THANG BANG ACID - BASE
Bang 9.2. Thanh phin cac chat hffu cd trong ntfdc tieu 24 gid
Thanh phin Ndng d$ Thanh phali Ndng do
Ure 25-30g Acid oxalic 0,015-0,02g
Creatinin M,8g Acid citric 0,2-l,2g
Creatin 0,06-0,15g Acid amin 0,15-0,2g
Acid uric 0,5-0,8g Acid lactic 0,05*-6,2g Acid glucuronic 0,3-l,0g Acid beo 0,05g Acid hippuric 0,l-l,0g
Ure
Ure la thanh phin cd nhieu nhat trong ntfdc tieu. Ltfdng nitd cda ure trong
ntfdc tieu chiem 80-85% ltfdng nitd toan phin cua ntfdc tieu. Stf bai xuat ure do
than la yeu tdquan trong nhat trong viec duy tri can bang dam cho cd the. Stf bai
xua't ure qua ntfdc tieu phu thuoc che do an. Viec dinh ltfdng ndng do ure trong
mau va trong ntfdc tieu la xet nghiem cd ban tham do chtfc nang than. Stf bai xua't
ure tang mot sdtrtfdng hdp benh ly nhtf sot cao, dai thao dtfdng hay tfu nang tuye'n thtfdng than va giam trong trtfdng hdp tdn thtfdng bieu md o'ng than do viem than cap, viem than do nhiem doc chi, thuy ngan.
Acid uric
Acid uric la san pham cuo'i cung cua stf thoai hoa cac base purin. Stf bai xua't acid uric thay ddi theo chd do an.
Ltfdng acid uric trong ntfdc tieu tang trong mot so'benh nhiem khua'n, benh chuyen hoa cda nucleoprotein nhtfbenh bach clu.
Trong benh gout ltfc bat dlu ltfdng acid uric nieu giam dot ngdt, nhtfng tdi ngay thtf ba thi tang dot bie'n. Neu benh dien tien de'n man tinh, nhffng thay ddi
tren trd nen khong rd ret.
Creatinin va Creatin
Creatinin la san pham cda stf phan giai creatin phosphat cua cd va cac cd quan khac. Ltfdng creatinin trong ntfdc tieu rat hang dinh trong nhffng dieu kien
sinh ly khac nhau. Stf bai xua't creatinin trong ntfdc tieu phu thuoc chd ye'u vao khdi ltfdng cd, trung binh d nam khoang 20-26mg/kg/ngay va d nff khoang 14- 22mg/kg/ngay. Ltfdng creatinin trong ntfdc tieu giam nhieu trong cac benh than (viem than) va tang trong cac trtfdng hdp teo cd kem theo thoai hoa cd, ctfdng tuyen can giap hay dai thao dtfdng.
Creatin thtfdng khong co hoac cd rat it trong ntfdc tieu ngtfdi ldn (khoang 0,06-0,15g/ngay). Ltfdng creatin nieu sinh ly tang khi dang ldn, cd thai, cd kinh. Tre em bai tiet nhieu creatin hdn creatinin. Ltfdng creatin nieu tang trong mot so'trtfdng hdp benh ly nhtf viem da cd, bai liet, ctfdng giap va giam trong suy giap.
Acid hippuric
Acid hippuric hinh thanh do stf ket hdp giffa acid benzoic va glycin d gan, than. Ltfdng acid hippuric dao thai trung binh trong ntfdc tieu khoang 0,1-1 g/ ngay.
Acid oxalic
Binh thtfdng chi cd mot ltfdng nhd oxalat bai xua't trong ntfdc tieu. Mud'i oxalat calci thtfdng tua trong ntfdc tidu acid. Oxalat la thanh phin quan trong tao
nen soi dtfdng nieu.
Acid lactic t
Acid lactic la san pham cuo'i cung cda qua trinh dtfdng phan yem khi. Binh thtfdng ham ltfdng acid lactic trong ntfdc tieu khoang 0,05-0,2g/ngay. Stf bai xuat acid lactic tang trong trtfdng hdp co cd keo dai, thieu oxy.
Amylase
Ltfdng enzym amylase binh thtfdng trong ntfdc tieu khoang 16-32 ddn vi Vongemuth/ml ntfdc tieu (<1310 U/l). Nong do nay tang trong cac trtfdng hdp benh quai bi, viem tuy cap.
Ngoai ra trong ntfdc tieu con cd mot ltfdng nhd cac acid amin, cac vitamin (BI, PP, C...), cac hormon steroid va cac san pham chuyen hoa (danh gia chung dtfdi dang cac chat 17-cetosteroid).
2.3. Nhffng chat b£t thtfcfng trong ntfdc tieu
Nhtfng chat bat thtfdng la nhffng chat chi xua't hien trong ntfdc tieu ngtfdi benh. Trong thtfc te, d ntfdc tieu ngtfdi binh thtfdng cung cd mot ltfdng rat nho cac chat nay nhtfng khong phat hien dtfdc bang cac xet nghiem thong thtfdng.
2.3.1. Glucid
Tinh khtf yeu cda ntfdc tidu binh thtfdng la do stf hien dien cda mot ltfdng nho cac ose nhtf glucose, fructose, galactose, arabinose, ribose.
Ose thtfdng xua't hien trong ntfdc tieu la glucose (goi la glucose nieu).
Glucose nieu gap trong trtfdng hdp benh dai thao dtfdng tuy do thie'u insulin, khi do glucose khong thoai hoa dtfdc dan den ndng do glucose trong mau tang vtfdt qua ngtfdng than (l,75g/l) nen bi dao thai ra ngoai va xua't hien trong ntfdc tieu.
Ben canh dd, glucose nieu cQng cd the gap trong nhffng trtfdng hdp glucose
huyet khong cao, do kha nang tai hap thu cda o'ng than giam. Ngoai ra, nhtfng ro'i loan enzym bam sinh cung lam cho xua't hien mot so' ose khac trong ntfdc tieu nhtf
fructose, galactose.
2.3.2. Protein
Binh thtfdng trong ntfdc tieu cung cd mot it protein, khoang 50-150 mg/ntfdc tieu 24 gid. Tuy nhien, d ndng do nay, khong phat hien dtfdc protein bang cac xet nghiem thdng thtfdng. Khi phat hien cd protein trong ntfdc tieu bang cac xet nghiem thong thtfdng thi do la trtfdng hdp protein nieu benh ly. Protein nieu benh ly thtfdng gap trong cac trtfdng hdp so't cao, benh dai thao dtfdng, benh tim mach,
cac benh ve than.
Phan tich protein nieu bang dien di, ngtfdi ta phan biet hai loai protein nieu nguon gd'c clu than va nguon gd'c o'ng than.
2.3.2.1. Protein ni£u clu than
Thtfdng do tang do loc qua clu than hoac do tang do khuech tan khi ndng
do protein trong mau cao.
Protein nieu do do loc tang la khi ntfdc tieu cd albumin va cac protein cd kich thtfdc nhd hdn albumin huye't ttfdng (nhtf hemoglobin, chudi nhe cda globulin trong u tuy...). Trtfdng hdp nay thtfdng do tdn thtfdng clu than lam tang do tham tha'u cda than, gap d cac benh ly nhtf viem clu than, viem than nhiem md.
Protein nieu do do khuech tan tang la khi ntfdc tieu cd albumin va cac protein cd kich thtfdc ldn hdn albumin. Thtfdng gap trong trtfdng hdp ndng do protein d mau clu than tang hoac khi cd stf tf dong ltfu ltfdng clu than tiep giap vdi
mang loc. Vi du: protein nieu trong suy tim, tac tinh mach than, cd thai...
2.3.2.2. Protein nieu do ong than
Trtfdng hdp nay it gap hdn, trong ntfdc tieu xua't hien cac protein cd trong Itfdng phan ttf nhd hdn albumin (dac biet la a2 va p2 microglobulin). Nguyen nhan
la do ro'i loan tai ha'p thu protein da dtfdc loc binh thtfdng bdi clu than. Thtfdng gap trong cac trtfdng hdp tdn thtfdng bam sinh dng than d tre em, ngo doc bdi kim loai nang. Ngoai ra cung cd the gap protein nieu do viem hoac tdn thtfdng doan dtfdi cda dtfdng tiet nieu, bang quang hay nieu quan, goi la protein nieu sau than.
Khi chan doan cac benh lien quan den than, cln phan biet rd ve mat trieu chtfng hoc. Ne'u tinh trang protein nieu xay ra lien tuc (hay thtfdng xuyen) thi cd the la do cac benh ly ve than gay ra. Ne'u tinh trang protein nieu xay ra khong lien tuc (gian doan) thi cd the la do ro'i loan chtfc nang, trtfdng hdp nay thtfdng do gang stfc, lao dong nang, do dtfng lau hay do van mach,"ret, cam dong.
Khi dien di protein nieu, ngtfdi ta phan biet dtfdc 4 loai protein nieu benh ly : ... - Protein nieu toan phin : cd mat tat ca thanh phin protein huye't thanh, gap trong viem clu than nang.
- Protein nieu chon loc : chu ye'u cd albumin huye't thanh va p-globulin, gap trong hoi chtfng than cd ton thtfdng nho d clu than.
- Globulin nieu chon loc : chd yeu cd oc2 va p-globulin, ty le albumin huyet thanh thap, do nguon goc o'ng than, gap trong viem o'ng than ke cap, viem o'ng than bam sinh, benh Wilson, galactose nieu.
- Protein nieu Bence-Jones: cd p, y-globulin vdi stf hien dien cda albumin huyet thanh hoac khong, con goi la protein nhiet tan (chi tua d 60-70°C), gap trong da u tuy xtfdng.
2.3.3. Cac chfi't cetonic
Ntfdc tieu binh thtfdng chtfa khoang vai mg acid acetyl acetic/lit va vai tram
mg acid P-hydroxybutyric. Cac chat cetonic tang trong rdi loan chuyen hoa glucid
(dai thao dtfdng), ddi va trong tang chuyen hoa lipid.
2.3.4. Sac to'mat - Muo'i mat
Trong ntfdc tieu xua't hien bilirubin lien hdp va mud'i mat trong trtfdng hdp vang da do viem gan va vang da do tac mat. Bilirubin lien hdp trong ntfdc tieu dtfdc goi la sac td mat. Trong tdn thtfdng gan, ntfdc tieu cung cd mot ltfdng urobilinogen,
la chat tao thanh ttf ruot va gan khong giff lai dtfdc.
2.3.5. Hdng cau va Hemoglobin
Hdng clu xua't hien trong ntfdc tieu gap trong viem than cap, lao than, ung
thtf than, sdi than...
Ntfdc tieu cd hemoglobin gap trong sd't ret ac tinh, vang da do tieu huyet,
bong nang...
2.3.6. Porphyrin
Binh thtfdng ltfdng porphyrin bai xua't ra ntfdc tieu khoang 50-200mg (copoporphyrin I va II). Hai loai porphyrin nieu bao gdm porphyrin vd can do di truyen, do thie'u enzym cda qua trinh tdng hdp hem va porphyrin nieu thtf phat, do nhiem doc dan den tfc che stf tdng hdp hem.
2.3.7. Dtfdng chap
Dtfdng chap la cac thanh phin cda dich bach huyet tran vao ntfdc tieu khi mach bach huye't vung than hay bang quang bi vd. Dtfdng chap lam cho ntfdc tieu trang due nhtf ntfdc vo gao, thtfdng cd trong ntfdc tieu benh nhan bi giun chi.
2.3.8. Can va soi
Cac loai can lang trong ntfdc tieu bao gdm gdm: acid uric,mud'i urat, carbonat, oxalat, phosphat..., doi khi la cystin, tyrosin, leucin. Cac can nay lang ket lau ngay cd the tao soi va tuy theo vi tri cd the tao sdi than hay sdi bang quang.
3. THLf NGHIEM THAM DO CHtfC NANG THAN
De danh gia tinh trang va chtfc nang loc cda than, ngtfdi ta thtfdng khao sat
cac chi tieu nhtf protein nieu, can nieu , ndng do ure trong mau, ndng do creatinin trong mau. Dac biet, viec khao sat ure va creatinin huyet con giiip tien ltfdng stf tien trien cda benh, nhat la viem than man. Tuy nhien, viec danh gia chtfc nang than bang cac chi tieu tren la khong dac hieu, vi con phu thuoc vao nhieu dieu kien khac. De cd the danh gia chinh xac, thtfdng ngtfdi ta thtfc hien cac nghiem phap tham do chtfc nang than.
3.1. Do thanh thai (Clearance)
Do thanh thai cda mot cha't la sd ml huye't ttfdng dtfdc loc het chat dd qua ntfdc tieu trong thdi gian mot phut.
Cong thtfc:
C: do thanh thai, tinh theo ml/phut
U: ndng do chat dtfdc thanh loc trong ntfdc tieu (mg/ml)
- P: ndng do chat dtfdc thanh loc trong huyet ttfdng (mg/ml)
V: the tich ntfdc tieu (ml/phut)
Do'i vdi ngtfdi binh thtfdng mdi chat deu cd do thanh thai rieng.
Nhffng chat dtfdc loc qua clu than, khong bi tai ha'p thu va khong dtfdc bai tiet them d o'ng than, cd do thanh thai khoang 120ml/phut. Dd thtfdng la cac chat
ngoai lai dung de didu tri hay chan doan nhtf inulin, manitol. Do thanh thai cda
inulin hay manitol phan anh do loc Cua cau than.
Nhffng chat dtfdc loc qua clu than, cd bi tai ha'p thu va khong dtfdc bai tiet them d o'ng than, cd do thanh thai dtfdi 120ml/phut. Creatinin dtfdc diing phd bie'n nhat vi it bi tai ha'p thu va bai tiet them. Binh thtfdng do thanh thai creatinin khoang
75-120ml/phut tuy theo tudi va trong ltfdng cd the. Do thanh thai creatinin nhd hdn 75ml/phiit chtfng td chtfc nang loc clu than kem. Do thanh thai creatinin cd y nghia va thtfdng dtfdc stf dung trong sinh dtfdc hoc va dtfdc lamsang.
Ngoai ra cd the xac dinh do thanh thai cda PAH (para amino hippuric) de do ltfu ltfdng mau than vi PAH vtfa dtfdc loc d clu than, vtfa dtfdc bai tiet them d o'ng than. Do thanh thai cda PAH binh thtfdng la 600-700ml/phut. Do thanh thai nay dtfdi 500ml/phut thtfdng gap trong cac trtfdng hdp ltfu ltfdng mau trjan kem, do tdn thtfdng clu than, dng than, hay nghen dong mach than.
3.2. Nghiem phap Zimnisky (nghiem phap 8 cd'c)
Nghiem phap Zimnisky (hay nghiem phap 8 cd'c) dung de danh gia kha nang thich nghi cua than theo trang thai sinh hoat cda cd the (thai nhieu khi an
nhieu, uong nhieu).
Nguyen tac cda nghiem phap nhtf sau:
- Ntfdc tieu dtfdc lay ttf 6g sang ngay horn trtfdc den 6 gid sang ngay horn sau va ntfdc tieu trong mdi 3 gid dtfdc gom thanh mot mau. Nhtf vay, trong 24 gid se cd
8 mau.
- Do the tich ttfng mlu (va ty trong ne'u cd the)
Ket qua: than dtfdc xem la thich nghi to't khi mau ban ngay cd the tich ldn hdn mau
ban dem.
Ne'u stf khac nhau khong dang ke chtfng td than thich nghi kem, thtfdng gap
trong viem than man tinh, suy than.
TAI LIEU DOC THEM
1. Bd mdn Hda sinh-Trtfdng Dai hoc Y ha Ndi. Hda sinh, NXB Y hoc Ha Ndi,
2001.
2. Bo mon Hda sinh - Dai hoc Y dtfdc TPHCM, Hda sinh y hoc NXB Y hoc TP
HCM 2003
3. Bd Y Te, Vu Khoa hoc va Dao tao, Hda sinh hoc, NXB Y hoc Ha Ndi, 2005 4.R.K. Murray, D.K. Granner, V.W. Rodwell-Harper's Illustrated Biochemistry 27th edition-Lange Medical Books/McGraw-Hill, 2006.
5. F. Percheron, R. Perles, MJ. Foglietti, Biochimie structurale et metabolique,
Tome 1, Masson, 1992.
6. P. Valdiguie, Biochimie clinique, EM Inter, 1993.
7. C.A. Burtis , E.R. Ashwood, D.e. Bruns - Tietz Textbook of Clinical Chemistry
and Molecular Diagnostics 4th edition- Elsevier saunders, 2006.
CAU HOI TU LI/0NG GIA Chon mot diu tra ldi dung nhat
1. Than bai xua't cac chat cd hai hay khdng cln thie't ra ngoai cd the dtfdi dang ntfdc tieu thong qua cac qua trinh:
a. Sieu loc d cau than
b. Tai ha'p thu va bai tie't d clu than c. Tai ha'p thu va bai tie't d o'ng than
d. a va c dung
2. Mdi ngay cd khoang 180 lit ntfdc tieu ban dlu dtfdc hinh thanh. Ntfdc tieu ban dlu cd thanh phan nhu* huye't ttfdng nhtfng:
a. Khdng cd cac protein cd trong Itfdng phan ttf ldn hdn 7000 b. Khdng cd cac protein co trong ltfdng phan ttf ldn hdn 70000 c. Khdng cd cac protein cd trong ltfdng phan ttf ldn hdn 700000 d. Khdng cd cac protein cd trong ltfdng phan ttf ldn hdn 50000
3. Qua trinh loc d clu than la nhd vao ap ltfc hieu dung Pf = Pg - (Po + Pc), trong dd Pg la:
a. ap sua't keo cda huye't ttfdng
b. ap sua't thdy tinh trong bao Bowman c. ap sua't thdy tinh trong clu than d. ap sua't thdy tinh trong huyet ttfdng
4. Glucose la chat cd ngtfdng than cao (1,75g/l). Vi vay glucose la chat:
a. Dtfdc tai ha'p thu hau het b. Dtfdc tai ha'p thu hoan toan c. Dtfdc tai ha'p thu mot phin d. Khdng dtfdc tai ha'p thu
5. Stf tai ha'p thu natri thtfdng kem theo stf tai ha'p thu ntfdc va nhieu chat tan
khac. Natri la chat:
a. Dtfdc tai ha'p thu hau het b. Dtfdc tai ha'p thu hoan toan c. Dtfdc tai ha'p thu mot phin d. Dtfdc tai ha'p thu phin ldn
6. Chtfc nang bai tiet cda than nham loai bo khdi cd the cac san pham chuyen hda cuoi cung va bat ky nhtfng chat vd cd dtfthtfa trong che do an. Cac chat sau dtfdc bai tiet vao o'ng than khi ndng do trong mau cao, ngoai trtf:
a. Kali b. Creatinin
c. NH4+
d. Manitol
7. Do pH cda ntfdc tieu thtfdng:
a. Kiem
-. .. b. Hdi kiem c. Hdi acid
d. Trung tinh
8. Cac chat cetonic trong ntfdc tieu:
a. Tang trong ro'i loan chuyen hoa glucid (dai thao dtfdng)
b. Giam khi tang chuyen hoa lipid c. Tang khi giam chuyen hda lipid d. a va c dung
9. Acid uric la san pham cuo'i cung cda stf thoai hoa cac base purin, trong ntfdc
tieu acid uric:
a. Tang trong mot so benh nhiem khua'n
b. Giam trong benh chuyen hoa cda nucleoprotein (benh bach cau)
c. Thay ddi theo che'do an d. a va c diing
10. Chat dtfdc tai ha'p thu hoan toan d than:
a. Bicarbonat b. Kali c. Glucose
d. a va c diing
11. Chat dtfdc tai ha'p thu hlu het d than:
a. Inulin b. Manitol
c. Natri hyposulfid
d. Bicarbonat
12. Cac chatbat thtfdng trong ntfdc tieu bao gdm:
a. Glucose b. Protein
c. Sac to' mat-muo'i mat d. Ca 3 deu dung
13. Chtfc nang loc clu than kem khi do thanh thai creatinin:
a. < 65 ml/phut b. < 75 ml/phut c. < 85 ml/phut d. < 95 ml/phiit Chon tap hdp cau diing
14. Cac chtfc nang cda than bao gdm:
a. Dieu hda thang bang acid - base
b. Tham gia vao mot so'chuyen hda cac chat
c. Khtf doc
d. Chtfc phan noi tie't
15. Than dong vai tro chinh trong viec duy tri thang bang acid - base thdng qua
cac cd che'sau :
a. Stf tai ha'p thu bicarbonat
b. Stf dao thai natri
c. Stf tai tao lai bicarbonat bang each dao thai ion H+dtfdi dang acid dinh
Itfdng
d. Stf tai tao lai bicarbonat bang each bai xua't NH4+
16. Cac nguyen nhan sinh ly va benh ly lam thay ddi the tich ntfdc tieu :
a. Tudi
b. Dai thao dtfdng c. Viem clu than
d. Nhiet do va do am cda khong khi 17. Do thanh thai C=U.V/P , trong do:
a. C la do thanh thai, tinh theo ml/phut
b. U la ndng do chat dtfdc thanh loc trong ntfdc tieu, mg/ml c. P la nong do chat dtfdc thanh loc trong huyet ttfdng, mg/ml d. V la the tich ntfdc tieu, ml/phut
18. Trong nghiem phap Zimnisky (nghiem phap 8 cd'c) de danh gia kha nang thich nghi cda than theo trang thai sinh hoat cda cd the:
a. Ngtfdi ta lay mau ttf 8 gid sang ngay hdm trtfdc den 8 sang ngay horn
s a u
b. Ntfdc tieu sau moi 3 gid dtfdc gom thanh 1 mau c. Do the tich ttfng mlu (va ty trong neu cd the)
d. Than thich nghi to't khi mlu ntfdc tieu ban ngay cd the tich ldn hdn mau
ntfdc tieu ban dem
19. Protein nieu benh ly thtfdng gap trong cac trtfdng hdp:
a. Sot cao
b. Benh dai thao dtfdng
c. Benh tim mach d. Cac benh ve than.
20. Stf bai xua't ure do than la yeu to'quan trong nhat trong viec duy tri can bang dam cho cd the. Stf bai xua't ure tang trong mot so'trtfdng hdp benh ly
nhtf:
a. Sot cao
b. Dai thao dtfdng
c. Lfu nang tuyen thtfdng than
a. Ton thtfdng bieu mo o'ng than do viem than cap