{"id":33617,"date":"2022-08-13T01:12:19","date_gmt":"2022-08-12T18:12:19","guid":{"rendered":"https:\/\/www.vnras.com\/drug\/?p=33617"},"modified":"2022-08-13T09:04:22","modified_gmt":"2022-08-13T02:04:22","slug":"huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh","status":"publish","type":"post","link":"https:\/\/vnras.com\/drug\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh\/","title":{"rendered":"H\u01b0\u1edbng d\u1eabn \u0111\u1eb7c bi\u1ec7t v\u1ec1 dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng \u1edf b\u1ec7nh nh\u1eadn c\u00f3 b\u1ec7nh th\u1eadn c\u1ea5p t\u00ednh ho\u1eb7c b\u1ec7nh th\u1eadn m\u1ea1n t\u00ednh"},"content":{"rendered":"<p style=\"text-align: right;\"><em>T\u00e1c gi\u1ea3: Enrico Fiaccadori<\/em><\/p>\n<p style=\"text-align: right;\"><em>Bi\u00ean d\u1ecbch: B\u00e1c s\u0129 L\u00ea Nguy\u1ec5n Quang Th\u00e1i<\/em><\/p>\n<p>vnras.com\/drug &#8211; \u0110\u1ec3 t\u1ea3i file PDF c\u1ee7a b\u00e0i vi\u1ebft <a href=\"https:\/\/www.vnras.com\/drug\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh.html\">H\u01b0\u1edbng d\u1eabn \u0111\u1eb7c bi\u1ec7t v\u1ec1 dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng \u1edf b\u1ec7nh nh\u1eadn c\u00f3 b\u1ec7nh th\u1eadn c\u1ea5p t\u00ednh ho\u1eb7c b\u1ec7nh th\u1eadn m\u1ea1n t\u00ednh<\/a>, xin vui l\u00f2ng click v\u00e0o link <a href=\"https:\/\/www.vnras.com\/drug\/wp-content\/uploads\/2022\/08\/ESPEN-2021-AKIAKD-and-CKD.Bs_.LeNguyenQuangThai.pdf\">\u1edf \u0111\u00e2y<\/a>.<\/p>\n<h2>Kh\u00e1i l\u01b0\u1ee3c<\/h2>\n<p>AKD &#8211; bao g\u1ed3m t\u00ecnh tr\u1ea1ng t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p t\u00ednh (Acute Kidney Injury- AKI) v\u00e0 b\u1ec7nh th\u1eadn m\u1ea1n t\u00ednh (Chronic Kidney Disease-CKD) r\u1ea5t ph\u1ed5 bi\u1ebfn \u1edf nh\u1eefng BN n\u1ed9i vi\u1ec7n, t\u1eeb c\u00e1c khoa Th\u1eadn, N\u1ed9i, Ngo\u1ea1i cho \u0111\u1ebfn \u0111\u01a1n v\u1ecb ICU, g\u00e2y ra nh\u1eefng bi\u1ebfn ch\u1ee9ng v\u1ec1 r\u1ed1i lo\u1ea1n chuy\u1ec3n h\u00f3a v\u00e0 dinh d\u01b0\u1ee1ng.<\/p>\n<p>H\u01a1n n\u1eefa, trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p li\u1ec7u ph\u00e1p thay th\u1ebf th\u1eadn (Kidney Replacement Therapy \u2013 KRT) \u0111\u01b0\u1ee3c b\u1eaft \u0111\u1ea7u, d\u00f9 v\u1edbi b\u1ea5t k\u1ef3 ph\u01b0\u01a1ng th\u1ee9c n\u00e0o th\u00ec c\u0169ng s\u1ebd g\u00e2y ra t\u00e1c \u0111\u1ed9ng \u0111\u1ed1i v\u1edbi t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng, s\u1ef1 c\u00e2n b\u1eb1ng c\u01a1 ch\u1ea5t c\u0169ng nh\u01b0 qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng l\u00e0 nh\u1eefng y\u1ebfu t\u1ed1 kh\u00f4ng th\u1ec3 xem nh\u1eb9.<\/p>\n<p>H\u01b0\u1edbng d\u1eabn n\u00e0y nh\u1eb1m cung c\u1ea5p c\u00e1c khuy\u1ebfn ngh\u1ecb d\u1ef1a tr\u00ean b\u1eb1ng ch\u1ee9ng v\u1ec1 dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng tr\u00ean b\u1ec7nh nh\u00e2n AKD v\u00e0 CKD nh\u1eadp vi\u1ec7n. Do s\u1ef1 ch\u01b0a \u0111\u1ed3ng nh\u1ea5t \u0111\u00e1ng k\u1ec3 c\u1ee7a qu\u1ea7n th\u1ec3 b\u1ec7nh nh\u00e2n n\u00e0y c\u0169ng nh\u01b0 s\u1ef1 thi\u1ebfu h\u1ee5t c\u1ee7a c\u00e1c ch\u1ee9ng c\u1ee9 ch\u1ea5t l\u01b0\u1ee3ng cao n\u00ean khuy\u1ebfn c\u00e1o n\u00e0y \u0111\u01b0\u1ee3c coi l\u00e0 c\u01a1 b\u1ea3n c\u1ee7a c\u00e1c b\u1eb1ng ch\u1ee9ng v\u00e0 trong h\u1ea7u h\u1ebft c\u00e1c tr\u01b0\u1eddng h\u1ee3p \u00fd ki\u1ebfn c\u1ee7a chuy\u00ean gia, \u0111\u01b0\u1ee3c t\u1ed5ng h\u1ee3p v\u00e0 \u0111\u1ed3ng thu\u1eadn \u0111\u1ec3 c\u1eadp nh\u1eadt hai H\u01b0\u1edbng d\u1eabn tr\u01b0\u1edbc c\u1ee7a ESPEN v\u1ec1 Dinh d\u01b0\u1ee1ng \u0111\u01b0\u1eddng Ti\u00eau h\u00f3a (Enteral-2006) v\u00e0 T\u0129nh M\u1ea1ch (Parenteral-2009) tr\u00ean b\u1ec7nh nh\u00e2n tr\u01b0\u1edfng th\u00e0nh c\u00f3 suy th\u1eadn. C\u00e1c tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh nh\u00e2n CKD \u1ed5n \u0111\u1ecbnh (t\u1ee9c l\u00e0 \u0111\u01b0\u1ee3c ki\u1ec3m so\u00e1t protein trong ch\u1ebf \u0111\u1ed9 \u0103n ho\u1eb7c ch\u1ebf \u0111\u1ed9 \u0103n gi\u1ea3m \u0111\u1ea1m, c\u00f3 ho\u1eb7c kh\u00f4ng vi\u1ec7c b\u1ed5 sung acid amin\/ketoanalogue \u1edf b\u1ec7nh nh\u00e2n CKD ngo\u1ea1i tr\u00fa giai \u0111o\u1ea1n IV v\u00e0 V), dinh d\u01b0\u1ee1ng trong gh\u00e9p th\u1eadn, v\u00e0 b\u1ec7nh th\u1eadn tr\u1ebb em s\u1ebd kh\u00f4ng \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp trong khuy\u1ebfn c\u00e1o hi\u1ec7n t\u1ea1i.<\/p>\n<h2>M\u1edf \u0111\u1ea7u<\/h2>\n<p>Khuy\u1ebfn c\u00e1o hi\u1ec7n t\u1ea1i n\u00e0y l\u00e0 b\u1ea3n c\u1eadp nh\u1eadt v\u00e0 m\u1edf r\u1ed9ng c\u1ee7a 2 khuy\u1ebfn c\u00e1o tr\u01b0\u1edbc \u0111\u00f3 c\u1ee7a ESPEN v\u1ec1 Dinh d\u01b0\u1ee1ng \u0111\u01b0\u1eddng ti\u00eau h\u00f3a 2006 [1] v\u00e0 Dinh d\u01b0\u1ee1ng \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch 2009 [2] tr\u00ean b\u1ec7nh nh\u00e2n suy th\u1eadn m\u1ea1n v\u00e0 \u0111\u01b0\u1ee3c so\u1ea1n th\u1ea3o b\u1edfi m\u1ed9t nh\u00f3m c\u00e1c chuy\u00ean gia thu\u1ed9c nhi\u1ec1u l\u0129nh v\u1ef1c (Th\u1eadn h\u1ecdc, ICU, c\u00e1c chuy\u00ean gia N\u1ed9i khoa kh\u00e1c) d\u1ef1a tr\u00ean ph\u01b0\u01a1ng ph\u00e1p nghi\u00ean c\u1ee9u m\u1edbi \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a theo quy tr\u00ecnh thao t\u00e1c chu\u1ea9n v\u1ec1 khuy\u1ebfn c\u00e1o v\u00e0 \u0111\u1ed3ng thu\u1eadn c\u1ee7a ESPEN [3].<\/p>\n<p>M\u1ee5c ti\u00eau c\u1ee7a nghi\u00ean c\u1ee9u n\u00e0y l\u00e0 ph\u00e1t tri\u1ec3n c\u00e1c h\u01b0\u1edbng d\u1eabn v\u1ec1 dinh d\u01b0\u1ee1ng cho BN n\u1ed9i tr\u00fa c\u00f3 t\u00ecnh tr\u1ea1ng t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p (AKI\/AKD) v\u00e0\/ho\u1eb7c b\u1ec7nh th\u1eadn m\u1ea1n (CKD) c\u00f3 ho\u1eb7c kh\u00f4ng suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn (Kidney Failure &#8211; KF). Khuy\u1ebfn c\u00e1o n\u00e0y kh\u00f4ng \u00e1p d\u1ee5ng cho c\u00e1c BN ngo\u1ea1i tr\u00fa c\u00f3 b\u1ec7nh th\u1eadn m\u1ea1n t\u1eeb giai \u0111o\u1ea1n 1-5 \u0111\u00e3 \u0111i\u1ec1u tr\u1ecb \u1ed5n \u0111\u1ecbnh v\u00e0 b\u1ec7nh nh\u00e2n ngo\u1ea1i tr\u00fa c\u00f3 l\u1ecdc th\u1eadn chu k\u1ef3. B\u1ea5t th\u01b0\u1eddng v\u1ec1 ch\u1ee9c n\u0103ng th\u1eadn, th\u01b0\u1eddng \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp \u0111\u1ebfn trong y v\u0103n m\u1ed9t c\u00e1ch r\u1ed9ng r\u00e3i v\u1edbi thu\u1eadt ng\u1eef l\u00e0 t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p (AKI\/AKD) ho\u1eb7c b\u1ec7nh th\u1eadn m\u1ea1n (CKD), r\u1ea5t ph\u1ed5 bi\u1ebfn \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n \u1edf c\u00e1c c\u01a1 s\u1edf l\u00e2m s\u00e0ng kh\u00e1c nhau, bao g\u1ed3m khoa Th\u1eadn v\u00e0 khoa N\u1ed9i, khoa Ngo\u1ea1i \u2013 ph\u1eabu thu\u1eadt v\u00e0 \u0111\u01a1n v\u1ecb H\u1ed3i s\u1ee9c t\u00edch c\u1ef1c (ICU). Tr\u00ean kh\u00eda c\u1ea1nh v\u1ec1 dinh d\u01b0\u1ee1ng, c\u00e1ch ti\u1ebfp c\u1eadn v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y khi nh\u1eadp vi\u1ec7n l\u00e0 r\u1ea5t ph\u1ee9c t\u1ea1p v\u00ec c\u00e1c \u0111\u1ed1i t\u01b0\u1ee3ng kh\u00f4ng c\u00f3 s\u1ef1 \u0111\u1ed3ng nh\u1ea5t, v\u1edbi c\u00e1c \u0111\u1eb7c \u0111i\u1ec3m trao \u0111\u1ed5i ch\u1ea5t, chuy\u1ec3n h\u00f3a v\u00e0 nhu c\u1ea7u dinh d\u01b0\u1ee1ng r\u1ea5t kh\u00e1c nhau.<\/p>\n<p>Trong t\u1ea5t c\u1ea3 c\u00e1c khoa l\u00e2m s\u00e0ng, t\u00ecnh tr\u1ea1ng AKI\/AKD v\u00e0 CKD (\u0111\u1eb7c bi\u1ec7t l\u00e0 t\u1eeb giai \u0111o\u1ea1n 3 \u0111\u1ebfn giai \u0111o\u1ea1n 5), c\u0169ng nh\u01b0 c\u00e1c ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb, c\u00f3 th\u1ec3 c\u00f3 c\u00e1c \u1ea3nh h\u01b0\u1edfng nghi\u00eam tr\u1ecdng \u0111\u1ed1i v\u1edbi t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng v\u00e0 chuy\u1ec3n h\u00f3a c\u01a1 ch\u1ea5t. H\u01a1n n\u1eefa, trong tr\u01b0\u1eddng h\u1ee3p b\u1eaft \u0111\u1ea7u v\u1edbi li\u1ec7u ph\u00e1p thay th\u1ebf th\u1eadn (KRT) v\u1edbi b\u1ea5t k\u1ec3 ph\u01b0\u01a1ng th\u1ee9c n\u00e0o \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh (ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o ng\u1eaft qu\u00e3ng th\u00f4ng th\u01b0\u1eddng; li\u1ec7u ph\u00e1p thay th\u1ebf th\u1eadn ng\u1eaft qu\u00e3ng k\u00e9o d\u00e0i PIKRT), ho\u1eb7c li\u1ec7u ph\u00e1p thay th\u1ebf th\u1eadn li\u00ean t\u1ee5c (CKRT), t\u00e1c \u0111\u1ed9ng c\u1ee7a c\u00e1c li\u1ec7u ph\u00e1p n\u00e0y \u0111\u1ed1i v\u1edbi t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng, s\u1ef1 c\u00e2n b\u1eb1ng c\u00e1c c\u01a1 ch\u1ea5t v\u00e0 qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng l\u00e0 r\u1ea5t \u0111\u00e1ng quan t\u00e2m.<br \/>\nKhuy\u1ebfn c\u00e1o hi\u1ec7n t\u1ea1i nh\u1eb1m \u0111\u01b0a ra c\u00e1c khuy\u1ebfn ngh\u1ecb d\u1ef1a tr\u00ean c\u00e1c b\u1eb1ng ch\u1ee9ng tr\u00ean c\u00e1c b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0 CKD n\u1ed9i tr\u00fa. Do ch\u01b0a thu th\u1eadp \u0111\u1ea7y \u0111\u1ee7 c\u00e1c ch\u1ee9ng c\u1ee9 c\u00f3 ch\u1ea5t l\u01b0\u1ee3ng cao n\u00ean khuy\u1ebfn c\u00e1o n\u00e0y \u0111\u01b0\u1ee3c coi l\u00e0 c\u01a1 b\u1ea3n c\u1ee7a c\u00e1c b\u1eb1ng ch\u1ee9ng v\u00e0 trong h\u1ea7u h\u1ebft c\u00e1c tr\u01b0\u1eddng h\u1ee3p \u00fd ki\u1ebfn c\u1ee7a chuy\u00ean gia, \u0111\u01b0\u1ee3c t\u1ed5ng h\u1ee3p v\u00e0 \u0111\u1ed3ng thu\u1eadn theo m\u1ed9t quy tr\u00ecnh ti\u00eau chu\u1ea9n. C\u00e1c tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh nh\u00e2n CKD \u1ed5n \u0111\u1ecbnh (t\u1ee9c l\u00e0 \u0111\u01b0\u1ee3c ki\u1ec3m so\u00e1t protein trong ch\u1ebf \u0111\u1ed9 \u0103n ho\u1eb7c ch\u1ebf \u0111\u1ed9 \u0103n gi\u1ea3m \u0111\u1ea1m, c\u00f3 ho\u1eb7c kh\u00f4ng vi\u1ec7c b\u1ed5 sung acid amin\/ketoanalogue \u1edf b\u1ec7nh nh\u00e2n CKD ngo\u1ea1i tr\u00fa giai \u0111o\u1ea1n IV v\u00e0 V), dinh d\u01b0\u1ee1ng trong gh\u00e9p th\u1eadn, v\u00e0 b\u1ec7nh th\u1eadn tr\u1ebb em s\u1ebd kh\u00f4ng \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp trong khuy\u1ebfn c\u00e1o hi\u1ec7n t\u1ea1i. Nh\u01b0 s\u1ebd \u0111\u01b0\u1ee3c th\u1ea3o lu\u1eadn s\u00e2u h\u01a1n \u1edf ph\u1ea7n sau \u0111\u00e2y, danh ph\u00e1p n\u0103m 2012 c\u1ee7a KDIGO cho b\u1ec7nh nh\u00e2n AKI\/AKD [4] v\u00e0 danh ph\u00e1p n\u0103m 2012 cho b\u1ec7nh nh\u00e2n CKD [5], \u0111\u01b0\u1ee3c c\u1eadp nh\u1eadt g\u1ea7n \u0111\u00e2y n\u0103m 2019 b\u1edfi H\u1ed9i ngh\u1ecb \u0111\u1ed3ng thu\u1eadn KDIGO s\u1ebd \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp trong b\u00e0i vi\u1ebft n\u00e0y.<\/p>\n<h2>Ph\u01b0\u01a1ng ph\u00e1p<\/h2>\n<h3>C\u00e1c kh\u00eda c\u1ea1nh chung v\u00e0 qu\u00e1 tr\u00ecnh ph\u00e1t tri\u1ec3n c\u1ee7a khuy\u1ebfn c\u00e1o<\/h3>\n<p>Khuy\u1ebfn c\u00e1o n\u00e0y \u0111\u01b0\u1ee3c t\u1ed5ng h\u1ee3p t\u1eeb c\u00e1c ch\u1ee9ng c\u1ee9 c\u01a1 b\u1ea3n v\u00e0 s\u1ef1 \u0111\u1ed3ng thu\u1eadn c\u1ee7a c\u00e1c chuy\u00ean gia theo quy tr\u00ecnh thao t\u00e1c chu\u1ea9n v\u1ec1 ph\u00e1t tri\u1ec3n h\u01b0\u1edbng d\u1eabn c\u1ee7a ESPEN [3]. Tr\u00ean c\u01a1 s\u1edf n\u00e0y, kh\u00e1i ni\u1ec7m \u201cDinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng nh\u1eb1m m\u1ee5c \u0111\u00edch ph\u00f2ng ng\u1eeba v\u00e0 \u0111i\u1ec1u tr\u1ecb suy dinh d\u01b0\u1ee1ng tr\u00ean n\u1ec1n b\u1ec7nh l\u00fd\u201d \u0111\u00e3 \u0111\u01b0\u1ee3c t\u1eadp trung v\u00e0 ti\u1ebfp c\u1eadn m\u1ed9t c\u00e1ch to\u00e0n di\u1ec7n, kh\u00f4ng t\u00e1ch bi\u1ec7t gi\u1eefa dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a (EN) v\u00e0 dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch (PN) nh\u01b0 trong h\u01b0\u1edbng d\u1eabn tr\u01b0\u1edbc \u0111\u00e2y c\u1ee7a ESPEN cho ng\u01b0\u1eddi tr\u01b0\u1edfng th\u00e0nh c\u00f3 suy ch\u1ee9c n\u0103ng th\u1eadn, v\u00e0 bao g\u1ed3m s\u00e0ng l\u1ecdc v\u00e0 \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng, t\u01b0 v\u1ea5n, b\u1ed5 sung dinh d\u01b0\u1ee1ng \u0111\u01b0\u1eddng u\u1ed1ng (ONS), c\u0169ng nh\u01b0 dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a v\u00e0 \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch [7]. Do \u0111\u00f3, khuy\u1ebfn c\u00e1o hi\u1ec7n t\u1ea1i l\u00e0 m\u1ed9t b\u1ea3n c\u1eadp nh\u1eadt v\u00e0 s\u1eeda \u0111\u1ed5i hai h\u01b0\u1edbng d\u1eabn ESPEN hi\u1ec7n c\u00f3 tr\u01b0\u1edbc \u0111\u00f3 v\u1ec1 Dinh d\u01b0\u1ee1ng \u0111\u01b0\u1eddng ti\u00eau h\u00f3a trong cho b\u1ec7nh nh\u00e2n suy ch\u1ee9c n\u0103ng th\u1eadn n\u0103m 2006 [1] v\u00e0 Dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch \u1edf b\u1ec7nh nh\u00e2n suy ch\u1ee9c n\u0103ng th\u1eadn n\u0103m 2009 [2]. Hai khuy\u1ebfn c\u00e1o tr\u01b0\u1edbc \u0111\u00e2y \u0111\u01b0\u1ee3c t\u1ed5ng h\u1ee3p b\u1edfi 7 chuy\u00ean gia thu\u1ed9c nhi\u1ec1u chuy\u00ean ng\u00e0nh kh\u00e1c nhau (Th\u1eadn h\u1ecdc, ICU, N\u1ed9i khoa) \u0111\u1ebfn t\u1eeb 3 qu\u1ed1c gia Ch\u00e2u \u00c2u (\u00dd, Th\u1ee5y \u0110i\u1ec3n, B\u1ec9) d\u1ef1a tr\u00ean quy tr\u00ecnh thao t\u00e1c chu\u1ea9n v\u1ec1 khuy\u1ebfn c\u00e1o v\u00e0 \u0111\u1ed3ng thu\u1eadn c\u1ee7a ESPEN [3]. C\u00e1c chuy\u00ean gia trong nh\u00f3m \u0111\u00e3 tuy\u00ean b\u1ed1 xung \u0111\u1ed9t l\u1ee3i \u00edch theo nguy\u00ean t\u1eafc c\u1ee7a \u1ee6y ban qu\u1ed1c t\u1ebf v\u1ec1 bi\u00ean t\u1eadp t\u1ea1p ch\u00ed y h\u1ecdc. Chi ph\u00ed cho nghi\u00ean c\u1ee9u n\u00e0y ho\u00e0n to\u00e0n do ESPEN \u0111\u00e0i th\u1ecd, kh\u00f4ng c\u00f3 s\u1ef1 t\u00e0i tr\u1ee3 t\u1eeb b\u1ea5t k\u1ef3 t\u1ed5 ch\u1ee9c l\u1ee3i nhu\u1eadn n\u00e0o. C\u00e1c quy tr\u00ecnh thao t\u00e1c chu\u1ea9n theo h\u01b0\u1edbng d\u1eabn m\u1edbi c\u1ee7a ESPEN [3] d\u1ef1a tr\u00ean ph\u01b0\u01a1ng ph\u00e1p \u0111\u00e3 \u0111\u01b0\u1ee3c quy \u0111\u1ecbnh b\u1edfi Association of Scientific Medical Societies of Germany, The Scottish Intercollegiate Guidelines Netword (SIGN) v\u00e0 The Center for Evidence-based Medicine at the University of Oxford. Theo \u0111\u00f3, m\u1ed9t c\u00e1ch ti\u1ebfp c\u1eadn tu\u1ea7n t\u1ef1 \u0111\u01b0\u1ee3c thi\u1ebft l\u1eadp, bao g\u1ed3m c\u1ea5u tr\u00fac c\u00e1c c\u00e2u h\u1ecfi l\u00e2m s\u00e0ng theo h\u1ec7 th\u1ed1ng PICO (B\u1ec7nh nh\u00e2n, Can thi\u1ec7p, Ki\u1ec3m so\u00e1t, K\u1ebft qu\u1ea3), c\u00f3 h\u1ec7 th\u1ed1ng t\u00ecm ki\u1ebfm t\u00e0i li\u1ec7u, v\u1edbi vi\u1ec7c \u0111\u00e1nh gi\u00e1 c\u00e1c h\u01b0\u1edbng d\u1eabn\/\u0111\u1ed3ng thu\u1eadn v\u00e0 x\u00e1c \u0111\u1ecbnh c\u00e1c t\u1eeb kh\u00f3a c\u1ee5 th\u1ec3. C\u00e1c c\u00e2u h\u1ecfi l\u00e2m s\u00e0ng non-PICO c\u0169ng \u0111\u01b0\u1ee3c c\u1ea5u tr\u00fac, v\u1edbi c\u00e1c kh\u00e1i ni\u1ec7m c\u01a1 b\u1ea3n v\u00e0 t\u1ed5ng qu\u00e1t li\u00ean quan \u0111\u1ebfn b\u1ec7nh th\u1eadn c\u1ea5p v\u00e0 b\u1ec7nh th\u1eadn m\u1ea1n t\u00ednh, \u0111\u1ecbnh ngh\u0129a v\u1ec1 h\u1ed9i ch\u1ee9ng suy<\/p>\n<p>gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn, ph\u00e2n lo\u1ea1i AKI\/AKD v\u00e0 CKD, ph\u01b0\u01a1ng th\u1ee9c \u0111i\u1ec1u tr\u1ecb thay th\u1ebf th\u1eadn (Kidney Replacement Therapy \u2013 KRT), v\u00e0 ch\u1ec9 \u0111\u1ecbnh. M\u1ed7i c\u00e2u h\u1ecfi d\u1eabn \u0111\u1ebfn m\u1ed9t ho\u1eb7c nhi\u1ec1u khuy\u1ebfn ngh\u1ecb\/c\u00f4ng b\u1ed1 v\u00e0 c\u00e1c b\u00e0i b\u00ecnh lu\u1eadn li\u00ean quan. C\u00e1c ch\u1ee7 \u0111\u1ec1 kh\u00e1c nhau li\u00ean quan \u0111\u1ebfn dinh d\u01b0\u1ee1ng tr\u00ean b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi AKI\/AKD ho\u1eb7c CKD \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp \u0111\u1ebfn, ch\u1eb3ng h\u1ea1n nh\u01b0 n\u1ec1n t\u1ea3ng trao \u0111\u1ed5i ch\u1ea5t khi ch\u1ee9c n\u0103ng th\u1eadn suy gi\u1ea3m, s\u1ef1 trao \u0111\u1ed5i ch\u1ea5t \u1ea3nh h\u01b0\u1edfng c\u1ee7a AKI\/AKD, AKI tr\u00ean n\u1ec1n CKD c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 KRT, CKD v\u00e0 CKD c\u00f3 KRT, s\u00e0ng l\u1ecdc b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1, \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng, ch\u1ec9 \u0111\u1ecbnh v\u00e0 th\u1eddi \u0111i\u1ec3m h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng, \u0111\u01b0\u1eddng nu\u00f4i \u0103n, nhu c\u1ea7u v\u1ec1 c\u00e1c ch\u1ea5t \u0111a l\u01b0\u1ee3ng v\u00e0 vi l\u01b0\u1ee3ng, dinh d\u01b0\u1ee1ng \u0111\u1eb7c hi\u1ec7u cho t\u1eebng b\u1ec7nh l\u00fd, k\u1ebft h\u1ee3p li\u1ec7u ph\u00e1p dinh d\u01b0\u1ee1ng v\u1edbi KRT, c\u0169ng nh\u01b0 theo d\u00f5i t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng v\u00e0 \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng. C\u00e1c b\u1eb1ng ch\u1ee9ng hi\u1ec7n c\u00f3 \u0111\u00e3 \u0111\u01b0\u1ee3c ph\u00e2n lo\u1ea1i, c\u0169ng nh\u01b0 c\u00e1c khuy\u1ebfn ngh\u1ecb v\u00e0 c\u00f4ng b\u1ed1 \u0111\u00e3 \u0111\u01b0\u1ee3c ph\u00e1t tri\u1ec3n v\u00e0 th\u1ed1ng nh\u1ea5t trong m\u1ed9t qu\u00e1 tr\u00ecnh \u0111\u1ed3ng thu\u1eadn nhi\u1ec1u giai \u0111o\u1ea1n. M\u1ee9c \u0111\u1ed9 m\u1ea1nh c\u1ee7a ch\u1ee9ng c\u1ee9 \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn trong b\u00e0i vi\u1ebft n\u00e0y \u0111\u01b0\u1ee3c cung c\u1ea5p theo ph\u00e2n lo\u1ea1i m\u1ee9c ch\u1ee9ng c\u1ee9 c\u1ee7a SIGN (NICE 2012), trong \u0111\u00f3 x\u1ebfp h\u1ea1ng b\u1eb1ng ch\u1ee9ng t\u1eeb 1++ cho c\u00e1c nghi\u00ean c\u1ee9u c\u00f3 ch\u1ea5t l\u01b0\u1ee3ng v\u00e0 \u0111\u1ed9 tin c\u1eady cao (ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p, \u0111\u00e1nh gi\u00e1 h\u1ec7 th\u1ed1ng c\u00e1c th\u1eed nghi\u1ec7m ng\u1eabu nhi\u00ean c\u00f3 \u0111\u1ed1i ch\u1ee9ng \u2013 RCT ho\u1eb7c RCT v\u1edbi sai s\u1ed1 r\u1ea5t nh\u1ecf) \u0111\u1ebfn m\u1ee9c b\u1eb1ng ch\u1ee9ng th\u1ea5p \u0111\u01b0\u1ee3c x\u1ebfp h\u1ea1ng 4 cho tr\u01b0\u1eddng h\u1ee3p l\u1ea5y \u00fd ki\u1ebfn chuy\u00ean gia [3].<\/p>\n<table>\n<tbody>\n<tr>\n<td>1++<\/td>\n<td>C\u00e1c ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p ch\u1ea5t l\u01b0\u1ee3ng cao, c\u00e1c \u0111\u00e1nh gi\u00e1 h\u1ec7 th\u1ed1ng v\u1ec1<\/p>\n<p>RCT ho\u1eb7c RCT v\u1edbi nguy c\u01a1 sai s\u1ed1 r\u1ea5t th\u1ea5p<\/td>\n<\/tr>\n<tr>\n<td>1+<\/td>\n<td>C\u00e1c ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p \u0111\u01b0\u1ee3c ti\u1ebfn h\u00e0nh t\u1ed1t, c\u00e1c \u0111\u00e1nh gi\u00e1 h\u1ec7 th\u1ed1ng<\/p>\n<p>ho\u1eb7c RCT v\u1edbi nguy c\u01a1 sai s\u1ed1 th\u1ea5p<\/td>\n<\/tr>\n<tr>\n<td>1\u2013<\/td>\n<td>C\u00e1c ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p, c\u00e1c \u0111\u00e1nh gi\u00e1 h\u1ec7 th\u1ed1ng ho\u1eb7c RCT c\u00f3 nguy c\u01a1<\/p>\n<p>sai s\u1ed1 cao<\/td>\n<\/tr>\n<tr>\n<td>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>2++<\/td>\n<td>C\u00e1c \u0111\u00e1nh gi\u00e1 c\u00f3 h\u1ec7 th\u1ed1ng ch\u1ea5t l\u01b0\u1ee3ng cao v\u1ec1 nghi\u00ean c\u1ee9u b\u1ec7nh ch\u1ee9ng ho\u1eb7c \u0111o\u00e0n h\u1ec7.<\/p>\n<p>C\u00e1c nghi\u00ean c\u1ee9u \u0111o\u00e0n h\u1ec7 ho\u1eb7c b\u1ec7nh ch\u1ee9ng ch\u1ea5t l\u01b0\u1ee3ng cao v\u1edbi nguy<\/p>\n<p>c\u01a1 g\u00e2y nhi\u1ec5u ho\u1eb7c sai s\u1ed1 r\u1ea5t th\u1ea5p v\u00e0 kh\u1ea3 n\u0103ng m\u1ed1i quan h\u1ec7 l\u00e0 quan h\u1ec7 nh\u00e2n qu\u1ea3 \u1edf m\u1ee9c cao.<\/td>\n<\/tr>\n<tr>\n<td>&nbsp;<\/p>\n<p>2+<\/td>\n<td>C\u00e1c nghi\u00ean c\u1ee9u \u0111o\u00e0n h\u1ec7 ho\u1eb7c b\u1ec7nh ch\u1ee9ng \u0111\u01b0\u1ee3c ti\u1ebfn h\u00e0nh t\u1ed1t v\u1edbi nguy c\u01a1 g\u00e2y nhi\u1ec5u ho\u1eb7c sai s\u1ed1 v\u1eeba ph\u1ea3i v\u00e0 kh\u1ea3 n\u0103ng m\u1ed1i quan h\u1ec7 l\u00e0<\/p>\n<p>quan h\u1ec7 nh\u00e2n qu\u1ea3 \u1edf m\u1ee9c v\u1eeba ph\u1ea3i.<\/td>\n<\/tr>\n<tr>\n<td>&nbsp;<\/p>\n<p>2\u2013<\/td>\n<td>C\u00e1c nghi\u00ean c\u1ee9u b\u1ec7nh ch\u1ee9ng ho\u1eb7c nghi\u00ean c\u1ee9u \u0111o\u00e0n h\u1ec7 c\u00f3 nguy c\u01a1 g\u00e2y nhi\u1ec5u ho\u1eb7c sai s\u1ed1 cao v\u00e0 nguy c\u01a1 \u0111\u00e1ng k\u1ec3 l\u00e0 m\u1ed1i quan h\u1ec7 kh\u00f4ng<\/p>\n<p>c\u00f3 quan h\u1ec7 nh\u00e2n qu\u1ea3.<\/td>\n<\/tr>\n<tr>\n<td>3<\/td>\n<td>C\u00e1c nghi\u00ean c\u1ee9u kh\u00f4ng ph\u1ea3i nghi\u00ean c\u1ee9u ph\u00e2n t\u00edch, v\u00ed d\u1ee5: b\u00e1o c\u00e1o ca<\/p>\n<p>b\u1ec7nh, b\u00e1o c\u00e1o h\u00e0ng lo\u1ea1t ca b\u1ec7nh.<\/td>\n<\/tr>\n<tr>\n<td>4<\/td>\n<td>\u00dd ki\u1ebfn chuy\u00ean gia.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><em>B\u1ea3ng 1. \u0110\u1ecbnh ngh\u0129a m\u1ee9c \u0111\u1ed9 m\u1ea1nh c\u1ee7a ch\u1ee9ng c\u1ee9 [3].<\/em><\/p>\n<h3>Chi\u1ebfn l\u01b0\u1ee3c t\u00ecm ki\u1ebfm th\u00f4ng tin<\/h3>\n<p>C\u00e1c t\u00e1c gi\u1ea3 \u0111\u00e3 t\u00ecm ki\u1ebfm b\u1eb1ng nh\u1eefng t\u1eeb kh\u00f3a tr\u00ean c\u00e1c c\u01a1 s\u1edf d\u1eef li\u1ec7u c\u1ee7a PubMed v\u00e0 Cochrane \u0111\u1ec3 t\u00ecm c\u00e1c nghi\u00ean c\u1ee9u v\u00e0 t\u1ed5ng quan h\u1ec7 th\u1ed1ng \u0111\u01b0\u1ee3c xu\u1ea5t b\u1ea3n cho \u0111\u1ebfn ng\u00e0y 1 th\u00e1ng 1 n\u0103m 2020. Ch\u1ec9 c\u00e1c b\u00e0i b\u00e1o v\u1ec1 c\u00e1c nghi\u00ean c\u1ee9u \u1edf b\u1ec7nh nh\u00e2n ng\u01b0\u1eddi l\u1edbn \u0111\u01b0\u1ee3c xu\u1ea5t b\u1ea3n b\u1eb1ng ti\u1ebfng Anh ho\u1eb7c v\u1edbi ph\u1ea7n t\u00f3m t\u1eaft b\u1eb1ng ti\u1ebfng Anh m\u1edbi \u0111\u01b0\u1ee3c xem x\u00e9t. RCT, ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p v\u00e0 \u0111\u00e1nh gi\u00e1 h\u1ec7 th\u1ed1ng c\u0169ng \u0111\u01b0\u1ee3c t\u00ecm ki\u1ebfm th\u1ee7 c\u00f4ng cho c\u00e1c nghi\u00ean c\u1ee9u kh\u00f4ng c\u00f3 trong t\u00ecm ki\u1ebfm c\u01a1 s\u1edf d\u1eef li\u1ec7u ban \u0111\u1ea7u.<\/p>\n<h3>Chi\u1ebfn l\u01b0\u1ee3c ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p<\/h3>\n<p>V\u1ec1 ch\u1ee7 \u0111\u1ec1 \u0111ang n\u00f3i \u0111\u1ebfn trong guideline n\u00e0y kh\u00f4ng c\u00f3 d\u1eef li\u1ec7u n\u00e0o \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n b\u1eb1ng c\u00e1ch ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p b\u00e0i b\u1ea3n.<\/p>\n<h3>Ch\u1ea5t l\u01b0\u1ee3ng c\u1ee7a c\u00e1c ch\u1ee9ng c\u1ee9<\/h3>\n<p>Vi\u1ec7c ph\u00e2n lo\u1ea1i t\u00e0i li\u1ec7u th\u00e0nh c\u00e1c c\u1ea5p \u0111\u1ed9 b\u1eb1ng ch\u1ee9ng \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n theo h\u1ec7 th\u1ed1ng thang \u0111i\u1ec3m SIGN, nh\u01b0 \u0111\u01b0\u1ee3c minh h\u1ecda trong B\u1ea3ng 1.<\/p>\n<h3>\u0110\u1ed9 m\u1ea1nh c\u1ee7a ch\u1ee9ng c\u1ee9 v\u00e0 ph\u00e2n lo\u1ea1i c\u00e1c khuy\u1ebfn ngh\u1ecb<\/h3>\n<p>M\u1ee9c \u0111\u1ed9 c\u1ee7a ch\u1ee9ng c\u1ee9 \u0111\u01b0\u1ee3c chuy\u1ec3n sang c\u00e1c khuy\u1ebfn c\u00e1o, t\u1eeb thi\u1ebft k\u1ebf nghi\u00ean c\u1ee9u v\u00e0 ch\u1ea5t l\u01b0\u1ee3ng nghi\u00ean c\u1ee9u c\u0169ng nh\u01b0 t\u00ednh nh\u1ea5t qu\u00e1n v\u00e0 t\u00ednh ph\u00f9 h\u1ee3p v\u1edbi l\u00e2m s\u00e0ng (b\u1ea3ng 3) [3]. Trong \u0111\u00f3, m\u1ee9c khuy\u1ebfn ngh\u1ecb th\u1ea5p nh\u1ea5t t\u01b0\u01a1ng \u1ee9ng v\u1edbi kinh nghi\u1ec7m th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng (GPP) d\u1ef1a tr\u00ean \u00fd ki\u1ebfn chuy\u00ean gia v\u00e0 ph\u1ea3n \u00e1nh quan \u0111i\u1ec3m \u0111\u1ed3ng thu\u1eadn c\u1ee7a c\u00e1c chuy\u00ean gia. Nh\u01b0 trong c\u00e1c khuy\u1ebfn c\u00e1o kh\u00e1c c\u1ee7a ESPEN [8], ph\u01b0\u01a1ng ph\u00e1p ti\u1ebfp c\u1eadn n\u00e0y ph\u1ea3n \u00e1nh nh\u1eefng c\u1ed1 g\u1eafng, n\u1ed7 l\u1ef1c \u0111\u01b0a ra c\u00e1c khuy\u1ebfn ngh\u1ecb t\u1ed1t nh\u1ea5t c\u00f3 th\u1ec3 tr\u00ean c\u01a1 s\u1edf c\u00e1c d\u1eef li\u1ec7u c\u00f3 s\u1eb5n v\u00e0 kinh nghi\u1ec7m l\u00e2m s\u00e0ng c\u1ee7a c\u00e1c chuy\u00ean gia, b\u1edfi do d\u1eef li\u1ec7u t\u1eeb c\u00e1c nghi\u00ean c\u1ee9u RCT kh\u00f4ng c\u00f3 s\u1eb5n ho\u1eb7c kh\u00f4ng \u0111\u1ea7y \u0111\u1ee7. C\u00e1c khuy\u1ebfn ngh\u1ecb \u0111\u01b0\u1ee3c x\u00e2y d\u1ef1ng m\u1ee9c \u0111\u1ed9 d\u01b0\u1edbi d\u1ea1ng \u201cm\u1ea1nh\u201d (\u201cs\u1ebd\u201d) ho\u1eb7c \u201cc\u00f3 \u0111i\u1ec1u ki\u1ec7n\u201d (\u201cn\u00ean\/c\u00f3 th\u1ec3\u201d) ho\u1eb7c kh\u00f4ng n\u00ean can thi\u1ec7p, d\u1ef1a tr\u00ean s\u1ef1 c\u00e2n nh\u1eafc gi\u1eefa l\u1ee3i \u00edch v\u00e0 nguy c\u01a1 c\u1ee7a c\u00e1c can thi\u1ec7p (b\u1ea3ng 3) [3]. Trong tr\u01b0\u1eddng h\u1ee3p kh\u00f4ng th\u1ed1ng nh\u1ea5t, c\u00e1c khuy\u1ebfn ngh\u1ecb d\u1ef1a tr\u00ean c\u1ea3 b\u1eb1ng ch\u1ee9ng c\u00f3 s\u1eb5n v\u00e0 d\u1ef1a tr\u00ean \u0111\u00e1nh gi\u00e1 c\u1ee7a c\u00e1c chuy\u00ean gia, bao g\u1ed3m t\u00ednh nh\u1ea5t qu\u00e1n, m\u1ee9c \u0111\u1ed9 li\u00ean quan l\u00e2m s\u00e0ng v\u00e0 t\u00ednh h\u1ee3p l\u1ec7 c\u1ee7a ch\u1ee9ng c\u1ee9 [8]. C\u00e1c khuy\u1ebfn ngh\u1ecb \u0111\u01b0\u1ee3c ph\u00e2n lo\u1ea1i theo \u0111\u1ed9 m\u1ea1nh c\u1ee7a s\u1ef1 \u0111\u1ed3ng thu\u1eadn (b\u1ea3ng 4) [3].<\/p>\n<p><em>B\u1ea3ng 3. \u0110\u1ecbnh ngh\u0129a v\u1ec1 \u0111\u1ed9 m\u1ea1nh, \u0111\u00e1ng tin c\u1eady c\u1ee7a khuy\u1ebfn c\u00e1o<\/em><\/p>\n<table>\n<tbody>\n<tr>\n<td>A<\/td>\n<td>\u00cdt nh\u1ea5t m\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p, \u0111\u00e1nh gi\u00e1 h\u1ec7 th\u1ed1ng ho\u1eb7c RCT \u0111\u01b0\u1ee3c x\u1ebfp h\u1ea1ng l\u00e0 1++ v\u00e0 \u00e1p d\u1ee5ng tr\u1ef1c ti\u1ebfp cho qu\u1ea7n th\u1ec3 m\u1ee5c ti\u00eau; ho\u1eb7c m\u1ed9t c\u01a1 s\u1edf b\u1eb1ng ch\u1ee9ng ch\u1ee7 y\u1ebfu bao g\u1ed3m c\u00e1c nghi\u00ean c\u1ee9u \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 l\u00e0 1+, \u00e1p d\u1ee5ng tr\u1ef1c ti\u1ebfp cho qu\u1ea7n th\u1ec3 m\u1ee5c ti\u00eau v\u00e0 ch\u1ee9ng minh<\/p>\n<p>t\u00ednh nh\u1ea5t qu\u00e1n t\u1ed5ng th\u1ec3 c\u1ee7a c\u00e1c k\u1ebft qu\u1ea3.<\/td>\n<\/tr>\n<tr>\n<td>B<\/td>\n<td>M\u1ed9t c\u01a1 s\u1edf b\u1eb1ng ch\u1ee9ng bao g\u1ed3m c\u00e1c nghi\u00ean c\u1ee9u \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 l\u00e0 2++, \u00e1p d\u1ee5ng tr\u1ef1c ti\u1ebfp cho qu\u1ea7n th\u1ec3 m\u1ee5c ti\u00eau; ho\u1eb7c m\u1ed9t c\u01a1 s\u1edf b\u1eb1ng ch\u1ee9ng bao g\u1ed3m c\u00e1c nghi\u00ean c\u1ee9u \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 l\u00e0 2+, \u00e1p d\u1ee5ng tr\u1ef1c ti\u1ebfp cho qu\u1ea7n th\u1ec3 m\u1ee5c ti\u00eau v\u00e0 ch\u1ee9ng minh t\u00ednh nh\u1ea5t qu\u00e1n t\u1ed5ng th\u1ec3 c\u1ee7a c\u00e1c k\u1ebft qu\u1ea3; ho\u1eb7c ch\u1ee9ng minh t\u00ednh nh\u1ea5t qu\u00e1n t\u1ed5ng th\u1ec3 c\u1ee7a c\u00e1c k\u1ebft qu\u1ea3; ho\u1eb7c b\u1eb1ng ch\u1ee9ng ngo\u1ea1i suy t\u1eeb c\u00e1c nghi\u00ean c\u1ee9u \u0111\u01b0\u1ee3c x\u1ebfp h\u1ea1ng l\u00e0<\/p>\n<p>1++ ho\u1eb7c 1+<\/td>\n<\/tr>\n<tr>\n<td>0<\/td>\n<td>B\u1eb1ng ch\u1ee9ng c\u1ea5p \u0111\u1ed9 3 ho\u1eb7c 4; ho\u1eb7c b\u1eb1ng ch\u1ee9ng ngo\u1ea1i suy t\u1eeb c\u00e1c<\/p>\n<p>nghi\u00ean c\u1ee9u \u0111\u01b0\u1ee3c x\u1ebfp h\u1ea1ng l\u00e0 2++ ho\u1eb7c 2+<\/td>\n<\/tr>\n<tr>\n<td>GPP<\/td>\n<td>\u0110i\u1ec3m th\u1ef1c h\u00e0nh t\u1ed1t\/\u0110\u1ed3ng thu\u1eadn c\u1ee7a chuy\u00ean gia: \u0110\u1ec1 xu\u1ea5t th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng t\u1ed1t nh\u1ea5t d\u1ef1a tr\u00ean kinh nghi\u1ec7m l\u00e2m s\u00e0ng c\u1ee7a nh\u00f3m chuy\u00ean<\/p>\n<p>gia ph\u00e1t tri\u1ec3n khuy\u1ebfn c\u00e1o.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><em>B\u1ea3ng 4. Ph\u00e2n lo\u1ea1i m\u1ee9c \u0111\u1ed9 \u0111\u1ed3ng thu\u1eadn<\/em><\/p>\n<table>\n<tbody>\n<tr>\n<td>\u0110\u1ed3ng thu\u1eadn m\u1ea1nh<\/td>\n<td>\u0110\u1ed3ng \u00fd &gt; 90% s\u1ed1 chuy\u00ean gia tham d\u1ef1<\/td>\n<\/tr>\n<tr>\n<td>\u0110\u1ed3ng thu\u1eadn<\/td>\n<td>\u0110\u1ed3ng \u00fd &gt; 75 \u2013 90% s\u1ed1 chuy\u00ean gia tham d\u1ef1<\/td>\n<\/tr>\n<tr>\n<td>Th\u1ecfa thu\u1eadn \u0111a s\u1ed1<\/td>\n<td>\u0110\u1ed3ng \u00fd &gt; 50 \u2013 75% s\u1ed1 chuy\u00ean gia tham d\u1ef1<\/td>\n<\/tr>\n<tr>\n<td>Kh\u00f4ng \u0111\u1ed3ng thu\u1eadn<\/td>\n<td>\u0110\u1ed3ng \u00fd &lt; 50% s\u1ed1 chuy\u00ean gia tham d\u1ef1<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3>Quy tr\u00ecnh \u0111\u1ed3ng thu\u1eadn<\/h3>\n<p>Nh\u00f3m chuy\u00ean gia \u0111\u00e3 chu\u1ea9n b\u1ecb m\u1ed9t d\u1ef1 th\u1ea3o h\u01b0\u1edbng d\u1eabn v\u1edbi t\u1ed5ng s\u1ed1 32 khuy\u1ebfn ngh\u1ecb v\u00e0 t\u00e1m c\u00f4ng b\u1ed1 \u0111\u01b0\u1ee3c c\u1ea3 nh\u00f3m v\u00e0 Ban bi\u00ean t\u1eadp c\u1ee7a ESPEN ch\u1ea5p thu\u1eadn, sau \u0111\u00f3 l\u00e0 b\u01b0\u1edbc b\u1eaft \u0111\u1ea7u c\u1ee7a th\u1ee7 t\u1ee5c \u0111\u1ed3ng thu\u1eadn, b\u1eb1ng c\u00e1ch cung c\u1ea5p b\u1ea3n th\u1ea3o cho c\u00e1c th\u00e0nh vi\u00ean ESPEN v\u1edbi l\u1ea7n \u0111\u1ea7u ti\u00ean b\u1ecf phi\u1ebfu tr\u1ef1c tuy\u1ebfn di\u1ec5n ra gi\u1eefa kho\u1ea3ng th\u1eddi gian t\u1eeb ng\u00e0y 21\/02 cho \u0111\u1ebfn ng\u00e0y 15\/03\/2020. K\u1ebft qu\u1ea3 c\u1ee7a cu\u1ed9c b\u1ecf phi\u1ebfu tr\u1ef1c tuy\u1ebfn n\u00e0y l\u00e0 s\u1ef1 \u0111\u1ed3ng thu\u1eadn m\u1ea1nh (\u0111\u1ed3ng thu\u1eadn &gt; 90%) \u0111\u1ed1i v\u1edbi 26 trong s\u1ed1 c\u00e1c khuy\u1ebfn ngh\u1ecb v\u00e0 b\u1ea3y trong s\u1ed1 c\u00e1c c\u00f4ng b\u1ed1 v\u00e0 s\u1ef1 \u0111\u1ed3ng thu\u1eadn (\u0111\u1ed3ng thu\u1eadn &gt; 75% &#8211; 90%) \u0111\u1ed1i v\u1edbi s\u00e1u trong s\u1ed1 c\u00e1c khuy\u1ebfn ngh\u1ecb v\u00e0 m\u1ed9t c\u00f4ng b\u1ed1. Ph\u1ea3n h\u1ed3i thu \u0111\u01b0\u1ee3c trong cu\u1ed9c b\u1ecf phi\u1ebfu tr\u1ef1c tuy\u1ebfn \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 s\u1eeda \u0111\u1ed5i v\u00e0 c\u1ea3i thi\u1ec7n c\u00e1c \u0111\u1ec1 xu\u1ea5t nh\u1eb1m \u0111\u1ea1t \u0111\u01b0\u1ee3c m\u1ee9c \u0111\u1ed9 \u0111\u1ed3ng thu\u1eadn cao h\u01a1n t\u1ea1i cu\u1ed9c h\u1ecdp \u0111\u1ed3ng thu\u1eadn cu\u1ed1i c\u00f9ng. Do \u0111\u1ea1i d\u1ecbch COVID-19, m\u1ed9t H\u1ed9i ngh\u1ecb \u0111\u1ed3ng thu\u1eadn theo k\u1ebf ho\u1ea1ch \u0111\u00e3 b\u1ecb h\u1ee7y b\u1ecf v\u00e0 \u0111\u01b0\u1ee3c thay th\u1ebf b\u1eb1ng m\u1ed9t cu\u1ed9c b\u1ecf phi\u1ebfu tr\u1ef1c tuy\u1ebfn l\u1ea7n th\u1ee9 hai, trong \u0111\u00f3 c\u00e1c khuy\u1ebfn ngh\u1ecb v\u00e0 c\u00f4ng b\u1ed1 c\u00f3 m\u1ee9c \u0111\u1ed3ng thu\u1eadn b\u1eb1ng ho\u1eb7c th\u1ea5p h\u01a1n 90% v\u00e0 nh\u1eefng n\u1ed9i dung c\u00f3 thay \u0111\u1ed5i \u0111\u00e1ng k\u1ec3 do nh\u1eadn x\u00e9t c\u1ee7a cu\u1ed9c b\u1ecf phi\u1ebfu tr\u1ef1c tuy\u1ebfn \u0111\u1ea7u ti\u00ean, \u0111\u01b0\u1ee3c b\u00ecnh ch\u1ecdn l\u1ea1i m\u1ed9t l\u1ea7n n\u1eefa. L\u1ea7n b\u00ecnh ch\u1ecdn tr\u1ef1c tuy\u1ebfn l\u1ea7n 2 di\u1ec5n ra v\u00e0o gi\u1eefa kho\u1ea3ng th\u1eddi gian t\u1eeb ng\u00e0y 15\/05 cho \u0111\u1ebfn ng\u00e0y 07\/06\/2020. Ch\u00edn khuy\u1ebfn ngh\u1ecb v\u00e0 m\u1ed9t c\u00f4ng b\u1ed1 \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u01b0a v\u00e0o cu\u1ed9c b\u1ecf phi\u1ebfu tr\u1ef1c tuy\u1ebfn l\u1ea7n th\u1ee9 hai. B\u1ed1n khuy\u1ebfn ngh\u1ecb v\u00e0 c\u00f4ng b\u1ed1 \u0111\u1ea1t m\u1ee9c \u0111\u1ed3ng thu\u1eadn &gt; 90% (\u0111\u1ed3ng thu\u1eadn m\u1ea1nh), n\u0103m khuy\u1ebfn ngh\u1ecb \u0111\u1ea1t m\u1ee9c \u0111\u1ed3ng thu\u1eadn &gt; 75 &#8211; 90% (\u0111\u1ed3ng thu\u1eadn).<\/p>\n<h3>\u0110\u1ecbnh ngh\u0129a v\u00e0 nh\u1eefng thu\u1eadt ng\u1eef<\/h3>\n<p>T\u1ea5t c\u1ea3 c\u00e1c \u0111\u1ecbnh ngh\u0129a v\u00e0 thu\u1eadt ng\u1eef \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong khuy\u1ebfn c\u00e1o hi\u1ec7n t\u1ea1i ph\u00f9 h\u1ee3p v\u1edbi thu\u1eadt ng\u1eef ESPEN khuy\u1ebfn ngh\u1ecb g\u1ea7n \u0111\u00e2y [9].<\/p>\n<p>Li\u1ec7u ph\u00e1p dinh d\u01b0\u1ee1ng y h\u1ecdc bao g\u1ed3m vi\u1ec7c s\u1eed d\u1ee5ng c\u00e1c ch\u1ebf ph\u1ea9m b\u1ed5 sung dinh d\u01b0\u1ee1ng \u0111\u01b0\u1eddng u\u1ed1ng, \u0111\u01b0\u1eddng ti\u00eau h\u00f3a (EN) v\u00e0 t\u0129nh m\u1ea1ch (PN), v\u00e0 thay th\u1ebf thu\u1eadt ng\u1eef &#8220;dinh d\u01b0\u1ee1ng nh\u00e2n t\u1ea1o&#8221;.<\/p>\n<p>C\u00e2n n\u1eb7ng th\u1ef1c t\u1ebf l\u00e0 tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 \u0111o \u0111\u01b0\u1ee3c trong th\u1eddi gian n\u1eb1m vi\u1ec7n; c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng l\u00e0 tr\u1ecdng l\u01b0\u1ee3ng li\u00ean quan \u0111\u1ebfn chi\u1ec1u cao \u0111\u1ec3 c\u00f3 ch\u1ec9 s\u1ed1 kh\u1ed1i c\u01a1 th\u1ec3 (BMI) l\u00e0 23 kg\/m2; c\u00e2n n\u1eb7ng hi\u1ec7u ch\u1ec9nh th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u1edf ng\u01b0\u1eddi b\u00e9o ph\u00ec v\u00e0 \u0111\u01b0\u1ee3c t\u00ednh b\u1eb1ng: (tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 th\u1ef1c t\u1ebf \u2013 tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 l\u00fd t\u01b0\u1edfng)x0.33 + c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng. Th\u00f4ng qua b\u00e0i vi\u1ebft n\u00e0y, c\u00e2n n\u1eb7ng tham chi\u1ebfu \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng l\u00e0 tr\u1ecdng l\u01b0\u1ee3ng kh\u00f4 c\u1ee7a c\u01a1 th\u1ec3 tr\u01b0\u1edbc khi nh\u1eadp vi\u1ec7n \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n b\u00ecnh th\u01b0\u1eddng v\u00e0 th\u1eeba c\u00e2n. \u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n b\u00e9o ph\u00ec, th\u00ec c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng \u0111\u1ec3 \u0111\u1ea1t BMI = 25 kg\/m2 n\u00ean \u0111\u01b0\u1ee3c x\u00e9t \u0111\u1ebfn.<\/p>\n<p>Dinh d\u01b0\u1ee1ng v\u1edbi n\u0103ng l\u01b0\u1ee3ng \u0111\u1ea7y \u0111\u1ee7 \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 khi cung c\u1ea5p 70- 110% so v\u1edbi m\u1ee5c ti\u00eau n\u0103ng l\u01b0\u1ee3ng hay nhu c\u1ea7u; nu\u00f4i d\u01b0\u1ee1ng k\u00e9m l\u00e0 khi n\u0103ng l\u01b0\u1ee3ng &lt; 70% so v\u1edbi nhu c\u1ea7u v\u00e0 nu\u00f4i d\u01b0\u1ee1ng th\u1eeba l\u00e0 khi n\u0103ng l\u01b0\u1ee3ng n\u1ea1p v\u00e0o &gt; 110% so v\u1edbi nhu c\u1ea7u. Nu\u00f4i \u0103n dinh d\u01b0\u1ee1ng l\u00e0 vi\u1ec7c cung c\u1ea5p t\u1ed1i thi\u1ec3u c\u00e1c ch\u1ea5t dinh d\u01b0\u1ee1ng \u0111\u1ec3 b\u1ea3o t\u1ed3n ch\u1ee9c n\u0103ng b\u00ecnh th\u01b0\u1eddng c\u1ee7a bi\u1ec3u m\u00f4 ru\u1ed9t v\u00e0 ng\u0103n ch\u1eb7n s\u1ef1 chuy\u1ec3n v\u1ecb c\u1ee7a vi khu\u1ea9n.<\/p>\n<p>Ch\u1ebf \u0111\u1ed9 \u0103n \u00edt protein ho\u1eb7c \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng b\u1ea3o t\u1ed3n \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n CKD ho\u1eb7c AKI\/AKD l\u00e0 ki\u1ec3m so\u00e1t protein n\u1ea1p v\u00e0o \u1edf m\u1ee9c \u2264 0.7 g\/kg\/ng\u00e0y.<\/p>\n<p>C\u00e1c \u0111\u1ecbnh ngh\u0129a sau \u0111\u00e2y \u0111\u01b0\u1ee3c tr\u00ecnh b\u00e0y chi ti\u1ebft trong B\u1ea3ng 5-7. AKI l\u00e0 s\u1ef1 gi\u1ea3m \u0111\u1ed9t ng\u1ed9t \u0111\u1ed9 l\u1ecdc c\u1ea7u th\u1eadn (GFR), bi\u1ec3u hi\u1ec7n r\u00f5 r\u00e0ng b\u1eb1ng s\u1ef1 gia t\u0103ng creatinin huy\u1ebft thanh ho\u1eb7c thi\u1ec3u ni\u1ec7u trong v\u00f2ng 48 gi\u1edd \u0111\u1ebfn 7 ng\u00e0y, v\u1edbi m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng (giai \u0111o\u1ea1n) c\u1ee7a AKI \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh b\u1eb1ng m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng c\u1ee7a s\u1ef1 gia t\u0103ng creatinin huy\u1ebft thanh ho\u1eb7c thi\u1ec3u ni\u1ec7u [4]. Hi\u1ec7n kh\u00f4ng c\u00f3 ti\u00eau ch\u00ed \u0111\u01b0\u1ee3c ch\u1ea5p thu\u1eadn cho c\u00e1c d\u1ea5u hi\u1ec7u t\u1ed5n th\u01b0\u01a1ng th\u1eadn trong tr\u01b0\u1eddng h\u1ee3p AKI, nh\u01b0 khi \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a cho CKD (v\u00ed d\u1ee5: protein ni\u1ec7u). Ng\u01b0\u1eddi ta th\u01b0\u1eddng ch\u1ea5p nh\u1eadn r\u1eb1ng ti\u00eau chu\u1ea9n v\u1ec1 l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u cho AKI ch\u1ec9 \u00e1p d\u1ee5ng trong c\u00e1c \u0111\u01a1n v\u1ecb ICU, trong khi vi\u1ec7c x\u00e1c \u0111\u1ecbnh AKI v\u00e0 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng c\u1ee7a n\u00f3 t\u1eeb th\u1eddi \u0111i\u1ec3m thay \u0111\u1ed5i n\u1ed3ng \u0111\u1ed9 creatinin huy\u1ebft thanh n\u00f3i chung \u0111\u01b0\u1ee3c coi l\u00e0 ch\u1ea5p nh\u1eadn \u0111\u01b0\u1ee3c \u1edf t\u1ea5t c\u1ea3 c\u00e1c c\u01a1 s\u1edf l\u00e2m s\u00e0ng kh\u00e1c. AKI \u0111\u01b0\u1ee3c ph\u00e2n lo\u1ea1i th\u00e0nh 3 giai \u0111o\u1ea1n (b\u1ea3ng 6), d\u1ef1a tr\u00ean khuy\u1ebfn c\u00e1o c\u1ee7a KDIGO [4]. AKD theo \u0111\u1ecbnh ngh\u0129a bao g\u1ed3m c\u1ea3 AKI nh\u01b0ng c\u0169ng bao g\u1ed3m c\u00e1c r\u1ed1i lo\u1ea1n \u0111\u01b0\u1ee3c \u0111\u1eb7c tr\u01b0ng b\u1edfi c\u00e1c d\u1ea5u hi\u1ec7u t\u1ed5n th\u01b0\u01a1ng th\u1eadn, ch\u1eb3ng h\u1ea1n nh\u01b0 ti\u1ec3u m\u00e1u, m\u1ee7 ho\u1eb7c t\u1eafc ngh\u1ebdn \u0111\u01b0\u1eddng ti\u1ebft ni\u1ec7u, trong \u0111\u00f3 t\u1ed1c \u0111\u1ed9 gi\u1ea3m GFR kh\u00f4ng nhanh nh\u01b0 \u1edf AKI. Ch\u1ea9n \u0111o\u00e1n AKD bao g\u1ed3m c\u00e1c d\u1ea5u hi\u1ec7u t\u1ed5n th\u01b0\u01a1ng th\u1eadn ho\u1eb7c gi\u1ea3m eGFR &lt; 60ml\/ph\u00fat\/1.73m2 da \u2264 3 th\u00e1ng v\u00e0 kh\u00f4ng ph\u00e2n lo\u1ea1i m\u1ee9c \u0111\u1ed9 n\u1eb7ng [6]. D\u01b0\u1eddng nh\u01b0 AKD kh\u00f4ng c\u00f3 AKI ph\u1ed5 bi\u1ebfn h\u01a1n AKI. CKD \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a d\u1ef1a tr\u00ean s\u1ef1 m\u1ea5t d\u1ea7n d\u1ea7n ch\u1ee9c n\u0103ng c\u1ee7a th\u1eadn v\u00e0\/ho\u1eb7c s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a c\u00e1c d\u1ea5u hi\u1ec7u v\u00e0\/ho\u1eb7c b\u1eb1ng ch\u1ee9ng h\u00ecnh \u1ea3nh h\u1ecdc\/m\u00f4 h\u1ecdc c\u1ee7a b\u1ec7nh th\u1eadn (v\u00ed d\u1ee5: protein ni\u1ec7u, si\u00eau \u00e2m th\u1eadn g\u1ee3i \u00fd b\u1ec7nh l\u00fd th\u1eadn, sinh thi\u1ebft th\u1eadn cho k\u1ebft qu\u1ea3 b\u1ec7nh l\u00fd, v.v&#8230;) k\u00e9o d\u00e0i theo n\u0103m th\u00e1ng. CKD trong giai \u0111o\u1ea1n ban \u0111\u1ea7u h\u1ea7u nh\u01b0 lu\u00f4n kh\u00f4ng c\u00f3 tri\u1ec7u ch\u1ee9ng v\u00e0 th\u01b0\u1eddng \u0111\u01b0\u1ee3c ph\u00e1t hi\u1ec7n tr\u00ean x\u00e9t nghi\u1ec7m m\u00e1u \u0111\u1ecbnh k\u1ef3 b\u1eb1ng c\u00e1ch t\u0103ng creatinin huy\u1ebft thanh ho\u1eb7c s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a protein\/m\u00e1u trong n\u01b0\u1edbc ti\u1ec3u [5]. C\u00e1c giai \u0111o\u1ea1n c\u1ee7a CKD \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp trong b\u1ea3ng 7. Suy ch\u1ee9c n\u0103ng th\u1eadn \u2013 KF, \u0111\u1eb7c tr\u01b0ng cho giai \u0111o\u1ea1n 5 c\u1ee7a CKD, c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 li\u1ec7u ph\u00e1p thay th\u1ebf th\u1eadn \u2013 KRT. C\u1ea7n ph\u1ea3i hi\u1ec3u r\u1eb1ng trong nhi\u1ec1u tr\u01b0\u1eddng h\u1ee3p, AKI\/AKD c\u00f3 th\u1ec3 x\u1ea3y ra tr\u00ean t\u00ecnh tr\u1ea1ng CKD tr\u01b0\u1edbc \u0111\u00f3 (AKI\/AKD tr\u00ean n\u1ec1n CKD).<\/p>\n<p><em>B\u1ea3ng 5. \u0110\u1ecbnh ngh\u0129a c\u1ee7a KDIGO v\u1ec1 AKI (t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p), AKD (B\u1ec7nh th\u1eadn c\u1ea5p t\u00ednh) v\u00e0 CKD (b\u1ec7nh th\u1eadn m\u1ea1n t\u00ednh)<\/em><\/p>\n<table>\n<tbody>\n<tr>\n<td>T\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p &#8211; Acute Kidney Injury (AKI)<\/td>\n<td>\u2264 7 ng\u00e0y<\/td>\n<td>Gi\u1ea3m \u0111\u1ed9t ng\u1ed9t ch\u1ee9c n\u0103ng th\u1eadn x\u1ea3y ra trong kho\u1ea3ng th\u1eddi gian h\u00e0ng gi\u1edd &#8211; ng\u00e0y (d\u01b0\u1edbi 7 ng\u00e0y)<\/p>\n<p>Ti\u00eau chu\u1ea9n:<\/p>\n<ul>\n<li>T\u0103ng n\u1ed3ng \u0111\u1ed9 Creatinin \u2265 0.3mg\/dl (26.5\u00b5mol\/L) trong v\u00f2ng 48h; ho\u1eb7c<\/li>\n<li>T\u0103ng n\u1ed3ng \u0111\u1ed9 Creatinine \u2265 1.5 l\u1ea7n so v\u1edbi chu\u1ea9n, \u0111\u00e3 bi\u1ebft ho\u1eb7c \u0111\u01b0\u1ee3c cho l\u00e0 \u0111\u00e3 x\u1ea3y ra trong v\u00f2ng 7 ng\u00e0y tr\u01b0\u1edbc \u0111\u00f3; ho\u1eb7c<\/li>\n<li>Th\u1ec3 t\u00edch n\u01b0\u1edbc ti\u1ec3u &lt; 0.5ml\/kg\/gi\u1edd<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td>B\u1ec7nh th\u1eadn c\u1ea5p t\u00ednh \u2013 Acute Kidney Disease (AKD)<\/td>\n<td>7 ng\u00e0y \u2013 3 th\u00e1ng<\/td>\n<td>T\u1ed5n th\u01b0\u01a1ng c\u1ea5p t\u00ednh ho\u1eb7c b\u00e1n c\u1ea5p t\u00ednh v\u00e0\/ho\u1eb7c m\u1ea5t ch\u1ee9c n\u0103ng th\u1eadn x\u1ea3y ra trong kho\u1ea3ng th\u1eddi gian t\u1eeb 7 \u0111\u1ebfn 90<br \/>\nng\u00e0y sau khi x\u1ea3y ra AKI.<\/td>\n<\/tr>\n<tr>\n<td>B\u1ec7nh th\u1eadn m\u1ea1n t\u00ednh \u2013 Chronic Kidney Disease (CKD)<\/td>\n<td>&gt; 3 th\u00e1ng<\/td>\n<td>B\u1ea5t th\u01b0\u1eddng v\u1ec1 c\u1ea5u tr\u00fac ho\u1eb7c ch\u1ee9c n\u0103ng c\u1ee7a th\u1eadn \u2265 90 ng\u00e0y c\u00f3 ho\u1eb7c kh\u00f4ng gi\u1ea3m eGFR<\/p>\n<p>Ti\u00eau chu\u1ea9n:<\/p>\n<ul>\n<li>B\u1ea5t th\u01b0\u1eddng v\u1ec1 c\u1ea5u tr\u00fac ho\u1eb7c ch\u1ee9c n\u0103ng th\u1eadn c\u00f3 ho\u1eb7c kh\u00f4ng gi\u1ea3m eGFR; ho\u1eb7c<\/li>\n<li>GFR &lt; 60ml\/ph\u00fat\/1.73m2 kho\u1ea3ng \u2265 3<br \/>\nth\u00e1ng v\u1edbi t\u1ed5n th\u01b0\u01a1ng th\u1eadn ho\u1eb7c kh\u00f4ng<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>B\u1ea3ng 6. Ph\u00e2n \u0111\u1ed9 c\u1ee7a KDIGO v\u1ec1 t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p<\/p>\n<table>\n<tbody>\n<tr>\n<td>Acute Kidney Injury<\/td>\n<td>&nbsp;<\/p>\n<p>Serum Creatinine<\/td>\n<td>&nbsp;<\/p>\n<p>Urine Output<\/td>\n<\/tr>\n<tr>\n<td>Stage 1<\/td>\n<td>1.5 &#8211; 1.9mg\/dLa x baseline or \u2265 0.3mg\/dLa above baseline<\/td>\n<td>&lt; 0.5ml\/kg\/h for 6-12h<\/td>\n<\/tr>\n<tr>\n<td>Stage 2<\/td>\n<td>2.0 \u2013 2.9mg\/dLa x baseline<\/td>\n<td>&lt; 0.5ml\/kg\/h for &gt; 12h<\/td>\n<\/tr>\n<tr>\n<td>&nbsp;<\/p>\n<p>Stage 3<\/td>\n<td>\u2265 3.0mg\/dLa x baseline, \u2265 4.0mg\/dLa, or initiation of renal replacement therapy<\/td>\n<td>&lt; 0.3ml\/kg\/h of anuria for \u2265 12h<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>\u0110\u1ed5i \u0111\u01a1n v\u1ecb sang \u00b5mol\/L, nh\u00e2n v\u1edbi 88.4<\/p>\n<p>B\u1ea3ng 7. Ph\u00e2n \u0111\u1ed9 c\u1ee7a KDIGO v\u1ec1 b\u1ec7nh th\u1eadn m\u1ea1n<\/p>\n<h2>C\u00e1c kh\u00eda c\u1ea1nh t\u1ed5ng qu\u00e1t (Non-Pico Question)<\/h2>\n<h3>T\u00e1c \u0111\u1ed9ng c\u1ee7a AKI\/AKD v\u00e0 CKD l\u00ean s\u1ef1 trao \u0111\u1ed5i c\u01a1 ch\u1ea5t ?<\/h3>\n<p><strong>Tuy\u00ean b\u1ed1 1: Suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn c\u00f3 t\u00e1c \u0111\u1ed9ng ti\u00eau c\u1ef1c \u0111\u1ebfn qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a carbohydrate, protein v\u00e0 lipid g\u00e2y ra t\u00e1c \u0111\u1ed9ng ti\u1ec1n vi\u00eam v\u00e0 c\u00f3 t\u00e1c \u0111\u1ed9ng ch\u00ednh \u0111\u1ebfn h\u1ec7 th\u1ed1ng ch\u1ed1ng oxy h\u00f3a<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed9 \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>Suy gi\u1ea3m nghi\u00eam tr\u1ecdng ch\u1ee9c n\u0103ng th\u1eadn (gi\u1ea3m \u0111\u1ed9 l\u1ecdc c\u1ea7u th\u1eadn), \u0111\u1eb7c bi\u1ec7t l\u00e0 AKI\/AKD v\u00e0 c\u00e1c giai \u0111o\u1ea1n v\u1ec1 sau c\u1ee7a CKD di\u1ec5n ti\u1ebfn \u0111\u1ebfn KF, kh\u00f4ng ch\u1ec9 \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn chuy\u1ec3n h\u00f3a n\u01b0\u1edbc, ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i v\u00e0 th\u0103ng b\u1eb1ng toan ki\u1ec1m m\u00e0 c\u00f2n t\u1ea1o ra nh\u1eefng thay \u0111\u1ed5i to\u00e0n b\u1ed9 trong \u201cn\u1ed9i m\u00f4i\u201d, c\u00f9ng v\u1edbi nh\u1eefng thay \u0111\u1ed5i r\u00f5 r\u1ec7t v\u1ec1 chuy\u1ec3n h\u00f3a protein, acid amin, carbohydrate v\u00e0 lipid [10]. Ngo\u00e0i ra, n\u00f3 th\u00fac \u0111\u1ea9y c\u00e1c ho\u1ea1t \u0111\u1ed9ng ti\u1ec1n vi\u00eam v\u00e0 g\u00e2y ra t\u00e1c \u0111\u1ed9ng ti\u00eau c\u1ef1c \u0111\u1ebfn qu\u00e1 tr\u00ecnh ch\u1ed1ng oxy h\u00f3a. AKI\/AKD, \u0111\u1eb7c bi\u1ec7t l\u00e0 trong H\u1ed3i s\u1ee9c t\u00edch c\u1ef1c \u2013 ICU, hi\u1ebfm khi \u0111\u1ea1i di\u1ec7n cho c\u00e1c qu\u00e1 tr\u00ecnh b\u1ec7nh l\u00fd \u0111\u01a1n thu\u1ea7n. Nh\u1eefng thay \u0111\u1ed5i v\u1ec1 chuy\u1ec3n h\u00f3a \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y \u0111\u01b0\u1ee3c nh\u1eadn \u0111\u1ecbnh l\u00e0 do b\u1ec7nh n\u1ec1n v\u00e0\/ho\u1eb7c b\u1ec7nh l\u00fd \u0111i k\u00e8m g\u00e2y ra, b\u1edfi s\u1ef1 r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng c\u01a1 quan c\u0169ng nh\u01b0 b\u1ecb \u1ea3nh h\u01b0\u1edfng b\u1edfi c\u00e1ch th\u1ee9c v\u00e0 c\u01b0\u1eddng \u0111\u1ed9 c\u1ee7a li\u1ec7u ph\u00e1p thay th\u1ebf th\u1eadn \u2013 KRT [10]. C\u00e1c b\u1ea5t th\u01b0\u1eddng v\u1ec1 chuy\u1ec3n h\u00f3a nghi\u00eam tr\u1ecdng li\u00ean quan \u0111\u1ebfn AKI\/AKD c\u1ee5 th\u1ec3 nh\u01b0 sau:<\/p>\n<ul>\n<li>D\u1ecb h\u00f3a protein<\/li>\n<li>Thay \u0111\u1ed5i chuy\u1ec3n h\u00f3a c\u1ee7a c\u00e1c acid amin<\/li>\n<li>\u0110\u1ec1 kh\u00e1ng insulin ngo\u1ea1i vi<\/li>\n<li>Gi\u1ea3m ph\u00e2n gi\u1ea3i lipid v\u00e0 l\u00e0m gi\u1ea3m qu\u00e1 tr\u00ecnh thanh th\u1ea3i ch\u1ea5t b\u00e9o<\/li>\n<li>S\u1ef1 suy y\u1ebfu c\u1ee7a h\u1ec7 th\u1ed1ng ch\u1ed1ng oxy h\u00f3a<\/li>\n<li>Kh\u1edfi \u0111\u1ea7u t\u00ecnh tr\u1ea1ng vi\u00eam<\/li>\n<li>Suy gi\u1ea3m mi\u1ec5n d\u1ecbch<\/li>\n<\/ul>\n<p>D\u1ecb h\u00f3a protein l\u00e0 d\u1ea5u hi\u1ec7u chuy\u1ec3n h\u00f3a c\u1ee7a AKI\/AKD, \u0111\u1eb7c bi\u1ec7t l\u00e0 trong t\u00ecnh tr\u1ea1ng b\u1ec7nh n\u1eb7ng t\u1ea1i ICU. S\u1ef1 trao \u0111\u1ed5i ch\u1ea5t c\u00f3 l\u00fac b\u1ea5t th\u01b0\u1eddng v\u00e0 kh\u00f4ng gi\u1ed1ng nhau c\u1ee7a c\u00e1c acid amin, m\u1ed9t s\u1ed1 acid amin kh\u00f4ng thi\u1ebft y\u1ebfu (nh\u01b0 l\u00e0 tyrosine) tr\u1edf n\u00ean c\u1ea7n thi\u1ebft m\u1ed9t c\u00e1ch c\u00f3 \u0111i\u1ec1u ki\u1ec7n v\u00e0 nh\u1eefng thay \u0111\u1ed5i c\u1ee7a c\u00e1c acid amin b\u00ean trong v\u00e0 b\u00ean ngo\u00e0i m\u00e0ng t\u1ebf b\u00e0o, c\u0169ng nh\u01b0 vi\u1ec7c s\u1eed d\u1ee5ng c\u00e1c acid amin ngo\u1ea1i sinh. T\u00ecnh tr\u1ea1ng t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft, do \u0111\u1ec1 kh\u00e1ng insulin \u1edf ngo\u1ea1i vi v\u00e0 do k\u00edch ho\u1ea1t qu\u00e1 tr\u00ecnh t\u00e2n t\u1ea1o glucose \u1edf gan. Ng\u01b0\u1ee3c l\u1ea1i v\u1edbi t\u00ecnh tr\u1ea1ng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n CKD \u1ed5n \u0111\u1ecbnh v\u00e0 nh\u1eefng ng\u01b0\u1eddi kh\u1ecfe m\u1ea1nh, s\u1ef1 gia t\u0103ng h\u00ecnh th\u00e0nh glucose kh\u00f4ng b\u1ecb \u1ea3nh h\u01b0\u1edfng b\u1edfi s\u1ef1 cung c\u1ea5p ch\u1ea5t dinh d\u01b0\u1ee1ng b\u00ean ngo\u00e0i. \u0110\u1ec1 kh\u00e1ng insulin, \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 t\u00ecnh tr\u1ea1ng t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft m\u1eb7c d\u00f9 n\u1ed3ng \u0111\u1ed9 insulin cao, \u0111i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 li\u00ean quan \u0111\u1ebfn t\u0103ng nguy c\u01a1 bi\u1ebfn ch\u1ee9ng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI\/AKD; thay \u0111\u1ed5i trong chuy\u1ec3n h\u00f3a lipid di\u1ec5n ra v\u00e0 \u0111\u1eb7c tr\u01b0ng b\u1edfi t\u0103ng triglycerid m\u00e1u do \u1ee9c ch\u1ebf ph\u00e2n gi\u1ea3i lipid. Sau c\u00f9ng c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn gi\u1ea3m thanh th\u1ea3i c\u00e1c h\u1ea1t ch\u1ea5t b\u00e9o ngo\u1ea1i sinh sau khi s\u1eed d\u1ee5ng lipid \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch ho\u1eb7c \u0111\u01b0\u1eddng ti\u00eau h\u00f3a [10].<\/p>\n<p>Th\u00eam v\u00e0o t\u00ecnh tr\u1ea1ng \u0111\u00f3 l\u00e0 t\u00ecnh tr\u1ea1ng t\u0103ng \u0111\u00e1p \u1ee9ng vi\u00eam v\u00e0 kh\u1ea3 n\u0103ng mi\u1ec5n d\u1ecbch b\u1ecb suy gi\u1ea3m. N\u1ed3ng \u0111\u1ed9 trong huy\u1ebft t\u01b0\u01a1ng c\u1ee7a c\u00e1c vitamin tan trong n\u01b0\u1edbc b\u1ecb gi\u1ea3m \u0111i v\u00e0 s\u1ef1 ho\u1ea1t h\u00f3a c\u1ee7a vitamin D b\u1ecb suy gi\u1ea3m, g\u00f3p ph\u1ea7n g\u00e2y ra c\u01b0\u1eddng c\u1eadn gi\u00e1p th\u1ee9 ph\u00e1t. H\u1eadu qu\u1ea3 l\u00e0 c\u00e1c Vitamin E, A c\u00f9ng v\u1edbi Selen s\u1ebd gi\u1ea3m th\u1ea5p v\u00e0 c\u00f3 suy gi\u1ea3m ch\u1ee9c n\u0103ng r\u00f5 r\u1ec7t c\u1ee7a h\u1ec7 th\u1ed1ng ch\u1ed1ng oxy h\u00f3a.<\/p>\n<p>C\u1ea7n n\u00f3i th\u00eam r\u1eb1ng v\u1edbi t\u00ecnh tr\u1ea1ng CKD \u0111\u00e3 c\u00f3 t\u1eeb tr\u01b0\u1edbc, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edf h\u1ea7u h\u1ebft c\u00e1c giai \u0111o\u1ea1n s\u1edbm, c\u00f3 th\u1ec3 \u0111\u00e3 g\u00e2y ra c\u00e1c m\u1ee9c \u0111\u1ed9 kh\u00e1c nhau c\u1ee7a thay \u0111\u1ed5i chuy\u1ec3n h\u00f3a bao g\u1ed3m t\u00ecnh tr\u1ea1ng oxy h\u00f3a h\u1ec7 th\u1ed1ng v\u00e0 \u0111\u00e1p \u1ee9ng vi\u00eam \u1edf m\u1ee9c th\u1ea5p. Ch\u1ee9c n\u0103ng th\u1eadn ng\u00e0y c\u00e0ng t\u1ed3i t\u1ec7 h\u01a1n \u1edf b\u1ec7nh nh\u00e2n CKD (c\u0169ng nh\u01b0 l\u00e0 AKI\/AKD tr\u00ean n\u1ec1n CKD) c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn nh\u1eefng thay \u0111\u1ed5i v\u1ec1 chuy\u1ec3n h\u00f3a th\u1eadm ch\u00ed c\u00f2n t\u1ed3i t\u1ec7 h\u01a1n v\u00e0 h\u1eadu qu\u1ea3 l\u00e0 nh\u1eefng thay \u0111\u1ed5i trong h\u1ec7 c\u01a1 x\u01b0\u01a1ng, m\u00f4 m\u1ee1 v\u00e0 th\u00e0nh ph\u1ea7n c\u01a1 th\u1ec3.<\/p>\n<h3>C\u00f3 ph\u1ea3i t\u00ecnh tr\u1ea1ng AKI\/AKD hay CKD l\u00e0 m\u1ed9t y\u1ebfu t\u1ed1 nguy c\u01a1 \u0111\u1ed9c l\u1eadp c\u1ee7a suy dinh d\u01b0\u1ee1ng ?<\/h3>\n<p><strong>Tuy\u00ean b\u1ed1 2: AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng t\u00ecnh tr\u1ea1ng suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn l\u00e0m t\u0103ng nguy c\u01a1 suy dinh d\u01b0\u1ee1ng b\u1edfi n\u00f3 g\u00e2y ra t\u00ecnh tr\u1ea1ng r\u1ed1i lo\u1ea1n chuy\u1ec3n h\u00f3a v\u00e0 gi\u1ea3m dung n\u1ea1p c\u00e1c ch\u1ea5t dinh d\u01b0\u1ee1ng.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>C\u01a1 ch\u1ebf b\u1ec7nh sinh c\u1ee7a suy dinh d\u01b0\u1ee1ng \u1edf b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn (KF) r\u1ea5t ph\u1ee9c t\u1ea1p v\u00e0 li\u00ean quan \u0111\u1ebfn nhi\u1ec1u y\u1ebfu t\u1ed1 v\u00e0 c\u01a1 ch\u1ebf kh\u00e1c nhau tr\u00ean t\u1eebng c\u00e1 th\u1ec3 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c x\u00e9t \u0111\u1ebfn [10,11]. Trong tr\u01b0\u1eddng h\u1ee3p AKI\/AKD ho\u1eb7c AKI\/AKD tr\u00ean n\u1ec1n CKD, \u0111\u1eb7c bi\u1ec7t l\u00e0 trong ICU, s\u1ef1 m\u1ea5t c\u1ea5p t\u00ednh ch\u1ee9c n\u0103ng c\u00e2n b\u1eb1ng n\u1ed9i m\u00f4i c\u1ee7a th\u1eadn \u0111\u00f3ng m\u1ed9t vai tr\u00f2 trung t\u00e2m trong vi\u1ec7c l\u00e0m cho r\u1ed1i lo\u1ea1n chuy\u1ec3n h\u00f3a t\u1ed3i t\u1ec7 h\u01a1n, l\u00e0 \u0111i\u1ec3n h\u00ecnh c\u1ee7a t\u00ecnh tr\u1ea1ng b\u1ec7nh n\u1eb7ng (H\u00ecnh 1) [10]. Tr\u1ecdng t\u00e2m c\u1ee7a qu\u00e1 tr\u00ecnh n\u00e0y l\u00e0 s\u1ef1 \u0111\u1ec1 kh\u00e1ng insulin [12], th\u01b0\u1eddng \u0111\u01b0\u1ee3c quan s\u00e1t th\u1ea5y \u1edf b\u1ec7nh nh\u00e2n AKI v\u00e0 li\u00ean quan ch\u1eb7t ch\u1ebd \u0111\u1ebfn nguy c\u01a1 l\u00e0m t\u0103ng t\u1ef7 l\u1ec7 t\u1eed vong [13], v\u00e0 ph\u00f3ng th\u00edch c\u00e1c ch\u1ea5t trung gian ti\u1ec1n vi\u00eam\/oxy h\u00f3a v\u00e0o h\u1ec7 tu\u1ea7n ho\u00e0n [14]. Tr\u00ean th\u1ef1c t\u1ebf, AKI hi\u1ec7n \u0111\u01b0\u1ee3c xem l\u00e0 h\u1ec7 qu\u1ea3 c\u1ee7a qu\u00e1 tr\u00ecnh vi\u00eam khu tr\u00fa \u1edf th\u1eadn ban \u0111\u1ea7u, sau \u0111\u00f3 nhanh ch\u00f3ng lan sang c\u00e1c c\u01a1 quan\/h\u1ec7 th\u1ed1ng kh\u00e1c [15]; khi chuy\u1ec3n h\u00f3a carbohydrate, protein v\u00e0 lipid c\u00f9ng b\u1ecb thay \u0111\u1ed5i s\u1ebd l\u00e0m m\u1ea5t c\u00e2n b\u1eb1ng n\u1ed9i m\u00f4i, \u0111\u00e2y l\u00e0 1 trong nh\u1eefng bi\u1ec3u hi\u1ec7n h\u1ec7 th\u1ed1ng c\u1ee7a h\u1ed9i ch\u1ee9ng vi\u00eam \u201cli\u00ean quan \u0111\u1ebfn\u201d th\u1eadn [16]. H\u1ea7u h\u1ebft c\u00e1c c\u01a1 ch\u1ebf d\u1eabn \u0111\u1ebfn suy dinh d\u01b0\u1ee1ng n\u00eau tr\u00ean c\u0169ng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c d\u00f9ng cho nh\u1eefng b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n m\u1eafc b\u1ec7nh c\u1ea5p t\u00ednh v\u1edbi AKI\/AKD tr\u00ean n\u1ec1n CKD ho\u1eb7c KF kh\u00f4ng n\u1eb1m t\u1ea1i ICU. Th\u1ef1c t\u1ebf, tr\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n CKD c\u00f3 ho\u1eb7c kh\u00f4ng suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn (KF) c\u00f3 suy dinh d\u01b0\u1ee1ng h\u1ea7u h\u1ebft \u0111\u1eb7c tr\u01b0ng b\u1edfi t\u00ecnh tr\u1ea1ng m\u1ea5t protein v\u00e0 n\u0103ng l\u01b0\u1ee3ng d\u1ef1 tr\u1eef do r\u1ed1i lo\u1ea1n chuy\u1ec3n h\u00f3a [17]. V\u00e0i y\u1ebfu t\u1ed1 l\u00e2m s\u00e0ng v\u00e0 chuy\u1ec3n h\u00f3a (b\u1ea3ng 8) c\u0169ng c\u00f3 th\u1ec3 g\u00e2y \u1ea3nh h\u01b0\u1edfng x\u1ea5u \u0111\u1ebfn t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng v\u00e0 kh\u1ed1i n\u1ea1c c\u01a1 th\u1ec3 [18,19], d\u1eabn \u0111\u1ebfn suy y\u1ebfu [20]. Ngo\u00e0i vi\u1ec7c n\u1ea1p v\u00e0o kh\u00f4ng \u0111\u1ee7 ch\u1ea5t dinh d\u01b0\u1ee1ng do t\u1ef1 \u00fd, m\u1ed9t s\u1ed1 y\u1ebfu t\u1ed1 kh\u00e1c nh\u01b0 nhi\u1ec5m toan chuy\u1ec3n h\u00f3a, \u0111\u1ec1 kh\u00e1ng insulin, vi\u00eam m\u1ea1n t\u00ednh, thay \u0111\u1ed5i h\u1ec7 vi sinh v\u1eadt \u0111\u01b0\u1eddng ru\u1ed9t (r\u1ed1i lo\u1ea1n sinh h\u1ecdc \u0111\u01b0\u1eddng ru\u1ed9t), nhi\u1ec5m tr\u00f9ng v\u00e0 oxy h\u00f3a do stress c\u0169ng g\u00f3p ph\u1ea7n v\u00e0o ti\u1ebfn tr\u00ecnh suy dinh d\u01b0\u1ee1ng. Ngo\u00e0i ra, c\u00e1c y\u1ebfu t\u1ed1 li\u00ean quan \u0111\u1ebfn b\u1ea3n th\u00e2n vi\u1ec7c \u0111i\u1ec1u tr\u1ecb CKD, ch\u1eb3ng h\u1ea1n nh\u01b0 nh\u1eefng h\u1ea1n ch\u1ebf v\u1ec1 ch\u1ebf \u0111\u1ed9 \u0103n u\u1ed1ng kh\u00f4ng ph\u00f9 h\u1ee3p ho\u1eb7c ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o, c\u00f3 th\u1ec3 \u0111\u00f3ng m\u1ed9t vai tr\u00f2 n\u00e0o \u0111\u00f3. V\u00e0 sau c\u00f9ng l\u00e0 t\u1ea1o n\u00ean v\u00f2ng xo\u1eafn b\u1ec7nh l\u00fd gi\u1eefa suy dinh d\u01b0\u1ee1ng v\u00e0 c\u00e1c bi\u1ebfn ch\u1ee9ng c\u1ee7a n\u00f3 (H\u00ecnh 1) [17].<\/p>\n<p><img decoding=\"async\" class=\"size-full wp-image-33620\" src=\"https:\/\/www.vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-1.jpg\" alt=\"H\u00ecnh 1. V\u00f2ng xo\u1eafn b\u1ec7nh l\u00fd c\u1ee7a Suy dinh d\u01b0\u1ee1ng tr\u00ean b\u1ec7nh nh\u00e2n CKD [17].\" height=\"700\" title=\"\" srcset=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-1.jpg 950w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-1-543x400.jpg 543w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-1-768x566.jpg 768w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-1-350x258.jpg 350w\" sizes=\"(max-width: 950px) 100vw, 950px\" \/> H\u00ecnh 1. V\u00f2ng xo\u1eafn b\u1ec7nh l\u00fd c\u1ee7a Suy dinh d\u01b0\u1ee1ng tr\u00ean b\u1ec7nh nh\u00e2n CKD [17].B\u1ea3ng 8. Nguy\u00ean nh\u00e2n v\u00e0 c\u01a1 ch\u1ebf g\u00e2y suy dinh d\u01b0\u1ee1ng protein n\u0103ng l\u01b0\u1ee3ng [17].<\/p>\n<table>\n<tbody>\n<tr>\n<td>\n<ol>\n<li>Gi\u1ea3m dung n\u1ea1p protein v\u00e0 n\u0103ng l\u01b0\u1ee3ng<\/li>\n<\/ol>\n<\/td>\n<td>Ch\u00e1n \u0103n:<\/p>\n<p>R\u1ed1i lo\u1ea1n \u0111i\u1ec1u ti\u1ebft c\u00e1c ch\u1ea5t trung gian k\u00edch th\u00edch \u0103n<\/p>\n<p>K\u00edch th\u00edch acid amin v\u00f9ng d\u01b0\u1edbi \u0111\u1ed3i<\/p>\n<p>Nhi\u1ec5m \u0111\u1ed9c ure<\/p>\n<p>H\u1ea1n ch\u1ebf trong ch\u1ebf \u0111\u1ed9 \u0103n kh\u00f4ng ph\u00f9 h\u1ee3p<\/p>\n<p>B\u1ec7nh l\u00fd \u0111\u01b0\u1eddng ti\u00eau h\u00f3a<\/p>\n<p>Sa s\u00fat tinh th\u1ea7n<\/p>\n<p>G\u1eb7p kh\u00f3 kh\u0103n trong chu\u1ea9n b\u1ecb th\u1ee9c \u0103n<\/p>\n<p>\u0110i\u1ec1u ki\u1ec7n kinh t\u1ebf &#8211; x\u00e3 h\u1ed9i th\u1ea5p<\/td>\n<\/tr>\n<tr>\n<td>2. T\u0103ng d\u1ecb h\u00f3a<\/td>\n<td>T\u0103ng ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng<\/p>\n<p>T\u00ecnh tr\u1ea1ng vi\u00eam m\u1ea1n t\u00ednh<\/p>\n<p>T\u0103ng ti\u1ebft c\u00e1c cytokine ti\u1ec1n vi\u00eam<\/p>\n<p>Thay \u0111\u1ed5i chuy\u1ec3n h\u00f3a c\u1ee7a adiponectin v\u00e0 resistin<\/p>\n<p>Thay \u0111\u1ed5i hormon<\/p>\n<p>\u0110\u1ec1 kh\u00e1ng insulin<\/p>\n<p>T\u0103ng ho\u1ea1t \u0111\u1ed9ng c\u1ee7a glucocorticoid<\/td>\n<\/tr>\n<tr>\n<td>3. Toan chuy\u1ec3n h\u00f3a<\/td>\n<td>T\u0103ng ph\u00e2n gi\u1ea3i protein, oxy h\u00f3a BCAA, \u0111\u1ec1 kh\u00e1ng insulin v\u00e0 IGF-1<\/td>\n<\/tr>\n<tr>\n<td>4. Gi\u1ea3m ho\u1ea1t \u0111\u1ed9ng th\u1ec3<\/p>\n<p>l\u1ef1c<\/td>\n<td>Gi\u1ea3m s\u1ee9c c\u01a1, gi\u1ea3m v\u1eadn \u0111\u1ed9ng t\u1ef1 ch\u1ee7, gi\u1ea3m hi\u1ec7u su\u1ea5t v\u1eadn \u0111\u1ed9ng<\/td>\n<\/tr>\n<tr>\n<td>5. Gi\u1ea3m \u0111\u1ed3ng h\u00f3a<\/td>\n<td>Gi\u1ea3m dung n\u1ea1p dinh d\u01b0\u1ee1ng (\u0103n k\u00e9m)<\/p>\n<p>\u0110\u1ec1 kh\u00e1ng insulin, GH\/IGF-1<\/p>\n<p>Thi\u1ebfu h\u1ee5t Testosterone<\/p>\n<p>Hormon tuy\u1ebfn gi\u00e1p gi\u1ea3m<\/td>\n<\/tr>\n<tr>\n<td>6. B\u1ec7nh n\u1ec1n v\u00e0 l\u1ed1i s\u1ed1ng<\/td>\n<td>B\u1ec7nh n\u1ec1n (\u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng, suy tim, b\u1ec7nh tim thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9, b\u1ec7nh m\u1ea1ch m\u00e1u ngo\u1ea1i vi)<\/p>\n<p>L\u1ed1i s\u1ed1ng t\u0129nh t\u1ea1i, \u00edt v\u1eadn \u0111\u1ed9ng<\/td>\n<\/tr>\n<tr>\n<td>7. L\u1ecdc m\u00e1u<\/td>\n<td>M\u1ea5t acid amin v\u00e0 protein do th\u1ea9m t\u00e1ch<\/p>\n<p>C\u00e1c qu\u00e1 tr\u00ecnh vi\u00eam li\u00ean quan \u0111\u1ebfn l\u1ecdc m\u00e1u<\/p>\n<p>T\u0103ng d\u1ecb h\u00f3a do l\u1ecdc m\u00e1u<\/p>\n<p>M\u1ea5t ch\u1ee9c n\u0103ng th\u1eadn c\u00f2n l\u1ea1i<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3>KRT l\u00e0 g\u00ec v\u00e0 nh\u1eefng ph\u01b0\u01a1ng th\u1ee9c n\u00e0o hi\u1ec7n \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n v\u1edbi AKI\/AKD ho\u1eb7c CKD c\u00f3 gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn (KF) ?<\/h3>\n<p>Thu\u1eadt ng\u1eef KRT (Kidney Replacement Therapy) hi\u1ec7n \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 bao g\u1ed3m t\u1ea5t c\u1ea3 c\u00e1c c\u00e1c ph\u01b0\u01a1ng th\u1ee9c \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 thay th\u1ebf ch\u1ee9c n\u0103ng th\u1eadn (\u0111\u1eb7c bi\u1ec7t l\u00e0 ch\u1ee9c n\u0103ng l\u1ecdc ho\u1eb7c ch\u1ee9c n\u0103ng c\u1ee7a c\u1ea7u th\u1eadn) \u1edf b\u1ec7nh nh\u00e2n AKI\/AKD ho\u1eb7c CKD v\u1edbi KF. KRT cho kh\u1ea3 n\u0103ng thanh th\u1ea3i c\u00e1c ch\u1ea5t tan (nh\u01b0 l\u00e0 creatinine, ur\u00ea, ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i, v\u00e0 c\u00e1c \u201c\u0111\u1ed9c t\u1ed1 ur\u00ea huy\u1ebft\u201d) t\u00f9y thu\u1ed9c v\u1ec1 tr\u1ecdng l\u01b0\u1ee3ng ph\u00e2n t\u1eed c\u1ee7a ch\u00fang, lo\u1ea1i b\u1ecf d\u1ecbch d\u01b0 th\u1eeba v\u00e0 duy tr\u00ec tr\u1ea1ng th\u00e1i th\u0103ng b\u1eb1ng toan ki\u1ec1m v\u00e0 c\u00e2n b\u1eb1ng \u0111i\u1ec7n gi\u1ea3i. Tuy nhi\u00ean, ch\u1ee9c n\u0103ng b\u00e0i ti\u1ebft v\u00e0 t\u00e1i h\u1ea5p thu c\u1ee7a \u1ed1ng th\u1eadn c\u0169ng nh\u01b0 ch\u1ee9c n\u0103ng n\u1ed9i ti\u1ebft c\u1ee7a th\u1eadn b\u00ecnh th\u01b0\u1eddng \u0111\u1ec1u kh\u00f4ng \u0111\u01b0\u1ee3c thay th\u1ebf b\u1eb1ng KRT \u0111\u01b0\u1ee3c. H\u01a1n n\u1eefa, \u0111\u1ed9 thanh th\u1ea3i ch\u1ea5t tan, ngay c\u1ea3 trong tr\u01b0\u1eddng h\u1ee3p KRT t\u1ed1i \u01b0u, c\u0169ng th\u1ea5p h\u01a1n \u0111\u00e1ng k\u1ec3 so v\u1edbi th\u1eadn b\u00ecnh th\u01b0\u1eddng, v\u00ec n\u00f3 ch\u1ec9 \u0111\u1ea1t kho\u1ea3ng 10- 20% \u0111\u1ed9 thanh th\u1ea3i sinh l\u00fd c\u1ee7a c\u00e1c ch\u1ea5t nh\u01b0 ur\u00ea ho\u1eb7c creatinin, v\u00e0 th\u1eadm ch\u00ed \u00edt h\u01a1n trong tr\u01b0\u1eddng h\u1ee3p ch\u1ea5t tan c\u00f3 kh\u1ed1i l\u01b0\u1ee3ng ph\u00e2n t\u1eed l\u1edbn h\u01a1n. Cu\u1ed1i c\u00f9ng, m\u1ed9t s\u1ed1 ch\u1ea5t c\u00f3 l\u1ee3i, v\u00e0 \u0111\u1eb7c bi\u1ec7t l\u00e0 m\u1ed9t s\u1ed1 ch\u1ea5t dinh d\u01b0\u1ee1ng \u0111a l\u01b0\u1ee3ng ho\u1eb7c vi l\u01b0\u1ee3ng ph\u00e2n t\u1eed th\u1ea5p, nh\u01b0 acid amin ho\u1eb7c vitamin tan trong n\u01b0\u1edbc c\u0169ng c\u00f3 th\u1ec3 b\u1ecb m\u1ea5t, v\u00ec ch\u00fang d\u1ec5 d\u00e0ng b\u1ecb lo\u1ea1i b\u1ecf trong qu\u00e1 tr\u00ecnh KRT. C\u00e1c nguy\u00ean t\u1eafc c\u01a1 b\u1ea3n c\u1ee7a vi\u1ec7c lo\u1ea1i b\u1ecf ch\u1ea5t tan b\u1eb1ng KRT l\u00e0 khu\u1ebfch t\u00e1n v\u00e0 \u0111\u1ed1i l\u01b0u (H\u00ecnh 2). S\u1ef1 khu\u1ebfch t\u00e1n l\u00e0 s\u1ef1 di chuy\u1ec3n c\u1ee7a c\u00e1c ch\u1ea5t tan t\u1eeb m\u1ed9t khu v\u1ef1c c\u00f3 n\u1ed3ng \u0111\u1ed9 cao \u0111\u1ebfn khu v\u1ef1c c\u00f3 n\u1ed3ng \u0111\u1ed9 th\u1ea5p qua m\u00e0ng b\u00e1n th\u1ea5m. S\u1ef1 d\u1ecbch chuy\u1ec3n \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c cho \u0111\u1ebfn khi \u0111\u1ea1t \u0111\u01b0\u1ee3c tr\u1ea1ng th\u00e1i c\u00e2n b\u1eb1ng. Trong tr\u01b0\u1eddng h\u1ee3p c\u1ee7a \u0111\u1ed1i l\u01b0u, dung m\u00f4i (v\u00ed d\u1ee5: n\u01b0\u1edbc) mang c\u00e1c ch\u1ea5t h\u00f2a tan qua m\u00e0ng (l\u1ef1c k\u00e9o ch\u1ea5t tan); ch\u1ea5t l\u1ecfng \u0111\u01b0\u1ee3c lo\u1ea1i b\u1ecf b\u1eb1ng \u0111\u1ed1i l\u01b0u (m\u1ed9t qu\u00e1 tr\u00ecnh \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 si\u00eau l\u1ecdc) c\u00f9ng v\u1edbi c\u00e1c ch\u1ea5t tan. M\u00e0ng b\u00e1n th\u1ea5m c\u00f3 th\u1ec3 l\u00e0 t\u1ef1 nhi\u00ean, n\u1ebfu l\u00e0 nh\u00e2n t\u1ea1o th\u00ec m\u00e1u c\u1ee7a b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c b\u01a1m b\u1eb1ng m\u00e1y trong b\u1ed9 l\u1ecdc theo chu tr\u00ecnh b\u00ean ngo\u00e0i c\u01a1 th\u1ec3. Trong tr\u01b0\u1eddng h\u1ee3p c\u00f2n l\u1ea1i, m\u00e0ng duy nh\u1ea5t c\u00f3 s\u1eb5n cho m\u1ee5c \u0111\u00edch n\u00e0y l\u00e0 m\u00e0ng b\u1ee5ng v\u00e0 d\u00f2ng m\u00e1u \u0111\u01b0\u1ee3c c\u1ea5p b\u1edfi h\u1ec7 vi tu\u1ea7n ho\u00e0n m\u00e0ng b\u1ee5ng. Do ch\u00eanh l\u1ec7ch th\u1ea9m th\u1ea5u t\u1ea1i c\u00e1c mao m\u1ea1ch, d\u1ecbch s\u1ebd \u0111\u01b0\u1ee3c lo\u1ea1i b\u1ecf khi \u0111\u01b0a v\u00e0o khoang ph\u00fac m\u1ea1c c\u00e1c d\u1ecbch \u01b0u tr\u01b0\u01a1ng (glucose \u01b0u tr\u01b0\u01a1ng ho\u1eb7c icodextrin). D\u1ef1a tr\u00ean nh\u1eefng nguy\u00ean t\u1eafc n\u00e0y, KRT c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c chia th\u00e0nh<\/p>\n<p>KRT ngo\u00e0i c\u01a1 th\u1ec3 (Hemodialysis \u2013 Ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o hay Th\u1ea9m t\u00e1ch m\u00e1u v\u00e0\/ho\u1eb7c Hemofiltration \u2013 Si\u00eau l\u1ecdc) v\u00e0 KRT trong c\u01a1 th\u1ec3 (th\u1ea9m ph\u00e2n ph\u00fac m\u1ea1c, t\u1ee9c PD). Khu\u1ebfch t\u00e1n v\u00e0 \u0111\u1ed1i l\u01b0u th\u01b0\u1eddng \u0111\u01b0\u1ee3c k\u1ebft h\u1ee3p v\u00e0 ti\u1ebfn h\u00e0nh \u0111\u1ed3ng th\u1eddi c\u1ea3 trong ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o v\u00e0 trong l\u1ecdc m\u00e0ng b\u1ee5ng &#8211; PD. Ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o &#8211; Hemodialysis (th\u01b0\u1eddng m\u1ed7i l\u1ea7n kho\u1ea3ng 4 gi\u1edd, ba l\u1ea7n m\u1ed9t tu\u1ea7n) l\u00e0 ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb ti\u00eau chu\u1ea9n cho b\u1ec7nh nh\u00e2n CKD \u1edf giai \u0111o\u1ea1n suy ch\u1ee9c n\u0103ng ph\u1ea3i \u0111i\u1ec1u tr\u1ecb thay th\u1ebf th\u1eadn, trong khi c\u00e1c b\u1ec7nh nh\u00e2n l\u1ecdc m\u00e0ng b\u1ee5ng ch\u1ec9 chi\u1ebfm m\u1ed9t ph\u1ea7n nh\u1ecf. Hi\u1ec7n nay, c\u00f3 nhi\u1ec1u ph\u01b0\u01a1ng ph\u00e1p thay th\u1ebf kh\u00e1c tr\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng c\u00f3 AKI\/AKD. T\u1ea5t c\u1ea3 ph\u01b0\u01a1ng ph\u00e1p tr\u00ean \u0111\u1ec1u d\u1ef1a tr\u00ean s\u1ef1 khu\u1ebfch t\u00e1n ho\u1eb7c \u0111\u1ed1i l\u01b0u ho\u1eb7c s\u1ef1 k\u1ebft h\u1ee3p c\u1ee7a c\u1ea3 hai, nh\u01b0ng hi\u1ec7u qu\u1ea3 (\u0111\u1ed9 thanh th\u1ea3i) v\u00e0 th\u1eddi gian s\u1ebd kh\u00e1c nhau \u0111\u00e1ng k\u1ec3 \u1edf t\u1eebng ph\u01b0\u01a1ng ph\u00e1p. Do \u0111\u00f3, vi\u1ec7c l\u1ef1a ch\u1ecdn ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb ph\u1ee5 thu\u1ed9c v\u00e0o \u0111\u1eb7c \u0111i\u1ec3m c\u1ee7a b\u1ec7nh nh\u00e2n v\u00e0 ch\u1ee7 y\u1ebfu d\u1ef1a tr\u00ean \u0111\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng v\u1ec1 nhu c\u1ea7u l\u1ecdc m\u00e1u (v\u00ed d\u1ee5 t\u1ed1c \u0111\u1ed9 d\u1ecb h\u00f3a), l\u01b0\u1ee3ng d\u1ecbch c\u1ea7n lo\u1ea1i b\u1ecf v\u00e0 t\u00ecnh tr\u1ea1ng huy\u1ebft \u0111\u1ed9ng c\u1ee7a b\u1ec7nh nh\u00e2n. Ch\u1ec9 m\u1ed9t s\u1ed1 \u00edt b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI\/AKD c\u00f3 th\u1ec3 l\u1ecdc \u0111\u01b0\u1ee3c v\u1edbi th\u1eddi gian t\u01b0\u01a1ng \u0111\u1ed1i ng\u1eafn, \u0111i\u1ec3n h\u00ecnh l\u00e0 l\u1ecbch ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o th\u00f4ng th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng th\u01b0\u1eddng quy cho b\u1ec7nh nh\u00e2n KF. C\u00e1c ph\u01b0\u01a1ng th\u1ee9c KRT k\u00e9o d\u00e0i h\u01a1n (t\u1eeb 8 \u0111\u1ebfn 12 gi\u1edd m\u1ed9t ng\u00e0y \u0111\u1ebfn 24 gi\u1edd m\u1ed9t ng\u00e0y, t\u1ee9c l\u00e0 li\u00ean t\u1ee5c) th\u01b0\u1eddng ph\u00f9 h\u1ee3p h\u01a1n n\u1ebfu x\u00e9t \u0111\u1ebfn huy\u1ebft \u0111\u1ed9ng. \u1ede c\u00e1c n\u01b0\u1edbc ph\u01b0\u01a1ng T\u00e2y v\u00e0 M\u1ef9, PD th\u01b0\u1eddng kh\u00f4ng \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh cho b\u1ec7nh nh\u00e2n n\u1eb7ng trong ICU. Do \u0111\u00f3, trong tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh nh\u00e2n n\u1eb7ng t\u1ea1i ICU th\u00ec KRT ngo\u00e0i c\u01a1 th\u1ec3 \u0111\u01b0\u1ee3c xem l\u00e0 ti\u00eau chu\u1ea9n v\u00e0ng, v\u00e0 th\u01b0\u1eddng \u0111\u01b0\u1ee3c ph\u00e2n lo\u1ea1i d\u1ef1a tr\u00ean th\u1eddi gian c\u1ee7a n\u00f3 [21]. M\u1ed7i ph\u01b0\u01a1ng th\u1ee9c c\u1ee7a KRT t\u1ea1i ICU (ng\u1eaft qu\u00e3ng, ng\u1eaft qu\u00e3ng k\u00e9o d\u00e0i v\u00e0 l\u1ecdc m\u00e1u li\u00ean t\u1ee5c) \u0111\u1ec1u c\u00f3 nh\u1eefng \u01b0u v\u00e0 nh\u01b0\u1ee3c \u0111i\u1ec3m, t\u00f9y thu\u1ed9c v\u00e0o t\u1eebng b\u1ec7nh nh\u00e2n. \u0110\u1ed1i v\u1edbi c\u00e1c b\u1ec7nh nh\u00e2n AKI\/AKD kh\u00f4ng n\u1eb1m t\u1ea1i ICU, ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o ng\u1eaft qu\u00e3ng l\u00e0 ph\u01b0\u01a1ng th\u1ee9c KRT \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng ph\u1ed5 bi\u1ebfn nh\u1ea5t.<\/p>\n<p><img decoding=\"async\" class=\"size-full wp-image-33621\" src=\"https:\/\/www.vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-2.jpg\" alt=\"H\u00ecnh 2. Nguy\u00ean t\u1eafc c\u1ee7a khu\u1ebfch t\u00e1n v\u00e0 \u0111\u1ed1i l\u01b0u trong KRT.\" height=\"700\" title=\"\" srcset=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-2.jpg 950w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-2-543x400.jpg 543w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-2-768x566.jpg 768w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/08\/huong-dan-dac-biet-ve-dinh-duong-lam-sang-o-benh-nhan-co-benh-than-cap-tinh-hoac-benh-than-man-tinh-anh-2-350x258.jpg 350w\" sizes=\"(max-width: 950px) 100vw, 950px\" \/> H\u00ecnh 2. Nguy\u00ean t\u1eafc c\u1ee7a khu\u1ebfch t\u00e1n v\u00e0 \u0111\u1ed1i l\u01b0u trong KRT.<\/p>\n<h3>C\u00e1c ph\u01b0\u01a1ng th\u1ee9c l\u1ecdc c\u1ee7a KRT<\/h3>\n<p>Ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o ng\u1eaft qu\u00e3ng l\u00e0 ph\u01b0\u01a1ng th\u1ee9c KRT ngo\u00e0i c\u01a1 th\u1ec3 ph\u1ed5 bi\u1ebfn nh\u1ea5t \u1edf b\u1ec7nh nh\u00e2n CKD ti\u1ebfn tri\u1ec3n trong giai \u0111o\u1ea1n KF, nh\u01b0ng c\u0169ng c\u00f3 th\u1ec3 ch\u1ec9 \u0111\u1ecbnh tr\u00ean b\u1ec7nh nh\u00e2n AKI\/AKD ho\u1eb7c AKI tr\u00ean CKD mi\u1ec5n l\u00e0 t\u00ecnh tr\u1ea1ng huy\u1ebft \u0111\u1ed9ng \u1ed5n \u0111\u1ecbnh. Ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o th\u01b0\u1eddng ba l\u1ea7n m\u1ed9t tu\u1ea7n trong kho\u1ea3ng 3 \u2013 4 gi\u1edd\/l\u1ea7n. L\u1ecdc m\u00e1u ng\u1eaft qu\u00e3ng c\u0169ng \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n KF \u0111ang KRT m\u1ea1n t\u00ednh m\u00e0 d\u1ec5 b\u1ecb t\u1ee5t \u00e1p*, v\u1edbi c\u01a1 ch\u1ebf \u0111\u1ed1i l\u01b0u. Tuy nhi\u00ean, trong h\u1ea7u h\u1ebft c\u00e1c tr\u01b0\u1eddng h\u1ee3p n\u00e0y*, ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o v\u00e0 l\u1ecdc m\u00e1u \u0111\u01b0\u1ee3c k\u1ebft h\u1ee3p trong c\u00f9ng m\u1ed9t phi\u00ean KRT (hemodiafiltration). Trong ICU, c\u00e1ch l\u1ecdc k\u00e9o d\u00e0i \u0111\u01b0\u1ee3c \u01b0u ti\u00ean h\u01a1n, nh\u01b0 l\u1ecdc m\u00e1u li\u00ean t\u1ee5c CKRT (hay CRRT) ho\u1eb7c L\u1ecdc m\u00e1u ng\u1eaft qu\u00e3ng k\u00e9o d\u00e0i (Prolonged Intermittment Kidney Replacement Therapy \u2013 PIKRT, hay PIRRT). Thu\u1eadt ng\u1eef PIKRT (hay PIRRT) l\u00e0 s\u1ef1 k\u1ebft h\u1ee3p \u01b0u \u0111i\u1ec3m c\u1ee7a c\u1ea3 2 ph\u01b0\u01a1ng ph\u00e1p KRT ng\u1eaft qu\u00e3ng v\u00e0 li\u00ean t\u1ee5c tr\u00ean c\u01a1 s\u1edf th\u1eddi gian th\u1ef1c hi\u1ec7n v\u00e0 t\u1ea7n su\u1ea5t \u0111i\u1ec1u tr\u1ecb [21].<\/p>\n<p>\u01afu \u0111i\u1ec3m c\u1ee7a c\u00e1c ph\u01b0\u01a1ng th\u1ee9c KRT k\u00e9o d\u00e0i nh\u01b0 CKRT (CRRT) hay PIKRT (PIRRT) \u0111\u00f3 l\u00e0 gi\u00fap cho t\u00ecnh tr\u1ea1ng huy\u1ebft \u0111\u1ed9ng \u1ed5n \u0111\u1ecbnh h\u01a1n, gi\u1ea3m lo\u1ea1i b\u1ecf c\u00e1c ch\u1ea5t tan, \u0111\u00e1p \u1ee9ng v\u1edbi r\u00fat d\u1ecbch t\u1ed1t h\u01a1n, do \u0111\u00f3 \u01b0u ti\u00ean ch\u1ec9 \u0111\u1ecbnh tr\u00ean b\u1ec7nh nh\u00e2n AKI c\u00f3 t\u00ecnh tr\u1ea1ng huy\u1ebft \u0111\u1ed9ng kh\u00f4ng \u1ed5n \u0111\u1ecbnh [22]. V\u00e0 l\u1ee3i \u00edch c\u1ee7a 2 ph\u01b0\u01a1ng ph\u00e1p n\u00e0y l\u00e0 nh\u01b0 nhau.<\/p>\n<h3>L\u1ecdc m\u00e0ng b\u1ee5ng<\/h3>\n<p>Ngo\u00e0i c\u00e1c ph\u01b0\u01a1ng ph\u00e1p KRT ngo\u00e0i c\u01a1 th\u1ec3 n\u00f3i \u1edf tr\u00ean th\u00ec l\u1ecdc m\u00e0ng b\u1ee5ng (PD) \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh \u1edf m\u1ed9t s\u1ed1 b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n. \u1ede c\u00e1c n\u01b0\u1edbc ph\u01b0\u01a1ng T\u00e2y, b\u1ec7nh nh\u00e2n t\u1ea1i ICU hi\u1ebfm khi \u0111\u01b0\u1ee3c l\u00e0m PD, nh\u01b0ng PD th\u01b0\u1eddng g\u1eb7p \u1edf c\u00e1c b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n m\u00e0 tr\u01b0\u1edbc \u0111\u00f3 \u0111\u01b0\u1ee3c l\u1ecdc m\u00e0ng b\u1ee5ng li\u00ean t\u1ee5c (CAPD, m\u1ed9t ph\u01b0\u01a1ng th\u1ee9c PD th\u1ee7 c\u00f4ng h\u00e0ng ng\u00e0y c\u1ee7a b\u1ec7nh nh\u00e2n t\u1ea1i nh\u00e0) ho\u1eb7c th\u1ea9m ph\u00e2n ph\u00fac m\u1ea1c t\u1ef1 \u0111\u1ed9ng (APD, m\u1ed9t ph\u01b0\u01a1ng th\u1ee9c PD, s\u1eed d\u1ee5ng b\u1eb1ng m\u1ed9t m\u00e1y \u0111\u01a1n gi\u1ea3n, th\u01b0\u1eddng \u1edf nh\u00e0 v\u00e0 v\u00e0o ban \u0111\u00eam). PD d\u1ef1a tr\u00ean s\u1ef1 trao \u0111\u1ed5i ch\u1ea5t tan gi\u1eefa c\u00e1c mao m\u1ea1ch ph\u00fac m\u1ea1c v\u1edbi d\u1ecbch th\u1ea9m t\u00e1ch v\u00e0 sau \u0111\u00f3 \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u ra ngo\u00e0i. Dung d\u1ecbch PD ch\u1ee9a glucose ho\u1eb7c m\u1ed9t lo\u1ea1i \u0111\u01b0\u1eddng kh\u00e1c \u0111\u1ec3 lo\u1ea1i b\u1ecf d\u1ecbch. Tuy nhi\u00ean, dextrose \u0111\u01b0\u1ee3c h\u1ea5p th\u1ee5 theo th\u1eddi gian, do \u0111\u00f3 c\u00f3 th\u1ec3 g\u00e2y ra c\u00e2n b\u1eb1ng glucose d\u01b0\u01a1ng kho\u1ea3ng 400 kcal\/ng\u00e0y.<\/p>\n<h2>C\u00e1c khuy\u1ebfn c\u00e1o<\/h2>\n<h3>Ch\u1ec9 \u0111\u1ecbnh dinh d\u01b0\u1ee1ng:<\/h3>\n<h4>\u0110i\u1ec1u tr\u1ecb v\u1edbi dinh d\u01b0\u1ee1ng c\u00f3 c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb kh\u00f4ng v\u00e0 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c l\u1ee3i \u00edch g\u00ec t\u1eeb \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 1 (Grade GPP): N\u00ean quan t\u00e2m \u0111\u1ebfn dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng cho c\u00e1c b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n c\u00f3 AKI\/AKD, AKD tr\u00ean n\u1ec1n CKD, CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 2 (Grade GPP): Dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng n\u00ean b\u1eaft \u0111\u1ea7u sau 48 nh\u1eadp vi\u1ec7n tr\u00ean b\u1ec7nh nh\u00e2n ICU c\u00f3 AKI\/AKD, AKI tr\u00ean n\u1ec1n CKD v\u00e0 CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>B\u1ec7nh nh\u00e2n suy th\u1eadn m\u1ea1n, \u0111\u1eb7c bi\u1ec7t l\u00e0 c\u00f3 suy ch\u1ee9c n\u0103ng th\u1eadn \u0111ang l\u1ecdc th\u1eadn m\u1ea1n t\u00ednh ho\u1eb7c kh\u00f4ng, \u0111\u1ec1u c\u00f3 nguy c\u01a1 r\u1ea5t cao r\u1ed1i lo\u1ea1n dinh d\u01b0\u1ee1ng ti\u1ebfn tri\u1ec3n [11], gi\u1ea3m d\u1ea7n protein v\u00e0 n\u0103ng l\u01b0\u1ee3ng d\u1ef1 tr\u1eef [23], v\u1edbi t\u1ed1c \u0111\u1ed9 t\u0103ng c\u00f9ng v\u1edbi m\u1ee9c \u0111\u1ed9 suy ch\u1ee9c n\u0103ng th\u1eadn [23]. Trong m\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p, t\u1ef7 l\u1ec7 suy dinh d\u01b0\u1ee1ng theo c\u00f4ng c\u1ee5 \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng SGA (Subjective Global Assessment) ho\u1eb7c thang \u0111i\u1ec3m MIS (Malnutrition-inflammatory Score) chi\u1ebfm t\u1ec9 l\u1ec7 t\u1eeb 11 \u2013 54% \u1edf b\u1ec7nh nh\u00e2n CKD kh\u00f4ng l\u1ecdc m\u00e1u giai \u0111o\u1ea1n 3-5 v\u00e0 t\u1eeb 28 \u2013 54% \u1edf b\u1ec7nh nh\u00e2n ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o m\u1ea1n t\u00ednh [24]. Tr\u00ean c\u01a1 s\u1edf \u0111\u00f3, cho th\u1ea5y r\u1eb1ng t\u1ea5t c\u1ea3 c\u00e1c b\u1ec7nh nh\u00e2n n\u1ed9i tr\u00fa \u0111\u1ec1u c\u00f3 nguy c\u01a1 suy dinh d\u01b0\u1ee1ng. V\u00ec l\u00fd do \u0111\u1ea1o \u0111\u1ee9c, kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o \u0111\u1ec1 c\u1eadp tr\u1ef1c ti\u1ebfp \u0111\u1ebfn \u1ea3nh h\u01b0\u1edfng c\u1ee7a vi\u1ec7c b\u1ecf \u0111\u00f3i b\u1ec7nh nh\u00e2n KF n\u1ed9i vi\u1ec7n. C\u00e1c d\u1eef li\u1ec7u v\u1ec1 h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng trong AKI r\u1ea5t khan hi\u1ebfm v\u00e0 ch\u1ee7 y\u1ebfu \u1edf d\u1ea1ng c\u00e1c nghi\u00ean c\u1ee9u ch\u1ea5t l\u01b0\u1ee3ng th\u1ea5p t\u1eeb nh\u1eefng n\u0103m 1980, \u0111\u01b0\u1ee3c t\u00f3m t\u1eaft trong c\u00e1c \u0111\u00e1nh gi\u00e1 g\u1ea7n \u0111\u00e2y [10,25,26]. Suy ch\u1ee9c n\u0103ng th\u1eadn kh\u00f4ng g\u00e2y \u1ea3nh h\u01b0\u1edfng nhi\u1ec1u \u0111\u1ebfn nhu c\u1ea7u dinh d\u01b0\u1ee1ng, m\u00e0 ch\u1ee7 y\u1ebfu do kh\u1edfi ph\u00e1t b\u1ec7nh n\u1ec1n v\u00e0 bi\u1ebfn ch\u1ee9ng d\u1eabn \u0111\u1ebfn r\u1ed1i lo\u1ea1n chuy\u1ec3n h\u00f3a dinh d\u01b0\u1ee1ng, do \u0111\u00f3 khuy\u1ebfn ngh\u1ecb v\u1ec1 dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng cho b\u1ec7nh nh\u00e2n AKI, CKD n\u1eb7ng c\u00f3 KF v\u00e0 b\u1ec7nh nh\u00e2n t\u1ea1i ICU l\u00e0 nh\u01b0 nhau [8]. D\u1ef1a v\u00e0o c\u00e1c khuy\u1ebfn ngh\u1ecb tr\u01b0\u1edbc \u0111\u00f3 c\u1ee7a ESPEN [1,2], th\u1eddi \u0111i\u1ec3m 48 gi\u1edd \u0111\u01b0\u1ee3c ch\u1ecdn l\u00e0m m\u1ed1c \u0111\u1ec3 b\u1eaft \u0111\u1ea7u dinh d\u01b0\u1ee1ng s\u1edbm cho b\u1ec7nh nh\u00e2n n\u1eb7ng [8,27] v\u00e0 ch\u00fang t\u00f4i th\u1ea5y \u0111i\u1ec1u n\u00e0y ph\u00f9 h\u1ee3p cho b\u1ec7nh nh\u00e2n AKI\/AKD hay CKD c\u00f3 KF t\u1ea1i ICU.<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 3 (Grade A): C\u00e1c b\u1ec7nh nh\u00e2n AKI\/AKD ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF kh\u00f4ng nguy k\u1ecbch c\u00f3 t\u00ecnh tr\u1ea1ng suy dinh d\u01b0\u1ee1ng, n\u1ebfu kh\u00f4ng \u0111\u1ea1t \u0111\u1ee7 nhu c\u1ea7u v\u1edbi ch\u1ebf \u0111\u1ed9 \u0103n th\u00ec c\u1ea7n b\u1ed5 sung th\u00eam ONS (Oral Nutritional Supplements: dinh d\u01b0\u1ee1ng b\u1ed5 sung \u0111\u01b0\u1eddng mi\u1ec7ng)<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>C\u00e1c b\u1ec7nh nh\u00e2n AKI\/AKD ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF n\u1ed9i vi\u1ec7n kh\u00f4ng nguy k\u1ecbch, dinh d\u01b0\u1ee1ng h\u1ed7 tr\u1ee3 \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh tr\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n suy dinh d\u01b0\u1ee1ng ho\u1eb7c c\u00f3 nguy c\u01a1 suy dinh d\u01b0\u1ee1ng [1,28,29]. ONS, \u0111\u1eb7c bi\u1ec7t l\u00e0 nh\u1eefng s\u1ea3n ph\u1ea9m cao n\u0103ng l\u01b0\u1ee3ng v\u00e0 gi\u00e0u protein, n\u1ebfu \u0111\u01b0\u1ee3c cung c\u1ea5p hai l\u1ea7n\/ng\u00e0y \u00edt nh\u1ea5t sau \u0103n 1 gi\u1edd c\u00f3 th\u1ec3 b\u1ed5 sung l\u00ean \u0111\u1ebfn 10-12 kcal\/kg\/ng\u00e0y v\u00e0 0.3-0.5g protein\/kg\/ng\u00e0y so v\u1edbi l\u01b0\u1ee3ng m\u00e0 m\u1ed9t b\u1ec7nh nh\u00e2n 70 kg t\u1ef1 \u0103n, do \u0111\u00f3 d\u1ec5 \u0111\u1ea1t \u0111\u01b0\u1ee3c m\u1ee5c ti\u00eau v\u1ec1 nhu c\u1ea7u dinh d\u01b0\u1ee1ng [23]. Theo ch\u00fang t\u00f4i \u0111\u01b0\u1ee3c bi\u1ebft, kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 v\u1ec1 ch\u1ee7 \u0111\u1ec1 n\u00e0y \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng nguy k\u1ecbch n\u1ed9i vi\u1ec7n v\u1edbi AKI\/AKD ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 KF. Tuy nhi\u00ean, b\u1eb1ng ch\u1ee9ng \u1edf b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n c\u00f3 nhi\u1ec1u b\u1ec7nh n\u1ec1n (\u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 hai ho\u1eb7c nhi\u1ec1u b\u1ec7nh m\u1ea1n t\u00ednh \u0111i k\u00e8m) cho th\u1ea5y r\u1eb1ng ONS c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng v\u00e0 ch\u00fang t\u00f4i suy \u0111o\u00e1n r\u1eb1ng b\u1eb1ng ch\u1ee9ng n\u00e0y c\u0169ng c\u00f3 th\u1ec3 \u00e1p d\u1ee5ng cho b\u1ec7nh nh\u00e2n c\u00f3 AKI\/AKD ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 KF m\u00e0 c\u00f3 nhi\u1ec1u b\u1ec7nh n\u1ec1n \u0111i k\u00e8m. Trong m\u1ed9t nghi\u00ean c\u1ee9u RCT v\u1edbi 200 b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n t\u1eeb c\u00e1c khoa n\u1ed9i, ONS k\u1ebft h\u1ee3p v\u1edbi v\u1eadt l\u00fd tr\u1ecb li\u1ec7u gi\u00fap t\u0103ng n\u0103ng l\u01b0\u1ee3ng v\u00e0 l\u01b0\u1ee3ng protein m\u00e0 kh\u00f4ng g\u00e2y \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn ti\u00eau th\u1ee5 th\u1ef1c ph\u1ea9m t\u1ea1i vi\u1ec7n, \u0111\u1ed3ng th\u1eddi duy tr\u00ec kh\u1ed1i n\u1ea1c trong qu\u00e1 tr\u00ecnh ph\u1ee5c h\u1ed3i v\u00e0 ba th\u00e1ng sau khi xu\u1ea5t vi\u1ec7n [30]. Trong m\u1ed9t RCT l\u1edbn kh\u00e1c (n = 445) b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n, ONS cung c\u1ea5p c\u1ea3i thi\u1ec7n \u0111\u00e1ng k\u1ec3 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng, \u0111\u00e1nh gi\u00e1 th\u00f4ng qua albumin huy\u1ebft thanh, folate h\u1ed3ng c\u1ea7u, n\u1ed3ng \u0111\u1ed9 vitamin B12, v\u00e0 gi\u1ea3m t\u1ea7n su\u1ea5t nh\u1eadp vi\u1ec7n b\u1ea5t th\u01b0\u1eddng (kh\u00f4ng theo l\u1ecbch h\u1eb9n) trong s\u00e1u th\u00e1ng sau khi xu\u1ea5t vi\u1ec7n [31]. Trong nhi\u1ec1u nghi\u00ean c\u1ee9u RCT kh\u00e1c th\u00ec ONS c\u0169ng cho k\u1ebft qu\u1ea3 t\u01b0\u01a1ng t\u1ef1, trong \u0111\u00f3 ONS gi\u00fap c\u1ea3i thi\u1ec7n t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng (\u0111\u00e1nh gi\u00e1 b\u1eb1ng tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 v\u00e0 ch\u1ee9c n\u0103ng) [32,33], gi\u1ea3m bi\u1ebfn ch\u1ee9ng [32] v\u00e0 t\u1ec9 l\u1ec7 t\u1eed vong [34,35].<\/p>\n<p>B\u00ean c\u1ea1nh \u0111\u00f3, nhi\u1ec1u nghi\u00ean c\u1ee9u RCTs tr\u00ean b\u1ec7nh nh\u00e2n KF ngo\u1ea1i tr\u00fa cho th\u1ea5y ONS c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng c\u0169ng nh\u01b0 ch\u1ea5t l\u01b0\u1ee3ng cu\u1ed9c s\u1ed1ng v\u00e0 ho\u1ea1t \u0111\u1ed9ng th\u1ec3 ch\u1ea5t [28,36-46]. Trong m\u1ed9t nghi\u00ean tr\u00ean b\u1ec7nh nh\u00e2n CKD ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o v\u1edbi albumin huy\u1ebft thanh th\u1ea5p th\u00ec vi\u1ec7c cung c\u1ea5p ONS c\u00f3 li\u00ean quan \u0111\u1ebfn c\u1ea3i thi\u1ec7n t\u1ef7 l\u1ec7 s\u1ed1ng c\u00f2n [43]. M\u1ed9t th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng tr\u00ean b\u1ec7nh nh\u00e2n CKD c\u00f3 suy dinh d\u01b0\u1ee1ng \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o cho th\u1ea5y ONS ti\u00eau chu\u1ea9n gi\u00fap c\u1ea3i thi\u1ec7n n\u1ed3ng \u0111\u1ed9 albumin huy\u1ebft thanh v\u00e0 transthyretin \u0111\u1ed9c l\u1eadp v\u1edbi t\u00ecnh tr\u1ea1ng vi\u00eam, v\u00e0 s\u1ef1 gia t\u0103ng transthyretin c\u00f3 \u1ea3nh h\u01b0\u1edfng t\u00edch c\u1ef1c \u0111\u1ebfn s\u1ef1 s\u1ed1ng c\u00f2n [47].<br \/>\nKhuy\u1ebfn c\u00e1o 4 (Grade A): Dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch b\u1ed5 sung cho nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb suy dinh d\u01b0\u1ee1ng n\u1ed9i vi\u1ec7n kh\u00f4ng nguy k\u1ecbch v\u1edbi CKD c\u00f3 KF \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o (Intradialytic Parenteral Nutrition \u2013 IDPN) ho\u1eb7c nh\u1eefng b\u1ec7nh nh\u00e2n t\u01b0\u01a1ng t\u1ef1 n\u1ebfu c\u00f3 nguy c\u01a1 suy dinh d\u01b0\u1ee1ng m\u00e0 kh\u00f4ng \u0111\u00e1p \u1ee9ng ho\u1eb7c kh\u00f4ng dung n\u1ea1p v\u1edbi ONS ho\u1eb7c dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a (Enteral Nutrition \u2013 EN).<\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (91.7%) B\u00e0n lu\u1eadn:<\/p>\n<p>IDPN (Intradialytic Parenteral Nutrition) l\u00e0 m\u1ed9t ph\u01b0\u01a1ng th\u1ee9c dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch (Parenteral Nutrition \u2013 PN) ch\u1ec9 \u0111\u1ecbnh cho b\u1ec7nh nh\u00e2n KF \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o m\u1ea1n t\u00ednh. N\u00f3 d\u1ef1a tr\u00ean vi\u1ec7c s\u1eed d\u1ee5ng c\u00e1c ch\u1ea5t dinh d\u01b0\u1ee1ng \u0111a l\u01b0\u1ee3ng v\u00e0 vi l\u01b0\u1ee3ng ngo\u00e0i c\u01a1 th\u1ec3 trong qu\u00e1 tr\u00ecnh ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o, ba l\u1ea7n m\u1ed9t tu\u1ea7n trong 3 \u0111\u1ebfn 4 gi\u1edd [48]. M\u1eb7c d\u00f9 \u0111\u01b0\u1eddng ti\u00eau h\u00f3a l\u00e0 \u01b0u ti\u00ean \u0111\u1ec3 b\u1ed5<br \/>\nsung dinh d\u01b0\u1ee1ng, th\u00ec vi\u1ec7c b\u1ed5 sung dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch trong khi ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o l\u00e0 an to\u00e0n v\u00e0 thu\u1eadn ti\u1ec7n cho nh\u1eefng ng\u01b0\u1eddi kh\u00f4ng th\u1ec3 dung n\u1ea1p dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng mi\u1ec7ng ho\u1eb7c \u0111\u01b0\u1eddng ru\u1ed9t. Nhi\u1ec1u nghi\u00ean c\u1ee9u, bao g\u1ed3m m\u1ed9t s\u1ed1 RCT, cho th\u1ea5y s\u1ef1 c\u1ea3i thi\u1ec7n dinh d\u01b0\u1ee1ng khi s\u1eed d\u1ee5ng IDPN \u1edf b\u1ec7nh nh\u00e2n KF \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o c\u00f3 t\u00ecnh tr\u1ea1ng suy dinh d\u01b0\u1ee1ng n\u0103ng l\u01b0\u1ee3ng-protein r\u00f5 r\u1ec7t [1,47,49-51]. Do kh\u00f4ng v\u01b0\u1ee3t tr\u1ed9i h\u01a1n ONS v\u00e0 gi\u1edbi h\u1ea1n th\u1eddi gian (ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o th\u01b0\u1eddng l\u00e0 4 gi\u1edd, ba l\u1ea7n m\u1ed9t tu\u1ea7n), IDPN l\u00e0 m\u1ed9t l\u1ef1a ch\u1ecdn h\u1ee3p l\u00fd cho nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111\u00e1p \u1ee9ng ho\u1eb7c kh\u00f4ng th\u1ec3 ti\u1ebfp c\u1eadn c\u00e1c ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb khuy\u1ebfn ngh\u1ecb, nh\u01b0ng vi\u1ec7c ch\u1ec9 \u0111\u1ecbnh r\u1ed9ng r\u00e3i IDPN tr\u01b0\u1edbc khi t\u01b0 v\u1ea5n v\u00e0 ONS l\u00e0 kh\u00f4ng \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o [52].<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 5 (Grade A): N\u1ebfu c\u00e1c b\u1ec7nh nh\u00e2n AKI\/AKD, CKD, CKD c\u00f3 KF kh\u00f4ng th\u1ec3 \u0111\u1ea1t m\u1ee5c ti\u00eau 70% nhu c\u1ea7u dinh d\u01b0\u1ee1ng b\u1eb1ng \u0111\u01b0\u1eddng mi\u1ec7ng th\u00ec EN*, PN hay EN k\u1ebft h\u1ee3p PN s\u1ebd \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh, b\u1ea5t k\u1ec3 t\u00ecnh tr\u1ea1ng n\u1eb7ng ho\u1eb7c kh\u00f4ng.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.7%)<\/p>\n<p>Ch\u00fa th\u00edch (*): EN, hay Enteral Nutrition, ngh\u0129a l\u00e0 dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a, b\u1eb1ng c\u00e1ch \u0111\u01b0a th\u1ee9c \u0103n tr\u1ef1c ti\u1ebfp v\u00e0o d\u1ea1 d\u00e0y ho\u1eb7c ru\u1ed9t th\u00f4ng qua sonde ho\u1eb7c \u0111\u01b0\u1eddng mi\u1ec7ng (u\u1ed1ng).<\/p>\n<p><em>B\u00e0n lu\u1eadn (Khuy\u1ebfn c\u00e1o 1-5):<\/em><\/p>\n<p>Ch\u1ec9 \u0111\u1ecbnh EN n\u1ebfu l\u01b0\u1ee3ng \u0103n v\u00e0o (c\u00f3 ho\u1eb7c kh\u00f4ng ONS) kh\u00f4ng dung n\u1ea1p \u0111\u1ee7 \u00edt nh\u1ea5t 70% nhu c\u1ea7u h\u00e0ng ng\u00e0y [1,8]. \u0110\u1ea1t m\u1ee5c ti\u00eau v\u1ec1 dinh d\u01b0\u1ee1ng l\u00e0 r\u1ea5t quan tr\u1ecdng trong vi\u1ec7c ng\u0103n ng\u1eeba s\u1ee5t c\u00e2n v\u00e0 m\u1ea5t kh\u1ed1i c\u01a1. Tuy nhi\u00ean, m\u00f4i tr\u01b0\u1eddng ch\u0103m s\u00f3c t\u1ea1i b\u1ec7nh vi\u1ec7n c\u00f3 nhi\u1ec1u y\u1ebfu t\u1ed1 c\u00f3 th\u1ec3 g\u00e2y kh\u00f3 kh\u0103n cho vi\u1ec7c t\u1ef1 \u0103n u\u1ed1ng c\u1ee7a b\u1ec7nh nh\u00e2n [53], bao g\u1ed3m t\u00ecnh tr\u1ea1ng ch\u00e1n \u0103n, ch\u1eadm l\u00e0m r\u1ed7ng d\u1ea1 d\u00e0y, kh\u00f3 nu\u1ed1t. Trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u00e0y th\u00ec vi\u1ec7c ch\u1ec9 \u0111\u1ecbnh EN ho\u1eb7c PN c\u00f3 th\u1ec3 l\u00e0m t\u0103ng l\u01b0\u1ee3ng dinh d\u01b0\u1ee1ng n\u1ea1p v\u00e0o [54,55]. Kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u c\u1ee5 th\u1ec3 n\u00e0o v\u1ec1 t\u00e1c d\u1ee5ng c\u1ee7a h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng ho\u1eb7c so s\u00e1nh EN v\u00e0 PN \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n (kh\u00f4ng ph\u1ea3i b\u1ec7nh n\u1eb7ng) c\u00f3 AKI\/AKD, CKD ho\u1eb7c CKD v\u1edbi KF. M\u1ed9t s\u1ed1 RCT \u0111\u00e3 so s\u00e1nh t\u00e1c \u0111\u1ed9ng c\u1ee7a h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng tr\u00ean k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb c\u1ee7a nh\u1eefng b\u1ec7nh nh\u00e2n n\u1ed9i tr\u00fa t\u1ea1i c\u00e1c khoa N\u1ed9i. M\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p c\u1ee7a 27 th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng g\u1ea7n \u0111\u00e2y cho th\u1ea5y vi\u1ec7c t\u0103ng n\u0103ng l\u01b0\u1ee3ng v\u00e0 protein s\u1ebd c\u00f3 l\u1ee3i \u0111\u1ed1i v\u1edbi c\u00e2n n\u1eb7ng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 EN khi so v\u1edbi nh\u00f3m ch\u1ee9ng [56]. C\u00f3 m\u1ed9t s\u1ed1 nghi\u00ean c\u1ee9u quan s\u00e1t \u0111\u00e3 so s\u00e1nh \u1ea3nh h\u01b0\u1edfng gi\u1eefa EN v\u00e0 PN \u0111\u1ed1i v\u1edbi k\u1ebft c\u1ee5c c\u1ee7a b\u1ec7nh nh\u00e2n (kh\u00f4ng ph\u1ea3i b\u1ec7nh n\u1eb7ng) thu\u1ed9c kh\u1ed1i N\u1ed9i [57]. Trong m\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t (v\u1edbi n = 1831) cho th\u1ea5y dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng c\u00f3 li\u00ean quan \u0111\u1ebfn gi\u1ea3m nguy c\u01a1 bi\u1ebfn ch\u1ee9ng v\u00e0 nhi\u1ec5m tr\u00f9ng. \u0110\u1eb7c bi\u1ec7t, nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb EN th\u00ec bi\u1ebfn ch\u1ee9ng do nhi\u1ec5m tr\u00f9ng v\u00e0 kh\u00f4ng do nhi\u1ec5m tr\u00f9ng th\u1ea5p h\u01a1n \u0111\u00e1ng k\u1ec3 so v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb PN [57]. Trong ch\u0103m s\u00f3c \u0111\u1eb7c bi\u1ec7t, c\u00e1c b\u1eb1ng ch\u1ee9ng cho th\u1ea5y EN gi\u1ea3m nguy c\u01a1 bi\u1ebfn ch\u1ee9ng h\u01a1n so v\u1edbi PN [8]. B\u00ean c\u1ea1nh \u0111\u00f3, m\u1ed9t nghi\u00ean c\u1ee9u tr\u00ean b\u1ec7nh nh\u00e2n n\u1eb7ng kh\u00f4ng suy dinh d\u01b0\u1ee1ng c\u00f3 AKI th\u00ec vi\u1ec7c tr\u00ec ho\u00e3n PN c\u00f3 \u01b0u \u0111i\u1ec3m h\u01a1n khi kh\u00f4ng dung n\u1ea1p ho\u1eb7c kh\u00f4ng th\u1ec3 s\u1eed d\u1ee5ng EN [58,59]. Vi\u1ec7c nu\u00f4i \u0103n ban \u0111\u1ea7u c\u1ea9n th\u1eadn v\u00e0 t\u0103ng d\u1ea7n li\u1ec1u l\u01b0\u1ee3ng gi\u00fap ph\u00f2ng ng\u1eeba h\u1ed9i ch\u1ee9ng nu\u00f4i \u0103n l\u1ea1i, \u0111\u1eb7c bi\u1ec7t tr\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n suy dinh d\u01b0\u1ee1ng n\u1eb7ng ho\u1eb7c c\u00f3 \u0103n k\u00e9m tr\u01b0\u1edbc v\u00e0 trong khi nh\u1eadp vi\u1ec7n [8].<\/p>\n<h3>\u0110\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng<\/h3>\n<h4>T\u1ea5t c\u1ea3 c\u00e1c b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD n\u1ed9i vi\u1ec7n n\u00ean \u0111\u01b0\u1ee3c t\u1ea7m so\u00e1t suy dinh d\u01b0\u1ee1ng ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 6 (Grade GPP): T\u1ea5t c\u1ea3 b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 KF n\u1ed9i vi\u1ec7n, \u0111\u1eb7c bi\u1ec7t l\u00e0 b\u1ec7nh nh\u00e2n nh\u1eadp ICU h\u01a1n 48 gi\u1edd, n\u00ean \u0111\u01b0\u1ee3c t\u1ea7m so\u00e1t suy dinh d\u01b0\u1ee1ng<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.7%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>B\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD n\u1ed9i vi\u1ec7n \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng v\u1edbi m\u1ed9t s\u1ed1 c\u00f4ng c\u1ee5 s\u00e0ng l\u1ecdc t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng hi\u1ec7n c\u00f3, trong \u0111\u00f3 b\u1ed9 c\u00f4ng c\u1ee5 MUST \u2013 Malnutrition Universal Screening Tool, c\u00f3 \u0111\u1ed9 nh\u1ea1y th\u1ea5p [60], c\u00f3 l\u1ebd do s\u1ef1 ph\u1ee9c t\u1ea1p v\u00e0 nhi\u1ec1u y\u1ebfu t\u1ed1 t\u00e1c \u0111\u1ed9ng c\u1ee7a suy dinh d\u01b0\u1ee1ng tr\u00ean nh\u00f3m b\u1ec7nh nh\u00e2n n\u00e0y. MUST c\u00f3 th\u1ec3 s\u00e0ng l\u1ecdc t\u00ecnh tr\u1ea1ng thi\u1ebfu \u0103n c\u1ea5p t\u00ednh nh\u01b0ng l\u1ea1i b\u1ecf qua m\u1ed9t s\u1ed1 y\u1ebfu t\u1ed1 nguy c\u01a1 quan tr\u1ecdng c\u1ee7a KF nh\u01b0 ch\u00e1n \u0103n v\u00e0 thi\u1ebfu h\u1ee5t dinh d\u01b0\u1ee1ng [61,62]. B\u1ed9 c\u00f4ng c\u1ee5 NRS-2002 (Nutritional Risk Screening 2002) c\u00f3 th\u1ec3 \u0111\u00e1nh gi\u00e1 \u0111\u1ea7y \u0111\u1ee7 t\u00ecnh tr\u1ea1ng suy dinh d\u01b0\u1ee1ng theo SGA c\u0169ng nh\u01b0 d\u1ef1 \u0111o\u00e1n di\u1ec5n ti\u1ebfn x\u1ea5u c\u1ee7a k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb [65,66]. Do ch\u01b0a r\u00f5 v\u1ec1 c\u00e1c nghi\u00ean c\u1ee9u so s\u00e1nh \u0111\u1ed9 tin c\u1eady c\u1ee7a c\u00e1c c\u00f4ng c\u1ee5 s\u00e0ng l\u1ecdc hi\u1ec7n c\u00f3 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y n\u00ean ch\u00fang t\u00f4i k\u1ebft lu\u1eadn r\u1eb1ng t\u1ea5t c\u1ea3 c\u00e1c c\u00f4ng c\u1ee5 s\u00e0ng l\u1ecdc \u0111\u01b0\u1ee3c coi l\u00e0 c\u00f3 gi\u00e1 tr\u1ecb nh\u01b0 nhau, cho \u0111\u1ebfn khi c\u00e1c nghi\u00ean c\u1ee9u so s\u00e1nh \u0111\u1ed9 tin c\u1eady \u0111\u01b0\u1ee3c ti\u1ebfn h\u00e0nh. C\u00e1c tri\u1ec7u ch\u1ee9ng li\u00ean quan \u0111\u1ebfn dinh d\u01b0\u1ee1ng c\u00f3 vai tr\u00f2 quan tr\u1ecdng trong vi\u1ec7c d\u1ef1 \u0111o\u00e1n nguy c\u01a1 suy dinh d\u01b0\u1ee1ng tr\u00ean b\u1ec7nh nh\u00e2n th\u1eadn, v\u00e0 trong s\u1ed1 \u0111\u00f3 th\u00ec ch\u00e1n \u0103n c\u00f3 gi\u00e1 tr\u1ecb ti\u00ean l\u01b0\u1ee3ng cao nh\u1ea5t [67,68]. G\u1ea7n \u0111\u00e2y, m\u1ed9t c\u00f4ng c\u1ee5 s\u00e0ng l\u1ecdc dinh d\u01b0\u1ee1ng m\u1edbi cho b\u1ec7nh nh\u00e2n th\u1eadn (Renal iNUT \u2013 Renal inpatient Nutritional screening Tool) \u0111\u01b0\u1ee3c ph\u00e1t tri\u1ec3n d\u00e0nh ri\u00eang cho b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n v\u1edbi AKI\/AKD v\u00e0 ho\u1eb7c CKD, ho\u1eb7c CKD v\u1edbi KF tr\u00ean KRT [60], c\u00f3 \u0111\u1ed9 nh\u1ea1y v\u00e0 \u0111\u1ed9 \u0111\u1eb7c hi\u1ec7u v\u00e0 gi\u00e1 tr\u1ecb ti\u00ean \u0111o\u00e1n d\u01b0\u01a1ng t\u1ed1t h\u01a1n so v\u1edbi SGA. Ngo\u00e0i th\u00e0nh ph\u1ea7n n\u1ec1n t\u1ea3ng c\u1ee7a MUST, Renal iNUT c\u00f2n bao g\u1ed3m c\u00e1c c\u00e2u h\u1ecfi v\u1ec1 s\u1ef1 th\u00e8m \u0103n, ch\u1ebf \u0111\u1ed9 \u0103n u\u1ed1ng, s\u1eed d\u1ee5ng ch\u1ebf ph\u1ea9m dinh d\u01b0\u1ee1ng b\u1ed5 sung v\u00e0 c\u00e1c chi ti\u1ebft v\u1ec1 c\u00e2n n\u1eb7ng c\u1ee7a b\u1ec7nh nh\u00e2n th\u1eadn (m\u1ee5c ti\u00eau v\u1ec1 c\u00e2n n\u1eb7ng kh\u00f4 ho\u1eb7c c\u00e2n n\u1eb7ng khi kh\u00f4ng ph\u00f9). Tuy nhi\u00ean, li\u1ec7u Renal iNut c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t c\u00f4ng c\u1ee5 th\u00edch h\u1ee3p \u0111\u1ec3 s\u00e0ng l\u1ecdc b\u1ec7nh nh\u00e2n th\u1eadn n\u1ed9i vi\u1ec7n hay kh\u00f4ng th\u00ec c\u1ea7n \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 th\u00eam.<\/p>\n<h4>\u0110\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng tr\u00ean b\u1ec7nh nh\u00e2n AKI\/AKD ho\u1eb7c CKD nh\u01b0 th\u1ebf n\u00e0o ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 7 (Grade GPP): Cho \u0111\u1ebfn khi m\u1ed9t c\u00f4ng c\u1ee5 \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng ri\u00eang bi\u1ec7t \u0111\u01b0\u1ee3c ch\u1ea5p thu\u1eadn, b\u1ea5t k\u1ef3 b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n n\u00e0o c\u00f3 AKI\/AKD ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF c\u00f3 nguy c\u01a1 suy dinh d\u01b0\u1ee1ng n\u00ean \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 t\u1ed5ng th\u1ec3 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (91.3%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>\u0110\u00e1nh gi\u00e1 t\u1ed5ng th\u1ec3 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng bao g\u1ed3m ti\u1ec1n s\u1eed b\u1ec7nh nh\u00e2n, ghi nh\u1eadn v\u1ec1 s\u1ee5t c\u00e2n kh\u00f4ng ch\u1ee7 \u00fd ho\u1eb7c gi\u1ea3m ho\u1ea1t \u0111\u1ed9ng th\u1ec3 l\u1ef1c tr\u01b0\u1edbc khi nh\u1eadp vi\u1ec7n<\/p>\n<p>ho\u1eb7c nh\u1eadp ICU, kh\u00e1m s\u1ee9c kh\u1ecfe, \u0111\u00e1nh gi\u00e1 t\u1ed5ng quan v\u1ec1 th\u00e0nh ph\u1ea7n c\u01a1 th\u1ec3, kh\u1ed1i c\u01a1 v\u00e0 s\u1ee9c c\u01a1.<br \/>\nCh\u01b0a c\u00f3 s\u1ef1 th\u1ed1ng nh\u1ea5t v\u1ec1 \u00e1p d\u1ee5ng m\u1ed9t c\u00f4ng c\u1ee5 duy nh\u1ea5t \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng n\u00ean ch\u1ea9n \u0111o\u00e1n suy dinh d\u01b0\u1ee1ng c\u1ea7n \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n d\u1ef1a tr\u00ean l\u00e2m s\u00e0ng v\u00e0 th\u0103m kh\u00e1m [3]. Nhi\u1ec1u c\u00f4ng c\u1ee5 \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng suy dinh d\u01b0\u1ee1ng \u1edf b\u1ec7nh nh\u00e2n n\u1ed9i tr\u00fa nh\u01b0ng h\u1ea7u h\u1ebft \u0111\u1ec1u c\u00f3 nh\u1eefng h\u1ea1n ch\u1ebf, \u0111\u1eb7c bi\u1ec7t l\u00e0 khi \u00e1p d\u1ee5ng cho b\u1ec7nh nh\u00e2n th\u1eadn [69] v\u00e0 nh\u1ea5t l\u00e0 b\u1ec7nh nh\u00e2n trong ICU [10].<\/p>\n<p>Tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 v\u00e0 BMI, tr\u1eeb khi qu\u00e1 th\u1ea5p (v\u00ed d\u1ee5: BMI &lt; 18.5 kg\/m2), l\u00e0 c\u00e1c c\u00f4ng c\u1ee5 \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng k\u00e9m hi\u1ec7u qu\u1ea3 tr\u00ean b\u1ec7nh nh\u00e2n n\u1ed9i tr\u00fa c\u00f3 AKI\/AKD, v\u00e0\/ho\u1eb7c CKD c\u00f3 KF ho\u1eb7c kh\u00f4ng. \u0110i\u1ec1u n\u00e0y do vi\u1ec7c \u0111o k\u00edch th\u01b0\u1edbc c\u01a1 th\u1ec3 kh\u00f4ng th\u1ec3 hi\u1ec7n \u0111\u01b0\u1ee3c t\u00ecnh tr\u1ea1ng qu\u00e1 t\u1ea3i d\u1ecbch \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y v\u00e0 kh\u00f4ng th\u1ec3 ph\u00e2n bi\u1ec7t \u0111\u01b0\u1ee3c m\u1ee1 t\u1eeb kh\u1ed1i c\u01a1 d\u1ef1 tr\u1eef [10]. Th\u1eeba c\u00e2n hay b\u00e9o ph\u00ec kh\u00f4ng ph\u1ea3i l\u00e0 hi\u1ebfm \u1edf b\u1ec7nh nh\u00e2n AKI ho\u1eb7c CKD v\u1edbi KF, c\u00f3 t\u00ecnh tr\u1ea1ng gi\u1ea3m ho\u1eb7c m\u1ea5t kh\u1ed1i n\u1ea1c hay kh\u1ed1i c\u01a1 x\u01b0\u01a1ng m\u1eb7c d\u00f9 c\u00f3 ch\u1ec9 s\u1ed1 BMI b\u00ecnh th\u01b0\u1eddng ho\u1eb7c th\u1eeba c\u00e2n (v\u00ed d\u1ee5: suy m\u00f2n c\u01a1 tr\u00ean n\u1ec1n b\u00e9o ph\u00ec) [70,71].<\/p>\n<p>SGA \u0111\u00e3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng kh\u00e1 r\u1ed9ng r\u00e3i \u1edf b\u1ec7nh nh\u00e2n AKI \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n r\u1ed1i lo\u1ea1n dinh d\u01b0\u1ee1ng v\u00e0 d\u1ef1 \u0111o\u00e1n k\u1ebft c\u1ee5c x\u1ea5u [72]. SGA c\u0169ng \u0111\u00e3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh suy dinh d\u01b0\u1ee1ng tr\u00ean b\u1ec7nh nh\u00e2n KF n\u1ed9i vi\u1ec7n \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o m\u1ea1n t\u00ednh [73]. Suy dinh d\u01b0\u1ee1ng n\u1eb7ng theo SGA t\u1ea1i ICU c\u0169ng li\u00ean quan \u0111\u1ebfn t\u1ef7 l\u1ec7 t\u1eed vong mu\u1ed9n (s\u00e1u th\u00e1ng sau khi xu\u1ea5t vi\u1ec7n) \u1edf b\u1ec7nh nh\u00e2n AKI [74]. M\u1eb7c d\u00f9 v\u1eady, SGA kh\u00f4ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng r\u1ed9ng r\u00e3i v\u00e0 kh\u00f3 \u00e1p d\u1ee5ng trong ICU.<\/p>\n<p>Tuy albumin huy\u1ebft thanh c\u00f3 \u0111\u1ed9 nh\u1ea1y nh\u01b0 m\u1ed9t c\u00f4ng c\u1ee5 s\u00e0ng l\u1ecdc v\u00e0 ti\u00ean l\u01b0\u1ee3ng nh\u01b0ng n\u00f3 l\u1ea1i kh\u00f4ng cho th\u1ea5y \u0111\u01b0\u1ee3c b\u1ea3n ch\u1ea5t ph\u1ee9c t\u1ea1p c\u1ee7a v\u1ea5n \u0111\u1ec1 dinh d\u01b0\u1ee1ng trong \u0111i\u1ec1u tr\u1ecb b\u1ec7nh nh\u00e2n AKI v\u00e0 CKD. N\u1ed3ng \u0111\u1ed9 albumin l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a qu\u00e1 tr\u00ecnh t\u1ed5ng h\u1ee3p, ph\u00e2n h\u1ee7y, ph\u00e2n b\u1ed1 v\u00e0 trao \u0111\u1ed5i gi\u1eefa b\u00ean trong v\u00e0 ngo\u00e0i th\u00e0nh m\u1ea1ch, c\u0169ng nh\u01b0 l\u01b0\u1ee3ng albumin m\u1ea5t \u0111i [75]. B\u00ean c\u1ea1nh \u0111\u00f3, albumin l\u00e0 m\u1ed9t ch\u1ea5t ph\u1ea3n \u1ee9ng ng\u01b0\u1ee3c trong giai \u0111o\u1ea1n c\u1ea5p, t\u1ee9c l\u00e0 trong giai \u0111o\u1ea1n b\u1ec7nh c\u1ea5p t\u00ednh s\u1ebd gi\u1ea3m t\u1ed5ng h\u1ee3p albumin d\u1eabn \u0111\u1ebfn n\u1ed3ng \u0111\u1ed9 trong huy\u1ebft thanh th\u1ea5p. Kh\u00f4ng n\u00ean xem x\u00e9t gi\u00e1 tr\u1ecb albumin m\u1ed9t c\u00e1ch \u0111\u01a1n \u0111\u1ed9c m\u00e0 c\u00f2n ph\u1ea3i kh\u00e1m v\u00e0 \u0111\u00e1nh gi\u00e1 tr\u00ean l\u00e2m s\u00e0ng th\u1eadt k\u1ef9 l\u01b0\u1ee1ng [76].<\/p>\n<h4>\u0110\u00e1nh gi\u00e1 kh\u1ed1i n\u1ea1c, kh\u1ed1i c\u01a1 v\u00e0 s\u1ee9c c\u01a1 nh\u01b0 th\u1ebf n\u00e0o ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 8 (Grade B): \u0110\u00e1nh gi\u00e1 th\u00e0nh ph\u1ea7n c\u01a1 th\u1ec3 n\u00ean \u0111\u01b0\u1ee3c \u01b0u ti\u00ean h\u01a1n c\u00e1c ph\u00e9p \u0111o nh\u00e2n tr\u1eafc h\u1ecdc khi ch\u1ea9n \u0111o\u00e1n v\u00e0 theo d\u00f5i suy dinh d\u01b0\u1ee1ng \u1edf b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.7%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>Do nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng b\u1ecb m\u1ea5t kh\u1ed1i c\u01a1 x\u01b0\u01a1ng nghi\u00eam tr\u1ecdng v\u00e0 t\u0103ng d\u1ea7n trong v\u00e0i ng\u00e0y \u0111\u1ea7u \u1edf ICU [8,77,78] n\u00ean vi\u1ec7c theo d\u00f5i th\u00e0nh ph\u1ea7n c\u01a1 th\u1ec3 trong th\u1eddi gian n\u1eb1m vi\u1ec7n l\u00e0 r\u1ea5t quan tr\u1ecdng. X\u00e1c \u0111\u1ecbnh s\u1edbm t\u00ecnh tr\u1ea1ng m\u1ea5t c\u01a1 r\u1ea5t quan tr\u1ecdng v\u00ec \u0111\u00e2y c\u00f3 th\u1ec3 l\u00e0 nguy\u00ean nh\u00e2n ch\u00ednh g\u00e2y ra ch\u1eadm cai m\u00e1y th\u1edf v\u00e0 l\u00e0 m\u1ed9t y\u1ebfu t\u1ed1 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng r\u1ed9ng r\u00e3i \u0111\u1ec3 ti\u00ean l\u01b0\u1ee3ng v\u1ec1 t\u1ef7 l\u1ec7 t\u1eed vong v\u00e0 b\u1ec7nh t\u1eadt khi nh\u1eadp vi\u1ec7n [79], ph\u1ee5c h\u1ed3i ch\u1ee9c n\u0103ng [80,81] v\u00e0 t\u00e0n t\u1eadt sau khi xu\u1ea5t vi\u1ec7n [82,83]. Tuy nhi\u00ean, v\u1ea5n \u0111\u1ec1 ch\u00ednh \u1edf \u0111\u00e2y l\u00e0 vi\u1ec7c thi\u1ebfu c\u00e1c c\u00f4ng c\u1ee5 t\u1ea1i gi\u01b0\u1eddng \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 kh\u1ed1i c\u01a1, t\u00e1c \u0111\u1ed9ng c\u1ee7a th\u1eeba d\u1ecbch v\u00e0 s\u1ef1 di chuy\u1ec3n \u0111\u1ed9t ng\u1ed9t c\u1ee7a d\u1ecbch khi s\u1eed d\u1ee5ng c\u00e1c c\u00f4ng c\u1ee5 th\u00f4ng th\u01b0\u1eddng. Do nh\u1eefng h\u1ea1n ch\u1ebf tr\u00ean d\u1eabn \u0111\u1ebfn t\u00e0i li\u1ec7u nghi\u00ean c\u1ee9u v\u1ec1 vai tr\u00f2 c\u1ee7a th\u00e0nh ph\u1ea7n c\u01a1 th\u1ec3 \u1edf b\u1ec7nh nh\u00e2n b\u1ec7nh th\u1eadn n\u1ed9i vi\u1ec7n r\u1ea5t khan hi\u1ebfm. M\u1ed9t nghi\u00ean c\u1ee9u tr\u00ean 31 b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p ph\u00e2n t\u00edch tr\u1edf kh\u00e1ng \u0111i\u1ec7n sinh h\u1ecdc (Bioelectric Impedance Analysis \u2013 BIA) quan s\u00e1t \u0111\u01b0\u1ee3c: c\u00e1c ph\u00e9p \u0111o \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n sau KRT ghi nh\u1eadn gi\u1ea3m kho\u1ea3ng 5% kh\u1ed1i n\u1ea1c so v\u1edbi c\u00e1c ph\u00e9p \u0111o \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n tr\u01b0\u1edbc KRT, cho th\u1ea5y BIA kh\u00f4ng \u0111\u00e1ng tin c\u1eady khi b\u1ec7nh nh\u00e2n qu\u00e1 th\u1eeba d\u1ecbch [84]. Trong m\u1ed9t nghi\u00ean c\u1ee9u kh\u00e1c, ph\u00e2n t\u00edch BIA ch\u1ec9 \u0111\u1ec1 c\u1eadp \u0111\u1ebfn t\u1ed5ng l\u01b0\u1ee3ng d\u1ecbch v\u00e0 l\u01b0\u1ee3ng m\u1ee1 th\u1eeba, n\u00ean kh\u00f3 ph\u00e1t hi\u1ec7n \u0111\u01b0\u1ee3c s\u1ef1 thay \u0111\u1ed5i kh\u1ed1i n\u1ea1c trong c\u01a1 th\u1ec3 [85]. \u0110o h\u1ea5p th\u1ee5 tia X n\u0103ng l\u01b0\u1ee3ng k\u00e9p (Dual Energy X-ray Absorptiometry \u2013 DEXA), ch\u1ee5p c\u1eaft l\u1edbp vi t\u00ednh (CT) v\u00e0 ch\u1ee5p c\u1ed9ng h\u01b0\u1edfng t\u1eeb (MRI) \u0111\u01b0\u1ee3c coi l\u00e0 c\u00e1c k\u1ef9 thu\u1eadt ti\u00eau chu\u1ea9n tham chi\u1ebfu \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 kh\u1ed1i c\u01a1 x\u01b0\u01a1ng v\u00e0 th\u00e0nh ph\u1ea7n c\u01a1 th\u1ec3 [86] nh\u01b0ng kh\u00f4ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng th\u01b0\u1eddng xuy\u00ean \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng trong ICU n\u00f3i ri\u00eang hay b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n n\u00f3i chung [86]. V\u1edbi \u0111\u1ed9 tin c\u1eady t\u1ed1t, vi\u1ec7c s\u1eed d\u1ee5ng si\u00eau \u00e2m \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 kh\u1ed1i c\u01a1 g\u1ea7n \u0111\u00e2y \u0111\u01b0\u1ee3c nghi\u00ean c\u1ee9u \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi AKI v\u00e0 CKD c\u00f3 KF \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o, l\u00e0 m\u1ed9t ph\u01b0\u01a1ng ph\u00e1p thay th\u1ebf ti\u1ec1m n\u0103ng [87,88]. Si\u00eau \u00e2m c\u01a1 l\u00e0 m\u1ed9t k\u1ef9 thu\u1eadt kh\u00f4ng x\u00e2m l\u1ea5n, d\u1ec5 \u00e1p d\u1ee5ng ngay c\u1ea3 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f3 h\u1ee3p t\u00e1c, hi\u1ec7u qu\u1ea3 kinh t\u1ebf, an to\u00e0n v\u00e0 kh\u00f4ng \u0111\u00f2i h\u1ecfi \u0111\u1ed9i ng\u0169 chuy\u00ean tr\u00e1ch c\u0169ng nh\u01b0 kh\u00f4ng c\u1ea7n ti\u1ebfp x\u00fac v\u1edbi tia X [87,89-91]. B\u00ean c\u1ea1nh \u0111\u00f3, ph\u01b0\u01a1ng ph\u00e1p si\u00eau \u00e2m c\u01a1 d\u01b0\u1eddng nh\u01b0 \u00edt b\u1ecb \u1ea3nh h\u01b0\u1edfng khi c\u00f3 hi\u1ec7n t\u01b0\u1ee3ng d\u1ecbch di chuy\u1ec3n \u0111\u1ed9t ng\u1ed9t (gi\u1eefa n\u1ed9i \u2013 ngo\u1ea1i b\u00e0o, gi\u1eefa m\u00f4 k\u1ebd v\u00e0 l\u00f2ng m\u1ea1ch) \u1edf b\u1ec7nh nh\u00e2n AKI v\u00e0 b\u1ec7nh nh\u00e2n CKD c\u00f3 KF \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o m\u1ea1n t\u00ednh [87,92]. Nhi\u1ec1u nghi\u00ean c\u1ee9u ki\u1ec3m ch\u1ee9ng \u0111\u00e3 b\u00e1c b\u1ecf CT \u1edf b\u1ec7nh nh\u00e2n AKI n\u1eb7ng, cho th\u1ea5y kh\u00f4ng c\u00f3 kh\u00e1c bi\u1ec7t t\u01b0\u01a1ng quan c\u00f3 \u00fd ngh\u0129a, v\u1edbi \u0111\u1ed9 ch\u00ednh x\u00e1c c\u00f3 m\u1ed9t ch\u00fat sai l\u1ec7ch nh\u1ecf [88]. V\u00ec thi\u1ebfu gi\u00e1 tr\u1ecb \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh kh\u1ed1i c\u01a1 \u1edf ng\u01b0\u1ee1ng th\u1ea5p b\u1eb1ng si\u00eau \u00e2m, ch\u00fang t\u00f4i \u0111\u1ec1 xu\u1ea5t si\u00eau \u00e2m c\u00f3 gi\u00e1 tr\u1ecb \u0111\u1ec3 theo d\u00f5i kh\u1ed1i c\u01a1 trong qu\u00e1 tr\u00ecnh ph\u1ee5c h\u1ed3i v\u00e0 \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 hi\u1ec7u qu\u1ea3 c\u1ee7a v\u1eadt l\u00fd tr\u1ecb li\u1ec7u v\u00e0 dinh d\u01b0\u1ee1ng. Ch\u1ee5p CT \u0111\u00e3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong ICU \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 kh\u1ed1i c\u01a1 x\u01b0\u01a1ng (m\u1ee9c \u0111\u1ed1t s\u1ed1ng L3), nh\u01b0ng ch\u1ec9 h\u1eefu \u00edch tr\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ch\u1ee5p CT b\u1ee5ng v\u00ec c\u00e1c nguy\u00ean nh\u00e2n kh\u00e1c [93]. Gi\u1ea3m kh\u1ed1i c\u01a1, kh\u1ea3o s\u00e1t b\u1eb1ng CT l\u00fac nh\u1eadp vi\u1ec7n, ti\u00ean l\u01b0\u1ee3ng k\u00e9o d\u00e0i th\u1eddi gian n\u1eb1m vi\u1ec7n v\u00e0 nguy c\u01a1 t\u1eed vong [94] c\u0169ng nh\u01b0 li\u00ean quan \u0111\u1ebfn nguy c\u01a1 t\u0103ng bi\u1ebfn ch\u1ee9ng v\u00e0 t\u1ec9 l\u1ec7 t\u1eed vong trong 30 ng\u00e0y \u1edf b\u1ec7nh nh\u00e2n ICU khi \u0111o t\u1ea1i th\u1eddi \u0111i\u1ec3m r\u00fat n\u1ed9i kh\u00ed qu\u1ea3n [95]. Tuy nhi\u00ean hi\u1ec7n nay th\u00ec s\u1eed d\u1ee5ng CT cho m\u1ee5c \u0111\u00edch nghi\u00ean c\u1ee9u b\u1ecb h\u1ea1n ch\u1ebf.<\/p>\n<p>T\u00f3m l\u1ea1i, trong s\u1ed1 c\u00e1c k\u1ef9 thu\u1eadt \u0111\u00e3 \u0111\u01b0\u1ee3c ki\u1ec3m ch\u1ee9ng hi\u1ec7n nay, si\u00eau \u00e2m c\u00f3 v\u1ebb h\u1ee9a h\u1eb9n v\u00e0 d\u1ec5 th\u1ef1c hi\u1ec7n trong ICU c\u0169ng nh\u01b0 c\u00e1c khoa \u0111i\u1ec1u tr\u1ecb trong b\u1ec7nh vi\u1ec7n. \u0110\u1ed1i v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n ch\u1ee5p CT b\u1ee5ng, \u0111\u00e1nh gi\u00e1 kh\u1ed1i c\u01a1 x\u01b0\u01a1ng t\u1ea1i v\u1ecb tr\u00ed \u0111\u1ed1t s\u1ed1ng th\u1eaft l\u01b0ng th\u1ee9 3 c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t c\u00f4ng c\u1ee5 ch\u1ea9n \u0111o\u00e1n v\u00e0 ti\u00ean l\u01b0\u1ee3ng c\u00f3 gi\u00e1 tr\u1ecb.<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 9 (Grade B): \u0110\u00e1nh gi\u00e1 s\u1ee9c c\u01a1 c\u1ee7a b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF b\u1eb1ng c\u00e1ch \u0111o s\u1ee9c c\u01a1 b\u00e0n tay (s\u1ee9c n\u1eafm).<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.7%)<\/p>\n<p><em> B\u00e0n lu\u1eadn (khuy\u1ebfn c\u00e1o 8 &amp; 9):<\/em><\/p>\n<p>Ngo\u00e0i suy dinh d\u01b0\u1ee1ng, c\u00e1c y\u1ebfu t\u1ed1 kh\u00e1c nh\u01b0 b\u1ec7nh vi\u00eam \u0111a d\u00e2y th\u1ea7n kinh do b\u1ec7nh n\u1eb7ng, b\u1ec7nh v\u1ec1 c\u01a1 do m\u1eafc b\u1ec7nh n\u1eb7ng v\u00e0 b\u1ec7nh teo c\u01a1 g\u00e2y ra b\u1edfi s\u1ef1 b\u1ea5t \u0111\u1ed9ng (n\u1eb1m l\u00e2u) c\u00f3 th\u1ec3 l\u00e0m t\u0103ng nguy c\u01a1 ti\u1ebfn tri\u1ec3n th\u00e0nh h\u1ed9i ch\u1ee9ng r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng th\u1ea7n kinh c\u01a1 trong v\u00e0 sau khi n\u1eb1m t\u1ea1i ICU, bao g\u1ed3m m\u1ed9t d\u1ea1ng suy nh\u01b0\u1ee3c c\u01a1 nghi\u00eam tr\u1ecdng \u0111i\u1ec3n h\u00ecnh tr\u00ean b\u1ec7nh nh\u00e2n n\u1eb7ng, hay c\u00f2n g\u1ecdi l\u00e0 suy nh\u01b0\u1ee3c do n\u1eb1m ICU l\u00e2u ng\u00e0y (ICU-acquired weakness) [96]. Gi\u1ea3m kh\u1ea3 n\u0103ng v\u1eadn \u0111\u1ed9ng tr\u01b0\u1edbc nh\u1eadp vi\u1ec7n c\u00f3 li\u00ean quan \u0111\u1ebfn t\u0103ng t\u1ef7 l\u1ec7 t\u1eed vong t\u1ea1i b\u1ec7nh vi\u1ec7n b\u1ea5t k\u1ec3 tu\u1ed5i t\u00e1c, b\u1ec7nh \u0111i k\u00e8m, m\u1ee9c \u0111\u1ed9 b\u1ec7nh v\u00e0 lo\u1ea1i h\u00ecnh nh\u1eadp v\u00e0o ICU [97]. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n t\u1eeb 70 tu\u1ed5i tr\u1edf l\u00ean [98], th\u00f3i quen sinh ho\u1ea1t, v\u1eadn \u0111\u1ed9ng tr\u01b0\u1edbc khi nh\u1eadp ICU c\u00f3 \u1ea3nh h\u01b0\u1edfng m\u1ea1nh m\u1ebd \u0111\u1ebfn kh\u1ea3 n\u0103ng v\u1eadn \u0111\u1ed9ng giai \u0111o\u1ea1n sau ICU. T\u00ecnh tr\u1ea1ng v\u1eadn \u0111\u1ed9ng tr\u01b0\u1edbc \u0111\u00f3, s\u1ef1 gi\u1ea3m v\u1eadn \u0111\u1ed9ng trong ICU v\u00e0 kh\u1ea3 n\u0103ng v\u1eadn \u0111\u1ed9ng sau nh\u1eadp ICU \u0111\u01b0\u1ee3c quy\u1ebft \u0111\u1ecbnh b\u1edfi nhi\u1ec1u y\u1ebfu t\u1ed1 theo th\u1eddi gian.<\/p>\n<p>Trong ICU, c\u00f4ng c\u1ee5 \u0111\u01b0\u1ee3c khuy\u1ebfn ngh\u1ecb \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 s\u1ee9c c\u01a1 l\u00e0 thang \u0111i\u1ec3m MRC \u2013 Medical Research Council (thang \u0111i\u1ec3m t\u1eeb 0 \u2013 5). T\u1ed5ng \u0111i\u1ec3m MRC &lt; 48 tr\u00ean 12 nh\u00f3m c\u01a1 (ho\u1eb7c MRC trung b\u00ecnh &lt; 4 cho m\u1ed7i nh\u00f3m c\u01a1) \u0111\u01b0\u1ee3c xem l\u00e0 ng\u01b0\u1ee1ng \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh t\u00ecnh tr\u1ea1ng suy nh\u01b0\u1ee3c do n\u1eb1m ICU l\u00e2u ng\u00e0y [99-101]. Tuy nhi\u00ean, \u0111\u00e1nh gi\u00e1 \u0111i\u1ec3m MRC \u1edf b\u1ec7nh nh\u00e2n ICU t\u1ed1n nhi\u1ec1u th\u1eddi gian v\u00e0 c\u1ea7n \u0111\u01b0\u1ee3c t\u1eadp hu\u1ea5n, \u0111\u00e0o t\u1ea1o. \u0110o s\u1ee9c s\u01a1 b\u00e0n tay (s\u1ee9c n\u1eafm) \u0111\u01b0\u1ee3c xem nh\u01b0 m\u1ed9t ph\u01b0\u01a1ng ph\u00e1p ch\u1ea9n \u0111o\u00e1n \u0111\u01a1n gi\u1ea3n v\u00e0 d\u1ec5 d\u00e0ng cho suy nh\u01b0\u1ee3c do n\u1eb1m ICU l\u00e2u ng\u00e0y v\u00e0 c\u00f3 th\u1ec3 nh\u1eadn bi\u1ebft c\u00e1c r\u1ed1i lo\u1ea1n tr\u01b0\u1edbc khi c\u00f3 nh\u1eefng thay \u0111\u1ed5i v\u1ec1 c\u00e1c th\u00f4ng s\u1ed1 c\u1ee7a th\u00e0nh ph\u1ea7n c\u01a1 th\u1ec3, gi\u00fap can thi\u1ec7p dinh d\u01b0\u1ee1ng \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n s\u1edbm h\u01a1n v\u00e0 c\u00f3 th\u1ec3 \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn ti\u00ean l\u01b0\u1ee3ng c\u1ee7a b\u1ec7nh nh\u00e2n [101,102]. Ch\u01b0a c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o v\u1ec1 s\u1eed d\u1ee5ng thang \u0111i\u1ec3m MRC \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb KF n\u1eb7ng. M\u1eb7t kh\u00e1c, s\u1ee9c n\u1eafm b\u00e0n tay \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng tr\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 s\u1ee9c c\u01a1. Trong m\u1ed9t nh\u00f3m thu\u1ea7n t\u1eadp ch\u1ec9 g\u1ed3m c\u00e1c b\u1ec7nh nh\u00e2n KF n\u1ed9i vi\u1ec7n c\u00f3 nguy c\u01a1 suy dinh d\u01b0\u1ee1ng, cho th\u1ea5y c\u00e1c gi\u00e1 tr\u1ecb \u0111o s\u1ee9c n\u1eafm c\u1ee7a b\u00e0n tay n\u1eb1m trong kho\u1ea3ng c\u00f3 suy m\u00f2n c\u01a1 [60]. Trong m\u1ed9t nghi\u00ean c\u1ee9u kh\u00e1c, s\u1ee9c n\u1eafm b\u00e0n tay th\u1ea5p h\u01a1n 10kg t\u1ea1i th\u1eddi \u0111i\u1ec3m xu\u1ea5t vi\u1ec7n v\u00e0 th\u1ea5p h\u01a1n 15kg m\u1ed9t th\u00e1ng sau khi xu\u1ea5t vi\u1ec7n c\u00f3 li\u00ean quan \u0111\u1ebfn nguy c\u01a1 t\u1eed vong [74]. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 KF \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o, s\u1ee9c n\u1eafm b\u00e0n tay c\u00f3 t\u01b0\u01a1ng quan v\u1edbi s\u1ed1 b\u1ec7nh \u0111\u1ed3ng m\u1eafc v\u00e0 \u0111i\u1ec3m MIS [92,103]. M\u1eb7c d\u00f9 c\u00f3 nh\u1eefng \u1ee9ng d\u1ee5ng \u0111\u1ea7y h\u1ee9a h\u1eb9n, ch\u00fang t\u00f4i kh\u00f4ng khuy\u1ebfn kh\u00edch s\u1eed d\u1ee5ng s\u1ee9c n\u1eafm b\u00e0n tay v\u00ec n\u00f3 c\u0169ng c\u00f3 m\u1ed9t s\u1ed1 h\u1ea1n ch\u1ebf. M\u1ed9t h\u1ea1n ch\u1ebf quan tr\u1ecdng \u0111\u00f3 l\u00e0 s\u1ef1 h\u1ee3p t\u00e1c c\u1ee7a c\u1ee7a b\u1ec7nh nh\u00e2n. B\u00ean c\u1ea1nh \u0111\u00f3, v\u1eabn ch\u01b0a c\u00f3 s\u1ef1 th\u1ed1ng nh\u1ea5t tuy\u1ec7t \u0111\u1ed1i v\u1ec1 c\u00e1ch \u0111o, l\u1ef1c k\u1ebf c\u1ea7m tay ph\u1ea3i \u0111\u01b0\u1ee3c hi\u1ec7u ch\u1ec9nh t\u1ed1t v\u00e0 \u0111i\u1ec1u ch\u1ec9nh theo k\u00edch th\u01b0\u1edbc tay \u0111\u1ec3 c\u00f3 c\u00e1c ph\u00e9p \u0111o ch\u00ednh x\u00e1c v\u00e0 cu\u1ed1i c\u00f9ng l\u00e0 thi\u1ebfu c\u00e1c gi\u00e1 tr\u1ecb tham chi\u1ebfu l\u00e0m ti\u00eau chu\u1ea9n cho s\u1ee9c n\u1eafm b\u00e0n tay [104].<\/p>\n<h4>X\u00e1c \u0111\u1ecbnh t\u00ecnh tr\u1ea1ng suy dinh d\u01b0\u1ee1ng tr\u00ean b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c b\u1ec7nh nh\u00e2n CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF nh\u01b0 th\u1ebf n\u00e0o ?<\/h4>\n<p><strong>Tuy\u00ean b\u1ed1 3: Ch\u01b0a c\u00f3 ti\u00eau chu\u1ea9n n\u00e0o \u0111\u01b0\u1ee3c th\u1ed1ng nh\u1ea5t v\u00e0 ph\u00ea chu\u1ea9n \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh suy dinh d\u01b0\u1ee1ng tr\u00ean b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c b\u1ec7nh nh\u00e2n CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF. C\u00e1c nghi\u00ean c\u1ee9u \u0111\u1ec3 c\u00f4ng nh\u1eadn GLIM \u2013 b\u1ed9 ti\u00eau chu\u1ea9n \u0111\u00e3 \u0111\u01b0\u1ee3c ESPEN ch\u1ee9ng th\u1ef1c, tr\u00ean b\u1ec7nh nh\u00e2n th\u1eadn c\u1ea7n \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>Sinh l\u00fd b\u1ec7nh c\u1ee7a r\u1ed1i lo\u1ea1n dinh d\u01b0\u1ee1ng \u1edf b\u1ec7nh nh\u00e2n b\u1ec7nh th\u1eadn r\u1ea5t ph\u1ee9c t\u1ea1p, li\u00ean quan \u0111\u1ebfn vi\u1ec7c gi\u1ea3m l\u01b0\u1ee3ng \u0103n v\u00e0o v\u00e0 r\u1ed1i lo\u1ea1n qu\u00e1 tr\u00ecnh \u0111\u1ed3ng h\u00f3a c\u00e1c ch\u1ea5t dinh d\u01b0\u1ee1ng c\u0169ng nh\u01b0 t\u00ecnh tr\u1ea1ng t\u0103ng d\u1ecb h\u00f3a li\u00ean quan \u0111\u1ebfn t\u00ecnh tr\u1ea1ng b\u1ec7nh t\u1eadt v\u00e0 b\u1ec7nh n\u1ec1n. Ch\u01b0a c\u00f3 s\u1ef1 th\u1ed1ng nh\u1ea5t v\u1ec1 c\u00e1ch \u0111\u1ecbnh ngh\u0129a c\u00e1c r\u1ed1i lo\u1ea1n n\u00e0y v\u00e0 c\u00e1c \u0111\u1ecbnh ngh\u0129a hi\u1ec7n c\u00f3 d\u1ef1a v\u00e0o c\u00e1c nghi\u00ean c\u1ee9u tr\u00ean b\u1ec7nh nh\u00e2n CKD \u1ed5n \u0111\u1ecbnh \u0111\u01b0\u1ee3c qu\u1ea3n l\u00fd ngo\u1ea1i tr\u00fa. V\u1ea5n \u0111\u1ec1 ch\u00fang t\u00f4i tranh lu\u1eadn \u1edf \u0111\u00e2y l\u00e0 m\u1ed9t s\u1ed1 \u0111\u1ecbnh ngh\u0129a n\u00e0y c\u00f3 th\u1ec3 kh\u00f4ng d\u00f9ng \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n cho b\u1ec7nh nh\u00e2n n\u1ed9i tr\u00fa, \u0111\u1eb7c bi\u1ec7t l\u00e0 AKI.<\/p>\n<p>The International Society of Renal Nutrition and Metabolism (ISRNM) [28], \u0111\u00e3 \u0111\u01b0a ra thu\u1eadt ng\u1eef \u201csuy dinh d\u01b0\u1ee1ng protein-n\u0103ng l\u01b0\u1ee3ng\u201d \u0111\u1ec3 ch\u1ec9 \u201ct\u00ecnh tr\u1ea1ng c\u01a1 th\u1ec3 gi\u1ea3m d\u1ef1 tr\u1eef protein v\u00e0 n\u0103ng l\u01b0\u1ee3ng (t\u1ee9c l\u00e0 kh\u1ed1i n\u1ea1c c\u01a1 th\u1ec3 v\u00e0 d\u1ef1 tr\u1eef m\u1ee1), c\u00f3 th\u1ec3 x\u1ea3y ra tr\u00ean b\u1ec7nh nh\u00e2n AKI ho\u1eb7c CKD v\u1edbi b\u1ea5t k\u1ef3 nguy\u00ean nh\u00e2n n\u00e0o v\u00e0 c\u00f3 li\u00ean quan \u0111\u1ebfn gi\u1ea3m kh\u1ea3 n\u0103ng v\u1eadn \u0111\u1ed9ng, v\u1ed1n c\u00f3 li\u00ean quan \u0111\u1ebfn t\u00ecnh tr\u1ea1ng stress chuy\u1ec3n h\u00f3a\u201d [28]. M\u1eb7c d\u00f9 \u0111\u1ecbnh ngh\u0129a n\u00e0y t\u01b0\u01a1ng \u1ee9ng v\u1ec1 m\u1eb7t sinh l\u00fd \u1edf b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n, c\u00e1c ti\u00eau chu\u1ea9n \u0111\u01b0\u1ee3c khuy\u1ebfn ngh\u1ecb \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n n\u00f3 c\u00f3 th\u1ec3 kh\u00f4ng ho\u00e0n to\u00e0n ph\u00f9 h\u1ee3p v\u1edbi t\u00ecnh tr\u1ea1ng b\u1ec7nh nh\u00e2n KF n\u1eb1m vi\u1ec7n v\u00e0 ch\u00fang t\u00f4i tham kh\u1ea3o c\u00e1c ph\u1ea7n 2.2 v\u00e0 2.3 \u1edf tr\u00ean v\u1ec1 c\u00e1c h\u1ea1n ch\u1ebf c\u1ee7a c\u00e1c c\u00f4ng c\u1ee5 ch\u1ea9n \u0111o\u00e1n. V\u1ea3 l\u1ea1i, ti\u00eau chu\u1ea9n ch\u1ea9n \u0111o\u00e1n suy dinh d\u01b0\u1ee1ng protein \u2013 n\u0103ng l\u01b0\u1ee3ng do r\u1ed1i lo\u1ea1n \u1edf ba trong b\u1ed1n ti\u00eau chu\u1ea9n dinh d\u01b0\u1ee1ng v\u1eabn thi\u1ebfu s\u1ef1 c\u00f4ng nh\u1eadn t\u1eeb b\u00ean ngo\u00e0i hay ngay trong n\u1ed9i b\u1ed9, m\u1eb7c d\u00f9 \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 c\u00f3 th\u1ec3 d\u1ef1 \u0111o\u00e1n t\u1ef7 l\u1ec7 t\u1eed vong d\u00e0i h\u1ea1n, \u00edt nh\u1ea5t l\u00e0 \u1edf b\u1ec7nh nh\u00e2n ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o m\u1ea1n t\u00ednh [105].<\/p>\n<p>C\u00e1c hi\u1ec7p h\u1ed9i dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng l\u1edbn tr\u00ean to\u00e0n th\u1ebf gi\u1edbi \u0111\u00e3 tham gia v\u00e0o Global Leadership Initiative on Malnutrition (GLIM), v\u00e0 thi\u1ebft l\u1eadp m\u1ed9t quy\u1ebft \u0111\u1ecbnh \u0111\u1ed3ng thu\u1eadn cho ch\u1ea9n \u0111o\u00e1n suy dinh d\u01b0\u1ee1ng \u1edf ng\u01b0\u1eddi l\u1edbn kh\u00f4ng ph\u1ee5 thu\u1ed9c v\u00e0o c\u0103n nguy\u00ean, t\u1eeb c\u00e1c c\u01a1 s\u1edf l\u00e2m s\u00e0ng kh\u00e1c nhau [76]. Ti\u00eau chu\u1ea9n GLIM g\u1ed3m m\u00f4 h\u00ecnh hai b\u01b0\u1edbc \u0111\u1ec3 s\u00e0ng l\u1ecdc nguy c\u01a1 suy dinh d\u01b0\u1ee1ng (v\u1edbi c\u00e1c c\u00f4ng c\u1ee5 nh\u01b0 NRS-2002, MUST, v\u00e0 d\u1ea1ng ng\u1eafn g\u1ecdn c\u1ee7a c\u00f4ng c\u1ee5 \u0111\u00e1nh gi\u00e1 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng \u1edf ng\u01b0\u1eddi gi\u00e0 \u0111\u00f3 l\u00e0 MNA-SF) v\u00e0 \u0111\u00e1nh gi\u00e1 ch\u1ea9n \u0111o\u00e1n suy dinh d\u01b0\u1ee1ng. \u0110\u00e1nh gi\u00e1 bao g\u1ed3m 5 ti\u00eau ch\u00ed: 3 ti\u00eau chu\u1ea9n v\u1ec1 ki\u1ec3u h\u00ecnh, \u0111\u00f3 l\u00e0: s\u1ee5t c\u00e2n kh\u00f4ng t\u1ef1 \u00fd, BMI th\u1ea5p (&lt;20kg\/m2 n\u1ebfu &lt; 70 tu\u1ed5i ho\u1eb7c &lt; 22kg\/m2 n\u1ebfu &gt; 70 tu\u1ed5i) v\u00e0 gi\u1ea3m kh\u1ed1i c\u01a1 (b\u1eb1ng DEXA, BIA, CT ho\u1eb7c MRI v\u1edbi c\u00e1c ti\u00eau chu\u1ea9n t\u01b0\u01a1ng \u1ee9ng c\u1ee7a ch\u00fang), v\u00e0 2 ti\u00eau chu\u1ea9n c\u0103n nguy\u00ean: \u0103n k\u00e9m ho\u1eb7c gi\u1ea3m \u0111\u1ed3ng h\u00f3a, v\u00e0 g\u00e1nh n\u1eb7ng b\u1ec7nh t\u1eadt\/t\u00ecnh tr\u1ea1ng vi\u00eam (t\u00ecnh tr\u1ea1ng b\u1ec7nh n\u1eb7ng c\u1ea5p t\u00ednh ho\u1eb7c b\u1ec7nh m\u1ea1n t\u00ednh c\u00f3 li\u00ean quan). Ch\u1ea9n \u0111o\u00e1n suy dinh d\u01b0\u1ee1ng c\u1ea7n \u00edt nh\u1ea5t m\u1ed9t ti\u00eau chu\u1ea9n ki\u1ec3u h\u00ecnh v\u00e0 m\u1ed9t ti\u00eau chu\u1ea9n c\u0103n nguy\u00ean. Cho \u0111\u1ebfn nay ch\u01b0a c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o c\u00f4ng nh\u1eadn vi\u1ec7c \u00e1p d\u1ee5ng c\u00e1c ti\u00eau chu\u1ea9n n\u00e0y \u1edf b\u1ec7nh nh\u00e2n b\u1ec7nh th\u1eadn n\u1ed9i vi\u1ec7n. H\u1ea1n ch\u1ebf c\u1ee7a vi\u1ec7c s\u1eed d\u1ee5ng BMI \u1edf b\u1ec7nh nh\u00e2n th\u1eeba d\u1ecbch c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn \u0111\u00e1nh gi\u00e1 th\u1ea5p t\u00ecnh tr\u1ea1ng suy dinh d\u01b0\u1ee1ng trong tr\u01b0\u1eddng h\u1ee3p n\u00e0y (b\u1ec7nh nh\u00e2n th\u1eeba d\u1ecbch s\u1ebd l\u00e0m cho BMI kh\u00f4ng gi\u1ea3m ho\u1eb7c gi\u1ea3m \u00edt n\u00ean d\u1ec5 b\u1ecb b\u1ecf qua nguy c\u01a1 suy dinh d\u01b0\u1ee1ng n\u1ebfu ch\u1ec9 d\u00f9ng BMI), do \u0111\u00f3 c\u1ea7n \u0111\u1eb7c bi\u1ec7t ch\u00fa \u00fd khi s\u1eed d\u1ee5ng ti\u00eau chu\u1ea9n n\u00e0y trong b\u1ed9 ti\u1ebfp c\u1eadn c\u1ee7a GLIM v\u1edbi c\u00e1c b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n c\u00f3 AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF.<\/p>\n<p>Thu\u1eadt ng\u1eef \u201csuy m\u00f2n\u201d \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 m\u00f4 t\u1ea3 m\u1ed9t h\u1ed9i ch\u1ee9ng li\u00ean quan \u0111\u1ebfn c\u00e1c t\u00ecnh tr\u1ea1ng b\u1ec7nh m\u1ea1n t\u00ednh, bao g\u1ed3m CKD v\u00e0 CKD c\u00f3 KF, v\u1edbi \u0111\u1eb7c tr\u01b0ng ch\u1ee7 y\u1ebfu l\u00e0 m\u1ea5t kh\u1ed1i c\u01a1. M\u1ea5t kh\u1ed1i m\u1ee1 c\u0169ng c\u00f3 th\u1ec3 xu\u1ea5t hi\u1ec7n nh\u01b0ng kh\u00f4ng ph\u1ea3i l\u00e0 \u0111i\u1ec1u ki\u1ec7n c\u1ea7n \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n [106]. C\u00e1c bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng c\u1ee7a suy m\u00f2n bao g\u1ed3m s\u1ee5t c\u00e2n sau khi \u0111\u00e3 hi\u1ec7u ch\u1ec9nh t\u0103ng c\u00e2n do gi\u1eef n\u01b0\u1edbc v\u00e0 ch\u00e1n \u0103n. Sinh l\u00fd b\u1ec7nh c\u1ee7a n\u00f3 t\u01b0\u01a1ng t\u1ef1 nh\u01b0 \u0111\u1ecbnh ngh\u0129a ISRNM v\u1ec1 suy dinh d\u01b0\u1ee1ng protein n\u0103ng l\u01b0\u1ee3ng, trong \u0111\u00f3 suy m\u00f2n \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t cho h\u1ea7u h\u1ebft c\u00e1c giai \u0111o\u1ea1n n\u1eb7ng c\u1ee7a suy dinh d\u01b0\u1ee1ng protein n\u0103ng l\u01b0\u1ee3ng [28,107]. Society of Sarcopenia, Cachexia and Wasting Disorders \u0111\u00e3 \u0111\u01b0a ra ti\u00eau chu\u1ea9n ch\u1ea9n \u0111o\u00e1n t\u01b0\u01a1ng t\u1ef1 nh\u01b0 suy dinh d\u01b0\u1ee1ng protein n\u0103ng l\u01b0\u1ee3ng, v\u00ec c\u1ea3 hai \u0111\u1ec1u d\u1ef1a v\u00e0o c\u00e1c x\u00e9t nghi\u1ec7m sinh h\u00f3a m\u00e1u, c\u00e1c ph\u00e9p \u0111o c\u01a1 th\u1ec3 v\u00e0 kh\u1ed1i c\u01a1 v\u00e0 l\u01b0\u1ee3ng dinh d\u01b0\u1ee1ng n\u1ea1p v\u00e0o, v\u1edbi ng\u01b0\u1ee1ng g\u00e2y suy m\u00f2n th\u1ea5p h\u01a1n so v\u1edbi suy dinh d\u01b0\u1ee1ng protein n\u0103ng l\u01b0\u1ee3ng. Tuy nhi\u00ean, nh\u01b0 \u0111\u00e3 \u0111\u1ec1 c\u1eadp \u1edf tr\u00ean, c\u00e1c ti\u00eau ch\u00ed n\u00e0y c\u00f3 th\u1ec3 kh\u00f4ng ho\u00e0n to\u00e0n ph\u00f9 h\u1ee3p v\u1edbi t\u00ecnh tr\u1ea1ng c\u1ea5p t\u00ednh, \u0111\u1eb7c bi\u1ec7t l\u00e0 trong ICU.<\/p>\n<p>Sarcopenia l\u00e0 m\u1ed9t h\u1ed9i ch\u1ee9ng l\u00e3o khoa ph\u1ee9c t\u1ea1p li\u00ean quan \u0111\u1ebfn m\u1ea5t kh\u1ed1i c\u01a1 v\u00e0 ch\u1ee9c n\u0103ng v\u1eadn \u0111\u1ed9ng [76]. Sarcopenia \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh l\u00e0 nguy\u00ean ph\u00e1t ho\u1eb7c th\u1ee9 ph\u00e1t. Trong tr\u01b0\u1eddng h\u1ee3p nguy\u00ean ph\u00e1t, \u0111\u00f3 l\u00e0 h\u1eadu qu\u1ea3 duy nh\u1ea5t c\u1ee7a qu\u00e1 tr\u00ecnh l\u00e3o h\u00f3a trong khi th\u1ee9 ph\u00e1t c\u00f3 c\u0103n nguy\u00ean t\u1eeb nhi\u1ec1u y\u1ebfu t\u1ed1 v\u00e0 c\u1ea3 2 tr\u01b0\u1eddng h\u1ee3p nguy\u00ean ph\u00e1t l\u1eabn th\u1ee9 ph\u00e1t l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y ra suy gi\u1ea3m ho\u1ea1t \u0111\u1ed9ng th\u1ec3 ch\u1ea5t, thay \u0111\u1ed5i h\u1ec7 th\u1ed1ng n\u1ed9i ti\u1ebft, s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a c\u00e1c b\u1ec7nh m\u1ea1n t\u00ednh ho\u1eb7c c\u1ea5p t\u00ednh, t\u00ecnh tr\u1ea1ng vi\u00eam, \u0111\u1ec1 kh\u00e1ng insulin, v\u00e0 thi\u1ebfu dinh d\u01b0\u1ee1ng [108]. Nhi\u1ec1u \u0111\u1ecbnh ngh\u0129a c\u00f3 hi\u1ec7u l\u1ef1c cho sarcopenia \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t trong th\u1eadp k\u1ef7 qua [76,108\u2013111]. Trong m\u1ecdi tr\u01b0\u1eddng h\u1ee3p, c\u00e1c \u0111\u00e1nh gi\u00e1 \u0111\u00e1ng tin c\u1eady v\u1ec1 s\u1ee9c c\u01a1 v\u00e0 ch\u1ee9c n\u0103ng c\u1ee7a c\u01a1 c\u00f3 th\u1ec3 kh\u00f3 \u0111\u1ea1t \u0111\u01b0\u1ee3c trong m\u00f4i tr\u01b0\u1eddng n\u1ed9i vi\u1ec7n, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edf b\u1ec7nh nh\u00e2n n\u1eb7ng.<\/p>\n<h3>Th\u1eddi \u0111i\u1ec3m v\u00e0 \u0111\u01b0\u1eddng nu\u00f4i \u0103n (c\u00e1ch th\u1ee9c nu\u00f4i \u0103n)<\/h3>\n<h4>\u0110\u01b0\u1eddng nu\u00f4i \u0103n n\u00e0o ph\u00f9 h\u1ee3p nh\u1ea5t v\u00e0 n\u00ean b\u1eaft \u0111\u1ea7u khi n\u00e0o ?<\/h4>\n<p>\u0110\u1ed1i v\u1edbi c\u00e2u h\u1ecfi PICO n\u00e0y, ch\u00fang t\u00f4i tham kh\u1ea3o khuy\u1ebfn ngh\u1ecb 8.1 c\u1ee7a h\u01b0\u1edbng d\u1eabn ESPEN cho b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n c\u00f3 nhi\u1ec1u b\u1ec7nh [29] v\u00e0 khuy\u1ebfn ngh\u1ecb 4 v\u00e0 5 c\u1ee7a h\u01b0\u1edbng d\u1eabn ESPEN cho b\u1ec7nh nh\u00e2n n\u1eb7ng [8].<br \/>\n<strong>H\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng s\u1edbm (t\u1ee9c l\u00e0 \u0111\u01b0\u1ee3c cung c\u1ea5p dinh d\u01b0\u1ee1ng trong v\u00f2ng &lt; 48 gi\u1edd k\u1ec3 t\u1eeb khi nh\u1eadp vi\u1ec7n) n\u00ean \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n \u1edf b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n \u0111a b\u1ec7nh so v\u1edbi vi\u1ec7c h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng mu\u1ed9n h\u01a1n, v\u00ec c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m suy m\u00f2n v\u00e0 c\u1ea3i thi\u1ec7n kh\u1ea3 n\u0103ng t\u1ef1 ch\u0103m s\u00f3c c\u1ee7a b\u1ec7nh nh\u00e2n.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95%) [29]\n<p><strong>N\u1ebfu kh\u00f4ng th\u1ec3 dung n\u1ea1p qua \u0111\u01b0\u1eddng mi\u1ec7ng, n\u00ean th\u1ef1c hi\u1ec7n\/b\u1eaft \u0111\u1ea7u EN s\u1edbm (trong v\u00f2ng 48 gi\u1edd) \u1edf b\u1ec7nh nh\u00e2n n\u1eb7ng h\u01a1n l\u00e0 tr\u00ec ho\u00e3n EN.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) [8]\n<p><strong>N\u1ebfu kh\u00f4ng th\u1ec3 dung n\u1ea1p qua \u0111\u01b0\u1eddng mi\u1ec7ng, n\u00ean th\u1ef1c hi\u1ec7n\/b\u1eaft \u0111\u1ea7u EN s\u1edbm (trong v\u00f2ng 48 gi\u1edd) \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng h\u01a1n l\u00e0 PN s\u1edbm.<\/strong><\/p>\n<p><strong>Grade A<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) [8] B\u00e0n lu\u1eadn:<\/p>\n<p>Nh\u01b0 \u0111\u00e3 th\u1ea3o lu\u1eadn \u1edf tr\u00ean trong ph\u1ea7n 1, nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng ph\u1ea3i b\u1ec7nh n\u1eb7ng v\u1edbi AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF l\u00e0 nh\u00f3m c\u00f3 nguy c\u01a1 cao ti\u1ebfn tri\u1ec3n suy dinh d\u01b0\u1ee1ng v\u00e0 m\u1ea5t kh\u1ed1i c\u01a1, v\u00e0 n\u00ean \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng khi c\u1ea7n thi\u1ebft. Theo hi\u1ec3u bi\u1ebft c\u1ee7a ch\u00fang t\u00f4i, kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 v\u1ec1 th\u1eddi gian b\u1eaft \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb nh\u01b0 v\u1eady tr\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n th\u1eadn n\u1ed9i vi\u1ec7n kh\u00f4ng ph\u1ea3i b\u1ec7nh n\u1eb7ng. Tuy nhi\u00ean, b\u1eb1ng ch\u1ee9ng cho th\u1ea5y r\u1eb1ng \u1edf b\u1ec7nh nh\u00e2n n\u1ed9i tr\u00fa \u0111a b\u1ec7nh (\u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 hai ho\u1eb7c nhi\u1ec1u b\u1ec7nh \u0111i k\u00e8m m\u00e3n t\u00ednh) c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c h\u01b0\u1edfng l\u1ee3i t\u1eeb vi\u1ec7c h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng s\u1edbm trong th\u1eddi gian nh\u1eadp vi\u1ec7n \u0111\u1ec3 tr\u00e1nh t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng tr\u1edf n\u00ean t\u1ed3i t\u1ec7 h\u01a1n v\u1edbi c\u00e1c k\u1ebft c\u1ee5c x\u1ea5u ti\u1ebfp theo [29]. Trong m\u1ed9t RCT tr\u00ean 200 b\u1ec7nh nh\u00e2n n\u1ed9i tr\u00fa cao tu\u1ed5i [30], h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng s\u1edbm v\u00e0 ph\u1ee5c h\u1ed3i ch\u1ee9c n\u0103ng c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m t\u00ecnh tr\u1ea1ng m\u1ea5t kh\u1ed1i c\u01a1 trong th\u1eddi gian n\u1eb1m vi\u1ec7n v\u00e0 gi\u00fap l\u1ea5y l\u1ea1i kh\u1ed1i n\u1ea1c c\u01a1 th\u1ec3 tr\u1edf l\u1ea1i gi\u00e1 tr\u1ecb ban \u0111\u1ea7u trong v\u00f2ng 12 th\u00e1ng sau khi xu\u1ea5t vi\u1ec7n. Trong m\u1ed9t nghi\u00ean c\u1ee9u kh\u00e1c [112], EN s\u1edbm c\u00f3 li\u00ean quan \u0111\u1ebfn vi\u1ec7c gi\u1ea3m t\u1ef7 l\u1ec7 nhi\u1ec5m tr\u00f9ng v\u00e0 kh\u1ea3 n\u0103ng t\u1ef1 ch\u0103m s\u00f3c t\u1ed1t h\u01a1n.<\/p>\n<p>Th\u1eddi \u0111i\u1ec3m b\u1eaft \u0111\u1ea7u v\u00e0 c\u00e1ch cho \u0103n t\u1ed1t nh\u1ea5t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng l\u00e0 m\u1ed9t v\u1ea5n \u0111\u1ec1 \u0111\u00e3 tranh lu\u1eadn trong nhi\u1ec1u n\u0103m. Khi so s\u00e1nh EN s\u1edbm v\u1edbi EN mu\u1ed9n (bao g\u1ed3m s\u00e1u nghi\u00ean c\u1ee9u \u1edf b\u1ec7nh nh\u00e2n ICU [113-118] v\u00e0 b\u1ed1n nghi\u00ean c\u1ee9u bao g\u1ed3m b\u1ec7nh nh\u00e2n kh\u00f4ng ICU [119-122]) v\u00e0 EN s\u1edbm so v\u1edbi PN (bao g\u1ed3m s\u00e1u nghi\u00ean c\u1ee9u \u1edf b\u1ec7nh nh\u00e2n ICU [123-128] v\u00e0 b\u1ea3y nghi\u00ean c\u1ee9u bao g\u1ed3m c\u1ea3 b\u1ec7nh nh\u00e2n kh\u00f4ng ICU [129-135]), h\u01b0\u1edbng d\u1eabn c\u1ee7a ESPEN \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng cho th\u1ea5y gi\u1ea3m c\u00e1c bi\u1ebfn ch\u1ee9ng c\u1ee7a nhi\u1ec5m tr\u00f9ng khi EN s\u1edbm. B\u00ean c\u1ea1nh \u0111\u00f3, EN s\u1edbm c\u0169ng li\u00ean quan \u0111\u1ebfn th\u1eddi gian n\u1eb1m vi\u1ec7n v\u00e0 n\u1eb1m ICU ng\u1eafn h\u01a1n so v\u1edbi PN s\u1edbm [8].<\/p>\n<p>V\u1edbi c\u00e1c h\u01b0\u1edbng d\u1eabn c\u1ee7a ESPEN v\u00e0 ESICM [8,27], ch\u00fang t\u00f4i \u0111\u1ec1 ngh\u1ecb ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh EN \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb b\u1ec7nh n\u1eb7ng v\u1edbi AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF khi: s\u1ed1c kh\u00f4ng ki\u1ec3m so\u00e1t \u0111\u01b0\u1ee3c, gi\u1ea3m oxy m\u00e1u v\u00e0 nhi\u1ec5m toan kh\u00f4ng ki\u1ec3m so\u00e1t, xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a tr\u00ean ch\u01b0a ki\u1ec3m so\u00e1t \u0111\u01b0\u1ee3c, th\u1ec3 t\u00edch d\u1ecbch h\u00fat d\u1ea1 d\u00e0y &gt;500 ml\/6 gi\u1edd, thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9 \u1edf ru\u1ed9t, t\u1eafc ru\u1ed9t, h\u1ed9i ch\u1ee9ng khoang b\u1ee5ng (t\u0103ng \u00e1p l\u1ef1c \u1ed5 b\u1ee5ng) v\u00e0 r\u00f2 ti\u00eau h\u00f3a cung l\u01b0\u1ee3ng cao m\u00e0 kh\u00f4ng c\u00f3 \u0111\u01b0\u1eddng v\u00e0o cho \u0103n xa l\u1ed7 r\u00f2.<\/p>\n<h3>Ch\u1ec9 \u0111\u1ecbnh dinh d\u01b0\u1ee1ng t\u0129nh m\u1ea1ch khi n\u00e0o ?<\/h3>\n<p>\u0110\u1ed1i v\u1edbi c\u00e2u h\u1ecfi PICO n\u00e0y, ch\u00fang t\u00f4i tham kh\u1ea3o c\u00e1c khuy\u1ebfn ngh\u1ecb 6 v\u00e0 7 c\u1ee7a ESPEN h\u01b0\u1edbng d\u1eabn cho b\u1ec7nh nh\u00e2n n\u1eb7ng [8].<\/p>\n<p><strong>Trong tr\u01b0\u1eddng h\u1ee3p c\u00f3 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng mi\u1ec7ng v\u00e0 \u0111\u01b0\u1eddng ti\u00eau h\u00f3a, n\u00ean th\u1ef1c hi\u1ec7n dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch trong v\u00f2ng 3-7 ng\u00e0y.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn (89%) [8].<\/p>\n<p><strong>Dinh d\u01b0\u1ee1ng t\u0129nh m\u1ea1ch (PN) s\u1edbm v\u00e0 t\u0103ng d\u1ea7n n\u00ean \u0111\u01b0\u1ee3c cung c\u1ea5p trong tr\u01b0\u1eddng h\u1ee3p ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a (EN) tr\u00ean b\u1ec7nh nh\u00e2n suy dinh d\u01b0\u1ee1ng n\u1eb7ng.<\/strong><\/p>\n<p><strong>Grade 0<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95%)<\/p>\n<p>B\u00e0n lu\u1eadn:<\/p>\n<p>M\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p c\u1ee7a c\u00e1c nghi\u00ean c\u1ee9u so s\u00e1nh dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a v\u1edbi \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch \u0111\u1ed9c l\u1eadp v\u1edbi th\u1eddi gian [136], cho th\u1ea5y dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a gi\u1ea3m r\u00f5 r\u1ec7t c\u00e1c \u0111\u1ee3t nhi\u1ec5m tr\u00f9ng so v\u1edbi dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch (RR 0.64, 95% CI 0.48-0.87, P = 0.004, I2 = 47%). Kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t khi nu\u00f4i t\u01b0\u01a1ng t\u1ef1 v\u1ec1 m\u1ee9c n\u0103ng l\u01b0\u1ee3ng (calories) gi\u1eefa EN v\u00e0 PN (h\u1ea7u h\u1ebft c\u00e1c nghi\u00ean c\u1ee9u g\u1ea7n \u0111\u00e2y), cho th\u1ea5y r\u1eb1ng nu\u00f4i th\u1eeba n\u0103ng l\u01b0\u1ee3ng c\u00f3 th\u1ec3 \u0111\u00f3ng vai tr\u00f2 trong c\u00e1c bi\u1ebfn ch\u1ee9ng nhi\u1ec5m tr\u00f9ng c\u1ee7a PN. Tuy nhi\u00ean, x\u00e9t tr\u00ean c\u00e1c h\u1eadu qu\u1ea3 x\u1ea5u c\u1ee7a suy dinh d\u01b0\u1ee1ng v\u00e0 m\u1ea5t kh\u1ed1i c\u01a1, v\u00e0 d\u1ef1a tr\u00ean s\u1ef1 \u0111\u1ed3ng thu\u1eadn c\u1ee7a c\u00e1c chuy\u00ean gia th\u00ec trong tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF c\u00f3 nguy c\u01a1 cao suy dinh d\u01b0\u1ee1ng ho\u1eb7c suy dinh d\u01b0\u1ee1ng n\u1eb7ng v\u00e0 kh\u00f4ng th\u1ec3 s\u1eed d\u1ee5ng EN th\u00ec vi\u1ec7c kh\u1edfi \u0111\u1ea7u PN n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t c\u1ea9n th\u1eadn v\u00e0 c\u00e2n \u0111\u1ed1i \u0111\u1ec3 ch\u1ed1ng nguy c\u01a1 c\u1ee7a nu\u00f4i d\u01b0\u1ee1ng th\u1eeba v\u00e0 nu\u00f4i \u0103n l\u1ea1i.<\/p>\n<h3>EN c\u00f3 li\u00ean quan \u0111\u1ebfn c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb so v\u1edbi PN hay kh\u00f4ng ?<\/h3>\n<p><strong>Tuy\u00ean b\u1ed1 4: Nh\u01b0 trong c\u00e1c c\u01a1 s\u1edf l\u00e2m s\u00e0ng kh\u00e1c (b\u1ec7nh nh\u00e2n \u0111a b\u1ec7nh n\u1ed9i vi\u1ec7n, b\u1ec7nh nh\u00e2n ICU) th\u00ec EN l\u00e0 con \u0111\u01b0\u1eddng cho \u0103n sinh l\u00fd nh\u1ea5t so v\u1edbi PN, v\u00e0 nh\u00ecn chung c\u00f3 li\u00ean quan \u0111\u1ebfn v\u1edbi t\u1ec9 l\u1ec7 nhi\u1ec5m tr\u00f9ng th\u1ea5p h\u01a1n c\u0169ng nh\u01b0 th\u1eddi gian n\u1eb1m t\u1ea1i ICU v\u00e0 th\u1eddi gian n\u1eb1m vi\u1ec7n ng\u1eafn h\u01a1n.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em> B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>Nh\u01b0 trong c\u00e1c c\u01a1 s\u1edf l\u00e2m s\u00e0ng kh\u00e1c, c\u00e1ch cho \u0103n ph\u1ee5 thu\u1ed9c nhi\u1ec1u h\u01a1n v\u00e0o ch\u1ee9c n\u0103ng \u0111\u01b0\u1eddng ti\u00eau h\u00f3a h\u01a1n l\u00e0 s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a t\u00ecnh tr\u1ea1ng suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn. Tr\u01b0\u1edbc \u0111\u00e2y, nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb b\u1ec7nh n\u1eb7ng v\u1edbi AKI\/AKD ch\u1ee7 y\u1ebfu \u0111\u01b0\u1ee3c nu\u00f4i d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch, trong khi hi\u1ec7n nay \u0111\u01b0\u1eddng ru\u1ed9t l\u00e0 l\u1ef1a ch\u1ecdn h\u00e0ng \u0111\u1ea7u cho li\u1ec7u ph\u00e1p dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng. An to\u00e0n v\u00e0 hi\u1ec7u qu\u1ea3 c\u1ee7a h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng ch\u1ec9 s\u1eed d\u1ee5ng EN \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 trong m\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t tr\u00ean 182 b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI, kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng n\u00e0o cho th\u1ea5y AKI c\u00f3 li\u00ean quan \u0111\u1ebfn s\u1ef1 gia t\u0103ng nh\u1ea5t qu\u00e1n c\u00e1c bi\u1ebfn ch\u1ee9ng ti\u00eau h\u00f3a, c\u01a1 h\u1ecdc ho\u1eb7c chuy\u1ec3n h\u00f3a trong EN [137]. Trong c\u00e1c c\u01a1 s\u1edf l\u00e2m s\u00e0ng kh\u00e1c, b\u1eb1ng ch\u1ee9ng \u1ee7ng h\u1ed9 EN thay v\u00ec PN \u0111\u01b0\u1ee3c c\u1ee7ng c\u1ed1 nhi\u1ec1u h\u01a1n. Trong m\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p c\u00e1c nghi\u00ean c\u1ee9u so s\u00e1nh EN v\u00e0 PN trong ICU \u0111\u1ed9c l\u1eadp v\u1edbi th\u1eddi gian, EN c\u00f3 th\u1ec3 gi\u1ea3m \u0111\u00e1ng k\u1ec3 nguy c\u01a1 nhi\u1ec5m tr\u00f9ng do ICU [136]. Trong khi c\u00e1c nghi\u00ean c\u1ee9u kh\u00e1c \u1edf b\u1ec7nh nh\u00e2n n\u1eb7ng [123\u2013128] v\u00e0 kh\u00f4ng ICU [129\u2013133], EN s\u1edbm cho th\u1ea5y gi\u1ea3m c\u00e1c bi\u1ebfn ch\u1ee9ng nhi\u1ec5m tr\u00f9ng, th\u1eddi gian n\u1eb1m t\u1ea1i ICU v\u00e0 th\u1eddi gian n\u1eb1m vi\u1ec7n ng\u1eafn h\u01a1n so v\u1edbi PN.<\/p>\n<h3>Li\u1ec7u EN c\u00f3 an to\u00e0n so v\u1edbi PN tr\u00ean b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF n\u1ed9i vi\u1ec7n c\u00f3 suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn ?<\/h3>\n<p><strong>Tuy\u00ean b\u1ed1 5: Kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng n\u00e0o cho th\u1ea5y c\u00f3 li\u00ean h\u1ec7 gi\u1eefa vi\u1ec7c gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn v\u1edbi s\u1ef1 gia t\u0103ng c\u00e1c bi\u1ebfn ch\u1ee9ng ti\u00eau h\u00f3a, c\u01a1 h\u1ecdc ho\u1eb7c chuy\u1ec3n h\u00f3a trong khi s\u1eed d\u1ee5ng EN \u1edf b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>EN \u0111\u1ea1i di\u1ec7n cho bi\u1ec7n ph\u00e1p \u0111\u1ea7u ti\u00ean v\u00e0 quan tr\u1ecdng nh\u1ea5t \u0111\u1ec3 h\u1ed7 tr\u1ee3 v\u00e0 ph\u1ee5c h\u1ed3i ch\u1ee9c n\u0103ng \u0111\u01b0\u1eddng ti\u00eau h\u00f3a, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng [8]. Tuy nhi\u00ean, th\u01b0\u1eddng kh\u00f4ng th\u1ec3 \u0111\u00e1p \u1ee9ng \u0111\u1ee7 nhu c\u1ea7u dinh d\u01b0\u1ee1ng ch\u1ec9 v\u1edbi EN \u0111\u01a1n \u0111\u1ed9c, do \u0111\u00f3 vi\u1ec7c b\u1ed5 sung m\u1ed9t ho\u1eb7c nhi\u1ec1u ch\u1ea5t dinh d\u01b0\u1ee1ng b\u1eb1ng \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch l\u00e0 c\u1ea7n thi\u1ebft. EN n\u00ean b\u1eaft \u0111\u1ea7u \u1edf m\u1ee9c th\u1ea5p v\u00e0 n\u00ean t\u0103ng t\u1eeb t\u1eeb (trong nhi\u1ec1u ng\u00e0y) cho \u0111\u1ebfn khi \u0111\u1ea1t \u0111\u1ee7 nhu c\u1ea7u. Hi\u1ec7n t\u1ea1i kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng r\u00f5 r\u00e0ng li\u00ean quan \u0111\u1ebfn t\u1ef7 l\u1ec7 m\u1eafc v\u00e0 m\u1ee9c \u0111\u1ed9 n\u1eb7ng c\u1ee7a h\u1ed9i ch\u1ee9ng nu\u00f4i \u0103n l\u1ea1i \u1edf b\u1ec7nh nh\u00e2n th\u1eadn n\u1ed9i vi\u1ec7n: tuy nhi\u00ean, \u0111i\u1ec7n gi\u1ea3i v\u00e0 ph\u1ed1t pho trong huy\u1ebft t\u01b0\u01a1ng ph\u1ea3i \u0111\u01b0\u1ee3c theo d\u00f5i nghi\u00eam ng\u1eb7t [1]. Hi\u1ec7n c\u00f3 r\u1ea5t \u00edt th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng c\u00f3 h\u1ec7 th\u1ed1ng v\u1ec1 EN tr\u00ean b\u1ec7nh nh\u00e2n b\u1ec7nh th\u1eadn nh\u1eadp vi\u1ec7n. Nghi\u00ean c\u1ee9u quan s\u00e1t l\u1edbn nh\u1ea5t cho \u0111\u1ebfn nay \u0111\u00e3 \u0111\u00e1nh gi\u00e1 t\u00ednh an to\u00e0n v\u00e0 hi\u1ec7u qu\u1ea3 c\u1ee7a h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng ch\u1ec9 d\u00f9ng qua \u1ed1ng sonde m\u0169i d\u1ea1 d\u00e0y b\u1eb1ng c\u00f4ng th\u1ee9c chu\u1ea9n ho\u1eb7c c\u00f4ng th\u1ee9c b\u1ec7nh l\u00fd d\u00e0nh ri\u00eang cho b\u1ec7nh nh\u00e2n KF \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o \u1edf 182 b\u1ec7nh nh\u00e2n AKI, [137]. Kh\u00f4ng t\u00ecm th\u1ea5y b\u1eb1ng ch\u1ee9ng n\u00e0o cho th\u1ea5y AKI c\u00f3 li\u00ean quan \u0111\u1ebfn s\u1ef1 gia t\u0103ng nghi\u00eam tr\u1ecdng c\u00e1c bi\u1ebfn ch\u1ee9ng ti\u00eau h\u00f3a, c\u01a1 h\u1ecdc ho\u1eb7c chuy\u1ec3n h\u00f3a khi ch\u1ecdn EN. L\u01b0\u1ee3ng d\u01b0 d\u1ecbch v\u1ecb cao \u1edf b\u1ec7nh nh\u00e2n AKI th\u01b0\u1eddng cao h\u01a1n so v\u1edbi nh\u1eefng ng\u01b0\u1eddi c\u00f3 ch\u1ee9c n\u0103ng th\u1eadn b\u00ecnh th\u01b0\u1eddng, nh\u01b0ng n\u00f3i chung, EN an to\u00e0n v\u00e0 hi\u1ec7u qu\u1ea3 [137].<\/p>\n<h3>Nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng<\/h3>\n<h4>X\u00e1c \u0111\u1ecbnh nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng nh\u01b0 th\u1ebf n\u00e0o ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 10: \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF n\u1ed9i vi\u1ec7n c\u1ea7n \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng, n\u00ean s\u1eed d\u1ee5ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp (Indirect Calorimetry \u2013 IC) \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 m\u1ee9c ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng \u0111\u1ec3 \u0111\u01b0a ra li\u1ec7u ph\u00e1p can thi\u1ec7p dinh d\u01b0\u1ee1ng (\u0111\u1ecbnh l\u01b0\u1ee3ng calo) v\u00e0 tr\u00e1nh nu\u00f4i \u0103n thi\u1ebfu ho\u1eb7c qu\u00e1 m\u1ee9c.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.7%)<\/p>\n<p>L\u01b0u \u00fd r\u1eb1ng c\u00e1c ph\u01b0\u01a1ng tr\u00ecnh d\u1ef1 \u0111o\u00e1n v\u00e0 c\u00f4ng th\u1ee9c d\u1ef1a tr\u00ean tr\u1ecdng l\u01b0\u1ee3ng c\u00f3 th\u1ec3 c\u00f3 s\u1ef1 sai l\u1ec7ch \u0111\u00e1ng k\u1ec3 v\u00e0 kh\u00f4ng ch\u00ednh x\u00e1c, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n th\u1eadn, kh\u00f4ng c\u00f3 IC, \u0111\u1ed1i v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng b\u1ecb b\u1ec7nh n\u1eb7ng c\u00f3 AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF \u0111ang \u0111i\u1ec1u tr\u1ecb \u1edf khoa l\u00e2m s\u00e0ng v\u00e0 kh\u00f4ng \u0103n ch\u1ebf \u0111\u1ed9 \u0103n \u00edt protein, ch\u00fang t\u00f4i tham kh\u1ea3o c\u00e1c khuy\u1ebfn ngh\u1ecb 4.2 v\u00e0 4.3a v\u00e0 4.3b theo h\u01b0\u1edbng d\u1eabn c\u1ee7a ESPEN cho b\u1ec7nh nh\u00e2n n\u1ed9i khoa nhi\u1ec1u b\u1ec7nh n\u1ec1n [29].<\/p>\n<p>\u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n CKD kh\u00f4ng b\u1ecb b\u1ec7nh n\u1eb7ng v\u1edbi KF (kh\u00f4ng c\u00f3 KRT) \u0111ang \u0111i\u1ec1u tr\u1ecb \u1edf khoa l\u00e2m s\u00e0ng\/khoa th\u1eadn kh\u00f4ng c\u00f3 y\u1ebfu t\u1ed1 stress v\u00e0 ti\u1ebfp t\u1ee5c ph\u00e1c \u0111\u1ed3 ch\u1ebf \u0111\u1ed9 \u0103n \u00edt protein \u0111\u00e3 thi\u1ebft l\u1eadp tr\u01b0\u1edbc \u0111\u00f3 trong th\u1eddi gian n\u1eb1m vi\u1ec7n, l\u01b0\u1ee3ng 30-35 kcal\/kg\/ng\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh trong c\u00e1c h\u01b0\u1edbng d\u1eabn tr\u01b0\u1edbc \u0111\u00e2y c\u1ee7a ESPEN [1,2] \u0111\u01b0\u1ee3c x\u00e1c nh\u1eadn.<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>Vi\u1ec7c x\u00e1c \u0111\u1ecbnh ch\u00ednh x\u00e1c nhu c\u1ea7u protein v\u00e0 n\u0103ng l\u01b0\u1ee3ng l\u00e0 r\u1ea5t quan tr\u1ecdng trong b\u1ec7nh c\u1ea3nh l\u00e2m s\u00e0ng n\u00e0y b\u1edfi v\u00ec c\u1ea3 vi\u1ec7c nu\u00f4i \u0103n th\u1eeba v\u00e0 thi\u1ebfu \u0111\u1ec1u c\u00f3 kh\u1ea3 n\u0103ng d\u1eabn \u0111\u1ebfn k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb x\u1ea5u [10,138].<\/p>\n<p>Ti\u00eau chu\u1ea9n v\u00e0ng \u0111\u1ec3 \u0111o nhu c\u1ea7u calo c\u1ee7a t\u1eebng c\u00e1 nh\u00e2n \u0111\u01b0\u1ee3c th\u1ec3 hi\u1ec7n b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp, m\u1ed9t ph\u01b0\u01a1ng ph\u00e1p kh\u00f4ng x\u00e2m l\u1ea5n cho ph\u00e9p \u0111\u00e1nh gi\u00e1 m\u1ee9c ti\u00eau th\u1ee5 n\u0103ng l\u01b0\u1ee3ng khi ngh\u1ec9 ng\u01a1i (REE) d\u1ef1a tr\u00ean c\u00e1c ph\u00e9p \u0111o ti\u00eau th\u1ee5 oxy v\u00e0 s\u1ea3n xu\u1ea5t carbon dioxide trong kh\u00ed th\u1edf ra [139]. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng, REE \u0111\u01b0\u1ee3c \u0111o b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp th\u01b0\u1eddng \u0111\u01b0\u1ee3c xem nh\u01b0 l\u00e0 cho y l\u1ec7nh v\u1ec1 dinh d\u01b0\u1ee1ng. Th\u1eadt kh\u00f4ng may, ph\u00e9p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp kh\u00f4ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng r\u1ed9ng r\u00e3i trong c\u00f4ng vi\u1ec7c th\u01b0\u1eddng ng\u00e0y c\u1ee7a b\u1ec7nh vi\u1ec7n [139].<\/p>\n<p>Ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp cho bi\u1ebft th\u00f4ng tin v\u1ec1 t\u1ed1c \u0111\u1ed9 chuy\u1ec3n h\u00f3a c\u00f3 li\u00ean quan \u0111\u1ebfn l\u00e2m s\u00e0ng nh\u01b0 trong m\u1ed9t nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng tr\u00ean 124 b\u1ec7nh nh\u00e2n ICU b\u1ecb AKI n\u1eb7ng cho th\u1ea5y t\u00ecnh tr\u1ea1ng t\u0103ng chuy\u1ec3n h\u00f3a l\u00e0 62% v\u00e0 gi\u1ea3m chuy\u1ec3n h\u00f3a l\u00e0 14% [140].<\/p>\n<p>\u0110\u00e3 c\u00f3 s\u1ef1 \u0111\u1ed3ng thu\u1eadn to\u00e0n c\u1ea7u v\u1ec1 t\u1ea7m quan tr\u1ecdng c\u1ee7a vi\u1ec7c s\u1eed d\u1ee5ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 REE. C\u1ea3 h\u01b0\u1edbng d\u1eabn c\u1ee7a Ch\u00e2u \u00c2u [8] v\u00e0 Hoa K\u1ef3 [141] \u0111\u1ec1u \u0111\u01b0a ra c\u00e1c khuy\u1ebfn c\u00e1o h\u1ed7 tr\u1ee3 cho vi\u1ec7c s\u1eed d\u1ee5ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp nh\u01b0 m\u1ed9t c\u00f4ng c\u1ee5 ti\u00eau chu\u1ea9n v\u00e0ng. \u0110i\u1ec1u n\u00e0y ph\u1ea7n l\u1edbn \u0111\u01b0\u1ee3c h\u1ed7 tr\u1ee3 b\u1edfi th\u1ef1c t\u1ebf l\u00e0 c\u00e1c ph\u01b0\u01a1ng tr\u00ecnh v\u00e0 c\u00f4ng th\u1ee9c nh\u1eb1m \u01b0\u1edbc t\u00ednh REE ph\u1ea7n l\u1edbn kh\u00f4ng ph\u00f9 h\u1ee3p, do \u0111\u00f3 c\u00f3 nguy c\u01a1 cho \u0103n thi\u1ebfu v\u00e0 th\u1eeba \u0111\u00e1ng k\u1ec3 v\u1ec1 m\u1eb7t l\u00e2m s\u00e0ng, \u0111i\u1ec1u n\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh r\u00f5 r\u00e0ng ngay c\u1ea3 trong b\u1ed1i c\u1ea3nh c\u1ee7a AKI v\u00e0 KRT [140,142,143].<\/p>\n<p>M\u1ed9t nghi\u00ean c\u1ee9u can thi\u1ec7p theo th\u1eddi gian tr\u00ean b\u1ec7nh nh\u00e2n ICU v\u1edbi AKI c\u00f3 KRT d\u01b0\u1edbi d\u1ea1ng CKRT (l\u1ecdc m\u00e1u li\u00ean t\u1ee5c) \u0111\u00e3 ch\u1ee9ng minh r\u1eb1ng m\u1ed9t m\u00e1y \u0111o chuy\u1ec3n h\u00f3a c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n vi\u1ec7c cung c\u1ea5p n\u0103ng l\u01b0\u1ee3ng c\u0169ng nh\u01b0 l\u00e0m t\u0103ng l\u01b0\u1ee3ng protein [144]. Khi \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn s\u1ef1 c\u00e2n b\u1eb1ng nit\u01a1 l\u00e0 d\u01b0\u01a1ng s\u1ebd gi\u00fap t\u0103ng t\u1ef7 l\u1ec7 s\u1ed1ng s\u00f3t [145].<\/p>\n<p>Trong khi c\u00e1c ph\u01b0\u01a1ng tr\u00ecnh d\u1ef1 \u0111o\u00e1n v\u00e0 c\u00f4ng th\u1ee9c d\u1ef1a tr\u00ean tr\u1ecdng l\u01b0\u1ee3ng \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 \u0111\u00e3 cung c\u1ea5p c\u00e1c \u01b0\u1edbc t\u00ednh h\u1ee3p l\u1ec7 v\u1ec1 nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng \u1edf c\u1ea5p \u0111\u1ed9 qu\u1ea7n th\u1ec3, c\u1ea3 hai ph\u01b0\u01a1ng ph\u00e1p \u0111\u1ec1u c\u00f3 sai s\u1ed1 \u0111\u00e1ng k\u1ec3 v\u00e0 kh\u00f4ng ch\u00ednh x\u00e1c khi \u00e1p d\u1ee5ng cho t\u1eebng b\u1ec7nh nh\u00e2n [142,143,146,147], \u0111\u00f2i h\u1ecfi ng\u01b0\u1eddi l\u00e0m l\u00e2m s\u00e0ng ph\u1ea3i th\u1ef1c hi\u1ec7n m\u1ed9t m\u1ee9c \u0111\u1ed9 \u0111\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng \u0111\u00e1ng k\u1ec3, \u0111\u1ec3 c\u00e1 nh\u00e2n h\u00f3a nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng. Do \u0111\u00f3, ng\u01b0\u1eddi l\u00e0m l\u00e2m s\u00e0ng c\u1ea7n nh\u1eadn th\u1ee9c \u0111\u01b0\u1ee3c nh\u1eefng h\u1ea1n ch\u1ebf c\u1ee7a vi\u1ec7c s\u1eed d\u1ee5ng c\u00e1c c\u00f4ng c\u1ee5 d\u1ef1 \u0111o\u00e1n nh\u01b0 v\u1eady \u0111\u1ec3 \u0111o c\u00e1c gi\u00e1 tr\u1ecb REE.<\/p>\n<p>C\u00e1c h\u01b0\u1edbng d\u1eabn tr\u01b0\u1edbc \u0111\u00e2y tr\u00ean b\u1ec7nh nh\u00e2n AKI c\u1ee7a ICU \u0111\u00e3 khuy\u1ebfn ngh\u1ecb l\u01b0\u1ee3ng calo kh\u00f4ng protein t\u1eeb 20-30 kcal\/kg\/ng\u00e0y [1,2,148], ho\u1eb7c t\u1ed5ng l\u01b0\u1ee3ng calo t\u1eeb 20-30 kcal\/kg\/ng\u00e0y [4,149,150]. Nh\u1eefng h\u01b0\u1edbng d\u1eabn n\u00e0y bao g\u1ed3m nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng trung b\u00ecnh \u1edf c\u1ea5p \u0111\u1ed9 qu\u1ea7n th\u1ec3 v\u00e0 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng l\u00e0m \u0111i\u1ec3m b\u1eaft \u0111\u1ea7u chung khi kh\u00f4ng c\u00f3 ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp. Tuy nhi\u00ean, trong nhi\u1ec1u tr\u01b0\u1eddng h\u1ee3p, n\u00f3 kh\u00f4ng \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp \u0111\u1ebfn n\u1ebfu th\u1ef1c t\u1ebf, c\u00e2n n\u1eb7ng tr\u01b0\u1edbc khi ph\u00e1t b\u1ec7nh ho\u1eb7c c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t \u0111\u1ec3 t\u00ednh to\u00e1n. C\u1ea7n c\u00e2n nh\u1eafc r\u1eb1ng b\u1ec7nh nh\u00e2n AKI th\u01b0\u1eddng xuy\u00ean b\u1ecb qu\u00e1 t\u1ea3i d\u1ecbch v\u00e0 c\u00f3 s\u1ef1 di chuy\u1ec3n \u0111\u1ed9t ng\u1ed9t c\u1ee7a d\u1ecbch li\u00ean quan \u0111\u1ebfn KRT, th\u1eadm ch\u00ed c\u00f2n kh\u00f3 kh\u0103n h\u01a1n \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 tham chi\u1ebfu \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 \u01b0\u1edbc t\u00ednh ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng c\u00e1c ph\u01b0\u01a1ng tr\u00ecnh d\u1ef1 \u0111o\u00e1n. V\u1ec1 v\u1ea5n \u0111\u1ec1 n\u00e0y, m\u1ed9t nghi\u00ean c\u1ee9u g\u1ea7n \u0111\u00e2y tr\u00ean 205 b\u1ec7nh nh\u00e2n n\u1eb7ng trong \u0111\u00f3 REE \u0111\u01b0\u1ee3c \u0111o b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp \u0111\u01b0\u1ee3c so s\u00e1nh v\u1edbi ph\u01b0\u01a1ng tr\u00ecnh Harris-Benedict \u0111\u01b0\u1ee3c t\u00ednh to\u00e1n v\u1edbi ba c\u00e2n n\u1eb7ng tham chi\u1ebfu kh\u00e1c nhau (c\u00e2n n\u1eb7ng th\u1ef1c t\u1ebf, c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng v\u00e0 c\u00e2n n\u1eb7ng \u01b0\u1edbc \u0111o\u00e1n), k\u1ebft lu\u1eadn r\u1eb1ng s\u1ed1 calo \u0111\u01b0\u1ee3c t\u00ednh b\u1eb1ng ph\u01b0\u01a1ng tr\u00ecnh Harris- Benedict, b\u1ea5t k\u1ec3 tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 tham chi\u1ebfu n\u00e0o \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng, kh\u00f4ng th\u1ec3 thay th\u1ebf k\u1ebft qu\u1ea3 \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp [151]. Ch\u1ec9 c\u00f3 hai nghi\u00ean c\u1ee9u quan s\u00e1t \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI, so s\u00e1nh v\u1ec1 m\u1ee9c ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng b\u1eb1ng vi\u1ec7c x\u00e1c \u0111\u1ecbnh nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp v\u1edbi m\u1ee9c ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng \u0111\u01b0\u1ee3c \u01b0\u1edbc t\u00ednh c\u1ee7a c\u00e1c c\u00f4ng th\u1ee9c d\u1ef1a tr\u00ean tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 ho\u1eb7c ph\u01b0\u01a1ng tr\u00ecnh d\u1ef1 \u0111o\u00e1n, bao g\u1ed3m c\u1ea3 ph\u01b0\u01a1ng tr\u00ecnh Harris-Benedict [142,143]. C\u1ea3 hai nghi\u00ean c\u1ee9u \u0111\u1ec1u \u0111\u1ed3ng \u00fd r\u1eb1ng c\u00e1c ph\u01b0\u01a1ng ph\u00e1p t\u00ednh to\u00e1n ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng n\u00e0y c\u00f3 \u0111\u1ed9 ch\u00ednh x\u00e1c th\u1ea5p, gi\u1edbi h\u1ea1n \u0111\u1ed3ng thu\u1eadn r\u1ed9ng v\u00e0 th\u01b0\u1eddng \u0111\u00e1nh gi\u00e1 th\u1ea5p h\u01a1n m\u1ee9c ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng th\u1ef1c t\u1ebf, t\u00f9y thu\u1ed9c v\u00e0o c\u00e2n n\u1eb7ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 t\u00ednh to\u00e1n. Do \u0111\u00f3, m\u1eb7c d\u00f9 l\u00e0 m\u1ed9t c\u00e1ch r\u1ea5t \u0111\u01a1n gi\u1ea3n \u0111\u1ec3 d\u1ef1 \u0111o\u00e1n m\u1ee9c ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng, nh\u01b0ng c\u00e1ch ti\u1ebfp c\u1eadn n\u00e0y c\u00f3 kh\u1ea3 n\u0103ng l\u00e0m t\u0103ng nguy c\u01a1 nu\u00f4i \u0103n th\u1eeba v\u00e0 thi\u1ebfu \u1edf b\u1ec7nh nh\u00e2n ICU c\u00f3 AKI.<\/p>\n<p>T\u1eeb vi\u1ec7c xem x\u00e9t c\u00e1c t\u00e0i li\u1ec7u, hi\u1ec7n t\u1ea1i, kh\u00f4ng th\u1ec3 x\u00e1c \u0111\u1ecbnh v\u00e0 do \u0111\u00f3 c\u0169ng kh\u00f4ng th\u1ec3 khuy\u1ebfn ngh\u1ecb r\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p n\u00e0o \u0111\u1ec3 d\u1ef1 \u0111o\u00e1n nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng l\u00e0 t\u1ed1t nh\u1ea5t v\u1ec1 m\u1eb7t \u0111\u01b0a \u0111\u1ebfn k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb t\u1ed1t h\u01a1n \u1edf b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF n\u1ed9i vi\u1ec7n. Do kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng ch\u1eafc ch\u1eafn, vi\u1ec7c tham kh\u1ea3o c\u00e1c h\u01b0\u1edbng d\u1eabn g\u1ea7n \u0111\u00e2y c\u1ee7a ESPEN tr\u00ean b\u1ec7nh nh\u00e2n n\u1eb7ng [8] v\u00e0 tr\u00ean b\u1ec7nh nh\u00e2n n\u1ed9i khoa nhi\u1ec1u b\u1ec7nh n\u1ec1n [29] c\u00f3 th\u1ec3 t\u1ea1o \u0111i\u1ec1u ki\u1ec7n thu\u1eadn l\u1ee3i cho vi\u1ec7c th\u1ef1c h\u00e0nh h\u00e0ng ng\u00e0y c\u1ee7a ng\u01b0\u1eddi l\u00e0m l\u00e2m s\u00e0ng v\u00ec c\u00e1c h\u01b0\u1edbng d\u1eabn n\u00e0y kh\u00f4ng lo\u1ea1i tr\u1eeb b\u1ec7nh nh\u00e2n b\u1ecb b\u1ec7nh th\u1eadn.<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 11: Ph\u00e9p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n trong qu\u00e1 tr\u00ecnh CKRT, l\u01b0u \u00fd nh\u1eefng h\u1ea1n ch\u1ebf n\u1ed9i t\u1ea1i c\u1ee7a ph\u01b0\u01a1ng ph\u00e1p. N\u00ean \u01b0u ti\u00ean kho\u1ea3ng th\u1eddi gian t\u1ed1i thi\u1ec3u l\u00e0 2 gi\u1edd sau khi ch\u1ea1y th\u1eadn ng\u1eaft qu\u00e3ng \u0111\u1ec3 c\u1ea3i thi\u1ec7n \u0111\u1ed9 ch\u00ednh x\u00e1c c\u1ee7a ph\u00e9p \u0111o<\/strong><\/p>\n<p><strong>Grade 0<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn (78.3%)<\/p>\n<p>B\u00e0n lu\u1eadn:<\/p>\n<p>C\u00e1c khuy\u1ebfn ngh\u1ecb hi\u1ec7n c\u00f3 t\u1eeb c\u00e1c chuy\u00ean gia cho r\u1eb1ng kh\u00f4ng n\u00ean th\u1ef1c hi\u1ec7n ph\u00e9p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp trong KRT, do KRT c\u00f3 th\u1ec3 can thi\u1ec7p v\u00e0o c\u00e2n b\u1eb1ng CO2 [139]. Tuy nhi\u00ean, g\u1ea7n \u0111\u00e2y h\u01a1n, c\u00e1c nghi\u00ean c\u1ee9u \u0111i\u1ec1u tra vi\u1ec7c \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp cho th\u1ea5y kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 REE \u1edf b\u1ec7nh nh\u00e2n c\u00f3 ho\u1eb7c kh\u00f4ng CKRT [144,152-154]. Th\u1eed nghi\u1ec7m MECCIAS g\u1ea7n \u0111\u00e2y \u0111\u00e3 ch\u1ec9 ra r\u1eb1ng \u1ea3nh h\u01b0\u1edfng c\u1ee7a s\u1ef1 thay \u0111\u1ed5i CO2 trong qu\u00e1 tr\u00ecnh CKRT l\u00ean REE l\u00e0 nh\u1ecf nh\u1ea5t v\u00e0 ph\u00e9p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp trong qu\u00e1 tr\u00ecnh CKRT n\u00ean \u0111\u01b0\u1ee3c \u01b0u ti\u00ean h\u01a1n v\u00ec hi\u1ec7u qu\u1ea3 c\u1ee7a n\u00f3 \u0111\u1ed1i v\u1edbi n\u0103ng l\u01b0\u1ee3ng ti\u00eau th\u1ee5 [154]. Trong ph\u00e9p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp, gi\u00e1 tr\u1ecb REE \u0111\u01b0\u1ee3c t\u00ednh to\u00e1n t\u1eeb vi\u1ec7c ti\u00eau th\u1ee5 O2 v\u00e0 s\u1ea3n sinh CO2 (ph\u01b0\u01a1ng tr\u00ecnh Weir), v\u00e0 c\u1ea3 hai kh\u00ed n\u00e0y c\u0169ng \u0111\u01b0\u1ee3c trao \u0111\u1ed5i trong tu\u1ea7n ho\u00e0n ngo\u00e0i c\u01a1 th\u1ec3 [155]. Tuy nhi\u00ean, trong qu\u00e1 tr\u00ecnh KRT, m\u1ed9t l\u01b0\u1ee3ng \u0111\u00e1ng k\u1ec3 CO2 (26 ml\/ph\u00fat) \u0111\u01b0\u1ee3c lo\u1ea1i b\u1ecf trong d\u1ecbch th\u1ea3i trong qu\u00e1 tr\u00ecnh CKRT, \u0111\u1ea1i di\u1ec7n cho 14% VCO2 trung b\u00ecnh th\u1edf ra [155], do \u0111\u00f3 ph\u00e9p \u0111o VCO2 kh\u00f4ng th\u1ec3 ph\u1ea3n \u00e1nh ch\u00ednh x\u00e1c l\u01b0\u1ee3ng s\u1ea3n sinh n\u1ed9i sinh CO2, h\u1ea1n ch\u1ebf vi\u1ec7c gi\u1ea3i th\u00edch ch\u00ednh x\u00e1c REE \u0111o \u0111\u01b0\u1ee3c d\u1ef1a tr\u00ean IC.<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 12: B\u1ea5t c\u1ee9 khi n\u00e0o t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng c\u1ee7a b\u1ec7nh nh\u00e2n thay \u0111\u1ed5i, n\u00ean \u0111o l\u1ea1i nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp.<\/strong><\/p>\n<p><strong>Grade GPP<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em> B\u00e0n lu\u1eadn cho khuy\u1ebfn c\u00e1o 12:<\/em><\/p>\n<p>Li\u1ec7u ch\u1ec9 m\u1ed9t l\u1ea7n \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp khi b\u1eaft \u0111\u1ea7u h\u1ed3i ph\u1ee5c c\u00f3 \u0111\u1ee7 \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh c\u00e1c nhu c\u1ea7u dinh d\u01b0\u1ee1ng trong th\u1eddi gian \u1edf ICU hay kh\u00f4ng v\u1eabn l\u00e0 m\u1ed9t c\u00e2u h\u1ecfi m\u1edf. Trong m\u1ed9t nghi\u00ean c\u1ee9u tr\u00ean b\u1ec7nh nh\u00e2n b\u1ecb AKI, kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t n\u00e0o \u0111\u01b0\u1ee3c quan s\u00e1t th\u1ea5y gi\u1eefa c\u00e1c ph\u00e9p \u0111o n\u0103ng l\u01b0\u1ee3ng \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n khi b\u1eaft \u0111\u1ea7u \u1edf ICU v\u00e0 trong v\u00f2ng m\u1ed9t tu\u1ea7n, c\u0169ng nh\u01b0 trong v\u00f2ng 48 gi\u1edd, m\u1eb7c d\u00f9 \u1edf \u0111\u1ea1i \u0111a s\u1ed1 b\u1ec7nh nh\u00e2n (68%) s\u1ef1 kh\u00e1c bi\u1ec7t l\u1edbn h\u01a1n \u00b1 10% \u0111o \u0111\u01b0\u1ee3c c\u00f3 th\u1ec3 c\u00f3 li\u00ean quan v\u1ec1 m\u1eb7t l\u00e2m s\u00e0ng [142]. M\u1ed9t nghi\u00ean c\u1ee9u h\u1ed3i c\u1ee9u tr\u00ean 1171 b\u1ec7nh nh\u00e2n n\u1eb7ng cho th\u1ea5y s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa c\u00e1c ng\u00e0y c\u00f3 \u00fd ngh\u0129a th\u1ed1ng k\u00ea, tuy nhi\u00ean, s\u1ef1 kh\u00e1c bi\u1ec7t n\u00e0y m\u1ea5t \u0111i \u00fd ngh\u0129a sau khi lo\u1ea1i tr\u1eeb hai ng\u00e0y \u0111\u1ea7u nh\u1eadp vi\u1ec7n [156]. M\u1ed9t b\u00e0i b\u00e1o c\u1ee7a chuy\u00ean gia v\u1ec1 ph\u00e9p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp \u1edf b\u1ec7nh nh\u00e2n n\u1eb7ng [139] n\u00f3i r\u1eb1ng n\u0103ng l\u01b0\u1ee3ng ti\u00eau hao c\u1ee7a b\u1ec7nh nh\u00e2n n\u1eb7ng l\u00e0 r\u1ea5t dao \u0111\u1ed9ng v\u00e0 ph\u1ee5 thu\u1ed9c v\u00e0o giai \u0111o\u1ea1n v\u00e0 m\u1ee9c \u0111\u1ed9 n\u1eb7ng c\u1ee7a b\u1ec7nh, \u0111i\u1ec1u tr\u1ecb v\u00e0 th\u1eddi gian n\u1eb1m t\u1ea1i gi\u01b0\u1eddng k\u00e9o d\u00e0i. Kh\u00e1i ni\u1ec7m t\u01b0\u01a1ng t\u1ef1 c\u0169ng ph\u00f9 h\u1ee3p v\u1edbi b\u1ec7nh nh\u00e2n AKI [1,2]. V\u00ec v\u1eady, khuy\u1ebfn c\u00e1o r\u1eb1ng b\u1ea5t c\u1ee9 khi n\u00e0o t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng c\u1ee7a b\u1ec7nh nh\u00e2n thay \u0111\u1ed5i, n\u00ean l\u1eb7p l\u1ea1i ph\u00e9p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp. N\u1ebfu kh\u00f4ng c\u00f3 ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp, th\u00ec vi\u1ec7c t\u00ednh to\u00e1n REE t\u1eeb VCO2 thu \u0111\u01b0\u1ee3c t\u1eeb m\u00e1y th\u1edf \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 ch\u00ednh x\u00e1c h\u01a1n c\u00e1c ph\u01b0\u01a1ng tr\u00ecnh \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng kh\u00f4ng \u0111i\u1ec1u tr\u1ecb CKRT [157] nh\u01b0ng \u00edt ch\u00ednh x\u00e1c h\u01a1n so v\u1edbi ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp [139]. Tuy nhi\u00ean, cho \u0111\u1ebfn nay ch\u01b0a c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o nh\u01b0 v\u1eady \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI.<br \/>\nN\u00f3i chung, ch\u00fang t\u00f4i tham kh\u1ea3o Tuy\u00ean b\u1ed1 2 t\u1eeb ESPEN Guideline v\u1ec1 dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng trong ICU [8].<\/p>\n<p><strong>N\u1ebfu kh\u00f4ng th\u1ec3 \u0111o nhi\u1ec7t l\u01b0\u1ee3ng, s\u1eed d\u1ee5ng VO2 (ti\u00eau th\u1ee5 oxy) t\u1eeb catheter \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i ho\u1eb7c VCO2 (carbon dioxide s\u1ea3n sinh) l\u1ea5y t\u1eeb m\u00e1y th\u1edf s\u1ebd cho \u0111\u00e1nh gi\u00e1 t\u1ed1t h\u01a1n v\u1ec1 m\u1ee9c ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng so v\u1edbi c\u00e1c ph\u01b0\u01a1ng tr\u00ecnh d\u1ef1 \u0111o\u00e1n.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn (82%)<\/p>\n<p>N\u1ebfu kh\u00f4ng c\u00f3 ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp, th\u00ec vi\u1ec7c t\u00ednh to\u00e1n REE ch\u1ec9 t\u1eeb c\u00e1c gi\u00e1 tr\u1ecb VCO2 thu \u0111\u01b0\u1ee3c t\u1eeb m\u00e1y th\u1edf (REE \u2013 VCO2*8.19) \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 ch\u00ednh x\u00e1c h\u01a1n c\u00e1c ph\u01b0\u01a1ng tr\u00ecnh [157], nh\u01b0ng k\u00e9m h\u01a1n so v\u1edbi ph\u00e9p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp [139]. Ngo\u00e0i ra, VO2 \u0111\u01b0\u1ee3c t\u00ednh t\u1eeb catheter \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i l\u00e0 m\u1ed9t l\u1ef1a ch\u1ecdn kh\u1ea3 thi kh\u00e1c [158].<\/p>\n<h4>Th\u1ebf n\u00e0o l\u00e0 m\u1ee9c n\u0103ng l\u01b0\u1ee3ng t\u1ed1i \u01b0u \u0111\u1ec3 tr\u00e1nh nu\u00f4i \u0103n thi\u1ebfu ho\u1eb7c th\u1eeba ?<\/h4>\n<p>V\u00ec kh\u00f4ng c\u00f3 s\u1ef1 thay \u0111\u1ed5i \u0111\u00e1ng k\u1ec3 n\u00e0o c\u1ee7a qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a n\u0103ng l\u01b0\u1ee3ng li\u00ean quan \u0111\u1ebfn AKI, v\u00e0 c\u0169ng v\u00ec c\u00e1c t\u00e1c \u0111\u1ed9ng li\u00ean quan nhi\u1ec1u \u0111\u1ebfn ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng th\u01b0\u1eddng l\u00e0 do y\u1ebfu t\u1ed1 m\u1ea1n t\u00ednh (nh\u01b0 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng, c\u01b0\u1eddng c\u1eadn gi\u00e1p n\u1eb7ng v\u00e0 vi\u00eam) ho\u1eb7c t\u00ecnh d\u1ecb h\u00f3a c\u1ea5p t\u00ednh c\u1ee7a c\u00e1c b\u1ec7nh \u0111i k\u00e8m v\u00e0 bi\u1ebfn ch\u1ee9ng [8,159,160], v\u00e0 do kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u ch\u1ea5t l\u01b0\u1ee3ng cao n\u00e0o kh\u1ea3o s\u00e1t vi\u1ec7c cung c\u1ea5p n\u0103ng l\u01b0\u1ee3ng \u1edf b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF n\u1ed9i vi\u1ec7n, ch\u00fang t\u00f4i tham kh\u1ea3o khuy\u1ebfn ngh\u1ecb 11.1 trong h\u01b0\u1edbng d\u1eabn c\u1ee7a ESPEN cho b\u1ec7nh nh\u00e2n \u0111a b\u1ec7nh n\u1eb1m vi\u1ec7n [29] v\u00e0 c\u00e1c khuy\u1ebfn ngh\u1ecb 8 v\u00e0 16-19 trong h\u01b0\u1edbng d\u1eabn c\u1ee7a ESPEN cho b\u1ec7nh nh\u00e2n n\u1eb7ng [8].<\/p>\n<p><strong>\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n n\u1ed9i tr\u00fa \u0111a b\u1ec7nh v\u1edbi \u0103n k\u00e9m v\u00e0 t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng k\u00e9m, c\u1ea7n \u0111\u1ea1t \u0111\u01b0\u1ee3c \u00edt nh\u1ea5t 75% nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng v\u00e0 protein \u0111\u1ec3 gi\u1ea3m nguy c\u01a1 \u0111\u01b0a \u0111\u1ebfn k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb b\u1ea5t l\u1ee3i.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) [29]\n<p><strong>Dinh d\u01b0\u1ee1ng v\u1edbi n\u0103ng l\u01b0\u1ee3ng th\u1ea5p (kh\u00f4ng v\u01b0\u1ee3t qu\u00e1 70% EE) n\u00ean \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n trong giai \u0111o\u1ea1n \u0111\u1ea7u c\u1ee7a pha c\u1ea5p.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) [8]\n<p>Sau ng\u00e0y th\u1ee9 ba, l\u01b0\u1ee3ng calo cung c\u1ea5p c\u00f3 th\u1ec3 t\u0103ng l\u00ean \u0111\u1ebfn 80-100% n\u0103ng l\u01b0\u1ee3ng ti\u00eau th\u1ee5.<\/p>\n<p><strong>Grade 0<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) [8]\n<p><strong>\u0110\u1ec3 tr\u00e1nh nu\u00f4i \u0103n qu\u00e1 nhi\u1ec1u, EN v\u00e0 PN \u0111\u1ea7y \u0111\u1ee7 giai \u0111o\u1ea1n s\u1edbm s\u1ebd kh\u00f4ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng cho nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng m\u00e0 n\u00ean \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh trong v\u00f2ng ba \u0111\u1ebfn b\u1ea3y ng\u00e0y.<\/strong><\/p>\n<p><strong>Grade A<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) [8]\n<p>N\u1ebfu s\u1eed d\u1ee5ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp, ch\u1ebf \u0111\u1ed9 dinh d\u01b0\u1ee1ng \u0111\u00fang nhu c\u1ea7u h\u01a1n l\u00e0 dinh d\u01b0\u1ee1ng v\u1edbi n\u0103ng l\u01b0\u1ee3ng th\u1ea5p c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n d\u1ea7n d\u1ea7n sau giai \u0111o\u1ea1n \u0111\u1ea7u c\u1ee7a pha c\u1ea5p.<\/p>\n<p><strong>Grade 0<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95%) [8]\n<p>N\u1ebfu s\u1eed d\u1ee5ng c\u00e1c ph\u01b0\u01a1ng tr\u00ecnh d\u1ef1 \u0111o\u00e1n \u0111\u1ec3 \u01b0\u1edbc t\u00ednh nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng, th\u00ec dinh d\u01b0\u1ee1ng n\u0103ng l\u01b0\u1ee3ng th\u1ea5p (d\u01b0\u1edbi 70% nhu c\u1ea7u \u01b0\u1edbc t\u00ednh) n\u00ean \u0111\u01b0\u1ee3c \u01b0u ti\u00ean h\u01a1n so v\u1edbi dinh d\u01b0\u1ee1ng \u0111\u1ea7y \u0111\u1ee7 trong tu\u1ea7n \u0111\u1ea7u ti\u00ean \u1edf ICU.<\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95%) [8] B\u00e0n lu\u1eadn:<\/p>\n<p>T\u1ef7 l\u1ec7 n\u0103ng l\u01b0\u1ee3ng tr\u00ean nit\u01a1 t\u1ed1i \u01b0u ch\u01b0a \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh trong AKI. M\u1ed9t nghi\u00ean c\u1ee9u theo th\u1eddi gian v\u1ec1 t\u00e1c \u0111\u1ed9ng c\u1ee7a vi\u1ec7c t\u0103ng t\u1ef7 l\u1ec7 calo tr\u00ean nit\u01a1 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb b\u1ec7nh n\u1eb7ng v\u1edbi AKI (40 kcal\/ kg\/ng\u00e0y so v\u1edbi 30 kcal\/kg\/ng\u00e0y) cho th\u1ea5y r\u1eb1ng c\u00e1ch ti\u1ebfp c\u1eadn n\u00e0y kh\u00f4ng li\u00ean quan \u0111\u1ebfn vi\u1ec7c c\u1ea3i thi\u1ec7n c\u00e2n b\u1eb1ng nit\u01a1; thay v\u00e0o \u0111\u00f3, quan s\u00e1t th\u1ea5y c\u00e1c bi\u1ebfn ch\u1ee9ng chuy\u1ec3n h\u00f3a nghi\u00eam tr\u1ecdng h\u01a1n c\u1ee7a li\u1ec7u ph\u00e1p dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng (t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft, t\u0103ng triglycerid m\u00e1u) v\u00e0 c\u00e2n b\u1eb1ng d\u1ecbch d\u01b0\u01a1ng h\u01a1n [161].<\/p>\n<p>C\u00f3 3 nghi\u00ean c\u1ee9u RCT \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng \u0111\u1ec3 xem x\u00e9t t\u00e1c \u0111\u1ed9ng c\u1ee7a c\u00e1c m\u1ee9c cung c\u1ea5p n\u0103ng l\u01b0\u1ee3ng kh\u00e1c nhau tr\u00ean c\u00e1c t\u1ea1ng kh\u00e1c nh\u01b0 l\u00e0 m\u1ed9t k\u1ebft c\u1ee5c ph\u1ee5 [162-164]. Kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o cho th\u1ea5y b\u1ea5t k\u1ef3 t\u00e1c \u0111\u1ed9ng t\u00edch c\u1ef1c n\u00e0o trong nh\u1eefng ng\u00e0y kh\u00f4ng KF ho\u1eb7c c\u00e1c k\u1ebft c\u1ee5c kh\u00e1c c\u1ee7a th\u1eadn, ngo\u00e0i vi\u1ec7c c\u00e2n b\u1eb1ng d\u1ecbch t\u0103ng trong khi nu\u00f4i \u0103n \u0111\u1ee7 [162].<\/p>\n<p>M\u1ed9t thi\u1ebft k\u1ebf nghi\u00ean c\u1ee9u RCT v\u1ec1 c\u00e1c m\u1ee9c \u0111\u1ed9 dung n\u1ea1p protein kh\u00e1c nhau \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI c\u00f3 CKRT \u0111\u01b0\u1ee3c cung c\u1ea5p trung b\u00ecnh 89% nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng \u0111o \u0111\u01b0\u1ee3c trong to\u00e0n b\u1ed9 th\u1eddi gian nghi\u00ean c\u1ee9u cho th\u1ea5y r\u1eb1ng nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u1ea1t \u0111\u01b0\u1ee3c c\u00e2n b\u1eb1ng nit\u01a1 d\u01b0\u01a1ng trong qu\u00e1 tr\u00ecnh nghi\u00ean c\u1ee9u c\u00f3 k\u1ebft qu\u1ea3 \u0111i\u1ec1u tr\u1ecb t\u1ed1t h\u01a1n, cho th\u1ea5y r\u1eb1ng t\u00e1c \u0111\u1ed9ng c\u1ee7a l\u01b0\u1ee3ng protein \u0103n v\u00e0o c\u00f3 th\u1ec3 quan tr\u1ecdng h\u01a1n t\u00e1c \u0111\u1ed9ng c\u1ee7a n\u0103ng l\u01b0\u1ee3ng \u0103n v\u00e0o; tuy nhi\u00ean, kh\u00f4ng c\u00f3 d\u1eef li\u1ec7u v\u1ec1 c\u00e1c bi\u1ebfn ch\u1ee9ng chuy\u1ec3n h\u00f3a [145]. Trong c\u00f9ng m\u1ed9t nghi\u00ean c\u1ee9u, EN c\u0169ng li\u00ean quan \u0111\u1ebfn k\u1ebft qu\u1ea3 t\u1ed1t h\u01a1n so v\u1edbi PN. Trong m\u1ed9t RCT kh\u00e1c g\u1ea7n \u0111\u00e2y h\u01a1n, v\u1edbi nu\u00f4i \u0103n \u0111\u1ea7y \u0111\u1ee7 nhu c\u1ea7u, \u0111\u01b0\u1ee3c t\u00ednh b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng 25-35 kcal\/c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng \u0111\u00e3 hi\u1ec7u ch\u1ec9nh\/ng\u00e0y \u0111\u01b0\u1ee3c cung c\u1ea5p b\u1eb1ng PN, \u0111\u01b0\u1ee3c ch\u1ee9ng m\u00ecnh l\u00e0 kh\u00f4ng c\u00f3 l\u1ee3i \u00edch trong vi\u1ec7c ph\u1ee5c h\u1ed3i ch\u1ee9c n\u0103ng th\u1eadn ho\u1eb7c t\u1ef7 l\u1ec7 AKI; thay v\u00e0o \u0111\u00f3 l\u00e0 c\u00f3 kh\u1ea3 n\u0103ng h\u1ed3i ph\u1ee5c ch\u1eadm \u1edf b\u1ec7nh nh\u00e2n AKI giai \u0111o\u1ea1n hai [59]. B\u00ean c\u1ea1nh \u0111\u00f3, kh\u00f4ng t\u00ecm th\u1ea5y s\u1ef1 c\u1ea3i thi\u1ec7n trong c\u00e2n b\u1eb1ng nit\u01a1, trong khi s\u1ef1 h\u00ecnh th\u00e0nh ur\u00ea t\u0103ng l\u00ean, c\u00f3 th\u1ec3 k\u00e9o d\u00e0i th\u1eddi gian c\u1ee7a KRT [59].<\/p>\n<p>\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng, \u0111\u1ea1t ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng th\u1ef1c t\u1ebf kh\u00f4ng n\u00ean l\u00e0 m\u1ee5c ti\u00eau trong 72 gi\u1edd \u0111\u1ea7u ti\u00ean. B\u1edfi v\u00ec trong giai \u0111o\u1ea1n \u0111\u1ea7u c\u1ee7a b\u1ec7nh n\u1eb7ng, n\u0103ng l\u01b0\u1ee3ng n\u1ed9i sinh \u0111\u01b0\u1ee3c s\u1ea3n sinh ra l\u00e0 500-1400 kcal\/ng\u00e0y, cho \u0103n \u0111\u1ea7y \u0111\u1ee7 s\u1edbm c\u1ed9ng v\u1edbi l\u01b0\u1ee3ng n\u00e0y c\u00f3 th\u1ec3 g\u00e2y ra cho \u0103n qu\u00e1 m\u1ee9c [165]. Th\u1eadt kh\u00f4ng may, v\u1eabn ch\u01b0a th\u1ec3 \u0111\u00e1nh gi\u00e1 s\u1ef1 s\u1ea3n sinh dinh d\u01b0\u1ee1ng n\u1ed9i sinh n\u00e0y, khi m\u00e0 \u0111\u00e1nh gi\u00e1 s\u1ea3n sinh dinh d\u01b0\u1ee1ng n\u1ed9i sinh s\u1ebd r\u1ea5t h\u1eefu \u00edch \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh s\u1edbm dinh d\u01b0\u1ee1ng \u0111i\u1ec1u tr\u1ecb v\u00e0 ng\u0103n ng\u1eeba c\u00e1c t\u00e1c \u0111\u1ed9ng c\u00f3 h\u1ea1i c\u1ee7a t\u00ecnh tr\u1ea1ng suy dinh d\u01b0\u1ee1ng (t\u0103ng th\u1eddi gian n\u1eb1m vi\u1ec7n, th\u1eddi gian th\u1edf m\u00e1y v\u00e0 t\u1ef7 l\u1ec7 nhi\u1ec5m tr\u00f9ng), c\u00f3 kh\u1ea3 n\u0103ng \u0111\u01b0\u1ee3c quan s\u00e1t th\u1ea5y khi s\u1eed d\u1ee5ng dinh d\u01b0\u1ee1ng t\u1eeb ngo\u1ea1i sinh c\u1ed9ng v\u1edbi n\u1ed9i sinh [166]. M\u1eb7t kh\u00e1c, l\u01b0\u1ee3ng h\u1ea5p th\u1ee5 d\u01b0\u1edbi 50% c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn t\u00ecnh tr\u1ea1ng thi\u1ebfu calo nghi\u00eam tr\u1ecdng v\u00e0 c\u1ea1n ki\u1ec7t n\u0103ng l\u01b0\u1ee3ng d\u1ef1 tr\u1eef, gi\u1ea3m kh\u1ed1i n\u1ea1c c\u01a1 th\u1ec3 v\u00e0 gia t\u0103ng bi\u1ebfn ch\u1ee9ng nhi\u1ec5m tr\u00f9ng [167,168]. G\u1ea7n \u0111\u00e2y, m\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t l\u1edbn bao g\u1ed3m 1171 b\u1ec7nh nh\u00e2n [156] \u0111\u00e3 x\u00e1c nh\u1eadn r\u1eb1ng c\u1ea3 nu\u00f4i \u0103n thi\u1ebfu v\u00e0 th\u1eeba \u0111\u1ec1u c\u00f3 h\u1ea1i v\u00e0 l\u01b0\u1ee3ng calo t\u1ed1i \u01b0u l\u00e0 t\u1eeb 70 \u0111\u1ebfn 100% n\u0103ng l\u01b0\u1ee3ng ti\u00eau th\u1ee5.<\/p>\n<p>T\u1ed5ng h\u1ee3p l\u1ea1i, th\u1eddi gian, \u0111\u01b0\u1eddng nu\u00f4i \u0103n v\u00e0 m\u1ee5c ti\u00eau caloric\/protein kh\u00f4ng c\u00f2n \u0111\u01b0\u1ee3c coi l\u00e0 ba v\u1ea5n \u0111\u1ec1 kh\u00e1c nhau, m\u00e0 n\u00ean \u0111\u01b0\u1ee3c t\u00edch h\u1ee3p v\u00e0o m\u1ed9t c\u00e1ch ti\u1ebfp c\u1eadn to\u00e0n di\u1ec7n h\u01a1n. Sau khi x\u00e1c \u0111\u1ecbnh th\u1eddi gian v\u00e0 \u0111\u01b0\u1eddng nu\u00f4i \u0103n, m\u1ee5c ti\u00eau n\u0103ng l\u01b0\u1ee3ng\/protein n\u00ean \u0111\u1ea1t \u0111\u01b0\u1ee3c t\u1eeb t\u1eeb v\u00e0 kh\u00f4ng tr\u01b0\u1edbc 48 gi\u1edd \u0111\u1ea7u ti\u00ean \u0111\u1ec3 tr\u00e1nh th\u1eeba dinh d\u01b0\u1ee1ng (nu\u00f4i \u0103n qu\u00e1 m\u1ee9c). S\u1ef1 ti\u1ebfn tri\u1ec3n n\u00e0y n\u00ean \u0111\u01b0\u1ee3c s\u1eafp x\u1ebfp theo m\u1ed9t quy tr\u00ecnh c\u1ee5c b\u1ed9 \u0111\u1ec3 ng\u0103n ch\u1eb7n s\u1ef1 gia t\u0103ng m\u1ea1nh v\u00e0 qu\u00e1 nhanh. Li\u1ec7u ph\u00e1p dinh d\u01b0\u1ee1ng \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c coi l\u00e0 \u0111\u1ea1t m\u1ee5c ti\u00eau khi \u0111\u1ea1t \u0111\u01b0\u1ee3c h\u01a1n 70% REE, nh\u01b0ng kh\u00f4ng qu\u00e1 100% [8]. Nh\u1eefng \u0111i\u1ec3m ch\u00ednh \u0111\u1ec3 b\u1eaft \u0111\u1ea7u dinh d\u01b0\u1ee1ng \u0111i\u1ec1u tr\u1ecb l\u00e0:<\/p>\n<ol>\n<li>Dinh d\u01b0\u1ee1ng b\u1eb1ng \u0111\u01b0\u1eddng mi\u1ec7ng c\u00e0ng s\u1edbm c\u00e0ng t\u1ed1t trong khi c\u00e2n nh\u1eafc c\u00e1c nguy c\u01a1 x\u1ea3y ra bi\u1ebfn ch\u1ee9ng (v\u00ed d\u1ee5: h\u00edt s\u1eb7c)<\/li>\n<li>EN s\u1edbm v\u1edbi t\u1ed1c \u0111\u1ed9 th\u1ea5p v\u00e0 t\u0103ng d\u1ea7n trong v\u00f2ng 48 gi\u1edd n\u1ebfu kh\u00f4ng th\u1ec3 th\u1ef1c hi\u1ec7n dinh d\u01b0\u1ee1ng b\u1eb1ng \u0111\u01b0\u1eddng u\u1ed1ng trong khi c\u00e2n nh\u1eafc nguy c\u01a1 bi\u1ebfn ch\u1ee9ng;<\/li>\n<li>X\u00e1c \u0111\u1ecbnh \u0111i\u1ec3m kh\u1edfi \u0111\u1ea7u t\u1ed1i \u01b0u v\u00e0 li\u1ec1u l\u01b0\u1ee3ng (b\u1ed5 sung) PN d\u1ef1a tr\u00ean nguy c\u01a1 x\u1ea3y ra bi\u1ebfn ch\u1ee9ng t\u1eeb \u0111\u01b0\u1eddng mi\u1ec7ng ho\u1eb7c EN, t\u00ecnh tr\u1ea1ng b\u1ec7nh c\u1ea5p t\u00ednh, v\u00e0 t\u00ecnh tr\u1ea1ng thi\u1ebfu\/suy dinh d\u01b0\u1ee1ng tr\u01b0\u1edbc \u0111\u00f3.<\/li>\n<\/ol>\n<h4>S\u1ef1 ph\u1ed1i h\u1ee3p t\u1ed1i \u01b0u n\u0103ng l\u01b0\u1ee3ng t\u1eeb carbohydrate v\u00e0 lipid cho dinh d\u01b0\u1ee1ng \u0111i\u1ec1u tr\u1ecb ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 13: \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF c\u1ea7n \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng, c\u00f3 th\u1ec3 ph\u1ed1i h\u1ee3p l\u01b0\u1ee3ng lipid v\u00e0 carbohydrate \u0111\u1ec3 t\u0103ng l\u01b0\u1ee3ng lipid v\u00e0 gi\u1ea3m cung c\u1ea5p carbohydrate d\u1ef1a tr\u00ean vi\u1ec7c s\u1eed d\u1ee5ng c\u01a1 ch\u1ea5t \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp.<\/strong><\/p>\n<h4><strong>Grade 0<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (91,3%)<\/h4>\n<h4><em> B\u00e0n lu\u1eadn:<\/em><\/h4>\n<p>B\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF c\u00f3 bi\u1ec3u hi\u1ec7n t\u00ecnh tr\u1ea1ng t\u0103ng chuy\u1ec3n h\u00f3a. Th\u1eadn c\u00f3 vai tr\u00f2 quan tr\u1ecdng trong qu\u00e1 tr\u00ecnh t\u1ea1o glucose, thanh th\u1ea3i insulin v\u00e0 h\u1ea5p thu glucose [10,138]. Do \u0111\u00f3, gi\u1ea3m qu\u00e1 tr\u00ecnh oxy h\u00f3a glucose \u0111\u01b0\u1ee3c mong \u0111\u1ee3i \u1edf b\u1ec7nh nh\u00e2n AKI, \u0111\u1eb7c bi\u1ec7t l\u00e0 nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi s\u1ef1 m\u1ea5t c\u00e2n b\u1eb1ng ph\u00f3ng th\u00edch c\u00e1c hormone d\u1ecb h\u00f3a v\u00e0 gi\u1ea3i ph\u00f3ng qu\u00e1 m\u1ee9c c\u00e1c cytokine ti\u1ec1n vi\u00eam. S\u1ef1 bi\u1ebfn \u0111\u1ed5i chuy\u1ec3n h\u00f3a lipid trong AKI ph\u1ee9c t\u1ea1p h\u01a1n. Suy gi\u1ea3m ph\u00e2n gi\u1ea3i lipid l\u00e0 m\u1ed9t hi\u1ec7n t\u01b0\u1ee3ng \u0111\u00e3 bi\u1ebft \u1edf AKI, m\u1ed9t t\u00ecnh tr\u1ea1ng \u0111\u1eb7c tr\u01b0ng b\u1edfi s\u1ef1 gi\u1ea3m ho\u1ea1t \u0111\u1ed9ng c\u1ee7a lipoprotein lipase v\u00e0 triglycerid lipase \u1edf gan v\u00e0 l\u00e0m ch\u1eadm qu\u00e1 tr\u00ecnh thanh th\u1ea3i nh\u0169 d\u1ecbch b\u00e9o ra kh\u1ecfi m\u00e1u [10]. B\u1eb1ng ch\u1ee9ng hi\u1ec7n c\u00f3 g\u1ea7n \u0111\u00e2y nh\u1ea5t cho th\u1ea5y r\u1eb1ng nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI th\u00ec vi\u1ec7c oxy h\u00f3a carbohydrate \u00edt h\u01a1n nhi\u1ec1u (56,7%) v\u00e0 t\u0103ng oxy h\u00f3a lipid h\u01a1n (150,7%) so v\u1edbi k\u1ef3 v\u1ecdng [169]. M\u1ed9t ph\u00e1t hi\u1ec7n t\u01b0\u01a1ng t\u1ef1 \u0111\u00e3 \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 trong m\u1ed9t nghi\u00ean c\u1ee9u tr\u01b0\u1edbc \u0111\u00f3 [170].<\/p>\n<p>H\u1ea7u h\u1ebft t\u1ea5t c\u1ea3 c\u00e1c c\u00f4ng th\u1ee9c EN v\u00e0 PN chu\u1ea9n hi\u1ec7n c\u00f3 \u0111\u1ec1u ch\u1ee9a m\u1ed9t t\u1ef7 l\u1ec7 cao n\u0103ng l\u01b0\u1ee3ng t\u1eeb carbohydrate, ngay c\u1ea3 trong c\u00e1c lo\u1ea1i s\u1eefa c\u00f4ng th\u1ee9c \u0111\u00e3 bao g\u1ed3m lipid. S\u1ef1 ph\u00e2n ph\u1ed1i ch\u1ea5t dinh d\u01b0\u1ee1ng \u0111a l\u01b0\u1ee3ng kh\u00f4ng t\u1eeb protein n\u00e0y c\u00f3 th\u1ec3 kh\u00f4ng th\u00edch h\u1ee3p cho b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n c\u00f3 KF. Tuy nhi\u00ean, t\u00e1c \u0111\u1ed9ng c\u00f3 th\u1ec3 c\u00f3 c\u1ee7a s\u1ef1 m\u1ea5t c\u00e2n b\u1eb1ng n\u00e0y \u0111\u1ed1i v\u1edbi t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng, b\u1ec7nh t\u1eadt v\u00e0 t\u1eed vong v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh r\u00f5.<\/p>\n<p>KRT c\u00f3 th\u1ec3 t\u00e1c \u0111\u1ed9ng nh\u01b0 th\u1ebf n\u00e0o \u0111\u1ebfn s\u1ef1 c\u00e2n b\u1eb1ng n\u0103ng l\u01b0\u1ee3ng b\u1edfi kh\u1ea3 n\u0103ng cung c\u1ea5p c\u00e1c c\u01a1 ch\u1ea5t n\u0103ng l\u01b0\u1ee3ng (citrate, lactate, glucose) ?<br \/>\n<strong>Khuy\u1ebfn c\u00e1o 14: \u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n \u0111ang \u0111i\u1ec1u tr\u1ecb KRT, t\u1ed5ng n\u0103ng l\u01b0\u1ee3ng cung c\u1ea5p b\u1edfi l\u01b0\u1ee3ng calo c\u1ed9ng th\u00eam d\u01b0\u1edbi d\u1ea1ng citrate, lactate v\u00e0 glucose t\u1eeb c\u00e1c dung d\u1ecbch l\u1ecdc HD\/HF n\u00ean \u0111\u01b0\u1ee3c t\u00ednh to\u00e1n \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh t\u1ed5ng n\u0103ng l\u01b0\u1ee3ng cung c\u1ea5p h\u00e0ng ng\u00e0y \u0111\u1ec3 tr\u00e1nh cho \u0103n qu\u00e1 nhi\u1ec1u.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) B\u00e0n lu\u1eadn:<\/p>\n<h4>M\u1ed9t s\u1ed1 gi\u1ea3i ph\u00e1p th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong quy tr\u00ecnh HD\/HF (d\u1ecbch l\u1ecdc m\u00e1u v\u00e0 d\u1ecbch thay th\u1ebf) c\u00f3 th\u1ec3 cung c\u1ea5p c\u01a1 ch\u1ea5t n\u0103ng l\u01b0\u1ee3ng \u1edf d\u1ea1ng:<\/h4>\n<ol>\n<li>Ch\u1ea5t kh\u00e1ng \u0111\u00f4ng v\u00f9ng Citrate (3 kcal\/g) s\u1eed d\u1ee5ng ACD-A (2.2% xitrat), TSC (4% trinatri citrat), ho\u1eb7c c\u00e1c dung d\u1ecbch citrate \u0111\u01b0\u1ee3c pha lo\u00e3ng g\u1ea7n \u0111\u00e2y h\u01a1n (citrate 12 ho\u1eb7c 18 mmol\/l)<\/li>\n<li>Glucose (3.4 kcal\/g) t\u1eeb ACD-A (2.45% dextrose) v\u00e0 d\u1ecbch thay th\u1ebf v\u00e0 d\u1ecbch l\u1ecdc (0 \u2013 110 mg\/dl)<\/li>\n<li>Lactate (3.62 kcal\/g), d\u00f9ng l\u00e0m ch\u1ea5t \u0111\u1ec7m<\/li>\n<\/ol>\n<p>Trong nh\u1eefng n\u0103m g\u1ea7n \u0111\u00e2y, ch\u1ed1ng \u0111\u00f4ng b\u1eb1ng citrate trong KRT \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 m\u1ed9t gi\u1ea3i ph\u00e1p thay th\u1ebf an to\u00e0n v\u00e0 hi\u1ec7u qu\u1ea3 so v\u1edbi c\u00e1c ph\u00e1c \u0111\u1ed3 ch\u1ed1ng \u0111\u00f4ng th\u00f4ng th\u01b0\u1eddng, th\u01b0\u1eddng d\u1ef1a tr\u00ean heparin kh\u00f4ng ph\u00e2n \u0111o\u1ea1n [22,171,172]. Citrate \u0111\u01b0\u1ee3c lo\u1ea1i b\u1ecf m\u1ed9t ph\u1ea7n kh\u1ecfi m\u00e1u b\u1edfi KRT, v\u00e0 t\u1ea3i citrate cho b\u1ec7nh nh\u00e2n ph\u1ee5 thu\u1ed9c v\u00e0o s\u1ef1 c\u00e2n b\u1eb1ng gi\u1eefa t\u1ed5ng li\u1ec1u d\u00f9ng trong tu\u1ea7n ho\u00e0n ngo\u00e0i c\u01a1 th\u1ec3 v\u00e0 l\u01b0\u1ee3ng citrate \u0111\u01b0\u1ee3c lo\u1ea1i b\u1ecf qua b\u1ed9 l\u1ecdc trong qu\u00e1 tr\u00ecnh KRT [173]. Citrate \u0111\u1ebfn h\u1ec7 tu\u1ea7n ho\u00e0n \u0111\u01b0\u1ee3c chuy\u1ec3n h\u00f3a ch\u1ee7 y\u1ebfu \u1edf gan, c\u0169ng nh\u01b0 \u1edf th\u1eadn v\u00e0 c\u01a1 x\u01b0\u01a1ng [171]. Citrate l\u00e0 anion c\u1ee7a acid tricarboxylic (acid xitric), l\u00e0 ch\u1ea5t chuy\u1ec3n h\u00f3a trung gian c\u1ee7a chu tr\u00ecnh Krebs. Do \u0111\u00f3, citrate kh\u00f4ng c\u1ea7n insulin \u0111\u1ec3 \u0111i v\u00e0o t\u1ebf b\u00e0o, n\u01a1i n\u00f3 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c chuy\u1ec3n h\u00f3a \u0111\u1ec3 t\u1ea1o ra n\u0103ng l\u01b0\u1ee3ng v\u00e0 bicarbonate (t\u01b0\u01a1ng \u1ee9ng l\u00e0 0.59 kcal\/mmol citrate v\u00e0 3mmol bicarbonate\/mmol citrate).<\/p>\n<p>N\u0103ng l\u01b0\u1ee3ng t\u0103ng c\u00f3 th\u1ec3 \u0111\u00e1ng k\u1ec3, t\u00f9y thu\u1ed9c v\u00e0o lo\u1ea1i v\u00e0 v\u1eadn t\u1ed1c d\u1ecbch l\u1ecdc \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng, v\u1edbi m\u1ed9t nghi\u00ean c\u1ee9u b\u00e1o c\u00e1o l\u00ean \u0111\u1ebfn 1300 kcal\/ng\u00e0y khi s\u1eed d\u1ee5ng nhi\u1ec1u d\u1ecbch thay th\u1ebf lactate v\u00e0 ch\u1ed1ng \u0111\u00f4ng b\u1eb1ng ACD-A [174]. Nhi\u1ec1u thay \u0111\u1ed5i trong m\u1ee9c t\u0103ng n\u0103ng l\u01b0\u1ee3ng \u0111\u00e3 \u0111\u01b0\u1ee3c ghi nh\u1eadn trong ba nghi\u00ean c\u1ee9u hi\u1ec7n c\u00f3 v\u1ec1 v\u1ea5n \u0111\u1ec1 n\u00e0y, t\u00f9y thu\u1ed9c v\u00e0o h\u00e0m l\u01b0\u1ee3ng lactate c\u1ee7a d\u1ecbch thay th\u1ebf v\u00e0 lo\u1ea1i ch\u1ea5t ch\u1ed1ng \u0111\u00f4ng m\u00e1u (115-1300 kcal\/ng\u00e0y) [174-176]. Nghi\u00ean c\u1ee9u g\u1ea7n \u0111\u00e2y nh\u1ea5t \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 v\u1ec1 ch\u1ee7 \u0111\u1ec1 n\u00e0y x\u00e1c nh\u1eadn c\u00f3 kh\u1ea3 n\u0103ng l\u00e0m t\u0103ng n\u0103ng l\u01b0\u1ee3ng th\u00eam \u0111\u00e1ng k\u1ec3, \u0111\u1eb7c bi\u1ec7t v\u1edbi vi\u1ec7c ch\u1ec9 \u0111\u1ecbnh l\u1ecdc m\u00e1u li\u00ean t\u1ee5c qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch (CVVH) l\u00e0m ph\u01b0\u01a1ng th\u1ee9c KRT. B\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng ch\u1ea5t ch\u1ed1ng \u0111\u00f4ng citrate d\u01b0\u1edbi d\u1ea1ng ACD- A v\u00e0 d\u1ecbch thay th\u1ebf d\u1ef1a tr\u00ean bicarbonate v\u1edbi glucose 110 mg\/dl, nghi\u00ean c\u1ee9u b\u00e1o c\u00e1o l\u01b0\u1ee3ng ph\u00e2n ph\u1ed1i trung b\u00ecnh h\u00e0ng ng\u00e0y l\u00e0 513 kcal (citrate 218 kcal, glucose 295 kcal). M\u1eb7t kh\u00e1c, vi\u1ec7c s\u1eed d\u1ee5ng d\u1ecbch thay th\u1ebf kh\u00f4ng ch\u1ee9a glucose c\u0169ng n\u00ean \u0111\u01b0\u1ee3c t\u00ednh \u0111\u1ebfn, v\u00ec n\u00f3 c\u00f3 th\u1ec3 g\u00f3p ph\u1ea7n l\u00e0m t\u0103ng l\u01b0\u1ee3ng glucose m\u1ea5t \u0111i th\u1ef1c s\u1ef1 v\u00ec l\u01b0\u1ee3ng glucose th\u1ea5t tho\u00e1t trong d\u1ecbch th\u1ea3i kh\u00f4ng \u0111\u01b0\u1ee3c thay th\u1ebf [177].<\/p>\n<p>\u0110\u1ec3 c\u00f3 th\u1ec3 tr\u00e1nh m\u1ed9t ph\u1ea7n cung c\u1ea5p th\u1eeba n\u0103ng l\u01b0\u1ee3ng do KRT b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng c\u00e1c dung d\u1ecbch c\u00f3 n\u1ed3ng \u0111\u1ed9 citrate th\u1ea5p h\u01a1n, bicarbonate l\u00e0m ch\u1ea5t \u0111\u1ec7m v\u00e0 c\u00e1c dung d\u1ecbch citrate kh\u00f4ng ph\u1ea3i ACD-A v\u1edbi li\u1ec1u l\u01b0\u1ee3ng th\u1ea5p h\u01a1n v\u00e0 kh\u00f4ng c\u00f3 glucose [21]. Ngo\u00e0i ra, c\u00e1c ph\u01b0\u01a1ng th\u1ee9c PIKRT khu\u1ebfch t\u00e1n, ch\u1eb3ng h\u1ea1n nh\u01b0 th\u1ea9m t\u00e1ch m\u00e1u ch\u1eadm hi\u1ec7u qu\u1ea3 th\u1ea5p (Subtained Low-efficiency Dialysis \u2013 SLED), d\u1ec5 d\u00e0ng cho ph\u00e9p t\u0103ng lo\u1ea1i b\u1ecf citrate b\u1eb1ng ch\u00ednh ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb [22,171], ch\u1ec9 v\u1edbi m\u1ed9t l\u01b0\u1ee3ng n\u0103ng l\u01b0\u1ee3ng h\u1ea1n ch\u1ebf (100-300 kcal\/ng\u00e0y) \u0111\u01b0\u1ee3c t\u00ednh v\u00e0o n\u0103ng l\u01b0\u1ee3ng n\u1ea1p v\u00e0o theo ch\u1ec9 \u0111\u1ecbnh c\u1ee7a b\u1ec7nh nh\u00e2n.<\/p>\n<h4>Nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng tr\u00ean b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF kh\u00f4ng b\u1eaft \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb KRT so v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 \u0111i\u1ec1u tr\u1ecb v\u1edbi KRT ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 15: Kh\u00f4ng c\u1ea7n t\u00ednh l\u01b0\u1ee3ng REE b\u1ed5 sung v\u00e0o REE \u0111\u00e3 \u0111\u01b0\u1ee3c t\u00ednh to\u00e1n s\u1eb5n \u0111\u1ec3 b\u00f9 \u0111\u1eafp cho KRT v\u00ec kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111i\u1ec1u tr\u1ecb KRT so v\u1edbi b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb KRT.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>Kh\u00f4ng c\u00f3 s\u1ef1 thay \u0111\u1ed5i l\u1edbn n\u00e0o c\u1ee7a qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a n\u0103ng l\u01b0\u1ee3ng li\u00ean quan \u0111\u1ebfn AKI, v\u00ec c\u00e1c t\u00e1c \u0111\u1ed9ng li\u00ean quan h\u01a1n \u0111\u1ebfn ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng th\u01b0\u1eddng l\u00e0 do c\u00e1c b\u1ec7nh c\u1ea5p t\u00ednh \u0111i k\u00e8m v\u00e0 c\u00e1c bi\u1ebfn ch\u1ee9ng [8,170]. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n th\u1edf m\u00e1y, kh\u00f4ng t\u00ecm th\u1ea5y s\u1ef1 kh\u00e1c bi\u1ec7t n\u00e0o c\u1ee7a REE do s\u1ef1 xu\u1ea5t hi\u1ec7n c\u1ee7a AKI [178]. Ngay c\u1ea3 tr\u01b0\u1eddng h\u1ee3p suy \u0111a c\u01a1 quan, m\u1ee9c ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng c\u1ee7a nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng kh\u00f4ng v\u01b0\u1ee3t qu\u00e1 130% m\u1ee9c ti\u00eau hao n\u0103ng l\u01b0\u1ee3ng \u0111\u01b0\u1ee3c \u01b0\u1edbc t\u00ednh [2]. C\u00e1c b\u1eb1ng ch\u1ee9ng khan hi\u1ebfm hi\u1ec7n c\u00f3 cho th\u1ea5y r\u1eb1ng ngay c\u1ea3 KRT c\u0169ng kh\u00f4ng ph\u1ea3i l\u00e0 nguy\u00ean nh\u00e2n l\u00e0m t\u0103ng nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng \u1edf b\u1ec7nh nh\u00e2n KF. M\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t \u1edf b\u1ec7nh nh\u00e2n CKD v\u1edbi KF kh\u00f4ng t\u00ecm th\u1ea5y s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 REE trong c\u00f9ng m\u1ed9t nh\u00f3m b\u1ec7nh nh\u00e2n tr\u01b0\u1edbc khi b\u1eaft \u0111\u1ea7u l\u1ecdc m\u00e1u (ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o v\u00e0 PD) v\u00e0 m\u1ed9t th\u00e1ng sau khi ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o ho\u1eb7c b\u1eaft \u0111\u1ea7u PD [179]; theo c\u00e1ch t\u01b0\u01a1ng t\u1ef1, nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI \u0111ang \u0111i\u1ec1u tr\u1ecb KRT c\u00f3 REE t\u01b0\u01a1ng t\u1ef1 \u0111\u01b0\u1ee3c \u0111o b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p \u0111o nhi\u1ec7t l\u01b0\u1ee3ng gi\u00e1n ti\u1ebfp so v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n AKI kh\u00f4ng KRT [142]. Ch\u1ec9 c\u00f3 m\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t cho th\u1ea5y s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa REE c\u1ee7a b\u1ec7nh nh\u00e2n AKI tr\u01b0\u1edbc khi b\u1eaft \u0111\u1ea7u KRT v\u00e0 sau n\u0103m ng\u00e0y l\u1ecdc m\u00e1u [180]. Tuy nhi\u00ean, nghi\u00ean c\u1ee9u c\u00f3 t\u1ef7 su\u1ea5t b\u1ecf cu\u1ed9c cao (24 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 t\u1ea1i th\u1eddi \u0111i\u1ec3m n\u0103m ng\u00e0y trong s\u1ed1 124 ng\u01b0\u1eddi \u0111\u0103ng k\u00fd).<\/p>\n<h3>Nhu c\u1ea7u Protein<\/h3>\n<h4>T\u00e1c \u0111\u1ed9ng ti\u1ec1m t\u00e0ng c\u1ee7a KRT \u0111\u1ed1i v\u1edbi s\u1ef1 c\u00e2n b\u1eb1ng protein \u1edf b\u1ec7nh nh\u00e2n AKI ho\u1eb7c AKI tr\u00ean CKD ho\u1eb7c CKD v\u1edbi KF so v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n t\u01b0\u01a1ng t\u1ef1 kh\u00f4ng KRT ? KRT c\u00f3 l\u00e0m t\u0103ng nhu c\u1ea7u protein kh\u00f4ng ?<\/h4>\n<p><strong>Tuy\u00ean b\u1ed1 6: KRT c\u00f3 th\u1ec3 g\u00e2y \u1ea3nh h\u01b0\u1edfng ti\u00eau c\u1ef1c \u0111\u1ebfn s\u1ef1 c\u00e2n b\u1eb1ng protein b\u1eb1ng c\u00e1ch g\u00e2y ra s\u1ef1 th\u1ea5t tho\u00e1t acid amin v\u00e0 peptite\/protein. Do \u0111\u00f3, nhu c\u1ea7u protein c\u00f3 th\u1ec3 t\u0103ng l\u00ean \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111ang \u0111i\u1ec1u tr\u1ecb v\u1edbi KRT.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>C\u00e1c li\u1ec7u ph\u00e1p thay th\u1ebf th\u1eadn nh\u01b0 CKRT ho\u1eb7c PIKRT nh\u01b0 SLED \u0111\u00e3 tr\u1edf th\u00e0nh ph\u01b0\u01a1ng th\u1ee9c \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n AKI n\u1eb7ng. C\u00e1c ph\u01b0\u01a1ng th\u1ee9c KRT chuy\u00ean s\u00e2u n\u00e0y, do l\u1ecbch tr\u00ecnh k\u00e9o d\u00e0i v\u00e0 lo\u1ea1i m\u00e0ng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng, c\u00f3 th\u1ec3 g\u00e2y \u1ea3nh h\u01b0\u1edfng ti\u00eau c\u1ef1c \u0111\u1ebfn s\u1ef1 c\u00e2n b\u1eb1ng protein b\u1eb1ng c\u00e1ch g\u00e2y th\u1ea5t tho\u00e1t acid amin v\u00e0 peptite\/protein (l\u1ea7n l\u01b0\u1ee3t l\u00ean \u0111\u1ebfn 15-20g\/ng\u00e0y v\u00e0 5-10g\/ng\u00e0y) [10,144,181-187]. C\u00e1c y\u1ebfu t\u1ed1 li\u00ean quan \u0111\u1ebfn ch\u1ec9 \u0111\u1ecbnh KRT s\u1ebd x\u00e1c \u0111\u1ecbnh bao nhi\u00eau acid amin s\u1ebd b\u1ecb m\u1ea5t bao g\u1ed3m ph\u01b0\u01a1ng th\u1ee9c c\u1ee7a KRT (li\u00ean t\u1ee5c ho\u1eb7c gi\u00e1n \u0111o\u1ea1n v\u00e0 \u0111\u1ed1i l\u01b0u, khu\u1ebfch t\u00e1n ho\u1eb7c c\u1ea3 hai), t\u1ed1c \u0111\u1ed9 d\u00f2ng ch\u1ea3y c\u1ee7a m\u00e1u v\u00e0 d\u1ecbch th\u1ea9m t\u00e1ch, t\u1ed1c \u0111\u1ed9 d\u1ecbch th\u1ea3i, c\u0169ng nh\u01b0 t\u00ednh ch\u1ea5t c\u1ee7a m\u00e0ng c\u1ee7a b\u1ed9 l\u1ecdc \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng [144,188]. B\u00ean c\u1ea1nh \u0111\u00f3, v\u00ec acid amin l\u00e0 nh\u1eefng ch\u1ea5t c\u00f3 tr\u1ecdng l\u01b0\u1ee3ng ph\u00e2n t\u1eed th\u1ea5p v\u1edbi h\u1ec7 s\u1ed1 s\u00e0ng g\u1ea7n 1.0, n\u00ean nhi\u1ec1u acid amin nh\u01b0 cysteine, arginine, alanine v\u00e0 glutamine c\u00f3 th\u1ec3 d\u1ec5 d\u00e0ng \u0111\u01b0\u1ee3c l\u1ecdc t\u1eeb m\u00e1u v\u00e0o d\u1ecbch th\u1ea3i [183,184]. Hi\u1ec7n t\u1ea1i, v\u1edbi s\u1ef1 gia t\u0103ng hi\u1ec7u qu\u1ea3 c\u1ee7a c\u00e1c ph\u01b0\u01a1ng th\u1ee9c KRT s\u1eb5n c\u00f3, cho ph\u00e9p t\u1ed1c \u0111\u1ed9 d\u00f2ng ch\u1ea3y c\u1ee7a m\u00e1u cao h\u01a1n v\u00e0 t\u0103ng kh\u1ea3 n\u0103ng lo\u1ea1i b\u1ecf d\u1ecbch th\u1ea3i, c\u00f3 th\u1ec3 \u01b0\u1edbc t\u00ednh r\u1eb1ng s\u1ef1 th\u1ea5t tho\u00e1t acid amin th\u1ef1c t\u1ebf c\u1ee7a b\u1ec7nh nh\u00e2n CKRT nhi\u1ec1u h\u01a1n so v\u1edbi nh\u1eefng g\u00ec \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o trong c\u00e1c nghi\u00ean c\u1ee9u tr\u01b0\u1edbc \u0111\u00f3 [181-184]. M\u1ed9t nghi\u00ean c\u1ee9u tr\u00ean t\u00e1m b\u1ec7nh nh\u00e2n (4 ng\u01b0\u1eddi b\u1ecb s\u1ed1c tim v\u00e0 4 ng\u01b0\u1eddi b\u1ecb nhi\u1ec5m tr\u00f9ng huy\u1ebft) b\u00e1o c\u00e1o r\u1eb1ng l\u01b0\u1ee3ng acid amin m\u1ea5t trung b\u00ecnh h\u00e0ng ng\u00e0y l\u00e0 3.8g\/ng\u00e0y \u1edf b\u1ec7nh nh\u00e2n nhi\u1ec5m tr\u00f9ng v\u00e0 7.4g\/ng\u00e0y \u1edf b\u1ec7nh nh\u00e2n b\u1ecb s\u1ed1c tim khi \u0111ang CVVH [182], trong khi m\u1ed9t nghi\u00ean c\u1ee9u g\u1ea7n \u0111\u00e2y h\u01a1n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng c\u00f3 CVVH b\u00e1o c\u00e1o s\u1ef1 m\u1ea5t acid amin trung b\u00ecnh l\u00e0 13.4g\/ng\u00e0y, dao \u0111\u1ed9ng t\u1eeb 11.8 \u0111\u1ebfn 17.4 g\/ng\u00e0y [189].<\/p>\n<h4>X\u00e1c \u0111\u1ecbnh nhu c\u1ea7u protein \u1edf b\u1ec7nh nh\u00e2n th\u1eadn nh\u01b0 th\u1ebf n\u00e0o ? L\u01b0\u1ee3ng protein cao c\u00f3 c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c so v\u1edbi l\u01b0\u1ee3ng protein ti\u00eau chu\u1ea9n hay kh\u00f4ng ?<\/h4>\n<p><strong>Tuy\u00ean b\u1ed1 7: Nhu c\u1ea7u protein ch\u1ee7 y\u1ebfu \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh tr\u00ean b\u1ec7nh n\u1ec1n, tuy nhi\u00ean, KRT k\u00e9o d\u00e0i c\u00f3 th\u1ec3 g\u00e2y \u1ea3nh h\u01b0\u1edfng ti\u00eau c\u1ef1c v\u1ec1 c\u00e2n b\u1eb1ng protein.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><strong>Tuy\u00ean b\u1ed1 8: Kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t \u0111\u00e1ng k\u1ec3 v\u1ec1 nhu c\u1ea7u protein gi\u1eefa ICU, b\u1ec7nh nh\u00e2n ph\u1eabu thu\u1eadt v\u00e0 b\u1ec7nh n\u1ed9i khoa c\u1ea5p t\u00ednh c\u00f3 AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF v\u00ec t\u1ea5t c\u1ea3 c\u00e1c t\u00ecnh tr\u1ea1ng n\u00e0y \u0111\u01b0\u1ee3c \u0111\u1eb7c tr\u01b0ng b\u1edfi d\u1ecb h\u00f3a protein.<\/strong><\/p>\n<p>M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (91.3%)<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 16: \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi AKI\/AKD v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF \u0111ang \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng, vi\u1ec7c ch\u1ec9 \u0111\u1ecbnh l\u01b0\u1ee3ng protein t\u1ed1t nh\u1ea5t l\u00e0 theo t\u1ed1c \u0111\u1ed9 d\u1ecb h\u00f3a protein thay v\u00ec ch\u1ec9 s\u1eed d\u1ee5ng c\u00e1c y\u1ebfu t\u1ed1 d\u1ef1 b\u00e1o \u0111\u01b0\u1ee3c chu\u1ea9n h\u00f3a theo tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 (xem khuy\u1ebfn c\u00e1o 18).<\/strong><\/p>\n<p>Grade GPP \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn (86.4%)<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 17: C\u1ea7n tr\u00e1nh nu\u00f4i \u0103n qu\u00e1 nhi\u1ec1u \u0111\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c c\u00e2n b\u1eb1ng nit\u01a1 d\u01b0\u01a1ng ho\u1eb7c gi\u1ea3m thi\u1ec3u s\u1ef1 c\u00e2n b\u1eb1ng nit\u01a1 \u00e2m hi\u1ec7n c\u00f3.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.7%)<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 18: L\u01b0\u1ee3ng protein n\u1ea1p v\u00e0o \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh theo:<\/strong><\/p>\n<ul>\n<li>B\u1ec7nh nh\u00e2n CKD n\u1ed9i vi\u1ec7n kh\u00f4ng c\u00f3 t\u00ecnh tr\u1ea1ng n\u1eb7ng ho\u1eb7c c\u1ea5p t\u00ednh: nu\u00f4i protein \u1edf m\u1ee9c 0.6-0.8g\/kg BW\/ng\u00e0y<\/li>\n<li>B\u1ec7nh nh\u00e2n CKD v\u00e0 KF n\u1ed9i vi\u1ec7n c\u00f3 KRT ng\u1eaft qu\u00e3ng th\u00f4ng th\u01b0\u1eddng m\u1ea1n t\u00ednh m\u00e0 kh\u00f4ng c\u00f3 b\u1ec7nh c\u1ea5p t\u00ednh\/nguy k\u1ecbch: \u2265 1.2 g\/kg BW\/ ng\u00e0y<\/li>\n<li>B\u1ec7nh nh\u00e2n AKI, AKI tr\u00ean n\u1ec1n CKD n\u1ed9i vi\u1ec7n kh\u00f4ng c\u00f3 b\u1ec7nh c\u1ea5p t\u00ednh\/nguy k\u1ecbch: 0.8-1.0g \/kg BW\/ng\u00e0y<\/li>\n<li>B\u1ec7nh nh\u00e2n AKI, AKI tr\u00ean n\u1ec1n CKD, CKD n\u1ed9i vi\u1ec7n c\u00f3 t\u00ecnh tr\u1ea1ng b\u1ec7nh c\u1ea5p t\u00ednh\/nguy k\u1ecbch, kh\u00f4ng KRT: b\u1eaft \u0111\u1ea7u v\u1edbi 1.0 g\/kg<\/li>\n<li>BW\/ng\u00e0y, v\u00e0 t\u0103ng d\u1ea7n l\u00ean \u0111\u1ebfn 1.3 g\/kg BW\/ng\u00e0y n\u1ebfu dung n\u1ea1p \u0111\u01b0\u1ee3c<\/li>\n<li>B\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI ho\u1eb7c AKI tr\u00ean CKD ho\u1eb7c CKD v\u1edbi KF c\u00f3 KRT ng\u1eaft qu\u00e3ng th\u00f4ng th\u01b0\u1eddng: 1.3-1.5 g\/kg\/ng\u00e0y<\/li>\n<li>B\u1ec7nh nh\u00e2n b\u1ecb b\u1ec7nh n\u1eb7ng v\u1edbi AKI ho\u1eb7c AKI tr\u00ean n\u1ec1n CKD ho\u1eb7c CKD c\u00f3 KF khi CKRT ho\u1eb7c PIKRT: 1.5g\/kg\/ng\u00e0y l\u00ean \u0111\u1ebfn 1.7 g\/kg\/ng\u00e0y<\/li>\n<\/ul>\n<p>N\u1ebfu c\u00f3 th\u1ec3, c\u00e2n n\u1eb7ng tr\u01b0\u1edbc khi nh\u1eadp vi\u1ec7n ho\u1eb7c c\u00e2n n\u1eb7ng th\u01b0\u1eddng c\u00f3 \u0111\u01b0\u1ee3c \u01b0u ti\u00ean d\u00f9ng h\u01a1n so v\u1edbi c\u00e2n n\u1eb7ng (BW) l\u00fd t\u01b0\u1edfng. C\u00e2n n\u1eb7ng th\u1ef1c t\u1ebf kh\u00f4ng n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t cho m\u1ed9t ch\u1ec9 \u0111\u1ecbnh v\u1ec1 l\u01b0\u1ee3ng protein n\u1ea1p v\u00e0o.<\/p>\n<p><strong>Grade 0<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn (82.6%)<\/p>\n<p><em>B\u00e0n lu\u1eadn cho tuy\u00ean b\u1ed1 7 &amp; 8 v\u00e0 khuy\u1ebfn c\u00e1o 16 \u2013 18:<\/em><\/p>\n<p>Nhu c\u1ea7u protein \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh b\u1edfi stress do vi\u00eam c\u1ee7a b\u1ec7nh c\u1ea5p t\u00ednh\/nguy k\u1ecbch. Nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi t\u00ecnh tr\u1ea1ng vi\u00eam v\u00e0 b\u1ea5t \u0111\u1ed9ng to\u00e0n th\u00e2n b\u1ecb d\u1ecb h\u00f3a m\u1ea1nh v\u00e0 \u0111\u01b0\u1ee3c \u0111\u1eb7c tr\u01b0ng b\u1edfi s\u1ef1 ph\u00e2n h\u1ee7y protein trong c\u01a1 nhi\u1ec1u v\u00f9ng v\u00e0 t\u1ed5ng h\u1ee3p protein b\u1ecb suy gi\u1ea3m, d\u1eabn \u0111\u1ebfn c\u00e2n b\u1eb1ng nit\u01a1 \u00e2m t\u00ednh [10]. Do \u0111\u00f3, nhu c\u1ea7u protein c\u00f3 th\u1ec3 t\u0103ng l\u00ean \u0111\u00e1ng k\u1ec3. Cung c\u1ea5p l\u01b0\u1ee3ng protein t\u0103ng l\u00ean c\u00f3 th\u1ec3 h\u1ea1n ch\u1ebf th\u1ea5t tho\u00e1t nit\u01a1, m\u1eb7c d\u00f9 n\u00f3 kh\u00f4ng th\u1ec3 \u0111\u1ea3o ng\u01b0\u1ee3c t\u00ecnh tr\u1ea1ng d\u1ecb h\u00f3a [145,161,186].<\/p>\n<p>Thay v\u00e0o \u0111\u00f3, c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 AKI kh\u00f4ng ph\u1ee9c t\u1ea1p, ch\u1eb3ng h\u1ea1n nh\u01b0 t\u1eafc ngh\u1ebdn \u0111\u01b0\u1eddng ti\u1ebft ni\u1ec7u ho\u1eb7c thu\u1ed1c g\u00e2y \u0111\u1ed9c v\u1edbi th\u1eadn ho\u1eb7c b\u1ec7nh th\u1eadn do thu\u1ed1c c\u1ea3n quang, trong tr\u01b0\u1eddng h\u1ee3p kh\u00f4ng c\u00f3 t\u00ecnh tr\u1ea1ng b\u1ec7nh c\u1ea5p t\u00ednh\/nguy k\u1ecbch. Trong nh\u1eefng \u0111i\u1ec1u ki\u1ec7n kh\u00f4ng d\u1ecb h\u00f3a n\u00e0y, b\u1ec7nh nh\u00e2n c\u00f3 th\u1ec3 \u1ed5n \u0111\u1ecbnh v\u1ec1 m\u1eb7t chuy\u1ec3n h\u00f3a v\u00e0 kh\u00f4ng c\u1ea7n t\u0103ng ch\u1ebf \u0111\u1ed9 protein. Tuy nhi\u00ean, vi\u1ec7c \u01b0\u1edbc t\u00ednh t\u1ed1c \u0111\u1ed9 d\u1ecb h\u00f3a protein c\u00f3 th\u1ec3 gi\u00fap hi\u1ec3u r\u00f5 h\u01a1n v\u1ec1 t\u00ecnh tr\u1ea1ng d\u1ecb h\u00f3a c\u1ee7a b\u1ec7nh nh\u00e2n v\u00e0 gi\u00fap h\u01b0\u1edbng d\u1eabn ch\u1ec9 \u0111\u1ecbnh dinh d\u01b0\u1ee1ng.<\/p>\n<p>L\u01b0\u1ee3ng protein t\u1ed1i \u01b0u \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n KRT n\u1ed9i vi\u1ec7n, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI v\u1eabn ch\u01b0a r\u00f5 r\u00e0ng. C\u1ea7n ph\u1ea3i \u0111\u1ecbnh l\u01b0\u1ee3ng \u0111\u1ee7 \u0111\u1ec3 l\u00e0m gi\u1ea3m s\u1ef1 m\u1ea5t kh\u1ed1i c\u01a1 trong khi cung c\u1ea5p c\u00e1c acid amin c\u1ea7n thi\u1ebft cho \u0111\u00e1p \u1ee9ng c\u1ee7a pha c\u1ea5p. Nhu c\u1ea7u protein \u1edf b\u1ec7nh nh\u00e2n AKI ho\u1eb7c AKI tr\u00ean n\u1ec1n CKD ho\u1eb7c CKD ch\u01b0a b\u1eaft \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb KRT n\u1ed9i vi\u1ec7n c\u00f3 th\u1ec3 ph\u1ee5 thu\u1ed9c ch\u1ee7 y\u1ebfu v\u00e0o b\u1ec7nh n\u1ec1n, b\u1ec7nh c\u1ea5p t\u00ednh \u0111i k\u00e8m v\u00e0 bi\u1ebfn ch\u1ee9ng h\u01a1n l\u00e0 do gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn. X\u00e9t theo s\u1ef1 t\u0103ng th\u1ea5t tho\u00e1t acid amin, b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb v\u1edbi KRT c\u00f3 th\u1ec3 c\u1ea7n l\u01b0\u1ee3ng protein cao h\u01a1n [10,190].<\/p>\n<p>T\u1ed5ng l\u01b0\u1ee3ng nit\u01a1 m\u1ea5t \u0111i \u1edf m\u1ed9t b\u1ec7nh nh\u00e2n CKRT \u0111\u1eb7c tr\u01b0ng c\u00f3 th\u1ec3 v\u00e0o kho\u1ea3ng 25g\/ng\u00e0y [184,186] c\u00e0ng l\u00e0m tr\u1ea7m tr\u1ecdng th\u00eam t\u00ecnh tr\u1ea1ng c\u00e2n b\u1eb1ng nit\u01a1 \u00e2m t\u00ednh. Gi\u00e1 tr\u1ecb t\u1ed1c \u0111\u1ed9 d\u1ecb h\u00f3a protein chu\u1ea9n l\u00e0 1.2-2.1g\/kg\/ng\u00e0y \u0111o \u0111\u01b0\u1ee3c b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p \u0111o quang ur\u00ea (urea kinetic method) \u1edf c\u00e1c nh\u00f3m nh\u1ecf b\u1ec7nh nh\u00e2n m\u1eafc AKI v\u1edbi nhi\u1ec1u ph\u01b0\u01a1ng th\u1ee9c KRT kh\u00e1c nhau v\u00e0 \u0111i\u1ec1u tr\u1ecb dinh d\u01b0\u1ee1ng (ph\u01b0\u01a1ng th\u1ee9c k\u00e9o d\u00e0i, li\u00ean t\u1ee5c v\u00e0 ng\u1eaft qu\u00e3ng) [142,161,191-195]. Hi\u1ec7n c\u00f3 r\u1ea5t \u00edt d\u1eef li\u1ec7u v\u1ec1 \u1ea3nh h\u01b0\u1edfng c\u1ee7a l\u01b0\u1ee3ng protein cao \u0111\u1ed1i v\u1edbi s\u1ef1 c\u00e2n b\u1eb1ng nit\u01a1 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111ang \u0111i\u1ec1u tr\u1ecb KRT. L\u01b0\u1ee3ng protein n\u1ea1p v\u00e0o l\u00ean \u0111\u1ebfn 2.5g\/kg\/ng\u00e0y, \u00edt nh\u1ea5t l\u00e0 trong c\u00e1c nghi\u00ean c\u1ee9u kh\u00f4ng ng\u1eabu nhi\u00ean, d\u1eabn \u0111\u1ebfn c\u00e2n b\u1eb1ng nit\u01a1 g\u1ea7n d\u01b0\u01a1ng ho\u1eb7c d\u01b0\u01a1ng nh\u1eb9 [145,186]. Trong m\u1ed9t nghi\u00ean c\u1ee9u kh\u00f4ng ng\u1eabu nhi\u00ean v\u1ec1 b\u1ec7nh nh\u00e2n AKI \u0111ang \u0111i\u1ec1u tr\u1ecb CKRT v\u1edbi li\u1ec1u b\u1ed5 sung protein cao h\u01a1n trong ch\u1ebf \u0111\u1ed9 \u0103n u\u1ed1ng 2.5g\/kg\/ng\u00e0y so v\u1edbi m\u1ed9t nh\u00f3m b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ch\u0103m s\u00f3c ti\u00eau chu\u1ea9n 1.2g\/kg\/ng\u00e0y v\u1edbi c\u00f9ng nh\u1eadn \u0111\u01b0\u1ee3c l\u01b0\u1ee3ng calo b\u1eb1ng nhau [185], b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c<br \/>\nnu\u00f4i v\u1edbi l\u01b0\u1ee3ng protein cao h\u01a1n c\u00f3 nhi\u1ec1u kh\u1ea3 n\u0103ng \u0111\u1ea1t \u0111\u01b0\u1ee3c c\u00e2n b\u1eb1ng nit\u01a1 d\u01b0\u01a1ng t\u1ea1i m\u1ecdi th\u1eddi \u0111i\u1ec3m trong qu\u00e1 tr\u00ecnh theo d\u00f5i (53.6% so v\u1edbi 36.7%; p &lt; 0.05) v\u00e0 c\u00f3 xu h\u01b0\u1edbng gi\u1ea3m c\u00e2n b\u1eb1ng nit\u01a1 \u00e2m t\u00ednh t\u1ed5ng th\u1ec3 h\u01a1n, nh\u01b0ng c\u1ea7n t\u0103ng \u201cli\u1ec1u\u201d CKRT do t\u00ecnh tr\u1ea1ng t\u0103ng s\u1ea3n sinh nit\u01a1 c\u00f3 trong ur\u00ea trong m\u00e1u. Trong m\u1ed9t nghi\u00ean c\u1ee9u chi ti\u1ebft v\u1ec1 chuy\u1ec3n h\u00f3a [193], b\u00e1o c\u00e1o r\u1eb1ng b\u1ec7nh nh\u00e2n AKI \u0111\u01b0\u1ee3c nu\u00f4i 2.0g protein\/kg \u0111\u00e3 c\u1ea3i thi\u1ec7n c\u00e2n b\u1eb1ng nit\u01a1 so v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c nu\u00f4i 1.5g protein\/kg. \u0110i\u1ec1u th\u00fa v\u1ecb \u1edf \u0111\u00e2y l\u00e0 vi\u1ec7c t\u0103ng l\u01b0\u1ee3ng calo t\u1eeb 10 \u0111\u1ebfn 15 kcal\/kg \u0111\u1ebfn 30 kcal\/kg c\u00f3 l\u1ee3i cho nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 l\u01b0\u1ee3ng protein th\u1ea5p h\u01a1n (0.6- 0.8g\/kg) nh\u01b0ng kh\u00f4ng c\u00f3 l\u1ee3i tr\u00ean nh\u00f3m b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c nu\u00f4i t\u0103ng protein. Nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c nu\u00f4i \u0103n th\u1eeba (40-60 t\u1ed5ng kcal\/kg) \u0111\u00e3 t\u0103ng t\u1ed1c \u0111\u1ed9 d\u1ecb h\u00f3a protein chu\u1ea9n v\u00e0 l\u00e0m x\u1ea5u \u0111i s\u1ef1 c\u00e2n b\u1eb1ng nit\u01a1. C\u00e2n b\u1eb1ng nit\u01a1 d\u01b0\u01a1ng c\u00f3 li\u00ean quan \u0111\u1ebfn vi\u1ec7c c\u1ea3i thi\u1ec7n kh\u1ea3 n\u0103ng s\u1ed1ng c\u00f2n c\u1ee7a b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI [144]. B\u1ed5 sung protein \u0111\u1ebfn m\u1ee5c ti\u00eau 2.0g\/kg\/ng\u00e0y c\u00f3 th\u1ec3 l\u00e0 mong mu\u1ed1n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb CKRT ho\u1eb7c PIKRT k\u00e9o d\u00e0i v\u1edbi c\u00e2n b\u1eb1ng nit\u01a1 \u00e2m. M\u1ed9t l\u01b0u \u00fd quan tr\u1ecdng li\u00ean quan \u0111\u1ebfn vi\u1ec7c cho y l\u1ec7nh v\u1ec1 protein l\u00e0 n\u00f3 th\u01b0\u1eddng \u0111\u01b0\u1ee3c chu\u1ea9n h\u00f3a theo tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 c\u1ee7a b\u1ec7nh nh\u00e2n. Xem x\u00e9t r\u1eb1ng nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI th\u01b0\u1eddng xuy\u00ean b\u1ecb qu\u00e1 t\u1ea3i d\u1ecbch, vi\u1ec7c x\u00e1c \u0111\u1ecbnh tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 tham chi\u1ebfu \u0111\u1ec3 s\u1eed d\u1ee5ng cho ch\u1ec9 \u0111\u1ecbnh v\u1ec1 l\u01b0\u1ee3ng protein l\u00e0 m\u1ed9t v\u1ea5n \u0111\u1ec1 t\u1ebf nh\u1ecb. Tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 kh\u00e1c nhau s\u1ebd d\u1eabn \u0111\u1ebfn \u01b0\u1edbc t\u00ednh nhu c\u1ea7u protein kh\u00e1c nhau, \u0111i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 gi\u1ea3i th\u00edch m\u1ed9t ph\u1ea7n cho ph\u1ea1m vi r\u1ed9ng c\u1ee7a c\u00e1c gi\u00e1 tr\u1ecb t\u1ed1c \u0111\u1ed9 d\u1ecb h\u00f3a protein chu\u1ea9n \u0111\u01b0\u1ee3c t\u00ecm th\u1ea5y trong c\u00e1c nghi\u00ean c\u1ee9u tr\u01b0\u1edbc \u0111\u00e2y. M\u1ed9t nghi\u00ean c\u1ee9u g\u1ea7n \u0111\u00e2y cho th\u1ea5y \u01b0\u1edbc t\u00ednh nhu c\u1ea7u protein d\u1ef1a tr\u00ean tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI \u0111\u00e3 \u01b0\u1edbc l\u01b0\u1ee3ng qu\u00e1 cao nhu c\u1ea7u protein \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111ang \u0111i\u1ec1u tr\u1ecb KRT, trong khi \u0111\u00f3 \u01b0\u1edbc l\u01b0\u1ee3ng th\u1ea5p h\u01a1n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111i\u1ec1u tr\u1ecb KRT [142]. Trong khi tr\u01b0\u1eddng h\u1ee3p \u0111\u1ea7u ti\u00ean (\u01b0\u1edbc l\u01b0\u1ee3ng qu\u00e1 cao nhu c\u1ea7u protein tr\u00ean BN KRT) c\u00f3 th\u1ec3 l\u00e0m t\u0103ng s\u1ea3n sinh ur\u00ea v\u00e0 nhu c\u1ea7u v\u1ec1 KRT, tr\u01b0\u1eddng h\u1ee3p th\u1ee9 hai (\u01b0\u1edbc l\u01b0\u1ee3ng protein th\u1ea5p \u1edf BN kh\u00f4ng KRT) c\u00f3 th\u1ec3 g\u00f3p ph\u1ea7n l\u00e0m t\u0103ng s\u1ef1 m\u1ea5t kh\u1ed1i c\u01a1. B\u1ea5t ch\u1ea5p nh\u1eefng kh\u00f3 kh\u0103n v\u1ec1 k\u1ef9 thu\u1eadt c\u00f3 th\u1ec3 x\u1ea3y ra trong qu\u00e1 tr\u00ecnh l\u1ea5y n\u01b0\u1edbc ti\u1ec3u v\u00e0 d\u1ecbch l\u1ecdc m\u00e1u trong 24 gi\u1edd, vi\u1ec7c t\u00ednh to\u00e1n t\u1ed1c \u0111\u1ed9 d\u1ecb h\u00f3a protein \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb KRT n\u1ed9i vi\u1ec7n l\u00e0 r\u1ea5t quan tr\u1ecdng.<\/p>\n<h4>C\u00f3 n\u00ean ch\u1ec9 \u0111\u1ecbnh gi\u1ea3m protein \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng nh\u1eadp vi\u1ec7n v\u1edbi AKI v\u00e0\/ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng KF \u0111\u1ec3 tr\u00ec ho\u00e3n vi\u1ec7c b\u1eaft \u0111\u1ea7u KRT ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 19: Kh\u00f4ng n\u00ean ch\u1ec9 \u0111\u1ecbnh gi\u1ea3m protein \u0111\u1ec3 tr\u00e1nh hay tr\u00ec ho\u00e3n KRT tr\u00ean b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n v\u1edbi AKI, AKI tr\u00ean n\u1ec1n CKD, ho\u1eb7c CKD v\u1edbi KF.<\/strong><\/p>\n<p><strong>Grade A<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.5%) B\u00e0n lu\u1eadn:<\/p>\n<p>Khi c\u00f3 s\u1ef1 gia t\u0103ng d\u1ecb h\u00f3a protein li\u00ean quan \u0111\u1ebfn gi\u1ea3m thanh th\u1ea3i s\u1ea3n ph\u1ea9m c\u1ee7a nit\u01a1 do gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn, vi\u1ec7c b\u1ed5 sung qu\u00e1 nhi\u1ec1u protein c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn t\u00edch l\u0169y th\u00eam c\u00e1c s\u1ea3n ph\u1ea9m cu\u1ed1i c\u00f9ng c\u1ee7a qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a protein v\u00e0 acid amin, v\u00e0 do \u0111\u00f3, l\u00e0m t\u0103ng gi\u00e1 tr\u1ecb nit\u01a1 trong ur\u00ea trong m\u00e1u (BUN). Tuy nhi\u00ean, s\u1ef1 d\u1ecb h\u00f3a protein \u1edf b\u1ec7nh nh\u00e2n AKI ch\u1ec9 b\u1ecb \u1ea3nh h\u01b0\u1edfng m\u1ed9t ph\u1ea7n b\u1edfi l\u01b0\u1ee3ng protein \u0103n v\u00e0o, t\u1ee9c l\u00e0 gi\u1ea3m l\u01b0\u1ee3ng protein \u0103n v\u00e0o kh\u00f4ng \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn t\u1ed1c \u0111\u1ed9 d\u1ecb h\u00f3a protein [85]. M\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p g\u1ea7n \u0111\u00e2y kh\u00f4ng t\u00ecm th\u1ea5y s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 k\u1ebft qu\u1ea3 gi\u1eefa th\u1eddi \u0111i\u1ec3m b\u1eaft \u0111\u1ea7u KRT (s\u1edbm v\u00e0 mu\u1ed9n) [196]. Do \u0111\u00f3, vi\u1ec7c ch\u1ec9 \u0111\u1ecbnh protein trong b\u1ec7nh c\u1ea3nh l\u00e2m s\u00e0ng n\u00e0y n\u00ean \u0111\u01b0\u1ee3c d\u1ef1a tr\u00ean t\u00ecnh tr\u1ea1ng d\u1ecb h\u00f3a c\u1ee7a b\u1ec7nh nh\u00e2n, v\u00e0 kh\u00f4ng n\u00ean gi\u1ea3m l\u01b0\u1ee3ng protein \u0111\u1ec3 tr\u00ec ho\u00e3n vi\u1ec7c b\u1eaft \u0111\u1ea7u KRT.<\/p>\n<h4>X\u00e9t v\u1ec1 h\u00e0m l\u01b0\u1ee3ng t\u01b0\u01a1ng \u0111\u1ed1i th\u1ea5p c\u1ee7a protein c\u00f3 trong c\u00f4ng th\u1ee9c chu\u1ea9n \u0111\u01b0\u1eddng ti\u00eau h\u00f3a (40-60g protein\/L), c\u00e1c c\u00f4ng th\u1ee9c \u0111\u1eb7c hi\u1ec7u cho b\u1ec7nh (th\u1eadn) c\u00f3 ch\u1ee9a 70-80g protein\/L c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c \u01b0u ti\u00ean h\u01a1n, ch\u1ee7 y\u1ebfu \u0111\u1ec3 gi\u1ea3m qu\u00e1 t\u1ea3i d\u1ecbch; trong m\u1ed9t s\u1ed1 tr\u01b0\u1eddng h\u1ee3p, vi\u1ec7c b\u1ed5 sung acid amin qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch \u0111\u01b0\u1ee3c khuy\u1ebfn kh\u00edch \u0111\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c m\u1ee5c ti\u00eau nhu c\u1ea7u protein b\u1eb1ng dinh d\u01b0\u1ee1ng qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a [1,2,137].<\/h4>\n<p>N\u00ean xem x\u00e9t \u00e1p d\u1ee5ng c\u00e1ch ti\u1ebfp c\u1eadn b\u1ea3o t\u1ed3n (gi\u1ea3m protein) trong t\u00ecnh hu\u1ed1ng n\u00e0o ?<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 20: Ph\u01b0\u01a1ng ph\u00e1p ti\u1ebfp c\u1eadn \u0111i\u1ec1u tr\u1ecb b\u1ea3o t\u1ed3n bao g\u1ed3m c\u00e1c ch\u1ebf \u0111\u1ed9 \u0103n h\u1ea1n ch\u1ebf protein v\u1eeba ph\u1ea3i, ch\u1ec9 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c xem x\u00e9t trong tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh nh\u00e2n AKI ho\u1eb7c CKD \u1ed5n \u0111\u1ecbnh v\u1ec1 m\u1eb7t chuy\u1ec3n h\u00f3a, kh\u00f4ng c\u00f3 b\u1ea5t k\u1ef3 t\u00ecnh tr\u1ea1ng d\u1ecb h\u00f3a\/b\u1ec7nh n\u1eb7ng n\u00e0o v\u00e0 kh\u00f4ng tr\u1ea3i qua KRT (xem khuy\u1ebfn c\u00e1o 18).<\/strong><\/p>\n<p><strong>Grade GPP<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn (87%) B\u00e0n lu\u1eadn<\/p>\n<p>Trong m\u1ed9t s\u1ed1 t\u00ecnh tr\u1ea1ng kh\u00f4ng d\u1ecb h\u00f3a v\u1edbi gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn c\u1ea5p t\u00ednh (ch\u1eb3ng h\u1ea1n nh\u01b0 AKI \u0111\u01a1n \u0111\u1ed9c do thu\u1ed1c, AKI do thu\u1ed1c c\u1ea3n quang v\u00e0 m\u1ed9t s\u1ed1 t\u00ecnh tr\u1ea1ng c\u1ee7a AKI sau th\u1eadn) ho\u1eb7c \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n CKD \u1ed5n \u0111\u1ecbnh v\u1ec1 chuy\u1ec3n h\u00f3a, \u0111i\u1ec1u tr\u1ecb b\u1ea3o t\u1ed3n c\u00f3 th\u1ec3 gi\u00fap \u0111i\u1ec1u ch\u1ec9nh phosphate, natri, kali, r\u1ed1i lo\u1ea1n th\u0103ng b\u1eb1ng toan ki\u1ec1m, c\u0169ng nh\u01b0 l\u00e0m gi\u1ea3m s\u1ef1 t\u00edch t\u1ee5 c\u1ee7a c\u00e1c ch\u1ea5t th\u1ea3i nit\u01a1, ch\u1eb3ng h\u1ea1n nh\u01b0 ur\u00ea. Thay v\u00e0o \u0111\u00f3, khi c\u00f3 t\u00ecnh tr\u1ea1ng d\u1ecb h\u00f3a, \u0111i\u1ec1u tr\u1ecb b\u1ea3o t\u1ed3n c\u00f3 th\u1ec3 ch\u1ec9 \u0111i\u1ec1u ch\u1ec9nh m\u1ed9t ph\u1ea7n c\u00e1c ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i, s\u1ef1 m\u1ea5t c\u00e2n b\u1eb1ng d\u1ecbch ho\u1eb7c th\u0103ng b\u1eb1ng toan ki\u1ec1m nh\u01b0ng lu\u00f4n l\u00e0m x\u1ea5u \u0111i s\u1ef1 c\u00e2n b\u1eb1ng nit\u01a1; trong h\u1ea7u h\u1ebft c\u00e1c tr\u01b0\u1eddng h\u1ee3p nh\u01b0 v\u1eady, n\u00ean b\u1eaft \u0111\u1ea7u KRT.<\/p>\n<h4>B\u1ec7nh nh\u00e2n CKD \u0111i\u1ec1u tr\u1ecb b\u1ea3o t\u1ed3n c\u00f3 n\u00ean duy tr\u00ec ch\u1ebf \u0111\u1ed9 \u0103n \u00edt protein h\u01a1n trong th\u1eddi gian n\u1eb1m vi\u1ec7n ?<\/h4>\n<p><strong>Khuy\u1ebfn c\u00e1o 21: B\u1ec7nh nh\u00e2n tr\u01b0\u1edbc \u0111\u00e2y duy tr\u00ec ki\u1ec3m so\u00e1t protein kh\u1ea9u ph\u1ea7n (g\u1ecdi l\u00e0 ch\u1ebf \u0111\u1ed9 \u0103n h\u1ea1n ch\u1ebf protein) kh\u00f4ng n\u00ean duy tr\u00ec ch\u1ebf \u0111\u1ed9 \u0103n n\u00e0y n\u1ebfu b\u1ec7nh c\u1ea5p t\u00ednh l\u00e0 l\u00fd do v\u00e0o vi\u1ec7n.<\/strong><\/p>\n<p><strong>Grade GPP<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>Nh\u01b0 \u0111\u00e3 th\u1ea3o lu\u1eadn \u1edf tr\u00ean, nh\u1eadp vi\u1ec7n do b\u1ec7nh n\u1eb7ng ho\u1eb7c c\u1ea5p t\u00ednh ho\u1eb7c ph\u1eabu thu\u1eadt l\u1edbn th\u01b0\u1eddng \u0111\u01b0\u1ee3c \u0111\u1eb7c tr\u01b0ng b\u1edfi t\u00ecnh tr\u1ea1ng ti\u1ec1n vi\u00eam v\u00e0 t\u0103ng d\u1ecb h\u00f3a protein, do \u0111\u00f3 ti\u1ebfp t\u1ee5c h\u1ea1n ch\u1ebf protein trong ch\u1ebf \u0111\u1ed9 \u0103n u\u1ed1ng l\u00e0 kh\u00f4ng th\u00edch h\u1ee3p. Nhu c\u1ea7u protein \u1edf b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n ph\u1ea3i \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh theo b\u1ec7nh n\u1ec1n \u0111\u00e3 g\u00e2y ra nh\u1eadp vi\u1ec7n nhi\u1ec1u h\u01a1n l\u00e0 do t\u00ecnh tr\u1ea1ng suy th\u1eadn c\u0103n b\u1ea3n. Ng\u01b0\u1ee3c l\u1ea1i, b\u1ec7nh nh\u00e2n CKD c\u00f3 th\u1ec3 ti\u1ebfp t\u1ee5c ch\u1ebf \u0111\u1ed9 \u0103n u\u1ed1ng c\u00f3 ki\u1ec3m so\u00e1t protein trong th\u1eddi gian nh\u1eadp vi\u1ec7n mi\u1ec5n l\u00e0 kh\u00f4ng c\u00f3 t\u00ecnh tr\u1ea1ng d\u1ecb h\u00f3a protein. B\u00ean c\u1ea1nh \u0111\u00f3, l\u01b0\u1ee3ng dinh d\u01b0\u1ee1ng \u0103n v\u00e0o ph\u1ea3i bao g\u1ed3m \u0111\u1ea7y \u0111\u1ee7 c\u00e1c acid amin thi\u1ebft y\u1ebfu v\u00e0 nhu c\u1ea7u n\u0103ng l\u01b0\u1ee3ng [197], v\u00e0 nhi\u1ec5m toan chuy\u1ec3n h\u00f3a ph\u1ea3i \u0111\u01b0\u1ee3c ng\u0103n ng\u1eeba ho\u1eb7c \u0111i\u1ec1u ch\u1ec9nh th\u1ecfa \u0111\u00e1ng [198]. N\u1ebfu kh\u00f4ng \u0111\u01b0\u1ee3c ki\u1ec3m so\u00e1t t\u1ed1t nh\u01b0 \u0111\u00e3 \u0111\u1ec1 c\u1eadp \u1edf tr\u00ean, b\u1ec7nh nh\u00e2n CKD s\u1ebd c\u00f3 nguy c\u01a1 cao c\u00e2n b\u1eb1ng nit\u01a1 \u00e2m v\u00e0 do \u0111\u00f3 b\u1ecb m\u1ea5t kh\u1ed1i c\u01a1, ngay c\u1ea3 trong t\u00ecnh tr\u1ea1ng kh\u00f4ng d\u1ecb h\u00f3a \u1ed5n \u0111\u1ecbnh v\u1ec1 m\u1eb7t chuy\u1ec3n h\u00f3a. Cu\u1ed1i c\u00f9ng nh\u01b0ng kh\u00f4ng k\u00e9m ph\u1ea7n quan tr\u1ecdng, c\u1ea7n ki\u1ec3m so\u00e1t t\u1ed1i \u01b0u qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a glucose \u0111\u1ec3 th\u1ef1c hi\u1ec7n h\u1ea1n ch\u1ebf protein an to\u00e0n v\u1ec1 m\u1eb7t dinh d\u01b0\u1ee1ng [199].<\/p>\n<h3>Nhu c\u1ea7u v\u1ec1 c\u00e1c vi ch\u1ea5t dinh d\u01b0\u1ee1ng<\/h3>\n<p>C\u00f3 n\u00ean b\u1ed5 sung c\u00e1c nguy\u00ean t\u1ed1 vi l\u01b0\u1ee3ng v\u00e0 vitamin ?<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 22: Do t\u0103ng nhu c\u1ea7u trong qu\u00e1 tr\u00ecnh KF v\u00e0 b\u1ec7nh n\u1eb7ng, v\u00e0 m\u1ea5t l\u01b0\u1ee3ng d\u1ecbch th\u1ea3i l\u1edbn trong qu\u00e1 tr\u00ecnh KRT, c\u1ea7n theo d\u00f5i v\u00e0 b\u1ed5 sung c\u00e1c nguy\u00ean t\u1ed1 vi l\u01b0\u1ee3ng. C\u1ea7n t\u0103ng c\u01b0\u1eddng ch\u00fa \u00fd \u0111\u1ebfn selen, k\u1ebdm v\u00e0 \u0111\u1ed3ng.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 23: Do t\u0103ng nhu c\u1ea7u trong qu\u00e1 tr\u00ecnh KF v\u00e0 b\u1ec7nh n\u1eb7ng, v\u00e0 m\u1ea5t l\u01b0\u1ee3ng d\u1ecbch th\u1ea3i l\u1edbn trong qu\u00e1 tr\u00ecnh KRT, c\u1ea7n theo d\u00f5i v\u00e0 b\u1ed5 sung c\u00e1c vitamin tan trong n\u01b0\u1edbc. C\u1ea7n \u0111\u1eb7c bi\u1ec7t ch\u00fa \u00fd \u0111\u1ebfn vitamin C, folate (B9) v\u00e0 thiamine (B1).<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn cho khuy\u1ebfn c\u00e1o 22 v\u00e0 23:<\/em><\/p>\n<p>Trong di\u1ec5n ti\u1ebfn b\u1ec7nh n\u1eb7ng, vitamin v\u00e0 c\u00e1c nguy\u00ean t\u1ed1 vi l\u01b0\u1ee3ng c\u00f3 th\u1ec3 t\u00e1c \u0111\u1ed9ng \u0111\u1ebfn vi\u1ec7c \u0111i\u1ec1u h\u00f2a mi\u1ec5n d\u1ecbch, l\u00e0m l\u00e0nh v\u1ebft th\u01b0\u01a1ng v\u00e0 c\u00f3 th\u1ec3 c\u00f3 \u0111\u1eb7c t\u00ednh ch\u1ed1ng oxy h\u00f3a [200,201]. M\u1eb7c d\u00f9 li\u1ec1u l\u01b0\u1ee3ng vi ch\u1ea5t dinh d\u01b0\u1ee1ng t\u1ed1i \u01b0u \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1eabn c\u00f2n l\u00e0 v\u1ea5n \u0111\u1ec1 tranh c\u00e3i, nh\u01b0ng c\u00f3 v\u1ebb r\u1eb1ng s\u1ef1 kh\u1edfi \u0111\u1ea7u c\u1ee7a KRT d\u01b0\u1edbi d\u1ea1ng CKRT \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 AKI ho\u1eb7c AKI tr\u00ean n\u1ec1n CKD ho\u1eb7c CKD c\u00f3 KF c\u00f3 \u1ea3nh h\u01b0\u1edfng ti\u00eau c\u1ef1c \u0111\u1ebfn m\u1ee9c vi ch\u1ea5t dinh d\u01b0\u1ee1ng trong huy\u1ebft thanh l\u00e0 kh\u00e1 r\u00f5 r\u00e0ng [202,203]. C\u01a1 ch\u1ebf th\u1ea3i tr\u1eeb c\u1ee7a c\u00e1c ph\u01b0\u01a1ng th\u1ee9c l\u1ecdc m\u00e1u c\u01a1 b\u1ea3n c\u00f9ng v\u1edbi s\u1ef1 h\u1ea5p ph\u1ee5 c\u1ee7a c\u00e1c lo\u1ea1i m\u00e0ng l\u1ecdc c\u00f3 th\u1ec3 l\u00e0m t\u0103ng nguy c\u01a1 thi\u1ebfu h\u1ee5t vitamin v\u00e0 nguy\u00ean t\u1ed1 vi l\u01b0\u1ee3ng, nh\u01b0ng v\u1eabn c\u00f2n thi\u1ebfu c\u00e1c ph\u01b0\u01a1ng ph\u00e1p dinh d\u01b0\u1ee1ng chuy\u00ean d\u1ee5ng v\u00e0 c\u1ee5 th\u1ec3 [204]. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb CKRT, \u0111\u00e3 m\u00f4 t\u1ea3 s\u1ef1 gi\u1ea3m n\u1ed3ng \u0111\u1ed9 folate, vitamin C, E, thiamine, k\u1ebdm v\u00e0 selen trong huy\u1ebft thanh, c\u00f3 th\u1ec3 l\u00e0 do h\u1eadu qu\u1ea3 c\u1ee7a vi\u1ec7c t\u0103ng c\u01b0\u1eddng s\u1eed d\u1ee5ng trong b\u1ec7nh n\u1eb7ng v\u00e0 m\u1ea5t th\u1ee9 ph\u00e1t sau CKRT [202,205-207]. C\u1ee5 th\u1ec3, b\u00e1o c\u00e1o v\u1ec1 s\u1ef1 m\u1ea5t h\u00e0ng ng\u00e0y trong d\u1ecbch th\u1ea3i kho\u1ea3ng 68 mg vitamin C, 0.3 mg folate v\u00e0 4 mg vitamin B1 (thiamine) [206,207]. Trong m\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t tr\u00ean 77 b\u1ec7nh nh\u00e2n CKD k\u00e8m KF \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o m\u1ea1n t\u00ednh, k\u1ebdm, thiamin v\u00e0 vitamin B6 l\u00e0 nh\u1eefng vi ch\u1ea5t dinh d\u01b0\u1ee1ng b\u1ecb thi\u1ebfu nhi\u1ec1u nh\u1ea5t (l\u1ea7n l\u01b0\u1ee3t l\u00e0 44,1%, 24,7% v\u00e0 35,1%) [208]. Trong m\u1ed9t th\u1eed nghi\u1ec7m ng\u1eabu nhi\u00ean tr\u00ean b\u1ec7nh nh\u00e2n ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o m\u1ea1n t\u00ednh [209], n\u1ed3ng \u0111\u1ed9 selen v\u00e0 k\u1ebdm trong huy\u1ebft thanh \u1edf 150 b\u1ec7nh nh\u00e2n ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o m\u1ea1n t\u00ednh kh\u00f4ng \u0111\u01b0\u1ee3c \u0111i\u1ec1u ch\u1ec9nh v\u1ec1 m\u1ee9c b\u00ecnh th\u01b0\u1eddng b\u1eb1ng c\u00e1ch b\u1ed5 sung \u0111i\u1ec1u \u0111\u1ed9 (l\u00ean \u0111\u1ebfn 75\u00b5g selen\/ng\u00e0y v\u00e0 50mg k\u1ebdm\/ng\u00e0y), cho th\u1ea5y t\u0103ng nhu c\u1ea7u \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y. Khuy\u1ebfn c\u00e1o hi\u1ec7n t\u1ea1i l\u00e0 l\u01b0\u1ee3ng selen v\u00e0 c\u00e1c vi ch\u1ea5t dinh d\u01b0\u1ee1ng kh\u00e1c b\u1ecb m\u1ea5t trong d\u1ecbch th\u1ea3i n\u00ean \u0111\u01b0\u1ee3c thay th\u1ebf v\u00e0o [210,211] v\u00e0 nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y s\u1ebd c\u1ea7n m\u1ed9t l\u01b0\u1ee3ng b\u1ed5 sung nhi\u1ec1u h\u01a1n d\u1ef1a v\u00e0o PN chu\u1ea9n [207,212]. Li\u1ec1u t\u1ed1i \u01b0u v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c bi\u1ebft, nh\u01b0ng li\u1ec1u l\u01b0\u1ee3ng 100mg\/ng\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t cho vitamin C [213]. S\u1ef1 th\u1ea5t tho\u00e1t l\u1edbn trong d\u1ecbch th\u1ea3i c\u1ee7a m\u1ed9t s\u1ed1 nguy\u00ean t\u1ed1 vi l\u01b0\u1ee3ng, nh\u01b0ng \u0111\u1eb7c bi\u1ec7t l\u00e0 \u0111\u1ed3ng \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 \u0111\u00e3 th\u1ea5t tho\u00e1t r\u1ea5t nhi\u1ec1u so v\u1edbi l\u01b0\u1ee3ng dinh d\u01b0\u1ee1ng n\u1ea1p v\u00e0o [207]. G\u1ea7n \u0111\u00e2y m\u1ed9t tr\u01b0\u1eddng h\u1ee3p t\u1eed vong do thi\u1ebfu \u0111\u1ed3ng \u0111\u00e3 \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 [212]. Khi c\u1ea7n ph\u1ea3i CKRT trong h\u01a1n hai tu\u1ea7n, n\u00ean x\u00e1c \u0111\u1ecbnh l\u01b0\u1ee3ng \u0111\u1ed3ng trong m\u00e1u. C\u00f3 \u0111\u1ec1 ngh\u1ecb d\u00f9ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch kho\u1ea3ng 3 mg \u0111\u1ed3ng\/ng\u00e0y \u0111\u1ec3 ng\u0103n ng\u1eeba s\u1ef1 thi\u1ebfu h\u1ee5t (d\u1ef1a tr\u00ean x\u00e1c \u0111\u1ecbnh l\u1eb7p l\u1ea1i \u1edf b\u1ec7nh nh\u00e2n ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o) [214]. K\u1ebft lu\u1eadn, do nh\u1eefng h\u1ea1n ch\u1ebf trong x\u00e9t nghi\u1ec7m m\u00e1u v\u00e0 thi\u1ebfu b\u1eb1ng ch\u1ee9ng v\u1ec1 l\u1ee3i \u00edch l\u00e2m s\u00e0ng c\u00f3 \u0111\u01b0\u1ee3c t\u1eeb vi\u1ec7c b\u1ed5 sung vi ch\u1ea5t dinh d\u01b0\u1ee1ng, vi\u1ec7c b\u1ed5 sung vi ch\u1ea5t dinh d\u01b0\u1ee1ng c\u1ea7n \u0111\u01b0\u1ee3c h\u01b0\u1edbng d\u1eabn b\u1edfi n\u1ed3ng \u0111\u1ed9 c\u1ee7a ch\u00fang trong huy\u1ebft thanh v\u00e0 l\u01b0\u1ee3ng th\u1ea5t tho\u00e1t do KRT.<\/p>\n<h3>Dinh d\u01b0\u1ee1ng \u0111\u1eb7c tr\u01b0ng theo b\u1ec7nh l\u00fd<\/h3>\n<p>Vi\u1ec7c s\u1eed d\u1ee5ng c\u00f4ng th\u1ee9c d\u00e0nh ri\u00eang cho b\u1ec7nh th\u1eadn (EN ho\u1eb7c PN) c\u00f3 l\u00e0m gi\u1ea3m bi\u1ebfn ch\u1ee9ng v\u00e0 t\u0103ng cung c\u1ea5p dinh d\u01b0\u1ee1ng so v\u1edbi c\u00f4ng th\u1ee9c ti\u00eau chu\u1ea9n kh\u00f4ng ?<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 24: Kh\u00f4ng c\u00f3 c\u00f4ng th\u1ee9c \u0111\u01b0\u1eddng ti\u00eau h\u00f3a ho\u1eb7c \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch \u0111\u1eb7c hi\u1ec7u n\u00e0o d\u00e0nh cho b\u1ec7nh nh\u00e2n suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn n\u00ean \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng th\u01b0\u1eddng xuy\u00ean \u1edf m\u1ecdi b\u1ec7nh nh\u00e2n b\u1ecb AKI, AKI tr\u00ean n\u1ec1n CKD, ho\u1eb7c CKD c\u00f3 KF so v\u1edbi c\u00e1c c\u00f4ng th\u1ee9c chu\u1ea9n. Thay v\u00e0o \u0111\u00f3, vi\u1ec7c s\u1eed d\u1ee5ng ch\u00fang ph\u1ea3i \u0111\u01b0\u1ee3c c\u00e1 th\u1ec3 h\u00f3a (xem khuy\u1ebfn c\u00e1o 26).<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: \u0111\u1ed3ng thu\u1eadn (87.5%)<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 25: Vi\u1ec7c l\u1ef1a ch\u1ecdn c\u00f4ng th\u1ee9c EN ho\u1eb7c PN th\u00edch h\u1ee3p nh\u1ea5t n\u00ean \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n d\u1ef1a tr\u00ean t\u1ef7 l\u1ec7 n\u0103ng l\u01b0\u1ee3ng v\u00e0 protein \u0111\u1ec3 cung c\u1ea5p li\u1ec1u l\u01b0\u1ee3ng ch\u00ednh x\u00e1c nh\u1ea5t trong th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (91.3%)<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 26: \u1ede m\u1ed9t s\u1ed1 b\u1ec7nh nh\u00e2n b\u1ecb m\u1ea5t c\u00e2n b\u1eb1ng d\u1ecbch v\u00e0 \u0111i\u1ec7n gi\u1ea3i, c\u00e1c c\u00f4ng th\u1ee9c EN ho\u1eb7c PN \u201cth\u1eadn\u201d \u0111\u1eadm \u0111\u1eb7c v\u1edbi h\u00e0m l\u01b0\u1ee3ng \u0111i\u1ec7n gi\u1ea3i th\u1ea5p h\u01a1n c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c \u01b0u ti\u00ean h\u01a1n c\u00e1c c\u00f4ng th\u1ee9c ti\u00eau chu\u1ea9n.<\/strong><\/p>\n<p><strong>Grade GPP<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.7%) B\u00e0n lu\u1eadn cho khuy\u1ebfn c\u00e1o 24 \u2013 26:<\/p>\n<p>\u0110\u00e1nh gi\u00e1 g\u1ea7n \u0111\u00e2y nh\u1ea5t v\u1ec1 ch\u1ee7 \u0111\u1ec1 n\u00e0y, bao g\u1ed3m t\u00e0i li\u1ec7u cho \u0111\u1ebfn th\u00e1ng 12 n\u0103m 2013, kh\u00f4ng cho th\u1ea5y b\u1ea5t k\u1ef3 l\u1ee3i \u00edch n\u00e0o \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh trong vi\u1ec7c s\u1eed d\u1ee5ng c\u00f4ng th\u1ee9c \u0111\u01b0\u1eddng ru\u1ed9t d\u00e0nh ri\u00eang cho b\u1ec7nh \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb b\u1ec7nh n\u1eb7ng [141]. Tuy nhi\u00ean, c\u00e1c c\u00f4ng th\u1ee9c \u0111\u01b0\u1ee3c thi\u1ebft k\u1ebf cho b\u1ec7nh nh\u00e2n KF \u0111\u1eadm \u0111\u1eb7c h\u01a1n v\u00e0 t\u1ea5t c\u1ea3 ch\u00fang \u0111\u1ec1u c\u00f3 h\u00e0m l\u01b0\u1ee3ng natri, kali v\u00e0 ph\u1ed1t pho th\u1ea5p h\u01a1n.<\/p>\n<p>Do \u0111\u00f3, ch\u00fang c\u00f3 th\u1ec3 c\u00f3 l\u1ee3i cho vi\u1ec7c \u0111\u1ea1t \u0111\u01b0\u1ee3c m\u1ee5c ti\u00eau protein \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 nhu c\u1ea7u protein cao h\u01a1n, c\u0169ng nh\u01b0 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i (v\u00ed d\u1ee5 t\u0103ng kali m\u00e1u) v\u00e0\/ho\u1eb7c qu\u00e1 t\u1ea3i d\u1ecbch.<br \/>\nVi\u1ec7c b\u1ed5 sung omega-3 ho\u1eb7c c\u00e1c nh\u0169 d\u1ecbch b\u00e9o gi\u00e0u omega-3 qua PN c\u00f3 l\u00e0m c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb kh\u00f4ng ?<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 27: Kh\u00f4ng c\u00f3 \u0111\u1ee7 b\u1eb1ng ch\u1ee9ng \u1ee7ng h\u1ed9 cho vi\u1ec7c s\u1eed d\u1ee5ng th\u01b0\u1eddng xuy\u00ean c\u00e1c acid b\u00e9o kh\u00f4ng b\u00e3o h\u00f2a \u0111a n\u1ed1i \u0111\u00f4i (PUFA) nh\u01b0 omega-3 ho\u1eb7c c\u00e1c ch\u1ebf ph\u1ea9m PN \u0111\u01b0\u1ee3c l\u00e0m gi\u00e0u omega-3 (PUFA) \u1edf b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi AKI, AKI tr\u00ean n\u1ec1n CKD ho\u1eb7c CKD v\u1edbi KF.<\/strong><br \/>\nGrade GPP \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.8%) B\u00e0n lu\u1eadn:<\/p>\n<p>Vai tr\u00f2 c\u1ee7a omega-3 PUFA \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n th\u1eadn v\u00e0 gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn n\u1ed9i vi\u1ec7n t\u1ea1i th\u1eddi \u0111i\u1ec3m n\u00e0y v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c bi\u1ebft r\u00f5. M\u1eb7c d\u00f9 c\u00f3 d\u1eef li\u1ec7u th\u1ef1c nghi\u1ec7m th\u00fa v\u1ecb [215,216], hi\u1ec7n kh\u00f4ng c\u00f3 RCT n\u00e0o \u1ee7ng h\u1ed9 cho khuy\u1ebfn c\u00e1o s\u1eed d\u1ee5ng omega-3 PUFA cho b\u1ec7nh nh\u00e2n AKI\/AKD v\u00e0\/ho\u1eb7c CKD nh\u1eadp vi\u1ec7n c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 KF [10]. Tuy nhi\u00ean, c\u00e1c nh\u0169 d\u1ecbch lipid truy\u1ec1n t\u0129nh m\u1ea1ch v\u1edbi omega-3 PUFA \u0111\u01b0\u1ee3c ESPEN khuy\u1ebfn c\u00e1o cho nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng do t\u00e1c d\u1ee5ng ch\u1ed1ng vi\u00eam v\u00e0 \u0111i\u1ec1u h\u00f2a mi\u1ec5n d\u1ecbch c\u1ee7a ch\u00fang v\u00e0 nh\u1eefng khuy\u1ebfn c\u00e1o n\u00e0y kh\u00f4ng lo\u1ea1i tr\u1eeb b\u1ec7nh nh\u00e2n b\u1ecb<br \/>\nAKI [8].<\/p>\n<p>Vi\u1ec7c b\u1ed5 sung glutamine c\u00f3 l\u00e0m c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c \u0111i\u1ec1u tr\u1ecb ?<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 28: \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng v\u1edbi AKI, AKI tr\u00ean n\u1ec1n CKD, ho\u1eb7c CKD v\u1edbi KF, kh\u00f4ng d\u00f9ng glutamine \u0111\u01b0\u1eddng ti\u00eam li\u1ec1u cao.<\/strong><\/p>\n<p><strong>Grade A<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) B\u00e0n lu\u1eadn:<\/p>\n<p>M\u1eb7c d\u00f9 l\u01b0\u1ee3ng glutamine m\u1ea5t \u0111i kho\u1ea3ng 1.2g\/ng\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c ghi nh\u1eadn trong qu\u00e1 tr\u00ecnh CKRT [217], v\u00e0 c\u00e1c nghi\u00ean c\u1ee9u v\u1edbi l\u1ef1c m\u1eabu th\u1ea5p tr\u01b0\u1edbc \u0111\u00f3 cho th\u1ea5y m\u1ed9t s\u1ed1 l\u1ee3i \u00edch c\u1ee7a L-glutamine b\u1eb1ng \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch ch\u1ec9 khi \u0111\u01b0\u1ee3c t\u00f3m t\u1eaft trong m\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p [218], b\u1eb1ng ch\u1ee9ng quan tr\u1ecdng nh\u1ea5t li\u00ean quan \u0111\u1ebfn glutamine l\u00e0 nghi\u00ean c\u1ee9u REDOX [219,220] cho th\u1ea5y li\u1ec1u cao ti\u00eam t\u0129nh m\u1ea1ch ho\u1eb7c qua EN c\u1ee7a alanyl-glutamine d\u01b0\u1eddng nh\u01b0 c\u00f3 h\u1ea1i \u1edf nh\u00f3m b\u1ec7nh nh\u00e2n b\u1ecb KF n\u1eb7ng. B\u00ean c\u1ea1nh \u0111\u00f3, m\u1ed9t th\u1eed nghi\u1ec7m quan tr\u1ecdng kh\u00e1c, th\u1eed nghi\u1ec7m MetaPlus [221] cho k\u1ebft qu\u1ea3 t\u01b0\u01a1ng t\u1ef1 tr\u00ean m\u1ed9t qu\u1ea7n th\u1ec3 b\u1ec7nh nh\u00e2n n\u1eb7ng.<\/p>\n<h3>Theo d\u00f5i<\/h3>\n<p>Vi\u1ec7c \u0111\u1ea1t v\u00e0 duy tr\u00ec m\u1ee9c \u0111\u01b0\u1eddng huy\u1ebft trong gi\u1edbi h\u1ea1n b\u00ecnh th\u01b0\u1eddng (80-110 mg) c\u00f3 l\u00e0m c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c kh\u00f4ng?<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 29: M\u1ee9c \u0111\u01b0\u1eddng huy\u1ebft ph\u1ea3i \u0111\u01b0\u1ee3c duy tr\u00ec trong kho\u1ea3ng 140-180 mg\/dl \u1edf b\u1ec7nh nh\u00e2n AKI, AKI tr\u00ean n\u1ec1n CKD, ho\u1eb7c CKD v\u1edbi KF n\u1ed9i vi\u1ec7n<\/strong><\/p>\n<p><strong>Grade A<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (95.5%)<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 30: Kh\u00f4ng theo \u0111u\u1ed5i vi\u1ec7c ki\u1ec3m so\u00e1t \u0111\u01b0\u1eddng huy\u1ebft ch\u1eb7t ch\u1ebd (80-110 mg\/dl) v\u00ec t\u0103ng nguy c\u01a1 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft<\/strong><\/p>\n<p><strong>Grade A<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em>B\u00e0n lu\u1eadn cho khuy\u1ebfn c\u00e1o 29 v\u00e0 30:<\/em><\/p>\n<p>Trong b\u1ed1i c\u1ea3nh l\u00e2m s\u00e0ng n\u00e0y, b\u1ec7nh nh\u00e2n c\u00f3 nhi\u1ec1u nguy c\u01a1 b\u1ecb c\u1ea3 t\u0103ng v\u00e0 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft [138]. T\u00ecnh tr\u1ea1ng \u0111\u1ec1 kh\u00e1ng insulin r\u1ea5t ph\u1ed5 bi\u1ebfn \u1edf b\u1ec7nh nh\u00e2n AKI v\u00e0 c\u00f3 li\u00ean quan \u0111\u1ebfn t\u0103ng nguy c\u01a1 t\u1eed vong [222]. N\u1ed3ng \u0111\u1ed9 glucose trong m\u00e1u cao c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c coi l\u00e0 m\u1ed9t trong nh\u1eefng y\u1ebfu t\u1ed1 \u0111\u1ed9c l\u1eadp d\u1ef1 b\u00e1o t\u1eed vong t\u1ed1t nh\u1ea5t trong b\u1ed1i c\u1ea3nh l\u00e2m s\u00e0ng n\u00e0y [222]. M\u1eb7t kh\u00e1c, v\u00ec insulin c\u0169ng \u0111\u01b0\u1ee3c chuy\u1ec3n h\u00f3a qua th\u1eadn, suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn nh\u01b0 l\u00e0 m\u1ed9t y\u1ebfu t\u1ed1 d\u1eabn \u0111\u1ebfn h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft. M\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng b\u1ecb ch\u1ea5n th\u01b0\u01a1ng \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng insulin \u0111\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c m\u1ee5c ti\u00eau 70-149 mg\/dl, cho th\u1ea5y h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft (&lt;60 mg\/dl) trong 76% tr\u01b0\u1eddng h\u1ee3p c\u00f3 KF \u0111\u1ed3ng th\u1eddi (AKI ho\u1eb7c CKD v\u1edbi KF), so v\u1edbi 35% \u1edf b\u1ec7nh nh\u00e2n c\u00f3 ch\u1ee9c n\u0103ng th\u1eadn b\u00ecnh th\u01b0\u1eddng [223]. Trong tr\u01b0\u1eddng h\u1ee3p h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft n\u1eb7ng (&lt;40mg\/dl), t\u1ef7 l\u1ec7 ph\u1ea7n tr\u0103m t\u01b0\u01a1ng \u1ee9ng l\u00e0 29% v\u00e0 0%, [223]. T\u01b0\u01a1ng t\u1ef1, s\u1ef1 thay \u0111\u1ed5i \u0111\u01b0\u1eddng huy\u1ebft t\u0103ng l\u00ean \u1edf b\u1ec7nh nh\u00e2n KF [223]. V\u1ec1 v\u1ea5n \u0111\u1ec1 n\u00e0y, vi\u1ec7c s\u1eed d\u1ee5ng c\u00e1c ph\u00e1c \u0111\u1ed3 c\u1ee5 th\u1ec3 \u0111\u1ea1t m\u1ee5c ti\u00eau c\u00e1c gi\u00e1 tr\u1ecb \u0111\u01b0\u1eddng huy\u1ebft cao h\u01a1n cho b\u1ec7nh nh\u00e2n AKI, AKI tr\u00ean n\u1ec1n CKD, ho\u1eb7c CKD v\u1edbi KF, \u0111\u1ed9c l\u1eadp v\u1edbi KRT, c\u00f3 th\u1ec3 g\u00f3p ph\u1ea7n l\u00e0m gi\u1ea3m t\u1ef7 l\u1ec7 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft \u1edf nh\u00f3m b\u1ec7nh nh\u00e2n n\u00e0y [224]. H\u01a1n n\u1eefa, s\u1ef1 \u0111\u00f3ng g\u00f3p c\u1ee7a qu\u00e1 tr\u00ecnh t\u1ea1o glucose \u1edf th\u1eadn c\u0169ng r\u1ea5t quan tr\u1ecdng, \u0111\u00f3ng g\u00f3p kho\u1ea3ng 30% t\u1ed5ng l\u01b0\u1ee3ng glucose trong c\u01a1 th\u1ec3 [225,226]. S\u1ef1 li\u00ean quan c\u1ee7a th\u1eadn trong chuy\u1ec3n h\u00f3a insulin v\u00e0 \u0111i\u1ec1u h\u00f2a glucose gi\u1ea3i th\u00edch s\u1ef1 t\u0103ng t\u1ef7 l\u1ec7 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft khi c\u00f3 AKI ho\u1eb7c CKD v\u1edbi KF, s\u1ef1 gi\u1ea3m nhu c\u1ea7u insulin \u1edf b\u1ec7nh nh\u00e2n \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng b\u1ecb CKD, c\u0169ng nh\u01b0 t\u0103ng nguy c\u01a1 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft trong AKI [138]. Nh\u01b0 l\u00e0 m\u1ed9t y\u1ebfu t\u1ed1 b\u1ed5 sung l\u00e0m ph\u1ee9c t\u1ea1p th\u00eam vi\u1ec7c ki\u1ec3m so\u00e1t \u0111\u01b0\u1eddng huy\u1ebft \u1edf b\u1ec7nh nh\u00e2n AKI trong ICU, m\u1ed9t s\u1ed1 gi\u1ea3i ph\u00e1p th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong quy tr\u00ecnh HD\/HF (d\u1ecbch l\u1ecdc v\u00e0 d\u1ecbch thay th\u1ebf) c\u00f3 th\u1ec3 cung c\u1ea5p c\u01a1 ch\u1ea5t n\u0103ng l\u01b0\u1ee3ng \u1edf d\u1ea1ng citrate, glucose v\u00e0 lactate) nh\u01b0 \u0111\u00e3 \u0111\u01b0\u1ee3c th\u1ea3o lu\u1eadn. Li\u00ean quan \u0111\u1ebfn k\u1ebft qu\u1ea3 c\u00e1c t\u00e1c \u0111\u1ed9ng c\u00f3 l\u1ee3i c\u00f3 th\u1ec3 c\u00f3 tr\u00ean th\u1eadn, c\u00e1c chi\u1ebfn l\u01b0\u1ee3c nh\u1eb1m ki\u1ec3m so\u00e1t \u0111\u01b0\u1eddng huy\u1ebft ch\u1eb7t ch\u1ebd h\u01a1n kh\u00f4ng \u0111\u01b0\u1ee3c \u1ee7ng h\u1ed9 [227-231].<\/p>\n<h3>Nhu c\u1ea7u \u0111i\u1ec7n gi\u1ea3i<\/h3>\n<p>\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi AKI, AKI tr\u00ean n\u1ec1n CKD, ho\u1eb7c CKD v\u1edbi KF \u0111ang KRT, li\u1ec7u vi\u1ec7c theo d\u00f5i c\u00e1c ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i (ch\u1ee7 y\u1ebfu l\u00e0 phosphate, kali v\u00e0 magie) c\u00f3 c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c l\u00e2m s\u00e0ng kh\u00f4ng ?<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 31: C\u00e1c b\u1ea5t th\u01b0\u1eddng v\u1ec1 \u0111i\u1ec7n gi\u1ea3i th\u01b0\u1eddng g\u1eb7p \u1edf b\u1ec7nh nh\u00e2n AKI, AKI tr\u00ean CKD, ho\u1eb7c CKD v\u1edbi KF nh\u1eadn KRT v\u00e0 n\u00ean \u0111\u01b0\u1ee3c theo d\u00f5i ch\u1eb7t ch\u1ebd.<\/strong><\/p>\n<p><strong>Grade A<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%) B\u00e0n lu\u1eadn:<\/p>\n<p>R\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i th\u01b0\u1eddng g\u1eb7p \u1edf b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n v\u00e0, m\u1eb7c d\u00f9 t\u1ef7 l\u1ec7 ch\u00ednh x\u00e1c v\u1eabn c\u00f2n ch\u01b0a r\u00f5 r\u00e0ng, m\u1ed9t t\u1ef7 l\u1ec7 m\u1eafc t\u00edch l\u0169y l\u00ean \u0111\u1ebfn 65% \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng [232]. Trong b\u1ed1i c\u1ea3nh l\u00e2m s\u00e0ng \u0111\u01b0\u1ee3c x\u00e9t \u0111\u1ebfn trong h\u01b0\u1edbng d\u1eabn n\u00e0y, c\u00e1c r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o ph\u1ed5 bi\u1ebfn nh\u1ea5t l\u00e0 h\u1ea1 natri m\u00e1u, t\u0103ng kali m\u00e1u, t\u0103ng phosphate m\u00e1u, h\u1ea1 calci m\u00e1u, v\u00e0 h\u1ea7u h\u1ebft ch\u00fang th\u01b0\u1eddng c\u1ea3i thi\u1ec7n khi b\u1eaft \u0111\u1ea7u KRT. Tuy nhi\u00ean, KRT, v\u00e0 \u0111\u1eb7c bi\u1ec7t l\u00e0 c\u00e1c ph\u01b0\u01a1ng th\u1ee9c KRT chuy\u00ean s\u00e2u nh\u1ea5t nh\u01b0 CKRT v\u00e0 PIKRT th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong ICU, c\u00f3 th\u1ec3 c\u00f3 c\u00e1c r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i kh\u00e1c, do hi\u1ec7u qu\u1ea3 n\u1ed9i t\u1ea1i cao c\u1ee7a c\u00e1c ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb trong vi\u1ec7c lo\u1ea1i b\u1ecf ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i [233,234].<\/p>\n<p>C\u00e1c b\u1ea5t th\u01b0\u1eddng trong th\u1eed nghi\u1ec7m th\u01b0\u1eddng g\u1eb7p li\u00ean quan \u0111\u1ebfn KRTs t\u00edch c\u1ef1c\/k\u00e9o d\u00e0i bao g\u1ed3m h\u1ea1 phosphate m\u00e1u, h\u1ea1 kali m\u00e1u v\u00e0 h\u1ea1 kali m\u00e1u [235,236]. H\u1ea1 phosphate m\u00e1u, \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 n\u1ed3ng \u0111\u1ed9 phosphate huy\u1ebft thanh &lt; 0.81 mmol\/l v\u00e0 th\u01b0\u1eddng \u0111\u01b0\u1ee3c ph\u00e2n lo\u1ea1i l\u00e0 nh\u1eb9, trung b\u00ecnh v\u00e0 n\u1eb7ng (t\u01b0\u01a1ng \u1ee9ng &lt; 0.81, 0.61 v\u00e0 0.32 mmol\/l), c\u00f3 t\u1ef7 l\u1ec7 ph\u1ed5 bi\u1ebfn \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o l\u00ean \u0111\u1ebfn 60-80% s\u1ed1 b\u1ec7nh nh\u00e2n ICU [237,238]. Do m\u1ed1i li\u00ean quan gi\u1eefa gi\u1ea3m phosphate m\u00e1u v\u1edbi suy h\u00f4 h\u1ea5p n\u1eb7ng d\u1ea7n v\u00e0 t\u0103ng nguy c\u01a1 k\u00e9o d\u00e0i th\u1eddi gian cai m\u00e1y th\u1edf, r\u1ed1i lo\u1ea1n nh\u1ecbp tim v\u00e0 k\u00e9o d\u00e0i th\u1eddi gian n\u1eb1m vi\u1ec7n v\u00e0 t\u00e1c \u0111\u1ed9ng ti\u00eau c\u1ef1c to\u00e0n b\u1ed9 \u0111\u1ebfn k\u1ebft c\u1ee5c c\u1ee7a b\u1ec7nh nh\u00e2n, gi\u1ea3m phosphate m\u00e1u \u0111\u1eb7c bi\u1ec7t quan tr\u1ecdng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1eb7ng [239-241]. S\u1ef1 c\u00e2n b\u1eb1ng photphat \u0111\u01b0\u1ee3c duy tr\u00ec th\u00f4ng qua s\u1ef1 t\u01b0\u01a1ng t\u00e1c ph\u1ee9c t\u1ea1p gi\u1eefa s\u1ef1 h\u1ea5p thu v\u00e0 b\u00e0i ti\u1ebft phosphate; \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n, c\u01a1 ch\u1ebf \u0111i\u1ec1u h\u00f2a n\u00e0y th\u01b0\u1eddng xuy\u00ean b\u1ecb gi\u00e1n \u0111o\u1ea1n, d\u1eabn \u0111\u1ebfn t\u0103ng nguy c\u01a1 h\u1ea1 phosphate m\u00e1u do ba c\u01a1 ch\u1ebf ch\u00ednh: \u0103n kh\u00f4ng \u0111\u1ee7 v\u00e0\/ho\u1eb7c gi\u1ea3m h\u1ea5p thu \u1edf ru\u1ed9t, t\u00e1i ph\u00e2n b\u1ed1 v\u00e0 m\u1ea5t phosphate [242]. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb KF, vi\u1ec7c b\u1eaft \u0111\u1ea7u KRT c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t y\u1ebfu t\u1ed1 nguy c\u01a1 \u0111\u00e1ng k\u1ec3 h\u01a1n n\u1eefa \u0111\u1ed1i v\u1edbi gi\u1ea3m phosphate m\u00e1u [232]. Cu\u1ed1i c\u00f9ng, trong b\u1ed1i c\u1ea3nh l\u00e2m s\u00e0ng n\u00e0y, vi\u1ec7c b\u1eaft \u0111\u1ea7u song song ch\u1ebf \u0111\u1ed9 dinh d\u01b0\u1ee1ng \u0111i\u1ec1u tr\u1ecb, \u0111\u1eb7c bi\u1ec7t l\u00e0 khi n\u0103ng l\u01b0\u1ee3ng t\u1eeb carbohydrate \u0111\u01b0\u1ee3c \u01b0u ti\u00ean, c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t y\u1ebfu t\u1ed1 th\u00eam v\u00e0o s\u1ef1 ti\u1ebfn tri\u1ec3n c\u1ee7a ch\u1ee9ng gi\u1ea3m phosphate m\u00e1u nh\u01b0 m\u1ed9t ph\u1ea7n c\u1ee7a h\u1ed9i ch\u1ee9ng nu\u00f4i \u0103n l\u1ea1i: g\u1ed3m m\u1ed9t lo\u1ea1t c\u00e1c tri\u1ec7u ch\u1ee9ng ph\u1ee9c t\u1ea1p v\u00e0 r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i m\u00e1u li\u00ean quan \u0111\u1ebfn vi\u1ec7c b\u1ed5 sung l\u1ea1i dinh d\u01b0\u1ee1ng b\u1eb1ng \u0111\u01b0\u1eddng u\u1ed1ng ho\u1eb7c \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch sau m\u1ed9t th\u1eddi gian thi\u1ebfu n\u0103ng l\u01b0\u1ee3ng n\u1ea1p v\u00e0o, c\u1ea5p t\u00ednh ho\u1eb7c m\u1ea1n t\u00ednh [243]. Trong qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb KRT k\u00e9o d\u00e0i, t\u1ef7 l\u1ec7 gi\u1ea3m phosphate huy\u1ebft c\u00f3 th\u1ec3 t\u0103ng l\u00ean 80%, \u0111\u1eb7c bi\u1ec7t khi \u00e1p d\u1ee5ng chi\u1ebfn l\u01b0\u1ee3c l\u1ecdc m\u00e1u t\u00edch c\u1ef1c v\u00e0 c\u00e1c gi\u1ea3i ph\u00e1p KRT kh\u00f4ng phosphate ti\u00eau chu\u1ea9n [[235,244-249] 2017]. H\u1ea1 kali m\u00e1u l\u00e0 m\u1ed9t bi\u1ebfn ch\u1ee9ng th\u00f4ng th\u01b0\u1eddng kh\u00e1c \u0111\u01b0\u1ee3c quan s\u00e1t th\u1ea5y \u1edf b\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n, v\u1edbi t\u1ef7 l\u1ec7 dao \u0111\u1ed9ng t\u1eeb 12 \u0111\u1ebfn 20% [250,251], v\u1edbi c\u00e1c gi\u00e1 tr\u1ecb \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o t\u0103ng l\u00ean \u0111\u1ebfn kho\u1ea3ng 25% \u1edf b\u1ec7nh nh\u00e2n KF b\u1eaft \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb KRT k\u00e9o d\u00e0i [235]. Nguy c\u01a1 h\u1ea1 kali m\u00e1u t\u1ef7 l\u1ec7 thu\u1eadn v\u1edbi li\u1ec1u l\u1ecdc m\u00e1u v\u00e0 c\u00f3 th\u1ec3 t\u0103ng l\u00ean khi s\u1eed d\u1ee5ng c\u00e1c dung d\u1ecbch thay th\u1ebf ho\u1eb7c d\u1ecbch l\u1ecdc m\u00e1u c\u00f3 n\u1ed3ng \u0111\u1ed9 kali th\u1ea5p, c\u0169ng nh\u01b0 do c\u00f9ng t\u1ed3n t\u1ea1i v\u1edbi vi\u1ec7c cung c\u1ea5p kh\u00f4ng \u0111\u1ee7 kali ho\u1eb7c c\u00e1c b\u1ec7nh \u0111i k\u00e8m c\u1ee7a b\u1ec7nh nh\u00e2n (v\u00ed d\u1ee5: ti\u00eau ch\u1ea3y, nhi\u1ec5m ki\u1ec1m chuy\u1ec3n h\u00f3a, \u0111i\u1ec1u tr\u1ecb l\u1ee3i ti\u1ec3u) [235,244]. Cu\u1ed1i c\u00f9ng, h\u1ea1 magie m\u00e1u, th\u01b0\u1eddng \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 m\u1ee9c magie huy\u1ebft thanh &lt; 0.7 mmol\/l v\u00e0 th\u01b0\u1eddng \u0111\u01b0\u1ee3c ph\u00e2n lo\u1ea1i l\u00e0 nh\u1eb9, trung b\u00ecnh v\u00e0 n\u1eb7ng (t\u01b0\u01a1ng \u1ee9ng gi\u1eefa 0.64-0.76, t\u1eeb 0.4 \u0111\u1ebfn 0.63 v\u00e0 &lt; 0.4 mmol\/l), \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o l\u00ean \u0111\u1ebfn 12% b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi t\u1ef7 l\u1ec7 m\u1eafc b\u1ec7nh kho\u1ea3ng 60- 65% trong s\u1ed1 b\u1ec7nh nh\u00e2n n\u1eb7ng [252,253]. Ngo\u00e0i nh\u1eefng nguy\u00ean nh\u00e2n ph\u1ed5 bi\u1ebfn nh\u1ea5t (nh\u01b0 ti\u00eau ch\u1ea3y, h\u1ed9i ch\u1ee9ng k\u00e9m h\u1ea5p thu, s\u1eed d\u1ee5ng thu\u1ed1c \u1ee9c ch\u1ebf b\u01a1m proton m\u1ea1n t\u00ednh v\u00e0 thu\u1ed1c l\u1ee3i ti\u1ec3u, t\u0103ng calci m\u00e1u v\u00e0 t\u0103ng th\u1ec3 t\u00edch d\u1ecbch), g\u1ea7n \u0111\u00e2y ng\u01b0\u1eddi ta c\u00f2n ch\u00fa \u00fd \u0111\u1ebfn vi\u1ec7c t\u0103ng th\u1ea5t tho\u00e1t magie trong qu\u00e1 tr\u00ecnh KRT [254]. \u0110\u1eb7c bi\u1ec7t, s\u1ef1 kh\u1edfi ph\u00e1t v\u00e0 \u0111\u1ee3t c\u1ea5p c\u1ee7a h\u1ea1 magie m\u00e1u trong qu\u00e1 tr\u00ecnh CKRT kh\u00f4ng nh\u1eefng li\u00ean quan \u0111\u1ebfn c\u01a1 ch\u1ebf th\u1ea3i tr\u1eeb d\u1ef1a tr\u00ean c\u01a1 s\u1edf c\u1ee7a \u0111i\u1ec1u tr\u1ecb l\u1ecdc m\u00e1u (thanh th\u1ea3i b\u1eb1ng khu\u1ebfch t\u00e1n ho\u1eb7c \u0111\u1ed1i l\u01b0u) m\u00e0 c\u00f2n li\u00ean quan \u0111\u1ebfn l\u01b0\u1ee3ng magie ion h\u00f3a \u0111\u01b0\u1ee3c t\u1ea1o th\u00e0nh b\u1edfi citrate khi s\u1eed d\u1ee5ng ch\u1ed1ng \u0111\u00f4ng v\u00f9ng citrate v\u00e0 magie b\u1ecb m\u1ea5t trong d\u1ecbch th\u1ea3i d\u01b0\u1edbi d\u1ea1ng ph\u1ee9c h\u1ee3p magnesium-citrate [246,255-258].<\/p>\n<p>H\u1ea1 phosphate m\u00e1u, h\u1ea1 kali m\u00e1u v\u00e0 h\u1ea1 magie m\u00e1u trong qu\u00e1 tr\u00ecnh KRT \u1edf b\u1ec7nh nh\u00e2n AKI, AKI tr\u00ean n\u1ec1n CKD, ho\u1eb7c CKD v\u1edbi KF c\u00f3 th\u1ec3 ng\u0103n ng\u1eeba \u0111\u01b0\u1ee3c b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng c\u00e1c dung d\u1ecbch HD\/HF \u0111\u01b0\u1ee3c l\u00e0m gi\u00e0u phosphate, kali v\u00e0 magie kh\u00f4ng ?<\/p>\n<p><strong>Khuy\u1ebfn c\u00e1o 32: N\u00ean s\u1eed d\u1ee5ng c\u00e1c d\u1ecbch l\u1ecdc m\u00e1u c\u00f3 ch\u1ee9a kali, phosphate v\u00e0 magie \u0111\u1ec3 ng\u0103n ng\u1eeba r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i trong qu\u00e1 tr\u00ecnh KRT.<\/strong><\/p>\n<p><strong>Grade B<\/strong> \u2013 M\u1ee9c \u0111\u1ed3ng thu\u1eadn: m\u1ea1nh (100%)<\/p>\n<p><em> B\u00e0n lu\u1eadn:<\/em><\/p>\n<p>Kh\u00f4ng khuy\u1ebfn c\u00e1o b\u1ed5 sung ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch \u1edf b\u1ec7nh nh\u00e2n \u0111ang \u0111i\u1ec1u tr\u1ecb CKRT. V\u1ec1 v\u1ea5n \u0111\u1ec1 n\u00e0y, do c\u00e1c t\u00e1c \u0111\u1ed9ng l\u00e2m s\u00e0ng c\u00f3 th\u1ec3 nghi\u00eam tr\u1ecdng v\u00e0 c\u00e1c r\u1ee7i ro li\u00ean quan \u0111\u1ebfn vi\u1ec7c b\u1ed5 sung ngo\u1ea1i sinh, vi\u1ec7c ng\u0103n ng\u1eeba s\u1ef1 thay \u0111\u1ed5i c\u00e1c ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i li\u00ean quan \u0111\u1ebfn KRT b\u1eb1ng c\u00e1ch \u0111i\u1ec1u ch\u1ec9nh th\u00e0nh ph\u1ea7n d\u1ecbch KRT c\u00f3 th\u1ec3 l\u00e0 chi\u1ebfn l\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb th\u00edch h\u1ee3p nh\u1ea5t v\u00e0 d\u1ec5 d\u00e0ng h\u01a1n [259-261]. Ng\u00e0y nay, c\u00e1c dung d\u1ecbch KRT tr\u00ean th\u1ecb tr\u01b0\u1eddng \u0111\u01b0\u1ee3c l\u00e0m gi\u00e0u phosphate, kali v\u00e0 magie, c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng m\u1ed9t c\u00e1ch an to\u00e0n l\u00e0m d\u1ecbch l\u1ecdc m\u00e1u v\u00e0 d\u1ecbch thay th\u1ebf, \u0111\u01b0\u1ee3c ph\u1ed5 bi\u1ebfn r\u1ed9ng r\u00e3i v\u00e0 ch\u00fang c\u0169ng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong khi ti\u1ebfn h\u00e0nh d\u00f9ng ch\u1ea5t ch\u1ed1ng \u0111\u00f4ng v\u00f9ng citrate. C\u00e1ch ti\u1ebfp c\u1eadn n\u00e0y c\u00f3 th\u1ec3 ng\u0103n ng\u1eeba s\u1ef1 kh\u1edfi \u0111\u1ea7u c\u1ee7a h\u1ea1 phosphate m\u00e1u, h\u1ea1 kali m\u00e1u v\u00e0 h\u1ea1 magie m\u00e1u. Vi\u1ec7c \u00e1p d\u1ee5ng c\u00e1c gi\u1ea3i ph\u00e1p KRT c\u00f3 ch\u1ee9a phosphate \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o l\u00e0 m\u1ed9t chi\u1ebfn l\u01b0\u1ee3c an to\u00e0n v\u00e0 hi\u1ec7u qu\u1ea3 \u0111\u1ec3 ng\u0103n ng\u1eeba h\u1ea1 phosphate m\u00e1u li\u00ean quan \u0111\u1ebfn CKRT, h\u1ea1n ch\u1ebf nhu c\u1ea7u b\u1ed5 sung ngo\u1ea1i sinh [242,262-264]. Theo c\u00e1ch t\u01b0\u01a1ng t\u1ef1, s\u1ef1 kh\u1edfi ph\u00e1t c\u1ee7a h\u1ea1 kali m\u00e1u trong qu\u00e1 tr\u00ecnh CKRT \u0111\u00e3 \u0111\u01b0\u1ee3c gi\u1ea3m thi\u1ec3u th\u00e0nh c\u00f4ng b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng c\u00e1c lo\u1ea1i d\u1ecbch thay th\u1ebf v\u00e0\/ho\u1eb7c d\u1ecbch l\u1ecdc c\u00f3 n\u1ed3ng \u0111\u1ed9 kali 4 mEq\/l [265]. Li\u00ean quan \u0111\u1ebfn magie, m\u1eb7c d\u00f9 ph\u1ea7n l\u1edbn c\u00e1c dung d\u1ecbch KRT ban \u0111\u1ea7u \u0111\u01b0\u1ee3c \u0111\u1eb7c tr\u01b0ng b\u1edfi n\u1ed3ng \u0111\u1ed9 magie th\u1ea5p \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh t\u00ecnh tr\u1ea1ng t\u0103ng magie m\u00e1u li\u00ean quan \u0111\u1ebfn KF, v\u1edbi s\u1ef1 khu\u1ebfch t\u00e1n c\u1ee7a ch\u1ea5t ch\u1ed1ng \u0111\u00f4ng v\u00f9ng citrate, c\u00f3 th\u1ec3 ch\u1ec9 \u0111\u1ecbnh s\u1eed d\u1ee5ng d\u1ecbch l\u1ecdc v\u00e0 d\u1ecbch thay th\u1ebf c\u00f3 n\u1ed3ng \u0111\u1ed9 magie t\u0103ng l\u00ean \u0111\u1ec3 ng\u0103n ng\u1eeba h\u1ea1 magie m\u00e1u li\u00ean quan \u0111\u1ebfn KRT [255,263].<\/p>\n<h2>K\u1ebft lu\u1eadn<\/h2>\n<p>B\u1ec7nh nh\u00e2n n\u1ed9i vi\u1ec7n v\u1edbi AKI\/AKD ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 KF l\u00e0 m\u1ed9t nh\u00f3m \u0111\u1ed1i t\u01b0\u1ee3ng r\u1ea5t kh\u00f4ng \u0111\u1ed3ng nh\u1ea5t v\u1edbi nhu c\u1ea7u dinh d\u01b0\u1ee1ng v\u00e0 kh\u1ea3 n\u0103ng h\u1ea5p th\u1ee5 dinh d\u01b0\u1ee1ng kh\u00e1c nhau. Tuy nhi\u00ean, v\u00ec t\u1ea5t c\u1ea3 nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y \u0111\u1ec1u c\u00f3 nguy c\u01a1 cao b\u1ecb suy dinh d\u01b0\u1ee1ng, t\u00ecnh tr\u1ea1ng dinh d\u01b0\u1ee1ng c\u1ea7n \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 k\u1ef9 l\u01b0\u1ee1ng. Ngo\u00e0i ra, nh\u1eefng nhu c\u1ea7u v\u1ec1 dinh d\u01b0\u1ee1ng c\u1ea7n \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 th\u01b0\u1eddng xuy\u00ean theo c\u00e1c kh\u00eda c\u1ea1nh \u0111\u1ecbnh l\u01b0\u1ee3ng v\u00e0 \u0111\u1ecbnh t\u00ednh c\u1ee7a ch\u00fang, \u0111\u01b0\u1ee3c c\u00e1 th\u1ec3 h\u00f3a v\u00e0 ph\u1ed1i h\u1ee3p v\u1edbi KRT m\u1ed9t c\u00e1ch th\u1eadn tr\u1ecdng, \u0111\u1ec3 tr\u00e1nh c\u1ea3 vi\u1ec7c nu\u00f4i \u0103n thi\u1ebfu v\u00e0 th\u1eeba. D\u00f9 cho m\u1ee9c \u0111\u1ed9 kh\u00f4ng \u0111\u1ed3ng nh\u1ea5t cao trong qu\u1ea7n th\u1ec3 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c x\u00e9t \u0111\u1ebfn c\u0169ng nh\u01b0 nh\u1eefng kh\u00f3 kh\u0103n v\u1ec1 ph\u01b0\u01a1ng ph\u00e1p lu\u1eadn v\u00e0 s\u1ef1 \u00edt \u1ecfi c\u1ee7a c\u00e1c ch\u1ee9ng c\u1ee9 ch\u1ea5t l\u01b0\u1ee3ng cao, th\u00ec c\u00e1c t\u00e0i li\u1ec7u c\u0169ng \u0111\u00e3 \u0111\u01b0\u1ee3c xem x\u00e9t nh\u1eb1m x\u00e1c \u0111\u1ecbnh c\u00e1c kh\u00eda c\u1ea1nh quan tr\u1ecdng ph\u00f9 h\u1ee3p nh\u1ea5t c\u1ee7a h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng trong c\u00e1c c\u01a1 s\u1edf l\u00e2m s\u00e0ng kh\u00e1c nhau c\u1ee7a b\u1ec7nh nh\u00e2n AKI\/AKD ho\u1eb7c CKD c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 KF n\u1ed9i vi\u1ec7n. C\u00e1c khuy\u1ebfn c\u00e1o v\u00e0 tuy\u00ean b\u1ed1 th\u1ef1c ti\u1ec5n \u0111\u00e3 \u0111\u01b0\u1ee3c ph\u00e1t tri\u1ec3n, nh\u1eb1m m\u1ee5c \u0111\u00edch x\u00e1c \u0111\u1ecbnh c\u00e1c \u0111\u1ec1 ngh\u1ecb cho th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng h\u00e0ng ng\u00e0y trong vi\u1ec7c c\u00e1 nh\u00e2n h\u00f3a h\u1ed7 tr\u1ee3 dinh d\u01b0\u1ee1ng \u1edf \u0111\u1ed1i t\u01b0\u1ee3ng b\u1ec7nh nh\u00e2n n\u00e0y. C\u00e1c nh\u00f3m t\u00e0i li\u1ec7u khan hi\u1ebfm ho\u1eb7c kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng c\u0169ng \u0111\u00e3 \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh, do \u0111\u00f3 c\u1ea7n th\u00eam c\u00e1c nghi\u00ean c\u1ee9u c\u01a1 b\u1ea3n ho\u1eb7c nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng.<\/p>\n<h3>Qu\u1ef9 t\u00e0i tr\u1ee3<\/h3>\n<p>H\u01b0\u1edbng d\u1eabn hi\u1ec7n t\u1ea1i kh\u00f4ng nh\u1eadn b\u1ea5t k\u1ef3 kho\u1ea3n t\u00e0i tr\u1ee3 n\u00e0o.<\/p>\n<h3>Xung \u0111\u1ed9t l\u1ee3i \u00edch<\/h3>\n<p>Ch\u01b0a ghi nh\u1eadn.<\/p>\n<h2>T\u00e0i li\u1ec7u tham kh\u1ea3o<\/h2>\n<ol>\n<li>Cano N, Fiaccadori E, Tesinsky P, Toigo G, Druml W, Kuhlmann M, et al. ESPEN guidelines on enteral nutrition: adult renal failure. Clin Nutr 2006;25: 295-310.<\/li>\n<li>Cano NJ, Aparicio M, Brunori G, Carrero JJ, Cianciaruso B, Fiaccadori E, et al. ESPEN Guidelines on Parenteral Nutrition: adult renal failure. 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Clin Nutr 2011;30:549-52.<\/li>\n<li>Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019;38:48-79.<\/li>\n<li>Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 2017;36:49-64.<\/li>\n<li>Fiaccadori E, Regolisti G, Maggiore U. Specialized nutritional support interventions in critically ill patients on renal replacement therapy. Curr Opin Clin Nutr Metab Care 2013;16:217-24.<\/li>\n<li>Carrero JJ, Stenvinkel P, Cuppari L, Ikizler TA, Kalantar-Zadeh K, Kaysen G, et al. Etiology of the protein-energy wasting syndrome in chronic kidney disease: a consensus statement from the international society of renal nutrition and metabolism (ISRNM). J Ren Nutr 2013;23:77-90.<\/li>\n<li>Mehta R. Glycemic control and critical illness: is the kidney involved? 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Intensive Care Med 2001;27:1037-43.98<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>T\u00e1c gi\u1ea3: Enrico Fiaccadori Bi\u00ean d\u1ecbch: B\u00e1c s\u0129 L\u00ea Nguy\u1ec5n Quang Th\u00e1i vnras.com\/drug &#8211; \u0110\u1ec3 t\u1ea3i file PDF c\u1ee7a b\u00e0i vi\u1ebft H\u01b0\u1edbng d\u1eabn \u0111\u1eb7c bi\u1ec7t v\u1ec1 dinh d\u01b0\u1ee1ng l\u00e2m s\u00e0ng \u1edf b\u1ec7nh nh\u1eadn c\u00f3 b\u1ec7nh th\u1eadn c\u1ea5p t\u00ednh ho\u1eb7c b\u1ec7nh th\u1eadn m\u1ea1n t\u00ednh, xin vui l\u00f2ng click v\u00e0o link \u1edf \u0111\u00e2y. 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