SINH L Y BENH
HOC
THAN
•
•
•
Than la eo quan sinh mang, do do nhirng benh than anh huong d€n to an bQ eo the.
Cau true than g6m nhtrng nephron, m6i nephron g6m cfiu than va 6ng than, nen benh ly
than la nhimg benh thuocc cfiu than va 6ng than.
Suy than la mot benh ly trfim trong, ma viec diSu tri la rftt kho khan, neu khong n6i la
tuyet vong.
Sau day ta se diem qua nhfrng benh than va nhirng r6i loan do chung gay ra.

1. B~nh viem c§u th~n cip (acute glomerular nephritis)
. 1.1. B?nh nguyen: do phan img mi~n dich lien quan d€n nhiem lien cfiu khu~n dung
nhom A, type 12 gay viem miii hong

huyet (streptococcus),

a tu fin thir

2, thtr 3.

55% do viern miii hong, amygdale, 25% do viem da, rang, phoi, con lai la do

viem

a cac noi khac
Benh hay gap

a tre

em.

Sinh thiet than khong tim thfty lien du, ma chi thay cac san pham cua phirc
hop mien dich g6m khang nguyen va khang the chong lien eau, cac IgG, IgM va cac
manh b6 the.

a mang

Cac san pharn nay lang dong

day gitra t€ bao noi mo cua maD mach va

t€ bao bieu mo cua cfiu than.
Thir huyet thanh thay tang khang the chong lien eau, cac san pham cua lien eau,
khang the chong than, hieu gia b6 the giam.
ThlJC nghiern: Masugi, dung khang huyet thanh vit chong than tho, tiem cho

tho, cavelti dung than tho nghien tron voi dQc t6 cua lien cfiu khuan, r6i tiem cho
tho, gay duce benh viem cfiu than. Bang chirng tren chirng to benh la do hau qua cua
cac phan irng mi~n dich khang nguyen - khang the x~y ra

a rnao

mach du than -

mang day.

1.2. Guchlb?nh


sinh:

1.2.1. Cac sari pham mi~n dich tu 6 nhiem trung tien phat (miii - hong) theo mau
d€n l~ng dong

a eau than.

0 day

voi

Sl,I

tham gia cua b6 the gay ra mot loat

cac phan irng nhir phan ung tieu, ph an irng viern, phan irng hoat h6a h~
dong mau, lam t6n thuong du than.
1.2.2. Dong thoi phirc hop khang nguyen - khang the eo the lien k€t voi cac cftu
true cua du than tao thanh mot phirc hop moi eo dac tinh khang nguyen.
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--~,


K~t qua tao ra mot qua trinh tu mi~n dich cua eo thS d6i voi chinh t6 chirc

than cua minh (khang thS chong than).
1.2.3. Cac san pham cua phan img mien dich gay h6a huong dong d6i voi bach
cAu trung tinh va dai thirc bao, dfrn d~n t6n thirong cac t~ bao nQi mo cua
mac mach cAu than.

Hau qua cua nhtrng qua trinh tren lam t6n thirong eau than, lam giam mire
loc cAu than, dfrn d~n thieu nieu va vo nieu, va dS lot protein va cac t~ bao
mau ra mroc tieu
Viem cAu than cAp la mot benh rAt nguy hiem, n6 c6 thS dfrn d~n suy than
cdp voi ure huyet tang cao va tu vong.
N~u virot qua nguy hiem benh c6 thS khoi, nhirng cling eo thS tro thanh
benh viem than man tinh, dfrn d~n suy than man.

2. B~nh viem Ang th~n c§p (acute tubular nephritis)

2.1. B?nh nguyen: benh viern 6ng than cap do nhieu nguyen nhan
Nhiem dQc: chi, thuy ngan, arsen, bismut, sulfamid,

cyanur, tetrachlorure

carbon. Nhiern doe ea n6c, c6c, la ng6n, ...
Nhiem khuan: Bacillus perfringens
ChAn thirong, mAt mau, phfru thu~t, bong, truyen nham nh6m mau, ...

2.2. CO' chi b?nh sinh: nhtrng nguyen nhan tren coi la nhtrng stress nang d6i voi eo
thS. Co thS se huy dong ca ch~ thAn kinh va thS dich dS chong lai voi stress.

2.2.1. Co ch~ thAn kinh: eo thS se huy dong thAn kinh giao cam va tuy thirong
than, ti~t ra catecholamines

lam eo manh tiSu dong mach vao du than, lam

giarn hrong mau vao cAu than, cAu than khong loc huyet tuong duce, mire
loc cAu than giam rnanh.


2.2.2. Co ch~ thS dich: hrong mau vao than giarn, th~n ti~t ra Renin, dfrn d~n viec
tao thanh angiotensin
~ vel-H2O-tr& v~ mau-nen

H. Angiotensin
luong-mroc

H gay eo mach va tang tai hdp thu Na +
t-i~u giam-;--

-

2.2.3. Ngoai ra cac chAt dQc gay lIC ch~ cac men chuyen h6a cua than, lam r6i loan
chuyen h6a, gay t6n thuong t~ bao biSu rno than.

2.3. Biiu hi?n lam sang:
Trieu chirng diSn hinh la thieu nieu, vo nieu, tang nito phi protein (non protein
nitrogen NPN) nhu ure, creatinine, toan huyet va nhiem dQc K+, dfrn d~n suy than

dp (acute

renal failure) hon me, eo gi~t va chet.

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2.4. ou« trj: t6t nhat la chay th~n nhan tao, t€ bao bieu mo than c6 the h6i phuc hoan
toan 100%, khong c6 chuyen sang t6n thirong man tinh nhu viem cfiu than cap.

3. B~nh vie m th,n man (chronic nephritis)

3 .1. Benh nguyen: mot s6 tnrong hQ'Pviern th~n man xu~t phat tu viem du than c~p,
con mot s6 la do viem be th~n hay do viem th~n man nguyen phat, n6 b~t dfiu tu
tu khong rfim rQ.

3.2. elf chi b?nh sinh: trong m6i the benh viem than man d~u c6 t6n thirong mach
mau

a cfiu than,

6ng than va khoang khe.

Trong giai doan tien trien, cac nephron cua than bi teo, r6i loan nang chirc nang
than: mat chirc nang IQc cua du than, chirc nang tai h~p thu va bai ti€t cua 6ng than,
Net n6i b~t tren lam sang la benh nhan dai ra albumin nhieu, lam giam protein
rnau va phu to giong benh than hu. Benh ti€n trien thanh suy than man voi ure huyet
cao (chronic renal failure)

4. Viem b~ th,n (pyelonephritis):

con goi la viem than kc hay viern than ngiroc dong

4.1. B?nh nguyen:
Xu~t phat tu nhirng 6 viern

a dirong

ti€t nieu va bang quang di ngiroc len, lan len

be than, r6i 6ng than va khoang ke.
Tu d~y t6n thuong phat trien d€n cac mach mau va cfiu than. Cu6i cling gay ra teo

than. Day la the benh hay g?P nhat cua viem than man va gay chet ty l~ cao.
Benh g~p nhieu

a phu

nu, c6 the len d€n 80%, vi dirong ti€t nieu (nieu dao) ngan,

va vi khuan d~ xam nhap.

4.2. Lam sang: giai doan dfiu mroc tieu c6 nhieu t€ bao mu v~ sau la nhtrng trieu
chirng cua suy than man (chronic renal failure).

5. HQi clnrng th,n htr (nephrotic syndrome)
Bieu hien chu y€u cua benh la protein nieu r~t cao, dfrn d€n giam protein mau va phu
nang. Benh kern theo r6i loan chuyen h6a lipid, triglyceride

va cholesterol

huyet

tuong tang cao.

Nhimg thay d6i tien phat la

a cfiu than:

m~t khoang each gitta t€ bao c6 chan voi mang

day, mang day day len, c6 nhtrng dam lang dong, C6 ea nhirng t6n thirong
voi cac dam


ma trong

a 6ng

th~n

bao tuong cua t€ bao bieu mo va cac tru mo trong long 6ng

than.
cfiu than bi t6n thuong, dff d~ cac protein binh thirong 19t qua, va thai ra mroc

tieu.
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Triglyceride

va cholesterol

tang trong mau duoc coi la

SlJ

bu d~p

SlJ

mau. M~t khac, fmg th~n thieu men chuyen hoa lipid nhu tributirase,
lipoprotein


giam protein
lipase,

lipase.

Do du than bi hu hai, d~ lot qua qua nhi€u lipid va protein. T€ bao 6ng than qua
Uti trong

SlJ

tai h~p thu protein va lipid, no 11 lai trong bao tirong cua t€ bao bieu

,

mo ong,
Co gia thuyet cho la hoi chirng than hu cling eo eo ch€ miSn dich nhu trong viem
d.u than c~p
Trong lam sang da cho di€u tri bang ACTH ea cortisol thay eo ket qua. Mot s6
tnrong hop benh tro thanh viem than man va suy than.

6. B~nh xo' vii'a mach th~n (Renal atherosclerosis)
6.1. Bfnh nguyen: do tinh trang xo vtra dong mach chung cua eo th~, xo vfra dong
mach than cung voi dong mach vanh tim va dong rnach nao.
Benh

eo 2

the: man tinh va dp tinh.


- Man tinh: g~p 6 ngiroi gia, do tinh trang xo hoa h~ mach do tuoi tac
- C~p tinh: do benh xo vtra dong mach.

6.2. Lam sang: vi luu hrong tim giam, nen dong mau than giam nhieu, benh ti€n trien
nhanh, d~n d€n suy than,

7. Co ch~ cua nhirng r&i loan trong b~nh th~n.
7.1. Nhimg hiiu hifn v~ nU'uctiiu.
7.1.1.

V€ s6

7.1.1.1.

hrong mroc tieu

Da nieu (hyperuria)

khi hrong mroc tiSu qua 2 lit! 24 gio, trong khi

hrong mroc dua vao eo th~ la binh thirong.
Do tang loc 6 du than hay giam tai h~p thu 6 6ng than
Viern than dp trong giai doan diiu: khi chi moi eo xung huyet do
phan irng viem, chua eo t6n thuong thirc thS, mau don d€n ciiu than
nhieu.
Xo than: t6 chirc xo phat trien quanh 6ng than, lam hep cac mach
mau, do do 6ng than giam tai h~p thu mroc.
Cac benh ngoai than: dai thao duong, dai thao nhat.
7.1.1.2.


ThiSu nieu (hyponuria)

khi hrong mroc tiSu nho hon 500 mll 24h,

khong phai do m~t mroc hay uong qua it mroc.

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Benh viem eau than, hay viem 6ng than, do giam 10c d.u than hay
tang tai hap thu 6ng.
7.1.1.3.

VO nieu (anuria) khi IUQ1lgmroc tieu duoi 100 mll 24h.
Viem 6ng than cap, viem d.u than c~p: do eo mach th~n. Dong

mau than giam manh, cftu than khong eo huyet nrong d~ 10c
Khi eo th~ bi stress nang: chan thirong, bong, ... Thfin kinh giao
cam va tuy thuong than bi kich thich manh, gay eo tieu dong mach

than.
Ltrong mau vao than giam, than ti~t renin, angiotensin

II diroc tao

ra, gay eo mach than.
7.1.2. V~ chat IUQ1lgmroc tieu
Niroc ti~u binh thuong eo mau vang nhat, do sic t6 urobilin, ty trong 10 18,

eo mot s6 ch~t chinh nhu NaCl, sulfate, phosphate,


ure, acid uric,

creatinine, ... va mot s6 t~ bao bieu rno. Khi eo r6i loan chirc nang gay ra
nhimg thay d6i
7.1.2.1.

Protein nieu: binh thuong

eo chirng

50 - 100 mg protein trong nuoc

ti~u 24 gio.
Khi IUQ1lgprotein tren ISO mg! L mroc tieu, moi goi la protein nieu Co che protein nieu la do mang loc cua cftu than bi t6n thuong, d~ lot
qua protein la nhtrng phan tu eo trong hrong 16'0, cling eo th~ la do 6ng

than khong tai h~p thu do t6n thuong.
Dftu tien la albumin qua tnroc (MW 69.000 - 72.000), sau moi den
globulin eo MW 1&0hon.
Dung ty s6 Ai G d~ danh gia t6n thirong, khi AI G mroc tieu cang nho
la benh cang nang, Trong viem than man, ty l~ nay la 3 - 10.
7 .1.2.2. Huyet nieu: mroc tieu binh thuong khong eo t~ bao rnau, can Addis
trung binh eo 800 - 1000 hong eau vel 1000 - 2000 bach du mLI min.
huyet nieu la do 2 eo che:
Do eo t6n thuong gay vcr mach mau 6 duong tiet nieu
Do t6n thuong gay tang tinh tham thanh mao mach d~ 19t hong
eau ra ngoai,
Ti~u mau dai th~; nhin mat thirong cling thay mau do
Ti~u mau vi th~: phai soi qua kinh hien vi moi thay hong duo


29


Tru nieu: la nhirng khuon 6ng than do protein, lipid hay t~ bao bi dong

7.1.2.3.

v6n diroi anh huong cua nhtrng thay d6i ly hoa mroc tieu gay ra. Chia
lam 2 loai tru:
Trv protein hay lipid
Tru t~ bao: hong c~u, bach eau, t~ bao biSu mo, xac vi khufrn
7.2. Nhtrng bieu hien (ymau:
7.2.1.

u-e mau:
Trong benh than, nito phi protein (NPN) tang cao, bao gom ure, NH3,
creatinin, quan trong nhfrt la ure, gay hoi chirng ure huyet cao voi cac trieu
chirng: chan an, met moi, hll~n, eo giat, hon me.
Ta nen nho r~ng ure la chfrt khong doe, cac trieu clnrng la do cac san pham

chuyen hoa.
7.2.2. Toan huyet: do than khong bai xuat duce cac san pham chuyen hoa. Nhu
cac chat CO2, H+, cac g6c sulfate, phosphate,

acid uric, ... Nen pH mau

giam, eo thS lam vao trang thai nhiem toan, eo thS d~n d~n eo giat, hon me
va chet.
7.2.3. Thh§u mau: do cac eo che sau:

- Mau loang, vi eo thS gift Na+ va mroc
- Thi~u erythropoietin

vi suy than

- Thi~u cac protein dn cho sir tao mau, vi mfrt protein do than
- Do chat dQc (san pham chuyen hoa) khong duce dao thai, U lai trong eo
thS, gay trc ch~ sir tao mau cua tuy xirong.
7.3. Nhtrng bieu hien toan than:
7.3.1. Phu:
7.3.1.1.

Phu do viem c~u than cap, viem than man.
Viem c~u than nen IQc giam, Na + duce IQc it, con 6ng than v~n
tai hap thu Na + binh thuong, eo thS gift Na + va gift mroc, gay phu,
Do tang ti~t aldosterone

thir phat, gift Na + va gift mroc

Do mfrt protein.
7.3 .1.2. Phu do hQi clurng th~n hir: do mfrt protein qua mire, lam giam protein
mau, giam ap sufrt keo.nuoc

thoat ra ngoai khoang khe gay phu.

Phu xufrt hien khi nong dQ proten huyet tirong con diroi 55g/ L hay
albumin diroi 25 g/ L.
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7.3.2. Tang huyet ap:
Cac t6n thirong 6 c~u than hay 6ng than, d~u gay ra giam dong mau than.
Tinh trang nay lam t€ bao canh c~u than ti€t renin, dfin d€n
angiotensin

SlJ

tao thanh

II, gay eo mach, tang huyet ap.

8. Nhfrng bi~u chimg ciia b~nh th,n
Cac benh than d~u eo th€ dfin d€n bien chirng suy than

8.1. Suy th~n clip (acute renal failure) ,
- Thirong gap trong viem 6ng than cap, xfry ra nhanh, nhung eo th€ h6i phuc
hoan toan.
- Trieu chtrng n6i b~t la thieu nieu hay va nieu, ure huyet tang cao, eo th€ d~n
d€n eo gi~t, hon

me va tu vong,

vi toan huyet va nhiem dQc K +

- Benh it chuyen thanh man tinh, vi t€ bao bieu mo cua 6ng than eo kha nang h6i
phuc cao. f)i~u tri hieu qua bang chay than nhan tao.
8.2. Suy than man (chronic renal failure):
Do cac benh than nhu: viern cftu than cc1p,viem c~u than man, viem than ke, hQi
clnrng than hir, xo than.
Benh di€n bi€n tu tu, cham chap, tien tri€n nrng dot

- Chirc nang than giam dan, tinh trang nhiem dQc ngay cang tang.
- Tien hrong xc1u,vi than khong h6i phuc diroc.
HQi chirng suy than man g6m cac trieu chirng sau:
- R6i loan mroc tieu: thuong la thieu nieu, trong mroc ti~u luon c6 protein, t~ bao
va tru nieu
- R6i loan mau: chu yeu la ure huyet tang cao va toan huyet
- Phu: thuong la phu toan than, mire dQ tuy theo tinh trang benh.
- Huyet ap cao: x€p vao loai tang huyet ap thir phat hay tang huyet ap trieu
clurng - Mire dQ tuy theo tinh trang benh,
8.3. Hon me than: la giai doan cuoi cung cua benh suy than.
- Ure huyet tang cao, nhung ure khong phai la chat gay dQC, ma la nhtrng san
pham kern theo, ta k€ ra:
- Toan huyet: th~n suy khong thai duce nhfrng san pham chuyen h6a nhu: acid
citric, acid oxalic, cac g6c sulfate, phosphate,

H+, CO2,

...

- Nhi€m dQC K+: than suy, khong bai ti€t duce K+, K+

u lai trong

mau, lam giam

tnrong luc eo, nhat la eo tim, melt tnrong luc, ngirng tim 6 thi tarn tnrong.
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- Nhtrng san pham dQc tu dirong ruot da tham vao mau nhu: indol, scatol,

phenol, ammoniac. Nhtrng chat nay khi vao mau, binh thirong diroc gan khir dQc
va thai qua mroc tieu. Nhung trong benh than, tinh trang nhiem dQc chung toan
than, lam cho chirc nang gan bi suy giam, khong khir doe duce, nhtrng chfit nay lr
lai trong eo th~ gay dQc.
- Nhtrng trieu chirng thuong gap la: met moi, ue oai, y~u at, nhirc dclu, ngu ga
ngu g~t, lu ldn, eo gi~t, buon non 6i va oi, tieu chay, kho tho. Cac trieu chirng duce
giai thich nhu sau:
•

Cac trieu clnrng met moi, nhirc dclu, ngu ga, ngu g~t, la do nao bi chen ep
boi phu n~, do tinh trang phu n~ chung cua eo th~.

• Nhirng trieu clnrng nhu la mo, y~u at, lu ldn la do h~ thcln kinh bi ire ch~
do r6i loan chuyen hoa.
•

Kho tho la do cac trung tarn ho hfip 6 hanh nao bi nhiem dQc.

•

Cac trieu chirng eo gi~t, non oi, tieu ehay la do giam calci ion h6a trong
mau, vi no ket hop voi cac g6c phosphate khong duce dao thai.

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