Nghiên cứu nồng độ beta2 microglobulin máu ở bệnh nhân suy thận mạn tính lọc máu chu kỳ

BỘ GIÁO DỤC VÀ ĐÀO TẠO BỘ QUỐC PHÒNG
HỌC VIỆN QUÂN Y
NGUYỄN HỮU DŨNG
NGHIÊN CỨU NỒNG ĐỘ BETA2-MICROGLOBULIN MÁU
Ở BỆNH NHÂN SUY THẬN MẠN TÍNH LỌC MÁU CHU
KỲ
LUẬN ÁN TIẾN SĨ Y HỌC
HÀ NỘI - 2014
BỘ GIÁO DỤC VÀ ĐÀO TẠO BỘ QUỐC PHÒNG
HỌC VIỆN QUÂN Y
NGUYỄN HỮU DŨNG
NGHIÊN CỨU NỒNG ĐỘ BETA2-MICROGLOBULINMÁU
Ở BỆNH NHÂN SUY THẬN MẠN TÍNH LỌC MÁU CHU KỲ
 Nội Thận - Tiết niệu
 62.72.01.46
LUẬN ÁN TIẾN SĨ Y HỌC
NGƯỜI HƯỚNG DẪN KHOA HỌC:
1. PGS. TS. Hoàng Trung Vinh
2. PGS. TS. Lê Việt Thắng
HÀ NỘI - 2014
LỜI CAM ĐOAN
 !"#$
%&%"' (%)*)+,
,-!.! 
Tác giả luận án
NGUYỄN HỮU DŨNG
MỤC LỤC
,
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/0$1
22

3%"4
52,$
52,67
52 Trang
ĐẶT VẤN ĐỀ 1
Chương 1 3
TỔNG QUAN 3
889:)1%;':<=
888> &?@AB%':<
88CD6&?'':<
88=E:':<
88F9;A':<
8C9;A"',G':8H
8C8':4#)0%I J
 
8CC K)1K K A&#$':
8=LM,NCO,P,&':<CC
8=8-Q?R+K%6S,NCO,
8=CD"R7T,NCO,P,&'
:<
8==D"#"UVCP,&J 
!.
8=F ,&K K$7T,NCO,
8FT%;,"R7T,NCO,P,&
':<J !.=W
8F8 )X
8FC )X
Chương 2 36
ĐỐI TƯỢNG VÀ PHƯƠNG PHÁP NGHIÊN CỨU 36
C89)+=H

C88I(J)+
C8CI:*)+
CCE)1K K=Y
CC8ZT@
CCC II ?K:?  [@2
F\
CC=E)1K K[]&
CCFL-;:
Chương 3 59
KẾT QUẢ NGHIÊN CỨU 59
=89^6)+_\
=CD"R7T,NCO,P,&HF
=C8D"R7T,NCO,PS%
S
=CC#37TVC%XT^6
,&
==`&#$JVCP,&[@2K)1%#$JS&
J! a_
==89^6 S)X!&K;A
==CD"RTb ?" K%,"P K
S[@2K)1K K%#$JS&J! 

===`&#$JVC KS[@2K)1J
%#$JS&J! 
Chương 4 87
BÀN LUẬN 87
F89^6)+Ya
FCD"R7T,NCO,%#%XT
P,&!\a
FC8D"R7T,NCO,P,&c

/>
FCC#3,NCO,%XTP
,&c/>
F=`&#$JVCP,&[@2K)1%#$JS&
J! 88W
F=89^6%&#$J KS88W
F=C`&#$J,NCO, KS88H
KẾT LUẬN 121
KIẾN NGHỊ 123
DANH MỤC CÁC CÔNG TRÌNH CÔNG BỐ KẾT QUẢ NGHIÊN CỨU
CỦA ĐỀ TÀI LUẬN ÁN 124
TÀI LIỆU THAM KHẢO
PHỤ LỤC
DANH MỤC CÁC CHỮ VIẾT TẮT
BMI: D@@Ndb!16e
β2M: DNCO,
CKD: >@N5NNdD&':e
CRP: OfN%NKNdENK$e
HBV: `NKDd%%De
HC: `7g
HCV: `NKd%%e
HDF - OL: `N@hNdI J ,i@A
("K*@AJe
Kuf: jhONhhNd&Je
MLCT: Jg'
PN: ES
R.O: fN%NNkdI-)+e
STMT LMCK:c':<J !.
STMT: c':<
STMTGĐC: c':<:

TG: N@
THA: U" K
TNT: ':
UF: jhdcJe
VCTM: Lg':
VTBTM: L',6':
DANH MỤC BẢNG
Bảng Tên bảng Trang
D$88E:':<
D$8CE:'
D$8=E:,&':<
D$8FZ7TVC,)0T@AJ16
)0
D$C8Kg@AJ
D$CCET" 
D$C=E::K@ NT:L&Z
D$CF b ,)0
dlm&SD&%&D:e
D$=8c R?X3S
D$=CE,,&NR?Xdn=CHe
D$==Z':<
D$=FE,,&N0J dn=CHe
D$=_9^6" KS,&
D$=H9^6" S,&
D$=a9^6DoS,&dn=CHe
D$=Yp&,&ST)0gR
%!XK%
D$=\>"#$Tm&'S,&
dn=CHe
D$=8Wp&B`DL?`LS,&dn=CHe


D$=88D"R7T,NCO, 
S,&%S
D$=8Cp&,&S7TVC U1S
dn=CHe
D$=8=Z7TVC NXSdnFYe
D$=8FZ7TVC NXS,&
dn=CHe
D$=8_/#7TVCNSRdn=CHe
D$=8HD"R7TVCN0J dn=CHe
D$=8a)1#37TVC %X0J 
dq/e%7TfE dn=CHe
D$=8Y/#7TVCP,&N
':<
D$=8\/#7TVCNS,&S:
B^!B%%
D$=CW/#7TVCNS,&S:
B`DL?`L! 
D$=C8/#7TVC%X:,$7)X6
dn=CHe
D$=CC/#37TVC%X, dn=CHe
D$=C=/#7TVCN:" ,&
dn=CHe
D$=CF/#7TVC%X:*KgK@
 S,&dn=CHe
D$=C_/#7TVC%XDoS,&
dn=CHe
D$=CH)1#37TVC %X7TKK%
N dn=CHe
D$=Ca9^6r)X!&K

D$=CYp&U" KP KS)X&K
D$=C\c  A,TTJ3
 KS
D$==Wc 7TNP KS[@2
#$Jgg
D$==8c 7TNP KS[
@2#$Jgg
D$==Cc &#$J KS[@2#$J
gg@(%bjff
D$===c &#$J KS[@2#$J
gg@(%b>sL
D$==FD"R7T&$[@2#$Jgg
D$==_D"RD?`N,?,?fE%DoH 
;A
D$==Hp&U" KP S,&[@2K)1
J! H ;A
D$==ag--&T,"PS
D$==Yc &#$JVCP KS[@2#$
Jgg
D$==\c &#$JVCP KS[@2#$
Jgg@(%bEfOVC
D$=FWc &#$JVCP KS[@2#$
Jgg@(%&$VCd>@e
D$=F8D"R7TVCH ;A
D$F8q A,VC T
D$FC#3&J%X!$UJ -
 K)1K K%#$JS&J! 
DANH MỤC BIỂU ĐỒ
Biểu đồ Tên biểu đồ Trang
D67=8E,,&N':<HW

D67=Cp&" S,&HC
D67==c  A,VC3SH_
D67=F)1#37TVC%X0J HY
D67=_Z7TVC ,S,&HY
J t_U%u_UHY
D67=H)1#37TVC%XfE H\
D67=a)1#37TVC%X7TKK a_
D67=Y)1#3VC%X7TN )XTJa_
D67=\D"R7TVC TJggP K
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D67=8WD"R7TVCH ;AP S,&
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DANH MỤC HÌNH
Hình Tên hình Trang
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`C8c17)1JF_
`CCc17)1ZF_
ĐẶT VẤN ĐỀ
c':TT% "6:<
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:?J,2%mK'/J,2TK)1K K;A
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,":^%b(&)+!)S&K:
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:" K@2K)1K K
/J ,G':!.TK)1K K;A"
@2- )0+K':':
)+ K@2KR,"%!x'!K:K?&#$?:"
K)1K K,&K2T% D$':b
$#")+Q)X@)*%$ -TMD&
J !m@@B-& ,"#):<?
,&]g!?)1!XK?SK$!6" ,"@
J,NCO,dVCevF=w?vH_w?v8Caw  @:,T@
JVC,")0^KP,&':<
:J !.q:g?(4JVC T(
"K%X!XK% -Q#!XK?Sy$)P
SS1#S?:/4JVC![%?
)!XK?$)P"U&%'T`&
J ,G#$JS&J-K%rKR,"?T
1
3&VCLX(K 6!J
&?gS3J&JS6J)+ -
SJ)+K[,SSVCvYHw?v88_wc%X
(K 6J?I J ,i@A("K*@AJ
d`N@hNO`5zOk/e)+ K@2?:&#$?S 
@2:,{)+ -SJ)+K[{?,%T
!NvYHw?v88_w
"XS;;#"VCP,&
':<J !.?;'K"1",&?,"
#"(4JVC% ,&K K@(KM?;A>"#$
!|AUVC^KKR,"P,&':
<J !.?#"T"1,&
})%&[@2 :J! v8Ww?vYYw?v88awZ"[
@2#$JS)1+KJ%&J!~I

 J yS @2$ !67TVC  ;
)X!$ ,"R7TVC%&#$I
 JN6$b))+;'Kg5S
Q(&;•Nghiên cứu nồng độ beta2-microglobulin máu
ở bệnh nhân suy thận mạn tính lọc máu chu kỳ" %X2
1. Khảo sát nồng độ beta2-microglobulin máu và mối liên quan với một
số thông sốở bệnh nhân suy thận mạn tính lọc máu chu kỳđược sử dụng quả
lọc có hệ số siêu lọc thấp.
2. So sánh kết quả lọc beta2-microglobulin bằng 3 phương thức: sử
dụng màng lọc có hệ số siêu lọc thấp đơn thuần, sử dụng màng lọc có hệ số
siêu lọc thấp kết hợp với màng lọc có hệ số siêu lọc cao và sử dụng màng lọc
có hệ số siêu lọc thấp kết hợp với thẩm tách siêu lọc bù dịch trực tiếp từ dịch
lọc thận (HDF online).
2
CHƯƠNG 1
TỔNG QUAN
1.1. Đại cương về suy thận mạn tính
1.1.1. Khái niệm, dịch tễ và nguyên nhân suy thận mạn tính
c':'#$i ,&'?"&:<
U'$@g)1%X)+NK',AR
)1%-U!7K2c':Jg
'$?%N U?:,G)X&$?
:,G!;%: UT"! '
# "6':S*+^%i
@r"':?Q'-U?
M{K$;A"'vaw?v88w?v8Yw
Z)0-G?!)+NKU$a_€
Jg'$_W€%X,)0?QX,4g-& 
&':vY_w• "6,&*!S
,&'"!':,8WU?}S6

b_U^CWUv=Cw?vFWwc'"6'.
T%% +"6^,&
Z@ABJ-p&'^KPX
d8?=8e?P3!%(~S%P3S@T^,&)
)0‚^)0,NvFCw?vFFw?v_Ww?v_8wZUCWWa?Px
S-Kb_8FHFC,&':%Xp&4X=_=
,&ƒ&@TUva8w?vYCw?v88Hwp&1P
)0xK%X!$\\a,&ƒ&@TU%P
)0x@4CaC,&4Xƒ&@TU
3
vHaw?vHYw?vaCw:L&?)+'X4!$_WW,&
s&@sUvaHw
Z':<S;:! ?)0@T
 ,7,&g'?,&!y'?,&
: '?,&,I%@;„vaw?v88w
1.1.2. Biểu hiện lâm sàng, cận lâm sàng của suy thận mạn
tính
* Biểu hiện lâm sàng:@:iNT'%,&
26D&S3,6&P1#,P
'$^-UJ@r"J -T
 ?:&$?,GO,N$)P"-$ 1
#16vCWw?v88\w
…5)0S +@" %J $KI
6 ?S6S@4J
…Ei':@%g':)0Ki?)+:%
'O,6':)0!SKi?P:S6Ki@
6@)†
…" T" )1%XT^
'" @':)0" |4?4"
 ,  )0? !  - ‡ K$   U   7  g  P  p

)15,&K$U!%S:-K4PT@R
)1S" ':)0@r
"" )+4v8_w?vH=w "%1",&
  "        '  :  <dce  ,  7  "  2
NKNdˆEke?$07g?BTp)1@(
<2N% -6 ! "$-7gp
)1?$-K4%$!$U%'64?"2%
4
%KN@,& U?U!!N"2KN?
h?4%T%g"# :7gv8Yw?v888w
…D6&%;:,":^K!$_W€OYW€
,&,A':,7
OU" K^K!$YW€,&':SU
" KD&c-&U" Kd`‰eQI
# "6X':<:dcq9e?
70U1,&:%Up& [%v\Ww?
v88FwZ%3"`‰P,&c@3
O)X?  U  : <  &   fN  O  ‰N  O  ‰@NN
df‰‰e?&g!$?)0' K:K U
 ?":T,1Z
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O>
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‰EN?^" :<v==w?
vHHw?v8WWw
O  L        !  ^  S  @A  -  &  P,&  
cq9% ?,6&)%
@! )S^6! ,A 
OD&1@ d,&1BTeE:- 
-)0^Kc%Xp&FW€?P,&J !.^K

XHWOYW€p&K:- UNT$U
'?P3,&SJg'_WsKQCH?a€?MP
3,&SJg'*C_"_WsKQ%@)XC_sKQ
p&=W?Y€%F_?C€)1 "K
:- `‰?" ?%@A?)0' K:
K ?:&g!(Tv\\w?v8C=wS?" 
T"#JQI# K:- ZZ@
dCWW\e-?p&K:- P3,&`‰Sc
1;%Xp&P,&`‰SU',)0
dFa?8€%X=8?8F€ev\\w
5
OD&:% ,6&,&:%PDZc
)0!‡?S6$P ,&dDZe !ŠKT
:%?-P3DZK:- ‡?S3)X;
^" ^>$CWOFW€DZcS,&" 
2,Tg^d!‡ &" 1
ev_w
OD&%Z"@%S%%R@)X
%? ,7},&]%R)1%
"P?<!ŠK%. )0^K1$%S% ?
"K"%S%T:NT $?%S%
 "C8€3,&J !.?p&% %^K
Ca?=€P,&c%^K=Y?\€P,&J !.vF8w?
v_Fw?v8C8w
Of:AK"@:&$dU>
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 evC8w?,&:%?
Oc'#$JO)X%U" K
^ R)1),&%?,&1?
^@:AK?" :v8WWw„

…& 
q:g?,& U?,7%?:S
6b$?m:&%)0 R)1)0
 P,&c})3,&! )0,4g,G
3: GTq:g?,&c)0
SU"@A@:@` d@N@e?KNKN?
:U")+@$Jg'?,&
4?(U`
…
!" )+,P)+"vF\w?
v8=YwT $G,&c)0SN:%
6
N"@:@$`@A@:@U7T
qU)+@AT@$)P"
T14%A
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8
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 KvY_w?v88\w
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> :•Ndq`eT,",&':
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,A'vCFw?vHCw
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K@dE`e•@;1"$6
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* Biểu hiện cận lâm sàng:
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OZ1KKN d:@&%NeUZ7T
 K2T%"TU%T  KN16
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9
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O2&S6-2:^2?27g?2,:
g„iN<-R)1g'
Oj?N&-K'^%N&

-K
ObJ% K(I-)X6P,&':b
J)X6% K(I-)X6-K>'^S
7pJ)X6-K3 r)X6%SA
!$8?W8W• K(I-)X6!$=WWks!Z"@%
'O,6':bJ%TI-)X6-K*!
%N )U
… &K KU@MU'
10
OJg'd/eJg'$uHWsKQ•
'^Jg'$
O>$U^)X6'$
1.1.3. Phân chia giai đoạn suy thận mạn tính
c':<"6N0? 1%AU',A
K @g$Jg'?<} T-% ,"
'ZBLUl':F:@(
%&$NT%7TN v=8w
Bảng 1.1: Phân chia giai đoạn suy thận mạn tính
Giai đoạn
suy thận
Hệ số thanh thải
creatinin
(ml/phút)
Creatinin máu
mg/dl µmol/l
o HW‘F8 u8?_ u8=W
oo FW‘C8 8?H‘=?_ 8=WOC\\
ooo CW‘88 =?H‘H?W =WWOF\\
ooo, 8W‘_ H?8‘8W _WWOY\\
oL u_ ’8W t\WW

* Nguồn: theo Nguyễn Văn Xang (2008) [31]
R)1':<"6':S6!m@_
O8WU^1iN($Q)+NKU?,6
&,G$Jg'5(NTM,iKg'
‰,N“q':F:v==w
11
Bảng 1.2: Phân chia giai đoạn suy thận
Giai đoạn
suy thận
MLCT
(ml/phút)
Creatinin máu
(μmol/l)
Chỉ định điều trị
q:,i aW‘F8 u8== D$7
q:M,i FW‘88 8==OaW\ D$7
q:-,i 8W‘_ a8WO8WHF
9;A"
q: u_ ’8WHF
* Nguồn: theo Abuelo J.G. (1995) [33]
>"     N  Z  >@N  z@”  >@N  5NN
kN•o%NdZ>zO>s5k•oeUCWWCv8WWwK:,&
':<@(%Jg')
Bảng 1.3: Phân chia giai đoạn bệnh thận mạn tính
Giai
đoạn
Biểu hiện
MLCT
(ml/phút/1,73m
2

)
Chỉ định điều trị
1
R  )1  '
)    J  g
',)0^
U
t\W
I %;A 
,&  !"  +K?     "  
  1    :?  
'  #    "  6
,&'
2
R)1'
$ŠJg
'
HWO\W
>6  "
1?  ,& !"  +K  
'"6,&'
3
q$    J  g
'T%*
=WO_\
I %;A 
,"    @  ,&  '

4
q$    J

Jg'
8_OC\
I,A K)1K K
;A"'
5 c' u8_
D4,T;A"
d"STUN
 e
* Nguồn:theo NKF-K/DOQI (2002) [100]
12