n g d A n c h A n b o A n v A b i E u t r i b £ n h N O i k h o a

- H an c h e tie n trie n den su y th a n m an tin h

- D a t du’O’c 3 m u c tieu tre n b ln g ca c lieu pha p m ien dich v o i it d o c tin h nhat

3 D ie u trj cu th e v ie m cau th an lup u s

P hu th u o c rat nhieu va o th e ton th u a n g m o benh hpc

a D ira tre n to n th u ’O’n g m o b e n h h p c th a n th i d ie u tri cd th e to m t i t nhu> s a u

- V ie m cau th a n lu pus c la s s I c h i dieu tri nhCrng bieu hien n g o a i than.

- V ie m ca u th a n lu p u s cla ss II: dieu tri n h u n g bieu hien n g o a i th a n Khi co tin h tran g lam sang nang, can sinh th ie t lai than N e u co th a y doi ve the ton th u a n g m o b e n h hpc th a n se dieu tri n h u th e ton

th u o n g (cla ss) m a i

- V ie m cau th a n lu p u s c la s s III: ton th u a n g nhe chu yeu die u tri b in g lieu pha p co rtico id Neu ton

th u a n g nang die u tri n h u v ie m cau th a n lu pus typ IV

- V ie m cau th a n lu p u s c la s s IV-V: la th e nang nhat, can dieu tri tic h c u c C o nhieu th u o c u c che m ien dich co th e lu a c h p n tu y th u o c v a o BN co chong ch i djnh v a i nh o m nao:

+ P re d n is o lo n (h o a c c u n g nho m tin h lieu tu o n g d u a n g ) 1 m g /k g /2 4 g ia h o a c 2 m g /k g /c a c h ngay tro n g

3 - 6 th a n g , kh o n g q u a 8 0 m g /n g a y va khon g qua 120m g ca ch ngay

+ Lieu uon g c y c lo p h o s p h a m id (E n d o xa n ) h oa c a z a th io p rin (Im u re l) tan cong (3 m g /kg /2 4 g ia ) tron g

2 - 3 thang, h o a c c y c lo s p o rin A (3 - 4 m g /k g /2 4 g ia ) tro n g 3 th a n g h oa c h on

+ Neu BN kh o n g d a p u n g (van con d ay du hoi c h u n g th a n h u neu la vie m cau th a n lu pus co hoi

c h u n g th a n h u ), d a p u n g kem h o a c co bieu hien lam sang nang n ga y tu dau (thieu nieu, vo nieu, tin h trang suy th a n n a n g ) co th e d u n g m e th y lp re d n is o lo n hoa c c y c lo p h o s p h a m id th e o lieu trin h n h u sau:

- M e th y lp re d n is o lo n lieu xu n g (pulse ): lieu tru n g b in h 3 0 m g /kg /n g a y, lieu toi da co th e ta i 1000m g, pha tro n g dun g d ich g lu c o s e 5% tru y e n tin h m ach ch a m tre n m o t g io , 3 n g a y lien tuc, sau do tie p tu c lieu uong 0,4 - 0 ,5 m g /k g /2 4 g ia , co th e n ha c lai m oi th a n g 1 lieu d a n (1 nga y) tro n g 6 thang

- C yc lo p h o s p h a m id : d u n g (0 ,7 g - 1g/m 2 dien tic h c a th e ) pha tru y e n tin h m a ch tu 30 phut den 2 g ia tuy th e o lieu d u n g 1 th a n g m o t lan tro n g 6 th ang, sau d o 3 th a n g m ot lan ch o den khi d a t d u p e hoi phuc

b T ro n g d ie u k ie n & V iet N a m c h ira s in h th ie t th a n d irp ’c c h o ta t ca cac B N viem cau th an lupus, vie c d ie u trj c d th e x e m x e t n h ir sau :

- BN kho n g co trie u c h u ’ng la m sang, c h i co roi lo an nhe ve n u o c tieu: p ro te in nieu d u a i 1 g/24 g ia ,

khong co hon g cau nieu h o a c hon g cau nieu it: dieu trj chu yeu la die u trj c a c b ie u hien ngoai than

- B e nh nhan co hoi c h u n g cau th a n cap: co th e chpn 1 tro n g ca c p h a c do sau:

+ P re d n iso n u o n g 1 - 1 ,5 m g /k g /2 4 g ia hang ngay h oa c ca ch nhat, tru n g b in h k h o a n g 1 , 5 - 2 thang, cung co th e ke o dai 3 th a n g h o a c h a n , kho n g v u a t q u a 6 thang Lieu han g n g a y khon g v u a t qua 80m g Lieu ca ch n g a y tan co n g kh o n g nen v u a t qua 120m g Sau do, g ia m lieu dan x u o n g lieu cung co b ln g

n u a lieu ta n co n g va d u y tri co th e hang nam v o i lieu th a p < 2 0 m g /2 4 g ia

+ C y c lo p h o s p h a m id 2 ,5 - 3 m g /k g /2 4 g ia kh o n g v u a t q u a 4 m g /k g /2 4 g ia D ie u trj tan cong tron g 1,5

- 2 th a n g , sau d o g ia m x u o n g lieu cung co bang n u a lieu tan co n g va d uy tri lieu th a p kho a n g 50m g/24

g io , th o i g ia n die u trj k h o n g nen q u a 1 nam

T £ c d u n g phu: g ia m b ach cau, suy b u o n g tru n g , vo tinh tru n g , v ie m b a n g q u a n g ch a y m au, ung th u bang qu a n g

+ A z a th io p rin (Im u re l) u o n g lieu 2 ,5 - 3 m g /k g /2 4 g ia tu 1,5 - 2 th a n g , sau do g ia m x u o n g lie u cung

co b a n g n u a lie u ta n c o n g va d u y tri lieu th a p 5 0 m g /2 4 g ia tro n g 1 n a m h o a c h a n neu BN d u n g nap

588 H u o n g d a n c h a n d o A n v A d i £ u t r i b E n h NOi k h o a

(khoang 2 0 m g /2 4 g ia ) neu dieu tri co rtico id ; ca c th u o c ire ch e m ien d ich k h a c it ta c dun g Sau d o giam xuon g lieu d uy tri k h o a n g 2 m g /k g /2 4 g ia co the hang nam Tuy nhien, b e n h cu n g hay tai phat sau khi giam lieu hoa c d irn g thuoc

Tac dung phu: su y gan, suy than, tang n gu y c a ung th ir

+ M y co p h e n o la t m o fe til (C E L L C E P T ): du’a c dun g rong rai tro n g ch o n g d a o th a i ta n g g h e p G an day

M M F d ira va o dieu tri vie m cau th a n lu p u s do lam g iam p ro te in nieu va h o n g cau nieu, d ira nong do bo the ve m ire bin h th u ’a n g , ta n g nong do alb u m in m au, ti le tai p ha t th a p va it ta c d u n g phu Lieu dung ban dau t ir 2 -3 g /2 4 g ia , ire che co the dun g keo dai ta i 12 thang

+ C o the pho i h a p co rtic o id v a i ca c th u o c ire che m ien dich kh a c v a i lieu tru n g b in h th o a n g bang

n ira lieu tan cong

+ C an nhac dieu tri b ln g tru y e n lieu cao m e th y lp re d n is o lo n h oa c c y c lo p h o s p h a m id (xem phan tren) ngay ca khi khon g co m o ben h hpc tro n g trira n g h a p kho n g d a p irn g v a i m o t tro n g ca c bien phap dieu tri neu tren

+ C ac p h u ’a n g pha p m a i dieu tri V C T lupus

- K h ang th e d a n d o n g (R itu xim a x ): tieu diet te bao lym p h o B (du’a c c h o la co va i tro tru n g tam)

- Lpc hu ye t tira n g h o a c th a y h u ye t tu ’a n g (p la s m a p h e re s is -p la s m a e x c h a n g e ): th a y 3-4 lit huyet tu’a n g m oi tu a n bang h u ye t tira n g hay san pham th a y the O u’a c c h i dinh d a c biet ch o nhCrng BN co

b in g c h irn g tang ro ret p h irc h a p m iln dich lu’u hanh D o n g th a i van pha i ke t h a p dieu tri tan cong b in g

co rtico id va ca c th u o c ire ch e m ien dich

c D ie u t r i c a c b ie u h ie n n g o a i th a n va b ie n c h u ’n g c u a lu p u s b a n d o h e th o n g

- NhCrng bieu hien n g o a i th a n nang h a n bao gom vie m k h a p kh o n g d a p irn g v a i th u o c khang viem

giam dau khon g stero id, vie m tra n dich m ang tim , m ang phoi; v ie m c a tim , bie u hien nao, viem phoi do

lu pus can s ir dun g lieu p h a p co rtico id va dieu tri ho tr a th e o ch u ye n kh o a , tu y th e o tin h trang cua BN

- NhCrng BN vie m cau th a n lu pus bi suy th a n m an giai d o a n c u o i ca n die u tri th a y the than suy co the lira chpn m ot tro n g ca c p h u 'a n g pha p th a n nhan tao chu ki, lo c m a n g b u n g lien tu c ngoai tru hoac ghe p than Tuy nhien co th e xu a t hien vie m cau th a n tren th a n ghe p C h ii y: v in can dieu tri cac bieu hien ngoai th a n cua lu p u s bang ca c th u o c ire che m ien dich a nho m BN nay

IV PHONG BENH

BN can d ira c den kh a m ch u ye n kh o a th a n khi da co bieu hien vie m cau th a n do lupus, can d u o c bac

sT ch u ye n khoa tir van, d u a ra la i kh u ye n ve che do dieu tri, ch e d o sin h h o a t ch e do thai san va theo doi dinh ki

t A i lieu tham k h A o

1 W a ld m a n M, A p p e l G B, “U pdate on the trea tm ent o f lu pus nephritis", K idney Int 7 0 :1 4 0 3 -1412 2006

2 G e ra ld B A p p e l* , G a b rie l C o n tre ra s M y c o p h e n o la te M o fe til v e rs u s C yclo p h o sp h a m id e for

In d u ctio n tre a tm e n t o f L u p u s N e phritis J A m Spc N e p h ro l 20: 1103-1112, 200 9.

3 Y L ee , J H W o o , S C h o i, J J i a n d G S o n g "In d u c tio n a n d m a in te n a n c e th e ra p y fo r lupus

n e p h ritis", a s y s te m a tic re v ie w and m e ta -a n a ly s is

Lupus, M ay 1, 2 01 0; 19(6): 703 - 710

4 F re d e ric A H o u s s ia u , M a n a g e m e n t o f L u p u s N e p h ritis A n U p d a te A m S o c N e phrol 15

269*-2 70 4, 269*-2004

h o ic h u t n g t h• A• n h i /

I.D jN H NG HIA

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