Những xét nghiệm hóa sinh hiện đại sử dụng trong lâm sàng Phần 2

Tiếp nối phần 1 ebook phần 2 tiếp tục trình bày về các xét nghiệm: Xét nghiệm adrenomedullin, hs-CRP, Lp-PLA2, myeloperoxidase. Nhằm cập nhật các xét nghiệm hóa sinh, đồng thời phân tích ưu nhược điểm của từng xét nghiệm, nguyên tắc và phương pháp định lượng chúng,... Cuốn sách này sẽ giúp cho các nhà lâm sàng có thêm công cụ để chẩn đoán và điều trị bệnh lý nhiễm trùng và tim mạch.

52

ADRENOMEDULLIN

Nguyjn Thi Bang Strang

1 TONG QUAN YE ADRENOMEDULLIN

Nam 1993, Kitamura va CS de phan lap mgt peptide mad tir u to bao

ua crom (pheochromocytoma) cita ngugi va Tat ten la "adrenomedullin" (ADM) ADM kich ,thich san xuet AMP yang (cycle AMP) tieu ceu gu6i va tac Ong rat manh, keo dai trong viec lam ha huyet ap ix chugt hixc nghiem Ban dau, ngugi ta nghi rang ADM chi dugc tong hgp bgi cac to bao u, tuy nhien cac nghien,cdu sau d6 cho thy no ding dugc san uat b&i thugng than va nhieu ca quan khac Ngay nay, ngtx6i ta hang dinh tac dung dia ADM nhu 1a mot hormone luu hanh va chat trung gian can ti /et tai ch'6 vgi nhieu chirc nang sinh hoc quan trong 1.1 Ciu frac ciia ADM

1

Hinh 5.1 CSu trim phan tiv cua ADM

NHU'NG XET NGHIEM HOA SINH HIEN DAI SCP DUNG TRONG LAM SANG

ADM dm nguai Om 52 acid amin Cau true cila no Mang dOng \Ted peptide lien quan den gen calcitonin (CGRP- calcitonin gene-related peptide), calcitonin va amylin, tat ca deu thtli)c ding gia dinh peptide nay Phan t* ADM chira mot \Tong Om 6 acid amin dugc tao thanh bai can not disulfua gifia acid amin so 16 va 21 (hinh 5.1), clau C tan ciaa ADM la acid amin tyrosin dugc lien k6t amid (-CONH-) Ca hai dee diem eau trtic nay rat can thiet cho hoat dOng sinh hoc dm ADM 0 clang khong chira yang not phan t*, ADM clang gan vao receptor dm ADM nhimg khong có hoat tit-1h sinh hoc va no dugc sir dung nhu chat doi khong receptor dm ADM

1.2 Qua trinh sinh tong hcrp, bai tiet va chuyen h6a

ADM dugc ma hoa bai gen nam tren nhi6m sac th6 so 11, gen chira 4 exon va 3 intron Dau tien chd6i DNA cUa ADM ma hoa tao phan tit den ADM là preproADM, gem 185 acid amin Phan Ong phan cat doan peptide tin h* (Om 21 acid amin) tai vi trf gifra acid amin threonin (vi

*1 21) va alanin (vi tri 22) se giai phong phan tit pro ADM Om 164 acid amin Pro ADM sau do dugc enzym peptidase thily phan lam giai ph6ng ADM gom 52 acid amin va mot doan peptide khac a dau N ten Om 20 acid amin dugc goi 1a PAMP (Proadrenomedullin N-terminal 20 peptide) Ca hai phan tir ADM va PAMP &su có hoat tit-1h sinh hoc PAMP lam giam huyet dp khi truyen tinh mach chem, tuy nhien tac dOng

dm no yeu han so vai ADM Trong mot phan tich trinh tkr DNA cua preproADM nguai to phat hiO ADM dugc ma hoa bad exon thin 4 va PAMP dugc ma h6a bai exon thin 2 va thir 3 Trong qua trinh phan cat preproADM, phan tit ADM -glycin- mot dang trung gian dia ADM (iADM: intermediate form) dugc tao thanh Sau do iADM dugc chuyen thanh clang ADM throng thanh (mADM) nho' enzym xtic tac tao lien ket amid, bai vey mADM có cau trite amid a dau C ten Dang *tieing thanh cua PAMP dugc tong hop theo co che tuang tix nhu ADM (hinh 5.2) ADM có tiled gian ban hily ngan trong huye't thanh (khoang 22 phut)

va dugc dieu hoa bai enzym thily phan protein va nhiet do luu trir nen có the anh hiking den ket qua Ngoai ra, con mot vai yeu to khac c6 the lam ket qua xet ngh*n ADM khong chInh )(de do là lien ket vai protein lam irc the chuyen biet len ADM trong phucmg phap, thinnghi'01 mien dich

Hinh 5.2 Sinh tong hov ADM, PAMP va tac dung sinh 19 cue chiing

Mid-Regional proADM (MR-proADM) c6 47 acid amin, On , dinh rong tuan hoan han, duot tiet ra vai so Wang mol phan t* bang so mol illa ADM MR-proADM khong co hoax tinh sinh hoc nhu ADM, nen khOng bi anh huang bai enzym they phan protein Viec xac dinh nong dO VIR-proADM c6 the phan anh trgc tiep n,Ssng dO ADM trong mau benh

nhan

, Mix dO bieu hien mRNA dia ADM tang cao a tuy thuang than va bieu hien thap han a tam nhi, tam that dia tim, than, phi va nhieu yang khac ciia nao Gen ADM ding bieu hien a to bao not mac mach mau va

to bao ca Iran Qua trinh san xuat ADM dugc dieu Ma tang len bai cac tress

' oxy h6a, cac cytokine tin viem nhu TNF-a va IL-1, angiotensin II

a endothelin-1 Anh huang dm stress len sr bai tiet ADM bad te, bac) not

6 van dang gay tranh cai, Ca hai tac dung kich thich va iirc che deu da

&rot mO ta Tinh trang thieu ,oxy kich thich giai ph6ng ADM a in vitro

lan in vivo Tang &rang huyet gay tang bai tiet ADM mach mau thOng

NHU'NG XET NGHIEM HOA SINH HIEN DAI SO DUNG TRONG LAM SANG

qua protein kinase C, lieu nay c6 the la met trong nhfing nguyen nhan lam tang ADM huyet tuong 6 benh nhan dai than dueng Su truyen ANP (atrial natriuretic peptide) gay tang nong de ADM huyet tuong 6 nguei

Ca viec tang the tich mau cap va tang tai natri man Milt deu khong c6 bat

ky anh huong nao den nong de ADM huyet tuong Aldosterone kich thich san xuat ADM or to bao co trop mach mau O My thugng than, ADM dugc &mg thei bai tiet vo7 catecholamine sau cac kich Mich bai tiet acetylcholine Ngugc lai vai cac peptide khac, ADM kh6ng dugc du trix trong cac hat tiet (ngoai trir a to bao not tiet cua tuy) ma dugc phong thich ngay sau khi tong hop

Neng de ADM huyet tuong dao deng trong khoang 2-10pM Ltic dau nguei ta,nghi nong do cao cila peptide trong thugng than c6 the la nguen goc cua ADM huyet tuong, tuy nhien nhieu bang chirng cho thay khong phal nhu vay Thir nhat, trai ngugc yeti catecholamine, nong de ADM trong tinh mach thugng than khong cao hon trong tinh mach chit duai Thin hai, cac kich Mich sinh 13'T dieu hea bai tiet catecholamine va ADM cna thugng than nhu ha dueng mau va ha huyet ap khong anh hueng den 'tong de ADM huyet tuong Mat khac nong de ADM huyet tuong khong tang Mei gian bi u to bao ua crom, trong khi catecholamine nhanh chong dugc giai phong Hien nay nguei ta tin rang ADM c6 nguen gOc chit' yeu tit cac to bao not me trong cac giueng mach mau khac nhau,

T -)ng huyet tuong, ADM g&'n dac hieu vai protein-1 lien ket nay thugr, than

to

adrenomedullin ,binding protein-1), dugc xem nhu la yeu th be the H Vic gan yeu to H lam tang tac dung qua trung gian receptor cila ADM nhung lai tirc che hoat tinh khang khuan dec lap vai receptor

to

no Mat khac ADM lien ket se lam tang cueng hoat deng yeu te H, la chat dc che con dueng thay the hoat hoa be the Sr tuong tac ADM-yeu to H coy nghia quan trong Tru6c het, ADM lien k& vai ,protein khong dugc Oat hien bai hau het cac thuat xet nghim huyet thanh, nhu vay nong de ADM toan phAn trong huyet thanh c6 ie cao hon so vai con se thuc,te dugc bao cao bad cac nghien ciru TruOrc day, nguei ta dal timg de xuat rang nong de ADM huyet tuong qua thap de tac deng tren cac receptor dm to &de va rang tac deng cita ADM chi tai cite eh* khong phai là hormone luu hanh trong mau Quan niem

to

do ADM toan phan trong choang nhiem khuen huyet tren thuc te duoc danh gia rat cao trong cac nghien dru truec day Ngtroc lai vai ADM, ca CGPR (calcitonin gene-related peptide) va PAMP deu khong gen vei yeu to H

ADM luu hanh trong mau bi phan giai nhanh chong voi thai gian ban huy khoang 20 pinit Neng de ADM huyet thanh trong cieng mach chili thap lion trong deng mach phei, dieu nay goi y phi có the la not thanh thai chinh cila ADM Nong de ADM trong nuec tieu cao gap 15 len so

of trong huyet Wong ADM huyet tucmg de clang duvc loc qua tieu cau hen va sau do bi phan giai bei cac endopeptidase trung hoe c6 trong ang to bao ria ban chai cue Ong 'Iron gan Mee du then co lien quan den

su thanh thai ADM nhung cac nha nghien ciru cho rang, peptide trong 1.rec tieu co nguon goc tix su san xuat tai cho trong then chic khong phai

ix he thong tun hoan

.3 Receptor va cac co' che" tru34n tin WO

ADM hoat hoa va gen vei It nhet hai loai receptor lien ket protein G Met so tac dung dm ADM duot thuc hien qua trung gian cac receptor CGRP1 va bi ire the bei chat doi khang dee hieu vai CGRP1 la CGRP Cac receptor nay có di h„rc cao vei CGRP hen ADM Receptor ADM dee hieu bi de the bed ADM va co di luc vei ADM cao hen vei AGRP Nguoc lai, receptor CGRP khong gen vei ca ADM va CGRP 0 Ong de pmol, ADM co kha nang,gan vei receptor caa calcitonin va dm amylin, tuy nhien, khong chac chan khi cho rang do la co che sinh 157 quan trong trong tac deng cua ADM

Gen day, cau trtic phan to cue receptor ADM va receptor CGRP1 de duoc )(de dinh (bang 5.1) Ton tai hai loai receptor 6 mang to bao, thuec gia Binh peptide calcitonin la receptor calcitonin (CTR: calcitonin receptor) va receptor giong vari receptor calcitonin (CRLR: calcitonin receptor-like receptor), cau true chinh dm chting tucmg &Ong vei nhau den 55% Mei receptor nay ket hop vei met protein phu CO ten le RAMP (receptor activity-modifying protein) CO 3 loai deng phan cna RAMP de

NHU'NG XET NGHIEM HOA SINH HIEN DAI SO' DUNG TRONG LAM SANG

dugc xac dinh la RAMP1, RAMP2 va RAMP3 Cac protein RAMP ket hop \raj phan tir receptor trong Wed not sinh chat va tao dieu kin thuan lgi cho stx van chuyen chung ra mang sinh chat Ngoai ra, cac RAMP dieu,hea,mirc,d6 dm receptor glycosylation va có the la mot phan cna vi tri gin ket phi tir, quyet dinh tinh dac hieu cna receptor

CRLR ket hop \Teri RAMP 1, 2 hoac 3 tao thanh cac receptor tuong ang la CGRP1, ADM1 va ADM2 Tuang to nhu vay, CTR có the ket hop voi mot trong cac dang RAMP hinh thanh ba clang receptor dm amylin la AM1, AM2 va AM3 (hinh 5.3) Ngoai ra, CTR khong lien ket RAMP hoat &Ong vbi to cach la receptor cna calcitonin Mac du cac (fang phan RAMP có s‘r khac biet trong viec phan bo a cac mo nhung khong

co six khac biet ve dugc 15T gifra ADM1 va ADM2 hoac gifia ba loai receptor dm amylin

Trong nhieu loai to bao, ADM va receptor CGRP1 ket hop vai protein, G va adenylate cyclase Ngoai ra, ADM co the lam tang hoac giam n6ng do Ca' not bao d6c lap voi AMP veng ADM kich thich tong hop oxid nitric (NOS) trong to bao co tam that cna tho va t6 bao nOi mo ADM có the kich thich cac protein kinase hoat hoa phan bao (MAPKs: mitogen-activated protein kinases) trong to bao ca trop mach mau va irc che hoat dong cua MAPK a to bao trung mo Cuoi clung, ADM kich hoat kenh phu thu6c ATP trong to bao co trop mach mau d6c lap vai cac con dueng tin hieu khac da dugc de cap a‘ teen

Bang 5.1 CAu trim phan t:' dm receptor ADM va cac receptor lien quan

Ten receptor Phan tiv

receptor

Protein RAMP Kich thich

C GRP, CRLR RAMP! CUR!' > ADM ADM, CRLR RAMP2 ADM > CGRP ADM2 CRLR RAMP3 ADM > CORP

AM, CFR RAMP"_' Amylin

Ting iv atit try

ixPofe ets ate tnthrg C, Diwir

Hint ttett Ong

AA wr.ft, PKG

Sif Intimatbioi•

Cac th; 40.41:, oxy ve sytokanes,

;Mt ReMOW:

R/WP 3

;AtA2 Receptor

AC GC- PCLC Krp r.AMPGW: coo

PLC rakRet

P Mit() e126;AX•rAla

MC s R"""2 • ' • -

Pea row,h

Hinh 5.3 Tac dung &la ADM

Vai tr6 caa ADM trong qua trinh to kh6i u

viem trong su' di6U h6a bgu Wan va bai tit

Sy' hinh thanh kh6i u bang cach kich thich

qua cac y6u to can ti6t xung quanh mach m

2 HOAT TINH SINN HOC CUA ADM

2.1 Tic dung tren he tim mach

ADM lam giam huye't op do giam sirc can mach mau ngoai vi Di6su nay thugng di kern vod su tang cung lugng tim sau giam ha'u ganh Su giam slim can ngoai vi NIA huyet ap gay ra nhip nhanh do phan x4, tuy nhien, nhip tim tango mire do thap hem khi so \Ted viec dung cac thuOc

thong qua cac receptor

Vai tr6 caa thgu oxy va cac cytokine ADM &xi cac to boo u ADM kich thich t6 boo u tang tru'&ng va ton tai th6ng

au

NHU'NG XET NGHIEM HOA SINH HIEN DAI SU' DUNG TRONG LAM SANG

dan mach lam 114 huyet dp Trong thgc nghiem, ADM lam dan mach cua cac gigerng mach mau khac nhau va a cac loci demg vat khac nhau Co che tac dung dan mach cua ADM da &roc de cap trong,nhieu nghien dm Cac dir lieu cho thay ADM c6 the gay dan not mo bang cach tac clOng vao cac receptor CGRP1 va lam tang AMP yang trong cac to bao co tron mach mau

VI ADM duoc bai tiet bOi cac t6 bao not mo, no có the hog dOng nhu mot trong nhUng yeir to gay dan mach c6 nguOn goc not mo ADM cung

có the kich hog cac kenh, kali to bao co tron lam tang six phan cgc cua

to bao Ngoai ra, ADM gan voi receptor dac hieu a cac to bao not mo va gay dan mach not mo qua trung gian cua oxid nitric, yeu to phan cgc c6 nguOn goc not me (EDHF: endothelium-derived hyperpolarizing factor), va/hoac cac prostanoid dan mach ADM kich hog tong hop oxid nitric not mo (eNOS: endothelial nitric oxide synthase) beyi It nhat hai co che Thir nhat, ADM lam tang nong dO calci not bao, dieu nay lam tang hog Ong eNOS Thir hai, ADM hoat h6a enzym phosphatidylinositol 3-kinase (PI3K) - va protein kinase B/Akt, gay phosphoryl hoa eNOS va tang hoat dOng cua no ngay ca khi nOng dO Ca++ thap ADM cung c6 the irc che to bao not me, sari xuat yeu to co mach endothelin-1

ADM iirc che six den ch8 cua cac to bao co tron mach mau gay ra bai angiotensin II hoac yeu to tang trixOng co nguon goc tieu cau ADM c6 the dieu Ilea six tang sinh cua cac to bao co trop thanh mach NO kich thich six tang sinh cac to bao co trop thanh mach mot cach thu dOng,ma kh6ng co six tham gia cac yeu to kich thich khac, nhung no che six fang sinh gay ra bad PDGF hoac huyet thanh cua bao thai ADM irc che hien Wong chet to bao lap trinh cua to bao nOi mo gay ra bai sg thieu tuai

mau Tac dung nay qua trung gian bai oxid nitric nhung khong phu thuOc vao GMP yang Mat khac, ADM kich thich tang sinh to bao not mo - qua trinh tham gia vao six tao mach va tai tao not mac cua mach mau bi ton thuang Anh htrang dm ADM tren chu kST to bao mach mau rat quan trong trong six tai tao ,mach mau trong tang huyet clOng mach hoac trong qua trinh phat trien tai hep sau phau thuat tai thong dOng mach Mac du viec truyen ADM lam tang cung luong tim nhung dieu nay khong quan trong bang giam six can ngoai vi Anh huang trirc tiep cua

tong

u chugt Nhieu nghien cu da chimg minh rang ADM che sinh tong hop protein va su phi,dai,co tim, cling nhu su tang sink nguyen bao soi tim va san xuat chat nen ngoai bao

VI ADM ducec tong hop va bai tiet boi to bao co tim co 14p va nguyen bao sgi cua tim nen peptide nay c6 the dieu hoa su phi dai co tim va to chirc lai trong tang huyet ap gong mach hoac suy tim theo each can ti'etingi tiet

Y nghia lam sang cua MR-proADM

Gici tri tien (loan suy tim sau nhoi mau ca tim

Nghien ciru mgt s6 luong lon bgnh nhan nhap vin vi nhgi mau co tim, nguai to da ket Juan rang nhitngodoi tucmg c6 Wong dg MR-proADM cao nhap thi c6 tS/ tien trien den suy tim cao hon

Ngoai ra, loi Ich co ban khi stir dung MR-proADM do là co kha nang tien doan iduoc tir vong tren Nnh nhgi mau co tim (hinh 5.4)

0.00 20000 4 00 00 800 00

Ngay Hinh 5.4 Ty 10 suy tim ho0c ch0t theo MR-proADM

NHU'NG XET NGHIEM HOA SINH HIEN DAI SCY DUNG TRONG LAM SANG

Gia tri ant MR-proADM ti'en Joan tir vong tren benh nhan kho tho cap

Khi nghien ciru tren cac b6nh nhan nhap vien vi MI6 th6 cap Ngu6i

ta nhan thay, nhfrng ngued c6 trieu chUng kho tha do suy tim thi nong d6 MR-proADM (trung binh 1,6 nmol/L) cao hem so v6i nhang nguyen nhan khac (hinh 5.5)

ADHF AECOPD Viern phOi Ranh ac tinh Tac nghen Tang thong Barth khac

phoi khi ph6i

Chin clown Hinh 5.5 Gib tri MR-proADM trong chAn down nguyen nhan kh6 the,

Ngoai ra, ngtx6i ta theo dOi ty 16 nhimg ngtr6i song sot trong khoang th6i gian 1 nam va thay rang nong d6 MR-proADM tang cao (trung vi 1,9 nmol/L) 6 dot tuong tit vong hon nhimg nguai con 10

‘ ■ 0 C1 4:t

O C

cl 0.66 (,)

Hinh 5.6 Wing do MR-proADM trong nhom tu' vong va song sot

Gia tri tien krong tir vong ngan han cilia MR-proADM ding clugc cac nha nghien cdu khdo sat trong tien ltrong to vong 30 ngdy va 90 ngdy, so sanh v&i BNP va NT-proBNP cac tac gia nhan thay MR-proADM có gia tri tot nhat; dien tich dui throng cong ROC (AUC) la 0,81 va, 0,77 tuong ang cho 30 ngay va 90 ngay

0

Thai gian che't (ngay)

Hinh 5.7 Dien tich duN±ei thrivng cong ROC am MR-proADM, BNP, NT-proBNP tien doan tip vong 30 ngay va 1 nam

NHU'NG XET NGHIEM HOA SINH HIEN DAI SCY DUNG TRONG LAM SANG 2.2 Tic dung teen th4n va can Wang ntrerc-di0 giai

Truyen tinh mach ADM hoac truyen ADM vao then se lam tang cung luting nu& tieu va bai filet natri nieu Hieu irng nay chit' yeu lien quan den dan mach than, lam tang luu Wang mau tai then va tang t6c de loc cau than Tuy n.hien, ADM ding ire the tai hap thu natri a ong than Ngoai ra, lieu thap dm ADM gay tang natri nieu ma khong anh hung den toe do loc cau than, dieu nay goi 5f ,tac dung tren Ong than la chU yeu ADM dugc san xuat trong cac tieu cau than, 'Ong lugn xa va 'Ong, gOp phan vay, kh6ng chi luu hanh trong mau ma ADM san xuat tai than c6 the dieu hea chdc nang then Su de che cua enzym endopeptidase trung hea lam tang tac dung bai tiet natri nieu dm ADM do giam thanh thai peptide Ca receptor d:ac hieu ADM Ira receptor CGRP1 dugc bieu hien trong nephron Ira ADM lam tang tong hop AMP veng trong chi tren thuec \Tung ve day va ong lugn xa cUa than

Tuy nhien, van con chua re lieu ADM c6 true tiep dieu hea six van

chuyen ey Ong than hay khong? Hai nghien ciru thuc nghiem cho thay

rang ADM kich thich ngugc tinh tham nuarc nha tham that tai ong gop phan ray va hap thu Na+ mang dinh cua Ong lugn xa Nhang tac Ong nay se c6 lqi cho su kich hoax tai hap thu ,a ong then Vi vay, nguai to cho rang ADM co the irc the su van chuyen tai ong than met each gian tiep bang each lam dan cac mach mau than va gia tang ap luc thtly tinh tai cac tieu quan ngoai vi Vai tre dm ADM trong diet' hea can bang Na+ van chua re rang vi su bieu hien gen cila ADM va receptor ctia no tai than deu kh6ng bi anh huang bai che de an nhieu hay It natri

ADM con tac Ong tren cac t6 bao trung mo ctia then ADM lam tang mire AMP veng trong cac to bao trung mo dua den dan,na cluing va tang

he so loc, tac Ong nay gap phan lam tang toe de loc cau then Ngoai ra, ADM ire che angiotensin II - yeu to nay lam di chuyen,tang sinh cac to bao trung m6 va san sinh cac clang oxy phan irng bed cac to bao nay Nhfing tac Ong nay co the han che su tien trien ctia cac benh than man tinh

2.3 Tac Ong teen he thAn kinh trung u.crng

ADM va receptor cita no Wen hien phong phd a nao voi mire do cao nhAt dugc tim thay trong doi thi, vung clued doi va thuy sau tuyen yen Ngoai phAn ADM san xuAt tai ch8, peptide tuan hoan c6 the di vao he

5 Adrenomodullin

th6ng than kinh trung uong qua cac co quan quanh nao that chang han vung postrema, khong co hang rao mau-nao Nhu vay, mot s6 tac dOng dia ADM ngoai vi co the gian tiep thong qua N than kinh trung uong Truyen ADM vao nao that se irc che hap thu nu6c gay nen bad angiotensin II Mac tang nong do osmol va su them mu6i gay ra bad giam the dal mau Mat khac, su bat hog dm ADM not sink bad cac oligonucleotide doi nghich hoar cac khang the dac hieu lam tang hap thu nuatc va mu6i, dieu nay cho did)/ ADM irc the cam giac khat va them mu6i chuOt cong, khi tiem ADM vao trung uong se lam tang cung luong nuoc tieu va tang bai tiet natri, kali nieu Do vay, mot vai hien *rig trung tam cila ADM nxong tirng vod hog d6ng cila no 6 ngoai vi Tuy nhien, trai ngugc vad tac dung ha huyet ap ngoai vi, ADM trung uong lam tang huyet ap va nhip tim do kich thich he than kiah giao cam

2.4 ADM va cac tuytn not Wet

ADM trung uong kich thich bai tiet oxytocin va *c the bai tiet vasopressin (kich thich bai su tang n6ng dO osmol) tai they sau tuyen yen Nghien ciru trong 6ng righiem cho thay ADM dc the ca hai qua trinh va CRH (corticotrophin releasing hormone) kich thich cac to bao thily tru6c tuyen yen bai tiet ACTH Su giam ACTH ding dugc quan sat sau khi ti'em ADM vao ngoai vi Ngugc lai, tiena ADM vao buOng nao that se kich thich truc \Tung duet dei-tuyen yen-thuong than bang cach kich haat t6 bao than kinh san xuat CRH

Nhieu nghien ciru de cap den tac dOng dm ADM tren tuyen thucmg than, trong do cac peptide dugc san xuat vad so Wong lon ADM va receptor cna no CO nhieu a ca viing va v6 thugng than, dac biet trong

yang tieu cau san xuat aldosterone ADM *c che tong hop aldosterone gay ra bad angiotensin II va kali trong cac to bao ZG rai rac Tac dung irc che dm ADM qua trung gian ciia receptor CGRP1 va gan lien voi giam Ca' nOi bac, ,Trong co the song, ADM khong anh hirong den aldosterone huyet tuong mac dU no Jam tang hoat dO renin huyet Wong, phu hop voi the dung *c the truc tiep cua no tren v6 thucmg than ADM acing ngan chan six gia tang neng dO aldosterone huyet tucmg gay ra bad viec truyen angiotensin II Tuy nhien, ADM co the gay tang tiet aldosterone co ban va ca tang tiet aldosterone kich thich bad ACTH, tac dOng qua trung gian cila receptor ADM dac hieu cung \Tad adenyl

NHU'NG XET NGHIEM HOA SINH HIEN DAI SU' DUNG TRONG LAM SANG

cyclase Nguvc vet ZG, ADM va receptor dm no dugc bieu hien Or mdc thap trong yang b6 va yang luOi cua vo thuong then, 1a cac yang tuong img tong hop cortisol va androgen Bai vey, ADM kh8ng anh hixemg den

su bai tiet cortisol bai cac to bao thuong than

Ngoai viec clieu hoa bai tiet hormone, ADM kich thich su phat trial

va tang sinh cac to bac) ZG theo cach phu thuOc MAPK Co ye nhu viec san xuat ADM dial Ilea six tang sinh cua cac to ban ZG, tir d6 su bat hoat cila ADM not sinh duoc gay ra bai cac oligonucleotide antisense hoc phong Oa receptor ADM dai han se irc the tang sinh cac to bac, ZG chuOt va gay ra six chet to bao lap trinh cua chting Mac du ADM c6 rat nhieu a tuy thuong than, hormone nay khong anh huang hoc chi kich thich rat yeu len qua trinh san xuat catecholamine ADM duoc tong hop trong to bao F san xuat polypeptide dao tuy Ngoai ra, receptor ADM duoc bieu,hien trong cac to bao san xuat insulin nhung khong bieu hien Of cac to bao khac cua tuyen tuy not tiet ADM ngoai sinh irc che bai tiet insulin co ban va su bai tiet insulin kich thich bai glucose nhung khong anh huOng den cac hormone khac ctia tuyen tuy Khang the khang ADM kichthich tiet insulin co ban, dial nay cho thy ADM not sinh irc che tiet insulin

Cac nghien cfru On day chimg minh ADM c6 anh huOng rat lan den qua trinh Tong h6a mo xuang ADM kich thick su tang sinh cua nguyen bao xuang va tac dOng tren cac to bao sun e mix do yeu hon, ADM kich thich su khoang h6a cua xuang a trong co the Tac dung nay bi irc che bed amylin, c6 le lien quan den receptor cua amylin

2.5 Tic deng tren he man dich va qua trinh viem

,

ADM co dec tinh khang khuan manh, no chong lad ca vi khuan Gram duong va Gram am Dec tinh nay lien quan den cau clang dm ADM, co ban chat la chai peptide Om mot yang mang dien tich ua nu& va mot vimg ky nuoc ngan cach vo7 nhau,, dieu nay cho no dan xen vao mang to bao vi khuan.,ADM clugc tong hop bad to bao Mai mO a be met niem mac dubng ho hap, tieu hoa va tiet nieu, khoang mieng va da Nha vey ADM c6 vai tr.() khang,khuan tai ch8, ngan can sg xam nhep vi

khuan vac> cac vimg nay Nang (10 ADM trong nu& bot cao gap 8 lan va

trong dich nuOu cao gap 20.000 l'An so vai trong huyet wow Su bieu

5 Adrenomodullin

hin cna gen ADM trong to bao sung a ming tang len khi c6 six hien din dm vi khuan thuang Op trong mie'ng Tu cau yang va cac vi khan tren da khac kich thich san xuat ADM trong to bac) bieu mo cila da, trong

khi do Helicobacter Pyroli kich :Mich tong harp ADM trong t6 bao bieu

mo da day Pieu thtl vi la nong dO ADM trong dich nuau a cac b'enh nhan

bi viem quanh chan rang thap hon 3 lan so vai nguai binh thuang, dieu nay chirng to six thieu but ADM la nguyen nhan dan den viem chan rang Gen ADM dugc bieu hien trong to bao bach cau don nhan dm mau ngoai vi va tang len nhanh ch6ng trong tiled diem chung Nen doi thanh dai thuc bao ADM irc che su bai tiet cac cytokine tin viem Ngoai tac Ong len cac to bao viem, ADM lam giam tinh tham not mo von di bi tang len bai cac phan tin oxy phan irng, not clOc to hoac cac cytokine va vi vay c6 the han che su hinh thanh dich ri viem

2.6 ADM va ung thu

Adrenomedullin va scrphat trien to bao kh& u

Adrenomedullin dugc chimg minh la co lien quan den chat gay ung thu va six ti len trien cua khoi u bang cach thuc day qua trinh tang sinh khi u, tang taco mach va irc the su chet to bao theo chuong trinh (apoptosis) Ngued to cho rang cac cytokine viem ding su thieu oxy lam tang bieu hien ADM a cac to bao u va clan den qua trinh nay (hinh 5.3)

Adrenomedullin va st! tang sinh to bao kh'ji

Wit s6 dOng to bao ung thu bieu me co tang bieu hien ADM &A tang

cuamg phat trien trong 'Ong nghiin va trong co the a cac mdc dO khac nhau VI vay, cac to bao ung thu not mac tir cung clang RL95.2 tang Weil hien ADM cho thay co su tang truang clang ke, tuy nhien khong c6 su tang truang doi vai Ishikawa - cac to bao ung thu bieu mo nOi mac dugc gay nhiem vao ADM ding duy tri tang sinh to bao dia clang to bao ung

hu vu T47D CuCii ding, mot khang the khang ADM dac hi'eu da lam iam su pilaf trien cila cac t6 bao u nguyen bac, dem U87 von di china Ong dO ADM ritii sinh rat cao

drenomedullin va sty tang sinh mach

Vai tro ctla ADM IT' mat sinh 47 va Nnh lY, dm six tao mach dä dugc chirng minh tren thuc nghi'em a chuOt, ADM gift vai tro trong dieu ilea

NHU'NG XET NGHIEM HOA SINN HIEN DAI SO' DUNG TRONG LAM SANG

hinh thanh mach mau tai duang sinh san cua phu nir, su phat trien mach mau trong qua trinh phoi thai, trong qua trinh tai tao mach a benh nhan thieu mau cuc bO ADM kith thich sr tang trixamg cac ,te bao not mo mach mau not mac to cung ngoai Cac nghien ciru tien hanh loaf b6 ADM a chuOt va ket qua cho thay ADM rat can thiet cho su tao hinh mach mau ADM ding lam tang luu luting mau va phat trien mao mach b6 sung trong thieu mau cuc WO cap tinh

Tuang to nhu vay, ADM có lien quan den cac gen tao mach (angiogenic) trong cac khoi u VI du, 6 cac khoi u ca tran, u co to cung lanh tinh, su bieu hien dm ADM tuang quan vOi mat dO mach mau va chi so tang twang cua to bao not mo Trong cac mo hinh khoi u ghep ngoai lai có sir dung not mac to cung ngu6i, clang to bao ung thu vu hoac ung thu tuyen tuy, thi mat dO mach mau se tang len neu to tang su bieu hien ciia ADM Tac dung tuang to dugc quan sat sau khi ghep ngoai lai

to bao u nguyen bao dem cila ngu6i, ma nhitng to bao nay da duac chimg minh c6 su Weil hien cao ciia ADM not sinh Nhang quan sat nay da duoc xac nhan a chuOt mang kieu gen ADM di hop tir, khi do six tang truang cua khoi u ,ghep ngoai lai bi giam va su tai tao mach giam di trong dieu kien thieu mau cuc bO

Vai tro ciia ADM trong su truomg thanh dia mach mau ding duac de xuat ADM kich thich t6 bao ca trop mach mau di cu va dan mach dOc lap cri to bao not mo CO the dong gop vao su trisong thanh cila mach man mac nghien cal gan day cho thay ADM khong chi tang cuemg su biet hoa cua to bao toy xucmg CO ngtion goc tir bach cau don nhan thanh

to bac) not mo ma con tao thuan loi cho su hinh thanh cac mach truCmg thanh bao g6m to bao co tron thanh mach mau (VSMC- vascular smooth muscle cell) Ngucc lai, mot s6 tac gia da chimg minh ADM not sinh có the bao ve chong lai su tai tao mach mau phi gay ra bai su thieu oxy hoac han the tang san nOi mac mach mau gay ra bai chan thuong

Adrenomedullin va qua trinh chet to bao lisp trinh

Adrenomedullin irc che qua trinh chet to bao lap trinh cua ca to bao not mo va kh6i u Vi du, ADM ngan chan su thieu but huyet thanh s u thieu but nay se gay ra hien tuang chet to bao lap trinh doi vai to bao not

mo chuOt Khi gay tang bieu hien ADM a to bao ung thu not mac ti cung

5 Adrenomodullin

cho dia.)/ to bao c6 sirc 6 khang v6i six thieu oxy, ma six thieu nay se gay chet to bao lap trinh thong qua co che trung gian cua bcl-2 Hon nfia,

cac to bao ung thu tuyen vu &rot gay tang bieu hien ADM thi 'long do

ctia cac yeu to tien chet, to bao trinh (proapoptosis) nhu Box, Bid va caspase 8 thap hcm nhieu so \Tad cac to bao khong dugc gay fang bieu i'en ADM

DINH LUVNG ADRENOMEDULLIN

Sir dung phuong phap mien dich huSTnh quang de dinh Wong ADM

t hoa chat dugc thiet ke de phat hien peptide d4c hie'u dua tren nguyen

Ac mien dich enzym canh tranh

.1 Nguyen 6c

Dia phan irng dugc trang truac bed mot lop khang the thin cap,r nhu

ay nhfing vi trf khong dlac hieu se bi chan lai Khang the thir cap c6

he gan vai doan Fc cua khang the chinh (khang the ADM) trong khi oan Fab caa khang the chinh se dugc gan canh tranh bai ca ADM lien

et voi biotin (c6 trong kit thu& thir) va ADM trong mati benh pham inh Wong (huyet thank hoac dung dich ADM chuan, ) ADM lien ket iotin,phan img v6i SA-HRP (streptavidin-horseradish peroxidase), xtic

de bin cloi co chat va phat huSTnh quang Cuong dO huSInh quang ty le huan vOi ham Wong phirc hop ADM lien ket biotin-SA-HRP nhung lai

le nghich ved ham luong ADM c6 trong inAu benh pham Dieu nay la

o , ADM lien ket biotin canh tranh v6i peptide ADM, (dm mL benh ham) de On vao khang the ADM MOt clu6ng cong chuan dugc thiet lap

ixa vao cac mL ADM chuan c6 nong des biet tru6c, va nong dO ADM ong thir &roc )(de dinh vac) duong cong chuan nay

ADM trong

mau Onh

Dia dir Ic trang phgm

lerpkhang tho 10,ingth6

thir cap chinh

NHU'NG XET NGHIEM HOA SINH HIEN DAI SO' DUNG TRONG LAM SANG

3.2 Thac thfi

1 Dung dich dem n6ng do 20X (50m1)

2 Dia pha'n img 96 ging (1 dia)

3 Mang day dia bang acetate (3 mieng)

4 Khang the chinh (khang th6 IgG cira th6) (1 10)

5 Dung dich ADM chuan (I jig)

6 ADM lien kk biotin (1 vial)

7 Streptavidin-horseradish peroxidase (SA-HRP) (30,u1)

8 Dung dich co chAt (13 ml)

9 Chimg duong (1 19)

10 Dung dich on dinh peroxide

11 Dung dich dimg (stop solution)

3.3 Quy trinh dinh lacing ADM

1) Pha bang n6ng d'6 dung dich dm 20 X \Jai 950m1nu6c cat Nhu vay

se có dung dich dkn lx, sir dung d pha bang cac thuoc thir khac hoac pha bang mAu b6nh pham

Luu neu c6 xuat hi6n cac tinh the trong dung dich dm 20 X thi nen u dung dich dm 20 X trong bon nuac am khoang 30 phdt hoac cho d6n khi khong con nhin thay cac tinh the TrOn that ky truOc khi sir dung

2) Ly tam va pha bang lo ADM chuAn vai lml dung dich dm 1 X, vortex Nong do cira dung dich g6c nay la 1.000ng/ml De dung dich

a nhik d6 phong it nhAt 10 phut (20-23°C) a hoa tan hoar) toan Ly tam va vortex ngay truac khi sir dung

3) H6a khang the chinh vOi dung dich dkn 1X De ei nhik d6 ph6ng It nhAt 5 phin de hea tan hohn town Tr6n du

4) Hoa rau chimg duong voi dung dich dm 1X

5) De ging A-1 va A-2 lam cing trong

6) Cho 500 dung dich lx vao ging B-1 va B-2 lam Total Binding 7) Cho 500 m8i dung dich ADM chuan tix 6ng 6 dn 6ng 2 vao cac gieng Wang img tir C-1 va C-2 dn G-1 va G-2

900

Ni

5 Adrenomodullin Bang 5.2 Cach chuan bi dung dich ADM chuan

Ong dung dich

ADM chufin

Th ' tich

_ Dung dich

Om lx

NOng di)

Dung dich 1 100plcUa dung dich gOc 9O0p1 10Ong/m1

Dung dich 2 100g1 da dung dich 1 900p1 10.000pg/m1

Dung dich 3 100p1 dm dung dich 2 900111 1000pg/m1

Dung dich 4 100p1 dm dung dich 3 900p1 100pg/m1

Dung dich 5 100111 caa dung dich 4 900p1 10pg/m1

Dung dich 6 100111 dm dung dich 5 900111 1.000pg/m1

100 p1 100 p1 100tH 100 p1 100 p1 100 p1

GOC

1000 ng/m1

1000 100 pg/mi pg/ml pg/mi 5/r,

Hinh 5.8 Cach pha dung dich ADM chuan

) Cho 500 mdu chirng duong vao gieng H-1 va H-2

) Cho 5Ou1mdu thin (vi du: huyet thanh, ) vao hai gieng theo chi dinh (I-1 va I-2, )

0) Them 250 khang the chinh (da dugc pha a buaec 3) vao meii ,gieng

ngoai trir gieng lam o'ng trang VC3 nhe nhang dia phan Ung de dam bao tr (On deu

Luu Y: khong dung pipet da kenh (multi-chanel pipette) de but khang the chinh vi có the lam thay ai ket qua ,

11) Dan dia phan ling bang ming dan dia acetat U dia a 4°C trong vOng 16-24 gie• (U qua dem)

NHU'NG XET NGHIEM HOA SINH HIEN Ded SO' DUNG TRONG LAM SANG

12) Vao ngay horn sau: hoan lo ADM gan biotin voi dung dich dem 1X

De It nhAt 5 phut cho flea tan hoar) toan TrOn k`ST' Ga mieng dan dia

ra, khOng Ina dia phan irng Cho them ,251.11 dung dich ADM gan biotin vao gieng ngoai trir gieng lam 'Ong tang

13) DAy dia phan irng bang mieng dan acetate U dia a nhiet dO phong (20-23°C) trong \Tong 90 phut Nen lac nhe a 300-400 veng trong qua trinh u

14) Ly tam lo HRP (3.000-5.000 vong trong 5 giay) va htirt 12p,1 HRP cho vao 12m1 dung dich dem 1X tao thanh dung dich SA-HRP, vortex ky

SA-15) Ga mieng dan khai dTa phan Tang Do dich thira trong cac giLg 16) Rira tmg gieng vai 3501i1 dich dem 1X, do dich dem, tip nguoc dia phan irng va tham kho Lap lai 4 lan

17) Cho them 1000 dung dich SA-HRP vao moi giLg

18) Day dia phan dng bang mieng dan acetate U a nhit dO phong 23°C) trong 1 gia

(20-19) TrOn 9 phan dung dich co chAt vai mot phan dung dich On dinh peroxide (stable peroxide solution) Dung dich hoat dOng nay on dinh trong 24 gia a nhiet dO phong va phai tranh anh sang De giam six Nen KA, can bang dung dich hoat &Ong a nhiet dO phong truac khi cho vao cac gieng

20) Ga be) mieng dan ra

21) Rim va tham kho dia phan irng bang dung dich 1X nhu buck 17, rap lai 4 lan

22) Cho them 100 1.11 dung dich co chat ,da" chuan bi buarc 19 vao m6i gieng nhe dia phan tang de trOn deu

23) DAy dia phan irng bang mieng dan acetate U 15-20 phut a nhiet do phong Lac 300-400 \Tong trong qua trinh u

24) Ga mieng dan Cho 1000 dung dich dung (stop solution) vao moi gieng de dung phan trig nhe dia de trOn deu Tien hanh cac buck tiep theo trong vang 20 phUt

25) Dua dTa phan Ung vao thiet bi doc huS/nh quang va do dan vi huSinh quang (RFU-relative fluorescence units) cda moi gieng Kich thich va phat xa circ dai dm dung dich ca chat tuong Ung la 325nm va 420nm

5 Adrenomodullin

Buck song khoang 315-340 cho phan ixng kich thich, 370-470 cho phan irng phin xa va ciing thing de phat

TOM TAT QUY TRINH DINH LU'ONG ADM

Cho 50 pi m'au chuan, chirng thrang hoc m5u huye't

thanhva 25 pi khang the' chinh

U a 4°C qua dem (16-24 gib') Cho them 25111 ADM ga'n biotin vao m61 gieng

U a nhit dp phong (20-23°C) trong 90 phut

RCra cac gi6ng 4 Ian val 350 pl dung dich dem IX

Cho them 100 p.1 dung dich SA-HRP vao mai giCng

a nhit d(5 phong trong 1 gib

Rira 4 Ian voi dung dich dem lx Cho them 100 pi dung dich ca chat (da pha loa'ng)

U nhi0 dci phong trong 15-20 phut Ke-tthilc phan trng brig 100 pi dung dich dirngphan trng

Do urang do huienh quang va tinh k6t qua

So ci6 5.2 Cac dinh Iu'o'ng ADM

NFICING XET NGHIEM HOA SINH HIEN DAI sir DUNG TRONG LAM SANG TAI LIEU THAM KHAO

1 Asakawa H, Nishikimi T, Suzuki T, Hara S, Tsubokou Y, Yagi H, Yabe A, Tsuchiya N, Horinaka S, Kangawa K, Matsuoka H Elevation of two

molecular forms of adrenomedullin in plasma and urine in patients with acute

myocardial infarction treated with early coronary angioplasty Clin Sci (Load)

2001 Jan;100(1):117-26

2 Beltowski J, Jamroz A Adrenomedullin what do we know 10 years since its

discovery? Pol J Pharmacol 2004 Jan-Feb;56(1):5-27

3 Hay DL, Walker CS, Poyner DR Adrenomedullin and calcitonin

gene-related peptide receptors in endocrine-gene-related cancers: opportunities and

challenges Endocr Relat Cancer 2010 Dec 13; 18(1):C1-14

4 Hinson JP, Kapas S, Smith DM Adrenomedullin, a multifunctional

regulatory peptide Endocr Rev 2000 Apr; 21(2):138-67 Review

5 Kato J, Tsuruda T, Kita T, Kitamura K, Eto T Adrenomedullin: a

protective factor for blood vessels Arterioscler Thromb Vasc Biol 2005 Dec;

25(12):2480-7

6 L L Nikitenko, S B Fox, S Kehoe, M C P Rees, R Bicknell Adrenomedullin

and tumour angiogenesis British Journal of Cancer (2006) 94, 1-7

7 Lopez J, Martinez A Cell and molecular biology of the multifunctional

peptide, adrenomedullin Int Rev Cytol 2002; 221:1-92 Review

8 Martinez A, Miller MJ, Catt KJ, Cuttitta F Adrenomedullin receptor

expression in human lung and in pulmonary tumors J Histochem Cytochem

1997 Feb; 45(2):159-64

9 Nicholls MG Hemodynamic and hormonal actions of adrenomedullin Braz J

Med Biol Res 2004 Aug; 37(8):1247-53

10 Nishikimi T, Yoshihara F, Mori Y, Kangawa K, Matsuoka H

Cardioprotective effect of adrenomedullin in heart failure Hypertens Res 2003

12 Zudaire E, Portal-NUriez S, Cuttitta F The central role of adrenomedullin in

host defense J Leukoc Biol 2006 Aug;80(2): 237-44

CRP dtrac phat hien dau tien boi Tillet va Frances vao nam 1930, hai

nha khoa hoc nay cid tim thay trong huye't thanh cua benh nhan bi viem

phoi do phe cau c6 mot protein ket tua \Teri C-polysaccharide (capsule

polysaccharide) dm vach vi khuan nay, do do c6 ten la C-reactive

protein Tuy nhien phai mot thoi gian ddi sau do vai tr6 ciia marker nay

trong qua trinh viem nhigm moi duot xac dinh

C-reactive protein (CRP) Id marker dm giai doan cap trong qua trinh

viem nhi'em dirge gan san xuat clued su kich hoat cua cac cytokine Xac

dinh nOng dO CRP trong mau ginp cho viec chan doan va theo dOi benh

13'T lien quan den qua trinh viem nhi6m va ton thuang mo Co nhiL k'S'T

thu4t dinh luting CRP trong do dinh luting hs-CRP là k'ST" thudt xet

nghiem moi c6 dO nhay cao dung dinh luting CRP a mirc nOng dO thap,

giup danh gia qua trinh viem thanh mach (ca the chinh trong hinh thAnh

mang xa vita), no &lig vai tro quan trong trong phan tang nguy ca benh

mach vanh nhu nhoi mau ca tim, dot quy, ya tit vong do tim a ngueyi khoe

manh va ngueri da c6 benh mach vanh giup phong ngira tien phat va thir

_phat cac su co mach vanh

2 CAU TRUC PHAN TIY

LA protein thuOc ho pentraxin,

dang cau co 5 ban dan vi xep doi

xlmg xung quanh to trung tam

(hinh 6.1) DuOng kinh ngodi là

102A°, throng kinh trong la 30A°,

dtx•mg kinh m8i ban dan vi la

36A° MOi ban don vi co 206 acid

amin, trong Kiang phan tir m8i

ban dan vi khoang 23kDa, cac

ban don vi lien k6t nhau khong Hinh 6.1 Phan tir CRP

PhosphatdOsenn haat Te bao chat

NHU'NG XET NGHIEM HOA SINH HIEN DAI sir DUNG TRONG LAM SANG

d'ong hoa tri tao thanh

phan tir CRP c6 trong

luting khoang 118kDa

Nam ban don vi nay

khong thuOc ding mat

phang ma xoay 15° - 20°

quanh ft-kw song song voi

\Tong xoan alpha trung

tam Dieu nay lam cho cac

yang xoan alpha dm cac

ban don vi nam gan nhau

hon va day cac ion Ca' ra

xa nhau Tren moi bdn

don vi c6 2 mat: mat B Hinh 6.2 Vi tri gAn ph6i tip cua CRP

(beta face) co met vi tri gan voi phOi tii (ligand) co di hre manh nhat voi

phosphocholine, vi tri gan nay co 2 ion Ca++ de gan voi nhom phosphate

va tui ky mac se ket hop \Tad nhom methyl Doi dien la mat A c6 fanh

sau (deep cleft) duvc tao bad cac dau C tan va N tan cua chai

polypeptide tiep gidp vai \Tong xoan alpha Tai ming cua fanh nay c6 vi

tri ket hop voi cac dau dang cau cua Clq hay thu the Fcy tren be mat cua

dai tlwc bao, bath cau da nhan trung tinh

3 CHirC NANG SINH

HOC

CRP nguOi c6 di luc

manh nhat vai gOc

phosphocholine, ngodi ra no

cling gan &roc vai mot so

cac ph6i tir not va ngoai

sinh khdc CRP se lila hoac

gay ngung ket cac cau true

nhu to bac), hat, phan tit

mang cac phoi tir nay Cac

phoi tir nOi sinh bao gom

6 hs-CRP

nguyen clang hay dal bien doi, mang to bao da v6, mot so phan to phospholipide hoac cac hop chat lien quan, hat ribonucleoprotein nh6 cua nhan to bao, cac t6 bao eh& theo chuong trinh Cac phi ttir ngoai sinh gom glycan, phospholipide va cac thanh, phan cau tao khac vi sinh vat nhu cau true nang, than vi khuan, vi nam, ky sinh trUng Trong qua trinh gay ngung ket hay tna khi CRP ket hop voi cac phi tir lon, CRP nguai se dugc nhan biet boi Clq va qua do hoat h6a clang tilde

bo the theo con duang co dien qua C3 Mat khac CRP khi gan voi phi

Ur se b0c 10 diem On thin phat (secondary binding site) vai yeu to H va

do do diet' hoa sg khuech dai con,duang thay doi (alternative — pathway)

va CS convertase Khi gan phi tir tren mang to bao, manh va hay mO

bi hoai tg, CRP co vai tro gay opsonin h6a ginp cac to bao cua he mien dich clac biet la dai thuc bao hay to bao neutrophil nhan biet va thixc bao nham loci b6 cac cau true nay

Tac dOng,thir phat cila CRP sau khi gan voi phi co tinh chat nhu cac khang the chgng to vai tro cUa CRP trong viec bao ve co' the thong lai tac nhan nhiem trUng, tham gia vao qua trinh sinh 13i benh nhu kiem soat, don dep cac cau true not sinh (cac manh v6 mang to bao, phan tix phopholipide, lipoprotein, )

Phosphocholine, phi tir chinh dm CRP, thanh phan cau tao cUa nhieu sinh vat tien nhan (prokaryote) va hau het to bao nhan that, la thanh phan lipopolysaccharide mang to bao va binh thuong khong b0c 10 Khi to bao 134 thuong b6i cac yeu to nhu Fang dong bo the, tac dOng cUa phospholipase, ton thuong hay chet tax nhien, phosphocholine 10 ra va to thanh muc tieu cUa CRP

Trong benh to mien, CRP c6 kha nang ket hop dm no voi cac khang nguyen nhan, CRP ket hop voi chat nhiem sac (chromatin) qua Wong tac voi histone, no khong ket hop vai DNA tran (naked DNA) Cac khang nguyen nay chiu trach nhiem chinh trong phan Ung khang nguyen khang the tax mien Do do co gia thiet cho rang no the dau khang nguyen hoac gidp loci b6 cac khang nguyen nay, do do CRP co vai tro phang ngira hay giam benh tg mien

Troponin T and I

Creattne kinase MB

ICAM-1 VCAM-1 E-selectin P-seiectin

NHU'NG XET NGHIE, M HOA SINN HIEN DAI SO DUNG TRONG LAM SANG

4 SINH TONG HOT

Gen tong hop CRP 11'am tren nhie'm sac the thin 1 (1q21-q23), Om 2 exon rieng biet va 1 intron, mot exon ma Ma 2 acid amin d'au va mot exon ma boa 204 acid amin con lai CRP sinh ra 3r6u gan duai sg dap cac yeu to trung gian cua qua trinh viem, ton thucmg m6 nhu interleukin 10, interleukin 6 Ara Alpha-TNF (alpha tumor nerosis factor) MOt so ca quan,ngoai gan dal duot xac dinh tong hop CRP la to bao bieu

mo duemg ho hap va lympho T Tuy nhien gan van duac xem la co' quan chinh y6u sinh tong hop CRP

C-reactive protein

Fibrinogen

Amyloid A huyet thanh

Hinh 4 Sinh tong hop CRP

O nguai binh thuo'ng nOng dO CRP trong mau có phan phi khong chuAn, loch phai voi trung vi khoang 0,6 — 1,1mg/L, bach phan vi thin 25: 0,32 — 0,55mg/L, thin 75: 2 — 2,5mg/L va thir 95: 7,3 — 9,65mg/L 6

nguai Viet Nam, Truang Phi Hung thuc hien tren 102 nguai khoe manh thAy trung vi hs-CRP la 1,5mg/L, thAp nhAt la 0,4mg/L Ala cao nhat la 6,1mg/L Binh thuemg a nguai khoe manh nOng dO CRP < 10mg/L Tang

dr mo Cac tinh trang nay, gay phong thich interleukine 6 va cac interleukine khac kich hoat tong hop CRP va fibrinogen, amyloid A tai

gan (hinh 6.4) CRP tang trong nhieu benh 15, khac nhau nen khong gidp

chan doan chuyen biet cho met benh cu the ma no chi la bang chirng cfra tinh trang viem nhi6m hay ton thuong mo oh co the

, O phase cap dm qua trinh viem, nong dO CRP tang nhanh trong 2 gib dau, vuot qua giai han binh thubng sau 6 gib, dat dinh 48 gib.,Khi viem giam nong dO CRP giam nhanh vai died gian ban hay tuong doi ngan ,19 gib CRP có the tang den 500 ran trong viem cap, nhu nhiem khuan NOng (10 CRP cao to 10-40mg/L co the gap trong viem nhe, nhiem virus; nong dO 40-200mg/L gap trong ,viem tin trien, nhiem do vi khuan; va

> 200mg/L gap trong nhfem khuan nang

Do nong dO va theo doi nong dO CRP gill') chAn doan, danh gia din tin benh va hi'eu qua dieu tri CRP phan anh dap img cap di-1h qua trinh 'viem nhay va chinh xac hon toc dO lang mau Thoi gian ban h-dy hang dinh va It bi anh huang bed cac yeti t6, khac Do do, nong dO CRP duoc guy& dinh chir yeti bbi mirc dO san xuat Trong 24 gib dau dia benh, tOc

dO lang mau binh thubng nhung CRP tang, va khi dieu tri co dap irng thi CRP giam nhanh ve binh thubng trong khi t6c dO lang mau van con cao Hau phdu, CRP tang vao gib thin 4 — 6 sau phdu thuat dat dinh vao ngay thir 2-3 va giam dan sau do Trong truemg hop co bien chirng sau

mo nong dO CRP có khuynh huong tang cao hon va keo dai han (so yed khong bien chirng) Ngubi ta khong khuyen kluich do nong dO CRP de phat hien Om nhie'rn khuan hau phdu vi thuong ton do cuOc mo gay nhieu va gay kilo khan trong viec din giai ket qua CRP Thong thubng

de theo doi hau phdu ngued ta do nong dO CRP vac) 3 thbi diem: tru6c hdu thuat,, vao ngay thir 3 va 5 sau phdu thuat Gia tri cna CRP trong theo doi ket qua dieu tri bi6n chirng nhi6m khan hdu phdu dal throe khang dinh

NHU'NG XET NGHIEM H6A SINH HIEN DAI SO' DUNG TRONG LAM SANG

O d6i Wong so sinh, CRP tang dAn sau sinh dat dinh khoang 24 -72 giO sau d6 giam clan tra ve duong nen khoang ngay thir 6 — 7 sau sanh Dinh Wang hs-CRP tren 134 tre khong benh nhiem khudn, tdc gia Melanie Muenzenmaier cho thynOng de hs-CRP 6 giO sau sanh: 0,7 ± 0,17mg/L (trung binh ± dO lech chudn); 24 gib.: 2,14 ± 1,95mg/L va 72 gib 4,11 ± 2,lmg/L Gia tri cUa hs-CRP trong tam sodt nhiem khuan so sinh con chua thong nhat (nguang, thoi diem, kiau theo doi, ) va can them nhieu nghien dm, tuy nhien nen dung xet nghiem CRP co de nhay cao de lam tang kha nang phat hien benh va tri marker nay trong theo dei dieu tri nhiem khuan so sinh dal dugc chi mg minh

5 CAC KY THUAT PHAN TICH

5.1 Dinh tinh va ban dinh ltromg CRP

Ky thuat nay dugc phat trien ddu tien, thuong dua vao nguyen tac ngung to va tua vai hat latex (ky thudt nay dugc Singer va CS giai thi'eu nam 1957) Hat latex dugc do yeti khdng the khdng CRP nguai khi dugc tren vai huyet thanh c6 neng do CRP cao se xuat hien ngung ket trong vai phut (quan sat bang mat thuong)

Kat qua dinh di-1h cho kat qua duong se dugc tiap theo bang ky thuat ban dinh Wong, ky thudt nhu dinh tinh CRP nhung mdu huyet thanh dugc pha bang clan, thong thuong la bang dung dich glycine/NaC1 (0,1M glycine va 0,15M NaCl) thanh cdc nang do 1:2; 1:4, 1:8; Dua vao nguang phdt hien va do pha bang mau cao nhAt cho kat qua duong tinh

de tinh ket qua bdn dinh luau&

Ngueng duong tinh cua xet nghiem dinh tinh la giai han tren ctia tri

so binh thuong, ,thuang gap la 6mg/L hoac 10mg/L tuy theo be kit va thuec thir cu the VI du Avitex CRP cUa hang Omega diagnostics c6 nguO.'ng dinh tinh CRP la 6mg/L (> 6 se cho kat qua duong tinh va 6 c6 ket qua am drib), Accutex CRP Latex cila Thermo Scientific lai dung ngung 1a 10mg/L

Chu )% hien tuong prozone (qud nhieu khang nguyen) se gdy am gia,

khi ket qua dinh tinh am di-1h khong phu hop benh canh lam sang (nghi ng6.) nen pha bang m-Au 1/10 rOi thir lai

5.2 Dinh prong CRP than (standard CRP, traditional CRP)

Phuong phap dang clang hien nay la ELISA va mien dich humh quang (immunofluorescence) deu dung khang the don dOng dugc danh dau voi enzym hay chat phat htinh quang (fluorescent tracer), dugc gan

co dinh tren cac gieng Khang the nay se ket hgp dac hieu voi CRP trong mau de hinh thanh phtrc hop CRP-ph6i td Cac khang the du se dugc rda

di Pink hop CRP-ph6i t11 dugc danh dau huynh quang dugc do voi dau

do, phik hop CRP-phoi tir danh dau bang enzym phan img voi co chat dugc them vao va sinh mau, mau nay se dugc do voi quang phO ke MOt phuong phap kha ph6 bien khac de xac dinh n6ng dO CRP la ngung ket voi hat latex sir dung ky thu4t do dO due (Latex turbidimetry) CRP trong mau se gay ngung ket Wei hat latex c6 do khang the khang CRP nguaei (thueng la khang the de, dru) Nong dO CRP trong mau se ty le voi six thay doi dO hap thu anh sang truac va sau khi c6 ngung ket xay ra Voi ky thuat dinh Wong CRP chua'n, dO nhay ky thuat co the den 1 — 4mg/L va tuyen tinh dat vai tram miligram CRP/L Nong dO CRP vugt nguOng tuyen tinh có the pha loang mau voi NaCl 0,9% r6i thin lai

Liu diem: xac dint' dugc n'ong dO CRP trong khoang do dugc cua phuong phap (vai den vai tram mg/L), giirp chan doan va theo doi hau het cac benh lien quan den viem, nhiem, benh dc tinh, hiau

Nhugc diem: khong do dugc n6ng dO CRP < lmg/L, gidei han nay quan trong trong viec phan tang nguy co benh mach vanh (xem phan hs-CRP) 6' nguai kh6e manh va theo doi nhfem khuan so sinh

5.3 hs-CRP (high sensitivity CRP)

La ky thu4t co dO nhay cao dugc phat trien gan day (khoang nhirng nam thap ky 90) nham xac dinh 'long dO CRP o mdc thap nguOng binh thuang) Theo Hiep hOi Tim mach va Trung tam kiem soat va phong ngtira benh cua my (AHA/CDC) thi do nhay cao la co kha nang do

NHU'NG XET NGHIEM HOA SINH HIEN DAI SU' DUNG TRONG LAM SANG

duce CRP mire thAp chinh xac chi de phan tango ngu6i kh6e manh theo tam phan vi, ttir phan vi va ngu phan vi Tren thixc to dieu nay nghia

la xet nghiem phai do dugc n6ng de 0,3mg/L va de lech (assay

imprecision) < 10% 6 neng do CRP tir < 0,5 den lmg/L

5.3.1 MOt so phwang phew alinh luvng hs-CRP

Mijn dich (10 dye (immunoturbidimetry assay): vi du b6 thuoc thir

hs-CRP ctila hang Randox thiet ke chay tren may Rx Daytona va

Rx Imola hay be thuoc thir Immage CRPH cua hang Beckman Coulter tren may mien dich t6 deng IMMAGE vgi phuang phap nay khoang do dugc 0,20-1440mg/L (tren may IMMAGE), de dat dugc de nhay nhu vay (0,2mg/L) kich thu6c hat latex phai tang 3-

4 lan so vOi thong thugng

Mien dich hoa phat quang (chemiluminescent assay): vi du thuoc

thir cila hang Diagnostic Product Corporation do tren he th6ng IMMULITE automated analyzer, khoang do dugc 0,10-500mg/L

Immunonephelometry: vi du thu6c thtir cua hang Dade Behring

tren may BNA nephelometer, khoang do dugc 0,18-1150mg/L

Lateral flow immunoassay: vi du Cholestech LDX hs-CRP

khoang xet nghiem 0,3-10mg/L

5.3.2 Lay va Veto quiin

Trong danh gia nguy co tim mach, CRP la marker viem,khong d4c hieu nen khuyen cao lay mau 2 Ian each nhau nhat 2 tuan, ket qua nong

de hs-CRP se" 14 trung binh Ong (thugng dung han) hay tri s6 dial) nhat trong cac ran lay mau

Trong cac ky thuat tren, ngoai air ky thuat lateral flow immunoassay

la c6 the dung mau toan phan, con lai dung mau huyet thanh hay huyet tuang yeti chong clang là EDTA, heparin, citrate deu dugc, six khac biet nOng de hs-CRP glib cac Joai mau nay la khong coy nghia Mau tinh mach duce lay vac) th6i diem bat kS/, khong can nhin an, khong thay doi theo nhip ngay — dem va on dinh trong mail qua nhieu ngay neu khong c6 tinh trang viem nhiem xay ra Neu la mau Tong phai ch6 cuc mau dOng hohn toan Ly tam 5.000 vong/phut x 10 phut Huy& thanh va huyet tucmg la phan dich ben tren dugc chit vao c6c mau

6 hs-CRP

Mau nen dung ngay, ne'u khong tra a 2-8°C trong 1 tuan va a -20°C dugc 6 thang vai dik kik khong ra dong nhik lan Truac khi xet nghim phai dua mau (tri-r lanh) ye nh* d6 pheng va tr6n deu tar& khi thin

- Kha on dinh: CRP on dinh trong mau mau toan phan a nhiet d6 phOng den 3 ngay Huyet thanh, huyet tuong va mau toan phan On dinh 7 ngay de,tu lanh va lau hon nk dd

Pho nhieu phuong phap hs-CRP to d6ng da co tren thi truang, su ph6 bin nay gill') a clang do dugc trong cac phOng xet nghiOn

- Huyet thanh cat chik thin cap quoc to (International secondary serum reference material) CMR 470, phat trim bai lien doan floa Lam Sang Qu6c Te, có sdn cho viec chuan hoa kit calibrator 1\1-6ng d6 CRP trong CRM 470 la 39,2mg/L

Ngay nay nguai ta xac dinh qua trinh viem clang vai tro chinh trong qua trinh hinh thanh ma'ng xo vita, co ch6 chinh trong sinh Nnh hoc ciia b@ih mach vanh CRP la marker dap irng cac kich thich bao gam xo vita, ton thuong, thik mau va hoai Ur, dugc sir dung danh gia nguy co dm Nnh mach vanh Yong d6 CRP a mirc binh thuemg (do bang xet nghim hs-CRP) coy nghia den lugng nguy co bkh mach vanh a,ngued khOe manh hay benh nhan dau that nguc on dinh Trong khi do nong d6 CRP tang cao lai coy ngliia du hau a cac Nnh nhan dau that nguc khong on dinh va nhoi mau co tim

CO mot s6 5/ kien phan bac vai tro ciia CRP trong bOh mach vanh

cho rang tang, CRP chi la tuong phu (epiphenomenon), tuy nhien cho den nay hau het cac k6t,qua nghien ciru clang tin cay (g6m cac ket qua phan tich g6p) va cac to chirc uy tin tren the gi6i iing ha vai tro cua hs-CRP trong viec gitlp danh gia nguy co bOh mach vanh Ngued ta thay rang: (1) viem man gay tang n6ng d6 CRP ding lam tang nguy co mac Nnh; (2) CRP la yeu to nguy co bkh mach vanh ngay ca sau khi da hik chinh vai cac yeu to nguy co khac va (3) CRP hien dien trong mo viem nhu mang xo vim, co tim bi nh6i mau

NFICYNG XET NGHIEM HOA SINH HIEN DA I SU' DUNG TRONG LAM SANG

Vai tre cua hs-CRP trong benh mach vanh dugc nghien ciru tren ba nhom doi arcing: (1) ngtrei khOe manh; (2) benh nhan on dinh c6 hay khong c6 benh mach vanh; (3) benh nhan hOi chimg mach vanh cap Nhom d6i along ngtrai khoe manh, ngued to nh4n thAy a phan vi nong dO

hs-CRP cao nhat c6 nguy co bi cac su co mach vanh cao gap 2-3 lan so

vOi nhom c6 nOng dO hs-CRP thAp nhAt

Hiep hOi tim mach (The American Heart Association-AHA) va trung tam kiem soat va phong ngira benh cua MS/ (US Centers for Disease Control and Prevention-CDC) phan nhom nguy co benh mach vanh nguai binh thuong,theo 'long hs-CRP

1 hs-CRP la marker viem cua benh mach vanh duoc chi dinh tren lam sang;

2 Berth nhan thuOc nhom nguy co benh mach vanh trung binh (10%-20%) nen duoc chi dinh hs-CRP de danh gia va quyet dinh dieu tri (du pheng), va

3 hs-CRP gitip tien Wong or benh nhan benh mach vanh (bao gom chit va su co mach vanh tai phat)

Tuy nhien huang an nay duoc dua ra nam 2003, tnroc khi c6 kit qua dm nghien ciru JUPITER (diing statin trong pheng benh mach vanh) Cac huang dAn mai hon trng dung kit qua dm nghien dm JUPITER, nhu HOi Tim mach Canada, yeu c'au do hs-CRP cho tat ca benh nhan c6 Ink nguy co trung binh

hs-CRP duoc dung de tai phan nh6m nguy co trong thang diem nguy

co Framingham Thang diem_Framingham duoc chic lam ba nhom nguy co: thap, vira va cao nham uac tinh nguy ca benh mach vanh trong 10 nam Nhom nguy co thap duoc uac tinh c6 < 10% MIA nang bi cac su co mach vanh, nguy co trung binh c6 10 -20%, va cao > 20% Thang nguy

co Framingham c6 lien quan den chin luvc pheng ngira cac sty co tim

Bi61.1 d6 6.2 hs-CRP trong phan tang nguy co, mot s6 nghien ciru

ARIC- Atherosclerosis Risk in Communities study, CHS- Cardiovascular Health Study, EPIC- Evaluation for Prevention of lschemic Complications-Norfolk study, FHS- Framingham Heart Study, HPFUS- Health Professionals Follow-Up Study, Iceland- Reykjavik Heart Study data, Kuopio-Kuopio Heart Study, MONICA- Monitoring Trends and Development in Cardiovascular Disease study, NHS- Nurses Health Study, PHS- Physicians' Health Study, PIMA- Pima Indian study, Strong- Strong Heart Study, UK- British general practice cohort, WHS- Women's Health Study

NHU'NG XET NGHIEM HOA SINN HIEN DAI sir DUNG TRONG LAM SANG

mach., Ngoai ta thy ring vai thang diem Framingham ban du dua va cac yeu to nguy co truy'Ll thOng (khong c6 tinh den hs-CRP) la nang ve y'eu to tuoi, nhieu tniang hop bi uec tinh duai mix (underestimation) nguy co that su, dAc biet là a nh6m nguy co trung binh Trong khi do hs-CRP dugc cho là yeu to nguy co d'Oc lap trong benh mach vanh, viec dua thong so hs-CRP vac) xem xet gidp tai sap xep lai bang phan loai nguy co dAc bit la nh6m co nguy co trung binh, co den 20% — 30% doi‘tuang nhom nguy co tim mach a mac trung binh then Framingham co 'long dO hs-CRP > 3mg/L va dugc xep lai vao nh6m c6 nguy co cao

So vai cac ye'u to nguy co truyLi thOng, hs-CRP IA ye'u CO den lugng manh nhat, ket hop vai cac yeu to tien lugng khac nhu nong dO cholesterol, LDL-cholesterol, triglyceride, va glucose, lam tang kha nang den lucmg benh Ngoai ra cac yeu to nguy co benh mach vanh khac ciang phai quan tam nhu but thuoc la, cao huyet ap va benh dai thao duOng

tugng hoi chfing mach vanh cap nOng,dO hs-CRP CO quan den dO nang, là yeu to gitip tien lugng cac su co mach vanh va tix vong NguOng dugc dung trong truang hop nay IA khoang 10mg/L Tuong tu, nhang benh nhan dp dung di* thuat can thiep mach vanh qua da nhom c6 hs-CRP cao hon se c6 du hau xau hon nhom co nong do hs-CRP thap ve

tan suat bi nhoi mau co tim hay tham chi t* vong

Ngoai uec doan nguy co_tim mach, ian day nguai ta con quan tam den vai tro hs-CRP lien quan den kha nang mac benh dai thao duOng va cao huyet Ap Ngoai c6 hs-CRP > 3mg/L co nguy co mac benh dai thao duang cao han gap 4-6 lan so vai nguai c6 'long do hs-CRP dial) hon

Stalin dugc cho là lam giam nong dO hs-CRP mau va viec giam nay phan len kh6ng lien quan nhieu den giam LDL-cholesterol 0 benh nhan

bi hoi chirng mach vanh cap, nhom co nong dO hs-CRP < 2mg/L sau khi dieu tri bang statin co du hau tot hon nhom co nong dO hs-CRP cao han, ngay ca khi nong dO LDL-cholesterol da giam xuong < 70mg/d1 Giam Ong dO hs-CRP bang statin khong tuang quan truc tiep vai giam nong

dO LDL-cholesterol hay vai lieu dieu tri (statin) VI vay huang clan mai

on dinh phai nhap vien hoac tix vong do- tim mach) khoang 44% (p <

0.001) Vai diem cuoi cua theo doi 1a nhoi mau co tim, thay giam khodrig 55%, trong khi d6 d6t quy giam 48% De,ngan ngira mot su c6, se lugng uac tinh can dieu tri trong 2 va 4 nam lan h.rgt la 95 va 31 Trong mot phan tich phu dia JUPITER, Ridker va cac clang nghiep thay rang du hau tim mach tot nhat a nhung benh nhan dat dugc LDL-cholesterol < 70mg/d1 va hs-CRP < lmg/L sau dieu tri statin

Sir dung aspirin trong viec phong ngixa cac su c6 mach vanh va d6t quy, do thieu matt can than trong vi no lam tang chay mau dung tieu hoa

va cac not khac MOt nghien dru 6 nhang ngueyi nam khOe manh hoan toan, dung aspirin lam giam coy nghia nguy co nh6i mau co tim a nhom hs-CRP tilt phan vi cao nhat (> 2,1 lmg/L; p < 0.001), trong khi do a nhom tilt phan vi thap nhat tai giam khong coy nghia (< 0,55mg/L) Dieu nay cho thay khong nen dieu tri aspirin trong phong nghia tien phat trir nh6m co nong d6 hs-CRP tuong doi cao

Dir lieu nghien ciru tix hiep h6i Sirc khOe cua Thay thu6c (My), nguai tang hs-CRP dung aspirin giam dugc 60% nguy co nhoi man co tim so vai chi 15% a nhom nong d6 hs-CRP thap, cho thay aspirin kh6ng chi c6 tac dung ch6ng ket tap tieu cau ma con giam viem Thong tu, thin nghiem cholesterol va Recurrent Events, ding thay nguei tang hs-CRP dUng pravastatin c6 nguy co tuong doi cila‘cac su c6 mach vanh la 1,3 thap han nhieu so ved nguy co tuong doi bang 3 a nhom dung gia dugc, cho thay pravastatin c6 tac dung khang viem Ngued dung pravastatin c6 trung vi hs-CRP giam khoang 20% trong 5 nam va dOc lap v6i LDL-cholesterol Anh twang tren hs-CRP cting thay tuong to khi dung thuOc khac ding nhom nhu atorvastatin va lovastatin

NHU'NG XET NGHIEM HOA SINH HIEN DAI SO DUNG TRONG LAM SANG

TAI LIEU THAM KHAO

1 Bodi V and F Lorenzo Short-Term Prognosis of Pateints Admitted for

Probable Acute Coronary Syndrome Without ST-Segment Elevation Role of

New Myocardial Damage Markers and Acute-Phase Reactants Rev Esp Cardiol 2002; 55: 823-30

2 Bodi V and J Sanchis Independent role of CRP to predict major events at

one-month and one-year in acute coronary syndrome without ST elevation

Med Clin (Barc) 2004;122: 248-52

3 Melanie Muenzenmaier, Marita Depperschmid, Christian Gille, Christian F Poets, Thorsten W Orlikowsky C-Reactive Protein, Detected With a Highly

Sensitive Assay, in Non-Infected Newborns and Those with Early Onset Infection

Tranfusion medicine and hemotherapy 2008; 35:37-41

4 Nguygn PinIc Nguyen Nghien dru su bien doi ifong do hs-CRP tnrot Nth sau can

thiep deng mach qua da o benh vien Trung trong Hue Tap chi Tim Mach 2007; 47: tr.210 — 217

5 Robert L Bard, Melvyn Rubenfire, Kim Eagle, Nicholas S.Clarke, Robert D.Brook Utility of C-Reactive Protein Measurement in Risk Statification During

Primary Cardiovascular Disease Prevention Am J Cardiol 2005; 95: 1378-1379

6 Snjeiana Rothkrantz-Kos, Maria P.J Schmitz, Otto Bekers, Paul P.C.A Menheerel and Marja P van Dieijen-Visser High-Sensitivity C-Reactive

Protein Methods Examined Clinical chemistry 2002; 18(2): 359-362

7 Thomas A Pearson et al Markers of inflammation and cardiovascular

disease: application to clinical and public health practice: a statement for healthcare professionals from the central for disease control and prevention and

the American Health Association Circulation 2003; 107: 499-511

8 Trtrung Quang Binh Benh Deng Mach Vanh Be:nh hoc NOi khoa 2009; tr

62-75

9 Truang Phi Hung Nghien ciru n6ng do C-Reactive protein mau b benh nhan

hOi chimg mach vanh cap Luan van Nei till 2005: tr 57-59

10 William L Roberts, Linda Moulton, Terence C Law, Genesis Farrow, Margaret Cooper-Anderson, John Savory and Nader Rifai Evaluation Of

Nine Automated High-Sensitivity C-Reactive Protein Methods: Implications For

Clinical And Epidemiological Applications Clinical Chemistry 2001; 47(3):

418-425